THE MOUTH, FAUCES, AND PHARYNX
Stomatitis--Roof of mouth: _Abscess_; _Gumma_; _Tuberculous disease_;
_Tumours_--Elongation of uvula--Epithelioma of floor of
mouth--Tonsillitis: _Varieties_--Hypertrophy of
tonsils--Calculus--Syphilis and
Tuberculosis--Tumours--Retro-pharyngeal abscess.
THE MOUTH
#Stomatitis.#--The term stomatitis is applied to any inflammation of
the buccal mucous membrane. The _catarrhal_ form is often associated
with the presence of carious teeth or an infected wound; the mucous
membrane is hyperaemic and swollen, and exudes an excessive amount of
viscid mucous secretion, and the epithelium desquamates in patches,
leaving small superficial erosions or ulcers, which are very
sensitive. The _aphthous_ form, met with in unhealthy, underfed
children, is characterised by the occurrence of patches of fibrinous
exudate into the superficial layers of the mucous membrane; the
epithelium is shed, leaving a series of whitish spots surrounded by a
red hyperaemic zone, which may become confluent and form small ulcers.
The condition known as _thrush_, which closely resembles aphthous
stomatitis, is met with in infants during the period of teething, and
is due to the _oidium albicans_, a fungus met with in sour milk. The
spots, which are most numerous on the lips, tongue, and throat, have
the appearance of curdled milk.
The _treatment_ of these forms consists in improving the general
condition of the patient, and in employing a mouth-wash, such as
peroxide of hydrogen, Condy's fluid, chlorate of potash, or
boro-glyceride. The superficial ulcers may be touched with silver
nitrate or with a 1 per cent. solution of chromic acid.
_Ulcerative stomatitis_ is frequently met with in debilitated subjects
with decayed teeth, and is specially liable to occur during the course
of acute febrile diseases in which sordes accumulate about the teeth
and gums. It also occurs in syphilitic subjects while under treatment
by mercury--_mercurial stomatitis_. Some patients show a special
susceptibility to mercury, and one of the first signs of intolerance
of the drug is some degree of stomatitis, which may ensue after a
comparatively small quantity has been administered. It begins in the
gums, which become swollen and spongy, growing on to the teeth and
into the interstices. The gums assume a bluish-red colour and bleed
readily, and the teeth may become loose and fall out. The tongue may
share in the swelling--mercurial glossitis. There is also profuse
salivation, and the breath has a characteristically offensive odour.
In severe cases the alveolar margin of the jaw undergoes necrosis. A
similar condition occurs in lead and in phosphorus poisoning, and in
patients suffering from scurvy.
The _treatment_ consists in removing the cause, and in employing
antiseptic and astringent mouth-washes. The internal administration of
chlorate of potash is also indicated, as this drug is excreted in the
saliva. Loose teeth should not be removed as they become fixed again
when the stomatitis subsides.
_Gangrenous stomatitis_, or cancrum oris (Fig. 245), has already been
described (Volume I., p. 102).
[Illustration: FIG. 245.--Cancrum Oris.
(Mr. D. M. Greig's case.)]
#Roof of the Mouth.#--_Suppuration_ in the muco-periosteum of the
palate is usually secondary to suppuration at the root of a carious
tooth. It may also arise in excoriations caused by an ill-fitting
tooth-plate, or from the impaction of a foreign body, such as a fish
or game bone, in the mucous membrane. The inflammation begins close to
the alveolus, and may spread back along the palate. The
muco-periosteum becomes swollen, red, and exceedingly tender, and, as
pus forms, is raised from the bone, forming a prominent, firm,
elongated swelling, which on bursting or being incised gives exit to
foul-smelling pus.
The _syphilitic gumma_, which begins as a rounded indolent swelling,
is usually situated in the middle line near the posterior edge of the
hard palate. The swelling gradually softens and ulcerates, and a
sequestrum may separate and leave a perforation in the palate (Fig.
246). The treatment consists in employing the usual remedies for
tertiary syphilis. If the perforation persists and causes trouble by
allowing food to pass into the nose, or by giving a nasal tone to the
voice, it may be closed by an operation on the same principle as that
performed for cleft palate, or an obturator may be fitted to occlude
the opening.
