Intranasal surgery

Front matter

= eetei~es Pisaeeerea :

*

51621030

Preface

IN our teachings, we have found doctors and advanced students vague in their knowledge of the anatomy of the nose, and especially of the ethmoidal region.

Some of the books are so technical and use such a multitude of terms that they are almost impossible to understand. Others, in describing an area, use so much text and bring in so many variations that the whole subject is confused. In describing operations, too much of the technic is taken for granted.

In this book, we have endeavored to arrange the chapters to avoid confusion, and some may seem elementary. To reinforce the text, we have used many illustrations.

The latest and recognized operations are described. The technic has been gone into in detail, each step has not only been described but the reason given for doing it that particular way, and then illustrated. Some of the technic and many of the drawings are original.

The drawings are anatomically correct and most of them are made from actual specimens. They were drawn by Jean Eleanor Hirsch in the Medical Art Shop of the University of Minnesota, assisted by Edith Sykes and Katharine Kingsbury.

(iii)

iv PREFACE.

The photographic work was done by Mr. Henry W. Morris, of the Department of Pathology, of the University of Minnesota. The text was typewritten, read and corrected by Miss Ina Sherlock. We wish here to thank all these for their painstaking care and interest in the preparation of this work.

We have taken liberally from books and articles whose titles will be found under Bibliography, and we would recommend them for further study.

If we have presented the matter in such a simple way that we have made it clear. we shall have accomplished our purpose.

Contents

CHAPTER .I.

ANATOMY, een

Nasal Chambers — Vestibule — Roof — Floor — Mesial Wall — Lateral Wall— Turbinates: Superior, Middle, Inferior — Meati: Superior, Middle, Inferior — Mucous Membrane— Glands of the Mucous Membrane — Jacobson’s Organ — Olfactory Sulcus — Arteries — Veins — Nerves — Lymphatics ............. 1-22

Chapter II Functions Of The Nose

Air Currents — Nasal Spacing — Functions: Phonatory, Gustatory, Respiratory: Cold Air, Warm Air, Dry Air, Filter — Micro-organisms — Ventilation of Sinuses — Function of Sinuses — Eus- MOAT AIT TRIES. rg cienic oe te phates Des a ak tae Ae ea cae Bs 23-30

CHAPTER CET.

DISEASES OF THE NASAL CHAMBERS.

Bacteriology — Vasomotor Changes — Inflammations : Acute, Chronic — Hypertrophia — Hyperplasia —Deflected Septa — Suppurative Cans — Nasal Polypi «9.06 ccs hes cake deve ce uhoweman 31-45

Chapter IV. Atrophic Rhinitis

Simple Chronic — Chronic — Ozena — Treatment: Constitutional, ee SNe ein walk Taine ala baie nels able hice Maw tae cach eo 46-54

Chapter V. Miscellaneous Conditions

Epistaxis — Septum: Ulcerations, Perforations, Hematomas, Abscesses — Rhinoliths — Foreign Bodies — Adhesions — Anosmia —Tumors: Papilloma, Fibroma, Angioma, Osteoma, Enchondroma, Cysts — Malignant Neoplasms —Congenital Occlusions : Anterior Nares, Posterior Nares, External Diseases — Hay ever —— Asthma — Use of Ol 2 iiic.s cies desias de scvckdeces 55-74 vi CONTENTS, CHAPTER VI.

THE SEPTUM AND THE SUBMUCOUS RESECTION.

