DISEASES OF THE NASAL PASSAGES.
BY HARRISON ALLEN, M.D.
Coryza.
Coryza is an acute inflammation of the mucous membrane of the nasal chambers. The disease is ordinarily idiopathic, but may be produced by irritative vapors, pollen, or dust. In the idiopathic form the symptoms of coryza are often preceded by malaise, with chilly sensations, and in severe attacks with headache. The attack itself is divided into two stages: that of determination or congestion, and that of exudation. In the first stage the excessive quantity of blood flowing into the arterio-venous network and the capillaries of the nasal mucous membrane distend them and obstruct the nasal chambers.
The symptoms are referable either to such obstruction of nasal respiration—in which group are included oral respiration, sensations of distension, and throbbing in the nose—or to reflexes, such as frontal headache, attacks of sneezing, and dull aching pain in the teeth.
The first stage lasts for a period varying from a few hours to several days, and is followed by the stage of exudation. This is characterized by a free watery or mucoid discharge from the nasal chambers, and by the cessation of the symptoms due directly or indirectly to pressure of the layers of swollen mucous membrane against each other. The discharge at first is watery, and is doubtless composed of transuded liquor sanguinis. It is followed by a mucoid fluid, which in severe or neglected cases may assume a purulent character. In many instances, even in mild cases, the discharge becomes muco-purulent toward recovery. The second stage is associated in children and adults of delicate constitution with excoriations of the nostrils.
Suppuration may take place in nurslings and in old people. It would appear that in coryza, as it exists in the northern countries of Europe, the beginning of the second stage is apt to be marked by free suppuration.
Acute coryza may involve the sinuses of the face, particularly the maxillary sinus. The involvement of the frontal and sphenoidal sinuses, while possible, is infrequent. Pharyngitis, laryngitis, and occasionally acute aural catarrh, often coexist with the disease.
The symptoms of coryza are so distinctive that the diagnosis is easily made. But since any obstructive or catarrhal state of the nose is described by patients as a cold in the head, it is necessary for the medical attendant to distinguish the various diseases so denominated. Acute coryza may be confounded with angiose hypertrophy; with the obstruction to nasal respiration due to deflection of the nasal septum or to an inflamed soft polypus; with catarrhal irritation affecting surfaces which are already enlarged by hyperplasia or which are undergoing atrophy; or with the effects of operative interference in the nose.
In angiose hypertrophy the swollen membranes will contract under a mild current of electricity or by change in the position of the body. Both chambers are rarely involved at the same time. Reflexes are of infrequent occurrence. Obstruction to nasal respiration due to a deflected septum arises from causes which are insignificant and do not affect the constitution. The genuine influenzal or catarrhal element is absent. In an inflamed soft nasal polypus an attempt at inspiration will, as a rule, detect the presence of the growth. In diffuse multiple polypi the case is different. Many persons who are reputed to take cold readily, or who may be said never to be free from cold, are really sufferers from neglected polypi. Persons suffering from atrophic catarrh always speak of an exacerbation of their symptoms as a fresh cold, and describe the disease itself as a cold. The sense of fulness, the throbbing, the heat, and the characteristic discharge of coryza are absent. A fresh cold in atrophic catarrh is an attack of inflammation (often catarrhal in character, it is true) which affects the involved surfaces, but is attended with an increase of plastic exudation and accompanying fetor.
It is a common occurrence for patients who have had a cautery application made or a polypus removed to return after a few days' absence with the report that they have contracted a cold. While the condition may be an attack of acute coryza, the chances are in favor of the symptoms being excited by the manipulation or the reaction from the operation. The symptoms are mild in character.
TREATMENT.—The treatment of coryza is both local and constitutional. The local treatment consists in applications of agents which tend to constrict the vessels of the nasal mucous membrane. In the first rank of such agents may be named cocaine, which in a 2 per cent. or a 4 per cent. solution will often give notable relief by overcoming the sense of obstruction. Individuals will be found in whom the effect is of short duration, and in some persons I found the medicine to have no effect whatever. In more favorable subjects the relief will be acknowledged for a period varying from four to six hours. Next in rank may be named a current of constant electricity (say from six to ten cells) passed through the cheeks. Should neither of the above-named agents be available, inhalations of iodine vapor, a few drops of chloroform rubbed upon the palms and inhaled, or the inhalation of the spirits of ammonia may be recommended. Toward the later stages of the disease detergents and mild astringents are well borne. The constitutional treatment includes the administration of diaphoretics and minute doses of opium, especially in the early stages of the disease. Coryza is commonly self-limited, and by far the larger number of cases do not come under the care of the physician.
Chronic Nasal Catarrh.
Chronic nasal catarrh embraces those more or less persistent affections of the nasal chambers whose symptoms resemble those of acute coryza. The term catarrh is inexact. It is used to include several diseases associated by a single characteristic—namely, the existence of an increased amount of mucous secretion upon the affected membranes.
In order to understand the varieties of nasal catarrh, it is necessary to have clear conceptions of the uses of the nasal chambers. The normal performance of the function of respiration demands that when the mouth is closed the currents of air should pass through the nose. These currents, however, do not sweep over the entire nasal surfaces, but are confined to those portions which answer to the inferior meatus and the space bounded within by the septum, without by the median surface of the inferior turbinated bone, and above by the under surface of the middle turbinated bone. In the lower mammals this space is separated posteriorly by a transverse bony lamina which effectively excludes the upper portion of the nasal chambers from the tract just named. Anteriorly, at the termination of the inferior meatus and the middle turbinated bone, the tract is in freer communication with the upper spaces. The passage thus briefly defined may be called the respiratory tract, and when it remains patulous no serious interference with nasal respiration can occur.
The transverse diameters of the tract are subject to frequent changes, owing to the erectile character of the mucous membrane in its walls. But as long as the surfaces do not touch one another obstruction cannot exist. The passage, even when narrowed to a chink or line intervening between the median and lateral walls of the tract or between the floor and the roof of the inferior meatus, is sufficient evidence that there is room for the transit of the currents of air. The membranes themselves are subject to changes in form which are dependent upon the degree of development of their erectile tissue.