[Illustration: FIG. 246.--Perforation of Palate, the result of
Syphilis, and Gumma of Right Frontal Bone.
(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]
_Tuberculous_ disease is chiefly met with in the form of lupus which
has spread from the nose or lips, and it may lead to widespread
destruction of the soft tissues, or even to perforation of the bony
palate.
Mucous cysts, dermoids, adenomas, lipomas, and fibromas are
occasionally met with. _Papillomatous thickening_ of the mucous
membrane sometimes occurs in association with leucoplakia. It resists
anti-syphilitic treatment, but yields to scraping with the sharp
spoon. _Endotheliomas_, or _mixed tumours_, similar to those met with
in the parotid gland, also occur in young subjects, and grow in the
submucous tissue of the soft palate, usually to one side of the middle
line. In their early stages they are of slow growth, and give rise to
no inconvenience save from their size, are easily removed, and show no
tendency to recur. Later, they grow more rapidly, tend to infiltrate
their surroundings and to assume malignant characters, so that
complete removal becomes difficult or impossible.
_Epithelioma_ may originate in the hard palate as a result of local
irritation, or may spread from adjacent parts. When it is confined to
the palate it is treated by removal of the palatal and alveolar
portions of the maxilla.
#Elongation of the uvula# is usually due to a chronic inflammatory
engorgement combined with glandular hypertrophy of the mucous
membrane. It often occurs in children, and is associated with a
constant hacking cough, which is usually worst when the patient is
lying down. By tickling the back of the tongue and pharynx it may
induce vomiting after meals. The treatment consists in snipping off
the redundant portion with scissors.
#Epithelioma of the floor of the mouth# frequently originates in the
mucous membrane between the frenum of the tongue and the inner aspect
of the gum. It develops insidiously, grows slowly, and gradually
spreads to the mandible and to the substance of the tongue, tacking it
down so that it cannot be protruded. The glands are early involved,
and their enlargement not infrequently first draws attention to the
condition. It is to be regarded as a particularly unfavourable site,
as local recurrence is frequent. For the complete removal of the
disease it is necessary to excise the tissues in the floor of the
mouth, and a variable portion of the tongue and mandible, and to clear
out the glands and fat from the submaxillary and submental regions.
THE TONSILS AND PHARYNX
#Infective Conditions.#--The majority of the infective conditions
included under the popular term "sore throat" originate in the
tonsils, and are due to the action of bacteria which under normal
conditions are present in the crypts of the tonsils and of the mucous
membrane of the naso-pharynx. The most important of these organisms
are streptococci, various forms of staphylococci and of
pneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. So
long as the health is good these organisms are harmless, but when
there is any lowering of the vitality they become virulent and give
rise to various forms of infection.
_Catarrhal tonsillitis_--usually attributed by the laity to "catching
cold"--is characterised by hyperaemia and congestion of the tonsils and
mucous membrane of the pharynx, soft palate, and uvula. It is often
met with in those who are much exposed to air contaminated with
organisms--for example, patients who have been long in hospital, or
the resident staff of hospitals (_septic_ or _hospital throat_), and
particularly in persons of a "rheumatic" tendency. There is slight
pain on swallowing, and a tickling sensation passes along the
Eustachian tube to the ear; the throat feels dry, and the patient has
a constant desire to clear it, and there is usually a rise of
temperature to 101 deg.-102 deg. F. As a rule the symptoms pass off in three
or four days, but the condition may spread along the Eustachian tube
to the ear, and interfere with hearing, or it may set up chronic
suppuration of the middle ear.
A similar condition of the pharynx is frequently one of the initial
symptoms in acute febrile diseases, such as scarlet fever, measles,
influenza, or acute rheumatism.
The _treatment_ of the throat affection consists in employing
antiseptic and soothing gargles, inhalations of chloride of ammonium,
or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozenges
or pastilles containing chloride of ammonium, chlorate of potash, and
cubebs may be employed. In rheumatic cases, salicin, aspirin, and
salicylate of soda are indicated.
