Catheterizing the Maxillary SinusFig. 320. Catheterizing the Maxillary Sinus.
Indications.It is chiefly employed as a diagnostic test. As a curative measure it is seldom successful except in comparatively recent infection. If the case be uncomplicated by suppuration in other cavities, if the teeth in the upper jaw on the same side be intact, and if the patient be anxious to avoid more severe measures and be willing to undergo the discomfort of a daily puncture, lavage has been reported as successful when repeated 27 times, even in a case with a history of 17 years’ duration.67Butunder the circumstances just mentioned it is wiser to recommend the establishment of an antro-nasal communication (seep. 637).
Lichtwitz’s and Moritz Schmidt’s Antrum NeedlesFig. 321. Lichtwitz’s and Moritz Schmidt’s Antrum Needles.
Operation.This is done under local anæsthesia from the inferior meatus. One pledget of cotton-wool, soaked in cocaine and adrenalin, is carefully tucked under the inferior turbinal on the affected side, and another is applied to the septum. At the end of 20 minutes a straight Lichtwitz’s or curved Moritz Schmidt’s (Fig. 321) hollow needle is passed under the inferior turbinal and introduced upwards and outwards as near as possible to the centre of its attachment. The handle of the needle is tilted against the cartilaginous septum, while the point is directed towards the malar eminence. When it is felt to encounter the thin, membranous part of the antro-nasal wall it is easily thrust through (Fig. 322).
Puncturing the Maxillary SinusFig. 322. Puncturing the Maxillary Sinus.The dotted part represents the portion of the exploring needle which passes under cover of the inferior turbinal.
While the nasal cavity is kept under inspection, air is blown throughthe needle, and any secretion can be observed escaping from under the centre of the middle turbinal. This douche of air is then followed by an irrigation of warm normal saline solution. In an acute case this lavage can be repeated daily until the symptoms of tension are relieved, or until the secretion begins to escape spontaneously.68
Puncturing the maxillary sinus from the middle meatus incurs a greater risk of striking the orbit and is not so likely to reveal a small amount of thick secretion on the floor of the cavity.
This is one of the oldest methods of drainage. It is less frequently employed nowadays, partly because carious teeth and empty sockets are not so commonly met with, and partly because the results have not proved very satisfactory.
Indications.The operation is useful as a diagnostic or palliative measure. In cases of unilateral multi-sinusitis, if a suitable tooth socket be available, the alveolar operation serves both to determine the condition of the maxillary sinus and to establish drainage, while the other cavities are being investigated or treated. In patients who are too old or feeble toendure more radical measures, or who decline them, the obturator may be left in indefinitely. In that case, if the neighbouring teeth be intact, a solid gold plug should be fitted to the denture bearing the false first molar. During the night this is exchanged for the soft rubber plug. If several teeth be missing it is more comfortable to have the obturator and denture separate—the latter being made with a setting to receive the flange.
An anæsthetic should always be given. Nitrous oxide gas or chloride of ethyl are generally recommended for this short operation, but in cases that present any difficulty it is better to follow the nitrous oxide with ether, or the chloride of ethyl with chloroform.
Antrum DrillsFig. 323. Antrum Drills.
Solid Rubber ObturatorsFig. 324. Solid Rubber Obturators.Used in alveolar drainage of the maxillary sinus.
Antrum NozzleFig. 325. Antrum Nozzle.
Operation.The most suitable tooth socket is that of the first molar, but if this be not available, that of the second bicuspid or second molar may be employed. If a tooth in one of those situations be carious, or be suspected as the cause of the sinusitis, its extraction and the drilling of the alveolus may be carried out under the same anæsthetic. The patient can be recumbent on an operating table, or lying back in a dentist’s chair. A small antrum drill (Fig. 323) is grasped in the hand as a bradawl is held, with the forefinger lying along it to within 1 to 1½ inches from the end, where it acts as a stop to prevent the instrument from plunging too deeply into the sinus. The drill is held vertically against the alveolar border, and with a few quick, rotatory thrusts is pushed into the cavity. The inner of the tooth sockets is selected. If required, the hole can be enlarged by a similar instrument of a larger bore. A plug, which fits firmly into the opening, is introduced, and nothing further is required for that day. A solid vulcanite obturator is recommended. It should be leftin situfor two or three days, when it is removed to allow of the cavity being syringed through, and is then replaced by a solid, soft rubber plug, of a somewhat smaller diameter (Fig. 324). The vulcanite obturator is better for establishing the canal; if removed too soon it may be difficult to replace it, and manipulation may set up severe neuralgia. A small size—No. 6 or 7—is quite sufficient.
Washing out the Maxillary Sinus from an Alveolar OpeningFig. 326. Washing out the Maxillary Sinus from an Alveolar Opening.
At the end of two or three days lavage of the cavity is gradually instituted. A pint of warm sterile normal saline solution is sent through the cavity by a Higginson’s syringe, fitted with a suitable nozzle (Fig. 325). As the stream issues from the nose it is received in a black vulcanite tray, which readily demonstrates the colour, quality, and quantity of antral secretion (Fig. 326). When the pint of liquid is finished, air is blown through, so as to leave the sinus as dry as possible. The patient should be advised to replace the rubber obturator, properly cleaned and purified, as soon as possible. If this be neglected—for even as short a time as 5 minutes—the soft tissues may obstruct the channel so as to render the reintroduction painful and perhaps impossible. Another useful warning is not to wear a plug so long as to allow of the flanges being worn away, and so risk the penetration of the rubber tube into the cavity.
