=Complications= arising after tracheotom_A System of Operative Surgery, Volume 4 (of 4)

tube:--

1. _Wound infection._ This rarely occurs at the present time, and

diphtheritic wounds are seldom seen. Some inflammation of the wound is

natural under the conditions, and may be associated with œdema of the

surrounding tissues; this generally yields to antiseptic treatment in a

few days. In very weakly children suffering from a virulent form of

disease the healing of the wound may be slow, and septic conditions are

apt to arise ending in cellulitis of the neck or even typical

erysipelas. Owing to the disposition of the fasciæ there is a tendency

for the infection to spread in a downward direction, and for mediastinal

inflammation or suppuration to occur: this appears to be more common

after low tracheotomy. The prognosis in such cases is not good, and

every endeavour should be made to prevent the possibility of their

occurrence by absolute cleanliness at the operation and by suitable

after-treatment of the wounds.

2. _Septic conditions_ of the trachea are less common since the

introduction of antitoxin, but occur in cases where false membrane is

abundant. There may be swelling of the mucosa, or copious discharge

which persists for long periods.

3. _Ulceration_ may be due to sepsis or to pressure from a badly fitting

tube, especially when the latter has been worn for a protracted period

(Fig. 270). It may cause perforation and localized abscess either in

front of the trachea or in the neighbourhood of the œsophagus, and may

result in a communication with the latter. In the region of the cricoid,

ulcers are liable to cause necrosis. The signs of such ulceration are:

continuance of purulent discharge, discoloration of the tube, bleeding

from the wound, and, above all, difficulty in removing the tube.

[Illustration: FIG. 270. TRACHEA SHOWING ULCERATION CAUSED BY A BADLY

FITTING TUBE. A, Tracheotomy opening; B, Ulcer caused by the end of the

tube. (_From Specimen No. 1659a in the Museum of St. Bartholomew’s

Hospital._)]

At the first indication of ulceration the cause of irritation should be

removed. It is advisable to discard a metal in favour of a rubber tube,

or, if possible, to remove the tube altogether. Strenuous efforts must

then be made to disinfect the trachea by the insufflation of

antiseptics, either as powders or in solution. The healing of such

ulcers is very slow, and granulations are apt to form resulting in

obstruction and preventing removal of the tube. In later stages

contraction of fibrous tissue causes stenosis; this is more common in

the neighbourhood of the cricoid, especially when the latter has been

divided at the time of the operation.

4. _Granulations._ The possible presence of granulations must always be

borne in mind. I believe this condition is far less common than is

generally supposed, and that in many cases the granulations are entirely

limited to the neighbourhood of the wound, where they can be seen. It is

doubtful whether they are responsible for the dyspnœa which occurs.

Great ingenuity and patience are required for the treatment of this

condition. The wound must be kept scrupulously clean and all source of

irritation removed. A rubber canula should be substituted in place of a

metal one; if it were possible it would be advisable to discard the tube

altogether, but as yet no form of dilator has been devised which will

take the place of the canula. If the granulations be large they should

be removed either with a sharp spoon or with suitable forceps, the area

having been anæsthetized previously by a small quantity of the novocaine

and adrenalin mixture. When small, the use of silver nitrate is

preferable. It may be necessary to repeat this after a few days, and as

soon as seems advisable a further attempt should be made to dispense

with the tube. At this stage time must be allowed for the various

tissues to regain their normal condition. Should this treatment prove

unsuccessful, a thorough investigation must be made under chloroform.

The wound is enlarged as far upwards as the cricoid, bleeding being

arrested with the mixture just described. By throwing a strong light

into the wound, the condition of the mucous membrane can be inspected

and granulations removed. If there be no granulations in the trachea, a

tube speculum can be passed through the mouth to ascertain the condition

of the larynx (see p. 480). Such a method of procedure is preferable to

the passage of probes, forceps, sponges, and other articles through the

larynx, in the hope that any obstruction may be removed. If ulceration

or necrosis of cartilage be discovered, it is impossible to relieve the

condition by surgical means without prolonged treatment with tubes and

the constant use of antiseptics. Under these conditions it is advisable

to consider the removal of the tracheotomy tube in favour of intubation.

In the hands of many foreign authorities the use of intubation tubes

covered with gelatine, in which antiseptic is introduced, has been

attended with such conspicuous success that further attempts should be

made in this country; there is little doubt that, as our knowledge of

the treatment of such wounds improves, better results are daily

attained. Whatever treatment is considered it is important first of all

that the actual cause should be distinguished. This is now possible

owing to the great advances made in methods of examining the larynx.

5. _Stenosis_ of the larynx or trachea occurs in old-standing cases, as

the result of ulceration, after some cases of crico-tracheotomy, and

especially where a tube has been worn for a very protracted period.

Breathing through a tube, if continued for a long time, interferes with

the natural growth of the air-passage above it. The child grows, but the

larynx remains stationary. This condition is aggravated by the fact that

some inflammation is constantly present, especially in the neighbourhood

of the wound, so that the tissue become fibrous and hard. The fibrous

tissue contracts and stenosis is caused. According to von Bruns,

Kohl,[28] and others, constrictions of the trachea may in rare instances

result from some kinking of its wall. Such conditions as a bulging of

the posterior wall due to the approximation of the posterior ends of the

cartilage secondary to the spreading of the anterior portions, inversion

of the tracheal margins from too small an incision, overlapping of the

tracheal wound, and cicatricial union between the thyreoid and cricoid,

must be exceedingly rare. Here, again, a definite diagnosis can always

be made by proper investigation, but treatment is more difficult.

Dilatation must be attempted by either continuous or intermittent

methods. If preferred, a short piece of rubber tubing can be passed

upwards from the tracheotomy wound into the larynx and kept in place for

several hours by two silk sutures, one passing out of the tracheal

wound, the other out of the mouth; or a stenosis canula can be inserted

with some form of hollow plug which passes upwards into the larynx (Fig.

272). The question whether the tracheotomy wound should be kept patent

is difficult to answer. When stenosis is extreme there is no

alternative, and the open wound allows of the constant passage of

graduated bougies, which is more easily accomplished from below than

from above. If treatment be persistent the prospect of a good result is

not unfavourable, and there is every reason to believe that in the

future the number of cases which require a permanent tracheotomy tube

will be reduced to a minimum.

[28] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 270.

[Illustration: FIG. 271. STENOSIS FOLLOWING TRACHEOTOMY. (_From Specimen

No. 1659d in the Museum of St. Bartholomew’s Hospital._)]

6. _Paralysis._ In the larynx there may be paralysis of the sensory or

of the motor nerves. In the former case food may enter into the trachea

and cause troublesome coughing and possibly ‘Schluck-pneumonie’. When

the motor nerves are affected, the paralysis is commonly abductor and

may be unilateral or bilateral, the latter associated with inspiratory

dyspnœa. ‘Complete paralysis of the recurrent laryngeal nerve may also

occur, but is nearly always confined to one side’ (C. A. Parker[29]).

Such paralyses may last from a few days to several months, and are very

troublesome when associated with the passage of food into the trachea;

when severe, nourishment should consist of fluids which can be

administered by a nasal tube.

[29] _Nose and Throat_, 1906, p. 94.

[Illustration: FIG. 272. TUBES USED IN THE TREATMENT OF STENOSIS OF THE

LARYNX. A, Lack’s; B, Störk’s; C, Schimmelbusch’s.]

Further complications arising during the after-treatment of tracheotomy:

7. _Broncho-pneumonia._ This occurs in the worst forms, and is

accompanied by high temperature with definite signs in the lungs. The

absence of septic discharge, the restlessness of the patient, and the

rapidity of the breathing (in many instances accompanied by ‘recession’

not caused by obstruction in the tube) make the condition easy to

recognize. There is no satisfactory treatment for septic

broncho-pneumonia which has already developed, but it may be prevented.

Within recent years it has become less common. This is due to better

technique in the operation, and to careful attention during the

after-treatment. The habit of passing feathers into the trachea has been

abandoned with advantage to the patient. When possible the child should

be removed from septic influences which are liable to infect the throat,

for the occurrence of tonsil[l]itis as a sequel to tracheotomy is

always to be feared in wards containing septic cases.

8. _Emphysema_ may occur in the neighbourhood of the wound, or in rare

cases may be extensive and involve the whole of the face, neck, and

chest. Champneys[30] was the first writer to call attention to this

complication of tracheotomy. After a large number of observations and

experiments, he was of opinion that emphysema of the anterior

mediastinum occurs in a certain proportion of tracheotomies and is of

frequent occurrence in cases that are fatal; that it may be associated

with pneumothorax; and that the conditions which favour its production

are a low division of the deep cervical fasciæ in the neighbourhood of

the sternum, combined with obstruction of the air-passages and strong

inspiratory efforts; artificial respiration, especially if improperly

performed; and want of skill on the part of the operator; further, that

the dangerous period of the operation is between the division of the

deep cervical fascia and the efficient introduction of the tube. To this

may be added those cases in which the tube slips out of the trachea into

the cellular tissue above the sternum and thus causes more or less

obstruction to breathing. It seems probable that the air is sucked into

the cellular tissues beneath the pretracheal fascia, rather from the

outside than from the trachea, and that with forced expansion of the

chest it finds its way beneath the fascia into the mediastinum.

[30] _Trans. Med. Chirurg. Soc._, vol. lxv, p. 85; vol. lxvii, p. 102.

[Illustration: FIG. 273. TRACHEA SHOWING ULCERATION INTO THE INNOMINATE

ARTERY AFTER TRACHEOTOMY. (_From Specimen No. 1622a in the Museum of St.

Bartholomew’s Hospital._) A, Aorta; B, Ulcer; C, Right subclavian; _D_,

Right common carotid; E, Left common carotid; F, Left subclavian.]

9. _Hæmorrhage_ may occur as the result of slipping of a ligature during

an attack of vomiting or struggling after the operation; it is usually

venous and requires nothing but passing notice. Secondary hæmorrhage may

result from ulceration into one of the larger arteries or veins.

Kocher[31] states that ‘the number of cases recorded is now about

eighty-seven, of which fifty-six are associated with the innominate

artery. Unfortunately it is not known how often in these cases inferior

tracheotomy had been performed. Low tracheotomy was performed in my case

because an excision of the larynx for cancer had been undertaken.

Doubtless the danger of these fatal complications is much greater with

inferior tracheotomy owing to the pressure of the canula.’ Von Bruns[32]

also agrees that ‘the vast majority of fatal hæmorrhages were in cases

of inferior tracheotomy. Of thirty-six cases in which the source of

hæmorrhage was given, twenty-eight were traced to the innominate vein,

two to the right carotid, and one each to the superior thyreoid, the

left innominate, the right jugular and the left jugular.’ Bleeding is

also recorded in cases of aneurism of the aorta, in which tracheotomy

has been performed, as the result of erosion of the tracheal wall and

the bursting of the sac. Further, troublesome oozing may take place from

the mucous membrane of the trachea when this is inflamed, or when

granulations are present, or when there is much sloughing of tissues,

and especially after a metal tube has been worn for a considerable

period. Hæmorrhage from an enlarged thyreoid isthmus is also described.

When due consideration is given to the septic condition of the wounds

and the close relation of large vessels, it is surprising to find that

hæmorrhage proves so seldom fatal.

[31] _Chirurg. Operat._, 1907, p. 631.

[32] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 265.

[Illustration: FIG. 274. ANEURISM OF THE AORTA PERFORATING THE TRACHEA.

(_From Specimen No. 1500 in the Museum of St. Bartholomew’s Hospital._)

A, Aorta; B, Left subclavian; C, Left common carotid; D, Ulcer in sac of

the aneurism.]

10. _Cardiac paralysis_ may also complicate tracheotomy. When

supervening in the acute stages of the disease, the patient becomes

prostrate and vomiting is persistent, while the heart gradually fails.

In other cases death occurs suddenly and unexpectedly, in mild as well

as in severe disease; this may happen at any period, during the first

days or later, during convalescence. Heart failure is more common in

diphtheria than in any other infectious disease which is met with in

this country.

=Prognosis.= It may be said that all cases of laryngitis caused by

diphtheria are of a serious nature, and especially those which require

tracheotomy (see Table, p. 517). The mortality amongst tracheotomized

patients during five years was 31.5%, and the variations in each

separate year were slight. Such results are far from satisfactory, but

it must be remembered that in pre-antitoxin days less than 30% recovered

after tracheotomy (Goodall[33]). The use of antitoxin, first suggested

by Behring, is undoubtedly responsible for this remarkable decrease in

the mortality. The sooner the serum is injected the better the prognosis

with tracheotomy. A large dose should be given, 8,000 to 18,000 units,

irrespective of age, and the dose may be repeated on the second day if

required. Improvement generally commences between twelve and twenty-four

hours after injection; the swelling of the mucosa subsides, and

secretion is diminished; false membrane is not so copious, and rarely

extends to the trachea and bronchi; crusts become less adherent, and are

expelled by the patient. In this manner the whole area of the disease

becomes clean, and there is less absorption of toxins. It is now

generally agreed that serum should be used in all suspicious cases, and

some authorities inject at once not only the patient, but also other

children living in the same house. It is hoped by early injection to

avoid the necessity for tracheotomy.

[33] _Brit. Med. Journ._, 1899, vol. i, p. 199, ‘On the Value of the

Treatment of Diphtheria by Antitoxin.’

