CHAPTER III

OPERATIONS UPON THE NASAL SEPTUM

OPERATIONS FOR DEFORMITIES

REMOVAL OF SPURS

=Indications.= A spur or ledge, uncomplicated with deviation of the septum, occasionally requires removal. It will generally be found in the lower meatus, at the junction of the quadrilateral cartilage and ethmoid with the superior maxillary crest and vomer.

=Operation.= The operation can be carried out painlessly and bloodlessly under cocaine and adrenalin. The galvano-cautery, trephine, and spokeshave should be avoided. An incision is made from behind forwards along the summit of the projection, and the muco-perichondrium is turned upwards and downwards. (For particulars as to reflecting these flaps see p. 605.) A straight, fairly stout nasal saw (Fig. 295) is inserted below the projection, and, while the patient’s head is steadied with the left hand, the saw is carried inwards and upwards with short, swift movements. During the first of these the cutting edge should be directed obliquely towards the opposite nostril so that the saw gets a good bite into the base of the spur. Otherwise, if simply directed vertically the resistance it meets with is likely to send it obliquely outwards, and the obstruction will be imperfectly removed. This defect will be the more apparent later on, when some heaping up of scar tissue is sure to take place over any trace of projection. In other words, in order to remove a spur flush with its base it is necessary to cut deeper than the base. At the same time it is important to avoid buttonholing the septum by cutting into the opposite nostril.

When the spur lies close along the floor of the nose it may be necessary to direct the saw from above downwards. The result is not so satisfactory, and the removal may have to be completed by seizing and twisting off the semi-detached spur with a pair of polypus forceps, or stripping it forwards with a spokeshave.

=After-treatment.= The reflected flaps of muco-perichondrium are replaced and maintained in position for 48 hours with plugs of cotton-wool. Subsequently a warm alkaline nasal lotion and a little ointment may be required.

=Perforating the septum.= It will be seen that if a spur is associated with a convexity of the septum to the same side it will be very difficult to remove the projecting obstruction adequately without cutting into the concave side of the septum, and so producing a perforation. Some surgeons even recommend that this should be done intentionally, and maintain that the resulting perforation seldom gives any trouble. This may be true in some cases, and the result is sometimes fairly good. But we have more completely satisfactory methods at our disposal; the perforation method does not relieve the majority of cases, and it interferes with the subsequent performance of more perfect operation. It can therefore only be approved of when the surgeon has not acquired the technique of the submucous resection operation (see p. 603).

_Operation._ When it has been decided to produce a perforation it is carried out with the nasal saw, as described for the removal of spurs (see p. 595). The saw is introduced so as to embrace as much as possible of the projection.

_After-treatment._ The drying and scabbing of discharge along the margin of the perforation is apt to give trouble for some weeks. This inconvenience is the more marked the nearer the perforation approaches to the anterior nares. It must be met by careful and repeated cleansing and lubrication of the nasal chambers. Any scabs should be carefully softened with hydrogen peroxide, lifted off the edge of the perforation, and any underlying ulceration treated with applications of nitrate of silver, argyrol, &c.

OPERATIONS FOR SIMPLE DEVIATION

It is very rare to find a deviation of the nasal septum without some accompanying spur or ledge. It is still more rare to meet with a deviation which is entirely limited to the cartilaginous septum; there is nearly always some bony formation in the deformity, contributed by the nasal spine of the superior maxilla, the vomer, or the perpendicular plate of the ethmoid, or by all three. Hence the limited field of application for the various operations which have been designed for ‘straightening the cartilaginous septum’. In the few cases where the deformity is almost entirely cartilaginous these operations are only partially successful in overcoming its resiliency. They will therefore be only briefly considered.

=Gleason-Watson operation.= For a thorough performance this operation requires a general anæsthetic. The scheme of the operation is to make a U-shaped incision around the convexity, leaving it attached above. The flap of cartilage is then pushed through the U-shaped opening into the concave side. As its bevelled edge is larger than the button-hole in the septum it will be to some extent prevented from slipping backwards (Fig. 296). This tendency may also be combated by an attempt to snap through the base of the flap of cartilage, and by careful packing of the formerly obstructed nostril. The operation is performed with a nasal saw, carried from below upwards, and maintained carefully in the antero-posterior axis of the septum.

=Asch’s operation.= The resiliency of a deviated cartilaginous septum is more completely overcome by this method of operating. It requires a general anæsthetic.

By means of appropriate cutting scissors (Fig. 297) a crucial incision is made over the summit of the convexity of the deviation, so that we have four triangular flaps meeting at the point of greatest stenosis. By means of the finger introduced into the obstructed nostril, or suitable septal forceps, these four flaps are snapped across at their bases so as to overcome their tendency to spring back.

