1. Tumours and infectious granulems overhead respiratory tracts.
2. Traumas, foreign bodies, bleeding from ENT-organs.
3. The first aid at ENT– illness.
TUMOURS AND INFECTIOUS
GRANULEMI OVERHEAD RESPIRATORY TRACTS
TUMOURS OF ENT ORGANS
The about 7000 ENT-oncologic patients every year come in
TUMOURS OF LARYNX
The new formations of larynx divide into no malignant and malignant. From the tumours of larynx no malignant most often meet fibroma, papilloma, gemangioma, limfangioma, cyst, laringotsele. Among malignant – cancer and considerably rarer – sarcoma, adenokartsinoma.
TUMOURS OF LARYNX NO MALIGNANT
FIBROMA. This is new formation from the connecting fabric, covered by the flat epithelium. From correlation between cages and connecting fabric distinguish soft and dense fibromata. Meets more frequent the men have age on years, 20-40. Grows very slowly, godami.
Symptoms
1. Hoarseness of voice
At examination (laryngoscopy) expose
1. Lonely tumour up and about by size from pin-head to little pea, which takes place more frequent only on to the free edge of vocal fold between front and middle its third, or in front komisure.
2. Sometimes the fibroma grows on the overhead or lower surface of vocal fold, on the vestibular fold, in the morganievom ventricle of larynx, has a wide basis.
Diagnostics
1. Indirect laryngoscopy:
а) typical localization of new formation;:
б) small size of tumour up and about;
в) complete mobility of vocal fold;
2. Histological research of new formation.
Medical Treatment
1. The Endolaringealnoe deleting of tumour.
2. After deleting new formation to the patient appoint the mode of silence, unirritating food, ban to smoke, to use an alcohol.
In case of deleting a tumour it is necessary to be very attentive, not to injure elastic tyag on the edge of vocal fold, that conduces to irreversible disfonii.
PAPILLOMA. Meets in early child’s age and at adult. At children the tumour often gives the relapses, and in the declining years – regenerates in malignant. Parenhimo papillomi there is a mnogosloyniy flat epithelium. More frequent meets as numerous excrescences of tumour (papillomatoz).
Factors, that assist to development of papillomi
1. Chronic irritation of larynx (burning, alcohol and others like that.)
2. Repeated infections of overhead respiratory tracts.
3. Filtering virus.
4. Tuberculosis of larynx.
Symptoms
1. Hoarseness of voice up to aphonia.
2. Labouring breath (at the large tumours).
At examination (laryngoscopy) expose
1. Coler of tumour more frequent all pinky.
2. Is localized mainly on the veritable vocal folds, quite often spreads on gullet, trachea.
3. After the original appearance papilloma reminds a cauliflower, berry of raspberry, red caviar.
Medical Treatment
1. Surgical deleting of papillomi (endolaringealno or through laringofissuru).
2. Rentgenoterapiya in the pooperatsionniy period.
3. Obsheukreplyuyushie facilities (polivitamini, cod-liver oil and others like that.)
4. Greasing a slizistoyobolochki larynx (in the posleoperatsionniy period) of podofillinom.
GEMANGIOMA And LIMFANGIOMA. The tumours from the blood (gemangiomi) and lymphatic (limfangiomi) vessels meet in larynx very rarely
Symptoms
1. Hoarseness of voice.
At examination (laryngoscopy) expose
1. Localization – more frequent all free edge of vocal fold in its front and middle third, and also in front komissure.
2. Size of new formation – from pin-head to to the pea.
3. Surface of new formation – uneven, reminds a berry of blackberry.
4. Coler – red with the different tints: bluish, brown, sine-fioletovim and others like that.
Medical Treatment
1. Efficient – deleting new formation by tongs or galvanokauterom.
2. Conservative – introduction to the tumour of alcohol-novocaine, rentgeno- and radial therapy.
MALIGNANT TUMOURS OF LARYNX
From the malignant new formations of larynx the first place is occupied by cancer (cancer laryngis). From data of literature, the cancer tumours of larynx make about 2% from the common quantity of cancer diseases of organism of man. After the histological structure in the 97% cases of shrines larynges are ploskokletochnimi, considerably rarer there is bazalnokletochniy, solid cancer and adenokartsinoma. The cancer of larynx mainly strikes the men (about 92%) in age from 40 on the about years, 70.
The malignant new formations of larynx after the clinical display divide into stages. International principle of division of tumours after their distribution (Т)is fixed in the basis of classification, on the state lymphatic knots (N) and by the presence of metastases (М).
Note: by the given classification it is possible to make to use and for determination of stage of tumour of other ENT-organs.
T1 – a tumour is limited by one department of larynx;
T2 – the tumour spreads outside one department of larynx;
T3 – the tumour occupies all departments of larynx;
T4 – the tumour spreads outside larynx.
N0 – the regional lymphatic knots not palpiruyutsya
N1 – the mobile lymphatic knots palpiruyutsya on the side of defeat
N2 – the mobile lymphatic knots palpiruyutsya on the opposite side, or from both sides
N3 – the immobile lymphatic knots palpiruyutsya
M0 – remote metastases are not not present
M1 – remote metastases are determined
Stages of tumular process
І stage – T1, N0, M0;
The II stage – T2, N0, M0; or T3, N0, M0;
The III stage – T1, T2, T3, N1, M0;
The IV stage – T4, N0, N1, M0 ;
Any T, N2, N3, M0;
Any T, any N, M1
Stage of development of malignant new formations of middle department of larynx
Factors, which assist to development of disease
1. Chronic inflammation of larynx
2. New formations of larynx no malignant
3. The Leykoplakiya mucous membrane of larynx
4. The Giperkeratoz mucous membrane of larynx
5. Professional irritations of mucous membrane of larynx
6. Use of alcohol
7. Burning
Clinic
Simptomatika at the shrine of larynx relies on stage and localization of tumour. The new formation of vestibular department of larynx can long time itself by nothing to show, but on the veritable vocal folds – enough early causes the change of voice. Most character displays of cancer of larynx depending on localization are the following:
The A. Vestibulyarniy department:
1. Feeling inconvenience and inorodnogotela in the laryngeal part of gullet;
2. Feeling pain in the laryngeal part of gullet;
3. Unpleasant smell from the oral cavity;
4. Disfagiya;
5. Krovoharkanie;
6. In the late stages – disfoniya, cachexy.
The B. Sredinniy department:
1. Hoarseness;
2. Difficulty In Breathing;
3. In the late stages – pains in case of swallowing.
The V. Podskladochniy department:
1. Difficulty In Breathing:
2. Hoarseness (in case of distribution of tumour on the vocal folds).
Patient on senior years, 40, man, which suffers by hoarseness on the more than weeks, 2, must be examined by ENT-doctor, not to skip .
At examination (laryngoscopy) expose
А) Middle localization:
At the beginning of disease
1. On the vocal fold, more frequent on its middle part, new formation is visible on to the wide basis
2. Limitation of mobility of vocal fold
In case of distribution of process:
1. The tumour strikes all fold, front komissuru, comes to the cherpalovidnogo cartilage, spreads oadgortannik. A surface of tumour is knobby, coler her can be various – from white to red;
2. Tumour of izyazvlyaetsya;
3. Admixtures of blood in mokrote;
4. As a result of second perihondrita nadgortannik and cherpalovidnie cartilages are multiplied, the contours of larynx change.
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Carcinoma of the vocal cord. This usually occurs in smokers. The indurated leukoplaki on this vocal cord (arrow) is a well-differentiated squamous cell carcinom that has arisen as result of chronic laryngitis with hyperkeratosis. The prognosis for or vocal cord carcinoma with radiotherapy is excellent, with a curerate of over 90% for early lesions. The voice returns to normal, as does the appearance of the vocal cord
At other localizations of shrines of larynx has a less expressed laryngoscopy picture
Б) Vestibular localization
1. Small compression (more frequent on the laryngeal surface of nadgortannika)
2. Infiltration and rigidnost of nadgortannika
3. Izyazvlenie new formation (in the late stages)
В) Podskladochniy department
In the podskladochnom department the primary cancer arises up enough rarely and some time at laryngoscopy of changes it is not. New formation is revealed on leaving for the limits of subplicate department
Diagnostics
1. Anamnesis (age, floor of patient, professional factors, clinical flow of disease and others like that.)
2. Given laryngoscopy
3. Palpatsiya of limfouzlov
4. Biopsy of infiltrata
5. Sciagraphy of larynx
Medical Treatment
In case of malignant new formations the larynges apply the combined medical treatment: radial therapy, chemotherapy and efficient interference. As for the order of application of these methods of medical treatment that and final opinion. Necessary individual approach. However most authors consider:
1. In the І and II stages of cancer of larynx of any localization to apply at first radial therapy within the limits of 60-80 Warm. If the tumour does not disappear – in a 1,5 month to conduct the efficient medical treatment: at the vestibular localization – laringektomiyu, megskladochnoy and podskladochnoy – possible resection of larynx.
2. At the III stage of disease: vestibular department – radial therapy, and after – laringektomiya (at testimonies complemented by the Kraylya operation). At the tumours of podskladochnogo department – at first to conduct the efficient medical treatment, and after – radial therapy. At the interplicate localization – the sequence of surgical interference and radial therapy does not matter
3. In the IV stage of cancer of larynx – symptomatic medical treatment: anaesthetic facilities, chemotherapy, palliative irradiation, if necessary – traheostomiya, gastrostomiya, bandaging vessels in case of bleeding and others like that.
