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Studies in chronic sinusitis in children
STUDIES IN CHRONIC SINUSITIS IN C H I I , D R E N
I. ITS t~ELATIONSHIP TO FREQUENT NASOPLIARYNGITIS J. S. UHR, M.D., AND J. W. Pt~G~, M.B., B.Cm NEW YORK IS customary for the pediatrician and, especially, the general pracI Ttitioner, to diagnose the rhinorrhea and cough of children as being almost invariably due to acute nasopharyngitis. It is the purpose of this paper to present anatomic, bacteriologic, and clinical facts so that the diagnosis o~ chronic sinusitis in children will frequently replace that of simple acute nasopharyngitis. Politzer postulated the law that in every case of acute otitis media there was also involvement of the accessory air spaces in the mastoid to a greater or lesser degree. We find a similar relationship existing between the nose and its accessory sinuses. Davis 1 presented the following facts in aa anatomic study of 160 lateral nasal walls of infants and children, 17 per cent of whom were less than one year old: The lateral ethmoidal mass proper is, in a majority of cases completely pneumatized at birth. Subsequently the cells increase in size by expansion as the ethmoidal area grows, and also by invasion of the surrounding tissue. The frontal sinus originates (in all cases) from one cell, or in the case of supernumerary frontal sinuses ~rom two cells, of the group of cells comprising the anterior ethmoidal are% the route of development being rarely demonstrable with absolute certainty before the sixth, and in many instanees~ before the t w e l f t h month of postnatal life. The pneumatizing sinus gradually extends from t h a t portion of the anterior ethmoidal area into the interior portion of the frontal bone, begins its ascent into the vertical portion during the second year, is 3.8 ram. above the level of the nasion at three years, and continues the vertical advance at an average rate of approximately L5 ram. per year until the fifteenth year. The maxillary sinus at birth is an oblong ovoidal sinus, its diameters averaging 8.9. ram. anteroposteriorly, 3.3 ram. vertically, and 2.8 ram. laterally. There is an average increase in the extent of pneumatizatioa of 2 mm. in both the lateral and vertical diameters, and 3 ram. in the anteroposterior diameter until the ninth year, after which the advance is slower until the fifteenth year, when the usual adult type is approximated. Later changes occur chiefly in the posteroinferior angle. The sphenoidal sinus develops as an extension from the posterosuperior portion of the recessus sphenoethmoidalis. I n children of less than one year of age the diameters of an average sphenoidal sinus are 2.8 ram. vertically, 2 nlm. laterally, and 1.5 ram. anteroposteriorly. Pneumatization goes on, the rate of resorption of the body of the sphenoid being such that by the eighth to the tenth year the posterosuperior portion of the sinus lies beneath the anterior portion of the sella tm'eic% and by the fifteenth year, is usually separated from the hypophysis by a very thin 418
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lamina of compact bone. By the fourteenth year pneumatization extends in many instances well into the pterygoid process.
Dean, 2 in a paper on paranasal sinus disease, states that of all the sinuses only the frontal is never present at birth, the ethmoidal cells are always present, the maxillary sinus only rarely absent, and that, while only rarely was the sphenoida] sinus present at birth as a cell, he was informed by Dr. J. Parsons Schaeffer that occasionally at birth the sphenoidal sinus would be of sufficient size to be diseased. He mentions a child, aged five and a half, that came to necropsy and showed a diseased sphenoidal sinus measuring 18 x 10 x 19 mm.--as large as an average adult sphenoidal sinus. Dean found the characteristic pathologic changes of chronic sinus disease in infants and children to be similar to those in the adult; i.e., thickened epithelial lining in some cases, with cells of the transitional type; at times typical metaplasia or beginning cyst formation in the mucous glands, or infiltration of the mucous membrane with inflammatory cells. The stroma of the mucosa may be densely fibrous; typical subepithelial granulation tissue may be present. Bone changes may be marked, showing erosions with poorly calcified bone deposits or abscesses. The periosteum may be: enormously thickened and infiltrated with inflammatory cells. The spaces in the bone resulting from absorption may be filled with fibrous tissue with distinct telangiectasis of the blood vessels. Small polyps are often found. He has seen necrosis of the ethmoids in an infant of sixteen months, that came to necropsy, and mentions a two-month-old infant who also came to necropsy, the pathologic diagnosis of the cause of death being paranasal sinusitis. Of the bacteriologic studies of the nasal accessory sinuses in disease o~e of the most complete and authoritative is the one made and reported by Ashley and Frick2 These investigators made a full study of the maxillary antrum in children, choosing that sinus because it was the one most commonly infected in childhood. In reviewing the previous literature, they came to the conclusion that the wide variation in bacteriologic findings hitherto obtained by the various authors was due to faults in technic leading to bacterial contamination. Their own results were obtained from the bacteriologic examination of antrum washings from 83 symptomless children, in which 54 p e r cent presented positive findings. The bacteria most frequently obtained in a series of 211 antral washings, were as follows: Staphylococcus aureus Micrococcus catarrhalis Streptococcus hemolyticus Streptococcus v i r i d a n s Staphylococcus albus Streptococcus fecalis
28.2% 21.1% 8.6% 1~.5% ]2.5% 2.4%
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Others obtained, but less frequently, were bacillus influenzae, bacillus mesentericus, diplocoecus pneumoniae, bacillus Hoffmani, bacillus pyocyaneus, and 3.6 per cent unidentified bacteria. Staphylococci were found most frequently, being present in 40.7 per cent of the positive eases, while the streptococci, taken collectively represented 23:3 per cent. The authors state that these figures for the streptococci compare favorably with those of Dean and Armstrong reported in June, 1919, but are lower than those obtained by most previous authors, one of whom, on material secured chiefly from operative eases, reported 96 per cent positive findings of streptococci. Let us here consider the history of a child with a typical case of chronic sinusitis. The chief complaint is that of frequent or almost constant colds, each attack accompanied by mild rhinorrhea and sore throat, spasmodic cough, which usually increases in frequency and intensity on lying down, and anorexia. The child appears listless, has slight edema of the lower lids and a pasty complexion with moderate paleness of the conjunctival mucous membranes, constantly breathes through his mouth, and is usually of subnormal weight. The adenoids and tonsils are most always hypertrophied and diseased, and the pharyngem mucous membrane moderately injected. At the advice of the physician, tonsillectomy and adenoidectomy are done, but within a period of three or fo.ur months the child returns, suffering from the former symptoms, probably in a more intensified form. Ruskin * has an interesting explanation for the exaggeration of these signs and symptoms following tonsillectomy and adenoidectomy. It is his opinion that a child suffering' from hypertrophied tonsils and adenoids has frequently associated with it a moderate or fairly severe grade of sinusitis, and that in these eases the nose is practically separated from the pharynx by the large adenoid which occupies the entire postnasal space, and .thus acts as a postnasal tampon. When the adenoid is removed, the discharge from the nose drains easily, especially during' the night, into the pharynx, larynx and trachea, thus increasing the frequency and severity of the cough; some of the mueopurulent materiM is swallowed and subsequently upsets the digestion, and the child's resistance becomes gradually impaired. The group of eases which we herewith present is selected from eases seen in the pediatric and otorhinolaryngological departments of the Vanderbilt Clinic in the Medical Center of Columbia University. The patients chosen all complained of frequent colds, and in no ease had the diagnosis of sinusitis been made. We were careful not to include in this group any patient with acute paranasal sinus disease. Each case was given a general examination by the pediatrician and a nose and throat examination by the rhinolaryngologist. The latter consisted of an examination of the nose and throat, followed by transillumination of the bones of the skull, and, in those eases that had not
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already been x-rayed, the demonstration of the condition of the p a r a nasal sinuses b y a series of roentgenograms of the skull. I f the presence of pus in the p a r a n a s a l s i n u s was detected by one or more of these three examinations, a sterile specimen was obtained and examined and cultured for organisms~ unless contraindicated. I n very young children; i.e., u n d e r three and a half years of age, a r d in older children who were unmanageable, it was f o u n d best to give an ethyl chloride general anesthesia. The duration of the anesthesia was ample for aspirating one or both antra, and the t r a u m a - both physical and p s y c h i c a l - - w a s at a minimum. Older children were examined on several visits, the examination being progressively more thorough a t each visit, the i n f r a t u r b i n a t e region being anesthetized on the visit preceding the actual antral puncture. By this means confidence was m a i n t a i n e d a n d the association of pain with medical attention p r e v e n t e d as f a r as possible. I n the actual aspiration of the specimen, W a t s o n - W i l l i a m s ' technic was used; in a minority of cases, where the contents of the sinus were solid masses of mucopus, these were washed out with sterile isotonic saline into sterile receivers, as done b y Babcock; the plugs of mueopus were then t r a n s f e r r e d to the culture tubes. T r e a t m e n t consisted of evacuation of the sinus content b y means of nasal irrigation, sinus irrigation through an antral puncture, a n d the instillation of a mild colloidal silver preparation. The condition of the children following t r e a t m e n t was watched by us, both with r e g a r d to their general condition, as well as the rhinologic, and it was g r a t i f y i n g and unexpected to find how very few a n t r a required more t h a n f o u r or five irrigations and, also, in what a large percentage of children the n a t u r a l ostium was sufficiently large to permit evacuation of the a n t r u m b y simple nasal irrigation. CASE REPORTS CASE 1.--R. 1%, age 61/2. Clinical Ilisto~y: Frequent running nose and bronchitis; a~orexia--2 years, Diphtheria a t 3 years. Diagnosis of chronic tonsillitis made in Presbyterian ttospital, at 3 8 9 years, Lordosis diagnosed here one year ago. Tonsillecto~n~ and Adenoidectocny : 1928. l~vsult : Temporary improvement. Gene~~ F ~ d i n ~ s : Malnutrition. Palpable c~rvieal glands at angtes of jaw. Tuberculin test negative, Blood and urine normal. Otor,hi~ola'ryngologio Fi~di~gs: Left naris filled with pus, Right naris clear. Pharyngeal mueosa injected. No tonsillar remnants. T~'ansillu.minatio~z: Frontals not translueent, lgight antrnm tran~Iucent. Left antrum hazy. Rocnt=genologiv Fi~gi~gs: Diffuse haziness of left maxillary sinus. Left ethmoid hazy. Frontals u~dex~eloped, No other abnormality, (Fig. 1.) Findings o~ Nasal and Siu,~s Irrigation : Mucopurnlent d4bris on nasal irrigation. Shreds of mueopus o~ irrigatiort of left antrum.
