An introductory study is made of the physiological function of the nose as the first line of defence
of the air passages. These consist essentially of an
upper part formed by the nose and naso-pharynx and a lower part comprising the larynx, trachea, bronchi and
bronchioles. Interference with the proper functioning
of the nose may have injurious results in the lower respiratory tract and therefore the interests of the
physician and the rhinologist meet on common ground.
The ciliary-mucus defence mechanism of the
nose is outlined in the case of infective organisms
invading the nose and its accessory sinuses. If the
defence is overcome the progress of an acute sinusitis
is followed and it is shown how in a rigid- walled space
such as the antrum, Nature's method of overcoming the
infection is by means of re- establishing its drainage
and aeration through its natural ostium, and by the
attempt at replacement of damaged lining membrane by
one having normal ciliated epithelium.. It is then
shown that in the presence of certain adverse factors
in the nose, such as deviated septum, the complete
opening of the ostium is interfered with and the infection in the sinus becomes chronic. The sinus now
becomes a suppurative focus, giving rise to toxic discharges which pass into the nose and throat, and from
which toxic products and bacteria may pass directly
into the blood-stream.
The maxillary antrum lends itself to
study since it is the sinus most often infected
and which for a long time may remain the only
sinus infected. In addition, its infection often
dates from childhood.
The rhinologist follows the principle
of drainage and aeration whatever his treatment of
the sinusitis may be,but in chronic infection he
aids the reparative process of nature by removing
the diseased)and often disorganised lining membrane,
and by making an artificial drainage opening into
the nose. This opening is situated nearer the
floor of the antrum and is of more favourable
size than the natural ostium.
Following a short historical review
tracing the evolution of the method used, a description of the method of access and drainage is
given as embodied in the classical Caldwell-Luc
operation with certain modifications such as the
high gingivo-labial incision and the formation of
a mucosal flap which is laid into the antrum.
The method of anaesthesia, and the precautions
taken to safeguard the lower respiratory tract
it
against blood or secretions flowing town into it are
outlined.
A clinical study then follows of 70
cases of chronic maxillary sinusitis. The local
effects are traced to see in how far the procedure
succeeded not only in removing the disease and
promoting drainage and aeration of the antrum,
but also how this was accomplished along the lines
of the physiological principles of the nose, so that a healthy nose and antrum may remain.
The studies first of all showed that
the antrum does not become obliterated after removal
of its lining membrane, but retains its form and
shape and becomes, in fact; lined with a newly - formed membrane. Support of this finding and reports of the histological examination of this membrane are given from the literature to show that
the desired ciliated epithelium is regenerated in
3 to 5 months. When this has occurrred the antral
cavity can again assist at its own drainage.
The functions of the artificial antronasal opening are outlined by a study of cases where
it had closed and it was concluded that it has a primary
function of drainage and aeration of the antrum in the
first 3 to 5 months before the regeneration of its
epithelium after which no ill effects would follow its
closure provided no adverse factors are present in the
nose that favour re-infection of the antrum in which
case its continued use would be highly desirable. It
is also shown from cases that where certain adverse
factors are present in the nose or recur,the presence of
an opening tends to reduce their ill effects on the
patient. With reference to cases the optimum size of
the opening is discussed in the light of the desired
functional results. It is shown that nothing is gained
by making . the opening too wide as much of the suction - drainage effect on the antrum would be lost.
The role of the mucosal flap is shown to be
that of providing a convenient nidus for the outgrowth
of new ciliated epithelium into the antrum and secondly
of helping to maintain the patency of the antro -nasal
opening especially at its important rounded ant.- inferior angle.
The effect on the inf. turbinate is studied in
the light of its important function of shaping the inspired air -stream in its arched course in the nose and
thereby being an integral part in the method of suction - drainage of the accessory sinuses. Interference with
this structure at operation should be minimal and even
if somewhat enlarged there is a tendency for it to
shrink afterwards. In addition, atrophy of the nasal
mucosa produced by the old disease often persists
giving a roomy nasal chamber where the presence of a reduced inf. turbinate Tould the more disturb the direction and force of the inspiratory air-current.
