laryngitis, associated with peculiar oedematous thickening of the mucous. membrane of the ventricular bands, vocal cords, and especially of the inter-arytenoid folds, is very common. Chronic tracheitis, bronchitis, and even bronchiectasis may be the direct consequence of the nasal disease. Pus trickling down into the pharynx may give rise to local septic affections, such as an acute post-pharyngeal abscess, recurring attacks of quinsy, or septic tonsillitis. The discharge coming forward through the anterior nares causes excoriation of the anterior nares and of the upper lip; impetiginous crusts may be seen not only in this region, but over the whole face. Little cracks or fissures may also form around the nares and allow the entrance of the specific micro-organisms. In this way, if the pus from the sinus contain streptococci, repeated attacks of erysipelas, or more often of a pseudo-erysipelatous erythema, may be set up. Again, the pus and discharge from the nose may be swallowed and give rise to more or less severe gastritis and disturbance of the alimentary canal.

Sometimes patients seek advice for affections of the ear, such as Eustachian obstruction and suppurative or non-suppurative middle ear disease. It has been stated that tinnitus may be due solely to antrum suppuration, and the true cause may be easily overlooked unless carefully sought for.1 Other patients seek relief for weakness of the eyes, for dimness of vision, asthenopia, or for conjunctival discharge and blepharitis. In such cases nothing but a systematic examination of the nose can prevent errors of diagnosis.

Signs of acute septic absorption are very uncommon, but occasionally there may be enlargement of the glands in the neck. Fever and other signs of constitutional disturbance may occur in closed or manifest empyema or when complications are present. Chronic septic absorption, as evidenced by pallor, anaemia, a muddy spotty complexion, general ill-health, lassitude, irritability of temper, capricious appetite, biliousness, dyspepsia and diarrhoea, is more common.

Various mental phenomena are frequently met with, but may be seen in other nasal diseases, especially those causing nasal obstruction, and afford no presumption of ethmoidal sinus disease, as is stated by Lermoyez, Hajek, and others. The most common form is mental depression, which may be so severe as to amount to hypochondria or melancholia. It is especially likely to occur when severe headaches or neuralgic pains are present. Patients often complain of inability to fix the attention, of mental dulness or stupidity, inability to undertake any mental work, and of great irritability of temper. These symptoms resemble the aprosexia of Guye. In other cases the patient is subject to congestion of the head and face, especially after meals or on taking alcohol or smoking. At such times. the whole face may become congested, and the patient may be extremely excitable and irritable, his whole mental characteristics being altered. Vertigo is common in ethmoidal and sphenoidal sinus disease.

1 Tilley, Lancet, 1904, i. 1415.

Impairment of the general health is frequently met with. It usually bears a direct relationship to the severity of the local symptoms. The disturbed rest from headaches and pain, the chronic absorption of septic products, may result in general anaemia, and often give rise to neurasthenia. Complications. The local complications of suppuration in the accessory cavities arise from direct extension of the disease to the adjoining parts, either as the result of caries or necrosis of the sinus walls, or of infection conveyed by the lymphatics. An abscess in the cheek, in the alveolar margin, or in the hard palate may arise from caries or necrosis of the walls of the antrum, with extension of pus into the soft tissues. The evidence obtained with the probe or finger after opening the abscess, or the effect of syringing, will speedily determine the diagnosis. Abscess or cellulitis of the orbit may arise from antral, ethmoidal, or frontal sinus disease. An abscess in connection with the antrum usually appears in the floor or inner wall of the orbit; when arising from ethmoidal cell disease, in the inner wall of the orbit; whilst that due to frontal sinus disease is usually situated in the roof of the orbit, and points almost in the centre of the upper lid. Proptosis, displacement outward of the eyeball, with extensive oedema of the lids and conjunctiva, may be present. When the abscess is opened, the insertion of a probe or of the finger will indicate the primary source of disease. Meningitis or cerebral abscess may arise in connection with frontal, ethmoidal, or sphenoidal sinus suppuration. In the latter case infection of the cerebral cavity may be indicated by proptosis or oedema of the orbital tissues from obstruction of the cavernous sinuses, or by sudden onset of blindness with or without optic neuritis, due to involvement of the optic tract. Most of these complications arise from caries or necrosis of the walls of the cavity and direct extension through into the adjoining soft tissues. Cerebral complications may, however, take place without apparent disease of the sinus walls; in this case infection probably takes place through the small lymphatic vessels running along the walls of the veins, which establish a direct communication between the mucous membrane of the sinuses and the cerebral cavity.

