Ecchondroses of the Septum 
Narium and their 
Removal 
BY 
CARL SEILER, M.D. 
PHILADELPHIA, PA. 
Reprinted from The Medical Record, February 18, 1888 
NEW YORK 
TROW'S PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1888 ECCHONDROSES OF THE SEPTUM NARI- 
UM AND THEIR REMOVAL.' 
By CART. SEILER, M.D., 
PHILADELPHIA, PA. 
Reprinted, from The Medical Record, February 18, 1888. 
I feel a great hesitancy in bringing before you a paper 
on the subject of ecchondroses of the septum of the 
nose, because, after having read the admirable-one might 
almost call it classic-paper on deformities of the septum 
which was read before the Academy by my esteemed 
friend, Dr. Frank H. Bosworth, not much more than a 
year ago, little remains to be said that he has not point- 
ed out. Yet, like him, I have been struck with the great 
importance of these excrescences of the septum in the 
production of the various, and often remote, symptoms 
which we notice in cases of chronic nasal catarrh ; and 
for this reason I hope you will pardon me if I give you 
my personal experience and the result of my own obser- 
vations, which extend over a period of several years. I 
will confine my remarks, however, to those excrescences 
which are found on the surface of the cartilaginous plate 
of the septum, and leave out of consideration those exos- 
toses and deformities which are found on the vomer, or 
those which are in connection with deviation from the 
normal position of the septum. Long before I realized 
that these protuberances on the surface of the cartilagi- 
nous septum played an important role in the production 
of the symptoms of chronic nasal catarrh, I was aware of 
their presence, and devised a little instrument which 
would assist in the differential diagnosis between them 
and deviation of the septum, a description of which was 
published in the second edition of my Handbook. Since 
then I have more and more come to the conclusion that 
it is necessary in many cases to restore the normal 
1 Read before the Laryngological Section of the New York Academy of Medi- 
cine. 2 
smooth surface of the septum in order to cure the chron- 
ic nasal catarrh. 
The origin and growth of these cartilaginous excres- 
cences which are seen in a great many of the cases, some 
of which have come under my observation, puzzled me 
greatly-the more so as I cannot accept the theory ex- 
pressed by many, and also by Dr. Bosworth, that they 
are of traumatic origin; and it was not until I had occa- 
sion to watch their formation in several instances that my 
opinion as to their origin was formed. And, therefore, I 
think that a short history of one or two instances will be 
of interest. 
Mrs. T , wife of a physician, consulted me at the 
request of her husband, three years ago, on account of a 
chronic nasal catarrh. An examination of the nasal 
cavities showed a perfectly formed normal septum, but 
a turgescence of the turbinated tissue over the anterior 
portion of the lower turbinated bone, which on the right 
side was in contact with the mucous membrane of the 
septum. As she declined positively any surgical inter- 
ference or cauterization of the superabundant tissue, I 
gave her an alkaline spray to use at home, and did not 
see her again until a year later. She then told me that she 
was better, but that the obstruction in the right nostril 
had been permanent, the nasal cavity opening up only 
occasionally, and then allowing the passage of air but for 
a few moments. For some time she had noticed that 
her nose, which had formerly been straight, had a tenden- 
cy to bend over to the left side. There was no history 
of any blow or fall on the nose. An examination gave 
an entirely different picture from that seen at the first 
examination, inasmuch as the cartilaginous septum was 
seen to bulge into the left nasal chamber, while on the 
right side there was a depression corresponding in size 
and position to the projection of tissue from the lower 
turbinated bone. This depression was bordered in front 
by a decided ridge, which ran obliquely upward. She 
again refused to be operated on, and I did not see her 
until a short time ago. An examination revealed the 3 
following condition : The tip of the nose was consider- 
ably deflected from the median line toward the left side ; 
the left nasal chamber was partially obstructed by a de- 
cided bulging of the cartilaginous septum, on the surface 
of which a tit-like projection came in contact with the 
turbinated tissue of the lower turbinated bone. On the 
right side, the turgescence of the turbinated tissue was 
still present, but the depression which had existed at the 
former examination had disappeared, and in its place 
was seen a shelf-like projection from the surface of the 
cartilaginous plate of the septum running back to a 
considerable distance. The upper surface of this shelf 
was gently sloped downward, while the lower surface was 
slightly concave, and separated from the floor of the na- 
sal chamber by a space of about one-eighth of an inch, 
so that a probe could easily be passed between it and the 
floor of the nose. The most prominent symptoms were 
fits of violent sneezing with every sudden change of sur- 
face temperature, such as getting out of bed, going out 
of a warm room into a cold one, or into the open air, and 
so forth ; severe neuralgic headaches over the right tem- 
ple, obstruction to nasal respiration, chronic laryngeal 
inflammation, and accumulation of thick viscid mucus 
in the naso-pharyngeal cavity, which had to be removed 
by hawking. 
