SUBSCRIBERS TO THE ANNALS OF OTOLOGY, RHINOLOGY, AND LARYNGOLOGY

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• Publication Date: November 30, 1949
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 r ~ ~= E ~ ?~.~w ..
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AfSTRI~TEf~ A
QS QEF~CQ~L~ ~~LY
THE
ANNALS
OF OTOLOGY
RHINOLOGY &
LARYNGOLOGY
b W1 L1Miai
T~ICTED
~S ~EE'IC~AI.S Q~~.
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THE ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY
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~~ o~~~~~~t~ a~~r
ANNALS OF
OTOLOGY, RHINOLOGY
AND LARYNGOLOGY
Lditor
ARTHUR W. PROI:.'fZ, M.U.,
Beaumont Building, St. Louis, 8
Associate L'ditor
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Missouri Theatre Building, St. Louis, 3
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A1navIN F. .ioNES, M.D. ? Ncw York
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Contents.
I-Antibiotics in the Treatment of Diseases of the Ear, Noae and Throat.
A. C. Furstenberg, M.D., Ann Arbor, Mich ....................................... 5
II-Diagnosis of Malignancy of the Nasophaxynx. Cytological Studies by
the Smear Technic. Lewis F. Morrison, M.D., Eugene S. Hopp,
M.D., and Rosalin Wu, M.D., San Francisco, Calif ............................. 18
III-The Relation between Hearing Loss for Specific Frequencies and
the Distance at Which. Speech Can Be Identified. E. Thayer Curry,
Ph.D., Urbana, Ill.-----?----??---?--------??---?--------?--?----------?---------------?--------- 33
IV-Tantalum in Rhino?plastic Surgery. Samuel L. Fox, M.D., Baltimore,
Md- ------------------------------------------------?-?-----?--------------------------?--??-?------...... 40
V-Vertebrated Magnets for Removal of Foreign Bodies from the Air
and Food Passages. Chevalier Jackson, M.D., and Chevalier L.
Jackson, M.D., Philadelphia, Pa ......................................................... 55
VI-Anesthesia in Fenestration Surgery. John Ilugh Tucci, M.D., Bos-
ton, Mass, _.........-?----?-?--??------? ......................... 61
VII-Chondro?ma and Chondrosarcoma of the Larynx. Melvin R. Link,
M.D., New York, N'. Y----------------------------------------------?------??------??----?--- 70
VIII-Some Physical Problems in Conduction Deafness. H. B. Perlman,
M-D., Chicago, IIL-------------------?--.--__.._....___......__....__........._....._.._....... 8G
IX-The Otologic Effects o?f Streptomycin Therapy. Linden J. Wanner,
M:D., Chicago, I11.-------?-----------------?--.....---------------------------?-------??-------- 11I
X-Amyloid Tumors of the Larynx, Trachea ar Bronchi. A Report of 15
Cases. David B. Stark, M.D., and Gordon B. New, M.D., Rochester,
Minn. -------?---??---??-?-------?--------?----------------?--...---?-----?----.....----....._..----.... 117
XI-C'ancellous Bone Grafts in Nasal Repair. Maurice H. Cottle, M.D.,
Roland M. Loring, M.D., Chicago, Ill., Maurice H. Cohen, M.D.,
Peoria, Ill., and Robert Kirachman, M.D., Chicago, Ill_ ____________________ 135
XII-Lateral Sinus Thrombosis. Review of Recent Literature and Report
of a Case. Peter D. Estella, M.D~., New Rochelle, N. Y., and Julius
H. Hopksns, M.D., Bronx, N. Y...-?------?------?----?--------------?-?--?--?---------.. 147
XIII-Angiosarcoma. A Review of the Literature. Joseph M. Kinkade,
M.D., Tuscon, Ariz.----------?-?--?---??-?-------?-?----?----?? ....................?..._.... 159
XIV-Carcinoma of the Antrum. Report of Nine Cases with aTen-year
Survey of Literature. Charles A. Seelig, M:D., New York, N. Y..... I:8
XV-Penicillin Aerosol Therapy in Sinusitis. Frank J. Hynes, M.D.,
New York, N. Y.----------?----------------------?--------?---??-------?-----------.?-..------?- 189
XVI-Naso~alveolar Cysts. Jack B. Miller, M.D., and Paul M. Moore, Jr.,
M.D., Cleveland, Ohio------------?-?---??--?-------------------?----.......--?--.....----.... 2~0
XVII-Cysts of the Nasal Vestibule. Fernand Montreuil, M.D., New
York, N'. Y ...........................................................?----?---------?........_...---. 21 Z
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Clinical Notes PAGE
XVIII-Neurinoma of the Facial Nerve in the Parotid Gland. John ].
O'Keefe, M.D., Philadelphia, Pa.--.------------------------?------.-.-----?------_--?-- 220
XIX--Congenital Posterior Choanal Occlusion. Lee R. Stoner, M.D.,
and Marvin S. Freeman, M.D., C1eveIand, Ohio________________________________ 226
XX-Oncocytic Cystadenoma of the Larynx. Max L. Som, M.D., and
Ralph Peimer, M.D., New York, N.Y_________________________________________________ 234
XXI-Factors Causing Delay in the Diagnosis of Lymphoblastoma.
Joseph G. Schoalman, M.D., and Henry A. Siegal, M.D., Chicago,
Ill. --?--------?-?-?-?-----?-?------?----------?-------------------?----?-------------------?------------ 243
XXII-Hiatoplasmoais of the Larynx. Edwin. B. Gammell, M.D., and
Robert L. Breckenridge, M.D., Philadelphia, Pa._._____________________________ 249
XXIII-Streptomycin in Acute Hematogenous Mastoiditis Due to Bacil-
lus Proteus. Morey Parkes, M.D., and Samuel Burtoff, M.D.,
Washington, D. C-----------------?--------?-?------?-?--------------------------------------._ 260
XXIV-Nontraumatic Aneurysm of the First Portion of the Right Verte-
bral Artery Associated with Vocal Cord Paralysis. David V. Habif,
M.D., New York, N. Y-------------?--------?-?-------------?-?---------?------------------._ 263
XXV-Location and Removal of Broken Needle in Tonsillar Fossa.
Herman I. Laff, M.D., Denver, Colo_________________________________________________ 2'68
XXVI-Otitic Hydrocephalus. Austin T. Smith, M.D., and Alvin Mir-
melstein, Capt., (MC) A.U.S., Philadelphia, Pa_________________________________ 275
XXVII-Frontal Sinus Infections-Complications and Management.
Claude D. Winborn, M.D., Dallas, Texas____________________________________________ 280
XXVIII-Foreign Body (Twig) in the Nose. Moses I. Marks, M.D.,
Cleveland, Ohio ---------?-----?-?----------------?--?-..?-----??---------------------------.._ 289
XXIX-A New Self-retaining Retractor for Use in Endaural Surgery.
J. Oliver Gooch, M.D., and Henry L. Williams, M.D., Rochester,
Minn- ---------------------------------------------?--._--?-----?----?------?-------------------------._ 293
Society Proceedings
Chicago Laryngological and Otological Society, Meeting of Monday,
November I, 1948. Food Allergy as a Cause of Myalgia of the
Posterior Cervical Muscles -The Problem of the Acoustic Neu-
roma -The Superior and Recurrent Laryngeal Nerves: Clinical
Conaiderations --------------------------------------------------------------?----------------._.. 295
Obituary
Lionel Colledge. F.R.C.S--------------------------------------------- --?----------?---??---?-?----- 303
Abstracts of Current Articles_______________________________________.._____.____-_-____-___._..._.. 304
Books Received -----------------------------------------------------------??-?-?--?-----------?--?--.. 313
Notices -------------------?--?-?----------?-----?-----------------------------------------------------------.. 318
Hearing Aida Accepted by the Council on Physical Medicine of The
American Medical Aasociation____________________________________________________________ 321
Officers of the National Otolaryngological Societies-______________________________ 322
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ANNALS
?TOLOGY, RHINOLOGY
AND
LARYNGOLOGY
VoL. S 8 MARCH, 1949
I
ANTIBIOTICS IN THE TREATMENT OF DISEASES
OF THE EAR, .NOSE AND THROAT
A. C. FURSTENBERG, M.D.
ANN ARBOR, MICH.
In this era of pervasive and uncontrolled utilization of the
antibiotics, there is justification, perhaps, for another review of thera-
peutic principles and a plea for their more thoughtful and sounder
application. With the discovery of penicillin, its allied agents, and
their mass production, clinicians have employed them in different
forms and by various methods for almost every illness in the category
of medicine. The urge to administer appears to transcend thera-
peutic rationale and provokes the use of the antibiotics for purposes
often obscure and irrelevant.
It is only natural that great inventions and discoveries should
gain wide acclaim and enthusiastic endorsement and enjoy universal
acceptance far in excess of that which they merit. The antibiotics
are typical examples. Their usage knows no limitations in the
practice of otolaryngology and methods for their administration, I'll
venture to say, will be restrained only when man's ingenuity fails
him in finding some new way of blowing or squirting the agent into
the human organism.
Read before the '~hicago ?Vlediail Society,
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Fortunately, in medicine we can look forward hopefully to a
reactionary wave which ultimately reduces a new discovery to its
true value. Medical investigators are rapidly placing the antibiotics
on the block of analysis, exploring their merits and classifying them
in accordance with intelligent and practicable principles of utilization.
In the case of penici~,lin these principles are clear cut and well
defined. They should be kept constantly in mind and sedulously
employed if one wishes to administer :penicillin in a rational and
scientific manner.
The first principle, well known to the profession, is an obvious
one, namely, that penicillin is a powerful antibacterial agent for
organisms for which it is specific. The vast majority of patients
with acute suppurative otitis media, furunculosis of the external
auditory canal, or acute nasal accessory sinus :disease will respond
promptly and effectively to the parenteral use. of penicillin. The
response, however, should not be delayed beyond a period of 72
hours. If resolution of the inflammatory process does not occur
within this time, to the extent that the patient is free from pain,
recovering from general reactive symptoms and exhibiting a decrease
in the quantity of purulent discharge from the ear or nose, it is
likely that one is dealing with an organism resistant to penicillin
and not amenable to this form of therapy. Unabated signs and
symptoms of-the acute infection call for bacteriological examinations
in an effort to identify the responsible organism and to determine
its sensitivity to the available antibiotics.
It would, of course, be an ideal in medicine if one might employ
bacteriological studies in every case of infection. Is the organism
sensitive to penicillin is a question we should like to have answered
in every instance of acute inflammatory disease. But it is doubtful
that a standard of such perfection is obtainable in the practice of
medicine today. It would be time-consuming and costly, and delay
in instituting specific therapeutic measures might prolong suffering
and cost Iives.
There can be no criticism of the present day practice of the
immediate administration of penicillin when the diagnosis of acute
infection is made, yet derision is justifiable when the antibiotic is
used indefinitely in the face of an unsatisfactory response. If an
acute infection in the middle ear, external auditory canal or nasal
accessory sinus is resolutely rebellious to penicillin therapy, it is
exceedingly important to identify the organism, determine its
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sensitivity or resistance and shift to another antibiotic if the
exigencies demand.
In the practice of otolaryngology one occasionally observes a
meningitis of otitic or sinus origin which fails to reveal the causative
organism in the spinal fluid. Unmistakable signs and symptoms of
the disease are present. The spinal fluid is under pressure and
cloudy. It shows a high cell count and other unquestionable labora-
tory evidences of a diffuse meningitis are observed.
Here, one is dealing with a killing disease. In spite of all
available therapeutic measures today, the mortality of pneumococcic
meningitis remains approximately 60%. The situation is too critical
to permit temporizing procedures until cultural studies demonstrate
the true identity of the infection. Delay is unwarranted and prompt
administration of both penicillin and streptomycin intramuscularly
and intrathecally is commendable therapeutics.
The matter of whether penicillin or streptomycin needs to be
employed intrathecally in meningitis is at present a controversial
issue. Our clinical observations give rise to the belief that this form
of therapy has some advantage over that in which the intramuscular
injections alone are employed. The trend of recommendation today
is, I believe, to use these antibiotics both systemically and intrathecally
when one is dealing with this dreaded disease. Moreover, one might
also advantageously employ the newest antibiotics, aureomycin or
chloromycetin, when so critical a condition as meningitis is at hand.
In short, everything that is available should be employed when we
are unable to reduce this serious problem to one for which a specific
antibiotic will furnish the solution.
Aureomycin and chloromycetin, the most recent therapeutic
discoveries, are exceedingly promising antibiotics. Their action is
interesting to a phenomenal degree. Current investigations have
indicated that they are effective when given by mouth; they permeate
cell membranes and are therefore particularly useful in the treat-
ment of the intracellular infections (rickettsial diseases). In our
limited experience they have not given rise to any of the toxic
symptoms which have occasionally restricted the use of the other
antibiotics. Among their many promising features, they seem to
overcome the cellular barrier to the spinal fluid; when given by
mouth they yield a concentration in the spinal fluid equal to S O ?lo
of that observed in the blood serum. Their ability to permeate
cell membranes, their consequent intracellular action and their rapid
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dissemination to the spinal fluid, make them agents of great promise
in the field of the antibiotics.
The second important principle governing the effectiveness of
penicillin is that the antibiotic must come in actual contact with the
organism and maintain a sustained contact. This obviously is
accomplished when penicillin is carried to the middle ear or to the
mucous membranes of the nasal accessory sinuses by the hematogen-
ous route, but falls short of this objective when. used locally in the
nose or throat. It is futile to expect phenomenal results from
penicillin sprayed into the nasal cavities. The common head cold is
a virus disease for which penicillin is not specific. There is, more-
over, considerable proof that the virus is intzacellular and the in-
fection submucosal, deeply situated beneath an edematous inflamed
mucous membrane. It is inconceivable, therefore, that penicillin
sprayed or dusted onto the mucous membrane. surfaces can possibly
reach the site of infection, even though it might be specific for the
offending virus.
Another physiologic factor which seriously militates against a
sustained contact between the penicillin and the infecting organisms
in the nose is the rapid vibration of mucous membrane cilia. Myriads
of these microscopic hairlike structures vibrate at the rate of seven
times a second and rapidly carry secretions posteriorly into the
pharynx. It is a matter of verity that any substance not possessed
of a cauterizing or corrosive action, sprayed or instilled into the nose
rapidly makes its escape into the pharynx by ciliary action.
It follows, therefore, that penicillin aerosol is of equivocal
value in the nose. It is not specific for the virus of the common head
cold and when sprayed or instilled into the nasal cavities, rapidly
disappears from the surface secretions. Even ifs it were present for
a sustained period and specific for the organisms which are secondary
invaders it could hardly be expected to reach these infections, situated
as they are in the deep structures of the nasal mucoua. The secondary
infections of acute rhinitis, the significant one of which is acute
nasal accessory sinus disease, are not lying on the surface of the
schneiderian membrane. They are submucosal, underneath the
swollen, inflamed superficial structures and not reached by agents
placed upon the surface of mucous membranes. Nothing has
happened in my experience to justify a continued interest in this
form of therapy.
Apropos of this discussion, it is to be emphasized that when
intranasal medication is used, for example a vasoconstrictor, the
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ANTIBIOTICS g
most acceptable method is to introduce the agent by a medicine
dropper into each nostril with the patient in the head low position.
Cawthornc has demonstrated that thorough coverage of the nasal
mucoua with a medicinal agent is best accomplished by the drop
method with the subject in the dorsal recumbent position with head
hanging backward and downward so that the crown of the head
faces the floor. This technique seems to have a distinct advantage
over the use of the spray, in that wider dissemination of the medicinal
preparation over the nasal mucous membrane is achieved.
We have found little reason to share current enthusiasm in
regard to the value of penicillin when used locally in the mouth and
throat. In co-operation with our Department of Bacteriology, we
have found it possible to reduce the number of organisms in the
mouth and pharynx by the use of penicillin lozenges, but the latter
have been of little value in the treatment of tonsillitis and pharyn-
gitis. The Streptococcus viridans was noticeably affected by this
form of therapy and in some instances was practically eliminated
from the throat flora. This organism, however, did not seem to be
the offender in most instances of acute infection and obviously
those that were causing the disorder were either resistant to the
penicillin, or not adequately contacted by the lozenge to cause their
destruction. It was noted that penicillin, as a rule, could not be
demonstrated within the mouth 10 minutes after the disappearance
of the lozenge and this was true even when five lozenges were taken
in succession within one hour.
It would appear that if penicillin is to be used for mouth and
throat infections, we must rely upon its systemic administration.
There is plenty of clinical evidence to support the contention that
this form of therapy is of distinct value in the treatment of acute
follicular tonsillitis, retropharyngeal and peritonsillar infections, acute
pharyngitis and Vincent's angina. The local employment of the
agent, however, is not dependable. An exception to this rule may
be found, perhaps, in the treatment of ulcerative lesions in the mouth
by direct application of cotton tampons saturated with penicillin
solution, 10,000 to 15,000 units per cc. Some of the mucous mem-
brane lesions of the blood dyscrasias as, for example, the leukemias,
have seemed to improve clinically when treated in this manner. A
plcdget of cotton saturated with penicillin solution is placed in the
lingual or buccal sulcus in direct contact with the ulcer and allowed
to remain for twenty minutes or longer, four or five times a day.
Obviously the effect is not curative but occasionally phenomenal
improvement is observed, due, no doubt, to the resolution of the
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customary secondary infections. In my experience, this technique of
administering penicillin locally is the only one wcarthy of mention.
Medical as well as lay literature has recently popularized
penicillin aerosol for many of the lower respiratory infections, such
as bronchitis, whooping cough, bronchiectasis, lung abscess, etc. The
results of this form of local administration of penicillin have been
most discouraging i.n our clinic. There is little we can say in its
favor. The method has not been effective in the treatment of lung
abscess and to date there has been insufficient improvement in our
patients with bronchiectasis to place any reliance in this form of
therapy. It is to be noted that some of the advocates of penicillin
aerosol recommend rather large doses of 15,000 to 30,000 units per
cc. of saline solution sprayed into the lower air passages every two
or three hours. In a few instances where doses cif these proportions
have been employed, we have found appreciable. blood levels of the
antibiotic. We strongly suspect, therefore, that some of the opti-
mistic reports of penicillin aerosol are based on the results of
absorption and systemic spread of the antibiotic. It is doubtful that
this technique of local application accomplishes more or even so
much as the intramuscular injection of the antibiotic. Until certain
reservations are dispersed by further studies of .penicillin aerosol and
somewhat less cumbersome and fatiguing techniques made available
for its usage, we have little to offer in its support.
Contrary to this view, however, we find that the local instil-
lation of pencillin into bronchiectatic cavities through the broncho-
scope is a measure worthy of consideration. We have seen some
examples of phenomenal improvement-when penicillin has been used
locally in this manner. The bronchiectatic cavity is visualized by
direct inspection through the bronchoscope, secretions are aspirated
and 2 or 3 cc. of penicillin in saline solution (50,000 units per cc.)
are instilled directly into the bronchiectatic cavity. Treatment is
employed three times a week until satisfactory improvement is
obtained.
The third maxim pertaining to the use of penicillin is one
worthy of recognition, namely, that the antibiotic is not effective
when used systemically in the treatment of a chronic abscess. The
surrounding capsule prevents the penicillin from reaching the local-
ized purulent collection and even when injected for its local effect, the
necrotic tissue within the abscess is a deterrent to antibiotic action.
It is also true that a foreign body within a circumscribed collection
of pus renders the latter resistant to penicillin. therapy. Although
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ANTIBIOTICS 11
these principles have been known since the National Research Council
gave them to the profession several years ago, it is not uncommon to
find the physician puzzled by the fact that penicillin has had no
effect upon a deep seated chronic abscess in the neck, or upon an
osteomyelitis of the cranial bones. Penicillin does not reach an
encapsulated abscess deep in the triangles of the neck and it cannot
be expected to cure a well established chronic inflammatory process
in the bones of the skull. It is true that the antibiotic often appears
to arrest the progress of an osteomyelitis or to prevent the spread of
a peritonsillar abscess or a case of Ludwig's angina, but these pro-
cesses, when once established, are not eradicated by this form of
therapy. Penicillin may be supportive; when used pre-operatively, it
inay be expected to prepare the patient for formidable surgical pro-
cedures which he might not otherwise tolerate, and when employed
postoperatively, it is a well known fact that it tends to prevent the
dissemination of infection and thereby reduces the incidence of
serious complications.
But to be more specific, I know of no authenticated instance
of any of the antibiotics having cured a chronic suppurative otitis
media and mastoiditis, or a chronic nasal accessory sinus disease, either
when used systemically, locally, or by both methods. In each of these
conditions there are factors present which adversely influence the
action of the antibiotic. In the chronically infected ear and mastoid
we encounter a thickened edematous membrane comparable to the
abscess capsule. The tympanum and mastoid cells contain necrotic
tissue and the chronic osteomyelitic process frequently gives rise
to the sequestration of bone and the foreign body so manifestly
deterrent to antibiotic activity.
Similarly, we have comparable pathological changes in chronic
nasal accessory sinus disease. The mucous membrane is thickened
and polypoid. Scarring is present in varying degrees, necrotic tissue
is in evidence throughout the sinus cavity and one frequently finds
the lining mucous membrane studded with multiple discrete abscesses
which by no stretch of the imagination could be eradicated by peni-
cillin therapy. Moreover, it is not uncommon to note signs of an
osteomyelitis beneath the lining. mucous membrane, another im-
portant factor which militates against the success of the antibiotic
therapy.
I freely admit that it is extremely difficult to evaluate accurately
and scientifically the results of most therapeutic procedures because
of our inability to observe a group of controls. Any experiment of
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unassailable scientific accuracy must necessarily call for a series of
cases with identical factors of age, resistance, tissue immunity, patho-
logical change, anatomical development, bacterial influence, etc., in
which specific therapy is employed in one-half of the group and
some other procedure, or no treatment at all, in the remaining half.
Obviously, ideal situations of this character do not exist in otolaryn-
gological practice. Nevertheless, over a period of years when the
antibiotics have been extensively employed both systemically and
locally, our observations lead to the conviction that these forms of
therapy have no place in the treatment of chronic suppurative otitis
media and mastoiditis, and chronic nasal accessory sinus disease.
They do not permit the violation of sound principles of surgery.
Operative procedures are imperative if one hopes to obtain a cure,
although as already emphasized, penicillin may often be an exceed-
ingly important supportive measure.
Experience in the practice of medicine has frequently led to the
observation that penicillin is the vanguard of many therapeutic pro-
grams. In otolaryngology it has been employed for everything from
nerve deafness and tinnitus to the psychogenic disturbances under-
lying an hysterical aphonia. I refer to these conditions, not in a
facetious sense, but to broach a premise that penicillin employed in
a healthy individual may not be devoid of harmful effects. I ain
frequently consulted by the apprehensive patient who has received
a vigorous course of penicillin therapy, because someone discovered
a streptococcus in his throat. I need not point out to you that there
is nothing abnormal in this finding. It is an organism that one
expects to find in nearly everybody's throat.. There is a normal
basic flora for the upper air passages and the nonhemolytic strepto-
coccus is the chief inhabitant of these regions.
It is a well known fact that the discovery of any particular
type of organism in one culture taken from the throat has no
clinical significance. In most instances, it is only a representative
of normal flora. In other cases it may be just a "hanger-on" that
has adapted itself temporarily to the environment of the upper air
passages. Again it may be a recent pathogenic offender which is
held over in the crypts of the tonsils after the i,ifection for which
it is responsible has resolved. Or, in the last category, it may be
the agent of an epidemic which has adapted itself to the mucous
membrane of the pharynx in some strange manner without pro-
ducing the reactions for which it is pathogenic. The meningococcus,
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Hernophilus influenzae and the hemolytic streptococcus are often
found in the throats of individuals in communities where these in-
fections have been occurring in epidemic form.
Smith and Bloomfield have clearly stated, on the basis of care-
ful studies of cultures taken from the upper air passages of human
subjects, that "in order to draw any safe conclusions as to the
significance of an organism isolated from the upper air passages, cer-
tain technical specifications must be met. The culture should be
(a) serial or repeated, (b) quantitative in the sense of some method
of plating which gives an idea of the relative numbers of the
various organisms isolated and (c) topographical, that is to say,
simultaneous swabs should be taken from the pharynx and each
tonsil or tonsillar region in order to differentiate local carriage from
free growth on the mucous membrane."
But what is of importance clinically is the fact that these ob-
servers have discovered that penicillin administered to individuals
free from active respiratory infection often changes the normal basic
flora of the pharynx. A coliform bacillus frequently appears in the
throat during penicillin therapy. In short, changes in "balance
of power among the throat flora" may be induced by antibiotics.
Specifically, it is altogether possible that under these circum-
stances one may replace nonpathogenic throat organisms by harmful
intruders.
I am convinced that this observation has been made a number
of times in my practice. Penicillin employed for some vague throat
irritation, often in the patient worried about cancer, has been fol-
lowed by an acute pharyngitis with general reactive symptoms. In
several instances, the mucous membrane of the throat was fiery
red, extremely sore, and because it led to the suspicion of some
toxic allergic reaction, an order to discontinue penicillin therapy was
issued. A return of the pharyngeal mucous membrane to normal
promptly occurred. In the light of observations made by Smith
and Bloomfield, a logical explanation for this clinical phenomenon
seems to have been posed.
In a further discussion of the antibiotics in otolaryngological
practice, one must refer to the great value of streptomycin in
tuberculous lesions. It seems to have exhibited its superior effective-
ness in the treatment of tuberculous adenitis and the mucous mem-
brane lesions produced by the tubercle bacillus. In laryngeal and
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trachiobronchial tuberculosis, one gram of streptomycin is adminis-
tered daily. It is not necessary to maintain a blood level. When
employed locally for tuberculous lesions, streptomycin in the nose
and larynx has not yielded satisfactory results.
Tuberculosis of the middle ear and mastoid is not a rare observa-
tion in an otological clinic and occasionally these conditions are com-
plicated by a tuberculous meningitis. Streptomycin has been used
both intramuscularly and intrathecally with effects which are hope-
ful in a disease otherwise highly fatal. In many cases, approxi-
mately 8 S %, the effect has been only that of an intermission or a
remission. Nevertheless, conservative statistics seem to indicate that
1 S fo of the patients are cured and it is hoped that other tubercu-
locidal substances will soon be found that will. add to these numbers.
In tuberculous meningitis SO mg. of streptomycin is administered
intrathecally every second day for a period of: six weeks or longer.
In our experience four patients who have apparently recovered
have been profoundly deafened, one of whom has had no auditory
sense for a period of two years and consequently is obviously per-
manently disabled. There can be little justification, however, for
assuming that the deafness is a direct result of the intrathecal adminis-
tration of streptomycin. Tuberculous meningitis is a deadly malady,
destructive to nervous tissue, and therefore might well be expected to
be directly responsible in itself for the auditory nerve injury. In
this connection it is interesting to note that two of the children with
profound hearing impairment aftex? recovery from tuberculous
meningitis did not receive streptomycin by the intraspinal route.
We have been particularly interested in the effect of strepto-
mycin upon the equilibratory mechanism. As has been noted since
the early discovery of this antibiotic, many patients develop vertigo
when streptomycin is administered intramuscularly as well as in-
trathecally. In the caurse of a few days after the initial dose of
streptomycin, one notes that the vestibular responses to the caloric
test are diminished. The hypo-activity slowly progresses until the
end of the third week of daily therapy, at which tune the caloric
labyrinthine reactions entirely disappear. It is at this juncture that
the patient exhibits vestibular manifestations.
It is significant that the vertigo is not that typically produced
by stimulation of the static labyrinth. It is not a true dizziness;
not that normally produced when the internal ear is stimulated by
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heat and cold or an electric current. The symptomatology is more
in the nature of giddiness or unsteady feeling, an ataxia as it were,
and not the true vertiginous seizure that characterizes an end organ
stimulation or lesion.
As might be surmised, pathological studies of the internal ear
fail to demonstrate that streptomycin exerts its toxic effects upon
the end organ. Meniere's disease which is due to a labyrinthine
hydrops and is characterized by violent attacks of dizziness is the.
classic example of a lesion within the internal ear. Pathologic studies
of the otic labyrinth have failed to indicate any changes which might
be attributed to the neurotoxic effects of streptomycin. We do not
know precisely the location of the pathological change produced by
this antibiotic, 'although we suspect that it must be situated some-
where in the basal nuclei or along the corticobulbar fibers of the
auditory nerve.
The catalytic hydrogenation of streptomycin has produced an
antibiotic, dihydrostreptomycin, which appears to be approximately
70 ?Jo less neurotoxic than the original preparation. In our hospital
it has largely replaced the latter agent for parenteral administration
because it can be given in larger doses, two grams daily, with little
or no effect upon the auditory and equilibratory mechanisms. It
is not advocated, however, for intrathecal use because it is irritating
to the meninges and therefore less satisfactory for intraspinal in-
jection than streptomycin. With improved methods of purification
it is hoped that this disadvantage may soon be overcome.
In recent cases of tuberculous meningitis, dihydrostreptomycin
has been employed intramuscularly and streptomycin intrathecally
with encouraging results. The resistance of organisms to both
preparations when used for long periods seems to be manifest to
an equal degree. It has been noted that when two grams of strepto-
mycin is administered systemically for 12S days, 75% of the patients
will demonstrate resistant organisms. If, however, only one gram is
employed daily for a period of 42 days, this percentage is reduced
to 25 ?/o. In those cases of mucous membrane tuberculous lesions
which have come under our observation, we have endeavored to
gain this advantage by using the minimum dose of one gram daily
for a period not to exceed six weeks.
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1. Nearly all the acute infections of the ears, nose, sinuses
and throat respond in a grratifying manner to the parenteral adminis-
tration of penicillin. The isolation and identification of the causative
organisms in every case of infection is an idealistic pronouncement
but hardly feasible and practicable in every day practice. When,
however, a definite clinical response to the antibiotic is not promptly
observed, the organism must be identified and its sensitivity de-
termined. No other course will permit the rationalization of specific
therapy.
Z. When dealing with meningitis where time is an essential
factor, delay for the identification of the organism can hardly be
advocated. There can be no eoinpromise with the prompt institu-
tion of therapy. Antibiotics of proven values, penicillin, strepto-
mycin and even aureomycin or chloromycetin, particularly the latter,
when an intracellular infection is suspected should be employed in
maximum dosage in conjunction with chemotherapy. It goes with-
out saying, however, that some of these agents will be eliminated
in favor of the specific antibiotic when the causative organism is
subsequently discovered and its sensitivity determined.
3. Penicillin, to be effective, must come in actual contact with
the organism and maintain a sustained contact. The difficulty of
applying this principle to the upper air passages is accountable, per-
haps, for the disappointing results observed from the popular methods
of topical administration. Penicillin aerosol is of little value in the
treatment of bronchiectasis, although the direct application of con-
centrated solutions of penicillin to the bronchiectatic cavities through
the bronchoscope has been productive of encouraging results.
4. A dense capsule surrounding a chronic abscess in the neck
is a barrier to penicillin therapy. Likewise, necrotic tissue or a
foreign body within the abscess renders the lesion resistant to the
antibiotic. Similar factos?s which influence adversely the effective-
ness of penicillin are found in chronic suppurative otitis media and
mastoiditis, osteomyelitis of the calvarium and facial bones, and
chronic nasal accessory sinus disease. These pathological entities
are not cured by any antibiotic in our present therapeutic arma-
mentarium, either when used systemically, locally or by both methods.
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aNrrlirorres 17
S. An admonition seems timely in regard to the possible in-
juri~~us effects of penicillin in the absence of infection. The normal
basic: flora of the throat may be altered to include harmful organisms.
It is to be emphasized also that the prolonged administration of the
antibiotic inay produce resistant organisms which fail to respond
to penicillin therapy at some subsequent time when the antibiotic
is sorely needed. We have a staff member under our observation
today who has received intensive penicillin therapy for a chronic
maxillary sinusitis. The treatment has been futile. More perturbing,
however, is the fact that he harbors a pneumococcus in his antrum
which is resistant to penicillin. This raises the question, has this
patient lost an important defense against the possible future develop-
ment of pneumococcic complication?
6. Streptomycin is particularly effective in tuberculous cervical
adenitis and in tuberculous mucous membrane lesions. It is highly
probable that its allied agent, dihydrostreptomycin, which is com-
paratively free from neurotoxic effects, will replace the original
antibiotic in the treatment of these conditions. Until further
experimentation yields an improved product devoid of irritating
effects, dihydrostreptomycin cannot be advocated for intrathecal
administration.
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DIAGNOSIS OF MALIGNANCY OF THE NASOPHARYNX.
CYTOLOGICAL STUDIES BY THE SMEAR TECHNIC
LI:~w Is F. MORRISOIV, M.D.
L''UGENE S. HOPP, M.D.
AND
IiOSALIN w' U, vLD,
SAnr FRANCISCO, CALIF.
The results of the cytological studies for diagnosis of nasopharyn-
geal malignancy by the smear technic are excellent. The procedure
is not offered as a substitute for histopathological diagnosis from
biopsy material but is recommended as an adjunct means of arriving
at a diagnosis. The technic is not difficult but is exacting. A nega-
tive smear does not eliminate the possibility of a nonexfoliating
lesion. A positive smear signifies the presence of an exfoliating lesion
in the upper respiratory tract. It is then mandatory that the origin
of the cells be found, the area biopsied and the final diagnosis made
from the tissue. Thus far no false positive smears have been found.
Such limiting factors as are present will be brought up under sub-
sequent headings.
The nasopharynx has maintained a fair degree of interest
throughout modern literature. The amount of this interest has
varied with the contributions and the contributors. The recent
wave of increased attention to this area is the direct result of the
numerous contributions emphasizing the importance of hypertrophic
and hyperplastic lymphoid tissue in, on and about the eustachian
orifice. As a result of this widespread information, attention has
been redirected to the area and tumors and malignancies of the
nasopharynx have regained importance as subject matter. No one
can review the literature on this subject without being impressed by
the fact that all contributors agree on two points: the importance
of early diagnosis and the difficulty in making an early diagnosis.
From the Department of Otorhinolaryngology, Divisign of Surgery, Univer-
sity of California Medical School, San Francisco, Californ~.
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Pig. 1.-RV., white female, aged S 1. Cemp'aint: Di:ficulty with
breathing through nose for over one year, tingling in left side of tongue
and palate for several months and paralysis of left external rectus muscle
of three weeks' duration. A. Smear showing normal cellular elements:
a ciliated columnar cell, a lymphocyte and squamous epithelial cells. B.
Biopsy. The surface mucous membrane is intact. This fact accounts for
the negative smear, There is no opportunity for exfoliation of malignant
cells. Diagnosis: Cylindroma.
The first point needs no elaboration. The general consensus of opin-
ion explaining the second point is summarized as follows:
1. The initial lesion is usually small.
2. The condition is usually asymptomatic until metastases
3. The first symptoms frequently are referred to some other
structure such as the neck, eye or ear.
4. The area is not as accessible for examination as are most of
the other structures of the nose and throat. ~ Many otorhinolaryn-
gologists do not make the examination of the nasopharynx a neces-
sary part of their routine examination.
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Fig. 2.-E. S., white female, aged 62. Complaint: Severe epistaxis.
History of right nasal obstruction of several months' duration. A. Smear
showing group of malignant cells. B. Biopsy. Diagnosis: Adenocarcinoma.
S. The variations in the appearance of the islands or masses of
lymphoid tissue in the nasopharynx that may be considered "within
the limits of normal" are greater than in other areas of the upper
respiratory tract.
6. It is difficult to obtain satisfactory and representative biopsy
specimens.
Such unanimity of opinion warrants attention. The various
credited ways and means of examining the nasopharynx and the
methods of evaluating the findings were reviewed acid discussed in de-
tail. Each had advantages and disadvantages. All a=cre found lacking
on one important point: negative findings did not rule out the possi-
bility of the presence of an unobserved malignancy. The suggestion
that the smear technic might have something to offer was presented.
The present available literature had nothing to offer on this subject.
The interest in the application of the excellent results obtained
by the smear technic as reported by Papanicolaou and Trautl in de-
tecting cancer cells in vaginal secretions to secretions from other areas
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Pig. 3.-J. G. R., white male, aged f 2. Complaint: Increasing ob-
struction of the right side of the nose of one year's duration. The right
ear has felt "stopped-up" for several months. A. Smear showing the large
number of malignant cells sometimes found in a single field. B. Biopsy.
There is marked similarity between the appearance of the cells in the fixed
tissue preparation and those in the smear. Diagnosis: Lymphoepithelioma.
had reached a point of justified enthusiasm. The examination of
bronchial secretions had proved its value in the diagnosis of -early
bronchogenic malignancies. It was logical to assume that a similar
technic could be used as an adjunct measure in the diagnosis of ex-
foliative lesions in the nasopharynx. The literature on the subject
of the recognition of cancer cells in body secretions is emphatic on
several points. One of the more important points is the necessity of
exact knowledge of the normal cellular content of the secretions
f rom a definite area. This means not only the ability to recognize
and classify the cells in their adult prime state but also in the varying
stages of senility and disintegration. This is atime-consuming bit
of exacting work but is essential, fundamental background.
No progress could be made until the normal cell content of the
secretion of the nasopharynx had been established. The normal
histology of the area is well known. A brief resume of this knowl-
edge shows that with the exception of a few areas the mucous inem-
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Fig. 4.-J. S., Negro male, abed 37. Complaint: Right frontal and
temporal headache and diplopia of four months' duration. A. Smear
shows variation in size and shape of malignant cells. B. Biopsy. Diagnosis:
Lymphoepithclioma.
brane that covers the nasopharynx is composed of a layer of pseudo-
stratified, ciliated, columnar epithelium. The apparent stratification
is due to the fact that thc:~ cell nuclei are distributed in several planes.
In the corium, beneath the surface epithelium, are numerous closed
lymphoid follicles. At the junction of the nasopharynx and oro-
pharynx there is a distinct change in the surface epithelium. A
characteristic of the latter area is that the surface cells are no longer
ciliated and are typically squamous. This knowledge offered a start-
ing point for orientation as to the origin and type of cells one would
consider normal constituents in the secretions of the nasopharynx
(Fig. 1) .
It was realized that the whole project might bog down if the
activities were confined wholly to obtaining a knowledge of the
normal cell population of the nasopharyngeal secretions. In order
to alleviate some of the drudgery phase, obtain peak enthusiasm and
at the same time have some basis for a check on the results, the smear
technic was applied to visible lesions of the mouth, tonsils and larynx.
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Fig. S.-H. T. G., Chinese male, aged 26. Complaint: Swellings in
neck for several weeks. tl. Smear showing a single malignant cell and a
nearby polymorphonuclcar leucocyte. There are several other fields that
show a sirnil.ar picture. None of the fields showed any grouping or clump-
ing of the malignant cells. B. Biopsy. Diagnosis: Transitional cell car-
cinoma.
The suggestion obtained the desired results as far as the interest factor
was concerned and in addition produced some findings that are
worthy of consideration. These findings are presented in Table 1.
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Fig. 6.-K C. C., white female, aged 4. Complaint. Sent into hos-
pital with diagnosis of question of cavernous sinus thrombosis as a compli-
cation of left pansinusitis. The "sinusitis" had been treated for three
months with several courses of various sulfa compounds and antibiotics.
A. Smear showing malignant cells and a multinucleated gia^.~ cell. B. Biopsy.
Diagnosis: Adenocarcinoma.
The one false negative; report (negative smear with positive
biopsy report) is readily explained by the fact that the laryngeal
lesion, although somewhat extensive, was of the so-called intramu-
cosal type. There was no evidence of ulceration or abnormal ap-
pearance other than smooth enlargement of the involved area. The
biopsy specimen showed an intact, normal appearing epithelial sur-
face. The unmistakable malignant cells were in .and beneath the
submucosa. Under these conditions one would not expect to find ex-
foliated malignant cells. This case did attest to the veracity of the
investigators. The visible clinical evidence of the malignancy of the
lesion in situ was classical. With these findings and the least bit of
wishful thinking it would have been a simple matter tcy find one or two
slightly atypical normal cells that would have justified aplus-minus
or suspiciously positive report from the examination of the smear.
It was not until several days later when the stained. paraffin sections
of the biopsy material were available that a positive diagnosis of
maignancy was made. In retrospect it is evident that one step was
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omitted.. After the biopsy material had been obtained a smear should
have been made from the raw surface of either the specimen or the
area from which the specimen had been removed. This can be done
without injury to either the specimen or the patient. This was done
in two later cases, one nasopharyngeal tumor and one tumor of the
hard palate, and produced excellent results.
Technic. No attempt to obtain secretions from the nasopharynx
is made until the routine examination of the ears, nose and throat
is completed and the findings noted. When this is completed the
nose mucous membrane is shrunk and anesthetized. The topical
application of a 2 ~/o solution of Pontocaine with one drop of 1:1000
adrenaline solution to each applicator is used for this purpose. The
use of adrenaline or epinephrine solution as a shrinking agent is not
permitted for routine decongestion purposes. However, the vigor-
ous action of these agents is necessary for detailed examination of
the nasopharynx. The advantages are sufficient to negate the im-
mediate and secondary reactions that may follow their use. In some
instances a variation in reaction to the usual blanching effect is in
itself grounds for suspicion as to the normalcy of the differentiated
area. In a very few minutes one is able to obtain a surprisingly good
view of the nasopharynx through one or both nares. Before any
smears are taken, the nasopharynx is thoroughly examined by means
of both the posterior rhinoscopic mirror and the nasopharyngoscope.
When these examinations are complete a tightly wound cotton
tipped applicator is passed directly to the nasopharynx through the
anterior naris. In order to be certain that both representative and
adequate material be obtained, the cotton must rub on the surface
of the nasopharyngeal mucoua and should preferably contact as much
of the nasopharynx as is possible. One's endeavors to obtain repre-
sentative surface cells should not permit tissue damage. A few red
cells in the smear may be commendable. Active bleeding is con-
clusive evidence of poor technic. Following the removal of the ap-
plicator the smears are made by gently rubbing the obtained secre-
tions on a clean, dry slide. The slides are immediately immersed in
the fixative solution consisting of equal parts of 9 S fo ethyl alcohol
and ethyl ether. The staining technic follows the modified method
of Papanicolaou and Traut2 used in the Vincent Laboratory, Massa-
chusetts .General Hospital, with but one exception, in step No. 6,
EASO replaces EA36 or 25.
Microsco~iic Findings-Normal. A knowledge of the histology
of the area offers a foundation for the kinds of cells one would expect
to find as normal constituents of the secretions from that area. One
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point should be considered before a description of the cell population
is presented. The exfoliated cells will all be adult, past their prime
and many will show evidence of lytic or autolytic change. .Even
when one has been more vigorous than necessary in swabbing the area
with the cotton tipped applicator only adult cells will be obtained.
In general, the exfoliated cells are larger than the same type of cell
when it is functional and in the relatively crowded normal surround-
ings. With this knowledge as a background, one would expect to
find, and does find, in the. smears from the nasopharynx numerous
ciliated columnar cells, columnar cells which have lost their cilia,
lymphocytes, polymorphonuclear leucocyces and occasional clasmat-
ocytes or tissue macrophages. These tissue macrophages can readily
be confused with malignant cells due to their characteristic variation
in size and shape. In addition, one commonly finds squamous epi-
thelial cells, bacteria, and erythrocytes. The presence of erythro-
cytes in the normal smear is the direct result of trauma caused by
the cotton tipped applicator. The normal columnar cells usually
present a clear cytoplasm. One common variation. is the foamy or
globular cytoplasm encountered normally during the secreting phase
of the goblet cell. The nuclei vary as to size, shape and position in
the cell. They are relatively large, oval in shape, and contain distinct
nucleoli. The chromatin content is evenly distributed as fine gran-
ules. The nuclear wall is distinct but not thickened or irregular. A
description of the characteristics of the cells that. permit classifying
a smear as "positive" is of no value to any one wlio is not familiar
with the cell content of the secretions obtained from the average,
routine, so-called normal nasopharynx.