The age of the patient is very important, as the following table shows:

TABLE SHOWING TOTAL DIPHTHERIA TRACHEOTOMIES PERFORMED AT THE FEVER

HOSPITALS IN LONDON DURING 1902-6, INCLUDING THOSE IN WHICH

INTUBATION WAS PREVIOUSLY PERFORMED AND THOSE IN WHICH NO ANTITOXIN

WAS USED

+---------+----------+-----------+----------------+

+---------+----------+-----------+----------------+

| Under 1 | 62 | 40 | 64.5 |

| 1-2 | 256 | 123 | 48.0 |

| 2-3 | 272 | 87 | 31.9 |

| 3-4 | 231 | 54 | 23.3 |

| 4-5 | 196 | 45 | 22.9 |

| 5-6 | 119 | 19 | 16.0 |

| 6-7 | 67 | 18 | 26.9 |

| 7-8 | 22 | 5 | 22.7 |

| 8-9 | 12 | 3 | 25.0 |

| 9-10 | 9 | 3 | 33.3 |

| Over 10 | 16 | 6 | 37.5 |

+---------+----------+-----------+----------------+

| Total | 1,262 | 403 | 31.9 |

+---------+----------+-----------+----------------+

From these figures it is apparent (1) that children less than one year

of age rarely recover after tracheotomy; this is especially true of

diphtheria, although in other forms of laryngeal obstruction cases of

recovery have been reported in children of six months; (2) that in the

early years of life tracheotomy is most commonly needed, especially

between the ages of one and five years; (3) that the death-rate

gradually decreases between the ages of one and six years, after which

there is a rise.

In explanation of these facts it appears probable that after five years

of age the larynx and trachea are increased in size, so that obstruction

is only met with where there is a large amount of membrane, namely, in

the worst cases; in patients over ten, the age which marks the change to

the adult type of larynx, the air-passages become so large that

obstruction seldom occurs even when much membrane is present; dyspnœa,

in these cases, points to extension of the disease to the smaller tubes,

and tracheotomy is unable to give the same relief.

In considering the prognosis, not only must the symptoms peculiar to the

case be taken into account (as for instance the pulse, temperature,

respiration and general condition), but also any complications that

arise. It must be borne in mind that tracheotomy does not cure, although

it can relieve, the patient; that nearly one-third of the cases die;

that the disease, and not the operation, is responsible for most of the

deaths. Moreover, the amount of toxæmia depends upon the virulence of

the infection, which is variable in different epidemics; upon the area

of mucous membrane infected; and upon the constitution of the patient.

In so-called hæmorrhagic diphtheria the result is always fatal.

_The effect on after-life._ It was stated by Landouzy at the Berlin

Tuberculosis Congress in 1899 that, judging by the rarity of the scar,

few tracheotomized children reach adult life, but inquiries in Germany

showed that this was incorrect. H. W. L. Barlow, in reviewing the

literature of the subject, concludes that ‘in the large majority of

cases the cure is permanent and complete’. In cases where a tracheotomy

tube has been retained for a long period, however, complications are

liable to arise; these include stenosis of the larynx or trachea,

bronchitis, pneumonia, and possibly tuberculosis (see p. 485).

TRACHEOTOMY IN CONDITIONS OTHER THAN DIPHTHERIA

The indications for tracheotomy in conditions other than diphtheria have

already been described. Although local anæsthetics are of little

practical value in children, their use is much preferred where adults

are concerned. The three drugs most commonly used at the present time

are eucaine, cocaine, and novocaine, and of these novocaine is

unquestionably to be preferred for subcutaneous injection as being less

toxic, less irritant to the tissues, and at least as efficient in

producing anæsthesia. Whichever drug is chosen, a small quantity of

chloride of sodium should be added in order to make the solution

isotonic with the blood serum, and thus to render it practically

non-irritant. Many surgeons add adrenalin to contract the vessels in the

injected area and so to prevent the drug from being absorbed into the

general circulation: owing to the large size of the vessels and their

proximity to the heart this is important, but it must also be remembered

that with strong solutions there is great contraction of vessels, and

that when the effects have disappeared there is a slight danger of

recurrent hæmorrhage. Semon has drawn attention to this danger in

connexion with operations upon the larynx, and after minor operations in

other regions of the body it is not uncommon to find a small hæmatoma

which necessitates reopening the wound.

In order to ensure the full effects of local anæsthesia with the least

possible disadvantage, the drug should be used in weak solution, and the

injection should be made at least a quarter of an hour before the

operation is commenced. It is only necessary to prick the skin at one

point, namely, at the upper end of the proposed incision; a small

quantity of the fluid should be expelled, after which the needle may be

withdrawn. After a short interval it is possible to reinsert the needle

(or a larger one if preferred) and to push it deeper, until the whole

length of the incision has been injected, without distress to the

patient.

The following solution will be found effective:

‘Novocaine, 4% solution ɱ x = 1.3%

Sodium chloride, 4% solution ɱ vj = 0.8%

Adrenalin, 1-1,000 ɱ i = 0.003%

Distilled water to ɱ xxx

[Transcriber’s note: ɱ (approximation to symbol in the text) is

thought to mean drops, minims, or parts by volume;

hence ɱ x = 10 parts/drops, ɱ vj = 6 parts/drops, ɱ i = 1 drop

made up to a total of 30 parts/drops with distilled water]

‘These local anæsthetics are all, more or less, rapidly decomposed

and rendered inactive in the presence of even traces of an alkali or

alkaline carbonate. If boiling is resorted to in order to sterilize

the syringe, great care must be taken that no soda is

present.’--LANG.

Moreover, the finished solution cannot be boiled without decomposing the

adrenalin, and it is customary therefore to add thymol or Ol. Gaultherii

(0.1%), which keeps the solution antiseptic without being irritant.

The operation, which is often required in adults, must be carried out

upon the lines already described. The enlargement of the thyreoid and

cricoid cartilages, the small amount of fat, the small size of the

thyreoid isthmus and of the pretracheal vessels after puberty, make the

trachea easy to find. Difficulties, however, arise and are determined by

the urgency of the case and the nature of the disease. Thus, with

inflammation, the neck may be so swollen that the trachea is many inches

from the surface; with tumours the trachea may be displaced, or the

obstruction may be in the thorax. Under such conditions it is important

to note the probable position of the trachea before the operation is

commenced, and to be prepared for serious hæmorrhage.

The after-treatment also corresponds to that which is adopted in

diphtheria. It is important to keep the tube clean and to prevent it

from irritating the trachea. The time for removal of the canula varies

according to the condition. Thus, when tracheotomy is performed for a

foreign body, the tube may be removed as soon as the object has been

extracted; on the other hand, when treating stenosis of the larynx it

may be necessary to advise permanent wearing of the canula.

Complications are less common than with tracheotomy for diphtheria.

Under favourable conditions there is little danger of pneumonia unless

the wound becomes infected, as may happen when the operation is

undertaken for the relief of septic inflammations.

Although tracheotomy is in itself a slight operation, it should be

reserved for cases that demand it. The mortality of the operation under

favourable conditions is probably very small; on the other hand, in

acute septic conditions and in patients suffering from bronchitis there

are grave dangers of complications.

TRACHEO-FISSURE AND RESECTION OF THE TRACHEA

Although these operations are very rarely performed, advance has been

made in their technique during recent years.

=Indications.= (i) _Tumours of the trachea._ These are uncommon.

Thiesen[34] in 1906 collected from literature 135 cases, of which 89

were innocent and 46 malignant. The majority of the former were

papilloma (25), fibroma (24), enchondroma (17), and intratracheal struma

(10). Of the latter, carcinoma (28) was more common than sarcoma (18).

More than half of these tumours were situated high up in the trachea.

These cases were collected from a period covering seventy-five years,

which proves that they are extremely rare as compared with tumours of

the larynx.

[34] _Trans. Amer. Laryng. Assoc._, 1906, p. 264, ‘Tumours of the

Trachea.’

(ii) _Stenosis due to previous inflammation._ Stenosis may be caused by

diphtheria or other fevers, syphilis, the presence of a foreign body, or

the inhalation of corrosive acids or chemical fumes. Such cases are

generally treated by endotracheal methods (see p. 559).

(iii) _Cut-throat, or injury._ An operation may be necessary after

crushing or bullet wounds, or, in later stages, owing to the development

of stenosis.

The diagnosis of these conditions is now comparatively easy, and with

the help of direct laryngoscopy and X-ray photography the exact

condition can, in many cases, be determined. In some instances the

tumour may be removed by endotracheal operation, especially if the

growth is innocent.

=Tracheo-fissure= is more reliable, and should always be performed when

there is any suspicion of malignancy. The preliminary stages are similar

to those of tracheotomy. A section of the trachea is first made in the

region of the tumour, and the opening is enlarged so that the growth can

be thoroughly explored; this can be better accomplished when the trachea

is illuminated by a good electric lamp, in some instances a Killian’s

tube being required. When possible, a tampon canula is inserted into the

lower part of the trachea. When the growth is low down, the patient is

placed in the Trendelenburg position in order to prevent the inspiration

of blood. Should the diagnosis be uncertain, a portion of the tumour can

be excised and a frozen section made. If proved to be innocent, the

growth can then be freely excised with scissors or galvano-cautery. The

bleeding is arrested, and the tracheotomy tube is retained for several

days. The after-treatment must be conducted on lines similar to those

laid down for laryngectomy, the patient being turned on the face in

order to prevent pneumonia. ‘Up to the present time about two dozen

operations of this sort have been reported. The author has removed in

this manner four intratracheal thyreoids with permanent result’ (von

Bruns).[35]

[35] Bergmann, E. von. _Sys. Pract. Surg._, vol. ii, p. 249.

[Illustration: FIG. 275. SARCOMA OF THE TRACHEA. (_From Specimen No.

1658a in the Museum of St. Bartholomew’s Hospital._)]

=Resection.= If the tumour be malignant, the surgeon must first decide

whether its removal is practicable or whether palliative tracheotomy is

preferable. In the former case the trachea is isolated laterally and

divided transversely well below the growth. Whenever possible the lower

end is then brought outwards and temporarily attached to the lower part

of the incision above the sternum. The resection of the trachea is then

carried out, so that the growth is freely removed, care being taken to

preserve the recurrent laryngeal nerves. ‘Where the section of the

trachea to be removed is limited to 4 centimetres or less, the two ends

can generally be approximated and united, restoring the calibre of the

tube and normal mouth respiration’ (Brewer).[36] This is accomplished by

numerous catgut sutures some of which include the entire thickness of

the tube. The muscles can be approximated so as to cover the incision,

and the wound can be drained freely. On the other hand, the lower end of

the trachea may be permanently fixed in the wound as described under

laryngectomy (see p. 498). Von Bruns has removed a cancer on the

posterior wall of the trachea with six tracheal rings, thus giving the

patient six years of life. He remarks: ‘operative treatment in tumours

of the trachea shows brilliant results. Untreated the condition leads to

death from suffocation. In seven cases operated upon by me, the results

were all favourable.’

[36] _Keen’s Surgery_, 1908, p. 510.

CHAPTER IV

INTUBATION OF THE LARYNX

Intubation, or ‘tubage’, was first recommended by Loiseau and Bouchut in

France; in 1880 attention was drawn to the subject by Sir W. Macewen in

England, and soon afterwards O’Dwyer[37] of New York published articles

which resulted in its being extensively tried in America; since that

time it has continued to be popular in that country for the treatment of

laryngeal diphtheria. ‘The good results which American physicians have

secured by intubation may be explained, perhaps, by the circumstance

that according to their reports diphtheria takes a milder form in

America’ (Tillmanns).[38] Intubation has been extensively used in

Europe, especially in Germany, but never to the same extent as

tracheotomy, and in England it has been practised at only a small number

of hospitals; thus, of the nine M. A. B. fever hospitals in London only

three used it regularly during 1906-7, and none of them so often as

tracheotomy.

[37] _New York Med. Journ._, 1885, vol. xlii, p. 145.

[38] _Text Book of Surgery_, 1900, vol. ii, p. 625.

=Intubation versus Tracheotomy in Diphtheria.= Since the introduction of

the newer method of treatment in 1880 the subject has been widely

discussed in America, on the continent of Europe, and in England. There

is no evidence to show that treatment with antitoxin has been beneficial

to one operation more than to the other.

The _advantages_ claimed for intubation are:

1. No anæsthetic is required.

2. Consent of friends is easily obtained.

3. No cutting: great rapidity.

4. No wound to heal.

5. Tube worn more easily than the tracheotomy tube.

6. Breathing through natural passages, so that warmth and moisture are

added to the air.

7. Its earlier performance.

8. Its better results in children under five.

9. Recovery is quicker.

The practical _disadvantages_ are:

1. Quite unsuitable except at special hospitals, as great dexterity and

constant practice are necessary.

2. Respiration is interfered with during introduction, so that celerity

is indispensable, accidents are frequent, and failure is common.

3. Tube may be coughed up (28%, Goodall[39]), blocked (12%, Goodall),

and does not provide good drainage for secretions.

4. Swallowing difficult.

5. Complications common: Broncho-pneumonia, ulceration, cicatrization.

6. After-treatment difficult and constant watching required.

7. Necessity for secondary tracheotomy (32.6%), which has a greater

mortality (death in 46.1%, see table below).

8. Retained tube.

[39] _Edin. Med. Journ._, 1902, p. 235, ‘Observations on Intubation of

the Larynx.’

In considering the above it is the obvious duty of the surgeon to advise

what he considers the better operation for the case, and this must

depend largely upon the amount of his experience; the argument that the

operation is superior because it can be previously practised on the

cadaver is a bad one, and implies a failure to realize the many

difficulties which will be encountered in the selection of cases, the

operation itself, and its after-management.

I am strongly of opinion that the operation ought not to be tried

indiscriminately by those who have no knowledge of these difficulties.

In the hands of an expert it is a justifiable method of treatment which

is suitable for selected cases, and it is one which can be used early;

tracheotomy, on the other hand, is naturally delayed, or used for

serious cases and those which have not derived relief from intubation.