The syringing should at first be daily, even twice a day if necessary, and then gradually diminished in frequency, until after the lapse of a week it is found that the maxillary sinus is quite free of any pus or flocculent mucus. By changing the obturator daily the patient can readily tell whether a washing out is required. When three to six months have passed without any trace of secretion, the empyema may be considered cured. This is the more likely if a formerly obscure sinus becomes translucent, and if the patient passes through a ‘cold’ without suppuration beginning in it again. A trifling amount of discharge is sometimes kept up by the mere presence of the obturator.
If the saline solution fails to arrest the discharge permanently, I have rarely found that any other lotion is more effective. Strong antiseptic solutions are too irritating; milder ones, like boric lotion, permanganate of potash, weak mercurial lotions, &c., are without effect. If the discharge remain thick and offensive, peroxide of hydrogen may be added to the salt solution in the proportion of 2 vols. %. As an astringent, sulphate or chloride of zinc may be tried, in the proportion of 1 grain to the ounce; or the cavity may occasionally be washed out with a 2% solution of argyrol or nitrate of silver.
In cases where a cure has been obtained, the obturator is first discontinued during the night and is then exchanged for one of smaller size. The opening in nearly all cases will close spontaneously. Occasionally the track may be stimulated with nitrate of silver, pure carbolic acid, or a small curette.
Results.This method of treatment is only curative in uncomplicated cases limited strictly to the maxillary sinus. If all suppuration has not disappeared before the end of three months, a complete cure is not to be expected by persevering longer.
Desault’s operation.Previously to the introduction of the Caldwell-Luc operation it was customary to make an opening into the maxillary sinus from the canine fossa, and to curette, drain, pack, and carry out all subsequent treatment through the buccal orifice. The reinfection of the cavity from the mouth was, of course, inevitable: the treatment was prolonged and unpleasant: and the results were so unsatisfactory that the method has now been abandoned in favour of one or other of the operations to be described.
Indications.This is the favourite operation in well-marked chronic empyema of the antrum.
The mouth, teeth, and gums are purified as thoroughly as possible. The face, with any moustache or beard, should also be well cleansed. The nose on the affected side is prepared with cocaine and adrenalin (seep. 572).
On the Continent this operation is sometimes carried out under local anæsthesia, but chloroform is generally employed. When the patient is unconscious, a sponge is packed in the post-nasal space (seep. 575), the tongue is drawn forward with a tongue clip (Fig. 314), and the chloroform administered from a Junker’s apparatus.
Operation.The surgeon, armed as usual with a forehead electric search-light or Clar’s mirror (Figs. 282,283), stands on the affected side.In addition to the post-nasal sponge, another is inserted far back between the molars on the side to be operated. This cheek sponge prevents any blood from running down into the pharynx and requires changing frequently.
The cheek being well retracted by an assistant, an incision is made half a centimetre below the gingivo-labial fold, extending from the first molar to the canine tooth (Fig. 327). It is carried down to the bone, so that the muco-periosteum can quickly be separated upwards, exposing the canine fossa. With hammer and chisel a circular piece of the wall is then cut through, measuring about half an inch across, and the opening is enlarged with bone-forceps or burr sufficiently to admit the surgeon’s little finger.
The Incision in the Caldwell-Luc Operation upon the Maxillary SinusFig. 327. The Incision in the Caldwell-Luc Operation upon the Maxillary Sinus.
The Caldwell-Luc Operation upon the Maxillary SinusFig. 328. The Caldwell-Luc Operation upon the Maxillary Sinus.Breaking through the antro-nasal wall below the level of attachment of the inferior turbinal. The opening has been purposely represented coming too far forward in order to include the view of the antro-nasal wall.
The first opening of the sinus is frequently accompanied by free bleeding. This soon ceases, particularly if the cavity is packed for a little while with a strip of 2-inch ribbon gauze. During the operation, pieces of this gauze, 1 to 1½ yards long, prove very useful in checking any oozing and allowing a clear inspection of the walls of the sinus. They may be dipped in adrenalin, or, if the bleeding is sharp, in a 10% solution of peroxide of hydrogen, and left in place for a few minutes, while iced water is freely applied to the face and neck. As soon as the bony wall has been removed, the diseased mucousmembrane presents in the opening in irregular, polypoid, bluish-greyish masses, bathed in pus which may be highly fœtid. The diseased mucous membrane should be carefully plucked out of the cavity with a pair of Grünwald’s forceps, supplemented by the use of a small ring curette, and guided by the eye and the touch of the operator’s little finger. Some surgeons recommend that the whole mucous lining of the sinus be carefully and completely removed, and the walls scraped down until they are white and bare. Unless the whole mucosa is diseased, this hardly seems necessary, particularly if a free opening be made into the nose. Polypoid masses and degenerate mucous membrane are chiefly met with on the floor of the antrum (in the crevices between the cusps of the teeth), on the inner wall in the neighbourhood of the ethmoid, and in the recess in the malar region, and it is to these areas that attention should be directed.