Microscoj~ic Fijz~lin-gs--Malignant. The cell nucleus, rather than
the cytoplasm, presents the characteristics that permit the cell to be
classified as malignant. A brief outline of these characteristics pre-
sents only the outstanding points of differentiation from the normal.
An enlarged nucleus and nucleolus with abnormal chromatin con
tent are significant. The eccentric position of the chromatin simu-
lates athickened nuclear membrane. The enlarged nucleoli may ap-
pear eosinophilic. These nuclei are frequently surrounded by a small
amount of cytoplasm. The cell wall is often distorted, indistinct or
absent. The presence of clumps of these cells is most significant
(Fig. 3) . The outlining of the differentiating characteristics in this
simple way is disarming to only the novitiate who, in his present
status, should be permitted the assumption that the opportunity for
confusing distorted normal cells with the characteristic malignant
one is unlikely. Such confusion is not only a possibility but a prob-
ability in poorly prepared, fixed or stained smears.
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DIAGNOSIS OF MALIGNANCY 27
Practical Application of the Method. The number of patients
with tumors of the nasopharynx available for study at any one
period of time is never large. We were fortunate on two scores, first,
there was a small backlog of post-radiation patients who had con-
cluded their therapy at periods of time ranging from a few months
to ten years; second, among the number of patients who reported for
one reason or another eight were found to have malignant lesions in
the nasopharynx. Not an overwhelming number, to be sure, but
sufficient for establishing the validity of the method. The results are
presented in Table 2.
Number of cases examined 85
Fosi,ive smear 7
Negative smear 77
False positive (Positive smear, negative biopsy) 03=
False negative (Negative smear, positive biopsy) 1
Positive biopsy 8
'~ In one instance the persistence of a positive smear encour-
aged repeated biopsy. The fifth biopsy showed anaplastic
carcinoma.
In this series as was the case in those presented in Table 1, there
is a surprising agreement between the smear technic and the histo-
pathological diagnosis. The one false negative warrants elaboration.
The patient presented definite evidence of an extensive lesion in the
nasopharynx as demonstrated by paralysis of the left sixth nerve,
diminished hearing in the left ear (conduction type with a serous
otitis media), roentgen evidence of extensive destruction of the base
of the skull, and a visible tumor in the left nasopharynx. It was a
moderately rounded mass occupying about one-third of the available
space of the left nasopharynx and arose from the vault and posterior
wall. It was covered with normal appearing mucous membrane.
There was no evidence of ulceration or breakdown. The tumor
mass was readily visualized by posterior rhinoscopy. The histo-
pathological picture verified the fact that the surface covering was
normal and intact. The neoplasm was a typical cylindroina. Nat-
urally there would be no exfoliation of malignant cells.
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28 MORRISON-IiOPP-W U
Two post-radiation patients are included in the group of nega-
tive smears. One has been symptom free for ten years and the other
for eleven years following extensive courses of deep x-ray therapy.
Both have a dry or relatively dry nasopharynx and one has an area
on the upper posterior pharyngeal wall about 1. S cin. in diameter
that acts as a site for crusting. This area corresponds to the loca-
tion of the neoplasm prior to treatment. It is almost twice the size
of the visible portion of the neoplasm when the original biopsy was
done. It is of interest that smears from both thew. patients showed
a preponderance of squamous cells and no ciliated, columnar cells.
'I"he available literature dealing with the application of the
smear technic for diagnosis of exfoliating lesions in the upper
respiratory tract was reviewed in the hope that soiree one had
preceded us in using the method for lesions in the nasopharynx. We
found no mention of its having been used in this area. Several of
the more recent articles and especially those dealing with the find-
ings obtained from sputum brought up points that are entitled to
limited discussion prior to confining our thoughts to the nasopharynx.
Formal and informal discussions of the validity of the method
and the veracity of the investigators employing 'the smear technic
leave no question but that there are some who would deny both. A
recent article3 contains tu~o statements in the introductory para-
graphs that may be used to substantiate this view. The first state-
ment reads in part: "It is necessary also that the pathologist have
no knowledge of the clinical status or even the age of the patient."
The second statement, also in part, reads: "All of the interpretations
were made by a single observer on the basis of numbered slides, with
no inkling of the clinical nature of the case." It so happened in our
series of cases that the report on the smears was available one to three
days before the fixed tissue slides were stained and mounted. This
was not the result of any forethought on our part; it just happened
that way. All three of us saw all of the cases and freely discussed
the clinical picture prior to obtaining the smears and biopsy material.
The entire responsibility of preparing, staining and scanning the
smear preparations fell to the lot of Dr. Wu. The two false nega-
tive cases and the one case v~rherein five biopsies were required to rule
out a false positive report offered ample opportunity for permitting
slight deviations in the cell population to be classified one way or the
other, depending on the clinical findings and the mental attitude of
the investigators, were it nc>t for the fact that the negative smears
contained only cells that vc-ere normal or variants of normal, and
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DIAGNOSIS OF MALIGNANCY 29
the positive smear contained unmistakably malignant cells. This
left no opportunity to report findings according to one's clinical
impressions nor did it permit aphis-minus report. A sufficient num-
ber of slides can be and should be made at the time the material is
obtained so that careful search will give a true picture of the cell
content. Additional time spent in searching these slides will usually
permit a direct answer of positive or negative. If, after diligent
search, there is any question, no answer should be offered until ad-
ditional material has been obtained and examined. It is a gross waste
of time and effort to attempt to draw any conclusion from slides
that are improperly prepared, fixed or stained. The examination
of the stained smears is a painstaking, time-consuming task that
must be carried out in an orderly manner. The criteria are exact
and the work is exacting. The smear technic is not a simple pro-
cedure to be put in the same category as routine blood and urine ex-
aminations. Fortunately the time factor essential for the present
accepted technical steps has been sufficient to discourage the usual
commercial laboratory from attempting to popularize the procedure.
The idea of a cloistered automaton to whom slides will be given
and from whom correct answers will be received is appealing as a
means of saving the clinician's time for other work. Even if such
a creature were obtainable it is illogical to assume or expect this dis-
interested party to obtain and maintain the meticulous attention to
detail essential for satisfactory results. Without the interest factor
the detailed search through innumerable slides becomes a dreary
task. There are few institutions that can afford to underwrite such
a program. The suggestion that trained technicians could be used
has been proposed, employed and found satisfactory to a degree. A
well trained technician can be of great help in screening out the un-
questioned negatives. The final answer should come from a source
of authority. The responsibility that accompanies a positive or neg-
ative answer is not a light one.
A positive smear obtained from the secretions removed from the
nasopharynx does not necessarily mean that the exfoliating lesion is
within the confines of the nasopharynx. A moment's reflection on
the normal physiology of the upper respiratory tract reminds one
that all of the secretions from the paranasal sinuses and nasal mucous
membrane pass over the nasopharynx. Many pertinent facts may be
obtained from the text by Proetz.~ In the chapter on ciliary action
one finds a short paragraph following some figures on the speed of
the streams of the mucous blanket that reads: "The significant con-
clusions to be derived from these figures, are, namely, that a sinus
with its full complement of cilia can renew its mucous coating in
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3~ MORRISON-HOPP-~C'U
the short space ~of some five or ten minutes and that the entire nasal
blanket is discarded into the pharynx at the rate of at least once
every half hour!" The facts allow the assumption that malignant
cells found in smears made from secretions obtained from the naso-
pharynx might have their origin in the nose or the accessory sinuses.
Fortune favored us in being able to prove the correctness of this
assumption. A patient who had had a biopsy of a neoplastic mass in
the right middle meatus some seven days previously was sent to the
middle meatus biopsied some seven days previously was sent to the
clinic-for consultation as to further advice for handling the problem.
The presenting surface of the biopsied mass was covered with a su-
perficially dry, bloody, disintegrating crust. Smears were taken from
the right posterior choana and the nasopharynx.. After this ma-
terial was obtained the crust was removed. Smears. were made from
the under surface of the crust and from the then raw surface of the
neoplasm. Past experience has shown that smears from the moist or
contact surfaces of crusts at?e of little value in that such cells as are
identifiable have undergone lytic action and have lost the differenti-
ating characteristics. The experience of the past was repeated in this
case. Smears made from the raw bleeding surface of the neoplasm
did contain some malignant cells but the fields were crowded with
red cells and debris. The smear from the secretions from the floor
of the nose and nasopharynx were strongly positive. It is note-
worthy that the exfoliated malignant cells were in an excellent state
of preservation. These findings permit repeating the injunction
that the finding of malignant cells in the material obtained from the
nasopharynx makes it mandatory that the source of those cells be
found (Fig. 2).
The source of these cells may be in any area from which the
mucous blanket comes. The speed of flow of the mucous stream
permits that source to be at any remote part of the upper respiratory
tract. There are no reasons for assuming that malignant cells found
in the nasopharynx would come from any area other than the upper
respiratory tract. The probability of diagnosing ~ ery early neo-
plasms in the sinuses is open for speculation. The known limiting
factors are, first, that the neoplasm be of the type that exfoliates;
second, the dilution-factor; and third, the presence of signs or symp-
toms of sufficient importance to direct the examiner's attention to
the necessity or advisability of examining the nasal or nasopharyn-
geal secretions by the smear method. We have no illusions in regard
to advocating the employment of the smear technic as one of the
steps in the routine nose and throat examination.
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DIAGNOSIS OF MALIGNANCY 31
We are sufficiently satisfied with the results presented to recoln-
mend the examination of the nasopharyngeal secretions as an ad-
junct in the diagnosis of exfoliating malignant neoplasms to anyone
equipped to carry out the necessary technical steps: Unfortunately
we are not able to ofFer any improvements in the technic of staining
the smears nor any speed-up method as a substitute for the laborious
field by field examination of the stained smears. We are confident
that the method will maintain a high degree of accuracy in the hands
of those who will spend the time necessary to obtain a knowledge
of the normal cytology and its variations before attempting to rec-
ognize the abnormal. We feel equally confident that the method
will be of little or no value if the examination of the stained smears
is turned over to a disinterested observer, no matter how well
trained this observer may be.
SUMMARY
1. The results obtained by the smear technic are excellent.
2. It is not a substitute for biopsy.
3. It is an excellent adjunct in the diagnosis of exfoliating
neoplasms and has shown itself to be so reliable that a positive smear
demands the finding of the source of the malignant cells.
4. A knowledge of the normal cytology of the area is a pre-
requisite that cannot be evaded.
5. It is atime-consuming procedure that demands meticulous
attention to detail. This is one reason why it will not become a
routine laboratory procedure on a level with blood counts and urin-
alysis.
6. Accurate diagnosis can only be made by a cytologist familiar
with the area. A well trained technician can be used to screen out
the unquestionably negative slides.
7. The method has nothing to offer the casual observer.
We wish to express our gratitude to Doctor Herbert F. Traut for permission
to use the facilities and materials of the Cytology Laboratory, Division of Obstetrics
and Gynecology, University of California Medical School, San Francisco, Cali-
fornia.
UNIVERSITY OF CALIFORNIA MEDICAL SCHOOL.
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REFERENCES
1. Papanicolaou, G. N., and Traut, H. F.: Diagnosis of Uterine Cancet by
the Vaginal Smear, New York, Commonwealth Fund, 1943.
2. Papanicolaou, G. N., and Traut, H. F.: tl New Procedure for Staining
Vaginal Smears, Science 95:438-439 (April 24) 1942.
3. Liebow, A?verill A., Lindskog, Gustaf E., and Bloomer, William E.:
Cytological Studies of Sputum and Bronchial Secretions in the Diagnosis of Cancer
of the Lung, Cancer 1:223-233 (July) 1948.
4. Proetz, Arthur W.: Applied Physiology of the Nosc, St. Louis, Annals
Publishing Co., 1941.
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THE RELATION BETWEEN HEARING LOSS FOR SPECIFIC
FREQUENCIES AND THE DISTANCE AT WHICH
SPEECH CAN BE IDENTIFIED
E. THAYER CURRY, PH.D.
URBANA, ILL.
The general effort of this introductory study has been an at-
tempt to determine the relative contribution made by individual
frequencies to the identification of the spoken voice. This is, of
course, a very broad general problem of speech intelligibility, many
aspects of which have been studied by previous investigators. Much
of the work of Fletcherl was devoted to this problem. Fowler,2
Steinberg and Gardner,3 Bunch,4 Beasley,5 Harris,e Goldman,' Mac-
Farlans and Hughson and Thoinpson? have all reported on various
aspects of the relationship between audiograms and speech intelligi-
bility.
The present study is intended to amplify these previous works
by supplying certain statistical relationships between individual fre-
quencies and the spoken speech score. It has been the specific pur-
pose of these statistical procedures to examine the relation between
the two .measures: (1) air conduction and bone conduction loss in
decibels for the individual frequencies 2 S 6, S 12, 1024 and 2048, and
(2) the distance measured in feet at which the spoken digits could
be identified. This study deals for the most part with the relation-
ships of individual frequencies to the total speech score. Most pre-
vious studies have been concerned with the relation of an averaged
decibel loss from selected frequencies of the audiogram.
Results are presented of a statistical study of the product-
moment correlation between hearing loss in decibels for specific
audiogram frequencies and the distance at which digits spoken by
an adult male voice could be identified. Clinical data including
tests of 1S6 ears were obtained from the files of the Speech and
Hearing Clinic of the University of Washington, Seattle, Wash-
ington. The cases represent the whole range of hearing-case-types
usually presented at a university speech and hearing clinic. The
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34 F. THAYER CURRY
individuals were from the following groups: (1) graduate and un-
dergraduate students of the University of Washington, (2) students
referred to the University Speech and Hearing Clinic from the
grade schools, junior high and senior high schools of Seattle, (3 )
individuals referred to the University Clinic by the Veterans' Re-
habilitation ,gdministration offices in Seattle, (4) individuals re-
ferred to the University Clinic by physicians anti otological special-
ists of the Seattle and nearby area, (S) individuals referred by va-
rious hearing aid dealers of the State of Washington, and (6) in-
dividuals of the general public who presented themselves at the
University Clinic for testing and retraining services.
All hearing loss cases on which the complete data necessary for
this study vas available were included in the statistical analysis.
The types of hearing loss represented by the cases of the study are,
for the most part, covered by the descriptive term "mixed loss". No
effort has been made to separate the cases into .conduction and per-
ception types. The age range is 16-72 years.
Part of the standard procedure for testing hearing at the Speech
and Hearing Clinic of the University of Washington (during the
academic year 1947-48) included the speech-whisper test as well
as audiometer tests for all individuals of suitable age. These were
but two of a group of diagnostic examinations which were admin-
istered according to the indication of the individual case.
The speech and whisper test was in all instances administered
by the same person. The voice used for the test was that of an adult
male, age 3 ti ; the average pitch level of the voice had been pre-
viously determined to be 131 cycles. The test was always admin-
istered in a room whose dimensions were 22 ft. by 16 ft. with a
ceiling eight feet above the floor. The surface of the ceiling was
treated with Acoustitex tile.
The speech-whisper test is completely described by Fletcher.io
Briefly, in the method used in this study, the tester pronounced
digits while moving slowly away from the subject. The score for
the test was the greatest distance (in feet) at which the patient
could identify the digits presented. In the procedure described by
Fletcher, the score for the test was the distance where the subject
just fails to identify the digits. It aras our opinion that the de-
termination of the point where digits were identified was a more
specific procedure than the determination of the point where digits
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could not be identified. Therefore, the present procedure diners
from Fletcher's in this respect.
Subjects were chosen because they showed no response to the
"average whisper" at a distance of one inch. That is to say they
responded to the spoken voice at distances between one inch and
twenty feet.
The audiometers used were a Sonotone Model 20 and an ADC
Model SOE. These were calibrated at the outset. Their adjustment
was checked once a week against the known hearing curves of two
individuals during the periods of the collection of the data. The
audiograms secured during the checking process did not in any
instance deviate more than S decibels from the original audiogram.
It was felt that the audiometers remained in essential calibration
during the period of testing.
The hearing loss in decibels for air conduction at the frequencies
2 S 6, S 12, 1024 and 2048 was correlated against the speech score in
feet by the product-moment correlation coefficient according to the
statistical method described by Edwards.ll Coefficients were also
determined for bone conduction losses at the same frequencies and
correlated with the speech score.
The figure for the American Medical Association percentage
hearing loss was determined according to the directions given by
the American Medical Association.i2 This percentage loss was then
correlated with the speech score by the method cited above.
The average audiometric loss was computed by averaging the
decibel loss values for S 12, 1024 and 2048 cycles and muliplying by
0.8, according to Bell.'' This averaged loss was then also correlated
with the speech score by the same method. The statistical analysis
of the results of this study is presented in the accompanying table.
The statistical analysis in general indicates that there is a rela-
tively low positive degree of association between the two quantities
correlated: (I) the hearing loss (either by air conduction or by
bone conduction) for one of the specific frequencies calculated and
(2) the distance at which digits can be identified by the subject
with reduced audition.
Column I lists the specific individual frequencies and averaged
frequency values (both for average decibel loss and AMA% loss)
which were correlated with the speech score.
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">> > ~>
Y ~r
?^.n'in 'm 'm'v~
as ~ a as
33 NB 33
00 00 00
N 1-~ ~ H F
>~ a~ ~y
vd
C p L
-' =
.-~ N
O sF
~/! 00
N ~-+
to O
N +-+
o0 O~ N
O~ O~ 00
'
K
O~ O~
1~ 00
00 Ol
O~ Q~ l~
~
~
,7 C ~
.7
v di
^'~
~
N
N
M
~
O
00 W
~
~+
%~
W
O
1
00
O
O
N~'+
p
p1~
r+O
00 N
b
~ ~
r~
>b
~Otppn
QQO~~Qi 4N0
C~
O O
O O
O O
0 0 O
A
~e d
~~>
a
~a
~~ ~~ ~~
O O
zz
zz
Yn ..-~ ~n n a, O ~n .. r. d~
t+~ N > ,Np., V~ M ~ O ~ O
a ?W APO d'P~l d'PO d'P4 a,' d'
a~ m d= o bA
tp N et 00 ~ W ~ 00 ~ ~ N
vi .r N e}' t.~ ~ ~~Ir G
N h O N ~~.yNN ~Ma
M "n W
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Column II indicates whether the "r" was computed for the
air conduction or bone conduction loss.
Column III lists the calculated correlation coefficient obtained
by the product-moment correlation method described by Edwards.~~
It will be seen that the obtained "r" values range from a low of
.011 for 2048 BC to a high of . S 2 S for S 12 AC.
Column IV indicates whether or not the obtained "r" is sig-
nificant at the 1 % level. That is, we can say with statistically great
certainty that there is a degree of association between the calcula-
tions of our study for which the "r" is significant at the 1% level.
In the values of this study the degree of association indicated is
usually low. But in seven of the ten correlations the association is
highly significant at the 1 % level.
Column V indicates whether or not the obtained "r" is statis-
tically significant at the S % level. It so happens that all correla-
tions of this study were either highly significant at the 1 % level or
were not significant at all. Those "r" values which did not indicate
a statistical significance were those for the correlations 2048 AC,
2048 BC and AMA % hearing loss. We should interpret our statis-
tical results to mean that the nonsignificant value obtained is a sug-
gestion that it is not reasonably certain that these three particular
correlations may not have been made for quantities which were un-
related linearly.
Column VI lists the standard error for each "r" for those who
may wish to examine the results further.
Column VII lists the statistical value of the variance of these
two correlated quantities which is explained by the correlation co-
efficient "r". The variance explained is uniformly low, varying
from .001 for 2048 BC to .275 for S12 AC.
Column VIII indicates the statistical value of the variance of
these two correlated quantities which is not explained by the calcu-
lated "r". These values of unexplained variance vary between .72 5
for S 12 AC and .999 for 2048 BC.
Column IX lists the relation between the two quantities cor-
related. For the seven values of the study for which a degree of
association was indicated, the qualitative evaluation given by Ed-
wards15 is shown. The correlations for S 12 AC and average decibel
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loss indicate a statistically "low" degree of association. Correlations
for 256 AC, 256 BC, 512 BC, 1024 AC, 1024 BC indicate a statis-
tically "very low" degree of association for the two quantities of
our study. For the correlations 2048 AC, 2048 BC and AMA h
hearing loss we cannot be certain that there is any degree of asso-
ciation at all.
It will be seen that the "r" value at each frequency uniformly
indicates a higer degree of association for -the air conduction cor-
relation than for the bone conduction correlation. Such a greater
association for the air conduction score than for the bone conduction
loss may well be in accord with the usual audiometricians view that
the tests for air conduction give greater testing efficiency than do
the present bone conduction testing methods.
It should be remembered that the results presented here are for
a specific group of cases, in a specific testing room, with a particular
speaking voice. We might well expect that we would change our
results with a change in any of the factors indicated. However,
within the limits of tl-is study, every effort has been made to control
the factors of testing voice, audiometer variation, and concise in-
structions to the subjects tested.
At least for the 156 ears of this study the individual audiometer
frequency values (either air conduction or bone conduction) for
decibel loss indicate little statistical association with the spoken speech
score. The correlation for the American Medical Association per-
centage hearing loss-indicates it is not statistically certain that there
was any degree of association with the spoken speech score.
This present study has confined itself to a correlation of the
score for spoken digits. The correlation for the whisper scores is
now under study. It is possible that, if these hearing loss cases were
separated into various loss types, some greater degree of association
might be demonstrated for the quantities of this study. Experi-
ments in this vein are now in progress.
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1. Fletcher, H.: Speech and Hearing, New York, D. Van Nostrand Co.,
Inc., 1936.
2. Fowler, E. P.: Hearing Standards for Acceptance, Disability Rating and
Discharge in the Military Service and in Industry, Laryngoscope 51:937-956
(Oct.) 1941.
3. Steinberg, J. C., and Gardner, M. B.: On the Auditory Significance of
the Term Hearing Loss, J. Acoust. Soc. Am. 11:270-277 (Jan.) 1940.
4. Bunch, C. C.: In Discussion in Military Symposium, Tr. Am. Laryng.,
Rhin. and Otol. Soc. 31:300-301, 1941.
S. Beasley, W. C.: The National Health Survey; Hearing Studies Series,
Bull. 2, U. S. Treas. Dept., Public Health Service, 1938.
6. Harris, J. D.: Free Voice and Pure Tone Audiometer for Routine Testing
of Auditory Acuity, Arch. Otolaryng. 44:452-467 (Oct.) 1946.
7. Goldman, J. L.: A Comparative Study of Whisper Tests and Audiograms,
Laryngoscope 54:559-572, 1944.
8. MacFarlan, D.: Speech Hearing and Speech Interpretation Testing, Arch.
Otolaryng. 31:517-528, 1940.
9. Hughson, W., and Thompson, E.: Correlation of Hearing Acuity for
Speech with Discrete Frequency Audiograms, Arch. Otolaryng. 36:526-540, 1942.
10. Fletcher, FL: op. cit. p. 202-206.
11. Edwards, A.: Statistical Analysis, New York, Rinehart & Co., 1946.
12. Carter, H. A.: Tentative Standard Procedure for Evaluating the Per-
centage. Loss of Hearing in Medicolegal Cases, J. A. M. A. 133:396-397 (Feb.)
1947.
13. Hughson, W., and Thompson, E.: op. cit. p. 534.
14. Edwards, A.: op. cit. p. 95.
15. Edwards, A.: op. cit. p. 98.
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IV
TANTALUM IN RHINOPLASTIC SURGERY
SAMUEL L. FOX, M.D.
BALTIMORE, MD.
For many years surgeons have sought an implant for building
up tissue defects, especially that known as "saddle-nose". The large
variety and number of substances thus used suggest that none has
been entirely satisfactory.
In 1900, Nelatonl introduced autoplastc cartilage, and this has
withstood. the test of time better than any other substance thus far
used. In the same year, Gersuny2 introduced vaselin as an implant,
while in 1901 Eckstein suggested paraffin. Soon afterwards, com-
binations of the two were tried, with the results known to all of us.
The immediate cosmetic results of such injections of vaselin and/or
paraffin were good, but almost invariably there was subsequent in-
flammation with abscess formation and ulceration at the point of
injection; or the hydrocarbons diffused into. the surrounding tissues;
or there developed a severe tissue reaction described pathologically
as "paraffinoma". There was also the danger of embolism, so that
these substances have since been discarded.
In 1903, Foderl` employed celluloid, the popularity of which
was short-lived. Still others have used gold and silver implants,
with some degree of success. In 1918, Joseph-' introduced ivory, and
for a time this substance enjoyed wide popularity. It was readily
available, easily sterilized and nonabsorbable, but, like all foreign
substances used up to this time, it was not capable of becoming an
integral part of the tissues and sooner or later either shifted or was
extruded.
In 1879 Reverdin3 introduced the use. of periosteum as a soft
tissue transplant; in 1913 Rueda4 used bundles of catgut; while in
Accepted as a candidate's thesis by the American Laryngological, Rhino-
logical and. Otological Society, January, 1948.
From the Department of Otolaryngology of the South Baltimore General
Hospital and the University of Maryland, School of Medicine.
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1914 KochS used fascia. In 1933 Stout? introduced bovine cartilage,
but all of the above substances tend to undergo absorption. In order
to overcome this objection, Magitot~ advocated their fixation by
formalin before introducing them into the body. This has not
proven satisfactory and none of these substances is now being used.
Many have advocated the use of septal cartilage and bone to
fill the saddle depression. The advantage of the method is its sim-
plicity and ease of accomplishment; its greatest disadvantage is that
so often insufficient material is available for adequately filling in the
depression. Peer has published several papers to show that such
septal cartilage grafts survive.7~ $
Most plastic surgeons have settled upon autografts of costal
cartilage as the safest and best type of implant. Some surgeons,
notably the late Lec Cohen,fl-i7 have favored osteochondral grafts in
which the outer table of rib bone was placed against the nasal bones
and the rib cartilage was placed in the defect in the cartilaginous
nasal dorsum. Until recently, this has been the method followed
by the author.
In order to overcome the difficulties of obtaining autografts,
numerous efforts have been made to employ isografts of costal carti-
lage; i.e., cartilage obtained from the same species (man) but not
from one's own body. For this purpose fresh autopsy material has
been obtained under sterile conditions, and then prepared and stored
in various ways.
Human cartilage obtained in this way and preserved in alcohol
was used rather extensively a generation ago to fill in depressions in
the nose. However, the procedure was discarded because it was
believed that such grafts were absorbed and replaced by fibrous
tissue. O'Connor and Pierce18 revived the method, utilizing fresh
cadaveric rib cartilage preserved in aqueous merthiolate solution and
refrigerated until used. They kept the cartilage for as long as a year
before use, without deleterious effect. The ultimate fate of these
grafts is not fully known, but Peer' reported that dead cartilage
grafts buried from 9 %2 months to 2 years showed progressive inva-
sion by fibrous tissue and partial absorption, whereas autogenous rib
cartilage grafts showed no invasion or absorption over the same
period of time. More recently, Peers stated that "this preserved
type of cadaveric cartilage has a wide field of use and represents a
valuable contribution to plastic surgery".
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Recently a case report appeared in which a satisfactory imme-
diate result was obtained with an isograft of costal cartilage which
had been boiled soon after obtaining it, preserving it in alcohol until
needed and then boiling it again before implantation.19
Since 1939 ticonium, plexiglass, vitalium and many acrylic
resins have been suggested, but none of these has gained wide accep-
tance. In 1945 Fomon et a120 advocated the use of cancellous bone
obtained from the ilium as a graft in saddle-n.ose deformities.
It is obvious from the above brief. review, that no "ideal" tissue
implant substance has yet been found. The qualifications of such
an "ideal transplant" require that it be readily available in sufficient
quantity, that it be of a consistency that will permit easy modeling,
that it be capable of resisting infection and absorption, that it be
well tolerated by the tissue, that it not be subject to change in shape
after implantation, and that it become an integral part of the tissues
where placed. Whereas good results can be obtained by the use of
autografts of rib cartilage, ar rib cartilage and bone, the many at-
tempts to find a more readily available substance emphasize the fact
that such autografts are not the "ideal" transplant. On the other
hand, the alloplastic materials thus far introduced have proven to
be incapable of becoming an integral part of the tissues, and sooner
or later, after the slightest trauma, are extruded from the tissues.
One of the surgical advances resulting from World War II was
the introduction of tantalum. Although first introduced as a plate
for closing cranial defects, it soon came to be recognized as an ex-
cellent nonabsorbable suture material, and has enjoyed widespread
use as a tissue implant. More than sixty papers have been published
on this "perfect metal" in surgery.
Anders Gustaf Ekeberg, a chemistry instructor at Upsala Col-
lege, Stockholm, discovered tantalum in 1802. die found what ap-
peared to be :~n unknown element in a piece of ore, and spent his
life trying to isolate it from its compounds. The tantalization which
he endured in these efforts led him to name the new element "Tan-
talum", after Tantalus, the ill-fated son of the Greek god, Zeus.
Although a small amount of tantalum was produced in Ger-
many from 1903 until the beginning of World War I, the metal
was not produced on a commercial scale until 1922, when an Amer-
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ican metallurgist, Balke, developed new methods of producing this
metal. Tantalum and its sister metal, columbium, occur together.
The ore cannot be refined by smelting, and hence special methods
of preparation are necessary. It has an extremely high melting point
(2996? C.), a characteristic bluish-gray color, and a luster similar
to platinum. It has a density of 16.6, about twice that of steel.
The strength of unannealed tantalum is comparable to cold rolled
steel. It compares favorably with stainless steel in its drawing,
stamping and forming characteristics. It becomes work-hardened,
or fatigued, at a much slower rate than most metals, a fact of con-
siderable importance to surgeons. Tantalum may be machined with
ordinary steel tools; and a reduction in thickness of 60 % or more
without intermediate anneal is common practice when it is being
worked.
Chemically, tantalum compares with glass in its resistance to
body chemistry. It is fully resistant to hydrochloric, nitric, hydri-
odic,. and hydrobromic acids, and their salts, in any concentration,
at any temperature at atmospheric pressure. It is also resistant to
concentrated sulfuric acid at temperatures not greater than 79? F.
It is fully resistant to dilute sulfuric acid at any temperature at
atmospheric pressure. Hydrofluoric acid, concentrated sulfuric acid
and strong alkalies in concentrated solutions attack tantalum. Weak
alkalies cause no reaction, but salts of strong alkalies attack the
metal.
Burke22 was the first to report on a comparative study of the
corrosion of metals in tissues in which tantalum was included in the
series. Meanwhile Carney and Burch23 were experimenting with
tantalum in surgery, and their report appeared soon thereafter. These
investigators felt that tantalum represented a truly biologically inert
metal.
Numerous reports followed in which tantalum was employed
as a plate in the fixation of fractures.24-so There soon followed a
large number of published reports on the use of tantalum plates in
the closure of large skull defects, both surgical and traumatic.si-5z
Pudenz and OdomS'3 carried out experimental studies with tantalum
foil in an effort to develop a material which would prevent ineningo-
cerebral adhesions, and reported the absence of foreign body reac-
tion and failure of adhesion between the cerebral and ineningeal
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surfaces following prolonged application of tantalum foil to the
surface of the brain. Others corroborated this work clinically.54, s5
Further animal studies by Pudenz'g~ 4s in which tantalum plates
were used to repair cranial defects demonstrate that tantalum pro-
vokes a minimal and nonprogressive encapsulation of connective
tissue. Studies of bone bordering the tantalum plate show that
osteoblastic activity is not hindered. This was corroborated by
others.s7, .,s, ?' Animals surviving 318 days showed a complete closure
of the cranial defect by formation of new bone tissue. The osseous
layer adhered so closely to the tantalum plates that a bony impres-
sion remained even when the plates were removed.
Burke22 was the first to report the use of tantalum as a suture.
Neurosurgeons soon took advantage of this material in repairing pe-
ripheral nerves, and reports by Spurling,5s, so, si Olsons~ Schnitker,82
Scarff,s3 and otherssg-sa began to appear which established the fact
that hair-like filaments of tantalum (.003 inch) can be used as
through-and-through sutures or fo.r end-to-end anastamosis with
minimal foreign body reaction and little interference with the down-
growing axones. Spurling~9 also reports the use of a tantalum foil
cuff to protect the anastamotic site of nerve repair and to prevent
adhesion to adjacent tissue. This method has been adopted for ten-
don repair by other surgeons.
It is a particularly valuable asset of tantalum that it can be
used in infected fields. In contrast to silk, tantalum is impermeable
and cannot harbor infection within its substance, thus reducing the
chances for the development of a persistent draining sinus.
OlsonE4 reports using tantalum wire sutures on a large number
of hand injuries, using the wire for both buried and cutaneous sutur-
ing, without a single infection, even though most of the wounds
were potentially contaminated. Kazan jian,42 Schnitker,48 and oth-
ers72 have reported the use of tantalum for repair of cranial defects
after operation for osteomyelitis of the skull, without immediate or
late complications because of the presence of the tantalum.
Several reports have appeared favoring the use of tantalum
wire in the correction of facial paralysis.70~7i Goodale73 published an
instructive paper on radical frontal sinus surgery in which he ad-
vocates the use of a strip of tantalum foil to prevent closure of the
.newly created nasofrontal duct. The author has tried this in one
case with gratifying results.
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Newman?' was the first to publish his results of the use of
.tantalum wool in correcting facial and cranial defects, although
many others had been using the method for some time.
It may thus be seen that whereas tantalum found its earliest
usefulness in the field of neurosurgery as a skull plate for closing
cranial defects, either as an inlay or as an onlay, many other surgical
uses have been found for this metal. It is now available in several
different forms: sheet tantalum, tantalum sutures, tantalum wire,
tantalum ribbon, tantalum hemostatic clips, tantalum foil, tantalum
screws, and more recently tantalum gauze was introduced for the
repair of hernial defects, etc. A wool fabricated from 0.003 inch
tantalum wire is the substance used in rebuilding facial and nasal
contours and to repair minor defects.
Tantalum is readily available in any quantity at nominal cost.
The wool is easily made from the .003 inch tantalum wire, and re-
quires but a few minutes of the surgeon's tune. There is no long
preparation needed: the wire is simply sterilized on the spool, and
is then prepared as a wool implant at the operating table. It is
readily modeled into the appropriate shape and size, and ordinary
surgical instruments (scissors, hemostats, forceps, etc.) arc all that
are required to prepare the implant. Once implanted, tantalum is
resistant to infection and does not undergo absorption. It is well
tolerated by the tissues, and soon becomes an integral part of them,
so that it cannot be removed at a later date without the removal of
some actual tissue. Fibroblasts grow into the interstices of the wool
mesh and the tantalum implant soon becomes a fixed and immovable
part of the tissues at the site of its implantation. When so implanted
it is not rigid, like ivory, but has a firm elasticity much like the
nasal tissues themselves. It will not change its shape unless severe
trauma occurs to the parts, in which case the very nasal bones would
probably suffer a similar fate. Tantalum permits tissue cells to attain
their normal growth unhampered, and some investigators have re-
ported that the attachment of fibroblasts to the metal itself can be
demonstrated. Normal growth of bone over tantalum fixation
plates and skull plates has also been repeatedly reported.
CASE 1.-A. R. P., aged 21 years, female, consulted me on
September 13, 1944, because of a saddle-nose which resulted from
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a septal abscess in childhood. The deformity was quite marked and
there was an accompanying web-like adhesion. of the left pyriform
opening which occluded this side of the nose about 50%0. The
serological tests for syphilis were negative. On. September 27, 1944,
a rhinoplasty was performed under general anesthesia, in which an
entire thickness of costal cartilage and the outer table of the seventh
rib were implanted into the concavity under the skin of the dorsum
of the nose. A splint. was worn by the patient for ten days. The
immediate result was excellent and the patient returned home (West
Virginia). Correspondence ensued during the next several months
and the patient continued to express delight with the result.
In January of 1946, about 1 S months after the operation, the
patient returned and complained that the nose was returning to its
original state of saddle concavity. Examination revealed complete
absorption of the cartilaginous implant with retention of the bone
implant. rJn questioning the patient:, she stated she first noticed a
change "just before Thanksgiving" and it had progressively grown
worse until the defect was quite obvious "by Christmas". I~/Iedical
examination and blood studies failed to reveal any disease. The
patient refused to undergo another rib resection. Since an auto-
graft had failed, an isograft was not considered. The author had
had some experience with tantalum as a skull plate, and it was de-
cided to try a tantalum wool implant. Accordingly, on February
20, 1946, under local anesthesia, a tantalum wool implant was fab-
ricated on the table and inserted beneath the. skin of the dorsum
through the usual intranasal lateral incisions. The incisions were
closed with one black silk suture on either side, a splint was applied,
and the patient was allowed to leave the hospital the next day. The
splint was removed in five days. The patient was last seen on July
17, 1948, and the result was excellent. Recent correspondence from
the patient indicates complete satisfaction with the result.
Cns~ 2.-H. S., aged 29 years, male, consulted me on April
29, 1946, regarding a rhinoplasty. He stated that in 1942 he had
had a submucous resection in North Carolina and his "bridge drop-
, ped" afterwards. Examination revealed awell-marked concave de-
formity of the dorsum of the nose, and some scoliosis vertically
because of lateral displacement of the left nasal bone with medial
displacement of the right one. The septum was flail but essentially
straight. T'he patient could only spend a few days in Baltimore and
refused to have rib resection, so that it was decided to use a tantalum
wool implant. The patient was told that no osteotomy would be
performed at this operation but that this might be needed later.
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TANTALUM 47
On April 30, 1946, under local anesthesia, a tantalum wool im-
plant was inserted under the skin of the dorsum of the nose to fill
in the concavity. The incisions were closed with one black silk
suture on either side and a splint was applied for four days. The
patient was discharged from the hospital on the second postoperative
day. The immediate result was good. The patient has subsequently
returned to Baltimore for examination in July of 1946 and in Feb-
ruary of 1947, at which times the result remained good. Recent
correspondence from the patient indicates complete satisfaction.
CASE 3.-J. W., aged 42 years, male, was first seen by me in
January of 1945 while he was a patient at the South Baltimore Uen-
eral Hospital under another surgeon's care. He was a railroad worker
who had been in a serious railway accident in May of 1943 and had
suffered numerous injuries, among them a compound, comminuted
fracture of the nose, loss of the upper half of the right auricle, a
depressed fracture of the right maxilla and zygoma, and loss of con-
siderable skin of the forehead by avulsion. I was asked to see the
patient because of a fistula which was present on the dorsum of the
nose as a result of the compound fracture. Two previous attempts
at surgical closure had failed, the last of which included a pedicle
graft to the nose from behind the ear.
The fistula was through-and-through but not in a straight line,
and was situated just to the right of the rnidline, near the lower border
of the right nasal bone, which was deficient. There was a skin de-
fect about 2 rnin. by 5 mm., running diagonally, with the long axis
in the vertical direction towards the tip. Repeated chemical cauter-
izations, externally and within, temporarily closed the perforation,
but it always reopened soon afterwards. Meanwhile the skin edges
began to show evidence of retraction, so that the defect grew larger.
On May 27, 1946, while implanting tantalum wool into the
zygornaticomaxillary defect of the fact, the edges of the skin of the
nasal fistula were freshened and slightly undermined, a small piece
of tantalum foil was inserted, and the wound edges were approxi-
mated with atraumatic silk sutures. For a while it was thought that
healing would take place. Soon, however, the skin edges separated
and began to retract and a status quo resulted, i.e., the fistula was
closed for all intents and purposes (by tantalum foil and granula-
tions) but the skin would not heal over the defect. It was decided
to do a more extensive plastic resection and closure.
Accordingly, on June 2, 1947, under local anesthesia, the skin
over the entire dorsum of the nose was elevated through the usual
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48 SAMUEL L. FOX
intranasal lateral incisions. The tantalum foil had become so im-
bedded in the tissues, and so engulfed by them, that it could not be
removed if desired. The skin edges of the fistula were again. fresh-
ened and brought together with vertical mattress atraumatic sutures
of No. 00000 silk placed every 2 mm. apart. Thrombin solution
was spread beneath the skin of the dorsum .and the overlying skin
fixed in place where desired. A splint was applied and worn for
several days. The sutures were removed, half in three days and the
rest on the seventh day. The fistula healed promptly and has re-
mained closed to date.
This case illustrates the tolerance that the tissues have for tan-
talum even in the face of infection and an open wound.
CASE 4.-R. P., aged 23 years, finale, consulted me on Novem-
ber 17, 1945, because of marked nasal obstruction and nasal de-
formity. He stated that he had broken his nose in childhood and
that no immediate correction was effected. However, two attempts
at submucous resection had been made in the past few years, the
last one while he was in the Army in December of 1943, but with-
out relief of obstruction. Examination revealed a markedly, scoliotic
nose, with the tip deflected to the right, and a very large bony hump
on the dorsum. The columella was sunken and the columellar sup-
port was absent, but the remaining septal cartilage appeared to be
present although markedly deflected and scoliotic, so that both sides
of the nose were obstructed. The condition was explained to the
patient, anal he was advised to have a submucous resection and
rhinoplasty, preferably at the same operation.
On November 28, 1945, under local anesthesia, a modified sub-
mucous resection and rhinoplasty were performed, in which it was
necessary to remove practically the entire septal cartilage as well as
perform a bilateral osteotomy and remove the hump. A portion of
septal cartilage was reinserted for support, but considerable concern
was felt at the time lest a saddle defect develop. The postoperative
course was complicated by an injury to the nose sustained in an
automobile accident while the patient was still wearing the splint.
This necessitated some manipulation of the nasal bones and reappli-
cation of the splint at a time when there was very marked edema and
ecchymosis present. The patient was discharged in January of 1946
with only a slight lateral displacement of the right nasal bone which
was attributed to the injury sustained during the early postoperative
period. Tl-iere was an excellent breathing space on both sides and
the patient was quite happy with the result.
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In August of 1946 the patient returned for examination be-
cause adefinite saddle deformity had become apparent where the
cartilaginous septum was resected. Examination revealed that the
reimplanted septal cartilage had become absorbed. A secondary
rhinoplasty was advised for implantation of tantalum. On Sep-
tember 26, 1946, under local anesthesia, a tantalum wool implant
was inserted under the skin of the dorsurn of the nose to fill in the
concavity. A splint was worn for several days only. The patient
has been seen fairly frequently since operation, and he has an ex-
cellent result.
CASE S.-R. C., aged 33, male, was referred to me by another
otolaryngologist on October 7, 1946, because of a saddle deformity
of the nose which resulted from an injury sustained on September
11, 1946, in an automobile accident. Examination revealed a large
septal perforation from previous submueous resection, separation of
both nasal bones at the dorsurn, with a depression at the osseocarti-
laginous junction. There was a small scar over the right nasal bone.
A tantalum implant was advised.
On October 9, 1946, under local anesthesia, a tantalum wool
implant was inserted under the skin of the dorsurn of the nose to
fill in the concavity. A splint was applied and worn for several
days. The patient Left the hospital on the second postoperative day.
The result was excellent, and the patient has been seen frequently
since operation.
CASE 6.-C. C., aged 23 years, female, consulted me because
of dissatisfaction with the result obtained after three consecutive
rhinoplastic operations by another surgeon. At the time of her first
visit on February 14, 1947, examination revealed the tip to be quite
bulbous and deflected to the right of the midline. There was a red
blush horizontally across the skin of the dorsurn of the nose at the
osseocartilaginous junction because of pressure from underlying car-
tilage and there was awell-marked saddle deformity. The right
ala was somewhat lower than the left one, but a similar asymmetry
existed throughout the face. Within, there was fairly marked oc-
clusion of bath pyriform openings due to cicatricial contracture and
adhesion of the alae to the septum at the dorsurn. Secondary rhino-
plasty was advised, and this was accepted.
