Part 85 (1/2)

OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES

BY

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

Professor of Laryngology and Physician for Diseases of the Throat, King's College Hospital, London

CHAPTER I

GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS ON THE NOSE AND NASO-PHARYNX

An intimate knowledge of the surgical anatomy of the nose is an important factor in successful treatment. It is sufficient to recall the close relations of the nasal chambers and their accessory sinuses with the cavities of the orbit and the cranium, and to remember that the shape and size of these air-s.p.a.ces may vary considerably within physiological limits.

The arrangements of the vascular, lymphatic, and nervous supplies, and their connexion with neighbouring parts and the body generally, have also to be kept in mind.

In planning and carrying out operative procedures it is also well to keep in mind the important physiological functions of the nose.

Disease in the nose involves both medical and surgical treatment. The general progress of surgery, improved technique, local anaesthesia, and the control of haemorrhage we now possess, have all tended to replace local medication by surgical measures. But in many affections of the nose--such as syphilis, or diphtheria--surgical relief is quite secondary to medical treatment. In any case the surgeon cannot dispense with a knowledge of suitable topical applications and the principles on which they are founded.

SOURCES OF ILLUMINATION

A good source of illumination is the first necessity for satisfactory operations on the upper air-pa.s.sages. The natural sources at our disposal are sunlight and diffuse daylight. They have the great advantage of not altering the natural colours of the parts examined.

Reflected sunlight forms a perfect illuminant, if we are careful not to bring the rays to an exact focus on the mucous membrane, as this might produce a burn.

Diffuse daylight is too feeble for the examination of the cavities of the nose and larynx, but it can be used for inspecting the mouth, pharynx, and ear. Direct daylight is particularly serviceable for examining suspicious rashes or patches in the mouth and pharynx, and eruptions on the skin.

Some form of artificial light is indispensable. That furnished by an ordinary paraffin lamp or a gas flame is sufficient for examination. The flame should have its flat side towards the observer, and be enclosed in a gla.s.s chimney, without a globe or shade. If neither of these lights be available, an ordinary candle, or, better still, three candles tied together, will suffice.

For use in the study a paraffin reading-lamp or a gas standard is equally suitable. The latter is rendered more effective by the adoption of an Argand burner or a Welsbach mantle. The oxy-hydrogen limelight is the most perfect of artificial illuminants, but it is bulky and expensive. The most convenient light is that given by a 32 or 50 candle-power electric light in a frosted globe, and with the filament waved. The Nernst electric burner gives increased brilliancy.

[Ill.u.s.tration: FIG. 281. LARYNGOSCOPE LAMP.]

The electric light has the further advantage that it is unnecessary to maintain it constantly vertical. When enclosed in a bull's-eye, the lamp can be rotated so as to direct the pencil of light-rays either upwards or downwards, as well as from side to side.

Whichever light is employed the rays can be concentrated and rendered more powerful by enclosing it in a dark chimney with a bull's-eye condenser. The light must also be provided with some arrangement by which it can be raised and lowered (Fig. 281). For operating the Clar light is useful (Fig. 282).

In all these methods the light is reflected, but the direct rays of the electric light can be used in a small lamp fixed on the forehead, and fed from an acc.u.mulator or direct from the street current through a suitable resistance. It is better than reflected light in operations on the nose and throat, and the portable acc.u.mulator and frontal photoph.o.r.e (Fig. 283) are convenient for use in the patient's own home.

[Ill.u.s.tration: FIG. 282. CLAR'S ELECTRIC LIGHT.]

[Ill.u.s.tration: FIG. 283. FRONTAL SEARCH-LIGHT.]

The lamp should be placed on a stand or table so that the light is on a level with the patient's ear, and 3 or 4 inches distant from it. In Continental schools it is customary to place the light on the patient's right hand. In this country the lamp is usually placed close to the patient's left ear, _i.e._ on the observer's right hand. As pract.i.tioners will often be called to see patients who are confined to a bed which can only be approached from one side, it is desirable that they should accustom themselves to work equally well with the light on either side, and the frontal mirror over either eye.

LOCAL ANaeSTHESIA

=Cocaine.= It is often desirable to secure a slight degree of local anaesthesia to facilitate complete exploration of the nose. Many operations can be carried out by rendering the nasal mucosa absolutely insensitive with cocaine.