Though its symptoms are distinctive, Harris found quently than heretofore into the differential diagnosis the disease confused in the literature with geographic of syphilis, and that familiarity with the various phases tongue, neuralgia of the tongue and lichen planus. of its symptomatology will be required of the derma¬ tologist. The possibility of confusing Vincent's Vincent's disease disease with syphilis is not as remote as might appear, It has been impressed on me by experience that, for the similarity of the lesions to mucous patches may with the return of our troops to their home com¬ be striking in the cases of moderate severity, and munities, Vincent's disease will probably become an search should always be made for the organisms. important factor in the differential diagnosis of lesions The possibility of coexistence of the two diseases of the and other mucous surfaces. Attention should be kept in mind, as well as the fact that mer¬ has been called to the increase in the number of cises curial treatment may arouse to activity quiescent types of Vincent's disease since 1915 in Canada13 and Eng¬ of Vincent's disease in the syphilitic. land, among both the soldiers and the civilian popula¬ tion; but similar statistics as to the prevalence of the disease in this are not available. As it is a country ACCESSORY NASAL communicable and curable affection, its SINUSES OF early recogni¬ CHILDREN tion is a mattter of considerable importance. Vincent's angina has been a widespread, though not common SEYMOUR M.D. disease in this for and OPPENHEIMER, country many years, small, NEW YORK localized epidemics have at times occurred. Among the overseas troops, "trench mouth" has been identi¬ The views that I have expressed in several previous fied as Vincent's disease, and statistics from one Brit¬ publications, dating back to 1912, as to the frequency ish military hospital in France state that it represented of accessory sinus diseases in children, hold at the 23 per cent, of all throat complaints. Most present time with additional emphasis. Subsequent of the patients with this affection whom I have seen investigation of anatomic specimens and references and who had been overseas gave a history of trench to the work of others seems to demonstrate that the mouth, usually described as of moderate severity; accessory nasal sinus development occurs at a much recent attacks were probably recurrent. earlier period than is generally considered by most Vincent's disease may appear on the tonsil as a deep investigators, and it is accepted that their variation ulcération; on the ramus of the lower jaw posterior in size, shape and position at different ages, up to the to the last molar tooth as a localized ulcerating patch ; period when they assume the adult type, is extreme. as a mouth infection almost the general involving SINUSITIS IN THE CHILD entire mucosa, , and at times the tongue, or From a remain limited to the gums, where it is often careful study of the early anatomic develop- primary ment of the and may be mistaken for pyorrhea alveolaris.14 Mild sinuses, it seems probable that many cases of are the result of cases tending to chronicity occur as tonsillitis or gin¬ meningitis unrecognized inflam- mation of some of the as the givitis of moderate degree, or on the cheeks and lips sinuses, symptoms of in shredlike patches resembling the condition observed sinusitis are more or less obscure in children. That this should be so can be in those who habitually bite the lip or cheek. These readily appreciated from the structure of these at an for are mild types may develop into severe attacks, with the parts early age, they formation of sloughing, serpiginous ulcers covered surrounded by much softer bone than at a later period of life ; there is a more of the with a heavy, pultaceous, creamy, often adherent profuse development and vascular and the mucosa is pseudomembrane. The ulcération may be superficial, lymphatic systems, in most intimate relation with so or and destructive it with the osseous tissue, deep ; may spread rapidity, that inflammation of the former and involve areas of the mucosa. The breath is slight must produce large some in the latter. fetid, the are swollen, and the often pre¬ pathologic change My experience glands patient has been that in the child, chronic sinusitis is sents a pallid or yellowish appearance, even in cases of common, the reaction is and it will be found on careful examination that many moderate severity, though systemic the often than would be instances of postnasal catarrh in child are but less expected. of The disease also ulcération and svmptoms some inflammatory condition of the adja¬ may produce gan¬ cent sinuses. grene of the vulva, conjunctivitis and an ulcerative balanitis. Greeley15 has recorded a case with coinci¬ DEVELOPMENT OF THE SINUSES dent purpuric eruption and bleeding from the nose The reasons for the development of the nasal acces¬ and gums, in several attacks, ending fatally. sory sinuses have been defined by various authors with The spirillum of Vincent and the associated fusi¬ varying théories. Killian believes that the develop¬ form bacillus are recognized as the causative agents ment of this area depends on the inherent biologic of the disease, and can be readily detected in smears. characteristics of the cells which go to form the The organisms are also readily seen in dark-field various structures in this area. Coffin and Frères, preparations, and I have made frequent use of this however, explain the development on a physical basis. method of diagnosis. The clinical resemblance to They believe that the reabsorption of bone is due to diphtheria is occasionally marked, and cultures should variations in air pressure, particularly that of be made in all doubtful cases, as the two diseases may expiration ; that the principal growth of the sinuses coexist. begins after breathing occurs ; that there is a distinct The predicted increase in the number of cases of similarity between the effect of air pressure on the Vincent's disease indicates that it will enter more fre- Read before the Section on Laryngology, Otology and Rhinology Warner Holmes: Canad. M. A. 1919. at the Seventieth Annual Session of the American Medical Associa- 13. Laughlen, and J. 9:345, 1919. 14. McKinstry, W. H.: Brit. M. J. 1: 421 (March 31) 1917. Camp- tion, Atlantic City, N. J., June, bell, A. R., and Dyas, A. D.: Vincent's Angina, J. A. M. A. 68: 1596 The bacteriologic observations contained in this paper were obtained (June 2) 1917. from experiments conducted by Dr. Mark J. Gottlieb, of the Laboratory 15. Greeley, H.: Am. J. M. Sc. 155:742 (May) 1918. for Clinical Research.

