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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

C OMPARED to many types of neopIasms affecting the body, sebaceous, epidermoid, incIusion dermoid and mucous cysts are reIativeIy unimportant. However, since the majority of such tumors occur about the head and neck where they are unsightIy or at Ieast conspicuous, there is always a demand for the removal of such growths by surgica1 procedures which leave a minima1 amount of residua1 scarring. WhiIe some individuaIs apparently are unconcerned over such tumors unIess they are associated with an active inflammatory process, there is an increasing number of peopIe who seek medica advice about such growths because of the fear that they may be of a maIignant nature, Aside from the patient’s viewpoint, the remova of a11 such cysts is to be recommended because many are IikeIy to become acuteIy infected and suppurate for a Iengthy period of time and because in rare instances one wiI1 undergo a maIignant change. Mucous cysts, which are lined with cuboida1 or coIumnar epitheIium and contain a mucoid materia1, offer no diagnostic uncertainties on microscopic examination. However, many cysts of the sebaceous, epidermoid and dermoid varieties are diffrcuIt to distinguish because their histologic structure may be very simiIar and because there is no uniformity among pathoIogists as to the exact characteristics of these tumors. Broders and WiIson have found that practicaIIy a11 so-caIIed sebaceous cysts which are Iined with stratified squamous epithehum do not contain the fatty, sebaceous and odorous materia1 typica of a sebaceous gland but contain layer upon Iayer of nonfatty, odorIess (unIess infected) keratin. They, therefore, prefer to calI these keratin filled tumors “ keratomas.” (Fig. I.) A true inclusion dermoid cyst, which deveIops along the embryonic clefts and Iines of fusion, is Iined with stratified epithelium which possesses sebaceous and sweat glands and hair foIIicIes; the cheesy materia1 in such a growth is of a sebaceous character. In the stratified epitheIia1 Iining membrane of an epidermoid cyst, no hair foIIicIes or sebaceous or sweat glands are evident aIthough the cystic contents are sebaceous in nature. The majority of epidermoid cysts are congenital and deveIop in situations corresponding with those of incIusion dermoids. The former, therefore, are probably incIusion dermoid cysts rather than sebaceous cysts; certainIy, they are not keratomas. Confusion is added to this conception of epidermoid cysts since many pathoIogists consider a11 sebaceous cysts and keratomas as epidermoid tumors. For the sake of cIarity I prefer to recognize those cystic skin tumors whose contents consist of‘ keratin as “keratomas,” and those which are of acquired origin and which contain sebaceous material as “sebaceous cysts.” I consider “inclusion dermoids” to be congenital cysts deveIoping aIong the embr\onic Iines of fusion and containing hair foIIicIes and sweat and sebaceous gIands in their wails. “ Epidermoids” are similar in nature to dermoid cysts with the exception that their Iinings possess none of the previously mentioned derma1 structures. Although keratomas and sebaceous cysts may arise in the subcutaneous tissues of any part of the body, the majority occur in the scalp and in the lobe and on the posterior surface of the ear. In these regions they are frequently muItiple. Such tumors

Extensive cicatricial stenosis of the larynx or the upper part of the trachea usually can be treated most successfully by an open operation through an incision in the neck; such direct exposure permits accurate excision of the thickened scar tissue producing the stricture. In those cases in which this precise method of reestablishing the normal dimensions of the laryngeal or the tracheal lumen is to be employed, it is distinctly advantageous to divide the course of treatment into three separate stages: first, the surgical removal of the cicatrix; second, the mechanical prevention of a tendency toward narrowing or constriction of the newly made lumen (over a long period, usually six months), and, third, the plastic closure of the external tracheal opening. The difficulties which arise in the care of patients during these three stages of treatment are due not to the want of technics which are capable of producing creditable

1. 1. The causes of and objective findings in mandibular prognathism have been presented. 2. 2. The relative values of various corrective procedures for this type of mandibular deformity have been discussed. 3. 3. A method consisting of bilateral resection of a segment of the body of the mandible, for mandibular prognathism, has been described. In this procedure, the segment of bone on either side is removed without injury to the mandibular nerve and vessels.

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.

