CHAPTER XXXI DIAGNOSIS OF DISEASES OF THE MOUTH (Part 1)

CHAPTER XXXI DIAGNOSIS OF DISEASES OF THE MOUTH TONSILS, FAUCES, AND OESOPHAGUS The mouth.— The inside of the cheek may be the seat of mucous patches, of white patches of thickened epithehum (leucoplakia), exactly like and generally accompanying the same affection of the tongue of syphilitic or peptic ulceration, of papilloma, sub- mucous fibroma, and of epithelioma. An acute superficial and very painful ulcer of the mucous membrane of the mouth, with a bright-red edge and a grey base, is a peptic ulcer. These ulcers are often multiple and recurrent, and are found in the subjects of chronic indigestion. Mucous patches are recognized by their being slightly raised, and whitish in colour, and by finding the ^'ipnvnema falhdum in the discharge on the surface or m the fluid obtained by lightly scratching the sur- face There are usually other evidences of secondary syphilis, and the Wassermann reaction is positive Syphilitic ulcers are irregular, sinuous, often ser- piginous, with raised, sharply cut edges, and leave firm, depressed cicatrices. Papilloma occurs as either a sessile or peduncu ated outgrowth of the mucous membrane. dTs- tmgu.shed from epithelioma by the absence o any infiltration of the submucous tissues. UlceratioJ ni^^ .suit from iniury to the tumour . ^mg 431 432 SUEGICAL DIAGNOSIS [chap. Submucous fibroma occiu-s as a firm nodule, covered by healthy mucous membrane, which grows slowly aird tends to become pedunculated. Epithelioma here as elsewhere is known by the infiltration of the mucous and submucous tissues, the warty, ulcerated surface, and the early infection of the lymphatic glands. A foreign body or a salivary calculus may be seen or felt in the orifice of Stenson's duct (ductus paro- ticus), or pus may be seen flowing from.it. Epithelioma is often met with in the floor of the mouth, usually starting close to the fragnum lingua;. It is recognized by the signs enumerated m con- nexion with epithelioma inside the cheek; there is also gradual fixation of the tongue, and the dis- eased surface becomes fixed to or spreads over the jaw. Salivation, pain, and foul discharge are late accompaniments. On passing the finger along the groove be- tween the tongue and the jaw a hard, shghtly tender swelling may be found ; this is a salivary calculus. The patient will usually complain of pam and stiffness about the part, and the submaxil- lary gland may be foimd enlarged, and may be noticed to swell with each meal and to subside in the intervals. n j_ x- A more or less globular, smooth, fluctuatmg swelling in the floor of the mouth, displacmg the tongue and interfering with its movements, will be recognized as a sublingual cyst; three varieties can be distinguished : i • 1 If the cyst appears m the mouth only, is covered with thin healthy mucous membrane, and has a transparent bluish appearance, it is a mtimis cyst, or ranula. , , , , 2. If the cyst is in the middle Imc, Inilgcs below xxxi] diseases op PALATE 433 the symphysis of the jaw as well as in the mouth, and has a dull white or yellow colour when seen through the mucous membrane, it is a dermoid cyst of the ihyro-glossal duct. 3. If the cyst has these same general characters, but is under the side of the tongue and projects in the neck imder one half of the jaw only, it is a branchial dermoid cyst. A soft, lobulated, movable tumour in this situa- tion is a lipoma. The palate. — In examining the palate, notice first its general form and integrity. A narrow, highly arched palate is the result of imperfect development, often associated with adenoids, sometimes due to congenital syphilis. Congenital clefts are recognized by their median position ; they may involve the uvula only, or uvida, soft palate, and just the posterior margin of hard palate, or may extend forwards to the alveolar process. Clefts in the alveolar process are not median, but on one or both sides of the inter- maxillary bone. There may be a cleft of the alveolar process only, not involving the palate proper. An acquired perforation of the palate is almost invariably the residt of syphilitic ulceration and necrosis ; in a very few cases it is the result of injury or operation. Its position, its shape, and the presence of scar tissue distinguish such a perforation from a congenital cleft. If the soft palate is of a bright-red colour and the patient has little or no pain in it, examine