Diseases Of The Nose Throat And Ear

74 THE NOSE AND PARANASAL SINUSES

to remember that the returning fluid contains not only the material contained
in the antrum but also the catarrh which may be lying in the nasal cavity. It
cannot be used for bacteriological tests with the same accuracy as that
obtained at aspiration, and it is less diagnostic of the source of the infected
material. An antral lavage is a therapeutic measure in that it mechanically
clears the infection from the maxillary antrum, and thus may cure a chronic
infection. It may have to be repeated on several occasions before the returning
fluid is clear, and this is usually done at weekly intervals.

Accidents may occasionally complicate this simple procedure. If the
maxillary sinus is small and narrow the trocar may be inserted with such
force as to penetrate both medial and lateral walls of the sinus so that fluid
is injected into the soft tissues of the cheek. This is recognized by pain and by
the appearance of a swelling visible on the face. Such swelling soon resolves
without incident if aseptic precautions have been observed. More un-
commonly, but more seriously, the roof of the sinus may be punctured so
that fluid is injected into the orbit with swelling and pain. Again this fluid is
absorbed in time. These complications are more liable to occur if the puncture
has been performed in children.

TREATMENT. The principles of treatment of chronic sinusitis are: (i) the
establishment of drainage from the infected sinus, which may provide a cure
if the pathological changes in the sinus mucosa are reversible, and (ii) the
surgical removal of infected mucosa when conservative therapy has failed or
when the pathological changes are irreversible.

Conservative therapy aims at the re-establishment of free drainage and the
control of infection, and it is usually advocated in the first instance, especially
in cases of relatively short duration. Antibiotics are given to combat the
infection. If the organisms are known as, for example, when infected material
has been cultured following a proof puncture, a course of the appropriate
antibiotic is prescribed for 7 days. In some cases lavage may be continued
through an indwelling polythene catheter during this time. If the infecting
organisms have not been identified a broad-spectrum antibiotic may have to
be used as the bacteriological flora varies considerably. Ampicillin is a suitable
drug. Many of the cultures are staphylococcal, some of which are penicillinase
producing in which event methicillin (Celbenin), cloxacillin (Orbenin) or
flucloxacillin (Floxapen) must be used. Carbenicillin (Pyopen) is employed if
the organisms are B.proteus, Esch. coli or pseudomonas which are penicillinase
producing. In some resistant cases cephalosporin will have to be used as
cephalexin (Ceporex or Keflex) but these should be reserved for particular
cases and never employed as a first choice. In chronic cases in which there is no
urgency about starting antibiotic therapy it is much more satisfactory to
identify the strain and sensitivity of the infecting organisms at proof puncture
before therapy is begun.

Decongestion should be combined with antibiotic therapy, and this is
achieved by nasal sprays or drops of 1 per cent ephedrine hydrochloride either
alone or combined with 1 per cent silver protein (Argotone). Steam inhalations
may also be used to promote drainage, and are given some 10 minutes after
the decongestant spray. Short-wave diathermy is indicated at this stage, and
the combination of decongestants, antibiotics, short-wave diathermy and
antral lavage, if the maxillary sinus is involved, is frequently effective in
curing the condition.