Part 91 (1/2)

=After-treatment.= The patient remains quiet for the rest of the day.

Ice may be given to suck and an iced cloth laid across the bridge of the nose. At the end of 48 hours the plugs are removed and will be found to come away very easily. The patient should be warned against blowing his nose, but may suck blood-stained mucus backwards and hawk it out through the mouth. Any discomfort may be soothed by spraying the nostrils with liquid vaseline, or introducing a piece of menthol and boric ointment into each nostril morning and evening.

[Ill.u.s.tration: FIG. 308. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded area indicates the extent of the bony and cartilaginous septum usually requiring removal.]

[Ill.u.s.tration: FIG. 309. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded portion indicates the extent of cartilage and bone removed in marked deformity, when the free end of the quadrilateral cartilage projects into one nostril.]

The relief to the former state of nasal obstruction may at once be appreciable. If there be any local reaction it may take 3 or 4 days for the obstruction to subside. In 7 to 10 days the patient begins to enjoy the benefit of the operation, but it is only after 3 weeks that the full advantage of it is established.

=Complementary operations.= As a rule the formerly patent nostril is found after this operation to be the more obstructed of the two. The reason of this is readily explained by a reference to Fig. 310. The now redundant hypertrophy in the formerly good nasal chamber is removed--according to its degree and extent--by one of the methods described on p. 587.

From long disuse marked alar collapse may interfere with the good results of the operation.

=Difficulties.= _Insufficient illumination_ is a difficulty that can easily be provided against by using a frontal photoph.o.r.e or Clar's mirror (see p. 571).

[Ill.u.s.tration: FIG. 310. SEMI-DIAGRAMMATIC TRANSVERSE SECTION OF THE NOSE. Shows the compensatory hypertrophy of the inferior turbinal in the un.o.bstructed nostril. Part of this frequently requires removal after the septum has been straightened.]

_Haemorrhage_ presents no difficulty if patients are prepared as directed (see p. 574), unless one happens unexpectedly on a patient with a haemophilic tendency. In one such case I had no trouble at the time of operation, but bleeding gave great annoyance for a fortnight afterwards.

_The incision_ I have described has always proved sufficient. In some cases this straight incision is unintentionally converted into an L-shaped one, when the flap is torn over a sharp low-lying spur.

Beginners may find it easier to start with an L-shaped incision, but it is unnecessary and does not leave so small and clean a wound.

The perichondrium should be raised with great care, for it is more easy than one would think to leave it adhering to the septum, while separating only the mucous membrane.

_Previous operations_ always increase the difficulties of the proceeding. The old-fas.h.i.+oned 'shaving off' of spurs often removed the entire thickness of the cartilage at one part, without perforating the concave mucosa. The submucous resection (window operation) is not infrequently not carried far enough. In either of these circ.u.mstances we are confronted with the great difficulty of trying to separate the two muco-perichondria--now closely united to one another.

OPERATION FOR PERFORATION OF THE NASAL SEPTUM

When a perforation of the nasal septum is situated at some distance within the nasal orifice it seldom gives any trouble. A perforation may also be situated close to the anterior nares without even making its presence known. But in some cases--no matter what the original cause of the perforation--constant annoyance is given to the patient by the crusting and bleeding which takes place along its margin. When these crusts have been carefully removed inspection will show that the cause of the trouble is the projecting free edge of the cartilage which prevents the edges of mucous membrane from each nostril from closing over it. When this circular edge is healed over smoothly, secretions cease to adhere to it, and the patient is not troubled by the annoying crust formation.

[Ill.u.s.tration: FIG. 311. OPERATION FOR PERFORATION OF THE SEPTUM. The muco-perichondrium is reflected for some distance round the opening so as to allow of the projecting rim of cartilage being removed. The exposed edge is then covered over by the mucous surfaces falling together.]

This desirable condition can be brought about in crusting perforations by means of the following operation designed by Goldstein.[62] After preparation with cocaine and adrenalin (see p. 573), the muco-perichondrium is reflected on each side along the whole circ.u.mference of the perforation for a distance of about a quarter of an inch from the free margin. Over the greater part of the circ.u.mference this can be done with Freer's sharp elevator, or with the small sharp elevator employed in submucous resection of the septum. In dissecting the anterior part of the circ.u.mference the same kind of elevator can be used, but with the operating edge bent forward at an acute angle (Fig.

311). A slit in the elevated mucous membrane, posterior to the perforation, will relieve tension. With a Ballenger's single-tine swivel septum knife a rim of cartilage is then cut away around the perforation, so that the two mucous surfaces from opposite nostrils can come in contact and overlap the circular edge of cartilage. This smooth surface will prevent any further sticking and crusting of discharge. It is kept _in situ_ for 48 hours by vaselined cotton-wool plugs, similar to those used in the submucous resection of the septum (p. 608).

[62] _The Laryngoscope_, xvi, 1906, p. 879.

OPERATION FOR ABSCESS

A free incision is made into it, under cocaine or nitrous oxide anaesthesia. A horizontal cut should extend right across the swelling, and as low in it as possible, to prevent the pocketing of pus. It is sufficient to make it on one side, as the pus from the other side can be pressed across through the defect in the cartilage. Any loose fragments of cartilage should be probed for and removed. The lips of the incision are kept apart by loosely tucking in a small piece of ribbon gauze. This promotes drainage of the lower part, and is changed daily. Afterwards healing takes place under simple cleansing measures.

OPERATION FOR HaeMATOMA

If the haematoma be small and not in a suppurating nose, evaporating lotions are applied externally and the swelling is left alone, being carefully inspected daily for early symptoms of suppuration. If the swelling be large and tense, it is safer to incise it freely as described above for abscess of the septum.

CHAPTER IV