There is doubtless a disposition on the part of the erectile tissue to grow in the direction of the least resistance, and thus to occupy, by a process of compensative hypertrophy, the spaces left as the result of variations or defects in development in the bones composing the framework of the nasal chambers. The greater development of the erectile tissue may in this way be found on the side answering to the larger respiratory tract, which may therefore be more apt to suffer from changes in the conditions of nasal breathing than the chamber having the smaller tract. The erectile tissue acts as a monitor to the throat and lungs by presenting warm surfaces over which the air passes, thereby having the temperature raised before it enters the throat and lungs. It also acts by occluding the chamber, and thus aids in shutting out irritant vapors and dust. The lower animals possess a higher degree of development of the tissue at the point where the adducted ala presses against the septum. This point answers to the position of the organ of Jacobson. With man, the locality of the adduction corresponds to the junction of the premaxillary with the maxillary portion of the nasal chambers, and is often the seat of a delicate band of mucus extending across from the inferior turbinated bone to the septum.
That portion of the nasal chamber above the respiratory tract may be called the olfactory tract. It does not appear to be involved in the diseases under consideration, or, if it is, no clinical signs or symptoms are presented with which the author is acquainted. It will therefore receive no attention in this article.
For convenience the varieties of chronic catarrh may be classified as follows:
FIRST VARIETY—that dependent on defective nasal respiration.
This variety is caused by—
(a) Osseous obstruction in the nasal chamber.
(b) Membranous obstruction in the nasal chambers from compensatory hypertrophy of the erectile tissue, alone or with hyperplasia.
(c) Obstruction arising from hypertrophy of the adenoid tissue in the pharyngeal vault.
(d) Contracture of the levator palati muscles.
SECOND VARIETY—that dependent on structural changes in the component parts of the nasal chamber.
This variety is associated with—
(a) Chronic inflammation of the nasal mucous membrane without hypertrophy of the erectile tissue.
(b) Atrophy of the turbinals and their associated mucous membrane.
(c) Necrosis of the bones which enter into the framework of the nasal chambers.
FIRST VARIETY.—Defects in nasal respiration induce hyperæmia, distension of the erectile tissue, hyperplasia of the mucous membrane, and inevitable distress in the nose. A sense of fulness across the bridge of the nose and at its sides is complained of. Frontal headache may be present.
(a, b) When the septum is deflected and the left nasal chamber is narrowed, the labor of sustaining nasal respiration is thrown on the right side. This arrangement invites a flow of blood to the already large turbinals, and creates obstruction which is frequently referred to the right side, although both are alike affected. Thus, subjects in which the initial obstacle is osseous complain of distress caused by cavernous-tissue hypertrophy of the lining membrane of the opposite side. This represents a very common class of cases.
When the septum is not deflected, but projections from it impede the current of air, there may be either unilateral or bilateral obstruction, dependent upon the shape of the septum itself. Hypertrophy of the cavernous layer of the mucous membrane usually coexists. These cases are numerous, but less common than those last described.
Infrequently, cases are seen where the distress is occasioned by defects of the osseous structures not accompanied by cavernous hypertrophy.
Treatment of the above disorders consists in restoring nasal respiration by removing obstructions, whether they be osseous or membranous. The septal projections may be drilled or filed away, or, if marked deflection of the anterior portion be present dependent upon a malposition of the triangular cartilage, an operation simple in character may be performed for its correction. This consists in severing the connection of the lower margin of the cartilage with the maxilla and slipping the partially free cartilage to a new position. The details attendant upon the operation need not be here given. The reduction of the hypertrophied membranes can be best accomplished by cauterization. The most efficient method is by means of the electric cautery. The electrode used should be flexible and of small size. The points which most frequently require cauterization are the premaxillary portion of the inferior turbinated bone, the under surface of the same, and the septum at the maxillary spur. Rarely the inferior surface of the inferior turbinated bone at the palatal region requires attention. The applications are best made over small surfaces at a time, and should be repeated at intervals of from two to three days until all suspected points have been at least once cauterized. Not infrequently, the effect of the cauterization at one spot will cause constriction to take place in the vessels of the entire mucous surface, so that while this condition lasts it is impossible to tell what additional points of the membranous obstruction demand removal. At the following visit, however, the vessels have become relaxed, the membranes are again turgescent, and if obstruction now occurs it can easily be detected.
The galvano-cautery can only be used in the nasal chamber in patients who are earnestly seeking relief and are willing to assist the physician in all his efforts. With the tractable, intelligent subject it can with proper care be limited exactly to the spot intended. It is scarcely necessary to observe that any erratic or unexpected motion of the head will sear unaffected and sensitive surfaces. The interior of the vestibule is perhaps the most sensitive of these, and should always be protected by the use of the nasal speculum. No additional protection is needed, though in the judgment of others, among whom may be mentioned E. Shurly of Detroit, Michigan, an ivory shield passed in the nose parallel to the electrode is a necessary safeguard.
The pain of the application is generally slight, and can be in part annulled by a previous application of a 4 per cent. solution of cocaine. Some annoyance is acknowledged on the following day from the pressure of the eschar. Traumatic congestion of the entire mucous surface of the corresponding chamber is at the same time detected, and is usually sufficiently decided to produce some of the effects of acute coryza. This condition will spontaneously terminate in from thirty-six to forty-eight hours. The most annoying features following an application of the galvano-cautery which has been too freely made do not belong to the group just indicated, but rather to reflex disturbances. Pains are occasionally excited in the teeth, in the temple, eye, nape of the neck, and the middle ear. On one occasion in the writer's experience a unilateral reflex excitation of the entire opposite side of the body occurred, and a prickling sensation, followed by numbness, ensued, which lasted for twenty-four hours. Very rarely a congestion of the pharynx, of the larynx, and the larger bronchial tubes ensues, which can scarcely be directly attributable to the application, yet it has followed in a sufficient number of cases to lead me to believe that the two are in some remote way associated. Perhaps such a condition is analogous to the slight irritation of the respiratory tract following excision of the tonsil. Careful use of the galvano-cautery will obviate the conditions above described. They are important to remember as serving as limitations to the use of this valuable agent.
