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Chronic Diseases of the Nose, Throat and Ear
CHRONIC DISEASES OF THE NOSE. THROAT AND EAR
CLYDE A. HEATLY, M.D., F.A.C.S.· CHRONIC SINUSITIS
THE most common as well as the most difficult problems encountered in chronic nasal disturbances involve diseases of the nasal sinuses. Many significant advances have been made in recent years in the diagnosis and management of these disorders. The competent rhinologist \ has learned the importance of allergy in relation to chronic sinusitis from accumulated failures in cases in which this factor had been overlooked. He has also come to a better understanding of the physiology of the nose and thereby to a sounder appreciation of the valu,e of carefully planned surgery which conserves rather than needlessly destroys nasal structures. Classification of Sinusitis.-Many classifications of chronic sinusitis have been suggested. It is perhaps simplest from the clinical standpoint to consider three groups: ( 1) chronic suppurative sinusitis; (2) chronic hyperplastic sinusitis, which is predominantly allergic, and (3) mixed forms in which a chronic infection has been superimposed on an underlying allergy. Allergy produces profound changes in the nasal and sinal mucosa ranging fronl simple pallor and edema to extensive polypoid formation. These structural changes favor the. stagnation of secretions by interference with ventilation and drainage and thereby promote the chronicity of secondary infections. It is now generally recognized that nasal polyps are a manifestation of chronic nasal allergy in most instances. Their well known tendency to recur, therefore, can be controlled only by appropriate management of allergy. Diagnosis.-1. A careful history is essential and should include questions directed to a possible underlying allergy. A family history of allergy is of great importance. The studies of Cooke and Vanderveer showed that, considering patients of all ages, about 60 per cent are sensitive with a unilateral family history and 67.5 per cent with a bilateral inheritance. In a group of 220 adult patients with nasal allergy reported by Hansel, 61.4 per cent gave a positive family history. 2. The intranasal examination should' note the color of the mucous membranes (pale, water-logged, boggy tissues suggest allergy), the presence of septal deviations or polyps, and the position of purulent secretions with relation to the middle turbinate. It will be recalled in From the Division of Otolaryngology, Department of Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, New York. ... Associate Professor of Surgery, in Charge of Otolaryngology and Bronchoscopy, Unjversity of Rochester, School of Medicine and Dentistry; Otolaryngologist:"i'n-Chief, Rochester Municipal and Strong Memorial Hospitals. ~ 330
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this connection that the anterior group of sinuses (antra, frontals and anterior ethmoids). empty into the nose beneath the middle turbinate, while the posterior group (posterior ethmoids and sphenoids) drain above the posterior portion of this structure. The routine use of the nasopharyngoscope should be urged as part of this study. 3. The transillumination test is easily done by any physician and· is of particular value in detecting changes in the· maxillary sinuses. 4. Study and culture of the nasal and sinal secretions. Smears of the nasal secretions and sinus washings should be stained with eosin-methylene blue and studied for eosinophils. In the allergic nose free from infection, a preponderance of eosinophilic cells may be demonstrated. In the presence of infection, however, these may be largely replaced by neutrophilic (acute infection) or lymphocytic (chronic infection) cells. In such cases it may be necessary to repeat the nasal smears carefully for several days before eosinophils are discovered. Hansel has repeatedly stressed the diagnostic' value of the cytologic examination and it is now accepted as an important part of the study of these chronic nasal and sinus disturbances. The predominating organisms should also be learned by appropriate bacteriological examination. 5. X-ray exmnination. The c.orrelation of well taken radiographs with the clinical and laboratory findings is of the greatest value in chronic sinusitis and should be done routinely in all difficult cases. This study may be further aided by the use of radiopaque substances introduced into the sinuses by cannula or by the displacement method. Treatment.-The limits of this paper do not permit a detailed summary of this important subject. This may be just as well since few experienced rhinologists are in complete agreement on many of the technical problems of management. A few general remarks, however, ~. may be permitted. 1. Systemic factors involving general health, constitutional diseases and, in particular, allergic states must be appropriately controlled so far as possible. Remember that the allergic types of chronic sinusitis can never be controlled by local or surgical methods alone, and that many of our outstanding failures spring from a lack of appreciation of this fact. 2. Local mechanical factors which interfere with proper sinus drainage must be surgically corrected. These include deviations of the nasal septum, hypertrophied turbinates and polyps. 3. A period of conservative local treatment, including irrigation of the affected sinuses or use of the Proetz displacement technic will cure many of the mild types of infection and is indicated in those cases where preliminary allergic study and treatment is to be carried out. The local use of sulfonamide solutions has not been of striking value in these chronic cases. 4. When it is at once or subsequently apparent that surgical meas-
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CLYDE A. HEATLY
