XIX. THE FACE, ORBIT, AND LIPS
FACE--Congenital malformations: Hare-lip and cleft palate; Macrostoma; Microstoma; Facial cleft; Mandibular cleft--Injuries of soft parts: Wounds; Burns--Bacterial diseases: Boils; Anthrax; Glanders, etc.; Lupus; Syphilis. Tumours: Epithelioma. ORBIT--Injuries: Contusion; Wounds; Fractures--Injuries of eyeball--Orbital cellulitis--Tumours. LIPS--Cracks; Chronic induration; Tuberculous ulcers; Syphilitic lesions--Tumours: Naevi; Lymphangioma; Cysts; Epithelioma.
THE FACE
CONGENITAL MALFORMATIONS.--The description of the various congenital malformations of the face will be simplified by a brief consideration of its development.
Development.--About the middle of the first month of intra-uterine life the prosencephalon bends acutely forward over the end of the notochord and sends out from its base a series of processes, which ultimately blend to form the face (Fig. 231). These processes surround a stellate depression, the primitive buccal cavity or stomatodaeum, from which the mouth and nasal cavities are developed. The buccal cavity is bounded above by the fronto-nasal process, which is divided by a fissure--the nasal cleft or olfactory pit--into a lateral nasal process, and a mesial nasal process, at the outer angle of which a spheroidal elevation appears--the globular process.
From the mesial nasal and globular processes the septum of the nose, the mesial segment of the premaxillary bone, and the middle portion of the upper lip are developed; while the lateral nasal process forms the roof of the nasal cavity, the ala nasi and adjacent portion of the cheek, and the lateral segment of the os incisivum or premaxillary bone. Each segment of the os incisivum carries one of the incisor teeth, and each of the mesial segments may contain in addition an accessory tooth. The nasal cleft ultimately becomes the anterior nares.
The primitive buccal cavity is bounded below by the mandibular arch, which contains Meckel's cartilage, and from which are developed the mandible, the lower lip, and the floor of the mouth.
From the lateral and back part of the mandibular arch springs the maxillary process, which grows upwards and blends with the lateral nasal process across the naso-orbital cleft--the deeper portion of which persists as the nasal duct. From the maxillary process are developed the cheeks, certain of the facial bones, the lateral portions of the upper lip, the soft and hard palate (with the exception of the os incisivum). The development of the face is completed about the end of the second month of intra-uterine life.
HARE-LIP AND CLEFT PALATE
Hare-lip is a congenital notch or fissure in the substance of the upper lip, and cleft palate a congenital defect in the roof of the mouth. Either of these conditions may exist alone, but they occur so frequently in combination that it is convenient to consider them together.
In hare-lip the cleft may be median or lateral, and it may or may not be associated with a cleft in the palate. The resemblance to the Y-shaped cleft in the upper lip of the hare, suggested by the name, is in most cases only superficial.
#Median hare-lip# is extremely rare. It occurs in two forms: one in which there is a simple cleft in the middle of the lip, the result of non-union of the two globular processes; another in which there is a wide gap due to entire absence of the parts developed from the mesial nasal process--the central portion of the lip, the mesial segment of the os incisivum, and the septum of the nose. The second form is usually associated with cleft palate.
#Lateral hare-lip# is much more common. It is due to imperfect fusion of the globular process with the labial plates of the maxillary process. There may be a cleft only on one side of the lip, or the condition may be bilateral. In some cases the cleft merely extends into the soft parts of the lip--simple hare-lip (Fig. 232) forming a notch with rounded margins on which the red edge of the lip shows almost to the apex. In other cases the cleft passes into the alveolus of the jaw--alveolar hare-lip--partly or completely separating the mesial and lateral segments of the premaxillary bone (Fig. 233). These cases are usually combined with cleft palate (Fig. 236).
When the hare-lip is bilateral, the two clefts may be unequal, one forming a simple notch in the lip, the other passing into the nostril. In most cases, however, both clefts are complete, and the mesial portion of the lip is entirely separated from the lateral portions. The central portion or prolabium is usually smaller than normal, and is closely adherent to the os incisivum. This bone may retain its normal position in line with the alveolar processes of the maxilla (Fig. 234), or it may be tilted forward so that the incisor teeth, when present, project beyond the level of the prolabium (Fig. 235). In aggravated cases, the os incisivum and prolabium are adherent to the end of the nose. In these cases there is a Y-shaped cleft in the palate.
#Cleft Palate.#--It has already been mentioned that the palate is formed by the blending of the two palatal plates of the maxillary processes with the four segments of the os incisivum, derived from the nasal processes. The foramen incisivum (anterior palatine foramen) marks the point at which these elements of the palate unite. The process of fusion begins in front and spreads backwards, the two halves of the uvula being the last part to unite.
As development may be arrested at any point, several varieties of cleft palate are met with. The uvula, for example, may be bifid, or the cleft may extend throughout the soft palate. In more severe cases, it extends into the hard palate as far forward as the foramen incisivum. In these varieties the whole cleft is mesial. In still more aggravated cases, the cleft passes farther forward, deviating to one or to both sides in the fissures between the mesial and lateral segments of the os incisivum or between the lateral segments and the maxillae. These cases are combined with double hare-lip.
The cleft varies considerably in width. It may be so wide that the imperfectly developed nasal septum is seen between its edges, and gives to the cleft the appearance of being double, or the septum is adherent to one edge of the palate--usually the right--and the cleft appears to be to the left of the middle line. In most cases the roof of the mouth is unduly arched, and is narrower than normal (Fig. 236).
Clinical Features.--Single hare-lip is about twice as common on the left as on the right side, and it occurs more frequently in boys than in girls. In a considerable proportion of cases there is a well-marked hereditary tendency to these deformities, and they frequently occur in several members of a family.
The nose is characteristically broad and flattened, the ala being bound down to the alveolar margin of the maxilla by fibrous tissue. The margins of the cleft in the lip are also attached to the alveolus by firm reflections of the mucous membrane. The orbicularis oris and other muscles of expression about the mouth being defective, the deformity is exaggerated when the child cries or laughs. In simple hare-lip the child may have difficulty in sucking, but this can usually be overcome by some mechanical contrivance to occlude the cleft.
When the hare-lip is double and combined with cleft palate, the child is unable to suck, and food introduced into the mouth tends to regurgitate through the nose. The nutrition can only be maintained by having recourse to spoon-feeding, and in feeding the child it is necessary to throw the head well back and to introduce the food directly into the back of the pharynx. Many of these infants are of such low vitality, however, that in spite of the most careful feeding they emaciate and die.
In those who survive, the voice has a peculiar nasal twang, as in phonation the air is expelled through the nose instead of through the mouth, and the articulation, especially of certain consonants, is very indistinct. Taste and smell are deficient. The constant exposure of the nasal and pharyngeal mucous membrane renders it liable to catarrhal inflammation and granular pharyngitis.
Treatment.--The only means of correcting these deformities is by operation, and, speaking generally, it may be said that the earlier the operation is performed the better, provided the general condition of the child is equal to the strain. In simple hare-lip the best time is between the sixth and the twelfth weeks. When cleft palate coexists with hare-lip, the lip should be operated on first, as the closure of the lip often exerts a beneficial influence on the cleft in the palate, causing it to become narrower.
Considerable difference of opinion exists as to when the cleft in the palate should be dealt with. Some surgeons, notably Arbuthnot Lane, recommend that it should be done in early infancy, as soon as the viability of the child is assured. We agree with R. W. Murray, James Berry, and others in preferring to wait until the child is between two and a half and three years old. It should not be delayed longer, because, even if the cleft in the palate is repaired, the nasal character of the voice persists, as the patient cannot overcome the habit of expelling the air through the nose.
Before the operation is undertaken, the child must be got into the best possible condition; and arrangements must be made for its constant supervision by a competent nurse. Success depends largely on the avoidance of infective complications, and on absence of tension between the rawed surfaces that are brought into apposition. More than one operation is sometimes required to effect complete closure of the cleft.
Voice Training.--The treatment of cleft palate does not cease with a successful operation; the importance of voice training must be explained to the parents. The child must be taught, in speaking, to send the stream of air through the mouth, instead of through the nose. If the soft palate is not sufficiently large and mobile to shut off the mouth from the nasal cavity, little improvement in speaking can be looked for.
In adolescents and adults, if the cleft is wide and the soft tissues of the palate are thin and atrophied, better physiological results may be obtained by the use of an artificial obturator or velum. With the aid of the dentist a plate of vulcanite or gold is fitted to the teeth and kept in position by suction.
#Other Congenital Deformities of the Face.#--Macrostoma is an abnormal enlargement of the mouth in its transverse diameter, due to imperfect fusion of the maxillary and mandibular processes.
Microstoma is due to excessive fusion of the maxillary and mandibular processes. In some cases the buccal orifice is so small as only to admit a probe.
Facial cleft is due to non-closure of the fissure between the nasal and maxillary processes. It passes upwards through the lip and cheek to the lateral angular process of the frontal bone.
Mandibular cleft occurs in the middle line of the lower lip, and may extend to, or even beyond, the chin; it is due to non-union of the two lateral halves of the mandibular arch.
These various deformities are treated by plastic operations carried out on the same principles as for hare-lip.
Fistulae of the Lower Lip.--Two small openings, about the size of a pin's head, are occasionally met with on the free border of the lower lip, near the middle line. On passing a probe, each is found to lead into a narrow cul-de-sac, which runs for about an inch laterally and backwards under the mucous membrane. Watery, saliva-like fluid exudes through the openings. These fistulae frequently occur in several members of the same family, and are usually associated with hare-lip. The treatment consists in dissecting them out.
#Injuries of the Soft Parts of the Face.#--Owing to its free blood supply, the skin of the face has great vitality, and even when severely lacerated it not only survives, but shows such resistance to bacterial infection that primary union frequently takes place. In plastic operations, also, even extensive flaps seldom become infected, and they heal so rapidly that the sutures can be removed in two or three days.
In incised wounds the bleeding is usually free at first, but unless one of the larger arteries, such as the external maxillary (facial) or temporal, is injured, it soon ceases. Paralysis of the muscles of expression may follow if the facial nerve is injured; and loss of sensation may result from injury to the supra-orbital or infra-orbital nerves. If the parotid gland is implicated, saliva may escape from the wound, but it usually ceases in a few days; if the duct is involved, a persistent salivary fistula may form.
Punctured wounds may perforate the orbit, the cranial cavity, or the maxillary sinus, and be followed by infective complications, particularly if the point of the instrument breaks off and is left in the wound.
Contused and lacerated wounds result from explosions and injuries by firearms, and foreign bodies, such as particles of stone or coal, or grains of gunpowder and small shot, may lodge in the tissues. Every effort should be made to remove such foreign bodies, as if left embedded they cause unsightly pigmentation of the skin. Ligatures are seldom necessary for the arrest of haemorrhage unless the larger branches are injured, as the bleeding from smaller twigs is arrested by the sutures. The edges of the wound are approximated by means of Michel's clips, or by a series of interrupted horse-hair stitches, and for this purpose a fine Hagedorn needle is to be preferred, as it leaves less mark than the ordinary bayonet-shaped needle. If the mucous membrane of the mouth or of the eyelid is implicated, its edges should be approximated by a separate row of catgut stitches.
Cicatricial contraction after severe burns may lead to marked deformities of the eyelids (ectropion), mouth, and nose. When the burn has implicated the neck, the chin may be drawn towards the chest, and the movements of the lower jaw and head seriously impeded.
#Bacterial Disease.#--Boils, carbuncles, and anthrax pustules frequently occur on the face, and when situated near the middle line, and particularly on the upper lip, are liable to give rise to general infection and to intra-cranial complications which may prove fatal. The primary infection of glanders and of actinomycosis may also occur on the face.
The various forms of tuberculous lupus are met with more frequently on the face than in any other situation (Fig. 237). Tuberculous disease of the facial bones, particularly of the lateral half of the orbital margin at the junction of the zygomatic (malar) bone with the maxilla, is not uncommon in children.
The primary lesion of syphilis, and the various forms of secondary and tertiary syphilides, may simulate tuberculous lupus, cancer, and other ulcerative conditions.
#Tumours.#--The simple tumours met with on the face include sebaceous and dermoid cysts, naevus, plexiform neuroma and adenoma; the malignant forms include the squamous epithelioma, and rodent, paraffin, and melanotic cancers.
Epithelioma occurs most frequently in men beyond the age of forty. The affection usually begins at the margin of the lip, the edge of the nostril, or the angle of the eye. There is generally a history of prolonged or repeated irritation, or the condition may develop in connection with a scar, a wart, a cutaneous horn, or an ulcerating sebaceous cyst. It may begin as a hard nodule, or as a papillary growth which breaks down on the surface, leaving a deep ulcer with a characteristically indurated base--the crateriform ulcer. The neighbouring lymph glands are infected early, but metastases to other organs are not common. The treatment consists in excising the growth and the associated lymph glands as early and as freely as possible. When excision is impracticable, benefit may be derived from the use of radium or of the X-rays.
The face is the commonest seat of rodent cancer (Volume I., p. 395).
THE ORBIT
#Injuries.#--Wounds of the eyelids are liable to be complicated by damage to the lachrymal apparatus, leading to stenosis of the canaliculus and persistent watering of the eye. If the wall of the lachrymal sac or nasal duct is torn, the patient should be warned not to blow his nose for some days lest air be forced into the tissues and produce emphysema. In suturing wounds of the lids care must be taken to secure accurate apposition at the free margins, and to avoid constricting the canaliculi.
Contusion of the eyelids and circum-orbital region--the ordinary "black eye"--is associated with extravasation of blood into the loose cellular tissue of these parts, and is followed within a few hours of the injury by marked ecchymosis. The lids may swell to such an extent that the eye is completely closed. In some cases the impinging object lacerates the vessels of the conjunctiva and produces a sub-conjunctival ecchymosis, which may be situated under the palpebral conjunctiva of the lower lid, or close to the corneal margin on the front of the globe. The blood effused under the conjunctiva remains bright red as it is aerated from the atmospheric air. The characteristic play of colours which attends the disappearance of effused blood is observed within a week or ten days of the injury.
Firm pressure applied by means of a pad of cotton wadding and an elastic bandage, if employed early, may limit the effusion of blood; and massage is useful in hastening its absorption.
A black eye is to be distinguished from the effusion which sometimes follows such injuries as fracture of the anterior fossa of the skull, fracture of the orbital ridges, or a bruise of the frontal region of the scalp, chiefly by the facts that in the former the discoloration comes on within a very short time of the injury, the swelling appears simultaneously in both lids, and the sub-conjunctival ecchymosis, when present, is coeval with the ecchymosis of the lids. In fractures of the orbital plate and bruises of the forehead, on the other hand, the ecchymosis does not appear in the eyelids for several days, and that under the conjunctiva is usually disposed on the globe as a triangular patch towards the lateral canthus.
Wounds of the orbit result from the introduction of pointed objects, such as knitting pins, pencils, or fencing foils, or from chips of stone or metal, or small shot. They are attended with considerable extravasation of blood, which may be diffused throughout the cellular tissue of the orbit, or may form a defined haematoma. In either case the eyeball is protruded, and the cornea is exposed to irritation and may become inflamed and ulcerated. The optic nerve may be lacerated, and complete and permanent loss of vision result. Sometimes the ocular muscles and nerves are damaged, and deviation of the eye or loss of motion in one or other direction results. The globe itself may be injured. Foreign bodies lodged in the orbit, so long as they are aseptic, may give rise to little or no disturbance, and are liable to be overlooked. The Roentgen rays are useful in determining the presence and position of a foreign body.
Infective complications are liable to follow injuries by bullets or fragments of shell, and they not only endanger the eyeball, but are liable to be associated with suppurative conditions in the adjacent air sinuses--frontal, maxillary, and ethmoidal--or in the cranial cavity. In purifying wounds of the orbit, and in extracting foreign bodies, great care is necessary to avoid injury of the eyeball or of its muscles or nerves.
Fracture of the margin of the orbit results from a direct blow, and is followed by circum-orbital and sub-conjunctival ecchymosis, and sometimes is associated with paralysis of the optic nerve, or of the other ocular nerves. Implication of the frontal sinus may be followed by emphysema of the orbit and lids, and if there is infection by suppurative complications.
The roof of the orbit is implicated in many fractures of the anterior fossa of the skull produced by indirect violence. It is also liable to be fractured by pointed instruments thrust through the orbit, in which case intra-cranial complications are prone to ensue, and these in a large proportion of cases prove fatal. When the medial wall is fractured and the nasal fossa opened into, epistaxis and emphysema of the orbit are constant symptoms. Sub-conjunctival ecchymosis, and some degree of exophthalmos, are almost always present. Treatment is directed towards the complications. When the nasal fossae or the air sinuses are opened into, the patient should be warned against blowing his nose, as this is liable to induce or increase emphysema of the orbit or lids.
#Injuries of the Eyeball.#--These injuries may be divided into two groups--(1) those in which the globe is contused without its outer coat being ruptured, and (2) those in which the outer coat is ruptured.
In cases belonging to the first group, while the sclerotic coat and cornea remain intact, the iris may be partly torn from its ciliary origin, and the blood effused collects in the lower portion of the anterior chamber; or the pupillary margin of the iris may be ruptured at several points, causing apparent dilatation of the pupil. The lens may be partly or completely dislocated, and in the latter case it may pass forward into the anterior chamber or backward into the vitreous. Among other injuries resulting from contusion of the eye may be mentioned haemorrhage into the vitreous, rupture of the choroid, and detachment of the retina.
Injuries in which the outer coat of the eyeball is ruptured may be further subdivided into two groups according to whether or not a foreign body is lodged in the globe.
Rupture of the outer coat, especially when it results from a punctured wound, adds greatly to the risk of the injury, by opening up a path through which infective material may enter the globe, and this risk is materially increased when a foreign body is retained in the cavity of the eyeball.
When the globe is burst by a blow with a blunt object, the sclerotic usually gives way, and as the rupture takes place from within outward, there is less risk of infection than in punctured wounds. The lens may be extruded through the wound, and the iris prolapsed. If the rupture is large, the conjunctiva torn, and the globe collapsed from loss of vitreous, the eye should be removed without delay. If sight is not entirely lost and there is no marked collapse of the globe, an attempt should be made to save the eye.
Wounds produced by stabs or punctures are liable to be followed by infective complications ending in panophthalmitis. When this is threatened, removal of the eye is indicated, not only because the affected eye is destroyed beyond hope of recovery, but to avoid the risk of "sympathetic ophthalmia" affecting the other eye.
#Orbital Cellulitis.#--Infection of the cellular tissue of the orbit by pyogenic bacteria is specially liable to follow punctured wounds and compound fractures, if a foreign body has lodged in the orbital cavity. It may also result from the spread of a suppurative process from the globe of the eye, the conjunctiva, or the nasal fossae or their accessory air sinuses. Both orbits may be affected simultaneously.
Clinical Features.--The disease is ushered in by rigors, high temperature, and severe pain, which radiates all over the affected side of the head. There is exophthalmos and fixation of the globe, with redness, swelling and tenderness of the eyelids, and congestion and ecchymosis of the conjunctiva. The pupil is usually dilated, the cornea becomes opaque and may ulcerate, and there is photophobia and sometimes diplopia. Suppuration usually ensues, and the pus burrows in every direction, and may ultimately point through the eyelids or conjunctiva. Sometimes the infection spreads to the meninges, and to the ophthalmic vein, and the phlebitis may then extend to the cavernous sinus. The eyeball may be infected and destructive panophthalmitis result. The prognosis therefore is always grave.
The treatment consists in making one or more incisions into the cellular tissue for the purpose of removing the pus and establishing drainage. A narrow bistoury is passed in parallel to the wall of the orbit, care being taken to avoid injuring the globe. When possible, the incision should be made through the reflection of the conjunctiva, but in some cases efficient drainage can only be established by incising through the lid. When the eye is destroyed by panophthalmitis, the propriety of eviscerating or enucleating it will have to be considered.
#Tumours of the Orbit.#--Tumours may originate in the orbit or may invade it by spreading from adjacent cavities. Those which originate in the orbit may be solid or cystic. Of the solid tumours the glioma and the sarcoma are the most common, and when they originate in the pigmented structures of the globe they present the characters of melanotic growths. Primary carcinoma begins in the lachrymal gland. Osteoma--usually the ivory variety--may originate in the wall of the orbit, or may spread from the adjacent sinuses.
Clinical Features.--In children, the tumour is usually a glioma, and it is frequently bilateral. It generally occurs before the age of four, is associated with increased intra-ocular tension, protrusion of the eyeball, and dilatation of the pupil, and soon produces blindness. The tumour fungates and bleeds, and rapidly invades adjacent structures and spreads along the optic nerve to the brain. It is highly malignant, and recurrence usually takes place, even when the tumour is removed early.
In adults melanotic sarcoma is most common. It occurs between the ages of forty and sixty, and is almost always unilateral; and while it shows little tendency to invade the brain, the adjacent lymph glands are early infected, and death usually results from dissemination.
In all varieties of intra-orbital tumour exophthalmos is a prominent feature (Figs. 238, 239), and when the protrusion of the eyeball is marked the lids become swollen, oedematous, and dusky. The eye is seldom pushed directly forward except when the tumour is growing in the optic nerve or its sheath. When the tumour is solid, the eye cannot be pressed back into the orbit, but in cystic tumours it may to some extent. The movements of the eyeball are restricted in a varying degree, and ptosis often results from paralysis of the levator palpebrae superioris. In almost all cases there is also more or less visual disturbance. The cornea being unduly exposed is liable to become inflamed, or even ulcerated. Pain is a variable symptom; when present, it usually radiates along the branches of the first and second divisions of the trigeminal nerve. Tenderness on pressure is not always present. It is comparatively uncommon for a tumour of the orbit to invade the globe directly.