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Bacteriology of Sinus Content: Hemolytic staphylococcus aureus. Treatme~.tl: Nasal irrigation. antrum irrigated for culture.
Tamponage with 10 per cent argyrol.
Ees~lt of Trea.t~tent: Cough diminished. Left antrum became translucent.
Weight increased.
One left
Appetite improved.
l~e~na~'ks: Nasal irrigation sufficient to remove antral coutent.
Fig. 1.--Case 1.
l=t. let. Diffuse haziness of the left maxillary sinus. hazy. ~rontals ~ndevelop~d.
Left ethmoid
CASE 2.--L. G., age 8.
C~inical History: Constant nasal discharge, worse the past 3 months, with cough. Paint in knees, especially at night. To~sillecton~y and Adeuoideetom~ : Tonsillectomy and adenoideetomy done. Resvlt : No improvement. General F~nd~ngs: Pale in appearance. Crackling rs at both bases. Blood and urine normal.
Tuberculin test + +.
Otorldno~aryn~qolo~ic Findings: pharynx.
A little secretion in nares. Tonsillar remnants in right fossa.
l'ra~sil~n~nat~on: l~rontals not translucent. Antra hazy. ~oent.genvlogio Finding's: ]~i]ateral clouding of maxillaries. region hazy.
Frontals undeveloped.
Mucopus in naso-
L e f t ethmoidal
(Fig. 2.)
Findings on Nasal a~d Sinus Irrigation: Few shreds on nasal irrigation. Following shrinkage of nasal mucosa, several mucopurulcnt plugs were obtained on nasal irrigation.
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Bacteriology of Si/~s negative diphtheroids.
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Nonhemolytie staphylococcus
albus.
Gram-
Treatment : Shrinkage of nasal mucosa followed by nasal irrigation. Eevult of Trea.tment : B r e a t h i n g improved. General condition improved. Hemoglobin rose from 76 to 85 per cent. Temperature dropped from 99.8 ~ to 98.4 ~.
Fig. 2.--Case 2. L . G .
Bilateral clouding of the antra. Frontals undeveloDed.
Left ethmoidal region hazy.
CASE 3.--T. R , age 9.
Clinical History : Frequent colds during the winter, with nasal obstruction. Tons~llectow~y a~d Adenoidecto~y : Adcnoidectomy at 2 months and at 8 years. T. & A.--1926. ttesult : No improvement. General Findin,gs : Small and undernourished Oto~Idnv~ary~qologic Findings: Mucopurulent ddbris in left naris. Mueopus in nasopharynx. Both drums very much retracted. Tra~sillum~nation: Frontals not translucent. Left antrum opaque. Right antrum clear. Eoentgeuologiv F~nd~gs: Cloudy left maxillary sinus. Cloudy left ethmoid. Frontals and sphenoidals undeveloped. Right maxillary clear. Findings on lVasa~ and S~n~s Irr~ation: Plugs of mucopus from l e f t naris. Small mucopurulent plugs on left antral irrigation. iBavteriology o~ Sinu~ Content : Hemolytic staphylococcus aureus. P'neumococcus-type I I L
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Treatment : N a s a l irrigation. Tamponage with 10 per ce}lt argyrol. Eight left antral irrigations. I~evult of Treatment: Considerabl~ improvement in local and general condition. Appetite improved. No colds in three months. CaSE 4.--]). L., age 7. Clinical History: Asthmatic attacks since 3 years old; becoming more frequent. Frequent colds. Eczema at 9 months; measles at It/._, years. Pertussis at 2 years. Tonsiltecto~ny ac~g Ade~midecto~uy: Tonsillectomy and adenoidectomy done. Eesult : No improvement. Gener Findings: PooEy developed, t l e a r t normal. Lungs clear.
Fig. 3.--Case 4. D . L .
Frontals undeveloped, l~ight antrum and ethmoid show definite increase in density.
Otorhinolaryngologic F~ndings: Dibris in nares. Polyp in left naris. Tonsil stumps present. Chronic 'pharyngitis. Trax~sillumination: Frontals not translucent. Right antrum darker than the left. Eoent,genologic Findi~,gs: Frontals undeveloped. Right maxillary and ethmoid show definite increase in density. (Fig. 3.) Findings or iVas:al and Sinus Irri,ga.tion: Large mucopurulent plugs washed from right antrum. Bacteriology of Sin~s Content : Streptococcus viridans. Gram-negative diplocoeci. Treatment: I r r i g a t i o n of right antrum. One per c e n t E p h e d r i n spray for use by the patient. Eesult o2" Treatment: Asthmatic attacks less frequent and less severe. Right antrum remained clear a f t e r four irrigations. tie,harks: Asthma probably both of allergic and sinus origin.
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CASE 5:m~. S., age 51~. Clinical History : Frequent colds--9 months. Anorexia. Daily temperature as high as 100.5 ~ Right epistaxis on several occasions. Right otitis media occasionally since 2 years of age. Measles. Diphtheria. Ton~illevtozay a~d Adeno~deetom~ : In 1927 and again in 1930. t~esult : No improvement. General Eindi~g's : Fairly well nourished. mal. Tuberculin test negative.
Heart and lungs normal.
Urine nor-
Otorhino~ary~gologie F ~ d i ~ g s : Nasal mucosa vel~ red. Mucopurulent d6bris in nares. Mucus obstructiag nasopharynx. Tonsillar fossae clean. Slight retraction of drums. Tra~s~llqzminatio~:
Frontals not translucent. Antra hazy.
t~oentgenologia Fiq~di~g~: Ethmoids clear.
Increased density of antra.
Frontals undeveloped.
F ~ d i ~ g s on ~.asal a~d Sinacs Irrigation : Plugs of mucopus on nasal irrigation. One left antral irrigation for culture. Bavter~ology of S~n~v Content : Hemolytic staphylococcus aureus. streptococcus. Treatment :
Nasal irrigation.
/qonhemolytic
Oily nasal spray for home use.
l~esult of Treat~ne~t : No improvement for 4 months. Then fever lessened from 100.2 ~ to 98.6 ~. Appetite improved; and improvement maintained. CASE 6.--M. M., age 10.
Cl~'aival History: Frequent colds~ spasmodic cough and hoarseness since birth. Anorexia; pain in knees--3 years.
Fig. 4.--Case 6. )]I.M. The findings Suggest thickened lining membranes of the antra, ethmoids and frontals. Sphenoids,are not affected.
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Tonsillectomy and Adenoidectom~: 1927. l~esu~t : No improvement. General Findings: General condition good. Heart, lungs, liver and spleen normal. Abdomen distended and tympanitic, tongue coated. Otorhinolaryngoloyiv Fi~d~nys: Purulent 46bris in nares. Granular pharyngitis. Tonsillar fossae clean. Transillwminatio~: Frontals clear. A n t r a hazy, especially right. Eocntgenoloyic Fin c~i~gv: Findings suggest thickened lining membranes of antra, ethmoids and frontals. Sphenoids not affected. (Fig. 4.) F~d~ngs on Naval and S i ~ s Irrig:ation: Mucous shreds on nasal irrigation. Cloudy return with mueopurulent shreds on irrigation of antra. Bacte~iolo~ of Si~umS Co~te~V : Staphylococcus albus. Pneumococeus--type I I I . Treatmen.t: Nasal irrigation. Antral irrigation. Tamponage with 10 per cent argyrol. l~ex~lt of Treatment : Free from former symptoms. General improvement. t~e~na~ks: l%emarkable improvement. CASE 7.--F. C., age 7. Clinical History: Continual colds and coughing since 2 8 9 years of age. Anorexia. Malnutrition. Questionable chorea a t 3 years. Bilateral acute otitis media with myringotomy 1 year ago. ' ~ N e r v o u s " child, sleeps restlessly.
