War Surgery and Medicine
CHAPTER 26 — Ear, Nose, and Throat Conditions
Ear, Nose, and Throat Conditions
EAR, nose, and throat conditions, though generally of a minor nature, account for a great deal of disability in an army. It has been stressed by Colonel R. A. Elliott, first ENT specialist in 2 NZEF, that there is an enormous, and often unnecessary, wastage of manpower due to the relatively trivial diseases of the ear, nose, and throat.
During the First World War a high incidence of infections of the ear was noted in the NZEF in the Middle East, and sinus infection was also prevalent. It was noted that many cases of old healed otitis media with perforation tended to develop fresh infection, and recommendations were made that such cases should not be accepted for overseas service.
Medical Boarding in New Zealand, 1939–45
The examining of recruits was undertaken by a panel of general practitioners. At one stage provision was made for a specialist ENT surgeon to be a member of the board, but this was not possible with the small number of specialists available. Arrangements were made by the boards to refer doubtful cases to specialists for their opinion. The short time allowed for examination tended to the elimination of special examination of the ears, and auriscopes were not used as a routine in examination of the drum. The estimation of deafness also was made on rough tests and the audiometer not used. It was inevitable, therefore, that many recruits with old perforated drums, many with chronic otitis media, and many with otosclerosis were accepted for service. Numbers were invalided back to New Zealand after a relatively short stay in Egypt.
In New Zealand the numerous cases referred for tonsillectomy created a serious problem for the civil hospitals and great delay in getting the recruits into camp. Undoubtedly tonsillectomy was recommended too frequently.
Specialist Staff in 2 NZEF
Shortly after the arrival of the First Echelon in Egypt, ENT consultations were arranged in camp and later at the hospital page 448 established at Helwan, to which Captain R. A. Elliott was posted. The RMOs were thereby enabled to get advice, both as regards treatment and the grading of personnel, from an ENT specialist. By attending the clinics they also gained valuable experience of the treatment of ENT conditions. Up to eighty cases were seen at each of the two clinics held each week. These out-patient clinics were continued when 2 General Hospital took over at Helwan, and similar clinics were set up by the other hospitals whenever circumstances warranted it.
In all the Middle East Forces it was found that 8 per cent of all troops, 20 per cent of all new patients, and 11.35 per cent of all admissions to hospital were suffering from ENT diseases. Endeavours were made by the British authorities to provide specialised staff for the hospitals, and mobile oto-laryngological teams were formed to provide specialist services in the forward hospitals and for men in rest areas behind the line. Ear treatment centres were also set up at the hospitals. New equipment on a more liberal scale was also provided. A consultant in ENT diseases was appointed later and was available in Italy.
In the first years of the war 2 NZEF had insufficient ENT specialists to provide an officer at each of the three hospitals, and was unable to get replacements from New Zealand. Only three ENT specialists went from New Zealand to the Middle East throughout the war. The appointment of specialists to administrative positions, as promotion to higher ranks was not possible in the specialties, also depleted the clinical staffs. Arrangements were therefore made to concentrate the cases in two of the hospitals. A relatively large number of men in widespread locations with minor ENT disabilities caused considerable wastage of manpower when there was an insufficient number of specialists to deal with them. An ENT specialist would have been very useful in the forward areas in preventing evacuation of men to Base.
Clinical Experience in Egypt
The ENT disabilities in the Middle East that called for treatment fell into two categories—those dating from pre-enlistment and cases arising on service. Pre-enlistment disabilities that had been missed at medical examination, or which recurred under the climatic and service conditions of Egypt, included the chronic perforations of the eardrum in which otorrhoea persisted or recurred, re-infected radical mastoid cavities, nasal polypi, and chronic sinusitis. It was felt that most of these should have been eliminated at the original boarding or else in camp before going overseas. Many of these cases were sent back on the first available ship. But page 449 the greatest problem in Middle East conditions was otitis externa, a very large number of men reporting sick with this annoying complaint. Acute and chronic rhinitis, often associated with sinusitis, was common, as was acute and recurrent tonsillitis. Factors contributing to these conditions were the hot, dusty climate, the primitive sanitation of the native race, and the large amount of swimming by the troops in overcrowded inland swimming pools. The mucosa of the upper respiratory tract was also rendered vulnerable by the extremely dry and hot atmosphere, with its drying effect on the normal secretions of the mucosa.
