Paper - The sinus maxillarus and its relations in the embryo, child, and adult man
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Schaeffer JP. The sinus maxillarus and its relations in the embryo, child, and adult man. (1910) Amer. J Anat. 10: 313-
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The Sinus Maxillarus and its Relations in the Embryo, Child, and Adult Man
By
Jacob Parsons Schaeffer,
Instructor in Anatomy, Cornell University Medical College, Ithaca, N. Y.
With 31 Figures.
Introduction
This paper is based upon a study of the sinus maxillaris in the embryo in successive stages up to the fetus at term, as well as in the child and adult man. Most of the adult specimens ranged in age from 18 to 80 years.
The lateral nasal wall of the embryo, at different stages of growth, was modeled; thus showing the relations of the sinus maxillaris and its progress in development. The blotting-paper method was used in all the reconstructions. Both solid structures and cavities were modeled, thus securing positive and negative views.
The work also covers a general consideration of the sinus in the child and the adult; including a study of the sinus relations, its ostium or aperture, and the ostium accessorium. Special attention was also given to the cause and effect of recesses occurring on the walls of the adult sinus. Dissections were made to cover all phases of the problem.
In determining the size of the sinus the following measurements were taken: (1) dorsosuperior diagonal; (2) ventrosuperior diagonal; (3) superoinferior; (4) ventrodorsal; (5) mediolateral.
The capacity of the sinus was determined by filling the cavity with a portion of a previously measured liquid, or by measuring the amount of water the hardened mucous membrane (representing the exact shape and size of the sinus) would displace.
I wish to take this opportunity for expressing grateful acknowledgment to the heads of the Departments of Anatomy, and Embryology and Histology for valuable criticisms and helpful suggestions. I also wish to express my grateful appreciation of the abundant material and oilier facilities placed at my disposal by the aforementioned departments. To Professor and Mrs. Gage, for the loan of embryos from the research collection, I wish to express thanks.
The Embryology and Early Relations of the Sinus Maxilla His
About the tenth week of fetal life the mucous membrane in the primitive middle meatus of the nose begins to pouch laterally. This pouch represents the Anlage of the sinus maxillaris, which pushes from the originally simple furrow separating the maxillo-turbinal (later concha nasalis inferior) and the first ethmo-turbinal (later concha nasalis media).
In order to gain a clearer conception of the location and relations of this primary maxillary pouch, and to better interpret adult conditions, a brief consideration of the lateral nasal wall, of the embryo, is necessary.
During the second month of intrauterine life, before the cavum nasi and the cavum oris have become separate cavities, we find three swellings on the lateral wall of the nasal fossa (maxillo-turbinal, appearing first; ethmo-turbinal, appearing next; naso-turbinal — extremely rudimentary in man, appearing later) (fig. 1). The maxillo-turbinal corresponds to the adult concha nasalis inferior. The naso-turbinal, which is termed by Peter, a der Agger nasi," and by Killian, in conjunction with the primitive processus uncinatus, "der erste Hauptmuschel, " persists in the adult as the agger nasi. The ethmo-turbinal undergoes subdivision, and by this division, according to Killian, five ethmo-turbinal plates, defined by six grooves, are usually formed. E. Kallius says, "Dass alle diese 6 Furchen ausgebildet sind, ist selten. " Zuckerkandl's investigations show that three ethmoturbinal plates are tho typical number. He says, "Drei Siebbeinmuscheln reprasentieren demnach die typische Faltungsweise des Siebbeines." According to the embryos studied for this paper, I find that the number of furrows and ethmoidal concha 1 varies, but in the specimens examined, four plates are rather common. The ethmo-turbinal plates and the resultant furrows become reduced in number as development goes on, and finally represent the conchse nasales, media and superior, and the meatus nasi, medius and superior, respectively. The reduction in number may not be carried so far, and this accounts for the supernumerary ethmoidal conchse and meatus in many adults.
Fig. 1 (X 10). Drawing of a frontal section through the head of an embryo aged about 45 days, in the region immediately dorsal to the organon vomeronasale (Jacobsoni), note the development of the early turbinal processes, and that there is no cartilage laid down in them at this early period. This is contradictory to the theory that the turbinal processes are primarily the result of an inpushing of the lateral nasal wall by cartilaginous strands which later become the nasal conchse.
Enc'lon, = encephalon; E. T., = ethmo-turbinalia; M. T., maxillo-turbinale; P. Pal., = processus palatinus; Sep. Nasi, = septum nasi.
Just how the primitive nasal processes and furrows are formed is interpreted differently. Some claim that the projections are due to an inpushing of the lateral nasal wall by the cartilaginous strands which become the nasal conchse. This latter claim I have been unable to verify, because I find that the folds or projections are invariably present before cartilage is found in them (fig. 1). The elevations at first consist of a duplication of the ectoderm filled with indifferent mesenchyma, which, in part, later changes into cartilage. The nasal conchal cartilages are, therefore, a result and not a cause of the early condition. Schoenemann claims that they are elevations left by excavations of furrows on the lateral wall of the nasal fossa. Killian and Mihalkovics hold that the projections are free ingrowing folds on the lateral wall of the nasal fossa. Glas concludes a discussion on the nasal conchae in rats thus:
- Die Bildungsmodus der Muscheln, ist die Resultierende zweier Komponenten ; (1) des Auswachsens die Wandpartien einwachsender Epithelleisten (Fissuren). (2) des Vorwachsens bestimmter Wandpartien.
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| Die Bildungsmodus der Muscheln, ist die Resultierende zweier Komponenten ; (1) des Auswachsens die Wandpartien einwachsender Epithelleisten (Fissuren). (2) des Vorwachsens bestimmter Wandpartien. | The formation mode of the muscles is the result of two components; (1) the growing out of the wall parts of growing epithelial ridges (fissures). (2) the growth of certain parts of the wall. |
After a study of these early conditions I am led to believe that the primitive furrows are primarily the result of an outpushing or outgrowing of the mucous membrane on the lateral wall of the nasal fossa. The projections, by duplication of the mucous membrane (especially true in the ethmo-turbinal region) (fig. 1), and the deepening of the furrows, become rapidly prominent. At times the two processes, an outgrowth or outpushing, and a duplication of the intervening mucous membrane and mesenchyme, seem to be at work simultaneously in forming the early projections and furrows. The theory that the furrows are primarily started as an outpushing or outgrowing of mucous membrane is entirely in accord with, apparently, similar processes taking place in the early embryo nose; namely, the pouching or outgrowing of the mucous membrane as the Anlagen of some of the sinus paranasales. That a similar process should cause the formation of primarily similar outgrowths seems plausible.
It is, however, not the province of this paper to speak in detail of the development of the early projections and furrows; suffice it to say that it is from the furrow separating the primitive conchae nasales, inferior and media, that the maxillary pouch evaginates. It is, therefore, the primitive meatus nasi medius with its contained structures, and the naso- and first ethmoturbinals that especially concern us in the development and relations of the primitive sinus maxillaris.
Killian terms the naso-turbinal and the subdivisions of the ethmo-turbinal, "Hauptmuscheln;" and the smaller projections appearing in the furrows between these " Hauptmuscheln, " as "Nebenmuscheln. " What he terms "die zweite Hauptmuschel " will be spoken of in this paper as the concha nasalis media (first ethmoidal concha).
The naso-turbinal plus the processus uncinatus and the concha nasalis media have marked bends, thus presenting ascending and descending crura. Correspondingly the furrow between these conchae has a bend, and presents ascending and descending limbs. For the sake of description we will consider the processus uncinatus as the descending crus of the nasoturbinal. The primitive meatus nasi medius has, therefore, as inferior boundaries the cura of the naso-turbinal and the space existing between the conchae nasales, media and inferior. The superior boundaries of the space are the crura of the concha nasalis media (zweite Hauptmuschel of Killian) (fig. 4). To say then, as has been done earlier in this paper, that the maxillary pouch evaginates from the space separating the primitive conchae nasales, inferior and media, is not giving the pouch its definite location. 1 The actual point of this primary pouching is from the primitive infundibulum ethmoidale, or the "unterer Recessus des absteigenden Astes der ersten Hauptfurche" of Killian.
This pouch is a minute epithelial sac, and forms the Anlage of the sinus maxillaris. Its earliest establishment precedes the appearance of the cartilage which later surrounds it. This is in accord with the statement of E. Kallius, that
die Nebenhohlen der Nase schon angelegt sind, ehe der Knorpel entsteht, und dass also das Skelett sich erst sekundar um jene herumlegt.
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| die Nebenhohlen der Nase schon angelegt sind, ehe der Knorpel entsteht, und dass also das Skelett sich erst sekundar um jene herumlegt. | the sinuses of the nose are already in place before the cartilage is formed, and so that the skeleton only wraps around them secondarily. |
The relation of the space existing between the conchae nasales, inferior and media, to the descending ramus or limb of the first furrow is spoken of thus by Killian, "Der Raum zwischen zweiter Hauptmuschel und unterer Muschel ist demnach nur eine Art Vorhof zum absteigenden Theil der ersten Haupfurche.
According to my observations the earliest evidences of maxillary pouching are found about the seventieth day of fetal life. Kallius places the time of the primary evagination during the middle of the third month, "Die Oberkieferhohle erscheint in der Mitte des 3. Monats. " J. Kollman places the time of pouching later, "Seine Anlage beginnt erst bei Foeten Von 8 cm. Lange." Gegenbaur quotes Dursy as authority for the following:
Schon bei 8 cm. lange Embryonen buchtet sich der Raum der Nasenhohle zwischen mittlerer und unterer Muschel gegen den hier verdickten Knorpel der Seitenwand der Nasenhohle aus und bildet die Anlage des Sinus Maxillaris.