ures are necessary for cure, plan the type of surgery to be tried whenever possible with careful thought to the restoration of a functioning nose. This may involve surgery for ventilation, surgery for drainage, or radical measures for the eradication of hopelessly diseased tissue. Proetz's dictum is worth repeating-"More surgery is almost never an improvement on too nluch surgery done before." 5. The exact limitations of intranasal and radical sinus surgery are controversial. F.or example, many experienced" rhinologists will advise an intranasal window resection in cases in which others will feel that only radical antrum surgery will suffice. Careful consideration of all \ the clinical and x-ray findings in the individual problem is imperative. 6. Do not be too hasty in advising sinus surgery in asthmatic states. Although the literature contains many reports of striking improvement in asthmatics after radical sinus surgery, there is increasing evidence that such benefit is either temporary or limited to a small group of patients. It is my opinion that sinus surgery in asthmatics should be carried out only after a preliminary period of careful allergy management, and then onl)T when there are pathologic changes in the sinuses that require operation on their OV\Tn merits or where there is strong evidence of a causal bacte~ial relation. CHRONIC TONSILLITIS
Pathology.-The lymphoid structures of the throat include the adenoid tissue in the nasopharynx, the palatine tonsils, the lingual tonsils and scattered, irregularly developed masses on the lateral and posterior walls of the pharynx. All are similar in that they contain lymphoid tissue with germinal centers. The tonsils possess a well defined capsule which facilitates complete and permanent removal by proper surgical methods. 1"'he adenoids, however, are loosely fonned without encapsulation so that recurrence after removal is commonly observed, particularly in early childhood when" a strong tendency to compensatory hypertrophy exists. A clear understanding of the histologic structure of these tissues is necessary to a proper appreciation of the many disturbances caused by chronic infection. The principal point of interest in this respect lies in the structure of the crypts. These are particularly well developed in the palatine tonsils where they are narrow, deep and ramified in contradistinction to the wide-mouthed, superficial and short crypts seen in the other lymphatic structures of the throat. The epithelium lining these crypts, notably in the palatine tonsils, contains a rich network of capillaries. We know from microscopic study that chronic infection results in ulceration and destruction of portions of this lining epithelium, thus producing a thrombosis of innumerable capillaries as well as many of the larger collecting veins which lie just under the epithelibm. The mouths of such infected crypts are frequently closed
CHRONIC DISEASES OF THE NOSE, THROAT AND EAR
333
by the formation of scar tissue, thus intensifying the infection through lack of drainage. There are no lllUCOUS glands in these crypts to assist .in the expulsion of bacteria and debris. The possibilities for dissemination of infection are further enhanced by the constant movements of the throat as well as by the compression incident to swallowing. It has been estimated that 75 per cent of all primary foci of infection occur in the mucous membranes of the head. The high incidence of chronic tonsillitis in this group can be easily understood in the light of these considerations. . There has been a decided tendency recently to discount the value of tonsillecto7ny and in fact to consider the whole relationship of focal infections greatly overemphasized. This can prove a healthy point of view if it prevents or even lessens indiscriminate surgery. The importance of the properly indicated and carefully performed tonsillectomy, however, is too thoroughly established_to justify a hasty endorsement of this trend.
The Relation of Chronic Tonsilliti~ to ,Certain Systemic Diseases.-l.
Acute Glomerulonephritis.-From the standpoint of etiology, two important clinical facts must be emphasized: (a) In a great majority of instances acute nephritis follows infections of the' upper respiratory tract. (b) Careful bacteriologic and immunologic studies indicate that the hemolytic streptococcus is the chief offender. The removal of diseased tonsils is of great importance in many of these cases. The time for operation should be determined by the internist and is as a rule after the general manifestations of the nephritis have disappeared. Acute exacerbations frequently follow such surgery but usually subside within a short period. 2. Acute Rheumatic Fever.-Rheumatic fever in well over 50 per cent of cases is preceded by a sore throat or tonsillitis. Accumulated experience on the effects of tonsillectomy in this disease may be briefly summarized as follows: (a) It occurs from 25 to 35 per cent less often in tonsillectomized children. (b) When a rheumatic infection has' once manifested itself, however, tonsillectomy does not safeguard the child against recurrent attacks nor against carditis. 3. Arthritis.-Certain forms of arthritis, notably of the infectious or rheumatoid group, seem to be definitely associated with focal infection and are often promptly relieved when the focus is removed. Needless removal of questionable foci should be avoided, especially in the hypertrophic or degenerative groups. 4. Allergy.-It is generally agreed that tonsillectomy does not aid in improving the effects of treatment of respiratory allergy in most instances. Statistics show that nasal or pulmonary allergy may occur with the sanle incidence in the tonsillectomized and nontonsillectomized groups. When tonsillectomy is indicated, it is particularly important to avoid the stage of active allergic symptoms. Patients who
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CLYDE A. HEATLY
are allergic or who give a positive family history of allergy should not be operated on during the hay fever season because of the danger of inducing bronchial or nasal allergy. Finally, all cases of allergy should be under control before resorting to surgery. . 5. Poliomyelitis.-Evidence has accumulated suggesting that there is a causal relationship between the removal of tonsils and the onset of bulbar poliomyelitis within the time interval corresponding to the incubation period of the disease. While this connection cannot be considered established at the present time in view of the conflicting opinions of competent observers, it would nevertheless seem prudent to avoid tonsillectomy when this disease is prevalent. THE CHRONIC EAR
