CHAPTER XVI. ACUTE SUPPURATION IN THE ACCESSORY CAVITIES. SYMPTOMS AND TREATMENT. THE clinical history of a case of acute suppuration is usually as follows: A patient suffering from acute rhinitis due to an ordinary cold, to influenza, or to one of the other causes enumerated in the preceding chapter, experiences a sudden increase of the nasal symptoms. One or both nostrils become more stuffy, or completely obstructed, and there is a feeling of burning heat with great fulness or tension in the nose and over the neighbourhood of the affected cavity. This is increased by stooping or lowering the head, by coughing, straining, etc. There is usually much headache, most severe in the supra-orbital region, but radiating over the vertex. In unilateral cases the pain is generally limited to the affected side. It is often of a throbbing character, and gradually increases in severity. There may also be severe neuralgia, not only in the affected part, but shooting along the branches of the trigeminal nerve. The exact distribution of the pain varies according to the sinus affected, as do also the areas of superficial and deep tenderness (see Chap. XVII.). In the more severe cases there are constitutional disturbances, malaise, fever, and anorexia; the patient may feel acutely ill; the walls of the cavity become tender on pressure or percussion and may bulge; the soft tissues overlying them may become red, swollen and oedematous. Examination of the nose shows evidence of acute rhinitis, redness, vascular engorgement of the inferior turbinate, and oedema of the tissues in the upper part of the nose. The middle turbinate is almost invariably swollen and tender to the touch. When one of the anterior set of accessory sinuses is affected, if the swollen turbinates permit a view, an oedematous swelling may be seen on the outer wall of the nose in the neighbourhood of the uncinate process when the antrum is affected the whole outer wall of the nose may appear to be pushed inwards. After a few hours or days of increasing suffering a sudden gush of discharge takes place from the nostril, consisting of mucus, muco-pus, or pus mixed, in the majority of cases, with more or less blood, and the symptoms are immediately relieved. The subsequent history varies. Sometimes all symptoms permanently disappear after the initial discharge: in other cases an intermittent discharge may continue for a few hours, and gradually decrease until complete cessation occurs. Or, after a brief interval all the symptoms may return and slowly increase in severity until a second discharge takes place. This cycle of events may be repeated once, twice or oftener, and then may result in complete recovery or, finally, the case may become chronic. Patients who have once suffered in this way are liable to have a repetition of the attacks, probably because of some predisposing anatomical peculiarities. Some patients have acute antral suppuration every time they take a fresh cold (see page 273). Diagnosis. The diagnosis is readily made by careful attention to the above history. The chief points to be attended to are the presence or history of an acute rhinitis, of influenza, of a bad tooth or of other exciting cause, the acute onset, the increasing severity of the symptoms, and the immediate relief following a sudden escape of discharge from the nose. The course of these symptoms is pathognomonic of an acute affection of one or other of the sinuses, though it may not be possible to say of which, unless definite local tenderness or swelling is present. The evidence to be obtained from the situation of the pus in the nose and from such means as transillumination and puncture, will be considered in Chapter XVIII. The affection most frequently confused with acute antral suppuration is acute osteomyelitis of the upper jaw. Instances of this affection are frequently recorded in the medical journals as cases of antral suppuration occurring at an unusually early age, for the disease is most common in infants and young children. Antral suppuration at these ages is practically unknown moreover the situation of the external abscesses or fistulae which may form is also characteristic (see Chap. XVIII.). I have seen one case, possibly unique, in which a foreign body in the nose simulated sinus suppuration. The patient was an adult who stated that pieces of food occasionally entered his nose without any apparent cause and gave rise to the complete cycle of events above related. There was increasing unilateral nasai obstruction and discharge, a painful feeling of tension, burning, and throbbing in the nose, severe facial neuralgia gradually increasing in intensity until all the symptoms terminated suddenly with the expulsion of pus and blood from the affected nostril. A history of similar attacks was given, and the case was looked upon as one of acute suppuration in the antrum until it was noticed that pieces of food were invariably present in the discharge. Treatment. The main objects of treatment are to cut short the inflammatory disturbance, and to reduce the swelling in the nose so as to allow a free escape for the pent-up discharge. These objects are best attained by employing both constitutional and local measures. The disease tends towards spontaneous cure, but much can be done to hasten this and thus to minimise the danger of secondary changes occurring in the affected cavity, which might lead to the suppuration becoming chronic. The patient should be kept in an even temperature, preferably confined to bed, and a brisk purge followed by a diaphoretic mixture should be administered in fact, he should be treated on the same lines as for a severe cold (see page 129). A simple warm, alkaline lotion should be used frequently to wash out the nose; if the nose and throat be acutely inflamed hot steam inhalations containing menthol often give great relief. When symptoms occur pointing to the presence of pent-up matter in a sinus, local measures must be adopted to reduce the swelling of the mucous membrane and remove the obstruction around the outlet of the affected cavity. The application of a powerful astringent, such as a strong solution of cocaine and suprarenal extract, to the nasal mucous membrane may first be tried. Pledgets of wool soaked in the solution should be carefully packed around the ostium of the affected sinus. When this is done successfully, the mucous membrane becomes anaemic and shrunken, and almost at once discharge from the cavity commences. If the antrum be