Headache and severe neuralgia are common, but may be absent. The growth is pinkish or red in colour and may be concealed from view by nasal polypi or oedematous mucous membrane. Epistaxis may occur, but is not frequent. A muco-purulent discharge is commonly met with, especially when the growth becomes large. As the tumour increases in size it produces displacement of the neighbouring parts usually in a somewhat irregular manner. Thus the growth may protrude into the orbit, causing a swelling on its inner wall and displacement outwards of the eyeball; it may obstruct the lachrymal duct and cause overflow of the tears It may extend up through the cribriform plate producing intense headache and other symptoms of intracranial pressure. The growth FIG. 98.-IVORY EXOSTOSIS OF ETHMOID. The upper part of the tumour, above the constriction, projected into the orbit: the lower part presented in the middle meatus. It was concealed from view on rhinoscopy by the polypi attached to its lower margin. may occlude the ostium of one of the accessory sinuses such as the frontal sinus or antrum and give rise to a mucocele. This is usually accompanied by severe neuralgic pain (see Chap. XXIII.). In a case referred to me by Mr. Lang, from Moorfields Ophthalmic Hospital, the growth had attained the size of an inch and a quarter at its longest, and of about half an inch at its shortest diameter. Half of this growth lay in the orbit : the other half projected into the nose, where it was completely concealed from view by nasal polypi (Fig. 98). The association of the polypi with the hard swelling in the orbit led to the diagnosis of a large ethmoidal bony cyst. The operation consisted in making a curved incision around the inner margin of the orbit and in thoroughly exposing the orbital part of the growth. An attempt to chisel away this portion, which was very hard, loosened its attachment to the orbital plate, and the large mass of growth presenting in the nasal fossae was then recognised. Although the tumour was thus loosened it was necessary to cut away a large part of the orbital plate of the ethmoid and even part of the nasal process of the superior maxilla in order to deliver the growth through the orbit. The patient made an uneventful recovery. Ordinary nasal polypi are seen actually growing from the specimen. Similar cases have been recorded by Helferichs,' by Milligan, in whose case the growth projected into the antrum and compressed the lachrymal duct, and by De Santi, in whose case the growth produced a mucocele of the frontal sinus. A more advanced case is recorded by Grossman, who observed the patient for upwards of 20 years, during which time the growth destroyed the sight of one eye. After the eye had sloughed and had been removed, the growth was operated upon with a fairly successful result. A smaller similar growth had been previously removed from the left orbit with an excellent result. Thelwall Thomas has recorded an exostosis of the frontal sinus projecting into the orbit, and Hamilton has related two similar cases. Treatment. No definite lines can be laid down for the treatment of every case. The best plan consists in laying open the nasal cavity as freely. as necessary so as to bring the attachment of the growth fairly into view. With chisel or cutting pliers it should then be possible to remove the osteoma together with the plate of bone to which it is attached. In this way, providing that the growth has not already extended to the cranium, good results should be obtained. There is probably very little fear of recurrence. FIBRO-ANGIOMA. Although these growths are very inadequately described in text-books. they are probably the commonest of all simple tumours of the nose. Notes of individual cases, usually under the term of "bleeding polypus" of the septum, are by no means infrequent in recent literature. Cases have been exhibited by Bond,2 Thomson, Spicer, Hunter Tod, and others in the Laryngological Society of London, and three have occurred in my own practice. Sometimes they have been erroneously regarded as malignant. Thus Baker has recorded a case under the designation of adeno-sarcoma. Symptoms. These growths are most frequent in adults. They give rise to gradually increasing nasal obstruction and to frequent attacks of epistaxis, which may lead to profound anaemia. On examining the nose the cause of the symptoms is at once apparent. A tumour usually about the size of a small cherry, red, vascular and smooth is seen attached by a broad base to the cartilaginous part of the nasal septum. It is usually soft and bleeds readily on touching with the probe. Pathology. Although these tumours have frequently been regarded as malignant and microscopically have been described as sarcoma and angio-sarcoma, they are in reality benign. They consist for the most part of a fine network of young fibrous tissue with numerous thin-walled vessels, and are covered with a layer of normal epithelium. In places, especially around the vessels, may be seen collections of round cells: in other parts degenerated tissue with haemorrhages may be found. Some growths are much more cellular than others. The general appearance