Another case in which I observed the development 
and growth of an ecchondrosis on the surface of the sep- 
tum was that of a boy, about fourteen years of age, who 
was afflicted with a large papillomatous growth in the 
larynx, and whose nose I examined only incidentally. 
His nasal chambers were perfectly normal as far as the 
anatomical relation of the parts was concerned, but 
there was a somewhat deficient watery secretion, and a 
tendency toward the formation of scabs of dried mucus 
which adhered to the surface of the septum, particularly 
on the left side, and which he was in the habit of remov- 
ing with his finger-nail. I cautioned him against this 
habit, which, as I explained to his parents, was likely to 
lead to a perforation of the septum. The papillomatous 4 
growth was successfully removed, and I did not see the 
patient again until about eighteen months later, when he 
returned with a chronic laryngitis which his parents 
thought was a return of the tumor, as it was accompa- 
nied by cough and hoarseness. He also complained of 
occlusion of the left nostril, which prevented free inspi- 
ration ; but there was no obstacle to the outflow of the 
air, and his mother told me that he breathed heavily at 
night, and slept with his mouth open, expectorating in 
the morning large scabs of dried mucus. On inquiry, I 
found that he had persisted in picking off scabs with his 
finger, and that there were frequent slight nasal hem- 
orrhages. I fully expected to find my prediction veri- 
fied, viz., that he had scratched through the cartilaginous 
septum, thus producing a perforation. But such was 
not the case, for, instead of a perforation, I found on ex- 
amination a conical projection from the surface of the 
septum on the left side, which was in contact with the 
atrophic turbinated tissue of the lower turbinated bone. 
Its apex was covered with dried mucus, and, on removal 
of which, presented a bleeding surface denuded of mucous 
membrane. The right side showed nothing abnormal 
except that the mucous membrane was dry, and the tur- 
binated tissue slightly atrophied. The most minute in- 
terrogation of the patient and his parents failed to elicit 
an account of any injury to the nose by a blow or fall 
during the interval between the two examinations, and 
for a long period before I saw the boy. 
In a number of other cases have I had the opportunity 
to observe a similar process of development of these 
ecchondroses of the cartilaginous septum, without the 
presence of a decided deviation existing previously, so 
that I have come to the conclusion that these simple 
cartilaginous excrescences are due, not to external trau- 
matism, but to internal local irritation of the mucous 
membrane of the cartilaginous septum primarily, and of 
the perichondrium secondarily. If we consider that a 
turgescent or hypertrophied portion of the turbinated 
tissue, which for a considerable length of time is in con- 5 
tact with the mucous membrane of the septum, must 
necessarily exert a certain amount of pressure upon that 
mucous membrane and upon the perichondrium under- 
lying it, and that even a very slight pressure, when it is 
kept up for a considerable period of time, will produce 
local congestion of the part pressed upon, be it on the 
outer integument of the body or the mucous membrane, 
it seems plausible to assume that this local congestion 
gives rise to changes of nutrition of the part sustaining 
the pressure. Taking into consideration the peculiar 
histological structure of cartilage, and particularly of 
hyaline cartilage, in which the blood is supplied by 
loops of vessels dipping into the substance of the car- 
tilage from the perichondrium, and the nutrition of the 
cells is carried on by osmosis from one to the other with- 
out the intervention of a capillary net-work of blood- 
vessels, we can readily see that a localized increase of 
blood-supply to these loops must necessarily give rise to 
a more rapid cell-division and proliferation of the inter- 
vening cartilage-cells than is demanded to supply the 
waste by cell-death, and localized increase of cartilage- 
tissue must result therefrom. 
