CHAPTER XXX
- DIAGNOSIS OF DISEASES OF THE NOSE
The four chief signs of disease of the nose are (1) epistaxis, (2) discharge, (3) obstruction, and (4) deformity ; and it will be well to consider these individually before proceeding to the diagnosis of separate diseases.
- Epistaxis, or bleeding from the nose, may be traumatic, and occasioned by direct injury of the nose itself, or by fracture of the base of the skull (see p. 83), or idiopathic. When idiopathic it may result from local congestion, from disease of the vessels, from altered blood states, from ulcera- tion of the mucous membrane, or from rupture of vessels in very vascular growths in the nose. Idio- pathic epistaxis occurring in young persons otherwise in good health, and especially when preceded by flushing of the face, noises in the ears, giddiness, and headache, is to be attributed to congestion ; when occurring in the course of fevers or in patients with disease of the Hver, it is due to alteration in the hlood as well as to congestion. A common cause of repeated bleeding from congestion caused by blowing the nose, etc., is a patch of varicose veins situated on one or both sides of the antero-inferior part of the septum, and readily recognized on examination with a specu- lum. Profuse hajmorrhage in healthy adults may sometimes be due to a small ulcer on the septum which has perforated an artery. In elderly patients,
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422 SURGICAL DIAGNOSIS [chap.
when preceded by signs of cerebral congestion, and the blood is dark and venous in character, it is due to congestion ; but when the blood, bright red m colour, flows out very fast, and especially if the superficial arteries are tortuous and rigid, it may be attributed to rwpiure of an atheromatous artery. Epistaxis also occurs in Immophilia. _
- Discharge irom the nose varies much m its characters; it may be very thin and watery mucous, muco-purulent, purulent, sanious, mixed with foul-sinelUng crusts, odourless, or horribly offensive. Mucous and muco-purulent discharge is caused by acute and chronic catarrh. Purulent dis- charge may be due to empyema of the antrum, to ulceration of the mucous membrane of the nose, especially after impaction of a foreign body, or to suppuration in the frontal, ethmoidal, or sphenoidal sinuses. Sanious pus indicates ulceration, or in acute cases intense congestion. Great fetor of discharge indicates retention of the matter in the nose and it^ decomposition, and is usually associated with syphilitic ulceration of the mucous membrane or atrophic rhinitis.
Something may be learnt from the mode ol escape of the discharge. Where this is constant it is probably secreted by the nasal cavity itself; where more or less intermittent it points to the fluid accumulating in some neighbouring cavity and from time to time escaping into the nose ; it tne flow of fluid is greatest when the head is resting on the opposite side, this strongly mdicates that it is secreted in the antrum ; when position has no influence upon the flow it may come from the frontal or other sinuses, and inquiry should be made for local pain. Pain in the region of the eyebrow, the cheek, and moiv rarelv in tlio, ^^VVOX teeth suggests disease
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423
in the autmm ; if above the eyebrow, between it and the hair-line, in the frontal sinus ; if behind the eyes and in the occipital region, in the sphenoidal sinus ; and if over the bridge of the nose, in the ethmoid sinus. In any of these the pain usually comes on in the morning and is relieved towards the evening.
Obstruction of the nose is indicated by a "nasal" tone of voice, by the patient's inability to blow down or to sniff up through the affected nostril, and rarely also by epiphora. It may be due to displacement of the walls of the nose from fractures and other injuries, to deflection of the septum, to outgrowths from the walls or neighbouring cavities into the nasal fosste (swelling of mucous membrane, spurs, polypi, hematoma, abscess, and sarcoma or carcinoma of upper jaw or sinuses, etc.), or, in children especially, and when unilateral, to foreign bodies blocking up the passage. Similar obstruction to respiration may be due to adenoid vegetations and tumours in the naso-pharynx and to adhesion of the soft palate to the back of the pharynx. With mucous polypi the obstruction is greater in damp than in dry weather.
Deformity o£ the nose may be congenital or acquired ; when the latter it is either tmumatic, the direct result of the violence, or idiopathic, occa- sioned either by imperfect development of the nose, deviation of the septum, by destruction of more or less of the bony framework of the nose and col- lapse of that feature, or by distension of its cavity by the progressive growth of a tumour within it. The distinction between these forms is therefore quite obvious. When the nose is greatly widened trans- versely, and the eyes pushed outwards and separated from each other, as occurs in chondroma or chondro-
424 SURGICAL DIAGNOSIS [chap.
sarcoma, tlie deformity, wliicli may reacli a liideoiis degree, is known as " frog-face."
