SOME OF THE EFFECTS OF 
CHRONIC NASAL OBSTRUC- 
TION. 
By CHARLES N. COX, M.D., 
Laryngologist to Bashwick Hospital; Surgeon Throat 
Department, Bushwick and East Brooklyn Dis- 
pensary; Asst. Surgeon (Aural Dept.) Brook- 
lyn Eye and Ear Hospital. 
Reprinted from 
The Brooklyn Medical Journal, 
October, 1896. Reprinted from The Brooklyn Medical Journal, October, 1896. 
SOME OF THE EFFECTS OF CHRONIC NASAL OBSTRUC- 
TION. 
BY CHARLES N. COX, M. D., 
Laryngologist to Bushwick Hospital; Surgeon Throat Department, Bushwick and East Brooklyn 
Dispensary ; Asst. Surgeon (Aural Dept.) Brooklyn Eye and Ear Hospital. 
Read before the Medical Society of the County of Kings, May 19, 1896. 
The importance of the nose as an accessory organ of respira- 
tion cannot be overrated. It is the purpose of this paper to point 
out some of the effects of chronic nasal obstruction. With the 
latter will be included not only effects on the organ itself and the 
rest of the respiratory tract, but also those on the organ of hear- 
ing, and, incidentally, certain general conditions which may 
ensue. 
Long-continued obstruction of the nose, from whatever cause, 
is very liable to be followed by some trouble; so that its effects 
may properly be considered, in a general way, without reference 
to the particular cause of obstruction. 
EFFECTS UPON THE NOSE ITSELF. 
Naturally, the first thing that will be noticed is an inter- 
ference with the passage of air through the nose, giving rise to 
mouth-breathing. This may vary in degree from a partial or 
occasional respiration through the mouth to a total and constant 
performance of breathing through that orifice. The latter degree 
is, of course, fraught with such discomfort that it is not likely to 
fail of recognition. We have all, at some time, experienced the 
abject misery of complete obstruction of the nose when suffering 
from an ordinary cold in the head. 
It is the lesser degrees that are liable to be unobserved-and, 
without doubt, they are every day overlooked. 
If both nostrils are obstructed there will be more or less 
impairment of the sense of smell. Indeed, the obstruction may 
be in the upper portion of the chamber and not interfere with 2 
CHARLES N. COX, M.D. 
respiration, and yet totally destroy the sense of olfaction; for we 
may remember that the olfactory nerve is distributed to the 
upper portion of the nasal cavity as far down as the middle of 
the middle turbinated body and the upper third of the septum. 
Now, if this portion of the nasal cavity be shut up, there can 
be no odoriferous particles brought in contact with the ter- 
minal filaments of the olfactory nerve, and olfaction will be sus- 
pended. 
As important as the sense of smell is to the enjoyment and 
well-being of man-and perhaps also to his protection-it is, 
after all, of secondary importance to the function of normal 
nasal respiration; and yet a slight impairment of the former is 
almost certain to elict complaint, while considerable abatement 
of the latter will pass unnoticed not only by the patient, but, in 
many instances, by the physician as well. And, worst of all, is 
sometimes not considered worthy of attention, even when 
observed. 
Other consequences of nasal obstruction are an excessive dis- 
charge of mucus or muco-purulent matter from the anterior nares, 
frequent attacks of sneezing and altered speech-the so-called nasal 
twang, which is to be differentiated from the "dead'' or muffled 
voice, caused by obstruction in the naso-pharynx by adenoid 
vegetations or other growths. It would be difficult to describe 
the difference between these two abnormal qualities of voice, but 
having heard them, it is possible to note it. 
Pain, or a feeling of tightness over the bridge of the nose, is 
sometimes produced by obstruction, particularly when the mid- 
dle turbinated body is enlarged and pressing against the 
septum. 
