A System of Operative Surgery Part 87

In the septum fracture generally takes place in the quadrilateral cartilage, or displacement occurs at its junction with the vomer or superior maxilla. It may be accompanied by a haematoma (see p. 612), and the occurrence of epistaxis shows that it is really a compound fracture.

Care should therefore be taken not to infect the wound in the nose, and the patient should be warned on the subject.

The application of cocaine and adrenalin may allow of careful inspection of the septum. But, as the exact condition of things is marked by swelling, it is nearly always advisable to administer a general anaesthetic. Crepitus can rarely be made out. A haematoma is dealt with as directed (see p. 612). If there be any displacement of the septum--and it generally takes place towards the side on which there is already some convexity or depression of the nasal bones--the parts should be raised into place by manipulation with the little finger in the nostril. A flat-bladed forceps, like those of Adams, may be used. One blade in each nostril will straighten the septum and, at the same time, raise the whole nose into place. Small pencils of sterilized cotton-wool, smeared with vaseline (see p. 608), are then carefully packed up into the roof of the nose and kept there by Meyer's vulcanite tube (Fig. 284). They are changed every 24 or 48 hours, for a week or so. The vomer is rarely fractured, although much callus is often thrown out in the displacements which occur between it and the cartilage.

Recent cases require no splints. In fact, if the displacement be promptly reduced--under general anaesthesia--the restored parts will generally maintain their position.

=Elevating an old fracture.= In neglected cases it may be necessary to re-fracture the nasal bones, and when these are replaced an external splint may be necessary. This can be made of plaster of Paris; or the outside of the nose may be covered with a piece of heavy adhesive plaster, and outside that a s.h.i.+eld of tin, copper, or, preferably, aluminium.[52]

[52] T. A. de Blois, _Trans. Amer. Laryn. a.s.sociation_, 1900, p. 12.

[Ill.u.s.tration: FIG. 284. MEYER'S HOLLOW VULCANITE NASAL SPLINT.]

Fracture of the ethmoid is, fortunately, rare. When it occurs it is apt to run into the cribriform plate, and be a.s.sociated with the escape of cerebro-spinal fluid and other indications of fracture of the anterior fossa of the skull.

OPERATIONS FOR CONGENITAL OCCLUSION OF THE NOSTRILS

=Operation for congenital occlusion of the anterior nares.= _If the web obstructing the nostril be thin and membranous_, and of low vitality, a simple and effective method is to destroy it with the galvano-cautery.

It is best to spread the treatment over several sittings, so as to diminish the local reaction. The application of cocaine may not be sufficient to numb the pain, as the tissue of the obstructing web is more allied to skin than to mucous membrane. It should therefore be punctured quickly in two or three places, with a sharp cautery point raised nearly to a white heat. If the patient be nervous it may be well to administer nitrous oxide gas.

After the operation the nasal orifice is kept distended until healing has taken place by wearing Meyer's vulcanite tube in it or short lengths of full-sized rubber drainage tube, well smeared with boric, aristol, zinc, or similar ointment. These simple nasal dilators are changed once or twice daily, and the nostril is well cleansed on each occasion.

_If the web obstructing the anterior naris be more fleshy in character_ (and it is more apt to be of this nature when it is incomplete), it may be necessary to remove it with a knife. So as to leave as much epithelial tissue as possible, and avoid retraction, the operation is done as follows, under local or general anaesthesia: A narrow, sharp-pointed instrument, such as a Graefe's or other ophthalmic knife, is used to puncture the web from before backwards, and it is then made to sweep round the obstructing diaphragm, while gradually cutting its way towards the central lumen. The tongue of skin thus formed can be used as a graft to cover most of the raw surface. The restored anterior naris is kept patent, as already described, till healing takes place.

[Ill.u.s.tration: FIG. 285. KRAUSE'S TROCHAR AND CANULA. For puncturing the maxillary antrum from the nose.]

[Ill.u.s.tration: FIG. 286. NASAL PUNCH-FORCEPS.]

