Venerologist. Local hygiene is necessary and the highly contagious nature of the

mucuous patches must be explained to the patient.

TUBERCULOSIS

Laryngeal Tuberculosis

Symptoms. They include hoarseness and coughing persisting for several months and

pain on swallowing radiating to the ear.

Pathogenesis. Tuberculous laryngitis is almost always secondary to active

pulmonary tuberculosis. The infection is transmitted to the larynx by bacillae

contained in the sputum. The posterior part of the larynx, the interarytenoid

area, and the epiglottis are those most commonly affected. There is a danger of

perichondritis. Monocorditis may also be caused by a miliary tuberculous

deposit.

Diagnosis. Microlaryngoscopy in fresh cases initially shows reddish-brown

submucous nodules which are partly confluent. Later ulcerations or granulations

develop. Monocorditis is characterized by redness and thickening, occasionally

with small ulceration of one vocal cord. Other investigations include histology,

culture, radiography, and examination by an internist.

Differential diagnosis. It includes vasomotor monocorditis, nonspecific chronic

laryngitis, and carcinoma.

Treatment. Antituberculous treatment is given in cooperation with a chest

physician. Pain is treated by blocking the superior laryngeal nerve. The patient

must be isolated, and contacts are investigated. The disease is reportable.

Course and prognosis. Laryngeal tuberculosis is infectious. Mucosal lesions

often heal with no permanent effects on laryngeal function, but if the

tuberculosis has affected the laryngeal cartilaginous framework defects arise

during healing. The prognosis currently is good.

Tuberculosis of the pharynx

Acute miliary tuberculosis is the most common variety found in the pharynx, but

Is a rare complication of the pulmonary lesion. It is characterized by minute

grey or yellow tubercles on the fauces or palate. These rapidly break down into

shallow ulcers which spread widely in the mouth and pharynx to cause pain on

swallowing, excess salivation, a throaty voice and rapid emaciation. The

diagnosis must be made from syphilis, in which pain is absent, and from

diphtheria, which is excluded by a throat swab and by a biopsy from the edge of

the ulcer. Treatment is by antituberculous therapy. The prognosis is improving,

but the miliary nature of the condition calls for a guarded outlook.

Tuberculosis of the Tonsil

Tuberculosis of the tonsil is now extremely rare, and it presents no

characteristic features. Attention is drawn to the tonsils by the diagnosis of

tuberculous cervical glands. The tubercle bacilli are presumed to reach the

glands via the tonsils, which may or may not remain infected. There is no means

of diagnosing this by clinical inspection, and the condition is discovered by

histological examination after tonsillectomy. This is the more unfortunate

because half of the tonsils so sectioned do not show evidence of tuberculosis.

It is, however, sound surgical practice to remove the tonsils from children who

have a tuberculous cervical adenitis rather than to leave potentially infected

tonsils in situ. Full antituberculous therapy should be started when the

diagnosis is made in the glands.

Lupus Vulgaris and Tuberculosis of the Nose

Lupus vulgaris is the name given to a slowly growing, indolent deep-skin

ulcerative condition caused by Mycobacterium tuberculosis which affects the

nasal vestibule, the septum and the ala. It is more common in females than

males, and is more often encountered than frank tuberculosis of the nasal

mucosa. If untreated it is slowly destructive, and can lead to gross and

embarrassing deformity. Tuberculosis of the respiratory part of the nose gives

rise to granulation tissue and ulceration with sanguineous mucopurulent

discharge.

Diagnosis. All granulomatous lesions of the nose, whether of the skin or the

mucosa, must be submitted for pathological examination. Sometimes the

histological picture is so characteristic that a firm diagnosis can be made, but

in cases of doubt material should be submitted for bacteriological culture for

M. Tuberculosis, and some help can also be obtained by carrying out a weak Heaf

test. There is frequently evidence of tuberculosis elsewhere in the body.

Treatment. It depends on the sensitivities of the organism, and usually takes

the form of a combination of two or more of the following drugs – streptomycin,

PAS, isoniazid, rifampicin and ethambutol.

Part 10

TRAUMAS, FOREIGN BODIES, HEMORRHAGES

IN THE EAR, NOSE, PHARYNX AND LARYNX

AND EMERGENT AID

TRAUMAS OF THE EAR

Trauma of the external ear

Every injury to the auricle and cartilaginous part of the external auditory

meatus may damage the perichondrium causing cartilaginous necrosis. Furthermore,

bacterial infection can cause perichondritis with partial or complete

destruction of the cartilaginous framework leading to a cauliflower ear or

atresia of the meatus. Patients with partial or complete amputation of the

auricle should be admitted immediately to the hospital along with the severed

part of the auricle. Even large, completely severed parts of the auricle may be

resutured by appropriate reconstructive techniques, provided the interval

between the injury and the operation does not exceed 1 h.

Sharp and blunt trauma requires extensive debridement, primary suture, and

antibiotic cover.

Hematoma of the auricle. This arises from closed blunt injury with dissection of

the skin and perichondrial layer from the cartilage, and the formation of a

subperichondrial hematoma.

Symptoms. Swelling on the lateral or medial surface of the auricle which may

have a bluish tinge and considerable pain is experienced.

Treatment. A wide incision is made along the anterior edge of the helix, and

necrotic tissue is removed by curettage. If necessary, a window is made in the

cartilage to allow the two perichondrial surfaces to adhere and to prevent

further accumulation of blood and serum between the cartilage and the

perichondrium. An oiled silk compression dressing is used for 1 week, and

antibiotic cover is given.

Repeated aspiration may cause a seroma or superinfection leading to

perichondritis.