TILLEY. Brit. Med. Journ., 1902, ii. p. 582.

MOURE. Journ. of Laryngol., 1903, xviii. p. 298.

MAYO COLLIER. Journ. of Laryngol., 1903, xviii. p. 635.

PETERSEN. Münch. med. Woch., 1903, 1. p. 449.

LOGAN TURNER. Edinb. Med. Journ., 1905, p. 239.
MILLIGAN. Brit. Med. Journ., 1905, i. p. 239.
GIBSON. Amer. Journ. Med. Science, 1903.

CHAPTER XXII.

TREATMENT OF SUPPURATION IN THE SPHENOIDAL

SINUS.

THE sphenoidal sinus was for a long time considered inaccessible, but modern methods have brought it well within the scope of surgical interference; it is in fact one of the easiest sinuses to treat successfully. method of treatment depends to a large extent upon the associated conditions.

The

Irrigation through the Natural Opening. When the nasal passages, including the cleft between the middle turbinate and the septum, are unduly wide, as is not uncommon in atrophic rhinitis, it may be possible to see the ostium of the sphenoidal sinus by anterior rhinoscopy, but generally it is necessary to remove the middle turbinate in order to bring this opening into view. When the ostium can be seen a cannula should be passed through it and the sinus washed out. If on inspection and probing no bone disease can be detected in the sinus walls. daily irrigation with a mild antiseptic, such as boracic acid solution, may be continued for a time. If this treatment does not effect a cure, or greatly diminish the discharge within a few days, stronger antiseptics may be applied. The best of these is a ten to twenty volume solution of hydrogen peroxide, or a two to five per cent. solution of sulphate of copper. A few drops of either solution may be injected into the sinus after it has been cleansed, left for a few seconds, and then thoroughly washed away with boracic lotion. Sulphate of copper is warmly recommended by Hajek, and as it is occasionally successful in cases of chronic antral suppuration, it seems well worthy of a trial.

Intranasal Operation. If treatment by irrigation fail, if the opening of the sinus be extremely small, or if caries of the sinus walls or oedema of the overlying mucous membrane be detected, it is better to operate. Bearing in mind the important anatomical relationships of the sphenoidal sinus, it is obvious that any operation must be carried out with extreme care. The best plan is to enlarge the natural opening with Hajek's hook or chisel. The anterior wall of the sphenoid is thoroughly anaesthetised and rendered bloodless with cocaine and suprarenal solution. In very

sensitive patients a general anaesthetic may be given, but as a rule it is unnecessary. The hook is passed through the natural opening of the sinus, and then its anterior wall is broken down by traction; the loose pieces may be clipped away with Grünwald's forceps. When the opening has been sufficiently enlarged, the cutting forceps shown in Fig. 119 may be used with great advantage. It is important to remove as much of the anterior wall as possible in order to obtain free drainage of the sinus, and because the opening shows some tendency to contract. Hajek and Onodi have drawn special attention to the fact that the anterior wall of the sinus consists of a nasal, usually narrower portion, an ethmoidal, usually broader portion, and occasionally of a third or maxillary portion (see Figs. 18, 120). Hajek strongly advises that the posterior ethmoidal cells should be opened before

MAVERANTATZEN

FIG. 119.-AUTHOR'S CUTTING FORCEPS FOR SPHENOIDAL SINUS.

operating on the sphenoidal sinus, as in this way better access can be obtained to the latter and its whole anterior wall removed. Moreover the posterior ethmoidal cells are usually simultaneously affected. This advice seems sound, and I have recently adopted the method.

If the sinus contains polypi or granulations they should be cut away with forceps or gently curetted. It is best not to attempt removal of the entire lining membrane even when there is extensive disease. Healing usually takes place when free drainage has been established, and it is better not to lay bare the bone. Moreover great care must be exercised in curetting, as injury of the roof or lateral walls of the sinus may entail the most serious consequences, and even prove fatal. In more than one case the cavernous sinus has been wounded, and has given rise to alarming haemorrhage.1

The after-treatment consists in irrigating the sinus daily with mild antiseptic lotions, and, if necessary, stronger solutions may be applied as above

1 MacDonald, Diseases of the Nose, London, 1892, p. 260; also Tilley, Journ. of Laryngol., 1903, xviii. p. 584.

Z

directed. An intelligent patient may sometimes be taught to carry out the irrigations for himself. At intervals of not less than twice a week the cavity should be washed out, dried with mops of wool on a probe, and carefully inspected until the edges of the opening have healed and there is no danger of further contraction. If there are signs of contraction Hajek advises that the edges should be cauterized on the tenth day, and again later if necessary. The results of these operations as far as my experience goes are good. The opening remains permanent, and the interior of the sinus soon becomes dry. A cure is usually obtained in two to eight weeks.

