It is very unlikely that these sinuses are ever the seat of an isolated suppura tive process. We would naturally expect to find more or less disease of the nasal foss and other sinuses. In free sup puration from these sinuses the pus is naturally discharged into the naso-phar ynx. In sphenoidal abscess the reten tion of pus may cause in tracranial and ocular symptoms. The most significant symptom, however, would seem to be pus flowing down the posterior wall of the pharynx, which can be traced up to and over the body of the sphenoid into the posterior nasal cavity.
Treatment. — No one would advise curetting in a location so dangerously near the brain, but it is possible that a probe could be carried through the anterior nares behind and above the middle turbinated against the anterior face of the sphenoidal sinus, and in this way carious bone might be appreciated, drainage improved, and the cavity suit ably washed.
Inflammation of the Frontal Sinus.
While authors describe acute catarrhal and acute purulent inflammation of these cavities, such affections are as yet insig nificant from a clinical stand-point, un less a frontal abscess should chance to form from obstruction of the outlet of the sinus. We shall, therefore, restrict our observations to the subject of puru lent inflammation, either free or latent.
Symptoms.—The symptomatology of free suppuration of the frontal sinus is unsatisfactory and the diagnosis is usu ally made by the exclusion of cthmoid and antral suppuration—no easy task, especially as the two latter sinuses may themselves be suppurating. The pus in some cases drains away continuously, while in others it seems to collect slowly and produce local symptoms of pain, tenderness, aprosexia, etc. Under the latter circumstances the pus, after filling the sinus, may escape en masse, with marked relief of symptoms. When the exit is completely obstructed, as it may be from polypi, etc., a frontal abscess forms, recognition of which is compara tively easy.
Etiology.—The cause of suppuration of the frontal sinus is largely a matter of conjecture. Doubtless, such attacks often follow a severe coryza; but, as this affection is not believed to be due to pyogenic bacteria, the connection be tween the two is not apparent. Influ enza appears to be able to provoke the disease in many instances; but, in all cases in which suppuration of this sinus follows a severe coryza or influenza, the predisposition must be no inconsiderable factor. If a few pyogenic cocci were
present in the sinus, repeated attacks of simple inflammation or perhaps a single intense attack might be sufficient to de velop the virulence of the germ and pro duce suppuration; or in case of any serious intranasal affection involving the middle meatus such as hypertrophic rhinitis, polypi, ethmoidal or antral dis ease, if a pyogenic factor were present, infection could readily travel along the infundibular passage into the frontal sinus. Summing up, there appear to be three modes of possible infection: I. Repeated attacks of severe coryza, such as occur in a nose with marked septal anomaly, may rouse local pyogenic micro organisms to activity. II. In the course of severe infectious diseases, such as scarlatina or influenza, the specific germ of the disease may establish a purulent focus in the sinus. III. If there is pres ent anywhere in the nose or other sinuses a chronic suppurative process, especially in the neighborhood of the middle mea tus, the infection might be propagated to the frontal sinus.
Treatment.—Since suppurative inflam mation of the frontal sinus occurs almost always by direct extension from the nasal passages upward, it may reasonably be expected that when such abnormalities as polypi, deflected septa, suppurating eth moiditis, antral disease, and any form of chronic rhinitis,—when all these have been corrected,—the frontal sinus will rapidly return to its normal condition without further treatment than the nec essary cleansing. Unnecessary probing of the frontal region is injurious rather than beneficial. After proper surgical work has been performed to correct the nasal disease which has done the harm, sedative applications of suitable oils and quieting powders will do more to allay inflammation in the frontal sinus than will efforts to make high applications, astringent and cauterizing in character. The cases are very few which will require external operation to relieve retained pus. In two such cases seen by the writer a discharge through the natural opening was accomplished by hot fomentations, the patients being placed in a Turkish bath. Sprays of weak solutions of co caine may be sufficient to free the pas sages into the frontal sinus.