A treatise on diseases of the nose and throat

Front matter

A TREATISE ON

BY

ERNEST L. SHURLY, M. D.

Introduction

This volume has been prepared for the perusal of the general practitioner and medical student rather than for the specialist in laryngology. It has therefore been the intention of the author to present more particularly the ideas and facts pertaining to the various subjects from the standpoint of practical experience or observation. To this end he has refrained from speculating upon unimportant theories and superfine distinctions, while at the same time endeavouring to give both sides of important controversies.

The therapy of the diseases described has received especial attention in as concise a manner as possible, while at the same time affording: a sufficient ran^e for indicating different plans of treatment. For the convenience of ready reference, an extensive formulary and chapter on local treatment will be found in the latter part of the book.

The chapters and subjects have been arranged according to a classification based upon the general nature of the disease treated rather than according to the anatomical region involved. The operations on the external nose and maxillae have been excluded, as thev belong to the domain of general surgery.

An honest endeavour has been made to give proper credit for the researches and writings of others, and those quoted have been duly credited. If in any instance this has been omitted, it has occurred through unintentional error, and not with any desire to plagiarize.

vj DISEASES OF THE ATOSE AND THROAT

The author desires to acknowledge his indebtedness to the excellent works of J. Solis-Cohen, Bosworth, Allen, M. Mackenzie, Lennox Browne, Ingals, Kyle, Burnett, Randall and De Schweinitz, Francotte, Schech, Hajek, Butlin, Rotch, Burow, Griinwald, Schnitzler, Ttirck, Luschka, Price Brown, McDonald, Woakes, Ziemssen, and others ; also to the many excellent monographs from which he has gleaned much valuable information. The author is under great obligation to his associate, Dr. P. M. Hickey, for his assistance in preparing the anatomical chapters and the illustrations. He would also express his thanks to Drs. W. S. Anderson, C. G. Jennings, B. R. Shurly, S. G. Miner, Thaddeus Walker, and Wadsworth Warren, for courtesies rendered.

32 Adams Avenue, W., Detroit, Mich.

CONTEXTS

Chapter I Page

Anatomy of the Upper Air Passages i

External nose ; Nasal chambers ; Accessory sinuses ; Nasopharynx ; Oropharynx ; Laryngo-pharynx ; Larynx ; Physiology of the upper air passage^ ; Olfaction ; Function of the pharynx and larynx ; Voice production.

CHAPTER II Examination of the Upper Air Passages . . . -34

Physical laws involved in laryngoscopy ; Illumination ; Instruments ; Anterior rhinoscopy ; Median rhinoscopy ; Pharyngoscopy ; Posterior rhinoscopy ; Obstacles to posterior rhinoscopy ; Digital examination of the nasopharynx ; Laryngoscopy ; Auto-laryngoscopy ; Obstacles to laryngoscopy.

CHAPTER III Acute Rhinitis, Pharyngitis, and Laryngitis ... 50

Pathology ; Etiology ; Symptomatology ; Treatment. Acute pharyngitis ; Etiology ; Symptomatology ; Treatment. Uvulitis ; Symptomatology ; Treatment. Acute laryngitis ; Etiology ; Symptomatology ; Treatment. Edematous laryngitis ; Etiology ; Symptomatology ; Differential diagnosis ; Treatment. Membranous laryngitis ; Acute glandular fever of children ; Herpes of the upper air passages ; Abscess of the septum.

CHAPTER IV Acute Infectious Diseases of the Upper Air Passage- . 79

Influenza ; Etiology ; Symptomatology ; Complications ; Differential diagnosis ; Treatment. Pandemic influenza ; Etiology ; Symptomatology ; Course ; Sequelae ; Prognosis ; Treatment.

CHAPTER V Diphtheria .......... 93

Definition ; History ; Etiology ; Pathology ; Classification ; Anomalous cases ; Complications ; Mixed infection : Prophylactic treatment ; Local treatment ; Constitutional treatment ; Action and dosage of antitoxin ; Preparation of the antitoxin.

vii viii DISEASES OF THE NOSE AND THROAT

Chapter VI Page

Fibrinous Rhinitis 129

Etiology ; Pathology ; Symptomatology ; Diagnosis ; Prognosis ; Course ; Treatment. Acute follicular tonsilitis ; Etiology ; Prognosis ; Treatment. Acute peritonsilitis ; Etiology ; Predisposing causes ; Age ; Diathesis ; Occupation ; Climate ; Season ; Hygienic surroundings ; Habits ; Exciting causes ; Pathology ; Treatment.

