=Advantages.= This operation has several advantages:--

(_a_) It is not difficult of execution, and can be carried out with a scalpel and a raspatory.

[Ill.u.s.tration: FIG. 319. ROUGE'S OPERATION. _Second stage._ The soft parts are retracted.]

(_b_) It gives a free access to the floor of the nose and the anterior part of the nasal fossae. The vestibule, the natural orifice of the nose, only measures 20 millimetres by 7 to 8 millimetres. Rouge's operation exposes an orifice measuring 3-1/2 centimetres by 2 centimetres. The posterior margin of the septum, instead of being 8 centimetres distant from the outside, is now brought within a reach of 5 centimetres. The floor of the nose lies on a lower level than that of the vestibular entrance, and is wider some distance in than it is at the orifice. By means of this operation the whole floor comes into clear view, and the exit from the nasal chambers becomes the widest part of the nose.

(_c_) The bones of the face are not interfered with, and the amount of traumatism is slight.

(_d_) Bleeding, which is so apt to be troublesome in operations through the skin of the face, is less and is easily controlled.

(_e_) The patient can be a.s.sured that there will not only be no disfigurement, but not even the slightest scar on the face.

(_f_) The operation can be repeated without any disfiguring scars. In operations upon the nose through the face the cicatrix becomes more marked with each intervention.

COMBINATION OF MOURE'S AND ROUGE'S OPERATIONS

The two methods above described can be combined if necessary. This would be called for particularly in growths so large that they could not be attacked through the narrow vestibule of the nose, and for those in which the attachment is evidently in the ethmoidal region. This combination might be called for in any large innocent or malignant growth.

EXTENSION OF ROUGE'S OPERATION TO ALLOW OF ACCESS TO THE MAXILLARY ANTRUM

When the growth involves both the nasal cavity and the maxillary sinus Rouge's operation can be extended so as to form part of the Caldwell-Luc operation (see p. 631).

The latter operation is modified as suggested by Denker (Fig. 332), _i.e._ the opening through the canine fossa is extended forwards until the nasal cavity is opened through the pyriform opening. This will give free access to the large cavity formed by throwing the antrum and the nasal chamber on the same side into one easily inspected s.p.a.ce (Fig.

332). Haemorrhage gives no cause for anxiety, there is no disfigurement, the original root of the implantation can be eradicated, and, if necessary, the operation can be repeated without difficulty. If the growth extends upwards and inwards to the ethmoidal region this infral.a.b.i.al opening can be combined with Moure's operation.

=Indications.= This operation is suitable for any form of growth invading both the antrum and nasal cavities, and is therefore generally called for in malignant growths.

OTHER METHODS

The other methods for obtaining access to the nasal cavity through the face--described as the methods of Hippocrates, Syme, Dupuytren, Langenbeck, Lawrence, Ollier, &c.--are now only of historical interest.

They all leave a scar on the face; bleeding is troublesome; they do not give a greatly enlarged field; and most of them do not bring the seat of disease any closer. With the advances made by rhinology the necessity for intervention through the face has become more infrequent.

CHAPTER V

OPERATIONS UPON THE ACCESSORY NASAL SINUSES

OPERATIONS UPON THE MAXILLARY SINUS

CATHETERIZING THE MAXILLARY SINUS

It is rarely possible to enter the antrum through its natural ostium.

The attempt may be made after the local use of cocaine and adrenalin (Fig. 320).

[Ill.u.s.tration: FIG. 320. CATHETERIZING THE MAXILLARY SINUS.]

PUNCTURING THE MAXILLARY SINUS FROM THE NOSE

=Indications.= It is chiefly employed as a diagnostic test. As a curative measure it is seldom successful except in comparatively recent infection. If the case be uncomplicated by suppuration in other cavities, if the teeth in the upper jaw on the same side be intact, and if the patient be anxious to avoid more severe measures and be willing to undergo the discomfort of a daily puncture, lavage has been reported as successful when repeated 27 times, even in a case with a history of 17 years' duration.[67] But under the circ.u.mstances just mentioned it is wiser to recommend the establishment of an antro-nasal communication (see p. 637).

[67] Koenig. _Soc. paris. de Laryn._, 1905, 30 juin.

[Ill.u.s.tration: FIG. 321. LICHTWITZ'S AND MORITZ SCHMIDT'S ANTRUM NEEDLES.]

[Ill.u.s.tration: FIG. 322. PUNCTURING THE MAXILLARY SINUS. The dotted part represents the portion of the exploring needle which pa.s.ses under cover of the inferior turbinal.]

=Operation.= This is done under local anaesthesia from the inferior meatus. One pledget of cotton-wool, soaked in cocaine and adrenalin, is carefully tucked under the inferior turbinal on the affected side, and another is applied to the septum. At the end of 20 minutes a straight Lichtwitz's or curved Moritz Schmidt's (Fig. 321) hollow needle is pa.s.sed under the inferior turbinal and introduced upwards and outwards as near as possible to the centre of its attachment. The handle of the needle is tilted against the cartilaginous septum, while the point is directed towards the malar eminence. When it is felt to encounter the thin, membranous part of the antro-nasal wall it is easily thrust through (Fig. 322).

