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THE UNIVERSITY
OF CALIFORNIA
PRESENTED BY
PROF. CHARLES A. KOFOID AND
MRS. PRUDENCE W. KOFOID
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THE
Anatomy and Surgery
OF THE
Frontal Sinus and Anterior
Ethmoidal Cells.
BY
HOWARD A. LOTHROP, M.D.,
OF BOSTON.
ASSISTANT IN ANATOMY, HARVARD UNIVERSITY.
4
REPRINTED FROM ANNALS OF SURGERY. I ^ f ^
■)
L
CONTENTS.
PAGE
Method of Investigation 7
PART I.
The Anatomy of the Frontal Sinus and Anterior Ethmoi-
dal Cells 9-53
Frontal Sinus 9
Location, surfaces, angles, borders.
General Considerations 17
Occurrence, external appearances, children, adults, transil-
lumination, thickness of walls, septa, dehiscences.
Ethmoid Bon*: 21
Lamina cribrosa, lamina perpendicularis, lateral masses,
labyrinth.
Lachrymal Bone, Nasal Bone 23
Internal Surface of Labyrinth, Ethmoidal Fissures ... 28
Inferior Ethmoidal Turbinate 29
Surfaces, borders, angles, relations, variations of form ;
other ethmoidal turbinate bones.
Processus Uncinatus 34
Surfaces, borders, extremities.
Bulla Ethmoidalis 39
Surfaces, foramina, extent, relations, variations, dehiscences
of lamina papyracea.
Hiatus Semilunaris 41
Bony outline, completion by membrane, variations of
closure at anterior end.
Infundibulum 43
External surface, internal surface, mucous membrane, ostium
maxillare, drainage into antrum, upper end of infundib-
ulum, modes of termination, ostia, naso-frontal canal.
Turbinate Fossa 47
Floor of Frontal Sinus (Nasal Portion), Ostiu.m Frontale 49
Lining OF Frontal Sinus, Vessels, Nerves 51
A FEW Anatomical Facts of Surgical Importance 52
Use of the curette, probing the ostium frontale, relation of
the ostium maxillare to the infundibulum, relation of
the anterior ethmoidal cells to the infundibulum.
M373273
CONTENTS.
PART II.
The Etiology, Pathology, and Treatment of Suppuration page
IN THE Frontal Sinus, together with the Necessary Con-
sideration of Disease of the Anterior Ethmoidal Cells 54-129
Historical 54
Etiology 55
Trauma, obstruction, inflammatory' processes, tuberculosis,
syphilis, new growths, influence of pathogenic bacteria.
Frequency 58
Pathology 59
Acute inflammation, chronic inflammation, tuberculosis,
syphilis, new growths.
Symptoms 68
Local, general, subjective, objective, symptoms referable to
nasal fossa, frontal area, orbital fossa, cerebral fossa.
Diagnosis 77
Previous history, differentiation from lesions, extranasal
and intranasal, differentiation of accessory sinus in-
flammation, their association.
Prognosis 89
Treatment (Acute Cases) 89
(Chronic Cases) 90
Intranasal methods, probing the frontal sinus, irrigation,
perforation of floor of sinus, suppuration in anterior eth-
moidal cells, in middle turbinate cells.
External Operations on Frontal Sinus loi
Indications, modes of procedure, obliteration of frontal sinus,
removal of nasal portion of its floor, anterior ethmoid
cells.
Entering Sinus through Anterior Surface no
Inferior surface, osteoplastic resection.
After-Treatment 117
Report of Various Types of Cases 118
Bibliography 129
Index 133
Table of Plates, 1-89 5
TABLE OF PLATES.
PLATES
Bone specimens in various sections 1-21
Sections of right and left nasal fossae 22-26
Series of lachrymal bones 27
Median sagittal sections 28-47
Orbital dehiscences 4S-50
Sagittal sections to one side of median line 51-54
Coronal sections 55-71
Horizontal sections 72-80
Incisions for operation Si
Showing bone flap 82
Pathological cases of frontal sinus disease 83-S6-89
Additional horizontal sections 87-88
METHOD OF INVESTIGATION.
This opportunity is taken to express my great indebted-
ness to Professor Thomas Dwight, of Harvard University,
not only for the unlimited privileges necessary to carry on
this investigation, but also for many valuable suggestions.
About 125 subjects, or 250 frontal sinuses, obtained
from dissecting-room material, form the basis of this re-
search. They were inspected when obtained, and preserved
in alcohol for future study and reference.
Fifty of these specimens were macerated, after examina-
tion, in the natural state, and about fifty more bony speci-
mens have been accessible for study.
The parts have been examined from sagittal, coronal,
and horizontal sections, and also by dissection of especial
regions, the use of probes, injection of fluids, etc.
The accompanying plates were made from photographs
taken by Bernard W. Trafiford, Esq., of Boston, whose assist-
ance and skill were invaluable in adding to the success of the
work. These photographs were taken from specimens se-
lected as seemed necessary to demonstrate the anatomy
under consideration, hence the relations are an exact repro-
duction. The size of the specimen reproduced in the plate is
not altered, except in a few obvious instances.
The aim of the anatomical portion of this paper is not
to describe accurately and completely any one or more bones,
but only the necessary portion of any bone entering into the
topography of the region to be considered.
7
PART I.
A STUDY OF THE ANATOMY OF THE FRONTAL
SINUS AND ANTERIOR ETHMOIDAL
CELLS.^
The Frontal Sinus.
The frontal sinuses are two cavities situated, for the
greater part, in the frontal bone, one on either side of the
median line, and anterior to the ethmoidal notch. No matter
how small the sinuses may be, they will be found at the an-
tero-internal junction of the horizontal (orbital) and vertical
(squamous) portions of the frontal bone, just internal to the
internal angular process. (Plate i.) Thence, according to
their development, they ma}'- extend for a variable distance
between the laminae of these portions of the frontal bone, as
will be described in detail.
Each sinus may be considered as the space formed by
the intersection of four planes, and assumes roughly the form
of a three-sided pyramid, and presents the following points
for examination: Three surfaces — anterior, posterior, inter-
nal — and a base, — inferior surface. (Plates 20, 53, 54, 56,
60.) All surfaces are roughly triangular. Of the several bor-
ders, three deserve particular mention, — anterior, superior,
and posterior. Three angles are prominent, — superior, ex-
ternal, and posterior.
Anterior Surface. — The anterior surface is situated en-
tirely in the vertical portion of the frontal bone, and is
bounded below by the supraorbital arch (Plate i), internally
^ This work was awarded the Warren Triennial Prize for the year 1S9S, by the
physicians and surgeons of the Massachusetts General Hospital.
9
lo HOWARD A. LOTHROP.
by the median line, generally represented by a partial suture
at its lower part, but the superior limit of this surface is very
variable, and has no external landmark. The surface as a
whole is somewhat convex from side to side, and more
so vertically, on account of the superciliary ridges which
traverse it from below upward and outward, and serve, to
a certain extent only, as a guide to the location and size
of the sinus. The superciliary ridges meet in front at the
nasal eminence or glabella, which is a useful landmark for the
surgeon. The surface, as a whole, is rather smooth and
covered with minute foramina, leading to cancellated tissue.
This is the thickest of the four surfaces, and varies from one
millimetre to six millimetres in thickness in different places,
according to age, sex, and race, although about two milli-
metres to three millimetres would be a fair average. This
sinus wall is apt to be thicker in the vicinity of its boundaries
and at the most prominent part of the superciliary ridge.
The anterior surface measures the height and width of
the frontal sinus, and is consequently very variable. Later-
ally, the sinus may extend only occasionally to the external
angular process of the frontal bone. An average of 200
sinuses, measured from the median line laterally, lie between
two centimetres and two and eight-tenths centimetres, and
this shows that it is not safe to trephine for the sinus external
to the supraorbital notch or foramen. The height of the
sinus is given as the measure of the internal border of the
anterior surface, close to the internal surface, from the base
to the apex of the pyramid. This will average one and eight-
tenths centimetres to two and one-half centimetres, and this
is usually the highest point of the sinus.
Above the superciliary ridge the smooth surface of bone
is uninterrupted, but below we come to the sharp supraorbital
arch, thick and generally notched, which terminates at the
internal angular process of the frontal bone. The lower bor-
der of this surface is then fixed by the suture between the
frontal bone, on the one hand, and the nasal bone and the
nasal process of the superior maxillary bone, on the other
THE FRONTAL SINUS. ir
hand. Where the nasal eminence is very prominent the lower
portion of the anterior surface looks somewhat downward as
well as forward. (See plates of sagittal sections.)
Anterior to this surface of the frontal bone are certain
facial muscles, supraorbital and frontal arteries, and supra-
orbital and supratrochlear nerves, all directly under the skin,
which is loosely connected to the deeper parts by the super-
ficial fascia. None of these structures should offer any hin-
derance to the surgeon in making any incision whatever over
the region of the frontal sinus.
Posterior Surface. (Plates 51, 53, 60, 67, sagittal sec-
tions.) — The posterior surface belongs in part to both the
vertical and horizontal portions of the frontal bone, and is
much thinner than the anterior surface. The vertical portion
is somewhat convex towards the sinus, as is also the hori-
zontal portion, if the sinus is small, but where the sinus ex-
tends laterally between the laminae of the orbital portion
(Plates 65, 71), then this posterior surface of the sinus be-
comes concave in conformity with the general arch of the
roof of the orbit. Posteriorly this surface forms part of the
wall of the anterior cranial fossa, and is in contact wdth the
frontal lobe of the brain and along its inner border with the
olfactory lobe. Just anterior to the ethmoidal notch the two
posterior surfaces come together in the median line, forming
with the ala processes of the ethmoid bone the foramen
caecum, A\hence ascends the frontal crest. (Plate 57.) The
upper and outer boundaries of the posterior surface of the
frontal sinus, as viewed from within the skull, are not de-
fined, but the internal border, moreover, follows the frontal
crest as far as the foramen ciecum, is reflected around the
crista galli, and then follows the lateral border of the cribri-
form plate (lamina cribrosa). (Plates 16, 17, 76.) The pos-
terior surface of the frontal sinus becomes horizontal in its
orbital portion, and is continued as the roof of the anterior
and then the posterior ethmoidal cells. (Plates 51, jy.)
This posterior wall of the frontal sinus is dense and brit-
tle, and contains no diploe. but sections of the anterior wall
12 HOWARD A. LOTHROP.
often show more or less cellular structure between two layers
of more dense bone. (Plate lo.) As compared with the
posterior wall, the anterior is tougher and more likely, up
to a given point, to bend them to fracture. Sections of the
vertical portion of the frontal bone show that the diploe
ceases rather abruptly (Plates 5, 9) at the junction of the pos-
terior and anterior surfaces (superior border), although, as
just mentioned, the anterior surface is somewhat cancellated.
If the vertical portion of the frontal sinus is wanting, the two
lamellae of bone are more nearly approximated, and the inter-
vening space filled with cancellated bone. Hence a careful
operator would observe the presence of this diploe, in case
the sinus was not developed, and avoid entering the cranial
cavity. (Plates 3, 4.)
Internal Surface. — Situated between the two sinuses is
a thin lamina of bone, easily perforated by a sharp-pointed
instrument, either side of which serves as the internal surface
of its corresponding sinus. The inferior border of this sep-
tum is usually near the median line, and is continuous with
the plane of the crista galli, the perpendicular plate of the
ethmoid, and the nasal spine of the frontal bone. This
border is considerably thickened, passes off laterally to form
a dense portion of the inferior surface or base of the sinus,
and is continued below in the median line at the nasal spine.
(Plates 9, 13, 56, 60, 62, 76.)
In the majority of cases this septum deviates to one side
or the other within a range of five millimetres, or even more,
notwithstanding its frequent median position inferiorly. Its
surface is usually convex near its centre, with a correspond-
ing concavity on the other side, unless, as occasionally hap-
pens, the septum is very thick and the sinuses are small, then
both surfaces are concave. (Plate 64.) The sinuses become
divergent towards their apices, so that the upper portion of
the septum is much thicker than its centre.
The plane of the septum is roughly antero-posterior,
passing between the anterior and posterior surfaces, but oc-
casionally it may be so deviated that one sinus lies partly
THE FRONTAL SINUS.
13
overlapping the other, even to an extent of two centimetres.
This is a point of obvious surgical importance. With re-
markable constancy, on account of its often delicate struct-
ure, this septum is usually complete, so that there is no
communication between the sinuses. An examination of 180
specimens has revealed two examples, one an oval perforation
near the centre of the septum, the other, its almost entire
absence. (Plate 55.)
Inferior Surface (floor or base of the sinus). (Plates 13,
15, 16, 57, 61, 65, 71.) — The inferior surface is divisible into
an orbital and a nasal portion.
The orbital portion lies external to the nasal portion,
enters into the formation of a part of the roof of the orbital
fossa, and its extent is open to considerable variation accord-
ing to the size of the sinus. Its surface is markedly convex
laterally towards the sinus, and but slightly so in the antero-
posterior direction. (Plate 54.) It is triangular, limited in
front by the supraorbital arch, internally by the suture be-
tween the frontal bone, on the one hand, and the os planum
(lamina papyracea) of the ethmoid bone and the superior
border of the lachrymal bone, on the other. (Plates 5, 20.)
There is nothing on the roof of the orbit to indicate its pos-
terior extent. This layer of bone forming the orbital portion
of the floor of the sinus is the inferior of the two lamince into
which the orbital portion of the frontal bone divides as it
approaches the ethmoidal notch; the superior lamina, more-
over, goes to complete a portion of the posterior surface of
the sinus. The outer portion of this inferior lamina is nearly
horizontal, but as it approaches the median line it turns a
sharp angle downward so as to be vertical at its termination.
(Plate 20.) The under surface is smooth and marked an-
teriorly by a slight depression or small tubercle of bone for
the cartilaginous pulley of the superior oblique muscle.
(Plate 13.) The sinus aspect of this lamina is likewise
smooth, but is frequently roughened by the presence of septa
connected with the sinus or anterior ethmoidal cells, to be
described in detail later.
14 HOWARD A. LOTH R OP.
In front, this surface usually extends laterally a little
beyond the supraorbital notch, frequently one centimetre
farther, and occasionally as far as the external angular pro-
cess of the frontal bone. (Plate 71.) Posteriorly its inner
border frequently reaches the anterior ethmoidal foramen
(Plate 5), and in rare instances it may nearly approach the
lesser wing of the sphenoid bone. Such a sinus would be
very large. With the exception of the thin walls of the eth-
moidal cells, which in part complete the nasal portion of the
fioor of the sinus (Plate 16), the orbital portion is the thinnest
of all the sinus walls. This is evident, not only from inspec-
tion of the bone, but also from the result of pathologi-
cal changes consequent on obstruction of the ostium fron-
tale.
Internally the plane of the inferior orbital lamella is con-
tinuous with the lachrymal bone and the os planum of the
ethmoid, so as to form the internal boundary of the orbital
fossa, and the external boundary of the lateral mass of the
ethmoid bone (Plate 20), indeed, from a surgical point of
view a portion of the lateral boundary of the nasal fossa.
This general curvature must be constantly kept in mind by
the operator when entering the sinus or anterior ethmoidal
cells from in front. Although not mathematically constant,
the general curvature is so regular, and its direction and con-
tour so uniform, that this lamella serves as the guide for the
surgeon in avoiding the orbital fossa.
The nasal portion of the inferior surface or floor of the
sinus is somewhat complicated, but a thorough understand-
ing of its composition and relations is of great surgical im-
portance. It is a comparatively small surface, and w^ell de-
fined only in selected cases. Its surface is very uneven and
interrupted by the rounded eminences of ethmoidal cells,
bony septa from different directions, and the presence of a
foramen of varying size and shape which leads into the nasal
fossa. (Plates 15, 16, 17.) These features may almost ob-
scure the surface, particularly behind, where it passes into the
posterior angle of the sinus. It is a surface of greater sur-
THE FRONTAL SINUS.
15
gical than anatomical importance, hence its consideration
will be dwelt upon at length.
In general, by the nasal portion of the floor of the frontal
sinus we mean the irregular, somewhat horizontal surface
which separates the sinus from certain ethmoidal cells and
other portions of the ethmoid bone, internal and at right
angles to the plane of the lachrymal bone and os planum.
(Plates 20, 72, 76, 79.) It terminates in front, at the line of
suture, between the frontal bone and the nasal process of the
superior maxilla, externally it joins the orbital lamina of the
frontal bone, internally it does not reach the septum nasi in
the median line, but is arrested at the line of junction of the
internal wall of the lateral mass of the ethmoid with the crib-
riform plate of the same. (Plates 13, 17, 79.) This internal
wall of the lateral mass is the upward prolongation of the
lower ethmoidal turbinate (commonly called the " middle
turbinate"), and is carried forward so as to continue the in-
ternal boundary of the nasal portion of the floor of the sinus
by articulating with the ethmoidal crest of the superior
maxilla. (Plates 2, 3.) This internal border of the nasal por-
tion of the floor is completed in front by a small portion of
the thickened frontal septum as it is continued into the nasal
spine. (Plates 11, 15.) Posteriorly the nasal portion of the
floor is lost in the posterior angle of the sinus. (Plate 76.)
On viewing the under surface of the frontal bone, an
irregular opening is observed which leads to the right or left
frontal sinus respectively, and is known as the hiatus frontalis.
(Plates 13, 15.) Following the circumference of the hiatus
frontalis, we have in front the articulation of the nasal pro-
cess of the superior maxilla, externally the lachrymal bone
and OS planum along the free edge of the inferior orbital
lamella, internally the frontal septum, behind which we come
to the ethmoidal notch formed by the two superior orbital
laminae. (Plates 14, 15, 16.) Hence, between these two or-
bital laminae in front is an opening, the hiatus frontalis, while
posteriorly the intervening space is interrupted by septa
forming cavities which help to complete certain of the an-
1 6 HOWARD A. LOTHROP.
terior and posterior ethmoidal cells when the frontal bone
is in situ. (Plate 13.) This inferior aspect of the hiatus fron-
talis, and the area immediately posterior to it, gives one the
best idea of what is meant by the nasal portion of the floor of
the frontal sinus. The ethmoidal notch is filled by the crib-
riform plate, whence descends in the median line the per-
pendicular plate of the ethmoid bone (lamina perpendicu-
laris). The cribriform plate forms a portion of the true
anatomical roof of the nasal fossa, is internal to the hiatus
frontalis and apices of ethmoidal cells (Plates 16, 17),
roughly parallel with the nasal surface of the frontal sinus,
yet on a little higher plane. Again, looking at the inferior
surface of a frontal bone (Plate 13) with the cribriform and
perpendicular plates in position, we have a space averaging
from one centimetre to one and eight-tenths centimetres
wide between the free edge of the inferior frontal lamina to
the lamina perpendicularis. This space is divided by a third
parallel lamina, w^hich is simply the upward continuation of
the inferior ethmoidal turbinate to its insertion on the lamina
cribrosa, and its anterior prolongation to the ethmoidal crest
of the superior maxilla. The outer space is occupied by the
nasal floor of the frontal sinus in front, behind by the an-
terior ethmoidal cells. (Plates 20, 58, 62, 65, 74, yy, 79.)
The internal space, somev/hat narrower, is roofed over by
the lamina cribrosa, and, although a dangerous locality, this
additional space is of value in the operative treatment of
diseases of the frontal sinus and anterior ethmoidal cells.
Further consideration of the floor of the nasal portion of
the frontal sinus must be deferred until a portion of the eth-
moid bone has been described.
The anterior border of the frontal sinus is formed by the
junction of the anterior and inferior surfaces, and follows the
line of the supraorbital arch. (Plates i, 53.) These surfaces
meet at an angle somewhat greater than 90 degrees, so that
this border is rounded rather than sharply defined.
The superior border follows the line of union of the
superior and posterior surfaces, which usually meet at a
THE FRONTAL SINUS.
17
rather acute angle, so that this border is well marked.
(Plates 51, 54.)
The posterior border follows the line of separation of the
orbital laminae as they diverge to become the inferior and
posterior surfaces of the sinus. Towards the external anele
this border is usually unobstructed (Plate 54), but, as it ap-
proaches the internal angle (Plate 53), the narrow space be-
tween the orbital laminre is filled up with one or more bony
cells of variable size, which protrude forward into the sinus
so as to diminish its size, often to a considerable degree.
These cells, together with those at the posterior angle, are so
intimately associated with the anterior ethmoidal cells that
they will call for a more detailed account later.
The superior angle is the apex of the sinus, lies in the
vertical portion of the frontal bone, and offers nothing of
particular interest.
The external angle is sharp and corresponds to the most
lateral portion of the sinus. Its location, like that of the
superior angle, varies according to the size of the sinus.
The posterior angle is usually filled with cells and is
of much surgical importance. It will be better understood in
connection with the nasal floor of the sinus and the anterior
ethmoidal cells.
Other borders and angles exist which call for no par-
ticular mention.
General Considerations.
External Appearances. — There are no absolutely certain
guides by which the degree of development of the frontal
sinuses in the adult can be determined before attempting to
expose them. At birth, the frontal bone is in two portions,
the sinus has not yet appeared, and the frontal eminences are
prominent. As the child grows the sinuses develop slowly
and the general shape of the head and frontal region changes.
At puberty, the sinuses are practically developed and the
frontal area has assumed its adult form. The gradual ap-
pearance of the superciliary ridges, which are apt to be most
l8 HOWARD A. LOTHROP.
marked over the sinuses and the nasal eminence, make the
supraorbital area of the adult more prominent, and the
frontal eminences less so when contrasted. In general, it is
fair to conclude that the more prominent the supraorbital
area, including both the superciliary ridges and nasal emi-
nence, the greater the probability of the presence of well-
defined sinuses. (Plates of sagittal sections.) Even fairly
well-marked superciliary ridges on a non-protruding supra-
orbital area are frequently accompanied by poorly developed
sinuses or even absence of their vertical portion. (Plate 6.)
Race characteristics have some influence, as shown by
poor sinus development in receding frontal bones.
Sinuses in the male appear to be relatively larger than
would seem to be warranted by the usual disproportion be-
tween the measurements of the bones in general of the male
and female skeleton. This may be but a part of the general
accentuation of eminences and depressions in the male sex,
particularly in the vicinity of joints.
Transillumination of the unopened sinus on the cadaver
after the removal of the calvarium, transmitting the light from
below towards the cranial cavity, is a good guide for deter-
mining, approximately, both the size of the sinus, its presence
or absence, and the thickness of the walls. The value of
transillumination in determining these points and also the
presence of exudate within the sinus in practice will be con-
sidered in Part II.
The relative thickness of the sinus walls has been con-
sidered, but the actual thickness is influenced more or less
by age, sex, and race. The walls are somewhat thicker in
the male, where the bones in general are heavier, and in races
characterized by well-developed bones. Bones of the aged
may lose a third of their weight by absorption, whereby bony
laminae become much thinner and more brittle. The size of
the sinus may be thereby somewhat increased, but to no
very appreciable extent.
Occurrence. — With very great regularity both sinuses are
present. Several anatomists are authority for the statement
THE FROXTAL SINUS.
^9
that one or both sinuses may be absent without indicating
whether the whole sinus or its vertical portion was meant.
A sagittal section, made so as to pass through the nasal
portion of the inferior surface, shows that the sinus, as a
whole, is flattened from l)efore backward, and curved upon
itself so as to present an anterior convexity. (Plates 9, 51,
52.) The superior part of the sinus lies within the vertical
portion of the frontal bone, the posterior part is in the orbital
portion, and the most prominent part of the convexity is at
the anterior border, which follows the line of the supraorbital
arch. (Plates 10, 11, 36.)
An examination of about 250 sinuses has given these
results:
(i) That in no instance has the orbital portion been
wanting, although it may be much diminished in size, and
correspond to an anterior ethmoidal cell. There has always
been an orbital space communicating with the middle meatus,
either indirectly through the infundibulum, or directly by an
ostium under the anterior line of insertion of the lower eth-
moidal turbinate, in conformity with one of the usual modes
of communication between the nose and frontal sinus.
(2) That in about 3 per cent, of the cases the frontal
sinus does not reach to the vertical portion of the frontal
bone, at least on one side. From a surgical stand-point such
a sinus may be said to be wanting, for the diagnosis and treat-
ment of suppuration in a small orbital sinus would not differ
materiallv from such a condition present in the anterior
ethmoidal cells.
(3) That a sinus may be of ordinary size on one side and
abortive on the other. (Plate 63.)
(4) That the sinuses of the two sides are never precisely
alike.
(5) That the sinus of each side opened into the corre-
sponding nasal cavity, with one exception.
(6) That in one case the frontal sinuses were of more
than average size; that there was no trace of a median sep-
tum except a slightly elevated ridge corresponding to its
20 HOWARD A. LOTHROP.
periphery; that on the left side of the median Hne there was
no ostium frontale, but on the right side there was one
ostium frontale in the usual location, serving as an outlet
for this large common sinus into the right nasal cavity. This
abnormal condition will be described later. (Plate 55.) The
pyramidal shape of the sinus can be made out in most cases
(Plate 53), but it may be obscured, however, from several
causes. The borders may be more than ordinarily rounded
and the angles cut off by protruding cells or excess of diploe.
Thus the sinus may appear as a small oval cavity. (Plates 5,
49, 50.)
Septa. — Wherever the sinus is of large size it is usually
the rule to observe bony septa, passing most commonly be-
tween the anterior and posterior surfaces. (Plates 10, 11,
20, 55, 56.) They may be apparently complete or partial, so
as to subdivide the sinus into smaller cavities. Where the
septum is nearly complete the communicating foramen is
usually towards the posterior border or posterior angle. The
plane of the septa is most commonly rather vertically placed
and running in a general antero-posterior direction, often
radiating from the posterior angle. Partial septa are often
of considerable thickness, and are more commonly found at
the superior and anterior borders, whereas the posterior bor-
der and angle are filled with cells. Septa are easily broken
down with the curette or bone forceps. They give additional
strength to the walls of the sinus.
Occasionally pockets lead from the inferior portion of
the sinus, thereby rendering this surface still more irregular.
The nasal process (Plates 32, 37) may be thus hollowed out,
and less frequently the crista galli of the ethmoid bone (Plate
26) may be only a shell containing a diverticulum from a
frontal sinus. More frequently a diverticulum pushes directly
downward into the space bounded externally by the lachry-
mal bone, internally by the upper extremity of the uncinate
process of the ethmoid, and in front by nasal process of the
superior maxilla. (Plates 51, 52.)
Defects in the continuity of the frontal sinus walls, de-
THE FRONTAL SIXUS. 21
scribed as dehiscences (Zuckerkandl), must l)e very unusual.
None have been detected in this series of 250 sinuses. They
are said to occur near the front of the fronto-nasal suture.
Several instances of orbital dehiscences, however, associated
with the anterior ethmoidal cells have been noted; these will
be considered later.
Ethmoid Bone. — Such parts only of this bone will be
considered as are concerned in the regional anatomy of the
frontal sinus and anterior ethmoidal cells.
Lamina Crihrosa (Plates 13, 16, 17, 18, y2, 76). — The
horizontal or cribriform plate (lamina cribrosa) is rectangu-
lar in shape and fills in the ethmoidal notch (Plate 15) of the
frontal bone articulating on three borders with the superior
lamina only of the orbital portion of the frontal bone. The
posterior border is notched for the reception of the eth-
moidal spine of the sphenoid bone. The plate is bisected by
the plane of the crista galli and hollowed out for the recep-
tion of the olfactory lobes. On each side of the median line
are three parallel rows of foramina for the transmission of the
olfactory nerves. The foramina of the inner row are the
largest, and lead to grooves on the lamina perpendicularis of
the ethmoid (Plate 28); those of the median row are the
smallest; and those of the outer row are intermediate in
size, and lead to grooves on the inner side of the internal
wall of the lateral mass. (Plates 2, 3.) Close inspection
shows that the larger foramina are merely depressions, at
the base of which are seen several minute openings. An-
teriorly, quite close to either side of the crista galli, is a slit-
like foramen for the passage of the nasal branch of the
ophthalmic division of the fifth cranial nerve.
Viewed from above, the cribriform plate will be seen to
be occasionally much obscured by the conformity of the or-
bital plate or by a wide crista galli.
Lamina Perpendicularis (Plates 20, 21). — Descending
from the median line of the lamina cribrosa is the lamina
perpendicularis which completes the greater portion of the
upper part of the nasal septum. It is a somewhat quadrangu-
2 2 HOWARD A. LOTHROP.
lar section of bone, thinner in the centre than at the periph-
ery. The superior border is attached to the cribriform plate,
and terminates at the anterior extremity of this plate.
The anterior border, two centimetres to three centi-
metres long, runs downward and forward, articulating above
with the nasal process of the frontal bone and near its ex-
tremity with the crest of the nasal bones. (Plates 19, 26.)
The plane of the lamina perpendicularis is usually concave to
one side or the other, and its surface grooved vertically for
nasal nerves.
Crista Galli. — In the same median plane, but situated
above and on the anterior portion of the lamina cribrosa, is a
prominent triangular crest of bone called the crista galli.
On each side of its anterior border is a process (processus
alaris) which helps complete the foramen caecum when articu-
lated with the frontal bone. The crista galli lies behind and
occasionally above the septum, between the frontal sinuses,
and generally in close proximity. (See sagittal sections.) It
may be thin and dense, or wide and cancellated; its anterior
border may be free or closely associated with the posterior
surface of the frontal sinus, and in exceptional cases it may
be hollow and form a portion of the sinus itself, — crista galli
diverticulum. (Plates 10, 26.)
Lateral Masses. Ethmoidal Labyrinth (Plates 17, 18, 19,
20, 21). — The lateral masses of the ethmoid bone are two
irregular bony structures, one suspended on either side of
the lamina perpendicularis from the lamina cribrosa. Each
lateral mass presents an inner and an outer wall, between
which is an intricate cellular net-work, called the ethmoidal
labyrinth.
The outer wall consists of a thin, rectangular lamina of
bone, called the os planum (lamina papyracea), which forms
a portion of the inner wall of the orbital fossa. (Plate 9.)
When the ethmoid bone is disarticulated, the os planum is
surrounded on all sides by a series of seemingly broken cellu-
lar spaces (Plate 19), but in the natural state these cells are
completed by neighboring bones. The superior border of
rilE FRONTAL SINUS.
23
the OS planum articulates with the inferior lamella of the or-
bital portion of the frontal bone, so that, obviously, the
broken cellular spaces between this border and the cribriform
plate are completed by corresponding spaces between the
orbital lamina.\ Hence, superiorly the ethmoid cells are par-
tially within the frontal bone. (Plates 13, 14.) The eth-
moidal foramina are at either extremity of this suture, the
anterior of which will concern us later.
The anterior border of the os planum articulates with
the lachrymal bone, which also covers in the cellular spaces
here. (Plates 5, 69.)
The inferior border articulates with the orbital surface
of the superior maxilla, and the posterior border does not
concern us.
The OS planum is usually intact, but dehiscences occur
(Plates 48, 50), the importance of which will be considered
with the anterior ethmoidal cells.
Before passing within the nasal cavity for the considera-
tion of the inner wall of the lateral mass and the anterior eth-
moidal cells, let us complete the internal orbital wall, as far
as may concern us.
Laclirymal Bone (Ossa Unguis) (Plates 5, 9, 27). — Di-
rectly anterior to the os planum is the lachrymal bone with
its two surfaces and four borders. The bone is thin and
scale-like, wnth no cellular spaces.
The outer or orbital surface is divided unequally by a
vertical ridge called the lachrymal crest, giving origin in part
to the tensor tarsi muscle. The surface posterior to this crest
is smooth and is in direct continuity with the surface of the
OS planum, the inferior lamina of the orbital portion of the
frontal bone, and the orbital surface of the superior maxilla.
The surface anterior to the crest is narrow^er but longer than
the posterior, is concave throughout its vertical extent, and
prolonged inferiorly in order to complete the inner and pos-
terior bony canal for the nasal duct. The superior portion
of this surface lodges the lachrymal sac.
The inner or nasal surface of the lachrvmal bone is char-
24 HOWARD A. LOrilROP.
acterized by a groove corresponding to the lachrymal crest.
Running obliquely across the surface from before backward
and downward is the inferior border of the uncinate process
of the ethmoid bone. This border is in contact directly, or
by means of small processes, and in the natural state the soft
parts complete this continuity. (Plates 8, lo, ii, 12.) The
upper surface of the nasal aspect of the lachrymal, as thus
marked off by the uncinate process, goes to complete, exter-
nally, certain of the anterior ethmoidal cells, oftentimes the
cellular space corresponding to the agger nasi (see inferior
ethmoidal turbinate), and a portion of the upper and outer
wall of the infundibulum. (Plates 5, 7, 9, 10.) This surface
is marked irregularly by slightly elevated ridges correspond-
ing to cellular laminae of the ethmoid. (Plate 27.)
The somewhat triangular and smaller inferior portion of
this nasal aspect forms a portion of the outer wall of the
nasal fossa, situated on the same plane and articulating with
the posterior border of the nasal process of the superior
maxilla, and continues posteriorly with the upper portion of
the uncinate process either directly by bone or in the recent
state by mucous membrane. Directly external and anterior
to this portion of the nasal surface is the nasal duct.
Inferiorly this surface is continued as a process to articu-
late with the lachrymal process of the inferior turbinate bone
so as to complete internally the bony nasal canal. (Plates
22, 24.) Just before the lachrymal crest reaches the inferior
border, it is continued as the hamular process, outward and
forward along the edge of the orbital surface of the superior
maxilla to the lachrymal tubercle of the same bone, so as to
complete the bony ring of entrance to the nasal canal. This
process may be a separate piece of bone.
