CHAPTER I

GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS ON THE NOSE AND NASO-PHARYNX

An intimate knowledge of the surgical anatomy of the nose is an important factor in successful treatment. It is sufficient to recall the close relations of the nasal chambers and their accessory sinuses with the cavities of the orbit and the cranium, and to remember that the shape and size of these air-spaces may vary considerably within physiological limits.

The arrangements of the vascular, lymphatic, and nervous supplies, and their connexion with neighbouring parts and the body generally, have also to be kept in mind.

In planning and carrying out operative procedures it is also well to keep in mind the important physiological functions of the nose.

Disease in the nose involves both medical and surgical treatment. The general progress of surgery, improved technique, local anæsthesia, and the control of hæmorrhage we now possess, have all tended to replace local medication by surgical measures. But in many affections of the nose--such as syphilis, or diphtheria--surgical relief is quite secondary to medical treatment. In any case the surgeon cannot dispense with a knowledge of suitable topical applications and the principles on which they are founded.

SOURCES OF ILLUMINATION

A good source of illumination is the first necessity for satisfactory operations on the upper air-passages. The natural sources at our disposal are sunlight and diffuse daylight. They have the great advantage of not altering the natural colours of the parts examined. Reflected sunlight forms a perfect illuminant, if we are careful not to bring the rays to an exact focus on the mucous membrane, as this might produce a burn.

Diffuse daylight is too feeble for the examination of the cavities of the nose and larynx, but it can be used for inspecting the mouth, pharynx, and ear. Direct daylight is particularly serviceable for examining suspicious rashes or patches in the mouth and pharynx, and eruptions on the skin.

Some form of artificial light is indispensable. That furnished by an ordinary paraffin lamp or a gas flame is sufficient for examination. The flame should have its flat side towards the observer, and be enclosed in a glass chimney, without a globe or shade. If neither of these lights be available, an ordinary candle, or, better still, three candles tied together, will suffice.

For use in the study a paraffin reading-lamp or a gas standard is equally suitable. The latter is rendered more effective by the adoption of an Argand burner or a Welsbach mantle. The oxy-hydrogen limelight is the most perfect of artificial illuminants, but it is bulky and expensive. The most convenient light is that given by a 32 or 50 candle-power electric light in a frosted globe, and with the filament waved. The Nernst electric burner gives increased brilliancy.

The electric light has the further advantage that it is unnecessary to maintain it constantly vertical. When enclosed in a bull’s-eye, the lamp can be rotated so as to direct the pencil of light-rays either upwards or downwards, as well as from side to side.

Whichever light is employed the rays can be concentrated and rendered more powerful by enclosing it in a dark chimney with a bull’s-eye condenser. The light must also be provided with some arrangement by which it can be raised and lowered (Fig. 281). For operating the Clar light is useful (Fig. 282).

In all these methods the light is reflected, but the direct rays of the electric light can be used in a small lamp fixed on the forehead, and fed from an accumulator or direct from the street current through a suitable resistance. It is better than reflected light in operations on the nose and throat, and the portable accumulator and frontal photophore (Fig. 283) are convenient for use in the patient’s own home.

The lamp should be placed on a stand or table so that the light is on a level with the patient’s ear, and 3 or 4 inches distant from it. In Continental schools it is customary to place the light on the patient’s right hand. In this country the lamp is usually placed close to the patient’s left ear, _i.e._ on the observer’s right hand. As practitioners will often be called to see patients who are confined to a bed which can only be approached from one side, it is desirable that they should accustom themselves to work equally well with the light on either side, and the frontal mirror over either eye.

LOCAL ANÆSTHESIA

=Cocaine.= It is often desirable to secure a slight degree of local anæsthesia to facilitate complete exploration of the nose. Many operations can be carried out by rendering the nasal mucosa absolutely insensitive with cocaine.

Applied in the nose cocaine is (_a_) an anæsthetic, (_b_) a powerful vaso-constrictor, and, consequently, it (_c_) produces local anæmia. Hence cocaine is of great value in nasal surgery, not only because it renders the mucous membrane insensitive, but also because it retracts the tissues and reduces the hæmorrhage.

_Methods of use._ A small area can be anæsthetized by placing a few crystals of hydrochlorate of cocaine on the required spot, where the mucus will dissolve it _in situ_. A 2 to 5% solution may be sprayed into narrow nostrils, to facilitate examination. It is a better plan to moisten pledgets of cotton-wool or ribbon gauze with a 10% solution, and place them in direct contact with the part to be operated on. The addition of a little suprarenal extract will not only facilitate examination and treatment by its hæmostatic action, but, for the same reason, will tend to prevent the cocaine being absorbed and producing its toxic effects.