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| Schon bei 8 cm. lange Embryonen buchtet sich der Raum der Nasenhohle zwischen mittlerer und unterer Muschel gegen den hier verdickten Knorpel der Seitenwand der Nasenhohle aus und bildet die Anlage des Sinus Maxillaris. | Already at 8 cm. long embryos, the space of the nasal cavity bulges between the middle and lower turbinate against the thickened cartilage of the side wall of the nasal cavity and forms the abutment of the maxillary sinus. |
I have found the primitive maxillary pouch duplicated, i. e., two pouches growing laterally side by side. (This may explain some of the duplications of the adult ostium maxillare — the two primary pouches fusing distally, leaving the two points of evagination as the ostia maxillaria of the adult sinus. Other duplications of the adult ostium may be caused in a manner similar to the formation of the accessory ostium).
This embryonal condition probably explains some of the cases in which the sinus maxillaris is divided into two partially or wholly separate compartments by a vertical partition, i. e., each pouch developing into an adult cavity independent of its mate (see subsequent paragraph).
The primary ostium maxillare varies greatly in its dimensions in different embryos (figs. 2, 3). This is entirely in accord with adult conditions, since the ostium of the adult sinus has a great range of dimensions (table D). The great differences in the dimensions of the ostium may be due to early fusion of two or more primary maxillary pouches; or the primitive pouching may have been single but extensive, as is frequently the case. These two latter would give rise to long slit-like ostia, while the single and less extensive pouching would give us the typically shaped and average sized adult ostium.
Sometime prior to the establishment of the maxillary pouch 2 a ridge appears immediately inferior to the point of maxillary evagination. This ridge is the Anlage of the processus uncinatus and, as said before, will be considered, merely for the sake of description, as the descending cms of the naso-turbinal. It will be recalled that Killian terms the latter two structures, "die erste Hauptmuschel. " This ridge has its free border directed superiorly, and it extends in a ventrosuperior direction. It early tends to form a shallow groove immediately superior to it, which is the primitive infundibulum ethmoidale (Recessus inferior des absteigenden Astes der ersten Hauptfurche of Killian). To be accurate, then, we must say that the maxillary pouch evaginates from the primitive infundibulum ethmoidale — a part of the meatus nasi medius.
2 It is indeed difficult, in some eases, to say which struct lire is the primary one in establishing an Anlage. It most eases the processus uncinatus is the first to appear, and in some instances it is impossible to say whether the pouching of the mucous membrane, or the formation of the ridge is first, It may, however, be said that both structures a.v more or less dependent upon each other in establishing anlagen.
Fig 2 ( X 10). Drawing of a reconstruction of portion of the right nasal cavity; including the meatus, infundibulum ethmoidal, and the sinus maxillaris. Only that portion of the nasal cavity necessary to include the sinus maxillaris and its relations is shown.
Compare the size of the ostium maxillare with the corresponding aperture in fig. 3.
The model was reconstructed from the nose of an embryo aged 105 days. It must be remembered that the drawing represents cavity and is, therefore, a negative.
M. N. M., M. N. I., = meatus nasi, medius et inferior; I. E., = infundibulum ethmoidale; C. N., = cavum nasi . H . S., = hiatus semilunaris; O. M., = ostium maxillare; S. M., = s inus maxillaris.
Fig. 3 (X 10). Drawing of a reconstruction of portion of the right nasal cavity of an embryo aged 120 days. The drawing includes the meatus, infundibulum ethmoidale, and the sinus maxillaris. Only that portion of the cavity, was modeled so as to include the sinus maxillaris and its relations. Since it represents cavity it is a negative.
Note the very extensive ostium maxillaie in comparison to that in fig. 2.
M. N S., = meatus nasi superior; M. N. M., M. N. I., = meatus nasi, medius he inferior; I.E., = infundibulum ethmoidale; C.N., = cavum nasi; H. S., = ttai us semilunaris; 0. M., = ostium maxillare; S. M., = sinus maxillaris.
Some time after the appearance of these structures there is a more or less uneven bulging on the lateral wall of the primitive meatus nasi medius, immediately superior and lateral to the free border of the processus uncinatus (fig. 4). This is the Anlage of the bulla ethmoidalis. The slit-like space existing between the free border of the processus uncinatus and the bulla ethmoidalis is the primary hiatus semilunaris. Through this slit the infundibulum ethmoidale communicates directly, and the primitive sinus maxillaris indirectly, with the meatus nasi medius.
Fig. 4 (X6.6). Drawing of a frontal section of the nose of an embryo aged 120 days. The section is 7.25 mm. from the tip of the nose. Note that on one side the section is in the region of the ostium maxillare, on the other it is dorsal to it; also the fusion between the processus uncinatus and a frontal concha.
Inf. Eth., = infundibulum ethmoidale; 0. M., = ostium maxillare; S. Max., = sinus maxillaris; Os., = developing bone; F. Cr. Ant, = fossa cranii anterior; B. Eth., = bulla ethmoidalis; H. Sem., = hiatus semilunaris; Proc. Unc, = processus uncinatus.
Killian subdivides the uneven thickening on the lateral wall of his "Ramus decendens der ersten Hauptfurche" into small projections with very shallow intervening furrows. The projections are his " absteigende Nebenmuscheln ", and the furrows the " obere und untere Zwischenfurchen " of the first furrow, or the primitive meatus nasi medius. He concludes that the bulla is formed by the early fusion of some of the processes (Nebenmuscheln). The space immediately inferior to his "untere Nebenmuschel " or the space he designates as the "Recessus inferior" of his first chief furrow, is the infundibulum ethmoidale — the exact place of the primary maxillary pouching.
At this juncture mention must be made of the primary pouching of the sinus frontalis in order to interpret later conditions in connection with adult front o-maxillary relations. It will be remembered that the furrow from which the maxillary pouch evaginates has ascending and descending rami, and that from the descending ramus the maxillary evagination takes place. The ascending ramus of this furrow widens and pushes ventrally and superiorly. Turner says:
It is generally held that the frontal sinus commences to develop at the end of the first or the beginning of the second year of life, as an upward expansion of the ethmoid cell labyrinth.
Hartman quotes Steiner for the following:
Der erste Anlage der Stirnhohle ist in der Anlage des Knorpeligen Siebbein-labyrinthes gegeben mit der Entwickelung der zelligen Raume des vorderen Siebbeinlabyrinthes beginnt auch die der Stirnhohle, denn letztere stellt eben nur die Ausdehnung der vorderen Siebbeinzellen nach oben dar.
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| Der erste Anlage der Stirnhohle ist in der Anlage des Knorpeligen Siebbein-labyrinthes gegeben mit der Entwickelung der zelligen Raume des vorderen Siebbeinlabyrinthes beginnt auch die der Stirnhohle, denn letztere stellt eben nur die Ausdehnung der vorderen Siebbeinzellen nach oben dar. | The first arrangement of the frontal sinus is given in the arrangement of the cartilaginous ethmoid labyrinth. The development of the cellular spaces of the anterior ethmoid labyrinth also begins with that of the frontal hollow, because the latter only represents the expansion of the anterior ethmoid cells upwards. |
Hartman makes the following statement :
Aus dem aufsteigenden Ast der ersten Hauptfurche bildet sich durch oberflachliche Verwachsung cine sackartige Bucht, der Recessus ascendens od. II. frontalis, die Stirnbucht. Ans der Stirnbucbt entwickelt sich die Stirnhohle.
The embryos studied showed evidence of a slight pouching at the superior and ventral end of the primitive meatus nasi medius. This doubtless corresponds to the "Recessus frontalis" of the first chief furrow of Hartman and Killian.
According to Killian's commendable work there are three processes and four furrows on the lateral wall of the recessus frontalis, which are designated by him as "Stirnmuscheln und Stirnfurchen," respectively. The processes, according to Killian,
The Sinus Maxillaris in Man. 323
merge, and form the cellular ethmoidales anterior, or cellula 1 frontales as some call them. From this he concludes that the sinus frontalis may continue its development in one of the following ways: (1) by extension of the frontal recess (direct method), (2) by extension of a frontal cell (indirect method), (3) by extension of the frontal recess and a frontal cell, (4) by extension of two frontal cells. With these facts kept in mind — allowing for further differentiation during development, it is easier to understand why the sinus frontalis, in the adult, connects either with the infundibulum ethmoidale, with the meatus nasi medius, or with both. These embryological facts are of importance in connection with adult fronto-maxillary relations. Doubtless more work should be done on the development of the nasofrontal duct in order to clear up some points in connection with the relations existing between the sinus frontalis and maxillaris. I am now working along this line and hope to report my findings at some future time.
Although the pouching to form the recessus frontalis, or what may be termed the Anlage of the sinus frontalis, begins during the third month of fetal life, as does that of the sinus maxillaris, the extension of the sinus frontalis is for a time so small that it is usually regarded as wanting at birth. This is in part due to the fact that the sinus frontalis is as a rule looked for in the frontal or vertical portion of the frontal bone, while the first evidences of it are to be sought elsewhere. In fact, according to Lothrop's investigations, the sinus frontalis of the adult does not reach the vertical or frontal portion of the frontal bone in about three per cent of cases — the only evidences of the sinus appearing in the horizontal or orbital portion of the frontal bone. It must, however, be said that the sinus frontalis is tardy in its development until after birth; while, on the other hand, the pouch forming the Anlage of the sinus maxillaris develops more rapidly and occupies a definite space in the lateral wall of the nasal fossa by the end of the third fetal month v^gs- 2, 3).
By the simultaneous processes of resorption of surrounding tissue and the growth of the maxillary pouch, the primitive cavity gains more amd more capacity. The pouch soon acquires
l'1
Jacob Parsons Schaeffer
Fir;. 5 (X 4). Drawings of the mucous membrane, representing the exact shapes of the sinus maxil laris at different stages of its development in the fetus and child.
A. From a I'd us aged 1 months. B. From a fetus at term. C. From a child aged 18 to 20 monl hs. D. From a child aged l'() to 12)! months.
The Sinus Maxillaris in Man. 325
a slit-like shape at the side of the nose (fig. 4). It has its greatest measurement in the ventrodorsal direction, while mediolaterally the cavity occupies comparatively little space. In embryos aged from 100 to 105 days the ventrodorsal measurement is about 2 mm. (fig. 2). In a 120-day embryo the distance is about 2.5 mm. (figs. 3 and 5 A). In a 100-day embryo the most ventral spur of the sinus is about 6.5 mm., and the most dorsal spur 8.5 mm. from the tip of the nose.
