ON
THE
PERNASAL SINUS
OPERATION
FOR
FRONTAL
SUPPURATION.
P. Watson-Williams, M.D.Lond., Lecturer on Otology, Rhinology, and Laryngology, University of Bristol, and in charge of the Department for Diseases of the Ear, Nose and Throat. Bristol
Royal Infirmary.
Many
patients
on
has been
operation suppuration
whom the writer's intranasal
performed
or
pernasal
for the relief of frontal sinus
have been demonstrated at
meetings
of the
Fig. Fig. 2. 2. Bone Bone specimen the fronto-nasal fronto-nasal passage*with showing the passage with specimen showing shows the the dotted dotted line line shows the route route probe probe passing passing through ;; the anterior entry and other other ante-conchal ante-conchal of of anterior agger entry through through agger and " " " cells. cells. is is well Note anterior Note the the anterior entry well in in front entry of front of "
the the
cribriform cribriform plate. plate.
Vol. XXXIII. No. 127.
26
DR.
P.
WATSON-WILLIAMS
Medico-Chirurgical Society, and I propose to describe shortly the operative technique of what I have termed the anterior route, without touching on the various methods of intranasal operation employed by other workers, which have been incorporated in my Introduction to a recent discussion on this subject at the Royal Society of Medicine. The non-external operations for frontal sinusitis fall under two classes, (a) those restricted to the removal of ethmoid Bristol
1
cells and other structures within the nasal fossa below the frontal sinus, i.e. the those in which the
strictly intranasal operations ; and (b) operative field comprises parts entering
into the formation of the sinus itself, e.g. the nasal crest and any other structures above the lower end of the ostium
frontale, in which but
case
the
operation
is
The terms intranasal
pernasal.
longer intranasal, and pernasal are, I no
FULL SIZE
Fig. 3. All author's spheno-ethmoidal angular forceps, made in two sizes. The author's inches from the tip, so that the precise distance the instruments are marked in inches determined? from the naris that any instrument has been passed can be at once determined-
think, better
terms for the difference in extent of
than the words
"
incomplete
"
and
"
complete,"
formerly used. Practically all the internal operations for disease in general use are various degrees 1 2
The term
Proc. Roy. Sos. Med., pernasal was suggested
operation
which I have frontal sinus of intranasal
1914, ii. 121-43. me by Mr. William Hill.
to
PERN AS AL OPERATION
FOR FRONTAL SINUS SUPPURATION.
27
Ingals, of Chicago, the credit is due of having devised the first practical method of operating on the frontal sinus ostium itself, i.e. of extending the operative field to the frontal sinus. Ingals reported in 1905 successful results from the operation, but it seemed to involve so much
operation.
To Fletcher
Fig. 4. Fig. 4. -The author's a standard burrs, guarded rotating The are fitted with a which are author's burrs, which " rotating ^ o. 2 Asch's guarded The nose to -\o. 2 Asch's " slip-on joint." been passed up burr having The burr up the nose having been joint." slip-on >s made to indicates the position of to lie against the face tip indicates face outside and its tip against A finger disconnecter, not !c b'trr be to be 1he cable to the cable allows the burr in in situ. situ. A finger disconnecter, not shown, shown, allows disconnected moment. disconnected at at any any moment.
risk to the
patient
accepted.
Others have tried to
Ingals, think
that his method has
the
an
on
been
generally
the methods of
some years I what I venture to methods which at least have the advantage of
being safe, provided with
improve have sought
and for are
never
reasonable
care
and skill be
conjoined
intimate practical acquaintance with the anatomy of
region
and its variations from what is
regarded as normal. pernasal operative measures for frontal sinus suppuration is the external operation, which unfortunately affords no certainty of a I he
alternative
to
intranasal
or
28
DR.
