Some recent, advances 
IN’ THE 
Diagnosis and Treatment 
OF THE 
ABSCESS (IF 111 ANTRUM OF HIGHMORE. 
J. H. BRYAN', M. I)., Washington, D. C. 
Eead by invitation before tbe Richmond (Va.) Academy of Medicine and Surgery, March 25th, 1890. 
[Reprint from Virginia Medical Monthly, April, 1890.] Some Recent Advances in the Diagnosis and Treatment 
OF THE 
Abscess of the Antrum of Highmore. 
At the last meeting of the American Medical Association, 
in a paper on the “Diagnosis and Treatment of Abscess of 
the Antrum,”* I called attention to tire fact that this disease 
occurs much more frequently than has been supposed. In 
that communication, I reported four cases; since then, my 
experience has been still further extended by the three cases 
I have the honor to report to-night. 
The accessory cavities of the nose being lined by mucous 
membrane, continuous with the lining membrane of that 
organ, are especially prone to a continuation of an inflam- 
mation affecting it; and owing to the very intimate anatom- 
ical relation which these cavities bear to each other, it is 
difficult to say which of them is the seat of the disease. 
Before proceeding further, let me call your attention to 
some of the objects found in the lateral wall of the nose, a 
perfect familiarity with which is necessary to enable u5 to 
understand some of the complex symptoms of these diseased 
cavities. 
The three turbinated bodies divide the lateral wall of the 
nose into the superior, middle, and inferior meatus. Of 
these, the middle meatus is the most important. The objects 
to be observed are the hiatus semilunaris, a semilunar 
groove between the processus uncinatus behind and the 
bulla ethmoidalis in front, varying in length and depth in 
different subjects from a mere slit to a deep groove. This 
groove contains the ostium maxillare, and as it passes up- 
ward and outward terminates in a funnel-shaped depression 
* Journal American Medical Association, October sth, 1889. 4 
known as the infundibulum, into which the frontal sinus 
and the anterior ethmoid cells empty. You will observe 
that in this meatus we have two openings very close to each 
other, viz; the natural opening of the maxillary sinus and 
the opening into the infundibulum. Occasionally, there is 
a third opening, known as the ostium accessorium of the 
maxillary sinus, situated below and in front of the natural 
opening. 
The maxillary sinuses will be found to vary in size in 
different individuals; and frequently, in the same subject, 
one cavity will be found larger than the other. 
Zuckerkandle speaks of dilatation and contraction of this 
cavity; but there is an anomalous condition which I have 
not observed noted, and which I think is worthy of record, 
as it may assist in explaining the obstinacy with which 
chronic abscess of the antrum frequently resists treatment. 
In specimen No. 2325 of the Army Medical Museum Col- 
lection, prepared by Dr. J. L. Wortman, anatomist to that 
institution, the antrum of the right side has three openings 
into the middle meatus. The posterior one is the largest, 
occupying a position slightly behind the middle of the inner 
wall, and upon a level corresponding to the lower edge of 
the middle turbinated bone. The middle opening is smaller, 
and has a position slightly above and behind the normal 
aperture. The anterior opening is normal so far as its posi- 
tion is concerned, but it communicates with a deep groove 
just in advance of the hiatus semilunaris, which leads into 
the opening of the frontal sinus. By means of this groove, 
it is possible to pass a probe from the cavity of the antrum 
directly into the frontal sinus, although, in so doing, it is 
made to enter the middle meatus first. The natural chan- 
nel for pus or fluid coming from the frontal sinus would be 
into the antrum, in preference to the middle meatus. 
Of the accessory cavities of the nose the antrum of High- 
more is the most important from a pathological standpoint, 
it being more frequently the seat of disease than the others. 
Suppurative inflammation is the form of disease most fre- 
quently met with, and the most common causes are an ex- 5 
tension of the inflammation from a suppurating pulpitis of 
a tooth, or an extension of an inflammation from the lining 
membrane of the nose. 