(c) It will be seen that osseous obstruction in the nasal chamber and hypertrophy of the cavernous nasal tissue often coexist. More rarely, a third element occurs as a complication, or it may be found independently of all other morbid processes. I allude to the presence of hypertrophy of the adenoid tissue in the pharyngeal vault. When this tissue is only moderately developed, it need not, and does not, interfere with nasal respiration; but when it projects downward to such a degree as to lie within the axis of the lower portion of the posterior nares, it produces the same effect upon nasal breathing as though obstruction existed within the chamber. The growths can be easily detected, as a rule, from behind by the aid of the rhinal mirror, but it should not be forgotten that they also can be seen from in front, provided the chamber is free from obstruction along the respiratory tract. In some individuals the ribbed or lobate structure of the mass can be discerned, but more often its presence is revealed by the minute points of light reflected from the lobules. If it be a matter of doubt whether these points of reflection are within the nasal chamber or beyond it in the pharyngeal vault, the patient may be requested to swallow, or to pronounce the letter e; when, if the point of reflection is within the nasal chamber, it will not change its position, but if it be within the naso-pharynx, it will be moved slightly from side to side, or it may for a moment disappear.
The symptoms of nasal catarrh which are provoked by the presence of such a growth can be alone successfully treated by the removal of the offending mass. In young individuals—say, from twelve to eighteen or twenty years of age—the finger inserted into the naso-pharynx from behind can often break down the growth. Slight hemorrhage follows this procedure, and the tags of imperfectly-destroyed tissue can be subsequently treated by caustics and powerful astringents. In the event of the patient proving intractable, the growth may be reached from in front through the nasal chamber, and the galvano-cautery can be used by passing the electrode backward through the nostril until it meets with resistance, which is invariably at the pharyngeal vault. Should this method of treatment not be permitted by an undisciplined or nervous person, the prolonged use of a glycerole of iodine may gradually reduce them in size; but no definite result can be promised from such treatment.
(d) Very rarely, through inordinate elevation of the soft palate owing to over-action of the levator palati muscles, the passage of communication between the naso-pharynx and the oro-pharynx is inadequate. Consequently, the nasal chamber is imperfectly ventilated, and its secretions, not flowing backward or being displaced to the normal extent, become semi-inspissated, and create obstruction by lodging in the respiratory tract, either in the premaxillary or palatal portions. To successfully combat this condition it is evident that no local treatment is demanded, either in the nose or the naso-pharynx, other than to increase the tonicity of the pharyngeal and palatal muscles. Very frequently in such cases there is a symmetrical atony in the muscles last named, which demands the internal use of strychnia and iron and the application of galvanism.
PROGNOSIS.—When nasal catarrh has proved to be dependent on defective respiration, the removal of the causes entering into this condition may with reason be expected to effect recovery. The prognosis, therefore, is favorable. In young persons, in whom reparative power is present in the highest degree, and in whom a secondary hypertrophy of the cavernous tissues is least developed, a prompt cure may be obtained by removal of the osseous or other forms of obstruction. In adults, however, the prognosis is less favorable, especially with those who have approached or passed middle life, and who have contracted vicious habits of breathing, which are likely to persist even after the removal of their causes. It is also tenable that in such subjects the mucous lining of the cranio-facial sinuses has become involved. Should anosmia persist after the capacity of the chambers has been augmented—in a word, should this condition not be dependent upon obstruction, but upon changes in the olfactory surfaces—the prognosis is less favorable than in any of the cases of the above-named group.
Treatment will, however, always secure amelioration of the symptoms, and few cases occur which cannot be greatly improved. The general health is invariably benefited. Should a tendency to asthma exist, it is apt to disappear, the complexion clears, and in adolescence the rate of general development is accelerated.
SECOND VARIETY.—The group of nasal diseases included under this head is not a natural one, since it embraces disorders characterized by a negative feature—viz. absence of obstruction to nasal respiration. Nevertheless, it is convenient to consider under a single head a number of relatively infrequent disorders in which there is invariably an underlying constitutional cause. Subjects of disorders herein embraced are not merely sufferers from insufficient oxygenation of the tissues, but have impaired general vitality or possess a decided constitutional taint, whether specific or otherwise. The nasal condition is simply the most prominent of the local manifestations.
Three distinct disorders are herein named: first, chronic inflammation of the nasal mucous membrane; second, atrophy of the turbinals and their associated mucous membrane; third, necrosis of the bones entering into the framework of the nasal chambers.
(a) Inflammatory thickening is a rare affection. It is more frequent in males than in females, and in persons of a sedentary occupation than in those who are actively employed. Those subject to it are apt to have light-blue or gray eyes and auburn or sandy hair. On examination, the chambers may be found free from peculiarities of bony structure, capacious, and without hypertrophy of the cavernous tissues, yet the membranes be of a deep-red color and of cushiony consistence, yield bright reflexes, and the shank of the instrument introduced into the nose is mirrored upon them. The most conspicuous alteration is not seen on the turbinals, but on the septum. The parts are very vascular, and the most moderate manipulation will often end in free capillary oozing. The discharge, though moderate in quantity, is inclined to be purulent, and resembles semi-coagulated albumen. Quite frequently, in the examination of a neglected case, minute flecks of this modified secretion are seen scattered over the septum and the inferior turbinated bone. Rarely, the discharge is maintained by the presence of a morbid growth or inflammatory products, either in the nasal chamber or a chamber accessory to it. The discharge then appears to consist of pure pus mixed with the normal secretion of the nose, and, thus rendered viscid and tenacious, it excites by its presence a condition of the lining mucous surface quite similar to that above described.
