Removal Of Meckel's Ganglion

Operating from the front through the maxillary sinus (Carnochan's operation, or removal of the sphenopalatine (Meckel's) ganglion and maxillary nerve). - The incision is V-shaped, the apex being 2 cm. above the angle of the mouth, and the branches 3 cm. long. This flap should consist of all tissues down to the bone. The bleeding will be free, as the facial vein and branches of the facial artery will be cut. As the infra-orbital foramen is reached, the nerve is detached from its under surface. The anterior wall of the maxillary sinus, which is quite thin, is broken with a chisel for an extent of 2 cm. The infra-orbital canal is opened from below, from the surface clear back to the posterior wall of the sinus. The infra-orbital nerve is then brought down into the sinus to serve as a guide to the foramen rotundum. Care should be taken (by opening the canal with comparatively blunt instruments) not to wound the infra-orbital artery. Then break a hole in the posterior wall of the sinus. This is very thin, and not over half a centimetre (1/5 in. ) intervenes between it and the anterior wall of the sphenoidal sinus, so that care should be taken not to drive the chisel too far back. The posterior wall having been broken with the chisel and the pieces picked away, the nerve is dragged downward, freed as far back as possible, and pulled loose. Traction on the nerve brings the ganglion forward, and with forceps it is then drawn out. The bleeding, after breaking through the posterior wall of the sinus, may be very free. Meckel's ganglion lies in the sphenopalatine fossa just below the maxillary nerve after it leaves the foramen rotundum. Two short branches unite the ganglion and nerve. It is here that the internal maxillary artery, in the third part of its course, divides into six branches: the infra-orbital and posterior dental, the posterior or descending palatine and Vidian, and the pterygopalatine and spheno- or nasopalatine arteries. If these arteries are wounded, as they are very apt to be, the bleeding is very free. To control it temporary packing is at first resorted to. If it persists, the nerve is removed as well as possible and the bleeding stopped with gauze. This may be firmly packed into the opening through the posterior wall at the upper inner portion of the sinus, but care should be taken not to push it roughly through the fossa and into the sphenoidal sinus (or cells) beyond.

J. D. Bryant (Operative Surgery, vol. i, p. 243) in cases of severe hemorrhage advises the prompt ligation of the external carotid artery, a procedure not, however, often required. It has been suggested that instead of making the incision on the cheek to make it in the mouth above the gums, and pull the cheek and mouth upward and outward. This procedure, while obviating the scar, makes the opera-tion somewhat more difficult. Kocher resects the malar bone with the outer wall of the sinus and turns it up, bringing it back into place on the completion of the operation.