According to my own experience, I believe that diseased 
teeth are the most frequent cause; others, however, hold 
that the inflammation more frequently has its origin in the 
nose, either from a direct extension of the inflammatory 
process into the antrum, or, as Bosworth* claims, by an hy- 
pertrophy, or any other pathological condition, such as po- 
lypi, that will close the natural opening and pen up the se- 
cretions in the cavity. 
Nearly all observers are of the opinion that the diagnosis 
of an abscess of the maxillary sinus is surrounded with con- 
siderable, and often insurmountable difficulties. I can re- 
call cases in my own practice in which I have been unable 
to make a satisfactory diagnosis. Any method, therefore, 
that will enable us to solve these difficult problems will be 
gratefully received by all who have these affections to treat. 
The symptoms that are laid down as characteristic are 
found occasionally to be wanting; and some are common to 
abscess in one or more of the other sinuses communicating 
with the nose. They will be found to vary according to 
whether the natural opening of the antrum in the middle 
meatus is closed or free. If closed, there will be intense 
neuralgic pains in the affected side of the face; pain on 
pressure; a crepitating sensation imparted to the fingers, 
due to a springing of the distended walls of the cavity; and 
frequently a bulging of the‘lateral wall of the nose. 
When the ostium maxillare is open, there will be a dis- 
charge of fetid pus from the nose, unilateral, unless both 
cavities are affected ; varying with the position of the head, 
and the condition of the nose; flowing forward when the 
head is bent on the chest, and backward into the nasal pha- 
rynx when in the recumbent position. 
On examining the nose,.pus will frequently be found in 
the middle meatus, and, upon close inspection, a pulsating 
* Op. cit. 6 
light reflex is occasionally seen, such as is observed in per- 
forations of the membrana tyinpani in suppurating otitis 
media. This symptom, when present, is regarded by Walb 
and Scholler as pathognomonic of abscess of the antrum. 
I have observed it only once, and in that case it was well- 
marked. 
Occasionally, most of the above-mentioned symptoms are 
wanting, the patient complaining simply of a nasal discharge 
with a bad odor. Upon examining such a case, the nasal 
chambers may be found free from pus and in a normal con- 
dition. 
Moritz Schmidt,§ of Frankfurt, has given us the most 
practical method of recent times for determining the pres- 
ence of pus in the antrum—that is, aspirating the cavity 
through the lateral wall of the nose. When pus is present, 
it can be drawn off in the small syringe used. He recom- 
mends that the inferior meatus be thoroughly anaesthetized 
with a 20 per cent, solution of cocaine, and by means of a 
small syringe, somewhat larger than an ordinary hypoder- 
mic, with a strong curved canula, sharp at the end, he per- 
forates the lateral wall about the middle of the inferior mea- 
tus. I have used this instrument as he directs on several 
occasions, and I find the bone is much thicker here than is 
generally supposed, so that, in spite of the cocaine,’the ope- 
ration is quite painful. Instead of aspirating through the 
inferior meatus, I now make the puncture in the middle 
meatus just above the inferior turbinated body. Here the 
wall is extremely thin, and, if the instrument has a suffi- 
ciently long curve, it can be made to reach near enough to 
the floor of the cavity to ascertain the presence of pus. 
This procedure has been objected to by some on account of 
the danger of wounding the floor of the orbit. There need 
be no fear of an accident of this kind if the point of the 
instrument is carried downward and outward. 
There are, however, cases where so trivial an operation as 
this would be objectionable, especially in weak and hysteri- 
| Berl. Klin. Wochenschr., December 10th, 1888. 7 
cal women. We may, then, have recourse to the method 
recently advocated by the late and lamented Voltolini, of 
Breslau. Voltolini, adopting a suggestion of Czermak for 
examining the larynx by means of transmitted light, made 
use of the same principle in examining the cavities of the 
head. He found the bones entering into the formation of 
the face and nose were translucent. Instead of using the 
sun-light, as suggested by Czermak, he made use of the elec- 
tric light, and found that, in the majority of cases, the bones 
were sufficiently thin to permit the passage of light through 
them. He then used the electric lamp to diagnose the dis- 
eased conditions of the antrum of Highmore. 
