ADENOIDS IN THE NASO-PHARYNX. CLINICAL LECTURE DELIVERED AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL. BY CHARLES H. KNIGHT, M.D., Professor of Diseases of the Throat and Nose, New York Post-Graduate Medical School 7 Surgeon to the Throat Department of the Manhattan . Eye and Ear Hospital. [Reprinted from International Clinics, Vol. I., Fifth Series.] ADENOIDS IN THE NASO-PHARYNX. CLINICAL LECTURE DELIVERED AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL. BY CHARLES H. KNIGHT, M.D., Professor of Diseases of the Throat and Nose, New York Post-Graduate Medical School; Surgeon to the Throat Department of tne Manhattan Eye and Ear Hospital. [Reprinted from International Clinics, Vol. I., Fifth Serie's.] ADENOIDS IN THE NASO-PHARYNX. CLINICAL LECTURE DELIVERED AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL. BY CHARLES H. KNIGHT, M.D., Professor of Diseases of the Throat and Nose, New York Post-Graduate Medical School; Surgeon to the Throat Department of the Manhattan Eye and Ear Hospital. Gentlemen,-The condition which we have illustrated in the case before us to-day has been variously denominated hypertrophy of the pharyngeal tonsil, lymphoid hypertrophy in the vault of the pharynx, and adenoid vegetations, of which the last term, or preferably adenoids, is, perhaps, in most common use. It consists of an actual hypertrophy of the lymphoid tissues in the vault, a condition which was first accurately described by Meyer, of Copenhagen, although it had been recognized a few years previously by Czermak. Meyer was the first to resort to operative procedures for its relief. The cause of this morbid condition is frequently hard to find, but it is a notorious fact that it develops often as a sequel of one of the eruptive fevers in children, and it is in a large proportion of cases associated with a general dyscrasia resembling struma in many of its phenomena, which has been described by Potain under the name " lymphatism." The symptoms of the condition are usually very pronounced, and are thoroughly well exemplified in the case before us. This child, six years of age, the mother tells us, had measles eighteen months ago. You observe that she sits with open mouth and heavy eyes, presenting a very dull expression of countenance ; the external nose is rather small and undeveloped ; the upper lip is thick and prominent. The mother says that the child never breathes through the nose during the day, that at night the breathing is noisy and labored, and that the child frequently awakes from sleep with a start, as though disturbed by troubled dreams. It is noticed, too, that in responding to our ques- tions the voice has a peculiar quality, having the characteristics of what has been called " the dead voice,"-very much the voice of one 332 333 ADENOIDS IN THE NASO-PHARYNX. having a cold in the head. The hearing also is impaired, questions having to be repeated often in a louder tone of voice. We are told, too, that the child has frequently complained of earache, and that she has been more or less disturbed by a hacking cough. She has had frequent attacks of nose-bleed, and we should recognize the fact that epistaxis in children is often dependent upon this condition. The pe- culiar deformity of the chest-wall, not very pronounced in this case, has been attributed by Dupuytren and others to increased labor in respiration due to the presence of these overgrowths combined with the impediment offered by the enlarged tonsils, but it is probable that the thoracic deformity is due quite as much to the systemic condition associated with the local lesion. It is seldom difficult to make a diagnosis of adenoids in the naso- pharynx from such appearances as we observe and the history which has been given in this case. If necessary, it is sometimes possible, even in young children, to confirm our suspicion by a rhinoscopic examination, and the picture seen in the mirror is quite unmistakable. Instead of the dome-shaped cavity met with in the normal condition, we perceive hanging from the roof of the naso-pharynx irregular, rounded masses of tissue, which cut off the normal symmetrical arches of the posterior nares. These growths or masses of lymphoid tissue are generally paler than the normal mucous membrane, and are fre- quently more or less coated with tenacious muco-purulent secretion. The more recent the growth, the more mammillated is its contour and the more vascular its appearance. In growths of longer standing, and in older subjects, the surface is frequently smooth and pale. Some- times these masses of lymphoid tissue extend down the lateral wall of the pharynx as well as down the posterior wall, so that their lower portion may be seen by inspection through the mouth when the palate is retracted. In some instances a rhinoscopic examination is impracti- cable owing to the intolerance or nervousness of the patient, or possi- bly to an abnormal contraction of the faucial space. In such cases it is possible to confirm the diagnosis by a digital exploration. This process is a disagreeable one to the patient, but may be done rapidly, and with safety to the examiner, in this way: The child being seated in the mother's lap, the examiner, standing erect to the left of the patient, places his right hand on the right side of the patient's head, and the child being directed to open the mouth, the cheek is firmly pressed inward between the teeth by means of the middle finger of the right hand. Thus the child cannot close the mouth without biting its cheek. Then the left forefinger is quickly passed into the mouth, 334 INTERNATIONAL CLINICS. crooked up behind the velum, and rapidly swept over the vault and into the posterior naris on either side, when the characteristic feeling of the diseased vault will be easily recognized, the sensation being conveyed to the finger of a soft, cushiony mass which has been likened to that of "a bunch of worms." This may be an adequate simile in some cases, and, when once perceived, cannot be mistaken for the sen- sation given by the normal wall of the pharynx. The novice might be misled by the impression given by the contracting muscles of the palate, but it should be remembered that these growths are situated above and behind rather than anteriorly. If any further confirmation is needed in this