Treatment.--When practicable, removal of the tumour is the only method of treatment, and in malignant tumours it is often necessary to sacrifice the eye to ensure complete removal. When the tumour has invaded the orbit secondarily, its removal may be impossible, but it may be necessary to remove the eye for the relief of pain.
The orbital dermoid usually occurs at the lateral end of the supra-orbital ridge (Fig. 240). A less common situation is the anterior part of the orbit, near the nasal wall, and this variety, from its position and from the fact that it is usually met with in children, is liable to be confused with orbital meningocele or encephalocele. Treatment consists in its removal by careful dissection, and this can usually be done under local anaesthesia.
Orbital aneurysms have already been described, Volume I., p. 317.
THE LIPS
Herpes of the lips, due to a mild staphylococcal infection, is common in delicate children and in the early stages of pneumonia. A crop of vesicles forms and, after bursting, these leave dry scabs.
A more severe staphylococcal infection may give rise to a carbuncular swelling with great oedema, and lead to infective phlebitis of the facial vein and general septicaemia. Excision of the focus is indicated.
The lip is sometimes the seat of the malignant pustule of anthrax.
Painful cracks and fissures are frequently met with in the middle line of the lip and at the angle of the mouth in young subjects. They usually develop during frosty weather, and as they are constantly being torn open by the movements of the mouth, they are difficult to heal. If local applications fail, it may be necessary to cocainise the fissure and scrape it with a sharp spoon.
Chronic Induration of the Lips (Strumous Lip).--A chronic oedematous infiltration, probably of the nature of a lymphangitis, sometimes affects the submucous tissue of the lips of delicate children. It is most common on the upper lip, and may be associated with a fissure or with chronic coryza. The lip is everted, and its mucous membrane unduly prominent. The cervical glands are frequently enlarged.
The treatment consists in removing the cause and in improving the general condition. In cases of long standing it may be necessary to remove from the inner aspect of the lip a horizontal strip of tissue having the shape of a segment of an orange.
The term "double lip" is applied to a condition occasionally met with in young men, in which there is a hypertrophy of the labial glands in the mucous membrane of the upper lip. It is of slow growth, and forms an elongated swelling on each side of the frenum, covering the teeth, and projecting the lip. It is shotty to the feel, and the only complaint is of disfigurement. The treatment consists in excising the redundant fold of mucous membrane, including the enlarged mucous glands.
Tuberculous disease may occur in the form of lupus or of ulcers. The ulcers generally occur in patients suffering from advanced pulmonary or laryngeal phthisis. They are usually superficial, may be single or multiple, and are exceedingly painful.
Syphilitic Lesions.--The upper lip is the most frequent seat of extra-genital chancre. The chancre of the lip begins on the mucous surface as a small crack or blister, which becomes the seat of a rounded, indurated swelling, about a quarter of an inch in diameter. The surface is smooth, of a greyish colour, and exudes a small quantity of sero-purulent fluid. The lip is swollen and everted, and there is a considerable area of induration around. The submental and submaxillary lymph glands on one or on both sides soon become enlarged, and may reach the size of a pigeon's egg. At first they are firm, but they may subsequently soften and become painful. In some cases the sore is much less characteristic, resembling an ordinary crack or fissure, and its true nature is only revealed when the secondary manifestations of syphilis appear.
Mucous patches and superficial ulcers are frequently met with on the mucous surface of the lips and at the angles of the mouth during the secondary stage of syphilis. In the inherited form of the disease deep cracks and fissures form, and often leave characteristic scars which radiate from the angles of the mouth.
Gummatous lesions occur on the lips, and are liable to be mistaken for epithelioma.
Tumours.--Naevi are not uncommon on the lips. When confined to the mucous surface they may be dissected out, but when they invade the skin they are best treated by electrolysis.
Lymphangioma.--The term macrocheilia is applied to a congenital hypertrophy of the lip (Fig. 241), which is probably of the nature of a lymphangioma (Middeldorpf). One or both lips may be affected. The lip is protruded, the mucous membrane everted, and, when the lower lip is implicated, it becomes pendulous and is liable to ulcerate. The substance of the lip is uniformly firm and rigid, so that it moves in one piece, and sucking, mastication, and phonation are interfered with.
The treatment consists in removing a wedge-shaped portion of the swelling on the same lines as for "strumous lip," or in employing electrolysis.
Mucous cysts occur as small rounded tumours, projecting from the inner surface of the lip. They are of a bluish colour, and contain a glairy fluid. They are treated by removal of the cyst wall, together with the overlying portion of mucous membrane.
#Epithelioma of the lip# is of the squamous-celled variety, and is met with either as a fungating wart-like projection, or as an indurated ulcer. It almost exclusively occurs on the lower lip of men over forty years of age. The growth begins about midway between the middle line and the angle of the mouth, either as a horny epidermal thickening, or as a warty excrescence, which bleeds readily and soon ulcerates. The affection is said to be especially common in those who smoke short clay pipes, and it is a suggestive fact that, while epithelioma of the lip is rare in women, the majority of those who do suffer are smokers.
The ulceration spreads along the lip, chiefly towards the angle of the mouth, and downwards towards the chin, and the substance of the lip becomes swollen and indurated (Figs. 242, 243). The edges are characteristically raised and hard, and the raw surface is extremely painful, especially when irritated by hot food or fluids. The growth is liable to spread to the mucous membrane and gum, and to invade the mandible. The disease spreads early to the submental and submaxillary glands, which are best felt with one finger inside the mouth, under the tongue, and another outside, behind the mandible. The infected glands tend to become fixed to the bone, and while at first extremely hard, so much so that they simulate a bony tumour of the jaw, they later soften, liquefy, and fungate (Fig. 244). Metastasis to internal organs is rare. Unless removed by operation, the disease usually proves fatal in from three to three and a half years.
The treatment consists in early and free removal of the affected portion of lip and of all the lymphatic connections in the submaxillary region and neck. Recurrence in the scar is rare; it is nearly always located in the glands.
The operation of cleaning out the glands below the mandible on both sides in men who are advanced in years is not free from risk to life, especially from respiratory complications which may or may not be traceable to the anaesthetic.
In inoperable cases benefit may follow the use of the X-rays, or of radium.
Epithelioma of the upper lip is less common. It occurs with equal frequency in the two sexes, progresses more slowly, and is, on the whole, less malignant. It sometimes appears to be due to contact infection from the lower lip. It is treated on the same lines as cancer of the lower lip.
XX. THE MOUTH, FAUCES, AND PHARYNX
Stomatitis--Roof of mouth: Abscess; Gumma; Tuberculous disease; Tumours--Elongation of uvula--Epithelioma of floor of mouth--Tonsillitis: Varieties--Hypertrophy of tonsils--Calculus--Syphilis and Tuberculosis--Tumours--Retro-pharyngeal abscess.
THE MOUTH
#Stomatitis.#--The term stomatitis is applied to any inflammation of the buccal mucous membrane. The catarrhal form is often associated with the presence of carious teeth or an infected wound; the mucous membrane is hyperaemic and swollen, and exudes an excessive amount of viscid mucous secretion, and the epithelium desquamates in patches, leaving small superficial erosions or ulcers, which are very sensitive. The aphthous form, met with in unhealthy, underfed children, is characterised by the occurrence of patches of fibrinous exudate into the superficial layers of the mucous membrane; the epithelium is shed, leaving a series of whitish spots surrounded by a red hyperaemic zone, which may become confluent and form small ulcers. The condition known as thrush, which closely resembles aphthous stomatitis, is met with in infants during the period of teething, and is due to the oidium albicans, a fungus met with in sour milk. The spots, which are most numerous on the lips, tongue, and throat, have the appearance of curdled milk.
The treatment of these forms consists in improving the general condition of the patient, and in employing a mouth-wash, such as peroxide of hydrogen, Condy's fluid, chlorate of potash, or boro-glyceride. The superficial ulcers may be touched with silver nitrate or with a 1 per cent. solution of chromic acid.
Ulcerative stomatitis is frequently met with in debilitated subjects with decayed teeth, and is specially liable to occur during the course of acute febrile diseases in which sordes accumulate about the teeth and gums. It also occurs in syphilitic subjects while under treatment by mercury--mercurial stomatitis. Some patients show a special susceptibility to mercury, and one of the first signs of intolerance of the drug is some degree of stomatitis, which may ensue after a comparatively small quantity has been administered. It begins in the gums, which become swollen and spongy, growing on to the teeth and into the interstices. The gums assume a bluish-red colour and bleed readily, and the teeth may become loose and fall out. The tongue may share in the swelling--mercurial glossitis. There is also profuse salivation, and the breath has a characteristically offensive odour. In severe cases the alveolar margin of the jaw undergoes necrosis. A similar condition occurs in lead and in phosphorus poisoning, and in patients suffering from scurvy.
The treatment consists in removing the cause, and in employing antiseptic and astringent mouth-washes. The internal administration of chlorate of potash is also indicated, as this drug is excreted in the saliva. Loose teeth should not be removed as they become fixed again when the stomatitis subsides.
Gangrenous stomatitis, or cancrum oris (Fig. 245), has already been described (Volume I., p. 102).
#Roof of the Mouth.#--Suppuration in the muco-periosteum of the palate is usually secondary to suppuration at the root of a carious tooth. It may also arise in excoriations caused by an ill-fitting tooth-plate, or from the impaction of a foreign body, such as a fish or game bone, in the mucous membrane. The inflammation begins close to the alveolus, and may spread back along the palate. The muco-periosteum becomes swollen, red, and exceedingly tender, and, as pus forms, is raised from the bone, forming a prominent, firm, elongated swelling, which on bursting or being incised gives exit to foul-smelling pus.
The syphilitic gumma, which begins as a rounded indolent swelling, is usually situated in the middle line near the posterior edge of the hard palate. The swelling gradually softens and ulcerates, and a sequestrum may separate and leave a perforation in the palate (Fig. 246). The treatment consists in employing the usual remedies for tertiary syphilis. If the perforation persists and causes trouble by allowing food to pass into the nose, or by giving a nasal tone to the voice, it may be closed by an operation on the same principle as that performed for cleft palate, or an obturator may be fitted to occlude the opening.
Tuberculous disease is chiefly met with in the form of lupus which has spread from the nose or lips, and it may lead to widespread destruction of the soft tissues, or even to perforation of the bony palate.
Mucous cysts, dermoids, adenomas, lipomas, and fibromas are occasionally met with. Papillomatous thickening of the mucous membrane sometimes occurs in association with leucoplakia. It resists anti-syphilitic treatment, but yields to scraping with the sharp spoon. Endotheliomas, or mixed tumours, similar to those met with in the parotid gland, also occur in young subjects, and grow in the submucous tissue of the soft palate, usually to one side of the middle line. In their early stages they are of slow growth, and give rise to no inconvenience save from their size, are easily removed, and show no tendency to recur. Later, they grow more rapidly, tend to infiltrate their surroundings and to assume malignant characters, so that complete removal becomes difficult or impossible.
Epithelioma may originate in the hard palate as a result of local irritation, or may spread from adjacent parts. When it is confined to the palate it is treated by removal of the palatal and alveolar portions of the maxilla.
#Elongation of the uvula# is usually due to a chronic inflammatory engorgement combined with glandular hypertrophy of the mucous membrane. It often occurs in children, and is associated with a constant hacking cough, which is usually worst when the patient is lying down. By tickling the back of the tongue and pharynx it may induce vomiting after meals. The treatment consists in snipping off the redundant portion with scissors.
#Epithelioma of the floor of the mouth# frequently originates in the mucous membrane between the frenum of the tongue and the inner aspect of the gum. It develops insidiously, grows slowly, and gradually spreads to the mandible and to the substance of the tongue, tacking it down so that it cannot be protruded. The glands are early involved, and their enlargement not infrequently first draws attention to the condition. It is to be regarded as a particularly unfavourable site, as local recurrence is frequent. For the complete removal of the disease it is necessary to excise the tissues in the floor of the mouth, and a variable portion of the tongue and mandible, and to clear out the glands and fat from the submaxillary and submental regions.
THE TONSILS AND PHARYNX
#Infective Conditions.#--The majority of the infective conditions included under the popular term "sore throat" originate in the tonsils, and are due to the action of bacteria which under normal conditions are present in the crypts of the tonsils and of the mucous membrane of the naso-pharynx. The most important of these organisms are streptococci, various forms of staphylococci and of pneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. So long as the health is good these organisms are harmless, but when there is any lowering of the vitality they become virulent and give rise to various forms of infection.
Catarrhal tonsillitis--usually attributed by the laity to "catching cold"--is characterised by hyperaemia and congestion of the tonsils and mucous membrane of the pharynx, soft palate, and uvula. It is often met with in those who are much exposed to air contaminated with organisms--for example, patients who have been long in hospital, or the resident staff of hospitals (septic or hospital throat), and particularly in persons of a "rheumatic" tendency. There is slight pain on swallowing, and a tickling sensation passes along the Eustachian tube to the ear; the throat feels dry, and the patient has a constant desire to clear it, and there is usually a rise of temperature to 101 deg.-102 deg. F. As a rule the symptoms pass off in three or four days, but the condition may spread along the Eustachian tube to the ear, and interfere with hearing, or it may set up chronic suppuration of the middle ear.
A similar condition of the pharynx is frequently one of the initial symptoms in acute febrile diseases, such as scarlet fever, measles, influenza, or acute rheumatism.
The treatment of the throat affection consists in employing antiseptic and soothing gargles, inhalations of chloride of ammonium, or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozenges or pastilles containing chloride of ammonium, chlorate of potash, and cubebs may be employed. In rheumatic cases, salicin, aspirin, and salicylate of soda are indicated.
In follicular tonsillitis, the infection first implicates the lymphoid follicles. The crypts are distended with yellowish-white plugs, composed of inflammatory exudate, leucocytes, and desquamated epithelium, and these may project from the openings, giving the tonsil a spotted appearance. Sometimes the exudate accumulates on the surface of the tonsils and pharynx, forming a thin, greyish-white film, which is liable to be mistaken for the false membrane of diphtheria. It can, however, usually be wiped off, and when examined microscopically does not contain the typical Loeffler's bacillus.
The tonsils are enlarged, and project so that they obstruct the isthmus of the fauces, sometimes even meeting in the middle line. There is pain on swallowing, and the respiration is impeded and noisy during sleep. There is usually some degree of fever, and the glands behind the angle of the jaw are enlarged and tender and may suppurate and set up cellulitis. The acute symptoms usually subside in four or five days, but if the deeper crypts are filled with plugs of exudate the condition may prove obstinate. The patient is liable to periodic attacks, particularly if the tonsils are chronically enlarged.
The treatment is carried out on the same lines as for the catarrhal form. In recurrent cases the tonsils should be removed.
#Acute Suppurative Tonsillitis and Peri-tonsillitis--Quinsy.#--This is an acute suppurative inflammation of the tonsils and peritonsillar tissue, due to infection with pyogenic bacteria. It affects the whole substance of the tonsils, and the cellular tissue of the pillars of the fauces, the soft palate, and the pharynx.
Clinical Features.--The onset is usually sudden, and the affection is ushered in by a rigor, high fever, and a feeling of malaise. There is persistent thirst and dryness of the throat, and the patient has the sensation of a foreign body being in the pharynx, with a constant desire to swallow. Swallowing is extremely painful, the pain shooting up to the ears, and the patient has difficulty in taking nourishment. The saliva accumulates in the mouth; the voice is thick and nasal; and the respiration impeded and noisy. If the patient can open the mouth sufficiently to afford a view of the back of the throat (which, however, is seldom the case), the inflamed parts are seen to be of a dull reddish-violet colour. One tonsil is often more swollen than the other, and the corresponding anterior pillar of the fauces more prominent. The uvula is swollen and oedematous, and is deviated towards the side on which there is least swelling. Suppuration occurs in from three to seven days; in adults it is usually in the peritonsillar tissue of the anterior pillar of the fauces, and extends into the soft palate. In children the pus sometimes forms in the substance of the tonsil. If left to burst, the abscess discharges itself into the mouth, and the patient experiences instant relief. The pus is always offensive, and if the abscess bursts during sleep, it may enter the air-passages and cause septic pneumonia. The lymph glands in the neck are usually enlarged and tender, and sometimes they suppurate and give rise to a diffuse cellulitis. General infection of the blood may follow, leading to metastatic invasion of different tissues and organs, particularly one or other of the large joints.
Treatment.--In the early stages soothing antiseptic gargles are indicated. Later, when the patient is unable to gargle, the inhalation of steam impregnated with the vapour of carbolic acid or friar's balsam, and the application of hot fomentations or a large linseed poultice to the neck may afford relief. When an abscess is formed, it should be opened by means of a fine-pointed pair of sinus forceps, thrust through the soft palate at a point opposite the base of the uvula, and in the line of the anterior pillar of the fauces. As those who suffer from quinsy are liable to have attacks coming on periodically, if the tonsils remain permanently enlarged they should be removed between attacks.
#Hypertrophy of the tonsils# is most commonly met with in children between five and ten years of age, and is often associated with adenoid vegetations in the naso-pharynx and chronic thickening of the pharyngeal mucous membrane.
The whole tonsil is enlarged, the mucous membrane thickened, and the connective tissue more or less sclerosed. The crypts appear on the surface as deep clefts or fissures, and the lymph follicles are enlarged and prominent. Secretion accumulates in the crypts, and a calculus may form from the deposit of lime salts. Sometimes food particles lodge in the crypts, and they may collect and form accumulations of considerable size, requiring the use of a scoop to dislodge them.
Clinical Features.--The hypertrophy is bilateral, but not always symmetrical. Sometimes the tonsils project to such an extent as almost to meet in the middle line; sometimes they scarcely pass beyond the level of the pillars of the fauces. They are usually sessile, but sometimes the base is so narrow as almost to form a pedicle. During childhood they are usually soft and spongy, but when they persist into adolescence or adult life they become firm and indurated. This sclerotic change is due to the repeated attacks of catarrhal or suppurative tonsillitis to which the patient is subject. The lymph glands behind the angle of the jaw are frequently enlarged. Swallowing is sometimes interfered with, and the patient is liable to attacks of nausea and vomiting. Respiration is always more or less impeded; the patient breathes through the open mouth, and snores loudly during sleep; and the hindrance to respiration interferes with the development of the chest. In some cases alarming suffocative attacks occasionally supervene during sleep, but the difficulty in breathing disappears as soon as the child is wakened. The voice is characteristically thick and nasal, especially when adenoids are present, and in many cases the patient has a vacant and stupid expression. Hearing is often impaired from obstruction of the Eustachian tube.
Treatment.--In early and mild cases, the tonsils should be painted with glycerine of tannic acid, or some other astringent, and an antiseptic mouth-wash, or spray of hydrogen peroxide, should be used several times a day. When the condition is interfering with the general health or with the development of the chest, or when there is deafness or disturbance of sleep, the tonsils should be removed.
#Calculi# composed of phosphate or carbonate of lime are sometimes formed in the crypts of enlarged tonsils; as a rule they are about the size of a pea, but they may be much larger. They cause a sharp stabbing pain on swallowing, and sometimes a persistent hacking cough. They are easily shelled out through a small incision into the tonsil.
#Syphilis.#--The fauces and tonsils are occasionally the seat of a hard chancre, and the condition may simulate malignant disease. The submaxillary glands, however, become enlarged sooner and increase more rapidly than in cancer, and they are tender. The secondary manifestations of the disease usually appear before the chancre has healed.
Early in secondary syphilis, mucous patches and superficial ulcers are frequently met with. Later, severe phagedaenic ulceration sometimes occurs, especially in alcoholic subjects, and may rapidly eat through the soft palate, leading to marked deformity from contraction when cicatrisation takes place.
In the tertiary stage, a diffuse gummatous infiltration occurs, and is liable to be followed by ulceration, which spreads to the pharyngeal wall and soft palate, and, by causing cicatricial contraction and adhesions, may lead to narrowing or even complete occlusion of the communication between the pharynx and the naso-pharynx.
#Tuberculous# lesions of the fauces and tonsils are almost invariably secondary to tubercle of the larynx or lungs, or to lupus of the face or naso-pharynx. They are attended with more pain than syphilitic lesions; are less prone to spread to the palate and cause perforation; but, when cicatrisation takes place, they are equally liable to produce contraction and deformity.
#Tumours.#--Innocent tumours--fibroma, lipoma, myoma--are comparatively rare. When sessile they cause inconvenience only by their bulk; when pedunculated they may hang down into the pharynx and interfere with swallowing and breathing. They may be shelled out, or ligated at the base and cut off, according to circumstances.
Malignant Disease.--The tonsil is frequently the primary seat of lympho-sarcoma, a very malignant form of round-celled sarcoma. The tumour is at first confined to the tonsil, which differs in appearance from simple hypertrophy only in being paler and more nodular. The growth rapidly infiltrates the peritonsillar connective tissue and adjacent palatal mucous membrane, which becomes pale and oedematous, and the condition at this stage may simulate a suppurative tonsillitis. As it increases, the tumour encroaches upon the cavity of the pharynx, causing interference with swallowing and breathing; the mucous membrane soon gives way, and widespread ulceration and sloughing of the tumour substance occurs, sometimes leading to serious and even fatal haemorrhage. The patient emaciates rapidly. The adjacent lymph glands are early infected.
Removal by operation is seldom practicable, but the introduction of a tube containing radium for several days has in some cases proved beneficial.
Carcinoma is more common than sarcoma. It may take the form of squamous epithelioma or of medullary cancer, and may originate in the tonsil, in the groove between the tonsil and the tongue, or in the soft palate. By the time the patient seeks advice it has usually implicated the fauces, soft palate, and pharyngeal wall as well as the tonsil.
