DISEASES OF THE EAR, NOSE AND THROAT (continued 2)

Tonsillectomy

We may safely conclude from this evidence, that in the growing child, it may be well to retain the tonsils providing they are not directly affected in such a way as to endanger the general health of the child, but that there is little, if any, danger in their early removal. In adults, there seems to be no reason why they should not be removed in cases in which there is evidence of involvement beyond restoration by treatment or those cases in which there is evidence of toxic absorption.

When surgical removal of the tonsils is indicated, the complete removal or tonsillectomy should always be done. A careful and complete enucleation of the tonsils when properly done will never be followed by any untoward results other than the temporary surgical sore throat. There is never any excuse, much less a reason, for partial removal of the tonsils or tonsillotomy, because such operations never accomplish the desired result and they nearly always require tonsillectomy later.

In association with a reputable vocal teacher I have studied the results of tonsillectomy on the voice. In none of the twenty cases studied was there any impairment following the operation, but on the other hand sixty per cent were improved either in range of pitch, quality or endurance, in addition to their being more free from laryngitis, pharyngitis, etc. for which the operation was done. Doctors Ruddy, Edwards and Reid of our profession have told me of similar experiences, so I am certain that tonsillectomy properly done will in selected cases, improve the voice.

Acute Tonsillitis

Acute tonsillitis is an acute infectious and often a contagious disease characterized pathologically by inflammation of the tonsils. Some authors differentiate between follicular tonsillitis in which the crypts or lacunæ are involved, and parenchymatous tonsillitis in which the parenchyma is involved.

Etiology.—The predisposing and exciting causes are the same as in other acute infections of the upper air passages except that there is usually a chronic tonsillitis as a result of some previous attack.

Symptoms and Diagnosis.—The symptoms also are similar to other acute infections of the nasopharyngeal tract, with sore throat, variable temperature, headache, etc. By direct examination of the pharynx, the protruding masses with white or yellow patches are readily seen.

Treatment.—Infection, drainage and elimination are three words inseparable in the therapeutics. The local treatment (I doubt if many will agree) in either acute or chronic tonsillitis is essentially the same—radical aspiration drainage. In all cases, except young children who will not permit it, I place a vacuum cup directly over the tonsil and apply as much vacuum as can be obtained. This treatment will, when properly done, empty the crypts of all pus. This accomplished, each crypt is probed with a cotton applicator dipped into phenol-glycerine.

Cervical and upper thoracic treatment and deep relaxation of the sub-tonsil tissues to increase the normal blood supply and to decrease congestion by drainage elimination are essential. The lower thoracic and lumbar should receive due attention for the purpose of increasing general elimination. The diet and other treatment are no different from that in other infectious fevers.

Peritonsillar Abscess

(Quinsy Sore Throat.)

Peritonsillar abscess results from the collection of pyogenic bacteria and pus formation between the tonsil and the pillars of the fauces. It is perhaps a result of the closing of an infected crypt causing deep penetration of the pus.

Diagnosis.—The symptoms are those of acute tonsillitis but usually more marked and with one tonsil decidedly more protruding than the other. In some cases the location of the abscess can be seen and it is comparatively easy to open with a knife or probe, but in many cases the abscess is so situated that it cannot be located except by exploratory probing.

Treatment.—Drainage by direct incision of the abscess pocket is indicated as early as a definite diagnosis can be made. There is no definite technic to be followed except to observe certain general principles. If the “pointing” of the abscess can be located, it is comparatively easy to make a good, free, direct incision and accomplish complete drainage. In many cases the only way to locate the pocket is to employ a probe or small, long, scalpel and explore between the pillar and tonsil until the pus pocket is found. As soon as this is located the pus pours out around the probe and this gives the location. Free drainage by means of a liberal incision should then be made. Aspiration of the pus pocket and filling with phenol-glycerine is effective after drainage has been obtained, but a liberal drainage must be maintained.

