Cyst of the Maxillary Sinus. 
BY 
CHARLES H. KNIGHT, M. D. 
REPRINTED FROM THE 
Neb) York iHeDIcal Seutnal 
for January il, 1896. Reprinted from the New York Medical Journal 
for January 11, 1896. 
CYST OF THE MAXILLARY SINUS* 
By CHARLES H. KNIGHT, M. D. 
In a discussion on the accessory sinuses before the 
Congress of Physicians and Surgeons in 1894, Bryan, fol- 
lowing the usual custom, divided cysts of the antrum into 
three varieties: (1) Those due to dilatation of a follicle in 
the mucous lining of the antrum; (2) those resulting 
from cystic degeneration of a polyp; and (3) dentigerous 
cysts, internal and external. The last-mentioned, external 
dentary cysts, are, properly speaking, not antral cysts, 
since they arc primarily developed outside of the maxillary 
sinus and reach its interior only by eroding and breaking 
down its bony wall. 
Dropsy of the antrum {hydrops antri), or an accumula- 
tion of non-purulent secretion within the cavity, due to ob- 
struction of the ostium maxillare, is discarded by the 
majority of modern observers as a separate pathological 
condition. In the Revue de laryngologie, etc , September 1, 
1894, p. 786, a case is reported by Delie under the title 
Dropsy of the Antrum: Nasal Hydrorrhoea. The title 
would imply that here the ostium maxillare was not closed, 
* Read before the American Laryngological Association at its seven 
teenth annual congress. 
Copybight, 1896, by D. Appleton and Company. 2 
CYST OF THE MAXILLARY SINUS. 
whence the inference that serous effusion may take place 
into the antral cavity while its nasal orifice remains patu- 
lous. In his well-known work on Surgery (page 590), Fer- 
gusson remarks that in some cases the ostium maxillare 
becomes closed, and the accumulating mucus produces 
enormous distention of the antrum with great disfigure- 
ment. lie gives a drawing (Fig. 390) which is supposed to 
illustrate the foregoing condition in which the tumor rup- 
tured during life. 
A very animated discussion of this subject was pro- 
voked at a meeting of the Paris Surgical Society by a case 
of antral fistula consecutive to ?l dropsy of the sinus reported 
by Quenu. He succeeded in closing the fistula by a rather 
elaborate plastic operation, which was pronounced by 
Berger to be entirely useless, the difficulty in these cases 
being not to close but to keep open the artificial passage 
from the antrum. Berger affirmed that this and similar 
cases called dropsy were really examples of dentary cyst 
described by Magilot, and that dropsy of the sinus without 
suppuration was so rare as to be almost unknown {Journal 
of Laryngology, vol. ii, 1888, p. 278). Watson also, in his 
work on Diseases of the Nose (second edition, 1890, p. 
17a), condemns the designation " dropsy " as being alto- 
gether inappropriate, since it implies a false idea of pa- 
thology and aetiology. 
Many of the cases reported as hydrops of the antrum 
are believed to be really cystic formations originating in 
the mucous membrane. On the other hand, a belief in the 
existence of a genuine dropsy of the antrum has not been 
abandoned by all, as appears from a paper in the last vol- 
ume of the St. Bartholomew's Hospital Reports (vol. xxx, 
1894, p. 237) by W. J. Walsham. In reviewing the points 
in differential diagnosis he mentions bulging of the walls 
of the antrum, prominence of the cheek, protrusion of the CYST OF THE MAXILLARY SINUS. 
3 
eyeball, nasal obstruction, and yielding of the anterior wall 
of the antrum under pressure in the canine fossa as being 
" well-known symptoms of dropsy oj the antrum." 
The term is still retained by many others, and probably 
will remain in our nomenclature to distinguish a watery 
accumulation in the antrum, of whatever origin, from em- 
pyema. Heath, who gives a most satisfactory description 
of affections of the antrum in his work on Injuries and Dis- 
eases of the Jaws (p. 1G8), believes that the name should 
be discarded, and evidently thinks that all cases reported 
as hydrops antri were primarily cystic. It woul 1 certainly 
relieve us of much confusion if Heath's suggestion should 
be adopted. 
