Adenoid Hyperplasia
(Adenoides)
The upper portion
of the nasopharyngeal wall contains the third, or pharyngeal, tonsil which is
made up of pale or red masses separated by vertical clefts. As a result of
repeated inflammations in the nose and pharynx, this tonsil often
hypertrophies, obstructing the openings of the choa-nae and Eustachian tubes
and filling up a large part of the nasopharynx.
Children's
infectious diseases, such as measles, scarlet lever, influenza and diphtheria,
sometimes stimulate the rapid growth of
adenoids. This hyperplasia is most frequently met with in children at the age
of three to eight or ten years, but it may also occur in the first year of life
and after puberty, when adenoids normally tend to disappear.
Symptoms. The symptoms
produced by adenoids are primarily those of nasal obstruction and continuous
rhinitis which does not respond to ordinary conservative treatment. In
consequence of nasal obstruction, children with adenoids sleep with their
mouths open, and most of them keep it half-open when awake, which flattens
their nasolabial fold and makes their facial expression apathetic and dull. Constant
mouth breathing causes the hard palate to become high-arched and narrow, i.e.
there forms the so-called "Gothic" palate. Hyperplasia of the
pharyngeal tonsil is often accompanied by a similar enlargement of other
lymphanic structures, above- all, the faucial tonsils, in which case nasal
obstruction becomes even more severe. This type of mouth breathing adversely
affects the child's constitution, particularly, the shape of its chest. That is
why children with adenoids look physically weak as well as mentally retarded.
They have various nervous disorders, primarily nocturnal enuresis, which ought
to be regarded as a reflex neurosis. They often complain of headache and
inability to concentrate.
The folds and
depressions of adenoids may harbour a numerous collection of bacteria, which
are responsible for frequently recurring and acute inflammations of the nasopharynx.
Adenoid hyperplasia which interferes with middle ear ventilation, may cause a
gradual loss of hearing or repeated inflammations in the middle ear. Owing to
nasal obstruction on the side of the choanae, the child speaks with a nasal
twang (rhinolalia clausa).
Diagnosis. Apart
from the symptoms described above, the diagnosis is based on rhinoscopy,
primarily postnasal mirror examination, which will offer a direct view of the
nasopharynx filled with adenoid hyperplasias hanging from the roof and
obstructing the choanae to a greater or lesser extent. Posterior rhinoscopy is
often impossible in children, in which case the finger must be used to palpate
the nasopharynx. This is an easy method of detecting adenoids, as well as of
determining whether they are of pasty
or less soft consistency.
Finger Palpation of
Nasopharynx
Treatment. In the
majority of cases, adenoids are treated surgically. Indications for
adenoidectomy should be sought for not so much in the size of the adenoids, as
in the constitutional disturbances they are likely to cause, such as constant
and stubborn rhinitis, which resists conservative treatment, and repeated
inflammations of the middle ear.
Position of
Pa-tiettt in Adenoidectomy
The operation is usually
performed in the morning when the stomach is empty by means of different types
of adenotomes available in five sizes to fit the size of the nasopharynx.
The child patient
is wrapped in a sheet and firmly held by the assistant, who jams its legs between
his own and keeps its head in position with one hand and its chest and arms
with the other. At operation the child should not be allowed to fidget or tilt
back its head. After the tongue has been pushed down with a spatula, the
adenotome is slipped into the nasopharynx, behind the soft palate, set strictly
along the mid-line and pressed to the nasopharyngeal roof, somewhat to the
front. The adenoids are then cut off with a quick jerk from front to rear along
the roof and jiosteriorwall of the nasopharynx, and withdrawn. Tags oll
exuberant tissue overhanging the nasopharynx are clipped off with a
con-chotome. Bleeding is usually scanty and easily controllable.
Contraindications
and postoperative care in adenoidectomy. After the operation the child is directed to clear the! nose of blood by
blowing it gently through one nostril at a time and to gargle the mouth with
hydrogen peroxide solution. Next, the child has its nose packed with cotton
wool until bleeding has ceased, is put in bed and encouraged] to lie quietly for two or three hours.
If hemorrhage
ensues the blood should not be swallowed j but spat out into a basin.
The aftercare may
be taken over by the parents who! must be instructed to keep the child in bed
for two or three! days, give it cool and liquid meals and clean its room with I
a wet cloth. These measures are aimed at prevention of 1 hemorrhage and
infection of the open wound in the child'si nasopharynx. With normal body
temperature and good general condition the child may go to school on the sixth
or seventh day after the operation.
The
operation is soon followed by the complete restoration of nasal breathing and
hearing and later by improvements
in the child's physical and
mental development.
Despite the removal
of adenoids measures for promoting a sound constitution in children should not
be neglected.
Following
adenoidectomy, some children are given breathing exercises to promote nasal
respiration.
If there are
serious contraindications for surgical removal of adenoids, X-ray therapy may be of assistance.
Hypertrophy of
Faucial Tonsils
Hypertrophy of the
faucial tonsils similar to that of the pharyngeal tonsil is more common in
children. In this condition, the tonsils are markedly enlarged and protrude
beyond the faucial pillars (Fig. 74) or are in contact in the mid-line.
Hypertrophied tonsils in children usually have no inflammatory signs. In time,
these "physiologically" hypertrophied tonsils shrink to their normal
size. This involution may be delayed, in which case comparatively large tonsils
will be found in an adult patient.
Tonsillotomy
Treatment. Health
promotion is the primary measure which includes a hygienic regimen, adequate
nourishment, rest in child health centres, etc. In children suffering from
marked hypertrophy of the faucial tonsils which interfere with speech,
breathing and the passage of food, tonsillectomy must be resorted to, the
redundant tissue protruding into the nasopharyngeal space being removed with a
ton-sillotome.
Foreign Bodies in
the Pharynx
Foreign bodies
enter the pharynx not only through the mouth, which is the most common route, but
also through the nose as well as the larynx and esophagus. Foreign bodies that
lodge in the pharynx, like fish bones, fruit stones, grains, and the like,
usually enter during a meal. Among other foreign bodies found in the pharynx
are fragments of .dentures, coins, small toys and other objects children put
in the mouth at play, as well as nails, drawing-pins, pins and buttons held in
the teeth by adults at work, particularly shoe-makers and tailors.
The danger of
foreign bodies slipping in with food through the mouth is greater in cases of
toothless jaws with dentures which shut off the feel of the hard palate. In
addition, foreign bodies often lodge in the pharynx at meals owing to a sudden
cough, laughter, sneezing and talking which distract attention from chewing.
Foreign bodies which become wedged in the pharynx are usually sharp and catch
in the faucial mucosa, tonsils, faucial pillars or lodge at the entrance to the
esophagus or larynx. Large and smooth foreign bodies more frequently pass down
to the esophageal entrance or become stuck in the esophagus itself.
Foreign bodies are
less likely to lodge in the nasopharynx. They may be broken-off pieces of
instruments entering through the nose, remnants of food and sometimes pinworms
belched out of the stomach. Sometimes live creatures, such as leeches, enter
the nasopharynx through drinking filthy water from swamps and irrigation
ditches.