The superior border is short, thickened at its anterior
extremity, and articulates with the internal angular process
of the frontal bone. It is in direct continuity with the ex-
ternal margin of the hiatus frontalis. (Plate 20.) The an-
terior border is the longest, articulates with the posterior
border of the nasal process of the superior maxilla, and ter-
THE FRONTAL SINUS. 25
minates inferiorly with the prolongation which meets the
lachrymal process of the inferior turbinate bone. The pos-
terior surface articulates with the os planum provided the
lachrymal bone is complete, otherwise it is a free rai^ged
edge. It is not unusual to find the posterior portion of the
lachrymal bone deficient (lachrymal dehiscence), in which
case the continuity is restored by fibrous membrane. The
inferior border, divided unequally by the lachrymal crest,
articulates posteriorly with the orbital surface of the superior
maxilla, anteriorly with the inferior turbinate as a rule.
In some instances where the lachrymal bone is small or
deficient, compensatory laminae from any neighboring bones
may complete this internal bony wall of the orbital fossa.
The relations about this bone are of much importance in the
surgery of the anterior ethmoidal cells and frontal sinus.
Continuing the internal orbital wall forward (Plates 5,
9), it is seen to be completed by the nasal process of the
superior maxilla. This process is a dense, rather vertically
placed lamina of bone, projecting from the upper and front
portion of the superior maxilla. Its external surface is
smooth, slightly concave, gives origin to certain facial mus-
cles, and is perforated by nutrient foramina. It continues
anteriorly with the external surface of the nasal bone. Its
internal surface (Plates 10, 11) forms part of the outer wall
of the nasal fossa. A small upper portion is roughened and
continues around to the thickened posterior border, articu-
lates with the anterior extremity of the lateral mass of the
ethmoid, thereby completing certain anterior ethmoidal cells.
(Plates 20, 24.) Just below this small area is the superior
turbinate crest for the anterior extremity of the inferior tur-
binate of the ethmoid (so-called " middle turbinate bone"),
and also, in most cases, the anterior extremity of the inferior
border of the uncinate process. (Plates 10, 11.) At the
lower border of this nasal surface of the process under con-
sideration is a second horizontal crest, for articulation with
the inferior turbinate bone. Between these crests the surface
is slightly concave and quadrangular, not so smooth as the
26 HOWARD A. LOTHROP.
outer surface, covered in the recent state by mucous mem-
brane, and forms a very firm boundary of the outer nasal wall.
To a more or less degree this surface is overlapped by the in-
ferior turbinated bone of the ethmoid.
The superior border of the nasal process is very short
and thick, and deeply and finely denticulated for articulation
with the frontal bone. This suture is at the anterior edge
of the hiatus frontalis, extending laterally to be continued
by the superior border of the lachrymal bone. In front,
towards the median line, this suture is completed by the
nasal bone (Plate i), the upper border of which is equally
thick as compared with that of the nasal process of the supe-
rior maxilla. Between the two internal angular processes of
the frontal bone is the frontal notch, for the reception of
the nasal processes and nasal bones. This region is just an-
terior to the margin of the hiatus frontalis of either side
(Plate 15), and to the bony space between these openings
into the frontal sinus, which is the lower, often much thick-
ened, border of the interfrontal septum. (Plate 56.) Ac-
cording to the deviation of this septum, the size of the hiatus
frontalis, the relative width of the nasal bone and nasal pro-
cess, a part of the superior border of the nasal bone must
be considered as bounding this hiatus. This partial bony ring
bounding the anterior and lateral aspects of the hiatus is of
much surgical importance in operations for curetting the
cells about the ostium frontale and the complete removal of
the nasal portion of the floor of the frontal sinus. (Plates
15, 16.) (The terms "hiatus frontalis" and "ostium fron-
tale" must not be confused. The former refers to the open-
ing in the frontal bone itself, and practically indicates the
extent of the nasal portion of the floor of the frontal sinus
after the ethmoid bone has been removed. The ostium
frontale refers to the foramen of communication between the
frontal sinus and nasal cavity when all the bones are in situ.)
To return to the nasal process of the superior maxilla.
The posterior border, very thick, is marked by a groove
which crosses diagonally from above downward and inward,
THE FROXTAL SINUS. 27
and lodg-es tlic lachrymal sac and nasal duct. The inner bor-
der of the groove articulates with the lachrymal bone, the
outer border is the anterior boundary of the inner wall of the
orbital fossa. The anterior border is comparatively thin, and
articulates with the nasal bones. (Plates 5, 9.)
Nasal Bones. — The general curves of the external sur-
face of the nasal process of the superior maxilla and of the
anterior wall of the frontal sinus are continued on to the
outer surface of the nasal bone, interrupted only by the su-
tures already mentioned. (Plate 9.) The thickness of the
superior border has been noted. The inner surface, for the
most part, belongs to the lateral w^all of the nasal fossa (Plate
11), but a small median strip forms the anterior limit of the
roof of the nasal fossa, and is directly continuous posteriorly
with a portion of the roof formed by the thick inferior border
of the frontal septum (Plate 56), which in turn passes on to
the lamina cribrosa. At the internasal suture the inner sur-
face of the bones is raised to form the nasal crest, which is the
beginning of the inner wall of the nasal fossa. This crest
articulates for the whole or part of its extent with the nasal
process of the frontal bone (Plate 11), otherwise w-ith a por-
tion of the lamina perpendicularis of the ethmoid, and on
either side is a groove for the nasal nerve in its course from
the nasal slit in the lamina cribrosa. Continuing the me-
dian line posterior and inferior to the median septum and
nasal spine of the frontal bone, we come to the lamina per-
pendicularis, which forms a large part of the inner wall of
the nasal fossa. (Plates 2, yy.)
It is of practical importance to note at this point,
although a matter of repetition, that anteriorly and internally
the hiatus frontalis is surrounded by an incomplete ring of
often very dense bone, w'hich may narrow its lumen or ex-
tend across the anterior portions of the nasal floor of the
sinus, thus obstructing the passage of instruments from
below, and serving as a troublesome barrier in external oper-
ations aimed to enlarge the opening between the frontal sinus
and nasal cavity.
28 HOWARD A. LOTHROP.
Let US now consider the inner wall of the lateral mass.
(Plates 2, 3, 4, 21, 29, 30, 69, 70, 78.)
This lamina of rough bone, thicker than the outer wall
of the labyrinth (os planum), passes vertically downward
from the lamina cribrosa for a variable distance, serving both
as the inner boundary of the labyrinth and as the superior
portion of the external wall of the nasal fossa. It terminates
below in a free curled lamina of bone called the inferior tur-
binate body of the ethmoid bone, but more commonly
spoken of as the middle turbinate bone.
The superior border of this wall arises from the whole
length of the under surface of lamina cribrosa, just external
to the outer line of foramina cribrosa (Plate 13), so that its
inner surface is grooved by the olfactory nerves, which reach
it immediately on emerging from the foramina. This border
is nearly parallel with the lamina perpendicularis, but is
slightly convex towards the median line, hence the narrowest
part of the roof of the nasal fossa is near the centre of the
lamina cribrosa, and becomes wider in front between the
nasal processes of the superior maxilla, and behind near the
anterior surface of the body of the sphenoid bone. This
narrow portion of the roof will average one millimetre to five
millimetres wide. The wider it is, just so much more room
is gained by the surgeon.
Running parallel and external to the superior border
of this boundary of the lateral mass is a narrow strip of the
lamina cribrosa from two millimetres to five millimetres wide.
This has a free, external, ragged border in the disarticulated
bone, but in the natural state it articulates with the superior
lamella of the orbital plate of the frontal bone and enters into
the formation of a part of the roof of both the anterior and
posterior ethmoidal cells. This is the outer rim of the lamina
cribrosa, is devoid of foramina, and is frequently hidden by
the orbital plate if the latter is markedly prominent towards
the median line. (Plates 16, 17, 76.)
Posteriorly this superior border passes from the cribri-
form plate to the under surface of the ethmoidal spine of the
THE FRONTAL SINUS.
29
sphenoid bone, and, curving outward, it descends on the an-
terior surface of the body of the sphenoid. The anterior
border of the inner wall of the labyrinth becomes the anterior
border of the inferior ethmoidal turbinate, and will be de-
scribed below. The inferior border hangs as a thickened free
edge of this same turbinate. (Plates 2, 20, 58.) The inner
surface is rough and marked superiorly by vertical grooves
for the olfactory nerves.
The most striking landmark on this surface is a deep
fissure, the inferior fissura ethmoidalis, which marks ofT the
posterior half of the inferior ethmoidal turbinate. (Plates 2,
3. 8, 29.) It arises somewhat below the centre of this surface
about fifteen millimetres to twenty millimetres from the an-
terior border, and runs obliquely downward and backward
towards the spheno-palatine foramen. Below it bounds the
upper border of a portion of the lower ethmoidal turbinate,
and above it is the lower edge of the succeeding ethmoidal
turbinate. There may be one, two, or three of these flssuroe
ethmoidales, with a corresponding number of ethmoidal tur-
binate bodies. Above and behind these one to three oblique
fissuras ethmoidales is a nearly vertical depression between the
posterior end of the inner surface of the lateral mass and the
anterior surface of the body of the sphenoid, known as the
recessus spheno-ethmoidalis, into which opens the ostium
sphenoidale. (Plates 2, 8, 18.) Into the fissuras ethmoidales
open the posterior ethmoidal cells by means of comparatively
large foramina knowai as ostia ethmoidalia; (Plates 4, 8, 34,
39- 5I-)
The region above and posterior to the superior border
of the inferior ethmoidal turbinate belongs to the domain of
the posterior ethmoidal cells, and need not concern us
further.
Inferior Efhiiioidal Turbinate (middle turbinate of nose). —
The lamina of bone forming the internal boundar}' of the
labyrinth, as already noted, is divided sufficiently for descrip-
tive purposes into two triangles by the incisura ethmoidalis
inferior and a line projected forsvard to the antero-superior
3°
HOWARD A. LOTHROP.
angle at the nasal process of the superior maxilla. (Plates
2, 3, 29.) The surface of the superior of these triangles is
interrupted by the remaining fissurse ethmoidales, which indi-
cate the number of ethmoidal turbinate bones. This triangle
does not concern us.
The inferior triangle is the inferior ethmoidal turbinate
bone, a thorough understanding of which is of importance
in the treatment of anterior ethmoidal and frontal sinus dis-
ease. This lamina of bone hangs with a free border which
projects into the nasal cavity (Plates 20, 57), and presents two
surfaces, three borders, and three angles for consideration.
The inner surface faces the septum nasi, is flattened
above but convex below, particularly in the antero-posterior
direction, on account of the curling outward of the lower
portion of the bone. (Plate 62.) It is roughened throughout
its whole extent, and grooved near its inferior border for the
branches of the spheno-palatine artery, which run forward
and upward. The bone, as a whole, is rather spongy, but
occasionally its surface is smooth. Corresponding to the
length of the fissura ethmoidalis inferior, the surface here
makes a right angle, or the bend may be even more acute, so
that the upper portion of the inner surface no longer presents
towards the septum nasi, but looks upward. (Plates 29, 30.
75.) This portion of the turbinate may be twelve millimetres
to twenty millimetres long, and about ten millimetres wide,
and its direction is of value in causing pus from the posterior
ethmoid cells and sphenoidal sinus to flow backward towards
the pharynx.
The outer surface of this ethmoidal turbinate is concave,
but somewhat flattened towards the superior angle. This
external concavity is called the sinus of the turbinate, and it
is in very constant relation to the bulla ethmoidalis and pro-
cessus uncinatus, as will be described later. (Plates 67, 69,
70.) This surface is often rougher than the internal aspect
of the turbinate, and characterized by depressions or pockets
even of considerable size. The openings of these depressions
may become constricted, thus giving rise to cell-like forma-
THE FROXTAL SINUS 3 1
tions resembling the ethmoidal cells. There may be a single
large cell or more commonly several smaller cells, all of which
open into the space below and external to the mferior eth-
moidal turbinate, known as the middle meatus of the nose.
(Plates 57, 58, 68.)
The superior border is the longest, and has a bony at-
tachment throughout its whole extent. Starting from the
spheno-palatine foramen, it passes upward and forward across
the superior turbinated crest of the palate bone, thence ob-
liquely along the cells of the labyrinth, to reach the lamina
cribrosa in front, then it is carried forward close to the me-
dian line, often in contact with the lamina perpendicularis
and thickened inferior border of the frontal septum, to ter-
minate on the inner surface of the nasal process of the supe-
rior maxilla. (Plates 4, 8, 10, 11, 29, 30. 34, 45.)
The anterior and shortest border of the turbinate begins
at this point, is carried downward for a variable distance on
the nasal process of the maxilla, commonly in conjunction
with the anterior extremity of the uncinate process. The
lower half of the anterior border bends a little backward, and
continues to the inferior angle as a free border.
The inferior border is free and connects the inferior and
posterior angles. (Plates 2, 3, 29, 30.) It is much thickened,
curled outward, spongy, and traversed by small canals for
vessels.
The posterior angle is at the junction of the superior
and inferior borders, and is just below the spheno-palatine
foramen, and on nearly the same vertical plane as the pos-
terior angle of the inferior turbinate bone.
The superior angle is somewhat obscurely placed near
the roof of the nasal fossa, internal to the ostium frontale.
The space just external to this angle is frequently somewhat
enlarged by carrying the anterior border forward on to the
nasal process of the superior maxilla and increasing the con-
cavity of the turbinate, so as to assume considerable im-
portance on account of the openings from the frontal sinus,
the frontal bulla, and anterior ethmoidal cells. This forward
32 HOWARD A. LOTH R OP.
prolongation of the cavity under cover of the turbinate is
called the agger nasi by H. Meyer, and is comparable with
an extra turbinate, as observed in some of the lower mam-
malia. (Plates 8, 12, 25, 30, 40, 51, 52, 58, 59, 65.)
The anterior angle is often very prominent, projects
freely into the nasal cavity, and is formed by the junction of
the inferior and anterior borders. This projecting flap-
like portion of the turbinate is known as the operculum
(Schwalbe), and is commonly removed in attempts to reach
the frontal sinus and anterior ethmoidal cells from within the
nasal cavity. (Plates 29, 30.)
The general outline of the inferior ethmoidal turbinate
is somewhat variable, yet it never loses its triangular shape.
The free portion of the anterior border may be long or short,
in which case the operculum is more or less prominent, and
the angle formed by the anterior and inferior borders acute
or obtuse. A long anterior border lowers this angle and
renders access to the labyrinth more dif^cult. The general
plane of the turbinate is a vertical one, but it may be deviated
strongly to one side or the other, thus lying in contact with
the septum nasi, on the one hand, or be crowded against the
labyrinth, on the other hand. (Plates 57, 59, 61,) Its nor-
mal, external concavity may be greatly exaggerated, and thus
impinge upon the labyrinth. The space between the anterior
border of the turbinate and the nasal process of the superior
maxilla will be accordingly narrow or wide, to the operator's
advantage or hinderance.
Now and then one or more deep furrows traverse the
inner surface more or less parallel to and near the lower
border, so as to give one the impression of the presence of an
extra turbinate when viewed from the anterior nares. The
lower border may be much thickened, or greatly rolled up
externally, to form a sort of gutter along the lower edge of
the sinus of the turbinate. (Plates 59, 60, 62.) Deep notches
not infrequently interrupt the general contour of the free
margin. Very rarely is the internal surface of this turbinate
concave.
THE FKOXTAL SINUS.
33
The formation of cells in the inferior ethmoidal turbinate
has been considered in connection with the external concave
surface (sinus), appearing in grades from simple niches to
well-formed cells, having distinct ostia, which open into the
middle meatus. This is the smaller and unusual variety of
well-marked cell. In about 200 observations, turbinate cells
were present in 18 per cent, of the cases. One-third of these
were of the variety arising from the turbinate sinus,, two-
thirds were cells differing in character and mode of origin, as
well as location of their ostia.
This latter variety is characterized by the presence of
one large cell rather than several smaller ones, is located
more commonly near the anterior border, which may be
eight millimetres to twelve millimetres wide. (Plates 45, 58,
65, 68, 70, 71, 80.) The turbinate may consequently fill up
the space between the septum nasi and bulla ethmoidalis, or
grow at the expense of either of these structures. Of these
larger cells, two-thirds open above the inferior ethmoidal
turbinate into what is commonly called the superior meatus
of the nose. To be exact, there is usually a single ostium,
and that is located on the superior border of this turbinate at
the anterior extremity of the fissura ethmoidalis inferior, oc-
casionally in common with one or more of the posterior eth-
moidal cells. It is important to note that the ostium is at the
apex of the cell, most unfavorable for drainage, and would
discharge into the superior meatus in two-thirds of the cases,
in common with the posterior ethmoidal cells and the sphe-
noidal sinus.
The cell may occupy a part of the turbinate only; or
occupy the greater portion of it, when it has received the
name of concha bullosa. The extent of the cell can be de-
termined during life by means of the probe.
The remaining ethmoidal turbinate bones are situated
above and behind the region under consideration (Plates 29,
30), therefore they do not concern us.
So much for the lateral and anterior boundaries of the
lateral mass, and we have now to consider the structures be-
3
34
HOWARD A. LOTIIROF.
tween these walls and their relation to the inferior surface
(nasal portion) of the frontal sinus.
Processus Uncinatits. — The processus uncinatus (Plates
4, 5, 8, 9, II, 22) is a portion of the ethmoid bone consisting
of a narrow, flattened, and somewhat curved bony lamella,
which presents two surfaces, two borders, and two extremi-
ties. Its anterior extremity is attached to the anterior por-
tion of the lateral mass of the ethmoid, in close proximity to
the upper part of the anterior border of the inferior eth-
moidal turbinate bone. (Plate 18.) From this point the
process takes a direction downward, backward, and a little
outward in a plane external to the turbinate bone, but the
inferior border of the process follows quite closely, in many
instances, the contour of the free margin of the turbinate.
An understanding of the relations of this process and
the septa connected with it, is of extreme importance, for
these conditions determine in part the formation of the ducts
and orifices pertaining to the frontal and maxillary sinuses,
as well as many of the anterior ethmoidal cells. The plane of
the bone is somewhat vertical, but its lower end is a little
twisted, so that each surface faces in three directions. This
tilting of the process, in conjunction with the bulla eth-
moidalis, and their mucous membrane connections, to be de-
scribed presently, is an important determining factor in
directing the flow of pus from the frontal sinus and some of
the anterior ethmoidal cells.
Internal Surface. — The internal or nasal surface of the
uncinate process faces inward, and to a lesser degree forward
and downward. Its anterior portion is united for a variable
distance to the outer surface of the anterior end of the inferior
ethmoidal turbinate, and in conjunction with this it is car-
ried forward to articulate with the posterior border of the
nasal process of the superior maxilla, and thence to the inner
surface of this process. (Plates 8, 11.) According to the
extent of union between these approximated surfaces of the
processus uncinatus and turbinate will be determined one
of the modes of approach to the floor of the frontal sinus.
■Jim j-ROXTAi. sixes.
35
With the exception of tliis smah anterior portion, the rest of
this snrface is free, and forms part of the onter wall of the
nasal fossa, just posterior to the nasal process of the superior
maxilla, part of the lachrymal 1)one, and lachrymal process
of the inferior tin-binate. There may be a space here, how-
ever, but the continuity is restored by mucous membrane.
This surface passes clown external to the operculum of the
turbinate with a varying distance between them. (Plate 65.)
Extcvwal Surface. — The external or infundibular surface
faces outward principally, and to a lesser degree upward and
backward. Its anterior portion is beautifully exposed on re-
moval of the lachrymal bone, and viewing the surface from
the orbital fossa. (Plates 5, 7, 9.) At once thin, irregular
laminse of bone come to view, connected with this surface
so as to form broken, cellular spaces, which, when articu-
lating with the corresponding slightly raised ridges already
described on the internal surface of the lachrymal bone (Plate
2y), complete certain of the anterior ethmoidal cells. Hence,
external to this portion of the external surface are ethmoidal
cells and lachrymal bone. Very soon, however, this surface
becomes the inner wall of the infundibulum, soon to be con-
sidered at length, into which this group of cells usually opens.
For the rest of its extent this outer surface, in the bony
state, is seen to cross the margin of the orbital surface of the
superior maxilla without touching it (Plate 9), and then to
face the antrum of Highmore. In the recent state, before
the mucous membrane is disturbed, this surface forms the
inner wall of the infundibulum, and is shut ofif from the inner
wall of the antrum, except at its lowest portion, whence
various processes radiate to be attached or not, as the case
may be, to the periphery of the bony outlet of the antrum,
thus partially completing the inner antral wall. Aside from
these slender bony processes, the processus uncinatus pro-
jects sickle-like nearly across the hiatus maxillaris, and dis-
tally helps form part of the wall of the antrum. (Plates 4, 8,
9, II.)
Inferior Border. — The inferior border is convex down-
36 HO WARD A. LOTHROP.
ward and forward. It arises superiorly in contact with the
middle turbinate and nasal process of the superior maxilla,
but for the rest of its course it is somewhat variable. As a
rule, in the bony state, it follows down the posterior part of
the inner surface of this nasal process, touches the lachrymal
bone, and is free to the posterior extremity of the process.
Common variations are the following:
(i) Processes connecting with the lachrymal bone.
(Plate II.)
(2) Direct contact with nearly the whole of the lower
part of the lachrymal line. (Plate 22.)
(3) Contact with lachrymal process of the inferior tur-
binate bone. (Plates 22, 24.)
(4) Union with ethmoidal process of the inferior tur-
binate bone, — very common. (Plates 4, 9.)
On the contrary, in the natural state, this border is never
free, but unites with the lower or deepest portion of the gut-
ter of the infundibulum. and is continued inferiorly as part of
the internal antral wall. The ostium maxillare will be con-
sidered with the infundibulum.
Superior Border. — The superior border of the uncinate
process is free both in the bony and natural state. It forms
a concavity roughly parallel with the prominence of the bulla
ethmoidalis, and in the natural state the slit between these
parts has received the name of hiatus semilunaris, and is the
only entrance to the infundibulum from the nasal cavity.
(Plates 8, 22, 24, 33, 38, 39.) The mode of connection of its
upper portion with the bulla ethmoidalis is the determining
factor as to the extent of the naso-frontal duct, the extent
and form of the upper portion of the infundibulum, and other
relations of much surgical importance. These will be con-
sidered in connection with the modes of entrance to the
frontal sinus.
Posterior Extremity. — The posterior extremity of the un-
cinate process lies approximately in the centre of the hiatus
maxillaris, in the partial closure of which it plays a small part
(Plates 5, 9, 11); but occasionally it may nearly fill this bony
THE FROXTAL SINUS.
37
hiatus by means of a very thin expanded lamina, one side of
which is covered by antral mucous membrane, the other by
nasal mucous membrane.
Two processes are very constant from this extremity,
the maxillary and turbinate. (Plates 5, 9, 11, 23, 24, 26.)
These processes arise more commonly from the inferior por-
tion of the extremity, the maxillary process, as though it was
the end of the processus uncinatus, bent up and carried up-
ward and outward to the edge of the orbital surface of the
superior maxilla. This process may be multiple or its com-
pletion may be wanting, but its presence is always partially
indicated. If complete, it forms the posterior border of the
ostium maxillare, and under these circumstances the normal
entrance to the maxillary sinus is entirely surrounded by
bone (Plates 23, 26), otherwise this boundary must be com-
pleted by membrane. This reflected maxillary process ter-
minates the lower extremity of the gutter or floor of the in-
fundibulum.
The turbinate process passes down from the lower bor-
der of the uncinate process between layers of antro-nasal
mucous membrane to meet the ethmoidal process of the in-
ferior turbinate bone. (Plates 4, 9, 24.) This process, to-
gether with others which may radiate from this extremity,
does not concern us.
Ethmoidal Cells. — The ethmoidal cells are bony cavities,
located, for the most part, in the lateral masses of the ethmoid
bone (Plates 17, 21, yy^, many of which are completed by
articulation with neighboring bones, as already mentioned.
These cells communicate with the nasal cavity by means of
ostia which are to be found in the fissur^e ethmoidales or
their homologues (hiatus semilunaris and fissure between
bulla ethmoidalis and upper border of the inferior ethmoidal
turbinate). (Plates 29, 30, 38, 46.)
Theoretically, it is fair to assume that there is some
regularity in the arrangement of the septa which go to form
these cells, but it is often very diflicult to follow out this
plan in practice. Zuckerkandl has suggested the following
38 HOWARD A. LOTHROP.
arrangement of bony septa, which is very satisfactory at least
for descriptive purposes. The labyrinth is bounded laterally
and above by bony walls, which have been described in suffi-
cient detail. Now, running across between these lateral
boundaries are septa obliquely placed, corresponding to the
lines of origin of the various ethmoidal turbinate bodies. —
viz., in the line of the fissures ethmoidales. Most of these
laminae join the os planum, the others the lamina cribrosa.
These planes are intersected by septa placed vertically in a
lateral direction, which divide the mass into cells of some-
what equal proportion. Such an ideal arrangement, of
course, naturally never exists. Certain cells are uniform and
larger than others. Certain cells exist in some cases, are
absent in others, and the shape of corresponding cells is
never the same. This irregularity is to be explained by the
crowding of the septa in one direction or the other, the ad-
dition of new septa and the loss of others.
The embryology of the ethmoid bone would suggest
that the cells first appear and grow by the development of
pockets or diverticula from the cartilaginous nasal wall
during the early years of infancy.
The ethmoidal cells of the adult are divided into two
groups, anterior and posterior. The former include all cells
opening under the inferior ethmoidal turbinate bone (" mid-
dle turbinate") into the hiatus semilunaris or the fissure
above the bulla ethmoidahs. The latter group includes all
cells having their ostia in the one to three fissurae eth-
moidales. Hence these cells open above the middle tur-
binate.
As a rule, the posterior cells are fewer yet larger than
the anterior, and their ostia are much larger.
Although the posterior cells may be involved in acute
processes as often as the anterior, spontaneous resolution is
more apt to follow, according as the general nasal mucous
membrane becomes normal, on account of the large size of
the ostia. The smaller ostia of the anterior cells are more
easily obstructed by polypi and hypertrophies, hence are
THE FRONTAL SINUS.
39
more frequently the site of chronic suppurative processes.
We will dismiss the posterior cells without further considera-
tion.
We have now to study the anterior ethmoidal cells and
their relations.
Bulla Etlniwidalis. — The bulla ethmoidalis (Zuckerkandl)
or promontorium (Zoja) is a very constant eminence, of con-
siderable importance as a landmark, made by the prominence
of the walls of one or, less frequently, several ethmoidal cells.
(Plates of most sagittal and many coronal sections.) It is
situated on the lower inner aspect of the lateral mass, under
cover of, and partially concealed by, the middle turbinate
bone, and is immediately above the posterior half of the pro-
cessus unciformis, with which it helps form the hiatus semi-
lunaris.
The bulla presents itself as a more or less prominent,
smooth, and rounded eminence, which is open to considerable
variation both as regards size and shape. It is best observed
on removal of the middle turbinate bone. The prominent
convex surface of the bulla looks inward, forward, and down-
ward. (Plates 22, 34.) If this surface is followed backward,
it is seen to be continuous with the horizontal portion of the
posterior part of the middle turbinate, directly under the
fissura ethmoidalis inferior. Following the surface down-
ward and outward, we come to the under surface of the
orbital wall of the superior maxilla, and pass to the maxillary
sinus (Plate 21), but in the natural state our progress would
be arrested by the membranous inner wall of this sinus, un-
less, perchance, we should be in the location of the ostium
maxillare, when our progress into the sinus would not be
interrupted. (Plates 61, 62, 69, 70.)
Passing forward and outward over the bulla, its convex
anterior surface is limited by, and corresponds very accu-
rately to, the anterior border of the lamina papyracea. (Plate
21.) If we follow the eminence of the bulla backward and a
little upward, we are arrested by a fissure formed by the junc-
tion of this surface with the insertion of the middle turbinate.
4°
JIOWARD A. LOrilKOP
(Plates 4, lo, 38, 40, 41.) Near the lower part of this fissure
is an ostium leading to the sinus of the bulla. This ostium
is elliptical, and rarely located low enough to drain the bulla
without residuum. There are usually one or more additional
ostia in this fissure, situated above the one to the bulla which
lead to cells located nearer the floor of the frontal sinus. In-
stead of several ostia in this fissure, we may have one long
elliptical ostium, extending quite to the lamina cribrosa, so
as to measure ten millimetres to fifteen millimetres. (Plate
42.) At the bottom of this long opening can be seen septa
giving rise to cells.
In most instances the prominence of the bulla is due to a
single, rather large cell, which extends outward until arrested
by the lamina papyracea. (Plates 62, 67.) It is not unusual
to have two cells form the bulla, only one of which reaches
to the orbital wall. (Plate 70.) These upper cells extend
between the laminae of the horizontal plate of the frontal
bone, and may push forward into the posterior border and
posterior angle of the frontal sinus. The frontal bulla (Plate
53), to be considered presently, may be formed thus.
As a rule, the antero-inferior convexity of the bulla eth-
moidalis corresponds to the upper concavity of the uncinate
process, and forms the superior boundary of the hiatus semi-
lunaris and a considerable extent of that of the infundibulum.
To summarize the relation of the ethmoid bulla, to-
gether with the cell of which it is a part, we have, —
Anteriorly and inferiorly, the infundibulum and hiatus
semilunaris, with the processus uncinatus.
Internally, inferior ethmoidal turbinate bone.
Superiorly, a group of anterior ethmoidal cehs, extend-
ing forward and sometimes backward, otherwise posterior
cells reach over the bulla.
Posteriorly, the horizontal portion of the middle tur-
binate shutting off the fissura ethmoidalis inferior, and pos-
terior ethmoidal cells. (Plate 75.)
Externally, the lamina papyracea.
Variations in the Bulla Ethmoidalis. — The average bulla
THE FRONTAL SINUS. 41
is about ten millinietres long, and extends over the superior
border of the processus uncinatus towards the median Hue
about two to five millimetres. (Plate 67.) Its whole con-
vexity is rather uniformly prominent. As extremes, the
longest bulla observed measured twenty-six millimetres, and
the widest, thirteen millimetres. The smallest bulla consisted
of a nearly flat lamina of bone, the free edge of which served
to separate the hiatus semilunaris from the ostium of the
bulla. (Plates 4, 33.)
Occasionally the convexity is drawn out like a nipple,
directed downward so as to project below and internal to the
uncinate process. (Plates 42, 44, 46.) In a few cases the
bulla may be in contact, particularly in the recent state, with
the superior border of the uncinate process, and be a serious
hinderance to instrumentation. (Plates 25, 31, 37, 41.) A
wide bulla may crowd the turbinate against the septum nasi.
(Plate 67.)
Orbital Dehiscences. — Defects in the orbital wall of the
labyrinth, known as dehiscences, are very unusual, except in
connection with the lachrymal bone. These need no men-
tion. Two cases have been observed where the os planum
was partly defective and the bony lamina replaced by mem-
brane. In both instances, the sinus of the bulla communi-
cated with the orbital fossa.
These cases are pictured in Plates 48, 49, 50, but their
great rarity divests them of much practical importance, other-
wise they would offer little resistance to the passage of pus,
either from the orbital fossa to the nasal fossa or z'ice versa,
or give rise to emphysema within the orbit.
Hiatus Semilunaris (Plates 4, 8, 10, 11, 12, also 30 to 47
inclusive). — The hiatus semilunaris is a half-moon-shaped
opening, as its name suggests, which leads from the nasal
cavity (middle meatus) into the infundibulum. (Plates 65,
67. 75-) The parts which bound this opening have been
more or less fully considered.
In the bony state, as well as the recent, the superior
border is formed by the convex surface of the bulla eth-
42
HOWARD A. LOTHROP.
moidalis, the inferior border by the superior free margin of
the processus uncinatus. (Plates 22, 38, 39.) Posteriorly
there is no bony limit, so that this portion of the lumen is
completed by mucous membrane passing between these two
bony landmarks. (Plates 11, 12.)
The anterior limit of the hiatus semilunaris is variable.
It is made by the presence of a bony lamina passing from the
anterior portion of the superior border of the processus un-
cinatus to the bulla ethmoidalis, or its continuation upward.
(Plates 4, 8, 31, 34, 41, 45, 49.) Very occasionally this sep-
tum is membranous. Another not unusual mode of closure
of the anterior end of the hiatus is observed where the inser-
tion of the superior border of the middle turbinate passes
directly across from the upper end of the bulla ethmoidalis
to the processus uncinatus, without the usual formation of a
pocket or sinus under the anterior upper extremity of this
turbinate. In other words, what we are to designate as tur-
binate fossa later is not always separated from the upper ex-
tremity of the infundibulum by a septum, but these two
cavities become one. (Plates 30, 40.)
A third variety, somewhat less common than the first,
is where no such lamina is present until the hiatus has ex-
tended nearly or quite to the roof of the nasal fossa, under
cover of the middle turbinate bone, close to the ostium fron-
tale. (Plates 11, 12, 33.)
Thus we have three types of closure of the anterior end
of this hiatus, which are of great importance in determining
the route to the frontal sinus.
(i) By means of a septum between uncinate process and
ethmoid bulla.
(2) Septum absent, hiatus reaches practically to orbital
roof.
(3) No septum, as in Plate 4, but the middle turbinate
takes its place. Really no fossa turbinalis present.
Ordinarily, the long boundaries of the hiatus are nearly
parallel, and from two to five millimetres apart; the length
of the hiatus will average about fifteen millimetres, with ex-
THE FRONTAL SINUS.
