«Scott-Brown's Otolaryngology Fifth edition General Editor Alan G. Kerr Advisory Editor John Groves Laryngology Editor P. M. Stell Historical ...»
Alan G. Kerr
P. M. Stell
About 36 years ago Bill Scott-Brown suffered a major coronary infarct and being
strictly ordered to 'rest' for six months set himself to create, as Editor (not author, because that
would have been too strenuous, he thought) this work of his own inspiration. In 1952 I was
among the first generation of FRCS candidates for whom it was the Bible. We all revered 'Negus' for the nose and throat (some of us still do) but Scott-Brown, in two volumes as it then was, provided the first post-war text for otolaryngology across the board. SB (as he was known) was probably the only person to be at all surprised by the success of his achievement, and to find himself in due course under notice from Butterworths to prepare a second edition.
It was at this stage that he recruited John Ballantyne and myself and the second, third and fourth editions were produced by the two of us under his friendly eye. For the third edition we succumbed to the inevitable by expanding two fat volumes into four (slightly) thinner ones, only to find that the fourth edition in its turn required four fat ones.
Throughout this 20 year period John Ballantyne and I derived constant satisfaction and pleasure from the ongoing association with so many willing friends and contributors past and present. We than them warmly.
We know that the ENT fraternity world-wide has pleasure in the knowledge that SB continued in his retirement still to take satisfaction from the perpetuation of his work. The sad news of his death came just as this new edition went to press. Those who knew him will perhaps see in this Fifth Edition, and the 35th year of his book, a memorial to his achievement.
John Groves Advisory Editor 1 Introduction When I was first invited to edit the Fifth edition of Scott-Brown's Otolaryngology, I thought I was aware of the enormity of the task and my own limitations. As time progressed, I realized that I had misjudged both.
This work has represented the mainstream of British otolaryngological thinking for over thirty years. However, the increase in the breadth and depth of our specialty is such that only a gifted few can be conversant with all aspects of it. Hence, I realized that I could not undertake the task without help. I have been most fortunate in having such a distinguished group of volume editors, all of whom are already well-known in British otolaryngology, and all of whom have been delightful and stimulating colleagues in this work. It has been a joy to work with them.
Modern otolaryngology has widened in recent decades, and procedures are now being performed that are no longer covered by the term 'ear, nose and throat surgery'. This work attempts to embrace all the areas that so-called ear, nose and throat surgeons are covering at the present time, and hence the change of the title to Scott-Brown's Otolaryngology.
For the new edition Scott-Brown has grown from four to six volumes. An entirely new volume has been introduced in recognition of the subspecialty of paediatric otolaryngology and the amount of material in audiological medicine is now great enough to justify its separation from the Ear volume. Although these are now specialties in their own rights, they are also, and will continue to be beyond the lifetime of this edition, part of the routine practice of most British otolaryngologist. To enable these new volumes to stand alone, a certain amount of overlap with other volumes has been necessary.
In any multi-author and multi-volume production, overlap is always necessary if each chapter is to be developed freely, and if there is to be easy reference to subjects dealt with in more than one volume. Consequently, I ask for the reader's indulgence in those sections where overlap has been planned and deliberate. Where it has occurred as a result of my ineptitude, I apologize.
The editorial team have been very pleased at the response of those invited to contribute, although, unfortunately, a few leading members of our specialty were unable to accept the invitation. However, by and large, those asked were both cooperative and energetic in their responses, and have given freely of themselves in their contributions. I have been most impressed by the spirit of goodwill among the otolaryngologists in this country, and I am grateful to them.
In the production of this edition, I have seen myself as custodian of a great British institution. I have always been aware of the privilege and responsibility of my position, and am grateful for the advice I have received from many senior and not so senior members of our specialty. I am particularly indebted to the Advisory Editor, John Groves, and to his formed editorial colleague, John Ballantyne. My respect and admiration for these colleagues has risen, not simply because of the invaluable help they have given so freely in this edition, but because I now realise the enormity of their accomplishment and their contribution to British otolaryngology in editing the last three editions.
2 I also wish to express my thanks to those in Belfast who have helped with, or suffered because of, the Fifth Edition. Some have done both, and without their backing and encouragement this work would not have been possible. It would be invidious to try to name everyone. Various secretaries have been of enormous help, and without this I could not have produced this edition. My consultant colleagues have advised and encouraged me, and my junior colleagues have given very practical advice in their down-to-earth comments and invaluable help with proof-reading. My family have been both encouraging and remarkably tolerant of the long hours required to edit such a work as this.
The staff at Butterworths were helpful and encouraging throughout. Initially, Peter Richardson set the wheels in motion. He was followed as publisher by Charles Fry, who was assisted by Anne Smith and Jane Bryant. The sub-editors have been Anne Powell and Jane Sugarman. The general spirit of pleasant cooperation and tolerance has been delightful.
I am sufficiently optimistic to believe that there will be a Sixth Edition. I do not know who will be editing it. However, if the reader has any constructive comments or criticisms, I should be pleased to have them... in writing! I can not guarantee to acknowledge these, but I promise that, if I am the editor, I shall give them due consideration, and, if not, I shall make them available to my successor.
Most diseases of the upper aerodigestive tract have an uncomplicated history.
However, the duration of symptoms may give some indication as to the origin, or aggressiveness of the disease process. Leading questions relating to dysfunction are asked.