Foreign bodies may
produce different symptoms depending on their individual features. In the case
of a sharp foreign body wedged in the mucous membrane, the patient will
complain of a more or less severe pricking pain, particularly marked on
swallowing. In other cases, a foreign body may produce mucosal inflammation
with signs of hyperemia, swelling and increased secretion, which in turncause
coughing, choking and sometim.es vomiting. Should a large foreign body become
lodged in the lower pharynx, at the laryngeal entrance, this may produce sudden
symptoms of asphyxia.
Treatment.
Following location of the foreign body by a thorough and consecutive
examination of all parts of the pharynx, it is extracted by aid of a straight
or angular forceps with the blades in close contact. The patient is sometimes
distressed by scratches and sores left by the removed foreign body which
simulate the latter. Aftercare consists of mildly antiseptic gargles and a
bland diet.
ACUTE INFLAMMATIONS
OF THE PHARYNX
Inflammation of
the_pharyngeal_mucosa may be acute orTiEronTc.
"Acute
pharyngitis (pharyngitis acuta). Acute inflammations of the pharyngeal mucosa
rarely occur of themselves, and are commonly provoked by a dqwnward xtension of
acute catarrh ojhenose and nasopharynx. Acute pharyngitis mayp Qucedifferent
subjective symptoms in the throat, such as dryness, slight pain or tension, sore
throat, etc. Physical examination reveals hyperemia of the mucous membrane,
which iff places is covered with mucopurulent secretion. Individual follicles
exhibit as red granules on Jthe retropharyngeal mucosa. The uvula is red,
swollen and slightly edematous. Body temperature is either normal or slightly
elevated, and bodily discomfort is mild. Acute pharyngitis frequently
foreshadows or accompanies tonsillitis.
Treatment. This is
similar to that of tonsillitis, namely, rest in bed, a bland diet of warm and
liquid or semi-liquid food, administration of salicylic and sulfonamide drugs,
application of a hot compress to the neck and use of the following antiseptic gargles:
Rp. Dec. radicis Althaeae 400.0
Natrii benzoici 6.0
Glycerini 10.0
T-rae Opii
benzoici 3.0
MDS. Gargle
Rp. Kalii
hypennanganici 1.0
DS. Two or three crystals in a glass of water for a
gargle
The gargle should
be warmed a little beforehand and the head tilted back to let the liquid
irrigate the farthest portions of the pharynx, na Foll icular Tonsillitis
Catarrhal, Lacunar an Tonsillitis is a generalized infectious disease with inflammation
of the pharyngeal lymphoid structures, above all the faucial tonsils, and with
swelling of the regional lymphatic glands.
The inflammation in
the pharynx presents a wide variety of morbid symptoms owing to the presence in
the pharyngeal mucosa of adenoid tissue which may be wholly or partly involved
in the process. The inflammation may be diffuse and superficial when it affects
the surface of the tonsils and their crypts, or it primarily involves adenoid
tissue, tonsillar parenchyma, with the follicles embedded in it.
The cause of
tonsillitis is invasion by streptococci and, less frequently, by staphylocci
and pneumococci, while the predisposing factors are thermic, chemical and
mechanical irritations of the mucosal receptors of the fauces and tonsils in
the presence of a diminished body resistance. The infection may be introduced
by external factors or be activated by an increased virulence of the germs
permanently inhabiting the tonsillar crypts, mouth and pharynx. The source of
infection may be a suppuration in the nose and paranasal sinuses or dental
caries.
Tonsillitis often
develops as a grave constitutional disease, which is evidenced by frequent
complications in such organs, as the heart, joints and kidneys, as well as by
the fact that the local signs in the fauces are often preceded by severe malaise
with fever, headache and rheumatic pain.
Tonsillitis may
occur in the catarrhal, lacunar and follicular forms depending on its severity
and on the presence or absence, as well as the character and location, of a
patchy membrane on the faucial tonsils.
Catarrhal
tonsillitis. The patient first complains of dry-ild JUneuufas 111 the throat
and later of moderate throat pain on swallowing. The temperature is usually
subfebrile, whereas in children a high-grade fever is more common, and vomiting
is one of the early symptoms. Headache and feebleness are frequent. The disease
continues three to four days. In mild cases, examination of the pharynx reveals
slightly swollen and red tonsils whose surface is coated with a yellowish
mucoid secretion. In severe cases, there is punctate hemorrhage on the mucosa
as well as edema of the uvula and faucial pillars. The lymph nodes below the
mandibular angle are swollen and
tender.
Catarrhal
tonsillitis is nearly always present with many acute infectious diseases. In scarlet
fever, it takes a peculiar course. At the onset, the inflammatory redness is
sharply outlined in the centre of the soft palate, whereas in unaccompanied
tonsillitis the tonsillar mucosa is most affected. Within a day or two, the
bright and limited redness caused by catarrhal tonsillitis present in scarlet
fever disappears, and hyperemia extends over a wider area invading the tonsils
and the posterior wall of the pharynx.
The characteristic
skin rash of scarlet fever appears after the first 23 or 24 hours. In measles,
hyperemia of the fauces is of spotted character and appears on the second or
third day after the onset of the disease as part of general enanthema.
In lacunar
tonsillitis the general symptoms are
more pronounced. The constitutional disturbance is more severe than in
catarrhal tonsillitis, while pain felt on swallowing and headache are worse.
There is a marked fever which in children rises as high as
Follicular
tonsillitis. This condition is another form of the same infectious disease
occurring independently or concomitant with lacunar tonsillitis. The red and swollen
mucosa of both tonsils becomes the site of eruption of a considerable number of
round and slightly prominent yellow or yellowish-white nodules the size of a
pin-head, which are suppurated tonsillar follicles. This disease differs from
other forms of tonsillitis with patches in that the suppurated follicles are of
uniform size and regular shape, and are confined to the free area of the
tonsils. In the process of suppuration, the yellowish-white follicles
gradually grow in size and burst into the pharyngeal space. Evacuation of their
contents into the connective tissue bed of the tonsil may produce a peritonsillar abscess.
The onset of
follicular tonsillitis is. often sudden, accompanied by a chill, a rapid rise
in temperature to
Follicular
tonsillitis may attack the pharyngeal and lingual tonsils simultaneously.
Though its course is severe this disease usually ends in complete recovery in
five to seven days' time.
Tonsillitis is
liable to produce a number of complications of a local and general character.
The former
refer to peritonsillar abscesses and acute otitis media, the latter—to cardiac
and articular rheumatism, renal
diseases and sepsis.
Diagnosis. This
disease is not difficult to recognise. In diagnosing lacunar tonsillitis
particular care should be taken not to mistake it for diphtheria. The
difference between them will be discussed in the section on diphtheria.
In tonsillar
syphilis, there is very little malaise, moderate pain on swallowing, and a
very slight fever. The faucial pillars and tonsils are bright red and covered
with greyish-white round papules which are also found on the mucosa of the
cheeks, gums and tongue. Numerous swollen and solid lymph nodes can be felt
under the mandible and on the neck. The diagnosis of tonsillar syphilis is
verified by general examination
and Wassermann's test.
