Manual of Surgery Volume II Part 59

Prognosis as regards hearing should be guarded at first. As a rule the rupture heals rapidly, and no treatment is necessary save the introduction of a piece of cotton-wool into the meatus. Syringing should be avoided unless suppuration has already occurred, in which case treatment for this condition must be adopted. As these injuries frequently have a medico-legal bearing, careful notes should be made.

#Acute Infection of the Middle Ear.#--This usually arises in connection with infective conditions of the throat and naso-pharynx.

It varies considerably in its severity, and may run a mild or a severe course. It is characterised by pain in the ear, deafness, and a certain degree of fever. In children the symptoms may simulate those of meningitis. When the tympanic membrane is examined in the mild forms of the affection or in the early stages of the more severe type, the vessels about the handle of the malleus and periphery of the membrane are injected, and possibly a number of injected vessels may be seen coursing across the surface of the membrane. In the later stages the whole membrane presents a red surface, the anatomical landmarks being indistinguishable, the membrane bulges outwards into the meatus, and, if an abscess is pointing, a yellowish area may be visible upon it. The sudden cessation of pain and the appearance of a discharge from the meatus indicate perforation of the membrana tympani.

The _treatment_ of acute ot.i.tis media varies with the severity of the attack. The patient should be confined to the house or to bed, alcohol and tobacco should be forbidden, and the bowels must be freely opened.

Pain may be allayed by repeated instillations of cocain and carbolic acid (5 grains of each to a dram of glycerine). A few drops of laudanum, hot boracic instillations, or the application of a dry hot sponge, may prove soothing. Two or three leeches may be applied over the mastoid, but should the pain persist or should rupture of the membrane appear imminent, paracentesis must be carried out. After spontaneous perforation or puncture, the meatus must be kept clean. It is probably safer not to inflate through the Eustachian tube in the acute stage. Attention must be paid to any affection of the nose or throat that may be present.

#Chronic Suppuration in the Middle Ear.#--Acute suppuration may pa.s.s into the chronic variety, which is characterised by a perforation of the tympanic membrane, a persistent purulent or muco-purulent discharge from the middle ear, and a certain amount of deafness.

_Various complications_ may arise in the course of chronic middle-ear disease, and so long as a person is the subject of a chronic otorrha, he is liable to one or more of these. The complications may be extra-cranial or intra-cranial. Those affecting the middle ear itself include granulations, polypi, cholesteatoma, caries and necrosis of the temporal bone, destruction and loss of one or more of the ossicles, facial paralysis, haemorrhage from the carotid artery or jugular vein, and malignant disease. As mastoid complications may be mentioned: suppurative mastoiditis, leading to destruction of the bone, mastoid fistula, and sub-periosteal mastoid abscess. The intra-cranial complications that may arise are: extra-dural abscess, sub-dural abscess, meningitis, cerebral and cerebellar abscess, and lateral sinus phlebitis with general septicaemia and pyaemia.

The _treatment_ of chronic middle-ear suppuration consists in keeping the parts clean by syringing with antiseptic lotions. The installation of hydrogen peroxide, followed by syringing with boiled water or boracic lotion, and inflation through the Eustachian tube once, twice, or thrice daily, according to the requirements of the case, const.i.tute a routine method. Packing the meatus with antiseptic gauze after washing out may be practised.

#Suppuration in the Tympanic Antrum and Mastoid Cells#, or _Acute Suppurative Mastoiditis_.--Acute suppuration may occur in the mastoid cells in the course of an attack of acute ot.i.tis media, or as a result of interference with drainage in chronic suppuration of the antrum and middle ear. As the outer wall of the mastoid is liable to be perforated by cario-necrosis, the pus may find its way externally and form an abscess over the mastoid process behind the ear. In some cases the pus escapes into the external auditory meatus by perforating its posterior wall; in others a sinus forms on the inner side of the apex of the mastoid, and the pus burrows in the digastric fossa under the sterno-mastoid--_Bezold's mastoiditis_. If the posterior wall or roof of the antrum is destroyed, intra-cranial complications are liable to ensue.