For the more complete anæsthesia required for operation the following plan is advised. Equal parts of a 20% solution of cocaine and the standard 1-1,000 extract of suprarenal gland are mixed together. Short strips of 1-inch wide ribbon gauze are moistened with this solution and laid flat in close contact with the nasal area to be operated on. They are left in place for at least half an hour, and even at the end of one hour local anæsthesia will only be more marked. While the final preparations are being made for operation a fresh layer of moistened gauze may be applied. Finally, if there should still remain the slightest degree of sensation over the spot to be treated, a few cocaine crystals will render it quite numb.

_Submucous injection of cocaine._ Great caution is necessary in making intracellular injection of cocaine, as the drug is intensely toxic in this form, and, fortunately, only a small dose is required. It is a good plan never to exceed 1 centigramme (1/6 grain) of the salt. As the hæmostatic effect of suprarenal gland extract is required at the same time, the two are combined; 1/6 grain of cocaine, 2 drops of adrenalin, 1/6 grain of sodium chloride, and 1/50 grain of morphia are dissolved in 60 minims or more of sterilized water, and slowly injected below the mucosa. At least 20 minutes must elapse to secure full effects.

_Substitutes for cocaine._ For submucous injection it is better to substitute eucaine or novocaine. Eucaine can be kept in a ready and portable form in small glass ampoules in the dose of 1/6 grain with 1/2000 grain of adrenalin, and tablets are sold containing 1 centigramme (1/6 grain) of either of these drugs in combination with adrenalin and chloride of sodium. One of these tablets is dissolved in 60 minims or more of water and boiled. It is reported that as much as 1 grain of novocaine may be injected at one sitting, but I prefer to keep to the limit of 1/6 grain, and have always been able to obtain complete local anæsthesia with it.

Eucaine is much less toxic than cocaine, and novocaine is said to be still safer. They act just as well for submucous injection, but, applied to the mucous surface, the anæsthesia is not so complete, and the vaso-constrictor effect is less. Still, for susceptible subjects, either is to be preferred to the more toxic cocaine.

LOCAL ISCHÆMIA

=Adrenalin.= The delicate manipulations of intranasal surgery have been greatly facilitated by the employment of the extract of the suprarenal gland under various names--adrenalin, adrenine, adrin, perinephrin, adnephrin, epinephrin, suprarenalin, suprarenin, epirenin, paranephrin, renaglandin, hemesine, hæmostasine, vasoconstrictine, renostypticin, &c. These liquids are generally of the strength of 1 in 1,000, and can be used undiluted on mucous surfaces. But they can be diluted with normal saline solution, solutions of cocaine, or other drugs. If kept in well-stoppered, tinted glass bottles the solution can be preserved for many weeks. The solid extract is useful for those who only employ it occasionally, and in this form it is conveniently made up with cocaine, eucaine, or novocaine, so that solutions of the desired strength are prepared as required.

Applied to a mucous surface adrenalin produces a local ischæmia by contracting the blood-vessels, so that the surface becomes pale and shrunken. At least 20 minutes are required to secure this effect and it is only more marked at the end of an hour. An extensive operation, such as submucous resection of the septum, can then be performed without the loss of more than a trifling amount of blood in most cases. The vaso-constrictor action is followed by a stage of dilatation, disposing to secondary hæmorrhage, which, according to some authorities, may be ‘violent and sometimes serious’.[47] I have been fortunate in not meeting with this occurrence. Its possibility can generally be guarded against, and need never prevent the employment of the drug when indicated.

[47] C. A. Parker, _Diseases of the Nose and Throat_, London, 1906.

Adrenalin has no anæsthetic power, but its constricting action lessens the tendency of cocaine to be deeply absorbed, increases the latter’s local effect, and allows of a weaker solution being employed.

Another secondary result is the very irritating rhinitis which is sometimes induced. It passes off in 24 to 48 hours.

_Uses._ The addition of a small quantity of adrenalin to a cocaine solution mitigates the toxic action of the latter, and its use appears to check tendency to collapse, either from shock or chloroform, during serious operations on the nasal cavities. Its chief use is to check hæmorrhage and allow us to perform practically bloodless operations in the nose.

_Methods._ Adrenalin is employed as described for cocaine. Disappointment in the result obtained is nearly always due to neglect in recognizing that its full effect cannot be obtained in less than 20 to 60 minutes.

