CHAPTER II

OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES, AND RHINOLITHS: OPERATIONS UPON THE TURBINALS: OPERATIONS IN SYPHILIS AND LUPUS

OPERATIONS FOR INJURIES TO THE NOSE

The external injuries of the nose belong to general surgery. It might be well to recollect that the fleshy end of the nose may be completely detached, and yet, if carefully and promptly replaced, perfect union will occur.[51]

[51] J. M. Renton, _Brit. Med. Journ._, December 16, 1905.

FRACTURES OF THE NASAL BONES AND SEPTUM

=Setting a recent fracture.= One or both nasal bones may be displaced, causing a flat bridge with a sharp ridge on either side.

In the septum fracture generally takes place in the quadrilateral cartilage, or displacement occurs at its junction with the vomer or superior maxilla. It may be accompanied by a hæmatoma (see p. 612), and the occurrence of epistaxis shows that it is really a compound fracture. Care should therefore be taken not to infect the wound in the nose, and the patient should be warned on the subject.

The application of cocaine and adrenalin may allow of careful inspection of the septum. But, as the exact condition of things is marked by swelling, it is nearly always advisable to administer a general anæsthetic. Crepitus can rarely be made out. A hæmatoma is dealt with as directed (see p. 612). If there be any displacement of the septum--and it generally takes place towards the side on which there is already some convexity or depression of the nasal bones--the parts should be raised into place by manipulation with the little finger in the nostril. A flat-bladed forceps, like those of Adams, may be used. One blade in each nostril will straighten the septum and, at the same time, raise the whole nose into place. Small pencils of sterilized cotton-wool, smeared with vaseline (see p. 608), are then carefully packed up into the roof of the nose and kept there by Meyer’s vulcanite tube (Fig. 284). They are changed every 24 or 48 hours, for a week or so. The vomer is rarely fractured, although much callus is often thrown out in the displacements which occur between it and the cartilage.

Recent cases require no splints. In fact, if the displacement be promptly reduced--under general anæsthesia--the restored parts will generally maintain their position.

=Elevating an old fracture.= In neglected cases it may be necessary to re-fracture the nasal bones, and when these are replaced an external splint may be necessary. This can be made of plaster of Paris; or the outside of the nose may be covered with a piece of heavy adhesive plaster, and outside that a shield of tin, copper, or, preferably, aluminium.[52]

[52] T. A. de Blois, _Trans. Amer. Laryn. Association_, 1900, p. 12.

Fracture of the ethmoid is, fortunately, rare. When it occurs it is apt to run into the cribriform plate, and be associated with the escape of cerebro-spinal fluid and other indications of fracture of the anterior fossa of the skull.

OPERATIONS FOR CONGENITAL OCCLUSION OF THE NOSTRILS

=Operation for congenital occlusion of the anterior nares.= _If the web obstructing the nostril be thin and membranous_, and of low vitality, a simple and effective method is to destroy it with the galvano-cautery. It is best to spread the treatment over several sittings, so as to diminish the local reaction. The application of cocaine may not be sufficient to numb the pain, as the tissue of the obstructing web is more allied to skin than to mucous membrane. It should therefore be punctured quickly in two or three places, with a sharp cautery point raised nearly to a white heat. If the patient be nervous it may be well to administer nitrous oxide gas.

After the operation the nasal orifice is kept distended until healing has taken place by wearing Meyer’s vulcanite tube in it or short lengths of full-sized rubber drainage tube, well smeared with boric, aristol, zinc, or similar ointment. These simple nasal dilators are changed once or twice daily, and the nostril is well cleansed on each occasion.

_If the web obstructing the anterior naris be more fleshy in character_ (and it is more apt to be of this nature when it is incomplete), it may be necessary to remove it with a knife. So as to leave as much epithelial tissue as possible, and avoid retraction, the operation is done as follows, under local or general anæsthesia: A narrow, sharp-pointed instrument, such as a Graefe’s or other ophthalmic knife, is used to puncture the web from before backwards, and it is then made to sweep round the obstructing diaphragm, while gradually cutting its way towards the central lumen. The tongue of skin thus formed can be used as a graft to cover most of the raw surface. The restored anterior naris is kept patent, as already described, till healing takes place.