Operation with Curette. Occasionally the sphenoidal sinus may be opened in another way. Thus it once happened that in curetting the

FIG. 120.-HORIZONTAL SECTION OF THE RIGHT NASAL FOSSA. Showing the relations of the anterior wall of the sphenoidal sinus. 1. Nasal cavity; 2. Posterior ethmoidal cells; 3. Antrum; 4. Sphenoidal sinus.

posterior ethmoidal region for polypi and suppuration the finger, forced well up into the post-nasal space, detected carious bone on the anterior surface of the sphenoid. The softened bone gave way on pressure, and the tip of the finger passed into a large cavity. From its position it was obvious that this cavity must be the sphenoidal sinus: the opening made was therefore enlarged by breaking down the carious anterior wall with the curette, guided by the finger. It may be noted that in this and in another similar case semi-gangrenous polypi associated with an intensely foetid discharge, were present in the nose, and that these polypi rapidly recurred until the curettement had been carried out. The large opening that was made remained permanent, and no after-treatment beyond simple irrigation of the nose was necessary. Three cases treated in this way were all cured,

both as regards the polypi and the suppuration. The method, however, is only applicable when there is extensive caries of the anterior wall of the sinus, and requires general anaesthesia.

Of other methods of operation I have had no personal experience, and must therefore speak more briefly. It has been recommended that when the ostium is invisible, the anterior wall of the sinus should be bored through from the front with an electric drill or burr, or opened with special forceps. Watson Williams has designed a special modification of Grünwald's forceps for this purpose. These methods seem dangerous owing to the great variability in the size of the sphenoidal sinus. I do not think it could ever be justifiable to bore into the anterior surface of the sphenoid in the hope of reaching the sinus unless the position and extent of the latter had been carefully ascertained beforehand by passing a hooked probe into it. Moreover I fail to see how a certain diagnosis can be made except by bringing the ostium of the sinus into direct view by anterior rhinoscopy. If the ostium can be seen the method above recommended can be adopted and offers obvious advantages in its ease and precision.

External Operation. It has also been recommended that the sphenoidal sinus should be reached by an external operation such as I have described for exposure of the ethmoidal cells (see page 333). A curved incision is made round the inner side of the orbit, the ethmoidal cells exposed and cut away one by one until the sphenoidal sinus is reached. This operation is not difficult upon the cadaver, but in the living subject the amount of bleeding that ensues, the small diameter and the great depth of the wound, make it extremely difficult and tedious. The risk of such a procedure seems unjustifiable when there is an alternative, simple, safe and rapid method. Even in acute disease the operation through the anterior nares could probably be carried out with greater speed and precision.

Jansen's Operation. Lastly, Jansen has recommended that the sphenoidal sinus should be opened through the antrum. Occasionally (see Fig. 120) the sphenoidal sinus comes into close relationship with the maxillary antrum and is separated from it by only a thin plate of bone. In these circumstances Jansen's operation may be easily performed. Onodi examined twenty-five skulls with special reference to this point, and found that the operation was anatomically possible in only three. Under normal conditions the operator would either first enter the nasal cavity and then the sphenoidal sinus, or he would damage the vessels and nerves which pass through the spheno-palatine foramen. Onodi considers the ordinary nasal route the only safe way to the sphenoidal sinus. It is difficult to see how Jansen's operation could give such a clear view of the field of operation. as the methods above described, but it may be a rapid and efficient method of dealing with multiple sinus suppurations, as almost all the sinuses can be attacked at the same sitting. It may also be justified when the nasal fossae are extremely narrow.