HYPERTROPHIED PHARYNGEAL TONSIL ASjTHE EXCITANT IN SUPPURATIVE OTITIS BY M. D. LEDERMAN, M.D. ASS't SURGEON, MANHATTAN EYE AND EAR HOSPITAL; ATTENDING AURAL SURGEON, UNI- VERSITY MEDICAL COLLEGE DISPENSARY ; LECTURER ON DISEASES OF THE NOSE AND THROAT, N. Y. POLYCLINIC. Reprinted from Manhattan Eye and Ear Hospital Reports, Jan., 1895 HYPERTROPHIED PHARYNGEAL TONSIL AS THE EXCITANT IN SUPPURATIVE OTITIS. M. D. LEDERMAN, M.D. ABOUT a year ago I had the honor of presenting a paper before the Otological Section of the Pan-American Con- gress, relating in part to the subject at present under consideration. At that time my observations did not permit me to positively assert that the post-nasal growth was the direct cause of the suppurative disturbance, as antiseptic treatment of the ears was continued for a time after the removal of the irritation. Since then I have purposely avoided prescribing aural antiseptics after pharyngeal operations in a number of cases, in endeavoring to ascertain the immediate effect of the surgical treatment. The cases selected were manifestations of suppurating mid- dle-ear disease, not complicated by exuberant granulation tissue, but in which local treatment had been carried out for some time previous without arriving at the desired result. In some of the patients the aural discharge had existed for a consider- able period, resisting the usual therapeutic means, but ceasing surprisingly soon, after ablation of what proved to be the ex- citing cause. That these growths are a distinctive feature in the production of suppurative otitis, especially in children, where the disease remains in activity for sometimes many years, is clearly proven by the histories of the cases which I report later on. When we recall the anatomical relationship existing between the rhino-pharynx and intra-aural cavities, we can readily ap- preciate the untoward influence arising from the lymphoid hypertrophy. Intra-tympanic air renewal is an essential ele- ment towards maintaining normal auditory perception, and we may reasonably trace the majority of middle-ear diseases to some derangement of this important function. This inter- Reprinted from Manhattan Eye and Ear Hospital Reports, Jan., i8g? 80 LEDERMAN. change of air depends mainly upon the patulence of the Eus- tachian tubes, and as the latter are not constantly open, in- creased air pressure in the naso-pharynx must exist before proper ventilation of the middle ear can take place. Volun- tary movements of the soft palate are accompanied by an opening of the tubal orifice, and the lifting of the soft palate augments the pressure in the naso-pharynx, thus assisting in air renewal. Adenoid tissue occupying this region, obviously in- terferes with these essential movements by encroaching upon the aerial boundaries, and by antagonizing the action of the levator palati and pharyngeal muscles. The diminished atmos- pheric pressure permits a dilatation of the blood-vessels of the mucous membrane lining the middle ear, which is soon followed by aural symptoms. These growths may give rise to a hyper- secretion of the glandular structure in the immediate vicinity, some of which may find its way into the Eustachian tubes during the act of deglutition, thus exciting an inflammatory process. After frequently observing the agreeable effect of the radical treatment applied to the pharyngeal obstruction, in suppura- tive manifestations of a chronic nature, which have resisted the usual local measures for many years in some instances, I feel we are justified in giving this predominating factor our imme- diate attention whenever it exists. Its presence predisposes the individual to affections of the middle ear, and sooner or later we are confronted with the evidence of its deleterious influence. The situation of the growth necessitates mouth- breathing, thus causing the subject to inhale air, which is drier, colder, and less free from impurities than that coming through the channels destined for its passage. Retarded oxidation is a natural consequence, and structural changes of the pneumonic tissue are liable to follow, thus impairing the general health by maintaining a low status of vitality. Prophylaxis assumes a prominent position in the treatment of aural disturbances, con- sequently diseases of the nose and naso-pharynx should receive our careful attention. Some observers believe that the loca- tion of the lymphoid mass has some bearing upon the form of the disease. Where the tissue principally occupies the pharyn- HYPERTROPHIED PHARYNGEAL TONSIL. 