Further Results of Opera- 
tive Treatment of Chronic 
Frontal Sinusitis. 
J. H. BEY AN, M. D., 
BY 
WASHINGTON, D. C. 
■Neto Yorfe Metrical journal 
REPRINTED FROM THE 
/or December 17, 1898. Reprinted from the New TorTc Medical Journal 
for December 17, 1898. 
FURTHER RESULTS 
OF OPERATIVE TREATMENT OF CHRONIC 
FRONTAL SINUSITIS * 
By J. H. BRYAF, M. D., 
WASHINGTON, D. C. 
The difficulties that are met with in the treatment 
of chronic suppurating frontal sinusitis are so great 
that I feel that any information regarding the progress 
made in its treatment will have the effect of still fur- 
ther improving our operative methods, and it is with 
this object in view that I desire to call your attention 
to some further operative experience in the treatment 
of this obstinate disease, illustrated with the report of 
two cases: 
Case I.—Chronic Suppurating Frontal Sinusitis; 
Caries of the Fronto-ethmoidal Cells; Orbital Abscess; 
Fistulous Opening at the Inner Angle of the Orbit.—l 
saw this patient, a young man eighteen years of age, 
for the first time September 10, 1897, in consultation 
with Dr. Belt, to whom I am indebted for the follow- 
ing history of the case: In the early part of April of the 
* Read before the American Laryngological Association at its twen- 
tieth annual congress. 
Copyright, 1898. by D. Appleton and Company. 2 
CHRONIC FRONTAL SINUSITIS. 
present year the patient suffered from a sharp attack of 
influenza which was accompanied by severe frontal head- 
aches. May 3d he consulted Dr. Belt for a severe pain 
in the left eye. At this time the left upper and lower 
lids were red and swollen, and there was also consider- 
able chemosis of the conjunctiva. The eyeball was 
immovable, owing to the great swelling of the orbital 
tissues. The swelling of the upper lid increasing, an in- 
cision was made at the inner canthus and a large quan- 
tity of pus evacuated; and on introducing a probe into 
the wound it was found to pass into the frontal sinus 
through a small opening at the inner angle of the orbit. 
The wound was cleansed with a two-per-cent, formalin 
solution and packed with iodoform gauze. Owing to 
the very ansemic condition of the patient, further opera- 
tive measures were not deemed advisable until his gen- 
eral health improved. He was accordingly put on a 
course of tonics, and the wound cleansed daily with 
hydrogen dioxide and a boric-acid solution. 
When I saw the patient, September 10th, there was 
a small fistulous opening at the inner angle of the left 
orbit through which pus in considerable quantities was 
discharging. There was a slight drooping of the upper 
lid, but there was no swelling of the skin over the fron- 
tal sinus and no pain on pressure. 
Examination of the nose showed the left middle tur- 
binate slightly enlarged, but no secretion was observed 
to pass from either nostril. 
September 17th, the patient was admitted to the 
Episcopal Eye, Ear, and Throat Hospital, when, after 
shaving the eyebrow and thoroughly cleansing the parts, 
an incision was made along the eyebrow, commencing 
at a point just within the supraorbital notch and ex- 
tending to the nasal boss. After elevating the skin 
and periosteum a small opening in the orbital plate of 
the frontal bone, at its inner angle and just under the 
supraorbital ridge, was found, communicating with the 
frontal sinus. This opening was enlarged by means of 
the gouge and rongeur sufficiently to admit of a thor- 
ough examination of the cavity, which was found filled CHRONIC FRONTAL SINUSITIS. 
3 
with granulation tissue, and it was also the seat of caries 
at its juncture with the fronto-ethmoid cells. The sinus 
was thoroughly curetted, removing all granulation and 
carious tissue, and an attempt was then made to pass 
a probe through the fronto-nasal duct, but, owing to 
the complete obliteration of this canal, a passage had to 
be made by passing a trocar through the sinus into the 
nose. The cavity was then irrigated with a solution of 
bichloride of mercury, 1 to 3,000, a self-retaining drain- 
age tube passed into the nose, and the wound closed 
and hermetically sealed with iodoform and collodion. 
The subsequent treatment consisted in the daily irriga- 
tion of the sinus through the drainage tube with a 
saturated solution of boric acid. At the end of a week 
the patient was discharged from the hospital, the ex- 
ternal wound having healed, and at the end of ten days, 
there being no secretions from the frontal sinus, the 
drainage tube was removed. - 
This patient made an unusually rapid recovery and 
has had no further trouble up to the present date. May 
10, 1898. The scar from the operation is not visible, 
being entirely concealed by the hair of the brow, but 
there remains a small pit just under the inner angle 
of the orbit, resulting from a contraction of the tissues 
at the seat of the fistula, caused by the orbital abscess. 
