Indications. The removal of naso-pharyngeal adenoids is not called for simply because they are accidentally discovered to be present, nor does the need of operation depend solely on the size of the growths or the nasal obstruction they produce. Adenoids require removal whenever the symptoms attributable to them call for relief. These symptoms may be arranged in three groups, according as they are those (i) of nasal stenosis, (ii) of secondary septic infection, or (iii) of reflex effects.
(i) Amongst the first are mouth-breathing and all the numerous sequelæ, including facial, buccal, dental, and thoracic deformities. It must not be forgotten that mouth-breathing may never be present, and yet deformities of the chest or septic or reflex results can be produced by a small amount of growth in the post-nasal space.
(ii) Amongst secondary septic infections are catarrhal conditions of the Eustachian tube and otitis media, and catarrhal infection of any part of the air-passages. Cervical glands and so-called ‘glandular fever’ occur in this group, as do septic gastritis and other conditions caused by the conveyance of sepsis to more distant parts.
(iii) Various reflex effects are sometimes attributable to naso-pharyngeal adenoids. Laryngismus stridulus, reflex cough, chorea, convulsions, night-terrors, enuresis nocturna, and aprosexia are some of the ailments which may justify operation on Luschka’s tonsil.
As it is chiefly in children that this operation is required it is important to see that they are free from indication of infectious fevers. The operation should be postponed until any acute catarrh has subsided. If there be otorrhœa the ears should receive suitable cleansing treatment for a week or two beforehand. The condition of the teeth requires attention.
The operation is so frequently carried out in private houses that it is well to make inquiries into the health of the members of the household, recent illness, and sanitation. When possible, a large, airy room with a south aspect should be chosen.
Operation. In adults it is possible to carry out the operation under cocaine. On the Continent, particularly in hospital practice, it is often done without any anæsthetic at all. In this country general anæsthesia is almost the universal custom. Opinion is divided as to which is the safest and most suitable anæsthetic to employ.
When the removal of tonsils or other operation is not carried out at the same time, an anæsthesia of less than a minute is sufficient. In adults, and in children over 10 years of age, nitrous oxide does excellently. Younger children are apt to be alarmed by the face-piece and apparatus necessary for nitrous oxide, and this gas does not seem so suitable for them as for adults. In younger children chloride of ethyl is extensively employed on the Continent, but has not met with general favour here.
When the tonsils require removal, or any other operation on the upper air-passages is carried out at the same time, and in young children generally, an anæsthesia allowing of more deliberation is desirable. For this, some operators employ ether,—preceded or not by nitrous oxide. But the well-known objections to pure ether in the surgery of the air-passages have caused the preference to be given to chloroform, or to one of the mixtures of chloroform and ether.
The patient should lie quite flat on the operating table, with only a low pillow or folded towel under the head. The anæsthetist, who takes charge of the gag and flexes or rotates the head as directed, stands at the end of the table. At the patient’s right hand stands the surgeon, and within easy reach are his instruments, sponges, and iced water. Standing on the same side and behind him is the nurse. Her duty is to soothe the patient while passing into unconsciousness, and later on to roll him well over on to his right side as the operation finishes.