A System of Operative Surgery Part 96

[73] _Die Komplikationen der Stirnhohlenentzundungen_, von P. H. Gerber, Berlin: S. Karger, 1908.

_Infection of the bone_ is indicated chiefly by a puffy, tender swelling on the forehead or temple, adjoining the upper flap. There may be little or no rise of temperature, and little complaint on the part of the patient. But no time should be lost in laying the wound freely open, searching for any shut-off focus of pus, and applying hot boric fomentations diligently. Once infection is established in the bone it may be impossible to stay its progress, even by the most thorough removal of diseased tissue: but the effort should be made.[74]

[74] H. Tilley, _Lancet_, 1899, August 19, p. 534, and _Edinburgh Medical Journal_, 1905, March, in paper of Logan Turner's.

_Meningitis_ is an equally dangerous complication. It may arise without direct injury to the cerebral wall of the sinus. If, during removal, the anterior end of the middle turbinal be damaged too high up, the lymph channels around the olfactory nerve may be opened so freely that infection spreads along them to the meninges. Or the cerebral wall may sometimes be broken through without a serious result, if the dura mater be left intact behind it. But if there be any damage done to the wall in the neighbourhood of the crista galli or cribriform plate, the dura mater is almost inevitably injured at the same time, and a rapid and fatal meningitis may be expected. The infection is generally streptococcal, and surgery is powerless to stop its progress.

_Abscess in the frontal cerebral lobe_ may arise from operation on the frontal sinus. In my experience it is more apt to occur independently of interference with the sinus, to remain latent, and then to be simply roused into activity by the local traumatism. The symptoms are, unfortunately, very vague. Rise of temperature, headache, irritability, drowsiness, and optic neuritis may be present. On the occurrence of these symptoms the sinus should be freely reopened, and the posterior (cerebral) wall carefully inspected for any necrosing area. In any case it should be removed and the frontal lobe explored in all directions.[75]

[75] A successful case is reported, _Proc. Roy. Soc. of Med., Lond._, 1908, June meeting, by L. V. Cargill, William Turner, and the writer.

These dangerous complications, in many cases, were no doubt due to a failure to recognize that the complicated group of ethmoidal cells were involved in all cases of chronic frontal suppuration, and that previous to the introduction of the Killian operation our operative methods were very apt to dam up suppuration in dangerous corners. Finally, it was only when rhinologists first began to investigate frontal sinusitis that it was recognized what a dangerous region this is. To be convinced of this it is only necessary to compare the anxiety inspired by our regard for the cerebral wall of the frontal sinus with the calmness with which we regard an opening into the middle fossa, or through the dura mater, in mastoid operations.

We are not yet in possession of definite evidence in regard to the proportionate number of deaths which are due directly or indirectly to pus in the frontal sinus. Some observers hold that more deaths have occurred from operation than from neglected cases. Molinie has followed the history of fifteen private patients with frontal sinusitis, and not operated on, for ten years. Only one has died, and that was from another cause.[76] In any case we may still accept Lermoyez's dictum: 'Avoir une sinusite chronique est chose moins grave qu'on ne croit: operer une sinusite frontale est chose plus serieuse qu'on ne le dit.'[77]

[76] _Annales des Maladies de l'Oreille_, 1905, juillet, ii. 72.

[77] Ibid., 1904, x.x.x. vi. 579.

Doubtless the dangers have been diminished since the more general adoption of the Killian operation, but accidents may occur in the most skilful hands. This must be kept in mind when drawing up the indications for interference.

=Results.= In uncomplicated cases, successfully operated on, the results are most satisfactory. The preservation of the Killian bridge quite prevents any really unpleasant disfigurement. The depression which may form above it is proportionate to the size and depth of the cavity. No man need decline the operation on account of the scar left. In women we are able, with the help of a radiograph, to form an idea beforehand as to the degree of depression which may be left. This, if required, can be remedied by the injection of paraffin (see Vol. I), but, fortunately, the frontal sinus in women is not, as a rule, so deep as in men.