The chronic ear is often bred of neglect and fostered by it. Recent advances in the management of acute aural infections by the intelligent use of chemotherapy may be expected to reduce the incidence of chronic suppuration. It must be emphasized, however, that certain cases of acute otitis, especially those complicating scarlet fever, measles, diphtheria and tuberculosis, have strong chronic tendencies from the onset due to their necrotizing effects on the drum and mucous membranes of the middle ear, as well ,as to the early bone involvement which frequently follows. The attention of both the physician and the patient is often centered on the mere nuisance of the chronic otorrhea without any thoughtful consideration of the potentially serious complications which may develop. The certain progressive loss of hearing, the possibilities of systemic disturbances from a chronic focus, and finally the constant menace of a sudden serious or fatal intracranial invasion make imperative a careful study of the individual case rather than the routine employment of antiseptic drops and a defeatist attitude. ' I. The Location and Signtficance of the Perforation.-Two general groups of perforations occur, the central and the marginal. The most meticulous cleansing of the external canal and drum may be necessary to establish this important distinction. The central perforation occurs in the membrana tensa and, as the name implIes, does not involve the margins of the drum. It is frequently seen in the lower anterior quadrant of the drum as the result of a chronic tubotympanic infection. A large kidney-shaped perforation occupying the lower half of the drum is another common variety. A central perforation is rarely accompanied by necrosis of the bony' walls of the tympanic cavity or of the ossicles, and may be properly classified as the nondcmgerous form of chronic otitis. The marginal perforation, on the other hand, must be viewed as an indication of a potentially dangerous .form of aural suppuration. This type~' ot perforation may appear in variable form, size and location,
CHRONIC DISEASES OF THE NOSE, THROAT AND EAR
335
but, by definition, shows destruction of the periphery of the drum and the annulus tympanicus. A particularly dangerous form of marginal perforation occurs in the membrana flaccida (Shrapnell's area) and is commonly referred to as an attic perforation. Perforations of this type may be small, concealed by a dry adherent crust, and easily overlooked by a casual inspection of the drum. They must be considered the most dangerous type of drum perforations because they indicate suppuration of the attic and tympanic antrum, caries of the incus, and a strong probability of cholesteatomatous formation. Total loss of the membrana tensa or· drum proper should be considered as marginal perforations. 2. Cholesteafoma.-The formation of cholesteatoma occurs in approximately one third of all chronic infections of the ear. Primary cholesteatoma is rare. The so-called secondary or common type follows perforations of the marginal or attic variety-never central perforations. It is caused by an extension of the squamous epithelium of the external canal and tympanic membrane into the middle ear' and as such represents a reparative attempt by nature to cure the suppuration. T~e cholesteatoma consists of a matrix attached to the bony walls of the tympanic antrum or attic from which masses of squamous epithelium are cast 9ff. The layers of epithelium accumulate and the desquamated masses of epithelial cells are trapped within the bony confines of. the tympanic spaces so that a gradually expanding type of tumor is produced. As a result, pressure erosion of surrounding bony structures takes place and invasion of the facial nerve, labyrinth (especially by way of the exposed horizontal canal), or adjacent dural surfaces frequently follows. Such serious complications commonly occur as the result of an acute exacerbation of the chronic suppuration during an acute upper respiratory infection or following swimming. . The cholesteatoma grossly may present a smooth, glistening appearance or in septic cases may resemble a mass of putty. Its odor is characteristically foul. On microscopic study it is found to consist of masses of desquamated epidermis and cholesterin crystals caused by the decomposition of organic matter in the absence of oxygen. In examining a case for the presence of cholesteatoma, material may be secured for microscopic study by passing a small bent cotton applicator through the perforation into the attic region or by gently douching with 50 per cent alcohol through a slender attic cannula. Greasy, foul scales resembling onion skin will be observed floating on the surface of the returned solution. It must be emphasized that many cases of cholesteatoma may remain relatively dormant for many years, with scanty or completely overlooked aural discharge. Such cases are particularly dangerous because the presence of this serious complication is frequently unsuspected until sudden manifest evidences of extension
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CLYDE A. HEATLY
arise. The formation of cholesteatoma may be small, limited to the middle ,ear or attic, or be of enormous size, destroying and occupying most of the mastoid process. 3. Aural Granulations and Polyps.-Granulations are commonly encountered in all forms of chronic otitis and may arise from any portion of the tympanum or attic. They consist of soft, red, easily bleeding tissue and as such are readily identified. Polyps may arise from the infected mucous membranes or from granulation tissue itself. They vary 'greatly in size and appearance. l\lany cases are seen in which a large polyp fills the entire external auditory canal. It is important to emphasize that, ,:vhile polyps may arise from the ossicles, edges of the drum or any portion of'the bony wall, they are commonly attached to the wall of the labyrinth itself. In such instances, removal may precipitate a sudden, overwhelming labyrinthine infection with rapidly fatal meningitis. It is i1nportant to counsel the practitioner against careless removal of aural polyps. If removal is attempted, the base of the polyp should always be cut through clearl)T with the aural snare, exercising great care to avoid traction. In cases of acute exacerbation of a chronic infection with headache, slight vertigo and obstruction to drainage by a large polyp of the canal, the situation calls for immediate radical mastoidectomy, and the physician who attempts to improve drainage by removal of the polyp alone risks a serious complication. It is imperative to conduct careful preliminary studies of labyrinthine function in all cases of aural polyps. 