The surgical afiections of this region are numerous. They may be considered in the following order: <Callout type="important" title="Important">1. Congenital deformities.</Callout> — Hare-lip is readily recognized; it may be uni- or bilateral, simple when it involves the soft structures only, alveolar when the maxilla is also cleft, and complicated when there is an associated cleft of the palate. Very rarely is the cleft central in position. In some cases of hare-lip the lower lip is the site of mandibular recesses, i.e., two short sinuses opening on either side of the central point of the lip. As rare facial deformities may be mentioned lateral facial cleft, i.e., a fissure extending from the lip up the side of the nose to the inner canthus, sometimes laying open the nasal duct and often associated with a <Callout type="important" title="Important">Goloboma of the iris.</Callout> And macrostoma, a condition in which the mouth extends outwards as a cleft for a varying distance through the cheek. <Callout type="warning" title="Warning">2. Ulcers.</Callout> — Notice particularly the age of the patient, the duration and mode of onset of the disease, the character of the ulcer — whether single or multiple, whether the edge is undermined, punched out, or thickened, whether the base is indurated smooth, sloughy, or irregular and fungous — and the condition of the associated lymphatic glands. In some cases it is necessary to examine the discharge for the Sfironema fallidum, and to apply Wasser- mann's test to the blood. <Callout type="important" title="Important">i. If the ulcer is single, of short duration, with distinct induration of the edge and base, and the surface is abraded, ulcerated, or covered with a very thin whitish slough, and several of the glands are enlarged, firm, and freely movable under the skin, it is a hard chancre. The diagnosis should be established by finding the Sfironema fallidum in the discharge. This afiection is more common on the upper lip than the lower, and in women than men. A chancre of the lip is, as a rule, accompanied by swelling and eversion of the whole lip, its induration is more spongy than in genital chancre, and the enlargement of the submaxillary glands is considerable, much greater than of those of the groin. The presence of signs of secondary syphilis will confirm the diagnosis.</Callout> <Callout type="important" title="Important">ii. If the ulcer commenced in early life, has been very chronic and slow in its progress, and was preceded by soft, raised, apple-jelly-like nodules, some of which are also found scattered around it, it is lupus. There may be other signs of tuberculosis. The lymphatic glands of the neck may be normal, and if enlarged this is not secondary to the lupus nor is it limited to the immediately associated glands. The discharge often forms adherent crusts.</Callout> <Callout type="important" title="Important">iii If the ulcer originated in firm, red, angry-looking nodules, which quickly broke down into ulcers with a punched-out appearance, with sharply cut edge and sloughy base, and the lymphatic glands are not enlarged, it is a lesion of tertiary syphilis. A positive Wassermann reaction and other cadences of syphilis should be sought for to confirm the diagnosis. Syphilis is much more, and more rapidly, destructive than lupus.</Callout> <Callout type="important" title="Important">iv. If the ulcer commenced in a small crack or wart, and the base and edge of the ulcer are thickened and firm, the former being irregular or granular in appearance, and if the associated lymphatic gland is enlarged, it is epithelioma. This ulcer is usually single, but it may occasionally be multiple; e.g., more than one epitheliomatous ulcer of the lip, or epitheliomata on the opposing surfaces of the two lips, may be seen. The patient is usually past middle age.</Callout> <Callout type="important" title="Important">v. An ulcer occurring in a person past middle life, which slowly and steadily progresses, with a smooth base, with a very narrow line of induration around the edge, and without any enlargement of the lymphatic glands, is a rodent ulcer. Such an ulcer may exist for many years, and cause wide and deep destruction of tissue, and a great chasm in the face. It may heal up and then break out again. It commences in a flat papule, and is most common at the side of the nose, on or near the lower eyelid, or near the angle of the mouth.</Callout> 3. Acute inflammation and gangrene. There are three varieties of acute gangrene of the face that must be distinguished from one another, viz. cancrum oris, cmlhrax, and carbuncle. If in a child, during or just after an attack of one of the exanthemata, one cheek becomes acutely swollen and an ulcer is found on the mucous surface, the base of which sloughs, and the ulceration and sloughing rapidly extend, it is cancrum oris or noma. The ulcer may perforate the cheek and cause extensive destruction of soft parts and necrosis of bone. The tongue is thickly coated, the breath very foul, and the temperature and pulse-rate are both high. A flat, slightly raised, livid lump on the face or neck, with a central black slough, surrounded by a ring of vesicles which are at first separate and quickly coalesce with the central swelling, is the 'malignant pustule' of