Frederic Francis Burghard

OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES
BY
StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)
Professor of Laryngology and Physician for Diseases of the Throat, King’s College Hospital, London

CHAPTER I
GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS ON
THE NOSE AND NASO-PHARYNX

An intimate knowledge of the surgical anatomy of the nose is an important factor in successful treatment. It is sufficient to recall the close relations of the nasal chambers and their accessory sinuses with the cavities of the orbit and the cranium, and to remember that the shape and size of these air-spaces may vary considerably within physiological limits.

The arrangements of the vascular, lymphatic, and nervous supplies, and their connexion with neighbouring parts and the body generally, have also to be kept in mind.

In planning and carrying out operative procedures it is also well to keep in mind the important physiological functions of the nose.

Disease in the nose involves both medical and surgical treatment. The general progress of surgery, improved technique, local anÆsthesia, and the control of hÆmorrhage we now possess, have all tended to replace local medication by surgical measures. But in many affections of the nose—such as syphilis, or diphtheria—surgical relief is quite secondary to medical treatment. In any case the surgeon cannot dispense with a knowledge of suitable topical applications and the principles on which they are founded.

SOURCES OF ILLUMINATION

A good source of illumination is the first necessity for satisfactory operations on the upper air-passages. The natural sources at our disposal are sunlight and diffuse daylight. They have the great advantage of not altering the natural colours of the parts examined. Reflected sunlight forms a perfect illuminant, if we are careful not to bring the rays to an exact focus on the mucous membrane, as this might produce a burn.

Diffuse daylight is too feeble for the examination of the cavities of the nose and larynx, but it can be used for inspecting the mouth, pharynx, and ear. Direct daylight is particularly serviceable for examining suspicious rashes or patches in the mouth and pharynx, and eruptions on the skin.

Some form of artificial light is indispensable. That furnished by an ordinary paraffin lamp or a gas flame is sufficient for examination. The flame should have its flat side towards the observer, and be enclosed in a glass chimney, without a globe or shade. If neither of these lights be available, an ordinary candle, or, better still, three candles tied together, will suffice.

For use in the study a paraffin reading-lamp or a gas standard is equally suitable. The latter is rendered more effective by the adoption of an Argand burner or a Welsbach mantle. The oxy-hydrogen limelight is the most perfect of artificial illuminants, but it is bulky and expensive. The most convenient light is that given by a 32 or 50 candle-power electric light in a frosted globe, and with the filament waved. The Nernst electric burner gives increased brilliancy.

The electric light has the further advantage that it is unnecessary to maintain it constantly vertical. When enclosed in a bull’s-eye, the lamp can be rotated so as to direct the pencil of light-rays either upwards or downwards, as well as from side to side.

Whichever light is employed the rays can be concentrated and rendered more powerful by enclosing it in a dark chimney with a bull’s-eye condenser. The light must also be provided with some arrangement by which it can be raised and lowered (Fig. 281). For operating the Clar light is useful (Fig. 282).

In all these methods the light is reflected, but the direct rays of the electric light can be used in a small lamp fixed on the forehead, and fed from an accumulator or direct from the street current through a suitable resistance. It is better than reflected light in operations on the nose and throat, and the portable accumulator and frontal photophore (Fig. 283) are convenient for use in the patient’s own home.

The lamp should be placed on a stand or table so that the light is on a level with the patient’s ear, and 3 or 4 inches distant from it. In Continental schools it is customary to place the light on the patient’s right hand. In this country the lamp is usually placed close to the patient’s left ear, i.e. on the observer’s right hand. As practitioners will often be called to see patients who are confined to a bed which can only be approached from one side, it is desirable that they should accustom themselves to work equally well with the light on either side, and the frontal mirror over either eye.

LOCAL ANÆSTHESIA

Cocaine. It is often desirable to secure a slight degree of local anÆsthesia to facilitate complete exploration of the nose. Many operations can be carried out by rendering the nasal mucosa absolutely insensitive with cocaine.

Applied in the nose cocaine is (a) an anÆsthetic, (b) a powerful vaso-constrictor, and, consequently, it (c) produces local anÆmia. Hence cocaine is of great value in nasal surgery, not only because it renders the mucous membrane insensitive, but also because it retracts the tissues and reduces the hÆmorrhage.

Methods of use. A small area can be anÆsthetized by placing a few crystals of hydrochlorate of cocaine on the required spot, where the mucus will dissolve it in situ. A 2 to 5% solution may be sprayed into narrow nostrils, to facilitate examination. It is a better plan to moisten pledgets of cotton-wool or ribbon gauze with a 10% solution, and place them in direct contact with the part to be operated on. The addition of a little suprarenal extract will not only facilitate examination and treatment by its hÆmostatic action, but, for the same reason, will tend to prevent the cocaine being absorbed and producing its toxic effects.

For the more complete anÆsthesia required for operation the following plan is advised. Equal parts of a 20% solution of cocaine and the standard 1–1,000 extract of suprarenal gland are mixed together. Short strips of 1-inch wide ribbon gauze are moistened with this solution and laid flat in close contact with the nasal area to be operated on. They are left in place for at least half an hour, and even at the end of one hour local anÆsthesia will only be more marked. While the final preparations are being made for operation a fresh layer of moistened gauze may be applied. Finally, if there should still remain the slightest degree of sensation over the spot to be treated, a few cocaine crystals will render it quite numb.

Submucous injection of cocaine. Great caution is necessary in making intracellular injection of cocaine, as the drug is intensely toxic in this form, and, fortunately, only a small dose is required. It is a good plan never to exceed 1 centigramme (1/6 grain) of the salt. As the hÆmostatic effect of suprarenal gland extract is required at the same time, the two are combined; 1/6 grain of cocaine, 2 drops of adrenalin, 1/6 grain of sodium chloride, and 1/50 grain of morphia are dissolved in 60 minims or more of sterilized water, and slowly injected below the mucosa. At least 20 minutes must elapse to secure full effects.

Substitutes for cocaine. For submucous injection it is better to substitute eucaine or novocaine. Eucaine can be kept in a ready and portable form in small glass ampoules in the dose of 1/6 grain with 1/2000 grain of adrenalin, and tablets are sold containing 1 centigramme (1/6 grain) of either of these drugs in combination with adrenalin and chloride of sodium. One of these tablets is dissolved in 60 minims or more of water and boiled. It is reported that as much as 1 grain of novocaine may be injected at one sitting, but I prefer to keep to the limit of 1/6 grain, and have always been able to obtain complete local anÆsthesia with it.

Eucaine is much less toxic than cocaine, and novocaine is said to be still safer. They act just as well for submucous injection, but, applied to the mucous surface, the anÆsthesia is not so complete, and the vaso-constrictor effect is less. Still, for susceptible subjects, either is to be preferred to the more toxic cocaine.

LOCAL ISCHÆMIA

Adrenalin. The delicate manipulations of intranasal surgery have been greatly facilitated by the employment of the extract of the suprarenal gland under various names—adrenalin, adrenine, adrin, perinephrin, adnephrin, epinephrin, suprarenalin, suprarenin, epirenin, paranephrin, renaglandin, hemesine, hÆmostasine, vasoconstrictine, renostypticin, &c. These liquids are generally of the strength of 1 in 1,000, and can be used undiluted on mucous surfaces. But they can be diluted with normal saline solution, solutions of cocaine, or other drugs. If kept in well-stoppered, tinted glass bottles the solution can be preserved for many weeks. The solid extract is useful for those who only employ it occasionally, and in this form it is conveniently made up with cocaine, eucaine, or novocaine, so that solutions of the desired strength are prepared as required.

Applied to a mucous surface adrenalin produces a local ischÆmia by contracting the blood-vessels, so that the surface becomes pale and shrunken. At least 20 minutes are required to secure this effect and it is only more marked at the end of an hour. An extensive operation, such as submucous resection of the septum, can then be performed without the loss of more than a trifling amount of blood in most cases. The vaso-constrictor action is followed by a stage of dilatation, disposing to secondary hÆmorrhage, which, according to some authorities, may be ‘violent and sometimes serious’.47 I have been fortunate in not meeting with this occurrence. Its possibility can generally be guarded against, and need never prevent the employment of the drug when indicated.

Adrenalin has no anÆsthetic power, but its constricting action lessens the tendency of cocaine to be deeply absorbed, increases the latter’s local effect, and allows of a weaker solution being employed.

Another secondary result is the very irritating rhinitis which is sometimes induced. It passes off in 24 to 48 hours.

Uses. The addition of a small quantity of adrenalin to a cocaine solution mitigates the toxic action of the latter, and its use appears to check tendency to collapse, either from shock or chloroform, during serious operations on the nasal cavities. Its chief use is to check hÆmorrhage and allow us to perform practically bloodless operations in the nose.

Methods. Adrenalin is employed as described for cocaine. Disappointment in the result obtained is nearly always due to neglect in recognizing that its full effect cannot be obtained in less than 20 to 60 minutes.

BLEEDING AND ITS CONTROL

Bleeding in the nose cannot be controlled as easily and directly as in the operations of general surgery, and there is always the risk of blood passing into the lower air-passages.

Causation. HÆmorrhage is apt to be not only more free, but also more serious, in young children and in patients over 60. The tendency is increased with menstruation or pregnancy, and hÆmophilia is to be particularly looked for. In the nose the vascular turbinals bleed freely; a small varicose vessel on the septum is the commonest source of epistaxis,—often very copious. Many vascular growths are met with, and malignant ones are apt to bleed profusely.

Secondary hÆmorrhage may occur between the third and eighth day, when clots or crusts become detached.

The prevention of local hÆmorrhage. The patient should be prepared more carefully than usual for an operation. HÆmophilia should be inquired after, and if there is any suspicion of it lactate of calcium is administered for three days beforehand, in doses of 15 to 30 grains twice a day. If the patient be an undoubted hÆmophilic, an operation should be avoided if possible. It is well to suspend the use of alcohol and tobacco for at least three days beforehand. Many risks are avoided if the operation can be carried out in the home or hospital where the patient has slept, and if he can remain there afterwards.

The arrest of local hÆmorrhage. The preliminary use of adrenalin will diminish bleeding in many cases (see p. 573). When it does occur, unless the hÆmorrhage is serious, it is well not to be too precipitate in efforts to arrest it. Such attempts, by stimulating the patient, detaching blood-clots, or exciting reflexes, may even maintain it. The clothing should be loose, the operating-room should be well aired and cool, and iced water should always be at hand. If freely sluiced over the face, behind the ears, and round the neck, cold water has such a remarkable reflex vaso-constrictor action that it alone is sufficient to arrest hÆmorrhage in the majority of operations on the nose and throat. Its stimulating effect on the respiration and circulation is always agreeable to the patient, and may be very valuable when he is under a general anÆsthetic.

If operated upon under a local anÆsthetic, the patient’s head should be inclined forwards, so that the blood can drip from the nose. The first formed clots may be expelled, but then he should avoid sniffing, sneezing, or coughing, and sit with the head forward and the nostrils completely closed with his thumb and forefinger. Five to ten minutes in this position will arrest the bleeding in most cases of epistaxis. A slight oozing of blood may be allowed to go on for a few hours in certain cases. If the bleeding persists, ice should be applied externally and held in the mouth, the nose may be syringed with very cold or with very warm salt and water (?i to the pint), and the horizontal position assumed.

If this fails, a pledget of cotton-wool is dipped in peroxide of hydrogen solution (10 vols. %) and introduced into the bleeding nostril, the orifice of which is then closed by the surgeon’s thumb. This may be repeated more than once, the patient lying on his side, face downwards, and pinching both nostrils. If a galvano-cautery be available, and the bleeding comes from a limited and visible point, it can be sealed with a touch of the cautery point.

If these methods fail, plugging must be resorted to. With the nasal speculum and good illumination, the bleeding area is cleansed with cocaine and adrenalin and a strip of 1-inch ribbon gauze is carefully packed on to the spot, the end being left just within the vestibule, so that the patient can remove it for himself at the end of 12 or 24 hours. It is better to use a single strip of gauze, instead of cotton-wool, as portions of the latter might be detached and left behind. If there be fear of the gauze strip becoming adherent, it can be well smeared with plain sterilized vaseline.

If the bleeding comes from far back in the nose, or from the post-nasal space, it may become necessary to plug the latter cavity. A sterilized sponge, about the size of a Tangerine orange, is squeezed very dry and tied round its centre with a piece of tape or a stout silk ligature, leaving two free ends of about 12 inches in length. A soft rubber catheter is passed along the floor of the nose till it appears below the soft palate, when the end is seized with forceps and drawn through the mouth. To this end one of the tapes is made fast, so that when the catheter is withdrawn from the nose, the sponge is pulled up into the post-nasal space; the other end hangs out of the mouth. The two tapes are tied together over the upper lip. The anterior part of the nostril can then be packed with gauze, if necessary. If the patient be under chloroform, one tape can be dispensed with; the soft palate is simply held forward with the forefinger of one hand, while the other passes the compressed sponge up into the naso-pharyngeal space.

Plugs in the nose should be avoided. They are painful, interfere with repair, prevent drainage, and may be followed by septic troubles in the nose, accessory sinuses, middle ear, or cranial cavity. Bleeding often recurs on their removal. In any case they should not be left unchanged for more than 24 or, at the most, 48 hours. Removal is facilitated by soaking them well with peroxide of hydrogen, and detaching them slowly and gently. Ligature of the external carotid (see Vol. I, p. 384) may be necessary in extreme cases.48

THE PROTECTION OF THE LOWER AIR-PASSAGES FROM THE DESCENT OF BLOOD

When operated upon under local anÆsthesia the patient is able to prevent blood descending from the nose or throat into the larynx or trachea. In this he is assisted by throwing the head forwards.

When the patient is under a general anÆsthetic other measures must be taken to guard against the descent of blood into the windpipe and lungs. The most important is to see that the anÆsthesia is never so deep as to abolish the swallowing or coughing reflexes. Fortunately these are amongst the last to go, yet in many cases it is well to let the patient come partly round, so as to expel blood and mucus by coughing. If the frontal sinus is being operated upon, the nose is carefully packed beforehand. When the ethmoidal labyrinth is being cleared, or the sphenoidal sinus opened, a sponge may be placed in the post-nasal space as described above until the operation is completed. During the operation upon the maxillary sinus through the canine fossa, a sponge placed between the last molar teeth and the cheek on the same side, and frequently renewed, will keep any blood from entering the pharynx. In operations upon the naso-pharynx, it is a wise precaution, when much bleeding is anticipated, to perform a preliminary temporary laryngotomy and plug the pharynx with a sponge (see p. 510).

In many proceedings security is attained by rolling the patient well over to one side, so that the blood runs out of the corner of the mouth, of blood is also swallowed. This may be vomited as consciousness returns; if not, an aperient should be given within 24 hours to prevent gastro-intestinal sepsis.

The descent of blood into the trachea and lungs, if sudden and copious, may cause immediate asphyxia; or, if less abundant, it may cause septic pneumonia. When it occurs, the anÆsthesia should be stopped, and the patient rolled well over on to his face or inverted, until the breathing is quite unobstructed. After all nose and throat operations it is a wise precaution for the patient to be kept on his side, the head on a low pillow, and face downwards, while the body is arranged in the gynÆcological position.

SHOCK

Shock, particularly in operations on the nose, is apt to be marked in young children and in elderly persons. It is for this reason that we try to avoid the removal of adenoids in patients under 3 years of age, or of polypi in those over 60; and that in all cases we endeavour to operate as rapidly as possible.

This possibility of shock is guarded against and treated in the usual way. The use of cocaine and adrenalin—even in patients under a general anÆsthetic—helps to avoid it,49 and anÆsthesia should never be too deep or prolonged. When operating under local anÆsthesia it is sometimes wiser not to attempt too much at one sitting, e.g. to treat only one side of the nose at a time. In certain conditions, and when a general anÆsthetic is employed, it may be safer to try and complete treatment at one operation.

SEPSIS AND OTHER COMPLICATIONS

Deaths have been recorded after the simple use of the galvano-cautery, or the removal of nasal polypi, and of course are more to be feared after major operations, such as the radical cure of sinus suppurations.

Septic infection from nasal operations may spread to the accessory sinuses, meninges, ear, eye, tonsils, glands, gastro-intestinal tract, bronchi, and lungs. From the naso-pharynx, the ears and the lower food and air tracts are chiefly threatened. The orbit may be invaded in operations on the ethmoid; the external muscles of the eye may be injured in the frontal sinus operation; and optic atrophy may be due to plugging of the ophthalmic vein.

While these accidents may sometimes be directly due to operation, it is well to remember that in treating such septic conditions as are entailed by nasal suppuration, the complications may only be precipitated by traumatism and may also be purely coincident. It is not to be forgotten that latent infection—of influenza, erysipelas, measles, scarlatina, diphtheria, or other disease—may develop immediately after an operation upon the nose or throat, and until its true character is recognized the operation is often unjustly blamed. Septic infection, in these necessarily exposed wounds of the air-passages, may be traced to insanitary surroundings.

ASEPSIS

The field of operation in rhinology can never be rendered completely sterile, and in many cases is particularly septic. Wounds through the mucous membrane cannot be protected with dressings in the usual way; so that the local methods of repair require particular study.

In the nose, when there is no suppuration, it is safer to make no attempt to purify the cavity, beyond cleansing the vibrissÆ and vestibules. The Schneiderian membrane will not tolerate any antiseptic lotion of such a strength as to be effective, and weaker solutions only interfere with the action of the cilia, the protective power of the mucus, and other defensive arrangements of the nose. If pus, scabs, or foreign bodies exist in the nose, it should be well washed with a simple tepid alkaline solution.

But every care should be taken to purify the surgeon’s hands, sterilize all instruments, and see that no contamination takes place during the operation. This is assisted by having the patient’s head surrounded by a carbolized towel, and his face, moustache, and beard well washed, for the surgeon’s hands and instruments come in frequent contact with these parts.

AFTER-TREATMENT

After all intranasal operations everything should be avoided which interferes with the drainage, ventilation, and natural repair of the region. Protective dressings cannot be employed, and we have in most cases to aim at healing under a blood-clot. Tags of semi-detached tissue and loose clots of blood are removed, but otherwise the parts are disturbed as little as possible. For the first two or three days the nose may be left alone, and if there be no bleeding the patient is encouraged to breathe through it. When there is much formation of thick mucus, or blood-clots or sloughs are loosening, a tepid alkaline lotion can be used. The pain of stiffness or dryness in the nose is relieved by an ointment or an oily spray.

Adhesions are apt to form between the septum and the outer wall when opposing surfaces are injured by the galvano-cautery. They may occur in narrow cavities after cutting operations. If an adhesion be seen to be threatening in the first few days, it should be broken down with a probe, and strips of gauze or plates of white celluloid introduced daily until healing takes place. If it forms later, it is wiser to wait until the fleshy bridge becomes less vascular and contracts, when it may be divided with a knife or the galvano-cautery at a white heat, and the opposing surfaces are then kept apart as described.