BLEEDING AND ITS CONTROL

Bleeding in the nose cannot be controlled as easily and directly as in the operations of general surgery, and there is always the risk of blood passing into the lower air-passages.

=Causation.= Hæmorrhage is apt to be not only more free, but also more serious, in young children and in patients over 60. The tendency is increased with menstruation or pregnancy, and hæmophilia is to be particularly looked for. In the nose the vascular turbinals bleed freely; a small varicose vessel on the septum is the commonest source of epistaxis,--often very copious. Many vascular growths are met with, and malignant ones are apt to bleed profusely.

Secondary hæmorrhage may occur between the third and eighth day, when clots or crusts become detached.

_The prevention of local hæmorrhage._ The patient should be prepared more carefully than usual for an operation. Hæmophilia should be inquired after, and if there is any suspicion of it lactate of calcium is administered for three days beforehand, in doses of 15 to 30 grains twice a day. If the patient be an undoubted hæmophilic, an operation should be avoided if possible. It is well to suspend the use of alcohol and tobacco for at least three days beforehand. Many risks are avoided if the operation can be carried out in the home or hospital where the patient has slept, and if he can remain there afterwards.

_The arrest of local hæmorrhage._ The preliminary use of adrenalin will diminish bleeding in many cases (see p. 573). When it does occur, unless the hæmorrhage is serious, it is well not to be too precipitate in efforts to arrest it. Such attempts, by stimulating the patient, detaching blood-clots, or exciting reflexes, may even maintain it. The clothing should be loose, the operating-room should be well aired and cool, and iced water should always be at hand. If freely sluiced over the face, behind the ears, and round the neck, cold water has such a remarkable reflex vaso-constrictor action that it alone is sufficient to arrest hæmorrhage in the majority of operations on the nose and throat. Its stimulating effect on the respiration and circulation is always agreeable to the patient, and may be very valuable when he is under a general anæsthetic.

If operated upon under a local anæsthetic, the patient’s head should be inclined forwards, so that the blood can drip from the nose. The first formed clots may be expelled, but then he should avoid sniffing, sneezing, or coughing, and sit with the head forward and the nostrils completely closed with his thumb and forefinger. Five to ten minutes in this position will arrest the bleeding in most cases of epistaxis. A slight oozing of blood may be allowed to go on for a few hours in certain cases. If the bleeding persists, ice should be applied externally and held in the mouth, the nose may be syringed with very cold or with very warm salt and water (ʒi to the pint), and the horizontal position assumed.

If this fails, a pledget of cotton-wool is dipped in peroxide of hydrogen solution (10 vols. %) and introduced into the bleeding nostril, the orifice of which is then closed by the surgeon’s thumb. This may be repeated more than once, the patient lying on his side, face downwards, and pinching both nostrils. If a galvano-cautery be available, and the bleeding comes from a limited and visible point, it can be sealed with a touch of the cautery point.

If these methods fail, plugging must be resorted to. With the nasal speculum and good illumination, the bleeding area is cleansed with cocaine and adrenalin and a strip of 1-inch ribbon gauze is carefully packed on to the spot, the end being left just within the vestibule, so that the patient can remove it for himself at the end of 12 or 24 hours. It is better to use a single strip of gauze, instead of cotton-wool, as portions of the latter might be detached and left behind. If there be fear of the gauze strip becoming adherent, it can be well smeared with plain sterilized vaseline.

If the bleeding comes from far back in the nose, or from the post-nasal space, it may become necessary to plug the latter cavity. A sterilized sponge, about the size of a Tangerine orange, is squeezed very dry and tied round its centre with a piece of tape or a stout silk ligature, leaving two free ends of about 12 inches in length. A soft rubber catheter is passed along the floor of the nose till it appears below the soft palate, when the end is seized with forceps and drawn through the mouth. To this end one of the tapes is made fast, so that when the catheter is withdrawn from the nose, the sponge is pulled up into the post-nasal space; the other end hangs out of the mouth. The two tapes are tied together over the upper lip. The anterior part of the nostril can then be packed with gauze, if necessary. If the patient be under chloroform, one tape can be dispensed with; the soft palate is simply held forward with the forefinger of one hand, while the other passes the compressed sponge up into the naso-pharyngeal space.

