SATTLER: Lesions of the Frontal Sinus.
50
the sinus removed, as advocated by Kuhnt,* a more or less disfiguring depression of the visible scar must necessarily result; unless the osteoplastic method of Czerny and Golvini is adopted. It is claimed for the latter that it may be resorted to harmlessly as an exploratory operation. Careful refracting by the shadow test showed a hypermetropia of 2.50 in the right eye, while the left had a hypermetropia of 4.75. This anisometropia may of course have existed previously, though the patient is positive that there was no difference in the eyes, but the question suggests itself whether the hypermetropia might not have been diminished by pressure of the frontal sinus above and the antrum below.
LESIONS OF THE FRONTAL SINUS AND ANTERIOR ETHMOIDAL CELLS IN INFANCY AND OLD AGE. BY ROBERT SATTLER, M.D.,
CINCINNATI, OHIO.
Lesions of the frontal sinus and adjacent cells of the ethmoidal labyrinth, in the two extremes of life - infancy and old age - are of interest not only because of the rarity of their occurrence, but also for the reason that noteworthy differences are observed so far as their course and clinical features are concerned. If the latter are carefully contrasted with similar, certainly more common, morbid processes during the intervening periods of life, this statement will be even more fully confirmed. In very young subjects, the air spaces of the frontal bone are known to be rudimentary cavities, and in some cases an interspace only between the two layers of the bone marks the site of a future development. During early life these spaces gradually assume more roomy proportions. The adjacent anterior cels of the ethmoidal labyrinth, separated only by fragile partitions of bone from the air spaces of the frontal bone, with which they have such a close anatomical relationship, are also during infancy and * Archives
of
Ophthalmology, xxvii, 297.
SATTLER: Lesions of the Frontal Sinus'.
5I1
early youth imperfectly developed, but they have, even at these early periods of life, a more distinct existence than the air cavities of the frontal. This probably explains why, before a more distinct development of these cavities and cells has taken place, sinus lesions are so uncommon. Nevertheless, it is probably also true (and this is supported by the clinical observations herewith mentioned) that such lesions are more common than has been generally supposed. An accurate or definite diagnosis of these lesions of the cells of the frontal and ethmoid bones is well nigh impossible in some cases; in others it is beset with the greatest difficulties, since the clinical evidences which are present suggest indefinitely only a lesion of the sinus. During the inception of such a lesion it may even be impossible to recognize its true character, because the general or constitutional symptoms rather suggest a cerebral or meningeal lesion, and overshadow, in severity and importance of expression, the local ones. Owing to the small size of the air cavities affected, pyogenic or bacterial infection which has traveled along the ostium frontale, lights up a reaction of lesser severity on the part of the sinus cavities of the frontal bone. The larger development of the adjacent ethmoidal cells, the fragile partition walls separating these cavities, also the not infrequent anomalous communication with the middle fossa of the nose or with the frontal sinus itself, cause it to happen that a more marked declaration of the morbid. changes enacted takes place here and the activity is withdrawn to the deeper recesses of this locality, attended, in most cases, by most uncertain and meager clinical symptoms. An apt illustration is afforded by the recital of the following cases:
CASE I. Child, i6 months: sudden choking of the rght frontal sinus and adjacent ethmoidal cells. Pyogenic infection from nose or gastro-intestinal canal. Increasing pro.ptosis; alarming symptoms. Recovery without operation. This patient, a girl aged i6 months, was the daughter of a fellow practitioner, who wrote me that she had been for some time
52
SATTLER: Lesions of the Frontal Sinus.