Into the formerly obstructed nostril is introduced a Meyer’s vulcanite hollow splint (Fig. 284), a Lake’s rubber splint (Fig. 298), or a gauze packing. This should be retained for 48 hours. Afterwards it will require daily changing and cleansing, possibly for several weeks. In the opposite nostril a lighter support will serve to keep the ends of the fragments _in situ_.

=Moure’s operation.= According to its author this operation can be carried out under local anæsthesia, but it is generally advisable to employ some such general anæsthetic as nitrous oxide or chloride of ethyl. By means of suitable scissors one incision is made through the septum parallel to the bridge of the nose and above the prominence of the deviation, and by another parallel to the floor of the nose the septum is divided below the deviation. This is now only fixed at its anterior and posterior extremities, but has been rendered more movable from side to side. By means of a specially designed dilator and splint the septum can be moulded into a good position, and maintained there until healing takes place.

The conditions in which any of these operations can prove suitable are rarely met with. In the worst forms of stenosis from septal deformity they are useless. At the best they can never completely remove it. In one of them a perforation is made on purpose, and in the others it not infrequently is produced unintentionally. The objections to a perforation have been described (see p. 598). Hæmorrhage, shock, and prolonged and painful after-treatment are important drawbacks. A dry scabby condition of the septum may be produced, and the patient may complain more of this than of his previous nasal stenosis; indeed, he may find that the stenosis is unrelieved and that a constant source of irritation has been added to it.

The perforation operation should only be employed when the patient is in circumstances where a complete submucous resection cannot be carried out. The Gleason-Watson operation is unsuitable where the deviation reaches high up. It should be avoided if it is seen that the perforation will have to be brought close forward to the anterior nares.

Another objection is that any of these operations, particularly the production of a perforation, will greatly increase the difficulties and diminish the benefits of the subsequent complementary operations which are only too often required.

Asch’s operation is easily carried out, and may be practised by those who have not mastered the technique of submucous resection (see p. 603). Moure’s operation is easily and quickly performed, and where a well-marked deviation of the anterior part of the cartilaginous septum is met with, it will give considerable relief.

OPERATION FOR COMBINED BONY AND CARTILAGINOUS DEFORMITY

_Submucous Resection (Window operation)_

This is the most perfect operation we at present possess for the cure of deformities of the nasal septum. It has largely supplanted those already outlined; it is suitable for the most extreme degree of deformity: and it will secure complete relief to the symptoms produced, whether they consist of stenosis of the air-way, obstruction to discharge, or reflex effects.

The design of the operation is to excise all obstructing cartilage and bone, with any projecting spurs or ledges, while preserving intact the mucous membrane on each side. It has been brought to its present degree of perfection chiefly by the work of Killian and Freer.[57]

[57] For bibliography and more detailed description, see StClair Thomson, _Med.-Chir. Trans._, vol. lxxxix, 1906; _Lancet_, July, 1906; and _Brit. Med. Journ._, vol. ii, 1906.

=Indications.= The special indications of this operation would appear to be:--

1. Cases where it is desirable to establish normal nasal respiration and remove mouth-breathing, with its numerous consequences.

2. Correction of the disfigurement caused by the lower end of the quadrilateral cartilage projecting into one nostril.

3. Cure of headaches or reflex neuroses of nasal origin.

4. The relief and treatment of Eustachian catarrh.

5. Facility for treating nasal polypi and affections of the accessory sinuses.

=Objections to the operation.= (_a_) That the excision of a large part of the septum may lead to flattening or deformity of the nose. This objection is groundless. A strip of septal cartilage is always left above, beneath the crest of the nose. Falling in of the bridge of the nose could only be consequent on entire removal of this ‘bowsprit’ of cartilage, or from its destruction through the wound becoming septic. No deformity has occurred in my hands in over 200 operations. On the contrary, the appearance of the nose is generally much improved.

(_b_) That the operation entails greater risks from any subsequent blows on the nose. This objection has been met by the experience of Otto Freer in four cases where severe blows, causing epistaxis and occurring even within a week of operation, did not result in any damage to the fleshy septum, nor to the external appearance of the nose.[58]

[58] _Annals of Otology, Rhinology, and Laryngology_, June, 1905.