The efficiency of the procedure has been testified to by 
such men as Stork, Gerhardt, Heryng, and others. 
Heryng, in an interesting article on the electrical trans- 
lucency of the antrum of Highmore,* gives a series of cases 
he was able to diagnose by this means. He advises the use 
of a small Edison’s electric lamp (five volts), attached to a 
TUrk’s tongue -depressor, and connected with a battery. 
Before using, the room should be darkened, and the depres- 
sor, with the lamp attached, introduced into the mouth. 
The tongue should be well-depressed before the mouth is 
closed, for the lamp becomes very hot, and it will burn the 
patient if allowed to come in contact with the mucous mem- 
brane. The current is then turned on, and the maxillary 
sinuses, if in a state of health, will become illuminated up 
to the lower eyelids. If, however, one of the cavities is the 
seat of an empyema, or a solid tumor, that side will remain 
opaque, while its fellow of the opposite side will be illumi- 
nated. 
I have proved the translucency of the maxillary sinuses 
In several healthy subjects; but since I became familiar with 
this procedure, I have not had an opportunity of trying it 
in a case of abscess of the antrum. This simple and pain- 
less device will assist us to diagnose a diseased antrum, but 
Cysts of the antrum are found to be translucent. 
* llerl. Klin. Wochemchr, September 2d and 9th, 1889. 8 
it cannot tell ns the .form of disease present without taking 
into consideration the accompanying symptoms. 
Another aid to the diagnosis of abscess of the maxillary 
sinus, none the less practical, but more difficult of carrying 
out, is sounding—that is, passing a small probe through the 
ostium maxillare; and if pus be present, it will flow out 
into the middle meatus. To successfully sound the antrum,, 
much depends on the size and position of the middle turbi- 
nated body. If it is unusually developed, and overlies the 
middle meatus, it will be impossible to introduce a probe 
into the opening of the maxillary sinus, or into the opening 
of the frontal sinus. Again the size and depth of the mid- 
dle meatus has an important influence on the success of the 
procedure. 
Hansberg,* of Dortmund, gives the following directions 
for sounding the maxillary sinus; a small probe is used 
about 15 cm. in length and If mm. in thickness. The 
probe is bent 0 mm. from the end at an angle of 110°; 
then, with the aid of good illumination, the parts having 
been previously anaesthetized with cocaine, the probe is in- 
troduced into the middle meatus, and the opening searched 
for, care being taken not to wound the membrane, as the 
resulting haemorrhage will be sufficient to obscure the field 
of vision, and render further probing useless. Entrance 
into the cavity is readily recognized by the resistance offered 
to the to-and-fro movements of the probe. Pus, if present 
in the cavity in sufficient quantity, will flow out into the 
middle meatus upon the withdrawal of the instrument. 
There are four operations for the relief of abscess of the 
antrum, viz; Cooper’s, through the alveolar process; De- 
sault’s, through the canine fossa; Mickulicz’s, through the 
inferior meatus; and Bertrandi’s, through the palatine pro- 
cess of the superior maxilla. In selecting one of these 
methods, we must be guided by the cause of the abscess; 
whether it be induced by dental caries and suppurating 
pulpitis, or whether it has an intra-nasal origin. If pro- 
Monatschr. f. Ohrenheilk., January, 1890. 9 
duced by disease of the teeth, then tha alveolar operation 
should be selected; the affected tooth, generally the second 
molar, withdrawn, and an opening made into the floor of 
the antrum. It frequently happens that the offending tooth 
has been lost before the patient comes under observation; 
then the opening should be made in this vacant space. This 
is best done by means of a drill, or trephine. I prefer the 
trephine, and have used one with a diameter of 3 mm. 
This leaves too small an opening, and I believe more satis- 
factory results would be obtained by the use of an instru- 
ment at least 8 mm. in diameter. The opening should be 
sufficiently large to admit of the ready removal of any ne- 
crosed portion of the alveolar process, and to permit of a free 
drainage. 
