ANATOMY OF THE
NOSE
The
nose is the frontal department of the upper respiratory tract (Fig. 37), and is subdivided into the
external nose and the nasal
cavity with the paranasal, or nasal accessory, sinuses. The external nose is a
triangular pyramid of irregular
shape composed of bone, cartilage and soft tissue. The upper angle of the pyramid adjoining the
forehead is the root of
the nose which extends downwards and
outwards to form the nasal dorsum rounded
with the tip of the nose at
the lower free angle. The lateral flaring and flexible expansions of the nose
are known as the ala nasi
or wings of the nose,
whose free lower margins are so shaped
as to form the nostrils or anterior nares.
Nasal
Cavity
The
nasal cavity borders on the cranial cavity above, the eye sockets on the sides, and the oral cavity
below. The nasal septum divides
the nasal cavity into two halves, which open out through the nostrils facing downwards at a slightly oblique angle. Posteriorly, the nasal
cavity communicates with the nasopharynx through two neighbouring orifices of oval shape called the choanae.
The
posterosuperior bony part of the nasal septum is made up of the vomer and
the perpendicular plate of the ethmoid
bone, while the anteroinferior cartilaginous
part is formed by the
quadrangular cartilage.
The external or lateral wall of the nasal cavity
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Fig.
38. Lateral Wall of the
Nasal Cavity
1) openings of anterior ethmoid cells, (2) openings
of medial ethmoid cells. (3) line
of section of middle turbinate, (4)
openings of posterior ethmoid cells; (5) opening of maxillary sinus; (6) mouth of nasolacrimal duct; (7) line of section of inferior turbinate;
(8) bulla ethmoidahs; (9) uniform
process (section-view); (10)
anterior ethmoid cell
is
the most complex structure, as well as the most important region from the practical aspect. Starting from
the external nose, it is
made up of the following bones: the nasal
bone, the frontal process and the nasal side of the maxilla, the lacrimal bone,
the ethmoid bone, the palatine bone
and the alar processes of the sphenoid bone.
Three ridges known as the conchae or turbinates
spring from the lateral
wall of the nasal cavity to divide it into the superior, middle and inferior meatuses. The nasal end of the nasolacrimal
duct opens below the inferior meatus. The middle nasal meatus
has openings to communicate with the paranasal sinuses: (1)
the larger, maxillary sinus,
or the antrum of Bighmore, which lies in the body of the maxilla;"i(2) the frontal
sinus lying in the squamous portion of
the frontal bone, and (3) the anterior cells of the ethmoid
labyrinth. The posterior ethmoid cells and the
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sphenoid sinus
communicate with the superior nasal meatus (Fig. 39).
The
cribriform plate of the ethmoid bone forms the roof of the nasal cavity, whose anterior slope consists of
the nasal bones and the
posterior—of the anteroinferior wall of the sphenoid sinus.
The
anterior and posterior parts of the nasal cavity floor consist of the palatine processes of the maxilla and
the horizontal plates of
the palatine bones respectively.
The
entire nasal cavity is lined with a mucous membrane covered by a stratified, columnar, ciliated
epithelium, whose hairs are inclined backwards,
towards the choanae.
The mucous membrane of the superior nasal meatus with the
adjacent areas of the mucosa of the
jnasal septum and the dipper
p^rtroiT^)f--4fee-Tarrdd4e-turbinate"ilTiined with a specific sensory epithelium containing a
ramified^ network of peripheral
olfactory nerve endings. This area of the mucous membrane is called the olfactory membrane, as distinct from the rest of the nasal mucosa which is lined with a stratified, columnar, ciliated epithelium and
is known as the respiratory
mucous membrane. The mucous membrane
varies in thickness over its area. It is thinnest and
most deficient in
mucous glands in the paranasal sinuses, and is thickest on the turbinates. Owing to the abundance of a thick meshwork of veins, cavernous or erectile
tissue forms in some places
of the submucosa which is particularly developed in the inferior nasal turbinate, along the margin of the middle turbinate
and on the posterior ends of the middle and superior conchae (Fig. 40).
The
walls of the vessels in the erectile tissue of the conchae are rich in smooth muscle and elastic fibres
which enable the erectile
tissue to swell and shrink quickly under the effect of various chemical, thermic and mental factors. This is the cause of the sudden fullness
in the nose which sometimes
occurs.
Vessels of the
nasal cavity. The
basic arterial supply comes
through the sphenopalatine artery which
is a branch of the internal
maxillary artery. The upper part of the lateral nasal wall receives its blood supply through
the anterior and posterior
ethmoidal arteries, which are bran-
ches of the ophthalmic artery, venous blood is
collected by numerous minor
blood vessels and carried into two major trunks. Part of the venous vessels of the upper nasal region and the superior paranasal sinuses drain directly into the longitudinal sinus of the dura mater.
The
mucous membrane of the nasal cavity also has a dense network of lymph vessels which communicate with the subdural and
subarachnoid spaces. This fact is one of the important factors contributing to the
extension of infection from the
nasal into the cranial cavity.
The
sensory nerves of the nasal cavity come from the first and second branches of the trigeminal nerve.
The
branches of the olfactory analysor enter the nasal cavity through openings in the cribriform plate of the
ethmoid bone, and are
distributed to specific, highly-differentiated epithelial cells serving as the receptors of
odour.
PHYSIOLOGY OF THE
NOSE
The
nose performs respiratory, olfactory, resonating and defensive functions. Free passage of inhaled air
through the nose is an
indispensable condition of normal breathing. The air passing through the nasal cavities is largely
filtered of its content
of inhaled dust particles, warmed to blood
heat and moistened when dry. Dust particles and bacteria, as well as larger particles of foreign
matter, are caught in the
vibrissae of the nasal vestibule as if in a filter. These hairs grow particularly thick in males. The
narrowness and irregularity of the
nasal meatus ensure close contact between the inhaled air stream and
the moist surface of the mucosa, whereby the air is humidified and warmed, and hard particles settle down on
the nasal walls. By the action
of the epithelial cilia pointing towards the nasopharynx, the particles are carried into the
latter with the mucous
secretion in which they are enmeshed and then expelled by expectoration or swallowed.
In this way, the
air reaching the lungs is filtered of dust to a considerable extent. Experiments performed on people and animals have proved that over a half of
the inhaled foreign matter
remains in the nose. In mouth breathing, however, all of the inspired dust gets directly
into the pharynx, larynx and
deeper into the respiratory tract, where it may cause various morbid conditions.
Nasal breathing has great
hygienic advantages over mouth breathing, since the inhaled bacteria
which have not been removed with dust are largely rendered harmless and killed by
the nasal mucus. The nasal
cavity also produces a
marked neutralising effect on smoke and toxic chemicals. Complete or partial obstruction of nasal
breathing may result in various
affections of the lower respiratory tract, such as pharyngitis, tracheitis,
bronchitis, etc. The results of
nasal obstruction are particularly unpleasant in some fields of industry.
