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 (see p. 630).

[Ill.u.s.tration: FIG. 334. RADIOGRAPH TO SHOW THE VALUE OF THE RoNTGEN 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.]

=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 four months' duration intranasal treatment was a failure, although carried out most carefully on 44 successive days.[71]

[71] _Proc. Royal Soc. Med._, 1907, December.

[Ill.u.s.tration: FIG. 335. RADIOGRAPH SHOWING CANULA IN THE FRONTAL SINUS.]

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.

OPENING THE FRONTAL SINUS IN ACUTE SUPPURATION

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 on p. 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 (see p. 652).

KILLIAN'S OPERATION

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 ftid discharge.

5. Persistent headache, particularly when a.s.sociated 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 (see p. 615). Even when healthy, the anterior extremity of the middle turbinal should be amputated (see p. 592). If the antrum be also suppurating and 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 s.p.a.ce (see p. 575).

[Ill.u.s.tration: FIG. 336. KILLIAN'S OPERATION UPON THE FRONTAL SINUS.

Shows the skin incision, with the transverse scratches made to ensure correct coaptation of the flaps.]

=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, pa.s.ses 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 whole extent 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 haemorrhage 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 pa.s.sing 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).

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

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.

[Ill.u.s.tration: FIG. 338. PERIOSTEAL ELEVATORS.]

[Ill.u.s.tration: FIG. 339. KILLIAN'S TRIANGULAR CURVED CHISEL.]

The pyogenic membrane is now carefully plucked away with a pair of Grunwald'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 sc.r.a.p 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 and other irregularities, and the systematic use of radiography will prevent him from being taken by surprise.

[Ill.u.s.tration: FIG. 340. CITELLI'S BONE-FORCEPS.]

[Ill.u.s.tration: FIG. 341. HAJEK'S BONE-FORCEPS.]

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 can now 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 as a rule it will disappear when the swelling subsides and the periosteum gets back to its anchorage (Fig. 342).

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

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 optic.u.m. One or two galleries may be met with in the roof of the orbit--prolongations of orbito-ethmoidal cells--pa.s.sing 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 Rontgen 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 s.p.a.ce, 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 st.i.tch-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 ftid, (4) there is any history of a tendency to wound complications, or (5) there is marked invasion of the diploe 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 ftid 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 a.s.sist 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.[72] This number has been exceeded by the fatalities since published and the much greater number which have never been recorded.[73] The chief dangers are (1) a spreading septic osteomyelitis, (2) meningitis, and (3) abscess in the frontal cerebral lobe.

[72] Logan Turner, _Edinburgh Medical Journal_, 1905, March.