It will be remembered that, in the embryo, the processus alveolaris of the maxilla is in proximity to the orbit, and when we recall the fact that the unerupted teeth are contained in this situation, it at once becomes evident that the sinus maxillaris must be correspondingly small at this time. Because of these facts the sinus of a 7-month fetus measures only 5 mm. in the ventrodorsal plane, while that of a fetus at term has increased this distance to approximately 7 mm. (fig. 5 B). During the latter month of intrauterine life the sinus gains in the mediolateral plane, so that at term this distance measures from 3 to 4 mm.
It is generally stated that the deciduous teeth hold the sinus maxillaris in check, and that the cavity rapidly assumes larger dimensions as the first dentition progresses. I, however, find that the growth of the sinus is rather uniform, and that the first dentition has little to do with any rapid increase in the size of the cavity. The age of the child and the size of the sinus, apparently, progress pari passu (fig. 6) .
The ventrodorsal measurement of the sinus in a child aged 6 months is 10 mm., but the cavity has not developed sufficiently in the mediolateral plane to reach beneath the orbit. In a child of 9 months the ventrodorsal distance is 14 mm., with a superoinferior measurement of 5 mm. At the end of the first year the sinus has reached a ventrodorsal measurement of 16 mm., a superoinferior of 6 mm. ; and has now reached a mediolateral point sufficient to pass beneath the orbit. As the maxilla grows, the sinus remains for some time on the medial side of the infraorbital canal (fig. 10). By the twentieth month the sinus measures ventrodorsally 20 mm. (fig. 5) and has, as a rule, extended above the rudimentary first permanent molar tooth.
326
Jacob Parsons Schaeffer,
\ BNTRODORSAL
Ml \M HF.MENT
AGE [l>A >S— -INTRAUTERINE
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A(iE MONTHS — EXTRA UTERINE
'.I 12 20
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19
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Fig. 0. Chart/showing the gradual increase in size of the sinus maxillaris in its ventrodorsal plane.
The Sinus Maxillaris in Man. 327
Before and during dentition the sin is maxillaris is separated from the front of the maxilla by the unerupted teeth (fig. 17). After the eruption of the deciduous teeth the cavity continues to have a more or less rounded and elongated shapa (fig. 5 D). It is really never spherical as is often stated, but has an irregular elongated form from the beginning.
After the eruption of the permanent teeth the sinus begins to lose its rounded and. elongated shape and to assume the adult pyramidal form (figs. 7, 8, and 9). By the twelfth or fifteenth year of age, when the second molar has appeared, the sinus approaches, though it has not yet attained its definite shape. The sinus reaches its full size between the fourteenth and eighteenth year.
THE ADULT SINUS MAXILLARIS.
The adult sinus maxillaris was known to Galenus (130-201), but apparently Dr. Nathaniel Highmore was the first to give any detailed description of it. In his work (1651), " Corporis Humani Disquisitio Anatomica, " he describes the cavity in the maxilla, to which his attention was drawn by a lady patient, in whom an abscess of this cavity, since known as the antrum of Highmore (sinus maxillaris), was drained by the extraction of the canine tooth (left). The following are the exact words of Doctor Highmore in describing the cavity located in the body of the maxilla. His report of the case also follows.
"ANTRUM MAXILLiB SUPERIORS."
Antrum hoc utrinque unum, sub oculi sede inferiore ubi os ad ocul tutelam quodammodo protub'erat, ad latera inferiora nasi situm est. Insigniter cavum sphaericum, aliquantulum vero oblongum, et ita amplum ut articulus pollicis majoris pedis ultimus in illo delitescat, • • • . Osse attenuata seu squamma ossea obtegitur: Os enim quod illud includit, et quod a dentium alveolis extremis distinguit, crassitie chartam Emporeticam non multum excedit. In basi hujus protuberantes quaedam eminentiae cernlintur, Quibus dentium apices tenniores includuntur. . . Dentium
alveoli margini hujus ossis inferiori insculpuntur, quibus dentes in
328 Jacob Parsons Schaeffer.
figuntur Antrum hoc frequentius vacuum, aliquando
aiuco repletum reperitur, in quod humores a capite per meatum quendam a cavitate ilia in osse frontis, et ab osse ethmoeide destillare poterunt.
Atque hie silentio praeterire non possumus, quod generosae cuidam foeminae suit nostra cura laboranti accedit. Cum sub ferina eaque continua falsi humoris distillations, per multos retro annos laborasset, omnesque pene* dentes corrosos ac cariosos evulserat; nee tamen a dolore liberata, tandem dente canino sinistri lateris effosso .... Simul squammosa ilia clistinctio inter cavitatem hanc et dentis foveam eriptur, adeo ut humorum, per alveolum dicti dentis, ab antro illo perrenis successerit destillatio; Qua multum perterrita, stylo argenteo in alveolum immissa originem fontis hujus exploratura, usque ad oculum, per uncias pene duas sursum adegit; magis adhuc metuens, pennam minorem plumis decerptis totam pene ad longitudinem palmae unius immisit. lam maximae consternata, ad Cerebrum usque decurrere existimans, me inter alias consulit; ubi autem singulas examinavimus circumstantias, pennae reduplicationes, illamque per cavitatem hanc circumgyrare invenimus. Atque sic, ubi in figura seguenti cavitatem hanc designavimus, illam de usu ac necessitate hujus satis instructam, perennisque illius fontis patentissimam habuimus, a timore et medicina simul desistit.
Antrum hoc levitatis ossium causa, quae hie oculorum situs gratia crassa esse debuere, factum esse arbitramur.
The antrum (sinus maxillaris) described by Highmore must have been an exceptionally large one, because the canine tooth does not as a rule come in relation with the sinus. This same tooth is mentioned by some writers even today as the tooth to extract in draining the sinus. It is a very bad tooth to select for this purpose in the great majority of cases. This fact will be referred to in a subsequent paragraph when considering teeth relations. It will also be noticed that Highmore had a somewhat faulty idea of the shape of the adult cavity. He, however, mentions some very essential conditions in his descriptions of the adult sinus. His consideration of the cavity is very brief and many important factors are omitted. His report of the case through which his attention was called to this cavity, is unique and interesting.
The Sinus Maxillaris in Man.
329
The adult sinus maxillaris, as we know it, is the large cavity within the body of the maxilla. It is the largest of the sinus paranasales, save in exceptional cases, when it is comparatively small and may be exceeded in size by the sinus frontalis and the
Smus Frontalis
C. N. M
Sinus Maxillaris
S. Sphenoidale
r C. N. Inf. M. N. I.
Fig. 7 (0.9). Photograph of a dissection of the sinus paranasales of the left side. The mucous membrane is shown, the bony walls have been dissected away after first hardening the subject in formalin.
C. N.M., C.N. Inf., = conchip nasales, media et inferior; Sep. Nasi, = septum nasi ; Cc. Ethmoidales, = eellulae ethmoidales; S. Sphenoidalis, = sinus sphenoidalis; M. N. S., M. N. M., M. N. I., = meatus nasi, superior, medius, et inferior, respectively.
sinus sphenoidalis. It lies lateral to the cavum nasi and resembles in shape a three sided pyramid (fig. 7). It follows in the main the shape of the body of the maxilla; and may be described as having a roof, a floor, and three walls. The walls of the sinus vary in thickness, usually from 5 to 8 mm.; but they may be
THE AMERICAN JOURNAL OP ANATOMY, VOL. 10, NO. 2.
330 Jacob Parsons Schaeffer.
reduced to a papery delicacy. The base or median wall is directed towards the cavum nasi, and the apex of the sinus extends into t he root of the processus zygomaticus of the maxilla. It may even extend into the maxillary border of the zygomatic bone; thus extending the recessus zygomaticus of the sinus maxillaris.
The ventral wall of the cavity corresponds to the anterior or facial surface of the maxilla, and looks ventrolateral^ . Part of this wall is at times greatly approximated to the dorsal wall and base of the sinus, due to a very prominent fossa canina. Occasionally the whole ventral wall bulges markedly into the cavity of the sinus.
The dorsal wall of the sinus corresponds to the infratemporal surface of the maxilla. It is a thin plate of bone, also forming the ventral boundary of the infratemporal and the pterygopalatine fossa 1 . This wall is usually the thickest of the sinus walls — it is, howevei, occasionally extremely thin (the processus alveolaris being recognized as the floor of the cavity and not as a wall).
The base or median wall is directed towards the cavum nasi. It presents a very irregular orifice — hiatus maxillaris, in the disarticulated bone, [n the articulated skull this opening is partly filled in by the pars perpendicularis of the palate bone, the processus uncinatus of the ethmoid bone, the processus maxillaris of the inferior nasal concha, and a portion of the lacrimal bone. In the undissected state this irregular aperture formed by these bones is rounded by mucous membrane, which is continued into the sinus maxillaris from the cavum nasi. This rounded opening — ostium maxillare, may be duplicated; and such duplication musl not be confused with the ostium maxillare accessorium, which is a direct passageway between the sinus and the cavum nasi. The ostium or ostia maxillaria establish a communication between the sinus and the infundibulum ethmoidal. The medial wall immediately inferior to the attachment of the concha nasalis inferior is very thin and is easily punctured in this region. This wall also forms the lateral boundary of the cavum nasi and often markedly encroaches upon the cavity of the sinus maxillaris, which greatly influences its size.
The Sinus Maxillaris in Man. 331
The roof of the sinus maxillaris is a very thin plate of bone, at times of a papery delicacy. It also forms the floor of the orbit and the orbital surface of the maxilla. It is often modeled by a ridge formed by the infraorbital canal. In some cases the ridge is replaced by a groove which is covered over with the mucous membrane of the cavity. At times the roof of the sinus is partially divided into two plates separated by air cells. Occasionally the palate bone aids in forming the roof.