Prognosis is
usually favourable, but it is rather common that recovery from tonsillitis,
however severe, is followed by grave constitutional complications, like
rheumatoid arthritis, rheumatic endocarditis, nephritis or septicopyemia. The
forecast, therefore, should be made with caution, particularly in cases of
recurrent tonsillitis followed by complications.
In all cases of
more or less severe tonsillitis, blood tests should be performed since this
condition may be a symptom of a serious disease of the blood, leukemia, etc.
Treatment. The
patient is advised to take to bed, as a prophylactic measure against
complications, is prescribed a diet of thin gruel and given acetylsalicylic
acid (aspirin) with caffeine orally.
Rp. Aspirini 0.5
Coneini
natrio-benzoici 0.1
M. f. pulv.
D. t. d. N. 10
S. One powder dose two or three times daily
Small children are
given a solution of sodium salicylate. Mildly antiseptic gargles, like boric
acid, sodium benzoate and other solutions, are used for throat irrigation.
Rp. Hydrogenii
hyperoxydati 3% medic. 100.0
DS. One or two tablespoonfuls in a glass of
a water
for a gargle
Rp. Acidi borici
25.0
DS. One teaspoonful
in a glass of warm boiled water
for a gargle Rp.
Gramicidini 2.0 D. t. d. N.
S. The contents of
one ampule dissolved in a glass of water for a gargle
Rp. Natrii benzoici 25.0 DS.
Half a teaspoonful
in a glass of water for a gargle
Children are given
plenty of warm drinks. A hot compress on the neck, preferably soaked in a
solution of one-third of alcohol to two-thirds of water, is effective as well as
steam inhalations from a hot 2% baking soda solution and administration of
laxatives. The condition of the heart and kidneys should be watched, in the
case of the latter—by analysis of urine. The hot compress will help diminish
infiltration and congestion in the pathologically changed organ, viz., in the
tonsils, after which the morbid process will speedily resolve, and pain will
be alleviated.
The streptococcic
nature of tonsillar infection is an indication for the use of streptocide and
other sulfonamide drugs as well as penicillin by intramuscular injection, and
biomycin and terramycin in tablet form. Streptocide, sulfathiazole and
sulfadimezin are given for a few days in 0.3 to
Prophylaxis. The
prevention of tonsillitis is based on general rules for strengthening the body
and enabling it to resist various
harmful external influences.
These rules are as
follows:
Observance of
sanitary and technical regulations in
industry, selection by fitness for a particular job, registra tion and
regular examination and
treatment of persons susceptible
to tonsillitis; more
hygienic living conditions,
personal hygiene and
body hardening; treatment of diseases conducive to tonsillitis, such as
chronic tonsillar hypertrophy, purulent highmoritis, adenoid hyperplasia, dental caries, etc.,
which affect the upper respiratory tract.
Although
tonsillitis infection is not highly contagious, it is advisable to isolate the
patient with tonsillitis and provide him with individual eating and other
utensils. Healthy persons, children in particular since they are especially
susceptible to the disease, should avoid contact with the patient. Acute
inflammation is not always restricted to the tonsils, but may often involve
the entire lymph-adenoid tissue of the pharynx; yet lesion of individual
tonsils may have peculiar clinical symptoms of its own.
Acute pharyngeal
tonsillitis. This condition commonly occurs in children, particularly in cases
of hypertrophy of the pharyngeal tonsil, and is called acute adenoiditis or
retronasal tonsillitis (angina retronasalis). The symptoms are fever, a general
feeling of weakness, and signs of rhinitis. The troublesome smarting sensation
in the nasopharynx is accompanied by cough and otalgia. The cervical lymph
nodes are often swollen and tender.
Treatment is the
same as that for acute rhinitis.
Acute lingua
tonsillitis. This condition is much rarer. Its general symptoms are similar to
those of other types of tonsillitis: local pain on swallowing, marked
tenderness at the base of the tongue on pressure with a spatula, a bright red
and swollen lingual tonsil, sometimes covered with yellowy dots or coated all
over as in lacunar tonsillitis.
Treatment. This is
similar to that applied to inflamed faucial tonsils. Ulcero-membranous
angina (Vincent's angina). This disease causes ulceration of the mucosa of the
soft palate and tonsils, less commonly of the gums, retropharyngeal wall and
cheeks. It is due to the symbiosis of a fusiform bacillus and an oral
spirochete which usually resides in a low virulent state within the folds of
the oral mucosa.
The condition is
marked by superficial necrotic patches of a yellowish-white colour on the
mucosa of the tonsils and soft palate. These necrotic patches quickly merge to
form superficial and sometimes deeper ulcers on the mucosa, which are not very
painful but often produce bad breath and salivation. The temperature is usually
subfe-brile or normal with little constitutional change. The regional lymphatic
glands are swollen
and tender.
The normal duration
of the disease is about a week, but it may linger for a few weeks and longer.
Ulcero-membranous
angina occurs either sporadically or in epidemics. When observing an outbreak
of this disease in
N. P. Simanovsky,
the first Russian to have written a treatise on this subject, in 1890 described
a similar epidemic of ulcero-membranous angina in St.
According to
earlier evidence of Russian physicians, namely, Filatov and others, ulceration
of the oral cavity and pharynx occurs with ulcerative stomatitis. Thus, the
identity of ulcero-membranous angina with ulceration of the oral mucosa had
been proved clinically long before Vincent discovered the pathogen of this
disease in 1898.
Diagnosis. The
diagnosis is verified by a laboratory investigation of smears taken from the
ulcer contents, which reveals both fusiform bacilli and spirochete. Sometimes,
external evidence is insufficient for differentiation of ulcero-membranous
angina from diphtheria, syphilis or cancer.
Treatment. In mild
cases,
Agranulocytic
angina (angina agranulocytotica). This condition is usually marked by a sudden
fever, sometimes accompanied by chills and sore throat. Examination of the
throat will reveal a markedly swollen mucosa covered with necrotic patches of a
dirty grey colour. Deep ulcers form later which are not confined to the tonsils
but spread all over the pharynx, oral cavity and larynx. Constitutional
disturbance is grave, and fever is of the septic type.
The blood picture
in such cases will nearly always reveal a drastic decrease and sometimes
nearly complete absence of granular leukocytes, or granulocytes, from the
blood. The number of white cells in the blood drops from between 6,000 and
7,000 to 500 per cu mm and less. In the absence of blood-test evidence this
disease may be mistaken for diphtheria and ulcero-membranous angina.
This exceedingly
grave disease is comparatively rare, and the precipitating causes are still
unknown. It lasts four to five days or up to several weeks and if untreated
frequently proves fatal.
Treatment. This is
by blood transfusion, X-ray irradiation of the bone marrow, drug therapy to
speed up leukocytosis and with pentoxyl given in
Tonsillitis in
Infectious Mononucleosis and Listeriosis
(Angina
monocitotica et listerellosa)
Infectious
mononucleosis is basically a sporadic disease, though, less frequently, it may
occur in epidemics confined to a small community or family. The clinical
picture of this condition was first described by N. F. Filatov in 1885 as
glandular fever characterized by swollen lymph nodes and distinctive changes in
the blood.
