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OTOLARYNGOLOGISTS have encountered fewer difficulties in preparing than in maintaining an artificially created passage from the frontal sinus to the nasal cavity in patients with an occluded infundibulum. Extranasal operations devised to create a frontonasal duct for adequate dependent drainage of the frontal sinus have become standard and reliable technics. But surgical procedures intended to prevent or to overcome the tendency toward partial or complete cicatricial stenosis of this newly constructed channel have been decidedly unsuccessful in a great many cases. Before making a plastic closure of an external fistula of the frontal sinus, it is essential that the frontonasal duct be open sufficiently to maintain drainage. If the sinus does not drain freely into the nose by a permanent channel, the fistula may recur. It was in making a frontonasal duct to secure drainage of the sinus that the present method was worked out. In a search for something

Cartilaginous tumors of varying degrees of malignancy may arise in the jaws, facial and nasal skeletal regions. Of the thirteen cases of cartilaginous tumor in this region encountered at the Mayo Clinic, which form the basis of this report, ten were cases of chondrosarcoma and three were cases of benign cartilaginous tumor. None of the lesions in this group affected the mandible, although chondrosarcomas of the mandible have been reported. As is true of cartilaginous tumors wherever they occur, differentiation of the benign from the malignant examples arising in this region may be difficult. Even if the cartilaginous tumor is considered to be a benign chondroma or borderline for malignancy, treatment should be radical, preferably en bloc resection getting well around the tumor. Radical surgical removal gives a reasonable chance of cure. With inadequate treatment, chondrosarcomas progress and eventually cause the death of the patient often by intracranial extension. Only in rare instances does the tumor metastasize. The natural history of chondrosarcoma is often of long duration. Therefore, a long follow-up period is required before a clinical cure can be claimed.

Whenever possible, soft-tissue injuries of the face should receive attention within a few hours after the accident. The early treatment of facial lacerations not only limits the degree of inflammatory reaction but also reduces the amount of subsequent scarring and distortion of the affected part. Hydrogen peroxide is a most effective agent for the removal of debris and coagulated blood from lacerated wounds, leaving clean tissues for suturing. The ultimate formation of scar tissue always is diminished by sharp excision of rough, irregular, ragged, or macerated margins of wounds. Furthermore, lacerations which have been cut on the oblique require excision of the edges of skin in order that they will be perpendicular to the external dermal surface; this is essential for proper suturing of the wound. Portions of skin in which the blood supply is so poor that sloughing is likely to occur should be removed promptly. Since the formation

Juvenile nasopharyngeal fibromas are rare and benign. There would be no need to discuss them again were it not for the fact that they produce such alarming symptoms and present such serious problems in treatment. Injudicious surgical or radiologic treatment of such lesions can cause frightening hemorrhages, intracranial disturbances, and even death. The mere removal of a small piece of tissue from this type of lesion for microscopic examination occasionally can produce bleeding so profuse that ligation of the external carotid artery and the administration of blood are necessary. These tumors often are referred to as "nasopharyngeal angiofibromas," which is a good term in view of the fact that the vascular elements in many of these neoplasms are more prominent than the fibrous component. Juvenile fibromas arise from the base of the skull and are attached to the vault of the nasopharynx, usually by a broad, sessile base. Although they

A study was made of seventy-seven patients with squamous cell carcinoma of the buccal mucosa (cheek) treated at the Mayo Clinic from 1945 through 1954. All patients who received any form of treatment were included. A five-year survival rate of 50 per cent of the patients who were followed up was obtained. An attempt was made to determine the most effective method of treatment of these lesions. Because of the difficulty in estimating the extent of the disease from the records, and because of the small number of patients in each category of treatment, no exacting conclusions could be drawn regarding the most effective method of treatment. In contrast to the many reported series in which radiation was the mainstay of treatment, most tumors in this series were removed by thorough electrocoagulation or excision, and cervical metastatic lesions were removed by block dissection of the neck. In this unselected series, a survival rate was obtained which was equally as good as has been obtained with other methods.

Fractures in the malar area and floor of the orbit can be divided into five groups. Treatment for each of these categories is discussed. The five divisions include (1) uncomminuted fractures less than a week old, (2) uncomminuted fractures more than a week old, (3) comminuted fractures in the malar region, (4) blowout fractures of the floor of the orbit, and (5) deformities due to old fractures in the malar region.

From January 1945 through January 1959, thirty-four patients with acute electric burns or deformities from old electric injuries were treated at the Mayo Clinic. Most of the patients had had treatment elsewhere prior to coming to the clinic. This series does not include minor electric burns or thermal burns from hot electric elements. A study of these thirty-four cases has led us to conclude that early excision of the burned region has little if any application in the high tension type of burn because vascular damage and tissue necrosis exist beyond the apparent limits of the burn. In these cases it seems preferable to wait until a definite line of demarcation between viable and nonviable tissue is evident. Even burns about the lips from electric cords are better left alone until healed, after which plastic repair of residual deformities can be undertaken; often these minor burns about the mouth will heal so satisfactorily that little, if any, subsequent plastic work is required.

