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Irradiation Treatment of Benign and Inflammatory Diseases of the Head and Neck
IRRADIATION TREATMENT OF BENIGN AND INFLAMMA_ TORY DISEASES OF THE HEAD AND NECK
J.
FRANCIS MAHONEY,
M.D.o
IT is the purpose of this communication to present the irradiation treatment of certain benign and inflammatory conditions of the head and neck that has stood the test of time, has proved itself to be the most effective form of therapy and is the primary choice and not an adjuvant of other forms of therapy. The .employment of irradiation in other benign and inflammatory diseases in which it is therapeutically useful but in which the trend of treatment is towards chemotherapeutic and antibiotic agents producing as good or better results, and which can be used on a larger and more economical scale and without as much specialized training and necessity for a mass of equipment, will not be discussed. Scepticism concerning the employment of irradiation in the treat· ment of the lesions under consideration has had its origin in many sources. Some of it is the product of the natural prejudice which physicians have for a nonspecific treatment-and the number and variety of diseases influenced favorably by irradiation confirms in their minds its nonspecific role. Others have always combined it with other therapeutic measures and such overlapping of therapy has masked the important role it plays in the cure. Many physicians still hesitate to request the employment of irradiation because of the widespread opinion among the laity that radium and x-rays are used only in the treatment of cancer, and to subject their patients to irradiation would provoke an unfavorable mental reaction and retard cure. And there remains that group of doctors who, remembering the dearth a number of years ago of well controlled experiments in the therapeutic uses of irradiation, neglect its potentials. Certainly none of these objections should be valid today. Investigations in the past ten years have produced a mass of reliable experimental results. The number of reports dealing with the favorable response of benign lesions to irradiation have multiplied and should be known to the medical profession. More benign than malignant lesions are treated and the widespread acceptance of the irradiation treatment of just one condition, subdeltoid bursitis,l has made the public conscious of the wider employment of x-rays outside the field of cancer. (l; Instructor in Radiology, School of Medicine and Graduate School of Medicine, University of Pennsylvania; Radiologist, Fitzgerald-Mercy Hospital, Darby, Penn· sylvania.
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Treatment of benign lesions is not nonspecific. The quality, quan.. tity and timing of such treatment is specifically directed to the condition present and the result desired, whether it be temporary or permanent suppression of some function of the human organism or selective destruction of some tissue of the body. The action of irradiation on inflammatory lesions is not fully understood. According to Jacobs 2 its effects, as far as we know, are on the host and not on the inflammation-producing agents. The amount of radiant energy necessary to kill bacteria directly is tremendous 3 and would never be used in treatment because of the irreparable damage to the host. There appears to be a stimulation of all the bodily defense mechanisms and countermeasures against bacterial invasion when irradiation is used in the commonly employed small doses. There is dilatation of the peripheral blood vessels with increased blood flow and lymph drainage identical with an active hyperemia, in contradistinction to the passive hyperemia resulting from the irritation of bacterial invasion. 4 There is a transient elevation in antibody formation for forty-eight to seventy-two hours 5 and the bactericidal quality of the blood is increased whether irradiation is given before or after the infection occurs. 6 Some investigators believe that the early destruction of leukocytes by irradiation makes available an earlier supply of free antibodies than is available in the untreated infection. 7 HEMANGIOMA
Hemangiomas are localized hyperplasias of the adult vascular channels in the cutaneous and subcutaneous tissue. They are classified as follows: 1. The port wine stain, composed of dilated capillaries usually without any appreciable localized tumor formation, red to purple in color but all shades having a definite purple tint. When the patient is crying or· straining, the color may become slightly darker but there is no increase in the size nor thickening of the lesion. When pressure is made over the· involved skin, the port wine stain does not blanche. 2. The plexiform hemangioma or "strawberry mark," composed of blood vessels larger than capillaries, showing definite localized tumor formation and tending to increase in thickness and become darker in color on exertion and when the blood How to the part is increased. They Hatten out and blanche on pressure. S. The cavernous hemangioma, containing large subcutaneous blood vessels that are seen faintly through the skin as blue streaks and can be palpated as vermiform swellings. They are commonly combined with the strawberry mark.
All types can vary in size from that of a pin point to involvement of as much as 25 per cent of the body surface. The sites of predilection are on the face, neck, upper extremities, the thighs and buttocks. The lesion on the face or on the exposed skin surfaces should be treated for the excellent cosmetic result that can be obtained. Moreover, in infants there is a tendency for some of the larger and softer
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hemangiomas to be traumatized and subsequently sluff out with considerable bleeding and secondary infection. While sluffing is curative, the bleeding may be alarming and the resulting scar at the site of the hemangioma is not nearly as satisfactory from a cosmetic standpoint as that of the properly treated lesion. Also, in extensive cavernous hemangiomas, the increased blood supply to the part will cause exaggeration of the growth rate with hypertrophy of the surrounding normal tissues. Fortunately the port wine stain is the least common type of hemangioma and, in total incidence, is an uncommon lesion. While the plexi.. form and cavernous types respond dramatically to treatment, no satisfactory results have been obtained as yet from numerous methods used to treat the port wine stain. It is not advocated that treatment be withheld from such lesions, for irradiation either with radium or x-rays will produce some blanching. The degree of improvement will depend upon the amount of blanching under diascopic pressure. If there is little or no blanching, treatment is useless. Very early in life, within the first month, many port wine stains will exhibit some blanching. When the final result is obtained, the parents should be instructed in the use of readily available camouflaging cosmetics, which give quite gratifying results. Treatment of the plexiform and cavernous types of hemangiomas should be instituted as soon as the lesion is detected. As most of these are present at birth, the first treatment should be given before the infant leaves the hospital. While it cannot be disputed that some of these hemangiomas tend to regress spontaneously, yet there are no criteria by which one can separate those lesions which will so dis.. appear from those which will continue to grow and become more unsightly and less sensitive to treatment. The best results are obtained when the child is put under immediate treatment; for the lesions involute more rapidly, less treatment is required and a better cosmetic result is obtained when treatment is instituted during the first month. Surely these advantages outweigh the waste in treating the occa.. sional hemangioma that may regress spontaneously. Because in the majority of the hemangiomas the cosmetic result is the most important consideration, treatment is planned with this objective first in mind. X-rays give a somewhat more satisfactory result in the ordinary lesion than does radium because of the more homogeneous dose delivered to the lesion and because of the quickness with which treatment may be carried out. Even the liveliest infant can· be restrained by the parents for one to two minutes while the desired dose of irradiation is delivered. When the lesion is more than 1 em. in thickness, tiny radon seeds may be inserted into its base where the desired sclerotic effect upon the blood vessels can be ob.. tained without overirradiation of the skin surface. In some extensive
BENIGN DISEASES OF THE HEAD AND NECK
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hemangiomas, particularly of the tongue, radium needles are inserted directly into the tumor. Some amazing results have been obtained in seemingly hopeless lesions by master radiotherapists. 8 There should be no increase in size of the hemangioma after the first treatment, but no definite regression may be expected in the interval before the second treatment, owing to the small dosage employed. 1'he usual dosage is 250 roentgens measured on the skin at 45-140 K.V. with 1 mm. of aluminum filtration at a distance of 20 to 30 em. Intervals between treatments are from four to six weeks so that the effect from the single dose can be accurately estimated before any additional irradiation is given. There are many hemangiomas, particularly those whose treatment was started within the first month of life, which will respond to three treatments so spaced. Others identical in size, shape, color, thickness and anatomical location will require six to ten treatments. The most satisfactory end result is a faint pink blush upon a flat· skin surface. Evidence of the hemangioma will never disappear entirely, for the skin which contained the hemangioma was not normal to begin with. KELOIDS
