Experience Seamless Full Ebook Downloads for Every Genre at textbookfull.

com

ENT: An Introduction and Practical Guide, Second

Edition James Tysome

https://textbookfull.com/product/ent-an-introduction-and-
practical-guide-second-edition-james-tysome/

OR CLICK BUTTON

DOWNLOAD NOW

Explore and download more ebook at https://textbookfull.com

 Recommended digital products (PDF, EPUB, MOBI) that
you can download immediately if you are interested.

ENT OSCEs-A Guide to Passing the DO-HNS and MRCS (ENT)

OSCE, Second Edition Joseph Manjaly (Author)

https://textbookfull.com/product/ent-osces-a-guide-to-passing-the-do-
hns-and-mrcs-ent-osce-second-edition-joseph-manjaly-author/

textboxfull.com

Biota Grow 2C gather 2C cook Loucas

https://textbookfull.com/product/biota-grow-2c-gather-2c-cook-loucas/

textboxfull.com

Head, Neck and Thyroid Surgery: An Introduction and

Practical Guide Neeraj Sethi

https://textbookfull.com/product/head-neck-and-thyroid-surgery-an-
introduction-and-practical-guide-neeraj-sethi/

textboxfull.com

Psychophysics, Second Edition: A Practical Introduction

Kingdom

https://textbookfull.com/product/psychophysics-second-edition-a-
practical-introduction-kingdom/

textboxfull.com
Family Theories: An Introduction 5th Edition James M.
White

https://textbookfull.com/product/family-theories-an-introduction-5th-
edition-james-m-white/

textboxfull.com

An Introduction to Physical Science 15th Edition James

Shipman

https://textbookfull.com/product/an-introduction-to-physical-
science-15th-edition-james-shipman/

textboxfull.com

Global ethics an introduction Second Edition. Edition

Hutchings

https://textbookfull.com/product/global-ethics-an-introduction-second-
edition-edition-hutchings/

textboxfull.com

Computational Materials Science: An Introduction, Second

Edition Lee

https://textbookfull.com/product/computational-materials-science-an-
introduction-second-edition-lee/

textboxfull.com

Second Language Processing an Introduction First Edition

Jiang

https://textbookfull.com/product/second-language-processing-an-
introduction-first-edition-jiang/

textboxfull.com
ENT
AN INTRODUCTION
AND PRACTICAL GUIDE
SECOND EDITION
 ENT
AN INTRODUCTION
AND PRACTICAL GUIDE
SECOND EDITION

EDITED BY
James Russell Tysome MA PhD FRCS (ORL-HNS)
Consultant ENT and Skull Base Surgeon
Cambridge University Hospitals NHS Foundation Trust

AND
Rahul Govind Kanegaonkar FRCS (ORL-HNS)
Consultant ENT Surgeon
Medway NHS Foundation Trust

Visiting Professor in Otorhinolaryngology

Professor of Medical Innovation
Canterbury Christ Church University
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-138-19823-4 (Paperback)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been
made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or
liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in
this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions
of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care
professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge
of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of
the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently
verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or
material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices
or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for
a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional
judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copy-
right holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this
form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify
in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in
any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilm-
ing, and recording, or in any information storage or retrieval system, without written permission from the publishers.

For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.
copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-
8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that
have been granted a photocopy license by the CCC, a separate system of payment has been arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifica-
tion and explanation without intent to infringe.

Library of Congress Cataloging‑in‑Publication Data

Names: Tysome, James Russell, author. | Kanegaonkar, Rahul Govind, author.

Title: ENT : an introduction and practical guide / [edited by] James Tysome, Rahul Kanegaonkar.
Description: Second edition. | Boca Raton, FL : CRC Press, Taylor & Francis Group, 2018. | Includes
bibliographical references and index.
Identifiers: LCCN 2017019190 (print) | LCCN 2017019740 (ebook) |
ISBN 9781315270524 (General eBook) | ISBN 9781351982337 (Adobe eBook) |
ISBN 9781351982320 (ePub eBook) | ISBN 9781351982313 (Mobipocket eBook) |
ISBN 9781138298149 (hardback : alk. paper) | ISBN 9781138198234 (pbk. : alk. paper)
Subjects: | MESH: Otorhinolaryngologic Surgical Procedures--methods |
Otorhinolaryngologic Diseases--surgery
Classification: LCC RF46.5 (ebook) | LCC RF46.5 (print) | NLM WV 168 | DDC 617.5/1--dc23
LC record available at https://lccn.loc.gov/2017019190

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
 Dedication
This book is dedicated to Dipalee, Amee and Deven,
and to Laura, George, Henry and Max
CONTENTS
Foreword ix
Preface x
Introduction xi
Contributors xii
1 Clinical anatomy 1
Max Whittaker
2 ENT examination 18
Ketan Desai
3 Common ENT pathology 26
Ketan Desai
4 Epistaxis 40
Joanne Rimmer
5 Audiology 49
Neil Donnelly
6 Tonsillectomy 58
James Tysome
7 Adenoidectomy 62
Ketan Desai
8 Grommet insertion 65
Rahul Kanegaonkar
9 Septoplasty 68
Joanne Rimmer
10 Septorhinoplasty 74
Joanne Rimmer
11 Turbinate surgery 77
Joanne Rimmer
12 Endoscopic sinus surgery (ESS) 80
Joanne Rimmer
13 Nasal polypectomy 84
Joanne Rimmer
14 Tympanoplasty 86
Neil Donnelly and Olivia Kenyon
 15 Mastoidectomy 92
Neil Donnelly and Olivia Kenyon
16 Stapedectomy 99
Neil Donnelly and Olivia Kenyon
17 Bone-anchored hearing aid 103
James Tysome
18 Panendoscopy 106
Ram Moorthy
19 Direct- and microlaryngoscopy 107
Ram Moorthy
20 Pharyngoscopy 109
Sonia Kumar
21 Rigid oesophagoscopy 111
Ram Moorthy
22 Examination of post nasal space 113
Sonia Kumar
23 Rigid bronchoscopy 114
Sonia Kumar
24 Submandibular gland excision 116
Ram Moorthy
25 Hemi- and total thyroidectomy 119
Ram Moorthy
26 Superficial parotidectomy 122
Ram Moorthy
27 Tracheostomy 125
Francis Vaz
28 Voice 132
Francis Vaz
29 Airway management 137
Francis Vaz
30 Radiology 140
Dipalee Durve and Kaggere Paramesh
31 Management of neck lumps 148
Francis Vaz
32 Vertigo and dizziness 152
Rahul Kanegaonkar

Index 161

viii Contents
FOREWORD
The ‘Introduction to ENT’ course has now become an established and
must-attend course for the novice ENT practitioner. The synergistic blend
of didactic teaching and practical skills training has allowed many junior
trainees to raise the standard of care that they deliver to their ENT patients.