CHAPTER VII Erysipelas of the Upper Air Passages . . . -151 Erysipelas of the nose ; Etiology ; Age ; Prognosis ; Treatment. Acute retropharyngeal abscess ; Etiology ; Age ; Symptomatology ; Diagnosis ; Treatment. Acute infectious phlegmonous pharyngitis ; Etiology ; Symptomatology ; Diagnosis ; Treatment.

Chapter VIII

Diseases of the Nasal Passages, Pharynx, and Larynx depending upon the Exanthemata and Essential Feyers 163

Scarlet fever ; Treatment. Measles ; Treatment. Rotheln ; Variola ; Typhoid fever ; Typhus fever ; Malarial fevers ; Rheumatism ; Treatment.

CHAPTER IX Neuroses of the Upper Air Passages 169

Neuroses of the nose and nasopharynx ; Parosmia ; Hyperosmia ; Anosmia ; Prognosis ; Treatment. Hay fever ; Etiology ; Exciting causes ; Age ; Sex ; Race ; Location ; Social condition ; Symptomatology ; Pathology ; Complications ; Treatment. Nasal hydrorrhea ; Etiology ; Symptomatology ; Treatment. Sialorrhcea ; Treatment. Xerostomia ; Etiology ; Symptomatology ; Diagnosis ; Course ; Appearances ; Treatment. Hyperesthesia of the nasal passages and nasopharynx ; Treatment. Hyperesthesia of the pharynx ; Treatment. Hyperesthesia of the larynx ; Treatment. Paresthesia of the nasal passages ; Treatment. Paresthesia of the pharynx ; Symptoms ; Age ; Sex ; Etiology ; Prognosis ; Treatment. Paresthesia of the larynx ; Etiology ; Symptoms ; Laryngoscopic examination ; Prognosis ; Treatment. Anesthesia and Analgesia ; Treatment. Spasmodic affections of the upper air passages ; Etiology ; Sex ; Age ; Social condition ; Occupation ; Nasal passages ; Pharynx ; Soft palate ; Larynx ; Spasm of the glottis ; Symptomatology ; Prognosis ; Treatment. Paralysis of the muscles of the upper air passages ; Paralysis of the muscles of the nose, soft palate, and pharynx ; Symptoms ; Treatment. Paralysis and paresis of the larynx ; Etiology ; Sex ; Location ; Diagnosis ; Prognosis ; Treatment. Functional aphonia; Etiology ; Age ; Sex ; Pathology ; Symptomatology ; Diagnosis ; Prognosis ; Treatment. Neuralgia of the upper air passages ; Nose and nasal passages ; Neuralgia of the pharynx and larynx ; Treatment.

COX TEXTS

IX

Chapter X Page

Chronic Infectious Diseases of the Upper Air Passages 239

Hereditary syphilis ; Symptomatology ; Primary syphilis of the upper air passages ; Secondary syphilis ; Tertiary syphilis ; Symptoms ; Diagnosis ; Pathology ; Sequelae; Treatment. Tuberculosis of the upper air passages ; Definition ; General etiology ; Latency ; Heredity ; Contagion ; Inoculation ; Predisposing causes ; Social condition ; Food ; Tuberculosis of fhe nasal passages ; Etiology ; Diagnosis ; Prognosis ; Tuberculosis of the nasopharynx ; Etiology ; Tuberculosis of the pharynx ; Diagnosis ; Prognosis ; Tuberculosis of the larynx ; Diagnosis ; Prognosis ; Treatment. Lupus of the upper air passages ; Symptomatology ; Appearances (Nose, Pharynx ; and Larynx) ; Etiology ; Pathology ; Differential diagnosis ; Treatment. Rhinoscleroma ; Etiology ; Clinical history ; Diagnosis ; Prognosis ; Treatment.