43
tremes at ten millimetres and thirty millimetres. The hiatus
semilunaris may be narrowed:
(i) By over prominence of the bulla ethmoidalis antero-
inferiorly. (Plates 31, 42, 46.)
(2) By tilting- the processus uncinatus in one of two
directions, — viz., pushing the process as a whole, or either
extremity, backward, or by rotating the upper border out-
ward towards the bulla. (Plates 25, 67.)
(3) By the addition of the soft parts. (Plate 32.)
(4) By pathological processes, — hypertrophies and pol-
ypi. (Plates 37-51.)
(5) Its lumen may be obstructed by abnormal proximity
of the inferior ethmoidal turbinate bone. (Plate 61.)
Infundihnlum (all plates showing hiatus semilunaris,
ethmoid bulla, and processus uncinatus). — The hiatus semi-
lunaris is the ostium of the infundibulum, so that the latter
is always as long, and in almost every instance is somewhat
longer. The infundibulum is a sort of foyer between the
nasal cavity, on the one hand, and certain ethmoidal cells,
the maxillary sinus and the frontal sinus in half of the cases,
on the other hand. Like the hiatus semilunaris, the infun-
dibulum is always present.
A considerable extent of the infundibulum is limited by
mucous membrane only, so that a study of the skeleton alone
is insufficient to determine its limits and shape. In general,
the infundibulum is like a long, curved canal, convex antero-
inferiorly, shallow at its posterior extremity, deep and gen-
erally lost to view at its anterior termination. It is bounded
above by the inferior surface of the bulla ethmoidalis
throughout the greater part of its extent, except anteriorly,
where the bulla is replaced by certain anterior ethmoidal
cells, already described. (Plates 22, 41.)
External Surface of the hifuiidibuhiin. — Following this
on the skeleton, we generally have, below, the maxillary pro-
cess of the processus uncinatus, then a fontanelle looking
into the antrum of Highmore, and as we ascend we cross the
free edge of the orbital plate of the superior maxilla (often
44 HOWARD A. LOTHROP.
separated into two laminae for the formation of the maxillary
cells), and then pass on to the inner surface of the lachrymal
bone. (Plates 5, 8, 9, 23.) The under surface of the bulla
and cells above it is usually extended forward to bound a
part of the external surface of the infundibulum. In the re-
cent state this surface is intact, except for the constant loca-
tion of the ostium maxillare, just under the orbital roof of
the antrum, and an occasional ostium from a cell in the
lachrymal region. (Plates 33, 39, 40, 41.)
The internal snrface of the infundibulum throughout its
whole length is bounded by the external surface of the pro-
cessus uncinatus, but its breadth is completed in part by the
hiatus semilunaris, and frequently a fold of mucous mem-
brane, which continues the concavity of the superior border
of the uncinate process. (Plates 39, 40, 41, 65, 67, 70.)
When the soft parts are undisturbed, the internal and
external surfaces meet below at an angle so as to form a sort
of gutter, which follows the general contour of the infun-
dibulum. The infundibulum, therefore, is comparable to a
gutter, the depth of which will depend upon the width of the
processus uncinatus, together with its increase by mucous
membrane, and also upon the lateral tilting of this process.
(Plates 59, 65, 70.)
At the lowest portion of this concave gutter, extending
somewhat on its outer side, is the ostium maxillare, well
guarded and hidden from view internally by the processus
uncinatus. (Plates 23, 38, 39, 40, 41, 61, 67, 69, 70, y^, 75.)
The importance of this topography, as regards the drainage
of pus and the association of accessory sinus diseases, will be
considered in Part II, hence the importance of this detail.
The posterior extremity of the gutter ascends more or less
after passing the ostium maxillare, and may disappear
smoothly on to the lateral wall of the nasal fossa, or be inter-
rupted by the fold of mucous membrane to which reference
has been made.
The ostium maxillare, therefore, is situated in a depres-
sion at the lowest portion of the infundibulum. Its size and
THE FRONTAL SI XL'S. 45
shape vary within narrow Hmits. It is usually oval, three
millimetres to five millimetres long, and about half as wide,
and is placed transversely at the highest part of the antrum,
close to the orbital wall. If the maxillary process of the
uncinate is complete, its contour is bony (Plate 23), other-
wise mucous membrane fills in the deficiency. In 250 cases
the ostium maxillare was never found wanting.
Accessory ostia for the maxillary sinus (Plates 32, 34,
35' 36, 38,. 40, 41). present in about 10 per cent, of cases, do
not enter into the present anatomical consideration.
Allowing a slight digression from strict anatomical de-
scription, let it be mentioned here, for the sake of emphasis,
that pus, travelling from the antrum, must first pass the
ostium maxillare, where it reaches the lower portion of the
infundibulum, thence, in order to reach the middle meatus,
it must ascend over the free edge of the uncinate process.
(Plates 65, 69, 71.) Furthermore, ihat pus having once reached
the infundibulum from other sources, such as the frontal sinus
and certain of the anterior ethmoidal cells, must of necessity
gravitate tozvards the ostium maxillare, and enter the antrum,
provided this ostium is patent. So much with the head in the
erect position, but, in that the head is constantly changing
its position, this antral drainage will be favored or hindered
accordingly. Elsewhere the cHnical evidence on this subject
will be considered.
We have now to consider the upper end of the infun-
dibulum, the cells related thereto, the mode of entrance to
the frontal sinus, and the role played by these structures in
the formation of the nasal portion of the floor of the sinus.
The upper extremity of the infundibulum becomes en-
larged, and its contour will depend on the distribution of pro-
cesses sent ofif from the upper broad extremity of the pro-
cessus uncinatus. (Plates 5, 7, 9.) On three walls, subject
to constant variation, are to be observed ostia of anterior
ethmoidal cells. Posteriorly are the openings (one to three)
leading to cells anterior to the group situated above the eth-
moid bulla, which may extend to the posterior angle of the
46 HOWARD A. LOTH R OP.
frontal sinus. On the outer wall are the ostia, connected with
the cellular spaces, completed when the lachrymal bone is in
situ. There may be only one such ostium or as many as
six in a vertical row, according to the number of cellular
spaces.
Anteriorly there is a very constant ostium, which leads
to a cell often of considerable size. It is the uppermost cell
external to the uncinate process, which it follows anteriorly
to the posterior border of the nasal process of the superior
maxilla, and is completed externally by the lachrymal bone.
This cell makes the prominence known as the agger nasi.
Its roof is completed by the termination of the processus
uncinatus, which arches over it from within outward. (Plates
5,20,24,33,35, 39, 51.)
The infundibulum may terminate above as follows:
(i) In 47 per cent, of the cases there is an ostium open-
ing into a canal which leads to the frontal sinus. This canal
is known as the naso-frontal duct.
(2) In 53 per cent, of the cases the infundibulum has' no
connection with the frontal sinus. In these cases the ter-
mination presents the following varieties:
(a) May end in a cell of considerable size, just internal
to the upper portion of the lachrymal bone, and even as
high as the internal angular process of the frontal bone. This
cell often corresponds to the prominence of the agger nasi.
Common. (Plates 5, 31, 52.)
{})) May end in a dilatation forming a cell in the pos-
terior angle of the frontal sinus. Common. May terminate
in the same way, except in a much more prominent cell,
which has forced its way into this angle and posterior border
of the sinus, forming a prominence known as the frontal
bulla. A cell of sufficient prominence to be called a frontal
bulla (Plates 37, 51, 55, 70, 76) is of fairly common occur-
rence. Of these frontal bullae, one-third open into the infun-
dibulum, the rest into the turbinate fossa, except an occa-
sional one opening into the fissure between the ethmoid bulla
and turbinate.
THE FRONTAL SINUS. 47
(f) Very rarely the infnnclibnlum ends 1)Hndly without
dilatation or ostia.
In 10 per cent, of all cases there is no septum between
the uncinate process and ethmoid bulla (Plate 11) shutting
off the infundibulum from the usual dilatation or fossa under
the extreme upper and anterior portion of the middle tur-
binate bone. (Plates 31, 34, 38.) In these cases (Plates 11,
30, 35, 40) the contiguous surfaces of the uncinate process
and turbinate are adherent throughout over the prominence
known as the agger nasi. In these cases there is no diver-
ticulum, directly under the turbinate, for the probe to enter,
but it passes at once through the hiatus semilunaris into a
dilatation, representing both the usual turbinate diverticulum
or fossa, and the upper extremity of the infundibulum, as a
single cavity. From this cavity are ostia leading in different
directions, as already indicated.
Turbinate Fossa. — In the great majority of cases it is
possible to follow up on the external surface of the inferior
ethmoidal turbinate nearly to the lamina cribrosa, and yet
not enter the infundibulum, which is separated by a lamina of
thin bone, which passes back from the processus uncinatus
to the upward continuation of the bulla ethmoidalis. If there
is a naso-frontal canal present, it is completed by this
lamina.
This space, bounded internally by the extreme upper
end of this turbinate, has been called by the writer, for de-
scriptive purposes solely, the turbinate fossa. (Plates 4, 8,
31, 32, 38, 45, 49, 58, 61, 65, 74, 77.)
Naso-Frontal Canal. — The naso-frontal canal is the up-
ward prolongation of the infundibulum, and it is completed
by the lamina of bone, as just mentioned. The length of the
canal will depend upon the extension downward of this
lamina, and will vary from two millimetres to fifteen milli-
metres. (Plates II. 12, 38, 40, 41.) The regularity of its
course is inconstant, on account of the canal being impinged
upon by neighboring cell walls. There may be no true canal
48 HOWARD A. LOTHROP.
whatever, and the passage to the frontal sinus may be
through an irregular series of ethmoidal cells. (Plates 7, 9,
52.) The canal terminates finally in an opening called the
ostium frontale, which is located in the nasal portion of the
floor of the frontal sinus. (Plates 11, 12, 16, 35, 72, 76.) A
passage corresponding to this canal may end blindly in the
bulla frontalis, as mentioned above. If this passage tinder
consideration fails to open into tJie frontal sinns, it loses its
identity as being a naso-frontal canal, consequently in 55 per
cent, of these cases there is no naso-frontal canal.
In this percentage of cases the frontal sinus opened directly
into the turbinate fossa with little or no canal, entirely indepen-
dent of the infiindibuluni or any of the cells emptying into it.
A naso-frontal canal existed in 47 per cent, of the cases.
Openings into the turbinate fossa:
(i) It may be blind in all directions and contain no ostia.
(Plate 38.)
(2) Fifty-three per cent, of the frontal sinuses open into
it. (Plates 4, 8, 31.)
(3) Two-thirds of the frontal bullae. (Plate 51.)
(4) Most of the anterior cells on the floor of the sinus
anterior to the ostium frontale, and often some of the small
cells just posterior to this ostium, which fill up the posterior
frontal angle and belong to the group above the bulla eth-
moidalis. These cells also open into the infundibulum and
the fissure above this bulla and below the turbinate. The
bulla frontalis is nothing more nor less than a very prominent
cell belonging to this group, which protrudes well into the
frontal sinus. The cells which crowd into the posterior bor-
der of the sinus likewise belong to this group.
To recapitulate the EtJinwidal Cells, zve have Tzvo Main
Groups. — (i) Posterior ethmoidal cells, — all cells formed
wholly or in part by the ethmoid bone, having their ostia
above the line of origin of the inferior ethmoidal turbinate
bone. These have not been considered in the foregoing
pages.
(2) Anterior ethmoidal cells, — also formed wholly or in
THE FROXTAL SIXUS. 49
part by the ethmoid bone, with their ostia in two grooves
corresponding to ethmoidal fissures opening below the in-
ferior ethmoidal turbinate into the middle meatus, — viz.,
(a) Hiatus semilunaris, — the ostium of the infundibulum.
{b) The fissure just under the inferior ethmoidal turbi-
nate, which is continuous above with the turbinate fossa in
line with its ostia, if any happen to exist.
These anterior cells have been grouped as follows:
{a) The one or more cells represented by the ethmoid
bulla, opening- by the ostium of the bulla.
{b) The cells just above, which crowd into the posterior
frontal angle, and are in the vicinity of the anterior ethmoidal
canal, which runs transversely across their apices. These
may empty into the infundibulum, the turbinate fossa, or
in the fissure just above the ostium of the bulla.
(c) The group of cells opposite the lachrymal bone, ex-
tending around in front of the infundibulum to the nasal pro-
cess of the superior maxilla, and superiorly often to the floor
of the frontal sinus. Most of these cells open into the in-
fundibulum. The cell corresponding to the agger nasi be-
longs to this group.
Floor of the Frontal Sinus (Nasal Portion) and tJic Ostium
Frontalc. — Wt are now able to understand in a few words
what structures go to make the nasal portion of the inferior
surface of the frontal sinus.
This area is bounded, strictly speaking, by the circum-
ference of the hiatus frontalis, but for surgical purposes it is
carried backward into the posterior angle among the eth-
moidal cells. (Plates 15, 16.)
Looking into a sinus wath a prominent superciliary
ridge, the lower part of this anterior surface (to which the
ridge belongs) passes backward to the anterior margin of the
hiatus frontalis, where there is usually a thick ridge. This is
the point of articulation with the nasal process of the superior
maxilla. (Plates 11, 51, 56.)
Keeping to our strict anatomical lines, this somewhat
horizontal surface is a portion of the anterior surface, ren-
4
5°
HOWARD A. LOTHROF.
dered thus on account of a prominent bulging forward
(superciliary ridge). This peculiarity does not appear when
the anterior wall is flattened. (Plates 24, 29, 49.)
Just posterior to this ridge we come to rounded emi-
nences, which extend outward and backward, and are made
by cells described as opposite the lachrymal bone, and ex-
tending towards the nasal process of the superior maxilla.
(Plates 9, 57, 72, 74, 76, yy, 79.)
Posterior and internal to the apices of these cells, quite
close to the frontal septum, is an opening called the ostium
frontale. The ostium is generall}^ well back towards the
posterior angle. (Plates 11, 12, 16, 37, 42, 65, 72, 76.) Pos-
terior to the ostium we come at once to the apices of the
cells represented as filling the posterior angle, which often
are of sufficient prominence to overhang and obscure the
ostium frontale. The bulla frontalis (Plates 37, 51, yj), if
present, appears at this angle often obscuring the ostium,
and extending laterally along the posterior border for a
variable distance.
Now and then diverticula are seen to extend down into
the nasal process of the frontal bone (Plates 11, 26, 37), and
less frequently backward into the crista galli. (Plates 10, 26.)
Diverticula occasionally run down vertically into the infun-
dibulum, independent of the naso-frontal canal.
The sagittal measurement of this surface is not often
more than ten millimetres, but in all cases it can be increased
surgically with but little element of danger, by curetting the
cells in the posterior angle. Laterally this floor corresponds
to the width of the hiatus frontalis. Surgically more space is
easily gained internally by breaking through the upper end
of the inferior ethmoidal turbinate towards the septum nasi,
inferior to the lamina cribrosa. (Plates 20, 59, 65.)
Ostium Frontale. — Little remains to be said concerning
this ostium. It may be oval, circular, or linear with its
longest measurement from two millimetres to eight milli-
metres. It is usually oval and about three millimetres long.
The most common location is well towards the posterior
THE I-RONTAL SINUS.
51
limit of the floor of the sinus, close to the frontal septum.
Each sinus has its ostium. One exception has been noted.
(Plates 55, 67, 68.) Its methods of opening into the nasal
cavity have been considered.
Lining of the Frontal Sinus. — The mucous membrane
which lines the frontal sinus does not difYer in essential char-
acteristics from that found in the other accessory nasal cavi-
ties. In general, it is somewhat thinner than that found in
the antrum of Highmore, and more easily detached from the
bony wall of the sinus.
In section, it presents the following layers: Facing the
cavity of the sinus is a layer of ciliated columnar epithelium,
between the cells of which are interspersed a variable number
of goblet cells. The cilia produce a current towards the
ostium frontale. Underneath the epithelium is a layer of
loose connective-tissue cells, between the meshes of which
are glands and round cells. This layer is capable of enormous
increase in thickness, in consequence of inflammatory pro-
cesses, by the addition of the serous element and leucocytes
from the blood. The cavity of small sinuses may thereby be
obliterated, and the consequent pressure gives rise to ex-
cruciating pain. The lining of the frontal sinus contains
fewer glands than that of the antrum, and their distribution
over the surface is unequal.
Underneath this loose layer we come to a rather dense
basement layer, composed of compact fibrous connective-
tissue cells. This is next to the bone and serves as a peri-
osteum. It is easily detached except in the vicinity of the
ostium frontale, where it is continuous, directly or indirectly,
as the case may be, with the mucous membrane of the nasal
cavity. Delicate vessels, passing between the membrane and
the sinus wall, help retain these structures in approximation.
The blood-supply of the sinus is derived from branches
of the spheno-palatine and anterior ethmoidal arteries, and to
a slight degree from arteries of external origin, just men-
tioned, which pass through minute foramina in the sinus
walls.
52
no WARD A. LOTHROP.
The nerve-supply is mainly through the nasal branch of
the ophthalmic division of the trifacial nerve. (Inzani.)
A Fezv Anatomical Facts of Surgical Importance. — It will
be obvious that in operating upon the floor of the sinus, in the
radical operation for empyema of the frontal sinus or of the
anterior ethmoidal cells, the curette should be directed down-
v*^ard, inward, or backward; that externally we should avoid
entering the orbital fossa through the lachrymal bone or os
planum; that the posterior surface of the sinus and the region
of the lamina cribrosa should be carefully avoided on account
of the liability of entering the cranial cavity. Anteriorly the
curette can be used with impunity against the posterior bor-
der of the nasal process of the superior maxilla.
The posterior surface possesses a curve which is very
constant for each case (Plate 51), and any sudden interrup-
tion in its contour towards the posterior angle is generally
due to cellular laminae, convex anteriorly, and it will be safe
to puncture these downward and inward.
The question of probing the frontal sinus and its prac-
ticability will be considered in Part II. Suffice it to say here
that it is a comparatively easy matter on the cadaver to pass
a probe from the sinus into the nasal cavity. On the other
hand, with the nasal fossae divided by a median sagittal sec-
tion and the septum removed, it is often easy to enter the
sinus, sometimes impossible, and often doubtful as to where
the probe has gone. Removal of the upper anterior portion
of the turbinate is of great assistance. Results obtained by
passage of the probe in the natural state, by the anterior
nares, are rarely to be trusted with absolute certainty. Grant-
ing that the probe enters for a considerable distance, if we
are fortunate enough to pass the many obstructions and
avoid the numerous ostia in our way, even then we can never
know whether the end of our instrument is only in a frontal
bulla or a single compartment of the sinus. The direct
course to the sinus is usually interrupted by prominences or
septa, and the ostium frontale may not face properly for the
reception of the probe or canula. Attempts to force the
THE FRONTAL SINUS. 53
probe up into the siiuis o-cncrally result iu injury to the
parts.
The relation of the ostium maxillarc to the infundibu-
lum has been considered in sufficient detail. In cases pos-
sessing a naso-frontal canal, it is not unusual to be able to
pass a straight probe from the frontal sinus to the antrum,
the probe passing successively the ostium frontale, naso-
frontal canal, infundibulum, and ostium maxillare. A slightly
curved probe can be made to do this frequently.
Where the ostium frontale opens into the turbinate fossa
(53 psi' cent, of the 250 cases examined) the uncinate pro-
cess is the principal determining factor as to whether a
slightly curved probe can be made to enter the antrum. This
could be done in numerous instances, and the course of the
probe would be as follows: Ostium frontale, turbinate fossa,
hiatus semilunaris, infundibulum, and ostium maxillare. In
these cases polypi and hypertrophies easily tend to direct
exudate from the frontal sinus into the infundibulum, and
thence into the antrum. At the same time, it is possible to
conceive that such obstruction could prevent drainage into
the antrum.
It will be observed that the ostia of the various groups
of anterior ethmoidal cells are distributed along the route
from the frontal sinus to the antrum, and in very intimate
relation thereto. Both the clinical and anatomical evidence
is such that the involvement of these cells, in suppurative
processes, may be either of primary or secondar}- connection
with similar processes in the frontal sinus.
These considerations will be more fully discussed in
Part II.
PART II.
THE ETIOLOGY, PATHOLOGY, AND TREATMENT
OF SUPPURATION IN THE FRONTAL SINUS,
TOGETHER WITH THE NECESSARY CONSID-
ERATION OF DISEASE OF THE ANTERIOR
ETHMOIDAL CELLS.
Historical.
Frontal sinus disease has been recognized for many-
years, but, until recent times, only certain manifestations,
now known to accompany a comparatively small number of
these affections, were looked for, and properly interpreted.
These symptoms are now known to be late developments in
the history of these cases and include the presence of a tumor
or fistulse in the vicinity of the frontal sinus or inner wall of
the orbital fossa.
During the last century such cases had been diagnosed
and operated upon by one of the so-called external opera-
tions.
In 1839, Dezeimeris published an exhaustive treatise,
as far as concerned the knowledge of that time. In 1859,
Bouyer published the results of his anatomical and patho-
logical research, and more recently (1872) we have the re-
sults of Steiner's investigations concerning the anatomy and
development of the frontal sinus.
The most exhaustive work, however, on the anatomy
and pathology of the nasal cavity and its accessory sinuses
has been carried out by Zuckerkandl. From a descriptive
point of view this work has never been equalled, but numer-
ous practical anatomical variations and particularly relations
have been published by clinical observers.
54
SUPPURATION IN TIIK FRONTAL SINUS. 55
One of the modern operators was Ogston (1884), and his
operation is still followed by certain surgeons. In recent
years, frontal surgery has been developed by Lichtwitz, Luc,
Schaeffer, Winckler, Nebinger, Jansen, Kuhnt, and others,
and pathological researches particularly by Weichselbaum
and Frankel.
Etiology. — It is often a difficult matter to trace the cause
of suppuration in any given case, but, nevertheless, there
are certain factors which predispose or give rise to this con-
dition. In the first place, most sinus affections are conse-
quent on infection from some source or other. We know
that different pathogenic bacteria may give rise to inflam-
matory processes on mucous membranes, and we find also
that the same bacteria may exist in sinuses without causing
any symptoms or changes whatever. The mere invasion of
the sinus by some bacteria is sufficient to give rise to inflam-
mation; in other instances, other factors play a more or less
important ro/^. For example:
Trauma. — Fractures of the frontal bone, involving the
sinus, are not uncommonly followed by suppuration within
the sinus. Tissues are bruised and may necrose. There has
been an escape of blood into the sinus which may clot and
obstruct the ostium, or the fracture may be such as to inter-
fere with its escape, and finally these changes furnish a good
nidus for the growth of bacteria, already present within the
sinus, or introduced at the time of injury. If there is neither
infection nor obstruction, such an injury will give rise to no
trouble. If the obstruction persists, a chronic discharging
fistula will result.
Injury by bullets and various weapons may give a simi-
lar result. Trauma may follow the careless use of instru-
ments in the anterior ethmoid cells near the ostium frontale,
and cause an inflammatory process to extend to the sinus.
Foreign bodies in the sinus, such as parasites, have been
reported as causing frontal empyema.
Mechanical obstruction, without infection, gives rise to
the condition known as mucocele. This may persist for
56 HOWARD A. LOTHROP.
years without much discomfort to the patient, but it may
become infected at any moment with complete change of the
cHnical picture.
On the other hand, obstructions may be of inflammatory
origin, as evidenced by the development of hypertrophies and
polypi. Inflammatory processes accompanied by or result-
ing in obstruction become acute, and must soon terminate in
one of several ways, to be considered later.
Most cases of frontal suppuration are not accompanied
by complete stenosis of the ostium frontale. although the
ostium may be somewhat narrowed, but owe their origin and
chronicity to certain bacteriological invasions, which give
rise to pathological changes in the lining walls of the sinus.
When deeply seated nothing but radical methods can pre-
vent a continuation of the suppuration. These cases are
said to be of infective or inflammatory origin.
Inflammatory Cases. — Bacteriological investigations have
thrown much light on the causation and frequency of sinus
afifections, as well as their relation to the various infectious
diseases. Inflammation in the sinus may follow: (i) Exten-
sion from neighboring foci of inflammation, particularly the
nasal cavity. (2) They may be primarily involved in a gen-
eral systemic infection. In these cases, whatever germ is
causing trouble elsewhere, may also be found in the sinus as
demonstrated by Weichselbaum and E. Frankel.
(i) Extension of Inflammation. — It is undoubtedly true
that many cases of frontal inflammation owe their origin to
the extension of a process primary in the nasal cavity. They
may arise almost simultaneously or may follow the nasal dis-
turbance a week or more later. A common history is to
learn that the patient has just recovered from an acute coryza
and now complains of frontal pain, etc., while the nasal ex-
amination is negative. Most of these cases recover spon-
taneously, but they are of common occurrence. Autopsies
prove these statements, and Turcsa offers a clinical case in
evidence, where the patient had a frontal fistula, in which
he observed that there was an acute exacerbation of the symp-
SUPI'IRATION IN THE FRONTAL SINUS.
57
toms with every attack of coryza. The position of the sinus
as a whole, and the location of its ostium, expose it less to
nasal extension than that of the other accessory cavities, and
these conditions tend to favor an early resolution.
Nasal obstructions and inflammations in connection with
hypertrophies render the sinus liable to invasion. These
cases may be of acute origin, or may develop slowly without
subjective symptoms, and be discovered only after nasal
causes for suppuration have been eliminated.
Caries of the frontal or ethmoid bones may involve the
sinus according to their proximity.
(2) General Systemic Infection. — That sinus affections
accompany or follow acute infection or suppurative diseases
with any degree of frequency is a comparatively recent dis-
covery, but this conclusion is demonstrated by recent bac-
teriological and pathological examinations at autopsy. In
a series of 146 autopsies by E. Frankel, sixty-three cases gave
evidence of an acute or subacute affection in one or more of
the accessory nasal cavities. The frontal sinus, however, was
much less frequently involved than the other sinuses, the
antrum of Highmore predominating in by far the larger pro-
portion. \\''eichselbaum was one of the earliest to demon-
strate this association of sinus infection with acute disease.
Recent investigations show that diphtheria is commonly as-
sociated with acute involvement of the sinuses, and that these
cavities may contain the Klebs-Lof!ler bacillus after its dis-
appearance from the nasal cavity and pharynx.
Children are more subject to acute suppuration than
adults, the reason of which is readily explained by the fre-
quency of the acute infectious diseases peculiar to childhood.
An enumeration, simply, of these causes is sufficient, — diph-
theria, scarlet fever, measles.
In the adult acute or chronic diseases of the sinuses have
been traced to the following causes: Pneumonia, influenza,
erysipelas, cerebro-spinal meningitis, peritonitis, typhoid
fever, variola.
Tuberculosis. — No evidence has been obtained to show
58 HOWARD A. LOTHROP.
that tubercular infection is ever primary in the frontal sinus,
and there are but few recorded cases where it has extended
to this sinus from neighboring foci.
Syphilis. — Syphilitic affections of the nasal cavity are
common, and the amount of destruction often extensive.
These processes often extend in any direction, irrespective
of the tissue which they meet, and thus invade the sinuses,
give rise to deep-seated pathological processes of the soft
parts, as well as to caries and necrosis of the bony walls.
Many of these cases recover under the influence of anti-
syphilitic treatment, but others remain unbenefited. The
reason of this is due to the depth of the destructive processes
and the usual mixed infection rendered possible by the syphi-
litic process, to which must be added mechanical obstructions
to the removal of the exudate. These cases have a syphilitic
origin, but their continuation and obstinacy under rigorous
antisyphilitic treatment are due to secondary complications.
The common pathogenic bacteria found in the frontal
sinus are pneumococcus lanceolatus (Frankel), staphylo-
coccus pyogenes aureus, staphylococcus pyogenes albus, and
streptococcus pyogenes. Other bacteria of rare occurrence
are bacillus influenza, tubercle bacilli, typhoid bacillus, and
bacterium coli commune.
Nezv Groivths. — Primary benignant or malignant tumors
of the sinus are very rare, but extension of malignant disease
into the sinus is not uncommon. That new growths of any
sort may sooner or later give rise to frontal sinus inflamma-
tion is obvious. They tend to obliterate the cavity of the
sinus, obstruct its ostium, and in time become infected, thus
giving rise to inflammatory complications.
Frequency. — The frequency of frontal sinus suppuration
is impossible to determine. Most acute cases pass unob-
served, and resolve spontaneously. Mild chronic cases may
fail to give rise to symptoms of sufficient annoyance to the
patient to cause him to seek medical advice. Many cases are
obscured by other causes of nasal suppuration.
E. Frankel's figures are interesting as showing that mild
SCPPUKATIOX IN riJE FRONTAL SINUS. 59
or even severe acute cases of accessory sinus disease are
common complications in acute disease, but that the frontal
sinus escapes far more frequently than the antrum or sphe-
noidal sinus. In a series of 146 autopsies, sixty-three had
one or more sinuses affected, but only five were frontal, none
of which were suspected during life. None of these frontal
cases were isolated, but were associated with inflammation
of some other sinus.
In fifty autopsies taken at random, Engelmann found
three cases.
Pathological processes were discovered in the sinuses
which served as a basis for the investigations described in
Part I, but owing to the nature of the material (dissecting
room) many changes could not be recognized, hence no re-
liable data could be obtained.
The frequency of frontal sinus fistul^e occurring in the
eye clinics of A^ienna has been figured as one in 9000 eye
cases, in Berlin as one in 18,000.
Pathology. — The inflammatory pathological changes
found in the frontal sinus are those peculiar to mucous mem-
branes in general, but certain variations and complications
may arise on account of the fixed walls and small ostium of
the sinus. Inflammation of mucous membranes does not
differ in essential characteristics from inflammation else-
where. In addition to the ordinary products of exudation
we may have mucus and columnar epithelium, often ciliated.
Nevertheless, the nomenclature and classifications of inflam-
matory processes are very confusing and inconsistent. Dif-
ferent names are given to the same pathological process, de-
pending upon the different appearances of the exudate and
the nature of the infection, as well as whether the ostium is
patent or not.
It is found that the same source of infection, under dif-
ferent circumstances, may cause but slight disturbance, or,
under altered conditions, may give rise to the most destruc-
tive processes or to various grades of disturbance between
these two extremes. The same organism may appear in
6o HOWARD A. LOTHROF.
both cases even in pure culture. Mixed infection may com-
plicate the process with consequent variations in different
directions. The exudate in acute processes will vary accord-
ing to the severity of the process and at different times in its
course, but the changes in the membrane itself are such as
to characterize the disturbance as acute or of short duration.
The exudate in long-continued or chronic cases may offer
nothing to distinguish it from the exudate of acute cases, yet
the mucous membrane, meanwhile, has undergone altera-
tions which are more or less permanent and mark a distinct
line of difference.
The inflammation of the frontal sinus mucous membrane
will be considered under the following groups:
(i) Acute inflammation, characterized particularly by
serous infiltration (oedema), (a) Exudative, — serous, fibrin-
ous, seropurulent, and purulent. (V) Diphtheritic.
(2) Chronic inflammation, characterized particularly by
connective-tissue formation. An exudate is always present,
which may be identical with that seen in acute processes;
meanwhile certain more or less permanent changes are under-
gone by the mucous membrane which alter its general char-
acter: (a) Scar-tissue or fibrous-tissue formation. (6) Hyper-
trophies and polypi may develop, (c) Cysts may appear, ((/)
Osteomata may be formed.
(3) Tuberculosis.
(4) Syphilis.
(i) (a) Exudative. — Acute inflammatory processes are
characterized by the pouring out of a varying amount of
serum into the submucous connective-tissue layer (inflam-
matory oedema). In the early stages there is no exudate on
the surface of the mucous membrane. In addition to the
serum leucocytes infiltrate this tissue, which begins to swell
rapidly and assume a reddish color, on account of the dilated
capillaries. As yet the epithelial lining remains intact, and
no exudate has reached its surface. The swollen mucous
membrane obliterates the angles and borders of the sinus,
and where the sinus is small and the oedema extensive, the
SLTPUKAUOX IN THE FRONTAL SINUS. 6 1
sinus cavity may be completely lilled. This is the period of
congestion, during which there is no discharge into the nasal
cavity. Sooner or later some of the serum, together with
some leucocytes, escapes through the epithelial layer into
the sinus. The serum, leucocytes, a few epithelial cells which
may be thrown off the surface, together with a certain num-
ber of bacteria, go to make up the serum type of exudation.
There is always a certain admixture of mucus in all instances
so long as any mucous membrane remains.
If the ostium frontale is obstructed by the oedematous
swelling or from any other cause, the exudate cannot escape,
but accumulates under pressure, with a corresponding
amount of pain which persists until this tension is relieved.
As the inflammation advances, capillary haemorrhages fre-
quently occur, the round-cell infiltration is more marked in
the vicinity of the glands, and there may be a slight amount
of epithelial exfoliation.
The character of the exudate may vary and become more
tenacious and sticky rather than w^atery. This is due to the
coagulation of fibrin derived from the blood, and we have
the so-called fibrinous type of exudation, but the condition
of the mucous membrane remains unaltered. The amount
of oedema has now probably reached its maximum, more cells
are poured out into the serous exudate, which becomes more
turbid and may be called seropurulent.
By this time several changes may have taken place.
Either the exudate has appeared in the nasal cavity through
an ostium wdiich was never obstructed or the ostium has
become patent, whereby there has been much relief from the
acuteness of the subjective symptoms, or, on the other hand,
there is still obstruction and the symptoms have not abated.