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 sinuses and on the alveoli of the lung, and that a The anterior group is by far the more important, constant change of air pressure in the sinuses, and, as its stornata are found along the semilunar hiatus finally, the direction of the inspired and expired air and the fissure between the ethmoidal bulla and the bear a relation to the anatomic formation of the inferior turbinated body, at a location at which infec¬ nose. These two authors also point out that children tion from intranasal morbid changes most frequently having adenoids present poorly developed sinuses, takes place. The anterior cells are more numerous because of the lack of normal air pressure in the nose than the posterior, although the latter are larger as during expiration. regards the capacity of the individual cells, and their Functions.—The functions of the nasal accessory stornata are much less in size than those of the anterior sinuses have been subject to considerable controversy, mass. As the internal wall of the orbital fossa forms and no particular theory as to the physiology of these the eternal boundary of the ethmoid, the possibility cavities has as yet been universally accepted. Whether of orbital symptoms, as a complication of ethmoidal the sinuses are the remains of rudimentary struc¬ infection, is apparent. In operating on this region, tures, which, in lower animals, serve as adjuvants this relationship must be borne in mind on account of to the act of smelling, or whether these cavities evenly the extreme thinness of the ethmoidal orbital wall, distribute the inspired air and thus help olfaction, and the danger of injuring the contents of the orbital is still open to discussion, as well as the suggestion cavity. that the pneumatization and extension of these cells FRONTAL AND SPHENOIDAL SINUSES serve to lighten the bones of the skull in order that Previous to the seventh or eighth year, the frontal proper poise and counterpoise, may be maintained. sinus is usually not developed, although not infre¬ The contention that they are an adjunct to respiration quently it is present as as the fifth year. Before air early by moistening the inspired is not supported by puberty, it does not extend far up in the frontal bone ; no mucous in histologie findings, as there are glands then a marked change takes place until the eighteenth the mucosa of these cavities. year, when its full development is accomplished. The Early Appearance.—In connection with the anatomic anatomic and surgical relation differs in no way from development, it should be remembered that the maxil¬ that in the adult, except that its relation to the cranial lary sinus is well defined, although rudimentary, at cavity, on account of the thin posterior wall, is most birth, and even in the fetus it is found about the intimate ; and this must be considered in relation to fourth month, so that inflammation of this sinus at inflammatory processes. an early age is not infrequent. From this early form, The sphenoidal sinus may show a definite cavity in which it has a triangular shape, it undergoes but as early as the third year, while, by the seventh year, little change until the second dentition, when the it is well developed ; and although its inflammatory development of the molars and bicuspid teeth play an changes have not been as much studied as have those important part in its relation to the bones of the face. of the other sinuses, I am of the opinion that it is Previous to the completion of the first dentition, more frequently involved than is usually thought. Its the odontoblasts are in the most intimate rela¬ lateral walls are largely within the intracranial cavity, tion with the floor of the sinus, which continues and this deserves special consideration in relation to to develop, but. does not reach the adult type until the development of obscure cases of basal meningitis, about the twelfth year. The thickest wall is then found as do also its intimate relations laterally and superiorly to be formed by the body of the superior with the internal carotid artery and cavernous sinus. posteriorly, while the orbital wall superiorly is of extreme tenuity. Much earlier, however, accessory recognition of sinusitis foramina are found, as in the adult, and the stornata The recognition of sinusitis in the child is more open into the middle meatus at the posterior end of difficult than in the adult, as the symptoms are usually the semilunar hiatus. obscure and rarely characteristic ; and it is unusual to have a sinus involved to the exclusion of IMPORTANCE OF CELLS single the others, the rule being that more than one sinus is Most important in the child are the inflammatory affected at the same time. One can well appreciate affections of the ethmoid cells, these cells and the the difficulty of differentiating individual inflamma¬ antrums being more frequently involved than the tory areas under such circumstances. When the upper frontal and sphenoidal sinuses. Evidences of the sinuses are the seat of a purulent inflammation, the ethmoidal area are seen in the fetus about the eighth discharges may reinfect those lower down, and espe¬ month ; but development into distinct cells does not cially the maxillary antrum, so that the soft tissues commence until the fourth year, and from that period around the stornata are kept irritated and swollen, on these tissues are susceptible to morbid changes, and it becomes most difficult to differentiate the exact the cells reaching their maximum development about underlying faulty condition. the twentieth year. In the child, as in the adult, the INVOLVEMENT middle turbinated body is essentially a portion of the DUE TO INFECTIOUS DISEASE ethmoid area, although its anterior end is thinned out, The frequency of occurrence of the infectious is small and runs parallel to the perpendicular plate, diseases in childhood, and the concomitant inflamma¬ so that the lower border is deflected inward. At about tory changes of the nasal mucosa, explain why the the eighth to the tenth year one finds that the eth¬ sinuses are involved during this period, and they are moidal ostia open into the nasal meatuses, and for involved particularly in influenza, scarlet fever, surgical purposes, and especially in the recognition measles and pneumonia. In the vast majority of of morbid changes, the cells can be grouped into an cases there is a primary inflammation of the nasal anterior mass communicating with the middle meatus, mucosa, and the sinuses involved become so from a while the posterior group opens into the superior direct extension of this inflammation, irrespective of meatus. its basal cause, the swelling of the soft tissues around

