Chronic maxillary sinusitis in children.

There has been a considerable volume of literature on the subject of sinusitis in childhood during the past 30 years; much of it deals with the results obtained in routine proof puncture or antral lavage. For example, Mollison and Kendall (1922) found evidence of sinus infection in 22% of 102 routine tonsil and adenoid cases. Crooks and Signy (1936) reported 24 positive proof punctures in 100 routine tonsil and adenoid cases, while Gerrie (1939) puts the percentage at 29 in 300 such patients. Carrying this further, we find that Carmack (1931) reports positive findings in 14-2% of a series of 211 tonsil and adenoid cases from which he had excluded all known sinusitic and allergic patients. There are two reports of proof puncture results in known or suspected sinus cases. Crooks (1947) found evidence of infection in 59-6% of 570 cases with opaque antra seen during 1946, while Walker (1947) obtained positive findings in 76% of 442 cases with sufficient signs and symptoms to warrant puncture out of 1,779 tonsil and adenoid patients. Lastly, Ebbs (1938) has obtained post-mortem evidence of sinus infection in 306% of 496 routine necropsies. It is small wonder that sinusitis has attracted considerable attention during this period, and the importance given to this condition is reflected in the space devoted to it in StClair Thomson's book. In the second edition, published in 1916, the condition is dismissed as rare, but in the current edition, published in 1948, several pages are given to it. The implications are obvious. Ebbs' figures suggest that nearly one-third of all children suffer from sinusitis, while other reports imply that one in every four or five children requiring removal of tonsils and adenoids also needs attention to the maxillary antra. If we accept this premise wholeheartedly, we must also be willing to accept the consequences, or be prepared to explain any anomalies in the deductions arising from this premise. The first question to be answered is how chronic sinusitis arises. It is generally conceded that, in adults at least, chronic sinusitis does not arise per se, but develops from an acute maxillary sinusitis in which the infected material cannot, or does not, drain away. Among adults, many more people suffer from acute maxillary sinusitis than ever develop chronic sinusitis, as most cases of acute infection return to normal. It is natural to assume that in children there will be many more cases of acute maxillary sinusitis for the same reason. Yet it is generally stated that acute maxillary sinusitis in children is an uncommon condition, and the records of the E.N.T. Department of the Royal Hospital for Sick Children in Edinburgh tend to support this opinion, as during the past five years, when over 10,000 new patients were examined, only one case of acute maxillary sinusitis was seen. How is this to be explained ? It may be that, as with acute tonsillitis, the young child makes no complaint of infra-orbital pain, accepting it as part of an acute coryza, or ascribing it to toothache. If this be so, it is possible that the great majority of children suffer from acute maxillary sinusitis, which results in one child in every three, four or five having chronic maxillary sinusitis. Or again it may be that chronic maxillary sinusitis in children differs from the adult infection by arising per se in the antrum. Might it not be that chronic sinusitis arises from acute sinusitis, and is not as common as one is led to believe ? The second question to be considered is concerned with the fact that during childhood the maxillary sinus, in common with other sinuses, is in a state of active development. It grows to fill the maxilla as the teeth descend to the alveolar margin and finally erupt. If there is chronic infection lying close to these developing teeth, why is there no evidence of the eruption of unhealthy teeth, such as one finds after osteomyelitis of the maxilla ? And, again, taking as a corollary the development. of the mastoid air cells, why is there no arrested aeration and growth of the maxillary air sinus ? The lack of development of a normally cellular