We ascertain by interrogation, (a) if the discharge is purulent or muco-purulent; (b) whether it is unilateral or bilateral; (c) whether it is continuous, intermittent, or influenced by change of posture; (d) if there is offensive smell perceived by the patient or by others; (e) pain is not usually complained of unless there is obstruction to drainage, and consequently retention of pus under pressure. Unilateral discharge suggests a foreign body in a child or sinus involvement in an adult. If it is intermittent or influenced by position probably originates in a sinus. Subjective fetor suggests sinusitis; while objective fetor, ozena; and combined subjective and objective is the rule in syphilitic necrosis. Location of pain is of very little, if any, use in diagnosis.
Rhinoscopy.—Attention directed to (a) situation of the pus; (b) polypi; (c) atrophy of the mucous membrane; (d) crusts; (e) ulcerations; (f) adenoids; (g) nasal obstruction; (h) foreign bodies. Under (a) beside usual cleansing of nasal cavities and reexamination to ascertain situation, he recommends “tamponading,” i. e., by blocking up first one part, then another, with pledgets of wool, and noticing whence the discharge reappears. (e) Ulceration may be syphilitic, simple, tubercular, or lupoid in origin. “It must not be forgotten that a perforation” of the septum “may be entirely the work of a misused finger-nail.” (g) The normal mucoid discharge damned up by nasal obstruction frequently becomes purulent.
Special methods of diagnosis as follows are mentioned: transillumination; examination of upper teeth; catheterization of the ostium, maxillares, naso-frontal canal, and outlet of the sphenoidal sinuses; external examination of antrum and frontal sinuses; exploratory puncture of the antrum through the inferior meatus, alveolar process, or canine fossa. Diagnosis of ethmoiditis is principally by exclusion.
Treatment of the accessory sinuses may be summed up under the following indications: (a) removal of the cause; (b) evacuation and drainage of pus; (c) antiseptic irrigation; (d) removal of morbid material, when present. PALMER.