Opening the Maxillary Sinus from the NoseFig. 329. Opening the Maxillary Sinus from the Nose.This is done with a Krause’s trochar and canula, after removal of the anterior end of the inferior turbinal.
The next step is the making of a free communication with the nose. If the inferior turbinal is hypertrophied on the affected side, or comes so low as to obstruct any access to the antro-nasal wall, its anterior extremity should first be removed (seep. 587andFig. 289). It is better to have done this a few weeks previously under cocaine. The antro-nasal wall lying below the attachment of the inferior turbinal is next attacked with a chisel, hammer, and punch-forceps (Fig. 330). This can be done from the antral aspect, but I have always found it useful to break it through first from the nose with Krause’s curved trochar and canula. When the end of this makes its appearance in the sinus, it forms a useful landmark (Fig. 329).
This antro-nasal opening should be made as large as possible, particular care being taken to bring it well forward and to smooth down the remainsof the ridge separating the nose from the sinus. The opening should allow of the surgeon’s little finger passing freely from the antrum into the floor of the nose, andvice versa(Fig. 328).
Carwardine’s Punch-forcepsFig. 330. Carwardine’s Punch-forceps.Used in breaking down the lower antro-nasal wall.
Whenever the ethmoid is diseased, as it often is in maxillary sinusitis, that part of it which bounds the inner antral walls should be punched away. The middle turbinal, in that case, will probably have been already removed.
The Opening into the Maxillary Sinus from the Inferior Meatus of the NoseFig. 331. The Opening into the Maxillary Sinus from the Inferior Meatus of the Nose.The anterior extremity of the inferior turbinal has been amputated. The opening can be extended backwards, level with the floor of the nose, and under cover of the inferior turbinal.
Some surgeons recommend that the infected corners of the antrum be now wiped out with a solution of chloride of zinc(40 grains to℥j), and the cavity packed with a strip of gauze which is led out through the nostril, whence it is removed at the end of 24 to 48 hours. The use of this irritant seems inadvisable. The sinus may be syringed out with warm saline solution, and temporarily packed with a long strip of iodoform gauze, while the operation is being completed. The wound in the cheek can be closed with a couple of catgut sutures; but if there has been no destruction of the bony alveolus, this is unnecessary: the soft parts will fall into natural and complete apposition. The post-nasal sponge is removed, the iodoform ribbon gauze is withdrawn through the nostril, and the patient is put back to bed with the affected side uppermost.
After-treatment.A large pad of cotton-wool, bound firmly to the cheek over the region of the canine fossa, will relieve pain and help to keep the edges of the wound together. Nourishment should be fluid forthe first three days, and taken from a feeding-cup from the opposite corner of the mouth. As a rule, there is no reaction, and the temperature seldom rises above 100° F. A little puffiness below the orbit will soon subside, and pain is relieved by a few doses of phenacetin, aspirin, pyramidon, or some similar anti-neuralgic. The patient is frequently up and out in a few days.
As a rule, the less the local after-treatment the better. The nose may require to be cleansed with the usual alkaline lotion (seep. 579). If secretion hangs about the antro-nasal opening, or collects in the cavity, the latter should be washed out once or twice daily until it ceases. A short length (4½ in.), but large bore, silver Eustachian catheter is passed from the nose into the maxillary sinus, and a pint of warm saline solution is sent through it with a Higginson’s syringe. The patient soon learns to do this for himself, and it may have to be continued for a few weeks. If the discharge persists, the cavity may be painted over with a solution of nitrate of silver, or a strip of ribbon gauze can be moistened with argyrol solution (25%) and passed through the antro-nasal opening into the sinus, where it is left for a few hours.
Results.In cases of chronic empyema of the maxillary sinus this operation is very successful. Failure may be due to overlooking stumps of teeth within the cavity, and from leaving detached pieces of the carious wall within it. If the pyogenic polypoid mucous membrane be not carefully removed, suppuration may persist. The corner which is difficult to reach is the acute anterior one. At the same time, an unnecessary denudation of the cavity will delay healing, and the scar tissuewhich more or less occupies the sinus will then tend to be irregular and dry, instead of being smooth and moist. Removal of too much of the inferior turbinal is apt to induce a scabby condition.
But persistence of nasal suppuration after this operation is generally found to be due to overlooked disease in some other sinus. The ethmoid is so frequently affected that it should always be carefully explored, and treated either before or at the time of the operation upon the maxillary sinus. Any suspicious-looking cells can be cleared away under cocaine during convalescence. Suppuration in the frontal sinus will have generally been excluded beforehand. It is perhaps more common for reinfection from the sphenoidal sinus to be overlooked.
Dangers.Operation upon this sinus is generally regarded as quite free from the risk of cerebral infection. This undeniably is so, when the antral empyema is uncomplicated by suppuration in other cavities, but the operation is not free from risk if they are also infected. An operation upon one maxillary sinus has been known, even in the most skilful hands, to cause death by meningitis or diffuse septic osteomyelitis of the cranium.Post-mortemexaminations show that this disaster was due to infection spreading upwards from an infected ethmoid, frontal, or sphenoidal sinus, when local resistance had been diminished, or the virulence of the organisms has been increased by the surgical traumatism of the maxillary sinus.
