Canaliculus DilatorFig. 163. Canaliculus Dilator
Operation.The operation is performed under adrenalin and cocaine, a little solid cocaine being rubbed in over the canaliculus.
The lid is slightly everted and put on the stretch by pulling it downwards and outwards with the thumb. The depression caused by the punctum is seen on the top of a small elevation. The point of the dilator is entered vertically into the punctum and then turned parallel with the lid margin and passed onwards with a steady pressure. At the same time it should be rotated between the finger and thumb, until the inner bony wall of the lachrymal sac is felt. The only difficulty which may be experienced is in entering the dilator into the punctum, owing to the small size of the latter. For this reason the fine point of Nettleship’s dilator is more suitable than the form modified by Lang. Even Nettleship’s dilator is too large in a few cases, and here a large sharp-pointed pin is sometimes of use in defining the punctum before using Nettleship’s dilator.
Indications.To enlarge the punctum and direct the entrance to the canaliculus inwards. This is especially desirable before ectropion operations and for the removal of concretions (leptothrix) from the duct. In former days the canaliculus used to be slit with the idea of passing very large probes down the lachrymal duct; this has now been abandoned, since slitting the canaliculus throughout its whole length, as is required for this treatment, does away with the capillary attraction.
Canaliculus KnifeFig. 164. Canaliculus Knife.
Instruments.Dilator, canaliculus knife (Fig. 164), straight iris forceps, sharp-pointed scissors.
Operation.It is usually performed on the lower canaliculus. The eye is cocainized as in the previous operation and the patient is made to look up.
First step.The canaliculus is first dilated. The knife is inserted for a short distance with the handle parallel to the lid margin. The lower lid being held on the stretch by the thumb, the handle of the knife israised towards the brow, thus dividing the canaliculus. The blade of the knife should be directed upwards and slightly backwards.
Second step.As the lips of the wound are liable to reunite, it is better to remove the posterior lip of the groove. This is performed by seizing the latter with forceps and dividing it with scissors. The entrance to the canaliculus should be kept open by means of the dilator passed twice a week for a month.
Indications.(i) To test whether the lachrymal canals are patent.
(ii) By constantly cleansing the sac and washing away all purulent discharge the mucous membrane may regain a more healthy condition, and so an obstruction due to an alteration in the mucous lining may be relieved. In cases with a purulent discharge a small quantity of protargol (10% solution) may be left in the sac after syringing.
(iii) The injection of adrenalin and cocaine into the sac before its excision.
Lachrymal SyringeFig. 165. Lachrymal Syringe.
Operation.The eye is cocainized and the patient made to look up. The punctum is everted by pulling down the lower lid. The canaliculus is then dilated. The nozzle of the lachrymal syringe (Fig. 165) should be passed until it is felt to impinge on the bony outer wall of the sac. Withdraw the syringe slightly and apply gentle pressure to the piston. The fluid will either regurgitate through the upper canaliculus or, if the duct be patent, pass down into the nose and so into the throat.
Complications.If too forcible syringing be used extravasation of the fluid may take place. This is accompanied by pain and swelling in the lachrymal region. It usually subsides under hot fomentations, but suppuration and even cellulitis of the orbit have been known to occur.
Indications.(i) In cases of congenital lachrymal obstruction due to débris blocking the duct.
(ii) When syringing has failed to bring about a cure, a probe may be passed once or twice to see if dilatation causes any improvement. It is especially useful in children.
(iii) As a preliminary to the insertion of styles.
Various forms of probes are employed, those of Bowman being in general use. Too fine a probe should not be used, otherwise a false passage is liable to be made.
Operation.This is performed under adrenalin and cocaine, which should be injected into the lachrymal sac.
The lower punctum is dilated and the probe passed parallel to the lid margin until it is felt to impinge upon the lachrymal bone. Keeping the point applied to the bone, the handle of the probe is rotated upwards through rather more than a quarter of a circle and passed by a gentle pressure downwards and slightly outwards into the duct, keeping the point of the probe close to the bone the whole way. The direction of the probe after entering the duct should be downwards, outwards, and backwards in the direction of the first molar tooth on the same side. The backward direction of the duct is much more marked in young children than in adults.
Complications.A false passage may be made into the antrum of Highmore. If such an accident should occur, no further attempt should be made to pass a probe for a few days until the wound has healed.
A few surgeons still insert styles into the lachrymal duct with the idea of continuous dilatation. The hollow styles used by Bickerton are the ones most frequently employed.