All post-operative conditions in the nose and throat will heal more rapidly and pleasantly if the patient be freely exposed, day and night, to abundance of fresh air; and while fatigue is generally to be avoided, the sooner the patient is out of bed and in the fresh air, the better for him. Our inability to operate under aseptic conditions should make us more careful to raise the resistance of the individual by general care, and to protect him from external dangers.

CLEANSING THE NOSE

The simplest and safest method of cleansing the nose is by blowing it,—one nostril at a time. Sometimes it is required to hawk any discharge backwards and expel it through the mouth.

Watery lotions are frequently required to assist in cleansing the nose. Strong antiseptics and astringents must be avoided. All nose lotions should be alkaline, and isotonic with the blood plasma. These requirements are met by prescribing one or more alkalis (bicarbonate of soda, borax, salt, &c.), in the strength of about 5 grains to the ounce. They may be rendered more pleasant by the addition of white sugar or glycerine. The addition of a small amount of some mild antiseptic—menthol, thymol, oil of eucalyptus, carbolic, sanitas, listerine, &c.—may give a pleasant flavour. But all antiseptics have a slight irritant action which is disagreeable if there be an intact mucosa, although they may be more helpful in certain cases of ulceration or intranasal sepsis. When the Schneiderian membrane is more or less damaged, when there are foreign bodies, sloughs, necrosis, &c., in the nasal chambers, these or similar antiseptics can be employed, though always with an alkaline basis.

All nose lotions should be employed tepid. They may be sniffed, irrigated, sprayed, or syringed into the nostrils. Crusts, scabs, and sloughs may have to be removed from the nose with forceps, after its sensitiveness has been deadened with cocaine; peroxide of hydrogen will help to detach them.

AFTER-RESULTS

Incomplete operation may be unsatisfactory in many ways. Thus, nasal obstruction may be unrelieved: foci of suppuration may be left in the accessory sinuses: portions of adenoid growth or tonsils left behind may continue to give trouble: malignant growths may not be extirpated freely enough. On the other hand, operations may fail to relieve, or even produce a worse state of affairs, if too much tissue be sacrificed. This is important as regards the nose, owing to the important respiratory and defensive function of its mucous membrane. It is a good rule to injure the inferior turbinal as little as possible, otherwise a condition of crusting rhinitis may be set up, with secondary atrophy in the pharynx and larynx.50

Much judgment is required in adapting the suitable operation to each case. While in some instances one or more small interventions are all that is required, in another a well-planned and more extensive operation may be indicated. In any case, the advice of Semon should be kept in mind, viz. that the magnitude of an operation should not exceed the gravity of the symptoms calling for relief.

CHAPTER II
OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES,
AND RHINOLITHS: OPERATIONS UPON THE TURBINALS:
OPERATIONS IN SYPHILIS AND LUPUS

OPERATIONS FOR INJURIES TO THE NOSE

The external injuries of the nose belong to general surgery. It might be well to recollect that the fleshy end of the nose may be completely detached, and yet, if carefully and promptly replaced, perfect union will occur.51

FRACTURES OF THE NASAL BONES AND SEPTUM

Setting a recent fracture. One or both nasal bones may be displaced, causing a flat bridge with a sharp ridge on either side.

In the septum fracture generally takes place in the quadrilateral cartilage, or displacement occurs at its junction with the vomer or superior maxilla. It may be accompanied by a hÆmatoma (see p. 612), and the occurrence of epistaxis shows that it is really a compound fracture. Care should therefore be taken not to infect the wound in the nose, and the patient should be warned on the subject.

The application of cocaine and adrenalin may allow of careful inspection of the septum. But, as the exact condition of things is marked by swelling, it is nearly always advisable to administer a general anÆsthetic. Crepitus can rarely be made out. A hÆmatoma is dealt with as directed (see p. 612). If there be any displacement of the septum—and it generally takes place towards the side on which there is already some convexity or depression of the nasal bones—the parts should be raised into place by manipulation with the little finger in the nostril. A flat-bladed forceps, like those of Adams, may be used. One blade in each nostril will straighten the septum and, at the same time, raise the whole nose into place. Small pencils of sterilized cotton-wool, smeared with vaseline (see p. 608), are then carefully packed up into the roof of the nose and kept there by Meyer’s vulcanite tube (Fig. 284). They are changed every 24 or 48 hours, for a week or so. The vomer is rarely fractured, although much callus is often thrown out in the displacements which occur between it and the cartilage.

Recent cases require no splints. In fact, if the displacement be promptly reduced—under general anÆsthesia—the restored parts will generally maintain their position.

Elevating an old fracture. In neglected cases it may be necessary to re-fracture the nasal bones, and when these are replaced an external splint may be necessary. This can be made of plaster of Paris; or the outside of the nose may be covered with a piece of heavy adhesive plaster, and outside that a shield of tin, copper, or, preferably, aluminium.52

Fracture of the ethmoid is, fortunately, rare. When it occurs it is apt to run into the cribriform plate, and be associated with the escape of cerebro-spinal fluid and other indications of fracture of the anterior fossa of the skull.

OPERATIONS FOR CONGENITAL OCCLUSION OF THE NOSTRILS

Operation for congenital occlusion of the anterior nares. If the web obstructing the nostril be thin and membranous, and of low vitality, a simple and effective method is to destroy it with the galvano-cautery. It is best to spread the treatment over several sittings, so as to diminish the local reaction. The application of cocaine may not be sufficient to numb the pain, as the tissue of the obstructing web is more allied to skin than to mucous membrane. It should therefore be punctured quickly in two or three places, with a sharp cautery point raised nearly to a white heat. If the patient be nervous it may be well to administer nitrous oxide gas.

After the operation the nasal orifice is kept distended until healing has taken place by wearing Meyer’s vulcanite tube in it or short lengths of full-sized rubber drainage tube, well smeared with boric, aristol, zinc, or similar ointment. These simple nasal dilators are changed once or twice daily, and the nostril is well cleansed on each occasion.

If the web obstructing the anterior naris be more fleshy in character (and it is more apt to be of this nature when it is incomplete), it may be necessary to remove it with a knife. So as to leave as much epithelial tissue as possible, and avoid retraction, the operation is done as follows, under local or general anÆsthesia: A narrow, sharp-pointed instrument, such as a Graefe’s or other ophthalmic knife, is used to puncture the web from before backwards, and it is then made to sweep round the obstructing diaphragm, while gradually cutting its way towards the central lumen. The tongue of skin thus formed can be used as a graft to cover most of the raw surface. The restored anterior naris is kept patent, as already described, till healing takes place.

In some cases the following operation has been shown to be easy and effective: An incision is made at the junction of the web with the septum, keeping close to the latter and passing straight down to the floor of the nose. On the outer side a similar incision is made, but sloping somewhat outwards. The flap formed between these two incisions is not cut off, but is bent backwards and fastened to the floor of the nose by a single horsehair stitch.53

Operation for congenital occlusion of the posterior choanÆ. If the obstruction be not freely and completely removed it tends to re-form. A general anÆsthetic is required. Unless the operator is ambidextrous he will find it most convenient to stand on the patient’s left hand, and to introduce his own left forefinger into the post-nasal space. This enables him to guide any straight, sharp instrument, such as an antrum drill (Fig. 323), Krause’s trochar (Fig. 285), or a surgical bradawl, from the front of the nose until it presses against and breaks through the obstructing diaphragm in two or more points. If preferred, an electric trephine can be used, and often pressure with the tip of a pair of nasal punch-forceps will be sufficient. The latter, either straight or tip-tilted (Fig. 286), are then inserted through the nostril, and, still guided by the left forefinger in the post-nasal space, are employed to clip away all the obstruction. To prevent any possibility of this reforming it is recommended by some surgeons that a small piece should be nipped out of the posterior margin of the bony septum. This can be done with the beaked punch-forceps of GrÜnwald (Fig. 286), passed through the nose, or with a pair of Loewenberg’s post-nasal forceps (Fig. 287) introduced through the mouth. In either case their action is controlled and directed by the operator’s left forefinger in the post-nasal space.

No special after-treatment is required. The patient should be ordered a tepid alkaline nose lotion, and should be encouraged to make use of the nasal air-way and acquire the habit of blowing the nose.

REMOVAL OF FOREIGN BODIES FROM THE NOSE

It might be helpful to remember that foreign bodies not only enter the nasal cavities (1) through the anterior nares, but also (2) through the posterior choanÆ, or (3) by penetration through the walls. They may also arise (4) in situ, as in the case of sequestra and rhinoliths. The last group will be considered separately.

A foreign body, if small, may form the centre of a rhinolith.

Operation. Great care and gentleness are required in the removal of foreign bodies from the nose. The extraction should never be attempted blindly, or forcibly, or hurriedly. A little delay to make necessary arrangements does no harm. If a child will not submit to examination it is much better to employ a general anÆsthetic so as to complete examination and, if found necessary, extraction at the one sitting. If the nose be not well illuminated and opened with a nasal speculum, groping about in the dark will only do further damage and result in disappointment.

In adults removal can generally be carried on under cocaine. The nostril is cleaned with cotton-wool, and if the extremity of the probe used for detecting the presence of a foreign body be curved to a right angle, it will also serve for gently levering or displacing it forwards. With a small pair of nasal dressing forceps (Fig. 288) it can generally be firmly seized and gently extracted, care being taken not to include any of the mucosa nor to drag the foreign body out regardless of the sinuosities of the cavity. Lister’s ear hook is a most useful instrument. Sometimes a nasal snare will help to extract the substance or to tilt or drag it into a better position.

Unless coated with solid accretions there is never any need to break up a foreign body; anything small enough to slip into the nose is small enough to be extracted entire. If it should be found impossible to remove the body through the anterior nares, it may be pushed backwards into the post-nasal space, where the forefinger of the left hand is in readiness to prevent its falling into the gullet or larynx.

The usual warm alkaline lotion may be used to clear the nose, but liquid should never be forcibly injected into the nostril with the idea of thus expelling the foreign body. If the lotion be sent up the nasal chamber on the same side it will only drive the intruding substance further in; if injected on the opposite side there is risk of otitis media.

In the case of small children it is sometimes recommended that a piece of muslin should be placed over the mouth, and that the practitioner should then apply his lips to those of the patient and by blowing forcibly through the mouth drive out the foreign body by the blast of air from the post-nasal space. Or the same principle may be applied by insufflating the air from a Politzer’s bag through the opposite nostril. Both plans are alarming and seldom effective.

The after-treatment consists of some simple cleansing lotion and soothing ointment.

REMOVAL OF RHINOLITHS (NASAL CALCULI, OR CONCRETIONS IN THE NOSE)

These concretions are almost unknown in children, in whom foreign bodies are met with most frequently. A general anÆsthetic is, therefore, not so often required, otherwise the remarks on the removal of foreign bodies will be found to apply to the extraction of calculi. With the help of cocaine and good illumination they can easily be removed with a strabismus hook, Lister’s ear hook, or a pair of fine probe-pointed nasal forceps with serrated extremities. In some cases where the calculus has sent prolongations into the recesses of the meatus, it might first be necessary to crush it. In that event a general anÆsthetic may be required.

The after-treatment consists in simple cleansing measures. Subsequent syringing of the nose should be done from the opposite side.

OPERATIONS UPON THE TURBINALS

Indications. In many cases of hypertrophic rhinitis it is necessary to remove portions of redundant turbinal tissue. It is never desirable—and it can only rarely be necessary—to remove the whole of the inferior turbinal. ‘Turbinotomy,’ or amputation of the whole inferior turbinal, was recognized as an operation some years ago. But it was never generally accepted, as it was always realized that the highly important physiological functions of the lower spongy bone could not be spared. Improved technique, particularly in being able to correct deformities of the septum without the sacrifice of any mucous membrane (see p. 603), now enables us to rectify nasal stenosis with the sacrifice of much less turbinal tissue.

The middle turbinal is not of so much importance in the physiology of the nose, and the whole of this body is not infrequently removed. This may be done not only because it is diseased, but even a healthy middle turbinal may require amputation in order to approach the accessory sinuses or diseases in the deeper regions of the nose. Part of the healthy inferior turbinal may also require removal—as in the radical operation on the maxillary sinus.

As these operations will be referred to frequently later on, and as their performance enters into different groups of operation, they will be described first.

OPERATIONS UPON THE INFERIOR TURBINAL

Amputation of the anterior end. Indications. The amputation may be required:

(i) On account of polypoid degeneration of the anterior extremity of the turbinal.

(ii) To allow of access to the antro-nasal wall (see p. 633).

(iii) To avoid operation on the septum by relieving nasal stenosis.

Operation. The local application of cocaine and adrenalin (see p. 573) is sufficient.

AnÆsthesia. With the patient sitting upright in a chair, and the nostril well illuminated, a pair of nasal scissors (such as Heymann’s, Walsham’s, or Beckmann’s) are made to grasp as much of the anterior extremity as it is desired to remove, generally the anterior third (Fig. 289). The scissors are pressed very firmly against the outer nasal wall, so as to divide the base of the turbinal as close as possible to its attachment. If the scissors slip off the bone it should be divided with GrÜnwald’s punch-forceps. The semi-detached extremity is then surrounded with a nasal snare, carrying a No. 5 piano wire, and cut through (Fig. 291).

It is well not to seize and twist off the anterior extremity, as this might lead to the ripping out of a larger portion than was intended. Besides, it might cause fracture of the base of the remaining piece of the inferior turbinal bone and this might become displaced inwards so as to block the air-way more than ever.

After-treatment. It is well to check the hÆmorrhage without the use of plugging. Some antiseptic powder—europhen, xeroform, formidine, aristol, &c.—if lightly insufflated over the wounded area, will assist in the formation of a protective scab. This should not be disturbed for some days, during which the nose is made comfortable by some menthol and boric ointment, or a paroleine spray. When the scab begins to break down its removal is assisted by warm alkaline lotions (see p. 579). The stump may require a few applications of nitrate of silver or other silver salt. There is no danger in this operation. Healing, as in other intranasal operations, takes from three to six weeks.

Amputation of the lower margin. Indications. This is not infrequently necessary when there is a general hypertrophy—as in the compensatory hypertrophy of septal scoliosis (Fig. 310)—or when the whole lower and outer margin is occupied by papillary hypertrophies (Fig. 289).

Operation. The operation can be carried out under the local application of cocaine and adrenalin, but is frequently performed as part of some other operation under a general anÆsthesia.

The steps have to be varied according to the degree and extent of the hypertrophic tissue requiring removal. When this is principally along the lower border of the turbinal it can be removed with one cut of a stout pair of nasal scissors (Fig. 290). Under good illumination a blade is insinuated along the concavity, while the other passes between the convexity and the septum. Care should be taken that the direction of the scissors is parallel to the axis of the turbinal body, and that the cut embraces only that portion of the lower area to be removed. The severed portion should be quickly seized with a pair of punch-forceps and lifted out, or the patient, if only under local anÆsthesia, may be requested to blow it forward into a tray. Otherwise it is apt to become obscured in the outpouring of blood, and, if the patient is unconscious, to be sucked backwards out of sight. If, as not infrequently happens, the lower margin remains attached at its posterior extremity, a wire snare is threaded along over it so as to cut this through. When the papillary hypertrophy is more diffuse it is apt to be concealed in the concavity of the turbinal. From this hiding-place it can be partially dislodged with a probe and then cut off with a snare.

The after-treatment is similar to that for removal of the anterior end.

Removal of the posterior end. Indications. The posterior extremity of the inferior turbinal is very subject to a moriform hypertrophy, and some delicacy and skill are required in removing it.

Operation. The interior of the nose on the affected side should be treated with a weak solution of cocaine and adrenalin. The most disagreeable part of the operation is the introduction of the operator’s finger into the post-nasal space. Hence the fauces should be freely sprayed with a 5% solution of cocaine. This will deaden painful sensation, but it will not prevent the discomfort nor the nausea often induced.

It is well to avoid as much as possible the direct application of cocaine or adrenalin to the moriform hypertrophy itself, for it is an extremely vascular growth, and if much contracted it is more difficult to ensnare.

The operation may also be carried out under a general anÆsthetic, when one is given for other surgical measures in the nose. In that case it is best to defer the removal of the moriform hypertrophy until the end—practically until the patient is commencing to recover consciousness—on account of the sharp hÆmorrhage which is apt to accompany it.

The chief difficulty of the operation lies in the fact that the part to be operated on cannot be kept in view, either directly or indirectly, and that therefore success depends a good deal on delicacy of touch.

A nasal snare—such as that of Blake, Krause, or Badgerow—is threaded with No. 5 piano wire, and a loop left out a little larger than sufficient to grasp the growth. This loop is then bent over smartly towards the side to be operated on, and a slight kink is given to it. The loop is then slightly withdrawn within the barrel, and this again brings it into a straight line. If now the snare be passed along the floor of the nose until the end of it is opposite the posterior extremity of the turbinal, and if the looped wire be slightly projected from the barrel, the loop will tend to curve outwards to the side on which it was kinked. In this way it will be felt to surround the moriform growth, which can then be cut off.

It must be confessed that this is not always successful, that there is no means of making sure that the snare is applied to the root of the growth, and that once the bleeding is started posterior rhinoscopy fails to reveal if any of it still remains. It is better therefore to introduce the purified forefinger of the left hand into the post-nasal space, so as to define the growth and guide the loop of the snare over it. The nail of the same finger then keeps the wire close to the base of the hypertrophy, while the loop is drawn home (Fig. 291). The patient may then be relieved of the discomfort of the operator’s finger in his throat, and may be given time to clear away the collected mucus. A little delay is advantageous, as it allows coagulation to take place in the large veins of the moriform growth. Some surgeons recommend that once the growth is strangled the snare should be left in situ for 10 or more minutes. This is irksome and unnecessary, and bleeding is seldom excessive if the snare be not employed for cutting off the hypertrophy, but is used as follows: Once the loop is drawn firmly home so as to embrace the growth tightly, a few minutes’ rest is given. Then, steadying the patient’s head with the now disengaged left hand, the snare is plucked from the nose with a quick movement. This brings away the mulberry hypertrophy in its grasp, and frequently a strip of mucosa from the lower margin of the turbinal. No bone is removed in this operation. The bleeding may be very sharp at first, but generally ceases under the usual measures (see p. 574). Occasionally it is extremely troublesome, and as the bleeding surface overhangs the post-nasal space the only local pressure which is available is that of a post-nasal plug.

After-treatment. As secondary hÆmorrhage is apt to be met with the patient should be advised to leave his nose alone, neither blowing nor clearing it, nor using any cleansing measures for 48 hours. After that time he can employ the usual warm alkaline nose lotion. He should be warned against the habit of hawking backwards, as this would tend to a recurrence of the hypertrophy.

Prognosis. Great relief can generally be promised within a few days. There is no danger in the operation. The hÆmorrhage may be troublesome, especially in men. The precautions described in the previous chapter are well worth observing (see p. 574).

Complete turbinotomy. Indications. As already remarked it must be extremely rare for this operation to be required. Papillary hypertrophy chiefly attacks the lower and posterior parts of the turbinal, and these can be removed as described above, so that if the entrance of the nostril is made free by anterior turbinectomy, there will still be left a sufficient area of functionally active mucosa. If, however, almost the entire inferior turbinal be degenerated, or if it be replaced by malignant growth, it can be removed in the following way.