WATSON-WILLIAMS
P.
successful result,
always exposes the patient to septic osteo-myelitis, which is usually fatal, and is liable to leave a depressed scar, which may amount to a cosmetic deformity. Though in the course of a fairly large series of external operations I have been fortunate in having no case of osteo-myelitis, and the majority have been cured with little and sometimes no cosmetic defect, such happy completely the risk of
results
far from invariable, and in two
are
termination resulted, the cribriform
once
plate,
from
a
fatal
congenital dehiscence in patient from a pre-
a
and in another
frontal lobe abscess.
existing
An external radical frontal sinus avoided unless the
symptoms
are
so
operation
or are
to
impossible
perform.
should be
that relief is
severe
called for, and unless intranasal
urgently failed
cases
operations
The intranasal
or
have per-
nasal method is sometimes rendered anatomical
irregularities,
entrance to the it is
impossible with
met
operation
one
which
sinus, and if
inapplicable owing to prevent one making a safe
no
entrance
can
be effected,
enlarge the fronto-nasal passage. I have such case, and subsequently an external
to
showed
clearly
that
no
operation through
the
nose
But, on the other hand, even a very fronto-nasal passage, such as affords ample and effective large between the sinus and the nasal passages, does not drainage could have succeeded.
satisfactory relief, for the sinus may polypoid granulations, or may be in communication by a narrow opening with some large orbito-ethmoidal cell, which is altogether out of the reach of any pernasal operation. Yet such conditions are exceptional, and by the method described below the large majority of cases of frontal ensure a cure or even
be full of
suppuration, greatly relieved
sinus so
external An
over go per cent., may be either cured or that there is no need to consider a radical
operation. acute
taneously,
but
frontal
sinusitis
chronic
frontal
will
often
sinusitis
recover
rarely,
sponand for
PERXASAL operation for frontal sinus suppuration. 29
the
reason
or
that
if
the
associated ethmoidal
existing anatomical cell infection
did not
conditions make
a
spontaneous recovery out of the question, the frontal sinus would have recovered in the early or acute stage, and thus would not have become chronic.
It is therefore
hardly
showing cells,showing andfronto-ethmoidal theethmoidal ethmoidallabyrinth l(lSramofofthe fronto-etlimoidalcells, laSra'n labyrinthand /1 c,tyvcd the frontal catheterization ofof the frontal c"n,edentry, methodofof catheterization oldmethod theold entry,AAtoto*,*,of0/the advocated, DD methodofofentry as entryadvocated, anterior method thedirect withthe directanterior comParcdwith ?
THE
PERNASAL SINUS
OPERATION
FOR
FRONTAL
SUPPURATION.
P. Watson-Williams, M.D.Lond., Lecturer on Otology, Rhinology, and Laryngology, University of Bristol, and in charge of the Department for Diseases of the Ear, Nose and Throat. Bristol
Royal Infirmary.
Many
patients
on
has been
operation suppuration
whom the writer's intranasal
performed
or
pernasal
for the relief of frontal sinus
have been demonstrated at
meetings
of the
Fig. Fig. 2. 2. Bone Bone specimen the fronto-nasal fronto-nasal passage*with showing the passage with specimen showing shows the the dotted dotted line line shows the route route probe probe passing passing through ;; the anterior entry and other other ante-conchal ante-conchal of of anterior agger entry through through agger and " " " cells. cells. is is well Note anterior Note the the anterior entry well in in front entry of front of "
the the
cribriform cribriform plate. plate.
Vol. XXXIII. No. 127.
26
DR.
P.
WATSON-WILLIAMS
Medico-Chirurgical Society, and I propose to describe shortly the operative technique of what I have termed the anterior route, without touching on the various methods of intranasal operation employed by other workers, which have been incorporated in my Introduction to a recent discussion on this subject at the Royal Society of Medicine. The non-external operations for frontal sinusitis fall under two classes, (a) those restricted to the removal of ethmoid Bristol
1
cells and other structures within the nasal fossa below the frontal sinus, i.e. the those in which the
strictly intranasal operations ; and (b) operative field comprises parts entering
into the formation of the sinus itself, e.g. the nasal crest and any other structures above the lower end of the ostium
frontale, in which but
case
the
operation
is
The terms intranasal
pernasal.
longer intranasal, and pernasal are, I no
FULL SIZE
Fig. 3. All author's spheno-ethmoidal angular forceps, made in two sizes. The author's inches from the tip, so that the precise distance the instruments are marked in inches determined? from the naris that any instrument has been passed can be at once determined-
think, better
terms for the difference in extent of
than the words
"
incomplete
"
and
"
complete,"
formerly used. Practically all the internal operations for disease in general use are various degrees 1 2
The term
Proc. Roy. Sos. Med., pernasal was suggested
operation
which I have frontal sinus of intranasal
1914, ii. 121-43. me by Mr. William Hill.
to
PERN AS AL OPERATION
FOR FRONTAL SINUS SUPPURATION.