In the first instance, simple, non-obstructive, the patho-
logical changes may advance no further, the serous infiltra-
tion becomes absorbed or exuded, the round cells disappear,
the exudate remains seropurulent for a short while, gradu-
ally decreases, and perfect resolution takes place. This is
62 HOWARD A. LOTHKOP
the history of simple acute cases, where all the parts are re-
stored to normal in the course of ten to fourteen days.
The acute process may be more intense as manifested
by the exudate, which contains a larger proportion of leuco-
cytes and is called purulent. The exudate is now made up
of a large percentage of pus-cells, often many red blood-
globules, bacteria, exfoliated cylindrical ciliated epithelium,
with more or less serum and mucus, and is alkaline in reac-
tion. Even now, if the pus can escape, resolution may be
complete, and all the symptoms disappear, for the changes in
the mucous membrane have not materially changed. There
has probably been an increase of the round-cell infiltration,
more superficial desquamation, and hsemorrhagic pigmenta-
tion, but these are not necessarily permanent changes. If
resolution should fail, and the exudation persist with free
exit, the pathological process may change its nature, mav
give rise to permanent alterations, and thus become chronic.
If the ostium still remains obstructed, our condition is
that of an abscess in a bony cavity, and nature will endeavor
to provide an avenue of escape for its contents, if not antici-
pated by surgical intervention. Meanwhile, increased ten-
sion aggravates the symptoms, the mucous membrane be-
comes more infiltrated, more lijemorrhagic, and the super-
ficial desquamation more extensive. The round-cell infil-
tration reaches the deeper layers, and finally the periosteum,
and then the bony wall itself. The pressure and infiltration
give rise to necrosis of the soft parts, an ulceration forms,
followed by caries in some portion of the sinus wall. The
moment that pus escapes from the sinus there is relief from
pain. Any wall of the sinus may thus become perforated,
but the thin inferior wall is the commoner site, and the clini-
cal picture will vary according to the exact point of perfora-
tion. If the point of perforation is well towards the front
of this surface and near the inner angle of the orbit, as is
usually the case, there will be an abscess form just under the
skin, which is commonly punctured, or may be allowed to
take its own course and rupture later. The swelling sub-
SUPPURATIOX IX TJIE J-KOXTAL SIX US. 63
sides and a fistula remains, which may continue to discharge
pus indefinitely. If the perforation is towards the posterior
part of the inferior surface, the pus will enter the orbit, giving
rise to a secondary orbital abscess.
Although there is no direct evidence, there would seem
to the writer to be every reason for believing that perfora-
tion frequently takes place in the nasal portion of the floor
of the sinus, perhaps oftener than through its orbital portion.
The reasons for this supposition are both anatomical and
clinical.
In the first place, the cell walls of the ethmoid bone
which complete the closure of the hiatus frontalis are thinner
than the orbital portion of the floor of the sinus, and, other
things being equal, ought to yield to pressure first. Again,
it is becoming more and more evident that empyema of the
frontal sinus is very often, if not almost always, associated
with suppuration in some of the anterior ethmoidal cells.
Again, the history of many acute cases of frontal suppura-
tion is that of a sudden gush of pus from the corresponding
nostril followed by relief from pain and eventual recovery
or persistent discharge into the nose. This discharge may
have made its exit either through an ostium which has be-
come patent again or through a perforation in the nasal por-
tion of the sinus floor. No one can say definitely what has
happened. The prognosis in cases of nasal perforation ought
to be better than where an external fistula is formed, for the
latter is frequently associated with nasal occlusion of the
sinus, and can be relieved only by operation.
Perforation of the posterior wall is not common, and
naturally is almost always fatal, in consequence of an acute
meningitis or less frequently a frontal abscess.
Perforation of the anterior wall is most unusual, on ac-
count of its thickness. It happened in Warren's case, and
gave rise to a pneumatocele. (Plate 85.)
As a rule, the interfrontal septum remains intact.
Resolution rarely follows these very intense acute in-
flammations. The destructive processes are often extensive,
64 HOWARD A. LOTHROP.
and the delay has been so long that the lymph-channels and
blood-vessels and glands cannot remove the dense infiltration
of round cells and other products of exudation. There is a
proliferation of connective-tissue cells rich in nuclei, the
mucous membrane remains thickened, and the exudative
process continues, and we have a beginning process, without
a marked dividing line, which we call a chronic infiammaiion.
Hence, in the exudative type of acute inflammation ive Jiave
a process cliaractcrizcd by serous and round-cell infiltration, ac-
companied by various forms of exudate, zvithout marked destruc-
tion of the epithelial layer. It may be follozved by resolution or
become chronic.
(b) Diphtheritic Inflammation. — Another type of acute
inflammation (misleading on account of its name, in that it
has nothing to do with the infectious disease) is diphtheritic
inflammation. It is characterized at the outset by a destruc-
tive process whereby an exudate forms on an ulcerated sur-
face, which cannot be removed intact without tearing the
mucous membrane itself. It is a necrosis of the mucous
membrane surrounded by an extensive round-cell infiltra-
tion.
It may occur on any mucous membrane, but must be
extremely rare in the frontal sinus.
(2) Chronic Inflammation. — There is no definite dividing
line between acute and chronic inflammation; the latter is
usually preceded by a longer or shorter period of the former
and the transition from one to the other is gradual. Tlie
characteristic feature of the chronic process is the formation of
fibrous connective tissue, which is permanent. The membrane
itself may undergo further changes, characteristic only of
the chronic process, but the exudate may correspond pre-
cisely with that of the acute process, with the difference that
a purulent discharge is commoner in cases of long standing.
As a further complication, an acute exacerbation may super-
vene at any time on an old process, whereby the appearance
of both the membrane and the exudate may become greatly
altered.
SUPPURATION IX THE FRONTAL SINUS. 65
At the beginning of the chronic process the mucous
membrane is still oedematous, but the round-cell infiltration
predominates. The tissue is very vascular and succulent,
and there is a great excess of nuclei. These proliferation
cells become spindle-shaped and develop into fibrous con-
nective-tissue cells, also known as scar-tissue.
In appearance the membrane is thickened, pale, and
translucent, and its surface somewhat irregular in conse-
quence of the contraction of the fibrous tissue at various
points. The thickening of the membrane tends to obliterate
the sharp angles and borders of the sinus, and reduce the
size of its cavity. On section, the cellular infiltration is par-
ticularly emphasized in the vicinity of the glands and nearer
the epithelial layer than the periosteum. The older the
process, the deeper the infiltration, and the greater the loss
of epithelium, which may be slight at first. Excoriations,
therefore, are late developments as a rule. The exudation
at this early stage is usually seropurulent, made somewhat
tenacious by the addition of mucus. This condition may
last for months with no discomfort other than the constant
presence of an annoying discharge from the nasal cavity.
These are the mild chronic cases, and are often amenable
to simple therapeutic measures, if the ostium frontale is suffi-
ciently patent.
Sooner or later, in all chronic cases, certain secondarv
changes take place in the mucous membrane, consequent on
the contraction of the fibrous tissue and deeper extension of
the infiltration.
These changes (already mentioned) are: (a) Increase of
fibrous tissue with general hypertrophy; {h) cyst formation;
(c) polypi and local hypertrophies; {d) osteomata.
(a) The hypertrophy, due directly to increase of fibrous
tissue, has been sufficiently considered, as well as its effects
in multiplying the thickness of the mucous membrane. Its
hinderance to the successful relief of empyema will be con-
sidered under therapeutics.
{b) Cysts are commonly seen in the antrum of High-
5
66 HOIVARD A. LOIHROP.
more, but are much less common in the h-ontal sinus, as a
result of chronic inflammation. They owe their origin to
an obstruction of the ducts of the glands of the mucous mem-
brane from the pressure of round-cell infiltration, or the con-
traction of the scar-tissue, whereby the glandular secretion
accumulates and forms a cyst. Microscopic cysts are prob-
ably present in most chronic cases, but it is unusual to find
them much larger than a pea. They may occur on any of
the sinus walls, and are invariably multiple.
The smaller cysts are lined with ciliated epithelium, but
the larger ones are lined in part with squamous cells. The
examination of the contents of cysts may reveal the presence
of pus, epithelial cells, granules, cholesterin, fat, mucus, and
albumen.
Another variety of cysts is formed by dilated lymph-
channels. These are very unusual formations, and are apt
to be solitary and of comparatively large size. They are
filled with serum and lined with endothelium.
Instead of gland-dilatation with cyst-formation the con-
tracting scar-tissue may obliterate the entire gland. This
always takes place more or less extensively in prolonged,
deep-seated processes.
(c) Hypertropliies and Polypi. — Small irregular promi-
nences on the surface of a chronically inflamed mucous mem-
brane are of common occurrence. They give a granular ap-
pearance to the surface, and are pale and translucent.
They are due to slight myxomatous growths, on the one
hand, and made more prominent by depressions from fibrous
contractions, on the other hand. The mucous membrane is
usually intact over their surface, but here and there small
excoriations may be evident. This irregularity of the surface
favors the retention of exudation, and hinders the action of
therapeutic agents.
Polypi dififer from these myxomatous hypertrophies
only in degree. They may be single or more commonly
multiple, and fill up the greater part of the cavity of the sinus.
Their bases may be broad, but in most instances they are
SUPPCKATIOX IX THE FRONTAL SlXi'S. 67
constricted. Tliese polypi differ in no respect from polypi
which may develop on any mucous membrane.
They are far less common than cysts in the frontal sinus,
and they rarely develop to be of sufficient size even to fill the
sinus. In structure, they consist of a wide-meshed reticu-
lated framework, containing serum and myxomatous tissue
and a few wide, thin-walled veins, all covered with ciliated
columnar epithelium.
There is considerable discussion as to whether polypi
are primary or secondary to inflammatory processes in the
mucous membrane of the nares and accessory sinuses, but
the evidence is decidedly in favor of the latter supposition,
although in some instances polypi may be of primary origin.
id) Osfconiafa. — As the inflammatory process reaches the
deeper portions of the lining of the sinus the periosteum be-
comes infiltrated with serum and round cells. Resolution may
follow if the process is arrested in time, otherwise the pro-
liferation of cells and capillaries advances, new tissue is
formed, and in due time inorganic salts are deposited, form-
ing bone. Thus the general thickness of the sinus wall may
be increased, but more commonly the new formation of bone
appears as thin plates, free or attached to the walls, or as
tubercles and spicules.
This bone-formation presupposes a deep-seated inflam-
matory process, amenable only to radical operative treatment.
At any time during the progress of chronic inflammation
acute exacerbations may supervene, and this is commonly
the case. The clinical symptoms are altered, the chronic
pathological changes remain fixed, but the oedema and addi-
tional round-cell infiltration, which characterize acute pro-
cesses, are added. The usual outcome is that the chronic
process becomes deeper seated.
Chronic inflammatory processes, therefore, are mani-
fested by a new formation of connective tissue, complicated
by changes in the superficial or deeper layers of the lining
membrane, and all of these changes may take place with a
comparatively intact epithelial layer, or, in fewer instances,
68 HOWARD A. LOTHROP.
superficial or deep ulcerations may exist. The depth of the
process and the inaccessibility of the part to ordinary thera-
peutic measures is sufficient explanation of the chronicity of
these cases.
(3) Tuberculosis. — The characteristic appearances of tu-
berculosis are evident here as elsewhere on mucous mem-
branes. The process is one of ulceration with connective-
tissue proHferation, and generally extends into the sinus as
a part of a local process elsewhere. (Further detail is un-
necessary.) Tubercle bacilli have been found at autopsy in
apparently normal sinuses in patients who have died of tuber-
culosis.
(4) Syphilis. — The manifestations of syphilis are com-
mon in the nasal cavity, whence they may extend to the ac-
cessory sinuses. The process is characterized by ulceration,
with the possible destruction of all tissues, followed by exten-
sive scar-formations.
The process may be so deep-seated and complicated by
mixed infection that it may fail to yield to ordinary anti-
syphilitic treatment. Involvement of the frontal sinus is
commonly secondary to local syphilitic ulcerations.
Nezv Grozvtlis. — In addition to the inflammatory pro-
cesses in the frontal sinus, we have the consideration of new
growths, which need but a passing mention.
Fibroma rare.
Cholesteatoma rare. First described by Virchow as a new
growth. Cases reported also by Wotruba. Not to be con-
fused with collections of epidermis, as observed in the mas-
toid antrum.
Malignant Tumors. — Sarcoma, carcinoma. These are
the results of extension in most instances, and offer nothing
particularly characteristic when they invade the sinus.
Symptoms. — All symptoms may be classified as local or
general.
General symptoms are of secondary importance in sinus
affections, except in certain acute cases, and in some of
the complications arising therefrom; hence these general
SUPPCRA7I0X IX THE I-'ROXTAI. S/XCS. 69
symptoms \\\\\ Ijc considered under local symptoms, as
called for.
Local symptoms may be subjective or objective.
Subjective Symptoms. — Pain. — Pain is very characteristic
of acute cases, and is often a symptom during the course of
a chronic case. In acute cases, there are several causes
which give rise to pain. The early pathological changes are
followed by oedema of the mucous membrane, which conse-
quently thickens so as to fill up more or less of the sinus, and
even obliterate its cavity, if small. This oedema presses the
nerve-endings on account of the resistant bony walls. This
swelHng may also occlude the ostium frontale with conse-
quent retention of exudate, which tends to accumulate under
pressure, and give rise to excruciating pain and secondary
reflex symptoms.
A common history of the pain in these acute cases is as
follows: Several days to two weeks after the cessation of an
acute coryza the patient complains of pain in one or both
frontal areas, which gradually increases in severity. It is
worse when the head is lowered or after coughing, sneezing,
blowing the nose, and any sudden movement. It is a con-
stant ache without remission, but with occasional darting
pains. Its severity increases slowly, and varies according to
the degree of tension of the exudate or the amount of oedema,
and may decrease slowly, but more commonly relief comes
rather suddenly. This is due to the returning patency of the
ostium and discharge of the exudate. Up to this moment
there has been no nasal discharge, when suddenly there is a
mucopurulent or purulent or even bloody discharge from the
corresponding nostril. The pain now decreases rapidl}', and
may cease to be a further element in the case, provided the
outlet remains unobstructed. The sinus may rupture into
the orbit, also, with relief. Internal medication with anti-
neuralgics is of no avail in these cases. Photophobia and
shedding of tears on the afifected side not rarely accompany
the pain of this stage.
On the other hand, many cases run a mild course
throughout. In chronic cases, pain is more commonly a
70
HOWARD A. LOTHROP.
symptom of secondary importance; when present, it is due
to the same causes, and is suggestive either of a simple re-
tention or of an acute exacerbation of the inflammatory pro-
cess. Most chronic cases complain of no pain, but rather
of an occasional dull ache. Pain is referable to the frontal
area, but when intense, it may radiate in any direction and
resemble a neuralgia or migraine. In severe cases, it may be
impossible to differentiate the pain accompanying frontal
ethmoidal or antral inflammation.
Pain is frequently of such a nature as to be described as
a headache, and is often accompanied by dizziness, with
flashes of light before the eyes on coughing.
Tenderness. — Tenderness is a symptom of great value.
In acute cases, it varies more or less with the severity of the
pain.
In chronic cases it may be sufficiently acute to attract
the attention of the patient, but very frequently it is too slight
to be of annoyance, and is discovered only by the examiner.
In all instances it conforms in area very closely to the frontal
region. It is most marked, however, at the inner angle of
the orbit, on the orbital portion of the floor of the sinus. The
tender spot is internal to the supraorbital notch, which is a
help in differentiating neuralgia.
Tenderness should be examined for, either by means of
graduated pressure or percussion.
Altered Sense of Smell. — Patients may complain of loss
of the sense of smell. This cannot be traced directly to the
frontal inflammation, but is probably consequent on troubles
in the nasal cavity itself.
Constitutional Symptoms. — During the course of acute
cases there is more or less febrile disturbance. We may have
chills with considerable rise of temperature lasting until the
sinus begins to discharge its contents. These febrile dis-
turbances need no further consideration.
In certain instances, the annoyance and worry of long-
continued suppuration give rise to a chain of nervous phe-
nomena, which, in time, may result in lowering the general
SUFPCRATIOX IN THE FROXTAL SIX US.
71
condition of the patient. ^Most chronic cases, however, rarely
complain of subjective symptoms.
Objective Symptoms. — (i) In nasal fossa. (2) Over
frontal area and at internal orbital angle and in orbital fossa.
(3) In cerebral fossa.
(i) In Nasal Fossa. — If the ostium frontale is occluded,
as is common in acute cases, and an occasional complication
of chronic cases, there may be no nasal symptoms whatever.
In late stages of acute cases and in all chronic cases, there
is to be observed one symptom which is the most important
we possess as regards its diagnostic value. This sign is the
presence of pus in the nasal cavity, and is of conclusive evidence
if its source can be traced to the froiital sinus. Concerning the
pus, there is nothing characteristic as regards its color, con-
sistency, or odor. The amount of the discharge may suggest
some accessory sinus affection and occasionally the degree
of inflammation.
The patient complains of a more or less constant dis-
charge of pus, sometimes very offensive, which appears at
the anterior or posterior nares. It flows more constantly by
day, and tends to accumulate at night while the patient is at
rest, but in the morning there is an excess of crusts and pus,
which necessitate cleansing the nose at once on rising. ]^Iost
cases of frontal empyema have objective symptoms referable
only to the nasal fossa.
The consideration of localizing the source of pus in the
nasal fossa, the differentiation of sinus affections, the value to
be attached to the presence of nasal polypi and hypertrophies,
will be considered under diagnosis.
(2) Over frontal area and in orbital fossa.
Objective symptoms in this group are consequent on
prolonged obstruction to the discharge of exudate from the
sinus. They are manifested by (a) local signs of inflamma-
tion; (b) presence of a fistula; (c) presence of a tumor; (d)
inflammation in the orbital fossa.
(a) In acute cases, where the obstruction persists, the
tension increases and the pathological changes travel deeper.
72 HOWARD A. LOTH R OP.
Sooner or later the upper eyelid becomes oedematoiis and
slightly reddened. This swelHng and redness extend towards
the median line and up onto the frontal area, and their extent
is limited only by the severity of the process. Pain and ten-
derness increase proportionally.
If the ostium becomes pervious before these changes
have advanced too far, then resolution may supervene with-
out further change, and the parts be restored to normal. It
is unusual to get marked external signs followed by resolu-
tion, for the pathological process goes on to further destruc-
tion, unless arrested by surgical intervention.
In time an abscess forms, which discharges pus freely,
and the swelling subsides and the subjective symptoms de-
crease. These changes may occupy several days, and be
accompanied by considerable constitutional disturbances.
An examination of this opening with the probe shows
that it communicates with the frontal sinus, which commonly
remains occluded towards the nasal fossa. There may be
no further subjective symptoms so long as this fistula remains
patent. i]
{h) Fistul(r. — The presence of a fistula presupposes the
history just mentioned, and indicates, besides, that there has
been a necrosis of the sinus wall. Its presence simplifies the
diagnosis of a suspected frontal empyema.
Its location is comparatively constant at the upper in-
ternal angle of the orbit, internal and posterior to the supra-
orbital notch. It is rarely external to this notch. With very
few exceptions the perforation is in the inferior wall of the
sinus, but a notable exception is a case pictured by Warren
(Plate 85), which was complicated by pneumatocele, where
the thick anterior wall w^as necrosed. Perforations in the
anterior wall are generally along the superciliary ridge.
Other sources give rise to fistulse in this vicinity, such
as orbital abscess, lachrymal cysts, gummata, etc. (to be con-
sidered under diagnosis), but an examination of the pus from
frontal cases may reveal the presence of ciliated epithelium.
These fistulse persist until nasal drainage is re-estab-
SUPPL'RATIOX IX THE FRONTAL SIX US.
73
lished (but may close temporarily only), or until the sinus is
obliterated by surgical intervention.
(c) Tumor. — There are several varieties of tumor which
may be connected with the frontal sinus, and appear in this
area: Abscess (has been considered), mucocele, pneumato-
cele, malignant tumor.
Mucocele is a rather rare affection. (Case IV, Plate 83.)
It is a tumor of very slow formation, and consists in the
gradual dilatation of the weaker parts of the sinus walls in
cases w^here an occluded ostium frontale prevents the escape
of mucus. The cases may last for years, while the tumor
progresses slowly without subjective symptoms. The slow,
steady pressure causes the thin inferior surface of the sinus
to yield, and the consec]uence is a tumor at the inner angle
of the orbit. Its growth may be so gradual as to fill up a
large part of the orbital fossa without ocular disturbance,
although the globe of the eye, meanwhile, has been pushed
well towards the malar bone. It may also crowd portions of
the ethmoid labyrinth towards the nasal septum.
It presents a smooth, rounded surface over which the
skin is freely movable, and on the periphery the surface seems
to be continuous with the surrounding bone. The tumor is
resistant in places and gives rise to the characteristic " egg-
shell crackle," as demonstrated in Case IV, but in places
where the bony wall is very thin or deficient, it feels soft and
fluctuating. These variations give an unevenness to the sur-
face. The tumor as a whole is immovable, except that in
certain instances its size may be somewhat temporarily re-
duced by pressure. If there is a rupture in the sac, the con-
tents may be squeezed .into the nasal cavity.
Patients suffering from mucocele may complain of ten-
derness and pain, which are usually accompanied by a change
in the size of the tumor. In Case I\^ the tumor would occa-
sionally decrease considerably and its surface become hard
and rough, but at certain seasons it would increase in size
and give rise to some pain and be tender on palpation. These
collections of mucus mav become infected, assume the char-
74 • HOWARD A. LOTHROP.
acter of pus with consequent chain of acute symptoms, and
then follow the course of an acute abscess connected with
the frontal sinus. Unless infection creeps in, these tumors
continue for years without rupture; otherAvise fistulas result.
The usual symptoms of mucocele are of a mechanical
nature and vary according to the size of the tumor. They
may be manifested as dislocation of the globe of the eye;
disturbance of the action of ocular muscles; pressure on the
optic nerve and ophthalmic vessels.
Disordered function of the lachrymal apparatus. The
dislocation of the globe takes place so slowly that the func-
tion of the eye remains normal for a long time. The eye is
pushed into the corner of the orbit opposite that occupied
by the mucocele. Hence it is dislocated outward and down-
ward, commonly with more or less exophthalmos. The fatty
tissue, external to the globe, gives way so that the sclerotic
coat may be in close proximity to the malar bone. The eye
appears smaller than the opposite one, because it is pushed
outward under the lids, which meet at the external canthus.
The action of the ocular muscles remains normal for a
long time and coordination may never fail. In advanced
cases, on the other hand, their function may be interfered
with so that double images are formed. Diplopia has never
been present in Case IV, although the globe is in contact
with the malar bone.
Pressure upon the optic nerve may give rise to choked
disk or atrophy of the optic nerve. Amblyopia or amaurosis
may be the consequence. These cases are exceptional, and
the tumor must be very large and extend back to the region
of the anterior or even posterior ethmoidal cells.
Mechanical disturbance with the lachrymal apparatus is
common, as manifested by the overflow of tears down the
cheek, which, in turn, may give rise to a troublesome eczema.
(Case III.) The intimate relation of the lachrymal sac and
nasal duct with the thin lachrymal bone, which continues
downward from the inferior surface of the frontal sinus (Plate
2.6), readily explains the frequency of these symptoms. The
SUPPURATIOX I.\ THE FRONTAL SINUS.
75
lachrymal bone is often pushed forward and outward, form-
ing part of the thin wall of the tumor which presses the
lachr3'mal sac between the tendo oculi and tensor tarsi muscle
so as to occlude its lumen.
Pneumatocele is a condition of very unusual occurrence.
Simple cases are manifested by the presence of air in the
cellular connective tissue in the vicinity of the sinus (emphy-
sema), or still less frequently by a well defined tumor con-
taining air, for the most part. Such conditions presuppose
a communication with the nasal cavity. Helly has collected
a series of nine cases, while Warren's case of double frontal
pneumatocele following perforation of the anterior sinus wall
is unique.
The causes leading to this condition may be:
Congenital or acquired dehiscence of the sinus wall. ^Nlay
have to differentiate from orbital dehiscences. (Plates 48,
49. 50-)
Fracture in the frontal bone allowing air to be forced up
from the nasal cavity under the skin (emphysema).
Inflaniniatory processes are the common cause of pneu-
matocele, consequent on necrosis and perforation of the sinus
wall, the overlying skin, moreover, remaining intact. This
is the usual cause of this rare complication. Such pneumato-
celes are of short duration, and are soon followed either by
resolution, or, more commonly, abscess-formation.
Nezv Grozcths. — New growths of a benignant or malig-
nant nature, primary in the frontal sinus, are also among its
rare affections. Their presence need hardly be suspected on
account of any nasal discharge, but should be considered as
a possibility on the appearance of any external tumor. This
sinus may be involved by a part of a malignant growth
originating in the orbital or nasal fossa, as occurred in two
cases subjected to extensive operations by Gussenbaur. Pri-
mary malignant tumors of the frontal sinus are never diag-
nosed early, and when discovered are usually beyond help.
The local and possible constitutional symptoms can be
readilv understood.
76 HOWARD A. LOTHROP.
(d) Inflammation in the Orbital Fossa. — Under the con-
sideration of local inflammation we have seen that mild symp-
toms and signs may subside with complete resolution, or may
end in abscess-formation, and rupture with consequent fistula,
but without further destructive process. On the other hand,
these processes can be carried further, and the orbital fossa
and its contents involved in the inflammatory process. These
complications must not only tend to obscure the diagnosis,
but also to add to the gravity of the situation.
The constitutional symptoms occasioned thereby are
those consequent on any febrile disturbance, and need no
further mention. The local symptoms are of importance.
The earlier signs are due to oedema or exudation in the in-
ternal and superior muscles of the eye, whereby their action
is impaired. The usual site of necrosis is in the inferior wall
of the sinus, which is in close proximity to the levator palpe-
brse superioris, rectus superior, rectus internus, and obliquus
superior muscles. Hence ptosis is an early sign, together
with inflammatory oedema of the upper lid. The ocular pare-
sis or paralysis gives rise to diplopia, consequent on more or
less fixation of the affected globe.
As the pus infiltrates the orbit mechanical symptoms
due to pressure arise, similar to those described above, but
more rapid* in their progress, and resulting in greater func-
tional disturbance, in that the parts have no time to become
adapted to the altered conditions.
Another group of symptoms follows when the eyeball
itself is involved giving rise to changes which may perma-
nently impair the function of the eye.
Finally, inflammation may be set up in the lachrymal sac
or nasal duct, manifested as a catarrhal process or abscess-
formation, both of which may lead to occlusion of the lumen
of the passage.
(3) Signs and Symptoms referable to the Cerebral
Fossa.
One of the possibilities which may result from inflam-
mation in the frontal sinus is perforation of the posterior
SUPPURATION IN THE FRONTAL SINUS.
77
wall. This may take place during- an active inflammation of
the sinus with obstructed ostium frontale, or at the time of
operation, or weeks and even months later, in consequence
of a slowly advancing caries.
In addition to the already existing- symptoms, whether
they be acute or quiescent, there is a sudden rise of tempera-
ture, usually ushered in by a chill. There is frontal head-
ache, unrelieved by medication, and more or less acute pain.
The usual amount of exudate from the sinus, if previously
discharging, becomes lessened. In a short time the ordi-
nary symptoms of an acute meningitis develop, and the case
will progress with the usual variations until the fatal termina-
tion.
Focal cerebral symptoms are not frequent, but somno-
lence and delirium are common features. In the later stages,
gravitation will carry the pus backward over the vertex or
along the base of the brain, with consequent convulsions or
other focal lesions. Perforation of the posterior wall is
usually a fatal complication, A series of twenty fatal cases
have been collected. The cause of death in twelve cases was
a suppurative meningitis; in five cases, abscess of the frontal
lobe, and in three cases both abscess and meningitis were
present. In three additional fatal cases death was conse-
quent on a thrombo-phlebitis, the frontal sinus serving as the
source of infection.
The site of perforation was commonly just to one side
and in front of the crista galli, although caries may occur at
any point in the posterior wall.
Diagnosis. — Some cases of frontal sinus suppuration
may be diagnosed at sight without questioning the patient,
other cases need weeks of careful examination and considera-
tion, and, finally, in many instances, the precise location of
the suppurating focus must be left problematical until de-
termined by exploratory measures, which may be of value
in treatment as well as diagnosis. Many of the procedures
used for treatment as well as diagnosis will be more fully
considered under subject of treatment.
78 HOWARD A. L0THR02\
Conclusions are drawn from the previous history of the
patients and from present subjective and objective symptoms.
Previous History. — A common antecedent history for
cases of acute disturbance in the frontal sinus is that of a
coryza, and that the frontal pain commenced from one to
two weeks after the nasal disturbance began to resolve. We
may obtain the history of the trouble which is possibly still
existing in the nose, such as polypi, ulcerations, etc.
The patient may have sustained some injury to the
frontal bone which has given rise to a sinus complication.
It is of importance to ascertain whether the patient has
recently undergone some acute infectious disease, especially
of the type previously considered.
Having exhausted the possibilities connected with the
previous history, our attention is to be directed to the pres-
ent symptoms of the case, both subjective and objective.
Objective symptoms are of much greater importance than
subjective, and with the latter alone a diagnosis must be
somewhat problematical. A suggestive previous history,
together with existing subjective and objective symptoms,
make it easy to diagnose suppuration in some one or more
of the nasal accessory sinuses, but a certain differentiation
may be most difficult without undertaking operative meas-
ures.
At first let us eliminate all lesions not connected with the
nasal fossa or its accessory sinuses, wdiich may enter into the
question of differential diagnosis.
Elimination of Lesions Extranasal. — Supraorbital Neu-
ralgia. — Pain is more or less characteristic and tenderness is
at supraorbital notch instead of nearer the median line on
the floor of the sinus. Absence of nasal or febrile symptoms.
History of neuralgia elsewhere.
Migraine, Hemicrania. — Characteristic location and at-
tacks of pain. Absence of all objective symptoms of dis-
turbance in the frontal sinus.
Orbital Complications. — Suppurative diseases in the or-
bital fossa or its vicinity must be carefully considered in every
SLTPURATION IX THE FROXTAL SI XL'S. 79
case of suspected sinus, which may be complicated by similar
lesions in this fossa. However, the presence of co-existing-
nasal symptoms will decide the question. For example, —
Orbital abscess may be primary in the fossa or second-
ary to perforation of the sinus wall. There is nothing dis-
tinctive in the abscess itself or the mechanical and inflam-
matory consequences. Its location in the upper internal
angle of the fossa is more suggestive of frontal sinus origin.
Nasal symptoms may be absent, for an occluded ostium fron-
tale is the probable cause of orbital perforation, but the pre-
vious history and tenderness over the sinus walls may be
suggestive.
Ptosis following cranial lesions is never accompanied by
oedema of the lid or inflammatory orbital processes.
Lachrymal Sac and Nasal Duct. — Suppuration in these
structures should always lead us to suspect trouble in the
anterior ethmoid cells, which in turn are very frequently in-
volved simultaneously with the frontal sinus. Stenosis of
the nasal duct with abscess-formation is still more suggestive.
Look for nasal symptoms.
Tumors. — A gradually increasing tumor near the upper
and inner anp-le of the orbital fossa, of long duration, without
subjective symptoms, occasionally slightly tender, its sur-
face rather hard, often with very slight bony irregularities,
is probably a mucocele. This may become infected at any
time, with the consequent addition of the symptoms and re-
sults of abscess-formation, of primary or secondary origin in
the orbit.
Malignant tumors call for no particular consideration
here.
Fistulcc. — A fistula may lead to the orbital fossa simply,
or be connected with the frontal sinus or anterior ethmoidal
cells. It presupposes, as a rule, the history of acute process
located either in the orbital fossa or the accessory sinuses
of the nose. The ordinary location of frontal fistulas has
been considered. The presence of tumor or fistula in con-
nection with nasal symptoms, or a suggestive history, sim-
8d HOWARD A. LOTHROP.
plifies the diagnosis to a large extent. So much for the
elimination of lesions external to the nasal fossa or its sinuses.
Nasal Fossa. — The objective symptoms in the larger
proportion of cases of frontal suppuration are limited to the
nasal fossa. Tlie important cardinal symptom is the presence
of pus. Hence, we must consider the following possibilities
as the source of the pus-formation:
(a) Acute inflammation in the nasal fossa.
{b) Chronic inflammation in the nasal fossa, complicated
or not by hypertrophies or polypi.
(c) Suppuration in cells of the middle turbinate.
{d) Inflammation in one or more of the accessory sinuses.
Having narrowed our source of pus to these sinuses, the next
problem is to determine which sinus is involved, and also to
consider the question of association of sinus inflammation.
(a) Acute Inflammation. — During acute nasal troubles,
it is difhcult to decide whether the frontal sinus is involved
at the same time. Frontal pain and tenderness are common
symptoms attending a " cold in the head," especially during
convalescence, and we are now led to believe that acute in-
flammation of the sinus, of a mild type, is of common occur-
rence. Delayed frontal tenderness or pain should always
arouse our suspicion of local trouble; the continuation of a
unilateral nasal discharge should lead us to examine for some
sinus affection, but during the acute period of the nasal in-
flammation, symptoms and signs referable to an acute sinus
inflammation are very frequently masked.
{b) Chronic Inflanunation in the Nasal Fossa and its Com-
plications. — Very frequently, the first problem to be solved by
the surgeon is, as to whether there is any or sufficient cause
in the nasal cavity to account for the quantity of pus which
may be present there. Most chronic nasal disturbances are
attended by a varying amount of exudate which may differ in
no respect from that of the sinuses. Hence, without further
detail, it will be necessary to eliminate all nasal causes of
suppuration. This may cause considerable delay on account
of the presence of hypertrophies and polypi which per se are
SUPPURATION IX THE FRONTAL SINUS. 8 1
commonly the cause of suppuration. In addition, they may
act mechanically, obstruct the infundibulum and ostium
frontale, and be the only hinderance to the recovery from a
sinus inflammation, as well as obscuring its existence.
