OPENING THE SPHENOIDAL SINUS

=Indications.= Profuse purulent post-nasal catarrh, persistent headache, orbital or ocular or intracranial symptoms, call at once for relief. Not infrequently suppuration in other cavities will not cease, even though operated on, until the sphenoidal sinus has been treated.

=Operation.= Unless long-standing suppuration or ozna have produced such atrophy of the middle turbinal that the front wall of the sphenoidal sinus is easily inspected from the front, it will be necessary to remove the greater portion of the middle turbinal. If the anterior end has had the typical amputation performed (see p. 592), then the rest can be removed with the punch-forceps of Grunwald, the wire snare, or, under nitrous oxide anaesthesia, the spokeshave.

This will bring the anterior wall of the sinus with its ostium into view. Killian's long nasal speculum (Fig. 346) may still be necessary.

With the help of cocaine the ostium can then be enlarged with various instruments. Hajek's hook can be inserted into the orifice and the front wall torn away. I have not found this satisfactory. It is much simpler to insert the beak of a small Grunwald's forceps into it, or a small ring-knife, and by a series of boring and s.c.r.e.w.i.n.g motions to render the ostium patent. It is then easy to introduce a beaked Grunwald's or some such punch-forceps as those of Cordes (Fig. 348) and cut away as much of the front wall as may be required. This can be done freely in an inward and downward direction, and an opening as large as the tip of the little finger, and sufficient for drainage and treatment, is thus established.

When describing the removal of posterior ethmoidal cells (see p. 616) it was pointed out that the tip of the forceps not uncommonly breaks through the thin portion of the anterior sphenoidal wall.

If the natural ostium sphenoidale be not visible it would be risky to make an artificial opening without first determining by radiography the presence and size of the sinus. When this has been ascertained, palpation with a pair of sinus-forceps or a Lichtwitz's trochar and canula will generally detect a thin spot where firm pressure is sufficient to penetrate into the cavity. The opening is then enlarged as described.

[Ill.u.s.tration: FIG. 346. KILLIAN'S LONG NASAL SPECULUM.]

In all these procedures care must be taken that the instrument does not burst suddenly through the front wall with such force that it impinges on and damages the posterior wall.

The opened sinus must be dealt with according to the conditions met with. Necrosed portions of bone may require to be removed, but they rarely occur, except in syphilitic cases. Polypoid ma.s.ses of mucous membrane, obscuring the opening, may be carefully lifted out with forceps or curette, so as to facilitate drainage; but it is never necessary to think of curetting the interior generally, and particular regard should be paid to the posterior wall.

=After-treatment.= Profuse haemorrhage has sometimes occurred after opening the sinus. In a case of Gleitsmann's the bleeding did not take place until seven days after the operation,[84] and in one of C. R.

Myles's cases profuse haemorrhage occurred on the ninth day and required ligature of the external carotid.[85] It is possible that the bleeding in such cases may come from a branch of the internal maxillary artery, or even from the cavernous sinus. It can be met by firm plugging with a long strip of 1-inch ribbon gauze, of which the end is soaked in adrenalin or peroxide of hydrogen. Haemorrhage is not a complication that I have ever met with, after having opened a large number of sphenoidal cavities, and I do not think it is to be dreaded if the opening be made as directed.

[84] _Transactions of the American Laryngological a.s.sociation_, 1895, p.

91.

[85] Ibid., 1903, p. 241.

[Ill.u.s.tration: FIG. 347. RADIOGRAPH SHOWING A PROBE IN THE SPHENOIDAL SINUS. An india-rubber obturator is in the maxillary antrum.]

The sinus is washed out with a warm normal saline solution. The addition of peroxide of hydrogen may be useful. The condition of the mucous membrane may be improved by cleansing the sinus with iodoform emulsion, or plugging it for twelve or twenty-four hours with iodoform ribbon gauze. Any pigment can be kept in contact with the walls for some time by dipping the end of a piece of ribbon gauze into a solution of argyrol (25%) or nitrate of silver (2%) and packing it into the cavity. The other end of the strip is left just within the vestibule of the nose, so that the patient can withdraw it himself.

But if a sufficient opening has been made into the cavity to allow of natural ventilation and drainage, it is well to abstain from too much local medication--particularly if there be neither polypus, necrosis, nor foreign body in the sinus, and if it be not subject to reinfection from the suppuration in the posterior ethmoidal cells. It is remarkable how, under such conditions, suppuration will cease in a sphenoidal sinus if left alone, when, if frequently treated, secretion will continue indefinitely. In my experience the sphenoidal sinus is one of the most satisfactory of the accessory sinuses to treat.[86]

[86] _Proceed. Royal Society of Medicine_, Meeting of June, 1908.

[Ill.u.s.tration: FIG. 348. SPHENOIDAL PUNCH-FORCEPS.]

=Other methods.= The sphenoidal sinus can also be opened and treated during Killian's operation on the frontal sinus (see p. 648).

It has been proposed to approach the sphenoidal sinus by first traversing the maxillary antrum. Such a complicated route, involving extensive destruction of tissue, has no advantage over the direct and simple method described. Attempts to reach the sphenoidal sinus from the naso-pharynx are not practical. This is easily seen by observing the thickness of the floor of the cavity depicted in Fig. 345.

OPERATION IN MULTIPLE SINUS SUPPURATION

Before starting treatment in a case of multi-sinusitis a complete examination should be formulated. The importance of making the differential diagnosis as complete as possible cannot be overestimated.

In initiating treatment attention should be directed first to the ethmoidal region. The ethmoid should be attended to in all cases of suppuration in the frontal sinus. It is generally necessary, in any case, to clear it away to gain access to the sphenoidal orifice. It is well to remove it before or during operation on the maxillary sinus. The sphenoidal sinus should be catheterized, and, if infected, the orifice will require enlarging and the cavity treating. A frontal sinus should be washed out several times before deciding on a radical operation. It not uncommonly ceases to secrete after the ethmoid has been cleared.

