Deviations of the nose, and especially cosmetic defects which result from injuries or disease, producing the so-called saddle-nose, when not extreme, may often be remedied by the injection of paraffin, the patient being either under cocaine or general anesthesia.
Burns, injuries, and serious ulcerations about the cheeks and lips produce conspicuous disfigurement (perhaps none more so than a serious form of cancrum oris) with a considerable loss of substance. In this way may be produced an acquired microstoma, or adhesion of cheek to jaw, which is known as syncheilia. More superficial lesions may produce ectropion or eversion of the lips, or acquired macrostoma. Cretins, idiots, and patients with facial paralysis acquire gradually a chronic swelling of the lower lip with drooling of saliva. The lip may enlarge to such an extent as to ulcerate as the result of exposure. Frostbite also produces serious deformity by ulceration of the skin. When a puncture of the cheek occurs at the opening of Stenson’s duct, i. e., opposite the second upper molar tooth, there may occur a salivary fistula. In a recent clean wound the duct ends may be stitched together. In old wounds Souchon recommends to introduce catgut into the distal end, and then by pressure on the parotid to discover the proximal end and stitch it with the catgut in the divided portion; or the wound may be enlarged and the proximal end turned into the mouth and there retained.
Considerable emphysema may follow contusions of the face, especially those causing fracture of the nose. In this way a face may be so distended as to produce almost a caricature of its former appearance; this, however, will subside within a few hours.
By virtue of its extreme vascularity wounds and injuries of the face heal with a surprising degree of promptitude and certainty. This affords the reason for the satisfactory results of extensive plastic operations. For the same reason secondary hemorrhages may easily occur and additional precautions should be taken. Exact hemostasis, before closure of wounds, will afford protection as against this event. Wound edges should be neatly trimmed and subcutaneous sutures may often be used to advantage to minimize the resulting scars. A lesson “how not to do it” may be learned from the faces of German university students who have indulged in the common but senseless sport of duelling, and who are said to rub salt and alum into their cuts in order to make the scars as conspicuous as possible.
NEUROSES AND CONSEQUENCES OF INJURIES OF NERVES OF THE FACE.
Anesthesia of parts supplied by the trifacial necessarily follows division of its various portions. It may also occur as the result of a deep-seated or central lesion. In course of time more or less sensibility will return, apparently due to an anastomotic process. Facial paralysis, so-called Bell’s palsy, may be of central origin, or be due to the effects of a “cold” following exposure, apparently with inflammation of and an exudate around the trunk of the facial nerve as it passes through its bony canal in the temporal bone. It is also the result of a division of the nerve trunk either outside of the bone or in the bony canal, where it is occasionally wounded in operations upon the mastoid or in removal of the parotid for malignant tumor. Facial neuralgia is an affection of one or more of the branches of the fifth nerve, and, when assuming a spasmodic and intermittent type, is often spoken of as tic douloureux. Its exciting cause may be a carious tooth, even though it give no pain, while other causes are lesions in the neighborhood, such as callus, foreign bodies, tumors, bone disease, and the like. Its special treatment has already been indicated in the chapter dealing with the Cranial Nerves. Many of these cases of neuralgia gradually diminish the patient’s strength.
ULCERATIVE AND GANGRENOUS LESIONS OF THE FACE.
The serious ulcerative lesions of the face are usually due to tuberculosis, syphilis, or malignant disease. In all of these conditions there will be enlargement of the neighboring lymphatics. This is true also of the lesions of actinomycosis, which should not be forgotten as a possible cause. The free border of the lips is occasionally ulcerated in patients with pulmonary tuberculosis. Otherwise tuberculous lesions are uncommon upon the lower lip, while in the upper lip they show a tendency to invade and spread. Syphilitic ulcers may be either primary chancres, which are most common on the lower lip, or the results of mucous patches, or other secondary or tertiary lesions. Of the cancerous ulcerations, which tend always to break down and spread, without any tendency to healing in the centre, epithelioma is the most common form. It is a frequent disease in men, occurring much oftener on the lower than upon the upper lip. In women it is exceedingly rare at this point. The difference is explained by the liability to constant irritation incurred by those who smoke pipes or are particularly careless about their teeth. Of epithelioma there are, as is well known, various types, including the so-called rodent ulcer, which, however, is less frequent here. The location of the lesion subjects it to constant irritation, as well as maceration from the moisture of the mouth. Such a growth may be superficial and raw, or it may be covered by scale or crust. It will nearly always have an indurated and raised periphery. A papillary form, with non-indurated edges, is also known, as well as a diffuse form, where several minute lesions seem to coalesce, with elevation of the central portion. This is perhaps the most malignant of all, as it has no well-defined boundaries. In nearly every well-marked case involvement of the submaxillary lymphatics can be detected. All of these cancers of the lip and face should be removed, with plastic re-arrangement of the parts. Growths of this kind seen early, before much tissue is involved, can be removed with permanent success. Error is made on the side of not doing sufficient rather than doing too much. (See [Chapter XXVI].)
Cancrum oris has already been described in the chapter on Gangrene. The extensive destruction which it may cause is also described there. The condition, when seen and recognized early, has been successfully treated by local applications of bromine and the actual cautery. It is, however, a destructive and unpromising condition with which to deal, as it rarely occurs in healthy children, but usually in those with a constitution already vitiated by heredity or environment. (See [p. 75].)