4. X-ray Studies.-It is important to obtain complete x-ray studies in all cases of chronic aural suppuration of the so-called dangerous variety. Nevertheless, it should be pointed out to the practitioner that such studies are seldom as informative as in acute conditions, usually showing a generalized sclerosis in a poorly developed or infantile type of mastoid. Occasionally, however, areas of erosion may be identified, especially in cases of· cholesteatoma. X-rays should be routinely obtained before undertaking radical mastoid surgery. 5. Treatment.-Nondangerous Chronic Otitis.-Chronic infections involving the sinuses or lymphoid structures of the throat must be cleared. In selected cases, particularly in childhood, the direct application of radium to the eustachian orifices has proved of value. Careful systenlatic cleansing of the tympanic cavity followed by insufflation of antiseptic powders, such as boric-iodine (Sulzberger formula) or sulfonamide mixtures, is indicated. Irrigation of the attic by means of a suitable cannula is an effective procedure especially where the perforation is large or in the upper posterior portion of the drum. Alcohol in 50 per cent solution is suitable for this purpose.. Antiseptic drops such as alcohol (50 per cent) or boric acid (20 grains) in alcohol may be presctibed for home use.
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Dangerous Type of Chronic Otitis.-These cases are as a rule best managed by appropriate surgical measures. This is particularly true in the presence of a complicating cholesteatoma. The radical or modified radical operation is generally necessary. The attention of the surgeon should not be distracted by efforts to conserve the already impaired hearing in these dangerous infections. His primary consideration should be meticulous complete removal of the infection. Many of the failures after surgery result from a disregard of this important principle. As a matter of record, it should be noted that the hearing may be slightly inlproved as well as decreased, in about equal proportions, after radical surgery. THE TREATMENT OF D~AFNESS IN CHILDHOOD BY IRRADIATION
Most physicians are aware of the fact that enlarged adenoids are at the root of the majority of ear disorders in childhood. T~e consequent partia~ or complete blockage of the eustachian orifices frequently results in an insidious, slowly progressing deafness, recurring attacks of acute middle ear suppuration, or a persistent chronic otorrhea of the nondangerous variety. It is not so commonly realized that recurrence is exceedingly common after adenoidectomy before the age of puberty (in fully i 5 per cent of cases according to Crowe), and that this recurrence or compensatory growth is frequently around the eustachian orifices where complete surgical removal is difficult or impossible because of possible damage to those important structures. The resulting tubal obstruction over a period of time causes disturbances in the mucous melnbrane of the middle ear, varying from early hyperemia and secretory changes to the formation of a myxomatous or fibrous tissue which interferes· with the mobility of the ossicles. While the physician may suspect a hearing disturbance from otoscopic evidence of retraction of Shrapnell's membrane or of the entire drum, only careful audiometric studies will show its true proportions. The earliest changes are in the high tones between 10,000 and 16,000 double vibrations, which are far above the speech range, but as the mucous menlbrane changes progress, the tones within the speech range gradually become involved. This impaired hearing for high tones with good hearing for low tones is the earliest symptom of middle ear deafness in childhood. Although apparently contrary to the classical dictum in otology that such high tone loss indicates an inner ear or nerve lesion, the extensive investigations of Crowe and his associates have established it as a clinical fact. The possibilities of reducing the size of lymphoid tissue and temporarily inhibiting its growth by irradiation in doses too small to injure surrounding structures have been known for many years. Crowe and Burnham first made extensive clinical use of radon applied by means of a special applicator passed through the nose to the region of the
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CLYDE A. HEATLY \
eustachian orifices. Their success in so treating these cases· of middle ear deafness in childhood has prompted others to employ a similar method, using radium rather than radon. The writer and his associates in 1942 reported* on the successful use of a special applicator holding two 12.5 mg. radium needles in its head. The use of two such applicators, using a total of 50 mg. of radium, permits the treatment of both eustachian orifices in twelve minutes, delivering a dose of 5· milligram hours to each orifice. Such a short treatment time with this small amount of radium is made possible by the fact .that a high proportion of beta radiation is used in actual conta.ct with the area to be treated. The applicators are small and can be introduced in most children under local anesthesia. An interval of three months is usually allowed before a second irradiation is given. This dosage is far below the amount of radium which could cause any injury to the mucous membranes and surrounding structures. The results have fully substantiated the successes reported by Crowe and his associates. The phY'sician who is alert to the frequency of deafness. in childhood and its common cause may thus render a valuable service in preventing the establishment of permanent changes. • Emerson, E. B., Dowdy, A. H., and Heady, C. A.: Use of Radium in Treatment of Deafness by Irradiation. Arch. Otolaryng., 35:845-852 (June) 1942.
