Fig. 265.—Acute Mastoid Disease, showing œdema and projection of auricle.

Treatment.—When arising in connection with acute otitis, the application of several leeches behind the ear, free incision of the membrane, and syringing with hot boracic lotion may be sufficient. As a rule, however, it is necessary to expose the interior of the antrum by opening through the mastoid cells—Schwartze's operation. When mastoid suppuration is associated with chronic middle-ear disease, it is usually necessary to perform the complete radical operation—Stacke-Schwartze operation. The operations are described in Operative Surgery, p. 98.

CHAPTER XXV
THE NOSE AND NASO-PHARYNX[6]

[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 maxillæ. 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 hæmatoma 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 anæsthetic 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.