Chapter 32

THE NOSE AND NASO-PHARYNX[6]

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

[6] Revised by Dr. Logan Turner.

#Fracture of the Nasal Bones and Displacement of the Cartilages.#--These injuries are always the result of direct violence, such as a blow or a fall against a projecting object, and in spite of the fact that the fracture is usually compound through tearing of the mucous membrane, infective complications are rare. The fracture usually runs transversely across both nasal bones near their lower edge, but sometimes it is comminuted and involves also the frontal processes of the maxillae. In nearly all cases the cartilage of the septum is bent or displaced so that it bulges into one or other nostril, and not infrequently a haematoma forms in the septum (p. 573). Sometimes the perpendicular plate of the ethmoid is implicated, and the fracture in this way comes to involve the base of the skull. The nasal ducts may be injured, obstructing the flow of the tears, and a lachrymal abscess and fistula may eventually form.

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

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

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

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

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

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

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

In reconstructing the nose it is necessary to provide skin, a supporting structure in the form of cartilage or bone, and an epithelial lining. In the "Indian operation" a racket-shaped flap, including skin and periosteum, is turned down from the forehead and fixed in position, the edges of the flap being inturned to provide a lining for the passage. An implant of free cartilage may be necessary to support the skin flaps and to prevent subsequent contraction. Flaps of skin may be formed by Gillies' tube-pedicle method from the cheek, the forehead, or the neck, and utilised to form the covering of the nose. When the deformity cannot be corrected by operation, the appearance may be greatly improved by wearing an artificial nose held in position by spectacles.

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

The treatment consists in paring away the protuberant masses until the normal size and contour of the nose are restored, care being taken not to encroach on the cartilages or on the orifices of the nostrils. There is comparatively little bleeding, and the raw surface rapidly becomes covered with epidermis.

#Examination of the Nasal Cavities.#--For the examination of the interior of the nose the following appliances are necessary: A reflector, such as is used in laryngoscopy, attached to a forehead band or spectacle frame; one of the various forms of nasal speculum; a long, pliable probe; a tongue depressor; and a small-sized mirror. As additional aids, a 10 per cent. solution of cocain, a grooved probe as a cotton-wool holder, and a palate retractor should be in readiness. Good illumination is important, and may be obtained from an electric light, or from a Welsbach or Argand burner. The light should be placed close to, and on a level with, the patient's left ear. Both the anterior and posterior nares should be examined.

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

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

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

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

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

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

_Erectile swelling_ of the inferior turbinated bodies is due to engorgement of the venous spaces contained in the mucous membrane. Obstruction from this cause is usually intermittent in character, and may be unilateral or bilateral. It is influenced by posture, being worse when the patient is in the horizontal position, and also by changes in atmospheric conditions and temperature. It is characterised objectively by a swelling of the mucous membrane, which is pink or red in appearance and of a soft consistence, pitting when touched with the probe, and shrinking on the application of a 5 per cent. solution of cocain. Its soft consistence and the fact that it becomes smaller when painted with cocain differentiate it from true hypertrophy of the mucous membrane. Its situation and immobility, its pink colour, and the shrinkage under cocain, distinguish it from the mucous polypus of the nose. The turgescence may involve the whole extent of the mucosa of the inferior turbinated bodies, including their posterior ends. After anaesthetising with cocain, the electric cautery, or fused chromic acid applied on a probe, may be employed for the relief of the condition. If a true hypertrophy exists, it is better to remove it with a nasal snare.

