Surgical Diseases of the Nose, Mouth, and Throat

The upper respiratory air passages (nose, mouth, and throat) are affected more frequently by disabling illness than any other area of the body. This is mainly the result of upper respiratory infections, such as the com­mon cold. More work days are lost each year from this group of illnesses than from all other causes. Many of the complications of such in­fections have surgical import. In more recent years this region has been benefited by great strides in the field of plastic surgery. And with the ever-increasing accident rates and the vul­nerability of this region, restorative operative procedures play a more important role in cos­metic rehabilitation.

Congenital Defects

Congenital defects may involve any portion of this system, and great variations in the type and degrees of deformities and in their specific cor­rective operations occur; therefore, detailed out­line of ail is not feasible. Two forms of con­genital defects of the face are fairly prevalent, however.

Harelip may appear as a small notch on the upper lip just below a nostril, or it may extend completely up into a nostril. This is correctable by plastic operation (stomato­plasty) and may be done soon after birth, and preferably should be done as early as possible if it interferes with nursing.

Cleft palate is the deformity wherein there is a partial absence of the bony or soft palate. This occurs as a slit-like opening between the mouth and the nasal cavity. There are all variations in the degree of such defect, and frequently it is associated with harelip on one side or both. Such a condition demands plastic correction and individual consideration must be given, but in general cleft palate is best repaired during the second year of life. Usually an associated hare­lip can be repaired simultaneously. In these re­pairs occasionally bone, cartilage, or skin graft­ing is necessitated. Functional and cosmetic re­sults have in recent years been gratifying.

Injuries

Injuries to the soft tissues of the face are quite common, often the result of automobile acci­dents. Lacerations are frequently extensive or jagged and may lead to disfiguring scars. There­fore, their prompt and careful repair is impera­tive. When such laceration is the solitary injury, repair under local anesthesia is usually the choice. Measures against infection must be taken.

Fractures of the facial and jaw bones, usually the result of blunt blows, take a great variety of forms. Depressed bone fragments must be ele­vated into normal position early to assure a nor­mal facial contour. Fractures of the nasal carti­lages and bones usually remain in position once replaced, but frequently intranasal packs and splints are necessary. Nosebleed (epistaxis) is a most common injury with or without nose fracture. This results from rupture of one of the vessels within the nasal cavity. Packing to tam­ponade the bleeding may be necessary but usu­ally it subsides spontaneously.

Facial fractures are frequently multiple and often associated with other body injuries.

Fracture of the septum may demand align­ment to avoid its healing in a displaced position, with resulting deviation of the nose. When the septum is deviated from the midline in a fixed position and obstructs one or both of the nasal passages, the airway or sinus drainage may be blocked. Frequently treatment of such is required and is necessarily surgical. Re-fracture and re­placement may be performed, but usually the operation submucous resection is to be pre­ferred; in this the bony septum is removed from between the two covering sheets of mucous mem­brane so that the septum remains of soft tissue. This is accomplished through the nose and usu­ally under local anesthesia.

Fractures of the upper jaw may extend into the sinuses and give rise to a leakage of air into the tissues under the skin. Infection from such fractures may ensue if there is leakage from the sinus cavity. Often there is associated fracture of the orbit, and usually hematoma and “black eye.” Fracture of the upper jaw may give rise to malocclusion of the teeth.

Fractures of the lower jaw are becoming more and more common, frequently the result of vehicular accidents. Mandible fractures are almost always compounded internally; that is, the fragments tear through the gum covering so that the bone fragments are exposed in the mouth. Bleeding within the mouth occurs, and care to avoid infections of the exposed bone must be taken. Solitary fracture of this semicircular shaped bone is rare; more often the mandible is broken in more than one place.

These are most often treated by fixing the lower jaw against the upper jaw to hold the frag­ments in place until they have healed. This is accomplished by wires placed about the teeth and elastic bands between the uppers and lowers. In some cases a head dressing binding the jaw in a fixed position may achieve the same goal. In other cases associated with severe injuries of other regions, such accurate fixation of the jaw may have to be deferred, or allow the fragments to remain malaligned.

When the jaw is immobilized by wires and such, diet must necessarily be liquid. Special nursing care and great patience are required.

Fractures of the larynx are not too com­mon but may occur as the result of blunt or sharp wounds. Vocal symptoms may result. When internal bleeding is massive, tracheotomy (see below) may be a necessary measure. Those fractures into the larynx associated with external wounds as a result of injury by sharp object de­mand operative treatment. Others resulting from injury by blunt blows may only need medical supportive measures. In all voice rest and avoid­ing airway obstruction are imperative.