Operation. AnÆsthesia may be local or general. If no other operative procedure be required at the same time, the anÆsthesia of nitrous oxide gas or chloride of ethyl will be long enough. Owing to the vascularity of the part adrenalin should be applied for at least 30 minutes beforehand.

Removal of the turbinal is easily and quickly carried out with Carmalt Jones’s or Moure’s spokeshave (Fig. 292). This is introduced, passed as far as the posterior extremity of the turbinal, and the edge is guided in place with the operator’s left forefinger in the post-nasal space. With a sharp pull the spokeshave is then drawn forwards and the detached body can be lifted out with a pair of punch-forceps. Owing to the slope of the attached border it is seldom that the whole of the turbinal is removed. Those who are skilled in the use of this instrument can manipulate it so as to leave a good part of the attached margin of the turbinal, and the spokeshave can be used instead of the scissors for removal of the inferior margin. But its action is apt to be uncertain, and as it may unexpectedly rip out more than was intended, it is seldom employed nowadays.

After-treatment. After the removal of such a large portion of secreting surface the nasal secretion may dry into adhering crusts and scabs for some weeks—possibly for six or even eight. The scabs should be softened by the use of ointment or oily sprays, and removed by the fere use of warm alkaline lotions. The even healing of the granulating surface requires watching; its progress should be inspected from time to time, as the surface may require touching with a weak nitrate of silver solution.

OPERATIONS UPON THE MIDDLE TURBINAL

Indications. Amputation of the anterior end may be required for (1) simple hypertrophy, (2) cyst or empyema in the anterior extremity, (3) to gain access to the ostia of the various accessory sinuses, (4) as a first step to uncover the ethmoidal cells, and (5) as a first step in removal of ethmoidal polypi.

Operation. Local anÆsthesia with cocaine and adrenalin is sufficient, and the operation can be carried out with the patient sitting in the examination chair. It frequently forms part of some other intranasal operation which is performed under a general anÆsthetic, but the preliminary application of cocaine and adrenalin should still be carried out (see p. 572). If the pieces of gauze soaked in the cocaine-adrenalin mixture be carefully tucked up on each side of the head of the turbinal, the part to be removed is generally well exposed. With a pair of GrÜnwald’s punch-forceps (Fig. 286) or Panzer’s scissors (Fig. 290), the anterior attachment to the outer wall is cut through (Fig. 293) so as to free the end, around which a cold wire snare can be passed and the extremity removed (Fig. 294.) In cases where it is difficult to introduce the punch-forceps under the attachment of the middle turbinal the blades may be applied to the lower margin, about half an inch from the anterior extremity so as to bite out a wedge. Into this the loop of the wire snare is inserted and the head of the turbinal can easily be snared off.

The snare is generally recommended as being safer than the punch-forceps. There is certainly a risk attending any slip in manipulating the latter in this region, more so, indeed, than in the deeper ethmoidal regions, for in the anterior part of the nasal roof the cerebral floor dips down lower than it does posteriorly, and the nasal fossa in the anterior part of the middle meatus is very narrow, so that if the forceps slipped they might impinge on the cribriform plate.

But when the middle turbinal is softened and broken down by disease it is as safe, and it is certainly more convenient, to take out a wedge from its centre, as directed above, and then with a pair of GrÜnwald’s or Luc’s forceps to twist out not only the anterior extremity, but also the posterior half. The latter part can also be removed with a spokeshave, as directed for the inferior turbinal (see p. 591).

After-treatment. There is not the same tendency to crusting as occurs after operation on the inferior turbinal. HÆmorrhage is also less troublesome. Plugging is therefore the less likely to be required, and should always be avoided if possible, since it would interfere with drainage from the various accessory sinuses, and this operation is frequently required when their contents are particularly septic. The best plan is to leave the nose severely alone for 48 hours, and then to clear it gradually with the help of warm alkaline lotions.

OPERATIONS FOR THE RESULTS OF SYPHILIS

Sequestrotomy. The discovery of a syphilitic sequestrum always calls for active treatment.

Operation. If the sequestrum be not loose we must wait until it is movable. Its detachment will be expedited by mercurial inunctions or injections, and suitable local cleansing and disinfecting measures. As soon as any movement can be detected in the dead mass we can proceed, under cocaine, to detach it. Various forms of polypus forceps and bone-pliers may be required, and the necrosed bone has to be raised from its bed by a variety of lever and to-and-fro movements. Several sittings may be necessary, but this is inevitable, as any violent measures are soon arrested by hÆmorrhage. When the necrosed bone has been mobilized it may be too large for extraction through the nares; such a mass as the greater part of the body of the sphenoid has sometimes necrosed en bloc. In such cases the dead bone must be broken up in situ and then removed piecemeal through either the anterior or posterior nares. Very rarely Rouge’s operation may be required (see p. 622).

Operations for post-syphilitic adhesions of the velum. So long as there is an adequate passage for nasal respiration it is best to leave any slight degree of stenosis alone. When there is complete atresia, and when mouth-breathing, deafness, or other consequences develop, some effort at relief should be made.

Operation. Under chloroform, and with the hanging head, W. G. Spencer54 separates the soft palate from its adhesion to the posterior pharyngeal wall, draws it forwards, and fixes it by two silk sutures to the muco-periosteum of the hard palate. Tilley carries out the same principle by threading the soft palate on both sides with strong silver wire and anchoring it to the incisor teeth. The wires cut out in 10 to 14 days, but by this time considerable healing will have taken place over the raw surfaces from which the adhesions had been separated.55

After freeing the soft palate, H. B. Robinson prevents it from again uniting by the following method: ‘A piece of lead plate is cut the full breadth of the naso-pharynx and bent so that one arm rests on the dorsal surface of the soft palate, and the lower one on the buccal surface, the cut margin being received between the plates and apposed to the bend, and so kept away from the pharyngeal wall.’ The piece of lead is kept in place by silk threads attached to the four corners, two passing forward through the nostrils and two through the mouth. The lead plate is not removed for a fortnight.56

Whatever method is employed to enlarge the stricture, dilatation must be kept up for some time by the frequent passage of the forefinger, a palate hook, or a dilatable bag.

Results. Stenosis of the passage from the naso-pharynx to the meso-pharynx, caused by syphilitic adhesions between the soft palate and the posterior pharyngeal wall, is one of the most difficult affections in this neighbourhood to operate on with satisfactory results. The cause of disappointment lies in the low vitality of specific scars and their well-known tendency to contract.

Surgical measures are sometimes required for the damage left by syphilis during the healing process.

The saddle-back deformity of the external nose is best corrected by subcutaneous injection of paraffin (see Vol. I, p. 681).

Perforations in the hard or soft palate may require operation to close them (see Vol. I, p. 717).

OPERATIONS FOR TUBERCULOSIS

Tuberculosis only occurs in the nose in the mitigated form of lupus. Surgical interference is frequently called for, generally in the form of curettage or the application of caustics.

The most satisfactory caustic is the galvano-caustic point, applied under cocaine, and at repeated sittings.

Curettage is required in more advanced cases. Chloroform is always required. Not only should all soft and diseased tissue be scraped away with a Volkmann’s spoon, but the curettage should be carried on vigorously until a healthy and resistant area has been reached. It is rare for too much tissue to be removed, whereas recurrences are only too frequent.

CHAPTER III
OPERATIONS UPON THE NASAL SEPTUM

OPERATIONS FOR DEFORMITIES

REMOVAL OF SPURS

Indications. A spur or ledge, uncomplicated with deviation of the septum, occasionally requires removal. It will generally be found in the lower meatus, at the junction of the quadrilateral cartilage and ethmoid with the superior maxillary crest and vomer.

Operation. The operation can be carried out painlessly and bloodlessly under cocaine and adrenalin. The galvano-cautery, trephine, and spokeshave should be avoided. An incision is made from behind forwards along the summit of the projection, and the muco-perichondrium is turned upwards and downwards. (For particulars as to reflecting these flaps see p. 605.) A straight, fairly stout nasal saw (Fig. 295) is inserted below the projection, and, while the patient’s head is steadied with the left hand, the saw is carried inwards and upwards with short, swift movements. During the first of these the cutting edge should be directed obliquely towards the opposite nostril so that the saw gets a good bite into the base of the spur. Otherwise, if simply directed vertically the resistance it meets with is likely to send it obliquely outwards, and the obstruction will be imperfectly removed. This defect will be the more apparent later on, when some heaping up of scar tissue is sure to take place over any trace of projection. In other words, in order to remove a spur flush with its base it is necessary to cut deeper than the base. At the same time it is important to avoid buttonholing the septum by cutting into the opposite nostril.

When the spur lies close along the floor of the nose it may be necessary to direct the saw from above downwards. The result is not so satisfactory, and the removal may have to be completed by seizing and twisting off the semi-detached spur with a pair of polypus forceps, or stripping it forwards with a spokeshave.

After-treatment. The reflected flaps of muco-perichondrium are replaced and maintained in position for 48 hours with plugs of cotton-wool. Subsequently a warm alkaline nasal lotion and a little ointment may be required.

Perforating the septum. It will be seen that if a spur is associated with a convexity of the septum to the same side it will be very difficult to remove the projecting obstruction adequately without cutting into the concave side of the septum, and so producing a perforation. Some surgeons even recommend that this should be done intentionally, and maintain that the resulting perforation seldom gives any trouble. This may be true in some cases, and the result is sometimes fairly good. But we have more completely satisfactory methods at our disposal; the perforation method does not relieve the majority of cases, and it interferes with the subsequent performance of more perfect operation. It can therefore only be approved of when the surgeon has not acquired the technique of the submucous resection operation (see p. 603).

Operation. When it has been decided to produce a perforation it is carried out with the nasal saw, as described for the removal of spurs (see p. 595). The saw is introduced so as to embrace as much as possible of the projection.

After-treatment. The drying and scabbing of discharge along the margin of the perforation is apt to give trouble for some weeks. This inconvenience is the more marked the nearer the perforation approaches to the anterior nares. It must be met by careful and repeated cleansing and lubrication of the nasal chambers. Any scabs should be carefully softened with hydrogen peroxide, lifted off the edge of the perforation, and any underlying ulceration treated with applications of nitrate of silver, argyrol, &c.

OPERATIONS FOR SIMPLE DEVIATION

It is very rare to find a deviation of the nasal septum without some accompanying spur or ledge. It is still more rare to meet with a deviation which is entirely limited to the cartilaginous septum; there is nearly always some bony formation in the deformity, contributed by the nasal spine of the superior maxilla, the vomer, or the perpendicular plate of the ethmoid, or by all three. Hence the limited field of application for the various operations which have been designed for ‘straightening the cartilaginous septum’. In the few cases where the deformity is almost entirely cartilaginous these operations are only partially successful in overcoming its resiliency. They will therefore be only briefly considered.

Gleason-Watson operation. For a thorough performance this operation requires a general anÆsthetic. The scheme of the operation is to make a U-shaped incision around the convexity, leaving it attached above. The flap of cartilage is then pushed through the U-shaped opening into the concave side. As its bevelled edge is larger than the button-hole in the septum it will be to some extent prevented from slipping backwards (Fig. 296). This tendency may also be combated by an attempt to snap through the base of the flap of cartilage, and by careful packing of the formerly obstructed nostril. The operation is performed with a nasal saw, carried from below upwards, and maintained carefully in the antero-posterior axis of the septum.

Asch’s operation. The resiliency of a deviated cartilaginous septum is more completely overcome by this method of operating. It requires a general anÆsthetic.

By means of appropriate cutting scissors (Fig. 297) a crucial incision is made over the summit of the convexity of the deviation, so that we have four triangular flaps meeting at the point of greatest stenosis. By means of the finger introduced into the obstructed nostril, or suitable septal forceps, these four flaps are snapped across at their bases so as to overcome their tendency to spring back.

Into the formerly obstructed nostril is introduced a Meyer’s vulcanite hollow splint (Fig. 284), a Lake’s rubber splint (Fig. 298), or a gauze packing. This should be retained for 48 hours. Afterwards it will require daily changing and cleansing, possibly for several weeks. In the opposite nostril a lighter support will serve to keep the ends of the fragments in situ.

Moure’s operation. According to its author this operation can be carried out under local anÆsthesia, but it is generally advisable to employ some such general anÆsthetic as nitrous oxide or chloride of ethyl. By means of suitable scissors one incision is made through the septum parallel to the bridge of the nose and above the prominence of the deviation, and by another parallel to the floor of the nose the septum is divided below the deviation. This is now only fixed at its anterior and posterior extremities, but has been rendered more movable from side to side. By means of a specially designed dilator and splint the septum can be moulded into a good position, and maintained there until healing takes place.

The conditions in which any of these operations can prove suitable are rarely met with. In the worst forms of stenosis from septal deformity they are useless. At the best they can never completely remove it. In one of them a perforation is made on purpose, and in the others it not infrequently is produced unintentionally. The objections to a perforation have been described (see p. 598). HÆmorrhage, shock, and prolonged and painful after-treatment are important drawbacks. A dry scabby condition of the septum may be produced, and the patient may complain more of this than of his previous nasal stenosis; indeed, he may find that the stenosis is unrelieved and that a constant source of irritation has been added to it.

The perforation operation should only be employed when the patient is in circumstances where a complete submucous resection cannot be carried out. The Gleason-Watson operation is unsuitable where the deviation reaches high up. It should be avoided if it is seen that the perforation will have to be brought close forward to the anterior nares.

Another objection is that any of these operations, particularly the production of a perforation, will greatly increase the difficulties and diminish the benefits of the subsequent complementary operations which are only too often required.

Asch’s operation is easily carried out, and may be practised by those who have not mastered the technique of submucous resection (see p. 603). Moure’s operation is easily and quickly performed, and where a well-marked deviation of the anterior part of the cartilaginous septum is met with, it will give considerable relief.

OPERATION FOR COMBINED BONY AND CARTILAGINOUS DEFORMITY

Submucous Resection (Window operation)

This is the most perfect operation we at present possess for the cure of deformities of the nasal septum. It has largely supplanted those already outlined; it is suitable for the most extreme degree of deformity: and it will secure complete relief to the symptoms produced, whether they consist of stenosis of the air-way, obstruction to discharge, or reflex effects.

The design of the operation is to excise all obstructing cartilage and bone, with any projecting spurs or ledges, while preserving intact the mucous membrane on each side. It has been brought to its present degree of perfection chiefly by the work of Killian and Freer.57

Indications. The special indications of this operation would appear to be:—

1. Cases where it is desirable to establish normal nasal respiration and remove mouth-breathing, with its numerous consequences.

2. Correction of the disfigurement caused by the lower end of the quadrilateral cartilage projecting into one nostril.

3. Cure of headaches or reflex neuroses of nasal origin.

4. The relief and treatment of Eustachian catarrh.

5. Facility for treating nasal polypi and affections of the accessory sinuses.

Objections to the operation. (a) That the excision of a large part of the septum may lead to flattening or deformity of the nose. This objection is groundless. A strip of septal cartilage is always left above, beneath the crest of the nose. Falling in of the bridge of the nose could only be consequent on entire removal of this ‘bowsprit’ of cartilage, or from its destruction through the wound becoming septic. No deformity has occurred in my hands in over 200 operations. On the contrary, the appearance of the nose is generally much improved.

(b) That the operation entails greater risks from any subsequent blows on the nose. This objection has been met by the experience of Otto Freer in four cases where severe blows, causing epistaxis and occurring even within a week of operation, did not result in any damage to the fleshy septum, nor to the external appearance of the nose.58

(c) That the operation is long and tedious. The duration of the operation depends on the nature of the case, the skill of the surgeon, and the difficulties met with—chiefly in the way of hÆmorrhage. A simple deviation of the cartilaginous septum can be removed by this method in 10 to 20 minutes. Many beginners are apt to be content with such a partial removal. More time is required in completely removing bony deformities. Many cases take 30 minutes, and none need exceed an hour when once the necessary dexterity has been acquired. More time is taken up if fresh applications of cocaine or adrenalin have to be made, if bleeding be troublesome, and if one of the flaps should be punctured.

(d) That the operation requires special skill. This is a real objection to the popularization of the operation. It does not seem probable that it can ever pass out of the hands of those who are kept in daily practice in rhinological technique.59

(e) That the operation is unsuitable for children. Owing to the small size of the nasal chambers the operation presents greater technical difficulties before the age of sixteen. My own practice formerly was to await this age, and Killian used to advise that children under twelve were not fit subjects. But Freer held that the operation is proper for children at all ages, although with them the deformity tends to recur unless every vestige of it has been removed. Killian has lately adopted this view, and agrees that the operation may be performed on children even as young as four years of age.60

Advantages of the operation. These may be summarized as follows:—

1. A general anÆsthetic is not inevitable.

2. HÆmorrhage gives no trouble.

3. Absence of pain and shock.

4. No reaction. The post-operative temperature seldom rises above 99° F.

5. Absence of sepsis, with its possible extension to ears, sinuses, or cranial cavity.

6. No splints are required, and no plugs after the first 48 hours.

7. Rapid healing, without crust formation.

8. No risk of troublesome adhesions.

9. Short after-treatment.

10. Speedy establishment of nasal respiration.

11. Suitability for every variety of deformity of cartilage or bone in the septum which may require treatment.

12. No ciliated epithelium is sacrificed.

13. Accuracy of result can be depended on; the prognosis is, therefore, the more definite.

14. If the external appearance of the nose be altered at all it is in the way of improvement.

It will be seen that the above advantages cancel most of the drawbacks which were formerly so annoying in nasal surgery.

Contra-indications. 1. Elderly people are so accustomed to their nasal obstruction, and its secondary consequences are generally so fully established, that the benefits would be much less marked than earlier in life.

2. Serious or progressive organic disease. This does not apply to quiescent or arrested tuberculosis.

3. Active syphilis.

4. Lupus.

5. The operation should be postponed if the patient shows any symptoms of influenza, or of acute or infectious catarrh.

Operation. Submucous resection can be completely carried out under local anÆsthesia, as described on p. 572. Killian and others secure local anÆsthesia by submucous injection of cocaine and adrenalin (see p. 572), but I have found this method alarming to the patient, apt to produce disagreeable palpitation, and not superior to the method of superficial application already described, particularly if sufficient time is allowed for the mixture to act, and if a few cocaine crystals are allowed to dissolve over the site of incision some minutes before starting it.

In nervous subjects it is better to administer chloroform, not so much because of any pain they suffer, but because of the mental strain they are apt to feel in watching the various manipulations.

Position. The operation is best done with the patient horizontal on an operating table, with the head and shoulders well raised. His nose is then almost on a level with the eye of the surgeon, who is armed with a frontal search-light or Clar’s mirror (see p. 571), although he can also operate successfully with an ordinary forehead reflector.

