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.

OPERATION THROUGH THE CANINE FOSSA ONLY

_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.

THE CALDWELL-LUC RADICAL OPERATION

=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 (see p.

572).

[Ill.u.s.tration: FIG. 327. THE INCISION IN THE CALDWELL-LUC OPERATION UPON THE MAXILLARY SINUS.]

On the Continent this operation is sometimes carried out under local anaesthesia, but chloroform is generally employed. When the patient is unconscious, a sponge is packed in the post-nasal s.p.a.ce (see p. 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 a.s.sistant, an incision is made half a centimetre below the gingivo-l.a.b.i.al 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.

[Ill.u.s.tration: FIG. 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 1-1/2 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 mucous membrane presents in the opening in irregular, polypoid, bluish-greyish ma.s.ses, bathed in pus which may be highly ftid. The diseased mucous membrane should be carefully plucked out of the cavity with a pair of Grunwald'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 sc.r.a.ped 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 ma.s.ses 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.

[Ill.u.s.tration: FIG. 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 (see p. 587 and Fig. 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 remains of the ridge separating the nose from the sinus. The opening should allow of the surgeon's little finger pa.s.sing freely from the antrum into the floor of the nose, and _vice versa_ (Fig. 328).

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.

[Ill.u.s.tration: FIG. 330. CARWARDINE'S PUNCH-FORCEPS. Used in breaking down the lower antro-nasal wall.]

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 for the 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 (see p. 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 (4-1/2 in.), but large bore, silver Eustachian catheter is pa.s.sed 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 pa.s.sed through the antro-nasal opening into the sinus, where it is left for a few hours.

[Ill.u.s.tration: FIG. 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.]

=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 tissue which 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.

[Ill.u.s.tration: FIG. 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.]

=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-mortem_ examinations 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 (see p. 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; st.i.tches need not be employed; and everything should be done to avoid retention and secure free drainage.

=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 Bonninghaus 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 st.i.tch 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 Bonninghaus can also be much more easily manipulated. It is said that there is no fear of disfigurement from the cheek falling in (Fig. 332).

DRAINAGE THROUGH THE NASAL WALL ONLY

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 Claoue and Rethi, and now has many supporters.

=Operation.= On the Continent it is frequently carried out under local anaesthesia, 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 (see p. 587 and Fig. 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,[69] that 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 the _Streptococcus pyogenes_ is the virulent organism, or where the streptococcus is a.s.sociated with the presence of squamous epithelium and lymphocytes,[70] it 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 anaesthesia.

[69] C. A. Parker, _Brit. Med. Journ._, October 10, 1908, p. 1099.

[70] Logan Turner, ibid., p. 1096.

OPERATIONS UPON THE FRONTAL SINUS

CATHETERIZING AND WASHING OUT THE FRONTAL SINUS

=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 by disease. When this has occurred--or when the anterior extremity of the middle turbinal has been removed, as described on p. 592--the anterior region of the middle meatus is well anaesthetized. 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 Rontgen rays (Figs. 334, 335).

[Ill.u.s.tration: FIG. 333. CATHETERIZING THE FRONTAL SINUS. The anterior end of the middle turbinal has been removed.]

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 (?j to Oj) [Transcriber's note: Oj = one pint] 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.