Dental (tooth) fractures are frequent, es­pecially of the incisors. These are treated by the dentist, most often with cosmetic application of artificial substances. Subluxation (loosening) of a tooth in its socket by injury is also a dental problem.

Other injuries to this system take a great variety of forms. Lacerations about the face and neck are common occurrences, as are contusions and abrasions. Specific details of surgical treatment of such varying injuries would be a formi­dable task.

Foreign Bodies

Foreign bodies in the respiratory tract may be encountered at any level. These are especially frequent in children. The foreign material may be any variety of object, from small food particles to rather large trinkets; coins, peanuts, toy parts, pins, paper clips, screws and bolts, jewelry, but­tons, beans and seeds, dental parts, marbles, stones, are all commonly found objects. Small children have an inordinate propensity for in­troducing such items in their nostrils and ears; or, while sucking and chewing such articles, they may be aspirated (or sucked) farther into the air passages. Needless to say, the deeper into the system the foreign article passes, the more dif­ficult the resulting condition.

Foreign bodies initiate difficulties by obstruct­ing the airway or by irritation of the tissues in which they are caught. Mechanical removal of the foreign article is the operative procedure; preferably this should be done early to avoid inflammatory reaction around the object and to preclude aspiration of it farther down the tract. Foreign articles in the nose may be removed simply by instrumentation, but those in the pharynx, esophagus, or trachea may require a more extensive procedure. Lighted instruments through which a grasping forceps is inserted may have to be introduced down to the object to directly view and grasp a foreign body for removal.

Bronchoscopy is the insertion of the lighted instrument into the lower respiratory passages (trachea and bronchi) for the removal of foreign material or for the study of the inside of this tract. This is done under topical or general anesthesia.

When foreign bodies have remained in the tract at any level undetected for a period of time, inflammatory reaction occurs around them and may result in respiratory obstruction, chronic in­fection, and even abscess formation; extension of the inflammation to adjacent vital parts may en­sue.

Foreign bodies which obstruct the upper air passageways to the extent that air exchange to the lung is insufficient may require the emer­gency operative procedure tracheostomy. This entails the formation of an artificial opening into the upper trachea at the lower mid neck. If such is available, a solid tube is installed into the opening to prevent collapse and assure the airway to the lungs. Tracheostomy (or tracheotomy) may also be necessary as an emergency air passage in certain acute infections and other blockages of the upper respiratory tract.

Nosebleed

Epistaxis (nosebleed) resulting from injury has been mentioned. Spontaneous bleeding from the nose may occur. This is often the result of chronic inflammation in the nasal cavity which has progressed to erode into a blood vessel. An­other common cause is high blood pressure which perforates a nasal blood vessel. Usually such bleeding stops spontaneously, or with the applica­tion of cold compresses or pressure. Frequently, however, packing of the nasal passage, or the application of medicines in the nose to constrict the bleeding vessel, or coagulation of the bleed­ing point with chemical cautery, may be necessary.

Allergies

Allergies of the ENT system make up a com­mon problem group of diseases. An allergy is an unusual or exaggerated susceptibility to a spe­cific substance which is harmless in similar amounts to most other people. Allergic symp­toms of the respiratory passages are most com­monly the result of inhaling a substance to which the patient is oversensitive. Less frequently, res­piratory allergies occur as the result of the sub­stance getting into the body by some other means. The offending substance producing the allergy reaction is known as an allergen. Those which may affect the respiratory system by being inhaled are various dusts, pollens, fumes and gases, spices, animal hairs, and the like.

In the nasal passage an allergy is manifested with swelling of the lining membrane and marked increase in secretions. This is called allergenic rhinitis. The swollen membrane may occlude the drainage opening of the sinuses or tear ducts or the eustachian tube. There may result sinusitis, tearing of the eyes, or middle ear disorders. Germs may find this swollen and inflamed nasal lining more desirable to invade, as the natural resistance is lessened; secondary infection is common and may extend to any of the adjacent parts.

Seasonal allergic rhinitis, or hay fever, is the allergic rhinitis which occurs at certain seasons of the year when a specific grass pollen to which the individual is sensitive is in the air.

Allergies may produce inflammation of the tonsils and adenoids. Drainage from the nose affected with allergic rhinitis may drain into the pharynx and lower respiratory system, to affect these parts. A chronic cough from such drainage into the larynx is common.

Allergy in the lower branches of the respiratory tree produces narrowing of the tubular system so that breathing is restricted. This is bronchial asthma or allergenic asthma.