ill with a gastro-intestinal affection, and also with pronounced coryza, but that the diagnosis was by no means clear. Suddenly new symptoms had developed on the part of the right eye and orbit with great prostration and cachetic appearance, which led him to infer either the presence of cellulitis orbitae or even malignant disease of the orbit. The child was seen by me on the following day. Asymmetry of the right side of the face with changed contour of the orbital margin, rigid infiltration and dusky discoloration of the inner half of the upper lid, great tenderness over the region of the sinus frontalis, pointed to a lesion of this cavity and the adjoining cells of the ethmoid. Proptosis was most pronounced and the globe firmly crowded against the outer wall of the orbit. Movements of the eye were but little restricted. Fever was high, and tenderness over affected region was pronounced. Anterior rhinoscopy showed the presence of numerous herpes vesicles and incrustations over the swollen and reddened mucous membrane. Preliminary to an exploratory operation, an expectant course was decided on, consisting of iced antiseptic compresses, spraying of the nose with alkaline antiseptic mixtures and, internally, small doses of calomel. On the following day, the child's condition seemed more favorable, but the exophthalmos was more marked, as well as the other local symptoms. In passing the finger over the swollen region, this seemed to yield to the pressure, whereupon more forcible stroking was practiced. This manipulation was repeated, and it, or a spontaneous rupture into the nose, caused a disappearance of all the alarming symptoms without operation. Thete was little room for any other conclusion than that this was a typical frontal sinus and ethmoidal labyrinth lesion, due to the transplantation of pyogenic or bacterial products from the nasal mucous membrane, or even from more remote sources of infection- the oral and gastro-intestinal lining - to these air cavities. Fortunately, discharge of the choked cavities came about along the natural channels into the nose. The close resemblance to malignant disease and cellulitis of the orbit, as
SATTLER: Ltsimns of the Froatal Sinus.
53
well as to meningeal or cerebral complications, are the features of interest and diagnostic importance.
CASE II. Infant, aged 5i months: chronic lesion of the right frontal sinus and ethmoidal cells with typical complex of symptoms, foriowed by periostosis and a general hyperostosis of the affected region. Two operations: recovery. Shortly after birth, the child suffering from blenorrhoea was brought to me. In due time, recovery without complication on the part of the cornea of either eye was brought about. There was no question concerning the venereal origin of the blenorrhoeal infection of the eyes. Several weeks afterwards the child was again brought to me. The occasion of this visit was a swelling near the inner and upper margin of the orbit. There was some cedema of the upper lid, slight redness but no displacement of the eye. The child's general appearance and nutrition had been excellent and in no way suggested congenital lues. During a short period of observation, proptosis (which, at this time, however, was transitory) manifested itself. More marked drooping and cedema of the upper lid were also noted. An exploratory operation was decided upon, but not until a thorough anti-specific course of treatment had been tried without favorable result. A free incision through the soft parts disclosed only a serous infiltration of the overlying tissues. The periorbita was firmly adherent. No pus was found, but a roughened area of bone with distinct periostosis directly over the sinus frontalis region was discovered. The entire region was thoroughly curetted and the wound packed with gauze. It healed without special incident. At no time after the operation did the proptosis disappear, which we supposed was due to the infiltration of the adjacent cellular tissues of.the orbit, and this dependent. upon the existing periorbitis or caries. On the contrary, it, and in particular the lateral displacement of the globe, steadily increased. Four weeks after the first operation a second operation was made, having for its purpose the thorough exploration of the frontal and adjacent sinuses.
54
SATTLER: Lesions of the Frontal Sinus.
