of the perforation is apt to give trouble for some weeks. This
inconvenience is the more marked the nearer the perforation approaches
to the anterior nares. It must be met by careful and repeated cleansing
and lubrication of the nasal chambers. Any scabs should be carefully
softened with hydrogen peroxide, lifted off the edge of the perforation,
and any underlying ulceration treated with applications of nitrate of
silver, argyrol, &c.
OPERATIONS FOR SIMPLE DEVIATION
It is very rare to find a deviation of the nasal septum without some
accompanying spur or ledge. It is still more rare to meet with a
deviation which is entirely limited to the cartilaginous septum; there
is nearly always some bony formation in the deformity, contributed by
the nasal spine of the superior maxilla, the vomer, or the perpendicular
plate of the ethmoid, or by all three. Hence the limited field of
application for the various operations which have been designed for
‘straightening the cartilaginous septum’. In the few cases where the
deformity is almost entirely cartilaginous these operations are only
partially successful in overcoming its resiliency. They will therefore
be only briefly considered.
=Gleason-Watson operation.= For a thorough performance this operation
requires a general anæsthetic. The scheme of the operation is to make a
U-shaped incision around the convexity, leaving it attached above. The
flap of cartilage is then pushed through the U-shaped opening into the
concave side. As its bevelled edge is larger than the button-hole in the
septum it will be to some extent prevented from slipping backwards (Fig.
296). This tendency may also be combated by an attempt to snap through
the base of the flap of cartilage, and by careful packing of the
formerly obstructed nostril. The operation is performed with a nasal
saw, carried from below upwards, and maintained carefully in the
antero-posterior axis of the septum.
[Illustration: FIG. 296. THE GLEASON-WATSON OPERATION FOR DEFORMITY OF
THE SEPTUM. _a_ shows the incision made from the stenosed nostril, and
below the convexity; _b_ represents the septum as pushed into the free
nostril; and _c_ shows the result after subsequent removal of the spur.]
=Asch’s operation.= The resiliency of a deviated cartilaginous septum is
more completely overcome by this method of operating. It requires a
general anæsthetic.
By means of appropriate cutting scissors (Fig. 297) a crucial incision
is made over the summit of the convexity of the deviation, so that we
have four triangular flaps meeting at the point of greatest stenosis. By
means of the finger introduced into the obstructed nostril, or suitable
septal forceps, these four flaps are snapped across at their bases so as
to overcome their tendency to spring back.
Into the formerly obstructed nostril is introduced a Meyer’s vulcanite
hollow splint (Fig. 284), a Lake’s rubber splint (Fig. 298), or a gauze
packing. This should be retained for 48 hours. Afterwards it will
require daily changing and cleansing, possibly for several weeks. In the
opposite nostril a lighter support will serve to keep the ends of the
fragments _in situ_.
=Moure’s operation.= According to its author this operation can be
carried out under local anæsthesia, but it is generally advisable to
employ some such general anæsthetic as nitrous oxide or chloride of
ethyl. By means of suitable scissors one incision is made through the
septum parallel to the bridge of the nose and above the prominence of
the deviation, and by another parallel to the floor of the nose the
septum is divided below the deviation. This is now only fixed at its
anterior and posterior extremities, but has been rendered more movable
from side to side. By means of a specially designed dilator and splint
the septum can be moulded into a good position, and maintained there
until healing takes place.
[Illustration: FIG. 297. ASCH’S CUTTING SCISSORS. Employed in the
operation upon the septum.]
[Illustration: FIG. 298. LAKE’S RUBBER SPLINT.]
The conditions in which any of these operations can prove suitable are
rarely met with. In the worst forms of stenosis from septal deformity
they are useless. At the best they can never completely remove it. In
one of them a perforation is made on purpose, and in the others it not
infrequently is produced unintentionally. The objections to a
perforation have been described (see p. 598). Hæmorrhage, shock, and
prolonged and painful after-treatment are important drawbacks. A dry
scabby condition of the septum may be produced, and the patient may
complain more of this than of his previous nasal stenosis; indeed, he
may find that the stenosis is unrelieved and that a constant source of
irritation has been added to it.
The perforation operation should only be employed when the patient is in
circumstances where a complete submucous resection cannot be carried
out. The Gleason-Watson operation is unsuitable where the deviation
reaches high up. It should be avoided if it is seen that the perforation
will have to be brought close forward to the anterior nares.
Another objection is that any of these operations, particularly the
production of a perforation, will greatly increase the difficulties and
diminish the benefits of the subsequent complementary operations which
are only too often required.
Asch’s operation is easily carried out, and may be practised by those
who have not mastered the technique of submucous resection (see p. 603).
Moure’s operation is easily and quickly performed, and where a
well-marked deviation of the anterior part of the cartilaginous septum
is met with, it will give considerable relief.
OPERATION FOR COMBINED BONY AND CARTILAGINOUS DEFORMITY
_Submucous Resection (Window operation)_
This is the most perfect operation we at present possess for the cure of
deformities of the nasal septum. It has largely supplanted those already
outlined; it is suitable for the most extreme degree of deformity: and
it will secure complete relief to the symptoms produced, whether they
consist of stenosis of the air-way, obstruction to discharge, or reflex
effects.
The design of the operation is to excise all obstructing cartilage and
bone, with any projecting spurs or ledges, while preserving intact the
mucous membrane on each side. It has been brought to its present degree
of perfection chiefly by the work of Killian and Freer.[57]
[57] For bibliography and more detailed description, see StClair
Thomson, _Med.-Chir. Trans._, vol. lxxxix, 1906; _Lancet_, July, 1906;
and _Brit. Med. Journ._, vol. ii, 1906.
=Indications.= The special indications of this operation would appear to
be:--
1. Cases where it is desirable to establish normal nasal respiration and
remove mouth-breathing, with its numerous consequences.
2. Correction of the disfigurement caused by the lower end of the
quadrilateral cartilage projecting into one nostril.
3. Cure of headaches or reflex neuroses of nasal origin.
4. The relief and treatment of Eustachian catarrh.
5. Facility for treating nasal polypi and affections of the accessory
sinuses.
=Objections to the operation.= (_a_) That the excision of a large part
of the septum may lead to flattening or deformity of the nose. This
objection is groundless. A strip of septal cartilage is always left
above, beneath the crest of the nose. Falling in of the bridge of the
nose could only be consequent on entire removal of this ‘bowsprit’ of
cartilage, or from its destruction through the wound becoming septic. No
deformity has occurred in my hands in over 200 operations. On the
contrary, the appearance of the nose is generally much improved.
(_b_) That the operation entails greater risks from any subsequent blows
on the nose. This objection has been met by the experience of Otto Freer
in four cases where severe blows, causing epistaxis and occurring even
within a week of operation, did not result in any damage to the fleshy
septum, nor to the external appearance of the nose.[58]
[58] _Annals of Otology, Rhinology, and Laryngology_, June, 1905.
(_c_) That the operation is long and tedious. The duration of the
operation depends on the nature of the case, the skill of the surgeon,
and the difficulties met with--chiefly in the way of hæmorrhage. A
simple deviation of the cartilaginous septum can be removed by this
method in 10 to 20 minutes. Many beginners are apt to be content with
such a partial removal. More time is required in completely removing
bony deformities. Many cases take 30 minutes, and none need exceed an
hour when once the necessary dexterity has been acquired. More time is
taken up if fresh applications of cocaine or adrenalin have to be made,
if bleeding be troublesome, and if one of the flaps should be punctured.
(_d_) That the operation requires special skill. This is a real
objection to the popularization of the operation. It does not seem
probable that it can ever pass out of the hands of those who are kept in
daily practice in rhinological technique.[59]
[59] ‘As all operators who know it will confess, the Fensterresektion of
the septum belongs to the most extremely difficult intranasal
operations.’ Zarniko, _Die Krankheiten der Nase_, 1905, p. 300.
(_e_) That the operation is unsuitable for children. Owing to the small
size of the nasal chambers the operation presents greater technical
difficulties before the age of sixteen. My own practice formerly was to
await this age, and Killian used to advise that children under twelve
were not fit subjects. But Freer held that the operation is proper for
children at all ages, although with them the deformity tends to recur
unless every vestige of it has been removed. Killian has lately adopted
this view, and agrees that the operation may be performed on children
even as young as four years of age.[60]
[60] _Beiträge zur Anatomie, &c. des Ohres, der Nase, und des Halses_,
Hefte 1-4, 1908.
=Advantages of the operation.= These may be summarized as follows:--
1. A general anæsthetic is not inevitable.
2. Hæmorrhage gives no trouble.
3. Absence of pain and shock.
4. No reaction. The post-operative temperature seldom rises above 99° F.
5. Absence of sepsis, with its possible extension to ears, sinuses, or
cranial cavity.
6. No splints are required, and no plugs after the first 48 hours.
7. Rapid healing, without crust formation.
8. No risk of troublesome adhesions.
9. Short after-treatment.
10. Speedy establishment of nasal respiration.
11. Suitability for every variety of deformity of cartilage or bone in
the septum which may require treatment.
12. No ciliated epithelium is sacrificed.
13. Accuracy of result can be depended on; the prognosis is, therefore,
the more definite.
14. If the external appearance of the nose be altered at all it is in
the way of improvement.
It will be seen that the above advantages cancel most of the drawbacks
which were formerly so annoying in nasal surgery.
=Contra-indications.= 1. Elderly people are so accustomed to their nasal
obstruction, and its secondary consequences are generally so fully
established, that the benefits would be much less marked than earlier in
life.
2. Serious or progressive organic disease. This does not apply to
quiescent or arrested tuberculosis.
3. Active syphilis.
4. Lupus.
5. The operation should be postponed if the patient shows any symptoms
of influenza, or of acute or infectious catarrh.
=Operation.= Submucous resection can be completely carried out under
local anæsthesia, as described on p. 572. Killian and others secure
local anæsthesia by submucous injection of cocaine and adrenalin (see p.
572), but I have found this method alarming to the patient, apt to
produce disagreeable palpitation, and not superior to the method of
superficial application already described, particularly if sufficient
time is allowed for the mixture to act, and if a few cocaine crystals
are allowed to dissolve over the site of incision some minutes before
starting it.
In nervous subjects it is better to administer chloroform, not so much
because of any pain they suffer, but because of the mental strain they
are apt to feel in watching the various manipulations.
[Illustration: FIG. 299. BAYONET KNIFE.]
_Position._ The operation is best done with the patient horizontal on an
operating table, with the head and shoulders well raised. His nose is
then almost on a level with the eye of the surgeon, who is armed with a
frontal search-light or Clar’s mirror (see p. 571), although he can also
operate successfully with an ordinary forehead reflector.
[Illustration: FIG. 300. INCISION FOR SUBMUCOUS RESECTION OF THE SEPTUM.
The incision is made, on the convex side, from B to A. If the free end
of the quadrilateral cartilage is displaced from behind the septum
cutaneum, and presents in one nostril, then the incision is made from
_b_ to _a_.]
_The incision._ This can be made with a narrow scalpel, but a much
shorter instrument mounted on a bayonet handle cutting all round the
point will be found more satisfactory (Fig. 299). The incision is made
from the side of the convexity, just anterior to it, and generally about
half a centimetre behind the junction of the skin and mucous membrane
(Fig. 300). It is started high up in the attic of the nose, and carried
downwards to the floor. Sometimes it curves a little backwards below,
but it is quite unnecessary to convert it into an L-incision by a second
cut backwards. The incision, in its whole extent, divides the mucous
membrane and cartilage at one cut, but without puncturing or wounding
the mucosa of the opposite (concave) side. In doing this the operator’s
forefinger in the opposite nostril serves as a useful guide (Fig. 301).
In those cases where the lower free end of the quadrilateral cartilage
is displaced from behind the septum cutaneum into one nostril--commonly
but erroneously described as ‘dislocation of the septum’--the incision
is made directly over the exposed extremity (Fig. 300, _b-a_).
_Raising the convex flap._ With a small sharp elevator the
muco-perichondrium is raised along the posterior edge of the incision.
Great care must be taken not to pass the raspatory between the mucous
membrane and the closely adhering perichondrium. The dead white,
slightly roughened surface of the bare cartilage should be distinctly
visible, and should not be coated with any soft, smooth, or pinkish
perichondrium. Once the flap is well started a dull-edged detacher (Fig.
302) will readily undermine it by sweeping movements gradually advancing
upwards and backwards. If possible the limits of the convexity should be
passed, but it is well not to attempt to go round sharp projections, as
it is there that perforations are apt to take place. It is easier at a
later stage to strip the flap off crests or spurs.
[Illustration: FIG. 301. MAKING THE INCISION FROM THE CONVEX SIDE IN
SUBMUCOUS RESECTION OF THE SEPTUM. The forefinger of the left hand acts
as a guard in the opposite nostril.]
_Incision through the cartilage._ If the cartilage has not already been
completely cut through at the first incision it is now divided in the
same extent as the cut in the muco-perichondrium, great care being taken
not to button-hole the mucosa of the concavity.
[Illustration: FIG. 302. DULL-EDGED DETACHER.]
_Raising the concave flap._ The sharp elevator, followed by the
dull-edged detacher, is introduced from the incision on the convex side.
The muco-perichondrium of the concavity is now raised in the same way
and with the same precautions already used on the convexity, the sharp
elevator and then the dull-edged detacher being introduced through the
incision in the obstructed orifice, and manœuvred between the cartilage
and the concave flap without puncturing the latter (Fig. 303).