Keloids are dense, fibrous growths developing in mesodermal tissue usually at the site of a scar and characterized histologically by' large homogeneous connective tissue fibers with a small proportion of connective tissue cells. Negroes and Mediterranean races are unusually suspectible to their development. While they may arise spontaneously in the skin, they commonly are secondary to damage of the connective tissue as the result of any agent which will cause a rupture of the overlying skin surface. Furuncles and electrodesiccation of the skin are frequently followed by the formation of hypertrophic scars. The young keloid is deeply seated in the skin, firm and rubbery in its consistency and shows a smooth red to pink dome. It may be perfectly circumscribed and confined strictly to the area of the scar or have a few arborizing extensions. Keloids and hypertrophic scars may be thick enough, particularly on the flexor surfaces of joints, to produce limitation of motion. They are commonly itchy and may produce a sensation of deep burning from pinching of new nerve filaments by the thick connective tissue growth. It has not been shown that there is any advantage in prophylactic treatment, either before or after operation, for avoidance of keloids in susceptible individuals. Treatment is directed to stopping the growth and bringing about regression as soon as the growth is clinically evident, for treatment of a new lesion is much more successful than the old, hard, fibrous one. In such an old lesion, it is preferable to excise it in toto if primary skin closure can be obtained. Then if
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the keloid recurs in the operative site, immediate treatment will usually produce a satisfactory result. If skin grafting is necessary, the strong possibility of keloid formation in the donor sites as well as in the grafted area must be considered. It has been noted that lesions on the face are more resistant to treatment than those on other body surfaces, and favorable results may be longer delayed because more treatment will be necessary. The usual plan of treatment is to give 250 roentgens lueasured on the skin at 120 to 140 K.V. with 1 mm. of aluminum filtration at a distance of 20 to 30 cm. This dose is delivered to the entire lesion and at least 1 inch of the surrounding normal skin. It is repeated every three weeks for a total of three doses. If there has not been- satisfactory regression in the thickness of the lesion or relief from pruritus and burning, the course is repeated after three months. In the usual case, two such series are necessary. In Negroes, there may be some tanning over the treated area for several months after treatment is completed. This is a temporary phenomena and the end result shows no change in the ordinary pigmentation of the skin. This amount of protracted treatment is well below the amount the normal skin can tolerate without evidence of any immediate·or late permanent damage. RINGWORM OF THE SCALP
Tinea capitis is infection of the hair of the scalp produced by vari.. ous fungi. Microsporum audouini is the offending organism in the epidemic form now prevalent in· the United States, but ringworm caused by Microsporum lanosum is endemic and a small percentage of the cases seen will be caused by it. Both of these fungi produce changes in the hair which cause them to fluoresce a characteristic apple-green under Wood's light, the so-called "black-light" produced by excluding the visible light from a source of ultraviolet light by a heavy nickel glass filter. The earliest appreciable lesion is a minute, rounded scaly patch upon the hair-bearing scalp, the location being just inside the hair line at the nape of the neck. The base of the lesion is reddened and hyperemic, but the scales are whitish or grayish in color. The patch slowly increases in diameter but there is no tendency for involution at the center of the lesion as one sees in the common types of ringworm infection on other portions of the body. The involved hair shafts become dry and brittle and, in the course of a few days or weeks, many of these hairs break off, leaving a partially bald area studded with broken hair shafts. A variable degree of itching is present and the excoriation of the lesions may involve the area with secondary infection which may in extreme cases consist of deep carbuncles with multiple draining sinuses. Rarely is this disease limited to the clinically infected site.
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A working diagnosis of tinea capitis can be made by examining the scalp under the Wood's light with the finding of fluorescent hair shafts. Final diagnosis is by culture of the fluorescent hairs and finding of the characteristic fungi. What cases of tinea capitis should be treated by x-ray? It is the feeling of many dermatologists-and statistical results have borne out this feeling fairly well-that cases of tinea capitis caused by nonfluorescent organisms, a large variety of large spore fungi, can be cured by local means and resort to roentgen depilation is unnecessary. In addition, the animal transmitted type of microsporum, Microsporum lanosum, is usually cured without resort to irradiation. Micro.. sporum audouini infections are the most resistant and chronic and it is in these cases that roentgen depilation is frequently necessary. In an epidemic, the new local fungicide, a saturated solution of copper undecylenate in carbowax 1500, will produce many cures 9 although wider use of this solution has tempered the enthusiasm of early reports. 10 Complete temporary depilation of the scalp by irradiation is the quickest and surest method of cure in the individual case. Depilation of the clinically infected areas in the scalp is not recommended as the disease is always more widespread than is apparent on examination and the so-called "spot" depilation technic has time and time again proved unsatisfactory. The advantages of x-ray treatment are multiple: 1. In the proper hands with adequate modern equipment, the procedure is perfectly harmless and painless to the patient. By vigilant attention to technic and dosage, the possibility of permanent alopecia can be eliminated. 2. It is a rare case of ringworm of the scalp treated by x-ray that is not cured. The best local drug therapy results to date have been reported in a Hagerstown epidemic where 57 per cent of the cases "vere cured using 5 per cent salicylanilide in carbowax 1500 or copper undecylenate saturated solution in carbowax 1500.9 3. X-ray treatment can be completed at one sitting. The entire procedure, including the examination of the patient, can be carried out by experienced personnel in less than one-half hour. 4. The patient becomes practically noninfectious at the end of the three weeks, when the scalp will be entirely depilated, although some infection will remain for several additional weeks. In this country, temporar~ roentgen depilation has been obtained by using the standardized procedure of Adamson and Kienbach and described by MacKee11 as the "five-point technic." In the AdamsonKienbach technic, the dose, the treating distance, and the position of the portals upon the scalp are standardized, the same factors being used for every type of scalp. Failures will occur with the very large,
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.quite small and the unusually shaped head. Using open overlapping fields, the low dosage point is at the center of each field and the high point intermediate between the fields. Since July 1945 at the Hospital of the University of Pennsylvania, we have used an individualized shielded portal technic with uniform safety and high cure rate. The child's head is not a sphere. The hairbearing areas of the scalp are usually composed of four to six fairly Hat plateaus joined together at rather acute angles. In the most common type, the anterior-superior portion of the head is a broad, Hat plateau with an abrupt angulation at the vertex and there is a smaller Hat area posterior to the edge of the occipital bone, and from the parieto-occipital sutures to the nape of the neck is another fairly Hat plateau. Viewing the child's head from the front, these three midline plateaus are joined to the flat lateral surface of the hair-bearing scalp by acute angles. Preliminary red ink lines are drawn to outline the various "flat" sur.. faces. Each is then treated in turn with careful lead shielding of the surrounding areas. Before the shield is removed at the completion of treatment to anyone area, the actual treatment area is outlined in contrasting black ink. All the areas are treated on the same day. Using these shielded portals, the high dosage point is at the center of the field an¢! the low point at the periphery of the field. The hair begins to fall out thirteen to sixteen days after irradiation. Depilation is complete in thirty days. New hair growth appears six to eight weeks after the defluvium. New hair growth is not like that seen from a shaved scalp, but rather like the fine growth of hair develop,.. ing on the infant's scalp. At first, the hair is sparse and fine and each week there is an augmented number of hairs which gradually become thicker until full hair growth is accomplished in six months. The scalp is quite dry after treatment. The amount of irradiation necessary to destroy temporarily the function of the hair follicle is sufficient to suppress temporarily the sebaceous glands of the scalp, and until full hair growth is accomplished the scalp will be dry. Normal oiliness returns within one or two months after full hair. regrowth. Exceedingly soft irradiation is used, 75 K.V.P. The pituitary gland receives approximately 180 tissue roentgens from the treatment of the entire scalp. The dose in roentgens is very close to the minimal depilation dose, as 80 per cent of aUf dose will not depilate the edges of the field and 60 per cent of the dose will produce no alopecia, even in the center of the field. In 120 cases, with a six months' fol1o~-up period, 119 cases have been cured without any damage to hair or scalp of the patients treated. In the one remaining case, hair regrowth has been perfectly normal but the infection persists.