The
nasal and nasopharyngeal cavities act as
resonating chambers for the
voice, wherein sound is amplified by air vibration and the voice acquires timbre and individual
sonority. In nasal obstruction,
the voice lacks resonance, is
muffled and has a nasal twang. This condition is known as rhinolalia clausa. If as a result of sagging of the soft palate,
due to paralysis, the nasopharynx remains open during phonation, the voice will
have a different nasal quality known as rhinolalia aperta.
Full or partial obstruction of nasal breathing impairs the sense of smell, and may prevent workers of
some specialities,
particularly workers employed in the chemical and food industries from fulfilling their duties.
The
olfactory sense not only serves to indicate the quality of inhaled matter, but together with the sense of
taste, conveys to us the
quality of food and drink entering the digestive tract. Moreover, numerous experiments
carried out by I.P. Pavlov prove
that the sense of smell furnishes a stimulus for reflex secretion of the gastric juices. This stimulus is particularly evident in the reflex
secretion of the salivary glands.
Obstruction
of nasal breathing interferes with pulmonary ventilation owing to shallow breathing and
consequential oxygen deficiency. At
the same time it has been found that
a longer negative pressure produced by nasal breathing in the deeper portions of the respiratory tract
ensures a better pulmonary
ventilation with a greater amount of oxygen being absorbed than in the case of mouth breathing Mouth breathing results in physical
maldevelopment, such as malformations of the chest and the facial bone
structure, malocclusion
of the
teeth, etc.
Procedures
Employed in Examining the Nose
Examination
of the nose consists in a preliminary inspection of the external nose and examination of the
deep-lying parts of the
nasal cavity.
In inspecting the
external nose, attention is paid to the nasal vestibule. The tip of the nose is lifted
upwards, and the patient's head is turned left and right alternately. Examination of the nasal cavity through the
nostrils known as anterior rhinoscopy is
made by means of a nasal speculum
(Fig. 41), artificial lighting and a concave head mirror. The source of illumination should be placed to
the right of the patient. The
blades of the closed speculum held by the
left hand are inserted into the nostril, and then are gently opened far enough to dilate the nostril and
bring the nasal cavity into
view. The beam of light from the head mirror is focussed within the nasal cavity. The examination should be made according to established routine.
At first, the examination is confined to the lower region of the nasal
septum, the inferior nasal turbinate and meatus, and then the attention is turned to the upper region of the nasal septum, the middle nasal turbinates and meatuses,
for which purpose the patient's head is tilted back slightly in the appropriate direction. This
method of examination is called anterior rhinoscopy
(Fig. 42). For convenience
in examining small children, it is advisable to use the aural speculum instead of the nasal type.
Frequently the view of the nasal interior is
obstructed by swollen nasal turbinates, in which case vasoconstrictive drugs, such as adrenalin, ephedrine and cocaine, are
helpful. A turbinate painted with one of
these remedies shrinks
considerably, and a much larger part of the nasal cavity thus becomes visible.
Should
anterior rhinoscopy not facilitate
inspection of the posterior region of the nasal cavity, the latter should be examined through the nasopharynx. This method
is known as posterior rhinoscopy (Fig. 43). The tongue is gently
depressed with a tongue depressor, or spatula, and a warmed small postnasal mirror is slipped in over the tongue,
until it is behind the soft palate. A spot of light from the lamp
is then focussed on the mirror, and the latter will show a reflected image of
the posterior nasal cavity and part of the nasopharynx. The mirror
should be inserted into the nasopharynx without touching the
soft palate, the palatine arches, the tongue and the
posterior wall of the pharynx, as it may cause the patient to
gag. The mirror will reflect the posterior edge of the
vomer, with the choanae on both sides and the posterior ends
of the inferior, middle and,
sometimes, superior conchae lying
in their gaps. In addition, the posterior surface of the soft palate, the vault of the nasopharynx, and
the pharyngeal openings of the auditory tubes
may also be examined (Fig. 44).
The
chief difficulty likely to arise in posterior rhinoscopy is that the patient may have a
hypersensitive pharynx and choke easily. This is especially the case with small children.
In such cases the pharynx is painted with 2-3% cocaine solution, while in the case of children the
finger may be used to palpate the
nasopharynx. This examination is made with the right forefinger and with another finger pressing the flesh of the child's cheek between in teeth
to keep it from biting (see Fig. 69, p. 181).
The
results of examination of the nose should be verified by probing. The latter is also used to determine the
consistency of the mucosa and the inflamed tissue or tumour. The probing of the nasal cavity in adults is
made with an eyed nasal probe (Fig.
45a and b); in a hypersensitive patient,
this should be preceded by painting his mucous membrane with 2-3%
cocaine or 1% dicaine solutions.
Assessment of the
nasal function consists in checking the passage of air through the nasal cavity and the acuity
of the sense of smell. The patency of the nasal
cavity can be easily checked by
directing the patient to take a deep breath and exhale the air through one nostril at a time. If the passage is free, a piece of loose cotton
wool held under the nostril will
flutter.
For practical purposes
the acuity of smell is determined by using various odours, as that of 0.5% acetic acid solution with a weak smell, spirit of wine moderate odour, a simple valerian tincture with a strong smell, camphor | and oil of cloves which have an extremely strong
smell.
When testing the
sense of smell, one nostril is jammed with a finger, and the other is left open to smell a piece of cotton wool or filter paper soaked in one or
another j solution. First come
solutions of weaker smell, and then stronger
solutions are used, if the patient fails to perceive the former.
Diseases of the
Nasal Septum
Deviation
of the nasal septum (deviate septinasi). In adults, the nasal septum rarely follows the midline. More commonly, it is displaced from the vertical to one side
or to_the other". These
deflections are of various sha_Des_XFig^.5-lX_and maybe~found Both in theanterior^and^the,
posterior parts of the nasal
septunT, though they areTnuch rarer in the latter.
A~p"5rT~froiii almple
deviations, the nasal
septum may
Fig.
51. Deflection of Nasal Septum
(a) slight deviation; (b) deviation with swollen mucosa, (c) S-shaped deviation; (d) angular deviation with swollen mucosa
often have bony
outgrowths known as spurs and ridges. These
projections often combine with deviations from the midline and are located on the convex
side of the nasal septum, mostly at the site where
the cartilage_is_atta,ched
y The basic
symptom of septal deviation isnasal obstruction in one or both
sides of the nose.Diagnosis. This
is easily made by anterior rhinoscopy.Treatment. A septal deformity can only be
corrected by surgery. The
indication for surgical interference is obstruction to proper nasal respiration in one or both
sides of the
nose.Submucous
resection of the septum is
performed in thefollowing manner.