This is noticeable only on close inspection, and is some- 
what annoying to the patient on account of the diffi- 
culty in keeping it clean. 
Case 11. Chronic Suppurating Frontal Sinusitis; 
Caries of the Ethmoid Cells and Middle Turbinate 
Bone.—Miss X., aged twenty-one years, an anaemic 
young woman, came under my observation December 
33, 1897, giving the following history: Her health had 
been excellent up to three years ago, when she con- 
tracted a severe head cold which was accompanied by 
frontal headaches of considerable severity. These head- 
aches have been increasing in intensity until now they 
are almost unbearable. The nasal secretions have also 
been increasing in quantity and have recently become 
foetid. Examination of the left side of the nose shows 4 
CHRONIC FRONTAL SINUSITIS. 
a profuse purulent secretion in the nasal chamber com- 
ing through a cleft in a very much enlarged middle 
turbinate bone, which is found adherent to the lateral 
wall of the nose, thus completely obliterating the middle 
meatus. The probe revealed considerable caries of the 
middle turbinate, and I was able to pass it some dis- 
tance through this body into the anterior ethmoid cells, 
showing them also to be in an advanced stage of caries. 
The right nasal cavity was found to be normal. There 
is no swelling of the skin of the frontal region, but 
slight pressure above and below the left supraorbital 
ridge is attended with severe pain. The movements of 
the eye are not interfered with, but she complains of 
intense pain back of the eyeball. The general condition 
of the patient was not at all good. She complained of 
lassitude, indigestion, morning nausea, and she found 
great difficulty in attending to her household duties. 
An external operation was advised as the only means 
of completely relieving the patient of her serious con- 
dition, but she was very much averse to submitting to 
this method of relief at this time. I therefore contented 
myself with removing by means of the curette, at vari- 
ous intervals, as much of the carious ethmoid cells and 
middle turbinate body as could be safely done through 
the nose. Her condition was not at all improved by 
these measures, but it grew gradually worse. On March 
25th she reported that a profuse purulent secretion, 
mixed with a large quantity of blood, was blown from 
the right nostril, thus showing the sseptum between the 
sinuses had broken down and the right cavity had be- 
come involved. The headaches increasing in severity, 
the seriousness of her condition was again pointed out 
to her, and a radical operation insisted upon. To this 
she acceded, and she was admitted to the Episcopal Eye, 
Ear, and Throat Hospital, April 10, 1898. 
April 11th, after shaving the eyebrow and thoroughly 
cleansing the field for operation, an incision was made 
through the eyebrow, commencing at a point just within 
the supraorbital notch and continuing over the nasal 
boss; the flap thus formed, composed of skin and peri- CHRONIC FRONTAL SINUSITIS. 
5 
osteum, was raised to a sufficient extent to admit of the 
removal of a centimetre of bone by means of a small 
crown trephine applied just above the supraorbital 
ridge and about two or three lines from the median 
line. On exposing the cavity it was found filled with 
thick, foetid pus and granulation tissue. After the re- 
moval of all secretion and granulations from the sinus 
its posterior wall was found to be carious in several 
places, the frontal sseptum broken down, the fronto- 
ethmoidal and the ethmoidal cells in an advanced state 
of caries. With a sharp spoon all caries of the walls 
of the cavity was scraped away, the sseptum was com- 
pletely removed, as was also all diseased bone between 
the sinus and the nose, thus leaving a large communi- 
cation between them. After thoroughly irrigating the 
parts with a solution of bichloride of mercury, 1 to 
3,000, the lining membrane of the sinus was touched 
with a twenty-per-cent, solution of the chloride of zinc, 
and the cavity packed with iodoform gauze, the free 
end of which was brought out through the nose. The 
periosteum was brought down over the opening and 
carefully secured with catgut sutures, and then the ex- 
ternal wound was closed by means of interrupted 
sutures and hermetically sealed with iodoform and col- 
lodion. 
April 12th.—The patient has reacted well from the 
operation; the temperature is normal, and she expresses 
herself as being free from pain for the first time in three 
years. 
Hth.—There being some odor from the nose, the 
gauze was removed, but there was very little secretion 
following an irrigation with a saturated boric-acid solu- 
tion. 
17 th.—The cavity has been irrigated daily with a 
boric-acid solution, and, while the secretions have slight- 
ly increased, there has been no pain and no rise of tem- 
perature. To-day the stitches in the eyebrow were re- 
moved, the wound having healed. 
20th.—There was a slight breaking down of the 
wound and a slight discharge of pus from its inner 6 
CHRONIC FRONTAL SINUSITIS. 
extremity caused by the retention of an overlooked 
suture. This small fistula was cleansed with a bichlo- 
ride solution and packed with iodoform gauze. The 
sinus was irrigated daily with a saturated solution of 
boric acid through a cannula passed through the nose. 