BENIGN DISEASES OF THE HEAD AND NECK
RADIATION IN OPHTHALMOLOGY
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Radiation in ophthalmology is not new. It has been found of value in the treatment of tuberculous infections, chronic iritis and iridocyclitis, and vernal conjunctivitis. Such treatment was fraught with danger because of the danger of irradiation cataracts. Experimental studies show that 250 tissue roentgens will produce demonstrable opacities on the posterior surface of the lens five to seven months after irradiation. 12 While this cataract is not progressive and the lens epithelium returns to its normal appearance ten months after irradiation, it is certainly a~ indication of the radiosensitivity of the crystalline lens and has made many hesitant to treat lesions about the eye. With the introduction of contact therapy, treatment of the palpebral conjunctiva for vernal conjunctivitis became practical. Contact therapy as produced by the Chaoul and Phillips apparatus is a long wave form of x-radiation between 40 and 60 K.V.P. The beam of irradiation is narrow and can be varied between a practical minimum of a few millimeters to a maximum of 20 mm. Such soft radiation in a narrow beam can be stopped by 1 mm. of lead shielding. By using commercial models or small concave shields of lead coated with paraffin in contact with the anesthetized cornea, the globe can be excluded from receiving any significant irradiation. The results of treatment of vernal conjunctivitis with contact therapy are not dramatic. There may be a period of several months before there is any subjective improvement. Coupled with the wearing of tinted glasses equipped with inclusive side shields so that the eyes are protected from air-borne pollen, the patient may carryon in school without disabling photophobia and lacriInation. When treating the cobble-stoned surfac~ of the conjunctiva, the cornea is first anesthetized and shielded with lead in contact. The lid is then inverted and secured in a lid clamp, the eyelashes and their bases protected with additional lead covering and the desired dosage delivered to the isolated conjunctiva through the small contact cone. At the Cleveland Clinic, Ruedemann and Glasser~3 have been using beta radiation from radium for treatment of corneal and lid lesions for the past five years. Beta particles .are produced by the disintegration of radium Band C and are high speed electrons which can penetrate tissue to a depth of only 15 mm. They are readily absorbed and penetrate only superficial layers of tissue and are safe to use in lesions of the cornea without producing a cataract-inducing dosage at the level of the crystalline lens. Tne beta ray applicator consists of a small glass sphere 4 mm. in diameter with a wall thickness of 0.1 mm. This glass sphere is filled with radon gas, usually 200 millicuries in quantity. Radon occurs normally in a gaseous state and is the first disintegration product of radium. Radium prepared in the form of an aqueous solution of its
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salt is placed in a closed system and as the radon gas bubbles up from the solution of radium, it is collected, purified and concentrated and measured. The ordinarily used radon contains radium A, Band C, and continues to emit alpha, beta and gamma radiation in unvarying fixed proportions for thirty days. Ninety per cent of radon>s emissions are alpha particles that are stopped by material as thick as a sheet of paper. The thin glass wall of the beta ray applicator effectively blocks off this alpha ray emission. Ninety-seven per cent of the rays emerging from the applicator are beta rays, gamma rays making up the other 3 per cent. The glass sphere is inserted into a small, open-ended brass holder with a wall 2 mm. thick. This thickness of brass is sufficient to block off beta particles emerging from the sphere in any direction but through the window on the distal side of the brass holder and allows accurate localization of treatment to the point desired. The handle is 35 em. long and is held by the operator at its very end, standard precautions being used to protect the operator and members of the staff from undue exposure to gamma irradiation. The duration of treatment is twenty-five seconds with the open-end of the applicator held against the lesion to be treated. The duration and depth of the corneal scars are the determining factors in the results. Superficial lesions respond promptly and satisfactorily. In most corneal scars, the vision is definitely improved, the scars becoming less dense and smaller and in the thicker scars by -contraction of the area and thinning of the margins. Cases of symblepharon, pseudopterygium and recurrent pterygium are cured by surgery followed by beta ray therapy one week later. Beta radiation has been used with most success in the prevention of vascularization of corneal grafts, the best results being obtained with preoperative treatment, but satisfactory regression of the vascular tree has been obtained when, in the postoperative case, vascularization of the graft has been noted under the slit lamp,. Such cases have also been treated with contact x-radiation. The immediate response is satisfactory but many recurrences develop and not enough cases have been treated to give a definite evalution of the place of contact therapy in ~he treatment of these lesions. It would seem that, as of this time, beta radiation is superior to contact irradiation with x-rays both in results obtained and in the avoidance of danger of irradiation cataract. RADIATION IN OTOLARYNGOLOGY
Irradiation is a most important method in the preservation of hearing. Crowe and Burnaln14 studied three thousand children and came to the conclusion that hypertrophied lymphoid tissue in the region of the nasopharyngeal openings at the eustachian tubes was an important cause of middle ear disease and deafness. This tissue, situated in the