In some cases the following operation has been shown to be easy and effective: An incision is made at the junction of the web with the septum, keeping close to the latter and passing straight down to the floor of the nose. On the outer side a similar incision is made, but sloping somewhat outwards. The flap formed between these two incisions is not cut off, but is bent backwards and fastened to the floor of the nose by a single horsehair stitch.[53]

[53] G. K. Grimmer, _Proc. Royal Soc. of Med._ (_Laryngol. Section_) April, 1908.

=Operation for congenital occlusion of the posterior choanæ.= If the obstruction be not freely and completely removed it tends to re-form. A general anæsthetic is required. Unless the operator is ambidextrous he will find it most convenient to stand on the patient’s left hand, and to introduce his own left forefinger into the post-nasal space. This enables him to guide any straight, sharp instrument, such as an antrum drill (Fig. 323), Krause’s trochar (Fig. 285), or a surgical bradawl, from the front of the nose until it presses against and breaks through the obstructing diaphragm in two or more points. If preferred, an electric trephine can be used, and often pressure with the tip of a pair of nasal punch-forceps will be sufficient. The latter, either straight or tip-tilted (Fig. 286), are then inserted through the nostril, and, still guided by the left forefinger in the post-nasal space, are employed to clip away all the obstruction. To prevent any possibility of this reforming it is recommended by some surgeons that a small piece should be nipped out of the posterior margin of the bony septum. This can be done with the beaked punch-forceps of Grünwald (Fig. 286), passed through the nose, or with a pair of Loewenberg’s post-nasal forceps (Fig. 287) introduced through the mouth. In either case their action is controlled and directed by the operator’s left forefinger in the post-nasal space.

No special after-treatment is required. The patient should be ordered a tepid alkaline nose lotion, and should be encouraged to make use of the nasal air-way and acquire the habit of blowing the nose.

REMOVAL OF FOREIGN BODIES FROM THE NOSE

It might be helpful to remember that foreign bodies not only enter the nasal cavities (1) through the anterior nares, but also (2) through the posterior choanæ, or (3) by penetration through the walls. They may also arise (4) _in situ_, as in the case of sequestra and rhinoliths. The last group will be considered separately.

A foreign body, if small, may form the centre of a rhinolith.

=Operation.= Great care and gentleness are required in the removal of foreign bodies from the nose. The extraction should never be attempted blindly, or forcibly, or hurriedly. A little delay to make necessary arrangements does no harm. If a child will not submit to examination it is much better to employ a general anæsthetic so as to complete examination and, if found necessary, extraction at the one sitting. If the nose be not well illuminated and opened with a nasal speculum, groping about in the dark will only do further damage and result in disappointment.

In adults removal can generally be carried on under cocaine. The nostril is cleaned with cotton-wool, and if the extremity of the probe used for detecting the presence of a foreign body be curved to a right angle, it will also serve for gently levering or displacing it forwards. With a small pair of nasal dressing forceps (Fig. 288) it can generally be firmly seized and gently extracted, care being taken not to include any of the mucosa nor to drag the foreign body out regardless of the sinuosities of the cavity. Lister’s ear hook is a most useful instrument. Sometimes a nasal snare will help to extract the substance or to tilt or drag it into a better position.

Unless coated with solid accretions there is never any need to break up a foreign body; anything small enough to slip into the nose is small enough to be extracted entire. If it should be found impossible to remove the body through the anterior nares, it may be pushed backwards into the post-nasal space, where the forefinger of the left hand is in readiness to prevent its falling into the gullet or larynx.

The usual warm alkaline lotion may be used to clear the nose, but liquid should never be forcibly injected into the nostril with the idea of thus expelling the foreign body. If the lotion be sent up the nasal chamber on the same side it will only drive the intruding substance further in; if injected on the opposite side there is risk of otitis media.

In the case of small children it is sometimes recommended that a piece of muslin should be placed over the mouth, and that the practitioner should then apply his lips to those of the patient and by blowing forcibly through the mouth drive out the foreign body by the blast of air from the post-nasal space. Or the same principle may be applied by insufflating the air from a Politzer’s bag through the opposite nostril. Both plans are alarming and seldom effective.

The _after-treatment_ consists of some simple cleansing lotion and soothing ointment.