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 the sinus opening causing the secretions to be retained were found in thirty-two instances, streptococci in as a result of the stenosis which is produced. five, staphylococci in thirty, and Bacillus influenzac In the new-born child, antral sinusitis may occur in four. A number of other organisms which are not as a consequence of infection by vaginal discharges ordinarily pathogenic were also found, but did not from the mother, or from injury—the result of instru¬ occur alone. In forty-seven chronic cases, pncu- mental delivery—and the resultant purulent inflam¬ mococci were found six times ; streptococci, nineteen ; mation involves the soft osseous antral walls. In my staphylococci, thirty-eight ; Bacillus injlucnzac, twice, experience, this condition arising in small children and many other organisms which were not supposed, from these causes or from others is a true sinusitis, however, to be patbogenic. as well defined as that found in the adult, and it is STAPHYLOCOCCI AS INFECTING not a tuberculous caries or , as has some¬ ORGANISMS times been claimed. As a rule, affections of the We bave observed in the results of all these investi¬ antrum occur during the second dentition, while. gations that staphylococci occur in equal, if not in infrequently, errors in the development of the teeth greater frequency than the other organisms men¬ may act as an exciting cause of the empyema. tioned. The question of whether or not staphylococci The ethmoid labyrinth in the older child is espe¬ are of infective consequence, when present in the cially liable to become involved in all. inflammatory secretions of infected nasal accessory sinuses, has affections of the nasal mucosa, and in coryza ; and arisen, therefore, many times in our mind. To in the contagious diseases of childhood these cells are answer the question we endeavored to determine affected in practically every instance, frequently whether or not the staphylococci isolated from the accounting, to my mind, for suppurative ethmoiditis purulent discharges procured from the nasal accessory in later life, which has, in reality, existed from early sinuses were pathogenic to rabbits. childhood. The nasal chambers were irrigated with a sterile DRAINAGE solution of sodium chlorid. The secretions were then sucked out of the nose into a sterile The nasal accessory sinuses are able, normally, to tube, and cul¬ drain themselves continuously by virtue of the fact tures were made from this pus on agar plates. The were means of their stain¬ their outlet are not in staphylococci identified, by that, although openings every characteristics with Gram's and the color instance situated at the most dependent portion of the ing stain, by and the appearance of their colonies. Of cavity, their mucous membrane is furnished with general ciliated which waft their cilia in seventeen specimens of pus secured from seventeen epithelia, constantly from acute sinus disease of or the direction of the outlet. Furthermore, the normal patients suffering one more cavities, were recovered in eleven. of some of these cavities are in the most staphylococci openings In was found of the sinus when the head is in four, Staphylococcus pyogcncs-aureus ; dependent portion in albus, and in two, the In the ethmoidal tract, the drain¬ eight, Staphylococcus Stapliv- upright position. lococcus citreus. aureus and albus be or intricate the indi¬ Staphylococcus age may exceedingly simple ; were recovered from three specimens. vidual one into the other together cells may drain by opening In endeavoring to ascertain whether these organisms or into the nasal chamber. directly were pathogenic to rabbits, we first determined the maximum dose BACTERIOLOGY of nonvirulent staphylococci which the animal could be intravenously without reasonable that given causing It is to presume the bacteria found its death. For this purpose agar slants of uniform in the nasal sinuses of infants and children accessory size were made, and the organisms were grown on during inflammatory conditions should be the same them for twenty-four hours. A sufficient amount of as the flora present in these cavities in the adult. sterile sodium chlorid solution was then that without physiologic Torne, as early as 1903, showed excep¬ poured into the tube up to the top of the slant, with tion healthy sinuses were found sterile in cadavers the tube held in the upright position. The organisms within two hours after death. Zarnico tabulated the were then scraped off the surface of the agar with a organisms in the order of their importance as infect¬ platinum loop, and the solution and the bacteria were ing agents in accessory sinus disease as follows : poured into another tube and thoroughly shaken. Diplococcus lanceolatus (pneumococcus), staphylococ- Five-tenths c.c. of such suspension of nonvirulent cus and , influenza bacillus, pseudo- staphylococci was the maximum dose that could be diphtheria bacillus, Friedländer's capsule bacillus, given to a rabbit intravenously without causing its Meningococcus inlraccllularis, Bacterium coli, Bacil¬ death. Twenty-four hours after the rabbits were lus pyocyaneus, Bacillus