CHAPTER XI Chronic Diseases of the L'pper Air Passages . . . $35

Chronic rhinitis ; Hypertrophic rhinitis ; Etiology ; Symptomatology ; Anterior hypertrophies ; Posterior hypertrophies ; Pathology ; Classification ; Diagnosis ; Treatment. Chronic atrophic rhinitis ; Etiology ; Symptomatology ; Pathology ; Prognosis ; Treatment. Ozena ; Etiology ; Pathology ; Treatment. Chronic follicular pharyngitis ; Etiology ; Pathology ; Symptomatology ; Objective signs ; Appearances ; Hypertrophic pharyngitis ; Atrophic pharyngitis ; Etiology ; Pathology ; Symptomatology ; Diagnosis ; Prognosis ; Treatment. Pharyngitis ulcerosa ; Pathology ; Treatment. Hypertrophy of the tonsils ; Etiology ; Symptomatology ; Pathology ; Diagnosis ; Prognosis ; Treatment. Adenoids ; Etiology ; Symptomatology ; Diagnosis ; Pathology ; Prognosis ; Treatment Lingual tonsil ; Acute inflammation ; Symptomatology ; Chronic enlargement ; Symptomatology ; Treatment. Chronic laryngitis ; Etiology ; Symptomatology ; Laryngoscopic appearances ; Pachydermia laryngis ; Pathology ; Diagnosis ; Course ; Treatment. Hyperplastic laryngitis.

CHAPTER XII Local Diseases of the Nose ....... 479

Perforation of the cartilaginous septum ; Etiology ; Treatment. Mycos Etiology; Pathology; Symptomatology; Diagnosis ; Prognosis ; Treatment. Varix ; Etiology ; Symptomatology ; Diagnosis ; Treatment. Leucoplakia ; Etiology ; Pathology ; Symptomatology ; Diagnosis ; Prognosis ; Treatment.

Chapter XIII

Diseases of the Accessory Cavities of the Nose, Antrum of hlghmore, frontal and sphenoidal slnuse?. and Ethmoid Cells ......... 494

Acute sinusitis ; General etiology ; Symptomatology ; Diagnosis ; Treatment ; Chronic diseases of the accessory cavities ; General etiology ; Ethx DISEASES OF THE NOSE AND THROAT

PAGE

moid cells; Antrum of Mighmore ; Frontal sinus ; Sphenoidal sinus ; Differential diagnosis ; Treatment.

CHAPTER XIV Neoplasms of the Upper Air Passages .... 520

Classification ; General etiology ; Benign neoplasms of the nasal passages and pharynx ; Malignant neoplasms of the nasal passages and pharynx ; Neoplasms of the accessory cavities ; Treatment. Chemical escharotics ; Neoplasms of the larynx ; Cysts of the larynx ; Malignant neoplasms of the larynx ; Symptomatology ; Laryngoscopy appearances ; Treatment of benign neoplasms ; Treatment of malignant neoplasms ; Intubation for neoplasms.

CHAPTER XV Injuries of the Nose ........ 597

External injuries ; Treatment. Injuries to the pharynx and larynx ; Treatment. Epistaxis ; Etiology ; Treatment.

CHAPTER XVI Deformities of the Upper Air Passages .... 616

Deformities of the nose ; Deformities of the nasal cavities ; Deviation of the septum ; Etiology ; Symptoms ; Diagnosis ; Cartilaginous deformities ; Results of septal operations ; Synechia ; Treatment. Deformities of the pharynx and larynx.

CHAPTER XVII Foreign Bodies in the Upper Air Passages . . . 650

Foreign bodies in the nasal passages ; Etiology ; Symptoms ; Parasites in the nose ; Symptoms ; Diagnosis ; Treatment. Foreign bodies in the pharynx, larynx, and esophagus ; Symptomatology ; Diagnosis ; Treatment.

f CHAPTER XVIII

Operations in the Pharyngeal and Laryngeal Regions

and Methods of Local Treatment .... 669

Preliminary measures ; Position of the patient ; Aseptic precautions ; Anaesthesia ; Pharyngotomy, lateral and subhyoid ; Esophagotomy ; Tracheotomy ; Operation ; After treatment. Intubation ; Indications for ; Operation ; Difficulties ; Thyreotomy ; Laryngectomy ; Partial laryngectomy ; Methods of local treatment ; Classification ; Pigments ; Sprays ; Douches ; Powders ; Injections ; Inhalations ; Curettement ; Electrolysis ; Cauterization ; Formulary.

COLOURED PLATES

Plate I

FIG.

i. Nasal polyp. (Griinwald.)