The sinus frontalis, considering the age of the patient, was found quite roomy but empty. The anterior wall was much thickened and the posterior wall appeared pearly white. The temporal angle of the sinus was fully exposed, and here perforation had taken place, followed by the growth of the osteophite referred to, in the account of the first operation. The ostium frontale was patulous. The entire sinus cavity appeared stripped of its mucous lining, and the inner wall or plate of the bone showed the same whiteness already referred to. It was evident that the morbid changes discovered did not explain the proptosis and lateral displacement of the globe. The adjacent ethmoidal cells were opened only to discover that there was no pus or other content, but the same pearly, almost chalky, appearance of the bony framework of the ethmoid was here also found. The cells were broken down and a free communication or opening was made with the nose. Recovery with subsidence of proptosis came about, as the accompanying photograph illustrates. This case presents several interesting features: the early period of inception of the sinus lesion and its latent course; the absence of pus or other pyogenic products. The operation, furthermore, disclosed marked morbid changes on the part of the frontal and ethmoid bones. Venereal disease, although denied, could not be excluded on the part of the parents. Aside from defective nasal bones (marked but not excessive flattening), there was nothing in the history of the early months of its life which upheld a syphilitic origin. Nevertheless, the low grade and latent course of the bone lesion and the resulting hyperostosis may assign it to one of the vagaries of congenital syphilis. It is a tenable inference that in this case micro-organisms or pyogenic products may have traveled from the nose into the frontal and ethmoidal air spaces and there started an insidious lesion which, after a comparatively long interval only, disclosed its real morbid nature. It is not improbable that the blenorrhoeal lesion of the conjunctiva may have contributed a certain share towards its causation and excitation. In the other extreme of life- old age -lesions of the air
SATTLER: Lesions of the Frontal Sinus.
55
spaces just referred to may give rise to symptoms which, because of their resemblance, might at first be considered the attendants of malignant disease. So close is the resemblance in some cases that this opinion is held until an exploratory operation or a spontaneous disappearance of the symptoms discloses the real nature of the morbid process and points out the error of diagnosis. In old persons, the sinus cavities of the skull, especially the sinus frontalis, as the result of normal or physiological causes, reach enormous proportions as far as capacity and dimensions are concerned. The -feature of excessive development may be accentuated if one or several of these spaces at any time - recent or remote - have been the seat of latent pathological invasions, or if an acute but wholly latent morbid process establishes itself. The roomy capacity prevents, in such cases, a more positive declaration and, owing to the thinning of the walls, perforation takes place at one or several points which offer a lesser resistance to the uniformly exerted pressure. Doubtless, also, trophic changes play a parf in the perforation of the walls and the subsequent discharge of the grumous contents. The periorbita is extensively dissected and elevated except at the apex and around the orbital margin where the attachment is so much firmer. But even here, and especially at the temporal side of the orbit, dissection of the pericranium and burrowing of pus under the temporal fascia and malar arch, are not infrequently observed. The symptoms, not characteristic but so generally associated with and strongly suggestive of sinus lesions, are: displacement - lateral and forward - of the globe; asymmetry of the upper part of the face on the affected side; drooping, swelling, and dusky discoloration of the inner one-third or one-half of the upper lid. Less commonly associated with these are pain and diplopia. The former is rarely a prominent symptom and the latter is often transitory. Disturbances of function are in most cases unimportant or absent. The feature, however, of interest, and one which two recent observations have, again corroborated, is that spontaneous disappearance of the entire clinical complex of symptoms may take place.
56
SATTLER: Lesions of the Frontal,-Sinus.
The two cases referred to were observed at the Ophthalmic Hospital of Cincinnati, and I am indebted to Dr. Christen for the clinical reports. The first patient was a man aged 64. He had marked proptosis with lateral displacement of the left eye. There was present a distinctly circumscribed, very hard, lobulated tumor, which could be felt occupying the inner wall, part of the roof and floor of the left orbit. The man was haggard in appearance, and, aside from numerous infirmities of senility, he had been in bad health for months. He complained of little or no pain. Diplopia was present, but because of the drooping upper lid gave rise to little or no annoyance. Rhinoscopic examination was negative, at least as far as gross abnormal findings were concerned, but there was a noticeable stenosis on the affected side and the usual attendants of chronic catarrhal disease. An operation was proposed to explore thoroughly the seat and character of the lesion, to be followed by whatever surgical interference the special needs might direct. During the interval of several days only, between his visit to the hospital and the day appointed for the operation, there came about a sudden, spontaneous disappearance of all the symptoms, with prompt recession of the exophthalmos after this had been present for several years. The second case was - as the accompanying photograph shows - equally pronounced. The man's age (70), his appearance, and the rapid course (6 to 8 months) rather suggested a malignant neoplasm. For nmonths he had occasional diplopia and steadily increasing proptosis, but there was little or no pain. Even at his first appearance at the hospital, the asymmetry of the left side of the face and orbital opening was pronounced. The globe was dislocated forwards, outwards, and downwards. There was also an extensive deep-seated swelling occupying the temporal and infra-orbital regions, and this was connected with that which occupied the cavity of the orbit. Exploratory puncture with aspirator needle failed to discover fluid. Rhinoscopic examination was negative, and the clinical features so commonly associated with the declaration of malignant disease of the bony
SATTLER: Lesions of the;Front1a Si*us.