Fig. 5.--Case 7.
•. C. Frontals undeveloped. Antra cloudy, more so on the right side. Left ethmoid slightly cloudy.
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Tonsillectomy a~d Adenoidectomy : 1927. Result: No improvement. General ]Fiq~di~gs: Poorly nourished. Cardiac hypertrophy. Sibilant and sonorous rgles on deep breathing. Otorh~olary'~gologic F~w~n,gs: Nares clear. Granular pharyngitis. Tonsillar fossae clear. Tra~sillq,m&~tio~.: Frontals clear. Antra equally hazy. t~ventgeno~oyic Fi~di~g~: Frontals undeveloped. Antra cloudy, more on right. Left ethmoid slightly cloudy. (Figs. 5 and 6.) Fiz~d~ngs o~ Nava.l and Si| Irrigation: Large mucopurulent plugs on nasal irrigation. Antral irrigation immediately following gave clear return.
Fig. 6.--Case 7. F . C .
Lateral view.
Bc~eteciolo~y o f Siq~s Con.tent : Pneumocoecus--type III. T~t,mv~t: Nasal irrigation. Antral irrigation for culture. Oily nasal spray for home use. ~es,t~lt o f Treatment: Considerable improvement in cough. Appetite improved. Weight increased. Nervousness gone--sleeps soundly. Bemaxks: Unusually good result. CASE 8.--F. P., age 6.
Cliniea~l History: Frequent colds past year, with sneezing and cough. Anorexia. Two attacks of acute otitis media with myringotomy. Severe pain in left knee in 1929. Pyuria treated in Babies Hospital in ]927. Continua] pyrexia past 6 months~ 99-100.4".
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Tonsillecto~ny a~d Adeno~dectomy : 1929. l~es,z~lt: No improvement. General Findings: Small and undernourished. Heart~ lungs~ and abdomen norreal. Small left inguinal hernia. Otorh~wlaryngolo.gio Find~n,gs: Copious purulent secretion in nares. Rhinopharyngitis. Tonsillar fossae clean. Tra~zillum~nation: Frontals not translucent. A n t r a opaque. ~oentgenolo~ie ]Findings: Frontals and sphenoldals undeveloped. Increased in density in maxillary sinuses, especially the right. (Fig. 7.) tr$ndin~ ozv Nasal and S~n~s Irrigation: Plugs of mucopus on nasal irrigation. Mucous ptug on a n t r a l irrigation. Bacteriology o f Si~vz~s Content: Staphylococcus aureus. Pneumococcus--type I I ] .
Fig. 7.--Case 8. P . P .
Frontals and sphenoidals undeveloped. Increase in density in the maxillary sinuses, especially the right.
Treatment: Frequent nasal irrigations. Tamponage with 10 per cent argyro]. Oily spray for home use. l~es~dt o f T~'ca.tu~c~t: Improvement in ~ ' c o l d s " and in appetite. Temperature lower (98~176 :Be~narks: Treatme~it considerably handicapped by neurotic mother and by home conditions. CASE 9.--I. S., age 5. Clin4cal History : Frequent colds and dry cough since grippe at 3 years of age. Mastoiditis at 16 months. Tons~l~ecto~ny and Adenoidectomy : ]927. l~esult: No improvement. General Pindings : Nutrition good. tIear~, lungs and abdomen normal. Otorh#mlaryngologic E~ndic~gs: Nares filled with mucus. Granular pharyngitis. Tonsi]lar fossae clean.
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Transillumination: Right antrum opaque. No other abnormalities. Roentgenolo~io Findings: Suggest right maxillary sinusitis. (Fig. 8.) ~ind~ngs o~ Naval a~d Sinus I~'rigation: Many shreds on nasal ir1~igation, also strings of mueopus from r i g h t naris. Milky pus obtained on aspiration of right antrum. Bavteriology of Sin~s Content: Hemolytic staphylococcus aureus. Hemolytic staphylococcus albus. Tre'a~t~nent!: Nasal irrigation. Tamponage with 10 per cent argyrol. Oily spray for home use. ~es~lt o f Treatwent : Right antrum became translucent. Coughing ceased. Nasal breathing improved.
Fig. 8.--Case 9. I . S .
The findings suggest right maxillary sinusitis.
CASE 10.--B. B , age 12. Cli~dva~ History : Very frequent colds since 2 years of age. Measles. Chickenpox. P a i n in knees--past year. No history of rheumatic fever. Constant rhinorrhea past 5 months. Tonsillevtomy a~d Adenoideotomy : 1926. t~esult: No improvement. Ge~,eral Findings: N u t r i t i o n good. Heart, lungs and abdomen normal. Otorhinolaryngoloyic Findings: !~ight naris occluded by deviated septum. Nares filled with mucus. Pharynx clear. Tonsillar fossae clean. Transillumina,tion: A n t r a hazy: Frontals clear. l~oent.genologie Findings: Suggest infection of ethmoids. All other sinuses clear. Findings on Nasal and Sinus Irr4#~a~ion: Following shrinkage of mucosa~ nasal irrigation returns large plugs of mucopus. Bacteriology of Si/nus Content: Sterile specimen unobtainable. Treatment: Shrinkage of nasal mucosa followed by irrigations. E p h e d r i a spray for home use.
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~esult of Treatment: I a 2 months hares became clear and remained so. ~emarks: Unusual, in that only the ethmoids were involved. CASE l l . - - W . C., age 5. Clingeal History: Frequent colds, nasal discharge and dry cough--2 years, with sore throats and nasal obstruction. Frontal headaches in 1930. Acute broncMtis and acute rheumatic fever diagnosed here ia 1930. Tonsillectomy and A denoidevto~y : 1931. t~es~It : No iml~rovement. General Findings: Malnutrition. Pallor. Exaggerated bronchovesicular breathind. No rhles. Systolic murmur over l~ulmonic area, with accentuated second 1o111monic sound.
~ig. 9.--Case
II.
W.C.
The frontals are normal. the right. The ethmoids are
The antra inc]istinct.
Otorh~no~acy~go~og~v FJ~dJngs: Nasal mucosa congested.
are hazy,
particularly
Postnasal discharge.
Trc~nsil~q~miq~ation: Antra opaque. Frontals clear. ~oentge~olo~t~v Findings: Frontals normal. Ethmoids indistinct. (Fig. 9.)
Antra hazy, particularly right.
Fi~,di~qs on Nazal a,nd Sinus Irrigation : Cloudy return with shreds of mucus on nasal irrigation. Cloudy return on l'ight antral irrigation. Strings of mucopus on left antral irrigation. Bacterioloy~ o~ Sin~s Content : Hemolytic staphylococcus aureus in each antrum. T~'ea.t~nent : ~!asal irrigation. Antral irrigation. CASE 12.--S. S., age 3 89 Clinical History : Very frequent colds and asthmatic attacks since 2 years old. lYieas]es at 21~. Acute otitis media with spontaneous rapture of drum at 3 years. Pneumonia at 3 years. Pain in knees since 2 89 years old. Tonsillectomy and Adeno~devtomy: 1930.