27
Ingals, of Chicago, the credit is due of having devised the first practical method of operating on the frontal sinus ostium itself, i.e. of extending the operative field to the frontal sinus. Ingals reported in 1905 successful results from the operation, but it seemed to involve so much
operation.
To Fletcher
Fig. 4. Fig. 4. -The author's a standard burrs, guarded rotating The are fitted with a which are author's burrs, which " rotating ^ o. 2 Asch's guarded The nose to -\o. 2 Asch's " slip-on joint." been passed up burr having The burr up the nose having been joint." slip-on >s made to indicates the position of to lie against the face tip indicates face outside and its tip against A finger disconnecter, not !c b'trr be to be 1he cable to the cable allows the burr in in situ. situ. A finger disconnecter, not shown, shown, allows disconnected moment. disconnected at at any any moment.
risk to the
patient
accepted.
Others have tried to
Ingals, think
that his method has
the
an
on
been
generally
the methods of
some years I what I venture to methods which at least have the advantage of
being safe, provided with
improve have sought
and for are
never
reasonable
care
and skill be
conjoined
intimate practical acquaintance with the anatomy of
region
and its variations from what is
regarded as normal. pernasal operative measures for frontal sinus suppuration is the external operation, which unfortunately affords no certainty of a I he
alternative
to
intranasal
or
28
DR.
WATSON-WILLIAMS
P.
successful result,
always exposes the patient to septic osteo-myelitis, which is usually fatal, and is liable to leave a depressed scar, which may amount to a cosmetic deformity. Though in the course of a fairly large series of external operations I have been fortunate in having no case of osteo-myelitis, and the majority have been cured with little and sometimes no cosmetic defect, such happy completely the risk of
results
far from invariable, and in two
are
termination resulted, the cribriform
once
plate,
from
a
fatal
congenital dehiscence in patient from a pre-
a
and in another
frontal lobe abscess.
existing
An external radical frontal sinus avoided unless the
symptoms
are
so
operation
or are
to
impossible
perform.
should be
that relief is
severe
called for, and unless intranasal
urgently failed
cases
operations
The intranasal
or
have per-
nasal method is sometimes rendered anatomical
irregularities,
entrance to the it is
impossible with
met
operation
one
which
sinus, and if
inapplicable owing to prevent one making a safe
no
entrance
can
be effected,
enlarge the fronto-nasal passage. I have such case, and subsequently an external
to
showed
clearly
that
no
operation through
the
nose
But, on the other hand, even a very fronto-nasal passage, such as affords ample and effective large between the sinus and the nasal passages, does not drainage could have succeeded.
satisfactory relief, for the sinus may polypoid granulations, or may be in communication by a narrow opening with some large orbito-ethmoidal cell, which is altogether out of the reach of any pernasal operation. Yet such conditions are exceptional, and by the method described below the large majority of cases of frontal ensure a cure or even
be full of
suppuration, greatly relieved
sinus so
external An
over go per cent., may be either cured or that there is no need to consider a radical
operation. acute
taneously,
but
frontal
sinusitis
chronic
frontal
will
often
sinusitis
recover
rarely,
sponand for
PERXASAL operation for frontal sinus suppuration. 29
the
reason
or
that
if
the
associated ethmoidal
existing anatomical cell infection
did not
conditions make
a
spontaneous recovery out of the question, the frontal sinus would have recovered in the early or acute stage, and thus would not have become chronic.
It is therefore
hardly
showing cells,showing andfronto-ethmoidal theethmoidal ethmoidallabyrinth l(lSramofofthe fronto-etlimoidalcells, laSra'n labyrinthand /1 c,tyvcd the frontal catheterization ofof the frontal c"n,edentry, methodofof catheterization oldmethod theold entry,AAtoto*,*,of0/the advocated, DD methodofofentry as entryadvocated, anterior method thedirect withthe directanterior comParcdwith ?