Following anesthesia axt incision^ ismade in the
mucous membrane and perichondrium and
carried dowrnto~tEe~caftilage on the
convex sIHe. The mu-cous
membrane with the perichondrium covering
the de-fofmed part of the nasal septum is elevated from the underlying
cartilage^ and The~Tatter is cut through in the line of the^grst
incision, care being taken not to perforate, the muc^sa^o^the~~opposite~5tde.
Through the incision in the cartilage/~tFe mucosa
with the perichondrium is elevatedon the other
side of the septum, after which the deformed part is removed with retention of
a
The instruments
used for submucous resection of ths
nasal septum are shown in Fig.
52. The Soviet surgeone V.I.
Voyachek and M.F. Tsytovich have suggested a new, economical operation on the nasal septum, whereby the latter can be made to fall in the midline without removal of its basal structure of bone and cartilage, in
which case the procedure is
mobilisation and redressment, or with removal
of a thin ring-shaped piece of cartilage known as circular resection.
Hematoma and abscess of the nasal septum (haematoma et abscessus septi nasi).
Hematoma
is a
frequent result of external
injuries causing hemorrhage under the perichondrium of the nasal septum. If a
hematoma is not opened in time it nearly always turns into an abscess as a
result of secondary
infection. An abscess may occur in cases of nasal erysipelas, caries of the incisor roots or
infectious diseases, by
metastasis. Rhinoscopy and sometimes
lifting the nasal tip with a
finger will show bag-like bright-red swellings
on both sides of the septum which pit readily if touched with an eyed probe. Abscess formation in
the nasal septum is
commonly characterised by a rise in temperature, marked subjective symptoms; headache and severe nasal obstruction. If the diagnosis is in
doubt, the abscess should be
punctured and its contents drawn into a syringe.
Treatment. The cure of hematoma and
abscess of the nasal septum is by free surgical incision, sometimes on both sides of the septum, in which case the
incisions should be made at
different levels. This operation may be entrusted to an assistant. Aftercare is by draining the
abscess with packs introduced
through the incision. A belated opening
of the abscess may result in saddle-nose deformity owing to a partial destruction of the quadrangular
cartilage.
ACUTE INFLAMMATIONS OF THE NOSE
Acute
rhiniti_(rhinitis
acuta). Acute rhinitis, otherwise known as acute coryza or the common cold, is one of
the most common
infections of the upper respiratory tract. It may occur independently or as the prodromal symptom
of an acute infectious disease.
Infection is the most common
cause of acute coryza. Chilling_of_the body makes^it susceptible
jto_germs. Among acute infectious diseases
ac-companiecf by the common cold is influenza, where the upper air
passages (nasal cavity) are often the basic or pri-mary focus of
the disease, as well asjooeasles^ scarlet fever, diphtheria
and_ erysipelas. TTitTcourse of
the common cold is~TisTlsHy~"'found to comprise three stages.
The onset is marked by a hot_and dry feelingin_tJie
nose, sneezing and fever" ol upwards" of_3_L_f£. The^ nasal mucosa,Ja jejA and
dry.
A
few hours, or sometimes two to three days, later, the clinical picture changes,
the mucous membrane becomes swollen
and_sodden, and a very "copious watery secretion beginsToTrip ffoin the nose. AFtnTsame
time",l"he"exfreme-Iy~obnoxioui"
feeling of tension in the nose and nasopharynx is relieved. Thesesymptoms refer to the,
second stage.
The
nasal discharg'e J.Een turns mucoid and
as a_ result o^ an admixture,
of shed epTtEefium and leukocytes, becomes purulent. T,he nasal discharge thins outj
thejnucous membrane begins to
heal rapidly, and full recuperation foHo~w"s~~ih~"one~or~ two weeks* time.
In its first stage the common cold is apt to produce a heavy feeling in the head and headache. If later there is an
extension of the inflammation Jojthe_frontal_and^J|igh-more's
sinuses, painful sensations may occur in the region of the forehead
and eye-socket. Nasal obstruction may often affect"~the
timbje_(sonoritv) _oX the voice and give it a
nasal quality. Sometimes it causes a decreased seiise
of smell.
The common cold is very liable to
complications in the eye conjunctiva, whose symptoms are reddening
of the eyes and excessive lacrimation. Extension of the
infection through the Eustachian tube
into the middle ear frequently causes catarrhal
or purulent inflammation in the latter. Nasal
discharge, particularly in children is apt to macerate the skin
of the nasal vestibule which becomes swollen, chapped
and tender.
Treatment. At the onset,
there is hope of halting the common cold by giving the patient hot tea,
sudorific and antifebrile drugs. Phenacetin in a Oj-
Rp.
Cocaini hydrochlorici 0.15
Sol.
Adrenalini hydrochlorici (1 : 1,000)
gtt. V Sol. Acidi borici 3% 10.0 MDS. Five drops in each nostril four to five times daily
Rp. Mentholi crystallisati 0.15 Acidi
borici pulverati Zinci oxydati aa 0.75 Vaselini flavi
15.0 DS. Nasal ointment
Rp.
Mentholi crystallisati 0.05
01. Amygdalarum
dulcium 10.0
MDS. Five drops in each nostril twice daily
Hydrochloric
ephedrine has a more durable vasoconstrictive effect than cocaine
and adrenalin. It is used as a solution, 2 or 3%, given in drops or ointment.
An
effective remedy is sanorin, a drug of Czechoslovak origin, which is given by drop instillation or in
emulsion.
The
sufferer from the common cold may be helped considerably by nasal insufflation of sulfonamides (white streptocide, sulfadimezin in equal weight portions) in
powder form combined
with penicillin in a 200,000 unit dose.
The common cold in babies. This disease presents a special danger to babies. The nasal meatuses in infants are very narrow, and nasal obstruction is very likely to
follow even a minor swelling
of the mucosa.
Apart
from disorders due to the absence of nasal respiration, such as excitability, broken sleep, etc.,
nasal obstruction may often
lead to emaciation of the baby, which is
unable to suck at the breast normally.
Infectious
nasopharyngitis disturbs the child's
appetite, and swallowing of the
toxic nasopharyngeal secretion may lead
to dyspepsia. 
Sometimes, the inflammation in the nasal mucosa extends to the mucous membranes of the nasopharynx and auditory tube with resulting acute otitis media, or it spreads down the respiratory tract to the larynx and
bronchi, and is
likely to cause
pneumonia.
The
crusts at the nasal vestibule should be softened with almond oil or a warm baking soda solution, and
cleansing the nose of mucus
and crusts by careful application of
a wet cotton or gauze tuft is recommended. To enable the child to suck at the breast, it is given a drop of
adrenalin in boric acid
solution or almond oil into the nose before sucking.
Rp. 01. Amygdalarum
dulcium 10.0 Sterilis! DS. Nasal drops
Rp. Sol.