pyogenes-foetidus. infected, blood cultures were made by paracentesis According to Turner, in twenty-two cases of acute cordis and every twenty-four hours thereafter, until and chronic fronto-ethmoidal sinus disease, the pneu¬ the cultures were found sterile or the animal died. mococcus was isolated in eight (36 per cent.), Streptococcus pyogenes in nine (40 per cent.), and EFFECT ON RABBITS the staphylococcus in ten (45 per cent.). An organ¬ One animal that received Staphylococcus aureus gave a ism which resembled the influenza bacillus occurred sterile blood culture within three days. Another, whose blood culture was after twenty-four hours, died the fol¬ in one case. In forty-three cases of maxillary sinus positive and on necropsy an extensive hemorrhage was disease, the pneumococcus was present in thirteen lowing day, in found in the pericardial sac. The animal died as the result, (30 per cent.), Streptococcus pyogenes thirty- probably, of the trauma incident to cardiopuncture. In a three (76 per cent.), staphylococci in thirty-four third, the blood culture remained positive until the animal's in Bacillus (79 per cent.), Bacillus influensae one. death, which was six days later, and on necropsy a purulent tuberculosis in one, and Micrococcus catarrhalis in pericarditis and of the liver and kidney were found. two. Babcock, in a recent investigation on the bac¬ Pure cultures of Staphylococcus aureus were recovered from teriology of sinus infections, has shown that in fifty- these lesions. The fourth animal was found dead one day the was three acute cases, pneumococci of the various groups after infection. Free fluid in pleural cavity found,

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 as well as an of the liver. Cultures from these pro¬ usually of the antrum and of the ethmoid cells, exists ; duced not only Staphylococcus aureus, but, in addition, a and while serious organic osseous changes are not gram-positive bacillus. All of the rabbits that were infected present, when they do occur the ethmoid structures with Staphylococcus albus gave negative blood cultures in are most frequently involved. In purulent inflam¬ from three to seven days. In one case, the animal died two mation of these sinuses, and especially in that acute, after the blood culture was found sterile. There was days sometimes seen, serious orbital com¬ marked of the right lung, dilatation of the right fulminating type congestion ensue as a result of the left heart and there were a few plications may pathologic changes heart, being empty, in the correlated vascular with the grayish-white spots in the substance of the left kidney. sinuses, develop¬ cavernous sinus and result- Unfortunately, no cultures were made from these lesions. ment of thrombosis of the In the two rabbits in which Staphylococcus citreus was tant pyemia, meningitis and death. In the milder injectad, the cultures were found sterile after the third day. form, a symptom not uncommon and always of diag¬ nostic value is edema of the eyelids from vascular It can be the number of readily seen, although pressure. In inflammatory processes affecting the examined is that one out of fpecimens small, only maxillary antrum, it is not uncommon to find some seventeen cultures of could be con¬ staphylococci involvement of the osseous structures of the superior sidered as virulent. Our definitely presumption, maxilla, if the purulent sinusitis is long continued ; therefore, is that in the great majority of cases staphy¬ but in the of instances the affection presents lococci are not but majority the primary infecting organisms, rather a course too unrec¬ the benign and, only frequently are secondary invaders which supplant offending it is treated as "nasal catarrh." After the and ognized, organism prolong the symptoms. nasal chamber has been cleansed the reappearance of in THE DIAGNOSIS pus the middle meatus is indicative of antral sup¬ ' but in older children puncture of the lateral The of the puration, recognition various sinus affections in nasal wall of the antrum is necessary to recognize the child is more difficult than in the adult, as the sub¬ the condition present. jective symptoms are not clearly defined. Transil- luminition is of value, but comparative studies must CLOSE RELATIONSHIP as of and is be made, the area light shadow rather Inflammatory changes in the ethmoid structures, a in use of made different than the adult. The carefully result of neglected rhinitis, are frequently found. roentgen plates, however, is of great service, espe¬ It has been my that isolated sinusitis is of experience cially as regards the presence pus in the antra uncommon. In younger children, the antrum also or frontal sinuses ; and, previous to the tenth year, is apt to be involved, while in older children the is the most the use of the roentgen ray valuable frontal sinus may be simultaneously affected. On diagnostic medium that we possess. The presence of account of the relation of the complicated ethmoid frequent headache should always occasion suspicion system to the other sinuses, and of the fact that the of sinus inflammation, and especially when parts pathologic changes occur here so frequently as a result are tender to touch over the sinus involved, bearing of the infectious diseases of childhood, it will be in mind, however, that localizing pain with any degree found that this sinus is the primary source of infec¬ of accuracy is difficult in the very young. In acute tion in the great majority of cases of pansinusitis, and sinusitis, pain of an aching character is almost invari¬ that this relationship is especially emphasized on ably present at some time during the course of the account of the rather intimate connection of the vari¬ inflammation, but in chronic cases it is very frequently ous stornata of its component cells with the other absent, unless the secretions are retained under pres¬ sinuses, so that the presence of a purulent discharge