The course manual is now a ‘Bible’ for junior students in nursing and
medicine, caring for patients on wards, clinics or in emergency rooms.
The Royal College of Surgeons has endorsed this course in the past and it
continues to maintain a high standard for postgraduate training. I strongly
recommend this course to any trainee embarking on a career in ENT.

Khalid Ghufoor
Otolaryngology Tutor
Raven Department of Education
The Royal College of Surgeons of England

ix
 PREFACE
This book has been written for trainees in otorhinolaryngology and to
update general practitioners. Common and significant pathology that
might present itself is described. Included also are relevant supporting
specialties such as audiology and radiology. A significant proportion
of this text has been devoted to common surgical procedures, their
indications and operative techniques, as well as to the management of their
complications. We do hope that the text will facilitate and encourage junior
trainees to embark on a career in this diverse and rewarding specialty.

Writing this book would not have been possible had it not been for the
encouragement of our many friends and colleagues, and the unfaltering
support of our families.

We would, however, like to make a special mention of some extraordinary

and gifted tutors without whom we might neither have initiated the
popular ‘Introduction to ENT’ course nor written the course manual
from which this text originates. Ghassan Alusi, Alec Fitzgerald O’Connor,
Khalid Ghufoor, Govind Kanegaonkar, Robert Tranter and the late Roger
Parker instilled in us a passion for teaching, nurtured our curiosity for
all things medical and encouraged us to undertake the research that has
served us so well.

James R Tysome and Rahul G Kanegaonkar

x
INTRODUCTION
Otorhinolaryngology (ENT) is a diverse and challenging specialty. It is
often poorly represented in busy medical school curriculums and specialty
optionals at some Universities. Although an estimated 20% of cases seen in
primary care are ENT related, many general practitioners have little or no
formal training in this specialty.

This second edition has been revised and updated to reflect recent advances
in Otorhinolaryngology.

This book has evolved from the ‘Introduction to ENT’ course manual,
which has served many of us so well. Over 3000 doctors have attended this
course and its ‘Essential Guide’ counterpart.

This book covers both common and uncommon, including life-threatening

emergencies that may present themselves in both primary and secondary
care. Management pathways are described as are commonly performed
surgical procedures and possible complications. This book further provides
a basis for referral if required.

The updated colour illustrations concisely depict relevant clinical anatomy

without unduly simplifying the topic in question.

I am certain that this current text will prove to be as, if not more, popular
and relevant to general practitioners than the ‘Introduction to ENT’ text
from which it is derived.

Dr Junaid Bajwa
October 2016

xi
 CONTRIBUTORS
Mr Ketan Desai FRCS
Associate Specialist in Otorhinolaryngologist
Royal Sussex County Hospital, Brighton, UK

Mr Neil Donnelly MSc (HONS) FRCS (ORL-HNS)

Consultant Otoneurological and Skull Base Surgeon
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Dr Dipalee Durve MRCPCH and FRCR

Consultant Radiologist
Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Mr James Tysome MA PhD FRCS (ORL-HNS)

Consultant ENT and Skull Base Surgeon
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Professor Rahul Kanegaonkar FRCS (ORL-HNS)

Consultant ENT Surgeon
Medway NHS Foundation Trust, Gillingham, UK
and
Visiting Professor in Otorhinolaryngology
Professor of Medical Innovation
Canterbury Christ Church University, Canterbury, UK

Dr Olivia Kenyon
ENT Senior House Officer
Cambridge University Hospitals, Cambridge, UK

Ms Sonia Kumar FRCS (ORL-HNS)

Fellow in Paediatric Otolaryngology
Great Ormond Street Hospital for Sick Children, London, UK

Dr Kaggere Paramesh
Specialist Registrar in Radiology
Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Mr Ram Moorthy FRCS (ORL-HNS)

Consultant ENT Surgeon
Heatherwood and Wexham Park Hospitals NHS Foundation Trust and
Honorary Consultant ENT Surgeon, Northwick Park Hospital, London, UK

xii
Ms Joanne Rimmer FRCS (ORL-HNS)
Consultant ENT Surgeon/Rhinologist, Monash Health
Honorary Senior Lecturer, Monash University, Melbourne, Australia

Professor Francis Vaz FRCS (ORL-HNS)

Consultant ENT/Head and Neck Surgeon
University College London Hospital, London, UK

Mr Max Whittaker FRCS (ORL-HNS)

Specialist Registrar in Otorhinolaryngology
Kent, Surrey and Sussex Deanery, London, UK

CONTRIBUTORS xiii
 1 CLINICAL ANATOMY
Max Whittaker

THE EAR
The ear is a highly specialized organ dedicated to Scaphoid fossa
the detection of both sound and head movement.
It is classically described as three separate but Helix Triangular fossa
functionally related subunits. The outer ear,
consisting of the pinna and external auditory
canal, is bounded medially by the lateral surface of Auricular
tubercle
the tympanic membrane. The middle ear contains Cymba conchae
the ossicular chain, which spans the middle ear
Antihelix Tragus
cleft and enables the transfer of acoustic energy
from the tympanic membrane to the oval window. Antitragus
Conchal bowl
The inner ear comprises both the cochlea, which Intertragic notch
converts mechanical vibrations to electrical
impulses in the auditory nerve, and the vestibular Lobule
apparatus.

The pinna acts to direct sound into the external Figure 1.1. Surface landmarks of the pinna.
auditory canal, and plays an important role in
sound localization. It consists predominantly of from each of the first and second branchial arches
an elastic cartilaginous framework over which the on either side of the first pharyngeal groove.
skin is tightly adherent (Figure 1.1). The cartilage is These rotate and fuse to produce an elaborate
dependent on a sheet of overlying perichondrium but surprisingly consistent structure. Incomplete
for its nutritional support; hence separation of this fusion may result in an accessory auricle or pre-
layer by a haematoma, abscess or inflammation auricular sinus, while failure of development of the
secondary to piercing may result in cartilage antihelix (from the fourth hillock) in a protruding
necrosis and permanent deformity (cauliflower or ‘bat’ ear.
ear). The lobule, in contrast, is a well-vascularized
fibrofatty skin tag. The external auditory canal is a tortuous passage
that redirects and redistributes sound from the
The pinna develops from six mesodermal conchal bowl to the tympanic membrane. The skin
condensations, the hillocks of His, as early as the of the lateral third of the external auditory canal is
sixth embryological week. Three hillocks arise thick, contains ceruminous glands, is hair-bearing