Such risks are best avoided by determining the condition of all the sinuses before commencing treatment of nasal suppuration. If a tooth socket be available, the maxillary sinus should first be drained through it, so as to diminish the septic intensity of the affection. The ethmoid region, if diseased, is next treated (seep. 615). The sphenoidal orifice should be enlarged if that cavity be diseased, and the frontal sinus, if suppurating, should be operated on before the maxillary. If no tooth socket be available, both frontal and maxillary sinuses can be operated upon at the same sitting. Plugs are best avoided; communication should be made as free as possible; stitches need not be employed; and everything should be done to avoid retention and secure free drainage.
Denker’s OperationFig. 332. Denker’s Operation.This is an operation for gaining access to the maxillary antrum and the lower part of the nasal cavity on the same side. The incision through the mucous membrane, and the steps of the operation, are a combination of the operations of Rouge and Caldwell-Luc.
Modification.In the above operation the region which generally requires to be denuded of mucous membrane is the rough floor—the irregular surface lying over the cusps of the teeth. The ridge of the antro-nasal opening is a situation in which secretion is apt to lodge and dry into scabs. To overcome this drawback it has been suggested by Bönninghaus that the muco-perichondrium of the outer part of the nasal floor and the interior surface of the antro-nasal wall should be carefully preserved in the form of a flap which is then laid down over this bare area, and fixed there by a stitch and packing.
Another drawback of the Caldwell-Luc operation is that, although inspection and treatment of the greater part of the maxillary sinus is secured, still there are two corners which are not well exposed. They are both on the floor of the antrum, the round posterior corner and the narrow acute corner in front. The antro-nasal wall corresponding to these two situations is not removed, and hence the corners are apt to escape inspection at the time of the operation and free drainage afterwards.
To avoid this Denker has proposed that the opening in the canine fossa should be carried forward into the nose, and the opening in the antro-nasal wall extended forwards to meet it. This allows of much more complete inspection and treatment of the sinus cavity, and abolishes the anterior angle. The flap of muco-perichondrium proposed by Bönninghaus can also be much more easily manipulated. It is said that there is no fear of disfigurement from the cheek falling in (Fig. 332).
It was long ago proposed by John Hunter, and later by Mikulicz and Krause, that an opening should be made into the maxillary sinus from the nose. This operation has latterly been developed by Claoué and Réthi, and now has many supporters.
Operation.On the Continent it is frequently carried out underlocal anæsthesia, but chloroform is generally required. If the inferior turbinal comes down close to the floor of the nose, the anterior third or half should be removed (seep. 587andFig. 289). The antro-nasal wall lying below the attachment of the inferior turbinal is then broken through with chisel and hammer, or a Krause’s trochar (Fig. 285), and the opening enlarged with punch-forceps (Fig. 286). For the anterior margin of the opening—the one most difficult to remove—special forceps which cut forwards have been designed (Fig. 330).
The opening is large enough to allow the introduction of curettes and of the application of treatment from the nose. The patient soon learns to wash out the sinus for himself, with a silver Eustachian catheter and Higginson’s syringe, as after the Caldwell-Luc operation.
Results.The advantages claimed for this operation are that it is simple, quicker, and as effective as the one with the opening from the canine fossa. But, of course, it does not allow any inspection, and only a partial removal, of the diseased contents of the sinus.
Still the results obtained are so satisfactory,69that it seems advisable to try it in the majority of cases as a necessary first step, even if the Caldwell-Luc operation has to be completed later. But where the case has a long history; marked obscurity on transillumination; a foreign body in the sinus; or where theStreptococcus pyogenesis the virulent organism, or where the streptococcus is associated with the presence of squamous epithelium and lymphocytes,70it adds little to the gravity or complexity of the procedure if the canine fossa be opened at the same time, the diseased cavity inspected, and everything completed under the one anæsthesia.
Catheterizing the Frontal SinusFig. 333. Catheterizing the Frontal Sinus.The anterior end of the middle turbinal has been removed.
Indications.This method is indicated—
(i) As a first step in diagnosis and treatment.
(ii) To diminish the risk of retention and decrease virulence in those patients where an external operation is not indicated or is declined.
(iii) It is rarely required for acute frontal sinusitis, although it might be used in acute exacerbation of a chronic suppuration.
Operation.It is very seldom that it is possible to sound a frontal sinus, unless the anterior ethmoidal cells have been broken down bydisease. When this has occurred—or when the anterior extremity of the middle turbinal has been removed, as described onp. 592—the anterior region of the middle meatus is well anæsthetized. Under good illumination a thin silver canula is then introduced until it reaches the middle meatus with its beak lying below and in front of the bulla ethmoidalis. By depressing the hand the point of the instrument is then directed upwards, forwards, and slightly outwards, until it slips into the frontal cavity (Fig. 333). No force should be employed. The end of the catheter is bent to suit the conditions met with. A bead of pus exuding from the hiatus semilunaris will often serve as a useful guide. If there be any uncertainty as to the catheter having entered the frontal sinus, its exact situation can be determined by the Röntgen rays (Figs. 334, 335).
