The various forms of tumors that are found in the nasal cavity, have been grouped together under the general term polypi, notwithstanding the structure, and malignancy vary under three heads, while, of course, the sub-division may be almost endless.
Papillary growths are common in the nose, and present all the characters of papillomate elsewhere. They are sessile, of course, and the “individual papillae are accuminated.” They spring mostly from the mucous covering of the septum, or cartilages, and are more frequently seen in children or young persons. The symptoms are few, and nothing can definitely determine their presence, but actual inspection. The discharge from the nose varies greatly, in different bases, sometimes profuse and of unhealthy characters, at others bland and scanty; there is at all times, however, much irritation of the nostrils, with disposition to pick the nose.
Mucous (gelatinous) polyps are the true polypi, and by far the most common of all forms of nasal tumor. They are usually pedunculated pendulous growths, somewhat pear-shaped in most instances, but occasionally lobulated and moulded to fit the cavity in which they are found. They may be single or multiple, oftener the latter – and are found growing from any of the mucous membranes covering the bones, particularly the turbinated, and rarely, if over from the septum or cartilaginous portion. They are elastic, of a shining translucent appearance, varying greatly in color, small blood vessels running on the surface, oftener gray, or greenish-gray. When incised they yield a sero- albuminoid fluid, closely resembling synovia. The symptoms are various, depending much upon the size and position of the tumors, and not conclusive unless inspected by the mirror or touch. In the beginning there will be a sensation as if the nose is filled up with something, and the finger is used to clear it away; as it increases in size breathing becomes difficult, the mouth is kept open, and snores while sleeping. In damp weather the tumor is enlarged, and the difficulty in respiration is aggravated. There may be an increased discharge from the nose, but in most cases it is unirritating, and not particularly noticeable; occasionally there is frequent haemorrhage, but not to an alarming extent as a rule. When the tumor grows from the roof of the pharynx, or the base of the skull, it is known as naso-pharyngeal polyp, and while of much greater size than when found elsewhere, is also productive of more urgent symptoms, and greater impediment to respiration. As they increase in size, in either situation, anterior or posterior nares, or pharynx-the cavity is first distended, and next the bones become eroded or even absorbed. In this way benign growths may induce as much deformity as Ozaena, and mislead the uninformed. Simple as a diagnosis may seem, cases are not rare in which one of the turbinated bones have been torn out, or the mucous membrane stripped away. It is becoming in young surgeons to be cautious in forming a diagnosis, or expressing an opinion in these cases. Bearing in mind the possibility of pharyngeal growths, no examination should be considered complete that does not include the use of the rhinoscope.
The pathology, according to DURHAM is as follows: “They consist of extensions of mucous membrane, including more or less closely reticulated fibro-cellular structure, which is continuous with the normal sub-mucous tissue. Their surface is covered by ciliated epithelium; and their substance is made up of delicate, waxy, interlacing filaments, the interstices of which are occupied by fluid, or semi-fluid material, containing round, oval, elongated, or caudate cells with nuclei, and very fine granules or molecules. The normal mucous glands, according to Billroth, are enlarged and converted into clustering formations, with very numerous sacculi, and these help to make up the mass. In some cases these sacculi become cystic in appearance, and the vesicular character of the polyp is pronounced. In other cases in connective tissue elements are developed in larger proportion, and the growths are consequently firmer and denser, and approaching in character the fibrous or sarcomatous polypi. Occasionally the softer polypi become comparatively condensed and opaque in places; and in some rare instances concretions of fibro-cartilaginous hardness are found in them.”
Fibrous polypi are of two kinds, according to my observation, the sessile and pedunculated, which differ enough in the structure to warrant a distinct classification. When pedunculated they seem to be formed very much as uterine fibroids are; that is a fibroid, differing in nothing from the same tumor elsewhere, except that its investment is mucous membrane, and the tumor frequently becoming separated from its vase, seems to lie loose and unattached in its mucous envelop. The other form is either sessile, or the pedicle is very broad and thick, and is firmly attached to the bones.
The vascularity is high, while in the mucous polyp it is low and the arterial distribution is on the surface; this gives rise to frequent haemorrhage, and the same higher grade of vitality renders their pressure more injurious to near parts. They are usually single, attain a large size grow slowly, and are quite firm to the touch; recurrence is the rule after removal, and they not infrequently take on a malignant character after frequent recurrences. When not arrested or removed early, they may attain enormous bulk, filling the nares completely, extending back into the throat, and produce a disfigurement GROSS calls “Frog-face”, from the distension of the parts. The naso-pharyngeal polyps are usually of the fibrous character. They are firmly attached to the periosteum, and it is though are continuous with it in structure, containing few, if any elastic fibres. Occasionally they are found containing calcareous concretions, in some instances ossific deposits, and GROSS mentions a notable case in which there was a coating of calcareous matter, highly organized. Fortunately these growths are not common in the nasal cavity, the uterus being the chosen seat.
The treatment of polypi, when large and inducting serious discomfort, must be operative. When smaller, not in very great numbers, or occurring in both nostrils, remedies must take precedence. It must be understood that even in the first instance, operative treatment is purely palliative; the tendency to recurrence can only be combatted successfully with remedies. The following remedies are oftener indicated, while many others, of exceptional value, might readily be added to the list.
Calcarea carb-This remedy has long stood at the head of the list for polyps, particularly of the mucous variety. There is a constant stench before the nose, like manure, gun powder, or putrid eggs; the polyps are large, in the anterior nares, plainly to be seen, and not sensitive.
Cepa.-RUCKERT gives a case cured, the polyp being mucus, in left nostril, with a “drugsmell” in the nose, fluent coryza of thick mucus, with later a thin watery discharge. Five doses of Cepa 6, caused the expulsion of the mass, and the coryza ceased. The mucous membrane of the opposite nostril was thicker, but no polyp.
Conium mac.-Fibrous polyp, hard and elastic, pricking and itching after touching or handling; excessively acute smell with purulent discharge.
Kali nit.-RUCKERT case of mucous polyp of right side, in … very large and distending the nose. Cured with six dose of the third attenuation.
Lycopodium. – Very sensitive small; violent coryza, acrid, and making the upper lip sore; posterior nares feels dry, and the nostril is closed, every morning, with what looked like inspissated pus.
Phosphorus.-Fibrous polyp, bleeding freely, and accompanied by scirrhous mischief to the nasal bones, threatening necrosis; profuse discharge of green or yellow mucus without coryza.
Teucrium-Mucous polyps, of pale red color, on the left side, and of large size; mostly in the anterior nares, and in plain sight without rhinoscope.
Sulphur.- I have always given this remedy, “on general principles” after the cure has seemed complete, on an assertion of JAHR’S that it “confirmed the cure.” Of course with what success cannot be definitely told, as a failure to the return might be considered evidence pro or con. by different observers.