CLYDE A. HEATLY, M.D., F.A.C.S.· CHRONIC SINUSITIS
THE most common as well as the most difficult problems encountered in chronic nasal disturbances involve diseases of the nasal sinuses. Many significant advances have been made in recent years in the diagnosis and management of these disorders. The competent rhinologist \ has learned the importance of allergy in relation to chronic sinusitis from accumulated failures in cases in which this factor had been overlooked. He has also come to a better understanding of the physiology of the nose and thereby to a sounder appreciation of the valu,e of carefully planned surgery which conserves rather than needlessly destroys nasal structures. Classification of Sinusitis.-Many classifications of chronic sinusitis have been suggested. It is perhaps simplest from the clinical standpoint to consider three groups: ( 1) chronic suppurative sinusitis; (2) chronic hyperplastic sinusitis, which is predominantly allergic, and (3) mixed forms in which a chronic infection has been superimposed on an underlying allergy. Allergy produces profound changes in the nasal and sinal mucosa ranging fronl simple pallor and edema to extensive polypoid formation. These structural changes favor the. stagnation of secretions by interference with ventilation and drainage and thereby promote the chronicity of secondary infections. It is now generally recognized that nasal polyps are a manifestation of chronic nasal allergy in most instances. Their well known tendency to recur, therefore, can be controlled only by appropriate management of allergy. Diagnosis.-1. A careful history is essential and should include questions directed to a possible underlying allergy. A family history of allergy is of great importance. The studies of Cooke and Vanderveer showed that, considering patients of all ages, about 60 per cent are sensitive with a unilateral family history and 67.5 per cent with a bilateral inheritance. In a group of 220 adult patients with nasal allergy reported by Hansel, 61.4 per cent gave a positive family history. 2. The intranasal examination should' note the color of the mucous membranes (pale, water-logged, boggy tissues suggest allergy), the presence of septal deviations or polyps, and the position of purulent secretions with relation to the middle turbinate. It will be recalled in From the Division of Otolaryngology, Department of Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, New York. ... Associate Professor of Surgery, in Charge of Otolaryngology and Bronchoscopy, Unjversity of Rochester, School of Medicine and Dentistry; Otolaryngologist:"i'n-Chief, Rochester Municipal and Strong Memorial Hospitals. ~ 330
CHRONIC DISEASES OF THE NOSE, THROAT AND EAR
331
this connection that the anterior group of sinuses (antra, frontals and anterior ethmoids). empty into the nose beneath the middle turbinate, while the posterior group (posterior ethmoids and sphenoids) drain above the posterior portion of this structure. The routine use of the nasopharyngoscope should be urged as part of this study. 3. The transillumination test is easily done by any physician and· is of particular value in detecting changes in the· maxillary sinuses. 4. Study and culture of the nasal and sinal secretions. Smears of the nasal secretions and sinus washings should be stained with eosin-methylene blue and studied for eosinophils. In the allergic nose free from infection, a preponderance of eosinophilic cells may be demonstrated. In the presence of infection, however, these may be largely replaced by neutrophilic (acute infection) or lymphocytic (chronic infection) cells. In such cases it may be necessary to repeat the nasal smears carefully for several days before eosinophils are discovered. Hansel has repeatedly stressed the diagnostic' value of the cytologic examination and it is now accepted as an important part of the study of these chronic nasal and sinus disturbances. The predominating organisms should also be learned by appropriate bacteriological examination. 5. X-ray exmnination. The c.orrelation of well taken radiographs with the clinical and laboratory findings is of the greatest value in chronic sinusitis and should be done routinely in all difficult cases. This study may be further aided by the use of radiopaque substances introduced into the sinuses by cannula or by the displacement method. Treatment.-The limits of this paper do not permit a detailed summary of this important subject. This may be just as well since few experienced rhinologists are in complete agreement on many of the technical problems of management. A few general remarks, however, ~. may be permitted. 1. Systemic factors involving general health, constitutional diseases and, in particular, allergic states must be appropriately controlled so far as possible. Remember that the allergic types of chronic sinusitis can never be controlled by local or surgical methods alone, and that many of our outstanding failures spring from a lack of appreciation of this fact. 2. Local mechanical factors which interfere with proper sinus drainage must be surgically corrected. These include deviations of the nasal septum, hypertrophied turbinates and polyps. 3. A period of conservative local treatment, including irrigation of the affected sinuses or use of the Proetz displacement technic will cure many of the mild types of infection and is indicated in those cases where preliminary allergic study and treatment is to be carried out. The local use of sulfonamide solutions has not been of striking value in these chronic cases. 4. When it is at once or subsequently apparent that surgical meas-
332
CLYDE A. HEATLY