Males suffer more frequently than females. The disease may exist for a considerable time before giving rise to marked symptoms, and attention may first be drawn to it by pain and difficulty in swallowing, or by pain shooting towards the ear. In some cases enlargement of the glands behind the angle of the jaw is the first thing to attract the patient's attention. The other symptoms are very like those of cancer of the tongue--pain during eating or drinking, salivation and foetid breath. Sometimes fluids regurgitate through the nose, and the voice may become nasal and indistinct. As the patient is usually unable to open the mouth widely, it is seldom possible to learn much by inspection, but a digital examination may reveal an irregular, hard, and ulcerated growth. The swelling is sometimes palpable from the outside, filling up the hollow behind the angle of the jaw, and in this situation also the enlarged lymph glands may be felt. These are often enlarged out of all proportion to the size of the primary growth. The disease tends to spread locally, causing increasing difficulty in swallowing and breathing. The patient gradually loses strength, and may die from exhaustion induced by pain and insomnia, from haemorrhage, or from septic pneumonia.
In early cases an attempt may be made to remove the disease by operation. In our experience radium has proved less efficacious in cancer than in sarcoma.
In advanced cases, it is only possible to relieve the patient's suffering by palliative measures. Antiseptic mouth-washes are used to diminish the foetor of the breath and the risk of pneumonia, and heroin or morphin to relieve pain. The use of the nasal tube, or even a gastrostomy, may be necessary to enable the patient to take sufficient food, and tracheotomy may be called for to relieve dyspnoea.
#Retro-pharyngeal Abscess.#--The chronic retro-pharyngeal abscess associated with tuberculous disease of the cervical vertebrae, in which the pus accumulates behind the prevertebral fascia, has already been described (p. 441).
The acute abscess occurs in the space between the prevertebral fascia and the wall of the pharynx. The infection usually begins in one of the lymph glands that occupy this space, and rapidly ends in suppuration, which spreads to the surrounding cellular tissue. It is most common in children during the first and second years, and the patient may be convalescent after one of the eruptive fevers attended with inflammation of the bucco-pharyngeal mucous membrane--such as scarlet fever, measles, or chicken-pox--or may suffer from nasal excoriations or coryza. In some cases the irritation of dentition is the only discoverable cause.
In infants, the condition is usually very acute, and is attended with fever, rigors, vomiting, and often with convulsions. The head is held rigid, and usually twisted to one side, and there is pain on attempting to move it. The child has great pain on swallowing, there is regurgitation of food, and the saliva dribbles from the mouth. There is marked dyspnoea and a short, dry cough. The back of the throat is red and swollen, and a localised projection, which is soft and fluctuating, and is usually asymmetrical, may be recognised by digital examination. Sometimes the voice is lost, and the patient has severe attacks of choking--symptoms which have led to the disease being mistaken for membranous laryngitis. In some cases a soft swelling is palpable on one or on both sides of the neck. Unless the abscess is promptly opened the condition usually proves fatal. The mouth is opened by means of a gag, the head allowed to hang over the end of the table, and the abscess incised, with a guarded bistoury, through the wall of the pharynx. The dangers associated with opening the abscess from the mouth appear to have been exaggerated.
A less acute form of retro-pharyngeal abscess sometimes develops in the course of chronic middle ear disease, the inflammatory process spreading along the Eustachian tube, in the wall of which an abscess forms and burrows into the retro-pharyngeal space.
XXI. THE JAWS, INCLUDING THE TEETH AND GUMS
TEETH: Dental caries--Impacted wisdom tooth. GUMS: Gingivitis; Pyorrhoea alveolaris; Hypertrophy; Epithelioma. JAWS: Pyogenic affections: Periostitis; Osteomyelitis; Tuberculosis; Syphilis; Actinomycosis--Tumours: Of alveolar process; Of maxilla; Of mandible--Fracture of maxilla--Fracture of mandible--Affections of the temporo-mandibular articulation: Dislocation of the mandible; Acute arthritis; Tuberculous arthritis; Arthritis deformans; Closure of the jaws.
#Dental caries# is a process of disintegration which begins in the enamel of a tooth--usually in the region of its neck--and gradually extends through the dentine till the pulp cavity is reached.
Infection of the exposed pulp cavity may set up an acute purulent pulpitis. This is associated with severe pain, which is not confined to the diseased tooth, but may spread to adjacent teeth, and sometimes to all the branches of the trigeminal nerve on the same side of the face.
The infection may spread from the tooth to the alveolo-dental periosteum, and set up a periodontitis. In the affected tooth there is at first a feeling of uneasiness, which is relieved by the patient biting against it. Later there is severe lancinating or throbbing pain. The affected tooth usually projects beyond its neighbours, and is excessively tender when the opposing tooth comes in contact with it in mastication. The gum becomes red and swollen, and the cheek is oedematous.
Periodontitis is usually followed by the formation of an alveolar abscess. The pus, which forms at the root of the tooth, in most cases works its way through the bone and into the gum, constituting a "gum-boil." The pus may then burst through the gum, or may spread underneath the external periosteum of the jaw and lead to necrosis.
In some cases the cheek becomes adherent to the gum and to the jaw before the abscess bursts, and the pus escapes through the skin, leaving a sinus which leads down to the defaulting tooth, and which is slow to heal, usually because there is a small sequestrum at the bottom of it. The opening of the sinus is most commonly situated at the under margin of the mandible a little in front of the masseter muscle. An alveolar abscess deeply seated in the maxilla may open into the maxillary antrum and set up suppuration in that cavity. To avoid a scar on the face, the abscess should be opened from the mouth. A periodontal abscess of one of the upper central incisors spreads backwards between the muco-periosteum and the bony palate, causing an elongated swelling in the roof of the mouth.
In all cases the extraction of the carious tooth is necessary before the abscess will cease discharging and the sinus heal. If a sequestrum is present it must be removed, and the bone scraped with a sharp spoon. Among the other effects of dental caries may be mentioned localised necrosis of the alveolar margin, cellulitis of the neck, and enlargement of the cervical lymph glands.
A cyst is frequently found attached to the root of a decayed tooth. It is lined with epithelium, and is probably derived from a belated portion of the enamel organ which has been stimulated to active growth by infective processes in the pulp cavity. It is seldom larger than a pea, and contains a pultaceous mass like inspissated pus. It gives rise to no symptoms, and is only recognised after extraction of the root.
Odontomas have already been described (Volume I., p. 192).
A localised swelling of the mandible, associated with pain referred to the ear and neck, and in some cases with spasmodic contraction of the muscles of mastication, may be due to impaction of the wisdom tooth (lower third molar). If the tooth is merely embedded in the gum, incision may allow of its eruption; if the X-rays show that it is wedged under the second molar it must be extracted, and this may prove a difficult dental operation.
#Affections of the Gums.#--Inflammation of the gums--gingivitis--usually occurs in association with a general stomatitis. The gums are swollen and spongy, and may show superficial ulceration, associated with bleeding and extreme foetor of the breath. The teeth become loose, project from the alveoli, and sometimes fall out. These symptoms are prominent in cases of scurvy, and of chronic mercurial poisoning. In chronic lead-poisoning a characteristic blue line is seen on the gums near the dental margin. The treatment consists in removing the cause, improving the hygienic and dietetic conditions of the patient, and administering lime-juice, iodide of potash, quinine, or cod-liver oil, according to the cause. Antiseptic mouth-washes and dentifrices are also indicated. Chlorate of potash, being excreted in the saliva, is particularly useful.
Pyorrhoea alveolaris is a chronic form of gingivitis, met with after middle life, which begins in relation to the necks of the teeth and the alveolo-dental periosteum. It is due to bacterial infection, and is associated with an accumulation of tartar between the gums and the teeth. A muco-purulent discharge escapes from within the free edge of the gum and alveolus. The alveolar borders and the gum subsequently undergo atrophy, so that the roots are exposed, and the teeth are liable to become loose and eventually to fall out. The condition may only affect a few teeth, or it may spread to them all, in which case the patient may in the course of some years become edentulous. Gastro-intestinal disturbances, chronic joint affections of the nature of arthritis deformans, a form of pernicious anaemia, and other general conditions have been attributed to the absorption of toxic products. The treatment consists in removing the tartar from the teeth, applying strong antiseptics to the groove between the teeth and the gums, and employing mouth-washes and dentifrices. Massage of the gums night and morning, and rubbing in a paste of chlorate of potash and menthol, is often of great value. Good results have followed the use of vaccines and improvement of the general health.
Hypertrophy of the gums is occasionally met with in children and young adults who are mentally defective, and the teeth appear early and are abnormally large. The gum almost buries the teeth, and large polypoid masses form which tend to fungate. The treatment consists in removing not only the hypertrophied gums, but also the affected alveolus (Heath).
A localised hypertrophy--polypus of the gum--sometimes results from the irritation of a carious tooth, or from the pressure of an artificial denture, and may simulate an epulis (p. 513). The swelling is usually pedunculated, and if cut away close to the alveolar margin does not tend to recur.
Epithelioma sometimes originates in the gum in relation to a carious tooth or to an artificial tooth-plate. The growth tends to invade the bone and to spread to the cheek or buccal mucous membrane, or to the maxillary antrum, and its malignant nature is suggested by its persisting after the removal of the irritation. The only treatment is early and complete removal of the growth and the adjacent segment of bone.
Other tumours of the gums, such as angioma and papilloma, are rare.
THE JAWS
#Pyogenic Infections.#--The jaws may be infected in fractures communicating with the mouth or as a result of the unskilful extraction of teeth, but the majority of pyogenic infections originate in relation to carious teeth, beginning as a periodontitis which is followed by diffuse periostitis that may lead to necrosis of considerable portions of bone. In workers exposed to the fumes of yellow phosphorus, the bone may be so devitalised that it readily becomes infected with pyogenic organisms and undergoes a process of cario-necrosis--the phosphorus necrosis of the older writers.
Acute osteomyelitis occasionally attacks the mandible, less frequently the maxilla. Pus rapidly forms under the periosteum, and a considerable area of bone may undergo necrosis.
In cancrum oris, also, the bones are frequently attacked and may undergo necrosis.
The treatment is to let out the pus, and, whenever possible, this should be done from the mouth to avoid a cicatrix on the face. When the angle or the ascending ramus of the mandible or the facial portion of the maxilla is involved, it is not possible to avoid making an external opening. Drainage is secured, and the mouth kept sweet by the frequent use of antiseptic washes. When the condition is due to a carious stump or to an unerupted tooth, this should be extracted at the same time as the abscess is opened.
The separation of a sequestrum is usually slow, taking from two to four months according to the acuteness of the infection and the extent of the necrosis. In the mandible the sequestrum becomes surrounded by a sheath of new periosteal bone, so that, even if the greater part of the jaw undergoes necrosis, the arch is reproduced, and after removal of the sequestrum little or no deformity results. The sequestrum can usually be removed after dividing the mucous membrane and gouging away a portion of the outer aspect of the new sheath. The cavity is packed with iodoform or bismuth gauze. When the ascending ramus is involved, precautions must be taken to prevent fixation of the jaw taking place during the healing process. In the maxilla no new case is formed, and deformity results from sinking in of the cheek, unless this is prevented by wearing a plate made by the dentist.
#Tuberculous disease# is comparatively rare. It is occasionally met with on the orbital margin of the maxilla and in the region of the zygomatic (malar) bone. In the mandible it usually occurs near the angle. Stockman isolated the tubercle bacillus from a series of cases of "phosphorus necrosis" investigated by him. The sinuses that form when a cold abscess bursts on the surface are peculiarly intractable and only heal after the diseased bone has been removed, leaving a characteristically depressed scar, which is adherent to the bone.
#Syphilitic# affections are also rare. A localised gumma may develop in the neighbourhood of the angle of the mandible, or the whole of the body of that bone may be the seat of a diffuse gummatous infiltration (Fig. 248). In either case the clinical importance of the condition lies in the fact that it is liable to be mistaken for a new growth, such as an osteo-sarcoma, or for actinomycosis.
#Actinomycosis.#--This condition is met with in the jaws more frequently than in any other part, and the mandible is attacked oftener than the maxilla. The actinomyces gain access to the bone through a carious tooth or through the gum.
At the outset the patient complains of pain and tenderness referred to one or more carious teeth. Within a few weeks a swelling forms--in the mandible near the angle as a rule, and in the maxilla in some part of the cheek. The swelling, which varies in consistence, implicates the bone and cannot be moved apart from it. The skin over it becomes red, suppuration occurs, and sinuses form and give exit to a sero-purulent fluid in which the characteristic yellow "sulphur grains" may be detected. The surrounding soft tissues are infiltrated, and the part becomes riddled with sinuses, which lead down to bare bone. The disease usually runs a chronic course, lasting for one or two years, and, unless pyogenic infection is superadded, is not attended with fever.
In the absence of the characteristic yellow granules, actinomycosis may readily be mistaken for tuberculous or syphilitic disease, or for sarcoma.
The treatment consists in removing the diseased tissue with the knife or sharp spoon, and in the administration of large doses of potassium iodide. The insertion of tubes of radium has a beneficial effect.
#Tumours of the Alveolar Process.--Epulis.#--The tumours that grow from the alveolar processes of the jaws appear at first sight to spring from the gums, hence the term epulis, generally applied to them. They really originate in the periosteum of the alveolus or in the periodontal membrane, and are essentially of the nature of fibro-sarcoma. In some, the fibrous element predominates, but the frequency with which they recur after removal, unless the segment of bone from which they spring is also excised, indicates their malignant tendency. In most cases the tumour is of the myeloid type--myeloma; in others new bone is formed in its substance--osteo-sarcoma.
An epulis usually begins in the gap between two teeth, and grows slowly, either towards the cavity of the mouth, or more frequently towards the lip or cheek, where it appears as a bright red, smooth, firm, rounded swelling, which is adherent to the jaw, and may be sessile or pedunculated (Fig. 249). It causes little pain, but is liable to interfere with mastication. As it increases in size it spreads over the alveoli of several teeth, becomes softer, and assumes a dark violet colour, and if subjected to pressure or irritation may ulcerate and bleed.
The true alveolar tumour is to be diagnosed from a mass of redundant granulations such as may form in relation to a carious tooth, from a polypus or an epithelioma of the gum, a tumour of the body of the jaw, or an angioma.
The treatment consists in removing the tumour together with a wedge-shaped or quadrilateral portion of the alveolar process from which it grows. A dental plate should be fitted to fill up the gap in the alveolus. After such free removal these tumours show little tendency to recur and metastases are rare.
#Malignant Tumours of the Maxilla.#--All varieties of sarcoma and carcinoma are met with; of the former, the round and spindle-celled are the most common. Carcinoma occurs chiefly in two forms, less commonly a columnar epithelioma arising from glandular epithelium, much more commonly a squamous epithelioma either originating within the antrum and causing its expansion, or spreading to the maxilla from the mucous membrane of the nose or mouth. Clinically it is practically impossible to differentiate sarcoma from carcinoma; in the later stages the infection of the glands below the mandible is more marked in carcinoma. An important point to determine is whether the growth arises within the maxilla or has spread to it from adjacent parts, such as the base of the skull, the nose, or the palate. In this the X-rays are helpful. Their malignancy is evidenced by the rapidity of their growth, the manner in which they infiltrate adjacent parts, and the frequency with which they recur after removal. They occur at all ages, and have been met with even in children.
The clinical features vary according to whether the tumour originates on the anterior aspect of the bone, in the maxillary antrum, or on the posterior aspect.
When the tumour originates in the periosteum covering the front of the bone, it forms a swelling under the cheek, usually in the vicinity of the zygomatic (malar) bone, and grows towards the mouth as well as towards the surface. The cheek is gradually invaded, and in some cases the growth extends into the maxillary sinus.
The typical malignant tumour of the upper jaw originates in the lining membrane of the antrum; it first fills the cavity and then bulges its walls in every direction, so that, on pressure being made over the swelling, the osseous shell of the sinus dimples and crackles under the finger. The sinus is dark on trans-illumination. The tumour may obstruct the nostril on the same side, and, by pressing on the tear duct, may cause the tears to flow over the cheek. It may be seen through the anterior nares, and may be attended with a sanious discharge from the nose. The eyeball is liable to be displaced upward, and if the ethmoid cells are invaded, it is also pushed outward; the palate may be depressed and the cheek projected (Figs. 250, 251).
When the tumour grows from the periosteum of the posterior aspect of the bone, and extends into the spheno-maxillary or pterygo-maxillary fossa, the eyeball is usually protruded by the invasion of the orbit from behind, and a swelling appears in the temporal region. If the sinus is invaded, the tumour spreads in the various directions already indicated. Not infrequently a tumour, which appears to have its seat in the maxilla, is really a downward prolongation of a growth originating in the base of the skull, a point on which the X-rays may yield valuable information.
In all cases the tumour tends to infiltrate the surrounding tissues indiscriminately. There is severe pain referred to the distribution of the maxillary division of the trigeminal nerve. Haemorrhage is liable to occur when exposed portions of the tumour ulcerate--for example in the nasal fossae. Sarcoma is to be distinguished from the solid and cystic forms of odontoma, which also may distend the bone, bulging the hard palate and projecting on the face.
Treatment of Malignant Disease.--Without the help of radiation the results of operative treatment of malignant disease of the maxilla are far from encouraging. Probably the best line to follow is to embed several tubes of radium in different parts of the tumour for several days, and when the resulting shrinkage of the growth appears to have attained its limits, the maxilla should be excised. If on microscopic examination it is found to be a carcinoma, the glands on the same side of the neck should be removed at a second operation on lines similar to those in Butlin's operation in cancer of the tongue. The aid of the dentist is required to fit a denture which will at least restore the hard palate and alveolar margin. The operation of excising the upper jaw is not a dangerous one, especially if the risk of broncho-pneumonia is minimised by the intra-tracheal administration of ether. The final illness in cases of malignant disease of the upper jaw left to nature, or when it has recurred after operation, is a terrible one; the growth displaces and destroys the globe, blocks the nose and fungating on the face, causes hideous disfigurement.
#Simple tumours# are rare. Fibroma may originate in the periosteum or in the lining membrane of the maxillary sinus. It usually tends to assume the characters of sarcoma. Chondroma usually begins either on the nasal surface of the bone or in the maxillary sinus. Osteoma occurs in two forms: the exostosis, which may be composed of cancellated or of compact tissue, and the diffuse osteoma or leontiasis ossea (Volume I., p. 485). All intermediate forms are met with, and when confined to the maxilla, the resulting disfigurement may be improved or remedied by operation; the cheek is raised or reflected and the bone shaved away with a strong knife or osteotome.
#Tumours of the Mandible.#--The same varieties are met with as in the maxilla. The non-malignant forms--osteoma, chondroma, and fibroma--are rare.
A dentigerous cyst appears as a smooth, rounded, and painless swelling, usually in the region of the molar teeth. The bone gradually becomes expanded and crackles on pressure. The cyst is filled with a glairy mucoid fluid, and may contain one or more unerupted teeth (Fig. 252). The X-ray appearances are characteristic. The treatment consists in removing the anterior wall of the cyst, scraping the interior, and packing the cavity with iodoform or bismuth gauze.
The myeloid tumour or myeloma is comparatively common. It develops in the interior of the bone and expands the affected segment (Fig. 253). It grows slowly, is more or less encapsulated, and therefore does not infiltrate the surrounding tissues. Sometimes it so weakens the bone that pathological fracture occurs. There is no glandular involvement, and the tumour shows little evidence of malignancy.
The periosteal sarcoma is the most malignant form. It grows rapidly, and infiltrates the surrounding tissues. The submaxillary salivary glands and the cervical lymph glands are usually implicated, and the disease tends to spread by metastasis to distant parts.
Epithelioma is the commonest new growth affecting the mandible; it usually involves the central portion of the bone, being a direct spread from the lower lip, tongue, or floor of the mouth. When it originates in the pillars of the fauces it implicates the ascending ramus. In all cases the infection of the cervical lymph glands is a serious factor both in prognosis and treatment.
Treatment.--Partial removal of the mandible may be undertaken for myeloma, and in cases of sarcoma and epithelioma in which the tumour is limited to a small area of the bone--for example, to the alveolar process, the angle, the horizontal ramus, or the symphysis; in other cases, the whole bone must be removed.
INJURIES OF THE JAWS
#Fracture of the Maxilla.#--Fractures of the maxilla are nearly always due to direct violence, such as a blow on the face, a stab, or a gun-shot wound. They are often rendered compound by opening into the mouth, into the maxillary sinus, or on to the skin of the cheek. The alveolar process, in whole or in part, may be separated from the body of the bone by a severe blow, such as the kick of a horse, and when the whole alveolus is detached, it may carry with it the hard palate. Limited portions of the alveolus are frequently broken in the extraction of teeth. The main trouble after severe alveolar fractures is that the upper teeth do not accurately oppose the lower ones, and mastication is thereby interfered with.
When the frontal (nasal) portion of the maxilla is broken, the lachrymal sac and nasal duct may be damaged and the flow of the tears obstructed. In such cases emphysema is also liable to develop. Fractures of the facial portion are frequently complicated by haemorrhage from the infra-orbital vessels, and anaesthesia of the area supplied by the infra-orbital nerve. Suppuration may occur in the maxillary sinus. In some cases the maxilla is driven in as a whole, and in others the fracture radiates to the base of the skull and cerebral symptoms develop.
The treatment consists in reducing any deformity that may be present, ensuring efficient drainage, and keeping the mouth as aseptic as possible. Union takes place rapidly, and owing to the vascularity of the parts necrosis is rare, even when suppuration ensues. When the alveolar portion is comminuted, the fragments may be kept in position by fixing the mandible against the maxilla by means of a four-tailed bandage (Fig. 255), or by adjusting a moulded lead or gutta-percha splint to the alveolus and palate.
The zygomatic (malar) bone is sometimes fractured by direct violence, along with the adjacent portion of the maxilla. It may be possible to manipulate the displaced fragments into position with the fingers introduced between the cheek and the gum; if this fails, a small incision should be made in the mucous membrane anterior to the masseter, and the bone levered into position with an elevator.