Nasal Septum — Embryology — Anatomy: Perpendicular Plate of Ethmoid, Triangular Cartilage, Maxillary Spine, Vomer, Blood Supply, Nerves — Deformities of the Nasal Septum — Adenoids — Traumatism — Submucous Resection — Operation — A fter Treatment — Complications: Tenting, Perforations, Scarlet Red, Hyperplasias, Hematomas, Cartilage Slough, Abscesses, Infections, Meaty Membrane, Loss of Sense of Smell, Dry Catarrh, Septum Hypertrophies, Lax Membrane, Whistles, Re-opera-

PAGE

CHAPTER VII. Dips 1N THE NASAL BriDGE

Cauges—— Use oisearaiin Imypections .:c@r os os «cate coe seteniee 127-133

Chapter VIII. Development Of The Lateral Wall

Embryology — Uncinate Process — Bulla Ethmoidalis — Infundibu-

CHAPTER TX:

LocaALIzED ANATOMY OF THE LATERAL WALL,

Sinuses — Maxillary —Frontal Ethmoids: Anterior, Posterior — Sphenoid — Nasal Ganglion — Vacuum Headaches — Operative

ABS qe heros nce ewe SPU a er ches pe on BRS at ayy TON EROR So Pe eN SN 166-174

Inferior — Hyperplasia: Anterior End, Border, Posterior End — Changes in Position — Middle — Lobulus — Hypertrophies: Anterior End, Lower Border, Posterior End — Infraction — Cystic — Operation for Cystic Middle — Superior — Compensatory

NasaliGrowths cocaine een ates oe en ee een eee 175-196

CONTENTS. Vii

CHAPTER XII.

THE ETHMOIDAL CELLS.

PAGE Description — Embryology — Anatomy: Anterior Ethmoid Cells, Agger Nasi, Infundibulum, Frontal recess, Bulla — Posterior Ethmoid Cells — Ethmoid Capsule — Ethmoiditis : Acute, Chronic, Hyperplastic, Empyemic, Suppurative, Mucocele — Intranasal Exenteration — Measurements — Operation — Complica- PAS Oe RRS eee ee eer ree peer ees 197-223 CHAPTER XIII.

THE SPHENOIDAL SINUS.

Embryology — Nasal Ganglion Neurosis — Sphenoidal Ostium — Sphenoiditis — Operation ........-...ceseceeere eee eseees 224-232 CHAPTER XIV.

THE FRONTAL SINUS.

Embryology: Development — Sinusitis: Acute, Chronic — OperaeA tt cael Seal Ges cae PaTEe Ny tie MAACO ears 233-278 CHAPTER XV.

Tue MAXILLARY SINUS.

Embryology — Hiatus — Sinus Floor — Sinusitis — Cysts — Inflammations: Acute, Chronic — Transillumination — Treatment : Puncture, Complications — Operation: Intranasal ......... 279-307

CHAPTER XVI.

CoronaL Heap SECTIONS.

ILLUSTRATIONS

FIG. PAGE Frontispiece.