Clinical anatomy 1
and tightly adherent to the underlying mechanism that allows debris to be directed out
fibrocartilage. of the canal. Disruption of this mechanism may
result in debris accumulation, recurrent infections
In contrast, the skin of the medial two-thirds is (otitis externa) or erosion of the ear canal, as seen
thin, hairless, tightly bound to underlying bone in keratitis obturans.
and exquisitely sensitive.
The tympanic membrane is bounded
The sensory nerve supply of the canal is largely circumferentially by the annulus, and is
provided by the auriculotemporal and greater continuous with the posterior wall of the ear canal.
auricular nerves. There are minor contributions It consists of three layers: laterally, a squamous
from the facial nerve (hence vesicles arise on epithelial layer; a middle layer of collagen fibres
the posterolateral surface of the canal as seen in providing tensile strength; and a medial surface
Ramsay Hunt syndrome) and Arnold’s nerve, a lined with respiratory epithelium continuous with
branch of the vagus nerve (provoking the cough the middle ear.
reflex when stimulated with a cotton bud or during
microsuction). The squamous epithelium of the The 80 mm2 of the tympanic membrane surface
tympanic membrane and ear canal is unique and area is divided into pars tensa, accounting for the
deserves a special mention. The superficial layer majority, approximately 55 mm2, and pars flaccida,
of keratin of the skin of the ear is shed laterally or attic (Figure 1.2). These regions are structurally
during maturation. This produces an escalator and functionally different. The collagen fibres of

Scutum
Pars flaccida

Chorda tympani Lateral process of

malleus
Long process of incus
Handle of malleus

Pars tensa
Umbo
Eustachian tube
Round window niche Light reflex
Promontory

Figure 1.2. Right tympanic membrane.

the pars tensa are arranged as lateral radial fibres posterior half of the tympanic membrane, while
and medial circumferential fibres that distort the low-frequency sounds alter the anterior half.
membrane. As a result, the pars tensa ‘billows’
laterally from the malleus and buckles when The handle and lateral process of the malleus are
presented with sound, conducting acoustic energy embedded within the tympanic membrane and
to the ossicular chain. In contrast, the collagen firmly adherent at the umbo (“Lloyd’s ligament”).
fibres of the pars flaccida are randomly scattered The long process of the incus is also commonly
and this section is relatively flat. Interestingly, seen, although the heads of the ossicles are hidden
high-frequency sounds preferentially alter the behind the thin bone of the scutum superiorly.

2 ENT: An Introduction and Practical Guide

 The middle ear ●● The relative lengths of the handle of malleus to
the long process of incus (1.3:1).
The middle ear is an irregular, air-filled space ●● The natural resonance of the outer and middle
containing the three ossicles: the malleus, ears.
incus and stapes. Its predominant function is ●● The phase difference between the oval and
to overcome impedance mismatch, energy lost round windows.
when transferring sound from one medium to ●● The buckling effect of the tympanic membrane
another, in this case converting air vibrations (2:1).
at the tympanic membrane to fluid vibrations In combination the total margin of improvement
within the cochlea. The ossicular chain is crucial amounts to 44:1.
in this process, by conducting vibrations to
the cochlea via the stapes footplate at the oval In order to optimise admittance, middle ear air
window. Without it the vast majority of acoustic pressure is equalized with atmospheric pressure.
energy would not be transmitted through the oval This is achieved via the Eustachian tube, which
window resulting in a conductive hearing loss of communicates with the nasopharynx, and opens
up to 50–60 dB. Clinically, ossicular discontinuity on chewing, swallowing and yawning, allowing
or fixation of the footplate by otosclerosis prevents air to pass into the middle ear cleft (Figure 1.3).
sound conduction to the inner ear, resulting in a The amount of air passing through the Eustachian
conductive hearing loss. tube varies greatly between individuals depending
on pressure gradient and volume of the mastoid
The middle ear mechanisms that improve sound air cell system; however, it is thought that the
transfer include: equalisation process occurs rapidly, between 0.15
●● The relative ratios of the areas of the tympanic and 0.34 seconds. In children, Eustachian tube
membrane to stapes footplate (17:1). dysfunction is common and may result in negative

Aditus (inlet) to
mastoid antrum

Malleus Facial n. (CN VII) in

facial canal
Incus Prominence of lateral
semicircular canal
Chordo tympani
Prominence of
facial canal
Tensor of tympani
Stapes
Tendon of
stapedius Promontory

Tympanic Tympanic
membrane plexus

Tympanic n.

Figure 1.3. Coronal section of the ossicles in the middle ear.

Clinical anatomy 3
 Flow of Flow of
endolymph endolymph

Vestibular
Ampulla afferent Head rotation Head rotation

4 ENT: An Introduction and Practical Guide

Membrane

Membrane
Membrane

potential (mV)

potential (mV)
potential (mV)

Time Time Time

Rest or constant rate of motion Acceleration Acceleration

Figure 1.4. The inner ear. Angular acceleration is detected by the ampullae of the lateral semicircular canals, while linear acceleration and static
head tilt are detected by the maculae of the utricle and saccule.
middle ear pressure, recurrent otitis media or functional pairs: the two horizontal semicircular
middle ear effusions. canals working in tandem, and the superior canals
paired with the contralateral posterior canals.
The inner ear
The sensory neuroepithelium of the semicircular
The inner ear consists of the cochlea and peripheral canals is limited to a dilated segment of the bony
vestibular apparatus (Figure 1.4). and membranous labyrinth, the ampulla. Within
this region, a crest perpendicular to the long
The cochlea is a two and three-quarter-turn
axis of each canal bears a mound of connective
snail shell that houses the organ of Corti. It is
tissue from which projects a layer of hair cells.
tonotopically arranged, with high frequencies
Their cilia insert into a gelatinous mass, the
detected at the base and low frequencies nearest the
cupula, which is deflected during rotational head
apical turn. Acoustic energy presented at the oval
movements.
window causes a travelling wave along the basilar
membrane, with maximal deflection at a frequency-
Within the utricle and saccule, the sensory patches,
specific region of the cochlea. This results in
called maculae are orientated in order to detect
depolarization of the inner hair cells at this region,
linear acceleration and head tilt in horizontal and
and through a process of mechanotransduction,
vertical planes, respectively. Hair cells in these
vibrational energy is converted to neural impulses
maculae are arranged in an elaborate manner
relayed centrally via the cochlear nerve.
and project into a fibro-calcareous sheet, the
The peripheral vestibular system is responsible otoconial membrane. As this membrane has a
for the detection of head movement. While the greater specific gravity than the surrounding
semicircular canals are stimulated by rotational endolymph, head tilt and linear movement result
acceleration, the saccule and utricle are dedicated in the otoconial membrane moving relative to the
to detecting static and linear head movements. underlying hair cells. The shearing force produced
This is achieved by two similar, but functionally causes depolarization of the underlying hair cells
different sensory receptor systems (Figure 1.4). with conduction centrally through the inferior and
superior vestibular nerves.
The semicircular canals are oriented in orthogonal
planes to one another and organized into