A clinical estimation then follows of the results of this method of drainage on the antral infection and the associated changes it had produced in the
nose. The aim of this method and the principles it
embodied was to render the patient free of symptoms and
gain a normal antrum and nasal cavity free of abnormal
secretions. Using this desired result as standard
45.7% of cases were "cured ", 21.4% were "much improved", 14.3% were "somewhat improved" and 18.6%
derived no local benefit. The causes for the less
favourable results were studied in detail and were
shown to be due to certain adverse factors present
chief of which were, first and foremost, residual ethmoidal (and sphenoidal) infection and secondly the persistence of the allergic diathesis with recurrence of
polypi. The persistence of the latter caused less
favourable results in 14.3% of all the cases (or 26.3%
of the "uncured "). Where septal deformity was present
polypi tended to recur and a poorer result followed.
Apart from the further treatment of septal deformities
and hypertrophies the patient should receive general
medicaltreatrnent directed against the allergic diathesis
failing which, the effect of radium application might
be tried.
Residual ethmoiditis (and sphenoiditis) was the
adverse factor present in 20% of all cases (or in
30.7% of the "uncured "). The potential danger of its
persistence in causing severe complications after opera
tion is stressed. In the "not improved" group it was
the factor responsible in 70% of them and its persistence was associated with the persistence of severe
types of headache, nasal- discharge and re- infection of
antrum and remote symptoms of toxic origin. Methods
were discussed to minimise the difficulties attendant
on adequately dealing with ethmoidal infection at the
time of the antral operation, and amongst others, the
transantral method of approach to the ethmoid was discussed, whereby using the usual method of ether anaesthesia both the antrum and the ethmoid could be dealt
with through the one approach.
The effect of the operation in producing possible damage to the nerve- supply of the teeth and gums
and of producing severe swelling or infection of the
cheek, or after - neuralgia of the cheek, is studied
in this seriesof cases. It was found to be minimal
and not sufficient to detract from its superior advantage as a physiological procedure.
The effect of the antral treatment on the Rasta
chien tube was shown to result in the cure of an appreciable proportion of cases of tinnitus and deafness.
In the case of the tonsils only two cases were found
where a healthier -looking tonsil resulted afterwards.
Tonsil sepsis was still present in 62.8% of all the
cases and even if originally caused by antral suppuration sepsis would most likely persist unchanged.
The important symptom of headache was present
in 60% of cases before treatment and was completely
relieved afterwards in half of these and greatly relieved in another quarter.
Headache that persisted unchanged was entirely of the
frontal type and was largely associated with the presence of septal deformity and ethmoiditis.
It was shown that all but 2 cases experienced
definite improvement in their general health after oper
ation which pleased them very much even where the local
result was not entirely favourable. This occurred
after an average interval of 3 months during which the
patient's general condition and resistance must be
considered, as regards the imposition of further
stresses, to be in a "refractory phase ".
Diseases of the lower respiratory tract were
present in 15.7% of these cases. The modes by which
antral infection produces these diseases were outlined
and the results obtained are given when the causal condition is removed. Four out of five cases of chronic
bronchitis cleared up completely with the cure of the
antral disease. Three cases of bronchiectasis were
met with. One showed dramatic improvement,clinically
and radiologically, after antral drainage and the other
two ware much irnproved,especially as regards their
'general condition. In this connection it is pointed
87.
out that all chest cases including those of pulmonary
tuberculosis, would benefit by the removal of co-existent, if not causal, sinus infection. Cases of
asthma were less promising since sensitivity existed,
both as the result of the bronchial infection and as the result of underlying allergy. In the first type
the sensitivity may persist even after antral infectio
is removed. Yet based on the results, seen in the 3
cases studied,and from the reported literature/one
might help the physician in advising treatment by
stating that the majority of asthmatic patients obtain
improvement. Whilst a few are cured/in many the attacks become less severe and their general condition
is so much improved4 that they can the better carry
the burden of the disease.
The pathology of antral infection in causing
remote complications is outlined. Cases are quoted
from this series of affections of the gastro -intestinal
tract, brain function, peripheral nerves, joints and
the eye. It was shown that following removal of the
antral infection most of these, if in relationship to
the infection, may be expected to clear up completely
of
or, if of too long standing, at least become improved.
This relationship was especially studied in one case of
peripheral neuritid and tachycardia, and using it as an
object lesson it was shown that the antrum/as the possible focus of infection might easily be overlooked when
examined by the usual radiological and clinical methods
because of the.type and latency of the pathological pro-
process present. Chronic antral infection should be
more widely recognized as a point of focal infection,
when its significance may be revealed. as being not much
less than that of tonsillar sepsis.