The zygomatic arch is occasionally fractured by a direct blow. As the depressed fragments are liable to interfere with the movement of the mandible, they should be elevated either by manipulation or through an incision.
#Fractures of the Mandible.#--The most common situation for fracture of the mandible is through the body of the bone in the vicinity of the canine tooth (Fig. 254). The depth of the socket of this tooth, and the comparative narrowness of the jaw at this level, render it the weakest part of the arch. The fracture is usually due to direct violence, such as a blow with the fist, the kick of a horse, or a fall from a height. It is sometimes bilateral, the bone giving way at the canine fossa on one side and just in front of the masseter on the other; or both fractures may be at the canine fossae. The fracture is usually oblique from above downwards and outwards, and is nearly always rendered compound by tearing of the mucous membrane of the mouth.
When only one side is broken, the smaller fragment is usually displaced outwards and forwards by the masseter and temporal muscles, so that it overlaps the larger fragment. In bilateral fractures the central loose segment is driven downwards and backwards towards the hyoid bone by the force causing the fracture, and is held in this position by the muscles attached to the chin, while both lateral fragments are tilted outwards and forwards by the masseters and temporals. The amount of displacement is best recognised by observing the degree of irregularity in the line of the teeth. Abnormal mobility and crepitus are readily elicited, and there is severe pain, particularly if the inferior dental nerve is stretched or crushed. The patient's attitude is characteristic; he supports the broken jaw with his hands, and keeps it as steady as possible when he attempts to speak or swallow. Saliva dribbles from the open mouth, and the speech is indistinct.
In adults, the bone may be broken at the symphysis as a result of lateral compression of the jaw--for example, pressing together of the angles. The general characters of the fracture are the same as those of fracture of the body, but the displacement is inconsiderable.
Fractures of the angle and through the ramus are less common, and are not attended with deformity, as the fragments are retained in position by the masseter and internal pterygoid muscles. Fracture of the coronoid process is rare.
The condyle is usually fractured just below the insertion of the external pterygoid muscle (Fig. 254) by a fall on the chin or by a severe blow on the side of the face. When the fracture is unilateral, the broken condyle is tilted inwards and forwards by the external pterygoid, and can be palpated from the mouth, while the rest of the jaw is displaced towards the affected side, and not away from it, as happens in unilateral dislocation. When the fracture is bilateral, the mandible falls backwards, so that the lower teeth lie behind those of the maxilla.
In a few cases the condyle has been driven through the floor of the glenoid cavity, causing fracture of the base of the skull. The diagnosis may be established by means of the X-rays.
Complications.--As the majority of these fractures are compound, suppuration is comparatively common during the process of repair, but if means are taken to keep the mouth clean it can usually be kept in check, and seldom leads to necrosis. The teeth adjacent to the fracture are liable to be loosened or displaced. If merely loosened they should be left in place, as they usually become firmly fixed in the course of a few days. Care must be taken that a displaced tooth does not pass between the fragments, as this has been the cause of difficulty in reducing a fracture and of its failure to unite. Irregular union, by destroying the alignment of the teeth, leads to interference with mastication. The bone usually unites in from four to six weeks. Want of union is a rare event.
Treatment.--In the majority of cases of unilateral fracture after reduction, the fragments can be kept in apposition by closing the mouth and keeping the lower jaw fixed against the upper by means of a four-tailed bandage (Fig. 255). Care must be taken that the posterior tails of the bandage do not pull the mandible backward. Additional security may be given by a light poroplastic or gutta-percha splint fitted to the chin, the vertical portion passing well up the ramus of the jaw. After a few days the apparatus is removed, the patient is encouraged to move the jaw, and massage is employed. The mouth must be regularly cleansed by an antiseptic mouth-wash, or by a spray of hydrogen peroxide.
In certain fractures implicating the body of the jaw, and particularly when bilateral, the co-operation of the dentist is necessary to obtain the best results. After the fragments have been coapted, a plaster impression is taken of the jaw and teeth, and from this a silver frame is cast which surrounds but does not envelop the teeth. This frame is then applied to the fractured jaw, and restrains movement of the fragments without interfering with the action of the jaw (W. Guy). The use of an intra-oral frame obviates the necessity of wiring the fragments.
Even in badly united fractures the original contour of the bone is eventually restored by the movements of the tongue moulding it into shape.
AFFECTIONS OF THE TEMPORO-MANDIBULAR ARTICULATION
#Dislocation of the Mandible.#--Dislocation of the lower jaw may be unilateral or bilateral. The bilateral form is the more common, and is met with most frequently in middle life, and in females. The liability to dislocation is greatest when the mouth is widely open--for example, in yawning, laughing, or vomiting--as under these conditions the condyle, accompanied by the meniscus, passes forwards out of the glenoid cavity and rests on the summit of the articular eminence. If, while the bone is in this position, the external pterygoid muscle is thrown into contraction, it pulls the condyle forward over the eminence into the hollow beneath the root of the zygoma, and the contraction of the masseter and temporal muscles retains it there. Muscular contraction is therefore an important factor in its production.
Dislocation may be produced also by a downward blow on the chin, by the unskilful introduction of a mouth gag, particularly while the patient is anaesthetised, or even in the attempt to take a big bite--say, of an apple. The dislocation that results from such causes is usually unilateral.
In some persons the ligaments of the joint are unnaturally lax, and dislocation is liable to occur repeatedly from comparatively slight causes--recurrent dislocation.
Clinical Features.--The appearance of a patient suffering from bilateral dislocation is characteristic. The mouth is open, the jaw fixed, and the chin protruded so that the lower teeth project beyond the upper. The patient has difficulty in swallowing, and the saliva dribbles from the mouth. As the lips cannot be approximated, the speech is indistinct and guttural. Just in front of the auditory meatus a deep hollow can be felt, and in front of this the condyle forms an undue projection. The coronoid process is displaced below and behind the zygomatic (malar) bone, and may be felt through the mouth. The contracted temporal muscle forms a prominence above the zygoma.
In unilateral dislocation the deformity is the same in character, but is less marked, and in mild cases its cause is liable to be overlooked. In most cases the chin deviates towards the sound side.
Treatment.--In recent cases, reduction is usually easily effected. The patient should be seated on a low chair or stool, an assistant supporting the head from behind. The surgeon, standing in front, places his thumbs, well protected by a roll of lint, far back on the molar teeth, and with his other fingers grasps the body of the jaw. Pressure is now made downwards and backwards to free the condyles from the articular eminence, and to overcome the tension of the temporal and masseter muscles, and as this is effected the tip of the chin is carried upward, while the whole jaw is pushed directly backward. The condyle slips into position, sometimes with a distinct snap. When difficulty is experienced in levering the condyle from its abnormal position, a cork may be placed between the molar teeth on each side to act as a fulcrum. After reduction the jaw is fixed by means of a four-tailed bandage for a few days. The patient is warned to avoid for some weeks opening the mouth widely.
Old-standing Dislocation.--It sometimes happens that, from having been overlooked or neglected, the dislocation remains unreduced. In such cases the movement of the jaw is in time partly restored, and the patient acquires sufficient control of the lips to be able to articulate intelligibly and to prevent dribbling of saliva. The power of masticating the food, however, remains impaired. The hollow behind the condyle and the projection of the chin persist. Reduction by manipulation is seldom possible after the dislocation has existed for more than three months, but it has been effected as long as ten months after the accident. Several attempts at reduction should be made at intervals of two or three days, and if these fail recourse may be had to operation. As the masseter and internal pterygoid muscles have assumed a vertical position and become shortened, they form an obstacle to reduction, and to overcome their action it is necessary to separate them from their insertion to the ascending ramus of the bone through an incision carried round the angle. If the adhesions about the dislocated condyle are then separated, reduction can be effected (Samter). In some cases it is necessary to excise the condyle to restore movement.
Internal Derangements of the Temporo-mandibular Joint.--The intra-articular cartilage is liable to be displaced by excessive traction exerted on it by the external pterygoid muscle during some sudden movement of the joint, particularly in closing the mouth. There is acute pain in the region of the joint, the teeth on the affected side cannot be brought into apposition, so that mastication is interfered with, and the patient is conscious of something locking inside the joint. The joint is tender to the touch, but there is no external swelling. Replacement is effected by keeping up firm pressure at the back of the condyle with the mouth open, and slowly closing the jaw. If recurrence takes place repeatedly, the disc may be sutured to the periosteum (Annandale), or excised (Hogarth Pringle).
#Arthritis# of the temporo-mandibular joint occurs in two forms, non-suppurative and suppurative.
The non-suppurative form is usually due to gonorrhoeal infection, and as a rule is bilateral. The patient complains of neuralgic pains shooting towards the ears and temples, and of pain in the joint on movement. The jaw is therefore kept fixed, usually with the mouth slightly open and the chin protruded. Mastication is impossible, and the speech is indistinct. There is effusion into the joint, and a swelling may be detected in front of the ear. The inflammation may subside and movement restored, or fibrous ankylosis may ensue.
The suppurative form may be due either to direct spread of infection from adjacent parts, as, for example, in middle ear disease, suppurative parotitis, or pyogenic affections of the mandible, or it may be part of a general pyaemic infection, as sometimes occurs after exanthematous fevers and in gonorrhoea. The clinical features are similar to those of the non-suppurative form, but the signs referable to the joint are often masked by those of the primary lesion. When the pus originates in the joint, it may point either towards the skin or into the external auditory meatus through the petro-tympanic (Glaserian) fissure. The joint is usually completely disorganised and ankylosis results.
#Tuberculous arthritis# is rare, and is usually secondary to disease of the mandible, the temporal bone, or the middle ear. It leads to destruction of the joint and ankylosis. It is treated by incision and scraping, or by excision of the condyle.
#Arthritis deformans# is a comparatively common affection, and is generally bilateral. In the earlier stages the condyle is usually hypertrophied and distorted, and the glenoid cavity is correspondingly broadened and flattened, and in time may be filled up by new bone. Osteophytic outgrowths form around the joint and lead to fixation or locking. The enlarged condyle may be felt in front of the ear, and there is pain and cracking on movement; the pain is worst at night and in wet weather. The jaw is usually depressed and the chin protruded. The disease runs a chronic course, with occasional acute exacerbations. Excision of the condyle may be advisable when non-operative measures have failed to give relief. In the later stages, the condyle, together with the meniscus, may be worn away and completely disappear.
#Closure or Fixation of the Mandible.#--Temporary fixation is due to spasmodic contraction of the muscles of mastication, particularly the masseter. This may be symptomatic of some inflammatory condition in the vicinity, such as a pyogenic affection of the lower jaw--for example, that associated with a carious root or an unerupted wisdom tooth, or with parotitis or tonsillitis. In such cases the spasm passes off on the removal of the cause. It is occasionally a manifestation of hysteria. The administration of a general anaesthetic and the introduction of a wedge or separator is usually necessary to confirm the diagnosis and, it may be, to permit of operative measures, such as the extraction of a wisdom tooth.
Muscular fixation may be due to rheumatic or syphilitic myositis, and this is sometimes followed by fibroid degeneration of the muscles, rendering the fixation permanent.
Permanent fixation may be due to a variety of causes. Fibroid degeneration of muscles following myositis has already been mentioned. Much more frequently it results from cicatricial contraction of the soft parts of the face or mouth following such conditions as cancrum oris, ulceration, or burns. Fixation following upon prolonged immobilisation after fracture or dislocation, or any of the forms of arthritis or suppurative or tuberculous disease of the adjacent portions of the mandible, is also met with. The ankylosis may be fibrous or osseous, and may be intra- or extra-articular.
The clinical features vary with the degree of separation of the jaws. There is always some deformity, and more or less interference with mastication and speech. The patient usually feeds himself by pushing small portions of bread or meat with the fingers through some gap between the badly opposed and badly formed and preserved teeth. As the patient is unable to keep the mouth clean, particles of food lodge and decompose there, causing irritation of the mucous membrane, caries of the teeth, and foetor of the saliva and breath. When osseous ankylosis occurs in childhood, it leads to arrest of development of the mandible, which is small and markedly receding, so that the teeth do not oppose those of the maxilla (Fig. 256).
Treatment.--When the cause of the fixation is in the joint itself, the best treatment is to resect one or both condyles.
When the fixation is due to cicatricial contraction of the soft parts, mobility is best restored by forming an artificial joint well in front of the cicatricial tissue, as suggested by Esmarch.
XXII. THE TONGUE
Surgical Anatomy--Wounds--Dental ulcer--Inflammatory affections: Acute parenchymatous glossitis and hemi-glossitis; _Mercurial glossitis_; Chronic superficial glossitis; Leucoplakia; Smoker's patch--Tuberculous disease; Syphilitic affections; Sclerosing glossitis; Gummas; Ulcers and fissures--Tumours: Carcinoma; Sarcoma; Innocent tumours; Cysts--Thyreo-glossal tumours and cysts--Malformations: Absence; bifid tongue; Tongue-tie; _Excessive length of frenum_; Macroglossia; Atrophy--Nervous affections.
#Surgical Anatomy.#--The tongue is composed of interlaced, striped muscle fibres, partly consisting of the terminations of the extrinsic muscles, and partly of the intrinsic muscles. A median fibrous septum divides it into two lateral halves so completely that but little communication takes place between the blood vessels and lymphatics of the two sides. It is covered by stratified squamous epithelium. For practical purposes it is described as consisting of an anterior or oral part, and a posterior or pharyngeal part.
The oral part, which includes the anterior two-thirds of the organ, is mobile, and the epithelium on its dorsal aspect is modified so as to form several varieties of papillae. A slight median depression is recognisable on the dorsum as far back as the vallate (circumvallate) papillae, which mark the boundary between the oral and pharyngeal parts. A double fold of mucous membrane--the frenum--connects the under aspect of the tip with the floor of the mouth and the mandible. On each side of the frenum, under the mucous membrane of the tip, are mucous glands--apical glands--in which cysts sometimes form. On the lateral border of the tongue, just in front of the anterior palatine arch, are several vertical folds of mucous membrane--the folia linguae, or foliate papillae.
The pharyngeal part, or base of the tongue, forms the anterior wall of the pharynx, and is attached to the hyoid bone. Its mucous membrane is devoid of papillae, but contains numerous lymphoid follicles--the lingual tonsil. The foramen caecum lies just behind the apex of the vallate papillae in the middle line.
The chief artery, the lingual, a branch of the external carotid, passes forward beneath the hyoglossus muscle, and is continued to the apex as the ranine, lying nearer the under than the upper aspect of the tongue. The pharyngeal part is supplied by the dorsalis linguae branch. The blood is returned to the internal jugular by the ranine vein, which can be seen under the mucous membrane on the inferior aspect near the frenum, and by the venae comites of the lingual artery and its branches.
The hypoglossal is the motor nerve of the tongue. The lingual branch of the mandibular (inferior maxillary) supplies the anterior two-thirds with common sensation. It is accompanied by the chorda tympani branch of the facial, which probably carries the taste fibres. The glosso-pharyngeal supplies the posterior third of the tongue with both common and gustatory sensation.
The lymph vessels of the anterior two-thirds of the tongue drain into the submental and submaxillary glands, and these in turn into the deep cervical group which accompany the internal jugular vein. The vessels of the base converge into several large trunks which pass out behind the tonsils and drain directly into the deep cervical glands. One of these, which lies in the angle between the internal jugular and common facial veins, is frequently infected in cancer of the tongue.
#Wounds# are commonly produced by the teeth, as, for instance, when a child falls on the chin with the tongue protruded, or when an epileptic bites his tongue during a fit. Less frequently a foreign body, such as a pipe-stem, a bullet, or a displaced tooth, is driven into the tongue. The immediate risk is haemorrhage, particularly when the posterior part of the tongue is implicated and the wound penetrates deeply. Of the later complications, infections and secondary haemorrhage are the most serious, and they are most liable to occur when a foreign body is embedded in the tongue.
Treatment.--In superficial wounds near the tip the oozing is efficiently arrested by sutures, but in deeper wounds a ligature must be applied to the bleeding vessel. Secondary haemorrhage is much more difficult to arrest on account of the friable state of the tissues, and it may be necessary to ligate the lingual or even the external carotid in the neck.
To prevent infective complications any foreign body must be removed and an antiseptic mouth-wash regularly employed.
Cases have been recorded in which such a foreign body as a bullet, a needle, or a piece of a pipe-stem, has remained embedded in the substance of the tongue for a long period, and caused a firm, indolent swelling liable to be mistaken for a new growth.
#Dental Ulcer.#--The continuous friction of a jagged tooth, or of an ill-fitting dental plate, is liable to cause swelling and excoriation of the side of the tongue. A painful superficial ulcer forms, and if the irritation continues and infection occurs, the surrounding parts become indurated, the ulcer assumes a crater-like appearance, not unlike that of a commencing epithelioma. If such an ulcer does not promptly heal on the removal of the irritant, a portion of the margin should be removed and submitted to microscopic examination to make sure that it is not cancerous.
#Inflammatory Affections.#--Acute Parenchymatous Glossitis is usually due to the action of streptococci. Although it affects mainly the mucous membrane and submucous tissue, it causes a diffuse oedematous swelling of the whole organ, and this may extend to the ary-epiglottic folds and give rise to oedema of the glottis. As a rule it does not go on to suppuration.
The onset is sudden, and is marked by pain and stiffness of the tongue, particularly when the patient attempts to masticate or to speak. The tongue rapidly swells, and in the course of twenty-four or forty-eight hours may fill the mouth and protrude beyond the teeth. There is profuse salivation, and in addition to difficulty in swallowing and speaking there may be considerable interference with respiration. The salivary and lymph glands in the submaxillary space are enlarged and tender. The symptoms begin to subside in three or four days, unless suppuration occurs.
The treatment consists in administering a sharp purge and employing a mouth-wash; leeches may be applied to the submaxillary region with benefit. When the swelling is excessive, it may be necessary to make longitudinal incisions into the substance of the tongue, and dyspnoea may call for laryngotomy. If an abscess forms it must be opened.
A similar condition has been met with in patients who have contracted the "foot and mouth disease" of cattle. Vesicles form on the mucous membrane, and after bursting, ulcerate, and a mixed infection with streptococci occurs, leading to diffuse oedema. Portions of the tongue may become gangrenous, and the infection may spread to the tissues of the neck and set up one form of angina Ludovici. The condition is usually fatal.
Acute Hemi-glossitis.--An acute transitory swelling, confined to one half of the tongue, in the distribution of the lingual nerve, is occasionally met with. It is attended with great pain and high temperature, and is believed to be analogous to herpes zoster (Gueterbock).
Mercurial Glossitis may accompany mercurial stomatitis (p. 496).
Chronic Superficial Glossitis.--Several forms of chronic superficial glossitis are met with. The most important, as it is frequently followed by the development of epithelioma, is that known as leucoplakia or leucokeratosis.
The tongue is studded over with white patches, which result from overgrowth and cornification of the surface epithelium, whereby it becomes thickened and raised above the surface, and at the same time there is small-celled infiltration of the submucous tissue. The patches are irregularly lozenge-shaped, and when crowded together they present the appearance of a mosaic (Fig. 257). Similar patches are often present on the mucous membrane lining the cheek.
The disease is met with almost invariably in men between the ages of forty and fifty. Syphilis appears to be a predisposing factor, and any form of irritation--for example, the chewing or smoking of tobacco, the drinking of raw spirits, friction by a rough tooth or tooth-plate--plays an important part in inducing or in aggravating the condition.
The milder forms give rise to no discomfort, but when the condition is advanced the patient complains of dryness and hardness of the tongue, with impairment of the sense of taste and persistent thirst. When cracks, fissures, or warts develop, there is pain on chewing or speaking, or on taking hot or irritating food. The glands below the jaw may be enlarged.
The disease is most intractable and persistent, and even after disappearing for a time is liable to recur. After a variable number of years epithelioma is prone to develop, usually in one or other of the fissures which accompany the condition.
The treatment consists in removing all sources of irritation, particularly smoking, and in employing mouth-washes. Butlin recommends antiseptic ointments applied before going to bed. In some cases painting the patches with chromic acid (10 grains to the ounce) or lactic acid (20 per cent.) is useful in removing the excess of epithelium, but stronger caustics are to be avoided. Constitutional treatment is of little use even when the patient has suffered from syphilis. The best results have been attained by the use of radium.
The "smoker's patch" consists of a small oval area on the front of the tongue from which the papillae have disappeared. It is slightly raised, smooth and red, and may be covered with a yellowish-brown or yellowish-white crust. It causes no discomfort unless the crust is removed, when a raw, sensitive surface is exposed. The condition is liable to spread over the tongue if the patient persists in smoking. It may eventually assume the characters of leucoplakia. The treatment consists in stopping the use of tobacco, and painting the patches with chromic acid, tannic acid, or alum, and employing a chlorate of potash mouth-wash.
#Tuberculous Disease.#--The tongue is rarely the primary seat of tuberculosis. The majority of cases occur in adult males, who suffer from advanced pulmonary or laryngeal phthisis, the tongue being infected by bacilli from the sputum or through the blood stream. In other cases the infection is due to direct spread of lupus from the face or nose.
The condition may begin as a firm, painless lump, seldom larger than a hazel-nut, on one side of the tongue, or near its tip. At first the swelling is covered by epithelium; in time caseation takes place, the epithelium gives way, and an open sore is formed.
The tuberculous ulcer is the form most frequently met with. The surface of the ulcer is uneven, pale and flabby, and is covered with a yellowish-grey discharge, with here and there feeble granulations showing through. The edges are shreddy, sinuous in outline, and there is little or no induration. The surrounding parts are slightly swollen, and may be studded with small tuberculous foci. The ulcer may be quite superficial, or it may extend into the muscular substance, and the tip of the tongue may be completely eaten away so that it looks as if it had been cut off with a knife. As the disease advances there is severe pain and usually profuse salivation. The submaxillary glands may be, but are not always, enlarged. The ulcer may heal, but tends to break down again.
