Paranasal Sinuses (of the)

PARANASAL SINUSES of the nose. The anterior cells are affected more often than the posterior ones. The number of affected cells also varies; usually single cells are affected. Hidden empyemas of the ethmoidal cells are observed as tumor-like protrusions at the anterior end of the middle turbinate, the free edge of the middle turbinate, pathological expansion of the bullae ethmoidalis, displacing the middle turbinate. The contents of the swellings, which are hard to the touch (different from polyps), may be pus (empyema) or mucus (mucocele). The diagnosis of open empyema of the ethmoidal cells is based on finding the source of the secretion with an assessment of the topographical relationships. The excretory openings of the ethmoidal cells open: a) on the roof of the middle nasal meatus, at the angle where the middle nasal turbinate attaches to the bullae ethmoidalis; b) in front of the infundibulum near the opening of the frontal sinus; c) in the agger nasi cells, the uncinate process, and deep in the infundibulum. As can be seen, topographically all this is close to the maxillary and frontal sinuses, which is why a final diagnosis can only be made by exclusion. Middle rhinoscopy according to Killian also helps—introduction of a mirror with long blades into the middle nasal meatus and displacement of the middle turbinate inward, followed by probing. Repeated examinations are necessary, especially in the mornings and during exacerbation of the process. Treatment in acute cases is conservative—similar to diseases of the maxillary and frontal sinuses. In chronic cases—first of all, removal of polyps and hypertrophy with a wire loop, removal of the anterior end of the middle nasal turbinate, resection of part of the bullae ethmoidalis and the uncinate process with a loop and conchotome. If after a certain interval (to calm inflammatory phenomena) purulent discharge continues, then the ethmoidal cells are opened with a Hayek hook, removing bone fragments and mucosal scraps with a conchotome. One should not go higher than 1 cm above the attachment of the middle turbinate, because otherwise the lamina cribrosa can be injured, thereby causing fatal meningitis. If there are threatening complications from the orbit or meningeal membranes, as well as external fistulas, it is better to operate externally according to the Kuhnt method. An incision along the inner edge of the orbit. After detaching the periosteum more towards the orbit and detaching the lacrimal sac, one reaches the lamina papyracea and opens the ethmoidal cells through it. Access is insufficient without simultaneous opening of the frontal sinus, which is why the Killian method is resorted to. The incision is as in frontal sinus surgery, but does not go far onto the eyebrow. The frontal process of the maxilla and the lamina papyracea are removed, and here, step by step, all the ethmoidal cells can be opened up to the sphenoid sinus. The third method of access to the ethmoidal cells is through the maxillary cavity (the method of Jansen and Winkler). A radical operation of the maxillary cavity is performed (see Maxillitis) and the upper-inner wall is removed, giving access to the ethmoidal cells. Nevertheless, external access according to Killian should be preferred, of course for complicated cases. The sphenoid sinus (sinus sphenoidalis). Inflammations of the sphenoid sinus in acute and chronic forms occur significantly less frequently than diseases of other paranasal sinuses. The cause of inflammation is more often influenza, although with other infections pus can get into the sphenoid sinus, especially during blowing the nose and sneezing. Patho-anatomical changes are the same as in other sinuses. Patients' complaints are often vague: headaches, a feeling of pressure in the occiput, deep in the head, behind the eyes. In chronic cases, pains are vague; sometimes dizziness is observed. Most inflammations of the sphenoid sinus run together with the disease of the posterior ethmoidal cells. Among objective symptoms, the most clear is the finding of pus in the olfactory cleft and in the nasopharynx. From there it can be traced to the posterior end of the middle turbinate, which is very important for the diagnosis. Crusts are often observed in the upper nasal meatus, simulating ozena. Polyps are observed rarely, which can be removed after resection of the middle nasal turbinate. If the process extends to the bone, serious complications are possible—transition of the inflammatory process to the orbit or to the meningeal membranes (blindness and meningitis). Probing (see above) and irrigation of the cavity facilitate the diagnosis. Treatment in acute cases is conservative, as with inflammations of other paranasal sinuses. In chronic inflammations, operation to open the anterior wall is resorted to. For free access to the sphenoid sinus, the posterior end of the middle turbinate must be removed beforehand. After this, the anterior wall is destroyed with some instrument (Hayek hook), removing bone fragments and mucosal scraps with a conchotome. Subsequent tamponade is better not to be done.

