For malignant growths in the regions mentioned, this route is particularly suitable, if, of course, the limitation of the growth and the absence of secondary infection justify intervention. The large space formed by throwing the nose and antrum into one cavity gives a freer field than removal of the superior maxilla, without the disfigurement and tendency to recurrence so apt to be associated with this latter operation, since it seldom includes removal of the ethmoid, which is the usual seat of origin of the disease. In Moure’s operation the functions of the eye, and of the nerves and muscles of the face, are not interfered with, nor are there those difficulties with phonation and deglutition which are left by removal of the upper jaw.
The interior of the nose is prepared with adrenalin and cocaine (see [p. 572]), chloroform is administered, and a sponge is packed into the naso-pharynx (see [p. 575]).
Operation. An incision is made from the inner border of the eyebrow, along the side of the nose, until it enters the lower margin of the nasal orifice. A second incision, starting from the same spot above, is next carried round the lower margin of the orbit and outwards as far as the malar eminence (Fig. 315).
| Fig. 315. Incisions for Lateral Rhinotomy (Moure’s Operation). | Fig. 316. The Area of Bone removed in Lateral Rhinotomy. The flaps have been retracted, and the dotted lines show where the bones are chiselled through. |
The lobule of the nose is then detached, so that the fleshy parts of the nose can be thrown over to the opposite side, while a triangular flap is turned downwards and outwards. With a raspatory the nasal process of the frontal bone, the nasal bone, the ascending process of the superior maxilla, and the canine fossa are next exposed. The lachrymal sac is carefully defined and retracted. A chisel is first driven through the superior maxilla, close to its junction with the malar bone, but avoiding the infra-orbital nerve, and the section is carried downwards across the canine fossa until it reaches the alveolar border (Fig. 316). From the lower extremity of this incision—which of course enters the maxillary sinus—the bone which separates it from the pyriform fossa is broken through with stout forceps. In this way the antro-nasal wall is detached close to the floor of the nose, and can be removed together with the inferior turbinal. The nasal bone itself is next removed, together with part of the lachrymal bone and the nasal process of the frontal. Finally the middle turbinal and lateral mass of the ethmoid are removed with punch-forceps (Grünwald’s or Luc’s), Volkmann’s sharp spoons, or a ring-knife.
Fig. 317. Lateral Rhinotomy. The side of the nose has been removed, and direct access obtained to the upper and deeper nasal regions.
A gouge, or Killian’s eye protector ([Fig. 342]), is then slipped inwards and downwards at the upper part of this opening until it comes in contact with the body of the sphenoid. An assistant holds it closely parallel to the cribriform plate, where it acts as a protector. With a large sharp spoon, acting from above downwards and forwards, the ethmoidal labyrinth can be cleared away with any tumour which may have infiltrated it. The os planum, if not already destroyed, can be removed, so as to obtain access to the orbit. Direct approach is given to the sphenoidal sinus. The septum can be readily resected, but an endeavour should always be made to preserve a strip of cartilage under the bridge of the nose to prevent any external deformity (see [p. 609]). It is needless to say that great care must be taken while working close to the cribriform plate.
A malignant tumour can then be removed with forceps, sharp spoons, and the fingers, any prolongations being followed into the naso-pharynx, the maxillary sinus, the sphenoidal sinus, the lateral mass of the ethmoid, or even into the pterygo-maxillary fossa. Success largely depends on the care with which this curettage is carried out. It should be followed by the application of caustics or Paquelin’s cautery.