Part 92 (2/2)

The lobule of the nose is then detached, so that the fleshy parts of the nose can be thrown over to the opposite side, while a triangular flap is turned downwards and outwards. With a raspatory the nasal process of the frontal bone, the nasal bone, the ascending process of the superior maxilla, and the canine fossa are next exposed. The lachrymal sac is carefully defined and retracted. A chisel is first driven through the superior maxilla, close to its junction with the malar bone, but avoiding the infra-orbital nerve, and the section is carried downwards across the canine fossa until it reaches the alveolar border (Fig. 316).

From the lower extremity of this incision--which of course enters the maxillary sinus--the bone which separates it from the pyriform fossa is broken through with stout forceps. In this way the antro-nasal wall is detached close to the floor of the nose, and can be removed together with the inferior turbinal. The nasal bone itself is next removed, together with part of the lachrymal bone and the nasal process of the frontal. Finally the middle turbinal and lateral ma.s.s of the ethmoid are removed with punch-forceps (Grunwald's or Luc's), Volkmann's sharp spoons, or a ring-knife.

[Ill.u.s.tration: FIG. 316. THE AREA OF BONE REMOVED IN LATERAL RHINOTOMY.

The flaps have been retracted, and the dotted lines show where the bones are chiselled through.]

A gouge, or Killian's eye protector (Fig. 342), is then slipped inwards and downwards at the upper part of this opening until it comes in contact with the body of the sphenoid. An a.s.sistant holds it closely parallel to the cribriform plate, where it acts as a protector. With a large sharp spoon, acting from above downwards and forwards, the ethmoidal labyrinth can be cleared away with any tumour which may have infiltrated it. The os planum, if not already destroyed, can be removed, so as to obtain access to the orbit. Direct approach is given to the sphenoidal sinus. The septum can be readily resected, but an endeavour should always be made to preserve a strip of cartilage under the bridge of the nose to prevent any external deformity (see p. 609). It is needless to say that great care must be taken while working close to the cribriform plate.

A malignant tumour can then be removed with forceps, sharp spoons, and the fingers, any prolongations being followed into the naso-pharynx, the maxillary sinus, the sphenoidal sinus, the lateral ma.s.s of the ethmoid, or even into the pterygo-maxillary fossa. Success largely depends on the care with which this curettage is carried out. It should be followed by the application of caustics or Paquelin's cautery.

[Ill.u.s.tration: FIG. 317. LATERAL RHINOTOMY. The side of the nose has been removed, and direct access obtained to the upper and deeper nasal regions.]

Bleeding is generally abundant at first. It can be controlled with tampons and the use of hydrogen peroxide. When the whole of the malignant growth has been removed, haemorrhage generally stops spontaneously. Firm packing of the wound is therefore unnecessary and is best avoided. The large cavity is filled with one long strip of 1-inch ribbon gauze, which is left projecting from the nostril, and the skin incisions are carefully brought together with silkworm-gut sutures.

Healing takes place by first intention. There may be a little flattening of the side of the nose, but there is no disfigurement, and a few months afterwards it is difficult to detect any trace of the operation. The strip of gauze is removed in 24 to 48 hours, and simple intranasal cleansing measures are then inst.i.tuted (see p. 579).

ROUGE'S OPERATION (SUBl.a.b.i.aL RHINOTOMY)

No special instruments are required for this operation. Full illumination--with a Clar's mirror or frontal search-light (see p.

571)--is particularly necessary.

In addition to the usual preparations, the mouth, teeth, and gums should be purified as much as possible beforehand.

General anaesthesia, preferably with chloroform, is required.

=Indications.= With the progress of rhinology the occasions for invading the nasal chambers otherwise than by the natural orifices have steadily diminished. Rouge's operation was formerly employed in dealing with deformities of the septum, in the treatment of ozna, in lupus of the nose, for the removal of simple mucous polypi, in operations on naso-pharyngeal fibromata, or as a simple method of exploration. In all these circ.u.mstances it is now uncalled for, as we are possessed of simpler, safer, and more effective methods.

In more modern times it has been advocated as a route of approach to the accessory cavities of the nose by some authors, but this proposition has not met with general support.

The chief indications for Rouge's operation are as follows:--

1. Very large sequestra. The majority of syphilitic sequestra can be removed through the natural orifice. In some cases they can be broken up after being mobilized and then removed through the nostrils. If still impossible of extraction Rouge's operation is indicated.

2. Osteomata are sometimes too large to be extracted through the natural orifice, and as they are much too hard to break up _in situ_, this operation is clearly indicated.

3. Malignant growths.

=Operation.= Standing behind the head of the patient, an a.s.sistant seizes the extremities of the upper lip between the forefinger and thumb of each hand, so as to turn it up against the nostrils and present its mucous surface. A small packet of loose gauze is placed at each corner of the mouth, to be handy for stanching any bleeding. An incision is then made across the gum, a little below the gingivo-l.a.b.i.al fold, from the first upper molar on one side to the other (Fig. 318). This is carried right down to the bone.

With a raspatory the soft parts can be easily and rapidly separated up, so as to bring the orifice of each nasal chamber into view. With a pair of scissors curved on the flat the cartilage of the septum is next detached from the nasal maxillary spine, or the latter can be detached with a chisel and hammer (Fig. 319). The a.s.sistant is now able to pull the everted lip with the fleshy parts of the nose further up on to the face, fully exposing the pyriform orifice of the nasal chambers, with part of the anterior wall of the superior maxilla exposed on each side.

[Ill.u.s.tration: FIG. 318. ROUGE'S OPERATION. _First stage._ The upper lip is everted and retracted by an a.s.sistant standing behind the patient's head. The dotted line indicates the line of incision.]

The conditions met with are then dealt with as required. Haemorrhage gives little trouble, and can generally be checked by pressure with strips of gauze, possibly supplemented by the use of peroxide of hydrogen. When the operation has been completed the everted lip is turned down, and falls into place, where it can be secured by a few catgut sutures.

=After-treatment.= Two pads of cotton-wool over the upper lip, to right and left of the nasal openings, will give relief and secure healing of the wound by first intention. The mouth should be kept as clean as possible, and cleansing measures to the nasal chambers will be required in proportion to the amount of destruction of its self-cleansing mucous membrane.

<script>