THE FACIAL NERVE

The facial nerve (CN VII) runs a tortuous course the nervus intermedius carrying parasympathetic
from the brainstem, through the temporal bone and sensory fibres. These are joined at the
before exiting the skull base at the stylomastoid internal acoustic canal by the motor fibres to
foramen and dividing within the parotid gland form the facial nerve, running anterosuperiorly
(Figure 1.5). Therefore, disease processes affecting through the meatal segment in relation to the
the inner ear, middle ear, skull base or parotid vestibulocochlear nerve. In the labyrinthine
gland may result in facial nerve paralysis. segment the nerve undergoes a posterior
deflection at the first genu, in close relation to the
The facial nerve arises from three nuclei in the geniculate ganglion, housing the cell bodies of
brainstem: the motor nucleus, superior salivatory the chorda tympani, and the greater superficial
nucleus in the pons, and the nucleus solitarius petrosal nerve exits via the facial hiatus to supply
in the medulla. During its intracranial segment the lacrimal gland. The facial nerve passes along
branches from the latter two nuclei join to form its tympanic horizontal portion within the medial

Clinical anatomy 5
 SUPERIOR Motor nucleus
“Bill’s” bar
Superior salivary nucleus
(parasympathetic)
VII SVN
ANTERIOR POSTERIOR Tractus solitarius
(taste)
IVN Internal auditory
CN canal Simple sensory
Transverse
crest I
Singular Geniculate II
nerve ganglion Greater
INFERIOR
petrosal n.

(b)
60°

Intracranial segment 24 mm
I – Meatal segment, 10 mm III
II – Labyrinthine segment, 5 mm. Dome of the lateral
The narrowest portion, 0.7 mm semicircular canal

6 ENT: An Introduction and Practical Guide

Malleus
III– Tympanic (horizontal) segment, 10 mm
IV – Mastoid (vertical) segment – 14 mm 30°

Chorda tympani
nerve
Cutaneous fibres
accompany auricular IV
fibres of vagus

Stylomastoid
foramen
(a)

Figure 1.5. The intratemporal course of the facial nerve (a), relative positions of the facial, cochlear and vestibular nerves within the internal
auditory canal (b). (VII = facial nerve, SVN = superior vestibular nerve, IVN = inferior vestibular nerve.)
wall of the middle ear to the second genu. At this
point it undergoes a further deflection inferiorly
to begin its vertical mastoid segment. Motor Temporal
branches are given off to stapedius and taste fibres Zygomatic
from the anterior two-thirds of the tongue are
received from the chorda tympani.

The facial nerve exits the skull base at the

stylomastoid foramen to begin its extratemporal Buccal
course, and adopts a more variable anatomy. Marginal mandibular
Lying in the tympanomastoid groove it courses
Cervical
anteriorly to enter the parotid gland, where it most
commonly forms superior and inferior divisions
before terminating in its five motor branches
(Figure 1.6). Additional branches supply the
Figure 1.6. External branches of the facial nerve.
posterior belly of digastric and stylohyoid muscles.

THE NOSE
The nose and nasal cavity serve a number of ●● Olfaction.
functions. While their principal function is ●● Drainage and aeration of the middle ear cleft
provision of an airway, secondary functions include: via the Eustachian tube.
●● Drainage and aeration of the paranasal sinuses.
●● Warming of inspired air. ●● Drainage for the nasolacrimal duct.
●● Humidification of inspired air. ●● Prevention of lung alveolar collapse via the
●● Filtering of large particulate matter by coarse nasal cycle.
hairs (the vibrissiae) in the nasal vestibule. ●● Voice modification.
●● Mucus production, trapping and ciliary ●● Pheromone detection via the Vomeronasal
clearance of particulate matter. organ of Jacobsen.
●● Immune protection (within mucus and via
presentation to the adenoidal pad).

Glabella Glabella

Nasion Nasal bone

Dorsum Hinion
Frontal process
of maxilla Septum
Supratip Upper lateral
cartilage
Tip
Lower
lateral
cartilage
Columella

Figure 1.7. Nasal landmarks and external nasal skeleton.

Clinical anatomy 7
 Nasal skeleton The nasal cavities

The external nasal skeleton consists of bone in The nasal cavities are partitioned in the midline
the upper third (the nasal bones) and cartilage in by the nasal septum, which consists of both
the lower two-thirds. External nasal landmarks fibrocartilage and bone (Figure 1.8).
are illustrated in Figure 1.7 and ensure accurate
description when assessing the nose prior to As with the cartilage of the pinna, the cartilage
considering surgical intervention. of the septum is dependent on the overlying

Perpendicular
plate of ethmoid

Septal cartilage
Vomer

Crest

Palatine bone

Figure 1.8. The skeleton of the nasal septum.

adherent perichondrium for its nutritional support. The nasal cavity has a rich blood supply
Separation of this layer by haematoma or abscess originating from both the internal and external
may result in cartilage necrosis, perforation and a carotid arteries (Figure 1.10). As a result, epistaxis
saddle nose deformity. may result in considerable blood loss which should
not be underestimated. In cases of intractable
In contrast to the smooth surface of the nasal posterior nasal bleeding, the sphenopalatine
septum, the surface of the lateral wall is thrown artery may be endoscopically ligated by raising
into folds by three bony projections: the inferior, a mucoperiosteal flap on the lateral nasal wall.
middle and superior turbinates (Figure 1.9). These Bleeding from the ethmoidal vessels requires a
highly vascular structures become cyclically periorbital incision and identification of these
engorged resulting in alternating increased airway vessels as they pass from the orbital cavity into the
resistance and reduced airflow from one nasal nasal cavity in the fronto-ethmoidal suture.
cavity to the other over a period of 2–3 hours. This
physiological process, under hypothalamic control, The venous drainage of the nose and mid-face
may be more noticeable in patients with a septal communicates with the cavernous sinus of the
deviation or in those with rhinitis. middle cranial fossa via the superior ophthalmic

8 ENT: An Introduction and Practical Guide

 Olfactory mucosa

Superior turbinate

Middle turbinate

Inferior turbinate

Eustachian tube cushion

Figure 1.9. The lateral surface of the nasal cavity.