Although intubation has received extensive trial, the published results

show great variations and do not prove that intubation is superior to

tracheotomy, but rather the reverse.

TABLE SHOWING DETAILS OF CASES DURING 1906 AND 1907 AT THE M. A. B.

HOSPITALS WHERE INTUBATION IS FAVOURED

+-------+------------+------------+------------+------------+

+-------+---+---+----+---+---+----+---+---+----+---+---+----+

| |_C |_D | |_C |_D | |_C |_D | |_C |_D | |

| | a | e | | a | e | | a | e | | a | e | |

| | s | a | | s | a | | s | a | | s | a | |

| | e | t | %. | e | t | %. | e | t | %. | e | t | %. |

| | s | h | | s | h | | s | h | | s | h | |

| | ._| s | | ._| s | | ._| s | | ._| s | |

| | | ._| | | ._| | | ._| | | ._| |

+-------+---+---+----+---+---+----+---+---+----+---+---+----+

|Eastern| 78| 4| 5.1| 44| 19|43.1| 30| 13|43.3|152| 36|23.6|

|Western| 25| 7|28.0| 10| 4|40.0|126| 41|32.5|161| 52|32.2|

|Park | 31| 3| 9.7| 11| 7|63.6| 16| 11|68.7| 58| 21|36.2|

+-------+---+---+----+---+---+----+---+---+----+---+---+----+

|Total |134| 14|10.4| 65| 30|46.1|172| 65|37.7|371|109|29.3|

+-------+---+---+----+---+---+----+---+---+----+---+---+----+

Certain points in the table deserve attention:

1. In cases treated by intubation only, the results are excellent,

namely, death in 10.4%.

2. In cases where tracheotomy was afterwards performed the mortality is

high, _i.e._ 46.1%.

3. Where tracheotomy was the original operation the mortality is also

high, _i.e._ 37.7%.

4. The total operations at these hospitals taken together show a rather

higher mortality than appears in the table below.

As regards the first three points, the facts are the same as in any

published statistics dealing with the relative advantages of the two

operations. I wish to emphasize that the results obtained by intubation

depend very largely upon the selection of the cases and I agree with

Turner and Cuff that, in order to arrive at any conclusion in the

matter, it is necessary to compare the total results of those hospitals

where intubation is favoured with those of the hospitals where

tracheotomy is chiefly employed.

TABLE SHOWING COMPARATIVE RESULTS AT ‘INTUBATION’ AND ‘TRACHEOTOMY’

HOSPITALS

+-------+------------------+--------------------+-----------------+

+-------+------+-----+-----+--------+-----+-----+-----+-----+-----+

| | _C | _D |_M p | _C | _D |_M p | _C | _D |_M p |

| | a | e | o e | a | e | o e | a | e | o e |

| | s | a | r r | s | a | r r | s | a | r r |

| | e | t | t | e | t | t | e | t | t |

| | s | h | a c | s | h | a c | s | h | a c |

| | ._ | s | l e | ._ | s | l e | ._ | s | l e |

| | | ._ | i n | | ._ | i n | | ._ | i n |

| | | | t t | | | t t | | | t t |

| | | | y ._| | | y ._| | | y ._|

+-------+------+-----+-----+--------+-----+-----+-----+-----+-----+

| 1902| 76 | 23 | 30.2| 222 | 71 | 32.0| 298| 94 | 31.5|

|[1]1903| | | | | | | | | |

| 1904|156 | 47 | 30.1| 173 | 47 | 27.1| 329| 94 | 28.5|

| 1905|157 | 46 | 29.3| 184 | 40 | 21.7| 341| 86 | 25.2|

| 1906|166 | 58 | 34.9| 188 | 51 | 27.1| 354| 109 | 31.5|

| 1907|205 | 51 | 24.8| 289 | 86 | 29.7| 494| 137 | 27.8|

+-------+------+-----+-----+--------+-----+-----+-----+-----+-----+

| Total |760[2]| 225 | 29.6|1,056[3]| 295 | 27.9|1,816| 520 | 28.7|

+-------+------+-----+-----+--------+-----+-----+-----+-----+-----+

[1] No return.

[2] Of these more than 400 were intubations.

[3] Of these 23 or more were intubations.

From these figures it will be seen that the total result for five years

is a mortality of 27.9% as against 29.6%, in favour of tracheotomy. This

serves, in my opinion, to strengthen the position of those hospitals

which rely upon tracheotomy. Upon a comparison of this sort it would

certainly appear that the results of intubation, at any rate in England,

are not so good as has been stated. I am aware that this opinion is not

shared by many authorities and that Stack[40] writes, ‘taking everything

into consideration, my impression is that under the most favourable

conditions of operating, nursing, &c., the mortality is almost halved by

doing intubation as a routine instead of tracheotomy.’

[40] Allbutt and Rolleston, _Sys. of Med._, 1905, vol. i, p. 1025.

It has been claimed that intubation gives better results in children

under five. This question has been worked out by H. W. L. Barlow,[41]

who concludes that ‘the younger the child, the longer will it require

the tube, and the more frequently, therefore, has the latter to be

inserted’, and ‘from the mortality alone, there is no indication that

one operation is better suited for certain age periods than another, but

since secondary tracheotomy appears to be rarest at three years old and

the intubation fatality is least between four and six years, it follows

that children from three to six are best adapted for intubation’.

[41] _Metropol. Asylums Board’s Ann. Rep., Med. Supplem._, 1904, p. 319.

_Conclusions._ Intubation is justifiable for diphtheria of a mild type

if sufficient experience can be obtained and if the after-treatment can

be personally carried out. The success of the operation depends largely

upon a proper selection of the cases; in other words, it is not suitable

for the worst types of this disease. It should never be performed upon a

patient in whose case the question of tracheotomy does not arise.

In my opinion it is not a good operation for those general hospitals

where there is constant change among the resident officers; it seems

probable that it will remain the treatment of a small number of

physicians who have frequent opportunities of practising their art.

=Indications.= (i) _In diphtheria_, intubation is justifiable when the

disease is of a mild type without great toxæmia, where early diagnosis

has been made, and antitoxin has been administered. It is not

recommended when there is great pharyngeal inflammation, or in cases

with bronchitis or pneumonia, or when the patient is prostrate, nor for

severe obstruction caused by excessive swelling or false membrane in the

larynx or trachea. In the last-mentioned condition intubation is

difficult to perform, and the patient may be choked by false membrane

which has been pushed down: intubation should be abandoned in favour of

tracheotomy when immediate relief is not obtained.

(ii) _In other forms of septic laryngitis_, there is evidence to show

that with intubation the mortality is higher than with tracheotomy; in

œdematous laryngitis, such as follows the inhalation of steam, every

effort should be made to prevent laryngeal obstruction by other forms of

treatment, for intubation is difficult to perform owing to the swollen

condition of the tissues; moreover, injuries are common, and there is a

danger that the upper opening of the tube will become obstructed. Again,

the tube may be expelled by coughing, and the child suffocated without

relief.

(iii) _In chronic stenosis_, intubation is now extensively employed.

Fibrous contraction such as follows some cases of thyrotomy, or syphilis

and other inflammatory diseases, can be treated successfully by this

method. Short light tubes, of vulcanite or similar material, are

inserted and retained in position for long periods, three months or

longer; with the pressure so exerted the amount of fibrous tissue

appears to be diminished, and the lumen of the larynx is dilated.

=Operation= (in diphtheria). The apparatus required consists of a gag

for opening the mouth, a set of tubes with a gauge showing the size for

each age, an instrument for intubation and extubation, and equipment for

tracheotomy.

[Illustration: FIG. 276. INSTRUMENTS FOR INTUBATION OF THE LARYNX. A,

Gag (O’Dwyer’s); B, Forceps for intubation and extubation (Thorner’s);

C, Gauge; D, Tubes: 1, O’Dwyer’s; 2, Thorner’s.]

The tubes recommended by O’Dwyer are of gilded bronze, but other

materials such as vulcanite or hard rubber are sometimes used. The tubes

have undergone frequent modifications and those designed by Bayeux are

shorter, lighter, and a great improvement (Goodall). In Thorner’s type

(Fig. 276) the lower end has been cut off at an angle, so that it may

pass more easily between the vocal cords; the intubator and extubator

have been replaced by a single pair of beaked forceps with a ratchet

attached to the handles, so that, when the beaks are separated, the

tube is gripped firmly and cannot be disengaged until the trigger of the

ratchet has been pulled; with these forceps the tube is not obstructed

while it is being taken in and out of the larynx, and there is less need

for hurry; further, the top of the tube has a funnel-shaped opening

‘which greatly facilitates the introduction of the beaks when the tube

is in the larynx, inasmuch as it allows the beak to glide from any point

of the rim almost automatically into the opening, and what this means

can be appreciated by those who have had experience with the old

extractor’ (Kyle).[42]

[42] _Diseases of the Nose and Throat_, 1907, p. 726.

No preparation of the patient is required, but a blanket must be wrapped

round the arms, body, and legs to control the struggling. Two assistants

are required, one to hold the patient, the other to steady his head and

manipulate a gag. The upright position is preferred by many surgeons

because the patient is less frightened, and the breathing is easier; but

the child may be laid upon a table, with the head slightly extended and

exactly in the middle line of the body, or the head may be allowed to

hang over the end of the table and the tube passed from behind, in a

manner similar to that used for direct laryngoscopy. No anæsthetic is

necessary. The first assistant or nurse should sit on a low chair with

the child on his knee, holding him so that he directly faces the

surgeon; a second assistant stands behind with a gag in his hand. A tube

of suitable size, with a thread attached, and mounted on the introducer,

is taken in the right hand; the assistant introduces the gag, opens the

mouth to the fullest extent, and steadies the head with his two hands;

the surgeon now passes the left index-finger over the back of the

tongue, so that the tip of it passes behind and below the epiglottis

until the cricoid is felt; this is the most important landmark, and as

soon as it is located the finger is drawn upwards and forwards in order

to hook up the epiglottis, and the introducer and tube are rapidly

passed over it; the method of introduction being that used for all

laryngeal instruments. As soon as the end of the tube is level with the

end of the finger, the handle of the introducer is raised so as to throw

the point as far forward as possible; the instrument is then bodily

lowered, so as to drive the tube downwards through the larynx until it

rests firmly and securely against the ventricular bands, which prevent

further passage of the collar; the tube is now held in place with the

left index-finger until the introducer is removed. The whole operation

in experienced hands should take from three to five seconds only, and

must be performed without force.

If the tube has been properly introduced, it is usual for the child to

begin coughing, and this may continue for a short time, accompanied by

noisy and rattling inspiration; the cough gradually disappears and

breathing becomes easy. The tube causes temporary aphonia, which may

persist for a few days after its removal, but is otherwise well

tolerated; the patient is not conscious of the presence of the canula

unless it becomes blocked.

The operation is simple in the hands of those who are accustomed to the

use of laryngeal instruments; in a normal larynx there is no difficulty

in introducing a tube, but in diphtheria the parts are inflamed and

obstruction is present. Children are often intolerant or frightened;

they are liable to retch or choke during introduction, but the latter

can sometimes be accomplished by waiting for an inspiratory effort; if

the struggling is very troublesome a small quantity of chloroform

(cocaine in adults) may be given with safety.

=Difficulties= of the operation. The difficulty of passing the tube over

the base of the tongue can be avoided by pulling the tongue downwards

and forwards and passing the introducer through the mouth with the hand

to the left of the patient’s face and rotating downwards when the point

is in the pharynx. Failure to find the opening of the larynx is often

due to not keeping the instrument exactly in the middle line. The tube

may be too large (even when it corresponds to the age of the child)

owing to swelling either in the larynx or in the subglottic region; in

such a case a smaller tube must be tried, and it is essential that no

force should be used to drive the tube into place, or dangerous

complications may arise. Even a smaller tube may not be passed on the

first occasion, and the surgeon has to decide whether he will try the

same tube again or one that is smaller; the latter may not be suitable

for the age. The tube may be too small, and this may be recognized by

the ease with which it passes; as a result, the first strong cough

expels it out of the larynx, and another must be introduced. A tube of

correct size may be in the larynx without relieving the dyspnœa; this

may be due to one of the following causes: (_a_) some membrane may have

been pushed in front of the tube, an event which is evidenced by the

noisy and difficult respiration, and which requires that the tube shall

be withdrawn with the thread and again introduced, after an interval;

(_b_) the tube itself may become blocked with membrane, with the result

that it is at once coughed out; or (_c_) the child may be asphyxiated so

that tracheotomy becomes a necessity. This last is a point that must

always be remembered: intubation should never be performed unless

everything has been prepared for opening the trachea. The tube may pass

into the œsophagus in spite of all care, and this may increase the

dyspnœa by pressing upon the posterior part of the larynx, in which case

it must be withdrawn by the thread and a further attempt made. It has

frequently happened that the tube with its thread has passed down the

œsophagus into the stomach, an accident which ought to be avoided. No

serious consequences are likely to occur, as the tube will be passed per

rectum, or in rare instances vomited.

The question arises as to how many attempts should be made before

intubation is abandoned. This varies in each case and depends upon the

amount of distress caused by the previous attempts. With each further

trial the child becomes more and more restless, and if the third attempt

fails, it is better to desist, or to allow at least an interval of half

an hour. When the dyspnœa becomes urgent there must be no hesitation,

and either the tube must be reintroduced or tracheotomy performed; both

operations are difficult under these circumstances, and the surgeon

should choose the method of which he has the greater experience.

It is very important to remember that tracheotomy is required in nearly

a third of the cases at one stage or another; at the M. A. B. fever

hospitals of London during 1902-6 there were 429 cases of intubation for

diphtheria, and of these 117 required tracheotomy later, _i.e._ 27.2%.

