The congenital malformations of the upper respiratory passages pertain mainly to the nasal septum and the interior of the complicated nasal cavities, which are rarely symmetrically arranged, and which often differ considerably. The nasal septum is frequently deviated or warped to one side, often to an extent making one nostril too restricted for easy breathing purposes. The nostrils are occasionally seen to be abnormally retracted. Malformations of the pharynx are of rare occurrence. The soft palate is occasionally found to be more of a diaphragm than is natural, and imperforation is sometimes seen. Pharyngeal fistulas have been mentioned in connection with incomplete closure of branchial clefts. They occur more commonly on the right than on the left side, and are usually incomplete. A fistula placed in the middle line and opening into the larynx or trachea is also occasionally seen, its inner opening being generally found on the side of the pharynx and just below the tonsil. This is not necessarily a persistent remains of the thyroglossal duct, but may have a different origin. Cystic distentions not infrequently occur along these fistulous tracts. Malformations of the larynx are rare and consist mainly of narrowings or stricture formations.
Acquired malformations of the respiratory passages are common and are the result usually of previous disease or injury. They may assume the obstructive type, as when the tonsils or the other adenoid or lymphoid tissues of the nasopharynx become hypertrophied, or they may assume the constrictive type, as when strictures result from ulceration, produced either by disease or by caustics. Such diseases as diphtheria cause not only paralyses, through the nervous system, but cicatricial deformity in consequence of ulceration. The latter is also true of burns, while fractures may permanently displace parts, this being particularly true of the nose, but holding good also for the hyoid, and even for the larynx. Nearly all these malformations permit of more or less surgical improvement by operations, some of which are simple and easy of performance, while some will need the highest degree of trained skill.
—Ozena is a general term applied to ulcerative lesions, especially involving the Schneiderian membrane in the nose, and causing more or less discharge of mucus, pus, and crusts, nearly always offensive, and accompanied by evidences of deeper ulceration, involving the fragile nasal bones or the nasal septum, and constituting expressions of caries or necrosis in this region. Ozena may be the consequence of a milder catarrhal inflammation, occurring in patients of vitiated constitution and bad habits of life, with insufficient attention or no care whatever. Another type of ozena is from the beginning of syphilitic origin, and it is especially the syphilitic cases which present the most offensive types of lesions, yet which are the most satisfactory to treat, because of the relative certainty with which they yield to properly directed treatment. Any case characterized by profuse and offensive nasal discharge, in which by suitable illumination and examination ulcerations can be detected, should be considered ozena.
—The treatment for all these cases should consist of local cleanliness, alkaline solutions in spray or by irrigation being especially indicated because of their cleansing properties. Warm sterilized salt solution may also be used for the same purpose. All visible ulcerations should be treated by local applications of mild silver nitrate solutions, or some other combined antiseptic and stimulant; or these may be alternated with local applications of an ointment of the yellow oxide of mercury in strength of 0.5 to 1 per cent. Local treatment, however, is but a part of that which should be instituted. In every case where the syphilitic element can be recognized, or where there is good reason for even suspecting it, vigorous antisyphilitic treatment should be begun and prosecuted. While these cases nearly always need one of the iodides, administered internally, there is no way of so quickly bringing them under the desired influence as by inunction with the ordinary mercurial ointment. Both measures should be carried along simultaneously until the combination proves to be too active, when the inunction may be discontinued.
In addition to these measures such cases need improvement of elimination and of nutrition, and the best restorative tonics may be combined to advantage with any other special medication which may seem to be indicated.
Nowhere, except perhaps in the ear, are foreign bodies more likely to find entrance, and become impacted, than in the respiratory passages. They are introduced either through the nose or the mouth. They consist of almost all imaginable substances, introduced either by accident or design, and belonging to all three kingdoms—animal, vegetable, and mineral. According to their nature, size, and lodging place, symptoms of more or less severity will ensue. Migratory bodies, especially small insects and parasites, may escape from the nasal cavity into one of the accessory sinuses, where they will give rise to great irritation, and necessitate perhaps serious measures for relief. The presence of a foreign body is not always promptly recognized. In some instances it is discovered only by accident, as when, having been present for some time, it has produced irritation, with or without ulceration and offensive discharge. Thus a shoe-button may have been pushed up the nose of a little child, and remain there undetected for some time, perhaps to be spontaneously extruded in the act of blowing the nose. The presence of a foreign body in the nasal passages, then, will be manifested by symptoms of obstructed nasal respiration and by other evidences of local irritation, with pain, tenderness, swelling, and discharge.