sure, when it may become most intense. which does not, to a greater or less degree, involve A marked symptom of great diagnostic value, when other sinuses, is almost impossible. present, is the cessation of pain with the appearance As a result of the late development of the frontal of a free nasal discharge, and the return of the pain sinus, as has been pointed out previously, chronic when the discharge lessens or temporarily ceases. changes are unusual ; but its involvement in the older The presence of a discharge, especially if unilateral child during acute intranasal inflammation is much and purulent, or semipurulent, in character, is always more frequent than is currently considered. The of diagnostic value, and especially if intermittent. If recognition of inflammatory changes in this region there is lymphoid tissue in the vault of the pharynx, does not differ from that in the adult, and the presence most marked on the side from which the discharge of pus in the middle nasal meatus will aid greatly in comes, it will often be found that the adenoids are establishing the diagnosis, although it may be easier not the sole source of the continued coryza from to eliminate suppuration of the frontal sinus than to which the child suffers, but that there is, in addition, define its presence. a sinusitis. Location of the source of the discharge is of great value in determining which sinus is affected, PURULENT SPHENOIDAL SINUSITIS and the method of ascertaining the source differs in The recognition of purulent sphenoidal sinusitis is no way from that employed in the case of the adult, by far the most difficult, as it is practically always which is so well known as to require no further dis¬ combined with ethmoidal changes, and the symptoms cussion. are not characteristic. Severe occipital or vertical Aprosexia and disturbance in the general health are headache, with more or less dizziness, is suggestive more or less inevitable concomitants of chronic of retained secretions in this sinus ; the discharges are purulent sinusitis, while complications, as in the adult, scant and usually become inspissated in the naso¬ are not as frequent, although orbital symptoms are not pharynx or along the posterior portion of the vomer uncommon. In the so-called strumous child, with and floor of the choanae, and it will not infrequently whom there is a purulent nasal discharge, with be found that the condition cannot be recognized until excoriated upper lip and marginal blepharitis, and exploration has been made of the interior of the sinus. frequently with corneal ulcers, purulent sinusitis, In the young adult, however, the exploration should

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 not be made until the presence of other sinus affec¬ to remove as much of the osseous tissue at such points tions of a purulent character has been eliminated. as may be required. The routine use of the pharyngoscope in young chil¬ When the frontal sinus is involved, its relation to dren has disclosed a surprisingly large number of the anterior group of ethmoid cells is such that atten¬ cases of posterior ethmoidal and sphenoidal suppura¬ tion must be paid to them before the inflammation of tion which would have remained unrecognized by any the mucosa lining the frontal sinus will subside. other method of examination. When the antrum is diseased inflammatory changes, Most important is the fact that these inflammatory as a rule, readily subside under ordinary treat¬ invasions mean a radical disturbance of the entire ment ; but in obstinate cases, after ffactoring drainage system of the nasal interior, and all treat¬ and pushing aside the inferior turbinated body, a ment, whether conservative or radical, must rest on large opening should be made through the inferior this basis. The relation of focal lesions in the acces¬ meatus into the sinus, and the parts drained in this sory nasal cavities of children to systemic diseases, way, the question of whether or not irrigation is such as arthritis, endocarditis and nephritis, must advisable is to be decided by the character and be considered of an importance equal to that of the chronicity of the purulent discharge. lesions occurring secondary to tonsillar and dental disease. Dr. Dean, the chairman of this section, has OPERATIVE PROCEDURE a very valuable contribution on this subject. In certain fulminating forms of sinusitis in the child, and in persistent suppurative cases resisting FIRST MEASURES IN TREATMENT endonasal treatment, with marked impairment of the In treatment of sinusitis in the child, the aim ought general health or other violently acute symptoms, an always to be to destroy as little tissue as is consistent external operation will be indicated. The physician with obtaining permanent results, and, as far as pos¬ must bear in mind, however, that before any radical sible, the intranasal mucosa should be preserved if external operation on the child is undertaken, a most operative procedures become necessary in the indi¬ careful examination should be made for any morbid vidual case. Palliative treatment will permanently changes in adjacent areas which may be keeping up cure the majority of acute sinus inflammations when the sinusitis by interfering with drainage, as it has such treatment is intelligently directed toward free been my experience that in not a few instances treat¬ drainage. ment for a considerable time may be of no benefit Previous to the employment of surgical measures, until a hypertrophy of the middle turbinated body- therefore, the use of warm alkaline sprays and of has been removed, or a lymphoid mass in the naso¬ weak epinephrin solution to reduce the congested pharynx, which has acted as a constant source of rein¬ mucosa, with, if the case is severe, rest in bed, fection. It should be emphasized that any enlarge¬ the employment of laxatives and such general mea¬ ment of the middle turbinated body is a serious sures as may be indicated