Radiograph to show the Value of the Röntgen RaysFig. 334. Radiograph to show the Value of the Röntgen Rays.The canula might be thought to have entered the frontal sinus, whereas the X-rays show that its point has only penetrated an ethmoidal cell. Compare with the following figure.
Radiograph showing Canula in the Frontal SinusFig. 335. Radiograph showing Canula in the Frontal Sinus.
A Politzer’s inflation bag is now connected with the end of the frontal canula, and air is blown through it. This will be heard gurgling through the sinus, and if the anterior region of the middle meatus is at the same time kept under observation, thick mucus or pus will be seen to be driven out by it. The Politzer’s bag is then replaced by a syringe, and a pint of warm sterile normal saline solution(ʒj to Oj)is sent into the sinus, and as it returns is received in a black vulcanite tray. The latter readily shows up the presence of any flakes of mucus or pellets of pus. If successful, the above proceeding can be repeated twice daily.
When the cavity can be catheterized from the nose it should be washed out daily with liquids similar to those indicated for suppuration in the maxillary antrum (seep. 630).
Results.I am very doubtful if a permanent cure is ever effected by this treatment in a case of established chronic suppuration. In a case in which I was certain that the suppuration was not of more than fourmonths’ duration intranasal treatment was a failure, although carried out most carefully on 44 successive days.71
The cause is very apparent whenever these sinuses come to be opened; the cavity itself is generally stuffed with fungating mucosa, and the fronto-ethmoidal cells—where the lavage never penetrates—are affected in the same way.
It is rare for this to be necessary. The contents of the cavity generally make their way through the natural ostium, before any of the bony walls give way. Still, the posterior (cerebral) wall may yield, giving rise to meningitis or cerebral abscess. The treatment of this complication is given onp. 650. The orbital wall may be penetrated, with the formation of an orbital abscess which should be evacuated. It is most uncommon of all for the anterior wall to give way. When this does occur the abscess should be opened through an incision designed on the principle given later on for chronic empyema (seep. 652).
At the present time the Killian operation is the one most generally employed.
Indications.The indications for this operation are thus given by Killian himself:—
1. Failure of other operations.
2. Presence of fistula or abscess, or indications of necrosis.
3. Symptoms of intracranial complications.
4. When in a case of chronic purulent frontal sinusitis there is pain and fever with a fœtid discharge.
5. Persistent headache, particularly when associated with discomfort in the region of the eye, and not relieved by intranasal treatment.
6. When the discharge from the sinus remains foul, in spite of repeated irrigations.
7. When recurring groups of polypi are produced by the suppuration in the frontal and ethmoidal cells.
8. When a simple purulent discharge is not relieved by careful intranasal treatment, and the patient desires permanent relief by radical operation.
A radiograph is taken and is an extremely useful help to indicate the size and extent of the frontal sinus, and to prepare the surgeon for meeting with troublesome orbito-ethmoidal cells.
As the ethmoid is diseased in nearly all cases it should be cleared away at previous sittings, under cocaine or chloroform (seep. 615). Even when healthy, the anterior extremity of the middle turbinal should be amputated (seep. 592). If the antrum be also suppuratingand a suitable tooth socket be available, the alveolus will have been drilled at one of these preliminary treatments. If the sphenoidal sinus be suppurating, its orifice will have been enlarged.
One hour before the operation the strips of ribbon gauze, soaked in adrenalin with the addition of 5% cocaine, are carefully laid all over the mucous membrane of the nose on the affected side. The face, moustache, and beard are well purified. When the patient is under chloroform three pencils of tightly rolled cotton-wool are introduced into the nose; one along the middle meatus, a second in front of the inferior turbinal upwards towards the bridge of the nose, and the third in the inferior meatus. The first two pledgets are useful afterwards for anatomical definition, and the third keeps them in place. A sponge is inserted in the post-nasal space (seep. 575).
Operation.There is no advantage in shaving off the eyebrow. It can be thoroughly purified and helps to locate the skin incision; if removed, it takes some time to grow again, and is apt not to correspond in size with the eyebrow of the opposite side. The skin incision is first defined by scratching through the cutis with the tip of the knife. It starts at the outer end of the eyebrow, passes inwards along the very centre of the eyebrow itself, and then sweeps downwards and outwards over the side of the nose, to end on the cheek (Fig. 336). When the wholeextent has been marked out three or four cross scratches are made. The object of this is to ensure correct coaptation of the flaps, and to avoid any risk of disfigurement. Returning to the outer extremity of the incision, it is now carried down through all the soft tissues till it meets the periosteum. The flaps are retracted a little upwards and downwards, while the free hæmorrhage is met with pressure forceps. The periosteum incisions are now carefully planned. Starting again from the outer corner the knife is drawn inwards parallel to, and slightly above, the upper margin of the supra-orbital arch; but, instead of curving round the inner end of the orbit, in the track of the skin incision, it is kept straight along under the upper flap to end over the glabella. The periosteum can now be reflected from the front of the sinus, and pushed upwards with the skin on to the forehead. The lower skin flap is detached and retracted downwards, until the inner third of the supra-orbital arch is defined. The periosteal covering is next cut through by carrying the knife along the lower border, but instead of passing inwards parallel to the first periosteal incision this second one sweeps down on to the side of the nose, in the track formed by the skin incision (Fig. 337).
