=Intranasal Surgery.=—Intranasal abnormalities, such as deflected
septum, spurs on the septum, hypertrophied turbinates, polypi, etc.,
which materially reduce the breathing space, usually demand surgery.
Nasal surgery, carefully and properly done, is always a great aid and
often absolutely essential to the successful treatment of hay fever and
asthma, but nasal surgery carelessly done frequently does more harm
than good.
The correction of a deflected septum or the removal of a spur on the
septum by submucous operation often aids materially in the prevention
of pressure irritation, increases the breathing space and normalizes
drainage from the sinuses.
Surgery is therefore very essential in many cases of hay fever, but
surgery is never the all essential part of the treatment, because if
the proper after treatment is not given, the surgery alone will seldom
result in either temporary relief or cure.
=Focal Infection.=—The importance of focal infection of the sinuses,
tonsils, teeth and occasionally other parts, such as the nasal
cavities, epipharynx, middle ear and mastoid cavities cannot be
overestimated. Such conditions may be effective in causing hay fever,
by causing direct infection of the membranes of the nasopharyngeal
tract or by auto-intoxication.
=Digital Surgery,= for the removal of adhesions in the posterior nares
and pharynx, is in my opinion, very essential, and this work should be
done thoroughly. Massage of the soft palate or pharyngeal walls is of
no particular value. All adhesions and adenoid tissue must be removed
because this removes an effective source of constant irritation and
focal infection and tends to normalize the direct and reflex nerve
mechanism.
The practice of the radical intranasal technique as originated by J.
D. Edwards, D. O., is indicated, I believe, in some cases in which the
crushing of cellular middle turbinates, or the breaking of adhesions is
indicated, but I am not yet ready to accept this theory of “curetting”
the mucous membrane by radical digital technique. The fracture of
the turbinates is not necessarily a bad technique provided they are
properly readjusted as Dr. Edwards does it, but to fracture and not
readjust is a dangerous practice. The efficiency and safety of any
method depends upon the operator’s definite knowledge of what needs to
be accomplished and how it is to be done.
There are contraindications to digital, as well as any other kind of
nasopharyngeal surgery, such as: (1) Acute infection of any part of the
nasopharyngeal tract; (2) evidence of sinus involvement; (3) septal
deflections, spurs and hypertrophied turbinates, which would not permit
such work without undue trauma.
There are certain other precautions such as thorough cleanliness of the
parts to be treated; aspiration of the sinuses before and afterward,
and the use of a finger of sufficient size which will not produce undue
trauma. In my opinion very few doctors have such fingers.
Failure in accomplishing results is due to three things, viz., (1)
Insufficient knowledge of diagnosis and prognosis; (2) insufficient
knowledge of what should be accomplished and the technique of doing it,
and (3) the necessary additional or supportive treatment.
It is a great mistake to think that the removal of adhesions in the
pharynx or nares is sufficient, because if this is not followed by
the proper supportive treatment, no results or even bad results will
frequently occur. This treatment is not a massage in any sense, but a
definite operative procedure and requires as much care and skill as the
removal of adenoids or tonsils.
Space will not permit an explanation of the digital technique and
the radical treatment should not be attempted without some definite
knowledge of the methods and technique.
=Intranasal Treatment.=—The intranasal method of treatment as explained
above under hypertrophic rhinitis is very effective and if carefully
and thoroughly done is in most cases just as efficient as intranasal
digital surgery. This treatment followed by irrigation and oil spray
and nasal packing will be found effective in most cases if the
treatment is properly done.
=Nasal Packing.=—Thorough packing of the nasal cavities after all
sources of focal infection have been removed and after thorough
cleansing has been done, by means of long strips of absorbent cotton
is effective in reducing the swelling and irritation.
=The Radical Packing Method.=—This method can be done best in a
hospital. The nares are prepared as for surgical operation, by complete
retraction of all erectile tissue, thorough cleansing by irrigation
and the application of a local anesthetic. Anesthesia need not be
complete. A careful examination is then made for any synechia, or focal
infections. Packing should never be done until the doctor is sure there
is no sinus involvement. The entire nasal cavity is then packed very
firmly with sterile gauze. This is best done by means of a special
packing instrument or long nasal packing forceps, using narrow gauze
contained in tubes. In some cases the nasal cavity is lubricated before
packing.
The packing should be done early in the morning and removed just before
bed-time, so that the patient may sleep. This treatment is repeated
daily until all signs and symptoms of nasal irritation are gone and
then replaced by irrigation and oil spray.
If this treatment is properly done, there will be a complete sloughing
of the pseudo-membrane followed by a restoration of normal and
resistive tissue. The results of our two years’ experience (we have
tried this on only a few patients each year) are very encouraging.
Relief from the symptoms are very prompt and seemingly more permanent
than from other methods.
=Treatment of Auto-intoxication.=—All sources of focal infection are
thoroughly treated. Sinus infection is very common and must receive
proper attention before any other treatment can be effective.
Our experience shows that many cases have auto-intoxication of
gastro-intestinal origin. The hospital care of such cases makes
possible the thorough cleansing of the colon by irrigation and the
reestablishment of an acid producing flora which seems to prevent
fermentation.
=Osteopathic Corrective Work.=—Thoroughness of treatment for the
removal of all causes is the secret of success. To successfully
remove the immediate sources of auto-intoxication by treating a
sinus infection or by thoroughly freeing the colon from fermentation
products means only temporary results if the underlying causes are not
corrected. A thorough osteopathic examination is necessary to determine
such causes and certainly such treatment should not be neglected.
Correction of all cervical and upper thoracic lesions and particularly
the clavicles and ribs is important. These lesions seem to be the
result rather than the cause, but normal respiratory functions
seemingly cannot be maintained unless such treatment is done.