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fossa of Rosenmiiller, is so located that its accurate and complete removal surgically is impossible and its recurrence following operation is the rule. In such a strategic location, hypertrophy of this lymphoid tissue will cause complete or partial blockage of the eustachian tube. The loss of normal aeration of the middle ear and changes in its pressure equilibrium may result in subclinical infections during periods of upper respiratory infection when there will be concomitant swelling of the lymphoid tissues of the nasopharynx. Such subclinioal recurrent infections in the middle ear will result in the gradual development of fibrosis in the mucous membrane lining and a lessened motility of the ossicles. The first evidence of this on otoscopic examination is usually retraction of Shrapnell's membrane. On early audiometric examination, the patient will show a selective loss of hearing for high tones. If there is complete blockage of the eustachian tube during upper respiratory infection, the combination of the infection and the blockage will promote the development of acute suppurative otitis media. ILLUSTRATIVE CASE.-A 3 year old white girl had repeated upper respiratory infections during the winter of 1945-1946, with three attacks of acute right suppurative otitis media requiring myringotomy, penicillin and sulfadiazine therapy. 111 June 1946, irradiation of the eustachian tubes and the nasopharynx was carried out using 200 K.V.P., with a filtration of 0.5 mm. of copper at a distance of 50 em. through a 7 Cffi. portal directed laterally to the nasopharynx from both the left and right sides to include the entire eustachian tube. Each side received approximately 300 roentgens measured in air over a period of two weeks. During the winter of 1946-1947 the frequency of upper respiratory infections was not changed, but there was at no time any evidence of infection in the middle ear. f
The importance of these findings was clearly demonstrated during the war by the control of air otitis (baro trauma-R.A.F.) in the Army Air Forces. 15 It was early recognized that many of the difficulties in ear ventilation of air crews who were forced to undergo rapid changes in altitude was caused by hyperpla~tic lymphoid tissue in the nasopharynx. In consultation with ten otologists, a standardized program was set up by the Air Surgeon.' Irradiation by local application of radium to the lymphoid tissue in the nasopharyngeal ends of the eustachian tube was proved definitely beneficial and was an important factor in obtaining proper strength of air crews. Seventy-four per cent had less difficulty in ventilating their ears, during Hight and 89 per cent Had objective improvement. Twenty-six per cent had no subjective improvement, while only 11 per cent showed no decrease in the amount of lymphoid tissue. Local applications of radium or its active products is the treatment of choice, for the area irradiated is confined to the lymphoid tissue
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in the fossa of Rosenmiiller and there is no significant exposure to irradiation of any of the surrounding tissues. Special. applicators are available for placement of the radium. These consist of modified metal nasal applicators bearing on their ends small monel metal chambers of 0.3 mm. wall thickness containing 50 mg. of radium. Seventy per cent of the transmitted radi.ation is gamma and 30 per cent beta radiation. Such applicators may also be modified to use radon, but the rapid disintegration of this radioactive product of radium makes the choice of radon an expensive one for the average clinic treating only a few cases a week. The standard commercial 0.3 mm. wall thickness monel metal applicator with the radium sealed into it is very expensive and its uses are limited. Special applicators can be built of low atomic weight metal with removable screw caps so that radium elements of 25 to 50 mg. strength can be inserted into them. This permits the use of forms of radium available in most hospitals. I'he applicator is small enough to be inserted readily through the nnesthetized nares. A direct vision nasoscope is inserted into one side and the radiuln applicator is inserted through the opposite nares and maneuvered into contact with the tip of the eustachian tube. It is then fixed in place for eight minutes. At the completion of treatment, the procedure is reversed and the other side treated. Three treatments at four week intervals are usually sufficient to cause marked regression of the lymphoid tissue. This regression usually lasts approximately eighteen months, at which time it may be repeated if symptoms recur without any untoward reaction of the normal sur.. rounding tissues. If, under direct examination, the lymphoid tissue shows regression by radium treatments but there is still selective loss of high tone and difficulty in ventilating the middle ear, it may be presumed that lymphoid tissue within the eustachian tube is causing continued blockage. At this time, external irradiation delivered to the eustachian tube is indicated. Approximately 400 roentgens measured in air delivered to each side is sufficient to cause comparable regression of lymphoid tissue to that obtained by local applications of radium in the nasopharynx. It must be stressed that this treatment is designed specifically to promote free aeration of the middle ear by destroying lymphoid tissue blocking the eustachian tube and the nasopharyngeal opening of the eustachian tube. Such treatment would be of no avail in other types or causes of deafness or infections of the middle ear. When there is midline hypertrophy of the adenoids, adenoidectomy should also be performed. SUMMARY
1. The primary role of radiation in the cure of certain benign and inflammatory diseases of the head and neck are discussed. 2. It is felt that irradiation treatment will produce th~ b~st resqlts
BENIGN DISEASES OF THE HEAD AND NECK
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in hemangiomas, keloids, tinea capitis, corneal scars and vascularization of corneal grafts and hypertrophy of nasopharyngeal lymphoid tissue.
REFERENCES 1. Pendergrass, E. P. and Hodes, P. J.: Roentgen Irradiation in the Treatment of Inflammations. Am. J. Roentgenol., 45:74, 1941. 2. Jacobs, L. G.: Short Wave Radiations, Mechanism of Anti-inHan1matory Effect. California & West. Med., 63:127, 1945. 3. Korb, G. N.: Radiosensitivity of Bacteria. Radiol. Rund. 2:120, 1933. 4. Dabasi, E.: Roentgenotherapy of Inflammations. Orovisi hetH., 76:682, 1932. 5. Hartley, P.: Effect of Radiation on Production of Specific Antibodies. J. Exper. Path., 5:306, 1924. 6. Bisgard, J. D. et al.: Mechanism of Action of Roentgen Therapy on Infection. Ann. Surg., 115:996, 1942. 7. Desjardins, A. D.: Dosage and Methods of Roentgen Therapy for Inflammatory Conditions. Radiology, 32:699, 1939. 8. Pfahler, G. E.: Treatment of Hemangioma. Radiology, 46:159, 1946. 9. Schwartz, L. et al.: Control of Ringworm of the Scalp among School Children. J.A.M.A., 132:58, 1946. 10. Whelen, S. T.: Personal communication. 11. MacKee, G. M. and Cipollaro, A.: Philadelphia, Lea & Febiger, 1946. 12. Poppe, E.: Experimental Investigation of Effect of Roentgen Rays on the Eye. Oslo, Kommisjon hos Jacob Dybwad, 1942. 13. Ruedemann, A. D. and Glasser, 0.: Beta Radiation Ophthalmology. Cleveland Clin. Quart., 13:104, 1946. 14. Crowe, J. J. and Burnam, C. F.: Recognition, Treatment and Prevention of Hearing Impairment in Children. Ann. OtoI., Rhin. and Laryng., 50: 15, 1941. i5. Combined Report on the Dse of Radium in the Aerotitis Control Program of the Army Air Forces. Ann. OtoI., Rhin. and Laryng., 54:650, 1945.
in
J.