Examination of the nose.— The nose should first of all be examined externally to detect any alteration in its contour. Compressing one nostril with his finger, the surgeon shoidd request the patient to breathe deeply through the other, when the fact of obstruction will be at once apparent ; the other nasal fossa must be similarly mvestigated. Then, placing the patient facmg a good hght, he should gently press up the tip of the nose, when he will be able to see the anterior nares and the septum, and detect deviation of the septum, ulcera- tion of the anterior nares, or a presenting polypus. To examine the cavity of the nose a speculum should be introduced, and a strong Ught thrown m by means of a mirror. The condition of the inner and outer walls, the size of the space between, and the nature of any discharge must be noted. If a spur, growth, or obstruction is seen, a probe should be passed up to ascertain its consistence, and an attempt made to move it. In cases of purulent discharge, pains must be taken to determine whether the pus escapes into the nose from beneath the middle and over the inferior turbinate bone-in which case it is coming • either from the antrum, the frontal sinus, or the anterior ethmoidal cells-or flows over the midd e turbinate bone from higher up, that posterior ethmoidal cells, or the f^^^^^.^l The posterior nares may be exammed ^^h the finder passed up behind the soft palate, or by poste or ihinoscopy," a small mirror being introduced into the pharynx behind the velum, and ^H^-J^^^'-^f light reflected from a head mirror through the mouth if the patient is under the influence of an ana^^sthetrc the surgeon can more satisfactorily examine the
XXX] NASAL DISCHARGE . m
posterior nares with the fiiiger passed behind the soft palate.
Nasal symptoms are often due to disease of the frontal or ethmoidal sinuses or of the antrum of High- more. The condition of these cavities can be investi- gated by " transillumination." In a darkened room, a small electric lamp is placed in the patient's mouth with the lips closed. The areas of light and shade on the two sides of the face and forehead are compared.
The diseases of the nose will, by means of this examination, readily be divided into those in which there is obvious obstruction to respiration, and those m which there is discharge only, the nasal f osste bemg free. The cases in which the discharge has a very offensive penetrating odour are known as cases of ozsena.
- Inodorous dischaicjc without obstruc- liou.— If the discharge is mucous or muco-purulent It is known as chronic coryza. Where this occurs m mfants, and leads to difficulty in sucking, and snufflmg respiration (" the snuffles "), it is a charac- teristic feature of inherited syphilis. When with this discharge the mucous membrane over the turbinate bones is found thickened and uneven there is chronic hypertrophic rhinitis. The thickened mucous mem- brane may look like a polypus, but it is found not to move over the bone when pressed by a probe, and contracts readily under cocaine and adrenalin' FissuT-es and small ulcers in the mucous membrane are probably syphilitic, and the patient should be carefully exam ned for other evidences of secondary syphihs. In midrUe-aged and elderly persons the lining of the nostril may be found red and irritable with dry adherent scabs, or thin watery discharge-^ eczema; such patients are often gouty, o*
426 SURGICAL DIAGNOSIS [cbaP.
If the discharge of pus is more abundant, and occurs periodically, especially when the patient lies down on the opposite side, or blows his nose violently, it is probably an empyema of the maxUlary antrum (sinus). If any of the upper teeth are carious, this will support the diagnosis. In these cases there is no distension of the antrum ; the patient may be conscious of an unpleasant smell, and of a nauseous taste in the morning from the pus trickling into his pharynx. The pus may be seen flowing into the nose, over the inferior turbinate bone (concha), and the antrum may be found to be opaque to transmitted light. Suppuration in the antrum is often attended with pain around the orbit, in the cheek, or in the upper teeth. The diagnosis can only be finally established by puncture cf the antrum. If there is a continuous discharge of pus from under the middle turbinate bone, associated with headache and sleeplessness, and unaffected by position, it is probably due to suppuration in the frontal sinus ; tenderness over the sinus with frontal pain will strengthen this supposition. Confirmation may be afforded by a skiagram. Pain over the bridge of the nose, and between the eyes, with a similar discharge of pus into the middle meatus, is characteristic of disease of the anterior ethmoidal cells. If the pus is seen to flow down over the middle turbinate bone or into the naso-pharynx it probably comes from the ethmoidal sinuses or posterior ethmoidal cells; a probe may occasionally detect necrosed ethmoid bono.
"a free discharge at times of clear watery fluid, frequently preceded or accompanied by a paroxysm of sneezing, indicates a vaso-motor rhinitis. This condition may be a symptom of mild sinus infection. In all eases it indicates irritation of the nasal mucosa. Hav-fcver is a form of this condition.
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If, following an injury to the head, there is a constant or intermittent trickling of thin watery fluid from one nostril, and the nasal cavity is quite free, the fluid may be cerebro-spinal, escaping from the subarachnoid space. {See p. 82.)