57
framework of the orbit, all appeared to be present. An unfavorable prognosis was given and, because -of the extensive involvement of the tissues within and adjacent to the orbit, surgical intervention was not at once resorted to. During the following months he was kept under observation, and it was noted that su'ddenly a marked improvement came about, the exophthalmos receded and the extensive swelling disappeared. In both cases, extensive osseous perforation due to erosion or pressure absorption, with extensive dissection of the periorbita, must have taken place. The ethmoidal cells were probably the principal starting places of the lesion, and s-pontaneous relief was effected at a. subsequent period by similar osseous perforation, affording partial exit at least of the contents of the choked up cells into the nose. ,Another expression of a sinus frontalis lesion, but in which the adjacent ethmoidal cells are not necessarily involved, corresponds in many of its features with a similar one of the mastoid cells - Bezold's mastoiditis. Clinically and pathologically, the two lesions have much in common. Both are eminently chronic. Almost without exception, during the early stages, their course is wholly latent. The real character of the morbid changes is not disclosed until multiple osseous perforation with extrusion of the contents of the distended air spaces under the periorbita has taken place. This is followed by deep burrowing and the appearance of fistulous openings at remote points from the original seat of the lesion. It may also happen that external fistulae do not make their appearance at all, but the ropy contents of the air cavities are forced through the bone perforation under the periorbita into the adjacent deeper tissues of the orbit, or even find their way under the tear sac into the maxillary antrum, and more frequently even into the nose. The accompanying brief history and photograph of a case illustrate the principle features of a left frontal sinus lesion belonging to this category. H. S., Swiss, aged 64, stated on admission to the Ophthalmic
58
SATTLER: Lesions of the Frontal Sinus.
Hospital that, with the exception of an attack of typhoid fever, he had enjoyed excellent health. At the age of 32 he had an offensive discharge from the nose, which, after several weeks, however, disappeared completely. Venereal disease was denied. Nine years after this attack of supposed acute coryza, he began to suffer from severe headaches, with swelling of the lower part of the forehead. This was almost inflammatory in character and was mistaken for erysipelas. The paroxysms, at first interrupted and of shorter duration, became more severe and constant until a spontaneous fistulous opening, one-half inch above the inner canthus, came about. This opening continued to discharge a thick, brownish, stringy fluid until the end of the year I898, at which time it closed. From this time, exophthalmos, which had long been present, as well as diplopia, became more pronounced, but vision was unimpaired. The asymmetry of the left side of the face became more and more marked. The constant suffering, the steady increase of the lobulated tumor (which occupied the region of the inner canthus and encroached so much upon the lumen of the orbit that the globe was displaced forwards and outwards), made surgical intervention imperative. The affected region was exposed for inspection and exploration. It disclosed a frontal sinus of enormous proportions. The periorbita had been detached and a large cavity which extended to the extreme apex of the orbit was filled with caseated pus, debris, and opalescent, ropy mucus. The outer lower wall was excessively thickened and the lateral or orbital partition wall was the seat of numerous perforations. The orbital plate of the frontal was so thinned that the dura was exposed over a large area. The ostium frontale was firmly closed. The adjacent ethmoidal cells were carefully exposed, but were not found implicated. The anterior cells and those near the floor of the frontal sinus were opened and a free communication established with the middle fossa of the nose. The subsequent course was tedious, but recovery with little deformity and the cessation of constant suffering was brought
about.