care- fully for other signs of secondary syphilis ; yajyules or slightly raised fiat bluish mucous patches are often seen in this stage o' the disease. Ulcers of the palate. — If the ulcer is superficial covered with pale granulations, and painful, it is probably tuberculous, and if the patient has tuJjer- 434 SURGICAL DIAGNOSIS [chap. culous disease of the tongue, laryux, or lungs, or if the tubercle bacillus is found in the secretion of the ulcer, the diagnosis is certain. A chronic ulcer starting behind the molar teeth, creeping over the pala*:e, healing at one edge and spreading at the other, is a tertiary syphilitic ulcer. If an ulcer in the palate is deep, with sloughy edges and base, or with necrosis of the bone, it is a gummatous syphilitic ulcer. These ulcers are often very extensive, and involve the pharynx as well as the palate, and when they heal they leave perforation of the palate and cicatricial deformity. A positive Wassermann re- action will support the diagnosis. If an ulcer in the palate has a firm infiltrated edge and base, and the surface is uneven, or raised and warty, discharging a foul sero-purulent fluid, it is an epithelioma. In- filtration of the lymph-glands at the angle of the mandible and beneath the upper part of the sterno- mastoid muscle, the insidious origin and steady ex- tension of the disease, and the age of the patient are important aids to diagnosis. A single ulcer in the palate, raised above the general surface, with a firm base and smooth surface, is most probably a hard chancre ; the diagnosis will be rendered certain by the discovery of several firm, movable glands in the neck, by the detection of the spiro- nema in the discharge from the chancre, and by the subsequent outbreak of secondary syphilis. Swellings of the palate. — A fluctuating swelling close to the alveolar process is mo.5t probably an alveolar abscess ; such an abscess may be acute, subacute, or recurrent. It may have burst into the mouth and be represented by a sinus discharging a little pus and leading down to a carious fang. Such a swelling may be a very soft sarcoma ; this is shown by punc- ture o[ the swelling yielding blood and not pus. XXXI] ENLARGED TONSILS 435 A solid tumour of the palate may be a gumma, an adenoma, or a malignant tumour. If it is softening in the centre, or ulcerating and sloughing, and the Wassermann reaction is positive, it is a gumma. If the tumour is well defined, covered with healthy mucous membrane, has grown slowly, or has been stationary for a time, and if it evinces no tendency to soften or to ulcerate, and is hmited to the oral surface of the palate, 'it is an adenoma. If the tumour ^has grown rapidly, infiltrates the mucous membrane, or fimgates through it, and extends into the alveolar process, nose, or antrum (maxillary sinus), it is a malirjna^it tumour. The hard palate is often depressed by tumours growing in the antrum [see p. 387). If a patient is taken acutely ill with dysphagia and dyspnoea, and the throat shows some swelling from the outside, while the soft palate is greatly swollen and cedematous, so as to conceal the back of the pharjmx, the condition is acute cedematous pharynfjitis. The tonsils. 1. Enlargements. — If the swelling is acute the surgeon must inquire whether it is in- creasing or diminishing, and he should notice the colour of the mucous membrane, the presence of false membrane, ulcers, or sloughs, also whether any part of it is " pointing," soft to the touch, or even fiuctuatmg, and whether there is surrounding oedema. The temperature and general condition of the patient must be carefully observed. When the swelling is chronic, _\ts duration, its mode and rate of growth, Its consistence, the limitation of the enlargement to the tonsil or its extension to the palate and pharynx the condition of the mucous membrane, and the state of the cervical lymphatic glands, are the points to be observed. 