(_c_) That the operation is long and tedious. The duration of the operation depends on the nature of the case, the skill of the surgeon, and the difficulties met with--chiefly in the way of hæmorrhage. A simple deviation of the cartilaginous septum can be removed by this method in 10 to 20 minutes. Many beginners are apt to be content with such a partial removal. More time is required in completely removing bony deformities. Many cases take 30 minutes, and none need exceed an hour when once the necessary dexterity has been acquired. More time is taken up if fresh applications of cocaine or adrenalin have to be made, if bleeding be troublesome, and if one of the flaps should be punctured.

(_d_) That the operation requires special skill. This is a real objection to the popularization of the operation. It does not seem probable that it can ever pass out of the hands of those who are kept in daily practice in rhinological technique.[59]

[59] ‘As all operators who know it will confess, the Fensterresektion of the septum belongs to the most extremely difficult intranasal operations.’ Zarniko, _Die Krankheiten der Nase_, 1905, p. 300.

(_e_) That the operation is unsuitable for children. Owing to the small size of the nasal chambers the operation presents greater technical difficulties before the age of sixteen. My own practice formerly was to await this age, and Killian used to advise that children under twelve were not fit subjects. But Freer held that the operation is proper for children at all ages, although with them the deformity tends to recur unless every vestige of it has been removed. Killian has lately adopted this view, and agrees that the operation may be performed on children even as young as four years of age.[60]

[60] _Beiträge zur Anatomie, &c. des Ohres, der Nase, und des Halses_, Hefte 1-4, 1908.

=Advantages of the operation.= These may be summarized as follows:--

1. A general anæsthetic is not inevitable.

2. Hæmorrhage gives no trouble.

3. Absence of pain and shock.

4. No reaction. The post-operative temperature seldom rises above 99° F.

5. Absence of sepsis, with its possible extension to ears, sinuses, or cranial cavity.

6. No splints are required, and no plugs after the first 48 hours.

7. Rapid healing, without crust formation.

8. No risk of troublesome adhesions.

9. Short after-treatment.

10. Speedy establishment of nasal respiration.

11. Suitability for every variety of deformity of cartilage or bone in the septum which may require treatment.

12. No ciliated epithelium is sacrificed.

13. Accuracy of result can be depended on; the prognosis is, therefore, the more definite.

14. If the external appearance of the nose be altered at all it is in the way of improvement.

It will be seen that the above advantages cancel most of the drawbacks which were formerly so annoying in nasal surgery.

=Contra-indications.= 1. Elderly people are so accustomed to their nasal obstruction, and its secondary consequences are generally so fully established, that the benefits would be much less marked than earlier in life.

2. Serious or progressive organic disease. This does not apply to quiescent or arrested tuberculosis.

3. Active syphilis.

4. Lupus.

5. The operation should be postponed if the patient shows any symptoms of influenza, or of acute or infectious catarrh.

=Operation.= Submucous resection can be completely carried out under local anæsthesia, as described on p. 572. Killian and others secure local anæsthesia by submucous injection of cocaine and adrenalin (see p. 572), but I have found this method alarming to the patient, apt to produce disagreeable palpitation, and not superior to the method of superficial application already described, particularly if sufficient time is allowed for the mixture to act, and if a few cocaine crystals are allowed to dissolve over the site of incision some minutes before starting it.

In nervous subjects it is better to administer chloroform, not so much because of any pain they suffer, but because of the mental strain they are apt to feel in watching the various manipulations.

_Position._ The operation is best done with the patient horizontal on an operating table, with the head and shoulders well raised. His nose is then almost on a level with the eye of the surgeon, who is armed with a frontal search-light or Clar’s mirror (see p. 571), although he can also operate successfully with an ordinary forehead reflector.

_The incision._ This can be made with a narrow scalpel, but a much shorter instrument mounted on a bayonet handle cutting all round the point will be found more satisfactory (Fig. 299). The incision is made from the side of the convexity, just anterior to it, and generally about half a centimetre behind the junction of the skin and mucous membrane (Fig. 300). It is started high up in the attic of the nose, and carried downwards to the floor. Sometimes it curves a little backwards below, but it is quite unnecessary to convert it into an L-incision by a second cut backwards. The incision, in its whole extent, divides the mucous membrane and cartilage at one cut, but without puncturing or wounding the mucosa of the opposite (concave) side. In doing this the operator’s forefinger in the opposite nostril serves as a useful guide (Fig. 301). In those cases where the lower free end of the quadrilateral cartilage is displaced from behind the septum cutaneum into one nostril--commonly but erroneously described as ‘dislocation of the septum’--the incision is made directly over the exposed extremity (Fig. 300, _b-a_).

