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cartilaginous portion, but not actually on to the tympanic membrane, a portion of the bony meatus must also be removed. This is done

by means of a gouge and hammer, a tube of bone being taken away, along with the cartilaginous meatus. The bleeding is arrested and the wound. brought together above and below, leaving a central cavity, at the bottom of which is the tympanic membrane. The auricle is then stitched back into position and skin-grafts may be placed over the cut surface of bone around the tympanum to promote immediate healing, and to maintain a passage leading to the membrana tympani.

When the disease has penetrated through the cartilaginous meatus and extends into the tissues around, especially the parotid, it is best not to operate in the majority of cases. If operation be undertaken it will be necessary to excise the parotid gland completely, and not to make any attempt to remove the diseased portions alone or to pick out the infected Unless the entire parotid gland is removed, the disease is certain to recur almost immediately.

[graphic]

FIG. 268.- PLASTIC OPERATIONS

FOR

The

REDUCING THE SIZE OF THE AURICLE.
lines abc show the incisions for reducing the
vertical dimensions of the ear; while de, fg,
dg represent those necessary to reduce its
transverse measurement.

glands.

WOUNDS OF THE PAROTID GLAND.

Wounds of the parotid gland are of importance because they may injure the external carotid artery and its branches, the facial nerve or the salivary ducts.

TREATMENT.-So far as the wound is concerned, the treatment is similar to that for accidental wounds elsewhere. The essential points to be considered in connection with these injuries are the three complications just mentioned.

Of Hæmorrhage. When a large vessel has been injured, the wound should be carefully enlarged, avoiding, if possible, any damage to the facial nerve. The opening should be enlarged in a transverse or oblique direction rather than vertically. When the parotid gland has been exposed, a flat dissector may be used to separate the parotid tissue itself, so as to avoid injury to the facial nerve. In most cases it is not advisable to enlarge the wound sufficiently to apply a ligature to a deep-seated vessel, as the chance of injuring the nerve is very great;

if the bleeding point can be caught in a pair of forceps, the latter should be left on for twenty-four hours, and this will ensure the occlusion of the vessel. If the bleeding is venous, it is only necessary to introduce a gauze plug down to the bleeding point.

When the terminal portion of the external carotid artery itself has been divided, the condition is very serious, because the vessel is deeplyseated, difficult to expose, and almost impossible to ligature without damage to the facial nerve. Hence, in very severe arterial bleeding from a wound of the parotid, it is best to compress the bleeding point with the finger and then expose the external carotid artery at its origin (see Vol. II. p. 204). A ligature is passed around it, but not tied. The artery may then be constricted by pulling upon the ligature, so that the wound can be sponged free from blood, and another effort made to catch the divided end. If the vessel is only partially divided, it must be cut across completely. If the bleeding cannot be controlled in this manner, a vertical incision must be made close in front of the auricle extending upwards and dividing the skin and fascia; the capsule of the parotid gland is then opened and the gland pulled forward, so as to expose its deeper surface and the vessels in that situation. The bleeding point can then be got at, and dealt with. When, however, the surgeon does not wish to perform this operation, the ligature round the external carotid should be tied and the wound in the parotid plugged for a couple of days, so as to prevent bleeding from the upper end. The plug may then be withdrawn and the wound sutured; if, however, there is much contusion, it is best to leave the wound open. This method of arresting the hæmorrhage is not a good one, however, as secondary hæmorrhage is very apt to occur when the sloughs separate.

Of Division of the Facial Nerve. When the facial nerve has been divided after it has broken up into its terminal branches, there is little hope of getting satisfactory union. If, on the other hand, the injury occurs behind this point, a careful search should be made for the cut ends, and they should be united with fine catgut (see Vol. II. p. 116). The chances of success, however, are not good, because it is not easy to identify the distal end or to bring the two ends together if they are found. To do this, it is better to expose the main trunk of the nerve by the ordinary operation than to try to find it by enlarging the wound.

Exposure of the Facial Nerve.-An incision is carried along the anterior margin of the mastoid process down to its tip and thence forwards to the angle of the jaw. The auricle and the parotid gland are pulled forwards, and the nerve is found as it leaves the stylo-mastoid foramen above the digastric muscle; when it has been exposed it can be traced forwards to the point of injury, and an attempt made to unite the divided portions (see Vol. II. p. 116).

In some cases, the question of anastomosing the distal end of the

nerve to the hypoglossal nerve will have to be considered. It may be easier to carry out this procedure than to unite the divided ends.

Anastomosis of the Facial Nerve. In cases of permanent facial paralysis due to some lesion situated between the origin of the nerve and the stylo-mastoid foramen-usually middle-ear disease-it may be possible to relieve the unsightly facial paralysis that ensues by grafting the distal end of the facial, after its emergence from the skull, upon some other sound nerve in the hope that the latter may send motor impulses down the terminal branches of the facial and that thus the functions of this nerve may be restored. For this purpose the hypoglossal has been frequently used with fair success; previously the spinal accessory had been used for a similar purpose, but the operation in this case is rather more difficult and, moreover, associated movements of the face and shoulder are apt to occur and persist for a long time.