The preliminary treatment of disturbances in the nasal
fossa, therefore, may result in simultaneous cure of the frontal
suppuration. The persistence of pus accumulation in the
middle meatus under the middle turbinate bone, after the
removal of all obstructions, points to a source in the sinuses.
(c) Cells ill the Middle Turbinate. — A middle turbinate
bone, when viewed from the anterior nares, may be seen to
be broader than usual. This may be due to a deep sinus
turbinalis, whereby the normal concavity of the bone is deeper
than normal, or the turbinate may have a double wall, giving
rise to the formation of one large cell, or occasionally several
cells. The ostium of this cell is almost always at its apex,
so that drainage is hindered, and much pus may accumulate
therein. Turbinate cells open more frequently into the fis-
sura ethmoidalis inferior, but enough open into the middle
meatus to be considered in this connection. (Part I.) Sup-
puration in these cells may give rise to a considerable amount
of exudate.
A deep sinus turbinalis can be differentiated from a large
cell by means of the probe with but little difificulty.
{d) Inflammation in the Accessory Sinuses. — We are now
supposed to have eHminated all possible external lesions in
the vicinity of the frontal sinus, and to have decided as to
whether some lesion of nasal origin is adequate to account
for all of the exudate found in the nasal fossa. If further
sources are suspected, careful and repeated examinations
must be made to determine the site where this pus appears
first.
The turbinate bodies and the ethmoidal fissures, or their
equivalents, with their respective ostia, are so situated that
pus appearing here or there suggests that it must come from
this or that sinus, or from a certain combination of sinuses.
Provided the normal cellular partitions are intact, pus ap-
6
82 HOWARD A. LOTHROP.
pearing above the middle turbinate bone must be derived
from either the sphenoidal sinus, the posterior ethmoidal
cells, and two-thirds of the cases where cells appear in the
middle turbinate bone. The posterior location of these ostia
in the nasal fossa and the contour of the turbinate bone (Part
I) are such that exudate from these sources will tend to gravi-
tate towards the pharynx in a great measure, but, neverthe-
less, it may reach almost any part of the nasal fossa, depend-
ing the much-mooted question of the value of this procedure
cern us except by way of elimination.
Pus appearing between the middle and inferior turbinate
bones may emanate from the antrum of Highmore, the fron-
tal sinus, the anterior ethmoidal cells, and from one-third of
the middle turbinate bones, possessing cell-like cavities. The
problem is to determine which sinus or what combination
of sinuses may be involved; it is a difficult problem, and one
that many times cannot be solved with any degree of cer-
tainty.
All reasonable measures suggested for the diagnosis of
sinus affections, whether of much value or not (provided
they are not harmful), should be resorted to, because some
little point may influence us one way or another in drawing
conclusions.
Percussion over the frontal sinus or antrum is of value
in deciding the question of tenderness, but their cavities are
too small for sound differences to be detected when full of
fluid, as Zenker would have us believe.
Transillumination. — Nothing would be gained by discuss-
ing the much mooted question of the value of this procedure
in diagnosis. Only the conclusions of the most experienced
observers will be given.
Antrum of Higlimore. — (i) Its use is often of value; (2)
A negative result will not rule out disease of the antrum; (3)
A positive result should make us suspicious, but is by no
means conclusive evidence of a pathological condition; (4)
Normal sinuses in the same subject may give rise to great
inequality of the intensity of the light for various reasons.
SCPPURA TION IX THE FRONTAL SINUS. 83
Frontal Sinus. — Transillumination has been practised in
these cases by placing the light either in the buccal cavity or
externally under the supraorbital arch. While antrum illumi-
nation may be of assistance, its use in suspected frontal sinus
cases is anything but satisfactory.
The great variation in the walls of frontal bones, and
the unsatisfactory relation of the position of the light and
the sinus for the transmission of rays, render frontal trans-
illumination of but little avail in practice.
Auscultation, with the simultaneous insufflation of air, is
a procedure which is unwise, on account of the spread of
pathogenic bacteria into healthy sinuses, and is of no prac-
tical value.
Association of Sinus Affections. — Having exhausted all
external methods for the differentiation of the sinuses under
consideration, with the possible satisfaction of some evidence
gained one way or another, we must resume the nasal ex-
amination. The nasal cavity has been cleared of obstruc-
tions (pathological), and our one cardinal symptom is the
presence of pus in the middle meatus under cover of the
middle turbinate bone. As already stated, this exudate may
be derived from several sources, and before considering a few
cardinal symptoms for each one, let us examine the clinical
evidence concerning the association of sinus empyemata, as
well as anv anatomical reasons for this association.
Empyema of the Frontal Sinus combined with that
OF THE Anterior Ethmoidal Cells.
Clinical Evidence. — Luc states that frontal empyema is
usually associated with the same disease in the anterior eth-
moidal cells. Jansen was early to suggest this combination,
and reports that in seven frontal cases, all were thus com-
plicated; that the infundibulum was obstructed by hyper-
trophies, — demonstrated by operation. As a result of au-
topsy, Zuckerkandl, with an enormous experience, never
observed a case of suppuration in the frontal sinus uncom-
84 HOWARD A. LOTHROP.
plicated by ethmoidal. E. Frankel performed 146 autopsies,
and did not find a single uncomplicated frontal empyema.
Cases III and V of this paper suffered from empyema
of the anterior ethmoid cells in connection with frontal em-
pyema, demonstrated by operation. Evidence obtained by
autopsy and operation is indisputable.
There are, on the other hand, undoubtedly many cases
of primary origin in the frontal sinus, notably those which
can be traced directly to external trauma, but the question
naturally arises as to whether in time these cases do not fre-
quently give rise to associated trouble in the ethmoid cells.
This will depend upon the anatomical relations of these cells
and their ostia to the sinus, and the course of the exudate,
and also to the secondary pathological changes acting me-
chanically or by extension.
Anatomical Evidence. — The intimate relation between
the frontal sinus and some of the anterior ethmoid cells and
the thinness of their walls has been considered in detail in
Part I, hence it will suffice here to enumerate a few of the
salient points:
(a) The nasal portion of the floor of the frontal sinus is
made up mostly of anterior ethmoid cells, which also crowd
into the posterior angle and posterior border of the sinus.
Their walls are very thin and easily broken through with
instruments.
(h) If a naso-frontal canal is present, it is more or less
surrounded by these cells on three sides, — viz., externally the
cells completed by the lachrymal bone, in front the cells on
the floor of the sinus just anterior to the ostium frontale, and
behind by the cells above the ethmoid bulla, which crowd
towards the posterior angle of the sinus.
(c) The ostia of these various cells generally open into
the upper portion of the infundibulum on different sides. In
close proximity to that of the naso-frontal canal, or into the
turbinate fossa. (Part I.) These ostia of the cells are dis-
tributed with no reference to the drainage of the cells, and
may face in any direction. The whole space under considera-
SUPPURATIOX /A' THE FRONTAL SINUS. 85
tion is small and the ostia are fairly numerous, so that they
are all in very close proximity. Their irregular distrilmtion
is such that, no matter what the position of the head, fluid or
pus from the frontal sinus tends to flow into some of these
cells, so that at least they may act as reservoirs. In time, the
constant irritation of pus may give rise to the development
of hypertrophies and polypi. These increase the liability of
secondary involvement of the cells by adding an obstructive
element to the discharge of pus from the frontal sinus.
id) Trauma, consequent on attempts to probe the ostium
frontale, may open the way for infection. There are many
clinical cases reported where the writer states that only the
frontal sinus was diseased, but unless carefully examined at
the time of a very radical external operation or post-mortem,
there is absolutely no known method of determining wdth
certainty that some of these cells are not involved.
Hence the clinical evidence and anatomical structure
would point very strongly to an involvement, sooner or later,
of anterior ethmoidal cells in connection with empyema of
the frontal sinus.
Empyema of the Frontal Sinus as a Cause of Empyema
OF THE Antrum of Highmore.
The Antrum as a Reservoir. — On account of the much
larger size of the antrum than the combined anterior eth-
moidal cells, and also from the fact that the former is a single
cavity, the latter a series of very small cavities, pus collec-
tions in the maxillary sinus are more extensive and more
easily recognized. Although the antrum may not be the
seat of an inflammatory process, if it serves as a reservoir for
pus arising elsewhere, even then this pus collection will give
rise to symptoms equally annoying, and w^hich must be re-
Heved.
Let us first examine the clinical evidence in regard to the
association of antrum and frontal empyema, complicated or
not, as may be the case, with ethmoid suppurations.
86 HOWARD A. LOTHROP.
Clinical Evidence. — In seven cases of frontal empyema,
Lichtwitz noted one antrum complication.
Bryan cites a case of antrum empyema secondary to that
of the frontal sinus.
Macdonald says that all of his cases co-existed with sup-
puration in the antrum and anterior ethmoidal cells.
Ortega states that if both antrum and frontal enipye-
mata are present, the frontal is the primary.
Alexander notes that where frontal empyema is accom-
panied by the presence of polypi in the vicinity of the infun-
dibulum, there is usually pus in the antrum.
Jansen reports seven cases of frontal empyema, all co-
existing with suppuration in the ethmoid cells, six of which
had pus in the antrum. He is of the opinion that most fre-
quently we have to do with a combined empyema, and that
isolated cases of antrum are more commonly of alveolar
origin. He cites one case of suppuration in the antrum which
followed his radical operation (see Treatment) for frontal em-
pyema, and attributes this consequence to the use of tampons
for haemorrhage. The writer is led to believe that the radical
external operation, where a large opening is made through
the floor of the sinus into the nasal fossa, of itself is liable to
be followed by pus in the antrum, if not already a complica-
tion. This statement is based on a study of the regional
anatomy, and operations on the cadaver; it will be considered
more fully under treatment.
Cases HI and V are examples of the association of the
three sinuses under consideration.
It is a comparatively simple matter to decide whether
the antrum is involved, and it should always be done before
operating on the frontal sinus. The inner wall of the antrum
should be punctured through the middle or preferably
through the inferior meatus, and the antrum contents as-
pirated, if in sufhcient quantity; otherwise the sinus may be
irrigated with a small volume of sterile salt solution after the
nasal fossa has been cleared of pus. Puncture may be avoided
if it is possible to catheterize the sinus.
SUPPURAriON IN THE FRONTAf. SINUS. 87
The existence of ethmoidal empyema alone can be de-
termined only by first eliminating the frontal sinus and the
antrum.
Another strong point, suggesting that antrum emjiyema
is often secondary to one of the other sinuses, is the fact of
the obstinacy and incurability of many such cases. This ob-
stinacy of antrum cases led Fillebrown to conclude that sev-
eral cases were prevented from recovering from their antrum
troubles on account of empyema of the frontal sinus, which
was evidentl}^ present in each instance.
Anatomical Evidence. — A detailed account of the anatomy
of the structures which intervene between the ostium fron-
tale and the ostium maxillare, together with variations, etc.,
from the normal, has been given in Part I, hence only certain
obvious conclusions need be tabulated here.
(a) In looking at the external wall of the nasal fossa,
with the middle turbinate bone removed as far as possible,
and this surface held at right angles to the observer, the os-
tium maxillare is very rarely in the field of vision. Verv fre-
quently it can never be seen, no matter how the specimen is
held. This is accounted for by the fact that this ostium is
concealed by the uncinate process, lies near its low'er border
so that the whole width of the process obscures the ostium
from view. The distance of the lower border of the ostium
from the free ^A^o. of the process will vary, consequently,
according to the width of process and its lateral angle of in-
clination. (Plates 38, 39, 40, 61, 67, 70.) The ostium, there-
fore, is situated at the lowest part of the infundibulum, and
extends somewhat on to its external wall, and could not be
better placed to drain the infundibulum, otherwise a blind
pocket would exist here. Hence, if fluids once reach the in-
fundibulum, they must gravitate towards the ostium maxil-
lare and thence into the antrum, provided the ostium is
patent. The infundibulum acts as a sort of gutter.
{h) In a little less than 50 per cent, of the cases there is
a naso-frontal canal which opens into the infundibulum from
the frontal sinus. If there are no mechanical obstructions.
88 HOWARD A. LOTHROP.
fluid will gravitate in every instance from the frontal sinus
to the antrum, with the head in the erect position.
Many times a straight probe can be made to follow this
course, and almost always a more or less curved probe.
Pathological hypertrophies may fill the infundibulum
and divert some of the fluid from this course.
(c) In a little more than 50 per cent, of the cases the
frontal sinus opens into the highest point of the turbinate
fossa by means of little or no canal. Fluid gravitates at once
into the general nasal cavity, passing under the middle tur-
binate bone. Now, very frequently the septum which sepa-
rates the turbinate fossa from the upper end of the infundibu-
lum is very narrow (Plates 11, 22, 33, 37), so that fluid soon
gets into this channel, and its further course continues as
above. A wide septum may prevent fluid reaching the in-
fundibulum and cause it to gravitate into the nasal fossa.
(Plates 25, 31, 32.) Such will be the result with the head in
the erect position, but, in that the head is constantly moving,
pus may gravitate in any direction. Frequently a slightly
curved probe can be passed through this route (turbinate
fossa and infundibulum) into the antrum.
id) Pus from the anterior ethmoid cells will follow the
same laws and course, in that it drains into the infundibulum
or turbinate fossa, or both.
ie) Pathological hypertrophies serve both to deflect pus
into the infundibulum from the turbinate fossa, and also as
a mechanical hinderance to its passage into the nasal fossa,
thereby raising tension and forcing it into ethmoidal cells and
antrum, especially if it leaves the frontal sinus under pressure.
The comparatively intimate relation of all these ostia
favors the passage of pus from one to the other.
Now and then, in the recent state, the superior border
of the processus uncinatus may be so close to the bulla eth-
moidalis that the hiatus semilunaris is merely a small ostium
and the infundibulum a closed canal, with- the ostium maxil-
lare an opening in its side.
The use of the probe and canula, and their practicability
SUPPURATION IN THE FRONTAL SINUS. 89
and value as means of diagnosis, will be considered under
treatment.
Prognosis. — Inferences as to the prognosis of suppurative
diseases of the sinus frontalis will naturally be drawn from
the foregoing pages. A certain prognosis can never be given,
notably in chronic cases, many of which never cease dis-
charging.
Although these cases are rarely fatal, and often only a
source of annoyance to both the patient and his companions
(nasal discharge with odor), a prognosis should always be
guarded and given with some degree of caution, on account
of the possibility of extension to the cranial fossa with its
usually serious termination. The frontal sinus is occasion-
ally the source of serious septica^mic or pyjemic infection.
Acute cases generally resolve spontaneously in from one
to three weeks. There is always the tendency to recurrence
with every attack of acute nasal disturbance, and finally the
frontal inflammation may become chronic.
Fatal complications come during a primary acute attack
or an acute exacerbation in a chronic case.
Chronic cases frequently never recover and are liable to
acute exacerbations at any moment. Aside from a constant
nasal discharge, they may cause no further trouble. The in-
fluence of combined sinus-disease, as well as other possi-
bilities, influencing the course of sinus suppuration need no
further consideration here.
The nature of the bacterial infection is of some impor-
tance. Streptococcus and staphylococcus infections are more
serious than pneumococcus infection.
We do not know why some cases resolve quickly, and
others remain chronic. The varying degree of the virulence
of the infection, the amount and character of the exudate, the
location and depth to which the bacteria have penetrated
with varying pathological results, and individual disposition
and idiosyncrasy, are all uncertain factors which must enter
into the prognosis of these cases.
Treatment. — Aeutc Cases. — During the acute stage of
9°
HOWARD A. LOTHKOP.
inflammation of the frontal sinus there are no direct local
measures which will be of much benefit, and in many in-
stances attempts at internal local treatment will do harm.
The ordinary analgesics for neuralgic pain will not re-
lieve many cases, and in certain severe attacks opiates must
be used. Occasionally the coal-tar products — phenacetin,
acetanilide, etc. — may be of some benefit, and no harm will
come from giving them a trial.
It is not a good plan to use nasal irrigations during any
stage of acute inflammation. It is not desirable, also, to in-
flate the nasal cavity after the method of Politzer. These
procedures may spread infection in various directions.
It is desirable to reduce the nasal congestion as much as
possible, with the idea of relieving obstruction at the ostium
frontale, which is probably oedematous, and not sufficiently
open to allow the frontal sinus exudate to escape.
It is a good thing to apply cocaine to the vicinity of the
infundibulum and turbinate fossa, either as a fine spray or
on a pledget of cotton carefully adjusted. This may relieve
the congestion sufficiently to allow the exudate to escape,
and it will relieve the pain for a time. An oily spray with
menthol is cooling to the patient, and tends to relieve con-
gestion.
External applications of cold to the frontal area may be
followed by good results.
It has been suggested that forcible inspirations, with
the anterior nares closed, will produce a negative pressure
in the nasal fossa, with the idea of thus aspirating the exu-
date from the sinus. This can never overcome marked ste-
nosis of the ostium frontale, but may be of some value in
certain instances.
Any treatment that will improve the condition of the
general nasal cavity, when acutely inflamed, will probably
help resolution in the frontal sinus.
Chronic Cases. — The treatment of any given case of
chronic suppuration of the frontal sinus will depend upon
the nature and complex of symptoms presented.
SUPPURATION IN THE FRONTAL SINUS.
91
In general, treatment may be classified as follows:
{A) Intranasal treatment.
(i) By means of the natural canal between the sinus and
the nasal cavity, using the probe and irrigation canula.
(2) By perforating the floor of the sinus.
{E) External operations,
(i) On the anterior sinus wall.
(2) On the inferior sinus wall.
(3) Complete removal of both of these walls.
(C) Both of these methods may be combined by enter-
ing the sinus externally and making a large opening into the
nasal fossa.
{A) Intranasal Methods of Treatment. — (i) Probing the
Frontal Sinus; Use of the Irrigation Canula. — These methods
are of value in diagnosis as well as in treatment, and, first of
all, it will be advisable to consider the evidence as to the
possibility of probing the frontal sinus.
Jurasz was one of the first to attempt this mode of treat-
ment, and in 1887 he published a series of twenty-one cases,
including both normal and pathological sinuses. He claims
to have succeeded as follows: Five times the probe entered
the sinus easily. Six times the probe entered with difficulty.
Ten times the probe failed to enter.
Schutter attempted to treat these cases by means of irri-
gation, and reports two successes.
Hartmann, Gruenwald, and Jansen make use of the
probe and canula for diagnosis, but they consider this
method of questionable value in treatment.
As to the possibility of probing the sinus, opinions are
at great variance, ^^'e have, on the one jiand, the results
of clinical evidence, and, on the other hand, the results of
study and experiments on the cadaver.
Various results obtained by different observers are as
follows:
Hansberg says that on the cadaver he was able to probe
half of the cases. He uses a probe one-half millimetre to one
millimetre thick, bent at an angle of 125 degrees thirty milli-
92
HOWARD A. LOTHROP.
metres from the end. He measures off five centimetres on
this probe to correspond to the distance from the floor of
the sinus to the lower part of the anterior nares.
Zuckerkandl observed that it was very difficult to pass
a probe from the nose to the sinus on the cadaver, and this
conclusion is the result of an enormous experience.
Rethi gives a report of twenty-six cases, stating that he
could probe six of them.
Katzenstein says there are many hinderances to passing
the probe.
Winckler says he could probe one-sixth of the male and
one-quarter of the female cases.
Ziem says that probing and syringing the frontal sinus
yield doubtful results.
Cholewa says that he can probe 60 per cent, of the cases
with the Hansberg probe.
Hartmann thinks 50 per cent, of all cases can be probed,
and adds that nasal irrigation will cure most of the cases if
the ostium frontale is free.
Herzfeld is emphatic in declaring that we cannot often
pass a probe to the sinus without injury to the anterior eth-
moidal cells.
Alezais speaks of various obstructions which prevent
passing a probe to the sinus.
Kuhnt and Schech say they have never succeeded in
passing the probe to the sinus and been sure as to the exact
location of the end of the instrument.
Engelmann says that he could probe half of the cases.
Killian was successful in only a small percentage of the
cases.
Lichtwitz experimented with thirteen sinuses (cadaver),
and failed to enter in only three instances. He uses a probe
one and a half to two and a half millimetres thick, bent at
a right angle ten centimetres from the end. He states that
the probe should enter the nose for a distance of seven to
eight centimetres in order to be certain that the sinus has
been entered. He admits that occasionally we cannot avoid
SUrrCKATIOX IN THE FRONTAL SINUS. 93
entering some of the ostia belonging to anterior ethmoidal
cells.
Of seven cases treated by irrigation, all were relieved
of the subjective symptoms, but only one absolute cure as
regards the nasal discharge. Only after the failure of nasal
treatment would he resort to the external operations.
It w'ill be observed, therefore, that results and opinions
differ widely concerning the possibility and practicability of
treatment of frontal empyema through the natural opening
of the sinus. Some authorities believe that the sinus can
never be probed with certainty, others declare that at least
60 per cent, of the cases are amenable to this mode of treat-
ment. The probes devised and lauded by one operator are
condemned by another; the solutions successful in one case
fail in the next.
Anatomical Evidence. — The ability or inability to pass a
probe into the frontal sinus will depend upon anatomical
formations in the first instance, and, secondly, the result will
vary with the presence or absence of pathological changes.
Two hundred and fifty sinuses and their approaches
have been examined with reference to the conditions which
favor or prevent the passage of the probe to the frontal
sinus. In the first place it is absolutely necessary that the
operator should be very familiar with the regional anatomy
in order to get the best results.
Examinations have been carried out on the following
plan:
(a) Probes of different lengths and angles were passed
through the anterior nares towards the sinus, and their posi-
tion noted later.
{b) Portions of the middle turbinate bone were removed
later, if found to act as an obstruction.
{c) The relations and variations of the uncinate process
and ethmoid bulla were noted wherever they interfered with
the passage of the instrument.
{d) The various ostia into which the probe was liable
to pass were noted.
94
HOWARD A. LOTHROP.
ie) The size, location, and plane of the ostium was
noted, together with variations in the size and shape of the
surrounding ethmoidal cells.
{f) The thickness of the various portions of the floor
of the sinus.
(o-) The various methods of approach to the ostium
frontale.
ill) The necessary measurements for the two arms of
the probe.
In Part I the regional anatomy has been given with
sufficient detail, and only general results will be briefly con-
sidered here.
It was found that the passage of the probe through the
nares with the turbinate bone undisturbed was attended with
many difficulties, and one could never be certain that the
distal end was in the sinus. Although it seemed to be buried
to a great depth, the end was frequently found only in a very
prominent frontal bulla or a long cell running exteriorly
along the posterior border of the sinus, or in only a single
compartment of a nearly divided sinus. These points can
never be determined on the living subject by nasal examina-
tion.
It was found that removal of the operculum of the
middle turbinate made exploration easier, but the greatest
gain was made when an incision with the scissors (Plates
29, 30) enabled one to remove more of the anterior turbinate
with the snare. Still more space was gained by removing a
little more of the upper wall of the turbinate, as shown in
most of the sagittal sections. As shown in Plate 30, the
posterior portion of the turbinate need not be disturbed, so
that it is really unnecessary to remove much of the turbinate
bone as a whole.
This procedure is of almost absolute necessity in treat-
ing these cases, in order to give the pus a free outlet of es-
cape. The region of the infundibulum and turbinate fossa
is frequently obstructed with polypi and hypertrophies, which
may be the sole cause of the persistence of the suppuration.
SUPPURATION IX THE PROXTAL SINUS. 95
This upper portion of the turbinate is removed most easily
by means of punch forceps.
The ethmoid bulla is only exceptionally an obstacle
after the turbinate has been properly excised. It is pos-
terior and inferior to the field of operation. It may be a
hinderance to the flow of pus, however, if it is sufficiently
developed to close the hiatus semilunaris.
The uncinate process is an important landmark in prob-
ing the sinus. Where the ostium frontale opens into the
nasal duct, which, in turn, must pass to the infundibulum,
the end of the probe must pass over the upper border of the
uncinate process to reach the infundibulum. Hence it is
easy to see that the shape and position of the process are of
great importance. It may prevent our entering the infun-
dibulum.
Having entered the infundibulum, we must pass through
a naso-frontal canal of varying length, according to the
width of the septum referred to (Part II), as passing between
the uncinate process and the infundibulum. This canal may
be straight, curved regularly in any direction, or it may be
very crooked, in consequence of anterior ethmoidal cells
crowding the canal in one or the other direction.
Hence the canal may offer no obstruction, or may pre-
vent the passage of the probe to the sinus, provided no injury
is done. In probing the sinus it is advisable to bend the
probe in different directions, until finally it may be possible
to enter the sinus.
Thus far we have considered the conditions where the
ostium opens into the infundibulum via a naso-frontal canal,
and the probe must pass through the hiatus semilunaris.
This group will include a little less than half of the cases, and
are by far the most difficult to treat.
About 53 per cent, of all cases have no naso-frontal duct.
and then the ostium frontale opens into the turbinate fossa
(Part I) by means of little or no canal. These cases are
much easier to probe, for the point of the probe passes up
under the middle turbinate bone, far forward, as high as it is
96 HOWARD A. LOTHROP.
possible to go, and the ostium is somewhere along the apex
of the fossa. (See plates with probes, etc.)
During life it is usually impossible to differentiate these
very different types of approach to the sinus, on account of
the small size of the region under consideration and its in-
accessibility. If the clinician succeeds in passing a probe
into the sinus, it is probably a case of the second type, and
the probe has not entered the infundibulum. The removal
of the upper extreme portion of the turbinate is particularly
efficacious in allowing these cases to drain. On the cadaver,
more than half of these cases could be probed, but very fre-
quently the angle and length of the probe had to be altered
for different sinuses. Where a naso-frontal canal existed
probing rarely succeeded.
A common barrier to the progress of the probe was the
existence of ostia of ethmoid cells, which may be numerous
in the vicinity of the ostium frontale. If such a cell is en-
tered, further progress in that direction means injury. A
frontal bulla may be entered in a similar way.
During life it is impossible to decide zvhcre the point of the
probe may lie, and on the cadaver the uncertainty is nearly as
great. The slight variations in distance, in any given case,
from the anterior nares to the upper anterior ethmoidal cells,
on the one hand, and the frontal sinus, on the other hand,
are at least equally balanced by the individual variations.
Hence no absolute measurements can be of much value, and
will serve only as a general guide.
The probes devised by Hansberg and Lichtwitz are
equally valuable.
Obstructions or hinderances to the passage of the probe
may be summarized as (i) variations in the middle turbinate
bone; (2) variations in the uncinate process; (3) large eth-
moid bulla; (4) small or crooked naso-frontal canal; (5) pro-
truding ethmoid cells; (6) ostia of ethmoid cells; (7) patho-
logical hypertrophies.
If a probe can be passed, then we should attempt to
irrigate the sinus with some very mild solution, such as a
SUPPURATION IN THE TRONTAL SINUS. 97
normal salt solution or a 2-per-cent. boric acid solution.
Strong astringents are harmful.
The question as to when nasal treatment is to be
adopted, and the length of time it should be continued, is
an important one. Some authorities declare that extensive
suppurations in the frontal sinus never get well under this
mode of treatment. If such be the case, then delayed ex-
ternal operation is a loss of time, and it should be resorted
to early. But there is ample evidence to show that nasal
treatment may give satisfactory results. If a complete cure
does not follow, the subjective symptoms are often relieved,
and the preliminary operations in the nose add to the success
of the external operation.
The only complaint may be on account of the annoying
discharge from the nose, and on this account it is better not
to subject the patient at once to the risk and disfigurement
of an external operation.
Every attempt to pass the canula will not be crowned
with the same degree of success, and the element of chance
is considerable. Accurate notes of the route, hinderances,
and all peculiarities of each case should be kept, as well as
the angle and curve of the probe. If the symptoms are not
very troublesome, weeks or months may be given up to this
treatment. If the symptoms indicate that the probe does
not enter the sinus, after all possible obstructions have been
removed, then it is a waste of time to delay the external
operation.
(2) Perforation of the Floor of the Sinus. — This proce-
dure was done first by Dieffenbach and later by Tillaux. In
recent times it has been revived by Schaefifer and championed
more or less by Winckler, but condemned strongly by most
authorities.
As suggested by SchaefTer, the instrument is to per-
forate the floor of the sinus median to the middle turbinate
bone.
Schaeffer publishes a series of twenty-five cases, of which
7
98 HOWARD A. LOTHROP.
he says that eighteen were cured. Winckler reports fifteen
cases, with six cures.
On the cadaver, Winckler experimented with sixty-six
sinuses, and was successful in entering thirty-five sinuses.
He failed in twenty-two instances, on account of the thick-
ness of the bone on the floor of the sinus, which averaged
from two to five millimetres near the median line. In sixteen
cases the floor was thick near the median line, but thin ex-
ternally. With one exception the instrument entered the
sinus anterior to the ostium frontale.
Engelmann experimented with ninety-seven sinuses and
could puncture only seven times, according to Schaefifer.
Lichtwitz, in similar experiments, succeeded in three
out of twelve sinuses. In eleven cases of empyema he con-
cluded that he entered the sinus three times, judging from
the length of the probe. Great resistance caused him to de-
sist in seven instances, and an alarming case of collapse led
him to abandon the procedure.
Mermod reports a fatal case of meningitis where the
instrument perforated the lamina cribrosa.
An examination of a large number of sinuses shows that
it is possible to perforate the floor in the great majority of
instances according to Schaeffer's method, when the parts
are exposed on sagittal section, but in the natural state this
is a most difficult, uncertain, and dangerous procedure.
In the first place, it is extremely unsurgical, for we are
working in the dark and performing a dangerous operation.
We are very liable to meet an impassable bony wall, or to
perforate the lamina cribrosa. We are internal to most of
the anterior ethmoidal cells which may be the seat of the
greater part of the trouble. An ordinary perforation would
not give satisfactory drainage, and the sinus itself is never
open to direct treatment by this dangerous method.
From an anatomical point of view, it is much more
rational to perforate the floor of the sinus just external to
the middle turbinate going through the anterior ethmoid
cells. There is more available space and the locality is a
scrruRATiox ix the frontal sixus. .^9
little less dangerous. On account of the probable associa-
tion of suppuration in the anterior ethmoidal cells with
frontal sinus suppuration, it may be a good thing to per-
forate these cells. There is danger of entering the orbital
fossa. Killian, Jurasc, and Hartmann rather favor this pro-
cedure.
Although less dangerous than the puncture internal to
the middle turbinate, both of these methods are too dan-
gerous, as Avell as offering but little hope of relieving the
condition, to be of any permanent value.
They are not in conformity with surgical methods, and
possess but little therapeutic value.
If the removal of nasal obstructions and attempts to re-
lieve the conditions by irrigation via the natural opening
fail, then we should consider the advisability of the external
operations.
A feiv considerations in regard to tlie treatment of suppu-
ration in the anterior ethmoidal cells.
Before discussing the various external operations for
the treatment of frontal empyema, it will be necessary to
consider very briefly the treatment of suppuration in the
anterior ethmoidal cells. The reason for this is obvious
when we consider the frequent associations of these pro-
cesses.
Bearing in mind the anatomical relations, we recall that
there are several groups of anterior ethmoidal cells, all of
which are either under cover of the middle turbinate bone
or are above and external to it. Hence, in order to accom-
plish much by way of nasal treatment, it will be necessary
to remove a portion of its anterior extremity. After this
preliminary step, we may possibly be able to see the bulla
ethmoidalis, which represents the lowest of these cells and
usually the largest. It is the most distant from the floor of
the frontal sinus and probably less frequently affected than
the other cells. Its protruding eminence can be removed by
means of punch-forceps, the burr-drill, or the curette without
much danger. With great care, it may be possible to reach
lOO HOWARD A. LOTHROP.
the cells just above the bulla. On account of hjemorrhage,
it is usually necessary to employ several sittings in order to
accomplish this object.
Most of the anterior ethmoidal cells are located in the
upper portion of the ethmoid bone, filling in the floor of the
frontal sinus and extending backward from its angle to reach
other cells, called posterior ethmoidal, on account of the loca-
tion of their ostia, and then they extend downward to meet
the cell or cells which form the bulla ethmoidahs. These
cells are comparatively small and numerous, and when once
involved, suppuration is probably general throughout them
all. They lie just internal to the inner wall of the orbital
fossa, may extend up between the laminae of the orbital por-
tion of the frontal bone, and consequently are just inferior to
the lamina cribrosa.
These cells are practically inaccessible to nasal treat-
ment, on account of their location and the consequences
which may follow operation, and, in connection with the
frontal sinus, they are the cells most frequently involved.
The parts are concealed by the first haemorrhage, so that
further operation would be unwise, hence many sittings are
requisite. Distances cannot be judged carefully on account
of monocular vision and the inaccessibility of the cells, so
that the natural consequence is a perforation into the cranial
or orbital fossa, even without the knowledge of the operator
at the time.
Just behind and above the bulla ethmoidalis are certain
large posterior ethmoidal cells, which can usually be treated
with safety intranasally, but externally and above we run the
same risk as in operating upon the anterior cells. However,
the posterior cells do not concern us particularly.
Hence, intranasally, only a very small portion of the
anterior ethmoidal cells are accessible to treatment within
the bounds of safety, whereas the cells commonly associated
with frontal sinus empyema are beyond the reach of intra-
nasal surgery. Attempts to curette them by this route are
too dangerous and are in every sense '' unsurgical." All
SUPPURATIOX JX ri/E FROXTAL SIXUS. loi
that can be clone safely is to remove the anterior extremity of
the middle turbinate as high as possible, and curette the cells
in or al)Out the immediate vicinity of the bulla ethmoidalis.