Etiology. Recent
clinical and bacteriological studies suggest that this disease is caused by a
virus, Some authorities believe that infectious mononucleosis is a form of
listeriosis caused by bacteria of the genus Listeria (Liste-rella
monocitogenes). This conjecture seems reasonable in view of the similarity that exists between the clinical symp-
toms of infectious mononucleosis and listeriosis. In the former case, the
disease runs a milder course with fewer of the grave complications fairly
common to listeriosis. _ The clinical picture and course. Infectious mononucleosis
occurs mainly in young people between 10 and 30 years °f age and is caused by
droplet infection. The disease has various, sometimes light, clinical forms. In
typical, more frequent, cases, the onset is marked by rigor, headache and a
high fever of 39° to
Tonsillitis in
infectious mononucleosis usually appears on the third or fourth day in a broad
variety of forms. It may be catarrhal, lacunar, and quasi-membranous resembling
diphtheria, as the patches spread over the faucial pillars, uvula and soft
palate. More severe cases may develop into the ulcero-necrotic form with deep
ulceration in the body of the tonsil coated with a greyish-green membrane and
foul odour from the mouth. These changes in the pharynx cause excruciating pain
and considerable enlargement of lymph nodes.
Diagnosis. This is
based on an examination of the blood which makes it possible to differentiate
this condition from leukemia, agranulocytosis, tularemia and brucellosis. The
blood picture shows a moderale leukocytosis (15,000-20,000 with a predominance
of mononuclear cells, which may number 50 to 90 per cent of the total
leukocytes. The red cell count is usually normal.
The disease lasts
two or three weeks, then the fever gradually subsides, local symptoms of
tonsillitis disappear, pain ceases, the spleen shrinks to its normal size and
the swollen lymph nodes gradually diminish to become impalpable. However, the
blood condition rises to normal more slowly.should be avoided. Septic angina
(alimentary toxic aleukia). The onset of this disease is marked by a sudden
fever of 39° to
The anginal stage
is not the onset of the disease and follows food intoxication that has been in
progress for one to three weeks
without any significant signs.
The disease is
caused by cereal food such as millet, wheat, rye, barley, buckwheat, and oats,
that had been left out in the
field during the winter.
Ingestion of this
grain, in particular millet, will cause a bitter taste and a burning sensation
in the mouth, pharynx, esophagus and stomach, as well as numbness in the
tongue. These symptoms are often accompanied by nausea, vomiting, and
headache. Further consumption of this food, however, does not cause a
recurrence of these sensations since the
body seems to become immune.
Yet in other cases,
the absorption of this food for only two or three weeks is followed by
headache, prostration and weakness. Punctate hemorrhage looking like flea bites
appears on the skin. Already at this early period of septic angina, blood
analysis will reveal a progressive reduction in the leukocyte count, viz.,
onset of the period of leukopenia.
Should consumption
of this winter-spoiled grain not be discontinued, and treatment not be started
immediately, then within one, two or three weeks there will be a sudden onset
of septic anginal syndrome. The whitish or yellowish-brown membrane which
appears on the tonsils marks the onset of necrosis which soon, in fact in 24
hours, causes deep ulcers that bleed readily. This ulceration commonly affects
not only the tonsils which soon collapse completely but other aggregations of
lymphadenoid tissue as well, and may extend to the palatine, pharyngeal and
esophageal mucosa and, sometimes, to that of the oral cavity.
Withdrawal of toxic
products from food at the initial period of the disease, prior to the onset of
anginal symp-tomps, may often bring recovery, especially if the total amount of
toxic food eaten has been moderate.
Advanced septic
angina is frequently fatal.
Medical aid for
this condition essentially consists in an early diagnosis of septic angina in
the leukopenic stage, a mass examination of inhabitants of districts where winter-spoiled
grain was used for food and an indispensable analysis of blood to
detect leukopenia.
Treatment. At the
first signs of the disease, toxic products should be immediately withdrawn from
food, and lavage of the stomach undertaken. The patient is then given large
doses of magnesium sulfate or sodium sulfate to cleanse the stomach of toxic
food residue. The diet must be nourishing and rich in proteins and vitamins,
and drink must be given in plenty to help expel toxins from the body. Local
treatment, apart from the use of gargles, and anesthetic ointments, is by
sprinkling the ulcerated surfaces with
streptocide or sulfadimezin powders twice daily.
Intramuscular
penicillin injections and pentoxyl have been used with success. Hemorrhage can
be checked by blood transfusion in 200-300 ml doses and by intravenous
injections of calcium chloride. Cardiac failure may be helped by administration
of camphor, caffeine and strychnine.
Prophylaxis. The
basic means of control of septic angina is prophylaxis by timely and careful
harvesting of all cereals and by making the public understand how dangerous it
is to use winter-spoiled cereals for food. The chemical nature of the poison
responsible has not yet been established, and only its heat resistance is
obvious, since neither cooking, nor boiling or any other culinary treatment of winter-spoiled grain can
reduce its toxicity.
Peritonsillar
Abscess or Quinsy
(Angina phlegmonosa, s. peritonsillitis abscendens)
The peritonsillar
abscess is a fairly common sequel to chronic tonsillitis and, more frequently,
to acute tonsillitis. The infection penetrates from the depth of a tonsil
crypt into the connective tissue bed of the tonsil causing an inflammatory
process which leads to the formation of an abscess.
Symptoms. The
commonest complaint in quinsy is a spontaneously growing pain. The patient who
has just recovered from tonsillitis again feels pain on swallowing, mostly
unilateral and has
a rising fever.
Half of the soft
palate becomes markedly red and increasingly swollen, gradually hiding the
tonsil and pushing the edematous uvula to the opposite side (coloured Table
III, Fig. 2). The pain is more severe than in lacunar or (a) anterosuperior
peritonsillar abscess, (b) posterior peritonsillar abscess Line indicates site of incision follicular tonsillitis, and is
felt even when the patient is motionless.
Peritonsillar
Abscess
It becomes a sharp
shooting pain, frequently radiates to the ear and increases on swallowing,
coughing, or any movement. The mouth is opened with pain and difficulty and
the patient inclines his head towards the sore side. The regional lymphatic
glands on the affected side are often swollen and tender. The almost complete
immobility of the soft palate makes the voice muffled and the swallowing of
food difficult or even impossible.
The abscess forms
in the connective tissue bed of the tonsil, commonly above and before or behind
the tonsil. It may also develop in connective tissue at the lower pole of the
tonsil and anteriorly to it.
In the event of an
anterosuperior abscess the most marked redness is in the soft palate and the
anterior faucial pillar. An abscess behind the tonsil is identified by an
oval-shaped and extremely tender swelling and redness in the posterior pillar,
with the soft palate and the anterior pillar showing no marked changes. The abscess
comes to a head in five to seven days. Its progress is accompanied by a
characteristic throbbing pain and increased infiltration with softening in a
particular place. Frequently the abscess ruptures through the anterior pillar
or drains above through the tonsil. The opening of the abscess between the
anterior pillar and the edge of
the tonsillar capsula is often inadequate for its full evacuation and should
therefore be enlarged to assist recovery.
Diagnosis.
Identification of quinsy involves no special difficulties. Peritonsillar
abscess is commonly preceded by tonsillitis where unilateral redness in the
fauces gradually expands, while swelling and increasing pain with a high-grade
fever serve as another pointer to the genuine cause of the condition.
