On the Treatment op 
Chronic Frontal Sinusitis 
By Means of an Opening through the 
Anterior Wall of the Sinus, and 
Drainage through the Nose. 
J. H. BRYAN, M.D., 
WASHINGTON, D. C. 
BY 
REPRINTED FROM THE 
Uffcto STorfe JWeMcal Sournal 
for October 2, 1897. Reprinted from the New York Medical Journal 
for October 2, 1897. 
ON THE 
TREATMENT OF CHRONIC FRONTAL SINUSITIS 
BY MEANS OF AN 
OPENING THROUGH THE ANTERIOR WALL OF THE SINUS, 
AND DRAINAGE THROUGH THE NOSE * 
J. H. BRYAN, M. D., 
WASHINGTON, D. C. 
In bringing this subject before the association again 
it is with the desire of trying to impress still further 
upon you the frequency of the anomalies that are met 
with in the fronto-ethmoidal and the fronto-maxillary 
regions; and also to direct your attention to a method 
of treating chronic suppurative inflammations of the 
frontal sinus which seems to shorten very materially the 
duration of this most obstinate disease. There is prob- 
ably no affection in the whole domain of surgery 
that tries the patience and skill of the surgeon more 
than chronic abscesses affecting this cavity, especially 
when they also involve the ethmoidal region. When we 
consider the accompanying photographs, the wonder is 
* Read before the American Laryngological Association at its nine- 
teenth annual congress. 
Copyright, 1897, by D. Appleton and Company. 2 
TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
not that they are so resistant to treatment hut that recov- 
ery ever takes place. 
With an increased knowledge of the anatomy of 
these cavities, and the advances that have been made in 
surgery, the success met with in treating these affections 
has, it may he said, kept abreast of the surgery of other 
regions. 
Until within recent years suppurating frontal sinusi- 
tis has been considered to be an uncommon disease in this 
country, but since the frequent visitations of epidemic 
influenza the cavity involved, as well as the other acces- 
sory sinuses, are found to be very frequently affected. 
The mortality of this affection is much greater than 
is generally supposed, owing to the ready extension of 
the morbid process to the brain. 
The three sinuses, the frontal, ethmoidal, and maxil- 
lary, are frequently affected at the same time, having a 
common origin for their disorder in the extension of the 
pathogenic organisms of an influenza from the nose. 
In some instances one cavity, generally the frontal, is 
acutely inflamed in the course of an influenza, and the 
ethmoidal and maxillary are subsequently involved by 
an extension of the morbid process to them, which can 
readily take place owing to their very intimate relations 
and to the very thin bony partitions separating them. 
Again, the extension may take place through direct but 
anomalous passages which are occasionally found con- 
necting the sinuses. This is especially the case in the 
relation of the frontal and maxillary cavities. In a pre- 
vious communication I exhibited a drawing of an inter- 
esting preparation in the Army Medical Museum which 
showed a direct communication between the frontal and 
maxillary cavities, thus explaining the readiness with TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
3 
which abscess of the antrum could complicate a suppura- 
tive inflammation of the frontal sinus. I regarded this as 
a rare anomaly, for I could find no mention of this con- 
dition in the anatomical works consulted. Eecently, 
however, I have read a paper hy Dr. Fillebrown,* of 
Boston, who has made some interesting investigations 
on this subject. He states that he examined “ eight 
different specimens in which the infundibulum, instead 
of terminating in the middle meatus, continues as a half 
tube, which terminates directly in the foramen of the 
maxillary sinus. In seven of these specimens there was 
a fold of membrane which served as a continuation of 
the unciform process, and reached upward covering the 
foramen, forming a pocket which effectually prevented 
any secretion from the frontal sinus getting into the 
meatus until the antrum and pocket were full to over- 
flowing.” In a private communication he further states 
that he examined fifteen more crania and found the 
infundibulum as described in his paper, and the pocket 
was present in all hut two. This so-called anomalous 
condition, according to this authority, then occurs very 
often. As it has a very important hearing on the pa- 
thology of these cavities, it is a subject that should he 
still further investigated. Owing to the very intimate 
relation of the frontal sinus to the ethmoid bone, an 
involvement of the fronto-ethmoidal cells, or the cells 
formed hy the union of these two hones, hy an extension 
of the morbid process from the frontal sinus is of com- 
mon occurrence. I believe in nearly all severe cases of 
empyema of this cavity the fronto-ethmoidal cells and 
the ethmoidal cells proper are involved to a greater or 
lesser degree. 
