THE NOSE. 



103 



be discovered and enlarged as thought necessary. The region of the ethmoidal cells 

 is that from which mucous polypi of the nose take their origin. They are a common 

 accompaniment of suppuration of the accessory nasal cavities. They are usually 

 removed by snares introduced through the anterior nares or more rarely by forceps. 

 Caries affecting the anterior cells may extend into the orbit and the pus may form a 

 fluctuating tumor above the inner canthus of the eye. Care should be taken not to 

 mistake a meningocele for such a tumor. 



The sphenoidal sinuses are the most posterior, lying still farther back than 

 the ethmoidal. They open into the spheno-ethmoidal recess above and posterior 

 to the superior turbinated bone. Discharge from them goes into the pharynx and is to 

 be seen with the rhinoscopic mirror. They can be reached by first removing the 

 middle turbinated bone and then introducing a probe upward and backward from the 

 anterior nares for a distance of 7.5 cm. (3 in. ) in women and 8 cm. in men. They can 

 be drained by cutting away their anterior wall with punch forceps introduced through 

 the anterior nares. 



The maxillary sinus lies beneath the orbit and to the outer side of the nasal 

 fossae. It is the seat of tumors, often malignant, and inflammation; the latter 

 accompanied by an accumulation of mucus or 

 pus. The walls of .the sinus are thin, so we 

 find tumors bulging forward, causing a protrusion 

 of the cheek. They press inward and obstruct 

 the breathing through that side of the nose, or 

 they push upward and cause protrusion of the 

 eye by encroaching on the orbit. In operating 

 on these tumors, the superior maxilla is usually 

 removed; the lines of the cuts through the bones 

 being shown in Fig. 64. In prying the bone 

 down posteriorly, it may not be torn entirely away 

 from the pterygoid processes and some plates of 

 bone may be left attached. This should be borne 

 in mind in operating for malignant growths. The 

 sphenoidal cells are behind the upper posterior 

 portion of the maxillary sinus, therefore in oper- 

 ating on Meckel's ganglion, if too much force is 

 used in breaking through the posterior wall of 

 the antrum, the instrument may pass across the 

 sphenomaxillary fossa, a distance of about 3 mm. , 

 and open the sphenoidal sinus. 



The infra-orbital nerve is usually separated 

 from the cavity of the sinus by a thin shell of 

 bone. At the upper anterior portion of the sinus 

 there may be a small cell between the bony canal 

 in which the nerve runs and the bony floor of the orbit. The superior dental nerves 

 reach the upper teeth usually by going through minute canals in the bone, but some- 

 times, particularly the middle set supplying the bicuspid teeth, may run directly beneath 

 the mucous membrane, and thus be irritated by troubles originating within the sinus. 



The inflammatory and infectious diseases of the sinus originate either by extension 

 from the nose or the teeth. The sinus opens into the nose by a slit-like opening into the 

 middle meatus about its middle,posterior to the hiatus semilunaris and 2. 5 cm. above the 

 floor of the nose. When the opening is close to the hiatus, liquids may run into it from 

 the hiatus. The bone beneath the hiatus and opening almost down to the floor of the 

 nose is quite thin, so that the sinus can readily be drained by thrusting a trocar and can- 

 nula through the outer wall of the nose into the sinus just below the hiatus semilunaris. 

 The sinus is also opened from the front through the canine fossa to the outer side of 

 the canine tooth. This opening affords direct access to the cavity, but is some distance 

 above the floor, thus it does not drain the cavity completely. The roots of the tipper 

 teeth project into the antrum forming elevations, usually covered by a thin plate of bone. 

 This is particularly the case of the first and second molars. Disease of the roots of these 

 teeth frequently infects the antrum and drainage is often made through their sockets. 



FIG. 126. Side view of the maxillary and 

 frontal sinuses. 



