1909 Journal of the American Medical Association  
Perforations in the course of submucous resections of deflections of the nasal septum are, in my experience, oftenest made during the denudation or excision of the bony part of the deflection after the removal of its car¬ tilaginous portion. Nearly all of these perforations occur in baring the so-called ridge of its periosteal cover¬ ings, the term "ridge" being used to describe the bony Fig. 1.-Raspatory for the denudation of bony deflections of the nasal septum. wall which, arising from the
more » ... arising from the nasal floor, forms the base of the septal skeleton and is composed of the incisor crest, anterior end of the vomer and superior maxillary crest. The ridge may be so low that it is barely indi¬ cated, or it may form a bony partition whose height may even reach five-eighths of an inch. When the septum is deflected into one or the other nostril, the ridge bends over into the naris of -the convexity of the deviation in a varying degree, so that in extreme cases it may lie almost flat on the nasal floor. The periosteum covering the ridge is commonly firm, thick and vascular and envelops its upper border, crossing over it into the other nostril. The periosteal envelope of the ridge is, therefore, dis¬ tinct from the perichondrial envelope of the cartilage of the septum, but perichondrium blends with periosteum along the top of the ridge, which thus marks the place where both perichondrium and periosteum of one side are continuous with these membranes on the other side of Fig. 2.-The left nostril, held open with retractors ; the clotted line, a, shows the incision which splits the periosteum along the upper border of the "ridge;" b, cut edge of the uplifted mucous covering of the posterior part of the deflection ; c, the mucous membrane of the opposite nostril (naris of the concavity of the deflection) uncovered by the removal of the cartilage; the retractor {öj holds the anterior (reversed L) flap forward. the septum. For this reason, after the removal of the cartilaginous deflection, the upper boundary of the ridge is not seen as bare bone, but is usually invisible under its covering of periosteum and has to be found by feeling with a probe. Observation has shown me that the diffi¬ culty so created in finding the ridge and resecting it, thus buried in adherent fibrous coverings, has made many operators afraid to touch it, so that they content themselves with merely removing the cartilaginous part of the deflection. Such neglect to take away the ridge is, in my experience, nearly always the cause of an imperfect clearing of the obstructed nostril. In several instances, when the space gained by a cartilaginous resection seemed sufficient, I have had to remove the ridge in a later operation, and I have known other sur¬ geons to have the same experience. Even when it merely takes up space because of excessive thickness and is hardly bent over, the ridge should always be removed, as the breathing-space thus obtained is of the greatest advantage to the patient. The perforations referred to are made along the upper limit of the ridge, the operator, after successfully removing the cartilaginous deflection, tearing or cutting his way into the other nostril in attempting to free the bone from its periosteum along the tipper border of the ridge and on the side of it which lies in the naris of the con¬ cavity of the deflection, the perforation occurring so easily that the surgeon does not know that he has made it until he looks through it into the other nostril. As the upper boundary of the ridge represents the bottom of the groove of the concavity, the perforation is seen in this bottom, when looking into the nostril containing the hollow of the deflection. The mucous membrane seems to tear with especial readiness in this region, so that what seems a mere slit at first usually becomes a large hole when the ridge is resected. While I succeeded in avoiding perforations in all but the rarest cases in this region in my earlier work, I never felt entirely sure that one would not be made until I began to bare the ridge Fig. 3.-The left nostril held open with retractors ; the entire bony deflection including the "ridge," a, has been bared of its coverings by the raspatory, which may be seen working toward the nasal floor on the concave side of the deflection ; b, mucous membrane of the opposite nostril uncovered by the removal of the cartilage and uplifted from the bony deflection ; e, cut edge of the uplifted covering of the posterior part of the deflection held away with a long retractor ; d, retractor holding forward the anterior (reversed L) flap. with the little raspatory here described, which gives me a feeling of security in preparing the bony deflection for resection that I never had before I began to use it. This raspatory (Fig. 1 ) is a small chisel-edged instrument whose blade is curved on the flat, and has a front and lateral cutting edges. It is used in the following manner : After finding the upper boundary of the ridge with a dull elevator, th« Downloaded From: by a University of Arizona Health Sciences Library User on 05/29/2015
doi:10.1001/jama.1909.92550230039003b fatcat:hj4vu6yzqjfy5impz6hhozy3dy