Men with a history of chronic nasal allergy did badly in Egypt, and this was borne out by the aggravation of asthmatic symptoms in the same climate. Swimming was blamed for a good deal of ear and nose trouble, and at various times orders were given banning high diving or underwater swimming. It would appear that the irritation of the water treated by substances intended to sterilise it caused at least as much trouble as water that was merely dirty and infected. Major Elliott considered that dust, dirt, sweat, and the drying air were the chief causes of the incidence of ear, nose, and throat diseases.
Otitis externa: As the condition is at first a trivial one, apart from acute furunculosis of the meatus, these men were usually treated first at their RAP, and reached the ENT specialist only when otitis was chronic and well-established. The first essential for successful treatment was found to be adequate and thorough daily toilets of the meatus done by a trained man with proper apparatus and adequate illumination. The lack of success with various antiseptics was illustrated by the number of these used. Elliott found that the best results were obtained by thorough frequent cleansing and the daily application of gauze wicks lightly packed into the full depth of the meatus. In the more acute cases he found that aluminium acetate on these wicks was helpful, and during healing some antiseptic such as acriflavine in spirit. Various antiseptic drops or ointments were used later to prevent recurrence. Others used lotio calamine if there was much weeping, and calamine cream if dry. For severe cases argyrol 10 per cent or protargol 5 per cent was painted on the meatus, or introduced on a wick of ribbon gauze and left on for twenty-four hours. Bathing was strictly forbidden. The recurrence rate was high. During the summers in Italy the conditions were as bad as, if not worse than, those in North Africa.
Otitis media was a very common complaint. Acute cases were admitted to hospital, if possible, and treated on the usual lines of sulphonamides by mouth, paracentesis where necessary, and page 450 careful ear toilets. Carbolic acid in glycerine was generally used in acute cases, followed later by boracic powder or spirit. Local sulphonamide treatment proved unsatisfactory. The results were very good as the cases were under the daily supervision of the specialist and the authorities wisely allowed certain nursing sisters to remain for lengthy periods attached to the ENT wards, and they thus became highly skilled at local treatments of the ear. Simple mastoid operations were done if urgently required, or if necessary to render a man safe for transport in a hospital ship.
Cases of chronic suppurative otitis media did badly if treated as out-patients at the RAP. The perfunctory administration of ear drops by an orderly on top of a pool of pus in the meatus was worse than useless. Many cases of suppurative otitis media were due to blast wounds in action.
Otorrhoea: All cases of chronic otorrhoea were admitted to hospital for intensive and skilled treatment, if beds were available. Under these conditions many healed. If the perforation persisted the man was boarded and usually returned to New Zealand, unless he had some special skill which could be utilised under good living conditions.
The radical mastoid operation was not done except for complications of an urgent nature, as these men were still unfit after operation to serve in the Middle East.
Nasal Sinusitis: A fairly large number of cases of chronic sinusitis which had not been eliminated by medical boards in New Zealand had to be down-graded or invalided. A much larger group were those who arrived as fit men and later acquired acute or chronic nasal infection. Treatment at the RAP by the dropping of a few minims of ephedrine solution up the nose was illusory as a cure or relief. The minor and favourable case recovered with, or in spite of, treatment. The resistant case could only be coped with by admission to hospital. Early in the war the new techniques of ephedrine replacements were not known, and treatment was inclined to be too radical. In the early years of the war Elliott tried ephedrine drops and inhalations. If these failed he did a small antrostomy purely to facilitate easy antral lavage. After the symptoms were relieved the antrostomy often closed. This routine cleared up most cases, combined as it was with the fact that the patient in hospital was living away from a dusty atmosphere. The resistant case was down-graded. Radical surgery of the antrum or frontal sinus was frowned upon, unless of lifesaving urgency.