An object easily seen is ordinarily easily removed, unless it has some peculiar shape which impedes its easy withdrawal. Local cleanliness is the first prerequisite, and then in most instances local anesthesia, which may be produced with cocaine or one of its substitutes. After this a probe, bent into the shape of a blunt hook, or forceps of various patterns and shapes may be required, and will usually suffice for all ordinary cases which can be detected by inspection through the nostrils or with the rhinoscope. In more difficult and unusual cases the fluoroscope or the skiagram may be made to render great service. Should some larger object be found, particularly in the antrum, deeply within the cranium, then a more formal operation will be demanded, whose details should be made to suit the needs of each individual case. When a mass of inspissated secretion or of granulation tissue more or less conceals the outline of the foreign body, everything should be cleaned away with irrigating spray, or with cotton wrapped around a probe or held within the forceps.
—A rare condition of calculus formation is occasionally met with in the nose, the concretions being formed by precipitation of the mineral elements from the nasal mucus, and constituting the ordinary rhinoliths. These become, in effect, foreign bodies, and are to be recognized and treated as such. After syphilitic ulceration portions of bone may be loosened spontaneously, and dropped into locations where they are caught instead of being spontaneously expelled.
It is known, also, that, especially in tropical climates, there are several species of insects which enter the nostrils and there deposit their eggs, which later are hatched into the resulting larvæ, the latter sometimes being expelled, or perhaps developing and burying themselves further within the nasal recesses. Any living organism may be killed by administration of chloroform or ether, and then expelled as an ordinary foreign body; or, in most cases, such larvæ or eggs can be washed away with an irrigating stream to which a little extract of tobacco should be added. Thus maggots have been found buried within the nasal mucosa, and requiring extraction by means of forceps. When larvæ have invaded the sinuses the case becomes more serious, for it will require free exposure by perhaps a somewhat formidable operation on the interior of the sinus, which should then be carefully cleansed and suitably drained. Living organisms within the nasal cavity or the sinuses will cause headache, lacrymation, sneezing, nasal discharge, perhaps with epistaxis, and almost every possible expression of local discomfort.
—Foreign bodies in the pharynx are usually, when small, lodged in the neighborhood of the tonsil, or caught in the lymphoid tissue of the tonsillar ring. According to their size they may become impacted at almost any point, and may even cause suffocation. They may be detected sometimes by the finger alone, or, at other times, only with good illumination and local anesthesia. The irritation which they produce leads to frequent acts of swallowing, the latter always exaggerating the former. Such objects as small fish-bones and the like, which may cause irritation, may easily escape or defy detection; moreover, such objects may be multiple.
For the sake of comfort pellets of ice may be frequently swallowed and cocaine may be used locally. Their extraction should be promptly practised. In rare instances emergency may call for prompt tracheotomy, but this is rarely the case unless the object be impacted below the epiglottis. Curious instances of impaction in the nasopharynx, of strange foreign bodies, have required the administration of anesthetics and even serious cutting operations for their removal, by combined manipulation through the nostril and the oropharynx. Such bodies, however, can be in some way always removed.
Liquids may be aspirated through the nose, and cause strangling attacks of coughing. They are then more easily drawn into the larynx or trachea, where they will cause reflex phenomena and actual obstruction, according to their nature. Again by free inhalation of steam, natural or superheated, burns and scalds of the respiratory passages may be produced, which will be followed by edema of the glottis or by pneumonia. The inhalation of extremely strong vapors, like that of ammonia, may cause spasm of the glottis. The entrance of blood, as from rupture of an aneurysm, or of pus, as from a bursting abscess, or the escape of pus from one side of the chest into the other lung by way of the trachea, may cause serious symptoms or may produce actual suffocation. In operations for pyopneumothorax, for instance, with one side of the chest well filled with pus, one should be careful to avoid turning the patient in such a way that pus may run over into the other lung and thus suffocate him. I have seen death occur on the operating table from this cause, in spite of every precaution, when the accident itself had been anticipated.