Carcinoma of the pyriform fossa and upper esophagus. The presenting signs are dysphagia for solids and pain, commonly referred to the ear. There is early metastasis to the cervical nodes. A carcinom involving mainly the medial wall of the pyriform fossa causes hoarseness. The prognosis is not good, particularly with upper esophageal carcinoma, whether reatment is with radiotherapy or surgery. Resection for the hese carcinomas involves a pharyngolaryngectomy and the replac acement oreconstruction of the he cervical esophagus poses technical problems. Immediate replacement with stomach or colon, mobilized and brought through the thorax and sutured to the pharynx is one techniq
TUMOURS OF GULLET
Distinguish the tumours of gullet no malignant and malignant. The clinical displays of new formation rely largely both on his histological structure, and from localization (nasal, mouth, laryngeal parts of gullet)
TUMOURS OF GULLET NO MALIGNANT
The new formations no malignant meet in all departments of gullet and can appear from the various fabrics. Most often in the nasal part of gullet meet:
male puberty ANGIOFIBROMS. She behaves toward tumours de bene esse no malignant, since enough often retsidiviruet or maligniziruetsya. The tumour develops mainly at the persons of men sex in age from 11 on the about years, 25.
Clinic
1. Frequent bleeding from nose
2. Complete exception of the nasal breathing
Diagnostics
1. Rinoskopiya (front and back)
2. Finger research of nasal part of gullet
3. Sciagraphy
4. Biopsy of tumour
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The angiofibroma of male puberty is a rare vascular malformation in the postnasal spac, whic may be become extremely large, presenting with nasal obstruction and epistaxis. Treatment is difficult, but surgical removal via a midfacial “degloving” approach b,c) allows access via the midfacial skeleton without facial scars. Some facial fractures and other midfacial tumours can managed via this approach. Very large angiofibroma being removed from the postnasal space.
In case of research expose
1. Tumour on the wide basis
2. At palpatsii surface of tumour smooth, sometimes knobby, immobile
3. At palpatsii the tumour often bleeds
Differentiate with the hypertrophy of gullet mindalini
Medical Treatment
1. Operation after Stenom or Zimontom
2. Before the efficient interference preliminary bandage an outward carotid from both sides
3. At soft angiofibromah – combined medical treatment (radial and surgical)
In the mouth and laryngeal parts of gullet from the tumours no malignant papillomi, angiomi, fibromata, “mixed” tumours – epiteliomi and others like that. At the beginning of its development of tumour by nothing can show not itself. In future are revealed at faringoskopii as single or a few uzloobraznih infiltratov.
Medical treatment is only efficient. Depending on localization and sizes the new formations apply the vnutrigorlovoy or outward surgical accesses.
MALIGNANT TUMOURS OF GULLET
Among the malignant tumours of gullet sarcomas, cancer and limfoepitelioma (the Shminke tumour)
Symptoms
1. At the beginning of its development of no special disorders the patients can feel not
2. Pain
3. Laboured swallowing (localization in the mouth part of gullet)
4. Change of voice, nasality of speech
5. Putrid smell of mouth
6. Disfagiya
7. Nose-bleeds (localization in the nasal part of gullet)
8. Labouring breath (localization in the laryngeal part of gullet)
9. The Zalogennost ears (localization in the nasal part of gullet)
10. Utrudnennoe opening of mouth (localization in the mouth part of gullet)
11. Common disorders (pain of head, insomnia, loss of appetite, cachexy and others like that.)
Diagnostics
1. Anamnesis
2. Rinoskopiya
3. Faringoskopiya
4. Finger research of nasal part of gullet
5. Palpatsiya of limfouzlov neck
6. Biopsy of tumour
At examination expose
1. Tumour of different size with the knobby surface of surplus closeness, sometimes with disintegration and dirty raid
2. The tumour germinates in the deep fabrics
3. Regional lymphatic (podchelyustnie and neck) knots are considerably multiplied and become immobile
Medical Treatment
1. Radial therapy
2. Surgical – deleting metastaticheskih limfouzlov necks
3. Chemotherapy
Prognosis – unfavorable
TUMOURS OF NOSE AND sinus
Among the tumours of nose no malignant and sinusof nose more frequent meet krovotechniy polypus, fibromata, papillomi, osteomi, angiomi, limfangiomi and others like that.
KROVOTOCHNIY POLYPUS. Is localized mainly in the cartilaginous part of partition of nose
Symptoms
1. Zalogennost one half of nose
2. Frequent nose-bleeds
Diagnostics
1. Anamnesis
2. Rinoskopiya
3. Palpatsiya of new formation
4. Biopsy of polypus
Priosmotre expose
1. Tumour of purple coler with the smooth or uneven surface
2. The tumour fills front departments of nose from one side
3. At palpatsii tumour of soft consistency, easily bleeds
Medical Treatment
1. Surgical deleting of polypus near his basis
2. Electro-coagulation of place of attachment of tumour
TUMOURS OF SINUS NO MALIGNANT
More frequent all among the tumours of sinusno malignant there is osteoma. She is localized more frequent in the frontal bosom and latticed labyrinth.
Symptoms
1. Since the tumour grows slowly, sometimes godami, long time in sick no complaints can be not present
2. Feeling pressure in the proper bosom
3. Pain of head
4. Violation of the nasal breathing (in case of germination of new formation from the sinus in the cavity of nose)
Diagnostics
1. Sciagraphy of sinus
2. Diagnostic punktsiya of bosom
3. Biopsy of new formation
Medical Treatment
1. Surgical – wide opening of okolonosovoy bosom with the subsequent deleting of tumour
MALIGNANT TUMOURS OF NOSE AND sinus
Among the malignant tumours of nose and sinusa sarcoma and cancer
MALIGNANT TUMOURS OF NOSE
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Tumours are localized in the different areas of cavity of nose. Among sarcomas select angiosarkomi, angiofibrosarkomi, hondrosarkomi and others like that. A cancer of nose is ploskokletochnim, tsilindrokletochnim and others like that. Frequency of sarcomas of nose is the same, as well as cancer tumours. However the sarcomas meet mainly early in life, cancer – in elderly.
Carcinoma of the nose. The apex of the nasal vestibule must be examined extremely carefully in a case of scanty pistaxis, where no obviou bleeding site is apparent in Little’s are area.
Symptoms
1. The Zalogennost nose, which passes to the complete impassability of that or other half of nose
2. Anosmiya
3. Periodic nose-bleeds
4. Selection from the nose of слизисто–гнойно-bloody character with the unpleasant smell
5. Slezotechenie
6. Head pains
7. Pains in area of nose
Diagnostics
1. Anamnesis
2. Rinoskopiya
3. Palpatsiya of new formation
4. Sciagraphy
5. Biopsy of new formation
At examination expose
1. At rinoskopii – tumour of red coler with smooth, or by the knobby surface
2. The tumour easily bleeds in case of touching by probe
3. Festering-with blood selection iose
4. Deformation of outward nose
5. Displacement of eyeball
Medical Treatment
The results of medical treatment largely rely on the term of beginning medical treatment. If it is begun on the first stages of development of disease, in part of patients it is possible to attain the complete convalescence, or it is considerably to continue the life of patients.
From the medical measures more frequent use :
1. Surgical – deleting a tumour within the limits of healthy fabric
2. Radial therapy
3. Chemotherapy
4. Symptomatic therapy
MALIGNANT TUMOURS OF sinus
More frequent a verhnechelyustnaya bosom is struck. The persons of senior age have mainly a cancer, young – sarcoma
Stages of development of malignant new formations of sinus
Symptoms
1. Difficulty of the nasal breathing
2. Слизист-festering excretions from one half of nose, sometimes with the admixtures of blood and unpleasant smell
3. Deformation in area of facial wall of sinus
4. Thrusting and displacement of eyeball out (especially at localization of tumour in the reshetchastom labyrinth)
5. Decline of sight, up to the complete blindness (tumours of basic bosom and back cages of reshtchastogo labyrinth)
6. Labouring nasal breath and swallowing (in case of distribution of tumour in the nasal part of gullet)
7. Neuralgic pains in the facial area with irradiation in skull and podchelyustnuyu region
8. General symptoms – pain of head, insomnia, cachexy and others like that.
Diagnostics
1. Anamnesis
2. Rinoskopiya
3. Palpatsiya
4. Sciagraphy of sinus
5. Biopsy of tumour
At examination expose
1. If the tumour from the okolonosovoy bosom did not germinate in the cavity of nose, at rinoskopii of changes it can be not
2. In case of germination of tumour in the cavity of nose new formation of red coler with the knobby or smooth surface, which easily bleeds in case of touch by probe is revealed
3. On sciagram – homogeneous darkening of additional bosom and unclear of its contours
4. Megascopic limfouzli necks and podchelyustnie
Medical Treatment
Is the most effective method of medical treatment of malignant tumours of sinuscombined, which includes:
1. Predoperatsionnaya radial therapy
2. Efficient interference on the staggered additional bosom
3. At presence of metastases in regional limfouzli – wide their deleting (operation of the Kraylya type)
4. In the 1У stage the tumours appoint palliative gamut-therapy and symptomatic medical treatment with bandaging an outward carotid
TUMOURS OF EAR
In the топографо-anatomic relation an ear (especially middle and inlying) is one most of unbeneficial by the region of organism of man in relation to the efficient interference concerning tumours. The new formations of ear divide into no malignant and malignant.
