Frontal sinus

“ The frontal sinus, that opprobrium phrenologicum, is a reality, not unfrequently of large size, and may wholly occupy the regions of five organs. The centres of ossification of the frontal and parietal bones, the muscular crests of these and of the occipital bones also, differ in their prominence in different skulls. Premature synostoses of sutures mould the brain without doing much injury to its parts. In such cases there are compensatory dilatations in other directions modifying sometimes to an extreme degree the relation of brain-surface to skull-surface. ”

“ The discharge from them is304 profuse and fetid, and in some cases blood flows in no small quantity. Such growths usually commence in one or other of the sinuses connected with the cavity of the nose—sometimes, though rarely, in the frontal sinus. When seated in the antrum maxillare, pain is experienced in the cheek for a short time before swelling occurs. Soon the part enlarges, its coverings are thickened, the bony cavity expands, and the patient’s sufferings are excruciating. The teeth loosen, and sanious matter is discharged from their roots. ”

“ In proportion as the horn core grows, there develops within it a cavity which may either be of a simple character or divided by a longitudinal partition. This communicates with the frontal sinus, a fact which explains the collection of pus in the sinuses as a result of injuries to the horns. The sinus of the horn core does not exist in young animals, and is not completely developed before the third or fourth year of life. ”

“ Disease and old age alone oppose obstacles to this proceeding; for by these causes the skull may be increased or diminished in volume, and it is generally irregular in thickness in old age: the sutures also interrupt absolute parallelism, but their situation is known and allowed for, and the frontal sinus, or cavity at the top of the nose, in the frontal bone, (which is often enlarged and covered by the schneiderian membrane giving great power to the nerves of smell) is so remotely connected that it can only affect a few organs,—five at the most. ”

“ While strain of accommodation is a frequent source of headache and is at once looked for by ophthalmologists, there seems no doubt that some headaches, much fewer than accommodation cephalalgias, are due to muscle difficulties, that is, a lack of balance among the external muscles of the eye, whose full pathological significance has perhaps not yet been worked out. Headaches are {551} frequently due to sinus troubles, especially to disturbances in the frontal sinus and to intranasal difficulties. These must be eliminated before the patient can be helped. ”

“ It is generally sessile and solitary, and may grow into the interior of the skull, into the frontal sinus, into the cavity of the orbit or nose, or may fill up the external auditory meatus, causing most unsightly deformity and interference with sight, breathing, and hearing. ”

“ The frontal sinuses are two irregular cavities extending upward and outward, from their openings on each side of the nasal spine, between the inner and outer layers of the skull, and separated from one another by a thin bony septum. They give rise to the prominences above the root of the nose called the nasal eminences. They are not developed till after puberty, and vary considerably in size, being usually larger in men than in women and young persons, in consequence of the greater prominence of the superciliary ridges in the former. ”

“ At a higher level and on a posterior plane is the anterior end of the middle concha or turbinated body, which is of a paler colour than the inferior, and is only visible when the head is tilted backwards. Between it and the inferior turbinated body is the middle meatus, with which communicate the openings of the maxillary sinus, the frontal sinus, and the anterior ethmoidal cells. A considerable area of the anterior part of the nasal septum is also visible by anterior rhinoscopy, and between it and the middle turbinal is a narrow chink—the olfactory sulcus. ”

“ The sphenoidal sinus near F opens into the upper meatus. The frontal, Z, and maxillary sinuses open into the middle meatus, and the nasal duct opens into the inferior sinus beneath the anterior inferior angle of the lower spongy bone, W.
In the living body the very vascular fleshy and glandular Schneiderian membrane which lines all parts of the nasal fossa almost completely fills this cavity. When polypi or other growths occupy the nasal fossae, they must gain room at the expense of neighbouring parts. ”

“ This sinus originates at the crista galli and, passing backwards along the attached margin of the falx cerebri, terminates at the internal occipital protuberance. It may be represented by a line drawn from the base of the nose (the nasion) , over the vertex of the skull, to the external occipital protuberance (the inion) —this line corresponding in its course to the occasionally persistent metopic suture between the two halves of the frontal bone, to the sagittal suture between the parietal bones, and to the middle line of the upper or tabular portion of the occipital bone. ”

“ L. H. Runge, a surgeon of Bremen, published, in 1750, a monograph on the diseases of the frontal and maxillary sinuses. He says that in cases of inflammation of Highmore’s antrum, the pus may make its way, corroding the bone, as far as the alveoli, or, sometimes, as far as the orbital cavity; and, vice versa, alveolar suppuration can give rise, by diffusion, to abscess of the maxillary sinus. In this latter, tumors of various kinds may form (polypi, cysts, sarcomas, cancers, exostosis) , the existence of which is ignored at first, and only becomes manifest tardily. ”

“ An operation upon one maxillary sinus has been known, even in the most skilful hands, to cause death by meningitis or diffuse septic osteomyelitis of the cranium. Post-mortem examinations show that this disaster was due to infection spreading upwards from an infected ethmoid, frontal, or sphenoidal sinus, when local resistance had been diminished, or the virulence of the organisms has been increased by the surgical traumatism of the maxillary sinus. ”

“ The longitudinal sinus does not contain blood, and the inner surface is normal in color. The pia is extensively thickened and opaque and a general subpial exudate exists which is more marked over the vertex where it lifts the pia from the brain surface to the extent of three centimeters in Rolandic, superior frontal, intraparietal, and mesial precentral sulci on each side. ”

