484

RHINOLOGICAL RECONSTRUCTIVE SURGERY*

By BRIAN 0 'BRIEN, M.Ch.,

St. Vincent's Hospital, Dublin.

M A Y I, at the outset, say ~hat this communicat ion is not on the subject of " Plastic Surgery ". I t is r a the r a recount ing of my own considered views on the t rend (or changing pat tern) of nasal

surgery as I see it. Many of you will disagree with much of my out- look and I hope you will say so - -our discussions are the most valuable pa r t of our Meetings.

In m y very ear ly days in our specialty radical nasal surgery was still very much to the fore in the t r ea tment of acute and chronic nasal sinus disease. Acute f ronta l sinusitis was an emergency every bit as real as an acute abdomen and os~eomyelitis of the f ronta l bone with all its t e r r i fy ing sequelae was not uncommon. In an effort to prevent in- t racrania l spread of infection widely destruct ive operat ions were d e v i s e d and carr ied out. We were quite famil iar then with cavernous sinus ~hrombosis and ~he awful death which followed it so often.

Operat ions on nasal sinuses sometimes were followed by a rap id ly spreading streptococcal septicaemia and pyaemia of a severi ty unknown today. Not all nasal sinus operat ions dealt with problems of this magni tude, but whatever the problems they were not lessened by the methods of anaesthesia which were then available. I n many cases the d e s i r e d results did not follow the operation. Indeed, it must be ad- mit ted tha~ in a significant propor t ion of cases damage to nasal funct ion left the pa t ien t with a nose which was to be a constant source of dis- comfort to him. Of course, the dissatisfied pa t ien t was often more vocal than he who had benefited f rom his nasal surgery and a belief became widespread among the lay public, and even in the medical profession, that a nasal operat ion might at t imes be unavoidable but tha t it was likely to lead to a t ra in of repeated nasal operations, each one more uncomfortable than the previous one and each one leaving some new discomfort.

Today, increasing knowledge of the nasal physiology and especially the working of the a l l - important ci l iary epithelium has al tered the whole approach to nasal surgery. Destruct ive surgery has given way to re- pa ra t ive operat ions designed to aid and restore function. Outs tanding among those who have advocated conservatism in dealing with the nose has been " Proetz " who in 1930 demonstra ted convincingly the impor- tance of the tenacious mucous blanket covering the ciliated nasal epithelium. I t was shown tha t antiseptic agents capable of destroying bacter ia in ~he nose would also destroy the cilia with disastrous results to the fu tu re nasal function. Radical removal of nasal and nasal sinus epithel ium was shown to produce ha rmfu l results which more than nega- t ived the t empora ry relief of acute infection. Nevertheless, acute and virulent suppura t ion often left no al ternat ive to radical surgery if the grea ter evil of in t racrania l spread of infection, ca r ry ing a very high

* Being the :Presidential Address delivered to the Section of Otorhinolaryngology, 10th February, 1956.

RHINOLOGICAL RECONSTRUCTIVE SURGERY 485

mortality, was to be avoided. Something further was needed before preservation of function could be gambled against the real danger to life.

The next advance was to be provided by the chemist. In the 1930's Prontosil and the succeeding sulphonamides showed that a greater degree of conservatism in the treatment of upper respiratory suppura- tion was justifiable and desirable. Sir Alexander Fleming with his dis- covery of penicillin and its antibiotic properties consolidated this advance and virtually removed the need for radical nasal surgery in acute suppurative nasal disease and has, to a large extent, altered our entire approach to chronic sinusitis.

At last, nasal surgery could really claim to be reparative. It does not mean that the need for surgery has disappeared, but 'that the faulty functioning elements of the upper respiratory tract, in future, are to b~ helped back to health rather than discarded. Surgery will play its essential part in the correction of anatomical abnormalities which are preventing normal nasal function. It is a new, more understanding surgical treatment where the surgeon must never cease to be at one and the same time a nasal physiologist, physician and operator. It calls for more delicate technique and makes new demands on the surgeon, but our difficulties are mitigated by the advances made by our anaesthetic colleagues whose technical developments have transformed the ease with which we can approach our field of surgery and who have achieved for us 'the bloodless field which alone allows refinements of surgical technique hitherto unattainable. As one who has worked through the years in which the open ether inhalation anaesthetic gave way to the kindlier induction agents which allowed the postponement of ether fumes until unconsciousness disguised its irritating and nauseating properties up to today, when premedication and intravenous anaesthesia has removed fear from even the most timid of us it is a pleasure to pay tribute to our debt to the skilled anaesthetist who today wields his armamentarium of analgesics and anaesthetics with such skill and safety.