In the majority of cases the cartilaginous projections 
from the surface of the septum corresponded in position 
and size to the line of pressure by turbinated tissue, and 
in those cases of atrophic rhinitis in which they are 
found, careful examination of the patient will elicit the 
fact that at some former period a hypertrophic rhinitis 
has existed, which has given rise to the ecchondroses in 
the manner described. It is, of course, impossible to 
state what length of time is required for their formation, 
and how long the pressure must exert its influence be- 
fore any elevation on the surface of the septum becomes 
apparent. And, further, it is impossible to give any rea- 
son why, in some instances, no apparent redundancy of 
tissue results from long-continued pressure by the turges- 
cent turbinated tissue. Individual peculiarities in this 
case, as in many other pathological formations in the body, 
must account for the differences noted in different cases. 6 
In a short paper on this subject read before the Ger- 
man Medical Society of Philadelphia, last spring, I men- 
tioned some instances in which an excessive growth of 
ecchondroses had caused a union between them and that 
portion of the turbinated bone lying opposite to them, 
so as to form a bridge across the floor of the nose, and 
explained this union by the fact that both the top of the 
ecchondrosis and that portion of the turbinated tissue 
which pressed against it had become denuded of mucous 
membrane, and an exostosis from the turbinated bone 
had projected to unite with the ecchondrosis on the 
septum. Since then I have had the opportunity to 
watch a case in which this condition existed, but union 
had not as yet taken place. In order to satisfy myself 
as to the result, I refrained from operating, and found 
that in the course of three months a firm union between 
the two had taken place, and the bridge was covered 
with mucous membrane, intact as far as I could deter- 
mine, thus proving in this instance my surmise, as to the 
origin of these bridges, to be correct. 
I will not tire you with an enumeration of the many 
and varied symptoms to which these obstructions to nasal 
respiration give rise, particularly as they have been so well 
described by Ingalls, Jarvis, Bosworth, Allen, John Mac- 
kenzie, Hinkel, and others, and will only mention one 
peculiarity, which I do not recollect to have seen a de- 
scription of in any of the writings on this subject, viz., the 
valve-like action of the alse of the nose when ecchondrosis 
on the septum exists low down. It will be noticed that 
in these cases inspiration alone is obstructed, because the 
pressure of the air upon the external surface of the ala of 
the nose, due to the suction, causes it to move slightly 
inward, and the lower portion of the turbinated tissue 
coming in contact with the ecchondrosis, more closely 
obstructs the lower orifice of the nasal chamber, like a 
valve which, as in the tube of an air-pump, permits the 
exit of the air, but prevents the influx through the same 
channel. By inserting a nasal speculum or dilator into 
the nostril this valve-action can be prevented, and the 7 
patient can breathe in and out with equal facility. A 
like result is obtained, if there is no other obstruction 
farther back in the nasal chamber, by removing a suffi- 
cient amount of the cartilaginous mass to prevent con- 
tact with the turbinated tissue during respiration. 
I will also refrain from describing in detail the vari- 
ous shapes and positions of these cartilaginous excres- 
cences, as this point has also been fully discussed by 
the above-mentioned writers, and will only add that my 
own experience has taught me that, if they have existed 
for some time, they are apt to become ossified or calci- 
fied in the centre. This ossification makes their re- 
moval much more difficult than it would otherwise be, 
and necessitates the employment of instruments which 
are capable of penetrating through this hard centre, so 
as to restore the normal flat surface of the septum. 