A possible, but fortunately unusual, effect of chronic nasal 
obstruction is the production of a red nose. This is a disfigure- 
ment that makes the possessor "the well-known butt of many a 
flinty joke." Of course, this congestion of the end of the nose is 
generally the reflex of some gastric or other disorder; but it is pos- 
sible for it to arise from a disturbance of the circulation within the 
nasal cavities, more especially from enlargement of the inferior 
turbinated bodies, as shown in the following illustrated cases, 
taken from my records: 
Case I.-Mr. P. R., age forty-six, consulted me July 7, 1891. 
Digestion and general health excellent. Suffering from post- 
jiasal catarrh. Both inferior turbinated bodies very much en- 
larged, producing sufficient obstruction to interfere materially CHRONIC NASAL OBSTRUCTION. 
3 
with nasal respiration. End of nose much reddened-and, 
indeed, this was the source of quite as much anxiety to the 
patient as the obstruction and catarrhal symptoms. 
Thorough cauterization of each inferior turbinated body, with 
the galvano-cautery, soon removed the cause of obstruction, and 
at the same time the nose gradually resumed its natural color. 
This symptom had been present for some months before treat- 
ment. I learned quite recently that there has been no return. 
Case IL--In April, 1895, I was consulted by Mrs. D. E., age 
thirty-four, who complained of occasional obstruction of the 
nose. Every time the nose was stopped up the tip of the organ 
became reddened. When the nose was free there was no red- 
ness. Touching the inferior turbinals with a probe cause them 
to swell, and at the same time the tip and alee suddenly be- 
come red. 
"Pinning" the turbinated bodies down, as Bosworth terms 
it, with the galvano-cautery has prevented ever since their 
swelling and the accompanying redness of the nose. 
EFFECTS UPON THE NASOPHARYNX, PHARYNX, LARYNX, ETC. 
One of the most common results of chronic nasal obstruction 
is nasopharyngeal or posl-nasal catarrh. I doubt if it be possible 
to have any considerable degree of obstruction for a length of 
time without more or less of this affection following. It is so 
well known as to need little description. All are familiar with 
the distress caused by the thick tenacious mucus which collects 
in the nasopharynx, and with the hawking and scraping efforts 
to remove it. This common condition, which in its appellation 
has attained the dignity of a disease, is attributable in great part 
to some form of nasal obstruction, and in its treatment this fact 
must be borne in mind. To overlook this important element 
means failure. General treatment and simple cleansing sprays 
along with astringent applications, while good in themselves, 
and always producing more or less temporary benefits, are but 
evanescent in their effects when there is mechanical obstruction 
in the nasal passages. 
To the failure to remove underlying causes is due the popular 
but erroneous idea that post-nasal catarrh cannot be cured. 
When the nose'is obstructed, and breathing takes place through 
the mouth, the pharynx undertakes to perform one of the very 
important functions of the nose, viz., that of moistening the air. 
Consequently there is an undue amount of water abstracted from 4 
CHARLES N. COX, M.D. 
the mucous membrane, which induces dryness of the throat. 
The same is to be said of the buccal cavity. Note the dryness 
and attendant discomfort of the mouth and throat following only 
a few hours of temporary obstruction of the nose. 
Lower down, that delicate and the wonderful organ, the larynx, 
may become irritated by breathing air that has not been filtered 
and freed from dust, nor sufficiently moistened nor warmed, as it 
should be had it passed through a normal nose. In consequence 
there may be set up an inflammation of that organ. 
EFFECTS ON THE EAR AND ITS ADNEXA. 
In the absence of a proper passage of air through the nose, 
every inspiration causes a partial vacuum in the nasopharynx. 
This may induce congestion of the Eustachian tube or tubo-tympanic 
congestion, giving rise to a stuffy sensation of the ear, more or less 
impairment of hearing, or tinnitus. 
This condition of affairs predisposes to attacks of acute or 
subacute middle ear catarrh. As a result of the former, acute sup- 
puration may ensue, which, if left alone, is quite prone to become 
chronic, with all its attendant evils. 
