Diseases of the Antrum. 
BY JOHN I HART, D.D.S., NEW YORK, N. Y. 
(Read before the Dental Society of the State of New York, at Albany, N. Y., May 15, 1890.) Diseases of the Antrum. 
JOHN I. HART, D.D.S., New York, N. Y. 
Mr. President and Gentlemen : 
THROUGH the courtesy of your Committee I have the pleasure of 
addressing you at the present session, the subject of my remarks 
being “The Antrum of Highmore, and some of its Diseases.’’ 
The antrum of Highmore, or maxillary sinus, is the large air-cavity 
situated in the body of the superior maxillary bone. Above is the 
floor of the orbit, internally is the nasal wall, below the alveolar 
process. With the possible exception of the alveolar process, its 
walls are exceedingly thin, its roof being formed by the orbital plate, 
its floor by the alveolar process, its anterior wall by the facial surface, 
and its posterior wall by the zygomatic plate. 
Its development is similar to the sinuses on the frontal bone, and 
like them is not completed until after the age of puberty, although it 
makes its appearance as early as the fifth or sixth month of foetal life ; 
consequently, in early life, the surrounding walls are thicker than in 
the adult. Its inner wall or base presents a large irregular aperture 
which communicates with the nasal fossa through the middle meatus 
of the nose. The margins of this opening are thin and ragged, and 
the aperture itself is considerably contracted by its articulation with 
the ethmoid above, the inferior turbinated below, and the palate bone 
behind. This aperture being situated near the upper part of the 
antrum, does not afford, when the head is perpendicular, a ready out- 
let to fluids collected within the cavity. The floor of the antrum is 
marked by irregular eminences corresponding to the roots of the molar 
teeth. Sometimes it is punctured by the roots of these teeth, which 
may extend into the sinus, when the roots are only covered by the 
mucous membrane of the antrunfT 2 
The walls of the maxillary sinus often support thin plates of bone, 
which subdivide it into small compartments. A knowledge of this 
fact is important in operating in this location, as the drill may pene- 
trate one of these compartments, misleading the operator as to the 
extent of the cavity. The mucous membrane lining the sinus is cili- 
ated, and is continuous with the membrane lining the nasal cavity, the 
frontal, ethmoidal, and sphenoidal sinuses, and for that matter, with the 
general gastro-pulmonic tract. Normally, it is less vascular, and 
thinner than the nasal mucous membrane. The posterior wall is 
penetrated by the posterior dental canals, through which the posterior 
dental vessels and nerves are conducted to and from the teeth ; the 
anterior wall is tunneled in a similar manner for the anterior dental 
vessels and nerves. 
It varies in size and capacity (from one to six ounces), and is larger in 
the male than in the female. It atrophies in old age and from the loss 
of teeth. The two antra may be of unequal size. 
The most frequent sources of difficulties are those arising from 
lesions secondary to the diseases of the teeth, and affections common 
to mucous membrane, wherever situated ; yet it is essential to recog- 
nize that even those diseases regarded as the least dangerous, and 
which may yield most readily to treatment, when instituted during 
their incipient or earlier stages, may assume, when neglected or im- 
properly treated, a form so aggravated as to bid defiance to the skill 
of the operator. Thus the most simple affections of this cavity may, 
through carelessness, become finally chronic, and many which are con- 
sidered the most dangerous may by timely treatment be effectually 
cured. 
Suppuration of the antrum, or, as it is sometimes termed, abscess, 
is ordinarily the result of inflammation extending from the teeth to the 
lining membrane of the cavity. As we have noticed that the roots 
of some molars penetrate, and that all are but slightly separated from 
the floor of the antrum by a thin septum of bone, we can easily recog- 
nize how the ordinarily carious tooth may develop a pulpitis, finally 
pulp death, suppuration ensuing, and the discharge pass through the 
apices of the roots into the antrum. 
If the irritation is from the adjacent teeth, the pulpitis may result in a 
maxillary abscess, which may then extend into the antrum. Symptoms 
of antral abscess are at first a dull, aching pain, and as the disease 
progresses, infra- and supra-orbital neuralgia with redness and swell- 
ing, a chill usually indicating the time of pus-formation. As the pus 
accumulates, the nasal wall is forced toward the septum, and when 3 
the patient is reclining on the side not affected, a slight flow of pus 
into the nostril may result. An offensive odor is detected by the 
patient, and on blowing the nose a purulent discharge is perceptible, 
and when lying down the discharge finds its way into the throat. 
From the constant swallowing of purulent fluid during sleep, for any 
considerable length of time, injury is done to the digestive organs, 
nutrition is incomplete, and their usefulness impaired. The patient 
is complaining, lacks appetite, and the ordinary remedies for gastric 
difficulties are of no benefit while the condition of the antrum is un- 
recognized, and consequently not treated. 
The treatment of suppuration of the antrum consists in the evacua- 
tion of the retained matter, the removal of all local and exciting 
causes of irritation, and finally the restoration of the lining membrane 
to its normal condition. The first molar being directly beneath the 
most dependent part of the sinus, is the most suitable tooth to be 
removed, if carious ; if it be sound, the second molar or either of 
the bicuspids, if carious, may be extracted in its stead, and in fact no 
tooth beneath the antrum in an unhealthy condition should be per- 
mitted to remain. If necessary, after the extraction of the tooth, the 
socket may be somewhat enlarged by means of a trephine in the 
engine. 