436 SURGICAL DIAGNOSIS [chap. i. Wlieu the tonsil is acutely swollen, deep red in coloiu', with osdema of the anterior pillar of the fauces, and the patient is febrile, with great pain in swallowing and discomfort from sticky mucus about the fauces, it is acute farenchymalous tonsillitis. If the swelling is increasing, with severe throbbing pain, and part of the tonsil is found soft, poiut- ing or fluctuating, there is an abscess of the tonsil, commonly known as quinsy. Where small yellow- ish-white" pea-like swellings, or ulcers formed by the bursting of small abscesses, are found on the surface, it is follicular tonsillitis. Follicular ulcers may coal- esce into larger ulcers with undermiued and swoUen edges. When there is any appearance of false membrane or of acute ulceration of the surface, a "swab" should be taken and submitted to careful bacteriological examination, particularly to determine the presence of the Klebs-Loffler bacillus of diph- theria, or the fusiform bacillus of Vincent and the Spironema dentium, the two organisms associated in Vincent's angina. In diphtheria the membrane spreads rapidly from the tonsil on to the palate ; in Vincent's angina it remains confined to the tonsil. In both there is moderate fever and enlargement of the cervical lymph-glands. ii. When the tonsil is chronically enlarged the surgeon has to distinguish between hypertrophy and malignant tumour. If the enlargement affects both tonsils, or, affecting only one, is limited to the tonsil, which is of a healthy pink colour, often much pitted on the suiiace, enlarging slowly, or quite stationary, and not causing pain unless it becomes acutely inEamed, it is liypeHrofhy. iii. When one tonsil is enlarged, the swelhng being steadily progressive, and attaining a large size, involving the pillars of the fauces as well as the xxxi] TONSILLAR ULCERS 437 tonsil, and covered with livid or very thin nmcous membrane which may be iiJcerated, and there is enlargement of the lymphatic glands behind the angle of the jaw, the disease is malignant tumour. These growths are usually softer than hypertrophy. Both sarcoma and carcinoma affect the lymphatic glands, and to distinguish between them may be impossible. In young persons the disease will be lij>npko-sarco)na, but in persons past middle life it may be carcinoma ; this is the rarer of the two diseases. The tumours when large ulcerate, and may fimgate, and bleed freely. 2. Ulcers. — i. Small circular yellowish-grey ulcers formed by the bursting of tiny abscesses are follicular ulcers. ii. A superficial ulcer, attended with slight red- ness of the fauces and no induration, is probably a secondary si/philitic ulcer, and the Sjnronona jMllidum should be searched for. The tonsil is a frequent seat of mucous 'patches. iii. If the ulcer is deep, with abrupt, sharply-cut edges and a dirty-grey base, and without well-marked surrormding induration or glandular enlargement, it is a gummatous ulcer. iv. If the ulcer is single, indolent, with well- marked induration around it, and several glands under the jaw and down the neck are enlarged, hard, but quite movable, it may be a hard chancre. The occurrence of secondary manifestations will, of course, corroborate the diagnosis. The Spironema fallidum should be sought for, to make an early diagnosis certain. v. If the ulcer is single, has a firm, uneven or warty base and thick everted edge, and spreads from the tonsil to the tongue or palate, and the glands at the angle of the jaw and under tlie upner 438 SURGICAL DIAGNOSIS [chap. part of the sterno-mastoid muscle are enlarged, it is epithelioma. The naso-pharynx is examined by noting the freedom or otherwise of nasal respiration, the pre- sence of discharge running down the pharynx fi-om behind the soft palate, or the bulging of a tumour in that situation, by looking at the part as reflected in a mirror passed behind the palate, and — best of all — by feehng with the finger. In children obstruc- tion to nasal respiration interferes with the develop- ment of the nose and face. In all patients growths in the naso-pharynx quickly cause deafness, and mahgnant growths in this situation, by extendmg into the cavity of the skull, may cause the symp- toms of a cerebral tumour. 1. Where a child has a " na.sal " voice, a narrow nose, keeps the mouth open with the upper lip drawn up over the incisor teeth, breathes heavily, and snores at night, the presence of adenoids is to be feared. If with a mirror soft lobulated masses are seen sprouting from the back of the pharynx, or if they are felt with the finger, the diagnosis is assured. These patients often suffer from epistaxis and deaf- ness, and sometimes from morning sickness caused by the swallowing of pharyngeal mucus in the night. 2. Adults with a " nasal " voice, oral breathing, a very narrow nose, and narrow high-arched palate, with the teeth crowded in the ill -developed maxilla, are suffering from the ill effects of adenoids in early life, even though none may be seen or felt in the naso-pharynx. 