[Illustration: FIG. 303. DENUDATION OF THE SEPTUM IN SUBMUCOUS
RESECTION. The muco-perichondrium has been raised from the convex side
of the septum, and the cartilage has been cut through (from A to B in
Fig. 300). The dull-edged detacher is shown separating the mucous
membrane from the concavity of the deflexion.]
[Illustration: FIG. 304. COMPLETE DENUDATION OF THE DEVIATED SEPTUM.
Semi-diagrammatic drawing of a transverse section of the nose, viewed
from above. The deviated septum has been divided in front, and its
muco-perichondrium has been stripped up on each side. The nasal speculum
is introduced through the convex nostril, and a blade is inserted on
each side of the septum, between it and its mucous covering.]
_Excision of the deviated cartilage._ A long Killian’s nasal speculum
(Fig. 346), or the long Thudichum’s speculum I have had made, is now
introduced through the obstructed nostril, one blade being inserted on
each side of the now denuded septum (Fig. 304). It is easy to see if the
mucous membrane has been sufficiently stripped off. If not, it can be
carried further with a few sweeps of the raspatory. Ballenger’s swivel
septum knife[61] (Fig. 305) is then placed astride the anterior cut
surface of the cartilage, pushed upwards and backwards below the roof of
the nose until it comes in contact with the ethmoid, then downwards and
backwards to the angle between the ethmoid and the vomer, and, finally,
pulled forwards along the upper margin of the vomer (Fig. 306). The
excised cartilage is thus removed _en bloc_, and may measure an inch by
one and a half inches.
[61] _The Laryngoscope_, vol. xv, June, 1905, No. 5, p. 417.
[Illustration: FIG. 305. BALLENGER’S SWIVEL SEPTUM KNIFE.]
The empty pocket between the two separated and flaccid mucous membranes
is wiped out and the two fleshy curtains are allowed to fall together.
With a nasal speculum each nasal chamber is next carefully inspected to
see that the thoroughfare is completely restored. As a rule deeper
obstructions, formerly invisible, will come into view, and the mucosæ
are again separated with a long nasal speculum and more of the septum is
shaved off with Ballenger’s knife or clipped away with Grünwald’s
punch-forceps, which also serve to remove portions of the vomer and of
the perpendicular plate of the ethmoid.
_Excision of bony spurs and ledges._ It has been pointed out that it is
extremely rare to find a deviation limited entirely to the cartilaginous
septum. I have never yet met a case in which it was not desirable to
remove some of the bony septum.
[Illustration: FIG. 306. THE METHOD OF EMPLOYING BALLENGER’S SWIVEL
SEPTUM KNIFE. The knife is shown cutting out the cartilaginous
deviation.]
When the deformity of the septum is principally composed of bone the
operation is started as already described. It is then easier to lay bare
any thickening or deviation of the nasal process of the superior
maxilla, or of the chondro-vomerine suture--the usual sites of bony
obstructions. When the main mass of deviated cartilage has been cut out
with Ballenger’s knife free access is obtained from above to these
deformities, and the fleshy muco-perichondrium can be peeled off on each
side with much less risk of a tear or puncture. Still, much care is
required in working round sharp corners, and, when the spurs lie low,
the flaps frequently require to be reflected right down to the floor of
the nose. Once well exposed, the maxillary spine is attacked with strong
punch-forceps or chisel and hammer, and as pieces of it are prised up
they are twisted off with forceps. Once the obstructing maxillary spine
is cleared away it is easier to deal with any vomerine deformity.
A great deal of the success of an operation depends on the complete
removal of these spurs and ledges, and as they may have to be followed
back nearly to the posterior choanæ this part of the operation may be
the most difficult, as it is the most necessary (Figs. 307-9).
The pocket between the two flaps is again carefully wiped free of
blood-clot and chips of bone and cartilage, and when the two mucous
membranes are allowed to fall together they should hang perfectly plumb
in the middle line and allow of an uninterrupted view through each nasal
chamber, right back to the post-nasal space.
_Stitches._ With a small Trélat’s needle the incision is closed with one
or two catgut stitches.
[Illustration: FIG. 307. SUBMUCOUS RESECTION OF THE SEPTUM. The arrows
indicate the points where the chisel may be applied when exostosis of
the nasal maxillary spine requires removal.]
_Dressing._ Plain sterilized cotton-wool is tightly rolled into pencils
about 3 inches long, and well smeared with sterilized vaseline. These
are carefully packed into each nostril. The nose should not be tightly
plugged, our object being to keep the two mucous membranes in
apposition, but at the same time entirely occluding nasal respiration.
=After-treatment.= The patient remains quiet for the rest of the day.
Ice may be given to suck and an iced cloth laid across the bridge of the
nose. At the end of 48 hours the plugs are removed and will be found to
come away very easily. The patient should be warned against blowing his
nose, but may suck blood-stained mucus backwards and hawk it out through
the mouth. Any discomfort may be soothed by spraying the nostrils with
liquid vaseline, or introducing a piece of menthol and boric ointment
into each nostril morning and evening.
[Illustration: FIG. 308. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded
area indicates the extent of the bony and cartilaginous septum usually
requiring removal.]
[Illustration: FIG. 309. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded
portion indicates the extent of cartilage and bone removed in marked
deformity, when the free end of the quadrilateral cartilage projects
into one nostril.]
The relief to the former state of nasal obstruction may at once be
appreciable. If there be any local reaction it may take 3 or 4 days for
the obstruction to subside. In 7 to 10 days the patient begins to enjoy
the benefit of the operation, but it is only after 3 weeks that the full
advantage of it is established.
=Complementary operations.= As a rule the formerly patent nostril is
found after this operation to be the more obstructed of the two. The
reason of this is readily explained by a reference to Fig. 310. The now
redundant hypertrophy in the formerly good nasal chamber is
removed--according to its degree and extent--by one of the methods
described on p. 587.
From long disuse marked alar collapse may interfere with the good
results of the operation.
=Difficulties.= _Insufficient illumination_ is a difficulty that can
easily be provided against by using a frontal photophore or Clar’s
mirror (see p. 571).
[Illustration: FIG. 310. SEMI-DIAGRAMMATIC TRANSVERSE SECTION OF THE
NOSE. Shows the compensatory hypertrophy of the inferior turbinal in the
unobstructed nostril. Part of this frequently requires removal after the
septum has been straightened.]
_Hæmorrhage_ presents no difficulty if patients are prepared as directed
(see p. 574), unless one happens unexpectedly on a patient with a
hæmophilic tendency. In one such case I had no trouble at the time of
operation, but bleeding gave great annoyance for a fortnight afterwards.
_The incision_ I have described has always proved sufficient. In some
cases this straight incision is unintentionally converted into an
L-shaped one, when the flap is torn over a sharp low-lying spur.
Beginners may find it easier to start with an L-shaped incision, but it
is unnecessary and does not leave so small and clean a wound.
The perichondrium should be raised with great care, for it is more easy
than one would think to leave it adhering to the septum, while
separating only the mucous membrane.
_Previous operations_ always increase the difficulties of the
proceeding. The old-fashioned ‘shaving off’ of spurs often removed the
entire thickness of the cartilage at one part, without perforating the
concave mucosa. The submucous resection (window operation) is not
infrequently not carried far enough. In either of these circumstances
we are confronted with the great difficulty of trying to separate the
two muco-perichondria--now closely united to one another.
OPERATION FOR PERFORATION OF THE NASAL SEPTUM
When a perforation of the nasal septum is situated at some distance
within the nasal orifice it seldom gives any trouble. A perforation may
also be situated close to the anterior nares without even making its
presence known. But in some cases--no matter what the original cause of
the perforation--constant annoyance is given to the patient by the
crusting and bleeding which takes place along its margin. When these
crusts have been carefully removed inspection will show that the cause
of the trouble is the projecting free edge of the cartilage which
prevents the edges of mucous membrane from each nostril from closing
over it. When this circular edge is healed over smoothly, secretions
cease to adhere to it, and the patient is not troubled by the annoying
crust formation.
[Illustration: FIG. 311. OPERATION FOR PERFORATION OF THE SEPTUM. The
muco-perichondrium is reflected for some distance round the opening so
as to allow of the projecting rim of cartilage being removed. The
exposed edge is then covered over by the mucous surfaces falling
together.]
This desirable condition can be brought about in crusting perforations
by means of the following operation designed by Goldstein.[62] After
preparation with cocaine and adrenalin (see p. 573), the
muco-perichondrium is reflected on each side along the whole
circumference of the perforation for a distance of about a quarter of an
inch from the free margin. Over the greater part of the circumference
this can be done with Freer’s sharp elevator, or with the small sharp
elevator employed in submucous resection of the septum. In dissecting
the anterior part of the circumference the same kind of elevator can be
used, but with the operating edge bent forward at an acute angle (Fig.
311). A slit in the elevated mucous membrane, posterior to the
perforation, will relieve tension. With a Ballenger’s single-tine swivel
septum knife a rim of cartilage is then cut away around the perforation,
so that the two mucous surfaces from opposite nostrils can come in
contact and overlap the circular edge of cartilage. This smooth surface
will prevent any further sticking and crusting of discharge. It is kept
_in situ_ for 48 hours by vaselined cotton-wool plugs, similar to those
used in the submucous resection of the septum (p. 608).
[62] _The Laryngoscope_, xvi, 1906, p. 879.
OPERATION FOR ABSCESS
A free incision is made into it, under cocaine or nitrous oxide
anæsthesia. A horizontal cut should extend right across the swelling,
and as low in it as possible, to prevent the pocketing of pus. It is
sufficient to make it on one side, as the pus from the other side can be
pressed across through the defect in the cartilage. Any loose fragments
of cartilage should be probed for and removed. The lips of the incision
are kept apart by loosely tucking in a small piece of ribbon gauze. This
promotes drainage of the lower part, and is changed daily. Afterwards
healing takes place under simple cleansing measures.
OPERATION FOR HÆMATOMA
If the hæmatoma be small and not in a suppurating nose, evaporating
lotions are applied externally and the swelling is left alone, being
carefully inspected daily for early symptoms of suppuration. If the
swelling be large and tense, it is safer to incise it freely as
described above for abscess of the septum.
CHAPTER IV
OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS: OPERATIONS
FOR OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX
OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS
REMOVAL BY SNARE
=Indications.= Operation with the snare is indicated in cases of simple
mucous polypi, if only a few polypi are present, and no sinus
suppuration is suspected. It is a suitable method for the removal of
papilloma, fibroma, and bleeding polypus of the septum. The snare is
also serviceable in the removal of enchondroma, osteoma, and growths, if
of limited size, after they have been detached from their bases or
broken up with a chisel or bone forceps.
[Illustration: FIG. 312. NASAL SNARE.]
=Instruments.= The surgeon will employ the pattern of snare to which he
is accustomed. The simpler models, such as those of Krause, or some
modification of Blake’s instrument, such as that of Badgerow, when
threaded with No. 5 piano wire will be found sufficient in most cases
(Fig. 312). For tougher growths, or those with a thicker pedicle, the
snare of Lack can be recommended. It is threaded with heavier wire, and
by a screw arranged in the handle the loop can be slowly and steadily
contracted.
=Operation.= The nose is carefully prepared with cocaine and adrenalin
(see p. 573), remembering that any growth or polypus is itself
insensitive. The anterior part of the nasal cavity, and particularly the
septum, should be thoroughly anæsthetized.
Under good illumination the snare is introduced with the loop vertical,
and passed alongside the growth,--between it and the septum or to the
outer side, as space permits. It is then swept round a half-circle, so
as to bring any tumour within the loop, and by a to-and-fro movement the
snare is worked upwards towards its base. The attachment of the ordinary
mucous polypus is generally in the region of the middle meatus. The wire
loop is thus threaded on to the growth or polypus. The loop is now
steadily tightened until it is felt that the pedicle is grasped,--it is
seldom visible. By a quick movement of avulsion the tumour is then torn
from its attachment. This will bring away some of the œdematous tissue
on the distal side of the loop, and there will be less tendency to
recurrence than if the root were simply cut across. With the removal of
a first polypus others come into view and they must be treated in the
same manner. The number which can be removed at one sitting will depend
on how well the patient is able to bear the manipulations and how much
bleeding there is. If both nostrils be affected it is well to treat them
on alternate weeks.
When the growth slips, or is pushed backwards, it can be brought forward
into the field of operation by asking the patient to blow down the nose,
with the opposite nostril closed. Or the presenting part of a polypus
may be seized with a pair of toothed catch-forceps and the wire loop
slipped over this.
If the growth be hanging backwards, and presents in the post-nasal
space, as it often does when it originates from the mucosa of the
maxillary antrum, it may be necessary for the surgeon to introduce his
left forefinger behind the palate,--as described on p. 590 (compare Fig.
291),--so as to steady the growth and at the same time slip the wire
loop around it. If there be no space for the latter manipulation, the
left forefinger is used to steady the mass while a pair of polypus
forceps is guided along the floor of the nose until the growth can be
seized between the blades so as to tear it from its attachment and pull
it out through the anterior nares.
=After-treatment.= The bleeding will generally cease spontaneously,
assisted by cold ablutions to the face, or pinching the end of the nose
until a clot forms (see p. 575). If bleeding persists, a piece of gauze,
moistened with peroxide of hydrogen, should be packed in lightly and
removed as soon as the patient can lie down quietly. It is best to avoid
the use of any plug. It was to plugging that Luc attributed the loss of
a patient from meningitis consequent on the removal of polypus.[63]
[63] _Revue hebd. de Laryn._, 1903, xxiv, Nr. 46, November 14, p. 597.