Treatment. This
depends on the stage of inflammation. In the beginning, at the stage of
infiltration, it may be possible to abort the process by adequate sulfonamide
therapy in a total dose of 3 to
The patient should be
given a diet of warm liquid or gruel. Severe pain may be relieved by aspirin
(with caffeine) given in
The ripe abscess
may often be opened with a blunt probe or bent forceps via the supratonsillar
fossa upon rupturingthe tonsillar capsule. Incision of an anterior peritonsillar
abscess is made in the anterior faucial pillar, 1 to
Opening of
Anterosuperior Peritonsillar Abscess Through Supratonsillar Fossa
Among the
complications of quinsy is hemorrhage due to pus corroding the walls of the
pharyngeal vessels, deep cervical phlegmons, edema of the larynx, and sepsis.
Prophylaxis. Oral
hygiene is extremely important as well as the treatment of chronic tonsillitis,
dental caries and suppurations in the paranasal sinuses. Frequent recurrence
of peritonsillar abscesses necessitates tonsillectomy, i.e. complete excision
of the tonsils three or four weeks after recovery from quinsy.
Where indicated,
however, the presence of a peritonsillar abscess is no obstacle to removal of
the faucial tonsils which, in particular, is a prophylactic against recurrent abscess formation.
Lingual Tonsil
Abscess (periamygdalitis abscendens lin-gualis). Inflammations or injuries of
the lingual tonsil may cause phlegmons at the base of the tongue similar to
phlegmons in the faucial tonsils. In this condition, there is always severe
malaise, high-grade fever, headache, acute pain on swallowing and speaking. At
first, the base of the tongue grows red, swollen and edematous. The edema may
sometimes encroach on the entrance to the larynx and epiglottis and threaten
death by suffocation. The abscess may develop towards a side of the neck
causing tender swelling and redness in the floor of the oral cavity or at the
mandibular angle.
Treatment. This
condition is treated in the same way as
the peritonsillar abscess.
Retropharyngeal
abscess (abscessus retropharyngeal). This abscess is most commonly encountered
in emaciated and weak infants and young children. It arises owing to suppuration
of the lymph nodes lying on the posterior pharyngeal wall in front of the
spinal column, in the so-called retropharyngeal space. The infection enters
here through lymphatic channels from the nasal cavity, sometimes after the
ordinary common cold, or from the oral cavity through fissures and abrasion
caused by improper care of the mouth in babies. In children aged above five or
six years retropharyngeal abscesses are rare because by this age the
prespinal lymph nodes
have usually atrophied.
Symptoms. In small
children the abscess causes a high fever of up to 39-
Treatment. Incision
of the abscess is indicated as soon as the diagnosis is made, in order to avoid
spontaneous rupture with the danger of suffocation by pus suddenly filling the
larynx, especially in sleep, or pneumonia due to pus aspiration into the lower
respiratory tract.
A small incision is
made in the abscess with a scalpel bound with an adhesive plaster
Infiltrative
abscesses must not be opened on the pharyngeal side as there is a danger of
secondary infection and formation of a fistula. They are treated by punctures
and suction followed by infusion of 5 to 10 ml of iodoform emulsion or
streptomycin solution.
Faucial Diphtheria
(Diphtheria
faucium)
Diphtheria is an
acute contagious disease caused by Loeffler's bacillus, whose clinical signs
occur between the second and seventh day of infection. The disease is communicated
either by direct contact wheii the patient sprays sputum particles in cough,
sneezing and talking, or by indirect contact through objects he has handled.
Infection may also be transmitted by recovered and healthy diphtheria
carriers. The disease most commonly affects the fauces and tonsils, and
primarily occurs in children aged between two
and six years.
In breast-fed
babies and adults faucial diphtheria is a comparatively rare phenomenon.
The clinical
picture and severity of the disease varies, and it is, therefore, subdivided
into the localized, diffuse^ toxic
and hemorrhagic forms.
The mild forms,
such as localized diphtheria, may be similar to lacunar or follicular
tonsillitis, the only difference being in body temperature, which is
subfebrile and in adults may often be normal. This condition is characterized
by the formation of a greyish or greyish-white patchy membrane on the
moderately swollen and congested surface of the tonsils and a slight
constitutional disturbance. Pain in the throat is not severe. The submandibular
lymph nodes are only swollen slightly, and the disease may disappear within
three or four days. Usually the individual spots on the tonsils soon merge to
form whitish, greyish-white or, less frequently, yellowish islands which grow
into compact, adherent crusts. The latter may not only occupy the free surface
of the tonsil, but, in the so-called diffuse form, may invade the faucial
pillars and soft palate and often rise above the surface of the mucosa. In the
event of the membrane being stripped
off the tonsil bleeding will ensue.
The severe forms,
otherwise known as toxic, cause a much graver constitutional disturbance with a
nigh fever of 39-
In the hemorrhagic
form of diphtheria, there is hemorrhage in the mucous membranes and on the
skin, while the membranous patches
become saturated with
blood.
In the toxic form,
where edema of cellular tissue spreads down to the clavicle and below, as well
as in the hemorrhagic form, it is not always possible to save the life of a
child patient. In the diffuse form without edema of the cervical cellular
tissue, recovery is certain, if serum treatment was started in time.
It is essential to
distinguish the localized diffuse form of diphtheria from lacunar tonsillitis,
especially when the latter causes extensive membrane formation. To facilitate
differentiation between faucial diphtheria and tonsillitis we have drawn up a
table listing the characteristic symptoms of both diseases (see page 206). In
this scheme each symptom taken separately is not pathognomonic of either
disease, whereas judgement based on the sum total of symptoms available may
help diagnosis in obscure cases.
A high fever
without obvious bodily discomfort is more common in tonsillitis, while a
moderate fever of over 37 to
In tonsillitis, the
membranous patches are more superficial and can easily be removed, whereas in
diphtheria the thicker membranes rise above the mucosal surface and are
difficult to remove. Tonsillitis membranes rarely extend beyond the limits of
the free tonsil surface. Where possible a throat swab should be taken to
ascertain the presence of diphtheria
bacilli.
Treatment. When
verifying the diagnosis and in uncertain cases, an antidiphtheric serum should
be given immediately without waiting for the bacteriologist's report.
The serum is
usually warmed and injected intramuscularly. In the localized form of faucial
diphtheria the serum dose is 5,000-8,000
a.u. (antitoxic units).
In the diffuse
form, the initial dose is 10,000-
In the hemorrhagic
form, the single dose is equal to 40,000-
Babies under one
year and between one and two years of age are given a quarter-dose and
half-a-dose respectively.
To prevent
anaphylactic phenomena, Bezredka's method is recommended whereby 1 ml of serum
is injected one or two hours before administration of the full therapeutical
dose.
Today, a dialysed,
that is protein-free and ferment-processed, serum known as diaferm possessing
antitoxin in an extremely high concentration is used for injection of large
doses of antitoxin. The seroreaction touched off by this serum is the least
possible.
Local treatment for
older children consists in antiseptic gargles of dilute boric acid, borax or
hydrogen peroxide.