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Result: Colds increased in frequency. General Findings: General condition good. Lungs--sibilant and sonorous r~les in many areas throughout the chest. Heart and abdomen normal. Liver and spleen normal. Otorhinolaryngolo,gic Findings: Nares filled with mucous d~bris. Granular t)har yagitis. Tonsillar fossae clean. Overflow seen from antra. Transillumination: A n t r a hazy. Frontals not translucent. Roe ntgeno~og~v Findings: C]oudlng of antra. Frontals undeveloped. F~ndi~gs on Nasal anc~ Sinus Irriga.tian: Considerable mucopus on nasal irrigariom Antral puncture ~or bacteriological diagnosis only. Bacteriology o f S i ~ s Co~tent : Staphylococcus aureus. Treatment: Nasal irrigation. Use of bily spray at home. t~esult o f Treatment: Nasal discharge lessened. Cough unaltered. CASE 13.--M. M., age 8. Clinival History : Continuous colds and cough for years. Sneezing and snuffling~ 3 months. Measles. Chickenpox. Pertussis. Tonsillevtomy and Adenoideetamy: 1928. Result : Unimproved. General F~ndings: L u n g s - - b u b b l i n g r~les at bases. ]:Ieart and abdomen normal. Oto.rhiuolazyngologie Findings: Dried secretion in nares. Mucopus in nasopharynx. Tonsillar fossae clean. Tran~ilbu~nination: Slight haziness of left antrum. All other sinuses clear. R.oentgenoloyie Findings: No x-ray evidence of sinusitis. Fin~im,ys on Nasal and Simms Irrigation : Nasa] irrigation cloudy with strings of mucopus. L e f t antrum aspirated for culture. Bacteriolo~y o f Siq~v Con2ent: Pneumococcus--typc I I I pure culture. Treatment: Nasal irrigation. Ephedrin spray for home use. ltesult of Treatment: Chest signs cleared up. Nasal discharge lessened. Sneezing ceased. Rew~arks: Positive case of sinusitis despite negative x-ray findings. CASE 14.--J. G., age 10. Cli~ival History : Very frequent colds and asthmatic attacks--7 years. Dyspnea, worse following exercise. Measles at 5 years. Tonsillevtomy and Adeno~deeto~ny : 1925. Result: No improvement. General Findings: General condition good. Lungs--Sibilant and sonorous r~les scattered throughout the chest. Heart, abdomen, liver and spleen normal. Otorhinoiaryngologio Finding's: Turblnates swollen. Pus in nares. Granular pharyngitis. Right ear drum scarred. T~nsill~qnination: Frontals not translucent. Antra hazy, especially left. goe~tLqenolo~e Fi~d~n~gs: Frontals undeveloped. Ethmoids and antra hazy. F~c~i~gv on Nas~a.1 an~ Sinus Irrigation: Shreds on nasal irrigation. Baeter~oio,gy o f Sin~s Content: Not performed~ because antral puncture was contraindicated. Treatment: Nasal irrigation. Tamponage with 10 per cent argyrol. Result of Treatment : Asthmatic attacks and colds ceased. CASE 15.--D. S., age 9. Clicaiea~ H~story: Nasal discharge~ vomiting~ anorexia--1 year. Chronic dry cough. Measles 2 months ag% with no apparent effect on nasal condition. Scarlet fever at 5 years. Tonsillitis during ilrst year.
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Tonsilleetom.y and Adenoidecto~y : 1923. l~esu~t : Improved until one year ago. Genera~ Fi~c~ings: Malnutrition. }Ieart, lungs and abdomen normal. Otortdnolwryngolog~c ~inding~ : Secretion in nares. Tonsillar fossae clean. Traq~sillu~nina~ion: Frontals appear small. A n t r a hazy. lCve~t~TenoIog~e ~F~ndings: Clouding of antra. Ethmoids clear. Frontals undeveloped. Findings on ~VasaT and Sinus Irrigation: Shreds of mueopus on nasal irrigatiom Bacteriology of Sinus Content: Not performed because a n t r a l puncture was contraindicated. Treatment : Nasal irrigation. Tamponage with 10 per cent argyrol. Oily spray for home use. l~esq~lt of Treatment: Considerable improvement. Nasal discharge became of normal amount and character. Vomiting and anorexia ceased. CASE 16.--J. J , age 10. Cl~nival History: Nasal discharge for 3 years. Acute catarrhal otitis media 3 years ago. P a i n in knees--2 years. Tonsillectomy and Ade~oi, deeto~n~j: :1927. l~e~lt : ~ o improvement. General ]Findings: General condition good. H e a r t - - r e d u p l i c a t e d second sound at ~pex. No other abnormality. OtorhinoTavyngologiv Findings: Nares clear. Granular pharyngitis. Tonsillar fossae clean. Right ear drum scarred. Transi~l~minar A n t r a hazy. F r o n t a l s clear. l~ventrgvnoZogic tZindin~s: Clouding of r i g h t antrum. Other sinuses normal. F~'ndi~,gs on ~asal and Sinus Irri.gation: Strings of mucopus on right antral irrigation. Bacteriology of SCnus Content: ~temolytie streptococcus. Streptococcus viridans. Hemolytic staphylococcus aureus. Treatment: Two irrigations of right antrum. Oily spray for home use. t~es~dt of Trear Nasal discharge ceased. P a i n in knees gone. CAs~ 17.--M. C., age 5. Cli~ioal History: Frequent colds with rhinorrhea and cough every winter since infancy. Anorexia. :Brings ~p much mucus. Nervousness. Vomiting. Tonsilleetom~j a.nd Ac~e~o~deetomy: 1928. t~esult : Improvement for 2 years. Genera~ Findings : Teeth, heart, lungs , liver and spleen normal. Abdomen ~orreal except for reducible umbilical hernia. Otorhinola~yngolo~gic Findings: I)6bris in nares. Mucopus seen overflowing through natural ostia of antra. Tonsillar remnants in fossae. Tra~sillu~ni~ation: Frontals not translucent. A n t r a hazy. 1~oentgenolo~ie Findings: Moderate thickening of the maxillary walls, Otherwise, no definite abnormalities seen. Findin,gs on Nasal a~d Sima~s Ivrggation: Shreds and strings of mucopus oil nasal irrigation. Antral aspiration for culture. Bacteriology of S~n~s Content: Streptococcus viridans. Few hemolytic streptococci. Staphylococcus albus. Trea.tment: Nasal irrigation. Use of oily spray at home. ttesq~lt of Treatment: Stopped vomiting. Colds less frequent. Weight increased.
C~s]~ 18.--A. S., age 4. Clinival H i s t o w : Very frequent Golds with thick ~asal discharge--1 year. Moderate cough, l~eadaches. Vomiting. Anorexia. Occasional temperature 100~ ~
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l'onsillectom~j and Adenoidectomy : 1930. l~eeult : More c~colds ' ' since operation. Gene~a.l Findings: Large glands o~ both sides of the neck. Coarse, loose r~les throughout the chest. Spleen palpable 1 finger below the costal margin. Otherwise normal. Blood and urine normal. Otorhi~ola~'yn,golagic Fin,d~gs: Nares filled with discharge. Tonsillar fossae clean. Nasopharynx contains discharge. Trao~silhominc~tion: Antra hazy. Right frontal clear. L e f t frontal not translucent. l~oentgenologiv Findings: L e f t frontal absent, l~ight frontal small. Ethmoids appear thickened and cloudy, as do the antra, but the latter less definitely so. Findings on Nasal and Si~ws Irrigation: Several large plugs of mucopus on nasal irrigation. Antral irrigation unnecessary. Bacteriolagy of SiT~v Conte~t : Not performed. Antral aspiration not indicated. Treatment : Nasal irrigation. Ephedrin in oil spray for home use. Eesult of Treatment: Greatly improved. No ~'co]ds" since treatment. Discharge became normal in quantity and character. l~emarks: Nasa] irrigation sufficient to aspirate pus from antra. BACTERIOLOGIC FINDINGS
1. Bacteria found in pure culture in 5 cases Hemolytic Staphylococcus aureus--twice Pneumococcus, type l I I ~ t w i c e Staphylococcus aureus--once 2. Bacteria found in association with one or more others in 9 cases Hemolytic Staphylococcus aureus--three times Hemolytic Staphylococcus albus--once Staphylococcus albus--three times Staphylococcus aureus--two times Pneumococcus, type III--three times Hemolytic streptococcus--two times Nonhemolytie streptococcus--once Streptococcus Viridans--four times Gram-negative Diphtheroids--once Gram-negative Diploeocei--once CONCLUSIONS
We have demonstrated in the foregoing group of cases, the very definite eonnection that exists between chronic nasopharyngitis and chronic sinus infection, and the remarkable improvement that follows the simplest treatment aimed at the true canse of the condition. It is desired by the authors to impress upon the medical profession the simplicity of the examination necessary for establishing the diagnosis of chronic paranasal sinusitis. No one likes to hurt a child-patient, even with the best of therapeutic intentions, and it is the suspicion that the pain connected with sinus irrigation will not be commensurate with the benefit obtained, that has
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restrained many physicians from making the diagnosis in children suffering from continual catarrh, inexplicable marasmus, and unaccountable pyrexias. The benefits observed by the authors resulting from such treatment, has convinced them of the value, indeed the necessity of the proper surgical treatment of "where there is pus, there should be drainage." We are grateful to those authorities of Babies Hospital and o2 Presbyterian Hospital who so kindly assisted us in every possible mahner, in the p~-eparation of this paper. RE~EREN CES 1. 2. 3. 4.
Davis, W . B . : Trans. See. Laryng., A. M. A. 8: 23, 1918. Dean, L . W . : J . A . ~ . A. 85: 317, 1925. Ashley a~d Frick: Ann. OtoL Rhinol. $ Laryngol. 39: June, 1930. Ruskin~ S . L . : Am. J. ])is. Child. 36: 1020~ 1928. :BABIES H O SPITAL~ ~RESBYTERIAhT HOSPITAL.
