On the Relation of Diseases of the 
Accessory Cavities to Diseases . 
of the Eye 
J. H, BRYAN, M.D. 
WASHINGTON, D. G. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 
NOVEMBER 11, 1809. 
CHICAGO 
American Medical Association Press 
1899 ON THE RELATION OF DISEASES OF THE 
ACCESSORY CAVITIES TO DISEASES 
OF THE EYE.* 
J. H. BEYAN, M.D. 
The relation between the diseases affecting the acces- 
sory sinuses of the nose and those of the orbit and its 
contents is such an intimate one that it seems strange 
so little has been done in the past in the way of clearing 
up the hazy ideas that have hitherto existed as to the 
influence of diseases of these pneumatic spaces on dis- 
eases of the eye. Indeed, in the ophthalmologic hand- 
books and text-books of to-day, very little on the relation 
of orbital diseases to the suppurative affections of the 
accessory cavities has been written, authors contenting 
themselves with a brief mention of some of the more de- 
cided orbital complications which have their origin in 
the pneumatic cavities. 
This is the first time in America, I believe, that a 
Joint meeting between the rhinologists and ophthal- 
mologists has been held with the view of Jointly studying 
these oftentimes very obscure and serious affections. I 
feel such a discussion can only be followed by the best 
results, for there is no region where so much depends on 
the harmonious action of the two specialties in order 
that the patient may be relieved from intense suffering, 
an eye preserved, or a life saved. 
♦Presented to the Section on Ophthalmology, at the Fiftieth 
Annual Meeting of the American Medical Association, held at Co- 
lumbus, Ohio, June 6-9, 1899. It is probably a matter of assurance to many of us 
that, if a better understanding of these diseases had only 
existed, cases of so-called supraorbital and infraorbital, 
or optic neuralgia would not have been treated so long 
without benefit, some of which have gone to the verge of 
excision, only to find the nerves were not the seat of the 
disturbance, but that one of the cavities adjoining the 
nose was the source of the trouble. 
The eye, partially surrounded by the accessory cavities 
whose thin walls go to make up the walls of the orbit, is 
very sensitive to any pathologic condition that takes 
place within them, and presents symptoms in many in- 
stances which, when carefully considered, will enable the 
surgeon to definitely locate the source of the disease. It 
is my custom to submit all such cases, no matter how 
triyial they may at first appear, to a most searching 
ophthalmologic examination. In this way I have been 
able to locate some obscure affections of the accessory 
sinuses, which would have been most difficult to recog- 
nize by rhinoscopic examination alone. 
It is to Dr. W. IT. Wilmer and his assistant. Dr. 
Greene, who have made most of the ophthalmologic ex- 
aminations of my cases, my thanks are due for the pain- 
staking care which they have practiced in making the 
searching examinations that such cases require. 
Several of the cases I propose to briefly mention in 
this paper have been previously reported to the American 
Laryngological Association, but short abstracts will here 
be made of them in order to illustrate some of the points 
I desire to elucidate. 
As in diseases of the nose, the affections of the frontal 
sinuses are frequently accompanied by ocular reflex dis- 
turbances: but they are frequently overlooked because 
of the difficulty in making a diagnosis of the diseased 
condition of the sinus. The reflex symptom most fre- 
quently observed in diseases of the frontal sinus is above 
all neuralgia of the supraorbital nerve, and it is present 
in both the acute and chronic forms of inflammation af- 
fecting the cavity. It occasionally happens that this 
symptom has been present long before the characteristic 3 
secretion makes its appearance in the nose. This neu- 
ralgia is not always constant but frequently occurs at 
regular intervals, and it does not always correspond to 
the diseased area, but may radiate to the parietal and 
temporal regions of the affected side. I have also oc- 
casionally noticed it to extend to the opposite side. This 
is probably one of the most frequently misinterpreted 
symptoms, puzzling not only the general practitioner 
but the specialist also. When we take into considera- 
tion, however, in the majority of cases of frontal head- 
ache either constant or intermittent in character, that 
there are other evidences of sinus disease, such as pain 
on pressure above and below the supraorbital ridge, 
especially at the inner angle, accompanied by a unilateral 
discharge of mucus or pus from the corresponding nos- 
tril, it seems difficult to understand why its true signifi- 
cance should not be more frequently understood. 
The frontal sinuses vary in size to a great degree in 
different individuals. After an examination of 120 
skulls, Herbert Tilley found the sinus large enough in 
some instances to contain an ordinary bean, while in 
others it was ten times as large. He considers a sinus 
normal where it measures 28 mm. from the median line 
outward, and in the vertical extent measured from the 
nasion from 20 to 22 mm. The size of this cavity, where 
the seat of a catarrhal or suppurative inflammation 
which is the most frequent pathologic condition met 
with, has a very important bearing on the ocular symp- 
toms; much depends also on the depth of its floor, and 
on the thickness or thinness of its walls. 