Solid objects may be of all shapes, sizes, and materials; living insects are occasionally aspirated and may not be at once killed, the local irritation caused by their presence producing intense spasm of the glottis. I have personally known of two cases of suffocation in restaurants, where men eating hastily died as the result of impaction of pieces of meat within the rima glottidis. Again, bodies may pass beyond the glottis proper and enter the trachea, or even one of the great bronchi; shoe-buttons, for instance; and in one case in my knowledge a small hat-pin passed down and was only removed after a low tracheotomy and careful search, aided by a skiagram. Owing to the anatomical arrangement the right bronchus is more frequently entered than the left. Immediate danger of suffocation, of obstruction, or spasm having passed, there is still serious menace from pneumonia, with or without abscess or gangrene of the lung. Such condition occurring in a young child, in the absence of the history of passage of a foreign body, may cause some difficulty in diagnosis. The greatest help would be afforded by the use of the Röntgen rays, although the laryngoscope alone will sometimes be sufficient. To use the latter to advantage it will probably be necessary to allay local irritation with the cocaine spray. (See Figs. 476 and 477.)
—Treatment should be operative, although in some cases it is sufficient to invert the patient and slap him on the back. With an object impacted in the glottis relief may be afforded with the finger, but this may be exceedingly difficult, for in the later stages of suffocation the jaw may be convulsively shut and it will be almost impossible to effect entrance. In such case the jaw should be hastily pried open and the index finger carried down behind the base of the tongue, lifting the epiglottis and dislodging the object. If this fail and respiration have ceased, attempt should be made to hastily open the trachea, even with the blade of a penknife, and to follow this with artificial respiration. Under these circumstances the vessels of the neck will be engorged with venous blood, which will escape freely; this may, however, be disregarded, the primary indication being to get into the trachea, which may be held open by turning the knife-blade at right angles, while artificial respiration is practised, and until a couple of hair-pins, for instance, can be secured, bent into shape of blunt hooks and made to act as temporary retractors. This is an illustration of what may be done in emergencies.
Fig. 476
Toy-pin (actual size) removed by external pharyngotomy from pharynx and esophagus of a two-year-old child. Recovery. Skiagram by Dr. Plummer. (Buffalo Clinic.)
Fig. 477
Skiagram of Fig. 476.
On the other hand these operations should, when possible, be done deliberately and with local anesthesia. Foreign bodies should be located with the laryngoscope, after which they may be removed with the aid of the illumination thus afforded, or by mere sense of touch. An object impacted in the larynx proper may be extracted by thyrotomy, whereas when it has passed below the larynx it will be necessary to open the trachea, perhaps even low down, making more than an ordinary opening for purposes of manipulation. Numerous forceps have been devised for these purposes. Roaldes reports having removed a piece of impacted iron from the bifurcation of the trachea, by means of a powerful electromagnet.
In the ensuing chapter there will be mentioned a method of exposing both the trachea and the esophagus by posterior incision or resection of the thoracic wall.
Fig. 478
Tack in bronchus of young child, removed after a low tracheotomy. Case of Dr. Parmenter’s. Skiagram by Dr. Plummer. (Buffalo Clinic.)
Besides those inflicted by foreign bodies injuries may be produced here from external conditions, gunshot wounds, fractures, and a variety of causes which need not be specified. The inhalation or the entrance of violent caustics, either fluid or volatile, may produce edema at least, or actual destruction of tissue. The glottis, being the narrowest portion of the respiratory tract, offers the greatest danger under conditions of obstruction, and fatal dyspnea may ensue. Thus, for instance, burns caused by inhaling steam, or hot vapors or flame, will be followed by most intense reaction, often extending beyond the trachea and to the air cells. Edema will be prompt, while pain, shock, dyspnea, and loss of voice will be instantly produced. If the patient survive the early complications he may succumb to pneumonia or other disastrous sequels in the lungs.