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

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

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

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

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

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

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

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

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

#Epistaxis.#--Bleeding from the nose may be due either to local or to general causes. Among the former may be cited injuries such as result from the introduction of foreign bodies, blows on the face, and fractures of the anterior fossa of the skull, and the ulceration of syphilitic, tuberculous, or malignant disease. Amongst the general conditions in which nasal haemorrhage may occur are typhoid fever, anaemia, and purpura cardiac and renal disease, cirrhosis of the liver, and whooping-cough. Prolonged oozing of blood may be an evidence of haemophilia. Nasal haemorrhage usually takes place from one or more dilated capillaries situated at the anterior inferior part of the septum close to the vestibule, and in such cases the bleeding point is readily detected. Occasionally bleeding occurs from one of the anterior ethmoidal veins, and under these circumstances the blood flows downwards between the middle turbinal and the septum. Before steps are taken to arrest the bleeding, the interior of the nose should, if possible, be inspected and the bleeding point sought for. As a preliminary to the use of local applications, the nose should be washed out with boracic lotion or salt solution to remove all clots from the cavity. In many cases this is all that is necessary to stop the bleeding. If the bleeding is not very copious, it may be stopped by grasping the alae nasi between the finger and thumb, or by spraying the nasal cavity with adrenalin. If the blood is evidently flowing from the olfactory sulcus, a strip of gauze soaked in adrenalin, turpentine, or other styptic should be packed between the septum and middle turbinated body. If recurrent haemorrhage takes place from the anterior and lower part of the septum, the application of the electric cautery at a dull red heat, or of the chromic acid bead fused on a probe, is the best method of treatment. Plugging of the posterior nares is rarely necessary, as, in the majority of cases, an anterior plug suffices. In bleeders, the administration of sheep serum by the mouth has proved efficacious.

#Suppuration in the Accessory Nasal Sinuses.#--As already stated, the presence of pus in the nose should always direct attention to its possible origin in one or more of the accessory sinuses, especially if the discharge is unilateral. The condition is usually a chronic one, and may be present for months, or even years, without the patient suffering much inconvenience save from the presence of the discharge.

If on examination by anterior rhinoscopy, pus is seen in the middle meatus, suspicion should be aroused of its origin in the maxillary sinus, frontal sinus, or anterior ethmoidal cells, as all these cavities communicate with that channel. If, on the other hand, the pus is detected in the olfactory sulcus, attention must be directed to the posterior ethmoidal cells and sphenoidal sinus (Fig. 267). Further evidence of its source in the last-named cavities may be gained by finding pus in the superior meatus above the middle turbinal on examination by posterior rhinoscopy.

As the anterior group of sinuses is most frequently affected, and of these most commonly the _maxillary sinus_, attention should first be turned to this cavity. Pain, tenderness on pressing over the canine fossa or on tapping the teeth of the upper jaw, and swelling of the cheek are rarely met with save in acute inflammation. The complaint of a bad odour or taste, the reappearance of pus in the middle meatus after mopping it away and directing the patient to bend his head well forwards, and opacity on trans-illumination of the suspected cavity, are signs which strongly suggest an affection of the maxillary sinus. The withdrawal of pus by a puncture through the thin outer wall of the inferior meatus of the nose with a fine trocar and cannula will establish the diagnosis.

The _treatment_ consists in opening and draining the sinus. If the infection is due to a carious tooth, this should be extracted, the socket opened up and drainage established through it in recent cases. If the teeth are sound, and the case is of long duration, the sinus is opened through the canine fossa and its walls curetted. To avoid the risk of reinfecting the cavity from the mouth, an opening may be made into the nose by removing a portion of the nasal wall of the sinus and part of the inferior turbinated bone, after which the incision in the buccal mucous membrane is closed with sutures.

Suppuration in the _frontal sinus_ is attended with frontal headache, vertigo, especially on stooping, and tenderness on pressure, particularly over the internal orbital angle, or on percussion over the frontal region. Pus escapes into the middle meatus of the nose, and if wiped away will reappear if the head is kept erect for a few minutes. After removal of the anterior end of the middle turbinated bone, it may be possible to catheterise the sinus and wash out pus from its interior. The diseased sinus may present a darker shadow than the healthy one on trans-illumination, or in an X-ray photograph.