When the cause is seated in the nose, such as nasal 
polypi, hypertrophic rhinitis, or a direct extension of the 
inflammatory process into the maxillary sinus, the opera- 
tion recommended by Mickulicz, somewhat modified, will 
enable us to treat the abscess without the removal of a 
sound tooth, which is frequently a matter of great con- 
sideration. Mickulicz advised opening the sinus through 
the inferior meatus by means of a sharp double-edged 
knife. The disadvantage of this instrument is that the re- 
sulting opening is too large, and the operation is frequently 
attended with severe haemorrhage. I have opened the 
antrum once through the inferior meatus, and used a small 
burr or drill devised by Dr. J. Solis-Cohen. It consists of 
an olive pointed burr attached to a small stem, encased in 
a canula sufficiently large to admit of the withdrawal of 
the burr after the bony wall has been perforated. The 
canula can then be left in the opening until the cavity has 
been thoroughly washed out. The instrument is propelled 
either by means of an electric motor or a surgical engine. 
This operation has the advantage of draining the cavity 
at its floor, without leaving a large ragged opening in the 
lateral wall of the nose. Every attempt at blowing the 
nose aspirates the cavity and keeps it free from pus; and 
the patient is saved the annoyance of having the secretions 10 
pass into the mouth; bacteria and food cannot get into the 
sinus, as in the alveolar operation, and assist in keeping up 
the inflammation. 
Bertrandi’s operation is one that should never be re- 
sorted to. 
The operation of Desault was held in high esteem by 
some of the older surgeons, but it is not so often used 
to-day. If the abscess points in the canine fossa, then of 
course it should be opened there. In severe and obstinate 
eases a counter opening to that in the inferior meatus can 
be made by resecting a small piece of bone from the canine 
fossa, and packing the cavity with iodoform gauze, as 
recommended by Semon. 
After the opening has been made, the cavity should be 
thoroughly washed out with a warm solution of salt until 
all signs of pus have disappeared. The invariably accom- 
panying fetor is best overcome by means of a five per cent, 
solution of permanganate of potash. 
Owing to the peculiar shape of the maxillary sinus, and 
frequently the long existence of the inflammation before it 
is discovered, the treatment is often very tedious. The 
cavity should be syringed out, if the inflammation is at all 
severe, two or three times a day with mild disinfectant solu- 
tions. The peroxide of hydrogen and glycozone have acted 
well in several of my cases. 
Fried!ander has recently reported a series of successful 
cases that he was able to cure in the unusually short period 
of two weeks. He recommends the opening in the inferior 
meatus, and after thoroughly washing out the cavity he 
dries it out with an air-bag and insufflates iodoform. . 
The following is a report of three interesting cases that 
have come under my observation recently, and as the first 
case is an instructive one I will give its history in detail; 
Case I.—Mr. D. E. C. consulted me last May for reflex 
nasal asthma, stating that he had always enjoyed good 
health up to eighteen months ago, when he was troubled 
with frequent head colds, which from neglect and exposure 
increased in intensity until he was forced to seek relief. 11 
He had frequently facial neuralgia and pain over the 
bridge of the nose, symptoms of nasal closure, cough, and 
a constant secretion dropping back into the nasal pharynx. 
There has been very little secretion from the front of the 
nose. About four months prior to consulting me asthma 
commenced, and the paroxysms have increased in intensity. 
He has lost flesh and strength rapidly, and he is unable to 
concentrate his attention on his work. The only relief he 
has had was during a short stay at Key West, Florida. 
On examination the patient presented a pale and an ema- 
ciated appearance. 
Examination of the lungs revealed numerous sonorous 
and sibilant rales, Heart sounds were normal. Exami- 
nation of the nose showed both chambers tightly blocked, 
and the membrane bathed with a thin serous fluid. On 
the application of a twenty per cent, solution of cocaine, 
the swollen inferior turbinals contracted sufficiently to en- 
able the middle turbinated bodies to be brought into view, 
showdng numerous small fibro-myomatous polypi springing 
from them and tightly blocking up both nasal chambers. 