Under excitement, as after an attack of coryza, the discharge becomes more serous in character, and is occasionally of a chocolate color from its admixture with blood. It is without odor. There is no obstruction to respiration except during sleep, when, in aggravated cases, mouth-breathing may be established. Thus, the patient will often complain of an obstruction which is never present at the time of the examination. He further complains of a sense of dryness in the nose, with some pharyngeal irritation. The palato-pharyngeal and palato-glossal muscles are weak and often asymmetrical; the tonsils are small, but the adenoid tissues are generally unaffected. In a dry atmosphere, especially if it be loaded with irritating particles, the pharyngeal irritation is increased—a complication which is probably due to the inspired air passing too rapidly through the capacious and imperfectly-guarded nasal chambers and throat. Although I have carefully searched for all indications of aural complications, especially for the symptoms of progressive dry catarrh, I have never detected them but in a single instance.
The prognosis is to be guarded, although a careful course of treatment and proper care of the general health will greatly improve, if not entirely cure, the disease.
TREATMENT.—This consists in the application of nitrate of silver, either in strong solution or in the solid stick, to the under surface of the inferior and middle turbinated bones, of washing the parts with a dilute solution of carbolic acid, and of passing through the cheek tissues a constant electrical current of a strength of from five to ten cells. Tonics and alteratives should not be neglected, and an outdoor life, as far as is practicable, should be enjoined. The galvano-cautery may be used to destroy any nodules of tissue which resist other treatment. All applications are well borne, if indeed we may not look upon the condition of the surfaces as partially analgesic, and thus far of unfavorable significance. It is certain that indurated tags of oedematous and chronically inflamed mucous membrane overlying a bone, such as the middle turbinated or the alveolar line about the necks of the teeth, will never yield to anything but the most powerful astringents. Upon such tissues the most concentrated solutions of nitrate of silver are never caustic. The premaxillary portion of the inferior turbinated bone is frequently seen hopelessly infiltrated, and it must then be destroyed by the electro-cautery. When a discharge of a pus-like character exists, careful search should be made for the cause. If a tumor or foreign body be found, it should be removed, but if the cause lie in one of the outlying spaces of the nasal chamber, it is evident that the above treatment is palliative only.
(b) In atrophy of the nasal mucous surfaces and turbinals we have, as in the last-named group, spacious chambers, a purulent discharge, pharyngeal irritation (in many cases), and always associated a thin and relaxed, if not a paretic, condition of the velal muscles. These cases might be looked upon as an advanced stage of the preceding affection, since it may be surmised that the stage of infiltration has been succeeded by one of atrophy. The mucous membranes are everywhere pale, and closely bound to the underlying bony framework. The discharge is purulent and confluent; where in contact with the air it is desiccated, but where protected, as by crust-like surface-layers, it is semi-fluid and tenacious. There is, consequently, no disposition for the discharge to escape from the nose, and it accumulates until the sense of obstruction induces the patient to remove it by artificial means. When first seen, the nasal chambers are frequently so fully occupied with discharge as to conceal the characteristic appearances of the mucous surface. This prolonged retention induces incipient decomposition of the mass, which gives rise to the odor so characteristic of this group of cases.
The subjects of atrophic catarrh (ozæna) are never in robust health. They are, as a rule, of spare habit, anæmic, and with family histories which, while not distinctive, indicate that the affection is, to some degree at least, hereditary. A few cases have come under my notice in which all the general features of atrophic catarrh were present, but with very slight although confluent discharge, unaccompanied by fetor. Such cases are, strictly speaking, examples of atrophic catarrh, while they could not, under the old nomenclature, be included under the head of ozæna.
The prognosis is unfavorable for entire recovery, but treatment systematically pursued will make the patient entirely comfortable to himself and others—will arrest the progress of the disease and vastly improve the general health. As in other forms of nasal disease, should anosmia be present the prognosis is less favorable.
| FIG. 19. |
| Antero-posterior section of the bones of the face in position, showing the premaxillary portion of the floor of the nose greatly elevated above the plane of the remaining portions. In ozæna, as mentioned in the text, a disposition of parts may exist similar to that delineated, and cause discharge to collect and undergo offensive decomposition. |
TREATMENT.—The parts should be carefully cleansed—an act which, while imperfectly accomplished by either the syringe or the douche, is, in my judgment, best performed by the galvano-cautery. This instrument, the one relied upon for the subsequent treatment of the case, is to be selected for its initiation. The largest speculum which the nose will admit being placed in position, a spiral-looped electrode is introduced cold into the nose and held against one of the crusts. When heated it will effect so firm an attachment to it as to enable the mass to be withdrawn with great ease. In patients with whom the palatal portion of the floor of the nose is depressed below the level of the maxillary a considerable quantity of discharge may lie concealed from observation. When, after the removal of all visible crusts, the fetor persists, it is reasonable to suppose that the palatal depression is filled with decomposed pus and mucus. To test such a condition, the electrode should be appropriately curved and introduced. I have been surprised at the quantities of discharge which can in this way be withdrawn from a locality which, as far as I know, cannot be cleansed in any other way.
With the removal of the crust relief is at once experienced, and if the discharge could be removed as fast as it forms the disease would not really be a source of offence. The general health would also improve, from the fact that an atmosphere tainted with a burden of decomposition would no longer be breathed. But in practice this cannot be attained, and it is imperative, after the chambers have been entirely cleansed, to cauterize the lining membrane throughout. I have been in the habit of beginning such cautery treatments with the middle turbinated bone, passing thence to the inferior turbinated bone, then to the roof of the nose in front of the sphenoidal sinus, and lastly to the septum. Small surfaces only should be covered at a single treatment, so that it may take a month or six weeks to finish a single series of applications. This treatment is almost always well borne, nothing ever ensuing beyond a slight headache or a temporary establishment of a serous discharge. Notwithstanding that the condition in question is one of atrophy, the reparative power of the mucous membrane remains apparently unaffected. At all events, no danger from sloughing is to be dreaded after such extensive destruction of tissue. The thin eschars separate within from three days to a week, leaving a healthy mucous membrane beneath. In one instance the cauterization had extended to a sufficient depth to expose the bone, and yet from this denuded surface no exfoliation took place, the parts healing rapidly and satisfactorily. No other local treatment is relied upon for fetid atrophic catarrh than the one mentioned. No disinfectant washes are required if the discharge is removed as described. Should the patient be so situated as to be unable to report regularly for its removal or treatment, a wash composed of one part of Labarraque's solution to sixteen parts of water may be ordered with advantage, or a solution of carbolic acid, gtt. j to fluidounce j, with a little glycerin, may be snuffed up the nose twice a day, or listerine, diluted one-half with water, may be used with advantage. The general health, of course, should be cared for, and any complications met. I have found that during the winter months arsenic and cod-liver oil are well borne, associated with minute doses of Lugol's solution. For adolescents earthy and the calcareous phosphates are indicated, and for all abundant exercise and careful dieting. When the symptoms have been relieved, the patient should be requested to report once a month, for it is not to be expected that all symptoms will disappear, and some point of advice can be advantageously offered at this interval.