The _treatment_ consists in exposing the anterior wall of the sinus, chiselling away sufficient bone to admit of free removal of all infected tissue, and establishing efficient drainage through the infundibulum (Fig. 267) into the nose.

The _anterior ethmoidal cells_ (Fig. 267) are frequently affected in conjunction with the frontal, and sometimes with the maxillary sinus. The presence of polypi and granulations, with pus oozing out from between them, and increasing after withdrawal of the probe, and the detection of carious bone are significant of ethmoidal suppuration.

The _treatment_ consists in extending the operation for the frontal or maxillary sinus so as to ensure drainage of the ethmoidal cells.

_Suppuration in the sphenoidal sinus_ (Fig. 267) is characterised in many cases by the presence of eye symptoms. Pus in the olfactory sulcus, on the upper surface of the middle turbinal posteriorly, and on the vault of the naso-pharynx, is suggestive of sphenoidal suppuration. The removal of the middle turbinated bone permits of inspection of the ostium sphenoidale by anterior rhinoscopy, and pus may be seen escaping from the orifice. A probe is then passed into the ostium, and the anterior wall of the sinus is removed with a curette or rongeur forceps.

The _posterior ethmoidal cells_ (Fig. 267) are frequently affected along with the sphenoidal sinus. The nasal appearances just noted are present, and if the sphenoidal sinus can be washed out and its ostium temporarily plugged, and pus rapidly reappears, its origin from these cells is probable. The operation for draining the sphenoidal sinus is extended by removing the inner wall of the posterior ethmoidal cells.

#Anomalies of Smell and Taste.#--_Anosmia_ or loss of smell and impairment or loss of the sense of recognising flavours may follow fracture of the anterior fossa attended with injury of the olfactory nerves, and is a common sequel of influenza. Any lesion that prevents the passage of the odoriferous particles to the olfactory region of the nose interferes with the sense of smell. In ozaena also the sense of smell is lost. _Parosmia_, or the sensation of a bad odour, may be of functional origin; it sometimes occurs after influenza. It may also be associated with maxillary suppuration.

#Reflex Symptoms of Nasal Origin.#--It is only necessary here to draw attention to the relation that exists between affections of the nose and asthma. When present in asthmatic subjects, nasal polypi, erectile swelling of the inferior turbinated bodies, spines of the septum in contact with the inferior turbinal, or areas on the mucous membrane which, when probed, produce coughing, call for treatment with the object of modifying the asthma.

#Post-nasal Obstruction--Adenoid Vegetations.#--The most common cause of post-nasal obstruction is hypertrophy of the normal lymphoid tissue which constitutes the naso-pharyngeal or Luschka's tonsil. _Adenoids_ form a soft, velvety mass, which projects from the vault of the naso-pharynx and extends down its posterior and lateral walls, in some cases filling up the fossae of Rosenmueller behind the Eustachian cushions. They do not grow from the margins of the posterior nares. Adenoids are frequently associated with hypertrophy of the faucial tonsils, and the patient often suffers from granular pharyngitis and chronic nasal catarrh.

These growths are sometimes met with in infants, but are most common between the ages of five and fifteen, after which they tend to undergo atrophy. They may, however, persist into adult life.

_Clinical Features._--The most prominent symptom in most cases is interference with nasal respiration, so that the patient is compelled to breathe through the mouth. The facies of adenoids is characteristic: the mouth is kept partly open, the face appears lengthened, the nose is flattened by the falling in of the alae nasi, the inner angles of the eyes are drawn down, and the eyelids droop, while the whole facial expression is dull and stupid. As the respiratory difficulty is increased during sleep, the patient snores loudly, and his sleep is frequently broken by sudden night terrors. Owing to the disturbed sleep, to imperfect oxygenation of the blood, and to frequent attacks of nasal and bronchial catarrh, the child's nutrition is interfered with, and he becomes languid and backward at his lessons.

When the adenoids encroach upon the Eustachian cushions, the patient suffers from deafness, frequent attacks of earache, and sometimes from suppurative otitis media with a discharge from the ear.

