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.



CHAPTER 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.



CHAPTER 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.



CHAPTER XXVI

THE NECK

Surgical Anatomy—Malformations: Cervical auricles; Thyreo-glossal cysts and fistulae; Lateral fistula—Cervical ribs—Wry-neck: Varieties; Cicatricial contraction—Injuries: Contusions—Fractures of hyoid, larynx, etc.: Cut-throat—Infective conditions: Diffuse cellulitis; Actinomycosis; Boils and Carbuncles—Tumours: Cystic: Branchial cysts; Cystic lymphangioma; Blood cysts; Bursal cysts—Solid: Lipoma; Fibroma; Osteoma; Sarcoma; Carcinoma—The thymus gland—The carotid gland.

Surgical Anatomy.—In the middle line the following structures may be recognised on palpation: (1) the hyoid bone, lying below and behind the body of the lower jaw, on a level with the fourth cervical vertebra; (2) the hyo-thyreoid membrane, behind which lies the base of the epiglottis and the upper opening of the larynx; (3) the thyreoid cartilage, to the angle of which the vocal cords are attached about its middle; (4) the crico-thyreoid membrane, across which run transversely the crico-thyreoid branches of the superior thyreoid arteries; (5) the cricoid cartilage, one of the most important landmarks in the neck. It lies opposite the disc between the fifth and sixth cervical vertebrae, and at this level the common carotid artery may be compressed against the carotid tubercle on the transverse process of the sixth cervical vertebra. The cricoid also marks the junction of the larynx with the trachea, and of the pharynx with the oesophagus; at this point there is a constriction in the food passage, and foreign bodies are frequently impacted here. At the level of the cricoid cartilage the omo-hyoid crosses the carotid artery—a point of importance in connection with ligation of that vessel. The middle cervical ganglion of the sympathetic lies opposite the level of the cricoid. (6) Seven or eight rings of the trachea lie above the level of the sternum, but they cannot be palpated individually. The isthmus of the thyreoid gland covers the second, third, and fourth tracheal rings. As the trachea passes down the neck, it gradually recedes from the surface, till at the level of the sternum it lies about an inch and a half from the skin. The thyreoidea ima artery—an inconstant branch of the anonyma (innominate) or of the aorta—runs in front of the trachea as far up as the thyreoid isthmus. The inferior thyreoid plexus of veins also lies in front of the trachea. In the superficial fascia, cross branches between the anterior jugular veins cross the middle line.

In children under two years of age the thymus gland may extend for some distance into the neck in front of the trachea and carotid vessels, under cover of the depressors of the hyoid bone.

Cervical Fascia.—This fascia completely envelops the neck, and from its deep aspect two strong processes—the prevertebral and pretracheal layers—pass transversely across the neck, dividing it into three main compartments. The posterior or vertebral compartment contains the muscles of the back of the neck, the vertebral column and its contents, and the prevertebral muscles. This compartment is limited above by the base of the skull, and below is continued into the posterior mediastinum. The middle or visceral compartment contains the pharynx and oesophagus, the larynx and trachea with the thyreoid gland, and the carotid sheath and its contents. These different structures derive their special fascial coverings from the processes that bound this compartment. The middle compartment extends to the base of the skull and passes into the anterior mediastinum as far as the pericardium. The connective tissue space around the subclavian vessels is continued into the axilla. The anterior or muscular compartment contains the sterno-mastoid muscle and the depressor muscles of the hyoid bone. It extends upwards as far as the hyoid bone and base of the mandible, and downwards as far as the sternum and clavicle. The arrangement and limits of the different layers of the cervical fascia explain the course taken by inflammatory products and by new growths in the neck.

Malformations of the Neck.—Various congenital deformities result from interference with the developmental processes which take place in and around the fore-gut. These malformations are associated chiefly with imperfect development of the visceral or branchial arches and clefts, or of the hypoblastic diverticula from which the thyreoid and thymus glands are formed.

The term cervical auricles is applied to small outgrowths, composed of skin, connective tissue, and yellow elastic cartilage, found usually along the anterior border of the sterno-mastoid. These appendages are usually unilateral, and are derived from the second visceral arch. Sometimes they are situated near the orifice of a lateral fistula. When, on account of their size, or their situation on an exposed part of the neck, they give rise to disfigurement, they should be removed.

