If the middle turbinal has not already been removed it may have to be amputated, as described on [p. 592]. In many cases of ethmoidal caries it is easily removed with nasal forceps.
Fig. 313. Luc’s Nasal Forceps.
The instrument I recommend is Luc’s forceps[64] (Fig. 313), supplemented by Grünwald’s punch-forceps ([Fig. 286]). The former are introduced vertically, so that one blade passes between the ethmoid and the septum and the other passes under cover of the middle turbinal. By insinuating them carefully, and gradually working them upwards and outwards, a large mass of tissue or carious ethmoid can be grasped, twisted off, and shaken from the forceps into the vessel of water. Before any marked flow of blood has taken place it will be possible to make a second or third introduction of the forceps, and seize the successive masses of growth which come into view. When the bleeding obscures the field of operation one of the strips of gauze can be picked up quickly in the forceps and used for plugging that side of the nose, while a similar operation is carried out in the opposite nasal chamber, if it is affected.
Hæmorrhage may require the plug being left in situ for a few minutes, so as to get a clear view of the depths of the nose. This is better secured if the end of the gauze strips are first soaked in either adrenalin or a 10% solution of hydrogen peroxide. In this way the main mass of the ethmoid can be completely cleared away, the posterior ethmoidal cells opened up, and the front wall of the sphenoidal sinus broken down. Not infrequently the surgeon finds afterwards that this latter cavity has been quite inadvertently, though successfully, opened.
Fig. 314. Tongue Clip. Keeps the tongue drawn forwards to allow of general anæsthesia, when the post-nasal space is plugged.
Operation under general anæsthesia. Under a general anæsthetic this operation can be even more satisfactorily carried out, but the surgeon has to keep well in view the anatomical relations of the parts, and the altered relationship to the horizontal position compared with what he is more accustomed to with the patient sitting in the examination chair. When chloroform is employed the interior of the nose is prepared in the same way beforehand with adrenalin and cocaine; the patient is placed horizontal on an operating table with his head and shoulders slightly raised; the post-nasal space is plugged with a sponge (see [p. 575]); and the tongue is drawn forward with a clip (Fig. 314) so that the administration of the anæsthetic through the mouth is quite uninterrupted. This method allows the surgeon to operate deliberately, generally with the hæmorrhage under easy control, the field of operation well illuminated, and no anxiety in regard to the anæsthetic.
The removal of polypoid ethmoid can thus be completely carried out. With this method I have removed at one sitting a mass of diseased ethmoid which weighed four ounces.[65] It also permits the introduction of the operator’s little finger to some distance, so as to detect polypoid or carious surfaces.
With a ring-knife any irregular spicules or projections can be smoothed down. The ring-knife—or a Volkmann’s spoon—is carefully introduced behind a mass of growth, and then pulled briskly out through the nose while hugging its outer wall. The nasal roof should be diligently respected.