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NASAL SINUSITIS IN CHILDREN

THE LANCET

LONDON: SATURDAY, SEPTEMBER 25, 1937

IT is increasingly recognised that infectednasal sinuses, rather than infected tonsils and

adenoids, may be responsible for the intractablecatarrhs of nose or upper respiratory tract so

often seen in childhood. A few months ago wereferred’ to an investigation at Great Ormond-street in which Mr. JAMES CROOKS found pus ormucus in one or both antra of 24 out of 100 children

undergoing tonsillectomy.2 This suggested that ina quarter of the cases the seat of the trouble mayhave been wrongly located, and that treatmentof the sinuses might have been more profitablethan removal of adenoids and tonsils. The samemoral may be drawn from the work that Mr. IVORGRIFFITHS records in our present issue. He comesto the conclusion that removal of the tonsils,and presumably adenoids, does not necessarilyimprove cases of middle-ear disease, snoring, ornasal catarrh, and he found infection of nasalsinuses in as many as 385 out of 5000 children

suffering from nose or throat complaints. He alsofound that sinusitis was commoner in childrenwho had had tonsillectomy than in those who hadnot; but this may well have been because suchchildren had catarrhal symptoms for which the

operation was mistakenly performed, rather thanbecause absence of tonsils predisposes to sinusitis.A remarkable feature of the ten cases Mr.

GRIFFITHS describes in detail is that it was only neces-sary to wash out the sinuses a few times to removethe infection: indeed four of the ten childrenseem to have recovered after the affected antrumor antra had been washed out once. Thisweakens his argument against making an artificialopening into the antrum because such openingsusually close in less than three months ; forif most cases are cured by washing out a few

times, it is to be expected that others will be curedby irrigation within this period. More intractable

discharge is probably due to infection of othersinuses. Dr. HERMAN B. MARKS says that intra-nasal opening followed by irrigation is their

regular method of treatment at the Boston Float-ing Hospital; he lays emphasis, both in preventionand treatment, on adequate nutrition and a dietrich in vitamins. The treatment of these cases

is certainly not yet stereotyped ; Mr. GRIFFITHSadvocates instillation of Argyrol, while Dr. MARKScondemns the use of drops, especially in youngchildren, because of the danger of their aspirationinto the alveoli of the lungs, and because theyinterfere with ciliary action.That tonsillitis may be a sequel to nasal sepsis

1 Lancet, 1937, 1, 93.2 Arch. Dis. Childh. 1936, 11, 281.

3 New Engl. J. Med. 1937 216 .604.

is well known. Mr. GRIFFITHS propounds the

interesting theory that a function of the tonsil isto excrete into the pharynx organisms that passinto it from the sinuses through the lymphatics ;

*

from which it would follow that the tonsils shouldnever be removed for nasal catarrh. He describes

experiments he has made with dogs and cats onthe passage of dyes and indian ink from thesinuses, in which he discovered the material con-stantly in the deep cervical and submaxillaryglands and (in small amount and by no meansalways) in the tonsil. He holds that the dyepasses into the tonsil by the lymphatics, eitherdirectly or through the deep cervical glands,although no afferent lymphatics to the tonsil canbe demonstrated. In one animal he sutured the

pillars over the tonsil to exclude the possibilityof the dye passing from the pharynx on to thetonsillar surface ; yet it duly appeared in thetonsil. On the other hand, many observers haveseen the ciliary current conveying material fromthe nose and sinuses along the side of the pharynx,and Dr. MARKS describes a branch of this current

trickling over the surface of the tonsil to rejointhe main stream lower down. It is hard to believethat the tonsil does not sometimes become infectedfrom the nose in this way.Knowledge of the prevalence of sinusitis should

mean that nasal catarrh in children will be lessoften treated by removal of tonsils and adenoids,performed as a routine. But children’s catarrhis not always due to sinusitis, and it may berecalled that only 24 of Mr. CROOKS’S 100 tonsil-lectomy cases had secretion in the antra. Nasaland respiratory catarrh can undoubtedly be causedby infected tonsils and adenoids, especially thelatter, and cured by their removal. We must takecare therefore lest the pendulum swing too far.

A NEW COLLEGE OF PHYSICIANSA PROJECT to establish -an Australasian College

of Physicians has now been realised. It has been

planned to some extent on the pattern of the RoyalCollege of Physicians of London, but this patternhas been adapted to the needs of a communitywhose professional schools and leaders are scatteredsparsely through a huge continent where means ofcommunication are not yet fully developed. Onedifference will be in the method of election of itscouncil and of its president. In the Australasian

college the proportion of fellows from each Stateto sit on the council will be arranged in advanceso as to make its governing body geographicallybalanced. The president will be elected by thecouncil and not, as in London, by a comitia of allthe fellows ; and the members of the collegewill have representation on the council. A morefundamental difference is that the assumptionof responsibility for a qualifying examination isnot contemplated ; the college will have no licen-tiates. Its two grades will be that of membership,conferred by a board of censors after examination,or, as here, on published work; and that of fellowship,awarded to those selected by the council year by yearfrom among the members of more than four years’

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standing. Foundation fellows will include all those

recognised as teachers of medicine by the medicalfaculties of the universities of Australia and ofNew Zealand. The college will absorb the Associa-tion of Physicians of Australasia (including NewZealand) whose members will become foundationfellows. The college will hereafter assume respon-sibility for carrying on the work of the Association,including the organisation of an annual meetingat different centres at which scientific communica-tions are submitted.

