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

by Alexis Thomson; Alexander Miles

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 anæsthetising 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 œdematous 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 hæmorrhage 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.

Hæmatoma 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 gonorrhœal 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 fœtid atrophic rhinitis (ozæna) and syphilis, and in these conditions the discharge is associated with a most objectionable and distinctive fœtor. Pus from the maxillary sinus is often fœtid, and the odour is noticed by the patient; while the odour of ozæna 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 anæsthesia, 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.

Ozæna, or fœtid 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.