=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 s.p.a.ce 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 a.s.sistant. 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.

[Ill.u.s.tration: FIG. 313. LUC'S NASAL 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 forceps[64] (Fig. 313), supplemented by Grunwald's punch-forceps (Fig. 286). The former are introduced vertically, so that one blade pa.s.ses between the ethmoid and the septum and the other pa.s.ses under cover of the middle turbinal. By insinuating them carefully, and gradually working them upwards and outwards, a large ma.s.s 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 ma.s.ses 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.

[64] _La Tribune Medicale_, 1905.

Haemorrhage 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 ma.s.s 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 anaesthesia.= Under a general anaesthetic 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 s.p.a.ce 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 anaesthetic through the mouth is quite uninterrupted. This method allows the surgeon to operate deliberately, generally with the haemorrhage under easy control, the field of operation well illuminated, and no anxiety in regard to the anaesthetic.

[Ill.u.s.tration: FIG. 314. TONGUE CLIP. Keeps the tongue drawn forwards to allow of general anaesthesia, when the post-nasal s.p.a.ce is plugged.]

The removal of polypoid ethmoid can thus be completely carried out. With this method I have removed at one sitting a ma.s.s 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.

[65] _Proc. Laryn. Soc. Lond._, 1907, xiv, p. 106.

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 ma.s.s 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 pa.s.s the forefinger of the left hand well up into the posterior choanae to detect and push forwards any ma.s.ses of growth which may have been driven backwards.

Haemorrhage 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 manuvring in the anterior part of the s.p.a.ce between the septum and the outer nasal wall. Here the punch-forceps are not directed backwards against the main ma.s.s 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 ma.s.ses 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]

[66] Moure, _Revue hebdomadaire de Laryngologie_, October 4, 1902; Duverger, ibid., September 2, 1905.

=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 s.p.a.ce 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 a.s.sociated 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 deglut.i.tion 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).

[Ill.u.s.tration: FIG. 315. INCISIONS FOR LATERAL RHINOTOMY (MOURE'S OPERATION).]

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 ma.s.s of the ethmoid are removed with punch-forceps (Grunwald's or Luc's), Volkmann's sharp spoons, or a ring-knife.

[Ill.u.s.tration: FIG. 316. THE AREA OF BONE REMOVED IN LATERAL RHINOTOMY.

The flaps have been retracted, and the dotted lines show where the bones are chiselled through.]

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 a.s.sistant 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 ma.s.s 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.

[Ill.u.s.tration: FIG. 317. LATERAL RHINOTOMY. The side of the nose has been removed, and direct access obtained to the upper and deeper nasal regions.]

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, haemorrhage 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 inst.i.tuted (see p. 579).

ROUGE'S OPERATION (SUBl.a.b.i.aL 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 anaesthesia, 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 ozna, 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 circ.u.mstances 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 a.s.sistant 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-l.a.b.i.al 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 a.s.sistant 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.

[Ill.u.s.tration: FIG. 318. ROUGE'S OPERATION. _First stage._ The upper lip is everted and retracted by an a.s.sistant standing behind the patient's head. The dotted line indicates the line of incision.]

The conditions met with are then dealt with as required. Haemorrhage 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.