As Goodall says: ‘Every case that was intubated four or more times came

to tracheotomy. I therefore lay down the rule that if three insertions,

each of several hours’ duration, fail to cure the laryngeal obstruction,

tracheotomy should be performed. Frequent expulsion of the tube by

coughing a few minutes after its insertion is also an indication for

tracheotomy.’

=After-treatment.= A case of intubation requires more personal attention

than one of tracheotomy. It is essential that the doctor should remain

within easy call, as the tube may be blocked or coughed out at any

moment. This danger is not so great as it appears; when the tube is

coughed out there is no immediate asphyxia, and a fatal result is

uncommon; an interval of at least twenty minutes usually occurs before

the dyspnœa becomes urgent, in which time the doctor can be called; it

may even happen that the tube is not required again, and that the

obstruction has disappeared. When the tube becomes blocked, the state is

more serious; in most cases it will be coughed out of the larynx, but if

the child is very weak or the tube very firmly fixed, the obstruction

must be at once relieved. It is for this reason that some surgeons

prefer to leave a thread attached so that the nurse can extract the

tube, but the latter has a disadvantage, namely, that the child may pull

the tube out. This can be prevented by tying up the hands of the child

while the tube is being worn, but even then the child may bite the

string; the general practice therefore is to remove the thread, and the

tube is then expressed by lateral pressure on the sides of the trachea,

or by passing the finger below and behind the larynx and so pushing out

the tube. The method is termed ‘enucleation’,[43] and where it fails the

extubator must be used. A nurse must be chosen who has had previous

experience of intubation; she must understand the symptoms which

necessitate interference with the tube, and the feeding of the child.

Swallowing is often difficult, and liquids tend to pass through the

canula into the trachea; the patient chokes and may cough up the tube.

The danger of pneumonia is also increased. To overcome the dysphagia the

patient should be made to suck uphill through a tube, or semi-solids may

be tried: in other cases nasal or rectal feeding can be ordered:

temporary removal of the tube has also been recommended for purposes of

feeding, but vomiting often occurs with reintroduction immediately after

a meal. In very troublesome cases there is distinct danger in repeated

intubation; tracheotomy should be performed if the child is becoming

exhausted from want of nourishment.

[43] For a description of this method see _Metropol. Asylums Board’s

Ann. Rep., Med. Supplem._, 1898, p. 187.

_Changing the tube._ O’Dwyer recommends that the tube should be retained

for forty-eight hours without change, after which it should be removed

once a day: it must, however, be remembered that while the tube is

retained coughing is greatly impeded, so that septic material collects

in the trachea and is liable to cause pneumonia.

Extubation by the thread and by enucleation has already been mentioned,

but these methods are not applicable in every case. Extubation is

difficult to perform, especially if respiration is obstructed and the

patient struggling; whenever necessary, chloroform should be given. The

preparation required is similar to that for intubation; a table and

tracheotomy instruments are made ready; the upright position is

preferred, and two assistants are required to hold the child and the

gag; expanding forceps are introduced as if intubation were being done,

and the tube is grasped securely and rapidly extracted, the whole

operation being carried out as quickly as possible and without any

suggestion of force. In experienced hands no danger is to be feared, but

if two or three attempts are unsuccessful, tracheotomy should be

performed. The time for removal of the tube varies from a few hours to

four or five days in favourable cases. The main object is to dispense

with the tube as soon as possible, and to err on the side of too early

removal even in spite of the fact that reintroduction may be necessary.

=Complications= may occur, but there is no evidence that they are more

numerous than with tracheotomy. Injury to the larynx is liable to

result, especially from inexperience of the method, and this may be

followed by hæmorrhage, emphysema, or abscess. In rare instances a

false passage has been made, generally through the ventricle of the

larynx: pressure ulcers may form, there may be necrosis of the

cartilage, peritracheal abscess, or cicatricial contraction; or, as with

tracheotomy, subglottic swelling may persist and granulations may be

formed. When urgent dyspnœa follows the removal of the tube, one of

these conditions must be suspected. O’Dwyer maintains that ‘the cause of

persistent stenosis following intubation in laryngeal diphtheria can be

summed up in a single word--traumatism,’ but ‘paralysis of the vocal

cords may possibly furnish an occasional exception to this rule’

(Jacobson).[44]

[44] _Operations of Surgery_, 5th ed., vol. i, p. 640.

‘_Retained tube_,’ which is the term applied to cases of more than five

days’ duration, is certainly more common after injury, but does not

occur more frequently than with tracheotomy; many cases have been

reported where intubation tubes were used for long periods with ultimate

recovery, but the method is uncertain unless the exact condition of the

larynx can be determined (see p. 480).

_Pneumonia._ It has been shown that large numbers of bacilli are present

in the lungs, where they may cause inflammation quite apart from any

operation; in laryngeal cases the danger is increased owing to the

obstruction which causes deficient aeration of, and improper

expectoration from, the lung. Where tracheotomy is performed the dyspnœa

is relieved and the expectoration easy; with intubation, on the other

hand, there is no stage of apnœa after introduction, which seems to

indicate that the air does not pass so easily through the smaller tube;

coughing is more difficult and the amount of expectoration less; mucus,

pus, or membrane in small pieces, can all be expelled through the tube,

but not so freely as through the larger canula, and are more likely to

be swallowed. For these reasons it would appear that pneumonia is less

to be feared after tracheotomy; there is, however, considerable

difference of opinion on this point, and statistics have not proved of

great value.

CHAPTER V

TRACHEOSCOPY AND BRONCHOSCOPY

=Indications.= (i) _Foreign bodies._ Accidental inhalation of foreign

bodies is more common in children than in adults in the proportion of

about two to one. The character of the foreign body should be considered

before treatment is advised, and for this purpose the inhaled bodies may

be divided into three classes:

(_a_) Pointed; such as bones, needles, teeth, nails, &c.

(_b_) Rounded; i. Hard, such as coins, stones, or buttons.

ii. Soft (in some cases capable of swelling),

such as meat, beans, peas.

(_c_) Fluid; such as blood, pus, or vomited food.

To these may be added pieces of necrosed cartilage from the larynx,

trachea, or bronchi; and calcareous concretions from bronchial glands,

which occasionally perforate the walls of the air-passages.

Any of the above may become impacted in the trachea or fall into one of

the bronchi: the right bronchus is affected nearly twice as often as the

left owing to its larger size, its direction (which is more nearly that

of the trachea), and the inclination of the septum to the left of the

middle line.

(ii) _Tumours of the trachea_ (see p. 546).

(iii) _Stricture of the trachea_ resulting from previous inflammation or

trauma. Tracheoscopy is useful both for accurate diagnosis and for

treatment of such conditions. The following case may be quoted as an

illustration: A boy of 17 was admitted to my hospital on account of

dyspnœa, caused by obstruction in the lower air-passages. The chest was

examined and a skiagram taken, the latter showing a definite shadow in

the position of the bifurcation of the trachea. This was possibly an

enlarged gland which pressed upon the trachea. I decided to give the boy

an anæsthetic and perform tracheoscopy. On passing the tube a stricture

was found in the trachea at the level of the suprasternal notch, which

was so small that a large probe completely blocked its lumen, thus

causing cessation of breathing. Under the condition it was impossible to

dilate the stricture by endotracheal methods. The trachea was therefore

exposed, but appeared to be normal. An opening was made into it above

the stricture, and it was then seen that the latter was caused by a

thickening of the anterior and lateral walls, involving two rings of the

trachea and apparently of inflammatory nature. As no history of

inflammation had been obtained the tissue was examined microscopically,

and this confirmed the diagnosis. Division of the stricture completely

relieved the dyspnœa, and after a few days the wound was allowed to

heal. Three months later there was some return of the dyspnœa, and

tracheoscopy was again performed. The stricture had to some extent

returned, but was easily dilated through the tube, and two months later

there had been no further dyspnœa. By the passage of bougies through a

bronchoscope a stricture of the bronchus has been relieved in a similar

manner.

(iv) _For diagnostic purposes_ alone, to determine the cause of pressure

upon the air-passages; as in tumours of the mediastinum, aneurism, and

the like.

The instruments required correspond in the main to those used for direct

laryngoscopy (see p. 480). The special instruments include (_a_)

bronchoscopes, which are long circular tubes of dimensions suitable to

the patient:

LENGTH AND SIZE OF TUBE REQUIRED IN UPPER BRONCHOSCOPY (KILLIAN)

_Adults._ _Children._

Length 30-40 cm. 20-30 cm.

Diameter 9-14 mm. 5-7 mm.

These should be marked externally in centimetres, measured from the

distal end of the tube, and should be provided with a lateral window to

allow of free breathing through the opposite bronchus when the tube is

introduced into the one which is obstructed; of the various forms in

use, the sliding tube of Bruenings appears to me superior; (_b_)

instruments for extraction, including forceps and hooks according to the

nature of the body to be removed; (_c_) aspirator for removal of mucus,

and sponge-holders, the length of the bronchoscope.

=Operations= (see also p. 481). As regards the anæsthetic, chloroform is

preferable in children, but in adults cocaine may suffice. The

operations are best performed in a room which can be made dark.

=Tracheoscopy.= The preliminary stages are similar to those of direct

laryngoscopy. If the larynx be found normal, a smaller tube can be

passed through the tube-spatula between the vocal cords, and the spatula

can then be divided and removed in separate halves. In Bruening’s

instrument the inner tubes are so constructed that they can be pushed

through the outer tube and made to project like a telescope to any

desired distance. In this way the subglottic region and trachea can be

explored.

[Illustration: FIG. 277. INSTRUMENTS FOR BRONCHOSCOPY. Bronchoscopes: A,

Killian’s; B, Jackson’s; C, Bruening’s. D, Instruments for extraction.

E, Handle (Watson Williams’s).]

=Upper bronchoscopy.= The tubes are passed through the mouth, and the

inner one is projected until the bifurcation of the trachea is visible.

In order to avoid injury to the tissues, the operation should be

performed entirely by sight and with great care. Three cases have been

recorded where tracheotomy was needed for the relief of dyspnœa caused

by œdema of the larynx which had followed traumatism.

The tube having been passed, cocaine (10%) is applied to the bifurcation

of the trachea, and mucus is removed by sponging or by an aspirator. If

the secretion be excessive, the foot of the table should be raised so

that the mucus drains away from the part to be explored.

It is the duty of the anæsthetist or some competent assistant to note

that normal respiration is maintained, and the necessity for tracheotomy

or artificial respiration must always be borne in mind.

[Illustration: FIG. 278. INSTRUMENTS FOR BRONCHOSCOPY. A, Aspirator for

mucus; B, Sponge-holder; C, Hooks.]

If the operator be experienced, bronchoscopy can be performed without

endangering the patient’s life even in the case of a young child. A baby

of eight months has been successfully treated by this method.

=Lower bronchoscopy.= Preliminary tracheotomy (median or low) having

been performed, a wide tube is introduced into the bronchus through the

wound in the trachea. This method has the following advantages: It is

easier to perform, and the surgeon requires less experience of

technique; the tube, being wider, is more readily illuminated; there is

little danger of asphyxia; in passing the tube no organisms are

introduced from the mouth, and there is less danger of pneumonia. If

these advantages are weighed, it becomes apparent that the lower

operation is preferable for surgeons without experience. In all cases

with urgent dyspnœa preliminary tracheotomy is practically essential.

By a combination of the above methods the diagnosis of foreign bodies

can be positively determined in the majority of cases. As Killian said

in 1902: ‘We have now reached a position in which, in many cases at

least, one can not only obtain a positive result but with confidence can

assert that the foreign body is not present.’ In support of this

statement numerous cases have been reported, especially in Germany and

America. Von Eicken, in 1904, collected 42 cases of bronchoscopy, in 35

of which a definite diagnosis of a foreign body was made; in 4 it was

shown that none was present; and in 3 only were negative results

obtained. Since that time the results have been equally good, for in

1907 Killian increased this number to 164 reported cases in which a

foreign body had been actually discovered.

As soon as the foreign body is clearly seen, a pair of forceps is

selected and introduced through the tube. The object is grasped and

drawn through the tube, if this be possible, or the tube and forceps may

be withdrawn together from the trachea. If the foreign substance be

broken the operation can be repeated until all of it has been removed.

If the patient becomes collapsed it may be necessary to postpone the

continuation of the treatment until the following day. A second attempt

is often successful when the first has proved a failure.

Bronchoscopy is comparatively easy to perform (_a_) when the foreign

body lies in the trachea or main bronchus; (_b_) when the foreign body

has been accurately located; or (_c_) when the operation can be

performed early, before inflammation has supervened. In the rare

instances where the body lies in one of the secondary or tertiary

bronchi, or has penetrated the substance of the lung, the difficulties

are much increased, and in such conditions the question of the

advisability of lower bronchoscopy should be considered.

=Complications= seldom occur after removal of foreign bodies by these

methods if the surgeon is careful to avoid injury when passing the

tubes. There may be temporary hoarseness owing to congestion of the

mucous membrane. Ingals has reported two cases in which death occurred

soon after the operation, with symptoms like those of delayed poisoning

from an anæsthetic, and has raised the question whether it is advisable

to use cocaine or atropin[e] in these operations. Delavan, on the other

hand, suggests that injury to the pneumogastrics may account for such

collapse. As stated above, the combination of chloroform and cocaine

does not appear to be dangerous if used with discretion.

[Illustration: FIG. 279. UPPER BRONCHOSCOPY WITH THE PATIENT IN THE

DORSAL POSITION.]

[Illustration: FIG. 280. LOWER BRONCHOSCOPY WITH THE PATIENT IN THE

DORSAL POSITION.]

