26 THE NOSE AND PARANASAL SINUSES anterior naris. The tube is withdrawn sufficiently to allow a cut to be made in one side, so that when it is drawn back again the cut lies in the nasopharynx, thus creating two nasal tubes joined over the posterior end of the nasal septum. The tubes are fixed across the columella, and are left in position for at least 2 months. Thereafter dilatation of the choanae by bougies is carried out at increasing intervals to ensure that the openings do not reclose. Treatment of a unilateral atresia may be similarly dealt with if it is diagnosed in infancy. If it is not recognized until later in life the operative approach is through an incision at the junction of the hard and soft palates. The soft palate is retracted, and the occlusion is removed together with part of the posterior edge of the septum and the border of the hard palate. A plastic tube is again inserted and anchored to prevent it from slipping. DERMATITIS AND FURUNCULOSIS OF THE NASAL VESTIBULE This skin infection involving the hair-bearing area of the nasal vestibule calls for a careful investigation of the nasal cavity and sinuses. There is redness, excoriation and fissuring of the skin around the nostril, leading to crusting which may cause obstruction. A nasal swab should be taken to determine the infecting organisms, which are usually staphylococcal, and to discover their antibiotic sensitivity. Treatment consists of the application of an ointment containing an antibiotic with or without hydrocortisone, e.g. a mixture of framycetin and gramicidin (Soframycin) or of oxytetracycline, nystatin and hydrocortisone (Terra-Cortril). The ointment should be applied twice daily, and should be continued for some days after the apparent cure, as the condition is prone to early recurrence. A course of the appropriate antibiotic by mouth may be given in addition. If the infection is in a hair follicle a furuncle occurs. This gives rise to pain in addition to the irritation of the dermatitis. The furuncle is easily seen in the anterior naris and the temptation to squeeze it must be resisted because the infection may be spread by this means to involve the cavernous sinus by a spreading thrombosis. Hot fomentations, or the local application of 10 per cent ichthyol in glycerin on ribbon gauze will relieve the pain, while a full course of the appropriate antibiotic should cure the infection. The most useful antibiotics are ampicillin, erythromycin or flucloxacillin. DEVIATIONS OF THE NASAL SEPTUM * A perfectly straight septum is rarely found, and, even when it is basically straight, it frequently shows a ridge or spur to one side or the other. Deviations and spurs of the septum may be very slight, causing no trouble, or very marked so as tojblock one cavity to a greater or lesser degree. In some deviations both sides may be obstructed. Individuals vary greatly in the degree in which they suffer from apparent blocking of the nose from septal deviation. In some in whom the obstruction appears slight there may be pronounced symptoms, while others make no complaint although one nostril is almost completely blocked. It is accordingly necessary to be guided largely by subjective symptoms in deciding the advisability of operative interference. Deviations may be developmental in origin or they may arise from trauma.