Chapter 98
The soft palate and uvula are carefully divided in the middle line, and a silk ligature is placed through each lateral half so that they can be held forward out of the way. This gives more direct access to the post-nasal tumour, and if then found to crowd the cavity too closely to allow of manipulation, the posterior part of the hard palate can be chiselled away in the middle line. At the conclusion of the operation the divided palate is carefully united in the middle line (see Vol. II).
=Selection of method.= In some cases operation through the mouth may have to be combined with a second operation from the front--such as the method of Moure (see p. 619) or that of Rouge (see p. 622).
Rapidity of operation is important, as, once the pedicle has been cut through, or the body of the tumour removed, the haemorrhage tends to subside spontaneously, or is quickly controlled by packing.
The hanging head (Rose) or the Trendelenburg position is generally recommended.
The preliminary laryngotomy seems desirable in all cases. The division of the palate should be avoided if possible. It may not always unite, and is less likely to do so if subsequent operations are required. The soft palate is very elastic, and in some cases it can be tied out of the way by means of a soft rubber catheter pa.s.sed along the floor of the nose, and out through the mouth.
Ligature of the external carotid, strongly recommended by Chevalier Jackson[87], is not necessary unless the patient is very anaemic or weak from former haemorrhages. It should then be only a temporary ligature (see Vol. I, p. 383).
[87] _The Laryngoscope_, xiv, 1904, p. 267.
Haemorrhage, as already remarked, is chiefly guarded against by rapid and complete operation. The preliminary use of adrenalin and cocaine, the administration of lactate of calcium, and the other methods recommended for the prevention of bleeding (see p. 574) should be carefully attended to. But in every case preparation should be made beforehand for ligature of the external carotids and for saline infusion.
OPERATION FOR RETROPHARYNGEAL ABSCESS
=Indications.= The disease is serious, and when not diagnosed almost inevitably ends in death. Before the abscess bursts death may result from spasm of the glottis, laryngeal dema, or asphyxia. The affection runs its course in 5 to 10 days, and if the abscess opens spontaneously death almost inevitably results--either from suffocation, or septic pneumonia, or cardiac failure.
=Operation.= When the diagnosis is settled intervention should be prompt. It is not necessary to wait for distinct fluctuation. The pus focus may be so difficult of manipulation in an infant, and the pharyngeal muscle may be so thick and indurated, that it is practically impossible, even in the later stages of retropharyngeal abscess, to detect the presence of pus by palpation.[88]
[88] M. A. Goldstein, ibid., xviii, January, 1908, p. 46.
_The evacuation of the abscess through the mouth_ was formerly looked upon as dangerous, owing to the difficulty of drainage, the fear of pus burrowing behind the sophagus, and the risk of flooding the larynx with pus. The more difficult plan of opening it from the neck was generally recommended. The majority of cases can be opened through the mouth with perfect safety.
No general or local anaesthetic is administered, but everything necessary for an immediate tracheotomy should be ready at hand. No gag should be employed, a tongue depressor or the operator's left forefinger being sufficient both to keep the mouth open and act as a guide. The infant is swaddled in a shawl so as to completely control the movements of the extremities and is then laid on its side on a low pillow, and held by a trustworthy a.s.sistant. The sinus-forceps used for opening a peritonsillar abscess are thrust into the most prominent part of the swelling, and the opening enlarged by separating the blades as they are withdrawn. A slender sharp-pointed bistoury, guarded and guided by the index-finger, may be used instead of the forceps. The pus will pour out through the nose and mouth. The incision of the pharynx should be free, deep and long, and directed against the posterior wall of the pharynx and as close to the median line as possible, so as to avoid any chance of wounding the internal carotid.
The surgeon may feel more security if, with the same precautions and with the patient in the same position, he first aspirates the pus cavity.
If more accustomed to it, he may also prefer to have the child flat on its back, with the head overhanging the edge of the table.
Suffocation may be so imminent when the patient is first seen that a preliminary tracheotomy is required.