—Wounds are nearly always complicated by other injuries of the neck or face, which may involve vessel or nerve trunks of primary importance. Moreover, such wounds are mostly infected and lead to extension of phlegmonous involvement, which may later cause mediastinal or deep cervical abscesses, and all sorts of septic and pyemic complications. Even when recovery ensues cicatricial contraction may produce laryngeal or tracheal stenosis, with defective voice, or sometimes fistulas, connecting usually with the trachea.
—In the treatment of such wounds provision should be made for drainage, and it is seldom advisable to make too accurate a closure lest its very intent be thereby defeated. Unless the patient be suffocating the first indication is to check hemorrhage, then to cleanse the wound, and later to make such approximation of its surfaces as the case may permit. Occasionally in order to obtain a good result in the upper part of the respiratory tract it would be good practice to make a tracheotomy below. At other times an O’Dwyer tube may be inserted.
The occurrence of edema may be prevented, or at least its severity in a measure controlled, by the use of adrenalin solution, 1 to 10,000, while the local use of mild cocaine solutions will be frequently indicated, in order to check irritability and the reflex phenomena to which it will lead. Local symptoms may also be combated by inhalation of vapor, with soothing solutions, such as weak preparations of cocaine or of one of the opiates, followed by mild astringents and antiseptics—tincture of benzoin or oil of eucalyptus, or some of their equivalents, being nebulized and used in a spray. Opiates internally should be prescribed; while with delirious, drunken, or maniacal patients every effort should be made to secure physiological rest and to subdue restlessness or frenzy.
—Fracture of the larynx is a somewhat uncommon accident, due to direct violence, which may instantly precipitate symptoms of the greatest severity. It may be simple or compound, the thyroid being obviously most often involved and the cricoid next. These injuries will occur more frequently in the aged, in whom the external cartilages of the larynx are prone to calcify and thus become more brittle. A fracture of the larynx precipitates extreme danger of suffocation, either from displacement or edema, and will usually require a prompt tracheotomy, which may be performed with a penknife in the absence of any better instrument. It may be indicated also by expectoration of bloody mucus, with froth, with stridulous respiration, dyspnea, pain—which is increased by pressure or motion, as in swallowing—and the local indications of injury. Thus death has occurred upon the field during a game of baseball, from a direct blow of the ball upon the larynx, no one who knew sufficient to perform it reaching the patient in time to do an emergency tracheotomy as above. Edematous laryngitis, which is not sufficiently serious to call for operation, is characterized by dyspnea, aphonia, dysphagia, cough, laryngeal irritability, and by more or less chemosis and congestion of the mucosa. The specialists treat certain of the milder forms of this condition by local scarification (i. e., with a knife made for the purpose), in order that by considerable local hemorrhage the vascular engorgement may be relieved.
These consist in large measure of deviations of the nasal septum, with or without turbinate hypertrophy, due to previous disease of the Schneiderian membrane, and followed by thickening and structural change. Nasal deviations are either of congenital or acquired origin. An absolutely symmetrically arranged and divided nasal cavity is a rarity. Thus, though one side is rarely a replica of the other, deviations which are sufficiently marked to cause nasal obstruction are commonly the result of rapid or slow disease. They will be seen in connection with other body deformities by which the head is habitually held in an abnormal position, so that growth in one direction is thereby favored. Such conditions may be caused either by irregularities of vision, by enlarged tonsils, or by spinal deformities.
The acquired deviations are frequently the result of injuries, not necessarily of those sufficiently severe to produce fractures. The nasal septum proper is made up of the cartilaginous or purely nasal portion, the vomer, and the perpendicular plate of the ethmoid, any one of which may be separated from its connections or warped from its perpendicular plane. Dislocation of the cartilages may also occur in the young, and, having once taken place, is rarely reduced unless treatment has been both prompt and scientific.
