NASAL STENOSIS. ITS INFLUENCE ON OLFACTION, AUDITION, VOCALIZA- By J. O. ROE, M.D., ROCHESTER, N. Y., FELLOW OF THE AMERICAN LARYNGOLOGICAL ASSOCIATION, ETC. (Read before the New York State Medical Society, February 1, 1881.) THE office of the nose in the animal economy is a very important one. the permanent incisors overlapping and convergent, the two halves of the upper dental arch more or less. V-shaped, the vault of the mouth high and narrow, and the nose very peculiarly prominent and projecting. This projecting appearance of the nose is due to two causes: 1st, a retarded growth of the perpendicular plate of the ethmoid; 2d, a high-pitched and narrow, hard palate. This prevents the vomer from growing downward, and, not being able to grow backward, it is crowded forward, thus producing the projecting and often unsightly nose. In addition to Besides being a part of the mechanism of facial ex- these errors in developmental force, we have another pression, it performs four very important functions: force operating on these delicate and yielding parts, 1st, it contains within its cavities one of the organs when the nasal passages become occluded. It is the of special sense, that of olfaction; 2d, it affords ac- suction caused by deglutition and the repeated atcess of air or ventilation to the middle ear, or tym-tempts at inspiration through the nose, which tend panum, through the nasal passages and Eustachian tube; 3d, it enters as a prominent factor into the mechanism of vocalization; 4th, it is a very important portion of the respiratory apparatus in affording protection to the organs below. For any or all of these functions to be performed properly the essential and indispensable condition is a clear and unobstructed passage through both the nasal openings. Obstructions of the nasal passages may be divided into three principal classes: 1st, those arising from defective growth or deformity of the cartilaginous and bony framework; 2d, those existing in the soft parts, resulting from hypertrophic or other diseased conditions; 3d, those caused by foreign bodies and neoplastic growths. I. Obstructions in the hard parts.-In studying the development of the nose in relation to the growth of other parts and organs, we find that it takes place much more slowly, and that the size of the nasal cavities in children are much smaller relatively than in adults. The anthra Highmorianum, which are the first of the sinuses to appear, begin to be formed about the fourth month of fetal life, and at birth are very small, round cavities, but as development takes place they become large, irregular, and pyramidal. The frontal sinuses and ethmoidal cells do not begin to form until two years later. At birth the vertical plate of the ethmoid is cartilaginous, but the vomer is already ossified. The cribriform plate is a mere membrane continuous with the falx cerebri of the dura mater, and attached behind to the partially ossified body of the sphenoid.1 It is this late development of the central portion of the face and skull, and more particularly of the frontal eminences and sinuses, that gives a flattened appearance to the nose of the infant. As a result of this tardy growth many errors of development take place. To those already recognized, viz., hare-lip, cleft palate, cervical fistulæ, and dermoid tumor, Dr. Harrison Allen, of Philadelphia, adds another, the asymmetrical rate of growth between the visceral arches, which prevents the perfect shaping of the oral and nasal cavities. Thus, when one arch has not grown as actively as the other, the nasal chamber on the same side will be found narrowed and obstructed, and the septum deflected to that side, while the opposite chamber will be large and capacious. In these cases of congenital deformity of the oral and nasal cavities the teeth will also be found irregular, 1 Watson: Diseases of the Nose, p. 22. Philadelphia Medical Times, December 6, 1879, p. 120. to produce a partial vacuum in the nasal chambers, thereby preventing the frontal eminences from expanding, and causing the anthra to remain small and undeveloped. Deviation of the septum from the normal median line is a frequent cause of nasal obstruction. The frequency of its occurrence has been shown by Dr. Allen in his study of fifty-eight adult crania preserved in the Wister and Horner Museum. Of these only eighteen exhibited normal nasal chambers; in the remaining forty, nineteen were found in which the curvature was so great as to be in contact with the superior and middle turbinated bones. In fortynine skulls examined by Semeleder, the septum was straight in ten of them, bent toward the left in twenty, toward the right in fifteen, and in four it was in the shape of an S. Usually, the deflection is in the anterior portion of the septum, although there may be as many as three distinct curves, thus forming in shape a letter S, and thereby occluding both nostrils. I have recently had under treatment a child four years old, having a severe catarrhal trouble and incipient deafness. In this case the septum had three distinct curves, closing both nostrils. This was congenital. and the nostrils had been impervious to air since birth. contour