No local after-treatment is required, and spraying or syringing may prove harmful. The patient should remain in the house for five or six days. If nasal obstruction has been the outstanding symptom, respiratory exercises through the nose should be carried out for some considerable time; on the other hand, if Eustachian obstruction and deafness have been the main features of the case, a course of Politzer inflation should be conducted after the wound has healed.

Tumours of the Naso-Pharynx.—Tumours are occasionally met with growing from the muco-periosteum of the basi-sphenoid and basi-occipital, and projecting from the vault of the naso-pharynx—naso-pharyngeal tumour or retro-pharyngeal polypus. This usually occurs between the ages of fifteen and twenty, and while it may originally be a fibroma, it tends to assume the characters of a fibro-sarcoma and to exhibit malignant tendencies. At first the tumour is firm, rounded, and of slow growth, but later it becomes softer, more vascular, and grows more rapidly, spreading forwards towards the nasal cavity and downwards towards the pharynx.

Clinical Features.—In its growth the tumour blocks the nostrils, and so interferes with nasal respiration and causes the patient to snore loudly, especially during sleep. It may also bulge the soft palate towards the mouth and interfere with deglutition. In some cases the face becomes flattened and expanded and the eyes are pushed outwards, giving rise to the deformity known as frog-face. Deafness may result from obstruction of the Eustachian tube. The patient suffers from intense frontal headache, and there is a persistent and offensive mucous discharge from the nose. Profuse recurrent bleeding from the nose is a common symptom, and the patient becomes profoundly anæmic. The tumour can usually be seen on examination with the nasal speculum or by posterior rhinoscopy, and its size and limits may be recognised by digital examination.

Unless removed by operation these tumours prove fatal from hæmorrhage, interference with respiration, or by perforating the base of the skull and giving rise to intra-cranial complications.

Treatment.—These growths are seldom recognised before they have attained considerable dimensions, and owing to the fact that they are permeated by numerous large, thin-walled venous sinuses, their removal is attended with formidable hæmorrhage. Attempts to remove them by the galvanic snare are seldom satisfactory, because the base of the tumour is left behind and recurrence is liable to take place. The operative treatment is described in Operative Surgery, p. 153.

CHAPTER XXVI
THE NECK

Surgical Anatomy.—In the middle line the following structures may be recognised on palpation: (1) the hyoid bone, lying below and behind the body of the lower jaw, on a level with the fourth cervical vertebra; (2) the hyo-thyreoid membrane, behind which lies the base of the epiglottis and the upper opening of the larynx; (3) the thyreoid cartilage, to the angle of which the vocal cords are attached about its middle; (4) the crico-thyreoid membrane, across which run transversely the crico-thyreoid branches of the superior thyreoid arteries; (5) the cricoid cartilage, one of the most important landmarks in the neck. It lies opposite the disc between the fifth and sixth cervical vertebræ, and at this level the common carotid artery may be compressed against the carotid tubercle on the transverse process of the sixth cervical vertebra. The cricoid also marks the junction of the larynx with the trachea, and of the pharynx with the œsophagus; at this point there is a constriction in the food passage, and foreign bodies are frequently impacted here. At the level of the cricoid cartilage the omo-hyoid crosses the carotid artery—a point of importance in connection with ligation of that vessel. The middle cervical ganglion of the sympathetic lies opposite the level of the cricoid. (6) Seven or eight rings of the trachea lie above the level of the sternum, but they cannot be palpated individually. The isthmus of the thyreoid gland covers the second, third, and fourth tracheal rings. As the trachea passes down the neck, it gradually recedes from the surface, till at the level of the sternum it lies about an inch and a half from the skin. The thyreoidea ima artery—an inconstant branch of the anonyma (innominate) or of the aorta—runs in front of the trachea as far up as the thyreoid isthmus. The inferior thyreoid plexus of veins also lies in front of the trachea. In the superficial fascia, cross branches between the anterior jugular veins cross the middle line.

In children under two years of age the thymus gland may extend for some distance into the neck in front of the trachea and carotid vessels, under cover of the depressors of the hyoid bone.

Cervical Fascia.—This fascia completely envelops the neck, and from its deep aspect two strong processes—the prevertebral and pretracheal layers—pass transversely across the neck, dividing it into three main compartments. The posterior or vertebral compartment contains the muscles of the back of the neck, the vertebral column and its contents, and the prevertebral muscles. This compartment is limited above by the base of the skull, and below is continued into the posterior mediastinum. The middle or visceral compartment contains the pharynx and œsophagus, the larynx and trachea with the thyreoid gland, and the carotid sheath and its contents. These different structures derive their special fascial coverings from the processes that bound this compartment. The middle compartment extends to the base of the skull and passes into the anterior mediastinum as far as the pericardium. The connective tissue space around the subclavian vessels is continued into the axilla. The anterior or muscular compartment contains the sterno-mastoid muscle and the depressor muscles of the hyoid bone. It extends upwards as far as the hyoid bone and base of the mandible, and downwards as far as the sternum and clavicle. The arrangement and limits of the different layers of the cervical fascia explain the course taken by inflammatory products and by new growths in the neck.