Unfortunately, the natural drainage from the accessory sinuses is defective. The subsidence of the superficial nasal infection is frequently not accompanied by a similar subsidence within the accessory cells; especially is this true in cases where the swelling of the mucous membrane of the nose due to circulatory disturbances may completely obstruct natural drainage from the air cells.

When your President, Doctor Elijah S. Burdsall, first wrote, inviting me to participate in your meeting, he at the same time asked for the title of my paper, cautioning me to pick a subject that would be interesting to general practitioners. I picked the above title because I feel that focal infection is a most important subject in the practice of medicine today, and one that should be of very vital interest to every physician no matter what his field of medicine may be. The subject of focal infection has grown to be one of so vast a scope that it would be impossible to cover it intelligently in a single paper. Therefore, I will confine myself to focal infection in its relation to the eye, ear, nose and throat, dwelling chiefly upon etiology and diagnosis. I shall strive to deal with the usual rather than with the rare case.

First, let us consider the nasal tract. Nasal focalization, especially that of the non-suppurative variety, is far more prevalent than often considered by many specialists; probably due to the fact that tonsillar and dental infections are easier to detect. The extension of an acute inflammatory process into the accessory cells of the nose is the common occurrence in those nasal infections associated with systemic symptoms loosely called “gripe.”

Unfortunately, the natural drainage from the accessory sinuses is defective. The subsidence of the superficial nasal infection is frequently not accompanied by a similar subsidence within the accessory cells; especially is this true in cases where the swelling of the mucous membrane of the nose due to circulatory disturbances may completely obstruct natural drainage from the air cells.

Nasopharyngeal infection is common in children in the form of infected lymphoid tissue (adenoids). Primary tuberculosis of the adenoids was found in fourteen out of 100 cases by Crowe, who also states that at least 25 per cent. of children with adenoids have defined indication for their removal, the most common being otitis media. Sphenoid infection is commonly associated with adenoids and may persist through adult life. Etiologic nasal focus in acute systemic manifestations has is highest incidence in young adults.

In later life and in the more chronic forms of secondary manifestations, the relative incidence is lower. However, in bronchial asthma, in the recurring headaches of the migraine type or the “indurative or rheumatic” type, in recurring or chronically progressive eye infections, in chronic myositis and in certain cases of chronic arthritis; a chronic sinus focal infection has frequently been found to be the etiologic factor.

The types of organisms usually isolated from nasal focal infections are the members of the streptococcus-pneumococcus group, the diphtheroid organisms, the bacillus influenza, the micrococcus catarrhalis, and the staphylococcus.

Secondly– Foci of infection of the tonsils holds a very foremost place as an etiological site of focal infections. In childhood bacterial invasion of the tonsils is almost universal. The anatomical structure of the tonsil is such that retention of infection is predisposed because of imperfect drainage. Many tonsils may be diseased even though they appear to be innocent. Tonsillar stumps, although atrophied and scarred are frequently seats of chronic infection giving rise to many systemic symptoms.

Here again the infecting agents are generally of the streptococcus-pneumococcus group, including the streptococcus hemolyticus, streptococcus viridans, micrococcus catarrhalis, bacillus influenzae, the diphtheroid organisms and the bacillus tuberculosis. Entamoeba gingivalis has been found in several cases but more frequently where there is an existing pyorrhoea alveolaris.

Thirdly– Bacterial invasion of dental and alveolar tissues with resulting focalization in the dental and predental tissues introduces another phase of etiological focal sites, perhaps more talked of than others, occurring more frequently in adults than in the young. Focal infections of the teeth or tonsils may cause chronic arthritis, arthritis deformans, aortitis, gastric or duodenal ulcers, etc.

Dental foci may exist in various forms, some of which are a periapical abscess, a perimetritis, a pulpitis, a granuloma or an interstitial gingivitis (both suppurative and non- suppurative). The organisms usually offending in these cases are usually a streptococcus of low-grade type (streptococcus viridans). Occasionally, such foci have a high degree of virulence, producing sudden and acute manifestations, the streptococcus possessing mild hemolytic properties.