As regards cessation of purulent discharge the result will depend on the extent of the sinus, the presence of complicated orbito-ethmoidal cells, and the skill of the operator. If the ethmoidal labyrinth has not been completely dealt with, one or two cells may continue to secrete. It may be wiser to leave them alone. In very deep sinuses a 'dead s.p.a.ce'

between the back of the Killian bridge and the posterior (cerebral) wall of the sinus remains open, and may continue to secrete if not cicatrized over evenly.

But secretion is no longer pent up in the fronto-ethmoidal group of cells, and the patient is relieved of headache, depression, and other symptoms of septic absorption.

THE OGSTON-LUC OPERATION

This operation was first described by Ogston,[78] but was independently conceived by Luc.[79] Its principle is to make a fairly free opening into the frontal sinus, and then establish a large communication with the nasal cavity. The inner part of the supra-orbital rim is sometimes destroyed. But the operation does not provide for the treatment of orbito-ethmoidal cells, the anterior ethmoidal region and the sp[h]enoidal wall are not exposed, and if there be a large orbital recess to the frontal sinus it cannot be satisfactorily dealt with.

[78] Ogston, _The Medical Chronicle_, 1884, December.

[79] Luc, _Societe Francaise d'Otologie_, Paris, 1896, mai.

=Indications.= But the Ogston-Luc procedure, or some modification of it, is still suitable in (1) exploratory openings of the frontal sinus, (2) when the sinus requires opening for a recent and acute infection[80], and (3) for mucoceles and suppurating mucoceles.[81]

[80] StClair Thomson, _The Pract.i.tioner_, 1906, July.

[81] Logan Turner, _Edinburgh Medical Journal_, 1907, November and December.

=Operation.= A general anaesthetic is required. It is not necessary to shave the eyebrow, but the surrounding skin should be well purified. A curved incision is made through the eyebrow down to the bone along the inner third of the supra-orbital ridge, reaching from the supra-orbital notch to opposite the inner canthus. In the latter direction it can be extended if the ethmoidal region is chiefly affected, and if the ethmoid only requires exposing the incision is placed lower down.

With a raspatory the soft parts are turned upwards and downwards so as to expose the anterior wall of the sinus, which is opened with chisel and hammer. A probe will indicate its depth and direction. The opening is enlarged with bone-forceps sufficiently to allow inspection of the interior of the cavity, and permit of the pa.s.sage into the nose being enlarged with forceps, curettes, or burrs. The polypoid mucosa occupying the sinus and the fronto-ethmoidal cells along the pa.s.sage to the nose are carefully plucked away. A drainage tube or wick of gauze is inserted from the sinus down into the cavity of the nose, so that it can be withdrawn from the anterior nares at the end of twenty-four hours. The drainage tube is replaced by some surgeons. The frontal wound is sometimes closed at the time of the operation, and sometimes left open.

=Results.= These are variously given by different observers. Thus one author states that it will effect a cure in 85% of cases,[82] while another operated by this method in eleven cases, of which two died and not one was completely cured.[83]

[82] Lermoyez, _Annales des Maladies de l'Oreille_, 1902, novembre.

[83] H. L. Lack, _Edinburgh Medical Journal_, 1902, June, p. 542.

The subject does not require further discussion, as most operators have now given this operation up in favour of the improvements wrought in it by Killian. Luc himself has abandoned it in favour of the Killian operation. The latter is undoubtedly to be preferred in all cases of well established chronic purulent sinusitis with fungating mucosa and involvement of the ethmoidal cells.

KUHNT'S OPERATION

In this operation the entire anterior wall of the frontal sinus is chiselled away, so as to allow of the soft parts covering it being pressed down into the cavity until they are applied to the posterior wall. This, naturally, effects a complete obliteration of the cavity, but in order to secure it the orbital ridge has frequently to be removed to such an extent that a frog-like prominence is given to the eye, and the resulting disfigurement is very marked. Besides, this operation does not deal with the orbital recess of the sinus, or the orbito-ethmoidal cells--the most important part of the operation. In fact, the only advantage of this operation--complete obliteration of the sinus--is secured by Killian's operation, which also allows these regions to be dealt with, permits free drainage into the nose, and avoids disfigurement.