condition we may resort to the injection of fluid into the nostril or spraying the nostril; when the naso-pharynx is free the fluid or spray will find its exit by the other nostril with equal freedom, which is not the case when the naso-pharynx is occluded by lymphoid hypertrophy. The prognosis in all these cases is almost invariably favorable, but the only resource is surgical intervention if immediate relief is desired. While it is quite true, as in the case of the palatal tonsils, atrophy of these growths is likely to take place at or soon after puberty, it is likewise true that in a certain proportion of cases shrinkage is long delayed, and in the mean time the patient is exposed to those perils regarding the ears with which we are so familiar. One of the most frequent causes of chronic suppurative otitis in young children is this condition of adenoid hypertrophy in the naso-pharynx. When we appreciate the truth of this fact we shall realize the importance of early operative interference. As regards treatment, while general medication is certainly insuffi- cient for a cure, it is important that we should not overlook the fact that in most of these cases tonics and good hygiene are valuable adju- vants. The early operative procedures, such as those practised and recommended by Meyer, consisted in an attack upon these growths by means of sharp curettes passed through the anterior nares. With in- creased familiarity with the condition it became evident that a better means of access to them was by the mouth, and various post-nasal forceps have been devised for the purpose of extracting the growths from behind the velum. The first post-nasal forceps used for this purpose was intended for evulsion rather than excision of the growth ; but we find that in attempting to tear away the growth from its site there is danger of stripping up adjacent mucous membrane and doing excessive damage to surrounding parts, so that the cutting edge has been adapted to the post-nasal forceps, and nowadays almost all of ADENOIDS IN THE NASO-PHARYNX. 335 the instruments for the removal of these masses are intended for ex- cision, either by scraping or cutting. In the development of operative procedures in this situation the forceps blades have been gradually increased in size with the object of enabling us to do the operation expeditiously, so that the instrument I now show you, known as the Gradle forceps, has a cutting edge nearly three times as great as that of the forceps used in the early days of this operation. Some forceps, as this one, cut from side to side; others cut antero-posteriorly, as the one devised by Mackenzie, and another with a large blade suggested by Major, of Montreal. A variety of curettes with cutting edges of different shapes and sizes have been proposed at various times; of these perhaps the best is that known as Gottstein's, of which there are several models, some being intended for the roof of the naso-pharynx, and others for the posterior wall. It is hardly necessary to have a great variety of instruments with various angles, for by simply tilting the hand which holds the instrument into various positions we may succeed in adapting the cutting edge of this model of the Gottstein forceps to any portion of the naso-pharynx. One of the best instru- ments for operating on certain of these cases is one with which we are all provided,-i.e., the forefinger. The forefinger will be found espe- cially useful in young children in whom the growth is of recent de- velopment and friable in texture, or in the case of very young children in whom we do not wish to use an anaesthetic. In my own experience I find the Gradle forceps, the Gottstein curette, and the forefinger capable of meeting all possible contingencies. It only remains to speak of the cold-wire snare and the galvano-cautery in the treatment of these cases. There are some operators who express a strong prefer- ence for the cold-wire snare, which can be made undoubtedly to serve a good purpose so far as including a large portion of tissue is con- cerned, but the manipulation of the snare seems to be rather difficult, especially when the patient is not under an anaesthetic or is intolerant. It is pretty safe to say that the galvano-cautery should be reserved for those cases in which we have reason to fear hemorrhage, or in which the use of a cutting instrument is forbidden by the patient. The galvano-cautery should never be employed without the assistance of a self-retaining palate retractor like this which I show you, which is a modification of one suggested by Dr. White, of Richmond. The use of the palate hook is an aid where we are called to operate upon older patients who will give us more or less assistance. The parts having been thoroughly cocainized, the introduction of the hook is easy, and its prolonged retention is not a source of very serious discomfort, It 336 INTERNATIONAL CLINICS. will be found, however, that in some cases its presence in the fauces causes a good deal of objection, and contraction of the palatal muscles is so violent as to restrict the operative field to a very annoying degree. Of course, all galvano-cautery operations should be done under the guidance of the rhinoscopic mirror. The method of operation to be chosen in my judgment in most instances in children is as follows: The patient is put under the influence of ether, the anaesthesia not being profound. The child is placed flat upon the back with the head rather over the edge of the table, a mouth-gag, of which this one known as Denhard's will be found to be a convenient form, is intro- duced, and the first step of the operation is to explore the naso-pharynx with the forefinger to determine the extent and distribution of the morbid growth. With the forefinger dragging the velum well for- ward, the Gradle forceps with blades closed are introduced well up into the naso-pharynx, at the same moment the forefinger being with- drawn. By giving the handle of the instrument a slight rotation we may determine that the blades of the forceps are free in the cavity of the naso-pharynx. The blades are then allowed to open by relaxing the grasp upon the handle, and while still open the shaft of the in- strument is forced upward strongly by pressure with the left forefinger. While the pressure is still