In the operation of facio-hypoglossal anastomosis the incision is made behind the ear close along the anterior margin of the mastoid process, beginning on a level with the centre of the external auditory meatus and running down the anterior margin of the sterno-mastoid muscle to the level of the hyoid bone. If the patient is fat or very muscular, this incision may be curved a little forward below over the submaxillary area, or a second short incision may be made from the centre of it to the angle of the jaw. The facial is exposed at its emergence from the stylomastoid foramen (vide supra). It should then be divided at the foramen. and its distal end turned forwards, while the hypoglossal is defined as it emerges beneath the digastric and stylo-hyoid muscles and just before it hooks round the occipital artery. From this point it is carefully traced back to the nearest point to the divided distal end of the facial which is pulled down into contact with it. If necessary both the digastric and stylo-hyoid muscles may be divided. A small slit is made into the sheath of the hypoglossal nerve at the spot chosen and a few of the nerve fibres are divided transversely. Into this slit the divided distal

end of the facial is implanted by the method of suture described in Vol. II. p. 122.

Anastomosis of the facial with the spinal accessory nerve can be performed through a similar incision. For the reasons given above it has been largely abandoned in favour of the former operation.

WOUNDS OF THE SALIVARY DUCTS.

These may result from wounds of the parotid gland-in which case one of the smaller ducts is usually damaged, and the fistula may be only temporary or from injuries to the cheek, when Stenson's duct may be injured, and a permanent fistula results.

Wounds of Ducts in the Parotid Gland.-When a wound over the parotid gland is accompanied by an escape of saliva, deep

stitches should be put in to bring the gland substance together over the divided duct, and the wound in the skin should be sewn up. When the injured duct is quite small, the wound may heal without any trouble. In other cases a small opening remains in the line of incision through which saliva escapes. Even here, however, the tendency is for the opening to close as the wound contracts. If the closure is very slow, it is well to touch the wall of the sinus with solid nitrate of silver or the actual cautery from time to time, so as to prevent the spread of epithelium along the wall of the fistula and at the same time to stimulate the growth of granulations.

Sometimes, however, the wound of the parotid gland may be complicated by considerable loss of skin and subcutaneous tissue, and a plastic operation must then be performed, a flap being turned in so as to cover the defect. A small fistulous opening usually forms somewhere in the line of union, but this fistula generally closes as the parts contract; closure may be hastened by the treatment mentioned above.

Wound of Stenson's Duct. This is a much more serious matter, but, owing to its small size and deep position, the duct is comparatively rarely injured except in the course of operations, or by stabs or gunshot wounds. The accident is of great importance, because it is usually followed by a salivary fistula which is extremely difficult to cure. Hence the condition of the duct should be ascertained in all cases in which there is a wound in its vicinity.

Treatment. If the accident is recognised at the time of its occurrence -for example, in the course of an operation-and if no portion of the duct has been removed, an attempt should be made to suture the duct with fine catgut, and then to unite the deeper parts and the wound in the skin. When the duct has been completely divided, a good plan is to take a piece of silver wire with blunt ends and pass one end along the proximal portion of the duct, and the other along the distal part making it emerge at the opening in the mouth. The two ends of the duct are then stitched together over this wire with fine catgut and the external wound is closed. The saliva finds its way into the mouth along the wire; the end of the wire in the mouth should be bent up against the cheek and guarded by a small piece of gauze. It will remain in position because it is pressed against the gums, and may be removed after two or three days; but mastication and talking should be rigorously avoided for some days longer.

When the tissues are much bruised and there is danger of sloughing, this plan is not likely to succeed, and a fistula will almost certainly follow. Therefore, when the wound in the duct is in front of the masseter, the incision should be deepened into the mouth; in doing this it is well to bear in mind that the branch of the facial nerve which runs along with the duct may have escaped division and should be avoided. All cutting must be done parallel to the duct. A medium-sized drainage tube is

then passed through the wound so that one end projects slightly in the mouth, while the other lies about a quarter of an inch beneath the opening in the skin. The buccal end of the tube is stitched to the mucous membrane and the skin wound is closed if it is healthy. When all sloughing has ceased, the tube is gradually shortened by pulling it into the mouth. When the external wound has soundly healed, the tube may be removed, the pressure of the saliva as it is secreted being sufficient to keep the buccal end of the wound open until a permanent orifice has been formed.

SALIVARY FISTULA.

This is a communicaton between one of the salivary ducts and the exterior; in the case of the parotid it occurs directly over the gland when one of the larger ducts of origin has been opened, or in the cheek when Stenson's duct has been injured. The condition may arise from a wound, from injury during operations, as the result of sloughing or abscess formation, or as a sequela of syphilitic or tuberculous mischief. The treatment of a fistula over the gland has already been indicated (vide supra); we need therefore only discuss the question of a fistula of Stenson's duct.

The fistulous opening in Stenson's duct may be either over the masseter or further forward on the cheek; the opening is usually small, and when once established never closes without operation.

TREATMENT.-Two points are aimed at in the treatment, namely to divert the stream of saliva into the mouth, and to close the opening in the skin. When the orifice of the duct is contracted and the opening in its wall is quite small, it may sometimes suffice to dilate the orifice of the duct, and then to pare the edges of the opening in the skin and stitch them together. The dilatation may be done with probes, but it is much more satisfactorily effected by slitting up the orifice so as to make a larger and more oblique opening. If possible a stitch should be inserted on each side between the duct wall and the mucous membrane. In most cases, however, the duct is more seriously damaged, and this treatment will not suffice. The exact method will then vary according to the situation of the fistulous opening; in any case it must commence by providing free escape for the saliva into the mouth.

If the fistulous opening lies over the masseter, the channel required for the escape of the saliva into the mouth is of considerable length and is best made by thrusting a large-sized trochar from the opening in the cheek forwards into the mouth; if necessary the opening into the mouth may be enlarged. A drainage tube is now introduced through this opening, one end projecting into the mouth and the other through the skin wound. This is kept in position by silk threads at each end, the two ends of the silk being knotted together behind the ear; the tube should be maintained in position for at least four days, when the

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