I. ITS t~ELATIONSHIP TO FREQUENT NASOPLIARYNGITIS J. S. UHR, M.D., AND J. W. Pt~G~, M.B., B.Cm NEW YORK IS customary for the pediatrician and, especially, the general pracI Ttitioner, to diagnose the rhinorrhea and cough of children as being almost invariably due to acute nasopharyngitis. It is the purpose of this paper to present anatomic, bacteriologic, and clinical facts so that the diagnosis o~ chronic sinusitis in children will frequently replace that of simple acute nasopharyngitis. Politzer postulated the law that in every case of acute otitis media there was also involvement of the accessory air spaces in the mastoid to a greater or lesser degree. We find a similar relationship existing between the nose and its accessory sinuses. Davis 1 presented the following facts in aa anatomic study of 160 lateral nasal walls of infants and children, 17 per cent of whom were less than one year old: The lateral ethmoidal mass proper is, in a majority of cases completely pneumatized at birth. Subsequently the cells increase in size by expansion as the ethmoidal area grows, and also by invasion of the surrounding tissue. The frontal sinus originates (in all cases) from one cell, or in the case of supernumerary frontal sinuses ~rom two cells, of the group of cells comprising the anterior ethmoidal are% the route of development being rarely demonstrable with absolute certainty before the sixth, and in many instanees~ before the t w e l f t h month of postnatal life. The pneumatizing sinus gradually extends from t h a t portion of the anterior ethmoidal area into the interior portion of the frontal bone, begins its ascent into the vertical portion during the second year, is 3.8 ram. above the level of the nasion at three years, and continues the vertical advance at an average rate of approximately L5 ram. per year until the fifteenth year. The maxillary sinus at birth is an oblong ovoidal sinus, its diameters averaging 8.9. ram. anteroposteriorly, 3.3 ram. vertically, and 2.8 ram. laterally. There is an average increase in the extent of pneumatizatioa of 2 mm. in both the lateral and vertical diameters, and 3 ram. in the anteroposterior diameter until the ninth year, after which the advance is slower until the fifteenth year, when the usual adult type is approximated. Later changes occur chiefly in the posteroinferior angle. The sphenoidal sinus develops as an extension from the posterosuperior portion of the recessus sphenoethmoidalis. I n children of less than one year of age the diameters of an average sphenoidal sinus are 2.8 ram. vertically, 2 nlm. laterally, and 1.5 ram. anteroposteriorly. Pneumatization goes on, the rate of resorption of the body of the sphenoid being such that by the eighth to the tenth year the posterosuperior portion of the sinus lies beneath the anterior portion of the sella tm'eic% and by the fifteenth year, is usually separated from the hypophysis by a very thin 418
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lamina of compact bone. By the fourteenth year pneumatization extends in many instances well into the pterygoid process.
Dean, 2 in a paper on paranasal sinus disease, states that of all the sinuses only the frontal is never present at birth, the ethmoidal cells are always present, the maxillary sinus only rarely absent, and that, while only rarely was the sphenoida] sinus present at birth as a cell, he was informed by Dr. J. Parsons Schaeffer that occasionally at birth the sphenoidal sinus would be of sufficient size to be diseased. He mentions a child, aged five and a half, that came to necropsy and showed a diseased sphenoidal sinus measuring 18 x 10 x 19 mm.--as large as an average adult sphenoidal sinus. Dean found the characteristic pathologic changes of chronic sinus disease in infants and children to be similar to those in the adult; i.e., thickened epithelial lining in some cases, with cells of the transitional type; at times typical metaplasia or beginning cyst formation in the mucous glands, or infiltration of the mucous membrane with inflammatory cells. The stroma of the mucosa may be densely fibrous; typical subepithelial granulation tissue may be present. Bone changes may be marked, showing erosions with poorly calcified bone deposits or abscesses. The periosteum may be: enormously thickened and infiltrated with inflammatory cells. The spaces in the bone resulting from absorption may be filled with fibrous tissue with distinct telangiectasis of the blood vessels. Small polyps are often found. He has seen necrosis of the ethmoids in an infant of sixteen months, that came to necropsy, and mentions a two-month-old infant who also came to necropsy, the pathologic diagnosis of the cause of death being paranasal sinusitis. Of the bacteriologic studies of the nasal accessory sinuses in disease o~e of the most complete and authoritative is the one made and reported by Ashley and Frick2 These investigators made a full study of the maxillary antrum in children, choosing that sinus because it was the one most commonly infected in childhood. In reviewing the previous literature, they came to the conclusion that the wide variation in bacteriologic findings hitherto obtained by the various authors was due to faults in technic leading to bacterial contamination. Their own results were obtained from the bacteriologic examination of antrum washings from 83 symptomless children, in which 54 p e r cent presented positive findings. The bacteria most frequently obtained in a series of 211 antral washings, were as follows: Staphylococcus aureus Micrococcus catarrhalis Streptococcus hemolyticus Streptococcus v i r i d a n s Staphylococcus albus Streptococcus fecalis
28.2% 21.1% 8.6% 1~.5% ]2.5% 2.4%
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Others obtained, but less frequently, were bacillus influenzae, bacillus mesentericus, diplocoecus pneumoniae, bacillus Hoffmani, bacillus pyocyaneus, and 3.6 per cent unidentified bacteria. Staphylococci were found most frequently, being present in 40.7 per cent of the positive eases, while the streptococci, taken collectively represented 23:3 per cent. The authors state that these figures for the streptococci compare favorably with those of Dean and Armstrong reported in June, 1919, but are lower than those obtained by most previous authors, one of whom, on material secured chiefly from operative eases, reported 96 per cent positive findings of streptococci. Let us here consider the history of a child with a typical case of chronic sinusitis. The chief complaint is that of frequent or almost constant colds, each attack accompanied by mild rhinorrhea and sore throat, spasmodic cough, which usually increases in frequency and intensity on lying down, and anorexia. The child appears listless, has slight edema of the lower lids and a pasty complexion with moderate paleness of the conjunctival mucous membranes, constantly breathes through his mouth, and is usually of subnormal weight. The adenoids and tonsils are most always hypertrophied and diseased, and the pharyngem mucous membrane moderately injected. At the advice of the physician, tonsillectomy and adenoidectomy are done, but within a period of three or fo.ur months the child returns, suffering from the former symptoms, probably in a more intensified form. Ruskin * has an interesting explanation for the exaggeration of these signs and symptoms following tonsillectomy and adenoidectomy. It is his opinion that a child suffering' from hypertrophied tonsils and adenoids has frequently associated with it a moderate or fairly severe grade of sinusitis, and that in these eases the nose is practically separated from the pharynx by the large adenoid which occupies the entire postnasal space, and .thus acts as a postnasal tampon. When the adenoid is removed, the discharge from the nose drains easily, especially during' the night, into the pharynx, larynx and trachea, thus increasing the frequency and severity of the cough; some of the mueopurulent materiM is swallowed and subsequently upsets the digestion, and the child's resistance becomes gradually impaired. The group of eases which we herewith present is selected from eases seen in the pediatric and otorhinolaryngological departments of the Vanderbilt Clinic in the Medical Center of Columbia University. The patients chosen all complained of frequent colds, and in no ease had the diagnosis of sinusitis been made. We were careful not to include in this group any patient with acute paranasal sinus disease. Each case was given a general examination by the pediatrician and a nose and throat examination by the rhinolaryngologist. The latter consisted of an examination of the nose and throat, followed by transillumination of the bones of the skull, and, in those eases that had not
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already been x-rayed, the demonstration of the condition of the p a r a nasal sinuses b y a series of roentgenograms of the skull. I f the presence of pus in the p a r a n a s a l s i n u s was detected by one or more of these three examinations, a sterile specimen was obtained and examined and cultured for organisms~ unless contraindicated. I n very young children; i.e., u n d e r three and a half years of age, a r d in older children who were unmanageable, it was f o u n d best to give an ethyl chloride general anesthesia. The duration of the anesthesia was ample for aspirating one or both antra, and the t r a u m a - both physical and p s y c h i c a l - - w a s at a minimum. Older children were examined on several visits, the examination being progressively more thorough a t each visit, the i n f r a t u r b i n a t e region being anesthetized on the visit preceding the actual antral puncture. By this means confidence was m a i n t a i n e d a n d the association of pain with medical attention p r e v e n t e d as f a r as possible. I n the actual aspiration of the specimen, W a t s o n - W i l l i a m s ' technic was used; in a minority of cases, where the contents of the sinus were solid masses of mucopus, these were washed out with sterile isotonic saline into sterile receivers, as done b y Babcock; the plugs of mueopus were then t r a n s f e r r e d to the culture tubes. T r e a t m e n t consisted of evacuation of the sinus content b y means of nasal irrigation, sinus irrigation through an antral puncture, a n d the instillation of a mild colloidal silver preparation. The condition of the children following t r e a t m e n t was watched by us, both with r e g a r d to their general condition, as well as the rhinologic, and it was g r a t i f y i n g and unexpected to find how very few a n t r a required more t h a n f o u r or five irrigations and, also, in what a large percentage of children the n a t u r a l ostium was sufficiently large to permit evacuation of the a n t r u m b y simple nasal irrigation. CASE REPORTS CASE 1.--R. 1%, age 61/2. Clinical Ilisto~y: Frequent running nose and bronchitis; a~orexia--2 years, Diphtheria a t 3 years. Diagnosis of chronic tonsillitis made in Presbyterian ttospital, at 3 8 9 years, Lordosis diagnosed here one year ago. Tonsillecto~n~ and Adenoidectocny : 1928. l~vsult : Temporary improvement. Gene~~ F ~ d i n ~ s : Malnutrition. Palpable c~rvieal glands at angtes of jaw. Tuberculin test negative, Blood and urine normal. Otor,hi~ola'ryngologio Fi~di~gs: Left naris filled with pus, Right naris clear. Pharyngeal mueosa injected. No tonsillar remnants. T~'ansillu.minatio~z: Frontals not translueent, lgight antrnm tran~Iucent. Left antrum hazy. Rocnt=genologiv Fi~gi~gs: Diffuse haziness of left maxillary sinus. Left ethmoid hazy. Frontals u~dex~eloped, No other abnormality, (Fig. 1.) Findings o~ Nasal and Siu,~s Irrigation : Mucopurnlent d4bris on nasal irrigation. Shreds of mueopus o~ irrigatiort of left antrum.