The non-surgical treatment as described under acute tonsillitis is to be applied here.

Chronic Tonsillitis

Chronic tonsillitis usually is the result of one or many attacks of acute infections of the tonsils. Occasionally cases of marked chronic tonsillitis occur in which the patient denies ever having had an acute attack.

The pathology consists of hypertrophy of the lymphoid tissue and connective tissue.

Diagnosis.—The purpose in diagnosis is not to determine whether the tonsil is hypertrophied but to determine whether the tonsil is causing any local or general physiological perversions and if so, whether local treatment or surgery should be applied.

The direct examination should be made very carefully, because otherwise a bad tonsil may be readily overlooked. The mere fact that a tonsil is large or has open crypts from which a whitish mass may be expressed does not mean that such a tonsil is directly responsible for local or systemic physiologic perversions.

The examination should be made by means of a tongue depressor, tonsil retractor and a good head mirror and reflecting lamp. Every part of the tonsil and surrounding pillars should be carefully examined. Firm pressure applied against the tonsil from in front and behind will often force material from the crypts or out around the capsular margin. Any such material thus expressed should be examined microscopically. By probing the crypts with a small pointed cotton-wound probe and staining the material obtained, the condition of the deep parts of the tonsil can be determined.

The symptoms in every case, are to be considered with the microscopic findings, but there are cases in which either of these, together with appearance on direct examination, is sufficient to determine the advisability of tonsillectomy.

In general, we may say that the following factors would indicate tonsillectomy.

1. Chronic, recurrent tonsillitis with or without complications, which does not respond to non-surgical treatment.

2. Positive evidence of arthritis of any form with microscopic evidence of some virulent organism, such as staphylococcus, streptococcus or long-chain pneumococcus, present deep in the tonsillar tissue.

3. Any persistent discharge of pus from the tonsil in which the microscope shows the presence of virulent bacteria and which will not be relieved by treatment.

4. Markedly hypertrophied tonsils which directly interfere with the voice, deglutition or respiration and which do not respond to treatment.

5. Persistent focal infections of the middle ears, or sinuses or root abscesses which do not respond to treatment and in which case there is a virulent infection of the deep parts of the tonsil, shown by microscopic examination.

The above are only general conditions and there are probably many other indications or groups of symptoms that would indicate tonsillectomy. In most cases, unless the findings show positively that tonsillectomy should not be delayed, we advise treatment. If treatment does not restore to normal, it will probably reduce the time of the surgical sore throat following the operation.

Non-surgical treatment.—The local direct treatment, as we practice it, consists of: 1. Direct aspiration by means of the tonsil cup, applying from fifteen to twenty inches of vacuum. 2. Application of phenol-glycerine by means of cotton applicator to the full depth of each crypt. 3. Irrigation of the crypts by means of a catheter and hot salt mixture solution. 4. Syringing of the crypts by means of the catheter and phenol 10%, alcohol 20% and glycerine 70%.

The digital treatment of the tonsil consists of: 1. Applying pressure against the anterior pillar thus forcing the contents out of the tonsil, the Ruddy method. 2. By the bidigital technic, the front finger of one hand inside, posterior and inferior to the tonsil and the fingers of the other hand outside exerting deep pressure and opposing the finger inside. In this way the tonsil can be lifted forward and upward and its contents expressed. The digital treatment is not as effective as that described above.

The osteopathic corrective treatment consists of adjustment of the atlas and axis and the mandibular articulation and the obtaining of free movement of the hyoid and the relaxation of the submaxillary musculature and other deep structures.

This treatment, if followed persistently, will relieve the local symptoms of a very high percentage of cases of chronic tonsillitis, and in many cases even the systemic complications will be relieved. Whether in cases of systemic absorption this is the preferable treatment I am not sure, because, once the local condition is improved the patient will usually refuse operation and even if the physician finds definite evidence of toxic absorption he cannot convince the patient that his tonsils require surgery.