FRANCIS MAHONEY,
M.D.o
IT is the purpose of this communication to present the irradiation treatment of certain benign and inflammatory conditions of the head and neck that has stood the test of time, has proved itself to be the most effective form of therapy and is the primary choice and not an adjuvant of other forms of therapy. The .employment of irradiation in other benign and inflammatory diseases in which it is therapeutically useful but in which the trend of treatment is towards chemotherapeutic and antibiotic agents producing as good or better results, and which can be used on a larger and more economical scale and without as much specialized training and necessity for a mass of equipment, will not be discussed. Scepticism concerning the employment of irradiation in the treat· ment of the lesions under consideration has had its origin in many sources. Some of it is the product of the natural prejudice which physicians have for a nonspecific treatment-and the number and variety of diseases influenced favorably by irradiation confirms in their minds its nonspecific role. Others have always combined it with other therapeutic measures and such overlapping of therapy has masked the important role it plays in the cure. Many physicians still hesitate to request the employment of irradiation because of the widespread opinion among the laity that radium and x-rays are used only in the treatment of cancer, and to subject their patients to irradiation would provoke an unfavorable mental reaction and retard cure. And there remains that group of doctors who, remembering the dearth a number of years ago of well controlled experiments in the therapeutic uses of irradiation, neglect its potentials. Certainly none of these objections should be valid today. Investigations in the past ten years have produced a mass of reliable experimental results. The number of reports dealing with the favorable response of benign lesions to irradiation have multiplied and should be known to the medical profession. More benign than malignant lesions are treated and the widespread acceptance of the irradiation treatment of just one condition, subdeltoid bursitis,l has made the public conscious of the wider employment of x-rays outside the field of cancer. (l; Instructor in Radiology, School of Medicine and Graduate School of Medicine, University of Pennsylvania; Radiologist, Fitzgerald-Mercy Hospital, Darby, Penn· sylvania.
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Treatment of benign lesions is not nonspecific. The quality, quan.. tity and timing of such treatment is specifically directed to the condition present and the result desired, whether it be temporary or permanent suppression of some function of the human organism or selective destruction of some tissue of the body. The action of irradiation on inflammatory lesions is not fully understood. According to Jacobs 2 its effects, as far as we know, are on the host and not on the inflammation-producing agents. The amount of radiant energy necessary to kill bacteria directly is tremendous 3 and would never be used in treatment because of the irreparable damage to the host. There appears to be a stimulation of all the bodily defense mechanisms and countermeasures against bacterial invasion when irradiation is used in the commonly employed small doses. There is dilatation of the peripheral blood vessels with increased blood flow and lymph drainage identical with an active hyperemia, in contradistinction to the passive hyperemia resulting from the irritation of bacterial invasion. 4 There is a transient elevation in antibody formation for forty-eight to seventy-two hours 5 and the bactericidal quality of the blood is increased whether irradiation is given before or after the infection occurs. 6 Some investigators believe that the early destruction of leukocytes by irradiation makes available an earlier supply of free antibodies than is available in the untreated infection. 7 HEMANGIOMA
Hemangiomas are localized hyperplasias of the adult vascular channels in the cutaneous and subcutaneous tissue. They are classified as follows: 1. The port wine stain, composed of dilated capillaries usually without any appreciable localized tumor formation, red to purple in color but all shades having a definite purple tint. When the patient is crying or· straining, the color may become slightly darker but there is no increase in the size nor thickening of the lesion. When pressure is made over the· involved skin, the port wine stain does not blanche. 2. The plexiform hemangioma or "strawberry mark," composed of blood vessels larger than capillaries, showing definite localized tumor formation and tending to increase in thickness and become darker in color on exertion and when the blood How to the part is increased. They Hatten out and blanche on pressure. S. The cavernous hemangioma, containing large subcutaneous blood vessels that are seen faintly through the skin as blue streaks and can be palpated as vermiform swellings. They are commonly combined with the strawberry mark.
All types can vary in size from that of a pin point to involvement of as much as 25 per cent of the body surface. The sites of predilection are on the face, neck, upper extremities, the thighs and buttocks. The lesion on the face or on the exposed skin surfaces should be treated for the excellent cosmetic result that can be obtained. Moreover, in infants there is a tendency for some of the larger and softer
1540
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hemangiomas to be traumatized and subsequently sluff out with considerable bleeding and secondary infection. While sluffing is curative, the bleeding may be alarming and the resulting scar at the site of the hemangioma is not nearly as satisfactory from a cosmetic standpoint as that of the properly treated lesion. Also, in extensive cavernous hemangiomas, the increased blood supply to the part will cause exaggeration of the growth rate with hypertrophy of the surrounding normal tissues. Fortunately the port wine stain is the least common type of hemangioma and, in total incidence, is an uncommon lesion. While the plexi.. form and cavernous types respond dramatically to treatment, no satisfactory results have been obtained as yet from numerous methods used to treat the port wine stain. It is not advocated that treatment be withheld from such lesions, for irradiation either with radium or x-rays will produce some blanching. The degree of improvement will depend upon the amount of blanching under diascopic pressure. If there is little or no blanching, treatment is useless. Very early in life, within the first month, many port wine stains will exhibit some blanching. When the final result is obtained, the parents should be instructed in the use of readily available camouflaging cosmetics, which give quite gratifying results. Treatment of the plexiform and cavernous types of hemangiomas should be instituted as soon as the lesion is detected. As most of these are present at birth, the first treatment should be given before the infant leaves the hospital. While it cannot be disputed that some of these hemangiomas tend to regress spontaneously, yet there are no criteria by which one can separate those lesions which will so dis.. appear from those which will continue to grow and become more unsightly and less sensitive to treatment. The best results are obtained when the child is put under immediate treatment; for the lesions involute more rapidly, less treatment is required and a better cosmetic result is obtained when treatment is instituted during the first month. Surely these advantages outweigh the waste in treating the occa.. sional hemangioma that may regress spontaneously. Because in the majority of the hemangiomas the cosmetic result is the most important consideration, treatment is planned with this objective first in mind. X-rays give a somewhat more satisfactory result in the ordinary lesion than does radium because of the more homogeneous dose delivered to the lesion and because of the quickness with which treatment may be carried out. Even the liveliest infant can· be restrained by the parents for one to two minutes while the desired dose of irradiation is delivered. When the lesion is more than 1 em. in thickness, tiny radon seeds may be inserted into its base where the desired sclerotic effect upon the blood vessels can be ob.. tained without overirradiation of the skin surface. In some extensive
BENIGN DISEASES OF THE HEAD AND NECK
1541
hemangiomas, particularly of the tongue, radium needles are inserted directly into the tumor. Some amazing results have been obtained in seemingly hopeless lesions by master radiotherapists. 8 There should be no increase in size of the hemangioma after the first treatment, but no definite regression may be expected in the interval before the second treatment, owing to the small dosage employed. 1'he usual dosage is 250 roentgens measured on the skin at 45-140 K.V. with 1 mm. of aluminum filtration at a distance of 20 to 30 em. Intervals between treatments are from four to six weeks so that the effect from the single dose can be accurately estimated before any additional irradiation is given. There are many hemangiomas, particularly those whose treatment was started within the first month of life, which will respond to three treatments so spaced. Others identical in size, shape, color, thickness and anatomical location will require six to ten treatments. The most satisfactory end result is a faint pink blush upon a flat· skin surface. Evidence of the hemangioma will never disappear entirely, for the skin which contained the hemangioma was not normal to begin with. KELOIDS