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Bacteriology of Sinus Content: Hemolytic staphylococcus aureus. Treatme~.tl: Nasal irrigation. antrum irrigated for culture.
Tamponage with 10 per cent argyrol.
Ees~lt of Trea.t~tent: Cough diminished. Left antrum became translucent.
Weight increased.
One left
Appetite improved.
l~e~na~'ks: Nasal irrigation sufficient to remove antral coutent.
Fig. 1.--Case 1.
l=t. let. Diffuse haziness of the left maxillary sinus. hazy. ~rontals ~ndevelop~d.
Left ethmoid
CASE 2.--L. G., age 8.
C~inical History: Constant nasal discharge, worse the past 3 months, with cough. Paint in knees, especially at night. To~sillecton~y and Adeuoideetom~ : Tonsillectomy and adenoideetomy done. Resvlt : No improvement. General F~nd~ngs: Pale in appearance. Crackling rs at both bases. Blood and urine normal.
Tuberculin test + +.
Otorldno~aryn~qolo~ic Findings: pharynx.
A little secretion in nares. Tonsillar remnants in right fossa.
l'ra~sil~n~nat~on: l~rontals not translucent. Antra hazy. ~oent.genvlogio Finding's: ]~i]ateral clouding of maxillaries. region hazy.
Frontals undeveloped.
Mucopus in naso-
L e f t ethmoidal
(Fig. 2.)
Findings on Nasal a~d Sinus Irrigation: Few shreds on nasal irrigation. Following shrinkage of nasal mucosa, several mucopurulcnt plugs were obtained on nasal irrigation.
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Bacteriology of Si/~s negative diphtheroids.
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Nonhemolytie staphylococcus
albus.
Gram-
Treatment : Shrinkage of nasal mucosa followed by nasal irrigation. Eevult of Trea.tment : B r e a t h i n g improved. General condition improved. Hemoglobin rose from 76 to 85 per cent. Temperature dropped from 99.8 ~ to 98.4 ~.
Fig. 2.--Case 2. L . G .
Bilateral clouding of the antra. Frontals undeveloDed.
Left ethmoidal region hazy.
CASE 3.--T. R , age 9.
Clinical History : Frequent colds during the winter, with nasal obstruction. Tons~llectow~y a~d Adenoidecto~y : Adcnoidectomy at 2 months and at 8 years. T. & A.--1926. ttesult : No improvement. General Findin,gs : Small and undernourished Oto~Idnv~ary~qologic Findings: Mucopurulent ddbris in left naris. Mueopus in nasopharynx. Both drums very much retracted. Tra~sillum~nation: Frontals not translucent. Left antrum opaque. Right antrum clear. Eoentgeuologiv F~nd~gs: Cloudy left maxillary sinus. Cloudy left ethmoid. Frontals and sphenoidals undeveloped. Right maxillary clear. Findings on lVasa~ and S~n~s Irr~ation: Plugs of mucopus from l e f t naris. Small mucopurulent plugs on left antral irrigation. iBavteriology o~ Sinu~ Content : Hemolytic staphylococcus aureus. P'neumococcus-type I I L
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Treatment : N a s a l irrigation. Tamponage with 10 per ce}lt argyrol. Eight left antral irrigations. I~evult of Treatment: Considerabl~ improvement in local and general condition. Appetite improved. No colds in three months. CaSE 4.--]). L., age 7. Clinical History: Asthmatic attacks since 3 years old; becoming more frequent. Frequent colds. Eczema at 9 months; measles at It/._, years. Pertussis at 2 years. Tonsiltecto~ny ac~g Ade~midecto~uy: Tonsillectomy and adenoidectomy done. Eesult : No improvement. Gener Findings: PooEy developed, t l e a r t normal. Lungs clear.
Fig. 3.--Case 4. D . L .
Frontals undeveloped, l~ight antrum and ethmoid show definite increase in density.
Otorhinolaryngologic F~ndings: Dibris in nares. Polyp in left naris. Tonsil stumps present. Chronic 'pharyngitis. Trax~sillumination: Frontals not translucent. Right antrum darker than the left. Eoent,genologic Findi~,gs: Frontals undeveloped. Right maxillary and ethmoid show definite increase in density. (Fig. 3.) Findings or iVas:al and Sinus Irri,ga.tion: Large mucopurulent plugs washed from right antrum. Bacteriology of Sin~s Content : Streptococcus viridans. Gram-negative diplocoeci. Treatment: I r r i g a t i o n of right antrum. One per c e n t E p h e d r i n spray for use by the patient. Eesult o2" Treatment: Asthmatic attacks less frequent and less severe. Right antrum remained clear a f t e r four irrigations. tie,harks: Asthma probably both of allergic and sinus origin.
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CASE 5:m~. S., age 51~. Clinical History : Frequent colds--9 months. Anorexia. Daily temperature as high as 100.5 ~ Right epistaxis on several occasions. Right otitis media occasionally since 2 years of age. Measles. Diphtheria. Ton~illevtozay a~d Adeno~deetom~ : In 1927 and again in 1930. t~esult : No improvement. General Eindi~g's : Fairly well nourished. mal. Tuberculin test negative.
Heart and lungs normal.
Urine nor-
Otorhino~ary~gologie F ~ d i ~ g s : Nasal mucosa vel~ red. Mucopurulent d6bris in nares. Mucus obstructiag nasopharynx. Tonsillar fossae clean. Slight retraction of drums. Tra~s~llqzminatio~:
Frontals not translucent. Antra hazy.
t~oentgenologia Fiq~di~g~: Ethmoids clear.
Increased density of antra.
Frontals undeveloped.
F ~ d i ~ g s on ~.asal a~d Sinacs Irrigation : Plugs of mucopus on nasal irrigation. One left antral irrigation for culture. Bavter~ology of S~n~v Content : Hemolytic staphylococcus aureus. streptococcus. Treatment :
Nasal irrigation.
/qonhemolytic
Oily nasal spray for home use.
l~esult of Treat~ne~t : No improvement for 4 months. Then fever lessened from 100.2 ~ to 98.6 ~. Appetite improved; and improvement maintained. CASE 6.--M. M., age 10.
Cl~'aival History: Frequent colds~ spasmodic cough and hoarseness since birth. Anorexia; pain in knees--3 years.
Fig. 4.--Case 6. )]I.M. The findings Suggest thickened lining membranes of the antra, ethmoids and frontals. Sphenoids,are not affected.
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Tonsillectomy and Adenoidectom~: 1927. l~esu~t : No improvement. General Findings: General condition good. Heart, lungs, liver and spleen normal. Abdomen distended and tympanitic, tongue coated. Otorhinolaryngoloyiv Fi~d~nys: Purulent 46bris in nares. Granular pharyngitis. Tonsillar fossae clean. Transillwminatio~: Frontals clear. A n t r a hazy, especially right. Eocntgenoloyic Fin c~i~gv: Findings suggest thickened lining membranes of antra, ethmoids and frontals. Sphenoids not affected. (Fig. 4.) F~d~ngs on Naval and S i ~ s Irrig:ation: Mucous shreds on nasal irrigation. Cloudy return with mueopurulent shreds on irrigation of antra. Bacte~iolo~ of Si~umS Co~te~V : Staphylococcus albus. Pneumococeus--type I I I . Treatmen.t: Nasal irrigation. Antral irrigation. Tamponage with 10 per cent argyrol. l~ex~lt of Treatment : Free from former symptoms. General improvement. t~e~na~ks: l%emarkable improvement. CASE 7.--F. C., age 7. Clinical History: Continual colds and coughing since 2 8 9 years of age. Anorexia. Malnutrition. Questionable chorea a t 3 years. Bilateral acute otitis media with myringotomy 1 year ago. ' ~ N e r v o u s " child, sleeps restlessly.