Adrenalini (1 : 1,000) gtt. X Sol.
Acidi borici 2% 10.0 MDS. Nasal
drops
If this fails to open up the nasal passages, the child should be fed from a teaspoon. Children under three
years of age should not be
given cocaine and menthol.
Prophylaxis. Hardening of the body is the basic means whereby acute inflammatory diseases of the upper
respiratory tract may be
prevented. Its essential aim is that the body should develop a capacity for quick adaptation to
changing environmental
conditions, such as chilling or overheating,
excess air humidity or dryness, draughts and wind, etc.
Regular
exposure of the skin to open air and sunlight, cool water showers and the like, various summer and
winter sports are reliable means of improving the cardiovascular and respiratory systems and ensuring normal
resistance of the vascular
system to unfavourable external factors.
Daily
exercise of the body heat-regulating system increases body resistance to chilling and overheating by
developing an
intricate system of
conditioned reflexes.
Exercises
for hardening the whole body must be performed regularly all the year round.
In a broader sense
this also implies a well-balanced diet, wearing suitable garments, as well as correct
personal hygiene, both at
home and at work.
Physical
training and weather hardening give the body reliable protection against cold-induced ailments, as
well as against
many infectious and
other diseases.
CHRONIC INFLAMMATIONS OF THE
NOSE (Chronic Rhinitis)
Chronic rhinitis occurs in three forms: (1) the
so-called chronic simple .rhinitis, (2) hy_nertrophic
rhinitis, and (3) avtrophic rhinitis (ozena).
'
Chronic rhinitis is frequently the result of repeated attacks of the common cold, i.e. acute
inflammations of the nasal mucosa, or of frequent and long irritations of the nasal mucosa owing
to various harmful factors. These refer to the effect of temperature, as in exposure to cold and hot air, and to harmful admixtures contained
in the air inhaled, such as
dust, smoke, and irritant gases. Chronic rhinitis may be caused by any of the factors liable to produce a prolonged or repeated disturbance of
blood circulation in the nasal
cavity, which may develop as hyperemia of the mucous membrane and its
progressive congestion in certain
infectious disease, like measles, scarlet fever and diphtheria, as well as in
diseases of the heart and
kidneys, emphysema, obesity, etc. Chronic rhinitis may also occur by extension of an inflammation from
other regions of the
respiratory tract, for example, from the nasopharynx with adenoid hypertrophy, or from the paranasal sinuses, as a result of the nasal mucosa being constantly
irritated by their purulent discharge.
Simple chronic catarrhal rhinitis (rhinitis chronica
simplex, s.
catarrhalis). This condition
causes diffuse hyperemia and uniform swelling of the
nasal mucosa. Its symptoms are
basically the same, though not so marked as those of acute rhinitis. The patient, as a rule, has no
constitutional
disturbance. Nasal obstruction is usually worse
when lying on the back or on a side. In the former instance, there is blood
congestion in the lower parts of the nose, i.e. in the posterior ends of the
nasal turbinates in both nasal cavities, whereas in the latter case blood
congestion is confined to the turbinates of one nasal cavity. The vessels of the erectile tissue swell with blood to cause
obstruction in one or both nasal
cavities. When turning over in bed, the nasal obstruction will change to the
dependent side. The nasal
discharge is fairly liquid. Complications of chronic catarrhal rhinitis
may involve full or partial loss of smell.
Another frequent complication is an ear disease. The swelling of the inferior turbinate, its posterior end in particular, may directly obstruct the mouth of the
auditory tube or aggravate obstructive symptoms within it, which may be
followed by chronic catarrhal otitis media
in consequence
of prolonged partial
tubal
obstruction.
Finajly, the lacrimal
apparatus is also subject to lesions due
fo""the swelling of the anterior end of the inferior tur-bmate,
which may block the~nearEjT inferior outlet of the nasolacrimal duct and cause excessive lacrimation, inflammation of the lacrimal sac and conjunctivitis.
Diagnosis. This is easily
established_bv anterior and posterior rhinoscopy.
jTo distinguish betweeff^tRe chronic simple and the hypertrophic forms of rhinitis the nasal mucosa should be painted with 0.1% adrenalin or 1-3% cocaine
solutions. A nearly compIete^simnEage" of
the~na-isaT mucosa foIWwing
cocaine application will indicate simple catarrhal rhinitis, whereas slight shrinkage or persistent swelling is characteristic of the hypertrophic form.
Prognosis.
This is favourable,
because swelling of the nasal
mucosa can nearly always be kept down by
conservative treatment or by
simple~surgical methods, like cauterization with trichloracetic and
chromic acids, galvanic current,
etc. Relapses can be prevented with certainty only if the
causes of chronic rhinitis can be eliminated.
Chronic hypertrophic rhinitis (rhinitis
chronica hyper troph-ica7TT7ewgrowTnsl!na'"p7oTm!ration in the connective tissue are the most marked in the hypertrophic form of chronic
rhinitis. The tissue cells usually grow for the most part in accumulated
erectile tissue, rather than all over the mucous membrane, that is, at the anterior or
posterior end of the inferior turbinate or
at the anterior end of the middle turbinate. Sometimes,
however, hypertrophy may affect
the entire lower margin of the inferior turbinate.
The surface of the
hypertrophied areas may take on a roughened lobular or
papillary ("mulberry") appearance. The posterior hypertrophied end of the turbinate sometimes forms a tumour-like protrusion into the nasopharynx. The hypertrophied areas may be pale grey-red,
bright red, or purple-red in
colour, depending on the amount of developed
connective tissue and the degree of blood congestion. The symptoms of hypertrophic
rhinitis are similar to those of
simple rhinitis. Nasal obstruction which results from more permanent factors, such as hypertrophy of the mucosa, is more persistent, scarcely diminishes even after the application of vasoconstrictive
drugs, and unlike simple rhinitis
is not prone to change with changes of the head and body position. The mucous
secretion is thicker and sticky. Violent
blowing of the nose through both nostrils often leads to a
middle ear disease^
Prognosis. This is comparatively good due to the possibilities of removing some of the hypertrophied
areas of the nasal mucosa and thus re-establishing the nasal
airway.
Treatment. • Rp. Sol. Ephedrini 3% 10.0
D.S. Dose of five drops to be repeated
twice daily
When
necessary, a stronger coagulative effect followed by a greater contraction may
be produced by drawing one or
two lines along the turbinate margin with
a pointed electrocauter.
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When
removing isolated and limited hypertrophied areas in the nasal mucosa,
which
are usually confined to places of
marked erectile tissue accumulation, preference should be given to the use of the nasal snare (Fig. 56) and
nasal scissors Atrophic rhinitis and ozena (rhinitis atrophica simplex et ozaena). Simple atrophic rhinitis
is a chronic disease of the nasal
cavity, characterised by atrophy of the mucosa which
grows thin and loses some of its
mucous glands. The disease
is often accompanied by diminished mucous secretion which tends to dry into crusts, but has no fetor.
