THE NOSE AND NASO-PHARYNX[6]
Fracture of nasal bones--Deformities of nose: _Saddle nose_; _Partial
and complete destruction of nose_; _Restoration of nose_;
_Rhinophyma_--Intra-nasal affections--Examination of the nasal
cavities: _Anterior rhinoscopy_; _Posterior rhinoscopy_; _Digital
examination_. CARDINAL SYMPTOMS OF NASAL AFFECTIONS: Nasal
obstruction: _Erectile swelling of inferior turbinals_; _Nasal
polypi_; _Malignant tumours_; _Deviations, spines, and ridges of
septum_; _Haematoma of septum_--Nasal discharge: _Foreign bodies_;
_Rhinoliths_; _Ozaena_; _Epistaxis_; _Suppuration in accessory
sinuses_--Anomalies of smell and taste: _Anosmia_;
_Parosmia_--Reflex symptoms of nasal origin--Post-nasal
obstruction: _Adenoids_--Tumours of naso-pharynx.
[6] Revised by Dr. Logan Turner.
#Fracture of the Nasal Bones and Displacement of the
Cartilages.#--These injuries are always the result of direct violence,
such as a blow or a fall against a projecting object, and in spite of
the fact that the fracture is usually compound through tearing of the
mucous membrane, infective complications are rare. The fracture
usually runs transversely across both nasal bones near their lower
edge, but sometimes it is comminuted and involves also the frontal
processes of the maxillae. In nearly all cases the cartilage of the
septum is bent or displaced so that it bulges into one or other
nostril, and not infrequently a haematoma forms in the septum (p. 573).
Sometimes the perpendicular plate of the ethmoid is implicated, and
the fracture in this way comes to involve the base of the skull. The
nasal ducts may be injured, obstructing the flow of the tears, and a
lachrymal abscess and fistula may eventually form.
The _clinical features_ are pain, bleeding from the nose,
discoloration, and swelling. Crepitus can usually be elicited on
pressing over the nasal bones. The deformity sometimes consists in a
lateral deviation of the nose, but more frequently in flattening of
the bridge--_traumatic saddle nose_. Within a few hours of the injury
the swelling is often so great as to obscure the nature of the
deformity and to render the diagnosis difficult. Subcutaneous
emphysema is not a common symptom; when it occurs, it is usually due
to the patient forcing air into the connective tissue while blowing
his nose. The lateral cartilages may be separated from the nasal bones
and give rise to clinical appearances which simulate those of
fracture. Sometimes the septum is displaced laterally without the bone
being broken, and this causes symptoms of nasal obstruction.
_Treatment._--As the bones unite rapidly, it is of great importance
that any displacement should be reduced without delay, and to
facilitate this a general anaesthetic should be administered, or the
nasal cavity sprayed with cocain. The bones can usually be levered
into position with the aid of a pair of dressing forceps passed into
the nostrils, the blades being protected with rubber tubing. After the
fragments have been replaced and moulded into position, it is seldom
necessary to employ any retaining apparatus, but the patient must be
warned against blowing or otherwise handling the nose. When the septum
is damaged and the bridge of the nose tends to fall in, rubber tubes
may be placed in the nostrils to give support, or, if this is not
sufficient, a soft lead or gutta-percha splint should be moulded over
the nose, and the splint and the fragments transfixed with one or more
hare-lip pins. These may be removed on the fourth or fifth day. Rigid
appliances introduced into the nostrils are to be avoided if possible,
as they are uncomfortable and interfere with proper cleansing and
drainage of the nose. The inside of the nose should be smeared with
vaseline to prevent crusting of blood, and the nasal cavities should
be frequently irrigated.
#Deformities of the Nose.#--The most common deformity is that known as
the _sunken-bridge_ or _saddle nose_ (Volume I., p. 174). It is most
frequently a result of inherited syphilis, the nasal bones being
imperfectly developed, and the cartilages sinking in so that the tip
of the nose is turned up and the nostrils look directly forward. The
bridge of the nose may sink in also as a result of necrosis of the
nasal bones, particularly in tertiary syphilis, and less frequently
from tuberculous disease. A similar, but as a rule less marked
deformity may result from fracture of the nasal bones or from
displacement of the cartilages.
