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-s.p.a.ces 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 anaesthesia, and the control of haemorrhage 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-pa.s.sages. 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 gla.s.s 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.

[Ill.u.s.tration: FIG. 281. LARYNGOSCOPE LAMP.]

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 acc.u.mulator 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 acc.u.mulator and frontal photoph.o.r.e (Fig. 283) are convenient for use in the patient's own home.

[Ill.u.s.tration: FIG. 282. CLAR'S ELECTRIC LIGHT.]

[Ill.u.s.tration: FIG. 283. FRONTAL SEARCH-LIGHT.]

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 pract.i.tioners 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 ANaeSTHESIA

=Cocaine.= It is often desirable to secure a slight degree of local anaesthesia 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 anaesthetic, (_b_) a powerful vaso-constrictor, and, consequently, it (_c_) produces local anaemia.

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 haemorrhage.

_Methods of use._ A small area can be anaesthetized 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 haemostatic action, but, for the same reason, will tend to prevent the cocaine being absorbed and producing its toxic effects.

For the more complete anaesthesia 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 anaesthesia 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 haemostatic 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.

_Subst.i.tutes for cocaine._ For submucous injection it is better to subst.i.tute eucaine or novocaine. Eucaine can be kept in a ready and portable form in small gla.s.s 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 anaesthesia 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 anaesthesia 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 ISCHaeMIA

=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, haemostasine, 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 gla.s.s 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 ischaemia 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 haemorrhage, 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.

[47] C. A. Parker, _Diseases of the Nose and Throat_, London, 1906.

Adrenalin has no anaesthetic 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 pa.s.ses off in 24 to 48 hours.

_Uses._ The addition of a small quant.i.ty 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 haemorrhage 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 pa.s.sing into the lower air-pa.s.sages.

=Causation.= Haemorrhage 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 haemophilia 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 haemorrhage may occur between the third and eighth day, when clots or crusts become detached.

_The prevention of local haemorrhage._ The patient should be prepared more carefully than usual for an operation. Haemophilia 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 haemophilic, 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 haemorrhage._ The preliminary use of adrenalin will diminish bleeding in many cases (see p. 573). When it does occur, unless the haemorrhage 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 haemorrhage in the majority of operations on the nose and throat.