Unless there is advanced pulmonary disease or other contraindication to operation, the ulcer should be excised under local anaesthesia. Care must be taken to avoid reinfecting the raw surface. When excision is impracticable, it is only possible to palliate the symptoms by dusting with orthoform, or applying local anaesthetics, and by attending to the hygiene of the mouth and removing all sources of irritation.
#Syphilitic Affections.#--A primary lesion on the tongue is accompanied by marked enlargement and tenderness of the submaxillary lymph glands on one or on both sides. It is most common in men, infection usually taking place through the medium of tobacco pipes, or implements such as the blow-pipes of glass-blowers.
During the secondary stage--particularly in the later periods--mucous patches and ulcers are common, and they may assume a condylomatous or warty appearance.
The tertiary manifestations in the tongue are sclerosing glossitis, gummas, and gummatous ulcers.
Sclerosing glossitis is the term applied by Fournier to a condition in which there is an abundant new formation of granulation tissue in the substance of the tongue, leading to the appearance of tuberous masses on the dorsum. These tend to be oval in outline, are elevated above the normal mucous membrane, and present a dull red mammilated or lobulated surface, comparable to the surface of a cirrhotic liver. They are firm, elastic, and insensitive.
A gumma is usually situated on the dorsum and more often towards the centre than at the edges. As it seldom implicates the floor of the mouth or the base of the tongue, the tongue can usually be protruded freely. It forms an indolent swelling, which tends to break down slowly and to ulcerate. So long as it remains unbroken it does not cause pain, and there is no enlargement of the adjacent lymph glands. Two forms are met with--the superficial, and the deep or parenchymatous.
A superficial gumma appears as a small hard nodule under the mucous membrane, varying in size from a pin's head to a pea. The mucous membrane over it is redder than normal, and in the early stages retains its papillae but later becomes smooth. It tends to break down early, forming a superficial ulcer. Superficial gummas are often multiple.
The deep or parenchymatous form varies in size from a hazel-nut to a walnut, and feels like a hard body in the substance of the tongue. The mucous membrane over the swelling is of normal colour, but is usually devoid of papillae. The gumma may remain for months unchanged, or may approach the surface, soften, and break down, leaving a deep, ragged ulcer.
Syphilitic ulcers and fissures are nearly always due to the softening and breaking down of gummas. The ulcers have seldom the typically rounded or serpiginous outline of gummatous ulcers on other parts of the body. The base is ragged and unhealthy, and on it a yellowish-grey slough resembling wash-leather may be seen. The edges are steep, ragged, and often undermined, and the surrounding parts thickened and indurated. The neighbouring glands are not usually enlarged. The ulcer is extremely painful when irritated by food, hot fluids, or spirits. If untreated, the sore may remain indolent and for months show no sign either of spreading or healing, but at any time it may become the seat of cancer.
Syphilitic fissures are met with as long, narrow, deep clefts, or as stellate or sinous cracks in the substance of the tongue. After the healing of these ulcers and fissures permanent furrows and depressed scars remain.
Treatment.--The tertiary manifestations of syphilis in the tongue are treated on the same lines as other tertiary lesions. Locally, the use of mouth-washes, such as chlorate of potash or black wash diluted with lime-water, the insufflation of powdered iodoform and borax with a small quantity of morphin, or the application of mercurial ointment is useful. The sore must be thoroughly cleansed before these remedies are applied.
NEW GROWTHS
#Carcinoma# is by far the most common form of new growth met with in the tongue, and it is almost invariably a squamous epithelioma.
Epithelioma generally occurs between the ages of forty and sixty, and attacks males oftener than females, in the proportion of about six to one. Its development is favoured by any long-continued irritation, such as the rubbing of the tongue against a carious tooth, an ill-fitting tooth-plate, or the rough end of a short clay pipe, particularly when such irritation leads to the formation of an ulcer. Chronic superficial glossitis associated with leucoplakia, and syphilitic fissures, ulcers, or scars, also act as predisposing factors. The repeated application of strong caustics to chronic inflammatory conditions is, according to Butlin, a determining cause of cancer. The degree of malignancy appears to vary in different cases, and is probably lowest when the disease originates in a patch of leucoplakia or other pre-cancerous lesion.
The disease is usually situated in the anterior half of the tongue, and more commonly on the edge than on the dorsum. It may begin as an excoriation, ulcer, or fissure, or as a warty growth, particularly in association with a patch of leucoplakia. In all cases ulceration begins early, and the base of the ulcer and the surrounding parts become indurated. The lymph glands are, as a rule, early infected.
Clinical Features.--The clinical appearances vary widely. Sometimes the surface presents a warty growth; sometimes it is excavated, forming a deep ulcer with raised nodular edges; in other cases the ulcer is smooth, and its edges even and rounded. Extreme hardness of the edges and base of the ulcer is always a characteristic feature. The tongue tends to become fixed, especially when the disease spreads to the floor of the mouth, so that it cannot be protruded, and the restriction of its movement produces a characteristic interference with articulation, certain words being slurred, and when the fixation is extreme it may interfere with mastication and swallowing. The patient complains of a constant gnawing pain in the tongue, and of severe pain shooting along the branches of the trigeminal nerve, and especially towards the ear. In the advanced stages there is salivation and foetor of the breath.
When the disease is situated on the edge of the tongue it tends to spread to the floor of the mouth and the muco-periosteum of the mandible. If situated far back on the dorsum, it spreads on to the epiglottis, the pillars of the fauces, and the tonsil.
The neighbouring lymph glands--particularly those under the jaw and along the line of the carotid vessels--soon become infected and are palpable. The submaxillary and sublingual salivary glands are also liable to be affected. The enlarged cervical glands later undergo softening, or suppurate and burst on the skin surface, forming fungating ulcers. Metastasis to the liver, lungs, and other viscera is exceptional. If the disease is allowed to run its course, the patient usually dies in from twelve to eighteen months from repeated small haemorrhages, toxin absorption, or septic broncho-pneumonia.
Differential Diagnosis.--Cancer of the tongue has to be diagnosed from syphilitic and tuberculous affections, from papilloma, and from simple ulcer and fissure. It is to be borne in mind that any of these conditions may take on malignant characters and develop into epithelioma. The microscopic examination of a portion of the growth removed under local anaesthesia from the base of the ulcer at some distance from its epithelial core is often the only certain means of establishing the diagnosis, and should be had recourse to as early as possible. When there is still doubt as to the nature of the growth, it should be treated as if it were cancerous.
An unbroken gumma is liable to be confused only with the uncommon form of epithelioma which begins as a nodule under the mucous membrane. Gumma, however, are often multiple, and the tongue shows old scars or other evidence of syphilis.
Gummatous ulcers are usually situated on the dorsum, are frequently multiple, and have sloughy, undermined edges; the surrounding parts, although indurated, are not so densely hard as in cancer; there is not necessarily any involvement of lymph glands. The cancerous ulcer is usually single and situated on the margin of the tongue; its edges are hard, raised, and nodular; and the glands are usually enlarged and hard. Little reliance is to be placed on the therapeutic effects of anti-syphilitic drugs in the differential diagnosis, as they are often inconclusive, and their use results in loss of time.
Tuberculous ulcers usually occur in association with other and unmistakable evidences of tuberculosis. A papilloma, when sessile, may simulate cancer; these tumours show a marked tendency to become malignant. Simple ulcers and fissures are usually recognised by the history of the condition, the absence of induration and of glandular involvement, and by the fact that they heal quickly on removal of the cause.
Treatment.--The only treatment that offers any hope of cure is free removal of the disease, and experience has proved that unless this is done early the prospect of the cure being a radical one is remote. Not only must the segment of the tongue on which the growth is situated be widely excised, but all the lymphatic connections must also be removed whether the glands are palpably enlarged or not.
The chief risk after operation is pneumonia resulting from the inhaling of blood and products of infection: hence the importance of rendering the mouth as dry and as sweet as possible before operation, special attention being paid to the teeth, and precautions being taken at the operation to prevent the passage of blood down the trachea. The patient is usually able to be out of bed on the second or third day, and is well in a fortnight or three weeks. The operation, even when followed by recurrence, usually prolongs life by six or eight months, and renders the patient more comfortable by removing the foul ulcer from the mouth. The speech, although impaired by the removal of one-half or even more of the tongue, is distinct enough for ordinary purposes. When recurrence takes place it is usually in the glands, and may be attended with great suffering.
Treatment of Inoperable Cases.--The mouth must be kept as sweet as possible. The pain may be relieved to some extent by cocain or orthoform, but as a rule the free administration of morphin is called for. Pain shooting up to the ear may be relieved by resection of the lingual nerve, or the injection of alcohol into its substance. If haemorrhage takes place from the ulcerated surface and cannot be controlled by adrenalin, or other local styptics, it may be necessary to ligate the lingual, or even the external carotid artery. Interference with respiration may necessitate tracheotomy. When the patient has difficulty in taking food, recourse should be had to the use of the stomach-tube or to gastrostomy. The use of radium or of the X-rays appears to have a restraining influence on the disease in the glands, but has not proved curative.
#Sarcoma# of the tongue is rare, and is sometimes met with in children. The round-cell type is the most common; it grows rapidly, and tends to ulcerate and fungate, pain becoming severe when the growth has broken down. The diagnosis is always difficult, and is seldom made until a portion of the growth has been removed and examined microscopically. The more slowly growing forms, if removed before ulceration has taken place, show little tendency to recur, but those which grow rapidly and break down, not only recur locally, but are liable to give rise to metastases. The treatment is the same as for cancer; the use of radium is more likely to be beneficial than in epithelioma.
#Innocent Tumour and Cysts.#--Lipoma, fibroma, and various forms of angioma (Fig. 258) are occasionally met with. They are all of slow growth, and give rise to inconvenience chiefly by their bulk, and should be removed.
Papilloma may occur on any part of the tongue, and at any age. It may be single or multiple, pedunculated or sessile, and is liable to become malignant, especially when associated with leucoplakia. It should be freely removed by excising a wedge-shaped portion of the tongue.
Dermoid cyst is met with beneath the tongue, lying in the middle line, between the genio-glossi (genio-hyoglossi), and on the upper surface of the mylo-hyoid muscles. It may be noticed soon after birth, or may only attract attention during adult life. The cyst usually projects under the chin, forming a soft swelling of putty-like consistence, which varies in size from a pigeon's to a turkey's egg (Fig. 259). When it bulges towards the mouth it is liable to be mistaken for a retention cyst of one of the salivary glands. It is distinguished by its medial position, its yellow colour, and its opacity, the retention cyst being to one side of the middle line, purplish in colour, translucent and fluctuating. The cyst should be dissected out, either from the mouth or from under the chin, according to circumstances.
A sebaceous cyst may reach such dimensions as to simulate a dermoid or thyreo-glossal cyst.
Hydatid and cysticercus cysts have also been met with in the tongue.
#Thyreo-glossal Tumours and Cysts.#--Tumours may develop in the embryonic tract which passes from the isthmus of the thyreoid gland to the foramen caecum at the base of the tongue--the thyreo-glossal tract of His. They have the same structure as the thyreoid gland, and occupy the dorsum of the tongue, extending from the foramen caecum backwards towards the epiglottis, in some cases attaining considerable size. They are of a bluish-brown or dark red colour, and are liable to repeated attacks of haemorrhage. These tumours sometimes become cystic, the cysts being lined with ciliated epithelium and containing colloid material. Bleeding may take place into a cyst, causing it to become suddenly enlarged, or the cyst may burst and the blood escape into the mouth. These variations in size and repeated attacks of bleeding help to distinguish thyreo-glossal cysts from other swellings of the tongue. Treatment is only called for when the swelling causes interference with speech or swallowing; it consists in removing the tumour by dissection.
When the lower end of the tract becomes cystic it forms a swelling in the neck (p. 583).
#Malformations.#--Complete or partial absence of the tongue is exceedingly rare.
Occasionally the fore part of the tongue is bifid. The function of the organ is not interfered with, and the operation of paring and suturing the two halves is only called for on account of the disfigurement.
Congenital tongue-tie is a condition in which the tip of the tongue is bound down to the floor of the mouth by an abnormally short and narrow frenum, or by folds of mucous membrane on each side of the frenum, so that the tongue cannot be protruded. Although this deformity is rare, it is common for parents to blame an imaginary tongue-tie when a child is slow in learning to speak, or when he speaks indistinctly or stammers, and the doctor is frequently requested to divide the frenum under such circumstances. In the vast majority of cases nothing is found to be wrong with the frenum. In the rare cases of true tongue-tie the edges of the shortened bands should be snipped with scissors close behind the incisor teeth, and then torn with the finger-nail.
Excessive length of the frenum is occasionally met with, and in children may allow of the tongue falling back into the throat and causing sudden suffocative attacks, one of which may prove fatal. In some cases the patient is able voluntarily to fold the tongue back behind the soft palate.
Macroglossia is the term applied to a variety of conditions in which the tongue becomes unduly large, so that it tends to be protruded from the mouth, and to become scored by the teeth. The typical form--lymphangiomatous macroglossia--is due to a dilatation of the lymph spaces of the tongue. It is often congenital, and may affect the whole or only a part of the tongue. The enlargement may be progressive from the first, or may remain stationary for years, and then begin to develop somewhat suddenly, sometimes after an injury or as a result of some infective condition. The treatment consists in removing a wedge-shaped portion of the tongue.
In certain cases of macroglossia in children, the lesion has been found to be a fibromatosis of the nerves of the tongue, analogous to the plexiform neuroma.
Atrophy of the tongue is rare as a congenital condition. Hemi-atrophy occurs in various diseases of the central nervous system, as well as after injuries and diseases implicating the hypoglossal nerve.
#Nervous Affections of the Tongue.#--Neuralgia confined to the distribution of the lingual nerve is comparatively rare. It usually yields to medical treatment, but in inveterate cases it is sometimes necessary to resect the nerve.
It is more common to meet with a condition in which the patient complains of severe burning or aching pain in the region of the foliate papilla, which is situated on the edge of the tongue just in front of the anterior pillar of the fauces. The patient is usually a middle-aged, neurotic woman, and often with a gouty or rheumatic tendency. The pain, for which it is seldom possible to discover any cause, is usually worst at night, and may last for months, or even years. The practical importance of the condition is that, as the foliate papilla is prominent and red, it is liable to be mistaken on superficial examination for a commencing epithelioma. An inspection of the opposite side of the tongue, however, will reveal an exactly similar condition, which is not painful. The first and most important step in treatment is to assure the patient that the condition is not cancerous. Caustics and other irritating applications are to be avoided.
Spasm of the tongue sometimes occurs after injuries of the head implicating either the centre or the trunk of the hypoglossal nerve. It may also appear as a reflex condition in infective affections of the teeth and gums, or as a manifestation of some general disease of the central nervous system.
Paralysis of the tongue--unilateral or bilateral--may be due to injury or disease of the nerve centres of the hypoglossal nerve, more frequently to injury of or pressure on the nerve-trunk. The nerve may be bruised or divided in operations for the removal of tuberculous glands or other tumours in the neck. When the tongue is protruded it deviates towards the paralysed side, being pushed over by the active muscles of the opposite side (Fig. 260), and speech and mastication may be interfered with. The paralysed half of the tongue subsequently undergoes atrophy, but the functional disability largely disappears.
XXIII. THE SALIVARY GLANDS
Surgical Anatomy--Injuries--Salivary fistulae--Salivary calculi--Infective conditions: Parotitis; Inflammation of submaxillary gland; Angina Ludovici; Inflammation of sublingual gland; Tuberculous disease--Tumours: Ranula; Mixed tumours of parotid; Sarcoma; Carcinoma; Tumours of submaxillary and sublingual glands.
#Surgical Anatomy.#--The parotid gland lies on the side of the face below and in front of the ear, and extends deeply behind the mandible reaching almost to the side wall of the pharynx. Its deeper part lies in close relation with the internal carotid artery, the internal jugular vein, and the vagus, glosso-pharyngeal, accessory, and hypoglossal nerves. The external carotid artery passes through the substance of the parotid, and bifurcates opposite the neck of the condyle into the temporal and internal maxillary arteries. It is accompanied by the venous trunk formed by the junction of the temporal and internal maxillary veins. The facial nerve and its branches traverse the lower third of the gland from behind forwards. The facial portion of the gland lies on the surface of the masseter muscle, and the parotid duct (Stenson's duct) emerges from its anterior border. After crossing the masseter, the duct pierces the buccinator muscle and the mucous membrane obliquely, and opens into the mouth opposite the second upper molar tooth. Its course is indicated by a line passing from the upper part of the lobule of the ear to a point midway between the ala of the nose and the margin of the upper lip--that is, at a higher level than the facial nerve. Several lymph glands--pre-auricular--lie inside the capsule of the parotid just in front of the ear.
The submaxillary gland lies under the integument and fascia in the triangle formed by the lower jaw and the two bellies of the digastric muscle. Its anterior part is crossed by the facial vessels, and several lymph glands lie inside its capsule. The submaxillary duct (Wharton's duct) opens into the mouth by the side of the frenum of the tongue.
The sublingual gland lies in the floor of the mouth just beneath the mucous membrane. It has numerous ducts, some of which open directly into the mouth, others into the submaxillary duct.
#Injuries.#--The parotid is frequently injured by accidental wounds and in the course of operations. If the blood vessels traversing the gland are divided, such wounds are liable to bleed freely, and if the facial and auriculo-temporal nerves are damaged, motor and sensory paralysis of the parts supplied by them ensues. Wounds of the parotid heal rapidly and without complications so long as infection is prevented, but if suppuration takes place they are liable to be followed by the escape of saliva, which may go on for weeks; in some cases a salivary fistula is thus established.
The parotid duct may be divided and a salivary fistula result. If the external wound heals rapidly, a salivary cyst may develop in the substance of the cheek, forming a swelling, which fills up at meals, and may be emptied by external pressure, the saliva escaping into the mouth.
In a wound implicating the whole thickness of the cheek the skin should be accurately sutured, care being taken that the stitches do not include the duct, but in order that the saliva may readily reach the mouth, the mucous membrane should not be stitched.
#Salivary Fistulae.#--A salivary fistula may occur in relation to the glandular substance of the parotid or in relation to the duct. Fistula in connection with the glandular substance--parotid fistula--seldom results from a wound, made, for example, in the removal of a tumour or in an operation on the ramus of the jaw, so long as it is aseptic; but as a sequel of suppuration in the gland, and particularly of an abscess developing around a concretion, it is not uncommon. The fistulous opening is usually small, and may occur at any point over the gland. The fistula may be dry between meals, or the saliva may escape in small transparent drops, but the quantity is always greatly increased when food is taken. A parotid fistula, although it may continue to discharge for weeks, or even for months, usually closes spontaneously.
In persistent cases, the edges of the fistula may be pared and brought together with sutures, or the actual cautery may be applied to induce cicatricial contraction.
Fistula of the parotid duct is more serious. It is usually due to a wound, less frequently to abscess or impacted calculus. From the minute opening, which is most frequently situated over the buccinator muscle, there is an almost continuous flow of clear limpid saliva, which is greatly increased in quantity while the patient is eating. These fistulae show little tendency to close spontaneously. Attempts to close the opening by the external application of collodion, by cauterising the edges, or even by paring the edges and introducing sutures, usually fail. It is necessary to establish an opening into the mouth, either by opening up the original duct or by making an internal fistula in place of the external one.
#Salivary Calculi.#--Salivary calculi are most commonly met with in the submaxillary gland or its duct. They consist of phosphate and carbonate of lime with a small proportion of organic matter, and result from the chemical action of bacteria on the saliva. In rare cases a foreign body, such as a piece of straw, a fruit-seed, or a fish-bone, forms the nucleus of the concretion. They vary in size from a pea to a walnut, and are hard, of a whitish or grey colour, and rough on the surface. Those that form in the gland itself are usually irregular, while those met with in the duct are rounded or spindle-shaped (Fig. 261).
A calculus in the duct gives rise to sharp lancinating pain, which is aggravated when the patient takes food. The duct is seldom completely obstructed, but the flow of saliva is usually so much impeded that the gland becomes greatly swollen during meals. The swelling gradually subsides between meals, or can be made to disappear by external pressure. The calculus can usually be felt by means of a probe passed along the duct, or by puncturing the swelling with a needle; or, with one finger inside the mouth and another under the jaw, a hard lump can be detected under the mucous membrane of the floor of the mouth. It may be revealed by the X-rays. When the obstruction is complete, a retention cyst forms in which suppuration is liable to occur, causing marked aggravation of the symptoms. In some cases the wall of the duct and the surrounding tissues become thickened and indurated, forming a swelling which is liable to be mistaken for a malignant growth. The treatment consists in making an incision through the mucous membrane over the calculus and extracting it with a scoop or forceps.
INFECTIVE CONDITIONS.--#Parotitis.#--Inflammation of the parotid gland may be non-suppurative or suppurative.
Of the non-suppurative varieties the most common is the epidemic form known as mumps. This is an acute infective condition, which usually attacks young children, and implicates both glands, either simultaneously or consecutively. It runs a definite course, which lasts for from one to two weeks, and almost invariably ends in resolution. The parotid gland is swollen and tender, there is pain on attempting to open the mouth, difficulty in swallowing, and dribbling of saliva. The surgical interest of this disease lies in the fact that it is frequently complicated by pain and swelling of the testis, oedema of the scrotum, and occasionally by a urethral discharge, and atrophy of the testis has been observed after such an attack. In females there is sometimes pain in the ovary, tenderness and swelling of the mamma, and a vaginal discharge.