A lump in the neck is a common symptom with many causes.
The patient's response to questions will also give the otolaryngologist an indication of the disability caused by the disease. Knowledge of the patient's general condition and attitude to his symptoms must also be obtained at this point. Most important is the patient's cardiorespiratory reserve. Direct questions about exercise tolerance, angina, cough and sputum production will usually reveal whether the patient's management will be determined by his general health or whether the disease can be treated on its own merits. Note should also be taken of diseases which might complicate management, for example diabetes, specific allergies, or any regular medication. It should be remembered that the patient will also be assessing his attending surgeon so that these early exchanges may dictate the future conduct of the examination and management of the problem.
The fundamental prerequisite for this examination is adequate lighting. The standard concave head mirror is 9 cm in diameter with a central aperture of 2 cm and a focal length of 18 cm. The light source for this mirror is normally positioned about 30 cm behind and lateral to the patient's ear, the side being determined by the surgeon's preference. The normal arrangement is shown. This system provides brilliant illumination of the area under study and also leaves both hands free for use in the examination.
Alternatives to the reflective head mirror include various types of head lights which obtain their light from either low voltage DC bulbs or even fibreoptic systems. Preference for each particular lighting system is personal, but it is customary to use one of the latter type of head lights in the operating theatre, as much greater independence of movement of the surgeon's head is necessary.
It is customary to examine the patient in the sitting position unless this is impossible for some reason. The patient should be comfortable in the examination seat, bending slightly forward with the hands resting on his knees. With the use of a good light, a relaxed cooperative patient and, if necessary, a darkened room, the examiner is now able to proceed to gain maximum information from the examination.
The various aspects of examination taught by surgical tutors such as the site, size, shape, texture as well as other physical characteristics appropriate to each specific pathology should be remembered. Cysts should be transilluminated. The scientific method also encourages accurate recording of the observations so that the effect of treatment or any change in physical characteristics can be assessed, for example size of surface ulceration, 'mobility' of neck masses, etc.
It is important to obtain adequate exposure of the area to be examined. It is probably best to have the patient remove enough clothing to expose the neck and shoulder tips. This allows the examiner not only to observe but also to palpate any area under suspicion.
Induration associated with ulceration may be assessed, as can fixity of tumours to bone. The obscure origins of some neck swellings can be confirmed or refuted using bimanual palpation with a gloved finger in the mouth. Biopsy of suspicious mouth ulcers can be performed under direct vision using local anaesthesia if necessary. When taking a biopsy it is important not to crush or distort the specimen. The biopsy, whether obtained by scalpel and dissecting forceps or punch biopsy forceps should be placed directly, without over manipulation, into the specimen pot which usually contains formalin or other fixative according to the wishes of the histopathologist, some preferring an unfixed fresh specimen.
The lips should be observed for pallor or angular stomatitis as these may indicate anaemia. The nature of ulceration of the lip is easily diagnosed by the history, site and its physical characteristics, for example an acutely painful aphthous ulcer, the recurring nature of herpes labialis, the persistent squamous carcinoma with raised rolled edges, etc.
Buccal cavity, teeth and tongue
A relaxed cooperative patient will usually permit examination of all parts of the oral cavity including the buccal mucosa, teeth and tongue. The examiner may wish to restrain the patient's head with his left hand while retracting the lip or cheek with a spatula in the right hand. Alternatively the nurse may support the patient's head from behind, thus freeing the examiner's other hand. Both sides of the mouth may be inspected by using wooden or metal spatulas, or special lip retractors. An orderly and thorough examination of the mouth is essential as so many disease processes affecting the mucosa may be systemic, for example Addison's disease; or multifocal, for example carcinoma in situ. The various fossae within the mouth should be inspected in a regular and systematic fashion. The author's preference is to examine the buccal surface of the lower lip followed by the lower buccogingival sulcus as far back as the last lower molar tooth on that side. The cheek is then retracted superolaterally to allow inspection of the upper buccogingival sulcus from posterior to anterior along the gingival surface of the upper lip and then the examination proceeds to the other side of the mouth. The opening of the parotid duct can be seen opposite the second upper molar tooth.
Any thickening of the duct or abnormal secretions should be noted. The various forms of disease affecting the mucosa inside the mouth including stomatitis are dealt with in Chapter 4.
The examiner now turns his attention to the teeth and the surrounding structures of the upper and lower jaw. Loose teeth, unhealed sockets and ill-fitting dentures are common symptoms of an expansive lesion within the jaw. The patient can usually point accurately to any specific point of complaint in this regard.
Malocclusion of teeth of the upper and lower jaw should be noted. This is important as strain may be placed on the temporomandibular joints and cause referred otalgia. Poor dental hygiene may result in carious teeth in the younger patient or more commonly gingivitis in adults.
Next the patient is asked to open the mouth widely so that the dorsum of the tongue is seen. The shape and symmetry of the tongue should be noted as well as fasciculation, seen in motor neuron disease. The patient is asked to move the tongue voluntarily in all directions.
Paralysis of a hypoglossal nerve may be easily overlooked in the early stages but becomes more obvious after disuse atrophy of the affected tongue muscles. The tongue may also be tethered by malignant infiltration.
The patient is then asked to raise the tip of the tongue to expose its ventral surface.