If the entrance to the nose be tender, it may be smeared with a little
menthol and boric ointment; ice-cold cloths may be kept across the
bridge of the nose; and pain or sensitiveness can be relieved by a few
doses of phenacetin or some similar anti-neuralgic.
Insufflations of antiseptic powder are useless, and the nasal cavity
should be left alone for 24 or 48 hours. A nose lotion should then be
used two or three times a day, until the local condition is again
inspected at the end of a week.
Any attempt to destroy the roots of polypi by the galvano-cautery is
useless and dangerous.
REMOVAL BY FORCEPS AND CURETTES
=Indications.= This operation is indicated in all cases of recurring
polypi and extensive caries of the ethmoid, but the plan of operation is
also suitable for the removal of some cases of papilloma, fibroma,
enchondroma, or osteoma.
It can also be employed in certain cases of malignant disease in the
nose. When the growth appears to be limited to the nasal fossæ, and
particularly in cases of sarcoma, the above operation may be indicated.
Even when glands are present this may still be the preferable operation,
as glands can be removed at a separate sitting.
Possibly a better method of deciding the case of malignant intranasal
disease suitable for this operation will be founded on the discovery of
the original attachment of the growth. If located towards the front of
the nose in the anterior part of the middle meatus, removal can be
carried out on the lines described.
=Contra-indications.= If there be any mental symptoms suggesting that
intracranial inflammation has taken place already, the patient should be
carefully examined before operation is embarked on. It is unsuitable for
debilitated and elderly subjects. In patients over 60 with recurrent
polypi it is wiser to secure relief by a series of small operations
under cocaine.
Many neoplasms and inflammatory hypertrophies, such as mucous polypi,
can be removed satisfactorily _per vias naturales_ by the method to be
described. Naturally the details will vary with the situation and extent
of the disease to be removed. The following description applies
particularly to growths or hypertrophies springing from the ethmoidal
region:--
=Operation under cocaine.= The nose is carefully prepared with adrenalin
and cocaine, the strips of moistened ribbon gauze being carefully tucked
in between the septum and the ethmoidal region, as well as between this
latter and the outer wall. The inferior turbinal and the front of the
nasal cavity should be similarly prepared, so as to diminish
vascularity, retract the healthy tissue, and thus increase the space for
operating in, while lessening the risk of wounding the septum and so
causing adhesions. At least one hour should be given for the solution to
act. The operation is done with the patient sitting upright in the
ordinary examination chair, with the body craned forward somewhat, and
the head supported and held in focus by an assistant. Ready to the
surgeon’s hand should be some lengths--about a yard--of 1-inch to 2-inch
ribbon gauze, and a vessel of cold sterilized water into which it is
easy to shake off the growths as they are removed with the forceps.
[Illustration: FIG. 313. LUC’S NASAL FORCEPS.]
If the middle turbinal has not already been removed it may have to be
amputated, as described on p. 592. In many cases of ethmoidal caries it
is easily removed with nasal forceps.
The instrument I recommend is Luc’s forceps[64] (Fig. 313), supplemented
by Grünwald’s punch-forceps (Fig. 286). The former are introduced
vertically, so that one blade passes between the ethmoid and the septum
and the other passes under cover of the middle turbinal. By insinuating
them carefully, and gradually working them upwards and outwards, a large
mass of tissue or carious ethmoid can be grasped, twisted off, and
shaken from the forceps into the vessel of water. Before any marked flow
of blood has taken place it will be possible to make a second or third
introduction of the forceps, and seize the successive masses of growth
which come into view. When the bleeding obscures the field of operation
one of the strips of gauze can be picked up quickly in the forceps and
used for plugging that side of the nose, while a similar operation is
carried out in the opposite nasal chamber, if it is affected.
[64] _La Tribune Médicale_, 1905.
Hæmorrhage may require the plug being left _in situ_ for a few minutes,
so as to get a clear view of the depths of the nose. This is better
secured if the end of the gauze strips are first soaked in either
adrenalin or a 10% solution of hydrogen peroxide. In this way the main
mass of the ethmoid can be completely cleared away, the posterior
ethmoidal cells opened up, and the front wall of the sphenoidal sinus
broken down. Not infrequently the surgeon finds afterwards that this
latter cavity has been quite inadvertently, though successfully, opened.
=Operation under general anæsthesia.= Under a general anæsthetic this
operation can be even more satisfactorily carried out, but the surgeon
has to keep well in view the anatomical relations of the parts, and the
altered relationship to the horizontal position compared with what he is
more accustomed to with the patient sitting in the examination chair.
When chloroform is employed the interior of the nose is prepared in the
same way beforehand with adrenalin and cocaine; the patient is placed
horizontal on an operating table with his head and shoulders slightly
raised; the post-nasal space is plugged with a sponge (see p. 575); and
the tongue is drawn forward with a clip (Fig. 314) so that the
administration of the anæsthetic through the mouth is quite
uninterrupted. This method allows the surgeon to operate deliberately,
generally with the hæmorrhage under easy control, the field of operation
well illuminated, and no anxiety in regard to the anæsthetic.
[Illustration: FIG. 314. TONGUE CLIP. Keeps the tongue drawn forwards to
allow of general anæsthesia, when the post-nasal space is plugged.]
The removal of polypoid ethmoid can thus be completely carried out. With
this method I have removed at one sitting a mass of diseased ethmoid
which weighed four ounces.[65] It also permits the introduction of the
operator’s little finger to some distance, so as to detect polypoid or
carious surfaces.
[65] _Proc. Laryn. Soc. Lond._, 1907, xiv, p. 106.
With a ring-knife any irregular spicules or projections can be smoothed
down. The ring-knife--or a Volkmann’s spoon--is carefully introduced
behind a mass of growth, and then pulled briskly out through the nose
while hugging its outer wall. The nasal roof should be diligently
respected.
When the operation has been completed the post-nasal plug is removed,
and it is well to pass the forefinger of the left hand well up into the
posterior choanæ to detect and push forwards any masses of growth which
may have been driven backwards.
Hæmorrhage generally ceases with the usual remedies (see p. 576). It is
better to avoid all plugs.
=Dangers and complications.= This operation in careless or inexperienced
hands is not free from risks. The chief danger is from injury to the
cribriform plate, as any damage in this area, occurring in the septic
conditions which generally call for operation, is generally followed by
fatal meningitis.
In addition to the usual precautions, particular attention should be
paid while manœuvring in the anterior part of the space between the
septum and the outer nasal wall. Here the punch-forceps are not directed
backwards against the main mass of the sphenoid, but, as the head has to
be extended in order to approach the anterior area, they follow an
obliquely upward direction which brings them into dangerous proximity
with the floor of the cranial fossa--which dips down lower in front than
it does posteriorly. Great care, therefore, is taken to avoid any
thrusting or boring movements with the forceps. They are first made to
press outwards as much as possible the opposing walls of this narrow
region, so that polypoid masses can fall between the blades under good
inspection.
Occasionally the os planum is perforated, resulting in emphysema of the
eyelids or an ecchymosis like a ‘black eye’. An orbital abscess may
follow (Lack).
METHODS OF OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND
NASO-PHARYNX
LATERAL RHINOTOMY, OR MOURE’S OPERATION
Direct inspection and treatment of the deeper regions of the nose, the
naso-pharynx, the ethmoidal labyrinth, and the neighbouring area of the
maxillary sinus, is well secured by the following operation, which has
been fully described by Moure of Bordeaux.[66]
[66] Moure, _Revue hebdomadaire de Laryngologie_, October 4, 1902;
Duverger, ibid., September 2, 1905.
=Indications.= This operation is particularly suitable for malignant
growths originating in the upper or inner walls of the maxillary sinus,
the ethmoidal labyrinth, the deeper regions of the nose, the
naso-pharynx, or the sphenoid. It might be required for very vascular
naso-pharyngeal fibromata with extensive prolongations. It is very
suitable for necrosis--generally syphilitic--of the sphenoid when
threatening the base of the brain.
For malignant growths in the regions mentioned, this route is
particularly suitable, if, of course, the limitation of the growth and
the absence of secondary infection justify intervention. The large space
formed by throwing the nose and antrum into one cavity gives a freer
field than removal of the superior maxilla, without the disfigurement
and tendency to recurrence so apt to be associated with this latter
operation, since it seldom includes removal of the ethmoid, which is the
usual seat of origin of the disease. In Moure’s operation the functions
of the eye, and of the nerves and muscles of the face, are not
interfered with, nor are there those difficulties with phonation and
deglutition which are left by removal of the upper jaw.
The interior of the nose is prepared with adrenalin and cocaine (see p.
572), chloroform is administered, and a sponge is packed into the
naso-pharynx (see p. 575).
=Operation.= An incision is made from the inner border of the eyebrow,
along the side of the nose, until it enters the lower margin of the
nasal orifice. A second incision, starting from the same spot above, is
next carried round the lower margin of the orbit and outwards as far as
the malar eminence (Fig. 315).
[Illustration: FIG. 315. INCISIONS FOR LATERAL RHINOTOMY (MOURE’S
OPERATION).]
The lobule of the nose is then detached, so that the fleshy parts of the
nose can be thrown over to the opposite side, while a triangular flap is
turned downwards and outwards. With a raspatory the nasal process of the
frontal bone, the nasal bone, the ascending process of the superior
maxilla, and the canine fossa are next exposed. The lachrymal sac is
carefully defined and retracted. A chisel is first driven through the
superior maxilla, close to its junction with the malar bone, but
avoiding the infra-orbital nerve, and the section is carried downwards
across the canine fossa until it reaches the alveolar border (Fig. 316).
From the lower extremity of this incision--which of course enters the
maxillary sinus--the bone which separates it from the pyriform fossa is
broken through with stout forceps. In this way the antro-nasal wall is
detached close to the floor of the nose, and can be removed together
with the inferior turbinal. The nasal bone itself is next removed,
together with part of the lachrymal bone and the nasal process of the
frontal. Finally the middle turbinal and lateral mass of the ethmoid are
removed with punch-forceps (Grünwald’s or Luc’s), Volkmann’s sharp
spoons, or a ring-knife.
[Illustration: FIG. 316. THE AREA OF BONE REMOVED IN LATERAL RHINOTOMY.
The flaps have been retracted, and the dotted lines show where the bones
are chiselled through.]
A gouge, or Killian’s eye protector (Fig. 342), is then slipped inwards
and downwards at the upper part of this opening until it comes in
contact with the body of the sphenoid. An assistant holds it closely
parallel to the cribriform plate, where it acts as a protector. With a
large sharp spoon, acting from above downwards and forwards, the
ethmoidal labyrinth can be cleared away with any tumour which may have
infiltrated it. The os planum, if not already destroyed, can be removed,
so as to obtain access to the orbit. Direct approach is given to the
sphenoidal sinus. The septum can be readily resected, but an endeavour
should always be made to preserve a strip of cartilage under the bridge
of the nose to prevent any external deformity (see p. 609). It is
needless to say that great care must be taken while working close to the
cribriform plate.
A malignant tumour can then be removed with forceps, sharp spoons, and
the fingers, any prolongations being followed into the naso-pharynx, the
maxillary sinus, the sphenoidal sinus, the lateral mass of the ethmoid,
or even into the pterygo-maxillary fossa. Success largely depends on the
care with which this curettage is carried out. It should be followed by
the application of caustics or Paquelin’s cautery.
[Illustration: FIG. 317. LATERAL RHINOTOMY. The side of the nose has
been removed, and direct access obtained to the upper and deeper nasal
regions.]
Bleeding is generally abundant at first. It can be controlled with
tampons and the use of hydrogen peroxide. When the whole of the
malignant growth has been removed, hæmorrhage generally stops
spontaneously. Firm packing of the wound is therefore unnecessary and is
best avoided. The large cavity is filled with one long strip of 1-inch
ribbon gauze, which is left projecting from the nostril, and the skin
incisions are carefully brought together with silkworm-gut sutures.
Healing takes place by first intention. There may be a little flattening
of the side of the nose, but there is no disfigurement, and a few months
afterwards it is difficult to detect any trace of the operation. The
strip of gauze is removed in 24 to 48 hours, and simple intranasal
cleansing measures are then instituted (see p. 579).
ROUGE’S OPERATION (SUBLABIAL RHINOTOMY)
No special instruments are required for this operation. Full
illumination--with a Clar’s mirror or frontal search-light (see p.
571)--is particularly necessary.
In addition to the usual preparations, the mouth, teeth, and gums should
be purified as much as possible beforehand.
General anæsthesia, preferably with chloroform, is required.
=Indications.= With the progress of rhinology the occasions for invading
the nasal chambers otherwise than by the natural orifices have steadily
diminished. Rouge’s operation was formerly employed in dealing with
deformities of the septum, in the treatment of ozœna, in lupus of the
nose, for the removal of simple mucous polypi, in operations on
naso-pharyngeal fibromata, or as a simple method of exploration. In all
these circumstances it is now uncalled for, as we are possessed of
simpler, safer, and more effective methods.
In more modern times it has been advocated as a route of approach to the
accessory cavities of the nose by some authors, but this proposition has
not met with general support.