30th.—The secretions from the fistula in the eye- 
brow and also from the sinus had diminished to such an 
extent that the patient was discharged from the hos- 
pital, to return daily for treatment. 
May 4th.—The condition of the patient to-day was 
not so favorable. She suffered during the night with 
severe headache, slight chilly sensations, and a decided 
increase in the secretions from the nose. On examina- 
tion the whole frontal region was observed to be greatly 
swollen and sensitive to pressure. The temperature at 
2 p. m. was 101°. A probe passed into the sinus through 
the nose showed the opening perfectly free, showing 
that it was not the cause of any retention of pus; but 
on passing the probe through the fistulous opening at 
the inner angle of the orbit it was found to enter readily 
the opening in the frontal bone, and on its withdrawal 
considerable pus followed, showing a subperiosteal ab- 
scess had formed around the margins of the opening 
in the bone. After freely evacuating the pus, the wound 
was cleansed with a bichloride-of-mercury solution and 
packed with iodoform gauze. 7 p.m., temperature, 100°; 
the headache was entirely relieved, and the swelling 
very much reduced. 
sth.—The condition of the patient to-day is mark- 
edly improved, there being less secretion from the nose 
and from the external opening; the swelling is still 
further reduced; no pain; the temperature is normal 
and has remained so up to the present date. 
9th.—To-day there is no swelling in the frontal 
region and, while the quantity of secretion is very much 
reduced, there is still some pus coming through the ex- 
ternal opening, as well as from the nose. The daily 
irrigations and the introduction of a gauze wick in the 
external opening are still continued. CHRONIC FRONTAL SINUSITIS. 
7 
I have gone somewhat into detail in relating the 
histories of these two cases, because they illustrate two 
different phases of this affection, and I have endeavored 
to show that no matter how carefully the technique of 
these operations is followed out, infection occasionally 
follows; for it must he remembered that we are expos- 
ing an aseptic wound to an infection with a most viru- 
lent secretion when the sinus is opened, and notwith- 
standing the careful antisepsis employed it is not pos- 
sible in every instance to completely destroy the highly 
infectious character of this pus. 
Case I illustrates very well that variety of abscess 
of the frontal sinus which is so frequently complicated 
with orbital abscess, and consequently is met with more 
frequently by the ophthalmologist than by the rhinolo- 
gist. Case II is the variety that we, as rhinologists, see 
most frequently. The clinical history of these cases 
is probably the same up to a certain stage, and that is 
the complete occlusion of the fronto-nasal duct, when 
the pent-up pus makes a vent for itself at the thinnest 
part of the sinus, which is the inner part of the, floor, 
and we then have an orbital abscess resulting, which so 
frequently results in loss of vision. 
In my last communication on this subject, read at 
the meeting of the association in Washington, I stated 
my preference for the external method of operating upon 
these cases, believing that the intranasal methods were 
dangerous and failed to give complete relief in those 
chronic cases which were complicated with caries to any 
extent, and I advocated the operation as originally de- 
vised by Ogston and later practised by Luc—that is, the 
median operation with drainage through the nose by 
means of a drainage tube. While this is the method 8 
CHRONIC FRONTAL SINUSITIS. 
that has found the greatest favor with operators during 
the past eighteen months, I believe the method which I 
have described will be found to possess many advantages 
over the Ogston-Luc operation. In the first place, it 
does away with the median incision, which in many in- 
stances leaves a sear which is to a greater or lesser de- 
gree visible; while the incision through the eyebrow 
affords just as wide a field for the operation, and the re- 
sulting sear is completely hidden by the hair of the eye- 
brow. In the second place, the drainage tube, which in 
itself is frequently a source of great irritation, can be 
dispensed with. This, I think, is a great step in advance 
in the treatment of these cases, for the gauze for the 
first few days acts as a drain, and after its removal the 
opening between the nose and the frontal cavity being 
of sufficient size permits of a free and constant drainage 
from the sinus into the nose. 
The opening through the ethmoid bone should be 
large and sufficiently free to permit a complete re- 
moval of all caries of the ethmoid cells, which in my 
experience nearly always complicates chronic abscess of 
the frontal sinus. After the removal of the drainage 
tube the opening through which it passes has a tendency 
to contract, and if an occasion should arise after its re- 
moval for a continuance of the local applications to the 
sinus, the passage is frequently difficult to find, and the 
passage of instruments through it very painful. Such 
occasions arise frequently long after the patient has been 
discharged cured, as many of you who have had much 
experience with the treatment of abscesses in the acces- 
sory sinuses can testify to the readiness with which in- 
flammations in these cavities are reexeited by a simple 
rhinitis.