REMOVAL OF RHINOLITHS (NASAL CALCULI, OR CONCRETIONS IN THE NOSE)

These concretions are almost unknown in children, in whom foreign bodies are met with most frequently. A general anæsthetic is, therefore, not so often required, otherwise the remarks on the removal of foreign bodies will be found to apply to the extraction of calculi. With the help of cocaine and good illumination they can easily be removed with a strabismus hook, Lister’s ear hook, or a pair of fine probe-pointed nasal forceps with serrated extremities. In some cases where the calculus has sent prolongations into the recesses of the meatus, it might first be necessary to crush it. In that event a general anæsthetic may be required.

The _after-treatment_ consists in simple cleansing measures. Subsequent syringing of the nose should be done from the opposite side.

OPERATIONS UPON THE TURBINALS

=Indications.= In many cases of hypertrophic rhinitis it is necessary to remove portions of redundant turbinal tissue. It is never desirable--and it can only rarely be necessary--to remove the whole of the inferior turbinal. ‘Turbinotomy,’ or amputation of the whole inferior turbinal, was recognized as an operation some years ago. But it was never generally accepted, as it was always realized that the highly important physiological functions of the lower spongy bone could not be spared. Improved technique, particularly in being able to correct deformities of the septum without the sacrifice of any mucous membrane (see p. 603), now enables us to rectify nasal stenosis with the sacrifice of much less turbinal tissue.

The middle turbinal is not of so much importance in the physiology of the nose, and the whole of this body is not infrequently removed. This may be done not only because it is diseased, but even a healthy middle turbinal may require amputation in order to approach the accessory sinuses or diseases in the deeper regions of the nose. Part of the healthy inferior turbinal may also require removal--as in the radical operation on the maxillary sinus.

As these operations will be referred to frequently later on, and as their performance enters into different groups of operation, they will be described first.

OPERATIONS UPON THE INFERIOR TURBINAL

=Amputation of the anterior end. Indications.= The amputation may be required:

(i) On account of polypoid degeneration of the anterior extremity of the turbinal.

(ii) To allow of access to the antro-nasal wall (see p. 633).

(iii) To avoid operation on the septum by relieving nasal stenosis.

=Operation.= The local application of cocaine and adrenalin (see p. 573) is sufficient.

=Anæsthesia.= With the patient sitting upright in a chair, and the nostril well illuminated, a pair of nasal scissors (such as Heymann’s, Walsham’s, or Beckmann’s) are made to grasp as much of the anterior extremity as it is desired to remove, generally the anterior third (Fig. 289). The scissors are pressed very firmly against the outer nasal wall, so as to divide the base of the turbinal as close as possible to its attachment. If the scissors slip off the bone it should be divided with Grünwald’s punch-forceps. The semi-detached extremity is then surrounded with a nasal snare, carrying a No. 5 piano wire, and cut through (Fig. 291).

It is well not to seize and twist off the anterior extremity, as this might lead to the ripping out of a larger portion than was intended. Besides, it might cause fracture of the base of the remaining piece of the inferior turbinal bone and this might become displaced inwards so as to block the air-way more than ever.

=After-treatment.= It is well to check the hæmorrhage without the use of plugging. Some antiseptic powder--europhen, xeroform, formidine, aristol, &c.--if lightly insufflated over the wounded area, will assist in the formation of a protective scab. This should not be disturbed for some days, during which the nose is made comfortable by some menthol and boric ointment, or a paroleine spray. When the scab begins to break down its removal is assisted by warm alkaline lotions (see p. 579). The stump may require a few applications of nitrate of silver or other silver salt. There is no danger in this operation. Healing, as in other intranasal operations, takes from three to six weeks.

=Amputation of the lower margin.= =Indications.= This is not infrequently necessary when there is a general hypertrophy--as in the compensatory hypertrophy of septal scoliosis (Fig. 310)--or when the whole lower and outer margin is occupied by papillary hypertrophies (Fig. 289).

=Operation.= The operation can be carried out under the local application of cocaine and adrenalin, but is frequently performed as part of some other operation under a general anæsthesia.