Anterior ethmoidal artery (I)

Posterior ethmoidal artery (I)

Sphenopalatine artery (E)

Little’s area

Superior labial artery (E) Greater palatine artery (E)

Figure 1.10. Arterial blood supply to the nose. The nose has a rich blood supply, supplied by both internal
(I) and external (E) carotid arteries.

vein, or deep facial vein and pterygoid plexus. The olfactory mucosa is limited to a superior region
As a result, infection in this territory may spread of the nasal cavity (Figure 1.9). Once dissolved in
intracranially, resulting in cavernous sinus mucus, olfactants combine with binding proteins
thrombosis and may be life-threatening. and stimulate specific olfactory bipolar cells.

Clinical anatomy 9
Their axons converge to produce 12−20 olfactory The paranasal sinuses are paired air-filled spaces
bundles, which relay information centrally to that communicate with the nasal cavity via ostia
secondary neurones within the olfactory bulbs at located on the lateral nasal wall (Figure 1.11). These
the cribriform fossae of the anterior cranial fossa. occur at different ages, with the maxillary sinuses

Posterior ethmoid ostia

Sphenoid sinus ostium
Anterior ethmoid ostia

Maxillary sinus ostia

Nasolacrimal duct

Sphenopalatine artery

Figure 1.11. The lateral wall of the nasal cavity. (The turbinates have been removed in order to allow
visualization of the ostia of the paranasal sinuses.)

present at birth and the frontal sinuses being the results in a spiral flow that directs mucus up and
last to fully form. In a minority of patients the medially to the ostium high on the medial wall.
frontal sinuses may be entirely absent. Mucus
produced by the respiratory epithelium within the The anterior and posterior ethmoidal air cells are
paranasal sinuses does not drain entirely by gravity. separated from the orbital contents by the lamina
In the maxillary sinus, for example, cilliary activity papyracea, a thin plate of bone derived from the

Frontal sinus

Anterior ethmoid sinus

Lamina papyracea
Middle turbinate
Osteomeatal complex
Maxillary sinus
Inferior turbinate

Septal cartilage

Figure 1.12. Coronal section of the paranasal sinuses.

10 ENT: An Introduction and Practical Guide

ethmoid bone. Infection within these paranasal The osteomeatal complex represents a region
sinuses may extend laterally through this layer, through which the paranasal sinuses drain
resulting in periorbital cellulitis and possible loss (Figure 1.12). Obstruction may lead to acute or
of vision. chronic sinusitis; hence opening this area is pivotal
when surgically treating sinus disease.

ORAL CAVITY
The oral cavity is bounded anteriorly by the inferiorly by the tongue base and superiorly by the
lips, posteriorly by the anterior tonsillar pillars, hard and soft palates (Figure 1.13).

Posterior tonsillar pillar

Hard palate (palatopharyngeus)
Soft palate

Uvula
Anterior tonsillar pillar
Tonsil (palatoglossus)
Sulcus terminalis
Retromolar region

Figure 1.13. The oral cavity.

The tongue consists of a mass of striated surface. The anterior two thirds, formed from
muscle separated in the midline by a fibrous the first arch, are coated by fungiform papillae,
membrane. Both the intrinsic muscles (contained which distinguish the five tastes: sweet, salty, sour,
entirely within the tongue) and the extrinsic bitter and umami. These are interspersed with the
muscles (inserted into bone) are supplied by the filiform papillae which do not contribute to taste
hypoglossal nerve, except for the palatoglossus but act to increase surface area, providing friction
(supplied by the pharyngeal plexus). A unilateral and enabling manipulation of food. Taste receptors
hypoglossal nerve palsy results in deviation of the are innervated by the chorda tympani, which
tongue towards the side of the weakness. hitchhikes with the lingual nerve to join the facial
nerve. The mandibular branch of the trigeminal
The tongue is derived from the mesoderm of nerve supplies touch and temperature sensation.
the first four branchial arches. Its embryological
origin is reflected in its pattern of innervation, The posterior third is predominantly derived
and arrangement of the fungiform, foliate, from the third and fourth arches, with a small
circumvallate and filiform papillae on its dorsal contribution from the second. Its surface is

Clinical anatomy 11
lined laterally by foliate papillae, with taste, The middle constrictor arises from the greater horn
touch and temperature sensation relayed by the of the hyoid bone, its fibres sweeping to enclose the
glossopharyngeal and superior laryngeal nerves. superior constrictor (as low as the vocal cords).

These two distinct regions are separated by a row The inferior constrictor consists of two
of circumvallate papillae in the form of an inverted striated muscles, the thyropharyngeus and
‘V’. The foramen caecum lies at the apex of this ‘V’ cricopharyngeus. A potential area of weakness
and represents the site of embryological origin of lies between the two muscles posteriorly: Killian’s
the thyroid gland (see below). Rarely, due to failure dehiscence. A pulsion divertivulum may form a
of migration, a lingual thyroid may present as a pharyngeal pouch at this site, leading to retention
mass at this site. and regurgitation of ingested material.

The floor of the mouth is separated from the The upper aero-digestive tract is divided into
neck by the mylohyoid muscle. The muscle fans the nasal cavity and nasopharynx, oral cavity
out from the lateral border of the hyoid bone to and oropharynx, larynx and hypopharynx
insert into the medial surface of the mandible (Figure 1.14).
as far back as the second molar tooth. A dental
root infection that is anterior to this may result The nasopharynx extends from the skull base to
in an abscess forming in the floor of the mouth the soft palate. It communicates with the middle
(Ludwig’s angina). This is a potentially life- ear cleft via the Eustachian tube (Figure 1.15).
threatening airway emergency and requires urgent This tube unwinds during yawning and chewing,
intervention to extract the affected tooth and drain allowing air to pass into the middle ear cleft
the abscess. and maintaining atmospheric pressure within
the middle ear. This mechanism depends on the
The hyoid bone lies at the level of the third
actions of levator and tensor veli palatini muscles,
cervical vertebra. The larynx is suspended from
hence a cleft palate is often associated with
this C-shaped bone, resulting in the rise of the
chronic Eustachian tube dysfunction. Equally,
laryngeal skeleton during swallowing.
blockage of the Eustachian tube may result in a
middle ear effusion. Whilst effusions are common
THE PHARYNX in children, unilateral effusions in adults should
raise suspicion of post-nasal space pathology,
such as a nasopharyngeal carcinoma arising from
The pharynx consists of a curved fibrous sheet, the fossa of Rossenmüller. The adenoid gland lies
the pharyngobasilar fascia, enclosed within three on the posterior nasopharyngeal wall, forming
stacked muscular bands: the superior, middle part of Waldeyers ring of immune tissue, along
and inferior constrictors. The muscle fibres of the with the palatine and lingual tonsils. Adenoid
constrictors sweep posteriorly and medially to meet enlargement may compromise airflow resulting in
in a midline posterior raphe. The pharyngeal plexus obstructive sleep apnoea, and may require surgical
provides the motor supply to the musculature of reduction.
the pharynx, except for the stylopharyngeus which
is supplied by the glossopharyngeal nerve. The oropharynx spans from the soft palate to the
level of the epiglottis. Its lateral walls are formed
The superior constrictor arises from the medial by the palatoglossus and palatopharyngeus
pterygoid plate, hamulus, pterygomandibluar muscles, between which lie the palatine tonsils.
raphe and mandible. The Eustachian tube passes These receive a rich blood supply from the lingual,
between its superior border and the skull base. facial and ascending pharyngeal branches of the
Stylopharyngeus and the glossopharyngeal and external carotid artery.
lingual nerves pass below the constrictor.