The _clinical features_ are pain behind the ear, tenderness on pressure or percussion over the mastoid, redness and dematous swelling of the skin, and, when pus forms under the periosteum, the dema may be so great as to displace the auricle downwards and forwards (Fig. 265). The deeper part of the posterior osseous wall of the meatus may be swollen so that it conceals the upper and back part of the membrane.

[Ill.u.s.tration: FIG. 265.--Acute Mastoid Disease, showing dema and projection of auricle.]

_Treatment._--When arising in connection with acute ot.i.tis, the application of several leeches behind the ear, free incision of the membrane, and syringing with hot boracic lotion may be sufficient. As a rule, however, it is necessary to expose the interior of the antrum by opening through the mastoid cells--_Schwartze's operation_. When mastoid suppuration is a.s.sociated with chronic middle-ear disease, it is usually necessary to perform the complete radical operation--_Stacke-Schwartze operation_. The operations are described in _Operative Surgery_, p. 98.

CHAPTER XXV

THE NOSE AND NASO-PHARYNX[6]

Fracture of nasal bones--Deformities of nose: _Saddle nose_; _Partial and complete destruction of nose_; _Restoration of nose_; _Rhinophyma_--Intra-nasal affections--Examination of the nasal cavities: _Anterior rhinoscopy_; _Posterior rhinoscopy_; _Digital examination_. CARDINAL SYMPTOMS OF NASAL AFFECTIONS: Nasal obstruction: _Erectile swelling of inferior turbinals_; _Nasal polypi_; _Malignant tumours_; _Deviations, spines, and ridges of septum_; _Haematoma of septum_--Nasal discharge: _Foreign bodies_; _Rhinoliths_; _Ozaena_; _Epistaxis_; _Suppuration in accessory sinuses_--Anomalies of smell and taste: _Anosmia_; _Parosmia_--Reflex symptoms of nasal origin--Post-nasal obstruction: _Adenoids_--Tumours of naso-pharynx.

[6] Revised by Dr. Logan Turner.

#Fracture of the Nasal Bones and Displacement of the Cartilages.#--These injuries are always the result of direct violence, such as a blow or a fall against a projecting object, and in spite of the fact that the fracture is usually compound through tearing of the mucous membrane, infective complications are rare. The fracture usually runs transversely across both nasal bones near their lower edge, but sometimes it is comminuted and involves also the frontal processes of the maxillae. In nearly all cases the cartilage of the septum is bent or displaced so that it bulges into one or other nostril, and not infrequently a haematoma forms in the septum (p. 573).

Sometimes the perpendicular plate of the ethmoid is implicated, and the fracture in this way comes to involve the base of the skull. The nasal ducts may be injured, obstructing the flow of the tears, and a lachrymal abscess and fistula may eventually form.

The _clinical features_ are pain, bleeding from the nose, discoloration, and swelling. Crepitus can usually be elicited on pressing over the nasal bones. The deformity sometimes consists in a lateral deviation of the nose, but more frequently in flattening of the bridge--_traumatic saddle nose_. Within a few hours of the injury the swelling is often so great as to obscure the nature of the deformity and to render the diagnosis difficult. Subcutaneous emphysema is not a common symptom; when it occurs, it is usually due to the patient forcing air into the connective tissue while blowing his nose. The lateral cartilages may be separated from the nasal bones and give rise to clinical appearances which simulate those of fracture. Sometimes the septum is displaced laterally without the bone being broken, and this causes symptoms of nasal obstruction.

_Treatment._--As the bones unite rapidly, it is of great importance that any displacement should be reduced without delay, and to facilitate this a general anaesthetic should be administered, or the nasal cavity sprayed with cocain. The bones can usually be levered into position with the aid of a pair of dressing forceps pa.s.sed into the nostrils, the blades being protected with rubber tubing. After the fragments have been replaced and moulded into position, it is seldom necessary to employ any retaining apparatus, but the patient must be warned against blowing or otherwise handling the nose. When the septum is damaged and the bridge of the nose tends to fall in, rubber tubes may be placed in the nostrils to give support, or, if this is not sufficient, a soft lead or gutta-percha splint should be moulded over the nose, and the splint and the fragments transfixed with one or more hare-lip pins. These may be removed on the fourth or fifth day. Rigid appliances introduced into the nostrils are to be avoided if possible, as they are uncomfortable and interfere with proper cleansing and drainage of the nose. The inside of the nose should be smeared with vaseline to prevent crusting of blood, and the nasal cavities should be frequently irrigated.