In _follicular tonsillitis_, the infection first implicates the
lymphoid follicles. The crypts are distended with yellowish-white
plugs, composed of inflammatory exudate, leucocytes, and desquamated
epithelium, and these may project from the openings, giving the tonsil
a spotted appearance. Sometimes the exudate accumulates on the surface
of the tonsils and pharynx, forming a thin, greyish-white film, which
is liable to be mistaken for the false membrane of diphtheria. It can,
however, usually be wiped off, and when examined microscopically does
not contain the typical Loeffler's bacillus.
The tonsils are enlarged, and project so that they obstruct the
isthmus of the fauces, sometimes even meeting in the middle line.
There is pain on swallowing, and the respiration is impeded and noisy
during sleep. There is usually some degree of fever, and the glands
behind the angle of the jaw are enlarged and tender and may suppurate
and set up cellulitis. The acute symptoms usually subside in four or
five days, but if the deeper crypts are filled with plugs of exudate
the condition may prove obstinate. The patient is liable to periodic
attacks, particularly if the tonsils are chronically enlarged.
The _treatment_ is carried out on the same lines as for the catarrhal
form. In recurrent cases the tonsils should be removed.
#Acute Suppurative Tonsillitis and Peri-tonsillitis--Quinsy.#--This is
an acute suppurative inflammation of the tonsils and peritonsillar
tissue, due to infection with pyogenic bacteria. It affects the whole
substance of the tonsils, and the cellular tissue of the pillars of
the fauces, the soft palate, and the pharynx.
_Clinical Features._--The onset is usually sudden, and the affection
is ushered in by a rigor, high fever, and a feeling of malaise. There
is persistent thirst and dryness of the throat, and the patient has
the sensation of a foreign body being in the pharynx, with a constant
desire to swallow. Swallowing is extremely painful, the pain shooting
up to the ears, and the patient has difficulty in taking nourishment.
The saliva accumulates in the mouth; the voice is thick and nasal; and
the respiration impeded and noisy. If the patient can open the mouth
sufficiently to afford a view of the back of the throat (which,
however, is seldom the case), the inflamed parts are seen to be of a
dull reddish-violet colour. One tonsil is often more swollen than the
other, and the corresponding anterior pillar of the fauces more
prominent. The uvula is swollen and oedematous, and is deviated
towards the side on which there is least swelling. Suppuration occurs
in from three to seven days; in adults it is usually in the
peritonsillar tissue of the anterior pillar of the fauces, and extends
into the soft palate. In children the pus sometimes forms in the
substance of the tonsil. If left to burst, the abscess discharges
itself into the mouth, and the patient experiences instant relief. The
pus is always offensive, and if the abscess bursts during sleep, it
may enter the air-passages and cause septic pneumonia. The lymph
glands in the neck are usually enlarged and tender, and sometimes they
suppurate and give rise to a diffuse cellulitis. General infection of
the blood may follow, leading to metastatic invasion of different
tissues and organs, particularly one or other of the large joints.
_Treatment._--In the early stages soothing antiseptic gargles are
indicated. Later, when the patient is unable to gargle, the inhalation
of steam impregnated with the vapour of carbolic acid or friar's
balsam, and the application of hot fomentations or a large linseed
poultice to the neck may afford relief. When an abscess is formed, it
should be opened by means of a fine-pointed pair of sinus forceps,
thrust through the soft palate at a point opposite the base of the
uvula, and in the line of the anterior pillar of the fauces. As those
who suffer from quinsy are liable to have attacks coming on
periodically, if the tonsils remain permanently enlarged they should
be removed between attacks.
#Hypertrophy of the tonsils# is most commonly met with in children
between five and ten years of age, and is often associated with
adenoid vegetations in the naso-pharynx and chronic thickening of the
pharyngeal mucous membrane.
The whole tonsil is enlarged, the mucous membrane thickened, and the
connective tissue more or less sclerosed. The crypts appear on the
surface as deep clefts or fissures, and the lymph follicles are
enlarged and prominent. Secretion accumulates in the crypts, and a
calculus may form from the deposit of lime salts. Sometimes food
particles lodge in the crypts, and they may collect and form
accumulations of considerable size, requiring the use of a scoop to
dislodge them.