The incision. This can be made with a narrow scalpel, but a much shorter instrument mounted on a bayonet handle cutting all round the point will be found more satisfactory (Fig. 299). The incision is made from the side of the convexity, just anterior to it, and generally about half a centimetre behind the junction of the skin and mucous membrane (Fig. 300). It is started high up in the attic of the nose, and carried downwards to the floor. Sometimes it curves a little backwards below, but it is quite unnecessary to convert it into an L-incision by a second cut backwards. The incision, in its whole extent, divides the mucous membrane and cartilage at one cut, but without puncturing or wounding the mucosa of the opposite (concave) side. In doing this the operator’s forefinger in the opposite nostril serves as a useful guide (Fig. 301). In those cases where the lower free end of the quadrilateral cartilage is displaced from behind the septum cutaneum into one nostril— commonly but erroneously described as ‘dislocation of the septum’—the incision is made directly over the exposed extremity (Fig. 300, b-a).

Raising the convex flap. With a small sharp elevator the muco-perichondrium is raised along the posterior edge of the incision. Great care must be taken not to pass the raspatory between the mucous membrane and the closely adhering perichondrium. The dead white, slightly roughened surface of the bare cartilage should be distinctly visible, and should not be coated with any soft, smooth, or pinkish perichondrium. Once the flap is well started a dull-edged detacher (Fig. 302) will readily undermine it by sweeping movements gradually advancing upwards and backwards. If possible the limits of the convexity should be passed, but it is well not to attempt to go round sharp projections, as it is there that perforations are apt to take place. It is easier at a later stage to strip the flap off crests or spurs.

Incision through the cartilage. If the cartilage has not already been completely cut through at the first incision it is now divided in the same extent as the cut in the muco-perichondrium, great care being taken not to button-hole the mucosa of the concavity.

Raising the concave flap. The sharp elevator, followed by the dull-edged detacher, is introduced from the incision on the convex side. The muco-perichondrium of the concavity is now raised in the same way and with the same precautions already used on the convexity, the sharp elevator and then the dull-edged detacher being introduced through the incision in the obstructed orifice, and manoeuvred between the cartilage and the concave flap without puncturing the latter (Fig. 303).

Excision of the deviated cartilage. A long Killian’s nasal speculum (Fig. 346), or the long Thudichum’s speculum I have had made, is now introduced through the obstructed nostril, one blade being inserted on each side of the now denuded septum (Fig. 304). It is easy to see if the mucous membrane has been sufficiently stripped off. If not, it can be carried further with a few sweeps of the raspatory. Ballenger’s swivel septum knife61 (Fig. 305) is then placed astride the anterior cut surface of the cartilage, pushed upwards and backwards below the roof of the nose until it comes in contact with the ethmoid, then downwards and backwards to the angle between the ethmoid and the vomer, and, finally, pulled forwards along the upper margin of the vomer (Fig. 306). The excised cartilage is thus removed en bloc, and may measure an inch by one and a half inches.

The empty pocket between the two separated and flaccid mucous membranes is wiped out and the two fleshy curtains are allowed to fall together. With a nasal speculum each nasal chamber is next carefully inspected to see that the thoroughfare is completely restored. As a rule deeper obstructions, formerly invisible, will come into view, and the mucosÆ are again separated with a long nasal speculum and more of the septum is shaved off with Ballenger’s knife or clipped away with GrÜnwald’s punch-forceps, which also serve to remove portions of the vomer and of the perpendicular plate of the ethmoid.

Excision of bony spurs and ledges. It has been pointed out that it is extremely rare to find a deviation limited entirely to the cartilaginous septum. I have never yet met a case in which it was not desirable to remove some of the bony septum.

When the deformity of the septum is principally composed of bone the operation is started as already described. It is then easier to lay bare any thickening or deviation of the nasal process of the superior maxilla, or of the chondro-vomerine suture—the usual sites of bony obstructions. When the main mass of deviated cartilage has been cut out with Ballenger’s knife free access is obtained from above to these deformities, and the fleshy muco-perichondrium can be peeled off on each side with much less risk of a tear or puncture. Still, much care is required in working round sharp corners, and, when the spurs lie low, the flaps frequently require to be reflected right down to the floor of the nose. Once well exposed, the maxillary spine is attacked with strong punch-forceps or chisel and hammer, and as pieces of it are prised up they are twisted off with forceps. Once the obstructing maxillary spine is cleared away it is easier to deal with any vomerine deformity.

A great deal of the success of an operation depends on the complete removal of these spurs and ledges, and as they may have to be followed back nearly to the posterior choanÆ this part of the operation may be the most difficult, as it is the most necessary (Figs. 307–9).

The pocket between the two flaps is again carefully wiped free of blood-clot and chips of bone and cartilage, and when the two mucous membranes are allowed to fall together they should hang perfectly plumb in the middle line and allow of an uninterrupted view through each nasal chamber, right back to the post-nasal space.

Stitches. With a small TrÉlat’s needle the incision is closed with one or two catgut stitches.

Dressing. Plain sterilized cotton-wool is tightly rolled into pencils about 3 inches long, and well smeared with sterilized vaseline. These are carefully packed into each nostril. The nose should not be tightly plugged, our object being to keep the two mucous membranes in apposition, but at the same time entirely occluding nasal respiration.

After-treatment. The patient remains quiet for the rest of the day. Ice may be given to suck and an iced cloth laid across the bridge of the nose. At the end of 48 hours the plugs are removed and will be found to come away very easily. The patient should be warned against blowing his nose, but may suck blood-stained mucus backwards and hawk it out through the mouth. Any discomfort may be soothed by spraying the nostrils with liquid vaseline, or introducing a piece of menthol and boric ointment into each nostril morning and evening.

The relief to the former state of nasal obstruction may at once be appreciable. If there be any local reaction it may take 3 or 4 days for the obstruction to subside. In 7 to 10 days the patient begins to enjoy the benefit of the operation, but it is only after 3 weeks that the full advantage of it is established.

Complementary operations. As a rule the formerly patent nostril is found after this operation to be the more obstructed of the two. The reason of this is readily explained by a reference to Fig. 310. The now redundant hypertrophy in the formerly good nasal chamber is removed—according to its degree and extent—by one of the methods described on p. 587.

From long disuse marked alar collapse may interfere with the good results of the operation.

Difficulties. Insufficient illumination is a difficulty that can easily be provided against by using a frontal photophore or Clar’s mirror (see p. 571).

HÆmorrhage presents no difficulty if patients are prepared as directed (see p. 574), unless one happens unexpectedly on a patient with a hÆmophilic tendency. In one such case I had no trouble at the time of operation, but bleeding gave great annoyance for a fortnight afterwards.

The incision I have described has always proved sufficient. In some cases this straight incision is unintentionally converted into an L-shaped one, when the flap is torn over a sharp low-lying spur. Beginners may find it easier to start with an L-shaped incision, but it is unnecessary and does not leave so small and clean a wound.

The perichondrium should be raised with great care, for it is more easy than one would think to leave it adhering to the septum, while separating only the mucous membrane.

Previous operations always increase the difficulties of the proceeding. The old-fashioned ‘shaving off’ of spurs often removed the entire thickness of the cartilage at one part, without perforating the concave mucosa. The submucous resection (window operation) is not infrequently not carried far enough. In either of these circumstances we are confronted with the great difficulty of trying to separate the two muco-perichondria—now closely united to one another.

OPERATION FOR PERFORATION OF THE NASAL SEPTUM

When a perforation of the nasal septum is situated at some distance within the nasal orifice it seldom gives any trouble. A perforation may also be situated close to the anterior nares without even making its presence known. But in some cases—no matter what the original cause of the perforation—constant annoyance is given to the patient by the crusting and bleeding which takes place along its margin. When these crusts have been carefully removed inspection will show that the cause of the trouble is the projecting free edge of the cartilage which prevents the edges of mucous membrane from each nostril from closing over it. When this circular edge is healed over smoothly, secretions cease to adhere to it, and the patient is not troubled by the annoying crust formation.

This desirable condition can be brought about in crusting perforations by means of the following operation designed by Goldstein.62 After preparation with cocaine and adrenalin (see p. 573), the muco-perichondrium is reflected on each side along the whole circumference of the perforation for a distance of about a quarter of an inch from the free margin. Over the greater part of the circumference this can be done with Freer’s sharp elevator, or with the small sharp elevator employed in submucous resection of the septum. In dissecting the anterior part of the circumference the same kind of elevator can be used, but with the operating edge bent forward at an acute angle (Fig. 311). A slit in the elevated mucous membrane, posterior to the perforation, will relieve tension. With a Ballenger’s single-tine swivel septum knife a rim of cartilage is then cut away around the perforation, so that the two mucous surfaces from opposite nostrils can come in contact and overlap the circular edge of cartilage. This smooth surface will prevent any further sticking and crusting of discharge. It is kept in situ for 48 hours by vaselined cotton-wool plugs, similar to those used in the submucous resection of the septum (p. 608).

OPERATION FOR ABSCESS

A free incision is made into it, under cocaine or nitrous oxide anÆsthesia. A horizontal cut should extend right across the swelling, and as low in it as possible, to prevent the pocketing of pus. It is sufficient to make it on one side, as the pus from the other side can be pressed across through the defect in the cartilage. Any loose fragments of cartilage should be probed for and removed. The lips of the incision are kept apart by loosely tucking in a small piece of ribbon gauze. This promotes drainage of the lower part, and is changed daily. Afterwards healing takes place under simple cleansing measures.

OPERATION FOR HÆMATOMA

If the hÆmatoma be small and not in a suppurating nose, evaporating lotions are applied externally and the swelling is left alone, being carefully inspected daily for early symptoms of suppuration. If the swelling be large and tense, it is safer to incise it freely as described above for abscess of the septum.

CHAPTER IV
OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE
NOSTRILS: OPERATIONS FOR OBTAINING DIRECT ACCESS
TO THE NASAL CAVITIES AND NASO-PHARYNX

OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS

REMOVAL BY SNARE

Indications. Operation with the snare is indicated in cases of simple mucous polypi, if only a few polypi are present, and no sinus suppuration is suspected. It is a suitable method for the removal of papilloma, fibroma, and bleeding polypus of the septum. The snare is also serviceable in the removal of enchondroma, osteoma, and growths, if of limited size, after they have been detached from their bases or broken up with a chisel or bone forceps.

Instruments. The surgeon will employ the pattern of snare to which he is accustomed. The simpler models, such as those of Krause, or some modification of Blake’s instrument, such as that of Badgerow, when threaded with No. 5 piano wire will be found sufficient in most cases (Fig. 312). For tougher growths, or those with a thicker pedicle, the snare of Lack can be recommended. It is threaded with heavier wire, and by a screw arranged in the handle the loop can be slowly and steadily contracted.

Operation. The nose is carefully prepared with cocaine and adrenalin (see p. 573), remembering that any growth or polypus is itself insensitive. The anterior part of the nasal cavity, and particularly the septum, should be thoroughly anÆsthetized.

Under good illumination the snare is introduced with the loop vertical, and passed alongside the growth,—between it and the septum or to the outer side, as space permits. It is then swept round a half-circle, so as to bring any tumour within the loop, and by a to-and-fro movement the snare is worked upwards towards its base. The attachment of the ordinary mucous polypus is generally in the region of the middle meatus. The wire loop is thus threaded on to the growth or polypus. The loop is now steadily tightened until it is felt that the pedicle is grasped,—it is seldom visible. By a quick movement of avulsion the tumour is then torn from its attachment. This will bring away some of the oedematous tissue on the distal side of the loop, and there will be less tendency to recurrence than if the root were simply cut across. With the removal of a first polypus others come into view and they must be treated in the same manner. The number which can be removed at one sitting will depend on how well the patient is able to bear the manipulations and how much bleeding there is. If both nostrils be affected it is well to treat them on alternate weeks.

When the growth slips, or is pushed backwards, it can be brought forward into the field of operation by asking the patient to blow down the nose, with the opposite nostril closed. Or the presenting part of a polypus may be seized with a pair of toothed catch-forceps and the wire loop slipped over this.

If the growth be hanging backwards, and presents in the post-nasal space, as it often does when it originates from the mucosa of the maxillary antrum, it may be necessary for the surgeon to introduce his left forefinger behind the palate,—as described on p. 590 (compare Fig. 291),—so as to steady the growth and at the same time slip the wire loop around it. If there be no space for the latter manipulation, the left forefinger is used to steady the mass while a pair of polypus forceps is guided along the floor of the nose until the growth can be seized between the blades so as to tear it from its attachment and pull it out through the anterior nares.

After-treatment. The bleeding will generally cease spontaneously, assisted by cold ablutions to the face, or pinching the end of the nose until a clot forms (see p. 575). If bleeding persists, a piece of gauze, moistened with peroxide of hydrogen, should be packed in lightly and removed as soon as the patient can lie down quietly. It is best to avoid the use of any plug. It was to plugging that Luc attributed the loss of a patient from meningitis consequent on the removal of polypus.63

If the entrance to the nose be tender, it may be smeared with a little menthol and boric ointment; ice-cold cloths may be kept across the bridge of the nose; and pain or sensitiveness can be relieved by a few doses of phenacetin or some similar anti-neuralgic.

Insufflations of antiseptic powder are useless, and the nasal cavity should be left alone for 24 or 48 hours. A nose lotion should then be used two or three times a day, until the local condition is again inspected at the end of a week.

Any attempt to destroy the roots of polypi by the galvano-cautery is useless and dangerous.

REMOVAL BY FORCEPS AND CURETTES

Indications. This operation is indicated in all cases of recurring polypi and extensive caries of the ethmoid, but the plan of operation is also suitable for the removal of some cases of papilloma, fibroma, enchondroma, or osteoma.

It can also be employed in certain cases of malignant disease in the nose. When the growth appears to be limited to the nasal fossÆ, and particularly in cases of sarcoma, the above operation may be indicated. Even when glands are present this may still be the preferable operation, as glands can be removed at a separate sitting.

Possibly a better method of deciding the case of malignant intranasal disease suitable for this operation will be founded on the discovery of the original attachment of the growth. If located towards the front of the nose in the anterior part of the middle meatus, removal can be carried out on the lines described.

Contra-indications. If there be any mental symptoms suggesting that intracranial inflammation has taken place already, the patient should be carefully examined before operation is embarked on. It is unsuitable for debilitated and elderly subjects. In patients over 60 with recurrent polypi it is wiser to secure relief by a series of small operations under cocaine.

Many neoplasms and inflammatory hypertrophies, such as mucous polypi, can be removed satisfactorily per vias naturales by the method to be described. Naturally the details will vary with the situation and extent of the disease to be removed. The following description applies particularly to growths or hypertrophies springing from the ethmoidal region:—

Operation under cocaine. The nose is carefully prepared with adrenalin and cocaine, the strips of moistened ribbon gauze being carefully tucked in between the septum and the ethmoidal region, as well as between this latter and the outer wall. The inferior turbinal and the front of the nasal cavity should be similarly prepared, so as to diminish vascularity, retract the healthy tissue, and thus increase the space for operating in, while lessening the risk of wounding the septum and so causing adhesions. At least one hour should be given for the solution to act. The operation is done with the patient sitting upright in the ordinary examination chair, with the body craned forward somewhat, and the head supported and held in focus by an assistant. Ready to the surgeon’s hand should be some lengths—about a yard—of 1-inch to 2-inch ribbon gauze, and a vessel of cold sterilized water into which it is easy to shake off the growths as they are removed with the forceps.

If the middle turbinal has not already been removed it may have to be amputated, as described on p. 592. In many cases of ethmoidal caries it is easily removed with nasal forceps.

The instrument I recommend is Luc’s forceps64 (Fig. 313), supplemented by GrÜnwald’s punch-forceps (Fig. 286). The former are introduced vertically, so that one blade passes between the ethmoid and the septum and the other passes under cover of the middle turbinal. By insinuating them carefully, and gradually working them upwards and outwards, a large mass of tissue or carious ethmoid can be grasped, twisted off, and shaken from the forceps into the vessel of water. Before any marked flow of blood has taken place it will be possible to make a second or third introduction of the forceps, and seize the successive masses of growth which come into view. When the bleeding obscures the field of operation one of the strips of gauze can be picked up quickly in the forceps and used for plugging that side of the nose, while a similar operation is carried out in the opposite nasal chamber, if it is affected.

HÆmorrhage may require the plug being left in situ for a few minutes, so as to get a clear view of the depths of the nose. This is better secured if the end of the gauze strips are first soaked in either adrenalin or a 10% solution of hydrogen peroxide. In this way the main mass of the ethmoid can be completely cleared away, the posterior ethmoidal cells opened up, and the front wall of the sphenoidal sinus broken down. Not infrequently the surgeon finds afterwards that this latter cavity has been quite inadvertently, though successfully, opened.

Operation under general anÆsthesia. Under a general anÆsthetic this operation can be even more satisfactorily carried out, but the surgeon has to keep well in view the anatomical relations of the parts, and the altered relationship to the horizontal position compared with what he is more accustomed to with the patient sitting in the examination chair. When chloroform is employed the interior of the nose is prepared in the same way beforehand with adrenalin and cocaine; the patient is placed horizontal on an operating table with his head and shoulders slightly raised; the post-nasal space is plugged with a sponge (see p. 575); and the tongue is drawn forward with a clip (Fig. 314) so that the administration of the anÆsthetic through the mouth is quite uninterrupted. This method allows the surgeon to operate deliberately, generally with the hÆmorrhage under easy control, the field of operation well illuminated, and no anxiety in regard to the anÆsthetic.

The removal of polypoid ethmoid can thus be completely carried out. With this method I have removed at one sitting a mass of diseased ethmoid which weighed four ounces.65 It also permits the introduction of the operator’s little finger to some distance, so as to detect polypoid or carious surfaces.

With a ring-knife any irregular spicules or projections can be smoothed down. The ring-knife—or a Volkmann’s spoon—is carefully introduced behind a mass of growth, and then pulled briskly out through the nose while hugging its outer wall. The nasal roof should be diligently respected.

When the operation has been completed the post-nasal plug is removed, and it is well to pass the forefinger of the left hand well up into the posterior choanÆ to detect and push forwards any masses of growth which may have been driven backwards.

HÆmorrhage generally ceases with the usual remedies (see p. 576). It is better to avoid all plugs.

Dangers and complications. This operation in careless or inexperienced hands is not free from risks. The chief danger is from injury to the cribriform plate, as any damage in this area, occurring in the septic conditions which generally call for operation, is generally followed by fatal meningitis.

In addition to the usual precautions, particular attention should be paid while manoeuvring in the anterior part of the space between the septum and the outer nasal wall. Here the punch-forceps are not directed backwards against the main mass of the sphenoid, but, as the head has to be extended in order to approach the anterior area, they follow an obliquely upward direction which brings them into dangerous proximity with the floor of the cranial fossa—which dips down lower in front than it does posteriorly. Great care, therefore, is taken to avoid any thrusting or boring movements with the forceps. They are first made to press outwards as much as possible the opposing walls of this narrow region, so that polypoid masses can fall between the blades under good inspection.

Occasionally the os planum is perforated, resulting in emphysema of the eyelids or an ecchymosis like a ‘black eye’. An orbital abscess may follow (Lack).