affected the evacuation may be facilitated by bending the patient's head forward or to the opposite side. This application, both by its astringent and anaesthetic action, usually gives great relief. The great disadvantages are that the astringent effect is only temporary, and that the swelling tends to recur as the effect of the drug passes off. If, however, complete evacuation of the discharge has been obtained there is usually no further trouble. After having emptied the cavity, the astringent action on the mucous membrane may be kept up by menthol, which also acts as a mild anaesthetic. It is best applied as an oily spray, a 1-3 per cent. solution of menthol in olive oil or paroleine being introduced into the nose with an atomiser. Other astringents, such as antipyrin and hazelin, in watery solution are used by many for a similar purpose: they are more irritating than menthol, and have no particular advantages. Should these measures fail to reduce the oedema sufficiently, or should it rapidly recur, the most effective and rapid means at our disposal is local blood-letting. This is a remedy I have never seen advocated for this condition, but in my hands it has proved the most successful means of treatment. When there is acute suppuration in one of the anterior set of cavities, such as the antrum or frontal sinus, free incisions should be made along the middle turbinate and along the outer wall of the nose just below the opening of the sinuses. These simple incisions made with a sharp knife allow the tissues to drain freely, and are apparently more effective than the removal of pieces of mucous membrane with punch forceps. By the latter method pieces of bone may also be removed, and the door opened up to infection: this may be followed by increased swelling and oedema. In conjunction with these methods of treatment hot fomentations should always be applied externally over the affected cavity: they are probably a useful aid in reducing the swelling, and prove very grateful to the patient. Further, any polypus or hypertrophy in the nose should be removed, and occasionally, when the middle turbinate is much swollen and pressed against the septum, it may be necessary to amputate the anterior part or the whole of it, but the effect of free incisions should be first tried. If these means fail more active measures must be adopted to secure the evacuation of the cavity. It has been recommended to attempt this by reducing the air pressure in the nose, as by sniffing as hard as possible with closed nostrils or by producing suction with a modification of Politzer's bag. I have had no personal experience of these methods, but they seem likely to increase the swelling and oedema in the nose by causing a partial vacuum, whilst they could hardly be effectual in sucking. out pus from any of the cavities, except, possibly, from the frontal sinus. The ordinary method of inflation with a Politzer bag seems likely to be dangerous as well as ineffective, for should pus be present in the infundibulum or in the cleft under the middle turbinate it seems quite possible to blow it into a healthy sinus and thereby cause a spread of infection. Also, there is a danger of infecting the middle ear through the Eustachian tube. For this very reason some authors, for instance Grünwald, recommend that even blowing the nose should be avoided as far as possible, or should be performed quite gently. If, then, the above treatment fails it is better to adopt at once more certain measures to secure evacuation of the cavity. This may be done by aspirating it, or by washing it out either through its natural opening or through a small puncture. The Maxillary Antrum. When the above treatment has failed, this cavity should be punctured and the contents washed out by irrigation with a mild antiseptic lotion, such as a solution of boracic acid. The various methods of doing this and the advantages and disadvantages attaching to each will be fully discussed later (see Chap. XIX.). If the affection be of dental origin the carious tooth should be at once removed and the antrum perforated through its socket. After thoroughly washing out the cavity a small plug should be inserted in the hole to prevent its closure, and the irrigation repeated daily until all discharge has ceased. As a rule there is no pus after the first washing, but it may continue a few days; in acute cases it is very rare not to obtain a rapid cure. If there be no dental trouble it is better to perforate the antrum from the inferior meatus of the nose with a Lichtwitz's trochar and cannula. A single irrigation is often sufficient to effect a cure, but it may have to be repeated in a day or two. Should these measures fail the case must be treated on the lines laid down for chronic suppuration (see Chap. XIX.). The Ethmoidal Cells. If any of the ethmoidal cells are affected the 1 Moll, Journ. of Laryngol., 1896, x. p. 333. best treatment is to open them at once. This may be accomplished by breaking into a cell with a Hajek's hook and then cutting away its floor, preferably with a pair of punch forceps such as Grünwald's (see Chap. XX.). The Frontal Sinus. The approach to the lower part of the infundibulum should first be cleared in the way above described, and then the anterior end, or whole of the middle turbinate, together with any thickening or swelling of the adjacent part of the outer wall of the nose, should be removed. Simple irrigations, menthol spray or inhalation, and such like treatment must be carefully practised. A cautious attempt may be made to introduce a suitably-bent cannula into the sinus, but no force must be used and especially no attempt must be made to puncture its floor from the nose. Should a cannula be successfully introduced the sinus may be irrigated, but should this prove impossible, and from anatomical considerations it has been shown how very likely it is to be so, the case must be left to nature for a time. The frontal sinus from the dependent position of its opening usually recovers spontaneously or by the use of the simple means already advised. An acute suppuration in the sphenoidal sinus, should it ever be recognised, must be treated on similar principles, the approach to it being cleared by the removal of the middle turbinate, and the sinus irrigated through its natural opening. The following articles may be consulted: AVELLIS. Archiv für Laryngol., AVELLIS. Münch. med. Woch., 1896, iv. p. 255. 1896, xliii. p. 720. AVELLIS. Archiv für Laryngol., 1900, x. p. 271. |