Part 98 (1/2)

The soft palate and uvula are carefully divided in the middle line, and a silk ligature is placed through each lateral half so that they can be held forward out of the way. This gives more direct access to the post-nasal tumour, and if then found to crowd the cavity too closely to allow of manipulation, the posterior part of the hard palate can be chiselled away in the middle line. At the conclusion of the operation the divided palate is carefully united in the middle line (see Vol. II).

=Selection of method.= In some cases operation through the mouth may have to be combined with a second operation from the front--such as the method of Moure (see p. 619) or that of Rouge (see p. 622).

Rapidity of operation is important, as, once the pedicle has been cut through, or the body of the tumour removed, the haemorrhage tends to subside spontaneously, or is quickly controlled by packing.

The hanging head (Rose) or the Trendelenburg position is generally recommended.

The preliminary laryngotomy seems desirable in all cases. The division of the palate should be avoided if possible. It may not always unite, and is less likely to do so if subsequent operations are required. The soft palate is very elastic, and in some cases it can be tied out of the way by means of a soft rubber catheter pa.s.sed along the floor of the nose, and out through the mouth.

Ligature of the external carotid, strongly recommended by Chevalier Jackson[87], is not necessary unless the patient is very anaemic or weak from former haemorrhages. It should then be only a temporary ligature (see Vol. I, p. 383).

[87] _The Laryngoscope_, xiv, 1904, p. 267.

Haemorrhage, as already remarked, is chiefly guarded against by rapid and complete operation. The preliminary use of adrenalin and cocaine, the administration of lactate of calcium, and the other methods recommended for the prevention of bleeding (see p. 574) should be carefully attended to. But in every case preparation should be made beforehand for ligature of the external carotids and for saline infusion.

OPERATION FOR RETROPHARYNGEAL ABSCESS

=Indications.= The disease is serious, and when not diagnosed almost inevitably ends in death. Before the abscess bursts death may result from spasm of the glottis, laryngeal dema, or asphyxia. The affection runs its course in 5 to 10 days, and if the abscess opens spontaneously death almost inevitably results--either from suffocation, or septic pneumonia, or cardiac failure.

=Operation.= When the diagnosis is settled intervention should be prompt. It is not necessary to wait for distinct fluctuation. The pus focus may be so difficult of manipulation in an infant, and the pharyngeal muscle may be so thick and indurated, that it is practically impossible, even in the later stages of retropharyngeal abscess, to detect the presence of pus by palpation.[88]

[88] M. A. Goldstein, ibid., xviii, January, 1908, p. 46.

_The evacuation of the abscess through the mouth_ was formerly looked upon as dangerous, owing to the difficulty of drainage, the fear of pus burrowing behind the sophagus, and the risk of flooding the larynx with pus. The more difficult plan of opening it from the neck was generally recommended. The majority of cases can be opened through the mouth with perfect safety.

No general or local anaesthetic is administered, but everything necessary for an immediate tracheotomy should be ready at hand. No gag should be employed, a tongue depressor or the operator's left forefinger being sufficient both to keep the mouth open and act as a guide. The infant is swaddled in a shawl so as to completely control the movements of the extremities and is then laid on its side on a low pillow, and held by a trustworthy a.s.sistant. The sinus-forceps used for opening a peritonsillar abscess are thrust into the most prominent part of the swelling, and the opening enlarged by separating the blades as they are withdrawn. A slender sharp-pointed bistoury, guarded and guided by the index-finger, may be used instead of the forceps. The pus will pour out through the nose and mouth. The incision of the pharynx should be free, deep and long, and directed against the posterior wall of the pharynx and as close to the median line as possible, so as to avoid any chance of wounding the internal carotid.

The surgeon may feel more security if, with the same precautions and with the patient in the same position, he first aspirates the pus cavity.

If more accustomed to it, he may also prefer to have the child flat on its back, with the head overhanging the edge of the table.

Suffocation may be so imminent when the patient is first seen that a preliminary tracheotomy is required.

_The external operation_, which leaves a certain scar, is reserved for some rare cases--as when the abscess is too low to be easily reached through the mouth, when the spasm of the ma.s.seters cannot be overcome, when a large pulsating vessel is noticed in front of the abscess, and when the abscess points towards the neck. It is also the suitable one for the chronic and generally tubercular form of abscess more commonly met with in older patients.[89]

[89] George E. Waugh, _The Lancet_, September 29, 1906.

The external operation is made through an incision along the posterior border of the sterno-mastoid muscle, and the dissection is carried behind the large vessels of the neck and in front of the prevertebral muscles.

=After-treatment.= The after-care of the patient will require consideration, since the disease is generally met with in the feeble and ill nourished.

If the abscess be opened in good time the patient is at once relieved and begins to recover rapidly.

REMOVAL OF NASO-PHARYNGEAL ADENOIDS

=Indications.= The removal of naso-pharyngeal adenoids is not called for simply because they are accidentally discovered to be present, nor does the need of operation depend solely on the size of the growths or the nasal obstruction they produce. Adenoids require removal whenever the symptoms attributable to them call for relief. These symptoms may be arranged in three groups, according as they are those (i) of nasal stenosis, (ii) of secondary septic infection, or (iii) of reflex effects.

(i) Amongst the first are mouth-breathing and all the numerous sequelae, including facial, buccal, dental, and thoracic deformities. It must not be forgotten that mouth-breathing may never be present, and yet deformities of the chest or septic or reflex results can be produced by a small amount of growth in the post-nasal s.p.a.ce.

(ii) Amongst secondary septic infections are catarrhal conditions of the Eustachian tube and ot.i.tis media, and catarrhal infection of any part of the air-pa.s.sages. Cervical glands and so-called 'glandular fever' occur in this group, as do septic gastritis and other conditions caused by the conveyance of sepsis to more distant parts.