TUMOURS OF OUTWARD EAR
А) No malignant
Among the tumours of narugnogoo ear no malignant most often meet papilloma, angioma, fibroma, angiofibroma, hondroma, osteoma and others like that.
Symptoms
1. Since the new formations of outward ear develop very slowly and without some feeling, the patient to this gets used and by the sole complaint in case of address to the doctor a presence of same tumour
2. In case of development of tumour in the outward auditory passage-way at patient the ear goes down
3. Sometimes in place of development of new formation of patient disturbs an itch of skin
Diagnostics
1. Anamnesis
2. Examination of patient
3. Sciagraphy (at osteomah of outward auditory passage-way)
4. Biopsy of new formation
At examination expose
1. On auricle or in the outward auditory passage-way infiltrat with the even surface, clear contours
2. At papillomah, fibromata, osteomah skin above the new formatioot practically changed, at gemangiomah – bluish with the red tint
3. At attempt to clean an outward auditory passage-way of angiomi can give the strong bleeding
Medical Treatment
1. Surgical deleting
2. The Kriodestruktsiya tumours
MALIGNANT TUMOURS OF OUTWARD EAR
Among the malignant tumours of narugnogoo ear a cancer (in the senior age) and sarcoma (early in life)
Symptoms
1. Hasty growth of new formation
2. The Krovotochivist tumours
3. Sickliness
Diagnostics
1. Anamnesis
2. Examination
3. Biopsy
At examination expose
1. New formation on auricle or in the outward auditory passage-way knobby, with disintegration, krovotochivoe
2. Infiltratsionniy growth of new formation in the surrounding fabrics
Medical Treatment
1. Surgical deleting of tumour
2. Radial therapy in in the posleoperatsionniy period
3. Symptomatic medical treatment in the 1У stage of disease
A prognosis at the malignant tumours of outward ear is serious, since the process can spread on the neighbouring areas
TUMOURS OF MIDDLE EAR NO MALIGNANT
Among the tumours of middle ear no malignant gemangioma and glomusnaya tumour – hemodektoma. These new formations arise up mainly the people have age on years, 30-60. The disease flows godami and even by ten of years.
Symptoms
1. Pulsating noise in ear
2. Decline of ear
3. Paralysis of facial nerve
4. Dizziness
5. Bleeding from ear
Diagnostics
1. Anamnesis
2. Otoskopiya
3. Kamertonalnoe and audiometricheskoe inspection
4. Sciagraphy
5. Biopsy of new formation (if the tumour did not still germinate in the inlying auditory passage-way, conduct diagnostic timpanotomiyu)
At examination expose
1. At the beginning of development of tumour the ear-drum can be without some changes
2. In case of development of disease the ear-drum bulges, gets a coler brightly from red darkly to bluish, pulsates
3. At the breach of ear-drum and going a tumour out the new formation of red coler comes in the auditory passage-way to light, knobby, easily krovotochivoe in case of touch by probe
4. In case of finger pridavlivanii on the neck of outward carotid (on the side of defeat) and simultaneous otoskopii – the coler of tumour becomes pale, she does not pulsate
Medical Treatment
1. Surgical deleting of new formation – extended generalcavernous operation in the various modifications from the previous perevyazkoy outward carotid and yaremnoy veni on the side of tumour
Prognosis – relatively favourable
MALIGNANT TUMOURS OF MIDDLE EAR
The malignant tumours of middle ear meet comparatively rarely, however they are in this area more frequent, thao malignant. Among the malignant new formations in the middle whisker more frequent all there is a cancer (mainly at adult) and sarcoma (early in life).
Symptoms
On the first stages of its development the malignant tumour of some character signs has, but flows as ordinary chronic inflammation of middle ear.
1. Permanent festering excretions from ear
2. Noise in ear
3. Decline of ear
4. Pain of head
. In a 2-3 month from the beginning of development of illness:
5. Festering excretions from ear with the unpleasant smell and admixtures of blood
6. Paralysis of facial nerve
7. Paralyses of other cranial cerebral nerves (okodvigatelnogo, taking and dr.)
8. Dizziness
9. General weakness, cachexy and others like that.
10. Sharp strengthening of pains in ear
Diagnostics
1. Anamnesis
2. Examination
3. Research of ear (by speech, by the tuning forks, audiometer)
4. Sciagraphy of temporal bone
5. Biopsy of new formation
At examination expose
1. Festering excretions with the admixtures of blood in the outward auditory passage-way
2. A tumour of dense consistency is revealed in the auditory passage-way, knobby, grey-red coler, bleeds, with disintegration
3. Sharp loss of ear on the staggered ear
4. Violation of contours of mammiform sprout
5. Phenomena of paralysis of facial nerve
6. On sciagram – unclear contours of drum cavity, homogeneous darkening of cages of mammiform sprout, defect of bone
Medical Treatment
1. On the first stages of development of disease – surgical deleting of new formation (extended generalcavernous operation in the various modifications)
2. In the posleoperatsionniy period – radial therapy (about 60 Warm on course the medical treatments)
3. In the 1У stage of illness – symptomatic medical treatment
Prognosis – very unfavorable.
INFECTIOUS GRANULEMS
Overhead respiratory tracts and above all things nose, gullet and larynx, can be struck by the such chronic infectious diseases as skleroma, tuberculosis and Syphilis. These diseases are caused by the specific exciter, and on slizistoyobolochke overhead respiratory tracts infiltrat appears – granulema, therefore these illnesses united in the group of infectious granulem.
SKLEROMA
A name of skleroma respiratory tracts was offered by our compatriot M.M.Volkovich in the 1888 year, which studied baktereologiyu and clinic of skleromi. And first described this disease F.Gebra in the 1870 year in vein, which looked after 9 patients with the defeat of fabrics of entrance iose and overhead lip by dense infiltratom, that did not respond to the medical treatment. Then he gave the name to illness – “rinoskleroma”. Later – in 1882, Frish in case of research of staggered fabrics of patients of skleromoy exposed in the large cages the microbes, that had a form of sticks, which he and defined, how exciter of skleromi. How appear, skleromoy is struck not only nose but also other respiratory tracts, including a trachea and bronchial tubes, therefore now a name of “skleroma” is used.
Skleroma this – endemic. More frequent all she meets in the Western regions of our state,
Patomorfologiya
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In fabrics of patients on skleromu appear dense, that is reminded by the cartilage, limited or poured out infiltrat, which in case of its growth spreads both to the surface of mucous membrane or skin, and in the depth of fabric. By the character feature of such infiltratov to eat that they, unlike infiltrata of other chronic infectious diseases (tuberculosis, Syphilis) never grow soft and not izyazvlyayutsya, but grow into the hard rubtsevuyu fabric.
Scleroma with scarring of the soft palat and oropharynx.
This is a specific chronic inflammatory disease of the upperespiratory tract mucosa
predominantly occurring in Eastern Europe, Asia, and
Skleroma is specific granulematoznim inflammation, which in case of microscopic research has so a character structure, that already in case of patogistologichnom research it is possible to put a diagnosis of disease: large vakuolizirovannie cages Mikulicha with the Frisha-Volkovicha sticks in them, plazmaticheskie cages of Una, gealinovie little bodies of Russelya and fibroznoelasticheskie fibre, that pierce skleromatoznuyu fabric.
Skleroma has a protracted latent period, that is counted by the 2-10 years, and set a moment and terms of infitsirovaniya of patient heavily. Therefore question of etiology of skleromi still and to the present tense is considered not to the last found out. However the most scientists consider exciter the skleromi stick Frisha-Volkovicha.
Skleroma has a cyclic flow in which distinguish three stages.
The FIRST stage – uzelkovaya or ochagovo-infiltrativnoy. The patients grumble about sense of dryness in area of overhead respiratory tracts, presence of viscous mucus iose, dry cough. But serious changes from the side of breathing or voice are not not present, capacity them is stored.
In case of research of ENT-organs on the surface of mucous membrane of respiratory tracts the knots or small flat infiltrat find, that take place on the atrophiing or normal mucous membrane. They are covered by the viscous mucus, can slightly bleed in case of touching. More frequent all skleromniy infiltrat can be localized in the narrowed areas of respiratory highway: entrance and going out in the cavity of nose, on verge of noso- and rotoglotki, in the podskladochnom department of larynx, in area of bifurkatsii trachea and in the places of fork of bronchial tubes. Such infiltrat in the first stage more frequent turns out in one of the described narrowing of respiratory tracts (more frequent in area of nose), but can be simultaneous and in a few areas. Since in the first stage of infiltrati comparatively small, they do not substantially recover and do not deform a road clearance of respiratory tracts and do not violate breathing. Other methods of diagnostics – the Borde-Gangu (reaction of fastening a compliment with the skleromnim antigen) reaction positive at the swingeing majority of patients, and the Frisha-Volkovicha sticks are sown almost always.
