In the septum fracture generally takes place in the quadrilateral cartilage, or displacement occurs at its junction with the vomer or superior maxilla. It may be accompanied by a hæmatoma (see [p. 612]), and the occurrence of epistaxis shows that it is really a compound fracture. Care should therefore be taken not to infect the wound in the nose, and the patient should be warned on the subject.
Fig. 284. Meyer’s hollow Vulcanite Nasal Splint.
The application of cocaine and adrenalin may allow of careful inspection of the septum. But, as the exact condition of things is marked by swelling, it is nearly always advisable to administer a general anæsthetic. Crepitus can rarely be made out. A hæmatoma is dealt with as directed (see [p. 612]). If there be any displacement of the septum—and it generally takes place towards the side on which there is already some convexity or depression of the nasal bones—the parts should be raised into place by manipulation with the little finger in the nostril. A flat-bladed forceps, like those of Adams, may be used. One blade in each nostril will straighten the septum and, at the same time, raise the whole nose into place. Small pencils of sterilized cotton-wool, smeared with vaseline (see [p. 608]), are then carefully packed up into the roof of the nose and kept there by Meyer’s vulcanite tube (Fig. 284). They are changed every 24 or 48 hours, for a week or so. The vomer is rarely fractured, although much callus is often thrown out in the displacements which occur between it and the cartilage.
Recent cases require no splints. In fact, if the displacement be promptly reduced—under general anæsthesia—the restored parts will generally maintain their position.
Elevating an old fracture. In neglected cases it may be necessary to re-fracture the nasal bones, and when these are replaced an external splint may be necessary. This can be made of plaster of Paris; or the outside of the nose may be covered with a piece of heavy adhesive plaster, and outside that a shield of tin, copper, or, preferably, aluminium.[52]
Fracture of the ethmoid is, fortunately, rare. When it occurs it is apt to run into the cribriform plate, and be associated with the escape of cerebro-spinal fluid and other indications of fracture of the anterior fossa of the skull.
OPERATIONS FOR CONGENITAL OCCLUSION OF THE NOSTRILS
Operation for congenital occlusion of the anterior nares. If the web obstructing the nostril be thin and membranous, and of low vitality, a simple and effective method is to destroy it with the galvano-cautery. It is best to spread the treatment over several sittings, so as to diminish the local reaction. The application of cocaine may not be sufficient to numb the pain, as the tissue of the obstructing web is more allied to skin than to mucous membrane. It should therefore be punctured quickly in two or three places, with a sharp cautery point raised nearly to a white heat. If the patient be nervous it may be well to administer nitrous oxide gas.