Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

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 œdematous, 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 hæmorrhage. 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 fœtid 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 hæmorrhage, 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 fœtor 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 dyspnœa.

Retro-pharyngeal Abscess.—The chronic retro-pharyngeal abscess associated with tuberculous disease of the cervical vertebræ, 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 dyspnœa 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.