Various writers have suggested and used a large vari- 
ety of different instruments for these operations, such as 
the saw and knife, the plough, the gouge, the snare, the 
rotating-knife or burr in the surgical engine, and so 
forth; but a careful consideration of the requirements 
of individual cases will at once show that none of these 
instruments can be successfully used in all cases to the 
exclusion of the others, and the armamentarium of the 
operator should include them all. 
But we must take into consideration that most oper- 
ators have a particular fondness for this or that instru- 
ment, and prefer to operate with it rather than use any 
other, if this is possible; probably because they have ac- 
quired especial dexterity in its manipulation. It is, 
therefore, natural that they should praise their pet tool, 
and obtain results with it which others, with less dex- 
terity in its use, can never hope to arrive at. 
The object is to remove the redundancy of tissue as 
thoroughly and quickly as practicable, leaving a plain 
surface without ragged edges, and to perform the oper- 
ation with as little pain and inconvenience to the pa 
tient as possible. And this can only be done by adapt 
ing the instruments to the requirements of the case. 8 
Before I proceed with the operation, however, in a 
given case, I treat the nasal mucous membrane with a 
view to reduce the existing hyperaemia, for it is my ex- 
perience that, if any surgical interference is undertaken 
at once, the shock following the operation is much more 
severe, and the wound does not heal as kindly nor as 
rapidly as when all acute or subacute inflammation has 
first been removed. For this purpose I use a spray of an 
alkaline solution, and make local applications with glycer- 
ole of iodine by means of a cotton carrier. Formerly I 
used the ordinary Dobell's solution for the spray, and also 
as a wash to be sniffed up the nose by the patient, morn- 
ing and night, but within the last two years I employ in- 
stead a solution composed of the following ingredients : 
Sodii bicarb 3 viij. 
Sodii bibor 3 viij. 
Sodii benzoate, 
Sodii salicylate aa gr. xx. 
Eucalyptol, 
Thymol aa gr. x. 
Menthol gr. v. 
01. gaultheria gtt. vj. 
Glycerine ? viiiss. 
Alcoholis | ij. 
Aquae q. s. 16 pints. 
This formula gives a solution which is sufficiently alka- 
line to dissolve the thickened secretion adhering to the 
nasal mucous membrane, and as it is of the proper den- 
sity, it is bland and unirritating, leaving a pleasant feel- 
ing in the nose. At the same time it is antiseptic and 
acts as a deodorizer, being in this respect far superior 
to Dobell's solution or any other non-irritating deodori- 
zer and antiseptic. As it is, however, inconvenient for 
many patients to have so large a quantity of solution on 
hand, one of our Philadelphia druggists made the solid 
ingredients into a compressed tablet, so that one, when 
dissolved in two ounces of water, will make a solution 
identical in its effects with the solution made after the 9 
above formula, and my patients prefer the tablets to the 
solution. 
As soon as the inflammation has subsided sufficient- 
ly, I introduce a pledget of cotton, saturated with a 
four per cent, solution of cocaine, into the nasal cavity 
Fig. i. 
so as to cover the ecchondrosis completely, and leave 
it there for about ten minutes, when it is removed, and 
a fine cambric needle inserted for the purpose of ascer- 
taining whether all sensibility has been destroyed, and 
also to determine whether any ossification has taken 
place in the substance of the excrescence. 
If the ecchondrosis is in the shape of a conical projec- 
tion or of a ridge running from below upward, and if no 
Fig. 2. 
ossification has taken place, I prefer a small, double- 
edged knife, slightly curved on the flat (Fig. i), with 
which I make an incision, first from below upward to 
about the middle of the excrescence, and then cut from 10 
above downward until the two cuts meet, and the car- 
tilaginous projection is ablated. If there exists a hard 
centre which cannot be cut through with the knife, I 
carry the two cuts from below and above to this centre, 
and then use a flat chisel (Fig. 2) to cut through the 
bony portion, which is easily effected by tapping the 
handle slightly with a leaden mallet (Fig. 3). 