The SECOND stage – difuzno-infiltrativnaya or specific. Common state of such sick to the middle weight or heavy, a capacity is considerably lowered, exhaustion and decline of forces is marked. Complaints of patients about the expressed difficulty of breathing, a dry cough with the laboured expectoration of crusts, hoarse voice, is absent sense of smell. Surrounding mark an unpleasant specific sweetish smell of the air breathed out to the patients.
In case of research find widespread diffuse infiltrati, that are in the initial departments of cavity of nose or in the podskladochnom department of larynx and in other departments of respiratory highway. In this stage as a result of scarring infiltrata in the area of tongue – he is pulled up on the back surface of soft palate and at examination of pharynx tailings it is possible to see him only posredstvom epifaringoskopii, thus expose the considerable narrowing of the hoanalnih opening. Quite often because of excrescence of hard infiltrata the more or less expressed deformation of outward nose comes.
It is possible to sow the Frisha-Volkovicha sticks in all not lechenih patients, especially when to take stroke with under epithelium. The Borde-Gangu reaction almost at all patients is positive.
The THIRD stage is scarring or regressive. In place of skleromnih infiltratov the connecting fabric develops, that conducts to the rubtsevih narrowing and deformations in the different areas of respiratory highway. The patients grumble about the heavy laboured breathing, exhausting cough with laboured othogdeniem slizisto-gnoyno mokroti and crusts, hoarse voice. Patients disabled.
In case of research in this stage find the partial or complete disconnectiooso- and rotoglotki rubtsevoy fabric, which soedenyaet between itself soft palate and back handles. Hoani sharply narrowed or are fully recovered by the rubtsevoy fabric, quite often there is superficial izyazvlenie and scarring soft fabrics of hard palate, palatal handles. At outward osmotre- covered nose of smart ksredine, and entrance in cavity closed by the hard rubtsevoy fabric.
Before the especially heavy functional changes leads development of rubtsevih changes in the podskladochnom department of larynx and in area of mouths of bronchial tubes. It succeeds to compensate the heavy violations of breathing through larynx by imposition of traheostomi, and the violation of ability to the travel cross-country of bronchial tubes can cause the irreversible changes in lights.
The Borde-Gangu reaction in the half of patients is negative or slabopologitelnaya, the Frisha-Volkovicha sticks are sown rarely.
Characteristically, that on the rubtsevoy fabric it is possible to see numerous granulyatsionnopodobnie knots, in case of touching to which the small bleeding arises up.
Diagnosis.
At diagnostics take into account character data for skleromi of clinical, patomorfologicheskogo, serologicheskogo and bacteriological researches. The consideration of all these indexes considerably promotes exactness of diagnostics of skleromi.
The complications can arise up at diagnostics of atipichnih forms of flow of skleromi, when the necessity of differentiation from such illnesses appears as lepra, tuberculosis, Syphilis and tumours. It is needed to remember, that in such cases facilitate diagnostics data about localization of defeat in the areas of respiratory tracts, and also results of specific serologicheskih reactions (Borde-Gangu) and patogistologicheskogo structure of pathological fabric.
Medical Treatment.
On the modern stage wide application in the medical treatment of skleromi found the antibiotics. By the first preparation, which successfully used for the medical treatment of skleromi there was streptomitsin: quickly infiltrat resolved, and the stick of skleromi disappeared. But it appeared, that shtammi, which lost a sensitiveness to preparation and the illness came back began to appear. The increase of antibiotic conduces to appearance of him ototoksicheskogo effect. Replacement of antibiotic is necessary. But almost all antibiotics, active in relation to the exciter of skleromi turned out ototoksichnimi. Except for streptomitsina the now definite distribution has gentamitsin, biomitsin, tobramitsin. The indicated preparations enter intramuscular on 0,5 twice in days. Before setting ototoksicheskih antibiotics necessarily expENTe an ear and function of buds and liver: in the cases of their violation the ototoksicheskie preparations deputize by other medical treatment since their use threatens to the patient by deafness. In such cases it is possible to use biomitsin, levomitsetin.
For strengthening action of antibiotics use dimeksid, lidazu, galuronidazu, ronidazu.
In case of medical treatment of rubtsevih and difuzno-infiltrativnih forms of skleromi along with the medicinal therapy apply delyatatsionnie measures, that have for an object expansion of narrowed areas of respiratory highway: bugirovanie special bugami narrowed areas of nose, gullets, larynges or surgical deleting of infiltrata and scars.
In patients, which have expressed stages of stenosis of larynx (III, the IV item), come running to tracheotomy, rarer – to intubatsii hollow bugami Shretera.
TUBERCULOSIS OF OVERHEAD RESPIRATORY TRACTS (TUBERCULOSIS NASI)
Defeat by tuberculosis of ENT-organs more frequent all arises up as a result of distribution of exciter from the primary hearth, which is in lights. Without the defeat of lights primary tuberculosis of larynx, nose, gullet and ear meets very rarely.
Tuberculosis of larynx (tuberculosis laryngis)
Tuberculosis of larynx is the most frequent defeat of ENT-organs, that arises up in patients on the white plague mainly at the kavernoznoy and disseminirovannoy form. The infection of larynx thus takes place in investigation of settling by the infitsirovannoy tubercular stick of mokroti in cracks and in the places of tearing away an epithelium of larynx. In patients on other forms of tuberculosis infitsirovanie takes place by the limfogematogennim way.
One vocal fold or megducherpalovidnoe space is mainly struck at tuberculosis, otechnost and hyperemia of mucous membrane arises up in this place. Infiltrat is multiplied in sizes, and then disintegrates, forming an ulcer, that impenetrates fabrics and spreads on surface mucous. Simultaneously with formation of tubercular infiltrata elsewhere larynx the vospalitelno-nekroticheskie processes, which strike a cartilage and ohryastya arise up, that can cause an edema of larynx. The related narrowing to this of road clearance of larynx can cause its stenosis, that requires the grant to the patient of urgent help.
In case of gematogennom distribution of infection the tubercular tubercles on the mucous membrane of larynx, which often arise up simultaneously with pouring on mucous out gullet and entrance in larynx appear. These gematogennie forms of tuberculosis exist rarer and are characterized by the more mushroom growth of process and are often accompanied disfagiey.
At the beginning of disease there is frequent repeated
Tuberculosis of nose.
Tuberculosis of nose is shown as infiltrata or ulcers. Infiltrat can be different size – mainly measuring 2-3 mm – as humps. On occasion infiltrat acquires considerable sizes 5-7 mm, and is named tuberkulomoy. Disintegration of tubercular humps and infiltrata on slizistoyobolochke nose results in formation of ulcers. The most frequent localization of tubercular ulcers is cartilaginous part of partition of nose, where in case of protracted flow of process the perforation appears.
At the beginning of disease the subjective symptoms can be absent. After because of disintegration of infiltrata and formation of ulcers appear festering, sometimes with blood selection, which dry up with formation of crusts. Mainly have not a selection from nose smell.
Diagnosis
tuberculosis of cavity of nose quite often stanovit for the doctor of difficulty and it has to come running to the biopsy. Especially herein the necessity arises up, when it is needed to differentiate with ulcers at the shrine of cavity of nose on the early stages of disease.
Tuberculosis of gullet (tuberculosis pharyngis)
As well as carry, a gullet was struck by tuberculosis second time by transference of infection by mokrotoy from cavities at the white plague or by the limfogematogennim way at the desseminorovannoy form.
On the first stage of disease tubercular infiltrat of gullet does not often cause the special complaints and the patients do not mainly apply for the help. In time infiltrat of izyazvlyaetsya, causing pain in case of swallowing, that forces a patient to appeal to the doctor. Therefore at first is examined to the mucous membrane of gullet expose tubercular ulcers. They are disposed on the soft palate, palatal handles and back wall of gullet; mindalini are struck rarer.
Tubercular ulcers are mostly shallow and have unequal (toothed) podritie edges of pinky coler. Meeting between itself, ulcers are quickly multiplied and acquire the largenesses. Swallowing becomes sharply sickly.
A flow of disease to application of streptomitsina of both other new antibiotics and other protivotuberkuleznih facilities (PASK, ftivazid and dr.) was always protracted and was quite often closed unfavorably.
Medical Treatment.
In the medical treatment of tuberculosis, especially tuberculosis of overhead respiratory tracts, recent considerable successes are attained in the years. Thanks to application of antibakterialnih preparations the possibility of the clinical curing of many forms of tuberculosis appeared, including such, which earlier were considered almost incurable, for example, ulcerous form of tuberculosis of larynx.
Tubercular patients are treated in the protivotuberkuleznih dispensaries, where patients are under the permanent supervision of doctors. Obligatory prophylactic examination of larynx in all patients on the white plague by doctor-otolaryngologist, which is included in the state of every dispensary, enables to expose in good time initial forms of tuberculosis of larynx and apply the effective medical treatment.
Since tuberculosis of overhead respiratory tracts mainly is complication of white plague, medical treatment of disease is conducted in the specialized department by ftiziatrom with participation of otolaryngologist. In the common medical treatment now use such visokoeffektivnie facilities as izoniazid, rifampitsin, streptomitsin, kanamitsin, etambutol, etionamid, tsikloserin, PASK and other protivotuberkuleznie preparations.