When the condition is due to mal-union of a fracture, the contour of
the nose may be restored by operation. A narrow knife is passed in at
the nostril and the skin freely separated from the bone; the bone is
then broken into several pieces with necrosis forceps, and the
fragments moulded into shape. A rubber drainage tube introduced into
each nostril maintains the contour of the nose till union has taken
place.
When it results from disease, it is much less amenable to treatment.
The present-day tendency is to discard the use of subcutaneous
paraffin injection and to employ grafts of cartilage or bone. An
artificial bridge has been made by turning down from the forehead a
flap, including the periosteum and a shaving of the outer table of the
skull, or by implanting portions of bone or plates of gold, aluminium,
or celluloid.
Portions of the alae nasi may be lost from injury, or from lupus,
syphilis, or rodent cancer. After the destructive process has been
arrested, the gap may be filled in by a flap taken from the cheek or
adjacent part of the nose. When the tip of the nose is lost, it may be
replaced by Syme's operation, which consists in raising flaps from the
cheeks and bringing them together in the middle line.
The whole of the nose, including the cartilages and bones, may be
destroyed by syphilitic ulceration or by lupus. In parts of India the
nose is sometimes cut off maliciously or as a punishment for certain
crimes.
In reconstructing the nose it is necessary to provide skin, a
supporting structure in the form of cartilage or bone, and an
epithelial lining. In the "Indian operation" a racket-shaped flap,
including skin and periosteum, is turned down from the forehead and
fixed in position, the edges of the flap being inturned to provide a
lining for the passage. An implant of free cartilage may be necessary
to support the skin flaps and to prevent subsequent contraction.
Flaps of skin may be formed by Gillies' tube-pedicle method from the
cheek, the forehead, or the neck, and utilised to form the covering of
the nose. When the deformity cannot be corrected by operation, the
appearance may be greatly improved by wearing an artificial nose held
in position by spectacles.
The term #Rhinophyma# has been applied by Hebra to a condition in
which the skin of the tip and alae of the nose becomes thick and
coarse, and presents large, irregular, tuberous masses on which the
orifices of the sebaceous follicles are unduly evident--_potato_ or
_hammer nose_ (Fig. 266). The capillaries of the skin are dilated and
tortuous, and the nose assumes a bluish-red colour, and its surface is
soft and greasy. The condition is met with in elderly men, and the
masses appear to be chiefly composed of sebaceous adenomas. The term
_lipoma nasi_, formerly employed, is therefore misleading.
[Illustration: FIG. 266.--Rhinophyma or Lipoma Nasi in man aet. 65.]
The treatment consists in paring away the protuberant masses until the
normal size and contour of the nose are restored, care being taken not
to encroach on the cartilages or on the orifices of the nostrils.
There is comparatively little bleeding, and the raw surface rapidly
becomes covered with epidermis.
#Examination of the Nasal Cavities.#--For the examination of the
interior of the nose the following appliances are necessary: A
reflector, such as is used in laryngoscopy, attached to a forehead
band or spectacle frame; one of the various forms of nasal speculum; a
long, pliable probe; a tongue depressor; and a small-sized mirror. As
additional aids, a 10 per cent. solution of cocain, a grooved probe as
a cotton-wool holder, and a palate retractor should be in readiness.
Good illumination is important, and may be obtained from an electric
light, or from a Welsbach or Argand burner. The light should be placed
close to, and on a level with, the patient's left ear. Both the
anterior and posterior nares should be examined.
