Part 95 (1/2)

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.]