On March S, 1947, under local anesthesia, a secondary plastic
operation was performed in which a tantalum wool implant was in-
serted under the skin of the dorsurn to fill in the concave deformity,
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the cicatrix within each naris was excised, and the tip was made less
bulbous. A splint was applied for four days. The patient left the
hospital on the second postoperative day. The immediate result was
excellent, and the only change that has occurred with time is that
the thin skin of the dorsum again shows its reddish blush where it is
stretched over the implant.
In October, 1947, the patient returned because of numerous
small pustules over the thin skin of the dorsum just at the site of
the tantalum implant. Soon thereafter several small filaments of
tantalum wire appeared through the skin of the dorsum. These
were snipped short with a small scissors, but more appeared during
the next several months. Also, pustules recurred periodically. The
patient was advised to have a secondary operation, and on April 6,
1948, under pentothal anesthesia, the skin of the dorsum was ele-
vated through bilateral intranasal incisions. The tantalum wire im-
plant was found tightly adherent, but was separated by careful dis-
section. Several small puncture points R~ere noted in the skin after
it was elevated. A strip of fascia lata was taken from the right
thigh and this was inserted beneath the skin of the dorsum of the
nose between the skin and the tantalum implant. A splint was re-
applied and worn far five days. The nose heard promptly, the
bluish discoloration previously noted on the dorsum (tantalum be-
neath the thin, split skin) was no longer present, and the skin per-
forations promptly healed. There has been no further difficulty and
the patient is quite satisfied with the result.
CASE 7.-V. E. S., aged 34 years, male, consulted me because
of marked nasal obstruction. He gave a history of having had a
submucous resection performed by another surgeon in 1933, after
which he stated his tip fell. Examination revealed a vertical de-
formity, with a depressed dorsum, an overhanging tip and sunken
columella. There was no columellar cartilaginous support, the tip
was deflected somewhat to the right, and both Hares were almost
completely obstructed. This latter state could be relieved by man-
ual elevation of the tip. 'Che septum was somewhat thickened an-
teriorly, and was almost totally lacking in cartilaginous or bony
support. Both lower turbinates were very prominent and failed to
shrink normally upon the application of a vasoconstrictor,
Rhinoplasty was advised, and on March 18, 1947, the opera-
tion was performed under local anesthesia. The tip was elevated a
full 1 cm., thus shortening the nose, and a tantalum wool implant
was inserted beneath the skin of the dorsurri of the nose to fill in the
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concavity and support the tip. At the same time both lower turbi-
nates were infracted laterally and compressed. A splint was worn
for four days, and the patient left the hospital on the second post-
operative day. The result has been excellent, both cosmetically and
as to function.
The history of tissue transplants and implants is briefly re-
viewed, and the advantages and disadvantages of the various ma-
terials are discussed. The requirements for an "ideal" implant are
also stated, and it is concluded that no such ideal substance has yet
been found.
A brief review of the history, and of the physical and chemical
properties of tantalum is presented. Its introduction into surgery
is discussed, and an extensive bibliography is presented of the litera-
ture published on the subject. Seven case reports are presented in
which tantalum implants have been employed successfully by the
author in rhinoplastic surgery.
REFERENCES
i. Nelaton, A.: Sur un Procede Nouveau de Rhinaplastie, Bull. et. mem. Soc.
de chir. de Paris 26:663, 1900.
2. Quoted by Joseph, J.: Nasenplastik and Sonstige Gesichtsplastik, Leipzig,
C. Kabitzscli, 1931.
3. Reverdin, A.: Greffes de Perioste de Lapin sur une Jeune Fille, Bans un
Cas de Rhinoplastie Partielle, Cong. internat. d. sci. mcd. (ses. 6): 430, 1879.
4. Quoted by Fomon, S.: The Surgery of Injury and Plastic Repair, Balti-
more, Williams & Wilkins Co., 1939.
5. Koch, F.: Neuere Methoden and Fragen der Nasenplastik, Berlin Klin.
Wchnschr. 50:1612, 1913.
6. Stout, P. S.: Bovine Cartilage in Correction of Nasal Deformities, Laryn-
goscope 43:976, 1933.
7. Peer, L. A.: The Fate of Autogenous Septal Cartilage after Transplan-
tation in Human Tissues, Arch. Otolaryng. 34:696, 1941.
8. Pecr, L. A.: The Neglected Septal Cartilage Graft, Arch. Otolaryng.
42:384, 1945.
9. Cohen, Lee: Further Observations in Correct Rhinoplasty, Surg., Gyn.
and Obst. 31:412, 1920.
10. Cohen, Lee: Corrective Rhinoplasty, Surg., Gyn. and Obst. 34:794, 1922.
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11. Cohen, Lee: Corrective Rhinoplasty, ANNALS OF OTOLOGY, RHINOLOGY
AND LARYNGOLOGY 33:342, 1924.
12. Cohen, Lee: Correction. of Pronounced Types of Saddle Nose with Mixed
Implants of Bone and Cartilage, ANNALS OF OTOLOGY, RHINOLOGY AND LARYN-
GOLOGY 36:639, 1927.
13. Cohen, Lee: Results Obtained in Corrective Rhinoplasty, Med. J. and
Rec. 127:354, 1928.
14. Cohen, I,ee: Report of Recent Results in Rhinoplasty, Va. Med. Mo.
SS:781, 1929.
1f. Cohen, Lee: External Deformities Corrected, ANNALS of OTOLOGY, RHI-
NOLOGY AND LARYNGOLOGY 44:233, ]935.
16. Cohen, Lee: Correction of Depressed Deformities of the External Nose
with Rib Graft, South. M. J. 30:680, 1937.
17. Cohen, Lee: Advantage of Mixed Bone and Cartilage Grafts in Correc-
tlOri of Saddle Nose, ANNALS OP OTOLOGY, RHINOLOGY AND LARYNGOLOGY 49:
410, 1940.
18. Pierce, G. W., and O'Connor, G. B.: Reconstructive Surgery of the Nose,
ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY 47:437, 1938.
19. Daley, J.: Use of Boiled Cartilage as a Nasal Implant, Eye, Ear, Nose and
Throat Mo. 26:31, 1947.
20. Fomon, S., Luongo, R. A., Schattner, A., and Turchik, F.: Cancellous
Bone Transplants for Correction of Saddle Nose, ANNALS of OTOLOGY, Rxi-
NOLOGY AND LARYNGOLOGY S4:S1S, 1945.
21. Trade Bulletin: Ethicon Tantalum Surgical Materials, New Brunswick,
Johnson & Johnson, 1946.
22. Burke, G. L.: The Corrosion of Metals in Tissues; and an Introduction to
Tantalum, Canad. M. A. J. 43:125, 1940.
23. Carney, H. M., and Burch, J. C.: Experimental Study with Tantalum,
Proc. Soc. Exp. Biol. and Med. S 1:147, 1942.
24. Bothe, R, T., Beaton, L. E., and Davenport, H. A.: Reaction of Bone to
Multiple Metallic Implants, Surg., Gyn. and Obst. 71:598, 1940.
25. Bothe, R. T., and Davenport, H. A.: Reaction of Bone to Metals: II,
Surg., Gyn. and Obst. 74:231, 1942.
26. Bull. U. S. Army Medical Department, News and Comments (Fixation
of Fractures with Metal) 88:3, 1944.
27. Venable, C. S.: Factors in the Choice of Materials for Bone Plates and
Screws, Surg., Gyn. and Obst. 74:541, 1942.
28. Venable, C. S., and Stuck, W. G.: Electrolysis Controlling Factor in Use
of Metals in Treating Fractures, J. A. M. A. 1 S :349 (Oct. 8) 1938.
29. Idem: A General Consideration of Metal for Buried Appliances in Sur-
gery, Surg., Gyn. and Obst. 76:297, 1943.
30. Idem: Fractures: Recent Advances in Treatment with Non-electrolytic
Metal Appliances, J. Indiana h'[. A. 31 :33 S, 193 8.
31. Baxter, H. A.: Tantalum in Plastic Surgery, McGill M. J. 12:287, 1943.
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32. Campbell, J. B., and Alexander, E., Jr.: Eosinophilic. Granuloma .of the
Skull-Report of a Case, J. Neurosurg. 1:365, 1944.
3 3. Carmichael, F. A.: -The Reduction of Hernia Cerebri by Tantalum Crani-
oplasty, J. Neurosurg. 5:379, 1945.
34. Conley, J. J.: Tantalum Implant in Correction of Defect Following Re-
moval of Frontal Ostcoma, Arch. Otolaryng. 40:295, 1944.
3 S. Echols, D. H., and Colclough, J. A.: Cranioplasty with Tantalum Plate,
Surgery 17:304, 1945.
36. Fulchcr, O. H.: Tantalum to Repair Cranial Defects, J. A. M. A. 121:931
(Mar. 20) 1943.
37. Gardner,- W. J.: Closure of Defects of Skull with Tantalum, Surg., Gyn.
and Obst. 80:303, 1945.
38. Idern: Tantalum in the Immediate Repair of Traumatic Skull Defects,
U. S. Navy M. Bull. 43:1100, 1944.
39. Harris, M. H., and Woodhall, B.: Plastic Closure of Skull Defect, Sur-
gery 17:422, 1945.
40. Hemberger, A. J., ~K/hitcomb, B. B., and Woodhall, B.: The Technic of
Tantalum Plating of Skull Defects, J. Neurosurg. 2:21, 1945.
41. Hook, F. R.: Treatment of War Injuries of the Skull and Brain, Dis-
cussion, Bull. Am. Col. Surg. 27:130, 1942.
42. Kazanjian, V. H., and Holmes, E. M.: Reconstruction after Radical Op-
eration for Osteomyelitis of the Frontal Bone, Surg, Gyn. and Obst. 79:397, 1944.
43. Kiskadden, W. S.: Tantalum in War Surgery, Proc. Am. Acad. Orth.,
p. 245, 1944.
44. Mayfield, F. Ii., and Levitch, L. A.: Repair of Cranial Defects with
Tantalus, Am. J. Surg. 67:319, 1945.
45. Pudenz, R. H.: The Repair of Cranial Defects with Tantalum, J. A. M. A.
121:478 (Feb. 13) 1943.
46. Reeves, D. L.: Tantalum in Repair of Traumatic Cranial Defects, Bull.
Los Angeles Neurol. Soc. 9:112, 1944.
47. Robertson, R. C. L.: Repair of Cranial Defects with Tantalum, J. Neuro-
surg. 1:227, 1944.
48. Schnitker, M. T., and McCarthy, W. D.: Osteomyelitis of the Skull, Sur.
gery 18:94, 1945.
49: Sheldon, C. H., Pudenz, R. H., and Craig, ~K/. M.: The Management of
the Head Injury Patient, Surg. Clin. N. A. (Dec.) 1944.
S0. Hamby, W. B.: A Tantalum Cranial Clip, J. Neurosurg. 1:331, 1944.
S 1. Woodhall, B., and Spurling, R. G.: Tantalum Cranioplasty for War
Wounds of the Skull, Ann. Surg. 121:649, 1945.
52. Woolf, J. I., and Walker, A. F.: Cranioplasty, Collective Review, Intern.
Abstr. of Surg. 81:1, 1945.
S 3. Pudenz, R. H., and Odom, G. L.: Meningocerebral Adhesions, Surgery 12:
791, 1942.
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54. Delarue, N. C., Linell, E. A., and McKenzie, K. G.: An Experimental Study
on the Use of Tantalum in the Subdural Space, J. Neurosurg. 1:239, 1944.
S S. Robertson, R. C. L., and Peacher, G.: The Use of Tantalum Foil in the
Subdural Space, J. Neurosurg. 4:281, 1945.
T6. Pudenz, R. H.: The Use of Tantalum Clips for Hemostasis in Neurosurgery,
Surgery 12:791, 1942.
T7. Olson, C, T.: Tantalum-A Glimpse of Its Surgical Future, Ind. Med.
13:738, 1944.
T8. Schram, W. R., and Fosdick, L. S.: Studies in Bone healing, J. Oral Hyg.
1:191, 1943.
T9. Spurling, R. G.: The Use of Tantalum Wire and Foil in the Repair of
Peripheral Nerves, Surg. Clin. N. A. (Dec.) 1943.
60. Idem: Peripheral Nerve Surgery, J. Neurosurg. 1:133, 1944.
61. Spurling, R. G., Lyons, W. R., Whitcomb, B. B., and Woodhall, B.: The
Failure of Whole Fresh Homogenous Nerve Grafts in Mau, J. Neurosurg. 2:79,
194 S.
62. Schnitker, M. T.: The Principles of Treatment in Peripheral Nerve In-
juries, Bull. U. S. Army Med. Dept. 73:53, 1944,
63. Scarff, J. E.: The Surgical Treatment of Injuries of the Brain, Spinal
Cord, and Peripheral Nerves, Surg, Gyn. and Obst. 4:405,1945.
64. Olson, C. T.: The Place of Tantalum in Surgery-Experience with Sutures
and Foil, Ind. Med. 13:917, 1944.
65. Weiss, P.: Nerve Generation and Nerve Repair, J. Neurosurg. 1:400, 1944.
66. Idem: Sutureless Reunion of Severed Nerves with Elastic Cuffs of Tan-
talum, J. Neurosurg. 1:219, 1944.
67. White, J. C., and Hamlin, H.: New Uses of Tantalum in Nerve Suture,
Control of Neuroma Formation, and Prevention of Regeneration after Thoracic
Sympathectomy, J. Neurosurg. T:402, 1945.
68. Colman, C.: Surgical Treatment of Peripheral Nerve Injuries, Surg., Gyn.
and Obst. 78:113, 1944.
69. Craig, W. M.: War Wounds of Peripheral Nerves, U. S. Naval M. Bull.
41:613, 1943.
70. Schuessler, W. W.: A New Technic for Repair of Facial Paralysis with
Tantalum Wire, Lancet 1:263, 1946.
71. Sheehan, J. E.: Unilateral Facial Paralysis; Correction with Tantalum
`,pire, Lancet 1:263, 1946.
72. Gardner, W. J.: Use of Tantalum for Repair of Cranial Defects in Infect-
ed Cases, Cleveland Clin. Quart. 13:72, 1946.
73. Goodale, F.. L.: Use of Tantalum in Frontal Sinus Surgery, ANNALS oa
OTOLOGY, RHINOLOGY AND LARYNGOLOGY S4:7S7, 1945.
74. Newman, J.: Use of Tantalum for Facial and Cranial Defects, Am. J.
Surg. 73:499, 1947.
7T. Venable, C:. S.: Osteosynthesis in Presence of Metals, South. M. J. 31:501,
1943.
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VERTEBRATED MAGNETS FOR REMOVAL
OF FOREIGN BODIES FROM THE AIR
AND FOOD PASSAGES
CHEVALIER JACKSON, M.D.
AND
CHEVALIER L. JACKSON, M.D.
PHILADELPHIA, PA.
As stated by Equen,' "Doctors have been working with magnets
for many years. It is just since a powerful magnet which could be
made small enough to be introduced through a bronchoscope that it
has proved most effective." Forty-three years ago a long series of
researches and experiments were reported,' formulating the principles.
underlying the use of magnetism for the removal of ferrous foreign
bodies from the air and food passages and giving a list of instru-
mental means that had been worked out in the practical application
of the principles involved. Later researches carried the experiments
further, and a powerful electric magnet was used to draw downward
and fix for grasping with forceps a steel-jacketed machine-gun
bullet that was located "around the corner" in the left upper lobe.
The- models of instruments developed in researches included rod
magnets; rods for permanent magnetic activation; rods for inter-
rupted electromagnetic activation; vertebrated rods for magnetic
activation; chains for magnetic activation; magnetic forceps; forceps
for interrupted electromagnetic activation; projected core magnets;
solenoid magnets; powerful magnets for activation of rods, chains,
etc., and for magnetic fixation. Practical results were obtained only
in cases in which the foreign body could have been snore easily re-
moved with forceps, because of the feeble magnetic energy exerted
by the best means known to the physicists of that time. The best
rod magnets were the permanently magnetised rods of quench-
hardened tool steel.
In recent years, a great industrial demand arose for a permanent
magnet of greater magnetic energy than that exerted by the per-
manent rod magnets of quench-hardened 1 % carbon steel. The
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demand led to the development of the alnico magnet by the General
Electric Company. It is made of an alloy chiefly of aluminum,
nickel, cobalt and iron and has great permeability as well as
indefinitely long retention. The alnico magnets are now made in an
endless variety of shapes and sizes for manifold industrial purposes.
There are about 300 built into an airplane. Various formulas and
processes for making the alloy have been developed for various special
industrial requirements.
Instruments using the alnico magnet have been devised and
successfully used for removal of foreign bodies from the air and
food passages by Equen,l-~ Silber, Kaplan and Epstein;'i Holinger;5
Tucker,12 Penta10 and others. Silber, Kaplan and Epstein removed a
ferrous padlock from the stomach. Equen used a Levin duodenal
tube as a carrier for the alnico magnet for removing a number of
ferrous foreign bodies (bobby pins) from the stomach. For the
removal of ferrous foreign bodies from the duodenum in 3 cases~~2
he had the child swallow an alnico magnet attached to a string with
which the foreign body was removed after the magnet had passed
into the duodenum and made contact. For use in the tracheo-
bronchial tree he used successfully a ureteral catheter as an alnico
magnet carrier. Holinger5 advocated rigid stems of brass for better
control and for safe disengagement of the foreign body from the
magnet by pushing downward with the endoscopi.c tube. At our
clinic the alnico magnet has been used in 1 S cases for removal of
ferrous foreign body: a nail from the right lower lobe bronchus; 10
bobby pins from the stomach, and a bobby pin frotn the duodenum;
a washer, a screw and a hairpin from the stomach..
Of the various forms of magnets described in the researches
and experiments mentioned in the first paragraph above, the verte-
brated rods are well adapted to alnico construction. With a view
of increasing facility of magnetic removal of ferrous foreign bodies
from the esophagus, stomach and the less accessible parts of the
tracheobronchial tree, we have worked out four forms of vertebrated
magnets to add to the magnetic armamentarium (Fig. 1) . The
magnets are carried at the distal extremity of the vertebrated end.
The four forms enable the operator to reach and enter practically
all segmental bronchi and to pass the magnetic end in any peripheral
direction as far as it is possible to work without risk of traumatizing
the parietal pleura. The vertebrated distal ends of the four instru-
ments are as follows:
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Fig. 1.-Vertebrated magnets for removal of foreign bodies from the
air and food passages.
A, is a straight form; the flexibility of the vertebrated portion
permits accommodation to tangential deviations up to about. 4?or
S ?, as it yields in following lumina in approximately caudad direc-
tions. By manual rotation of the angular handle the magnetic distal
end can be guided into segmental bronchi of small tangential angles
in any caudad direction by biplane fluoroscopic guidance, in co-
operation with the radiologist. Both major segmental orifices of the
middle lobe can be similarly entered with this magnet or with the
one described in the paragraph below (B) .
B. The extreme distal end of this magnet is bent at about a 60 ?
angle; the spring of the vertebrated end of the curve enables the
magnetic end to deflect in passage down either main bronchus and
automatically enter any orifice to which it may be pointed under
control of the handle: for example, the orifice of either upper-lobe
bronchus.
C. On this model the entire vertebrated part is curved 90? on
a 2-ern. radius and in model D, the entire vertebrated end is curved
180?, on a 25-mm. radius. On the same mechanical principle as the
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upper-lobe bronchus forceps, the vertebrated distal end of both the
90? and the 180? forms straightens out for passage through the
bronchoscope, esophagoscope or open-tube gastroscope, resuming its
curve after ernerging at the distal tube mouth, the radius of curva-
ture being controlled by the degree of emergence permitted by the
controlling fingers on the angulated handle.
The inferior segmental branch of the lingular division of the
left upper-lobe bronchus is easily found with the guidance of the
eye at the bronchoscope; then the straight vertebrated magnet can
be inserted into the orifice, and deeper passage will be controlled
tinder guidance of the biplane fluoroscope, in co-operation with the
radiologist. The superior segmental branch will require the 90 ?
curved vertebrated magnet, or in some cases, the 180?. The anterior
and apical posterior branches will require the 180? curved instrument.
The vestibule of the right upper-lobe bronchus is easily entered
with the short angular tipped mo-del, B, by simply keeping the
conical distal end pointed toward the right in the coronal plane as
the magnet is passed down the right bronchus, or toward the left
in the case of the left upper-lobe. Though a click may be felt as
the ferrous foreign body jumps into contact, the whole procedure
should be done under fluoroscopic guidance. The anterior and the
posterior segmental bronchi of the right upper lobe are reachable with
the 90 ? curved vertebrated magnet. The apical segmental bronchus
will require the 180? curved vertebrated form. In both these pro-
cedures utmost caution and slowness in permitting emergence are
necessary to avoid pushing the foreign body toward the periphery,
where difficulties would be greater.
Endogastric version of steel safety-pins and endogastric cephalic
version of staples may be done with the vertebrated magnets A and
B, under fluoroscopic guidance, using the vertebrated magnet in
the same way as the ring-rotation forceps are used in the Chevalier
Jackson technic of endogastric version. The magnetic energy is not
sufficient to pull the safety-pin into the tube mouth and close it,
as can be done with the forceps, but the pull is sufficient to draw
the safety-pin up through the esophagus trailing, if kept near, but
not touching, the tube mouth.
The magnetic energy of the alnico magnet leaves only one
absolute limitation, namely, the foreign body must be permeable to
magnetic energy. This eliminates all except ferrous foreign bodies
and foreign bodies of a few rarely encountered metals. However,
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iron and especially steel are commonest of metallic substances and
now that they are available in practically inoxidizable alloys, they
are increasingly supplanting brass and other alloys of copper for
manufacture of many small objects. To determine magnetic per-
meability of a foreign body in a particular case Equen has used the
Berman locator developed by the Waugh Laboratories. When passed
on the external surface of the patient's body it will buzz as the region
of a ferrous foreign body is approached. If this instrument should
be unavailable, a heavy electric eye magnet may be used. Close watch
at the fluoroscopic screen with visual axis 90? to the plane of the
magnetic lines of force will detect slight movement of the foreign
body toward the magnet as the core is quickly approached to the
chest wall, if the foreign body is ferrous and of sufficient size.?
Magnetic energy of any degree is absolutely harmless to human
tissues. Apart from trauma, which is entirely avoidable by gentle-
ness and care, only one precaution is particularly necessary. A
magnet made from cast alnico alloy is extremely brittle; it must
be handled with utmost care and gentleness. The sintered alnico
alloy is less brittle but is brittle enough to require utmost care in
handling to prevent breakage which would add another feature to
the foreign-body problem, namely, the physical law that when a
magnet breaks, each fragment is polarized, and the other physical
law that like poles repel. Therefore if fracture of an alnico magnet
should occur the fragment should be removed with a soft iron rod
of the same form as the magnet carrier used in the case but un-
magnetized to avoid possible repulsion by like poles. Soft iron would
not polarize and the fragments of the broken magnet would attach
themselves to it. Unmagnetized forceps might be used, if better
suited to the particular case, but they might become polarized by
the broken magnet if the grasp were released, unless they were
entirely of brass.
1. Equen, Murdock, S.: Magnetic Influence in Bronchoscopy, Laryngoscope
58:726 (July) 1948.
2. Equen, Murdock S.: Foreign Bodies in Duodenum, South. Med. J. 41:187
(Mar.) 1948.
3. Equen, Murdock, S.: A New Magnet for Removal of Foreign Bodies in
Food and Air Passages, J.A.M.A. 127:87 (Jan. 13) 1945.
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4. Equen, Murdock, S.: Magnetic Removal of Foreign Bodies from Food and
Air Passages under Fluoroscopic Guidance, South Med. J. .38:245, 1945.
S. Holinger? Paul H.: Magnets for Extraction of Foreign Bodies from the
Air and Food Passages, Trans. Am. Broncho-Esophagological .!~sso., pp. 18-19, 1946.
6. Jackson, Chevalier: Magnetic Aid in the Bronchoscopic and Esophago-
scopic Removal of Foreign Bodies from the Air and Food Passages, ANNALS of
OTOLOGY, RHINOLOGY AND LARYNGOLOGY 37:435 (June) 1928; also Proc. Am.
Bronchoscopic Soc. 1927.
7. Jackson, Chevalier: Foreign Bodies in the Trachea, Bronchi and Oesophagus.
The Aid of Ocsophagoscopy, Bronchoscopy and Magnetism in Their Extraction,
Laryngoscope 15:257-281 (Apr.) 1905.
8. Jackson, Chevalier: Peroral Endoscopy and Laryngeal Surgery, St. Louis,
The Laryngoscope Co., 1915.
9. Jackson, Chevalier: A Bullet in the Lung; Bronchoscopic Removal with
the Aid of Magnetic Fixation, J.A.M.A., 90:1272 (Apr. 21) 1928.
10. Penta, Arthur Q.: Electra-Magnet for the Removal of Magnetic Objects
from the Bronchial and Esophageal-Gastric Tract, Trans. Am. Broncho-Esophago-
logical Asso, pp. 15-16, 1948.
11. Silber, S., Kaplan, C. and Epstein, B.S.: The Use of a Permanent Magnet
in the Peroral Removal of a Metallic Foreign Body (Padlock) from the Stomach,
ANNALS OF OTOLOGY, RHINOLOGY Al\D LARYNGOLOGY 53:589 (Sept.) 1944.
12. Tucker, Gabriel: A Flexible Gastroscopic Forcep with Magnetic Tip,
Trans. Am. Broncho-Esophagological Asso., p. l7, 1946.
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vI
ANESTHESIA IN FENESTRATION SURGERY
JOHN HUGH TLTCCI, M.D.
BOSTON, MASS.
There has been, from the very first, serious controversy regard-
ing the ideal anesthesia for fenestration procedures. The early work-
ers in the field have steadfastedly adhered to a regime of heavy pre-
operative medication plus a "hands off" policy during the actual
operation. This attitude may have been considered legitimate in 1938:
otolaryngological anesthesia, according to modern concepts, had little
to offer then.
The comparative lack of safety, the prolonged and even severe
periods of suboxygenation, the unmanageable restlessness of some
patients on the operating table, and the dull prospects of serious
postoperative states of hypotension and respiratory insufficiency have
caused a great many clinicians to abandon this method of anesthetic
management. Unfortunately, the alternatives, chosen at random,
have been in many instances no better. Thus, the heavy usage of
depressant drugs preoperatively has continued.
The surgical requirements for this, the most intricate and deli-
cate form of surgery yet devised, are simple and few, but exacting.
The surgeon will demand a quiet, and at times, completely immobile
patient. Unquestionably he prefers a bloodless field during the latter
third of the procedure, for indeed his ratio of success is in direct
proportion to the dryness of his operative field. Lastly, he would
be pleased and reassured if the vital statistics, during the operative
as well as the postoperative periods, are well within normal physi-
olggical limits.
Let us consider first the several objections voiced by the otologists
to some of the methods now in common usage among anesthetists.
Management under diethyl ether is very frequently advocated but
we are told that the induction takes considerable time, and that
endotracheal intubation is not without its well known hazards of
trauma to the cords and adjacent structures. We may, parenthet-
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ically, answer this objection by stating that the danger of cord dam-
age is almost negligible when compared to the advantages of a clear
airway. Recovery and postoperative management may be long and
detailed, especially since the surgery itself causes vertigo and nausea
to a great extent. Diathermy cannot be used with absolute safety;
the patient cannot be "word-tested" on the table. It is believed that
bleeding is more likely and more serious with ether than with other
anesthetics. Finally, the well known objections of many patients to
the ordeal of ether induction must be taken into account.
Those who rebel against the use of deep basal anesthesia with
preoperative barbiturates and opiates do so because of the great and
unpredictable variability of result in that some patients are lightly,
and some too deeply anesthetized. Patients become quite restless at
times and often delirious on the table. This frequently causes post-
ponement of the surgical procedure. Postoperative morbidity rates
are understandably high, and occasionally a death is reported. Nausea
and emesis are serious and may occur at crucial times during the
operation. The amounts of supplemental anesthesia necessary may
cause further respiratory depression which cannot always be satis-
factorily handled in some clinics. Finally, the straining observed
under some conditions of pain and struggling causes troublesome
bleeding.
Lately tribromethanol (Avertin) anesthesia has been advocated
by some not anly for its anesthetic effect but for its tendency to
cause hypotension which would help to maintain a bloodless field.
The dangers inherent in such a regime are fairly obvious when we
recognize the serious and even irreversible pathological changes that
sustained hypotensive states will engender in the kidneys, myocar-
dium and brain.. Except under unusual circumstances the use of
Avertin has been ruled out quite universally, and justly so. Toxic
liver manifestations, in spite of preoperative diets rich in sugars,
severe hypotensive states and episodes of respiratory depression, as
well as the serious lack of control on the part of the anesthetist have
rightly combined to oust this agent from our consideration.
In an endeavor to assess the value of and compare adequately
some of the common methods of management, and to accumulate a
list of operative and postoperative complications, we have outlined
a method of study we have pursued during the past two years.
One hundred consecutive operations on 92 patients extending
to June 30, 1948, have been studied. This series includes 62 women
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and 30 men whose total average age was 34.2 years. Our youngest
patient was 17, and our oldest 59.
No serious physical or psychological contraindication either to
surgery or to anesthesia was encountered. All these patients had
otosclerosis and were referred to and examined by physicians of the
Winthrop Foundation, interviewed by the Social Service Depart-
ment member attached to the Clinic and later discussed openly by a
panel of physicians as to the advisability of operation.
The following minor conditions revealed themselves after care-
ful physical and psychological examination:
1. Mild hypotension, 10 cases (average blood pressure 102/74}.
2. .Secondary anemia, 11 cases (average hemoglobin of 11
gm.) .
3. Undiagnosed cause of albuminuria, 3 cases.
4. Hypo-ovarianism, 2 cases.
5. Tuberculosis, arrested, 2 cases.
6. Mild bronchiectasis, 2 cases.
7. Allergic rhinitis, 2 cases.
8. Psychotic backgrounds, 4 cases.
None of these conditions could be related to any of the opera-
tive disturbances encountered, and no distinction was made in this
series of 100 as far as choice of anesthesia, surgeon, or anesthetist
was concerned.
Regarding distribution of cases among the surgical personnel,
the' Chief of the Clinic operated on half (54%) of this series, and
the remaining half was divided between four associates. With the
exception of the operations performed under pentothil sodium or
pentobarbital sodium (Nembutal) which were conducted by a
physician anesthetist, snore than half of these cases were managed by
competent nurse technicians under the supervision of a physician
anesthetist.
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The cases in this series were divided as follows: 57 patients were
medicated rather heavily and then operated on under procaine hydro-
chloride (Novocaine) regional block alone; 43 patients were lightly
medicated in comparison and were conducted under gas-oxygen-
ether sequence, or under pentothal or Nembutal administered intra-
venously together with procaine infiltration. The following table
demonstrates the differences in premedication between the two groups
which will hereinafter be designated as plan "A" or plan "B".
Plan "A" Plan "B"
(Followed by Regional (Followed by Nemb., Pent.,
Anesthesia) GOE)
It will be observed that of the 57 cases originally scheduled
under procaine block alone, almost half (28) required some form of
supplemental anesthesia during the course of the operation. This
at times becomes necessary with the medication under plan "A"; in
clinics where supplemental drugs are not allowed the amount. of
premedication used is almost triple the doses we have employed under
plan "A". Metheridine hydrochloride (Demerol), in doses of 25 to
S 0 mg. intravenously, was routinely first used in all cases requiring
supplement. IE an initial dose proved insufficient to control pain,
nausea, or restlessness, a second dose was given after an appropriate
interval. No case of this type was given over 100 mg. of Demerol
during the course of the entire procedure. Of these 28 cases, four
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required nitrous oxide-oxygen mixtures by the semiclosed technique
within an average time of SO minutes from the start of the procaine
block. Lastly, in three of these four cases, it was found either neces-
sary .or expedient to add ether to the gas mixture, and thus deepen
the anesthesia to the required plane.
Procaine hydrochloride 2%, with epinephrine 1:50,000 con-
centration, was used routinely for the block. If large quantities of
procaine were to be used, the concentration of epinephrine was lim-
ited to a 1:200,000 strength. The efficacy of the blocl~ varies greatly
in the hands of different operators, and is directly concerned with
the amount of supplement anesthesia required during the course
of the operation. This was shown by the fact that all of the patients
operated upon by either one of two associates required sizable doses
of supplcinental drugs. In only one-fifth (19 ~o) of the remaining
patients, blocked and operated on by one of the three other surgeons,
was supplemental anesthesia found necessary.
Definite indications for the use of supplemental medication such
as Demerol, are found in the following occurrences:
1. Minor movements of hands or feet.
2. Steady increase in respiratory rate and tidal volume.
3. Sharp increase in pulse rate.
4. Restlessness and head movements while unconscious.
S. Verbal complaints of pain or tiredness.
The first few cases done under pentobarbital sodium (Nem-
butal) were handled by the "Drip" method, but the great majority
were induced simply with an initial intravenous dose of approxi-
mately 3.5 cc. (0.2 S gm.) within the first five minutes. Varying
amounts were thereafter given as necessary. We have routinely used
"Solution of Pentobarbital Sodium" (Abbott), each cubic centi-
meter representing one grain or 60 mg. of the drug.
Pentothal sodium, when used, was administered in a solution
of 2 ampoules (2 gm.) to S 00 cc. of 0.8 5 % saline, thus representing
a 0.4 ~o concentration of the drug. This infusion was controlled
by a tunnel clamp to ascertain the amounts given per minute. It
was found necessary in most of the cases to maintain anesthesia at
1 able 4 illustrates the complications encountered as well as their
incidence. Several interesting points may be demonstrated in a
comparison such as this. It is understandable that one-fourth of
plan "A" patients should be in a rather deep stage of narcosis on
arrival at the operating room. It has been our observation that in
clinics using even heavier premedication routines than ours more
than two-thirds of the patients seen immediately before operation
are in dangerously deep levels of barbiturate intoxication.
Respiratory depression was encountered in one-third of the
first group and only half as frequently in the second group and then
later during the procedure. Depression was considered to be present
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about the level of early third stage for most of the procedure. At
certain points along the way, that is, the initial incision, preparation
of the skin flap, making of the new window, and packing with hot
paraffiin wax, the anesthesia could and was lowered appreciably. It
was very gratifying to observe the ease with which the different
planes of anesthesia could be controlled by the :anesthetist using this
dilute solution of penrothal. Pentothal was .never allowed to be-
come the analgesic factor in the procedure, for additional procaine
injections,_instillations of a few drops of 10 Jo cocaine in the middle
if respirations remained at a level of 10 or lower per minute for 10
minutes, or 12 or lower for 20 minutes minimally. It was further
noticed clinically, and with some consistency, that tidal volumes
were appreciably lower among patients in plan. "A". Administra-
tion of oxygen was more frequently resorted to for these patients in
an attempt to bolster blood oxygen concentrations when rising pulse
rates or pale, perspiring appearances of the skin. indicated some de-
gree of respiratory insufficiency and suboxygenation. This greater
depression was carried on, as will be shown, into the recovery period
also. As was expected, the tidal volumes of the patients done
under Nembutal were greatly decreased, and constitute S of the 6
cases seen in this group under plan "B".
The apparent prophylactic value of Demerol, and/or atropine
sulfate preoperatively, is demonstrated in the fact that 6 of a total
of 8 cases under plan "A" with annoying and rather constant nausea
had not received this drug either as premedication or as supplemental
anesthesia during the operation. Of much interest also was the
fact that bleeding was "moderate to troublesome" (to quote from
the surgeon's operative notes) in 14'/0 of the first group, and only
one-third as pronounced in the second group where, it should be
noted, 13 cases of the 43 were conducted under the much maligned
diethyl ether. It was not possible, in our experience, to indict ether
in this regard where the anesthesia was conducted smoothly and
carefully, and when an endotracheal technique was employed.
Pain, restlessness, and poor relaxation were slightly higher in
the second group, but the patients responded much better to sup-
plemental anesthesia than did. those in the first group. Of a total
of 19 cases among both groups, eight were associated with varying
degrees of anoxemia; these eight were patients treated under plan
"A". This, apparently, is the price to be paid for a totally immobile
patient during the entire operation.
Table 5, which depicts the postoperative complications, reveals
a total of 34 complaints among 21 patients. 1`one of these were at
all serious except perhaps three of the six cases with "more than usual
dizziness", and, of course, the two cases of facial palsy. These, for-
tunately, were of very short duration. It is noteworthy that with
the possible exception o# the "hypotensive" group, all recorded com-
plications, though all mild in character, fell into the plan "A" group.
We also see confirmed our belief that patients operated on under
continuous Nembutal medication are very slow in recovering con-
sciousness postoperatively.
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FENESTRATION ANESTHESIA
TABLE 5.
POSTOPERATIVE COMPLICATIONS.
69
Anesthesia
Types
Totals Plan "A" Plan "B"
Local
Pent.
Nemb.
Hypotensive states
16
9
7
9
2
5
More than usual vertigo
6
6
0'
4
2
0
More than usual nausea
3
3
0
3
0
0
Severe dermatitis
1
0
1
0
1
0
Transient palsies
2
2
0
1
1
0
Tachycardia
2
2
0
2
0
0
Prolonged recovery
4
1
0
1
0
3
We have had no deaths from any cause among the patients of
this series, the earliest of which were operated on over a year ago.
Neither have we run across any pulmonary complication, that is:
atelectasis, pneumonia, or tracheobronchitis, in either group. We
have not seen postoperative Inauic demonstrations, severe gastro-
intestinal disturbances, or cardiovascular accidents. The great ma-
jority of these patients have been most happy and well clinically
within 24 hours of their surgical experience.
We are planning a more complete method of clinical investi-
gation for the immediate future. One fourth of the cases will con-
tinue to receive the routine under plan "A" merely as controls, and
will be compared to a like number which is already being treated
under a regime of greatly reduced preoperative medication associated
with the more liberal use of nitrous-oxide-oxygen and intravenous
medication (Demerol) during the operation. We believe this will
afford more control over the patient than is possible with heavy pre-
medication alone. The remaining half will be conducted as in the
past with "Drip" pentothal and a minimum of premedication. We
further intend systematically to calibrate tidal volumes and ascer-
tain blood oxygen levels in all patients.
The surgeons and personnel of the Winthrop Foundation have
contributed greatly to the accumulation of this data by their cour-
teous understanding and unfailing co-operation. It is our earnest
hope that other groups Inay be influenced to work on the specific
problem of anesthesia in fenestration surgery and also report their
trials and tribulations.
ANESTHESIA DEPARTMENT
MASSACHUSETTS EYE AND EAR INFIRMARY.
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Ml'sLVIN R. LINK, M.D.
NLw YORK, N. Y.
The benign neoplasms of the laryngeal cartilages known as
chondromas are especially rare tumors when compared with their
incidence in other regions of the body. Of course, the literature of
any subject represents only the cases reported. Nevertheless, the
rarity of cartilaginous tumors of the larynx has been fully borne
out by the clinical experiences of the older group of laryngologists.
The first comprehensive survey of the world's literature on
laryngeal chondromas was made by Irwin IVloorel in 192 5. He
collected 62 cases reported as chondromatous tumors of the larynx,
but excluded nine of those because five were diagnosed on insuf-
ficient evidence and four were instances of hypertrophy. He there-
fore collected S3 cases which he considered to be true cartilaginous
tumors. The most recent survey was made by McCall, Dupertius,
and Gardinerz in 1944 who collected an additional 3 0 cases since
Moore's report and added two of their own, making a total of 8 S
cases. Rosedale? in 1947 and Moore' in 1948 each reported a case
and these, with the case presented here, brings the total to 8 8 cases
reported in literature.
Site.-l~ccording to the reviews the favorite. site of development
of chondrorna of the larynx was on the endolaryngeal surface of
the posterior plate of the cricoid cartilage, followed by the thyroid
cartilage, the epiglottis, and the arytenoid cartilage in order of
frequency, with the greatest number arising from the cricoid carti-
lage. In the case of the true chondroma presented in this paper
the origin eras from the cricoid cartilage.
Patholagy.-Ewing`' states that localized overgrowth of car-
tilage occurs in several forms between which it is sometimes difficult
From the Department of Otolaryngology, College of Physicians and Surgeons,
Columbia University, New York, N. Y
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to draw sharp distinctions. Limited outgrowths of pre-existing
cartilage occurs on the ribs, in the larynx, and about joints which
exhibit the characteristics of a simple hyperplastic process, and are
called ecchondroses. Enchondromas or chrondromas are tumors that
presumably start from cartilaginous cells in noncartilaginous tissue.
This differentiation is of extreme value in a clinical way for the
tumors that spring from cartilages of the larynx in most cases involve
and obliterate. the normal laryngeal framework so that the larynx
is destroyed; whereas the tumors that start in the region of the
larynx, entirely disconnected from any of the laryngeal cartilage,
may compress the larynx almost to the point of obliteration, but
when removed, the uninvolved laryngeal cartilages can resume their
original positions and the larynx can resume its function.
In general the true chondroma is a rather common tumor. It is
a benign tumor of mesodermal origin with the histologic character-
istics of the various normal types of cartilage, chiefly the hyaline
variety. Ranvier12 classified chondromas according to their structure
in four groups: (1) a single lobe of hyaline cartilage, (2) several
lobules of hyaline cartilages separated by fibrocartilage, (3) fetal
cartilage and (4) cartilage with stellate cells. Histologically there
is no difference between chondroma of the larynx and those of other
parts of the body. The cells are characterized by clear or vacuolated
staining ovoid or stellate nuclei. The cells may be more or less
numerous than in normal cartilage. They vary greatly in size and
usually lack the orderly arrangement into groups of cells with
opposed surfaces flattened. The growing cells of a chondroma are
not, as a rule, those enclosed in the matrix, but rather those on the
periphery of the tumor.
The chondroma usually produces a hard, rounded, lobulated
tumor which may reach large dimensions. The nutrition of the
solid chondroma is maintained by a rich system of lymphatics from
the periphery. It is because of this characteristic of being maintained
by lymph that one may find these tumors iri locations such as
joints and in spaces in which other connective tissue tumors could
not ordinarily attain such dimensions.
While most chondromas are solid, ynany become softened by
mucinous degeneration and cysts filled with mucinous, serous or
fatty material may form. chondromas are usually localized and
benign; they sometimes grow extensively into blood vessels, filling
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the lumen with nodular or solid masses and extending over wide areas.
These latter cases should be considered malignant and classified as
chondrosarcoma.
The understanding of chondrosarcoma is still being hindered by
the idea that to make a diagnosis of chondrosarcoma on a histologic
basis alone i.s often difficult, if not impossible. This difficulty exists
for the better differentiated cases, while in the frank sarcomatous
tumors a histological diagnosis of malignancy is usually obvious.
Lichtenstein and Jaffez believe that even in certain apparently
benign cartilaginous turnors one will find, at least in scattered fields,
if adequate material is examined, subtle but tell-tale evidences of
cytologic atypism of the cartilage cells which will betray the malig-
nant character of the lesion. They hold that a cartilage tumor
should no longer be regarded as benign if, :when viable and not
heavily calcified areas are examined, it shows even. in scattered fields
(1) many cells with plump nuclei, (2) more than an occasional
cell with two such nuclei, and especially (3) any giant cartilage
cell-with large single or multiple nuclei or with clumps of chromatin.
Even iE left to themselves, some chondrasarcomas of well dif-
ferentiated type are likely to remain only locally invasive for years,
but when they finally spread the tumors tend to break into the
regional venous channels, and, by intravascular growth and extension,
may reach t:he heart anal lungs. The possibility of lymphatic spread
also exists and extension of the tumor to lymph nodes, especially
regional, has occasionally been reported.
Sy~rz~tcmis.-Symptoms of chondroma of the larynx vary accord-
ing to the situation and its size and rate of growth. As a rule, these
growths develop slowly and their presence may be noted only when
they begin to interfere with function.
