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CHRONIC SINUSITIS                                  75

Chronic infection of the frontal sinus may be treated by broad-spectrum
antibiotics, decongestants and short-wave diathermy. Chronic infection of the
ethmoidal sinuses is less amenable to conservative methods because of the
production of nasal polypi in many instances.

Surgical Treatment. Surgery is generally reserved for those cases not
responding to conservative means, but it may be recommended initially in
cases of chronic infection of long standing, especially if radiography shows
mucosal changes of such a nature as to be regarded as irreversible, and in cases
in which the disease appears to be producing complications. The aim of
surgery is to establish drainage and to remove the chronically infected
mucosa. In most instances these aims are accomplished at the same operation,
but in cases of short duration or in children preference may be given to simple
drainage operations in the first instance. Surgery by itself will not produce a
cure and it requires to be supplemented by conservative means in many cases.
Maxillary Sinus. This is by far the most commonly infected sinus, and its
anatomical situation makes it readily approached surgically as it is separated
from the nasal cavity by a thin bony wall and it lies superficially antero-
laterally. The most conservative surgical procedure is antral lavage, which has
been described (p. 73). Antral lavage may be curative in children and in
many adults with short histories, but it may have to be repeated weekly until
the return flow of fluid is clear.

Intranasal Antrostomy. This may be recommended in children in whom
antral lavage has failed to cure the condition, and it may be performed hi
adults for similar reasons if radiography does not suggest irreversible mucosal
changes. The principle is to create a drainage hole low down in the medial
wall of the sinus through which secretions may easily escape from the
antrum. It is essentially the same operation as the proof puncture except that a
larger opening is fashioned lower down on the medial antral wall by drill and
punch forceps. If there is hypertrophy of the anterior end of the inferior
concha this may be trimmed to facilitate drainage and subsequent lavage.
This is effective hi many cases if these have been properly selected. It may be
performed under local anaesthesia, but a general anaesthetic is usually
employed. The stay in hospital is only for a few days. Decongestant sprays
and inhalations are usually prescribed following surgery. Some surgeons wash
out the antrum on the day after the operation to get rid of blood clot and
secretions, and some continue this at intervals after the patient has gone
home. This serves to maintain the patency of the opening created.

Radical Antrostomy. Radical antrostomy, or the Caldwell-Luc operation,
is performed in cases where conservative therapy and minor surgery have
failed to produce a cure, but it may be advocated as a first choice in long-
standing cases in whom radiography shows dense mucosal thickening with
polypoid formation in the antrum. It consists in opening the antrum through
an incision in the gingivolabial fold (Fig. 33). The sinus is opened with a
gouge, the opening enlarged and infected material aspirated to afford a view
of the walls of the sinus (Fig. 34). Polypi are removed and thickened lining
membrane is cleared out. A large counter-opening is made into the nasal
cavity through the inferior meatus and the incision closed with catgut sutures.
After-treatment is similar to that for the intranasal operation, the cavity being
washed out through the nasal opening. The sutures slough out in about a
week and the patient is then discharged from hospital to continue with