Part 88 (2/2)

=Operation.= Local anaesthesia with cocaine and adrenalin is sufficient, and the operation can be carried out with the patient sitting in the examination chair. It frequently forms part of some other intranasal operation which is performed under a general anaesthetic, but the preliminary application of cocaine and adrenalin should still be carried out (see p. 572). If the pieces of gauze soaked in the cocaine-adrenalin mixture be carefully tucked up on each side of the head of the turbinal, the part to be removed is generally well exposed. With a pair of Grunwald's punch-forceps (Fig. 286) or Panzer's scissors (Fig. 290), the anterior attachment to the outer wall is cut through (Fig. 293) so as to free the end, around which a cold wire snare can be pa.s.sed and the extremity removed (Fig. 294.) In cases where it is difficult to introduce the punch-forceps under the attachment of the middle turbinal the blades may be applied to the lower margin, about half an inch from the anterior extremity so as to bite out a wedge. Into this the loop of the wire snare is inserted and the head of the turbinal can easily be snared off.

[Ill.u.s.tration: FIG. 293. FIRST STEP IN THE REMOVAL OF THE ANTERIOR END OF THE MIDDLE TURBINAL.]

[Ill.u.s.tration: FIG. 294. SECOND STEP IN THE REMOVAL OF THE ANTERIOR END OF THE MIDDLE TURBINAL.]

The snare is generally recommended as being safer than the punch-forceps. There is certainly a risk attending any slip in manipulating the latter in this region, more so, indeed, than in the deeper ethmoidal regions, for in the anterior part of the nasal roof the cerebral floor dips down lower than it does posteriorly, and the nasal fossa in the anterior part of the middle meatus is very narrow, so that if the forceps slipped they might impinge on the cribriform plate.

But when the middle turbinal is softened and broken down by disease it is as safe, and it is certainly more convenient, to take out a wedge from its centre, as directed above, and then with a pair of Grunwald's or Luc's forceps to twist out not only the anterior extremity, but also the posterior half. The latter part can also be removed with a spokeshave, as directed for the inferior turbinal (see p. 591).

=After-treatment.= There is not the same tendency to crusting as occurs after operation on the inferior turbinal. Haemorrhage is also less troublesome. Plugging is therefore the less likely to be required, and should always be avoided if possible, since it would interfere with drainage from the various accessory sinuses, and this operation is frequently required when their contents are particularly septic. The best plan is to leave the nose severely alone for 48 hours, and then to clear it gradually with the help of warm alkaline lotions.

OPERATIONS FOR THE RESULTS OF SYPHILIS

=Sequestrotomy.= The discovery of a syphilitic sequestrum always calls for active treatment.

=Operation.= If the sequestrum be not loose we must wait until it is movable. Its detachment will be expedited by mercurial inunctions or injections, and suitable local cleansing and disinfecting measures. As soon as any movement can be detected in the dead ma.s.s we can proceed, under cocaine, to detach it. Various forms of polypus forceps and bone-pliers may be required, and the necrosed bone has to be raised from its bed by a variety of lever and to-and-fro movements. Several sittings may be necessary, but this is inevitable, as any violent measures are soon arrested by haemorrhage. When the necrosed bone has been mobilized it may be too large for extraction through the nares; such a ma.s.s as the greater part of the body of the sphenoid has sometimes necrosed _en bloc_. In such cases the dead bone must be broken up _in situ_ and then removed piecemeal through either the anterior or posterior nares. Very rarely Rouge's operation may be required (see p. 622).

=Operations for post-syphilitic adhesions of the velum.= So long as there is an adequate pa.s.sage for nasal respiration it is best to leave any slight degree of stenosis alone. When there is complete atresia, and when mouth-breathing, deafness, or other consequences develop, some effort at relief should be made.

=Operation.= Under chloroform, and with the hanging head, W. G.

Spencer[54] separates the soft palate from its adhesion to the posterior pharyngeal wall, draws it forwards, and fixes it by two silk sutures to the muco-periosteum of the hard palate. Tilley carries out the same principle by threading the soft palate on both sides with strong silver wire and anchoring it to the incisor teeth. The wires cut out in 10 to 14 days, but by this time considerable healing will have taken place over the raw surfaces from which the adhesions had been separated.[55]

[54] _Proc. Laryngol. Soc., London_, vol. v, November, 1897, p. 4.

[55] Ibid., vol. x, March 6, 1903, p. 81.

After freeing the soft palate, H. B. Robinson prevents it from again uniting by the following method: 'A piece of lead plate is cut the full breadth of the naso-pharynx and bent so that one arm rests on the dorsal surface of the soft palate, and the lower one on the buccal surface, the cut margin being received between the plates and apposed to the bend, and so kept away from the pharyngeal wall.' The piece of lead is kept in place by silk threads attached to the four corners, two pa.s.sing forward through the nostrils and two through the mouth. The lead plate is not removed for a fortnight.[56]

[56] Ibid., vol. xiv, June, 1907, p. 106.

Whatever method is employed to enlarge the stricture, dilatation must be kept up for some time by the frequent pa.s.sage of the forefinger, a palate hook, or a dilatable bag.

=Results.= Stenosis of the pa.s.sage from the naso-pharynx to the meso-pharynx, caused by syphilitic adhesions between the soft palate and the posterior pharyngeal wall, is one of the most difficult affections in this neighbourhood to operate on with satisfactory results. The cause of disappointment lies in the low vitality of specific scars and their well-known tendency to contract.

Surgical measures are sometimes required for the damage left by syphilis during the healing process.

The saddle-back deformity of the external nose is best corrected by subcutaneous injection of paraffin (see Vol. I, p. 681).

Perforations in the hard or soft palate may require operation to close them (see Vol. I, p. 717).

OPERATIONS FOR TUBERCULOSIS

Tuberculosis only occurs in the nose in the mitigated form of lupus.

Surgical interference is frequently called for, generally in the form of curettage or the application of caustics.

The most satisfactory caustic is the galvano-caustic point, applied under cocaine, and at repeated sittings.

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