* International Dental Journal. 1897. 4 
TREATMENT OF CIIRONIO FRONTAL SINUSITIS. 
In approaching a case of frontal-sinus abscess, with 
the view of an external operation, great caution must be 
exercised by the surgeon, for the sinuses vary greatly in 
size, and the variation between the two cavities in the 
Fig. I.—A, A. floor of frontal sinuses, which is observed to extend posteriorly to 
an unusual degree. B, B, anterior fronto-ethmoidal cells projecting into the 
sinuses. 
same subject is sometimes very marked. In nearly all 
cases in normal conditions they are separated by a ssep- 
tum, wdiich in the majority of instances is complete, al- 
though the cavities occasionally communicate through a 
small opening. The sasptum is frequently not straight. TREATMENT OF CHRONIC FRONTAL SiNUSl’ilS. 
5 
deviating to one side or the other, thereby rendering 
one cavity smaller than the other, while in disease it is 
either entirely or partially destroyed. 
There is no external sign which will enable us to as- 
certain the size of the sinuses, the prominence of the 
superciliary ridges being no guide as to the dimension 
of the cavities beneath them. 
Herbert Tilley,* in an examination of one hundred 
and twenty skulls, found these cavities varying to a great 
degree. He found the sinus large enough in some in- 
stances to contain an ordinary bean, while the other was 
ten times as large, and occasionally the sinus was absent. 
He considers a sinus normal when it measures twenty- 
eight millimetres from the median line outward, reaching 
to about the junction of the inner and middle thirds of 
the supraorbital ridge; and in vertical extent, measured 
from the nasion, from twenty to twenty-two millimetres. 
Lamb f has also made some measurements of these 
cavities which may be of some interest, as they are ex- 
pressed in a different way. He states that he found the 
right cavity with a varying capacity from a third to a 
drachm and a half, or one and a third to six cubic 
centimetres, while that of the left cavity was from 
a third to a sixth of a drachm, or one and a third to four 
and two thirds cubic centimetres; as showing the differ- 
ence existing between the two sides, he found in one case 
the left sinus was to the right as 70 to 95. 
Fig. 1 is a photographic view of a frozen section of 
the head of an adult negress just above the floor of the 
frontal sinuses. 
In this subject the size of the cavities is unusually 
* Lancet, London, September 26, 1896. 
f Reference Handbook of the Medical Sciences, vol. vii, p. 659. 6 
TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
large, and they project posteriorly to a greater depth 
than usual. Another interesting feature of this section 
is the development of the fronto-ethmoidal cells, the most 
anterior of which are seen to project into the frontal 
cavities. 
Fig. 2.—Showing the intricate arrangement of the ethmoid cells, with the poi 
tericr cells, D, D, unusually developed. C, C, sphenoidal sinuses. 
Fig. 2 is a section made on a lower plane, passing 
through the ethmoid cells, and which shows very clearly 
the intricate arrangement of these cells. TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
7 
Of the various methods proposed for the treatment 
of these chronic cases, the external method is generally 
conceded by most authorities to he the best. 
The operation that offers the greater advantages is 
that proposed originally by Ogston,* and latterly inde- 
pendently advocated by Luc.f In this operation the 
incision is made in the median line, commencing at the 
root of the nose and extending from an inch and a half 
to two inches on to the forehead. 
The skin and periosteum are elevated, and a centi- 
metre of hone removed by means of a small crown 
trephine (Fig. 3) applied just outside of the median 
Fig. 3. 
line and immediately above the supraorbital ridge. This 
opening will be found sufficiently large to allow of a 
thorough exploration of the sinus, and of the removal 
by means of the curette of any carious bone or polypoid 
tissue that may he present. The fronto-nasal duct should 
now he located with a probe, and enlarged by passing a 
* Medical Chronicle, December, 1894. 
f Archiv. internal, de laryngol., Paris, 1896, ix, pp. 163-178. 8 
TREATMENT OF CHRONIC FRONTAL SINUSITIS- 
trocar into the nose, using the little finger within the nos- 
tril as a guide. This duct is, as a rule, situated quite far 
hack, and generally forms a large curve in its passage into 
the nasal cavity. If the trocar is passed into the nose at 
this point all danger of fracture of the cribriform plate of 
the ethmoid hone will he avoided, as well as the risk of 
septic infection. 