The frequency of cysts of the antrum is not very 
great. Luschka, quoted by Heath, found cystic growths 
in the antrum five times in sixty post-mortem examina- 
tions. Heath himself states that no instance of the kind 
was discovered by Beck in an examination of the antra 
of thirty subjects. Weber, quoted by Lefferts, in Ash- 
hurst's International System of Suryery (vol. v, p. 451), has 
reported three hundred and seven cases of tumor of the an- 
trum, twenty of which were cystoma. Undoubtedly a cyst 
mav exist for some time without exciting any disturbance. 
When pressure effects are produced, or the tumor ruptures 
and its contents escape into the cavity of the antrum and 
thence reach the nasal fossa, the patient is apt to seek 
advice. 
A study of some of the reported cases is of interest as 
bearing especially upon the questions of diagnosis and 
treatment. In the Medical Chronicle, July, 1894, two cases 
are recorded by G. A. Wright which in some features re- 
semble my own. In each of these cases the bony wall of 
the antrum had been displaced and more or less absorbed, 
and in each some of the teeth were carious. In one there 4 
CYST OF THE MAXILLARY SINUS. 
was a history of traumatism, two incisor teeth having been 
broken by a fall down stairs six years before. The treat- 
ment in each was by incision above the alveolus, where the 
tumor protruded, a clear watery fluid being drained off. 
The reporter does not venture to choose between a diag- 
nosis of dropsy of the antrum and mucous retention cyst, 
but suggests that either explanation may be possible. Tn a 
case reported by Morales (abstract in Journal of Laryn- 
gology, etc., vol. i, 1887, p. 186) of tumor of the left cheek, 
the diagnosis of cyst of the maxillary sinus was based upon 
the escape of seropurulent fluid from a spontaneous open- 
ing in the neighborhood of the second molar tooth. The 
sinus was opened under cocaine along the alveolus and a 
great quantity of fluid escaped. The cavity was drained 
and dressed antiseptically, and the patient is said to have 
been discharged cured in about three weeks. 
The diagnosis of these cysts is not always a simple 
matter. Heath cites Fergusson's case, in which prepara- 
tions had been made to remove the upper jaw for a sup- 
posed solid tumor, which was shown to be fluid by a pre- 
liminary explorative puncture (Lancet, London, June 29, 
1850). The same author refers to a case within his own 
knowledge, "in which a very able surgeon removed the 
upper jaw before discovering the error of his diagnosis." 
A parallel case is reported by Marchant (abstract in Journal 
of Laryngology, etc., vol. iv, 1890, p. 164), in which a den- 
tary cyst simulated a sarcoma and was treated by resection 
of the superior maxilla. A similar error might readily 
have occurred in my own case, but for exploration with the 
needle and translumination, the wall of the tumor being so 
tense and the mass itself so resistant that many who ex- 
amined it pronounced it a solid tumor. 
Cysts of the antrum may be single, as in several in- 
teresting cases described by Adams, who was the first to CYST OF THE MAXILLARY SINUS. 
5 
investigate this subject, or multiple, as in specimens por- 
trayed by Giraldes in his prize thesis (1853). The latter 
observer found cases in which the tumors were very numer- 
ous, the entire mucous lining of the sinus apparently having 
undergone cystic degeneration. 
The history of my own case is as follows: 
W. H. C., aged twenty-nine years, clerk, has always had 
excellent health. Eighteen months ago he first noticed a 
painless swelling of the gum at the root of the canine tooth 
of the left upper jaw. It grew steadily without pain or sensi- 
tiveness, and the left side of the face became noticeably 
prominent. The teeth have always been soft and inclined to 
decay, but never painful or ulcerated. There has never been 
any nasal stenosis or indication of catarrhal trouble. There 
is no distinct history of traumatism. The only point recalled 
by the patient is that in bowling, which he has practised for 
many years, lie has been in the habit of resting the heavy ball 
against his left cheek. Was the concussion, or possible con- 
tusion, thus produced an setiological factor in the case? 