Ie @ reas sceriomeoh a MOLMAl NOSE. ss icccvegistwe'sie s Sorte awele nese 0 3 Zev estindieiet.the node Outlined 2. 00.6 cs cccsn bade see maslele’e 94 5 3. Side view of the roof of nasal cavity outlined ................ 5 Maile Tae tiie -Siakal Cavity ac stake as ss eas ees ans pe eicen + ets ee 7 rear oa te asad “CAVIRY? os iets ties sve eae eee Tqde sea cnee 7 Gene fresco SOME RINNE: oc uc ecicelcie'e ie Sav awa o wlebtlaa Se cei qe aves wake 9 7. superion turbinate-and “its: attachment | 2.06 08. cele ee oe 9 eee eldle: tit biniate and its -attachitient: cis acs ce c dontictete scares atoisige 11 eolnterior turpinate and its attachments <2... ce. ccs... etisiv cele os 11 10. The spheno-ethmoidal recess outlined .............. 000 eee cece 13 Wr iinerne Wicains outlined 22). coc. . 2 send ete nis ewe eh wis eases 13 Pee Oetmie meats OMtied .Jniei.. Psa etines canes vce ca deans ee 13 eae casero : WeATIG-OULHNEN 2. oo. 5:. oc pes os oo oo 0 AERA Ro gis Vanes 15 14. The blood supply of the nasal cavity <... 16.6.6 cae ee eee 17 15. The. nerve. supply of the. nasal cavity .........c.cececeeeeeee 19 16. Lymphatic drainage of the nasal cavity ............-eeeeeee 21 17. Direction of air currents through: the nose ..........00.-000s 25 18. Position of patient when using oil in the nose ...........+... 74 19. A straight septum and nasal cavities of equal size ............ 77 20. Perpendicular plate of the ethmoid ...........eecceeeeccees 79 21. Triangular cartilage and tail-like projection of cartilage backward toward the body of the sphenoid .................. 79 22. Maxillary spine ....-.......ece eee e cece eter ete e nec cee tees 81 PE PAI TLICC MRI es 22 dh 5 iah ior o a. > cise ce oa a one THe oI, © erage love echivietera 81 er REMNE SEEING. Sak a5, o Foe a asin n G0 e'a.e doe alain 8 vhs We Mia's sin aieleie stareed aiees 83 25. NGSEE 8 eee ae aaa ere ate es Mr ier eek ETF: 83 26. Some of the different deflections and thickenings ina septum .. 85 CPPaNETRCKEMLESIEN =. u.uioie, Bel ¢uiwieratee os alee ee oe a Simrad! a’ Wale ahd b.scw deka, wine bie 85 28. Patient in semi-reclining position .........cccceceeeeeeseeses 87 29. Monosmith nasal speculum opening the nostril .............. 89 30. Cotton wound applicators in position on nerves for anesthesia .. 89 31. Original incision. The ridge on the septum represents a spur .. 91 32. Pushing back the membrane with the edge of knife to expose cartilage at center of the cUt .......eeeeee cere reer eeees 91 33. Elevating center of cut with small elevator ..........-++++++ 93 34. Elevating the membrane at upper part of cut from the inside with angular elevator .........ccceee cess secseeeeereees 93 35. Elevating the membrane at lower part of cut from the inside with angular elevator ........c.ccececcsecceesetccececes 95

ILLUSTRATIONS.

PAGE

. Completing cut above with the Freer knife from the inside out 95 . Completing cut below with the Freer knife from the inside out 97 . Elevating the membrane back and down to the edge of spur, with the: long ‘blade elevator sis ie. 2ic(sare cio: <tersiew viv d-eoie.s' oleae 97

. Extending original cut down on the floor .........0+eeeeeeeee 99 . Elevating the membrane on the floor with small elevator .... 99 . Elevating the membrane on under side of the spur after the membrane on the floor has been raised ............+005: 101 . Cutting the fibers of the perichondrium and periosteum along

1 pRB EL Oh Re ee DENG tr tac Gris 7 ber rarer tates Pause Rg." 101 . The membrane raised from above down onto the floor like the

Ride: Odicz tet toae. svn sere Wareshe arieedtet aren eas ate hee staat a oceans 102 . Incising the cartilage with the Freer septum knife ........... 103

. The angle at which the septum knife cuts through the car-

PIES ue co eaiha Gg vd ee ele rae be Te ne aes baa Sie eae 103

. Long blade elevator elevating the membrane on the opposite side through the cut made by the septum knife ........... 105

. Elevating the membrane on the opposite side well down in front with the- angular clevator sc<6.0ct i p.6e anesclnede tance vont 105

. Foster-Ballenger speculum in place to hold the flaps away from the cartilage and bony septum ........cccccesceseesceees 107

_A small slice of cartilage has been removed from the inner

. The direction the Ballenger swivel knife takes to remove as little.cartilagzesase possible. ci vasdjwisle bls A ole a gee oilers ethene 109

. Cut made if necessary in the piece of cartilage left to make it arie “Strait in F098 s,s eel oe eee 109

. Drawing to show how cut in cartilage makes it hang straight .. 110 . Cuts made by the Jansen-Struyker forceps up under the ridge 111 . Cuts made by the Jansen-Struyker forceps along the upper