A survey of 59 cases referred for investigation of sinuses in February 1944 was made by Captain Simpson at 3 General Hospital, page 451 Bari. Twenty-one were sent from the forward units with a diagnosis of sinusitis, and the other cases arose among the in-patients and out-patients of the hospital. Simpson pointed out that the diagnosis was difficult except in obvious cases with mucopus pouring like lava into the middle meatus. Symptoms of pain and nasal discharge, combined with signs such as fever, tenderness over one or other sinus, or mucopus in the nose, led to a diagnosis of sinusitis, especially by RMOs. If these signs and symptoms were bilateral, the conditions might well be a common head cold more severe than the average. If the signs and symptoms were unilateral, the condition was much more likely to be sinusitis. A symptom of great significance was the occurrence of bouts of pain, relieved by discharge from the nose. The discharge in true sinusitis varied in consistency but was always yellow. Maxillary sinusitis had been found to be the most common, true frontal sinusitis being a rarity. Cases of severe persistent headache should be evacuated ‘Headache NYD’ to be fully investigated at the hospital, and not diagnosed as sinusitis lest soldiers become ‘sinus conscious’. At the hospital X-ray was a help in diagnosis, but the final decision depended on diagnostic puncture, by which the contents of the maxillary antrum could be inspected and also a judgment formed as to the thickness of the mucosa and the presence or absence of polyposis. The finding of thick yellow mucopus in sufficient quantity (at least 1 c.c.) justified positive diagnosis and operative interference. A small quantity of grey mucopus or flakes was inadequate evidence. Gross polyposis, even in the absence of pus, generally required operation. Of the 59 cases, 49 were clinically negative, and in these X-ray was positive in 29; diagnostic puncture done on 23 of the 29 cases was positive in 9. An analysis indicated that the most certain diagnoses could be made in those cases where clinical and X-ray findings were both positive, but unless X-rays were taken and diagnostic puncture performed in selected cases from those clinically negative, then a large number of positive cases would be overlooked.
Nasal Polypi and Chronic Allergic Rhinitis: Nasal polypi were in Elliott's opinion a definite bar to a man serving out of a temperate climate, and at that, outside a base organisation. A history of nasal polypi should result in a recruit being graded for home service only. In the Middle East polypi recurred in a matter of weeks after removal. The polypi were removed with a simple snare and the soldier regraded. Chronic allergic rhinitis, if a very definite cause cannot be found for the allergy, should preclude a man serving out of a temperate climate.
Deflected Nasal Septum: Many men who are quite fit for any vigorous exercise in a temperate climate, and who are rightly page 452 passed as fit for active service, find difficulties in a hot, dusty theatre of war. Many of these men have nasal obstruction due to either a congenital or acquired deflection of the nasal septum. In Egypt it was found that the hot climate increased the respiratory rate. The soldier, burdened with his equipment and weapons, marched often in a cloud of dust raised by his comrades ahead. The mouth breather was sadly handicapped, and was either forced to fall out of the line of march or ended the day severely fatigued. Many of these cases were referred to the ENT specialist and were found to have nasal obstruction due to a deviated nasal septum. The SMR operation was carried out in a large number of cases with excellent results. Under normal conditions SMR operations were not advised, and the AIF actually prohibited the operation later in the war.
The Tonsil Problem: The question of tonsillectomy on the soldier serving overseas is a very vexed one. In 2 NZEF the principle was adopted that, if a man was otherwise fit and was disabled on several occasions by acute tonsillitis with fever, then tonsillectomy was justified in the hope that the man would then be fit for normal duties. In camp conditions a soldier should remain at least twelve days in a general hospital and then another ten days either in a convalescent depot, or excused duty, before resuming training.
Operations Overseas: In general, routine ENT operations, as all other similar operative procedures elsewhere in the body, were not performed overseas. Operation was restricted to those cases of urgency and to those which would normally lead to the increased efficiency and lengthened service of the soldier, without too long hospitalisation.
The only battle casualties that are worthy of special comment are those due to the effects of blast on the ear. These cases fell into two main groups—the sudden injury and the gradual one.
