CHAPTER IV

OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS: OPERATIONS FOR OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX

OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS

REMOVAL BY SNARE

=Indications.= Operation with the snare is indicated in cases of simple mucous polypi, if only a few polypi are present, and no sinus suppuration is suspected. It is a suitable method for the removal of papilloma, fibroma, and bleeding polypus of the septum. The snare is also serviceable in the removal of enchondroma, osteoma, and growths, if of limited size, after they have been detached from their bases or broken up with a chisel or bone forceps.

=Instruments.= The surgeon will employ the pattern of snare to which he is accustomed. The simpler models, such as those of Krause, or some modification of Blake’s instrument, such as that of Badgerow, when threaded with No. 5 piano wire will be found sufficient in most cases (Fig. 312). For tougher growths, or those with a thicker pedicle, the snare of Lack can be recommended. It is threaded with heavier wire, and by a screw arranged in the handle the loop can be slowly and steadily contracted.

=Operation.= The nose is carefully prepared with cocaine and adrenalin (see p. 573), remembering that any growth or polypus is itself insensitive. The anterior part of the nasal cavity, and particularly the septum, should be thoroughly anæsthetized.

Under good illumination the snare is introduced with the loop vertical, and passed alongside the growth,--between it and the septum or to the outer side, as space permits. It is then swept round a half-circle, so as to bring any tumour within the loop, and by a to-and-fro movement the snare is worked upwards towards its base. The attachment of the ordinary mucous polypus is generally in the region of the middle meatus. The wire loop is thus threaded on to the growth or polypus. The loop is now steadily tightened until it is felt that the pedicle is grasped,--it is seldom visible. By a quick movement of avulsion the tumour is then torn from its attachment. This will bring away some of the œdematous tissue on the distal side of the loop, and there will be less tendency to recurrence than if the root were simply cut across. With the removal of a first polypus others come into view and they must be treated in the same manner. The number which can be removed at one sitting will depend on how well the patient is able to bear the manipulations and how much bleeding there is. If both nostrils be affected it is well to treat them on alternate weeks.

When the growth slips, or is pushed backwards, it can be brought forward into the field of operation by asking the patient to blow down the nose, with the opposite nostril closed. Or the presenting part of a polypus may be seized with a pair of toothed catch-forceps and the wire loop slipped over this.

If the growth be hanging backwards, and presents in the post-nasal space, as it often does when it originates from the mucosa of the maxillary antrum, it may be necessary for the surgeon to introduce his left forefinger behind the palate,--as described on p. 590 (compare Fig. 291),--so as to steady the growth and at the same time slip the wire loop around it. If there be no space for the latter manipulation, the left forefinger is used to steady the mass while a pair of polypus forceps is guided along the floor of the nose until the growth can be seized between the blades so as to tear it from its attachment and pull it out through the anterior nares.

=After-treatment.= The bleeding will generally cease spontaneously, assisted by cold ablutions to the face, or pinching the end of the nose until a clot forms (see p. 575). If bleeding persists, a piece of gauze, moistened with peroxide of hydrogen, should be packed in lightly and removed as soon as the patient can lie down quietly. It is best to avoid the use of any plug. It was to plugging that Luc attributed the loss of a patient from meningitis consequent on the removal of polypus.[63]

[63] _Revue hebd. de Laryn._, 1903, xxiv, Nr. 46, November 14, p. 597.

If the entrance to the nose be tender, it may be smeared with a little menthol and boric ointment; ice-cold cloths may be kept across the bridge of the nose; and pain or sensitiveness can be relieved by a few doses of phenacetin or some similar anti-neuralgic.

Insufflations of antiseptic powder are useless, and the nasal cavity should be left alone for 24 or 48 hours. A nose lotion should then be used two or three times a day, until the local condition is again inspected at the end of a week.

Any attempt to destroy the roots of polypi by the galvano-cautery is useless and dangerous.

REMOVAL BY FORCEPS AND CURETTES

=Indications.= This operation is indicated in all cases of recurring polypi and extensive caries of the ethmoid, but the plan of operation is also suitable for the removal of some cases of papilloma, fibroma, enchondroma, or osteoma.

It can also be employed in certain cases of malignant disease in the nose. When the growth appears to be limited to the nasal fossæ, and particularly in cases of sarcoma, the above operation may be indicated. Even when glands are present this may still be the preferable operation, as glands can be removed at a separate sitting.

Possibly a better method of deciding the case of malignant intranasal disease suitable for this operation will be founded on the discovery of the original attachment of the growth. If located towards the front of the nose in the anterior part of the middle meatus, removal can be carried out on the lines described.

=Contra-indications.= If there be any mental symptoms suggesting that intracranial inflammation has taken place already, the patient should be carefully examined before operation is embarked on. It is unsuitable for debilitated and elderly subjects. In patients over 60 with recurrent polypi it is wiser to secure relief by a series of small operations under cocaine.

Many neoplasms and inflammatory hypertrophies, such as mucous polypi, can be removed satisfactorily _per vias naturales_ by the method to be described. Naturally the details will vary with the situation and extent of the disease to be removed. The following description applies particularly to growths or hypertrophies springing from the ethmoidal region:--

=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 space 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 assistant. 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.

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 Grünwald’s punch-forceps (Fig. 286). The former are introduced vertically, so that one blade passes between the ethmoid and the septum and the other passes under cover of the middle turbinal. By insinuating them carefully, and gradually working them upwards and outwards, a large mass 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 masses 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 Médicale_, 1905.

Hæmorrhage 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 mass 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 anæsthesia.= Under a general anæsthetic 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 relationship 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 space 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 anæsthetic through the mouth is quite uninterrupted. This method allows the surgeon to operate deliberately, generally with the hæmorrhage under easy control, the field of operation well illuminated, and no anxiety in regard to the anæsthetic.

The removal of polypoid ethmoid can thus be completely carried out. With this method I have removed at one sitting a mass 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 mass 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 pass the forefinger of the left hand well up into the posterior choanæ to detect and push forwards any masses of growth which may have been driven backwards.

Hæmorrhage 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 manœuvring in the anterior part of the space between the septum and the outer nasal wall. Here the punch-forceps are not directed backwards against the main mass 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 masses 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 space 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 associated 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 deglutition 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).

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 mass of the ethmoid are removed with punch-forceps (Grünwald’s or Luc’s), Volkmann’s sharp spoons, or a ring-knife.

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 assistant 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 mass 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.

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, hæmorrhage 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 instituted (see p. 579).

ROUGE’S OPERATION (SUBLABIAL 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 anæsthesia, 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 ozœna, 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 circumstances 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 assistant 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-labial 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 assistant 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.

The conditions met with are then dealt with as required. Hæmorrhage 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.

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

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

(_b_) It gives a free access to the floor of the nose and the anterior part of the nasal fossæ. 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 assured 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 space (Fig. 332). Hæmorrhage 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 infralabial 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.