Many
theories have been advanced to explain the cause of atrophic rhinitis,
but none of them can account for all of
the clinical symptoms seen in this disease. It may be assumed that both atrophic
and hypertrophic changes occurring in the nose are due to a single process of
trophic disturbances in the
nasal tissue. Some theorists, therefore, hold the view that atrophic
rhinitis always develops from hypertrophic rhinitis of which it is simply a later stage. It is true, no one has directly observed the
transition of hyperplasia
to
atrophy, but their relation is considered possible in view of their frequent joint appearance.
The assertion of formal
geneticists to the effect that this disease is congenital holds no water, as
no scientific proof exists to support
their view.
Numerous
investigations of Soviet scientists have established that atrophic rhinitis
may be due to environmental causes,
such as dust and unfavourable climate. The effect of silicate, cement, tobacco and some other kinds of
dust is especially pernicious.
Subjective
symptoms. These are not always
very marked. The patient
complains in the main of constant dryness in the nose and nasopharynx. Another
common complaint is one of a
feeling of dull pressure at the nasal root, and headache. There is severe nasal
obstruction owing to heavy
crusting. The decay of the crusts will lend them a fetid
odour. This condition
is known as ozena.
The
basic signs of ozena are the following:
(1) heavy crusting in the nose;
(2) a peculiar fetor; (3) severe atrophy of the nasal mucosa as
well as of the bony structure of the turbinates.
In
addition, ozena is commonly accompanied
by total anosmia owing to the
spread of atrophy to the olfactory area. After removal of the crusts, the nasal
passages are seen to be very wide
and in anterior rhinoscopy offer a clear view of the posterior wall of the
nasopharynx. The crusts cause
severe itching, and the patient is constantly tempted to pick the nose, which frequently leads to
injury and subsequent perforation of the nasal septum.
Etiology.
The true cause of ozena is unknown. Many theories have been offered to explain it, none of
them reliable. Neither is
there any valid proof that this disease is communicable, although the fetid odour from the nose makes the patient a social outcast.
No
doubt, environmental factors, of social nature in particular, have a bearing on
the origin and course of ozena. In the past quarter-century,
its incidence has shown a
marked decrease owing to the rising welfare and cultural standards of the mass of the Soviet people.
Diagnosis.
This is easily
established by rhinoscopic examination.
Other signs aiding diagnosis are characteristic complaints, marked atrophy of the nasal mucosa, and foul-smelling crusts with anosmia commonly present. Ozena, however, produces no ulceration
in the nose, as distinct from
nasal tuberculosis and syphilis.
Prognosis. Reliable prognostication in ozena is doubtful.
True, it is not difficult to relieve the most troublesome symptoms, but efforts to restore the nasal mucosa to full normal function have hitherto
been unsuccessful. This also
refers to the sense of smell.
Treatment.
In ozena, just as in simple atrophic rhinitis, the treatment may only be symptomatic. It aims to
relieve
dryness and crusting in the
nose by alkaline douches with subsequent
application of iodine glycerol snlntinn,
ointments or menthol oil.
The nose may also be cleansed of cruslsT)y
H warm alkaline spray.
Below are the
formulae of the alkaline
solution and some of the drops and ointments commonly used:
Rp. Jodi puri 0.05-0.1
Kalii jodati 0.2
Glycerini
Aq. destill.
aa 5.0
Menthae pip. gtt. 1
DS. Five
drops in each nostril twice a day
Rp. Mentholi
crystallisati 0.1 01.
Provincialis 20.0 DS. Five drops in each nostril twice a day
Rp.
Natrii bicarbonici 60.0
Natrii
biborici 30.0
Natrii chlorati 10.0
01. Menthae pip. gtt. V
M.
f. pulv. t
DS. One teaspoonful in a glass of watelr'for
a nasal douche '
In
view of the fact that ozena is
accompanied by the growth of
innumerable bacteria in the nasal cavity, which leads to a characteristic fetid odour, a combination
of antibiotics and nicotinic acid has been suggested for treatment of ozena. This
treatment should be given only if prescribed by a specialist. Biomycin (auromycin, terramy-cin) is given day and night once in every six
hours in an overall dose of
VASOMOTOR OR
ALLERGIC RHINITIS
(Rhinitis
vasomotorica)
Vasomotor rhinitis
is characterised by intermittent attacks
with very brief and sometimes long periods of relief. The attacks, very violent at times, are accompanied by
prolonged paroxysms of sneezing,
nasal obstruction and profuse,
mostly watery, discharge from the nose. Many patients have additional symptoms of lacrimation, itching of
the eyes, nasal interior
and hard palate, and headache. The nasal mucosa is edematous and swollen, the meatuses are filled with a watery or foamy secretion, and nasal
breathing is highly inadequate.
In the intervals between the attacks, all morbid symptoms may utterly
disappear, but in protracted
cases, the swelling of the nasal mucosa may
become stable or turn into hyperplasia, as in chronic rhinitis. Vasomotor rhinitis mostly occurs in subjects with a hypersensitive
nervous system. It is mainly caused by abnormal reactions of the body, as a result of which a number
of external and internal factors,
such as temperature and atmospheric
pressure changes, the effect of chemicals, emotional strain, etc., may give rise to inadequate,
physiologically groundless body
reactions. Even a slight chilling or some other irritation of the central or peripheral nervous system may cause a sudden and acute attack of
rhinitis in such subjects,
which very often passes just as suddenly.
In
view of a changed body reactivity, vasomotor rhinitis frequently occurs together with bronchial
asthma, angioneurotic edema, nettle
rash, etc. Some forms of vasomotor rhinitis, therefore, can be regarded as a
peculiar local anaphylactic reaction to an unknown allergen. Cytological examination of swabs taken from the mucous
membrane of the inferior turbinates reveals that many patients have
marked eosinophilia, i.e. eosinophils accounting
for more than half of the
aggregate number of blood cells.
Treatment.
Measures should be
taken to normalize the function
of the central nervous system first and foremost. The heightened body reactivity is reduced by
appropriate hardening of the
whole organism which implies wearing rational garments, getting plenty of fresh air, and other hygienic habits.
ACUTE AND CHRONIC DISEASES OF PARANASAL
SINUSES
Acute
maxillary simifUip (si.mi.i.tis acuta maxillaris).
Acute
inflammations of the antrum of Highmore
frequently occur with acute
rhinitis, influenza, measles, scarlet fever and other infectious diseases, as well as
following an injury to the paranasal sinus.
|
pain, |
In mild cases of this disease, the subjective symptoms are those of a feeling of pressure and tension in
the region of the affected sinus
and unilateral nasal obstruction. In more
severe cases, in addition to these symptoms there will be pain,
frequently confined to the region of_the oftever
and malaise^Anterior rhmoscopyrasually reveals congesTTorTand swelling of the mucosa of the middle nasal meatus containing excessive mucous
secretion and, sometimes, pus which runs in
a string fronr under the middle turbinate.