50
the sinus removed, as advocated by Kuhnt,* a more or less disfiguring depression of the visible scar must necessarily result; unless the osteoplastic method of Czerny and Golvini is adopted. It is claimed for the latter that it may be resorted to harmlessly as an exploratory operation. Careful refracting by the shadow test showed a hypermetropia of 2.50 in the right eye, while the left had a hypermetropia of 4.75. This anisometropia may of course have existed previously, though the patient is positive that there was no difference in the eyes, but the question suggests itself whether the hypermetropia might not have been diminished by pressure of the frontal sinus above and the antrum below.
LESIONS OF THE FRONTAL SINUS AND ANTERIOR ETHMOIDAL CELLS IN INFANCY AND OLD AGE. BY ROBERT SATTLER, M.D.,
CINCINNATI, OHIO.
Lesions of the frontal sinus and adjacent cells of the ethmoidal labyrinth, in the two extremes of life - infancy and old age - are of interest not only because of the rarity of their occurrence, but also for the reason that noteworthy differences are observed so far as their course and clinical features are concerned. If the latter are carefully contrasted with similar, certainly more common, morbid processes during the intervening periods of life, this statement will be even more fully confirmed. In very young subjects, the air spaces of the frontal bone are known to be rudimentary cavities, and in some cases an interspace only between the two layers of the bone marks the site of a future development. During early life these spaces gradually assume more roomy proportions. The adjacent anterior cels of the ethmoidal labyrinth, separated only by fragile partitions of bone from the air spaces of the frontal bone, with which they have such a close anatomical relationship, are also during infancy and * Archives
of
Ophthalmology, xxvii, 297.
SATTLER: Lesions of the Frontal Sinus'.
5I1
early youth imperfectly developed, but they have, even at these early periods of life, a more distinct existence than the air cavities of the frontal. This probably explains why, before a more distinct development of these cavities and cells has taken place, sinus lesions are so uncommon. Nevertheless, it is probably also true (and this is supported by the clinical observations herewith mentioned) that such lesions are more common than has been generally supposed. An accurate or definite diagnosis of these lesions of the cells of the frontal and ethmoid bones is well nigh impossible in some cases; in others it is beset with the greatest difficulties, since the clinical evidences which are present suggest indefinitely only a lesion of the sinus. During the inception of such a lesion it may even be impossible to recognize its true character, because the general or constitutional symptoms rather suggest a cerebral or meningeal lesion, and overshadow, in severity and importance of expression, the local ones. Owing to the small size of the air cavities affected, pyogenic or bacterial infection which has traveled along the ostium frontale, lights up a reaction of lesser severity on the part of the sinus cavities of the frontal bone. The larger development of the adjacent ethmoidal cells, the fragile partition walls separating these cavities, also the not infrequent anomalous communication with the middle fossa of the nose or with the frontal sinus itself, cause it to happen that a more marked declaration of the morbid. changes enacted takes place here and the activity is withdrawn to the deeper recesses of this locality, attended, in most cases, by most uncertain and meager clinical symptoms. An apt illustration is afforded by the recital of the following cases:
CASE I. Child, i6 months: sudden choking of the rght frontal sinus and adjacent ethmoidal cells. Pyogenic infection from nose or gastro-intestinal canal. Increasing pro.ptosis; alarming symptoms. Recovery without operation. This patient, a girl aged i6 months, was the daughter of a fellow practitioner, who wrote me that she had been for some time
52
SATTLER: Lesions of the Frontal Sinus.
