A system of practical medicine. By American authors. Vol. 3

by Unknown

(a, b) When the septum is deflected and the left nasal chamber is narrowed, the labor of sustaining nasal respiration is thrown on the right side. This arrangement invites a flow of blood to the already large turbinals, and creates obstruction which is frequently referred to the right side, although both are alike affected. Thus, subjects in which the initial obstacle is osseous complain of distress caused by cavernous-tissue hypertrophy of the lining membrane of the opposite side. This represents a very common class of cases.

When the septum is not deflected, but projections from it impede the current of air, there may be either unilateral or bilateral obstruction, dependent upon the shape of the septum itself. Hypertrophy of the cavernous layer of the mucous membrane usually coexists. These cases are numerous, but less common than those last described.

Infrequently, cases are seen where the distress is occasioned by defects of the osseous structures not accompanied by cavernous hypertrophy.

Treatment of the above disorders consists in restoring nasal respiration by removing obstructions, whether they be osseous or membranous. The septal projections may be drilled or filed away, or, if marked deflection of the anterior portion be present dependent upon a malposition of the triangular cartilage, an operation simple in character may be performed for its correction. This consists in severing the connection of the lower margin of the cartilage with the maxilla and slipping the partially free cartilage to a new position. The details attendant upon the operation need not be here given. The reduction of the hypertrophied membranes can be best accomplished by cauterization. The most efficient method is by means of the electric cautery. The electrode used should be flexible and of small size. The points which most frequently require cauterization are the premaxillary portion of the inferior turbinated bone, the under surface of the same, and the septum at the maxillary spur. Rarely the inferior surface of the inferior turbinated bone at the palatal region requires attention. The applications are best made over small surfaces at a time, and should be repeated at intervals of from two to three days until all suspected points have been at least once cauterized. Not infrequently, the effect of the cauterization at one spot will cause constriction to take place in the vessels of the entire mucous surface, so that while this condition lasts it is impossible to tell what additional points of the membranous obstruction demand removal. At the following visit, however, the vessels have become relaxed, the membranes are again turgescent, and if obstruction now occurs it can easily be detected.

The galvano-cautery can only be used in the nasal chamber in patients who are earnestly seeking relief and are willing to assist the physician in all his efforts. With the tractable, intelligent subject it can with proper care be limited exactly to the spot intended. It is scarcely necessary to observe that any erratic or unexpected motion of the head will sear unaffected and sensitive surfaces. The interior of the vestibule is perhaps the most sensitive of these, and should always be protected by the use of the nasal speculum. No additional protection is needed, though in the judgment of others, among whom may be mentioned E. Shurly of Detroit, Michigan, an ivory shield passed in the nose parallel to the electrode is a necessary safeguard.

The pain of the application is generally slight, and can be in part annulled by a previous application of a 4 per cent. solution of cocaine. Some annoyance is acknowledged on the following day from the pressure of the eschar. Traumatic congestion of the entire mucous surface of the corresponding chamber is at the same time detected, and is usually sufficiently decided to produce some of the effects of acute coryza. This condition will spontaneously terminate in from thirty-six to forty-eight hours. The most annoying features following an application of the galvano-cautery which has been too freely made do not belong to the group just indicated, but rather to reflex disturbances. Pains are occasionally excited in the teeth, in the temple, eye, nape of the neck, and the middle ear. On one occasion in the writer's experience a unilateral reflex excitation of the entire opposite side of the body occurred, and a prickling sensation, followed by numbness, ensued, which lasted for twenty-four hours. Very rarely a congestion of the pharynx, of the larynx, and the larger bronchial tubes ensues, which can scarcely be directly attributable to the application, yet it has followed in a sufficient number of cases to lead me to believe that the two are in some remote way associated. Perhaps such a condition is analogous to the slight irritation of the respiratory tract following excision of the tonsil. Careful use of the galvano-cautery will obviate the conditions above described. They are important to remember as serving as limitations to the use of this valuable agent.

(c) It will be seen that osseous obstruction in the nasal chamber and hypertrophy of the cavernous nasal tissue often coexist. More rarely, a third element occurs as a complication, or it may be found independently of all other morbid processes. I allude to the presence of hypertrophy of the adenoid tissue in the pharyngeal vault. When this tissue is only moderately developed, it need not, and does not, interfere with nasal respiration; but when it projects downward to such a degree as to lie within the axis of the lower portion of the posterior nares, it produces the same effect upon nasal breathing as though obstruction existed within the chamber. The growths can be easily detected, as a rule, from behind by the aid of the rhinal mirror, but it should not be forgotten that they also can be seen from in front, provided the chamber is free from obstruction along the respiratory tract. In some individuals the ribbed or lobate structure of the mass can be discerned, but more often its presence is revealed by the minute points of light reflected from the lobules. If it be a matter of doubt whether these points of reflection are within the nasal chamber or beyond it in the pharyngeal vault, the patient may be requested to swallow, or to pronounce the letter e; when, if the point of reflection is within the nasal chamber, it will not change its position, but if it be within the naso-pharynx, it will be moved slightly from side to side, or it may for a moment disappear.

The symptoms of nasal catarrh which are provoked by the presence of such a growth can be alone successfully treated by the removal of the offending mass. In young individuals—say, from twelve to eighteen or twenty years of age—the finger inserted into the naso-pharynx from behind can often break down the growth. Slight hemorrhage follows this procedure, and the tags of imperfectly-destroyed tissue can be subsequently treated by caustics and powerful astringents. In the event of the patient proving intractable, the growth may be reached from in front through the nasal chamber, and the galvano-cautery can be used by passing the electrode backward through the nostril until it meets with resistance, which is invariably at the pharyngeal vault. Should this method of treatment not be permitted by an undisciplined or nervous person, the prolonged use of a glycerole of iodine may gradually reduce them in size; but no definite result can be promised from such treatment.

(d) Very rarely, through inordinate elevation of the soft palate owing to over-action of the levator palati muscles, the passage of communication between the naso-pharynx and the oro-pharynx is inadequate. Consequently, the nasal chamber is imperfectly ventilated, and its secretions, not flowing backward or being displaced to the normal extent, become semi-inspissated, and create obstruction by lodging in the respiratory tract, either in the premaxillary or palatal portions. To successfully combat this condition it is evident that no local treatment is demanded, either in the nose or the naso-pharynx, other than to increase the tonicity of the pharyngeal and palatal muscles. Very frequently in such cases there is a symmetrical atony in the muscles last named, which demands the internal use of strychnia and iron and the application of galvanism.

PROGNOSIS.—When nasal catarrh has proved to be dependent on defective respiration, the removal of the causes entering into this condition may with reason be expected to effect recovery. The prognosis, therefore, is favorable. In young persons, in whom reparative power is present in the highest degree, and in whom a secondary hypertrophy of the cavernous tissues is least developed, a prompt cure may be obtained by removal of the osseous or other forms of obstruction. In adults, however, the prognosis is less favorable, especially with those who have approached or passed middle life, and who have contracted vicious habits of breathing, which are likely to persist even after the removal of their causes. It is also tenable that in such subjects the mucous lining of the cranio-facial sinuses has become involved. Should anosmia persist after the capacity of the chambers has been augmented—in a word, should this condition not be dependent upon obstruction, but upon changes in the olfactory surfaces—the prognosis is less favorable than in any of the cases of the above-named group.