The secondary changes in the orbit, due to frontal 
sinusitis, are of the greatest interest, and they may be 
brought about simply by mechanical pressure, resulting 
in change of form of the orbit, in a displacement of the 
eyeball with a disturbance of its mobility and function, 
and in an interference with the flow of tears. 
Disturbances in the function of the eye of a high 
degree have been observed in cases of frontal sinusitis, 
such as dilatation of the pupil and congestion of the 
papilla, varying in intensity with the degree of pressure; 4 
a narrowing of the field of vision, especially for colors, 
scotomata, and in very severe cases amblyopia or amau- 
rosis. This, according to Kuhnt, serves to bring into 
prominence the fact that the peripheral and central 
sight in these cases can be raised up to a certain grade 
through intense illumination which points not to atrophy, 
but only to a lowering of the perception and conducti- 
bility. Frequently after the removal of the mechanical 
obstruction caused by the abscess, there is a rising of 
the central and peripheral sight; changes in refraction 
toward the hypermetropic and astigmatic side are ob- 
served in the cases where the pressure of the dilated sinus 
wall is made at the equator of the eyeball or on its pos- 
terior half. If the purulent secretion is not discharged 
through the nose, it may result in a diseased condition 
of the osseous walls of the sinus, causing an ostitis or 
periostitis of the walls of the orbit, the walls finally be- 
coming so thin that the secretion can be discharged 
through a fistulous opening in the supraorbital ridge, 
through a fistulous opening at the inner angle of the 
orbit where the floor of the sinus is the thinnest, or 
farther back into the orbit, producing an orbital abscess 
which is accompanied by all the compression phenomena 
from the side of the eye. 
Abscess of the orbit is rarely primary. In the major- 
ity of instances it is the result of an extension of an in- 
flammation from one of the adjoining sinuses, generally 
the frontal. The first symptom that shows itself may 
be the appearance of a small swelling at the inner angle 
of the orbit, while at other times the phenomena of 
ocular compression make their appearance, such as lach- 
rymation, pain in the eye, exophthalmus, strabismus, 
mechanical diplopia, edema with a stretching of the up- 
per lid and, when the disease has advanced to any extent, 
ectropion. Before the pus has made its outward appear- 
ance there may be considerable chemosis which partly 
or completely immobilizes the eyeball, especially for its 
upward or downward movements. 
The following is a brief abstract of a case of orbital 
abscess referred to me by Dr. Belt of Washington : 5 
CHRONIC FRONTAL SINUSITIS, CARIES OF THE FEONTO- 
ETHMOIDAL CELLS, ORBITAL ABSCESS, FISTULOUS 
OPENING AT THE INNER ANGLE OF THE ORBIT, 
Case I.—On May 2, 1897, this patient consulted Dr. 
Belt, after an attack of influenza, for a severe pain in 
the left eye. At this time the left upper and lower lids 
were red and swollen, and there was considerable chem- 
Chart 1 white; == black; -- - yellow; red; -= = green. 
osis of the conjunctiva. The eyeball was immovable, 
owing to the great swelling of the orbital tissues. The 
swelling increasing, an incision was made at the inner 
canthus and a large quantity of pus evacuated. A probe 
introduced into the wound was found to pass into the 
frontal sinus through a small opening at the inner angle 
of the orbit. Owing to the very anemic condition of the 6 
patient, further operative measures were not deemed ad- 
visable until his general health improved. 
When I first saw him, Sept. 10, 1897, there was a small 
fistulous opening at the inner angle of the left orbit, 
through which pus in considerable quantities was dis- 
charging. There was a slight drooping of the upper 
lid, but no swelling of the skin over the frontal sinus, 
and no pain on pressure. 
The patient was admitted to the Episcopal Eye, Ear 
and Throat Hospital, September 17, when after shaving 
the eyebrow and thoroughly cleansing the parts, an in- 
cision was made along the eyebrow, commencing just 
within the supraorbital notch and extending to the 
nasal boss. After elevating the skin and periosteum, a 
small opening in the orbital plate of the frontal bone 
was found, communicating with the frontal sinus. This 
opening was sufficiently enlarged by means of a gouge 
and rongeur, to admit of a thorough examination of the 
cavity, which was found filled with granulation tissue, 
and also found to be the seat of caries at its junction 
with the fronto-ethmoidal cells. The sinus was thor- 
oughly curetted, and all granulation and carious tissue 
was removed. The frontonasal duct being closed, an 
opening into the nose was made with a trocar, and a self- 
retaining drainage-tube passed into the nose. The cavity 
was irrigated with a solution of biehlorid of mercury, 
3-3000, the wound closed and hermetically sealed with 
iodoform and collodion. The sinus was irrigated daily 
through the drainage-tube, with a saturated solution of 
boric acid. At the end of a week, the external wound 
having healed, the patient was discharged from the hos- 
pital, and in ten days, there being no secretions from the 
sinus, the drainage-tube was removed. This is the form 
of orbital abscess so frequently met with resulting from 
a suppurative inflammation in the frontal sinus. It is, 
however, not always inevitable for a perforation of the 
walls of the sinus to take place, for in certain cases, in 
spite of the most minute examinations, we do not find 
any perforations. Pauas has described such cases as 
abces circonvoisin. He believes, on account of the thin 7 
walls of the sinus, the process is propagated to the peri- 
osteum without any perforation1. 
