J. Lewin
1930 BMJ (Clinical Research Edition)  
IN thlis article only such conditions will be described as have their origin and poinits of attack in the nose and throat. The diseases under this heading are all inflammations in which the eye changes, thouglh often the first to appear, are nevertheless only secondairy to foci of gross infection in neighbouring structures. It is te emphasize and familiarize these imliportant relationships that these notes are put together; Anatomical Considerations. The spread of infection from the nose and
more » ... rom the nose and throat to the eye may take place along any of the usual channels; but as in one or two important instances such spread is dirsect, it is necessary to appreciate the anatomy of the par ts and, in particular, the anatomy of the accessorv nasal sinuses which are grouped round the orbital cavities. The major part of the skeleton of the nose may be regarded as suspended from the base of the skull between the two orbits, and several bones on either side eniter into the formation of both str uctures. These bones are the sphenoid, etlimlioid, imiaxilla, palate, frontal, and lacrmymial. The os planum of the ethmoid forms the largest par t of the inner wall of the orbit, and attached to it on the nasal aspect is the lateral mass enclosing the anterior, middle, and posterior groups of the ethmoidal air cells. These air cells are incomplete in parts in the disarticulated bone, andin life are closed in by neighbouring structures. Oin the upper surface a fewl half-cells of the middle group are completed by sinmilar half-cells on the under surface of the orbital plate of the frontal bone bordering the ethmoidal notch. The anterior or infundibular cells are completed by the lacrymnal bonie and maxilla, wlhere they form the anterior part of tile inner orbital wall. Tlle posterior ethmoidal cells open into the spheno-ethmoidal recess where they are opposed to the conchae covering the sphenoidal air sinuses. The anterior ethmoidal artery, though a vessel of no great size, is of considerable importance in the group of diseases under consideration, owing to its anatomical position. A branch of the ophthalmic artery, it runs inwards anid leaves the orbit by passing with its accomiipanying vein and the nlasal nierve through thie aniterior ethmoidal canal. T'his canal lies between the cells on the upper surface of the lateral mi1ass of the etlhmoid, and is commoinly completed by the articulationi of the oribital plate of the frontal. From this canial the artery emerges oni to tIme cribriform plate lying under the dura of the anterior fossa, whence it runs forwards, and piercing the bone at the side of the crista galli enters the cavity of the nose, where it lies on the deep surface of the niasal bojne. The antrumii of Highmoire lies immediately beneath the orbit, and its oof, formed by the orbital plates of the imiaxilla and palate, is also the floor of the orbit. In its roof is a canal containing the infra-oribital nerve anl vessels, the latter joining the parenit truniks in the spheno-m-axillary fossa. The anitruimn opens into the nose in the imliddle meatus. All the accessory nasal sinuses open into the nose and are at alny time liable to becollme inifected fromn the nasal passages. Otrbital Cellulitis. The first conidition to be dealt with is orbital cellulitis. It is unfortunately true that its relationship to ethmoid or other sinus disease is far from being generally appreciated, yet apart from cases caused by penetrating wounds of the orbit, oribital cellulitis is practically always secondary to inflammation in the ethmoidal cells. Its treatament therefore lies essentially in the hands of the nasal surgeon. Simple drainage operations on tlhe orbit frequently fail to save the life of the patient, anid still more frequently leave a persistent discharging sinus. Orbital cellulitis is a coimplication of acute, but iarely of chronic, sinus iiiflaniniiation, ill spite of the fact that chronic ethmoiditis, characterize(d often by the formiatioii of nasal polypi, is a very commllon disorder. The reason for this anomaly will be found in the discussion to follow oni the mode of spread of the infection. Following the rules governing the spread of infection elsewhere in the body there arie three possible routesnamnely, the blood stream, the lymphaltics, and some direct path. There is no suggestion that infection is via tlle blood stream, except perhaps as a terininal event when a widespread dissemiiination may take place from on-e of tlhe larger venous sinuses. Spread by lymphatics may also be excluded, as the parts are but poorly supplied with lymph vessels, anid there is nio connexion demonstrated betw-een the oirbital and ethmoidal symlptomiis. A direct spread is the one that almost certainly takes place, and there are one oIr two alternative routes evlle heIe to be conisidered. A possible route is through the os planuiui, but although this is a very thin plate of bone, it is fairly tough; moreover, experience in operating on these cases nearly always reveals it intact. T'her c is no evidence that, save in nieglected cases, it allows the passaga of infection. The most probable path is that along the line of the ethmoidal vessels, and there are several poinits str'ongly in favour of this view. There is a ready-nmade comnmunication in the ethmoidal canal between the ethmioidal and the orhital cavities. The pus founid in the orbit in eases of orbital cellulitis is always in the upper anid inner plart of the cavity-that is, about the opening of the aintelrior ethm-ioidal canal. Furthermore, the passage of infection by this route accounts satisfactorily for two of the most comiiion and importan-it complications of orbital cellulitis-])amely, cavernous sinius throinbosis and mieningitis. Tlle mere preseciie of a collection of pus in the orbit is not in itself sufficient to cause thrombosis of the veins in. the neighbourhood, amid of the sinuses into wlich thlev drain, but such a condition would readily arise as i;he result of a spread of thrombosis along the radicles a rd trunk of the ethmoidal vein, which opens into the opl)tlhaliic vein, and so into the cavernous sinlus. It is w,orth noting here the parallel way in whlieh cavernous sinus thromllbosis may arise from sepsis oni the face by splread along the infra-orbital vessels. It hals alr.eady been noted, too, that part of the course of the etlhmnoidail v-essels lies under the dura covering the cribriformim plate. In this situationi the duira' is perforated by the olfactory roots, and affords a portal of entry for infection from a septio phlebitis such as obtains in the conditions under consideiationl. Meninoitis occurs quite frequently in. fatal cases of orbital cellulitis, and is evidenced by intense heladaches, and, more typically, by hyperpyrexia. Altlhough the othmoidal air cells have alonie been considered as the startinig point of orbital cellulitis, this condition may nevertheless coiimplicate acute infections in the frontal sinus anid the sphenoidal sinus, though less fr equently. Quite often both frontal and ethmoid, or sphenoid and ethmoid, are affected together. The above account is the argument for treatinig orbital cellulitis bv radical operationi on the accessorv nasal sinus by the exter-nal route. Apart fromii haemorrhage, the resulmit of inflammatory engorgemelit, the steps of the operation can be followed deliberately and the source of the itnfection tiraced and eliminated. Briefly, the operation conlsists in perforating the nasal process of the maxilla and opening up the fromital siiius antd the lateral mass of the etlhnoid. Infected cells are openied al-d removed as far as possible, and the os planuma is cut through to drain the orbital cavity. The anterior etlrnoidal artery is almost constantly severed. Bleedinig yields readily to mooderate gauze pressure, but the site of the haemorrlhage demonstrates very well, in the living, its close relation to tIme orbit. It i3 importanit to make as complete a clearance as possible, as infection ofteni starts far back, but the patiemits are often so gravely ill that complete removal of the lateral mass is not alwavys possible, and one has to be contemit witl ample drainage. i
doi:10.1136/bmj.2.3645.820 fatcat:rrjyd3imuzfn3eakjes2iulr34