The chief indications for Rouge’s operation are as follows:--
1. Very large sequestra. The majority of syphilitic sequestra can be
removed through the natural orifice. In some cases they can be broken up
after being mobilized and then removed through the nostrils. If still
impossible of extraction Rouge’s operation is indicated.
2. Osteomata are sometimes too large to be extracted through the natural
orifice, and as they are much too hard to break up _in situ_, this
operation is clearly indicated.
3. Malignant growths.
=Operation.= Standing behind the head of the patient, an assistant
seizes the extremities of the upper lip between the forefinger and thumb
of each hand, so as to turn it up against the nostrils and present its
mucous surface. A small packet of loose gauze is placed at each corner
of the mouth, to be handy for stanching any bleeding. An incision is
then made across the gum, a little below the gingivo-labial fold, from
the first upper molar on one side to the other (Fig. 318). This is
carried right down to the bone.
With a raspatory the soft parts can be easily and rapidly separated up,
so as to bring the orifice of each nasal chamber into view. With a pair
of scissors curved on the flat the cartilage of the septum is next
detached from the nasal maxillary spine, or the latter can be detached
with a chisel and hammer (Fig. 319). The assistant is now able to pull
the everted lip with the fleshy parts of the nose further up on to the
face, fully exposing the pyriform orifice of the nasal chambers, with
part of the anterior wall of the superior maxilla exposed on each side.
[Illustration: FIG. 318. ROUGE’S OPERATION. _First stage._ The upper lip
is everted and retracted by an assistant standing behind the patient’s
head. The dotted line indicates the line of incision.]
The conditions met with are then dealt with as required. Hæmorrhage
gives little trouble, and can generally be checked by pressure with
strips of gauze, possibly supplemented by the use of peroxide of
hydrogen. When the operation has been completed the everted lip is
turned down, and falls into place, where it can be secured by a few
catgut sutures.
=After-treatment.= Two pads of cotton-wool over the upper lip, to right
and left of the nasal openings, will give relief and secure healing of
the wound by first intention. The mouth should be kept as clean as
possible, and cleansing measures to the nasal chambers will be required
in proportion to the amount of destruction of its self-cleansing mucous
membrane.
=Advantages.= This operation has several advantages:--
(_a_) It is not difficult of execution, and can be carried out with a
scalpel and a raspatory.
[Illustration: FIG. 319. ROUGE’S OPERATION. _Second stage._ The soft
parts are retracted.]
(_b_) It gives a free access to the floor of the nose and the anterior
part of the nasal fossæ. The vestibule, the natural orifice of the nose,
only measures 20 millimetres by 7 to 8 millimetres. Rouge’s operation
exposes an orifice measuring 3-1/2 centimetres by 2 centimetres. The
posterior margin of the septum, instead of being 8 centimetres distant
from the outside, is now brought within a reach of 5 centimetres. The
floor of the nose lies on a lower level than that of the vestibular
entrance, and is wider some distance in than it is at the orifice. By
means of this operation the whole floor comes into clear view, and the
exit from the nasal chambers becomes the widest part of the nose.
(_c_) The bones of the face are not interfered with, and the amount of
traumatism is slight.
(_d_) Bleeding, which is so apt to be troublesome in operations through
the skin of the face, is less and is easily controlled.
(_e_) The patient can be assured that there will not only be no
disfigurement, but not even the slightest scar on the face.
(_f_) The operation can be repeated without any disfiguring scars. In
operations upon the nose through the face the cicatrix becomes more
marked with each intervention.
COMBINATION OF MOURE’S AND ROUGE’S OPERATIONS
The two methods above described can be combined if necessary. This would
be called for particularly in growths so large that they could not be
attacked through the narrow vestibule of the nose, and for those in
which the attachment is evidently in the ethmoidal region. This
combination might be called for in any large innocent or malignant
growth.
EXTENSION OF ROUGE’S OPERATION TO ALLOW OF ACCESS TO THE MAXILLARY
ANTRUM
When the growth involves both the nasal cavity and the maxillary sinus
Rouge’s operation can be extended so as to form part of the Caldwell-Luc
operation (see p. 631).
The latter operation is modified as suggested by Denker (Fig. 332),
_i.e._ the opening through the canine fossa is extended forwards until
the nasal cavity is opened through the pyriform opening. This will give
free access to the large cavity formed by throwing the antrum and the
nasal chamber on the same side into one easily inspected space (Fig.
332). Hæmorrhage gives no cause for anxiety, there is no disfigurement,
the original root of the implantation can be eradicated, and, if
necessary, the operation can be repeated without difficulty. If the
growth extends upwards and inwards to the ethmoidal region this
infralabial opening can be combined with Moure’s operation.
=Indications.= This operation is suitable for any form of growth
invading both the antrum and nasal cavities, and is therefore generally
called for in malignant growths.
OTHER METHODS
The other methods for obtaining access to the nasal cavity through the
face--described as the methods of Hippocrates, Syme, Dupuytren,
Langenbeck, Lawrence, Ollier, &c.--are now only of historical interest.
They all leave a scar on the face; bleeding is troublesome; they do not
give a greatly enlarged field; and most of them do not bring the seat of
disease any closer. With the advances made by rhinology the necessity
for intervention through the face has become more infrequent.
CHAPTER V
OPERATIONS UPON THE ACCESSORY NASAL SINUSES
OPERATIONS UPON THE MAXILLARY SINUS
CATHETERIZING THE MAXILLARY SINUS
It is rarely possible to enter the antrum through its natural ostium.
The attempt may be made after the local use of cocaine and adrenalin
(Fig. 320).
[Illustration: FIG. 320. CATHETERIZING THE MAXILLARY SINUS.]
PUNCTURING THE MAXILLARY SINUS FROM THE NOSE
=Indications.= It is chiefly employed as a diagnostic test. As a
curative measure it is seldom successful except in comparatively recent
infection. If the case be uncomplicated by suppuration in other
cavities, if the teeth in the upper jaw on the same side be intact, and
if the patient be anxious to avoid more severe measures and be willing
to undergo the discomfort of a daily puncture, lavage has been reported
as successful when repeated 27 times, even in a case with a history of
17 years’ duration.[67] But under the circumstances just mentioned it
is wiser to recommend the establishment of an antro-nasal communication
(see p. 637).
[67] Koenig. _Soc. paris. de Laryn._, 1905, 30 juin.
[Illustration: FIG. 321. LICHTWITZ’S AND MORITZ SCHMIDT’S ANTRUM
NEEDLES.]
[Illustration: FIG. 322. PUNCTURING THE MAXILLARY SINUS. The dotted part
represents the portion of the exploring needle which passes under cover
of the inferior turbinal.]
=Operation.= This is done under local anæsthesia from the inferior
meatus. One pledget of cotton-wool, soaked in cocaine and adrenalin, is
carefully tucked under the inferior turbinal on the affected side, and
another is applied to the septum. At the end of 20 minutes a straight
Lichtwitz’s or curved Moritz Schmidt’s (Fig. 321) hollow needle is
passed under the inferior turbinal and introduced upwards and outwards
as near as possible to the centre of its attachment. The handle of the
needle is tilted against the cartilaginous septum, while the point is
directed towards the malar eminence. When it is felt to encounter the
thin, membranous part of the antro-nasal wall it is easily thrust
through (Fig. 322).
While the nasal cavity is kept under inspection, air is blown through
the needle, and any secretion can be observed escaping from under the
centre of the middle turbinal. This douche of air is then followed by an
irrigation of warm normal saline solution. In an acute case this lavage
can be repeated daily until the symptoms of tension are relieved, or
until the secretion begins to escape spontaneously.[68]
[68] Logan Turner, _Edinburgh Medical Journal_, August, 1906, p. 152.
Puncturing the maxillary sinus from the middle meatus incurs a greater
risk of striking the orbit and is not so likely to reveal a small amount
of thick secretion on the floor of the cavity.
[Illustration: FIG. 323. ANTRUM DRILLS.]
[Illustration: FIG. 324. SOLID RUBBER OBTURATORS. Used in alveolar
drainage of the maxillary sinus.]
[Illustration: FIG. 325. ANTRUM NOZZLE.]
PUNCTURING THE MAXILLARY SINUS FROM THE ALVEOLAR MARGIN
This is one of the oldest methods of drainage. It is less frequently
employed nowadays, partly because carious teeth and empty sockets are
not so commonly met with, and partly because the results have not proved
very satisfactory.
=Indications.= The operation is useful as a diagnostic or palliative
measure. In cases of unilateral multi-sinusitis, if a suitable tooth
socket be available, the alveolar operation serves both to determine the
condition of the maxillary sinus and to establish drainage, while the
other cavities are being investigated or treated. In patients who are
too old or feeble to endure more radical measures, or who decline them,
the obturator may be left in indefinitely. In that case, if the
neighbouring teeth be intact, a solid gold plug should be fitted to the
denture bearing the false first molar. During the night this is
exchanged for the soft rubber plug. If several teeth be missing it is
more comfortable to have the obturator and denture separate--the latter
being made with a setting to receive the flange.
An anæsthetic should always be given. Nitrous oxide gas or chloride of
ethyl are generally recommended for this short operation, but in cases
that present any difficulty it is better to follow the nitrous oxide
with ether, or the chloride of ethyl with chloroform.
=Operation.= The most suitable tooth socket is that of the first molar,
but if this be not available, that of the second bicuspid or second
molar may be employed. If a tooth in one of those situations be carious,
or be suspected as the cause of the sinusitis, its extraction and the
drilling of the alveolus may be carried out under the same anæsthetic.
The patient can be recumbent on an operating table, or lying back in a
dentist’s chair. A small antrum drill (Fig. 323) is grasped in the hand
as a bradawl is held, with the forefinger lying along it to within 1 to
1-1/2 inches from the end, where it acts as a stop to prevent the
instrument from plunging too deeply into the sinus. The drill is held
vertically against the alveolar border, and with a few quick, rotatory
thrusts is pushed into the cavity. The inner of the tooth sockets is
selected. If required, the hole can be enlarged by a similar instrument
of a larger bore. A plug, which fits firmly into the opening, is
introduced, and nothing further is required for that day. A solid
vulcanite obturator is recommended. It should be left _in situ_ for two
or three days, when it is removed to allow of the cavity being syringed
through, and is then replaced by a solid, soft rubber plug, of a
somewhat smaller diameter (Fig. 324). The vulcanite obturator is better
for establishing the canal; if removed too soon it may be difficult to
replace it, and manipulation may set up severe neuralgia. A small
size--No. 6 or 7--is quite sufficient.
[Illustration: FIG. 326. WASHING OUT THE MAXILLARY SINUS FROM AN
ALVEOLAR OPENING.]
At the end of two or three days lavage of the cavity is gradually
instituted. A pint of warm sterile normal saline solution is sent
through the cavity by a Higginson’s syringe, fitted with a suitable
nozzle (Fig. 325). As the stream issues from the nose it is received in
a black vulcanite tray, which readily demonstrates the colour, quality,
and quantity of antral secretion (Fig. 326). When the pint of liquid is
finished, air is blown through, so as to leave the sinus as dry as
possible. The patient should be advised to replace the rubber obturator,
properly cleaned and purified, as soon as possible. If this be
neglected--for even as short a time as 5 minutes--the soft tissues may
obstruct the channel so as to render the reintroduction painful and
perhaps impossible. Another useful warning is not to wear a plug so long
as to allow of the flanges being worn away, and so risk the penetration
of the rubber tube into the cavity.
The syringing should at first be daily, even twice a day if necessary,
and then gradually diminished in frequency, until after the lapse of a
week it is found that the maxillary sinus is quite free of any pus or
flocculent mucus. By changing the obturator daily the patient can
readily tell whether a washing out is required. When three to six months
have passed without any trace of secretion, the empyema may be
considered cured. This is the more likely if a formerly obscure sinus
becomes translucent, and if the patient passes through a ‘cold’ without
suppuration beginning in it again. A trifling amount of discharge is
sometimes kept up by the mere presence of the obturator.
If the saline solution fails to arrest the discharge permanently, I have
rarely found that any other lotion is more effective. Strong antiseptic
solutions are too irritating; milder ones, like boric lotion,
permanganate of potash, weak mercurial lotions, &c., are without effect.
If the discharge remain thick and offensive, peroxide of hydrogen may be
added to the salt solution in the proportion of 2 vols. %. As an
astringent, sulphate or chloride of zinc may be tried, in the proportion
of 1 grain to the ounce; or the cavity may occasionally be washed out
with a 2% solution of argyrol or nitrate of silver.
In cases where a cure has been obtained, the obturator is first
discontinued during the night and is then exchanged for one of smaller
size. The opening in nearly all cases will close spontaneously.
Occasionally the track may be stimulated with nitrate of silver, pure
carbolic acid, or a small curette.
=Results.= This method of treatment is only curative in uncomplicated
cases limited strictly to the maxillary sinus. If all suppuration has
not disappeared before the end of three months, a complete cure is not
to be expected by persevering longer.
OPERATION THROUGH THE CANINE FOSSA ONLY
_Desault’s operation._ Previously to the introduction of the
Caldwell-Luc operation it was customary to make an opening into the
maxillary sinus from the canine fossa, and to curette, drain, pack, and
carry out all subsequent treatment through the buccal orifice. The
reinfection of the cavity from the mouth was, of course, inevitable: the
treatment was prolonged and unpleasant: and the results were so
unsatisfactory that the method has now been abandoned in favour of one
or other of the operations to be described.
