When bleeding persists it is met by keeping the patient very quiet and free from alarm, in a cool and well-ventilated room, and only lightly covered with clothes. Ice is given to suck and applied on each side of the neck, while iced cloths are applied to the face and forehead. Clots are blown out of the nose so as to permit the access of fresh cold air to the post-nasal space. With a pipette, or a pledget of cotton-wool, a few drops of adrenalin can be trickled into the nostril and allowed to run backward. If these measures fail—as they rarely do—the post-nasal space must be plugged (see [p. 575]). When hæmorrhage takes place after the removal of adenoids and tonsils, it will generally be found that the source of it is in the tonsillar area.
The uvula may retract strongly at the moment of introducing the curette and then get crushed against the posterior pharyngeal wall: or it may be seized by mistake with the post-nasal forceps and be torn away. The same instrument has sometimes been responsible for fracturing the posterior margin of the septum, injuring the Eustachian cushion, and tearing off strips of mucosa from the pharynx. These complications are avoided by using a frontal search-light, operating deliberately, and abandoning the forceps in favour of the curette. This latter instrument can be manipulated without these risks if it be first guided safely behind the uvula and then used more like a carpenter’s adze than a curette. The stroke with the caged curette should be carried through in one movement and exactly in the middle line of the body, but always on the posterior wall. There is no need to attempt removal of adenoid tissue on the lateral walls. This atrophies if the main mass is removed, and the fossa of Rosenmüller can be cleared out with the forefinger.
Local sepsis rarely follows if the precautions described be observed, and local douching is avoided. Any local fœtor—if not arising from the stomach—is generally traceable to some semi-detached fragment which can be removed from the posterior wall with a wire snare ([Fig. 312]) or a pair of forceps ([Fig. 287]).
Deafness, earache, and otitis media will sometimes follow the operation, even when the use of a nasal douche has been carefully avoided. They are best met by warm applications, disinfection of the ear with carbolic lotion (5%), and early incision of the drum under nitrous oxide gas.
Other methods of operation. Removal through the nasal chambers—the route originally used by Meyer for his ring-knife—is not to be recommended.
Treatment of the growth with the galvano-cautery, introduced through the mouth, is difficult, risky, and unsatisfactory.
The use of Loewenberg’s forceps, or some modification ([Fig. 287]), is generally abandoned by any one who has become accustomed to the Gottstein’s curette. A small pair of forceps is, however, very serviceable in quite young children in whom the post-nasal space may be so small as to prevent the manœuvring of any form of curette.
The position with the extended head over the end of the table—Rose’s position—increases the congestion and hæmorrhage, and by throwing forward the cervical vertebræ makes the approach to the roof of the naso-pharynx more difficult.