Instrumentsfor dilating, slitting the canaliculus, probing, and styles. Also Stilling’s knife.
Operation.A general anæsthetic is desirable.
First step.The canaliculus is dilated and slit up, the posterior lip being removed (seep. 29).
Second step.The duct is dilated by probing (vide supra) or enlarged by passing Stilling’s knife down it.
Third step.A style is passed down the dilated duct. The lower end of the style should rest upon the floor of the nose, otherwise there is a tendency for the style to slip into the duct and disappear. Care should be taken that the upper end does not rub on the globe. Styles should generally be left in position from three to six months. A style should at first be made of lead wire and moulded until a suitable pattern is obtained, from which a hollow gold style can be made subsequently.
Complications.1.Dacrocystitismay follow the insertion of a style, which should then be removed until the inflammation has subsided.
2.The style may slip down the duct.If this should occur an attemptshould be made to grasp it through the slit canaliculus. The lower end may present in the nose and the style can then be withdrawn with forceps. Occasionally styles lodge in the antrum of Highmore, in which case they must be removed after localization by the X-rays through an opening from the mouth above the canine tooth.
When syringing and probing have failed to relieve the lachrymal obstruction, one of the following operations for the obliteration of the lachrymal passages may be employed.
Indications.In cases of lachrymal obstruction in which an immediate operation upon the globe is required.
Operation.Under cocaine. Fine sutures armed with a small curved needle are passed beneath both the upper and lower can[al]iculus and tied so as to include them in the ligature. Permanent obliteration may be caused by the destruction of the lining membrane with the actual cautery.
Indications.(i) For mucocele in cases of lachrymal obstruction which have failed to yield to other treatment.
(ii) In all cases of tuberculous disease of the sac.
(iii) For a recurrent lachrymal abscess after subsidence of the acute inflammation.
(iv) For hypopyon ulcer associated with lachrymal obstruction.
(v) Before operation on the globe in cases of lachrymal obstruction.
(vi) For lachrymal fistula.
Instruments.Small scalpel, forceps, Muller’s speculum (Fig. 166), Axenfeld’s retractor (Fig. 167), straight scissors, horsehair sutures.
Muller’s Retractor for Excision of the Lachrymal SacFig. 166. Muller’s Retractor for Excision of the Lachrymal Sac.
Axenfeld’s Retractor for Excision of the Lachrymal SacFig. 167. Axenfeld’s Retractor for Excision of the Lachrymal Sac.
Operation.Hæmorrhage is the most troublesome part of this operation; it is best controlled by injecting adrenalin (made from the dried gland,ʒj, and ℥jof water) and cocaine, 10%, into the sac a quarter of an hour before operating. Swabs on the end of a glass rod dipped in adrenalin and cocaine may also be used during the operation. A general anæsthetic is desirable, but many surgeons perform the operation under local anæsthesia, produced by injecting 5% cocaine with 1 in 1,000 adrenalin into the tissue surrounding the sac; but the latter plan has the disadvantage that the mixture may cause severe toxic effects, and the patient usually experiences some pain while the upper portion of the incision is being made and the lower end of the sac is being divided.
First step.The internal tarsal ligament is first defined by putting the lids on the stretch. An incision should be made, 15 millimetres in length (5 millimetres of which should fall above the tarsal ligament), backwards and inwards directly over the lachrymal sac. Muller’s retractor is then inserted to retract the wound laterally, the hooks being made to engage the margins of the incision by means of forceps. The superficial fascia and the fibres of the orbicularis muscle are then divided. The internal tarsal ligament in the upper part of the wound, together with the glistening deep fascia, is exposed and divided carefully so as not to injure the lachrymal sac, which is found directly beneath it (Fig. 168).
Excision of the Lachrymal SacFig. 168. Excision of the Lachrymal Sac.Showing the internal tarsal ligament in the upper part of the wound with the sac lying beneath.
Excision of the Lachrymal SacFig. 169. Excision of the Lachrymal Sac.Showing the method of defining the upper end of the sac. The internal tarsal ligament has been divided and the sac is well pulled forward with forceps.
