DISEASES OF THE EAR, NOSE, AND THROAT.

479

DISEASES OF THE EAR, NOSE, AND THROAT.

UNDER THE CHARGE OF

P. M'BRIDE, M.D., F.R.C.P.Ed.,

SURGEON TO THE EAR AND TIIROAT DEPARTMENT, ROYAL INFIRMARY, EDINBURGH ;
AND

A. LOGAN TURNER, M.D., F.R.C.S.Ed.,

SURGEON FOR DISEASES OF THE EAR AND THROAT, DEACONESS HOSPITAL, EDINBURGH.

TUHEKCULOSIS OP TIIE jStASAL FoSS/E.

The existence of primary tuberculous disease of the nasal fossae is
now an established fact. In our remarks upon tuberculosis in this
region we wish to exclude all reference to the subject of lupus, and
draw attention mainly to some interesting facts in the pathology of
tuberculosis of the nose other than lupus. A number of facts demon-
strate that, in spite of the action of the nasal vibrissa? and cilia, and
the phenomenon of intranasal phagocytosis, tubercle bacilli can enter
these cavities, and there give rise to tuberculous lesions. The mucosa
in many cases may be predisposed by traumatism or a pre-existing
catarrhal condition. Infection may also doubtless be introduced into
the nose by the finger of the patient. AYe find, further, that in a
very large proportion of the patients affected with nasal tuberculosis,
there is an absence of any sign of tubercle elsewhere in the body. AVe
find, too, that post-mortem examination of the nasal chambers in
subjects dying from pulmonary or other forms of tuberculosis, shows
in a striking way how the nose may escape secondary infection.
Willigk only found the nose on one occasion afiected with tubercle in
*47G post-mortems 011 subjects dying of tuberculosis; Weichselbaum
found nasal tubercle twice in 14G similar post-mortems; while E.
Frankel obtained negative results in fifty subjects which he examined.
These figures show a striking contrast to what we are accustomed to
observe when studying the association of pulmonary and laryngeal
tuberculosis. In case these figures should convey a wrong impression,
it is
right to merely note here that individual cases of nasal infection
from the sputum of phthisical patients have been reported.
At least two distinct forms of tubercle of the nasal fossa can be
recognised?the so-called tuberculous tumour or tuberculoma and the
tuberculous ulcer. Both these forms may coexist in the same patient.
It is to the tumour variety of the disease that we wish to draw special
attention at the present time. Two valuable papers have recently dealt
with this subject at some length. 1 Iasslauer of AViirzburg (Arch./. Laryn-
gol., Berlin, 1900, Bd. x. lleft 1,), in a long paper upon tumours of the
nasal septum, devotes a section to tuberculous disease; while in the
newly published volume of Guys IIosp. Rep., London, vol. liv., Francis
-1. Steward records six interesting cases which were met with at that
hospital.
Both these authors tabulate very fully a largd number of pub-
lished cases. Steward's six cases, and ninety-four already published
by others, since 1S89, combine to make a total of one hundred, well
480 RECENT ADVANCES IN MEDICAL SCIENCE.