. Piece of bone broken out between the cuts made by the Jansen-

Struyker forceps by the duck bill forceps ............--. 113

. Angular elevator removing the strip of cartilage along the upper ridge of the vomier 2.0. i ivess lets be eaacena renee 13

. Drawing showing the position of the cartilage when spurs are

PTOSCHE ~ caus C24 wee at Le hain Tae eie os kn eR ER 115

. The V-shaped chisel on the maxillary spine to fracture the anterior: part-o1 tHe VGMG? 205 ii0 a os sens a ees ieee 115

. Posterior part of the vomer removed with the duck bill forceps 117 . Amount of cartilage and bone removed in a complete operation 117 . Method of placing suture to close the flaps ................. 119 . Drawing showing tenting from above, also tenting from below in Wicomiplete- operations - £5. ceo gieda tae oe ce eee ee els 120

. Flap on one side torn and a perforation in the other ......... 121

ILLUSTRATIONS. Xi FIG. PAGE GA; Shiding flap-to close perforation. oii... sce cd coe eves 121 65. Using inferior turbinate to close perforation in septum ...... 122 66. Soft hypertropliy om the septumt: 00... ee eee ce eeee sees sees 123 67. Cautery marks in soft hypertrophy .........cccesecsesecees 123 68. Incision around the perforation and elevation of the flap ..... 125 69. Elevating the flap from behind the perforation with the angu- Nigel GIOWRINY 222s Seas LR a TERS CA 0s See's Od Rew Secs Sie 125 70. The complete cut in a re-operation on the septum with a per- HOLE UST one RR Eee EO ci Re nn er ens ere 126 71. Side view showing dip in nasal bridge. Front view showing HGIRS ie HOHE T ON TNE AEIOIRE alae s (cle uiviele sialic cre avatende sige aise Weots 129 ANE cata Gina's Wie aa ee MOE oe nee VF OS be OU Ua E DR SS 131 73. Side view of the dip in nasal bridge. Also showing position et needle ta fill dip with paraffin < 05 coo. cw cicde eons chee 133 74. The development of the lateral wall on the forty-fifth day. NE RCNOCNC) onc sy Sere so ak a8 Coan sees lh nahn ts ss 135 75. At the fiftieth day, the lateral wall has developed rapidly. Sere T SONU HEY) betes o0 ee eces toh rast eee tedeaennd 137 76. At one hundred days shows the prominent swelling of the turbinal bodies with their meati between. (After Schaeffer.) 139 me Biiee Pater ec wicl b AE IEE Ms aac e646 cleie cs oo 6 0re slniole Blecerdefeigie-cocers 141 Deer It Gral wall at SEVEN VEAL oc 5.306 8jn cre <jeicleiw eletousinie’s wise See Lao gee Pie ater al Wallin the adalts 2s sii. wintnedcce wale coin victveeidieieeecle 145 80. The beginning of a series of six views, showing coronal sections of the nasal region as near as possible to the ostium Serie Sia ttlaty SIHOS os cas Fe eas as Sate Oksees mabe ches 148 81. The nasal region of a sixty-five day fetus ........ceceeeees 149 82. The nasal region of a fetus at one hundred and twenty-one MI Re abe ces che ads ed chat Vas Poaceae sie see evayee 150 aa. bhe nasal resion-of-a-newborn babe -. iii0.0sties ccees i ealseseds 151 84. The nasal region at four and one-half years ........ceeeeeeee 151 Sh. bhe nasal-région of an addi Fit. Se. TIO cc cece ecewencs 152 86. An idea of what lies under the structures of the lateral wall in relation to the position of the turbinates .............e06- 13 87. The position of the uncinate Process ........cceccecccecececs 154 88. The bulla ethmoidalis in position just posterior to the uncinate De, ee ee Teer erent aee ee rere eee ee eee eh 155 89. The uncinate process and ethmoid bulla ..........e.sse eevee 156 00. The group of cells and their positions under the middle turbinate, which collectively compose the anterior ethmoidal a ks sae a akN REE RE bet OSORNO e Rae vada ae ies 157 91. The attachment of the middle turbinate ..........eeeeeeeees 158 92. The group of cells and their position under the superior turbinate, known as the posterior ethmoidal cell ..........-. 158 xii

FIG.

