Selection of method. In some cases operation through the mouth may have to be combined with a second operation from the front—such as the method of Moure (see [p. 619]) or that of Rouge (see [p. 622]).
Rapidity of operation is important, as, once the pedicle has been cut through, or the body of the tumour removed, the hæmorrhage tends to subside spontaneously, or is quickly controlled by packing.
The hanging head (Rose) or the Trendelenburg position is generally recommended.
The preliminary laryngotomy seems desirable in all cases. The division of the palate should be avoided if possible. It may not always unite, and is less likely to do so if subsequent operations are required. The soft palate is very elastic, and in some cases it can be tied out of the way by means of a soft rubber catheter passed along the floor of the nose, and out through the mouth.
Ligature of the external carotid, strongly recommended by Chevalier Jackson[87], is not necessary unless the patient is very anæmic or weak from former hæmorrhages. It should then be only a temporary ligature (see Vol. I, p. 383).
Hæmorrhage, as already remarked, is chiefly guarded against by rapid and complete operation. The preliminary use of adrenalin and cocaine, the administration of lactate of calcium, and the other methods recommended for the prevention of bleeding (see [p. 574]) should be carefully attended to. But in every case preparation should be made beforehand for ligature of the external carotids and for saline infusion.
OPERATION FOR RETROPHARYNGEAL ABSCESS
Indications. The disease is serious, and when not diagnosed almost inevitably ends in death. Before the abscess bursts death may result from spasm of the glottis, laryngeal œdema, or asphyxia. The affection runs its course in 5 to 10 days, and if the abscess opens spontaneously death almost inevitably results—either from suffocation, or septic pneumonia, or cardiac failure.
Operation. When the diagnosis is settled intervention should be prompt. It is not necessary to wait for distinct fluctuation. The pus focus may be so difficult of manipulation in an infant, and the pharyngeal muscle may be so thick and indurated, that it is practically impossible, even in the later stages of retropharyngeal abscess, to detect the presence of pus by palpation.[88]