EFFECTS OF A GENERAL NATURE. 
It should always be borne in mind that effects of a general 
nature may be produced by nasal obstruction. Pretty much 
every trouble that the human body is heir to has been by ex- 
tremists attributed to nasal obstruction, and, while it is possible 
that the most distant organs may, on rare occasions, be affected 
thereby, the whole list of more frequently observed effects can 
be narrowed down to a very few. 
Asthma is one of these. There may be those to-day who dis- 
believe in any nasal origin of asthma. But their number is 
small. The frequent mitigation and cure of asthma by removal 
of nasal polypi or other obstructing neoplasms or lesions is proof 
so convincing as to leave little doubt that this distressing disease 
may sometimes be caused by nasal obstruction. The fact is of 
sufficient importance to warrant and demand a careful examina- 
tion of the nasal cavities in every case of asthma that presents 
itself to the physician, if his desire is to try to remove the cause 
as well as to relieve the patient temporarily. 
Cough is another occasional result of nasal obstruction. An 
enlarged turbinated body or a septal spur may be the cause of a 
slight tickling cough that has worried the patient and his friends 
and resisted the onslaughts of hosts of cough mixtures. CHRONIC NASAL OBSTRUCTION. 
5 
The anterior and posterior ends of the inferior turbinated body 
are the most frequent seats of such a reflex. Where it exists, 
cough can be produced at will by touching the sensitive areas 
with a probe. 
Headache is quite frequently the result of nasal obstruction. 
It is, in fact, quite a common cause-especially of frontal head- 
ache or pain located over the frontal sinuses. 
Aprosexia, or inability to fix the attention, loss of memory, 
etc., caused by circulatory disturbances within the brain, may 
be, and is sometimes, due to nasal obstruction. Although, to 
digress, I think this condition is more frequently observed in 
nasopharyngeal obstruction, as from adenoid vegetations. In 
fact, with the latter it is not infrequent. 
It remains to speak of ocular disturbances. Certain affections 
of the eye are caused or aggravated by long-continued nasal 
obstruction. In great obstruction, as from fibrous polypus, the 
visual organ may even be displaced. With lesser degrees of 
intranasal pressure the eye is often so affected as to resist all 
forms of treatment directed to itself alone, the removal of the 
obstructing lesion within the nose being necessary to completely 
overcome the difficulty. 
Occlusion of the lower orifice of the nasolachrymal duct, due 
to hypertrophy of the inferior turbinal, is sometimes overlooked 
in dacryocystic disease. I am inclined to think that this fact is 
not quite as fully appreciated by ophthalmologists as it should 
be, and that the nasal speculum would frequently reveal the 
main seat of the mischief, which, being removed, would save the 
patient the disagreeable if not painful ordeal of having a probe 
passed through the duct at frequent intervals for months with, at 
best, only temporary benefit. . 
Dr. E. H. Babcock: I would like to make one slight addition 
to the paper, or to the thoughts suggested there, and that is 
more or less from a dental standpoint. We all know that the 
teeth, if the jaws are normally developed, occlude, and by their 
very occlusion prevent any change in the form of the mouth. 
Where there is nasal obstruction, as Dr. Cox has presented it, 
especially at night, the mouth is thrown open, and the masseter 
muscles acting on either side are very apt to draw the teeth in 
and disturb the arch. Consequently patients many times are 
unable to masticate their food, the saliva is not properly sup- 
DISCUSSION. 6 
CHARLES N. COX, M.D. 
plied, and there is disturbance of the digestion of the starchy 
food. 
Dr. H. A. Aiderton: Mr. Chairman, I do not know that I have 
anything further to add to Dr. Cox's paper. He has explained 
about all the ill effects that come from diseases of the nose. A 
thought that struck me during the course of the reading was that 
some ill effects come from treatment of the nose. 