The otolaryngologist controls a dynamics of flow of tubercular process in area of overhead respiratory tracts and executes if necessary necessary medical measures.
In case of appearance of pain in case of swallowing before every acceptance of food it is needed to conduct insufflation, spraying or inhalation of anaesthetic matters.
At presence of sickly ulcers of infiltrata in area of nose, that poorly respond to the common medical treatment, local cauterization by their concentrated solutions of acids is shown or galvanokauterom.
For the local medical treatment of tuberculosis the gullets appoint the ultraviolet irradiation of gullet, rinse by decoctions of camomile, clary, peroxides of hydrogen, unirritating food.
Prophylaxis.
Ideal maintenance of the sanitarno-gigienicheskogo mode is a necessary condition of correctly organized care of tubercular patient. Necessarily it is needed to watch after the normal temperature of apartment (18—19°), often ventilating him by the winter and in summer, after the timely feed of patients and after the correct and timely acceptance of medications. It follows to explain to the patient, what important value has rest of larynx. It is necessary to watch after that patients rozplevivali mokrotu on floor, but coughed up her in the special spittoons with the poured disinfectant liquid in them, because mokrota is a source of infection for surrounding.
SYPHILIS (LYUES) OF OVERHEAD RESPIRATORY TRACTS
Syphilis of ENT-organs is as primary, second and tertiary Syphilis. Thus are struck nose, gullet and larynx. The infection arises up by the sexual and unsexual ways through the damaged mucous membrane of overhead respiratory tracts.
Syphilis of gullet (syphilis pharyngis)
Syphilis of gullet meets in all three stages.
Primary Syphilis of gullet develops as a hard chancre, that takes place on one of mindalin or on the back wall of gullet. Thus pains in gullet insignificant or are quite absent. At first there is dense infiltrat, which then eroziruetsya with formation of ulcer of rozmerom 0,5-1 see The ulcer has cartilaginous consistency and greasy bottom, edges her valikoobrazno rise above the surrounding fabrics. Through the set time limfadenit of neck arises up and cervical limfouzlov, which are multiplied, are made a more compact and become sickly.
The second Syphilis of gullet usually turns out in the form of syphilitic quinsy, which is characterized by the insignificant rise of temperature of body, almost by the complete absence of pain, by the poured, copper-coloured out hyperemia, that takes mindalini, palatal handles and neighbouring areas of soft palate.
In other cases in this period it is possible to expose wide kandilomi or papulae. The papuleznaya pouring appears on the sharply red palatal handles or mindalinah out as серувато-white round or oval, surrounded by the red bar name-plates, that slightly overpeer above surface. Regional lymphatic knots are always megascopic and bezboleznenni (if the second infection joined).
A tertiary stage of Syphilis is shown as limited gummoznoy otechnosti or diffuse infiltrata with hyperemia for peripheries. Through the greater or less interval of time after disintegration of gummoznih educations the glubokaya gummoznaya ulcer appears with the even edges and greasy bottom, that is been by the nekroticheskiy disintegration of fabric.
In default of timely medical treatment there is subsequent destruction of soft and bone fabrics of gullet: perforation of soft and hard palate, destruction of his handles and others like that.
After the medical treatment the cicatrization with formation of dense scars of character zvezdchatoy form usually comes, although the thus distorting accretions and perforations can remain.
Syphilis of nose (syphilis nasi)
A practical value is had by the tertiary form of Syphilis of nose, which exists more frequent other. There is formation of limited or diffuse syphilitic infiltrata, so-called gumm, with next their disintegration. Syphilitic infiltrat, that appeared in the mucous membrane, after disintegration grows into the deep ulcer with the sharp edges and greasy bottom, which in future can jump into bone and cartilage. If gumma is localized in bone or nadhryashnitse, through violation of feed of bone, there is its necrosis with formation of sequestrum. Sekvestratsiya is accompanied by the unpleasant smell from nose.
The Gummoznaya form of Syphilis can strike all fabrics of nose, but the most favourite place is bone part of nasal partition. In course of time gumma disintegrates, forming a large fistula in partition. The destruction can also test and bottom of cavity of nose, so that opening, which connects a nose with the cavity of mouth appears. As a result of necrosis of sitoobraznoy plate of latticed bone the vnutricherepnie complications can develop.
The destruction of nasal partition and nasal bones with the subsequent change of form of outward nose arises in the rare cases up, when he takes shape of saddle.
Syphilis of larynx (syphilis laryngis)
The syphilitic defeat of larynx exists at the second and tertiary forms of Syphilis. At the second Syphilis the erythemas and papulae appear in larynx. The erythemas, that arise up on the mucous larynx at Syphilis, do not almost differ from hyperemia at the sharp laryngitis; it is possible to suspect them after the presence of other second displays of Syphilis on body. The papulae in larynx have a type of white name-plates, that overpeer above the surface of mucous membrane; some superficial ulcers are at their disintegration, that meet between itself.
Tertiary Syphilis of larynx is characterized by gummoznim infiltratom, at disintegration of which arise up hondroperihondriti laryngeal cartilages and firm scar changes. Especially often nadgortannik, which sometimes fully collapses is struck. A laryngoscopy picture of larynx at tertiary Syphilis is very various. As a result of disintegration of some gummoznih knots smears to appear deep ulcer with the character sharply outlined edges, greasy bottom and infiltrirovannoy periphery. Ulcers and destruction of larynx small boleznenni until the second infection does not join, that is caused by the flegmonoznoe inflammation or perihondriti laryngeal cartilages. The scars result in the firm stenosis of larynx and need tracheotomy. In case of joining the second infection the type of larynx changes, that very bothers correct diagnostics.
At diagnostics take into account anamnesis, local changes, data of common inspection and the Vassermana reactions. In the difficult cases of diagnostics, when it has to differentiate Syphilis, tuberculosis and cancer of larynx, come running to the biopsy.
Medical Treatment.
As well as in case of medical treatment of other chronic infectious granulem overhead respiratory tracts, medical treatment of Syphilis is specific. Common medical treatment of patient is conducted by дермато-venereologist in the venereology dispensary. Wide distribution in case of medical treatment were got by preparations of group of penicillin.
At stenosis of larynx, which does not diminish under act of specific medical treatment, it is necessary to watch after patients, to conduct in good time tracheotomy.
At examination of patients on Syphilis it is needed to adhere to the carefulness, especially in the second, most contagious period. Quite a bit cases of infection through the ushnie catheters are described in the old literature, probes, spatula and others like that. For such sick it is needed to have some instruments, which after every use it follows with application to sterilize. After the different greasing in throat and larynx in such sick cotton wool from probe it follows to take off only by pincers and throw down her in crockery with sulemoy or immediately burn.
TRAUMAS, FOREIGN BODIES, BLEEDING FROM
ENT-ORGANS AND THE FIRST AID AT THEM.
Burns of nose
Burn – damage of skin covers of nose, which arises up as a result of action of high temperature, chemical matters or radial radiation. Often burns of outward nose are accompanied by the burns of skin of person, rarer – heads and necks.
Causes
The burns can be caused by action of high temperatures – thermal or radial energy, and also by the hit on the skin of aggressive chemical matters. The thermal burns arise up because of influencing hot objects, liquids or gases (water, steam), action of opened flame or zagigatelnih mixtures (phosphorus, napalm and others like that). The radial burns arise up as a result of irradiation of areas of nose and person by the ultraviolet rays (the sun or quartz lamp in case of wrong use), or x-ray photography or by gamma-rays (radial radiation). Chemical burns – in case of hit on skin or by inhalation of steams of acids, alkalis, salts of heavy metals and others like that.
Clinic
1. Sharp, burning pain.
2. Changes of skin depending on the degree of burn.
Select four degrees of burns:
І degree – in place of burn are marked turn by red and was swollen skins, disturbs a smart. These symptoms disappear, mainly, through 2-3 days.
The ІІ degree – the blisters, filled by the transparent liquid appear on skin. The cicatrization comes in 5-6 days and later.
The ІІІ degree – the necrosis (numbness) of all layer of skin arises up. The areas of burn acquire the crimson colouring, the unbearable pain disturbs. Through joining an infection the cicatrization can delay on the protracted time.
The ІV degree – is characterized by numbness of skin and placed fabrics is deep (charring).
The state of patient relies on the degree of burn and his prevalence. Especially the unfavorable consequences arise up at the burns of skin and mucous membranes of overhead respiratory tracts (inhalation of opened flame).
Medical Treatment
1. At the thermal burns oil a burn surface by the vaseline, lanolin or other indifferent ointment.
2. At the chemical burns wash a surface by the clean water and neutralize action of aggressive matter by antipillboxes: acids – by alkalis (2% solution of gidrokarbonata of sodium, soapy water and others like that), and alkalis – by acids (1-2% solution of vinegar or lemon acid).
3. Anaesthetic facilities.
4. The Mazevie bandages (ointment of Vishnevskogo, antibakterialnie ointments and others like that).
5. Introduction of protivostolbnyachnoy whey.
Getting by frost-bitten a nose
Cause
Getting by frost-bitten arises up in case of local action of low temperature (colds) on the outward nose.