2. Adenoid vegetations of the nasopharynx. (Griinwald.)

3. Polypoid hypertrophy of the posterior ends of the inferior turbinate. (Griinwald.)

4. Pharyngomycosis. (Griinwald ;

5. Chronic follicular pharyngitis with lateral hypertrophy. (Griinwald.)

6. Hypertrophy of the tonsils. (Griinwald.)

Plate II

1. Hard wart. (Griinwald.)

2. Lupus ; cicatrized loss of substance of epiglottis ; growths on the posterior wall of

the larynx, on the posterior surface of the epiglottis, and on the vocal cords. (Tiirck.) '

3. Catarrhal erosive ulcers of decubital origin. (Griinwald.)

4. Papilloma. (Griinwald.;

5. Erysipelas of the larynx. (Griinwald.)

6. Normal larynx during deep respiration. (Schnitzler.)

Plate III

1. First stage of tubercular infiltration. (Griinwald.)

2. Multiple tubercle infiltration in early stage. (Griinwald.)

3. Mixture of destructive and retrograde tubercular infiltration. (Griinwald.)

4. Tubercular infiltration and ulceration. (Griinwald.)

5. Diffuse tubercular infiltration of the mucous membrane. (Griinwald.)

6. Tuberculous and early (?) tertiary syphilis. (Griinwald.)

Plate IV

1. Hyperplastic tuberculosis. (Griinwald.)

2. Diffuse tubercular infiltration of the whole larynx and tumour. (Griinwald.)

3. Tubercular tumours. (Griinwald.)

4. Tuberculosis, lupoid form. (Griinwald.)

5. Syphilitic ulcer on the upper part of the posterior wall of the larynx. (Tiirck.)

6. Lupus (laryngeal) ; ulcers of epiglottis commencing to cicatrize : hypertrophy ot

the mucous glands at base of tongue. (Griinwald.)

xi xii DISEASES OE TI/E XOSE A XT) THROAT

Plate V

FIG.

i. A norma] pharynx.

2. Solitary ulcer of faucial pillar. (Siegel.)

3. Acute follicular pharyngitis.

4. Varix of lingual tonsil.

5. Peritonsilitis of the right side of the fauces, showing congestion and swelling of

the tissues.

6. Acute follicular tonsilitis.

Plate VI

1. Mass of threads in tonsillar crypt. (Wright )

2. Mycelial threads. (Wright.)

3. Hyperemia of the larynx. (Schnitzler.)

4. Acute laryngeal catarrh. (Schnitzler.)

ILLUSTRATIONS IX THE TEXT

FIG.

I. 2.

4;

5- 6.

23- 24. 25. 26. 27.

29. 30. 31.

33- 34-

35- 36.

tenoid mu scle

Dissection of the nose (external) ....

Sagittal section of the head .....

Coronal section of the head, showing turbinated bones

Coronal section of the head, showing turbinated bones and ethmoidal sinu:

Sagittal section of the head, showing frontal and ethmoidal sinuses

Coronal section through maxillary sinuses and turbinated bones .

Sagittal section showing frontal sinus and the turbinated bones

Asymmetrical development of the turbinated bones

Sagittal section of the head, showing turbinated bone;

Sagittal section of the head (the middle turbinated bone so elevated

show the hiatus semilunaris) Ethmoid bone .....

Muscles of the soft palate and pharynx

Coronal section through sphenoidal sinus and posterior end of nasal cavity

Hyoid bone and laryngeal cartilages

Photomicrograph showing section of arytenoid cartilage

Posterior view of the larynx .....

Lateral view of the larynx .....

Section of vocal cord showing internal fibres of the thyro-ary: Adult larynx opened in the posterior median line ....

Vertical section through the olfactory mucosa of a rabbit ( x 560) .

Vertical section through the olfactory region of a young rat ( x 4?o)

Head mirror supported by the teeth

Bosworth's nasal speculum

Simrock's nasal speculum

Goodwillie's nasal speculum .

Bosworth's tongue depressor .

Shurly's tongue depressor

Chair for patient in laryngoscopy .

Position for anterior rhinoscopy

Pharyngoscopy ....

Rhinoscopic image ....

\\ hite's palate retractor in position

Method of holding laryngeal mirror

Enlarged sketch of normal laryngoscopic image in respiration

Laryngoscopic image showing bifurcation of the trachea

Laryngoscopic image showing the posterior wall of the larynx

Auto-laryngoscopy ..........

xiii

PAGE

3 4 5 6

7 S

9 10

XIV

/'/SEASES OF THE NOSE AND THROAT and

FIG.

