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 ozæna 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 fossæ of Rosenmüller 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 alæ 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 anæsthesia. 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 Lœwenberg's—a tongue depressor, a gag, and one or two throat sponges on holders. The patient having been anæsthetised, 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 fossæ of Rosenmüller 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.