A System of Operative Surgery Part 99

One day in bed is generally sufficient, and a child may be allowed out in two or three days, though fatigue should be avoided for a week.

Suitable after-treatment in the way of breathing exercises, gymnastics, speech correction, and tonics is often needed. Relief of nasal stenosis may require completion by attention to the condition of the turbinals and septum.

The operation in adults is performed under nitrous oxide. This can be carried out in exactly the same way as that already described, but some surgeons prefer to have the patient sitting up in a dentist's chair. In that case, after the removal of the ma.s.s of growth, the patient's head is thrown forward between his knees.

=Difficulties and dangers.= It may be said that the operation itself, carried out with usual care and in a patient who is not a haemophilic, is free from danger. The chief anxiety is from the anaesthetic, and no inconsiderable number of deaths from this cause have been reported. When possible, it is well to secure the services of an expert anaesthetist who is well used to laryngological work, and accustomed to the operator's particular methods.

_Haemorrhage_ may be brisk, even profuse, for a few minutes, but as a rule it promptly ceases if the operation be completed, the patient well rolled to one side, the air thoroughfare left clear so as to allow free breathing and avoid congestion, and the gag removed to permit swallowing and diminish pharyngeal reflexes. The more rapidly and completely the operation is executed, the less will be the bleeding. It not infrequently originates from semi-detached fragments of growth. Even when the haemorrhage is profuse it is better to push on and complete the removal of growth before attempting to check it. The value of free applications of ice-cold water cannot be exaggerated (see p. 574). In many cases bleeding is maintained by the surgeon's anxious efforts to stop it with sponging, pressure, or the application of styptics. The greatest danger arises in the case of haemophilics. If this diathesis be undoubtedly present, the operation should be avoided. If only suspected, more care than usual should be taken in preparing the patient for operation, and lactate of calcium in 15 to 30 grain doses twice a day might be given for two or three days beforehand.

When bleeding persists it is met by keeping the patient very quiet and free from alarm, in a cool and well-ventilated room, and only lightly covered with clothes. Ice is given to suck and applied on each side of the neck, while iced cloths are applied to the face and forehead. Clots are blown out of the nose so as to permit the access of fresh cold air to the post-nasal s.p.a.ce. With a pipette, or a pledget of cotton-wool, a few drops of adrenalin can be trickled into the nostril and allowed to run backward. If these measures fail--as they rarely do--the post-nasal s.p.a.ce must be plugged (see p. 575). When haemorrhage takes place after the removal of adenoids and tonsils, it will generally be found that the source of it is in the tonsillar area.

_The uvula_ may retract strongly at the moment of introducing the curette and then get crushed against the posterior pharyngeal wall: or it may be seized by mistake with the post-nasal forceps and be torn away. The same instrument has sometimes been responsible for fracturing the posterior margin of the septum, injuring the Eustachian cushion, and tearing off strips of mucosa from the pharynx. These complications are avoided by using a frontal search-light, operating deliberately, and abandoning the forceps in favour of the curette. This latter instrument can be manipulated without these risks if it be first guided safely behind the uvula and then used more like a carpenter's adze than a curette. The stroke with the caged curette should be carried through in one movement and exactly in the middle line of the body, but always on the posterior wall. There is no need to attempt removal of adenoid tissue on the lateral walls. This atrophies if the main ma.s.s is removed, and the fossa of Rosenmuller can be cleared out with the forefinger.

_Local sepsis_ rarely follows if the precautions described be observed, and local douching is avoided. Any local ftor--if not arising from the stomach--is generally traceable to some semi-detached fragment which can be removed from the posterior wall with a wire snare (Fig. 312) or a pair of forceps (Fig. 287).

_Deafness_, _earache_, and _ot.i.tis media_ will sometimes follow the operation, even when the use of a nasal douche has been carefully avoided. They are best met by warm applications, disinfection of the ear with carbolic lotion (5%), and early incision of the drum under nitrous oxide gas.

=Other methods of operation.= Removal through the nasal chambers--the route originally used by Meyer for his ring-knife--is not to be recommended.

Treatment of the growth with the galvano-cautery, introduced through the mouth, is difficult, risky, and unsatisfactory.

The use of Loewenberg's forceps, or some modification (Fig. 287), is generally abandoned by any one who has become accustomed to the Gottstein's curette. A small pair of forceps is, however, very serviceable in quite young children in whom the post-nasal s.p.a.ce may be so small as to prevent the manuvring of any form of curette.

The position with the extended head over the end of the table--Rose's position--increases the congestion and haemorrhage, and by throwing forward the cervical vertebrae makes the approach to the roof of the naso-pharynx more difficult.