Factors, that assist to the origin of getting by frost-bitten
1. Local violation of circulation of blood.
2. Common weakening of organism.
3. Intoxication.
Degrees of getting by frost-bitten
І degree – the skin of nose becomes pale, sensitiveness her goes down; pain is at first insignificant, then increases;
The ІІ degree – the edema and expressed turn by red of skin appears, the blisters appear on her, the pain becomes expressed;
The ІІІ degree – the areas of necrosis arise up and appear ulcers mainly on the free edge of nostrils.
At the ІІ and ІІІ degrees of getting by frost-bitten possibly common indisposition and rise of temperature of body.
Medical Treatment
At the І degree of getting by frost-bitten grind a nose in the cold apartment to appearance of turn by red.
In case of grinding a skin it does not follow to use snow from the kristalikami ice, not to entail the mechanical damage of skin covers.
1. Washes by the vinegar water (1 soupspoon of vinegar on 1 l of water).
2. Greasing staggered areas by the 10% streptotsidovoy and albutsidovoy ointments.
3. In case of getting by frost-bitten to oil the ІІ and ІІІ degrees staggered areas by the Shostakovskogo balsam or ointment, that contains the antibiotics and glyukokortikoidi.
Prophylaxis of getting by frost-bitten a nose
1. Tempering an organism.
2. Rise of general soprotivlyaemosti of organism.
MECHANICAL TRAUMAS
A nose as part of person which comes forward is damaged enough often. The character of damage relies on the size of operating force, its direction and character of injuring agent. And the injury of soft fabrics of nose can therefore be, wounds of skin of nose or violations of integrity of cartilaginous and bone skeleton of outward nose (breaks a secret of bones of nose).
Causes
· Action of dull mechanical injuring agent (in case of falling, blow by fist or dull object).
· Action of sharp injuring agent (prickly, cutting objects).
· Ognestrelnie wounds.
Clinic
1. Was swollen soft fabrics of nose.
2. Sinyushnost soft fabrics of nose, overhead and lower eyelids.
3. Nose-bleed.
4. Difficulty of the nasal breathing.
5. Loss or decline of sense of smell.
6. Slezotechenie.
7. Nasal likvoreya – selection through the nose of transparent spinal liquid, that arises up in case of damage of sitoobraznoy plate of latticed bone.
At examination expose
· Nose-bleed.
· Deformation of outward nose (breaks a secret of bones of nose).
· Lacerated wounds of nose.
· Defect of fabrics of nose.
At front rinoskopii more frequent expose filling a cavity of nose by the bloody clots, fragments of mucous membrane, oblomkami of bone or pieces of cartilage.
In case of breaking a secret of bones of nose of palpatorno it is possible to define krepitatsiyu bone wreckages and pathological mobility of outward nose. Thus possibly displacement of all pyramid of vstoronu or pressing a back of nose – sedloobrazniy nose. On the lateral sciagram of nose it is possible to see a site of fracture of nasal bones.
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Traumas of nose are enough often accompanied by the various complications: by deformation of outward nose, haematoma or abscess of nasal partition, vnutricherepnimi complications (by meningitis, by the thrombosis of sine, by the abscess of brain and others like that).
Medical Treatment
The medical measures rely on the type of defeat and his volume and presence of complications. They include:
1. Stop of bleeding.
2. Anaesthetic and protivoshokovie facilities.
3. Primary surgical treatment of wound.
4. Local and general antibiotikoterapiyu.
5. Introduction of protivostolbnyachnoy whey.
At the wounds of outward nose conduct their taking in by the thin stitch material.
In case of taking wounds of nose in it follows carefully to check up a wound in the presence of foreign to the tel.
In case of breaking a secret of bones of nose with displacement execute repozitsiyu bone otlomkov. For this operation prepare:
1. Nasal elevator.
2. Nasal mirror.
3. Pincers.
4. Syringe by volume of 2-5 ml with needle.
5. Solution of anestetika.
6. 3-5 turund long 3-7 sm (for cleaning a nose).
7. Turundi long 40-60 sm (for front tamponadi and stops of bleeding).
Execute such operation mainly not later than the 5-7 days after trauma, since in the more late terms otlomki of bones accrete between itself, that considerably bothers them repozitsiyu. The Repozitsiyu bones of nose it is better to conduct under the brief anesthesia. In the cases when there are not terms for conducting anesthesia, come running to the local anaesthetizing: oil a mucous membrane of nose by the anaesthetic solutions (dikain, lidokain) and infiltriruyut fabrics by solutions of anestetikov.
Depending on the type of displacement of pyramid of nose, repozitsiyu otlomkov conduct variously.
In case of displacement of all pyramid of vstoronu, repozitsiyu execute by the large finger of right or left hand: press on wall, toward which a nose was displaced, and move her in the direction of middle line (in the normal position). In case of pressing a back of nose in his cavity enter a nasal elevator, by which levitate falling back part, and by the fingers of other hand give to the nose natural position and form. During such actions the character crunch of bone otlomkov, which come back into its previous place arises up. After this it follows necessarily to conduct front tamponadu nose. The gauze tampon will retain a nose in the necessary position and warn the nose-bleed. On this term necessarily appoint the antibiotics.
Delete a tampon through 48-72 hour.
Care of patient
The patient, especially in the early terms after the trauma of nose, requires the permanent supervision. Sometimes small on the face of it the traumas of nose can be combined with the considerable damages of cerebrum. It should be remembered that after the possible excitation of psyche of patient braking with the following can come ugnetenim respiratory center and center of circulation of blood. All this requires from the medical sister to watch after the observance to the patients of the appointed (mainly koechnogo) mode and by the careful implementation of all setting of doctor. For the trained nurse the appearance or strengthening head pain must cause a watchfulness, sharp rise of temperature of body, appearance of meningealnih symptoms, dizziness, nausea and others like that. About development of such pathological displays it is needed immediately to reveal to the treating or duty doctor. Origin of bleeding from nose or from wound requires imposition of bandage on wound, prashoobraznoy bandages oose or implementation of front tamponadi nose.
NOSE-BLEED
Depending on causes, distinguish the traumatic and symptomatic bleeding.
Causes
• Local – traumatic bleeding: deleting crusts from nose or other manipulations in the cavity of nose; dull trauma of outward nose (blow, falling and others like that); surgical or ognestrelnaya trauma.
• General (symptomatic bleeding):
1. Disease of blood (haemophilia, trombotsitopeniya).
2. Disease of the serdechno-sosudistoy system (atherosclerosis, hypertensive illness).
3. Disease of buds.
4. Disease of liver.
5. Infectious diseases (flu, malaria and others like that).
6. Considerable physical tension.
7. Protracted stay in the sunshine.
Rinoskopiya and orofaringoskopiya
Appearance of blood from one or both halves of nose or on the back wall of gullet.
Medical Treatment
Depending on degree and periodicity of bleeding, come running to such measures:
1. Patient pridavlivaet itself the wings of nose to the nasal partition on the 3-5 mines (if bleeding in the front departments of nasal partition).
2. Introduction to the cavity of nose of gemostaticheskih facilities (gemostaticheskoy sponges; cotton wools, by the moistened peroxide of hydrogen or solutions of ferokrila, antipyrine and others like that).
3. Cauterization of site of bleeding: by the trihENTotstovoy acid, galvanokauterom, kristalami margantsovokislogo potassium, by the concentrated solution of silver nitrate.
4. Front tamponada nose.
5. Back tamponada nose.
6. Bandaging leading arterial vessels (outward carotid or latticed artery).
7. Introduction of medicinal facilities (vikasol, chENTous calcium, epsilon-aminokapronovaya acid, etamzilat, transfusion of frozen odnogrupnoy plasma and others like that).
Care of patient
Foresees the permanent supervision after the state of patient foremost taking into account possibility of origin of the repeated bleeding. About the exposure of fact of bleeding it follows immediately to reveal to the treating or duty doctor. In case of bleeding, which take place from the back departments of nose, the patient can splevivat a blood by mouth. If the blood flows down in gullet and zaglativaetsya, after some time vomiting can arise up by the black bloody masses. Such bleeding is exposed at examination of gullet (faringoskopii). If bleeding arose up at patient, at which before this a nose already was zatamponprovan, present tampon from nose it is needed to delete and conduct repeated front tamponadu. In the case when and she did not stop bleeding, conduct back tamponadu. In default of doctor this does medical sister, which must be able to make to use frontal reflector and nasal mirror and in the exigent cases to execute front tamponadu nose.
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The patients with the front tampon iose can have a laboured outflow of tear through the nososlezniy channel. In case of such phenomena it follows to begin to drip in eye 2-3 drops 20-30% solution of сульфацил-sodium or furatsillina (1:5000). In patients with the back tampon swallowing (through the edema of soft palate)can be violated, therefore it is better them to appoint a spoon-meat. Tampon, usually, delete from nosoglotki through 48 hour, since possible development of sharp middle otitov.
Control ontrol of epist epistaxis. axis. Firm pressure ure with the finger or thumb on the lateral wall of the nose opposite Little’s area on the side of the bleeding, if maintained for about four minutes, will control the bleeding.
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Incorrect technique for controlling epistaxis. The pre pressure ure is over the nasal bones and ine ineffectiv. The arrow indicates the site where pressure should be applied.