The floor of the sinus is formed by the processus alveolaris of the maxilla. It is by far the thickest of the osseous boundaries of the cavity — the thickness of the floor depending upon the degree of hollowing out of the process. In cases where the hollowing out has been carried far, the floor of the sinus will bear an important relation to some of the teeth and their sockets. The floor of the sinus may be thrown into irregular elevations by the fangs of the teeth — this depending upon the thickness of the layer of spongy bone. This layer varies in thickness in different skulls and there may be considerable asymmetry on the two sides of the same skull. The relation of the teeth will be considered in a subsequent paragraph.
THE RELATION OF THE SINUS FLOOR TO THE NASAL FLOOR.
The relation of the floor of the sinus maxillaris to the floor of the nose depends largely upon the degree of hollowing out of the processus alveolaris of the maxilla. The degree of arching of the palatum durum— thereby affecting the floor of the nose, has also some bearing on this relation. When the layer of spongy bone is thin, i. e., the processus alveolaris of the maxilla markedly hollowed out, the floor of the sinus is at a level inferior to the nasal floor. On the other hand, when the processus alveolaris is comparatively thick, the floor of the nose is inferior to the sinus floor. Occasionally both floors are in the same plane (figs. 8, 9 and 11). When the anterior surface of the maxilla and the lateral wall of the nose are markedly bulging towards the sinus maxillaris, the floor of the nose is, as a rule, inferior to the floor of the sinus. It, however, remains that the majority of sinuses
332 Jacob Parsons Schaeffer.
have their floors, at varying distances, inferior to the floor of the nose. Sixty adult specimens were examined to ascertain this relation, with results as appended:
NUMBER BINUS FLOOD NOSE FLOOR SAME
EXAMINED [NFEEIOB 1NFERIOH LEVEL
60 39 12 9
The difference in levels of these two floors, when not in the same plane, varies from one-half to 10 nun. C. Resschreiter says that it is a male characteristic to find the sinus floor at an
m.
Fig. 8 (X. 385). Photograph of a dissection of the sinus maxillaris and frontalis from a ventral view.
S. Fron., S. Max., = sinus frontalis el maxillaris, respectively.
inferior level to the nasal floor. I have, however, been unable to verify this statement, and give the following as typical of my findings:
NUMBEB
SIM S I 1 lie Hi
NOSE 1- i.i ii m
s \ ME
EXAMINED
i NFEBIOR
INFERIOR
LEVEL
12 (female)
9
2
1
The Sinus MaxiJlaris in Man.
333
RELATION OF THE SINUS MAXILLARIS TO THE TEETH.
Since the sinus maxillaris varies greatly in size in different skulls, and on the two sides of the same skull, it at once becomes apparent that the relations of the teeth to the sinus cannot be constant. As stated before, the layer of spongy bone between
S. Fron.
S. Sph.
S. Max. s£J
Palatum M. r
Palatum D
S. Fron.
Cc
. Eth.
o.
Sph.
s.
Sph.
S. Max.
C. N. Inf. Sep. Nasi
Fir;. 9 (X .64). Photograph of a dissection of the sinus par anas ales from a dorsal view. The mucous membrane of the cavities is shown, the bony walls have been dissected away. The sinus frontalis and sphenoidalis, and the cellules ethmoidales of the right side have been opened.
S. Fron., S. Sph., S. Max., = sinus frontalis, sphenoidalis, and maxillaris, respectively; Palatum M., Palatum D., = palatum molle and palatum durum, respectively; Cc. Eth., = cellulae ethmoidales; 0. Sph., = ostium sphenoidale; C. N. Inf., = concha nasalis inferior; Sep. Nasi., = septum nasi.
the roots of the teeth and the floor of the sinus varies in thickness in different skulls, and the asymmetry on the two sides of the same skull is at times marked. When this layer of spongy bone is comparatively thin the projecting tooth fangs form elevations, of a greater or less degree, on the floor of the sinus. These elevations at times aid in recess formation (fig. 10). Direct communi
i!
Jacob Parsons Schaeffer,
cation between the fangs of the teeth and the mucous membrane of the sinus, due to extreme hollowing out of the processus alveolaris of the maxilla, occurs most frequently in the aged (fig. 15). This latter condition docs, however, occasionally prevail in the young adult (fig. 16). That very intimate relations frequently exist between the teeth and the sinus maxillaris is a fact that we should be cognizant of, but I find that these intimate relations have been somewhat exaggerated by some writers.
Clnf
S. Max
Fig. 10 (x .8). Photograph of :i frontal section of a child's face aged from 16 to 18 months. Note the infraorbital canal and aerve, and the relation of the sinus maxillaris to the developing teeth. It will be noticed thai (ho sinus maxillaris has developed sufficiently to reach beneath the orbit but that il is medial to the infraorbital canal.
C. Info., = canalis infraorbitalis; S. Max., = sinus maxillaris.
The number of teeth that bear a direct relation to the sinus is necessarily inconstant, as stated before. In exceptional cases, when the cavity is very large — especially in the line of the ventrosuperior diagonal, all of the teeth of the true maxilla may be in relation with the sinus (tig. If)). It is, however, only an occasional occurrence to have the canine in direct relation with the sinus. In a certain number of cases the first premolar tooth
The Sinus Maxillaris in Man.
335
bears a direct relation to the cavity, and in a slightly larger percentage of cases the second premolar bears a similar relation. The three most constant teeth, however, in direct relation to the sinus are the three molars. When the sinus maxillaris is small the first molar must be omitted from the direct relation (figs. 12 to 16).
S. Max.
B. Eth.^
H. Sem.
Proc. Unc.
..nfo. » x |nf. Eth.
r
Fig. 11 (X .8). Photograph of a frontal section of an adult's face in the region of the sinus maxillaris. Note the location of the ostium maxillare and th infundibulum ethmoidale. Although the section is not exactly a frontal one there is nevertheless a marked asymmetry in the size of the two sinus maxillares. There is also quite a difference in the relation of the sinus floor to the nasal floor on the two sides.
S. Max., = sinus maxillaris; B. Eth., = bulla ethmoidalis; H. Sem., = hiatus semilunaris; Proc. Unc, = processus uncinatus; C. Info., = canalis infraorbitalis; Inf. Eth., = infundibulum ethmoidale; 0. M., = ostium maxillare.
It is a fairly safe rule to follow that, when the canine fossa and the lateral nasal wall are simultaneously approximated, the canine and premolar teeth do not bear a direct relation to the sinus maxillaris. In such cases a perforator pushed through a premolar-tooth socket might readily enter the lateral nasal wall — even pass through it, passing entirely free of the sinns cavity. Again, if the perforator were pushed through the lateral nasal wall, inferior to the concha nasalis inferior, the instrument could readily be pushed through the soft structures of the cheek, unless the point were directed well superodorsally.
Figs. 12 to 17. Photographs of dissections showing variations in the teeth relations of the sinus maxillaris.
Figs. 12, 13 (X .48). Note the short ventrosuperior diagonal of the sinus maxillaris, due to the simultaneous approximation of the ventral wall and the base of the sinus. As a result, the only teeth in direct relation to the cavity are the second and third molars.
Fig. 14 (X .456). Note that the premolar teeth are not in direct relation, and that the canine tooth, as in the preceding figures, would certainly he a had tooth to use in attempting to drain the cavity through the canine socket.
Fig. 15 (X .48). This figure shows to what extreme the body of the maxilla may he hollowed out by the sinus maxillaris. Note the very delicate walls of the cavity, especially the shell-like alveolar process. Due to the extensive recessus alveolaris the "remaining tooth" projects into the lumen of the cavity and is merely covered with the mucuous membrane of the sinus.
FlG. 16 (X .552). Although the processus alveolaris is comparatively thick, the second-molar tooth fangs just reach the mucous membrane of the cavity. Note the large ostium maxillare accessorium.
Fig. 17 (X 1.28). Showing the relations of the developing teeth to the sinus maxillaris, of a child aged from 18 to 20 months. Note the position of the Anlagen of the permanent teeth.
S. Max., = sinus maxillaris; C. P., = crescent ic projection; D. p. r., = dentes permanentes rudimentii; Sep. Nasi., = septum nasi; F. Info., = foramen infraorbitale; D. d., = dentes decidui.
Ridges, Crescentic Projections, and Septa on the Sinus Walls
It is important to note how frequently the walls of the sinus are found uneven. These irregularities may consist of mere ridges or of differenl sized crescentic projections. The crescentic projections have been reported occasionally replaced by septa which completely divide the sinus into two cavities, each having its independent opening into the nasal fossa, but not communicating with each other (fig. 22). The smaller ridges are of little consequence and may be omitted from further consideration. The larger ridges and crescentic projections, on the other hand, tend to form pockets and recesses, of varying depths, within the cavity. The septa, when they exist, may be placed either superoinferiorly or ventrodorsally ; thus forming either ventral and dorsal, or inferior and superior compartments, respectively. According to Zucherkandl's findings, the superior and dorsal cavities communicate with the meatus nasi superior, and the ventral and inferioi cavities with the infundibulum ethmoidale. Bruhl found the inferior compartment communicating with the meatus nasi inferior. Gruber found a complete division of the sinus maxillaris in 2.5 per cent of cases.
In the material used for this paper no sinus was found showing division into two distinctly separate compartments, but the specimens repeatedly showed crescentic projections and ridges which formed pockets of a greater or less depth (figs. 18 to 23).
Sixty sinuses were examined to cover this phrase of the work, with results as follows:
NUMBER RIDGES OK CRESCENTIC SINUS WALLS
I \ \mim:i> PROJECTIONS \.\ EN
GO 2!) 31
It must be borne in mind that, in the 29 positive sinuses, quite a number of them showed mere ridges the latter will be omitted from further study. The remaining number of the positive group fall, however, into a very important class of specimens. That these crescentic projections offer, at times, almost insuperable obstruction in attempting to drain fluid from the sinus through an opening either in the processus alveolaris, or in the meatus nasi inferior, is a fact that we should be cognizant of. This was repeatedly demonstrated by first filling the sinus with a liquid, then making an opening at some point on the processus alveolaris; thus draining out what would come away. If some of the fluid was retained — allowing for adherence to mucous membrane — the facial or anterior surface of the maxilla was removed to find where the remaining fluid was lodged. As a rule the poition of fluid was retained by a recess or recesses on one or more of the sinus walls. At other times a second and even a third opening was made, either through the alveolar border or through the meatus nasi inferior, before the remaining fluid would come away. If after repeated attempts the fluid could not be located, the ventral wall of the cavity was removed to ascertain the reason for its retention, and the fact was thus demonstrated that repeated punctures, in some cases, would not reach all of the recesses.