of the nose is usually straight, but, as the In children with deformed nasal septa the external child develops, the growth of the septum turns the nose to one side, narrowing or nearly closing one or both nostrils. This is also the case with the cartilaginous portion, whether from congenital deformity or accidental displacement of the cartilage, which has been allowed to go uncorrected. Deflection or deformity of the nose is often produced by the common practice of pressing more firmly on one side than the other in the act of blowing, in order to force out a profuse or tenacious secretion from the other side. Beclard explains it by the habit of wiping the nose with the right hand, as it is most often turned to that side, while in left-handed people it is turned to the left side. I have seen several cases in which the septum was deflected to such a degree from this cause as to greatly narrow the calibre of the nostrils. In other bony structures of the nasal fossa we meet with deformities diminishing its calibre. Not unfrequently one or more of the turbinated bones are very large, and projecting across to the vomer, occluding or greatly narrowing the nostril; and, as has been observed by Lennox Browne, the ⚫ American Journal of Medical Science, January, 1880, p. 70. . nostril may also be occluded by angular curvature forward of the upper cervical vertebra." II. Obstruction by the soft parts.-The form of nasal obstruction which is most frequently found in the soft parts is a hypertrophied or turgescent condition of the tissues covering the inferior and middle turbinated bones and the lower half of the septum. The cause for this is in the histological structures of the tissues of this region. Each nasal passage is divided anatomically into three distinct regions, viz. the vestibule, the respiratory region, and the olfactory region. It is the engorgement of this tissue which causes the sudden impaction of the nose in attacks of acute coryza or on exposure to irritants, and not simply engorgement of the vascular mucous membrane, as is so commonly supposed. The effect which pro The vestibule, the anterior portion of the nasal cavity, contains but little loose cellular tissue, but few blood-vessels, and accordingly it is rare that an obstruction occurs in the soft parts of this region, except from membranous occlusion. The olfactory region is located in the superior portion of the passage, and extends downward to the upper border of the middle tur-longed engorgement of this cavernous tissue will binated bone, and to a corresponding extent on the septum, where the olfactory nerve is supposed to terminate. The respiratory passage is that portion of the cavity below this point, and is to be regarded as a continuation of the respiratory tract. FIG. 1.-Portion of upper jaw, showing inferior and middle turbinated bones, sections of turbinated corpora cavernosa, inflated, dried, and magnified two diameters (after Bigelow). The tissues of these two regions differ greatly in character and thickness. The mucous membrane covering the superior portion is scantily supplied with blood-vessels, and is quite thin, except where the olfactory nerve is distributed. Here the membrane is thick, soft, and pulpy, and contains numer ous glands of Bowman, which are peculiar to this region. In the respiratory portion the mucous membrane and submucous tissue is thick and vascular and contains numerous mucous glands. In addition to the numerous venous plexi, which are here found very abundant, particularly over the posterior portion of the turbinated bones and the septum, there exists a true erectile tissue analogous to the cavernous tissue of the penis. The analogy of this tissue in the nares to the erectile tissue of the genital organs was observed by Kohlrausch' twenty-seven years ago. Afterward, Kölliker" observed the same similarity; but to Prof. Bigelow, of Boston, is due the honor of demonstrating the identity of these tissues, and pointing out the connection of this erectile tissue in the nose with nasal disease. To this he gave the name of "turbinated corpora cavernosa," a microscopic section of which is shown in Figs. 1 and 2. A study of this tissue, in connection with frequent colds in the head, discloses the key to the great prevalence of obstructed nostrils from hypertrophied tissue, and also of nasal catarrh. The rarity of the recognition of this cause leads Professor Bigelow to remark that "it will be perhaps conceded that practitioners are not generally familiar with this anatomy, of which they will readily make a practical application." British Medical Journal, August 24, 1878, p. 282. Handbuch der Gewebelehre des Menchen. p. 741. Leipzig, 1867. produce in the surrounding parts is illustrated by the case cited by Dr. Bumstead of an attack of urethritis, which was brought on by an excitement of one day's duration. Thus, as a result of each cold monly find it, as taken from one of a number of similar cases in the practice of the writer. We can readily understand from the nature of this tissue, being as it is under the control of the vasomotor nerves, subject and very sensitive to emotional influence from various external