Among the rarer conditions attributed to adenoids are asthma, inspiratory laryngeal stridor, persistent cough, chorea, and nocturnal enuresis.

A _diagnosis_ should never be made from the symptoms alone; an attempt must be made to examine the naso-pharynx by posterior rhinoscopy and by digital examination. The interior of the nose must always be examined and any further cause of obstruction excluded.

_Treatment._--Thorough removal is the only satisfactory line of treatment, and this should be done under general anaesthesia. The following instruments are necessary: two Gottstein's adenoid curettes, one provided with a cradle and hooks, the other without, a Hartmann's lateral ring knife, and one pair of adenoid forceps--Kuhn's or Loewenberg's--a tongue depressor, a gag, and one or two throat sponges on holders. The patient having been anaesthetised, his head should be drawn over the end of the table. An assistant standing on the left side inserts the gag and maintains it in position. The operator, being on the patient's right, depresses the tongue and insinuates the curette provided with the hooks behind the soft palate, carrying it to the roof of the naso-pharynx between the growth and the posterior free edge of the nasal septum. Firm pressure is then made against the vault of the naso-pharynx, and the curette is carried backwards and downwards in the mesial plane and withdrawn with the main mass of the adenoids caught in the hooks. The unguarded curette is then introduced and several strokes are made with it, the instrument being carried on either side of the mesial plane. With Hartmann's lateral ring knife the posterior naso-pharyngeal wall and fossae of Rosenmueller are curetted. The curette should not be used on the lateral pharyngeal wall in case the Eustachian orifices and cushions are damaged. Bleeding soon ceases when the head is again elevated, and the patient should be at once laid well over upon his side so that the blood may escape from the mouth.

No local after-treatment is required, and spraying or syringing may prove harmful. The patient should remain in the house for five or six days. If nasal obstruction has been the outstanding symptom, respiratory exercises through the nose should be carried out for some considerable time; on the other hand, if Eustachian obstruction and deafness have been the main features of the case, a course of Politzer inflation should be conducted after the wound has healed.

#Tumours of the Naso-Pharynx.#--Tumours are occasionally met with growing from the muco-periosteum of the basi-sphenoid and basi-occipital, and projecting from the vault of the naso-pharynx--_naso-pharyngeal tumour_ or retro-pharyngeal polypus. This usually occurs between the ages of fifteen and twenty, and while it may originally be a fibroma, it tends to assume the characters of a fibro-sarcoma and to exhibit malignant tendencies. At first the tumour is firm, rounded, and of slow growth, but later it becomes softer, more vascular, and grows more rapidly, spreading forwards towards the nasal cavity and downwards towards the pharynx.

_Clinical Features._--In its growth the tumour blocks the nostrils, and so interferes with nasal respiration and causes the patient to snore loudly, especially during sleep. It may also bulge the soft palate towards the mouth and interfere with deglutition. In some cases the face becomes flattened and expanded and the eyes are pushed outwards, giving rise to the deformity known as _frog-face_. Deafness may result from obstruction of the Eustachian tube. The patient suffers from intense frontal headache, and there is a persistent and offensive mucous discharge from the nose. Profuse recurrent bleeding from the nose is a common symptom, and the patient becomes profoundly anaemic. The tumour can usually be seen on examination with the nasal speculum or by posterior rhinoscopy, and its size and limits may be recognised by digital examination.

Unless removed by operation these tumours prove fatal from haemorrhage, interference with respiration, or by perforating the base of the skull and giving rise to intra-cranial complications.

_Treatment._--These growths are seldom recognised before they have attained considerable dimensions, and owing to the fact that they are permeated by numerous large, thin-walled venous sinuses, their removal is attended with formidable haemorrhage. Attempts to remove them by the galvanic snare are seldom satisfactory, because the base of the tumour is left behind and recurrence is liable to take place. The operative treatment is described in _Operative Surgery_, p. 153.