94. 95.

110. 111.

113. 114.

115. 116. 117.

ILLUSTRATIONS.

PAGE

How the anterior ethmoidal cells, the posterior ethmoidal cells,

and the sphenoidal sinus are on a line with each other .... 159 The lateral wall covered and protected by the turbinates ...... 159 A right side view of the wax model of the nasal cavities and

Stat E Ic peer Ren et Pate ear panne meee ary merry aria enOon) i 160 A left side view of the wax model of the nasal cavities and

Sy EEG cc ene A ee MINE le Tinh rhe baa asi HR. TOC Ie c= 161 A view looking from before backward on the wax model .... 162 A view looking from behind downward on the wax model .... 163 A view looking from above downward on the wax model ... 164 A view looking from below upward on the wax model of the

fiasal cavities: And sinuses sic. es (eS cas sesnSed Guanes aee ee 165 Areas OT head Gains. 5.5 ca discos Oke sss is Vinee bw oe ee 167 A hyperplasia of the anterior end of the inferior turbinate .... 177 A hyperplasia of the inferior turbinate ...........ee eee ee es 179 The snare removing a posterior hyperplasia of the lower tur-

ian k cc datses Tons aus Ss rts IE 6 SiS np RGA a ovens oreo a ETO 179 The position of lines that are made by the cautery to tempor-

arily reduce a hypertrophy of the inferior turbinate ..... 181 The removal of the lobulus of the middle turbinate with a

Sek Vi ERB eR ERIE bee CATE) PTC ERIS Cera. Pal cans 181 A large hyperplasia of the middle turbinate frequently present

With a -GEMeCteG sSEptUil wacins wicasete eapmnnee seloiniee Came serene 183 The snare removing a posterior hyperplasia of the middle tur-

SELLA CE paseo oak a areas oe STTLG wu eotreT cs la cl wes habatent olan cee eee eae 183 An elevator under the anterior end of the middle turbinate in

AN Wiaction Oh tue vtuimbiniatec:. <iicse oo me alakeea ee ements 185 Instruments used in infraction of the middle turbinate ........ 185 A specimen showing an extremely large .cystic middle turbin-

MBE fae ech patpeeicia mata tat 4nd lees yhcns ck oe a. na a 187 The different steps in the operation for the reduction of the

Cystic middle “turbinistivs « sao tec vy hese tl cieky Ree ores 189 Instruments used in operation on the cystic middle .......... 191 The position of the compensatory growth of the septum, at

about the position of the septal tubercle ................. 193 The position of the anterior and posterior compensatory

growths. onthe lateral wal ci. undies cen. vs ee reste es eeag 195 A specimen cut horizontally just below the roof of the eth-

mbitdl. capsule and ‘lifted up. cites yo deid nea ced ee eee Sacre 199 The position of the nasal sinus, if seen transparently through

The marking on the side of a head, a skull and the lateral half of a skull, which gives the external measurements for the location of the posterior wall of a normal sphenoid ...... 203

FIG,

Zz.