impressions, how it is that the nostrils will become so suddenly closed from slight exposure to local irritating causes, as dust, acrid vapors, and the like; or from peripheral reflex causes, as sitting in a slight draught or sudden exposure to cold chilling the surface of the 90 body; or from cold hands or feet. Turgidity of this tissue is often caused by emotions. The emotional effect of a blush is also participated in by the other parts as well as by the cheek. It is often observed that in conditions of apparently slight cold one nostril may be closed when soon there will be an interchange to the opposite nostril, the first nostril becoming free. This is doubtedly due to the functional activity of the coats of the vessels. When the nostril becomes closed the local irritant is excluded and the engorgement soon taken place to in turn become a cause for further and continued trouble. In addition to obstruction and atresia of the nasal passages by hypertrophied tissue or by a congenital osseous deformity, a variety of other pathological processes may produce this condition-such as syphilitic ulcerations and cicatricial contractions, polypi, and other tumors and neuroses. Functions depending on unobstructed nasal passages. un--We will now briefly consider the functions depending on normally free and unobstructed nasal passages, viz.: Olfaction, audition, vocalization, and respiration, and the manner in which these become impaired or deranged by the narrowing or closing of these passages. Olfaction. In the perfect performance of the olfactory function there is of necessity a free and complete interchange of the air in the nasal cavities during each respiration, by which means the odoriferous particles are brought in contact with the terminal fibres of the olfactory nerve. To fully perceive a very delicate odor we instinctively snuff or draw the air forcibly through the passages to carry the odorous particles with full force and in greater quantities up into the olfactory region; consequently, if the free circulation of air through the nose is obstructed or cut off altogether, the sense of smell becomes correspondingly impaired. FIG. 4.-Represents the anterior appearance of the hypertrophy on In many instances, however, the impairment of the The sense of smell is also impaired by the disease obstructing the respiratory passage extending by continuity of tissue to the tissue of the olfactory reEtiology.-Hypertrophy of the nasal mucous mem-gion, impairing the free ends of the olfactory cells, brane can invariably be traced to a catarrhal origin. In many cases it is supposed to be due to a catarrhal, strumous, tuberculous, rachitic, or gouty diathesis, which, to my mind, are only so many terms to indicate different and peculiar manifestations of teriorly or posteriorly, as well as if it be located at the region of olfaction. Effect on the voice. The tortuous nasal passages have the effect on the voice to increase its resonance, or to re-enforce it, as it is termed an effect similar to that of the sounding-board in the piano, or, to use a better illustration, of the long and curved pipe in the horn or cornet. the naso-pharyngeal space and middle ear, by the suction naturally following the descent of the bolus. This tendency to produce a partial vacuum is prevented by air entering freely through the nasal passages, and the normal air-pressure in the posterior nares and middle ear is maintained. If the anterior nasal passages become closed, it is readily perceived that, during each act of swallowing, In addition to the nasal cavities we have six sinu- a corresponding degree of disturbance in air-pressure ses-two maxillary, two frontal, and two sphenoidal-will take place in the nasal cavity, and in the ear which communicate with the nasal cavities and also also, because of the direct communication through act as resonators to the voice. the Eustachian tube. These are evidently somewhat analogous in their effect to the reverberations produced by the fosse found in the os hyoides in howling monkeys.1o Obstruction of the nasal passages has a marked effect on the acoustic properties of the voice. It is a very common observation in case of attacks of acute nasal catarrh, or coryza, where the nasal passages are blocked by the swollen pituitary membrane, that the voice loses its timbre or resonant qualities, and, in common parlance, we "speak through the nose," a term, however, which expresses a condition directly opposite to the one that in reality exists. The peculiar thickness in the articulation, and indistinctness of enunciation, or so-called stagnation" of the tone, caused by partially obstructed nostrils, is most marked in pronouncing words ending in "ing," when the nasal ending is cut off. This defective enunciation and unpleasant nasal twang is to be observed in many public speakers, and is made painfully apparent to their listeners by the absence of euphony from their most rounded and polished sentences. In cases of complete obstruction, the letters "m" and "n" become perverted into "b" and "d," as was first pointed out by Meyer" to be the case in obstruction from adenoid growths. The manner in which this substitution takes place is very clearly explained by Löwenberg." In obstructed nares, much of the melody, richness, and fulness of the singing voice is lost. The highest, the head-tones, and usually the richest tones of the voice, are absent, and accordingly the voice becomes flat and nasal. Effect on the ear.