TRAUMATIC DAMAGES OF OUTWARD EAR
MECHANICAL TRAUMAS
An auricle through its location is injured more frequent, than outward auditory passage-way. Traumas, that are accompanied by the damage of skin covers of shell, more dangerous, since infitsirovanie of nadhryashnitsi and cartilage can result in perihondritu and to hondritu with the subsequent expressed deformation of shell, that is distorted by the type of man.
WOUND OF AURICLE
Causes
An auricle is damaged as a result of blow, bite, falling on ear, road traffic accident, ognestrelnogo wound and others like that.
Clinic
Size of damage and feature of wound rely on the character of injuring agent. On occasion there is the partial or complete tearing of auricle off.
Injuries and mechanical damages, that violate integrity of skin cover of shell, are dangerous by transition of inflammation oadhryashnitsu and cartilage, and this can result in volume, that the shell will grow into the scar appendage of ear of indefinite form, which does not decorate a head of man.
Medical Treatment
Relies on the size of injured surface and infitsirovaniya of wound. The superficially placed wounds process by solutions of antiseptikov and, sprinkle by the protivovospalitelnimi powders and nakladayut assepticheskuyu bandage. Appoint the antibiotics, anaesthetic facilities.
The surgical treatment consists in deleting nonviable fabrics and imposition of stitches into the places of breaks, imposition of assepticheskoy bandage. Intensive krovosnabgenie of auricle predetermines good regenerator properties and possibility of prigivleniya of shell even in case of tearing complete her off.
It follows to wash torn off pieces of auricle in solutions of antibiotics, to wrap up by the sterile serviette, to assess by ice (that will give possibility to lower exchange processes in the torn off fabrics) and deliver in the shortest time together with patient in hospital.
WOUND OF OUTWARD AUDITORY PASSAGE-WAY
Such traumas can be localized in the перепончасто-cartilaginous and bone departments of passage-way. Traumas of перепончасто-cartilaginous department are often combined with the traumatic damages of auricle.
The isolated wounds of bone department of auditory passage-way exist at blows on the lower jaw or falling on her. At such traumas the head of lower jaw can tear a joint, to break a front wall of auditory passage-way or even «fail» in the outward auditory passage-way.
Ognestrelnie wounds are mainly accompanied by the heavy combined wounds of ear, when simultaneously with the outward auditory passage-way are damaged mammiform sprout, drum cavity, joint of lower jaw, inlying ear and others like that. Such wounds can often penetrate and in the cavity of skull. As a rule, these damages are accompanied by the break of ear-drum, and afterwards, in most cases, by development of festering inflammation of middle ear.
Medical Treatment
In case of deep wounds consists: in the primary surgical treatment of wound, deleting freely located otlomkov, providing an outflow of ekssudata from the outward auditory passage-way; setting common and local protivovospalitelnih anaesthetic facilities and others like that.
Wound of outward auditory passage-way, foremost slanting breaks, need the assiduous sewing together of skin and protracted tamponadi auditory passage-way for warning his narrowing (stenosis) or complete zarosheniya (atrezii).
Before elucidation of volume of damages it is nowise impossible to wash an auditory passage-way with the purpose of his cleaning (danger of distribution of infection in the middle and inlying ear, cavity of skull, joint of lower jaw and others like that)!
Care of patient
In case of all damages of ear it is needed to secure to the patient complete rest and strict koechniy mode, since damage can be more serious, than seems on the face of it (breaks a secret of basis of skull and others like that). In case of bleeding or effluence of transparent liquid (likvora) from ear it is needed to avoid any manipulations in the outward auditory passage-way, only to close an ear of sterile turundoy and quickly transport a patient in the medical establishment.
Hematomas of the pinna
Otgematoma arises up at the dull trauma of auricle: blow by fist, compression of shell, falling on her and others like that. This is accompanied by the break of vessels, which krovosnabgayut outward ear. As a result of break of vessels betweeadhryashnitsey and by the cartilage of shell the blood or серозно-bloody liquid accumulates – otgematoma arises up.
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Hematomas of the he pinna following trauma. Bruising with – minimal swelling settle (a). A he hematoma or collection of serous fluid, however, is common, and the these, particularly if recurrent from frequent injury and left untreated, will result in a “cauliflower ear.” The fluid, if aspirated with a syringe (b, c), usually recurs, and incision and drain drainage may be necessary. Some thickening, however, of the he underlying cartilage invariably takes place, and a return to a completely normal-shaped pinna is not usual
Clinic
Exists rounded form slight swelling, more frequent in the overhead half of outward surface of auricle, without the expressed reaction from the side of surrounding fabrics. The slight swelling has a krasno-sinyushniy coler, she slaboboleznennaya and flyuktiruet at palpatsii.
At punktsii of otgematomi get a blood or krovyanisto-seroznuyu liquid.
Punktirovat is needed, strictly toing the lines of asseptiki, not to add an infection to the cavity of otgematomi and cause not perihondrit.
Complication
Frequent otgematomi result in the expressed deformation of shell (ear of boxer).
Infitsirovanie of otgematomi can cause festering perihondrit, necrosis of cartilage and considerable cosmetic defect.
Medical Treatment
Small otgematomi resolve independently.
Punktiruyut large otgematomi (sometimes once or twice), otsasivayut maintenance and lay on a pressing bandage on ear. If content of otgematomi is a bloody clot, do dissection of skin parallel to the outlines of shell, delete a clot, wash a cavity of haematoma and enter a rubber strip for drainage. After this nakladayut pressing bandage and appoint the antibiotics for the prophylaxis of perihondrita.
GETTING BY FROST-BITTEN AURICLE
Appearance of thin fabric of auricle outside a head is instrumental in such defeat.
Clinic
Distinguish three degrees of getting by frost-bitten:
І degree – the skin of auricle becomes pale, sensitiveness her goes down; pain at first insignificant, after increases.
The ІІ degree – the edema and expressed turn by red of skin appears, the blisters appear on her, the pain becomes considerable.
The ІІІ degree – the areas of necrosis arise up and appear ulcers mainly on the free edge of auricle.
Complication
Possible origin of perihondrita auricle with the subsequent cosmetic defect.
Medical Treatment
In case of getting by frost-bitten the І degree apply the careful grinding.
Intensive thermal procedures contra-indicated states through possibility of worsening of staggered shell. Grinding by snow contra-indicated damage through possibility of skin by the shallow lenses of the eye of ice.
In the case of getting by frost-bitten the ІІ degree executes sterile punktsiyu of blisters with sucking their content. Appoint the antibiotics.
In case of getting by frost-bitten the ІІІ degree applies protivovospalitelnuyu therapy, expect limitation of areas of necrosis from the healthy fabrics and surgically delete them.
BURNS OF OUTWARD EAR
Burns of outward ear are caused by action of high temperature or chemical matters (acids, alkalis and others like that), that get on the skin of auricle and in the outward auditory passage-way. These defeats are often related to the professional activity (burns by pair, by the hot water, by the aggressive matters, at explosions and others like that).
Burns of auricle are three degrees:
І degree – turn by red and was swollen fabrics of shell, a patient is disturbed by the easy pain and feeling burning.
The ІІ degree – was swollen skins, formation of blisters with seroznim or even by the festering content, expressed pain and burning;
The ІІІ degree – numbness of skin, deep defeat of fabric, unbearable pain, worsening a common state. By investigation of burns the ІІІ degree can be necrosis and tearing away some parts of auricle, as a result the obezobragivanie fish soup comes.
Burns of outward auditory passage-way are caused by the erroneous burying in the ear of aggressive matters (acids, alkalis), and also by the hit of drops of molten metal during the welding works. Thus a skin of passage-way is damaged and can be struck ear-drum. Changes of skin of outward auditory passage-way are shown turn by red and burn bubbles. The investigation of burn can be an inflammatory process, which flows as outward and middle otit.
In case of burying drops in ear it follows carefully to check up maintenance of bottle and temperature of liquid, not to entail a chemical or thermal burn of outward auditory passage-way and ear-drum.
Medical Treatment
Conduct the same as at the burns of skin of any other area of body. At the chemical burns it is necessary to apply as quick as possible the neytraliziruyushie matters: in case of action of acids – 2 % solution of soda, at burns by alkalis – 1% solution of vinegar or lemon acid.
At the considerable burns of outward auditory passage-way it is needed protractedly tamponirovat an auditory passage-way of turundami with the hormonal and protivovospalitelnimi ointments, in order to avoid his narrowing or zarasheniya.
FOREIGN BODIES OF NOSE
Causes
The foreign bodies can get iose in case of different circumstances. More frequent they meet at children, which hide in the cavity of nose shallow toys or their parts, metallic marbles, corns of bob, cereals, stone of cherries and others like that. Sometimes mentally the sick persons enter itself iose foreign bodies (as a rule, in relation to largenesses). During the work accidents the molten metal can get in the cavity of nose, otlomki of glass, metal, stone and others like that. The food products become foreign bodies during vomiting or eating, especially in patients with paresis of soft palate. The living foreign bodies (leeches, intestinal worms) get iose at vomiting or drink of muddy water.
Clinic
The foreign bodies can itself nothing not to show. More frequent such symptoms are in patients:
1. Labouring breath, mainly one-sided.
2. Slizist- festering excretions from one half of nose, that have an unpleasant smell and can contain the admixtures of blood.