Angular deviation to an extent which often produces a spur is not necessarily of serious inconvenience unless it protrude sufficiently from its proper plane to come in contact with one of the turbinates, in which case a nearly complete obstruction may result, with symptoms of constant nasal irritation. Absolute symmetry being rare, and mild deviations being very common, it is only those which produce either visible deformity or local irritation which require surgical treatment. Obviously after injury to these parts attention should be given to overcome present and prevent further dislocation. This may be conveniently done by the introduction of small, tubular, nasal splints, of celluloid or caoutchouc, made for the purpose. In their absence short pieces of a stout, silk catheter may be used, one inserted on either side of the septum, and packed around with a light tampon of antiseptic gauze. All intranasal splints, no matter how made, will cause considerable local irritation, with tendency to discharge, and will need to be renewed every day or two.
Deviation having resulted in permanent deformity, no matter how produced, it can be relieved by operation. Except in the young this may be performed under local cocaine anesthesia. These measures fall under two heads—those made for removal of projections, or spurs, and those directed to straightening of warped or deviated septa, which do not show much thickening.
For the treatment of projections caustics and the actual cautery were formerly much in use. They have been now almost abandoned for the use of instruments, such as a strong knife, a small intranasal saw, or cutting forceps of various patterns, adapted for use within the nose. Only these latter means will be mentioned in this place. Cutting instruments may be actuated by hand or by electric motors. When the field of operation is small cocaine anesthesia is nearly always sufficient. Extensive operation involving both nasal cavities may often be better performed under a general anesthetic. The nasal cavity should have been previously thoroughly cleansed by the aid of irrigation with alkaline solutions, and then just previous to operation with hydrogen peroxide. Instruments should be absolutely clean and sterile. When local anesthesia is complete it is sufficient to seat the patient with the head supported, opposite to the operator, to illuminate the nasal cavity with the head mirror or some substitute therefor, and to introduce the knife, saw, or forceps in such a way that the removal may be effected with one movement, while injury to surrounding tissues is avoided. An intranasal saw should be blunt-pointed, and should never be pushed so as to touch the posterior wall of the pharynx. After division of bone the final detachment of the mucosa should be made with scissors or knife. Bleeding after these operations is rarely severe, although free at first, and may be controlled by a tampon made of a narrow, continuous strip of antiseptic gauze, either packing it into the nostril and occluding it, or inserting a nasal tube and packing snugly around it. Only in rare instances is it necessary to tampon the nose from the pharynx by the use of the Bellocq cannula. (See below.)
Warped and deviated septa, without angular projections, may be sometimes successfully treated by dividing the septum, either with knife or scissors, or with cutting forceps whose blades make a stellate incision, by which the curved surface is so much weakened that it can be pressed back into normal shape, where it is retained by tamponing the nostril on the affected side. The pressure required for this purpose is, however, sometimes irksome or even intolerable. A method of using a long pin, like a small hat-pin, has been suggested, it being passed through one nostril into and out of and again into the septum, in such a way that it serves as a splint, to keep it straight for a sufficient length of time. Later this pin may be removed without difficulty, its enlarged head lying meantime concealed within one of the nostrils.
This was first suggested by Killian as affording a method not subject to the objections of the older authorities. It may be performed under cocaine anesthesia, each side of the septum being swabbed with a 20 per cent. cocaine solution. A semilunar incision made through the mucous membrane and perichondrium on one side is the more convenient. Through this opening the coverings are separated from cartilage by means of a sharp and a plain elevator. Unless the perichondrium be itself elevated the mucous membrane will be torn in the pressure of loosening. The cartilage is then cut through with suitable instruments or burred away with a dental engine, the instrument being guarded by a finger in the opposite nostril, which acts as a guide, it not being desirable that the membrane on that side shall be cut through. In this way any spurs or ridges may be removed submucously with such instrument as the operator may select. The separated membranes then fall together and may be retained by light gauze packing without any suture.