All this emphasis might suggest that nasal surgery will seldom be required in the future. Yet tremendous and far-reaching though the influence of antibiotics has been in acute nasal sinus disease their effect on established suppuration of the nasal sinuses, especially in the case of the maxillary sinuses, is limited. Acute suppuration of the antra leads to paralysis of ciliary action and when the products of inflammation. accumulate this breakdown of the essential means of removing it leave~ behind a septic tank and a vicious circle of infection, followed by ciliary paralysis, followed by further extension of infection. The recovery power of nasa] mucosa is considerable, but unless the septic tank is emptied and further accumulation prevented the ciliary epithelium will be replaced by stratified epithelium and eventually a reticulo-fibroblastic~ reaction; by then the mucosal changes will be irreversible.

What then is the par~ to be played by surgery today in nasal sinus: suppuration as it applies to the most commonly involved sinus--the maxillary antrum ? Four methods of surgical treatment have their place ::

1. Antral irrigation.

2. Simple drainage of the antrum without removal of the mucous; membrane.

486 I R I S H J O U R N A L OF M E D I C A L S C I E N C E

3. Submucous resection of the nasal septum.

4. The sublabial or Caldwell-Luc approach with excision of the mucosa.

In the early acute stage adequate and appropr ia t e antibiotic t reat- ment combined with short and intensive vasoconstriction methods to promote drainage f rom the affected sinuses should be energetically pushed dur ing the ear ly invasion stage and it should not be forgot ten tha t rest in bed to allow mobilisation of the body's resistance forces is an essential pa r t of the t reatment . Pa in should be controlled by analgesics. The temptat ion to puncture the an t rum at this ear ly stage

shou ld be resisted even where pa in localises the site of the lesion in one or both antra. I t should be remembered that the entire u p p e r respira- to ry t rac t is involved and even minor surgical t r a u m a is be t ter avoided unt i l the affected an t rum is a localised area of persistent suppura t ion in a nose in which the generalised acute invasive stage is subsiding. Even the anxiety to relieve the tension pa in of an acute maxi l lary sinusitis is ra re ly justified as it is precisely at this stage tha t the mucosal react ion to infection is most extreme and pus format ion is not the cause of the pain. In those rare eases where extreme pain overrules one's bet ter judgment and lavage is decided upon general anaesthesia should be used as the mucosal oedema prevents adequate action of surface anaesthetics. I f the t ime for lavage has been well chosen the relief is s t r iking aad even in severe at tacks a fu r the r washout ~ week later may reveal a normal clean ant rum. In my opinion a shorter intervM than this between washouts is, if not actuMly harmful , cer ta inly not helpful. The local appl icat ion of antibiotics either in the fo rm of drops or by using an indwelling polythene tube does not appea r to offer any ad- vantage over systemic adminis t ra t ion dur ing the invasion stage and the tube introduces an undesirable element of t rauma. In the la ter chronic stage simple drainage would seem to be at least as effective; since the introduction of the tube requires an intranasM antrostomy, it seems bet ter to look upon such t rea tment as being one of drainage and ensure an adequate antrostomy.

This brings me to the second line of t rea tment , viz., surgical dra inage of the ant rum.

Where improved an t ra l dra inage holds the key to recovery I am more and more eonvineed tha t an t ros tomy is of little, if any, value and that i f adequate venti lat ion of the normal ostium is secured the an t rum will, if dra inage is the answer, achieve it through the normal ostium. To do this it may require a submucous resection of the nasal septum and f r ac tu re of an oedematous middle turb ina l without sacrificing the anter ior half. Occasionally crushing of a cystic turbinal may be necessary.

The submucous resection of the nasal septum remains the most valuable measure in our hands for restorat ion of normal nasal function. Rare ly if ever does persistent infection of an an t rum occur without there being a co-existing obstruction to its drainage in which an abnormal nasal sep tum is a decisive fac tor ; until its correction is complete all other methods of surgical t r ea tment are doomed to failure. I~ is also a fact tha t where a submucous resection is under taken it must be an extensive one. F a r too many of these operations have been l imited to removal of

R H I N O L O G I C A L R E C O N S T R U C T I V E SURGERY 487

a localised area of septal carti lage and have not achieved the purpose of the operation. A real ly complete septal resection should provide the basis for sat isfactory t rea tment of recurrent ethmoidal and frontal sinus suppurat ion. I t has been general experience in recent years that radical operat ions on the f ronta l sinuses have no place in nasal surgery today. In pre-antibiotic days such operat ions were ra re ly necessary and seldom sat isfactory in their results. Today they are quite cont rary to our con- ception of the rSle of surgery in restoring normal nasal physiology.

