Table Of ContentDISEASES OF THE
EAR, NOSE, AND
THROAT
By
DOUGLAS G. CARRUTHERS
M.B., Ch.M. (Sydney), F.R.A.C.S.
Honorary Ear, Nose, and Throat Surgeon, Sydney Hospital, and
Eastern Suburbs Hospital, Sydney; Consulting Ear, Nose, and
Throat Surgeon, Canterbury District Memorial Hospital, Sydney
SECOND EDITION
BRISTOL: JOHN WRIGHT AND SONS LTD.
LONDON: SIMPKIN MARSHALL (1941) LTD.
1948
First Issued, 1943
{by Angus & Robertson Ltd., Sydney)
Second Edition, October, 1948
The second edition of this book is being published under the present
imprint by arrangement with Messrs. Angus & Robertson Ltd.,
of Sydney. From the reception accorded the first edition it is felt
that it should be given a circulation wider than would be possible
by publication primarily for the Australasian market.
PRINTED IN GREAT BRITAIN BY JOHN WRIGHT AND SONS LTD.
THE STONEBRIDGE PRESS, BRISTOL
PREFACE TO THE SECOND EDITION
THE development and application of antibiotic chemotherapeutic
agents, such as penicillin and the sulphonamides, has changed the outlook
in many of the infective disorders of the ears, nose, and throat so that
the mode of treatment and subsequent course have been considerably
modified. The present-day methods of use of these substances have been
described in each section, but care has been taken not to omit the earher
description of the course previously known to follow when these Hfe-
saving preparations were unknown. The true picture of disease in
these parts may thus be envisaged by the student.
Wartime experience of tropical otitis externa having been extensive,
and the subject of considerable research, the method of treatment of this
condition has been described in new form.
The discovery in Austraha that rubella occurring in the pregnant
mother is a cause for congenital deafness and mutism has enabled me to
describe the partial lifting of the veil of mystery previously obscuring
these conditions.
Now that it is almost the general custom for every practitioner to
perform dissection of tonsils, this operation has been described in sufficient
detail, and illustrated, so that the technique may be learned from this
book, which is a student and general practitioner's text-book. Further
more, since local anaesthesia has been found to be so suitable for tonsil
operations, a full description of the method has been set out.
I have appreciated and made notes of all comments and suggestions
from critics of the first edition, and many useful suggestions have been
incorporated in this subsequent edition.
D. G. C.
PREFACE TO THE FIRST EDITION
THE rapid unfolding of fresh knowledge and the development of refine
ments in diagnosis and in therapeutic technique have brought about the
necessity for speciaUzation in many branches of medical practice. To
equip the new graduate and general practitioner adequately, however,
the medical curriculum must include a considerable amount of teaching
in the special branches of human physiology and disease.
Every medical student, then, to be fitted for his subsequent hospital
or general practice, must at least be equipped with such knowledge as
will provide an understanding of the broad principles of the various
specialties and will assure abihty at least to recognize all the emergencies
which may arise in the special departments. In addition, it is necessary
that he shall appreciate the association of focal disease with more remote
ailments, and shall also be sufficiently versed in the examination of the
special parts to be able to direct his own skill or that of others to the
correction of disorders therein.
The medical course has been extended from four years to six and even
seven because of this accumulation of fresh knowledge and the general
demand for a large degree of skill and efficiency in the treatment of all
forms of human ailment. Even with such a lengthening of the under
graduate period, time does not permit the mastering of more than the
broad theory, and then perhaps a brief cHnical experience, in the special
departments.
The student's requirement is for a book that is not too large, yet
comprehensive enough to form a useful component of his reference
library in later years of practice. I have aimed to produce such a book.
In introducing each of the regions, I have tried to explain, physio
logically and anatomically, how disease and disordered function are
brought about, and thereafter to suggest, in a broad manner, the reasons
for the steps that must be taken to restore the normal relations and
function.
Controversial theories and incompleted knowledge (such as that of the
mechanism of hearing or of the semicircular canals) can be but briefly
touched upon while the student is at the special department. One
presumes, of course, that the various theories have been already referred
to in the department of physiology. Likewise I have included descrip
tions only of emergency surgery and the commonest operations, beUeving
firmly that the undergraduate curriculum cannot provide sufficient
knowledge or experience for the undertaking of the major surgical
procedures. For these, a more intensive study is required, and then a
long apprenticeship with experienced operators, so that the handling of
comphcations and dangerous emergencies, such as may arise in what at
first may appear to be a simple procedure, may be learned. The risks of
labyrinthine or other injury in the mastoid operation, or the httle refine
ments of technique which may preserve hearing, cannot be appreciated
without lengthy study and considerable practical experience ; therefore
only a brief outhne of mastoid operations has been given in this work.
