But when the middle turbinal is softened and broken down by disease it is as safe, and it is certainly more convenient, to take out a wedge from its centre, as directed above, and then with a pair of Grünwald’s or Luc’s forceps to twist out not only the anterior extremity, but also the posterior half. The latter part can also be removed with a spokeshave, as directed for the inferior turbinal (see [p. 591]).
After-treatment. There is not the same tendency to crusting as occurs after operation on the inferior turbinal. Hæmorrhage is also less troublesome. Plugging is therefore the less likely to be required, and should always be avoided if possible, since it would interfere with drainage from the various accessory sinuses, and this operation is frequently required when their contents are particularly septic. The best plan is to leave the nose severely alone for 48 hours, and then to clear it gradually with the help of warm alkaline lotions.
OPERATIONS FOR THE RESULTS OF SYPHILIS
Sequestrotomy. The discovery of a syphilitic sequestrum always calls for active treatment.
Operation. If the sequestrum be not loose we must wait until it is movable. Its detachment will be expedited by mercurial inunctions or injections, and suitable local cleansing and disinfecting measures. As soon as any movement can be detected in the dead mass we can proceed, under cocaine, to detach it. Various forms of polypus forceps and bone-pliers may be required, and the necrosed bone has to be raised from its bed by a variety of lever and to-and-fro movements. Several sittings may be necessary, but this is inevitable, as any violent measures are soon arrested by hæmorrhage. When the necrosed bone has been mobilized it may be too large for extraction through the nares; such a mass as the greater part of the body of the sphenoid has sometimes necrosed en bloc. In such cases the dead bone must be broken up in situ and then removed piecemeal through either the anterior or posterior nares. Very rarely Rouge’s operation may be required (see [p. 622]).
Operations for post-syphilitic adhesions of the velum. So long as there is an adequate passage for nasal respiration it is best to leave any slight degree of stenosis alone. When there is complete atresia, and when mouth-breathing, deafness, or other consequences develop, some effort at relief should be made.
Operation. Under chloroform, and with the hanging head, W. G. Spencer[54] separates the soft palate from its adhesion to the posterior pharyngeal wall, draws it forwards, and fixes it by two silk sutures to the muco-periosteum of the hard palate. Tilley carries out the same principle by threading the soft palate on both sides with strong silver wire and anchoring it to the incisor teeth. The wires cut out in 10 to 14 days, but by this time considerable healing will have taken place over the raw surfaces from which the adhesions had been separated.[55]
After freeing the soft palate, H. B. Robinson prevents it from again uniting by the following method: ‘A piece of lead plate is cut the full breadth of the naso-pharynx and bent so that one arm rests on the dorsal surface of the soft palate, and the lower one on the buccal surface, the cut margin being received between the plates and apposed to the bend, and so kept away from the pharyngeal wall.’ The piece of lead is kept in place by silk threads attached to the four corners, two passing forward through the nostrils and two through the mouth. The lead plate is not removed for a fortnight.[56]
Whatever method is employed to enlarge the stricture, dilatation must be kept up for some time by the frequent passage of the forefinger, a palate hook, or a dilatable bag.