38. Kilian's method of examining the posterior wall of the larynx

39. Position for autoscopy

40. Acute edematous laryngitis

41. Klebs-Loeffler bacillus (Stengel) ....

42. I, eland's tonsil knife

43. Left recurrent paralysis. Adduction

44. Bilateral paralysis of lateral crico-arytenoids .

45. Left recurrent paralysis. Adduction

46. Bilateral paralysis of internal thyro-arytenoids and arytenoid

47. Bilateral paralysis of external tensors

48. Bilateral recurrent paralysis

49. Paralysis of left posterior crico-arytenoid. Inspiration

50. Relaxed or cadaveric position ....

51. Diagram showing outline of the rima glottidis in paralysis

52. Symmetrically crescent-shaped condylomata of soft palate

53. Deep secondary syphilitic ulceration of the soft palate and fa

54. Deep syphilitic ulceration of soft palate and fauces

55. Sequestrum of bone from case of nasal syphilis

56. Tertiary syphilitic ulceration and perforation at junction of soft

palate

57. Double perforation (syphilitic) of palate .

58. Syphilitic perforation of palate .....

59. Syphilitic ulceration of right pillar and perforation of palate

60. Healed cicatrix of case illustrated in Fig. 59 .

61. Syphilitic ulceration of the larynx with perichondritis .

62. Cicatrix after loss of part of soft palate and uvula .

63. Healed cicatrix of case illustrated in Fig. 62

64. Section through interarytenoid space of normal larynx .

65. Acute inflammatory oedema of tuberculous larynx .

66. Superficial tubercular ulcers of the vocal cords and of the free ed

epiglottis .

67. Tubercular ulceration of the glottis in the form of a girdle

68. Unusual manifestation of tuberculosis of the larynx

69. A pale larynx with swollen and roughened posterior wall

changes about the left vocal cord ....

70. Unusual manifestations of tuberculosis of the larynx

71. Tuberculosis of the larynx — granular hyperplasia .

72. Tubercular tumour .......

73. Tubercular ulceration and granulomata on the posterior wall

74. Tubercular ulceration of the posterior wall of the larynx

75. Tubercular perichondritis of the arytenoid

76. Tubercular perichondritis of the arytenoid

77. Extensive tubercular ulceration of the larynx — necrosis of cricoid with

siderable new tissue formation ....

78. Lateral half of a tubercular larynx ....

79. Lupus vulgaris of the right nasal passage and ala of the nose

80. Lupus of the mucous membrane ....

81. Rhinoscleroma .......

82. Section of cyst of middle turbinated bone

83. Bony cysts and of the lary hard ges of the cicatricial

ILLCSTRAT/OXS IX THE TEXT

XV

ic6.

116. 117. 118. 119.

Microscopical appearances of tissue in chronic hypertrophic nasal inflamma

Microscopical section, nasal hypertrophy Posterior hypertrophies of the right and left inferior turbina Post-rhinoscopic image showing hypertrophied turbinal Shurly's nasal speculum with ivory slide, right and left Snare (Tarvis) ........

Transfixion needle .......

Hickey's snare for posterior hypertrophies . Atrophic rhinitis ........

Atrophic pharyngitis (with enlarged follicle>) Exsected hypertrophied tonsil .....

Section of hypertrophied faucial tonsil ....

Tiemann *\: Co.'s tonsillotome .....

Mackenzie's tonsillotome ......

Dr. Farlow's tonsil snare ......

Typical facial appearance of a mouth breather . Section of adenoid vegetations .....

Post-nasal forceps

Gottstein curette ........

(Edema of the glottis — unilateral .....

Chronic laryngeal catarrh, affecting principally the vocal cord on the left

Chronic laryngeal catarrh, showing circumscribed swell in cord of

Chronic inflammation of the vocal cords

Ulcers of the vocal cords

Chronic laryngeal catarrh, with swelling of the ventricular bands Chronic laryngeal catarrh, with thickened mucus adhering to the Chronic laryngeal catarrh, with paresis of vocal cords . Chorditis vocalis hypertrophica superior ....

Chorditis vocalis hypertrophica inferior ....

Perichondritis of the left half of the cricoid cartilage with abscess ..........