in the particular case, will obstacle to the cure of inflammatory changes in any often produce the most happy results ; and in this con¬ sinus, and until it has been relieved the sinusitis will nection it should be remembered that the tendency prove most obstinate to treatment. of acute sinusitis is toward cure, and the use of the Free drainage must be secured before a cure can measures outlined will not infrequently remove the be obtained, and if intranasal treatment fails to obtain inflammation when operation would have been resorted such a result, then whatever radical operation may to unnecessarily, with possibly much less satisfactory be selected should be performed. It should also be results. emphasized in this connection that free drainage means In these instances in which the sinus disease has free nasal respiration, and this is another prominent continued and resists treatment, it will often be found factor that must be taken into consideration in the that the general health of the child was more or less surgical treatment of these conditions. In addition, seriously affected previous to the development of it is essential that when pus is found in any of the the nasal affection, as a result of the original disease sinuses it must be evacuated as a surgical principle, causing it ; and until proper care of the general health and granulations and necrosed tissues must be thor¬ is instituted, local measures alone will not be of great oughly removed. On this basis rests the surgical avail. treatment of all chronic sinus affections, with the The employment of some type of suctional, nega¬ various modifications of technic in the care of the tive pressure apparatus, applied intranasally for free¬ individual sinuses dependent on the peculiar anatomic ing the nose and ostia of secretions, proves very bene¬ structural characteristic of each. ficial. The congestive hyperemia which is thereby When the external radical operation on the frontal induced is oftentimes decidedly curative. I have had sinus is under consideration, it is essential, therefore, no experience with the employment of autogenous vac¬ as a preliminary step, to remove the anterior portion cines in the treatment of sinus disease of children, of the middle turbinated body in order to secure thor¬ but believe they probably have the same relative value ough drainage, and not infrequently this procedure as in the adult. The question of dosage must, how¬ may bring about a cure. The external operation on ever, be carefully considered. the frontal sinus in the young should be performed I believe intranasal treatment to be indicated pri¬ with the greatest reluctance in the absence of definite marily in all cases of sinusitis in children ; but it should external or intracranial symptoms. In those cases in be strongly emphasized that the turbinal tissue should which the frontal sinusitis has been unrecognized, a be preserved ; and while it is necessary at times to fistula may have resulted, and the condition possibly remove the anterior end of the middle turbinated body, has been treated as a dacrocystitis. The only method the removal of its entire structure to reach the by which relief may be obtained is by thoroughly stornata of any of the sinuses is not warranted. When opening the sinus, externally cleaning out the anterior possible, drainage should be obtained through the ethmoid cells, which are always involved, and obtain¬ natural openings, and to accomplish this it is proper ing free drainage through the nasal chambers.

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 OTHER METHODS Oppenheimer that it is the frequent headache which is a In children, the antrum external symptom of sinusitis in a child. I believe that a persistent, rarely requires chronic operation, as opening the lower nasal fossa with irri¬ headache, that headache for which a child so often wears glasses without relief, is the characteristic headache gation is usually sufficient to obtain a cure of the sup¬ which signifies a sinus condition. I had one case where a puration. In young work on the children, operative chronic headache had existed since the patient was 8 years antrum must be with cau¬ maxillary performed great of age, and it was relieved when he was 16 years of age on by tion, account of the relation to the teeth at this taking off the sphencidal wall at the right side, although the age. Such procedures, during the formative period cavity had been washed out at different periods for several of the teeth, are apt to result most disastrously. years. As a result of these studies it has been my experi¬ Dr. Emil Mayer, New York: I want to call attention to ence that a radical external operation for the relief one form of this affection that Dr. Oppenheimer evidently of purulent sinusitis is rarely indicated and is not overlooked, and that is the infection of the antrum and ethmoid in the child, the productive of as satisfactory results as the more con¬ very young infant. There are only servative intrunasal Should indications a few cases on record. I believe I was among the first to procedures. call attention to that in the arise such external inter¬ many years ago, and looking up however, demanding surgical few cases which were recorded it was remarkable to observe the same of attack as ference, type operative applies the similarity of the symptoms. Each one of these patients in the adult. had a curious opening on the cheek and a foul-smelling dis¬ 45 East Sixtieth Street. charge from the nose. In those instances there is only one thing to do, and that is to enlarge the already existing open¬ ABSTRACT OF DISCUSSION ing and curet entirely through the nose and cleanse it. This case occurred before the day of the roentgen ray and before Dr. Charles Gilmore New York : In my Kerley, we knew about the work I have been unable in several instances anything bacteriology of it, but the chair¬ professional man in his article on affections of the