Jackson and Jackson' state that it is well to remember that in
the early stages. of chondroma of the larynx, especially of the cricoid
cartilage, th.e only sign may be impaired motility. They observed
three cases where chondromas developed in the larynx with slightly
impaired adduction but no evidence of arthritis or of impairment
of the crico-arytenoid joint.
When the tumor is within the larynx the symptoms depend
upon the location. If located on the posterior surface of the cricoid
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cartilage, the symptoms will be for a long time those of difficulty
in swallowing, rather than those of breathing. When -the growth
starts on the endolaryngeal surface of the posterior plate of the cricoid
cartilage, as it does in most cases, the encroachment upon the breath-
ing space .will be more noticeable. Wheezing and dyspnea are early
symptoms and asphyxia will result sooner or later if trachetomy
or other surgical relief does not prevent it. Hoarseness is a prominent
symptom when the tumor interferes with laryngeal motility. Im-
paired .adduction may produce air waste; aphonia with whispered
voice will be present in most of the cases in the later stages.
The breathing difficulty may be mild for a long period with
sudden development of extreme dyspnea in case of any change that
affects the larynx. This sudden development of extreme dyspnea
may be caused by an episode of acute laryngitis with resultant
laryngeal edema, or may be caused by obstruction of the laryngeal
airway by food becoming lodged there while eating. Cough may
be present and is frequently the most troublesome symptom.
Tumors arising outside of the larynx may cause no symptoms
and the only complaint may be the swelling in the neck. The
symptoms referable to the larynx or to the esophagus may be so
mild as to be ignored by the patient until laryngeal or esophageal
obstruction creates concern or alarm.
Diagnosis.-If the neoplasm protrudes into the interior of the
larynx, the diagnosis can be made by direct laryngoscopy. Usually
a chondroma protruding into the lumen will show as a smooth,
hard, rounded mass, covered with mucosa of unchanged appearance.
Ulceration has never been reported. Because of the hardness of the
mass a satisfactory biopsy may be difficult to obtain. As soon as the
tumor increases in size the amount of deformity increases, and
there. is distortion of the outline of the glottic chink depending upon
whatever portion of the lumen it encroaches.
If the tumor is protruding externally, external palpation with
delicate sense of touch will determine whether or not a cartilaginot}s
tumor is attached to or springs from one of the laryngeal cartilages.
When a mass is palpated in the neck, it should move with movement
of the larynx and, conversely, ballottement of the cervical mass
should cause the intraglottic mass to change its position. Free
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motility of the mass, its pallor and firm texture are almost diagnostic
to the examiner who is familiar with gross .pathologic characteristics
of this tumor.
Tobeck~ stressed the importance of roentgenographic examina-
tion and recommended that both lateral and anteroposterior views
be taken. The roentgenogram is particularly instructive if there is
calcification or ossification of the tumor. In the two cases presented
in this- paper, the tumors were well outlined by the above views.
Tomographic studies of the second case were- very helpful in the
delineation of the tumor.
Figi~ stressed the significance of the appearance of the blood
vessels which stand out prominently in the apparently normal
mucous membrane covering a smooth sessile mass.
Treatment.-Currently it is believed that the only proper treat-
ment for this condition is surgical removal. It is necessary to excise
every fragment of the tumor with a .fairly wide .margin in order to
avoid recurrence. All cartilaginous tumors regardless of size or
location should be removed, if possible, as soon as the diagnosis is
made, for there is always a small percentage that will take on malig-
nant characteristics.
In chondroma and chondrosarcoma of the larynx tracheotomy
is, of course, indicated as a precautionary mc:~sure whenever the
patient shows any signs of cyanosis and dyspnea, and should be done
low. Tracheotomy is usually done routinely whenever any form
of laryngeal surgery is performed which may result in postoperative
laryngeal edema, and especially whenever any part of the framework
of the larynx is sacrificed. Endolaryngeal removal by direct laryn-
goscopy should be limited to tumors which are small and accessible.
When the tumor is attached to the cricoid cartilage, laryngofissure
with complete removal is the method of choice. If it arises from the
thyroid cartilage it may be removed by an external approach and
submucous resection or morcellation without removing any of the
laryngeal mucoua. If morcellation is the operation selected, great
care should be taken to see that the tumor bed is well curetted.
Total laryngectomy should be strongly advised in cases in
which the larynx is obliterated and it is impossible to carve a new
larynx from the tumor mass, and in those cases where the tumor has
become so large that its removal will sacrifice the framework of the
larynx and result in collapse and stenosis.
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In our case of true chondroma the entire cricoid cartilage was
removed, half of the cartilage being removed in 1938 by Dr. John
D. Kernan and the other half in 1944. 1-1t no time after the second
operation did the patient show any evidence of laryngeal stenosis.
The stenosis in this case may have been prevented by the thick
capsule which was found surrounding the tumor mass at operation.
Rosedale in his case sacrificed half of the cricoid cartilage and
half of the first two tracheal rings and then used a prosthesis to
prevent stenosis. Several articles have appeared where tracheal rings
have been removed and acrylic molds or glass tubes have been used
to prevent stenosis. Longmire,10 in a recent article, presented a case
of aten-year-old boy whose cervical trachea had been avulsed two
years previously. In this case he used a Lucite tube which was left
in place ten and a half months to permit the tracheal wall to become
as rigid as possible in order to prevent subsequent contraction.
In the series of cases reviewed by Moore, operation was per-
formed in 39, of which nine were laryngofissures and six total
laryngectomies. In McCall's review there were ten laryngofissures
and eight total laryngectomies. In Rosedale and Moore's cases laryn-
gofissures were done. Up to this report there have been 21 laryn-
gofissures and 14 total laryngectomies performed for chondromas
of the larynx. In the case now presented in this paper a laryngofissure
was performed.
It cannot be overemphasized that the only form of therapy for
chondrosarcoma which nowadays offers any prospect of cure is
surgery and that surgical treatment should be definitely of the radical
type. The wider the margin of supposedly normal tissue, the better.
li radical procedure offers the best promise of success when it is
undertaken at the initial intervention. The second case in this paper
is an example of incomplete removal at first operation with recurrence
in 17 months.
Irradiation therapy is hardly of. any value since this type of
tumor is highly resistant to such treatment. The growth continues
or resumes in spite of it. Irradiation may serve at most as a palliative
agent for a chondrosarcoma in a site inaccessible to surgical interven-
tion and should not be used with any higher expectations.
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Fig. 1, Case 1.-Lateral roentgenogram showing the encroachment
of the soft tissue mass upon the posterior margin of the air column and the
tiny deposits of calcium ,cattered throughout the tumor mass.
CASE 1.-Chorzdrorraa Of CYICOtd Cartllct,~e.-A 53-year-old
white male, a physician., was first admitted to the Ear, Nose and
Throat Service as a private patient of Dr. John D. Kernan on April
26, 1937, at which tiu~e he gave a history of interval hoarseness
for two and a half years.
Physical examination showed a well developed white male. The
examination of the heart showed a systolic murmur over the apex
area. The blood pressure was 132/80. Indirect mirror examination
of the larynx showed an elevated, irregular area at the junction of
the middle a.nd posterior third of the left vocal cord. On direct
laryngoscopy biopsy was taken from the above area and was reported
as polyp of the vocal cord.
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LARYNGEAL CHONDROMA 77
The patient was then followed as an out-patient and on March
14, 1938, x-ray examination of the larynx and soft tissue of the
neck showed a soft tissue mass somewhat fusiform in outline and
containing numerous tiny deposits of calcium, extending along the
posterior border of the larynx down to the level of the cricoid
cartilage. It seemed to displace -the trachea forward and slightly
to the right. Roentgenographic diagnosis was that of a cartilaginous
tumor of the cricoid cartilage.
The patient was readmitted on June 1, 1938, at which time he
stated he had had continued hoarseness and an increase in the size
of the external mass. Physical examination at this time was es-
sentially the same as on the first admission, except for the laryngeal
findings. Externally there was a smooth hard mass definitely at-
tached to the laryngeal structures extending along the left side of the
neck from the level of the hyoid bone to approximately the level
of the second tracheal ring.
On indirect mirror examination of the larynx the mucous
membrane was approximately normal in color. There was no move-
ment of the left arytenoid and the left vocal cord had agray-red
appearance and lay near the midline. The right vocal cord was
normal. There was a large, firm, red, smooth mass that appeared
to have its origin on the left side. The mass occupied about one-
quarter of the tracheal lumen.
On June 1, 1938, a laryngofissure was performed and the mass
was found to be localized to the left side of the cricoid cartilage.
An attempt was made to remove the left cricoid ring and tumor in
toto, by cutting the cricoid cartilage in the midline anteriorly and
dissecting the mucous membrane fret from the cartilage. This was
unsuccessful, however, and the cricoid cartilage and the tumor mass
were removed piecemeal with various sizes of Spratt's curettes. A
tracheotomy was done as a precautionary measure.
The patient had a febrile postoperative course for two weeks
as the result of secondary infection of the wound. He was discharged
from the hospital on the thirty-seventh postoperative day with the
tracheotomy tube in place.
The pathological report on the specimen obtained at operation
stated: "The microscopic section is composed almost entirely of
hyaline cartilage which stains rather poorly. It appears somewhat
embryonic in type.
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"This is a well differentiated chondroma without any collagen
or elastic tissue in it. There is no histological indication of malig-
nancy but these tumors sometimes display infiltrative growth, and if
excision has not been complete, the remnants may continue to grow.
"Diagnosis: chondroma of cricoid cartilage."
The patient was readmitted to the hospital on May 16, 1939, at
which time .his only complaint was his inability to breathe without
the tracheotomy tube. On direct laryngoscopy the entire larynx
was found to be swollen. On passing a 9-mm. bronchoscope a small
nodular mass was seen in the area of the thyroid cartilage and cricoid
cartilage on the left side. The mass was removed for biopsy and
was reported as chondroma of the larynx with no evidence of
malignancy.
His next admission was on March 23, 1944, at which time there
was a firm mass obstructing the subglottic area. At operation the
incision was made at the anterior border of the right sternocleido-
mastoid muscle. With large curettes the cheesy material was scooped
out of the cricoid cartilage. During this process the entire cricoid
cartilage was removed.
The pathological report was chondroma of the larynx.
The patient had an uneventful postoperative course and the
tracheotomy tube was removed prior to his discharge. During the
next six months he was admitted to the hospital several times for
direct laryngoscopy and during this period the lumen was never
smaller than a No. 3 8 French sound.
This patient has now been followed in the o#fice since 1945 and
there has been no evidence of any local recurrence or laryngeal
stenosis.
CASE 2.-Chondrosctrconacs o f cricoid Cartilage.-This patient
is a 40-year-old negress who was first admitted to the Ear, Nose and
Throat Service on June 29, 1948, at which time her main complaint
was that of loss of voice and a progressive enlargement of a mass
in her left neck. She stated that in March, 1947, at another univer-
sity hospital in another city she had had a small tumor removed
from the left side of her neck. During the operation a tracheotomy
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LARYNGEAL CHONDROMA 79
Fig. 2, Casc 2.-Lateral photograph showing the size of the tumor.
was performed and she had been unable to get along without the
tracheotomy tube since that time.
Examination of the neck revealed a bony, hard mass 5 by S cm.
overlying the left thyroid cartilage, fully movable under the skin
but constituting a part of the larynx. She had a No. S tracheotomy
tube in situ.
On indirect mirror examination of the larynx there was no
movement of the left arytenoid nor of the left vocal cord. The
glottic chink was very narrow. No ulcerations nor masses were
seen.
The blood pressure was 184/80; the pulse rate 120. There were
no heart murmurs and the rhythm was regular. No enlargement
of the heart was perceived on percussion.
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Fig. 3, Case 2.-Photamicro~raphs showing (top) an area of imma-
ture atypical cartilage area of the tumor and (bottom) a moderately well
differentiated area of the tumor. (Hematoxylin and eosin; X 180).
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On June 29, 1948, a direct laryngoscopy was performed and a
paralysis of the left vocal cord was confirmed. In the left subglottic
area a hard, round mass was seen. There were. no ulcerations. No
biopsy was taken. X-ray examination of the chest was negative.
Sedimentation rate was 47 inm. /hr., hemoglobin was 11.9 gm. and
the ~ red blood count 3,700,000. Postern-anterior and lateral stereo-
scopic films of the neck and tomographic studies taken at 12, 13, 14,
1 S, and 16 cm. showed a large soft tissue mass arising from the region
of the cricoid cartilage. The mass extended posteriorly and to the
left, displacing the esophagus and the proximal end of the trachea
to the right. The tracheal air column was almost completely
obliterated.
In the meantime an abstract of the findings from the other
hospital was received and summarized as follows:
The patient is a 39-year-old negress who was admitted to General
Surgical Service because of a lump in the left side of the neck, and
dysphonia, especially for the high notes, of eight months' duration.
Examination showed a round mass about the size of the tip of the
'little finger, attached to the inferior cornua of the thyroid or cricoid
cartilages. The mass was firm, smooth, and nontender. Roentgeno-
grams of the heart, lungs and neck were negative.
On March 28, 1947, the patient had been taken to the operating
room and an attempt at endotracheal intubation made, but this
was unsuccessful due to an obstruction just below the vocal cords.
Anesthesia without intubation was then carried out and the operation
was performed, exposing the tumor, approximately 2 cm. in diameter,
arising from the cricoid cartilage. In an attempt so remove this,
the trachea was entered and it was felt that some tumor mass was
left in the inner surface below the vocal cord. A tracheotomy was
performed. The patient had an uneventful postoperative course and
she was discharged from the hospital on the twelfth day with the
tracheotomy tube in situ. She was given an appointment to return
to the Ear, Nose and Throat Department with regard to possible re-
moval of the tracheotomy tube and evaluation as to the need for
future operation on the tumor.
The pathological report from the other hospital stated: "The
frozen section examination of the tissue obtained at operation reveals
numerous isolated and small clumps of cells characterized by irregular
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Fig. 4, C'.ase 2.-Anteroposterior and lateral roentgenogram showing,
in the first, almost complete obliteration of the tracheal air column and in
the second, th.e large tumor mass extending posteriorly.
hyperchromatic and small nuclei, and clear nongranular cytoplasm.
These cells are identified as chondrocytes and are embedded in a
matrix resembling hyaline cartilage. There is no anaplastic character
to these cells axed their arrangement, although they appear distinctly
irregular and double nuclei are frequently seen.
"The permanent sections add no further information. We are
classifying this tumor as a chondroma on the basis of the presence
of a capsule, and of osteoid tissue and the absence of any extremely
irregular and anaplastic characteristics of the chondrocytes. It is
felt, however, that a diagnosis is to be made with. many reservations
because the tissue is not the usual type of cartilage and many of the
chondrocytes exhibit some degree of irregularity and double nuclei.
"Diagnosis: chondroma of cricoid cartilage."
The pathological specimen forwarded with the abstract was
examined by our Surgical Pathology Department and the following
report was made: "Sections show a cartilaginous growth in which
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LARYNGEAL CHONDROMA 83
there are areas of ossification. The matrix of the cartilage cells vary
somewhat in appearance. Most of them have small nuclei, however,
and in several places are more cellular areas with darkly staining
plump nuclei which almost fill the lacunae. In addition there are
fields in which the lacunae contain two or more nuclei. No mitotic
activity is observed. In some areas the cartilaginous growth appears
to extend into the fibrous capsule.
"Some of the above mentioned features, namely, the more cellu-
lar areas .with plump nuclei, the lacunae with two or more nuclei
and the giant multinucleated cartilage cells are regarded as signs of
a probable malignancy.
"Diagnosis: Chondrosarcoma (?) of cricoid cartilage."
On August 20, 1948, the patient was prepared for lowering of
the tracheotomy tube and for removal of the tumor mass. While
performing the tracheotomy under local anaesthesia the pulse rate
gradually rose to 200 so that operation on the tumor was postponed.
A complete medical work-up was performed including radio-
active iodine studies and the unexplained sinus tachycardia persisted.
On September 2, 1949, under general anesthesia, through a hori-
zontal incision it was found that the lower half of the left thyroid
cartilage and four-fifths of the cricoid cartilage was replaced by a
tumor the size of a golf ball. The tumor was well localized and did
not invade the laryngeal mucosa. By blunt dissection the underlying
laryngeal mucosa and posteriorly situated hypopharynx and thyroid
gland were separated from the tumor. A separate segment of ad-
jacent tracheal mucosa was secondarily sacrificed because of its
adjacency to the inferior tumor margin.
The subglottic laryngeal defect was repaired by a free graft
from the thigh. It was sutured to the adjacent laryngeal mucosa and
held in place by a rubber tube fitting the laryngeal lumen.
The pathological report of the specimen obtained at operation
stated: "The microscopic sections reveal that the tissue is composed
principally of a cartilaginous matrix with a few scattered bony trabec-
ulae. The chondrocytes vary in size, are usually oval to round, and
many show chromatic plump nuclei. The cells sometimes do not fill
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the cartilage capsules and a few multinucleated cells are seen. No
mitotic figures are seen. The usual territorial arrangement of the
cartilage cells is lost, the cells being diffusely and haphazardly scat-
tered throughout the stroma. A fibrous capsule surrounds the cartil-
aginous tumor, but this appears to be invaded by tumor at one point.
"Diagnosis: Chondrosarcoma of cricoid cartilage."
On the fifteenth postoperative day the rubber tube was removed
from the larynx through a laryngeal speculum. Attempts to close
off the tracheotomy tube were unsuccessful as the patient tolerated
the corking poorly. On September 28, 1948, direct Iaryngoscopy was
performed and laryngeal dilators up to size No. 32 were passed with-
out difficulty but upon their withdrawal there was a collapse of the
laryngotracheal lumen.
Because of the collapse of the laryngeal structures it was felt
that a total laryngectomy would eventually be necessary. In view
of the patient's persistent tachycardia it was thought that the oper-
ation should be postponed until her general condition improved. On
October 11, 1948, the patient was discharged from the hospital to
be followed in the laryngeal clinic.
On the first clinic visit on October 27, 1948, it was felt that the
glottic chink had increased in size although some fullness persisted
below the cord.
Cartilaginous neoplasms of the laryngeal cartilages are compara-
tively rare. Two cases, chondroma and chondrosarcoma, have been
presented and discussed from the standpoint of site, pathology, symp-
toms, diagnosis, and treatment. In discussion on microscopic differ-
entiation between benign and malignant cartilaginous tumors, Lichen-
stein and Jaffee believe that a cartilage tumor should no longer be
regarded as benign if, when viable and not heavily calicified areas
are examined, it shows even in scattered fields (1) many cells with
plump nuclei, (2) more than an occasional cell with two such nuclei,
and especially (3) any giant cell with large single or multiple nuclei
or with clumps of chromatin.
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The only treatment for these neoplasms is surgical excision and
in general the same as that for any tumor. It is essential to remove
every fragment of the tumor with a fairly wide margin in order to
avoid recurrence.
Microscopic reports and pathological photographs were prepared by Dr. Raffaele
Lattes, Assistant Professor of Surgery, College of Physicians and Surgeons, Columbia
University, New York City.
PRESBYTERIAN HOSPITAL.
1. Moore, L: Cartilaginous Tumors of the Larynx, J. Laryng. and Otol.
40:9-14; 84-109; 145-164, (Jan., Feb., and Mar.) 1925.
2. McCall, J. W., Dupertius, S. M. and Gardiner, F. S.: Chondroma of Larynx,
Review of Literature and Report of Two Cases, Laryngoscope 54:1-17 (Jan.) 1944.
3. Rosedale, R. S.: Laryngeal Chondroma, Arch. Otolaryng. 45:543-549 (May)
1947.
4. Moore, P. M., Jr.: Chondroma of Larynx, Cleveland Clinic Quarterly 1:4-8
(Jan.) 1948.
S. Jackson and Jackson: Disases and Injuries of Larynx, New York, The
MacMillan Co., pp. 401-407.
6. Ewing, James: Neoplastic Diseases, 4th Ed., Philadelphia, W. B. Saunders Co.,
p. 206.
7. Lichenstein, L. and Jaffe, H. L.: Chondrosarcoma of Bone, Am. J. Path.
19:553-574 (May) 1943.
S. Tobeck, A.: Die Chondrome der Kehlkope, Arch. f. Ohren, Nasen u.
Kehlkoph 146:79-98, 1939.
9. Figi, F. A.: Tumors of the Larynx, Minn. Med. 21:553-f S8 (Aug.) 1938.
10. Longmire, W. P., Jr.: The Repair of Large Defects of the Trachea, ANNALS
OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY 3:875-883 (Sept.) 1948.
11. Kernan, John D.: Personal communication.
12. Ranvier, Louis: Contribution a 1'etude de la structure et du development
des tumours cartilagineuses, Bull. Sac. Anat. de Paris 40:534, 1865.
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VIII
SOME PHYSICAL PROBLEMS IN CONDUCTION DEAFNESS
H. B. PEALMAN, M.D.
CHICAGO, ILL.
Most of our concepts about the acoustic response of the healthy
and the diseased conduction apparatus are based on indirect evi-
dence. Measurement of distant effects such as the auditory threshold
in man,1_7 cochlear microphonics-10 nerve action potential, middle
ear muscle reflex and the conditioned response are examples.
On the other hand, direct observations upon the vibrating
structures themselves have been limited. Earlier methods for making
direct observatio~rs (stroboscopic, optical, etc.) were insensitive and
limited in range. In recent years many methods have been devel-
oped by Bekesyl' for studying the physical phenomena produced in
the ear by acoustic stimulation. Electronic means for detecting
minute acoustic displacements used by physicists have been adapted12
to the special conditions prevailing in the ear.
Such direct observations are important not only in clarifying
normal function but in helping the otologist to understand varia-
tions due to disease as reflected in the threshold curve. Using fresh
cadaver ears a wide variety- of conduction lesions can be investigated
in this manner
The experiments reported here were restricted to the study of
the vibrations of the ear drum and of a rubber diaphragm in models
under several simulated pathological conditions.
Temporal bones were removed at autopsy anal preserved in a
cold, moist chamber with 1/4000 aqueous merthiolate to prevent
bacterial growth. In this manner the elastic properties of the con-
duction apparatus could be maintained for many months. While
some of the observations were made on specimens immediately after
From the Division of Otolaryngology, University of Chicago, Chicago, Illinois.
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Fig. 1.-Approximate relation of foil area to total drum surface, Foil
is just below and posterior to the incudostapedial articulation as seen through
the thin pars tensa. The curved band of light below the umbo and near the
annulus marks the site of maximum drum cu.rvaturc.
removal at autopsy no appreciable alteration in response was ob-
served in properly preserved specimens. Furthermore with the
procedures adopted, long periods of observation were possible at
each experimental session without alteration in the response curve
due to drying. The dissection was carried out to expose the part
to be studied. In this case the drum area was exposed and a piece of
metal foil about 2 sq. mm. was made to adhere to the surface with
a spot of vaseline (Fig. 1 and 2) . The pick-up arm firmly fastened
in a vise was then advanced until the end of the probe was less than
1 mm. away from the foil. The sensitivity is not critically dependent
on spacing between probe and foil over a rather wide range, although
this spacing can be determined by electrical measurement. To pre-
vent artefacts due to the acoustic vibrations of rods and clamps
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Fig. 2.-Inner surface of drum with ossicular chain indicating the size
of the foil relative to the stapes footplate and drum.
the bone was buried in a mass of modelling clay exposing only the
part to be studied. Both the vise holding the probe and the block
of clay carrying the specimen were mounted on a heavy metal plate.
The plate was supported by special mounts that absorb the vibra-
tions of the work table upon which it stood. Sound was delivered
from a loud speaker adjacent to, but not in contact with, the
specimen and the intensity of the stimulus was. measured with a
calibrated condenser microphone and probe tip at the drum. Equip-
ment used in earlier experiments12 was not sensitive enough to
obtain a signal from drum movements at moderate sound pressures.
Original experiments were therefore conducted by delivering rela-
tively intense sound through tubing sealed in the external canal. This
very strong acoustic stimulus was able to induce sufficient movement
of the middle ear elements to permit detection by our pick-up unit.
The working end of the original probe was larger in diameter and
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CONDUCTION DEAFNESS 89
required a larger foil area, thus interfering with proper placement
of the foil and the probe. After careful elimination of spurious
vibrations it is possible with our present equipment to obtain a
signal corresponding closely to the vibration of he part to which
the foil adheres. A moderately intense acoustic stimulus (of the
order of 80 db. re 0.0002 dyne/cm.''') can produce sufficient oscilla-
tion of the drum so that a clear signal can be obtained from the
pick-up device and presented upon the screen of a cathode-ray
oscilloscope. The amplitude and wave shape can both be studied
on the screen. For still greater sensitivity the obtained signal can
be fed into a wave analyzer and a direct voltage reading of the
signal obtained for the frequency of the presented stimulus to the
exclusion of the wide band of electrical "noise" background inherent
in all vacuum tube operation. After proper arrangement of appa-
ratus, sounds of constant pressure were presented as measured on a
Ballantine voltmeter activated by a calibrated condenser microphone
and pre-amplifier. Response to frequencies from 200 up to 10,000
cycles was usually explored at about octave intervals, although
response at the higher frequencies is considered significant only for
comparative purposes due to the effects of the short wave lengths.
The scope was observed for the signal and wave shape and the
amplitude recorded.
A variety of initial response curves was obtained from the
posterosuperior portion of the drum. These usually showed an
amplitude more or less peaked at about 1000 cycles. The response
at the umbo, however, was more uniform (Fig. 3) . When the
preparation was allowed to dry for several hours the resonant ampli-
tude peak shifted to a higher frequency (Fig. 4). This could be
reversed by wetting the preparation. The extreme degree of resonant
frequency change was observed in specimens that were allowed to
remain exposed to room air for many weeks. The entire bone became
very dry, the drum was parchment-like and the ossicular chain
was fixed to static displacement. The posterosuperior portion of
the drum was now found to be very insensitive at ordinary fre-
quencies but showed a marked amplitude peak in the vicinity of
14,000 cycles. Such a specimen could be altered by wetting and by
returning it to a moist chamber. The frequency response of the
drum would then be found to peak at a considerably lower frequency
with definite improvement in overall sensitivity. Changes in fre-
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quency response of the posterosuperior area of the drum were pro-
duced by varying degrees of drying and by pulling on the suitably
isolated tensor tympani muscle. Responses obtained from the postero-
superior quadrant of the drum typically exhibited an amplitude
resonance between 1000 and 2000 cycles, above which the amplitude
fell off rapidly.
The other main group of experiments were concerned with
changes in drum vibration when the middle ear contained fluid
(normal saline) . Some difficulty was encountered in sealing the
fluid within the middle ear and in making complete fillings without
air bubbles. In other experiments the middle ear was only partially
filled with saline. In general the alterations in vibration of the
drum were striking in these acute experiments. Reduction in the
peak amplitude of vibration and a change in its frequency was
uniformly and repeatedly produced. There was a marked reduction
in the response to high frequencies and often a relative improvement
of the response to low frequencies. The amplitude resonance peak
was shifted towards the low frequencies (Fig. S, 6, 7 and 8).
One must proceed with caution when interpreting the results
obtained on vibration of the posterosuperior area of the drum since
the vibration of the malleus is known to differ from the vibration
of this area, particularly at the higher frequencies. Further, while
the vibration of the malleus rather faithfully follows that of the
central area of the drum, by the time the stimulus reaches the stapes
footplate it is affected by the action of the intervening ossicles with
their middle ear muscle attachments. Using a "capacitative probe"
Bekesyll found that in an intact ear exposed to sound of the same
pressure the drum vibrates together as a conical piston with uniform
amplitude up to about 2000 cps. Furthermore, above 2400 cycles
the malleus does not faithfully follow the drum vibration but
appears to lag behind it. At these high frequencies the drum loses
its rigidity as a piston and vibrates as a stretched membrane. Never-
theless, given a certain alteration in drum vibration a similar type
of alteration might be expected in the stimulus reaching the foot-
plate. Bekesy observed a selective effect on pressure transformation
from the drum to the footplate when the middle ear air pressure
was changed to + or -10 cm. of water. That this was not due
to simultaneous pressure on the oval and round window was evident
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CONDUCTION DEAFNESS 91
because the stapes was immobilized by a counter acoustic stimulus
at the same time the measurements were made. He thought that
this effect on the pressure transformation at the footplate was the
result of a change from a pistonlike action of the drum to that of a
stretched membrane, which produces less pressure transfer by the
drum through the ossicular chain to the footplate. The reduction
in pressure transfer concerned only the low frequencies (up to about
800 cycles) and there was little effect above 1000 cycles. A similar
degree of loudness change is produced in man under these conditions.
Bekesy observed overtones in the vibration of the footplate only
when the acoustic pressure at the drum was near the level of feeling.
For the sound intensities used in our experiments, the vibration of
the points on the drum which were studied was essentially sinusoidal.
Bekesy found that the sound pressure per sq. cm. at the footplate
needed to immobilize it, divided by the driving sound pressure
per sq. cin. at the drum, indicated a normal pressure increase at the
footplate of 10 to 20 times up to 2000 cycles. This was a little
higher around 2000 cycles (30 to 40 times that of the drum) when
the sound pressure was measured not at the drum but at the opening
of the external canal because of the resonance effect of the canal itself.
Opening the middle ear or cutting the tensor tympani produced no
change in this pressure transfer from drum to footplate. Moss
of our measurements on drum vibration were made after the external
canal was largely removed to permit an approach of the probe tip.
Hence the effect of canal resonance does not come into consideration
in our findings. Our investigations were not directed towards ex-
ploration of the vibrating drum surface for points of maximum and
equal amplitude. A single placement of the foil, usually in the
upper posterior quadrant, was used while studying the effect of a
given lesion.
We have not repeated the observations of Bekesy on vibration
amplitudes of various parts of the drum. He found that maximum
amplitude occurs in the markedly curved fold of the drum near the
annulus and below the umbo (see Fig. 1) . This curved fold per-
mitted the drum to yield as a unit, covering about S S sq. mrn. of
the total drum area of 85 sq. rnm. and (below 3000 cps.) to vibrate
as a conical piston with its attached malleus, through an axis near
the top of the drum. Our observations with a stroboscope clearly
show this piston-like nature of the acoustically vibrating drum at
180 cycles. However, some additional motion between the umbo
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92 H. B. PERLMAN
and the periphery is seen, especially in the posterosuperior quadrant
of the drum where there is a greater distance of drum between umbo
and annulus. Bekesy points out that the shape of the deformity of
the drum to a point pressure is circular as is the shape of the artificial
perforation. This indicates uniform forces in both radial and circular
direction. To permit overall flattening of the arched periphery of
the drum towards the central umbo, differences between circular
and radial fibers should be present, and should appear as deviations
from the circular shape to pin point pressure and to perforation into
an oval shape parallel with the direction of the radial fibers.
Therefore the amplifying effect on the malleus due to this
type of preferential deformity of the drum fibers as claimed by
Helmholtz is discounted by Bekesy and the pressure transferred to
the footplate is said to be dependent only on differences in effective
areas of the two pistons and the small Lever factor of the ossicles,
1.3 (see Fig. 2) . The drum and malleus response is not appreciably
altered by severing the axis ligaments, according to Bekesy, in-
dicating that the center of gravity of the ossicular masses is at this
same region to permit effective oscillation without the ligaments.
Below 200 cycles, however, the absence of the Ligaments results in
erratic oscillation of the chain. The ligaments are not needed to
maintain the turning axis of the ossicles for high frequencies. The
reduction in pressure transfer below 200 cycles is the result of inter-
action of the ossicles with the axis ligaments. The pressure transfer
is unstable below 200 cycles when the axis ligaments are cut. At
these lower frequencies where the mass effect is smaller, the turning
axis is firmly controlled by the axis ligament. We observed that the
elastic character of the drum together with its conical shape is
altered when the anterior ligament of the malleus is detached, so
that the frequency response of such a unit is that of a mass con-
trolled system. This is also true of the drum, detached from the
annulus in its upper third, with malleus head amputated (see Fig. 8,
graph 2) . On the other hand the conical shape is preserved when
the anterior ligament remains but the drum vibration is mass con-
trolled. With the incus in. place, the acoustic vibrations are changed
to resemble the response of the intact system which is stiffness con-
trolled over a considerable frequency range. Freeing of the incus
at the fan-shaped ligament itself does not appreciably alter the vibra-
tion characteristics of the chain as observed at the drum and malleus
head (see Fig. ?, graph S) . Bekesy13 reports that for constant sound
pressure at the drum the vibration amplitude or the displaced volume
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CONDUCTION DEAFNESS 93
of the round window is about the same for frequencies up to 3000
cycles. The volume displaced by the associated movement of the
cochlear partition is therefore also constant through this frequency
range. However, for the lower frequencies (100 cycles) a greater
length of the basilar membrane is moved than for the higher fre-
quencies (1 S 00 cycles) . Therefore a longer length of the reacting
basilar membrane must move with a smaller amplitude to equal the
volume displaced by a shorter length of the basilar membrane. This
smaller amplitude results in less stimulation of the hair cells which
may account for the lower sensitivity of the ear at low frequencies14.
Phase studies at the round window indicate that the whole system
together operates as an elastic system at low frequencies and that a
strong resistance enters at high frequencies.
Resonances at 600 and 1200 cycles were often seen by Bekesy,
however, but were not presented in his curves.
Phase studies indicate an 800-cycle resonance for the coupled
system and a 1400-cycle resonance for the labyrinth fluid with the
round window but without the footplate. With both windows the
system seems elasticity controlled except at high frequencies. With-
out the windows, however, the vibration of the labyrinth fluid appears
to be friction or mass controlled. Bekesy found that only a great
increase in labyrinth fluid pressure affects the vibration amplitude of
the round window.
Other recent observations help the otologist to visualize the
changes in vibration of the conducting system in middle ear disease
and help to clarify the role of the round window in hearing undep
normal and pathological conditions.
Lowyla observed that mineral oil in the middle ear affected
the phase of the cochlear microphonic as well as the amplitude, the
phase lagging the stimulating sound pressure below 1000 cycles and
leading above 2000 cycles. He explains this primarily on the basis
of an increased resistance or damping of the conduction mechanism
because of the oil. A primary increase of mass would result in a
phase lag throughout the entire frequency range while a primary
increase in stiffness would result in a phase advance over the initial
condition. He produced the latter condition by pressure on the
malleus with a fine wire. Since mineral oil in the middle ear showed
both a phase lag through the lower frequencies and a phase advance
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in the higher frequencies, an increase of resistance or damping was
considered to be the major alteration in the system.
Lowy1? observed differences between the effect on the cochlear
microphonic of a cotton pledget tightly pressed against the stapes
and a drop of mercury on the oval or round window. The latter
improved only the low frequency response of the cochlear micro-
phonic and unpaired the high frequency response (over 4000 cycles) .
This was explained as due to an increase in the effective mass of
an acoustically vibrating system which improves its response below
resonance and impairs its response above resonance. On the other
hand a cotton pledget pressed against the stapes in the oval window
improved the high frequency response. This was explained as due
to an increase in the stiffness of the oval window.
Experiments on the of?ect of pressure and weighting of the
round window membrane as reflected in the cochlear microphonic
were recently reported by Wever and Lawrence70. They observed
very little effect on the cochlear response when a probe was pressed
against the round window membrane. Air pressure against the
round window membrane up to 2S mm. of mercury was also in-
effective in changing the mechanical function of the intact system as
reflected in the microphonic output. This experiment requires that
the round window be complete]y isolated from they rest of the middle
ear by tubing. This isolation does not appear to affect the output
of the cochlear microphanics. Sirnilary Bekesy isolated the round
window in order to measure its volume displacement in response to
sound in the external canal. A wax plug or a drop of mercury
against the round window membrane did impair the cochlear micro-
phonic for the high frequencies by about 4 db. With the chain re-
moved (except stapes footplate) and sound delivered by tubing to
the oval window, blocking the round window with wax did not
effect the high frequency response but did impair the low fre-
quency response (around 100 cycles).. These workers considered that
with the intact system a plug of wax against the round window
caused an overall increase in the mass of the vibrating system and
hence a high frequency impairment, while with the chain destroyed
putting a wax plug against the round window caused an overall
increase in the stiffness of the vibrating system and hence a low
tone impairment in the cochlear microphonics. The already great
stiffness added by the conduction apparatus to the cochlear system
is not changed appreciably by the plug against the round window
membrane.
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CONDUCTION DEAFNESS 95
The otologist is largely dependent on the interpretation of
threshold curves in evaluating functional losses. One is continually
challenged to find the factors that determine the shape of this
threshold curve. The systematic investigations of Bekesy have helped
greatly in developing a clear picture of the purely mechanical
phenomena in the ear as separate from the neural phenomena and
throws new light on the normal sensitivity curve.
In addition to the difficulties in explaining the normal sensitivity
of the ear, changes in sensitivity with ear disease have to be con-
sidered. Alteration in the vibrating condition of the drum is a
relatively simple problem to study: The direct evidence that the
drum oscillates to a wide frequency range of sounds has only recently
been obtained. Bekesy reported on drum vibrations up to 3000
cycles. However, such methods permit observations of vibration
through an even larger part of the auditory spectrum and reveal
that under certain conditions vibrations of certain areas of the drum
at 14,000 per second and higher can be detected. Clinical examples
producing fundamentally different conditions for drum vibration
are found and can be produced experimentally in the living subject
(Fig 9) . Alterations in air pressure between the two sides of the
drum, associated with tubal obstruction or inflammatory reactions in
the middle ear are examples. While alterations in the vibrating of
a flat plate due to changes in stiffness on the one hand and changes
in mass on the other have been recorded and are mathematically
defined in acoustics, detection and measurement of the altered
vibrations of the ear drum have been limited even in the laboratory.
Alterations in the vibrations of the drum, reflected in the ultimate
stimulus which reaches the cochlea, are measured in the living subject
by the threshold curve. Hence it is important to prove in what
way experimental lesions simulating clinical states alter the normal
response. We see here demonstrated a direct effect on amplitude of
drum vibration when the middle ear is filled with fluid. The re-
duction in response to high frequencies is in the right direction to
explain the drop in the air threshold curve at these high frequencies
in serous otitis for example. Bone conduction tests through this
high frequency range, as with a monochord, further indicate that
air conducted stimuli are chiefly involved in this disease.
The hearing impairment most marked through the low fre-
quencies is the more classical picture in middle ear disease. Altera-
tions in the stiffness of the drum, either intrinsic or associated with
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stiffness changes in the ossicular chain, might explain this type of
hearing loss. Arise in the resonant frequency that is produced
by this change shifts the peak of sensitivity toward the high fre-
quency end of the acoustic spectrum. This state was simulated in
the experiment. Corresponding alterations in the human threshold
curve and in the cochlear rnicrophonics of the animal ear are reported.
Differential air pressure and action of the tensor tympani muscle
were effective stimuli.
With the introduction of the newer techniques for physical
measurements upon the various components of tl~e conduction ap-
paratus one obtains a better understanding of the function of the
normal and disea~cd middle ear. The wide variety and constantly
changing procedures advanced to improve hearing in conduction
lesions have been based almost entirely on clinical observations.
Failure to establish the exact cause of impairment in conduction lesions
and to define the acoustical nature of the lesion leads to vagaries
in interpretations of observed clinical effects.
This work was aided by a grant from the Douglas Smith Foundation of the
University of Chicago.
"The author acknowledges the assistance of Mr. J. E. Hind in the develop-
ment and use of the electronic equipment used in these studies.
1. Van Dishoeck, H. A. E.: Negative Air Pressure and Loss of Hearing in
Tubal Catarrh, Acta Otolaryng. 29:303-312, 1941.
2. Van Dishoeck, H. A. T:.: Loading and Covering of Tympanic Membrane
and Obstruction of the External Auditory Canal, Acta Otolaryng. 32:99-112, 1944.
3. Luscher, E.: Effect of Experimental Disturbances of the Tympanic Mem-
brane in Hearing Capacity, Acta Otolaryng. 27:250-267, 1940.
4. Perlman, H. B.: Lesions of the Conduction Apparatus, Arch. Otolaryng.
37:680-690, 1943.
S. Rasmussen, Helmer: Studies on the Effect upon Hearing through Air Con-
duction Brought about by Variations of the Pressure in the Auditory Meatus, Aeta
Otolaryng. 34:415-425, 1946.
6. Luscher, E.: The Functional Effect of Loading of the Tympanic Membrane,
Acta Otolaryng. 33:265-273, 1945.
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7. Von Dishoeck, II. A. E. and de Wit, G.: Loading and Covering of the
Tympanic Membrane and Obstruction of the External Auditory Canal, Acta
Otolar~~+ng. 32:99-112, 1944.
8. Wever, E. G., Bray, C. W. and Lawrence, M.: The Effect of Middle Ear
Pressure upon Distortion, J. Acoustical Society America, 13:182-187 (Oct.) 1941.
9. Wever, E. G., Lawrence, M. and Smith, K. R.: The Effects of Negative
AlY Pressure in the Middle Ear, ANNALS OF OTOLOGY, RHINOLOGY AND LARYN-
GOLOGY 57:418-428, 1948.
10. Wever, E. G. and Lawrence, M.: The Function of the Round Window,
AniNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY 57:579-589 (Sept.) 1948.
11. Bekesy, G.: Uber die messingen der Schwingungs Amplitude der Gehorhek-
nochelchen mittels einer Kapacitativen Sande, Akustische Ztschr. 6:1-1 f, 1941..
12. Perlman, H. B.: Some Physical Properties of the Conduction Apparatus,
ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY 56:334 (June) 1947.
13. Bekesy, G.: Uber die Schwingungen der Scheckentrennwand beim Pre-
parat and Ohrmodel, Akustische Ztschr. 7:173-186, 1942.
14. Bekesy, G.: Uber die Resonzkurve and die abklingzeit der vershiedenen
Stellen der Scheckentrennwand, Akustische Ztschr. 8:66-75, 1943.
1 S. Lowy, K.: Phase Shift due to Impedance, J. Acoustical Society America
13:389-392, 1942.
16. Lowy, K.: Experiments in the Pellet Type of Artificial Drum, J. Acoustical
Society America, 13:383-388 (Apr.) 1942.
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_~_
~_L
_~~ ~ ~ _~~
I I'
- - , -i-
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Pig. 3. Graph 1. General contour of drum response seen in malleus response.
Graph 2. Obliteration of the resonant peak at the umbo.
Graph 3. Resonant peak of the drum reduced at the umbo.
Graph 4. Umbo response shows overall reduction in amplitude as com-
pared to the drum. This is particularly marked through the resonant
area.
Graph 6. Closure of mastoid air cells does not effect drum response.
Fluid in middle ear has greatest effect at 2000 cycles.
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Fig. 4. Graph 1. Increasing stiffness of drum and chain and reducing the effec-
tive mass of the fluid, shifts the resonance peak from 700 to 5000
cycles.
Graph 2. Response of dry drum after wetting. Before this there was
no signal through this frequency range but a maximum response at
13,000 cycles.
Graph 3. Increasing stiffness of drum and ossicular chain by drying
reduces peak response and shifts peak from 2000 to 2500 cycles.
Graph 4. Pull on tensor increases stiffness of drum and results in a shift
of the resonance peak from 1500 to 4000 cycles.
Graph S. Peak response shifts to 10,000 cycles due to increased stiffness.
Signals were obtained in dry state up to 18,000 cycles.
Graph 6. Closure of this perforation produces greatest effect through
the middle frequency range.
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_ 6
_ _ _
_-
lT
e~-
c_ T
15,~
_
Q
---
I
--
~ -~-
--'
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I
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__.
j ?I
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Fig. 5. Graph 1. Perforated drum response in dry specimen is changed by
wetting and closure of perforation.
Graph 2. Fluid in middle ear improves low frequency response and
impairs responses at high and middle frequencies. Specimen was then
removed from moist chamber for twelve hours, after which period
there was very little drum vibration below 4500 cycles.
Graph 3. Drum vibration peaks at 4500 cycles with practically no low
frequency signal. This sensitivity is reversed by fluid in the middle ear.