Second step.With scissors the sac-wall is then separated from the deep fascia which encloses it, first externally and then internally, the canaliculi being divided. Axenfeld’s retractor is then inserted in the longitudinal axis of the wound (Fig. 167). The middle of the sac is grasped with forceps and pulled forward, and the top of the sac is defined and detached. This is frequently difficult owing to the troublesome hæmorrhage which often occurs. The sac is pulled well forward, and the posterior wall is separated, the neck of the sac being divided as far down the duct as possible by means of scissors. A large probe is passed down the duct into the nose. Some surgeons remove the periosteum of the lachrymal bone as well as the sac, which is unnecessary. The wound is closed by three sutures, the middle one including the divided ends of the internal tarsal ligament. A firmdressing should be applied so as to keep the walls of the cavity in contact. In tuberculous cases it is desirable to curette the lower end of the duct after removal of the sac. The stitches are removed on the seventh day.
Complications.These may be immediate or remote.
Immediate.1.Inability to find the sac.This may happen to a beginner, and is generally due to the fact that the dissection is carried too much inwards towards the nose. It should not occur if the guides to the sac carefully borne in mind, namely, the internal tarsal ligament and, on the inner side, the lachrymal crest, which can easily be felt with the finger or forceps in the wound.
2.Opening the conjunctival sac.This may take place when dividing the canaliculi. It is more likely to occur if the deep fascia has been imperfectly divided before carrying out the dissection to the inner side. As a rule the opening heals readily.
3.Opening of the orbit, due to the division of the fascia attached to the posterior lip of the lachrymal groove. It is recognized by the fact that orbital fat presents in the wound, and for this reason it makes the operation more difficult. It is most likely to happen when the lower end of the sac is being divided. It lays the orbit open to the possibility of septic infection. The internal rectus has been divided, no doubt due to the fact that the fascia, which passes from the outer surface of this muscle, is attached to the posterior lip of the lachrymal groove, and the musclehas been thereby pulled up into the wound; with ordinary caution such an accident is impossible.
4.Injuries to the cornea.Corneal abrasions by the clumsy insertion of retractors may lead to severe corneal ulceration.
Remote.1.Epiphora.Normally the lachrymal secretion is largely removed from the conjunctival sac by a process of evaporation. It is only when the hypersecretion of tears takes place that the lachrymal apparatus is called much into use. As a rule, patients who have had the lachrymal sac excised do not complain of epiphora, except in a cold wind. Occasionally this epiphora may be so troublesome that removal of the palpebral portion of the lachrymal gland is desirable for its relief. There is no fear of the conjunctival sac becoming dry after this operation, since there are numerous accessory lachrymal glands (glands of Waldeyer and Krause) opening on to the superior fornix.
2.A sinus.The wound may break down and a sinus may form at the site of the incision. These cases are nearly always of tuberculous origin and not infrequently have underlying bone trouble. They can usually be made to heal by the use of iodoform and scraping.
3.Recurrence of the mucocele or lachrymal abscess.Occasionally the mucocele may re-form, or an abscess result after removal of the sac. This is due either to a piece of sac-wall being left behind, or to the relining of the cavity with epithelium from the cut end of the duct. It is particularly liable to occur in cases of a tuberculous nature. Firm pressure with the dressings after the operation is the best method of preventing the cavity relining with epithelium. If the condition has arisen, the pseudo-sac should be excised.
Indications.Lachrymal abscess is due to an inflammation around the sac-wall through which infection of the cellular tissue has taken place. The abscess should not be opened until pus is present, as even considerable swelling and œdema will often subside without suppuration; this is usually about the end of the third day. Further, if the opening be made too soon, the inflammation takes considerably longer to subside.
Instruments.Beer’s knife, forceps, and probe.
Operation.Usually performed under gas. An incision is made over the lachrymal sac and is carried downwards and inwards to the bone by a single puncture of the knife. The pus is evacuated, and the cavity stuffed with gauze, which should be changed daily for the first three days. Hot fomentations should be applied. As soon as the swelling has subsided, the lachrymal obstruction should be treated by one of the methods previously described.
Excision of the Palpebral Portion of the Lachrymal GlandFig. 170. Excision of the Palpebral Portion of the Lachrymal Gland.The lid is doubly everted and the gland is dissected out from within outwards.
Indications.For obstinate epiphora after removal of the lachrymal sac.
Instruments.Fixation forceps (two pairs), two sharp hooks, strabismus scissors, suture.
Operation.Usually performed under adrenalin and cocaine.
First step.The upper lid is doubly everted. The eversion is best carried out by holding the singly everted lid between forceps and then re-everting it; the forceps are then given to an assistant to hold. With a syringe a few drops of 5% cocaine are injected through the conjunctiva into the area to be operated upon.