The steps have to be varied according to the degree and extent of the hypertrophic tissue requiring removal. When this is principally along the lower border of the turbinal it can be removed with one cut of a stout pair of nasal scissors (Fig. 290). Under good illumination a blade is insinuated along the concavity, while the other passes between the convexity and the septum. Care should be taken that the direction of the scissors is parallel to the axis of the turbinal body, and that the cut embraces only that portion of the lower area to be removed. The severed portion should be quickly seized with a pair of punch-forceps and lifted out, or the patient, if only under local anæsthesia, may be requested to blow it forward into a tray. Otherwise it is apt to become obscured in the outpouring of blood, and, if the patient is unconscious, to be sucked backwards out of sight. If, as not infrequently happens, the lower margin remains attached at its posterior extremity, a wire snare is threaded along over it so as to cut this through. When the papillary hypertrophy is more diffuse it is apt to be concealed in the concavity of the turbinal. From this hiding-place it can be partially dislodged with a probe and then cut off with a snare.

The after-treatment is similar to that for removal of the anterior end.

=Removal of the posterior end.= =Indications.= The posterior extremity of the inferior turbinal is very subject to a moriform hypertrophy, and some delicacy and skill are required in removing it.

=Operation.= The interior of the nose on the affected side should be treated with a weak solution of cocaine and adrenalin. The most disagreeable part of the operation is the introduction of the operator’s finger into the post-nasal space. Hence the fauces should be freely sprayed with a 5% solution of cocaine. This will deaden painful sensation, but it will not prevent the discomfort nor the nausea often induced.

It is well to avoid as much as possible the direct application of cocaine or adrenalin to the moriform hypertrophy itself, for it is an extremely vascular growth, and if much contracted it is more difficult to ensnare.

The operation may also be carried out under a general anæsthetic, when one is given for other surgical measures in the nose. In that case it is best to defer the removal of the moriform hypertrophy until the end--practically until the patient is commencing to recover consciousness--on account of the sharp hæmorrhage which is apt to accompany it.

The chief difficulty of the operation lies in the fact that the part to be operated on cannot be kept in view, either directly or indirectly, and that therefore success depends a good deal on delicacy of touch.

A nasal snare--such as that of Blake, Krause, or Badgerow--is threaded with No. 5 piano wire, and a loop left out a little larger than sufficient to grasp the growth. This loop is then bent over smartly towards the side to be operated on, and a slight kink is given to it. The loop is then slightly withdrawn within the barrel, and this again brings it into a straight line. If now the snare be passed along the floor of the nose until the end of it is opposite the posterior extremity of the turbinal, and if the looped wire be slightly projected from the barrel, the loop will tend to curve outwards to the side on which it was kinked. In this way it will be felt to surround the moriform growth, which can then be cut off.

It must be confessed that this is not always successful, that there is no means of making sure that the snare is applied to the root of the growth, and that once the bleeding is started posterior rhinoscopy fails to reveal if any of it still remains. It is better therefore to introduce the purified forefinger of the left hand into the post-nasal space, so as to define the growth and guide the loop of the snare over it. The nail of the same finger then keeps the wire close to the base of the hypertrophy, while the loop is drawn home (Fig. 291). The patient may then be relieved of the discomfort of the operator’s finger in his throat, and may be given time to clear away the collected mucus. A little delay is advantageous, as it allows coagulation to take place in the large veins of the moriform growth. Some surgeons recommend that once the growth is strangled the snare should be left _in situ_ for 10 or more minutes. This is irksome and unnecessary, and bleeding is seldom excessive if the snare be not employed for cutting off the hypertrophy, but is used as follows: Once the loop is drawn firmly home so as to embrace the growth tightly, a few minutes’ rest is given. Then, steadying the patient’s head with the now disengaged left hand, the snare is plucked from the nose with a quick movement. This brings away the mulberry hypertrophy in its grasp, and frequently a strip of mucosa from the lower margin of the turbinal. No bone is removed in this operation. The bleeding may be very sharp at first, but generally ceases under the usual measures (see p. 574). Occasionally it is extremely troublesome, and as the bleeding surface overhangs the post-nasal space the only local pressure which is available is that of a post-nasal plug.

=After-treatment.= As secondary hæmorrhage is apt to be met with the patient should be advised to leave his nose alone, neither blowing nor clearing it, nor using any cleansing measures for 48 hours. After that time he can employ the usual warm alkaline nose lotion. He should be warned against the habit of hawking backwards, as this would tend to a recurrence of the hypertrophy.