THE CALDWELL-LUC RADICAL OPERATION
=Indications.= This is the favourite operation in well-marked chronic
empyema of the antrum.
The mouth, teeth, and gums are purified as thoroughly as possible. The
face, with any moustache or beard, should also be well cleansed. The
nose on the affected side is prepared with cocaine and adrenalin (see p.
572).
[Illustration: FIG. 327. THE INCISION IN THE CALDWELL-LUC OPERATION UPON
THE MAXILLARY SINUS.]
On the Continent this operation is sometimes carried out under local
anæsthesia, but chloroform is generally employed. When the patient is
unconscious, a sponge is packed in the post-nasal space (see p. 575),
the tongue is drawn forward with a tongue clip (Fig. 314), and the
chloroform administered from a Junker’s apparatus.
=Operation.= The surgeon, armed as usual with a forehead electric
search-light or Clar’s mirror (Figs. 282, 283), stands on the affected
side. In addition to the post-nasal sponge, another is inserted far
back between the molars on the side to be operated. This cheek sponge
prevents any blood from running down into the pharynx and requires
changing frequently.
The cheek being well retracted by an assistant, an incision is made half
a centimetre below the gingivo-labial fold, extending from the first
molar to the canine tooth (Fig. 327). It is carried down to the bone, so
that the muco-periosteum can quickly be separated upwards, exposing the
canine fossa. With hammer and chisel a circular piece of the wall is
then cut through, measuring about half an inch across, and the opening
is enlarged with bone-forceps or burr sufficiently to admit the
surgeon’s little finger.
[Illustration: FIG. 328. THE CALDWELL-LUC OPERATION UPON THE MAXILLARY
SINUS. Breaking through the antro-nasal wall below the level of
attachment of the inferior turbinal. The opening has been purposely
represented coming too far forward in order to include the view of the
antro-nasal wall.]
The first opening of the sinus is frequently accompanied by free
bleeding. This soon ceases, particularly if the cavity is packed for a
little while with a strip of 2-inch ribbon gauze. During the operation,
pieces of this gauze, 1 to 1-1/2 yards long, prove very useful in
checking any oozing and allowing a clear inspection of the walls of the
sinus. They may be dipped in adrenalin, or, if the bleeding is sharp, in
a 10% solution of peroxide of hydrogen, and left in place for a few
minutes, while iced water is freely applied to the face and neck. As
soon as the bony wall has been removed, the diseased mucous membrane
presents in the opening in irregular, polypoid, bluish-greyish masses,
bathed in pus which may be highly fœtid. The diseased mucous membrane
should be carefully plucked out of the cavity with a pair of Grünwald’s
forceps, supplemented by the use of a small ring curette, and guided by
the eye and the touch of the operator’s little finger. Some surgeons
recommend that the whole mucous lining of the sinus be carefully and
completely removed, and the walls scraped down until they are white and
bare. Unless the whole mucosa is diseased, this hardly seems necessary,
particularly if a free opening be made into the nose. Polypoid masses
and degenerate mucous membrane are chiefly met with on the floor of the
antrum (in the crevices between the cusps of the teeth), on the inner
wall in the neighbourhood of the ethmoid, and in the recess in the malar
region, and it is to these areas that attention should be directed.
[Illustration: FIG. 329. OPENING THE MAXILLARY SINUS FROM THE NOSE. This
is done with a Krause’s trochar and canula, after removal of the
anterior end of the inferior turbinal.]
The next step is the making of a free communication with the nose. If
the inferior turbinal is hypertrophied on the affected side, or comes so
low as to obstruct any access to the antro-nasal wall, its anterior
extremity should first be removed (see p. 587 and Fig. 289). It is
better to have done this a few weeks previously under cocaine. The
antro-nasal wall lying below the attachment of the inferior turbinal is
next attacked with a chisel, hammer, and punch-forceps (Fig. 330). This
can be done from the antral aspect, but I have always found it useful to
break it through first from the nose with Krause’s curved trochar and
canula. When the end of this makes its appearance in the sinus, it forms
a useful landmark (Fig. 329).
This antro-nasal opening should be made as large as possible, particular
care being taken to bring it well forward and to smooth down the
remains of the ridge separating the nose from the sinus. The opening
should allow of the surgeon’s little finger passing freely from the
antrum into the floor of the nose, and _vice versa_ (Fig. 328).
Whenever the ethmoid is diseased, as it often is in maxillary sinusitis,
that part of it which bounds the inner antral walls should be punched
away. The middle turbinal, in that case, will probably have been already
removed.
[Illustration: FIG. 330. CARWARDINE’S PUNCH-FORCEPS. Used in breaking
down the lower antro-nasal wall.]
Some surgeons recommend that the infected corners of the antrum be now
wiped out with a solution of chloride of zinc (40 grains to ℥j), and the
cavity packed with a strip of gauze which is led out through the
nostril, whence it is removed at the end of 24 to 48 hours. The use of
this irritant seems inadvisable. The sinus may be syringed out with warm
saline solution, and temporarily packed with a long strip of iodoform
gauze, while the operation is being completed. The wound in the cheek
can be closed with a couple of catgut sutures; but if there has been no
destruction of the bony alveolus, this is unnecessary: the soft parts
will fall into natural and complete apposition. The post-nasal sponge is
removed, the iodoform ribbon gauze is withdrawn through the nostril, and
the patient is put back to bed with the affected side uppermost.
=After-treatment.= A large pad of cotton-wool, bound firmly to the cheek
over the region of the canine fossa, will relieve pain and help to keep
the edges of the wound together. Nourishment should be fluid for the
first three days, and taken from a feeding-cup from the opposite corner
of the mouth. As a rule, there is no reaction, and the temperature
seldom rises above 100° F. A little puffiness below the orbit will soon
subside, and pain is relieved by a few doses of phenacetin, aspirin,
pyramidon, or some similar anti-neuralgic. The patient is frequently up
and out in a few days.
As a rule, the less the local after-treatment the better. The nose may
require to be cleansed with the usual alkaline lotion (see p. 579). If
secretion hangs about the antro-nasal opening, or collects in the
cavity, the latter should be washed out once or twice daily until it
ceases. A short length (4-1/2 in.), but large bore, silver Eustachian
catheter is passed from the nose into the maxillary sinus, and a pint of
warm saline solution is sent through it with a Higginson’s syringe. The
patient soon learns to do this for himself, and it may have to be
continued for a few weeks. If the discharge persists, the cavity may be
painted over with a solution of nitrate of silver, or a strip of ribbon
gauze can be moistened with argyrol solution (25%) and passed through
the antro-nasal opening into the sinus, where it is left for a few
hours.
[Illustration: FIG. 331. THE OPENING INTO THE MAXILLARY SINUS FROM THE
INFERIOR MEATUS OF THE NOSE. The anterior extremity of the inferior
turbinal has been amputated. The opening can be extended backwards,
level with the floor of the nose, and under cover of the inferior
turbinal.]
=Results.= In cases of chronic empyema of the maxillary sinus this
operation is very successful. Failure may be due to overlooking stumps
of teeth within the cavity, and from leaving detached pieces of the
carious wall within it. If the pyogenic polypoid mucous membrane be not
carefully removed, suppuration may persist. The corner which is
difficult to reach is the acute anterior one. At the same time, an
unnecessary denudation of the cavity will delay healing, and the scar
tissue which more or less occupies the sinus will then tend to be
irregular and dry, instead of being smooth and moist. Removal of too
much of the inferior turbinal is apt to induce a scabby condition.
But persistence of nasal suppuration after this operation is generally
found to be due to overlooked disease in some other sinus. The ethmoid
is so frequently affected that it should always be carefully explored,
and treated either before or at the time of the operation upon the
maxillary sinus. Any suspicious-looking cells can be cleared away under
cocaine during convalescence. Suppuration in the frontal sinus will have
generally been excluded beforehand. It is perhaps more common for
reinfection from the sphenoidal sinus to be overlooked.
[Illustration: FIG. 332. DENKER’S OPERATION. This is an operation for
gaining access to the maxillary antrum and the lower part of the nasal
cavity on the same side. The incision through the mucous membrane, and
the steps of the operation, are a combination of the operations of Rouge
and Caldwell-Luc.]
=Dangers.= Operation upon this sinus is generally regarded as quite free
from the risk of cerebral infection. This undeniably is so, when the
antral empyema is uncomplicated by suppuration in other cavities, but
the operation is not free from risk if they are also infected. An
operation upon one maxillary sinus has been known, even in the most
skilful hands, to cause death by meningitis or diffuse septic
osteomyelitis of the cranium. _Post-mortem_ examinations show that this
disaster was due to infection spreading upwards from an infected
ethmoid, frontal, or sphenoidal sinus, when local resistance had been
diminished, or the virulence of the organisms has been increased by the
surgical traumatism of the maxillary sinus.
Such risks are best avoided by determining the condition of all the
sinuses before commencing treatment of nasal suppuration. If a tooth
socket be available, the maxillary sinus should first be drained through
it, so as to diminish the septic intensity of the affection. The ethmoid
region, if diseased, is next treated (see p. 615). The sphenoidal
orifice should be enlarged if that cavity be diseased, and the frontal
sinus, if suppurating, should be operated on before the maxillary. If no
tooth socket be available, both frontal and maxillary sinuses can be
operated upon at the same sitting. Plugs are best avoided; communication
should be made as free as possible; stitches need not be employed; and
everything should be done to avoid retention and secure free drainage.
=Modification.= In the above operation the region which generally
requires to be denuded of mucous membrane is the rough floor--the
irregular surface lying over the cusps of the teeth. The ridge of the
antro-nasal opening is a situation in which secretion is apt to lodge
and dry into scabs. To overcome this drawback it has been suggested by
Bönninghaus that the muco-perichondrium of the outer part of the nasal
floor and the interior surface of the antro-nasal wall should be
carefully preserved in the form of a flap which is then laid down over
this bare area, and fixed there by a stitch and packing.
Another drawback of the Caldwell-Luc operation is that, although
inspection and treatment of the greater part of the maxillary sinus is
secured, still there are two corners which are not well exposed. They
are both on the floor of the antrum, the round posterior corner and the
narrow acute corner in front. The antro-nasal wall corresponding to
these two situations is not removed, and hence the corners are apt to
escape inspection at the time of the operation and free drainage
afterwards.
To avoid this Denker has proposed that the opening in the canine fossa
should be carried forward into the nose, and the opening in the
antro-nasal wall extended forwards to meet it. This allows of much more
complete inspection and treatment of the sinus cavity, and abolishes the
anterior angle. The flap of muco-perichondrium proposed by Bönninghaus
can also be much more easily manipulated. It is said that there is no
fear of disfigurement from the cheek falling in (Fig. 332).
DRAINAGE THROUGH THE NASAL WALL ONLY
It was long ago proposed by John Hunter, and later by Mikulicz and
Krause, that an opening should be made into the maxillary sinus from the
nose. This operation has latterly been developed by Claoué and Réthi,
and now has many supporters.
=Operation.= On the Continent it is frequently carried out under local
anæsthesia, but chloroform is generally required. If the inferior
turbinal comes down close to the floor of the nose, the anterior third
or half should be removed (see p. 587 and Fig. 289). The antro-nasal
wall lying below the attachment of the inferior turbinal is then broken
through with chisel and hammer, or a Krause’s trochar (Fig. 285), and
the opening enlarged with punch-forceps (Fig. 286). For the anterior
margin of the opening--the one most difficult to remove--special forceps
which cut forwards have been designed (Fig. 330).
The opening is large enough to allow the introduction of curettes and of
the application of treatment from the nose. The patient soon learns to
wash out the sinus for himself, with a silver Eustachian catheter and
Higginson’s syringe, as after the Caldwell-Luc operation.
=Results.= The advantages claimed for this operation are that it is
simple, quicker, and as effective as the one with the opening from the
canine fossa. But, of course, it does not allow any inspection, and only
a partial removal, of the diseased contents of the sinus.
Still the results obtained are so satisfactory,[69] that it seems
advisable to try it in the majority of cases as a necessary first step,
even if the Caldwell-Luc operation has to be completed later. But where
the case has a long history; marked obscurity on transillumination; a
foreign body in the sinus; or where the _Streptococcus pyogenes_ is the
virulent organism, or where the streptococcus is associated with the
presence of squamous epithelium and lymphocytes,[70] it adds little to
the gravity or complexity of the procedure if the canine fossa be opened
at the same time, the diseased cavity inspected, and everything
completed under the one anæsthesia.
[69] C. A. Parker, _Brit. Med. Journ._, October 10, 1908, p. 1099.
[70] Logan Turner, ibid., p. 1096.
OPERATIONS UPON THE FRONTAL SINUS
CATHETERIZING AND WASHING OUT THE FRONTAL SINUS
=Indications.= This method is indicated--
(i) As a first step in diagnosis and treatment.
(ii) To diminish the risk of retention and decrease virulence in those
patients where an external operation is not indicated or is declined.
(iii) It is rarely required for acute frontal sinusitis, although it
might be used in acute exacerbation of a chronic suppuration.
=Operation.= It is very seldom that it is possible to sound a frontal
sinus, unless the anterior ethmoidal cells have been broken down by
disease. When this has occurred--or when the anterior extremity of the
middle turbinal has been removed, as described on p. 592--the anterior
region of the middle meatus is well anæsthetized. Under good
illumination a thin silver canula is then introduced until it reaches
the middle meatus with its beak lying below and in front of the bulla
ethmoidalis. By depressing the hand the point of the instrument is then
directed upwards, forwards, and slightly outwards, until it slips into
the frontal cavity (Fig. 333). No force should be employed. The end of
the catheter is bent to suit the conditions met with. A bead of pus
exuding from the hiatus semilunaris will often serve as a useful guide.