3. The Matseratsiya skins of entrance iose.
4. Bleeding (priinorodnih bodies with the sharp edges).
5. Head pain.
6. Making to progress keratit (inflammation of cornea eyes).
Diagnostics
1. Foreign body, mainly, well evidently at front rinoskopii.
2. In case of sounding the probe comes across the foreign obstacle.
3. In case of protracted stay of inorodnogotela iose (godami) appear rinoliti – stratification on the foreign body of salts of uglekislogo and fosfornokislogo calcium.
Medical Treatment
1. The small foreign bodies sometimes delete in case of the strong blowing of nose.
2. The rounded foreign bodies delete by the arcuated hook.
3. The wedged and foreign bodies of wrong form delete by pincers or nasal tongs.
4. Rinoliti grind at first down on fragments and delete by tongs by parts.
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5. Large rinoliti, which it does not succeed to grind up, delete by the operation.
6. The metallic foreign bodies sometimes delete by electromagnet.
Rhinolith. A foreign body that is ignored accumulates a calcareous deposit and presents year later as a fetid, stony, hard mass–a rhinolith. This is well demonstrated on x- ray, and a rhinolith may become large, eroding the lateral wall and floor of the nose. Although at first sight appearing easy to remo, the impaction may be extremely firm, particularly with the larger rhinoliths.
It is impossible to delete spherical hard objects from nose (marbles from bearing, stone of cherries and others like that) by pincers, because this can result in zatalkivaniyu of foreign body vglub and hit of him in the lower respiratory tracts.
FOREIGN BODIES OF GULLET
The foreign bodies mainly get in gullet from the cavity of mouth during meal, considerably rarer – from the cavity of nose, larynx or gullet. Foreign bodies, that remain in gullet, more frequent all are brought here with meal, for example, fish bones, needles, pins and others like that. Assist to this sudden cough, laughter, sneeze, talk, which divert attention from the act of mastication. A hit of foreign bodies from the cavity of mouth is facilitated at presence of dentures, which worsen the control from the side of hard palate.
The objects can also penetrate in the walls of gullet, that the children at the play, adult (bootmakers, taiENTs) during work hold in to the mouth (nails, buttons, pins and buttons); wreckages of dentures.
Usually those foreign bodies, which pierced by its sharp end in the mucous membrane of pharynx, area of mindalin or palatal handles are stopped in gullet only. The large and smooth foreign bodies more frequent pass in gortanoglotku – to the entrance in gullet and larynx, or are stopped in same gullet.
Rarer foreign bodies are localized iosoglotke. Here the foreign bodies can get through nose, that broke off as a result of trauma, or tailings of meal at vomiting. From the living foreign bodies the leeches sometimes here get – in case of drink of bog water, the ascarids can get iosoglotku.
Clinic
The symptoms of foreign bodies can be various and rely on their character. Complaints of patients at the sharp foreign bodies, that pierced in the mucous membrane, are taken to the prickly pain, which increases in case of swallowing. More frequent all foreign bodies are in midaline, in the palatal handles and korene language. In case of protracted stay of foreign body the inflammation of mucous membrane of gullet as hyperemia, edema and promoted products of mucus arises up, that, in same queue, causes a cough, salivation, sometimes – nausea. In case of stopping a large foreign body in the lower department the gullets, at the entrance in larynx, can develop sudden phenomena of difficulty in breathing. Other display of foreign bodies of lower departments of gullet or gullet is «lakes» of saliva in the grusheobraznih sines.
To expose sharp foreign bodies, that stuck in gullet (fish bone) it is possible in case of greasing a mucous membrane by the quilted jacket on probe with cutting. Piece of cotton wool, that remained on the mucous membrane, catching for the tag of foreign body, indicates on his localization in gullet.
Medical Treatment
By the careful and system examination of all departments of gullet it succeeds to expose a foreign body. Delete him posredstvom direct or arcuated korntsanga with branshami, that close soprikasayutsya between itself. Sometimes scratches or scratches, which stopped behind after swallowing a foreign body, immediately sick and simulate his stay in gullet. In such cases recommend repeated examination through on days, 1-3. After deleting a foreign body the disinfectant rinses appoint, sparing a diet.
Care of patient
Foresees the attentive supervision after patient with determination of common state and measuring a temperature, setting a sparing diet. About any displays of inflammatory reaction reveal to the doctor, since possible development of septic complications or stenosis of larynx.
FOREIGN BODIES OF LARYNX, TRACHEA AND BRONCHIAL TUBES
Foreign bodies of larynx, trachea and bronchial tubes more frequent meet at children in age from a few months of about 3-5 years. This is explained to those, that small children all take in mouth, and protective reflexes at them are still badly expressed.
Causes
• From the cavity of mouth the foreign body gets in larynx at the sudden uncontrolled inhalation (fright, laughter, scream, talk, use of meal and others like that).
• The foreign bodies can get in the respiratory tracts from gullet during vomiting.
• In case of wound of neck the foreign bodies in larynx and trachea can penetrate through the ranevoy channel.
• Otlomki of tracheotomy pipes can get in trachea in patients with traheostomoy.
Clinic
1. Fits of the convulsive coughing during a few seconds or minutes, which are accompanied:
• by the ballot of lung of foreign bodies (moving a foreign body during cough to the serried vocal folds, that is caused by the origin of character sound and returning a body to bifurkatsii tracheas during inhalation);
• by the labouring breath;
• by cyanosys of slizstih and skin covers.
2. Mokrota appears in a 1-2 day of stay of foreign body during cough, painted krovyu.
3. If the foreign body gets to bronh and blocks his road clearance, breathing weakens and becomes dull perkutorniy sound on the side of defeat.
Diagnostics
1. Anamnesis.
2. Laryngoscopy (direct or indirect).
3. Sciagraphy and rentgenoskopiya of thorax.
4. Traheobronhoskopiya.
Complication
The unrecognized foreign bodies can cause an asphyxia or entail the heavy complications (abstsediruyushie bronhopnevmonii, festering mediastinit and others like that).
Medical Treatment
Possible wilful othogdenie foreign body with mokrotoy during cough. However this is enough rarely, and for deleting foreign bodies come running to such measures:
1. Deleting foreign bodies posredstvom the okonchastih tongs from a traheobronhoskopicheskogo set at the direct laryngoscopy.
2. Traheobronhoskopiya.
It is impossible to delete a foreign body, that caused atelektaz one lung posredstvom overhead traheobronhoskopii. This can result in death of patient in the case when the foreign object, stealing out from tongs, will block main bronh healthy lung.
FOREIGN BODIES OF EAR
Foreign bodies of outward auditory passage-way more frequent all meet at children by age on years, 3-7. The children push itself in ear various objects: shallow toys or their parts, –pugovitsi, beads, seeds, fruit stone and others like that. Adult have otlomki of matches, tufts of cotton wool, corns of cereals, branches of bushes, parts of metal, uglya and others like that.
Rarer there are living foreign bodies, mainly chlenistonogie: bedbugs, cockroaches, ticks, which crawl in ear. At chronic middle otitah, especially when have a selection from ear unpleasant smell, the larvae of flies can be in ear.
Clinic
If foreign bodies smooth and slippery and do not injure a wall of auditory passage-way, they can during the protracted time cause not a complaint at patient. In case of protracted stay in whisker on the foreign body the sulphur accumulates and him becomes heavily to recognize at otoskopii.
A large danger for patient is made by the foreign body, but clumsy attempt of his deleting!
The objects with the sharp jagged edges can be a cause of the unpleasant feeling and decline of ear. Living foreign bodies by its motions can cause sharp pain in ear and noise.
Medical Treatment
Before to delete a foreign body, it is needed necessarily to conduct otoskopiyu and define his form and character. The most safe method of deleting foreign bodies is washing, that is conducted the same as in case of deleting a sulphuric cork. If in case of research it is exposed, that washing is inadvisable, it is possible to delete a foreign body by pincers or the special dull hook, that the doctor must do.
The flat foreign bodies delete by the ushnim pincers or mikroshiptsami.
It never follows to delete rounded hard foreign bodies by pincers or tongs, because by such instruments taking them succeeds, but at attempt to fix, such bodies viskalzivayut and are is still deep pushed in the inlying auditory passage-way. The such foreign bodies delete by hook, which lead for body and draw out outside, that the doctor must conduct.
Bulging and jammed in the outward auditory passage-way foreign bodies, such, as bobs (pea, kidney bean), corn and others like that, add to the preliminary dehydration by the repeated inflowing in the ear of concentrated (96°) alcohol and delete by instruments.
If to delete a foreign body it did not succeed through the sharp inflammation of walls of outward auditory passage-way or deep his penetration in the bone department of passage-way, delete him by the operation.
The living foreign bodies delete so: at first bury in ear an alcohol or butter, to put to death or obezdvigit an insect, and then wash by the Gane syringe or delete by the special instruments.
Care of patient
After washing an uncomplicated foreign body process an auditory passage-way by alcohol and cover by the marble of sterile cotton wool. Cotton wool is deleted through the 30 mines, to the patient recommend to avoid the hit of water in ear during the 5-7 days. At the complicated foreign bodies, depending on presence and character of damages, conduct the medical treatment the same as at the traumas of outward ear.