(Dashed line indicates no measurement due to insufficient sound
pressure. )
Graph 4. Obliteration of resonance peak at 800 cycles with marked
reduction above 400 cycles produced by fluid in the middle ear.
Graph S. Increased stiffness due to drying shifts resonance peak from
3000 to 7000 cycles and reduces response to low and middle fre-
quencies.
Graph 6. Shift in resonance peak with change in the amount of fluid;
appearance of an additional resonance peak when more fluid is removed.
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~.
T~
_.
-''
'
j
I
I i
fib
~~
~ i ~
~
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- }-i
~~
iT
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._...
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,
.
,~
.
~
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Fig. 6. Graph 1. Fluid in the middle ear produces the greatest reduction in
drum. response through the middle frequency range.
Graph 2. Change in height and position of peaked response due to fluid
in middle ear.
Graph 3. A little moisture in tympanic cavity has only a little effect on
drum response (curve B). Filling the ear has a marked effect
(curve C).
Graph 4. Note shift in resonance peak from 3000 to 600 cycles and
the overall reduction in amplitude relatively greater for the higher
frequencies when fluid fills the middle car.
Graph 5. Drop in resonance peak from 1800 to 600 cycles when the
middle car is partly filled with fluid.
Graph 6. Partial restoration of middle frequency response when the
fluid in the middle ear is partly removed (curve C).
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r;:
a .;
__
:,
-
- -
,.
~
-~
~~
,,~
-
,
y~
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~,
.
~
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,
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~
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Fig. 7. Graph 1. Dried specimen first restored by wetting. Then fluid is placed in
the middle ear with characteristic effect on the frequency response of
the drum.
Graph 2. Note shift in resonance peak from 4500 to 600 cycles when
the effective mass of the drum is increased by fluid in the middle ear.
Graph 3. Curves A and B taken after fluid has been removed from the
middle ear. (Small perforation in the drum.)
Graph 4. Note the shift in the resonance peak from 2500 to 800 cycles
when some fluid remains in the middle ear (curve B).
Graph S. Chain intact but fan-shaped ligament of the incus detached.
Shape of drum response curve not markedly affected by this lesion
(curve A). Fluid in the middle ear has a marked effect (curve B).
Graph 6. Characteristic change in the frequency response curve of the
drum when fluid fills the middle ear.
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108 H. B. PERLMAN
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Fig. 8. Graph 1. Note similarity in the frequency response curve of a model
with air and with fluid against a rubber diaphragm to that of the
ear drum with and without fluid in the middle ear cavity.
Graph 2. Frequency response of a partly detached drum without ossicu-
lar chain resembles that of amass controlled system. Fluid against
this drum impairs its low frequency response.
Graph 3. Mass on the inctts affects drum vibration, shifting resonance
peak from 2000 to 1000 cycles.
Graph 4. Closures of cavity behind rubber diaphragm markedly reduces
resonance peak. Closed middle car and mastoid air spaces may con-
tribute to the shape of the frequency response curve of the drum.
Graph 5. With rubber diaphragm of model half covered with water,
closure of tube has little effect on frequency response (compare with
graph 4).
Graph 6. Mass applied to malleus head affects movement of drum oblit-
erating resonance peak.
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goo ~~_~
~ c
I S S F _ __
A. N P ?S D D 1d
_ B .N A P S kE -- -..
0 D
Fig 9:-Graph 1. Progressive high tone conduction. deafness due to
fluid in the middle ear.
Graph 2. Progressive low tone conduction deafness due to
negative pressure on the drum.
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IX
THE OTOLOGIC EFFECTS OF STREPTOMYCIN THERAPY
LINDEN ,J. WALLNER, M.D.
CHICAGO, ILL.
In a discussion on streptomycin, an otologist remarked that it
was the first of the antibiotics to increase rather than decrease the
work in the specialty. He was referring to the toxic effects on the
inner ear and the practice of observing the cochlear and vestibular
function frequently during the course of treatment.
This is a report of the results of such tests done on 93 patients
receiving streptomycin in the treatment of tuberculosis at the Hines
Hospital.
Of the 93 patients all but two were in the special streptomycin
study group, one of 20 such groups in the Veterans' Administration.
Before the drug was administered, each patient underwent a
complete ear examination. The hearing was tested on a Maico
D 4 audiometer in an especially equipped room. While this room
is not completely sound proof, it is lined with acoustic tile, and has
a heavy, tight door. Air conduction alone was tested. The audio-
grams were done by a trained Veterans' Administration technician.
The routine for vestibular testing was as follows: The presence
of spontaneous nystagmus was noted. The patient's head was placed
with one ear up and the canal filled with ice water, about 2 cc., for
45 seconds. The water was allowed to run out, the nystagmus being
determined in the two usual positions, head forward at 30 degrees,
and backward at 60 degrees. The gaze was fixed with the eyes look-
ing straight ahead at some distant object. The nystagmus was timed
with a stop watch from the beginning of stimulation. This rather
simple method was suggested by McNally.l When performed in
this manner, the after-nystagmus in a normal individual lasts from
140 to 180 seconds. Frenzel or other special lenses were not used.
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Whenever possible patients were sent for an audiogram and
caloric tests every two weeks during treatment and once a month
afterward. Subjective complaints were recorded at each visit. The
caloric tests were done by different individuals, mainly by the resi-
dent otolaryngologists, under the direction of the attending staff.
Since the toxic effect of streptomycin seems related to dosage,
the patients were divided into two groups. Group I received 1.8
gm. or 2 gm. per 24 hours in divided doses for four months. Group
II received 1 gm. per 24 hours for four months. Since November,
1947, patients starting treatment have been given only 0. S gm. per
24 hours, but none of the patients in this report were given this
lower dosage. All but one received the drug for some form of
tuberculosis.
1. Subjective Complaints. These were common during treat-
ment and consisted of dizziness, staggering gait, tinnitus, nausea. and
vorniting and visual disturbances. The latter consisted of inability
to read, blurring of distant vision, of objects moving, or of spots
before the eyes. A group of 11 patients with eye complaints was
studied by Field and Koransky.~ They checked the central and
peripheral vision, accomodation, convergence and occular motility.
They were unable to find any evidence of disease of the eyes, and
concluded the occular complaints were the result of the vestibular
dysfunction.
In Group 1, those receiving 2 gm. per day, 42 of the 53, or
79.2 %, had subjective complaints of varying degree. In Group II,
those who received 1 gm. per day, I8 of the 40, or 4 S ~/`o, had symp-
toms.
2. Spontaneous Nystagmtss. It was common to observe a fine
nystagmus on lateral gaze. This usually occurred in those patients
with subjective symptoms, and objective evidence of depression of
the labyrinth. A report on the exact number urith this symptom
cannot be given. The nystagmus was often rather intangible and
transitory, and was evaluated differently by the different observers.
Some felt that it was physiological.
3. Hearing. None of the patients in the study group noted
any loss of hearing. A co-nparison of audiograms made before, dur-
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ing and after treatment did not reveal any significant change. In-
cluded were those with a severe loss of hearing in one ear, older
patients with high tone loss, and some wixh a dip at 4096 d.v., com-
monly seen in servicemen exposed to gunfire. One patient, not in
the study group, received the 2-gm. dose for three weeks. He was
a paraplegic, in coma and critically ill with a kidney infection. No
pretreatment ear examination was performed. His general condi-
tion improved markedly, but suddenly, on the twenty-first day, he
was noted to be profoundly deaf. When seen the next day there
were no caloric responses, and he could not hear the shouted voice
or any of the forks. The audiogram revealed an average loss of 80
decibels. This loss of cochlear and vestibular function has persisted.
He had an anuria, and undoubtedly a very high blood concentration
of streptomycin.
4. Caloric Tests. Depending on the duration and character of
the after-nystagmus, the results of caloric tests were classified as
normal, slight, moderate or marked depression, or absent responses.
A gradual diminution was not always seen. The result could be
normal at one visit but on repeating the tests two or three weeks
later no response would be obtained. No case with complete loss
of function was found to improve. Of the S 3 patients in Group
I, there were 21 with absent caloric responses after completing treat-
ment. One patient had absent responses in only one ear. 'Two had
slight and one moderate depression of function. This makes 25 out
of 53, of 47%, in Group I with objective evidence of vestibular
damage.
Of 40 patients in Group II, those receiving 1 gm. per day, only
six had absent responses at the end of their course of the drug.
Three had slight, three moderate and one marked vestibular depres-
sion. Thus 13 of 40, or 3 2. S %, of the patients on the 1 gm.-dosage
had objective evidence of vestibular damage.
There was close correlation between subjective symptoms and
objective findings. While not all who complained of dizziness and
staggering had evidence of damage, the opposite was true. The pa-
tients found to have depressed or absent caloric responses had com-
plained of symptoms during treatment.
The patients who had no caloric reaction had a characteristic
walk. The feet were wide apart; the gait seemed studied. When
blindfolded they had great difficulty walking on irregular surfaces,
tending to weave and even fall.
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Other observers `'~ }~" have reported a higher percentage of ob-
jective evidence of vestibular damage than found in this study. An
all or none effect was noted in these patients; the vestibular responses
were entirely absent or normal. It is admitted this may be due to
the less delicate method of testing. The method of using hot and
cold stimuli to determine directional preponderance, proposed by
Fitzgerald and Hallpikes and used by Fowler," may be more sensitive.
It was felt to be too involved for this study where the personnel
performing the tests frequently changed.
According to Jones' it would seem that .the vestibular tests
could be used to diagnose and accurately localize cerebral lesions.
This opinion has changed with the years until recently the caloric
tests have been used more to determine the presence or absence of
response in the labyrinth. The number of patients who have vesti-
bular symptoms after streptomycin therapy may stimulate interest
in a precise method which will localize the site of the damage. Even
using the directional-preponderance method Fowler was not able to
determine whether the site was central or peripheral. The results
of this study do not help in localization, unless it can be argued that
a process so commonly involving vestibular and not cochlear func-
tion is central rather than peripheral. Amore precise method than
the tilt table method of testing the static labyrinth, the maculae of
the saccule and utricle, would be of value.
No standard method of recording vestibular tests exists. A
graph similar to an audiogram would seem to be most desirable.
Fitzgerald and Hallpike" have such a :record, called a calorigram.
It is based entirely on the duration of the after-nystagmus measured
from the beginning of the stimulus. It does not take into account
the quality, speed, vigor and amplitude of the eye movements. It
is not easy to determine the end point exactly in streptomycin cases,
especially those with the fine spontaneous nystagmus.
The question may well be raised as to the value of vestibular
tests in streptomycin therapy. Chances of hearing loss are so remote
that frequent audiograms do not seem necessary. The caloric tests
are not a guide to therapy in these cases, the patients being ill with
a serious disease, and treatment was completed in spite of evidence
of loss of labyrinthine function. The tests have had the value of
demonstrating the percentage with loss of function with the different
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dosages. The problem may well be solved by the new low dosage
of 0. S gm. if it proves as effective against tuberculosis.
It is not the scope of this report to evaluate the effect of the
drug in tuberculosis. However, it is difficult to refrain from men-
tioning the amazing improvement seen in patients with severe tuber-
culous laryngitis. Tuberculous otitis media has also responded
promptly after local measures had been used with little result.
The difficulties confronting the patients may increase after they
leave the hospital. It will have to be determined whether they can
drive a car, climb stairs, board street cars, and carry on their previous
occupations. There may also be medicolegal implications.
This is a report of the results of ear examinations done on 93
patients receiving streptomycin at Hines Hospital. They are divided
into two groups according to dosage. Group I received 2 gm. per
24 hours for four months. Group II received 1 gm. per day. Audio-
grams and caloric tests were done before, during and after treatment.
One patient with an anuria suffered almost total loss of hearing,
but no other patient was found to have any hearing loss from the
drug.
Of the 53 patients in Group I, 42 noticed subjective symptoms
of dizziness, staggering gait or visual disturbances, and 2 S had ob-
jective evidence of depressed or absent vestibular function. Of the
40 in Group II, 18 complained of subjective symptoms, and 13 had
depressed or absent caloric responses. No return of function was
noted later in those without response. They also continued to have
subjective complaints, trouble in walking in the dark and dizziness,
although these symptoms diiiiinished. These patients were grateful
for the improvement in their general condition and did not seem to
feel the vestibular disturbances were too high a price to pay for it.
REFERENCES
1. McNally, W. J.: The Physiology of the VestiUular Mechanism in Relation
CO VCYtlgO, ANNALS OP OTOLOGY, R7-[INOLOGY AND LARYNGOLOGY 56:514-533
(Sept.) 1947.
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2. Field, Homer B., and Koransky, David: Personal communication on work
to be published.
3. Brown, H. A., and Hinshaw, H. C.: Toxic Reaction of Streptomycin on the
8th Nerve Apparatus, Proc. Staff Meet. Mayo Clinic 21:34.', 1946.
4. Fowler, E. P., Jr., and Seligman, Ewing: Otic Complications of Strepto-
mycin Therapy, J. A. M. A. 133:87-91 (Jan. 11) 1947.
S. Glorig, Aram and Fowler, E. P., Jr.: Tests for the Labyrinth Function
Following Streptomycin Therapy, ANNALS OF OTOLOGY, RHINOLOGY AND LARYN-
col.ocY 56:379-394 (June) 1947.
6. Fitzgerald, Gerald, and Hallpike, C. S.: Studies in Human Vestibular Func-
tion: I. Observations on the Directional Preponderance ("Nystagmus-bereitschaft")
of Caloric Nystagmus Resulting from Cerebral Lesions, Brain 65:115-137 (June)
1942.
7. Jones, I. H., and Fischer, L.: Equilibrium. and Vertigo, Philadelphia, J. B.
Lippincott, 1918.
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AMYLOID TUMORS OF THE LARYNX, TRACHEA
OR BRONCHI
DAVID B. STARK, M.D.
AND
GORDON B. NEw, M.D.
ROCHESTER, MINN.
The larynx and trachea are the most common sites of localized
deposition of amyloid. Although of infrequent occurrence, the
disease may present definite diagnostic and therapeutic problems. A
clinical and pathologic review of 15 cases of tumor-forlning amyloid
disease of the larynx, trachea or bronchi forms the basis for this
paper.
In 18 S 3 Virchowl observed that the substance present in organs
which were the seats of so-called lardaceous or waxy change reacted
with iodine to form a characteristic yellowish-red or reddish-violet
color. This changed to a perfectly blue or violet color when the
application of iodine was followed by the very cautious addition of
sulfuric acid. This reaction being similar to, but not the same as,
the reaction of starch with iodine, Virchow considered the "waxy"
substance to be starch-like, or "amyloid", and probably a form of
animal cellulose.
The chemical composition2~` of this amyloid has not been ex-
actly determined. It would appear to be somewhat inconstant, con-
sisting of one or snore protein fractions and asulfur-containing poly-
saccharide similar, at least, to chondroitin-sulfuric acid.
The distinctive reaction of amyloid with iodine, and iodine and
sulfuric acid in the gross, delnonstratcd by Virchow, distinguished
this material from other hyaline materials. Jurgens, Heschl and
l~bridgment of thesis submitted by Dr. Stark to the Faculty of the Graduate
School of the University of Minnesota in partial fulfillment of the requirements
for the degree of Master of Science in Surgery.
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Cornils introduced the use of methyl violet as a stain to aid in the
more nearly accurate observation of histologic details.' Subsequently,
Congo red was introduced as a dye with a special affinity for amyloid,
to be used in the staining of microscopic sections, and, as in Benhold's
test, to be used in the clinical determination of the presence of amyl-
oid in the living person'.
To simplify the rather confusing terminology used to distin-
guish the various forms of amyloid disease, Reimann, Koucky and
Eklund suggested a simple clinicopathologic classification of amyl-
oid disease: (1) primary amyloidosis, (2) secondary amyloidosis,
(3) tumor-forming amyloidosis, and (4) amyloidosis associated with
multiple myelomas.
The amplification of this classification by these authors follows.
Primary Amyloidosis. The primary (by some caned the "atyp-
ical" or "systematized") form of the disease is characterized by:
(1) absence of preceding disease, (2) absence of involvement of
organs or tissues usually affected in the secondary form of the disease,
(3) involvement of the mesodermal tissue, cardiovascular system,
gastro-intestinal tract and smooth and striated muscle, (4) a failure
of the amyloid deposits to react in the ordinary manner to the ac-
cepted stains for amyloid, and (S) a tendency to nodular deposits
of amyloid material.
Secondary A7zzyloidosis. The secondary (by some called the
"typical," "classical" or "generalized") form of the disease usually
follows a chronic wasting disease (such as chronic pulmonary tuber-
culosis, chronic empyema and chronic osteomyelitis). It is char-
acterized by large deposits of amyloid material, especially in the
spleen, liver, kidneys and suprarenal glands, and. by the typical
staining reactions of the deposits.
Tzsmor-forming Am~~loidosis. Tumor-forming amyloidosis is
characterized by the presence of small solitary or multiple tumors in
the eyes, bladder, urethra, pharynx, tongue and especially in the
respiratory tract.
Amyloidosis Associated with Mztiltiple Myeloznas. Amyloidosis
occurring with multiple myelomas is secondary in nature, but the
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distribution and character of the deposits frequently resemble those
of the primary form of the disease.
Even the foregoing classification is not entirely satisfactory be-
cause of the frequent overlapping of characteristics.
Burow and Neumann10 in 1875 apparently were the first to
report a case of amyloid tumor of the larynx. A number of reports
of amyloid tumor involving the larynx, trachea or bronchi have
been published since that time. The pertinent literature has been
reviewed by Pollak,ll, iz New,i3 Schmidt,'- Kramer and Som,15 and
Rey.is
Incidence. Nineteen cases of laryngeal amyloidosis have been
reported in the American literature to date, by Hooper,l' Eisen-
brey,l$ Newi3 (4 cases), Thompson,1? Beavis20 (S cases), Kramer
and Som,16 Pearson and associates,21 Figi,22, Clerf,z3 Seyde11,24 Jack-
son,2~ and Spain and Barrett.26 Kramer and Som considered that of
95 cases of primary or "idiopathic" amyloid tumors of the upper
part of the respiratory tract included in the literature up to 193 5,
36 involved the larynx alone, 8 involved the larynx and tongue, 13
involved the trachea alone, and 4 involved the trachea and bronchi.
Lesions involving the bronchi have been reported by Balser,27 Glock-
ner,28 Werdt29 and Falconer.so
Classification. According to one of us (G. B. N.) , amyloid
tumors of the larynx, trachea or bronchi may be considered to occur
either in association with amyloid degeneration elsewhere in the body,
or as isolated deposits. The isolated deposits may be divided into
three groups: (1) diffuse subepithelial infiltration by amyloid, (2 )
tumor-forming amyloid deposits, and (3) amyloid degeneration in
apre-existing tumor.
The cases of laryngeal amyloidosis reported by Pearson and
associates, and Spain and Barrett are examples of laryngeal lesions
associated with the deposition of amyloid elsewhere in the body.
Since the laryngeal lesions are incidental to the more generalized
disease, and since treatment and prognosis apply essentially to the
generalized form of the disease, laryngeal amyloidosis associated with
generalized amyloidosis will not be included in the subsequent dis-
cussion.
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Causation. That am}>loid tumors most often occur in organs
consisting in part of cartilage and in which abnormal calcification or
ossification is a frequent occurrence has been rioted by many
authors.`T1 The fact that calcification or even osteoid tissue occurs
so often in amyloid tumors, and the presence of amyloid material in
tumors considered to be primarily the results of exostosis or ecchon-
drosis`'s are suggestive evidence that some factor is common to the
formation of amyloid material, osteoid tissue and 3ocal calcification.
Chronic inflammation has been considered a causative factor. The
association of conjunctival amyloidosis with trachoma would seem
to support this conjecture. Ainyloid tumors have been described
in syphilitic scars,s' and in some reports the importance of chronic
recurrent infection of the upper air passages prior to formation of
the amyloid tumor has been emphasized.l~ However, in many re-
ports this pre-existent chronic inflammation is not disclosed. Amyl-
oid degeneration of pre-existing tumors has been described.~~~ 34 The
association of amyloid material with a squamous-cell epithelioma as
described by Beavis (case 2) would seem to be coincidental, although
a closer relationship might be suggested. It is noticeable that a great
number of amyloid tumors have no apparent associated pathologic
process which might be considered of causative importance.
Sex. The lesion occurs more frequently in inen in about the
ratio of 3 men to 1 woman.t`j-i:,
Age. The majority of patients are between the ages of 50 and
70 years at the time the diagnosis of amyloid tumor is made. In the
literature, the youngest patient was 19 years old"` and the oldest
patient was 80 years old3" at the time of diagnosis.
Sync j~tonas. When symptoms are present, they are caused by
the physical presence, size and location of the tumor. Usually, they
are hoarseness and dyspnea. Willimann3e reported. a case in which
the diagnosis was made six weeks after the onset of symptoms.
Thompson13 described a woman 32 years old whose chief symptom
of hoarseness had been present at least twenty-five years before the
diagnosis of deposition of amyloid was made. The usual duration
of symptoms before diagnosis has been between one year and two
years.
Gross Aspects o f the Tunaor. The typical gross appearance of
the amyloid tumor has been said to be a waxy, translucent, yellow or
yellow-gray swelling without ulceration of the overlying mucosa.
The lesion has been reported to have either a smooth or a nodular out-
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Fig. 1.-Photomicrographs showing: a, amyloid material deposited along
the basement membrane of mucous glands (x200); b, concentric ringed
masses: the well-demarcated lines are very evident (x2 S O) . Both sections
stained with crystal violet.
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Pig. 2.-a, Lateral roe~ztgenogram of the larynx in case 1 S, demon-
strating a retrotracheal soft-tissue mass causing significant narrowing of
the airway: note the areas of calcification; b, tomogram of the larynx in
the same case as in a, demonstrating some thickening of the true cords, and
~, tumor mass in the subglottic region on both sides.
line, and to be either diffuse or well localized. The tissue has been
described as being either hard on palpation and difficult to curet be-
cause of this consistency,' or friable and vascular, in which case the
color has been red.
Microscopic Appe~rrance. There is no difference between the
microscopic appearance of the diffuse lesion and that of the tumor-
forrning type of lesion.ig Subepithelial deposition of the homogene-
ous hyaline amyloid material occurs. The mucoua and submucosa
are elevated by the amyloid deposit, which is seen. in layers closely
packed between the connective tissue. The walls of the blood ves-
sels are especially affected.I" Beavis noted that the rounded masses
present in many amyloid tumors appeared to arise in the blood ves-
sels. Many authors noticed that the basement membrane of the
mucous glands was swollen by the homogeneous amyloid31 (Fig. la).
Courvoisiera8 described a lesion in which this involvement had pro-
gressed to such extent that the glands had been replaced by masses
of amyloid material (Fig. 1b). Giant cells have been considered by
some to be typical of the lesion.l''
As a rule, the amyloid material is stained selectively by Congo
red and iodine, and it is stained metachromatically with crystal violet
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AMYLOID TUMORS 123
and other related aniline dyes. Beavis and others have described
lesions in which apparently only the oldest portions of the deposit
stained as amyloid, the reaction in the remainder being nondescript.
Many authors consider that these specific color reactions may be
weak3~ or not present at a11.4o, ~1
Diagnosis. The diagnosis of an amyloid tumor is made by mi-
croscopic examination of sections of tissue from the lesion. The
extent of the lesion may be determined visually by laryngeal exam-
ination, roentgenologic examination (Figs. 2a and b), tracheoscopy
or bronchoscopy.z2, 37 Evaluation of the extent of a recurrent lesion
or a lesion of which the diagnosis has been established may be simpli-
fied by staining of the amyloid by the intravenous injection of
Congo red.l'
Treatment. Occasionally, tracheotomy has been necessary to
relieve the obstruction brought about by the amyloid tumor in the
larynx or trachea. Excision of the lesion, when feasible, has been
considered the treatment of choice.15 Partial excision, when total
excision is not possible, to be followed by irradiation, has been sug-
gested.13 Mutschler42 used a diathermy loop for removal of the
tumor in an effort to avoid scarring. Willimann43 and Simonetta44
advised roentgen therapy. Kriegsmann~5 recommended. the produc-
tion of local hyperemia by the use of short waves. Bauer`~e in 1932
suggested that extirpation of a subglottic or tracheal lesion followed
by use of a dermal graft over the denuded area might be feasible.
Figi in 1942 described how he had removed an extensive subglottic
lesion and grafted the resulting bare area with asplit-thickness graft.
This prevented the extensive scarring which would have resulted if
the denuded area had been left uncovered.
Results o f Treatment. The value of irradiation therapy has not
been definitely determined. Bauer considered such therapy to be
ineffective. Repeated recurrences have been reported by ~ many
authors after attempted removal of the lesion. Pollak and
Greifenstein47 described cases in which the lesion regressed after
incomplete removal. Rey considered the prognosis of untreated
amyloid tumor to be good. He said that malignant degeneration
did not occur. There was reported to be some danger of respiratory
obstruction, dependent on the size and location of the deposits. The
prognosis, then, was considered to be that associated with any be-
nign tumor of the same size and in the same location. It was con-
sidered to be bad if the lesion was located in the lower part of the
respiratory tract.
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Fig. 3.-Photomicrograph showing sharply outlined well-demarcated
flakes of amyloid material. (Hematoxylin and eosin; x101)).
Kecords of 28 cases in which the diagnosis was amyloid degen-
eration of the larynx, trachea or bronchi were found in the surgical
files of the Mayo Clinic. In all. the cases the diagnosis of amyloid
disease had been made by microscopic examination. of tissue removed
for biopsy or at operation. In the vast majority of instances the
diagnosis had been made on the basis of the appearance of the frozen
section stained with hematoxylin and eosin. Adequate amounts of
tissue for further study with special stains were available in 24 cases.
In three cases, only slides of sections stained with hematoxylin and
eosin were available. In one case (case 2 in a previous clinic series13)
neither slide nor tissue was available.
A detailed study of the histopathologic aspects and staining re-
actions of the available mzterial has been undertaken.``
Briefly, the patho'ogic features considered characteristic of the
tumors were: (1) The homogeneous amyloid material occurred
mainly in the form of "flakes" (Fig. 3 } or "concentric-layered
masses" (Fig. 1 b) , and (2) this amyloid material reacted character-
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istically with one or more of the so-called amyloid stains. The
diagnosis of amyloid degeneration was confirmed by this study in 1 S
of the 28 cases reviewed. Records of the 1 S patients who had amyl-
oid lesions form the basis for the subsequent material (see table) .
Sex. There were 10 men and S women, a ratio of 2:1.
Age. The age of patients at the time of examination varied
moderately. The youngest patient was 3 6 years old; the oldest was
69 years; the average age was SS years (see table).
LocaEion o f Lesion. In seven instances the lesion involved the
larynx at or above the vocal cords. In four instances only the sub-
glottic region was involved. In one instance the vocal cords and sub-
glottic region, and in two instances the subglottic region and the
trachea, were involved. In only one instance was bronchial involve-
ment demonstrated. The larynx also was involved in this case.
Syrnptonas. The duration of symptoms varied from five months
to seven years, the average duration being about eighteen months.
Hoarseness was the presenting complaint in 11 cases. Three of these
patients complained also of dyspnea. Dyspnea was the presenting
complaint in two instances, and hoarseness was an associated symp-
tom in both of these. Cough was the presenting complaint in only
one instance. One patient had no complaints referable to the respira-
tory tract.
Appearance o f Lesions. Four of the lesions were sufficiently well
circumscribed to be considered local tumors. The remainder of the
lesions were less well localized and might be described as "diffuse
submucosal thickenings." The lesion usually was smooth in out-
line, although in two instances (cases 1 and 15) irregularities were
noted. In ten cases the color was not remarkable enough to cause
comment. Yellow areas were noted on three occasions. One lesion
was described as gray throughout, and one lesion was described as
being red. The mucosa overlying the lesion was uniformly healthy.
Diagnosis. Preoperatively, four of the lesions were considered
to be malignant. The remaining 11 lesions were considered preop-
eratively to be benign. A diagnosis of "amyloid tumor" was con-
sidered in three of these cases. A definite diagnosis was made only
by microscopic examination of tissue from the lesion.
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3 ~ ~; ~,
o a,~ ; bo?~, ,,
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 Approved For Release 2002/07/24 :CIA-RDP80-00926A001800010009-4
+
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Causataou. In no instance was there a general debilitating dis-
ease of the type which might be considered as predisposing to the
secondary form of amyloidosis. The only observation considered
significant was the general age group to which these patients be-
longed: the age group in which degenerative processes of many kinds
do occur.
CnsE S.-A man S 3 years old was examined at the clinic in
January, 1929. He complained of progressive hoarseness and dysp-
nea of three years' duration. Indirect laryngeal examination dis-
closed amarked thickening in the region of the posterior two-thirds
portions of both vocal cords, mare marked on the right side, and full-
ness in the subglottic region. Although there was considerable lim-
itation of the airway in the subglottic region, the vocal cords moved
freely. The mucosa overlying the thickening appeared to be healthy.
The lesion was considered to be an epithelioma.
Results of a roentgenogram of the thorax, blood count, floc-
culation test and urinalysis were normal. General examination dis-
closed some degree of emphysema and chronic bronchitis.
A diagnosis of amyloid degeneration was made by biopsy of a
specimen of the laryngeal lesion. Tracheotomy .was performed be-
cause of the limited airway. The lesion was cauterized on two oc-
casions. In answer to a letter of inquiry in Febru:~ry, 1947, eighteen
years after the time of diagnosis, the patient wrote that he had con-
tinued to wear the tracheotomy tube because without it he would
become dyspneic on exertion. He considered his voice to be normal.
He had had no additional treatment, and believed that the laryngeal
condition was not progressing.
Comment on Case S. This case demonstrates that the occur-
rence of an amyloid tumor is not incompatible with long life. No
disease which might have contributed to the deposition of the amyl-
oid became evident over the years. The self-limiting nature of the
disease in this case is indicated by the fact that although enough. of
the tumor remained to obstruct the airway, the lesion did not pro-
gress to involve the vocal cords to a degree sufficient to produce-more
hoarseness.
The tumor in this instance was mainly subglottic in distribu-
tion, and the vocal cords moved freely. We believe that wide ex-
cision of the lesion followed by grafting the denuded area with split-
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Fig. 4.-Roentgenogram of the thorax in case 13, showing a hilar
mass on the left, with a suggestion of bronchial obstruction.
thickness skin would have provided this paticnt with an adequate
airway and would have eliminated the necessity for a permanent
tracheostoma.
CASE 12.-A man 63 years old was examined at the clinic in
July, 1942. He complained of progressive hoarseness of a year's
duration. Indirect laryngeal examination disclosed a tumor 1 cm. in
diameter on the anterior half of the left false cord.
Results of a roentgenogram of the thorax and of a flocculation
test were negative. Urinalysis demonstrated albuininuria of grade
1-~-. General examination disclosed an obese man with dental caries.
A diagnosis of amyloid degeneration was made on the basis of
biopsy of a section of the laryngeal lesion. The tumor was removed
with biting forceps, and the base was destroyed with electrocautery.
In answer to a letter of inquiry this patient's physician stated that
in 1944, when the patient was last examined, there was no hoarse-
ness or evidence of laryngeal obstruction.
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Comment on Case 12. The excellent functional result to be
expected after excision of a localized tumor is demonstrated by this
case.
CnsE 13.-A man 68 years old ~~as re-examined at the clinic
in September, 1943. lie complained of an intractable, nonproduc-
tive cough of six months' duration. This cough persisted after a
febrile illness which was considered to be an atypical form of pneu-
monia. The cough was most annoying when the patient was up
and around, and abated when he was lying down. Indirect laryn-
geal examination disclosed a fullness of the anterior part of the right
false cord, causing it to overhang so that the right true cord was not
visible.
A roentgenogram of the thorax (Fig. 4) disclosed a hilar mass
on the left. The possibility of bronchial obstruction was suggested.
Urinalysis demonstrated albuminuria of grade 2-~ and pyuria. Re-
sult of a flocculation test was negative. General examination dis-
closed that a neurofibroma had been removed. from the spinal cord
in 1931, with resultant "cord bladder." N~ other abnormalities
were noted.. A roentgenogram of the thorax. made in 1931 had
been reported as disclosing nothing remarkable.
C7n bronchoscopic examination, the right side of the larynx ap-
peared to be fixed by an infiltrating lesion. When the bronchoscope
was introduced into the left main bronchus, the medial wall was
noted to be pushed laterally. It was infiltrated and had the gross
app?arance of carcinoma. A diagnosis of amyloid degeneration was
made by biopsy of a section of this lesion.
The patient was treated postoperatively with roentgen rays
directed to the left hilar region, and the cough was controlled by a
sedative cough mixture. A roentgenogram of the thorax made one
year after this treatment was reported to show no change in the
pulmonary fields. In answer to a letter of inquiry, the patient's
physician stated that the patient had had no more difficulty with his
thoracic lesion. In April, 1945, eighteen months after the diagnosis,
the patient had a cerebral hemorrhage, with residual paralysis and
mental changes. In August, 1945, terminal pneumonia developed
and the patient died.
Comment on Case 13. Endobronchial amyloid tumors have
been reported infrequently; the lesions have been observed at post-
mortem examination. This case is reported as an instance of a
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diffuse amyloid tumor involving the bronchial tree (and larynx )
diagnosed during the life of the patient. Postmortem examination
was not performed in this instance, and we have no proof that amyl-
oid was absent in other organs of the body. Conversely, there is no
evidence to suggest that such depositions did exist. It does not seem
probable that the cerebrovascttlar accident in 1945 was at all related
to the amyloid disease.
The treatment of this type of lesion is difficult and unsatis-
factory. Endobronchial removal of amyloid material by instru-
mentation or the use of roentgen therapy to the involved region is
the most obvious form of therapy. Should the lesion be localized
to one bronchus, and should other treatment prove inadequate so
that symptoms secondary to bronchial obstruction become prom-
inent, lobectomy or pneumonectomy should be considered.
Although there is not universal agreement as to the best form of
treatment of amyloid tumors situated in the respiratory tract, cer-
tain general principles are apparent.
The form of treatment and the prognosis as to functional re-
covery after treatment will depend on the type of amyloid involve-
ment (whether the lesion is a localized tumor or a more diffuse sub-
epithelial infiltration) and the location of the amyloid involvement.
The well-localized tumor, no matter what its location, should
be removed surgically. A diffuse infiltrating lesion involving the
subglottic region and the trachea is best treated by surgical removal
of as much of the lesion as is possible, and by covering the resulting
denuded area with asplit-thickness skin graft in the manner reported
by Figi. In such cases the functional results can be expected to be
good.
Treatment of the diffuse infiltrating lesion involving the larynx
proper has not produced as gratifying results. Attempts at exten-
sive removal of the lesion have brought about deformities which
themselves have prevented a satisfactory functional result. Exten-
sive removal of the lesion with successful application of a skin graft
to the denuded area should exclude the necessity for a permanent
tracheostorna, but permanent hoarseness would be inevitable. Al-
though the true status of irradiation therapy in this disease has not
been established to the satisfaction of all, there have been enough
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favorable reports to warrant employment of such therapy in those
cases in which complete surgical removal of the lesion is not feasible
(case 7).
The observation that patients live many years with evidence of
the presence of the intralaryngeal tumor without progression of
symptoms to the paint at which tracheotomy is required to provide
an adequate airway, is good evidence that the disease tends to be
self-limiting. In no instance in this series could the death of a pa-
tient be ascribed to the amyloid tumor.
The clinical features of 15 cases in which the pathologic diag-
nosis was amyloid tumor of the larynx, trachea or bronchi have been
reviewed. The pathologic features considered characteristic of the
tumors are occurrence of the homogeneous amyloid material mainly
in the form of flakes or concentric-layered masses, and a character-
istic reaction of the amyloid material with one or more of the so-
called amyloid stains. No concomitant disease considered of etiologic
significance was noted. The presenting signs and symptoms of amyl-
oid tumor are dependent on the size and location of the lesion. Class-
ification of the tumors into the localized tumor-forming variety and
the diffuse infiltrating variety is of significance in determination of
the type of treatment to be employed and the prognosis after treat-
ment. The localized tumor was surgically removed, with an excel-
lent functional result. The diffuse lesion involving the subglottic
region and the upper part of the trachea was removed with imme-
diate grafting of the resultant denuded area. A permanent trache-
ostoma was avoided, and the functional. results were excellent. The
functional results obtained by treatment of the diffuse lesion involy-
ing the glottis proper were not as satisfactory. The prognosis as to life
was excellent, with the possible exception of those patients who had
endobronchial lesions. The disease tended to be self-limiting.
REFERENCES
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3. Hass, George: Studies of Amyloid; II. The Isolation of a Polysaccharide
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 Approved For Release 2002/07/24 :CIA-RDP80-00926A001800010009-4
4. Hass, G. M., Huntington, Robert and Krumdieck, Newton: Amyloid;
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10. Burow and Neumann: Quoted by New, G. B,13
11. Pollak, E.: Quoted by Kramer, Rudolph, and Som, M.L.1'
12. Pollak, E.: Quoted by Rey, Wilhclm.Ic
13. New, G. B.: Amyloid Tumors of the Upper Air Passages, Laryngoscope
29:327-341 (June) 1919.
14. Schmidt, M.: Quoted by Kramer, Rudolph, and Som, M. L.I"
1 S. Kramer, Rudolph, and Som, M. L.: Local Tumor-Like Deposits of Amyloid
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21:324-334 (Mar.) 1935.
16. Rey, 1~/ilhelm: Zur Klinik der Amyloidtumoren der abcren Luftwege,
Arch. f. Ohren-, Nascn- u. Kehlkapfh. 143:216-232, 1937.
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20. Beavis, J. O.: Local Amyloid Disease of the Upper Air Passages; Report
of Five Cases, Arch. Otolaryng. 19:439-450 (Apr.) 1934.
21. Pearson, B., Rice, M. M., and Dickens, K. L.: Primary Systemic Amyloid-
osis; Report of 2 Cases in Negroes, with Special Reference to Certain Histologic
Criteria for Diagnosis, Arch. Path. 32:1-10 (July) 1941.
22. Figi, P. A.: Excision of Amyloid Tumor of the Larynx and Skin Graft;
Report of Casc, Proc. Staff Mcet., Mayo Clin. 17:239-240 (Apr. 15) 1942.
23. Clerf, L. H.: Amyloid Tumor of Larynx, Trans. Am. Laryn?. Asso. 64:
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24. Scydcll, E. M.: Discussion, Trans. Am. Laryng. Asso. 64:148, 1942.
2S. Jackson, C. L.: Discussion, Trans. Am. Laryng, Asso. 64:149, 1942.
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26. Spain, D. M., and Barrett, R. C.: Amyloidosis in, 'ltypical Sites (Cardiac
Valves, Larynx), Arch. Path. 38: 203-206 (Oct.) 1944.
27. Balser: Quoted by Robertson, H. E.71
28. Glockncr, A.: Quoted by Robertson, H. E.31
29. Werdt, F.: Quoted by Robertson, H. E.`'1
30. Falconer, B.: Ein Fall von Amyloidtumor der Trachea and der grossen
Bronchien mit dyspnoischcn Erscheinungen, Acta oto-laryug. 26:353-357, 1938.
31. Robertson, H. E.: Local Amyloid with Special Reference to Socalled Amyl-
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29:773-795 (Dec.) 1920.
32. Schranck: Quoted by Robertson, H. E.~`~
33. Mager: Quoted by Robertson, H. E.~31
34. Ziegler, E.: Quoted by New, G. B.t''
3 S. Saltykow, S:. Quoted by New, G. B.1~
36. Willimann, H.: Quoted by New, G. B.t3
37. Reuter: Quoted by Rcy, Wilhclm.lf
38. Courvoisier: Quoted by Robertson, H. E.jI
39. Huebschmann, P.: Uber Kehlkopfknotchen mit sogenannten "amyloiden"
Einlagerungen (Fibrinoid-hyaline Knotchen), Virchows Arch. f. path. Anat.
275:698-710, 1930.
40. Cocchiarole: Quoted by Rey, Wilhelm.l''
41. Hinnen: Quoted by Rey, Wilhelm.i''
42. Mutschler: Quoted by Rey, Wilhelm.l~'
43. Willimann: Quoted by Rey, Wilhelm.1f
44. Simonetta: Quoted by Rey, Wilhelm.i~'
45. Kriegsmann: Quoted by Rey, Wilhelm.t''
46. Bauer, A.: Ein Fall von lokalem Amyloid der Trachea, Muchen, med.
Wchnschr. 79:1596-1598 (Sept. 30) 1932.
47. Greifenstein: Quoted by Rey, Wilhelm.I~
48. Stark, D. B., and McDonald, J. R.: Amyloid "Tumors" of the Larynx,
Trachea and Bronchi. A Histologic Study of Fifteen Cases, Am. J. Clin. Path.
18:778-788 (Oct.) 1948.
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In 1941 he reported 40 cases of cartilage transplant, chiefly
for the correction of loss of nasal bridge support, and 11 S cases of
iliac bone transplants of which 102 cases were transplants to the
nasal bridge.
The cartilage transplants proved unsatisfactory because 2S?fo
of them became severely distorted.
Mowlem stated that the first case of iliac bone transplantation
to restore the nasal bridge recorded in Great Britain was carried out
in 1932 by Gillies. The donor area was the iliac crest. The cases
reported by Mowlem were operated upon between 193 S and 1941.
His operative procedure is described as follows:
"The iliac crest is exposed, the attachments of the abdominal muscles and
gluteal muscles are cleared by blunt dissection. The dense outer lip of the iliac
crest is removed. The requisite piece of cancellpus bone may consist of either
part or whole of the blade of the ilium. Shaping is carried out by sharp cutting
instruments and during this process as much of the cortical bone as possible u
eliminated. In other words, the transplant is designed to consist chiefly of can-
cellous tissues and to contain the minimal number of traumatized cells."
The grafts were inserted into the nose by splitting the columella
and separating the two layers of the septum as far up as the- lower
margin of the remnants of the nasal bones. The periosteum over
the remnants was raised to enable the transplant to lie in close con-
tact with these bones.
In 66 of his 102 cases, bony union was obtained with the under-
lying bones. There was no clinical or radiographic difference be-
tween those grafts which became adherent and those which remained
unattached.
He further noted on x-ray study that irregularities in contour
became rounded off in about two months and the graft decreased
slightly in size. The peripheral cancellous bone became replaced by
an apparently normal cortical structure. There was no phase of
rarefaction. One graft superimposed upon another might easily
acquire bony union with it.
Malbec3 employed autogenous, homogenous and heterogenous
cortical bone grafts in rhinoplastic procedures. His subsequent
x-ray studies and observations proved that autotransplants adapted
themselves best of all.
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XI
CANCELLOUS BONE GRAFTS IN NASAL. REPAIR
MAURIGE H. COTTLE, M.D.
CI-IICAGO, ILL.
ROLAND M. CORING, M.D.
CHICAGO, ILL.
MAURICE H. COHEN, M.D.
PEORIA, ILL.
AND
ROBERT KIRSCHMAN, M.D.
CHICAGO, ILL.
The use of cancellous bane obtained from the crest of the ilium
is gaining widespread recognition for its value in the correction of
saddle-noses. Fomon and his collaborators) have stimulated a great
interest in this subject and have inspired many surgeons to use this
material not only for the correction of saddle-nose but also for
other deformities about the face and forehead. cancellous bone is
readily available and its consistency permits easy modeling. It
resists infection and absorption, is well tolerated by the tissues and
is not subject to change in shape. These qualities make it most
desirable for building up depressions of the nose. Fomon compared
cancellous bone with all other materials that have been used in
grafts and pointed out the advantages of the former over white
vaseline, ivory, celluloid, gold, platinum, silver, aluminum, amber,
triconium, Plexiglas, vitallium, acrylic resins, tantalum, and the
soft tissue implants such as periosteum, muscle, fascia, derma grafts
and catgut.
