Diagnosis. The symptoms already described, i.e., the appearance of the child, the speech, deafness, and the mucopurulent secretion on the posterior pharyngeal wall make the diagnosis easy. Hypertrophic rhinitis, a congenital smallness of the nasopharynx, or other tumor, may however lead to errors in diagnosis. A direct inspection of the naso pharynx by. posterior rhinoscopy, or examination with the index linger of the right hand, xvill clear up all doubts.
Treatment.—An operation (adenotomy) is the only form of treat ment. for most eases. This should be performed, even in nursing infants, as soon as its necessity has been determined. Hamtophilia, and acute inflammatory processes in the pharynx, would be contraindications. Medical treatment and local applications will not do much good. The operation should however only be performed when positive syntptoms, directly caused by the ale n oi d growth, are present, as for example, mouth breathing, nasal speech, and deafness.
A decision is more difficult when inflammatory compli cations occur. The oper ation is of doubtful service when there is only a small amount of lymphoid tissue causing recurring etatarrhal attacks. Such attacks often go with general constitu tional disturbances. A chroni c purulent rhinitis, pharyngitis, or an otitis media, are usually' taken to be positive indi cations for an operation. Enlarged ,glands in the neck occasionally show improvement after adenotomy.
To perform the operation, curettes (Gottstein's, Beckmann's, Kirstein's and Fein's) are in common use. Juraz and Schech's forceps and the adenototne are also used a good deal. The child is seated on the lap of an assistant and held firmly, the mouth being held open with a tongue depressor or preferably a mouth gag (Beckmann's or Jansen -Windier's). The curette is then inserted back of the velum between the
growth and the posterior flares, carried to the vault of the pharynx and swept downwards, the growth being often carried out of the mouth with it. The piece often drops into the throat and is swallowed. Fragments left behind may be removed with forceps. The bleeding which is at first severe soon ceases. General antesthesia is recommended by some pity sicians, and is not employed at all by others. It is well to examine with the finger to determine whether fragments are left behind.
Deep ana-sthesia at any rate is unnecessary. The child should be kept in bed for a short time and on a soft diet. Secondary limmorrhages are rare, and occur either at once or one or two hours after the opera tion. They are produced either by htemophilia, or by the presence of only partially removed adenoid fragments. If the usual hamtostatics, (adrenalin) fail, tampons or gelatin may have to be employed. Fatal cases are recorded. Secondary fever occurs at times, and is usually due to retained pieces of the growth, which lead to inflammatory symptoms. Graver complications such as post-operative paratonsillar or retropharyngeal abscesses occasionally occur. Severe septic con ditions of the mouth and pharynx have :Also been reported. Careful asepsis should be observed in operating.
The results of the operation are excellent. Recurrences occur in a small percentage of cases operated upon, but as a rule are not very common if a thorough operation has been performed. Tbey cannot be positively prevented however.