The polypi were thoroughly removed, and the middle 
turbinated bodies cauterized with the galvano cautery. As 
a consequence of the treatment, the asthmatic attacks were 
much less frequent and severe, but the cough and post- 
nasal secretion continued about the same. Owing to the 
highly nervous state of the patient, it was impossible, even 
with the aid of cocaine, to make a posterior rhinoscopic 
examination. 
There was considerable hypertrophy of the inferior tur- 
binated body on the right side, which was reduced by 
means of the galvano-cautery. Upon removing a slough 
one morning resulting from a cauterization, the middle 
meatus suddenly filled with thick creamy pus, presenting 
a pulsating light reflex, such as is occasionally observed in 
perforations of the membrana tympani in suppurating 
otitis media. 
Upon further examination, the upper second bicuspid 
and the first and second molar teeth on both sides wrere 
found to be absent. There was no swelling of the right 
side of the face, and no pain on pressure. 
The diagnosis of abscess of the antrum having been es- 
tablished, I trephined through the alveolar process about 
the seat of the second molar tooth, and syringed out the 
cavity with a tepid solution of common salt. A large 
quantity of very fetid pus came out through the nose. The 12 
cavity was washed out twice daily with peroxide of hydro- 
gen and an antiseptic alkaline solution, with the result of 
greatly diminishing the secretion of pus. After the abscess- 
had been opened the patient felt greatly relieved, the asthma 
subsided almost entirely, and he was able to sleep the night 
through—something he had not been able to do for several 
months. The cough and post-nasal secretion ceased. 
About this time, August Ist, I left the city for my vaca- 
tion, and did not see the patient again until October sth, 
when he presented himself again for treatment, stating that 
during August he contracted a severe cold, which caused a 
return of the asthma and of the inflammation in the 
antrum. 
Upon examination of the nose, I found the polypi on the 
left side had re-developed, and they were much larger and 
more myxomatous in character. There was considerable 
pus found in the middle meatus after the polypi were re- 
moved. As it was impossible to say what its source was, I 
aspirated the antrum, but did not find any secretion. By 
means of the probe I was able to determine that there was 
considerable necrosis of the middle turbinated body pre- 
sent. 
The patient was recommended to go to the Garfield Hos- 
pital, where a more thorough examination could be made 
with the aid of an anaesthetic. On November 11th, he was 
etherized, and with the little finger passed into the left nasal 
chamber as far as it would reach, I found the middle turbi- 
nated bone very friable, breaking down under slight pres- 
sure; small spicula of bone were felt high up, projecting 
across the vestibule of the nose, and probably impinging 
on the septum. 
On the right side the middle turbinated bone was smooth 
and firm. 
With a sharp) curette passed into the left nasal chamber,. 
I scraped away all the broken down tissue I could reach. 
Wh en the patient came from under the influence of ether, 
the nose was washed out with a solution of bichloride of 
mercury (1-2000) and insufflated with iodoform. The pa- 
tient made a rapid recovery, with almost an entire cessation 
of asthmatic paroxysms. After the parts had thoroughly 
healed, it was found that more than half of the middle tur- 
binated bone had been removed. 
The inflammation in the antrum subsided under the 
treatment previously adopted. The patient did well until 
he contracted the grippe, which in his weakened and de- 
pressed state of health came near proving fatal to him. 13 
When last heard from he was much improved in general 
health, but he has not entirely rallied from the melancholy 
and depressed mental condition which has been a marked 
feature of the case from the beginning. 
Case II.—Lieut. , U. S. A., consulted me in June, 
1889, stating that he was suffering from nasal catarrh, and 
gave the following history: He has had hay fever every 
autumn since 1878, excepl for the three years he spent in 
South America, where, at an elevation of 9,000 feet, he was 
entirely free from all catarrhal symptoms. In 1882 he had 
the right upper second molar tooth filled, and shortly after- 
wards he had an attack of facial neuralgia, followed by an 
alveolar abscess. Last 4th of March he contracted a severe 
cold in the head, and since then he has had a profuse secre- 
tion of fetid pus from the right side of the nose. 
On examination there was no swelling of the face, but 
there was some tenderness on pressure. The inferior turbi- 
nated body on the right side was dilated, but not hyper- 
trophied. Under the influence of cocaine it contracted suf- 
ficiently to allow the middle meatus to be brought into full 
view. No pus was found there, nor in the post-nasal space. 