If there be any uncertainty as to the catheter having entered the
frontal sinus, its exact situation can be determined by the Röntgen rays
(Figs. 334, 335).
[Illustration: FIG. 333. CATHETERIZING THE FRONTAL SINUS. The anterior
end of the middle turbinal has been removed.]
A Politzer’s inflation bag is now connected with the end of the frontal
canula, and air is blown through it. This will be heard gurgling through
the sinus, and if the anterior region of the middle meatus is at the
same time kept under observation, thick mucus or pus will be seen to be
driven out by it. The Politzer’s bag is then replaced by a syringe, and
a pint of warm sterile normal saline solution (ʒj to Oj) [Transcriber’s
note: Oj = one pint] is sent into the sinus, and as it returns is
received in a black vulcanite tray. The latter readily shows up the
presence of any flakes of mucus or pellets of pus. If successful, the
above proceeding can be repeated twice daily.
When the cavity can be catheterized from the nose it should be washed
out daily with liquids similar to those indicated for suppuration in the
maxillary antrum (see p. 630).
[Illustration: FIG. 334. RADIOGRAPH TO SHOW THE VALUE OF THE RÖNTGEN
RAYS. The canula might be thought to have entered the frontal sinus,
whereas the X-rays show that its point has only penetrated an ethmoidal
cell. Compare with the following figure.]
=Results.= I am very doubtful if a permanent cure is ever effected by
this treatment in a case of established chronic suppuration. In a case
in which I was certain that the suppuration was not of more than four
months’ duration intranasal treatment was a failure, although carried
out most carefully on 44 successive days.[71]
[71] _Proc. Royal Soc. Med._, 1907, December.
[Illustration: FIG. 335. RADIOGRAPH SHOWING CANULA IN THE FRONTAL
SINUS.]
The cause is very apparent whenever these sinuses come to be opened; the
cavity itself is generally stuffed with fungating mucosa, and the
fronto-ethmoidal cells--where the lavage never penetrates--are affected
in the same way.
OPENING THE FRONTAL SINUS IN ACUTE SUPPURATION
It is rare for this to be necessary. The contents of the cavity
generally make their way through the natural ostium, before any of the
bony walls give way. Still, the posterior (cerebral) wall may yield,
giving rise to meningitis or cerebral abscess. The treatment of this
complication is given on p. 650. The orbital wall may be penetrated,
with the formation of an orbital abscess which should be evacuated. It
is most uncommon of all for the anterior wall to give way. When this
does occur the abscess should be opened through an incision designed on
the principle given later on for chronic empyema (see p. 652).
KILLIAN’S OPERATION
At the present time the Killian operation is the one most generally
employed.
=Indications.= The indications for this operation are thus given by
Killian himself:--
1. Failure of other operations.
2. Presence of fistula or abscess, or indications of necrosis.
3. Symptoms of intracranial complications.
4. When in a case of chronic purulent frontal sinusitis there is pain
and fever with a fœtid discharge.
5. Persistent headache, particularly when associated with discomfort in
the region of the eye, and not relieved by intranasal treatment.
6. When the discharge from the sinus remains foul, in spite of repeated
irrigations.
7. When recurring groups of polypi are produced by the suppuration in
the frontal and ethmoidal cells.
8. When a simple purulent discharge is not relieved by careful
intranasal treatment, and the patient desires permanent relief by
radical operation.
A radiograph is taken and is an extremely useful help to indicate the
size and extent of the frontal sinus, and to prepare the surgeon for
meeting with troublesome orbito-ethmoidal cells.
As the ethmoid is diseased in nearly all cases it should be cleared away
at previous sittings, under cocaine or chloroform (see p. 615). Even
when healthy, the anterior extremity of the middle turbinal should be
amputated (see p. 592). If the antrum be also suppurating and a
suitable tooth socket be available, the alveolus will have been drilled
at one of these preliminary treatments. If the sphenoidal sinus be
suppurating, its orifice will have been enlarged.
One hour before the operation the strips of ribbon gauze, soaked in
adrenalin with the addition of 5% cocaine, are carefully laid all over
the mucous membrane of the nose on the affected side. The face,
moustache, and beard are well purified. When the patient is under
chloroform three pencils of tightly rolled cotton-wool are introduced
into the nose; one along the middle meatus, a second in front of the
inferior turbinal upwards towards the bridge of the nose, and the third
in the inferior meatus. The first two pledgets are useful afterwards for
anatomical definition, and the third keeps them in place. A sponge is
inserted in the post-nasal space (see p. 575).
[Illustration: FIG. 336. KILLIAN’S OPERATION UPON THE FRONTAL SINUS.
Shows the skin incision, with the transverse scratches made to ensure
correct coaptation of the flaps.]
=Operation.= There is no advantage in shaving off the eyebrow. It can be
thoroughly purified and helps to locate the skin incision; if removed,
it takes some time to grow again, and is apt not to correspond in size
with the eyebrow of the opposite side. The skin incision is first
defined by scratching through the cutis with the tip of the knife. It
starts at the outer end of the eyebrow, passes inwards along the very
centre of the eyebrow itself, and then sweeps downwards and outwards
over the side of the nose, to end on the cheek (Fig. 336). When the
whole extent has been marked out three or four cross scratches are
made. The object of this is to ensure correct coaptation of the flaps,
and to avoid any risk of disfigurement. Returning to the outer extremity
of the incision, it is now carried down through all the soft tissues
till it meets the periosteum. The flaps are retracted a little upwards
and downwards, while the free hæmorrhage is met with pressure forceps.
The periosteum incisions are now carefully planned. Starting again from
the outer corner the knife is drawn inwards parallel to, and slightly
above, the upper margin of the supra-orbital arch; but, instead of
curving round the inner end of the orbit, in the track of the skin
incision, it is kept straight along under the upper flap to end over the
glabella. The periosteum can now be reflected from the front of the
sinus, and pushed upwards with the skin on to the forehead. The lower
skin flap is detached and retracted downwards, until the inner third of
the supra-orbital arch is defined. The periosteal covering is next cut
through by carrying the knife along the lower border, but instead of
passing inwards parallel to the first periosteal incision this second
one sweeps down on to the side of the nose, in the track formed by the
skin incision (Fig. 337).
[Illustration: FIG. 337. KILLIAN’S OPERATION UPON THE FRONTAL SINUS. The
thick lines indicate the incisions through the periosteum.]
The periosteum is carefully peeled off the nasal process of the superior
maxilla, and turned down from the inner third of the supra-orbital
arch, exposing a triangular area of bone. The periosteum must be
carefully preserved over the inner part, to avoid the risk of necrosis
of the arch, which is converted into a bridge, the ‘Killian bridge’, by
the opening in bone below and above it.
The upper flap of soft parts, with the periosteum, is well retracted up
on to the forehead. The radiograph will have given an idea of the extent
to which the front wall of the sinus must be laid bare. With a chisel
and hammer the sinus is opened at its inner extremity. A good plan is to
employ Killian’s triangular curved chisel (Fig. 339) and to cut a trench
in the bone along the upper margin of the bridge. This trench is
gradually deepened at the inner end until the sinus is entered. The
entry is generally announced by the bulging upwards of the blue,
polypoid, pyogenic membrane into which the thin white delicate mucosa of
the cavity has been converted. The anterior wall is now completely
removed with hammer, chisel, and forceps. Those of Lombard, Horsley,
Hajek (Fig. 341), Jansen, Citelli (Fig. 340), or similar models enable
us to bevel down the margins of the cavity carefully as it slopes up on
to the forehead.
[Illustration: FIG. 338. PERIOSTEAL ELEVATORS.]
[Illustration: FIG. 339. KILLIAN’S TRIANGULAR CURVED CHISEL.]
The pyogenic membrane is now carefully plucked away with a pair of
Grünwald’s forceps. I never find it necessary to curette the cavity,
which must always be a risky proceeding. Small pledgets of ribbon gauze,
if gently rubbed along the surface and into the corners, will detach
every scrap of diseased mucosa.
The septum separating the two frontal sinuses may be found to be
defective. The opening through the eyebrow on one side may open into a
cavity which communicates only with the nasal cavity of the opposite
side--one sinus being very large and extending far beyond the middle
line, while the other is quite small. Or only one frontal cavity may be
present. An extensive acquaintance with the surgical anatomy of the
region is required to prepare the surgeon for encountering these and
other irregularities, and the systematic use of radiography will prevent
him from being taken by surprise.
[Illustration: FIG. 340. CITELLI’S BONE-FORCEPS.]
[Illustration: FIG. 341. HAJEK’S BONE-FORCEPS.]
The next step is to make the opening below the bridge. The exposed
surface of the nasal process of the superior maxilla is cut through with
the triangular chisel. The opening is enlarged with bone-forceps until
free access is obtained to the anterior ethmoidal cells. The pledgets of
cotton-wool placed in the nose at the beginning of the operation now
come in to help as guides. The periosteum is further elevated from the
lachrymal bone above its groove, from the orbital plate of the ethmoid
as far back as the anterior ethmoidal vessels, and from the orbital
plate of the frontal bone below the bridge and extending outwards to the
trochlear attachment and the supra-orbital notch. During this proceeding
the contents of the orbit are protected from pressure by several folds
of gauze, and are carefully retracted outwards by Killian’s protector.
The area of bone which can now be clipped away comprises parts of the
lachrymal, of the lamina papyracea, and of the floor of the frontal
sinus. The whole of the floor of the sinus must be removed, either from
above the bridge or from below. If this cannot be done without anxiety
as regards the attachment of the pulley of the superior oblique, it is
better to risk this than to leave pus-secreting pockets of
orbito-ethmoidal cells cut off from drainage in the roof of the orbit.
But the pulley of the superior oblique should never be divided from its
attachment to the rim of the orbit. It is much safer to reflect the
periosteum further outwards and downwards from the lower border of the
Killian bridge. In doing this the pulley of the superior oblique is
detached with it; any diplopia, most noticeable on looking downwards and
outwards, is generally temporary; and as a rule it will disappear when
the swelling subsides and the periosteum gets back to its anchorage
(Fig. 342).
[Illustration: FIG. 342. KILLIAN’S OPERATION UPON THE FRONTAL SINUS. The
periosteum has been preserved on the bridge. Above this the frontal
sinus is exposed: at its inner (nasal) extremity the frontal bulla is
indicated, mounting up into the cavity; at the outer extremity an arrow
indicates the orifice of a fronto-orbital cell which should be opened
up. The periosteum lying above the bridge has been retracted up with the
soft parts on to the forehead. Below the bridge is the opening to the
ethmoidal region. The curved retractor is protecting the eyeball.]
It is this part of the operation which is the most delicate, tedious,
and important. It is very common to meet with irregularities. The
orbital recess of the frontal sinus itself may run back in the roof of
the orbit nearly as far as the foramen opticum. One or two galleries may
be met with in the roof of the orbit--prolongations of orbito-ethmoidal
cells--passing outwards as far as the temporal end of the eyebrow. Their
presence can only be revealed after removal of the floor of the frontal
sinus proper, and in this way two or three bony dissepiments may have to
be removed before the orbital fat arises, as it should do, to occupy the
lower part of the exposed frontal sinus. In this part of the operation
much help is obtained by the careful use of a probe, by frequently
securing a field free from bleeding by pressure with adrenalin or
peroxide, and by the knowledge previously gained by skiagraphy.
If the Röntgen rays have shown that the frontal sinus does not extend
above the level of the bridge, or if radiography be not available and
there is any uncertainty as to the extent of the cavity, this lower
opening should be made first.
In the inner part of the large orifice which has been made below the
bridge the deeper ethmoid cells can be treated, and the sphenoidal
ostium is much nearer than when viewed from the introitus narium, so
that it is easy to enlarge it and deal with the contents.
Now, as throughout the operation, great care must be taken to shield the
eyeball with gauze pads and the protector. The hanging pressure forceps
are apt to be pushed against the globe.
The whole area of operation is next carefully cleaned with warm normal
saline solution. Any projecting corners or loose spicules of bone are
removed. If any point of pus should show up it must be carefully
followed to its source. The cotton-wool pledgets are removed from the
nose. The pressure forceps are twisted off, and any vessels that require
it are ligatured. A strip of ribbon gauze is loosely packed in the lower
part of the enlarged fronto-ethmoidal space, and the end is led down to
the nasal orifice. The flaps are brought together, and care is taken
that the reflected periosteum is pulled back with them. Formerly Killian
in the majority of cases used to sew up the whole wound at once. He now
agrees that it is safer to leave the external angle with a small
drainage tube running inwards and downwards to the area of the
fronto-ethmoidal cells. The inner part of the incision in the eyebrow,
and all the part lying below the bridge, can be closed. Killian employs
aluminium-bronze wire, and a metal suture seems preferable, as the
contamination of the wound edges makes stitch-abscess not uncommon.
Secondary suture--on the second or third day--is reserved by Killian for
cases when (1) the history or appearance of the mucosa indicates a
recent exacerbation, (2) there is a history of erysipelas, (3) the pus
is very fœtid, (4) there is any history of a tendency to wound
complications, or (5) there is marked invasion of the diploë in the
frontal bone.