Of true neoplasms in the nose the most common are those myxomatous or fibromyxomatous developments from the Schneiderian membrane, which are called nasal polypi. Histologically most of these are of myxomatous character. Clinically, however, they seem to be in large degree products of inflammatory and irritative conditions. At all events they constitute sessile and later pendulous outgrowths, occupying different areas or occurring in clusters, those from the upper part of the nose being covered with columnar cells, while those of the lower pharynx are covered with flat epithelium. They are firm or soft, according to the amount of connective stroma which they contain. They are poorly supplied with blood and their contained fluid is largely composed of mucin. When involving a considerable area the condition is referred to as polypoid degeneration. They are observed at all ages and in both sexes. Their most common seat is the middle turbinate, toward its posterior extremity, and they also hang from the septum, but may be found in any part of the nasal cavity. From it they may spread to fill the adjoining accessory sinuses, even producing absorption of their bony walls by pressure. They also produce distortion of the nose, with such obstruction as to prevent nasal respiration. They may involve one side or both, and may hang so loosely attached that a flapping, valve-like sound is heard on respiration.
—They produce nasal obstruction, with irritation; more or less discharge of watery or acrid mucus, the latter sometimes leading to excoriation; while by pressure they produce headache, especially when located high in the nose, or deafness, as when they press upon the Eustachian outlets, or symptoms of sinusitis according as they invade one or other of the sinuses. Other reflex symptoms, such as facial neuralgia, reflex cough, lacrymation, and conjunctivitis, frequently accompany them, and mouth breathing and snoring are almost inevitable consequences. The voice becomes impaired, as does occasionally the sense of taste.
In most cases they are easily revealed by artificial illumination and exposure with the nasal speculum. In color they are usually pinkish, and may be seen to move with the respiratory effort. While it is usually easy to see at least some of them, when present, it is difficult to detect their exact point of origin. With the rhinoscopic mirror they may be seen projecting into the nasopharynx. Occasionally one will be detached by violent effort at sneezing or blowing the nose.
Fig. 479
Jarvis snare.
Aside from the danger of retained secretion, which they may bring about, and that attending their extension into adjoining cavities, there is in elderly people at least an actual possible danger of their undergoing malignant transformation, although this is not common. There is, however, good reason for their removal, and none for allowing them to remain, for they are always both irritant and obstructive.
—Almost every other method of treatment has yielded to that of removal by the Jarvis snare, or its equivalent, supplemented by the occasional use of forceps. In order, however, to expose them sufficiently to permit of removal it is often necessary to cut away a portion of the middle turbinate. In extensive polypoid disease this would be practically always required, and it should be done thoroughly, for nasal polypi tend usually to recur unless radically attacked. Local anesthesia is sufficient for the majority of cases, but an aggravated instance will call for complete anesthesia and thorough work, especially if the accessory sinuses have been infected.
The snare figured in Fig. 479 is a type of instrument which can be used to great advantage in dealing with these cases. When, however, it cannot be made effective by being applied around the actual base of each growth its use should be supplemented by that of the curette. No actual assurance can ever be given that there will be no subsequent development of polypi. Nevertheless it does not follow that new polypoid development is of the actual nature of recurrence. It may occur independently from the same causes that produced its first appearance.
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 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.
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.)
—Local applications being of small avail in producing either condensation or resorption, the treatment of this condition is essentially surgical. With children an anesthetic is always necessary. With adults cocaine may be sufficient. The best position for the patient is that with the down-hanging head (Rose’s), as blood is not swallowed nor passed into the lungs, but may be removed as fast as it collects. The hemorrhage in these operations is generally profuse but of short duration.