The parotid on one or both sides may suddenly become swollen and tender in patients who are taking large doses of mercury, in gouty subjects, or in patients suffering from infective conditions of the genito-urinary organs, such as orchitis, ovaritis, urethritis, or cystitis. The condition is usually transient and leads to no complications.
Recurrent enlargement of the parotid and submaxillary glands, as well as of the lachrymal glands, is occasionally met with in adults, and was first described by Mikulicz. It may be associated with salivary lithiasis, xerostomia, or organic narrowing of the ducts, but in the majority of cases no such cause can be discovered (D. M. Greig). When the parotid is affected the condition tends to be bilateral and there is some constitutional disturbance. The submaxillary form is usually unilateral and the symptoms are entirely local. The affected gland rapidly becomes swollen, painful and tender to the touch, and the swelling increases markedly while the patient is eating. Each attack lasts for a few hours to one or two weeks, and then subsides spontaneously. The intervals between attacks vary from a few weeks to a year or more. In the course of a few years there is considerable deformity, and sometimes deficiency in the glandular secretion, but the disease is not attended by other inconvenience. Benefit has followed the administration of arsenic and iodides, and the use of radium and X-rays.
The treatment of these non-suppurative forms of parotitis consists in relieving the symptoms.
Suppurative parotitis may be due to direct spread of infection from the mouth along the parotid duct, or to extension of suppurative processes from the temporo-mandibular joint, the jaw, or a lymph gland. It is liable to occur also in the course of any disease in which there is an infection of the blood with pyogenic bacteria, and has been met with in diphtheria, typhoid fever, scarlet fever, measles, and other eruptive fevers.
The post-operative form of parotitis is most frequently met with after laparotomy for such conditions as suppurative appendicitis, perforated gastric ulcer, ovarian cyst, and pyosalpinx.
These secondary forms are probably due to infection from the mouth under conditions in which the secretion of saliva is arrested or its escape from the gland interfered with.
The early symptoms are apt to be overshadowed by those of the general disease from which the patient suffers. At first the gland is swollen, hard, and tender, and the seat of constant, dull, boring pain; later there is redness, oedema, and fluctuation. The movements of the jaw are restricted and painful, the patient is unable to open the mouth, and has difficulty in swallowing. The inflammation reaches its height on the third or fourth day, and usually ends in suppuration. The pus is scattered in numerous foci throughout the gland, and sometimes large sloughs form. The dense capsule of the gland prevents the pus reaching the surface and causes it to burrow among the tissues of the neck, giving rise to dyspnoea and dysphagia. It may find its way downwards towards the mediastinum, inwards towards the pharynx--where it constitutes one form of retro-pharyngeal abscess--or upwards towards the base of the skull. Not infrequently it burrows into the temporo-mandibular joint, or escapes by bursting into the external auditory meatus. Serious haemorrhage may result from erosion of the vessels traversing the gland or of the internal jugular vein, or venous thrombosis may ensue. Persistent paralysis may follow destruction of the facial nerve; and salivary fistulae may form. Death may take place from toxaemia even before pus forms.
Treatment.--During the first two or three days hyperaemia is induced by means of poultices, hot fomentations, or Klapp's suction bells, and the mouth is frequently washed out with an antiseptic. As soon as there is reason to believe that pus has formed an incision is made behind the angle of the jaw, parallel to the branches of the facial nerve, the abscess opened by Hilton's method, a finger passed into the gland, and all septa broken down and drainage secured.
Acute infection of the #submaxillary gland# is met with under the same conditions as that of the parotid. Both glands are occasionally attacked at the same time.
The acute phlegmonous peri-adenitis of the submaxillary gland, known as angina Ludovici, is referred to at p. 597.
The treatment consists in making incisions through the deep fascia in order to relieve the tension, or to let out pus if it has formed.
Acute suppurative inflammation of the #sublingual gland# may occur under the same conditions as in the parotid, and is associated with the formation of an exceedingly painful and tender swelling under the tongue. The tongue is gradually pushed against the roof of the mouth, so that swallowing is difficult and respiration may be seriously impeded. There is marked constitutional disturbance. An incision into the swelling is immediately followed by relief of the symptoms.
#Tuberculous disease# of the salivary glands is rare. It usually begins in the lymph glands within the capsule of the parotid or submaxillary, and spreads thence to the salivary gland tissue.
TUMOURS.--#Cystic Tumours--Ranula.#--The term ranula is applied to any cystic tumour formed in connection with the glands in the floor of the mouth. Formerly these tumours were believed to be retention cysts due to blocking of the salivary ducts. They are now known to be the result of a cystic degeneration of one or other of the secreting glands in the floor of the mouth. They contain a thick glairy fluid, which differs from saliva in containing a considerable quantity of mucin and albumin, while it is free from any amylolytic ferment or sulpho-cyanide of potassium. Numerous degenerated epithelial cells are found in the fluid.
The sublingual ranula is the most common variety. It appears as a painless, smooth, tense, globular swelling of a bluish colour. It usually lies on one side of the frenum, and over it the mucous membrane moves freely. As it increases in size it gradually pushes the tongue towards the roof of the mouth, and so causes interference with speech, mastication, and swallowing. It is to be differentiated from a retention cyst of the submaxillary gland by the fact that a probe can usually be passed down the submaxillary duct alongside of the swelling, and from sublingual dermoid (p. 539).
The treatment consists in making an incision through the mucous membrane over the swelling, dissecting away the whole of the cyst wall if possible, and, if any portion cannot be removed, swabbing it with a solution of chloride of zinc (40 grains to the ounce), after which the cavity is stuffed with bismuth gauze and allowed to close by granulation. It is sometimes found more satisfactory to dissect out the cyst through an incision below the jaw, and in the event of recurrence this should be undertaken.
Cystic tumours, similar to the sublingual ranula, form in the other glands in the floor of the mouth--for example, the incisive gland, which lies just behind the symphysis menti, as well as in the apical gland on the under aspect of the tip of the tongue. The latter is distinguished by the fact that it moves with the tongue. In rare cases children are born with a cystic swelling in the floor of the mouth--the so-called congenital ranula. It is usually due to an imperfect development of the duct of the submaxillary or sublingual gland.
#Solid Tumours--Mixed Tumours of the Parotid.#--The most important of the solid tumours met with in the salivary glands is the so-called "mixed tumour of the parotid." This was formerly believed to be an endothelioma derived from a proliferation of the endothelial cells lining the lymph spaces and blood vessels of the gland. A more probable view is that it develops from rests derived from the first branchial arch an not from the parotid. The matrix of the tumour is made up of cartilaginous, myxomatous, sarcomatous, or angiomatous tissue, the proportion of these different elements varying in individual specimens, and it may include some portions that are adenomatous. A gelatinous substance forms in the intercellular spaces of the tumour, and may accumulate in sufficient quantity to give rise to cysts of various sizes. There is reason to believe that the tumours of the parotid previously described as adenoma, chondroma, angioma, myxoma, and many of the cases of sarcoma, were really mixed tumours in which one or other of these tissues predominated.
The tumour usually develops in the vicinity of the parotid, and presses on the salivary tissue, thinning it out and causing it to undergo atrophy.
Clinical Features.--The mixed tumour is usually first observed between the ages of twenty and thirty. It is of slow growth and painless, and forms a rounded, nodular swelling, the consistence of which varies with its structure. The skin over the swelling is normal in appearance and is not attached to the tumour (Figs. 263, 264). Only in rare cases does paralysis result from pressure on the facial nerve.
Although usually benign, these tumours may, after lasting for years, take on malignant characters, growing rapidly, implicating adjacent lymph glands, and showing a marked tendency to recur after removal.
The treatment consists in shelling out the tumour, care being taken to avoid injuring the facial nerve or the parotid duct by making the incision and the subsequent cuts in the dissection run parallel to them. If the tumour is removed early and completely, recurrence is the exception.
#Sarcoma and carcinoma# are rare. They are very malignant, grow rapidly, infiltrate surrounding parts, including the skin, and infect the adjacent lymph glands. There is severe neuralgic pain, and paralysis from involvement of the facial nerve is an early symptom.
The treatment consists in excising the whole of the parotid gland with the tumour, no attempt being made to conserve the facial nerve or other structures traversing it. Recourse should be had to the use of radium both before and after operation, otherwise recurrence is all but inevitable.
The submaxillary and sublingual glands may be the seat of the same varieties of tumour as the parotid. These glands are particularly liable to become invaded along with the adjacent lymph glands in epithelioma of the tongue and floor of the mouth.
XXIV. THE EAR[5]
Surgical Anatomy--CARDINAL SYMPTOMS OF EAR DISEASE: Impairment of hearing; Tinnitus aurium; Earache; Giddiness; Discharge--Hearing tests--Inspection of ear--Inflation of middle ear. AFFECTIONS OF EXTERNAL EAR: Deformities; Haematoma auris; Epithelioma and Rodent cancer; Impaction of wax; Eczema; Boils; Foreign bodies. AFFECTIONS OF TYMPANIC MEMBRANE AND MIDDLE EAR: Rupture of membrane; Acute inflammation of middle ear; Chronic suppuration; Suppuration in the mastoid antrum and cells.
[5] We desire here to acknowledge our indebtedness to Dr. Logan Turner for again revising this chapter.
#Surgical Anatomy.#--The anatomical subdivision of the ear into three parts--the external, middle, and internal ear--forms a satisfactory basis for the study of ear lesions. The outer ear consists of the auricle and external auditory meatus, the latter being made up of an outer cartilaginous portion half an inch in length, and a deeper osseous portion three-quarters of an inch long. The canal forms a curved tube, which can be straightened to a considerable extent for purposes of examination by pulling the auricle upwards and backwards. It is closed internally by the tympanic membrane, which separates it from the tympanic cavity or middle ear. The middle ear includes the tympanum proper, which is crossed by the chain of ossicles--malleus, incus, and stapes--the Eustachian tube, which communicates with the naso-pharynx, and the tympanic antrum and mastoid cells. As these cavities lie in close relation to the middle and posterior cranial fossae, infective conditions in the tympanum and mastoid cells are liable to spread to the interior of the skull. The internal ear or labyrinth lies in the petrous part of the temporal bone, its outer boundary being the inner wall of the middle ear.
Physiologically the different parts of the auditory mechanism may be divided into (1) the sound-conducting apparatus, which includes the outer and middle ears; and (2) the sound-perceiving apparatus--the internal ear and central nerve tracts. Impairment of hearing may be due to causes existing in one or other or both of these subdivisions. The condition of the sound-conducting apparatus can be investigated by direct inspection through the speculum, and by inflation of the Eustachian tube and tympanum, while that of the sound-perceiving apparatus is ascertained partly by testing the hearing, and partly by excluding affections of the outer and middle ear. When the sound-conducting apparatus is at fault, the resulting deafness is spoken of as "obstructive"; when the sound-perceiving apparatus is affected, the term "nerve deafness" is used. The semicircular canals, which are peripheral organs concerned in the maintenance of equilibration, form part of the inner ear apparatus.
CARDINAL SYMPTOMS OF EAR DISEASE.--The most important symptom of ear disease is impairment of hearing, which varies in degree, and may be due to lesions either in the sound-conducting or in the sound-perceiving apparatus. The sudden onset of deafness may be due to impaction of wax in the external meatus or to haemorrhage or effusion into the labyrinth. A gradual onset is more common. In children there is a great tendency for acute inflammatory conditions of the middle ear to arise in connection with the exanthemata and in association with adenoids. In adult life chronic catarrhal processes are more common causes of gradually increasing deafness, while in advanced age there is a tendency to acoustic nerve impairment. Certain anomalous conditions of hearing are occasionally met with, such as the "paracusis of Willis"--a condition in which the patient hears better in a noise; "diplacusis," or double hearing; and "hyperaesthesia acustica," or painful impressions of sound.
Tinnitus aurium, or subjective noises in the ear, may constitute a very annoying and persistent symptom. These sounds vary in their character, and may be described by the patient as ringing, hissing, or singing, or may be compared to the sound of running water or of a train. They are usually compared to some sound which, from his occupation or otherwise, the patient is accustomed to hear. They may be purely aural in origin, being due, for example, to increased pressure on the acoustic nerve endings from causes in the labyrinth itself or in the middle or external ear; or they may be due to certain reflex causes, such as naso-pharyngeal catarrh or gastric irritation. Vascular changes such as occur in anaemia, Bright's disease, and heart disease may also be concerned in their production.
Pain, or earache, varies in degree from a mere sense of discomfort to acute agony. The pain associated with a boil in the external meatus is usually aggravated by movements of the jaw, by pulling the auricle, and by pressure upon the tragus. The pain of acute middle-ear inflammation is deep-seated, intermittent in character, and worse at night, and is aggravated by blowing the nose, coughing, and sneezing--acts which increase middle-ear tension by forcing air along the Eustachian tube. Mastoid pain and tenderness are indicative of inflammation in the antrum or cells, and when these symptoms supervene in the course of a chronic middle-ear suppuration, they should always be regarded as of grave import. Severe neuralgia of the ear may simulate the pain of acute mastoiditis, and it must not be forgotten that earache may be traced to a diseased tooth. A careful examination, not only of the ear, but also of the throat and teeth, should therefore be made in all cases of earache.
Vertigo, or giddiness, may be produced by causes which alter the tension of the labyrinthine fluid, such, for example, as the pressure of wax upon the tympanic membrane, or exudation into the middle ear or into the labyrinth. Giddiness occurring in the course of chronic middle-ear suppuration may be significant of labyrinthine or of intra-cranial mischief, but is not necessarily so. Giddiness preceded by nausea suggests a gastric origin; if followed by nausea it points to an aural origin. In cases of suspected aural vertigo, the patient's "static sense" should be carefully tested. He should be asked (1) to stand with both feet together with the eyes closed, (2) to stand on one or other foot with eyes closed, (3) to walk in a straight line, (4) to hop backwards and forwards off both feet. His incapacity for performing such movements should be noted. As nystagmus may be associated with disturbance of equilibrium due to ear disease, the movements of the eyeballs must be carefully tested.
Labyrinthine nystagmus is of a rhythmic character, and consists of a slow and a rapid movement. Physiological nystagmus can be induced by stimulating the movement of the endolymph in the semicircular canals, by syringing the ear with hot and cold water (caloric test), by rotating the individual (rotation test), and by the galvanic current. Any departure from the normal reactions which these tests may produce, should raise the suspicion of a pathological condition of the semicircular canals.
Discharge from the ear, or otorrhoea, is occasionally due to an eczematous condition of the skin lining the external meatus. It is then usually of a thin, watery character, and contains epithelial flakes and debris. An aural discharge is, however, most commonly of middle-ear origin. It may be muco-purulent and stringy, or purulent and of thicker consistence. A peculiar, offensive odour is characteristic of chronic middle-ear suppuration. The surgeon should smell the speculum in suspicious cases. He should never accept the patient's statement as regards the absence of discharge, but should satisfy himself by inspection and by the introduction of a cotton-wool wick.
#The Hearing Tests.#--In testing the hearing, a definite routine method should be adopted, the watch, whisper, voice, and tuning-fork tests being systematically employed. Although the patient only complains of one ear, both must be examined. Each ear should be tested separately, and the patient should be so placed that he cannot see the lips of the examiner. While one ear is being tested, the other should be closed with the finger, and each test should be commenced outside the probable normal range of hearing. All the results should be written down at once, and the date of the test recorded, as this is essential for following the progress of the case.
Tuning-fork Tests.--To differentiate between deafness due to a lesion in the sound-conducting apparatus and that due to labyrinthine causes, it is necessary to enter into a little more detail. The tone produced by a vibrating tuning-fork is conducted to the nerve terminations in the labyrinth both through the air column in the external meatus (air-conduction), and through the cranial bones (bone-conduction). When, in a deaf ear, the vibrations of a tuning-fork placed in contact with the mastoid process are heard better than when the fork is held opposite the meatus, the lesion is in the sound-conducting apparatus. When, on the other hand, the vibrations are heard better by air-conduction, the lesion is in the sound-perceiving apparatus. In addition to these facts, we find also that in obstructive deafness low tones tend to be lost first, while in nerve deafness the higher notes are the first to go. This may be investigated by tuning-forks of different pitch or with the aid of a Galton's whistle. Again, in middle-ear deafness, hearing may be better in a noisy place, and be improved by inflation of the tympanum; while in labyrinthine deafness, hearing may be better in a quiet room, and be rendered worse by inflation.
#Inspection of the Ear.#--This should be carried out by the aid of reflected light, the ear to be examined being turned away from the window, lamp, or other source of light that may be employed. A small ear reflector, either held in the hand or attached to a forehead band, and a set of aural specula are required. Before introducing the speculum, the outer ear and adjacent parts should be examined, and the presence of redness, swelling, sinuses or cicatrices over the mastoid, displacement of the auricle, or any inflammatory condition of the outer ear observed. To inspect the tympanic membrane, a medium-sized speculum held between the thumb and index finger is insinuated into the cartilaginous meatus, the auricle being at the same time pulled upwards and backwards by the middle and ring fingers, so as to straighten the canal. The tympanic membrane is then sought for and its appearance noted.
The normal membrane is concave as a whole on its meatal aspect; it occupies a doubly oblique plane, being so placed that its superior and posterior parts are nearer the eye of the examiner than the anterior and inferior parts. While varying to some extent in colour, polish, and transparency, it presents a bluish-grey appearance. The handle of the malleus traverses the membrane as a whitish-yellow ridge, which appears to pass from its upper and anterior parts downwards and backwards to a point a little below the centre. At the lower end of the handle of the malleus a bright triangular cone of light passes downwards and forwards to the periphery of the membrane. At the upper end of the handle is a white knob-like projection, the short process of the malleus. Passing forwards and backwards from this are the anterior and posterior folds. The portion of the membrane situated above the short process is known as the membrana flaccida or Shrapnell's membrane. Behind the malleus the long process of the incus may be visible through the membrane. The mobility of the membrana tympani should be tested by inflating the tympanum or by means of Siegle's pneumatic speculum.
Various departures from the normal may be observed. Atrophy of the membrane is characterised by extreme transparency of the whole disc. Circumscribed atrophic patches appear as dark transparent areas, which show considerable mobility and bulge prominently on inflation. A cicatrix in the membrane is evidence of a healed perforation, and is also transparent, but differs from an atrophic patch in being more sharply defined from the surrounding membrane. A thickened membrane presents an opaque white appearance. Calcareous or chalky patches are markedly white, and when probed are hard to the touch; they are often evidence of past suppuration. An indrawn or retracted membrane, resulting from Eustachian obstruction, is characterised by increased concavity, undue prominence of the lateral short process of the malleus and of the anterior and posterior folds, and by the handle of the malleus assuming a more horizontal position. An inflamed membrane, showing congestion of the vessels about the malleus or a general diffuse redness, is evidence of middle-ear inflammation. A yellow appearance of the lower part of the membrane, limited above by a dark line stretching across the drum-head, is indicative of sero-purulent exudation into the tympanum. The membrane may be bulged outwards into the meatus by the fluid, and thus lie nearer the observer's eye than normally. A perforation is usually single, and varies in size from a small pinhead to complete destruction of the membrane. The labyrinthine (inner) wall of the tympanum may be visible through the perforation, and is recognised by being on a deeper plane than the membrane, and by its hard bony consistence when touched with the probe. The diagnosis of a perforation associated with middle-ear discharge may be further assisted by inspection during inflation, when bubbles of air and secretion are visible. When the perforation is invisible, its existence may be inferred if a small pulsating spot of light can be recognised through the speculum. Granulations in the tympanum appear as red fleshy masses of different sizes. When large they constitute aural polypi, which are recognised by their proximity to the outer end of the meatus, their soft consistence and mobility, and the fact that the probe may be passed round them. Granulations and polypi usually indicate the presence of middle-ear suppuration.
#Inflation of the Middle Ear.#--Before proceeding to inflate the middle ear, the examiner should inspect the nose, naso-pharynx, and pharynx. This should be made a routine part of the examination in all cases of ear disease. As inflation is not only an aid in diagnosis, but is also of great assistance in prognosis, it is necessary that the hearing should be tested and noted before the ear is inflated. There are three methods of inflating the tympanum: Valsalva's method, Politzer's method, and by means of the Eustachian catheter.
In Valsalva's inflation the patient himself forces air into his Eustachian tubes, by holding his nose, closing his mouth, and forcibly expiring. This method of inflation has only a limited application and is of little therapeutic value.
Politzer's Method.--For this a Politzer's air-bag and an auscultating tube, one end of which is inserted into the patient's ear and the other into the ear of the examiner, are required. The nasal end of the bag should be protected with a piece of rubber tubing or be provided with a nozzle. The patient retains a small quantity of water in his mouth until directed to swallow. The nozzle of the bag is inserted into one nostril, and the other is occluded by the fingers of the surgeon. The signal to swallow is then given, and, simultaneously with the movement of the larynx during this act, the bag is sharply and forcibly compressed. Holt's modification of this method consists in directing the patient to puff out his cheeks while the lips are kept firmly closed.
Inflation through the Eustachian Catheter.--For this method, in addition to the Politzer's bag and the auscultating tube, a silver or vulcanite Eustachian catheter is required. The silver instrument has the advantage that it can be sterilised by boiling. The patient is seated facing the light, while the surgeon stands in front of him, and, having placed the auscultating tube in position, with his left thumb he tilts up the tip of the patient's nose. The beak of the catheter is now inserted into the inferior meatus, point downwards, and carried horizontally backwards along the floor of the nose until the convexity of the curve touches the posterior wall of the naso-pharynx. When the posterior pharyngeal wall is felt, the point of the instrument is rotated inwards through a quarter of a circle; the position of the point is indicated by the metal ring upon the outer end of the catheter. The finger and thumb of the left hand should now grasp the stem of the catheter just beyond the tip of the nose so as to steady it. It is now gently withdrawn until the concavity of the beak is brought against the posterior edge of the septum nasi. With the right hand the point of the instrument is then rotated downwards and outwards through a little more than half a circle, so that the point slips into the Eustachian orifice and the metal ring looks outwards and upwards towards the external canthus of the eye of the same side. While the instrument is maintained in this position by the left hand, the nozzle of the Politzer's bag is inserted into the funnel-shaped outer extremity of the catheter, and inflation is gently carried out with the least possible jerking. Before withdrawing the catheter its point must be disengaged from the Eustachian opening by turning it slightly downwards. Difficulties in introducing the catheter may arise from the presence of spines and ridges upon, and deviations of, the septum, and it may be necessary to pass the instrument under the guidance of the mirror and speculum.
