Part 86 (1/2)

Its stimulating effect on the respiration and circulation is always agreeable to the patient, and may be very valuable when he is under a general anaesthetic.

If operated upon under a local anaesthetic, the patient's head should be inclined forwards, so that the blood can drip from the nose. The first formed clots may be expelled, but then he should avoid sniffing, sneezing, or coughing, and sit with the head forward and the nostrils completely closed with his thumb and forefinger. Five to ten minutes in this position will arrest the bleeding in most cases of epistaxis. A slight oozing of blood may be allowed to go on for a few hours in certain cases. If the bleeding persists, ice should be applied externally and held in the mouth, the nose may be syringed with very cold or with very warm salt and water (?i to the pint), and the horizontal position a.s.sumed.

If this fails, a pledget of cotton-wool is dipped in peroxide of hydrogen solution (10 vols. %) and introduced into the bleeding nostril, the orifice of which is then closed by the surgeon's thumb. This may be repeated more than once, the patient lying on his side, face downwards, and pinching both nostrils. If a galvano-cautery be available, and the bleeding comes from a limited and visible point, it can be sealed with a touch of the cautery point.

If these methods fail, plugging must be resorted to. With the nasal speculum and good illumination, the bleeding area is cleansed with cocaine and adrenalin and a strip of 1-inch ribbon gauze is carefully packed on to the spot, the end being left just within the vestibule, so that the patient can remove it for himself at the end of 12 or 24 hours.

It is better to use a single strip of gauze, instead of cotton-wool, as portions of the latter might be detached and left behind. If there be fear of the gauze strip becoming adherent, it can be well smeared with plain sterilized vaseline.

If the bleeding comes from far back in the nose, or from the post-nasal s.p.a.ce, it may become necessary to plug the latter cavity. A sterilized sponge, about the size of a Tangerine orange, is squeezed very dry and tied round its centre with a piece of tape or a stout silk ligature, leaving two free ends of about 12 inches in length. A soft rubber catheter is pa.s.sed along the floor of the nose till it appears below the soft palate, when the end is seized with forceps and drawn through the mouth. To this end one of the tapes is made fast, so that when the catheter is withdrawn from the nose, the sponge is pulled up into the post-nasal s.p.a.ce; the other end hangs out of the mouth. The two tapes are tied together over the upper lip. The anterior part of the nostril can then be packed with gauze, if necessary. If the patient be under chloroform, one tape can be dispensed with; the soft palate is simply held forward with the forefinger of one hand, while the other pa.s.ses the compressed sponge up into the naso-pharyngeal s.p.a.ce.

Plugs in the nose should be avoided. They are painful, interfere with repair, prevent drainage, and may be followed by septic troubles in the nose, accessory sinuses, middle ear, or cranial cavity. Bleeding often recurs on their removal. In any case they should not be left unchanged for more than 24 or, at the most, 48 hours. Removal is facilitated by soaking them well with peroxide of hydrogen, and detaching them slowly and gently. Ligature of the external carotid (see Vol. I, p. 384) may be necessary in extreme cases.[48]

[48] Chevalier Jackson, _Transactions American Laryngological a.s.sociation_, 1907.

THE PROTECTION OF THE LOWER AIR-Pa.s.sAGES FROM THE DESCENT OF BLOOD

When operated upon under local anaesthesia the patient is able to prevent blood descending from the nose or throat into the larynx or trachea. In this he is a.s.sisted by throwing the head forwards.

When the patient is under a general anaesthetic other measures must be taken to guard against the descent of blood into the windpipe and lungs.

The most important is to see that the anaesthesia is never so deep as to abolish the swallowing or coughing reflexes. Fortunately these are amongst the last to go, yet in many cases it is well to let the patient come partly round, so as to expel blood and mucus by coughing. If the frontal sinus is being operated upon, the nose is carefully packed beforehand. When the ethmoidal labyrinth is being cleared, or the sphenoidal sinus opened, a sponge may be placed in the post-nasal s.p.a.ce as described above until the operation is completed. During the operation upon the maxillary sinus through the canine fossa, a sponge placed between the last molar teeth and the cheek on the same side, and frequently renewed, will keep any blood from entering the pharynx. In operations upon the naso-pharynx, it is a wise precaution, when much bleeding is antic.i.p.ated, to perform a preliminary temporary laryngotomy and plug the pharynx with a sponge (see p. 510).

In many proceedings security is attained by rolling the patient well over to one side, so that the blood runs out of the corner of the mouth, of blood is also swallowed. This may be vomited as consciousness returns; if not, an aperient should be given within 24 hours to prevent gastro-intestinal sepsis.

The descent of blood into the trachea and lungs, if sudden and copious, may cause immediate asphyxia; or, if less abundant, it may cause septic pneumonia. When it occurs, the anaesthesia should be stopped, and the patient rolled well over on to his face or inverted, until the breathing is quite un.o.bstructed. After all nose and throat operations it is a wise precaution for the patient to be kept on his side, the head on a low pillow, and face downwards, while the body is arranged in the gynaecological position.

SHOCK

Shock, particularly in operations on the nose, is apt to be marked in young children and in elderly persons. It is for this reason that we try to avoid the removal of adenoids in patients under 3 years of age, or of polypi in those over 60; and that in all cases we endeavour to operate as rapidly as possible.

This possibility of shock is guarded against and treated in the usual way. The use of cocaine and adrenalin--even in patients under a general anaesthetic--helps to avoid it,[49] and anaesthesia should never be too deep or prolonged. When operating under local anaesthesia it is sometimes wiser not to attempt too much at one sitting, _e.g._ to treat only one side of the nose at a time. In certain conditions, and when a general anaesthetic is employed, it may be safer to try and complete treatment at one operation.

[49] G. W. Crile, _Journal Amer. Med. a.s.soc._, June 17, 1905.

SEPSIS AND OTHER COMPLICATIONS

Deaths have been recorded after the simple use of the galvano-cautery, or the removal of nasal polypi, and of course are more to be feared after major operations, such as the radical cure of sinus suppurations.

Septic infection from nasal operations may spread to the accessory sinuses, meninges, ear, eye, tonsils, glands, gastro-intestinal tract, bronchi, and lungs. From the naso-pharynx, the ears and the lower food and air tracts are chiefly threatened. The orbit may be invaded in operations on the ethmoid; the external muscles of the eye may be injured in the frontal sinus operation; and optic atrophy may be due to plugging of the ophthalmic vein.

While these accidents may sometimes be directly due to operation, it is well to remember that in treating such septic conditions as are entailed by nasal suppuration, the complications may only be precipitated by traumatism and may also be purely coincident. It is not to be forgotten that latent infection--of influenza, erysipelas, measles, scarlatina, diphtheria, or other disease--may develop immediately after an operation upon the nose or throat, and until its true character is recognized the operation is often unjustly blamed. Septic infection, in these necessarily exposed wounds of the air-pa.s.sages, may be traced to insanitary surroundings.

ASEPSIS