Part 92 (1/2)
=Operation under cocaine.= The nose is carefully prepared with adrenalin and cocaine, the strips of moistened ribbon gauze being carefully tucked in between the septum and the ethmoidal region, as well as between this latter and the outer wall. The inferior turbinal and the front of the nasal cavity should be similarly prepared, so as to diminish vascularity, retract the healthy tissue, and thus increase the s.p.a.ce for operating in, while lessening the risk of wounding the septum and so causing adhesions. At least one hour should be given for the solution to act. The operation is done with the patient sitting upright in the ordinary examination chair, with the body craned forward somewhat, and the head supported and held in focus by an a.s.sistant. Ready to the surgeon's hand should be some lengths--about a yard--of 1-inch to 2-inch ribbon gauze, and a vessel of cold sterilized water into which it is easy to shake off the growths as they are removed with the forceps.
[Ill.u.s.tration: FIG. 313. LUC'S NASAL FORCEPS.]
If the middle turbinal has not already been removed it may have to be amputated, as described on p. 592. In many cases of ethmoidal caries it is easily removed with nasal forceps.
The instrument I recommend is Luc's forceps[64] (Fig. 313), supplemented by Grunwald's punch-forceps (Fig. 286). The former are introduced vertically, so that one blade pa.s.ses between the ethmoid and the septum and the other pa.s.ses under cover of the middle turbinal. By insinuating them carefully, and gradually working them upwards and outwards, a large ma.s.s of tissue or carious ethmoid can be grasped, twisted off, and shaken from the forceps into the vessel of water. Before any marked flow of blood has taken place it will be possible to make a second or third introduction of the forceps, and seize the successive ma.s.ses of growth which come into view. When the bleeding obscures the field of operation one of the strips of gauze can be picked up quickly in the forceps and used for plugging that side of the nose, while a similar operation is carried out in the opposite nasal chamber, if it is affected.
[64] _La Tribune Medicale_, 1905.
Haemorrhage may require the plug being left _in situ_ for a few minutes, so as to get a clear view of the depths of the nose. This is better secured if the end of the gauze strips are first soaked in either adrenalin or a 10% solution of hydrogen peroxide. In this way the main ma.s.s of the ethmoid can be completely cleared away, the posterior ethmoidal cells opened up, and the front wall of the sphenoidal sinus broken down. Not infrequently the surgeon finds afterwards that this latter cavity has been quite inadvertently, though successfully, opened.
=Operation under general anaesthesia.= Under a general anaesthetic this operation can be even more satisfactorily carried out, but the surgeon has to keep well in view the anatomical relations of the parts, and the altered relations.h.i.+p to the horizontal position compared with what he is more accustomed to with the patient sitting in the examination chair.
When chloroform is employed the interior of the nose is prepared in the same way beforehand with adrenalin and cocaine; the patient is placed horizontal on an operating table with his head and shoulders slightly raised; the post-nasal s.p.a.ce is plugged with a sponge (see p. 575); and the tongue is drawn forward with a clip (Fig. 314) so that the administration of the anaesthetic through the mouth is quite uninterrupted. This method allows the surgeon to operate deliberately, generally with the haemorrhage under easy control, the field of operation well illuminated, and no anxiety in regard to the anaesthetic.
[Ill.u.s.tration: FIG. 314. TONGUE CLIP. Keeps the tongue drawn forwards to allow of general anaesthesia, when the post-nasal s.p.a.ce is plugged.]
The removal of polypoid ethmoid can thus be completely carried out. With this method I have removed at one sitting a ma.s.s of diseased ethmoid which weighed four ounces.[65] It also permits the introduction of the operator's little finger to some distance, so as to detect polypoid or carious surfaces.
[65] _Proc. Laryn. Soc. Lond._, 1907, xiv, p. 106.
With a ring-knife any irregular spicules or projections can be smoothed down. The ring-knife--or a Volkmann's spoon--is carefully introduced behind a ma.s.s of growth, and then pulled briskly out through the nose while hugging its outer wall. The nasal roof should be diligently respected.
When the operation has been completed the post-nasal plug is removed, and it is well to pa.s.s the forefinger of the left hand well up into the posterior choanae to detect and push forwards any ma.s.ses of growth which may have been driven backwards.
Haemorrhage generally ceases with the usual remedies (see p. 576). It is better to avoid all plugs.
=Dangers and complications.= This operation in careless or inexperienced hands is not free from risks. The chief danger is from injury to the cribriform plate, as any damage in this area, occurring in the septic conditions which generally call for operation, is generally followed by fatal meningitis.
In addition to the usual precautions, particular attention should be paid while manuvring in the anterior part of the s.p.a.ce between the septum and the outer nasal wall. Here the punch-forceps are not directed backwards against the main ma.s.s of the sphenoid, but, as the head has to be extended in order to approach the anterior area, they follow an obliquely upward direction which brings them into dangerous proximity with the floor of the cranial fossa--which dips down lower in front than it does posteriorly. Great care, therefore, is taken to avoid any thrusting or boring movements with the forceps. They are first made to press outwards as much as possible the opposing walls of this narrow region, so that polypoid ma.s.ses can fall between the blades under good inspection.
Occasionally the os planum is perforated, resulting in emphysema of the eyelids or an ecchymosis like a 'black eye'. An orbital abscess may follow (Lack).
METHODS OF OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX
LATERAL RHINOTOMY, OR MOURE'S OPERATION
Direct inspection and treatment of the deeper regions of the nose, the naso-pharynx, the ethmoidal labyrinth, and the neighbouring area of the maxillary sinus, is well secured by the following operation, which has been fully described by Moure of Bordeaux.[66]
[66] Moure, _Revue hebdomadaire de Laryngologie_, October 4, 1902; Duverger, ibid., September 2, 1905.
=Indications.= This operation is particularly suitable for malignant growths originating in the upper or inner walls of the maxillary sinus, the ethmoidal labyrinth, the deeper regions of the nose, the naso-pharynx, or the sphenoid. It might be required for very vascular naso-pharyngeal fibromata with extensive prolongations. It is very suitable for necrosis--generally syphilitic--of the sphenoid when threatening the base of the brain.
For malignant growths in the regions mentioned, this route is particularly suitable, if, of course, the limitation of the growth and the absence of secondary infection justify intervention. The large s.p.a.ce formed by throwing the nose and antrum into one cavity gives a freer field than removal of the superior maxilla, without the disfigurement and tendency to recurrence so apt to be a.s.sociated with this latter operation, since it seldom includes removal of the ethmoid, which is the usual seat of origin of the disease. In Moure's operation the functions of the eye, and of the nerves and muscles of the face, are not interfered with, nor are there those difficulties with phonation and deglut.i.tion which are left by removal of the upper jaw.
The interior of the nose is prepared with adrenalin and cocaine (see p.
572), chloroform is administered, and a sponge is packed into the naso-pharynx (see p. 575).
=Operation.= An incision is made from the inner border of the eyebrow, along the side of the nose, until it enters the lower margin of the nasal orifice. A second incision, starting from the same spot above, is next carried round the lower margin of the orbit and outwards as far as the malar eminence (Fig. 315).
[Ill.u.s.tration: FIG. 315. INCISIONS FOR LATERAL RHINOTOMY (MOURE'S OPERATION).]