Adenoids are removed either with a snare, the curette, or by special instruments constructed on the type of a tonsillotome, and having a concealed blade. The curette is also used as forceps. Two or three curettes and forceps are sufficient for nearly all purposes. In operating the instruments are guided entirely by the sense of touch and the operator’s knowledge of anatomy, for he relies upon his finger-tip for information as to whether the tissue has been completely removed or needs further attention. These instruments are used until the entire vault of the pharynx and its openings into the nasal cavities (choanæ) are freed from all hypertrophied tissue or excrescence. The posterior wall of the pharynx should be scraped until it is smooth. In addition the tonsils should be removed if it be necessary, while the lingual tonsil may be also removed with curette or forceps if it be involved. For a few moments there will be a free flow of blood through both nose and mouth. In some instances there will be indications for cutting away hypertrophied turbinates and removing nasal polypi. Hemorrhage, at first profuse, quickly subsides. A mixture of 1 per cent. cocaine solution with a little adrenalin is the best hemostatic for local use. The nostrils may be packed if the turbinate has been cut away, or the entire passage-way may be left open for the purpose of permitting the later use of an irrigating stream, by which blood clot may be washed away and antiseptics applied. While using and relying upon instruments for the greater part of this work there is no better curette for concluding the work than the finger-nail of the index finger. The finger being introduced recognizes the degree of relief afforded, and the finger-nail may be used to scrape away any remaining projecting tissue.
Various operators have devised formidable operations, varying from the temporary resection of one upper jaw to Cheever’s ingenious method of dividing and separating both upper jaws in one piece from the cranium, and thus exposing the nasopharynx from in front and above. Such operations are rarely performed.
Other neoplasms in this region are cysts and dermoids of congenital origin—those involving the original craniopharyngeal canal, and those produced from pharyngeal diverticula. These produce only the ordinary manifestations of tumor and are of pathological rather than surgical interest.
The escape of a small amount of blood from the nose, especially in childhood, is a common occurrence, and may occur in consequence of slight traumatisms or even spontaneously. The so-called nose-bleeding of children, then, is scarcely of sufficient importance to justify consideration here, nor would it were it not for the fact that it may become severe and even dangerous. Children in whom it frequently recurs will lose sufficient blood to become anemic, while the effect of its frequent occurrence may bespeak a depraved condition of the blood as well as of the tissues which permit of its escape. A history of repeated nose-bleed should prompt an investigation into the general condition of the patient as well as a local examination of the nasal passages, where some explanation may be afforded. For instance, a polypus may be found whose removal will then be indicated, or an exceedingly spongy and vascular area may be revealed, which will call for a touch of the actual cautery or the use of the curette.
Besides the frequent expressions of this kind in childhood, some of which may occur during sleep, there are other forms of nasal hemorrhage. A vicarious menstruation is known to assume this type, individuals thus losing blood every month. This is a rare but well-known phenomenon. A plethoric individual may suffer serious epistaxis at any time, and this may be beneficial unless it be too extensive. Nasal hemorrhages may occur with certain fevers. Individuals with a hemorrhagic diathesis are peculiarly liable to it, and it is seen in connection with purpura hæmorrhagica. When this occurs in the debilitated or dissipated it may be fatal. Thus epistaxis may terminate fatally in spite of all that can be done. This statement requires some explanation. The nasal cavity may be tightly plugged, but such plugging cannot be made permanent because of decomposition of products thus retained and their absorption, with consequent septic infection. Nasal tampons should be removed every day or two, for the purpose of cleanliness, although their removal is contra-indicated when the necessity for physiological rest of the part is realized. The treatment, then, of epistaxis may be trying, at least, and in rare cases will prove absolutely disappointing and ineffectual. I have even been compelled to tie the common carotid to save life.
—The ordinary nose-bleed of a young child will usually subside with the application of cold to the nose, elevation of the arms, or firm pressure upon the upper lip just below the nasal septum. It may be also checked by an irrigating stream of cold water, or by a spray of cocaine or weak adrenalin solution. A 5 per cent. antipyrine solution also makes an excellent styptic for the purpose. Within a day or two after a serious hemorrhage, after the remaining clots have been cleaned away, a thorough inspection of the nasal cavity should be made in order to reveal the source of the hemorrhage and permit local treatment.