Plugs in the nose should be avoided. They are painful, interfere with repair, prevent drainage, and may be followed by septic troubles in the nose, accessory sinuses, middle ear, or cranial cavity. Bleeding often recurs on their removal. In any case they should not be left unchanged for more than 24 or, at the most, 48 hours. Removal is facilitated by soaking them well with peroxide of hydrogen, and detaching them slowly and gently. Ligature of the external carotid (see Vol. I, p. 384) may be necessary in extreme cases.[48]

[48] Chevalier Jackson, _Transactions American Laryngological Association_, 1907.

THE PROTECTION OF THE LOWER AIR-PASSAGES FROM THE DESCENT OF BLOOD

When operated upon under local anæsthesia the patient is able to prevent blood descending from the nose or throat into the larynx or trachea. In this he is assisted by throwing the head forwards.

When the patient is under a general anæsthetic other measures must be taken to guard against the descent of blood into the windpipe and lungs. The most important is to see that the anæsthesia is never so deep as to abolish the swallowing or coughing reflexes. Fortunately these are amongst the last to go, yet in many cases it is well to let the patient come partly round, so as to expel blood and mucus by coughing. If the frontal sinus is being operated upon, the nose is carefully packed beforehand. When the ethmoidal labyrinth is being cleared, or the sphenoidal sinus opened, a sponge may be placed in the post-nasal space as described above until the operation is completed. During the operation upon the maxillary sinus through the canine fossa, a sponge placed between the last molar teeth and the cheek on the same side, and frequently renewed, will keep any blood from entering the pharynx. In operations upon the naso-pharynx, it is a wise precaution, when much bleeding is anticipated, to perform a preliminary temporary laryngotomy and plug the pharynx with a sponge (see p. 510).

In many proceedings security is attained by rolling the patient well over to one side, so that the blood runs out of the corner of the mouth, of blood is also swallowed. This may be vomited as consciousness returns; if not, an aperient should be given within 24 hours to prevent gastro-intestinal sepsis.

The descent of blood into the trachea and lungs, if sudden and copious, may cause immediate asphyxia; or, if less abundant, it may cause septic pneumonia. When it occurs, the anæsthesia should be stopped, and the patient rolled well over on to his face or inverted, until the breathing is quite unobstructed. After all nose and throat operations it is a wise precaution for the patient to be kept on his side, the head on a low pillow, and face downwards, while the body is arranged in the gynæcological position.

SHOCK

Shock, particularly in operations on the nose, is apt to be marked in young children and in elderly persons. It is for this reason that we try to avoid the removal of adenoids in patients under 3 years of age, or of polypi in those over 60; and that in all cases we endeavour to operate as rapidly as possible.

This possibility of shock is guarded against and treated in the usual way. The use of cocaine and adrenalin--even in patients under a general anæsthetic--helps to avoid it,[49] and anæsthesia should never be too deep or prolonged. When operating under local anæsthesia it is sometimes wiser not to attempt too much at one sitting, _e.g._ to treat only one side of the nose at a time. In certain conditions, and when a general anæsthetic is employed, it may be safer to try and complete treatment at one operation.

[49] G. W. Crile, _Journal Amer. Med. Assoc._, June 17, 1905.

SEPSIS AND OTHER COMPLICATIONS

Deaths have been recorded after the simple use of the galvano-cautery, or the removal of nasal polypi, and of course are more to be feared after major operations, such as the radical cure of sinus suppurations.

Septic infection from nasal operations may spread to the accessory sinuses, meninges, ear, eye, tonsils, glands, gastro-intestinal tract, bronchi, and lungs. From the naso-pharynx, the ears and the lower food and air tracts are chiefly threatened. The orbit may be invaded in operations on the ethmoid; the external muscles of the eye may be injured in the frontal sinus operation; and optic atrophy may be due to plugging of the ophthalmic vein.

While these accidents may sometimes be directly due to operation, it is well to remember that in treating such septic conditions as are entailed by nasal suppuration, the complications may only be precipitated by traumatism and may also be purely coincident. It is not to be forgotten that latent infection--of influenza, erysipelas, measles, scarlatina, diphtheria, or other disease--may develop immediately after an operation upon the nose or throat, and until its true character is recognized the operation is often unjustly blamed. Septic infection, in these necessarily exposed wounds of the air-passages, may be traced to insanitary surroundings.

ASEPSIS

The field of operation in rhinology can never be rendered completely sterile, and in many cases is particularly septic. Wounds through the mucous membrane cannot be protected with dressings in the usual way; so that the local methods of repair require particular study.