Since
acute inflammation of the mucosa or pus
in the middle nasal meatus may with equal reason be ascribed either to lesion of the maxillary and frontal
sinuses or to lesion of the
ethmoid cells, the final diagnosis rests on additional information gained by transillumination, skiagraphy, proof puncture and irrigation
of the antrum of Highmore.
Transillumination of the paranasal sinuses,
otherwise known as
diaphanoscopy, is made in complete darkness with a bright electric light placed within the
patient's mouth (Fig. 59). When
the lips are closed, a cherry-red glow
will show through both sides of the face. A dimmer glow on any facial side may provide evidence of lesion
of the maxillary or ethmoid sinus.
The degree of pneumatiza-tion of the frontal sinuses is determined by placing the lamp against the inner corner of the orbit, i.e.
the floor of the frontal sinus.
Examination
of the middle nasal meatus may be
facilitated by cocainization
and, sometimes, by probing the natural orifice of the maxillary sinus proper.
The
puncture of the antrum of Highmore on the
side of the middle meatus is made by means of a special cannula or needle (Fig. 60). The antrum
is usually punctured through the inferior meatus with a 6 to
Treatment.
In cases of acute
inflammation of the paranasal sinuses with a high-grade fever,
the patient should be kept in bed
and treated wrthjebrlfuges^ such as ^aspirin (acetylsalicylic acid) and caffeine. These are
given injOJSjj aad_u.l g powder
doses "respectively two or three_ times daily. To reduce swelling ot the mucosa in the natural oTffices of the paranasal
sinuses and to promote the drainage of secretion, a 5% solution of cocaine is used to
paint the middle nasal meatus, as well as the instillation of cocaine drops with adrenalin into the nose
several times daily.
Rp. Cocaini hydrochlorici 0.2
Sol. Adrenalini 1 : 1,000 gtt. X Sol. Acidi borici 4% 10.0 DS. Five
drops in each nostiil three to four times a day
Ephedfine drops are used for the same purpose.
Rp. Sol. Ephedrini hydrochlorici 3% 10.0
DS. Five
drops in each nostril three to four times daily
The
patient should be taught the correct technique of drop instillation in which the head should be tilted
far back and a little
towards the affected side to let the drops get into the middle nasal meatus.
The natural orifice of the paranasal sinus
narrowed by the swollen mucosa broadens under the effect of treatment, and in certain cases pus may flow directly out
of the middle nasal meatus.
An effective cure in
acute maxillary sinusitis is a hot compress, blue, "sollux" and ultraviolet light, as well as ultrashort-wave diathermy, which is given in
daily quarter-hour sessions for 12
to 15 days and is particularly helpful. If, ten to twelve days following the onset of this
condition its acute
symptoms have subsided, and sinus drainage is free, diathermy may be used to
cure residual symptomsas
well as puncture of the antrum followed
by its injection with penicillin and streptomycin.
Chronic maxillary sinusitis (sinuitis chronica
maxilla-ris)l
Although
chronTcinflammation of the antral mucosa usually results from residual symptoms of an
acute inflammation, it may arise
in the absence of a preceding acute process by extension of a chronic
inflammation from the nasal
cavity or other paranasal sinuses, above
all the ethmoid labyrinth.
Another cause of chronic highmoritis may be an inflammation in the root of a tooth.
Symptoms.
The subjective
symptoms are unmarked. The patient
complains of unilateral nasal obstruction, more or less copious
nasal discharge, often^pjirulentj^headache, and eariy__wearinggs_ from menTaT
exertion. A fairly~common symptom is
hyposmia and, sometimes, perception of a foul odour in the nose, known as cacosmia.
Physical examination reveals pathological changes in the middle nasal meatus, such as inflammatory symptoms in the mucosa and polips, as well as a purulent or mucopurulent discharge which quickly reappears after being wiped off with a cotton
tampon.
Diagnosis.
The diagnosis of
chronic maxillary sinusitis is
based on the record of complaints and physical signs. A differential diagnosis is facilitated by auxiliary
methods, such as X-ray
photography, transillumination, proof puncture
and irrigation of the
antrum
of Highmore.
Treatment.
An effective
conservative treatment of chronic maxillary
sinusitis is by irrigation of the antrum with
a saline solution_followed by its injection
jvith_ penicillin or streptomycin solutions, 200.000_ tg_2501000_jmits ia a
The
irrigation is made with the aid of a puncture needle following puncture of the antrum in the inferior nasal meatus. In light cases, diathermy,
ultra-high frequency ^currents,
and "sollux" light therapy may sometimes prove successful.
In
the majority of cases, however, surgery is indicated for the removal of polyps and granulations from the
sinus, and to provide for a
wide communication between the latter and
the nasal cavity. An improved technique of this operation has been suggested by A.F. Ivanov The first stage is incision of the mucosa under the upper lip (Fig. 62), which elevates the soft tissues to
expose the anterior bony wall of
the antrum. The wall is opened as wide as possible with a chisel and forceps
(Fig. 63). The initial cut is
always made at the site of attachment of the maxillary zygomatic process,
as this will always provide access to the sinus
interior, however small it may be. Pus and
diseased mucosa are then removed from the
sinus through the opening in the
anterior antral wall, whereas normal mucosa is
left in situ. Communication with the nasal cavity is set up by removing part of the internal wall
of the antrum in the inferior
nasal meatus (Fig. 64). The operation is performed under local anesthesia.
Following the operation, an ice-bag is applied
to the cheek to keep down
the swelling. The patient is given cold liquid food for three to four days. Postoperative
treatment consists of
antiseptic douches through the newly-formed naso-antral window given four to five days after the operation.
Prophylaxis. Prevention
of inflammatory diseases of the maxillary
sinuses is by a correct and timely treatmentof both acute and chronic rhinitis as well as by treatment of the upper molar teeth which have a direct relation to these sinuses.
nuitis acuta frontalis). The circumstances
and causes of frontal sinusitis
are the same as in maxillary sinusitis. The basic complaint in this condition is one of pain and exquisite tenderness on finger pressure over the floor of the frontal sinus at the
upper inner corner of the orbital
roof. Frontal sinusitis may be accompanied
by photophobia, j^criiaation__ana2Ipain m_the__or£it. In severe cases, particularly with poor drainage from the frontal sinus, there may be swelling in the upper eyelid and over the brow.
Anterior rhinoscopy will reveal the same physical signs as
in maxillary sinusitis.
Diagnosis. This
is made with the aid of transillumination and X-ray films.
"Furthermore,
the drainage of secretion from
the sinus must be ensured by
painting the middle nasal meatus with cocaine, and
sometimes a little
surgeryis required in this area to remove the anterior end
of the middle turbinate.