Just what these recesses mean in all cases is difficult to say. Some of them are of course formed by elevations caused by tooth fangs, but these as a rule are of minor importance and only occasionally form deep recesses. Others are formed by projections of mucous membrane, which may or may not be caused by crescentic bone projections. Where complete septa exist, the sinus maxillaris very likely developed from two primary pouches. In some cases the intervening wall may have disappeared in part, thus leaving the larger crescentic projections which occasionally are found in the adult sinus. A double pouching of the primitive sinus maxillaris was mentioned in a previous paragraph on the development of the cavity. Unequal resorption of the bone during the growth of the sinus is doubtless a cause for some projections occurring on the walls of the cavity.
Figs. 18 to 23. Drawings of specimens showing septa and crescentic projections on the walls of the sinus maxillaris. Note how these projections form recesses within the cavity. (Fig. 22 is modified from E. Zuckerkandl, Normale und pathologische Anatomie der Nasenhohle und 'direr pneumatisch< n Anhange).
C. P., = crescentic projection; O. M., = ostium maxillare; 0. M. A., = ostium maxillare accessorium; S. Max., -sinus maxillaris.
The Size of the Sinus Maxillaris
The sinus maxillaris varies greatly in size in different individuals. There may also exist considerable asymmetry on the two sides of the same individual. The statement that all old people have large sinuses is very fallacious, as is also the statement that all females have smaller sinuses than males (tables A, B, C.)
The investigations of Zuckerkandl have shown that enlargement of the sinus maxillaris may be produced by:
a. Hollowing out of the processus alveolaris of the maxilla (recessus alveolaris) ;
b. Excavation of the floor of the nasal fossa by a pushing of the recessus alveolaris between the plates of the palatum durum (recessus palatinus) ;
c. Extension of the sinus maxillaris into the processus frontalis of the maxilla (recessus infraorbitalis) ;
d. Hollowing out of the processus zygomaticus of the maxilla (recessus zygomaticus) ;
e. Extension to, and appropriation of an air cell within* the processus orbitalis of the palate bone;
To these should be added, according to my findings:
f. Extreme hollowing out of the body of the maxilla in all directions, thus causing the sinus walls to be thin and the recesses all markedly developed;
g. The rarer condition when the lateral nasal wall is bulging towards the cavum nasi ;
h. The extension of the recessus zygomaticus of the sinus maxillaris into the maxillary border of the zygomatic bone.
Zuckerkandl has found that the sinus mav be made smaller, on the other hand, by :
a. Deficient absorption of the cancellated bone on the floor of the sinus;
b. Encroachment of the ventral wall of the cavity ;
c. A deep fossa canina;
d. Thick sinus walls;
e. Excessive lateral bulging of the nasal wall :
f. A combination of the above conditions;
g. Imperfecl dentition.
The thickness of the sinus walls varies from 5 to 8 mm. and down to that of a papery delicacy. The statement that all large cavities have thin walls and small cavities invariably thick walls does not hold in all cases. The smallest sinus measured in this series had the thinnest walls— of a papery delicacy. The smallness of this cavity was in part due to the marked simultaneous approximation of the ventral and medial walls.
The size of the sinus maxillaris is best determined by a series of measurements, viz:
Dorsosuperior diagonal ( D. S. D. ) Ventrosuperior diagonal (V. S. D.) Superoinferior (S. I.) Ventrodorsal (V. D.) Mediolateral (M. L.)
1. 2. 3. 4. 5.
These several measurements are determined thus (tig. 24)
Fig. 24. Schematic drawing of the righl maxilla. The ventrolateral wall of the sinus maxillaris has been removed, thus exposing the base or median wall of the cavity'. The lines drawn on the base indicate the position of the several measurements.
i, Dorsosuperior diagonal; 2, Ventrosuperior diagonal; 3, Superoinferior;
4, Ventrodorsal; 5i Mediolateral.
1. The dorsosuperior diagonal, from the most dorsal and lateral part of the sinus floor diagonally across the base or median wall of the sinus, to the most medial and superior part of the recessus infraorbitalis;
2. The ventrosuperior diagonal, from the most ventral and medial part of the recessus alveolaris diagonally across the base of the sinus, to the most lateral and superior point of the cavity;
3. The superoinferior, from the roof or infraorbital wall of the sinus, to the sinus floor (always using uniform points) ;
4. The ventrodorsal, from the most ventral point of the cavity midway between the roof and the floor, to the dorsal wall ;
5. The mediolateral, from the base midway between its most ventral and dorsal points, to the processus zygomaticus of the maxilla (in some cases this extends into the maxillary border of the zygomatic bone due to the extension of the recessus zygomaticus of the sinus maxillaris into this bone).
The ventrodorsal distance is especially affected by the degree of approximation of the ventral wall of the sinus; the superoinferior by the degree of hollowing out of the processus alveolaris of the maxilla; the mediolateral by the degree of encroachment of the lateral nasa^ wall; the ventrosuperior diagonal by the extent of the recessus alveolaris; and the dors superior diagonal by the extent of the recessus infraorbitalis. Of course there are other contributing factors to shorten or lengthen these distance-;, but these are the primary factors especially affecting the several measurements.
In order that the measurements of the sinus maxillaris may be of most value, it is necessary to compare the two sinuses of the same individual, to compare them with the respective sinuses of another individual; also to consider the age and the sex.
A careful examination of the following tables (A, B, C) will show conclusively that the sinus maxillaris has a rather wide range of variation. These tables also show that in the adult, age does not have much bearing on the size of the cavit} 7 . A reference to table C will show that the smallest cavity is that of an old man, aged 70 years; while the largest cavity is also that of an old man, aged 77 years. This same table shows that the cavity of a young adult, aged 21 years is a close second to the largest sinus found in the whole series. Although the cavity in the male averages slightly larger than that of the female, a reference to table ( 3 will show that sex affects the size of the sinus but slightly.
The following may be given as average measurements of the adult sinus maxillaris, based on the measurements of 90 specimens:
in in .
1 Dorsosuperior diagonal 38
2 Ventrosuperior diagonal 38-5
! Superoinferior 33 4 Wnl rodorsal 34
5 Mediolateral 23
Due to the great differences in the several measurements, the capacity of the sinus, in different individuals, must also differ. The range in capacity, of the sinuses studied to ascertain this fact, was from 9.5 cc. to 20 cc, with an average of 14.75 cc.
The tables A, B and ( ) show the range of measurements.
The conditions which produce these varied differences in the dimensions of the sinus maxillaris may be readily ascertained. Take for example the following two conditions which showa marked difference in the mediolateral plane and yet the other measurements are inversed:
No. V. D. M. L. S.I. 1). S. D. V. S. D.
Him. mm ■ mm. mm. mm.
1 30 is 40 41 41
2 35 35 35 40 30
In case number 1 the- lateral nasal wall was markedly bulging towards the sinus. In consequence of this encroachment, the mediolateral distance was greatly lessened. In case 2 the recessus alveolaris was poorly developed, hence the short ventrosuperior diagonal in comparison with the respective measurement in case number 1. These cases show that even though a sinus may greatly exceed another in one of its measurements, it may be exceeded in size in its other planes.
Again there may be a great difference in the ventrodorsal distance. This means a marked inpushing of the ventral wall of the
TABLE A.
s m
a S
SEX
AGE
SIDE
VENTRODORSAL
MEDIOLATERAL
BUPERO INFERIOR
DORSOSUPERIOR DIAGONAL
VENTROSUPERIOR DIAGONAL
m in .
m m .
>n m .
linn .
mm.
right
26
15
20
30
26
1
M
54 <
Left
30
16
22
32
26
right
41)
22
50
50
50
2
M
GS <
•
left
35
24
35
45
50
f
right
32
32
40
40
38
3
M
36
I
left
30
18
40
41
41
right
30
15
30
33
30
4
M
65 •
•
left
25
15
25
35
36
r
right
40
25
40
45
45
5
M
55
•
left
40
22
38
36
45
f
right
40
21
32
50
38
6
M
57
I
left
32
25
30
32
43
r
right
35
22
45
45
40
7
M
71 •
left
40
18
35
40
45
f
right
40
22
33
45
45
s
M
59 <
I
left
40
35
40
50
45
r
right
30
30
35
41
40
9
M
79
^
left
43
20
30
41
37
j
right
31
24
30
30
38
10
M
55 '
•
left
32
25
35
40
40
346
Jacob Parsons Schaeffer.
TABLE B.
a a a S
BEX
AGE
S1DK
VENTR
iiiihs \
v.
//( III .
|
righl
.-)
1
F
68
lefl
10
f
righl
»
2
F
52
left
35
righl
10
3
F
53 •
•
lefl
33
r
right
36
4
F
47
•
left
37
s
right
33
5
F
73 •
•
left
37
r
right
33
6
F
50
•
left
33
c
righl
30
7
F
35
■
left
30
c
right
34
8
F
39 <
•
left right
33 38
9
F
72 <
.
lefl
35
r
right
35
10
F
52 •
!
left
35
MBDIO I.ATKK \l.
SUPEBO l \ i l 1 1 1 1 1 1 1
DORSOBUPERIOB DIAGONAL
Ill III .
111 III .
in in .
35
35
10
16
30
43
21
30
10
21
28
38
25
30 '
60
30
45
45
26
25
37
28
5
35
24
31
38
24
37
30
17
30
35
22
33
38
IS
32
30
21
30
30
25
33
32
22
33
32
25
38
32
23
3S
33
21
30
40
21
32
38
VENTRO- i PERIOR
UIAOii\ w.
in in .
30 36 40 45 42 46 37 37 40 42 40 34 35 40 35 21 34 35 36 35
The Sinus Maxillaris in Man.
347
TABLE C.