A REVIEW of the Iiterature on carcinoma of the tongue reveaIs many conflicting opinions concerning the importance of the grade of mahgnancy, the significance of cervical metastasis, the vaIue of various methods of treatment and the roIe of prophylactic procedures. In the hope of resoking some of the confusion in our minds on this subject, we have anaIyzed a series of our own patients and have attempted to compare these tindings with data compiIed from the avaiIabIe worId Iiterature, which to date includes 10,454 cases of lingual cancer

Benign tumors of the larynx are of interest and importance to the laryngologist, not only because of the symptoms which they produce by interference with the normal functions of the vocal mechanism or by obstruction of the respiratory tract but because of the necessity of distinguishing them from malignant laryngeal lesions. Tumors of a bengin nature do not occur frequently in the larynx. During the past thirty years 722 patients with benign laryngeal growths have been examined at the Mayo Clinic. It is interesting to find that these tumors, apparently, are encountered less often than are malignant neoplasms, as approximately 1,100 malignant tumors of the larynx were observed during this same period. In any discussion of benign tumors of the larynx, there arises the need of defining the term "benign laryngeal tumor." Occasionally, there occur benign new growths, composed of cells which resemble various normal tissue cells but which fulfill

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

Congenital or embryonic cysts of the larynx are of interest to the laryngologist primarily because of their extreme rarity. In fact, any type of cyst is seen rather infrequently in this region. Of 722 cases of benign laryngeal tumors encountered at the Mayo Clinic prior to 1938, only 35 were cases of cysts, and in but 1 was the cyst of embryonic origin. This case was reported previously. 1 Since then we have encountered 2 other cases of congenital cysts of the larynx, of which we wish to mention 1 and to report the other at this time. Cysts of the larynx are of three types, namely, mucous, hemorrhagic and congenital. Most common are the mucous cysts; their etiology undoubtedly points to an inflammatory basis which results in an obstruction of the ductal portion of a mucous gland. Because of this atresia, the mucus is unable to escape and accumulates within

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

Traumatic rupture of the trachea is usually secondary to a crushing injury of the thorax. The rupture may be complete or partial, and it may occur in the cervical or in the thoracic portion of the trachea. The former site is much more vulnerable to injury because of its superficial position. Injuries to the intrathoracic part of the trachea are, fortunately, rare. It is possible that the state of the glottis at the time of accident is an important factor in rupture of the trachea. If the vocal cords are fixed in the midline, with the patient holding his breath in anticipation of a collision, one would expect the intratracheal and intrabronchial pressure to be greatly increased and that the trachea might rupture when any violent force is transmitted to the thoracic wall. Persons who have complete tears through all layers of the trachea usually die unless surgical intervention is accomplished early. These tears usually occur on the posterior wall of the trachea, and tension pneumothorax develops rapidly and persists despite all attempts at decompressing the pleural space. Bronchoscopic examination should reveal the laceration; if the tear is found early, thoracotomy is indicated for tears located in the thoracic portion of the trachea. In partial rupture of the trachea, hemorrhage into the tracheal wall may produce varying degrees of stenosis. Granulation tissue may form readily and also produce tracheal obstruction. Disruption of the attachments of one or more tracheal cartilages usually is present, and this produces tracheal obstruction of varying degrees. The site of rupture is important. It usually occurs in the middle or lower third of the trachea, and thus insertion of the usual tracheotomy tube will not relieve the tracheal stenosis. It is necessary in these instances to use a tracheotomy tube of sufficient length that its distal end passes by the stenotic zone. This will give great relief to the injured patient. The following four cases illustrate traumatic rupture of the trachea. Case 1: An acutely ill 29-year-old man came to the Mayo Clinic in April, 1936. Twelve days before, he had been in an automobile accident in which he had struck the steering wheel forcibly over the upper half of the sternum. Following this, he had noted severe pain In this region and had experienced difficulty in breathing.

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.

IN ANALYZING 568 cases of carcinoma of the larynx encountered at the Mayo Clinic during the period from 1934 through 1943, my associates and I found that 48 per cent of the patients were treated by laryngectomy, 41 per cent by thyrotomy and 11 per cent by diathermy or application of radon during suspension laryngoscopy. In spite of the medical profession's intensive educational program to teach the public the value of early diagnosis in the treatment of cancer, it is apparent that in the greater number of malignant tumors of the larynx which we encounter the lesion is so extensive as to require total removal of the larynx rather than a more conservative procedure. Laryngectomy, therefore, still is an important therapeutic measure in the treatment of carcinoma of the larynx. In recent years, much intensive work by capable laryngologists has changed the manner of performing laryngectomy from a faulty, and

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.