Southern medical journal (Birmingham, Ala. Print)
Fraser and Stewart  favour Coakley's modification of the Killian operation, which consists of opening the frontal sinus through its anterior wall, and entering the ethmoidal region through its lateral wall in the region of the inner canthus, leaving a bridge of bone between the upper and lower openings. This operation has, however, been abandoned by the majority of rhinologists, not so much on account of the resultant disfigurement (particularly if necrosis of the 11 bridge" occurs), as
... e" occurs), as because of the serious risk of spread of infection into the diploe of the cranial bones, with the production of diffuse osteomyelitis and intracranial complications, or pyremia. There is, moreover, the possibIlity of some pathological mucous membrane being left behind in the "blind area" created by the bridge, which may give rise to subsequent trouble. . It is, nevertheless, the operation of election when intracranial complications are already present. The remaining external operation is the Howarth, which enables the most radical removal of the mucous membrane to be 'carried out, or more conservative measures to be adopted; it has the additional. advantage of leaving no "blind area", and lastly, being carried out through the floor of the sinus, which consists of compact bone, there is distinctly less risk of ensuing diffuse osteomyelitis than when an entry is made through the anterior sinus wall. . The Howarth Operation.-This operation is being described in detail as the author has found the following technique satisfactory even under Indian conditions. After careful preparation of the skin on four consecutive days, as a preliminary to operation on the fifth day, the anterior nares are swabbed out with 75 per cent spirit, and the nasal cavity of the affected side is packed with a long strip of gauze soaked in equal parts of 10 per cent cocaine and 1: 1,000 adrenalin half an hour before operation. It is essential that good radiograms be available in the theatre throughout operation. The operation is performed under intratracheal anresthesia, chloroform-ether mixture being preferred; and the nasopharynx is well packed off. Two radiating scratches are made to assist subsequent accurate closure. The skin is then drawn upwards, and a curved incision made from a point a little internal to the supraorbital notch to another point opposite or a little below the inner canthus.