Killian’s Operation upon the Frontal SinusFig. 336. Killian’s Operation upon the Frontal Sinus.Shows the skin incision, with the transverse scratches made to ensure correct coaptation of the flaps.
Killian’s Operation upon the Frontal SinusFig. 337. Killian’s Operation upon the Frontal Sinus.The thick lines indicate the incisions through the periosteum.
The periosteum is carefully peeled off the nasal process of the superior maxilla, and turned down from the inner third of the supra-orbital arch,exposing a triangular area of bone. The periosteum must be carefully preserved over the inner part, to avoid the risk of necrosis of the arch, which is converted into a bridge, the ‘Killian bridge’, by the opening in bone below and above it.
Periosteal ElevatorsFig. 338. Periosteal Elevators.
Killian’s Triangular Curved ChiselFig. 339. Killian’s Triangular Curved Chisel.
The upper flap of soft parts, with the periosteum, is well retracted up on to the forehead. The radiograph will have given an idea of the extent to which the front wall of the sinus must be laid bare. With a chisel and hammer the sinus is opened at its inner extremity. A good plan is to employ Killian’s triangular curved chisel (Fig. 339) and to cut a trench in the bone along the upper margin of the bridge. This trench is gradually deepened at the inner end until the sinus is entered. The entry is generally announced by the bulging upwards of the blue, polypoid, pyogenic membrane into which the thin white delicate mucosa of the cavity has been converted. The anterior wall is now completely removed with hammer, chisel, and forceps. Those of Lombard, Horsley, Hajek (Fig. 341), Jansen, Citelli (Fig. 340), or similar models enable us to bevel down the margins of the cavity carefully as it slopes up on to the forehead.
Citelli’s Bone-forcepsFig. 340. Citelli’s Bone-forceps.
Hajek’s Bone-forcepsFig. 341. Hajek’s Bone-forceps.
The pyogenic membrane is now carefully plucked away with a pair of Grünwald’s forceps. I never find it necessary to curette the cavity, which must always be a risky proceeding. Small pledgets of ribbon gauze, if gently rubbed along the surface and into the corners, will detach every scrap of diseased mucosa.
The septum separating the two frontal sinuses may be found to be defective. The opening through the eyebrow on one side may open into a cavity which communicates only with the nasal cavity of the opposite side—one sinus being very large and extending far beyond the middle line, while the other is quite small. Or only one frontal cavity may be present. An extensive acquaintance with the surgical anatomy of the region is required to prepare the surgeon for encountering these andother irregularities, and the systematic use of radiography will prevent him from being taken by surprise.
Killian’s Operation upon the Frontal SinusFig. 342. Killian’s Operation upon the Frontal Sinus.The periosteum has been preserved on the bridge. Above this the frontal sinus is exposed: at its inner (nasal) extremity the frontal bulla is indicated, mounting up into the cavity; at the outer extremity an arrow indicates the orifice of a fronto-orbital cell which should be opened up. The periosteum lying above the bridge has been retracted up with the soft parts on to the forehead. Below the bridge is the opening to the ethmoidal region. The curved retractor is protecting the eyeball.
The next step is to make the opening below the bridge. The exposed surface of the nasal process of the superior maxilla is cut through with the triangular chisel. The opening is enlarged with bone-forceps until free access is obtained to the anterior ethmoidal cells. The pledgets of cotton-wool placed in the nose at the beginning of the operation now come in to help as guides. The periosteum is further elevated from the lachrymal bone above its groove, from the orbital plate of the ethmoid as far back as the anterior ethmoidal vessels, and from the orbital plate of the frontal bone below the bridge and extending outwards to the trochlear attachment and the supra-orbital notch. During this proceeding the contents of the orbit are protected from pressure by several folds of gauze, and are carefully retracted outwards by Killian’s protector. The area of bone which cannow be clipped away comprises parts of the lachrymal, of the lamina papyracea, and of the floor of the frontal sinus. The whole of the floor of the sinus must be removed, either from above the bridge or from below. If this cannot be done without anxiety as regards the attachment of the pulley of the superior oblique, it is better to risk this than to leave pus-secreting pockets of orbito-ethmoidal cells cut off from drainage in the roof of the orbit. But the pulley of the superior oblique should never be divided from its attachment to the rim of the orbit. It is much safer to reflect the periosteum further outwards and downwards from the lower border of the Killian bridge. In doing this the pulley of the superior oblique is detached with it; any diplopia, most noticeable on looking downwards and outwards, is generally temporary; and asa rule it will disappear when the swelling subsides and the periosteum gets back to its anchorage (Fig. 342).
It is this part of the operation which is the most delicate, tedious, and important. It is very common to meet with irregularities. The orbital recess of the frontal sinus itself may run back in the roof of the orbit nearly as far as the foramen opticum. One or two galleries may be met with in the roof of the orbit—prolongations of orbito-ethmoidal cells—passing outwards as far as the temporal end of the eyebrow. Their presence can only be revealed after removal of the floor of the frontal sinus proper, and in this way two or three bony dissepiments may have to be removed before the orbital fat arises, as it should do, to occupy the lower part of the exposed frontal sinus. In this part of the operation much help is obtained by the careful use of a probe, by frequently securing a field free from bleeding by pressure with adrenalin or peroxide, and by the knowledge previously gained by skiagraphy.