The safest and most radical mode of treating the ante-
rior ethmoid cells will be considered later.
Suppuration in Middle Turbinate Cells. — If such a condi-
tion is suspected, resection of the requisite inferior portion
of the turbinate bone is all that is required. The lower por-
tion of the cell is thus removed, and it can no longer retain
pus. If necessary, its cavity can be curetted.
(B) External Oper.\tions on the Frontal Sinus.
Before resorting to external measures it must be care-
fully decided for each individual case whether such a step is
necessary. Certain acute obstructive cases demand an ex-
ternal operation at once, in order to avoid possibly a fatal
complication, but most cases are not urgent, and the ad-
vantages to be gained by nasal treatment more than out-
weigh the disadvantage occasionally consequent on delay.
Most patients will refuse the external operation, if pro-
posed at once, particularly the extreme radical operation
aimed at obliterating the sinuses. ]Most external operations
result in considerable deformity, which is a considerable ob-
jection to the radical operation, wherever the empyema
symptoms are not very annoying. All things considered,
it is best to attempt to relieve the symptoms by intranasal
treatment as described above, and if this fails, we can resort
to more radical measures.
On the other hand, aside from certain acute complica-
tions, there are cases where it can be decided at once that
it will be useless to expect to derive much benefit from in-
tranasal treatment, cases where we can be certain at the out-
set that only radical measures will be of benefit. In general,
cases complicated with external objective signs rarely re-
cover without external interference. This is due not only
to sinus complications beyond the reach of intranasal sur-
gery, but also to the associated empyema of the anterior
I02 HOWARD A. LOTHROP.
ethmoidal cells, which can be safely and thoroughly curetted
from in front, either through the orbital fossa or with better
satisfaction, all things considered, through the floor or in-
ferior wall of the sinus.
Under this group should be included all cases compli-
cated by fistulse, and most of the cases of mucocele, also
most of the cases complicated by abscess-formation about
the frontal sinus.
The indications for some external operation may be
tabulated as follows:
(i) Where the intranasal treatment has failed to accom-
plish the desired end.
(2) To remove the element of danger, particularly in
acute cases.
(3) To avoid drainage into the cerebral fossa in sus-
pected perforation of the posterior wall of the sinus.
(4) To remove the mechanical symptoms consequent
on the presence of a tumor from any cause.
(5) For profuse, persistent, often fetid, nasal discharge.
(6) To relieve pain in certain cases.
(7) Whenever there is an external fistula, which fails to
close, after a reasonable length of time.
Having determined upon some external operation, there
are numerous questions to be decided. We may enter the
sinus from the anterior or inferior wall, or combine both of
these routes. We have then to decide whether we will de-
pend solely upon external drainage without disturbing the
floor of the sinus, or whether we shall make an opening down
into the nose and then close the wound of entrance, or,
finally, whether both external and internal drainage shall be
combined. Some surgeons are still more radical, and be-
lieve that the sinus must be obliterated. The question of
the extent of curetting, also, is open to argument.
Let us examine these various procedures as carried out
by operators who have had the most experience.
The earliest external operations were performed on
SUPPURATION IX THE FRONTAL SINUS. 103
cases complicated by fistula, but these were not commonly
followed by cure.
In 1838, Riberi enlarged the communication of the sinus
with the nasal cavity.
Pean was early to advise thorough curetting of the
mucous membrane.
The modern operations date from 1884, with the method
advised and practised by Ogston. He made a vertical median
incision, four centimetres long, starting from the root of the
nose and passing upward. The skin and periosteum were
reflected laterally and the frontal bone trephined in the me-
dian line, thus opening both sinuses simultaneously. A
trocar was then passed into the nasal cavity in the vicinity
of the ostium frontale and the opening enlarged. The mu-
cous membrane was then curetted, sw^abbed with a zinc
chloride solution, and a drainage-tube, the size of a '' crow's
quill," inserted, and the external wound closed. He reports
two successful cases.
With this operation, serving as a general type, we have
numerous modifications, but, nevertheless, many radical
differences.
Schmidt makes an incision along the eyebrow from the
angle of the orbit and reflects flaps up and down. He makes
a small hole into the sinus with a chisel, examines with the
probe, and then acts according to circumstances. He passes
a trocar into the nasal fossa, uses the curette on all the sinus
walls, and leaves a gauze tampon in the sinus.
Schech would make this same incision with the same
general treatment, and he takes occasion to add that intra-
nasal treatment offers but little encouragement.
Gruenwold follows this same incision, particularly for
anterior ethmoidal suppuration, but for frontal sinus cases
he makes a nearly vertical incision parallel with the corruga-
tor supercilii muscle, starting below about midway between
the median line and the supraorbital notch. He separates
the skin and periosteum, chisels a small hole into the sinus,
and injects sterile water in order to make sure that he has
I04
HOWARD A. LOTHROr.
entered the right sinus. The sinus should then be explored
with the probe, the opening enlarged, the mucous membrane
curetted, the nasal opening curetted, if necessary, and the
sinus packed with gauze. He does not believe in closing
the external wound. He reports that he gets very little scar.
Silcock and Dundas Grant advise the external opera-
tions, but do not curette the opening into the nasal fossa.
They advise passing a small wire through the naso-frontal
canal and over it a small rubber tube, if possible, to act as a
drain.
We come now to the more radical operations. Neb-
inger advises removal of the whole anterior wall of the
sinus. He incises from the naso-frontal suture of the
affected side along the supraorbital arch beyond the supra-
orbital notch, exposes the bone at once, and reflects the
periosteum above, chisels a small hole, examines the extent
of the sinus with the probe, and acts accordingly.
If conditions call for the radical operation, he erects a
vertical incision four to six centimetres long, just to one side
of the median line, raises this triangular flap so as to expose
the entire anterior wall of the sinus, which he removes as
extensively as possible. He probes the ostium frontale and
curettes the vertical portion of the sinus last, on account of
hsemorrhage. He endeavors not to injure the interfrontal
septum, but if it is perforated, he removes it in toto.
He curettes the opposite sinus from this same opening,
if accessible, otherwise he extends the horizontal incision
across to the opposite side. He approximates the vertical
incision but drains at the inner end of the horizontal inci-
sion.
The essentials of this operation are (i) complete re-
moval of anterior wall; (2) complete curetting of entire
mucous membrane followed by immediate tampons; (3)
enlarging the nasal opening, but depending mainly on ex-
ternal drainage.
Krecke and Fehleisen depend mainly upon external
drainage.
SUPPURATION IN THE FRONTAL SINUS. 105
Jansen's operation consists essentially in removing the
inferior surface of the sinus and making a large opening into
the nasal fossa. His idea is to obliterate the sinus by allow-
ing the orbital fat to fill its cavity. He makes an incision
along the supraorbital arch, and separates the orbital peri-
osteum well back into the orbit. He then proceeds to re-
move the orbital and nasal portion of the floor, and, in cases
where the sinus is large, he removes a strip of the lower
border of the anterior surface from one-fourth to one-half
centimetre wide. He curettes a large hole into the nasal
fossa, thereby removing the anterior ethmoid cells in the
vicinity of the floor of the sinus. He maintains that he can
thus inspect the antrum and sphenoid sinus as well as the
anterior and posterior ethmoidal cells.
The operation is liable to give rise to considerable dis-
turbance in the orbital fossa, and frequently requires several
months for healing. Where the sinus is small, good results
are obtained, but if it be large, the progress is slow and the
deformity may be considerable.
Kuhnt is even still more radical in that he removes both
the anterior and inferior walls. For simple cases, deter-
mined by exploration with the probe, he removes the orbital
portion of the floor near the internal angle, but if the sinus
is large, he erects a vertical incision at the inner end of his
horizontal one, turns up a flap of skin, and then removes,
completely, the anterior and the inferior surfaces of the sinus.
Then he bevels the sharp edges of the sinus walls, to make
the cavity as flat as possible, curettes the remaining surface,
and strives to obliterate the sinus by causing the flap of skin
to become adherent to the posterior wall. He does not
curette the anterior ethmoidal cells unless they are involved,
but depends upon external drainage.
In these cases the resulting depression must be very
marked. If the sinus is very large, it is impossible to make
-the skin-flap reach the entire posterior surface.
Killian makes the usual horizontal incision just above
the supraorbital arch, which he continues in the middle line
io6 HOWARD A. LOTHROP.
down on to the nasal bones. He makes an exploratory
opening into the sinus, passes a probe into the ostium fron-
tale, which he leaves in position, then, by means of a chisel,
he separates the nasal bone from the median line, and turns
this bone-flap outward. He then removes all the structures
between the probe and the external opening. The lower
part of the incision is to be closed at once and a drainage-
tube inserted into the nose.
The external wound is not to be allowed to close until
the walls of the wound are practically healed and not liable
to occlude the lumen between the nasal fossa and frontal
sinus.
Luc reports a series of cases subjected to the external
operation. His early cases did not do well, on account of
failure to enlarge the opening into the nose. Later he com-
bined this large opening with external drainage, but now he
thinks it wise to close the external wound, and depends upon
the nasal drainage alone. He thinks the chances are better
if the sinus can be obliterated, but the disfiguration conse-
quent therefrom is a matter to be considered in every case.
Luc enters the sinus through a large opening in the anterior
wall.
Czerny reports a case where he attempted to turn a
bone-flap, but the consequent suppuration interfered with
the success of the operation. A curved incision was made
over the glabella, convex below and with the base of the
flap towards the median line. There was a large opening
made into the nasal fossa and the external wound closed.
The case did badly on account of suppuration, the wound
had to be reopened and the other sinus treated. This com-
plication defeated the object of the operation.
Gussenbauer reports two cases of extensive malignant
disease in the orbits and accessory sinuses, which he ap-
proached by a very extensive plastic bone operation which
exposed these parts, including the frontal sinuses.
Consideration of External Operations. — As will be seen
from the foregoing pages, there is considerable choice as to
SUPPURATION IN THE FRONTAL SINUS. 107
the best method to pursue, but at the outset it must be said
that each case will usually present features that call for
special consideration. Hence there are no definite rules to
be followed.
Our problem is to relieve suppuration existing in a bony
cavity (with consequent rigid walls) lined with mucous mem-
brane, which has probably undergone permanent patho-
logical changes. The situation is rendered more complex
on account of the exposed location of the sinus, with the
objection to a large or hideous scar. The presence of a fis-
tula or a tumor gives us more reason for operating exter-
nally, and the consequent scar will be less objectionable.
On the other hand, most cases of frontal empyema have
no external objective signs, hence it should be our object
to leave as little deformity as possible.
Without going into detail, it would seem that the best
mode of getting rid of a frontal empyema would be to ob-
literate the cavity of the sinus. This can be done provided
the sinus is small, and, at the same time, the anterior eth-
moidal cells can be curetted. The resulting scar may be
very slight, but, where the sinus is large, the deformity fol-
lowing the removal of the anterior or the anterior and in-
ferior walls is too great to recommend tl^is radical procedure
in many cases. Besides, a cure cannot be warranted and the
deformity will always persist.
Although there exists a very radical difference of
opinion as to the advisability of making a large opening
into the nasal fossa from the frontal sinus, general principles
would seem to indicate that a large permanent opening was
the only logical alternative. It has certainly been followed
by the most favorable results.
A glance at the pathological changes consequent on
chronic inflammatory processes in the frontal mucous mem-
)rane will make it evident that this membrane should be
most thoroughly curetted.
y
lo8 HOWARD A. LOTHROP.
(C) External Methods of Operation.
(i) Obliteration of the Frontal Sinus. — Certain operators
strive for this result in every instance. If the sinus is small,
it can be readily obliterated, but frequently the condition of
the case will not be materially improved thereby, because a
small sinus cannot be the source of an excessive exudate into
the nasal fossa. Careful investigation will show that the
ethmoidal cells are involved.
A few unusual cases of suppuration in the frontal sinus
will be observed where there is no nasal discharge, but there
is a persistent external fistula (Cases VII and IX). This
condition means that the ostium frontale is occluded, and
that the ethmoidal cells are probably not involved. The size
of the sinus can be determined by means of the probe passed
through the fistulous opening, and upon the size will depend
the best method of procedure. If the sinus is small, for
example, not extending laterally as far as the supraorbital
notch, and measuring vertically not more than ten to fifteen
millimetres on the anterior surface, it may be an easy matter
to obliterate its cavity. In the great majority of cases the
fistula leads through the inferior wall of the sinus (Cases IX
and X) and will serve somewhat as a guide. A curved inci-
sion should be made, starting just above and external to
the inner canthus, extending upward and outward along the
supraorbital arch, just below the eyebrow, nearly to the
supraorbital notch. By means of a periosteum elevator the
inferior wall of the sinus should be exposed and all haemor-
rhage stopped in order to have a dry field of operation.
Then the sinus should be entered carefully through this in-
ferior surface (orbital portion of floor of sinus) by means of
chisel, burr-drill, and bone-forceps, as may be convenient,
and then this whole surface of bone removed. The interior
of the sinus is to be thoroughly curetted without communi-
cating with the nasal cavity, which is already shut ofif by an
occluded ostium frontale. The best result will be obtained
by letting such a sinus gradually close by granulation.
SUPPURATION IN THE FRONTAL SINUS. 109
These small sinuses offer the best chance for relief by this
means.
Where the sinus is larger, the removal of the inferior
surface is less effectual, so that some surgeons remove the
anterior wall in addition. This has been followed by relief
in a few instances where the ethmoidal cells were not in-
volved, but the common subsequent history of these cases is
the presence of a permanent or a recurring fistula. In every
instance, a more or less depressed scar will follow, and this
is an objection of considerable importance. Hence, the com-
plete obliteration of a large sinus is a difficult matter, and
both the success and failure of such an attempt are followed
by objectionable deformity. Furthermore, the sinuses which
are small enough for us to attempt to obliterate with reason-
able hope of success and with only a slight scar are not the
source of a large portion of the exudate appearing in the
nasal cavity. Clinical and pathological evidence shows that
the anterior ethmoidal cells are also involved in the majority
of these obstinate cases, where treatment of the frontal sinus
alone fails to relieve the condition. Operative measures,
therefore, simply for the obliteration of the sinus, without
involving the nasal portion of the floor of the sinus or enter-
ing the nasal cavity, are of value only in a limited number
of cases. In many instances, however, where the nasal por-
tion of the floor of the sinus and the anterior ethmoid cells
are curetted away through an opening in the orbital portion
of the floor of the sinus, it is possible and probably desirable
to let the soft tissues of the orbit crowd into the sinus and
thus fill up and destroy the cavity. Free nasal drainage,
nevertheless, is the secret of success in these cases.
(2) Complete Removal of the Nasal Portion of the Floor
of the Sinus. — In considering the question of treatment of
chronic suppuration in the frontal sinus, we must strive to
understand why such suppuration is so persistent. In the
first place we have to deal with a bony cavity, with conse-
quent rigid walls, hence this space must remain as a cavity,
imless subjected to the treatment just considered, which is
no HOWARD A. L07HR0P.
practicable in occasional cases. The outlet of this cavity is
situated at its lowest part, but is of comparatively small size.
The pathological changes which accompany chronic inflam-
mation are such as to diminish the size of the cavity by
filling it with hypertrophied and polypoid tissue. These
changes decrease the size of the lumen of exit. Thus the
retention of pus is favored and the changes in the mucous
membrane are such that the sinus cannot be properly irri-
gated. Furthermore, as so often mentioned in these pages,
the association of the frontal sinus and anterior ethmoidal
cells is such that in the majority of cases it is useless to treat
the sinus without destroying the complicated labyrinth of
ethmoid cells directly under the nasal portion of the floor
of the sinus. These bony cells give rise to and also retain
the products of exudation, and thus tend to prevent recovery.
They cannot be reached and treated with safety through the
nasal fossa, but must be destroyed by means of an external
operation.
The essential features in the treatment of these cases
consist in the removal of the whole of the nasal portion of
the floor of the frontal sinus, destroying the partitions in the
sinus, the complete destruction of the anterior ethmoidal
cells, and careful curetting of the whole region. Thus the
cavity of the sinus may become lined with smooth walls and
connected with the nasal fossa by the largest possible open-
ing, and, moreover, there will be no ethmoidal cells to col-
lect exudate or interfere later with irrigation of the frontal
sinus from the nose. The mode of entering the sinus from
without is a matter of cosmetic result and facility in per-
forming the above rather than an essential in accomplishing
the desired result.
Entering the Frontal Sinus through the Anterior Surface.
■ — The favorite route of entrance with most surgeons is
through the anterior surface, but if the resulting bony de-
fect is large, the amount of deformity is considerable, even
though the wound is closed at once. A small opening in the
bone may be made which will be sufficient in some cases and
SUPPURATION IN THE FRONTAL SINUS. m
give good cosmetic results, but, as a rule, a careful and thor-
ough operation cannot be done unless the cavity of the sinus
is well exposed.
In order to avoid the usual depression over the sinus
the following method of procedure is suggested as practised
on the cadaver and carried out in Case IV. As a preliminary
step the posterior nares should be tamponed, and thus there
will be no annoyance whatever from blood entering the
pharynx or larynx.
A curved incision, commencing over the upper portion
of the nasal bone near the naso-frontal suture (Plate 8i), is
carried upward parallel with the folds of the skin made by
the corrugator supercilii muscle for about fifteen millimetres,
gradually curving outward over the glabella, and following
the horizontal folds of the skin. The upper part of the in-
cision is just above the eyebrow, and is carried boldly down
to the bone without elevating the periosteum. By means
of a burr-drill, or small trephine, an opening three to five
millimetres in diameter is made through the anterior wall in
the line of incision just above the supraorbital arch at the
inner angle of the orbit. On the skull this point will be seen
to be on the anterior wall of the sinus, just below the inner
extremity of the superciliary ridge (Plates i, 8i). If any
sinus is present in the vertical portion of the frontal bone,
it will be situated at that point, otherwise the presence of
diploe will be an indication of its absence. If no sinus is
detected, the inference will be that the ethmoid cells are the
source of the exudate, which can be treated as described
below.
Having entered the sinus by this small opening, a careful
exploration should be made with the probe to determine its
extent in all directions, and, if possible, to decide as to the
changes in the mucous membrane. If the sinus is very
lall, the opening may be enlarged a little, the mucous mem-
brane curetted, and the nasal portion of the floor of the sinus
removed in the manner to be considered. Where the sinus
extends to the supraorbital notch or beyond, as is usually
112 HOWARD A. LOTHROP.
the case, more room must be had for inspection and opera-
tion. For this purpose the original incision is continued
horizontally in the folds of the skin and then carried down-
ward to the supraorbital notch (Plate 8i), so that the ex-
tremities of the incision are more or less concealed by the
corrugator folds and the eyebrow. jMeanwhile, the peri-
osteum must not be disturbed.
Starting from the small exploratory opening in the bone,
a bone-flap is to be chiselled corresponding to the line of
incision, with the supraorbital arch serving as a base (Plate
82). Towards the median line the bone is to be chiselled
as far as the naso-frontal suture, and then directly downward
and backw^ard towards the orbital plate of the frontal bone.
The external extremity passes down across the arch to meet
this same plate. Now it will be very easy to pry the bone-
flap forward so that it will fracture along the thin orbital sur-
face or floor of the sinus close to the arch. If done care-
fully, the entire piece of bone will be adherent to the peri-
osteum. An extensive view of the sinus is obtained at once,
whereby its whole cavity can be inspected and treated. After
completion of the operation on the floor of the sinus, the
bone-flap is to be replaced and the wound closed with in-
terrupted or buried sutures. So much in regard to entering
the sinus through the anterior wall. The great advantages
of this route are that the whole sinus may be open to perfect
inspection, and a large opening made into the nasal fossa
without disturbing the orbital fossa or its contents.
Entering the Frontal Sinus through the Inferior Surface.
— There are many cases where this route is infinitely prefer-
able. It does not allow such good exposure of the sinus,
but usually sufficient for all cases; it renders the ethmoidal
region very accessible; the operation is followed by little or
no deformity (Case V); it is more liable to give rise to in-
flammable disturbance in the orbital fossa, or interfere with
the lachrymal apparatus, if not carefully done. This route
is preferable in cases complicated by fistula or orbital tumor.
The preferable incision is that figured in Plate 81, No.
SUPPURATION IN THE FRONTAL SINUS. 113
2. It commences opposite the inner canthus, in front of the
margin of the orbit, over the nasal process of the superior
maxilla. It is carried upward, gently curving outward to
meet the eyebrow, and is then carried along the centre of
the eyebrow as far as the supraorbital notch. Previous to
making this incision, which is carried directly to the bone,
the lower half of this inner portion of the eyebrow should be
shaved, for the incision should be healed in a week, and thus
there will still be a portion of the eyebrow along its whole
length, so that the immediate appearance of the patient is
not much altered. In time, only a small portion of the in-
cision (about one centimetre) will remain uncovered by hair.
Haemorrhage may be expected from the supraorbital
and angular arteries, which can be troublesome. The peri-
osteum is to be elevated and the flap turned down so as to
expose the vicinity of the internal angular process of the
frontal bone (Plates i, 5, 9). The field of operation should
be made perfectly dry, and no further hjemorrhage need be
expected from the external wound. The pulley of the ex-
ternal oblique muscle is liable to be reflected with the peri-
osteum, but this does not seem to affect the position or
motion of the eyeball.
By means of a chisel a small opening is to be made
through the orbital portion of the floor of the sinus, just
above the internal angular process of the frontal bone, in
the line of the margin of the orbit, which separates the an-
terior from the inferior surface of the sinus. The bone here
is thinner than on the anterior surface and quite easily per-
forated. The opening into the sinus should be large enough
to admit the examining probe, which is made to perforate
the lining mucous membrane. If there is an empyema of
the sinus, pus will be seen coming out of the exploratory
opening, otherwise the natural inference is that the sinus
is not much affected and that the pus originates in the an-
terior ethmoid cells, provided the antrum, as a primary
source, has been eliminated. If only the ethmoid cells are
involved, we are in a very favorable position to treat them.
114 HOWARD A. LOTHROP.
The examining probe, now in the sinus, is passed in all
directions in order to ascertain its shape and size, so that
we may know where it will be safe to work. The explora-
tory opening should now be enlarged so as to be somewhat
oval in shape, with the long diameter vertical, and measuring
not over fifteen millimetres. This opening corresponds to a
portion of the inner wall of the orbital fossa, including, for
the most part, the orbital portion of the floor of the sinus
at the internal angular process of the frontal bone, a part
of the upper end of the lachrymal bone, and extending in
front as far forward as the posterior border of the nasal pro-
cess of the superior maxilla, and posteriorly as far as the os
planum of the ethmoid. The situation of this opening is
such that no deformity will result, as it is on a plane at right
angles to and posterior to the broad fibrous diaphragm, con-
taining the tarsal cartilages, which stretches across the
margin of the orbit. The lachrymal apparatus will not be
injured, for the upper portion of the lachrymal sac will be
reflected from the bone with the soft parts. This bony open-
ing will generally be sufficient to enable the operator to be
certain that the sinus has been cleared of all septa and hyper-
trophies.
So much for the preliminary portion of the operation,
which consists in entering the sinus either through the an-
terior or inferior walls, and we are now ready to perform the
most important step in the operation. This consists in the
removal of the entire nasal portion of the floor and thor-
ough curetting the anterior ethmoid cells, and thus estab-
lishing as large a communication with the nasal fossa as
possible.
If the sinus has been entered through the anterior wall,
it should be our aim during the operation to avoid entering
the orbit through the vicinity of the lachrymal bone or os
planum. A small probe should be passed through the ostium
frontale into the nose and left in position as a guide. A
study of the anatomical relations will show that it is not safe
to force instruments directly backward on account of the
SUPPURATION IX THE FRONTAL SINUS. 115
danger of entering the cranial cavity (Plates 9, 40, 51, 53).
The general curvature of the posterior surface is fairly con-
stant and regular (Plate 51), so that any sudden interruption
in this curvature is suggestive of the presence of a frontal
bulla or ethmoidal cells crowding into the posterior angle of
the sinus. It will be safe to break through these cells with
the instrument directed downward, inward, or somewhat
backward. The contour of the orbital wall of the sinus is
very regular as it passes down to become the internal wall
of the orbital fossa (Plates 20, 57, 65), and this regularity is
a sufificient guide against entering the orbital fossa. It is
our aim to remove as much of the nasal portion of the floor
of the sinus as possible in order to establish the best drain-
age. The lateral anatomical limits are the nasal septum in-
ternally, and the downward prolongation of the orbital por-
tion of the flloor of the sinus externally (Plates 13, 20).
Anteriorly we are limited by the thick bony ring around the
hiatus frontale, where the frontal bone articulates with the
nasal bone and nasal process of the superior maxilla (Plates
13, 15, 63). Posteriorly there is no immediate hinderance
after we reach the posterior angle of the sinus, for here we
come upon the anterior ethmoid cells, and continue back-
ward under the plane of the cribriform plate to the posterior
ethmoid cells (Plates 13, 16, 17, 51, jy, 88). Hence, from
the vicinity of the ostium frontale, in which the probe has
been placed as a guide, it will be safe to perforate the floor
of the sinus directing instruments downward, backward, or
inward. The best instruments are small curettes of different
sizes, both curved and straight, and also small chisels. It
was discovered on the cadaver that the fifth finger could be
introduced into the anterior nares almost without exception
beyond the second joint (which measures five centimetres in
circumference), so that the tip of the finger reached the body
of the sphenoid bone. Thus the nasal cavity could be ex-
plored and the movement of the curette directed to immense
advantage. This procedure was carried out in Case V with
Il6 HOWARD A. LOTHKOP.
perfect ease. The finger should be lubricated with sterilized
oil or vaseline.
In the early attempts to overcome the frontal or eth-
moidal suppuration the anterior extremity of the middle
turbinate has probably been removed (Plate 30), but if it
remains, it will be broken away by the curettes. All the
anterior ethmoidal cells should be curetted away as thor-
oughly as possible, and it will do no harm if some of the
posterior cells are injured. The finger itself may break up
some bony partitions as well as serving as a guide for the
curette passed in through the external opening. Practi-
cally this operation consists in removing the greater part of
the lateral mass of the ethmoid, which fills in the hiatus fron-
tale, with a comparatively small external opening and the
fifth finger in the anterior nares. Meanwhile no blood has
reached the pharynx on account of the tampon. All septa
in the frontal sinus should be broken down, and as a final
act the lining mucous membrane should be thoroughly
curetted. The opening into the nose is such that no drain-
age-tube will be required, and the external wound should be
closed without drainage and protected with a sterile dressing.
The nose should be packed with iodoform gauze for twenty-
four hours.
Where the sinus has been entered from the inferior wall
it is somewhat easier to reach the ethmoid cells, but in gen-
eral the same directions are to be followed, as when operating
through the anterior wall. The sinus is not so well exposed,
but all septa can be destroyed and the nasal portion of its
floor removed, so as to establish perfect drainage. The
posterior ethmoid cells, also, are very accessible by this route.
No nasal drainage-tube will be needed, and the external
wound is to be closed absolutely.
In every instance we must consider whether the antrum
is free or has become involved in the suppurative process
primarily, or is acting as a reservoir for pus coming from
above. In the early examinations it is well to determine as
accurately as possible the condition of the antrum, but con-
surruRATiox ix the j-koxtal sixes. 117
elusions can be verified just before the operation by the in-
troduction of a needle into the cavity through the inferior
meatus. If the anterior ethmoid cells are involved, it is
common to find pus in the antrum. If pus is found in the
antrum, it is well to be certain that there will be a sufficient
aperture for drainage. Operations on the cadaver show that
it is very easy for the curette to enter the antrum when de-
stroying the upper part of the uncinate process, so that, in-
tentionally, where we find pus in the antrum, it is well to
make a large opening through the middle meatus. The
antrum may call for special treatment (Lothrop, " Empyema
of the Antrum of Highmore," Boston Medical and Surgical
Journal, ]\Iay, 1897), which does not concern us at this time.
After-Trcatment. — The treatment of the external wound
offers nothing peculiar. There will be more or less oedema
of both eyelids, which will subside in a few days.
The gauze in the nasal fossa is to be removed in about
twenty-four hours. On account of the large opening into
the sinus, drainage will be perfectly free. The lower portion
of the nasal fossa can be irrigated two or three times a day,
but it is well not to force fluids up into the sinus for a few
days, until the external wound has become united. A warm
2-per-cent. boric acid solution is the most satisfactory. An
efficient apparatus for irrigation consists of a slender S-
shaped canula, bent so as to pass from the anterior nares,
attached to a rubber tube, which in turn is fastened to a
barrel syringe with a capacity of at least 100 cubic centi-
metres. The patient can readily be taught to use this ap-
paratus. At the time of operation all fragments are to be
removed from the nasal fossa as well as possible, but some
will remain, which can be trimmed later by means of the
snare and forceps.
For the reason that we are dealing with a region already
infected at the time of operation, it is not surprising if the
e^t^mal wound should fail to unite at once throughout its
whole extent, and a fistula result. If, however, free nasal
drainage has been established, such a fistula will not persist
for a long time.
Il8 HOWARD A. LOTHROP.
Report of Cases.
The following cases have been selected to serve as types
of acute and chronic inflammatory processes involving the
frontal sinus, complicated or not by extension in various
directions. They are presented only in moderate detail.
Case I. — Acute Inflammation in the Frontal Sinus followed by
Resolution. — J. T. E. had just passed through an attack of acute
coryza of average severity. Seven days later he began to have
pain in the right frontal area, which increased in severity so
as to be unendurable. It was relieved by no sort of internal
medication. The frontal area was very tender on palpation, and
there were no intranasal symptoms referable to the frontal sinus.
A tampon of cotton, saturated with a 4-per-cent. solution of
cocaine, was applied as high as possible under the middle tur-
binate bone, and removed after a few minutes.
During the day the patient sprayed the nose with an oily
solution of menthol. The pain continued for thirty-six hours,
and then rapidly decreased, followed by a considerable discharge
from the right nostril. This continued for a few days only. One
week after there was no further trouble, nor has there been any
recurrence.
This case is an example of the extension of an acute inflam-
matory process from the nasal cavity to the frontal sinus, with
practically a spontaneous resolution. Such cases are of common
occurrence.
Case II. — Acute Inflammation in. the Frontal Sinus of Marked
Severity becoming Chronic. — Miss A., seventy-five years of age,
while under treatment for a surgical affection, suffered from an
attack of influenza. Following immediately after the onset of
acute nasal inflammation, symptoms of acute inflammation ref-
erable to the left frontal sinus, arose.
These symptoms were very severe and lasted two weeks.
]\Ieanwhile there was much seropurulent discharge from the
left nostril, and oftentimes containing more or less blood. At
the end of three weeks all the subjective symptoms had disap-
peared, but the nasal discharge continued. Eight months later
the same objective symptoms persist; there is some tenderness
SUPPURATION IN THE FRONTAL SINUS. 119
over the frontal sinus, but she has no pain. Her age and physical
condition contraindicate operative interference.
Case III (Plate 83). — Mucocele of Left Frontal Sinus, be-
coming a Chronic Empyema of the Frontal Sinus and Anterior Eth-
moid Cells: Secondary Involvement of the Antrum. — I am indebted
to Dr. J. W. Farlow, of Boston, for the privilege of publishing
this case, under whose treatment the patient has been for the last
year.
R. M., twenty-five years of age, baker, has had a swelling in
the upper inner angle of the left orbital fossa for the last ten years.
He states that it first appeared while suffering from scarlet fever.
It has increased slowly without ever causing acute symptoms,
although it is occasionally a little tender. It was incised once
with a negative result. He is not subject to coryza, and has never
had any nasal discharge. At times the tumor is a little smaller
than usual, and then he has observed that its surface is rough and
irregular.
The tumor has always obstructed the tear-duct, so that tears
escape over the cheeks. The eye soon became dislocated, and
continues to remain so, but vision has not been affected in any
way.
Nearly a year ago the patient first appeared for treatment,
on account of a sudden increase in the size of the tumor, accom-
panied by pain and tenderness and oedema of the eyelids. The
size of the tumor at this time is shown in Plate 83.
Examination reveals a tumor about the size of a robin's
tgg, continuous on the periphery with the frontal bone above,
the lachrymal bone in front, but posteriorly its outline is lost in
the orbital fossa. Its surface is soft and fluctuating in places,
alternating with thin bony areas, which extend from a protruding
bony periphery. " Egg-shell crackle" could be detected here and
there.
Intranasal examination shows that the mucocele has pushed
the middle turbinate against the septum of the nose. The eye-
ball is dislocated downward, forward, and outward, so that it is
in close proximity to the malar bone, but neither subjective nor
objective symptoms have resulted therefrom. There are no par-
ticular constitutional symptoms.
After removing a portion of the middle turbinate bone under
cocaine anaesthesia, a polypoid mass appeared, which was found
I20 HOWARD A. LOTHKOP.
to consist of a thin sac containing about an ounce of thick viscid
fluid, which escaped from the anterior nares. This circumstance
was followed by a diminution in the size of the external tumor,
and relief from pressure symptoms.
From time to time various intranasal operations have been
performed in order to estabUsh free drainage from the frontal
sinus and ethmoid cells. After the removal of the original con-
tents of the mucocele the discharge became purulent, as is char-
acteristic in these cases, and has remained so ever since. The
external tumor has decreased very much, and is marked by an
irresrular bonv outline. The eveball still remains close to the
malar bone, and external palpation would suggest that the eth-
moid cells are involved in the suppurative process.
