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dc.contributor.authorMorgenthal, J.en
dc.date.accessioned2019-02-15T14:37:58Z
dc.date.available2019-02-15T14:37:58Z
dc.date.issued1944en
dc.identifier.urihttp://hdl.handle.net/1842/35401
dc.description.abstracten
dc.description.abstractAn 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractFollowing 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.en
dc.description.abstractA 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractA 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.en
dc.description.abstractResidual 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractThe 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.en
dc.description.abstractIt 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 ".en
dc.description.abstractDiseases 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.en
dc.description.abstractThe 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.en
dc.publisherThe University of Edinburghen
dc.relation.ispartofAnnexe Thesis Digitisation Project 2019 Block 22en
dc.relation.isreferencedbyen
dc.titleThe promotion of antral repair, drainage and aeration: a clinical study of the local and general effects in chronic maxillary sinusitisen
dc.typeThesis or Dissertationen
dc.type.qualificationlevelDoctoralen
dc.type.qualificationnamePhD Doctor of Philosophyen


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