_Raising the convex flap._ With a small sharp elevator the muco-perichondrium is raised along the posterior edge of the incision. Great care must be taken not to pass the raspatory between the mucous membrane and the closely adhering perichondrium. The dead white, slightly roughened surface of the bare cartilage should be distinctly visible, and should not be coated with any soft, smooth, or pinkish perichondrium. Once the flap is well started a dull-edged detacher (Fig. 302) will readily undermine it by sweeping movements gradually advancing upwards and backwards. If possible the limits of the convexity should be passed, but it is well not to attempt to go round sharp projections, as it is there that perforations are apt to take place. It is easier at a later stage to strip the flap off crests or spurs.

_Incision through the cartilage._ If the cartilage has not already been completely cut through at the first incision it is now divided in the same extent as the cut in the muco-perichondrium, great care being taken not to button-hole the mucosa of the concavity.

_Raising the concave flap._ The sharp elevator, followed by the dull-edged detacher, is introduced from the incision on the convex side. The muco-perichondrium of the concavity is now raised in the same way and with the same precautions already used on the convexity, the sharp elevator and then the dull-edged detacher being introduced through the incision in the obstructed orifice, and manœuvred between the cartilage and the concave flap without puncturing the latter (Fig. 303).

_Excision of the deviated cartilage._ A long Killian’s nasal speculum (Fig. 346), or the long Thudichum’s speculum I have had made, is now introduced through the obstructed nostril, one blade being inserted on each side of the now denuded septum (Fig. 304). It is easy to see if the mucous membrane has been sufficiently stripped off. If not, it can be carried further with a few sweeps of the raspatory. Ballenger’s swivel septum knife[61] (Fig. 305) is then placed astride the anterior cut surface of the cartilage, pushed upwards and backwards below the roof of the nose until it comes in contact with the ethmoid, then downwards and backwards to the angle between the ethmoid and the vomer, and, finally, pulled forwards along the upper margin of the vomer (Fig. 306). The excised cartilage is thus removed _en bloc_, and may measure an inch by one and a half inches.

[61] _The Laryngoscope_, vol. xv, June, 1905, No. 5, p. 417.

The empty pocket between the two separated and flaccid mucous membranes is wiped out and the two fleshy curtains are allowed to fall together. With a nasal speculum each nasal chamber is next carefully inspected to see that the thoroughfare is completely restored. As a rule deeper obstructions, formerly invisible, will come into view, and the mucosæ are again separated with a long nasal speculum and more of the septum is shaved off with Ballenger’s knife or clipped away with Grünwald’s punch-forceps, which also serve to remove portions of the vomer and of the perpendicular plate of the ethmoid.

_Excision of bony spurs and ledges._ It has been pointed out that it is extremely rare to find a deviation limited entirely to the cartilaginous septum. I have never yet met a case in which it was not desirable to remove some of the bony septum.

When the deformity of the septum is principally composed of bone the operation is started as already described. It is then easier to lay bare any thickening or deviation of the nasal process of the superior maxilla, or of the chondro-vomerine suture--the usual sites of bony obstructions. When the main mass of deviated cartilage has been cut out with Ballenger’s knife free access is obtained from above to these deformities, and the fleshy muco-perichondrium can be peeled off on each side with much less risk of a tear or puncture. Still, much care is required in working round sharp corners, and, when the spurs lie low, the flaps frequently require to be reflected right down to the floor of the nose. Once well exposed, the maxillary spine is attacked with strong punch-forceps or chisel and hammer, and as pieces of it are prised up they are twisted off with forceps. Once the obstructing maxillary spine is cleared away it is easier to deal with any vomerine deformity.

A great deal of the success of an operation depends on the complete removal of these spurs and ledges, and as they may have to be followed back nearly to the posterior choanæ this part of the operation may be the most difficult, as it is the most necessary (Figs. 307-9).

The pocket between the two flaps is again carefully wiped free of blood-clot and chips of bone and cartilage, and when the two mucous membranes are allowed to fall together they should hang perfectly plumb in the middle line and allow of an uninterrupted view through each nasal chamber, right back to the post-nasal space.

_Stitches._ With a small Trélat’s needle the incision is closed with one or two catgut stitches.

_Dressing._ Plain sterilized cotton-wool is tightly rolled into pencils about 3 inches long, and well smeared with sterilized vaseline. These are carefully packed into each nostril. The nose should not be tightly plugged, our object being to keep the two mucous membranes in apposition, but at the same time entirely occluding nasal respiration.