OPERATIONS UPON THE SPHENOIDAL SINUS

=Surgical Anatomy.= In operating on this sinus there are many anatomical and pathological points which it is desirable to remember. Only a few of them can be recalled.

The cavity is seldom absent, although it may be quite small. Its size and conformation may be irregular. Thus in one instance it may extend far out into the wing of the sphenoid, while in another it may be even smaller than a posterior ethmoidal cell invading the body of the sphenoid bone and lying above it.

While the sphenoidal sinus on one side is very small the opposite one may be so large that it comes in relation with the optic groove of the opposite side.

The anterior wall of the sphenoidal sinus can be opened with safety. The roof comes into close relation with the structures round the sella turc[ic]a. The outer wall is close to many large blood-vessels which might cause troublesome haemorrhage if wounded. The upper outer wall may be as thin as paper.

There may be deficiencies present in the bony walls, so that, for instance, the mucous membrane of the sinus and the dura mater may be in direct contact.

The Rontgen rays give such valuable information as to the size and relations of the cavity, as well as to diseases in its cavity or walls, that a radiograph should be taken in all cases (Figs. 343 and 344).

SOUNDING AND WASHING OUT THE SPHENOIDAL SINUS

=Indications.= Lavage alone may be sufficient for acute or recent cases, but in chronic forms of suppuration a larger and permanently patent ostium must be established, both to allow of more effective drainage and of treatment of the interior of the cavity.

When the interior of the nasal chamber is in a normal condition it is only possible to catheterize this cavity in a limited number of cases.

The region of the middle turbinal and olfactory cleft is carefully prepared with cocaine and adrenalin. A pledget soaked in the mixture is inserted between the middle turbinal and the septum, and pushed backwards until it reaches the anterior wall of the sinus.

[Ill.u.s.tration: FIG. 343. RADIOGRAPH OF THE SPHENOIDAL SINUS. The beak of a punch-forceps is seen in a posterior ethmoidal cell (which has been opened) and pressing against the anterior wall of the sphenoidal cavity.]

A canula is then inserted in a sloping direction inwards and upwards diagonally across the plane of the middle turbinal until it impinges on the nasal surface of the sphenoid, in the neighbourhood of the ostium (Fig. 345). The latter is found by feeling with the tip of the catheter.

The opening is never visible in health. It may lie a little external to the direction of the olfactory cleft--about 5 millimetres from the middle line.

[Ill.u.s.tration: FIG. 344. RADIOGRAPH OF THE SPHENOIDAL SINUS. This is a sequel to the preceding ill.u.s.tration. The front wall of the sinus has been broken through, and the beak of the forceps is now shown inside the sphenoidal cavity.]

If this plan be not successful, the ostium sphenoidale can more certainly be discovered in the following way. A more complete and prolonged application of cocaine is carried out, particularly in the neighbourhood of the olfactory cleft and the spheno-ethmoidal recess.

Killian's long nasal speculum (Fig. 346), sterilized and warmed, is inserted between the middle turbinal and the septum. By separating the blades of the speculum the pa.s.sage is dilated, so that the instrument can be slipped further in, and so, by alternating movements of expansion and advance, the front wall of the sinus is brought into view. During this procedure the middle turbinal is crowded outwards, and no alarm need be caused if a slight cracking sound shows that its attachment has been fractured.

The mouth of the sphenoidal sinus is often indicated by the muco-pus oozing from it or pulsating in harmony with the pulse. If discharge be not escaping the ostium may be only a potential and not an actual orifice--like that of the meatus urinarius--and has then to be more carefully sought for and detected with a probe. If there be difficulty in finding the ostium, the front wall should not be broken through until the presence and size of the sinus has been demonstrated by means of a radiograph (Figs. 343 and 344). The sinus is washed out, as described for the frontal and maxillary cavities.

[Ill.u.s.tration: FIG. 345. CATHETERIZING THE SPHENOIDAL SINUS.]