Nasal hemorrhage may be subdued by plugging the anterior nares with strips of gauze, or, better still, after the introduction of a tube through which air may pass freely, and around which packing may be firmly inserted. The ordinary dry styptics should not be used, for they may produce such a crusting of tampons as to make it difficult to remove them. More efficient materials can be used in solution. No tampon should be introduced into the nostrils which is not tied with a ligature of silk in such a way that it may be by it more easily withdrawn, and, at the same time, prevented from going too far. If the source of the bleeding be in the anterior part of the nasal cavity anterior packing may be sufficient. The surgeon should not, however, be deceived by the apparent cessation of bleeding, which cannot escape through the nostrils under these circumstances, but may continue into the nasopharynx, the patient swallowing the blood as it trickles down. Inspection of the pharynx should be made after the use of tampons. A much greater degree of safety is afforded by posterior tamponing of each side of the nasal cavity, which is most easily effected by means of the little instrument known as Bellocq’s cannula, whose use is illustrated in Fig. 480.
Fig. 480
Plugging the nares with Bellocq’s cannula. (Fergusson.)
It is, however, by no means necessary to have this special instrument in order to accomplish the purpose. A soft catheter may be passed backward through the nostril until its end appears in the nasopharynx, where it is caught with forceps and drawn into the mouth. Here, by means of a needle or knot, a piece of silk is fastened to this end. When the catheter is drawn out from the nose it pulls up after it and out through the nostril this bit of silk, to whose middle is tied a tampon, made of a sufficient amount of gauze or similar material, folded or rolled into the desired shape. By combined manipulation, as the silk thread is drawn upward and outward through the nostril, it pulls up the tampon into the nasopharynx, where it should be guided into its place by the tip of the index finger of the disengaged hand. If necessary this procedure is then repeated upon the other side, and thus a complete double tamponing can be effected. If the procedure be made difficult by the extreme sensitiveness of the part this can be overcome by local anesthesia. The tampon may be saturated with a weak adrenalin solution if desired. Ordinarily such a tampon can be easily disengaged and removed by again passing the finger up behind the soft palate and dislodging and withdrawing it, using curved forceps for the purpose of securing it. A tampon inserted for the control of hemorrhage should be left in situ for at least forty-eight hours, possibly longer. The case should be watched for a while after its removal, lest it might require re-introduction. This maneuver is made easier by fastening the tampon in the middle of a long piece of silk as described; one end being brought out through the nostril is tied to the other portion, which is allowed to come out of the mouth. The latter will provoke some discomfort, and patients should be cautioned not to disturb it, its purpose being explained to them.
Mulford, of Buffalo, has suggested a method of dealing with cases of epistaxis by injecting two or three drops of reduced adrenalin solution into the tissues at the base of the upper lip, in close proximity to the course of the arteries which pass upward on either side and supply the septum. The injection should be made in the fold of the mucous membrane just beneath the septum of the nose.
This has already been referred to as the product of tuberculous disease in the upper cervical vertebræ, or in the neighboring lymph nodes, or as the possible sequel of more acute infections occurring in the upper portions of the neck, proceeding usually from infected tooth sockets or other lesions within the nose and mouth. Collections of pus in this location may be circumscribed or may be extensive and rapidly assume serious phases. A chronic abscess is essentially a tuberculous expression. Acute abscesses, either in the tissue behind the pharynx or to either side of it, may be seen in cachectic children and assume serious phases.
The first evidences in these cases are those of pharyngitis, but swelling and edema occur rapidly, septic indications become unmistakable, and, finally, almost complete nasopharyngeal obstruction may occur. The discovery by the palpating finger of a fluctuating swelling will make the presence of pus practically positive. If the operator be still in doubt he may use the exploring needle. The experienced practitioner will at once plunge the point of a knife into such a swelling, and, at the same time, plan his opening in such a way as to afford the best possible drainage.[48] For the purpose it may be necessary to have the patient in the position of down-hanging head, or, in extreme cases, the patient may be almost inverted in order that pus as it gushes forth may escape through the mouth rather than into the larynx or down the esophagus. The operation should be done without an anesthetic. The mouth may be opened with the O’Dwyer mouth-gag, or it may be forced and held open with the ordinary tongue depressor. When pus has travelled to such an extent as to give the case the importance and aspect of a deep cervical phlegmon, such as described in the chapter on the Neck, then anesthesia is necessary in order that by external, combined with internal, incision, escape of pus and provision for drainage may be permitted.