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instances almost obliterate the sinus. The encroachment upon the cavity by any considerable depression of the facial wall reveals itself in the architecture of the face, while unusual width of a nasal stenosis of the maxillary sinus. not rarely asymmetric (Fig. 45).

meatus also suggests The two cavities are On the other hand,

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FIG. 44.-Right superior maxilla; antrum opened from the external side: O. m (large), maxillary orifice; O. m. a, accessory maxillary orifice; p, uncinate process (Zuckerkandl).

the space is often enlarged by the formation of niches or recesses in the solid bone, leading to the formation of an alveolar-palatal-infra-orbital or molar sinus, while in other instances the cell in the orbital process of the palate bone may constitute a posterior niche connected with the maxillary sinus. These recesses are sometimes spaced off by incomplete bony partitions. Occasionally

more or less complete bony septa, vertical or horizontal, divide the entire sinus into two separate chambers, each communicating with the nose.

The floor of the antrum, formed by the junction of the external and posterior walls, varies in width in different subjects, and is often reticulated by the prominences corresponding to the teeth beneath the floor. According to the degree of absorption of the cancellated tissue, the

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FIG. 45. Asymmetry of the two maxillary sinuses. On the right side, at a, a deep alveolar recess, while on the left side the alveolar process, b, extends upward (Zuckerkandl).

roots of the teeth may project into the cavity or be separated from it by a thick alveolar process. The number of teeth below (or in) the floor of the antrum varies with the development of the alveolar and palatal niches. Zuckerkandl found in 26 skulls that the sinus reached from the last molar to the first molar 6 times, to the second bicuspid 3 times, to the first bicuspid 13 times, to the canine teeth 4 times. The infra-orbital canal, containing the infra-orbital nerve, which passes along the roof of the antrum, is partly deficient in some subjects, leaving the nerve exposed.

The opening between the nose and sinus is in the upper part of the nasal wall of the antrum, close to the roof or orbital wall of the sinus (see Fig. 37). It is usually oblong, its height ranging between 2 and 5 mm., and its length between 3 and 10 mm. But this opening leads only indirectly into the nose through the space called the infundibulum. The large aperture found in the upper half of the nasal wall of the macerated max

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FIG. 46.-R, Superior maxilla, nasal surface, the inferior concha partly resected in order to show the maxillary process: P. m, Maxillary process of the turbinated bone; P. e, ethmoid process of the turbinated bone; P. I, lachrymal process of the turbinated bone; C. t, turbinal crest of the palate bone; C. e, ethmoid crest of the palate bone; C. e', ethmoid crest of the maxillary bone (Zuckerkandl).

illary bone is narrowed by the articulation below with the maxillary process of the inferior turbinated and the uncinate process, posteriorly with the vertical lamella of the palatal bone, and above with the hollow process of the ethmoid-the bulla ethmoidalis (Fig. 46). The latter forms a cornice slanting backward and somewhat downward on the nasal side of the sinus wall. The uncinate process of the ethmoid bone, shaped like a sickle, begins

in front and below the bulla, and, passing backward and somewhat downward, crosses the bony aperture and divides this opening into an anterior (lower) and a posterior (upper) half. The spaces between the uncinate process and the rim of the bony opening are closed by mucous membrane and constitute the nasal fontanels of the antrum, usually containing a few delicate bony bridges. Near the center of the upper or posterior fontanel, between the uncinate process and bulla, is the orifice of the maxillary sinus. The cornice-like projecting bulla and the uncinate process inclose between them a semilunar slit, a curved recess slanting backward and downward like the processes which surround it—of a width of from 2 to 6 mm. and a length of from 20 to 30 mm. This slit, the hiatus semilunaris, is the nasal gateway into the space between the bulla and uncinate process, the infundibulum,-in the external wall of which the actual opening into the sinus is found. In the wider anterior portion of the infundibulum there is usually the orifice of the frontal sinus; sometimes, however, it is anterior to it. The aperture of the maxillary sinus is thus situated unfavorably for the escape of secretions, and every slight swelling of the mucous lining of the semilunar hiatus or of the infundibulum may shut off the communication between the nose and sinus. As the semilunar slit is completely covered by the middle turbinal, it is invisible during life. It is hence difficult and often impossible to enter it with instruments. A second accessory maxillary aperture is found in about 10 per cent. of subjects in either the upper or the lower fontanel, but is usually smaller than the principal orifice.

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CHAPTER VII.

DISEASES OF THE MAXILLARY SINUS.

ACUTE MAXILLARY SINUITIS.

47. Acute inflammation of the maxillary sinus is clinically an occurrence of but moderate frequency, and not nearly so common as the findings of fresh lesions at autopsies. The clinical picture is, however, well defined and not difficult to recognize. It occurs either as the sequel of an acute nasal catarrh or an influenza rhinitis, or sometimes apparently primarily. In other less common instances the infection proceeds from diseased teeth. In rare instances the disease is brought about by intranasal operations, especially cauterization. Acute onset of moderate fever, with general malaise for a few days, disturbed appetite, and bad taste usher it in. As a rule, there is considerable infra-orbital pain, sometimes shooting into the teeth, and often supra-orbital pain and tenderness, suggesting involvement of the frontal sinus, which is not present. The cheek is tender to touch, sometimes slightly edematous.

The acute disease is usually one-sided. Free discharge of pus from one side of the nose occurs within the second day. Sometimes this is offensive from the start. Even if the pus is bland, the patient usually complains of a subjective bad smell.

The acute symptoms begin to subside in the course of about a week. In favorable cases the disease heals spontaneously in from three to six weeks. It is doubtful whether a spontaneous cure ever occurs in cases of dental origin. The liability to become chronic is increased. by the coincidence of intranasal lesions causing stenosis. The diagnosis, which is strongly suggested by the sub

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