Part 97 (1/2)

OPENING THE SPHENOIDAL SINUS

=Indications.= Profuse purulent post-nasal catarrh, persistent headache, orbital or ocular or intracranial symptoms, call at once for relief. Not infrequently suppuration in other cavities will not cease, even though operated on, until the sphenoidal sinus has been treated.

=Operation.= Unless long-standing suppuration or ozna have produced such atrophy of the middle turbinal that the front wall of the sphenoidal sinus is easily inspected from the front, it will be necessary to remove the greater portion of the middle turbinal. If the anterior end has had the typical amputation performed (see p. 592), then the rest can be removed with the punch-forceps of Grunwald, the wire snare, or, under nitrous oxide anaesthesia, the spokeshave.

This will bring the anterior wall of the sinus with its ostium into view. Killian's long nasal speculum (Fig. 346) may still be necessary.

With the help of cocaine the ostium can then be enlarged with various instruments. Hajek's hook can be inserted into the orifice and the front wall torn away. I have not found this satisfactory. It is much simpler to insert the beak of a small Grunwald's forceps into it, or a small ring-knife, and by a series of boring and s.c.r.e.w.i.n.g motions to render the ostium patent. It is then easy to introduce a beaked Grunwald's or some such punch-forceps as those of Cordes (Fig. 348) and cut away as much of the front wall as may be required. This can be done freely in an inward and downward direction, and an opening as large as the tip of the little finger, and sufficient for drainage and treatment, is thus established.

When describing the removal of posterior ethmoidal cells (see p. 616) it was pointed out that the tip of the forceps not uncommonly breaks through the thin portion of the anterior sphenoidal wall.

If the natural ostium sphenoidale be not visible it would be risky to make an artificial opening without first determining by radiography the presence and size of the sinus. When this has been ascertained, palpation with a pair of sinus-forceps or a Lichtwitz's trochar and canula will generally detect a thin spot where firm pressure is sufficient to penetrate into the cavity. The opening is then enlarged as described.

[Ill.u.s.tration: FIG. 346. KILLIAN'S LONG NASAL SPECULUM.]

In all these procedures care must be taken that the instrument does not burst suddenly through the front wall with such force that it impinges on and damages the posterior wall.

The opened sinus must be dealt with according to the conditions met with. Necrosed portions of bone may require to be removed, but they rarely occur, except in syphilitic cases. Polypoid ma.s.ses of mucous membrane, obscuring the opening, may be carefully lifted out with forceps or curette, so as to facilitate drainage; but it is never necessary to think of curetting the interior generally, and particular regard should be paid to the posterior wall.

=After-treatment.= Profuse haemorrhage has sometimes occurred after opening the sinus. In a case of Gleitsmann's the bleeding did not take place until seven days after the operation,[84] and in one of C. R.

Myles's cases profuse haemorrhage occurred on the ninth day and required ligature of the external carotid.[85] It is possible that the bleeding in such cases may come from a branch of the internal maxillary artery, or even from the cavernous sinus. It can be met by firm plugging with a long strip of 1-inch ribbon gauze, of which the end is soaked in adrenalin or peroxide of hydrogen. Haemorrhage is not a complication that I have ever met with, after having opened a large number of sphenoidal cavities, and I do not think it is to be dreaded if the opening be made as directed.

[84] _Transactions of the American Laryngological a.s.sociation_, 1895, p.

91.

[85] Ibid., 1903, p. 241.

[Ill.u.s.tration: FIG. 347. RADIOGRAPH SHOWING A PROBE IN THE SPHENOIDAL SINUS. An india-rubber obturator is in the maxillary antrum.]

The sinus is washed out with a warm normal saline solution. The addition of peroxide of hydrogen may be useful. The condition of the mucous membrane may be improved by cleansing the sinus with iodoform emulsion, or plugging it for twelve or twenty-four hours with iodoform ribbon gauze. Any pigment can be kept in contact with the walls for some time by dipping the end of a piece of ribbon gauze into a solution of argyrol (25%) or nitrate of silver (2%) and packing it into the cavity. The other end of the strip is left just within the vestibule of the nose, so that the patient can withdraw it himself.

But if a sufficient opening has been made into the cavity to allow of natural ventilation and drainage, it is well to abstain from too much local medication--particularly if there be neither polypus, necrosis, nor foreign body in the sinus, and if it be not subject to reinfection from the suppuration in the posterior ethmoidal cells. It is remarkable how, under such conditions, suppuration will cease in a sphenoidal sinus if left alone, when, if frequently treated, secretion will continue indefinitely. In my experience the sphenoidal sinus is one of the most satisfactory of the accessory sinuses to treat.[86]

[86] _Proceed. Royal Society of Medicine_, Meeting of June, 1908.

[Ill.u.s.tration: FIG. 348. SPHENOIDAL PUNCH-FORCEPS.]

=Other methods.= The sphenoidal sinus can also be opened and treated during Killian's operation on the frontal sinus (see p. 648).

It has been proposed to approach the sphenoidal sinus by first traversing the maxillary antrum. Such a complicated route, involving extensive destruction of tissue, has no advantage over the direct and simple method described. Attempts to reach the sphenoidal sinus from the naso-pharynx are not practical. This is easily seen by observing the thickness of the floor of the cavity depicted in Fig. 345.

OPERATION IN MULTIPLE SINUS SUPPURATION

Before starting treatment in a case of multi-sinusitis a complete examination should be formulated. The importance of making the differential diagnosis as complete as possible cannot be overestimated.

In initiating treatment attention should be directed first to the ethmoidal region. The ethmoid should be attended to in all cases of suppuration in the frontal sinus. It is generally necessary, in any case, to clear it away to gain access to the sphenoidal orifice. It is well to remove it before or during operation on the maxillary sinus. The sphenoidal sinus should be catheterized, and, if infected, the orifice will require enlarging and the cavity treating. A frontal sinus should be washed out several times before deciding on a radical operation. It not uncommonly ceases to secrete after the ethmoid has been cleared.

The radical operation on the frontal sinus should not be embarked on until the ethmoid and sphenoid have been attended to. A radical frontal operation should take precedence of the maxillary, unless both cavities are operated on at the same time.