=Results.= Removal of foreign bodies by bronchoscopy gives far better

results than the older methods of treatment such as tracheotomy,

bronchotomy, and thyrotomy. With the last-named operations more than

one-third of the cases have been fatal: while on the other hand, taking

the 164 cases[45] collected by Killian, it is found that in 159 (leaving

out 5 with unknown result) only 21 (or 13%) died, viz. 2 from cocaine; 2

because it was impossible to remove the object on account of bronchial

stenosis; 1 from suffocation in spite of upper and lower bronchoscopy;

and the remaining 16 of pulmonary complications--5 with the foreign body

in the lung, and the others in spite of its removal. Upper bronchoscopy

was fully successful in 54 cases, and lower bronchoscopy in 63. The

result of the remaining 21 operations is not stated.

[45] _Trans. Amer. Laryng. and Otol. Soc._, 1907, p. 80, ‘The Treatment

of Foreign Bodies in the Respiratory Tract and Esophagus.’

Speaking of his own cases, Killian writes: ‘My own statistics give

perhaps a better judgment for the future of cases of foreign bodies in

the deeper air-passages than the general, since I have gradually

acquired a larger experience and more practice. Nevertheless, I have the

impression that in many cases my technic has not reached the highest

mark, and I hope to obtain better results in the future. As shown by the

list of cases, only one death resulted in the eighteen cases, and this

was six months after the removal of the foreign body, caused by severe

lung complication due to its long sojourn in the air-passages. In only

two cases was I unable to find the foreign body and in only one was I

unable to remove it on account of its being coughed up.

‘Upper bronchoscopy was performed in twelve cases, upper and lower in

five, and lower tracheo-bronchoscopy in one. However, I hope in the

future, with improved technic, to be successful with the upper method at

the first sitting and to use the lower only in the severest cases.’

To Killian of Freiburg is due the chief credit for having introduced a

safe method of treatment, the value of which is at last beginning to be

generally recognized in England. As Paterson[46] says, ‘it is earnestly

to be hoped that the time has now come when workers in this country will

recognize its enormous advantages.’

[46] _Brit. Med. Journ._, 1906, vol. ii, p. 357, ‘The Direct Examination

of Œsophagus and Upper Air-passages.’

SECTION V

OPERATIONS UPON THE NOSE AND

ITS ACCESSORY CAVITIES

StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)

Professor of Laryngology and Physician for Diseases of the Throat,

King’s College Hospital, London

CHAPTER I

GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS ON THE NOSE AND

NASO-PHARYNX

An intimate knowledge of the surgical anatomy of the nose is an

important factor in successful treatment. It is sufficient to recall the

close relations of the nasal chambers and their accessory sinuses with

the cavities of the orbit and the cranium, and to remember that the

shape and size of these air-spaces may vary considerably within

physiological limits.

The arrangements of the vascular, lymphatic, and nervous supplies, and

their connexion with neighbouring parts and the body generally, have

also to be kept in mind.

In planning and carrying out operative procedures it is also well to

keep in mind the important physiological functions of the nose.

Disease in the nose involves both medical and surgical treatment. The

general progress of surgery, improved technique, local anæsthesia, and

the control of hæmorrhage we now possess, have all tended to replace

local medication by surgical measures. But in many affections of the

nose--such as syphilis, or diphtheria--surgical relief is quite

secondary to medical treatment. In any case the surgeon cannot dispense

with a knowledge of suitable topical applications and the principles on

which they are founded.

SOURCES OF ILLUMINATION

A good source of illumination is the first necessity for satisfactory

operations on the upper air-passages. The natural sources at our

disposal are sunlight and diffuse daylight. They have the great

advantage of not altering the natural colours of the parts examined.

Reflected sunlight forms a perfect illuminant, if we are careful not to

bring the rays to an exact focus on the mucous membrane, as this might

produce a burn.

Diffuse daylight is too feeble for the examination of the cavities of

the nose and larynx, but it can be used for inspecting the mouth,

pharynx, and ear. Direct daylight is particularly serviceable for

examining suspicious rashes or patches in the mouth and pharynx, and

eruptions on the skin.

Some form of artificial light is indispensable. That furnished by an

ordinary paraffin lamp or a gas flame is sufficient for examination. The

flame should have its flat side towards the observer, and be enclosed in

a glass chimney, without a globe or shade. If neither of these lights be

available, an ordinary candle, or, better still, three candles tied

together, will suffice.

For use in the study a paraffin reading-lamp or a gas standard is

equally suitable. The latter is rendered more effective by the adoption

of an Argand burner or a Welsbach mantle. The oxy-hydrogen limelight is

the most perfect of artificial illuminants, but it is bulky and

expensive. The most convenient light is that given by a 32 or 50

candle-power electric light in a frosted globe, and with the filament

waved. The Nernst electric burner gives increased brilliancy.

[Illustration: FIG. 281. LARYNGOSCOPE LAMP.]

The electric light has the further advantage that it is unnecessary to

maintain it constantly vertical. When enclosed in a bull’s-eye, the lamp

can be rotated so as to direct the pencil of light-rays either upwards

or downwards, as well as from side to side.

Whichever light is employed the rays can be concentrated and rendered

more powerful by enclosing it in a dark chimney with a bull’s-eye

condenser. The light must also be provided with some arrangement by

which it can be raised and lowered (Fig. 281). For operating the Clar

light is useful (Fig. 282).

In all these methods the light is reflected, but the direct rays of the

electric light can be used in a small lamp fixed on the forehead, and

fed from an accumulator or direct from the street current through a

suitable resistance. It is better than reflected light in operations on

the nose and throat, and the portable accumulator and frontal photophore

(Fig. 283) are convenient for use in the patient’s own home.

[Illustration: FIG. 282. CLAR’S ELECTRIC LIGHT.]

[Illustration: FIG. 283. FRONTAL SEARCH-LIGHT.]

The lamp should be placed on a stand or table so that the light is on a

level with the patient’s ear, and 3 or 4 inches distant from it. In

Continental schools it is customary to place the light on the patient’s

right hand. In this country the lamp is usually placed close to the

patient’s left ear, _i.e._ on the observer’s right hand. As

practitioners will often be called to see patients who are confined to

a bed which can only be approached from one side, it is desirable that

they should accustom themselves to work equally well with the light on

either side, and the frontal mirror over either eye.

LOCAL ANÆSTHESIA

=Cocaine.= It is often desirable to secure a slight degree of local

anæsthesia to facilitate complete exploration of the nose. Many

operations can be carried out by rendering the nasal mucosa absolutely

insensitive with cocaine.

Applied in the nose cocaine is (_a_) an anæsthetic, (_b_) a powerful

vaso-constrictor, and, consequently, it (_c_) produces local anæmia.

Hence cocaine is of great value in nasal surgery, not only because it

renders the mucous membrane insensitive, but also because it retracts

the tissues and reduces the hæmorrhage.

_Methods of use._ A small area can be anæsthetized by placing a few

crystals of hydrochlorate of cocaine on the required spot, where the

mucus will dissolve it _in situ_. A 2 to 5% solution may be sprayed into

narrow nostrils, to facilitate examination. It is a better plan to

moisten pledgets of cotton-wool or ribbon gauze with a 10% solution, and

place them in direct contact with the part to be operated on. The

addition of a little suprarenal extract will not only facilitate

examination and treatment by its hæmostatic action, but, for the same

reason, will tend to prevent the cocaine being absorbed and producing

its toxic effects.

For the more complete anæsthesia required for operation the following

plan is advised. Equal parts of a 20% solution of cocaine and the

standard 1-1,000 extract of suprarenal gland are mixed together. Short

strips of 1-inch wide ribbon gauze are moistened with this solution and

laid flat in close contact with the nasal area to be operated on. They

are left in place for at least half an hour, and even at the end of one

hour local anæsthesia will only be more marked. While the final

preparations are being made for operation a fresh layer of moistened

gauze may be applied. Finally, if there should still remain the

slightest degree of sensation over the spot to be treated, a few cocaine

crystals will render it quite numb.

_Submucous injection of cocaine._ Great caution is necessary in making

intracellular injection of cocaine, as the drug is intensely toxic in

this form, and, fortunately, only a small dose is required. It is a good

plan never to exceed 1 centigramme (1/6 grain) of the salt. As the

hæmostatic effect of suprarenal gland extract is required at the same

time, the two are combined; 1/6 grain of cocaine, 2 drops of adrenalin,

1/6 grain of sodium chloride, and 1/50 grain of morphia are dissolved in

60 minims or more of sterilized water, and slowly injected below the

mucosa. At least 20 minutes must elapse to secure full effects.

_Substitutes for cocaine._ For submucous injection it is better to

substitute eucaine or novocaine. Eucaine can be kept in a ready and

portable form in small glass ampoules in the dose of 1/6 grain with

1/2000 grain of adrenalin, and tablets are sold containing 1 centigramme

(1/6 grain) of either of these drugs in combination with adrenalin and

chloride of sodium. One of these tablets is dissolved in 60 minims or

more of water and boiled. It is reported that as much as 1 grain of

novocaine may be injected at one sitting, but I prefer to keep to the

limit of 1/6 grain, and have always been able to obtain complete local

anæsthesia with it.

Eucaine is much less toxic than cocaine, and novocaine is said to be

still safer. They act just as well for submucous injection, but, applied

to the mucous surface, the anæsthesia is not so complete, and the

vaso-constrictor effect is less. Still, for susceptible subjects, either

is to be preferred to the more toxic cocaine.

LOCAL ISCHÆMIA

=Adrenalin.= The delicate manipulations of intranasal surgery have been

greatly facilitated by the employment of the extract of the suprarenal

gland under various names--adrenalin, adrenine, adrin, perinephrin,

adnephrin, epinephrin, suprarenalin, suprarenin, epirenin, paranephrin,

renaglandin, hemesine, hæmostasine, vasoconstrictine, renostypticin, &c.

These liquids are generally of the strength of 1 in 1,000, and can be

used undiluted on mucous surfaces. But they can be diluted with normal

saline solution, solutions of cocaine, or other drugs. If kept in

well-stoppered, tinted glass bottles the solution can be preserved for

many weeks. The solid extract is useful for those who only employ it

occasionally, and in this form it is conveniently made up with cocaine,

eucaine, or novocaine, so that solutions of the desired strength are

prepared as required.

Applied to a mucous surface adrenalin produces a local ischæmia by

contracting the blood-vessels, so that the surface becomes pale and

shrunken. At least 20 minutes are required to secure this effect and it

is only more marked at the end of an hour. An extensive operation, such

as submucous resection of the septum, can then be performed without the

loss of more than a trifling amount of blood in most cases. The

vaso-constrictor action is followed by a stage of dilatation, disposing

to secondary hæmorrhage, which, according to some authorities, may be

‘violent and sometimes serious’.[47] I have been fortunate in not

meeting with this occurrence. Its possibility can generally be guarded

against, and need never prevent the employment of the drug when

indicated.

[47] C. A. Parker, _Diseases of the Nose and Throat_, London, 1906.

Adrenalin has no anæsthetic power, but its constricting action lessens

the tendency of cocaine to be deeply absorbed, increases the latter’s

local effect, and allows of a weaker solution being employed.

Another secondary result is the very irritating rhinitis which is

sometimes induced. It passes off in 24 to 48 hours.

_Uses._ The addition of a small quantity of adrenalin to a cocaine

solution mitigates the toxic action of the latter, and its use appears

to check tendency to collapse, either from shock or chloroform, during

serious operations on the nasal cavities. Its chief use is to check

hæmorrhage and allow us to perform practically bloodless operations in

the nose.

_Methods._ Adrenalin is employed as described for cocaine.

Disappointment in the result obtained is nearly always due to neglect in

recognizing that its full effect cannot be obtained in less than 20 to

60 minutes.

BLEEDING AND ITS CONTROL

Bleeding in the nose cannot be controlled as easily and directly as in

the operations of general surgery, and there is always the risk of blood

passing into the lower air-passages.

=Causation.= Hæmorrhage is apt to be not only more free, but also more

serious, in young children and in patients over 60. The tendency is

increased with menstruation or pregnancy, and hæmophilia is to be

particularly looked for. In the nose the vascular turbinals bleed

freely; a small varicose vessel on the septum is the commonest source of

epistaxis,--often very copious. Many vascular growths are met with, and

malignant ones are apt to bleed profusely.

Secondary hæmorrhage may occur between the third and eighth day, when

clots or crusts become detached.

_The prevention of local hæmorrhage._ The patient should be prepared

more carefully than usual for an operation. Hæmophilia should be

inquired after, and if there is any suspicion of it lactate of calcium

is administered for three days beforehand, in doses of 15 to 30 grains

twice a day. If the patient be an undoubted hæmophilic, an operation

should be avoided if possible. It is well to suspend the use of alcohol

and tobacco for at least three days beforehand. Many risks are avoided

if the operation can be carried out in the home or hospital where the

patient has slept, and if he can remain there afterwards.

_The arrest of local hæmorrhage._ The preliminary use of adrenalin will

diminish bleeding in many cases (see p. 573). When it does occur, unless

the hæmorrhage is serious, it is well not to be too precipitate in

efforts to arrest it. Such attempts, by stimulating the patient,

detaching blood-clots, or exciting reflexes, may even maintain it. The

clothing should be loose, the operating-room should be well aired and

cool, and iced water should always be at hand. If freely sluiced over

the face, behind the ears, and round the neck, cold water has such a

remarkable reflex vaso-constrictor action that it alone is sufficient to

arrest hæmorrhage in the majority of operations on the nose and throat.

Its stimulating effect on the respiration and circulation is always

agreeable to the patient, and may be very valuable when he is under a

general anæsthetic.