Pansinusitis (pansinusitis). The combination of inflammatory diseases of several sinuses or all sinuses on one side is a frequent occurrence. Combinations of the disease of the frontal sinus and anterior ethmoidal cells, combined disease of the frontal and maxillary cavities, and less frequently disease of all sinuses on one side are most common. The reasons why in one case only one sinus is affected, while in others several, are unclear. When sneezing, the secretion that is secreted into the nasal cavity from one sinus can easily get into other sinuses and infect them. Inflammatory swelling of the mucous membrane at the excretory openings facilitates the transition of these processes to the chronic form. Symptoms consist of a combination of phenomena from various sinuses. If after irrigation of the maxillary cavity pus continues to be secreted again after 10–15 minutes, then it does not come from the maxillary cavity, but from the frontal sinus or from the ethmoidal cells. Further examination of the nose, X-ray data, and diaphanoscopy allow the elucidation of further details. Treatment in acute cases is conservative, in chronic cases—operative. The operation should begin with the maxillary cavity. Often in such cases, accompanying inflammations of the ethmoidal cells or frontal cavity pass on their own. If the first operation does not give an effect, one has to resort to opening other cavities—ethmoidal cells, frontal, and sphenoid. In the presence of external fistulas in the upper or inner angle of the eye, the operation begins with expanding the fistula and cleaning neighboring cells. In the presence of changes in other cavities, one moves from the initial incision, expanding it, to other cavities. Orbital and intracranial complications of inflammations of the accessory cavities of the nose. The close anatomical neighborhood of the paranasal sinuses with the orbit causes complications from its contents. This is facilitated by the thinness of the walls, the presence of lymphatic and vascular anastomoses, and congenital openings in the bone (dehiscences). Inflammations of the contents of the orbit, depending on diseases of the accessory cavities of the nose, are rare. Inflammations of the orbit of this etiology make up only 0.3–0.4% of the total number of orbit inflammations. Inflammations of the orbit occur with inflammation of the frontal and ethmoidal sinuses, less often the sphenoid and maxillary, causing orbital cellulitis. They cause protrusion of the eyeball or deviation of it downwards and outwards and usually form fistulas in the upper-inner angle of the eye. From the side of the eyeball, iritis, iridocyclitis, and retinitis are observed. With the disease of posterior sinuses (posterior ethmoidal cells and sphenoid), retrobulbar neuritis is often observed. Intracranial complications are observed in the form of meningitis and brain abscess. They occur quite rarely, at least 15 times less often than analogous diseases depending on ear involvement (according to Burger's statistics). According to Burger's aggregate statistics, out of 534 cases of complicated sinusitis, there were 262 meningitis, 181 brain abscesses, and 91 diseases of venous sinuses (especially the cavernous sinus). These diseases occurred depending on the frontal sinus in 321 cases, sphenoid in 94, ethmoidal in 79, maxillary in 18, and with parasinusitis in 22. Symptoms and treatment see Meningitis and Brain—private pathology. Neoplasms of the paranasal sinuses occur rarely: benign ones—in the form of osteoma of the frontal and ethmoidal bone, malignant ones—in the form of sarcomas and carcinomas. During their growth, they penetrate into the nasal cavity and other nearby cavities (orbit, nasopharynx). Their symptoms consist of headaches, difficulty breathing, bloody discharge, and nosebleeds. Upon examination of the nose, it is seen that its cavity is filled with polyps or a tumor, which bleeds easily upon contact. The patho-anatomical structure of the tumor is established by biopsy. Treatment is operative, followed by radium. Methods of operations see Nose and Nasopharyngeal Space.

17» I causes complications from its contents. This is facilitated by the thinness of the walls, the presence of lymphatic and vascular anastomoses, and congenital openings in the bone (dehiscences). Inflammations of the contents of the orbit, depending on diseases of the accessory cavities of the nose, are rare. Inflammations of the orbit of this etiology make up only 0.3–0.4% of the total number of orbit inflammations. Inflammations of the orbit occur with inflammation of the frontal and ethmoidal sinuses, less often the sphenoid and maxillary, causing orbital cellulitis. They cause protrusion of the eyeball or deviation of it downwards and outwards and usually form fistulas in the upper-inner angle of the eye. From the side of the eyeball, iritis, iridocyclitis, and retinitis are observed. With the disease of posterior sinuses (posterior ethmoidal cells and sphenoid), retrobulbar neuritis is often observed. Intracranial complications are observed in the form of meningitis and brain abscess. They occur quite rarely, at least 15 times less often than analogous diseases depending on ear involvement (according to Burger's statistics). According to Burger's aggregate statistics, out of 534 cases of complicated sinusitis, there were 262 meningitis, 181 brain abscesses, and 91 diseases of venous sinuses (especially the cavernous sinus). These diseases occurred depending on the frontal sinus in 321 cases, sphenoid in 94, ethmoidal in 79, maxillary in 18, and with parasinusitis in 22. Symptoms and treatment see Meningitis and Brain—private pathology. Neoplasms of the paranasal sinuses occur rarely: benign ones—in the form of osteoma of the frontal and ethmoidal bone, malignant ones—in the form of sarcomas and carcinomas. During their growth, they penetrate into the nasal cavity and other nearby cavities (orbit, nasopharynx). Their symptoms consist of headaches, difficulty breathing, bloody discharge, and nosebleeds. Upon examination of the nose, it is seen that its cavity is filled with polyps or a tumor, which bleeds easily upon contact. The patho-anatomical structure of the tumor is established by biopsy. Treatment is operative, followed by radium. Methods of operations see Nose and Nasopharyngeal Space.