In small children,
the mouth is kept clean by spraying or
syringing it with the same solutions or 2 % baking soda solution.
The most serious
complications of diphtheria are lesions of the cardiovascular system
(myocarditis) and symptoms of nephrosis. Therefore, all diphtheria patients
should be strictly confined to bed and given cardiac stimulants, such as
caffeine, camphor, strychnine, etc., as indicated
clinically.
Injection of serum
is sometimes followed in 7 to 12 days by the onset of serum sickness marked by
urticarial rashes, fever and pain in
the joints.
The itching is
relieved with hot baths, administration of calcium chloride, orally or by
intravenous injection, while pain in the joints is allayed with hot-water
bottles and hot compresses.
In some cases,
three to four weeks after recovery, there is temporary paralysis of the soft
palate when liquid food enters the nose
and the voice acquires a nasal
quality.
Mild forms of such
paralysis remit spontaneously, whereas more severe forms are given, where
possible, electrical treatment, as well as arsenic and strychnine drugs
orally, in T-rae Strychni form in doses of as many drops as the child's years
twice or three times daily.
Prophylaxis and
nursing care. The patient with diphtheria should be immediately isolated,
preferably in a hospital.
If hospitalization
is delayed, even for a few hours, the patient should be given the first
injection of antidiphthe-ritic serum on the spot, since early serum administration
is essential for its
efficacy.
Anyone having had
contact with diphtheria patients must have throat swabs taken for
bacteriological examination. They must be isolated and may only leave
quarantine seven or ten days later provided all'clinical symptoms of diphtheria
are absent and the bacteriological tests are negative.
Following his
hospitalization, the patient's flat should be
disinfected.
It should be borne
in mind that diphtheria bacilli may be discharged not only by active carriers
but also by convalescents, who are thus a danger to the community. Their
condition is known as the
bacilli-carrier state.
Eradication of the
bacilli-carrier state is a major problem of diphtheria control. The
development of this condition largely depends on the extent of the child's
debility following a severe illness as well as on the pathological condition
in the nose, pharynx and tonsils, whose treatment must be part of the complex
measures against the bacilli-carrier state. Immediate destruction of the bacilli
is produced by local, intramuscular or combined administration of antibiotics.
The nasal cavity is sprayed with a mixture of penicillin and streptomycin,
preferably in the aerosol form, whereas levomycetin, biomycin, tetracycline and
erythromycin are given orally in three
Since there is no
reliable protection against diphtheria carriers, they must be isolated; in the
case of children they may not attend school, etc., and should be kept in the
open-air as long as possible, until they are bacilli-free. Antiseptic
gargles are also helpful.
The child may be
considered free of the bacilli-carrier state only when this has been proved by
three examinations of nasal and throat swabs taken consecutively at intervals
of a few days.
Diphtheria patients
may be discharged from hospital a week after the disappearance of clinical
symptoms if the bacteriological tests have proved negative. It is extremely
important that information about diphtheria and the measures necessary for its
prevention be made widely known among the general public. The ancillary
personnel must be taught the rules governing the care of a diphtheria patient;
persons in charge of the patient should wash their hands in mercury bichloride
solution, 1 : 1,000, after any contact with him. No one should be permitted to
sit on the patient's bed, visitors should not be admitted, nor should the patient's
utensils be taken from the ward or room. Gauze and cotton wool used to cleanse
the patient's nose and mouth must
be burned immediately.
The patient's
temperature and pulse rate must be carefully watched because weakened heart
activity is the most dangerous symptom in diphtheria. The diet consists of
liquid or gruel-like meals of milk, broth, butter and jelly sufficient in
vitamins, especially, vitamin C, which may be given in ascorbic acid drugs.
CHRONIC INFLAMMATIONS OF THE PHARYNX
Chronic tonsillitis
(tonsillitis chronica). Chronic inflammation of the faucial tonsils, or
chronic tonsillitis, is a frequent disease caused by repeated attacks of acute
tonsillitis in the adult. The morbid process is confined to the tonsillar
crypts or may primarily affect the tonsillar parenchyma.
The squamous
epithelium of the crypts comes off in scales to form fetid caseous masses
plugging the crypts and containing numerous bacteria and leukocytes. Owing to
the expansion of the crypts the tonsils appear porous and spongy, and the
faucial pillars often adhere to the free surface of the tonsils. The crypts
become a most convini-ent place for the retention and propagation of virulent
streptococci and staphylococci whose vital activity keeps up the inflammatory
process in the tonsils. In unfavourable conditions, like chilling or reduced
body resistance, etc., these bacteria may cause exacerbations, such as acute
tonsillitis, peritonsillar abscess and a number of general complications, for
example, infectious polyarthritis, rheumatic
heart, nephritis, etc.
Patients with
chronic tonsillitis often complain of discomfort in the tonsillar area, pain
on swallowing and, sometimes, of bad breath. There may often be the sensation
of a foreign body in the throat and reflex otalgia caused by the pressure of an
increased caseous plug. In cases of frequent exacerbations of chronic
tonsillitis, the regional lymph glands, both submandibular and cervical, are
swol len and tender. Some patients, however, are not conscious of the disease
at all.
Irrigation of
Tonsil Crypts (1) tonsil
crypts, (2) irrigation
cannula
The patient's
history will indicate frequent recurrence of tonsillitis, peritonsillar
abscesses, or complications in the form of constitutional diseases immediately
consequent upon tonsillitis. Chronic tonsillitis may produce a prolonged slight
fever setting in at night for five or six months and longer as well as a
constitutional disturbance manifest in apathy, inability to work,
headache, etc.
Consideration of
complaints and anamnestic data is not enough for a final judgement; careful
examination of both tonsils is necessary to verify the diagnosis.
Treatment. This may
be conservative or surgical. The former is by painting the tonsillar crypts
with a 5% solution of iodine tincture, trichloracetic acid, 1% Lugol solution
or 1-3% silver nitrate solution. If carried out regularly, this procedure
frequently causes the tonsils to shrink and stops plug formation. Similar
results may be obtained by regular irrigation of the tonsillar crypts with 4%
boric acid or penicillin solution,
etc. (Fig. 80).
Good results are also obtained
sometimes by dissection of the tonsillar crypts with a galvanocauter or a
blunt-pointed curved knife followed by removal of tissue tags with a
conchotome.
Complete excision
of the tonsils is indicated in a frequently recurring peritonsillar abscess
and tonsillitis, especially when the latter is liable to cause such
complications as rheumatic heart, nephritis, etc. This operation, known as
tonsillectomy, comprises the complete enucleation of the tonsils in their
capsules. In nearly all cases, tonsillectomy is a reliable method to prevent
relapses of tonsillitis.
The operation is
made under local anesthesia at an impatient clinic. This operation is
contraindicated in subjects with a hemopoietic disease or poor blood clotting.
Instruments Used in
Tonsillectomy
(1) grasping
forceps to engage tonsil; (2) elevator for separation tonsil; (3) tonsil snare
Immediately after
the operation, the patient should be carefully watched, because of the likelihood
of postoperative hemorrhages. The patient is forbidden to swallow and
instructed to spit saliva into a basin or towel. The patient should refrain
from taking food, at least for the first 8 to 12 hours after the operation.
