toms may remain trivial for some months. Gradual interference with speech and deglutition, pharyngeal irritation, and secretion lead to their detection. Carcinoma is, as a rule, painful in its late stages. Either tumor may finally cause starvation on account of the difficulty in swallowing. The main sites are the tonsil, the lingual tonsil, and the palate. The posterior wall is least often affected, and if at all, more likely secondary to a laryngeal growth. Sarcoma is rather a more distinctly circumscribed tumor than carcinoma, which appears and spreads usually as a diffused infiltration with early ulceration. In sarcoma ulceration occurs later, if at all. The breaking down of the growth gives rise to awful fetor of the breath. Cachexia becomes marked by this time, and may become complicated by sepsis. Subacute inflammatory attacks frequently start from the growth, and sometimes cause much inflammatory edema. Corrosion of large arterial twigs, occasionally with fatal hemorrhage, has been observed. Unless a radical operation is feasible, death is only a question of time. In the diagnosis of malignant growths, especially of carcinoma, all obtainable evidence must be carefully weighed in order to decide between this process, syphilitic chancre, gumma, and tuberculosis. The cervical lymph-glands are enlarged early in cancer and primary syphilitic sores; often, but not always, in tuberculosis, and, as a rule, not at all in sarcoma and gumma. 21 CHAPTER XXVIII. FOREIGN BODIES IN THE UPPER AIR-PASSAGES. INJURIES AND FRACTURES. CICATRICIAL CON- 252. Foreign bodies get into the nose principally in consequence of mischievous pranks of children. Beads, beans and peas, seeds and kernels, small buttons, paper wads, and similar articles are the most likely objects. Bullets and fragments resulting from an explosion occasionally remain lodged in the nose after perforating the facial bones or migrating with suppurative inflammation. Rarely do solid pieces of food, bits of bone, etc., enter the posterior choanæ by reason of coughing while swallowing or during vomiting. Equivalent to foreign bodies are concretions formed in place, the rhinoliths. They are hard bodies, consisting principally of phosphate of calcium. As a rule, they form around a foreign particle as a nucleus, sometimes around a bit of inspissated pus. They occur especially in workmen in cement factories and lime-works. In other instances their origin is obscure. They may be of any size up to that of a plum-kernel or even larger, sometimes smooth and oval, or again of irregular shape and rough. Their color is quite variable. Foreign bodies are lodged mostly in the inferior nasal meatus, but may be impacted anywhere. Unless smooth and bland, they are rarely tolerated long without causing inflammation, with purulent or seropurulent discharge, sometimes bloody, almost always offensive, and, of course, ordinarily one-sided. Such a discharge should raise a suspicion of foreign body, especially in young children, in whom suppurative sinuitis is very rare. Granulations are apt to form around the offending substance and may hide it from view. Ulceration, even perforation of the septum, can be caused by sharp-cornered bodies, especially rhinoliths. Under these circumstances distant disturbances, headache, especially one-sided, and even asthma are not uncommon. Nevertheless, foreign bodies have sometimes been endured by patients for years and escaped detection. The diagnosis depends upon feeling the foreign body with the probe. Its removal may require tact, especially when dealing with a child. When recently introduced and not impacted, a foreign body like a button can often be blown out by forcing air through the other nostril, according to Politzer's method of inflation of the ear. If forced back by blowing into the involved side, the substance enters the pharynx and may be swallowed. When this method fails, the simplest way is to grasp the body with stout forceps with scoop-shaped or large perforated blades and to extract it. An unruly child requires narcosis. Good illumination is indispensable. In the case of round, smooth substances, especially when far back in the nose, a spoon-shaped curet is often better than forceps. If the purulent rhinitis does not subside within a few days after extraction, it should be treated according to ¶ 34. 253. A special form of foreign bodies, found a number of times in the nose, are animal parasites-the maggots of various species of flies, and particularly the screw-worn. They may be present in large numbers and extend into the maxillary and frontal sinuses, causing violent suppurative sinuitis. Their presence causes always much inflammatory reaction and often extensive ulceration. Death from cranial involvement or sepsis has occurred in a noticeable proportion of reported cases. The diagnosis is evident when maggots or worms are found on searching with forceps. It has not always been found possible to remove all parasites mechanically. Probably the least. objectionable antiparasitic poison is chloroform vapor blown through the nostrils, while the patient breathes through the open mouth. As an exceptional occurrence the intestinal parasitic worms, ascaris or oxyuris, have been found in the nasal cavity and the maxillary sinus. 254. Foreign bodies may get into the maxillary sinus through an artificial opening, especially when in the alveolar process. Fragments of surgical instruments, metal cannulæ, remnants of gauze, etc., may maintain. suppurative inflammation until removed. If not felt by the probe, when suspected they may be demonstrated by an X-ray photograph, if of a material opaque to those rays. 255. In the pharynx sharp foreign bodies get caught when accidentally swallowed or aspirated. Fish-bones and pins are the commonest objects, and they are usually found in the tonsil or impacted in the pyriform sinus between tongue and epiglottis. It is sometimes difficult to see them. When found, they can be grasped by any forceps with broad ends. 256. With the exception of fractures of the external nose surgical injuries extend very rarely into the nose or the pharynx. Although traumatism accounts for a moderate number of septum deformities, its frequency has been much overrated in some books. It is true that violence to the external nose is very common in children, but it cannot break the septum unless it smashes or dislocates the bridge of the nose. This statement is based upon tests on the noses of cadavers by Zuckerkandl, as well as upon his dissections of (united) fractures of the septum. The history of a blow some time ago in the case of a septum deformity is not proof that the latter resulted therefrom, unless the nasal obstruction appeared at once after the accident. Traumatic bleeding from the nose occurs so readily that a fracture cannot be inferred merely on account of epistaxis. Fracture with or without dislocation of the nasal bones can be easily detected soon after the accident, but within a few hours the swell If the ing may be so intense that nothing can be made out. Of course, such extreme swelling is by itself highly suspicious of fracture of the bridge of the nose. fracture is complicated by tearing of the mucous surface, gaseous distention-emphysema of the face-may happen when the patient sneezes. The interior of the nose should be promptly examined whenever the bridge is broken. A fracture of the septum involves always the cartilaginous part. The ethmoid perpendicular plate will break only from intense violence; the vomer, never. The line of fracture is usually nearly horizontal, rarely vertical, sometimes multiple. As a rule, the fracture is a simple one with intact mucous membrane. The fragments of the septum may override more or less. There may also be dislocation and lateral displacement of the cartilaginous plate at its junction with the vomer. Occasionally a fracture of the nasal bones causes only bending, but no fracture of the septum. In the bony septum the reunion is ultimately due to callus, while the cartilaginous fragments are merely joined by connective tissue. Unless a broken septum heals with accurate adaptation of the fragments, there will always remain more or less nasal obstruction. Fracture of the nasal bones leaves flattening of the bridge of the nose proportionate to the dislocation of the fragments. Not infrequently disfiguring asymmetry of the external nose results from a break of the bridge and septum. When the patient is seen before firm union of the fractured bones has taken place, every effort should be made to restore the plane of the septum and the shape of the external nose. Immediate firm tamponing of the nasal passages with gauze has, on the whole, given the best results. The bridge should be lifted from the interior with the largest rod or thickest probes, which can be introduced and the septum straightened in the same manner. Broad forceps, especially the Asch pattern, used in the operation for deflected septum (Fig. 66), may aid in reducing the dislocation of the septal fragments. Narco |