The operation may also be carried out under a general anæsthetic, when one is given for other surgical measures in the nose. In that case it is best to defer the removal of the moriform hypertrophy until the end—practically until the patient is commencing to recover consciousness—on account of the sharp hæmorrhage which is apt to accompany it.
The chief difficulty of the operation lies in the fact that the part to be operated on cannot be kept in view, either directly or indirectly, and that therefore success depends a good deal on delicacy of touch.
A nasal snare—such as that of Blake, Krause, or Badgerow—is threaded with No. 5 piano wire, and a loop left out a little larger than sufficient to grasp the growth. This loop is then bent over smartly towards the side to be operated on, and a slight kink is given to it. The loop is then slightly withdrawn within the barrel, and this again brings it into a straight line. If now the snare be passed along the floor of the nose until the end of it is opposite the posterior extremity of the turbinal, and if the looped wire be slightly projected from the barrel, the loop will tend to curve outwards to the side on which it was kinked. In this way it will be felt to surround the moriform growth, which can then be cut off.
Fig. 291. Amputation of the Posterior End of the Inferior Turbinal.
It must be confessed that this is not always successful, that there is no means of making sure that the snare is applied to the root of the growth, and that once the bleeding is started posterior rhinoscopy fails to reveal if any of it still remains. It is better therefore to introduce the purified forefinger of the left hand into the post-nasal space, so as to define the growth and guide the loop of the snare over it. The nail of the same finger then keeps the wire close to the base of the hypertrophy, while the loop is drawn home (Fig. 291). The patient may then be relieved of the discomfort of the operator’s finger in his throat, and may be given time to clear away the collected mucus. A little delay is advantageous, as it allows coagulation to take place in the large veins of the moriform growth. Some surgeons recommend that once the growth is strangled the snare should be left in situ for 10 or more minutes. This is irksome and unnecessary, and bleeding is seldom excessive if the snare be not employed for cutting off the hypertrophy, but is used as follows: Once the loop is drawn firmly home so as to embrace the growth tightly, a few minutes’ rest is given. Then, steadying the patient’s head with the now disengaged left hand, the snare is plucked from the nose with a quick movement. This brings away the mulberry hypertrophy in its grasp, and frequently a strip of mucosa from the lower margin of the turbinal. No bone is removed in this operation. The bleeding may be very sharp at first, but generally ceases under the usual measures (see [p. 574]). Occasionally it is extremely troublesome, and as the bleeding surface overhangs the post-nasal space the only local pressure which is available is that of a post-nasal plug.
After-treatment. As secondary hæmorrhage is apt to be met with the patient should be advised to leave his nose alone, neither blowing nor clearing it, nor using any cleansing measures for 48 hours. After that time he can employ the usual warm alkaline nose lotion. He should be warned against the habit of hawking backwards, as this would tend to a recurrence of the hypertrophy.
Prognosis. Great relief can generally be promised within a few days. There is no danger in the operation. The hæmorrhage may be troublesome, especially in men. The precautions described in the previous chapter are well worth observing (see [p. 574]).
Complete turbinotomy. Indications. As already remarked it must be extremely rare for this operation to be required. Papillary hypertrophy chiefly attacks the lower and posterior parts of the turbinal, and these can be removed as described above, so that if the entrance of the nostril is made free by anterior turbinectomy, there will still be left a sufficient area of functionally active mucosa. If, however, almost the entire inferior turbinal be degenerated, or if it be replaced by malignant growth, it can be removed in the following way.