Likewise, one feels that to describe the operation of tonsil dissection
without a very full series of illustrations or without minute description
of how the correct planes are to be found, or how accidental injury to
deeper parts may be avoided and such other necessary details of practical
technique, must only lead to an impression that this operation is a simple
task, fit for all to attempt. I find no objection to the performance of
major surgery by the general practitioner or non-specialist, but insist
that the study of technique should not be from the smaller text. The
practitioner who would perform these tasks may and should look to one
or more of the major works where he will not only learn the classical
procedures, but will read of the various difficulties and appropriate
variations of technique which will enable him confidently to take his
patient's well-being, if not his hfe, into his hands. On the other hand,
the various steps in the operations which every practitioner is expected
to perform have been fully set out and illustrated. Many may beheve
that abihty to remove tonsils and adenoids with the guillotine, or to
perform the operation of paracentesis tympani is a natural gift that goes
with the medical degree. That this is not so is soon impressed upon us
all by the number of cases in which we see imperfect results. The
reader of this work will find a full description of these procedures, so
that he should be able to perform such operations successfully after
studying this text and after watching an experienced surgeon once or
twice at work in the teaching hospital.
The advice of others has been sought in a review of each section during
its compilation. I am indebted to Dr. H. Seaward Marsh, Dr. Garnet
Halloran, Dr. Norman H. Meacle, and Dr. Hamilton Kirkland, all of
Sydney, for their assistance in this direction. Finally, Dr. R. S. Godsall,
lecturer in otorhinolaryngology in the University of Sydney, has to be
thanked for a complete reading of the text, and for variations suggested
—notably the inclusion of a separate chapter at the commencement,
covering the methods of examination, so that the student may come to
the out-patient dinic provided at the outset with a description of how to
look and what to look for in each of the regions, in the quickly passing
and varied cases to be seen there. Dr. D. G. Maitland of Sydney, and
of the honorary radiographic staiT of Sydney Hospital, has written the
sections on X-ray examination and has supplied many of the films and
descriptive diagrams which appear in those sections.
Thanks are due to the Kanematsu Institute at Sydney Hospital for
most of the photographs, and to Mr. David Farrell of the Anatomy
Department, University of Sydney, and Miss Stephens of Sydney, for
drawings and colour illustrations.
D. G. C.
DISEASES OF T HE
EAR, NOSE, AND THROAT
/. THE METHODS OF EXAMINATION
CHAPTER I
CLINICAL EXAMINATION OF THE REGIONS
OF THE EAR, NOSE, AND THROAT
THE study and practice of otorhinolaryngology must, like the consider
ation of any other section of medicine or surgery, be built upon the
three scientific cornerstones which provide the foundation of our under
standing of all disease. These are anatomy, physiology and pathology.
At this stage the student may be expected to have passed through the
departments deaUng with these subjects, and he should possess good
books and notes acquired during his term in these departments. He
has now to learn how to inspect the special regions and how to test their
functions before passing on to the actual clinical examination of disease
processes and the observation of the various methods of therapy.
Since it is commonly recognized in medical practice that more mistakes
are made from not looking than from not knowing, so it is essential,
especially in ear, nose and throat work, that the student or practitioner
should first thoroughly master the methods whereby he may be able to
look, with the aid of the various instruments which are available for such
puφose. The recesses to be inspected are small and often tortuous.
Overhanging soft parts and sensitive structures have to be lifted aside
adequately and yet without causing undue discomfort, while curves and
angles have often to be straightened out to permit inspection of deeply
placed structures. Finally, fight has to be projected into the small spaces
and passageways and thence reflected again to the eyes of the examiner.
Only practice and the watching of others at work will bring the necessary
skill to the beginner. Such practice, however, calls first for an apprecia
tion of how to hold the instruments, how to adjust the source of fight, and
how to manipulate the parts in a manner that wiU produce a minimum
of discomfort to the patient and yet permit inspection of aU reasonably
accessible regions. Having learned to use the instruments and having
1
2 DISEASES OF THE EAR, NOSE AND THROAT
in the mind a broad knowledge of the normal anatomy and physiology
of these parts, the student, when in the out-patients' dinic, may then
know how to look and to appreciate what he should look for.
The medical student is advised first to practise his examinations of
the ear, nose and throat upon feUow students and to aUow others to
examine himself so that the little discomforts which may be caused with
the instruments may be felt and thus be avoided. Dexterity is thus
achieved in a manner that not only enables the examiner to see the normal
anatomy and appearances, but also assures such gentleness and precision
as will enfist the patient's co-operation in tolerating attempts to look
around corners and past the various sensitive parts. A student who at
examination shows some abifity in handling his instruments must at
least commence by giving a good impression to his examiner.
