The evacuation of the abscess through the mouth was formerly looked upon as dangerous, owing to the difficulty of drainage, the fear of pus burrowing behind the œsophagus, and the risk of flooding the larynx with pus. The more difficult plan of opening it from the neck was generally recommended. The majority of cases can be opened through the mouth with perfect safety.
No general or local anæsthetic is administered, but everything necessary for an immediate tracheotomy should be ready at hand. No gag should be employed, a tongue depressor or the operator’s left forefinger being sufficient both to keep the mouth open and act as a guide. The infant is swaddled in a shawl so as to completely control the movements of the extremities and is then laid on its side on a low pillow, and held by a trustworthy assistant. The sinus-forceps used for opening a peritonsillar abscess are thrust into the most prominent part of the swelling, and the opening enlarged by separating the blades as they are withdrawn. A slender sharp-pointed bistoury, guarded and guided by the index-finger, may be used instead of the forceps. The pus will pour out through the nose and mouth. The incision of the pharynx should be free, deep and long, and directed against the posterior wall of the pharynx and as close to the median line as possible, so as to avoid any chance of wounding the internal carotid.
The surgeon may feel more security if, with the same precautions and with the patient in the same position, he first aspirates the pus cavity.
If more accustomed to it, he may also prefer to have the child flat on its back, with the head overhanging the edge of the table.
Suffocation may be so imminent when the patient is first seen that a preliminary tracheotomy is required.
The external operation, which leaves a certain scar, is reserved for some rare cases—as when the abscess is too low to be easily reached through the mouth, when the spasm of the masseters cannot be overcome, when a large pulsating vessel is noticed in front of the abscess, and when the abscess points towards the neck. It is also the suitable one for the chronic and generally tubercular form of abscess more commonly met with in older patients.[89]
The external operation is made through an incision along the posterior border of the sterno-mastoid muscle, and the dissection is carried behind the large vessels of the neck and in front of the prevertebral muscles.
After-treatment. The after-care of the patient will require consideration, since the disease is generally met with in the feeble and ill nourished.
If the abscess be opened in good time the patient is at once relieved and begins to recover rapidly.