I have left to the last the r a d i c a l ope: ra t ion on the an t rum with removal of its l ining membrane. The necessary indications for these operations would also seem to be disappear ing rap id ly and to be confined to those cases where long-continued suppura t ion was established before anti- biotic t rea tment was available or where infection, perhaps because of unwise surgery, has become superimposed on prol i ferat ive allergic rhinit is and sinusitis. This polypoid hype r t rophy remains the most un- sa t is factory nasal condition with which to deal and for which we have as yet no adequate answer, but we have increasing evidence that fu tu re t rea tment will be along medical lines.

I t will be apprecia ted tha t the surgery of oro-ant~'al fistula poses different problems to those under discussion and may call for extensive operations other than the securing of adequate sinus drainage. So also will mal ignant disease of the nasal sinuses call for radical and often very destructive operations, but these are subjects for separate discussion.

The purpose of this pape r has been to stress what might be te rmed " the changing pa t te rn of nasal surgery " and one of the most signifi- cant changes has been the realisation that restorat ion of function does not complete our responsibil i ty if the pat ient is left with an ugly nose. I t is also our du ty to t r y to restore its original shape. The nose is such a conspicuous fea ture tha t if it is ugly or deformed it may condemn its owner to suffer ridicule or, at least, be a source of very great embarrass- ment. There may have been a t ime when personal appearance was accepted as unavoidable but this is no longer so and today it is a reflec- tion on us if pat ients have to go elsewhere for relief. I t is not only on the stage tha t an ugly nose may be a bar to employment. I t is said tha t had Cleopatra ' s nose been a shade shorter Mark Antony might have mar r ied her and changed the entire his tory of the world.

Most of the nasal deformities which require correction are the result of nasal f rac tures which may, or may not, have been recognised as such at the time of happening. Very many of these cases are indeed missed and it is impor tan t to remember if a child is s t ruck or falls on the nose and if bleeding f rom the inside of the nose follows there has been a f rac ture ; the bleeding occurring because the edge of a bone has cut through the mucosa. The simplest case of this kind is where there is depression of a bony f ragment which can be restored with the aid of a surface local anaesthetic by simple elevation with an ord inary a r te ry forceps covered with gauze or rubber. While rais ing the bone the free hand can mould the bones into position and while doing this a distinct " click " can usually be felt and often heard as the bones go back into place. In a simple case no internal or external suppor t is required. The ideal t ime for replacement to be pe r fo rmed is immediately af ter the accident before swelling has occurred. Delay increases the difficulty of

488 I R I S H JOURNAL OF MEDICAL S CIEN CE

satisfactory restoration and necessitates splinting to maintain the bones in position.

I f the in ju ry has been more severe there will usually be a dislocation or f rac ture dislocation of the nasal septum and, I personally, am not satisfied that where septal replacement is required I can achieve it with- out open operation and resection of the displaced septum and associated vomerine bony spur. I t is my belief that, unless such steps are taken when the t rauma is of recent origin they will have to be taken at a later date when bony fixation and established deformity make the repair a fa r more troublesome matter.

When the correction of established bony deformity is called for ] suggest to you that it should be under taken by our specialty by vi r tue of our t ra ining and experience in dealing with the nose and its problems.

Briefly there are certain varieties of deformity which present them- selves for correction :

1. There is the " hump-backed " nose and with it the abnormally large nose, both types which require surgical reduction and lowering of the dorsal line with or without shortening and possibly narrowing of the nose.

2. There is the " depressed " or " saddle " type of nose which pro- duces such an ugly deformity.

In the case of the first group, al though each problem must be con- sidered on its merits certain basic methods are common to all. The first of these is the incision between the upper and lower lateral cartilages f rom within the vestibule on each side. The incision should be started lateral ly to swing medially and forward between cartilage and skin unti l it reaches the dorsum of the septum, when it swings first towards the tip and then downwards through the membranous septum thus separat ing the carti laginous septum from the columella. Through this incision the skin is f reed f rom the entire dorsum of the nose and the carti laginous and bony skeleton of the nose is exposed for t rea tment whether it be removal of a hump or the reduction in size of the entire nose.