After thoroughly removing all diseased tissue and 
washing the cavity out with antiseptic solutions the lin- 
ing membrane may he touched with a twenty-per-cent, 
solution of chloride of zinc. A self-retaining rubber 
drainage-tube (Fig. 4) should now be introduced through 
Fig. 4. 
the enlarged fronto-nasal duct, and the wound closed by 
means of interrupted or subcutaneous sutures, and her- 
metically sealed with iodoform and collodion. 
The following is a report of an instructive case, show- 
ing some of the difficulties met with in treating these 
very obstinate and serious conditions. 
Mrs. , aged fifty-eight years, consulted me June 
26, 1896, giving the following history: About two years 
ago she had a severe attack of influenza, which was pre- 
vailing at that time. The inflammation was confined 
principally to the upper respiratory tract. She suffered 
from excruciating headaches, the severity of which sub- 
sided as the inflammation grew less severe. The head- 
aches have been continuous, however, being greater at 
times than at others, and they have been attributed 
to various ocular disturbances, which were not relieved 
by treatment. 
She also complained of catarrhal symptoms, the se- TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
9 
cretions being thick and yellow and confined to the left 
side of the nose. When she came under my observation, 
June 26th, she had the following symptoms: Pain over 
the left side of the face, but of greatest intensity over 
the supraorbital ridge and at the internal angle; morn- 
ing nausea, loss of appetite, and general lassitude. The 
facial expression was an anxious one. 
On rhinoscopic examination pus was observed in the 
left middle meatus, passing freely into the nasopharynx 
and through the anterior nares. The middle turbinate 
was somewhat enlarged. Percussion on the frontal bone 
and over the canine fossa was accompanied by consid- 
erable pain. The electric light showed the left frontal 
and maxillary sinus to be opaque. 
July Ist.—The left second upper molar tooth was 
extracted and a small abscess found at the apex of the 
palatine root, which, however, did not communicate with 
the sinus. The antrum was opened by means of a small 
trephine at this point and a large quantity of thick, foetid 
pus evacuated. The cavity was irrigated daily with a 
saturated solution of boric acid and hydrogen dioxide. 
Under this method of treatment the inflammation in 
the antrum subsided within three or four weeks. 
While the quantity of secretion within the nose was some- 
what reduced, the frontal headaches continued with 
about the same severity. Upon my return from my sum- 
mer vacation, September Ist, I found the patient’s con- 
dition about the same as when I left her on July Ist, with 
the exception that the frontal pains seemed to be more 
severe. On attempting to probe the fronto-nasal duct 
the anterior ethmoid cells were found to be in a state 
of caries, which condition did not exist or was not dis- 
covered when previous attempts at probing were made. 
September ll^th.—Curetted the anterior ethmoid 
cells, removing several large spicula of bone, which re- 
sulted in better drainage, with a slight abatement of the 
frontal pain. 
October 10th.—During the past ten days there has 
been no improvement in the patient’s condition; the 10 
TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
frontal headaches have increased and are accompanied 
by nausea and vertigo. To-day, for the first time, there 
was detected a slight swelling of the skin over the left 
frontal region with some pitting on firm pressure. The 
patient’s condition had now become so serious that an 
external operation was insisted upon. 
13th.—After thoroughly cleansing the parts a ver- 
tical incision was made in the median line extending 
from the nasal boss to two inches on the forehead; the 
integument and periosteum were elevated, and a small 
button of hone about a centimetre in diameter was re- 
moved from over the frontal sinus by means of a crown 
trephine applied about two lines to the left of the 
median line and about three to four lines above the supra- 
orbital ridge. After removing the hone with the tre- 
phine the cavity was found filled with a thick, foetid, 
purulent secretion, and with numerous small granula- 
tions. 
The cavity was thoroughly curetted and washed out 
with a solution of bichloride of mercury (1 to 3,000). 
It was then discovered that the posterior wall at its most 
dependent part was the seat of extensive caries, which 
was carefully removed with a sharp spoon. The sasptum 
was examined and found to he intact. The fronto-nasal 
duct, which was situated unusually far hack, was en- 
larged by means of a trocar passed into the nose, using 
the little finger as a guide, and a drainage-tube was 
introduced through the enlarged opening. The external 
wound was then closed by means of a subcutaneous cat- 
gut suture, and hermetically sealed with iodoform and 
collodion. 
