Complete Text (Part 26)

sense of obstruction, disturbances of smell, nasal resonance of the voice, and increased secretion. The secretion may be watery, mucous, puru- lent, or cheesy in character, and has a characteristic bad odor. The odor is usually recognizable by the patient himself. Pain of a neuralgic cha- racter, extending over the face through the forehead, teeth, etc., is gen- erally present. When occurring in the new-born, the secretion is puru- lent in character, mixed with blood, and has a foul-smelling odor. Besides, there is a noticeable obstruction in the breathing. The skin of the upper lip and entrances to the nares may be excoriated. Syphilis in the adult, occurring in the later stages, attacks the septum most fre- quently. The cartilaginous as well as the osseous portion is affected. In the cartilaginous portion there is first infiltration ; this is followed by ulceration and perforation, which may be so extensive as to lead to de- struction of the entire cartilage. The osseous portion may be similarly affected, destruction of the bone taking place, and as a result the nose assumes a characteristic shape which has been described as the saddle- shaped nose. Next in point of attack come the turbinated bodies, and of these the lower one is that most frequently affected. Here there is ulceration of the mucous membrane, followed by its complete destruc- tion, so that the bone itself is seen entirely denuded. The process may involve the bone. The floor of the nose is often the seat of the later stages of syphilis. Infiltration, ulceration, and perforation follow each other, till finally there exists a communication between the oral and nasal cavities. When the alse of the nose are affected, there is induration, followed by ulceration and cicatrization. Occasionally the skin of the nose is affected, when it shows itself in the form of small red nodules. What is the diagnosis? The diagnosis of the primary form is, as a rule, easy, provided other symptoms of syphilis are present. In the stage of gummatous infiltra- tion, where ulceration is not present, it may present some _ difficulty. Lupus affecting the interior of the nose may be confounded with it, In the later course of the disease, where there are ulceration and perfora- tion of the septum, the diagnosis of syphilis can be made. What is the prognosis? In beginning cases, provided a diagnosis is made, the prognosis is favorable. In infants and young children a fatal termination sometimes occurs. In the later stages, where there is extensive destruction of the cartilages and bones, the prognosis is not so favorable. Where the sphenoid bone and the lamina cribrosa become affected, prognosis is serious. Where a cure results, there often remain unpleasant sequels, such as atrophic rhinitis. 214 THE NOSE. What is the treatment of nasal syphilis ? The treatment must be both general and local. In the early stages mercury should be administered. It can be given in solution by inunc- tion or by injection. In the later stages iodide of potassium should be given. It may be combined with the mercury. The local treatment consists in the thorough cleansing of the nose two or three times a day by means of the nasal douche or spray. Dobell's solution may be used or a solution of boric acid or permanganate of potassium. Where the crusts adhere so that the spray or douche does not remove them, they must be removed by means of the forceps. Ul- cerations should be cauterized by the solid nitrate-of-silver stick or chlo- ride of zinc. Insufflations of iodoform or iodol can be made. Some recommend the scraping of the ulcerations by means of a sharp spoon. Abscesses should be opened and all necrosed pieces of bone removed. Where there is destruction of the external nose, plastic operations or the wearing of artificial noses can be resorted to. TUBERCULOSIS OP THE NOSE. Give a brief description of miliary tuberculosis of the nose, with its pathology, course, and treatment. Tuberculosis of the nose is rare, and usually occurs as a secondary affec- tion. It appears in the form of swellings of various sizes or ulcerations. These swellings usually present the form of miliary nodules. After a time the surface of these nodules ulcerate, and there is a breaking down. Microscopically, they are seen to consist of lymph-cells joined together by means of connective tissue. Epithelioid and giant cells are also pres- ent. The septum is the most frequent seat of this affection. The symptoms are those of a chronic catarrh with a foetid bloody secretion. The diagnosis is made upon the presence of the above-described swell- ings and ulcerations and of other phthisical symptoms. Microscopical examination of the nodules aids in a diagnosis. The prognosis is unfavorable. The treatment must be both general and local. The general treatment consists in nourishment of the patient and the administration of tonics. The local treatment consists in the removal of swellings with the snare or their destruction by means of the galvano-cautcry : in the cauteriza- tion of ulcerations by means of nitrate of silver or chlorate of zinc ; in cleansing of the nose ; and in insufflation of iodoform. SCROFULA. Describe briefly scrofulous affections of the nose. There is often seen in children who have scrofula an acute or chronic rhinitis, which, etiologically, is a part of the disease itself. Some look upon it as tuberculosis. In scrofulous catarrh of the nose there are red- BENIGN TUMOES POLYPI. 