(c) Necrosis in the nasal chamber is a cause of catarrh, inasmuch as the fragments of bone lying within the nose excite irritation and induce discharge. I have never seen a case of this form of disease which was not due to syphilis. The remains of syphilitic angina are apt to be present, and the general manifestations of constitutional syphilis are well developed. The septum is more frequently affected than the turbinals.
Discharge due to necrosis can be readily distinguished from that arising from any other cause by the presence of detached fragments of denuded bone, by the characteristic fetor, and by the history of the case.
The prognosis is favorable, for all symptoms will cease upon the extraction of the fragments, or at least those which remain are of an entirely different character, and are due to the resultant imperfections of the septum, and consequent irritation arising from the too free entrance of air into the nose. I have seen in one case an extensive tumefaction and infiltration of the tissues covering the middle turbinated bone at the same time that the septum was breaking down. These masses require treatment with the galvano-cautery and astringents after the dead fragments have been removed.
A TABLE OF NASAL DISEASES GROUPED BY SYMPTOMS.
| Cases in which interference with nasal respiration is a conspicuous symptom: | ||
| Due to deflection of nasal septum (common). Due to angiose hypertrophy of the mucous membrane (common). Due to tumors lodged in the nasal chamber. Due to adenoid hypertrophy in the naso-pharynx. Due to over-activity of the levator palati muscles (rare). | ||
| Cases in which discharge is a conspicuous symptom: | ||
| Due to hyperplasia of the mucous membrane over the turbinated bones (common). The discharge when flowing backward is described as a dropping; when forward, as a running at the nose. The discharge is either mucoid or muco-purulent. Due to tumors lodged in the nasal chambers or appendages. The discharge is usually excessive. When due to myxomata (polypi) the discharge is mucoid (common). In inflammatory complications of the same the discharge is muco-purulent (common). When due to neoplasms other than myxomata the discharge is purulent, and rarely muco-hæmic (rare). | ||
| Cases in which retention of mucus in the nose or upper part of the throat is a conspicuous symptom: | ||
| Due to retention of inspissated mucus at the roof of the naso-pharynx (common). Due to the mucous secretion of the nose and throat being excessively tenacious (rare). | ||
| Cases in which fetor is a conspicuous symptom: | ||
| Odor putrid. | Due to retention and decomposition of plasmic exudation from atrophied bone and mucous membrane (common). Due to necrosis of the bones within or bordering upon the nose (rare). Due to decomposition of muco-pus in the maxillary sinus (rare). | |
| Odor musty. | Due to partial decomposition in small patches of desiccated mucous crusts (common). Due to morbid secretion unaccompanied by profound alteration in the structure of the nose (rare). Due to ulcerations of the mucous membrane (rare). | |
| Cases in which a sense of dryness is a conspicuous symptom: | ||
| Due to ineffective erectile tissue permitting air imperfectly warmed to enter the nose and the pharynx (often met with in neurosis). It is caused by temporary constriction of the erectile tissue or by the atrophy of the tissue. Due to neurosis. Neurotic patients will often complain of a sense of dryness in the nose and the naso-pharynx when all the conditions of excessive mucoid discharge are present. | ||
| Cases in which hyperæsthesia exists, so that slight lesions that in any way interfere with the nasal functions form the basis of persistent complaint (not infrequent). | ||
Epistaxis.
Epistaxis, or nose-bleed, is a form of local hemorrhage perhaps of more frequent occurrence than hemorrhage from any other mucous surface of the body. This is doubtless owing to the extreme vascularity of the lining membrane of the nose and the special arterio-venous (cavernous) spaces of the turbinated bones; and the bleeding may be said to be of grave character in proportion as these spaces are involved. In some individuals a special disposition to nasal hemorrhage exists. From the fact that the affection is transmitted from parent to offspring, and is frequently found in all members of a given family, this form of hæmophilia is probably dependent upon some structural peculiarities in the cavernous spaces.
The causes of epistaxis are both local and general. Among the local causes may be included traumatism, either from blows or other injuries, attempts on the part of the patient to relieve irritation by picking the nose, or from the use of cutting or other instruments in the hands of the surgeon. Septal ulcerations in this way are often accompanied by moderate bleeding. In a case reported by R. G. Curtin the nasal branch of the ophthalmic artery was thought to have been ruptured. Among the general causes the most frequent is undoubtedly the depressed state of the system preceding or accompanying typhoid and other anæmic states. Thus, among the prodromes of typhoid fever epistaxis holds a conspicuous position. It is also seen in chlorotic females, especially in those suffering from that phase of anæmia known as Grave's disease. It also occurs in vicarious menstruation and in local facial or encranial congestions. In those disorders of nutrition accompanied by a tendency to capillary extravasation, such as purpura and scurvy, the nasal mucous surface participates in the general disorder. In a case of the former disorder coming under the notice of the writer the blood had forced its way out in large quantities by every capillary avenue.
TREATMENT.—Epistaxis when a symptom of a dyscrasia is of course to be treated as a local expression of a general condition. In typhoid fever, scurvy, and purpura or anæmia the bleeding is a sign of the general distress, and requires no special local method of treatment. Epistaxis when of local character should be treated, first, by removing the cause; second, by diminishing the flow of blood to the part; third, by cold and astringent washes to the affected surface; and, fourth, by compression.