15th.—The patient has fully recovered from the 
effects of the operation, and is quite comfortable, with 
no pain in the head. Temperature and pulse normal. 
The secretions are passing freely through the drainage- 
tube. The sinus was washed out with a solution of 
formalin (1 to 2,000). This application was attended 
with considerable pain, which, however, subsided in a 
few minutes. TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
The use of the formalin solution was persisted in 
notwithstanding the pain, as it was considered to be an 
ideal antiseptic for such cases, in view of its supposed 
penetrating qualities; hut little benefit could be obtained 
from its use, as the secretions continued to flow through 
the drainage-tube in about the same quantity. The pa- 
tient continued to do well until the morning of October 
23d, when the drainage-tube slipped out of the nose. 
The cavity was, however, thoroughly washed out with the 
formalin solution through a Eustachian catheter. 8 
a. m., temperature, 98°; 9p. m., 100.6°. During the day 
she complained of great general discomfort and pain 
in the head. There was also noticed a slight putfiness 
of the skin over the opening into the frontal sinus. 
24th The patient passed a restless and wakeful 
night, suffering greatly from hiccough, and complaining 
frequently of chilly sensations. BA. M., temperature, 98°. 
At 9 p. m. she had a severe chill, followed by vomiting. 
11 a. M., temperature, 103.6°. She was given a brisk 
cathartic, and, after a thorough evacuation of the bowels, 
she received in a suppository ten grains of quinine every 
three hours, and half an ounce of whisky every two 
hours. The swelling over the frontal sinus was greatly 
increased and more painful. The iodoform and collo- 
dion dressing was removed, when an abscess was found 
to have formed in the lower half of the line of incision. 
This was thoroughly cleansed with hydrogen dioxide and 
dressed with iodoform gauze. The sinus was washed out 
with a saturated boric-acid solution and hydrogen diox- 
ide. At 10 p. m. the temperature had fallen to 101.4°. 
25th.—There was a decided improvement in the pa- 
tient’s condition this morning. The sinus and wound 
were treated as on the previous day. 8 a. m., tempera- 
ture, 99.4°; 9 p. m., 100.4°. 
26th.—Passed a good night; secretions from the 
frontal sinus very much diminished, and frontal wound 
healing, the margins of which were now drawn to- 
gether with adhesive strips. Ba. m., temperature, 99.2°; 
9 p. m., 99.2°. 12 
TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
27th.—The temperature was normal this morning, 
and continued so during the rest of the patient’s illness. 
Under the local application of the boric-acid solution and 
hydrogen dioxide the secretions from the sinus rapidly 
subsided. The frontal wound healed within ten or twelve 
days without leaving a very perceptible scar, the natural 
cleavage of the skin being a little more pronounced than 
originally. 
The patient was practically well within six weeks 
from the date of the operation. The duration of her 
treatment might have been very much reduced had it 
not been for the unfortunate accident resulting in a 
slight septic infection. This infection can he accounted 
for in one of two ways. The operation was done in as 
thoroughly an aseptic manner as possible, but after the 
drainage-tube slipped out of the nose some retention 
of pus probably took place and the under surface of the 
frontal wound, which was in close proximity to the open- 
ing into the sinus, might have received some infection 
from the cavity, or the catgut suture employed may 
not have been absolutely sterile. I believe the infection 
took place from the sinus. All danger of retention 
could have been avoided had a self-retaining drainage- 
tube been used. 
The operation offers many advantages over that of 
making the incision along the under surface of the supra- 
orbital ridge and entering the sinus at the inner angle, 
in that the opening is made sufficiently large to permit 
of a thorough inspection of the interior of the cavity, 
and any diseased tissue, as carious bone, granulation or 
polypoid tissue can be thoroughly removed; the sseptum 
dividing the two cavities can be thoroughly inspected 
to ascertain whether it is intact, and a drainage-tube TREATMENT OF CHRONIC FRONTAL SINUSITIS. 
13 
passed from the sinus into the nose without any danger 
of injuring the cribriform plate of the ethmoid hone. 
The method of treating empyema of this cavity by 
passing a drainage-tube through the frontal opening into 
the forehead leaves a very unsightly scar, and occasion- 
ally the patient recovers with a fistulous opening in the 
forehead.