The advantages of cancellous bone over the use of cartilage,
either isogenous or autogenous, were demonstrated by Mowlem.2
From the Departments of Otolaryngology, Cook County Hospital, Illinois
Masonic Hospital and Chicago Medical School, Chicago, Illinois.
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MacCollum4, writing on the correction of old nasal fractures,
discussed preparation of the nose for the reception of bone grafts as
follows:
"These old fractures arc characterized by a flattening of the entire nasal bridge
in addition to a crushed and badly deviated septum which is not able to be per-
manently raised or straightened. It is preferable to perform a submucous resection
of the distorted septum and possibly during the same operative procedure to refrac-
ture and set the nasal bones into as nearly normal a position as possible. After a
six month interval, further elevation of the bridge-line can be accomplished by
the insertion of the graft."
MacCollum employed cortical bone as grafting material.
Barsky, in discussing bone grafts, emphasized the use of molded
bone grafts but made a point not to advocate these for use in the
nose, because "any minute irregularity would be too obvious." How-
ever, he reported the successful use of iliac grafts consisting of
shavings of dense bone and spongy bone molded into shape for the
restoration of facial contours.
In the healing of grafts cancellous bone is of greater usefulness
than cortical bone and in the article of Abbotto, who in his summary
gives the following conclusions, we find perhaps the best reason
for this fact. He states:
"We should emphasize that the mature elements of either cortical or cancel-
lous bone grafts seldom survive transplantation. Those elements which may sur-
vive and produce new bone are the cells of so-called endosteal and periosteal layers.
A cortical graft is a solid mass of mature elements with its surface covered by
endostcum and periosteum. Therefore, it possesses strength but has little osteo-
genetic power. On the contrary, cancellous bone has a loose pattern with inter-
lacing and branching trabeculae, every one of which is covered with ?endosteal
cells. It possesses a high osteogenetic power. Furthermore, this very loose struc-
ture permits of early and thorough revascularization. Cortical bone as a grafting
material is most useful where strength is of primary importance, as in the ununited
fractures of the shafts of long bones. It may be used to advantage with can-
cellous bone which furnishes the osteogenetic medium. Cancellous bone as a
grafting substance is preferable in the treatment of ununited fractures of the ends
of long bones and defects of bone caused by tumors or infection, for fusion of
joints, fusion of the spine, and in correction of severe deformities by the open
wedge type of ostcotomy."
As to the mechanics of the healing of these bone grafts, Blocker'
from his own experience and from the writings of Gormley,s~o
Murray, 10,11 Erich and Austin, 12,13 and Fry la states that:
"We know from experimentation and from experience that healing following
transplantation of bone occurs in much the same fashion as after primary frac-
ture. Organization of a clot occurs in the graft bed and there is invasion by
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organizing vascular connective tissue at a rate which is in inverse proportion to the
density of the graft."
Our own studies definitely corroborate the value of the use
of iliac bone as an ideal graft material for the correction of nasal
deformities.
Prej~aring the Bed.-To approach the dorsum of the nose an
incision is made just at the caudal border of the lower lateral
cartilage. By undermining with scissors and knives, the skin over the
"dorsum" of the nose is separated from the bone and cartilage. This
incision may be part of a typical rhinoplasty or a remodeling of the
lobule, or it may be done alone or together with a similar incision
on the other side. These incisions may be combined with the inter-
cartilaginous incisions usually used in the start of a typical rhino-
plasty. Just making a bed in this fashion is, in our opinion, not quite
adequate. We believe that the bed must be so prepared that the bone
graft comes into actual. contact with freshly cut bone, the nasal
bones or the superior maxillae. We have seen many times that the
bone graft, although clinically satisfactory is, nevertheless, not
fixed. This is due to the fact that the bone graft has had no op-
portunity to come in contact with freshly cut bone in the bed
because the bones of the nasal bridge are covered with connective
tissue, and unless this is removed vigorously and the nasal bones cut
through or sawed off the bony graft will not grow to the underly-
ing bone. Also, there may be present from a previous operation a
graft of cartilage which will not become firmly adherent to any
other substance, including bone. It is therefore our practice to
chisel through the nasal bones or, if feasible, saw off a part of the
bones of the nasal bridge which will smooth off and make a better
bed in the first place, and secondly will provide good fresh cut
bone to serve as the union area for the new bone graft.
To estimate the size and shape of the graft, Fomon recommended
making a .Brent model of the graft from a mask made from the
patient's nose and face. This gives a rough idea of the size and
shape of the piece of bone that needs to be replaced providing no
surgery of the nasal bridge is done. When the bed has been surgically
changed we use a large piece of isogenous cartilage cut to the size
and shape that is thought will fit the best. This can be modeled,
taken out and remodeled and the best possible fit made. The cartilage
is then removed and used as a sample for size and form in taking out
the bone graft. The chief difficulty is to estimate the contour of
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E. Direction of
chiS?1 cuts
F. W?cl(~? of
Gancel7ouS bone
G. Shap?ct and
rea$y to insert
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140 COTTLF,-I,ORING-COHLN--KIRSCIIMAN
A. Saddle deformity $. $on? QraEt wiih C. Small wedl5,e of bone
inSvff icient prof eetion added to tnereaSe
pre~j ?etiort
the floor of the bed. For this, soft materials, such as wax or moist
cotton wound an an applicator, can be pressed onto the floor and
after a moment or two removed, and the impressions made on the
wax or moist cotton can be a guide as to how the base of the graft
should be trimmed in order to fit most snugly into the bed.
Before removing the iliac bone from the donor area it is of
technical advantage to shave off as much of the cortical bone as
possible. Apiece of cancellous bone is removed large enough to
permit extensive modeling and to provide material for the use of
buttons for the tip, columella battens or grafts and for supplementary
grafts (Fig. 1) .
If a graft is too small or so cut or trimmed that one feels a
larger piece would be an advantage, a piece of cancellous bone in
the form of a wedge the width of the base of the graft may be
placed between the graft and the freshly trimmed nasal bones (Fig.
2 and 3) , or a smaller graft may be placed onto the larger one
(Fig. 4). Thus available material may be used to greater advantage
and the need to go into the other hip for a new graft may be avoided.
Clinical Possibilities.-Bone may be grafted into the nose as a
single operation or it may be done with additional nasal operations.
Modeling of the lobule or total rhinoplasty may be done at the
same time. All this may be supplemented with septum surgery.
In other words we are of the opinion ghat an iliac bone graft may
be used in addition to any external nasal surgery or septal surgery
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Pig. 3. Small wedge of bone (A) placed under graft to increase
projectign. (Six months after operation.)
Fig. 4.-Smaller graft (A) put onto larger graft (B). (Two weeks
after operation - no cortical bone present.)
that is necessary in a given case. The following case reports indicate
the variety of these possibilities.
CnsE 1.-A 4S-year-old female with a large perforation of
the septum gave a definite history of lues. In this case a slight cutting
of the nasal bones with rasping was done after the skin was elevated
through an incision in the right ala, caudal to the right alar cartilage.
No surgery of the lobule was performed. Healing was prompt.
Penicillin was given in large doses postoperatively.
CasE 2.-A 22-year-old male who had sustained an injury
in early childhood had had two previous operations for the im-
plantation of cartilage for the correction of saddle nose. At the
operation one large piece of cartilage vras removed, the second piece
was left and a bone graft from the left hip was introduced. The
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Fig. S.-Graft grown onto ends of nasal bones. Note development of
cortical thickening.
Fig. 6.~raft considerably shrunken. though .firmly grown to nasal
bones (A). Bane "button" in tip (B).
appearance and the retention of the bone graft is satisfactory but
the bone graft is movable.
CASE 3-A girl aged 19 had sustained a .crushing injury of the
nose in childhood. The bed was prepared by separating skin over
the nose from the underlying tissues via intercartilaginous incisions.
The columella was corrected by the insertion of an isogenous cartilage
batten; the lobule was modified by delivering the lower lateral
cartilages, trimming them and modeling them to size. The aloe were
narrowed. A cancellc>us bone graft from the left hip was placed
into the nose. The appearance two years later is adequate but the
graft is not fixed but is movable on pressure.
CASE 4.-In a large man, aged. 26, the bone-cartilage nasal
pyramid was not proportionately developed. In this patient the
bed was prepared and the lobule modified and corrected. The nasal
bones were separated by chiselling and a very large bone graft was
inserted onto them. This bone graft is fixed. and seems to be an
integral part of the nose itself. There has been no reaction or any
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BONE GRAFTS 143
discomfort. X-ray film reveals union with nasal bones and develop-
ment of cortex (Fig. S) .
CASE S.-A 34-year-old white female gave a history of a
nasal injury 20 years ago with a persistent deformity. This was later
aggravated by an injury when she was assaulted. This case illustrates
a repair involving rhinoplasty and hip graft and partial septum
surgery. The pyramid was uncovered and a transfixion was performed.
A "hump" of about 7? was removed and considerable rasping of the
dorsum was done. A columella pocket was made. The lower lateral
cartilages were trimmed about 40 of`o, the tips were bared, the medial
crura were trimmed and sewed together with catgut sutures. The alae
were freed, thinned and, after wedges were removed, narrowed.
The caudal end of the septum was freed and moved to the right.
The upper laterals were shortened about half an inch. A hip graf t was
inserted and two small pieces of bone were used as tip buttons. This
graft has not become appreciably smaller and is not movable.
CASE 6.-A 37-year-old male had a marked nasal deformity
and considerable difficulty of breathing. He had had many nasal
injuries. This case represents another instance of the possibilities of
performing many operative procedures in the nose at the same time:
a total rhinoplasty, a total septal removal and reconstruction and a
hip graft. The details of the procedure are given to emphasize how
much was done. The pyramid was uncovered, encountering much
scarring, a right hemitransfixion was performed with the .resection
of all the cartilage and bony septum. An autogenous cartilage
strut was put into the columella. Chisel separation of the nasal
bones and lateral osteotomies were performed with infraction and
torsion of the bones. Packing was put into each nasal chamber and
pieces of bone and cartilage were placed into the septum, according
to a method previously described.12 The lower lateral cartilages
were trimmed about 20%, the medial crura were sewed together.
Cancellous bone graft from the right iliac crest was placed on the
"dorsum." The alae were- narrowed. This patient had uneventful
healing with a fixed graft and improved breathing.
CASE 7.-A 45-year-old white male gave a history of a nasal
injury 20 years ago with a resulting marked deformity. A recon-
struction was done about 1929 with a dorsal ivory implant and a
columella strut, both of which were lost because of infection. Later
other dorsal and columella implants were inserted, but these too were
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144 COTTLF..-LORING-COHI;N-KIRSCHM,4N
lost, this time because of injury. There was a saddling of the carti-
lage vault and a clef t in the tip through which the previous operation
was performed. The collapse of the alae, and puiching and scarring
of the tip of the nose were marked. The caudal end of the septum
was absent. The essential surgical. procedures consisted of the
shaving of the bony arch with a saw followed by chisel separation,
the correction of the remainder of the nasal septum and the modeling
of the lobule and tip. Lateral osteotomies, infracture and the in-
sertion of autogenous cancellous bone graft of the dorsum and also
a cancellous bone graft in the columella completed the operation.
One year later the graft was fixed but had become considerably
smaller, possibly because of the poor blood supply of the scarred
tissues which made up the recipient area (Fig. 6) .
CASE 8.-A 21-year-old male was involved in a very serious
railroad accident with a marked deformity of the nose with scarring
both inside and outside. The left nostril was completely occluded
by scar tissue. The operation included partial correction of the
septum, removal of scar tissue from the left nasal chamber and
lining this raw area with a free skin graft. The bed was made via
incisions caudal to the lower lateral cartilages through which the
free cancellous bone graft was placed. After the bone graft was
in position it was felt that the nasal arch was not high enough and
a wedge of bone was placed between the nasal bones, which had
previously been separated with a chisel, and the hone graft proper
(Fig. 3).
CASE 9-A women of 4 S years of age was in an automobile
accident and had a complete crushing injury of the nose. This was
corrected at the time by the insertion of very thick pieces of isogenous
cartilage in the form of an L. The columella strut was over one half
inch thick and with great difficulty this material was removed. The
septum was corrected and a chisel separation of the nasal bones per-
formed. A cancellous bone graft was placed into the dorsum and
into the columella. In spite of the marked scarring which had
accompanied the presence of these enormous cartilaginous grafts,
a firm nonmoving union occurred and the whole appearance of this
individual was changed. With the cartilage grafts in place, the
nose had an artificial, mask-like stiffness. After correction the nose
took on a normal, mobile, expressive appearance.
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CASE 10-A boy of 17 years of age had sustained a severe
crushing injury of the nose when he was 8 years of age, which re-
sulted in a complete absence of the bony arch of the nose. Only
remnants of the superior maxillae were present. The problem con-
sisted in making the nose as prominent as the skin would allow.
After the bed was prepared and the lobule modified, a wide graft
was inserted and, onto it, another smaller one (Fig. 4). Complete
fixation of both grafts resulted.
Disease, injury and congenital anomalies Inay cause flattening
or saddling of the nasal arch. It is not difficult to correct such de-
formities. The availability of an ideal material, the crest of the ilium,
and the ease with which it may be procured, must encourage us to
correct these deformities as often as the need becomes apparent. It
is seen from the cases presented that the surgical procedures done at
one time may include rhinoplasty, complete septum reconstruction,
skin grafts on the inside of the nose, columella repair and lobule
corrections. It is our feeling that healing is improved and takes place
more quickly when all the procedures that are necessary are done at
the same time. We have never seen a bone graft performed in the
manner described which did not have a successful take. Several that
seemed a little uneven in appearance at the completion of operation
and during the early weeks of convalescence have, in a few months,
smoothed themselves out and become completely adequate.
3O NORTH MICHIGAN AVENUE.
1. Fomon, S., Luongo, R. A., Schattner, A. and Turchilc, F.: Cancellous Bone
TYariSplant5 fOY Correction Of Saddle NOSe, ANNALS OP ~"rOLOGY, RIIINOLOGY AND
LARYNGOLOGY 54:518-533 (Sept.) 1945.
2. Mowlem, R.: Bone and Cartilage Transplants, Their Use and Behavior,
Brit. J. Surg. 29:182-193 (Oct.) 1941.
3. MalUec, E. F.: Osseous Autotransplantations in Partial Rhinoplasties,
Semana Med. 2:350-354 (Aug.) 1941.
4. MacCollum, D. W.: Elevation of Bridge Line (Use of Iliac Bone), Surgery
12:97-108 (July) 1942.
S. Barsky, Major A. J.: Molded Bone Grafts, Surgery 18:755-763 (Dec.)
194 S.
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COTTLE-LORING-COHEN-KI RSCHMAN
6. Abbott, L. C.: The Evaluation of Cortical and Cancellous Bone as Grafting
Material, J, Bone and Joint Surg. 29:381-414 (Apr.) 1941.
7. Blocker, Col. T. G.: Use of Cancellous Bone in the Repair of Defects about
the Jaws, Ann. Surg. 123:622-640 (Apr.) 1946.
8. Ghormley, R. K.: Choice of Bone Grafts in Bone and Joint Surgery,
Ann. Surg. 115:427-434, 1942.
9. Ghormley, R. K.: Preparation of Patients for Bonc Grafting in Cases of
Non-union, Amer. Acad. Orth. Surgeons' Lectures, pp. 7-] I, 1944.
10. Murray, C. R.: The Basic Problems in Bone Grafting for Ununited Com-
pound Fractures, J, Bane and Joint Surg. 26:437, 1944.
11. Murray, C. K.: The Principles Underlying All Bone Grafting Procedures,
Amer. Acad. Orth. Surgeons' Tectures, pp, 532-534, 1944.
12. Erich, John B., and Austin, L. T.: Traumatic Injuries of Facial Bones;
An Atlas of Treatment, Philadelphia, W. B. Saunders, 1944.
13. Erich, John B., and New, Gordon B.: Bone Grafts to the Mandible
Amer. J, Surg. 63:153-167, 1944.
14. Fry, W. Kelsey, Shepard, P. Rae, McLeod, Alan, and Parfitt, Gilbert J.:
The Dental Treatment of Maxilla-Facial Injuries, Philadelphia, J. B. Lippincott Co.,
1944.
1 S. Cottle, M. H. and Loring, R. M.: Corrective Surgery of the External
Nasal Pyramid and the Nasal Septum for Restoration of Normal Physiology, Ill.
Med. J. 90:119-131 (Aug.) I946.
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XII
LATERAL .SINUS THROMBOSIS
REVIEW OF RECENT LITERATURE AND REPORT OF A CASE
PETER D. LATELLA, M.D.
NEW ROCHELLE, N. Y.
JULIUS H. HOPKINS, M.D.
BRONX, N. Y.
With the advent of chemotherapy and, later, penicillin, there
has been a natural but marked decline in the reports of intracranial
complications of otitic origin. This paper deals with the literature
from the first reports on sinus thrombosis treated with the combined
procedures of antibiotics and surgery, or the former alone, until this
date.
Hubertl reported on 9S cases of lateral sinus thrombosis from
1929 to 1936, and 24 cases from 1937 to 1940; the latter series was
treated with the combined procedures. The first group showed a
mortality of 32.6%0, the second group, 12.5%. Singleton2 pointed
out that Herrel and Brown in a series of 274 cases showed that the
recovery rate was almost doubled by the use of sulfonamides.
There is no doubt of the efficacy of the antibiotics in the treat-
ment of severe middle ear infections. The great question, however,
with which the literature abounds, is how much damage is produced
in cases where the signs and symptoms are completely masked by the
action of these agents on temperature, hematology and the over-all
picture of many patients before the individual comes to the operat-
ing room. The pathological changes that continue under the cloak
of antibiotic therapy must be a matter of conjecture to the physician
in many middle ear infections thus treated; the treatment therefore
incorporates watchful waiting.
Published with permission of the Chief Medical Director, Department of
Medicine and Surgery, Veterans' Adrninistratian, who assumes no responsibility
for the opinions expressed or conclusions drawn by the authors.
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148 I,ATELLA-HOPKINS
Kopetsky3 has cited "the need of conserving the hearing of
patients with acute middle ear infections by avoiding undue pro-
longation of conservative therapy. In a patient who has an ordinary
acute infection, who has classic symptoms and who is operated on
promptly, healing takes place in the wound anal resolution takes
place in the tympanic cavity and the infection has not been estab-
lished long enough to cause permanent and serious damage; hence,
in the majority of patients thus operated on, the hearing is main-
tained. On the other hand, if a protracted course of conservative
therapy has been followed, when the patient finally recovers there
is considerable loss of hearing." This author is of the opinion that
"an acute lesion should be permitted to develop and present its symp-
toms, so that the severity of the attack may be estimated; then,
according to the course which the disease runs, the focal infection
should be eliminated, after which sulfonamides should be admin-
istered."
In the same vein of thought Cirillo~ pointed out that every
purulent otitis carries with it a number of intracranial complications,
the early recognition of which is important. These complications are
correctly diagnosed by the patient's general condition and appear-
ance, the temperature curve, in the spinal fluid picture and the
effect on the fields of vision and ocular fundi. The author stated
that "since 1936, an entirely new approach to the problem of infec-
tion in the middle ear has been advocated. There is a tendency to
prescribe chemotherapy to mastoiditis and its complications." He
cited a series of 16 cases treated for sinus thrombosis before the
advent of chemotherapy. Only one patient died despite the fact
that seven of them had metastatic abscesses. He then discussed four
fatal cases due to the masking of the classic symptoms of the com-
plications of progressive otitis media. This author vas adamant in his
belief that chemotherapeutic temporizing with middle ear suppura-
tions tends to delay life-saving surgical operations in cases of serious
intracranial complications.
Many authors heartily endorse surgical intervention combined
with antibiotic therapy in the majority of cases of mastoiditis and
its complications.
Sauer and ~'oolsey~' have reported a case of thrombophlebitis
of the lateral sinus, complicated by pregnancy, with complete re-
covery using this procedure. Birrels reported a case of lateral sinus
thrombosis due to Bacillus proteus, with recovery. Rosenwasser'
reported on the last 100 cases operated upon at Mount Sinai Hospital:
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LATERAL SINUS THROMBOSIS 149
19 patients received sulfonamides postoperatively, with two deaths.
The total mortality was 27 deaths in these 100 cases. Singleton2
reported on six cases; his treatment included sulfonamides, heparin
and surgical intervention. McCall and Frecmans reported on a case
due to Friedlander's bacillus treated with the combined procedure,
with recovery. Adler and Klapper? reported a case due to Bacillus
proteus treated with the combined procedure, with death of the pa-
tient. However, their comment was that the perisinal and extra-
dural abscesses present at the time of operation were not completely
drained, and were probably responsible for the septic thrombi which
caused the pulmonary infarct to which the patient's death can be
reasonably attributed. Tresidder10 reported a case where, after the
use of sulfonamides, a lateral sinus thrombosis was unexpectedly
found at operation. He states that "this acute exacerbation of a
chronic otitis media well illustrates the type of case in which sulfo-
namides are contraindicated as a sole preliminary form of treat-
ment." Rosenl~ reported a very interesting case with typical history
and physical and laboratory findings of lateral sinus thrombosis with
metastasis to the knee joint and blood culture of hemolytic strepto-
coccus. The treatment in this case was solely large doses of penicillin,
as the patient refused surgery. However, the author stated that a
combination of antibiotics and surgery may give the best results in
the largest number of cases.
J. M., a 26-year-old white male, was admitted on October 7,
1947, complaining of a painful left ear. The patient's history dated
back to four years before admission when he experienced a discharg-
ing, painless left ear. This was treated with ear drops and sulfona-
mides. Since this episode the patient had had four other similar ex-
periences at infrequent intervals. This symptom of painless aural
discharge was not associated with acute coryza.
Elpproximately six days previous to admission the patient had
developed painless aural discharge; local therapy was of no avail and
about two days later the discharge ceased and pain became evident.
There was slight, occasional vertigo, but to no severe degree. '!'here
was no history of vomiting or tinnitus. Slight to moderate deafness
had been present since the first episode.
Examination revealed a well developed young white male in
acute distress. No adenopathy was present. The eyes reacted to light
and accommodation. The nasal septum was slightly deviated to
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1 ~O LATELLA-HOPKINS
the right; the turbinates were normal. No exudate was present.
The right ear was normal. In the left ear there was no tragal tender-
ness, but exquisite tenderness was present over the antrum and tem-
poral region. The left canal contained a small amount of purulent,
foul-smelling yellowish exudate. The tympanic membrane was
thickened and no landmarks were evident. Two small polypi which
were present along the posterior drum margin appeared to originate
in the antrum. On lifting up the lower poly p a small amount of
pus escaped. Whispered voice was heard on the right at 15/1 S; on
the left at S/15; the Rinne and Schwabach tests were negative, and
the Weber lateralized to the left. There was no tenderness on com-
pression of the jugular vein and no change in the type of discharge.
Audiometric testing showed an 80-decibel loss in lower tones and
speech range, and a 100-decibel loss in the 4096 and 8192 range.
The mouth and throat were essentially within normal limits; the
tonsils had been removed. The chest, lungs and heart were normal.
Blood pressure was 120!80. The abdomen, genitalia, nervous sys-
tem, etc., were all within normal limits.
The x-ray report stated: "The right mastoid is well pneu-
matized and the cells are mixed in type. There is no abnormality
noted at this area. The. left mastoid is of the same general type as
the right and shows diffuse sclerosis with no evidence of air cells.
There is a zone of radiolucency in the supratentorial portion of the
mastoid in the temporal bone with several small areas of increased
density. Impression: Chronic, sclerotic, left mastoiditis with prob-
able superimposed acute disease. An acute infectious process in the
left temporal bone is to be considered."
Wassermann and Kihn tests were negative. Urinalysis was nor-
mal. Ear cultures were not returned. The hematological study on
admission showed: red cell count, 4.15; white cell count, 9,000;
neutrophils, 65 ~o ; lymphocytes, 26 ~o ; monocytes, S ?/~o ; eosinophils,
3 ?Jo; basophils, i ~o; hemoglobin, 14.5 gm.; sedimentation rate, 28
mm./hr.
On the afternoon of admission the patient had a temperature of
101? F. (oral) and a pulse rate of 88. The only complaint was
tenderness behind the left ear. That evening the temperature was
normal but rose to 100? F. (oral) the following morning. The
patient was put on penicillin, 100,000 units intramuscularly as the
initial dose and 50,000 units intramuscularly every three hours. Later
that evening, the temperature was normal and rose to 99? F. (oral)
the next morning. A diagnosis of subacute mastoiditis with dural in-
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LATERAL SINUS THROMBOSIS 1S1
volveinent was made and the patient was scheduled for a radical
mastoidectomy on October 10, 1947, the third day following ad-
mission. On that morning the temperature was normal and the
complaint the same: pain behind the left ear. On the elevator the
patient had a violent chill and his temperature rose to 101" F. (oral) .
Under general anesthesia a postauricular incision was made
and the antrum entered directly by means of mechanical burs, with
the release of a small amount of frank pus. In removing the cortex
posteriorly, over the sinus, a large perisinal abscess was uncovered
with the release of a large amount of pus pulsating under pressure.
The sinus was exposed from the bulb to approximately 1 cm. from
the torcula Herophili before active bleeding was encountered from
the bulbar end. The entire sinus was necrotic and collapsed, the
sinus wall being also soft and necrotic. Iodoform packs were placed
between the bony overhang and the sinus at the torcular and bulbar
ends, and the sinus incised. A thrombus, 4 cm. in length, was re-
moved. The dura was then exposed at the sinodural angle and was
seen to be red and injected. The mastoid cavity was completely ex-
enterated of all necrosis and a vaseline packing placed into the cavity,
which was left open. The left neck region was prepared and the
internal jugular vein exposed with difficulty and ligated above the
facial tributary; the vein was then severed. The patient was returned
to the ward in good condition. Radical mastoidectomy was not
completed at this time because the patient was too ill for further
surgical procedure.
On the first postoperative day the temperature was 102.6? F.
(rectal) in the morning and fell to 100? F. in the evening; on the
second day the temperature ranged from 102 ? to 100.4 ? F. For these
first 48 hours the patient had severe nausea and vomiting which
cleared, leaving him symptom free. The fundi were examined and
were found to be normal. On the third, fourth, fifth and sixth
postoperative days the temperature ranged from normal to 101? F.
(rectal) . The hematological study on the second postoperative day
showed: red cell count, 4.65; white cell count, 10,000 with a fairly
normal differential count; sedimentation rate, 26 rnm.ihr.
On October 17, 1947, a radical mastoidectomy was performed,
the drain in the left neck region was removed and a secondary clos-
ure of the neck wound was carried out. The iodoform packs were
removed from the torcular and bulbar ends of the lateral sinus and no
fresh bleeding was noted. A small amount of granulation tissue was
seen in the mastoid cavity. Much necrosis and granulation tissue
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152 f,ATELF.A-HOPKINS
was encountered in the antrum and in the middle ear, and inad-
vertently the stapes was removed. The patient returned to the ward
in good condition.
On the first postoperative day the patient had severe nausea and
vomiting, vertigo and spontaneous nystagmus to the right, stating
that the room appeared to be revolving in that direction. The tem-
perature was 100.4'' F. (rectal).
On the second postoperative day he had the same signs
and symptoms as the previous day but to a less marked degree.
The temperature was 100 ? F. (rectal) . The white cell count
was 9,400 with a normal differential count and a sedimentation
rate of 23 rnm./hr. The patient stated that he was much more
comfortable lying on his right side and looking upward to his left
(slow component) .
On the fourth postoperative day all signs of the acute laby-
rinthitis had disappeared and the temperature had returned to
normal.
Froin this day the patient made an uneventful recovery with
excellent epithelialization of the mastoid and middle ear cavity.
Penicillin therapy was discontinued after 22 day,' administration.
On October 29, 1947, his twenty-second day in the hospital, the
hematological study showed: red cell count, 4.0; white cell count,
5,600; hemoglobin, 14.0 gm. The differential count was within
normal limits and the sedimentation rate was 10 mm.!hr. The pa-
tient received a total of 6,100,000 units of penicillin and 168 gm.
sulfadiazine. Cultures taken at operation were reported as E. coli
two weeks later.
This patient's only complaint was pain in the ear and tender-
ness to pressure over the antrum and temporal regio3i. Definite signs
of intracranial complications were completely lacking until the pa-
tient was on his way to the operating room. The. temperature of
101? F. (oral) on admission returned to normal 12 hours after the
administration of penicillin. Our reasoning for performing the
mastoidecto~ny (before the rigor) was that the present condition
was due to a mechanical block of the purulent discharge with an
increase in the pressure causing the pain and tenderness; surgical
intervention was to prevent intracranial complications. The pa-
tient's history and his present acute symptoms with persistent mas-
toid pain and discharge led us to conclude that the present condition
was an acute episode of chronic mastoiditis with pathological dural
exposure.
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Discussion among the staff postoperatively brought up the ques-
tion of the necessity of tying off the internal jugular vein in this
case and in cases of lateral sinus thrombosis in general..
Hubertl stated that the treatment at the Manhattan Eye, Ear
and Throat Hospital is as follows: "Free exposure of the lateral sinus.
After iodoform plugs have been properly placed at the torcular and
bulbar ends, the wall of the sinus and the thrombus, when one is
present, is removed. Free bleeding is established if possible. When
there is no bleeding from the bulbar end and sepsis is present, the
jugular vein is ligated or resected.
"The present tendency is to carry out the necessary operations
on the mastoid and lateral sinus. If sepsis continues and progress is
unsatisfactory then ligation or resection of the jugular vein is con-
sidered in order."
Singleton2 in his report on the recent developments in the treat-
ment of lateral sinus thrombosis stated that he had found this ques-
tion the most controversial in the management of septic thrombo-
phlebitis of the lateral sinus. Ersner and Myers have pointed out
that the pioneers in the field follow the hard and fast rule that the
vein is to be ligated and the clot to be removed in all cases, while
many of the outstanding otologists hold that ligation is seldom, if
ever, indicated. It is thought that thorough exenteration of the
mastoid cells with incision and drainage of the sinus appears to be
adequate in most cases. Where symptoms of sepsis continue and
there is evidence of involvement of the jugular vein, it should be
exposed, ligated and drained. The author believes that the vein
should be ligated before attempting to remove the clot in order to
prevent liberating emboli into the blood stream.
Harkness believes that the logical therapy is operation on the
mastoid process followed by observation of the clinical course. The
procedure is surgical treatment of the sinus and continued observa-
tion, to be followed when necessary by ligation of the internal ju-
gular vein.
Rosenwasser,7 in reporting the last 100 cases of lateral sinus
thrombosis, based his treatment of the jugular vein on the thesis
that if there is any doubt as to the safety of leaving the vein patent
it should be ligated; at times, subsequent ligation was carried out,
and in other instances obliteration of the lateral sinus sufficed to
cure the general invasion. It is also interesting to note that in the
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series reported there was no significant increase in the number of
metastatic foci in the cases in which ligation of the internal jugular
vein was performed together with the obliteration of the sinus. Port-
mann reported that he has had no deaths among his patients for an
eight-year period, and explained his results on the basis of prompt
surgical intervention with regard to both the lateral sinus and the
internal jugular vein.
Koch'" reported 44 cases in eight years with 12 fatalities. In
12 of the cases there were no signs of sinus thrombosis, yet the con-
tinuation of the high sepsis made an opening of the sinus necessary,
together with the ligation of the jugular vein; he concluded that
ligation of the vein alone is not sufficient for the prevention of bac-
teremia.
Blassingeme13 quotes Meltzer as stating that the majority of
undesirable complications of lateral sinus thrombosis occur after li-
gation, and Ersner and Myers as saying that extension of the infec-
tion from the lateral sinus is retrograde rather than downward, and
believing, for that reason, that ligation is superfluous. The author
stated that the "similarity of the pathological aspects between lateral
sinus thrombosis and abscesses in a general sense suggests that the
same surgical procedures should be adapted to the management of
the one as is universally practiced in the other, namely, provision
for free drainage." The latter is carried out in an abscessed throm-
bus by adequate incision of the sinus wall, remo~-ing the obstructing
detritus in the cavity and maintaining an. avenue of escape for the
disintegrating material. Blassingeme holds that complete removal
of the clot is no more advisable than breaking down the protective
wall of an abscess.
Other than the efficacy of tying off the internal jugular vein
per se to prevent bacteremia and metastases, the problem of venous
return from the head on the side involved in the otitis disease
must be considered. Waltnerl' pointed out that the variations of
the lateral and sigmoid sinuses are independent of each other as they
are evolved from different anlages. "the sigmoid portion shows
greater constancy as the lateral sinus has to adapt itself to the in-
creasing size and changing form of the surrounding structures, i.e.,
the brain and otitis capsule, while the sigmoid sinus is located close
to the base of the brain from the very beginning of its developmen=.
Mayfield`' divides intracranial edema, or, as it has been alluded
to, "serous meningitis", "otitis hydrocephalus", "toxic hydrocepha-
lus", "pseudo-abscess" or "cerebral edema", into two groups: one
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may be explained by an aseptic intracranial inflammatory process
secondary to an extradural abscess; the other group, in which there
is intracranial hypertension with choked discs and headache without
cellular reactions in the spinal fluid, will occur in certain instances if
the major sinus is occluded.
It has been established that the right lateral sinus is the pre-
dominant channel of venous return from the skull in the majority
of persons. Studies by Woodhall in 1936 showed the right lateral
sinus predominated in 29 ~o ; the left side predominated in 13 /o ;
the major disproportion between the two sides in 24?Jo; inadequate
cross circulation at the torcula in 10 % and complete absence of one
lateral sinus in 4 ?fo.
There it is noted that in approximately 2 S % the venous return
from the skull is impeded when the predominant side is obstructed
either by thrombus or surgical intervention. Fatality is evident if
only one sinus is present.
Considerable significance can be attached to roentgenologic evi-
dence of the size of the sinus and its capacity. Seyde1117 states that
Frenckner found that the relative size of the lateral sinus and the
jugular foramen were proportionate in practically every instance,
that is, when both sinuses were of equal size, the foramina were
equal; when one sinus was smaller, the foramina of that same side
showed a proportionate decrease in diameter.
In certain instances, the collateral circulation may be ade-
quate to compensate after a period of time; in that event the patient
will recover spontaneously. In others, decompressive measures may
be required to protect the patient's eyes from atrophy as a result of
choking of the discs and to save life.
Evans18 reports that the literature contains two cases cif bilateral
internal jugular ligation and reports a third with recovery. Seven
cases of bilateral internal jugular ligation (not of otitic origin) were
found in the literature. Precechtcl lists the intracranial symptoms
that may be noted in disturbances of the circulation in the cranial
cavity: impaired consciousness increasing to unconsciousness, mania,
apathy and amentia, headache, vomiting, retarded pulse, choked disc,
affected sight ranging to blindness, convulsions, paresis of limbs,
labyrinth irritation, disturbed heat regulation, glycosuria, polyphagia
and obesity, aphasia and venoestasis of the face.
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However, in the cases discussed by Evans, temporary papille-
dema and a variable amount of venoestasis of the head and neck were
the only complications observed. Also, in the 1G patients with un-
paired cranial venous return, only three died, twelve completely re-
covered and in one the result is unknoa-n.
Freisner,19 in discussing the ocular changes in otitic thrombosis,
mentions dilatation of the veins, blurring of the disc margins, slight
papilledema and marked papilledema as the most constant findings.
However, there is no adequate explanation of papilledema, as those
explanations which have been offered, viz., stasis, increased intra-
cranial pressure and toxic state can all be challenged. Dean has
stated that he has never noted evidence of papilledema from the
blocking of the circulation in an uninfected sinus. The cranial si-
nuses are part of the dura and the one factor common to all these
cases is the inflammation of the dura. It is possible that the latter,
with its attendant edema and infiltration, may be an important
factor in the development of papilledema with sinus thrombosis.
This case and a review of the literature are being presented be-
cause of many interesting features: (1) The sulfonamides and peni-
cillin produced a masked picture of extensive mastoid breakdown
with extension and obliteration of the left lateral sinus. This process
evidently was going on for some time and yet the patient was feeling
fairly well, being up and about with no symptoms. (2) This pa-
tient postoperatively received penicillin while awaiting the return
of the cultures taken at operation. Unfortunately they were not
obtainable for a period of two weeks. The cultures were reported
as E. coli; with this organism streptomycin would have been the
drug of choice, but the patient evidently did very well on penicillin.
(3) During the operation the stapes was inadvertently removed.
The patient developed a moderate labyrinthitis but no other difficulty
nor more serious complication resulted. (4) The ligation and resec-
tion of the jugular vein was carried out because at operation the
thrombus extended down to and beyond the bulb, and the patient
had had evidence of sepsis just before operation. As is well brought
out in the literature, there is appreciable controversy as to the
procedure of ligation and resection of the jugular vein, and one
still must depend upon his own judgment at the time of operation.
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1. Hubert, Louis: Thrombosis of the Lateral Sinus. An Analysis of Results
Obtained in 119 Cases, J. A. M. A. 117:1409-1415 (Oct.) 1941.
2. Singleton, Dudley J.: Lateral Sinus Thrombosis: Recent Developments in
Treatment, South. M. J. 35:756-761 (Aug.) 1942.
3. Kopetsky, Samuel, J.: Purulent Otitis Media, Mastoiditis, Sinus Thrombosis
and Suppuration of the Petrous Pyramid, Arcli. Otolaryng. 35:115-131 (Jan.)
1942.
4. Grillo, A. A.: Masking of the Pathologic Status in Otitis Media by Chemo-
therapy, Arch. Otolaryng. 36:541-547 (Oct.) 1942.
S. Sauer, Wm. E., and Woolsey, Doris Sules: Thrombophlebitis of Lateral
Sinus, Complicated by Pregnancy with Complete Recovery, Laryngoscope S S : S 19-
523 (Sept.) 1945.
6. Birrell, J. F.: A Case of Lateral Sinus Thrombosis Due to Bacillus Proteus
with Recovery, J. Laryng. and Otol. 60:85-89, 1945.
7. Rosenwasscr, Harry: Thrombophlebitis of the Lateral Sinus, Arch. Ota-
laryg. 41:117-132 (Feb.) 1945.
8. McCall, J. W., and Freeman, M. D.: Septicemia Due to Fricdlander's Bacil-
lus: Report of a Case Following Chronic Otitis Media Complicated by Sinus
Thrombosis; Recovery Following Therapy with Sulfanilamide and Its Derivatives,
Arch. Otolaryng. 35:772-776 (May) 1942.
9. Adler, Hartwig M., and Klapper, Claude: Bacillus Proteus Septicemia Ac-
companying Acute Mastoiditis with Thrombosis of the Lateral Sinus, Arch. Oto-
laryng. 37:74-77 (June) 1943.
10. Tresidder, C. I. C. and Lord, M. S.: Case of Lateral Sinus Thrombosis,
Lancet 2:543 (Nov.) -1942.
11. Rosen, Samuel: Thrombosis of a Lateral Sinus with Metastasis; Penicillin
Therapy: Recovery, Arch. Otolaryng. 42:417-418 (Nov.-Dec.) 1945.
12. Koch, F. X. (Gray) : Quart. Rev. Otorhinolaryng. (Abstr. Sect.) 13:67-68
(Dec.) 1940.
13. Blassigemc, Charles D.: Lateral Sinus Thrombosis with Case Reports,
Laryngoscope 52:569-576 (July) 1942.
14. Collins, E. G.: Unusual Intracranial Complications of Otitic Origin, J.
Laryng. and Otol. 60:56-67, 1945.
15. Walther, Jules G.: Anatomic Variations of the Lateral and Sigmoid Sinuses,
Arch. Otolaryng. 39:307-312 (April) 1944.
16. Mayfield, Franlc H.: Intracranial Edema Following Occlusion of One
Lateral Sinus, Arch. Otolaryng. 34:825-828 (Oct.) 1941.
17. Seydell, Ernest M.: The Influence of Variations in the Size and Structure
of the Cranial Venous Sinuses on the Clinical Picture of Sinus Thrombophlebitis,
South. M. J. 35:555-559 (June) 1942.
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18. Evans, Maurice: Bilateral Jugular Ligation Followin;; Bilateral Suppurative
Ma5tOlditlS, ANNALS OF OT"OLOGY, RHINOLOGY' AND LARYNGOLOGY 51:615-625
(Sept.) 1942.
19. Friesner, Isidore: An Analysis of the Ocular Fundus Changes in Otitic
SIRIlS T1lYOmbOSI:S, ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY SO:32-
37 (Mar.) 1941.
20. Beck, Diana, J. K., and Russell, Dorothy S.: Experiments on Thrombosis
of the Superior Longitudinal Sinus, J. Neurosurg. 3:337-347 (July) 1946.
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XIII
ANGIOSARCOMA
A REVIEW OF THE LITERATURE
JOSEPH M. KINKADE, M.D.
TUSCON, ARIZ.
Angiosarcoma is generally considered to be a very rare lesion.
However, when the writer's own report20 of such a neoplasm coin-
cided with the publication of a similar case by Dr. Cruthirds,i2 the
question was bound to arise whether angiosarcoma is actually as rare
a disease as had been previously reported.
At first it was intended to submit merely a list of all cases re-
ported in the literature, similar to the one compiled by Freilich and
Coei'' for the years 1918 to 1934. While it is understood that all
such lists are of necessity incomplete, the main difficulty in this in-
stance. lay in the fact that no agreement exists concerning the use
of the term "angiosarcoma". Consequently, a number of different
terms have been employed throughout the literature in order to de-
scribe malignant vascular tumors; thus, for instance, in the list of
Freilich and Coe, cases diagnosed as angioleiomyosarcoma, telangi-
ectatic sarcoma; systemic angiosarcoma, and cavernous angiosarcoma,
appear side by side with others which are classified as angiosarcoma
(hemangiosarcoma, lylnphangiosarcoma). In addition to these term-
inologic difficulties there arise other problems due to the fact that
some published reports do not sufficiently substantiate the proposed
diagnosis. This has been recognized by Stout:35 "In spite of the
fact that blood vessels are ubiquitous, and benign vascular tumors
exceedingly common, malignant tumors of blood vessels are ex-
ceedingly rare. Just how many of them have been recorded is
impossible to say because many tumors have been reported as such
with insufficient or obviously erroneous data. After reading reports
of 118 cases labelled with some name suggestive of a malignant vas-
cular tumor, the writer felt compelled to reject 41, or 3 S per cent
of them, either because there was an inadequate or no histologic
report, or because, in his opinion, the illustrations and text described
a tumor of some other kind."
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160 JOSEPH M. KINKADE
Thus, the clinician is faced with the fact that the question of
the incidence of angiosarcoma remains equally unsolved for the path-
ologist as it is for himself. Moreover, the issue underlying the pre-
vailing terminologic difficulties, that is, the problem of the char-
acter of angiosarcoma, and whether there exist indeed true malig-
nant vascular neoplasms, has not as yet been conclusively determined
by the oncologists.
While EwingY~ merely reports on the issue without entering
into a detailed discussion, the range of current opinions on the sub-
ject is well illustrated through the opposite views held by men like
Stout on the one side and Willis on the other. Stout and his co-
worker no longer speak of angiosarcoma per se, but rather treat of
a number of different groups of malignant vascular tumors, includ-
ing hemangioendothelioma,3' hemangiopericytoma,37 and either a
vascular form of leiomyosarcoma or, on the other hand, Kaposi's
disease.3e Contrary to Stout's view, it is the opinion of Willis that
vascular hamartomas as well as other types of vascular tumors have
often been wrongly diagnosed as angiomas.42 Similarly, multifocal
lesions have been classified as angios~rcomas.}` Even the distinction
between benign and malignant angiomatous growths is by no means
an easy matter.~l Of greatest importance, however, is Willis' ob-
servation that "the ready metaplastic conversion of proliferating
mesenchymal tissue of one kind into tissue of another kind, seen in
both non-neoplastic and neoplastic lesions, makes the grouping of
mesenchymal tumors into separate species somewhat arbitrary ;
Predominantly angiomatoud structure in a mesenchymal tumor does
not necessarily denote a specific vascular origin." i2 Willis concludes,
therefore, that it is advisable "to regard true angiomas and angio-
sarcomas, not as a fixed species, but merely as conspicuously vaso-
formative variants of the genus mesenchymoma."42
There can be little doubt that progress in the clinical under-
standing of angiosarcoma will remain greatly impeded as long as no
effort is made to co-ordinate the opposing views of different path-
ologists. An attempt will be made here to integrate these seemingly
irreconcilable opinions. To this end it is necessary to appreciate
more fully the difficulties which sometimes are encountered in the
differentiation of angiomatous tumors into benign and malignant ,
neoplasms.