Sudden injury due to blast was a very common one. It was far more common than generally realised, as a man with a painful wound from a near-bursting missile often failed to notice his aural symptoms until much later, or, if they healed, failed ever to be aware of them. When Major Elliott was in command of an ADS at the Battle of Alamein he made a survey of ear injuries. In this battle the vast majority of wounds were due to mines, mortar and aerial bombs, and to shells. All these weapons produce a blast effect not present with small-arms fire. Of all cases passing through the ADS at least 30 per cent showed some clinical lesion of the eardrum. These ranged from gross perforation through page 453 contusion and flame-shaped haemorrhage, down to minimal hyperaemia with deafness and tinnitus. Many of the men did not complain of aural symptoms until questioned.
In the early days of the war perforations of the eardrum with the usual haemorrhage due to blast were treated by the instillation of spirit drops, or even by syringeing out the blood clot. They nearly all became infected and became cases of suppurative otitis media, often chronic, and resulted in permanent damage to the ear and down-grading. Later in the war the standard treatment, laid down by definite orders, was that no local treatment should be employed apart from a plug of sterile dry cottonwool in the ear. Sulphonamides were often given by mouth. A prophylactic course of sulphonamide was given for blast rupture, and a full therapeutic course for all infected cases. Cases so treated usually healed without infection. After healing of the drumhead, hearing often returned, but a fair percentage had permanent impairment of hearing, usually of the high tone type. Troublesome tinnitus was a frequent sequel and was very difficult to relieve, still being seen often in war pensioners.
In a survey of 1000 battle casualties admitted to 2 NZ General Hospital in 1944–45, Major F. B. Korkis found that 3.1 per cent had deafness attributable to blast. Half of these cases were found to have had a rupture of the drum. Deafness was generally of mixed middle and inner ear types, 83 per cent having some nerve deafness which showed little or no recovery. Infection in some degree had occurred in half the cases with rupture of the drum. Acute mastoiditis was uncommon, but the sub-acute type was relatively common and was treated by drainage when it persisted for more than five weeks. The smaller lesions of the drum healed spontaneously in the absence of infection.
Blast injury of gradual onset is an occupational disease of gunners, mortar crews, and the like. The incidence varies according to the weapon, the high-velocity gun such as the anti-tank gun and guns fitted with muzzle breaks being the worst offenders. Gunners of long service often began to get troublesome tinnitus and developed a high tone nerve deafness. These disabilities were found to be permanent and are frequent causes of pensions claims. During the Second World War much attention was given to the problem, but it was never satisfactorily solved. The use of verbal orders precluded the wearing of efficient ear protectors, and, in Middle East conditions, certain types of ear plugs caused a high incidence of otitis externa. A vaselined wool plug was held to be reasonably effective. This is a subject requiring more research both by medical and artillery officers.page 454
Other Wounds: Wounds of the temporal bone, the larynx, and the facial bones were dealt with in consultation with the general and the plastic surgeons.
Neurosis Aspect: There was a danger of establishing a neurosis complex through the interpretation of minor nasopharangeal symptoms as a chronic disability. Major Elliott believed that most of the troops who went through the North African desert campaign or a summer of fighting in hot and dusty Italy had nasal symptoms and headaches to a greater or lesser degree. The threshold at which a man reported sick depended on the stamina and will to fight of the individual.
In Italy in May 1944 Captain Simpson said: ‘An increasing number of soldiers are becoming “sinus conscious” and every headache is attributed to sinusitis—in some cases to an obsessive degree. It is a more fixed idea where a previous attack has been labelled sinusitis. These obsessions may be infectious unless the RMOs narrow down the diagnosis of sinusitis to the true cases, and discourage loose talk on the subject.’
As a general rule it was 2 NZEF policy not to carry out surgical procedures unless they were urgent or else offered the prospect of permanent relief of symptoms sufficient to enable a man to be retained in useful employment overseas. Cases that were graded for return to New Zealand included all the chronic suppurative otitis media cases, cases of chronic sinusitis that had failed to respond satisfactorily to treatment, cases of nasal polypi, cases of deafness that would tend to deteriorate under service conditions, all cases of chronic laryngitis, and some selected cases of otitis externa which were resistant to treatment and had a nuisance value owing to constant requirement of medical supervision. The sort of case that could safely be retained overseas was the dry aural perforation in a safe area of the drum or the mildly deaf.