125. 126. :

ILLUSTRATIONS. xill

PAGE The lines on the face, the skull and a coronal section that mark the position of the cribriform plate, the ethmoid capsule

ane the entrance tothe ‘frontal sinus)... occ. Se... wesc 205 Instruments used in exenteration of the ethmoids under the

Seitelenlee UNG PEM Tne wae Marae er ca capa creld ced a Wiscate wilde Weiaielae © 207 The position of the cocain swabs in anesthetizing the nasal

ganglion and the anterior ethmoidal nerve ............... 209

In opening anterior ethmoidal cells, the head is tipped back ... 211 On opening the posterior ethmoidal cells, the head is tipped forward to nearly a horizontal position, and the instrument follows back along the roof of the frontal bone .......... 213 The straight end of the Pratt curette is shown in the anterior

ethmoidal cells under the middie turbinate .............. 215 The attachment of the middle turbinate ...............00000- 217

The Gruenwald biting forceps breaking into the anterior cells just under the anterior attachment of the middle turbinate 217

The Gruenwald forceps progressing backward and opening the Wmieting: etNiNoldal “CONS iis seaels a boas puree ee Rae eisienw nes 219 The Pratt ethmoid curette in the posterior ethmoid cells after the biting forceps has removed all the soft tissue ....... 221 The angular end of the Pratt ethmoid curette in position ...... 221 A cross section showing an operated ethmoid ............... 223 Instruments used in opening the sphenoid ................... 227 Position of nasal ganglion (Meckel’s) in relation to the posterior ethmoids and sphenoidal sinus .............-....0. 229 A frontal sinus opening directly into the frontal recess ....... 234 The lateral wall of the nose with the middle turbinate removed 235 The middle turbinate removed showing its attachment ....... 237 The fronto-nasal suture is a dividing line .................... 239 A specimen showing the true frontal sinus with the entire cell lying above the fronto-nasal suture ..............2000e0 241 A specimen showing the frontal ethmoidal cell, when the greater portion lies above the fronto-nasal suture .............. 243 A specimen showing the ethmo-frontal cell where the greater part of the cell lies below the fronto-nasal suture ........ 245 A specimen showing a true frontal sinus situated above the MOHEGAN AL GUEIEE EE, ce nla naires cate ne ee acide A age ee be ents 247 A specimen showing a large fronto-ethmoidal sinus, the ostium of which opens directly into the infundibulum ............ 249 The front half of a specimen showing extremely large fronto- SRE COUR Ne eck a ro ORO Rei ROT ETE ec Alea heeds 251 The posterior portion of the section showing the extremely large Bernier tal: Celis: cccis kone ko catees tae kee tis chess 252

A specimen showing the frontal sinus opening direct into the ‘irundibulune ethmoidalis o60602c. Sous deta vtacebes 3 ine 253

Xiv

148. 149.

ILLUSTRATIONS.

PAGE A specimen showing the frontal sinus opening into the frontal PCCSS 5 fics wtp clean Rea SO Bare Ree et es Ss ps RoE 254 A specimen where the frontal sinus is opening into both the infundibulum and the middle meattis ..............+-.-> 255 Instruments used in opening the frontal sinus intranasally .... 256 The curette breaking down the cells leading to the frontal sinus 257 The position of the Thompson flat-backed rasp in the frontal sinus under the middle turbinate after the anterior ethmoids have been exenterated fics hic iteanew Seda bays ea eae 258 The Good-Thompson rasp in the left frontal sinus ........... 259 The Good-Thompson rasp is under the anterior end of the mid-

le -4utbmate; ito the: trontal~ sinus--.5 os s..%..s)sG eee tele 260 A No. 6 Ritter frontal dilator in the frontal sinus ........... 261 An X-ray plate showing absence of the frontal sinuses ....... 262 An X-ray plate showing well marked frontal sinuses with broad

floors opening into the anterior ethmoids ............... 263 This X-ray p!ate shows large frontal sinuses, with broad floors

leading to the anterior ethmoids ...0....0...--cscseee ee 264

This X-ray plate clearly shows the very large frontal sinuses, with partial partitions and ridges running from the peri-

BE ais Set a iaag Sates Rie RI SE ONS STE Gave pincare mints REE Fe 265 This X-ray plate is of a very pneumatic head ............... 266 A front view X-ray plate showing the large orbito-frontal cells

