CONGENITAL OCCLUSION OF THE POSTERIOR NARES. ■BY WM. SCHEPPEGRELL, A. M., M. D.' OF NEW ORLEANS. REPRINTED FROM ANNALS OF OPHTHALMOLOGY AND OTOLOGY, Vol III, No. 2. April, 1894. CONGENITAL OCCLUSION OF THE POSTERIOR NARES. By Wm. Scheppegrell, A. M., M. D., OF NEW ORLEANS. ASSISTANT SURGEON TO EYE, EAR, NOSE AND THROAT HOSPITAL, ETC. AMONG the congenital deformities of the nose, none have a more important bearing on the health of the patient than the occlusion of the nares. When the occlusion is bilateral, even the life of the patient is in danger. Although this abnormality is not referred to in many of our treatises on rhinology, still a number of cases have been described, as by Voltolini,1 Luschka,2 Cohen,3 Emmert,4 Bennett,6 and others. It is, however, fortunately a rare form of lusus naturae, as is demonstrated by the fact that of 12,000 cases treated in the ear, nose and throat department of the Eye, Ear, Nose and Throat Hos- pital of this city, no case of congenital atresia naris has yet been registered. The etiology of this condition is clouded in the same darkness which obscures our knowledge of teratology generally. Symptoms and Prognosis. In cases of unilateral occlusion of the posterior nares, symptoms, except such as refer to a certain discomfort from inability to clear the nostril of its secretions, may be entirely absent. Thus, in one case which came under my observation, the patient, a married lady of about 27 years of age, having a congenital occlusion of the left choana, complained of no ear or throat symptoms, but only of an inability to clear the nostril of mucus by blowing the nose. In other cases, however, we find the usual symptoms resulting from nasal stenosis. In the case which I will report in this article, the patient frequently suffered from laryngitis and bronchitis, and had had, on two occasions, a purulent discharge from the ear on the affected side. The voice also had a marked nasal intonation. 1Voltolini: Die Anwendung der Galvano-Kaustik, Vienna, 1870. 2 Luschka: Der Schlundkopf der Menschen, 18G8. 3 Cohen : Diseases of the Throat and Nasal Passages, New York, 1879. 4Emmert: Lehrbuch der Chirurgie, Stuttgart, 1853. 5Bennett: Annals of Ophthalmology and Otology, January, 1893. 2 When a child is born with bilateral occlusion of the posterior nares its life is endangered unless relief can be given by operative measures. The difficulty in breathing tends to develop a pulmo- nary engorgement, aggravated during sleep by the suction drawing the tongue over the orifice of the larynx. The nursing is also interfered with, and unless speedily relieved, the child soon succumbs. In a case reported by Ronaldson,6 the child died soon after birth from inability to breathe through the nostrils. An examination showed that the posterior nares were completely occluded by a thick membrane. Diagnosis. The diagnosis is made by means of the nasal spec- ulum and probe, together with the rhinoscopic mirror, or in child- ren, with the finger inserted into the post-nasal space. The history of the case is important and will materially assist the diagnosis. The nostril being examined by reflected light, and the mucous membrane cocainized, a probe is passed into the nostril and if no passage can be found into the post-nasal space, then the soft palate should be cocainized so that a palate retracter may be applied and the posterior nares carefully examined with the rhinal mirror. In children in whom this manipulation cannot be carried out, bromide of ethyl anesthesia should be induced, and the parts care- fully examined with the index finger in the naso-pharynx, and a probe passed anteriorly through the nostril. The previous history and clinical appearance will usually allow an easy differentiation of a congenital occlusion from an acquired atresia due to lues, rhino-scleroma or the blenonhoea of Stoerk. Robertson also reports a case of nasal occlusion following an attack of scarlet fever. The obstruction may be due to a membranous or osseous forma- tion, or both. The bony wall may be due to an excessive develop- ment of the pterygoid process of the sphenoid, or excessive devel- opment or a lateral curvature of the vomer towards the affected side. In the case upon which I operated, the nostril ended in a wedge-shaped funnel, the obstruction being due to a welding to- gether of the posterior extremities of the turbinals and vomer into one bony mass. Treatment. A membranous occlusion may be relieved by the electro-cautery, but a bony wall requires an electric or dental engine and drill, and sometimes the nasal saw. As in the stenoses 6 Ronaldson: Edinburgh Medical Journal^ May, 1881. 3 of other canals, this condition has a tendency to recur from cica- trical contraction, which tendency is aggravated by repeated opera- tions The object then should be to make the opening as large as practicable at the first operation, so that after cicatrical contraction has taken place there will still be left a passage of sufficient size. While the operation for opening the occluded choana does not appear to present any special danger, still one case of a fatal result is reported by Lange7 of Copenhagen. In this case the right choana of a 19-year old patient was occluded by a septum, the perforation of which was accomplished by means of the electro- cautery under chloroform anesthesia, the operation being followed by free breathing. The next day, however, meningeal symptoms developed, followed by death. No post-mortem was made, but the author supposed that the fatal result was due to a sinus throm- bosis. After operating for atresia of the anterior part of the nostrils, I