=Prognosis.= Great relief can generally be promised within a few days. There is no danger in the operation. The hæmorrhage may be troublesome, especially in men. The precautions described in the previous chapter are well worth observing (see p. 574).

=Complete turbinotomy.= =Indications.= As already remarked it must be extremely rare for this operation to be required. Papillary hypertrophy chiefly attacks the lower and posterior parts of the turbinal, and these can be removed as described above, so that if the entrance of the nostril is made free by anterior turbinectomy, there will still be left a sufficient area of functionally active mucosa. If, however, almost the entire inferior turbinal be degenerated, or if it be replaced by malignant growth, it can be removed in the following way.

=Operation.= Anæsthesia may be local or general. If no other operative procedure be required at the same time, the anæsthesia of nitrous oxide gas or chloride of ethyl will be long enough. Owing to the vascularity of the part adrenalin should be applied for at least 30 minutes beforehand.

Removal of the turbinal is easily and quickly carried out with Carmalt Jones’s or Moure’s spokeshave (Fig. 292). This is introduced, passed as far as the posterior extremity of the turbinal, and the edge is guided in place with the operator’s left forefinger in the post-nasal space. With a sharp pull the spokeshave is then drawn forwards and the detached body can be lifted out with a pair of punch-forceps. Owing to the slope of the attached border it is seldom that the whole of the turbinal is removed. Those who are skilled in the use of this instrument can manipulate it so as to leave a good part of the attached margin of the turbinal, and the spokeshave can be used instead of the scissors for removal of the inferior margin. But its action is apt to be uncertain, and as it may unexpectedly rip out more than was intended, it is seldom employed nowadays.

=After-treatment.= After the removal of such a large portion of secreting surface the nasal secretion may dry into adhering crusts and scabs for some weeks--possibly for six or even eight. The scabs should be softened by the use of ointment or oily sprays, and removed by the fere use of warm alkaline lotions. The even healing of the granulating surface requires watching; its progress should be inspected from time to time, as the surface may require touching with a weak nitrate of silver solution.

OPERATIONS UPON THE MIDDLE TURBINAL

=Indications.= Amputation of the anterior end may be required for (1) simple hypertrophy, (2) cyst or empyema in the anterior extremity, (3) to gain access to the ostia of the various accessory sinuses, (4) as a first step to uncover the ethmoidal cells, and (5) as a first step in removal of ethmoidal polypi.

=Operation.= Local anæsthesia with cocaine and adrenalin is sufficient, and the operation can be carried out with the patient sitting in the examination chair. It frequently forms part of some other intranasal operation which is performed under a general anæsthetic, but the preliminary application of cocaine and adrenalin should still be carried out (see p. 572). If the pieces of gauze soaked in the cocaine-adrenalin mixture be carefully tucked up on each side of the head of the turbinal, the part to be removed is generally well exposed. With a pair of Grünwald’s punch-forceps (Fig. 286) or Panzer’s scissors (Fig. 290), the anterior attachment to the outer wall is cut through (Fig. 293) so as to free the end, around which a cold wire snare can be passed and the extremity removed (Fig. 294.) In cases where it is difficult to introduce the punch-forceps under the attachment of the middle turbinal the blades may be applied to the lower margin, about half an inch from the anterior extremity so as to bite out a wedge. Into this the loop of the wire snare is inserted and the head of the turbinal can easily be snared off.

The snare is generally recommended as being safer than the punch-forceps. There is certainly a risk attending any slip in manipulating the latter in this region, more so, indeed, than in the deeper ethmoidal regions, for in the anterior part of the nasal roof the cerebral floor dips down lower than it does posteriorly, and the nasal fossa in the anterior part of the middle meatus is very narrow, so that if the forceps slipped they might impinge on the cribriform plate.

But when the middle turbinal is softened and broken down by disease it is as safe, and it is certainly more convenient, to take out a wedge from its centre, as directed above, and then with a pair of Grünwald’s or Luc’s forceps to twist out not only the anterior extremity, but also the posterior half. The latter part can also be removed with a spokeshave, as directed for the inferior turbinal (see p. 591).