_Clinical Features._--The hypertrophy is bilateral, but not always
symmetrical. Sometimes the tonsils project to such an extent as almost
to meet in the middle line; sometimes they scarcely pass beyond the
level of the pillars of the fauces. They are usually sessile, but
sometimes the base is so narrow as almost to form a pedicle. During
childhood they are usually soft and spongy, but when they persist into
adolescence or adult life they become firm and indurated. This
sclerotic change is due to the repeated attacks of catarrhal or
suppurative tonsillitis to which the patient is subject. The lymph
glands behind the angle of the jaw are frequently enlarged. Swallowing
is sometimes interfered with, and the patient is liable to attacks of
nausea and vomiting. Respiration is always more or less impeded; the
patient breathes through the open mouth, and snores loudly during
sleep; and the hindrance to respiration interferes with the
development of the chest. In some cases alarming suffocative attacks
occasionally supervene during sleep, but the difficulty in breathing
disappears as soon as the child is wakened. The voice is
characteristically thick and nasal, especially when adenoids are
present, and in many cases the patient has a vacant and stupid
expression. Hearing is often impaired from obstruction of the
Eustachian tube.
_Treatment._--In early and mild cases, the tonsils should be painted
with glycerine of tannic acid, or some other astringent, and an
antiseptic mouth-wash, or spray of hydrogen peroxide, should be used
several times a day. When the condition is interfering with the
general health or with the development of the chest, or when there is
deafness or disturbance of sleep, the tonsils should be removed.
#Calculi# composed of phosphate or carbonate of lime are sometimes
formed in the crypts of enlarged tonsils; as a rule they are about the
size of a pea, but they may be much larger. They cause a sharp
stabbing pain on swallowing, and sometimes a persistent hacking cough.
They are easily shelled out through a small incision into the tonsil.
#Syphilis.#--The fauces and tonsils are occasionally the seat of a
hard chancre, and the condition may simulate malignant disease. The
submaxillary glands, however, become enlarged sooner and increase more
rapidly than in cancer, and they are tender. The secondary
manifestations of the disease usually appear before the chancre has
healed.
Early in secondary syphilis, mucous patches and superficial ulcers are
frequently met with. Later, severe phagedaenic ulceration sometimes
occurs, especially in alcoholic subjects, and may rapidly eat through
the soft palate, leading to marked deformity from contraction when
cicatrisation takes place.
In the tertiary stage, a diffuse gummatous infiltration occurs, and is
liable to be followed by ulceration, which spreads to the pharyngeal
wall and soft palate, and, by causing cicatricial contraction and
adhesions, may lead to narrowing or even complete occlusion of the
communication between the pharynx and the naso-pharynx.
#Tuberculous# lesions of the fauces and tonsils are almost invariably
secondary to tubercle of the larynx or lungs, or to lupus of the face
or naso-pharynx. They are attended with more pain than syphilitic
lesions; are less prone to spread to the palate and cause perforation;
but, when cicatrisation takes place, they are equally liable to
produce contraction and deformity.
#Tumours.#--_Innocent tumours_--fibroma, lipoma, myoma--are
comparatively rare. When sessile they cause inconvenience only by
their bulk; when pedunculated they may hang down into the pharynx and
interfere with swallowing and breathing. They may be shelled out, or
ligated at the base and cut off, according to circumstances.
_Malignant Disease._--The _tonsil_ is frequently the primary seat of
_lympho-sarcoma_, a very malignant form of round-celled sarcoma. The
tumour is at first confined to the tonsil, which differs in appearance
from simple hypertrophy only in being paler and more nodular. The
growth rapidly infiltrates the peritonsillar connective tissue and
adjacent palatal mucous membrane, which becomes pale and oedematous,
and the condition at this stage may simulate a suppurative
tonsillitis. As it increases, the tumour encroaches upon the cavity of
the pharynx, causing interference with swallowing and breathing; the
mucous membrane soon gives way, and widespread ulceration and
sloughing of the tumour substance occurs, sometimes leading to serious
and even fatal haemorrhage. The patient emaciates rapidly. The adjacent
lymph glands are early infected.