Keloids are dense, fibrous growths developing in mesodermal tissue usually at the site of a scar and characterized histologically by' large homogeneous connective tissue fibers with a small proportion of connective tissue cells. Negroes and Mediterranean races are unusually suspectible to their development. While they may arise spontaneously in the skin, they commonly are secondary to damage of the connective tissue as the result of any agent which will cause a rupture of the overlying skin surface. Furuncles and electrodesiccation of the skin are frequently followed by the formation of hypertrophic scars. The young keloid is deeply seated in the skin, firm and rubbery in its consistency and shows a smooth red to pink dome. It may be perfectly circumscribed and confined strictly to the area of the scar or have a few arborizing extensions. Keloids and hypertrophic scars may be thick enough, particularly on the flexor surfaces of joints, to produce limitation of motion. They are commonly itchy and may produce a sensation of deep burning from pinching of new nerve filaments by the thick connective tissue growth. It has not been shown that there is any advantage in prophylactic treatment, either before or after operation, for avoidance of keloids in susceptible individuals. Treatment is directed to stopping the growth and bringing about regression as soon as the growth is clinically evident, for treatment of a new lesion is much more successful than the old, hard, fibrous one. In such an old lesion, it is preferable to excise it in toto if primary skin closure can be obtained. Then if
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the keloid recurs in the operative site, immediate treatment will usually produce a satisfactory result. If skin grafting is necessary, the strong possibility of keloid formation in the donor sites as well as in the grafted area must be considered. It has been noted that lesions on the face are more resistant to treatment than those on other body surfaces, and favorable results may be longer delayed because more treatment will be necessary. The usual plan of treatment is to give 250 roentgens lueasured on the skin at 120 to 140 K.V. with 1 mm. of aluminum filtration at a distance of 20 to 30 cm. This dose is delivered to the entire lesion and at least 1 inch of the surrounding normal skin. It is repeated every three weeks for a total of three doses. If there has not been- satisfactory regression in the thickness of the lesion or relief from pruritus and burning, the course is repeated after three months. In the usual case, two such series are necessary. In Negroes, there may be some tanning over the treated area for several months after treatment is completed. This is a temporary phenomena and the end result shows no change in the ordinary pigmentation of the skin. This amount of protracted treatment is well below the amount the normal skin can tolerate without evidence of any immediate·or late permanent damage. RINGWORM OF THE SCALP
Tinea capitis is infection of the hair of the scalp produced by vari.. ous fungi. Microsporum audouini is the offending organism in the epidemic form now prevalent in· the United States, but ringworm caused by Microsporum lanosum is endemic and a small percentage of the cases seen will be caused by it. Both of these fungi produce changes in the hair which cause them to fluoresce a characteristic apple-green under Wood's light, the so-called "black-light" produced by excluding the visible light from a source of ultraviolet light by a heavy nickel glass filter. The earliest appreciable lesion is a minute, rounded scaly patch upon the hair-bearing scalp, the location being just inside the hair line at the nape of the neck. The base of the lesion is reddened and hyperemic, but the scales are whitish or grayish in color. The patch slowly increases in diameter but there is no tendency for involution at the center of the lesion as one sees in the common types of ringworm infection on other portions of the body. The involved hair shafts become dry and brittle and, in the course of a few days or weeks, many of these hairs break off, leaving a partially bald area studded with broken hair shafts. A variable degree of itching is present and the excoriation of the lesions may involve the area with secondary infection which may in extreme cases consist of deep carbuncles with multiple draining sinuses. Rarely is this disease limited to the clinically infected site.
BENIGN DISEASES OF THE HEAD AND NECK
1543
A working diagnosis of tinea capitis can be made by examining the scalp under the Wood's light with the finding of fluorescent hair shafts. Final diagnosis is by culture of the fluorescent hairs and finding of the characteristic fungi. What cases of tinea capitis should be treated by x-ray? It is the feeling of many dermatologists-and statistical results have borne out this feeling fairly well-that cases of tinea capitis caused by nonfluorescent organisms, a large variety of large spore fungi, can be cured by local means and resort to roentgen depilation is unnecessary. In addition, the animal transmitted type of microsporum, Microsporum lanosum, is usually cured without resort to irradiation. Micro.. sporum audouini infections are the most resistant and chronic and it is in these cases that roentgen depilation is frequently necessary. In an epidemic, the new local fungicide, a saturated solution of copper undecylenate in carbowax 1500, will produce many cures 9 although wider use of this solution has tempered the enthusiasm of early reports. 10 Complete temporary depilation of the scalp by irradiation is the quickest and surest method of cure in the individual case. Depilation of the clinically infected areas in the scalp is not recommended as the disease is always more widespread than is apparent on examination and the so-called "spot" depilation technic has time and time again proved unsatisfactory. The advantages of x-ray treatment are multiple: 1. In the proper hands with adequate modern equipment, the procedure is perfectly harmless and painless to the patient. By vigilant attention to technic and dosage, the possibility of permanent alopecia can be eliminated. 2. It is a rare case of ringworm of the scalp treated by x-ray that is not cured. The best local drug therapy results to date have been reported in a Hagerstown epidemic where 57 per cent of the cases "vere cured using 5 per cent salicylanilide in carbowax 1500 or copper undecylenate saturated solution in carbowax 1500.9 3. X-ray treatment can be completed at one sitting. The entire procedure, including the examination of the patient, can be carried out by experienced personnel in less than one-half hour. 4. The patient becomes practically noninfectious at the end of the three weeks, when the scalp will be entirely depilated, although some infection will remain for several additional weeks. In this country, temporar~ roentgen depilation has been obtained by using the standardized procedure of Adamson and Kienbach and described by MacKee11 as the "five-point technic." In the AdamsonKienbach technic, the dose, the treating distance, and the position of the portals upon the scalp are standardized, the same factors being used for every type of scalp. Failures will occur with the very large,
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.quite small and the unusually shaped head. Using open overlapping fields, the low dosage point is at the center of each field and the high point intermediate between the fields. Since July 1945 at the Hospital of the University of Pennsylvania, we have used an individualized shielded portal technic with uniform safety and high cure rate. The child's head is not a sphere. The hairbearing areas of the scalp are usually composed of four to six fairly Hat plateaus joined together at rather acute angles. In the most common type, the anterior-superior portion of the head is a broad, Hat plateau with an abrupt angulation at the vertex and there is a smaller Hat area posterior to the edge of the occipital bone, and from the parieto-occipital sutures to the nape of the neck is another fairly Hat plateau. Viewing the child's head from the front, these three midline plateaus are joined to the flat lateral surface of the hair-bearing scalp by acute angles. Preliminary red ink lines are drawn to outline the various "flat" sur.. faces. Each is then treated in turn with careful lead shielding of the surrounding areas. Before the shield is removed at the completion of treatment to anyone area, the actual treatment area is outlined in contrasting black ink. All the areas are treated on the same day. Using these shielded portals, the high dosage point is at the center of the field an¢! the low point at the periphery of the field. The hair begins to fall out thirteen to sixteen days after irradiation. Depilation is complete in thirty days. New hair growth appears six to eight weeks after the defluvium. New hair growth is not like that seen from a shaved scalp, but rather like the fine growth of hair develop,.. ing on the infant's scalp. At first, the hair is sparse and fine and each week there is an augmented number of hairs which gradually become thicker until full hair growth is accomplished in six months. The scalp is quite dry after treatment. The amount of irradiation necessary to destroy temporarily the function of the hair follicle is sufficient to suppress temporarily the sebaceous glands of the scalp, and until full hair growth is accomplished the scalp will be dry. Normal oiliness returns within one or two months after full hair. regrowth. Exceedingly soft irradiation is used, 75 K.V.P. The pituitary gland receives approximately 180 tissue roentgens from the treatment of the entire scalp. The dose in roentgens is very close to the minimal depilation dose, as 80 per cent of aUf dose will not depilate the edges of the field and 60 per cent of the dose will produce no alopecia, even in the center of the field. In 120 cases, with a six months' fol1o~-up period, 119 cases have been cured without any damage to hair or scalp of the patients treated. In the one remaining case, hair regrowth has been perfectly normal but the infection persists.