maintained the blades of the instrument are closed, and whatever lymphoid tissue may be hanging from the vault between them is of course seized in their grasp. Then, the instrument still being firmly closed, by a combined dragging aud twisting move- ment the tissues which have been seized are extracted. The patient is immediately turned on the face to allow the effusiug blood to escape. After the bleeding has begun to cease, the child is returned to the position on the back, more ether given, the gag again introduced, and another exploration of the naso-pharynx made to determine whether or not there are any stubs of tissue remaining. If any are found, they are removed with the forefinger, or, if large, they are removed with the forceps. In this way we endeavor to clear out all possible frag- ments of hypertrophied tissue. In the mean time the anaesthesia should never be so complete as to abolish the reflexes and so endanger the larynx from the entrance of blood and dtibris. We are protected in a measure against this accident also by the position of the patient, the head hanging over the edge of the table. The after-treatment of these cases is very simple. The little patient should be put to bed, as a rule, and kept there for two or three days, especially in unfavorable weather. The less handling of the parts by means of applications or douching of any kind the better. ADENOIDS IN THE NASO-PHARYNX. 337 There are certain complications which are possible, but are fortu- nately not frequent. There have been some half-dozen fatal cases of hemorrhage after the removal of adenoids, but several of them occurred in young children who were allowed to sleep after the operation, and the bleeding continuing, so much blood was swallowed that the child became extremely exsanguinated, and could not be restored. Such an accident impresses upon us the importance of carefully watching these patients, and under no circumstances permitting them to sleep much for several hours after the operation. In case the hemorrhage is alarm- ingly profuse it may be necessary to resort to measures to stop it. Irrigation of the naso-pharynx with very hot water has been tried with success, and it may be necessary to resort to post-nasal plugging. My own experience with hemorrhage after adenotomy is limited to a single case, in which I finally arrested the bleeding by direct pressure with pledgets of gauze passed in behind the velum, the pressure having to be kept up for nearly half an hour. Another serious sequela is occasionally met with,-namely, inflammation of the middle ear. These cases generally occur in those who have already had ear compli- cation in the shape of chronic otorrhoea, and when we have a history of old ear-trouble we should take special precautions against exposure sub- sequent to the operation. The treatment of the ear inflammation under such circumstances would of course be carried out on ordinary lines. In conclusion, I would refer briefly to an unusual case of reflex neurosis which occurred in my experience at the Manhattan Eye and Ear Hospital following the removal of adenoids. We are familiar with certain reflex disturbances which have been attributed by various observers to this condition of lymphoid hypertrophy, such as laryngeal spasm, asthma, etc.; but in my experience the occurrence of torticollis as a sequela of the removal of adenoids is unique. Such a case oc- curred in the person of a little girl, six years of age, at my clinic at the hospital, the symptoms of wry-neck developing about twenty-four hours after operation and persisting for a period of eight or ten days, or until the operative wound had nearly healed. Such a complication must certainly be very infrequent, and may be possibly due to exces- sive traumatism, as in the case to which I have referred. The violence exerted at the moment of operation does not appear to have been ex- cessive, but the extent of the traumatism was certainly unusual in consequence of the distribution of the lymphoid hypertrophy, which reached completely to the oro-pharynx over the entire posterior wall of the pharynx and invaded the posterior nares as well, so that the wound-surface must have been unusually extensive. Vol. I. Ser. 5.-22 338 INTERNATIONAL CLINICS. There are certain causes of failure in the operation which may be referred to. In the very large majority of cases we may safely prom- ise, and shall expect to get absolute, prompt relief to the subjective symptoms. A child who has been hitherto breathing with open mouth at night will on the night following the operation enjoy tranquil sleep, and the breathing previously stridulous and labored will be peaceful and quiet. But we shall find that in a certain proportion of cases the relief is not so marked, and in fact may not be strikingly apparent. There are three possible causes of failure,-viz., the child has got in the habit of breathing through the mouth, and, never having used the nasal respiratory tract, he must be taught to breathe through the nose. For this purpose various devices have been suggested, such as shields to be worn within the lips. The best of all is the method practised by Dr. French, of Brooklyn,-namely, binding up the chin during sleep until the child has formed the habit of keeping the mouth closed. Another cause of failure is the contraction of the pharyngeal space as a result of prolonged disuse, the parts never having undergone normal development. In consequence there is no adequate breathing space. In such cases it will only be after the lapse probably of many months, or years, that the full benefit of the operation will be obtained. The third cause of failure is incomplete removal of the growth, and it is my impression that in a large number of cases in which relapse takes place the recurrence is due to this fact. Undoubtedly recurrence may take place even after a thorough removal, especially when the opera- tion has been performed early in life in children of pronounced lym- phatic tendency; but in the majority of cases we are compelled to admit that the relapse is due to. incompleteness of the operation. Nasal stenosis is also an important factor in recurrence. The area of mucous membrane behind a nasal obstruction is always in a state of hyperemia favorable to the formation of new lymphoid tissue.