EXTENSION TO THE NASAL PASSAGES, EUSTACHIAN TUBE AND MIDDLE EAR The false membrane of a pharyngeal diphtheria spreads to the nasal passages by advancing along the lateral wall of the pharynx or else by coming down the front and up the posterior surface of the soft palate, more rarely by a continuous advance from the posterior pharyn goal wall up along the base of the skull. High fever develops, and a sense of pressure with obstruction of the nasal passages. Excessive secretion at first serous, later bloody and containing particles of mem brane, finally purulent, flows constantly from the nostrils over the lips; it may also be seen in the pharynx, coining down from the posterior nares. The skin of the upper lip and around the nostrils is red. swollen, excoriated and covered with bloody crusts, which may disclose a thin membrane as they fall off. The necessary breathing through the mouth makes the tongue and lips dry and fissured. The voice is thick and palatal. On rhinoscopic examination the mucous membrane is seen to be very red and swollen and on the septum and turbinates there are gray ish white deposits, isolated or presenting a frost-like appearance. As a result of the confluence of these spots or by spreading at the periphery the membrane enlarges and may ultimately form a thick, fat-looking layer covering the whole inucosa of the upper air-passages even in its deepest folds, filling up completely the pars posterior (the pars anterior is rarely attacked alone or to any extent). The course of retrogression and healing occur as in pharyngeal diphtheria and take about the same length of time. Deep ulceration may result in cicatricial closures, espe cially syneehia of the septum with the turbinates, closure of the mouths of the Eustachian tubes, partial adhesions of the soft palate with the posterior pharyngeal wall (W. Anton). Sometimes the disease subsides to a chronic form, running for several months and affecting by preference the anterior part of the nasal passages (Concetti, Monti).
Involvement of the nasal passages is not always a grave compli cation of advancing pharyngeal diphtheria. Sometimes, however, the nose becomes the starting-point of a gangrenous diphtheria. Swelling and oedema of the nose occur with marked pallor and a characteristic shining appearance of the overlying skin (Oertel), involving frequently the checks and eyelids. The nasal secretion becomes offensive and of bad odor, while the particles of membrane in it are of a blackish hue and fetid, and profuse epistaxis may occur.
In about three-fifths of all cases the organs of hearing become af fected. In the mildest form the pharyngeal mouth of the Eustachian tube is closed. The tympanic membrane is strongly retracted and sub jective sensations of hearing arise. In other cases the inflammation and fibrinous exudate extend exceptionally through the tube even into the tympanic cavity and mastoid cells (Wendt, Habermann).
Diphtheritic otitis, which may begin very insidiously, is extremely painful. It is accompanied often by violent headache or even distur bance of consciousness, and it causes in the majority of cases large per forations which go on to rapid destruction of the tympanic membrane. Examination with the speculum shows in the beginning only a serous infiltration of the drumhead, obliteration of the outlines of the hammer; later, after perforation, firmly seated diphtheritic false membranes are seen deep in the external canal or in the tympanic cavity.
The discharge is at first scanty and seropurulent, but after separa tion of the membranes it becomes copious, fetid and discolored or tinged with blood. The course of such a middle ear suppuration is almost always tedious and frequently injurious through the great disturbances which follow the destruction of the ligaments of the ossicles, through caries and necrosis and the extension of suppuration to the labyrinth. Deafness of high degree often persists and occasionally total loss of hearing (W. Anton) results.