_Anterior Rhinoscopy._--Before the introduction of the speculum the
tip of the nose should be tilted up and the interior of the vestibule
and the anterior part of the septum examined. In this way the
existence of eczema or small furuncules, the presence of dilated or
bleeding vessels upon, or a perforation of, the anterior part of the
septum may be noted, and the general appearances observed. After
inserting the speculum into the vestibule and dilating it, the
following parts should be sought for and examined:--Close to the
floor, and attached to the outer wall of the nasal cavity, is the
anterior end of the inferior concha or turbinated body (Fig. 267),
which overhangs the inferior meatus. It presents a pink appearance,
and its size varies in different persons. At a higher level and on a
posterior plane is the anterior end of the middle concha or turbinated
body, which is of a paler colour than the inferior, and is only
visible when the head is tilted backwards. Between it and the inferior
turbinated body is the middle meatus, with which communicate the
openings of the maxillary sinus, the frontal sinus, and the anterior
ethmoidal cells. A considerable area of the anterior part of the nasal
septum is also visible by anterior rhinoscopy, and between it and the
middle turbinal is a narrow chink--the olfactory sulcus.
[Illustration: FIG. 267.--The outer wall of Left Nasal Chamber, after
removal of the middle turbinated body. (After Logan Turner.)]
_Posterior Rhinoscopy._--Examination of the posterior nares and
naso-pharynx is frequently attended with difficulty. The patient is
directed to breathe through the nose, the tongue is depressed with a
spatula, and a small-sized laryngeal mirror, comfortably warmed and
with its reflecting surface turned upwards, is introduced behind the
soft palate. When a good examination of the naso-pharynx is obtained,
the following parts may be seen reflected in the mirror: the posterior
surface of the uvula and soft palate, and above them, in the mesial
plane, the posterior free edge of the septum nasi; on each side of the
septum the apertures of the posterior nares, in which may be seen the
upper part of the posterior end of the inferior turbinal, the middle
meatus, the posterior end of the middle turbinal, the superior meatus,
and occasionally a portion of the superior turbinal. On the lateral
wall of the naso-pharynx the Eustachian opening and cushion can be
seen, while by tilting the mirror backwards the vault of the
naso-pharynx can be inspected.
_Digital examination_ of the naso-pharynx may be required, especially
in children. The examiner passes his left arm and hand round the back
of the child's head, and with one of his fingers presses the cheek
inwards, between the jaws. His right forefinger is carried along the
dorsum of the tongue, passed up behind the soft palate and a rapid
examination made of the post-nasal space.
CARDINAL SYMPTOMS OF NASAL AFFECTIONS.--The chief symptoms of nasal
disease are: nasal obstruction, nasal discharge, anomalies of smell
and taste, and certain reflex phenomena.
#Nasal Obstruction.#--This may be partial or complete, intermittent or
constant, and may be the cause of such symptoms as alteration in the
tone of the voice, catarrh of the respiratory passages, snoring,
cough, headache, inability to concentrate the attention, alteration in
the physiognomy, or deformity of the chest. The half-open mouth,
drooping jaw, lengthened appearance of the face, narrow nostrils, and
vacant expression are characteristic signs of nasal obstruction.
Nasal obstruction may be due to _intra-nasal_ or to _post-nasal_
(naso-pharyngeal) causes. Amongst the former may be noted as the more
common, erectile swelling and hypertrophy of the mucous membrane
covering the inferior turbinated bones, and nasal polypi growing from
the middle turbinal and middle meatal region. Causes originating in
the septum include deviations, spines, and ridges, and septal haematoma
and abscess. Obstruction may also be due to the presence of a foreign
body in the nasal cavity, to a rhinolith, and to imperfect development
of the nasal chambers. Further, tumours, both simple and malignant,
and such conditions as tubercle, lupus, syphilis, and glanders may
interfere more or less with nasal respiration. The most common cause
of post-nasal obstruction is the presence of adenoids; more rarely
fibro-mucous polypi, fibrous tumours, malignant disease, and
cicatricial contractions and adhesions resulting from syphilis are met
with.
_Erectile swelling_ of the inferior turbinated bodies is due to
engorgement of the venous spaces contained in the mucous membrane.