If operated upon under a local anæsthetic, the patient’s head should be

inclined forwards, so that the blood can drip from the nose. The first

formed clots may be expelled, but then he should avoid sniffing,

sneezing, or coughing, and sit with the head forward and the nostrils

completely closed with his thumb and forefinger. Five to ten minutes in

this position will arrest the bleeding in most cases of epistaxis. A

slight oozing of blood may be allowed to go on for a few hours in

certain cases. If the bleeding persists, ice should be applied

externally and held in the mouth, the nose may be syringed with very

cold or with very warm salt and water (ʒi to the pint), and the

horizontal position assumed.

If this fails, a pledget of cotton-wool is dipped in peroxide of

hydrogen solution (10 vols. %) and introduced into the bleeding nostril,

the orifice of which is then closed by the surgeon’s thumb. This may be

repeated more than once, the patient lying on his side, face downwards,

and pinching both nostrils. If a galvano-cautery be available, and the

bleeding comes from a limited and visible point, it can be sealed with a

touch of the cautery point.

If these methods fail, plugging must be resorted to. With the nasal

speculum and good illumination, the bleeding area is cleansed with

cocaine and adrenalin and a strip of 1-inch ribbon gauze is carefully

packed on to the spot, the end being left just within the vestibule, so

that the patient can remove it for himself at the end of 12 or 24 hours.

It is better to use a single strip of gauze, instead of cotton-wool, as

portions of the latter might be detached and left behind. If there be

fear of the gauze strip becoming adherent, it can be well smeared with

plain sterilized vaseline.

If the bleeding comes from far back in the nose, or from the post-nasal

space, it may become necessary to plug the latter cavity. A sterilized

sponge, about the size of a Tangerine orange, is squeezed very dry and

tied round its centre with a piece of tape or a stout silk ligature,

leaving two free ends of about 12 inches in length. A soft rubber

catheter is passed along the floor of the nose till it appears below the

soft palate, when the end is seized with forceps and drawn through the

mouth. To this end one of the tapes is made fast, so that when the

catheter is withdrawn from the nose, the sponge is pulled up into the

post-nasal space; the other end hangs out of the mouth. The two tapes

are tied together over the upper lip. The anterior part of the nostril

can then be packed with gauze, if necessary. If the patient be under

chloroform, one tape can be dispensed with; the soft palate is simply

held forward with the forefinger of one hand, while the other passes the

compressed sponge up into the naso-pharyngeal space.

Plugs in the nose should be avoided. They are painful, interfere with

repair, prevent drainage, and may be followed by septic troubles in the

nose, accessory sinuses, middle ear, or cranial cavity. Bleeding often

recurs on their removal. In any case they should not be left unchanged

for more than 24 or, at the most, 48 hours. Removal is facilitated by

soaking them well with peroxide of hydrogen, and detaching them slowly

and gently. Ligature of the external carotid (see Vol. I, p. 384) may be

necessary in extreme cases.[48]

[48] Chevalier Jackson, _Transactions American Laryngological

Association_, 1907.

THE PROTECTION OF THE LOWER AIR-PASSAGES FROM THE DESCENT OF BLOOD

When operated upon under local anæsthesia the patient is able to prevent

blood descending from the nose or throat into the larynx or trachea. In

this he is assisted by throwing the head forwards.

When the patient is under a general anæsthetic other measures must be

taken to guard against the descent of blood into the windpipe and lungs.

The most important is to see that the anæsthesia is never so deep as to

abolish the swallowing or coughing reflexes. Fortunately these are

amongst the last to go, yet in many cases it is well to let the patient

come partly round, so as to expel blood and mucus by coughing. If the

frontal sinus is being operated upon, the nose is carefully packed

beforehand. When the ethmoidal labyrinth is being cleared, or the

sphenoidal sinus opened, a sponge may be placed in the post-nasal space

as described above until the operation is completed. During the

operation upon the maxillary sinus through the canine fossa, a sponge

placed between the last molar teeth and the cheek on the same side, and

frequently renewed, will keep any blood from entering the pharynx. In

operations upon the naso-pharynx, it is a wise precaution, when much

bleeding is anticipated, to perform a preliminary temporary laryngotomy

and plug the pharynx with a sponge (see p. 510).

In many proceedings security is attained by rolling the patient well

over to one side, so that the blood runs out of the corner of the

mouth, of blood is also swallowed. This may be vomited as consciousness

returns; if not, an aperient should be given within 24 hours to prevent

gastro-intestinal sepsis.

The descent of blood into the trachea and lungs, if sudden and copious,

may cause immediate asphyxia; or, if less abundant, it may cause septic

pneumonia. When it occurs, the anæsthesia should be stopped, and the

patient rolled well over on to his face or inverted, until the breathing

is quite unobstructed. After all nose and throat operations it is a wise

precaution for the patient to be kept on his side, the head on a low

pillow, and face downwards, while the body is arranged in the

gynæcological position.

SHOCK

Shock, particularly in operations on the nose, is apt to be marked in

young children and in elderly persons. It is for this reason that we try

to avoid the removal of adenoids in patients under 3 years of age, or of

polypi in those over 60; and that in all cases we endeavour to operate

as rapidly as possible.

This possibility of shock is guarded against and treated in the usual

way. The use of cocaine and adrenalin--even in patients under a general

anæsthetic--helps to avoid it,[49] and anæsthesia should never be too

deep or prolonged. When operating under local anæsthesia it is sometimes

wiser not to attempt too much at one sitting, _e.g._ to treat only one

side of the nose at a time. In certain conditions, and when a general

anæsthetic is employed, it may be safer to try and complete treatment at

one operation.

[49] G. W. Crile, _Journal Amer. Med. Assoc._, June 17, 1905.

SEPSIS AND OTHER COMPLICATIONS

Deaths have been recorded after the simple use of the galvano-cautery,

or the removal of nasal polypi, and of course are more to be feared

after major operations, such as the radical cure of sinus suppurations.

Septic infection from nasal operations may spread to the accessory

sinuses, meninges, ear, eye, tonsils, glands, gastro-intestinal tract,

bronchi, and lungs. From the naso-pharynx, the ears and the lower food

and air tracts are chiefly threatened. The orbit may be invaded in

operations on the ethmoid; the external muscles of the eye may be

injured in the frontal sinus operation; and optic atrophy may be due to

plugging of the ophthalmic vein.

While these accidents may sometimes be directly due to operation, it is

well to remember that in treating such septic conditions as are entailed

by nasal suppuration, the complications may only be precipitated by

traumatism and may also be purely coincident. It is not to be forgotten

that latent infection--of influenza, erysipelas, measles, scarlatina,

diphtheria, or other disease--may develop immediately after an operation

upon the nose or throat, and until its true character is recognized the

operation is often unjustly blamed. Septic infection, in these

necessarily exposed wounds of the air-passages, may be traced to

insanitary surroundings.

ASEPSIS

The field of operation in rhinology can never be rendered completely

sterile, and in many cases is particularly septic. Wounds through the

mucous membrane cannot be protected with dressings in the usual way; so

that the local methods of repair require particular study.

In the nose, when there is no suppuration, it is safer to make no

attempt to purify the cavity, beyond cleansing the vibrissæ and

vestibules. The Schneiderian membrane will not tolerate any antiseptic

lotion of such a strength as to be effective, and weaker solutions only

interfere with the action of the cilia, the protective power of the

mucus, and other defensive arrangements of the nose. If pus, scabs, or

foreign bodies exist in the nose, it should be well washed with a simple

tepid alkaline solution.

But every care should be taken to purify the surgeon’s hands, sterilize

all instruments, and see that no contamination takes place during the

operation. This is assisted by having the patient’s head surrounded by a

carbolized towel, and his face, moustache, and beard well washed, for

the surgeon’s hands and instruments come in frequent contact with these

parts.

AFTER-TREATMENT

After all intranasal operations everything should be avoided which

interferes with the drainage, ventilation, and natural repair of the

region. Protective dressings cannot be employed, and we have in most

cases to aim at healing under a blood-clot. Tags of semi-detached tissue

and loose clots of blood are removed, but otherwise the parts are

disturbed as little as possible. For the first two or three days the

nose may be left alone, and if there be no bleeding the patient is

encouraged to breathe through it. When there is much formation of thick

mucus, or blood-clots or sloughs are loosening, a tepid alkaline lotion

can be used. The pain of stiffness or dryness in the nose is relieved by

an ointment or an oily spray.

Adhesions are apt to form between the septum and the outer wall when

opposing surfaces are injured by the galvano-cautery. They may occur in

narrow cavities after cutting operations. If an adhesion be seen to be

threatening in the first few days, it should be broken down with a

probe, and strips of gauze or plates of white celluloid introduced daily

until healing takes place. If it forms later, it is wiser to wait until

the fleshy bridge becomes less vascular and contracts, when it may be

divided with a knife or the galvano-cautery at a white heat, and the

opposing surfaces are then kept apart as described.

All post-operative conditions in the nose and throat will heal more

rapidly and pleasantly if the patient be freely exposed, day and night,

to abundance of fresh air; and while fatigue is generally to be avoided,

the sooner the patient is out of bed and in the fresh air, the better

for him. Our inability to operate under aseptic conditions should make

us more careful to raise the resistance of the individual by general

care, and to protect him from external dangers.

CLEANSING THE NOSE

The simplest and safest method of cleansing the nose is by blowing

it,--one nostril at a time. Sometimes it is required to hawk any

discharge backwards and expel it through the mouth.

Watery lotions are frequently required to assist in cleansing the

nose. Strong antiseptics and astringents must be avoided. All nose

lotions should be alkaline, and isotonic with the blood plasma. These

requirements are met by prescribing one or more alkalis (bicarbonate

of soda, borax, salt, &c.), in the strength of about 5 grains to the

ounce. They may be rendered more pleasant by the addition of white

sugar or glycerine. The addition of a small amount of some mild

antiseptic--menthol, thymol, oil of eucalyptus, carbolic, sanitas,

listerine, &c.--may give a pleasant flavour. But all antiseptics have a

slight irritant action which is disagreeable if there be an intact

mucosa, although they may be more helpful in certain cases of ulceration

or intranasal sepsis. When the Schneiderian membrane is more or less

damaged, when there are foreign bodies, sloughs, necrosis, &c., in the

nasal chambers, these or similar antiseptics can be employed, though

always with an alkaline basis.

All nose lotions should be employed tepid. They may be sniffed,

irrigated, sprayed, or syringed into the nostrils. Crusts, scabs, and

sloughs may have to be removed from the nose with forceps, after its

sensitiveness has been deadened with cocaine; peroxide of hydrogen will

help to detach them.

AFTER-RESULTS

Incomplete operation may be unsatisfactory in many ways. Thus, nasal

obstruction may be unrelieved: foci of suppuration may be left in the

accessory sinuses: portions of adenoid growth or tonsils left behind may

continue to give trouble: malignant growths may not be extirpated freely

enough. On the other hand, operations may fail to relieve, or even

produce a worse state of affairs, if too much tissue be sacrificed. This

is important as regards the nose, owing to the important respiratory and

defensive function of its mucous membrane. It is a good rule to injure

the inferior turbinal as little as possible, otherwise a condition of

crusting rhinitis may be set up, with secondary atrophy in the pharynx

and larynx.[50]

[50] W. H. Stewart, _Proc. Laryngol. Soc. Lond._, March 5, 1898, p. 57.

Much judgment is required in adapting the suitable operation to each

case. While in some instances one or more small interventions are all

that is required, in another a well-planned and more extensive operation

may be indicated. In any case, the advice of Semon should be kept in

mind, viz. that the magnitude of an operation should not exceed the

gravity of the symptoms calling for relief.

CHAPTER II

OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES, AND RHINOLITHS:

OPERATIONS UPON THE TURBINALS: OPERATIONS IN SYPHILIS AND LUPUS

OPERATIONS FOR INJURIES TO THE NOSE

The external injuries of the nose belong to general surgery. It might be

well to recollect that the fleshy end of the nose may be completely

detached, and yet, if carefully and promptly replaced, perfect union

will occur.[51]

[51] J. M. Renton, _Brit. Med. Journ._, December 16, 1905.

FRACTURES OF THE NASAL BONES AND SEPTUM

=Setting a recent fracture.= One or both nasal bones may be displaced,

causing a flat bridge with a sharp ridge on either side.

In the septum fracture generally takes place in the quadrilateral

cartilage, or displacement occurs at its junction with the vomer or

superior maxilla. It may be accompanied by a hæmatoma (see p. 612), and

the occurrence of epistaxis shows that it is really a compound fracture.

Care should therefore be taken not to infect the wound in the nose, and

the patient should be warned on the subject.

The application of cocaine and adrenalin may allow of careful inspection

of the septum. But, as the exact condition of things is marked by

swelling, it is nearly always advisable to administer a general

anæsthetic. Crepitus can rarely be made out. A hæmatoma is dealt with as

directed (see p. 612). If there be any displacement of the septum--and

it generally takes place towards the side on which there is already some

convexity or depression of the nasal bones--the parts should be raised

into place by manipulation with the little finger in the nostril. A

flat-bladed forceps, like those of Adams, may be used. One blade in each

nostril will straighten the septum and, at the same time, raise the

whole nose into place. Small pencils of sterilized cotton-wool, smeared

with vaseline (see p. 608), are then carefully packed up into the roof

of the nose and kept there by Meyer’s vulcanite tube (Fig. 284). They

are changed every 24 or 48 hours, for a week or so. The vomer is rarely

fractured, although much callus is often thrown out in the displacements

which occur between it and the cartilage.

Recent cases require no splints. In fact, if the displacement be

promptly reduced--under general anæsthesia--the restored parts will

generally maintain their position.

=Elevating an old fracture.= In neglected cases it may be necessary to

re-fracture the nasal bones, and when these are replaced an external

splint may be necessary. This can be made of plaster of Paris; or the

outside of the nose may be covered with a piece of heavy adhesive

plaster, and outside that a shield of tin, copper, or, preferably,

aluminium.[52]

[52] T. A. de Blois, _Trans. Amer. Laryn. Association_, 1900, p. 12.