The diagnosis of abscess of the antrum was made, and as 
it was dependent originally upon the tooth, he was advised 
to have the second molar extracted. Before this was done, 
however, the filling was removed, and a quantity of very 
fetid gas escaped. 
On removal of the tooth its anterior root was found to 
have perforated the floor of the antrum, and the pulp cavity 
communicated directly with it. 
The alveolar process was found to be somewhat necrosed 
around the tooth socket. This was removed, and the open- 
ing into the antrum enlarged. The cavity was washed out 
thoroughly with warm distilled water. A large quantity of 
very fetid pus escaped through the nose. The antrum was 
syringed out daily with mild antiseptic and stimulating 
lotions, with the effect of greatly reducing the amount of 
secretion, but not entirely checking it. There is probably 
some pocket which is so situated that the applications do 
not thoroughly reach the inflamed surface. The case is 
still under observation. 
Case 111.—Mrs. C. came under observation in May, 1889, 
complaining of naso-pharyngeal catarrh and loss of smell. 
The condition then was as follows: The middle turbi- 
nated bodies were red and swollen; no secretion in either 14 
nasal chamber. On post-nasal inspection the posterior ends 
of the middle and superior turbinated bodies and the fornix 
were bathed with a white secretion. 
She complained of the great annoyance from the secre- 
tions dropping back into the pharynx. 
The middle turbinated bodies were cauterized with chro- 
mic acid, with the result of greatly reducing them in size 
and improving the sense of smell. She then passed from 
under observation, and I did not see her again until No- 
vember 30th, when she stated that the sense of smell was 
improving, but the quantity of post-nasal secretion was 
greater than formerly. Inclining the head forward caused 
the secretion to flow from the nose, which she thinks is con- 
fined to the left side. Her husband and children complain 
of a bad odor of her breath. 
I made frequent examinations of the nose, but could not 
find any secretion in the cavities. The post-nasal was 
about in the the same condition as previously described. 
The teeth were in good condition, only one or two having 
small amalgam fillings. 
Not being able to say definitely what was the source of 
secretion flowing from the nose, I aspirated the left antrum 
through the middle meatus, and drew off about two 
drachms of a sero-mucous fluid. 
The diagnosis made was a catarrhal inflammation of the 
antrum, complicated with a catarrhal inflammation of the 
posterior ethmoid cells and of the sphenoidal sinus. 
As the patient objected to losing a tooth, I determined to 
open the antrum through the inferior meatus with Cohen’s 
nasal drill. 
On December 17th she was put under the influence of 
nitrous oxide gas, and I perforated the antrum just anterior 
to the middle of the inferior meatus. The drill was with- 
drawn and the canula left in the opening until she came 
from under the influence of the gas. The cavity was then 
syringed out with warm distilled water, but as there was 
some haemorrhage following the operation, it was impossible 
to say what the character or quantity of the secretion was. 
The haemorrhage ceased in a short time. The next day the 
patient expressed herself as greatly relieved ; the secretions 
into the post-nasal space and from the front of the nose had 
greatly diminished. 
The antrum was washed out daily for ten days with a 
mild alkaline solution through the opening in the nose, at 
the end of which time, all secretions from the cavity seem- 15 
ing to have ceased, the treatment was discontinued. There 
still remained a diminished post-nasal secretion, which gave 
the patient very little annoyance. 
In conclusion, the points to which I would respectfully 
draw attention are: 
Ist. The disease is a serious one, and, owing to the ab- 
sence of positive signs, it frequently goes unrecognized for a 
long time. 
2d. That with the aids to the diagnosis mentioned in this 
paper there can be no reasonable excuse for not recognizing 
its presence. 
3d. In many cases the easiest and simplest method of 
treatment is to open the sinus through the alveolar process* 
but when the cause of the disease is intra-nasal, the opening 
made in the inferior meatus by means of Cohen’s nasal 
drill will offer many advantages ov§r the alveolar opera- 
tion. 
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