It is not due to Dr. Cox that I bring this forward, but recently 
in the work of the Eye and Ear Hospital it has been brought to 
my notice in a number of cases of operations on the nose, 
especially in the treatment of adenoids, that the tendency is with 
the operative procedure to set up troubles of the middle ear. I 
noticed in a number of these cases that, notwithstanding rigid 
antisepsis, the removal of growths in the nasopharynx or in the 
nose proper has been provocative of middle-ear suppuration. 
This fact furnishes no reason why we should neglect operating 
on the nose, but it is only brought forward as one of the reasons 
for cautiousness in operative interference. Of course the growths 
should be removed as radically as possible, but the above is a 
result which may follow radical operations in the nose and naso- 
pharynx. 
There is another form of treatment in the nose which may 
produce trouble in the ear; that is, through long treatment of the 
nose, irritation of the mucous membrane is set up by the use of 
sprays or the repeated use of cauteries or astringent or irritating 
applications, by which a subacute condition is produced in the 
Eustachian tube or in the middle ear. 
The above caution has been uttered merely to bring forward 
the fact that the man who treats the nose and the throat must 
also beware of proceeding too rapidly and too radically, except 
as he may do it tentatively, watching closely the surrounding 
regions. 
Dr. J. E. Sheppard: I saw this morning what makes the third 
case I have seen within a short time of motion of the membrana 
tympani with respiration. It seemed to me a matter of some 
little interest. In two of the three cases there was certainly some 
obstructive lesion of the nose, which led me to believe that the 
partial vacuum, which Dr. Cox speaks of in his paper, was at work 
in these cases. 
In the case I saw this afternoon the nose was thoroughly 
wide open and there was plenty of room for respiration. In all 
the cases the motion of the drum-membrane has been inward CHRONIC NASAL OBSTRUCTION. 
7 
with inspiration and outward with expiration, indicating, as 
shown by this last case, that even with normal respiration 
through the nose there is a tendency to exhaustion of the air in 
the tympanic cavity. This must be certainly more marked where 
there is obstruction in the nose. One case I saw, which seems 
to have some relation to these other cases, was produced by pro- 
longed public speaking. If the man went through a day without 
any public speaking his ears were perfectly comfortable. If he 
had a good deal of public speaking to do his ears felt "stuffy" 
after he had gotten through with his labor, and in this case there 
was some very slight obstructive lesion, the man, though breath- 
ing through his nose, had some difficulty in doing so A little 
opening up of the nostrils soon cleared up the ear symptoms. 
Dr. J. S. Prout: Mr. President, I am going to ask Dr. Shep- 
pard to explain to us how these operations produce middle-ear 
trouble. I never understood it very well, but I know it is an 
operation that is as necessary as any in surgery. Will Dr. Shep- 
pard tell us a little more about how that happened ? 
Dr. Sheppard: The cases in which I have seen this occurrence 
take place have been, I believe, uniformly after operation on the 
nasopharynx. I do not remember seeing any in operations on 
the nose. After thorough radical removal of the so-called ade- 
noid growths from the nasopharynx I think it is common for us 
to see for one, two or three days, or sometimes for a week, even 
more greatly obstructed nasal respiration than before the opera- 
tion was performed. I have seen that repeatedly. The supposi- 
tion on my part-I do not know whether it is a very scientific 
explanation or not-has been that there was a good deal of irri- 
tation, probably amounting to inflammation of the mucous mem- 
brane, of the whole nasopharynx, including that around the 
mouth of the Eustachian tube, and that this inflammation very 
naturally would extend and involve the mucous membrane of the 
whole tube, in that way causing insufficient ventilation to the 
tympanic cavity, and we all know that insufficient ventilation of 
the tympanic cavity, if maintained a sufficiently long time, may 
bring about inflammatory changes there, even to the extent of 
suppuration. 