Obstruction from this cause is usually intermittent in character, and
may be unilateral or bilateral. It is influenced by posture, being
worse when the patient is in the horizontal position, and also by
changes in atmospheric conditions and temperature. It is characterised
objectively by a swelling of the mucous membrane, which is pink or red
in appearance and of a soft consistence, pitting when touched with the
probe, and shrinking on the application of a 5 per cent. solution of
cocain. Its soft consistence and the fact that it becomes smaller when
painted with cocain differentiate it from true hypertrophy of the
mucous membrane. Its situation and immobility, its pink colour, and
the shrinkage under cocain, distinguish it from the mucous polypus of
the nose. The turgescence may involve the whole extent of the mucosa
of the inferior turbinated bodies, including their posterior ends.
After anaesthetising with cocain, the electric cautery, or fused
chromic acid applied on a probe, may be employed for the relief of the
condition. If a true hypertrophy exists, it is better to remove it
with a nasal snare.
_Nasal polypi_ spring from the mucous membrane covering the middle
turbinated bone and from the adjacent parts of the middle meatus, but
rarely from the septum. They consist of oedematous masses of mucous
membrane, and are as a rule multiple. They are usually pedunculated,
and as they increase in size they become pendulous in the nasal
cavity. They are smooth, rounded in outline, of a translucent
bluish-grey colour, soft in consistence, and freely movable. These
characters, and the fact that the probe can be passed round the
greater part of the polypus, serve to differentiate this affection
from the erectile swelling. It must not be forgotten that nasal polypi
may be associated with suppuration in one or more of the accessory
sinuses. They are frequently present also in malignant disease, and in
these cases they bleed readily. They are best removed by means of the
cold snare, with the aid of the speculum and a good light. Several
sittings are usually necessary.
_Carcinoma_ and _sarcoma_ sometimes grow from the muco-periosteum in
the region of the ethmoid. They tend to invade adjacent parts, giving
rise to haemorrhage and symptoms of nasal obstruction, and as they
increase in size they may cause considerable deformity of the face. If
diagnosed early, an attempt should be made to remove the growth.
_Deviations, spines, and ridges of the septum_ may produce partial or
complete occlusion of the anterior nares. In deviation of the septum,
the obstructed nostril is more or less occluded by a smooth rounded
swelling of cartilaginous or bony hardness, which is covered with
normal mucous membrane, while the opposite nostril shows a
corresponding concavity or hollowing of the septum. Sometimes the
convex side is thickened in the form of a ridge. A simple spine of the
septum is usually situated anteriorly, and presents an acuminate
appearance, often pressing against the inferior turbinated body; it is
hard to the touch. Ridges and spines may be cut or sawn off, or
removed with the chisel. Many methods of dealing with a deviated
septum have been suggested, such as forcible fracture or excision of a
portion of the cartilage. A submucous resection of the deflected
portion is to be preferred.
_Haematoma of the septum_ is usually traumatic in origin. As the result
of a blow, an extravasation of blood takes place beneath the
perichondrium on each side of the septum, and a bilateral, symmetrical
swelling, smooth in outline and covered with mucous membrane, is
visible immediately within the anterior nares. The blood is usually
absorbed and should not be interfered with. If suppuration occurs,
however, the swelling becomes soft, fluctuation can be detected, and
the patient's discomfort increases. The abscess must then be incised
and the cavity drained. It is sometimes found that a portion of the
cartilage undergoes necrosis, leading to perforation of the septum.
#Nasal discharge# may be mucous, muco-purulent, or purulent in
character. When it is of a clear, watery nature, it is usually
associated with erectile swelling of the inferior turbinated bodies. A
purulent discharge may be complained of from one or both nostrils. If
unilateral, it should suggest, in the case of children, the presence
of a foreign body; in adults, the possibility of suppuration in one or
more of the accessory sinuses. In infants, a purulent discharge from
both nostrils may be due to gonorrhoeal infection or to inherited
syphilis. Nasal discharge may be constant or intermittent. It is
sometimes influenced by changes in posture; for example, it may be
chiefly complained of at the back of the nose and in the throat when
the patient occupies the horizontal position, or it may flow from the
nostril when he bends his head forward or to one side. The discharge
may be intra-nasal in origin, or due altogether to naso-pharyngeal
catarrh. It varies somewhat in colour and consistence, and may be
associated with such intra-nasal conditions as purulent rhinitis
following scarlet fever and other exanthemata or ulceration
accompanying malignant disease, syphilis, or tuberculosis. Sometimes
it contains shreds of false membrane, for example in nasal diphtheria;
or white cheesy masses as in coryza cascosa. The formation of crusts
is significant of foetid atrophic rhinitis (ozaena) and syphilis, and
in these conditions the discharge is associated with a most
objectionable and distinctive foetor. Pus from the maxillary sinus is
often foetid, and the odour is noticed by the patient; while the odour
of ozaena is not recognised by the patient, although very obvious to
others.