Some operators prefer, if the teeth are not decayed on the side af- 
fected, puncturing just above the alveolus, claiming that the aperture is 
less apt to close, and because food is not so liable to find its way into 
the antrum ; but when the opening is made from the palatal surface 
of the antrum, and properly guarded, no difficulty is experienced in 
keeping it free from food, and the cavity is much more readily cleaned. 
Whatever the method employed for emptying the antrum, it is im- 
portant that the cavity should be thoroughly cleaned by means of warm 
salt water (a teaspoonful of salt to a half-pint of water) until free com- 
munication is established with the nostril. For this purpose the ordi- 
nary pipe syringe is not efficient, and one should be employed with 
perforations at the side of the pipe, near its extremity, instead of a 
single orifice at the end, thus forcing the medicines employed all over 
the cavity, and not against a single point. 
After thoroughly cleansing with the salt water, some detergent 
and slightly astringent lotion should be regularly injected to restore 
the health of the parts. The following are a few of the many prepara- 
tions in use : permanganate of potassium, 2 grains ; water, one ounce ; 
listerine ; carbolic acid, one dram ; glycerine, one dram ; water, eight 
ounces ; saturated solution boracic acid with water. 4 
Too frequent injections, and those of too stimulating a nature, are 
often employed ; this should be carefully guarded against, by making 
them at first weak, and afterward increasing their strength as occasion 
may require. If the perforation has been made through the socket of 
a tooth, the antrum should be guarded by plugging the opening with 
cotton wool, saturated with carbolized oil (one part carbolic acid, fifteen 
parts oil of sweet almonds); this is retained in position by attaching to 
a tooth or a plate worn in the mouth, or, as suggested by Salter, by 
fitting a plate to the mouth with a small tube to fill the aperture, which 
can be corked at will, and serves as an opening for injection. 
If no improvement is apparent after some days, the antrum should 
be syringed with the carbolic solution just mentioned, with the addi- 
tion of one dram of tincture of iodine. As the discharge decreases, 
the opening made is gradually permitted to close, using smaller tents 
after each treatment. If the antral trouble is the result of constitu- 
tional disease, appropriate remedies should be used, as well as the 
local treatment. 
Catarrh of the antrum usually coexists with catarrh of the Schnei- 
derian membrane. A patient takes cold, the nasal mucous membrane 
becomes inflamed, and by simple continuity of surface the lining 
membrane of the antrum becomes affected. If the inflammation is 
sufficient to cause a closing of the connection, then the mucus is 
retained in the antrum, and this will, sooner or later, act as a source 
of irritation. This condition is rarely met with, as the congestion is 
seldom sufficient to obliterate the connection, and consequently the 
discharge is poured into the nasal cavity, and not confined in the 
antrum. It has been so severe, however, as to cause ozaena, an ulcera- 
tion of the pituitary membrane of the nose. In the mild stages, a 
saline cathartic will usually reduce the congestion. Where the disease 
has advanced to engorgement, and the antrum is enlarging, it becomes 
necessary to direct treatment to that cavity. The manner of accom- 
plishing this has been described under abscess of the antrum. 
Dropsy of the antrum, or hydrops-antritis, is marked by a gradual 
painless distension of the walls of the antrum. The old explanation 
of these phenomena was, that the aperture between the antrum and the 
nostril having become obstructed, the mucous secretion was thought to 
be retained, and by its gradual accumulation to produce the symptoms 
mentioned. Bordenae, in his “ Observations on Diseases of the Max- 
illary Sinus,” gives details of probing and injecting through the nasal 
orifice ; but after showing that there is great difficulty and uncertainty 
in finding the natural orifice, remarks that ‘ ‘ there are few cases in 5 
which the employment of injections through the natural openings 
would effect a complete cure. ’ ’ Some of these cases, and probably 
all of them, originate in the growth of a cyst, where it is unilocular, 
or in cysts, where they are multilocular, within the antrum, which 
either grow to such a size as to be mistaken for the cavity of the 
antrum, when opened, or break into the antrum by absorption of the 
cyst wall, so that on subsequent examination no evidence of cyst- 
formation can be discovered. 
This explanation, as pointed out by Coleman, is supported by the 
fact that in cases of hydrops-antri the contained fluid in no respect 
resembles ordinary mucus, but is invariably a clear yellow fluid, fre- 
quently containing cholestrum. 
Epithelioma of the antrum may involve considerable surface before 
its discovery, and it is difficult to eradicate. It has been discovered 
in France under the name epithelioma tetetraut. 
A molar may become loose, and on being extracted the antrum is 
found to be lined with epithelioma growth, or a wart appears on the 
hard palate, which is gradually destroyed, permitting the finger to 
pass into an antrum, the walls of which are of malignant growth. 
This variety of growth is met with in people of middle or advanced 
life. The treatment is necessarily radical : either the jaw must be re- 
moved, or the morbid growth scraped, and strong escharotics applied. 
Polypus of the antrum is closely connected with cystic growths of 
the same cavity, and is doubtless due to hypertrophy of some elements 
of the mucous and submucous tissues. According to Heath, “when 
the connective or areolar tissue predominates, the fleshy polypus is 
produced ; when the glandular element is affected, we have the cystic 
form produced.” Polypi of the antrum are very vascular, and 
consequently bleed freely when interfered with. The most common 
situation of the polypus is the nasal wall. It is usually unrecognized 
until the growth is sufficient to encroach upon its surroundings. 
Osseous tumors are also met with in the antrum.