Sinus

“ 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. ”

“ 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. ”

“ 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. ”

“ If a sinus or sinuses have formed under the skin or between the muscles, from the extension of disease in the cellular or areolar structure, they must be laid open, and the cautery applied; for if any part affected be left untouched or undestroyed by the acid, the disease will recommence and spread from that point. ”

“ In the event of the wound being compound, air may enter into the sinus. Insomuch, however, as the sinus pressure is, under normal conditions, positive, this complication is of rare occurrence, unless the patient is in a state of profound shock, from loss of blood, or suffers from urgent dyspnœa. ”

“ If this sinus have remained long open, its surface, like that of the chronic abscess, becomes changed, and a coat is formed, like the cyst of a tumour. When this is thick and hard, the sinus has been called a fistula, and it has been deemed necessary to dissect out the tube; but it is in general sufficient to use the remedies which increase the vigour of the action, and make it run its natural progress; such as the seton, or a free incision, if the parts be superficial, or no considerable vessel or nerve runs the risk of being wounded. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ However, the honor of having initiated the rational treatment of diseases of the maxillary sinus is not exclusively due to William Cowper and to James Drake; a large share is also due to the celebrated German250 physician and anatomist, Heinrich Meibom. The mucous membrane of the maxillary sinus was considered by him as the real point of departure of the diseases which occur in this cavity, it being liable to become inflamed and to suppurate, thus giving rise to much pain and to various accidents. ”

“ 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. ”

“ 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. ”

“ No brain abscess. Ventricles contained more than normal quantity of fluid. Frontal sinuses and cribriform plate of ethmoid and ethmoidal cells normal.
To right of the sella turcica there was some necrosis of the walls of the sphenoidal sinus. Probe readily passed from base of skull through sphenoidal sinus into the nose. Large free opening from said sinus into nose, which sinus was full of muco-pus. Cavernous sinus not thrombosed. Right antrum of Highmore contained about a dram of thick glairy mucus. ”

“ The inferior longitudinal sinus begins at the fore part of the brain, but rung deeper down in the pia mater between the two hemispheres of the brain, terminates in the straight sinus which empties into the wine press. Beginning at the base of the cerebellum are the two occipital sinuses which run together and terminate in the wine press. After all the blood has been gathered together in the [140] wine press, it leaves by means of the right and left lateral sinuses which pass down as far as the jugular foramen. ”

“ The sinus also receives ducts from the hinder part of the mesonephros, either separately, as in the female, or by a common duct on each side—the so-called metanephric duct—as in the male. Two tubular caecal outgrowths from the sinus form two sperm sacs. Only the anterior portions of the Müllerian ducts with their coelomic apertures are retained in the adult. ”

“ Thus when the sinus is in the arm, and the mouth of the sore is near the elbow, by placing the hand in an elevated position, you will render the discharge from the ulcer below easy. And when the sinus is in the thigh, and has its outlet near the knee, you must make the position declining by putting a soft pillow below the back part of the knee, so that the groin may be in a lower position than the knee ”

“ 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 fact, the instant when an odour enters the nose, having the air for its vehicle, it cannot at once pass into the sinuses, because the orifices by which these cavities communicate with the nose are very small ”

“ 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. ”

“ These blood sinuses pass usually from before backwards: a superior longitudinal along the upper border of the falx cerebri as far as the internal occipital protuberance; an inferior longitudinal along its lower border as far as the tentorium, where it joins the straight sinus, which passes back as far as the same protuberance. ”

“ 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. ”

“ The sinuses may be so tortuous that a probe cannot be passed to the primary focus of disease, and their course and disposition can only be demonstrated by injecting the sinuses with an emulsion of bismuth and taking X-ray photographs. ”

“ We consider that stimuli are also propagated from one chamber of the heart to another through nervous channels: thus we find that irritation of the venus sinus will sometimes produce simultaneous contractions of the auricle and ventricle, instead of the ventricular beat succeeding the auricular in the ordinary way. ”

“ 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. ”

“ The accessory sinuses of the nose are also prone to disease. The maxillary antrum may become filled with muco-pus, forming an empyema, pus escaping intermittently by way of the nose. The condition causes pain and swelling, and may require the irrigation and drainage of the antrum. The frontal sinuses may become filled with mucous, owing to the swelling of the nasal mucous membrane over the middle turbinated bone, or an acute inflammation may spread to the frontal sinuses, giving rise to an empyema in that locality. ”

“ Every child knows that the nasal fossæ are formed to receive sensations, as by their depth and extent a larger surface is given to the pituitary membrane, and these soft sinuses, or cavities, are enabled to retain a greater mass of air loaded with odoriferous matter. ”

“ The gastro-pulmonary surface penetrates into the interior by the mouth, the nose and the anterior face of the eye. 1st. It lines the first and second of these cavities, extends from the first to the excretory ducts of the parotid and sub-maxillary glands, from the other into all the sinuses, forms the conjunctiva, dips down into the puncta lachrymalia, the nasal duct, the sac of the same name, and is continued into the nose ”

“ Besides which it may be observed, that in dotage the person is often sluggish and lethargic; and that as a defect of the nutritive faculty in the brain will permit the sinuses to be more easily distended, so a distention of the sinuses, from this or any other cause, may impede the due nutrition of the brain. ”

“ 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. ”

“ To restore breathing, put the pipe of a common bellows in one nostril, carefully closing the other and the mouth; at the same time drawing downward, and pushing gently backward, the upper part of the windpipe, to allow a more free admission of air; blow the bellows gently, in order to inflate the lungs, till the breast be raised a little; then set the mouth and nostrils free, and press gently on the chest; repeat this until signs of life appear. When the patient revives, apply smelling-salts to the nose, give warm wine or brandy and water. Cautions.—1. Never rub the body with salt or spirits. ”

“ The beneficent Creator, with that wisdom which characterizes all his works, has very wisely placed the organ of this sense just above the mouth, in order that the scent of many things that are hurtful may warn us from partaking of them before they reach the mouth. The air-passages of the nose, in which this sense is located, are lined with a thin skin, called the mucous membrane, which is continuous with the lining membrane of the parts of the throat and of the external skin. ”