If the Röntgen rays have shown that the frontal sinus does not extend above the level of the bridge, or if radiography be not available and there is any uncertainty as to the extent of the cavity, this lower opening should be made first.
In the inner part of the large orifice which has been made below the bridge the deeper ethmoid cells can be treated, and the sphenoidal ostium is much nearer than when viewed from the introitus narium, so that it is easy to enlarge it and deal with the contents.
Now, as throughout the operation, great care must be taken to shield the eyeball with gauze pads and the protector. The hanging pressure forceps are apt to be pushed against the globe.
The whole area of operation is next carefully cleaned with warm normal saline solution. Any projecting corners or loose spicules of bone are removed. If any point of pus should show up it must be carefully followed to its source. The cotton-wool pledgets are removed from the nose. The pressure forceps are twisted off, and any vessels that require it are ligatured. A strip of ribbon gauze is loosely packed in the lower part of the enlarged fronto-ethmoidal space, and the end is led down to the nasal orifice. The flaps are brought together, and care is taken that the reflected periosteum is pulled back with them. Formerly Killian in the majority of cases used to sew up the whole wound at once. He now agrees that it is safer to leave the external angle with a small drainage tube running inwards and downwards to the area of the fronto-ethmoidal cells. The inner part of the incision in the eyebrow, and all the part lying below the bridge, can be closed. Killian employs aluminium-bronze wire, and a metal suture seems preferable, as the contamination of the wound edges makes stitch-abscess not uncommon.
Secondary suture—on the second or third day—is reserved by Killian for cases when (1) the history or appearance of the mucosa indicates a recent exacerbation, (2) there is a history of erysipelas, (3) the pus is very fœtid, (4) there is any history of a tendency to wound complications, or (5) there is marked invasion of the diploë in the frontal bone.
Double cyanide gauze, rung out of boric lotion and covered with a good supporting pad of cotton-wool, is then put on. But when there is any question of intracranial complication, when the pus is fœtid or there is any necrosis, and when the surgeon is forced to operate during an acute exacerbation, it is better to apply warm boric fomentations and leave the upper and outer supra-orbital part of the incision freely open.
After-treatment.The patient is put to bed on the sound side, so as to assist drainage. He is advised not to blow the nose, but to hawk as much of the secretion as possible backwards and then expectorate it. The gauze drain is removed from the nose at the end of twenty-four hours, and is not renewed. The drainage tube at the temporal end of the incision is changed at the end of forty-eight hours, and afterwards is removed and cleansed daily. The dressing is also changed daily, after the first forty-eight hours, so as to keep a careful watch for any retention. On the fifth day the sutures can be removed, and soon afterwards the dressing can be discontinued and the eye left uncovered. Intranasal treatment should be avoided for a while. But after two or three weeks the granulating surface behind the bridge is painted occasionally with a 2 to 3% solution of nitrate of silver. Any crusts are removed after soaking with peroxide of hydrogen.
Complications and dangers.The operation is not free from danger. Latent cerebral trouble connected with the sinus may be roused into activity by the local traumatism, however skilfully effected. The shock, or the lowered local resistance, may stimulate a latent infection in neighbouring sinuses, and also weaken the lines of defence protecting the cranial cavity.
In 1905 Logan Turner collected the record of twenty-four deaths which had occurred after operation on the frontal sinus.72This number has been exceeded by the fatalities since published and the much greater number which have never been recorded.73The chief dangers are (1) a spreading septic osteomyelitis, (2) meningitis, and (3) abscess in the frontal cerebral lobe.
Infection of the boneis indicated chiefly by a puffy, tender swelling on the forehead or temple, adjoining the upper flap. There may belittle or no rise of temperature, and little complaint on the part of the patient. But no time should be lost in laying the wound freely open, searching for any shut-off focus of pus, and applying hot boric fomentations diligently. Once infection is established in the bone it may be impossible to stay its progress, even by the most thorough removal of diseased tissue: but the effort should be made.74
Meningitisis an equally dangerous complication. It may arise without direct injury to the cerebral wall of the sinus. If, during removal, the anterior end of the middle turbinal be damaged too high up, the lymph channels around the olfactory nerve may be opened so freely that infection spreads along them to the meninges. Or the cerebral wall may sometimes be broken through without a serious result, if the dura mater be left intact behind it. But if there be any damage done to the wall in the neighbourhood of the crista galli or cribriform plate, the dura mater is almost inevitably injured at the same time, and a rapid and fatal meningitis may be expected. The infection is generally streptococcal, and surgery is powerless to stop its progress.
Abscess in the frontal cerebral lobemay arise from operation on the frontal sinus. In my experience it is more apt to occur independently of interference with the sinus, to remain latent, and then to be simply roused into activity by the local traumatism. The symptoms are, unfortunately, very vague. Rise of temperature, headache, irritability, drowsiness, and optic neuritis may be present. On the occurrence of these symptoms the sinus should be freely reopened, and the posterior (cerebral) wall carefully inspected for any necrosing area. In any case it should be removed and the frontal lobe explored in all directions.75
These dangerous complications, in many cases, were no doubt due to a failure to recognize that the complicated group of ethmoidal cells were involved in all cases of chronic frontal suppuration, and that previous to the introduction of the Killian operation our operative methods were very apt to dam up suppuration in dangerous corners. Finally, it was only when rhinologists first began to investigate frontal sinusitis that it was recognized what a dangerous region this is. To be convinced of this it is only necessary to compare the anxiety inspired by our regard for the cerebral wall of the frontal sinus with the calmness with which we regard an opening into the middle fossa, or through the dura mater, in mastoid operations.