While the nasal cavity is kept under inspection, air is blown through the needle, and any secretion can be observed escaping from under the centre of the middle turbinal. This douche of air is then followed by an irrigation of warm normal saline solution. In an acute case this lavage can be repeated daily until the symptoms of tension are relieved, or until the secretion begins to escape spontaneously.[68]

[68] Logan Turner, _Edinburgh Medical Journal_, August, 1906, p. 152.

Puncturing the maxillary sinus from the middle meatus incurs a greater risk of striking the orbit and is not so likely to reveal a small amount of thick secretion on the floor of the cavity.

[Ill.u.s.tration: FIG. 323. ANTRUM DRILLS.]

[Ill.u.s.tration: FIG. 324. SOLID RUBBER OBTURATORS. Used in alveolar drainage of the maxillary sinus.]

[Ill.u.s.tration: FIG. 325. ANTRUM NOZZLE.]

PUNCTURING THE MAXILLARY SINUS FROM THE ALVEOLAR MARGIN

This is one of the oldest methods of drainage. It is less frequently employed nowadays, partly because carious teeth and empty sockets are not so commonly met with, and partly because the results have not proved very satisfactory.

=Indications.= The operation is useful as a diagnostic or palliative measure. In cases of unilateral multi-sinusitis, if a suitable tooth socket be available, the alveolar operation serves both to determine the condition of the maxillary sinus and to establish drainage, while the other cavities are being investigated or treated. In patients who are too old or feeble to endure more radical measures, or who decline them, the obturator may be left in indefinitely. In that case, if the neighbouring teeth be intact, a solid gold plug should be fitted to the denture bearing the false first molar. During the night this is exchanged for the soft rubber plug. If several teeth be missing it is more comfortable to have the obturator and denture separate--the latter being made with a setting to receive the f.l.a.n.g.e.

An anaesthetic should always be given. Nitrous oxide gas or chloride of ethyl are generally recommended for this short operation, but in cases that present any difficulty it is better to follow the nitrous oxide with ether, or the chloride of ethyl with chloroform.

=Operation.= The most suitable tooth socket is that of the first molar, but if this be not available, that of the second bicuspid or second molar may be employed. If a tooth in one of those situations be carious, or be suspected as the cause of the sinusitis, its extraction and the drilling of the alveolus may be carried out under the same anaesthetic.

The patient can be rec.u.mbent on an operating table, or lying back in a dentist's chair. A small antrum drill (Fig. 323) is grasped in the hand as a bradawl is held, with the forefinger lying along it to within 1 to 1-1/2 inches from the end, where it acts as a stop to prevent the instrument from plunging too deeply into the sinus. The drill is held vertically against the alveolar border, and with a few quick, rotatory thrusts is pushed into the cavity. The inner of the tooth sockets is selected. If required, the hole can be enlarged by a similar instrument of a larger bore. A plug, which fits firmly into the opening, is introduced, and nothing further is required for that day. A solid vulcanite obturator is recommended. It should be left _in situ_ for two or three days, when it is removed to allow of the cavity being syringed through, and is then replaced by a solid, soft rubber plug, of a somewhat smaller diameter (Fig. 324). The vulcanite obturator is better for establishing the ca.n.a.l; if removed too soon it may be difficult to replace it, and manipulation may set up severe neuralgia. A small size--No. 6 or 7--is quite sufficient.

[Ill.u.s.tration: FIG. 326. WASHING OUT THE MAXILLARY SINUS FROM AN ALVEOLAR OPENING.]

At the end of two or three days lavage of the cavity is gradually inst.i.tuted. A pint of warm sterile normal saline solution is sent through the cavity by a Higginson's syringe, fitted with a suitable nozzle (Fig. 325). As the stream issues from the nose it is received in a black vulcanite tray, which readily demonstrates the colour, quality, and quant.i.ty of antral secretion (Fig. 326). When the pint of liquid is finished, air is blown through, so as to leave the sinus as dry as possible. The patient should be advised to replace the rubber obturator, properly cleaned and purified, as soon as possible. If this be neglected--for even as short a time as 5 minutes--the soft tissues may obstruct the channel so as to render the reintroduction painful and perhaps impossible. Another useful warning is not to wear a plug so long as to allow of the f.l.a.n.g.es being worn away, and so risk the penetration of the rubber tube into the cavity.

The syringing should at first be daily, even twice a day if necessary, and then gradually diminished in frequency, until after the lapse of a week it is found that the maxillary sinus is quite free of any pus or flocculent mucus. By changing the obturator daily the patient can readily tell whether a washing out is required. When three to six months have pa.s.sed without any trace of secretion, the empyema may be considered cured. This is the more likely if a formerly obscure sinus becomes translucent, and if the patient pa.s.ses through a 'cold' without suppuration beginning in it again. A trifling amount of discharge is sometimes kept up by the mere presence of the obturator.

If the saline solution fails to arrest the discharge permanently, I have rarely found that any other lotion is more effective. Strong antiseptic solutions are too irritating; milder ones, like boric lotion, permanganate of potash, weak mercurial lotions, &c., are without effect.

If the discharge remain thick and offensive, peroxide of hydrogen may be added to the salt solution in the proportion of 2 vols. %. As an astringent, sulphate or chloride of zinc may be tried, in the proportion of 1 grain to the ounce; or the cavity may occasionally be washed out with a 2% solution of argyrol or nitrate of silver.