TREATMENT OF CHRONIC EMPYEMA OFs THE 
ANTRUM OF HIGHMORE 
TEMPORARY OSTEOPLASTIC RESECTION OP THE 
ANTERIOR ANTRAL WALL 
N. SENN, M. D., Ph. D., LL.D., 
Professor of Surgery in Rush Medical College; Professor of Surgery in 
Chicago Policlinic; Attending Surgeon Presbyterian Hospital; 
Surgeon-in-Chief St. Joseph’s Hospital. 
(Reprinted from “ Pacific Medical Journal,” December, 1897.) 
Very little improvement has been made in these days of ag- 
gressive surgery in the treatment of chronic empyema of the 
antrum of Highmore. Every surgeon knows how obstinately 
chronic suppuration of this cavity resists the customary opera- 
tive treatment ‘described in our text-books of to-day. The 
operation usually resorted to is the one devised by John Hunter; 
it consists in opening the antrum through the socket of one of 
the molars, usually the second, with some kind of a bone drill. 
Christopher Heath recommends puncture of the antrum 
above the alveolus. Mikulicz devised a curved stilet with which 
he opens the antrum from the nasal side, puncturing the septum 
below the inferior turbinated, and by following the operation by 
prolonged drainage, aims to establish a free communication be- 
tween the nasal passage and the affected antrum. All of these 
procedures have their legitimate place in the treatment of sup- 
purating antral disease, but they fail in effecting a cure in all 
cases in which permanent pathological conditions maintain the 
suppuration, and which cannot be removed or corrected through 
such a small opening as is advised and made in all of these 
operations. The inflammation of the mucous membrane which 
lines the antrum in chronic antral disease frequently results in 
partial, and in some cases in complete, closure of the narrow 
communicating opening between the antrum and the nasal pas- 
sage, which in time causes retention of the products of th® 2 
Chronic Empyema of the Antrum of Highmore. 
suppurative inflammation in the diseased antrum. The inner 
wall of the antrum or base presents, in the disarticulated bone, 
a large, irregular aperture which communicates with the nasal 
fossa. “ The margins of the aperture are thin and rugged, and 
the aperture itself is much contracted by its articulation with 
the ethmoid above, the inferior turbinated below, and the palate 
bone behind. In the articulated skull this cavity communicates 
with the middle meatus of the nasal fossae, generally by two 
small apertures left between the above-mentioned bones. In 
the recent state usually one small opening exists, near the upper 
part of the cavity, sufficiently large to admit the end of a probe, 
the other being closed by the lining membrane of the sinus.” 
It is not difficult to conceive that chronic inflammation of the 
nasal or antral mucous membrane would frequently result in so 
much narrowing of this small opening as to become, frequently, 
a permanent obstruction, and that in some cases the opening 
would become completely obliterated. Drilling through or 
above one of the molar sockets would prove of no value in re- 
establishing the normal communication between the antrum and 
the nose; hence, the perforation made must be kept permanently 
open for the escape of the purulent discharge or secretion of 
the antrum. Prolonged or permanent drainage from the side of 
the mouth is also objectionable owing to the entrance from the 
mouth through the artificial opening of particles of food and 
infectious material. 
Nasal drainage, as advised by Mikulicz, is free from such ob- 
jections, but the opening made cannot be utilized to advantage 
in removing from the antrum foreign bodies, and permanent 
sources of irritation and infection which maintain the suppura- 
tion. Drainage tubes and strips of gauze used in keeping the 
artificial opening patent, have occasionally been lost in the 
antrum, and have been the sole cause of indefinitely prolong- 
ing the suppuration. In a case that recently came under the 
observation of the writer, the antrum had been opened by 
drilling through the socket of the second molar tooth, and the 
opening was plugged daily with a strip of iodoform gauze, after 
washing out the cavity. This treatment was continued for 
months without effecting any improvement. A profuse and 
very offensive discharge led to the belief that a sequestrum in the 
antrum was the cause of the continuation of the symptoms for 
which the operation had been performed. The antrum was now Chronic Empyema of the Antrum of Highmore. 
3 
opened by making a temporary resection of its anterior wall, 
when a number of strips of gauze were removed. 
In chronic cases that have resisted the ordinary treatment, the 
writer has resorted, for a number of years, to temporary osteo- 
plastic resection of the anterior antral wall, for the purpose of 
detecting and removing the cause of the chronic suppuration. 
After performing what is entitled to be called a radical oper- 
ation, a free communication is established between the antrum 
and the nasal passage, either by dilating the normal opening or 
by making a new one from the antrum into the inferior meatus, 
by perforating the thin, bony septum with a curved forceps. 
Disinfection of the cavity and thorough tubular drainage, com- 
plete the operation. 
The operation is performed under partial general anaesthesia. 
The cheek and lips must be well retracted, when a u-shaped 
incision is made through the mucous membrane and the peri- 
osteum down to the bone, in such a way that the anterior ver- 
tical incision falls just behind the eminence of the root of the 
canine tooth; the second vertical incision about three-quarters 
of an inch behind the first, and the connecting transverse 
incision at a point above the alveolus, on a level with the floor 
of the antrum. With a thin carver’s chisel, three-quarters of 
an inch in width, the anterior antral wall is cut in the same 
directions, and the bone at the base of the square quadrangular 
flap is fractured by inserting an elevator into the antrum through 
the transverse cut, and using it as a lever. The flap, composed 
of mucous membrane, periosteum and bone, is now turned 
upward, and through the opening the antrum is explored care- 
fully by inserting the little fiager. 
Projecting roots of carious teeth, caries of the inner surface 
of the antral walls, sequestra, fungous granulations, and the 
presence of foreign bodies, are the conditions most frequently 
found as permanent causes of suppuration. The use of the 
sharp spoon is indispensable in effecting mechanical removal 
of infected tissues or loose foreign substances. 
With a sharply curved forceps an adequate opening is made 
from the antrum into the nose at one of the points indicated 
above, and with the same instrument, or with a probe armed 
with a loop of strong silk thread, a fenestrated tube the size of 
a lead pencil is drawn through the antrum into the mouth and 
cut short near the opening in the antrum. With a rongeur 4 
Chronic Empyema of the Antrum of Highmore. 
forceps a small semicircular defect is made in the lower margin 
of the deflected quadrangular bone flap to furnish space for the 
drainage tube, when the flap is brought into position and sutured 
in place with two catgut sutures, which include only the mucous 
membrane and the periosteum. The two ends of the rubber 
tube are connected with a silk thread. The cavity is flushed 
daily with a saturated solution of boric acid or Thiersch’s solu- 
tion, and if the discharge is fetid or profuse, the irrigation is 
preceded by an injection of peroxide of hydrogen. As soon as 
suppuration ceases, the silk thread is out and the rubber drain 
drawn into the antrum; the same local treatment being con- 
tinued. The opening in the antrum on the side of the mouth 
closes in a short time, with little or no defect of the bony wall 
of the antrum, The nasal drainage should be continued for 
several weeks, long enough for the opening to become perman- 
ent and lined with mucous membrane. 
If further local treatment is found necessary after the drain 
has been removed, this can be done through an antral catheter, 
in the use of which the patient must be instructed, and which 
he soon learns to manipulate safely and with great dexterity. 
The radical treatment of chronic suppuration of the antrum, 
in the manner described above, has yielded ideal results in the 
hands of the writer in more than ten consecutive cases, and as 
the result of this favorable experience, he earnestly recommends 
it to the attention of his colleagues.