In some cases the following operation has been shown to be easy and effective: An incision is made at the junction of the web with the septum, keeping close to the latter and pa.s.sing straight down to the floor of the nose. On the outer side a similar incision is made, but sloping somewhat outwards. The flap formed between these two incisions is not cut off, but is bent backwards and fastened to the floor of the nose by a single horsehair st.i.tch.[53]

[53] G. K. Grimmer, _Proc. Royal Soc. of Med._ (_Laryngol. Section_) April, 1908.

=Operation for congenital occlusion of the posterior choanae.= If the obstruction be not freely and completely removed it tends to re-form. A general anaesthetic is required. Unless the operator is ambidextrous he will find it most convenient to stand on the patient's left hand, and to introduce his own left forefinger into the post-nasal s.p.a.ce. This enables him to guide any straight, sharp instrument, such as an antrum drill (Fig. 323), Krause's trochar (Fig. 285), or a surgical bradawl, from the front of the nose until it presses against and breaks through the obstructing diaphragm in two or more points. If preferred, an electric trephine can be used, and often pressure with the tip of a pair of nasal punch-forceps will be sufficient. The latter, either straight or tip-tilted (Fig. 286), are then inserted through the nostril, and, still guided by the left forefinger in the post-nasal s.p.a.ce, are employed to clip away all the obstruction. To prevent any possibility of this reforming it is recommended by some surgeons that a small piece should be nipped out of the posterior margin of the bony septum. This can be done with the beaked punch-forceps of Grunwald (Fig. 286), pa.s.sed through the nose, or with a pair of Loewenberg's post-nasal forceps (Fig. 287) introduced through the mouth. In either case their action is controlled and directed by the operator's left forefinger in the post-nasal s.p.a.ce.

[Ill.u.s.tration: FIG. 287. POST-NASAL FORCEPS.]

No special after-treatment is required. The patient should be ordered a tepid alkaline nose lotion, and should be encouraged to make use of the nasal air-way and acquire the habit of blowing the nose.

REMOVAL OF FOREIGN BODIES FROM THE NOSE

It might be helpful to remember that foreign bodies not only enter the nasal cavities (1) through the anterior nares, but also (2) through the posterior choanae, or (3) by penetration through the walls. They may also arise (4) _in situ_, as in the case of sequestra and rhinoliths. The last group will be considered separately.

A foreign body, if small, may form the centre of a rhinolith.

=Operation.= Great care and gentleness are required in the removal of foreign bodies from the nose. The extraction should never be attempted blindly, or forcibly, or hurriedly. A little delay to make necessary arrangements does no harm. If a child will not submit to examination it is much better to employ a general anaesthetic so as to complete examination and, if found necessary, extraction at the one sitting. If the nose be not well illuminated and opened with a nasal speculum, groping about in the dark will only do further damage and result in disappointment.

[Ill.u.s.tration: FIG. 288. NASAL DRESSING FORCEPS.]

In adults removal can generally be carried on under cocaine. The nostril is cleaned with cotton-wool, and if the extremity of the probe used for detecting the presence of a foreign body be curved to a right angle, it will also serve for gently levering or displacing it forwards. With a small pair of nasal dressing forceps (Fig. 288) it can generally be firmly seized and gently extracted, care being taken not to include any of the mucosa nor to drag the foreign body out regardless of the sinuosities of the cavity. Lister's ear hook is a most useful instrument. Sometimes a nasal snare will help to extract the substance or to tilt or drag it into a better position.

Unless coated with solid accretions there is never any need to break up a foreign body; anything small enough to slip into the nose is small enough to be extracted entire. If it should be found impossible to remove the body through the anterior nares, it may be pushed backwards into the post-nasal s.p.a.ce, where the forefinger of the left hand is in readiness to prevent its falling into the gullet or larynx.