Fig. 5.--Case 7.
•. C. Frontals undeveloped. Antra cloudy, more so on the right side. Left ethmoid slightly cloudy.
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Tonsillectomy a~d Adenoidectomy : 1927. Result: No improvement. General ]Fiq~di~gs: Poorly nourished. Cardiac hypertrophy. Sibilant and sonorous rgles on deep breathing. Otorh~olary'~gologic F~w~n,gs: Nares clear. Granular pharyngitis. Tonsillar fossae clear. Tra~sillq,m&~tio~.: Frontals clear. Antra equally hazy. t~ventgeno~oyic Fi~di~g~: Frontals undeveloped. Antra cloudy, more on right. Left ethmoid slightly cloudy. (Figs. 5 and 6.) Fiz~d~ngs o~ Nava.l and Si| Irrigation: Large mucopurulent plugs on nasal irrigation. Antral irrigation immediately following gave clear return.
Fig. 6.--Case 7. F . C .
Lateral view.
Bc~eteciolo~y o f Siq~s Con.tent : Pneumocoecus--type III. T~t,mv~t: Nasal irrigation. Antral irrigation for culture. Oily nasal spray for home use. ~es,t~lt o f Treatment: Considerable improvement in cough. Appetite improved. Weight increased. Nervousness gone--sleeps soundly. Bemaxks: Unusually good result. CASE 8.--F. P., age 6.
Cliniea~l History: Frequent colds past year, with sneezing and cough. Anorexia. Two attacks of acute otitis media with myringotomy. Severe pain in left knee in 1929. Pyuria treated in Babies Hospital in ]927. Continua] pyrexia past 6 months~ 99-100.4".
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Tonsillecto~ny a~d Adeno~dectomy : 1929. l~es,z~lt: No improvement. General Findings: Small and undernourished. Heart~ lungs~ and abdomen norreal. Small left inguinal hernia. Otorh~wlaryngolo.gio Find~n,gs: Copious purulent secretion in nares. Rhinopharyngitis. Tonsillar fossae clean. Tra~zillum~nation: Frontals not translucent. A n t r a opaque. ~oentgenolo~ie ]Findings: Frontals and sphenoldals undeveloped. Increased in density in maxillary sinuses, especially the right. (Fig. 7.) tr$ndin~ ozv Nasal and S~n~s Irrigation: Plugs of mucopus on nasal irrigation. Mucous ptug on a n t r a l irrigation. Bacteriology o f Si~vz~s Content: Staphylococcus aureus. Pneumococcus--type I I ] .
Fig. 7.--Case 8. P . P .
Frontals and sphenoidals undeveloped. Increase in density in the maxillary sinuses, especially the right.
Treatment: Frequent nasal irrigations. Tamponage with 10 per cent argyro]. Oily spray for home use. l~es~dt o f T~'ca.tu~c~t: Improvement in ~ ' c o l d s " and in appetite. Temperature lower (98~176 :Be~narks: Treatme~it considerably handicapped by neurotic mother and by home conditions. CASE 9.--I. S., age 5. Clin4cal History : Frequent colds and dry cough since grippe at 3 years of age. Mastoiditis at 16 months. Tons~l~ecto~ny and Adenoidectomy : ]927. l~esult: No improvement. General Pindings : Nutrition good. tIear~, lungs and abdomen normal. Otorh#mlaryngologic E~ndic~gs: Nares filled with mucus. Granular pharyngitis. Tonsi]lar fossae clean.
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Transillumination: Right antrum opaque. No other abnormalities. Roentgenolo~io Findings: Suggest right maxillary sinusitis. (Fig. 8.) ~ind~ngs o~ Naval a~d Sinus I~'rigation: Many shreds on nasal ir1~igation, also strings of mueopus from r i g h t naris. Milky pus obtained on aspiration of right antrum. Bavteriology of Sin~s Content: Hemolytic staphylococcus aureus. Hemolytic staphylococcus albus. Tre'a~t~nent!: Nasal irrigation. Tamponage with 10 per cent argyrol. Oily spray for home use. ~es~lt o f Treatwent : Right antrum became translucent. Coughing ceased. Nasal breathing improved.
Fig. 8.--Case 9. I . S .
The findings suggest right maxillary sinusitis.
CASE 10.--B. B , age 12. Cli~dva~ History : Very frequent colds since 2 years of age. Measles. Chickenpox. P a i n in knees--past year. No history of rheumatic fever. Constant rhinorrhea past 5 months. Tonsillevtomy a~d Adenoideotomy : 1926. t~esult: No improvement. Ge~,eral Findings: N u t r i t i o n good. Heart, lungs and abdomen normal. Otorhinolaryngoloyic Findings: !~ight naris occluded by deviated septum. Nares filled with mucus. Pharynx clear. Tonsillar fossae clean. Transillumina,tion: A n t r a hazy: Frontals clear. l~oent.genologie Findings: Suggest infection of ethmoids. All other sinuses clear. Findings on Nasal and Sinus Irr4#~a~ion: Following shrinkage of mucosa~ nasal irrigation returns large plugs of mucopus. Bacteriology of Si/nus Content: Sterile specimen unobtainable. Treatment: Shrinkage of nasal mucosa followed by irrigations. E p h e d r i a spray for home use.
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~esult of Treatment: I a 2 months hares became clear and remained so. ~emarks: Unusual, in that only the ethmoids were involved. CASE l l . - - W . C., age 5. Clingeal History: Frequent colds, nasal discharge and dry cough--2 years, with sore throats and nasal obstruction. Frontal headaches in 1930. Acute broncMtis and acute rheumatic fever diagnosed here ia 1930. Tonsillectomy and A denoidevto~y : 1931. t~es~It : No iml~rovement. General Findings: Malnutrition. Pallor. Exaggerated bronchovesicular breathind. No rhles. Systolic murmur over l~ulmonic area, with accentuated second 1o111monic sound.
~ig. 9.--Case
II.
W.C.
The frontals are normal. the right. The ethmoids are
The antra inc]istinct.
Otorh~no~acy~go~og~v FJ~dJngs: Nasal mucosa congested.
are hazy,
particularly
Postnasal discharge.
Trc~nsil~q~miq~ation: Antra opaque. Frontals clear. ~oentge~olo~t~v Findings: Frontals normal. Ethmoids indistinct. (Fig. 9.)
Antra hazy, particularly right.
Fi~,di~qs on Nazal a,nd Sinus Irrigation : Cloudy return with shreds of mucus on nasal irrigation. Cloudy return on l'ight antral irrigation. Strings of mucopus on left antral irrigation. Bacterioloy~ o~ Sin~s Content : Hemolytic staphylococcus aureus in each antrum. T~'ea.t~nent : ~!asal irrigation. Antral irrigation. CASE 12.--S. S., age 3 89 Clinical History : Very frequent colds and asthmatic attacks since 2 years old. lYieas]es at 21~. Acute otitis media with spontaneous rapture of drum at 3 years. Pneumonia at 3 years. Pain in knees since 2 89 years old. Tonsillectomy and Adeno~devtomy: 1930.