Points valuable in the diagnosis of orbital abscess re- 
sulting from suppurating frontal sinusitis, are the po- 
sition of the eye, the direction in which the eyeball is 
pushed, as well as the corresponding immobility of the 
eye. If the tumor is felt above, or above and internal, 
and if the eyeball is pushed downward and a little out- 
Chart 2 white; == black; -- - yellow; red; -- = green. 
ward, while its movements upward and inward are 
diminished, it indicates a breaking through from the 
frontal sinus. 
A suppurative inflammation of the frontal sinus, of 
any severity or duration, in ray experience, rarely exists 
alone, but is usually accompanied by caries of the fronto- 
i Progrts Med., 1890. 8 
ethmoidal and ethmoidal cells. While this complication 
occasionally gives no evidence of its existence by a rhin- 
oscopic examination, it is much in evidence as soon as 
the frontal sinus is opened. In such eases the ocular 
symptoms are increased in severity and render the 
diagnosis more difficult, for, added to the signs of frontal 
sinus inflammation are those which are peculiar to the 
ethmoidal alone. In such cases I have found the visual 
fields for colors always narrowed, exophthalmus more 
pronounced than in simple uncomplicated frontal si- 
nusitis, especially so when the lateral and superior pres- 
sure is either at or posterior to the equator of the eyeball 
—the displacement is pronouncedly downward and out- 
ward, and its movement inward especially restricted. 
CHRONIC FRONTAL SUPPURATING SINUSITIS AND SUPPUR- 
ATING ETHMOIDITIS. 
Case 2.—This is a very instructive one and illustrates 
the various disturbances these serious inflammations 
have on the eye. S. G., aged 15, was referred to me 
Oct. 26, 1898, by Dr. Wilmer. The patient stated that, 
while never robust, he had enjoyed fairly good health. 
He does not recall having had influenza. 
During August of the present year, while at the sea- 
shore, he was taken ill with what was supposed to be 
malaria, but which finally proved to be an inflammation 
of the right frontal sinus. During this illness, in the 
absence of Dr. Wilmer from the city, he was seen by 
Dr. Burnett, who kindty gave me his notes of the case 
at this time: 
August 12, there was an enlargement, very hard to the 
touch, near the right lachrymal region, but superior to the sac, 
without discharge from the puncta on pressure on the sac. 
The nasal duct was patulous, and fluid passed into the nose on 
syringing. 
August 14, he had a chill followed by fever; the right upper 
lid red and edematous, the swelling extending to the forehead 
at the root of the nose where it was more tender than else- 
where: quite a marked exophthalmus and diminished movement 
of the right eye; pupil larger than the left. 
August 15, swelling was slightly diminished; no chemosis- 
of the conjunctiva; temperature normal. 9 
August 17, some subsidence of the swelling and exophthalmus 
was noted; pupil normal; eye more movable; swelling confined 
to the upper lid; the fundus showed no change when examined 
with the ophthalmoscope; some bloody mucus discharged from 
the l ight nostril and increased by pressure on the tumor at the 
inner canthus. 
August 20, the swelling was gone, no diplopia in any part 
of the field of fixation, no defect in the visual field on rough 
testing. 
Chart 3 white; == black; yellow; ■— red; == = green. 
August 22, there was still some swelling at the inner canthus 
and tender on deep pressure. 
About this time the patient left the city and did not 
return until October 26, when I saw him. He then com- 
plained of intense frontal headaches, pain on pressure 
above and below the supraorbital ridge, and over the 
swelling at the inner angle of the orbit; slight exophthal- 10 
mils. He complained of chilly sensations, giddiness 
and nausea, temperature 100. He was quite anemic in 
appearance, and stated that he had lost twenty pounds 
during the preceding month. 
Rhinoscopic examination showed the right middle 
turbinate much swollen and, on probing, caries of the 
ethmoid cells was discovered. The secretions were puru- 
lent and, while not very profuse, were observed to come 
principally from the right nostril, also flowing back 
into the postnasal space over the posterior end of the 
middle turbinate body. The electric light showed the 
right frontal sinus opaque, while the left frontal cavity 
and both maxillary sinuses were translucent. 