The two cuts are necessary because the knife, after 
Fig. 3. 
having passed through the cartilaginous tissue, finds not 
sufficient resistance in the mucous membrane if the 
operation is made with one sweep of the knife from 
above downward, and the ablated piece falls over into 
the mass of coagulated blood, being still attached to 
the surface of the septum at its lower edge by the mu- 
cous membrane. It is then difficult to grasp with the 
forceps, and much time is lost in finally severing the 
mucous membrane. 
If, on the other hand, the shape of the ecchondrosis 
Fig. 4. 
is shelf-like, with a downward-sloping upper surface, and 
a concave under surface separated from the floor of the 
nose by a narrow space, and running backward for some 
distance, I know beforehand that I have to deal with an 
ossified excrescence, and proceed as follows : After 
having thoroughly anaesthetized the parts with cocaine 
solution, I introduce a grooved director, slightly bent at 11 
an angle, into the space between the floor of the nose and 
the under surface of the shelf-like projection, with the 
groove upward. I then dilate the nostril to its full ex- 
tent with Bosworth's (Fig. 4) or Jarvis' self-retaining 
nasal dilator, and insert the dull point of a plough-shaped 
knife (Fig. 5) into the groove of the director, pushing it 
backward so as to cut through the base of the projec- 
tion ; very much in the same way as a wood-carver uses 
a similar tool. As soon as I find that the bony centre 
presents an obstacle to the further progress of the knife, 
I remove the latter and insert a gouge-the cutting edge 
of which is slanting-with its point into the groove of the 
director, and with a few blows from the mallet upon the 
end of the gouge, I cut through the ossified portion. In 
order that the view of the nasal cavity be not obstructed 
by the handle of the instrument and the hand holding it, 
I find it advantageous to insert the tool into the handle 
at an angle of about sixty degrees fastening its stem by a 
set-screw, and allowing the former to project slightly so as 
to receive the blows from the mallet in a direct line with 
Fig. 5. 
the direction of the cut to be made. The hand holding 
the cutting instrument should be steadied against the chin 
of the patient, so as to prevent injury to the parts beyond 
the projection, which might easily result from the cutting 
edge or point of the instrument getting out of line and 
going beyond the posterior end of the projection,into the 
vault of the pharynx. A little practice soon enables the 
operator to feel when the gouge has cut through the hard 
tissue. The tool is then removed, and, keeping the 
grooved director in position, a pair of scissors bent at an 
angle is passed along its groove, so as to sever any por- 
tion of the mucous membrane at the upper surface of 
the shelf which may not have been cut by the plough or 
gouge. A straight chisel is not as advantageous as the 12 
gouge, because it cannot be so easily kept in the line in 
which the cut should be made; and, although the cut sur- 
face is slightly concave, I have in no case observed any 
retardation in the healing of the wound from this cause. 
In the case of a union between the turbinated exostosis 
and the ecchondrosis of the septum, I have found it best 
to divide the exostosis first, with a saw, close to the tur- 
binated bone, and then to ablate the ecchondrosis with 
the knife and chisel, or gouge. 
These operations are absolutely painless if the cocaine 
has fully anaesthetized the parts, and the only objection 
made by the patients is the jarring produced by the 
blows of the mallet upon the end of the gouge or chisel. 
The hemorrhage resulting from these cutting operations, 
as a rule, is comparatively slight, and can always be con- 
trolled by placing a pledget of borated cotton against the 
wound for a few hours. As soon as all oozing has 
stopped, this should be removed and the nasal cavity 
should be washed out twice daily with the antiseptic solu- 
tion, so as to prevent any sepsis. The healing process 
is usually complete in about ten days, but may, in some 
cases, be prolonged for a few days more. There is no 
soreness of the nose, and no great amount of inflamma- 
tion of the surrounding mucous membrane following the 
operation, and the patient is able to attend to his duties 
at once. I do not, however, wish to be understood that 
other methods of operation are not as successful, and 
that the saw or revolving-knife should not be used in 
cases of ecchondrosis of the septum. I only wished to 
give my personal experience, which, probably owing to 
want of dexterity with these instruments, has taught me 
that I obtain better results, and more easily, with the 
knife and gouge, than with the revolving-knife or saw. 
1346 Spruce Street.