12 ENT: An Introduction and Practical Guide

 Nasal cavity Sphenoid sinus

Adenoid pad
Tonsil of Gerlach
Hard palate
NASOPHARYNX

Tongue
Palatine tonsil
Lingual tonsil
OROPHARYNX
Vallecula
Hyoid bone
Epiglottis
Vocal cord HYPOPHARYNX
Thyroid cartilage
Cricoid cartilage
Cricoid cartilage
Cervical esophagus

Thyroid isthmus

Figure 1.14. Sagittal section through the head and neck. Note the hard palate lies at C1, the hyoid bone at
C3 and the cricoid cartilage at C6.

Adenoid

Fossa of Rossenmüller

Eustachian tube cushion Posterior margin

of septum
Lateral nasal wall
Eustachian tube orifice To oropharynx
Soft palate

Figure 1.15. Endoscopic view of the right postnasal space.

Clinical anatomy 13
The laryngopharynx lies posterior to the larynx. cricopharyngeus marks the transition into the
It is bounded inferiorly by the cricoids, where the oesophagus.

THE LARYNX
The principal function of the larynx is that of secondary function. The three single cartilages of
a protective sphincter preventing aspiration of the larynx are the epiglottic, thyroid and cricoid
ingested material (Figure 1.16). Phonation is a cartilages. The three paired cartilages of the larynx

Interarytenoid bar Posterior

pharyngeal wall
Right arytenoid

Cricoid cartilage Left pyriform

fossa
Right vocal cord
Laryngeal inlet
Quadrangular
membrane
Epiglottis Left vallecula

Median Lingual tonsil

glossoepiglottic
fold

Figure 1.16. Endoscopic view of the larynx.

are the arytenoid, corniculate and cuneiform complete ring of cartilage in the airway, trauma may
cartilages. cause oedema and obstruction of the central lumen.

The arytenoid cartilages are pyramidal structures The formula describes airflow through the lumen
from which the vocal cords project forward and of a tube (Figure 1.17).
medially. Abduction (lateral movement) of the
cords is dependent on the posterior cricoarytenoid
muscle, hence this is described as the most
important muscle of the larynx. Additional r
instrinsic and extrinsic muscles provide adduction
and variable cord tension.
PB l PA
4
The motor supply of the muscles of the larynx is Flow (L/min) = (PA−PB) × v × r × π
l 8
derived from the recurrent laryngeal nerves. An
ipsilateral palsy results in hoarseness, while a bilateral PA = pressure A
PB = pressure B
palsy results in stridor and airway obstruction. v = viscosity
l = length
The cricoid is a signet ring-shaped structure which r = radius
supports the arytenoid cartilages. As the only
Figure 1.17. Flow through a tube.

14 ENT: An Introduction and Practical Guide

Exploring the Variety of Random
Documents with Different Content
 PLATE CCCXXV.

CODON ROYENI.
Prickly Codon.
CLASS XI. ORDER I.
DODECANDRIA MONOGYNIA. Twelve Chives. One Pointal.
GENERIC CHARACTER.
Calyx. Perianthium monophyllum, duodecempartitum; foliolis subulatis,
persistentibus, erectis, alternis brevioribus.
Corolla monopetala, campanulata, basi torulosa; limbo
duodecimpartito, aquali.
Nectarium duodecim loculare ex squamis 12, unguibus staminum insertis,
conniventibus, receptaculum tegentibus.
Stamina. Filamenta duodecim, longitudine corollæ. Antheræ crassæ.
Pistillum. Germen superum, conicum. Stylus simplex, longitudine
staminum. Stigmata duo, longa, setacea, divergentia.
Pericarpium. Capsula bilocularis.
Semina plurima, subrotunda, nigra.
Empalement. Cup one-leaf, twelve-divided; leaflets awl-shaped,
remaining, upright, the alternate ones shorter.
Blossom one petal, bell-shaped, rather swelled at the base; border twelve-
divided, equal.
Honey-cup twelve-celled, consisting of 12 scales, inserted into the claws of
the chives, approaching, covering the receptacle.
Chives. Twelve threads, the length of the blossom. Tips thick.
Pointal. Seed-bud above, conical. Shaft simple, the length of the chives.
Summits two, long, like bristles, straddling.
Seed Vessel. Capsule two-celled.
Seeds numerous, roundish, black,
SPECIFIC CHARACTER.
 Codon foliis alternis, cordato-ovatis, acuminatis, setaceo-spinosis;
floribus subcapitatis, terminalibus.
Codon with alternate leaves, between heart-shaped and oval, tapered to
the point, with spine-like bristles; flowers grow nearly in heads, terminating
the branches.
REFERENCE TO THE PLATE.
1. The Empalement.
2. A Blossom spread open, with the chives in their place.
3. The same shewn from the outside.
4. The Seed-bud, Shaft and Summits.
5. The Seed-bud, cut transversely.
As an interesting desideratum, this plant has stood long amongst botanical
collectors; but till the year 1801, it was never seen, in a vegetating state, in
Britain; at which period, it was introduced to our gardens, by Mr. Niven,
from the Cape of Hope. It is not, we believe, (although considered hitherto
as such,) an annual; but rather, a half woody shrub, easily destroyed by
moisture. As the seed appears to ripen freely, although there seems no other
mode of perpetuating the plant, we shall stand in no danger of losing it; its
attractions are, indeed, not great as to beauty, but much so as to singularity;
since we have no plant to which it affines in general habit. The seeds should
be sown on a gentle hot-bed, in March, and transplanted when about two
inches high, into pots, to flower, which they will do about September. Our
drawing was made at the Hammersmith Nursery. Having had the opportunity
of examining the flowers, of more than twenty plants; we are convinced it
has been wrong placed by Van Royen to decandria; for although many
flowers may be found, even on the same plant, some with eight, others with
ten chives, yet at least 90 out of 100 have twelve; wherefore we have,
without scruple, placed it to dodecandria.
 PLATE CCCXXVI.