[Illustration: FIG. 284. MEYER’S HOLLOW VULCANITE NASAL SPLINT.]

Fracture of the ethmoid is, fortunately, rare. When it occurs it is apt

to run into the cribriform plate, and be associated with the escape of

cerebro-spinal fluid and other indications of fracture of the anterior

fossa of the skull.

OPERATIONS FOR CONGENITAL OCCLUSION OF THE NOSTRILS

=Operation for congenital occlusion of the anterior nares.= _If the web

obstructing the nostril be thin and membranous_, and of low vitality, a

simple and effective method is to destroy it with the galvano-cautery.

It is best to spread the treatment over several sittings, so as to

diminish the local reaction. The application of cocaine may not be

sufficient to numb the pain, as the tissue of the obstructing web is

more allied to skin than to mucous membrane. It should therefore be

punctured quickly in two or three places, with a sharp cautery point

raised nearly to a white heat. If the patient be nervous it may be well

to administer nitrous oxide gas.

After the operation the nasal orifice is kept distended until healing

has taken place by wearing Meyer’s vulcanite tube in it or short lengths

of full-sized rubber drainage tube, well smeared with boric, aristol,

zinc, or similar ointment. These simple nasal dilators are changed once

or twice daily, and the nostril is well cleansed on each occasion.

_If the web obstructing the anterior naris be more fleshy in character_

(and it is more apt to be of this nature when it is incomplete), it may

be necessary to remove it with a knife. So as to leave as much

epithelial tissue as possible, and avoid retraction, the operation is

done as follows, under local or general anæsthesia: A narrow,

sharp-pointed instrument, such as a Graefe’s or other ophthalmic knife,

is used to puncture the web from before backwards, and it is then made

to sweep round the obstructing diaphragm, while gradually cutting its

way towards the central lumen. The tongue of skin thus formed can be

used as a graft to cover most of the raw surface. The restored anterior

naris is kept patent, as already described, till healing takes place.

[Illustration: FIG. 285. KRAUSE’S TROCHAR AND CANULA. For puncturing the

maxillary antrum from the nose.]

[Illustration: FIG. 286. NASAL PUNCH-FORCEPS.]

In some cases the following operation has been shown to be easy and

effective: An incision is made at the junction of the web with the

septum, keeping close to the latter and passing straight down to the

floor of the nose. On the outer side a similar incision is made, but

sloping somewhat outwards. The flap formed between these two incisions

is not cut off, but is bent backwards and fastened to the floor of the

nose by a single horsehair stitch.[53]

[53] G. K. Grimmer, _Proc. Royal Soc. of Med._ (_Laryngol. Section_)

April, 1908.

=Operation for congenital occlusion of the posterior choanæ.= If the

obstruction be not freely and completely removed it tends to re-form. A

general anæsthetic is required. Unless the operator is ambidextrous he

will find it most convenient to stand on the patient’s left hand, and to

introduce his own left forefinger into the post-nasal space. This

enables him to guide any straight, sharp instrument, such as an antrum

drill (Fig. 323), Krause’s trochar (Fig. 285), or a surgical bradawl,

from the front of the nose until it presses against and breaks through

the obstructing diaphragm in two or more points. If preferred, an

electric trephine can be used, and often pressure with the tip of a pair

of nasal punch-forceps will be sufficient. The latter, either straight

or tip-tilted (Fig. 286), are then inserted through the nostril, and,

still guided by the left forefinger in the post-nasal space, are

employed to clip away all the obstruction. To prevent any possibility of

this reforming it is recommended by some surgeons that a small piece

should be nipped out of the posterior margin of the bony septum. This

can be done with the beaked punch-forceps of Grünwald (Fig. 286), passed

through the nose, or with a pair of Loewenberg’s post-nasal forceps

(Fig. 287) introduced through the mouth. In either case their action is

controlled and directed by the operator’s left forefinger in the

post-nasal space.

[Illustration: FIG. 287. POST-NASAL FORCEPS.]

No special after-treatment is required. The patient should be ordered a

tepid alkaline nose lotion, and should be encouraged to make use of the

nasal air-way and acquire the habit of blowing the nose.

REMOVAL OF FOREIGN BODIES FROM THE NOSE

It might be helpful to remember that foreign bodies not only enter the

nasal cavities (1) through the anterior nares, but also (2) through the

posterior choanæ, or (3) by penetration through the walls. They may also

arise (4) _in situ_, as in the case of sequestra and rhinoliths. The

last group will be considered separately.

A foreign body, if small, may form the centre of a rhinolith.

=Operation.= Great care and gentleness are required in the removal of

foreign bodies from the nose. The extraction should never be attempted

blindly, or forcibly, or hurriedly. A little delay to make necessary

arrangements does no harm. If a child will not submit to examination it

is much better to employ a general anæsthetic so as to complete

examination and, if found necessary, extraction at the one sitting. If

the nose be not well illuminated and opened with a nasal speculum,

groping about in the dark will only do further damage and result in

disappointment.

[Illustration: FIG. 288. NASAL DRESSING FORCEPS.]

In adults removal can generally be carried on under cocaine. The nostril

is cleaned with cotton-wool, and if the extremity of the probe used for

detecting the presence of a foreign body be curved to a right angle, it

will also serve for gently levering or displacing it forwards. With a

small pair of nasal dressing forceps (Fig. 288) it can generally be

firmly seized and gently extracted, care being taken not to include any

of the mucosa nor to drag the foreign body out regardless of the

sinuosities of the cavity. Lister’s ear hook is a most useful

instrument. Sometimes a nasal snare will help to extract the substance

or to tilt or drag it into a better position.

Unless coated with solid accretions there is never any need to break up

a foreign body; anything small enough to slip into the nose is small

enough to be extracted entire. If it should be found impossible to

remove the body through the anterior nares, it may be pushed backwards

into the post-nasal space, where the forefinger of the left hand is in

readiness to prevent its falling into the gullet or larynx.

The usual warm alkaline lotion may be used to clear the nose, but liquid

should never be forcibly injected into the nostril with the idea of thus

expelling the foreign body. If the lotion be sent up the nasal chamber

on the same side it will only drive the intruding substance further in;

if injected on the opposite side there is risk of otitis media.

In the case of small children it is sometimes recommended that a piece

of muslin should be placed over the mouth, and that the practitioner

should then apply his lips to those of the patient and by blowing

forcibly through the mouth drive out the foreign body by the blast of

air from the post-nasal space. Or the same principle may be applied by

insufflating the air from a Politzer’s bag through the opposite nostril.

Both plans are alarming and seldom effective.

The _after-treatment_ consists of some simple cleansing lotion and

soothing ointment.

REMOVAL OF RHINOLITHS (NASAL CALCULI, OR CONCRETIONS IN THE NOSE)

These concretions are almost unknown in children, in whom foreign bodies

are met with most frequently. A general anæsthetic is, therefore, not so

often required, otherwise the remarks on the removal of foreign bodies

will be found to apply to the extraction of calculi. With the help of

cocaine and good illumination they can easily be removed with a

strabismus hook, Lister’s ear hook, or a pair of fine probe-pointed

nasal forceps with serrated extremities. In some cases where the

calculus has sent prolongations into the recesses of the meatus, it

might first be necessary to crush it. In that event a general anæsthetic

may be required.

The _after-treatment_ consists in simple cleansing measures. Subsequent

syringing of the nose should be done from the opposite side.

OPERATIONS UPON THE TURBINALS

=Indications.= In many cases of hypertrophic rhinitis it is necessary to

remove portions of redundant turbinal tissue. It is never desirable--and

it can only rarely be necessary--to remove the whole of the inferior

turbinal. ‘Turbinotomy,’ or amputation of the whole inferior turbinal,

was recognized as an operation some years ago. But it was never

generally accepted, as it was always realized that the highly important

physiological functions of the lower spongy bone could not be spared.

Improved technique, particularly in being able to correct deformities of

the septum without the sacrifice of any mucous membrane (see p. 603),

now enables us to rectify nasal stenosis with the sacrifice of much less

turbinal tissue.

The middle turbinal is not of so much importance in the physiology of

the nose, and the whole of this body is not infrequently removed. This

may be done not only because it is diseased, but even a healthy middle

turbinal may require amputation in order to approach the accessory

sinuses or diseases in the deeper regions of the nose. Part of the

healthy inferior turbinal may also require removal--as in the radical

operation on the maxillary sinus.

As these operations will be referred to frequently later on, and as

their performance enters into different groups of operation, they will

be described first.

OPERATIONS UPON THE INFERIOR TURBINAL

=Amputation of the anterior end. Indications.= The amputation may be

required:

(i) On account of polypoid degeneration of the anterior extremity of the

turbinal.

(ii) To allow of access to the antro-nasal wall (see p. 633).

(iii) To avoid operation on the septum by relieving nasal stenosis.

[Illustration: FIG. 289. FIRST STEP IN REMOVING THE ANTERIOR END OF THE

INFERIOR TURBINAL, WHICH IS SEEN TO HAVE UNDERGONE POLYPOID

DEGENERATION.]

=Operation.= The local application of cocaine and adrenalin (see p. 573)

is sufficient.

=Anæsthesia.= With the patient sitting upright in a chair, and the

nostril well illuminated, a pair of nasal scissors (such as Heymann’s,

Walsham’s, or Beckmann’s) are made to grasp as much of the anterior

extremity as it is desired to remove, generally the anterior third (Fig.

289). The scissors are pressed very firmly against the outer nasal wall,

so as to divide the base of the turbinal as close as possible to its

attachment. If the scissors slip off the bone it should be divided with

Grünwald’s punch-forceps. The semi-detached extremity is then surrounded

with a nasal snare, carrying a No. 5 piano wire, and cut through (Fig.

291).

It is well not to seize and twist off the anterior extremity, as this

might lead to the ripping out of a larger portion than was intended.

Besides, it might cause fracture of the base of the remaining piece of

the inferior turbinal bone and this might become displaced inwards so as

to block the air-way more than ever.

[Illustration: FIG. 290. NASAL SCISSORS.]

=After-treatment.= It is well to check the hæmorrhage without the use of

plugging. Some antiseptic powder--europhen, xeroform, formidine,

aristol, &c.--if lightly insufflated over the wounded area, will assist

in the formation of a protective scab. This should not be disturbed for

some days, during which the nose is made comfortable by some menthol and

boric ointment, or a paroleine spray. When the scab begins to break down

its removal is assisted by warm alkaline lotions (see p. 579). The stump

may require a few applications of nitrate of silver or other silver

salt. There is no danger in this operation. Healing, as in other

intranasal operations, takes from three to six weeks.

=Amputation of the lower margin.= =Indications.= This is not

infrequently necessary when there is a general hypertrophy--as in the

compensatory hypertrophy of septal scoliosis (Fig. 310)--or when the

whole lower and outer margin is occupied by papillary hypertrophies

(Fig. 289).

=Operation.= The operation can be carried out under the local

application of cocaine and adrenalin, but is frequently performed as

part of some other operation under a general anæsthesia.

The steps have to be varied according to the degree and extent of the

hypertrophic tissue requiring removal. When this is principally along

the lower border of the turbinal it can be removed with one cut of a

stout pair of nasal scissors (Fig. 290). Under good illumination a blade

is insinuated along the concavity, while the other passes between the

convexity and the septum. Care should be taken that the direction of the

scissors is parallel to the axis of the turbinal body, and that the cut

embraces only that portion of the lower area to be removed. The severed

portion should be quickly seized with a pair of punch-forceps and lifted

out, or the patient, if only under local anæsthesia, may be requested to

blow it forward into a tray. Otherwise it is apt to become obscured in

the outpouring of blood, and, if the patient is unconscious, to be

sucked backwards out of sight. If, as not infrequently happens, the

lower margin remains attached at its posterior extremity, a wire snare

is threaded along over it so as to cut this through. When the papillary

hypertrophy is more diffuse it is apt to be concealed in the concavity

of the turbinal. From this hiding-place it can be partially dislodged

with a probe and then cut off with a snare.

The after-treatment is similar to that for removal of the anterior end.

=Removal of the posterior end.= =Indications.= The posterior extremity

of the inferior turbinal is very subject to a moriform hypertrophy, and

some delicacy and skill are required in removing it.

=Operation.= The interior of the nose on the affected side should be

treated with a weak solution of cocaine and adrenalin. The most

disagreeable part of the operation is the introduction of the operator’s

finger into the post-nasal space. Hence the fauces should be freely

sprayed with a 5% solution of cocaine. This will deaden painful

sensation, but it will not prevent the discomfort nor the nausea often

induced.

It is well to avoid as much as possible the direct application of

cocaine or adrenalin to the moriform hypertrophy itself, for it is an

extremely vascular growth, and if much contracted it is more difficult

to ensnare.

The operation may also be carried out under a general anæsthetic, when

one is given for other surgical measures in the nose. In that case it is

best to defer the removal of the moriform hypertrophy until the

end--practically until the patient is commencing to recover

consciousness--on account of the sharp hæmorrhage which is apt to

accompany it.

The chief difficulty of the operation lies in the fact that the part to

be operated on cannot be kept in view, either directly or indirectly,

and that therefore success depends a good deal on delicacy of touch.

A nasal snare--such as that of Blake, Krause, or Badgerow--is threaded

with No. 5 piano wire, and a loop left out a little larger than

sufficient to grasp the growth. This loop is then bent over smartly

towards the side to be operated on, and a slight kink is given to it.