Perichondritis of the posterior part and left half of the cricoid C2 Idiopathic perichondritis .......

Hemorrhagic laryngitis . .......

Hypertrophied mucous membrane of the ethmoid

Dr. Myles's curved cannula needle .....

Lamp for transillumination .......

Electric motor for operating nasal drill ....

Hand drill, with guard ........

Buck's nasal and ear curette

Section of nasal polypus .......

Section of papillary fibroma of the nose ....

Angioma of the nose ........

Section of papilloma of the uvula . .....

Sarcoma in the left nasal passage ......

Carcinoma of antrum and secondary growth in orbit .

PAGE 346

554 356 356

409 411 411 412

457 45 7 457 457 500 507

516 517 5*7

XVI

DISEASES OE THE NOSE AXD THROAT

FIG. PAGE

130. Carcinoma of the larynx and the pharynx, involving cervical glands . . 553

131. Hosworth's snare , 557

133. Simrock's polypus forceps 559

134. Upson's syringe for hypodermic injections ....... 562

135. Congenital papillomata .......... 564

136. Fibroma of the vocal cord 568

137. Fibro-myxoma 568

138. Myxoma of the epiglottis 568

139. Subglottic myxoma 569

140. Cyst of the larynx 571

141. Epithelioma of the larynx 579

142. Author's case of epithelioma of the larynx removed by the operation of

laryngectomy 579

143. Epithelioma of the larynx — laryngectomy 580

144. Sarcoma of the epiglottis . . . . 581

145. Primary lupus of the larynx . . 5S1

146. Supposed case of enchondroma 581

147. Schrotter's laryngeal lancet and forceps 584

148. Fauvel's laryngeal polypus forceps 584

149. Mackenzie's lateral throat forceps 585

150. Mackenzie's antero-posterior throat forceps 585

151. Gibbs's laryngeal ecraseur or snare . 586

152. Jarvis's laryngeal applicator . . 587

153. Apparatus for repairing a broken nose . 599

154. An eligible method of repairing a broken nose ...... 600

155. Gunshot wound of the larynx ......... 603

156. Injury to larynx from contusion 603

157. Case of paralysis of left vocal band following an incised wound of the neck 604

158. Case of paralysis of left vocal band following an incised wound of the neck 604

159. Stenosis of the larynx following typhus fever 605

160. Rubber tampon for plugging the nose . 613

161. Hopkins's bridge 617

162. Coronal section of dry specimen, showing bony spur ..... 620

163. Spud for dissecting up the septal mucous membrane 630

164. Pin operation for removal of spur of septum ...... 632

165. Steele's septum forceps 633

166. Asch's curved gouge for breaking up adhesions between septum and tur-

binate 634

167. Cartilage scissors for operation of deflected septum 635

168. Transfixion needle 640

169. Atresia of the right nostril 646

170 and 171. Deformity of the epiglottis 648

172. Deformity of the epiglottis 648

173. Congenital web of the larynx 649

174. Bifid uvula 649

175. A pin which was removed from the larynx two years after having been

swallowed 663

176. Esophageal forceps 666

177. Trousseau's dilator, to facilitate the introduction of cannula . . . 676

ILLUSTKATIOXS IX THE TEXT

XV11 low tha

FIG.

178. Pilcher's retractor .

179. Double silver trachea tube, with movable plate ......

180. Position of child, operator, and assistants, for intubation . . . .

181. Scale of lengths for O'Dwyer's intubation tubes . ....".

153. O'Dwyer's intubation tube and introducer .

184. Insertion of finger to locate epiglottis and arytenoids .

1S5. Tube entering larynx ...........

186. Illustrating the error of depressing the handle of the introducer, resulting in

the tube entering the esophagus instead of the larynx . 1S7. Removal of the introducer with the finger holding tube in the larynx . 188. Tube in the larynx, with the string attached ......

1S9. Withdrawal of the string, with the finger on the tube to hold it in position

190. Tube in situ. Showing the head of the tube upon the vocal cords, and the

position of its distal end in the trachea .......

191. Method of removing the tube. The beak of the extractor, guided by the

finger, is just entering the tube .....

192. Diphtheritic cast of trachea and bronchi (natural size) .

193. Extractor for intubation tube ......

194. Feeding intubated child with nursing bottle, the head being

the shoulders .........