A side view X-ray plate of the case of Mr. S., showing the rare orbito-frontal cells and also large frontal sinuses .... 268

Side view X-ray plate of the case of Mr. S. ..............065 269 A direct front view X-ray plate of the case of Mr. S. ....... 270 A side view of the case of Mr. McK., showing a rasp in the PEOMCALMSIIN IS ESE Mirae 6 Bisese syst ataincqis aorecseialy. sate ee 271 A front view of the case of Mr. McK. The rasp is shown in the “ELOntal “SMUSES i. 53. isc oes 5 cwaweees cs 0 Pe eee dares 272 X-ray plate of the case of Mrs. F., showing the Ritter frontal dilators in- the frontal sintses saci wvkes osc cae atone ome 2s

A side view X-ray plate of the case of Mrs. F., with the Ritter frontal dilators in the frontal sinuses A side view X-ray plate of the case of Mrs. F., with a Ritter frontal diladtar: NGG. S. eccntes case oe nail eee 275 X-ray plate of the case of Mrs. D., shows the suction catheter in the frontal sinus and a curette in the posterior ethmoidal SRAGE TS Vcc Xe eens hg te een 8 BY O34 a eee eee 276 Mr. H. had a radical operation of the frontal sinuses, with complete removal of the frontal plate. In the X-ray plate, the curette is up to the floor of the frontal sinus

FIG,

182, 183.

ILLUSTRATIONS. XV

PAGE

The X-ray plate of the case of Mr. H. is a side view, showing

the curette up to the floor of the sinuses and the great deformity caused by the radical operation ............... 278 A section showing the size and shape of the antra ........... 281 An X-ray showing one antrum involved ..............0eeceeee 283 An X-ray showing both antra involved ..............00ceeee 285 Instruments used in puncturing the maxillary antrum ...... 287

Shows the position of the Coakley antrum trocar as it enters CAR NSE ip Ea AS Se ati ae a a 289

A diagrammatic drawing to show the position of naso-lachrymal estrim of the naso-lachrymal duct .3...0.<.. cscs cccceacss 291

A specimen showing a dentigerous cyst larger than the antrum Apa PRION ue eae ee ide ia, oe ee sg GP tee 293 Instruments used in opening the antrum intranasally ......... 295

Three-quarter view of the lateral wall, showing the anterior attachment of the inferior turbinate cut and the turbinate

La CL AUS Se pane tiny oy Pee ery ana ok age ae ares d at aoe West chisel as it punctures the antrum ..................... 299 Thompson rasp in position, to rasp away the anterior wall of

the antrum to enlarge the opening ...............-..0000: 301 Movable blade of the Gruenwald forceps in the antrum through

EST cs Sa Nn ee ee ee 303 NVagnet forceps cttttine forward...) oi. <6... co cece donc ece., 305

Angular end of the Pratt ethmoid curette, curetting the antrum in every direction through the opening previously made ... 307

184-194. Coronal sections of a decalcified head—anterior and pos-

WP SINUS Fata hae Sacre one y eR ics KONG Ce oe 317-327

CHAPTER I. Anatomy

THE NASAL CHAMBERS.

THE nasal chambers are two more or less regular spaces, triangular in shape, situated one on either side of the middle line of face, extending from the base of the cranium to the roof of the mouth, and separated from each other by a thin vertical septum. They open on the face through the pearshaped anterior nasal aperture or anterior nares; and their posterior openings, called posterior nares or choane, communicate with the nasal part of the pharynx. They are much narrower above than below, and in the middle than at their anterior or posterior openings; their depth, which is considerable; is greatest in the middle. They communicate with the frontal ethmoidal. sphenoidal and maxillary sinuses.

THE VESTIBULE.

