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.
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.