#Deformities of the Nose.#--The most common deformity is that known as the _sunken-bridge_ or _saddle nose_ (Volume I., p. 174). It is most frequently a result of inherited syphilis, the nasal bones being imperfectly developed, and the cartilages sinking in so that the tip of the nose is turned up and the nostrils look directly forward. The bridge of the nose may sink in also as a result of necrosis of the nasal bones, particularly in tertiary syphilis, and less frequently from tuberculous disease. A similar, but as a rule less marked deformity may result from fracture of the nasal bones or from displacement of the cartilages.

When the condition is due to mal-union of a fracture, the contour of the nose may be restored by operation. A narrow knife is pa.s.sed in at the nostril and the skin freely separated from the bone; the bone is then broken into several pieces with necrosis forceps, and the fragments moulded into shape. A rubber drainage tube introduced into each nostril maintains the contour of the nose till union has taken place.

When it results from disease, it is much less amenable to treatment.

The present-day tendency is to discard the use of subcutaneous paraffin injection and to employ grafts of cartilage or bone. An artificial bridge has been made by turning down from the forehead a flap, including the periosteum and a shaving of the outer table of the skull, or by implanting portions of bone or plates of gold, aluminium, or celluloid.

Portions of the alae nasi may be lost from injury, or from lupus, syphilis, or rodent cancer. After the destructive process has been arrested, the gap may be filled in by a flap taken from the cheek or adjacent part of the nose. When the tip of the nose is lost, it may be replaced by Syme's operation, which consists in raising flaps from the cheeks and bringing them together in the middle line.

The whole of the nose, including the cartilages and bones, may be destroyed by syphilitic ulceration or by lupus. In parts of India the nose is sometimes cut off maliciously or as a punishment for certain crimes.

In reconstructing the nose it is necessary to provide skin, a supporting structure in the form of cartilage or bone, and an epithelial lining. In the "Indian operation" a racket-shaped flap, including skin and periosteum, is turned down from the forehead and fixed in position, the edges of the flap being inturned to provide a lining for the pa.s.sage. An implant of free cartilage may be necessary to support the skin flaps and to prevent subsequent contraction.

Flaps of skin may be formed by Gillies' tube-pedicle method from the cheek, the forehead, or the neck, and utilised to form the covering of the nose. When the deformity cannot be corrected by operation, the appearance may be greatly improved by wearing an artificial nose held in position by spectacles.

The term #Rhinophyma# has been applied by Hebra to a condition in which the skin of the tip and alae of the nose becomes thick and coa.r.s.e, and presents large, irregular, tuberous ma.s.ses on which the orifices of the sebaceous follicles are unduly evident--_potato_ or _hammer nose_ (Fig. 266). The capillaries of the skin are dilated and tortuous, and the nose a.s.sumes a bluish-red colour, and its surface is soft and greasy. The condition is met with in elderly men, and the ma.s.ses appear to be chiefly composed of sebaceous adenomas. The term _lipoma nasi_, formerly employed, is therefore misleading.

[Ill.u.s.tration: FIG. 266.--Rhinophyma or Lipoma Nasi in man aet. 65.]

The treatment consists in paring away the protuberant ma.s.ses until the normal size and contour of the nose are restored, care being taken not to encroach on the cartilages or on the orifices of the nostrils.

There is comparatively little bleeding, and the raw surface rapidly becomes covered with epidermis.

