Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

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.

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 hæmatoma 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.