anthrax. The source of infection can be traced to contact with horses, furs, or hides. Constitutional disturbance follows the local lesion after an interval of a day or two; it may end in septicemia. The Bacillus anthracis can be detected in the fluid of the vesicles. A firm, painful, and edematous swelling of the skin and subcutaneous tissue, in which foci of suppuration quickly appear, accompanied from the first by a rise of temperature, is a carbuncle. Extensive sloughing occurs, firm and tender lymphatic or venous cords are felt, the neighbouring glands are swollen and painful. Staphylococci are found in the pus. The disease runs a more rapid course and is more serious when it is situated on the face than when it occurs elsewhere. Erysipelas of the so-called idiopathic variety, i.e., arising in the absence of a demonstrable breach in the skin, is prone to occur upon the face. The constitutional symptoms vary in different cases from only slight pyrexia to high fever and delirium. [See p. 28.] 4. Sinus.— If a sinus in the cheek discharges a thin watery fluid, which streams out during mastication, it is a salivary fistula. The nature of the fluid should be tested by its amylolytic action. The patient may notice a dryness of the mouth on the same side. <Callout type="important" title="Important">If the sinus is puckered in and adherent to the bone, it should be carefully explored with a probe for necrosed bone or a carious tooth. In all such cases the teeth should be carefully examined. A skiagram will be useful.</Callout> 5. Fluctuating tumours, i. Acute.— If a rumour immediately follows an injury, and is attended by bruising of the skin, it is a hematoma. These tumours sometimes give a creaking sensation to the fingers. If attended by the signs of acute inflammation, the swelling is an abscess. <Callout type="important" title="Important">ii Chronic— If painless, globular in outline, adherent to the skin, and freely movable over the deeper structures, the tumour is a sebaceous cyst. These cysts are most common in the region of the whiskers. A cyst with these characters, except that it is not adherent to the skin, especially if it occurs in a young person, IS a dermoid cyst Such a cyst is commonly situated at the outer or inner angle of the orbit or at the side of the nose. A cyst in the cheek, which becomes more tense during mastication, is a salivary or parotid cyst If the cyst is deep beneath the Zecf/T//^, be difficult or impossible to detect fluctuation in it, and it is then liable to be mistaken for a solid growth. The outline and elastic consistence are unlike solid growths, and if any variation in size with mastication is observed it makes the diagnosis certain. A cyst under the mucous membrane of the lip, with bluish colour, IS a mucous labial cyst.</Callout> 6. Swellings in the parotid region.— This region is bounded above by the zygomatic arch and below by the angle of the mandible; it is limited laterally by the external pterygoid muscle and medially by the ramus of the mandible. The gland may be enlarged by simple inflammation, by tuberculous disease or by secondary malignant disease. A tubercular swelling may be solid or softened down into a fluctuating swelling. A cancerous growth may be fixed to the parotid gland and to the skin. <Callout type="important" title="Important">ii A general acute swelling of this region, with tenderness and pain increased in mastication and attended with fever, is acute parotitis. If occurring unmanly, affecting both glands, and accompanied by a mild febrile course, it is mumps. This generally occurs in children or young adults; an attack often affects several members of a family. The submandibular and sublingual glands, as well as the testicle, ovary, or mamma, may also be affected. Parotitis is met with, too, as a sequela of acute fevers, or in septicemia and pyrexia, and is still very occasionally encountered after abdominal operations. If the surface becomes cedematous and the pain and tension increase, and especially if rigors occur or fluctuation can be detected, there may be a growing tumour situated below and in front (sometimes behind) the lobule of the ear, movable under the skin and in the parotid gland. Its mobility in the parotid hand varies with the position and depth of the tumour; if part of the tumour lies deep in the gland between the ramus of the mandible and the external pterygoid muscle, it may be difficult to detect fluctuation. Being soft fibrous and sarcomatous tissue being found and cartilage being very firm or hard, all structures, and sometimes also adenomatous tissue, are found in this situation. <Callout type="important" title="Important">iii A chronic but staccato swelling 1 of the parotid gland and firm in consistency is a malignant tumour of the parotid, usually carcinoma. Later on it becomes fixed to the bones and the skin, it may ulcerate and fuiigate on the face, and be attended by secondary enlargement of the cervical glands. Severe pain in the ear and up along the side of the head, inability to open the mouth, facial palsy, and deafness are characteristic effects.</Callout> 7. Other affections of the lips.