I t is seldom possible to remove a hump without narrowing of the nose also being necessary; to effect this, a fur ther incision is required on each side just inside the nostri l base to allow a nasal saw to cut through the f ronta l process of the maxilla on each side unti l it can be f rac tured medially and produce the required narrowing. I f shortening of the dorsum of the nose is required it is achieved by excision of a piece of the lower end of the septum which in the original incision has been freed from the columella; following this excision, the new lower end of the carti laginous septum is su tured back to the membranous septum and columella. This reduction of septal length is exceedingly important and calls for careful judgment if a satisfactory tip of the nose is to result, and it is quite surpr is ing how ugly a deformity an unduly re- t racted columella can produce. Finally, the shortening of the septum brings into prominence redundan t upper lateral cartilage which must be t r immed on each side.

So much for the problem of deformities which require reduction of the nose.

There is also the " saddle " type depression of the nose which calls

R H I N O L O G I C A L R E C O N S T R U C T I V E S U R G E R Y 489

for a building up of the nasal profile to restore its contour and to correct an ugly defect produced by the collapse of the cartilaginous bridge of the nose whether f rom fracture , abscess, specific disease or operative removal of the nasal septum. Such a restorat ion of support requires a t r ansp lan t ei ther of bone or cart i lage or some inert substance according to the taste of the operator. I t is not my intention to express an opinion on the meri ts of the different mater ia ls used; all have advantages and disadvantages.

Whatever mater ia l is used large one-piece dorsal t ransplants give excellent support , and the simplest and possibly best method of insertion is through an external columellar incision which allows a shaped trans- p lant to be inserted on the dorsum of the nose over the nasal bones.

In l imit ing my references on corrective surgery to two pr incipal classi- fications according to whether the emphasis is on the reduction of de- fo rmi ty produced by overgrowth of one or more elements of the nasal f r amework or whether the problem is one of building up collapsed or lost portions of the nasal scaffolding, I realise that 1 have but touched on the f r inge of a very considerable field of nasal surgery. I t has been my intention to commend this work to your interest.

I am aware that the nose is only pa r t of ~he problem. F rac tu res of the facial skeleton are of common occurrence in the accidents of today. How seldom we see these cases which, more often than not, are allowed to resolve with unreplaced f rac tures to produce la te r facial and alveolar deformities which are in many cases preventable.

I f my communication has any purpose at all it is to endeavour to arouse your interest and to encourage you to expand your field of action beyond the narrow, sometimes self-imposed, boundaries of ~he past.

I f we neglect this oppor tun i ty we shall see our field suffer fu r the r shrinkage. We have only to remember tha t bronchial and oesophageal disease was first s tudied and t reated by otolaryngologists only to be lost la ter to the thoracic surgeon.

In our own specialty the time of re t reat has come to an end - -we must, once again, expand our frontiers.

Discussion.

Mr. J . M. CURTr~r : I th ink we mus t offer to the President th is evening our sincere thanks for his ex t remely interesting communicat ion. Wi th regard to the first par~ there m a y be some points on which I disagree. I think, as he says, the less you do to an acute condition the bet ter . I do not feel tha t antibiotics have been quite the answer to the problem, bu t we are forced to use them. I am puzzled to know w h y he favours a general anaesthetic for an an t rum puncture . Wi th regard to sinusitis I th ink tha t when it occurs during pregnancy it is often very difficult to manage. The pat ient suffers a lot of pain and usually has a thick discharge. My own experience with regard to the Caldwell-Luc operat ion is tha t it is very sat isfactory for a dental cyst or polypus. I m p r o v e m e n t of ugly noses. I th ink tha t we all agree tha t it is a. ma t t e r for ourselves to be able to show tha t we are the people who can do this type of work bet ter t h a n anyone else. Does he favour the use of hypotensive anaesthesia ? Does he take any ext ra precaut ions to control the ccchymosis which occurs ? Falls and fractures in children are always neglected. I th ink it is wor th while doing septum operations in children. I n the improvement of saddlenose I have always favoured the use of the iliac crest. I th ink the incision which he describes was first advocated by Sheehan of New York ; it has this advantage tha t you can go in m a n y t imes if you are not satisfied.