PHARNACEUM LINEARE.
Linear-leaved Pharnaceum.
CLASS V. ORDER III.
PENTANDRIA TRIGYNIA. Five Chives. Three Pointal.
GENERIC CHARACTER.
Calyx. Perianthium pentaphyllum; foliolis subovatis, concavis,
patentibus, æqualibus, persistentibus, intus coloratus, margine tenui.
Corolla nulla; hinc calycis margo tenuis et calyx interne coloratus.
Stamina. Filamenta quinque, subulata, longitudine calycis. Antheræ basi
bifidæ.
Pistilla. Germen ovatum, trigonum. Styli tres, filiformes, longitudine
staminum. Stigmata obtusa.
Pericarpium. Capsula ovata, obsoletè trigona, tecta, trilocularis, trivalvis.
Semina numerosa, nitida, orbiculata, depressa, margine acuto cincta.
Empalement. Cup five-leaved; leaflets nearly egg-shaped, concave,
spreading, equal, permanent, coloured within, with a thin edge.
Blossom none; hence the edge of the cup is thin and the inside of it is
coloured.
Chives. Five-threads, awl-shaped, the length of the cup. Tips cleft at the
base.
Pointals. Seed-bud egg-shaped, three-sided. Shafts three, thread-shaped,
the length of the chives. Summits blunt.
Seed-vessel. Capsule egg-shaped, bluntly three-cornered, covered, three-
celled, three valves.
Seeds numerous, shining, orbicular, flattened, surrounded by a sharp rim.
SPECIFIC CHARACTER.
Pharnaceum foliis linearibus, verticillatis; umbellis inequalibus; calycibus
aurantiis; caule decumbente.
 Pharnaceum with linear leaves, growing in whorls; umbels unequal; cups
orange coloured; stem bending downwards.
REFERENCE TO THE PLATE.
1. The Cup, shewn from the front, with the chives.
2. The same, shewn from the hind part attached to the fruit-stalk.
3. The Seed-bud and Pointals, natural size.
4. The same, magnified.
5. The Seed-bud, cut transversely, magnified.
This little plant much resembles our Corn Spurry, or Spergula arvensis, at
first sight. It is a native of the Cape of Good Hope, seldom grows more than
six inches high, and is very apt to be destroyed by the damps of our winters.
It should be placed in the airyest part of the greenhouse, and kept in light
sandy loam. To propagate it, the cuttings should be put in, about the month
of March, in the heat of a gentle hot-bed, or the bark-bed of the hot-house;
the seeds are sometimes perfected. It has been often introduced to us, but as
often lost; as it is not a plant of much shew, no great deal of pains has,
hitherto, been taken for its preservation. Our drawing was taken from a plant
in the Hibbertian Collection, in the month of July, 1802.
 PLATE CCCXXVII.

XERANTHEMUM ARGENTEUM.
Silvery Everlasting-Flower.
CLASS XIX. ORDER II.
SYNGENESIA POLYGAMIA SUPERFLUA. Tips united. Superfluous
Pointals.
ESSENTIAL GENERIC CHARACTER.
Receptaculum paleaceum. Pappus setaceus. Calyx imbricatus, radiatus;
radio colorato.
Receptacle chaffy. Feather bristly. Cup tiled, rayed; ray coloured.
See Xeranthemum speciocissimum, V. I. Pl. LI.
SPECIFIC CHARACTER.
Xeranthemum fruticosum; foliis lanceolatis, carinatis, sericeis; floribus
paniculatis, argenteis.
Everlasting flower with a shrubby stem; leaves lance-shaped, keeled, and
silky; flowers grow in panicles, and silvery.
REFERENCE TO THE PLATE.
1. An hermaphrodite Floret, natural size.
2. The same, magnified.
3. An inner scale of the Empalement.
4. The Receptacle, cleared of the scales and florets.
5. A female Floret, magnified.
6. The Pointal of the above, natural size.
7. The same magnified.
This new species of Everlasting-flower was introduced to us, at the same
time, with the X. spirale this work, Pl. CCLXII. by Montague Burgoyne,
Esq. of Mark Hall, Essex, in the year 1801. It is a quick growing plant, and
has flowered for the first time last April, when our drawing was taken. The
flower stems grow to the length of eighteen inches, or more; and the buds,
upon their first appearance, have a fine tint of flesh colour, which, however,
totally disappears upon the expansion of the flower. It is propagated by
cuttings, seeds, (which ripen in this country,) or by parting the branches at
the root, as it makes many from one base, which are easily separated by
passing a knife between them. It thrives best in sandy peat with a small
portion of loam, and must be kept in an airy, dry part of the greenhouse.
 PLATE CCCXXVIII.

GERANIUM BUBONIFOLIUM.
Macedonian-Parsley-leaved Geranium.
CLASS XVI. ORDER IV.
MONADELPHIA DECANDRIA. Threads united. Ten Chives.
ESSENTIAL GENERIC CHARACTER.
Monogyna. Stigmata quinque. Fructus rostratus, pentacoccus.
One Pointal. Five Summits. Fruit furnished with long awns, five dry
berries.
SPECIFIC CHARACTER.
Geranium foliis pinnatis, pinnis oppositis, lobatis, distantibus, lobis
inciso-dentatis, glabris; petalis emarginatis, albis; staminibus quinque
fertilibus; radice tuberosa.
Geranium with winged leaves, wings opposite, lobed, distant, lobes deep
cut and toothed, smooth; petals notched at the end, white, five fertile chives;
root tuberous.
REFERENCE TO THE PLATE.
 1. The Cup cut and spread open.
2. The Chives and Pointal.
3. The Chives cut and spread open, magnified.
4. The Pointal, magnified.
This Geranium, from the Cape of Good Hope, is quite distinct in its habit,
from most of the tuberous species; the leaflets or wings of the leaves being
more hand-shaped, and at a greater distance from each other, than in any
which has come under our observation; having much the appearance of those
of the plant from which we have derived its specific title. The plant was
introduced by Mr. Niven, to the Clapham Collection, in 1800; where our
drawing was taken in the month of June, 1802. The cultivation as usual, for
the plants of this branch of the Geranium family.
 PLATE CCCXXIX.

P H A R N A C E U M L I N E A R E . Va r. f l o . a l b o .
Linear-leaved Pharnaceum. White Var.
CLASS V. ORDER III.
PENTANDRIA TRIGYNIA. Five Chives. Three Pointals.
ESSENTIAL GENERIC CHARACTER.
Calyx 5-phyllus. Corolla nulla.
Capsula 3-locularis, polysperma.
Cup 5-leaved. Blossom none.
Capsule 3-celled, many-seeded.
See Pharnaceum lineare. Pl. CCCXXVI. V. V.
SPECIFIC CHARACTER.