More accurate information is gained from the use of the catheter than from Politzer's inflation, and it is the safer method to employ when a cicatrix or atrophied patch exists in the tympanic membrane, as by the latter method rupture of these areas might occur. Further, the catheter has the advantage of only inflating one ear, and thus preventing any undue strain being put upon the other. In children the catheter can seldom be employed, on account of the difficulty in passing it.
Considerable information may be derived from inflation. If the Eustachian tube is patent, a full clear sound is heard close to the examiner's ear through the auscultating tube. If the Eustachian tube is obstructed, the sound is fainter and more distant. If there is fluid in the tympanum, a fine moist sound may be detected, which must not be confounded with the coarser and more distant gurgling sound associated with moisture at the pharyngeal opening of the tube. If a small dry perforation exists in the tympanic membrane, the air may be heard whistling through it, while if the perforation is large, a sensation which is almost painful may be produced in the examiner's ear. If there is fluid associated with the perforation, these sounds may be accompanied by a bubbling noise. The effect of inflation upon the hearing must be carefully tested and recorded.
AFFECTIONS OF THE EXTERNAL EAR
#Deformities.#--The auricle, together with the external auditory meatus, may be congenitally absent on one or on both sides. The condition is not amenable to surgical treatment. Double auricles are occasionally met with; more frequently rudimentary auricular appendages about the size of a pea, consisting of skin, subcutaneous connective tissue and nodules of cartilage occur in front of the tragus, on the lobule or in the neck. These appendages should be snipped off with scissors. These congenital deformities are due to errors in development of the mandibular arch, and are frequently associated with macrostoma, facial clefts, and other malformations of the face.
Outstanding ears may be treated by excising a triangular or elliptical portion of skin and cartilage from the posterior surface of the pinna and uniting the cut edges with sutures. Abnormally large ears may be diminished in size by the removal of a V-shaped portion from the upper part of the auricle.
The term #haematoma auris# is applied to a sub-perichondrial effusion of blood, which may occur either as the result of injury to the auricle, for example in football players, or as a result of trophic changes in the cartilage and perichondrium. The latter form is not uncommon among the insane. A more or less tense fluctuating swelling forms on the anterior surface of the auricle, presenting in some cases a distinctly bluish coloration. Inflammation may ensue, and in some cases suppuration and even necrosis of cartilage may follow.
The treatment in a recent case consists in applying cold or elastic compression with cotton-wool and a bandage, or in withdrawing the effused blood by means of a hollow needle. In the event of suppuration supervening, incision and drainage must be carried out.
#Epithelioma# may attack the auricle and extend along the external auditory meatus. It begins as a small abrasion which refuses to heal, and is attended with a constant foetid discharge and intense pain. The disease may spread to the middle ear and invade the temporal bone, and facial paralysis then ensues. The adjacent lymph glands are early infected. The treatment consists in removing the growth freely, and excising the associated lymph glands at an early stage of the disease. In inoperable cases radium or the X-rays may be employed.
#Rodent cancer# also may attack the outer ear.
#Impaction of Wax or Cerumen.#--Hyper-secretion may result from unknown causes, or it may accompany or be induced by the discharge from a chronic middle-ear suppuration. The association of these two conditions should be borne in mind. An accumulation of wax may be caused by the too zealous attempts of the patient to keep the ear clean, the wax being forced into the narrow deeper part of the meatus.
The chief symptom of impacted wax is deafness, which is often of sudden onset. Impaction of wax causes deafness only when the lumen of the auditory canal becomes completely occluded by the plug. Tinnitus aurium and vertigo are sometimes present, and may be troublesome if the wax rests upon the tympanic membrane. Pain is occasionally complained of, and is usually due to the pressure of the plug upon an inflamed area of skin. Certain reflex symptoms, such as coughing and sneezing, have been met with.
It is only by an objective examination of the ear that the diagnosis can be made. The plug varies in colour and consistence, and may be yellow, brown, or black in appearance. Sometimes from the admixture of a quantity of epithelium it is almost white in colour.
Treatment.--The ear should be syringed with a warm antiseptic or sterilised solution. The lotion is at a suitable temperature if the finger can be comfortably held in it. The ear should be turned to the light, a towel placed over the patient's dress, and a kidney basin held under the auricle and close to the cheek. A syringe provided with metal rings for the fingers and armed with a fine ear nozzle should be held with the point inserted just within the aperture of the external meatus and in contact with the roof of the canal. Care must be taken that all the air is first removed from the syringe. To straighten the canal, the pinna should be pulled upwards and backwards by the left hand. It may be necessary to exert some considerable degree of force before the plug becomes dislodged, but this must be done with caution. The ear should then be dried out with cotton-wool, and a small plug of wool inserted for a few hours. If pain is complained of, or if the wax is hard and cannot be readily removed, the syringing should be stopped, and means taken to soften it by the instillation of a few drops of a solution of bicarbonate of soda (10 grains to the ounce of water or glycerine), or of peroxide of hydrogen, several times daily.
#Eczema of the external meatus# is often associated with eczema of the auricle and of the surrounding parts. Not infrequently there also exists a chronic middle-ear suppuration, which may be the cause of the eczema. Intense itchiness is the most characteristic symptom, and a watery discharge may also be complained of. Deafness and tinnitus are dependent upon the accumulation of epithelium and debris. After the ear is syringed the skin may present a dry, scaly appearance, while sometimes fissures and an indurated condition of the outer end of the meatus may be noted. Rarely is the outer surface of the tympanic membrane itself involved.
Treatment consists in keeping the ear clean by syringing and careful drying. Probably the best local application is nitrate of silver (10 grains to the ounce of spiritus aetheris nitrosi). This is applied by means of a grooved probe dressed with a small piece of cotton-wool. Care should be taken that none of the fluid is allowed to escape upon the cheek, otherwise staining of the skin occurs. A plug of cotton-wool is inserted, and the solution is re-applied at the end of a week. Sometimes the condition is very intractable.
Occasionally the vegetable parasite aspergillus is present in the external meatus, and produces a condition that is liable to be mistaken for eczema. Strong antiseptic lotions are required to kill the fungus.
#Furunculosis# or #Boils#.--Boils in the ear may arise singly or in crops, and may be associated with eczema of the meatus or with chronic suppuration of the middle ear. Pain is the chief symptom complained of, and it may be very acute. Deafness ensues when the meatus becomes completely blocked by the swelling. The boil occurs in the cartilaginous meatus, and it is to be borne in mind that the skin may present a normal appearance even when suppuration has occurred. Palpation of the affected area with the probe causes intense pain. Sometimes oedema over the mastoid with displacement forwards of the pinna supervenes, and simulates acute inflammation of the mastoid.
Treatment.--If seen in the earliest stages, an attempt may be made to relieve the pain by the application of a 20 per cent. menthol and parolein solution, or by the use of carbolic acid and cocain, 5 grains of each to a dram of glycerine. When suppuration has occurred, the best treatment is by early incision, transfixing the base of the swelling with a narrow knife and cutting into the meatus. If the tendency to boils persists, a staphylococcal vaccine will be found of value.
#Foreign Bodies.#--It is unnecessary to enumerate all the varieties of foreign bodies that may be met with in the ear. They may be conveniently classified into the animate--for example maggots, larvae, and insects; and the inanimate--for example beads, buttons, and peas. Pain, deafness, tinnitus, and giddiness may be produced, and such reflex symptoms as coughing and vomiting have resulted.
The main practical point consists in identifying the body by inspection. The mere history of its introduction should not be taken as proof of its presence. In children it is advisable to give a general anaesthetic so that a thorough examination may be made with the aid of good illumination. If previous attempts to remove the body have caused oedema of the meatal walls, and if the symptoms are not urgent, no further attempt should be made until the swelling has been allayed by syringing with warm boracic lotion, and by applying one or more leeches to the tragus. An attempt should always be made in the first instance to remove the body by syringing. It is rare to find this method fail. Should it do so, a small hook should be used, sharp or blunt according to the consistence of the body. Maggots, larvae, and insects should first be killed by instillations of alcohol and then syringed out.
AFFECTIONS OF THE TYMPANIC MEMBRANE AND MIDDLE EAR
#Traumatic Rupture of the Tympanic Membrane.#--Perforating wounds may result from direct violence caused by the patient--for example, in attempts to remove wax or foreign bodies, or by clumsiness on the part of the surgeon. It is also a comparatively common complication of fracture of the middle fossa of the base of the skull. More commonly, perhaps, the membrane is ruptured from indirect violence due to great condensation of the air in the external auditory meatus, following blows upon the ear, heavy artillery reports, or diving from a height. The injury is followed by pain in the ear, often by considerable deafness and tinnitus, and bleeding is frequently observed. If early examination of the ear is made, coagulated blood may be found in the meatus or upon the membrane, or ecchymosis may be visible on the latter. A rupture in the membrane following indirect violence is usually lozenge-shaped. During inflation by Valsalva's method the air may be heard to whistle through the perforation. In all such injuries the hearing should be carefully tested, and the possibility of an injury to the labyrinth investigated by means of the tuning-fork test. Prognosis as regards hearing should be guarded at first. As a rule the rupture heals rapidly, and no treatment is necessary save the introduction of a piece of cotton-wool into the meatus. Syringing should be avoided unless suppuration has already occurred, in which case treatment for this condition must be adopted. As these injuries frequently have a medico-legal bearing, careful notes should be made.
#Acute Infection of the Middle Ear.#--This usually arises in connection with infective conditions of the throat and naso-pharynx. It varies considerably in its severity, and may run a mild or a severe course. It is characterised by pain in the ear, deafness, and a certain degree of fever. In children the symptoms may simulate those of meningitis. When the tympanic membrane is examined in the mild forms of the affection or in the early stages of the more severe type, the vessels about the handle of the malleus and periphery of the membrane are injected, and possibly a number of injected vessels may be seen coursing across the surface of the membrane. In the later stages the whole membrane presents a red surface, the anatomical landmarks being indistinguishable, the membrane bulges outwards into the meatus, and, if an abscess is pointing, a yellowish area may be visible upon it. The sudden cessation of pain and the appearance of a discharge from the meatus indicate perforation of the membrana tympani.
The treatment of acute otitis media varies with the severity of the attack. The patient should be confined to the house or to bed, alcohol and tobacco should be forbidden, and the bowels must be freely opened. Pain may be allayed by repeated instillations of cocain and carbolic acid (5 grains of each to a dram of glycerine). A few drops of laudanum, hot boracic instillations, or the application of a dry hot sponge, may prove soothing. Two or three leeches may be applied over the mastoid, but should the pain persist or should rupture of the membrane appear imminent, paracentesis must be carried out. After spontaneous perforation or puncture, the meatus must be kept clean. It is probably safer not to inflate through the Eustachian tube in the acute stage. Attention must be paid to any affection of the nose or throat that may be present.
#Chronic Suppuration in the Middle Ear.#--Acute suppuration may pass into the chronic variety, which is characterised by a perforation of the tympanic membrane, a persistent purulent or muco-purulent discharge from the middle ear, and a certain amount of deafness.
Various complications may arise in the course of chronic middle-ear disease, and so long as a person is the subject of a chronic otorrhoea, he is liable to one or more of these. The complications may be extra-cranial or intra-cranial. Those affecting the middle ear itself include granulations, polypi, cholesteatoma, caries and necrosis of the temporal bone, destruction and loss of one or more of the ossicles, facial paralysis, haemorrhage from the carotid artery or jugular vein, and malignant disease. As mastoid complications may be mentioned: suppurative mastoiditis, leading to destruction of the bone, mastoid fistula, and sub-periosteal mastoid abscess. The intra-cranial complications that may arise are: extra-dural abscess, sub-dural abscess, meningitis, cerebral and cerebellar abscess, and lateral sinus phlebitis with general septicaemia and pyaemia.
The treatment of chronic middle-ear suppuration consists in keeping the parts clean by syringing with antiseptic lotions. The installation of hydrogen peroxide, followed by syringing with boiled water or boracic lotion, and inflation through the Eustachian tube once, twice, or thrice daily, according to the requirements of the case, constitute a routine method. Packing the meatus with antiseptic gauze after washing out may be practised.
#Suppuration in the Tympanic Antrum and Mastoid Cells#, or Acute Suppurative Mastoiditis.--Acute suppuration may occur in the mastoid cells in the course of an attack of acute otitis media, or as a result of interference with drainage in chronic suppuration of the antrum and middle ear. As the outer wall of the mastoid is liable to be perforated by cario-necrosis, the pus may find its way externally and form an abscess over the mastoid process behind the ear. In some cases the pus escapes into the external auditory meatus by perforating its posterior wall; in others a sinus forms on the inner side of the apex of the mastoid, and the pus burrows in the digastric fossa under the sterno-mastoid--Bezold's mastoiditis. If the posterior wall or roof of the antrum is destroyed, intra-cranial complications are liable to ensue.
The clinical features are pain behind the ear, tenderness on pressure or percussion over the mastoid, redness and oedematous swelling of the skin, and, when pus forms under the periosteum, the oedema may be so great as to displace the auricle downwards and forwards (Fig. 265). The deeper part of the posterior osseous wall of the meatus may be swollen so that it conceals the upper and back part of the membrane.
Treatment.--When arising in connection with acute otitis, the application of several leeches behind the ear, free incision of the membrane, and syringing with hot boracic lotion may be sufficient. As a rule, however, it is necessary to expose the interior of the antrum by opening through the mastoid cells--Schwartze's operation. When mastoid suppuration is associated with chronic middle-ear disease, it is usually necessary to perform the complete radical operation--Stacke-Schwartze operation. The operations are described in Operative Surgery, p. 98.
XXV. THE NOSE AND NASO-PHARYNX[6]
Fracture of nasal bones--Deformities of nose: Saddle nose; Partial and complete destruction of nose; Restoration of nose; Rhinophyma--Intra-nasal affections--Examination of the nasal cavities: Anterior rhinoscopy; Posterior rhinoscopy; Digital examination. CARDINAL SYMPTOMS OF NASAL AFFECTIONS: Nasal obstruction: Erectile swelling of inferior turbinals; Nasal polypi; Malignant tumours; Deviations, spines, and ridges of septum; Haematoma of septum--Nasal discharge: Foreign bodies; Rhinoliths; Ozaena; Epistaxis; Suppuration in accessory sinuses--Anomalies of smell and taste: Anosmia; Parosmia--Reflex symptoms of nasal origin--Post-nasal obstruction: Adenoids--Tumours of naso-pharynx.
[6] Revised by Dr. Logan Turner.
#Fracture of the Nasal Bones and Displacement of the Cartilages.#--These injuries are always the result of direct violence, such as a blow or a fall against a projecting object, and in spite of the fact that the fracture is usually compound through tearing of the mucous membrane, infective complications are rare. The fracture usually runs transversely across both nasal bones near their lower edge, but sometimes it is comminuted and involves also the frontal processes of the maxillae. In nearly all cases the cartilage of the septum is bent or displaced so that it bulges into one or other nostril, and not infrequently a haematoma forms in the septum (p. 573). Sometimes the perpendicular plate of the ethmoid is implicated, and the fracture in this way comes to involve the base of the skull. The nasal ducts may be injured, obstructing the flow of the tears, and a lachrymal abscess and fistula may eventually form.
The clinical features are pain, bleeding from the nose, discoloration, and swelling. Crepitus can usually be elicited on pressing over the nasal bones. The deformity sometimes consists in a lateral deviation of the nose, but more frequently in flattening of the bridge--traumatic saddle nose. Within a few hours of the injury the swelling is often so great as to obscure the nature of the deformity and to render the diagnosis difficult. Subcutaneous emphysema is not a common symptom; when it occurs, it is usually due to the patient forcing air into the connective tissue while blowing his nose. The lateral cartilages may be separated from the nasal bones and give rise to clinical appearances which simulate those of fracture. Sometimes the septum is displaced laterally without the bone being broken, and this causes symptoms of nasal obstruction.
Treatment.--As the bones unite rapidly, it is of great importance that any displacement should be reduced without delay, and to facilitate this a general anaesthetic should be administered, or the nasal cavity sprayed with cocain. The bones can usually be levered into position with the aid of a pair of dressing forceps passed into the nostrils, the blades being protected with rubber tubing. After the fragments have been replaced and moulded into position, it is seldom necessary to employ any retaining apparatus, but the patient must be warned against blowing or otherwise handling the nose. When the septum is damaged and the bridge of the nose tends to fall in, rubber tubes may be placed in the nostrils to give support, or, if this is not sufficient, a soft lead or gutta-percha splint should be moulded over the nose, and the splint and the fragments transfixed with one or more hare-lip pins. These may be removed on the fourth or fifth day. Rigid appliances introduced into the nostrils are to be avoided if possible, as they are uncomfortable and interfere with proper cleansing and drainage of the nose. The inside of the nose should be smeared with vaseline to prevent crusting of blood, and the nasal cavities should be frequently irrigated.
#Deformities of the Nose.#--The most common deformity is that known as the sunken-bridge or saddle nose (Volume I., p. 174). It is most frequently a result of inherited syphilis, the nasal bones being imperfectly developed, and the cartilages sinking in so that the tip of the nose is turned up and the nostrils look directly forward. The bridge of the nose may sink in also as a result of necrosis of the nasal bones, particularly in tertiary syphilis, and less frequently from tuberculous disease. A similar, but as a rule less marked deformity may result from fracture of the nasal bones or from displacement of the cartilages.
When the condition is due to mal-union of a fracture, the contour of the nose may be restored by operation. A narrow knife is passed in at the nostril and the skin freely separated from the bone; the bone is then broken into several pieces with necrosis forceps, and the fragments moulded into shape. A rubber drainage tube introduced into each nostril maintains the contour of the nose till union has taken place.
When it results from disease, it is much less amenable to treatment. The present-day tendency is to discard the use of subcutaneous paraffin injection and to employ grafts of cartilage or bone. An artificial bridge has been made by turning down from the forehead a flap, including the periosteum and a shaving of the outer table of the skull, or by implanting portions of bone or plates of gold, aluminium, or celluloid.
Portions of the alae nasi may be lost from injury, or from lupus, syphilis, or rodent cancer. After the destructive process has been arrested, the gap may be filled in by a flap taken from the cheek or adjacent part of the nose. When the tip of the nose is lost, it may be replaced by Syme's operation, which consists in raising flaps from the cheeks and bringing them together in the middle line.
The whole of the nose, including the cartilages and bones, may be destroyed by syphilitic ulceration or by lupus. In parts of India the nose is sometimes cut off maliciously or as a punishment for certain crimes.
In reconstructing the nose it is necessary to provide skin, a supporting structure in the form of cartilage or bone, and an epithelial lining. In the "Indian operation" a racket-shaped flap, including skin and periosteum, is turned down from the forehead and fixed in position, the edges of the flap being inturned to provide a lining for the passage. An implant of free cartilage may be necessary to support the skin flaps and to prevent subsequent contraction. Flaps of skin may be formed by Gillies' tube-pedicle method from the cheek, the forehead, or the neck, and utilised to form the covering of the nose. When the deformity cannot be corrected by operation, the appearance may be greatly improved by wearing an artificial nose held in position by spectacles.
The term #Rhinophyma# has been applied by Hebra to a condition in which the skin of the tip and alae of the nose becomes thick and coarse, and presents large, irregular, tuberous masses on which the orifices of the sebaceous follicles are unduly evident--potato or hammer nose (Fig. 266). The capillaries of the skin are dilated and tortuous, and the nose assumes a bluish-red colour, and its surface is soft and greasy. The condition is met with in elderly men, and the masses appear to be chiefly composed of sebaceous adenomas. The term lipoma nasi, formerly employed, is therefore misleading.
The treatment consists in paring away the protuberant masses until the normal size and contour of the nose are restored, care being taken not to encroach on the cartilages or on the orifices of the nostrils. There is comparatively little bleeding, and the raw surface rapidly becomes covered with epidermis.
#Examination of the Nasal Cavities.#--For the examination of the interior of the nose the following appliances are necessary: A reflector, such as is used in laryngoscopy, attached to a forehead band or spectacle frame; one of the various forms of nasal speculum; a long, pliable probe; a tongue depressor; and a small-sized mirror. As additional aids, a 10 per cent. solution of cocain, a grooved probe as a cotton-wool holder, and a palate retractor should be in readiness. Good illumination is important, and may be obtained from an electric light, or from a Welsbach or Argand burner. The light should be placed close to, and on a level with, the patient's left ear. Both the anterior and posterior nares should be examined.
Anterior Rhinoscopy.--Before the introduction of the speculum the tip of the nose should be tilted up and the interior of the vestibule and the anterior part of the septum examined. In this way the existence of eczema or small furuncules, the presence of dilated or bleeding vessels upon, or a perforation of, the anterior part of the septum may be noted, and the general appearances observed. After inserting the speculum into the vestibule and dilating it, the following parts should be sought for and examined:--Close to the floor, and attached to the outer wall of the nasal cavity, is the anterior end of the inferior concha or turbinated body (Fig. 267), which overhangs the inferior meatus. It presents a pink appearance, and its size varies in different persons. At a higher level and on a posterior plane is the anterior end of the middle concha or turbinated body, which is of a paler colour than the inferior, and is only visible when the head is tilted backwards. Between it and the inferior turbinated body is the middle meatus, with which communicate the openings of the maxillary sinus, the frontal sinus, and the anterior ethmoidal cells. A considerable area of the anterior part of the nasal septum is also visible by anterior rhinoscopy, and between it and the middle turbinal is a narrow chink--the olfactory sulcus.