At the time of his first examination the patient complained 
of nothing whatever, except the obvious deformity caused by 
the tumor in the left malar region. The mass pushed the 
upper lip forward, and seemed to reach nearly to the lower 
margin of the orbit. It extended from the ala nasi across the 
left side of the face. The skin was unchanged and not ad- 
herent. There was no feeling of crepitation or crackling, 
mentioned by many writers in describing these cases. The 
sense of fluctuation was so obscure that several who examined 
it believed it to be a solid tumor. The diagnosis of serous 
effusion was, however, very beautifully confirmed by the trans- 
lumination test, and still further by the exploring needle. 
On raising the upper lip the tumor could be plainly seen pro- 
truding in the gingivo-labial fold. The first bicuspid tooth 
was missing and the second was carious. There was no sen- 
sitiveness on percussion or palpation of the alveolus or of the 
tumor at any point. There was no malformation of the roof 
of the mouth, and the left nasal fossa was quite normal. 6 
CYST OF THE MAXILLARI SINUS. 
With the expectation of finding a cyst of the antrum, an 
incision an inch and a half in length was carefully made 
along the gingivo-labial furrow. What appeared to be a cyst 
wall was thus exposed. On attempting to dissect out the tu- 
mor it was found to be firmly adheren tto the bone, and it was 
finally ruptured. The lining membrane of the antrum seemed 
to constitute the cyst wall. A section of the membrane as 
large as a ten-cent piece was cut away for microscopic ex- 
amination. It was then discovered that the anterior bony 
wall of the antrum had been almost entirely absorbed, only a 
thin shell of bone being left near the nose. Upward of two 
ounces of thin, slightly turbid fluid were evacuated. Digital 
examination of the interior of the antrum discovered nothing 
abnormal. There was no exposed, necrosed, or carious bone, 
and no polypoid degeneration of the mucous membrane could 
be detected. On the contrary, the membrane seemed thin 
and closely attached to the bony walls of the cavity. The 
root of the second bicuspid tooth projected into the floor of 
the antrum, but was covered by intact mucous membrane. As 
its crown was badly decayed it was extracted. A director 
was passed with some difficulty from the antral cavity into 
the nasal fossa through the ostium. The cavity, having been 
washed out, was packed with iodoform gauze, and the lip was 
replaced, no other dressing being applied. No reaction or 
disturbance of any kind followed the operation. The gauze 
plug was removed on the second day and was not renewed. 
No sign of suppuration occurred. The opening through the 
alveolus gradually contracted until, at the time of the present 
report, four months since the operation, it has nearly closed. 
No indications of recurrence have as yet appeared, and the 
patient has no inconvenience from his small antral fistula. 
In the light of modern pathology this case is reported 
as one of cyst of the antrum, although it presents many of 
the clinical features which we might expect in true hydrops 
antri. It was impossible to distinguish a separate cyst 
wall, and it is difficult to believe that a cyst could have be- 
come so agglutinated to the walls of the antrum as to CYST OF THE MAXILLARY SINUS. 
7 
obliterate at all points a line of demarcation between its 
wall and the lining membrane of the antrum. Its disap- 
pearance is explained by absorption, the cyst rupturing 
into the antral cavity and every trace of the sac ultimately 
becoming effaced. The character of the fluid found in 
the cavity supports the cyst theory, since it resembled mu- 
cus in no respect, but, on the contrary, was a yellowish, 
slightly turbid serum. Cholesterin crystals are often met 
with in the effusion and are considered pathognomonic of 
cystic formation. In the present instance the examination 
of the fluid was negative, no cholesterin being found. An 
examination of the excised piece of tissue by my friend 
Dr Jonathan Wright failed to indicate whether it was the 
thickened lining of the antrum or a cyst wall. Ilis report 
is as follows: After having been stained, one surface of 
the specimen was seen to be lined by a thin layer of flat- 
tened epithelial cells (three or four rows deep usually). 
Diiectly beneath this was a layer of fibrous connective tis- 
sue with very few round cells or nuclei; but everywhere a 
dense crowd of red blood-corpuscles. At one point, near 
the edge and free from epithelial covering, were a few 
bundles of striated muscular tissue (?). There were but 
few blood-vessels and no glands, although in certain places 
the rea< tion with luematoxylon stain suggested the pre- 
existence of glandular structure destroyed by pressure. 
Beneath the dense fibrous layers which constitute most of 
the thickness of the specimen were areas of loose connect- 
ive tissue. 
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