Double cyanide gauze, rung out of boric lotion and covered with a good
supporting pad of cotton-wool, is then put on. But when there is any
question of intracranial complication, when the pus is fœtid or there is
any necrosis, and when the surgeon is forced to operate during an acute
exacerbation, it is better to apply warm boric fomentations and leave
the upper and outer supra-orbital part of the incision freely open.
=After-treatment.= The patient is put to bed on the sound side, so as to
assist drainage. He is advised not to blow the nose, but to hawk as much
of the secretion as possible backwards and then expectorate it. The
gauze drain is removed from the nose at the end of twenty-four hours,
and is not renewed. The drainage tube at the temporal end of the
incision is changed at the end of forty-eight hours, and afterwards is
removed and cleansed daily. The dressing is also changed daily, after
the first forty-eight hours, so as to keep a careful watch for any
retention. On the fifth day the sutures can be removed, and soon
afterwards the dressing can be discontinued and the eye left uncovered.
Intranasal treatment should be avoided for a while. But after two or
three weeks the granulating surface behind the bridge is painted
occasionally with a 2 to 3% solution of nitrate of silver. Any crusts
are removed after soaking with peroxide of hydrogen.
=Complications and dangers.= The operation is not free from danger.
Latent cerebral trouble connected with the sinus may be roused into
activity by the local traumatism, however skilfully effected. The shock,
or the lowered local resistance, may stimulate a latent infection in
neighbouring sinuses, and also weaken the lines of defence protecting
the cranial cavity.
In 1905 Logan Turner collected the record of twenty-four deaths which
had occurred after operation on the frontal sinus.[72] This number has
been exceeded by the fatalities since published and the much greater
number which have never been recorded.[73] The chief dangers are (1) a
spreading septic osteomyelitis, (2) meningitis, and (3) abscess in the
frontal cerebral lobe.
[72] Logan Turner, _Edinburgh Medical Journal_, 1905, March.
[73] _Die Komplikationen der Stirnhöhlenentzündungen_, von P. H. Gerber,
Berlin: S. Karger, 1908.
_Infection of the bone_ is indicated chiefly by a puffy, tender swelling
on the forehead or temple, adjoining the upper flap. There may be
little or no rise of temperature, and little complaint on the part of
the patient. But no time should be lost in laying the wound freely open,
searching for any shut-off focus of pus, and applying hot boric
fomentations diligently. Once infection is established in the bone it
may be impossible to stay its progress, even by the most thorough
removal of diseased tissue: but the effort should be made.[74]
[74] H. Tilley, _Lancet_, 1899, August 19, p. 534, and _Edinburgh
Medical Journal_, 1905, March, in paper of Logan Turner’s.
_Meningitis_ is an equally dangerous complication. It may arise without
direct injury to the cerebral wall of the sinus. If, during removal, the
anterior end of the middle turbinal be damaged too high up, the lymph
channels around the olfactory nerve may be opened so freely that
infection spreads along them to the meninges. Or the cerebral wall may
sometimes be broken through without a serious result, if the dura mater
be left intact behind it. But if there be any damage done to the wall in
the neighbourhood of the crista galli or cribriform plate, the dura
mater is almost inevitably injured at the same time, and a rapid and
fatal meningitis may be expected. The infection is generally
streptococcal, and surgery is powerless to stop its progress.
_Abscess in the frontal cerebral lobe_ may arise from operation on the
frontal sinus. In my experience it is more apt to occur independently of
interference with the sinus, to remain latent, and then to be simply
roused into activity by the local traumatism. The symptoms are,
unfortunately, very vague. Rise of temperature, headache, irritability,
drowsiness, and optic neuritis may be present. On the occurrence of
these symptoms the sinus should be freely reopened, and the posterior
(cerebral) wall carefully inspected for any necrosing area. In any case
it should be removed and the frontal lobe explored in all
directions.[75]
[75] A successful case is reported, _Proc. Roy. Soc. of Med., Lond._,
1908, June meeting, by L. V. Cargill, William Turner, and the writer.
These dangerous complications, in many cases, were no doubt due to a
failure to recognize that the complicated group of ethmoidal cells were
involved in all cases of chronic frontal suppuration, and that previous
to the introduction of the Killian operation our operative methods were
very apt to dam up suppuration in dangerous corners. Finally, it was
only when rhinologists first began to investigate frontal sinusitis that
it was recognized what a dangerous region this is. To be convinced of
this it is only necessary to compare the anxiety inspired by our regard
for the cerebral wall of the frontal sinus with the calmness with which
we regard an opening into the middle fossa, or through the dura mater,
in mastoid operations.
We are not yet in possession of definite evidence in regard to the
proportionate number of deaths which are due directly or indirectly to
pus in the frontal sinus. Some observers hold that more deaths have
occurred from operation than from neglected cases. Molinié has followed
the history of fifteen private patients with frontal sinusitis, and not
operated on, for ten years. Only one has died, and that was from another
cause.[76] In any case we may still accept Lermoyez’s dictum: ‘Avoir une
sinusite chronique est chose moins grave qu’on ne croit: opérer une
sinusite frontale est chose plus sérieuse qu’on ne le dit.’[77]
[76] _Annales des Maladies de l’Oreille_, 1905, juillet, ii. 72.
[77] Ibid., 1904, XXX. vi. 579.
Doubtless the dangers have been diminished since the more general
adoption of the Killian operation, but accidents may occur in the most
skilful hands. This must be kept in mind when drawing up the indications
for interference.
=Results.= In uncomplicated cases, successfully operated on, the results
are most satisfactory. The preservation of the Killian bridge quite
prevents any really unpleasant disfigurement. The depression which may
form above it is proportionate to the size and depth of the cavity. No
man need decline the operation on account of the scar left. In women we
are able, with the help of a radiograph, to form an idea beforehand as
to the degree of depression which may be left. This, if required, can be
remedied by the injection of paraffin (see Vol. I), but, fortunately,
the frontal sinus in women is not, as a rule, so deep as in men.
As regards cessation of purulent discharge the result will depend on the
extent of the sinus, the presence of complicated orbito-ethmoidal cells,
and the skill of the operator. If the ethmoidal labyrinth has not been
completely dealt with, one or two cells may continue to secrete. It may
be wiser to leave them alone. In very deep sinuses a ‘dead space’
between the back of the Killian bridge and the posterior (cerebral) wall
of the sinus remains open, and may continue to secrete if not cicatrized
over evenly.
But secretion is no longer pent up in the fronto-ethmoidal group of
cells, and the patient is relieved of headache, depression, and other
symptoms of septic absorption.
THE OGSTON-LUC OPERATION
This operation was first described by Ogston,[78] but was independently
conceived by Luc.[79] Its principle is to make a fairly free opening
into the frontal sinus, and then establish a large communication with
the nasal cavity. The inner part of the supra-orbital rim is sometimes
destroyed. But the operation does not provide for the treatment of
orbito-ethmoidal cells, the anterior ethmoidal region and the
sp[h]enoidal wall are not exposed, and if there be a large orbital
recess to the frontal sinus it cannot be satisfactorily dealt with.
[78] Ogston, _The Medical Chronicle_, 1884, December.
[79] Luc, _Société Française d’Otologie_, Paris, 1896, mai.
=Indications.= But the Ogston-Luc procedure, or some modification of it,
is still suitable in (1) exploratory openings of the frontal sinus, (2)
when the sinus requires opening for a recent and acute infection[80],
and (3) for mucoceles and suppurating mucoceles.[81]
[80] StClair Thomson, _The Practitioner_, 1906, July.
[81] Logan Turner, _Edinburgh Medical Journal_, 1907, November and
December.
=Operation.= A general anæsthetic is required. It is not necessary to
shave the eyebrow, but the surrounding skin should be well purified. A
curved incision is made through the eyebrow down to the bone along the
inner third of the supra-orbital ridge, reaching from the supra-orbital
notch to opposite the inner canthus. In the latter direction it can be
extended if the ethmoidal region is chiefly affected, and if the ethmoid
only requires exposing the incision is placed lower down.
With a raspatory the soft parts are turned upwards and downwards so as
to expose the anterior wall of the sinus, which is opened with chisel
and hammer. A probe will indicate its depth and direction. The opening
is enlarged with bone-forceps sufficiently to allow inspection of the
interior of the cavity, and permit of the passage into the nose being
enlarged with forceps, curettes, or burrs. The polypoid mucosa occupying
the sinus and the fronto-ethmoidal cells along the passage to the nose
are carefully plucked away. A drainage tube or wick of gauze is inserted
from the sinus down into the cavity of the nose, so that it can be
withdrawn from the anterior nares at the end of twenty-four hours. The
drainage tube is replaced by some surgeons. The frontal wound is
sometimes closed at the time of the operation, and sometimes left open.
=Results.= These are variously given by different observers. Thus one
author states that it will effect a cure in 85% of cases,[82] while
another operated by this method in eleven cases, of which two died and
not one was completely cured.[83]
[82] Lermoyez, _Annales des Maladies de l’Oreille_, 1902, novembre.
[83] H. L. Lack, _Edinburgh Medical Journal_, 1902, June, p. 542.
The subject does not require further discussion, as most operators have
now given this operation up in favour of the improvements wrought in it
by Killian. Luc himself has abandoned it in favour of the Killian
operation. The latter is undoubtedly to be preferred in all cases of
well established chronic purulent sinusitis with fungating mucosa and
involvement of the ethmoidal cells.
KUHNT’S OPERATION
In this operation the entire anterior wall of the frontal sinus is
chiselled away, so as to allow of the soft parts covering it being
pressed down into the cavity until they are applied to the posterior
wall. This, naturally, effects a complete obliteration of the cavity,
but in order to secure it the orbital ridge has frequently to be removed
to such an extent that a frog-like prominence is given to the eye, and
the resulting disfigurement is very marked. Besides, this operation does
not deal with the orbital recess of the sinus, or the orbito-ethmoidal
cells--the most important part of the operation. In fact, the only
advantage of this operation--complete obliteration of the sinus--is
secured by Killian’s operation, which also allows these regions to be
dealt with, permits free drainage into the nose, and avoids
disfigurement.
OPERATIONS UPON THE SPHENOIDAL SINUS
=Surgical Anatomy.= In operating on this sinus there are many anatomical
and pathological points which it is desirable to remember. Only a few of
them can be recalled.
The cavity is seldom absent, although it may be quite small. Its size
and conformation may be irregular. Thus in one instance it may extend
far out into the wing of the sphenoid, while in another it may be even
smaller than a posterior ethmoidal cell invading the body of the
sphenoid bone and lying above it.
While the sphenoidal sinus on one side is very small the opposite one
may be so large that it comes in relation with the optic groove of the
opposite side.
The anterior wall of the sphenoidal sinus can be opened with safety. The
roof comes into close relation with the structures round the sella
turc[ic]a. The outer wall is close to many large blood-vessels which
might cause troublesome hæmorrhage if wounded. The upper outer wall may
be as thin as paper.
There may be deficiencies present in the bony walls, so that, for
instance, the mucous membrane of the sinus and the dura mater may be in
direct contact.
The Röntgen rays give such valuable information as to the size and
relations of the cavity, as well as to diseases in its cavity or walls,
that a radiograph should be taken in all cases (Figs. 343 and 344).
SOUNDING AND WASHING OUT THE SPHENOIDAL SINUS
=Indications.= Lavage alone may be sufficient for acute or recent cases,
but in chronic forms of suppuration a larger and permanently patent
ostium must be established, both to allow of more effective drainage and
of treatment of the interior of the cavity.
When the interior of the nasal chamber is in a normal condition it is
only possible to catheterize this cavity in a limited number of cases.
The region of the middle turbinal and olfactory cleft is carefully
prepared with cocaine and adrenalin. A pledget soaked in the mixture is
inserted between the middle turbinal and the septum, and pushed
backwards until it reaches the anterior wall of the sinus.
[Illustration: FIG. 343. RADIOGRAPH OF THE SPHENOIDAL SINUS. The beak of
a punch-forceps is seen in a posterior ethmoidal cell (which has been
opened) and pressing against the anterior wall of the sphenoidal
cavity.]
A canula is then inserted in a sloping direction inwards and upwards
diagonally across the plane of the middle turbinal until it impinges on
the nasal surface of the sphenoid, in the neighbourhood of the ostium
(Fig. 345). The latter is found by feeling with the tip of the catheter.
The opening is never visible in health. It may lie a little external to
the direction of the olfactory cleft--about 5 millimetres from the
middle line.
[Illustration: FIG. 344. RADIOGRAPH OF THE SPHENOIDAL SINUS. This is a
sequel to the preceding illustration. The front wall of the sinus has
been broken through, and the beak of the forceps is now shown inside the
sphenoidal cavity.]
If this plan be not successful, the ostium sphenoidale can more
certainly be discovered in the following way. A more complete and
prolonged application of cocaine is carried out, particularly in the
neighbourhood of the olfactory cleft and the spheno-ethmoidal recess.
Killian’s long nasal speculum (Fig. 346), sterilized and warmed, is
inserted between the middle turbinal and the septum. By separating the
blades of the speculum the passage is dilated, so that the instrument
can be slipped further in, and so, by alternating movements of expansion
and advance, the front wall of the sinus is brought into view. During
this procedure the middle turbinal is crowded outwards, and no alarm
need be caused if a slight cracking sound shows that its attachment has
been fractured.