A number of cases have been reported in which large parts of
the tumor present the structure of benign hemangioma, while in
other portions of the growth, transition towards a sarcomatous ar-
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rangement is unmistakably evident;3~ 2z, 2? in some instances, the
tumor is described as "partly sarcomatous";31 in others, repeated
histologic examinations may be required in order to establish con-
.. elusively the diagnosis of a malignant vascular neoplasm.s~ e While
formerly metastatic spread originating from a benign hemangioma
had been accepted as possible,ls Robinson and Castleman30 concluded
that "the occurrence of metastases should be the deciding factor and
not the histologic features" and that, therefore, "the primary tumor,
in spite of the absence of histologically malignant properties, was not
benign." This opinion was confirmed by Stout35 who, upon re-
examination of the same specimen, discovered in certain areas of the
neoplasm indubitable proof that the primary growth was after all
not a simple hemangioma, but rather a hemangioendothelioma, that
is, a malignant tumor according to his definition.
Practical conclusions of considerable importance may be drawn
from these difficulties in establishing the true character of a vascular
neoplasm. In the first place, tumors of this kind should never be
excised without preceding histologic examination of a biopsy speci-
men; omission of this indispensable precaution may lead to recur-
rence or metastases, and is at least partly responsible for the high
fatality rate.3? A tumor specimen which is too small may not in-
clude any of the areas in which characteristic histologic or cytologic
changes have occurred; similarly, correct diagnosis may prove im-
possible in the presence of infection.? On account of these circum-
stances, no accurate determination can be expected when material
obtained through aspiration or punching is submitted, and, if at all
possible, a representative portion of the tumor should be surgically
excised.3B Whenever the histologic examination remains inconclu-
sive, serial sections are required.31
Similar difficulties to those encountered in the distinction be-
tween benign and malignant vascular growths arise in the differenti-
ation between vascular tumors and other types of neoplasms, as well
as in the classification of malignant angioblastic growths. Accord-
ing to Magnusson22 there does not exist a typical microscopic ap-
pearance of angiosarcoina: "From foci with endothelium-like cells
there are all sorts of transitions to tissue resembling fibrosarcoma with
a fairly great amount of stroina"; furthermore, "it is impossible to
decide which cells in the tumor originate from the endothelium, and
which come from the adventitia." The indeterminate character of
neoplasms of this type is -well exemplified by a hemangiofibro-
sarcoma, in which angiomatous as well as fibrosarcomatous com-
ponents were encountered.27 A case which was clinically considered
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162 JOSEPH M. KINKADE
a lipoma was microscopically diagnosed as xanthomatous angiosar-
coma: within the vascular tumor little cysts filled with cells infil-
trated by lipoid matter were found; the presence of xanthoma cells
within the vascular tumor is traced to the pluripotence of the angio-
blasts.32 Still more varied neoplasms have been reported by other
authors, as, for instance, a mixed mesenchymatous tumor presenting
highly differentiated lipomatous, myomatous, and angiomatous com-
ponents, together with groups of undifferentiated fusiform cells.al
DeNavasquez2~ discovered in malignant tumors of this type "potenti-
alities to differentiate along several lines, either to the formation of
well-defined vascular channels which remain primitive in form, or
towards nondescript endothelium, occurring in bundles, whorls, papil-
lary processes, or layers covering epithelial structures."
On the basis of all these observations, it might be possible to
harmonize the seemingly opposing views of Stout and Willis out-
lined earlier in this paper, and also to indicate a tentative solution
of the terminologic problem. According to ` Gemmill and Pusch,l`'
the present confusion is at least partly due to-the fact that two dif-
ferent approaches can be used in order to arrive at a pathologic diag-
nosis: at times it is exclusively based on the histogenic approach,
while in other instances it represents a formulation of the morpho-
log'.c findings in a specific case, irrespective of the histogenesis. This
state of terminologic uncertainty is indicative of the fact that in
many instances of malignant vascular tumors, the microscopic find-
ing~ do not bear a definite character. According to Stout, the mor-
pho'_ogic features of sarcomas of this type are not equally distinctive
as those characteristic of carcinomas; furthermore, it may prove
impossible to ascertain the precise cellular origin of vascular sarcomas
through examination of a single tissue specimen, or even through
extensive morphologic investigations; cells explanted in vitro, on the
other hand, grow in a manner representative of their origin, and
such a tissue culture is often required in order to discover the true
nature of a vascular tumor.`'
It may be concluded that in the prevailing state of medical
science the histologic diagnosis of malignant vascular tumors is faced
with a number of unavoidable obstacles. While a future solution of
these problems may be expected, micropathologic findings at the
present time do not seem to be sufficiently conclusive to permit gen-
eralization into unequivocal terms. On such an uncertain basis it
is evidently impossible to formulate a classification of neoplasms of
this kind which could be generally acceptable.
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The resulting terminologic confusion is by no means a purely
theoretical problem. By reason of this uncertainty it is impossible
to co-ordinate a sufficiently large number of cases of malignant vas-
cular tumors. For lack of such well-founded tabulations we are at
present unable to arrive at valid conclusions about the clinical ap-
pearance of these neoplasms, the course of the disease, or its statistical
prognosis. Reliable information of this kind could be of great aid
to the clinician. It is, therefore, desirable to establish a terminology
which would permit the compilation of published case records, in
order to make past experience available for future therapeutic
practice.
Attempts at a generalization of some of the characteristic fea-
tures of malignant vascular tumors for clinical purposes have been
made in the past: Schmidt3~ came to the conclusion that angiosar-
comas are most often observed in the soft parts of the extremities.
According to Stout,3" about half of the number of all cases of hem-
angioendothelioma (in his definition, a malignant vascular tumor)
appear during childhood or youth; in infants, the tumor presents
as a rule a higher degree of differentiation and is, therefore, prob-
ably less malignant. On the basis of a case of their own and of four
published cases, Ransom and Samson`'s were able to formulate a
number of clinical signs of angiosarcoma of the greater omentum.
Berezin, Sharnoff and Stein reported that clinical diagnosis has up
to the present time not been possible in a single case of primary
hemangioendothelioina of the liver in infants; but they suggested
that under certain conditions the presence of this disease should be
taken into consideration.
.Still more important than these findings is the observation of
Stout and Murray:37 "The hemangiopericytoma emerges as a tumor
which does not have sufficiently arresting gross features to enable
one to recognize it clinically," and in almost all aspects "it behaves
very much like other angiomatous tumors." Hemangiopcricytornas,
as defined by Stout and Murray, are, in the majority of cases, of
benign character. Their observations, however, that some of the
subgroups obviously required for a systematic description of micro-
scopic findings are irrelevant from the point of view of classification
for clinical purposes, are of equal importance with regard to malig-
nant vascular tumors.
There exists, as shown above, no agreement concerning the
highly differentiated terms used for the micropathologic distinction
of malignant vascular tumors. It has even been suggested that many
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1F4 JOSIiPI~ M. KINKADE
of these minute differences exist merely during certain stages in the
development of such neoplasms, but that they undergo anaplasia to
homologous sarcomas with increasing malignancy.='s In spite of these
uncertainties, there can be no doubt that a set of highly differentiated
terms is the prerequisite for accurate description and advance in the
understanding of the histologic pattern of malignant vascular tu-
mors. However, in view of a future statistical compilation from
which valid conclusions about the clinical aspect of this disease might
be drawn, there exists independently an equal need for a term which
at the same time would have to be less controversial and more com-
prehensive. To this end, the expression "mesenchymoma of preval-
ently vascular appearance" might be acceptab]e. Wi11is42 speaks of
the "conspicuously vasoformative variants of the genus mesenchy-
moma", while Courville and Abbotttl discovered in certain tumors
a "special propensity to form new blood channels." Thus the pro-
posed term would have the advantage of gathering the pathologic
experience into an Basil}~ understandable expression which might serve
the practical purpose of a future tabulation of cases of "angio-
sarcoma".
On the basis of the present thorough, yet by no means ex-
haustive, search of the literature on the subject, it may be stated
that angiosarcoma is not as rare a condition as had been assumed
heretofore. While earlier statistical figures should not be uncritically
accepted, it is nevertheless noteworthy that Simon33 was able to col-
lect no less than 41 cases of hemangioendothelial sarcoma of the
thyroid alone. Tinozzi{0 reported a case of angioblastic sarcoma
merely for the purpose of establishing a basis for discussion of the
possible development of tumors from scar tissue. Bracco and Oghis
published a detailed description of a special procedure of interscapu-
lothoracic amputation, and mentioned incidentally an instance of
reticuloangiosarcoma. While collecting material. for an investigation
of gemmangioma, Schmidt'i` detected in seven and one-half years
six cases of angiosarcoma at a moderate sized hospital; and besides,
these cases are submitted only in order to substantiate Schmidt's
theory of gemmangioma.
All these indications point to the fact that the rate of incidence
of angiosarcoma is higher than formerly reported. Correct deter-
mination, however, will have to wait until, thrc;ugh unification and
simplification of terminology, it will be possible to arrange the avail-
able case material into a comprehensive statistical tabulation.
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ANGIOSARCOMA 165
SUMMARY
1. The literature on angiosarcoma beginning with the year
1934 is reviewed.
2. At the present time, it is impossible to compile a reliably
complete list of published cases, as a number of different terms have
been used in order to classify identical or at least similar pathologic
entities.
3. The histologic diagnosis of "angiosarcoma" encounters con-
siderable difficulties, and even more specialized terms have been used
in the description of microscopic findings.
4. For the purpose of a statistical tabulation from which con-
clusions about incidence and clinical features of the disease may be
drawn, a more comprehensive term is required; to this end the use
of the expression "mesenchymoma of prevalently vascular appear-
ance" is proposed.
5. The present review of the literature leads to the impres-
sion that angiosarcoma is probably more frequently encountered
than had previously been assumed.
1. Alurralde, M. A., and Sepich, M. J.: Angiosarcoma of Ccrebcllopontile
Angle, Rev. Asoc. med. Argent. 48:573 (June) 1934.
2. Bailey, O. T., and Ford, R.: Sclerosing Hemangiomas of the Central Ner-
vous System, Am. J. Path. 18 :1 (Jan.) 1942.
3. Bauer, D. do F. and Stanford, R.: Splenic Hcmangiosarcoma, Arch. Path.
41:668 (June) 1946.
4. Berczin, S. ~~/., Sharnoff, J. G., and Stein, J. D.: Primary Hemangiocn-
dothelioma of the Liver in Infancy, New England J. Med. 238:906 (June 24)
1948.
S. Berger, A.: Hemangiosarcoma of the Mandible (Metastatic?), Ann. Dent.
1:15. (June) 1942.
6. Bodart, P., Plorentin, R., Grimaud and Blum: Angiosarcoma of the Floor
of the Mouth in a Small Girl, Rev. med. de Nancy 66:1009 (Dec. 1) 1938.
7. Bosse, M. D.: I-Icmangioendothelial Sarcoma of Thyroid Gland, Arch. Path.
36:316 (Sept.) 1943.
8. Bracco, J. A., and Oghi, A.: Interscapulothoracic Amputation for Rcti-
culoangiosarcoma of Scapula, Prensa med. Argent. 31:23 S 1 (Nov. 1 S) 1944.
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9. Cabot Case 2 S 3 81: Retroperitoneal Hemangiosarcoma, New England J.
Med. 221:469 (Sept. 21) 1939.
10. Castellanos, A. et al: HemangioendothcIiosarcoma, Primary in the Liver
Of a 1 S Months Old Boy, Archivos de med. Infant. 15:1 (Jan.-Mar.) 1946.
11. Courville, C. B., and Abbott, K. H.: The Angioblastic Group of Meningi-
cmas, Bull. Los Angeles Neurol. Soc. f :47 (Mar.) 1940,.
12. Cruthirds, A. E.: An:~io-Epithelioma of the Postnasal Space, ANNALS os
OTOLOGY, RHINOLOGY ANll LARYNGOLOGY 57:230 (Mar.) 194$.
13. Druckerman, L. J.: Pulsating Angioblastic Sarcoma, J. Mt. Sinai Hosp.
3:20 (May-June) 1936.
14. Ewing, J.: Neoplastic Diseases, Philadelphia, W. B. Saunders Company,
1940, ed. 4, pp. 339-340.
1 S. Frcilich, E. B., and Coe, G. C.: Angiosareoma. Case Report and Review
of Literature, Am. J. Cancer 26:269 (Feb.) 1936.
16. Gemmill, W. F., and Pusch, L. C.: Angioblastic Sarcoma of Lip, Am. J.
Surg. 46: 395 (Nov.) 1939.
17. Garlock, J. H.: Primary Angio-Sarcoma of Spleen, J. Mt. Sinai Hosp.
6:319 (Mar.-Apr.) 1940.
18. Hall, E. L.: A Malignant Hemangioma of the Lunt; with Multiple Metas-
tases, Am. J. Path. 11:343 (Mar.) 1935.
19. Hauser, H.: Angiosarcoma of Bone, Am. J. Roentgenol. 42:656 (Nov.)
1939.
20. Kinkade, J. M.: Angiosarcoma of the Petrous Portion of the Temporal
lione, ANNALS OF OTOLOGY, RHINOLOGY AND L.4RYNGOLOGY 57:23$ (Mar.) 1948.
21. Lilienthal, H.: HemanSiosarcoma of the R4ediastinum, Ann. Surg. 104:1107
(llec.) 1936.
22. Magnusson, K.: Sarcoma of the Small Intestine in Connection with a
Case of Hemangiosarcoma of the Jejunum, Acta chit. Scandinav. 73:576, 1934.
23. Melnick, P. J.: Generalized Primary Angiosarcomatosis of the Lymph
Nodes, Arch. Path. 20:760 (Nov.) 1935.
24. Miller, J. K.: Primary Sarcoma of Liver; Endothelioblastoma, Am. J. Surg.
44:458 (May) 1939.
25. De Navasquez, S.: Angioblastoma of the Spleen with Metastases in the Liver,
J. Path. Bact. 42:651 (May) 1936.
26. Penna de Azevedo, A., and Duarte, E.: Primary Hemangioendotheliosar-
coma of the Liver, Mem. Inst. Osvvaldo Cruz 38:53, 1943.
27. 1'iitz, Th.: Hemangiofibrosarcoma of the Ligamentum Ovarii Proprium En-
countered Accidentally During Laparotomy, Arch. f. Gynak. 171:47, 1941.
28. Ransom, H. K., and Samson, P. C.: Malignant Tumors of the Greater
Omentum, Ann. Surg. 100:523 (Sept.) 1934.
29. Rintelen, F.: Hemangioblastic Sarcoma of the Lower Eyelid, Klin. Monatsbl.
f. Augenh. 94:463 (April) 1935.
30. Robinson, J. M., and Castleman, B.: Benign Metastasizing Hemangioma,
Ann. Surg. 104:453 (Sept.) 1936.
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31. Dos Santos, R., and Wohlwill, F.: Lipomyoangiosarcoma; Bilateral Partially
Sarcomatous Lipomyoangioma of Kidneys with Cystic Disease of Lung, Lisboa med.
19:131 (Mar.) 1942.
32. Schmidt, H.: Aspects of Gernmangioma and its Relation to Angiosarcoma,
Frankfurt. Ztschr. f. Path. S 1:43, 1937.
33. Simon, M. A.: Hemangioendothelial Sarcoma of the Thyroid with Ex-
tension into the Trachea and. Massive Hemoptysis, Arch. Path. 27:571 (Mar.)
1939.
34. Snodgrass, T. J.: Report of Casc of Retroperitoncal Hcmangioendotheli-
oma, Surgery 15:988 (June) 1944.
3 S. Stout, A. P.: Hemangio-Endothelioma: A Tumor of Blood Vessels Featuring
Vascular Endothelial Cells, Ann. Surg. 118:445 (Sept.) 1943.
36. Stout, A. P.: Sarcomas of the Soft Parts, J, Missouri State Med. Ass. 44:329
(May) 1947.
37. Stout, A. P., and Murray, M. R.: Hemangiopcricytorna. A Vascular
Tumor Featuring Zimmermann's Pericytcs, Ann. Surg, 116:26 (July) 1942.
38. Tavella, A.: Intrathoracic Angiosarcoma in a Petus, Ann. ostet. c ginec.
S8:9S3 (July 31) 1936.
39. Tejerina-Fotheringham, W.: Hemangiocndothcliosarcorna, Pulsating Tumor
of Temporal and Masseter Muscles, Bol. y trab. do la Soc. de cir. de Buenos Aires,
18:141 .(flprl 2S) 1935.
40. Tinozzi, F. P.: Angioblastic Sarcoma on Wound Granulation Tissue, Rass.
internaz. di clin. c terap. 21:811 (Nov. 30) 1940.
41. Willis, R. A.: The Spread of Tumors in the Human Body, London, J. and
A. Churchill, 1934, pp. 148-1 S 1.
42. Willis, R. A.: Pathology of Tumors, St. i.oui5, C. V. Mosby Company,
1948, pp. 700-713.
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XIV
CARCINOMA OF THE ANTRUM
REPORT OF NINE CASES WITH A TEN-YEAR
SURVEY OF LITERATURE
CHARLES A. SEELIG, M.D.
NEW Yoxx, N. Y.
Carcinoma of the antrum is by no means a new subject. A
perusal of the literature and solve of the excellent articles of the past
decade leave little room for doubt that the otolaryngologist is aware
of its scope. The insidious onset is appreciated. It is now more
frequently recognized. The gloomy outlook of early writings has
been supplanted by some degree of optimism as diagnostic and thera-
peutic approaches have improved. However, it appears generally
agreed that there is much to be accomplished by way of early diag-
nosis, which is tantamount to a favorable progllosis. There is still
too much time lost between the appearance of the first signs or symp-
toms and the start of actual therapy. In an attempt to determine
some of the manifestations leading to early diagnosis, nine cases, eight
of which were observed at the New York City Hospital and one
private case, are presented, and literature of a ten-year period, from
193 S to 1946 inclusive, is reviewed.
CesE 1.-The patient, a 67-year-old white woman, was admitted to the hos-
pital on November 11, 1943. Her chief complaints were swelling of the right
eye and difficulty in swallowing. The history was unsatisfactory because of her
mental condition. She was said to have had a convulsion the evening before ad-
mission, about two hours after taking a sedative.
She had been operated on at another hospital five weeks before. At that
time the chief complaint was bilateral nasal obstruction of six months' duration,
repeated epistaxis and headache for three months, and protrusion and loss of vision
of the right eye for one month. Physical examination revealed marked proptosis
of the right eye with chemosis of the conjunctiva and complete lass of vision to
light perception. The left eye showed a loss of the nasal field of vision, otherwise
it was normal. There was complete obliteration of the nasal airway due to a tumor
mass and marked swelling of the mucous membranes with bilateral mucopurulent
Presented as a candidate's thesis to the American Laryngological, Rhinological
and Otological Society.
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Fig. 1.-Photomicrograph. Case 1. Specimen of antral lesion showing
carcinoma of adenoidcs cysticum type (x 90).
discharge. The right maxilla was swollen with a palpable, hard tumor mass.
Downward extension of the tumor had resulted in ulceration of the hard palate on
the right side.
X-ray films revealed a far advanced destructive process of the right antrum
and right ethrnoid. In addition, there was destruction of the medial portion of
the floor of the right orbital fossa. The right sphenoid sinus appeared destroyed
and the anterior portion of the sclla turcica was involved. The process had ex-
tended through the floor of the antrum with considerable destruction of the hard
palate on the right side and partial invasion of the left antrum. Specimens taken
from both antra showed carcinoma with squamous and cystic features on the right
and mainly cystic features on the left. The pathological diagnosis was epithelioma
adenoidcs cysticum. The therapy was irradiation; the patient received 2000 "r"
units to the right antrum and later 12 S 0 "r" units to both antra.
On admission to City Hospital the patient appeared chronically ill and cachec-
tic. The face was asymmetrical and the right side edematous. The right angle
of the mouth drooped and the tongue deviated to the left. The left upper tendon
reflexes were absent, the right were present. There was a definite left Babinski
and an equivocal right Babinski sign.
X-ray films revealed in addition to the findings at the other institution, an
extension of the process with destruction of the right anterior clinoid, a destruc-
tive lesion of the tenth right rib posteriorly, a fracture of the left eighth rib in
the axillary lino, and a productive infiltration of both upper pulmonary lobes with
abscess formation.
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Fig. 2, Case 9.-X-ray film showing erosion of floor of the right
orbit by squamous cell carcinoma of the right antrum.
There was clinical evidence of a cardiac dccompensation. She was trans-
ferred to a home for incurables two weeks later, where she died on November
30, 1943. Permission for autopsy was not obtained.
Permission for autopsy was not obtained.
The total duration of recognized carcinoma was two months.
CesE 2.-The patient, a 57-year-old white laborer, was admitted on July
3, 1944. The chief complaint was pain in the head and roof of the mouth. He
was first seen by his private physician on January 24, 1944. At that time he
gave a history of pain over the left side of the face of several years' duration and
the extraction of two upper left molars five weeks previously. At the site of
extraction there was a large ulcerated mass, a specimen of which was obtained by
biopsy and proven to be squamous cell carcinoma. A resection of the antrum was
performed with the complete removal of the medionasal wall and part of the roof
of the mouth, A large mass of carcinoma was readily stripped from the lateral
and posterior bony walls. The orbital floor appeared uninvolved. A course of deep
x-ray therapy was instituted.
On admission to this hospital he was co-operative and appeared chronically
ill. The breath was extremely foul and most of the teeth were missing. There
was a crusty mucoid discharge from the nose. The left check was pigmented from
x-ray therapy. There were no other pertinent findings.
He was discharged to Cancer Hospital two days later l~nr custodial care, and
he died there on July 31, 1944. Permission for autopsy was not obtained.
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Fig. 3, Case 9.-High power photomicrograph of squamous cell car-
cinoma.
The duration of recognized carcinoma was four and one-half months.
Cass 3.-The patient, a S1-year-old Japanese, was admitted on June 4, 1945,
with the chief complaint of pain in the right side of the face for four months.
He stated that he had had right sinusitis all his life, and an operation had been
advised 30 years previously. On examination the right side of the face, including
the eye and temporal region, appeared swollen and was considerably tender. The
right nasal cavity was completely obstructed. Decongestion was followed by a
flow of putrid yellow pus. There was a slight postnasal discharge. There were
no other pertinent findings. The temperature was 99.2? F.; pulse, 88; and res-
piration, 18.
X-ray films showed a far advanced destructive lesion of the bones of the
right antrum to the roof, the adjacent portions of the right ethmoidal cells, the
zygoma and right supra-orbital area. There was extensive soft tissue swelling in
the right frontal and ethmoidal areas and right nasal cavity. The left antrum
had moderate mucosal thickening.
A Caldwell-Luc procedure with wide intranasal antrotomy was performed.
Thick putrid pus flowed from the cavity as soon as it was entered. The mucosa
throughout was polypoid, its removal from the posterior and lateral. walls causing
moderate bleeding. The bone encountered was very friable.
Pathological examination showed squamous cell carcinoma.
He was transferred to Cancer Hospital two weeks later where he received a
course of x-ray therapy totalling 2,000 "r" units to the field. Death occurred
on August 30, 1945. Permission for autopsy was not obtained.
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The total duration of recognized carcinoma was six months.
Coss 4.-The patient, a 71-year-oId white woman, was admitted on March
8, 1946. The current illness dated back two months. She first noticed a small
subcutaneous swelling of the right cheek which was constantly painful and throb-
bing and accompanied by marked serous discharge from the right nostril. The
mass continued to grow, all the symptoms increased in severity, and on admission
the chief complaint was constant severe throbbing pain. in the right maxillary
region. During the previous month there had been mild pain in the right fronto-
parietal region with loss of hair at this site. During the last two years, there
had been a 40-16. weight loss. The only previous illness was a coronary attack
three years before. Since then she had been on digitalis therapy. Her father had
died of gastric cancer at the age of 54.
Examination showed an obese female in no acute distress. The right fronto-
parietal area was sparse of hair. In the right maxillary area there was a palpable
firm diffuse swelling extending from its medial to its lateral border and giving a
sensation of induration. The right lower eyelid was swolle,i and the eye proptosed.
The nasal mucosa was edematous and hyperemic. There was a small mass pre-
senting into the nose under the right inferior turbinate. 'The septum deviated to
the right. Othcra~ise the physical examination revealed nothing relevant. The
blood pressure was 1608 S.
X-ray films showed right maxillary antral clouding with destruction of the
floor of the orbit. Lipiodol studies showed marked narrowing and deformity of the
right antrum, extending from the roof to the medial orbital region.
A modified Caldwell-Luc operation was performed. On incision into the
right canine fossa, the anterior wall of the sinus was found completely eroded and
replaced by a rubbery, spongelike mass which occupied the antra] cavity but had
not yet infiltrated the soft tissues of the check. Medially, the mass had eroded
the wall with a small extension into the nose. As complete an excnteration as
was possible was done by clectrocautery.
A course of deep x-ray therapy was begun., but interrupted when the patient
insisted on being allowed to go home. Inasmuch as the involvement was so ex-
tensive, it was felt that the case was hopeless and she was released. Pathological
examination showed primary squamous cell carcinoma of the antrum.
She died on July 7, 1946. As far as is known, no autopsy was performed.
The total duration of recognized carcinoma was six months.
Cass S.-The patient, an 80-year-old white woman, aas admitted on August
12, 1943. She had suffered from left maxillary sinusitis for ten years. Four
weeks previously Icft nasal obstruction. was discovered on attempting to irrigate
the nose with tepid boric acid. At the same time it had been noticed that the left
cheek was becomin,Q swollen and red. For the Iast three ur three and one-half
years she bad had postnasal "drip" in the morning. During the last two years,
she had lost 75 lbs. in weight. On examination the patient. was co-operative and
not in any acute distress. The left cheek was swollen and red, there was purulent
discharge in the left median epicanthus suggestive of occlusion of the nasolacrimal
duct and dacryocystitis. The left nostril had a polyp preventing and there was
a circular, edematous, tender area over the left maxillary inus. In the mouth,
about the site of the second left molar, was a small cyst measuring 3 cm. by 3 cm.
The upper teeth were missing, the few remaining lower ones were carious. There-were
no other pertinent findings. The temperature was 99.6; poise, 100; and respira-
tion, 24. The swelling increased after admission to involve the lower eyelid and
molar region. Slight pressure forced pus through the lacrimal duct.
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Roentgenological study showed diffuse clouding of the left maxillary sinus,
left nasal cavity and left anterior ethmoidal cells, and destruction of the lateral
and inferior walls of the maxillary sinus. There were several roots present in the
upper jaw. One was removed; the swelling in the molar region increased and was
incised and drained.
On the sixth hospital day, polypi were removed surgically from the left antrum
by the Caldwell-Luc procedure, and from the lower and middle meatuses by a
snare. There was little bleeding and the left antrum and nose were vacked. There
was a slight febrile response for two days.
Pathological examination showed polypi, anaplastic squamous carcinoma being
present in one mass.
She was transferred to New York City Cancer Hospital on September 23,
1943, for x-ray therapy. Shc died on June 23, 1.944. Permission was not obtained
for autopsy.
The clinical history raises two interesting questions. Why should a 70-year-
old individual suddenly develop sinusitis? Should this have suggested the possi-
bility of sinus malignancy?
The total duration of recognized carcinoma was one year.
CASE 6.--The patient, a 67-year-old white man, was admitted on May 3, 1945.
He had been under treatment at Memorial Hospital since November 21, 1944, for
carcinoma of the left antrum. The findings at that time indicated extensive de-
struction of the maxillary bone, and invasion of the left orbital floor. Biopsy
confirmed the presence of carcinoma. He had received high voltage x-ray ther-
apy throughout two lateral portals, total dosage 4,200 "r" units, with marked
regression in the tumor and considerable relief from discomfort for about two
months. In March, evidence of metastatic involvement appeared; first, a lymphatic
cervical node and. later, subcutaneous involvement at the angle of the jaw. The
cervical node was treated by three doses of radon seeds, total 28 mc. The sub-
cutaneous involvement was treated by 3,000 "r" units of high voltage therapy.
There was not much regression.
He was referred for custodial care and transferred to Cancer Hospital, May
10, 1945, where he died 18 days later. Autopsy revealed squamous cell epithelioma
of the left antrum with metastases to the cervical lymph nodes, pleurae and right
first rib.
The total duration of recognized carcinoma was six months.
CnsE 7.-The patient, a S 5 -year-old white man, messenger by occupation,
was admitted on April 7, 1947. He had. noted increasing fatigue and exertional
dyspnca for the past three weeks. For two years he had a cough initiated by
postnasal "drip". The cough which was productive of yellowish sputum was
becoming progressively more severe, being worse in the morning when it occa-
sionally caused vomiting, and in the evening. More recently the sputum had be-
come blood streaked. He had had "sinus trouble" for one year. For the past week
there had been pain over the right side of the face and a sensation of "pins and
needles". There had been a recent weight loss of 1 S lbs. during the last two to
three weeks. There was nothing else of note. On examination he appeared well
nourished and well developed, The region of the right antrum was tender. There
was a discharge from the right nostril and the septum was deviated, The heart
was enlarged. The blood pressure was 19075, and he had double apical and aortic
murmurs. He was considered in mild cardiac decompensation and was' treated
accordingly,
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X-ray examination showed the right antrum to be completely obliterated
and the right frontal sinus moderately cloudy. The remaining sinuses were clear.
The right antrum was explored by the Caldwell-Luc approach with a 2-in.
incision in the bucco-alveolar fossa. The bone bled profusely. There was a de-
fect admitting the tip of the little finger in the canine surface of the right maxilla,
filled with soft, gray, easily bleeding tissue growing out into the muscles of the
cheek. The bony defect was enlarged and as much tissue as possible removed
from the antrum with "cold knife" followed by cautery.
Pathological examination showed squamous cell carcinoma.
He was transferred to Cancer Hospital on May 29, 1947, for x-ray therapy.
He died on October 17, 1947.
The total duration of recognized carcinoma was six months.
CesE 8.-The patient, a 59-year-old negro, was admitted on August 3, 1945.
He first came under medical observation in another institution on July 10, 1941.
At that time he had a tender, hard swelling of the right superior maxillary region
of one month's duration, becoming progressively worse. It was accompanied by
right nasal blockage and profuse purulent foul discharge. Usually the discharge
was bloody, sometimes almost hemorrhagic. There was considerable recent weight
loss. He appeared well developed, poorly nourished, rather uncomfortable, and
had a slight temperature. Over the right maxillary region was a firm, slightly
nodular, tender swelling. There was profuse foul discharge from the right nostril.
The right lower and middle turbinates were large and red. The left nostril was clear.
The root of a molar tooth was present in the right upper jaw. The pharynx was
red and there was some postnasal discharge. The right cervical lymph nodes were
palpable. The edge of the liver was palpable 1 cm. belo~.v the costal margin and
was slightly tender. Other findings were noncontributory. Abiopsy specimen of
the right side of the nose was diagnosed as squamous cell carcinoma. Three dental
extractions were done subsequently. On repeated antral irrigations with a Coak-
ley trocar almost the entire bony medial wall was found destroyed by tumorous
tissue. X-ray therapy and sulfathiazole by mouth were almost without result,
the foul smelling discharge persisting unchanged. Polypi and the anterior tip of
the right middle turbinate were removed in an attempt to obtain better drainage.
sulfathiazole was instilled into the antrum and later azochloramid was substituted,
still without any effect on the discharge. On December 11, 1941, a radical antrotomy
with removal of the entire floor of the antrum a=as performed under general anes-
thesia. Electroeautery was used, preceded by ligation of the right common carotid
artery. Feedings by a stomach tube were instituted. Eleven days later he de-
veloped aspontaneous pneumothorax which was confirmed by x-ray examination.
Recovery from this was uneventful. The antral cavity began to clear, the gran-
ulation tissue was healthy looking and very little discharge was present in the
daily dressings. He was finally able to eat soft foods by mouth. There was no
discernible extension of the carcinoma and his general condition was satisfactory
when he was transferred to Cancer Hospital nn February 25, 1942.
While at Cancer Hospital, he attempted suicide several times, once by jumping
into the river. On being rescued he a=as admitted to City Hospital via ambulance,
suffering from submersion. After recovery he was transferred to a psychopathic
hospital. At present he is a patient in a state mental institution. The antral
condition, as far as is known, is satisfactory.
This patient is still alive and apparently free of recurrence seven years after
operation.
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CnsE 9.-The patient was a woman 40 years of age. The current illness was
of three months' duration. The presenting features were swelling about the right
eye and. headache. They were followed in one month by right nasal obstruction
and discharge. Protrusion of the right eye developed two weeks later. There was
a weight loss of 7 lbs. during the current illness. She had been treated conserva-
tively with nasal packs and irrigation for two months with no improvement. At
this time she came under our observation.
On examination the right eyelids and cheek were swollen and the eye exoph-
thalmic, protruding S mm. In the floor of the orbit, a firm but resilient mass
continuous with bone was palpable, extending along the entire floor from the
internal to external canthus. The extra-ocular movements were intact, diplopia was
absent and the fundi were normal. The right naris was occluded by a large middle
turbinate bathed in ptts.
X-ray examination revealed, in the right antrum, a marked density resembling
a polypoid change, complete erosion of the infra-orbital margin and naso-antral
wall, erosion of the floor of the right orbit, and invasion of the nasal cavity. The
left antrum seemed to be filled with a material of the density of bone, especially
marked on the posterior wall, which was evidently bone proliferation. The ethmoid
sinuses showed severe involvement from extremely dense tissue; there had been
complete absorption of all cell structure on both sides. The sphenoid sinuses were
extremely small and practically obliterated by dense material. The frontal sinuses
showed mild mucosal thickening. The only change in the skull was an osteitic
thickening of the lesser wing of the sphenoid bone. The interpretation was a
malignant growth involving the right antrum, possibly extending into the lef:
antrum, and also involving the right nasal cavity.
Cautery antrotomy, after preliminary ligation of the right external carotid
artery, disclosed a large tumor mass completely filling the right antrum, which
had destroyed the anterior face of the superior maxilla and had invaded the in-
ferior orbital plate and the right lateral naris. Pathological examination showed
squainous cell carcinoma.
The therapy consisted of gold seeds on three occasions, given three days apart
as follows: 1) 14.21 mc. through antrotomy into the upper anterior and lateral
aspects of the roof; 2) 15.28 mc. through 'antrotomy into the lower posterior and
medial aspects; 3) 16.0 S mc. through antrotomy into the upper and anterior
portions.
T'he exophthalmos increased, the vision was failing and enucleation became
necessary approximately seven weeks after operation. Two weeks later the patient
developed meningitis and became completely disoriented. A severe hemorrhage,
approximately 750 cc., from the wound occurred two days later. It was controlled
by packing. The following day the patient expired.
The autopsy diagnoses were septic surgical defect of the face, posterior right
antrotomy and cxenteration of the right orbit, basal meningitis, cerebral abscess
and thrombosis of the right ophthalmic vein. There was no microscopic evidence
of residual tumor.
The total duration of recognized carcinoma was three months.
Anatomy. The antrum is one of the earliest of the paranasal
sinuses to develop, being known to be present as a small slit in the
first half of intra-uterine life (Barnhilh).
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TABLE L
AVERAGE MEASUREMENTS OF THE ANTRUM AT BIRTH
AND AT FIFTEEN YEARS OF AGE.
AGE
LENGTH
WIDTH
HEIGHT
At Bir.h
7 - 8 mm.
3 - 4 rnm.
4 - 6 mm.
At Fifteen Years
31 - 32 mm.
19 - 20 mm.
18 - 20 mm.
The largest of all the paranasal sinuses, when fully developed
it is pyramidal in shape with its apex situated laterally at the side of
the articulation of the rnalar bone with the superior maxilla, and with
the base against the lateral wall of the nasal cavity. The upper wall
is thin and forms the floor of the orbit. It contains the infra-orbital
canal through which run the infra-orbital artery and nerve. The
latter, from the second division of the fifth nerve, gives off numerous
branches to the face. From the floor of the orbit the fifth nerve
gives off the anterior, middle and posterior superior alveolar branches,
which, in addition to providing the antral mucoua with sensation,
supply all the upper teeth. With this in mind, sensory disturbances
in the cheek and teeth encountered in carcinoma of the antrum can
be better understood.
The lower wall is somewhat thicker and lies above the alveolar
process in close relation to the teeth.
The inner or naso-antral v~~all is usually thin. and has the nasal
turbinates attached. It contains the maxillary ostium.
The lymphatics of the antrum and those of the other paranasal
sinuses connect with those in the nose mainly about the natural Ostia
of the sinuses. The posterior nasal lymph current empties into the
retropharyngeal lymph nodes, while others penetrate deeply through
the muscles of the nasopharyngeal region to nodes around the carotid
and jugular sheaths in the neck (Eggston and Wolff).
Histology. According to Sobotta-Piersol,3 the antral cavity is
lined by a relatively thin mucous coat which has a simple ciliated
epithelium and few glands or none at all.
According to Eggston and Wo1fI,=' the antral cavity is lined
with pseudostratified columnar epithelium with a few goblet cells
which may be irritation forms of columnar cells. These goblet cells
increase in number when there is irritation of the structures. The
glands, though few in number, are found in greater proportion in
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the antrum than in the frontal, ethmoid, or sphenoid sinuses, though
less than in the turbinates. These glands are more frequent on the
mesial wall.
Pathology. According to Harmer4 and Geschickter," 60 % of
nasal growths are carcinomas; 30% are sarcomas and 10 fo endo-
theliomas.
The antrum is the most frequently involved of the paranasal
sinuses, the ethmoid, sphenoid and frontal being less frequently in-
volved in the order mentioned.
Antrum cancers originate from the lining mucous membrane.
In most cases, they are slow growing and metastasize late and infre-
quently as long as they arc contained within the intact cavity of the
sinus. Extension of the growth inay occur by contiguity or by true
metastases. By contiguity, the palate, nasopharynx or face become
secondarily involved, as the bony wall is eroded. By true metastases
the deep cervical glands are most frequently involved followed by
the cervical vertebrae, lungs and brain, in order of frequency.
They may arise from surf ace epithelium or from glands. His-
tologically, those arising from the surface epithelium may be char-
acterized by columnar cells, transitional cells, squamous cells, ana-
plastic cells, or by an adenoides cysticum architecture. Those arising
from glands are adenocarcinomas.
The most common type of cancer of the antrum is the squamous
carcinoma; the transitional and columnar types are uncommon. The
epithelioma adenoides cysticum is classed by Ewing as a basal cell car-
cinoma because it resembles one type of basal cell carcinoma found
in skin. It is very unusual among antral carcinomas. Many tumors,
although classifiable in other groups, inay have areas showing marked
anaplasia or the entire tumor may have that character. The adeno-
carcinomas are uncommon probably because glands are infrequent.
New and Cabot? present a series of 141 malignant tumors of the
antrum, of which 91 are apparently primary and 50 apparently
secondary. Of the 91 primary tumors, 63 were squamous cell car-
cinomas; 6 adenocarcinomas; 2 of undetermined cell type and the
remainder were various types of sarcoma. Of the SO secondary tu-
mors, 3 0 were squamous cell carcinomas; 5 adenocarcinomas; 11 of
undetermined cell type and the remainder sarcoma.
Etiology. It is thought by some authorities that chronic sup-
puration is an etiological factor in malignancy of the antrum. Ex-
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~
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a ~ pi H ... O M U O Rf ctl tC IC f6 t0 O ld 0.i ;er than. their neighbors., and hay _? nuclei which. either
resemble those of the parent organ or are. somcw fiat pyknotic. Their
outstanding characteristic is a finely granular. cidophilic cytoplasm
which renders them easily identifiable within the tissues. These
oncocytes have been found in the tongue, phar}-nY, uvula, esophagus,
salivary glands, all parts of the pituitary gland, '' ver, pancreas, testes,
uterine tubes, n:zsaE mucosa, trachea, bronchi :~ ,d larynx. It is of
further interest that the shape of cancocvtes va~~ies according to the
epithelium from which they arose. They may ~ccur only in adults,
rarely before the age of S0, and quite regularly rt the age of 70 and
above. Hampcrl and others have noted that tr._nsitional forms were
to be found between the oncocvtc and the norr;zal functioning cells
cri= mucous or serous g~;znds. Amitosis has been. noted by various
observers.
Our knowledge of the origin and function, of oncocytcs is in-
ccnnplete, according to ~ti~riters on the subject. "' heir origin has been
~?ariously regarded as: _ 1 a regenerative proccs ; 2) a degenerative
I~r~>m r_hc Ou>LirvnLnloQ ; monocytes, 6 ~Io ; eosino-
phils, 2%0; basophils, 2Io. The total plasma protein was 8.27 mg.
?Jo; albumin, 3.57; globulin, 4.7. No acid-fast bacilli were seen in
the sputum.
A histoplasmin skin test was found to be weakly positive in 48
hours. A first strength tuberculin skin test (P.P.D.) vvas positive.
No histoplasma organisms were found in the peripheral blood or
in the sternal bone marrow.
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Direct laryn~;oscopy revealed an ulcerated le;-on which involved
the left vocal cord anc'-. extended laterally int~~ the floor of the
~~enxricle. 13iops~~ a~as d:~ne.
The tissue removed From the larynx consisted of six irregular
!r_cces of grayish black Tissue. The lamest piece measured 7 mm.
by ~ mm. by 3 mm. 1'he tissue was firm, gr.nular and slightly
i riable. The tissue was composed of many fibroblasts, macrophages,
a few polymorphonuclear leukocytes and gi zt cells with an
eusinophilic cytoplasm. Af o well formed tubercle, were present. A
iew blood and lymph channels permeated the t sue. Clear bodies
resembling Histo?lusnzA crapsta.hatrrnz were found sie~gly and in clusters
within the cytoplasm of the macrophages (Fig. = ).
l~ullowing this examination the patient ha~i a severe systemic
reaction with fever, dyspnea, pleuritic pain, na_asea and vomiting.
This was relieved by the parentcral administrati~~n of fluids.
1)ircct examination of the larynx perfornr.d nine days later
disclosed a recurrence of the original lesion. Adct~tional biopsies and
secretions were secured f~~r study. These biopsie, were similar both
grossly and microscopically to those reviewed at she original exam-
ination. Colonies typical of Histoplrts>rre cca~isulciluTU were grown on
'~abouraud's agar at room temperature from the ni aerial removed by
laryngeal biopsy and from laryngeal secretions. Flo growth was
obtained on the blood cat--ate agar recommended b~~ ~k'eed and Park-
1ri.1P `when inoculated wish the same material.
z'lfter the diagnr~sis of histoplasmosis was magic from the laryn-
geal tissue, one of the subcutaneous nodules was excised for exam-
ination. The skin surface was dark, soft and wrinkled. The under-
lying dermis was thickened, slightly firm and g~-iyish tan. Histo-
logically, numerous gran ulomatous lesions were seen scattered ir-
regularly in the dermis. Some of them had .~ solid tuberculous
arrangement. T'he lesions were. composed of z:'ie same elements,
including the clear bodies, as those in the larynx.
l)cspite the use of .?arious antibiotics and s~, mptomatic trcat-
ment, the patient"s course was progressively dr~~.unhill. She died
lour months after admissi:>n.
