It should hardly be necessary to insert here the caution that no operation of even this degree of simplicity should be effected without careful cleansing of the nasal cavity.
Of the other tumors that may occur within the nasal cavities none can be said to frequently occur here, but all varieties may be encountered. Of the more benign tumors the most common are the vascular growths and the fibromas, or mixed form of fibromas and papillomas. Epithelioma and sarcoma occur occasionally.
FIBROMA OF THE NASOPHARYNX.
Fibroma of the nasopharynx is much more common than in the nasal cavity proper. Here it assumes its usual characteristics as a more or less firm and dense tumor, growing slowly, sometimes from a large base and again in pedunculated form. A form occasionally met with springs from the periosteum of the base of the skull and slowly extends into the nasopharynx, causing in time a complete obstruction, with disappearance of the surrounding structure by its pressure effects. Some of these growths are of a considerable degree of vascularity. When arising from the base of the skull they become almost inoperable after obtaining considerable size. I have seen death upon the operating table, in one of the foreign clinics, from uncontrollable hemorrhage occurring during the removal of one of these growths. A growth thus situated should be attacked with extreme caution, and preferably after easier access has been made to it by division of the soft palate, and removal of a portion of the hard, or perhaps by a temporary or permanent resection of the upper jaw; the route being left in each case to the decision of the operator. Provisional ligation of the carotids may be also made.
The same is true of the other tumors of the nose and nasopharynx. The less malignant they are the more they justify radical attack. By the time a sarcoma or adenocarcinoma of deep origin has declared itself it is usually too late to justify its removal.
ADENOIDS OF THE PHARYNX.
A new-growth of different form, occurring in the vault or around the outlines of the pharynx, is frequently seen in the shape of great hypertrophy or overgrowth of the lymphoid tissue, already and elsewhere alluded to as composing a part of the original lymphoid ring which marks the site of the embryonic nasopharyngeal canal. This lymphoid hypertrophy, whose commencing expressions are seen in the tonsil, is referred to as adenoid growth. Associated with it occurs more or less hypertrophy of the other tissues, fibrous, etc., according to whose proportion the growths will be soft and spongy or more dense and resistant. The so-called adenoids occupy more or less of the nasopharynx proper, reducing its dimensions, encroaching upon the vault of the pharynx, materially reducing the breathing space, thus leading to the establishment of the mouth-breathing habit, as well as to alteration of voice and the accompanying disagreeable features of increased secretion of the parts. It leads to characteristic appearances which may be recognized at a distance, consisting of a mouth habitually open, with more or less projecting teeth, pinched nostrils, Gothic roof of mouth, stooped shoulders, deformed thorax, loss of hearing, irritative cough, and possibly remote reflex effects, such as laryngeal spasm, general neuroses, chorea, and epilepsy. The effect of these changes is to give not merely an appearance of stupidity, but actually to interfere with mental development. Save in exceptional instances, a child with the mouth-breathing habit, and with that peculiarity of voice which indicates nasal obstruction, will nearly always be found to be defective in cerebral activity, if not actually stupid. The longer the condition is allowed to persist the greater the permanent alterations and damage permitted.
Pronounced degrees of the condition may be easily recognized by the habitually open mouth and the character of voice. A moment’s inspection will usually reveal the character and the degree of involvement. When adenoids in the nasopharynx attain a size sufficient to produce these results the tonsils are also usually involved, and the clinical picture is thereby made more pronounced. The rhinoscopic mirror, if it can be used, will give a picture of the condition, while the finger-tip passed upward behind the soft palate will give an idea as to the extent to which the cavity is filled.
By virtue of the interference with the vital function of respiration thus produced, and because of the retention of secretion and the greater exposure to irritation through the constantly open mouth, individuals with this condition are usually anemic, while many of them give evidence of the status lymphaticus, to which attention has been called in the preceding pages. To such an extent is this true that the administration of an anesthetic is frequently attended by extra danger, and the operator should give the necessary relief only after careful preparation. This should consist not only of general measures, by which the condition of the patient may be improved, but by local cleansing of parts; and finally, as a preparation for the anesthetic, of the local use of a weak cocaine solution, by which reflex excitability may be controlled. Just before administering the anesthetic in these cases it is well to spray into the nostrils and pharynx a weak cocaine solution, after which the anesthetic may be administered. In most instances it would be better to use ethyl chloride or ether than chloroform, not because the latter is necessarily more dangerous, but because one is placed less upon the defensive in case of accident, owing to the belief that it is not so safe as some other anesthetics. (See [p. 164].)