#Examination of the Nasal Cavities.#--For the examination of the interior of the nose the following appliances are necessary: A reflector, such as is used in laryngoscopy, attached to a forehead band or spectacle frame; one of the various forms of nasal speculum; a long, pliable probe; a tongue depressor; and a small-sized mirror. As additional aids, a 10 per cent. solution of cocain, a grooved probe as a cotton-wool holder, and a palate retractor should be in readiness.

Good illumination is important, and may be obtained from an electric light, or from a Welsbach or Argand burner. The light should be placed close to, and on a level with, the patient's left ear. Both the anterior and posterior nares should be examined.

_Anterior Rhinoscopy._--Before the introduction of the speculum the tip of the nose should be tilted up and the interior of the vestibule and the anterior part of the septum examined. In this way the existence of eczema or small furuncules, the presence of dilated or bleeding vessels upon, or a perforation of, the anterior part of the septum may be noted, and the general appearances observed. After inserting the speculum into the vestibule and dilating it, the following parts should be sought for and examined:--Close to the floor, and attached to the outer wall of the nasal cavity, is the anterior end of the inferior concha or turbinated body (Fig. 267), which overhangs the inferior meatus. It presents a pink appearance, and its size varies in different persons. At a higher level and on a posterior plane is the anterior end of the middle concha or turbinated body, which is of a paler colour than the inferior, and is only visible when the head is tilted backwards. Between it and the inferior turbinated body is the middle meatus, with which communicate the openings of the maxillary sinus, the frontal sinus, and the anterior ethmoidal cells. A considerable area of the anterior part of the nasal septum is also visible by anterior rhinoscopy, and between it and the middle turbinal is a narrow c.h.i.n.k--the olfactory sulcus.

[Ill.u.s.tration: FIG. 267.--The outer wall of Left Nasal Chamber, after removal of the middle turbinated body. (After Logan Turner.)]

_Posterior Rhinoscopy._--Examination of the posterior nares and naso-pharynx is frequently attended with difficulty. The patient is directed to breathe through the nose, the tongue is depressed with a spatula, and a small-sized laryngeal mirror, comfortably warmed and with its reflecting surface turned upwards, is introduced behind the soft palate. When a good examination of the naso-pharynx is obtained, the following parts may be seen reflected in the mirror: the posterior surface of the uvula and soft palate, and above them, in the mesial plane, the posterior free edge of the septum nasi; on each side of the septum the apertures of the posterior nares, in which may be seen the upper part of the posterior end of the inferior turbinal, the middle meatus, the posterior end of the middle turbinal, the superior meatus, and occasionally a portion of the superior turbinal. On the lateral wall of the naso-pharynx the Eustachian opening and cushion can be seen, while by tilting the mirror backwards the vault of the naso-pharynx can be inspected.

_Digital examination_ of the naso-pharynx may be required, especially in children. The examiner pa.s.ses his left arm and hand round the back of the child's head, and with one of his fingers presses the cheek inwards, between the jaws. His right forefinger is carried along the dorsum of the tongue, pa.s.sed up behind the soft palate and a rapid examination made of the post-nasal s.p.a.ce.

CARDINAL SYMPTOMS OF NASAL AFFECTIONS.--The chief symptoms of nasal disease are: nasal obstruction, nasal discharge, anomalies of smell and taste, and certain reflex phenomena.

#Nasal Obstruction.#--This may be partial or complete, intermittent or constant, and may be the cause of such symptoms as alteration in the tone of the voice, catarrh of the respiratory pa.s.sages, snoring, cough, headache, inability to concentrate the attention, alteration in the physiognomy, or deformity of the chest. The half-open mouth, drooping jaw, lengthened appearance of the face, narrow nostrils, and vacant expression are characteristic signs of nasal obstruction.

Nasal obstruction may be due to _intra-nasal_ or to _post-nasal_ (naso-pharyngeal) causes. Amongst the former may be noted as the more common, erectile swelling and hypertrophy of the mucous membrane covering the inferior turbinated bones, and nasal polypi growing from the middle turbinal and middle meatal region. Causes originating in the septum include deviations, spines, and ridges, and septal haematoma and abscess. Obstruction may also be due to the presence of a foreign body in the nasal cavity, to a rhinolith, and to imperfect development of the nasal chambers. Further, tumours, both simple and malignant, and such conditions as tubercle, lupus, syphilis, and glanders may interfere more or less with nasal respiration. The most common cause of post-nasal obstruction is the presence of adenoids; more rarely fibro-mucous polypi, fibrous tumours, malignant disease, and cicatricial contractions and adhesions resulting from syphilis are met with.

