mucus, which escaped apparently under pressure as soon as the cavity had been perforated through the alveolar margin. Removal of the tumour through the nose and a single washing through the antrum effected a cure of the antral condition. CASE 4. A man with sarcoma involving the inferior turbinate and outer wall of the nose. Rouge's operation was performed, the antrum freely laid open, and its whole inner wall cut away. The antral cavity was found to be distended with mucous fluid, the ostium being blocked with the growth. CASE 5. A man complaining of severe neuralgia of ten days' duration. The pain affected the right infra-orbital region, the upper teeth, and spread over the malar bone to the top of the head; the corresponding nostril was partially obstructed. There was deep tenderness on pressure over the antrum, but no distension of the cavity except on its inner wall. On transillumination the cheek was dark. The antrum was punctured, but it was impossible to syringe through the cavity. Repeated attempts at syringing being unsuccessful, a large opening was made into the antrum through the inferior meatus, a large polypus was brought away together with thick mucus and blood clot, and all symptoms immediately disappeared. The subsequent washings were clear until ten days later, when there was a sudden snap, and a collection of straw-coloured mucus came away, obviously from rupture of a cyst. There seems little doubt that the whole antral cavity was originally distended with mucus, the outlet into the nose being obstructed by polypi or cystic degeneration of the antral mucous membrane. These and other similar cases appear to demonstrate, what indeed one would expect, that the ostium of the maxillary sinus can become obstructed by the same processes which cause obstruction of the outlets of other accessory sinuses, and when this occurs the normal secretion accumulates and distension of the antrum results. As already stated, Turner denies the existence of this affection. Killian, however, appears to accept the occurrence of distension of the antrum, and supports his opinion on one of Zuckerkandl's post-mortem observations. The examination presented the following appearances. The outer wall of the middle meatus bulged into the nose; there was no ostium maxillare visible; the antrum contained a large quantity of thick pus, its lining membrane was swollen, and the mucous glands showed evidence of cystic degeneration. Dmochowski has described a still more definite case. In an autopsy on a young woman, he found the left ostium maxillare obliterated; the antrum contained thirty cubic centimetres of a transparent yellow fluid, which completely filled the cavity. The walls of the sinus were so thin that they could be indented by slight pressure. The sinus also contained a pedunculated mucous polypus the size of a hazel nut. Microscopic examination of the lining membrane of the antrum showed that the epithelium had disappeared, while the mucosa consisted of a thin layer of compact fibrous tissue. This case is probably similar to one I have already described. The probable cause in both cases was catarrhal inflammation of the antrum. and nose, in consequence of which the ostium maxillare became obliterated. The almost complete disappearance of the ciliated epithelium in Dmochowski's case was probably due to the pressure of the fluid, which also caused atrophy of the mucous glands and thinning and distension of the antral walls. Diagnosis. The diagnosis has to be made from distension of the upper jaw by cysts arising in connection with the teeth. The latter cause swelling in the region of the canine fossa and expansion of the alveolus, but never bulging of the upper or inner wall of the antrum. Suppuration of the maxillary antrum never gives rise to slowly progressive distension of its walls. Malignant disease may be more difficult to distinguish. The occurrence of frequent, lancinating pain, the bulging of the antrum into the cheek or in some other unusual situation, oedema of the lower eyelid, obstruction of the lachrymal duct, the occurrence of growth in the nose, and the age of the patient, would help to clear up the diagnosis. mucocele the antrum may be translucent, whilst a solid tumour would certainly cause darkening. Treatment. In two of my cases puncture and irrigation of the antrum on a single occasion were sufficient to effect a cure. This treatment has sufficed in the great majority of those cases described as serous disease, or hydrops of the antrum. When there was bulging of the antral walls it was necessary to make a large opening from the antrum into the inferior meatus, and in other cases the associated disease of the nose required still more extensive and radical measures. Such cases must be treated according to the conditions present; no general rules can be laid down. Mucocele of the Sphenoidal Sinus. No example of distension or mucocele of the sphenoidal sinus has, so far as I am aware, been placed on record, nor have I met with one. It is quite probable that they occur, but from the inaccessibility of this cavity, have hitherto been overlooked. The following articles may be consulted: LOGAN TURNER. (A contribution to the pathology of "bone cysts" in the accessory sinuses of the nose.) Edin. Med. Jour., 1903, lvi. pp. 299, 405, 517; 1904, lvii. p. 47. Gives full references. KILLIAN. Heymann's Handbuch der Rhinol. u. Laryngol., Band iii. Wien, 1899. Ethmoidal. STIEDA. Archiv für Laryngol., 1895, iii. p. 359. LOTHROP. Annals of Surgery, 1898, xxviii. pp. 611, 747. MANN. Münch. med. Woch., 1901, xlviii. p. 1154. Prontal Sinus. GRE WELL BABER. Journ. of Laryngol., 1897, xii. p. 47. DE SANTI. Proc. Laryngol. Soc. of Lond., 1898, v. p. 69. LUC. Annales des Mal. de l'Oreille, etc., 