When the deformity of the septum is principally composed of bone the operation is started as already described. It is then easier to lay bare any thickening or deviation of the nasal process of the superior maxilla, or of the chondro-vomerine suture—the usual sites of bony obstructions. When the main mass of deviated cartilage has been cut out with Ballenger’s knife free access is obtained from above to these deformities, and the fleshy muco-perichondrium can be peeled off on each side with much less risk of a tear or puncture. Still, much care is required in working round sharp corners, and, when the spurs lie low, the flaps frequently require to be reflected right down to the floor of the nose. Once well exposed, the maxillary spine is attacked with strong punch-forceps or chisel and hammer, and as pieces of it are prised up they are twisted off with forceps. Once the obstructing maxillary spine is cleared away it is easier to deal with any vomerine deformity.
A great deal of the success of an operation depends on the complete removal of these spurs and ledges, and as they may have to be followed back nearly to the posterior choanæ this part of the operation may be the most difficult, as it is the most necessary (Figs. 307–9).
| Fig. 308. Submucous Resection of the Septum. The shaded area indicates the extent of the bony and cartilaginous septum usually requiring removal. | Fig. 309. Submucous Resection of the Septum. The shaded portion indicates the extent of cartilage and bone removed in marked deformity, when the free end of the quadrilateral cartilage projects into one nostril. |
The pocket between the two flaps is again carefully wiped free of blood-clot and chips of bone and cartilage, and when the two mucous membranes are allowed to fall together they should hang perfectly plumb in the middle line and allow of an uninterrupted view through each nasal chamber, right back to the post-nasal space.
Stitches. With a small Trélat’s needle the incision is closed with one or two catgut stitches.
Dressing. Plain sterilized cotton-wool is tightly rolled into pencils about 3 inches long, and well smeared with sterilized vaseline. These are carefully packed into each nostril. The nose should not be tightly plugged, our object being to keep the two mucous membranes in apposition, but at the same time entirely occluding nasal respiration.
After-treatment. The patient remains quiet for the rest of the day. Ice may be given to suck and an iced cloth laid across the bridge of the nose. At the end of 48 hours the plugs are removed and will be found to come away very easily. The patient should be warned against blowing his nose, but may suck blood-stained mucus backwards and hawk it out through the mouth. Any discomfort may be soothed by spraying the nostrils with liquid vaseline, or introducing a piece of menthol and boric ointment into each nostril morning and evening.
The relief to the former state of nasal obstruction may at once be appreciable. If there be any local reaction it may take 3 or 4 days for the obstruction to subside. In 7 to 10 days the patient begins to enjoy the benefit of the operation, but it is only after 3 weeks that the full advantage of it is established.