ures are necessary for cure, plan the type of surgery to be tried whenever possible with careful thought to the restoration of a functioning nose. This may involve surgery for ventilation, surgery for drainage, or radical measures for the eradication of hopelessly diseased tissue. Proetz's dictum is worth repeating-"More surgery is almost never an improvement on too nluch surgery done before." 5. The exact limitations of intranasal and radical sinus surgery are controversial. F.or example, many experienced" rhinologists will advise an intranasal window resection in cases in which others will feel that only radical antrum surgery will suffice. Careful consideration of all \ the clinical and x-ray findings in the individual problem is imperative. 6. Do not be too hasty in advising sinus surgery in asthmatic states. Although the literature contains many reports of striking improvement in asthmatics after radical sinus surgery, there is increasing evidence that such benefit is either temporary or limited to a small group of patients. It is my opinion that sinus surgery in asthmatics should be carried out only after a preliminary period of careful allergy management, and then onl)T when there are pathologic changes in the sinuses that require operation on their OV\Tn merits or where there is strong evidence of a causal bacte~ial relation. CHRONIC TONSILLITIS
Pathology.-The lymphoid structures of the throat include the adenoid tissue in the nasopharynx, the palatine tonsils, the lingual tonsils and scattered, irregularly developed masses on the lateral and posterior walls of the pharynx. All are similar in that they contain lymphoid tissue with germinal centers. The tonsils possess a well defined capsule which facilitates complete and permanent removal by proper surgical methods. 1"'he adenoids, however, are loosely fonned without encapsulation so that recurrence after removal is commonly observed, particularly in early childhood when" a strong tendency to compensatory hypertrophy exists. A clear understanding of the histologic structure of these tissues is necessary to a proper appreciation of the many disturbances caused by chronic infection. The principal point of interest in this respect lies in the structure of the crypts. These are particularly well developed in the palatine tonsils where they are narrow, deep and ramified in contradistinction to the wide-mouthed, superficial and short crypts seen in the other lymphatic structures of the throat. The epithelium lining these crypts, notably in the palatine tonsils, contains a rich network of capillaries. We know from microscopic study that chronic infection results in ulceration and destruction of portions of this lining epithelium, thus producing a thrombosis of innumerable capillaries as well as many of the larger collecting veins which lie just under the epithelibm. The mouths of such infected crypts are frequently closed
CHRONIC DISEASES OF THE NOSE, THROAT AND EAR
333
by the formation of scar tissue, thus intensifying the infection through lack of drainage. There are no lllUCOUS glands in these crypts to assist .in the expulsion of bacteria and debris. The possibilities for dissemination of infection are further enhanced by the constant movements of the throat as well as by the compression incident to swallowing. It has been estimated that 75 per cent of all primary foci of infection occur in the mucous membranes of the head. The high incidence of chronic tonsillitis in this group can be easily understood in the light of these considerations. . There has been a decided tendency recently to discount the value of tonsillecto7ny and in fact to consider the whole relationship of focal infections greatly overemphasized. This can prove a healthy point of view if it prevents or even lessens indiscriminate surgery. The importance of the properly indicated and carefully performed tonsillectomy, however, is too thoroughly established_to justify a hasty endorsement of this trend.
The Relation of Chronic Tonsilliti~ to ,Certain Systemic Diseases.-l.
Acute Glomerulonephritis.-From the standpoint of etiology, two important clinical facts must be emphasized: (a) In a great majority of instances acute nephritis follows infections of the' upper respiratory tract. (b) Careful bacteriologic and immunologic studies indicate that the hemolytic streptococcus is the chief offender. The removal of diseased tonsils is of great importance in many of these cases. The time for operation should be determined by the internist and is as a rule after the general manifestations of the nephritis have disappeared. Acute exacerbations frequently follow such surgery but usually subside within a short period. 2. Acute Rheumatic Fever.-Rheumatic fever in well over 50 per cent of cases is preceded by a sore throat or tonsillitis. Accumulated experience on the effects of tonsillectomy in this disease may be briefly summarized as follows: (a) It occurs from 25 to 35 per cent less often in tonsillectomized children. (b) When a rheumatic infection has' once manifested itself, however, tonsillectomy does not safeguard the child against recurrent attacks nor against carditis. 3. Arthritis.-Certain forms of arthritis, notably of the infectious or rheumatoid group, seem to be definitely associated with focal infection and are often promptly relieved when the focus is removed. Needless removal of questionable foci should be avoided, especially in the hypertrophic or degenerative groups. 4. Allergy.-It is generally agreed that tonsillectomy does not aid in improving the effects of treatment of respiratory allergy in most instances. Statistics show that nasal or pulmonary allergy may occur with the sanle incidence in the tonsillectomized and nontonsillectomized groups. When tonsillectomy is indicated, it is particularly important to avoid the stage of active allergic symptoms. Patients who
334
CLYDE A. HEATLY
are allergic or who give a positive family history of allergy should not be operated on during the hay fever season because of the danger of inducing bronchial or nasal allergy. Finally, all cases of allergy should be under control before resorting to surgery. . 5. Poliomyelitis.-Evidence has accumulated suggesting that there is a causal relationship between the removal of tonsils and the onset of bulbar poliomyelitis within the time interval corresponding to the incubation period of the disease. While this connection cannot be considered established at the present time in view of the conflicting opinions of competent observers, it would nevertheless seem prudent to avoid tonsillectomy when this disease is prevalent. THE CHRONIC EAR