81 geal vault, a suppurative otitis is supposed to be the most fre- quent sequela ; if the hypertrophy arises from the posterior and lateral walls of the pharynx, and is accompanied by thick- ened folds of the mucous membrane, we have a mechanical occlusion of the Eustachian canal, and a catarrhal process is probably the result. Out of 456 cases treated, 112 were between the ages of 6 weeks and 17 years. Fifty of this number suffered from a chronic otorrhoea, in whom adenoid vegetations were present. Nineteen (19) of the fifty had enlarged tonsils, either unilateral or bilateral. Sixteen out of the 112 were diagnosed acute sup- purative otitis, with pharyngeal complication ; of these six had hypertrophied tonsils. The youngest patient operated upon was an infant six weeks old. She had a running ear for two weeks, and the mother stated that the child could not take the breast on account of mouth-breathing. As the little one's ex- istence depended upon removal of the post-nasal disease, same was accomplished by means of the finger. At the end of two weeks we were gratified to learn that the ear discharge had ceased, and the young one was able to take its nourishment in the usual manner. The curtailed histories of the cases here- with offered, corroborate the statement made at the beginning of these few remarks. Case i. H. P., male, 10 years old, had a purulent discharge from both ears for over four years. Pain was not severe at any time. Parent attributed disease to a severe cold acquired at the time. Boy is subject to colds, and with each catarrhal attack the aural symptoms would be worse. Local treatment had been carried out for some time previous to my seeing the patient. Examination revealed a moderate collection of pus, giving off a disagreeable odor in both external auditory canals. After cleansing, perforations of both memb. tymp. could be seen in the post. inf. quadrant ; the opening in the right drum being the larger. Perforation whistle was readily elicited. Rhino-pharyngeal inspection showed a large mass of adenoid vegetations hanging from the vault. These were removed with forceps, curette, and finger, at one sitting. Ten days later no discharge was seen in either canal ; hearing somewhat better to voice ; margins of perforation touched with a 4 per cent, solu- tion of argent, nitras., occasional treatment to perforations as 82 LEDERMAN. above. After an interval of three months from time of opera- tion, the patient returned, and both drums were found healed ; no discharge since time mentioned ; hearing and general health much improved ; can now understand his teacher at school ; never could before ; articulation decidedly clearer. Case 2. N. J., male, 5 years old ; has had a running ear for three years ; exacerbations frequent with severe otalgia, the latter appearing principally at night ; elevation of temperature during first day or two of acute symptoms. Antiseptics and hot water douching were prescribed by family physician, with amelioration of symptoms. Patient was referred for an opinion. Finger discovered soft growths in the vault and in posterior wall of pharynx. Operation was advised and performed with curette and finger. Three weeks later suppuration no longer present ; perforation not visible. Case 3. E. M., female, 17 years of age ; double-sided discharge of two years' duration ; has had local treatment ; been using drops for ears, and blisters over mastoid to relieve localized tenderness. During attacks has had considerable febrile movement and pain. Abundant flow of pus from both ears ; no odor ; on inspection found bilateral tonsillar hyper- trophy, and finger diagnosed lymphoid swelling in vault and in lateral walls. Double tonsillotomy and adenotomy were per- formed during the same sitting. For three days after the operation, the aural discharge was stimulated, and then it grad- ually became less, until it ceased entirely at the end of four weeks. Hearing and general appearance of the patient much improved. Case 4. J. T., male, seven months : right ear discharging for two weeks ; occasional pain in the part affected was indi- cated by child placing hand over same ; sleep not disturbed by pain. Pharyngeal vault filled with soft growth ; removed easily with finger. Three days after removal, some pus was still found in canal, but this disappeared at the end of a week. Case 5. C. L., male, 5 years old ; has had O. M. S. C. for over three years, with acute symptoms off and on. Pain was dis- tressing ; prevented sleep ; temperature perceptibly elevated at times ; right ear affected ; slight discharge observed on ex- amination ; perforation at ant. inf. portion of M.T. Consider- able " adenoids " in vault and on post, wall ; usual operation. Suppuration stopped in two weeks ; opening in drum not entirely closed. A month later found M.T. healed completely. Voice test showed marked improvement. HYPERTROPHIED PHARYNGEAL TONSIL. 83 The after-treatment in these cases consisted of a mild anti- septic nasal spray (four per cent, solution of boric acid) used every hour for the first day, and then less frequently. A liquid diet was kept up until the condition of the parts permitted the swallowing of solid food without annoyance. If pus was present in the canals after the operation, warm water was used as a douche. No antiseptics were used in the ears. I fully appreciate the great value of antiseptics and deodorizers in aural suppuration, and do not wish to leave the impression that they are discarded by me ; on the contrary, in routine practice I combine their action with the operative interference, and anticipate prompt results -merely refrained from using them in a series of cases to demonstrate the etiological importance of the disease under consideration. "Cbe Tknicfcerbocfcer ipress, Dlcw lL?ork