Opthalmologic examination, made by Dr. Wilmer on 
October 27, was as follows: 
Ophthalmometer showed a corneal astigmatism in the right 
eye, of 0.50 D., with rule, in the left eye corneal astigmatism 
of 1.50 D. 
it. E. V .=2O/15; accepted cyl. + 0.25; axis 180. 
L. E. V.=2o/30 with cyl. +0.62, 90=20/15. 
Reads Jaeger No. 1 2" equal; 20 feet, Exo. 2° ad. 4°, ah. 4a. 
Color sense was good. The ophthalmoscope showed no change 
at all in the fundus. The perimeter showed a decided narrow- 
ing of the visual fields for white and colors in the right eye. 
There was also marked scotoma with its center corresponding 
to the normal blind spot, amounting to something more than 
its mere enlargement-—as shown in the charts 1 and 2. 
The left frontal sinus was the seat of a slight mucocele which 
was sufficient to reduce the visual field for white and colors. 
The patient was admitted to the Episcopal Eye, Ear 
and Throat Hospital, October 27, and on the following 
day, under ether anesthesia the frontal sinus was opened 
in the following manner: After shaving the right eyebrow 
and thoroughly cleansing the parts, an incision was 
made through the brow commencing just within the 
supraorbital notch, and continued on to the nasal boss. 
The flap, composed of integument and periosteum, 
was elevated, and a button of bone 1 cm. in diameter 
was removed by means of a crown trephine applied just 
above the supraorbital ridge and about one line from 
the median line. The outer table showed signs of com- 
mencing softening. On opening the sinus it was found 11 
filled with thick fetid pus and granulation tissue. The 
anterior wall and fronto-ethmoidal cells were in a cari- 
ous condition, as were also the ethmoid cells, at least as 
far back as the junction of the middle with the posterior 
cells. 
All diseased tissue was removed from the sinus, and 
with the little finger in the nose for a guide, all the 
Chart 4 white; =■= black; yellow; «■■■ red; == - green. 
ethmoid cells were removed with a sharp curette, as far 
back as they seemed to be diseased; a large opening was 
thus left between the sinus and nose. The walls of the 
sinus were then touched with a 20 per cent, solution of 
the chlorid of zinc, the cavity packed with iodoform 
gauze, one end being drawn out through the nose; the 
wound was then closed and hermetically sealed with 
iodoform and collodion. 12 
On the second day of the operation the gauze drain 
was removed from the sinus through the nose, and the 
cavity irrigated daily with a saturated solution of boric 
acid. The patient made a rapid convalescence, and was 
discharged from the hospital on November 9, the secre- 
tions very much diminished in quantity. The irrigations 
were continued daily for two weeks longer, when the se- 
cretions from the sinus practically ceased. Examination 
of the eye, made nineteen days after the operation, 
showed no exophthalmus; mobility of the eye, normal. 
R. E. V. = 20/20; 
L. E. V. = 20/20; 
20 ft., exo. 1/2, ad. 12°, ab. 4°. 
The ophthalmometer showed a corneal astigmatism 
of 1.50 I), with the rule in both. 
The visual fields, taken November 16, showed a 
marked improvement for white and colors, although 
they did not reach quite the normal standard, as will 
be observed by referring to Charts 3 and 4. When 
these abscesses have existed some time, they may result 
in a disease of the deeper structures of the eye, as in 
the form of an iridochoroiditis. 
CHRONIC ABSCESS OF THE FRONTAL SINUS AND ETHMOID 
CELLS FOLLOWED BY A IRIDOCHOROIDITIS. 
Case 3.—This case demonstrates the serious results 
that are apt to follow these suppurative conditions. Mr. 
, aged 71, consulted me Dec. 4, 1894, giving a his- 
tory of frontal neuralgia of ten years’ standing, the 
pain starting at the inner angle of the orbit, radiating 
over the corresponding side of the head and face, and 
increased in intensity by an acute coryza. For a num- 
ber of years he has had a yellowish purulent discharge 
from the left nostril, no swelling at the inner angle of 
the orbit, and he states that he has no disturbance of 
vision. 
Rhinoscopic examination showed the left middle 
turbinate slightly enlarged, and a thin purulent secretion 
was observed coming from above, and below it in the 
middle meatus. The probe, when passed into the middle 
meatus, revealed an extensive caries of the ethmoid cells. 13 
By means of a sharp curette I removed large quantities 
of pus and carious tissue from the region of the anterior 
ethmoid cells, after which the probe could readily be 
passed into the frontal sinus. The cavity was frequently 
irrigated with a saturated solution of boric acid. As this 
was followed by a very decided improvement in his con- 
dition, it was thought best not to resort to any more rad- 
ical measures for his relief on account of his age and a 
decidedly irregular heart action. 