Removal by operation is seldom practicable, but the introduction of a
tube containing radium for several days has in some cases proved
beneficial.
_Carcinoma_ is more common than sarcoma. It may take the form of
_squamous epithelioma_ or of _medullary cancer_, and may originate in
the tonsil, in the groove between the tonsil and the tongue, or in the
soft palate. By the time the patient seeks advice it has usually
implicated the fauces, soft palate, and pharyngeal wall as well as the
tonsil.
Males suffer more frequently than females. The disease may exist for a
considerable time before giving rise to marked symptoms, and attention
may first be drawn to it by pain and difficulty in swallowing, or by
pain shooting towards the ear. In some cases enlargement of the glands
behind the angle of the jaw is the first thing to attract the
patient's attention. The other symptoms are very like those of cancer
of the tongue--pain during eating or drinking, salivation and foetid
breath. Sometimes fluids regurgitate through the nose, and the voice
may become nasal and indistinct. As the patient is usually unable to
open the mouth widely, it is seldom possible to learn much by
inspection, but a digital examination may reveal an irregular, hard,
and ulcerated growth. The swelling is sometimes palpable from the
outside, filling up the hollow behind the angle of the jaw, and in
this situation also the enlarged lymph glands may be felt. These are
often enlarged out of all proportion to the size of the primary
growth. The disease tends to spread locally, causing increasing
difficulty in swallowing and breathing. The patient gradually loses
strength, and may die from exhaustion induced by pain and insomnia,
from haemorrhage, or from septic pneumonia.
In early cases an attempt may be made to remove the disease by
operation. In our experience radium has proved less efficacious in
cancer than in sarcoma.
In advanced cases, it is only possible to relieve the patient's
suffering by palliative measures. Antiseptic mouth-washes are used to
diminish the foetor of the breath and the risk of pneumonia, and
heroin or morphin to relieve pain. The use of the nasal tube, or even
a gastrostomy, may be necessary to enable the patient to take
sufficient food, and tracheotomy may be called for to relieve
dyspnoea.
#Retro-pharyngeal Abscess.#--The _chronic_ retro-pharyngeal abscess
associated with tuberculous disease of the cervical vertebrae, in which
the pus accumulates behind the prevertebral fascia, has already been
described (p. 441).
The _acute_ abscess occurs in the space between the prevertebral
fascia and the wall of the pharynx. The infection usually begins in
one of the lymph glands that occupy this space, and rapidly ends in
suppuration, which spreads to the surrounding cellular tissue. It is
most common in children during the first and second years, and the
patient may be convalescent after one of the eruptive fevers attended
with inflammation of the bucco-pharyngeal mucous membrane--such as
scarlet fever, measles, or chicken-pox--or may suffer from nasal
excoriations or coryza. In some cases the irritation of dentition is
the only discoverable cause.
In infants, the condition is usually very acute, and is attended with
fever, rigors, vomiting, and often with convulsions. The head is held
rigid, and usually twisted to one side, and there is pain on
attempting to move it. The child has great pain on swallowing, there
is regurgitation of food, and the saliva dribbles from the mouth.
There is marked dyspnoea and a short, dry cough. The back of the
throat is red and swollen, and a localised projection, which is soft
and fluctuating, and is usually asymmetrical, may be recognised by
digital examination. Sometimes the voice is lost, and the patient has
severe attacks of choking--symptoms which have led to the disease
being mistaken for membranous laryngitis. In some cases a soft
swelling is palpable on one or on both sides of the neck. Unless the
abscess is promptly opened the condition usually proves fatal. The
mouth is opened by means of a gag, the head allowed to hang over the
end of the table, and the abscess incised, with a guarded bistoury,
through the wall of the pharynx. The dangers associated with opening
the abscess from the mouth appear to have been exaggerated.
A _less acute_ form of retro-pharyngeal abscess sometimes develops in
the course of chronic middle ear disease, the inflammatory process
spreading along the Eustachian tube, in the wall of which an abscess
forms and burrows into the retro-pharyngeal space.