195. Feeding intubated child by suction of fluids through rubber catheter

196. Phillips's electric photophore, with adjustment for focusing light

197. Trendelenburg's tracheal tampon .

198. Bosworth's applicator .....

199. Wagner's laryngeal and post-nasal brushes .

200. Shurly's cotton applicator ....

201. Lente's platina cup for fusing nitrate of silver

202. Jarvis's laryngeal applicator ....

203. Japanese atomizer ..... 2C4. De Vilbliss's atomizer .....

205. Hard-rubber pharyngeal and posterior nares syringe

206. Lefferts's anterior and posteiior nasal syringe

207. Warner's catarrhal douche ....

208. De Vilbliss's powder blower ....

209. Amberg's powder blower ....

210. Shurly's powder blower ....

211. Hypodermic syringe .....

212. Tobold's laryngeal syringe ....

213. Shurly's globe inhaler with rubber face shield

214. Shurly's hot water inhaler ....

215. Tyndale's antiseptic oro-nasal respirator

216. Tobold's pneumatic apparatus

217. Cohen's laryngeal curette ....

218. Mackenzie's laryngeal lancet

219. Needles for electrolysis ....

220. Dawson's universal cautery electrode .

221. C. H. Knight's electric tonsil snare

222. Nasal electrode ......

223. Mackenzie's laryngeal electrode .

PAGE 676

686 687

689 690 690

707 708

717 717 717 718

DISEASES OF THE XOSE AND THROAT

Chapter I

The component parts of the upper air passages are the nose, pharynx (naso-, oro-. and laryngo-), and larynx. The nose is divided into the external nose and the nasal fossae. The external nose consists of the rigid or bony structure, supplemented with cartilages and the coverings of muscles and integument. The rigid structure is composed of the nasal bones and the nasal processes of the superior maxillaries ; the nasal bones, two in number, form the bridge of the nose and articulate with each other, the frontal bones and the superior maxillaries. The cartilages of the nose are the septal, the four lateral, and the accessory, usually four in number (Fig. 1 1. The septal cartilage, sometimes denominated the triangular, and by some authors the quadrilateral, forms the anterior part of the nasal septum, and one of the boundaries of the nasal vestibule. The upper and lower lateral cartilages form on each side the alas of the nose. The accessory or sesamoid cartilages are posterior to the two lateral and serve as a flexible attachment to the maxillarv bones. The muscles of the nose are the levator labii superioris alaeque nasi, the dilators — anterior and posterior — of the nares, the compressor nasi, and the depressor alae nasi.

The anterior nares open into the vestibule, which is the part of the internal nose whose walls are cartilaginous. Posterior are the nasal fossae proper, extending back to the posterior nares and separated one from the other by the nasal septum. The septum is divided into an anterior or cartilaginous part and a posterior or bonv part formed bv the perpendicular plate of the ethmoid and by the vomer < Fig. 2).

2 DISEASES OE THE NOSE AXD THROAT

The components of the upper and posterior boundaries of the nasal chambers are the nasal bones, the body of the sphenoid, and the cribriform plate of the ethmoid. The outer wall is

Fig. i.— :Dissection of external nose. A, A, reflected integument ; B, B, alar (or lateral) cartilages ; C, C, nasal bones.

made up of parts of the superior maxillary, lachrymal, palatal, ethmoidal, and sphenoidal bones. The floor of these passages is formed by the palatine processes of the superior maxillaries, and by the horizontal plates of the palate bones. Encroaching on the lumen of each cavity are three small bones known as the turbinals, so named from their scroll-like appearance (Figs. 3, 4, 5, 6, and 7). The superior turbinated bone projects from the lateral mass of the ethmoid, forming a distinct ridge posteriorly, while anteriorly it merges into the middle turbinal, which is also a part of the ethmoid. The middle turbinal is a broad, thin, bony plate curling downward upon itself, and has on its anterior inferior surface a slight projection known as the agger nasi ; opposite to this upon the septum will usually be found a corresponding small protuberance ; these two points may be taken as marking the line between the respiratory and olfactory parts of the nasal tract. The inferior turbinated bone is an independent structure articulating anteriorly with the nasal process of the superior maxillary, centrally with the lachrymal and ethmoidal bones, and posteriorly with the lower crest of the palate bone. These supplementary bones, which are nearly parallel with and approximately equi-

