The Common Head Cold:
Principles And Practice Of Hardening
Home Care And Treatment
Nasal Obstruction And Mouth Breathing
Voice And Speech
Summary And Conclusions
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( Originally Published Early 1900's )
In the chapter "Anatomical Outlines" we have briefly described a group of air chambers hollowed out of the bones of the face and skull and designated as paranasal or nasal accessory sinuses, because they surround on all sides the nasal chambers, forming as it were, hollow out-shoots from these central cavities with which they are in direct communication.
The term sinus, it is evident then, is not to be confined to the cavities in the forehead, as many seem to suppose, but refer equally to the cavities of the cheek bone, (maxillary sinuses or antra), the honeycomb-like mass of cells which lie between the eyes (the ethmoid) (Fig. 15.) and the cavities situated above and back of the nose at the very base of the brain, (sphenoid sinuses). (Figs. 2 and 5.)
In the chapter "Symptoms, Complications and Sequelae," we pointed out how easily these sinuses might become involved by extension of the inflammation from the nose, and we indicated by what symptoms and signs, the involvement was evidenced.
So important is the rôle of the sinus in the tragedy we call catching cold, that it merits particular attention. More often than any other thing it is sinus disease that is the "nigger in the wood pile." Whenever a cold is seen to be of unusual severity, or when it persists with unusual obstinacy or displays an annoying tendency to recur with slight provocation, it is more than half a chance that the explanation is to be found in some involvement of one or the other of the sinuses, or it may be several of them together.
Sinuses tend to maintain and aggravate the symptoms of a cold by acting as reservoirs for the secretion which overflows into the nasal cavity and often backward into the nose, giving rise to the annoying symptom of "dropping" of which the patients often complain.
Secretions remaining pent up in the sinuses, become stagnant, and, if infection is added, undergo decomposition, and become of a more or less purulent character. This infection may spread to the neighbourhood of the nose, and to the other sinuses.
Let no one "lay the flattering unction to his soul" that he must be free of sinus trouble be-cause he is free of pain. Except with the frontal sinus, pain is by no means a regular symptom, and is generally absent when the sinus disease has become chronic. It is not infrequent to find persons who for years have been going about with one of the sinus cavities filled with purulent exudate, and its bony wall badly decomposed, who have no local symptoms other than perhaps a persistent catarrh, or the symptoms of hay-fever. Unfortunately even the x-ray sometimes fails to disclose these suppurative foci and occasionally physicians as well as patients overlook them as a cause or as a source of an obstinate rheumatic condition, or of a general bad state of health.
The nasal accessory sinuses are regarded by some authors as mere vestigial remains of organs which in the lower animals and in primitive man had important olfactory functions. Originally they formed a part and parcel of the nasal cavities which communicated with them through wide openings, but as their usefulness as olfactory organs lessened, they became gradually walled off, leaving only small communicating apertures or channels, which we can readily under-stand must be maintained in order to provide ventilation and drainage of cavities still lined with functionally active mucous membranes. If the vestigial character of the sinuses be accepted, it follows that this must explain on the one hand their reputed vulnerability to disease, and on the other their incapacity for complete repair after extensive injury.
The mucous membrane of the sinuses differs from the mucous membrane of the nose in degree rather than in kind. The glandular elements and nerve filaments are less numerous, and the blood supply to the submucosa less abundant. Not only, however, is the layer of epithelial cells (the most superficial layer) thinner, but especially to be noted is the fact that the underlying so-called genetic layer of the epithelial surface is less substantial, all facts pointing, it seems to me, quite significantly to a lessened power of regeneration on the part of the submucosa.
Therefore from histological as well as developmental considerations, arguments are to be drawn which speak strongly against extensive operative intervention and in favour of extreme conservatism in dealing with the nasal accessory sinuses.
The maxillary sinus (antrum) is present in but a very rudimentary form at birth; its final shape and normal position are not obtained until after the eruption of the permanent teeth. The frontal sinus is not present at all at birth; it makes its first appearance at about the second year, and, only at about the eighth year, assumes the form of a distinct cavity. The ethmoid and sphenoid sinuses are present at birth, but like the others, develop slowly and do not assume their complete form and size until puberty or even later.