have successfully used a packing of iodoform gauze, changed every second day until the healing process was completed, but the pack- ing does not work advantageously in the posterior nares, partly on account of the difficulty of properly packing the part without danger of the gauze falling into the throat, and partly because the congestion, which follows the operation, makes it difficult to adjust the packing at the posterior part of the nostril after the first day. Hemorrhage is usually considerable, but may be controlled by packing with iodoform gauze. Cocaine anesthesia is used, a twenty per cent solution being applied both to the anterior and posterior part of the obstruction. The modus op^randi^ which the writer has found most practic- able, will be described in the following case: Annie M., aged 16, was referred to me on account of a complication of ear, nose and throat trouble. The patient complained of noises and pain in the right ear, and stated that she has had an " abscess " in the ear on two occasions. She coughed considerably, especially during cold changes of the weather, and easily became hoarse. She had an accumulation of mucus in the right nostril which she could not blow out, but prevented the dis- charge from falling out by occasionally " mopping " the nose. She had never been able to blow through this nostril since her birth. After cocainizing the nostril, an attempt was made to pass a probe through the nostril, but was stopped at the posterior end. With the rhino- scopic mirror, the posterior opening of the left nostril appeared normal, but, on the right side, there was absolutely no opening-differing in this respect, from another case which I saw, in which there was an opening just large enough to admit a probe. 7Lange : Journal of Laryngology, Rhinol. and Otol., Vol. VI. 4 To the right of the septum could be seen a slight vertical depression, indicating the line where the vomer was attached to the fused mass of turbinals, whose outline could be faintly made out. The whole side, however, was covered with an unbroken surface of mucous membrane, and, as was learned during the progress of the opera- tion, the obstructing wall was composed of bony tissue. The right nostril was first cocainized and also the posterior part of the obstruction. The pharyngeal surface of the velum palati was also cocain- ized in order that a White's palate-retractor could be applied, so as to give more room to follow the operation from the post-nasal space. A long pin, similar to a lady's hat-pin, was then passed into the nostril and through the obstruction, in order to note at what point it entered the naso-pharynx. A small opening was then drilled with a burr, operated by an electric motor, the course of the burr into the naso-pharynx being watched by means of the rhinoscopic mirror. The first opening was then enlarged by the use of successively larger burrs and the reamer, operated by the motor. Congenital Occlusion of Hight Choana-Rhinoscopic Image. The white line shows the artificial opening after operation. (Fig. 1.) After the first opening through the obstruction was made, it was found difficult to watch the course of the operation by means of the rhinoscopic mirror, on account of the blood obscuring the mirror and the opening which had been made in the obstruction. The index finger was thereupon passed into the post-nasal space, and materially faciliated the operation. The revolving point of the drill could be felt entering the naso-pharynx, and without injury to the finger. This proceedure was also followed in another similar operation, at which I assisted, and also worked well in this case. The drilling was continued with burrs and reamer until an opening about seven millimeters in diameter was made, which appeared to allow the passage of a sufficient quantity of air. The bottom of the opening was in a line with the upper surface of the soft palate so as to allow freer drainage from the nose. Hemorrhage was free but not alarming, and was controlled by stopping occasionally to pack the bleeding part with iodoform gauze. The patient complained of but little pain. After the operation, the nostril was insuf- flated with aristol, and the posterior part packed with iodoform gauze. 5 The operation was apparently successful. The patient stated that she experienced great relief in breathing through this nostril, that she slept better and felt brighter. This continued for about three weeks when the patient complained that she felt less and less air through the affected nostril, and in spite of the daily passage of sounds, the opening became gradually smaller until the nostril was again almost occluded. A second operation was therefore decided upon. An opening about six millimeters in diameter was drilled through the lower part of the obstruction, and a similar opening through the upper part. The interven- ing piece of bone was then removed with the nasal saw, and the edges made even with the reamer. The hemorrhage was controlled as before, and the same after-treatment was carried out as after the first operation. There was a certain amount of contraction in the opening, but the passage has never since closed, and is sufficiently large for breathing. Six months after the operation, the patient was reported to me to be still breathing freely through the nostril, and to have materially improved in her general health. Medical Building. ANNALS OF OPHTHALMOLOGY ANH OTOLOGY. A QUARTERLY JOURNAL OF PRACTICAL OPHTHALMOLOGY. OTOLOGY. RHINOLOGY AND LARYNGOLOGY. Price per annum, in advance, $4.00. Single Copies, - - 1.25. 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