1909 Journal of the American Medical Association  
A discussion of the choice of operative measures necessary to relieve or to cure any pathologic condition in the body frequently has to take into account many factors other than those directly connected with the disease in question. Nowhere, perhaps, is this so marked as it is in discussing the advisability of treat¬ ing diseases of the nasal accessory sinuses by intranasal surgery or by an external operation. Rhinologists at present are at considerable variance, and personally I find myself,
more » ... ly I find myself, as the result of wider ex¬ perience, changing my views considerably from year to year as to the desirability of resorting to an intranasal or an external operation for the relief or cure in any given case of sinus disease. External surgical operations undertaken for the cure of disease of the frontal, ethmoid and sphenoid sinuses require a thorough knowledge of the anatomy of this region, acquired not only from the many excellent mono¬ graphs on this subject, but also from an extensive prac¬ tical experience resulting from numerous dissections. The operator should also have had a thorough training in general surgical technic and have acquired skill and reasonable rapidity in operating before attempting these long major operations. The proximity of the brain and the great variety in the size, shape and relation of these cavities to the cranium renders unskilled work on the part of the operator likely to be followed by serious consequences to the patient. In all but the very acute cases complicated by cellu¬ liti?, when an immediate external operation is indi¬ cated, before deciding on recommending to the patient the intranasal or external operative route, a complete examination should be made. This includes : First.-The determination of the number of sinuses involved. Second.-Having a skiagraph made which, if good, will show the size and shape of the frontale and the number of septa within them; the width of the ethmoidal area and the approximate size of the sphenoids. Third.-The general condition of the patient. In chronic sinus disease, the presence of marked disease of the arteries, heart, lungs or kidneys makes the external operation far more serious and frequently undesirable. Fourth.-Determine, if possible, whether the disease is acute or chronic. In very few acute cases, not com¬ plicated by the external manifestations described later, does the condition require an external operation. Fifth.-If acute, decide whether the history points to a simple acute inflammation of a previously healthy sinus or to an acute exacerbation of a chronically dis¬ eased sinus. In the latter case it is wiser to defer the external operation until the acute symptoms have sub¬ sided. Sixth.-The severity of the symptoms, more especially of headache and its effect on the patients. I have not yet been able to determine why some patients suffer so much more from sinus disease than others. There is nothing in either the character or amount of discharge to help us, nor even in the size of the sinuses as shown by the skiagraph. As a rule, those with very large sinuses suffer more than those with small sinuses, but I have seen many exceptions to this rule. If intranasal operations fail to give the desired relief, then an ex¬ ternal operation is indicated. Seventh.-The ultimate result of the treatment of chronic sinus disease should be carefully explained to the patient by his physician. Intranasal methods re¬ lieve and may cure. The cavities remain and may again become infected. External operations remove all the diseased membrane, obliterate the cavities and result in a permanent cure. There is a scar and frequently some deformity in a portion of the anatomy where it is easily seen by the patient, and this fact alone often deters some individuals from submitting to the external opera¬ tion. Eighth.-As intranasal treatment necessitates fre¬ quent operations at short intervals, many who can ill spare the time for such treatment prefer the more thor¬ ough and less time-consuming external operation. Ninth.-The neurasthenic patient who is prostrated each time any intranasal operation is attempted and rarely submits to enough being done to make much headway against the disease should be urgently advised to submit to the external operation. Tenth.-Very narrow nasal chambers add greatly to the difficulty of intranasal operations, and to such pa¬ tients with chronic suppuration of the frontal, ethmoid and sphenoid, we recommend the external operation. CONDITIONS REQUIRING THE EXTERNAL OPERATION When considering the diseased conditions in the vari¬ ous sinuses requiring external operation, it would seem best to divide them into an acute and chronic type. 1. Acute Frontal, Ethmoid and Sphenoid Involve¬ ment.-Whenever acute involvement of these sinuses is accompanied by marked edema of the skin of the fore¬ head, eyelids or side of the nose, exophthalmos, orbital cellulitis, local heat, great focal tenderness, with or without a rise in the body temperature, an external operation is imperative and should be done without delay for fear of supervening meningeal or other intracranial complications. On the other hand, it must not be considered that we would invariably advocate exter¬ nal operation for the relief of very slight local edema and swelling without first attempting by intranasal treatment to relieve the condition. It is possible that deflections of the septum, or large bony exostoses, might render it impossible to give adequate intranasal treat¬ ment, in which case external surgery must be resorted to. The proportion of acute cases demanding external operation is few as compared to those which can be cured by intranasal treatment. 2. Acute Maxillary Sinusitis.-Very rarely one meets with an osteomyelitis of the superior maxilla associated with acute maxillary sinusitis. Such cases should be treated by a larger opening and drainage through the gingivo-buccal fold. All other cases of acute disease of this sinus may be satisfactorily treated intranasally. S. Chronic Suppuration of the Frontal, Ethmoid and Sphenoid.-As all three of these groups are usually simultaneously involved, we will consider them to¬ gether : A. Those associated with multiple polyp formation in the nose. Most of these cases are accompanied by such extensive alterations in the mucous membrane lining the frontal, ethmoid and sphenoid, that intranasal treat-Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/15/2015
doi:10.1001/jama.1909.92550130001001k fatcat:rb7py3ymgvh5xarv3rnlotpbni