These nasal accessory sinuses in the adult are variable with regard to form, dimension and capacity, and the situation of their apertures. In general, however, we find that they have taken together a volumetric capacity equal to twice that of the nasal fossae proper, and, normally, each sinus will have at least one aperture of communication, through which the mucous membrane covering its wall becomes continuous with that lining the nasal passages. As pathological processes tend to spread by continuity throughout any homogeneous structure, it is nothing more than we could expect that inflammation affecting the nasal passages should involve the sinuses. The inference to be drawn is that in the treatment of sinus diseases, due attention must be given to securing at the same time a healthy condition of the nasal passages proper.
When the openings of the sinuses are in proximity, infection of one of these cavities from the other is always imminent. Therefore, the frontal, anterior ethmoidal and the maxillary sinuses, which constitute the anterior group and open near each other are frequently observed to be concomitantly diseased. Similarly, we find the posterior ethmoidal cells very often involved in cases of suppuration of the sphenoid sinus, or vice versa, because these two constituting the posterior group, open near each other in the region of the superior meatus. Capillary attraction and syphonage are probably the active forces in causing a spread of the purulent infection.
In addition to the fact that certain of these sinuses are in such intimate anatomic relation through their cell walls and ostia, another fact arguing for their mutual pathological dependence is to be found in their common vascular and vasomotor supply. Causes which act through these media are likely to influence simultaneously, in greater or lesser degree, the entire nasal accessory system.
The obvious deduction to be drawn from these considerations is, of course, that treatment of any kind, restricted to a single sinus, may prove futile so long as a neighbouring sinus continues to suppurate. Radical measures, once decided upon, will therefore often have to be much more extensive than originally contemplated.
The maxillary sinus, (antrum) in addition to those causes common to other sinuses, is in a certain proportion of cases affected by caries of the. roots of teeth, which are in anatomical relation with its floor,—most commonly the second bicuspid and first molar. The dental origin, formerly regarded as responsible for about one-half of all antral suppuration, seems to have lessened as a factor and according to later statistics can hardly be incriminated for more than one-third of all cases.
Of great interest in connection with the treatment as well as the genesis of sinus inflammation is the size, conformation, and especially the situation of their ostia, or apertures of communication.
Looking at a sagittal section exposing the lateral walls of the nose, we observe that the frontal sinus has its outlet at the most dependent place so that the secretions will fall downward through a narrow channel, opening either in the upper part of a slit known as the hiatus semi-lunaris, or just anterior to it.
The opening of the maxillary sinus, which may be seen in the lower posterior end of this hiatus, instead of being at the most dependent locality is situated, on the contrary, near the roof, so that when the patient is in the upright position no fluid can flow out by force of gravity until the cavity is practically full.
The same is true also of the sphenoid, whose opening may be seen in the superior meatus on the upper part of the anterior sinus wall.
Much has been made of these various positions on the ostia relative to the sinus cavities. The deduction generally made with regard to treatment is that, while a frontal sinus may be depended upon to get rid of a purulent collection because of the favourable situation of its outlet for drainage, the case is hopeless for the antrum and the sphenoid unless surgical measures are resorted to. To hold such a view means to have far too little confidence in the resources of Nature, who has provided other means for the emptying of the sinuses than gravity alone.
Skillern has shown that if finely powdered lamp black is strewn over the mucous lining of the sinus of freshly slaughtered calves, the black particles may be observed to travel the space of 1 cm. per minute toward the ostium, no matter what the situation, and that in a short time it will have completely escaped into the nasal cavity. This is without doubt the most potent force in ridding the sinuses of contained secretion. The mucous membrane of all the nasal accessory sinuses is of the ciliated type. The fine hairs or cilia are in rapid and constant motion and always towards the sinus opening.
The waving of one of these cilia described else-where is estimated to occur at the rate of about twelve times a second, the forward movement being twice as rapid as the return. Warmth and an alkaline reaction of the secretions favour their activity whereas cold, too great acidity and irritant chemicals have a retarding effect, therefore, in the action of powerful force overcoming the laws of gravity. We see at the same time the necessity of their integrity being maintained and of the importance of securing a proper environment for their activity, from which facts we may not only draw general arguments in favour of conservatism, but also some practical deductions for local treatment.
It shows the advantage of bringing into con-tact with the membranes no medicaments which have not been warmed; and if in solution they must be alkaline and bland, never strongly irritant. When the secretions become thick, viscid and abundant, ciliated action is embarrassed and their removal is consequently a rational indication.