Minor allergies may be treated by medications which counteract the allergic reaction. In the severe allergies it may be necessary to determine the specific allergen. This may be a formidable task, since the probabilities are many. Skin test­ing with some of the several hundred possible allergens may be necessary. When the allergens have been definitely determined, the disease may then be treated by elimination of the substance from the patient’s environment; such as, sub­stituting foam rubber for feather pillows when feathers are the allergen. But if the allergen can­not be eliminated, as with dusts and pollens, the patient may have to be desensitized with a series of extracts of the allergen.

Infections

Infections of various parts of the ENT sys­tem are common. For the most part, these are medical diseases and surgery plays a role only in the treatment of certain complications. Nomen­clature specifying infections of the various parts follows:

• Infection of mouth — stomatitis
• of tongue — glossitis
• of gums — gingivitis
• of nasal cavity — rhinitis
• of pharynx — pharyngitis
• of adenoids — adenoiditis
• of tonsils — tonsillitis
• of parotid gland — parotitis
• of larynx — laryngitis
• of trachea — tracheitis
• of bronchus — bronchitis

Such infections may occur in combinations, such as rhino-pharyngitis (nose-throat infection).

Tonsillectomy

Tonsillectomy (tonsil-out) is a frequently in­dicated operation for repeated bouts of tonsillitis. Usually there remains a low-grade chronic in­fection between the acute infectious episodes. In most individuals the tonsils degenerate and shrink in size after the fourth year of life, when chronic infection is not present. However, in many persons the tonsils enlarge and become repeatedly infected; the general state of health may be impaired. Most tonsillectomies become necessary between the fourth and twelfth years of life. However, many times removal of the tonsils is indicated in adults.

Adenoidectomy

Adenoidectomy (adenoid-out) is similarly performed for chronic or recurring acute ade­noiditis, or for enlargement with breathing ob­struction. When the adenoids become enlarged, their position is such that they may block the nasal air passage; the child neces­sarily becomes a “mouth breather.” The tonsils and adenoids, being constituted of the same type tissue, are most often involved simultaneously; when either is infected or enlarged, the other is also. Usually when one operation is indicated, so is the other, and tonsillectomy and adenoidectomy (T & A) is performed. In children the operation is usually done under general anes­thesia, but in adults local anesthesia is more often the method of choice. The organs are removed by dissecting them free from their attachments and controlling the bleeding points of their beds. The areas are left open and within a few days the membrane regenerates over the region.

When tonsillitis progresses to extend into the adjacent parts, pus formation may develop into an abscess, known as the peritonsillar abscess, or “quinsy.” This may require surgical drainage along with medical measures.

Chronic sinusitis

Chronic sinusitis for the most part is a medi­cal disease, but may require certain operative procedures. Any of the sinuses may be so in­volved, and assuring an opening into the nasal cavity is imperative. This may be accomplished by medications taken by mouth or introduced into the nose. Sometimes irrigation of the sinuses is necessary, by inserting a small tube through the nose into the involved sinus (sinus catheteri­zation). In other cases enlargement of the open­ing into the sinus may be a necessary operative procedure. X-ray pictures will give the diagnosis and the extent of chronic sinusitis.

Tumors

Tumors may originate in any part of the ENT system and may be benign or malignant. For­tunately none is especially common. The most effective treatment measures vary with type of new growth and its location. Most benign tumors will require surgical removal, as will many of the malignant growths; some malignancies may be amenable to x-radiation treatment.

Cancer of the lip is a most common new growth of this system, but a high rate of cure exists since the area is visible and early treat­ment is usually sought. Surgical treatment con­sists of a V-shaped wedge excision of the in­volved part of the lip (lip resection) which can be accomplished without resulting disfigurement.

Removal of the lymph glands in the neck by radical neck dissection may be an indicated operation when malignancy involves the upper respiratory passages.

Removal of the tongue for malignancy is called glossectomy (tongue-out) which may be total or partial. Removal of half the tongue is hem i-glossectomy.

Laryngectomy (larynx-out) may be neces­sary in cancer of this part. It may be partial or complete, the latter followed by loss of voice, for which artificial devices for speech are avail­able.

Nasal polyp is a common benign new growth in the nose which develops following prolonged chronic inflammation; this may be infectious or allergic inflammation. Treatment rests with oper­ative removal of the polyps and amelioration of the inflammation.

Actually, any portion of the respiratory pas­sages may become involved with benign or malig­nant tumors. Suffice it to say, the benign new growths and many of the malignant ones will require operative removal; some malignancies will respond to x-ray. In all, early diagnosis and treatment are mandatory.