sinuses in to induce the to make a of sinusitis accessory laryngologist diagnosis children last year mentioned that class of and I believe in children where I thought it ought to be made. It seemed cases, it should be recorded in connection with the kind of cases to me that with the rhinologists and laryngologists sinusitis mentioned by the speaker. in the child was sometimes overlooked. This was not the Sir St. Clair fulminating case, which is easy to diagnose. The cases that Thomson, London, England: This is a very come to me as a pediatrist are those that have often gone important question, because we have not yet realized the con¬ nection between in through the hands of the laryngologist. As one mother rhinitis and sinusitis infancy and child¬ hood expressed it, the laryngologist had cut out everything in sight and the atrophie rhinitis and ozena of later life. I would and out of sight, and still the child had a persistent running suggest to those in active practice that they try to g«t nose. She told me that the discharge was enormous and what we have long been working for, that is, postmortem claimed that it took three handkerchiefs to make the trip to examinations. We should get the pathologists in every hos¬ my office and back, a period of five hours. She showed me pital to open all the sinuses in every case that comes to post¬ a handkerchief, and it was filled with a secretion, moist and mortem, it is an operation that can be done without special of a lightish yellow color, showing that it was purulent. I equipment and it should be done as systematically as open¬ told this mother that her child had sinus disease. Where¬ ing the other chief cavities of the body. Of course, the cases upon she told me a laryngologist had sent her to me because we should like to see are those that end fatally and suddenly he had finished with the case and it was up to me to build as the result of an accident, because it will for some time up the child. This boy was a bright, normal, husky boy. be difficult to say whether the pus found in the sinuses of a He had his urine was good blood, normal and yet he had patient dying of an ordinary disease, say bronchitis, dysen¬ this What did he have? He had a persistent discharge. tery, typhoid fever or pneumonia, is merely a part of the a sinus infection without multiple infection, multiple any death process and not a primary focus. I throw that out as back of secretions. Headache damming of obscure origin is a suggestion. Sinusitis in children can be divided into those a in these cases. When a child prominent symptom has cases that are due to a focus of infection in the adenoids, and when he of he does not headache, complains pain, deceive. those where the focus is somewhere else. As to the infec¬ Pain of a child means and head¬ complained by always pain, tion which comes from somewhere else much work has been ache is a frequent symptom in the sinus cases. Another done in England to show that cases which we are apt to symptom is a persistent fever. A child has a fever that call sinusitis are really cases of of the ranges from 99 to 101. the condition has continued osteomyelitis superior Perhaps maxillary. Speaking of Sir William who for several weeks. We examine for for tuberculosis adenoids, Osier, pyelitis, has had experience in three countries—Canada, the United and other conditions that might cause a persistent slight ele¬ States and England—has given it as his opinion that there vation of temperature. Sinusitis of a mild type has to be are more adenoid children to the acre in England than any¬ considered in making a diagnosis when there is a persistent where else in the world. My experience is that a majority temperature elevation extending over a considerable period of cases of sinusitis in children, just as are a of of time. Another point that has been impressed on me in majority cases of bronchial infection and, I am almost inclined to connection with work with children is that there are various think, also a majority of cases of chronic catarrh, diseases of adults that are acquired in childhood. is gastric Pyelitis are due to infection of the adenoid mass. I do not think one. I am confident that children have sinus may disease, that every mass of adenoid tissue is the which, because of the obscure characteristic is dangerous. Quite symptoms, contrary. I am making some in an institution not recognized and is carried into adult life. investigations with which I am connected and where adenoids and septums Dr. M. New York: J. McTiernan, Several years ago I and sinuses do not come for treatment, that is, a sanitarium heard Dr. ask for some Kerley definite information as to for the tuberculous where I go once a week and examine sinus conditions in a children, and I kept record of 197 cases every patient. Many patients still possess their tonsils and referred to me for removal of tonsils and adenoids. I found septums, their adenoids are still there and are doing no an almost normal in nasopharynx eighteen cases. These harm. It is not a mechanical process in the adenoid itself had a chronic patients discharge from the nostrils, a pale that it becomes a focus of infection. That is the dugout thickened membrane and were marked mouth breathers. where the enemy entrenches itself, and we think it is easier Where sinus if a saline complications exist, solution is used and, if I may use the term, a more sporting proposition to first to wash out the nasal and then a few cavity drops of blow up that dugout than to try to drive out the enemy by epinephrin are used, often the diagnosis can be made. I poison gas. The first line of attack is the adenoid. The have seen headache and malaise in children relieved entirely only objection is that the young is apt to see the treatment of sinus conditions. laryngologist by However, all mouth a fee in an adenoid, sometimes when there is no adenoid breathers are subject to headaches. I cannot agree with Dr. there.

Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 Dr. I. W. Voorhees, New York : How does Dr. Oppen¬ nose. I have had constructed a very thin bladed speculum heimer examine these patients in his office? Children come of the Killian type which I am able to introduce into the nose accompanied by their mother and are very much afraid. If and frequently I am able to illuminate the regions that other¬ you have another child or nervous adults waiting outside and wise are not visible. The use of the nasopharyngoscope is they hear a cry or scream, it disrupts the day's work. most valuable, plus the employment of suction methods in Another point is the necessity of differentiating between a withdrawing secretions. It is not unusual, instead of find¬ foreign body and unilateral sinus disease. Just recently a ing a nose full to find no evidence of secretion ; but after the girl, 8 years of age, came to the clinic with a unilateral employment of suction methods the secretion is profuse. Sir nasal discharge. I attempted to see if there was any foreign St. Clair Thomson referred to the fact that the young laryn- body present but found none. I then examined her under gologist saw in the adenoids a fee. That is quite correct. I ether and failed to find a foreign body. She was then roent- have seen a number of children, both in private and hospital genographed and the report stated : "Left antrum filled with practice, where on inspection of the throat a large mass of pus." The child was admitted for opening of the naso- mucopus was seen dropping down from the nasopharynx. antral wall, but unfortunately the admission slip was lost We may jump to the conclusion that the child has a mass of and a tonsillectomy and an adenectomy were reported done lymphoid tissue, but the history in some cases is that the instead. The mother came back three days later and said child has been operated on already. In some instances the that four years ago the tonsils had been removed. I exam¬ secretions may come from an infected sphenoid cavity, and, ined the child and found signs of an old successful tonsillec¬ as I stated, it has been a source of surprise to me how fre¬ tomy. She still has empyema of the antrum and the mother quently we have been able to demonstrate pus coming will allow nothing to be done. directly from the posterior ethmoid cells and from .the Dr. G. W. McKenzie, Philadelphia : I understood Dr. sphenoid cavity, and in several cases we have been able to Oppenheimer to say that the sinus contained no mucous show it coming from the ostium of the sphenoid cavity. Any glands. I question that, because I have done a lot of study- excessive temperature elevation in a child should always call on that and my impression is that the sinuses do contain attention to the nasal accessory sinuses. mucous glands, and that there are mucus secreting cells. Dr. Kerley asked what is the symptom complex of chronic Dr. Lee W. Dean, Iowa City, Iowa : In connection with sinusitis. I might reply to that by saying, the intranasal disease of the nasal sinuses in children, it seems to me there finding of purulent discharge. The other general systemic is one thing that is axiomatic, and that is the point made by manifestations, such as aching, temperature elevation and a Sir St. Clair Thomson, that the first treatment of sinus dis¬ general lack of well being must be considered, but a good ease in children or infants is the eradication of the diseased diagnosis is practically established by finding a mucopurulent adenoid tissue in the nasopharynx, which is usually the source discharge from the nose. It must be borne in mind that a of infection. We have now a series of from 75 to 100 cases mucopurulent discharge from the nose does not come from of sinus disease in infants and children under 12 years of the nasal mucosa per se, but that every child recovering from age, where four out of five have been completely cured, so scarlet fever or measles has evidence of a mucopurulent dis¬ far as the nasal sinus disease is concerned, by the removal of charge from the nose and that is coming from the nasal the diseased adenoid tissue in the nasopharynx. The inves¬ accessory cavities. tigation was made in this way. These patients were exam¬ ined, a diagnosis was made, and then the diseased adenoid tissue was removed. No other treatment was given. The THE ANALYSIS OF HUMAN MILK patients left our service and in four or five weeks came again for examination. We found that four out of five of TECHNIC OF OBTAINING SAMPLES AND these young children were well, so far as the nasal sinus INTERPRETATION OF RESULTS disease was concerned. When we found that the fifth child did not get well, we resorted to other measures. Investigat¬ FRITZ B. TALBOT, M.D. ing the bacteriology of our sinus cases in infants and young BOSTON children, we found that in eleven out of twelve cases in The which there was an arthritis the hemolytic streptococcus was increased interest in breast feeding, which has been the of in the sinus, while in those cases in which there was no result recent articles both by pediatricians marked systemic lesion the hemolytic streptococcus was and by those interested in public health, has the again found in only 4 or 6 per cent, of the cases. In twelve turned the attention of clinicians to the chemical com- cases with tonsils arthritis, the and adenoids had been position of human milk. It is in place at this time, removed months before the cases were investigated. Follow¬ therefore, to draw attention to mistakes which may ing treatment of the sinuses which were affected marked be made in the for chemical of the arthritis resulted in case. obtaining specimens analy- improvement every sis, the method of and the of Dr. Seymour Oppenheimer, New York: In a paper read analysis, interpretation in New York Dr. Dean brought out particularly the rela¬ reports sent by the chemist. Human milk has often been sent to tionship of accessory sinus disease to general systemic mani¬ the chemical laboratory for analysis when festations. It has been his experience, as well as my own, a baby is sick, and a report returned giving the per- that in any number of cases that have been referred to us centage of fat, lactose and protein. In many instances from the pediatrie department or from the general practi¬ the practitioner has not been sufficiently familiar with tioner for determination of where the focus was which was the normal composition of human milk, and its varia- causing the arthritis or other manifestation, that by very tions under normal conditions, to interpret from the careful observation we were able to localize and cure the results of the examination whether the milk is abnor- manifestation after having determined that the focus systemic mal or not; and because of this babies was in the nasal cavities. Dr. Dean called atten¬ ignorance many accessory have been tion to the fact that in some instances it is not necessary to deprived of their mother's milk when the attack these cavities surgically; however, the simple removal milk has been normal. It should be a rule, therefore, of a mass of lymphoid tissue may be sufficient to allow the that an infant should not be weaned because of the proper drainage. I also want to refer to a method mentioned analysis of the milk until it has been proved, first, in the chairman's paper, that is, the investigation of these that the milk is harmful to the infant, and secondly, cases while the child is under anesthesia when it is being that its composition is abnormal. The composition operated on for diseased adenoids and tonsils. That is the cannot be said to be abnormal until it is found to be time to puncture the antrum and irrigate it. Dr. Voorhees spoke of the difficulty of examination. I grant that it is From the Children's Medical Department of the Massachusetts extremely difficult in children, but there are methods which General Hospital. Read before the Section on Diseases of Children at the Seventieth be First of all we must estimate can employed. something Annual Session of the American Medical Association, Atlantic City, as to the general appearance of the mucous membrane of the N. J., June. 1919.

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