In making these plans, the new college has takenfull advantage of information put at its disposalby the Royal College of Physicians of London, wholast winter appointed Sir EDMUND SPRIGGS as anemissary, charged to convey information and

messages of goodwill. His visit to Australia wasfollowed by one to this country from Sir CHARLESBLACKBURN (Sydney), Dr. S. V. SEWELL (Mel-bourne), Dr. L. S. LATHAM (Melbourne), Dr. A. W.HOLMES 1. COURT (Sydney), and Dr. E. B. GuNSON(Auckland), who conferred with Lord DAWSON OFPENN and other colleagues at Pall Mall East. Apartfrom the promotion of research in clinical medicineand the dissemination of knowledge, the Austra-lasian College will, it is hoped, serve as a meetingpoint for physicians and provide opportunities fordiscussion and common action when legislativeor other measures affecting the national health arise.We are glad to believe that, with its elder sister,the Royal Australasian College of Surgeons, thenew college will serve to strengthen the social aswell as the purely professional ties between thoseworking for better health in different parts of ourCommonwealth of Nations.The first president of the college is Sir CHARLES

BLACKBURN, hon. consulting physician to the

Royal Prince Alfred Hospital, Sydney, and deanof the faculty of medicine in the University from1932 to 1935, and the vice-president Dr. S. V.SEWELL, hon. physician to the Melbourne Hospitaland lecturer in clinical medicine in the University.

INTERNAL PNEUMOLYSISIT is one of the axioms of collapse therapy that

an ineffective pneumothorax should either bemade effective or abandoned. The direct section ofadhesions by endoscopy or their indirect relaxationby phrenic paralysis can no longer be dismissed asoperations only occasionally required in artificialpneumothorax treatment; they are coming to beregarded as an essential part of collapse therapy,for too often the induction of a pneumothoraxfails to secure collapse of the diseased area andmerely provides a space in which the endoscopistcan work. A partial pneumothorax may thus beonly the first stage of the internal pneumolysiswhich must be performed before complete collapseof diseased lung can be secured. The risks attend-ing internal pneumolysis are not great ; but were

they more serious than they are, they would stillbe less than those of the untreated disease. It issurely justifiable to take risks when life is at stake ;and the patient’s life is endangered so long as avomica remains patent. Endoscopic section ofadhesions is now becoming the rule when in the

course of artificial pneumothorax treatment a

radiogram shows an uncollapsed cavity, andeven when, though a cavity is not detected, thecontinued expectoration of bacilli proves that lungulceration is still responsible for an

"

open " lesion.Since internal pneumolysis imposes a nervous

strain upon the patient and is not devoid of risk,even in the hands of a prudent and skilful operator,it has been customary not to interfere withadhesions unless persistent cavitation could be

proved or surmised. Further experience hasmodified this conservative attitude. Dr. F. G.CHANDLER has published detailed records 1 of 210consecutive operations performed on 157 patients,with an account of their subsequent fate. They aredivided into two series : the first of 110 operationsperformed on 89 patients between 1929 and 1934,and the second of 100 operations performed on68 patients between 1934 and 1936. Of the firstseries of 89 patients 47 (52’8 per cent.) are reportedup to the end of 1936 as being in good health witha negative sputum, 11 (12’3 per cent.) in fairhealth, while 15 (16’8 per cent.) are dead; 7

patients are untraced. In the second series of68 patients 46 (67’6 per cent.) are in good healthwith a negative sputum and a further 11 (16’1 percent.) in fair health. Only’ 1 patient in thesecond series has died and none is untraced.The second group of patients have, of course, notbeen long under observation and some of those" in fair health " will become sputum-negative;on the other hand, the mortality-rate of the groupwill, perhaps, show a slight rise. The incidenceof empyema, whether tuberculous, pyogenic, or

mixed, was 7 in the first series and only 1 in thesecond. A fair deduction from these figures is thatthe operation as performed by Dr. CHANDLERto-day is far more successful than when he beganto divide adhesions seven years ago, and he is nowone of many who are obtaining excellent resultsfrom operations of this kind. Among the interest-ing points of technique is the discard in the secondseries of diathermy as a cutting current. Hoomor-

rhage, sufficiently serious to be recorded, occurred16 times in the first series, diathermy havingbeen used alone in 8 of these cases. In the secondseries, diathermy was never used as a cuttingcurrent and haemorrhage is only reported once,even then being not sufficiently profuse to give riseto a hæmothorax. The 8 cases in which haemor.

rhage followed the use of diathermy alone alldeveloped effusions immediately after operation.Dr. CHANDLER observes justly that diathermyis no more likely to excite an effusion per se thanthe electrocautery ; but blood in the pleuralspace leads to effusion and diathermy used as acutter is a potential cause of haemorrhage. Nowthat the " dull red glow " of the electrocautery,without previous diathermy, is being used moreand more to provide both coagulation and sectionthere is no increase either of haemorrhage or ofimmediate effusions.The object of artificial pneumothorax is to

secure rest for a diseased area of lung. A lung1 Tubercle, April, 1937, p. 298, and May, 1937, p. 348.