Second step.The gland is seen beneath the conjunctiva at the outer part of the upper fornix, seized with forceps, and drawn forwards. A horizontal incision is made with scissors through the conjunctiva, which is dissected backwards. The edges of the wound are then held apart by means of sharp hooks (Fig. 170).
Third step.The gland, which is seen as a nodule, is drawn forward with forceps. By means of the scissors the gland is separated from itsattachments along its whole length, starting on the inner side, the wound being subsequently closed with a few points of catgut suture.
Indications.It is usually undertaken for tumours (endotheliomata, &c.) and retention cysts.
Instruments.Knife, artery and dissecting forceps, retractors, ligatures.
Operation.Performed under a general anæsthetic.
First step.An incision, three inches long, is made through the skin immediately below the outer third of the orbital margin. The underlying orbicularis palpebrarum is divided, and the orbital fascia covering the gland is defined and incised.
Second step.The gland is first separated from the periosteum of the depression in the bone in which it lies, and is drawn forward and carefully dissected out from the lid. The wound is then closed with sutures.
An abscess in the lachrymal glandshould be opened by an incision similar to, but not so long as that in the above operation.
In this operation the bony outer wall of the orbit is divided above and below, and turned outwards so as to expose the orbital contents without interfering with the globe; the bony wall, being kept attached to the overlying tissue, can be replaced subsequently without fear of necrosis.
Indications.The operation is performed in cases of a suspected tumour of the orbit, which, if small and non-malignant, can be removed, the eye being leftin situ. If doubt exists as to the nature of the tumour a piece can be removed and examined microscopically, either at the time of the operation or later. It is especially suitable for tumours of the optic nerve and for orbital cysts behind the globe.
Instruments.Scalpel, dissecting forceps, artery forceps, scissors, periosteum detacher, chisel and hammer, or preferably, a motor rotary saw, and retractors.
Operation.Performed under a general anæsthetic.
First step.A slightly curved incision with the convexity forwards is made so as to expose the outer margin of the orbit and carried down to the bone. The periosteum is separated from the inner surface of the outer wall of the orbit by means of a periosteum detacher and divided horizontally, the finger is inserted, and the orbit explored. If a smalltumour or cyst be found it can sometimes be shelled out through this incision without enlarging the wound further.
Second step.The eye and orbital contents are carefully protected with a large flat retractor. The bone is first divided above, by means of either a chisel or a saw. The upper incision should pass through the base of the external angular process of the frontal bone, and run backwards and slightly downwards to the posterior end of the spheno-maxillary fissure. The lower incision should run directly backwards from the lower orbital margin into the spheno-maxillary fissure. The triangular wedge of bone attached by its outer surface to the soft tissues in the temporal fossa is then forced outwards. In doing this care must be taken not to fracture the orbital wall anteriorly, otherwise the space to work in will be much reduced.
Third step.Consists in the removal of the tumour. Care must be taken to displace the external rectus to one side so as to avoid injury to it as much as possible. If the case should be one of an optic nerve tumour, for which the operation is most frequently performed, the optic nerve is divided close behind the globe. The tumour is freed from the surrounding ciliary nerves and the ophthalmic artery and brought up into the wound as much as possible. The optic nerve is then divided at the apex of the orbit and the tumour removed. The wound in the periosteum of the outer wall of the orbit is closed with a catgut suture, the bone, together with the soft parts, replaced in position and the skin wound closed by sutures. A drainage tube should be inserted for at least twenty-four hours.
Complications.1.Proptosis.The operation is liable to be followed by great proptosis as the result of hæmorrhage into the orbit. If the optic nerve has been removed, the globe may be dislocated forwards between the lids and come in contact with the dressings.
2.Corneal ulceration.As the cornea is frequently anæsthetic from division of the ciliary nerves, ulceration is very liable to follow. It is, therefore, desirable in many cases to stitch the lids together after closing the skin wound.
3.Defective outward movement in the globeis of frequent occurrence, owing either to injury of the external rectus or the sixth nerve, or to involvement of them in the scar tissue. Stitching the periosteum together obviates the latter to a certain extent.
4. As the wound cicatrizes a certain amount ofenophthalmosis very liable to result.
Indications.This operation is usually performed for some form of new growth originating either in the eye or the orbit.
Operation.This may be modified (1) according to thepositionof the growth. In severe cases of rodent ulcer and sarcomatous growths, which involve the lids, it is desirable that the lids should be removed with the tumour; but in cases of tumour of the optic nerve, or disease situated far back in the orbit, and not involving the lids or conjunctiva, these structures may be retained, since a much better socket is thus obtained. (2) Thenatureof the growth. In simple tumours, such as nævi and some cases of arterio-venous aneurism which have failed to yield to other treatment, the incomplete method, in which the lids are retained, is all that is necessary, but in malignant cases they should be removed.