In passing it is well to remember that there is a possibility of direct extension of bacteria along the ducts of the salivary glands, thereby permitting primary bacterial invasion into the gland. Hematogenous infection of the gland from other foci occurs a great deal more frequently than formerly believed. A continued persistence of the infection in the gland acts as a primary focus from which secondary infections and systemic reactions may arise. Though invasion of most any type of organism may occur in the salivary glands, those of the streptococcus-pneumococcus group are the chief offenders.

Fourthly.– Aural focal infections are not as rare as a great many believe. Middle ear infection by extension through the Eustachian tube is considered a frequent occurrence, but infection may also occur as an hematogenous metastasis. The metastatic complications are not so uncommon and involve venous sinuses and meninges. Aural focal infections often cause acute or chronic mastoiditis, which in turn may give rise to general bacteremia with multiple acute lesions or sinus thrombosis, brain abscess or meningitis.

An involvement of the lymphatic drainage of these parts usually occurs, resulting in a secondary lymphadenitis. Staphylococcus, the bacillus influenza or the diphtheroid organisms are usually found to be the predominant infecting agents in these cases; occasionally the pneumococcus and bacillus coli act as causative agents.

Fifthly.– The eye can become directly infected by direct invasion of the invading organism but more frequently suffers as a result of a focus of infection elsewhere in the body, especially in teeth, tonsils, gall bladder, appendix, gastro- intestinal tract. Any or all of the following eye conditions may be caused by a focus infection:.

Uveitis Corneal ulcers.

Keratitis Optic neuritis.

Iritis Optic atrophy.

Cyclitis Asthenopia.

Retinitis Affections of eye muscles.

Choroiditis Chronic glaucoma.

In diagnosing a case of focal infection, clinical history is valuable. Repeated occurrence of nasal and throat infections, of acute sinusitis, of peritonsillitis, of otitis media, of mastoiditis, or acute lymphadenitis, of alveolar abscess is always significant as indicating portals of entry and possible chronic foci of infection. Devitalized dental root canals and unerupted teeth are guides toward possible foci.

The history of jaundice as indicating an acute cholecystitis or the eliciting of the symptom-complex of appendicitis indicates the possibility of persistent secondary foci of infection, which may be the primary cause of the systemic symptoms under observation. Various metabolic disturbances, neurasthenia, chloranemia are signs of a possible persistent feeding focus of infection, either primary or secondary. Of less importance but not to be disregarded is the history of such acute bacterial invasion as the acute exanthemata, pneumonia, typhoid fever and puerperal infections.

Special attention should be given to the presence of septal deflections, septal spurs, hypertrophied turbinates, all of which interfere with the normal drainage of the nasal passages thus predisposing sinus infection. Persistent sinus infection is usually suppurative when acute but not necessarily however, in the chronic form it is usually non-suppurative in type with an absence of discharge.

Hypertrophied granular middle turbinates, polypoid degeneration of the turbinates, or protrusion of polypus into the nasal cavity from the middle meatus, or the closure of the middle meatus with a sticky exudate indicates chronic sinus disease. Enlargement of deep cervical glands may indicate persistent nasal infection. Roentgenography assists in the diagnosis of those diseased cells containing pus. Positive findings in the roentgenogram are conclusive; negative findings do not exclude the accessory sinuses as locations of focal infections. Transillumination is also of value in diagnosis.

In patients giving an indefinite history with sudden loss of vision, let us consider the sinus. I am sure we are all giving them the attention they deserve if we dont forget that every suppurating sinus is a menace to his life and best results are only to be expected from early intervention.

Hypertrophied tonsils per se do not always indicate disease according to some authorities, but I feel that the hypertrophy is a pathological state and should be watched very closely. However, when cheesy material can be expressed from the follicles, local disease is present. Liquid pus is positive proof of surface infection and usually indicated bacterial invasion and the formation of an abscess in the lymphoid tissue of the tonsil. Localized abscesses are frequently found between the tonsils and the pillars.

C. Ivins William