#Foreign bodies# of various descriptions have been met with in the
nasal cavities, particularly of children. They set up suppuration and
give rise to a unilateral discharge, which is often offensive in
character. The surgeon must not be satisfied with the history given by
the parents, but, with the aid of good illumination, and, in young
children, under general anaesthesia, the nose should be carefully
inspected and probed. If there is much swelling, the introduction of a
5 per cent. solution of cocain will facilitate the examination by
diminishing the congestion of the mucous membrane. No attempt should
be made to remove a foreign body from the nose by syringing. If fluid
is injected into the obstructed nostril, it is liable to force the
body farther back, while, if injected into the free nostril, it is apt
to accumulate in the naso-pharnyx and to pass into the Eustachian
tubes. A fine hook should be passed behind the body and traction made
upon it, or sinus forceps or a snare may be employed. Care must be
taken that the body is not pushed still deeper into the cavity. Fungi
and parasites should first be killed with injections of chloroform
water, or by making the patient inhale chloroform vapour.
#Rhinoliths.#--Concretions having a plug of inspissated mucus or a
small foreign body as a nucleus sometimes form in the nose. They are
composed of phosphate and carbonate of lime, and have a covering of
thickened nasal secretion. They are rough on the surface, dark in
colour, and usually lie in the inferior meatus. They give rise to the
same symptoms as a foreign body, and are treated in the same way. The
stone, which is usually single, may be so large and so hard that it is
necessary to crush it before it can be removed.
#Ozaena#, or #foetid atrophic rhinitis#, is characterised by atrophy of
the nasal mucous membrane, and sometimes even of the turbinated bones,
and is accompanied by a muco-purulent discharge and the formation of
crusts having a characteristic offensive odour, which is not
recognised by the patient. It is usually bilateral, and the nasal
chambers, owing to the atrophy, are very roomy. It may be
differentiated from a tertiary syphilitic condition by the absence of
ulceration and necrosis of bone, by the odour, and by the fact that it
is not influenced by anti-syphilitic treatment.
Various methods of treatment are in vogue, but thorough cleanliness is
the most essential factor, and this is best secured by regular
syringing. Plugging of the nostrils with cotton-wool for half an hour
before washing out the nose greatly facilitates the detachment of the
crusts. A pint of lukewarm solution containing a teaspoonful of
bicarbonate of soda or of common salt, is then used with a Higginson's
syringe, the patient leaning over a basin and breathing in and out
quickly through the open mouth. The patient should then forcibly blow
down each nostril in turn, the other being occluded with the finger,
so that the infective material may thus be blown out without risk of
it entering the Eustachian tubes, as may happen when the handkerchief
is used in the ordinary way. Antiseptic sprays, such as peroxide of
hydrogen, and ointments may be applied to the mucous membrane after
cleansing.
#Epistaxis.#--Bleeding from the nose may be due either to local or to
general causes. Among the former may be cited injuries such as result
from the introduction of foreign bodies, blows on the face, and
fractures of the anterior fossa of the skull, and the ulceration of
syphilitic, tuberculous, or malignant disease. Amongst the general
conditions in which nasal haemorrhage may occur are typhoid fever,
anaemia, and purpura cardiac and renal disease, cirrhosis of the liver,
and whooping-cough. Prolonged oozing of blood may be an evidence of
haemophilia. Nasal haemorrhage usually takes place from one or more
dilated capillaries situated at the anterior inferior part of the
septum close to the vestibule, and in such cases the bleeding point is
readily detected. Occasionally bleeding occurs from one of the
anterior ethmoidal veins, and under these circumstances the blood
flows downwards between the middle turbinal and the septum. Before
steps are taken to arrest the bleeding, the interior of the nose
should, if possible, be inspected and the bleeding point sought for.