The Complete Method.An incision down to the bone is first made, completely encircling the orbital margin and including any growth that may be involving the skin. The periosteum is then separated completely, as near to the optic foramen as possible. Care must be taken in dealing with the periosteum over the lachrymal bone, as the bone is liable to be fractured and an opening made into the nose if undue force be used. The apex of the cone formed by the periosteum is divided, as far back as possible, with curved scissors, and the whole orbital contents are removed. The wound is packed with gauze, and skin-grafting is subsequently performed when the bone has become covered with granulations; this usually occurs about the end of the second week.
The Incomplete Method.The globe is first enucleated and the outer canthus divided. The lids are well retracted and an incision is carried down to the bone along the orbital margins. The periosteum is then stripped up from the walls of the orbit and the apex of the cone divided as far back as possible, as in the previous operation. The conjunctiva and outer canthus are then united with sutures. As a rule, skin-grafting is not necessary after this operation.
Orbital abscesses should be incised where they point. In the upper lid care should be taken not to divide the levator palpebræ muscle; the incision should be placed well to one side. In making an incision over the inner side of the orbit care should be taken not to detach the pulley of the superior oblique. The cause of the abscess should be ascertained if possible. Suppuration in the ethmoidal sinuses coming through from the nose is the commonest cause, and should be treated appropriately (see Section V).
SECTION IIIOPERATIONS UPON THE EARBYHUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)Aural Surgeon to the London Hospital
In order to perform successfully the various operations upon the ear, it is essential that the surgeon should be familiar with the technique of its examination, which, for the sake of convenience, will first be briefly described.
Clar’s LampFig. 171. Clar’s Lamp.
For this purpose it is necessary to make use of certain instruments in order to obtain a clear view of the deeper parts of the auditory canal and tympanic membrane. Most important amongst these are the following:—
Mirror.A head-mirror, such as the ordinary laryngological mirror with a focus of eight inches, is to be preferred to the hand-mirror, as it leaves both hands free for manipulation.
Sources of illumination.Although the light reflected from the sky on a bright cloudless day is excellent, it can seldom be made use of, and so for practical purposes the source of light is usually artificial. It is wiser always to use the same kind of light—for instance, electric—as in this way a more accurate comparison can be made of the various pathological conditions seen on examination. In the consulting room, the lamp recommended by Dr. Greville Macdonald, furnished either with a thirty-two candle-power frosted burner or with a Nernst light, is most suitable. As a portable lamp, it is useful to have an electric bull’s-eye lamp, run off from a dry-celled battery: it can be held in the position of theordinary lamp, the light being reflected into the ear by means of the head mirror. The ordinary surgical head-lamp, although not well adapted for inspection of the deeper parts of the auditory canal, is eminently suited for obtaining good illumination during the performance of the mastoid operations; or in its stead a head-mirror with lamp attached may be used, as recommended by Clar (Fig. 171).
Aural specula.Of the various aural specula employed, Gruber’s is very good (Fig. 172). A special speculum in which a portion has been removed from the narrow end is sometimes useful in order to facilitate operative procedures within the external meatus.
Forceps.The best are angular spring forceps with bulbous points (Fig. 173).
Gruber’s Aural Speculum
Fig. 172. Gruber’s Aural Speculum.
Angular Spring ForcepsFig. 173. Angular Spring Forceps.
Position of the patient.The patient should sit upright in a chair with the side to be examined turned towards the surgeon. To prevent movement, the head should be supported by an assistant or by a head-rest fixed to the back of the chair. The lamp is placed a little behind and to the left of the patient’s head, on a level with the head of the examiner.
Technique of examination.To convert the external meatus into a straight canal, the auricle has to be pulled backwards and downwards in an infant, backwards in a child, and backwards and upwards in an adult. The speculum should be warmed and inserted gently into the meatus by the thumb and index-finger of the left hand, whilst the pinna is held between and pulled back by the second and third fingers (Fig. 174). This leaves the right hand free for manipulation. The largest possible speculum should be used, in order to give the maximum amount of room and illumination. It should only be introduced into the meatus as far as the adaptable cartilaginous portion permits—about half an inch in the adult—and not forced into the bony portion. The utmost gentleness is essential in order to obtain the confidence of the patient; this is absolutely necessary for the performance of the various small operations upon the auditory canal and tympanic cavity under local anæsthesia.
