After the operation the nasal orifice is kept distended until healing has taken place by wearing Meyer’s vulcanite tube in it or short lengths of full-sized rubber drainage tube, well smeared with boric, aristol, zinc, or similar ointment. These simple nasal dilators are changed once or twice daily, and the nostril is well cleansed on each occasion.
If the web obstructing the anterior naris be more fleshy in character (and it is more apt to be of this nature when it is incomplete), it may be necessary to remove it with a knife. So as to leave as much epithelial tissue as possible, and avoid retraction, the operation is done as follows, under local or general anæsthesia: A narrow, sharp-pointed instrument, such as a Graefe’s or other ophthalmic knife, is used to puncture the web from before backwards, and it is then made to sweep round the obstructing diaphragm, while gradually cutting its way towards the central lumen. The tongue of skin thus formed can be used as a graft to cover most of the raw surface. The restored anterior naris is kept patent, as already described, till healing takes place.
In some cases the following operation has been shown to be easy and effective: An incision is made at the junction of the web with the septum, keeping close to the latter and passing straight down to the floor of the nose. On the outer side a similar incision is made, but sloping somewhat outwards. The flap formed between these two incisions is not cut off, but is bent backwards and fastened to the floor of the nose by a single horsehair stitch.[53]
Fig. 285. Krause’s Trochar and Canula. For puncturing the maxillary antrum from the nose.
Fig. 286. Nasal Punch-forceps.
Operation for congenital occlusion of the posterior choanæ. If the obstruction be not freely and completely removed it tends to re-form. A general anæsthetic is required. Unless the operator is ambidextrous he will find it most convenient to stand on the patient’s left hand, and to introduce his own left forefinger into the post-nasal space. This enables him to guide any straight, sharp instrument, such as an antrum drill ([Fig. 323]), Krause’s trochar (Fig. 285), or a surgical bradawl, from the front of the nose until it presses against and breaks through the obstructing diaphragm in two or more points. If preferred, an electric trephine can be used, and often pressure with the tip of a pair of nasal punch-forceps will be sufficient. The latter, either straight or tip-tilted (Fig. 286), are then inserted through the nostril, and, still guided by the left forefinger in the post-nasal space, are employed to clip away all the obstruction. To prevent any possibility of this reforming it is recommended by some surgeons that a small piece should be nipped out of the posterior margin of the bony septum. This can be done with the beaked punch-forceps of Grünwald (Fig. 286), passed through the nose, or with a pair of Loewenberg’s post-nasal forceps (Fig. 287) introduced through the mouth. In either case their action is controlled and directed by the operator’s left forefinger in the post-nasal space.
