Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Epistaxis.—Bleeding from the nose may be due either to local or to general causes. Among the former may be cited injuries such as result from the introduction of foreign bodies, blows on the face, and fractures of the anterior fossa of the skull, and the ulceration of syphilitic, tuberculous, or malignant disease. Amongst the general conditions in which nasal hæmorrhage may occur are typhoid fever, anæmia, and purpura cardiac and renal disease, cirrhosis of the liver, and whooping-cough. Prolonged oozing of blood may be an evidence of hæmophilia. Nasal hæmorrhage usually takes place from one or more dilated capillaries situated at the anterior inferior part of the septum close to the vestibule, and in such cases the bleeding point is readily detected. Occasionally bleeding occurs from one of the anterior ethmoidal veins, and under these circumstances the blood flows downwards between the middle turbinal and the septum. Before steps are taken to arrest the bleeding, the interior of the nose should, if possible, be inspected and the bleeding point sought for. As a preliminary to the use of local applications, the nose should be washed out with boracic lotion or salt solution to remove all clots from the cavity. In many cases this is all that is necessary to stop the bleeding. If the bleeding is not very copious, it may be stopped by grasping the alæ nasi between the finger and thumb, or by spraying the nasal cavity with adrenalin. If the blood is evidently flowing from the olfactory sulcus, a strip of gauze soaked in adrenalin, turpentine, or other styptic should be packed between the septum and middle turbinated body. If recurrent hæmorrhage takes place from the anterior and lower part of the septum, the application of the electric cautery at a dull red heat, or of the chromic acid bead fused on a probe, is the best method of treatment. Plugging of the posterior nares is rarely necessary, as, in the majority of cases, an anterior plug suffices. In bleeders, the administration of sheep serum by the mouth has proved efficacious.

Suppuration in the Accessory Nasal Sinuses.—As already stated, the presence of pus in the nose should always direct attention to its possible origin in one or more of the accessory sinuses, especially if the discharge is unilateral. The condition is usually a chronic one, and may be present for months, or even years, without the patient suffering much inconvenience save from the presence of the discharge.

If on examination by anterior rhinoscopy, pus is seen in the middle meatus, suspicion should be aroused of its origin in the maxillary sinus, frontal sinus, or anterior ethmoidal cells, as all these cavities communicate with that channel. If, on the other hand, the pus is detected in the olfactory sulcus, attention must be directed to the posterior ethmoidal cells and sphenoidal sinus ([Fig. 267]). Further evidence of its source in the last-named cavities may be gained by finding pus in the superior meatus above the middle turbinal on examination by posterior rhinoscopy.

As the anterior group of sinuses is most frequently affected, and of these most commonly the maxillary sinus, attention should first be turned to this cavity. Pain, tenderness on pressing over the canine fossa or on tapping the teeth of the upper jaw, and swelling of the cheek are rarely met with save in acute inflammation. The complaint of a bad odour or taste, the reappearance of pus in the middle meatus after mopping it away and directing the patient to bend his head well forwards, and opacity on trans-illumination of the suspected cavity, are signs which strongly suggest an affection of the maxillary sinus. The withdrawal of pus by a puncture through the thin outer wall of the inferior meatus of the nose with a fine trocar and cannula will establish the diagnosis.

The treatment consists in opening and draining the sinus. If the infection is due to a carious tooth, this should be extracted, the socket opened up and drainage established through it in recent cases. If the teeth are sound, and the case is of long duration, the sinus is opened through the canine fossa and its walls curetted. To avoid the risk of reinfecting the cavity from the mouth, an opening may be made into the nose by removing a portion of the nasal wall of the sinus and part of the inferior turbinated bone, after which the incision in the buccal mucous membrane is closed with sutures.

Suppuration in the frontal sinus is attended with frontal headache, vertigo, especially on stooping, and tenderness on pressure, particularly over the internal orbital angle, or on percussion over the frontal region. Pus escapes into the middle meatus of the nose, and if wiped away will reappear if the head is kept erect for a few minutes. After removal of the anterior end of the middle turbinated bone, it may be possible to catheterise the sinus and wash out pus from its interior. The diseased sinus may present a darker shadow than the healthy one on trans-illumination, or in an X-ray photograph.

The treatment consists in exposing the anterior wall of the sinus, chiselling away sufficient bone to admit of free removal of all infected tissue, and establishing efficient drainage through the infundibulum ([Fig. 267]) into the nose.

The anterior ethmoidal cells ([Fig. 267]) are frequently affected in conjunction with the frontal, and sometimes with the maxillary sinus. The presence of polypi and granulations, with pus oozing out from between them, and increasing after withdrawal of the probe, and the detection of carious bone are significant of ethmoidal suppuration.

The treatment consists in extending the operation for the frontal or maxillary sinus so as to ensure drainage of the ethmoidal cells.

Suppuration in the sphenoidal sinus ([Fig. 267]) is characterised in many cases by the presence of eye symptoms. Pus in the olfactory sulcus, on the upper surface of the middle turbinal posteriorly, and on the vault of the naso-pharynx, is suggestive of sphenoidal suppuration. The removal of the middle turbinated bone permits of inspection of the ostium sphenoidale by anterior rhinoscopy, and pus may be seen escaping from the orifice. A probe is then passed into the ostium, and the anterior wall of the sinus is removed with a curette or rongeur forceps.