On account of undue prominence of the anterior wall of the
superior maxilla the antrum was aspirated through the inferior
meatus, and found to contain pus. A tooth was extracted and
the antrum irrigated through the alveolus. There would seem
to be a general association of the left accessory sinuses.
The external appearance of the patient has been greatly im-
proved, and the amount of discharge from the nose has decreased
very much. The patient is still under Dr. Farlow's treatment.
This case has just been reported in detail before the American
Laryngological Association.
Case IV. — Suppuration in all the Accessory Sijiuses of the
Left A^asal Fossa, zvitJi Caries of the Frontal and Superior Maxil-
lary Bones. — A. G., twenty-eight years old, has suffered for the
last eleven years from extensive caries in different facial bones
of syphilitic origin. She has undergone several operations at the
hands of dififerent surgeons with little or no improvement. Ex-
treme antisyphilitic treatment has been of no avail.
When first seen there was marked deformity as the result
of inflammatory oedema (Plate 84), and this swelling never de-
creased. There was profuse discharge of pus into the middle
meatus. At times the whole left side of the face was painful, with
tenderness localized particularly over the facial wall of the an-
trum and the inferior surface of the frontal sinus. She had ab-
scesses in the vicinity of both lachrymal sacs, which were incised,
and on the left side the tears no longer passed normally into the
nose, but escaped over the cheek, and had given rise to a very
troublesome chronic eczema.
SUPPURATION IN THE FRONTAL SINUS. 121
All the teeth of the upper jaw had been removed, and she
had undergone the canine and alveolar operations, but still the
antrum was full of pus, as demonstrated by the exploratory
needle. On account of the failure of these methods to overcome
the antrum suppuration, and the great chronicity of the case, the
naso-antral septum under the inferior turbinate bone was re-
moved, as previously referred to (Boston Medical and Surgical
Journal, May, 1897). Patient recovered well from the operation,
and at the end of about four weeks the antrum irrigations were
free from pus. Nevertheless, the facial deformity remained un-
changed, also the frontal tenderness, and there was a certain
amount of pus referable to the frontal sinus, the anterior ethmoid
cells, or both.
The frontal sinus was opened through the anterior wall and
a bone-flap turned down, as has been previously described in
detail. The nasal portion of the floor of the sinus was carefully
removed and the anterior ethmoid cells curetted. On account
of the post-nasal tampon there was no annoyance from haemor-
rhage. A rubber drainage-tube was inserted leading from the
sinus to the anterior nares, and held in position by two fine wire
sutures, which also served to retain the replaced bone-flap. Such
drainage is no longer considered necessary, for later experience
has demonstrated that the enlarged opening into the sinus is
ample. On account of the extensive persistent swelling over the
malar and superior maxillary regions, an exploratory incision
was made below the malar bone, in order to discover necrosed
bone, but none was found.
The frontal wound was closed without external drainage and
united permanently, except where the wire suture, connected
with the drainage-tube, appeared. This fistula healed at the
end of about four weeks, and the wound remained permanently
closed. There was no depression of the anterior wall of the sinus.
The nasal discharge became gradually less, but the general
swelling of the face, present before the operation, remained con-
stant.
Two months after the operation the patient had a rise of
temperature with severe headache and other symptoms, which
evidently due to an acute meningitis. This complication
proved fatal.
An incomplete pcst-mortem examination was allowed, when
122 HOWARD A. LOTHROP.
it was ascertained that there was a perforation in the posterior
wall of the frontal sinus near the external angle. The perforation
itself would just admit a small probe, but it was surrounded by an
area of carious bone. There was found an acute meningitis, most
marked in the left frontal region, and there were several small
pus-collections in the cortex of the frontal lobe.
There was a small amount of muco-pus in the frontal sinus,
but its walls were smooth, and the enlarged opening into the
cavity admitted the little finger. There was firm union in the
vicinity of the bone-flap. Death was obviously the result of a
meningitis, due to a perforation in the posterior wall of the sinus,
which in turn was consequent on a carious process in the bone.
In view of the past history this was a syphilitic process. Cul-
tures revealed a mixed infection with a predominance of strepto-
cocci. On account of the lapse of time since the operation (two
months), and the location of the carious bone, it is fair to assume
that the perforation was not of traumatic origin. It was clearly
demonstrated that such a plastic bone operation was practicable.
Case V. — Combined Empyema of the Frontal Sinus and Eth-
moid Cells, with Ptis draining into the Antrum: Complete Recovery
folloiving the Operation. — N. R., twenty-six years of age, has been
troubled with a suppurative process in the accessory sinuses of
the left nasal cavity for the last ten years. The nasal discharge
has been profuse most of that time, meanwhile she has suffered
from constant headache in the frontal region, which was fre-
quently severe enough to cause her to remain in bed. She states
that she was never free from suffering. The pain was referable
to the whole left side of the face, particularly in the left frontal
area.
Eighteen months ago there appeared a swelling a! the upper
inner angle of the left orbital fossa accompanied by pain and ten-
derness, together with swelling of the eyelids and soft parts in
the vicinity. These external signs disappeared spontaneously at
the end of three weeks, but the pain and discharge remained as
before.
About sixteen months ago she was referred, by Dr. J. A.
Gordon, of Quincy, to Dr. F. C. Cobb, of Boston. Nasal exami-
nation showed the presence of polypi in the left cavity, in addi-
tion to a profuse discharge of pus. These polypi were removed
by Dr. Cobb, and some time later the anterior extremity of the
SUPPURATIOX IN rilE FRONTAL SINUS.
123
middle turbinate. For a time there was a decrease in the amount
of pain and discharge, but eventually the general condition re-
mained about the same. It was also discovered that the left
antrum contained pus, as demonstrated by transillumination and
confirmed by the aspirating needle.
Two months ago the patient was kindly referred to me for
radical treatment by Dr. Cobb. The frontal and orbital pain had
become more severe of late and the discharge was profuse, but
without particular odor. There was marked tenderness at the
inferior wall of the frontal sinus, but no swelling. Nasal exami-
nation showed nothing beyond the presence of pus escaping
above the inferior turbinate, and the absence of the anterior end
of the middle turbinate. After ten years of suffering the patient
was very willing and anxious to have anything done for her
relief, and consented to an external operation.
Operation (ether). — As a preliminary step the antrum was
aspirated through the inferior meatus and found to contain pus.
The posterior nares were plugged with a gauze tampon. The
lower half of the inner portion of the eyebrow was shaved, and
the vicinity prepared for operation. The incision already de-
scribed for exposing the floor of the sinus (Plate 81, No. 2) was
made down to the bone, and the flap reflected so as to include the
periosteum. Hence, two-thirds of the incision was in the eye-
brow, while the inner extremity arched downward towards the
inner canthus. The exposed bone included the floor of the sinus
near the internal angular process of the frontal bone, the upper
portion of the os planum and nasal process of the superior
maxilla. Haemorrhage from the supraorbital and angular arteries
was controlled by gauze pressure. After the wound was dry
a small opening was chiselled into the floor of the sinus, and on
passing through the lining mucous membrane considerable pus
escaped. The probe showed the sinus to be of average size. This
opening was then enlarged to about ten millimetres in diameter.
According to the method described in detail in the previous
pages, the nasal portion of the floor of the sinus and the eth-
moid cells were carefully curetted. The little finger, introduced
through the anterior nares, was of immense value in guiding the
curette passed through the external wound, and also served to
destroy some of the ethmoid cells. The operation was practically
a curettement of the anterior portion of the lateral mass of the
124
HOWARD A. LOTHROP.
ethmoid. An opening into the antrum was made through the
middle meatus.
No drainage-tube was used between the sinus and the nasal
cavity, the sinus walls were carefully curetted, and the external
wound closed without drainage. The nasal cavity was packed
with iodoform gauze through the anterior nares. Absolutely no
blood reached the pharynx on account of the postnasal tampon.
On the following day the gauze was removed and no further
packing used. With the exception of the extreme inner end of
the incision, primary union resulted throughout and remained
firm. On account of the free nasal drainage the sinus was not
irrigated during the first week, but the nasal cavity was cleansed
three times during the day with a 2-per-cent. boric acid solution.
At the end of two weeks the fistula had healed and remained so
for three weeks, when it reopened for a period of three weeks,
and has remained closed ever since.
The pain and headache disappeared at once after the opera-
tion and have not returned. Two months after the operation
there was not enough discharge for the patient to perceive it.
The anaesthesia produced by cutting the supraorbital nerve is
gradually disappearing.
Since the first week after the operation the sinus has been
irrigated three times daily with a 2-per-cent. boric acid solution.
This was performed readily by the patient using a bent canula
and barrel syringe. By means of the snare a few polypoid granu-
lations were removed from the ethmoid region. The antrum
remains free from pus. The patient has gained considerable
weight, is perfectly free from pain, has a cicatrix that is hardly
perceptible, and states that she feels perfectly well.
Case VI. — Repeated Pus Accunnilations in Left Frontal Sinus;
Spontaneous Evaeuations into Nasal Cavity; Present Absence of
Symptoms. — I am indebted to the kindness of Dr. L. S. Pilcher,
of Brooklyn, for the privilege of publishing the following three
cases. His records of the cases are as follows:
" T. A. T., male; forty-one years of age; of somewhat deli-
cate constitution. Ten years ago suffered in quick succession
from pneumonia, haemoptysis, and acute articular rheumatism, as
a result of which he was an invalid for three years. Prior to this
he had suffered for a period of about five years from a chronic
nasal catarrh followinsr a severe attack of acute corvza. This
SUPrURATION IN THE FRONTAL SINUS. 125
acute attack was attended with special distress between the eyes,
and with severe general headache. During- the time he was the
subject of the pulmonary and rheumatic troubles, and for some
years after his recovery from these, he was free from nasal symp-
toms. However, in 1885, he began to suffer much from frontal
and supraorbital headache, affecting the left side especially. Two
or three times each winter these would be complicated with
severe attacks of acute coryza, attended with a sense of great dis-
comfort and distention between the eyes; the left conjunctiva
would become congested, while the right would remain un-
afifected; there would be severe pain in the left orbit, diffusing
itself thence over the forehead and backward to the left side of
the head.
" Some of these attacks gradually subsided without any
noticeable crisis ; at other times, immediate relief to all the symp-
toms would suddenly occur after a free flow of pus from the left
nasal cavity. Again, sudden abundant escape of pus would at
times occur, not preceded by acute pain, but only by a variable
period of dull distress in the forehead. After these gushes of
pus would take place a continuous purulent discharge, amounting
to from one to two and one-half ounces daily, would persist for a
time, gradually diminishing in quantity, until it ceased altogether.
During the winter of 1889 he had an unusually severe and pro-
longed attack, extending over some months.
" The patient has had no particular treatment for his condi-
tion, and his recoveries have been spontaneous. There have been
no recent reports from this case."
Case VII. — Abscess of Left Frontal Sinus with Necrosis of
Anterior Wall and Floor of Sinus: Sequestrotomy; Obliteration of
Sinus with Cure. — Dr. Pilcher's record: "Ellen T., aged nine-
teen years, appeared with a suppurating sinus of the upper and
inner part of the left orbit, of which she gave the following his-
tory: Ten years previously she had been struck by a stone upon
the left frontal eminence, inflicting a wound which healed in
three weeks, but from that time she began to suffer from daily
headaches. Two years ago a swelling over the left eye appeared,
which, however, disappeared again in a few days under local ap-
plications. At the end of eighteen months the parts again be-
came swollen and painful. Repeated incisions into the swelling,
12 6 HO WARD A. LO THE OP.
with liberation of pus, were made during the months following,
resulting finally in the persistent sinus noted above.
" She was referred to me by Dr. Arthur Mathewson, and an
exploratory operation under chloroform was performed. After
making incisions through the soft parts sufficiently free to expose
the margin of the orbit and the surface of the frontal bone, at the
inner angle of the orbit, two bony sequestra were exposed, lying
loosely in the tissues. These sequestra were removed.
" Examination of these shows that together they compose
the anterior and inferior walls of the frontal sinus. The exposed
shallow cavity of the sinus was shut ofif from the nasal cavity and
its mucous membrane hypertrophied. This was curetted and
the skin replaced so as to obliterate the sinus. Rapid repair took
place with very little deformity."
Case VIII. — Chronic Frontal Empyema zvith Orbital Tumor
and Fistula; Operation for Obliteration of Sinus follozved by Re-
covery. — Dr. Pilcher's records: " S. B. S., sixty years of age, an
oysterman, had a well-marked tumor at the inner angle of the left
orbit, extending upward and inward to the midfrontal region
(Plate 89). At the most prominent part of the tumor was a fistu-
lous opening leading upward into a large cavity.
" For ten years or more he had had some nasal catarrh with
occasional discharge of offensive pus and crusts from his nose
without subjective symptoms. Four years ago he first noticed a
swelling at the inner angle of the orbit, which, without tenderness
or redness or subjective symptoms, slowly increased to the size
of a small hen's egg, pushing the eye outward so as to cause
diplopia. Within a year the tumor began to discharge into the
nostril. At the Brooklyn Ear and Eye Hospital repeated inci-
sions into the tumor caused the evacuation of pus, but not the
collapse of its walls, hence the case was referred to me, when the
following operation was performed:
" Free incision of the fistulous track having been done, an
opening of some size through the anterior wall exposed the fron-
tal sinus, which was greatly dilated. No communication was
found with the nasal cavity. The posterior wall of the sinus had
been absorbed over an area about one centimetre in diameter,
bringing the sac of the abscess into immediate juxtaposition to
the dura mater at that point. Hence it was determined to obliter-
SI:PPUKATIOi\ in the frontal sinus. 127
ate the sinus on account of the risk of further trouble following
attempts to preserve it and restore nasal communication.
" The whole anterior wall of the sinus was removed, the
mucous membrane thoroughly curetted away, and the skin-flaps
replaced and retained by compress. Primary adhesion of much
of these flaps w^as secured, the remainder became healed by
granulation with limited suppuration. A fistula persisted for
some time, which finally became healed."
Case IX. — Abscess of Frontal Sinus; Occlusion of Ostium
Frontalc; Necrosis zvitJi Persistent Fistula. — This case occurred in
the practice of Dr. J. C. ]\Iunro, of Boston, and he has kindly al-
lowed me to publish these notes:
Jos. C, Italian, sixty years of age. About one year ago there
appeared a swelling in the upper inner angle of the right orbit,
which was red, tender, and painful. This ruptured spontaneously,
discharged pus, and a fistula resulted, persisting after an attempt
to overcome it by operation.
When first seen by Dr. Munro there w-as a small discharging
sinus at the inner angle of the orbit; there Avas oedema of the
upper eyelid, with apparently some dislocation of the e} eball.
The probe reveals the presence of necrosed bone. Antisyphilitic
treatment has been of no avail. There was no nasal discharge.
Operation (ether narcosis). — Vertical incision at inner angle
of orbit extending to frontal bone. Fragments of necrosed bone
were removed from the vicinity of the ethmoid region, and a
small perforation was discovered leading through the inferior
wall of the frontal sinus. All of these openings were enlarged,
the necrosed fragments removed, and the wound packed with
gauze. The opening was made into the nasal fossa. The usual
amount of oedema followed the operation, together with some
conjunctivitis, both of which subsided in due time. Two months
later there still remained a granulating area. Patient was lost
sight of for a month, when he returned with a loose fragment of
bone appearing at the old wound. Under ether a sequestrum of
bone, tapering at one end, one and one-half inches long, and half
an inch wide, was removed. This fragment of bone seemed to
be in the nature of a sequestrum originating in the frontal sinus,
and the remaining cavity of the sinus was apparently walled off
in all other directions. The wound closed rapidly so that a very
128 HOWARD A. LOTHROP.
small fistula remained. IMeanwhile there have been no nasal
symptoms.
From time to time this fistula has closed, but has never re-
mained permanently healed. This case shows that under careful
treatment it has been impossible to obliterate the frontal sinus,
either on account of its size or the presence of an obscure piece
of necrosed bone. The absence of nasal discharge is proof of the
occlusion of the ostium frontale, hence, if there is any cause for
the persistence of the exudate, the fistula will fail to heal. Under
the circumstances it would seem that the only alternative would
be to establish nasal drainage in the manner already described.
Case X. — Frontal Empyema following Trauma; Uncompli-
cated Recovery. — The following case occurred in the practice of
Dr. F. B. Lund, of Boston, and to him I am indebted for the fol-
lowing notes :
" A boy of twelve years was operated for a compound de-
pressed fracture of the frontal bone in the vicinity of the frontal
sinus. All wounds healed, and he made an apparently good re-
covery. Two months later he returned for treatment on account
of two sinuses which had appeared at either end of the naso-
frontal suture. There was considerable swelling of the subcu-
taneous tissue and a moderate amount of seropurulent discharge
from the sinuses. A probe passed into the left opening in such
a way that the end was evidently in the frontal sinus, the resistant
bony walls of which could be detected, but there was no evidence
of necrosed bone. The right sinus connected with the left one
under the skin. There was some left nasal discharge.
" Operation (ether narcosis). — The left eyebrow being shaved,
an incision was made at its inner end running horizontally out-
ward, down to the bone, and, on elevating the skin, it was found
that the anterior wall of the left frontal sinus had been fractured
into three pieces and driven inward; these fragments of bone
were in a healthy condition.
" The anterior wall of the sinus was removed, showing the
absence of hypertrophied or polypoid mucous membrane. A
probe was passed through the ostium frontale into the nasal
cavity, and the natural opening enlarged by means of a fine cu-
rette. A drain of half a dozen strands of silkworm gut passed
down to the nares, but this was pulled out by the patient on
coming out of ether. The sinuses in the skin were curetted, and
SUPPURATION IN THE FRONTAL SINUS.
129
the incision over the frontal sinus closed without drainage. The
wound healed by first intention and the sinuses closed in a few
days. The after-treatment for the nasal cavity consisted in three
or four daily irrigations with a normal salt solution. A perfect
recovery resulted."
This case evidently was not complicated by suppuration in
the anterior ethmoid cells. Restoration of nasal drainage was
sufficient for recovery, without attempting to obliterate the sinus.
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9
130
HOWARD A. LOTHROP.
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SUPPURATION IN THE FRONTAL SINUS.
'31
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iem : The Operative and Diatetic Treatment of Suppuration in the Ac-
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132 HOWARD A. LOTHROP.
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July.
Plate J.
Anterior View of Skull.
.^. Glaljella or nasal eminence, s.r. Superciliary ridge, s.a. Supra orbital
arch. s. n. Supra orbital notch or foramen. ;/. Nasal bone. n.p. Nasal process
of superior maxillary bone. /. Lachrymal bone. n.f.s. Naso-frontal suture.
/./. Inferior turbinate bone. I. p. Lamina perpendicularis.
Sagittal Section to Right of Nasal Septum, Showing Lateral Wall of
Nasal Fossa. Turbinate Bones Undisturbed.
F. Frontal sinus. vS. Sphenoidal sinus, i.t. Inferior turbinate bone. in.t.
Middle turbinate bone (inferior ethmoidal turbinate bone), j and 4. Middle and
superior ethmoidal turbinate bones, e.g. Crista galli. ;/. Nasal bone. i.m. In-
ferior meatus, ni.ni. Middle meatus.
Plate 3.
Bonk. Lkft Nasal Fossa, Kxthrnal Wam,, vShows Atroi'hv
OF Rone in Aged.
/./. Inferior turbinate. ))i.i. Middle turbinate. .S". Sphenoidal sinus. i.))t.
Inferior meatus. }>t.)ii. ]\Iiddle meatus, f.c.i. I'issura ethmoidalis inferior. /-.
Internal wall of lateral mass. n.p. Nasal process of superior maxilla. /. Lach-
rymal bone. I. p. Lachrymal process of inferior turbinate bone. ;/. Nasal l)one.
/". Frontal bone.
Plate 4.
Bone. Right Nasal Fossa, External Wall, Miudle TrknixATE Bone
Removed Along Dotted Line.
/. Nasal process of frontal bone. i.t. Inferior turbinate. /./>. Laclirymal pro-
cess of inferior turbinate, e.p. Kthnioidal process of inferior turbinate. U. Un-
cinate process of ethmoid bone. B . Bulla ethnioidalis with its ostium just above.
-S". vSeptum between Uncinate process and Bulla. /. Probe passed into frontal
sinus through turbinate fossa. 3. Probe passed through Hiatus Semi-lunaris. into
Infundibulum to Anterior bUhmoid Cells, r.i,''. Crista galli.
Plate 5.
Bone. Left Orbital Fossa, Inner Wai.i,, I.achrvmal Bone Removed.
o.p. Os Planum, c.f. Anterior ethmoidal foramen. F. Frontal sinus, a. Its
anterior wall. p. Its posterior wall. /. Orbital portion of its inferior wall.
;/. Nasal bone. n.p. Nasal process. A. Inner wall of Antrum of Hi^hmore.
i.p. Internal angular process of frontal bone. i'. Uncinate process.
J-
f^*'^,^.--^
Bone. Coronai^ Section through Posterior Angi,es of Frontai, Sinu.s'
Looking into the Sinus from Behind.
F. Frontal siuus. p. Its posterior wall. /. Its inferior wall. r.i,''. Crista
galli. n.s. Small portion of nasal septum. A. Antrum, ni.t. Line of insertion of
anterior extremity of the left middle turbinate on the nasal process of the superior
maxilla. a. a. a. Anterior ethmoidal cells. Arrow showing course of nasal
duct.
Plate 7.
Internal Wall of Left Orbital Fossa with IvAChrvmal Bone Removed,
Showing Upper Portion of Uncinate Process and Bonv Septa,
WHICH Complete Certain Anterior Ethmoid Cells
when the Lachrymal Bone is in Situ.
u.u.ii. Uncinate process, and incomplete ethmoid cells.
Plate 8.
Bone. Right Nasal Cavity, External Wale, :Mn)i)LE Tekbinate Bone
Removed alonc; Dotted Line.
B. Ethmoid Bulla. U. Processus Uncinatus. ;;/. Its maxillary process.
/. Lachrymal bone, f.c.i. Fissura Ethmoidalis Inferior. /./. Inferior turbinate.
/. Probe through turliinate fossa to frontal sinus. 3. Probe throuijti Hiatus Semi-
lunaris and infundibuluin to anterior ethmoid cells situated between lachrymal
bone and upper extremity of Uncinate process. /. Nasal process of frontal bone.
A. .^jiger Nasi. .v. Septum between I'ncinate and Bulla. >i.p. Nasal process of
superior maxilla, i.m. Inferior meatus.
Plate 9.
Bone. Ixni;i< Wai.i,, Ric.ht Orbit, Lachrvmai, Bonk Rkmoved.
F. Frontal sinus, a. vSuperciliary ridge on anterior wall. />. Posterior
wall. /. Inferior wall, at internal angular process of frontal bone. ti. Nasal
bone. )i.p. Nasal process of superior maxilla, u.u.u. Uncinate process with
septa and incomplete ethmoidal cells, m. Maxillary process of uncinate,
closing ostium maxillare. /. Turbinate process of uncinate. <)./>. ()s Planum
c. Nasal canal. A. Internal wall of Antrum.
Plate 10.
Bone. Left Nasal Fossa, External Wall, Middle Turbinate
Removed Along Dotted Line, and also the
Lachrymal Bone Removed, (/).
/. Probe through turbinate fossa to frontal sinus. 2. Probe
through Hiatus Semi lunaris and Infundibulum to anterior ethmoid
cells, situated between uncinate process and bulla ethmoidalis.
/. Space completed by nasal aspect of lachrymal bone, forming
thereby a portion of the bony external wall of the nasal fossa.
C I'ncinate process (Fig. 2 on its maxillary jirocess). B. Kthmoid
Bulla, its ostium just above. /./. Inferior turbinate, s.p. Its lach-
rymal process. c.p. Its ethmoid process. A. Agger Nasi. /•'.
Frontal sinus, with septa, r.i.' . Crista galli hollowed out by a divert-
iculum. .S". Sphenoidal sinus. s.p. Spheno-palatine foramen.
a.a. Bony fontanelles leading to Antrum. o.)n. Ostium maxillare.
s. Septum between T'ncinate and Bulla. //. Nasal bone. ;/./>. Nasal
process of superior-maxilla, j ami ./. Middle and superior turbi-
nate bones of the ethmoid.
Plate n,
^
Bone. Nasal Cavity. Extkkxal Wall, Middle Tukhinatk Rkmovkd. Sep-
tum Between Uncinate Process and Ethmoid Bulla Wanting
so that the Turbinate Fossa and Upper End
OF iNlTNDIIUI.rM ARE ONE CAVITY.
/, 2, J. Probes in divisions of rii(ht frontal sinus leading to the cavity common
to the turbinate fossa, and upper end of Infundibuluni. 4.4.4- Dotted line mark-
ing insertion of middle turbinate. 5. Small Ethmoiil Bulla. 6. Superior turbi-
nate. 7. Spheno-ethmoidal recess. U. Uncinate process. /. Lachrymal bone.
.S". vSphenoidal sinus. /./. Inferior turbinate. ,s\/>. Spheno-palatiue foramen, i.m.
Inferior meatus. /"./'. Fontanelles leading to .\ntruin.
Plate 12.
Bone. Left Nasal Cavity, External Wall, Middle Turbinate Removed
ALONG the Dotted Line. No Septum between Uncinate Process
and Ethmoid Bulla, so that Turbinate Fossa and Upper
End of Infundibulum are One Cavity, into which
Opens the Frontal Sinus, as Shown hv Pkohi;.
.T. Septum hetween'fronal sinuses. B. Ethmoid Bulla. V . Uncinate process.
(/. Afi!.jer Nasi. /./. Inferior turbinate. /'./'. I'ontanelles to Antrntn. s./>. .Spheno-
palatine foramen. /. Lachrymal bone. /./>. Lachrymal ])rocess of inferior turbin-
ate. ;/. Nasal bone. ;/./> N'asal process of superior maxilla.
Plate 13.
Frontal Bone Removed at Naso-frontal Suture, Including Lamina
Cribrosa and a part of the Lamina Perpendicularis, Viewed
FROM Below, to Show the Width of the Nasal Cavity.
and the Available Operating Space. Arrow
Passing to Frontal Sinus Through
Hiatus Frontalis.
I.e. Over the location of the lamina cribrosa. /./>. I^aniina perpendicularis.
a.a.a. Anterior ethmoidal cells, p-p-p- Posterior ethmoidal cells. S. Sphenoidal
sinus. O. Roof of Orbit. C/. OlabeHa. «. Articulates with nasal bone. ;/./.
Articulates with nasal process of superior maxilla. /. .\rticulates with lachrymal
bone. o.p. Articulates with os planum. /./. Inferior lamina of orbital ]>ortion
frontal bone. s.l. Superior lamina of orbital portion frontal bone. /. Internal
wall of lateral mass.
Plate 14.
Lower Portion of Specimen Figured in Plate 13, Showing the Broken
Cells of the Lateral Masses. Septum of the Nose Missing.
Arrow Passing to Infundibulum from the
Direction of the Frontal Sinus.
71. Nasal bone. w./>. Nasal process of superior maxilla. /. Lachrymal bone.
o.p. Os Planum, a.a.a. Anterior ethmoid cells. />■/>■/>• Posterior ethmoid cells.
n.c. Nasal canal. O. Orbital surface superior maxilla. i. Internal wall of lateral
mass.
Plate 15.
Inferior Surface of Two Frontal Bones, to Show the Vicinity
OF THE Hiatus Frontalis.
H. Hiatus FVontalis, looking into frontal sinus. S. Inferior border of frontal
Septum, s.n. Supra-orbital notch, i.p. Internal angular process, c.c. Roof of
an anterior ethmoid cell protruding into frontal sinus from below, oi. Ethmoidal
notch formed by the superior laminae of the orbital portion of the frontal bone,
which articulate with the lamina cribrosa. /./. Inferior lamina of same. E. Space
between these two laminae, interrupted by septa forming broken cells, correspond-
ing from before backwards to the anterior ethmoidal cells in the posterior angle
of the frontal sinus, anterior ethmoid cells opposite Os Planum, and finallv the
posterior ethmoid cells, i.s. Orbital portion of inferior surface of frontal sinus.
n. Articulation of nasal bone. n.p. Articulation of nasal process of superior
maxilla. /. Articulation with lachvmal bone.
Plate 16.
Frontai. Bone Removed, Showing the Broken Anterior and Posterior
Ethmoid Cells, and the Thickened Line of Articulation with
THE Nasal Bones and Nasal Processes ok the Superior
Maxillae in Front. Probe in Left
Ostium Frontale.
e.g. Crista galli. I.e. Lamina cribrosa. n.d. Nasal duct. ;/. Xasal l)one (su-
perior border), n.p. Nasal process (Superior border"). /. Lachrymal bone (^Supe-
rior border), o.p. Os Planum (Superior border). .S". Roof of sphenoidal sinus.
F. Nasal portion of floor of frontal sinus. O. Inferior surface of orbital fossa.
Plate 17.
Sui'imioR Surface of Ethmoid and Sphkxoid Bones, Showing the Broken
Anterior and Posterior Ethmoid Cells, and Opening into
Lia-^r Sphenoidal Sinus.
A. Anterior ethmoid cells. /'. Posterior ethmoid cells. 6". Sphenoidal sinus.
/.( . Lamina cribrosa. cj^. Crista Galli. ;/./. Naso-f rental canal. /./. Lamina per-
pendicularis.
Plate iS.
Inp'Erior Surfack of samk IJonfs. Arrow in Lkft Ostium Sphenoidale.
■V. Inferior surface of l)ody of sphenoid bone. ///J. Inferior bonier of middle
lurl)inate. C. Uncinate process. //./. At point of union of middle turbinate and
uncinate process, which articulates with the nasal process of the superior maxilla.
/./. Lamina perpendicularis. s.m. Superior meatus, m.m. ISIiddle meatus. /._/.
Arrow directed towar. Lamina
perpendicularis. c.,(;. Crista Galli. e.c. Broken anterior ethmoidal cells com-
pleted by articulation with lachrymal bone. /. Dilated cell like termination of
Infundibulum bounded internally by the uncinate process (upper extremity), and
externally by the lachrymal bone. s.yn. Lower border of Os Planum, articulating
with orbital surface of superior maxilla. /. Articulation of lachrymal bone.
Plate 20.
BoNi-;.
Coronal Section Throich Osthm Maxii.lauk. Antp;ri()r Half.
Posterior Wai.i, of Frontal Sinus Rioiovkh.
F. An anterior wall of frontal sinus, showin.tj a vertical Septum. .S". Septum
between the frontal sinuses. /'./. Inferior turbinate. ;//./. Middle turbinate.
o.m. Ostium Maxillare. U. Uncinate Process. /. Os lachrymale. /. Turbinate
fossa, a.a.a. Anterior ethmoidal cells, internal to lachrymal bone. A. Antrum
of Highmore. /./>. Lamina perpendicularis. i.o;. Crista Galli. i.m. Inferior
meatus. ))i in. Middle meatus, s.in. Superior meatus. /. Inferior wall of frontal
sinus (Orbital portion). Dotted line corresponds to nasal portion. See Plate 21.
Plate 21.
Posterior Half of Same Section.
A. Antrum, ni.t. Middle turbinate. /./. Inferior turbinate. />. Bulla eth-
nioidalis. i.»i. Inferior meatus, m./n. Middle INIeatus. a. a. a. Anterior ethmoid
cells just above Bulla and internal to lachrymal bone and Os Planum. /./. Portion
of inferior lamina of horizontal ]^art of frontal bone. sj. Point of articulation of
superior lamina of same, with lamina cribrosa. O.F. Orbital fossa. /./. Lamina
perpendicularis. c,^. Crista dalli. /.< . I. Small Bulla ethmoidalis. C Un-
cinate process, o.ni. Ostium maxillare. n. Nasal bone. n.p. Nasal process of
frontal bone. /. Inferior turbinate crests of superior maxillary and palate bones,
for articulation with inferior turbinate bone. 2. Opening of nasal duct completed
by turbinate bone. j. Fissura Ethmoidalis Inferior. A. Antrum. /. Lachrymal
boue.
Plate 27.
A Skries of Lachrymal Boxks.
A. Right lachrymal bones, orbital surface. B. Left lachrymal bones, nasal
surface. I.e. Lachrymal crest. /. Lachrymal groove, a.a.a. Depressions sepa-
rated by slightly elevated ridges, completing certain anterior ethmoid cells.
Dotted line corresponds to inferior border of uncinate process, the portion of bone
below which completes a part of the external wall of nasal fossa. The surface of
bone above this line completes ethmoidal cells.
Plate 28.
vSagittaIv vSection, vShowixg Septum Nasi.
F. Frontal sinus. S. vSplienoidal sinus. /.;/. Posterior nares.
Plate 29.
Sagittal Section, Kxternal Wall of Right Nasal P'ossa.
F. Frontal sinus. S. .Sphenoidal sinus. /. Inferior turbinate bone. 2. Infe-
rior ethmoidal turbinate bone (" middle tiirbinate.") 3 and 7. INIiddle and supe-
rior ethmoidal turbinate bones. i.»i. Inferior meatus. m.})i. Middle meatus.
f.e.i. Fissura ethmoidalis inferior, f.e.s. Fissura ethmoidalis superior. s.e.r.
Spheno-ethmoidal recess. Arrow passes through Ostium sphenoidale. /.:'. Plica
vestibuli. e.g. Crista Galli. e. Orifice of Eustachian canal, o. Operculum.
Dotted line corresponds to an incision in middle turbinate bone necessary before
removal of its anterior portion, in order to expose satisfactorily the upper extrem-
ity of Infundibulum.
Plate 30.
