These consist in large measure of deviations of the nasal septum, with or without turbinate hypertrophy, due to previous disease of the Schneiderian membrane, and followed by thickening and structural change. Nasal deviations are either of congenital or acquired origin. An absolutely symmetrically arranged and divided nasal cavity is a rarity. Thus, though one side is rarely a replica of the other, deviations which are sufficiently marked to cause nasal obstruction are commonly the result of rapid or slow disease. They will be seen in connection with other body deformities by which the head is habitually held in an abnormal position, so that growth in one direction is thereby favored. Such conditions may be caused either by irregularities of vision, by enlarged tonsils, or by spinal deformities.
The acquired deviations are frequently the result of injuries, not necessarily of those sufficiently severe to produce fractures. The nasal septum proper is made up of the cartilaginous or purely nasal portion, the vomer, and the perpendicular plate of the ethmoid, any one of which may be separated from its connections or warped from its perpendicular plane. Dislocation of the cartilages may also occur in the young, and, having once taken place, is rarely reduced unless treatment has been both prompt and scientific.
Angular deviation to an extent which often produces a spur is not necessarily of serious inconvenience unless it protrude sufficiently from its proper plane to come in contact with one of the turbinates, in which case a nearly complete obstruction may result, with symptoms of constant nasal irritation. Absolute symmetry being rare, and mild deviations being very common, it is only those which produce either visible deformity or local irritation which require surgical treatment. Obviously after injury to these parts attention should be given to overcome present and prevent further dislocation. This may be conveniently done by the introduction of small, tubular, nasal splints, of celluloid or caoutchouc, made for the purpose. In their absence short pieces of a stout, silk catheter may be used, one inserted on either side of the septum, and packed around with a light tampon of antiseptic gauze. All intranasal splints, no matter how made, will cause considerable local irritation, with tendency to discharge, and will need to be renewed every day or two.
Deviation having resulted in permanent deformity, no matter how produced, it can be relieved by operation. Except in the young this may be performed under local cocaine anesthesia. These measures fall under two heads—those made for removal of projections, or spurs, and those directed to straightening of warped or deviated septa, which do not show much thickening.
For the treatment of projections caustics and the actual cautery were formerly much in use. They have been now almost abandoned for the use of instruments, such as a strong knife, a small intranasal saw, or cutting forceps of various patterns, adapted for use within the nose. Only these latter means will be mentioned in this place. Cutting instruments may be actuated by hand or by electric motors. When the field of operation is small cocaine anesthesia is nearly always sufficient. Extensive operation involving both nasal cavities may often be better performed under a general anesthetic. The nasal cavity should have been previously thoroughly cleansed by the aid of irrigation with alkaline solutions, and then just previous to operation with hydrogen peroxide. Instruments should be absolutely clean and sterile. When local anesthesia is complete it is sufficient to seat the patient with the head supported, opposite to the operator, to illuminate the nasal cavity with the head mirror or some substitute therefor, and to introduce the knife, saw, or forceps in such a way that the removal may be effected with one movement, while injury to surrounding tissues is avoided. An intranasal saw should be blunt-pointed, and should never be pushed so as to touch the posterior wall of the pharynx. After division of bone the final detachment of the mucosa should be made with scissors or knife. Bleeding after these operations is rarely severe, although free at first, and may be controlled by a tampon made of a narrow, continuous strip of antiseptic gauze, either packing it into the nostril and occluding it, or inserting a nasal tube and packing snugly around it. Only in rare instances is it necessary to tampon the nose from the pharynx by the use of the Bellocq cannula. (See [below].)
Warped and deviated septa, without angular projections, may be sometimes successfully treated by dividing the septum, either with knife or scissors, or with cutting forceps whose blades make a stellate incision, by which the curved surface is so much weakened that it can be pressed back into normal shape, where it is retained by tamponing the nostril on the affected side. The pressure required for this purpose is, however, sometimes irksome or even intolerable. A method of using a long pin, like a small hat-pin, has been suggested, it being passed through one nostril into and out of and again into the septum, in such a way that it serves as a splint, to keep it straight for a sufficient length of time. Later this pin may be removed without difficulty, its enlarged head lying meantime concealed within one of the nostrils.
SUBMUCOUS RESECTION OF THE NASAL SEPTUM.
This was first suggested by Killian as affording a method not subject to the objections of the older authorities. It may be performed under cocaine anesthesia, each side of the septum being swabbed with a 20 per cent. cocaine solution. A semilunar incision made through the mucous membrane and perichondrium on one side is the more convenient. Through this opening the coverings are separated from cartilage by means of a sharp and a plain elevator. Unless the perichondrium be itself elevated the mucous membrane will be torn in the pressure of loosening. The cartilage is then cut through with suitable instruments or burred away with a dental engine, the instrument being guarded by a finger in the opposite nostril, which acts as a guide, it not being desirable that the membrane on that side shall be cut through. In this way any spurs or ridges may be removed submucously with such instrument as the operator may select. The separated membranes then fall together and may be retained by light gauze packing without any suture.
NEOPLASMS OF THE NASAL CAVITIES.
Of true neoplasms in the nose the most common are those myxomatous or fibromyxomatous developments from the Schneiderian membrane, which are called nasal polypi. Histologically most of these are of myxomatous character. Clinically, however, they seem to be in large degree products of inflammatory and irritative conditions. At all events they constitute sessile and later pendulous outgrowths, occupying different areas or occurring in clusters, those from the upper part of the nose being covered with columnar cells, while those of the lower pharynx are covered with flat epithelium. They are firm or soft, according to the amount of connective stroma which they contain. They are poorly supplied with blood and their contained fluid is largely composed of mucin. When involving a considerable area the condition is referred to as polypoid degeneration. They are observed at all ages and in both sexes. Their most common seat is the middle turbinate, toward its posterior extremity, and they also hang from the septum, but may be found in any part of the nasal cavity. From it they may spread to fill the adjoining accessory sinuses, even producing absorption of their bony walls by pressure. They also produce distortion of the nose, with such obstruction as to prevent nasal respiration. They may involve one side or both, and may hang so loosely attached that a flapping, valve-like sound is heard on respiration.