The rush of blood which now takes place is met by rolling the patient well over to his right side, with his face over the edge of the table, so that the blood can run into the right cheek and so out through the mouth. With the patient on his side there is no anxiety of asphyxia from descent of blood or fragments of growth into the trachea, and the surgeon can more deliberately explore the post-nasal space and, with a simple adenoid curette, remove any lateral remains of growth which may have escaped the caged curette.
Sponges are merely used to cleanse the mouth and pharynx in order to make sure that no semi-detached fragments are left behind. If present, tonsils can be conveniently removed at this stage.
Bleeding, which may be very free for a minute or two without any cause for anxiety, is promptly arrested by freely sluicing the patient’s face and neck with ice-cold water.
After-treatment. The patient is put back to bed, lying well over to one side. He should not be allowed to lie on his back, or left unattended, until consciousness has returned. Collapse may occur at this time, generally as a precursor of vomiting, or blood may be vomited and then, owing to the patient’s semi-conscious condition, may be drawn into the trachea.
Ice may be sucked. After a few hours, if there be no vomiting, barley-water, lemonade, tea, thin beef-tea, or beef jelly can be given. Milk and milky food should be avoided. An aperient should be given the same evening, as any foul breath or feverish condition is more likely to be due to blood and mucus in the stomach than to local sepsis. The mouth is kept cleansed with the tooth-brush and an alkaline wash.
It is best to avoid local treatment for the nose. At the end of a few hours the patient is encouraged to clean the nose, and if he be supplied with abundance of fresh air through freely opened windows, the wound in the post-nasal space will heal promptly without any local or general reaction. Occasionally an alkaline nose lotion is required if there has been much secondary rhinitis, or if the child be kept in vitiated air.
One day in bed is generally sufficient, and a child may be allowed out in two or three days, though fatigue should be avoided for a week. Suitable after-treatment in the way of breathing exercises, gymnastics, speech correction, and tonics is often needed. Relief of nasal stenosis may require completion by attention to the condition of the turbinals and septum.
The operation in adults is performed under nitrous oxide. This can be carried out in exactly the same way as that already described, but some surgeons prefer to have the patient sitting up in a dentist’s chair. In that case, after the removal of the mass of growth, the patient’s head is thrown forward between his knees.
Difficulties and dangers. It may be said that the operation itself, carried out with usual care and in a patient who is not a hæmophilic, is free from danger. The chief anxiety is from the anæsthetic, and no inconsiderable number of deaths from this cause have been reported. When possible, it is well to secure the services of an expert anæsthetist who is well used to laryngological work, and accustomed to the operator’s particular methods.
Hæmorrhage may be brisk, even profuse, for a few minutes, but as a rule it promptly ceases if the operation be completed, the patient well rolled to one side, the air thoroughfare left clear so as to allow free breathing and avoid congestion, and the gag removed to permit swallowing and diminish pharyngeal reflexes. The more rapidly and completely the operation is executed, the less will be the bleeding. It not infrequently originates from semi-detached fragments of growth. Even when the hæmorrhage is profuse it is better to push on and complete the removal of growth before attempting to check it. The value of free applications of ice-cold water cannot be exaggerated (see [p. 574]). In many cases bleeding is maintained by the surgeon’s anxious efforts to stop it with sponging, pressure, or the application of styptics. The greatest danger arises in the case of hæmophilics. If this diathesis be undoubtedly present, the operation should be avoided. If only suspected, more care than usual should be taken in preparing the patient for operation, and lactate of calcium in 15 to 30 grain doses twice a day might be given for two or three days beforehand.