If the ostium of a patient's maxillary sinus is blocked, he has pain in his cheek. If it is full of pus he has fever, and perhaps signs of inflammation on his cheek. Ephedrine nose drops may open his blocked ostium, but if his sinus is chronically full of pus, it needs puncturing and washing out, which is not difficult. Opinions differ as to whether a Caldwell-Luc operation should be in the repertoire of the generalist, so try to refer a patient who needs one. Fortunately, it is rarely necessary. Its main indication is chronic infection of the antrum which fails to respond to non-operative treatment.
Fig. 25-6 THE MAXILLARY ANTRUM. A, an antral washout. Push a cannula into a patient's antrum through the lateral wall of his nose in his inferior meatus. Wash the contents of his antrum out through the ostium. B, an intranasal antrostomy. After Bull PB, ''Lecture Notes on Diseases of the Ear, Nose and Throat', (6th edn). Blackwell Scientific Publications, permission requested.
MAXILLARY SINUSITIS TRANSILLUMINATION needs to be interpreted with care, because antra are often asymmetrical. Take the patient into a darkened room, shine a small torch with a bright beam on to his hard palate, and close his lips around it. If his maxillary antrum is normal, his cheek on that side glows red. If one antrum transilluminates less well than the other, it may contain thickened mucosa, pus, blood, a tumour, a polyp, or a foreign body.
X-RAYS tell you more than transillumination. Take an AP film with his head tilted backwards. If you take an erect film, you may be able to see a fluid level.
BLOCKED OSTIUM. Give him 0.5% ephedrine nose drops in the head-down position, so that they run into the higher part of his nose. Lay him on his back with his head over the end of the couch, as in Fig. 25-8, and let him sniff them up during 10 minutes.
ANTRAL WASHOUTS [s7]FOR SINUSITIS INDICATION. Pus in the maxillary antrum.
METHOD. Ask an assistant to stand behind him to steady his head. Obtain good local anaesthesia, especially under his inferior turbinate where the trocar will penetrate: (1) Anaesthetize the anterior end of his inferior turbinate with lignocaine 4%, applied on gauze, or as a spray. (2) Twist cotton wool on to the serrated end of a Jobson Horne probe. Load this with cocaine paste, or soak it in 4% lignocaine. Gently paint under his inferior turbinate. Or, (3) use a long thin needle to inject lignocaine into it. Give the local anaesthetic a few minutes to act.
Take an antral trocar. Grasp the side of his head with your fingers behind it and your thumb over his zygoma. With your finger along the trocar to prevent it going in too far, push it along the floor of his nose, under his inferior turbinate. Slide it along the wall, then push it laterally towards the outer canthus of his eye, until it will not go any further. About 5 cm should go inside.
Aspirate the contents. In most diseased antra aspiration is impossible, because the ostium is blocked. If you aspirate air, it suggests that his antrum is normal. Ask him to lean forwards over a bowl, and to breathe through his mouth. Pump saline through the needle with a 20 ml syringe, or a Higginson's syringe, and let it run out through the ostium into the bowl.
If his ostium is sufficiently blocked to prevent the saline draining (rare), insert a second needle to let it drain.
CAUTION ! (1) Don't go right through his antrum into his cheek. You should be able to waggle the tip of the trocar slightly when it is inside his antrum. (2) Keep the Higginson's syringe full of saline. If you blow air in, and his ostium is blocked, he may possibly die of air embolism (very rare).
CALDWELL[nd]LUC OPERATION INDICATIONS. (1) Chronic infection of the antrum which fails to respond to non-operative treatment. (2) Exploration. (3) To obtain a biopsy, and reduce the bulk of the tumour, in suspected carcinoma of the maxillary antrum. Refer him if you can.
ANAESTHESIA. (1) General anaesthesia with tracheal intubation and a pack in his throat. (2) Intravenous ketamine.
METHOD. Using a dental syringe and cartridge, infiltrate his mucosa with an adrenalin containing local anaesthetic to reduce bleeding. Starting over his canine tooth, make a 5 cm incision through his mucous membrane and his periosteum, in the sulcus between his gum and his lip, well above the sockets of his teeth. Raise the periosteum and reflect flaps upwards and downwards. Reflect the upper flap to just below the floor of his orbit. As you do so, find and preserve his infraorbital nerve. If you damage it, he will have numbness of his lip and cheek. Reflect the insertions of his facial muscles with his periosteum.
Use an osteotome to open the anterior wall of his antrum[md]well above his tooth sockets, and the floor of his antrum. Start by making a small hole, and enlarge it with nibblers, a punch, or bone forceps. Use a small dissector to remove all damaged mucous membrane. Remove benign tumours and cysts with forceps and scissors.
CAUTION ! (1) Take care when you approach the the roof of his antrum, because the bony covering of his infraorbital nerve is thin and easily damaged. It supplies sensation to an area of his cheek and upper teeth. Remove all bony fragments. (2) Don't try to clear the sinus blind, try to see into it. Don't damage the roots of his teeth, which often project into it.
If the cavity is severely infected, with very diseased muscosa, make an opening from the medial wall of his antrum through into his nasal cavity, under his inferior turbinate (intranasal antrostomy, B, 25-6). The medial wall of his antrum bulges inwards, so you can do this easily. Use a small gouge to lift away the bone and reveal the mucosa of the inferior meatus of his nose. Incise this anteriorly, superiorly, and posteriorly, to allow an inferiorly hinged flap to fall into his antrum.
If you have difficulty controlling bleeding, pack his antrum (seldom necessary) with the tail of the pack coming through his antrostomy into his nose. Impregnate the pack with ''BIPP' (4.11), or, less satisfactorily, gauze soaked in saline. 48 hours later remove the pack through his nose
CLOSE THE WOUND in his oral mucosa with several small absorbable sutures. If you don't close it securely, he may develop an oro-antral fistula.
Fig. 25-7 CALDWELL[nd]LUC OPERATION. A, incise the patient's mucosa and periosteum well above his tooth sockets in his canine fossa. B, elevate his periosteum. C, open the anterior wall of his antrum with an osteotome. D, enlarge the opening with bone cutters. E, clear his antrum. F, close the opening with a mucosal flap. After Lor[ac]e JM, ''An Atlas of Head and Neck Surgery', p. 73. WB Saunders, with kind permission.