THE FACE, MOUTH AND PHARYNX 177 



glands, is scattered throughout the substance of the gland, 

 though chiefly situated near its surface. The anterior auricular 

 lymph glands drain the frontal and temporal regions and receive 

 some of the deep facial lymph vessels. The parotid lymph 

 glands drain the upper and posterior part of the naso-pharynx 

 and the pterygoid lymph glands. Abscesses arising in connec- 

 tion with the anterior auricular lymph glands point superficially, 

 but, when they arise in connection with the parotid lymph glands, 

 they rarely point on the surface, owing to the strength of the 

 parotid sheath. In these cases the pus may pass upwards and 

 find its way into the external acoustic meatus, or it may travel 

 medially and reach the side wall of the nasal pharynx. In the 

 latter case it ultimately descends along the medial side of the 

 carotid sheath. 



Pus inside the parotid gland is evacuated by Hilton's method, 

 but the surgeon must be certain of its presence before exploring 

 the gland. Irreparable damage may be done to the facial 

 nerve by repeated unsuccessful endeavours to locate pus. 



An isolated lymph gland of the parotid group, which lies 

 near the surface of the salivary gland at about the level of the 

 tragus, is not uncommonly affected alone. It can be shelled 

 out through a small horizontal incision, parallel to the facial 

 nerve. The superficial structures, the sheath of the gland, and 

 probably some parotid tissue are cut through before it is reached. 

 Mixed tumours of the parotid (as well as some inflammatory 

 swellings) sometimes produce slight facial paralysis. Encapsuled 

 tumours can often be enucleated through a larger incision in 

 the same region without much damage to the facial nerve, 

 provided that all cutting is done parallel to its branches (p. 178). 



When Eemoval of the whole Parotid Gland for malignant 

 disease is contemplated, a large curved incision is necessary. 

 It commences at the mastoid process, and passes down the 

 anterior border of the sterno-mastoid to a point below the angle 

 of the mandible, and it is then carried upwards and forwards 

 on to the face. The flap is turned upwards, and the external 

 jugular vein and the external carotid artery are secured at once. 

 The gland is most easily freed from below and then from in front, 

 after ligature of the parotid duct. In separating the deep 

 surface of the gland from the muscles attached to the styloid 

 process, care must be taken lest the internal jugular vein be 

 injured, as it may be in direct contact with the gland. 



The Facial Nerve (pp. 213, 215) leaves the skull at the 



12 