wortliy of detailed consideration. If in the first instance we analyse

these six cases, recorded for the first time, it is found that five of the
patients complained of nasal obstruction, while in the sixth there were
no nose symptoms, the lesion
being mainly confined to the left orbital
cavity. This case, however, is included in the series, as it was found
at the operation that the disease, which had commenced in the orbit,
had invaded the lateral mass of the ethmoid bone. Objective exam-
ination disclosed in four the swelling or tumour so called, while in the
fifth both inferior turbinateds were enlarged and showed lobulated
masses attached to their inferior borders. These swellings were red in
colour, firm in consistence, but bleeding somewhat readily when touched
with the probe. The surfaces were ulcerated in one or two small
areas. In three the growths Avere attached to the cartilaginous
septum; in one both inferior turbinateds were affected; in the other
the posterior end of the right inferior turbinated was enlarged by
a distinct new growth. When this last case had originally presented
itself, the naso-pliarynx was found filled with a large swelling, which
was at that time removed. In two of the septal cases perforation
of the cartilaginous septum occurred, thus affording additional evidence
of the fact that a perforating ulcer in this locality may be of tuberculous
origin. In one of the cases, enlarged tuberculous glands in the neck
developed, but in the remaining five there was no other evidence of this
disease present. Microscopical examination of the tissue removed
revealed in all of them giant cell systems, but only in one were tubercle
bacilli found. The difficulty in finding bacilli in these cases has been
experienced by most investigators. In Hasslauer's tables (op. cit.), con-
taining eighty cases, tubercle bacilli were found in twenty; in every
case tabulated, however, there was
present granulation tissue with
tubercle nodules, containing giant and epithelioid cells.
Treatment in Steward's cases consisted in curetting followed by
application of lactic acid. Recurrence took place in two of them.
Three of the patients were .males and three females, Avhile their respect-
ive ages were 17, 18, 34, 35, 36, and 54 years.
An analysis of the ninety-four cases tabulated by Steward, along
with the six recorded by himself, brings out some interesting facts. As
regards sex, fifty-nine were females and forty-one males, thus showing
a greater proportion of the former. The majority of the cases occurred
before 40, the greatest number being between 20 and 30 years of age.
The youngest is reported as being 8 months old, while the oldest was
71 years. With respect to age, it resembles tuberculosis generally.
In fifty-eight the nasal disease is stated to be of primary, in thirty-seven
of secondary origin, while in five it was doubtful into which of the
groups it could be placed. If the observations upon which these figures
are based are correct, there is abundant evidence of the
primary nature
of nasal tuberculosis. In nearly all the cases the nasal septum was
involved, thus demonstrating it to be the seat of election. In seventy
eases the disease affected the septum alone ; and if Ave add to this
those cases in Avhicli some other part of the nose, in addition to the
septum, Avas also affected, Ave find that there was septal disease in eighty-
nine out of the total of one hundred. The cartilaginous septum Avas
very frequently perforated. The tuberculous condition shoAved itself as
 DISEASES OF THE EAR, NOSE, AND THROAT. 481

a non-ulcerated swelling in forty instances, while in twenty-seven there

was ulceration without tumour formation, and in thirty-three there was
either an ulcerated swelling or a swelling in one part of the nose and
ulceration in another, thus making, in all, seventy-three cases in which
an evident intranasal swelling was the prominent lesion. This may
reach the size of a walnut, or even he larger, occluding one or both
nostrils, and even projecting from the clioanae behind. Removal of the
disease may be undertaken by the knife, the cold snare, curetting, and
the application of lactic acid, and by the use of the cautery.

1. Cerebral Abscess complicating a case of Chronic Middle Ear

and Frontal Sinus Suppuration.

2. Meningitis complicating a case op Acute Middle Ear Suppura-

tion, and Suppuration in the Sphenoidal Sinuses.
The two cases reported below present several points of undoubted
interest. They help to swell the ever-increasing list of intracranial
complications consequent upon suppuration in the nasal accessory
sinuses. In the one case a frontal lobe abscess, in the other a basal
meningitis, brings about a fatal termination. In the former, a chronic
nasal discharge accompanies a chronic otorrhoea from the
right ear; in
the latter, an acute middle ear suppuration on the left side is
present
without any nasal symptoms, so that the
etiology of the intracranial
complication was very perplexing. Both cases are carefully reported
by their authors, and the clinical histories and the description of the
autopsies repay the reader.
Case 1.?This is reported by Koebel of Stuttgart (Beitr. 2. /din.
Cliir., Tiibingen, 1899, Bd. xxv.). The patient, set. 39, first complained
of purulent discharge from his right ear, fifteen years ago, and at that
time it lasted for several months. When under examination at the
present time, there had again been discharge for two months. At the
same time he
complained that he had suffered from nasal purulent
discharge since he was a young man, and sometimes had pain in the
frontal region. Rhinoscopy revealed pus in both nasal fossa?, associated
with a polypus upon the right middle turbinated body. The discharge
from the right ear at this examination was copious, but there were no
mastoid symptoms. Antiseptic treatment was ordered both for the nose
and ear.
Fourteen days later, the patient suddenly developed feverish
symptoms with violent headache, especially in the frontal and temporal
regions. His whole appearance altered, and he became sleepy and
languid ; the face was slightly cyanosed, and the countenance assumed
a
stupid aspect, and produced the impression as of one who was intoxi-
cated. He also vomited, lie did not answer all questions perfectly
clearly, and was apparently somewhat uncertain about the days of the
week and the hours of the day. The aural condition at this time
remained the same, and there was neither mastoid swelling, redness, nor
pain. Pus still came from both nostrils, but there was no frontal or
maxillary tenderness. The tongue was dry and furred. There was no
paralysis of the palate, no disturbance of speech or swallowing, and no
ocular paralysis. The pulse, which was easily compressible but regular
482 RECENT ADVANCES IN MEDICAL SCIENCE.