THE SOURCE OF ILLUMINATION
In the inspection of the small cavities of the ear, nose and throat, two
methods of illumination are available, the appfication of either being
governed by the fact that the smallness of the apertures permits very
little divergence of the incident fight beam which passes into the aperture,
or of the reflected rays which pass out again to the eye of the examiner.
The common method of examination in the surgery and operating
theatre is with head-mirror reflected fight {Fig. 1). Were one to endeavour
\
Fig. 1.—The pathways of Ught in the head-mirror method of examin
ation of a small cavity such as the ear.
to direct fight from an ordinary lamp into such a smaU cavity as, say,
the ear, it would be found that, in order to bring the eye into fine with the
reflected iUumination from that cavity, the examiner's head would
obstruct the fight from the lamp. So it is that a source of light in front
of the examiner's head becomes essential. The head-mirror, which
reflects fight from its surface, or an electric light attached to the surgeon's
head, each serves this purpose. A further advantage of this type of illumina
tion in which the source of fight is attached to the examiner's head is
THE METHODS OF EXAMINATION 3
that whenever the examiner moves his head in order to look round corners
and into deep recesses, the source of illumination is caused to move
Ukewise. A bright hght, preferably from a frosted globe or from a focusing
spot-light, is reflected into the cavity to be examined. It will help in
the use of the reflecting head-mirror if the reader will recall a little of
the theory of reflected light. The mirror surface, it will be noted, is
concave, the purpose of this being to bring the illuminating beam of
reflected light to a small focal point about 9 inches in front of the mirror
surface. Thus, from a relatively large reflector of about 4 inches diameter,
the beam of light is made to converge into quite a narrow spot so that
concentrated illumination may be given to the small cavities and recesses
which it is proposed to look into. The examiner is able to see the struc
tures within these small recesses owing to the beams of light, which are
again reflected outwards. It will readily be understood that such beams
of light, passing from small and deep apertures such as the nostrils or
the external auditory meatus, must pass more or less directly outwards
in a narrow beam, without divergence, and so would come to impinge
again on the surface of the mirror. In order, then, that these outwardly
reflected beams from the illuminated structures within the nose or ear
may reach the eye of the examiner, the mirror is provided with a central
aperture.
The advent of minute electric globes has permitted the use of self-
illuminating instruments, but, since these are very small and require the
undivided use of one hand to hold them, the head-mirror illumination,
which leaves both hands free and which at the same time permits of a
very much wider range of illumination and manipulation, continues to
be the method of choice for all except home bedside examinations.
GENERAL EXAMINATION OF THE MOUTH AND THROAT
It is wise always to examine the various regions in a systematic routine.
The teeth and the gums should be inspeaed for caries and pyorrhoea
respectively. Next the condition of the palatal arch should be noted,
with the object of studying its general architecture. It may, for instance,
be narrow and highly arched, with badly fitting or overlapping teeth,
as in the palate which has developed in association with maldevelopment
of the nose and defective nasal breathing—conditions that may arise in
a child growing up with enlarged and diseased adenoids or chronic
sinusitis. Attention is next to be given to the condition of the soft palate.
Note whether this structure moves freely and adequately in phonation of
palatal sounds such as " k FinaUy, in this general examination, the
condition of the mucosa should be observed, attention being given to the
4 DISEASES OF THE EAR, NOSE AND THROAT
presence of congestion or pallor, excessive dryness or moisture, ulceration
or scarring. An examination should next be made of the tonsils.
Fig. 2.—The method of holding a child for nose and throat examinauon.
Note that with one hand the nurse holds the child's head still, and to the
front. With the other hand she holds both the patient's hands. The
child's legs are secured between the nurse's knees.
EXAMINATION OF THE TONSILS
The patient is told to open the mouth widely and to breathe cahnly in
and out through the mouth. It is necessary that the patient should be
instructed not to hold the breath. Breathing through the mouth causes
the palate to rise and the tongue to drop and relax. If the patient holds
his breath the throat is likely to remain closed and insertion of the spatula
will be more difficult. The examiner in inserting the spatula should
appreciate the fact that every throat possesses a natural retching or
gagging reflex, which may be more sensitive in some than in others ;
but this reflex need not be over-stimulated if the throat is first opened
by the patient's own breathing efforts as described, and if the examiner is
defiberate yet gentle in all manipulation of instruments, and thus does
not excite the afferent arc of the reflex. The instrument is placed flatly
and firmly on the appropriate part of the tongue. The tongue is first
depressed by placing the spatula slightly towards the side adjacent to the