215 dening and swelling of the mucous membrane, with a rich purulent secretion. Obstruction may be present, and is usually due to dried-up crusts at the entrance to the anterior nares. The external nose may be reddened and swollen. An atrophic condition may be present. Ulcera- tions of the mucous membrane are rarely seen. The diagnosis is at times difficulty and is to be distinguished from syphilitic rhinitis. Besides the condition of the nose, the other symp- toms of scrofula help in making a diagnosis. The prognosis is doubtful. What is the treatment? The treatment is constitutional and local. The former consists in the administration of cod-liver oil, iron, etc. When possible a residence in the country is often beneficial. The local treatment is the same as in other forms of catarrh. LUPUS. Describe lupus of the nose. Lupus especially attacks the external nose, and then extends to the mucous membrane. It attacks, as a rule, the alae of the nose first, gradually involving the bridge and root of the nose. In a case of lupus the nose appears hard and thickened, and is covered with nodules, which are single or multiple and in color are dark or reddish brown. They may be partially ulcerated, and in some places covered with crusts. The alae of the nose gradually become destroyed and shrink up into a cicatrized mass. In the interior of the nose the cartilaginous portion is usually affected. Here are seen nodules varying in size, which ulcerate and may cause perforation of the septum. The diagnosis is sometimes difficult. One is apt to mistake the disease for ulcerating gummata or tuberculous swellings. The age and tuberculous condition of a given case may render the diagnosis less diffi- cult. The microscopical examination leaves no room for doubt. Prognosis is doubtful. The treatment consists in destruction of the affected portions by means of the galvano-cautery, lactic acid, chloride of zinc, or the curette. The internal treatment is by cod-liver oil, iron, etc. BENIGN TUMORS OF THE NOSE— POLYPI. How many varieties of polypi are there ? Two — the mucous and the fibrous. What is the etiology? Chronic inflammation of the nasal mucous membrane is generally sup- posed to be the most frequent cause of polypi. The male sex seems to 216 THE NOSE. be especially predisposed, and, as a rule, polypi are never seen until after the fifteenth year of life (Fig. 84). Give the pathology. The form of polyp most frequently observed is the mucous polyp. The angle of the middle turbinated body, the external wall of the nose,. Fig. 84. Vertical Section through Nasal Cavity, showing nasal polypi (Seiler). the middle turbinated space, and the roof of the nose are, as a rule, the seats of their origin. In the beginning they have a bullet-like shape ; as they grow larger they assume the shape of the space in which they grow. They vary in size. In consistency they are soft and elastic. In color they are whitish, grayish, and reddish. Microscopically, they are seen to consist of delicate connective tissue, with an epithelial covering. Numbers of round and oval cells are present, which later become spindle- shaped. What are the symptoms ? If the polyps are small, they may present no symptoms ; when large, BENIGN TUMORS POLYPI. 217 thej7 give rise to headache, nasal obstruction, and an increased secretion. In damp weather they increase in size, owing to their hygroscopic nature, causing a greater amount of obstruction. Reflex symptoms may be pres- ent. Violent attacks of sneezing occur, and the voice assumes a nasal twang if obstruction be present in a marked degree. Their presence is said to be often a cause of asthma. Give the diagnosis. By inspection and probing with the sound a diagnosis is easily made. Their color, transparency, and consistency differ from those of other growths. What is the prognosis? As regards danger to life there is none, but the growths are, as a rule, apt to recur. What is the treatment of nasal polypi ? Treatment consists in their removal. Several methods have been rec- ommended, but the surest and safest is the method by means of the cold snare. The snare is introduced vertically into the nose and then turned horizontally, so that the polyp falls within the loop. The snare is then elevated as far as possible to the pedicle, and then tightly drawn, and the polyp is thus removed. Bleeding may be slight or excessive, and is easily stilled. By this method a number of polyps can be removed in one sitting. The after-treatment consists in the cauterization of the base by means of the galvano-cautery. Give a brief description of fibrous polypi. Fibrous polypi are not of such frequent occurrence as the mucous, and are usually found in the post-nasal cavity instead of the anterior. Path- ologically, their covering is the same as that of the mucous, whilst their interior is seen to consist of fibrous tissue and round cells with blood- vessels. The symptoms are similar to those of the mucous polyps. In the later stages as they increase in size they absorb bone and other tissues. Expansion of the nasal bones ensues, and the nose becomes deformed. This deformity is known as frog-face. If not removed, they are apt to degenerate into sarcoma. By means of the rhinoscope and probe they can be readily diagnosed from the mucous polyp. _ The treatment consists in their removal. This is effected by means of the cold snare, galvano-cautery, or electrons. Owing to their large size an external operation often becomes necessary. What other growths are occasionally found in the nose? I. Papillomata. — These are wart-like in their structure, and are chiefly composed of connective tissue. They spring from the mucous membrane of the septum or inferior turbinated body. 218 THE NOSE. When small the application of nitric acid is sufficient for their destruc- tion ; when large the cold snare should be used. II. Cystic— -These resemble mucous polypi, and are found to contain a clear fluid on incision. Removal by the snare is the best method of treatment. III. Enchondromata are cartilaginous tumors usually springing from the septum. Arising from other portions of the nasal cavity, they act like fibromata, though they do not grow so rapidly. When the tumor is septal, what are the symptoms ? Nasal obstruction