The chronic ear is often bred of neglect and fostered by it. Recent advances in the management of acute aural infections by the intelligent use of chemotherapy may be expected to reduce the incidence of chronic suppuration. It must be emphasized, however, that certain cases of acute otitis, especially those complicating scarlet fever, measles, diphtheria and tuberculosis, have strong chronic tendencies from the onset due to their necrotizing effects on the drum and mucous membranes of the middle ear, as well ,as to the early bone involvement which frequently follows. The attention of both the physician and the patient is often centered on the mere nuisance of the chronic otorrhea without any thoughtful consideration of the potentially serious complications which may develop. The certain progressive loss of hearing, the possibilities of systemic disturbances from a chronic focus, and finally the constant menace of a sudden serious or fatal intracranial invasion make imperative a careful study of the individual case rather than the routine employment of antiseptic drops and a defeatist attitude. ' I. The Location and Signtficance of the Perforation.-Two general groups of perforations occur, the central and the marginal. The most meticulous cleansing of the external canal and drum may be necessary to establish this important distinction. The central perforation occurs in the membrana tensa and, as the name implIes, does not involve the margins of the drum. It is frequently seen in the lower anterior quadrant of the drum as the result of a chronic tubotympanic infection. A large kidney-shaped perforation occupying the lower half of the drum is another common variety. A central perforation is rarely accompanied by necrosis of the bony' walls of the tympanic cavity or of the ossicles, and may be properly classified as the nondcmgerous form of chronic otitis. The marginal perforation, on the other hand, must be viewed as an indication of a potentially dangerous .form of aural suppuration. This type~' ot perforation may appear in variable form, size and location,
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but, by definition, shows destruction of the periphery of the drum and the annulus tympanicus. A particularly dangerous form of marginal perforation occurs in the membrana flaccida (Shrapnell's area) and is commonly referred to as an attic perforation. Perforations of this type may be small, concealed by a dry adherent crust, and easily overlooked by a casual inspection of the drum. They must be considered the most dangerous type of drum perforations because they indicate suppuration of the attic and tympanic antrum, caries of the incus, and a strong probability of cholesteatomatous formation. Total loss of the membrana tensa or· drum proper should be considered as marginal perforations. 2. Cholesteafoma.-The formation of cholesteatoma occurs in approximately one third of all chronic infections of the ear. Primary cholesteatoma is rare. The so-called secondary or common type follows perforations of the marginal or attic variety-never central perforations. It is caused by an extension of the squamous epithelium of the external canal and tympanic membrane into the middle ear' and as such represents a reparative attempt by nature to cure the suppuration. T~e cholesteatoma consists of a matrix attached to the bony walls of the tympanic antrum or attic from which masses of squamous epithelium are cast 9ff. The layers of epithelium accumulate and the desquamated masses of epithelial cells are trapped within the bony confines of. the tympanic spaces so that a gradually expanding type of tumor is produced. As a result, pressure erosion of surrounding bony structures takes place and invasion of the facial nerve, labyrinth (especially by way of the exposed horizontal canal), or adjacent dural surfaces frequently follows. Such serious complications commonly occur as the result of an acute exacerbation of the chronic suppuration during an acute upper respiratory infection or following swimming. . The cholesteatoma grossly may present a smooth, glistening appearance or in septic cases may resemble a mass of putty. Its odor is characteristically foul. On microscopic study it is found to consist of masses of desquamated epidermis and cholesterin crystals caused by the decomposition of organic matter in the absence of oxygen. In examining a case for the presence of cholesteatoma, material may be secured for microscopic study by passing a small bent cotton applicator through the perforation into the attic region or by gently douching with 50 per cent alcohol through a slender attic cannula. Greasy, foul scales resembling onion skin will be observed floating on the surface of the returned solution. It must be emphasized that many cases of cholesteatoma may remain relatively dormant for many years, with scanty or completely overlooked aural discharge. Such cases are particularly dangerous because the presence of this serious complication is frequently unsuspected until sudden manifest evidences of extension
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arise. The formation of cholesteatoma may be small, limited to the middle ,ear or attic, or be of enormous size, destroying and occupying most of the mastoid process. 3. Aural Granulations and Polyps.-Granulations are commonly encountered in all forms of chronic otitis and may arise from any portion of the tympanum or attic. They consist of soft, red, easily bleeding tissue and as such are readily identified. Polyps may arise from the infected mucous membranes or from granulation tissue itself. They vary 'greatly in size and appearance. l\lany cases are seen in which a large polyp fills the entire external auditory canal. It is important to emphasize that, ,:vhile polyps may arise from the ossicles, edges of the drum or any portion of'the bony wall, they are commonly attached to the wall of the labyrinth itself. In such instances, removal may precipitate a sudden, overwhelming labyrinthine infection with rapidly fatal meningitis. It is i1nportant to counsel the practitioner against careless removal of aural polyps. If removal is attempted, the base of the polyp should always be cut through clearl)T with the aural snare, exercising great care to avoid traction. In cases of acute exacerbation of a chronic infection with headache, slight vertigo and obstruction to drainage by a large polyp of the canal, the situation calls for immediate radical mastoidectomy, and the physician who attempts to improve drainage by removal of the polyp alone risks a serious complication. It is imperative to conduct careful preliminary studies of labyrinthine function in all cases of aural polyps. 