The loop is then slightly withdrawn within the barrel, and this again

brings it into a straight line. If now the snare be passed along the

floor of the nose until the end of it is opposite the posterior

extremity of the turbinal, and if the looped wire be slightly projected

from the barrel, the loop will tend to curve outwards to the side on

which it was kinked. In this way it will be felt to surround the

moriform growth, which can then be cut off.

[Illustration: FIG. 291. AMPUTATION OF THE POSTERIOR END OF THE INFERIOR

TURBINAL.]

It must be confessed that this is not always successful, that there is

no means of making sure that the snare is applied to the root of the

growth, and that once the bleeding is started posterior rhinoscopy fails

to reveal if any of it still remains. It is better therefore to

introduce the purified forefinger of the left hand into the post-nasal

space, so as to define the growth and guide the loop of the snare over

it. The nail of the same finger then keeps the wire close to the base of

the hypertrophy, while the loop is drawn home (Fig. 291). The patient

may then be relieved of the discomfort of the operator’s finger in his

throat, and may be given time to clear away the collected mucus. A

little delay is advantageous, as it allows coagulation to take place in

the large veins of the moriform growth. Some surgeons recommend that

once the growth is strangled the snare should be left _in situ_ for 10

or more minutes. This is irksome and unnecessary, and bleeding is seldom

excessive if the snare be not employed for cutting off the hypertrophy,

but is used as follows: Once the loop is drawn firmly home so as to

embrace the growth tightly, a few minutes’ rest is given. Then,

steadying the patient’s head with the now disengaged left hand, the

snare is plucked from the nose with a quick movement. This brings away

the mulberry hypertrophy in its grasp, and frequently a strip of mucosa

from the lower margin of the turbinal. No bone is removed in this

operation. The bleeding may be very sharp at first, but generally ceases

under the usual measures (see p. 574). Occasionally it is extremely

troublesome, and as the bleeding surface overhangs the post-nasal space

the only local pressure which is available is that of a post-nasal plug.

=After-treatment.= As secondary hæmorrhage is apt to be met with the

patient should be advised to leave his nose alone, neither blowing nor

clearing it, nor using any cleansing measures for 48 hours. After that

time he can employ the usual warm alkaline nose lotion. He should be

warned against the habit of hawking backwards, as this would tend to a

recurrence of the hypertrophy.

[Illustration: FIG. 292. NASAL SPOKESHAVE.]

=Prognosis.= Great relief can generally be promised within a few days.

There is no danger in the operation. The hæmorrhage may be troublesome,

especially in men. The precautions described in the previous chapter are

well worth observing (see p. 574).

=Complete turbinotomy.= =Indications.= As already remarked it must be

extremely rare for this operation to be required. Papillary hypertrophy

chiefly attacks the lower and posterior parts of the turbinal, and these

can be removed as described above, so that if the entrance of the

nostril is made free by anterior turbinectomy, there will still be left

a sufficient area of functionally active mucosa. If, however, almost the

entire inferior turbinal be degenerated, or if it be replaced by

malignant growth, it can be removed in the following way.

=Operation.= Anæsthesia may be local or general. If no other operative

procedure be required at the same time, the anæsthesia of nitrous oxide

gas or chloride of ethyl will be long enough. Owing to the vascularity

of the part adrenalin should be applied for at least 30 minutes

beforehand.

Removal of the turbinal is easily and quickly carried out with Carmalt

Jones’s or Moure’s spokeshave (Fig. 292). This is introduced, passed as

far as the posterior extremity of the turbinal, and the edge is guided

in place with the operator’s left forefinger in the post-nasal space.

With a sharp pull the spokeshave is then drawn forwards and the detached

body can be lifted out with a pair of punch-forceps. Owing to the slope

of the attached border it is seldom that the whole of the turbinal is

removed. Those who are skilled in the use of this instrument can

manipulate it so as to leave a good part of the attached margin of the

turbinal, and the spokeshave can be used instead of the scissors for

removal of the inferior margin. But its action is apt to be uncertain,

and as it may unexpectedly rip out more than was intended, it is seldom

employed nowadays.

=After-treatment.= After the removal of such a large portion of

secreting surface the nasal secretion may dry into adhering crusts and

scabs for some weeks--possibly for six or even eight. The scabs should

be softened by the use of ointment or oily sprays, and removed by the

fere use of warm alkaline lotions. The even healing of the granulating

surface requires watching; its progress should be inspected from time to

time, as the surface may require touching with a weak nitrate of silver

solution.

OPERATIONS UPON THE MIDDLE TURBINAL

=Indications.= Amputation of the anterior end may be required for (1)

simple hypertrophy, (2) cyst or empyema in the anterior extremity, (3)

to gain access to the ostia of the various accessory sinuses, (4) as a

first step to uncover the ethmoidal cells, and (5) as a first step in

removal of ethmoidal polypi.

=Operation.= Local anæsthesia with cocaine and adrenalin is sufficient,

and the operation can be carried out with the patient sitting in the

examination chair. It frequently forms part of some other intranasal

operation which is performed under a general anæsthetic, but the

preliminary application of cocaine and adrenalin should still be carried

out (see p. 572). If the pieces of gauze soaked in the cocaine-adrenalin

mixture be carefully tucked up on each side of the head of the turbinal,

the part to be removed is generally well exposed. With a pair of

Grünwald’s punch-forceps (Fig. 286) or Panzer’s scissors (Fig. 290), the

anterior attachment to the outer wall is cut through (Fig. 293) so as to

free the end, around which a cold wire snare can be passed and the

extremity removed (Fig. 294.) In cases where it is difficult to

introduce the punch-forceps under the attachment of the middle turbinal

the blades may be applied to the lower margin, about half an inch from

the anterior extremity so as to bite out a wedge. Into this the loop

of the wire snare is inserted and the head of the turbinal can easily be

snared off.

[Illustration: FIG. 293. FIRST STEP IN THE REMOVAL OF THE ANTERIOR END

OF THE MIDDLE TURBINAL.]

[Illustration: FIG. 294. SECOND STEP IN THE REMOVAL OF THE ANTERIOR END

OF THE MIDDLE TURBINAL.]

The snare is generally recommended as being safer than the

punch-forceps. There is certainly a risk attending any slip in

manipulating the latter in this region, more so, indeed, than in the

deeper ethmoidal regions, for in the anterior part of the nasal roof the

cerebral floor dips down lower than it does posteriorly, and the nasal

fossa in the anterior part of the middle meatus is very narrow, so that

if the forceps slipped they might impinge on the cribriform plate.

But when the middle turbinal is softened and broken down by disease it

is as safe, and it is certainly more convenient, to take out a wedge

from its centre, as directed above, and then with a pair of Grünwald’s

or Luc’s forceps to twist out not only the anterior extremity, but also

the posterior half. The latter part can also be removed with a

spokeshave, as directed for the inferior turbinal (see p. 591).

=After-treatment.= There is not the same tendency to crusting as occurs

after operation on the inferior turbinal. Hæmorrhage is also less

troublesome. Plugging is therefore the less likely to be required, and

should always be avoided if possible, since it would interfere with

drainage from the various accessory sinuses, and this operation is

frequently required when their contents are particularly septic. The

best plan is to leave the nose severely alone for 48 hours, and then to

clear it gradually with the help of warm alkaline lotions.

OPERATIONS FOR THE RESULTS OF SYPHILIS

=Sequestrotomy.= The discovery of a syphilitic sequestrum always calls

for active treatment.

=Operation.= If the sequestrum be not loose we must wait until it is

movable. Its detachment will be expedited by mercurial inunctions or

injections, and suitable local cleansing and disinfecting measures. As

soon as any movement can be detected in the dead mass we can proceed,

under cocaine, to detach it. Various forms of polypus forceps and

bone-pliers may be required, and the necrosed bone has to be raised from

its bed by a variety of lever and to-and-fro movements. Several sittings

may be necessary, but this is inevitable, as any violent measures are

soon arrested by hæmorrhage. When the necrosed bone has been mobilized

it may be too large for extraction through the nares; such a mass as the

greater part of the body of the sphenoid has sometimes necrosed _en

bloc_. In such cases the dead bone must be broken up _in situ_ and then

removed piecemeal through either the anterior or posterior nares. Very

rarely Rouge’s operation may be required (see p. 622).

=Operations for post-syphilitic adhesions of the velum.= So long as

there is an adequate passage for nasal respiration it is best to leave

any slight degree of stenosis alone. When there is complete atresia, and

when mouth-breathing, deafness, or other consequences develop, some

effort at relief should be made.

=Operation.= Under chloroform, and with the hanging head, W. G.

Spencer[54] separates the soft palate from its adhesion to the posterior

pharyngeal wall, draws it forwards, and fixes it by two silk sutures to

the muco-periosteum of the hard palate. Tilley carries out the same

principle by threading the soft palate on both sides with strong silver

wire and anchoring it to the incisor teeth. The wires cut out in 10 to

14 days, but by this time considerable healing will have taken place

over the raw surfaces from which the adhesions had been separated.[55]

[54] _Proc. Laryngol. Soc., London_, vol. v, November, 1897, p. 4.

[55] Ibid., vol. x, March 6, 1903, p. 81.

After freeing the soft palate, H. B. Robinson prevents it from again

uniting by the following method: ‘A piece of lead plate is cut the full

breadth of the naso-pharynx and bent so that one arm rests on the dorsal

surface of the soft palate, and the lower one on the buccal surface, the

cut margin being received between the plates and apposed to the bend,

and so kept away from the pharyngeal wall.’ The piece of lead is kept in

place by silk threads attached to the four corners, two passing forward

through the nostrils and two through the mouth. The lead plate is not

removed for a fortnight.[56]

[56] Ibid., vol. xiv, June, 1907, p. 106.

Whatever method is employed to enlarge the stricture, dilatation must be

kept up for some time by the frequent passage of the forefinger, a

palate hook, or a dilatable bag.

=Results.= Stenosis of the passage from the naso-pharynx to the

meso-pharynx, caused by syphilitic adhesions between the soft palate and

the posterior pharyngeal wall, is one of the most difficult affections

in this neighbourhood to operate on with satisfactory results. The cause

of disappointment lies in the low vitality of specific scars and their

well-known tendency to contract.

Surgical measures are sometimes required for the damage left by syphilis

during the healing process.

The saddle-back deformity of the external nose is best corrected by

subcutaneous injection of paraffin (see Vol. I, p. 681).

Perforations in the hard or soft palate may require operation to close

them (see Vol. I, p. 717).

OPERATIONS FOR TUBERCULOSIS

Tuberculosis only occurs in the nose in the mitigated form of lupus.

Surgical interference is frequently called for, generally in the form of

curettage or the application of caustics.

The most satisfactory caustic is the galvano-caustic point, applied

under cocaine, and at repeated sittings.

Curettage is required in more advanced cases. Chloroform is always

required. Not only should all soft and diseased tissue be scraped away

with a Volkmann’s spoon, but the curettage should be carried on

vigorously until a healthy and resistant area has been reached. It is

rare for too much tissue to be removed, whereas recurrences are only too

frequent.

CHAPTER III

OPERATIONS UPON THE NASAL SEPTUM

OPERATIONS FOR DEFORMITIES

REMOVAL OF SPURS

=Indications.= A spur or ledge, uncomplicated with deviation of the

septum, occasionally requires removal. It will generally be found in the

lower meatus, at the junction of the quadrilateral cartilage and ethmoid

with the superior maxillary crest and vomer.

[Illustration: FIG. 295. CRESSWELL BABER’S NASAL SAW.]

=Operation.= The operation can be carried out painlessly and bloodlessly

under cocaine and adrenalin. The galvano-cautery, trephine, and

spokeshave should be avoided. An incision is made from behind forwards

along the summit of the projection, and the muco-perichondrium is turned

upwards and downwards. (For particulars as to reflecting these flaps see

p. 605.) A straight, fairly stout nasal saw (Fig. 295) is inserted below

the projection, and, while the patient’s head is steadied with the left

hand, the saw is carried inwards and upwards with short, swift

movements. During the first of these the cutting edge should be directed

obliquely towards the opposite nostril so that the saw gets a good bite

into the base of the spur. Otherwise, if simply directed vertically the

resistance it meets with is likely to send it obliquely outwards, and

the obstruction will be imperfectly removed. This defect will be the

more apparent later on, when some heaping up of scar tissue is sure to

take place over any trace of projection. In other words, in order to

remove a spur flush with its base it is necessary to cut deeper than the

base. At the same time it is important to avoid buttonholing the septum

by cutting into the opposite nostril.

When the spur lies close along the floor of the nose it may be necessary

to direct the saw from above downwards. The result is not so

satisfactory, and the removal may have to be completed by seizing and

twisting off the semi-detached spur with a pair of polypus forceps, or

stripping it forwards with a spokeshave.

=After-treatment.= The reflected flaps of muco-perichondrium are

replaced and maintained in position for 48 hours with plugs of

cotton-wool. Subsequently a warm alkaline nasal lotion and a little

ointment may be required.

=Perforating the septum.= It will be seen that if a spur is associated

with a convexity of the septum to the same side it will be very

difficult to remove the projecting obstruction adequately without

cutting into the concave side of the septum, and so producing a

perforation. Some surgeons even recommend that this should be done

intentionally, and maintain that the resulting perforation seldom gives

any trouble. This may be true in some cases, and the result is sometimes

fairly good. But we have more completely satisfactory methods at our

disposal; the perforation method does not relieve the majority of cases,

and it interferes with the subsequent performance of more perfect

operation. It can therefore only be approved of when the surgeon has not

acquired the technique of the submucous resection operation (see p.

603).

_Operation._ When it has been decided to produce a perforation it is

carried out with the nasal saw, as described for the removal of spurs

(see p. 595). The saw is introduced so as to embrace as much as possible

of the projection.

=Complications= arising after tracheotomy and preventing removal of the