As a preliminary to the use of local applications, the nose should be
washed out with boracic lotion or salt solution to remove all clots
from the cavity. In many cases this is all that is necessary to stop
the bleeding. If the bleeding is not very copious, it may be stopped
by grasping the alae nasi between the finger and thumb, or by spraying
the nasal cavity with adrenalin. If the blood is evidently flowing
from the olfactory sulcus, a strip of gauze soaked in adrenalin,
turpentine, or other styptic should be packed between the septum and
middle turbinated body. If recurrent haemorrhage takes place from the
anterior and lower part of the septum, the application of the electric
cautery at a dull red heat, or of the chromic acid bead fused on a
probe, is the best method of treatment. Plugging of the posterior
nares is rarely necessary, as, in the majority of cases, an anterior
plug suffices. In bleeders, the administration of sheep serum by the
mouth has proved efficacious.
#Suppuration in the Accessory Nasal Sinuses.#--As already stated, the
presence of pus in the nose should always direct attention to its
possible origin in one or more of the accessory sinuses, especially if
the discharge is unilateral. The condition is usually a chronic one,
and may be present for months, or even years, without the patient
suffering much inconvenience save from the presence of the discharge.
If on examination by anterior rhinoscopy, pus is seen in the middle
meatus, suspicion should be aroused of its origin in the maxillary
sinus, frontal sinus, or anterior ethmoidal cells, as all these
cavities communicate with that channel. If, on the other hand, the pus
is detected in the olfactory sulcus, attention must be directed to
the posterior ethmoidal cells and sphenoidal sinus (Fig. 267). Further
evidence of its source in the last-named cavities may be gained by
finding pus in the superior meatus above the middle turbinal on
examination by posterior rhinoscopy.
As the anterior group of sinuses is most frequently affected, and of
these most commonly the _maxillary sinus_, attention should first be
turned to this cavity. Pain, tenderness on pressing over the canine
fossa or on tapping the teeth of the upper jaw, and swelling of the
cheek are rarely met with save in acute inflammation. The complaint of
a bad odour or taste, the reappearance of pus in the middle meatus
after mopping it away and directing the patient to bend his head well
forwards, and opacity on trans-illumination of the suspected cavity,
are signs which strongly suggest an affection of the maxillary sinus.
The withdrawal of pus by a puncture through the thin outer wall of the
inferior meatus of the nose with a fine trocar and cannula will
establish the diagnosis.
The _treatment_ consists in opening and draining the sinus. If the
infection is due to a carious tooth, this should be extracted, the
socket opened up and drainage established through it in recent cases.
If the teeth are sound, and the case is of long duration, the sinus is
opened through the canine fossa and its walls curetted. To avoid the
risk of reinfecting the cavity from the mouth, an opening may be made
into the nose by removing a portion of the nasal wall of the sinus and
part of the inferior turbinated bone, after which the incision in the
buccal mucous membrane is closed with sutures.
Suppuration in the _frontal sinus_ is attended with frontal headache,
vertigo, especially on stooping, and tenderness on pressure,
particularly over the internal orbital angle, or on percussion over
the frontal region. Pus escapes into the middle meatus of the nose,
and if wiped away will reappear if the head is kept erect for a few
minutes. After removal of the anterior end of the middle turbinated
bone, it may be possible to catheterise the sinus and wash out pus
from its interior. The diseased sinus may present a darker shadow than
the healthy one on trans-illumination, or in an X-ray photograph.
The _treatment_ consists in exposing the anterior wall of the sinus,
chiselling away sufficient bone to admit of free removal of all
infected tissue, and establishing efficient drainage through the
infundibulum (Fig. 267) into the nose.
