Fig. 292. Nasal Spokeshave.
Operation. Anæsthesia may be local or general. If no other operative procedure be required at the same time, the anæsthesia of nitrous oxide gas or chloride of ethyl will be long enough. Owing to the vascularity of the part adrenalin should be applied for at least 30 minutes beforehand.
Removal of the turbinal is easily and quickly carried out with Carmalt Jones’s or Moure’s spokeshave (Fig. 292). This is introduced, passed as far as the posterior extremity of the turbinal, and the edge is guided in place with the operator’s left forefinger in the post-nasal space. With a sharp pull the spokeshave is then drawn forwards and the detached body can be lifted out with a pair of punch-forceps. Owing to the slope of the attached border it is seldom that the whole of the turbinal is removed. Those who are skilled in the use of this instrument can manipulate it so as to leave a good part of the attached margin of the turbinal, and the spokeshave can be used instead of the scissors for removal of the inferior margin. But its action is apt to be uncertain, and as it may unexpectedly rip out more than was intended, it is seldom employed nowadays.
After-treatment. After the removal of such a large portion of secreting surface the nasal secretion may dry into adhering crusts and scabs for some weeks—possibly for six or even eight. The scabs should be softened by the use of ointment or oily sprays, and removed by the fere use of warm alkaline lotions. The even healing of the granulating surface requires watching; its progress should be inspected from time to time, as the surface may require touching with a weak nitrate of silver solution.
OPERATIONS UPON THE MIDDLE TURBINAL
Indications. Amputation of the anterior end may be required for (1) simple hypertrophy, (2) cyst or empyema in the anterior extremity, (3) to gain access to the ostia of the various accessory sinuses, (4) as a first step to uncover the ethmoidal cells, and (5) as a first step in removal of ethmoidal polypi.
Operation. Local anæsthesia with cocaine and adrenalin is sufficient, and the operation can be carried out with the patient sitting in the examination chair. It frequently forms part of some other intranasal operation which is performed under a general anæsthetic, but the preliminary application of cocaine and adrenalin should still be carried out (see [p. 572]). If the pieces of gauze soaked in the cocaine-adrenalin mixture be carefully tucked up on each side of the head of the turbinal, the part to be removed is generally well exposed. With a pair of Grünwald’s punch-forceps ([Fig. 286]) or Panzer’s scissors ([Fig. 290]), the anterior attachment to the outer wall is cut through (Fig. 293) so as to free the end, around which a cold wire snare can be passed and the extremity removed (Fig. 294.) In cases where it is difficult to introduce the punch-forceps under the attachment of the middle turbinal the blades may be applied to the lower margin, about half an inch from the anterior extremity so as to bite out a wedge. Into this the loop of the wire snare is inserted and the head of the turbinal can easily be snared off.
| Fig. 293. First Step in the Removal of the Anterior End of the Middle Turbinal. | Fig. 294. Second Step in the Removal of the Anterior End of the Middle Turbinal. |
The snare is generally recommended as being safer than the punch-forceps. There is certainly a risk attending any slip in manipulating the latter in this region, more so, indeed, than in the deeper ethmoidal regions, for in the anterior part of the nasal roof the cerebral floor dips down lower than it does posteriorly, and the nasal fossa in the anterior part of the middle meatus is very narrow, so that if the forceps slipped they might impinge on the cribriform plate.