Examination of the EarFig. 174. Examination of the Ear.
Aural Forceps holding Cotton-woolFig. 175. Aural Forceps holding Cotton-wool.
Method of cleansing the ear.Except when the auditory canal is completely blocked by inspissated pus, cerumen, or epithelial débris, it is sufficient to mop out the ear with small pledgets of cotton-wool. To prevent injury to the walls of the meatus and to the tympanic membrane, the pledget is held between the blades of the forceps in such a fashion that it partially projects beyond its points (Fig. 175). The forceps is passed through the lumen of the speculum along the auditory canaland then quickly withdrawn. This is repeated with fresh pledgets until the meatus is cleansed. If there is much purulent discharge, only a brief moment may be given (after the withdrawal of the forceps) in which to inspect the deeper parts. Such a view, however, should always be obtained in order to form an accurate diagnosis. If this method fails to cleanse the ear, syringing becomes necessary.
Technique of syringing.The patient should be sitting down, as syringing may cause giddiness. The fluid should be aseptic, and at a temperature of 100° F. The patient’s head is inclined to the affected side, and the auricle is pulled upwards or backwards. The syringe is inserted a short distance within the meatus, and applied to the upper posterior wall so that the stream of lotion flows along the roof of the canal to the drum, and returns along the floor, thus washing out the contents. The best syringe is one with a metal plunger, as it can be easily sterilized. After syringing, the auditory canal should be dried and again inspected. If the inspissated pus or epithelial débris cannot be removed by simple syringing, an ear-bath of warm hydrogen peroxide (10 vols. %) should be given, and the ear again syringed after ten minutes.
Milligan’s Intratympanic SyringeFig. 176. Milligan’s Intratympanic Syringe.
Syringing out of the attic.In certain cases of chronic attic suppuration, it is advisable to syringe out the attic. For this a special syringe is necessary. It consists of a fine canula whose point is turned up almost at right angles to its shaft (known as Hartmann’s canula), to which is fitted a piece of india-rubber tubing and a ball syringe. Milligan’s modification of this instrument is now generally used, as it permits of the canula being held in the hand, and instead of having a ball syringe, is connected by rubber tubing to a small irrigator (Fig. 176).
The patient sits upright in a chair in the ordinary position for examination of the ear; a speculum is inserted into the meatus, and held in position with the left hand; the canula, together with the ball syringe (if Hartmann’s is used), is held in the right hand. Under good illumination the canula is passed inwards along the auditory canal, and its point inserted through the perforation. By gently pressing on the syringe, the fluid is forced into the attic, which is thus washed out.
With Milligan’s instrument, the irrigator is fixed about two feet above the level of the ear. While the canula is being inserted, the escape of lotion is prevented by compressing the tube against the shaft of the instrument by means of the thumb. After the canula has been inserted into the opening, relaxation of this pressure permits of flow of the lotion. Milligan’s method is better than Hartmann’s, as the surgeon has more control over the instrument. Pain due to the introduction of the canula may be greatly minimized by previously inserting within the margins of the perforation either a pledget of cotton-wool soaked in a saturated solution of cocaine, or a crystal of cocaine.
After the cavity has been thoroughly washed out, the auditory canal is carefully dried as a final step, gentle inflation by Politzer’s method may be performed in order to expel any fluid still remaining within the attic.
In this connexion two points must be borne in mind: (1) The surgeon must have a good view of the part operated upon. For this reason when operating upon the auditory canal, the tympanic membrane, and tympanic cavity, he will usually require to work by reflected light.
(2) There must be no movement of the patient’s head during the operation. If the operation is performed under a local anæsthetic, it is therefore very important that the patient’s head should be kept fixed by means of an assistant.
Preliminary surgical toilet.If there be no existing suppuration, the ear should be cleansed, some twelve hours before the operation, by first giving an ear-bath of hydrogen peroxide lotion. This is done by making the patient incline the head to the opposite side so that the affected ear is uppermost. The warm solution is then poured into the meatus. After ten minutes the ear is syringed out with a 1 in 5,000 aqueous solution of biniodide of mercury, and a strip of sterilized gauze is then inserted into the auditory canal. The auricle and surrounding parts should also be surgically cleansed, and afterwards protected by a simple aseptic compress. If, as in furunculosis of the external meatus, syringing or cleansing of the ear is very painful, drops of a 10% solution of carbolic acid in glycerine may be instilled frequently into the meatus instead. If there is an existing otorrhœa, it is obviously impossible to render the field of operation absolutely aseptic. The ear, however, should be cleansed, but the auditory canal should not be plugged with gauze. The existence of a purulent discharge is no excuse for lack ofcleanliness. Failure of such precautions may lead to disaster; for example, to perichondritis of the auricle as a sequel of the mastoid operation.