Just within the anterior naris is the vestibule. It is a triangular pyramidal cavity, wider behind than in front. It is bounded on the median side by the nasal septum, and on the lateral side by the soft tissues of the nose. It is bounded by the anterior naris in front while the posterior margin corresponds to a line dropping perpendicularly from the fronto-nasal suture, through the anterior end of the inferior turbinate body. It is therefore mostly within the soft tissue structure, but about one-quarter of an inch of it extends within the space bounded by the nasal bones. It corresponds to the external nose.

BOUNDARIES OF THE NASAL CHAMBERS.

Each of the main cavities is bounded by a roof, a floor, a mesial and a lateral wall.

THE ROOF.

The roof is horizontal in its central part, but slopes downward in front and behind; it is formed in front by the nasal bone and the spine of the frontal; in the middle, by the cribriform plate of the ethmoid; and behind, by the body of the sphenoid, the sphenoidal concha, the ala of the vomer and the sphenoidal process of the palate bone. In the cribriform plate of the ethmoid are the foramina for the olfactory nerves.

THE FLOOR.

The floor is flat from before backwards and concave from side to side, it is slightly wider behind than in front and slants downward from _ before backwards so that the level of the floor behind is about one-quarter of an inch lower than in ection of a normal nose,

. 1—Cross s

Fig front. It is formed by the palatine process of the maxilla and the horizontal part of the palatine bone.

THE MESIAL WALL.

The mesial wall (septum nasi) is formed above in front by the crest of the nasal, the spine of the frontal bones and the triangular cartilage; above behind by the perpendicular plate of the ethmoid; behind by the rostrum of the sphenoid and the vomer; below by the anterior nasal spine, the crest of the maxillz, the vomer and palatine bones. Its bony surface is marked by numerous furrows for vessels and nerves and by the grooves for the naso-palatine nerve and is traversed by the sutures connecting the bones of which it is formed.

THE LATERAL WALL.

The lateral wall is formed, in front, by the ala nasi, the frontal process of the maxilla and by the lachrymal bone; in the middle above by the superior and middle turbinates (conche), under which lie the ethmoidal sinuses, and below, the inferior turbinate; behind, by the vertical plate of the palatine bone, and the mesial pterygoid plate of the sphenoid.

THE TURBINATES (CONCH).

The turbinate bodies, so named from their scrolllike appearance, are three in number and are located upon the lateral wall of the nasal chambers. They are covered with mucous membrane containing

Fig. 2—Vestibule of the nose outlined.

venous plexuses, known as “swell bodies.” They are called the superior, middle and inferior turbinates and are nearly parallel and approximately an equal distance from each other, and sub-divide the nasal passages into three channels called meati.

THE SUPERIOR TURBINATE.

The superior turbinate is not a distinct bone but a projection from the lateral mass of the posterior ethmoid, forming a ridge posteriorly while anteriorly it merges into the middle turbinate. It is much smaller than the other two turbinates and is located in the extreme upper-and posterior part of the nasal cavity.

THE MIDDLE TURBINATE.

The middle turbinate is not an independent bone but a large overhanging appendage of the lateral ethmoid mass.

The attachment, starting posteriorly, follows the lower border of the superior meatus to its anterior end, then turns abruptly to the cribriform plate, curving forward to end at the agger nasi ridge.

The vertical line of the attachment separates the anterior from the posterior ethmoidal cells. The anterior ethmoidal cells lie under the anterior superior half of the turbinate, while the posterior halt is simply an overhang.

A line drawn through the lower border of the middle turbinate divides the nasal chamber into about equal halves.

Fig. 4—Roof of the nasal cavity.

Fig. 5.—Floor of the nasal cavity.

THE INFERIOR TURBINATE.

The inferior turbinate is an independent structure articulating anteriorly with the nasal process of the superior maxillary, centrally with the lachrymal and ethmoidal bones, and, posteriorly, with the crest of the palate bone. It is the largest of the three turbinates and its mucous membrane contains the greatest number of the “swell bodies.”