The usual warm alkaline lotion may be used to clear the nose, but liquid should never be forcibly injected into the nostril with the idea of thus expelling the foreign body. If the lotion be sent up the nasal chamber on the same side it will only drive the intruding substance further in; if injected on the opposite side there is risk of ot.i.tis media.

In the case of small children it is sometimes recommended that a piece of muslin should be placed over the mouth, and that the pract.i.tioner should then apply his lips to those of the patient and by blowing forcibly through the mouth drive out the foreign body by the blast of air from the post-nasal s.p.a.ce. Or the same principle may be applied by insufflating the air from a Politzer's bag through the opposite nostril.

Both plans are alarming and seldom effective.

The _after-treatment_ consists of some simple cleansing lotion and soothing ointment.

REMOVAL OF RHINOLITHS (NASAL CALCULI, OR CONCRETIONS IN THE NOSE)

These concretions are almost unknown in children, in whom foreign bodies are met with most frequently. A general anaesthetic is, therefore, not so often required, otherwise the remarks on the removal of foreign bodies will be found to apply to the extraction of calculi. With the help of cocaine and good illumination they can easily be removed with a strabismus hook, Lister's ear hook, or a pair of fine probe-pointed nasal forceps with serrated extremities. In some cases where the calculus has sent prolongations into the recesses of the meatus, it might first be necessary to crush it. In that event a general anaesthetic may be required.

The _after-treatment_ consists in simple cleansing measures. Subsequent syringing of the nose should be done from the opposite side.

OPERATIONS UPON THE TURBINALS

=Indications.= In many cases of hypertrophic rhinitis it is necessary to remove portions of redundant turbinal tissue. It is never desirable--and it can only rarely be necessary--to remove the whole of the inferior turbinal. 'Turbinotomy,' or amputation of the whole inferior turbinal, was recognized as an operation some years ago. But it was never generally accepted, as it was always realized that the highly important physiological functions of the lower spongy bone could not be spared.

Improved technique, particularly in being able to correct deformities of the septum without the sacrifice of any mucous membrane (see p. 603), now enables us to rectify nasal stenosis with the sacrifice of much less turbinal tissue.

The middle turbinal is not of so much importance in the physiology of the nose, and the whole of this body is not infrequently removed. This may be done not only because it is diseased, but even a healthy middle turbinal may require amputation in order to approach the accessory sinuses or diseases in the deeper regions of the nose. Part of the healthy inferior turbinal may also require removal--as in the radical operation on the maxillary sinus.

As these operations will be referred to frequently later on, and as their performance enters into different groups of operation, they will be described first.

OPERATIONS UPON THE INFERIOR TURBINAL

=Amputation of the anterior end. Indications.= The amputation may be required:

(i) On account of polypoid degeneration of the anterior extremity of the turbinal.

(ii) To allow of access to the antro-nasal wall (see p. 633).

(iii) To avoid operation on the septum by relieving nasal stenosis.

[Ill.u.s.tration: FIG. 289. FIRST STEP IN REMOVING THE ANTERIOR END OF THE INFERIOR TURBINAL, WHICH IS SEEN TO HAVE UNDERGONE POLYPOID DEGENERATION.]

=Operation.= The local application of cocaine and adrenalin (see p. 573) is sufficient.

=Anaesthesia.= With the patient sitting upright in a chair, and the nostril well illuminated, a pair of nasal scissors (such as Heymann's, Walsham's, or Beckmann's) are made to grasp as much of the anterior extremity as it is desired to remove, generally the anterior third (Fig.

289). The scissors are pressed very firmly against the outer nasal wall, so as to divide the base of the turbinal as close as possible to its attachment. If the scissors slip off the bone it should be divided with Grunwald's punch-forceps. The semi-detached extremity is then surrounded with a nasal snare, carrying a No. 5 piano wire, and cut through (Fig.

291).

It is well not to seize and twist off the anterior extremity, as this might lead to the ripping out of a larger portion than was intended.

Besides, it might cause fracture of the base of the remaining piece of the inferior turbinal bone and this might become displaced inwards so as to block the air-way more than ever.