_The external operation_, which leaves a certain scar, is reserved for some rare cases--as when the abscess is too low to be easily reached through the mouth, when the spasm of the ma.s.seters cannot be overcome, when a large pulsating vessel is noticed in front of the abscess, and when the abscess points towards the neck. It is also the suitable one for the chronic and generally tubercular form of abscess more commonly met with in older patients.[89]
[89] George E. Waugh, _The Lancet_, September 29, 1906.
The external
=After-treatment.= The after-care of the patient will require consideration, since the disease is generally met with in the feeble and ill nourished.
If the abscess be opened in good time the patient is at once relieved and begins to recover rapidly.
REMOVAL OF NASO-PHARYNGEAL ADENOIDS
=Indications.= The removal of naso-pharyngeal adenoids is not called for simply because they are accidentally discovered to be present, nor does the need of operation depend solely on the size of the growths or the nasal obstruction they produce. Adenoids require removal whenever the symptoms attributable to them call for relief. These symptoms may be arranged in three groups, according as they are those (i) of nasal stenosis, (ii) of secondary septic infection, or (iii) of reflex effects.
(i) Amongst the first are mouth-breathing and all the numerous sequelae, including facial, buccal, dental, and thoracic deformities. It must not be forgotten that mouth-breathing may never be present, and yet deformities of the chest or septic or reflex results can be produced by a small amount of growth in the post-nasal s.p.a.ce.
(ii) Amongst secondary septic infections are catarrhal conditions of the Eustachian tube and ot.i.tis media, and catarrhal infection of any part of the air-pa.s.sages. Cervical glands and so-called 'glandular fever' occur in this group, as do septic gastritis and other conditions caused by the conveyance of sepsis to more distant parts.
(iii) Various reflex effects are sometimes attributable to naso-pharyngeal adenoids. Laryngismus stridulus, reflex cough, ch.o.r.ea, convulsions, night-terrors, enuresis nocturna, and apros.e.xia are some of the ailments which may justify operation on Luschka's tonsil.
As it is chiefly in children that this operation is required it is important to see that they are free from indication of infectious fevers. The operation should be postponed until any acute catarrh has subsided. If there be otorrha the ears should receive suitable cleansing treatment for a week or two beforehand. The condition of the teeth requires attention.
The operation is so frequently carried out in private houses that it is well to make inquiries into the health of the members of the household, recent illness, and sanitation. When possible, a large, airy room with a south aspect should be chosen.
=Operation.= In adults it is possible to carry out the operation under cocaine. On the Continent, particularly in hospital practice, it is often done without any anaesthetic at all. In this country general anaesthesia is almost the universal custom. Opinion is divided as to which is the safest and most suitable anaesthetic to employ.
When the removal of tonsils or other operation is not carried out at the same time, an anaesthesia of less than a minute is sufficient. In adults, and in children over 10 years of age, nitrous oxide does excellently.
Younger children are apt to be alarmed by the face-piece and apparatus necessary for nitrous oxide, and this gas does not seem so suitable for them as for adults. In younger children chloride of ethyl is extensively employed on the Continent, but has not met with general favour here.
When the tonsils require removal, or any other operation on the upper air-pa.s.sages is carried out at the same time, and in young children generally, an anaesthesia allowing of more deliberation is desirable.
For this, some operators employ ether,--preceded or not by nitrous oxide. But the well-known objections to pure ether in the surgery of the air-pa.s.sages have caused the preference to be given to chloroform, or to one of the mixtures of chloroform and ether.
The patient should lie quite flat on the operating table, with only a low pillow or folded towel under the head. The anaesthetist, who takes charge of the gag and flexes or rotates the head as directed, stands at the end of the table. At the patient's right hand stands the surgeon, and within easy reach are his instruments, sponges, and iced water.
Standing on the same side and behind him is the nurse. Her duty is to soothe the patient while pa.s.sing into unconsciousness, and later on to roll him well over on to his right side as the operation finishes.
The operation can be carried out more correctly, rapidly, safely, and comfortably if the surgeon be armed with an electric forehead search-light (see p. 571). Failing this, the table should be brought close up and parallel to a window, with the patient's right hand next the light.