In the early
postoperative period, the patient is given a cool and bland diet of milk,
broth, jelly, and half-liquid gruels. Naturally, the diet should contain
vitamins in plenty.
Chronic pharyngitis
(pharyngitis chronica). Chronic diseases of the pharyngeal mucosa occur in the
catarrhal, hypertrophic and atrophic forms. Their etiology may be of local
and systemic character. The former refers to chronic rhinitis, suppuration in a
paranasal sinus, chronic tonsillitis, etc. The latter refers to metabolic
disturbances and stasis in the venous system in diseases of the heart,
lungs, liver and kidneys.
Another important
cause is unfavourable climate and occupational hazards presented by dry air,
drastic temperature changes and dirty surroundings found in various industries,
such as cement plants, porcelain factories, flour mills, etc. Vapour and gases
in the chemical industry as well as the constant abuse of tobacco and alcohol
may have a pernicious effect on the pharyngeal mucosa.
Symptoms. In the
atrophic form of chronic pharyngitis, there is a sensation of tickling,
scratchiness and dryness in the throat. In the hypertrophic form, the basic complaint
is one of a large accumulation in the nasopharynx ot tenacious mucous secretion
which causes much coughing and expectoration, especially in the morning, when
it may be accompanied by retching and sometimes vomiting.
In the hypertrophic
form, the mucosa is red and thickened, and the posterior pharyngeal wall is
covered with a sticky mucopurulent secretion which trickles down through the
nasopharynx. In the atrophic form, however, the mucosa is dry and glazed as
though covered with a thin film of varnish. Sometimes, it is covered with a
viscid, almost dry mucus or crusts which are hard to remove even if a medication
has been applied.
The lymphoid structures of the mucosa often
respond to chronic irritation with a marked hyperplasia of individual
follicles exhibited as red granules scattered over the posterior pharyngeal
wall and symptomatic of granular pharyngitis. Sometimes there is hypertrophy of
adenoid tissue embedded in the lateral pharyngeal folds, which in this case are
seen as prominent bright-red and thick bands behind the posterior faucial
pillars. This condition is known as
lateral pharyngitis.
Treatment. The
first essential is to eliminate the basic cause of the condition.
Local treatment of
the mucosa comprises the removal of the adherent secretion and alleviation of
irritation by frequent throat irrigations with warm alkaline solutions of baking
soda, borax and weak, 0.5-1%, saline solutions. For their prescriptions see the
section on atrophic rhinitis.
The following
gargles are also recommended:
Rp. Natrii benzoici
Natrii biborici
Natrii bicarbonici aa
DS. Half a
teaspoonful in a glass of warm water
for a gargle
Rp. Natrii benzoici 3.0
T-rae Opii simplicis gtt. XX
Aq. Amygdalarum
amararum 2.0
Glycerini 10.0
Aq. Menthae 50.0
Aq. destill. 200.0
MDS. To be used as a warm gargle three or four times
daily, or bicarmint is prescribed
in one or two lozenges in half a glass of water for a
gargle
In the event of
copious secretion, mildly antiseptic and styptic gargles are used two or three
times daily. For this a tablespoonful of camomile or a teaspoonful of sage
leaves, which have a stronger styptic effect, are steeped in a glass of boiling
water. The tea thus prepared is strained and used as a gargle while being warm.
Warm irrigation has a soothing effect on the mucosa and keeps down hypersensitivity and
unpleasant sensations in the
throat.
The porous and
hypertrophied mucosa is shrunk by painting it with l%-2%-3%-5% silver nitrate
solution once in every two or three days. In the atrophic form, 1%
iodine-gly-cerol or 1 % menthol solution in liquid petrolatum are used after a
preliminary application of alkaline
gargles.
Pharyngomycosis
(pharyngomycosis benigna s. leptothri-cia).
This disease is
marked by hornification of the squamous epithelium of adenoid tissue. There are
white or creamy plaques or thorn-like excrescences found on the unchanged
tonsillar surface as well as on the lateral folds of the posterior pharyngeal
wall and at the base of the tongue. These pointed or round, as though
calcareous, excrescences markedly protruding above the mucosal surface are
firmly adherent to their beds. The thorns harbour numerous organisms of the
fungus Leptothrix buccalis.
Symptoms-
Leptothrix lesions are usually symptomless and are detected only by chance or
when they cause a slight pricking sensation. Though this condition is stubborn
and resists treatment, it entails no serious complications. Pharyngomycosis is
very often mistaken for lacunar tonsillitis.
Treatment. This has
been of little effect so far. The common methods are electric cauterization or
regular application to the excrescences of 5% iodine tincture, the use of
alkaline gargles with an addition of five drops of iodine in a glass of water,
as well as oral iodine in doses of five drops repeated for two or three weeks.
Frequently the lesions heal of
their own accord.
BENIGN TUMOURS OF THE PHARYNX
Benign pharyngeal
tumours which grow as pedunculated papillomas and fibromas from the pillars or
soft palate are not dangerous.
Treatment. The
tumour is removed by surgery.
Nasopharyngeal
fibroma. The nasopharyngeal fibroma is a special type of tumour which occurs
almost exclusively in males between the age of 8 to 13 years and in full
puberty, i.e. from 20 to 25 years, when the tumour, if still present, begins to
shrink.
The essential element of a nasopharyngeal fibroma is
dense connective
tissue containing a great number of elastic fibres and blood capillaries. The
tumour is histologically benign, but for its clinical course marked as it is
by irresistible growth and destruction of the surrounding tissue,
postoperative relapses and frequent copious hemorrhages endangering the
patient's life, it may sooner be classified
as a malignant neoplasm.
Symptoms. The
initial clinical symptom is unilateral nasal obstruction. After four to six
months full nasal obstruction occurs as well as more or less marked complications
in the ear. In advanced cases with a rapid growth of the tumour it causes the
eye, as well as the soft and hard palates to bulge, swells out the nose, etc.
Repeated nasal hemorrhages at the very onset of the disease weaken the patient
and aggravate his condition still further.
Diagnosis. The
tumour is recognized easily. Anterior rhinoscopy usually reveals a red, smooth
tumour filling one side of the nose and bleeding readily on probing. When
examining the pharynx, a swelling in the soft palate with the edge of a pink,
smooth tumour often showing from behind it can be seen. The tumour differs
from a choanal polyp by its greater density and broad area of attachment.
Treatment. The
treatment is by surgery. The operation is rather difficult because of the deep
position of the tumour, its firm adherence to the basal tissue and severe
hemorrhage. Small tumours located in the nasopharynx are removed via the nose
or mouth.
In neglected cases
where the tumour invades the zygomatic area and paranasal sinuses the removal
is performed only after a preliminary operation has been undertaken to provide
access to the tumour proper. This access may be obtained through the antrum of Highmore
with complete removal of the lateral nasal wall. Recently surgical diathermy
has been successfully used to remove the tumour. Radiotherapy, particularly
X-rays, is sometimes also effective.
MALIGNANT TUMOURS
OF THE PHARYNX Cancer of the nasopharynx. This disease is frequently met with
after 40 years of age, in younger subjects it is far less requent. The symptoms
of malignant nasopharyngeal tumours
should be sought in the progress of the tumour and the functional disturbances
attending this progress, particular attention being paid to the initial stages
of their development.