_Erectile swelling_ of the inferior turbinated bodies is due to engorgement of the venous s.p.a.ces contained in the mucous membrane.

Obstruction from this cause is usually intermittent in character, and may be unilateral or bilateral. It is influenced by posture, being worse when the patient is in the horizontal position, and also by changes in atmospheric conditions and temperature. It is characterised objectively by a swelling of the mucous membrane, which is pink or red in appearance and of a soft consistence, pitting when touched with the probe, and shrinking on the application of a 5 per cent. solution of cocain. Its soft consistence and the fact that it becomes smaller when painted with cocain differentiate it from true hypertrophy of the mucous membrane. Its situation and immobility, its pink colour, and the shrinkage under cocain, distinguish it from the mucous polypus of the nose. The turgescence may involve the whole extent of the mucosa of the inferior turbinated bodies, including their posterior ends.

After anaesthetising with cocain, the electric cautery, or fused chromic acid applied on a probe, may be employed for the relief of the condition. If a true hypertrophy exists, it is better to remove it with a nasal snare.

_Nasal polypi_ spring from the mucous membrane covering the middle turbinated bone and from the adjacent parts of the middle meatus, but rarely from the septum. They consist of dematous ma.s.ses of mucous membrane, and are as a rule multiple. They are usually pedunculated, and as they increase in size they become pendulous in the nasal cavity. They are smooth, rounded in outline, of a translucent bluish-grey colour, soft in consistence, and freely movable. These characters, and the fact that the probe can be pa.s.sed round the greater part of the polypus, serve to differentiate this affection from the erectile swelling. It must not be forgotten that nasal polypi may be a.s.sociated with suppuration in one or more of the accessory sinuses. They are frequently present also in malignant disease, and in these cases they bleed readily. They are best removed by means of the cold snare, with the aid of the speculum and a good light. Several sittings are usually necessary.

_Carcinoma_ and _sarcoma_ sometimes grow from the muco-periosteum in the region of the ethmoid. They tend to invade adjacent parts, giving rise to haemorrhage and symptoms of nasal obstruction, and as they increase in size they may cause considerable deformity of the face. If diagnosed early, an attempt should be made to remove the growth.

_Deviations, spines, and ridges of the septum_ may produce partial or complete occlusion of the anterior nares. In deviation of the septum, the obstructed nostril is more or less occluded by a smooth rounded swelling of cartilaginous or bony hardness, which is covered with normal mucous membrane, while the opposite nostril shows a corresponding concavity or hollowing of the septum. Sometimes the convex side is thickened in the form of a ridge. A simple spine of the septum is usually situated anteriorly, and presents an ac.u.minate appearance, often pressing against the inferior turbinated body; it is hard to the touch. Ridges and spines may be cut or sawn off, or removed with the chisel. Many methods of dealing with a deviated septum have been suggested, such as forcible fracture or excision of a portion of the cartilage. A submucous resection of the deflected portion is to be preferred.

_Haematoma of the septum_ is usually traumatic in origin. As the result of a blow, an extravasation of blood takes place beneath the perichondrium on each side of the septum, and a bilateral, symmetrical swelling, smooth in outline and covered with mucous membrane, is visible immediately within the anterior nares. The blood is usually absorbed and should not be interfered with. If suppuration occurs, however, the swelling becomes soft, fluctuation can be detected, and the patient's discomfort increases. The abscess must then be incised and the cavity drained. It is sometimes found that a portion of the cartilage undergoes necrosis, leading to perforation of the septum.

