1428 HUMAN ANATOMY. 



Attempts have been made to pass a probe into the ostium frontale from the nose, 

 but this is exceedingly difficult because of the concealed position of its orifice behind 

 the anterior end of the middle turbinate bone, and sometimes because of its tortuous 

 course. Efforts to reach the sinus through the nose are usually made by removing 

 the anterior end of the middle turbinate bone, at the same time opening the 

 anterior ethmoidal cells which are frequently involved by the same inflammatory 

 process. By this method an aperture is left for the permanent discharge of the 

 sinus into the nose, whereas by the external method the opening into the nose may 

 remain closed. 



The maxillary sinus, or antrum of Highmore, is the largest and most 

 important of the accessory sinuses of the nose. It is most frequently the seat of 

 pathological processes, as infections and tumors. 



Infection may reach it from the nose through the opening in the middle meatus, 

 when it may be secondary to disease of the frontal and anterior ethmoidal sinuses, 

 the openings into all three being closely associated ; or it may be caused by caries of 

 the teeth, especially of the first and second molars, the roots of which frequently 

 produce prominences in the floor of the antrum, or may very exceptionally extend 

 into its cavity. Occlusion of the small orifice with retention of the pus frequently 

 causes great pain from pressure on the infraorbital nerve in the roof of the antrum. 

 The pus may burrow into the nose, the ethmoidal cells, or the orbit. 



The normal orificeis too high on the internal wall for drainage, and is too small 

 for effective irrigation, which may be provided for (a), if the cause is a carious tooth, 

 by removing a tooth and making an opening through the roof of the socket into the 

 antrum ; this affords dependent drainage, but permits the entrance of food from the 

 mouth ; () by perforating the bony wall between the antrum and the inferior meatus 

 with or without removing the anterior end of the inferior turbinate ; or (Y) by 

 making an opening through the thin anterior wall, above the roof of the second 

 bicuspid tooth, at the level of the canine fossa. 



A tumor of the maxillary sinus may be either benign or malignant. Its growth 

 will lead to enlargement of the cavity, and to the following symptoms, one or more 

 of which will predominate, according to the direction it takes : (a) inward, through 

 the thin inner wall of the sinus, causing epistaxis, obstructed respiration, epiphora 

 from pressure on the nasal duct ; (6~) inward and backward, involving the naso- 

 pharynx and interfering v/ith both respiration and deglutition ; (c*) forward, pushing 

 the anterior wall also thin before it and obliterating the inframalar depression in 

 the cheek; (X) upward, causing infraorbital neuralgia (as the infraorbital nerve 

 runs in the roof of the sinus), toothache from compression of its middle and anterior 

 superior dental branches, face ache from involvement of the other branches of the 

 superior maxillary, and later exophthalmos and diplopia ; (<?) downward, pushing 

 down the arch of the hard palate so that the roof of the mouth on the affected side- 

 becomes convex, and, by pressure on the superior dental nerves, causing severe 

 odontalgia in the upper teeth, which later become loosened. Benign growths may 

 be removed through an opening made by cutting away the anterior wall. Malignant 

 growths necessitate excision of the superior maxilla. 



In diseases of the sphenoidal sinuses their intimate relation wi.th the brain 

 above, the optic nerve and ophthalmic artery above and to the outer side, and, along 

 the outer wall, with the internal carotid artery, the cavernous sinus and tin- nerves 

 passing through the sphenoidal fissure, should be borne in mind. Such diseist -s 

 may lead to (a) optic neuritis and blindness, if the optic nerve is involved ; ( b ) 

 to general ophthaimoplegia if the third, fourth, the (ophthalmic division of the fifth, 

 the sixth, and the sympathetic filaments from the cavernous plexus (all transmitted 

 through the sphenoidal fissure are implicated; (r) to cavernous sinus thrombosis 

 if the ophthalmic vein passing through the same fissure is infected. 



Tumors of the pituitary body resting in the pituitary fossa in the sella turcica 

 and just above the roof of the sinus may penetrate its cavity. The opening of each 

 sinus is in the upper part of the anterior wall, a very unsuitable position for drainage, 

 in the presence of infection. Encroachment on any of the surrounding structures 

 mi^ht lead to serious results. The anterior wall may be exposed and attacked by the 

 surgeon, but only with considerable difficulty, because of its deep situation and its 



