Part 89 (2/2)

The conditions in which any of these operations can prove suitable are rarely met with. In the worst forms of stenosis from septal deformity they are useless. At the best they can never completely remove it. In one of them a perforation is made on purpose, and in the others it not infrequently is produced unintentionally. The objections to a perforation have been described (see p. 598). Haemorrhage, shock, and prolonged and painful after-treatment are important drawbacks. A dry scabby condition of the septum may be produced, and the patient may complain more of this than of his previous nasal stenosis; indeed, he may find that the stenosis is unrelieved and that a constant source of irritation has been added to it.

The perforation operation should only be employed when the patient is in circ.u.mstances where a complete submucous resection cannot be carried out. The Gleason-Watson operation is unsuitable where the deviation reaches high up. It should be avoided if it is seen that the perforation will have to be brought close forward to the anterior nares.

Another objection is that any of these operations, particularly the production of a perforation, will greatly increase the difficulties and diminish the benefits of the subsequent complementary operations which are only too often required.

Asch's operation is easily carried out, and may be practised by those who have not mastered the technique of submucous resection (see p. 603).

Moure's operation is easily and quickly performed, and where a well-marked deviation of the anterior part of the cartilaginous septum is met with, it will give considerable relief.

OPERATION FOR COMBINED BONY AND CARTILAGINOUS DEFORMITY

_Submucous Resection (Window operation)_

This is the most perfect operation we at present possess for the cure of deformities of the nasal septum. It has largely supplanted those already outlined; it is suitable for the most extreme degree of deformity: and it will secure complete relief to the symptoms produced, whether they consist of stenosis of the air-way, obstruction to discharge, or reflex effects.

The design of the operation is to excise all obstructing cartilage and bone, with any projecting spurs or ledges, while preserving intact the mucous membrane on each side. It has been brought to its present degree of perfection chiefly by the work of Killian and Freer.[57]

[57] For bibliography and more detailed description, see StClair Thomson, _Med.-Chir. Trans._, vol. lx.x.xix, 1906; _Lancet_, July, 1906; and _Brit. Med. Journ._, vol. ii, 1906.

=Indications.= The special indications of this operation would appear to be:--

1. Cases where it is desirable to establish normal nasal respiration and remove mouth-breathing, with its numerous consequences.

2. Correction of the disfigurement caused by the lower end of the quadrilateral cartilage projecting into one nostril.

3. Cure of headaches or reflex neuroses of nasal origin.

4. The relief and treatment of Eustachian catarrh.

5. Facility for treating nasal polypi and affections of the accessory sinuses.

=Objections to the operation.= (_a_) That the excision of a large part of the septum may lead to flattening or deformity of the nose. This objection is groundless. A strip of septal cartilage is always left above, beneath the crest of the nose. Falling in of the bridge of the nose could only be consequent on entire removal of this 'bowsprit' of cartilage, or from its destruction through the wound becoming septic. No deformity has occurred in my hands in over 200 operations. On the contrary, the appearance of the nose is generally much improved.

(_b_) That the operation entails greater risks from any subsequent blows on the nose. This objection has been met by the experience of Otto Freer in four cases where severe blows, causing epistaxis and occurring even within a week of operation, did not result in any damage to the fleshy septum, nor to the external appearance of the nose.[58]

[58] _Annals of Otology, Rhinology, and Laryngology_, June, 1905.

(_c_) That the operation is long and tedious. The duration of the operation depends on the nature of the case, the skill of the surgeon, and the difficulties met with--chiefly in the way of haemorrhage. A simple deviation of the cartilaginous septum can be removed by this method in 10 to 20 minutes. Many beginners are apt to be content with such a partial removal. More time is required in completely removing bony deformities. Many cases take 30 minutes, and none need exceed an hour when once the necessary dexterity has been acquired. More time is taken up if fresh applications of cocaine or adrenalin have to be made, if bleeding be troublesome, and if one of the flaps should be punctured.

(_d_) That the operation requires special skill. This is a real objection to the popularization of the operation. It does not seem probable that it can ever pa.s.s out of the hands of those who are kept in daily practice in rhinological technique.[59]

[59] 'As all operators who know it will confess, the Fensterresektion of the septum belongs to the most extremely difficult intranasal operations.' Zarniko, _Die Krankheiten der Nase_, 1905, p. 300.

(_e_) That the operation is unsuitable for children. Owing to the small size of the nasal chambers the operation presents greater technical difficulties before the age of sixteen. My own practice formerly was to await this age, and Killian used to advise that children under twelve were not fit subjects. But Freer held that the operation is proper for children at all ages, although with them the deformity tends to recur unless every vestige of it has been removed. Killian has lately adopted this view, and agrees that the operation may be performed on children even as young as four years of age.[60]

[60] _Beitrage zur Anatomie, &c. des Ohres, der Nase, und des Halses_, Hefte 1-4, 1908.

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