The mouth of the sphenoidal sinus is often indicated by the muco-pus
oozing from it or pulsating in harmony with the pulse. If discharge be
not escaping the ostium may be only a potential and not an actual
orifice--like that of the meatus urinarius--and has then to be more
carefully sought for and detected with a probe. If there be difficulty
in finding the ostium, the front wall should not be broken through until
the presence and size of the sinus has been demonstrated by means of a
radiograph (Figs. 343 and 344). The sinus is washed out, as described
for the frontal and maxillary cavities.
[Illustration: FIG. 345. CATHETERIZING THE SPHENOIDAL SINUS.]
OPENING THE SPHENOIDAL SINUS
=Indications.= Profuse purulent post-nasal catarrh, persistent headache,
orbital or ocular or intracranial symptoms, call at once for relief. Not
infrequently suppuration in other cavities will not cease, even though
operated on, until the sphenoidal sinus has been treated.
=Operation.= Unless long-standing suppuration or ozœna have produced
such atrophy of the middle turbinal that the front wall of the
sphenoidal sinus is easily inspected from the front, it will be
necessary to remove the greater portion of the middle turbinal. If the
anterior end has had the typical amputation performed (see p. 592), then
the rest can be removed with the punch-forceps of Grünwald, the wire
snare, or, under nitrous oxide anæsthesia, the spokeshave.
This will bring the anterior wall of the sinus with its ostium into
view. Killian’s long nasal speculum (Fig. 346) may still be necessary.
With the help of cocaine the ostium can then be enlarged with various
instruments. Hajek’s hook can be inserted into the orifice and the front
wall torn away. I have not found this satisfactory. It is much simpler
to insert the beak of a small Grünwald’s forceps into it, or a small
ring-knife, and by a series of boring and screwing motions to render the
ostium patent. It is then easy to introduce a beaked Grünwald’s or some
such punch-forceps as those of Cordes (Fig. 348) and cut away as much of
the front wall as may be required. This can be done freely in an inward
and downward direction, and an opening as large as the tip of the little
finger, and sufficient for drainage and treatment, is thus established.
When describing the removal of posterior ethmoidal cells (see p. 616) it
was pointed out that the tip of the forceps not uncommonly breaks
through the thin portion of the anterior sphenoidal wall.
If the natural ostium sphenoidale be not visible it would be risky to
make an artificial opening without first determining by radiography the
presence and size of the sinus. When this has been ascertained,
palpation with a pair of sinus-forceps or a Lichtwitz’s trochar and
canula will generally detect a thin spot where firm pressure is
sufficient to penetrate into the cavity. The opening is then enlarged as
described.
[Illustration: FIG. 346. KILLIAN’S LONG NASAL SPECULUM.]
In all these procedures care must be taken that the instrument does not
burst suddenly through the front wall with such force that it impinges
on and damages the posterior wall.
The opened sinus must be dealt with according to the conditions met
with. Necrosed portions of bone may require to be removed, but they
rarely occur, except in syphilitic cases. Polypoid masses of mucous
membrane, obscuring the opening, may be carefully lifted out with
forceps or curette, so as to facilitate drainage; but it is never
necessary to think of curetting the interior generally, and particular
regard should be paid to the posterior wall.
=After-treatment.= Profuse hæmorrhage has sometimes occurred after
opening the sinus. In a case of Gleitsmann’s the bleeding did not take
place until seven days after the operation,[84] and in one of C. R.
Myles’s cases profuse hæmorrhage occurred on the ninth day and required
ligature of the external carotid.[85] It is possible that the bleeding
in such cases may come from a branch of the internal maxillary artery,
or even from the cavernous sinus. It can be met by firm plugging with a
long strip of 1-inch ribbon gauze, of which the end is soaked in
adrenalin or peroxide of hydrogen. Hæmorrhage is not a complication that
I have ever met with, after having opened a large number of sphenoidal
cavities, and I do not think it is to be dreaded if the opening be made
as directed.
[84] _Transactions of the American Laryngological Association_, 1895, p.
91.
[85] Ibid., 1903, p. 241.
[Illustration: FIG. 347. RADIOGRAPH SHOWING A PROBE IN THE SPHENOIDAL
SINUS. An india-rubber obturator is in the maxillary antrum.]
The sinus is washed out with a warm normal saline solution. The addition
of peroxide of hydrogen may be useful. The condition of the mucous
membrane may be improved by cleansing the sinus with iodoform emulsion,
or plugging it for twelve or twenty-four hours with iodoform ribbon
gauze. Any pigment can be kept in contact with the walls for some time
by dipping the end of a piece of ribbon gauze into a solution of argyrol
(25%) or nitrate of silver (2%) and packing it into the cavity. The
other end of the strip is left just within the vestibule of the nose, so
that the patient can withdraw it himself.
But if a sufficient opening has been made into the cavity to allow of
natural ventilation and drainage, it is well to abstain from too much
local medication--particularly if there be neither polypus, necrosis,
nor foreign body in the sinus, and if it be not subject to reinfection
from the suppuration in the posterior ethmoidal cells. It is remarkable
how, under such conditions, suppuration will cease in a sphenoidal sinus
if left alone, when, if frequently treated, secretion will continue
indefinitely. In my experience the sphenoidal sinus is one of the most
satisfactory of the accessory sinuses to treat.[86]
[86] _Proceed. Royal Society of Medicine_, Meeting of June, 1908.
[Illustration: FIG. 348. SPHENOIDAL PUNCH-FORCEPS.]
=Other methods.= The sphenoidal sinus can also be opened and treated
during Killian’s operation on the frontal sinus (see p. 648).
It has been proposed to approach the sphenoidal sinus by first
traversing the maxillary antrum. Such a complicated route, involving
extensive destruction of tissue, has no advantage over the direct and
simple method described. Attempts to reach the sphenoidal sinus from the
naso-pharynx are not practical. This is easily seen by observing the
thickness of the floor of the cavity depicted in Fig. 345.
OPERATION IN MULTIPLE SINUS SUPPURATION
Before starting treatment in a case of multi-sinusitis a complete
examination should be formulated. The importance of making the
differential diagnosis as complete as possible cannot be overestimated.
In initiating treatment attention should be directed first to the
ethmoidal region. The ethmoid should be attended to in all cases of
suppuration in the frontal sinus. It is generally necessary, in any
case, to clear it away to gain access to the sphenoidal orifice. It is
well to remove it before or during operation on the maxillary sinus. The
sphenoidal sinus should be catheterized, and, if infected, the orifice
will require enlarging and the cavity treating. A frontal sinus should
be washed out several times before deciding on a radical operation. It
not uncommonly ceases to secrete after the ethmoid has been cleared.
The radical operation on the frontal sinus should not be embarked on
until the ethmoid and sphenoid have been attended to. A radical frontal
operation should take precedence of the maxillary, unless both cavities
are operated on at the same time.
CHAPTER VI
OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS FOR RETROPHARYNGEAL
ABSCESS: OPERATIONS FOR NASO-PHARYNGEAL ADENOIDS
METHODS OF OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE NOSE
Many growths in the naso-pharynx, whether originating in the space or
descending into it from the posterior choanæ, can be removed by the
following method.
=Indications.= This operation is indicated for the ordinary mucous
polypus of the nose when presenting in the post-nasal space. Polypoid
masses of the ethmoid may project through the posterior cavity and are
removed in the same way. A naso-pharyngeal polypus (also called choanal
polypus, post-nasal polypus, or benign pharyngeal polypus) is easily
removed by this procedure. Innocent tumours of the post-nasal space,
such as papilloma, adenoma, fibroma, and cysts, can be removed by the
same method.
=Under cocaine.= Cocaine and adrenalin (see p. 572) should be carefully
applied to the septum and turbinals, as it is the passage of the
instrument from the front which is often the most painful part of the
proceeding. The pharynx should be lightly sprayed with a 5% solution of
cocaine so as to check reflex action.
While the patient is seated in the ordinary examination chair the
surgeon stands at his left hand and introduces a looped snare (Fig. 312,
p. 613) through the nostril most suitable for approaching the root of
the growth. When the snare has reached the post-nasal space, the surgeon
introduces the purified forefinger of the left hand through the mouth
and up behind the soft palate, as in Fig. 291. Here it serves to
manipulate the loop over the growth, and holds it close to the root of
the pedicle while the snare is pulled home.
A few minutes should be allowed to elapse to permit the patient to
recover from the unpleasant manipulation, and also to allow of
coagulation of the strangulated blood-vessels. The growth should not be
cut through, as it is wiser to pluck it from its attachment by a quick
movement of avulsion.
The growth may come away with the snare through the nostril, or may fall
into the pharynx and be expectorated.
In fairly roomy nostrils a stout polypus forceps can be used instead of
the snare.
=Under chloroform.= In nervous subjects the same method should be
carried out under a general anæsthetic, care being taken that the growth
does not cause embarrassment by occluding the larynx.
Under chloroform, of course, more extensive operations can be carried
out on the post-nasal space. The pedicle can be attacked with a pair of
scissors with long handles, short blades, and slightly curved on the
flat. These are introduced through that nostril which appears to be in
most direct line with the pedicle, to act as a raspatory, and then cut
through the base of the growth. In some cases an instrument such as
Langenbeck’s elevator (Fig. 338) will prove useful if introduced through
the nostril. The growth is then removed through the mouth by a twisting
movement with a strong volsella.
OPERATIONS FOR OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE MOUTH
Many growths in the naso-pharynx can be removed through the mouth,
without preliminary operations through the face or through the hard or
soft palate.
=Indications.= The following method of access to the naso-pharynx is
chiefly called for in true fibroma of the naso-pharynx, otherwise called
naso-pharyngeal polypus, fibroid tumour of the base of the skull,
fibroid tumour of the naso-pharynx, retro-maxillary polypus, or juvenile
sarcoma of the naso-pharynx.
It is also a plan of procedure which may be called for in any very
large, innocent tumours of the naso-pharynx, particularly in cases where
nasal stenosis prevents access from the nostrils. It would be a suitable
method in any operable cases of malignant disease of the post-nasal
space.
=Operation.= The patient is chloroformed and placed in the position of
Rose (hanging head). The mouth being propped open, and the tongue drawn
forward, the tumour is first explored with the forefinger, to detect and
detach any secondary adhesions. A raspatory which works laterally is
next passed from one side of the naso-pharynx to the other above the
growth. A rugine which works in a sagittal plane is then introduced
below the tumour and made to pass upwards behind it--the reverse
movement of Gottstein’s curette in the removal of adenoids (Fig. 350).
This movement is facilitated by securely gripping the tumour and
dragging it forwards with a stout pair of alligator or volsella forceps.
The tumour can thus be so liberated that, with some twisting movements,
it can sometimes be extracted entire--often dragging down with it
through the naso-pharynx any prolongations thrown forward into the nose.
It is useless to attack such growths as true fibroma of the naso-pharynx
with an ordinary wire snare, or such an instrument as a pair of adenoid
forceps. For these firm tumours, specially powerful forceps have been
designed by Doyen and Escat.
_Hæmorrhage_ is apt to be sudden and copious, but the more rapidly and
completely the growth is removed the sooner will bleeding cease--even
spontaneously. After complete removal firm pressure with a marine sponge
will generally check it. A post-nasal plug should be avoided, and is not
usually required. Incomplete operations not only start hæmorrhage but
may start septic absorption.
=Modifications.= (_a_) _Preliminary laryngotomy._ A preliminary
laryngotomy, strongly recommended by J. W. Bond and extensively adopted
by Butlin, adds nothing to the dangers of the case. It allows of the
laryngo-pharynx being packed, so that there is no anxiety in regard to
the descent of blood into the lungs, and it permits the steady
administration of the anæsthetic through the laryngotomy canula. The
surgeon is thus relieved of two great anxieties, and can devote himself
without embarrassment to more deliberate operation.
The laryngotomy tube can be removed as soon as the patient recovers
consciousness and all hæmorrhage has ceased.
(_b_) _Division of the soft palate._ In addition to the operation of
laryngotomy, the following procedure will allow of more deliberate
removal.
The soft palate and uvula are carefully divided in the middle line, and
a silk ligature is placed through each lateral half so that they can be
held forward out of the way. This gives more direct access to the
post-nasal tumour, and if then found to crowd the cavity too closely to
allow of manipulation, the posterior part of the hard palate can be
chiselled away in the middle line. At the conclusion of the operation
the divided palate is carefully united in the middle line (see Vol. II).
=Selection of method.= In some cases operation through the mouth may
have to be combined with a second operation from the front--such as the
method of Moure (see p. 619) or that of Rouge (see p. 622).
Rapidity of operation is important, as, once the pedicle has been cut
through, or the body of the tumour removed, the hæmorrhage tends to
subside spontaneously, or is quickly controlled by packing.
The hanging head (Rose) or the Trendelenburg position is generally
recommended.
The preliminary laryngotomy seems desirable in all cases. The division
of the palate should be avoided if possible. It may not always unite,
and is less likely to do so if subsequent operations are required. The
soft palate is very elastic, and in some cases it can be tied out of the
way by means of a soft rubber catheter passed along the floor of the
nose, and out through the mouth.
Ligature of the external carotid, strongly recommended by Chevalier
Jackson[87], is not necessary unless the patient is very anæmic or weak
from former hæmorrhages. It should then be only a temporary ligature
(see Vol. I, p. 383).
[87] _The Laryngoscope_, xiv, 1904, p. 267.