First. Should the bleeding be kept up by fragments of bone impinging upon or lacerating the mucous membrane, they should be restored as far as possible to their natural position and retained there by appropriate apparatus. If they are entirely denuded of their periosteum and mucous membrane, they should be removed. Foreign bodies should be extracted, and if septal ulceration be present it should be carefully treated, the crusts removed, the ulcerated surfaces touched with nitrate of silver in stick, and the nasal chamber plugged from in front to exclude the outside air.—Second. The position of the body is of great importance in treating epistaxis. The recumbent position is no doubt to be preferred. The patient often holds one arm elevated or ties a cord about the proximal end of a limb. These innocent accessories to treatment may be permitted, since they are based upon well-known physiological principles, although it must be said that the bleeding can in all instances be checked without their aid. Cold applications to the nape and sides of the neck are often of service. Various internal remedies, such as ergot, gallic or sulphuric acid, and erigeron, may be administered with good effect in addition to the local measures.—Third. Astringent washes, such as a solution of alum—about drachm j to the pint—will often check a moderate degree of capillary bleeding without other aid. Tannic or gallic acid may also be used. Should these measures fail, the Monsel solution may be used on pledgets of cotton carried up to the bleeding spots. In Curtin's case, already quoted, a pledget saturated with the solution of the perchloride of iron placed over the nasal branch of the ophthalmic artery promptly arrested the bleeding. In lieu of these styptics the platinum wire loop of the galvano-cautery battery may be used. The writer has often succeeded in checking bleeding after a removal of a polypus or the use of the galvano-cautery when the exact position of the hemorrhage is known by laying upon the affected spot a little square of patent lint. It acts much as in checking the bleeding from a leech-bite.—Fourth. Compression of the mucous lining of the nose and exclusion of these surfaces from the air—a method familiarly known as plugging the nose—is the dernier ressort in the treatment of epistaxis, and is to be relied upon in the event of failure of other methods. This failure is, however, relatively infrequent. Observers agree in describing the procedure tedious and rather disagreeable, as much to the operator as to the patient, who has already been exhausted by loss of blood and the previous measures resorted to for his relief.
| FIG. 20. |
| Bellocq's Canula. |
The instrument usually relied upon for this purpose is known as Bellocq's canula (Fig. 20). This little instrument consists of a hollow curved tube of metal fashioned somewhat like a Eustachian catheter, and bearing within it a flexible and adjustable metallic band which carries at its extremity an eyelet. Any one who has used the Eustachian catheter will recall the number of instances in which it could not be passed, or if passed the frequency in which great distress followed. If this be true of the Eustachian catheter, it is also true of the Bellocq canula, the difficulty in the case of the catheter, indeed, being the lesser of the two, inasmuch as the physician has a number of sizes to select from. Conceding, however, that the instrument (with a long stout thread passed through the eyelet of the stylet) has been placed in position in the nasal chamber, one end of the thread is seized within the mouth and brought out between the lips, while the other, carried by the instrument, is withdrawn through the nose and is allowed to hang from the nostril. The two ends of the thread are now tied firmly together, and a pledget of lint or cotton, fashioned somewhat after the shape of the posterior naris, is tied to the thread. Traction is now made upon the nasal portion of the thread until the plug is firmly lodged against and within the posterior naris. The remaining portion of the oral thread is now cut off close to the velum, and the free end of the nasal thread secured by adhesive plaster to the integument. The nostril should next be stopped from in front by pledgets of lint or absorbent cotton. The size of the nasal chamber and naso-pharyngeal varies so markedly that a rhinoscopic examination is of use in fixing upon the size of the plug. If it be too small, it will be drawn entirely within the nose, and possibly beyond the bleeding spot. If it be too large, it will partially or entirely occlude the posterior naris of the opposite side, and thus by interfering with nasal respiration greatly increase the distress, or by pressure against the Eustachian fossa and velum interfere with the hearing and with deglutition. The plug should be retained in position until a purulent mucus appears within the nose: this is usually about the third day. The plug now usually becomes a little loose, and can readily be withdrawn by pushing it back into the pharynx, where it is seized with forceps. Too long retention of the plug in position is followed by great fetor and the free formation of muco-pus—conditions which tend to debilitate the patient.
D. Hayes Agnew informs me that he for a long time practised stopping nasal hemorrhage by plugging the chamber from in front. Strips of patent lint four inches long by half an inch wide are employed for this purpose. They are gradually pushed into the chamber until the entire space is filled as far as is practicable. An essentially similar method is described by F. H. Bosworth in his Manual of Diseases of the Throat and Nose.
Morbid Growths.
These may be said to include the myxoma, sarcoma, fibroma, carcinoma, also the true hypertrophies and submucous inflammatory thickening.
The myxoma, more commonly known by the name of soft or gelatinous polyp, is the most prominent of the morbid nasal growths. It occurs ordinarily in small pedunculated seed-like masses, ranging in size from that of a grain of wheat to a grape. The most common seat is on the anterior portion of the middle turbinated bone and on the median surface of the inferior turbinated bone at the palatal portion. Instead of being pedunculated, they may be sessile; that is, each tumor may have a base equal to, if not exceeding, any diameter of the tumor.
The symptoms of nasal polypus are of three kinds: (1) those arising from obstruction of the nasal respiration; (2) those arising from the irritation excited by their presence; (3) the symptoms, reflex in character, manifested at points beyond the limit of the nasal chambers.
(1) The polypi necessarily tend to obstruct the respiratory tract of the nasal chamber. The first symptoms are of this character, and as a rule furnish the first intimation to the patient that trouble exists. Difficulty of nasal respiration is acknowledged, accompanied with a sense of tension and fulness, which is found to be worse during damp weather than when the air is dry and bracing. If the growths are freely pendulous, the act of blowing the nose may change the position of the mass and secure temporary freedom from distress. Incidental to obstruction, an intonation of the voice is often present. Loss of smelling and of taste is a frequent result of the mass interfering with the movement of the odoriferous particles. The loss of the sense of taste is dependent upon the loss of the sense of smelling.
