Exostosis of the Septum as a Cause 
of Chronic Naso=Pharyngitis. 
BY 
CHARLES H. KNIGHT, M.D., New York. 
[Reprint from The Laryngoscope, St. Louis, April. 1897.] EXOSTOSIS OF THE SEPTUM AS A CAUSE OF CHRONIC 
NASO=PHARYNGITIS.* 
BY CHARLES H. KNIGHT, M.D., NEW YORK. 
One of the most obstinate and annoying disorders met with in the 
upper air tract is chronic naso-pharyngitis. Its prominent subjective 
symptoms are a sensation as of a foreign body above the soft palate 
and a frequent desire to clear the throat by the act of "hawking." 
The subjects of this condition are prone to attacks of acute naso- 
pharyngitis, which may be very rebellious to treatment. They often 
form a peculiar habit of forcibly expelling short blasts of air through 
the nostrils in an instinctive effort to get rid of an obstruction. This 
little trick, repeated at intervals of a few minutes, becomes a source of 
great annoyance to the patient's associates. In an ordinary ' ' cold in 
the head," which everyone has at times and almost everybody neglects 
as being a trivial affair, the naso-pharynx usually becomes involved 
earlier or later. As a matter of clinical experience, we find that 
attacks of acute naso-pharyngitis are exacerbations of a chronic con- 
dition, and are encouraged by the existence of some nasal abnormality, 
such as a septal deflection, or an hypertrophy of the posterior end of 
the inferior turbinated body. The relation of naso-pharyngitis to 
lymphoid hypertrophy in the vault of the pharynx, to inflammation of 
the pharyngeal bursa, and to suppuration in the accessory sinuses, is 
by no means infrequent, and many cases, on careful examination, will 
prove to have their source in one or the other of these pathological 
conditions. 
What is believed to be a very common etiological factor in post- 
nasal disorders, and one easily overlooked in the usual rhinoscopic 
examination, is exostosis of the septum. It has been my frequent 
experience to meet with cases of obstinate "post-nasal catarrh," 
so-called, associated with a tendency to " catch cold," which yielded 
only after the removal of a conical projection from the bony septum, 
so situated as to interfere with breathing or drainage. Such a pro- 
jection may assume the form of an irregular ridge running forward 
more or less parallel with the floor of the nose, and impinging upon or 
even adhering to the inferior or middle turbinated body. Under such 
*Read before the Section in Laryngology of the New York Academy of Medicine, Decem- 
ber 23, 1896. 2 
circumstances, it can hardly escape detection. It may ■ be concealed 
by an anterior turbinated hypertrophy, or a deviation of the septum, 
and may be discovered only by the use of cocaine and the probe. No 
rhinoscopic examination is complete without recourse to these aids to 
diagnosis. 
It is uncertain whether these exostoses of the septum originate in 
traumatism or result from hypernutrition. They are seldom, if ever, 
met with in early life, which hardly would be the case if the former 
were the sole cause. Moreover, they are found far back upon the 
vomer in a situation supposed to be especially protected from injury. 
Behind such an obstruction there always exists a more or less exten- 
sive area of hyperemia owing to rarefaction of the air during inspira- 
tion. This region is, therefore, more susceptible to the influences 
which are usually recognized as conducive to an acute naso-pharyn- 
gitis. The disturbances due to diminution in air pressure are perhaps 
less serious than those dependent upon impeded nasal drainage. 
In other words, a very considerable bony obstruction may exist with- 
out marked derangement of the nasal respiratory function. Either its 
growth is so slow that the patient becomes habituated to it, or else 
the opposite nostril is so ample as to compensate for the stenosis, or 
possibly it may be quite above the level of the air current. Such a 
projecting shoulder offers a site for the lodgment and retention of 
secretion, which in process of decomposition becomes an additional 
source of irritation. The indications are therefore clear in every case 
of chronic naso-pharyngitis-in the first place, to supplement simple 
inspection of the nasal chambers by exploration with the probe after 
thorough cocainization, and, secondly, to remove all overgrowths from 
the septal surface which seem to obstruct respiration or drainage. 
The latter statement may seem somewhat radical, but I believe it may 
be accepted even by those conservatives who deprecate the unwar- 
rantable activity in nasal surgery which has prevailed in recent years. 
Whatever good may be accomplished in certain cases of catarrhal 
disease by the list of astringents and various local applications usually 
recommended, they will fail to give permanent relief when the 
mechanical obstruction referred to exists as an etiological factor. In 
every case of intractable and recurrent naso-pharyngitis, it should be 
sought for, and, if present, removed. 