Thyreo-glossal Cysts and Fistulae.—The thyreo-glossal cyst is developed in relation to the thyreo-glossal tract of His, which in early embryonic life extends from the foramen caecum at the base of the tongue to the isthmus of the thyreoid. Those that form in the upper part of the tract, in relation to the base of the tongue, have already been described (p. 538). Those arising from the lower part form a swelling in the middle line of the neck, usually above, but sometimes below the hyoid bone. They have to be diagnosed from other forms of cyst occurring in the middle line of the neck—sebaceous and dermoid cysts—and when giving rise to disfigurement they should be excised.

Such a cyst may rupture on the surface, usually as a result of superadded infection, and give rise to a thyreo-glossal or median fistula of the neck. As a rule the external opening of the fistula is above the hyoid bone, only the upper part of the duct having remained pervious. When the whole length of the duct has persisted, the fistula extends from the skin to the foramen caecum, passing usually in front of, but sometimes through the substance of, the hyoid bone. Occasionally the fistula only extends as high as the hyoid.



The part of the tract near the tongue is lined by squamous epithelium; the lower part by columnar epithelium, which, below the level of the hyoid, is usually ciliated. Lymphoid tissue and mucous glands are found in its wall.

The treatment consists in excising the duct and the connections, and it is usually necessary to resect the central portion of the hyoid bone to ensure complete removal.

The lateral fistula of the neck—formerly described as a branchial fistula—according to Weglowski, usually takes origin from the remains of the hypoblastic diverticulum, which arises from the pharyngeal part of the third visceral cleft and extends downwards to form the thymus gland. The internal opening is situated in the lateral wall of the pharynx in the region of the posterior palatine arch close to the tonsil, and the fistula passes out above the hypoglossal nerve, and runs downwards and laterally between the carotids and along the medial border of the sterno-mastoid muscle. When the fistula is complete, the external opening is situated a short distance above the sterno-clavicular joint. As the lower part of the thymus canal most often persists, an incomplete external fistula is the form most frequently met with. It is lined with ciliated columnar epithelium.

The fistula may be present at birth, or may result from the rupture of a cystic swelling, which has become infected. Clear viscous fluid exudes from it, and, when the fistula is complete and the lumen sufficiently wide, particles of food may escape. As the track is tortuous, it is seldom possible to pass a probe along it, but its extent and course may be recognised by injecting an emulsion of bismuth and taking an X-ray photograph.

The treatment consists in excising the fistula in its whole length, but, owing to its long and tortuous course, and its relations to important structures, the operation is a tedious and difficult one. Less radical measures, such as scraping with the sharp spoon, cauterising, or packing, are seldom successful.

Cervical Ribs.—Supernumerary ribs are not infrequently met with in connection with the seventh cervical vertebra, and in the majority of cases the condition is bilateral. The extra rib may be thin and pointed, and project straight out from the transverse process terminating in a free end, in which case, as it passes above the subclavian artery and the brachial plexus, it gives rise to no trouble. In other cases it arches downwards and forwards, and is attached by dense fibrous tissue to the first thoracic rib about the level of the scalene tubercle, or to the sternum by cartilage like an ordinary rib. When it encroaches upon the posterior triangle the scalene muscles are attached to it, and the subclavian artery and the lower trunk and medial cord of the brachial plexus pass over it in a groove behind the scalenus anterior. The pleura may reach as high as the medial border of the rib.

Clinical Features.—The condition, which is more common in women than in men, is seldom recognised before the age of twenty, and is often discovered accidentally, for example after some emaciating illness, or by a tight collar causing pain. The diagnosis is established by the X-rays.



When symptoms arise, they may be referable either to pressure on the artery or on the nerve roots. When the subclavian artery is displaced upwards it may be recognisable as a prominent pulsatile swelling, and as the part of the vessel distal to the rib is sometimes dilated and yields a systolic bruit, it may simulate an aneurysm (Sir William Turner). The pulse beyond is weakened while the arm hangs by the side, but may be restored by raising the hand above the head. Gangrene of the tips of the fingers has been observed in rare instances, but it is probably nervous rather than vascular in origin.

Symptoms referable to pressure on the nerve roots usually affect the right arm, and may be either neuralgic or paralytic in character (Wm. Thorburn). In the neuralgic group there is tingling pain, a feeling of numbness, and sensations of cold in the limb, most marked along the ulnar border of the forearm; the arm is weak, and susceptible to cold. This condition may be mistaken for brachial neuritis; it is relieved, however, by holding the arm above the head, for example, during sleep.

In the paralytic group, the pressure symptoms are referred to the first dorsal, or first dorsal and eighth cervical roots. The paralysis is most marked in the muscles of the thumb, and becomes less towards the ulnar side; the affected muscles atrophy, especially those forming the thenar eminence, and the finer movements of the thumb and fingers are impaired.