The radical operation on the frontal sinus should not be embarked on until the ethmoid and sphenoid have been attended to. A radical frontal operation should take precedence of the maxillary, unless both cavities are operated on at the same time.

CHAPTER VI

OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS FOR RETROPHARYNGEAL ABSCESS: OPERATIONS FOR NASO-PHARYNGEAL ADENOIDS

METHODS OF OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE NOSE

Many growths in the naso-pharynx, whether originating in the s.p.a.ce or descending into it from the posterior choanae, can be removed by the following method.

=Indications.= This operation is indicated for the ordinary mucous polypus of the nose when presenting in the post-nasal s.p.a.ce. Polypoid ma.s.ses of the ethmoid may project through the posterior cavity and are removed in the same way. A naso-pharyngeal polypus (also called choa.n.a.l polypus, post-nasal polypus, or benign pharyngeal polypus) is easily removed by this procedure. Innocent tumours of the post-nasal s.p.a.ce, such as papilloma, adenoma, fibroma, and cysts, can be removed by the same method.

=Under cocaine.= Cocaine and adrenalin (see p. 572) should be carefully applied to the septum and turbinals, as it is the pa.s.sage of the instrument from the front which is often the most painful part of the proceeding. The pharynx should be lightly sprayed with a 5% solution of cocaine so as to check reflex action.

While the patient is seated in the ordinary examination chair the surgeon stands at his left hand and introduces a looped snare (Fig. 312, p. 613) through the nostril most suitable for approaching the root of the growth. When the snare has reached the post-nasal s.p.a.ce, the surgeon introduces the purified forefinger of the left hand through the mouth and up behind the soft palate, as in Fig. 291. Here it serves to manipulate the loop over the growth, and holds it close to the root of the pedicle while the snare is pulled home.

A few minutes should be allowed to elapse to permit the patient to recover from the unpleasant manipulation, and also to allow of coagulation of the strangulated blood-vessels. The growth should not be cut through, as it is wiser to pluck it from its attachment by a quick movement of avulsion.

The growth may come away with the snare through the nostril, or may fall into the pharynx and be expectorated.

In fairly roomy nostrils a stout polypus forceps can be used instead of the snare.

=Under chloroform.= In nervous subjects the same method should be carried out under a general anaesthetic, care being taken that the growth does not cause embarra.s.sment by occluding the larynx.

Under chloroform, of course, more extensive operations can be carried out on the post-nasal s.p.a.ce. The pedicle can be attacked with a pair of scissors with long handles, short blades, and slightly curved on the flat. These are introduced through that nostril which appears to be in most direct line with the pedicle, to act as a raspatory, and then cut through the base of the growth. In some cases an instrument such as Langenbeck's elevator (Fig. 338) will prove useful if introduced through the nostril. The growth is then removed through the mouth by a twisting movement with a strong volsella.

OPERATIONS FOR OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE MOUTH

Many growths in the naso-pharynx can be removed through the mouth, without preliminary operations through the face or through the hard or soft palate.

=Indications.= The following method of access to the naso-pharynx is chiefly called for in true fibroma of the naso-pharynx, otherwise called naso-pharyngeal polypus, fibroid tumour of the base of the skull, fibroid tumour of the naso-pharynx, retro-maxillary polypus, or juvenile sarcoma of the naso-pharynx.

It is also a plan of procedure which may be called for in any very large, innocent tumours of the naso-pharynx, particularly in cases where nasal stenosis prevents access from the nostrils. It would be a suitable method in any operable cases of malignant disease of the post-nasal s.p.a.ce.

=Operation.= The patient is chloroformed and placed in the position of Rose (hanging head). The mouth being propped open, and the tongue drawn forward, the tumour is first explored with the forefinger, to detect and detach any secondary adhesions. A raspatory which works laterally is next pa.s.sed from one side of the naso-pharynx to the other above the growth. A rugine which works in a sagittal plane is then introduced below the tumour and made to pa.s.s upwards behind it--the reverse movement of Gottstein's curette in the removal of adenoids (Fig. 350).

This movement is facilitated by securely gripping the tumour and dragging it forwards with a stout pair of alligator or volsella forceps.

The tumour can thus be so liberated that, with some twisting movements, it can sometimes be extracted entire--often dragging down with it through the naso-pharynx any prolongations thrown forward into the nose.

It is useless to attack such growths as true fibroma of the naso-pharynx with an ordinary wire snare, or such an instrument as a pair of adenoid forceps. For these firm tumours, specially powerful forceps have been designed by Doyen and Escat.

_Haemorrhage_ is apt to be sudden and copious, but the more rapidly and completely the growth is removed the sooner will bleeding cease--even spontaneously. After complete removal firm pressure with a marine sponge will generally check it. A post-nasal plug should be avoided, and is not usually required. Incomplete operations not only start haemorrhage but may start septic absorption.

=Modifications.= (_a_) _Preliminary laryngotomy._ A preliminary laryngotomy, strongly recommended by J. W. Bond and extensively adopted by Butlin, adds nothing to the dangers of the case. It allows of the laryngo-pharynx being packed, so that there is no anxiety in regard to the descent of blood into the lungs, and it permits the steady administration of the anaesthetic through the laryngotomy canula. The surgeon is thus relieved of two great anxieties, and can devote himself without embarra.s.sment to more deliberate operation.

The laryngotomy tube can be removed as soon as the patient recovers consciousness and all haemorrhage has ceased.

(_b_) _Division of the soft palate._ In addition to the operation of laryngotomy, the following procedure will allow of more deliberate removal.