CHAPTER XVIII.

THE DIAGNOSIS OF CHRONIC SUPPURATION IN THE ACCESSORY CAVITIES OF THE NOSE.

LATENT EMPYEMA.

WHEN external signs are present, that is when the empyema is manifest, the diagnosis is usually easy. In latent empyema, on the other hand, when a purulent discharge from the nose may be the only symptom, or when, indeed, even this may fail, the diagnosis is frequently a matter of considerable difficulty.

must be carefully enquired into, various symptoms described in The localisation of any pain or discharge, may not only establish

The history of the patient's illness and the presence or absence of the the preceding chapter must be noted. tenderness, or the peculiarities of the a diagnosis of sinus suppuration, but may indicate the actual cavity which is affected. The evidence to be obtained from these sources has already been fully described.

Presence of Pus. The first step in the diagnosis is to ascertain the existence of a purulent discharge. Pus may be recognised by its opacity, Whenever pus is seen in the nose,

If

its fluidity, and its lemon-yellow colour. or whenever there is a history of an intermittent or occasional discharge of mattery fluid-which history may be confirmed by examination of the patient's handkerchief, sinus suppuration should be suspected. no pus be seen on the first occasion the examination must be repeated, cocaine and suprarenal extract applied to reduce the swelling of the nasal mucous membrane, and the patient's position varied by bending the head forward or to one side. When the discharge is scanty, it may readily dry up and form crusts. These should be removed with forceps, when a bead of pus may be seen immediately to well up. The necessity of repeated examinations must be emphasized, as owing to the neglect of this precaution it is probable that sinus suppuration is still frequently overlooked even by competent observers.

Other Sources of Pus. A purulent secretion from the nose may arise from other causes, such as the following: Tertiary syphilis, tuberculous disease including lupus, malignant disease, the presence of a foreign body

or sequestrum, acute suppurative rhinitis such as occurs in diphtheria and fibrinous rhinitis and ozaena. In some diseases of the naso-pharynx pus may also run forward into the nose. If these affections are borne in mind they can hardly fail to be recognised. Still it must be remembered that sinus suppuration may coexist with any of them. Thus syphilitic disease of the outer wall of the nose may lead to necrosis of the antro-meatal septum, and consequent infection of the antral cavity, and a similar result may occur in tuberculosis and malignant disease. As already shown, acute purulent rhinitis and ozaena are common causes of sinus suppuration.

Origin of the Discharge. Having determined the presence of pus in the nose, the next point is to make certain of the spot at which the discharge first appears. Of course pus gravitates and therefore is frequently seen forming a pool on the floor of the inferior meatus, or, as already stated, the discharge may take place entirely into the post-nasal space. Still, with careful and repeated examinations, a thin streak of pus can often be traced running up the septum or outer wall of the nose, towards the orifice of one of the accessory cavities. If the streak of pus proceeds from the middle meatus, and if this appearance is seen on repeated examinations at different periods, sinus suppuration is present. If even a mere bead of pus is repeatedly seen issuing from the middle meatus, the existence of sinus trouble is almost certain. Further, in a very large majority of cases pus in the middle meatus has come from the antrum, the frontal sinus, or the anterior ethmoidal cells. The discharge from the sphenoidal sinus and posterior ethmoidal cells is rarely seen in this position and never repeatedly. Pus appearing in the olfactory cleft, that is between the middle turbinate and the septum, points to posterior ethmoidal or sphenoidal sinus disease. The probability of the latter is greatly increased if, on post-rhinoscopic examination, pus is seen lying on the posterior ends. of the superior and middle turbinates and on the anterior surface of the sphenoid. The diagnostic value of the amount, of the foetor and of the periodicity of the discharge has already been discussed. (See page 293.)