Most carcinomas in the nasopharynx are highly malignant tumors, which because of their location and activity are preferably treated by irradiation rather than by surgical means. In the treatment of lymphosarcoma and lymphoepithelioma, external radiation alone is usually the method of choice. Squamous-cell carcinoma, however, is more radioresistant, and experience has shown that intracavitary radium therapy combined with external roentgen radiation may offer a better prognosis than external radiation alone, particularly if the lesion is localized. On the other hand, very high energy radiation (radioactive cobalt or 2,000,000-volt x-rays) can be administered safely by external means alone, in doses equal to those attainable by combined intracavitary radium and moderate-voltage external roentgen therapy. If this high energy radiation is employed, there usually is no need for supplementary intracavitary radium therapy; however, since high energy equipment is not universally available, intracavitary radium therapy remains a valuable adjunct to the treatment of certain

Chronic ulcerations and portions of actinodermatitis near and around the anus sometimes require pedicle flaps of skin for repair. The types of flaps which offer the most satisfactory results for this purpose have been described.

In other communications, 1,2 we have briefly reviewed the progress of treatment of squamous-cell carcinoma of the anterior portion of the tongue and the floor of the mouth. The treatment of carcinoma of the mandibular gingiva, like that of the two types just mentioned, has passed through many different phases. Prior to this century, the occasional open surgical resection of such lesions was truly a major undertaking. As methods of electrosurgery and irradiation improved, the majority of such lesions were treated by these techniques, and the immediate mortality rate was reduced considerably. However, it became apparent that patients who had malignant invasion of the mandible were cured only occasionally by irradiation. Also, irradiation was found to be unsatisfactory as a treatment of metastatic tumors in the cervical lymph nodes. Thus, the primary lesion usually was treated by irradiation or electrocoagulation, and the cervical metastatic lesions were treated by surgical removal

A study of 174 patients with squamous cell carcinoma of the upper jaw and antrum who were treated at the Mayo Clinic was undertaken. A five-year survival rate of 39.4 per cent was obtained for the traced patients. Although more patients survived who were treated by electrocoagulation alone, these patients had less extensive tumors and tumors of lower histologic grade. The favorable survival rate obtained in the more extensive higher grade lesions, treated by a program of electrocoagulation or surgical removal combined with radiation therapy, led us to the conclusion that this probably represents the best treatment for the majority of patients having squamous cell carcinoma of the upper jaw and antrum.

A study of the data on all patients (269 cases) with squamous cell carcinoma of the anterior part of the tongue treated in any manner at the Mayo Clinic in the years 1945 to 1954, inclusive, disclosed little difference in survival among the various treatment groups when the extent of the local and the metastatic lesions was considered. Such difference as was observed appeared to favor wide local excision or hemiglossectomy plus removal of the homolateral cervical lymphatics, as either a composite or a separate procedure. The five-year survival rate for the entire series was 46.2 per cent.

Observations on forty-four osteogenic sarcomas of the jaws and facial bones demonstrate that surgical treatment affords a reasonable chance of cure. A tendency to late systemic spread and a relatively low average degree of malignancy are among the factors that contribute to successful therapy. In the present series vague symptoms were commonly present and led to many dental and minor surgical procedures prior to establishment of the correct diagnosis. This fact emphasizes that a relatively painless non-ulcerating mass occurring in the upper or lower jaw, particularly about the alveolus, should suggest the possibility of osteogenic sarcoma. In the antral and ethmoid regions, early symptoms are lacking. Roentgenographic examination is extremely helpful in most instances, but definitive diagnosis depends on histologie studies. Four of the sarcomas in this series arose in regions previously radiated for benign conditions of bone or soft tissue. More alertness on the part of dentists and physicians would favor earlier correct diagnosis and treatment of osteogenic sarcoma of the jaw.

Retrusion of the mandible is characterized by posterior displacement of the entire lower jaw. It may be a unilateral or a bilateral deformity but is more frequently the latter. In all such defects of the lower jaw there is some degree of bony hypoplasia; often there is an actual loss of bone with much distortion of the anatomic structures of the mandible. Malocclusion is invariably present, and underdevelopment and recession of the symphysis may accentuate the deformity. The most conspicuous feature in all cases of mandibular retrusion is retraction of the chin; this may or may not be associated with shortening of the upper lip (Figs. 1 and 2). Retrusion of the mandible may be due to (1) malocclusion alone or (2) arrested growth of the lower jaw complicated by malocclusion. In all patients having mandibular retrusions resulting from malocclusion and characterized by a distal relationship of the lower to

Before 1920, few operations intended to cure carcinoma of the floor of the mouth were proposed. Because of the morbidity and the high mortality rates involved in radical surgical removal of malignant lesions in this location, early surgeons were led to search for more effective but less dangerous methods. Irradiation with radium and by external sources was being perfected and was looked on with high hope. After a thorough trial period, it became clear that the primary tumor often could be controlled by irradiation but that metastatic lesions of the cervical lymph nodes seldom were cured by irradiation alone. At some institutions, electrosurgical removal of the primary lesion was undertaken with some degree of success. Thus, for many years, the usual treatment for malignant tumors in the floor of the mouth consisted in eradicating the primary lesion by electrocoagulation or irradiation or both, and in treating lesions in the cervical

ArrEnrPrs at reconstruction for total loss of the mandible by means of autogenous bone grafts have proved completely unsatisfactory, by constructing a prosthesis which is inserted into a surgically prepared, skin-lined pocket in the mouth. (Fig . I .) In all such cases the tissues of the lower half of the face are badly retracted and distorted by scar tissue . An intraoral incision made behind the lower lip, chin and cheeks frees these structures, permits reposi