Dr. E. H. Bartley: I do not wish to take very much part in 
this discussion, because it is something I am not very familiar 
with, but I have seen a number of these operations, but have not 
seen any of these cases of middle-ear inflammation, following 
operations upon this location. I have noticed that after the 8 
CHARLES N. COX, M.D. 
removal of those adenoid growths there is usually, for a time 
a somewhat disagreeable discharge. There is almost always 
more or less odor from the breath; and the very manner of 
performing the operation would lead to such a result. The 
operation is not a clean-cut operation, that leaves behind no 
material for disintegration, suppuration, or septic infiltration. It 
would appear to me that the explanation of these results might 
be purely septic, or a creeping up perhaps of a septic trouble fol- 
lowing this operation, which, we must admit, is somewhat crude. 
The method of removing the growths by simply tearing them off, 
or scraping them off, or pinching them with a pair of forceps and 
getting rid of them in that way would not in other locations, 
where we could get at it, be regarded as very good surgery; but 
here, where there is no other way to treat them, you cannot make 
a nice, clean-cut operation, and I see no other way of doing it. 
But it strikes me that the explanation is purely one of sepsis-I 
mean the result following the operation, and traveling up the 
Eustachian tube is one of septic origin. If that is incorrect I 
would be glad to be corrected on the subject. 
Dr. L. H. Miller: Mr. President, I would like to ask, in the 
majority of cases, where they have middle-ear trouble following 
adenoid operation, if it is not in cases where there has existed, 
middle-ear trouble previously, for a large majority of cases of 
earache in children, I think, will be found to be due to adenoids. 
It would seem to me that in a large number of cases where we 
have middle-ear trouble following adenoid operation, it is where 
the trouble has existed or been there previously. 
For the last few years I have done quite a large number of 
adenoid operations and I do not remember having seen a case 
where middle-ear trouble followed the adenoid operation except 
it existed there before. As far as the matter of sepsis is con- 
cerned after adenoid operation, I think we can be fairly antiseptic 
in the future treatment in most cases. 
Dr. Aiderton: I might add a few words to the last gentle- 
man's remarks. I would say that I suppose there are as many 
adenoids removed in the Brooklyn Eye and Ear Hospital as in 
most institutions, and in my experience there, hardly a day goes 
by in which I do not send from two to five patients to be oper- 
ated upon. They have been operated upon by competent men, 
men who are as thoroughly able to perform the operation as any 
under anesthesia, cocaine, ether, or chloroform, and also with 
antiseptic precautions, and it has been my experience that some- CHRONIC NASAL OBSTRUCTION. 
9 
of these cases have been sent back to me with a suppurative 
otitis, cases that had previously no trouble of the middle ear- 
when I say previously no trouble, I mean previously no suppura- 
tive trouble. They might perhaps have had tubal obstruction or 
retraction of the drum producing some deafness, but no previous 
suppurative trouble-and following the operation the ears have 
gone on to acute suppuration on one or both sides, and the 
trouble has kept up for a longer or shorter period. Only recently 
a case was sent in after having been operated on, and that was 
the condition present. I myself have operated on a patient, a 
grown girl, in whom I took all the precautions I possibly could. 
She never had had any trouble with the middle ear-never had 
deafness-the drums were normal, tubes normal and in every 
way there was no trouble of the middle ear previous to operation. 
After the operation, with all the antiseptic precautions I was 
master of, unilateral suppuration set in, and was only controlled 
after treatment lasting a few weeks. 
Dr. Bartley: Perhaps I do not make myself understood. It 
was a suggestion rather more than a statement. I did not mean 
to intimate that sepsis immediately,followed the operation, but 
as a result of the disintegration of tissues left behind, or tissues 
somewhat disorganized by the operation and then allowed to 
slough and come away. The operation might be perfectly 
aseptic, and yet the after-infection might take place in that way. 