Before the actual operation takes place, if necessary after the anæsthetic has been given, the ear and surrounding parts should again be carefully cleansed, and the auditory canal syringed out with biniodide of mercury solution.
In intrameatal operations the head should be wrapped in a sterilized towel, and a square of sterilized lint, having an aperture in the centre so as to expose only the auricle and meatus, should be placed over the side of the head and face. In operations on the mastoid process, and in those involving a post-auricular incision, the head should also be shaved for at least two or three inches beyond the region of the ear.
Anæsthesia.Both local and general anæsthesia are used. Unless contra-indicated for some special reason, and unless the operation is a very trivial one, it is wiser to give ageneral anæsthetic. Of these, chloroform is the most suitable in adults and infants, and the A. C. E. mixture in children. Ether, although it may be safer, is frequently a source of annoyance to the operator, as it tends to increase the hæmorrhage.
In order to producelocal anæsthesiatwo methods may be employed: (1) The instillation of fluids into the meatus; (2) subcutaneous injection of fluids beneath the lining membrane of the meatus and into the surrounding parts of the auricle.
The solution usually employed is a sterilized aqueous solution of cocaine hydrochloride in varying strengths up to 20%, to which may be added equal parts of 1 in 1,000 adrenalin chloride solution; the latter not only increases its analgesic properties, but also acts as a powerful hæmostatic.
Instillation.As the auditory canal and the tympanic membrane are lined with epithelium which is very resistant to the absorption of fluids, complete anæsthesia is almost impossible to obtain. This method, therefore, is practically limited to such trivial operations as the curetting away or snaring off of granulations or polypi from the external or middle ear. To render anæsthesia more complete, the affected part may be finally rubbed over with a crystal of solid cocaine hydrochloride just before the operation—is begun. On the other hand, if the raw surface is large—for example, the wound left after a recently performed complete mastoid operation—the cocaine employed should not be stronger than a 5% solution in order to minimize the risk of poisoning. Gray of Glasgow has suggested, as a more penetrating anodyne solution, a mixture consisting of a 10% solution of cocaine hydrochloride in equalparts of aniline oil and absolute alcohol, a solution which he especially advocates in order to produce anæsthesia of the tympanic membrane before doing paracentesis.
Subcutaneous injection.This is a modification of Schleich’s method, and was first introduced by Neumann of Vienna. It consists in injecting a very weak solution of cocaine and adrenalin chloride subcutaneously beneath the periosteum lining the auditory canal. By this method even the complete mastoid operation has been performed, and in certain clinics it is used continually in the minor operations of paracentesis of the tympanic membrane, division of intratympanic adhesions, extraction of polypi, and ossiculectomy. A solution of beta-eucaine or novocaine may be used in preference to cocaine, as being less dangerous. According to Neumann, three solutions are necessary: (a) a 1 in 2,000 solution of adrenalin chloride containing a 1% solution of beta-eucaine; (b) a 1 in 3,000 solution of adrenalin chloride containing a 1% solution of cocaine; (c) a 20% solution of cocaine.
Neumann’s Syringe for Subcutaneous InjectionFig. 177. Neumann’s Syringe for Subcutaneous Injection.
The syringe for injecting the solution has a capacity of 1 cubic centimetre, and for convenience its needle is fixed at an obtuse angle to the body of the syringe (Fig. 177). The technique of the injection depends on whether the operation is to be limited to the auditory canal and tympanic cavity, or is to involve the mastoid process.