Re-appearance of Discharge. The next step is carefully to wipe away every trace of discharge, and then to note when and where the pus re-appears. If it is repeatedly replaced in the middle meatus within a short time after mopping it away, in all probability either the frontal sinus or the ethmoidal cells are affected. If, however, the pus does not re-appear while the patient sits upright, but does when his head is lowered or bent over towards the opposite side, then the probabilities are in favour of the antrum being affected. The situation of the outlets of the cavities explains this phenoThe opening of the antrum being situated at the highest part of the cavity, pus cannot overflow until the sinus is completely filled, or until the relationship between the sinus and its opening has been altered. On the other hand, the openings of the frontal sinus and ethmoidal cells are near the lower part of the cavities, and therefore pus will constantly

menon.

drain away. The re-appearance of the discharge on lowering the patient's head in cases of antral suppuration, sometimes known as Fränkel's sign, was previously described by Spencer Watson.

Localisation of Oedema. The next point is to note carefully the existence and situation of any polypi, hypertrophies, swelling, or oedema of the mucous membrane. Swelling on the outer surface of the middle turbinate or adjacent part of the wall of the nose, and granulations protruding from the middle meatus, point to affection of one of the anterior set of sinuses. In this condition the pus frequently seems to issue from a cleft in the middle turbinate; in rare cases this is actually the case, the floor of an enlarged suppurating cell in the anterior end of the middle turbinate having given way. The probe introduced into the opening whence the pus exudes meets with bare, friable bone. More usually, however, the mass forming the inner boundary of the "cleft" is the middle turbinate, and the outer part of the cleft is formed by inflammatory swelling of the uncinate process or of the bulla ethmoidalis. This condition was formerly considered pathognomonic of antral suppuration, but it is frequently seen in suppuration of the frontal sinus and ethmoidal cells. On the other hand, if the oedema of the nasal mucous membrane be limited to the inner or upper surface of the middle turbinate, and to the corresponding part of the septum, suppuration in the posterior set of sinuses should be suspected. In affections of these latter sinuses, a patch of oedema is often seen on the septum, near the anterior end of the middle turbinate, a spot on which the discharge is apt to collect, and, when not very profuse, to dry and form crusts.

Polypus is of similar significance, and may be found in association with suppuration in any of the cavities. When limited to the middle meatus of the nose it is usually associated with suppuration in one of the anterior set of cavities, and when limited to the posterior and upper part of the nose, with suppuration in one of the posterior cavities. When multiple polypi, or when numerous small, oedematous, granulation-like growths are present in the ethmoidal region with pus exuding between them, I believe suppuration will invariably be found in the ethmoidal cells, with or without accompanying disease in other sinuses. It is extremely rare for polypi actually to protrude from one of the accessory sinuses into the nose, except from the ethmoidal cells. It is, indeed, hardly possible, unless the wall of the sinus has given way. Oedema of the anterior surface of the sphenoid is a positive indication of suppuration in the sphenoidal sinus.

Bone Changes, Caries or Necrosis. Pathological changes in the bones, apart from the rarifying osteitis associated with nasal polypus, are uncommon even in long standing sinus suppuration. The diagnosis requires to be made with the greatest care. A blunt probe must be used, as the mucous membrane overlying the ethmoid is extremely thin, and easily perforated by a sharp instrument. Care must also be taken that the probe 1 MacDonald, Diseases of the Nose, London, 1892, p. 169.