Various
physiotherapeutic procedures, including
exposure to blue and
"sollux" light, as well as ultrashort-wave diathermy are most helpful.
Chronic frontal sinusitis (sinuitis chronica
frontalis). The
subjective symptoms of this disease are much milder than in acute inflammation of the same sinus. These
symptoms may be
aggravated, however, by poor drainage of the frontal sinus with a resulting pressure increase
within it and extreme
tenderness on pressure over its floor. The pain in the frontal sinus may increase due to the
inflow of blood to the head
precipitated by strong drink, smoking, nightwork^ etc. A fistula may sometimes develop in the
inner corner of the orbit.
Diagnosis. This
is usually easily established after an analysis of all subjective symptoms and physical signs has been made following auxiliary diagnostic procedures, like transillumination, X-ray photography,
and probing the nasofrontal duct.
Treatment. Surgical
interference is indicated should conservative
measures fail to cure the grave forms of frontal sinusitis with a headache so severe as to render
the patient incapable of
working. Clear indications for a radical operation on the frontal sinus are
also lesions of the bony walls, fistulas and, above all, complications occurring by extension of the inflammatory process to
the tissues within the
cranial cavity or the orbit.
The
operation is, as a rule, performed under local anesthesia. The incision of the skin and periosteum is
carried along the brow, past
the inner corner of the eye, and down along
the nasal bone to the lower ridge of the orbit (Fig. 65). The soft parts are pushed upwards and downwards to expose the anterior wall and floor of the
frontal sinus, whereupon a wide
hole is made in the sinus floor. Morbid mucosa, pus and granulations are then
removed from the sinus, and a wide
passage is formed between the frontal sinus
and the nasal cavity.
In view of the fact
that the anterior ethmoid cells are usually affected together with the frontal
sinus, A.F. Iva-nov has suggested
that the so-called fronto-ethmoid trephi nation 'be performed in all cases of the
above-described operation by a
simultaneous opening of the ethmoid cells. The operation ends with insertion into the frontal
sinus of a thick-walled
rubber drain passed through the nose and
the naso-frontal passage made during the operation. The incision is securely closed with stitches in the
soft tissue.
Postoperative
treatment is similar to that employed in the opening of the maxillary sinus, that is, by
periodical antiseptic douches
of the frontal sinus.
Acute
and chronic ethmoiditis (sinuitis
ethmoidalis acuta et chronica). The symptoms of acute inflammation of the ethmoid cells resemble those of frontal
sinusitis.
The
fact that pain is mostly felt at the nasal root and the inner corner of the orbit may indicate affection
of the ethmoid cells. In
chronic cases, subjective symptoms may with equal reason be associated with
either frontal or ethmoid
sinus disease, yet there may also be an absence of symptoms. Rhinoscopy in
chronic forms of ethmoidal inflammation will reveal more or less typical
signs. Frequently the middle
nasal meatus is filled with polyps with
pus oozing between them.
The presence of pus in the superior nasal meatus above the middle turbinate is diagnostic of suppuration in the posterior ethmoid cells or the
sphenoid sinus.
Treatment.
In acute cases, the
treatment is the same as
in acute frontal sinusitis. In
chronic cases, surgery is required to open all of the affected ethmoid cells. This operation is usually
performed via the nose with a
special set of instruments (Fig. 66a). After the cells have been opened, tags of torn tissue
are removed with a
conchotome or forceps (Fig. 66b) and with
a nasal snare, the entire space of the ethmoid labyrinth being cleansed.
In
the event of a lesion of the anterior cells adjoining the floor of the frontal sinus and in the presence of
external fistulas, this
operation is made through an external incision
on the face, as in cases affecting the frontal sinus.
Sphenoiditis (sinuitis sphenoidalis). Sphenoid sinus suppuration is commonly connected with a lesion of the
posterior ethmoid cells which closely adhere to the sphenoid sinus. A
distinctive symptom of this condition is remittent headache with reflex pain in the" nape, or less
frequently
in the forehead
or vertex. Rhinoscopy will show pus in
the superior nasal meatus which flows down into the nasopharynx. Probing and irrigation of the sphenoid
sinus both form part of the
treatment and diagnosis. Intranasal surgical opening of the sphenoid sinus is sometimes
indicated.
Orbital
and intracranial complications. An acute or chronic inflammation in the paranasal sinus may give rise to intraorbital and intracranial
complications, which are sometimes
fatal. These complications may arise by direct contact between the infected tissue and the contents
of the orbital or cranial cavities as
well as by extension of the
infection by blood and lymph vessels. The veins which directly connect the superior part of the nasal cavity
and the paranasal sinuses with the longitudinal sinus
of the dura mater may provide
a route for the infection extending
into the latter sinus and causing its phlebitis.
The pressure of the inflammatory
infiltrate on the eyeball and ophthalmic nerve may markedly displace
the eyeball or cause it to protrude. Another result is loss
of vision which in mild cases may be quickly restored, as soon
as the basic cause of the condition is eliminated.
In
some cases of closed empyema within the
ethmoid cells, the infection
may spread to and cause suppuration in
the postocular cellular tissue with a danger of complications threatening the organ of sight and the
life of the
patient.
The antrum of Highmore is more frequently the
source of orbital rather than
intracranial complications.
Among
intracranial complications, such as an extradural abscess, purulent meningitis and cerebral abscess, the
latter is the most
dangerous and often proves fatal.
Timely
treatment of inflammations in the paranasal sinuses will prevent these dangerous complications.
In the event of suspected intracranial complication a radical operation will be required followed by intensive
antibiotic therapy with large
doses of penicillin, streptomycin, and the like.
Should
the condition be serious enough to warrant surgical interference in the cranial cavity, the common
rules of brain surgery must
be employed.
ANATOMY
OF THE PHARYNX
The
pharynx is the expanded portion of the alimentary tract lying between the oral cavity and the esophagus.
It is also part of the respiratory
tract, as it connects the nasal
cavity with the larynx. The upper part of the pharynx, called the epipharynx, communicates with
the nasal cavity through the choanae and is known as the nasopharynx.
The
openings of the Eustachian tubes lying on
a level with the posterior
ends of the inferior nasal turbinates are
to be found on the lateral walls
of the nasopharynx. An accumulation
of lymphadenoid tissue in the top part of the posterior wall of the nasopharynx forms the pharyngeal or third tonsil, consisting of 5-6 lobes, and
diverging from a common centre.
In children aged two or three years this tonsil is often hypertrophied, as they
grow older it decreases in
size and by the age of puberty consists of diffuse lymphadenoid tissue scarcely emerging over the
surface of the mucous membrane
covering the nasopharyngeal roof. A plane
which is a backward extension of
the hard palate separates
the nasopharynx from the middle part of the pharynx, known as the mesopharynx or, more commonly, as
the oropharynx
(Fig. 67).