ill with a gastro-intestinal affection, and also with pronounced coryza, but that the diagnosis was by no means clear. Suddenly new symptoms had developed on the part of the right eye and orbit with great prostration and cachetic appearance, which led him to infer either the presence of cellulitis orbitae or even malignant disease of the orbit. The child was seen by me on the following day. Asymmetry of the right side of the face with changed contour of the orbital margin, rigid infiltration and dusky discoloration of the inner half of the upper lid, great tenderness over the region of the sinus frontalis, pointed to a lesion of this cavity and the adjoining cells of the ethmoid. Proptosis was most pronounced and the globe firmly crowded against the outer wall of the orbit. Movements of the eye were but little restricted. Fever was high, and tenderness over affected region was pronounced. Anterior rhinoscopy showed the presence of numerous herpes vesicles and incrustations over the swollen and reddened mucous membrane. Preliminary to an exploratory operation, an expectant course was decided on, consisting of iced antiseptic compresses, spraying of the nose with alkaline antiseptic mixtures and, internally, small doses of calomel. On the following day, the child's condition seemed more favorable, but the exophthalmos was more marked, as well as the other local symptoms. In passing the finger over the swollen region, this seemed to yield to the pressure, whereupon more forcible stroking was practiced. This manipulation was repeated, and it, or a spontaneous rupture into the nose, caused a disappearance of all the alarming symptoms without operation. Thete was little room for any other conclusion than that this was a typical frontal sinus and ethmoidal labyrinth lesion, due to the transplantation of pyogenic or bacterial products from the nasal mucous membrane, or even from more remote sources of infection- the oral and gastro-intestinal lining - to these air cavities. Fortunately, discharge of the choked cavities came about along the natural channels into the nose. The close resemblance to malignant disease and cellulitis of the orbit, as
SATTLER: Ltsimns of the Froatal Sinus.
53
well as to meningeal or cerebral complications, are the features of interest and diagnostic importance.
CASE II. Infant, aged 5i months: chronic lesion of the right frontal sinus and ethmoidal cells with typical complex of symptoms, foriowed by periostosis and a general hyperostosis of the affected region. Two operations: recovery. Shortly after birth, the child suffering from blenorrhoea was brought to me. In due time, recovery without complication on the part of the cornea of either eye was brought about. There was no question concerning the venereal origin of the blenorrhoeal infection of the eyes. Several weeks afterwards the child was again brought to me. The occasion of this visit was a swelling near the inner and upper margin of the orbit. There was some cedema of the upper lid, slight redness but no displacement of the eye. The child's general appearance and nutrition had been excellent and in no way suggested congenital lues. During a short period of observation, proptosis (which, at this time, however, was transitory) manifested itself. More marked drooping and cedema of the upper lid were also noted. An exploratory operation was decided upon, but not until a thorough anti-specific course of treatment had been tried without favorable result. A free incision through the soft parts disclosed only a serous infiltration of the overlying tissues. The periorbita was firmly adherent. No pus was found, but a roughened area of bone with distinct periostosis directly over the sinus frontalis region was discovered. The entire region was thoroughly curetted and the wound packed with gauze. It healed without special incident. At no time after the operation did the proptosis disappear, which we supposed was due to the infiltration of the adjacent cellular tissues of.the orbit, and this dependent. upon the existing periorbitis or caries. On the contrary, it, and in particular the lateral displacement of the globe, steadily increased. Four weeks after the first operation a second operation was made, having for its purpose the thorough exploration of the frontal and adjacent sinuses.
54
SATTLER: Lesions of the Frontal Sinus.
