Nasal Accessory Sinus Diseases Clinically and Roentgenographically Correlated

Abstract

NOT long ago we passed through what may be described as the Surgical Age of nasal sinus disease. Numerous unnecessary operations, many of them detrimental to the patient, were performed, at least a part of them due to the fact that a proper relationship did not exist between the otolaryngologist and the roentgenologist. From the surgical standpoint too much stress was laid on the x-ray picture: signs and symptoms were not correlated with the x-ray plate. This was not the fault of the roentgenologist; perhaps it was due in part to the tendency to teach surgical procedure without stressing physiology, pathology, and diagnosis. Otolaryngology does not differ from any other branch of medicine in its relation to the x-ray service. The primary factor in the proper examination of the patient is the history, a statement which may be illustrated by the following case: A boy, 12 years of age, developed in August what seemed to be a terrific infectious pansinusitis. What appeared to be thick white pus poured from each nostril. The x-ray examination was made early in the study of the case. All the sinuses were seen to be cloudy. An immediate radical operation was advised. For some reason or other it seemed advisable to go over the patient again. In the second examination, considerable attention was directed to the securing of a meticulously exact history. Certain outstanding facts were elicited: First, the onset of the acute condition occurred on a dry hot day in July; the patient had had two previous attacks, both in hot weather; he was practically free of trouble during midwinter. A cytological study was made of his nasal discharge, which was found to contain 50 per cent eosinophils and only an occasional polymorphonuclear neutrophil. In spite of the fact that the nasal discharge was typical of macroscopic pus, a different recommendation was made, namely, that the patient leave the laryngologic service and enter the allergic service. As the result of withholding milk from the diet the clinical condition of the patient rapidly improved and in four months' time the roentgenologist expressed the opinion that the x-ray plates showed almost perfect healing. This is not an unusual result: it occurs often when one devotes at least twenty minutes to the securing of the history. A good history may bring to light a correlation of facts and takes precedence over either clinical or laboratory examination. To me it seems obvious that a cytologic examination of the nasal and otologic discharges should be made in every case in which these conditions are present. The chest man would not think of neglecting a cytologic examination of the sputum: the genito-urinary man always makes a careful microscopic study of the urine: the cytologic examination of the nasal discharge is just as important. The presence of polymorphonuclear neutrophils in the discharge taken from the neighborhood of the ostium of a sinus means one thing; the absence of cells means another.