According to the
primary site of origin the initial symptoms of the tumour may be associated
with the following phenomena: (1) otalgia and hearing disorders due to tumour growth
beside the Eustachian tube which occurs in six out of every ten cases; (2)
nasal obstruction caused by tumour growth in the choanae; (3) neuralgia and
paralysis when the tumour grows upwards and presses on the cra-nio-cerebral
nerves. These symptoms are absent in some cases, and the first morbid signs,
therefore, may be "lymphadenitis" in the neck and submandibular
region caused by metastases into the nearest lymph nodes. Metastases into the
cervical lymph nodes are especially early in lymphepithelial tumours.
At first, the
patient complains of gradual obstruction of one and then of both sides of the
nose. Blowing the nose expels secretion containing blood filaments and sometimes
causes nasal hemorrhage or pyoichorous nasal discharge. The patient is usually
late in resorting to medical aid. Examination of the nasopharynx by posterior
rhinoscopy and palpation with the finger, which is quite indispensable in such
cases, will reveal a large or small knobby mass which often disintegrates,
bleeds on palpation and merges evenly into the surrounding tissue.
Early diagnosis and
correct X-ray treatment of malignant nasopharyngeal tumours improve their
outlook, formerly quite hopeless. Recovery may be facilitated by stimulation
therapy with repeated blood transfusions in fractional doses, whereas the use
of leukopenia-preventive drugs, such as pentoxyl, campolon, etc., permits an
adequate dose of irradiation to be administered to cases which until recently
were regarded as
incurable.
Malignant tumours
in the middle and lower pharynx. A malignant tumour in the form of a dense
knobby infiltration, which very easily ulcerates due to its traumatic
irritation by the passage of food, may develop on the soft palate, tonsils
(Fig. 82), posterior and lateral walls of the pharynx or in its lower
portions, namely, the pyriform sinuses. With the onset of ulceration in the
tumour, it begins to ache, grows in size and interferes with the passage of
food. There are early metastases to the nearest lymph glands in the neck and at
the base of the skull.
Surgical removal of
these tumours from healthy tissue is often belated and its outcome may,
therefore, be unfavourable. New hope has been given by X-ray and radium or
radio cobalt therapy after a preliminary ligation of the external carotid
artery. This treatment sometimes arrests the growth of the tumour for a long
time and so delays the fatal outcome.
Lymphosarcoma of
the tonsils occurs more frequently than other kinds of pharyngeal sarcoma, and
mostly in young people.
ACUTE LARYNGITIS
(Laryngitis acuta)
Acute laryngitis is
most commonly found in acute catarrh of the upper respiratory tract. The
disease is often associated with total or partial chilling of the body. It may
also be caused by inhalation of acrid vapours, very dirty air, as well as by
overexertion of the vocal cords, such as in prolonged and loud talking.
Laryngeal inflammation may also be the result of highly contagious diseases, such as measles, scarlet fever and typhoid.
Course and
symptoms. Laryngoscopy reveals diffuse hyperemia of the laryngeal mucosa, more
or less markedly swollen and congested true vocal cords, and clots of viscid
secretion. Phonation sometimes fails to produce complete approximation of the
vocal cords due to paresis of the vocal muscles. According to the degree of the
laryngeal lesion the voice becomes hoarse and rough with cough, dry at first
and accompanied by a feeling of dryness and burning in the throat. The scanty
sputum, which is hard to expectorate, gradually grows in quantity, whereupon it
may be expectorated with ease producing a marked amelioration in
the patient's general
condition.
The general feeling
of illness is sometimes combined with headache and a slight fever. The disease
commonly persists for only seven to ten days and passes quickly if
treatment is adequate.
Treatment. The
basic remedy is to remove the harmful factors which have provoked the onset of
the disease. The patient must give his larynx complete rest by speaking as
little as possible for five to ten days depending on the severity of the case.
He is advised at first to inhale penicillin aerosols and then proceed with
alkaline inhalations a few times daily and a hot compress on the neck.
The following
prescriptions may also be recommended:
Rp. Cocaini
hydrochlorici 0.1
Aq. Amygdalarum
amararum 4.0
Glycerini puri 6.0
Aq. Menthae 50.0
Aq. destill.
150.0
MDS. For
steam inhalation
If a vaporizer is
not available, the following prescription may be used for inhalation:
Rp. Mentholi crystallisati 1.0 Spiritus vini rectificati
10.0
MDS. Ten to twenty drops in a glass of boiling
water for steam inhalation
Febrifuges and
narcotics, such as codeine powder, are given for fever and cough, and mixtures are
used to promote expectoration.
Codeine or dionin
may be used in drops or solution together with bromine drugs.
Id case of marked
dryness of the mucosa and dry crusting, oily solutions are applied to the
larynx, such as:
Frequent
ventilation of the room and clean fresh air assist speedy recovery.
Prophylaxis. See
section on prevention of diseases of the upper respiratory tract.
CHRONIC LARYNGITIS
(Laryngitis
chronica)
Chronic laryngitis
follows repeated acute attacks. Furthermore, chronic laryngeal inflammation
may be due to irremovable factors which cause acute laryngeal catarrh present
in habitual alcoholics and inveterate smokers. Occupational laryngeal catarrh
is often met with among singers, teachers and people who work in dusty surroundings
or are^ exposed to chemical hazards. Long-continued inflammations in the upper
airways, such as chronic coryza, paranasal sinus suppuration, tonsillitis,
pharyngitis, etc., as well as in the lower portions of the respiratory tract,
such as tracheitis, purulent bronchitis, may cause a chronic inflammation of
the larynx.
Symptoms. These are
similar to those of acute laryngitis, though somewhat milder. At times, there
is exacerbation and aggravation of the condition in the affected area. The
patient complains of
hoarseness which grows
worse at
Rp. Sol Argenti nitrici 1-2-3% 10.0
MDS. For laryngeal painting Rp. Tannini 1.01
Glycerini 10.0
MDS. For laryngeal painting
Inhalation of
alkaline vapours of baking soda and natrium benzoicum solutions are used, as
well as iodine-glycerol given for atrophy and crusting.
Apart from painting
the larynx with iodine-glycerol, infusions of an aqueous iodine-glycerol
solution are also helpful, and their effect is somewhat milder. The formula of
this solution is as follows:
Rp. Jodi puri 0.15
Kalii jodati 1.0
Aq. destill.
Aq. Menthae a 100.0
Glycerini 10.0 MDS.
For laryngeal
infusion
Inhalations are
given a few times daily with special instruments described above. If these are
not available, two or three glassfuls of boiling water should be poured into a
basin and the steam inhaled through a make-shift paper tube for two or three
minutes a few times daily. Penicillin is an effectual remedy against
exacerbations of chronic laryngitis.
Prophylaxis. To
ward off this disease, one should avoid' a sudden exposure of the larynx to
cold upon leaving a heated room, abstain from singing and loud talk in the
frost after a hot bath as well as from continual straining of the voice in dry
and dusty surroundings, particularly in the absence of nasal breathing.