When the New Zealand brigade went to Fiji in 1940 it had at first no specialist ENT service, but Major L. S. Talbot was sent there in January 1941. Very little equipment was available, and it had to be supplemented with what could be spared from Talbot's personal supplies. In 1942 more equipment became available, some from America. Clinical conditions were found to be much the same as those occurring in New Zealand, but the hot, humid climate was favourable to middle ear infections, and some ears that had been ‘dry’ for long periods became active. Likewise chronic page 455 nasal accessory sinus infections became troublesome and did not respond well to local treatment. Such cases often had to be employed at Base, or else returned home.
The climate of New Caledonia was much the same as that of Fiji during the summer and autumn months, and the high humidity at this period had much the same effect on middle ear diseases, sinus cases, and allergic manifestations. However, the cases did better in the winter, and the equipment provided was a very considerable improvement on that available in Fiji.
External otitis was very prevalent in the climate of the Pacific—in Fiji, New Caledonia, and the Solomons. By the time patients were referred to a hospital the infection, whether mycotic or bacterial at first, had usually become a mixed one, with great swelling and tenderness of the tissues of the external auditory canal, so that local treatment was difficult to apply effectively. The method found by Major Talbot to give the best response was the repeated application of hypertonic solutions, such as 15 to 20 per cent magnesium sulphate, sometimes introducing it into the depths of the canal with a blunt hypodermic needle. It was found that the patient was more quickly returned to full duty by a period in hospital to enable such treatment to be applied effectively. When the swelling was reduced, other treatments applied on gauze wicks could be used at the RAP. Complete cure was difficult, and the patient was usually left with a chronic or recurrent otitis which could to a certain extent be kept in check by daily ear toilet.
RNZAF Experience in Pacific
The sickness rate for ear diseases was found by the RNZAF in the Pacific to be more than three times the New Zealand rate in 1944–45 (33.6 as against 9.8 per thousand per annum). The increase was principally due to a high incidence of otitis externa and otitis media in the Pacific. The warmth and humidity encouraged all bacterial and fungoid growth, and it was thought that minute particles of sand or coral in suspension in swimming water were causative agents. Most cases of otitis externa were found to have occurred in those who had been swimming within the preceding week. Sea water was the chief offender, probably owing to contamination by drainage from camps and refuse from ships, but bathing and diving in fresh-water pools in the coral also preceded infection. The primary lesion was thought to be caused by small abrasions of the lining of the external auditory meatus by particles of coral or sand, with bacteria from the water or air rapidly invading the wound and producing infection. With appropriate treatment healing occurred rapidly, the infection page 456 subsiding within ten to fourteen days. In the absence of any or appropriate treatment the condition would become chronic and remain so for weeks. In all cases there was a marked tendency to recur.
The most important part of the treatment was considered by Squadron Leader A. North, at Espiritu Santo, to lie in the constant and careful personal examination and supervision by the medical officer himself at all stages. In his opinion the commonest cause of recurrence was incomplete healing in the medial parts of the external auditory meatus at the time the patient was discharged as cured. In a series of 44 cases of otitis externa he found that the most effective and reliable treatment consisted in cleansing the meatus daily, insertion of cotton-wool wicks soaked in 10 per cent sodium sulphadiazine solution for three to five days till dry, followed by daily insufflations with 0.75 per cent iodised boracic powder till healed. Results of treatment with propamidine 0.1 per cent suspension in water soluble jelly base were not as good. From experience at the hospital at Espiritu Santo it was suggested that, if practicable, a separate ear clinic be held where there were a number of cases of otitis externa. One tray could be set up and the instruments re-sterilised between each case. This allowed better observation, attention, and concentration on treatment, also saving time for both patients and staff.