The sinus frontalis, considering the age of the patient, was found quite roomy but empty. The anterior wall was much thickened and the posterior wall appeared pearly white. The temporal angle of the sinus was fully exposed, and here perforation had taken place, followed by the growth of the osteophite referred to, in the account of the first operation. The ostium frontale was patulous. The entire sinus cavity appeared stripped of its mucous lining, and the inner wall or plate of the bone showed the same whiteness already referred to. It was evident that the morbid changes discovered did not explain the proptosis and lateral displacement of the globe. The adjacent ethmoidal cells were opened only to discover that there was no pus or other content, but the same pearly, almost chalky, appearance of the bony framework of the ethmoid was here also found. The cells were broken down and a free communication or opening was made with the nose. Recovery with subsidence of proptosis came about, as the accompanying photograph illustrates. This case presents several interesting features: the early period of inception of the sinus lesion and its latent course; the absence of pus or other pyogenic products. The operation, furthermore, disclosed marked morbid changes on the part of the frontal and ethmoid bones. Venereal disease, although denied, could not be excluded on the part of the parents. Aside from defective nasal bones (marked but not excessive flattening), there was nothing in the history of the early months of its life which upheld a syphilitic origin. Nevertheless, the low grade and latent course of the bone lesion and the resulting hyperostosis may assign it to one of the vagaries of congenital syphilis. It is a tenable inference that in this case micro-organisms or pyogenic products may have traveled from the nose into the frontal and ethmoidal air spaces and there started an insidious lesion which, after a comparatively long interval only, disclosed its real morbid nature. It is not improbable that the blenorrhoeal lesion of the conjunctiva may have contributed a certain share towards its causation and excitation. In the other extreme of life- old age -lesions of the air
SATTLER: Lesions of the Frontal Sinus.
55
spaces just referred to may give rise to symptoms which, because of their resemblance, might at first be considered the attendants of malignant disease. So close is the resemblance in some cases that this opinion is held until an exploratory operation or a spontaneous disappearance of the symptoms discloses the real nature of the morbid process and points out the error of diagnosis. In old persons, the sinus cavities of the skull, especially the sinus frontalis, as the result of normal or physiological causes, reach enormous proportions as far as capacity and dimensions are concerned. The -feature of excessive development may be accentuated if one or several of these spaces at any time - recent or remote - have been the seat of latent pathological invasions, or if an acute but wholly latent morbid process establishes itself. The roomy capacity prevents, in such cases, a more positive declaration and, owing to the thinning of the walls, perforation takes place at one or several points which offer a lesser resistance to the uniformly exerted pressure. Doubtless, also, trophic changes play a parf in the perforation of the walls and the subsequent discharge of the grumous contents. The periorbita is extensively dissected and elevated except at the apex and around the orbital margin where the attachment is so much firmer. But even here, and especially at the temporal side of the orbit, dissection of the pericranium and burrowing of pus under the temporal fascia and malar arch, are not infrequently observed. The symptoms, not characteristic but so generally associated with and strongly suggestive of sinus lesions, are: displacement - lateral and forward - of the globe; asymmetry of the upper part of the face on the affected side; drooping, swelling, and dusky discoloration of the inner one-third or one-half of the upper lid. Less commonly associated with these are pain and diplopia. The former is rarely a prominent symptom and the latter is often transitory. Disturbances of function are in most cases unimportant or absent. The feature, however, of interest, and one which two recent observations have, again corroborated, is that spontaneous disappearance of the entire clinical complex of symptoms may take place.
56
SATTLER: Lesions of the Frontal,-Sinus.
The two cases referred to were observed at the Ophthalmic Hospital of Cincinnati, and I am indebted to Dr. Christen for the clinical reports. The first patient was a man aged 64. He had marked proptosis with lateral displacement of the left eye. There was present a distinctly circumscribed, very hard, lobulated tumor, which could be felt occupying the inner wall, part of the roof and floor of the left orbit. The man was haggard in appearance, and, aside from numerous infirmities of senility, he had been in bad health for months. He complained of little or no pain. Diplopia was present, but because of the drooping upper lid gave rise to little or no annoyance. Rhinoscopic examination was negative, at least as far as gross abnormal findings were concerned, but there was a noticeable stenosis on the affected side and the usual attendants of chronic catarrhal disease. An operation was proposed to explore thoroughly the seat and character of the lesion, to be followed by whatever surgical interference the special needs might direct. During the interval of several days only, between his visit to the hospital and the day appointed for the operation, there came about a sudden, spontaneous disappearance of all the symptoms, with prompt recession of the exophthalmos after this had been present for several years. The second case was - as the accompanying photograph shows - equally pronounced. The man's age (70), his appearance, and the rapid course (6 to 8 months) rather suggested a malignant neoplasm. For nmonths he had occasional diplopia and steadily increasing proptosis, but there was little or no pain. Even at his first appearance at the hospital, the asymmetry of the left side of the face and orbital opening was pronounced. The globe was dislocated forwards, outwards, and downwards. There was also an extensive deep-seated swelling occupying the temporal and infra-orbital regions, and this was connected with that which occupied the cavity of the orbit. Exploratory puncture with aspirator needle failed to discover fluid. Rhinoscopic examination was negative, and the clinical features so commonly associated with the declaration of malignant disease of the bony
SATTLER: Lesions of the;Front1a Si*us.
