THE GUTTURAL POUCHES 83 



The pouch is here simply covered by the skin, subcutaneous fascia, 

 and the thin layer of the panniculus muscle, and this is the situation 

 of the prominent swelling which appears near the angle of the 

 inferior maxilla when the pouch is distended. 



A cutaneous incision is made in the middle of the triangular area 

 mapped out by the boundaries mentioned, the direction of the incision 

 being parallel to that of the fibres of the sterno-maxillaris. The skin 

 and panniculus muscle are carefully incised, and by separating the lips 

 of the incision thus made, the wall of the pouch is exposed. To avoid 

 injury to the surrounding structures, the wall is punctured by means 

 of a trocar, and if it should be necessary to enlarge the opening, 

 this is done by tearing the wall of the pouch with the fingers. 



Fleming and Lecocq recommend the piercing of the stylo-hyoid 

 muscle. MoUer and Dollar pierce the occipito-styloid. The last- 

 named muscle lies immediately over the pouch, and this is the seat 

 which, when adopted, entails the least risk of injury to the important 

 vessels and nerves in this region. Moreover, the landmarks by which 

 the operator is guided to the seat of his incision into the pouch, are 

 prominent and definite. 



The first and perhaps the most important landmark is the wing 

 of the atlas, the anterior edge of which should be most carefully 

 located. A cutaneous incision should then be carried upwards and 

 backwards, parallel to the edge of the wing, from about its middle, 

 whilst from the same point an incision about an inch and a half in 

 length should be carried upwards and forwards. We have thus a 

 V-shaped incision, with the apex directed downwards. 



Reflect upwards the flap of skin incised, together with the thin 

 subcutaneous layer, when the parotid gland, in addition to the edge of 

 the wing of the atlas, will be exposed. The posterior auricular vein, 

 which runs in a vertical direction, and the auricular branch of the second 

 cervical nerve, which ascends obliquely upwards and forwards on the 

 outer aspect of the gland, are clear of the operation area, since they are 