Pharnaceum foliis linearibus, verticillatis; umbellis inequalibus; calycibus

albo-virentibus; caule decumbente.
Pharnaceum with linear leaves, growing in whorls; umbels unequal; cups
whitish green; stem bending downwards.
REFERENCE TO THE PLATE.
1. A Flower.
2. The Cup and Chives.
3. The Seed-bud and Pointals, natural size.
4. The same, magnified.
5. The Seed-bud, cut transversely, magnified.
We have given this variety of the linear-leaved Pharnaceum, at the same time
with the orange-coloured, as being the only two Cape species, at present, in
our gardens. It is equally tender and delicate with its fellow, is equally
difficult to propagate; and was introduced, this last time, to the Hibbertian
Collection in 1800, by Mr. Niven, with it.
 PLATE CCCXXX.

N Y M P H Æ A S T E L L ATA .
Starr’d Water-Lily.
CLASS XIII. ORDER I.
POLYANDRIA MONOGYNIA. Many Chives. One Pointal.
ESSENTIAL GENERIC CHARACTER.
Calyx 4, 5, seu 6-phyllus. Cor. polypetala. Bacca multilocularis, truncata.
Cup 4, 5 or 6-leaved. Bloss. many petals. Berry many-celled, appearing
cut off at top.
See Nymphæa cœrulea, Pl. CXCVII. Vol. III.
SPECIFIC CHARACTER.
Nymphæa foliis subrotundis, sinuatis, subtus purpurascentibus; lobis
divaricatis, acutis; calyce tetraphyllo, petalis acutis cœruleis longiore.
Water-lily with nearly round leaves, scollopped and purplish underneath;
lobes straddling and pointed; cup four-leaved, longer than the pointed, blue
petals.
REFERENCE TO THE PLATE.
1. The Cup divested of the petals.
2. A Chive, natural size.
3. The seed-vessel, nearly arrived to maturity.
4. The same, cut transversely.
This fine species of Water-lily is a native of the East Indies, on the Malabar
coast; and has been given by Rheed, in his Hortus Malabaricus, Vol. II. p.
53. fig. 27. At first sight, it has much the appearance of N. cœrulea, but upon
closer inspection it is found to possess many strongly differing characters,
viz. In this, the under part of the leaves are purplish, the lobes straddle; in
that, they are tiled, or lay upon each other; in N. stellata the petals or chives
seldom exceed ten; whereas, the N. cœrulea has an indefinite number of
both. The roots, likewise, are perfectly distinct; in N. cœrulea the diverging
roots proceed from the lower part of the bulb, from whence the leaves issue,
but in N. stellata from the top, leaving below them a smooth top-shaped
bulb. The parts which compose the summit, or rather the summits, (for
indeed we should consider them, if it lay with us, as distinct pointals,) are
expanded horizontally when the flower is in its perfect state, forming a star
like appearance, whence its specific name. It is much tenderer than N.
cœrulea, and will not flower but in strong heat. Mr. Anderson informs us that
the plants which have produced perfect seeds, this year, were from seeds,
received by A. B. Lambert, Esq. (communicated by Dr. Roxburgh from
India) in the month of March, and raised by him for the collection of J. Vere,
Esq. Kensington Gore, where our drawing was made in August.
 PLATE CCCXXXI.

X Y L O P H Y L L A FA L C ATA .
Cymitar-shaped-leaved Xylophylla.
CLASS XXI. ORDER III.
MONŒCIA TRIANDRIA. Chives and Pointals separate. Three Chives.
GENERIC CHARACTER.
* Masculi flores.
Calyx. Perianthium monophyllum, tripartitum, coloratum; laciniis ovatis,
patulis, ovatis.
Corolla. Petala tria, ovata, concava.
Stamina. Filamenta tria, brevissima, basi approximata. Antheræ
subrotundæ, didymæ.
* Feminei flores in eodem fasciculo cum masculis.
Calyx. Perianthium ut in mare.
Corolla ut in mare.
Nectarium corpusculis glandulosis germen ambientibus.
Pistillum. Germen subrotundum, trisulcatum. Styli tres, patuli, bifidi.
Stigmata obtusa.
Pericarpium. Capsula trigona, trisulca, trilocularis; loculis bivalvibus.
Semina solitaria.
* Male flowers.
Empalement. Cup one leaf, three divided, coloured; segments egg-shaped,
spreading, oval.
Blossom. Petals three, egg-shaped, concave.
Chives. Threads three, very short, and approaching at the base. Tips
roundish, double.
* Female flowers in the same tuft with the males.
Empalement. Cup as in the male.
Blossom as in the male.
Honey-cup is formed of small glandular bodies surrounding the seed-bud.
 Pointal. Seed-bud roundish, three-furrowed. Shafts three, short.
Summits blunt.
Seed-vessel. Capsule three-sided, three-furrowed, three cells; cells two-
valved.
Seeds solitary.
SPECIFIC CHARACTER.
Xylophylla foliis sparsis, integris, falcatis, crenatis; crenis remotis,
floriferis; floribus rubris.
Xylophylla with leaves scattered on the stem, entire, cymitar-shaped and
scolloped; the scollops distant, and having the flowers on them; flowers red.
REFERENCE TO THE PLATE.
1. A male flower, magnified.
2. The blossom of male flowers, spread open, with the honey-cups.
3. A Female flower, magnified.
4. The Germ from a female flower, cut transversely, magnified.
It should seem that this Genus has not been observed with sufficient
accuracy, at least those plants known to us, and which have been treated of
as belonging to the class Pentandria. The present one, for instance, which is
unquestionably the plant designed by Swartz, Commelin, Seba, &c. an is
acknowledged by Swartz to be triandrous and monœcious, yet that it should
be continued in the Kew Catalogue and by Willdenow, &c. to Pentandria, is
astonishing. We have no hesitation in declaring our opinion that the whole
genus as it now stands ought to be thrown to Phyllanthus. But, as the title
Xylophylla is so well known for these plants; we have thought it more safe
to give the Genus those characters the plants bear under their true Class and
Order, than make any alteration in it. The Xylophylla falcata is a native of
the West India Islands, and has been long cultivated in our hot-houses; so
long ago as the year 1739. It is a tender plant, and will not flower without the
assistance of the bark-bed; is easily propagated by cuttings; grows best in
sandy peat, and flowers in August. Our drawing was made at the
Hammersmith Nursery.
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

textbookfull.com