numbered from 50 to 60 beats per minute, but on the following day was
reduced to 48 and 52. The temperature fell. The pupils reacted on
both sides. The patient slept a great deal, vomited once during the
night, complained of no special headache, but of a dull pressure in both
temporal regions. Twitcliings now commenced in the left hand and
arm.
The right temporo-sphenoidal lobe was exposed. There was no
brain pulsation, and no pus escapcd after probing and incising the
brain tissue. The roof of the tympanum was then removed, and some
granulations were found in the attic, and pus in the tympanum proper.
There Avas no caries detected, nor was there any pus in a cavity believed
to be the antrum, but on passing backwards and removing the bone
towards the knee of the lateral sinus, pus suddenly welled out from the
bone, and the probe passed into a bony cavity filled with pus and granula-
tions, which was really the antrum. It was decided to do nothing in the
meanwhile but to observe the patient and prepare to open the frontal or
sphenoidal sinuses. The patient, however, became rapidly worse, and
died in a few hours. At the autopsy there was found in the posterior
wall of the right frontal sinus a hole the size of a pea, and another
smaller one situated near it. Both frontal sinuses contained pus. On
the anterior aspect of the right frontal lobe pus escaped from a sinus,
and, on section of the brain, an abscess cavity of the size of a hen's egg
was foimd in the right frontal lobe, occupying its anterior and lower

part. No other cerebral abscess was found.

Case 2 is recorded by Toubert (Rev. held, de Laryngol., etc., Bordeaux,
September 15, 1900), and it will not be out of place to summarise it
here in connection with that narrated above. The patient, a young
soldier, set. 22, was admitted into hospital in December 1899, suffering
from an attack of influenzal bronchitis. After recovery from this, an
acute otitis media on the left side developed; this was followed
immediately by a second severe attack in the same ear. A fortnight
later the patient was prostrated with intense headache, not localised to
any particular region, but of a very severe type. Repeated rigors
occurred. There was a considerable rise of temperature, Nothing
could be observed suggesting mastoid or lateral sinus complications.
The thoracic and abdominal organs were healthy. For three days the
patient remained in this state, free from coma or delirium. The pupils
were equal and moderately dilated; the fundus showed no changes ;
there was occasional bilious vomiting, and the temperature remained
high, with slight oscillations. Typhoid fever was carefully excluded,
and, while an endocranial complication of otitic origin Avas suspected,
the local signs Avere quite negative. After a fortnight's illness from the
commencement of the acute general symptoms, the patient died after a
short period of coma.
At the autopsy, nothing AATas found in the chest or abdomen. On
opening the skull, the veins of the dura mater AATere observed to be
intensely congested, Avliile at the base of the brain there Avas meningitis,
the lesion being most marked about the circle of Willis. There Avas
purulent exudation beneath the pia mater, Avhich Avas afterAvards found
to contain streptococci, Avliile the inflammatory condition extended on
either side into the fissures of Sylvius and Rolando in a markedly
 PUBLIC HEALTH. 483

symmetrical way. There was no cerebral abscess. The left lateral

sinus was healthy, and there was no trace of phlebitis. The lining
membrane of the mastoid antrum was liyperajmic, and the cavity
contained a gelatinous rather than a purulent exudation. It was then
decided to open the nasal accessory sinuses, and accordingly the roof of
the sphenoidal sinus was removed. Both of these cavities?the inter-
vening septum being almost completely destroyed?contained pus
swarming with streptococci. The secretion was not of very fluid
consistence. All the other sinuses were healthy. Death was evidently
due to a basal meningitis, secondary to suppuration in the sphenoidal
sinus.