METHODS OF OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX

LATERAL RHINOTOMY, OR MOURE’S OPERATION

Direct inspection and treatment of the deeper regions of the nose, the naso-pharynx, the ethmoidal labyrinth, and the neighbouring area of the maxillary sinus, is well secured by the following operation, which has been fully described by Moure of Bordeaux.66

Indications. This operation is particularly suitable for malignant growths originating in the upper or inner walls of the maxillary sinus, the ethmoidal labyrinth, the deeper regions of the nose, the naso-pharynx, or the sphenoid. It might be required for very vascular naso-pharyngeal fibromata with extensive prolongations. It is very suitable for necrosis—generally syphilitic—of the sphenoid when threatening the base of the brain.

For malignant growths in the regions mentioned, this route is particularly suitable, if, of course, the limitation of the growth and the absence of secondary infection justify intervention. The large space formed by throwing the nose and antrum into one cavity gives a freer field than removal of the superior maxilla, without the disfigurement and tendency to recurrence so apt to be associated with this latter operation, since it seldom includes removal of the ethmoid, which is the usual seat of origin of the disease. In Moure’s operation the functions of the eye, and of the nerves and muscles of the face, are not interfered with, nor are there those difficulties with phonation and deglutition which are left by removal of the upper jaw.

The interior of the nose is prepared with adrenalin and cocaine (see p. 572), chloroform is administered, and a sponge is packed into the naso-pharynx (see p. 575).

Operation. An incision is made from the inner border of the eyebrow, along the side of the nose, until it enters the lower margin of the nasal orifice. A second incision, starting from the same spot above, is next carried round the lower margin of the orbit and outwards as far as the malar eminence (Fig. 315).

The lobule of the nose is then detached, so that the fleshy parts of the nose can be thrown over to the opposite side, while a triangular flap is turned downwards and outwards. With a raspatory the nasal process of the frontal bone, the nasal bone, the ascending process of the superior maxilla, and the canine fossa are next exposed. The lachrymal sac is carefully defined and retracted. A chisel is first driven through the superior maxilla, close to its junction with the malar bone, but avoiding the infra-orbital nerve, and the section is carried downwards across the canine fossa until it reaches the alveolar border (Fig. 316). From the lower extremity of this incision—which of course enters the maxillary sinus—the bone which separates it from the pyriform fossa is broken through with stout forceps. In this way the antro-nasal wall is detached close to the floor of the nose, and can be removed together with the inferior turbinal. The nasal bone itself is next removed, together with part of the lachrymal bone and the nasal process of the frontal. Finally the middle turbinal and lateral mass of the ethmoid are removed with punch-forceps (GrÜnwald’s or Luc’s), Volkmann’s sharp spoons, or a ring-knife.

A gouge, or Killian’s eye protector (Fig. 342), is then slipped inwards and downwards at the upper part of this opening until it comes in contact with the body of the sphenoid. An assistant holds it closely parallel to the cribriform plate, where it acts as a protector. With a large sharp spoon, acting from above downwards and forwards, the ethmoidal labyrinth can be cleared away with any tumour which may have infiltrated it. The os planum, if not already destroyed, can be removed, so as to obtain access to the orbit. Direct approach is given to the sphenoidal sinus. The septum can be readily resected, but an endeavour should always be made to preserve a strip of cartilage under the bridge of the nose to prevent any external deformity (see p. 609). It is needless to say that great care must be taken while working close to the cribriform plate.

A malignant tumour can then be removed with forceps, sharp spoons, and the fingers, any prolongations being followed into the naso-pharynx, the maxillary sinus, the sphenoidal sinus, the lateral mass of the ethmoid, or even into the pterygo-maxillary fossa. Success largely depends on the care with which this curettage is carried out. It should be followed by the application of caustics or Paquelin’s cautery.

Bleeding is generally abundant at first. It can be controlled with tampons and the use of hydrogen peroxide. When the whole of the malignant growth has been removed, hÆmorrhage generally stops spontaneously. Firm packing of the wound is therefore unnecessary and is best avoided. The large cavity is filled with one long strip of 1-inch ribbon gauze, which is left projecting from the nostril, and the skin incisions are carefully brought together with silkworm-gut sutures. Healing takes place by first intention. There may be a little flattening of the side of the nose, but there is no disfigurement, and a few months afterwards it is difficult to detect any trace of the operation. The strip of gauze is removed in 24 to 48 hours, and simple intranasal cleansing measures are then instituted (see p. 579).

ROUGE’S OPERATION (SUBLABIAL RHINOTOMY)

No special instruments are required for this operation. Full illumination—with a Clar’s mirror or frontal search-light (see p. 571)—is particularly necessary.

In addition to the usual preparations, the mouth, teeth, and gums should be purified as much as possible beforehand.

General anÆsthesia, preferably with chloroform, is required.

Indications. With the progress of rhinology the occasions for invading the nasal chambers otherwise than by the natural orifices have steadily diminished. Rouge’s operation was formerly employed in dealing with deformities of the septum, in the treatment of ozoena, in lupus of the nose, for the removal of simple mucous polypi, in operations on naso-pharyngeal fibromata, or as a simple method of exploration. In all these circumstances it is now uncalled for, as we are possessed of simpler, safer, and more effective methods.

In more modern times it has been advocated as a route of approach to the accessory cavities of the nose by some authors, but this proposition has not met with general support.

The chief indications for Rouge’s operation are as follows:—

1. Very large sequestra. The majority of syphilitic sequestra can be removed through the natural orifice. In some cases they can be broken up after being mobilized and then removed through the nostrils. If still impossible of extraction Rouge’s operation is indicated.

2. Osteomata are sometimes too large to be extracted through the natural orifice, and as they are much too hard to break up in situ, this operation is clearly indicated.

3. Malignant growths.

Operation. Standing behind the head of the patient, an assistant seizes the extremities of the upper lip between the forefinger and thumb of each hand, so as to turn it up against the nostrils and present its mucous surface. A small packet of loose gauze is placed at each corner of the mouth, to be handy for stanching any bleeding. An incision is then made across the gum, a little below the gingivo-labial fold, from the first upper molar on one side to the other (Fig. 318). This is carried right down to the bone.

With a raspatory the soft parts can be easily and rapidly separated up, so as to bring the orifice of each nasal chamber into view. With a pair of scissors curved on the flat the cartilage of the septum is next detached from the nasal maxillary spine, or the latter can be detached with a chisel and hammer (Fig. 319). The assistant is now able to pull the everted lip with the fleshy parts of the nose further up on to the face, fully exposing the pyriform orifice of the nasal chambers, with part of the anterior wall of the superior maxilla exposed on each side.

The conditions met with are then dealt with as required. HÆmorrhage gives little trouble, and can generally be checked by pressure with strips of gauze, possibly supplemented by the use of peroxide of hydrogen. When the operation has been completed the everted lip is turned down, and falls into place, where it can be secured by a few catgut sutures.

After-treatment. Two pads of cotton-wool over the upper lip, to right and left of the nasal openings, will give relief and secure healing of the wound by first intention. The mouth should be kept as clean as possible, and cleansing measures to the nasal chambers will be required in proportion to the amount of destruction of its self-cleansing mucous membrane.

Advantages. This operation has several advantages:—

(a) It is not difficult of execution, and can be carried out with a scalpel and a raspatory.

(b) It gives a free access to the floor of the nose and the anterior part of the nasal fossÆ. The vestibule, the natural orifice of the nose, only measures 20 millimetres by 7 to 8 millimetres. Rouge’s operation exposes an orifice measuring 3½ centimetres by 2 centimetres. The posterior margin of the septum, instead of being 8 centimetres distant from the outside, is now brought within a reach of 5 centimetres. The floor of the nose lies on a lower level than that of the vestibular entrance, and is wider some distance in than it is at the orifice. By means of this operation the whole floor comes into clear view, and the exit from the nasal chambers becomes the widest part of the nose.

(c) The bones of the face are not interfered with, and the amount of traumatism is slight.

(d) Bleeding, which is so apt to be troublesome in operations through the skin of the face, is less and is easily controlled.

(e) The patient can be assured that there will not only be no disfigurement, but not even the slightest scar on the face.

(f) The operation can be repeated without any disfiguring scars. In operations upon the nose through the face the cicatrix becomes more marked with each intervention.

COMBINATION OF MOURE’S AND ROUGE’S OPERATIONS

The two methods above described can be combined if necessary. This would be called for particularly in growths so large that they could not be attacked through the narrow vestibule of the nose, and for those in which the attachment is evidently in the ethmoidal region. This combination might be called for in any large innocent or malignant growth.

EXTENSION OF ROUGE’S OPERATION TO ALLOW OF ACCESS TO THE MAXILLARY ANTRUM

When the growth involves both the nasal cavity and the maxillary sinus Rouge’s operation can be extended so as to form part of the Caldwell-Luc operation (see p. 631).

The latter operation is modified as suggested by Denker (Fig. 332), i.e. the opening through the canine fossa is extended forwards until the nasal cavity is opened through the pyriform opening. This will give free access to the large cavity formed by throwing the antrum and the nasal chamber on the same side into one easily inspected space (Fig. 332). HÆmorrhage gives no cause for anxiety, there is no disfigurement, the original root of the implantation can be eradicated, and, if necessary, the operation can be repeated without difficulty. If the growth extends upwards and inwards to the ethmoidal region this infralabial opening can be combined with Moure’s operation.

Indications. This operation is suitable for any form of growth invading both the antrum and nasal cavities, and is therefore generally called for in malignant growths.

OTHER METHODS

The other methods for obtaining access to the nasal cavity through the face—described as the methods of Hippocrates, Syme, Dupuytren, Langenbeck, Lawrence, Ollier, &c.—are now only of historical interest. They all leave a scar on the face; bleeding is troublesome; they do not give a greatly enlarged field; and most of them do not bring the seat of disease any closer. With the advances made by rhinology the necessity for intervention through the face has become more infrequent.

CHAPTER V
OPERATIONS UPON THE ACCESSORY NASAL SINUSES

OPERATIONS UPON THE MAXILLARY SINUS

CATHETERIZING THE MAXILLARY SINUS

It is rarely possible to enter the antrum through its natural ostium. The attempt may be made after the local use of cocaine and adrenalin (Fig. 320).

Indications. It is chiefly employed as a diagnostic test. As a curative measure it is seldom successful except in comparatively recent infection. If the case be uncomplicated by suppuration in other cavities, if the teeth in the upper jaw on the same side be intact, and if the patient be anxious to avoid more severe measures and be willing to undergo the discomfort of a daily puncture, lavage has been reported as successful when repeated 27 times, even in a case with a history of 17 years’ duration.67 But under the circumstances just mentioned it is wiser to recommend the establishment of an antro-nasal communication (see p. 637).

Operation. This is done under local anÆsthesia from the inferior meatus. One pledget of cotton-wool, soaked in cocaine and adrenalin, is carefully tucked under the inferior turbinal on the affected side, and another is applied to the septum. At the end of 20 minutes a straight Lichtwitz’s or curved Moritz Schmidt’s (Fig. 321) hollow needle is passed under the inferior turbinal and introduced upwards and outwards as near as possible to the centre of its attachment. The handle of the needle is tilted against the cartilaginous septum, while the point is directed towards the malar eminence. When it is felt to encounter the thin, membranous part of the antro-nasal wall it is easily thrust through (Fig. 322).

While the nasal cavity is kept under inspection, air is blown through the needle, and any secretion can be observed escaping from under the centre of the middle turbinal. This douche of air is then followed by an irrigation of warm normal saline solution. In an acute case this lavage can be repeated daily until the symptoms of tension are relieved, or until the secretion begins to escape spontaneously.68

Puncturing the maxillary sinus from the middle meatus incurs a greater risk of striking the orbit and is not so likely to reveal a small amount of thick secretion on the floor of the cavity.

PUNCTURING THE MAXILLARY SINUS FROM THE ALVEOLAR MARGIN

This is one of the oldest methods of drainage. It is less frequently employed nowadays, partly because carious teeth and empty sockets are not so commonly met with, and partly because the results have not proved very satisfactory.

Indications. The operation is useful as a diagnostic or palliative measure. In cases of unilateral multi-sinusitis, if a suitable tooth socket be available, the alveolar operation serves both to determine the condition of the maxillary sinus and to establish drainage, while the other cavities are being investigated or treated. In patients who are too old or feeble to endure more radical measures, or who decline them, the obturator may be left in indefinitely. In that case, if the neighbouring teeth be intact, a solid gold plug should be fitted to the denture bearing the false first molar. During the night this is exchanged for the soft rubber plug. If several teeth be missing it is more comfortable to have the obturator and denture separate—the latter being made with a setting to receive the flange.

An anÆsthetic should always be given. Nitrous oxide gas or chloride of ethyl are generally recommended for this short operation, but in cases that present any difficulty it is better to follow the nitrous oxide with ether, or the chloride of ethyl with chloroform.

Operation. The most suitable tooth socket is that of the first molar, but if this be not available, that of the second bicuspid or second molar may be employed. If a tooth in one of those situations be carious, or be suspected as the cause of the sinusitis, its extraction and the drilling of the alveolus may be carried out under the same anÆsthetic. The patient can be recumbent on an operating table, or lying back in a dentist’s chair. A small antrum drill (Fig. 323) is grasped in the hand as a bradawl is held, with the forefinger lying along it to within 1 to 1½ inches from the end, where it acts as a stop to prevent the instrument from plunging too deeply into the sinus. The drill is held vertically against the alveolar border, and with a few quick, rotatory thrusts is pushed into the cavity. The inner of the tooth sockets is selected. If required, the hole can be enlarged by a similar instrument of a larger bore. A plug, which fits firmly into the opening, is introduced, and nothing further is required for that day. A solid vulcanite obturator is recommended. It should be left in situ for two or three days, when it is removed to allow of the cavity being syringed through, and is then replaced by a solid, soft rubber plug, of a somewhat smaller diameter (Fig. 324). The vulcanite obturator is better for establishing the canal; if removed too soon it may be difficult to replace it, and manipulation may set up severe neuralgia. A small size—No. 6 or 7—is quite sufficient.

At the end of two or three days lavage of the cavity is gradually instituted. A pint of warm sterile normal saline solution is sent through the cavity by a Higginson’s syringe, fitted with a suitable nozzle (Fig. 325). As the stream issues from the nose it is received in a black vulcanite tray, which readily demonstrates the colour, quality, and quantity of antral secretion (Fig. 326). When the pint of liquid is finished, air is blown through, so as to leave the sinus as dry as possible. The patient should be advised to replace the rubber obturator, properly cleaned and purified, as soon as possible. If this be neglected—for even as short a time as 5 minutes—the soft tissues may obstruct the channel so as to render the reintroduction painful and perhaps impossible. Another useful warning is not to wear a plug so long as to allow of the flanges being worn away, and so risk the penetration of the rubber tube into the cavity.

The syringing should at first be daily, even twice a day if necessary, and then gradually diminished in frequency, until after the lapse of a week it is found that the maxillary sinus is quite free of any pus or flocculent mucus. By changing the obturator daily the patient can readily tell whether a washing out is required. When three to six months have passed without any trace of secretion, the empyema may be considered cured. This is the more likely if a formerly obscure sinus becomes translucent, and if the patient passes through a ‘cold’ without suppuration beginning in it again. A trifling amount of discharge is sometimes kept up by the mere presence of the obturator.

If the saline solution fails to arrest the discharge permanently, I have rarely found that any other lotion is more effective. Strong antiseptic solutions are too irritating; milder ones, like boric lotion, permanganate of potash, weak mercurial lotions, &c., are without effect. If the discharge remain thick and offensive, peroxide of hydrogen may be added to the salt solution in the proportion of 2 vols. %. As an astringent, sulphate or chloride of zinc may be tried, in the proportion of 1 grain to the ounce; or the cavity may occasionally be washed out with a 2% solution of argyrol or nitrate of silver.

In cases where a cure has been obtained, the obturator is first discontinued during the night and is then exchanged for one of smaller size. The opening in nearly all cases will close spontaneously. Occasionally the track may be stimulated with nitrate of silver, pure carbolic acid, or a small curette.

Results. This method of treatment is only curative in uncomplicated cases limited strictly to the maxillary sinus. If all suppuration has not disappeared before the end of three months, a complete cure is not to be expected by persevering longer.

OPERATION THROUGH THE CANINE FOSSA ONLY

Desault’s operation. Previously to the introduction of the Caldwell-Luc operation it was customary to make an opening into the maxillary sinus from the canine fossa, and to curette, drain, pack, and carry out all subsequent treatment through the buccal orifice. The reinfection of the cavity from the mouth was, of course, inevitable: the treatment was prolonged and unpleasant: and the results were so unsatisfactory that the method has now been abandoned in favour of one or other of the operations to be described.

THE CALDWELL-LUC RADICAL OPERATION

Indications. This is the favourite operation in well-marked chronic empyema of the antrum.

The mouth, teeth, and gums are purified as thoroughly as possible. The face, with any moustache or beard, should also be well cleansed. The nose on the affected side is prepared with cocaine and adrenalin (see p. 572).

On the Continent this operation is sometimes carried out under local anÆsthesia, but chloroform is generally employed. When the patient is unconscious, a sponge is packed in the post-nasal space (see p. 575), the tongue is drawn forward with a tongue clip (Fig. 314), and the chloroform administered from a Junker’s apparatus.

Operation. The surgeon, armed as usual with a forehead electric search-light or Clar’s mirror (Figs. 282, 283), stands on the affected side. In addition to the post-nasal sponge, another is inserted far back between the molars on the side to be operated. This cheek sponge prevents any blood from running down into the pharynx and requires changing frequently.

The cheek being well retracted by an assistant, an incision is made half a centimetre below the gingivo-labial fold, extending from the first molar to the canine tooth (Fig. 327). It is carried down to the bone, so that the muco-periosteum can quickly be separated upwards, exposing the canine fossa. With hammer and chisel a circular piece of the wall is then cut through, measuring about half an inch across, and the opening is enlarged with bone-forceps or burr sufficiently to admit the surgeon’s little finger.

The first opening of the sinus is frequently accompanied by free bleeding. This soon ceases, particularly if the cavity is packed for a little while with a strip of 2-inch ribbon gauze. During the operation, pieces of this gauze, 1 to 1½ yards long, prove very useful in checking any oozing and allowing a clear inspection of the walls of the sinus. They may be dipped in adrenalin, or, if the bleeding is sharp, in a 10% solution of peroxide of hydrogen, and left in place for a few minutes, while iced water is freely applied to the face and neck. As soon as the bony wall has been removed, the diseased mucous membrane presents in the opening in irregular, polypoid, bluish-greyish masses, bathed in pus which may be highly foetid. The diseased mucous membrane should be carefully plucked out of the cavity with a pair of GrÜnwald’s forceps, supplemented by the use of a small ring curette, and guided by the eye and the touch of the operator’s little finger. Some surgeons recommend that the whole mucous lining of the sinus be carefully and completely removed, and the walls scraped down until they are white and bare. Unless the whole mucosa is diseased, this hardly seems necessary, particularly if a free opening be made into the nose. Polypoid masses and degenerate mucous membrane are chiefly met with on the floor of the antrum (in the crevices between the cusps of the teeth), on the inner wall in the neighbourhood of the ethmoid, and in the recess in the malar region, and it is to these areas that attention should be directed.