-Toynbee first demonstrated by a series of experiments the altered condition of atmospheric pressure in the fauces and ears when swallowing with closed nostrils. Lucae repeated these experiments, and also observed that, with obstructed nostrils, these changes in atmospheric pressure produced abnormal tension of the membrana tympani, which gradually produced indistinctness in hearing." Let us briefly consider the manner in which these changes are produced. With the completion of the first stage, and during the second stage, in the act of swallowing, the nasal passages and the upper pharyngeal space are almost completely shut off from the pharynx by the soft palate being closed firmly against the posterior pharyngeal wall. In the third stage of this act, the pharyngeal constrictors close by reflex action on the substance swallowed, and force it onward in its course to the stomach, and at the same time air is exhausted from This aural pressure one can very easily illustrate on himself by closing the nostrils while swallowing, when a marked sensation of pressure will be felt in both ears, supposing the Eustachian tubes to be unobstructed, and with the aural speculum this movement inward of the drum-head can readily be seen. I have found it to be a rule that when the nostrils are not free enough to permit one to breathe entirely through them, even during a brisk walk, they are not sufficiently free to maintain the aural equilib rium during continued acts of swallowing. It is an undoubted fact that, even in a state of repose, air continually permeates the Eustachian tubes," and that more or less of the aërial conduction of the sounds of the voice in autophony is through the Eustachian tubes. Were this not the case, and did air enter the ears only during the act of deglutition, as stated by most authorities, an uncomfortable aural pressure and a slight impairment of the hearing would not take place almost immediately upon the stoppage of the Eustachian tubes by a plug of mucus, or from any other cause, whereas one may remain for hours, awake or asleep, without swallowing, and yet the ears and hearing remain perfectly normal. Thus we see that a continually free communica tion of the external air with the middle ear is necessary to perfect hearing, and as the air cannot be supplied to the tympanic cavity by any other route than through the nasal passages and Eustachian tubes, so the aural pressure is lessened in proportion to the degree of nasal obstruction. If the obstruction is great, aural changes take place rapidly; if it is only slight, they go on more slowly, sometimes imperceptibly, and sooner or later the most serious functional and structural changes take place. The continuous external pressure increases the concavity, and causes a rigidity of the membrana tympani. From this results an inactivity of the ossicular chain, and from this inactivity the delicate articulations become stiffened, impacted, and finally immovable. Besides, the tensor tympani muscle and ligament become relaxed and ultimately rigid from disuse, so that, as remarks Cassells," "were it possible, which it seldom is, to remove the other consequences of altered tension, this contracted tendon, and ligament mars the best efforts of the practi tioner to effect an improvement." The characteristic symptoms are gradually increas ing deafness, giddiness, distressing tinnitus, which diminish or altogether pass away as the deafness deepens. If this condition is still allowed to go unrelieved, another and sometimes more serious set of changes supervene. In consequence of the catarrh and thickening of the mucous membrane of the naso-pharynx, the Eustachian tubes become invaded, and concentrically closed, 1st, by the collapse of their flaccid walls by the suction or negative pressure; 2d, by the catarrh and thickening of the mucous membrane of the naso-pharynx invariably attending nasal stenosis. The air thus shut up in the tympanic cavities is speedily disposed of, and, as a result of the diminished pressure, engorgement of the lining membrane of the cavity follows, and free serous transudation takes place sufficiently to fill the tympanum, and from the pressure of the imprisoned fluid the membrana tympani gives way, and an otorrhoea is established. Thus, when "unrelieved by art, nature attempts, although in a rude way, to perform a natural cure," by establishing an opening to the middle ear. Effect of nasal stenosis on the organs of vocalization and respiration.