SURGICAL TREATMENT OF NASO-PHARYNGEAL

CATARRH.

By D. H. GOODWILLIE, M.D., D.D.S.,

NEW YORK.

Or the etiology of naso-pharyngeal catarrh, I desire only to say in reference to those cases that shall occupy our attention at this time, that their history, in many instances, commences in early life, even in infancy. Particularly is this the case in deviations and exostosis of the nasal septum.

The sides of each nasal fossa contain the three turbinated. bones, and throw the mucous membrane that covers them into folds, so that in a small space a large amount of mucous surface is exposed a wise provision for tempering and cleansing the air that passes over it to the lungs. Experiments have shown that air respired through the nose is raised in temperature two degrees higher than that respired by the mouth.

Respired air must pass through both the nostrils alike to produce a healthy respiration.

In the same proportion that respiration is prevented through the nose, the gateway to the lungs, will there be catarrhal conditions of the upper air passages, and in many cases reaching the lungs ultimately.

Of the passages through the nostrils the inferior meatus is the most important, as it is the chief respiratory passage for air and for the carrying off, in a great measure, the nasal secretions. For the latter purpose it is lined with ciliated columna epithelium. The mucous membrane is quite vascular, and consequently subject to very sudden engorgement.

I do not propose to say anything respecting catarrhal conditions that require medical treatment only, but shall speak of such cases as have passed that point, and can only be relieved by surgical interference.

Some of the pathological conditions requiring surgical treat

ment, to which I desire at this time to call attention, are the following, viz.:

1. Exostosis. 2. Deviated nasal septum. 3. Hypertrophy of the erectile cavernous tissue on the turbinated bones. 4. Polypi. 5. Necrosis from struma or syphilis. 6. Chronic antrum disease. Chronic maxillary abscess from tooth disease.

7.

The time allotted me will only suffice for the consideration of some of these, which I will endeavor to illustrate by a few cases and by means of diagrams and wax models.

Exostosis of the turbinated bones is not so frequent as are exostoses in the vomer when associated with deviated septum. Such growths are attended usually by pains of a neuralgic character; they prevent respiration, and by pressure cause sloughing and necrosis of adjacent parts.

Exostosis with deviations of the septum is of more common occurrence. Wherever the vomer takes a sharp deflection there is often found an exostosis on the convex side just at the greatest part of the curve. When this occurs along the line and into the inferior meatus, as it more often does, it gives a great deal of catarrhal trouble by preventing free respiration and the passage outward of the nasal secretions, which not being changed by a free respiration become fetid by decomposition.

Deviations of cartilaginous septum are quite numerous-curves in between the bony septum and the columna in many directions. Dislocation of the lower end of the septum with displacement of the nasal spine also produces abnormal respiration.

Hypertrophy of the erectile cavernous tissue covering the inferior turbinated bones.-Some years ago Dr. Henry J. Bigelow, of Boston, in an article in the Boston Medical and Surgical Journal for April 29, 1875, stated that he had found "a remarkable and well-formed cavernous structure at least upon the middle and inferior turbinated bones. The difference in size of the distended and collapsed cavernous bodies is quite striking, and is best seen upon the inferior turbinated. Collapsed, the outline and dimensions are nearly those of its attenuated bony framework. Distended, it becomes an angry, turgid mass of uneven surface and livid color, completely closing the lower nostril. A pouch-like dilatation projects from the rear of the bone, increasing its length, and, with the aid of a blowpipe, readily showing on section to the naked eye cavernous cells. It is this reticulated pouch that is seen with the mirror at the back

of the nares. Above is seen the middle turbinated mass similarly distended, and if the injection of the whole membrane is considerable, the nasal septum also swells to nearly the thickness of one-quarter of an inch. If inflated and dried, the cells project upon the surface. A section gives further evidence of a cavernous structure with closely juxtaposed cavities tolerably uniform in size and equally distributed, approaching quite nearly both the mucous surface and the bone. They communicate by irregular apertures while minute bands or septa traverse and connect their common walls.