We are not yet in possession of definite evidence in regard to theproportionate number of deaths which are due directly or indirectly to pus in the frontal sinus. Some observers hold that more deaths have occurred from operation than from neglected cases. Molinié has followed the history of fifteen private patients with frontal sinusitis, and not operated on, for ten years. Only one has died, and that was from another cause.76In any case we may still accept Lermoyez’s dictum: ‘Avoir une sinusite chronique est chose moins grave qu’on ne croit: opérer une sinusite frontale est chose plus sérieuse qu’on ne le dit.’77
Doubtless the dangers have been diminished since the more general adoption of the Killian operation, but accidents may occur in the most skilful hands. This must be kept in mind when drawing up the indications for interference.
Results.In uncomplicated cases, successfully operated on, the results are most satisfactory. The preservation of the Killian bridge quite prevents any really unpleasant disfigurement. The depression which may form above it is proportionate to the size and depth of the cavity. No man need decline the operation on account of the scar left. In women we are able, with the help of a radiograph, to form an idea beforehand as to the degree of depression which may be left. This, if required, can be remedied by the injection of paraffin (see Vol. I), but, fortunately, the frontal sinus in women is not, as a rule, so deep as in men.
As regards cessation of purulent discharge the result will depend on the extent of the sinus, the presence of complicated orbito-ethmoidal cells, and the skill of the operator. If the ethmoidal labyrinth has not been completely dealt with, one or two cells may continue to secrete. It may be wiser to leave them alone. In very deep sinuses a ‘dead space’ between the back of the Killian bridge and the posterior (cerebral) wall of the sinus remains open, and may continue to secrete if not cicatrized over evenly.
But secretion is no longer pent up in the fronto-ethmoidal group of cells, and the patient is relieved of headache, depression, and other symptoms of septic absorption.
This operation was first described by Ogston,78but was independently conceived by Luc.79Its principle is to make a fairly free opening into the frontal sinus, and then establish a large communication with the nasal cavity. The inner part of the supra-orbital rim is sometimesdestroyed. But the operation does not provide for the treatment of orbito-ethmoidal cells, the anterior ethmoidal region and the sp[h]enoidal wall are not exposed, and if there be a large orbital recess to the frontal sinus it cannot be satisfactorily dealt with.
Indications.But the Ogston-Luc procedure, or some modification of it, is still suitable in (1) exploratory openings of the frontal sinus, (2) when the sinus requires opening for a recent and acute infection80, and (3) for mucoceles and suppurating mucoceles.81
Operation.A general anæsthetic is required. It is not necessary to shave the eyebrow, but the surrounding skin should be well purified. A curved incision is made through the eyebrow down to the bone along the inner third of the supra-orbital ridge, reaching from the supra-orbital notch to opposite the inner canthus. In the latter direction it can be extended if the ethmoidal region is chiefly affected, and if the ethmoid only requires exposing the incision is placed lower down.
With a raspatory the soft parts are turned upwards and downwards so as to expose the anterior wall of the sinus, which is opened with chisel and hammer. A probe will indicate its depth and direction. The opening is enlarged with bone-forceps sufficiently to allow inspection of the interior of the cavity, and permit of the passage into the nose being enlarged with forceps, curettes, or burrs. The polypoid mucosa occupying the sinus and the fronto-ethmoidal cells along the passage to the nose are carefully plucked away. A drainage tube or wick of gauze is inserted from the sinus down into the cavity of the nose, so that it can be withdrawn from the anterior nares at the end of twenty-four hours. The drainage tube is replaced by some surgeons. The frontal wound is sometimes closed at the time of the operation, and sometimes left open.
Results.These are variously given by different observers. Thus one author states that it will effect a cure in 85% of cases,82while another operated by this method in eleven cases, of which two died and not one was completely cured.83
The subject does not require further discussion, as most operators have now given this operation up in favour of the improvements wrought in it by Killian. Luc himself has abandoned it in favour of the Killian operation. The latter is undoubtedly to be preferred in all cases of well established chronic purulent sinusitis with fungating mucosa and involvement of the ethmoidal cells.
In this operation the entire anterior wall of the frontal sinus is chiselled away, so as to allow of the soft parts covering it being pressed down into the cavity until they are applied to the posterior wall. This, naturally, effects a complete obliteration of the cavity, but in order to secure it the orbital ridge has frequently to be removed to such an extent that a frog-like prominence is given to the eye, and the resulting disfigurement is very marked. Besides, this operation does not deal with the orbital recess of the sinus, or the orbito-ethmoidal cells—the most important part of the operation. In fact, the only advantage of this operation—complete obliteration of the sinus—is secured by Killian’s operation, which also allows these regions to be dealt with, permits free drainage into the nose, and avoids disfigurement.