(2) Polypi when large enough to press against the membranes of the nose excite an increased flow of mucus. As a rule, this flows forward, and is removed by the handkerchief. The quantity of fluid thus escaping is often very great. Patients often report the necessity of carrying about with them for a single day's use from eight to ten handkerchiefs. In the turgesence excited by an attack of coryza the mucus becomes thicker and of a yellowish color. Occasionally a sensation of dropping of mucus from the nose into the throat is a source of complaint.
(3) The reflex symptoms belonging to the presence of nasal polypi are, as a rule, referred to the forehead. This is especially the case if the growths involve the middle turbinated bone. When the tumors are so located, and have not impinged upon the respiratory tract, the symptoms of obstruction may be absent, and those of mucus excitement so moderate as not to excite attention, while the tension in the forehead, especially over the frontal bos, is pronounced. This sensation is intensified by prolonged inclination of the head forward, being especially aggravated in the acts of writing at a desk, working at a sewing-machine, kneeling at prayer, etc. Occasionally tinnitus aurium and suffusion of the conjunctivæ are present.
Neglected polypus ends in deformity of the nasal chambers and bones of the face. The face assumes a peculiar expression called by the older observers frog face. This is rarely if ever seen in this country, owing doubtless to the fact that the sufferers from nasal polypus seek medical advice in the early stages of the affection. Moderate degrees, however, of deformation of the turbinated bones are often seen.
Since the symptoms of soft nasal polypus are produced entirely by mechanical means, they can be closely imitated if not replaced by other morbid states of the mucous membrane. A hyperplastic state of the membrane over the middle turbinated bone will give rise to all the symptoms of a sessile polypus in the same situation. It is well to remember that this condition of the membrane often coexists with polypus, and of course will persist after the polypus has been removed. It follows that a guarded prognosis should always be made in case of sessile polypus. A tedious course of treatment of the indurated and chronically inflamed membranes may be required after the tumors have been removed before a cure is effected. The prognosis of soft polypus is more favorable as to the immediate results of treatment than in sessile polypus. The liability to recurrence can be materially lessened by carefully conducted after-treatment.
The diagnosis of soft pedunculated polypus is readily accomplished if the examination is made by aid of an appropriate speculum, the rhinal mirror, and a powerful light. Even without these aids the tumors can be seen by direct sunlight within the nostril if they are entirely occluding the chambers, and even in the event of nothing being visible by such inspection the movement of the masses by the act of blowing the nose will be noticed. The fact that the nasal obstruction is aggravated by damp weather seems to assist the physician in framing a diagnosis.
The diagnosis of sessile polypus requires a careful use of all the aids of rhinoscopy. They can be distinguished from hyperplasia of the mucous membrane by their lobulated form, and from the fact that the probe can move them slightly from their base. They can be distinguished from adenoid growths at the root of the pharynx by the fact that they remain unmoved during the act of swallowing.
The disease is not apt to recur if the treatment is thoroughly carried out.
The treatment of soft polypus consists in their removal. All observers are now agreed on this point. Injection by astringents and acetic acid—a process that at one time held out much promise—has been generally abandoned. In removal of the polypus one of two methods may be resorted to: that by avulsion, and that by the use of the snare. Avulsion is effected by forceps adapted for this special use. With such an instrument the polyps can readily be seized and removed. The rule that nothing should be seized which is not seen is subject to no exception. In no other way can the operator be secure against accidents. Incautious operators have frequently torn away strips of mucous membrane or portions of the turbinated bones in their crude attempts to remove these growths. Severe hemorrhage and death through violent lacerations of the ethmoid bone near the cribriform plate, and subsequent extension of the inflammation thereby excited to the membranes of the brain, have been known to follow these crude surgical procedures.
| FIG. 21. |
| The Author's Nasal Forceps. |
W. C. Jarvis of New York has modified the wire snare for application to the nose for the removal of polypi and hypertrophied tissues, and reports that it is a safer, more expeditious, and less painful method of operation than the forceps, which he unqualifiedly condemns. His instrument, while undoubtedly an ingenious adaptation of the principle of the snare, and a valuable addition to our means of treating nasal affections, cannot, in my judgment, take the place of the forceps in removing nasal polypi. As the aurist finds both the forceps and the snare useful in removing growths from the external meatus of the ear, so I am sure the physician will need both in the treatment of nasal polypi. In many cases the malformations of the nasal septum are such that I have been unable to use the snare where the forceps could be used with relative ease. I find when the loop is quickly drawn the same amount of bleeding follows as when the forceps are used. When it is slowly drawn, the sitting is tedious, and both the patient and attendant find the process wearying. The amount of blood lost when the forceps are properly used is not considerable, and is always under control. F. H. Bosworth1 describes the operation as extremely painful. So far from this being the case in my experience, I find the patients complain greatly of the constriction of the wire loop on the pedicle of the polypus, and invariably prefer the forceps. I must add that this preference was in no way influenced by myself, for I was disposed at one time to agree with the writers who have of late criticised the method of removal of the polyps by avulsion.
1 A Manual of Diseases of the Throat and Nose, 1881, p. 241.
No matter which of the methods be accepted, the treatment of polypus resolves itself into two simple propositions. When one or two large polypi are present in a capacious nasal chamber, the removal of the growths either by avulsion or snaring is a simple matter, and can often be accomplished in a single sitting. When numbers of small polypi are scattered over a large surface, particularly if they grow from the sides of the middle turbinated bone, the treatment is tedious, and even after the growths are removed a series of applications are required to cure the thickened and infiltrated mucous membrane.