1899, April. Antrum. DMOCHOWSKI. Centralb. für Allg. Pathol., 1895, vi. p. 177, and Archiv für Laryngol., 1895, iii. p. 255. NOLTENIUS. Monatschr. für Ohrenheilk., 1896, xxx. pp. 447-452. KREBS. Archiv für Laryngol., 1896, iv. p. 424. ALEXANDER. Archiv für Laryngol., 1897, vi. p. 116. WERTHEIM. Archiv für Laryngol., 1900, xi. p. 228. CASSELBERRY. Journ. of Laryngol., 1901, xvi. p. 456. LENNOX BROWNE. Journ. of Laryngol., 1901, xvi. p. 539. Dental Cysts Projecting into Nose. GEREER. Archiv für Laryngol., 1904, xvi. p. 502. JACQUES AND MICHEL. Journ. of Laryngol., 1900, xv. p. 440. BAYER. La Presse Oto-Laryngologique, 1904, iii. p. 367. BROWN KELLY. Journ. of Laryngol., 1898, xiii. p. 272. (Gives full bibliography.) CHAPTER XXIV. AFFECTIONS OF THE POST-NASAL SPACE. POST-NASAL CATARRH. POST-NASAL catarrh is a common affection characterized by the "hawking up" of mucus from the back of the throat. It is a symptom of many nasal diseases in all forms of chronic rhinitis there is more or less associated catarrh of the naso-pharynx, besides which much of the nasal discharge flows backwards through the posterior nares into the throat. The catarrh may be associated with general congestion of the mucous membrane of the naso-pharynx, or with swelling or hypertrophy of the lymphoid tissues. In children the latter condition means adenoids, in adults the inflammation is often confined to strands of lymphoid tissue, which run downwards from near the median line towards the sides of the pharynx, and end behind the posterior pillars of the fauces. Inflammatory swelling of these bands is termed hypertrophic lateral pharyngitis. In rhinitis sicca and in ozaena the dry, unwarmed, unpurified air enters the post-nasal space and causes a dry catarrh, or there may be a direct extension of the disease. Occasionally post-nasal catarrh may be a true adenitis, the lymphoid tissue being studded with small white caseous masses of exudation projecting from the gland follicles. Symptoms. The chief symptom is discharge falling down into the throat, clinging round the back of the pharynx, and exciting a constant desire to hawk and spit. This hawking is most common in the morning, the secretion having accumulated during sleep, and the efforts to dislodge it may bring on retching and vomiting. The voice is altered, being thick. and 'nasal' in character: the throat aches if the voice be much used. There is often catarrh of the neighbouring organs, the Eustachian tubes. and middle ear, the pharynx and larynx. When associated with rhinitis sicca the secretion is apt to take the form of adherent mucous or mucopurulent crusts, the detachment of which may be associated with slight bleeding. The patient is often alarmed by discovering minute, reddishblack specks of blood in his expectoration. On examination the roof of the post-nasal space may be found to be covered with dry crusts, which may collect more especially in one of the recesses or furrows normally existing in Luschka's tonsil. This appearance was specially described by Tornwaldt, hence it has been termed Tornwaldt's disease. Prognosis. The affection may be acute or chronic: the cure to a large extent depends on the possibility of removing the nasal disease. In the acute cases recovery soon takes place; chronic catarrh is very intractable, and when associated with dry or atrophic rhinitis, it is almost incurable. In hypertrophic rhinitis, and especially hypertrophy of the posterior ends of the inferior turbinates, much can be done by operation. When the seat of the disease is limited to the lymphoid tissue a cure is more easily obtained. Treatment. The treatment must be directed to the removal of the causative nasal disease. An alkaline lotion should be ordered, and may be varied to suit the special requirements of the case (see Chaps. VIII., IX.). Where hypertrophy of the inferior turbinates or excessive lymphoid tissue is present, operation should be carried out. Much good may often be done by curetting even a small amount of adenoid tissue. The general treatment is of the greatest importance. A change of air, especially to the seaside or to a bracing mountain resort, will often do more good than any other treatment. Special attention must be directed to the alimentary functions: many patients suffer from indigestion and constipation, and it is quite impossible to cure their throat trouble until this has been corrected. Dieting alone may cause great improvement or even cure in other cases suitable tonics are required. POST-NASAL ADENOID GROWTHS. Although small vegetations had been seen in the post-nasal space by previous observers, among whom may be mentioned Czermak, Meyer was the first to recognise the importance of these growths. In 1868 he gave an accurate description of their pathology and introduced an efficient method of treatment. Their importance was beginning to be recognised in 1881 at the International Medical Congress in London, but it is only in the last fifteen years that the far-reaching effects of adenoids have been demonstrated, and that the influence of free nasal respiration in childhood upon the development of the upper and lower jaws, teeth, face, and chest has been understood. It is possible that in some respects the pendulum of opinion has swung even too far, and a large number of affections have been ascribed to adenoids which are not really due to them. It seems certain that undue importance has sometimes been attached to the presence of a small amount of growth not producing any real symptoms, and that, in consequence, a number of unnecessary operations have been performed. Aetiology. Adenoids are most commonly seen in children under 10 years of age. Brieger1 considers that hypertrophy of lymphoid tissue in 1 Archiv für Laryngol., 1902, xii. p. 254. |