BENIGN DISEASES OF THE HEAD AND NECK
RADIATION IN OPHTHALMOLOGY
1545
Radiation in ophthalmology is not new. It has been found of value in the treatment of tuberculous infections, chronic iritis and iridocyclitis, and vernal conjunctivitis. Such treatment was fraught with danger because of the danger of irradiation cataracts. Experimental studies show that 250 tissue roentgens will produce demonstrable opacities on the posterior surface of the lens five to seven months after irradiation. 12 While this cataract is not progressive and the lens epithelium returns to its normal appearance ten months after irradiation, it is certainly a~ indication of the radiosensitivity of the crystalline lens and has made many hesitant to treat lesions about the eye. With the introduction of contact therapy, treatment of the palpebral conjunctiva for vernal conjunctivitis became practical. Contact therapy as produced by the Chaoul and Phillips apparatus is a long wave form of x-radiation between 40 and 60 K.V.P. The beam of irradiation is narrow and can be varied between a practical minimum of a few millimeters to a maximum of 20 mm. Such soft radiation in a narrow beam can be stopped by 1 mm. of lead shielding. By using commercial models or small concave shields of lead coated with paraffin in contact with the anesthetized cornea, the globe can be excluded from receiving any significant irradiation. The results of treatment of vernal conjunctivitis with contact therapy are not dramatic. There may be a period of several months before there is any subjective improvement. Coupled with the wearing of tinted glasses equipped with inclusive side shields so that the eyes are protected from air-borne pollen, the patient may carryon in school without disabling photophobia and lacriInation. When treating the cobble-stoned surfac~ of the conjunctiva, the cornea is first anesthetized and shielded with lead in contact. The lid is then inverted and secured in a lid clamp, the eyelashes and their bases protected with additional lead covering and the desired dosage delivered to the isolated conjunctiva through the small contact cone. At the Cleveland Clinic, Ruedemann and Glasser~3 have been using beta radiation from radium for treatment of corneal and lid lesions for the past five years. Beta particles .are produced by the disintegration of radium Band C and are high speed electrons which can penetrate tissue to a depth of only 15 mm. They are readily absorbed and penetrate only superficial layers of tissue and are safe to use in lesions of the cornea without producing a cataract-inducing dosage at the level of the crystalline lens. Tne beta ray applicator consists of a small glass sphere 4 mm. in diameter with a wall thickness of 0.1 mm. This glass sphere is filled with radon gas, usually 200 millicuries in quantity. Radon occurs normally in a gaseous state and is the first disintegration product of radium. Radium prepared in the form of an aqueous solution of its
1546
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salt is placed in a closed system and as the radon gas bubbles up from the solution of radium, it is collected, purified and concentrated and measured. The ordinarily used radon contains radium A, Band C, and continues to emit alpha, beta and gamma radiation in unvarying fixed proportions for thirty days. Ninety per cent of radon>s emissions are alpha particles that are stopped by material as thick as a sheet of paper. The thin glass wall of the beta ray applicator effectively blocks off this alpha ray emission. Ninety-seven per cent of the rays emerging from the applicator are beta rays, gamma rays making up the other 3 per cent. The glass sphere is inserted into a small, open-ended brass holder with a wall 2 mm. thick. This thickness of brass is sufficient to block off beta particles emerging from the sphere in any direction but through the window on the distal side of the brass holder and allows accurate localization of treatment to the point desired. The handle is 35 em. long and is held by the operator at its very end, standard precautions being used to protect the operator and members of the staff from undue exposure to gamma irradiation. The duration of treatment is twenty-five seconds with the open-end of the applicator held against the lesion to be treated. The duration and depth of the corneal scars are the determining factors in the results. Superficial lesions respond promptly and satisfactorily. In most corneal scars, the vision is definitely improved, the scars becoming less dense and smaller and in the thicker scars by -contraction of the area and thinning of the margins. Cases of symblepharon, pseudopterygium and recurrent pterygium are cured by surgery followed by beta ray therapy one week later. Beta radiation has been used with most success in the prevention of vascularization of corneal grafts, the best results being obtained with preoperative treatment, but satisfactory regression of the vascular tree has been obtained when, in the postoperative case, vascularization of the graft has been noted under the slit lamp,. Such cases have also been treated with contact x-radiation. The immediate response is satisfactory but many recurrences develop and not enough cases have been treated to give a definite evalution of the place of contact therapy in ~he treatment of these lesions. It would seem that, as of this time, beta radiation is superior to contact irradiation with x-rays both in results obtained and in the avoidance of danger of irradiation cataract. RADIATION IN OTOLARYNGOLOGY
Irradiation is a most important method in the preservation of hearing. Crowe and Burnaln14 studied three thousand children and came to the conclusion that hypertrophied lymphoid tissue in the region of the nasopharyngeal openings at the eustachian tubes was an important cause of middle ear disease and deafness. This tissue, situated in the
1547
BENIGN DISEASES OF THE HEAD AND NECK