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Result: Colds increased in frequency. General Findings: General condition good. Lungs--sibilant and sonorous r~les in many areas throughout the chest. Heart and abdomen normal. Liver and spleen normal. Otorhinolaryngolo,gic Findings: Nares filled with mucous d~bris. Granular t)har yagitis. Tonsillar fossae clean. Overflow seen from antra. Transillumination: A n t r a hazy. Frontals not translucent. Roe ntgeno~og~v Findings: C]oudlng of antra. Frontals undeveloped. F~ndi~gs on Nasal anc~ Sinus Irriga.tian: Considerable mucopus on nasal irrigariom Antral puncture ~or bacteriological diagnosis only. Bacteriology o f S i ~ s Co~tent : Staphylococcus aureus. Treatment: Nasal irrigation. Use of bily spray at home. t~esult o f Treatment: Nasal discharge lessened. Cough unaltered. CASE 13.--M. M., age 8. Clinival History : Continuous colds and cough for years. Sneezing and snuffling~ 3 months. Measles. Chickenpox. Pertussis. Tonsillevtomy and Adenoideetamy: 1928. Result : Unimproved. General F~ndings: L u n g s - - b u b b l i n g r~les at bases. ]:Ieart and abdomen normal. Oto.rhiuolazyngologie Findings: Dried secretion in nares. Mucopus in nasopharynx. Tonsillar fossae clean. Tran~ilbu~nination: Slight haziness of left antrum. All other sinuses clear. R.oentgenoloyie Findings: No x-ray evidence of sinusitis. Fin~im,ys on Nasal and Simms Irrigation : Nasa] irrigation cloudy with strings of mucopus. L e f t antrum aspirated for culture. Bacteriolo~y o f Siq~v Con2ent: Pneumococcus--typc I I I pure culture. Treatment: Nasal irrigation. Ephedrin spray for home use. ltesult of Treatment: Chest signs cleared up. Nasal discharge lessened. Sneezing ceased. Rew~arks: Positive case of sinusitis despite negative x-ray findings. CASE 14.--J. G., age 10. Cli~ival History : Very frequent colds and asthmatic attacks--7 years. Dyspnea, worse following exercise. Measles at 5 years. Tonsillevtomy and Adeno~deeto~ny : 1925. Result: No improvement. General Findings: General condition good. Lungs--Sibilant and sonorous r~les scattered throughout the chest. Heart, abdomen, liver and spleen normal. Otorhinoiaryngologio Finding's: Turblnates swollen. Pus in nares. Granular pharyngitis. Right ear drum scarred. T~nsill~qnination: Frontals not translucent. Antra hazy, especially left. goe~tLqenolo~e Fi~d~n~gs: Frontals undeveloped. Ethmoids and antra hazy. F~c~i~gv on Nas~a.1 an~ Sinus Irrigation: Shreds on nasal irrigation. Baeter~oio,gy o f Sin~s Content: Not performed~ because antral puncture was contraindicated. Treatment: Nasal irrigation. Tamponage with 10 per cent argyrol. Result of Treatment : Asthmatic attacks and colds ceased. CASE 15.--D. S., age 9. Clicaiea~ H~story: Nasal discharge~ vomiting~ anorexia--1 year. Chronic dry cough. Measles 2 months ag% with no apparent effect on nasal condition. Scarlet fever at 5 years. Tonsillitis during ilrst year.
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Tonsilleetom.y and Adenoidecto~y : 1923. l~esu~t : Improved until one year ago. Genera~ Fi~c~ings: Malnutrition. }Ieart, lungs and abdomen normal. Otortdnolwryngolog~c ~inding~ : Secretion in nares. Tonsillar fossae clean. Traq~sillu~nina~ion: Frontals appear small. A n t r a hazy. lCve~t~TenoIog~e ~F~ndings: Clouding of antra. Ethmoids clear. Frontals undeveloped. Findings on ~VasaT and Sinus Irrigation: Shreds of mueopus on nasal irrigatiom Bacteriology of Sinus Content: Not performed because a n t r a l puncture was contraindicated. Treatment : Nasal irrigation. Tamponage with 10 per cent argyrol. Oily spray for home use. l~esq~lt of Treatment: Considerable improvement. Nasal discharge became of normal amount and character. Vomiting and anorexia ceased. CASE 16.--J. J , age 10. Cl~nival History: Nasal discharge for 3 years. Acute catarrhal otitis media 3 years ago. P a i n in knees--2 years. Tonsillectomy and Ade~oi, deeto~n~j: :1927. l~e~lt : ~ o improvement. General ]Findings: General condition good. H e a r t - - r e d u p l i c a t e d second sound at ~pex. No other abnormality. OtorhinoTavyngologiv Findings: Nares clear. Granular pharyngitis. Tonsillar fossae clean. Right ear drum scarred. Transi~l~minar A n t r a hazy. F r o n t a l s clear. l~ventrgvnoZogic tZindin~s: Clouding of r i g h t antrum. Other sinuses normal. F~'ndi~,gs on ~asal and Sinus Irri.gation: Strings of mucopus on right antral irrigation. Bacteriology of SCnus Content: ~temolytie streptococcus. Streptococcus viridans. Hemolytic staphylococcus aureus. Treatment: Two irrigations of right antrum. Oily spray for home use. t~es~dt of Trear Nasal discharge ceased. P a i n in knees gone. CAs~ 17.--M. C., age 5. Cli~ioal History: Frequent colds with rhinorrhea and cough every winter since infancy. Anorexia. :Brings ~p much mucus. Nervousness. Vomiting. Tonsilleetom~j a.nd Ac~e~o~deetomy: 1928. t~esult : Improvement for 2 years. Genera~ Findings : Teeth, heart, lungs , liver and spleen normal. Abdomen ~orreal except for reducible umbilical hernia. Otorhinola~yngolo~gic Findings: I)6bris in nares. Mucopus seen overflowing through natural ostia of antra. Tonsillar remnants in fossae. Tra~sillu~ni~ation: Frontals not translucent. A n t r a hazy. 1~oentgenolo~ie Findings: Moderate thickening of the maxillary walls, Otherwise, no definite abnormalities seen. Findin,gs on Nasal a~d Sima~s Ivrggation: Shreds and strings of mucopus oil nasal irrigation. Antral aspiration for culture. Bacteriology of S~n~s Content: Streptococcus viridans. Few hemolytic streptococci. Staphylococcus albus. Trea.tment: Nasal irrigation. Use of oily spray at home. ttesq~lt of Treatment: Stopped vomiting. Colds less frequent. Weight increased.
C~s]~ 18.--A. S., age 4. Clinival H i s t o w : Very frequent Golds with thick ~asal discharge--1 year. Moderate cough, l~eadaches. Vomiting. Anorexia. Occasional temperature 100~ ~
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433
l'onsillectom~j and Adenoidectomy : 1930. l~eeult : More c~colds ' ' since operation. Gene~a.l Findings: Large glands o~ both sides of the neck. Coarse, loose r~les throughout the chest. Spleen palpable 1 finger below the costal margin. Otherwise normal. Blood and urine normal. Otorhi~ola~'yn,golagic Fin,d~gs: Nares filled with discharge. Tonsillar fossae clean. Nasopharynx contains discharge. Trao~silhominc~tion: Antra hazy. Right frontal clear. L e f t frontal not translucent. l~oentgenologiv Findings: L e f t frontal absent, l~ight frontal small. Ethmoids appear thickened and cloudy, as do the antra, but the latter less definitely so. Findings on Nasal and Si~ws Irrigation: Several large plugs of mucopus on nasal irrigation. Antral irrigation unnecessary. Bacteriolagy of SiT~v Conte~t : Not performed. Antral aspiration not indicated. Treatment : Nasal irrigation. Ephedrin in oil spray for home use. Eesult of Treatment: Greatly improved. No ~'co]ds" since treatment. Discharge became normal in quantity and character. l~emarks: Nasa] irrigation sufficient to aspirate pus from antra. BACTERIOLOGIC FINDINGS
1. Bacteria found in pure culture in 5 cases Hemolytic Staphylococcus aureus--twice Pneumococcus, type l I I ~ t w i c e Staphylococcus aureus--once 2. Bacteria found in association with one or more others in 9 cases Hemolytic Staphylococcus aureus--three times Hemolytic Staphylococcus albus--once Staphylococcus albus--three times Staphylococcus aureus--two times Pneumococcus, type III--three times Hemolytic streptococcus--two times Nonhemolytie streptococcus--once Streptococcus Viridans--four times Gram-negative Diphtheroids--once Gram-negative Diploeocei--once CONCLUSIONS
We have demonstrated in the foregoing group of cases, the very definite eonnection that exists between chronic nasopharyngitis and chronic sinus infection, and the remarkable improvement that follows the simplest treatment aimed at the true canse of the condition. It is desired by the authors to impress upon the medical profession the simplicity of the examination necessary for establishing the diagnosis of chronic paranasal sinusitis. No one likes to hurt a child-patient, even with the best of therapeutic intentions, and it is the suspicion that the pain connected with sinus irrigation will not be commensurate with the benefit obtained, that has
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TI~IE JOURNAL OF PEDIATRICS
restrained many physicians from making the diagnosis in children suffering from continual catarrh, inexplicable marasmus, and unaccountable pyrexias. The benefits observed by the authors resulting from such treatment, has convinced them of the value, indeed the necessity of the proper surgical treatment of "where there is pus, there should be drainage." We are grateful to those authorities of Babies Hospital and o2 Presbyterian Hospital who so kindly assisted us in every possible mahner, in the p~-eparation of this paper. RE~EREN CES 1. 2. 3. 4.
Davis, W . B . : Trans. See. Laryng., A. M. A. 8: 23, 1918. Dean, L . W . : J . A . ~ . A. 85: 317, 1925. Ashley a~d Frick: Ann. OtoL Rhinol. $ Laryngol. 39: June, 1930. Ruskin~ S . L . : Am. J. ])is. Child. 36: 1020~ 1928. :BABIES H O SPITAL~ ~RESBYTERIAhT HOSPITAL.