— A congenital thickening of one lip, due as a rule to the presence within it of dilated lymph-spaces, is known as macrocheilia. A chronic thickening of the lip, leading to eversion of its red border, and associated with slow superficial ulceration of its mucous surface, may be a part of the so-called strumous diathesis—strumous hypertrophy—or may be due to syphilis; the history of the case, the characters of associated lesions, and the Wassermann reaction enable the distinction to be made between these two causes. Small, firm, shot-like nodules felt under the mucous membrane of the lip are adenomata of the mucous glands of the lip Larger tumours in this situation, if fluid, are mucous cysts, and if solid are labial tumours, often containing myxomatous tissue and cartilage as well as glandular tissue and small cysts. Groups of small clear vesicles on a bright-red base, drying up into a thin yellow or brown scab, and attended with itching and smarting are herpes. Chronic fissures at the angle of the mouth, with a watery discharge, are syphilitic rhagades; they are often seen in children the subjects of inherited syphilis and they leave behind puckered scars. Flat, slightly raised patches of mucous membrane of a pale bluish-white colour are mucous patches. Irregular fissure-like ulcerations of the mucous surface, chronic in character, and painful, are syphilitic ulcers. Corroboration of the diagnosis in these last three cases should, of course, be sought in other syphilitic manifestations, in the detection of the Sfironema pallidum, or in Wassermann reaction. Small whitish spots on the mucous surface, which terminate in very superficial circular abrasions or ulcers are aphthi; adjacent ulcers may coalesce. They are attended with pain, soreness, and increased flow of saliva. Thrush may be found on the lip in the form of opaque white streaks and patches not causing ulceration. If the white material is removed, and examined microscopically, its found to contain the fibres and spores of a fungus, Candida albicans.</Callout> 8. If a patient has an acute, painful and very tender oedematous swelling over fther jaw it is probably an alveolar abscess (See p. 384.)
Key Takeaways
- Identify congenital deformities like hare-lip and macrostoma.
- Recognize ulcers by their characteristics, such as hard chancre or lupus.
- Distinguish between acute gangrene types: cancrum oris, cmlhrax, and carbuncle.
- Diagnose parotid swellings for potential malignancy.
- Differentiate between various lip tumors and cysts.
Practical Tips
- Always examine the lymph nodes when diagnosing ulcers on the lips to rule out secondary syphilis or tuberculosis.
- For suspected cancerous growths in the parotid region, perform a skiagram for further evaluation.
- Use the Wassermann reaction and other tests to confirm diagnoses of syphilitic conditions.
Warnings & Risks
- Be cautious when diagnosing ulcers on the lips as they can be indicative of serious systemic diseases like syphilis or tuberculosis.
- Avoid misdiagnosing a rodent ulcer, which can cause extensive tissue destruction and disfigurement if left untreated.
- Do not overlook the possibility of malignant tumors in the parotid region; early detection is crucial.
Modern Application
While many of the techniques described in this chapter are historical, the principles of recognizing and diagnosing diseases affecting the lips and face remain relevant. Modern practitioners can apply these diagnostic methods to identify potential health issues during survival scenarios or in remote areas with limited medical resources.
Frequently Asked Questions
Q: How can one differentiate between a hard chancre and other ulcers on the lip?
A hard chancre is typically single, of short duration, with distinct induration of the edge and base. Its surface may be abraded or covered in a thin whitish slough, and several associated lymph nodes are often enlarged and firm. This condition is more common in women than men and can be confirmed by finding Sfironema fallidum in the discharge.
Q: What are some signs of lupus that should be noted during diagnosis?
Lupus ulcers usually commence in early life, have a very chronic and slow progression, and are preceded by soft, raised, apple-jelly-like nodules. These nodules may also be found scattered around the ulcer. The lymphatic glands of the neck may be normal or enlarged but not limited to the immediately associated glands.
Q: How can one confirm a diagnosis of syphilis in cases where ulcers are present?
To confirm a diagnosis of syphilis, look for signs such as hard chancre, lupus, and tertiary syphilis. A positive Wassermann reaction or other tests for syphilis should be sought if the ulcer is suspected to be related to this disease.
Q: What are some common congenital deformities of the lips that need to be recognized?
Common congenital deformities include hare-lip, which can be unilateral or bilateral and may involve the soft structures only or extend to the maxilla. Other rare conditions like lateral facial cleft and macrostoma should also be noted.
Q: How can one differentiate between a salivary fistula and other types of sinus in the cheek?
A salivary fistula discharges a thin watery fluid during mastication, which can be tested for amylolytic action. If the sinus is puckered in and adherent to the bone, it should be carefully explored with a probe for necrosed bone or a carious tooth before concluding that it is a salivary fistula.