4. X-ray Studies.-It is important to obtain complete x-ray studies in all cases of chronic aural suppuration of the so-called dangerous variety. Nevertheless, it should be pointed out to the practitioner that such studies are seldom as informative as in acute conditions, usually showing a generalized sclerosis in a poorly developed or infantile type of mastoid. Occasionally, however, areas of erosion may be identified, especially in cases of· cholesteatoma. X-rays should be routinely obtained before undertaking radical mastoid surgery. 5. Treatment.-Nondangerous Chronic Otitis.-Chronic infections involving the sinuses or lymphoid structures of the throat must be cleared. In selected cases, particularly in childhood, the direct application of radium to the eustachian orifices has proved of value. Careful systenlatic cleansing of the tympanic cavity followed by insufflation of antiseptic powders, such as boric-iodine (Sulzberger formula) or sulfonamide mixtures, is indicated. Irrigation of the attic by means of a suitable cannula is an effective procedure especially where the perforation is large or in the upper posterior portion of the drum. Alcohol in 50 per cent solution is suitable for this purpose.. Antiseptic drops such as alcohol (50 per cent) or boric acid (20 grains) in alcohol may be presctibed for home use.
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Dangerous Type of Chronic Otitis.-These cases are as a rule best managed by appropriate surgical measures. This is particularly true in the presence of a complicating cholesteatoma. The radical or modified radical operation is generally necessary. The attention of the surgeon should not be distracted by efforts to conserve the already impaired hearing in these dangerous infections. His primary consideration should be meticulous complete removal of the infection. Many of the failures after surgery result from a disregard of this important principle. As a matter of record, it should be noted that the hearing may be slightly inlproved as well as decreased, in about equal proportions, after radical surgery. THE TREATMENT OF D~AFNESS IN CHILDHOOD BY IRRADIATION
Most physicians are aware of the fact that enlarged adenoids are at the root of the majority of ear disorders in childhood. T~e consequent partia~ or complete blockage of the eustachian orifices frequently results in an insidious, slowly progressing deafness, recurring attacks of acute middle ear suppuration, or a persistent chronic otorrhea of the nondangerous variety. It is not so commonly realized that recurrence is exceedingly common after adenoidectomy before the age of puberty (in fully i 5 per cent of cases according to Crowe), and that this recurrence or compensatory growth is frequently around the eustachian orifices where complete surgical removal is difficult or impossible because of possible damage to those important structures. The resulting tubal obstruction over a period of time causes disturbances in the mucous melnbrane of the middle ear, varying from early hyperemia and secretory changes to the formation of a myxomatous or fibrous tissue which interferes· with the mobility of the ossicles. While the physician may suspect a hearing disturbance from otoscopic evidence of retraction of Shrapnell's membrane or of the entire drum, only careful audiometric studies will show its true proportions. The earliest changes are in the high tones between 10,000 and 16,000 double vibrations, which are far above the speech range, but as the mucous menlbrane changes progress, the tones within the speech range gradually become involved. This impaired hearing for high tones with good hearing for low tones is the earliest symptom of middle ear deafness in childhood. Although apparently contrary to the classical dictum in otology that such high tone loss indicates an inner ear or nerve lesion, the extensive investigations of Crowe and his associates have established it as a clinical fact. The possibilities of reducing the size of lymphoid tissue and temporarily inhibiting its growth by irradiation in doses too small to injure surrounding structures have been known for many years. Crowe and Burnham first made extensive clinical use of radon applied by means of a special applicator passed through the nose to the region of the
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eustachian orifices. Their success in so treating these cases· of middle ear deafness in childhood has prompted others to employ a similar method, using radium rather than radon. The writer and his associates in 1942 reported* on the successful use of a special applicator holding two 12.5 mg. radium needles in its head. The use of two such applicators, using a total of 50 mg. of radium, permits the treatment of both eustachian orifices in twelve minutes, delivering a dose of 5· milligram hours to each orifice. Such a short treatment time with this small amount of radium is made possible by the fact .that a high proportion of beta radiation is used in actual conta.ct with the area to be treated. The applicators are small and can be introduced in most children under local anesthesia. An interval of three months is usually allowed before a second irradiation is given. This dosage is far below the amount of radium which could cause any injury to the mucous membranes and surrounding structures. The results have fully substantiated the successes reported by Crowe and his associates. The phY'sician who is alert to the frequency of deafness. in childhood and its common cause may thus render a valuable service in preventing the establishment of permanent changes. • Emerson, E. B., Dowdy, A. H., and Heady, C. A.: Use of Radium in Treatment of Deafness by Irradiation. Arch. Otolaryng., 35:845-852 (June) 1942.