« a n s
SEX
AGE
SIDE
VENTRODORSAL
MEDIOLATERAL
SUPEBOINFERIOR
DOSROSUPERIOR DIAGONAL
VENTRO SUPERIOR
DIAGONAL
in in .
m in .
m in .
in in .
111 III .
1
M
70
right
15
12
21
21
18
2
M
70
left
16
12
21
21
20
3
M
35
left
22
20
30
31
25
4
M
54
left
25
15
22
32
27
5
F
54
right
20
15
20
30
26
6
M
00
left
30
20
22
38
25
7
F
52
right
35
25
30
37
38
8
M
59
left
40
22
32
45
45
9
M
21
right
46
33
26
50
50
10
M
77
left
47
40
50
57
60
sinus, on the one hand, and a shallow fossa canina with a lessened encroachment on the other hand. Thus:
No.
V. D.
M. L.
S. I.
D. S. D.
V. S. D
m in .
in in .
in in .
mm.
mm.
1
25
15
25
35
36
2
43
20
30
41
37
If the body of the maxilla is hollowed out to a marked degree in all directions the measurements will be correspondingly lengthened. When this hollowing out has not been carried far, and when associated with some of the above mentioned conditions, the measurements will be markedly lessened. Thus:
No.
V. D.
M. L.
S. I.
D. S. D.
V. S. D
mm.
m in .
mm.
mm.
mm.
1
47
40
50
57
60
2
16
12
21
21
20
These few examples show how anatomical conditions will affect the measurements of the sinus maxillaris. It, therefore, appears reasonable that, by examination of the anterior surface of the maxilla and the lateral nasal wall, the size of the sinus may be approximately determined and the teeth relations judged. It does, however, not necessarily follow, because the ventral and median walls of the sinus are closely approximated, that the sinus capacity is markedly lessened, These sinuses may have marked infraorbital recesses and the processus alveolaris may be hollowed out towards its dorsal termination. In this manner compensation may be made for the marked bulging toward the cavity of the ventral and median walls of the sinus. It, however, remains that in the vast majority of cases, where these walls are simultaneously bulging into the cavity, the sinus is correspondingly reduced in size and the canine and premolar teeth not in direct relation to the sinus.
Fig. 25 (X 1). Composite chart showing how anatomical variations in the extenl of the recesses ami the approximation of the walls of (he sinus maxillaris affect I lie shape and size of ils median wall or base.
1 to (i, outlines of different bases; V. D., S. I., V. S. D.,D.S. D., = ventrodorsal, superoinferior, vent rosuperior diagonal, and dorsosuperior diagonal, respectively.
These variations in the approximation of the sinus walls, and the great difference in the extent of the various recesses, have a marked effect on the shape of the base of the cavity. A reference to figure 25 will show various shapes and sizes. Note especially case 4 in which the ventrosuperior diagonal is very short, and the dorsosuperior, because of a marked infraorbital recess, comparatively long. The great difference in the two diagonals produces a peculiarly shaped base.
The Ostium Maxillare
When considering the embryology of the lateral nasal wall it will be remembered that the primitive maxillary pouch had certain relations of importance. These structures were the processus uncinatus, the infundibulum ethmoidale, the hiatus semilunaris, and the bulla ethmoidalis. The location of the ostium maxillare,' of the adult, corresponds to the place of the primitive maxillary pouch. This pouch gradually develops into the pyramidal cavity of the adult, leaving the place of communication with the infundibulum ethmoidale at the point of primary evagination. It is, therefore, quite evident that these structures which in the embryo bore so close a relation to the Anlage of the sinus maxillaris, must now bear even more important relations to the ostium maxillare. On raising or removing the middle nasal concha, in the adult, a rounded elevation— the bulla ethmoidalis, is seen. This structure is directed interiorly and ventrally. Immediately beneath it is the well defined curved margin of the processus uncinatus of the ethmoid bone. Between these structures there is a narrow slit or semilunar cleft— the hiatus semilunaris, which is from 15 to 20 mm. long. This is an important opening, for it serves as the communication between the meatus nasi medius and the gutter-like groove (infundibulum ethmoidale) formed by these structures. The bulla ethmoidalis varies considerably in size. At times it is feebly developed and again it may assume comparatively large proportions. The size of the bulla greatly influences the width of the semilunar cleft or hiatus semilunaris. The bulla may be so large that its convexity comes in direct contact with the free margin of the processus uncinatus of the ethmoid bone. In other cases the hiatus semilunaris may be of considerable width.
It is easy to conclude what effect these conditions will have on the ostium maxillare directly, and on the sinus maxillaris indirectly. In one case the cleft of communication between the ostium maxillare and the meatus nasi medius is practically shut off, while in the other case a freer communication exists. It must be remembered that, even though the bulla touches the free margin of the processus uncinatus — thus greatly narrowing the hiatus semilunaris, the infundibulum ethmoidale may be of average dimensions. This is an important fact, and must always be borne in mind when considering the fronto-maxillary relations.
The processus uncinatus with its covering of mucous membrane projects interiorly and dorsally. By its free superior border it forms the inferior boundary of the hiatus semilunaris. This process frequently terminates dorsally in what may be termed two roots; the inferior one passes towards the superior edge of the concha nasalis inferior, while the superior root curves superiorly behind the dorsal termination of the bulla ethmoidalis (figs. 28 and 29). Such a condition, as the latter, causes the infundibulum ethmoidale to end dorsally in a pocket. This fact is of extreme importance because the pocket is so situated that it will direct any fluid coming to the dorsal end of the infundibulum ethmoidale into the sinus maxillaris, via the ostium maxillare which is in the immediate location.
The infundibulum ethmoidale is a groove or gutter situated upon the lateral nasal wall. It is bounded superiorly by the inferior surface of the bulla ethmoidalis throughout the greater part of its extent, save ventrally and superiorly where the bulla is replaced by some anterior ethmoidal cells. The inferior and medial boundary of the groove is formed by the lateral surface of the processus uncinatus. This groove communicates with the meatus nasi medius through the hiatus semilunaris. The infundibulum may end, as stated above, in a pocket; or may loose its depth gradually and be lost in the meatus nasi medius (figs. 28, 29, 30). The superior and ventral end of the infundibulum may terminate blindly without dilatation, or in an air cell; or may be continuous with the nasofrontal duct. The lateral wall of the infundibulum is formed partly by mucous membrane. The depth of this gutter-like channel, or the distance from the superior border of the processus uncinatus to the floor of the groove, varies from 1 to 12 mm., with approximately an average of 5 mm.
The sinus maxillaris communicates indirectly with the meatus nasi medius by means of an opening — the ostium maxillare— which pierces the superior and ventral part of (he base of the cavity to open into the infundibulum ethmoidale, thence via the hiatus semilunaris into the meatus nasi medius. It must be clearly kept in mind that the ostium is located in the superior part of the sinus, and that it opens into infundibulum ethmoidale and not into the hiatus semilunaris as many writers say. The ostium maxillare may be either in the most dependent part of the infundibulum or in the lateral wall of this channel. This opening varies in distance from the hiatus semilunaris from 1 to 12 mm. This distance is dependent upon the width of the processus uncinatus and the resultant depth of the infundibulum ethmoidale at this point.
Fig. 26 (X .66). Drawing of a specimen showing a direct communication between the sinus frontalis and maxillaris (indicated by the arrow).
Note the very large slit-like ostium maxillare. The lateral wall of the infundibulum ethmoidale is entirely wanting.
S. Fron., = sinus frontalis; S. Max., = sinus maxillaris; 0. M., = ostium maxillart.
The ostium may be round, but as a rule is either oval or elliptical. In my series of 90 cases it has a great range of dimensions; varying from 1 to 20 mm. in length, and from 1 to 6 mm. in width. In some cases where the ostium has reached considerable size it may almost entirely replace the lateral wall of the infundibulum ethmoidale, thus forming a long slit-like communication
1 M.TH
WIDTH
// /// .
mm.
1
1
3
3
3
2
5
3
7
4
8
3
10
6
11
4
11
6
14
3
10
3
20
3
between the sinus maxillaris and the infundibulum ethmoidale (fig. 26) (table D, nos. 7 to L2).
The following table gives an idea of the range of dimensions of the ostium maxillae as found in the series of specimens studied :
TABLE D.
N i MBER
1
2
3
4
5
6
7
s
9
10
11
12
The Ostium Maxillare Accessorium
In many cases the sinus maxillaris has an accessory ostium communicating directly with the meatus nasi medius — the ostium maxillare accessorium: This opening is, as a rule, situated in the membranous portion of the lateral wall of the meatus nasi medius a short distance above the superior border of the concha nasalis inferior, at about the junction of its middle and posterior, thirds. In some instances the accessory ostium is placed immediately behind the dorsal termination of the infundibulum ethmoidale (fig. 27). This accessory ostium must not be confused with the duplication of the ostium maxillare, which communicates with the infundibulum ethmoidale.
According to Chiari and Hajek an accessory opening is found in every fifth case in the meatus nasi medius, posterior and inferior to the normal aperture. Giraldes says it is found in 10 per cent of cases, and represents a pathological condition. Zuckerkandl and Kallius report it present in 10 per cent of cases. Turner found it four times in nine dissections.
That this accessory opening occurs more frequently than is generally supposed seems proven by the study of 80 adult specimens. Out of SO specimens examined 35 showed accessory ostia, or a percentage of 43; while three cases had two accessory ostia, or a percentage of 3.75. From this it seems that the former figures were much too low. Whether this series had a special run for accessory ostia or whether too few specimens were used in the former reports is of course not known. It may, however, he said that the opening occurs very frequently and that the earlier reports, apparently, placed the percentage of occurrence far too low.
Fig. 27. Diagrams of the lateral nasal wall. The conchse nasales mediae have been partially cut away so as to bring to view the underlying structures. Note the positions and varying sizes of the ostium maxillare accessorium in the different diagrams. The accessory ostia are designated by the deep black circles. The upper and lower right hand diagrams show two accessory ostia and the others but one.