57
framework of the orbit, all appeared to be present. An unfavorable prognosis was given and, because -of the extensive involvement of the tissues within and adjacent to the orbit, surgical intervention was not at once resorted to. During the following months he was kept under observation, and it was noted that su'ddenly a marked improvement came about, the exophthalmos receded and the extensive swelling disappeared. In both cases, extensive osseous perforation due to erosion or pressure absorption, with extensive dissection of the periorbita, must have taken place. The ethmoidal cells were probably the principal starting places of the lesion, and s-pontaneous relief was effected at a. subsequent period by similar osseous perforation, affording partial exit at least of the contents of the choked up cells into the nose. ,Another expression of a sinus frontalis lesion, but in which the adjacent ethmoidal cells are not necessarily involved, corresponds in many of its features with a similar one of the mastoid cells - Bezold's mastoiditis. Clinically and pathologically, the two lesions have much in common. Both are eminently chronic. Almost without exception, during the early stages, their course is wholly latent. The real character of the morbid changes is not disclosed until multiple osseous perforation with extrusion of the contents of the distended air spaces under the periorbita has taken place. This is followed by deep burrowing and the appearance of fistulous openings at remote points from the original seat of the lesion. It may also happen that external fistulae do not make their appearance at all, but the ropy contents of the air cavities are forced through the bone perforation under the periorbita into the adjacent deeper tissues of the orbit, or even find their way under the tear sac into the maxillary antrum, and more frequently even into the nose. The accompanying brief history and photograph of a case illustrate the principle features of a left frontal sinus lesion belonging to this category. H. S., Swiss, aged 64, stated on admission to the Ophthalmic
58
SATTLER: Lesions of the Frontal Sinus.
Hospital that, with the exception of an attack of typhoid fever, he had enjoyed excellent health. At the age of 32 he had an offensive discharge from the nose, which, after several weeks, however, disappeared completely. Venereal disease was denied. Nine years after this attack of supposed acute coryza, he began to suffer from severe headaches, with swelling of the lower part of the forehead. This was almost inflammatory in character and was mistaken for erysipelas. The paroxysms, at first interrupted and of shorter duration, became more severe and constant until a spontaneous fistulous opening, one-half inch above the inner canthus, came about. This opening continued to discharge a thick, brownish, stringy fluid until the end of the year I898, at which time it closed. From this time, exophthalmos, which had long been present, as well as diplopia, became more pronounced, but vision was unimpaired. The asymmetry of the left side of the face became more and more marked. The constant suffering, the steady increase of the lobulated tumor (which occupied the region of the inner canthus and encroached so much upon the lumen of the orbit that the globe was displaced forwards and outwards), made surgical intervention imperative. The affected region was exposed for inspection and exploration. It disclosed a frontal sinus of enormous proportions. The periorbita had been detached and a large cavity which extended to the extreme apex of the orbit was filled with caseated pus, debris, and opalescent, ropy mucus. The outer lower wall was excessively thickened and the lateral or orbital partition wall was the seat of numerous perforations. The orbital plate of the frontal was so thinned that the dura was exposed over a large area. The ostium frontale was firmly closed. The adjacent ethmoidal cells were carefully exposed, but were not found implicated. The anterior cells and those near the floor of the frontal sinus were opened and a free communication established with the middle fossa of the nose. The subsequent course was tedious, but recovery with little deformity and the cessation of constant suffering was brought
about.