Sarcoma, fibroma, and carcinoma are infrequent causes of nasal disease. When located in the nasal chambers they do not present any characters with which I am familiar which distinguish them from the expressions they assume in other parts of the body. When involving the respiratory tract they alike create symptoms by obstruction, by excitement of the secretions, and by the reflexes due to the involvement of the branches of the fifth pair of nerves. When situated in the olfactory track the obstruction to nasal respiration is absent, but the reflex symptoms are pronounced: the patient is liable to depression of spirits and to frontal headache. Encroachment upon the orbital, pharyngeal, and encranial spaces is common in the last stages.
Perhaps the most common way in which these morbid growths induce symptoms referable to the nose is by obstruction of the respiratory tract by the incursions of a mass originating at a point beyond the limits of the nasal chambers. In this way a growth in the pharynx may close one or both choanæ, or protrude into the nose from the spheni-palatine space by breaking down the ascending plate of the palatal bone as it forms the median wall of this space; or the growth may project inward from the superior maxilla.
In one case under my care, of obscure growth high up within the nose, which ended fatally by involvement of the membranes of the brain, a tenacious mucus of a dark chocolate color was withdrawn from the nose into the throat. The peculiar color of the mucus was found to be caused by a mixture of blood. In my judgment, this peculiar mixture of blood and pus was significant. The blood and mucus had not been mixed in the nasal chamber to cause the chocolate or rusty hue, for then we would have had the appearance customary in epistaxis of bright blood and frothy mucus mechanically held together. The even dissemination of the blood through the mucus would point to the conclusion that the blood had escaped in small quantity at the time of the formation of the mucus. Why such mucus does not constantly form in inflammatory states of the mucous membrane of the nose, as it does from the pulmonary mucous membrane in pneumonia, I am not prepared to say. But existing as it did in a case where a deep-seated disease was present may be accepted as a fact in some way connected with the invasion of a morbid growth in and upon the nasal mucous surface.
The pharynx is always in a state of hyperæmia when morbid growths of the above groups are present in the nose. The front of the velum is apt to be covered with a great number of minute papillæ, which, however, are often seen in anæmic individuals, and are not therefore pathognomonic.
The treatment of the growths enumerated and the general conduct of the cases are subjects for the general surgeon, and a consideration of them here would be out of place.
It may, however, be well to describe a few instruments which have been found useful in the large group of cases where cauterization is the principal treatment indicated. Foremost among these is the instrument shown in Fig. 22, which combines advantageously the essential features of the galvano-cautery and the wire snare.
| FIG. 22. |
| The Galvano-cautery Snare described in the text: 1, the cable of the battery; 2, the canula (which is not shown in full length); 3, the platinum wire; 4, the vulcanite carriage, with screws holding the ends of the platinum wire in metallic contact with the hinge-connections, by which the current is transmitted from the battery; 5, a slotted barrel of aluminium; 6, a movable nut on the screw; 7, a small portion of the screw disengaged from the slotted barrel; 8, milled stationary screw-head. |
| FIG. 23. |
| The Double Battery employed by the Author: The two sets of plates are seen united by a flat band of metal. The case which encloses the two separate batteries opens in front, displaying the cells, the plates (which are seen pendent over the cells), and the treadle. Above the figure of the battery lies a figure of the Flemming electrode handle and the electrode in position. |
It is well known that a loop of wire which is steadily narrowed has great power in severing the attachment of tumors and other outgrowths. When of a large size, it may be sufficiently powerful to pass through bony structures, as well as the softer parts of the body. The principle of the snare has been employed both in the throat, the ear, and the nose; but when my attention was first directed to this subject the forms available were too large and heavy for the delicacy of manipulation demanded in removing small tumors lodged in the narrower recesses of the nose. Moreover, no snare that I could then find would permit the galvanic current to pass through the loop at the time it was being narrowed. I was led, therefore, to inquire into the practicability of an instrument which would at once be light, be of small size, and yet be sufficiently powerful to remove that class of hypertrophied tissues and polypoid growths which are of such frequent occurrence in the nasal chambers. The instrument shown in Fig. 22 combines these qualifications, and satisfactorily performs the service for which it was designed. The only feature of an essential character which may be said to be novel is the fact that the platinum wire (3, Fig. 22) forming the snare is covered with a uniform coat of copper, excepting alone the portion forming the loop, which is bare. As a consequence of this arrangement the current of electricity from the battery is conducted through a double canula (2, Fig. 22) by means of the copper. The length of the instrument being about 9½ inches, and its weight less than ½ ounce, delicacy of manipulation is not interfered with. Besides possessing all the features of the cold wire snare, it has the additional advantage of securing a more rapid and painless operation, without any hemorrhage. Sessile (pyramidal) or resilient growths may be removed by first burning a groove of any depth into them, after which the loop is drawn while the current is passing through it. For this task the cold wire snare is obviously incompetent. Growths of unusual size or hardness may be destroyed by the same procedure, and nodules no larger than a grain of wheat may also be excised with great nicety. It will be seen that failure to remove at least a portion of the growth attacked is an event exceedingly unlikely to occur. I have been particularly struck with the facility with which hypertrophies of the inferior turbinated bone can in this way be treated; and if cocaine be freely applied before the operation, it constitutes, in my judgment, the most speedy and the least painful of any means by which such conditions can be reduced. By using a canula with a curved end it is easy to snare growths situated on the posterior portion of the inferior turbinated bone. The current passing through the battery (Fig. 23, B) to the instrument can be interrupted by any of the numerous devices with which the practical electrician is familiar; or the treadle of the battery can be depressed and locked by the lever-catch, and the interruption of the current be determined by the pressure of the finger on the knob in the handle (Fig. 23, A). This is under all circumstances desirable, since the weight of the cells is sufficient to demand considerable force to be exerted by the foot—always enough to destroy the delicacy of the manipulation of the instrument.
| FIG. 24. |
| Two Electrodes of peculiar shape in use by the Author. |
An electrode which is wrapped nearly to its distal end (Fig. 24), and used either in a straight or a curved form, is of great advantage in reaching growths within the naso-pharynx. The straight form can be thrust directly back through the nasal chamber, and the curved form can be passed from the oro-pharynx to the naso-pharynx without danger of burning the posterior border of the soft palate.