From time to time I have seen this patient, and about 
two years ago there seemed to be a tendency to an exten- 
sion of the suppuration process backward into deeper 
and posterior ethmoid cells. Drainage, established by 
means of an occasional curetting, seemed to give the 
patient relief from his painful symptoms. 
About two years ago the left eye commenced to trouble 
him, and he then consulted Dr. Herbert Harlan of Balti- 
more who has kindly given me the following notes on 
bis eye-condition since he has been under his observation: 
February 11; He complained of “a little mistiness of the 
left eye.” V. O. D. = 15/100, V. O. S. = 8/100. He 
had been wearing bifocals. +1.50 gives O. D. 15/30; O. 
S. 15/200. The right fundus was a little cloudy, but good. 
Deep physiologic pitting of disc was evident. The left had 
large floating bodies in the vitreous. The vitreous was muddy. 
A patch of choroiditis was made out to the nasal side. He 
was put on a tablet containing iron, arsenic and strychnia, 
and his reading glasses changed to +4 D. 
February 25; The eye was a little better. V. O. S. = 
15/100 with glasses. Treatment was changed to ferri et hyd. 
chlor. cor. comp. (Mulford). 
April 7: “Eye doing well until a few days ago.” Now had 
marked iritis with adhesions. Atropia solution was used. 
April 10: The pupil was partly dilated, the fundus muddy, 
and the eye red. Treatment was kal. iod., grs. xv, in essence 
of pepsin t. i. d. 
April 28: “Eye more inflamed, last two days. Very uncom- 
fortable. No great pain.” Tension +, blood in ant. chamber, 
cornea cloudy. Eserin was instilled, and after a few minutes 
the eye felt better, and tension was less. Eserin was ordered 
and KI stopped, but ferri et hyd. given. 
May 3; Tension was less and less blood in the anterior cham- 
ber. 
June 17: “Eye did well until about ten days ago.” Now 14 
very red, with blood in the anterior chamber, the pupil was 
closely contracted, tension +l. Atropia was ordered to be used 
carefully. 
June 21: The left eye was better, the blood in the anterior 
chamber nearly absorbed, vitreous muddy; no fundus; light 
only. 
July 17; 0. S., no longer red; cornea hazy; no fundus; 
O. D. +2.50, 15/15; 1+ +4.50 reading. 
April 18: O. S.; cornea clear, lens opaque, light; O. D.; 
pupil a little dilated, and responds sluggishly to light. V.= 
15/15; field taken and found good; use of his distance glasses 
advised. Fraser’s quin. comp, tablets were ordered. 
May 18; The condition was the same. 
November 15: The condition was the same. 
December 30: A letter says the left eye is red and irritable 
and he wishes some other drops. 
Jan. 26, 1899: +O. S., red and irritable; pupil closed; na 
light; O.D. well; kal. iod. and Fairchild’s essence of pepsin 
were ordered. 
March 20: O. S., red and heavy; tension;, atropia was 
ordered and KI continued. 
April 13: Enucleation was advised for 0. S. 
ETHMOIDAL AFFECTIONS IN RELATION TO DISEASES OF 
THE EYE. 
Affections of the ethmoid cells are generally caused 
by diseases of the nose, and may exist alone, or compli- 
cate suppurative inflammations in the frontal, as has 
been previously mentioned, also in the maxillary and 
sphenoidal sinuses. According to the intensity of the 
inflammation and the cells involved, caries of the eth- 
moid may or may not be accompanied by ocular symp- 
toms, a great deal depending whether the abscess is 
open or closed, and whether the anterior or middle and 
posterior cells are involved. In the open variety, where 
the pus has a free discharge into the nose, the eye may 
escape any injurious effects until the carious process has 
made sufficient advances to involve the deeper cells. 
In the closed variety, however, the ocular symptoms 
are almost immediately present. Abscesses in this re- 
gion are accompanied by the same ocular disturbances 
that are met with in frontal sinus inflammation, the 
pressure symptoms varying somewhat from those in the 
upper cavity. Supra- and infraorbital neuralgia, so- 15 
called cysts of the orbit, orbital abscess, exopbthalmns, 
disturbances in refraction, scotomata, iridochoroiditis, 
changes in the visual field, are the symptoms most fre- 
quently found in well-advanced cases. The so-called 
cysts of the orbit are generally the manifestation of 
some form of disease of the ethmoid cells, either in the 
form of a closed abscess or a dilatation of the cells, the 
pressure being so great as to cause a marked displace- 
ment of the eye. 
If the middle or posterior cells are affected without 
any involvement of the other neighboring cavities, the 
displacement of the eye is generally outward, while the 
inward mobility of the eyeball is decidedly interfered 
with. 