=After-treatment.= There is not the same tendency to crusting as occurs after operation on the inferior turbinal. Hæmorrhage is also less troublesome. Plugging is therefore the less likely to be required, and should always be avoided if possible, since it would interfere with drainage from the various accessory sinuses, and this operation is frequently required when their contents are particularly septic. The best plan is to leave the nose severely alone for 48 hours, and then to clear it gradually with the help of warm alkaline lotions.

OPERATIONS FOR THE RESULTS OF SYPHILIS

=Sequestrotomy.= The discovery of a syphilitic sequestrum always calls for active treatment.

=Operation.= If the sequestrum be not loose we must wait until it is movable. Its detachment will be expedited by mercurial inunctions or injections, and suitable local cleansing and disinfecting measures. As soon as any movement can be detected in the dead mass we can proceed, under cocaine, to detach it. Various forms of polypus forceps and bone-pliers may be required, and the necrosed bone has to be raised from its bed by a variety of lever and to-and-fro movements. Several sittings may be necessary, but this is inevitable, as any violent measures are soon arrested by hæmorrhage. When the necrosed bone has been mobilized it may be too large for extraction through the nares; such a mass as the greater part of the body of the sphenoid has sometimes necrosed _en bloc_. In such cases the dead bone must be broken up _in situ_ and then removed piecemeal through either the anterior or posterior nares. Very rarely Rouge’s operation may be required (see p. 622).

=Operations for post-syphilitic adhesions of the velum.= So long as there is an adequate passage for nasal respiration it is best to leave any slight degree of stenosis alone. When there is complete atresia, and when mouth-breathing, deafness, or other consequences develop, some effort at relief should be made.

=Operation.= Under chloroform, and with the hanging head, W. G. Spencer[54] separates the soft palate from its adhesion to the posterior pharyngeal wall, draws it forwards, and fixes it by two silk sutures to the muco-periosteum of the hard palate. Tilley carries out the same principle by threading the soft palate on both sides with strong silver wire and anchoring it to the incisor teeth. The wires cut out in 10 to 14 days, but by this time considerable healing will have taken place over the raw surfaces from which the adhesions had been separated.[55]

[54] _Proc. Laryngol. Soc., London_, vol. v, November, 1897, p. 4.

[55] Ibid., vol. x, March 6, 1903, p. 81.

After freeing the soft palate, H. B. Robinson prevents it from again uniting by the following method: ‘A piece of lead plate is cut the full breadth of the naso-pharynx and bent so that one arm rests on the dorsal surface of the soft palate, and the lower one on the buccal surface, the cut margin being received between the plates and apposed to the bend, and so kept away from the pharyngeal wall.’ The piece of lead is kept in place by silk threads attached to the four corners, two passing forward through the nostrils and two through the mouth. The lead plate is not removed for a fortnight.[56]

[56] Ibid., vol. xiv, June, 1907, p. 106.

Whatever method is employed to enlarge the stricture, dilatation must be kept up for some time by the frequent passage of the forefinger, a palate hook, or a dilatable bag.

=Results.= Stenosis of the passage from the naso-pharynx to the meso-pharynx, caused by syphilitic adhesions between the soft palate and the posterior pharyngeal wall, is one of the most difficult affections in this neighbourhood to operate on with satisfactory results. The cause of disappointment lies in the low vitality of specific scars and their well-known tendency to contract.

Surgical measures are sometimes required for the damage left by syphilis during the healing process.

The saddle-back deformity of the external nose is best corrected by subcutaneous injection of paraffin (see Vol. I, p. 681).

Perforations in the hard or soft palate may require operation to close them (see Vol. I, p. 717).

OPERATIONS FOR TUBERCULOSIS

Tuberculosis only occurs in the nose in the mitigated form of lupus. Surgical interference is frequently called for, generally in the form of curettage or the application of caustics.

The most satisfactory caustic is the galvano-caustic point, applied under cocaine, and at repeated sittings.

Curettage is required in more advanced cases. Chloroform is always required. Not only should all soft and diseased tissue be scraped away with a Volkmann’s spoon, but the curettage should be carried on vigorously until a healthy and resistant area has been reached. It is rare for too much tissue to be removed, whereas recurrences are only too frequent.