=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.

[Ill.u.s.tration: FIG. 308. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded area indicates the extent of the bony and cartilaginous septum usually requiring removal.]

[Ill.u.s.tration: FIG. 309. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded portion indicates the extent of cartilage and bone removed in marked deformity, when the free end of the quadrilateral cartilage projects into one nostril.]

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 photoph.o.r.e or Clar's mirror (see p. 571).

[Ill.u.s.tration: FIG. 310. SEMI-DIAGRAMMATIC TRANSVERSE SECTION OF THE NOSE. Shows the compensatory hypertrophy of the inferior turbinal in the un.o.bstructed nostril. Part of this frequently requires removal after the septum has been straightened.]

_Haemorrhage_ presents no difficulty if patients are prepared as directed (see p. 574), unless one happens unexpectedly on a patient with a haemophilic 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 circ.u.mstances 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.

[Ill.u.s.tration: FIG. 311. OPERATION FOR PERFORATION OF THE SEPTUM. The muco-perichondrium is reflected for some distance round the opening so as to allow of the projecting rim of cartilage being removed. The exposed edge is then covered over by the mucous surfaces falling together.]

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 circ.u.mference of the perforation for a distance of about a quarter of an inch from the free margin. Over the greater part of the circ.u.mference 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 circ.u.mference 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).

[62] _The Laryngoscope_, xvi, 1906, p. 879.

OPERATION FOR ABSCESS

A free incision is made into it, under cocaine or nitrous oxide anaesthesia. 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 HaeMATOMA

If the haematoma 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.

[Ill.u.s.tration: FIG. 312. NASAL SNARE.]

=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 anaesthetized.

Under good illumination the snare is introduced with the loop vertical, and pa.s.sed alongside the growth,--between it and the septum or to the outer side, as s.p.a.ce 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 dematous 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 s.p.a.ce, 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 s.p.a.ce for the latter manipulation, the left forefinger is used to steady the ma.s.s 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, a.s.sisted 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]

[63] _Revue hebd. de Laryn._, 1903, xxiv, Nr. 46, November 14, p. 597.

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 fossae, 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:--