The lack of any audiometer examination of the recruits made it inevitable that many cases of otosclerosis should be overlooked and men be accepted for service with no note of any impairment. This in turn has led to the granting of pensions to many of these cases, as under the law any disability arising or increasing during service is held attributable to service. Some therefore contend that pensions of a permanent nature are being paid for what is a constitutional disease in no way caused, though in some cases possibly aggravated, by service in the forces. The sum paid is a large one amounting to about £40,000 yearly. On the other hand, it is held that the majority of these men performed full service overseas and applied for pension when the increasing deafness became noticeable after their return to New Zealand. This is borne out by the Pensions Department figures, which show that only 130 had applied for pensions at the end of March 1944, but that 687 had applied by 1950. Audiometer examination could have eliminated most of these cases and pensions payments been reduced accordingly. As against this the forces would have lost the service given by those men, which for the want of contrary evidence must be assumed to have been satisfactory.page 457
The introduction of the Pulheems system and more efficient examination of recruits will not provide a solution to the problem, which turns almost entirely on the pensions legislation. If a pension was not paid unless the condition was actually caused by service, and the men with slight constitutional disability were accepted for service on that understanding, the men would be able to give valuable service to their country without the question of pensions payments arising. The more marked cases of deafness would, of course, not be accepted for service.
APPLICATIONS FOR WAR PENSIONS AT 31 MARCH 1951
|Deafness, catarrhal and otosclerosis||688||162||850|
Recommendations for the Future
In the medical boarding of recruits a careful history should be taken of any nasal or aural discharge, headache, nasal obstruction, sore throat, or operation. Every ear should be examined with an electrically lighted otoscope, or with a head mirror and ear speculum, and, if necessary, wax or debris removed till the drum is clearly seen. If necessary the cavity should be syringed with warm normal saline solution. If the drum cannot be clearly seen, or if there is any perforation or discharge, or if there is any history of aural disease, or any scar of previous operation, or any doubt, the case should be referred to a specialist.
Hearing should be tested under satisfactory conditions of quiet and space by test sentences or words by the spoken voice at ordinary conversation pitch at 20 feet distance, the ears being tested separately, one being shut off by a finger. When any doubt exists the hearing should be tested with an audiometer under the supervision of a specialist.
The pharynx should be examined and the ability to breathe through each nostril tested.
Men with any of the following disabilities should not be sent overseas: chronic otitis media, any large perforation of the drum, old radical mastoid operation, chronic sinusitis, nasal polypi, serious deafness.page 458
Overseas there should be an ENT specialist for every general hospital, and one available for consultation on treatment and grading at the divisional level. Normally he could be attached to the CCS.
Higher rank should be granted to the senior ENT specialist, and specialist rank to any fully qualified specialist.
Specialists should not be appointed to field or administrative posts unless there is a full quota of specialists for clinical duties.
Sisters and orderlies trained in specialist treatments should be made available.
Special ear treatment rooms should be set up in base camps and in the divisional area with trained staff on call to carry out toilets and dressings.
Operations for remedial treatment in New Zealand, such as tonsillectomy, should be strictly limited, and likewise operations overseas, except for acute conditions.
|Battle Casualties||Accidental Injuries|
|Rupture drum, bilateral, and otitis media||8||1|
|Rupture drum, bilateral, and deafness||47|
|Rupture drum, single, and otitis media||18||1|
|Rupture drum, single, and deafness||11||3|
|Rupture drum, bilateral||9|
|Rupture drum, single||15|
|Blast and deafness||4|
|Penetrating ear, with deafness||3|
|ear sickness—||nose and throat—|
|Deafness, middle ear||19||Epistaxis||2|
|Nerve deafness||25||Cleft palate and obstr.||3|
|Catarrhal deafness||3||BC trachea||2|
|Mixed deafness||2||BC nose and loss tissue||1|
|R. A. Elliott||2 NZEF Survey (unpublished).|
|F. B. Korkis||British Medical Journal, 9 February 1946.|
|A. North||Report on RNZAF in Pacific (unpublished).|
|W. H. Simpson||Report on Sinus infection in Italy (unpublished).|
|Furunculosis||88||Rupture of tympani||16|