The next step is the making of a free communication with the nose. If the inferior turbinal is hypertrophied on the affected side, or comes so low as to obstruct any access to the antro-nasal wall, its anterior extremity should first be removed (see p. 587 and Fig. 289). It is better to have done this a few weeks previously under cocaine. The antro-nasal wall lying below the attachment of the inferior turbinal is next attacked with a chisel, hammer, and punch-forceps (Fig. 330). This can be done from the antral aspect, but I have always found it useful to break it through first from the nose with Krause’s curved trochar and canula. When the end of this makes its appearance in the sinus, it forms a useful landmark (Fig. 329).

This antro-nasal opening should be made as large as possible, particular care being taken to bring it well forward and to smooth down the remains of the ridge separating the nose from the sinus. The opening should allow of the surgeon’s little finger passing freely from the antrum into the floor of the nose, and vice versa (Fig. 328).

Whenever the ethmoid is diseased, as it often is in maxillary sinusitis, that part of it which bounds the inner antral walls should be punched away. The middle turbinal, in that case, will probably have been already removed.

Some surgeons recommend that the infected corners of the antrum be now wiped out with a solution of chloride of zinc (40 grains to ?j), and the cavity packed with a strip of gauze which is led out through the nostril, whence it is removed at the end of 24 to 48 hours. The use of this irritant seems inadvisable. The sinus may be syringed out with warm saline solution, and temporarily packed with a long strip of iodoform gauze, while the operation is being completed. The wound in the cheek can be closed with a couple of catgut sutures; but if there has been no destruction of the bony alveolus, this is unnecessary: the soft parts will fall into natural and complete apposition. The post-nasal sponge is removed, the iodoform ribbon gauze is withdrawn through the nostril, and the patient is put back to bed with the affected side uppermost.

After-treatment. A large pad of cotton-wool, bound firmly to the cheek over the region of the canine fossa, will relieve pain and help to keep the edges of the wound together. Nourishment should be fluid for the first three days, and taken from a feeding-cup from the opposite corner of the mouth. As a rule, there is no reaction, and the temperature seldom rises above 100° F. A little puffiness below the orbit will soon subside, and pain is relieved by a few doses of phenacetin, aspirin, pyramidon, or some similar anti-neuralgic. The patient is frequently up and out in a few days.

As a rule, the less the local after-treatment the better. The nose may require to be cleansed with the usual alkaline lotion (see p. 579). If secretion hangs about the antro-nasal opening, or collects in the cavity, the latter should be washed out once or twice daily until it ceases. A short length (4½ in.), but large bore, silver Eustachian catheter is passed from the nose into the maxillary sinus, and a pint of warm saline solution is sent through it with a Higginson’s syringe. The patient soon learns to do this for himself, and it may have to be continued for a few weeks. If the discharge persists, the cavity may be painted over with a solution of nitrate of silver, or a strip of ribbon gauze can be moistened with argyrol solution (25%) and passed through the antro-nasal opening into the sinus, where it is left for a few hours.

Results. In cases of chronic empyema of the maxillary sinus this operation is very successful. Failure may be due to overlooking stumps of teeth within the cavity, and from leaving detached pieces of the carious wall within it. If the pyogenic polypoid mucous membrane be not carefully removed, suppuration may persist. The corner which is difficult to reach is the acute anterior one. At the same time, an unnecessary denudation of the cavity will delay healing, and the scar tissue which more or less occupies the sinus will then tend to be irregular and dry, instead of being smooth and moist. Removal of too much of the inferior turbinal is apt to induce a scabby condition.

But persistence of nasal suppuration after this operation is generally found to be due to overlooked disease in some other sinus. The ethmoid is so frequently affected that it should always be carefully explored, and treated either before or at the time of the operation upon the maxillary sinus. Any suspicious-looking cells can be cleared away under cocaine during convalescence. Suppuration in the frontal sinus will have generally been excluded beforehand. It is perhaps more common for reinfection from the sphenoidal sinus to be overlooked.

Dangers. Operation upon this sinus is generally regarded as quite free from the risk of cerebral infection. This undeniably is so, when the antral empyema is uncomplicated by suppuration in other cavities, but the operation is not free from risk if they are also infected. An operation upon one maxillary sinus has been known, even in the most skilful hands, to cause death by meningitis or diffuse septic osteomyelitis of the cranium. Post-mortem examinations show that this disaster was due to infection spreading upwards from an infected ethmoid, frontal, or sphenoidal sinus, when local resistance had been diminished, or the virulence of the organisms has been increased by the surgical traumatism of the maxillary sinus.

Such risks are best avoided by determining the condition of all the sinuses before commencing treatment of nasal suppuration. If a tooth socket be available, the maxillary sinus should first be drained through it, so as to diminish the septic intensity of the affection. The ethmoid region, if diseased, is next treated (see p. 615). The sphenoidal orifice should be enlarged if that cavity be diseased, and the frontal sinus, if suppurating, should be operated on before the maxillary. If no tooth socket be available, both frontal and maxillary sinuses can be operated upon at the same sitting. Plugs are best avoided; communication should be made as free as possible; stitches need not be employed; and everything should be done to avoid retention and secure free drainage.

Modification. In the above operation the region which generally requires to be denuded of mucous membrane is the rough floor—the irregular surface lying over the cusps of the teeth. The ridge of the antro-nasal opening is a situation in which secretion is apt to lodge and dry into scabs. To overcome this drawback it has been suggested by BÖnninghaus that the muco-perichondrium of the outer part of the nasal floor and the interior surface of the antro-nasal wall should be carefully preserved in the form of a flap which is then laid down over this bare area, and fixed there by a stitch and packing.

Another drawback of the Caldwell-Luc operation is that, although inspection and treatment of the greater part of the maxillary sinus is secured, still there are two corners which are not well exposed. They are both on the floor of the antrum, the round posterior corner and the narrow acute corner in front. The antro-nasal wall corresponding to these two situations is not removed, and hence the corners are apt to escape inspection at the time of the operation and free drainage afterwards.

To avoid this Denker has proposed that the opening in the canine fossa should be carried forward into the nose, and the opening in the antro-nasal wall extended forwards to meet it. This allows of much more complete inspection and treatment of the sinus cavity, and abolishes the anterior angle. The flap of muco-perichondrium proposed by BÖnninghaus can also be much more easily manipulated. It is said that there is no fear of disfigurement from the cheek falling in (Fig. 332).

DRAINAGE THROUGH THE NASAL WALL ONLY

It was long ago proposed by John Hunter, and later by Mikulicz and Krause, that an opening should be made into the maxillary sinus from the nose. This operation has latterly been developed by ClaouÉ and RÉthi, and now has many supporters.

Operation. On the Continent it is frequently carried out under local anÆsthesia, but chloroform is generally required. If the inferior turbinal comes down close to the floor of the nose, the anterior third or half should be removed (see p. 587 and Fig. 289). The antro-nasal wall lying below the attachment of the inferior turbinal is then broken through with chisel and hammer, or a Krause’s trochar (Fig. 285), and the opening enlarged with punch-forceps (Fig. 286). For the anterior margin of the opening—the one most difficult to remove—special forceps which cut forwards have been designed (Fig. 330).

The opening is large enough to allow the introduction of curettes and of the application of treatment from the nose. The patient soon learns to wash out the sinus for himself, with a silver Eustachian catheter and Higginson’s syringe, as after the Caldwell-Luc operation.

Results. The advantages claimed for this operation are that it is simple, quicker, and as effective as the one with the opening from the canine fossa. But, of course, it does not allow any inspection, and only a partial removal, of the diseased contents of the sinus.

Still the results obtained are so satisfactory,69 that it seems advisable to try it in the majority of cases as a necessary first step, even if the Caldwell-Luc operation has to be completed later. But where the case has a long history; marked obscurity on transillumination; a foreign body in the sinus; or where the Streptococcus pyogenes is the virulent organism, or where the streptococcus is associated with the presence of squamous epithelium and lymphocytes,70 it adds little to the gravity or complexity of the procedure if the canine fossa be opened at the same time, the diseased cavity inspected, and everything completed under the one anÆsthesia.

OPERATIONS UPON THE FRONTAL SINUS

CATHETERIZING AND WASHING OUT THE FRONTAL SINUS

Indications. This method is indicated—

(i) As a first step in diagnosis and treatment.

(ii) To diminish the risk of retention and decrease virulence in those patients where an external operation is not indicated or is declined.

(iii) It is rarely required for acute frontal sinusitis, although it might be used in acute exacerbation of a chronic suppuration.

Operation. It is very seldom that it is possible to sound a frontal sinus, unless the anterior ethmoidal cells have been broken down by disease. When this has occurred—or when the anterior extremity of the middle turbinal has been removed, as described on p. 592—the anterior region of the middle meatus is well anÆsthetized. Under good illumination a thin silver canula is then introduced until it reaches the middle meatus with its beak lying below and in front of the bulla ethmoidalis. By depressing the hand the point of the instrument is then directed upwards, forwards, and slightly outwards, until it slips into the frontal cavity (Fig. 333). No force should be employed. The end of the catheter is bent to suit the conditions met with. A bead of pus exuding from the hiatus semilunaris will often serve as a useful guide. If there be any uncertainty as to the catheter having entered the frontal sinus, its exact situation can be determined by the RÖntgen rays (Figs. 334, 335).

A Politzer’s inflation bag is now connected with the end of the frontal canula, and air is blown through it. This will be heard gurgling through the sinus, and if the anterior region of the middle meatus is at the same time kept under observation, thick mucus or pus will be seen to be driven out by it. The Politzer’s bag is then replaced by a syringe, and a pint of warm sterile normal saline solution (?j to Oj) is sent into the sinus, and as it returns is received in a black vulcanite tray. The latter readily shows up the presence of any flakes of mucus or pellets of pus. If successful, the above proceeding can be repeated twice daily.

When the cavity can be catheterized from the nose it should be washed out daily with liquids similar to those indicated for suppuration in the maxillary antrum (see p. 630).

Results. I am very doubtful if a permanent cure is ever effected by this treatment in a case of established chronic suppuration. In a case in which I was certain that the suppuration was not of more than four months’ duration intranasal treatment was a failure, although carried out most carefully on 44 successive days.71

The cause is very apparent whenever these sinuses come to be opened; the cavity itself is generally stuffed with fungating mucosa, and the fronto-ethmoidal cells—where the lavage never penetrates—are affected in the same way.

OPENING THE FRONTAL SINUS IN ACUTE SUPPURATION

It is rare for this to be necessary. The contents of the cavity generally make their way through the natural ostium, before any of the bony walls give way. Still, the posterior (cerebral) wall may yield, giving rise to meningitis or cerebral abscess. The treatment of this complication is given on p. 650. The orbital wall may be penetrated, with the formation of an orbital abscess which should be evacuated. It is most uncommon of all for the anterior wall to give way. When this does occur the abscess should be opened through an incision designed on the principle given later on for chronic empyema (see p. 652).

KILLIAN’S OPERATION

At the present time the Killian operation is the one most generally employed.

Indications. The indications for this operation are thus given by Killian himself:—

1. Failure of other operations.

2. Presence of fistula or abscess, or indications of necrosis.

3. Symptoms of intracranial complications.

4. When in a case of chronic purulent frontal sinusitis there is pain and fever with a foetid discharge.

5. Persistent headache, particularly when associated with discomfort in the region of the eye, and not relieved by intranasal treatment.

6. When the discharge from the sinus remains foul, in spite of repeated irrigations.

7. When recurring groups of polypi are produced by the suppuration in the frontal and ethmoidal cells.

8. When a simple purulent discharge is not relieved by careful intranasal treatment, and the patient desires permanent relief by radical operation.

A radiograph is taken and is an extremely useful help to indicate the size and extent of the frontal sinus, and to prepare the surgeon for meeting with troublesome orbito-ethmoidal cells.

As the ethmoid is diseased in nearly all cases it should be cleared away at previous sittings, under cocaine or chloroform (see p. 615). Even when healthy, the anterior extremity of the middle turbinal should be amputated (see p. 592). If the antrum be also suppurating and a suitable tooth socket be available, the alveolus will have been drilled at one of these preliminary treatments. If the sphenoidal sinus be suppurating, its orifice will have been enlarged.

One hour before the operation the strips of ribbon gauze, soaked in adrenalin with the addition of 5% cocaine, are carefully laid all over the mucous membrane of the nose on the affected side. The face, moustache, and beard are well purified. When the patient is under chloroform three pencils of tightly rolled cotton-wool are introduced into the nose; one along the middle meatus, a second in front of the inferior turbinal upwards towards the bridge of the nose, and the third in the inferior meatus. The first two pledgets are useful afterwards for anatomical definition, and the third keeps them in place. A sponge is inserted in the post-nasal space (see p. 575).

Operation. There is no advantage in shaving off the eyebrow. It can be thoroughly purified and helps to locate the skin incision; if removed, it takes some time to grow again, and is apt not to correspond in size with the eyebrow of the opposite side. The skin incision is first defined by scratching through the cutis with the tip of the knife. It starts at the outer end of the eyebrow, passes inwards along the very centre of the eyebrow itself, and then sweeps downwards and outwards over the side of the nose, to end on the cheek (Fig. 336). When the whole extent has been marked out three or four cross scratches are made. The object of this is to ensure correct coaptation of the flaps, and to avoid any risk of disfigurement. Returning to the outer extremity of the incision, it is now carried down through all the soft tissues till it meets the periosteum. The flaps are retracted a little upwards and downwards, while the free hÆmorrhage is met with pressure forceps. The periosteum incisions are now carefully planned. Starting again from the outer corner the knife is drawn inwards parallel to, and slightly above, the upper margin of the supra-orbital arch; but, instead of curving round the inner end of the orbit, in the track of the skin incision, it is kept straight along under the upper flap to end over the glabella. The periosteum can now be reflected from the front of the sinus, and pushed upwards with the skin on to the forehead. The lower skin flap is detached and retracted downwards, until the inner third of the supra-orbital arch is defined. The periosteal covering is next cut through by carrying the knife along the lower border, but instead of passing inwards parallel to the first periosteal incision this second one sweeps down on to the side of the nose, in the track formed by the skin incision (Fig. 337).

The periosteum is carefully peeled off the nasal process of the superior maxilla, and turned down from the inner third of the supra-orbital arch, exposing a triangular area of bone. The periosteum must be carefully preserved over the inner part, to avoid the risk of necrosis of the arch, which is converted into a bridge, the ‘Killian bridge’, by the opening in bone below and above it.

The upper flap of soft parts, with the periosteum, is well retracted up on to the forehead. The radiograph will have given an idea of the extent to which the front wall of the sinus must be laid bare. With a chisel and hammer the sinus is opened at its inner extremity. A good plan is to employ Killian’s triangular curved chisel (Fig. 339) and to cut a trench in the bone along the upper margin of the bridge. This trench is gradually deepened at the inner end until the sinus is entered. The entry is generally announced by the bulging upwards of the blue, polypoid, pyogenic membrane into which the thin white delicate mucosa of the cavity has been converted. The anterior wall is now completely removed with hammer, chisel, and forceps. Those of Lombard, Horsley, Hajek (Fig. 341), Jansen, Citelli (Fig. 340), or similar models enable us to bevel down the margins of the cavity carefully as it slopes up on to the forehead.

The pyogenic membrane is now carefully plucked away with a pair of GrÜnwald’s forceps. I never find it necessary to curette the cavity, which must always be a risky proceeding. Small pledgets of ribbon gauze, if gently rubbed along the surface and into the corners, will detach every scrap of diseased mucosa.

The septum separating the two frontal sinuses may be found to be defective. The opening through the eyebrow on one side may open into a cavity which communicates only with the nasal cavity of the opposite side—one sinus being very large and extending far beyond the middle line, while the other is quite small. Or only one frontal cavity may be present. An extensive acquaintance with the surgical anatomy of the region is required to prepare the surgeon for encountering these and other irregularities, and the systematic use of radiography will prevent him from being taken by surprise.

The next step is to make the opening below the bridge. The exposed surface of the nasal process of the superior maxilla is cut through with the triangular chisel. The opening is enlarged with bone-forceps until free access is obtained to the anterior ethmoidal cells. The pledgets of cotton-wool placed in the nose at the beginning of the operation now come in to help as guides. The periosteum is further elevated from the lachrymal bone above its groove, from the orbital plate of the ethmoid as far back as the anterior ethmoidal vessels, and from the orbital plate of the frontal bone below the bridge and extending outwards to the trochlear attachment and the supra-orbital notch. During this proceeding the contents of the orbit are protected from pressure by several folds of gauze, and are carefully retracted outwards by Killian’s protector. The area of bone which can now be clipped away comprises parts of the lachrymal, of the lamina papyracea, and of the floor of the frontal sinus. The whole of the floor of the sinus must be removed, either from above the bridge or from below. If this cannot be done without anxiety as regards the attachment of the pulley of the superior oblique, it is better to risk this than to leave pus-secreting pockets of orbito-ethmoidal cells cut off from drainage in the roof of the orbit. But the pulley of the superior oblique should never be divided from its attachment to the rim of the orbit. It is much safer to reflect the periosteum further outwards and downwards from the lower border of the Killian bridge. In doing this the pulley of the superior oblique is detached with it; any diplopia, most noticeable on looking downwards and outwards, is generally temporary; and as a rule it will disappear when the swelling subsides and the periosteum gets back to its anchorage (Fig. 342).

It is this part of the operation which is the most delicate, tedious, and important. It is very common to meet with irregularities. The orbital recess of the frontal sinus itself may run back in the roof of the orbit nearly as far as the foramen opticum. One or two galleries may be met with in the roof of the orbit—prolongations of orbito-ethmoidal cells—passing outwards as far as the temporal end of the eyebrow. Their presence can only be revealed after removal of the floor of the frontal sinus proper, and in this way two or three bony dissepiments may have to be removed before the orbital fat arises, as it should do, to occupy the lower part of the exposed frontal sinus. In this part of the operation much help is obtained by the careful use of a probe, by frequently securing a field free from bleeding by pressure with adrenalin or peroxide, and by the knowledge previously gained by skiagraphy.

If the RÖntgen rays have shown that the frontal sinus does not extend above the level of the bridge, or if radiography be not available and there is any uncertainty as to the extent of the cavity, this lower opening should be made first.

In the inner part of the large orifice which has been made below the bridge the deeper ethmoid cells can be treated, and the sphenoidal ostium is much nearer than when viewed from the introitus narium, so that it is easy to enlarge it and deal with the contents.

Now, as throughout the operation, great care must be taken to shield the eyeball with gauze pads and the protector. The hanging pressure forceps are apt to be pushed against the globe.

