[Ill.u.s.tration: FIG. 290. NASAL SCISSORS.]

=After-treatment.= It is well to check the haemorrhage without the use of plugging. Some antiseptic powder--europhen, xeroform, formidine, aristol, &c.--if lightly insufflated over the wounded area, will a.s.sist 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 a.s.sisted 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 anaesthesia.

The steps have to be varied according to the degree and extent of the hypertrophic tissue requiring removal. When this is princ.i.p.ally 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 pa.s.ses 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 anaesthesia, 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 s.p.a.ce. 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 anaesthetic, 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 haemorrhage 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 pa.s.sed 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.

[Ill.u.s.tration: FIG. 291. AMPUTATION OF THE POSTERIOR END OF THE INFERIOR TURBINAL.]

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 s.p.a.ce, 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 s.p.a.ce the only local pressure which is available is that of a post-nasal plug.

=After-treatment.= As secondary haemorrhage 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.

[Ill.u.s.tration: FIG. 292. NASAL SPOKESHAVE.]

=Prognosis.= Great relief can generally be promised within a few days.

There is no danger in the operation. The haemorrhage 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.= Anaesthesia may be local or general. If no other operative procedure be required at the same time, the anaesthesia 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, pa.s.sed 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 s.p.a.ce.

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 anaesthesia 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 anaesthetic, 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 Grunwald'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 pa.s.sed 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.

[Ill.u.s.tration: FIG. 293. FIRST STEP IN THE REMOVAL OF THE ANTERIOR END OF THE MIDDLE TURBINAL.]

[Ill.u.s.tration: FIG. 294. SECOND STEP IN THE REMOVAL OF THE ANTERIOR END OF THE MIDDLE TURBINAL.]

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 Grunwald'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. Haemorrhage 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 ma.s.s 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 haemorrhage. When the necrosed bone has been mobilized it may be too large for extraction through the nares; such a ma.s.s 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 pa.s.sage 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.

Spencer[54] 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]

[54] _Proc. Laryngol. Soc., London_, vol. v, November, 1897, p. 4.

[55] Ibid., vol. x, March 6, 1903, p. 81.

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 pa.s.sing forward through the nostrils and two through the mouth. The lead plate is not removed for a fortnight.[56]

[56] Ibid., vol. xiv, June, 1907, p. 106.

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

=Results.= Stenosis of the pa.s.sage 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.