Part 93 (1/2)

=Advantages.= This operation has several advantages:--

(_a_) It is not difficult of execution, and can be carried out with a scalpel and a raspatory.

[Ill.u.s.tration: FIG. 319. ROUGE'S OPERATION. _Second stage._ The soft parts are retracted.]

(_b_) It gives a free access to the floor of the nose and the anterior part of the nasal fossae. The vestibule, the natural orifice of the nose, only measures 20 millimetres by 7 to 8 millimetres. Rouge's operation exposes an orifice measuring 3-1/2 centimetres by 2 centimetres. The posterior margin of the septum, instead of being 8 centimetres distant from the outside, is now brought within a reach of 5 centimetres. The floor of the nose lies on a lower level than that of the vestibular entrance, and is wider some distance in than it is at the orifice. By means of this operation the whole floor comes into clear view, and the exit from the nasal chambers becomes the widest part of the nose.

(_c_) The bones of the face are not interfered with, and the amount of traumatism is slight.

(_d_) Bleeding, which is so apt to be troublesome in operations through the skin of the face, is less and is easily controlled.

(_e_) The patient can be a.s.sured that there will not only be no disfigurement, but not even the slightest scar on the face.

(_f_) The operation can be repeated without any disfiguring scars. In operations upon the nose through the face the cicatrix becomes more marked with each intervention.

COMBINATION OF MOURE'S AND ROUGE'S OPERATIONS

The two methods above described can be combined if necessary. This would be called for particularly in growths so large that they could not be attacked through the narrow vestibule of the nose, and for those in which the attachment is evidently in the ethmoidal region. This combination might be called for in any large innocent or malignant growth.

EXTENSION OF ROUGE'S OPERATION TO ALLOW OF ACCESS TO THE MAXILLARY ANTRUM

When the growth involves both the nasal cavity and the maxillary sinus Rouge's operation can be extended so as to form part of the Caldwell-Luc operation (see p. 631).

The latter operation is modified as suggested by Denker (Fig. 332), _i.e._ the opening through the canine fossa is extended forwards until the nasal cavity is opened through the pyriform opening. This will give free access to the large cavity formed by throwing the antrum and the nasal chamber on the same side into one easily inspected s.p.a.ce (Fig.

332). Haemorrhage gives no cause for anxiety, there is no disfigurement, the original root of the implantation can be eradicated, and, if necessary, the operation can be repeated without difficulty. If the growth extends upwards and inwards to the ethmoidal region this infral.a.b.i.al opening can be combined with Moure's operation.

=Indications.= This operation is suitable for any form of growth invading both the antrum and nasal cavities, and is therefore generally called for in malignant growths.

OTHER METHODS

The other methods for obtaining access to the nasal cavity through the face--described as the methods of Hippocrates, Syme, Dupuytren, Langenbeck, Lawrence, Ollier, &c.--are now only of historical interest.

They all leave a scar on the face; bleeding is troublesome; they do not give a greatly enlarged field; and most of them do not bring the seat of disease any closer. With the advances made by rhinology the necessity for intervention through the face has become more infrequent.

CHAPTER V

OPERATIONS UPON THE ACCESSORY NASAL SINUSES

OPERATIONS UPON THE MAXILLARY SINUS

CATHETERIZING THE MAXILLARY SINUS

It is rarely possible to enter the antrum through its natural ostium.

The attempt may be made after the local use of cocaine and adrenalin (Fig. 320).

[Ill.u.s.tration: FIG. 320. CATHETERIZING THE MAXILLARY SINUS.]