3. A smooth, pale-blue or yellow, rounded, very soft swelling seen or felt hanging down behind the soft palate is an antro-choanal polyp {see p. 428). 4. A growth in the naso-pliarynx which is firmer than adenoids, or ulcerated, and is attended with xxxi] PHARYNGEAL EPITHELIOMA 439 deafness in one ear, fixation of the soft palate on the same side, inability to open the mouth widely, and trigeminal neuralgia, is an endothelioma. There is usually nasal obstruction on one side at least, and occasional hiemorrhage. The glands beneath the upper part of the sterno-mastoid muscle very soon become enlarged and fixed, and lose all definite out- line. The patient is almost always a male, and very often a youth. The pharynx. — The mucous membrane may be acutely inflamed as an extension of an acute in- flammatory condition of the nose, mouth or fauces. Chronic inflammation is not uncommon in heavy smokers and public speakers, the mucosa being congested and streaked with tenacious mucus, or pale and dotted with enlarged follicles. Syphilitic ulcers occur in the pharynx. Fibroma, adenoma and myoma are very rare, but may occur as either sessile or pedunculated growths. " ; .1 An acute swelling bulging forward the posterior' pharyngeal wall, and producing difficulty in breath- ing and swallowing, is an acute retropharyngeal abscess. In a child this results from an acute in- flammation of the retropharyngeal lymphatic glands secondary to some focus of infection in nose or face, in an adult, these glands have disappeared, and the abscess is most probably the direct result of an infected wound of the pharyngeal wall. A chronic soft, rounded, bulging forwards of the posterior wall ot the pJiarynx is a chronic retropharyngeal abscess or an aneurysm. Feel it carefully fur pulsation, which (S" p 402^'" ^'o^i^^itrons. Pharyngeal epithelioma.-Thcre are important differ- ences in this disease as it arises above the opening, of the larynx, ,n the sinus pynformis, or below the 440 SURGICAL DIAGNOSIS [chap. opening of the larynx. Epilaryngeal epithelioma starts in the epiglottis or in the aryteno-epiglottic fold, and spreads circularly around the pharynx. It gives rise to hoarseness, dyspnoea, and dysphagia quite early in the course of the case. Efithelioma of the si?ius fyriformis is for a long time concealed - within this deep cavity and is very liable to be overlooked. Its signs at this stage are slight hoarse- ness, oedematous swelling of one aryteno-epiglottic fold, the discharge of muco-pus from between this swelling and the side of the pharynx, a firm swell- ing of the thyroid cartilage on the same side, as felt from the neck, and, very early, enlargement of glands along the carotid sheath. Hypolanjn- cjeal epithelioma is attended with early and marked dysphagia. It occui's in middle-aged women, while the other two forms are met with almost exclusively in men. In all forms the lymphatic glands are in- fected early, and their enlargement may be the first thing that attracts the patient's attention. The cesophagus (gula).— The most constant symptom of diseases of the ossophagus is dysphagia, and it will be convenient, therefore, to deal with the diagnosis of affections of the gullet in the form of a discussion of the investigation of a case of dysphagia. Dysphagia may be caused (1) by spasm or paralysis of the muscles of the tongue, palate, pharynx, or gullet; (2) by obstruction to the lumen of the pharynx or gullet, whether due to (a) swelling of its walls, {h) narrowing of its lumen, (c) pressure upon it from without, or {d) extension into it of growths ; (3) by pain in the act of swallowing, due to either [a) pain in the muscles involved, [h] sensitiveness of the surface over which the bolus passes, or (c) sensitive- ness in the parts which move in swallowing. xxxi] DYSPHAGIA 441 In investigating a case of dysphagia the surgeon should first notice the age and sex of the patient, the mode of onset, whether gradual or abrupt, the duration of the difficulty, and the amount of accom- pan}'ing wasting. He should himself see the patient swallow, and examine any regurgitated food and fluid, noticing its amoimt, reaction, and odour. The mouth, the neck, and the chest should be carefully examined to detect any swelling, enlargement of glands, displacement of parts, and, especially, evi- dence of aortic aneurysm. The history of the