Surgeons differ as to the degree of anaesthesia desirable. Some like it to be quite light, so that the patient is all the time in the struggling stage and requires his hands to be controlled by the nurse. I think this is quite as dangerous as when the anaesthesia is pushed until the patient is relaxed, with the corneal reflex just abolished, and the swallowing and coughing reflexes still present.
When the anaesthetic is administered steadily, with plenty of air, a degree of unconsciousness is generally secured which will allow of an operation lasting two or three minutes without any further adminis[t]ration. Should the patient show signs of recovering consciousness more chloroform can be given from a Junker's apparatus.
The anaesthetist then opens the mouth with a suitable gag, such as Doyen's or Mason's, and maintains the patient's head exactly in the middle line of the body. Directing the electric search-light into the pharynx, the surgeon depresses the tongue with a spatula in the left hand, while with the right he holds the adenoid curette--some modification of the original Gottstein model (Fig. 349). This is best seized firmly dagger-wise (Fig. 351). It is then introduced along the tongue and slipped up into the post-nasal s.p.a.ce. Once safely behind the soft palate and kept straight in the middle line, no harm can be done.
Dropping the tongue depressor, the surgeon depresses the handle of his instrument until the beak of it is felt in contact with the posterior free margin of the septum. Pressing the cutting blade firmly and steadily along this it is swept upwards, backwards, and downwards along the vault of the naso-pharynx, while the curette revolves around an imaginary centre in its shaft (Fig. 350). As the instrument is withdrawn from the pharynx, its cage will be found to contain the adenoid growth, removed _en bloc_ and generally complete (Fig. 351). Should the growth slip from the cage, or remain semi-detached from the posterior pharyngeal wall, it can be seized and lifted from the throat with a pair of post-nasal forceps (Fig. 287).
[Ill.u.s.tration: FIG. 349. ADENOID CURETTE. StClair Thomson's modification.]
The rush of blood which now takes place is met by rolling the patient well over to his right side, with his face over the edge of the table, so that the blood can run into the right cheek and so out through the mouth. With the patient on his side there is no anxiety of asphyxia from descent of blood or fragments of growth into the trachea, and the surgeon can more deliberately explore the post-nasal s.p.a.ce and, with a simple adenoid curette, remove any lateral remains of growth which may have escaped the caged curette.
[Ill.u.s.tration: FIG. 350. THE REMOVAL OF NASO-PHARYNGEAL ADENOIDS.
Semi-diagrammatic ill.u.s.tration to show how the curette revolves around an axis which moves from _a_, through _b_ and _c_, to _d_. The growth is pressed into the fenestra of the instrument in the _a'_ position, and when the sweeping movement has brought it to _d'_, it is detached and caught in the cage.]
Sponges are merely used to cleanse the mouth and pharynx in order to make sure that no semi-detached fragments are left behind. If present, tonsils can be conveniently removed at this stage.
Bleeding, which may be very free for a minute or two without any cause for anxiety, is promptly arrested by freely sluicing the patient's face and neck with ice-cold water.
=After-treatment.= The patient is put back to bed, lying well over to one side. He should not be allowed to lie on his back, or left unattended, until consciousness has returned. Collapse may occur at this time, generally as a precursor of vomiting, or blood may be vomited and then, owing to the patient's semi-conscious condition, may be drawn into the trachea.
[Ill.u.s.tration: FIG. 351. REMOVAL OF NASO-PHARYNGEAL ADENOIDS. The growth is shown as partially removed from its attachment, and bulging into the cage of the instrument which opens to receive it.]
Ice may be sucked. After a few hours, if there be no vomiting, barley water, lemonade, tea, thin beef-tea, or beef jelly can be given. Milk and milky food should be avoided. An aperient should be given the same evening, as any foul breath or feverish condition is more likely to be due to blood and mucus in the stomach than to local sepsis. The mouth is kept cleansed with the tooth-brush and an alkaline wash.
It is best to avoid local treatment for the nose. At the end of a few hours the patient is encouraged to clean the nose, and if he be supplied with abundance of fresh air through freely opened windows, the wound in the post-nasal s.p.a.ce will heal promptly without any local or general reaction. Occasionally an alkaline nose lotion is required if there has been much secondary rhinitis, or if the child be kept in vitiated air.