and structure is similar to that of the ordinary angioma of the skin. Bulloch,1 who reported on one of Tod's cases, described the growth as a perithelioma. Glas considers the tumours are closely related etiologically to rhinitis sicca anterior and perforating ulcer of the septum. The irritation produced by the crusts leads to ulceration, if organisms gain admission to the tissues, and to tumour growth, if no micro-organisms are present. Prognosis. Apparently these tumours have considerable tendency to recurrence, many of the recorded cases having recurred two or three times after removal. This is probably the result of imperfect operation : if the growth be eradicated it will not return. In no case has the clinical history pointed to malignancy: there is no record of metastatic deposits, no enlargement of the lymphatic glands, and no destruction of the surrounding tissues. Treatment. From what has already been said it will be seen that radical surgical treatment is necessary. It probably makes little difference how the growth is removed provided its removal is thorough. Under local anaesthesia the bulk of the mass may be cut off with a snare, and the base thoroughly seared with the galvano-cautery. The cauterization may be repeated in a few days. Another excellent plan is to cut through. the mucous membrane all round the attachment of the growth with a redhot galvano-cautery knife. Having divided the soft parts down to the cartilage, the mucous membrane and perichondrium forming the base of the growth is detached with raspatory or blunt dissector. In this way the whole of the growth with its attachment down to the cartilage is removed. Since the necessity for thorough removal has been recognised less has been heard of recurrence. Lipoma and Adenoma. Of these extremely rare growths one instance of each has been recorded in recent years. Gomperz2 describes a lipoma the size of a cherry growing from the septum. It was successfully Journ. of Laryngol., 1903, xviii. p. 257. 2 Monatschr. für Ohrenheilk., 1894, xxvii. p. 280. P removed with a snare, and the diagnosis was confirmed by microscopical examination. Eichler1 records an adenoma of the septum. The following works may be consulted: MAGNUS. Archiv für Laryngol., 1905, xvii. p. 433. Papilloma. HUNTER MACKENZIE. Lancet, 1896, ii. p. 460. LOGAN TURNER. Proc. Laryngol. Soc. of London, 1896-97, iv. p. 21. HELLMAN. Archiv für Laryngol., 1897, vi. p. 171 (contains full references). BRONNER. Journ. of Laryngol., 1902, xvii. p. 372; Proc. Laryngol. Soc. of London, 1901-2, ix. p. 114. Exostosis. ANDREW. Medical Record, 1887, p. 261. GROSSMAN. Brit. Med. Journ., 1902, ii. p. 1425. THELWALL THOMAS. Brit. Med. Journ., 1896, ii. p. 1132. DE SANTI. Journ. of Laryngol., 1898, xiii. p. 297. HAMILTON. Journ. Amer. Med. Assoc., 1901, xxxvi. p. 246 (gives statistics of frontal sinus tumours). Fibro-Angioma of Septum. HUNTER TOD and others. Proc. Laryngol. Soc. of London, Journal of Laryngol., 1903, xviii. pp. 257 and 262. GLASGOW. New York Med. Journ., 1898, lxvii. p. 39. THOMSON and discussion. Laryngol. Soc. of London, Jan., 1904. Journ. of GLAS. Archiv für Laryngol., 1905, xvii. p. 22. MALIGNANT DISEASE OF THE NOSE. Both sarcoma and carcinoma may occur in the nose, the former being the more common, even when the fact is allowed for that a large number of growths formerly described as alveolar sarcoma are now considered to be carcinoma. Both forms of malignant disease are rare, and do not amount to more than 5 in 10,000 cases of nose and throat diseases (Moritz Schmidt). These figures closely agree with my own experience. Herzfeld in 28,000 out-patients saw only one case of malignant disease of the nose, Finder saw 5 cases in 40,000. In 848 cases of sarcoma, 1Archiv für Laryngol., 1898, vii. p. 466. the nose was the site of disease in 15, whilst in 9,554 cases of cancer the nose was affected in 4. Gurlt in 10,000 cases of malignant disease found the nose affected in 18, in four by carcinoma and in fourteen by sarcoma. SARCOMA. Of sarcomata the most common variety is the small spindle-celled growth. It forms a soft, rapidly growing tumour with a broad, deep attachment. It most commonly springs from the anterior part of the septum; more rarely from the ethmoidal region. It is often difficult to differentiate this tumour from an inflammatory growth. A sarcoma is usually distinguishable by its deep attachment, its broad base and often by its larger size, by its To the right is seen the edge of the growth; to the left a typical nasal polypus, which, whilst pressure causing absorption of the surrounding bones and by the penetration of processes extending from the main tumour into the various sinuses. If any doubt remain, a small piece of the growth should be removed and submitted to careful microscopical examination. Sarcoma can be distinguished from fibroma by its comparative softness and its more rapid growth, although it must be admitted that soft fibromata, especially those originating in the post-nasal space may closely resemble sarcoma both in their clinical features and microscopical appearance and it may be impossible to draw a sharp dividing line between them. |