Just what the ostium maxillare accessorium means in all cases is indeed difficult to say. It seems almost incredible that so large a percentage of specimens should have pathological openings, Giraldes bases his claim of a pathological origin on the facts that the accessory ostium is absent in the young individual, and that the mucous membrane becomes thinned out in this locality — even though the opening fails to establish itself. Zuckerkandl corroborates the thinning of the mucous membrane in this locality at times, but claims that we have no evidence that it is always a pathological process causing this condition. He says that occasionally the accessory opening is caused by neighboring structures.
Seltcncnfalls entsteht em Ostium maxillare accessorium durch Druck von Seite nachbarlicher Organe; ich habe gesehen, das ein abnorm breiter zugespitzer Hakenfortsatz der Nasenscheidewand an der hinteren Nasonfontanelle eine Durchlocherung veranlasst hatte.
I have not found the accessory ostium present in the fetus and infant. Unfortunately I have been unable to secure a sufficient number of specimens between the ages of 6 and 15 years to draw any conclusions of value on the occurrence of the ostium maxillare accessorium during this period of time. I found the accessory opening occasionally present in the young adult — 17 to 20 years. The specimens (adult) studied, ranged in age from 17 to 80 years, with the majority from subjects over 50 years old. That some cases of accessory ostia are of pathological origin is doubtless true, but many cases certainly do not give any evidence of a pathological process. The thinning of the mucous membrane of which Giraldes and Zackerkandl speak, is very evident in many specimens. I, however, believe with Zuckerkandl that we must, in the majority of cases, look elsewhere than to a pathological process for the determining factor in this condition.
In this connection it is important to note that out of the 35 sinus maxillares having accessory ostia, 27 of them had positive relations with the sinus frontalis; i. e., the infundibulum ethmoidale continuous with the nasofrontal duct. This would indicate that 77 per cent of sinus maxillares having positive fronto-maxillary relations have accessory ostia communicating directly with the meatus nasi medius.
Another explanation for this accessory ostium may be found in the fact that since the sinus maxillaris develops by the growth of the sac and resorption of surrounding bone, its walls have a tendency to become thinned out most at points of least resistance. Such a point is found in the membranous portion of the base of the sinus, where bone is entirely wanting — the usual seat of the accessory opening. The mucous membrane in this position may become thinned out to such an extent, by the growth of the sinus, that an opening is formed; thus establishing the ostium maxillare accessorium.
Since the ostium maxillare opens into the infundibulum ethmoidale, and secondarily by way of the hiatus semilunaris into the meatus nasi medius, it is apparent that the ostium maxillare accessorium, with its more dependent location and direct communication with the meatus nasi medius, is more advantageously placed as a drainage opening for the sinus maxillaris. In some cases the ostium maxillare certainly seems inadequate — due to its position, relations, and size — to properly drain the sinus. Why then may we not say that this accessory ostium, in some cases, of necessity comes to be formed as a means by which the sinus maxillaris can more readily dispose of accumulated fluid? The process by which this is brought about need not necessarily be termed pathological. Doubtless more information is necessary on this point before we dare draw conclusions.
Of course some specimens present accessory ostia which look decidedly pathological; and as Zuckerkandl points out some are due to pressure caused by neighboring structures. I hope to study the subject more extensively in the embryo and child to see whether the opening, after all, at times, does not have an embryological significance. Thus far I must agree with (iiraldes that the ostium maxillare accessorium does not appear in the embryo and young- child.
The accessory ostium varies much in size. In the series I studied the range of measurements was from 1 to 10 mm. long, and from one-half to 10 mm. wide. The opening may be round or elliptical.
The appended table selected from a series of 80 specimens gives the range in size:
TABLE E.
LONG
WIDI
mm.
in in.
1
1 2
2
1
1
4
6
4
7
5
10
10
The Fronto-Maxillary Relations
It is interesting to note that Nathaniel Highmore (1651) recognized the fact that the sinus maxillaris at times receives fluid from other sources. In his description of the cavity (see previous paragraph) he makes brief mention of this important condition.
Antrum hoc frequentius vacuum, aliquando muco repletum reperitur, in quod humores a capite per meatum quendam a cavitate ilia in osse frontis, et ah osse ethmoeide distillare poterunt.
Although mentioning that fluid from the cavities in the frontal and ethmoid bones occasionally reaches the sinus maxillaris by way of the "meatum," he does not attempt to explain how this is brought about.
Tillaux ('40) found when injecting fluid into the sinus frontalis that some of it passed into the sinus maxillaris, instead of the whole amount passing into the meatus nasi medius. Cryer ('94, '01, '07), Fillibrown ('96, '97), reported on fronto-maxillary relations. Lothrop's investigations ('98) show that in 47 per cent of cases the infundibulum ethmoidale is continuous with the nasofrontal duct, while 53 per cent show that the infundibulum ethmoidale has no connection with the sinus frontalis. Turner ('01) speaks briefly about the relation, and Wilson ('08) in his paper on the "Variations of the Ostium Frontale" alludes to this important relation. Some clinicians have reported isolated cases where they believed the maxillary trouble secondary to preexisting frontal trouble; without, however, attempting to explain any anatomical conditions which would justify the clinical conclusions.
In order to secure the fronto-maxillary relations in the specimens at hand, I undertook a series of investigations; including special dissections, filling the sinus frontalis with a fluid to determine the direction of drainage, and the determination of the efficiency of the infundibulum ethmoidale.
It will be remembered that the infundibulum ethmoidale at its superior and ventral termination is either continuous with the nasofrontal duct ; or ends blindly without dilation, or in an air cell. The cases where it is continuous with the nasofrontal duct or with the sinus frontalis directly, represent what will be here spoken of as the positive jronto-maxillary relations. Where the infundibulum ends blindly or in an air cell, the conditions will be spoken of as negative fronto-maxilary relations.
According to the specimens I examined, the sinus frontalis may discharge fluid put into it in one of the following ways :
a. By the nasofrontal duct or the sinus frontalis beingcontinuous with the infundibulum ethmoidale (in some cases there is no nasofrontal duct and the sinus frontalis is directly continuous with the infundibulum ethmoidale) (positive relation) (fig. 28).
b. By the nasofrontal duct communicating directly with the meatus nasi medius (negative relation) (fig. 29).
c. By a combination of the above conditions — in which case the sinus frontalis had two nasofrontal ducts; one continuous with the infundibulum ethmoidale, and the other communicating directly with the meatus nasi medius (positive and negative relations) (fig. 30).
d. By the nasofrontal duct being continued down to the infundibulum ethmoidale; and in conjunction there being a passage-way. between the ventral attachment of the concha nasalis media and the processus uncinatus of the ethmoid bone, to the meatus nasi medius (considered as positive relations).
e. By a direct communication between the sinus maxillaris and the sinus frontalis, by what may be termed the maxillofrontal duct (direct relation) (fig. 26).
Fig. 28. A semidiagrammatic drawing of the Lateral nasal wall showing positive fronto-maxillary relations. Note that the infundibulum ethmoidale is directly continuous with the naso-frontal duct. Note also the superior and lateral curving of the processus uncinatus at its dorsal termination, thus forming a pocket at the dorsal end of the infundibulum ethmoidale. This pocket is so situated that it will direct fluid coming to the dorsal end of the infundibulum ethmoidale to the ostium maxillare and into the sinus maxillaris.
The concha nasalis media is in part cut away so as to expose the underlying structures.
Fig. 20. A semidiagrammatic drawing of the lateral nasal wall with the concha nasalis media partially removed. Note that the infundibulum ethmoidale terminates blindly at its superior and ventral end. The nasofrontal duct communicates directly with the meatus nasi medius and not with the infundibulum ethmoidale as in the preceding figure (28). This represents negative fronto-maxillary relations.
Fig. 30. A semidiagrammatic drawing of the lateral nasal wall showing that the sinus frontalis, in this case, has two nasofrontal ducts, one communicating with the infundibulum ethmoidale and the other with the meatus nasi medius.
Note that the infundibulum ethmoidale terminates at its dorsal extremity in the meatus nasi medius without a pocket formation (compare this condition with fi^s. 28, 29).
C. N.Sup.,C. N.Med., C. N. Inf.,=
concha' nasalcs, superior, media and inferior; S. Sph., = si mis sphenoidalis; S. F., = sinus frontalis; B. Eth., = bulla ethmoidals; Inf.Eth., = infundibulum ethmoidale; Proc. Unc, = processus uncinatus.
Of the 80 specimens studied to ascertain the fronto-maxillary relations; 45 showed a positive relation, or a percentage of 56.25; 32 a negative relation, or a percentage of 40; 2 a combination of positive and negative, or a percentage of 2.5; 1 a direct communication between the two sinuses, or a percentage of 1 .25.
The importance of the above conditions was in each case tested by putting fluid unto the sinus frontalis to determine the course of drainage. It at once became apparent that the specimens falling under classes (a) and (d) should be classed together as representing positive fronto-maxillary relations. The only difference in the above two conditions is that in class (a) all of the fluid put into the sinus frontalis will reach the superior and ventral part of the infundibulum ethmoidale; while in class (d) some of it will pass directly into the meatus nasi medius, and the remaining portion to the infundibulum ethmoidale.
Class (b) will drain fluid from the sinus frontalis directly into the meatus nasi medius. It is, however, important to know that even in these cases some fluid may reach the infundibulum ethmoidale, because of the intimate relations existing between the nasofrontal duct and the superior and ventral end of the infundibulum ethmoidale (fig. 29).
Class (c), where the sinus frontalis has two nasofrontal ducts, the drainage is of course partly into the meatus nasi medius and partly into the infundibulum ethmoidale. This class leads to similar results as mentioned above, the only difference being that the infundibulum does not receive as much fluid in a given time.
Class (e) fortunately represents a rare condition. Here the sinus frontalis drains directly into the sinus maxillaris. In the specimen I found with this direct relation there was also a communication between the infundibulum ethmoidale and the sinus frontalis. Cryer, Bryan, and Brophy have reported direct relations between the two sinuses, which I have been able to verify in this one specimen. In cases where the lateral wall of the infundibulum ethmoidale is largely wanting, fluid from the frontal sinus (providing the infundibulum ethmoidale is continuous with the nasofrontal duct) will pass almost directly into the sinus maxillaris, and will, therefore, very closely simulate a direct communication between the two sinuses. A probe passed from the sinus frontalis will, in such cases, also pass into the sinus maxillaris. Doubtless some of these cases have been considered by some clinicians as direct communications, whereas a further dissection would have proved them otherwise (fig. 26).