-An office of most vital importance which the nasal passages perform is the protection which they give to the throat and lungs in the modification of the air we breathe, rendering it suitable for respiration. The evil consequences of mouth-breathing are scarcely appreciated by those who have not studied or stopped to consider its effects. Occasional allusion has been made to the subject by medical writers, but the first to draw definite attention to the serious results of mouth-breathing was George Catlin, the famous American traveller, whose accuracy of observation on this subject, for a non-medical man, was quite remarkable. Catlin observed the practice of mouth breathing to be "the most destructive of all habits," and applied to it the classical but significant name of "malo-inferno," and remarked: "If I were to endeavor to bequeath to posterity the most important motto which human language can convey, it should be in three words, Shut your mouth." The importance of this injunction can scarcely be too forcibly impressed on the minds of all. The lower animals are nose-breathers, many of them by necessity, as they are not provided with a communication between the mouth and the respiratory passage. This we find to be the case with the solipeds. That man was intended to be a nose-breather is clearly shown by the fact that the first inspiration of the newly born babe is through the nostrils, and if these passages are closed the child can scarcely breathe at all, even though the mouth be open and unobstructed. Cases are known of suffocation occurring in infants from closure of the nares alone. That air enters the nostrils of the infant before it enters the mouth is shown by Cassells by cases in which "air was found in the tympanic cavities of the newly born infant, when no air could be demonstrated to be present in the lung-tissue." " When the nares become closed, it is a long time before we can become accustomed to the perverted process. Many of the troubles of the pharynx, larynx, and lungs are the direct result of mouth-breathing. The disease called clergyman's sore throat, com 18 Op. cit., p. 730., mon to public speakers and singers, is caused, not by the excessive use of the throat, but by the excessive amount of mouth-breathing commonly indulged in while speaking or singing. If we will observe a collection of people on a foggy or dusty day, or in a dusty hall, we will at once notice the prevalence of mouth-breathing, and the marked contrast between the quiet, noiseless breathing of the nose-breathers, and the coughing, sputtering, and spasmodic action of the respiratory muscles of those who are mouth-breathers. The air is not only freed from dust and foreign substances by passing through the nose, but moisture is imparted to it and its temperature elevated,1o thus rendering it more uniform and suitable for respiration. When nasal respiration is cut off there is a noticeable diminution in the air-supply to the lungs, which, as Berhart 20 observes, can be readily ascertained by listening to the chest of one who alternately breathes through the mouth and the nose. Many cases of spasmodic asthma are due directly to polypi and other conditions occluding the nasal passages, as was first pointed out by Voltolini." Symptoms.-The symptoms attending nasal stenosis have been mainly enumerated in detailing the derangements of the various functions which depend on free nasal passages-as inability to breathe through the nose and consequent impairment of the sense of smell, with its accompanying absence of the perception of flavors; deafness; hoarseness, and disturbances in speech; respiratory obstruction; asthma; inability to remove the nasal secretions; a painful dryness and parching of the throat; a sense of fulness and pressure about the nasal and frontal region; often more or less persistent frontal headache; a dull and languid feeling, with indisposition or incapacity for mental effort; weakness of the eyes, which become painful and congested on reading for a short time; a constantly open mouth, giving to the countenance a vacant, silly expression; and a sensation of taking cold on slight unfavorable changes in the weather. A person who breathes through the mouth almost invariably snores during sleep. He is restless and his sleep broken. "Tired nature's sweet restorer, balmy sleep," is seldom known to the mouth-breather.. He is apt to arise with a feeling of lassitude and general malaise, an unpleasant, bad taste in the mouth, and a morning headache. A few or many of the above enumerated symptoms may be present in one case at one time, but nasal obstruction is almost invariably attended by all the symptoms of an obstinate and annoying nasal catarrh, and in many cases by offensive breath and serious derangements of the digestive organs. In infants there is also an inability to take the breast and breathe at the same time. Diagnosis.-The objective symptoms are invariably sufficient for a diagnosis. The two conditions most liable to be confounded on a subjective examination are the hypertrophy of the tissues covering the turbinated bones, polypi, or other tumors, but these can readily be differentiated by the situation and appearance and by exploration with a probe. (To be continued.) 19 Milne Edwards: Anatom. et Physiol. Comp., tome ii., p. 266. It has been shown by experiment that the air is raised in temperature 2 higher when respired through the nose than when by the mouth. Goodwillie: Med. Gazette, N. Y.. July 31, 1880. 20 Asthma: its Pathology and Treatment, p. 238. London, 4878. 91 Galvano Kaustic, S. 246, U. 312. 1871. |