=After-treatment.= The patient remains quiet for the rest of the day. Ice may be given to suck and an iced cloth laid across the bridge of the nose. At the end of 48 hours the plugs are removed and will be found to come away very easily. The patient should be warned against blowing his nose, but may suck blood-stained mucus backwards and hawk it out through the mouth. Any discomfort may be soothed by spraying the nostrils with liquid vaseline, or introducing a piece of menthol and boric ointment into each nostril morning and evening.

The relief to the former state of nasal obstruction may at once be appreciable. If there be any local reaction it may take 3 or 4 days for the obstruction to subside. In 7 to 10 days the patient begins to enjoy the benefit of the operation, but it is only after 3 weeks that the full advantage of it is established.

=Complementary operations.= As a rule the formerly patent nostril is found after this operation to be the more obstructed of the two. The reason of this is readily explained by a reference to Fig. 310. The now redundant hypertrophy in the formerly good nasal chamber is removed--according to its degree and extent--by one of the methods described on p. 587.

From long disuse marked alar collapse may interfere with the good results of the operation.

=Difficulties.= _Insufficient illumination_ is a difficulty that can easily be provided against by using a frontal photophore or Clar’s mirror (see p. 571).

_Hæmorrhage_ presents no difficulty if patients are prepared as directed (see p. 574), unless one happens unexpectedly on a patient with a hæmophilic tendency. In one such case I had no trouble at the time of operation, but bleeding gave great annoyance for a fortnight afterwards.

_The incision_ I have described has always proved sufficient. In some cases this straight incision is unintentionally converted into an L-shaped one, when the flap is torn over a sharp low-lying spur. Beginners may find it easier to start with an L-shaped incision, but it is unnecessary and does not leave so small and clean a wound.

The perichondrium should be raised with great care, for it is more easy than one would think to leave it adhering to the septum, while separating only the mucous membrane.

_Previous operations_ always increase the difficulties of the proceeding. The old-fashioned ‘shaving off’ of spurs often removed the entire thickness of the cartilage at one part, without perforating the concave mucosa. The submucous resection (window operation) is not infrequently not carried far enough. In either of these circumstances we are confronted with the great difficulty of trying to separate the two muco-perichondria--now closely united to one another.

OPERATION FOR PERFORATION OF THE NASAL SEPTUM

When a perforation of the nasal septum is situated at some distance within the nasal orifice it seldom gives any trouble. A perforation may also be situated close to the anterior nares without even making its presence known. But in some cases--no matter what the original cause of the perforation--constant annoyance is given to the patient by the crusting and bleeding which takes place along its margin. When these crusts have been carefully removed inspection will show that the cause of the trouble is the projecting free edge of the cartilage which prevents the edges of mucous membrane from each nostril from closing over it. When this circular edge is healed over smoothly, secretions cease to adhere to it, and the patient is not troubled by the annoying crust formation.

This desirable condition can be brought about in crusting perforations by means of the following operation designed by Goldstein.[62] After preparation with cocaine and adrenalin (see p. 573), the muco-perichondrium is reflected on each side along the whole circumference of the perforation for a distance of about a quarter of an inch from the free margin. Over the greater part of the circumference this can be done with Freer’s sharp elevator, or with the small sharp elevator employed in submucous resection of the septum. In dissecting the anterior part of the circumference the same kind of elevator can be used, but with the operating edge bent forward at an acute angle (Fig. 311). A slit in the elevated mucous membrane, posterior to the perforation, will relieve tension. With a Ballenger’s single-tine swivel septum knife a rim of cartilage is then cut away around the perforation, so that the two mucous surfaces from opposite nostrils can come in contact and overlap the circular edge of cartilage. This smooth surface will prevent any further sticking and crusting of discharge. It is kept _in situ_ for 48 hours by vaselined cotton-wool plugs, similar to those used in the submucous resection of the septum (p. 608).

[62] _The Laryngoscope_, xvi, 1906, p. 879.

OPERATION FOR ABSCESS

A free incision is made into it, under cocaine or nitrous oxide anæsthesia. A horizontal cut should extend right across the swelling, and as low in it as possible, to prevent the pocketing of pus. It is sufficient to make it on one side, as the pus from the other side can be pressed across through the defect in the cartilage. Any loose fragments of cartilage should be probed for and removed. The lips of the incision are kept apart by loosely tucking in a small piece of ribbon gauze. This promotes drainage of the lower part, and is changed daily. Afterwards healing takes place under simple cleansing measures.

OPERATION FOR HÆMATOMA

If the hæmatoma be small and not in a suppurating nose, evaporating lotions are applied externally and the swelling is left alone, being carefully inspected daily for early symptoms of suppuration. If the swelling be large and tense, it is safer to incise it freely as described above for abscess of the septum.