Mr. T. G. W~LSON : I have listened wi th great pleasure to this paper. I th ink the place for the polythone tube probably is in the chronic case wi th c reamy pus. You can often restore tha t a n t r u m to normal by pu t t ing in a tube and leaving it there for a b o u t

490 IRISH JOURNAL OF MEDICAL SCIENCE

four days . I agree t h a t we should no t a l low the p las t ic surgeons to do us out of t h i s t y p e of work . I would l ike to k n o w w h a t is the bes t i m p l a n t for saddle.nose. I f you t a k e i t f rom the i l iac crest i t absorbs qu i c k ly a nd m a n y of the i m p l a n t s of t h a t n a t u r e have been absorbed. I h a v e been us ing po ly thene imp lan t s , and t h e y are v e r y satis- fac tory . I t is said t h a t one of t he d i s a d v a n t a g e s is t h a t t h e y work out, b u t I t h i n k t h i s is p r o b a b l y e x a g g e r a t e d . Y ou do need to ge t t h e m wel l b e d d e d in.

Mr. WOODS : Mr. O 'Br icn m u s t be one of the fo r tuna te i nd iv idua l s who has never had an acu te infec t ion of the a n t r u m . I f he h a d he would know t h a t the one t h i n g which is 100 per cent . is to ge t i t washed ou t as soon as you poss ib ly can. I have had th i s done on m a n y occasions, a nd I feel t h a t i f he t e l l s his p a t i e n t s t h a t t h e y h a v e to go to bed for a week or so he is m a k i n g a b ig t h i n g out of some th ing which is no t a b ig th ing .

Mr. T. O. GRAHAM : We h a v e h a d a v e r y full discussion on this , and I m u s t say I would agree w i t h Mr. Woods. I w o u l d l ike m y a n t r u m w a s h e d ou t u n t i l t he p a i n is r e l i eved ; morph ine wil l not re l i eve i t . Give an t ib io t i cs by all means , b u t do the wash ou t as well . W h e n I am do ing p las t i c work I use an i m p l a n t f rom a r ib. I m a k e m y incis ion a lways jus t b e t w e e n the eyes for al l of us have a crease there and i t does no t show. I do not r e m e m b e r see ing one absorbed.

Mr. O'BRIE~ (Cork) : The d iagnos i s of the de fo rmi ty is v e r y i m p o r t a n t . You m u s t be v e r y careful of a t w i s t e d nose. I used a lways t a k e photographs , b u t have no t been do ing th i s la te ly , b u t I a l w a y s t a k e a cast . I t is v e r y i m p o r t a n t to h a v e a record of the p re -ope ra t ive face and nose for medico- lega l purposes . I a lways do the fo rmal operat ion, and I t h i n k i t is a v e r y good one. Saddle-nose can g ive the m o s t spec tacu la r resul ts . T h e y are v e r y obvious a n d t h e y are no t as easy as one is led to believe, b u t I got the impress ion t h a t the P r e s i d e n t dea l t w i t h i t r a the r l ight ly . Y o u h a v e to r e m e m b e r t h a t the nose is s t i c k i n g out, and you m a y have to nar row it . I f i t is due to s e p t u m d e f o r m i t y you m u s t t a k e i t al l down. I t a k e a cas t and I w o r k on i t . I f you t a k e a graf t you w a n t to k n o w w h a t size you are dea l ing wi th . You w a n t to be careful where you m a k e y o u r incision. Y ou w a n t to t a k e down the b o n y nose u n t i l i t is abso lu te ly flat, t h e n c lear ou t the debr is and graf t in.

THE PRESIDENT (Reply) : This paper was a t es t on m y p a r t to see i f the m e m b e r s of t he Sect ion are in te res ted in th i s subject . I would l ike to t h i n k t h a t i t is an e x p a n d i n g field and t h a t we m i g h t m a k e an effort to p roduce cases of t h i s t y p e a t c l in ica l sessions so t h a t we m i g h t accumula te knowledge. My feel ing is t h a t the surgery which we u n d e r t a k e should e x p a n d . Mr. Cur t in was inc l ined to d isagree on the va lue of ant i - biotics, b u t in acu te s inus i t i s if we do not accept the effect iveness of an t ib io t i c s how can we e x p l a i n the a lmos t t o t a l d i sappearance of these cases f rom our p r ac t i c e s ? Mr. Wi l son m e n t i o n e d the ques t ion of p o l y t h e n e t r a n s p l a n t . We h a v e been us ing one, and so far i t seems to be effect ive. We have no t ha d enough cases y e t ; we can on ly w a i t and see. I do no t d i sagree w i t h Mr. Woods or Mr. G r a h a m in s ay ing t h a t a wash -ou t is of ten necessary . On m a n y occasions I h a v e washed one out, and h a v e fa i led to ge t a n y pus out and I found t h a t the p a i n was inc reased a f te rwards . I agree t h a t once pus is p resen t i t m u s t be r emoved .