The question now arises — what happens to the fluid that has reached the superior and ventral end of the infundibulum ethmoidale? In the first place it may be said that the efficiency of the infundibulum ethmoidale, as a carrier of fluid, is in direct ratio to its depth and to the degree of overhanging of the mucous membrane from the free border of the processus uncinatus of the ethmoid bone. In some cases the processus uncinatus is so narrow that the infundibulum ethmoidale has no appreciable depth at its superior end, and in these cases the fluid which has reached it from the frontal region will soon leave the shallow groove after entering it — at least a goodly portion of it. In other cases the processus uncinatus is broad, and the resultant infundibulum ethmoidale deep and channel-like. It must also be recalled that in a previous paragraph mention was made of the fact that frequently the infundibulum ethmoidale ends dorsally in a pocket, so situated that it will direct the flow of fluid coming to the dorsal end of the infundibulum ethmoidale into the ostium maxillare — thence into the sinus maxillaris (the ostium maxillare beingpatent) (figs. 28, 29).
We have, therefore, a gutter-like channel, of varying depth and efficiency, communicating between the frontal region and the sinus maxillaris; including the sinus frontalis in 56 per cent of cases and some of the cellulce ethmoidales anterior in nearly all cases.
In the cases where the infundibulum ethmoidale does not end in a pocket dorsally (fig. 30), much of the fluid that would otherwise be directed into the sinus maxillaris by this pocket, passes from the dorsal termination of the infundibulum ethmoidale into the meatus nasi medius. This, however, makes little difference — the very fact that some of the fluid gets into the sinus maxillaris makes the condition similar to the above. It requires merely more time to accomplish the same end result — a filled sinus maxillaris.
In case the ostium maxillare is not patent, the fluid after reaching the dorsal end of the infundibulum ethmoidale rises in the channel and finally passes through the hiatus semilunaris into the meatus nasi medius.
That the sinus maxillaris, because of its position and relations, is a reservoir for some or all of the fluid coming to the dorsal end of the infundibulum ethmoidale, is a fact that admits of no debate (the ostium maxillare being patent).
Important Nerve Relations of the Sinus Maxillaris
The roof or orbital wall of the sinus maxillaris is traversed by the infraorbital sulcus and the infraorbital canal. These passageways transmit the infraorbital vessels and nerve (considering the maxillary nerve as the infraorbital nerve from the proximal end of the infraorbital sulcus on). As a rule the canal has comparatively thick walls, but in many cases the inferior wall of the canal is of a papery delicacy and is easily compressed against the contained nerve and vessels. Frequently the canal is replaced by a groove, with the opening of the groove directed towards the sinus maxillaris. The structures — infrarobital nerve and vessels — contained in the groove are merely covered with the mucous membrane of the sinus.
The posterior superior alveolar (dental) nerves, branches of the maxillary nerve, in most of my cases were found to pass interiorly and vent rally upon the infratemporal surface of the maxilla, through the alveolar foramina into the alveolar canals. They thus aided in the formation of the superior dental plexus of nerves. Occasionally some of the branches of these nerves instead of taking the above course, passed entirely through the infratemporal surface of the maxilla into the sinus maxillaris. They then passed under cover of the mucous membrane of the sinus inferiorly and vent rally to the sinus floor; thence to the superior dental plexus.
Fig. 31 (X .633). Drawing from a dissection showing the anterior superior alveolar nerve (N.A.S.A.) passing diagonally from the roof or orbital wall of the sinus to the ventral or facial wall. The nerve in this position is suspended freely in the cavity of the sinus maxillaris merely covered with mucous membrane.
N.A.S.A. = nervus alveolaris superior anterior; N. Info., = nervus infraorbitals; S. Max., = sinus maxillaris.
The middle superior alveolar (dental) nerve, a branch of the infraorbital nerve, was as a rule given off in the proximal part of the infraorbital canal. It passed inferiorly and ventrally in a canal in the lateral wall of the sinus maxillaris and aided in establishing the superior dental plexus of nerves. The nerve I found in one case to arise from one of the anterior superior alveolar nerves. It also rarely passed under cover of the mucous membrane of the sinus to the superior dental plexus.
The anterior superior alveolar (dental) nerve was given off from the infraorbital nerve, proximal to the infraorbital foramen. It passed inferiorly in the alveolar canal of the anterior surface of the maxilla and took part in forming the superior dental plexus of nerves. From this plexus arose the superior dental nerves which supply the fangs of the teeth, the gums, and give numerous branches to the maxilla and the mucous membrane of the sinus maxillaris.
I also observed — a very important condition — that in one case the anterior superior alveolar nerve came off' from the infraorbital nerve quite a distance proximal to the infraorbital foramen. The nerve then passed through the inferior wall of the infraorbital canal and took a course diagonally across the sinus from the roof to its ventral wall. The nerve thus suspended freely in the cavity of the sinus maxillaris was surrounded merely with mucous membrane (fig. 31).
Conclusions
- The Anlage of the sinus maxillaris appears during the third month of fetal life as a minute epithelial sac evaginating and growing at first inferiorly, later more laterally, from the dorsal end of the primitive infundibulum ethmoidale.
- The primitive maxillary pouch may be duplicated. In some cases this may account for the duplication of the ostium maxillare of the adult sinus, i. e., the two pouches fusing distally, leaving the two points of evagination as the adult ostia. Other duplications of the ostium may develop in a way similar to that of the accessory ostium.
- The primitive ostium maxillare varies very much in its dimensions in different embryos. This is entirely in accord with adult conditions, since the ostium of the adult sinus has a great range of dimensions.
- Dentition seems to influence the size of the cavity but little. The age of the child and the size of the sinus apparently progress pari passu.
- The cavity enlarges by the simultaneous growth of the sac and the resorption of surrounding tissue. These two processes taking place pari passu with the growth of the face.
- In a fetus at term the ventrodorsal measurement of the sinus is about 7 mm., and in a child aged 20 months it is about 20 mm. The cavity reaches its full size from the fourteenth to the eighteenth year.
- The following may be given as average measurements of the adult sinus maxillaris, based on the measurements of 90 adult specimens : 1 Dorsosuperior diagonal 38 mm; 2 Ventrosuperior diagonal 38.5 mm; 3 Superoinferior 33 mm; 4 Ventrodorsal 34 mm; 5 Mediolateral 23 mm
- The range in capacity of the sinuses studied to ascertain this fact was from 9.5 cc. to 20 cc. ; with an average of 14.75 cc.
- In the majority of cases the sinus floor is at an inferior level to the nasal floor. This distance varies from one-half to 10 mm. Sex has little influence on this relation.
- The number of teeth that bear a direct relation to the sinus is inconstant, due to the great difference in the size of the cavity in different individuals. The three most constant teeth in direct relation are the three molars.
- The tooth fangs may cause the formation of elevations on the sinus floor. Occasionally the fangs of some teeth are in direct communication with the mucous membrane of the cavity.
- Frequently the walls of the sinus are uneven, due to ridges, or crescentic projections. These prominences form pockets and recesses within the cavity. Occasionally the cavity is divided by a septum into two distinctly separate compartments, each having an independent opening into the nasal fossa, but not communicating with each other.
- The adult sinus varies much in size in different individuals, and the asymmetry on the two sides of the same individual is often marked.
- Age, sex, and side influence the size of the adult sinus but little.
- The adult ostium maxillare varies much in size. It is located in the superior and ventral part of the base of the cavity, and serves as a means of communication between the sinus maxillaris and the infundibulum ethmoidale. Occasionally it replaces the greater portion of the lateral wall of the infundibulum ethmoidale, and represents a slit-like aperture. The ostium may be duplicated.
- The ostium maxillare accessorium is of very frequent occurrence. It serves as a means of direct communication between the sinus maxillaris and the meatus nasi medius. In my series of specimens it was present in 43 per cent of cases. The aperture was not found in the fetus and infant.
- Most of the accessory ostia do not look pathological, and the writer believes that we must, in many cases, look elsewhere than to a pathological process for the determining factor in this condition.
- Of the specimens studied to ascertain the fronto-maxillary relations, 56 per cent showed that the infundibulum ethmoidale was intimately related with the nasofrontal duct or with the sinus frontalis directly, — in case the nasofrontal duct was wanting; 40 per cent showed that the nasofrontal duct communicated directly with the meatus nasi medius — the infundibulum ethmoidale ending blindly or in an air cell; 2.5 per cent showed two nasofrontal ducts, one continuous with the infundibulum ethmoidale, and the other communicating with the meatus nasi medius ; 1.25 per cent showed a direct communication between the sinus frontalis and maxillaris.
- Since the infundibulum ethmoidale receives the ostium maxillare at its dorsal and inferior end in all cases, and the nas ofrontal duct, or the sinus frontalis directly, at its ventral and superior end in over one-half the cases, it very frequently serves as a gutter-like channel, of varying depth and efficiency, communicating between the frontal region and the sinus maxlaris.
- The sinus maxillaris, therefore, acts as a reservoir for fluids coming to the dorsal end of the infundibulum ethmoidale (the ostium maxillare being patent) .
- Frequently the processus uncinatus by a superior curving; at its dorsal end causes the iufundibulum ethmoidale to end in a pocket. This pocket is so situated that it directs fluids coming to the dorsal cud of the iufundibulum ethmoidale into the sinus maxillaris. — via the ostium maxillare which is in the immediate vicinity.
- Occasionally branches of the superior alveolar nerves in passing to the superior dental plexus pass entirely through the walls of the sinus, thence under cover of the mucous membrane of the cavity to their destination. Rarely the anterior superior alveolar ramus, instead of taking its usual course, passes diagonally from the roof of the sinus to its ventral wall, — the nerve thus suspended freely in the cavity is merely covered with mucous membrane.
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