~~lecrnj~s~ Fiu~liuL~c. ~t necropsy the larynx was quite regular,
smooth and glistening. `I~he pertinent findings ~; ~~re: . l j a serous
cihusion of the pleura, p~.rricardium anc{ peritonc?um: (2) bilateral
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rirsTOrLnsMOSis 257
pleural adhesions involving the upper lobes; (3) grayish black gran-
ular nodules producing complete obliteration of the normal paren-
chymal pattern of both upper lobes; (4) shotty nodules throughout
the lungs; (5) lymphadenopathy of mediastinal and abdominal
nodes; (6) right cardiac dilatation; (7) congestion of the spleen;
(8) a fine grayish white mottling and a few yellowish granular
nodules of the liver and (9) firm white nodules measuring up to
4 mm. in both adrenal glands.
A chronic granulomatous lesion was seen histologically in the
lung, lymph nodes and adrenal glands. Structures resembling H.
caj~sulatu~~a were found in the lesions of the adrenal glands. These
lesions appeared. to be of more recent origin than the others. The
vocal cords were completely healed. and showed no evidence of a
granulomatous lesion.
Cultures were taken from the lesions of the larynx, lungs, lymph
nodes, spleen, kidneys, liver and bone marrow, from the bronchial
secretions and from fluid from the pericardial, thoracic and peri-
toneal cavities. They were seeded on Sabouraud's glucose agar and
kept at room temperature. A fine fluffy, white cotton-ball colony
grew in 28 days from the culture of the left adrenal gland (Fig. 4).
The other cultures showed no growth after 60 days. Smears from
the colony revealed the branching septate hyphae bearing small,
smooth, round to pyriform conidia, and the large, round, thick
walled tuberculate chlamydospores (Fig. 5) . The latter are char-
acteristic and establish the diagnosis.
Two cases of systemic histoplasmosis with lesions involving the
larynx are reviewed. The two cases were similar in a number of
respects. Hoarseness was the chief complaint. The laryngeal lesions
were responsible for the patients being admitted to the hospital.
The larynges showed an ulcerated, granular, infiltrating lesion in-
volving the vocal cords and extending into the ventricles. The in-
volved vocal cords were fixed.. The histologic sections revealed
granulomatous lesions containing the yeast form of H. r~aj~sulatum
within macrophages and monocytes.
The difficulty of isolating the fungus on artificial. media was
experienced in both cases. Seeding on Sabouraud's glucose agar kept
at room temperature for at ].east one month was the most satisfactory
technique.
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The histoplasmin skin tests were either negative or weakly
positive. The adrenal glands were involved in both patients.
Present day antibiotics were unable to r~ lmbat the infection.
It was believed, however, that they may have been responsible for
the disappearance of the laryngeal lesions in the second case.
t_UNCI.L`SIOLC~
1. 1 he larynx may be involved- in sti-str~nic histoplasmosis.
2. f ?aryngeal lesions arc ulcerating, granui.,r, infiltrating lesions
causing fixation of the ~~acal cords.
i. Hoarseness is 1 conunon symptom w17:~n the larynx is i.n-
4. I'he diagnosis may be made ba histo ~>gic sections ar cul-
tures from laryngeal lesions, preferably early l~~tiians.
~. Cultures on Sabouraud's glucose agar dept at room tem-
perature far at least rtive. The white
blood count was 16,600 with 82~ polymorphor,uclear leukocytes.
Culture of the aural dis: harge showed Bacillus .>roteus, hemolytic
Staphylococcus aureus, and Streptococcus faecali~. X-ray films re-
.ealed marked sclerosis of both mastoids but nc~ evidence of bone
destruction. Skull plates were negative.
f-le was given penicillin ((00,000 u,zits ever,, three hours) and
sulfadiazine (4 gm. initial dose and t gm. every four hours) upon
admission, to which was added U. S gm. streptomyci~~~ every four hours
~n~hen the report of the ecr cu!turc was received. His fever, head-
ache and toxemia increased and on June ~i>th the tc nperature reached
a peak of l 04" .E. (rectal ; accomnanicd by chills. Nn clinical signs
~,i~ meningeal irritation mere noted, but lumbar puncture revealed
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a pressure of 37S mm. of water. The spinal fluid was clear. There
were four cells per cubic millimeter present. The chemical examina-
tions were normal. The Tobey-Ayer manometer test was negative.
Examination of the eyes on June 21st showed no abnormality. The
fundi were normal, and there was no evidence of papilledema.
On June 21st a right mastoidectomy was performed under
endotracheal anesthesia. The mastoid was small and sclerotic with
areas of necrosis throughout, especially marked at the tip and in the
region of the antrum and extending forward into the zygomatic area.
The sinus plate was necrotic. The lateral sinus was exposed for
about one inch and its wall found to be markedly thickened and
inflamed. $ecause of the likelihood of a thrombus being present, the
internal jugular vein was ligated in the neck and the lateral sinus
was incised. A partial thrombus was evacuated and the sinus packed.
A blood culture taken at the time of operation was reported as
showing an anerobic streptococcus and an anerobic gram-negative
bacillus. Culture from the mastoid cavity showed an anerobic
streptococcus, anerobic gram-negative bacillus, and Bacillus proteus.
He had a chill immediately following operation, and his temperature
was 104? F. (rectal), His headache was severe, requiring 1/16 of a
grain Dilaudid every two hours for relief.
On the second postoperative day spinal puncture showed a
pressure of over 600 mm. of water. After removal of 25 cc. of
spinal fluid the pressure dropped to 220 mm. and the headache, which
was pronounced before the tap, was greatly relieved. The spinal
fluid was clear. Twenty-one white blood cells per cubic millimeter
were present and culture of the fluid showed no growth. Neuro-
logical examination at this time was negative. Localized infection
in the neck occurred at the site of the jugular ligation, and on
June 28th the skin over the area was opened and about 50 cc. of
foul-smelling pus was evacuated, the culture o# which showed a
gram-negative bacillus, later identified as anerogenic paracolon.
He gradually became afebrile. The mastoid and neck wounds
healed, and on August 19th he was discharged from the hospital.
The spinal fluid pressure at that time was still high, measuring 450
mm. of water. Examination of the eyes was again negative with no
signs of papilledema.
Following his discharge from the hospital the patient returned
to his work as a painter, but he did not feel entirely well. He tired
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easily and had the sensation of objects whiriinr when he stood up
from a sitting position or turned his head to tiu~ left. He also had
mild intermittent headaches. He had no somn4 fence, ataxia, nausea
or vomiting. The mastoid wound was slightly tender. The ear was
dry.
~)n November ith the mastoid wound began to discharge puru-
lentmaterial and he was readmitted to the hospir.~l the following day.
He said he felt better vt-hen the mastoid began r., drain.
9'hvsical examin.ati~m upon the second adt:-Fission revealed dis-
~~harge from the inferior portion of the right m >>toidectomy wound
.nd the right external auditory canal through :perforation in the
inferior portion of r.he membrana tympani. "I '.~e neurological ex-
amination was negative. Lumbar puncture r ode on November
?th showed a pressure of 380 mm, of water. Th~:~ fluid was clear of
cells anal chemical exanunati.on was normal. ~ xamination of the
eves nn. November 11rh revealed bilateral enla.rs:~ment of the blind
spot; 3 diopter elevar.ic~n OS? S dioprer eleva-ion. C)1~, engorged
veins, arteriovenrnis nicking, peripapillar exud.,te, macular edema
anal flame shaped hem~~rrhages bilaterally. T+e diagnosis given
lay the ophthalmologist was papilledema secondary to increased in-
tracranial pressure probably due to abscess in *he right temporo-
sphenoidal lobe.
1 [e was examined bs the neurosur,t,>cal consultant the same day
who stated that an abscess of the right tc~mporosph~~noidal lobe should
he ruled out. Skull films were obtained and were reported as normal.
On November 18th an :electroencephalogram w.~, done and found
to be normal. That afternoon he was operated x~!~on by the neuro-
surgeon. `I"he brain was exposed by a right tem E~oral bur hole. [t
was described as "wet" and the intracranial Aressits increased the
calibre.
`I'hc duration of the presence of the foreign ~~ody in the present
lase can only be conjectured. It must have beet, a period anywhere
between $ to 12 years because of the following, history. Between
the years 193 S to 1939, the patient was in an asp ium for the insane,
because of a severe involutional. melancholia following a hysterec-
tomy. '1"h.e insertion of the foreign body most likely occurred dur-
ing those years at the as?.~lum because the patient has been perfectly
normal since 1939 and because she recalls that ~~ bile in the as~~lum
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I~ig. 1.-Porcign body (twig) in the nose.
she was taken to the operating room for the removal of another
foreign body, namely a bead, from one of the ears.
The rapidity of recovery, that is, the return to normal anatom-
ical appearance and function was most amazing. Striking improve-
ment was observed in three days and within seven days there was
almost complete return to normal.
The literature on foreign bodies in the nose of long standing
was reviewed, and' several cases were found where objects were in
the nose for as long as 13 to 28 years.
Worthington) reported a piece of stick with bark on it removed
from the nose after 13 years. The symptoms were fetid discharge
during that period.
Kelemen~ reported a cast in a 34-year-old white male of a piece
of wood from the tip of an umbrella, lodged in the right half of
the nose for 28 years. It became partially calcified and was ex-
pelled spontaneously with mild local inflammatory signs through a
perforation of the nasal wall at the level of the inner canthus.
Camerer`~ reported a foreign body in a 22-year-old seaman who
had no symptoms or totally disregarded them despite the fact that
his nose had. been host to a calcified cork for 17 years.
Donnelly` reported. the presence of a metal screw in the nose of
a child for two years without any perceptible discharge or odor.
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1. i~`orthington, R. f\.: T urei,yn Rudy Rc~r~~ced from ~he \ose after I i ~'~?ars,
l'roc. Roy. Soc. Med. 12:159-160, ]918-1919.
?. Kclemen, ("~.. tipuntaneous Expulsion o[ Forci}:n kodv by Transini:;ration
chmu,~h ~lasal Wall after 2R Years, Laryn,~~iscupe SS:3''+-379 (Tuly) 1945.
3.. Camerer, (~. R.. i~orug^ Hoc{v in Nara:, LI. S. N-, ~y M. Bu11. 19:11R-169
f11u~.) 1923.
}. Donnelly, J. (~.,r Nasal Ic~reisn Rnw been thoroughly tested at the operating
table and has given us satisfaction. We feel. that it is a definite im-
provement over the otter?r self-retaining: retracts rs which we have
had an opportunity to examine.
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Society Proceedings
CHICAGO LARYNGOLOGICAL AND OTOLOGICAL
SOCIETY
Meeting of Monday, November 1, 1948
THE PRESIDENT, DR. WILLIAM A. SMII.EY, IN THE CHAIR
Food Allergy as a Cause of Myalgia of the Posterior Cervical Muscles
THEODORE G. RANDOLPH, M.D.
(by invitation)
(Abstract)
Localized muscular reactions manifested by pulling, drawing,
tightness, aching and "knotty" sensations in the posterior cervical
muscles are commonly observed in the allergic patient during the
course of individual food tests (Rinkel's technic) for the specific
diagnosis of food allergy. The fact that such symptoms may be
induced experimentally or relieved following avoidance of specific
allergenic foods is the basis for the thesis that they are, at least
sometimes, of allergic origin.
During the past century, the descriptive features of this syn-
drome have been described by Vallcix, Norstrom, Halle, Edinger,
Mithoefer, Seydell and Williams. Both the last named associated
these symptoms with the allergic patient, but Rowe (1931) was
the first to demonstrate that they might be reproduced as a part
of the allergic reaction.
Chronic myalgia of the posterior cervical region is one of the
most common localized allergic manifestations involving muscle
groups. This condition is much more frequent than represented by
the complaints of patients, as originally pointed out by Seydell. It
also may or may not be associated with headaches, chronic fatigue
and other constitutional or localized allergic manifestations.
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In a few instances, acute torticolli , or "wryneck", has been
demonstrated to be on ~ similar mechanism. I'he most favorable
circumstances for the development of such an acute reaction include:
the presence of a high degree of specific sensiti ~ ty to a commonly
ingested food which pr4viously has been avoid.~.j for at least three
or four days prior to an evening meal. This ~s usually associated
with an allergic reaction of such severity as to ~-ause the individual
to retire shortly after the meal. Acute, localizAi.n: I want to cc, emend Dr. Oldberg
on this excellent presentation. I think, after h:rring this, it would
be fairly easy to diagnose an acoustic tumor. ~s otologists we are
probably seeing these cases much earlier than neurosurgeons do,
perhaps in conjunction with a neurologist whc~ sends them to us
to get an acoustic picture. It is true there arc varying degrees of
deafness and tinni.tus and the case must be ob~a~rved over a period
c>f years before we can he anywhere near certain about an acoustic
tunrar.
would like to ask Dr. (7ldber,, whether I ~ attaches any im-
portance to x-ray examination of the internal meatus, and whether
he finds any information. from that source; is it helpful in early
diagnosis?
1)R, Ex[c C)LDT~PRG (closing): In reply to [Jr. Shapiro's Ques-
tion whether early diagnosis would influence tLc convalescence of
these-patients anti permit easier removal of the tur nor,. I may say that
it would, very much.
1 )r. "I'heoba(d asked wvhether or not x-ray st Cady was important
in eariy cases, particul-~rl} x-rav films of the internal acoustic meatus.
lUnfortunateiy, tine films commonly show no sign ~icant erosion ~~rntil
the tumor is Quct urge. 'I h:rr is no reason fog- not taking them,
however.
Jac: has also het?n asked whether or not ex~r~nration should he
+nade of all patients who come ro the otologist ~.~ith the complaint
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of tinnitus following increasing deafness. That is a difficult question
and, theoretically, it would be nice to be able to do it. The trouble
is that such an operation is a major procedure, and one likes to have
a reasonable degree of certainity that he will find a surgically amen-
able lesion before undertaking it. To operate upon all patients with
minimal symptoms and findings would be like doing an abdominal
exploration for everyone who complains of a transitory stomach ache.
Tlne Superior and Recurrent Laryngeal Nerves:
Clinical Considerations
LAWRENCE f. LAWSON, M.D.
(Abstract)
The vagus nerves may be involved from the cerebral cortex to
the termination of their branches.
In studying the complex functional innervation of the recurrent
laryngeal nerve Murtagh noted that a stimulus controlled for 1/100
of a second at 10 volts caused an abduction response, while stimula-
tion for 1/100 of a second above 12 volts produced adduction. This
study gives a logical means of understanding the dual function and
opposed action of the intralaryngeal musculature.
Familiarity with the course of the right and left recurrent
laryngeal nerves clarifies involvements occurring in the course of
each. Paralysis of an intrinsic muscle may be due to:
A cerebral lesion only if bilateral.
A lesion in the medulla from degeneration of the nucleus
ambiguus, pressure from neoplasm., or meningeal inflammatory
thickening.
Destruction of motor nerve fibers in the vagus trunk or
its recurrent branch from intracranial growths, or growths
about the jugular foramen in the neck, or tumor gr-,~wth in the
thorax.
Peripheral neuritis.
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Muscular diseases or myopathis palsies.
Abductor paralysis rs the usual form. Only rarely can it result
from cortical involvement. In the bulbar region it may result from
thrombosis, hemorrhage, embolism, tumors compressing the bulb,
tabes, disseminated sclerosis, syringomyelia. 'l'he more common
lesions affecting the motor fibers arc listed.
The superior laryngeal nerve divides into ,~.n external branch
containing motor fibers to the thyro~epiglottic and crieothyroid
muscles, and an interna. branch supplying sensation to the entire
mucous membrane of the larynx.
A case is reported of cerebral tumor causin~~ symptoms of in-
volvement of both branches of the superior laryngeal nerve, and
glottis adductor spasm indicating recurrent '..zryngeal irritation
originating from tumor irritiation of the mot~ar cortex. Mental
fogging occurred because of the left temporal lobe location.
~ record is presented of an accurately loc aed tumor having
adductor spasm from cortical irritation transmitted through the
recurrent laryngeal nerve; and laryngeal. anesthesia and crieothyroid
paralysis from impairmer_t of the superior laryng+~al nerve function.
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LIONEL COLLEDGE, F.R.C.S.
Lionel Colledge, for many years one of the best known laryn-
gologists in England, died on December 19th at the age of 6S.
He was educated at Cheltenham College and Caius College,
Cambridge, and took his medical degree at St. George's I-Iospital in
1910. He served in the first World War as aural surgeon to the
First Army and was on the staff of several London hospitals.
For many years he was interested in malignant disease of the
larynx and was co-author with Sir St. Clair Thomson of a monograph
on that subject, for which he is best known in this country. He
was Semon Lecturer in Laryngology at the University of London m
1927. Later, he was associated with Sir Charles Ballance in researches
on nerve anastomosis for the relief of vocal paralysis.
Mr. Colledge was one of the founders of the Association of
Otolaryngologists and at various times was president of the sections
on laryngology and otology of the Royal Society of Medicine and
editor of their Proceedings.
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Abstracts of Current Articles
Meniere's Syndrome. Successful Treatment by Surgery on the Sympat?3etic.
;'~r+sr, l;. R. Gurm~lf ~+iz,f ,SE ~ molt*. J_ .5.: Brit. 1irr/. /- ; 'J~n~ F) 19~R_
~i'he authors discuss the various fonris or trea~_nent, both medical
and surgical, of this syndrome, omitting only the excellent work
performed by Day. They put forth a vascular . ase to explain. the
hydrops of the labyrinth and suggest that differ aces in the blood
supply to different portions of the internal ear -nay well account
E.or the relative differences in they degree of deafness and vertigo.
Since the vertebral artery supplies the internal ear they attack
this vessel through the ?ubclavian triangle and. after dividing or
stripping it, they excise the stellate ganglion. C>f the 12 patients
operated upon all were relieved of their vertigo; n all but one the
hearing was improved; in nine cases the tinnitu~ was modified or
abolished. While this is only a small number of ~ ~_ses the results are
encouraging. The twelve case reports are given.
Che Use of f'uracin in the Treatment of Aural Infection::_
lir,rcXlass, (;. C.: I.ar~;+~~crrcl~~- ~4~7?4.1'?? ~(>cc.) 1'.-8.
i"he successful usr. of turacin (-S-nitro-2-furalc~ehvde semicarha-
zc,ne) in the treatment of t q S cases of aural suppu r itions is reported.
`[:'he solution. was adminisrered to the afl~ected ea- six drops three
times daily until elimination of disease or until it was felt that
maximum benefit had been obtained.
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ABSTRACTS OF CURRENT ARTICLES 305
Use of Nitrofuran Therapy in External Otitia.
Anderson, J. R. and Steele, C. IL: Laryngoscope 58:1279-1285 (Dec.) 1948.
In a similar report to that of Douglass, these authors also found
furacin an effective drug in the treatment of aural infections.
They explain the effectivness of the drug in cases of external
otitis on the assumption that most of the so-called fungus infections
of the ear are fundamentally bacterial in nature.
The solution is appiled an the form of saturated cotton wicks
which are kept moist by the patient. In the presence of fungi a
wick of 1 % thymol in cresatin is applied the second day and left
in place for six hours. This is also the method of treatment with
aural furunculosis.
Three days of treatment should suffice in most cases.
cholesteatoma in the Petroua Bone Causing Progressive Facial Palsy.
Lurtdgren, Nils: Acta Oto-Laryngologica 36:75, 1943.
A cholesteatoma may be present in the petrous apex despite the
absence of local middle car signs and symptoms. The characteristic
symptoms of this condition are impaired hearing and slowly pro-
gressive peripheral facial palsy. Dizziness is not a common finding,
even though caloric reaction is absent or difficult to induce in all
cases. Diagnosis is established by x-ray, using the Stenver projec-
tion. Early surgery is indicated to improve or restore facial function.
Two cases proven by pathological examination are cited in this
article. The question of the primary or secondary nature of the
cholesteatoma is discussed but not solved.
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~Ob ABSTRA(:TS OF CURRENT ART1CLl~S
PHARYNX
Malignant Plasmocytoma of the Nasopharynr;.
Maurice M. Greenfield r"Cabt j M.C. A.U.S.: Radenlo,~y SO '~61-665 (May) i94R.
A case of a primary extramedullary plasmocytoma of the
nasopharynx occurring in an 18-year-old white male is reported. In
July, 1943, multiple po ypoid growths were r: moved from the
nasopharynx. The tissue was diagnosed as plasmot ytoma. In Janu-
ary, 1-945, the right cervical Lymph nodes bee+~rne enlarged .and
biopsy in July revealed a plasmocytoma. The !esion in the left
posterior sixth rib received 4000 "r" x-radiation and the lesion. in
the right lateral sixth rib. 2600 "r". Slow but c+~mplete regression
followed. In June, 1946, severe right orbital headache occurred and
a nasopharyngeal nodule appeared. Biopsy reveaitd plasmocytoma.
~l'he tumor area received 6610 "r" x-radiation with ~:~nly symptomatic
improvement. "The physical factors used are given,
Poatcricoid Pharyngo-oesophageal Perforation Due to Endoacopy Treated by
Immediate Suture.
(~oliRber, ~. C.: T,a~rcet 254:~)RS (June 26) 19~3N.
"I'wo cases of postcric:oid perforation are rep+~rted, one due to
esophagoscopy and the ot:ier to gastroscopy. Th~: first patient on
whom an esophagoscopy was performed died in spite of the ad-
ministration of 100,000 units of penicillin everythree hours and a
deep incision of the neck along the anterior border of the sterno-
mastoid muscle where pus or gas was not encountered under tension.
In the second case gastroscopy was done o+ a male patient
63 years of a,,e. Three hours after the gastroscc~oy the neck ap-
peared swollen. and surgical emphysema u~as detected on both sides.
Radiography did not reveal any emphysema in the mediastinum.
i~our and three-fourths h~~urs later an incision a( Ong the anterior
horder of the sternomastoid muscle was made. The omohyoid was
severed. The sternomastoid muscle was retracted laterally and the
strap muscles medially. after division of the middle thyroid vein
and inferior thyroid artery, the thyroid cartilage was rotated and
the posterior pharyngo-esophageal wall exposed. A circular perfora-
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tion of the posterior wall of the pharynx, about half an inch in
diameter, was found. After the insertion of a fairly large rubber tube
down the pharynx to demonstrate the lumen of the perforation,
this was closed by mucosal and muscle and fascia sutures. Penicillin-
sulfanilamide powder was instilled and a rubber drain placed. Post-
operatively, the patient received 100,000 units of penicillin every
three hours and 1 gram of sulfamezathine every four hours. The
patient was fed by stomach tube and by rectum for six days, after
which he was able to swallow semisolid food. The patient made an
uneventful recovery
The author believes that perforation of the posterior wall of
the pharynx or esophagus in the neighborhood of the cricoid cartilage
constitutes a small but definite risk associated with gastroscopy and
esophagoscopy. The predisposing factor seems to be the anterior
prominence of the extended cervical spine, particularly when rough-
ened by the presence of osteophytes. The prophylactic measures to
be taken by the endoscopist include routine radiography of the neck
to exclude dangerous cervical spurs and avoidance of undue extension
of the neck at all stages. The correct treatment is immediate ex-
posure and suture of the perforation, followed by drainage and in-
tensive chemotherapy.
Roentgen Therapy for Carcinoma of the Larynx.
Harris, W., Krasner, R. and Silverstone, S. M.: Radialagy 51:708-715 (Nov.)
1948.
Of 80 cases of squamous celled carcinoma (proven by biopsy)
of the larynx treated primarily with x-ray, from 1931 to 1942 in-
clusive, 67 were suitable for statistical analysis. The five-year
survival rate was S S %, for intrinsic lesions, 73 ~/o, and extrinsic
lesions, 40%.
Of the group, 3 6 were instrinsic and 44 extrinsic according to
the anatomical classification of Hayes Martin. Prom measurements
in a water phantom, it was calculated that the majority of patients
received a tumor dose of 4,000 to 6,000 "r". Technic, dose estima-
tion and radiation reactions arc outlined.
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Total laryngectomies performed in nine s-ray failures were
successful in ane case. A. number of factors or conditions indicating
unfavorable response are discussed. Prognosis d~?pended upon extent
and location of the c,~rcinotna. Cervical lymph node metastasis
occurred, as a rule, late in the disease and was usually associated with
an extensive lesion. 'These metastases may be controlled by surgical
or radiological methods. Eleven. tables ~f statistics are included.
BRONCHI
Bronchiectasis Following Aspiration of Tim?athy Grass
tarter, M14. C:., and ll'r(c~h, r-:_ J.: Neel" Frr,~larzd ~. Med. ~'9:R~?_ (June 1(1~ 1948.
Eight cases of timothy grass foreign bodies in the bronchi are
reported. Seven. of thesE~ required lobectomy because of subsequent
Bronchiectasis or lung ~~bscess. One, the youns;est in the groupo
aged 14 months, recovered with hrorechoscopi~_ removal. Trt all
cases the grass heads progressed peripherally, and in the older children
~uas soon lost ts~ bronchs~scopic view. in the ;. oungest child the
,mallet bronchi trapped the grass at a higher pe~int. The value of
studying unstained smears of bronchial secretion For timothy tabers
in suspected cases is sue;gested.
-31SCF.LLANEOUS
3':ntality Associated with Ren.=.dryl Therapy.
l3lask,eean, Norman !, /Ca,~:!.1 hl ~:~~, A_IL~. e~ul ~1,i~ _ J;a,7t:?s C. (Cap,'.
~A.t:.-_ ~1.ILS_: ,3iirrn, (~1~;~>r~ (Nm~.l 1'~-I~R_
"3'he authors report the death of .tn ~~.sthmztic ?.vho had receives;
Bcnadryl just prior to the terminal episode. Since ~~oma was presenr_
ar.d autopsy failed, in the suth~r's np;nion, to reve;71 sufficient organic
s.hanges to explain her de:Yth, they felt that the primary cause. of
death may well have been severe denres~aion of t}~~: central ncr~?^re and Lifting out of the facial nerl-e
branches when necessary, g.ves satisfactory results. The treatment
of carcinoma is generally unsatisfactory. [~~nless seen early, radiation
is not effective.
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Books Received
Diseases of the Nose and Throat.
A Textboolz for Students arad Practitioners. liy Sir St. Clair Thmnson, M.D.,
F.R.C.P. and V.E. Ncgus, M.S., P.R.GS. Sth I;d. Pp. xix+1004, with 13
color, 20 radiographic and 11 other plates and 369 figures. New York,
Appleton-Century-Crofts, Inc., 1949. (Price $16.00).
Since its first appearance in 1911 St. Clair Thomson's Diseases
of the Nose and Throat has been accepted, almost by common con-
sent, as the outstanding text on the subject in the English language.
Through four editions it has kept abreast of progress in the specialty,
new material having been selected with the taste and discrimination
for which its author was celebrated.
The present, fifth, edition carried forward after Sir St. Clair's
death by his collaborator and disciple, Mr. V. E. Negus, not only
continues in the old tradition of completeness and authenticity but
achieves a certain freshness of its own.
This is no routine textbook, nor is it especially English. Mr.
Negus, in the face of unusual difficulties imposed by the war and
the disrupted publication. and distribution of the world's medical
journals, has managed to adduce a wealth of new references and
thought which makes this a truly international work.
It has established itself as a classic and belongs in every medical
library.
Diseases of the Ear, Nose and Throat.
By William Wallace Morrison, M.D., Professor of Otolaryngology acid Attending
Otolaryngologist, New Ynriz I'olycli~a.ic Medical School and 1lospital; Se~~aior
Assistant Surgeon, i~z Oto~laryragology, New York Eye and Ear Infirmary;
Associrste Clinical Professor of Otolaryngology, New Yorh University College
of Medicine; Caj~lain, Mc?dical Corps (U.S.N.R.) Pp. xviii~~772, illustrated.
Ncw York, Appleton-Century-Crofts, Inc., 1948. (Price $8.50).
As a writer and teacher the author of this text requires no intro-
duction.
This present volume based upon the teaching material accumu-
lated over a quarter of a century is directed to the requirements of
the undergraduate student and the medical practitioner. It is char-
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1 ~ RC)(~KS RF_CF,IVF,I)
acterized by clear writing, careful choice of material and a simple
diagrammatic type of ilLastration from the auth~~r's own pen.
For the convenience of the practitioner, there are appended a
"Formulary of 1?rescriptions for Medications tr, he Used by the
Patient" and an Index of Symptoms.
Qral Anatomy.
13y Ifarry Sieber, M.D., Pro~4~ssor of Anatnmzl~ and Hietoi.~,gy, Loyola University
.School of Dentistry, Chicago College of Dental Sur,gerF~. Pp. 529, with 334
illustrations. St. Louis, The C. V. Mosby Ccmoany, 1949.
"The title of this vc:rd excellent work is an unfortunate under-
statement of its scope. V~'hile it gives the impression that the book
may have been written for dentists and oral surgeons, there is
scarcely a page or an illustration which i:; not instructive to anyone
engaged in the care of the whole upper respiratory tract.
Nerves, fascial planes of the neck, anesthesia, ligation and many
other matters of everyday in erect to the laryngologist are well
described anal beautifully illustrated. Sections on the blood and lymph
vessels of the head and neck are especially good.
Diseases of the Ear, Nose and Thoat.
Ijy Dosr,glas G_ Carrutberr, hf.B., Ch.M. (Sydne_y) F.R.A.C.S., Honorary Ear,
Nrrse and Throat Szzrgenn, Sydney HoslZilal, azzd Easte~'~z Suburbs Hospital,
Sydney; Canstsltin.q F,ar, i~'ose and Throat Szergeon, (;arzterbury District
Memorial Hus~ital, Sydney. 2nd Ed., pp, viii+344, a~ich 140 illustrations.
Baltimore, The Williams anc Wilkins Co., 1948. (Price 1:7.00)
11 small, practical and, for its size, comprehensive manual par-
ticularly adapted to the needs of the general practitioner.
Phylogenesis of the Ear. A monograph, tracing- the phylogenesis of the ear
from the lowest animal form, coelenterate, to man.
R y l uuis Gu,ggenheirn, !Yi.I)., -l.csociatc~ Pro f e~vsar o f Molar - ~zgology, University
of ,Southern California. Lst }~.d., pp. 277, with 196 ilfustririons. Culver Ci[y,
California, Murray and Gee, [nc., 194. (Price 172.501
1lfter forty years of delving into the tenuous 'iterature on the
subject, of nonproductive conversations with embryologists anal
finally of studying his own collection of serially see Toned embryos
and those of others, r.he author has produced this m~~nograph on the
phylogenesis of the ear.
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After a short introductory chapter in which evolutionary
changes are correlated with periods in the earth's history the text
devotes itself to the development of the auditory organ from the
coelenterates to the mammals, including man. While there is a
considerable amount of detail, the treatment is too superficial to be
of much scientific value and the illustrative material with the ex-
ception of some excellent photomicrographs is often so poorly drawn
as to be practically indecipherable. The choice of exceptionally large
type, wide spacing and arrangement is unfortunate both for the
general appearance of the book and smooth reading.
Collected and arranged by George Koseu, M.D., and Beate Caspari-Rosen, M.D.
Pp. xvii-I-429, New York, I-Icnry Schuman, 1947, (Price $5.00)
An engaging collection of autobiographical material dealing
with the lives and works of medical men. The editors have adopted
the novel expedient of arranging the excerpts from many writings
of many great and near-great physicians as they fit into the periods of
a man's life: Early Years, School Days, The Medical Student, and so
on, to Reflections on Lifc and Death.
The subject matter, while not all of a medical nature, deals
with the physician's slant on life, his reactions to its problems and his
philosophy in times of crisis. Each selection is prefaced with a
paragraph or two, by the compilers, on the author, and since there
are well over a hundred of these some biographical flavor creeps into
what would otherwise be purely an anthology.
Recommended reading for any protagonist of bureaucratic
medicine.
Twentieth Century Speech and Voice Correction.
Edited by Emil Froescbelr, M.D., President, International Society for Lo~gopedics
and Phoniatrics; Preside~at, New York Society for Speech and Voice Therapy.
Pp, x-321, illustrated. New York, Philosophical Library, 1948.
This small volume, the composite effort of nineteen outstand-
ing workers in the field of speech correction, was produced to keep
interested persons abreast of the times and trends. Advancement in
the science of audiometry, in the perfection of hearing devices, radio,
television and screen, not to mention the problems incidental to
aviation, public safety and the national defense have all combined
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to increase the interest. of diverse groups in sound production and
perception and its chie' vehicle, speech..
`I"he present work which deals with sound ~~nd word production
and its deficiencies is approached from many .ogles by its authors
independently. 7"he presentation is simple ani direct. The bibli-
ography is adequate.
liy ALexrrnJer &fitcr,6~erlich, M.7)., F1e~d n f ; he Gerrna.~~ Medical Co~n.mis:cicm to
1. J. lbizlitarry T`vibunrtl Nn. 7, Nttrrraenhrrrg, anti F~~?'d Mielke. Pp. xxsix~-
172, with tf ;ilusrredor;, New York, Henry Schum._n, 1.949. (Price $3.00)
this is an account cif the trial of twenty G~ a-man physicians and
three German. civilian a ds, for murder and othd~~- criminal acts pur-
portedly committed in the inxerest of science up,~n political prisoners
and unwanted minority groups in the prison camps of. Buchenwald,
llachau and Strasshurg,
iYiuch of the mate~ial, which was collected by two Germans,
one a medical. man., consists of the unedited transcript of testimony
given in 1947 before an American military tribunal in Nuremberg
which subsequently condemned seven of the defendants to death and
nine to imprisonment. Emphasis is laid upon the perversion of
C,erman medical thought: and ethics by the Nazi ideology.
...about as revolting an evening's reading as one is likely to
encounter anywhere.
By Maurice Srncr,~ilLe, Prof=~cceur %!c Clinigr~e Oto-Rhitt~~-#,aryngologlque a la
F2culte de Mc~fccin~~ .le titrashnur,~, Pp. 253, with ~'"2 illustrations. Paris,
Masson et (:ie, 194$_ {Price 7c0 fr.)
Tl1is monograph is the latest of the author's communications
dealing with his operations for the restoration +-~f hearing in oto-
sclerosis. The first appeared in 1929; the present 7ublication follows
his previous one by almos- ten years and should prcwe of interest to
those who have engaged i-a this work in the intersah
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L'Exploration Clinique en Oto-Rhino-Laryngologie, Technique et Semeiologie.
By George Portnaann, Professeur de Clinique oto-rhino-laryngologigzse d l'Uni-
versite de Bordeaux; Membre corres~ondant de l'Academie de Medeciaze
Pp. 934, with 54l illustrations and 11 color plates. Paris, IVfasson et Cie, 1948.
(Price 2500 fr.)
Amigdalitis Cronica-Diagnostico y tratamiento. Cirugia de ias Amigdalas
Palatinas.
By Miguel de Paternizza, M.D., Sazz Sebastidn, Shain. 1st I:d., pp. xsr3S6, with
222 illustrations. 13arcclona, Editorial labor, 1948.
Theorie der Schneckenmechanik. Qualitative and Quantitative Analyse.
By Jozef Zwislochi-Moscichi, Durchgefiihrt inz I;lelztroahustischen Laboratorium
der Uzaiversitdtsklinilz fur Ohrezz-, Naseiz- zzzzd Ilalshranlzhriteax, Basel.
Acts Oto-Laryngologica Supplcmcntum LXXII. Pp. 7G with 26 illustrations.
Solothurn, Buchdruckcrci (Gassmann A.G. 1948.
Kurze Klinik der Ohren-, Nasen- and Halskrankheiten.
By Dr. Z;rhard Liischer, ordentlicber Professor der Ohren-, Nasen- and Salsheil-
hunde and Dirchtor der Universitdtsklirzifz zznd Poli/lizzih fur Ohren-, Nasen?
and HalslzranJze in Basel. Pp. 513, with 201 illustrations. [Iasel, Benno
Schwabe & C.o., 1948. Imported by Grune & Stratton, Inc., New York. (Price,
Bound, Fr. 54.)
Trattato di patologia a Clinics Otorinolaringologica.
By Pietro Caliceti, Ordinario di Clinics Otorinolaringologica dell'Universita di
Bologna. Volumes I and II. Pp. xii-F9S2, with 410 illustrations, and pp
vii-f-825, with 407 illustrations. bologna, I,. Cappelli, 1948.
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~otice.s
('he Department :~f Otolaryngology, Wa>,hington University
School of Medicine, Sai-it Louis, announces an eight months' course
in otolaryngology beginning October 3rd, 1949.
Address cnn~tnunications to The Registrar- Washington Uni-
versity School of Medicine, i~.uclid Avenue and l:ingshighway, Saint
1~_ouis 1(1. Missouri.
t1n intensive two weeks' course in Clinical \udiometry will be
offered at the State University of Iowa, June 1- to 28, 1949. The
course will he conductec_ daiiv froth R:OQ to S:nQ and will include
lectures on audiometry, ip-reading, spceci~ training for the hard of
hearing, psychological prublen~s of the acousticali` :~ handicapped and
clinical otolaryngology; laboratory work:, including observation and
participating in hearing testing and hearing aid fittings for clinical
patients in the llepartmcnt of Otolarvn~;ology .{nd Oral Surgery,
,State University of Iowa Hospital; observation : f the University's
comprehensive speech pathology program; and special lectures and
demonstrations by Profes.tinr John S. Steinberg of -:he Bell Telephone
D,aboratories and Mrs, Bernice Rutherford c,f she Rehabilitation
Center, St. Paul, Minnesota.
One of the Iowa H~.aring Clinics, involving, medical, psycho-
logical, speech, audiometric and social work an-~roaehes to cases
assembled by the T)epartntent of Otolaryngology :.nd Oral Surgery,
the Iowa State School for the Deaf, and the Spe,.~ch Clinic will be
scheduled during the intensive course.
l~or further informa-ion address: Professor `.~endell Johnson,
Director, Speech Clinic, State University cif Iowa, T+~wa City, Iowa.
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AMIJRICAN HEARING SOCIETY
THL KENPIELD MEMORIAL I'UND
A sum of money was subscribed in 1937 in memory of Miss
Coralie N. Kenfield of San Francisco, California, a teacher who was
known throughout the United States for her high ideals and advanced
methods in teaching lip reading. `I"his money was placed in the
Kenfield Memorial Fund. The interest provides a scholarship known
as the Coralie Noyes Kenfield Scholarship for Teachers' Training
Courses for Teachers of Hard of Hearing Adults. (The Scholarship
offered in 1949 is $100.00) The American Hearing Society is the
trustee of the Kenfield Memorial. Fund.
Applications will be considered from any prospective hard v f
heaving teacher of lip reading to hard of hearing adults who lives
in the United States and who can meet the following requirements:
A. Personal characteristics necessary for successful teaching.
B. Ability to read lips as certified upon examination by an
approved instructor in lip reading.
C. A bachelor's degree, or
Two years of college work plus twelve semester hours of
work in adult education, psychology of the handicapped, voice pro-
duction and control, sight conversation, social service, or
Two years of successful experience in teaching In public or
private schools, plus twelve semester hours of work in adult education,
psychology of the handicapped, voice production and control, social
service, or kindred subjects.
D. Professional training in lip reading distributed as follows:
Thirty clock hours of private instruction under an approved
teacher of lip reading, or
Sixty clock hours of instruction in public school under an
approved teacher of lip reading.
The winner of the scholarship may take the normal course from
any normal training teacher, school or university in the United
States offering a course acceptable to the Teachers' Committee of
the American Hearing Society.
The applicant for the scholarship must be a prospective teacher.
Applications from those who arc teaching lip reading now can not
be considered. The scholarship must be used within one. year from
the granting of the award..
Applications must be filed between March 1, 1949 and May
1, 1949, with:
Miss Rose V. Feilbach,
American Hearing Society.
817 14th Street, N. W., Washington S, D. C.
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* * * * ~ ~* ~r ~k * y!-
A direct appeal is being made to the 8,000 young physicians and
dentists who were trained at government expense under the wartime
(army Specialized Training Program and the wavy V-12 program,
and who have given little or no service to ,he Armed Forces, to
voiun.teer for active d.,ty in one of the three caned Services, It is
estimated that the government expended almost $10,000,000 to
educate, feed and clothe the 8,000 men why ~ participated in the
r/artime programs.
i'he appeal is alsc hein~ directed. to the ~~,000 physicians and
dentists who were deferred during the war to c,_~mplete their medical
c;r dental. educations at their own expense, and .yho have not served
a the ~~rmed Forces, tee volunteer for active dory.
Secretary of Defense James Forrestal said that by the end of
~u(y of this year, the Armed Forces w-i_ll have Est almost one-third
of the present number of physicians and dentists now in service.
I"ltis will result in a shortage of about 1600 i~hysicians and l [60
dentists. f this condition is allowed to devel~~p the number will
i:ave increased to 2200 ,physicians anal ].400 dc:nr sts by December-.
tf th.e present r.un)~aign for volunteers is u~.successful a,nsider-
;ztion must be given to i_he followin,~ a_Iternatiye~~
~-) To ask for draft legislation covering i~hysicians and den-
tists who ha.vr~ not responded to the ccf~1 for volunteers.
(2) To ask those men. urho served in ~'or1 ~ War II, and who
hold reserve ~-ommissions, tc~ re-enter for active duty in
the Armed Forces.
(3) To retain those men now on fluty, bur who are entitled to
be relieved f ^om the service upon ; ~ rmpletion of their
respective tours of duty, until the shortage has been
corrccr.ed,
i'41r. Forrestal. pain ed out that this pro?~ ssional manpower
shortage in the Armed Forces is so serious that legislation for a
physician and dentist dntft has already been prc~i~ared and is being
held for possible use. He added, "~3l'e have an obligation ro
the millions of persons concerned. These include the men and
women in the Armed Forces themselves, :znd the fathers and mothers
of these men anal women who depend upon t`te pledge of this
Government to take care of the medical and dermal needs of those
who serve their n:,tion thr?c,ughout the world."
* * * * * ~ yt
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HEARING AIDS ACCEPTED BY THE COUNCIL ON PHYSICAL MEDICINE
OP THE AMERICAN MEDICAL ASSOCIATION
(List Corrected to March 1, 1949)
Acousticon Model A-100 Radiocar Model 4S-M-magnetic
bone conduction rcccivcr
Aurex (Semi-Portable)
Radiocar Permo-Magnetic Uniphone
Silver Micronic Hearing :did,
Model 101
Silver Micronic Hearing Aids,
Models 202M and 202C
Solopak 1-Tearing Aids
Sonotonc Audicles Nos. 530,
531 and 533
Sonotonc Model 60U
Sonotonc Model 700
Sonotonc Model 900
Supcrfonic ITcaring Aid
Ivlicronic Model. 101 (Magnetic Telex Model 22
Receiver) Tclcx Model 97
Microtonc T-3 Audiomatic Telex Model 612
Microtonc T-4 Audiomatic Tclcs Model 900
Microtonc T-S Audiomatic Telex Model 1020
National CuU Model 'Telex Model 1 S S 0
National Standard Model Toncmastcr Model Royal
National Star Model Trimm Vacuum 'T'ube Model 300
Otarion, Model A-1 Uncx Model "A"
Otarion, Modc1 A-3
Otarion, Models A-4 J & S Vactuphonc Model 3
Otarion, Model E-1
Otarion, Model E-1S Western Electric Orthu-tropic l~fodel
Otarion, Model E-2 Wcstcrn Electric Model 63
Western Electric Model 64
Paravox Models VH and VL
Paravox Madel XT Western Electric Models 65 and 6G
Paravox Model XTS
Zenith Radionic Model A-2-A
Precision Table Hearing Aid
Zenith Radionic Model A-3-A
Radiocar Model 45-CM
Zenith Radionic Model B-3-A
Radiocar Model 4S-M-magnetic air
conduction rcccivcr Zenith Model 75
All of the accepted hearing devices employ vacuum tubes.
Aurex Model C-B and Model