When pressure symptoms are present, the extra rib should be removed through an incision which exposes the posterior triangle sufficiently to admit of the bone and its periosteum being excised, without damage being inflicted on the brachial plexus, the subclavian artery, or the pleura.

Similar clinical features to those of cervical rib may be caused by a prominent transverse process of the first thoracic vertebra and similarly got rid of by its removal.

Branchial cysts and branchial tumours are described with tumours of the neck (p. 598).

WRY-NECK OR TORTICOLLIS.—The term wry-neck or torticollis is applied to a condition in which the head assumes an abnormal attitude, which is usually one of combined lateral flexion and rotation.

The most important form is due to faulty action of the cervical muscles, and three varieties of muscular wry-neck are recognised—(1) the acute or transient; (2) the chronic or permanent; and (3) the spasmodic.

Acute or transient wry-neck—so-called "rheumatic torticollis"—comes on suddenly, usually after the patient has been exposed to a draught of cold air or to damp. The condition is popularly known as "stiff neck," and is probably associated with fibrositis of the affected muscles. The sterno-mastoid, and often the trapezius, are contracted, and pull the head to one side, twisting the face slightly towards the opposite side (Fig. 270). There is tenderness on pressing over the affected muscles, and sometimes over the vertebral spines, and in the lines of the cervical nerves, and severe pain on attempting to move the head. Usually in the course of a few days the condition passes off as suddenly as it came on, but in some cases a certain amount of wasting of the affected muscles ensues.



In the diagnosis of this form of wry-neck it is necessary to exclude such conditions as cellulitis, inflammation of the cervical glands, and disease of the cervical spine, in which the head may assume an abnormal attitude, the position being that which gives the patient greatest comfort.

The treatment consists in ensuring free action of the bowels and kidneys, in inducing hyperaemia by means of heat, and applying gentle massage. Salicylates and similar drugs are useful in relieving the pain.

Permanent or true wry-neck is due to an organic shortening of the sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and the levator scapulae muscle may also undergo shortening, along with their investing sheaths derived from the cervical fascia.

The sternal head of the sterno-mastoid is always markedly shortened, and stands out as a tight cord; sometimes the clavicular head is also prominent.

There is evidence that in the majority of cases the deformity results from some interference with the development of the muscles during intra-uterine life. This is probably the effect of undue pressure on the foetus diminishing the arterial supply to the central part of the muscle, with the result that the muscle fibres undergo degeneration with subsequent sclerosis and contraction. It may result also from cicatricial contraction of the muscle following rupture of its fibres during delivery. In such cases there is a history that the birth was a difficult one, the presentation having been abnormal; and that a swelling was observed in the sterno-mastoid shortly after birth. This swelling—a haematoma of the sterno-mastoid—is at first soft, later becomes smaller, and eventually disappears. In course of time, sometimes months, sometimes years after the disappearance of the swelling, shortening of the muscle takes place, and the deformity is established.

Clinical Features.—Although the condition is usually described as "congenital," it is the common experience in practice that the child has reached the age of from seven to ten years before advice is sought. The appearance of the patient is characteristic (Fig. 271). The shortening of the sterno-mastoid pulls the head towards the affected side, usually the right, so that the ear is approximated to the shoulder. At the same time the head is rotated towards the opposite side and slightly tilted backwards, with the result that the chin is directed towards the opposite side, and is somewhat raised. The shortened sterno-mastoid stands out prominently, and, on any attempt to straighten the head, can be felt as a firm, fibrous band. The skin of the affected side of the neck may be thrown into transverse folds. The patient is unable to correct the deformity, but it is usually possible to diminish it by manipulation.



If the condition is not corrected, all the structures on the affected side of the neck undergo organic shortening, with the result that the deformity becomes accentuated. In advanced cases a lateral curvature, with the convexity towards the normal side, occurs in the cervical region, the vertebrae becoming wedge-shaped from side to side, and a compensatory curve may develop in the thoracic region (Fig. 272).



There is also asymmetry of the head and face, the affected side being the smaller. The eye on this side lies on a lower level, and is more oblique than its neighbour, the cheek is flattened, and the mouth asymmetrical. Instead of the eyebrows and the lips forming parallel lines, their axes converge towards the side of the contracted muscles and fasciae.

Treatment.—While it may be possible when the condition is recognised during infancy to counteract the tendency to contraction and deformity by manipulations, massage, and exercises alone, it is usually necessary to divide the shortened structures as a preliminary to orthopaedic measures.