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the cavernous sinus is likewise a possible consequence, as well as fatal meningitis.

66. The diagnosis depends upon exploration of the sphenoid sinus through its orifice. If the probe slants sufficiently backward and upward, it is bound to touch the anterior surface of the sphenoid body. By holding it nearly vertical and probing too near the front end of the middle turbinal its tip reaches the dangerous nasal roof. But by crossing the middle turbinal behind its center this danger is avoided. The sphenoid orifice is situated close to the roof of the nose and nearer to the lateral wall than to the septum. By bending the tip of the probe a trifle upward, it is quite often possible to enter the sphenoid orifice. The distance from the inferior rim of the pyriform aperture to the sphenoid opening varies from 6 to 8 cm. in the adult. After entering the orifice the probe can then slip into the sinus to the extent of 1 to 2 cm. When pus issues next to the probe or adheres to the probe, the diagnosis is established. If this test fails, a slender cannula can be substituted for the probe, and an attempt made to dislodge the sphenoid secretion by warm salt solution. It is often difficult, sometimes impossible, to distinguish between suppuration of the posterior ethmoid cells and of the sphenoid sinus until the middle turbinal has been nearly entirely removed.

67. Treatment.-When the inflammatory process in the sphenoid is of a superficial character, a few irrigations through the natural orifice will sometimes terminate the disease. In instances attended with suffering, the first successful irrigation gives relief. If irrigation through the natural opening proves impossible or insufficient, the anterior wall of the sinus can be opened in the safest manner by means of Hajek's hook. Traction with a hook does not involve the risk of slipping that attends the use of a drill or a perforating curet. The opening of the sinus suffices for a gradual cure, except when its interior lining is permanently hypertrophied. In such instances the mucous membrane has been successfully removed by means of

the curet or the introduction of a pledget of cotton on a probe moistened with chlorid of zinc solution. This should be introduced through a tube in order to protect the nasal lining. On account of the possible thinness of the upper wall of the sinus, Hajek advises as the safer method the evulsion of the thickened mucous membrane with forceps rather than with a curet working in the confined space. The use of the curet on the inferior wall involves no risk. In the majority of instances, suppuration of the sphenoid sinus can be controlled by treatment with more certainty than extensive disease of the ethmoid cells.

MULTIPLE EMPYEMA OF SEVERAL ACCESSORY CAVI

TIES.

68. Although sinuitis is mostly limited to one cavity, multiple disease of several spaces is not uncommon. Such instances may be one-sided or bilateral, in the latter cases perhaps most frequently with symmetric involvement on both sides. In the case of the frontal sinus bilateral disease is sometimes due to a defect or morbid perforation of the median partition wall. The The spaces which participate the oftenest in multiple empyema are the ethmoid cells, the anterior in connection with maxillary or frontal sinus disease, the posterior with sphenoid suppuration. Occasionally all cavities are found diseased on one or even both sides.

As in the case of disease of a single sinus, the symptoms may vary greatly. On the one hand, a few patients complain of nothing but a very profuse discharge. It is remarkable how little disturbance of health there

may be in such exceptional cases. On the other hand, there may be, besides the local discomfort and the nasal secondary disturbances, headaches of great severity, general malnutrition, and neurasthenia, until the patient becomes a physical wreck.

The diagnosis can be made only gradually, as the involvement of one cavity after another is being recognized.

Efforts must be made to trace the origin of the pus according to the indications discussed previously.

69. In instances in which no severe or dangerous symptoms are present, the attempt may be made to expose the suppurating spaces by the same intranasal operations which apply in disease of each individual sinus. But whenever urgency is called for, a more radical method is the free opening of the accessory spaces from the outside. A number of different modifications of osteoplastic operations have been devised by Gussenbauer, Winkler, and Killian. All of them give fairly satisfactory results; none of them have received extensive trial. The principle of such an operation for one side at a time is the following:

General narcosis, tamponing of the nasopharynx, incision down to the bone in the median line from the upper level of the frontal sinus along the bridge of the nose down to beyond the lower border of the nasal bone, pushing back the periosteum sufficiently for separation of the nasal bones at the nasofrontal suture. Subperiosteal resection at the same level through frontal process of superior maxilla with a fine saw or chisel, opening the bony frame of the external nose through the suture between the two nasal bones, and pushing outward the external wall of the nose (nasal bone and frontal process of submaxilla), if necessary after grooving along its nasal surface in case it offers too much resistance. The ethmoid cells can now be entered from the front, and by breaking down all cross partitions and septa with forceps, they can be changed into a single continuous space from lamina papyracea to middle turbinal, opening freely into the nose. The operation can be extended to the anterior sphenoid wall, and the sphenoid sinus exposed. In case of frontal empyema a horizontal incision is extended through the brow, a portion of the anterior wall of the sinus is resected, the duct identified by a probe introduced into it, and the floor of the sinus chiseled away as far as it is accessible from the nose. Gauze tam

pons leading into the nose, replacing of bone flaps, primary or early secondary suture. After-treatment through the nose.

In Gussenbauer's operation for bilateral disease the cutaneous incision begins near the middle of each eyebrow, runs down vertically (about 5 mm. beyond the internal canthus) along the sides of the nose, and connects across the nose at the lower border of the nasal bones. A single bony flap is made of all the nasal walls circumscribed by the incision, including the lachrymal bone and a slice of the lamina papyracea, as well as the perpendicular plate of the ethmoid. After sawing and chiseling through all connections, the flap is reflected upward and access obtained to the upper part of the interior of the nose and the entire ethmoid labyrinth on both sides. After the complete exenteration of all diseased spaces the flap is replaced.

CHAPTER IX.

OZENA (FETID ATROPHIC RHINITIS). SIMPLE ATROPHIC RHINITIS.

70. Symptoms and Course.-Atrophic rhinitis is characterized by a purulent secretion, drying in the form of adherent crusts, and accompanied by progressive atrophy of the nasal mucous lining and of the turbinated bones. In the "simple" form the crusts are nearly odorless; in the fetid form-the more common variety-the crusts have a very strong offensive and characteristic smell. As the fetid form can be changed by treatment into the odorless simple form, the two varieties of the diseasesimilar in course-may be considered under one head.

The

The beginning of the disease has been but little described and is probably not seen often. In some personal observations it began as a minimal localized focus of characteristic suppuration on the middle turbinal, with crust-formation gradually extending in area. The subjective annoyance is but moderate. There is some transient obstruction when large scabs form, which diminishes, however, as the atrophy proceeds. crusts cause the patient to blow forcibly in order to expel them, as there is but little fluid discharge. In neurotic subjects severe headaches, both more or less irregularly continuous pain, as well as periodic attacks of migrain, are not uncommon. The patients have occasional fresh "colds," with increased discharge, but these attacks are both less severe and less common in atrophic rhinitis than in other chronic forms of nasal disease. They cease almost entirely when the atrophy has advanced far. The most distressing symptom, present only in the fetid form, is the foul odor noticeable sometimes across the room, but not perceptible to the patient. The patient's sense

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