The oropharynx is bounded by the posterior and
lateral walls continuous with
the corresponding walls of the nasopharynx,
and anteriorly it communicates with the oral cavity through the fauces. The fauces are bounded
by the soft palate above, by
the base of the tongue below and by
the anterior and posterior palatine arches, otherwise called faucial pillars, on the sides
(I) posterior
wall of pharynx, (2) uvula, (3) palatine tonsil, (4) anterior faucial pillar, (5), (6) posterior faucial pillar, (7) soft
palate
The
pharynx contains well-developed lymphadenoid tissue which forms fairly large masses embedded on both
sides between the faucial
pillars, which are known as the first and second palatine or faucial
tonsils. The letter's free surface
facing the pharynx contains numerous pit-like depressions, or crypts, running through the entire body
of the tonsil (Fig. 68). The squamous epithelium which lines the free surface of the tonsil also lines
the crypts. A similar accumulation
of lymphadenoid tissue at the base of the tongue forms the lingual, or fourth, tonsil. The ring-like chain of lymphoid tissue made up of these four tonsils and the lymphatic follicles in the mucous
membrane is known as the lymphoid ring of the pharynx.
The
plane that extends backwards from the base of the tongue divides the oropharynx
from the laryngopharynx, or hypopharynx, which lies below and directly
opens into the esophagus. The
lower portion of the pharynx opens into
the larynx. The mucous membrane of the nasopharynx consists of a stratified, columnar, ciliated
epithelium, while its other two
departments are lined with a stratified squamous epithelium. The pharyngeal
mucosa contains numerous mucous glands.
PHYSIOLOGY OF THE PHARYNX
The pharynx serves as
a passage for air and food, and also
as a resonating chamber for the voice. Because the digestive and
respiratory tracts cross each other at the pharynx it has
reflex mechanisms to regulate the passage of food and
air. At rest, the nasopharynx is open to the oral cavity,
whereas in swallowing and in the articulation of certain vowels and consonants
the soft palate is pulled up against the posterior pharyngeal wall and firmly shuts off the nasopharynx from the oropharynx, so preventing food
from getting into the nasopharynx and nose, which sometimes happens in
paralysis of the soft palate, for example, following
diphtheria.
The
passage of the alimentary bolus is accompanied by closure of the larynx, which moves up slightly under
the base of the tongue, whose pressure
compressed the epiglottis against the
narrow entrance to the larynx, whereupon the bolus is passed into the
esophagus.
The
pharynx which is studded with gustatory nerve endings on the soft palate and at the base of the tongue,
also functions as the organ of taste and performs the protective function of reflex muscular contraction in
response to sharp thermic and
chemical irritation or to the entry of foreign bodies.
As to the exact function of the pharyngeal
lymphoid ring, this is still a matter for
discussion. Most authors adhere to the
"protective theory", that is, regard the tonsils and the other lymphadenoid structures as a
protective barrier against bacterial infection. In pathological
conditions, the tonsils with their crypts
which always harbour microbes prove,
on the contrary, to be an entryway for infection and so account for the causal relationship between inflammations of the tonsils and constitutional
diseases. In essence, the function of
the lymphadenoid structures of the
pharynx cannot be separated from the function of similar follicular structures
in other organs, like Peyer's patches
of the small intestine, which produce lymphocytes and presumably
neutralize infectious toxins entering the blood.
For this reason, the removal of pathologically altered tonsils, corroborated by everyday practice,
should not lead to any substantial
damage from the viewpoint of their
functional value for the body as a whole.
The other parts of the lymphoid ring
and the lymphadenoid structures
of the digestive tract will compensate for the defective function of pathological tonsils as well
as for their complete removal.
The functional
examination of the oral cavity and nasopharynx, the process of chewing and deglutition
excluded, essentially consists
in a gustatory test by using sugar, quin- ine, common salt and vinegar solutions to determine
the taste for sweet, bitter, salty and sour
substances respectively. The solution is
applied on a glass stick to either side of the tongue in turn, with the nose being firmly closed to shut off the sence of smell.
In view of their different nerve-supply systems, the anterior and posterior parts of the tongue should
be examined separately. The
residue of the earlier used solution must be washed out of the mouth before any further
examination is made.
METHODS OF EXAMINING THE PHARYNX
The
oral cavity and oropharynx may be
examined by means of artificial
and natural lighting.
The patient and the source of light are placed
in the same position as for examination of the nose; the head
mirror is used similarly. Examination of the oral cavity which is
a necessary prelude to examination of the pharynx commences with
inspection of the lips and vestibule of the mouth. A
spatula, or tongue depressor, is used to retract, in turn,
the corners of the mouth and to avert with a gentle tug the upper and lower
lips in order to note the colour of the mucosa, detect scratches, ulcers or fistulas and to inspect the gums and teeth. The tongue, as well as the hard and soft palates, should also be
inspected. The floor of the oral
cavity is examined by using the spatula to push up the tip of the tongue. The parts which are
examined next are the faucial tonsils and the
posterior pharyngeal wall. Here, the spatula is used gently to push down the dorsum of
the tongue. The spatula must not be inserted too far into the mouth, or else the gag reflex will be brought into play. The patient should not put out
his tongue or hold his breath, as
this will interfere with the examination.
A stubborn child
who resists examination by clenching its teeth must be firmly fixed in the same position as in adenoidectomy (see Fig. 71). If it does not open its mouth for breathing when its nose is pinched, the
spatula is inserted in the mouth
corner, behind the posterior molar, and pushed as far as the base of the tongue. This will cause the child to gag and open its mouth, which enables
the doctor to depress its tongue with the spatula in order to examine
the pharynx.
Attention
is paid to the soft palate with its axches, the mobility of the soft palate as well as to possible
fistulas, scars or fissures in the roof of the
mouth. The normal colour of the pharyngeal mucosa is pink-red or pink, whereas the uvula and the faucial pillars often have a
deeper hue.
In examination of the faucial tonsils,
attention is given to the colour of their mucous membranes as well as to their
size, possible adhesions to the faucial pillars, and the contents of the tonsillar crypts.
For
inspection of the free surface of the tonsils hidden between the faucial pillars, as well as of the
contents of the crypts, the
anterior pillar is pulled outwards with a spatula or a blunt hook, and the
spatula is gently pressed on
the anterior pillar to shift the tonsil from its bed and to express the contents of its deep depressions.
When the laryngeal part of the pharynx is being
inspected the tongue is firmly pressed down and outwards, preferably with a curved spatula or a postnasal mirror,
as in laryngoscopy.
In
examination of the oral cavity and pharynx, it is essential to note simultaneously the condition of the submaxillary region and the lateral parts of the neck to detect enlarged lymph nodes metastases or tumour outgrowths, phlegmons, etc.