Fig. 2. — Sagittal section of head. A, quadrilateral cartilage ; B, perpendicular plate of the ethmoid bone : C. frontal sinus.

distant from each other, subdivide the nasal passages into three channels called meatuses, the superior meatus lying between the superior and middle turbinate, the middle meatus between the middle and inferior turbinate, the inferior meatus between the inferior turbinal and the floor of the nose (Fig. 8). The superior meatus contains the opening of the posterior

Fig. 3. — A, superior turbinated bone; B, B, middle turbinated bones; C, C, inferior turbinated bones ; D, Z>, ethmoidal cells ; E, E, maxillary sinus ; H, H, cavity of orbit. (Superior turbinated bone on the right side is attached to the middle turbinate.)

ethmoidal cells, the middle communicates with the anterior ethmoidal cells, and has upon its external wall the hiatus semilunaris, the convexity of whose curve is directed forward and downward ; at its anterior end is the opening into the infundibulum, communicating with the frontal sinus, while the ostium maxillare, or opening into the antrum of Highmore, is at the posterior part, where is also found the prominence known as the bulla ethmoidalis, formed by the bulging of one of the ethmoidal cells. In the inferior meatus is the opening of the lachrymal duct (Figs. 9 and 10).

Communicating with each nasal chamber are four cavities, known as the accessory sinuses — the frontal, ethmoidal, maxillary, and sphenoidal. The frontal sinuses are of varying

AX ATOMY OF THE UPPER AIR PASSAGES -

size and shape, and lie between the two tables of the frontal bone just above the orbit ; they are rudimentary at birth, but develop later in life. Each opens into the middle meatus through the infundibulum, though there is often a channel of communication of one frontal sinus with the other. While the ethmoidal sinuses are dignified with the name of cavities, they are in reality an aggregation of bony cells divided into the anterior and posterior groups. The anterior cells open into the middle meatus by the ostia ethmoidalia ; the posterior cells communicate with the superior meatus (Fig. ii). The maxillary sinus, more commonly known as the antrum of Highmore, is an irregularly pyramidal cavity in each superior maxillary bone. The upper boundary is the floor of the orbit, the

Fig. 4. — A, ethmoidal sinus ; B, opening from the maxillary sinus ; C, middle turbinated bone ; D, inferior turbinated bone.

lower boundary is the roof of the mouth, and the inner boundary is the outer wall of the nasal cavitv. It communicates with the middle meatus by the ostium maxillare. The sphenoidal sinuses are two rounded cavities, often asymmetrical, in the body of the sphenoid, separated the one from the other by a thin bony plate. They open into the upper and back part of each nasal cavity (Fig. 13).

The lining of the vestibule at the opening of the anterior nares is a continuation of the integument; this gradually changes until it assumes completely the character of a mucous membrane at the junction of the vestibule with the nasal fossa. In this vestibular lining are found sebaceous glands and numerous minute hairs called vibrissas, which serve as a nitre against the ingress of gross particles in the inspired air. The Schnei-

Fig. 5. — A, frontal sinus ; B, ethmoidal sinus ; C, middle turbinated bone ; D, middle meatus ; E, bristle passed into Eustachian tube ; E, inferior turbinated bone ; 6", inferior meatus.

derian or mucous membrane of the nasal fossae shares the general character of mucous membranes elsewhere in the air passages. The columnar epithelium is ciliated in the respiratory tract

ANATOMY OF THE UPPER AIR PASSAGES j

and non-ciliated in the olfactory tract. The membrane lining the sinuses is continuous with that of the nasal fossse, though its secretion has more of a serous nature. The covering of

Fig. 6. — Coronal section (dry specimen) through maxillary sinuses and turbinated

bones.

the turbinated bones and the posterior parts of the septum deserves more extended consideration, as an understanding of its peculiar structure explains many of the facts of its special pathologv. Beneath the epithelial layer is the submucous connective tissue of varying thickness, whose lower layers form the periosteum and perichondrium. Within this connective tissue are imbedded the tubular mucous glands. The special points are the existence of venous sinuses or plexuses capable of distention and of containing large quantities of blood. When thus enororo-ed the thickness of the membrane is erreatly increased, so that it has been likened to an erectile tissue, from its propertv of intumescence. According to Bresgen there is one plexus for the inferior turbinated body, one for the middle border of the middle turbinated body, and one for the posterior end of each of the turbinated bodies.