Posterior Rhinoscopy.--Examination of the posterior nares and naso-pharynx is frequently attended with difficulty. The patient is directed to breathe through the nose, the tongue is depressed with a spatula, and a small-sized laryngeal mirror, comfortably warmed and with its reflecting surface turned upwards, is introduced behind the soft palate. When a good examination of the naso-pharynx is obtained, the following parts may be seen reflected in the mirror: the posterior surface of the uvula and soft palate, and above them, in the mesial plane, the posterior free edge of the septum nasi; on each side of the septum the apertures of the posterior nares, in which may be seen the upper part of the posterior end of the inferior turbinal, the middle meatus, the posterior end of the middle turbinal, the superior meatus, and occasionally a portion of the superior turbinal. On the lateral wall of the naso-pharynx the Eustachian opening and cushion can be seen, while by tilting the mirror backwards the vault of the naso-pharynx can be inspected.
Digital examination of the naso-pharynx may be required, especially in children. The examiner passes his left arm and hand round the back of the child's head, and with one of his fingers presses the cheek inwards, between the jaws. His right forefinger is carried along the dorsum of the tongue, passed up behind the soft palate and a rapid examination made of the post-nasal space.
CARDINAL SYMPTOMS OF NASAL AFFECTIONS.--The chief symptoms of nasal disease are: nasal obstruction, nasal discharge, anomalies of smell and taste, and certain reflex phenomena.
#Nasal Obstruction.#--This may be partial or complete, intermittent or constant, and may be the cause of such symptoms as alteration in the tone of the voice, catarrh of the respiratory passages, snoring, cough, headache, inability to concentrate the attention, alteration in the physiognomy, or deformity of the chest. The half-open mouth, drooping jaw, lengthened appearance of the face, narrow nostrils, and vacant expression are characteristic signs of nasal obstruction.
Nasal obstruction may be due to intra-nasal or to post-nasal (naso-pharyngeal) causes. Amongst the former may be noted as the more common, erectile swelling and hypertrophy of the mucous membrane covering the inferior turbinated bones, and nasal polypi growing from the middle turbinal and middle meatal region. Causes originating in the septum include deviations, spines, and ridges, and septal haematoma and abscess. Obstruction may also be due to the presence of a foreign body in the nasal cavity, to a rhinolith, and to imperfect development of the nasal chambers. Further, tumours, both simple and malignant, and such conditions as tubercle, lupus, syphilis, and glanders may interfere more or less with nasal respiration. The most common cause of post-nasal obstruction is the presence of adenoids; more rarely fibro-mucous polypi, fibrous tumours, malignant disease, and cicatricial contractions and adhesions resulting from syphilis are met with.
Erectile swelling of the inferior turbinated bodies is due to engorgement of the venous spaces contained in the mucous membrane. Obstruction from this cause is usually intermittent in character, and may be unilateral or bilateral. It is influenced by posture, being worse when the patient is in the horizontal position, and also by changes in atmospheric conditions and temperature. It is characterised objectively by a swelling of the mucous membrane, which is pink or red in appearance and of a soft consistence, pitting when touched with the probe, and shrinking on the application of a 5 per cent. solution of cocain. Its soft consistence and the fact that it becomes smaller when painted with cocain differentiate it from true hypertrophy of the mucous membrane. Its situation and immobility, its pink colour, and the shrinkage under cocain, distinguish it from the mucous polypus of the nose. The turgescence may involve the whole extent of the mucosa of the inferior turbinated bodies, including their posterior ends. After anaesthetising with cocain, the electric cautery, or fused chromic acid applied on a probe, may be employed for the relief of the condition. If a true hypertrophy exists, it is better to remove it with a nasal snare.
Nasal polypi spring from the mucous membrane covering the middle turbinated bone and from the adjacent parts of the middle meatus, but rarely from the septum. They consist of oedematous masses of mucous membrane, and are as a rule multiple. They are usually pedunculated, and as they increase in size they become pendulous in the nasal cavity. They are smooth, rounded in outline, of a translucent bluish-grey colour, soft in consistence, and freely movable. These characters, and the fact that the probe can be passed round the greater part of the polypus, serve to differentiate this affection from the erectile swelling. It must not be forgotten that nasal polypi may be associated with suppuration in one or more of the accessory sinuses. They are frequently present also in malignant disease, and in these cases they bleed readily. They are best removed by means of the cold snare, with the aid of the speculum and a good light. Several sittings are usually necessary.
Carcinoma and sarcoma sometimes grow from the muco-periosteum in the region of the ethmoid. They tend to invade adjacent parts, giving rise to haemorrhage and symptoms of nasal obstruction, and as they increase in size they may cause considerable deformity of the face. If diagnosed early, an attempt should be made to remove the growth.
Deviations, spines, and ridges of the septum may produce partial or complete occlusion of the anterior nares. In deviation of the septum, the obstructed nostril is more or less occluded by a smooth rounded swelling of cartilaginous or bony hardness, which is covered with normal mucous membrane, while the opposite nostril shows a corresponding concavity or hollowing of the septum. Sometimes the convex side is thickened in the form of a ridge. A simple spine of the septum is usually situated anteriorly, and presents an acuminate appearance, often pressing against the inferior turbinated body; it is hard to the touch. Ridges and spines may be cut or sawn off, or removed with the chisel. Many methods of dealing with a deviated septum have been suggested, such as forcible fracture or excision of a portion of the cartilage. A submucous resection of the deflected portion is to be preferred.
Haematoma of the septum is usually traumatic in origin. As the result of a blow, an extravasation of blood takes place beneath the perichondrium on each side of the septum, and a bilateral, symmetrical swelling, smooth in outline and covered with mucous membrane, is visible immediately within the anterior nares. The blood is usually absorbed and should not be interfered with. If suppuration occurs, however, the swelling becomes soft, fluctuation can be detected, and the patient's discomfort increases. The abscess must then be incised and the cavity drained. It is sometimes found that a portion of the cartilage undergoes necrosis, leading to perforation of the septum.
#Nasal discharge# may be mucous, muco-purulent, or purulent in character. When it is of a clear, watery nature, it is usually associated with erectile swelling of the inferior turbinated bodies. A purulent discharge may be complained of from one or both nostrils. If unilateral, it should suggest, in the case of children, the presence of a foreign body; in adults, the possibility of suppuration in one or more of the accessory sinuses. In infants, a purulent discharge from both nostrils may be due to gonorrhoeal infection or to inherited syphilis. Nasal discharge may be constant or intermittent. It is sometimes influenced by changes in posture; for example, it may be chiefly complained of at the back of the nose and in the throat when the patient occupies the horizontal position, or it may flow from the nostril when he bends his head forward or to one side. The discharge may be intra-nasal in origin, or due altogether to naso-pharyngeal catarrh. It varies somewhat in colour and consistence, and may be associated with such intra-nasal conditions as purulent rhinitis following scarlet fever and other exanthemata or ulceration accompanying malignant disease, syphilis, or tuberculosis. Sometimes it contains shreds of false membrane, for example in nasal diphtheria; or white cheesy masses as in coryza cascosa. The formation of crusts is significant of foetid atrophic rhinitis (ozaena) and syphilis, and in these conditions the discharge is associated with a most objectionable and distinctive foetor. Pus from the maxillary sinus is often foetid, and the odour is noticed by the patient; while the odour of ozaena is not recognised by the patient, although very obvious to others.
#Foreign bodies# of various descriptions have been met with in the nasal cavities, particularly of children. They set up suppuration and give rise to a unilateral discharge, which is often offensive in character. The surgeon must not be satisfied with the history given by the parents, but, with the aid of good illumination, and, in young children, under general anaesthesia, the nose should be carefully inspected and probed. If there is much swelling, the introduction of a 5 per cent. solution of cocain will facilitate the examination by diminishing the congestion of the mucous membrane. No attempt should be made to remove a foreign body from the nose by syringing. If fluid is injected into the obstructed nostril, it is liable to force the body farther back, while, if injected into the free nostril, it is apt to accumulate in the naso-pharnyx and to pass into the Eustachian tubes. A fine hook should be passed behind the body and traction made upon it, or sinus forceps or a snare may be employed. Care must be taken that the body is not pushed still deeper into the cavity. Fungi and parasites should first be killed with injections of chloroform water, or by making the patient inhale chloroform vapour.
#Rhinoliths.#--Concretions having a plug of inspissated mucus or a small foreign body as a nucleus sometimes form in the nose. They are composed of phosphate and carbonate of lime, and have a covering of thickened nasal secretion. They are rough on the surface, dark in colour, and usually lie in the inferior meatus. They give rise to the same symptoms as a foreign body, and are treated in the same way. The stone, which is usually single, may be so large and so hard that it is necessary to crush it before it can be removed.
#Ozaena#, or #foetid atrophic rhinitis#, is characterised by atrophy of the nasal mucous membrane, and sometimes even of the turbinated bones, and is accompanied by a muco-purulent discharge and the formation of crusts having a characteristic offensive odour, which is not recognised by the patient. It is usually bilateral, and the nasal chambers, owing to the atrophy, are very roomy. It may be differentiated from a tertiary syphilitic condition by the absence of ulceration and necrosis of bone, by the odour, and by the fact that it is not influenced by anti-syphilitic treatment.
Various methods of treatment are in vogue, but thorough cleanliness is the most essential factor, and this is best secured by regular syringing. Plugging of the nostrils with cotton-wool for half an hour before washing out the nose greatly facilitates the detachment of the crusts. A pint of lukewarm solution containing a teaspoonful of bicarbonate of soda or of common salt, is then used with a Higginson's syringe, the patient leaning over a basin and breathing in and out quickly through the open mouth. The patient should then forcibly blow down each nostril in turn, the other being occluded with the finger, so that the infective material may thus be blown out without risk of it entering the Eustachian tubes, as may happen when the handkerchief is used in the ordinary way. Antiseptic sprays, such as peroxide of hydrogen, and ointments may be applied to the mucous membrane after cleansing.
#Epistaxis.#--Bleeding from the nose may be due either to local or to general causes. Among the former may be cited injuries such as result from the introduction of foreign bodies, blows on the face, and fractures of the anterior fossa of the skull, and the ulceration of syphilitic, tuberculous, or malignant disease. Amongst the general conditions in which nasal haemorrhage may occur are typhoid fever, anaemia, and purpura cardiac and renal disease, cirrhosis of the liver, and whooping-cough. Prolonged oozing of blood may be an evidence of haemophilia. Nasal haemorrhage usually takes place from one or more dilated capillaries situated at the anterior inferior part of the septum close to the vestibule, and in such cases the bleeding point is readily detected. Occasionally bleeding occurs from one of the anterior ethmoidal veins, and under these circumstances the blood flows downwards between the middle turbinal and the septum. Before steps are taken to arrest the bleeding, the interior of the nose should, if possible, be inspected and the bleeding point sought for. As a preliminary to the use of local applications, the nose should be washed out with boracic lotion or salt solution to remove all clots from the cavity. In many cases this is all that is necessary to stop the bleeding. If the bleeding is not very copious, it may be stopped by grasping the alae nasi between the finger and thumb, or by spraying the nasal cavity with adrenalin. If the blood is evidently flowing from the olfactory sulcus, a strip of gauze soaked in adrenalin, turpentine, or other styptic should be packed between the septum and middle turbinated body. If recurrent haemorrhage takes place from the anterior and lower part of the septum, the application of the electric cautery at a dull red heat, or of the chromic acid bead fused on a probe, is the best method of treatment. Plugging of the posterior nares is rarely necessary, as, in the majority of cases, an anterior plug suffices. In bleeders, the administration of sheep serum by the mouth has proved efficacious.
#Suppuration in the Accessory Nasal Sinuses.#--As already stated, the presence of pus in the nose should always direct attention to its possible origin in one or more of the accessory sinuses, especially if the discharge is unilateral. The condition is usually a chronic one, and may be present for months, or even years, without the patient suffering much inconvenience save from the presence of the discharge.
If on examination by anterior rhinoscopy, pus is seen in the middle meatus, suspicion should be aroused of its origin in the maxillary sinus, frontal sinus, or anterior ethmoidal cells, as all these cavities communicate with that channel. If, on the other hand, the pus is detected in the olfactory sulcus, attention must be directed to the posterior ethmoidal cells and sphenoidal sinus (Fig. 267). Further evidence of its source in the last-named cavities may be gained by finding pus in the superior meatus above the middle turbinal on examination by posterior rhinoscopy.
As the anterior group of sinuses is most frequently affected, and of these most commonly the maxillary sinus, attention should first be turned to this cavity. Pain, tenderness on pressing over the canine fossa or on tapping the teeth of the upper jaw, and swelling of the cheek are rarely met with save in acute inflammation. The complaint of a bad odour or taste, the reappearance of pus in the middle meatus after mopping it away and directing the patient to bend his head well forwards, and opacity on trans-illumination of the suspected cavity, are signs which strongly suggest an affection of the maxillary sinus. The withdrawal of pus by a puncture through the thin outer wall of the inferior meatus of the nose with a fine trocar and cannula will establish the diagnosis.
The treatment consists in opening and draining the sinus. If the infection is due to a carious tooth, this should be extracted, the socket opened up and drainage established through it in recent cases. If the teeth are sound, and the case is of long duration, the sinus is opened through the canine fossa and its walls curetted. To avoid the risk of reinfecting the cavity from the mouth, an opening may be made into the nose by removing a portion of the nasal wall of the sinus and part of the inferior turbinated bone, after which the incision in the buccal mucous membrane is closed with sutures.
Suppuration in the frontal sinus is attended with frontal headache, vertigo, especially on stooping, and tenderness on pressure, particularly over the internal orbital angle, or on percussion over the frontal region. Pus escapes into the middle meatus of the nose, and if wiped away will reappear if the head is kept erect for a few minutes. After removal of the anterior end of the middle turbinated bone, it may be possible to catheterise the sinus and wash out pus from its interior. The diseased sinus may present a darker shadow than the healthy one on trans-illumination, or in an X-ray photograph.
The treatment consists in exposing the anterior wall of the sinus, chiselling away sufficient bone to admit of free removal of all infected tissue, and establishing efficient drainage through the infundibulum (Fig. 267) into the nose.
The anterior ethmoidal cells (Fig. 267) are frequently affected in conjunction with the frontal, and sometimes with the maxillary sinus. The presence of polypi and granulations, with pus oozing out from between them, and increasing after withdrawal of the probe, and the detection of carious bone are significant of ethmoidal suppuration.
The treatment consists in extending the operation for the frontal or maxillary sinus so as to ensure drainage of the ethmoidal cells.
Suppuration in the sphenoidal sinus (Fig. 267) is characterised in many cases by the presence of eye symptoms. Pus in the olfactory sulcus, on the upper surface of the middle turbinal posteriorly, and on the vault of the naso-pharynx, is suggestive of sphenoidal suppuration. The removal of the middle turbinated bone permits of inspection of the ostium sphenoidale by anterior rhinoscopy, and pus may be seen escaping from the orifice. A probe is then passed into the ostium, and the anterior wall of the sinus is removed with a curette or rongeur forceps.
The posterior ethmoidal cells (Fig. 267) are frequently affected along with the sphenoidal sinus. The nasal appearances just noted are present, and if the sphenoidal sinus can be washed out and its ostium temporarily plugged, and pus rapidly reappears, its origin from these cells is probable. The operation for draining the sphenoidal sinus is extended by removing the inner wall of the posterior ethmoidal cells.
#Anomalies of Smell and Taste.#--Anosmia or loss of smell and impairment or loss of the sense of recognising flavours may follow fracture of the anterior fossa attended with injury of the olfactory nerves, and is a common sequel of influenza. Any lesion that prevents the passage of the odoriferous particles to the olfactory region of the nose interferes with the sense of smell. In ozaena also the sense of smell is lost. Parosmia, or the sensation of a bad odour, may be of functional origin; it sometimes occurs after influenza. It may also be associated with maxillary suppuration.
#Reflex Symptoms of Nasal Origin.#--It is only necessary here to draw attention to the relation that exists between affections of the nose and asthma. When present in asthmatic subjects, nasal polypi, erectile swelling of the inferior turbinated bodies, spines of the septum in contact with the inferior turbinal, or areas on the mucous membrane which, when probed, produce coughing, call for treatment with the object of modifying the asthma.
#Post-nasal Obstruction--Adenoid Vegetations.#--The most common cause of post-nasal obstruction is hypertrophy of the normal lymphoid tissue which constitutes the naso-pharyngeal or Luschka's tonsil. Adenoids form a soft, velvety mass, which projects from the vault of the naso-pharynx and extends down its posterior and lateral walls, in some cases filling up the fossae of Rosenmueller behind the Eustachian cushions. They do not grow from the margins of the posterior nares. Adenoids are frequently associated with hypertrophy of the faucial tonsils, and the patient often suffers from granular pharyngitis and chronic nasal catarrh.
These growths are sometimes met with in infants, but are most common between the ages of five and fifteen, after which they tend to undergo atrophy. They may, however, persist into adult life.
Clinical Features.--The most prominent symptom in most cases is interference with nasal respiration, so that the patient is compelled to breathe through the mouth. The facies of adenoids is characteristic: the mouth is kept partly open, the face appears lengthened, the nose is flattened by the falling in of the alae nasi, the inner angles of the eyes are drawn down, and the eyelids droop, while the whole facial expression is dull and stupid. As the respiratory difficulty is increased during sleep, the patient snores loudly, and his sleep is frequently broken by sudden night terrors. Owing to the disturbed sleep, to imperfect oxygenation of the blood, and to frequent attacks of nasal and bronchial catarrh, the child's nutrition is interfered with, and he becomes languid and backward at his lessons.
When the adenoids encroach upon the Eustachian cushions, the patient suffers from deafness, frequent attacks of earache, and sometimes from suppurative otitis media with a discharge from the ear.
Among the rarer conditions attributed to adenoids are asthma, inspiratory laryngeal stridor, persistent cough, chorea, and nocturnal enuresis.
A diagnosis should never be made from the symptoms alone; an attempt must be made to examine the naso-pharynx by posterior rhinoscopy and by digital examination. The interior of the nose must always be examined and any further cause of obstruction excluded.
Treatment.--Thorough removal is the only satisfactory line of treatment, and this should be done under general anaesthesia. The following instruments are necessary: two Gottstein's adenoid curettes, one provided with a cradle and hooks, the other without, a Hartmann's lateral ring knife, and one pair of adenoid forceps--Kuhn's or Loewenberg's--a tongue depressor, a gag, and one or two throat sponges on holders. The patient having been anaesthetised, his head should be drawn over the end of the table. An assistant standing on the left side inserts the gag and maintains it in position. The operator, being on the patient's right, depresses the tongue and insinuates the curette provided with the hooks behind the soft palate, carrying it to the roof of the naso-pharynx between the growth and the posterior free edge of the nasal septum. Firm pressure is then made against the vault of the naso-pharynx, and the curette is carried backwards and downwards in the mesial plane and withdrawn with the main mass of the adenoids caught in the hooks. The unguarded curette is then introduced and several strokes are made with it, the instrument being carried on either side of the mesial plane. With Hartmann's lateral ring knife the posterior naso-pharyngeal wall and fossae of Rosenmueller are curetted. The curette should not be used on the lateral pharyngeal wall in case the Eustachian orifices and cushions are damaged. Bleeding soon ceases when the head is again elevated, and the patient should be at once laid well over upon his side so that the blood may escape from the mouth.
No local after-treatment is required, and spraying or syringing may prove harmful. The patient should remain in the house for five or six days. If nasal obstruction has been the outstanding symptom, respiratory exercises through the nose should be carried out for some considerable time; on the other hand, if Eustachian obstruction and deafness have been the main features of the case, a course of Politzer inflation should be conducted after the wound has healed.
#Tumours of the Naso-Pharynx.#--Tumours are occasionally met with growing from the muco-periosteum of the basi-sphenoid and basi-occipital, and projecting from the vault of the naso-pharynx--naso-pharyngeal tumour or retro-pharyngeal polypus. This usually occurs between the ages of fifteen and twenty, and while it may originally be a fibroma, it tends to assume the characters of a fibro-sarcoma and to exhibit malignant tendencies. At first the tumour is firm, rounded, and of slow growth, but later it becomes softer, more vascular, and grows more rapidly, spreading forwards towards the nasal cavity and downwards towards the pharynx.
Clinical Features.--In its growth the tumour blocks the nostrils, and so interferes with nasal respiration and causes the patient to snore loudly, especially during sleep. It may also bulge the soft palate towards the mouth and interfere with deglutition. In some cases the face becomes flattened and expanded and the eyes are pushed outwards, giving rise to the deformity known as frog-face. Deafness may result from obstruction of the Eustachian tube. The patient suffers from intense frontal headache, and there is a persistent and offensive mucous discharge from the nose. Profuse recurrent bleeding from the nose is a common symptom, and the patient becomes profoundly anaemic. The tumour can usually be seen on examination with the nasal speculum or by posterior rhinoscopy, and its size and limits may be recognised by digital examination.
Unless removed by operation these tumours prove fatal from haemorrhage, interference with respiration, or by perforating the base of the skull and giving rise to intra-cranial complications.
Treatment.--These growths are seldom recognised before they have attained considerable dimensions, and owing to the fact that they are permeated by numerous large, thin-walled venous sinuses, their removal is attended with formidable haemorrhage. Attempts to remove them by the galvanic snare are seldom satisfactory, because the base of the tumour is left behind and recurrence is liable to take place. The operative treatment is described in Operative Surgery, p. 153.