Right Nasal Fossa, External Wall, Portion of Middle Turbinate
Removed, as Shown by Dotted Line.
B. Ethmoid Bulla. Arrow passes through Hiatus senii-lunaris iuto Infundi-
bulum via naso-frontal duct to frontal sinus. /. Inferior turbinate bone. 2.
Middle Turbinate bone, j and 4. Superior and middle ethmoidal turbiuate bones.
p.v. Flica vestibuli. i.i>i. Inferior meatus, jn.m. Middle meatus, f.e.i. Fissura
ethmoidalis inferior, f.c.s. Fissura ethmoidalis superior, s.e.r. Spheno-eth-
moidal. recess. .9. Sphenoidal sinus.
Plate 31.
RicHT Nasal Cavity External Wall, Middle Turbinate Bone Removed
Along Dotted Line.
B. Bulla ethnioidalis, its Ostium just above. U. Uncinate process. S. vSeptum
between Uncinate and Bulla. Arrow passes through turbinate fossa and Ostium
froutale into frontal sinus, h.s. Hiatus Senii-lunaris leading to iufundibulum.
Plate 32.
IvKiT Nasal Cavity, External Wall, Middle Turbinate Bone Removed
ALONG Dotted Line. Arrow Passes from Turbinate Fossa
TO Frontal Sinus.
/?. Bulla ethnioiilalis iu contact with Uncinate process below. U. Uncinate
process, Hiatus semi-lunaris between, s. Septum between Uncinate and Bulla,
separating turbinate fossa from upper end of Infundibulum. /". Frontal sinus.
S. Sphenoidal sinus.
I
Plate 33.
Right Nasal Fossa, External Wall, Middle Turbinate Bone Removed,
Showing Infundibulum carried nearly to Floor of Frontal
Sinus, and Continued as a Short Naso-Frontal
Canal, as Shown by Course of Arrow.
F. Frontal sinus divided by a septum. U. Uncinate process. B . Small Bulla
■with a long ostium above it. i.i. Marks outer wall of infundibulum with a long
ostium above it.
Plate 34.
Right Nasal Fossa, ]Middlk Ttrbixatk Rkmovkd.
t. Turbinate fossa leading to frontal sinus. Arrow. />'. Small ethmoid Bulla.
/ '. I'ncinate process, f.e.i. Fissura ethmoidalis inferior, in which may be seen
ostia of posterior ethmoidal cells. vS. vSphenoidal sinus oj^eninj; into recessus
S])heno-ethmoidalis. /. Arrow disappearing through Hiatus frontalis into Infundi-
bulum. a.o.i'i. Accessory Ostium maxillare.
Plate 35.
Left Xasai. Fossa, Extekxai, Wall, IMiddlk Turhinatk RhmovI'D, Showing
Absexce of Septcm between BfLLA Ethmoidalis and Uncinate
Process, whereby the Turbinate Fossa and Upper End
OF Infundibuum Coincide.
F. Frontal sinus. B. Bulla ethmoidalis. U. Uncinate process. Hiatus semi-
lunaris between these two, in which can be seen a small probe, (i) jiassing from
the Aniiutn to the Frontal Sinus. Large probe, (2) passing from sinus through a
second ostium frontale appearing just under the middle turbinate bone. .\ sinall
septum can be seen between these probes, which separates ostia of anterior eth-
moidal cells. Accessory ostium maxillare of large size, to be seen just above in-
ferior turbinate bone. See Plate 36.
Plate 36.
^-^
Zi.
Same Specimen Enlarged, more ok the Turbinate Bone Removed, Show-
ing FREE Passage to Frontal Sinus. Arrow leads
TO OsTiiTM Maxillare.
a.o.m. Accessory ostium maxillare.
Plate 37.
Left Nasal Fossa, External Wall, Turbinate Bone Removed. Probe
FROM Turbinate Fossa to Frontal Sinus. Arrow is lost in
Infundibulum under Septum between Bulla Ethmoi-
DALis and Uncinate Process. Lower Portion
OF Hiatus Semi-Lunaris Obstructed by
A SMALL Polyp (/>) which hangs
FROM the Ethmoid
Bulla {B).
f.e.i. Fissura ethnioidalis inferior. F. Frontal sinns. r.h. Frontal Bulla.
Plate 38.
Ric.HT Nasal Fossa, ExXKUNAr, Wall, Middi.i', Ti-rbinatic Ricmovi'-.d with
Arrow Liiading to Turbinate Fossa, which Ends Blixdi.v tndkr
THK Superior Angle of the Turbinate.
B. Bulla ethmoidalis, with its Ostium. U. Uncinate process. Well marked
Hiatus Semi-luuaris between these two structures leading to Infundibulum, into
which opens the naso-frontal canal. a.o.)ii. Accessory Ostium maxilhire. J.e.i.
Fissura ethmoidalis inferior. .S'. Sphenoidal Sinus. See Plate 39.
Plate 39.
Samk SrKCiMp;N-, :\iore of thk TrRBiNATK Bone Rkmovkd, Rxposixg the
Turbinate Fossa.
//. Turbinate fossa. Portion of Uncinate process removed showing depth of
Infundibulum at the lowest point of which is a small probe in the Ostium max-
illare. On the external wall of the Infundibulum are small cell-like cavities.
a.o.m. Accessory Ostium maxillare. />. Bulla ethmoidalis, with its ostium just
above. /'. External wall of Infundibulum.
Plate 40.
Lkft Nasal Fossa, External Wall, Middle Turbixatk Rkmovkd. Un-
cinate Process Incised, and its Upper Portion Reflected Forward
and Retained in Position by a Probe Passing Down from the
Frontal Sinus into the Infundibulum. A Short Probe
Shows the Location of the Ostium Maxillare.
a.o.jH. Accessory Ostium maxillare. I'. Reflected portion of Uncinate process.
B. Bulla ethmoidalis, with a long ostium above, f.e.i. Fissura ethmoidalis in-
ferior. -S". vSphenoidal sinus. /'./. Inferior turbinate. /././. Infundibulum.
F. Frontal sinus.
Plate 41.
Lkft Nasal Fossa, External Wall, Middle Turbinate Removed, I'nxi-
NATE Process Divided and Upper Portion Reflected Forward and
Inward. Probe Passed from Frontal Sinus to Antrum
Through Naso-Frontal Canal and Infundibi'lum
Showing its Depth and the Tendency
OF Fluids to Gravitate into
THE Antrum.
B. Bulla elhnioidalis with its Ostium just aI)ove. ii.u. Ou ])ortioiis of unci-
nate process, a. a.m. Accessory Ostium maxillare. J.i'.i. Fissura ethmoiilalis
inferior. .S". Sphenoidal sinus. /•'. I'routal sinus broken away. .v. Septum
between uncinate process and Bulla ethmoidalis separatinga blind turbinate fossa
from the upper extremity of the Infundibuluni.
Plate 42.
Rr;ht NasaIv Fossa, External Wall; Middle Turbinate and Part of
Floor of Frontal Sinus Rfcmoved, so as to Show a Direct
Commi'nication Between the: Infundibulum and Sinus.
B. Bulla ethnioidalis, very larjije and overlianjijs the Tncinate process, so as
to obscure the Hiatus Senii-lunaris, its long ostium continued well toward the
frontal sinus; its mucous membrane is considerably hypertrophied. U. Processus
Uncinatus. /././. Infundibulum. f.e.i. Fissura ethmoidalis inferior, above which
hangs a small polyp. F. Frontal Sinus. See Plate 44.
Plate 43.
Left Nasai. Fossa, External Wall, Middle and Inkerior Turbinates Re-
moved ALONG Dotted Lines. Arrow through Turbinate
P'ossA TO Frontal Sinus.
B. Bulla ethinoidalis, rather small with large ostium above. h.s. Hiatus
Semi-lunaris narrowed lielow by the approximation of the Bulla ethmoidalis and
processus Uncinatus (6''). f.e.i. Fissura ethmoidalis inferior. i.m. Inferior
meatus .
vSame Specimen (Reduced ix Size) as Plate 42, Less of Middle Ti-rbixate
Removed ; Figures Correspond to those in Previous Plate.
Arrow Passes to Frontal Sinus through
Hiatus Semi-Lunaris.
Plate 45.
Left Nasai. Fossa, External Watj,, Middle Turbinate Bone Partially
Severed and Hanging in Front of Inferior Tirhinate.
Arrow Passes Through Turbinate Fossa to
Frontal Sinis.
/•". P'rontal vSinus. .S". Broad Septum, from Unciuate process to Bulla ethmoi-
dalis, forming the inner wall of the turbinate fossa, c.c.c. Cells in middle turbi-
nate bone. p. I'ine proDe in small Hiatus Semi-lunaris. B. Bulla ethmoidalis,
■very small. ( \ Processus Uncinatus. verv small.
Plate 46.
Left Nasal Fossa, External Wall, Specimen Reduced in Size,
Middle Turbinate Removed.
B. Ethmoid Bulla small, but markedly convex forward and downward so as to
over-lap the Uncinate process. U. Uncinate process. Arrow is lost in a l)lind
Infundibulum. p. Probe passing through turbinate fossa to frontal sinus. J.i\i.
Fissura ethmoidalis inferior.
Plate 47.
Left Nasal Fossa, Extkrxai, Wall, Middle Tirbinate Removed.
Arrow passes through turbinate fossa to frontal sinus. B . Cavity of Bulla
ethmoidalis opened on section. I'. I'ncinate process, h.s. Broad Hiatus Semi-
lunaris, a.o.iii. Accessory Ostium maxillare. f'.e.i. Fissura ethmoidalis inferior.
S. Sphenoidal sinus.
Plate 48.
Internal Wall ok IvEFT Orbital Fossa, Shuwinc". Kxtensive Dehiscence
OF Os Planum, which Communicates with the Cells of the
Ethmoid Bulla. Arrow Passing Through Dehi-
scence to the Cells of the Bulla
Kthmoidalis.
n.d. nasal duct. ./. Antrum.
Plate 49.
Nasal Aspect of Same Specimen, Middle Turbinate Removed and
Left Hanging.
B. Bulla ethtnoidalis. U. Processus Uncinatus. Arrow passes through the
ostium of the Bulla ethmoidalis and the dehiscence of the Os Planum, into the
orbital fossa. The upper arrow passes through the turbinate fossa and ostium
frontale to the frontal sinus. F. Frontal sinus. .S". vSphenoidal sinus, f.c.i. Fis-
sura ethmoidalis inferior. /'./. Inferior turbinate.
Plate 50.
Internal Wall of Left Orbital Fossa, to Show a Small r)EHLSCp;NCE
BETWEEN THE Lachrymal Bone and Os Planum.
o.p. Os Planum. /. Os lachrymale. s.m. Orbital surface of superior maxilla.
F. I'rontal sinus, a. Anterior wall. /. Posterior wall. /. Inferior wall. e. An-
terior ethmoidal foramen. D. Dehiscence. A. Antrum.
Plate 5J.
Sagittai, Section to Left of Medium Line, Exposing the FrontaIv Sinus
AND Ethmoidal Celes.
F. Frontal sinus, a. Anterior walL /. Posterior WalL f.b. Frontal Bulla
protruding into frontal sinus ; its cell large. U. Uncinate process to which are
attached numerous polypi so as to obstruct the Hiatus semi-lunaris. The anterior
portion of the uncinate process has been partly removed so as to expose a large
cell situated between this process and the lachrymal bone. Its ostium is marked
by an arrow directed toward the Infundibulum. This cell is of very constant
occurrence. B. In cell corresponding to Bulla ethmoidalis. Dotted lines indicate
points of removal of middle turbinate. S. Sphenoidal sinus, c An Anterior
ethmoidal cell. i.t. Inferior turbinate, p.v. Plica vestibuli. a.o.m. Accessory Os-
tium maxillare. d. Posterior ethmoid cells, i.m. Inferior meatus, w.w. Middle
meatus. The long arrow passes through the Hiatus vSemi-lunaris into the Infun-
dibulum, which is converted into a canal by polypi, thence through the exposed
naso-frontal canal into the frontal sinus.
Plate 52.
Sagittal Section to Right of Median Line, Lower Portion of Uncinate
Process Removed, and Large Opening made into Antrum,
Middle Turbinate Removed.
F. Frontal sinus. A. Antrum. />'. Bulla ethinoidalis. /. Large cell just
external to iipper end of Infunilil)uluin which has been removed, f.e.i. Fissura
ethmoidalis inferior, r. I'ncinate process.
Plate 53.
Sagittal Suction Through Hve-baij,, internai, half, Showing the Tri-
ANGUEAR Shape of the Frontae Sinis.
F. Frontal sinus. a. Anterior wall. /. Inferior wall. p. Posterior wall.
f.b. Large frontal bulla. A. Antrum. a.o.m. .Accessory Ostium maxillare. /:".
Eyeball, m.c.f. Middle cranial fossa. See Plate 54.
Plate 54.
Same Specimen. External Half, Letters Correspond. (See Plate 53-)
Plate 55.
CoRONAi, Section Looking into a Large Frontal Sinus, Containing Num-
erous Septa but no Inter-Frontal vSeptum. Both Sinuses Form
One Cavity. Arrow Marks the Presence of a Single
Ostium Frontale which Opens into the Right
Turbinate Fossa. No Ostium Frontale on
THE Left of the Median Line.
s.s.s. Variovis incomplete septa of the common frontal sinus,
hulla on left side which opens into the left turbinate fossa.
/"./'. I'"rontal
Plate 56.
Coronal Section Through Frontal Sinus.
F. Frontal sinus, posterior wall. J.s. Septum between frontal sinuses, .v.
Thick Septum in the right frontal sinus, dotted line marks the suture between
the frontal bone on the one hand, and the nasal and superior maxillary bones on
the other hand. m.t. Middle turbinate. /. Inferior surface of frontal sinus
(orbital portion), t.c. Triangular cartilage of nasal septum.
Plate 57.
'^?^V
COROXAI. SlXTIOX THKorCrH POSTKRIOR PORTION OF FrONTAI, SiXUS PASSING
Through Nasal Canai,.
F.F. Front'al sinuses each divided by a septum (,?). i.s. Inter-frontal septum.
f.c. Frontal crest. })i.t. Left middle turbinate containing a cell. Arrow passing
through turbinate fossa to frontal sinus, n.d. Nasal ducts with probes. A. An-
trum. /./. Inferior turbinate, i.ni. Inferior meatus, in. in. middle meatus, s.iii.
Superior meatus. a. a. a. Anterior Ivthmoid cells opposite lachrymal bone.
s.H. Septum nasi.
CuKoxAi, Section Thkoic.h Ostium Frontalk ok Both Sini'SES,
Posterior Hai,f.
F. PVontal sinus, o.f. Ostiuin Frontale (posterior half) at apex of turbinate
fossa, c. Cell in left middle turbinate, a.a.a. Anterior ethmoid cells, opposite
lachrymal bone. b.b. Anterior ethmoid cells internal to Ostium frontale. A.
Antrum, i.t. Inferior turbinate, in.t. Middle turbinate, s.n. Septum nasi.
Plate 59.
Coronal Section Through the Left Ostium Maxillare and Behind the
Right Ostium Maxii^lare, as Shown By Arrow passing
from Infundidulum to Antrum.
A. Antrum. U. Unciuate process, f.c. Frontal crest. J./>. Frontal Bulla.
m.t. Middle turbinate, a.a.a. Anterior ethmoid cells. B. Bulla ethmoidalis on
section. »t.7n. Middle meatus.
Plate 60.
Coronal vSection through Frontal Sinus Passing Through Nasal Ducts,
AS Shown bv Probk in Left Duct. {>i.d.)
F. Frontal sinus, posterior wall. /..v. Frontal septum, becoming thicker to-
ward the floor of the right sinus, m.t. Middle turbinate with very broad lower
border, in consequence of a deep turbinate sinus. A. Antrum, a. Anterior
ethmoid cell.
Plate 6t.
Coronal vSection, Anterior Portion, Passing Through Right Ostium
Maxillare, but Posterior to that on the Left Side, as shown by
Arrow Passing Into Infundibulum. Probe on Right Side, in
INFUNDIBULUM. An ARROW PASSES FROM LEFT
Turbinate Fossa to Frontal Sinus.
F. Frontal Sinus, showing superior and inferior walls. B. Bulla ethmoidalis
(left) on section, m.t. Middle turbinate, r. Processus Uncinatus. A. Antrum.
f.c. Frontal crest.
CoRONAi, .Section, Postkrior Portion, just Anterior to Bulla Ethmoidalis
ON Right Side, but on Left Side Bulla is Seen on Section.
/'. Prontal sinus, showiiiff posterior and inferior walls. B. Bulla ethmoidalis.
a.a. Anterior ethmoid cells just a])Ove Bulla. w.A IVIiddle turbinate much curled,
forming a deep sinus turVjinalis {s.t.) i.m. Inferior meatus, in.in. ^Middle meatus.
s.m. Superior meatus, s.n. Septum nasi with prominent spur. A. Antrum, e.g.
Crista Galli.
Plate 63.
Coronal Section Passing through Frontal Sinuses, Right Nasal Duct
(arrow) and both Antra. Anterior Portion.
.-/. Antrum. F. Frontal sinus. /./. Anterior extremity of inferior turbinate.
iit.t. Anterior extremity of middle turbinate, s.n. Septum nasi. _/..?. Thick septum
between frontal sinuses, f.c. Frontal crest. A wire is seen passinsj across a thick
portion of bone just anterior to the Hiatus frontalis, at the articulation of the
frontal bone with the nasal bone and the nasal process of the superior maxilla.
Plate 64.
CoRONAi. vSection Through the Frontal Sinus and Nasal Ducts.
F. Frontal sinus, f.s. Frontal septum. 7i.c. Nasal canal. A. Antrum. O.
Orbital fossa, s.n. vSeptum nasi. /./. inferior turbinate, ni.t. Middle turbinate.
CoROXAi, Section, Antkkiok I'uktiox Passing Thkui gh Uoth Ostia ^Iaxil-
I.AKIA AND THK POSTERIOR ANGLES OF THE FrONTAL SiNl'SES.
/-'. Frontal sinus. . /. Antrum. o.))i. Anterior portion of Ostium maxillare.
/. Processus I'ncinalus. On right side arrow passes through Ostium maxillare
into Infundibuluni to appear in a cell opposite lachrymal l)one, and a second arrow-
passes through the turbinate fossa to the frontal sinus, a.a. Anterior ethmoidal
cells opposite lachrymal bone. /. Infundibuluni. of. Anterior portion of Ostium
frontale. /. /". Turbinate fossa. /./. Inferior turbinate. in.l. Middle turbinate.
c. Cells in middle turbinate bone. s.n. Septum nasi with spur. /•. Roof of nasal
fossa.
Coronal Section Through Ostium Maxii,i,are, Posterior Portion just
IncIvUding the Posterior Angi,e of Frontai^ Sinus.
F. Frontal sinus. U. Uncinate process. B. Bulla ethnioidalis showing two
cells, o.m. Posterior portion of Ostium niaxillare. A. Space occupied by An-
trum. O. Orbital fossa, a.a.a. Anterior ethmoidal cells, iii J . Middle turbinate.
Plate 67.
>'^ ■l.J^^'f"
A-^?^'^'
Coronal Section Through Ostium Maxii.i.ark, Anterior Portion. On
Left Side Bulla Ethmoidalis Removed, Showing Arrow Pas-
sing Through Ostium Maxillare and Infundibulum
TO a Large Frontal Bulla.
B. Large Bulla ethmoidalis on section. /. Probe passing from Antrum to a
frontal bulla seen on section, f.b. Frontal bulla. 2. Probe passing through tur-
binate fossa to the frontal sinus. C. Processus Uncinatus. A. Antrum. i.m.
Inferior meatus. w.;«. Middle meatus /./. Turbinate fossa,
nate. »i.i. Middle turbinate, c. Cyst in Mucous membrane
Anterior portion of Ostium maxillare. i. Infundibulum. s.ti.
large spur. See Plate 68.
/./. Inferior turbi-
of Antrum. o.in.
Septum nasi with
Plate 6S,
Same Spkcimkn, Posterior Portion.
A. Antrum, o.m. Ostium maxillare, posterior edge. r. Cysts in mucous mem-
brane of Antrum. C\ Processus Uncinatus. /./. Inferior turbinate. /«./. Middle
turbinate. B. Bulla ethmoidalis on section composed of several cells. /•'. Poster-
ior angles of frontal sinus. /. Cell in right turbinate bone. s.». vSeptum nasi with
large spur.
Coronal vSkction, Postkriok to Ostium Maxii.i^are which
Contains a Probe.
A. Antrum. B. Bulla ethnioidalis very broad and overhanging. /./. Inferior
turbinate. tuJ. Middle turbinate. i.)>i. Inferior meatus, vi.t/i. Middle meatus.
U. Processus Uncinatus. a. a. Anterior ethmoidal cells, e.g. Crista galli. /.
Internal wall of lateral mass.
Plate 70.
Coronal Section, Anterior Portion, Through Ostium Maxillakh and
Posterior Portion of a Large Frontal Sinus ;
Septum of the Nose Removed.
A. Antrum with small cysts (c). Probe passes from Antrum through Infun-
dibulum to frontal sinus. The InfuuiHbulum is converted into a canal bv the
approximation of the Uncinate process and ethmoid bulla. B. Ethmoid bulla con-
taining two cells. /•'./•". Frontal sinus (/>) posterior wall (/) inferior wall. /./. In-
ferior turbinate, in.t. ^Middle turbinate containing a very large cell which opens
into the superior meatus, as shown by arrow. fJ\ .\nterior wall of frontal l)ulla.
m.m. Middle meatus, s.m. Superior meatus, c.^-. Cristagalli. /. Turbinate fossa
See Plate 71.
Plate 71.
Posterior Portion of Sppximen, Figurkd in Pi,ati<; 70.
F. Frontal sinus, f.h. Frontal Bulla on section. . /. Antrum. o.i>i. Ostium
maxillare posterior portion. /'./. Inferior turbinate. ;;/./. Middle turbinate con-
taining posterior half of cell seen in Plate 70. l\ I'ncinate process. B. Bulla
ethnioidalis in contact with Uncinate process, i. Iiifundibulum.
Plate 72.
Horizontal Skction at the Lkvel ok the Lamina Cribrosa vShowinc; a
Considerablp: Portion of the Floor of the Left Frontal Sinis.
/■'. Frontal sinus. I.e. Lamina cribrosa, a small portion on either side of the
Crista galli {eg), f.s. Septum between the frontal sinuses. /. Posterior ansjle of
left frontal sinus, a.a.a. Some anterior ethmoid cells, i'. Sphenoidal sinus,
septum to right of median line. p.e. Posterior ethmoid cell.
Horizontal Section just above the Ostium Maxii.i.ark Looking
Downward.
71. s. Nasal septum. ./. Apex of Antrum, o.in. Ostium ^Nlaxillare. ('. Pro-
cessus Uncinatus. ;«./. Portiou of middle turbinate. .V. Left sphenoidal sinus.
Arrow passes down right Infundibulum through Ostium maxillare to .\ntrum.
Plate 74.
HoRizoNTAi, Section Jist Bhlow the Lamixa Cribrosa Lookinc Downward,
Showing Numerous Anterior and Posterior Ethmoidal Cells.
a.a.a. Anterior ethmoidal cells, p-p-p- Posterior ethmoidal cells. I'. I'pper
extremity of I'ucinate process. )n.t. Anterior extremity of middle turbinate
meeting the nasal process of the superior maxilla in front. /. Turbinate fossa.
.S". Sphenoidal sinus. Arrow passing down Infundibulum lo Antrum. ;/..v. Nasal
septum. E. Eyeball, n.c. Nasal cavity.
Plate 75.
Horizontal Section just Above Ostium Maxi^lark Looking Uownwakd
Through The Middi^e Turbinate Showing its upper Horizontal
Portion. Arrow Passes Down Left-Infundibulum
Through Ostium Maxillare to Antrum.
0.1H. Ostium Maxillare. U. Unciuate process. Ji.d. Nasal duct. n.c. Nasal
cavity, ni.t. Middle turbinate, showing its horizontal portion, s.t. Superior tur-
binate, posterior extreniit)'. O. Orbital surface of Antrum. S. Sphenoidal sinus.
5. External concave surface of middle turbinate showing sinus turbinalis. B.
Bulla ethmoidalis (lower portion). />. Po-sterior ethmoid cell.
Plate 76.
A
/
■\
>^
Horizontal Section just above the Lamina Cribrosa Showing Floor of
Frontal Sinus.
F. Frontal sinus. Arrow passing through right Ostium frontale. j .b. Frontal
Bulla, i. Inferior wall of frontal sinus, corresponding to inferior lamina of frontal
bone. (Orbital portion), p. Posterior wall of frontal sinus corresponiling to the
superior lamina of the orbital portion of the frontal bone. e.g. Crista galli. f.s.
Septum between the frontal sinuses. I.e. Lamina cribrosa. C. Anterior cranial
fossa.
Plate 77.
HoRizoNTAi, Section Just Bklow Lamina Cribrosa, Looking Downward,
Showing Numerous Anterior and Posterior
Ethmoidal Cells.
s.ii. Septum nasi, a.a.a. Some anterior ethmoidal cells, ppp- Some posterior
ethmoidal cells, n.f. Naso-frontal canal. /. Apex of turbinate fossa, n.c. Nasal
cavity. S. Sphenoidal sinus with septum far to the right of median line.
U. Upper extremity of uncinate process, ni.t. -Anterior upper extremity of middle
turbinate. E. Eyeball. ;/. Nasal bone. //./>. Nasal process of superior maxilla.
/. Lachrymal bone. o.p. Os Planum, .\rrow passes down into right naso-frontal
canal from right frontal sinus.
Plate 78.
Horizontal vSection of same Specimen at a Lower Level than Plate 77,
Looking Downward.
s./i. Nasal septum. «.r. Nasal cavity. ;/.(/. Nasal duct. C'. Processus I'nci-
natus. /. Infundibuluni on rij^ht side through which the arrow seen in Plate 77,
continues to the antrum, which has been exposed on the right side onh*. (J.a.a.
Some anterior ethmoidal cells, numerous opposite left lachrymal ])one. /. Turbi-
nate fossa. (?.;/. Agger Nasi. /.re. Internal lateral wall of labyrinth continued
anteriorly as the middle turbinate bone. .S'. Sphenoidal sinus. />./>./>. Posterior
ethmoidal cells.
Plate 79.
Horizontal Section, Looking Upward, ]\Iade at a Levkl so as to Cut
THE Apices of the Antra.
n.c. Nasal cavity, n.s. Nasal septum. ./. Apex of Antrum. E. Eyeball.
a.ni.f. Anterior extremity of middle turbinate. p.)ii.f. Posterior extremity of
middle turbinate, c. Cells in middle turbinate, a.a.a. Some anterior ethmoidal
cells, p.p. Posterior ethmoidal cells. ;/./'. Naso-frontal canal. ('. Processus Un-
cinatus. f.c.i. Fissura ethmoidalis inferior, with free edge of superior turliinate
toward the medium line. vSee plate 80.
Plate 80.
IIOKIZOXTAL vSkCTIOX, OTHKR HAI^F OF PLATE 79, LoOKIXc; DOWNWARD.
Arrow Passf:s down Naso-Frontal Caxal to Antrum.
.4. Antrum. E. Eyeball. U. Processus Uiicinatus. a.m.t. Anterior portion
of middle turbinate, p.m.t. Posterior portion of middle turbinate showinj^ its
horizontal aspect. /. Infundibulum. /<'. Bulla ethmoidalis on section. m.m.
Middle meatus, t. Turbinate fossa. t\ Cell in middle turbinate, a.a.a. Some
anterior ethmoid cells. P-P-p- Some posterior ethmoid cells. ,?. vSinus of the
Bulla ethmoidalis on the left side. 11. c. Nasal cavity, n.s. Nasal septum.
Plate 81.
vShowixg line of Incision for Osteo-Plastic Operation, part ok which
IS Concealed by the Eyebrow. It follows, in a Measure, the
Natural Wrinkles of the Skin. 2. Incision for Appro.\ch-
iNG THE Inferior Wall of the Frontal Sinus and
Anterior Ethmoidal Cells.
Plate 82.
vShowixg Boneflap Turxed Down, axd Frontal Sixus Exposed. Posterior
Wali, of Sinus to be seex in the Background.
Plate 83.
Mi'CocKLE Ixvoi.viNC. J.iUT I'kuntai, vSinus. Kvk I)iSLOCAT.:n Downward
AND OiTWAKD. vSee Case 4.
Plate 54.
Combined Empyema of the Frontal vSinus, the Antrum of Highmore, and
THE Anterior Ethmoid Cells. See Case 3.
Plate 85.
DouBi,E Frontal Pneumatocele, Reported by Warren, Figured by
Albert ; IvEhrbuch der Chirurgie.
Plate 86.
Mucocele. Albert, Lehrbuch der Chirurgie.
Plate 87,
Horizontal Section just above the LeveIv of the Lamina Cribrosa.
Upper Half of Section, Looking into large Frontal Sinuses
Containing Numerous Septa.
/'. F'rontal Sinus. /..?. Inter-frontal septum. .?. Irregular septa. Z".*^. P'rontal
bulla, a.a.a. Anterior ethmoid cells, p'p-p- Posterior ethmoid cells. S. Sphe-
noidal sinus, n.c. Nasal cavitv. vSee Plate 88.
Plate
Lower Half of Specimkn Figured ix Plate 87, Looking Downward.
Showing the Floor of large Frontal Sinuses. Arrow
through Ostium Frontale.
F. Frontal sinus, /..v. Inter-frontal septum. I.e. lamina cribrosa. c.o;. Crista
galli. /.(6. Frontal Inilla. (/. ./>./>. Posterior ethmoid
cells. S. Sphenoidal sinus, n.c. Nasal cavity.
Plate 89.
Dr. Pii.chi!;r'.s Case of Empyema of the Frontal Sinus.
INDEX.
Abscess of frontal sinus, 62, 79, 127.
Acute inflammation, 60.
After-treatment, 117.
Agger nasi, 32, 46, 47.
Antral drainage, 45.
Antrum as a reservoir, 85, 122.
Association of sinus affections, 83, 1 19,
120, 122.
B
Bibliography, 129.
Bone-flap, 112.
Bulla ethmoidalis, 39.
frontalis, 46, 48.
Cases, 118.
Cells in middle turbinate bone, 30, 33.
Cerebral fossa, 76.
Chronic inflammation, 60, 64.
Concha bullosa, ^2-
Cribriform plate, 16, 21.
Crista galli, 22.
Cysts of mucous membrane, 65.
D
Development of frontal sinus, 17.
Diagnosis, 77.
Diphtheritic inflammation, 64.
Drainage from infundibulum, 45.
Ethmoid bone, 15, 21.
Ethmoidal bulla, 39.
cells, 22, 29, 37, 48, 99.
fissures, 29.
Ethmoidal inflammation, 83, 99.
notch, 15.
Etiology, 55.
External operations, loi, 108.
FissurDe ethmoidales, 29.
Fistula, 62, 72, 79, 127.
Foramen crecum, II.
Fossa turbinalis, 47,
Frontal bulla, 46, 48,
crest, II.
septa, 20.
septum, 12, 19.
Frontal sinus, abscess of, 62.
acute inflammation of, 60, 11 8.
angles of, 17.
anterior surface of, 9.
blood-supply of, 51.
borders of, 16, 17.
chronic inflammation of, 60,
64.
diverticula from, 50.
frequency of inflammation of,
58.
inferior surface of, 13, 49, 109,
112.
internal surface of, 12.
mucous membrane of, 51.
nerve-supply of, 52.
occurrence of, 18.
pathology of, 59.
perforation of walls of, 63.
posterior surface of, 11.
Glabella, 10.
^33
134
INDEX.
H
Hemicraiiia, 78.
Hiatus frontalis, 15, 27, 49.
historical, 54.
maxillaris, 43.
semilunaris, 41.
I
Inferior ethmoidal turbinate, 15, 28, 29.
Infundibulum, 43, 46.
Intranasal treatment, 91.
Irrigation, 91.
Lachrymal bone, 23.
dehiscence, 25
Lamina cribrosa, 16, 21, 28.
papyracea, 22.
perpendicularis, 16, 21.
Lateral mass of ethmoid, 15, 22, 28.
M
Middle turbinate bone, 15, 28, 29, 81,
lOI.
Migraine, 78.
Mucocele, 73, 119.
N
Nasal bone, 27.
eminence, 10.
fossa, inflammation in, 80.
process of superior maxilla, 25.
Naso-frontal canal, 47.
Neuralgia, 78.
o
Operculum, 32.
Orbital dehiscence, 41.
fossa, 76, 78.
Os planum, 22, 28.
Osteomata, 67.
Osteoplastic resection, 112.
Ostia eihmoidalia, 29, 38.
Ostium frontale, 49, 50, 53, 127.
maxillare, 44.
Pathology, 59.
Pneumatocele, 75.
Polypi, 60.
Probing the frontal sinus, 52, 91.
Processus uncinatus, 34.
Prognosis, 89.
Promontorium, 39.
Sinus turbinalis, 30.
Superciliary ridge, lo, 50.
Supraorbital arch, 9.
Symptoms, 68.
Syphilis, 58, 68.
Systemic infection, 57.
Transillumination, 18, 82.
Trauma, 55, 128.
Treatment, 89.
after-treatment, 117.
external operations, loi, 108.
intranasal, 91.
perforation of floor of sinus, 97.
Tuberculosis, 57, 68.
Tumors, 68, 75, 79, 119, 126.
Turbinate fossa, 47.
cells, 30, 33.
sinus, 30.
u
Uncinate process, 34.
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