Dr. J. M. Van Cott, Jr.: Professor Miller, of Berlin, in his able 
monograph on mouth organisms, has shown that sixty varieties 
of organisms exist in the mouth and nasal passages. I agree 
entirely with Dr. Bartley from that standpoint. It seems to me 
that it would be practically impossible to remove all the organ- 
isms in the mucous membrane in the locality under discussion 
prior to operation. I do not see how it would be possible to get 
behind the adenoids and render the field of operation perfectly 
sterile. It should also be remembered further that in the course 
of the operation for adenoids a very considerable amount of 
trauma is done to the tissues. You cannot get the organisms out 
nor can you get the adenoids out without producing the trauma 
which would make it possible for the infection to occur. I do 
not think it is competent to blame anybody for such infection, 
for it is neither possible to get the organisms out nor to avoid 
inducing the locus minoris resistentiae. 
Dr. L. H. Miller: I do not want to be understood that I con- 
sider it at all possible to keep a nasal operation thoroughly anti- 10 
CHARLES N. COX, M.D. 
septic. I think it is utterly impossible, and I have no doubt that 
the fact of sepsis is one of the main causes when an acute or 
subacute exacerbation of middle-ear trouble follows this opera- 
tion, and it is perhaps as liable to occur after my operations as 
anyone's, but, at least, I have been very lucky in that matter thus 
far, and at the Ear Infirmary, where I see and assist in treating 
a large number of ear cases, it is an extremely rare occurrence 
that the usually preexisting ear trouble is made even temporarily 
worse by the adenoid operation. The chief of that clinic also 
informs me that he remembers of but one case where middle-ear 
trouble seemed to start up de novo soon after this operation. 
Dr. Sheppard: 1 would like to add one word. I feel as if I 
might be put in a false light without a word of explanation. 
The extension of the inflammation of which 1 spoke has as its 
undoubted cause, sepsis; I had in mind when speaking rather the 
manner of extension than its cause, with regard to which I agree 
entirely with Dr. Bartley. 
The Chairman: If there is nothing further to be said, will Dr. 
Cox please close the discussion. 
Dr. Cox: Only a word, Mr. President. In reply to the first 
speaker, I purposely omitted any mention of any effect upon the 
teeth-the palatal arch being drawn out of shape, etc.-for this 
reason, that I aimed to confine my paper to the effects of 
chronic nasal obstruction, and while of course nasal obstruction, 
as well as nasopharyngeal obstruction, might bring about such 
results, it has generally taken place in childhood, and in child- 
hood the obstruction is usually in the nasopharynx. Obstruc- 
tion in the nose is not nearly as common in children as in adults, 
the obstruction being found in the majority of cases in the naso- 
pharynx. 
Relating to the results of treatment in the nose, the discussion 
as to its possible effects on the ear and so on has been so 
thoroughly gone over that I will not speak further of them, but I 
would like to mention one other additional evil effect of treat- 
ment that might be brought about. Dr. Seiss, of Philadelphia, 
reports several cases of closure of the lower end of the naso- 
lachrymal duct as a result of cautery operations, bringing about 
the very thing that hypertrophy of the turbinated body itself 
might do, so of course we cannot be too careful in the use of the 
cautery in the nose. 
There is one part of the nose I am very cautious about using 
the cautery on, and that is the posterior nares. I hesitate to CHRONIC NASAL OBSTRUCTION. 
11 
apply the cautery to the posterior end of the turbinated bodies. 
I believe disastrous results follow that sometimes, setting up 
inflammation there which extends very readily to the ear through 
the Eustachian tube. It seems to be prone to violent reaction, 
perhaps more so than at the more anterior portions of the turbin- 
ated body. Where there is any hypertrophy of the posterior end 
of the inferior turbinated body it is best to remove it by a cutting 
operation as with a snare; and apropos of this, Seiler, of Phila- 
delphia, makes the point-and I believe he is correct in that- 
that very frequently posterior hypertrophies will disappear after 
treatment of anterior ones. I have fre ]uently seen this occur.