fossa of Rosenmiiller, is so located that its accurate and complete removal surgically is impossible and its recurrence following operation is the rule. In such a strategic location, hypertrophy of this lymphoid tissue will cause complete or partial blockage of the eustachian tube. The loss of normal aeration of the middle ear and changes in its pressure equilibrium may result in subclinical infections during periods of upper respiratory infection when there will be concomitant swelling of the lymphoid tissues of the nasopharynx. Such subclinioal recurrent infections in the middle ear will result in the gradual development of fibrosis in the mucous membrane lining and a lessened motility of the ossicles. The first evidence of this on otoscopic examination is usually retraction of Shrapnell's membrane. On early audiometric examination, the patient will show a selective loss of hearing for high tones. If there is complete blockage of the eustachian tube during upper respiratory infection, the combination of the infection and the blockage will promote the development of acute suppurative otitis media. ILLUSTRATIVE CASE.-A 3 year old white girl had repeated upper respiratory infections during the winter of 1945-1946, with three attacks of acute right suppurative otitis media requiring myringotomy, penicillin and sulfadiazine therapy. 111 June 1946, irradiation of the eustachian tubes and the nasopharynx was carried out using 200 K.V.P., with a filtration of 0.5 mm. of copper at a distance of 50 em. through a 7 Cffi. portal directed laterally to the nasopharynx from both the left and right sides to include the entire eustachian tube. Each side received approximately 300 roentgens measured in air over a period of two weeks. During the winter of 1946-1947 the frequency of upper respiratory infections was not changed, but there was at no time any evidence of infection in the middle ear. f
The importance of these findings was clearly demonstrated during the war by the control of air otitis (baro trauma-R.A.F.) in the Army Air Forces. 15 It was early recognized that many of the difficulties in ear ventilation of air crews who were forced to undergo rapid changes in altitude was caused by hyperpla~tic lymphoid tissue in the nasopharynx. In consultation with ten otologists, a standardized program was set up by the Air Surgeon.' Irradiation by local application of radium to the lymphoid tissue in the nasopharyngeal ends of the eustachian tube was proved definitely beneficial and was an important factor in obtaining proper strength of air crews. Seventy-four per cent had less difficulty in ventilating their ears, during Hight and 89 per cent Had objective improvement. Twenty-six per cent had no subjective improvement, while only 11 per cent showed no decrease in the amount of lymphoid tissue. Local applications of radium or its active products is the treatment of choice, for the area irradiated is confined to the lymphoid tissue
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FRANCIS MAHONEY
in the fossa of Rosenmiiller and there is no significant exposure to irradiation of any of the surrounding tissues. Special. applicators are available for placement of the radium. These consist of modified metal nasal applicators bearing on their ends small monel metal chambers of 0.3 mm. wall thickness containing 50 mg. of radium. Seventy per cent of the transmitted radi.ation is gamma and 30 per cent beta radiation. Such applicators may also be modified to use radon, but the rapid disintegration of this radioactive product of radium makes the choice of radon an expensive one for the average clinic treating only a few cases a week. The standard commercial 0.3 mm. wall thickness monel metal applicator with the radium sealed into it is very expensive and its uses are limited. Special applicators can be built of low atomic weight metal with removable screw caps so that radium elements of 25 to 50 mg. strength can be inserted into them. This permits the use of forms of radium available in most hospitals. I'he applicator is small enough to be inserted readily through the nnesthetized nares. A direct vision nasoscope is inserted into one side and the radiuln applicator is inserted through the opposite nares and maneuvered into contact with the tip of the eustachian tube. It is then fixed in place for eight minutes. At the completion of treatment, the procedure is reversed and the other side treated. Three treatments at four week intervals are usually sufficient to cause marked regression of the lymphoid tissue. This regression usually lasts approximately eighteen months, at which time it may be repeated if symptoms recur without any untoward reaction of the normal sur.. rounding tissues. If, under direct examination, the lymphoid tissue shows regression by radium treatments but there is still selective loss of high tone and difficulty in ventilating the middle ear, it may be presumed that lymphoid tissue within the eustachian tube is causing continued blockage. At this time, external irradiation delivered to the eustachian tube is indicated. Approximately 400 roentgens measured in air delivered to each side is sufficient to cause comparable regression of lymphoid tissue to that obtained by local applications of radium in the nasopharynx. It must be stressed that this treatment is designed specifically to promote free aeration of the middle ear by destroying lymphoid tissue blocking the eustachian tube and the nasopharyngeal opening of the eustachian tube. Such treatment would be of no avail in other types or causes of deafness or infections of the middle ear. When there is midline hypertrophy of the adenoids, adenoidectomy should also be performed. SUMMARY
1. The primary role of radiation in the cure of certain benign and inflammatory diseases of the head and neck are discussed. 2. It is felt that irradiation treatment will produce th~ b~st resqlts
BENIGN DISEASES OF THE HEAD AND NECK
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in hemangiomas, keloids, tinea capitis, corneal scars and vascularization of corneal grafts and hypertrophy of nasopharyngeal lymphoid tissue.
REFERENCES 1. Pendergrass, E. P. and Hodes, P. J.: Roentgen Irradiation in the Treatment of Inflammations. Am. J. Roentgenol., 45:74, 1941. 2. Jacobs, L. G.: Short Wave Radiations, Mechanism of Anti-inHan1matory Effect. California & West. Med., 63:127, 1945. 3. Korb, G. N.: Radiosensitivity of Bacteria. Radiol. Rund. 2:120, 1933. 4. Dabasi, E.: Roentgenotherapy of Inflammations. Orovisi hetH., 76:682, 1932. 5. Hartley, P.: Effect of Radiation on Production of Specific Antibodies. J. Exper. Path., 5:306, 1924. 6. Bisgard, J. D. et al.: Mechanism of Action of Roentgen Therapy on Infection. Ann. Surg., 115:996, 1942. 7. Desjardins, A. D.: Dosage and Methods of Roentgen Therapy for Inflammatory Conditions. Radiology, 32:699, 1939. 8. Pfahler, G. E.: Treatment of Hemangioma. Radiology, 46:159, 1946. 9. Schwartz, L. et al.: Control of Ringworm of the Scalp among School Children. J.A.M.A., 132:58, 1946. 10. Whelen, S. T.: Personal communication. 11. MacKee, G. M. and Cipollaro, A.: Philadelphia, Lea & Febiger, 1946. 12. Poppe, E.: Experimental Investigation of Effect of Roentgen Rays on the Eye. Oslo, Kommisjon hos Jacob Dybwad, 1942. 13. Ruedemann, A. D. and Glasser, 0.: Beta Radiation Ophthalmology. Cleveland Clin. Quart., 13:104, 1946. 14. Crowe, J. J. and Burnam, C. F.: Recognition, Treatment and Prevention of Hearing Impairment in Children. Ann. OtoI., Rhin. and Laryng., 50: 15, 1941. i5. Combined Report on the Dse of Radium in the Aerotitis Control Program of the Army Air Forces. Ann. OtoI., Rhin. and Laryng., 54:650, 1945.
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