"A wet microscopic section exhibits thin trabecule and walls, composed mainly of connective tissue, presenting cavities of unequal dimensions, and closely resembling the cavernous structure of the penis; although the smooth muscular elements, as also the tunica albuginea of the latter, are somewhat more pronounced, as might be anticipated from the comparative erectile tension of this organ."

I pass around for your inspection two wax models of cleft palates, showing the extensive hypertrophy of the tissues covering these bones. When fully erected, they entirely fill up the cleft. In one will be observed this condition, while in the other there is a state of non-erection.

By experiment made on them, I found that anything that would excite the salivary and muciparous glands to increased action caused an erection of this hypertrophied erectile tissue. When the exciting cause was removed, after a short time it receded.

This erection and collapse is a physiological fact in the normal condition, and is intended to purify the tidal air passing in respiration from all impurities, and so protect the pulmonary organs against disease. The hairs in the vestibule of the nostrils and this erectile tissue are faithful sentinels to arrest impurities in the respired air.

By a constant irritation of this erectile tissue by impurities in the respired air, by a mechanical irritation caused by a constant and forcible blowing of the nose in chronic catarrh, the effect of which is felt on the anterior part of the inferior turbinated bone just within the vestibule, a hyperplasia is thereby set up, which results in so thickening this tissue that normal respiration is very much interfered with, and, in some cases, entirely

prevented. To the above causes may be added, in many cases, a constitutional predisposition to catarrhal diseases.

Treatment of exostosis of the turbinated bones, when large, consists in drilling the enlargement at its base by means of the surgical engine, when it may be removed with the nasal forceps. (See Fig. 1.)

Fig. 1.

Cutting Drills.

The exostosis on the vomer is removed by the revolving multiple knife carried through the nostrils to the pharynx, inclosed within the sheath, so as not to cut any tissue except the exostosis. The small exostoses of the turbinated bones are removed in the same way. (Fig. 2.)

a

Fig. 2.

a

D.H.GOODWILLIE.MD.

Kuife (a) within the sheath. Revolving Knives.

For the treatment of the deviated cartilaginous septum, I have found no operation so successful as removing a section containing the bend, by means of the excising nasal forceps devised some years ago.

One blade contains the circular or oval knife, and the other is flat, against which the knife comes when it has cut its way through the septum. (Fig. 3.)

Fig. 3.

My attention has been called to a somewhat similar instrument described in Dict. Encycloped. des Sciences Méd. et Chirurg., article Nez.

It requires some half a dozen forceps of different sizes and shapes to meet every case.

In dislocation of lower end of cartilaginous septum, make an incision over the end of the dislocated and protruding cartilage down to the cartilage, denude it of the periosteum, push this back and then amputate the protruding cartilage (and nasal spine also if it is displaced), replace the denuded soft tissues and hold them together by small sutures.

The hypertrophied erectile tissues on the turbinated bones are removed by means of the galvano- or thermo-cautery. For the Paquelin cautery I have devised a new handle, which is held between the two fingers and thumb. In the office, use the condensed air instead of forcing the air by the hand-balls. The cautery is very efficiently held and the force of the air easily controlled by the thumb. The thermo-cautery can only be used in the anterior nares. (Fig. 4.)

Dotted lines represent the shield through which the cautery passes. The part of the cautery within the shield is covered over with asbestos to protect the vestibule from the heat.

Fig. 5.

The galvano-cautery is by far the most efficient cautery to be used in the nose. By the use of properly constructed electrodes it can be used anywhere in the nose, pharynx, or larynx. The vestibule of the nostrils is protected from the heat by a shield made of glass and asbestos. The lower part of the shield is flanged so as to be easily held between the fingers. The top of it embraces the part to be cauterized. The electrode, when heated to a high heat, is passed through the shield on to the parts to be removed. (Fig. 5.)

PH.SCHMIDT

Chronic antrum disease is a frequent source of naso-pharyngeal catarrh. This commences almost always by a decomposed dental pulp opening into and setting up trouble in the antrum. With this there is more or less facial neuralgia. I do not think this