#Nasal discharge# may be mucous, muco-purulent, or purulent in character. When it is of a clear, watery nature, it is usually a.s.sociated with erectile swelling of the inferior turbinated bodies. A purulent discharge may be complained of from one or both nostrils. If unilateral, it should suggest, in the case of children, the presence of a foreign body; in adults, the possibility of suppuration in one or more of the accessory sinuses. In infants, a purulent discharge from both nostrils may be due to gonorrhal infection or to inherited syphilis. Nasal discharge may be constant or intermittent. It is sometimes influenced by changes in posture; for example, it may be chiefly complained of at the back of the nose and in the throat when the patient occupies the horizontal position, or it may flow from the nostril when he bends his head forward or to one side. The discharge may be intra-nasal in origin, or due altogether to naso-pharyngeal catarrh. It varies somewhat in colour and consistence, and may be a.s.sociated with such intra-nasal conditions as purulent rhinitis following scarlet fever and other exanthemata or ulceration accompanying malignant disease, syphilis, or tuberculosis. Sometimes it contains shreds of false membrane, for example in nasal diphtheria; or white cheesy ma.s.ses as in coryza cascosa. The formation of crusts is significant of ftid atrophic rhinitis (ozaena) and syphilis, and in these conditions the discharge is a.s.sociated with a most objectionable and distinctive ftor. Pus from the maxillary sinus is often ftid, and the odour is noticed by the patient; while the odour of ozaena is not recognised by the patient, although very obvious to others.

#Foreign bodies# of various descriptions have been met with in the nasal cavities, particularly of children. They set up suppuration and give rise to a unilateral discharge, which is often offensive in character. The surgeon must not be satisfied with the history given by the parents, but, with the aid of good illumination, and, in young children, under general anaesthesia, the nose should be carefully inspected and probed. If there is much swelling, the introduction of a 5 per cent. solution of cocain will facilitate the examination by diminishing the congestion of the mucous membrane. No attempt should be made to remove a foreign body from the nose by syringing. If fluid is injected into the obstructed nostril, it is liable to force the body farther back, while, if injected into the free nostril, it is apt to acc.u.mulate in the naso-pharnyx and to pa.s.s into the Eustachian tubes. A fine hook should be pa.s.sed behind the body and traction made upon it, or sinus forceps or a snare may be employed. Care must be taken that the body is not pushed still deeper into the cavity. Fungi and parasites should first be killed with injections of chloroform water, or by making the patient inhale chloroform vapour.

#Rhinoliths.#--Concretions having a plug of insp.i.s.sated mucus or a small foreign body as a nucleus sometimes form in the nose. They are composed of phosphate and carbonate of lime, and have a covering of thickened nasal secretion. They are rough on the surface, dark in colour, and usually lie in the inferior meatus. They give rise to the same symptoms as a foreign body, and are treated in the same way. The stone, which is usually single, may be so large and so hard that it is necessary to crush it before it can be removed.

#Ozaena#, or #ftid atrophic rhinitis#, is characterised by atrophy of the nasal mucous membrane, and sometimes even of the turbinated bones, and is accompanied by a muco-purulent discharge and the formation of crusts having a characteristic offensive odour, which is not recognised by the patient. It is usually bilateral, and the nasal chambers, owing to the atrophy, are very roomy. It may be differentiated from a tertiary syphilitic condition by the absence of ulceration and necrosis of bone, by the odour, and by the fact that it is not influenced by anti-syphilitic treatment.

Various methods of treatment are in vogue, but thorough cleanliness is the most essential factor, and this is best secured by regular syringing. Plugging of the nostrils with cotton-wool for half an hour before washing out the nose greatly facilitates the detachment of the crusts. A pint of lukewarm solution containing a teaspoonful of bicarbonate of soda or of common salt, is then used with a Higginson's syringe, the patient leaning over a basin and breathing in and out quickly through the open mouth. The patient should then forcibly blow down each nostril in turn, the other being occluded with the finger, so that the infective material may thus be blown out without risk of it entering the Eustachian tubes, as may happen when the handkerchief is used in the ordinary way. Antiseptic sprays, such as peroxide of hydrogen, and ointments may be applied to the mucous membrane after cleansing.