In the plan of the lymphatic distribution, unlike the case of the blood supply, there is no reason for the common involvement of the sinuses or the extension of disease from one to the other. The lymphatics, forming an interlacing network over the walls of the individual cavities, seem to radiate in each case towards the ostium, where they communicate with the nasal fossae. They are no doubt a part of a protective mechanism, and acting in conjunction with the ciliated cells, tend to relieve the cavities of exudate and epithelial debris, which accumulates as a result of inflammation of its lining walls. The direction of the flow being toward the nasal cavities, inflammatory engorge-ment within the latter will naturally impede this wholesome draining process, produce stasis or blockage of the lymphatics of the sinus, and thus favour bacterial invasion.
In addition to the action of the ciliated cells of the lymphatics, certain physical forces, according to Yankauer, may be counted upon to promote the evacuation of the sinuses. These are especially capillary attraction and syphonage. Through adhesiveness of the secretion to the sinus wall, assisted by ciliated action of the epithelium, an accumulation of fluid in one of the sinuses will never be perfectly level, but have always a high meniscus reaching as a rule to the ostium. Then capillary attraction and syphonage come into play, the former favoured by the conformation of the ostial edges, the latter by the continuity of the secretions within the cavity, with what has escaped into the nasal passages through the natural orifice of communication.
Now apertures of the sinuses are maintained evidently by nature for another function besides that of draining away the secretions. As we have already mentioned, there was a period in physical development, when the sinuses widely communicated with the nose and were constantly in contact with the inspired air. It is for this reason probably that air is still a necessity for their normal health and vitality. Just as the tympanic cavity becomes congested and diseased when its normal supply of air is cut off by obstruction of the Eustachian tube, so the nasal sinuses suffer when the ostia become in any way occluded. The air in the enclosed cavity becomes gradually absorbed, and the resulting rarefaction tends to produce a sagging in of the yielding membranous lining attended with marked passive congestion. If in such a case a purulent secretion is already present in the cavity, micro-organisms of a parasitic character (so called saprophytes) multiply and bring about a decomposition of the stagnant secretions. It is quite likely that the severe pains experienced in some cases of sinusitis may be due to the pressure of gases arising from the decomposition of pus. How many physiological facts seem therefore to point to the positive necessity of keeping these ostia clear, as one of the prime indications of sinus treatment?
The bacteriology of the sinus is a topic of great interest, closely related to the subject in hand, but unfortunately, though much has been written, very little has resulted of practical value. The nor-mal sinuses, contrary to our former opinions, have been shown by more recent investigations to be nearly, if not completely, sterile. Experiments seem to prove that the mucoid secretions, if they do not possess actual bactericidal properties, at least are capable of inhibiting bacterial growth.
A great variety of micro-organisms is found in sinus suppuration and no one can be rightly called the specific cause. An inflammation which may have begun with a certain micro-organism predominating will often later on show an entirely different one taking its place, and it is the rule to find mixed cultures, in a suppuration that has lasted any length of time. For these reasons, if for no other, vaccine treatment of sinus inflammation in the chronic form must be regarded as somewhat chimerical.
Pyogenic cocci seem more often associated with sinus suppuration than baccilli. Those most frequently found are the pneumococci, streptococci, staphylococci, and diplococci.
While many infectious diseases are complicated with sinusitis, in most instances they must be looked upon as only predisposing causes, preparing the soil, as it were, for local infection. Exception must be made of four diseases in which apparently the sinus inflammation is directly and primarily due to the specific organism of the dis-ease. These are influenza, croupous pneumonia, diphtheria and erysipelas. Of these by far the most frequent cause is influenza, whose importance as a cause of sinusitis was first pointed out by Lindenthal and later emphasised by Hajek.
Since sinus trouble was unknown a generation ago, and now seems to be an exceedingly prevalent infection, it is often wondered if it is a new disease, or if our forefathers also had it, and, if they did, how they made out when so little was known about it. It is certainly not a new disease. We have always had our sinuses and it is natural to believe that they were susceptible to disease in generations gone by as they are to-day. But in recent times on account of new technique and methods of examination we have been able more easily to discover a diseased condition here, and have found it is of rather frequent occurrence.
In former days patients suffered without knowing what they suffered from, and their afflictions were included in such general designations as neuralgic colds, catarrh, abscess and migraine. Today the exact nature of the trouble may be at once recognised, and if properly treated, may be promptly relieved and eventually successfully cured.
To effect a permanent cure in a chronic case with necrosis on decay of bone, a radical operation may be necessary. This requires free opening of the cavity and exposure of the diseased part,—and can be properly done only by a skilled surgeon.