At times, when there is a swelling and projection of 
the cells toward the orbit, it becomes very difficult to 
differentiate between a closed abscess, a cyst or a solid 
tumor. 
The following case illustrates some of the difficulties 
that are met with: 
NASAL POLYPI, ALVEOLAR SARCOMA OP THE ETHMOID 
CELLS, LATER INVOLVING THE ORBIT; PURULENT 
ACCUMULATION IN THE ANTRUM. 
Case 4.—Mrs. , aged 57, was referred to me by 
Dr. Stone, U. S. IST., and stated that in October, 1898, 
she noticed a great difficulty in breathing through the 
left nostril, which on examination was found to be due 
to the presence of several large mucous polypi. These 
were removed in January, 1899, and some time afterward 
she had a profuse hemorrhage from that side of the nose 
which, however, was not attributed to the removal of the 
polypi. 
March 1, when she first consulted me, she complained 
of pain in the supraorbital and infraorbital regions, 
pain in the e}re, inability to breathe through the left 
nostril, photophobia and lachrymation. Examination 
of the eve, by Dr. Wilmer, showed both lids of the left 
eye swollen, there being also an extensive chemosis of the 
conjunctiva at the lower inner angle of the eye. Motion 16 
of the eyeball was interfered with to some extent, owing 
to the swollen condition of the orbital tissues. On pal- 
pation a firm mass was found along the orbital ridge of 
the malar bone, extending from the inner canthus 5 
mm. outward. 
No ophthalmometric reading could be made, owing to 
the condition of the eye. The patient was myopic, but 
normal sight could be obtained by use of proper lenses. 
Examination of the muscles showed the following: image 
seen with left eye, Ifib0 to the left and 1° below that 
of the right. Ophthalmoscopic examination revealed 
the veins and arteries very much engorged, slight pulsa- 
tion, and slight elevation of the retina at the inner lower 
angle. 
The day following, the chemosis had increased greatly 
and examination showed continued diplopia. The fields 
for white and colors were normal. Ehinoscopic examina- 
tion showed the left nostril partially occluded by nu- 
merous small mucous polypi springing from a greatly 
swollen middle turbinate body. No pus was observed 
in the nasal chamber, but on forcibly blowing the nose 
small quantities of thick purulent secretion could be 
blown out, and she complained of a constant dropping 
into the postnasal space. Examination with the electric 
light showed both frontal and right maxillary sinuses 
translucent, while the left was absolutely opaque. The 
diagnosis in this case lay between a closed abscess of the 
ethmoid cells bulging into the orbit, and secondarily af- 
fecting the maxillary sinus, a dilatation of the ethmoid 
cells, or a solid tumor originating within them. The 
patient having lost her teeth several years before, on 
March 2, I perforated the left antrum, through the 
alveolar ridge about the location of the first molar, by 
means of a small trephine, and evacuated about a dram 
of rather thick pus. The cavity was irrigated daily with 
a saturated solution of boric acid, with the result of an 
almost complete disappearance of pus within three or 
four days. 
I made several attempts to reach the seat of the eth- 
moid disturbance through the nose by means of a curette, 17 
but without much success; as the chemosis was rapidly 
increasing and the eye symptoms becoming more threat- 
ening it was decided to operate without further delay. 
March 26 the patient was etherized, and, assisted by 
Drs. Wilmer and Greene, an incision was made through 
the base of the lower lid extending from the inner angle 
to nearly the full extent of the infraorbital ridge; the 
bulging ethmoid cells were exposed, and opened by means 
of a perforator. Through this opening a curette was 
passed into the ethmoid cells and with the little finger 
in the nose for a guide I was enabled to remove nearly 
all of these cells, which were found to be broken down 
and filled with pus and granulation tissue as far back 
as the posterior cells. The nasal wall of the antrum in 
relation with the ethmoid bone was also found badly 
diseased, and was removed, leaving a large communica- 
tion between that sinus and the nose. The parts were 
then thoroughly cleansed with a boric acid solution, 
and the external wound closed. There was no microscopic 
examination made of the tissue removed from the eth- 
moid cells at this time. The external wound healed 
quickly, but at the end of a week it broke down at its 
inner third; the nose and antrum were irrigated daily 
with a boric acid solution. 
The patient’s condition was much improved for a 
time by the operation, especially in the subsidence of 
the chemosis and the pressure on the eye. The secretions 
from the nose and from the external wound were at no 
time profuse. 
About two weeks after the operation she complained 
of increasing pain in the eye, in the infraorbital and 
supraorbital and temporal regions, the eye condition 
remaining about the same. 