In the nose, when there is no suppuration, it is safer to make no attempt to purify the cavity, beyond cleansing the vibrissæ and vestibules. The Schneiderian membrane will not tolerate any antiseptic lotion of such a strength as to be effective, and weaker solutions only interfere with the action of the cilia, the protective power of the mucus, and other defensive arrangements of the nose. If pus, scabs, or foreign bodies exist in the nose, it should be well washed with a simple tepid alkaline solution.

But every care should be taken to purify the surgeon’s hands, sterilize all instruments, and see that no contamination takes place during the operation. This is assisted by having the patient’s head surrounded by a carbolized towel, and his face, moustache, and beard well washed, for the surgeon’s hands and instruments come in frequent contact with these parts.

AFTER-TREATMENT

After all intranasal operations everything should be avoided which interferes with the drainage, ventilation, and natural repair of the region. Protective dressings cannot be employed, and we have in most cases to aim at healing under a blood-clot. Tags of semi-detached tissue and loose clots of blood are removed, but otherwise the parts are disturbed as little as possible. For the first two or three days the nose may be left alone, and if there be no bleeding the patient is encouraged to breathe through it. When there is much formation of thick mucus, or blood-clots or sloughs are loosening, a tepid alkaline lotion can be used. The pain of stiffness or dryness in the nose is relieved by an ointment or an oily spray.

Adhesions are apt to form between the septum and the outer wall when opposing surfaces are injured by the galvano-cautery. They may occur in narrow cavities after cutting operations. If an adhesion be seen to be threatening in the first few days, it should be broken down with a probe, and strips of gauze or plates of white celluloid introduced daily until healing takes place. If it forms later, it is wiser to wait until the fleshy bridge becomes less vascular and contracts, when it may be divided with a knife or the galvano-cautery at a white heat, and the opposing surfaces are then kept apart as described.

All post-operative conditions in the nose and throat will heal more rapidly and pleasantly if the patient be freely exposed, day and night, to abundance of fresh air; and while fatigue is generally to be avoided, the sooner the patient is out of bed and in the fresh air, the better for him. Our inability to operate under aseptic conditions should make us more careful to raise the resistance of the individual by general care, and to protect him from external dangers.

CLEANSING THE NOSE

The simplest and safest method of cleansing the nose is by blowing it,--one nostril at a time. Sometimes it is required to hawk any discharge backwards and expel it through the mouth.

Watery lotions are frequently required to assist in cleansing the nose. Strong antiseptics and astringents must be avoided. All nose lotions should be alkaline, and isotonic with the blood plasma. These requirements are met by prescribing one or more alkalis (bicarbonate of soda, borax, salt, &c.), in the strength of about 5 grains to the ounce. They may be rendered more pleasant by the addition of white sugar or glycerine. The addition of a small amount of some mild antiseptic--menthol, thymol, oil of eucalyptus, carbolic, sanitas, listerine, &c.--may give a pleasant flavour. But all antiseptics have a slight irritant action which is disagreeable if there be an intact mucosa, although they may be more helpful in certain cases of ulceration or intranasal sepsis. When the Schneiderian membrane is more or less damaged, when there are foreign bodies, sloughs, necrosis, &c., in the nasal chambers, these or similar antiseptics can be employed, though always with an alkaline basis.

All nose lotions should be employed tepid. They may be sniffed, irrigated, sprayed, or syringed into the nostrils. Crusts, scabs, and sloughs may have to be removed from the nose with forceps, after its sensitiveness has been deadened with cocaine; peroxide of hydrogen will help to detach them.

AFTER-RESULTS

Incomplete operation may be unsatisfactory in many ways. Thus, nasal obstruction may be unrelieved: foci of suppuration may be left in the accessory sinuses: portions of adenoid growth or tonsils left behind may continue to give trouble: malignant growths may not be extirpated freely enough. On the other hand, operations may fail to relieve, or even produce a worse state of affairs, if too much tissue be sacrificed. This is important as regards the nose, owing to the important respiratory and defensive function of its mucous membrane. It is a good rule to injure the inferior turbinal as little as possible, otherwise a condition of crusting rhinitis may be set up, with secondary atrophy in the pharynx and larynx.[50]

[50] W. H. Stewart, _Proc. Laryngol. Soc. Lond._, March 5, 1898, p. 57.

Much judgment is required in adapting the suitable operation to each case. While in some instances one or more small interventions are all that is required, in another a well-planned and more extensive operation may be indicated. In any case, the advice of Semon should be kept in mind, viz. that the magnitude of an operation should not exceed the gravity of the symptoms calling for relief.