The _anterior ethmoidal cells_ (Fig. 267) are frequently affected in
conjunction with the frontal, and sometimes with the maxillary sinus.
The presence of polypi and granulations, with pus oozing out from
between them, and increasing after withdrawal of the probe, and the
detection of carious bone are significant of ethmoidal suppuration.
The _treatment_ consists in extending the operation for the frontal or
maxillary sinus so as to ensure drainage of the ethmoidal cells.
_Suppuration in the sphenoidal sinus_ (Fig. 267) is characterised in
many cases by the presence of eye symptoms. Pus in the olfactory
sulcus, on the upper surface of the middle turbinal posteriorly, and
on the vault of the naso-pharynx, is suggestive of sphenoidal
suppuration. The removal of the middle turbinated bone permits of
inspection of the ostium sphenoidale by anterior rhinoscopy, and pus
may be seen escaping from the orifice. A probe is then passed into the
ostium, and the anterior wall of the sinus is removed with a curette
or rongeur forceps.
The _posterior ethmoidal cells_ (Fig. 267) are frequently affected
along with the sphenoidal sinus. The nasal appearances just noted are
present, and if the sphenoidal sinus can be washed out and its ostium
temporarily plugged, and pus rapidly reappears, its origin from these
cells is probable. The operation for draining the sphenoidal sinus is
extended by removing the inner wall of the posterior ethmoidal cells.
#Anomalies of Smell and Taste.#--_Anosmia_ or loss of smell and
impairment or loss of the sense of recognising flavours may follow
fracture of the anterior fossa attended with injury of the olfactory
nerves, and is a common sequel of influenza. Any lesion that prevents
the passage of the odoriferous particles to the olfactory region of
the nose interferes with the sense of smell. In ozaena also the sense
of smell is lost. _Parosmia_, or the sensation of a bad odour, may be
of functional origin; it sometimes occurs after influenza. It may also
be associated with maxillary suppuration.
#Reflex Symptoms of Nasal Origin.#--It is only necessary here to draw
attention to the relation that exists between affections of the nose
and asthma. When present in asthmatic subjects, nasal polypi, erectile
swelling of the inferior turbinated bodies, spines of the septum in
contact with the inferior turbinal, or areas on the mucous membrane
which, when probed, produce coughing, call for treatment with the
object of modifying the asthma.
#Post-nasal Obstruction--Adenoid Vegetations.#--The most common cause
of post-nasal obstruction is hypertrophy of the normal lymphoid
tissue which constitutes the naso-pharyngeal or Luschka's tonsil.
_Adenoids_ form a soft, velvety mass, which projects from the vault of
the naso-pharynx and extends down its posterior and lateral walls, in
some cases filling up the fossae of Rosenmueller behind the Eustachian
cushions. They do not grow from the margins of the posterior nares.
Adenoids are frequently associated with hypertrophy of the faucial
tonsils, and the patient often suffers from granular pharyngitis and
chronic nasal catarrh.
These growths are sometimes met with in infants, but are most common
between the ages of five and fifteen, after which they tend to undergo
atrophy. They may, however, persist into adult life.
_Clinical Features._--The most prominent symptom in most cases is
interference with nasal respiration, so that the patient is compelled
to breathe through the mouth. The facies of adenoids is
characteristic: the mouth is kept partly open, the face appears
lengthened, the nose is flattened by the falling in of the alae nasi,
the inner angles of the eyes are drawn down, and the eyelids droop,
while the whole facial expression is dull and stupid. As the
respiratory difficulty is increased during sleep, the patient snores
loudly, and his sleep is frequently broken by sudden night terrors.
Owing to the disturbed sleep, to imperfect oxygenation of the blood,
and to frequent attacks of nasal and bronchial catarrh, the child's
nutrition is interfered with, and he becomes languid and backward at
his lessons.
When the adenoids encroach upon the Eustachian cushions, the patient
suffers from deafness, frequent attacks of earache, and sometimes from
suppurative otitis media with a discharge from the ear.