April 12 the eye condition was not so good, there be- 
ing increased swelling of the lower lid, very hard to the 
touch, chemosis increasing. The nose, which had been 
thoroughly relieved by the first operation, now showed 
a return of the swelling, which on examination was 
seen to come from the seat of the operation. 
By April 14 the pressure on the eye had increased 18 
decidedly—the preceding two days—chemosis being very 
much increased. The symptoms were so threatening 
that a second operation was insisted on. 
April 15 the patient was etherized, and Dr. Wilmer, 
operating through the previous incision in the lower lid, 
discovered the floor of the orbit filled with a tumor 
formation of very firm consistency. It had extended 
from the ethmoid cells along the floor of the orbit, in- 
filtrated the lower lid and was extending into the upper 
lid back of the lachrymal sac. 
Not having authority to remove the eyeball and the 
contents of the orbit, as the indications so strongly called 
for, he had to be content with removing as much of the 
tumor as possible through the external wound, removing 
a portion of the floor of the orbit at its juncture with the 
ethmoid bone. A drainage-tube was passed into the 
orbit, and the wound closed. A microscopic examina- 
tion, made by Dr. Walter Eead, U. S. A., showed the 
tumor to be of the alveolar sarcoma variety. The pa- 
tient’s husband, who is a physician, realizing the un- 
favorable prognosis of the case declined a more radical 
operation for her relief. 
April 20 the patient was discharged from the hospital, 
in order that she might be removed to her home in New 
York State. In a letter shortly after her arrival home 
her husband stated that the growth was slowly in- 
creasing. 
DISEASES OF THE SPHENOIDAL SINUSES IN RELATION TO 
DISEASES OF THE EYE. 
There is no means of knowing to what extent sphe- 
noidal disease exists. Whether it is as frequent or less 
frequent than inflammations in the neighboring cavities 
of the nose is a question yet to be determined. In cases 
in which the symptoms are not well defined, it is im- 
possible to make a diagnosis, and it is frequently only 
when the disease has advanced to such an extent as to 
cause serious eye disturbance or other symptoms that 
threaten an extension to the meninges, that we can form 
a definite opinion as to the condition of these cavities. 19 
These cavities are subject to the same forms of inflam- 
mation noticed in other sinuses, and they are also oc- 
casionally the seat of tumor formations. A suppurative 
inflammation in these cavities alone is exceedingly rare, 
for it is generally associated with disease of the ethmoid 
and frontal sinuses. 
The diagnosis of abscess of the sphenoidal sinnses 
rests almost entirely on rhinoseopic and ophthalmologic 
examinations, for the subjective symptoms may be whol- 
ly wanting, or of such a manifold variety as to make it 
impossible to diagnose with even a slight probability a 
disease of this cavity. The most common rhinoseopic 
finding is the appearance of pus in the superior meatus, 
posteriorly. Even this is not positive evidence that the 
source of the trouble is the sphenoid alone, for in many 
instances the posterior ethmoid cells are the seat of the 
disease. But when these cells are the seat of a suppura- 
tive inflammation, it is safe to say the sphenoidal cav- 
ities are also involved, for the bony partition that sep- 
arates these cavities is so thin they can not withstand 
any pressure without giving way under it, thus forming 
a direct communication for the extension of any patho- 
logic process from one cavity to the other. Occasionally 
the anterior wall of the sphenoid sinus may bulge for- 
ward. When this occurs the source of the purulent secre- 
tion is then readily recognized. 
In mild cases, where the pus finds a ready exit through 
the nose, the eye may not be involved; but where the 
inflammation is severe from its outset, or there is an 
obstruction to the outflow of pus, pain in the occipital 
region, extending to the vertex, will be marked. There 
may be also an increased lachrymation, photophobia, 
pain in the orbit back of the eye, exophthalmos, ptosis, 
strabismus, diplopia, orbital abscess, and from a partial 
to a complete loss of vision. 
The following case represents some of the manifesta- 
tions of this disease. 
ABSCESS OF THE SPHENOID SINUS, PARALYSIS OF THE 
EXTERNAL RECTI. 
Case 5.—Mr. , aged 57, was referred to me by 20 
Dr. Wilnier, April .17, 1899. When I first saw this pa- 
tient he complained of intense pains in the occipital re- 
gion, radiating to the vertex; giddiness, nausea, and 
double vision. There was a profuse fetid purulent dis- 
charge from both nostrils and from the postnasal space. 
After thoroughly irrigating the nose, a rhinoscopic ex- 
amination showed the frontal, ethmoidal and maxillary 
sinuses to be free from disease. The posterior wall of 
the nasopharynx was observed bulging forward, nearly 
touching the velum palati, the bulging being greater on 
the right than on the left side. Pus in large quantities 
was seen in the vault of this space, flowing forward in 
the nasal chambers and below into the pharynx. 
lie was first seen by Dr. Wilmer, Feb. 27, 1899, when 
he showed a complete paralysis of the right external 
rectus only. Examination of the eye, with correction 
for refraction showed the sight normal in each eye. Pu- 
pillary reaction was normal, as were also the visual fields 
for white and for colors. The interior of the eye showed 
nothing abnormal. 