is present in a more or less marked degree, according to the size of the tumor. When the tumor is so large that it touches the other side of the cavity, erosion takes place, sometimes followed by a dis- charge, pain, headache, sneezing, and impaired sense of smell. When the tumor is in other portions of the nasal cavity, it may be sarcomatous in nature and grow rapidly, causing displacement of the nasal walls, and as a result deformity. The treatment of the septal enchondromata consists in their removal by means of snare or bistoury. When the enchondromata originate from bone and are situated in other portions of the cavity, where they grow rapidly, surgical measures are to be adopted. MALIGNANT TUMORS OF THE NOSE. Describe carcinoma and sarcoma of the nose. The causation of these tumors in the nose is, as in other portions of the body, still unknown. They arise chiefly from the septum, but may arise from the roof or from any other point in the nose. They vary in size here as elsewhere. The symptoms they give rise to vary according to the position and size of the growths. Nasal obstruction and hemorrhage are frequent symp- toms. The secretion is profuse and foetid in character. Pain may be present in a marked degree in the infraorbital region. Disfigurement of the face may take place on account of the growth of the tumor. The diagnosis is easy: the microscope leaves no doubt as to the nature of the growth. The prognosis is unfavorable. The treatment consists in complete removal of the diseased portions. Where this is impossible the treatment should be palliative. FOREIGN BODIES IN THE NOSE. What foreign bodies are sometimes found in the nose? What are the symptoms they give rise to, and what is their treatment ? Foreign bodies, as a rule, are found only in the nose of children, and are usually beans, pebbles, cherry-stones, etc. Their presence at first EPISTAXIS. 219 may cause but little trouble, but soon a mucous discharge makes its appearance, which soon becomes purulent, and may be tinged with blood. Symptoms of obstruction and headache are present. The treatment, of course, consists in the removal of the foreign body. If the case is seen early, douching by the post-nasal douche may suffice to remove it. Where this fails, the forceps or curette may be cautiously used. Where the foreign body is situated far back, Sajous' method is useful. This consists in the introduction of a piece of slender wire along the floor of the nose as far as the pharynx. The end is drawn out of the mouth by means of forceps, and a cotton tampon attached. This is drawn up behind the palate into the posterior nares, and pulled through the nasal cavity with the foreign body: What are rhinoliths ? Rhinoliths are calcareous concretions resulting from the deposit of phosphate of lime from the nasal secretions around a foreign body. They give rise to symptoms similar to those caused by a foreign body. The treatment consists in their removal by means of forceps, curette, or the method of Sajous as above described. EPISTAXIS. Give the etiology. Epistaxis may be caused by a blow or fall on the nose, picking the nose with the finger-nail, the presence of foreign bodies, and the use of probes or other instruments by a physician. It is a frequent symptom of tumors of the nose, whether benign or malignant, and of various forms of rhinitis, especially if ulceration be present, Certain blood-conditions predispose to it, such as anaemia, chlorosis, haemophilia, scurvy, eruptive and relapsing fevers, etc. A common cause is active hyperemia or stasis occurring in a large number of diseases of the heart, lungs, and blood-vessels. Diseases of the kidneys, liver, and spleen often give rise^ to it. It is sometimes a form of vicarious menstruation. What are the symptoms? Prodromal symptoms are seldom present, and are slight in their nature. There may be headache, redness of the face, and a sensation of itchiness in the nose. As a rule, the bleeding comes on without premonition, and generally from one side of the nose. Sometimes the bleeding occurs from both sides of the nose in the course of fevers. If the bleeding occurs in the posterior portion of the nose, the blood is frequently swal- lowed and then vomited. Quantity and quality of the blood may vary. Give the diagnosis. The diagnosis is easy. If the blood flows from the mouth or is vom- ited, it must not be mistaken for hemorrhage of the lungs or stomach. 220 the nose; The symptoms accompanying such hemorrhages and the use of the rhinoscope should prevent such a mistake. What is the prognosis ? The prognosis is, as a rule, good ; only in debilitated persons is a fatal issue to be feared. What is the treatment of epistaxis ? In cases of moderate bleeding pressure should be applied. The appli- cation of ice and the sniffing of ice-water will often suffice. Insuffla- tions of tannic acid and alum and the preparations of iron are useful. Where these do not suffice, plugging the nostril with cotton should be resorted to. The cotton may be dipped in a 5 per cent, solution of co- caine. The plugs should be removed in twenty-four hours, and. if neces- sary, fresh ones applied. Anterior packing is often insufficient where the hemorrhage is far back. Bellocq's canula should then be used. This consists of a metallic tube with a curved steel spring passing- through it. This is introduced into the nose and the curved spring- forced through the mouth. At the end of the spring is a knob, to which a string with a cotton tampon is attached. The instrument is drawn out and the tampon is pulled up behind the soft palate. In a large number of cases the introduction of the canula is difficult on account of its size or the presence of deviations or hypertrophies. An elastic catheter should then be used or a bougie. The tampon should not be left in longer than twenty-four hours, as it may cause