| Fig. 303. Denudation of the Septum in Submucous Resection. The muco-perichondrium has been raised from the convex side of the septum, and the cartilage has been cut through (from A to B in Fig. 300). The dull-edged detacher is shown separating the mucous membrane from the concavity of the deflexion. | Fig. 304. Complete Denudation of the Deviated Septum. Semi-diagrammatic drawing of a transverse section of the nose, viewed from above. The deviated septum has been divided in front, and its muco-perichondrium has been stripped up on each side. The nasal speculum is introduced through the convex nostril, and a blade is inserted on each side of the septum, between it and its mucous covering. |
Fig. 305. Ballenger’s Swivel Septum Knife.
Fig. 306. The Method of employing Ballenger’s Swivel Septum Knife. The knife is shown cutting out the cartilaginous deviation.
Excision of the deviated cartilage. A long Killian’s nasal speculum ([Fig. 346]), or the long Thudichum’s speculum I have had made, is now introduced through the obstructed nostril, one blade being inserted on each side of the now denuded septum (Fig. 304). It is easy to see if the mucous membrane has been sufficiently stripped off. If not, it can be carried further with a few sweeps of the raspatory. Ballenger’s swivel septum knife[61] (Fig. 305) is then placed astride the anterior cut surface of the cartilage, pushed upwards and backwards below the roof of the nose until it comes in contact with the ethmoid, then downwards and backwards to the angle between the ethmoid and the vomer, and, finally, pulled forwards along the upper margin of the vomer (Fig. 306). The excised cartilage is thus removed en bloc, and may measure an inch by one and a half inches.
The empty pocket between the two separated and flaccid mucous membranes is wiped out and the two fleshy curtains are allowed to fall together. With a nasal speculum each nasal chamber is next carefully inspected to see that the thoroughfare is completely restored. As a rule deeper obstructions, formerly invisible, will come into view, and the mucosæ are again separated with a long nasal speculum and more of the septum is shaved off with Ballenger’s knife or clipped away with Grünwald’s punch-forceps, which also serve to remove portions of the vomer and of the perpendicular plate of the ethmoid.
Fig. 307. Submucous Resection of the Septum. The arrows indicate the points where the chisel may be applied when exostosis of the nasal maxillary spine requires removal.
Excision of bony spurs and ledges. It has been pointed out that it is extremely rare to find a deviation limited entirely to the cartilaginous septum. I have never yet met a case in which it was not desirable to remove some of the bony septum.