April 17 there was a paralysis of both external recti, 
but no other changes in the eyes. He complained of 
great pain at the back of the head and vertex. 
April 21 the patient was admitted to the Episcopal 
Eye, Ear and Throat Hospital, and on the following 
day, under cocain anesthesia, I opened the left sphenoidal 
sinus by means of a gouge passed through the nose. 
The opening was made rather too high, but was suffi- 
ciently large to admit of a free discharge of pus, which 
gave him considerable relief and which lasted for sev- 
eral days. At this time I supposed both sinuses com- 
municated, and hoped that one opening would be suffi- 
cient, but the pains soon returned and seemed to increase 
in intensity. 
April 28, under ether anesthesia, I made a free open- 
ing in the right sinus, by means of the gouge passed 
through the nose, using my finger in the postnasal space 
as a guide. This was followed by a profuse discharge 
of very thick fetid pus. The sinus was freely curetted, 
removing as much carious bone as could be reached by 21 
my instrument, and was irrigated with a saturated so- 
lution ol bone acid. Tins operation was followed b) 
almost complete relief from pain, and a very decided 
improvement in the paralysis of the right external rectus, 
while there is none in the paralysis of the left. 
The sinuses have been irrigated daily with a boric 
acid solution, resulting in a decided dimunition in the 
quantity of purulent secretion. He was discharged from 
the hospital on May 2, greatly improved. The opening 
in the left sinus shows a tendency to close, and in con- 
sequence the occipital and vertex pains have returned, 
but they are not so intense. This cavity will probably 
have to be opened again. This case is especially inter- 
esting from the fact that the other sinuses are not in- 
volved, and the pressure, instead of being made on the 
optic nerve, as is usually the case, is directed upward 
and outward and involves the abducens nerves just before 
passing through the sphenoidal fissure. 
DISEASES OF THE MAXILLARY SINUS IN RELATION TO THE 
DISEASES OE THE EYE. 
The maxillary sinus is subject to the same diseased 
conditions that are met with in the other accessory cav- 
ities, and probably is the most frequently affected, as it 
has both the teeth and the nose from which pathologic 
processes may extend. It probably is, however, less fre- 
quently complicated with diseases of the eye than the 
other accessory sinuses. 
Many of the eye symptoms that are met with in ab- 
scess of the maxillary sinus are reflex in character, such 
as narrowing of the field of vision, photophobia, dilata- 
tion of the pupil, blepharospasm, and ptosis; while others 
are the result of an inflammatory extension; such as 
osteoperiostitis, abscess of the orbit, dacryocystitis, and 
iridochoroiditis. 
It will be observed that there are many symptoms of 
diseases of the eye, when associated with accessory sinus 
inflammations, which are common to one or more of the 
affected cavities. There are, however, certain symptoms 
which are peculiar to certain sinuses, and it is only by 22 
the closest observation of these cases,, both from the 
rhinoiogic and ophthalmologic side, that we can hope 
to make an early diagnosis. While pain is a symptom 
met with in these affections, its location will frequently 
aid one in determining the cavity which is the seat of the 
inflammation. This, however, must not be depended on 
alone, for occasionally in ethmoidal abscess the pain is 
referred to the supraorbital ridge as well as to the eye 
and infraorbital region. 
Orbital abscess may occur as readily from an extension 
of an inflammation of one cavity as from another. I 
believe, however, basing my opinion on my own experi- 
ence, it more frequently results from frontal sinus dis- 
ease. A narrowing of the field of vision for white and 
for colors may follow an abscess in either the frontal, 
ethmoidal, sphenoidal, or maxillary cavities. It is, 
however, more frequently met with when the frontal 
and ethmoidal sinuses are jointly diseased. Refractive 
disturbances are more frequently noticed in inflamma- 
tions of the frontal and ethmoidal cavities, and generally 
in those eases where the pressure is exerted either at or 
posterior to the equator of the eyeball. 
Exophthalmus may be present in any well-advanced 
abscess of the accessory sinuses; the extent and direction 
in which the eye is pressed from its normal plane indi- 
cates the cavity which is affected; e.g., in frontal- dis- 
ease the eye is pushed forward and downward, in eth- 
moidal, forward and outward, in sphenoidal, directly 
forward and slightly outward, while in maxillary disease 
it is directed upward and outward. 
Sudden blindness, together with ptosis and strabismus, 
when associated with abundant discharge into the post- 
nasal space, is indicative of sphenoidal disease. THE JOURNAL 
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