The whole area of operation is next carefully cleaned with warm normal saline solution. Any projecting corners or loose spicules of bone are removed. If any point of pus should show up it must be carefully followed to its source. The cotton-wool pledgets are removed from the nose. The pressure forceps are twisted off, and any vessels that require it are ligatured. A strip of ribbon gauze is loosely packed in the lower part of the enlarged fronto-ethmoidal space, and the end is led down to the nasal orifice. The flaps are brought together, and care is taken that the reflected periosteum is pulled back with them. Formerly Killian in the majority of cases used to sew up the whole wound at once. He now agrees that it is safer to leave the external angle with a small drainage tube running inwards and downwards to the area of the fronto-ethmoidal cells. The inner part of the incision in the eyebrow, and all the part lying below the bridge, can be closed. Killian employs aluminium-bronze wire, and a metal suture seems preferable, as the contamination of the wound edges makes stitch-abscess not uncommon.

Secondary suture—on the second or third day—is reserved by Killian for cases when (1) the history or appearance of the mucosa indicates a recent exacerbation, (2) there is a history of erysipelas, (3) the pus is very foetid, (4) there is any history of a tendency to wound complications, or (5) there is marked invasion of the diploË in the frontal bone.

Double cyanide gauze, rung out of boric lotion and covered with a good supporting pad of cotton-wool, is then put on. But when there is any question of intracranial complication, when the pus is foetid or there is any necrosis, and when the surgeon is forced to operate during an acute exacerbation, it is better to apply warm boric fomentations and leave the upper and outer supra-orbital part of the incision freely open.

After-treatment. The patient is put to bed on the sound side, so as to assist drainage. He is advised not to blow the nose, but to hawk as much of the secretion as possible backwards and then expectorate it. The gauze drain is removed from the nose at the end of twenty-four hours, and is not renewed. The drainage tube at the temporal end of the incision is changed at the end of forty-eight hours, and afterwards is removed and cleansed daily. The dressing is also changed daily, after the first forty-eight hours, so as to keep a careful watch for any retention. On the fifth day the sutures can be removed, and soon afterwards the dressing can be discontinued and the eye left uncovered. Intranasal treatment should be avoided for a while. But after two or three weeks the granulating surface behind the bridge is painted occasionally with a 2 to 3% solution of nitrate of silver. Any crusts are removed after soaking with peroxide of hydrogen.

Complications and dangers. The operation is not free from danger. Latent cerebral trouble connected with the sinus may be roused into activity by the local traumatism, however skilfully effected. The shock, or the lowered local resistance, may stimulate a latent infection in neighbouring sinuses, and also weaken the lines of defence protecting the cranial cavity.

In 1905 Logan Turner collected the record of twenty-four deaths which had occurred after operation on the frontal sinus.72 This number has been exceeded by the fatalities since published and the much greater number which have never been recorded.73 The chief dangers are (1) a spreading septic osteomyelitis, (2) meningitis, and (3) abscess in the frontal cerebral lobe.

Infection of the bone is indicated chiefly by a puffy, tender swelling on the forehead or temple, adjoining the upper flap. There may be little or no rise of temperature, and little complaint on the part of the patient. But no time should be lost in laying the wound freely open, searching for any shut-off focus of pus, and applying hot boric fomentations diligently. Once infection is established in the bone it may be impossible to stay its progress, even by the most thorough removal of diseased tissue: but the effort should be made.74

Meningitis is an equally dangerous complication. It may arise without direct injury to the cerebral wall of the sinus. If, during removal, the anterior end of the middle turbinal be damaged too high up, the lymph channels around the olfactory nerve may be opened so freely that infection spreads along them to the meninges. Or the cerebral wall may sometimes be broken through without a serious result, if the dura mater be left intact behind it. But if there be any damage done to the wall in the neighbourhood of the crista galli or cribriform plate, the dura mater is almost inevitably injured at the same time, and a rapid and fatal meningitis may be expected. The infection is generally streptococcal, and surgery is powerless to stop its progress.

Abscess in the frontal cerebral lobe may arise from operation on the frontal sinus. In my experience it is more apt to occur independently of interference with the sinus, to remain latent, and then to be simply roused into activity by the local traumatism. The symptoms are, unfortunately, very vague. Rise of temperature, headache, irritability, drowsiness, and optic neuritis may be present. On the occurrence of these symptoms the sinus should be freely reopened, and the posterior (cerebral) wall carefully inspected for any necrosing area. In any case it should be removed and the frontal lobe explored in all directions.75

These dangerous complications, in many cases, were no doubt due to a failure to recognize that the complicated group of ethmoidal cells were involved in all cases of chronic frontal suppuration, and that previous to the introduction of the Killian operation our operative methods were very apt to dam up suppuration in dangerous corners. Finally, it was only when rhinologists first began to investigate frontal sinusitis that it was recognized what a dangerous region this is. To be convinced of this it is only necessary to compare the anxiety inspired by our regard for the cerebral wall of the frontal sinus with the calmness with which we regard an opening into the middle fossa, or through the dura mater, in mastoid operations.

We are not yet in possession of definite evidence in regard to the proportionate number of deaths which are due directly or indirectly to pus in the frontal sinus. Some observers hold that more deaths have occurred from operation than from neglected cases. MoliniÉ has followed the history of fifteen private patients with frontal sinusitis, and not operated on, for ten years. Only one has died, and that was from another cause.76 In any case we may still accept Lermoyez’s dictum: ‘Avoir une sinusite chronique est chose moins grave qu’on ne croit: opÉrer une sinusite frontale est chose plus sÉrieuse qu’on ne le dit.’77

Doubtless the dangers have been diminished since the more general adoption of the Killian operation, but accidents may occur in the most skilful hands. This must be kept in mind when drawing up the indications for interference.

Results. In uncomplicated cases, successfully operated on, the results are most satisfactory. The preservation of the Killian bridge quite prevents any really unpleasant disfigurement. The depression which may form above it is proportionate to the size and depth of the cavity. No man need decline the operation on account of the scar left. In women we are able, with the help of a radiograph, to form an idea beforehand as to the degree of depression which may be left. This, if required, can be remedied by the injection of paraffin (see Vol. I), but, fortunately, the frontal sinus in women is not, as a rule, so deep as in men.

As regards cessation of purulent discharge the result will depend on the extent of the sinus, the presence of complicated orbito-ethmoidal cells, and the skill of the operator. If the ethmoidal labyrinth has not been completely dealt with, one or two cells may continue to secrete. It may be wiser to leave them alone. In very deep sinuses a ‘dead space’ between the back of the Killian bridge and the posterior (cerebral) wall of the sinus remains open, and may continue to secrete if not cicatrized over evenly.

But secretion is no longer pent up in the fronto-ethmoidal group of cells, and the patient is relieved of headache, depression, and other symptoms of septic absorption.

THE OGSTON-LUC OPERATION

This operation was first described by Ogston,78 but was independently conceived by Luc.79 Its principle is to make a fairly free opening into the frontal sinus, and then establish a large communication with the nasal cavity. The inner part of the supra-orbital rim is sometimes destroyed. But the operation does not provide for the treatment of orbito-ethmoidal cells, the anterior ethmoidal region and the sp[h]enoidal wall are not exposed, and if there be a large orbital recess to the frontal sinus it cannot be satisfactorily dealt with.

Indications. But the Ogston-Luc procedure, or some modification of it, is still suitable in (1) exploratory openings of the frontal sinus, (2) when the sinus requires opening for a recent and acute infection80, and (3) for mucoceles and suppurating mucoceles.81

Operation. A general anÆsthetic is required. It is not necessary to shave the eyebrow, but the surrounding skin should be well purified. A curved incision is made through the eyebrow down to the bone along the inner third of the supra-orbital ridge, reaching from the supra-orbital notch to opposite the inner canthus. In the latter direction it can be extended if the ethmoidal region is chiefly affected, and if the ethmoid only requires exposing the incision is placed lower down.

With a raspatory the soft parts are turned upwards and downwards so as to expose the anterior wall of the sinus, which is opened with chisel and hammer. A probe will indicate its depth and direction. The opening is enlarged with bone-forceps sufficiently to allow inspection of the interior of the cavity, and permit of the passage into the nose being enlarged with forceps, curettes, or burrs. The polypoid mucosa occupying the sinus and the fronto-ethmoidal cells along the passage to the nose are carefully plucked away. A drainage tube or wick of gauze is inserted from the sinus down into the cavity of the nose, so that it can be withdrawn from the anterior nares at the end of twenty-four hours. The drainage tube is replaced by some surgeons. The frontal wound is sometimes closed at the time of the operation, and sometimes left open.

Results. These are variously given by different observers. Thus one author states that it will effect a cure in 85% of cases,82 while another operated by this method in eleven cases, of which two died and not one was completely cured.83

The subject does not require further discussion, as most operators have now given this operation up in favour of the improvements wrought in it by Killian. Luc himself has abandoned it in favour of the Killian operation. The latter is undoubtedly to be preferred in all cases of well established chronic purulent sinusitis with fungating mucosa and involvement of the ethmoidal cells.

KUHNT’S OPERATION

In this operation the entire anterior wall of the frontal sinus is chiselled away, so as to allow of the soft parts covering it being pressed down into the cavity until they are applied to the posterior wall. This, naturally, effects a complete obliteration of the cavity, but in order to secure it the orbital ridge has frequently to be removed to such an extent that a frog-like prominence is given to the eye, and the resulting disfigurement is very marked. Besides, this operation does not deal with the orbital recess of the sinus, or the orbito-ethmoidal cells—the most important part of the operation. In fact, the only advantage of this operation—complete obliteration of the sinus—is secured by Killian’s operation, which also allows these regions to be dealt with, permits free drainage into the nose, and avoids disfigurement.

OPERATIONS UPON THE SPHENOIDAL SINUS

Surgical Anatomy. In operating on this sinus there are many anatomical and pathological points which it is desirable to remember. Only a few of them can be recalled.

The cavity is seldom absent, although it may be quite small. Its size and conformation may be irregular. Thus in one instance it may extend far out into the wing of the sphenoid, while in another it may be even smaller than a posterior ethmoidal cell invading the body of the sphenoid bone and lying above it.

While the sphenoidal sinus on one side is very small the opposite one may be so large that it comes in relation with the optic groove of the opposite side.

The anterior wall of the sphenoidal sinus can be opened with safety. The roof comes into close relation with the structures round the sella turc[ic]a. The outer wall is close to many large blood-vessels which might cause troublesome hÆmorrhage if wounded. The upper outer wall may be as thin as paper.

There may be deficiencies present in the bony walls, so that, for instance, the mucous membrane of the sinus and the dura mater may be in direct contact.

The RÖntgen rays give such valuable information as to the size and relations of the cavity, as well as to diseases in its cavity or walls, that a radiograph should be taken in all cases (Figs. 343 and 344).

SOUNDING AND WASHING OUT THE SPHENOIDAL SINUS

Indications. Lavage alone may be sufficient for acute or recent cases, but in chronic forms of suppuration a larger and permanently patent ostium must be established, both to allow of more effective drainage and of treatment of the interior of the cavity.

When the interior of the nasal chamber is in a normal condition it is only possible to catheterize this cavity in a limited number of cases. The region of the middle turbinal and olfactory cleft is carefully prepared with cocaine and adrenalin. A pledget soaked in the mixture is inserted between the middle turbinal and the septum, and pushed backwards until it reaches the anterior wall of the sinus.

A canula is then inserted in a sloping direction inwards and upwards diagonally across the plane of the middle turbinal until it impinges on the nasal surface of the sphenoid, in the neighbourhood of the ostium (Fig. 345). The latter is found by feeling with the tip of the catheter. The opening is never visible in health. It may lie a little external to the direction of the olfactory cleft—about 5 millimetres from the middle line.

If this plan be not successful, the ostium sphenoidale can more certainly be discovered in the following way. A more complete and prolonged application of cocaine is carried out, particularly in the neighbourhood of the olfactory cleft and the spheno-ethmoidal recess. Killian’s long nasal speculum (Fig. 346), sterilized and warmed, is inserted between the middle turbinal and the septum. By separating the blades of the speculum the passage is dilated, so that the instrument can be slipped further in, and so, by alternating movements of expansion and advance, the front wall of the sinus is brought into view. During this procedure the middle turbinal is crowded outwards, and no alarm need be caused if a slight cracking sound shows that its attachment has been fractured.

The mouth of the sphenoidal sinus is often indicated by the muco-pus oozing from it or pulsating in harmony with the pulse. If discharge be not escaping the ostium may be only a potential and not an actual orifice—like that of the meatus urinarius—and has then to be more carefully sought for and detected with a probe. If there be difficulty in finding the ostium, the front wall should not be broken through until the presence and size of the sinus has been demonstrated by means of a radiograph (Figs. 343 and 344). The sinus is washed out, as described for the frontal and maxillary cavities.

OPENING THE SPHENOIDAL SINUS

Indications. Profuse purulent post-nasal catarrh, persistent headache, orbital or ocular or intracranial symptoms, call at once for relief. Not infrequently suppuration in other cavities will not cease, even though operated on, until the sphenoidal sinus has been treated.

Operation. Unless long-standing suppuration or ozoena have produced such atrophy of the middle turbinal that the front wall of the sphenoidal sinus is easily inspected from the front, it will be necessary to remove the greater portion of the middle turbinal. If the anterior end has had the typical amputation performed (see p. 592), then the rest can be removed with the punch-forceps of GrÜnwald, the wire snare, or, under nitrous oxide anÆsthesia, the spokeshave.

This will bring the anterior wall of the sinus with its ostium into view. Killian’s long nasal speculum (Fig. 346) may still be necessary. With the help of cocaine the ostium can then be enlarged with various instruments. Hajek’s hook can be inserted into the orifice and the front wall torn away. I have not found this satisfactory. It is much simpler to insert the beak of a small GrÜnwald’s forceps into it, or a small ring-knife, and by a series of boring and screwing motions to render the ostium patent. It is then easy to introduce a beaked GrÜnwald’s or some such punch-forceps as those of Cordes (Fig. 348) and cut away as much of the front wall as may be required. This can be done freely in an inward and downward direction, and an opening as large as the tip of the little finger, and sufficient for drainage and treatment, is thus established.

When describing the removal of posterior ethmoidal cells (see p. 616) it was pointed out that the tip of the forceps not uncommonly breaks through the thin portion of the anterior sphenoidal wall.

If the natural ostium sphenoidale be not visible it would be risky to make an artificial opening without first determining by radiography the presence and size of the sinus. When this has been ascertained, palpation with a pair of sinus-forceps or a Lichtwitz’s trochar and canula will generally detect a thin spot where firm pressure is sufficient to penetrate into the cavity. The opening is then enlarged as described.

In all these procedures care must be taken that the instrument does not burst suddenly through the front wall with such force that it impinges on and damages the posterior wall.

The opened sinus must be dealt with according to the conditions met with. Necrosed portions of bone may require to be removed, but they rarely occur, except in syphilitic cases. Polypoid masses of mucous membrane, obscuring the opening, may be carefully lifted out with forceps or curette, so as to facilitate drainage; but it is never necessary to think of curetting the interior generally, and particular regard should be paid to the posterior wall.

After-treatment. Profuse hÆmorrhage has sometimes occurred after opening the sinus. In a case of Gleitsmann’s the bleeding did not take place until seven days after the operation,84 and in one of C. R. Myles’s cases profuse hÆmorrhage occurred on the ninth day and required ligature of the external carotid.85 It is possible that the bleeding in such cases may come from a branch of the internal maxillary artery, or even from the cavernous sinus. It can be met by firm plugging with a long strip of 1-inch ribbon gauze, of which the end is soaked in adrenalin or peroxide of hydrogen. HÆmorrhage is not a complication that I have ever met with, after having opened a large number of sphenoidal cavities, and I do not think it is to be dreaded if the opening be made as directed.

The sinus is washed out with a warm normal saline solution. The addition of peroxide of hydrogen may be useful. The condition of the mucous membrane may be improved by cleansing the sinus with iodoform emulsion, or plugging it for twelve or twenty-four hours with iodoform ribbon gauze. Any pigment can be kept in contact with the walls for some time by dipping the end of a piece of ribbon gauze into a solution of argyrol (25%) or nitrate of silver (2%) and packing it into the cavity. The other end of the strip is left just within the vestibule of the nose, so that the patient can withdraw it himself.

But if a sufficient opening has been made into the cavity to allow of natural ventilation and drainage, it is well to abstain from too much local medication—particularly if there be neither polypus, necrosis, nor foreign body in the sinus, and if it be not subject to reinfection from the suppuration in the posterior ethmoidal cells. It is remarkable how, under such conditions, suppuration will cease in a sphenoidal sinus if left alone, when, if frequently treated, secretion will continue indefinitely. In my experience the sphenoidal sinus is one of the most satisfactory of the accessory sinuses to treat.86

Other methods. The sphenoidal sinus can also be opened and treated during Killian’s operation on the frontal sinus (see p. 648).

It has been proposed to approach the sphenoidal sinus by first traversing the maxillary antrum. Such a complicated route, involving extensive destruction of tissue, has no advantage over the direct and simple method described. Attempts to reach the sphenoidal sinus from the naso-pharynx are not practical. This is easily seen by observing the thickness of the floor of the cavity depicted in Fig. 345.

OPERATION IN MULTIPLE SINUS SUPPURATION

Before starting treatment in a case of multi-sinusitis a complete examination should be formulated. The importance of making the differential diagnosis as complete as possible cannot be overestimated.

In initiating treatment attention should be directed first to the ethmoidal region. The ethmoid should be attended to in all cases of suppuration in the frontal sinus. It is generally necessary, in any case, to clear it away to gain access to the sphenoidal orifice. It is well to remove it before or during operation on the maxillary sinus. The sphenoidal sinus should be catheterized, and, if infected, the orifice will require enlarging and the cavity treating. A frontal sinus should be washed out several times before deciding on a radical operation. It not uncommonly ceases to secrete after the ethmoid has been cleared.

The radical operation on the frontal sinus should not be embarked on until the ethmoid and sphenoid have been attended to. A radical frontal operation should take precedence of the maxillary, unless both cavities are operated on at the same time.

CHAPTER VI
OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS
FOR RETROPHARYNGEAL ABSCESS: OPERATIONS FOR
NASO-PHARYNGEAL ADENOIDS

METHODS OF OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE NOSE

Many growths in the naso-pharynx, whether originating in the space or descending into it from the posterior choanÆ, can be removed by the following method.

Indications. This operation is indicated for the ordinary mucous polypus of the nose when presenting in the post-nasal space. Polypoid masses of the ethmoid may project through the posterior cavity and are removed in the same way. A naso-pharyngeal polypus (also called choanal polypus, post-nasal polypus, or benign pharyngeal polypus) is easily removed by this procedure. Innocent tumours of the post-nasal space, such as papilloma, adenoma, fibroma, and cysts, can be removed by the same method.

Under cocaine. Cocaine and adrenalin (see p. 572) should be carefully applied to the septum and turbinals, as it is the passage of the instrument from the front which is often the most painful part of the proceeding. The pharynx should be lightly sprayed with a 5% solution of cocaine so as to check reflex action.

While the patient is seated in the ordinary examination chair the surgeon stands at his left hand and introduces a looped snare (Fig. 312, p. 613) through the nostril most suitable for approaching the root of the growth. When the snare has reached the post-nasal space, the surgeon introduces the purified forefinger of the left hand through the mouth and up behind the soft palate, as in Fig. 291. Here it serves to manipulate the loop over the growth, and holds it close to the root of the pedicle while the snare is pulled home.