“ That animal has no development of this description, and therefore it only shows ignorance to operate with a special view to opening an imaginary cavity. The maxillary sinuses are spacious cells, and freely communicate with the frontal sinuses, which are also large. These facial sinuses have but a limited and kind of valvular opening into the nasal chambers, and if pus is allowed to remain within them there is little hope of cure: therefore a [160] means must be found for its escape. ”

“ Having in my surgical work demonstrated the existence of a hitherto unrecognized connecting passage or canal between the air cavities of the face and those of the forehead, [2] the play of resonance in the cavities above the nostrils is more easily understood. The function of the cavities known as the frontal sinuses (see Fig. 1) has long been a mystery, but now that their direct connection with the lower cavities is proven, and the great significance of resonance is also beginning to be recognized, the mystery disappears. ”

“ At the end of twenty-four hours the symptoms are intensified 106or altered. The eyelids are more swollen and the flow of tears more profuse; the nasal discharge becomes slimy, and streaked with blood, and accumulations take place in the frontal sinuses as indicated by the increasing heat of the forehead and the dullness on percussion. ”

“ The sphenoidal sinus is involved in at least 40-50 per cent. of basic fractures, comminution of the sinus wall being often so excessive that a probe can be passed with the greatest ease from the middle fossa into the naso-pharynx. Blood is thus allowed to escape readily into the naso-pharynx, and a source is opened up for the possible development of meningeal infection. ”

“ Sometimes, indeed, there are no clinical symptoms, the condition perhaps only being discovered whilst performing the complete mastoid operation as a prophylactic measure. The sinus is generally exposed accidentally whilst following out a tract of carious bone, and, to the surprise of the surgeon, pus or granulations may be seen to exude or protrude from an opening in its outer wall. On further exposure of the sinus on each side of the thrombus, the dura mater may appear to be of a dark colour for a short distance, but beyond this to be of normal appearance. ”

“ To expose this tributary, which enters the lateral sinus at the point at which it turns downwards to form the sigmoid sinus, bone must be removed in front of the lateral sinus along the angle forming the roof and inner wall of the mastoid and antrum; that is, along the superior margin of the petrosal bone. If the inner surface of the lateral sinus in its neighbourhood be normal, nothing need be done. If, however, the sinus wall be infected, the petrosal sinus should be followed out, if possible, its outer wall being incised and the clot removed, bleeding being afterwards arrested by pressure. ”

“ The fourth species of sinuses, are those where a specific action exists39, and prevents the healthy ulcerative action from forming. Of this kind is the scrophulous sinus, which is generally accompanied with a caries bone, or diseased cartilage, and, therefore, is a complicated sinus40. This is distinguished, where the bone is diseased, by a shining or polished red skin, like a cicatrix, surrounding the fungus papilla at the orifice of the sinus, or the scrophulous-looking sore which exists there. When no caries bone exists, we have no papilla, but only the diseased ulcer at the orifice. ”

“ The presence of a foreign body is often suggested by a mass of redundant granulations at the mouth of the sinus. If a sinus passes through a muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. ”

“ A sinus is lined by granulation tissue, and when it is of long standing the opening may be dragged below the level of the surrounding skin by contraction of the scar tissue around it. As a sinus will persist until the obstacle to closure of the original abscess is removed, it is necessary that this should be sought for. It may be a foreign body, such as a piece of dead bone, an infected ligature, or a bullet, acting mechanically or by keeping up discharge, and if the body is removed the sinus usually heals. ”

“ Feb. 19th, 9 a.m.,—pulse 106, temp. 99.5. Both sinuses discharging very freely. Made an opening in the lower part of the pouch to the left of the pubis for better drainage, as the patient usually lies [Pg 14] on the right side. Laxative has operated. After washing out both sinuses with a five per cent. solution of carbolic acid, I inject the smaller sinus with liquid vasaline.
Feb. 20th, 9 a.m.,—pulse 112, temp. 103.5. There is a great amount of pus being discharged from the large sinus on the back, not so much from the small one. Patient had a chill last night. ”

“ In cases of unilateral multi-sinusitis, if a suitable tooth socket be available, the alveolar operation serves both to determine the condition of the maxillary sinus and to establish drainage, while the other cavities are being investigated or treated. In patients who are too old or feeble to endure more radical measures, or who decline them, the obturator may be left in indefinitely. ”

“ From an examination of many skulls in the Hunterian Museum, I find that the absence of the ‘bumps,’ even in middle age, does not necessarily imply the absence of the sinuses, since they may be formed by a retrocession of the inner wall of the skull. In old persons, as a rule, when the sinuses enlarge, it is by the encroachment of the inner table on the brain case. ”

“ This species is distinguished by our feeling the extraneous body, or diseased bone, with the probe, and by the fungous protuberance, or papilla, which shoots out from the orifice. In addition to the method of curing other sinuses, we must here endeavour to remove the adventitious cause, which is generally very difficult to be done. If the foreign body be deep, or if the diseased bone lie deep, and the sinus be narrow, we can do little in this way ”

“ He states that the blood is derived from one or more radicles of the superior longitudinal sinus, especially from those veins which, in their upward passage in the sulci of the brain, leave their cerebral beds for a short and comparatively unprotected course, immediately previous to their entry into the lacunæ laterales of the superior longitudinal sinus. ”

“ These fistulæ may open into the rectum, bladder, vagina, uterus, or some spot on the anterior abdominal wall below or near the umbilicus. The treatment is simple, and consists in dilating the sinus and extracting all the fragments. If this be thoroughly carried out the sinus quickly closes. Partial operations are useless: if but a bit of a bone remain, a troublesome sinus will persist. It is bad practice to attempt to extirpate the sac in such condition; such an operation usually terminates fatally. ”