Among the rarer conditions attributed to adenoids are asthma,
inspiratory laryngeal stridor, persistent cough, chorea, and nocturnal
enuresis.
A _diagnosis_ should never be made from the symptoms alone; an attempt
must be made to examine the naso-pharynx by posterior rhinoscopy and
by digital examination. The interior of the nose must always be
examined and any further cause of obstruction excluded.
_Treatment._--Thorough removal is the only satisfactory line of
treatment, and this should be done under general anaesthesia. The
following instruments are necessary: two Gottstein's adenoid curettes,
one provided with a cradle and hooks, the other without, a Hartmann's
lateral ring knife, and one pair of adenoid forceps--Kuhn's or
Loewenberg's--a tongue depressor, a gag, and one or two throat sponges
on holders. The patient having been anaesthetised, his head should be
drawn over the end of the table. An assistant standing on the left
side inserts the gag and maintains it in position. The operator, being
on the patient's right, depresses the tongue and insinuates the
curette provided with the hooks behind the soft palate, carrying it to
the roof of the naso-pharynx between the growth and the posterior free
edge of the nasal septum. Firm pressure is then made against the vault
of the naso-pharynx, and the curette is carried backwards and
downwards in the mesial plane and withdrawn with the main mass of the
adenoids caught in the hooks. The unguarded curette is then introduced
and several strokes are made with it, the instrument being carried on
either side of the mesial plane. With Hartmann's lateral ring knife
the posterior naso-pharyngeal wall and fossae of Rosenmueller are
curetted. The curette should not be used on the lateral pharyngeal
wall in case the Eustachian orifices and cushions are damaged.
Bleeding soon ceases when the head is again elevated, and the patient
should be at once laid well over upon his side so that the blood may
escape from the mouth.
No local after-treatment is required, and spraying or syringing may
prove harmful. The patient should remain in the house for five or six
days. If nasal obstruction has been the outstanding symptom,
respiratory exercises through the nose should be carried out for some
considerable time; on the other hand, if Eustachian obstruction and
deafness have been the main features of the case, a course of Politzer
inflation should be conducted after the wound has healed.
#Tumours of the Naso-Pharynx.#--Tumours are occasionally met
with growing from the muco-periosteum of the basi-sphenoid
and basi-occipital, and projecting from the vault of the
naso-pharynx--_naso-pharyngeal tumour_ or retro-pharyngeal polypus.
This usually occurs between the ages of fifteen and twenty, and while
it may originally be a fibroma, it tends to assume the characters of a
fibro-sarcoma and to exhibit malignant tendencies. At first the tumour
is firm, rounded, and of slow growth, but later it becomes softer,
more vascular, and grows more rapidly, spreading forwards towards the
nasal cavity and downwards towards the pharynx.
_Clinical Features._--In its growth the tumour blocks the nostrils,
and so interferes with nasal respiration and causes the patient to
snore loudly, especially during sleep. It may also bulge the soft
palate towards the mouth and interfere with deglutition. In some cases
the face becomes flattened and expanded and the eyes are pushed
outwards, giving rise to the deformity known as _frog-face_. Deafness
may result from obstruction of the Eustachian tube. The patient
suffers from intense frontal headache, and there is a persistent and
offensive mucous discharge from the nose. Profuse recurrent bleeding
from the nose is a common symptom, and the patient becomes profoundly
anaemic. The tumour can usually be seen on examination with the nasal
speculum or by posterior rhinoscopy, and its size and limits may be
recognised by digital examination.
Unless removed by operation these tumours prove fatal from haemorrhage,
interference with respiration, or by perforating the base of the skull
and giving rise to intra-cranial complications.
_Treatment._--These growths are seldom recognised before they have
attained considerable dimensions, and owing to the fact that they are
permeated by numerous large, thin-walled venous sinuses, their removal
is attended with formidable haemorrhage. Attempts to remove them by the
galvanic snare are seldom satisfactory, because the base of the tumour
is left behind and recurrence is liable to take place. The operative
treatment is described in _Operative Surgery_, p. 153.