- Ozaina. — The immediate cause of this con- dition is the decomposition of retained and dried secretion due to the loss of the cilia on the surface of the mucosa, with consequent stagnation. It occurs as a manifestation of late syphilis, and as a non- syphilitic atrophic rhinitis." In the former there may be a clear history of syphilis, the Wassermann reaction is porsitive, and in addition to the crusted and atrophic state of the mucosa with atrophy of the turbinate bones and roominess of the na.sal fossae, a probe may detect bare, necrosed bone.
Atrophic rhinitis occurs in young women of the poorer classes, and is never accompanied by necrosis of bone. It mu.st not be forgotten that the impaction of foreign bodies may lead to a fetid discharge.
3 Obslruelioii in the nasal fossa. — i. If the cavity is seen to be filled up with a yellowish or bluish and semi-transimrent soft body which yields and moves before a probe, or moves with stroni^ respiration, it is a mucous polypu;. These polypi are often multiple; they grow slowly, and neVer cause frequent and profuse haemorrhages ; they may cause epiphora and loss of smell, and in long-standing cases a marked widening of, and slight chronic a.dema over, the bridge of the nose ; they occasion more distress in wet weather than in dry.
ii. If on examining the cavity a soft mucous .surface, red or dark imrple in colour, is seen pro jecting from the outer wall of the nose which is not moved by the probe or by respiration, it is to be distinguished as hypertrophy of the mucous
428 SURGICAL DIAGNOSIS [chap.
covering of the inferior turbinated bone (concha) ; it is frequently seen in chronic coryza, and may be mistaken for a polypus.
iii. If the nose is found to be obstructed by a deep-red or livid mass, firm to the touch, and there has been frequent severe epistaxis, the surgeon may diagnose nbrous polypus, which should rather be spoken of as a sarcoma. This disease is most often seen in young subjects ; the tumour- grows steadily, and causes great distension of the nasal fossa?, spreadmg through the septum, widely separatuig the eyes, fill- ing the antrum, and projecting into the pharjnix and mouth. It does not give rise to metastases, and after puberty undergoes spontaneous retrogression. The sru-geon should endeavour with probe or finger to find the point of attachment of the polyp; it may spring from the base of the skull and grow through into that cavity, causing coma and . death.
iv. If on looking into the mouth m a case of nasal obstruction, a rounded bluish or semi-transparent tumour is seen behind the soft palate round which the finger can be passed freely, it is an antro-choanal polyp, projecting backwards from the region of the ostium of the antrum on one side. Although simple in nature, it may recur after removal with a snare or forceps.
V. Deviation of the septum to one side or a spur on the septum may cause imilateral obstruction ; these conditions are easily recognized by uispection.
vi. When the septum is found projecting mto both fossa), or possibly one only, without a corre- sponding depression on the other side, there is a tumour of the septum. Examine whether it is solid or fluid. If fluid and quickly formed, and attended with much pain and redness, it is an acute abscess.
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and larobably a siii^puratiug lisematoma. If fluid, chronic, comparatively painless, and not attended with oedema, it is a chronic abscess. If the swelling is firm and soUd, but slightly yielding, it is probably an enchondroma, while if of stony, unyielding hard- ness it is an osteoma. (For hwrnatoma of the septum, see p. 114.)
vii. If a firm rounded substance is found in one or other nasal fossa, not attached to either wall, it is a foreign body. There may be a history of its mtroduction, or its examination after removal may show it to be a pea, a small marble, a wad or paper, or some_ similar substance. Such foreign bodies may remain in the nose for many years. If, however, it is calcareous in nature, it is a nasal calculus ; these calculi usually develop around foreign bodies.
viii. Warts are sometimes seen growing from the mucous membrane ; their fine-branching surface at once distinguishes them from other tumours. They may bleed readily when touched with a probe.
IX. When the tone of voice indicates nasal obstruction, which is found not to be complete, and the nasal fossae are free, a careful examination of the posterior nares and naso- pharynx should be made, by means of a postnasal mirror or, failing this, with the finger, and if a soft mass showing deep vertical fissures is found there it will be recog- nized as adenoid vegetations, or hypertrophy of the normal lymphoid tissue of the part. This is usually met with m delicate children, often in conjunction ^^ath hypertrophy of the tonsils; as secondary efiects may be mentioned a characteristic lateral flattening of the nostrils, with breathing through the open mouth and raising of the upper lip, deafness noises in the ears, slight discharge of blood into the phar>Tix m the morning, excess of mucus in the
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430 SURGICAL DIAGNOSIS
pharynx, and sometimes chronic coryza with or without involvement of the sinuses.
X. Gradually increasing obstruction of one nasal fossa, especially if preceded or associated with re- peated small hsemorrhages and an aching pam in the part, is characteristic of a malignant tumour encroaching upon the nose. Examine carefully for evidence of swelling, for displacement of bone and the protrusion of growth into the nasal fossa, and for the enlargement of glands. The growth is fre- quently sloughing on the surface, and bleeds readilv when examined with a probe.