Granting that nasal affections are principally pyogenic infections processes and allergic reactions and that many of their symptoms are similar, how are they to be differentiated? History is important. Sinus infection usually dates to a certain severe cold or general infection disease, such as influenza, measles, scarlet fever, or pertussis in children. The severity of the symptoms may show relapses or exacerbations with recurrent colds. While the allergic condition usually gives a family history of allergy, other allergic manifestations in the patient and the onset is usually not associated with general illness.
Too, much can be determined by the appearance of the nasal membranes. In acute infection, the membrane is swollen, bright red with perhaps small haemorrhages and covered with purulent secretion. In chronic sinus infection, the nose may be very little swollen and may appear quite normal but careful inspection will reveal purulent secretion in the middle meatus or in the naso-pharynx. An allergic membrane on the other hand will be swollen and moist, frequently bluish in color, or a bluish background and a pale surface. If both an infection and allergic reaction exist, there may be purulent secretion, or if there is no infection, only a watery secretion will be seen. Polyps or hyperplastic swelling are always evidence of allergy.
Smears from the nose that show a preponderance of eosinophils indicates allergy. Also, an increase of eosinophils in the blood is an allergic sign. X-ray diagnosis can be very useful but too often is misleading. Most people who take x-rays of the sinus do not get pictures that can be diagnosed and are unable to read the pictures after they are made. Too often a picture that shows a shaded lumen is considered a positive sinus, but it may be either an allergic swelling or a pyogenic thickening.
A proper x-ray should reveal the thickness of the mucosa and if it is an inflammatory thickening, there will be a dense line next to the bone while a thick membrane without this line indicates allergic membrane. The treatment of allergic affections is usually not surgical unless the condition may be mixed, but consists of avoiding the provoking allergy or in reducing the susceptibility by injection of small doses of the allergen. While in uncomplicated infections, drainage, lavage and surgical eradication are the methods.
Probably surgery has received much of its bad reputation in sinus disease because it is applied too often to allergic conditions. Surgical eradication can and does eliminate sinus infection but it will not eradicate allergic reaction. However, as before stated, the mixed condition, the bacterial allergic reaction present a compound problem that tries the ingenuity of the physician to cure, and too frequently, can not be eliminated by methods now available.
The treatment of chronic forms of deafness has also been an unsatisfactory procedure. And unsatisfactory for two reasons. First, because of “lack of definite location of the pathologic lesion” and on account of the peculiar psychic reactions of deaf people. The ear is a difficult organ to study. One can not look into the ear and study its pathology. It is only possible to study symptoms. Nor is it convenient to study lesions of the ear in the pathologic laboratory. Consequently, only fragmentary information has been obtained.
Due to the fact that the tympanum and its membrane and eustachian tube were more available to study, much of the chronic deafness has been thought to be caused by lesions in these parts. Therefore, it was natural that treatment was directed to these parts. Better diagnostic methods have shown that most progressive deafness is really in the inner ear and not in the middle ear and is not subject to local treatment. So, because of incorrect diagnosis, most of the treatment has failed.
No doubt, the fruitless effort to return and restore hearing by treatment has been stimulated by the depressing effect of deafness upon people. It has been considered justifiable to continue useless treatment of deafness for the psychic effect alone. That is no longer necessary as we now have a much better method of restoring useful hearing. It is the electric hearing apparatus.
In conclusion, to this somewhat pointless discourse, a few points should be emphasized. First, every man to his job. A Rhinologist who is sincere and alert surely knows more about a nose than does the general practitioner, the internist or the advising public. If he has difficulty in making diagnosis with his experience, by all the means at his disposal, those in other branches of medicine should not be too positive in their snapshot, x-ray, or other forms of diagnosis.
A rhinologist is probably as intelligent and studious and honest as physicians in other branches of medium and unless they live in glass houses, let them not criticize his efforts. Also, it becomes evident that to be a rhinologist, a physician must be something of an allergist. Probably he should be a trained allergist to carry out in detail, allergic treatment; for who is in a better position to study allergy. And last, as is true in all branches of medicine, he should have an open mind, able to make deductions from his observations, and courage to do so. For after all, the opportunity to do clinical research is even available to the practicing physician.