If the complete mastoid operation is going to be performed, the needle of the syringe, now filled with the eucaine solution, is thrust through the skin about the middle point of the mastoid process, and a few drops of the solution are injected. The needle is then forced upwards towards the temporal ridge, at the same time being thrust in deeply until it touches the bone, so that a syringeful of the solution is injected beneath the periosteum. The needle is then withdrawn and reinserted at the same point, but in a backward direction, the solution being injected along the posterior portion of the mastoid process; in a similar manner the solution is injected downwards towards the tip of the mastoid. The ear being now pulled well forward, the needle is made to pierce the fold between the auricle and the mastoid process, just above the posterior ligament, and is pushed inwards between the anterior border of the mastoid process and the cartilage of the meatus, anda further syringeful of the solution is injected. A large speculum is now inserted into the ear, so that by pressing it against the wall of the meatus the skin, at the termination of the cartilaginous portion, is made to project in folds. The needle of the syringe, filled with cocaine solution, is pushed into this fold, and a few drops of the solution injected. By degrees the needle is still further pushed inwards, keeping it in close contact with the bony wall so that the fluid is injected beneath the periosteum. If the injection has been successful, a white bulging of the superior wall of the auditory canal will be noticed. To render anæsthesia complete, further injections may be made into the inferior and anterior walls of the auditory canal. Finally, a pledget of cotton-wool soaked in a 20% solution of cocaine is pushed into the tympanic cavity.
In the case of simple opening of the mastoid, subcutaneous injections into the auditory canal are not necessary. On the other hand, if the operation is limited to the auditory canal and tympanic cavity, the injections into the mastoid process are not required, but a primary injection of a small quantity of eucaine solution into the auriculo-mastoid fold considerably diminishes the pain produced during the act of injection into the auditory canal. Fifteen minutes should be allowed to elapse before the operation is begun. The anæsthesia lasts about half an hour.
Difficulties.It is by no means easy to inject fluid beneath the periosteum of the auditory canal, owing to its close adherence to the bone. The needle by mistake may repierce the skin at a point farther in, so that the fluid, instead of being injected beneath the periosteum, is injected into the auditory canal itself. In these cases anæsthesia will not be obtained, and the operator may possibly blame the principle of subcutaneous injection, rather than his own faulty technique.
In favour of subcutaneous injection it is urged that most of the minor operations within the tympanic cavity, including ossiculectomy, may be performed with the patient sitting up in the chair in the consulting room, and further, that the patient can afterwards go home; that the operation is rendered more easy owing to there being practically no bleeding; and that in the case of the more severe operations, such as opening of the mastoid antrum, the surgeon, in a case of emergency, may make use of this method if he cannot possibly obtain the services of an anæsthetist.
Against subcutaneous injection is the pain of the injection, which may be so great that the patient will not submit to it, and in consequence the proposed operation may have to be postponed.
In the case of the mastoid operation, it is difficult to believe that local anæsthesia, however efficient, will be looked upon with favour either by thesurgeon or by the patient, except when a general anæsthetic is absolutely contra-indicated. The discomfort produced by retraction of the parts, the jarring caused by chiselling, and the consciousness of what is taking place, are far more unpleasant and more of a shock to the patient, than a general anæsthetic carefully given. Further, it is not always possible to foretell the extent of the operation, and if repeated injections become necessary, there is danger of eucaine or cocaine poisoning being produced.
Position of the patient and the surgeon
1. In the minor operations the patient may be operated on whilst in the sitting posture, whether a local anæsthetic or a general one of gas and oxygen is employed. The relative positions of the patient and the surgeon are then the same as for the ordinary routine examination of the ear. Special care, however, should be taken that the patient’s head is supported by the anæsthetist or assistant in order to prevent involuntary movements.
2. If the patient is operated on in the recumbent position, the head may rest comfortably on an ordinary pillow, but if chiselling is going to take place, the best support is a loosely filled sand-bag. The head should be turned towards the opposite side so that the affected ear is uppermost, and the surgeon stands at the side to be operated on. The lamp, the source of reflected light, should be held about six inches above the patient’s shoulder on the opposite side.
The operative treatment consists in incising the furuncles and, if necessary, curetting out their contents.
Indications.(1) If, in spite of palliative treatment for two days, the pain be so intense as to prevent sleep, and be accompanied by pyrexia.
(2) If there be accompanying œdema of the auricle and surrounding parts.
(3) If the furuncles occur during the course of a middle-ear suppuration, and occlusion of the external meatus prevents free drainage of the purulent secretion.
When possible, it is always preferable to operate under a general anæsthetic, such as gas and oxygen. If, however, the patient objects to a general anæsthetic, it should be explained that, in spite of the application of anodynes, the operation, although of momentary duration, will be excessively painful.
Operation.After the ear has been thoroughly cleansed, a large aural speculum is inserted within the meatus and the auditory canal dried with pledgets of cotton-wool.
The instrument usually used for this operation is a small and narrow sharp-pointed knife known as Hartmann’s furunculotome (Fig. 178,C). Equally suitable, however, is a fine bistoury; or, if necessary, a small tenotome or the ordinary paracentesis knife.