Manual of Surgery Volume II Part 60

#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 circ.u.mstances 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 pa.s.sed 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 pa.s.sage 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 a.s.sociated 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 const.i.tutes the naso-pharyngeal or Luschka's tonsil.

_Adenoids_ form a soft, velvety ma.s.s, 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 Rosenmuller behind the Eustachian cushions. They do not grow from the margins of the posterior nares.

Adenoids are frequently a.s.sociated 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 ot.i.tis media with a discharge from the ear.

Among the rarer conditions attributed to adenoids are asthma, inspiratory laryngeal stridor, persistent cough, ch.o.r.ea, 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 Lwenberg'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 a.s.sistant 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 ma.s.s 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 Rosenmuller 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 a.s.sume 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 deglut.i.tion. 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 sophagus; at this point there is a constriction in the food pa.s.sage, 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 pa.s.ses 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--pa.s.s 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 sophagus, 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 pa.s.ses into the anterior mediastinum as far as the pericardium. The connective tissue s.p.a.ce 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 a.s.sociated 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 caec.u.m 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 caec.u.m, pa.s.sing usually in front of, but sometimes through the substance of, the hyoid bone.

Occasionally the fistula only extends as high as the hyoid.

[Ill.u.s.tration: FIG. 268.--Congenital Branchial Cyst in a woman aet. 33.

(Microscopically the cyst was lined with squamous epithelium and the wall contained rudimentary salivary-gland tissue.)]

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 pa.s.ses 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 ca.n.a.l 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 pa.s.s a probe along it, but its extent and course may be recognised by injecting an emulsion of bis.m.u.th 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 sc.r.a.ping with the sharp spoon, cauterising, or packing, are seldom successful.