I hope that my position on the question of intranasal surgery may 
not be misunderstood. It is very far from my intention to urge the 
removal of every septal irregularity. On the contrary, I believe it 
is high time that we should learn to have more respect for the intra- 
nasal structures. No one condemns more heartily than myself the 3 
wholesale slaughter of turbinates which may seem to be simply a lit- 
tle larger than our sesthetic taste demands. But, on the other hand, 
there can be no good reason in attempts at preserving a membrane 
which has undergone polypoid degeneration, or in a state of such ad- 
vanced hyperplasia that its function is wholly abrogated. The late 
Dr. Henry Schweig, of this city, many years ago advocated the plan 
of " submucous cauterization " of the hypertrophied turbinates, and 
for the purpose used a sharp-pointed cautery electrode. The idea has 
been lately revived by Blondian*, and in another form by Dr. Norval 
H. Piercef, of Chicago. Efforts in this line are certainly most com- 
mendable, provided they be limited to tissues which are still useful. 
There certainly can be no sense in trying to save those which are prac- 
tically foreign bodies. The advice is sometimes given to trim down 
the turbinated bodies rather than meddle with a deformed septum in 
cases of nasal stenosis, the impression being that the septum is par- 
ticularly resentful of surgical interference. In cases of the class re- 
ferred to in my paper, I believe there should be no hesitation in choos- 
ing to attack the septum. In my experience these wounds do well. 
Examined months and years after operation, no trace of the original 
trouble can be seen except perhaps a slight bulging of the septal sur- 
face. Hemorrhage at the time of operation, or after the cocaine ef- 
fects have passed away, is often quite free, but only on two or three 
occasions have I found it necessary to plug the nostril. Under the 
use of a fresh, strong solution of cocaine the removal of an exostosis 
may be accomplished absolutely without pain, unless the patient is 
the unfortunate victim of an idiosyncrasy which resists the anesthetic 
effects of the drug. Some of our patients seem to enjoy the distinc- 
tion associated with a surgical operation, while others dread the knife 
and will submit to months of treatment with sprays and medication 
rather than take the chance of pain. It is a satisfaction to be able to 
assure such individuals that no great amount of pain need be appre- 
hended either during the operation or afterwards. The increase in 
comfort as regards nasal breathing, and the relief from symptoms fol- 
lowing the removal of one of these septal deformities, are generally 
admitted to be full compensation. 
In conclusion, let me say a few words regarding the method of removing 
an exostosis. When its projection from the surface of the septum is 
abrupt, there is but little difficulty in operating with a hand saw. And 
in most cases a saw, preferably one of the pattern known as Bos- 
worth's, is a convenient instrument. If the base of the bony spur is 
*The Jour. Laryngology, etc., Dec. 1886, p. 333. 
+The N. Y. Med. Jour., 1896, No. 938. 4 
shelving, the saw should be started in an oblique position, its teeth being 
directed towards the septal surface. When once it has made a furrow 
through the soft parts, it may be brought to a vertical line without 
danger of slipping. In order to obviate stripping up the mucous 
membrane at the completion of the section, it is a good plan to make 
a preliminary cut from below upwards, the main division of the bone 
being made from above downwards. The various electric saws, de- 
vised or modified by Roe, Schmidt, Potter, Black, and others, are 
very ingenious, and are thought to have the advantage of doing the 
work more quickly. In exostosis of unusual width, it will be found 
easier to tunnel through with the electric nasal trephine, and after- 
wards trim off the projections left by the trephine with cutting for- 
ceps or the saw. Exostoses of moderate extent, which have not be- 
come densely ossified, may be removed with the spokeshave, sug- 
gested by Woakes; but I am almost prepared to say that a septal ex- 
cresence which this instrument is capable of removing, does not re- 
quire interference. Bony outgrowths often offer too great resistance;, 
soft hyperplasias are better reduced by means of the electric cautery. 
Nothing has been said about the relation of septal exostosis to re- 
flex neuroses, or to various aural disturbances-not because it is by 
any means infrequent or unimportant; but because this phase of the 
subject opens too wide a field for discussion at the present time. 
To most of you I fear that the contents of my paper may seem 
extremely elementary. But I cannot help feeling that in our search 
for strange and unusual morbid phenomena, we are apt to forget first 
principles. An occasional review of the field and a comparison of 
experiences may be of value to all of us.