Part 89 (1/2)

Curettage is required in more advanced cases. Chloroform is always required. Not only should all soft and diseased tissue be sc.r.a.ped away with a Volkmann's spoon, but the curettage should be carried on vigorously until a healthy and resistant area has been reached. It is rare for too much tissue to be removed, whereas recurrences are only too frequent.

CHAPTER III

OPERATIONS UPON THE NASAL SEPTUM

OPERATIONS FOR DEFORMITIES

REMOVAL OF SPURS

=Indications.= A spur or ledge, uncomplicated with deviation of the septum, occasionally requires removal. It will generally be found in the lower meatus, at the junction of the quadrilateral cartilage and ethmoid with the superior maxillary crest and vomer.

[Ill.u.s.tration: FIG. 295. CRESSWELL BABER'S NASAL SAW.]

=Operation.= The operation can be carried out painlessly and bloodlessly under cocaine and adrenalin. The galvano-cautery, trephine, and spokeshave should be avoided. An incision is made from behind forwards along the summit of the projection, and the muco-perichondrium is turned upwards and downwards. (For particulars as to reflecting these flaps see p. 605.) A straight, fairly stout nasal saw (Fig. 295) is inserted below the projection, and, while the patient's head is steadied with the left hand, the saw is carried inwards and upwards with short, swift movements. During the first of these the cutting edge should be directed obliquely towards the opposite nostril so that the saw gets a good bite into the base of the spur. Otherwise, if simply directed vertically the resistance it meets with is likely to send it obliquely outwards, and the obstruction will be imperfectly removed. This defect will be the more apparent later on, when some heaping up of scar tissue is sure to take place over any trace of projection. In other words, in order to remove a spur flush with its base it is necessary to cut deeper than the base. At the same time it is important to avoid b.u.t.tonholing the septum by cutting into the opposite nostril.

When the spur lies close along the floor of the nose it may be necessary to direct the saw from above downwards. The result is not so satisfactory, and the removal may have to be completed by seizing and twisting off the semi-detached spur with a pair of polypus forceps, or stripping it forwards with a spokeshave.

=After-treatment.= The reflected flaps of muco-perichondrium are replaced and maintained in position for 48 hours with plugs of cotton-wool. Subsequently a warm alkaline nasal lotion and a little ointment may be required.

=Perforating the septum.= It will be seen that if a spur is a.s.sociated with a convexity of the septum to the same side it will be very difficult to remove the projecting obstruction adequately without cutting into the concave side of the septum, and so producing a perforation. Some surgeons even recommend that this should be done intentionally, and maintain that the resulting perforation seldom gives any trouble. This may be true in some cases, and the result is sometimes fairly good. But we have more completely satisfactory methods at our disposal; the perforation method does not relieve the majority of cases, and it interferes with the subsequent performance of more perfect operation. It can therefore only be approved of when the surgeon has not acquired the technique of the submucous resection operation (see p.

603).

_Operation._ When it has been decided to produce a perforation it is carried out with the nasal saw, as described for the removal of spurs (see p. 595). The saw is introduced so as to embrace as much as possible of the projection.

_After-treatment._ The drying and scabbing of discharge along the margin 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 anaesthetic. 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 b.u.t.ton-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.

[Ill.u.s.tration: 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 anaesthetic.

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 anaesthesia, but it is generally advisable to employ some such general anaesthetic 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.

[Ill.u.s.tration: FIG. 297. ASCH'S CUTTING SCISSORS. Employed in the operation upon the septum.]

[Ill.u.s.tration: FIG. 298. LAKE'S RUBBER SPLINT.]