While theoretically these would seem to be the reasonable causes of antral dis ease, yet the relation of antral suppura tion to pre-existing nasal disease is less apparent and direct than is ethmoidal suppuration to iniddle-turbinated in flammation. We can hardly realize a severe middle-turbinated affection which might not eventually involve the eth moidal labyrinth. But in the case of the maxillary sinus, while theoretically it is easy to understand the extension of in flammation from the middle meatus through the maxillary opening, yet the antrum seems anatomically to be a cavity more isolated and consequently not shar ing so intimately in nasal inflammations as do the ethmoidal cells. We can also understand that a rhinitis excited by a specific bacillus, as in the intense coryzas an eruptive disease, may involve the antrum; but our experience would seem to confirm the belief that, where sup puration of the antrum exists alone or precedes the suppuration of any other sinus, it originates quite as often from caries of the teeth or disease of the supe rior maxilla as from the ordinary forms of rhinitis. There are a large number of cases of empyema of the antrum which are clearly secondary to ethmoidal sup puration, in which case the antrum is filled with the pus, which runs down from the ethmoidal cells over the outer wall. Transillumination often shows the max illary sinus clouded when there have been no acute symptoms abort the cheek which would indicate active inflammation.
Many authors speak of diseases of the middle meatus as competent factors, but such affections are vague and are seldom appreciated except as associated with sup purative ethmoiditis and polypi. The most common source of pus in the an trum is, first, from the ethmoidal cells above; second, the form of suppurative inflammation caused by carious teeth; and, last, a secondary involvement of the antrum from especially severe forms of rhinitis.
Treatment. — The antral cavity must necessarily be drained of pus and thor oughly disinfected whether it be the primary seat of trouble or secondarily involved. When it is simply the recep
tacle of pus from other sources, washing alone with suitable disinfecting solutions —such as a 10-per-cent. solution of boro formalin or borolyptol, 1 to 10,000 mer curic bichloride, Seiler's or Dobell's solu tion, 10-per-cent. solution of peroxide of hydrogen—will be sufficient for the treatment of this cavity while other forms of intranasal disease are being remedied. But when there is a sup purating focus in the antrum itself, and the lining walls of the cavity have de generated into fungoid granulations and polypi, it will be necessary to make the opening into the antrum so large that a curette can be used and that suitable dressings can be employed. If the teeth are perfectly good on the affected side and the pus in the antrum is from other sources, then it may be sufficient to make the opening into the antrum through the middle meatus. The cav ity may be washed out by means of a small tipped syringe, or a small-sized Eustachian catheter. But where degen erative changes have taken place in the antrum, and especially where there is evidence of dental disease, an opening made by trephining through the alveolar process will be much more satisfactory. After such an opening has been made the patient may be sent to the dental surgeon, who fits a suitable metal tube into the opening long enough to extend from the alveolar process above the floor of the antrum, so as to avoid clogging of the inner opening. This tube is held in position by a clasp about the nearest tooth. Disinfecting washes should be employed several times a day in the beginning, but later the strength of the solution should be diminished and they should be employed less frequently until the cessation of the pus through the tube will allow the intermission of all washes. Sometimes after long washing such pow ders as bismuth, boric acid, aristol, and proper combination of all of aid materially in restoring the lining of the antrum to a normal con dition. Extensive curetting will some times be found necessary.