Curettage is required in more advanced cases. Chloroform is always required. Not only should all soft and diseased tissue be sc.r.a.ped 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.

[Ill.u.s.tration: FIG. 295. CRESSWELL BABER'S NASAL SAW.]

=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 b.u.t.tonholing 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 a.s.sociated 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 anaesthetic. 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 b.u.t.ton-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.

[Ill.u.s.tration: FIG. 296. THE GLEASON-WATSON OPERATION FOR DEFORMITY OF THE SEPTUM. _a_ shows the incision made from the stenosed nostril, and below the convexity; _b_ represents the septum as pushed into the free nostril; and _c_ shows the result after subsequent removal of the spur.]

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

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 anaesthesia, but it is generally advisable to employ some such general anaesthetic 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.

[Ill.u.s.tration: FIG. 297. ASCH'S CUTTING SCISSORS. Employed in the operation upon the septum.]

[Ill.u.s.tration: FIG. 298. LAKE'S RUBBER SPLINT.]

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). Haemorrhage, 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 circ.u.mstances 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]

[57] For bibliography and more detailed description, see StClair Thomson, _Med.-Chir. Trans._, vol. lx.x.xix, 1906; _Lancet_, July, 1906; and _Brit. Med. Journ._, vol. ii, 1906.

=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]

[58] _Annals of Otology, Rhinology, and Laryngology_, June, 1905.

(_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 haemorrhage. 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 pa.s.s out of the hands of those who are kept in daily practice in rhinological technique.[59]

[59] 'As all operators who know it will confess, the Fensterresektion of the septum belongs to the most extremely difficult intranasal operations.' Zarniko, _Die Krankheiten der Nase_, 1905, p. 300.

(_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]

[60] _Beitrage zur Anatomie, &c. des Ohres, der Nase, und des Halses_, Hefte 1-4, 1908.