A few minutes should be allowed to elapse to permit the patient to recover from the unpleasant manipulation, and also to allow of coagulation of the strangulated blood-vessels. The growth should not be cut through, as it is wiser to pluck it from its attachment by a quick movement of avulsion.

The growth may come away with the snare through the nostril, or may fall into the pharynx and be expectorated.

In fairly roomy nostrils a stout polypus forceps can be used instead of the snare.

Under chloroform. In nervous subjects the same method should be carried out under a general anÆsthetic, care being taken that the growth does not cause embarrassment by occluding the larynx.

Under chloroform, of course, more extensive operations can be carried out on the post-nasal space. The pedicle can be attacked with a pair of scissors with long handles, short blades, and slightly curved on the flat. These are introduced through that nostril which appears to be in most direct line with the pedicle, to act as a raspatory, and then cut through the base of the growth. In some cases an instrument such as Langenbeck’s elevator (Fig. 338) will prove useful if introduced through the nostril. The growth is then removed through the mouth by a twisting movement with a strong volsella.

OPERATIONS FOR OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE MOUTH

Many growths in the naso-pharynx can be removed through the mouth, without preliminary operations through the face or through the hard or soft palate.

Indications. The following method of access to the naso-pharynx is chiefly called for in true fibroma of the naso-pharynx, otherwise called naso-pharyngeal polypus, fibroid tumour of the base of the skull, fibroid tumour of the naso-pharynx, retro-maxillary polypus, or juvenile sarcoma of the naso-pharynx.

It is also a plan of procedure which may be called for in any very large, innocent tumours of the naso-pharynx, particularly in cases where nasal stenosis prevents access from the nostrils. It would be a suitable method in any operable cases of malignant disease of the post-nasal space.

Operation. The patient is chloroformed and placed in the position of Rose (hanging head). The mouth being propped open, and the tongue drawn forward, the tumour is first explored with the forefinger, to detect and detach any secondary adhesions. A raspatory which works laterally is next passed from one side of the naso-pharynx to the other above the growth. A rugine which works in a sagittal plane is then introduced below the tumour and made to pass upwards behind it—the reverse movement of Gottstein’s curette in the removal of adenoids (Fig. 350). This movement is facilitated by securely gripping the tumour and dragging it forwards with a stout pair of alligator or volsella forceps. The tumour can thus be so liberated that, with some twisting movements, it can sometimes be extracted entire—often dragging down with it through the naso-pharynx any prolongations thrown forward into the nose.

It is useless to attack such growths as true fibroma of the naso-pharynx with an ordinary wire snare, or such an instrument as a pair of adenoid forceps. For these firm tumours, specially powerful forceps have been designed by Doyen and Escat.

HÆmorrhage is apt to be sudden and copious, but the more rapidly and completely the growth is removed the sooner will bleeding cease—even spontaneously. After complete removal firm pressure with a marine sponge will generally check it. A post-nasal plug should be avoided, and is not usually required. Incomplete operations not only start hÆmorrhage but may start septic absorption.

Modifications. (a) Preliminary laryngotomy. A preliminary laryngotomy, strongly recommended by J. W. Bond and extensively adopted by Butlin, adds nothing to the dangers of the case. It allows of the laryngo-pharynx being packed, so that there is no anxiety in regard to the descent of blood into the lungs, and it permits the steady administration of the anÆsthetic through the laryngotomy canula. The surgeon is thus relieved of two great anxieties, and can devote himself without embarrassment to more deliberate operation.

The laryngotomy tube can be removed as soon as the patient recovers consciousness and all hÆmorrhage has ceased.

(b) Division of the soft palate. In addition to the operation of laryngotomy, the following procedure will allow of more deliberate removal.

The soft palate and uvula are carefully divided in the middle line, and a silk ligature is placed through each lateral half so that they can be held forward out of the way. This gives more direct access to the post-nasal tumour, and if then found to crowd the cavity too closely to allow of manipulation, the posterior part of the hard palate can be chiselled away in the middle line. At the conclusion of the operation the divided palate is carefully united in the middle line (see Vol. II).

Selection of method. In some cases operation through the mouth may have to be combined with a second operation from the front—such as the method of Moure (see p. 619) or that of Rouge (see p. 622).

Rapidity of operation is important, as, once the pedicle has been cut through, or the body of the tumour removed, the hÆmorrhage tends to subside spontaneously, or is quickly controlled by packing.

The hanging head (Rose) or the Trendelenburg position is generally recommended.

The preliminary laryngotomy seems desirable in all cases. The division of the palate should be avoided if possible. It may not always unite, and is less likely to do so if subsequent operations are required. The soft palate is very elastic, and in some cases it can be tied out of the way by means of a soft rubber catheter passed along the floor of the nose, and out through the mouth.

Ligature of the external carotid, strongly recommended by Chevalier Jackson87, is not necessary unless the patient is very anÆmic or weak from former hÆmorrhages. It should then be only a temporary ligature (see Vol. I, p. 383).

HÆmorrhage, as already remarked, is chiefly guarded against by rapid and complete operation. The preliminary use of adrenalin and cocaine, the administration of lactate of calcium, and the other methods recommended for the prevention of bleeding (see p. 574) should be carefully attended to. But in every case preparation should be made beforehand for ligature of the external carotids and for saline infusion.

OPERATION FOR RETROPHARYNGEAL ABSCESS

Indications. The disease is serious, and when not diagnosed almost inevitably ends in death. Before the abscess bursts death may result from spasm of the glottis, laryngeal oedema, or asphyxia. The affection runs its course in 5 to 10 days, and if the abscess opens spontaneously death almost inevitably results—either from suffocation, or septic pneumonia, or cardiac failure.

Operation. When the diagnosis is settled intervention should be prompt. It is not necessary to wait for distinct fluctuation. The pus focus may be so difficult of manipulation in an infant, and the pharyngeal muscle may be so thick and indurated, that it is practically impossible, even in the later stages of retropharyngeal abscess, to detect the presence of pus by palpation.88

The evacuation of the abscess through the mouth was formerly looked upon as dangerous, owing to the difficulty of drainage, the fear of pus burrowing behind the oesophagus, and the risk of flooding the larynx with pus. The more difficult plan of opening it from the neck was generally recommended. The majority of cases can be opened through the mouth with perfect safety.

No general or local anÆsthetic is administered, but everything necessary for an immediate tracheotomy should be ready at hand. No gag should be employed, a tongue depressor or the operator’s left forefinger being sufficient both to keep the mouth open and act as a guide. The infant is swaddled in a shawl so as to completely control the movements of the extremities and is then laid on its side on a low pillow, and held by a trustworthy assistant. The sinus-forceps used for opening a peritonsillar abscess are thrust into the most prominent part of the swelling, and the opening enlarged by separating the blades as they are withdrawn. A slender sharp-pointed bistoury, guarded and guided by the index-finger, may be used instead of the forceps. The pus will pour out through the nose and mouth. The incision of the pharynx should be free, deep and long, and directed against the posterior wall of the pharynx and as close to the median line as possible, so as to avoid any chance of wounding the internal carotid.

The surgeon may feel more security if, with the same precautions and with the patient in the same position, he first aspirates the pus cavity.

If more accustomed to it, he may also prefer to have the child flat on its back, with the head overhanging the edge of the table.

Suffocation may be so imminent when the patient is first seen that a preliminary tracheotomy is required.

The external operation, which leaves a certain scar, is reserved for some rare cases—as when the abscess is too low to be easily reached through the mouth, when the spasm of the masseters cannot be overcome, when a large pulsating vessel is noticed in front of the abscess, and when the abscess points towards the neck. It is also the suitable one for the chronic and generally tubercular form of abscess more commonly met with in older patients.89

The external operation is made through an incision along the posterior border of the sterno-mastoid muscle, and the dissection is carried behind the large vessels of the neck and in front of the prevertebral muscles.

After-treatment. The after-care of the patient will require consideration, since the disease is generally met with in the feeble and ill nourished.

If the abscess be opened in good time the patient is at once relieved and begins to recover rapidly.

REMOVAL OF NASO-PHARYNGEAL ADENOIDS

Indications. The removal of naso-pharyngeal adenoids is not called for simply because they are accidentally discovered to be present, nor does the need of operation depend solely on the size of the growths or the nasal obstruction they produce. Adenoids require removal whenever the symptoms attributable to them call for relief. These symptoms may be arranged in three groups, according as they are those (i) of nasal stenosis, (ii) of secondary septic infection, or (iii) of reflex effects.

(i) Amongst the first are mouth-breathing and all the numerous sequelÆ, including facial, buccal, dental, and thoracic deformities. It must not be forgotten that mouth-breathing may never be present, and yet deformities of the chest or septic or reflex results can be produced by a small amount of growth in the post-nasal space.

(ii) Amongst secondary septic infections are catarrhal conditions of the Eustachian tube and otitis media, and catarrhal infection of any part of the air-passages. Cervical glands and so-called ‘glandular fever’ occur in this group, as do septic gastritis and other conditions caused by the conveyance of sepsis to more distant parts.

(iii) Various reflex effects are sometimes attributable to naso-pharyngeal adenoids. Laryngismus stridulus, reflex cough, chorea, convulsions, night-terrors, enuresis nocturna, and aprosexia are some of the ailments which may justify operation on Luschka’s tonsil.

As it is chiefly in children that this operation is required it is important to see that they are free from indication of infectious fevers. The operation should be postponed until any acute catarrh has subsided. If there be otorrhoea the ears should receive suitable cleansing treatment for a week or two beforehand. The condition of the teeth requires attention.

The operation is so frequently carried out in private houses that it is well to make inquiries into the health of the members of the household, recent illness, and sanitation. When possible, a large, airy room with a south aspect should be chosen.

Operation. In adults it is possible to carry out the operation under cocaine. On the Continent, particularly in hospital practice, it is often done without any anÆsthetic at all. In this country general anÆsthesia is almost the universal custom. Opinion is divided as to which is the safest and most suitable anÆsthetic to employ.

When the removal of tonsils or other operation is not carried out at the same time, an anÆsthesia of less than a minute is sufficient. In adults, and in children over 10 years of age, nitrous oxide does excellently. Younger children are apt to be alarmed by the face-piece and apparatus necessary for nitrous oxide, and this gas does not seem so suitable for them as for adults. In younger children chloride of ethyl is extensively employed on the Continent, but has not met with general favour here.

When the tonsils require removal, or any other operation on the upper air-passages is carried out at the same time, and in young children generally, an anÆsthesia allowing of more deliberation is desirable. For this, some operators employ ether,—preceded or not by nitrous oxide. But the well-known objections to pure ether in the surgery of the air-passages have caused the preference to be given to chloroform, or to one of the mixtures of chloroform and ether.

The patient should lie quite flat on the operating table, with only a low pillow or folded towel under the head. The anÆsthetist, who takes charge of the gag and flexes or rotates the head as directed, stands at the end of the table. At the patient’s right hand stands the surgeon, and within easy reach are his instruments, sponges, and iced water. Standing on the same side and behind him is the nurse. Her duty is to soothe the patient while passing into unconsciousness, and later on to roll him well over on to his right side as the operation finishes.

The operation can be carried out more correctly, rapidly, safely, and comfortably if the surgeon be armed with an electric forehead search-light (see p. 571). Failing this, the table should be brought close up and parallel to a window, with the patient’s right hand next the light.

Surgeons differ as to the degree of anÆsthesia desirable. Some like it to be quite light, so that the patient is all the time in the struggling stage and requires his hands to be controlled by the nurse. I think this is quite as dangerous as when the anÆsthesia is pushed until the patient is relaxed, with the corneal reflex just abolished, and the swallowing and coughing reflexes still present.

When the anÆsthetic is administered steadily, with plenty of air, a degree of unconsciousness is generally secured which will allow of an operation lasting two or three minutes without any further adminis[t]ration. Should the patient show signs of recovering consciousness more chloroform can be given from a Junker’s apparatus.

The anÆsthetist then opens the mouth with a suitable gag, such as Doyen’s or Mason’s, and maintains the patient’s head exactly in the middle line of the body. Directing the electric search-light into the pharynx, the surgeon depresses the tongue with a spatula in the left hand, while with the right he holds the adenoid curette—some modification of the original Gottstein model (Fig. 349). This is best seized firmly dagger-wise (Fig. 351). It is then introduced along the tongue and slipped up into the post-nasal space. Once safely behind the soft palate and kept straight in the middle line, no harm can be done. Dropping the tongue depressor, the surgeon depresses the handle of his instrument until the beak of it is felt in contact with the posterior free margin of the septum. Pressing the cutting blade firmly and steadily along this it is swept upwards, backwards, and downwards along the vault of the naso-pharynx, while the curette revolves around an imaginary centre in its shaft (Fig. 350). As the instrument is withdrawn from the pharynx, its cage will be found to contain the adenoid growth, removed en bloc and generally complete (Fig. 351). Should the growth slip from the cage, or remain semi-detached from the posterior pharyngeal wall, it can be seized and lifted from the throat with a pair of post-nasal forceps (Fig. 287).

The rush of blood which now takes place is met by rolling the patient well over to his right side, with his face over the edge of the table, so that the blood can run into the right cheek and so out through the mouth. With the patient on his side there is no anxiety of asphyxia from descent of blood or fragments of growth into the trachea, and the surgeon can more deliberately explore the post-nasal space and, with a simple adenoid curette, remove any lateral remains of growth which may have escaped the caged curette.

Sponges are merely used to cleanse the mouth and pharynx in order to make sure that no semi-detached fragments are left behind. If present, tonsils can be conveniently removed at this stage.

Bleeding, which may be very free for a minute or two without any cause for anxiety, is promptly arrested by freely sluicing the patient’s face and neck with ice-cold water.

After-treatment. The patient is put back to bed, lying well over to one side. He should not be allowed to lie on his back, or left unattended, until consciousness has returned. Collapse may occur at this time, generally as a precursor of vomiting, or blood may be vomited and then, owing to the patient’s semi-conscious condition, may be drawn into the trachea.

Ice may be sucked. After a few hours, if there be no vomiting, barley-water, lemonade, tea, thin beef-tea, or beef jelly can be given. Milk and milky food should be avoided. An aperient should be given the same evening, as any foul breath or feverish condition is more likely to be due to blood and mucus in the stomach than to local sepsis. The mouth is kept cleansed with the tooth-brush and an alkaline wash.

It is best to avoid local treatment for the nose. At the end of a few hours the patient is encouraged to clean the nose, and if he be supplied with abundance of fresh air through freely opened windows, the wound in the post-nasal space will heal promptly without any local or general reaction. Occasionally an alkaline nose lotion is required if there has been much secondary rhinitis, or if the child be kept in vitiated air.

One day in bed is generally sufficient, and a child may be allowed out in two or three days, though fatigue should be avoided for a week. Suitable after-treatment in the way of breathing exercises, gymnastics, speech correction, and tonics is often needed. Relief of nasal stenosis may require completion by attention to the condition of the turbinals and septum.

The operation in adults is performed under nitrous oxide. This can be carried out in exactly the same way as that already described, but some surgeons prefer to have the patient sitting up in a dentist’s chair. In that case, after the removal of the mass of growth, the patient’s head is thrown forward between his knees.

Difficulties and dangers. It may be said that the operation itself, carried out with usual care and in a patient who is not a hÆmophilic, is free from danger. The chief anxiety is from the anÆsthetic, and no inconsiderable number of deaths from this cause have been reported. When possible, it is well to secure the services of an expert anÆsthetist who is well used to laryngological work, and accustomed to the operator’s particular methods.

HÆmorrhage may be brisk, even profuse, for a few minutes, but as a rule it promptly ceases if the operation be completed, the patient well rolled to one side, the air thoroughfare left clear so as to allow free breathing and avoid congestion, and the gag removed to permit swallowing and diminish pharyngeal reflexes. The more rapidly and completely the operation is executed, the less will be the bleeding. It not infrequently originates from semi-detached fragments of growth. Even when the hÆmorrhage is profuse it is better to push on and complete the removal of growth before attempting to check it. The value of free applications of ice-cold water cannot be exaggerated (see p. 574). In many cases bleeding is maintained by the surgeon’s anxious efforts to stop it with sponging, pressure, or the application of styptics. The greatest danger arises in the case of hÆmophilics. If this diathesis be undoubtedly present, the operation should be avoided. If only suspected, more care than usual should be taken in preparing the patient for operation, and lactate of calcium in 15 to 30 grain doses twice a day might be given for two or three days beforehand.

When bleeding persists it is met by keeping the patient very quiet and free from alarm, in a cool and well-ventilated room, and only lightly covered with clothes. Ice is given to suck and applied on each side of the neck, while iced cloths are applied to the face and forehead. Clots are blown out of the nose so as to permit the access of fresh cold air to the post-nasal space. With a pipette, or a pledget of cotton-wool, a few drops of adrenalin can be trickled into the nostril and allowed to run backward. If these measures fail—as they rarely do—the post-nasal space must be plugged (see p. 575). When hÆmorrhage takes place after the removal of adenoids and tonsils, it will generally be found that the source of it is in the tonsillar area.

The uvula may retract strongly at the moment of introducing the curette and then get crushed against the posterior pharyngeal wall: or it may be seized by mistake with the post-nasal forceps and be torn away. The same instrument has sometimes been responsible for fracturing the posterior margin of the septum, injuring the Eustachian cushion, and tearing off strips of mucosa from the pharynx. These complications are avoided by using a frontal search-light, operating deliberately, and abandoning the forceps in favour of the curette. This latter instrument can be manipulated without these risks if it be first guided safely behind the uvula and then used more like a carpenter’s adze than a curette. The stroke with the caged curette should be carried through in one movement and exactly in the middle line of the body, but always on the posterior wall. There is no need to attempt removal of adenoid tissue on the lateral walls. This atrophies if the main mass is removed, and the fossa of RosenmÜller can be cleared out with the forefinger.

Local sepsis rarely follows if the precautions described be observed, and local douching is avoided. Any local foetor—if not arising from the stomach—is generally traceable to some semi-detached fragment which can be removed from the posterior wall with a wire snare (Fig. 312) or a pair of forceps (Fig. 287).

Deafness, earache, and otitis media will sometimes follow the operation, even when the use of a nasal douche has been carefully avoided. They are best met by warm applications, disinfection of the ear with carbolic lotion (5%), and early incision of the drum under nitrous oxide gas.

Other methods of operation. Removal through the nasal chambers—the route originally used by Meyer for his ring-knife—is not to be recommended.

Treatment of the growth with the galvano-cautery, introduced through the mouth, is difficult, risky, and unsatisfactory.

The use of Loewenberg’s forceps, or some modification (Fig. 287), is generally abandoned by any one who has become accustomed to the Gottstein’s curette. A small pair of forceps is, however, very serviceable in quite young children in whom the post-nasal space may be so small as to prevent the manoeuvring of any form of curette.

The position with the extended head over the end of the table—Rose’s position—increases the congestion and hÆmorrhage, and by throwing forward the cervical vertebrÆ makes the approach to the roof of the naso-pharynx more difficult.