A System of Operative Surgery Part 86

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 anaesthetic.

If operated upon under a local anaesthetic, 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 (?i to the pint), and the horizontal position a.s.sumed.

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 s.p.a.ce, 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 pa.s.sed 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 s.p.a.ce; 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 pa.s.ses the compressed sponge up into the naso-pharyngeal s.p.a.ce.

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 a.s.sociation_, 1907.

THE PROTECTION OF THE LOWER AIR-Pa.s.sAGES FROM THE DESCENT OF BLOOD

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

When the patient is under a general anaesthetic 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 anaesthesia 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 s.p.a.ce 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 antic.i.p.ated, 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 anaesthesia should be stopped, and the patient rolled well over on to his face or inverted, until the breathing is quite un.o.bstructed. 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 gynaecological 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 anaesthetic--helps to avoid it,[49] and anaesthesia should never be too deep or prolonged. When operating under local anaesthesia 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 anaesthetic is employed, it may be safer to try and complete treatment at one operation.

[49] G. W. Crile, _Journal Amer. Med. a.s.soc._, 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-pa.s.sages, 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 vibrissae 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 a.s.sisted 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 a.s.sist 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.

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.