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Relationship between the otolaryngologist and the plastic surgeon
RELATIONSHIP BETWEEN THE
OTOLARYNGOLOGIST
AND THE PLASTIC SURGEON*
HAROLD
HAYS, M.D.
F.A.C.S.
ConsuIting Oto-Laryngologist, Safian Pavilion for PIastic Surgery, The Park West HospitaI; Medical Director, The Park West and The Park East HospitaIs NEW YORK
T
HE
diffrcuIt for the bronchoscopist to remove any type of growth from the Iarynx, frequentIy under IocaI anesthesia. PoIypi beIow or above the voca1 cords, papilIomata on the cords, cysts, etc., are excised with precision and frequentIy an intrinsic maIignant growth is removed from one cord, x-ray or radium appIied and the patient is cured. Such procedures wouId need no discussion here if it were not for the fact that a stenosis of the Iarynx may resuIt, particuIarIy after inff ammatory processes folIowing diphtheria or the inhaIation of some strong irritant. The surgeon must confine his attention to two factors: first, the restoration of breathing and secondly, if possible, a restoration of the voca1 cords so that the patient may be abIe to speak. Such operations are preferabIy performed intra-oraIIy, If indicated, operative procedures are done but in the majority of cases, a11 that is necessary is repeated diIatation of the interIaryngea1 space by the introduction of obturators of increasing size which have an opening in the center so that the patient is abIe to breathe. CompIete diIatation may take pIace, with or without permanent injury to the voca1 cords. In certain cases, the voca1 cords themseIves may be repaired by proper interna or externa1 operation.
plastic or reconstruction surgeon is primariIy interested in reparative operations upon the exterior of the body and the restoration of functioning parts, such as repair to injuries of tendons and nerves. This Ieaves a special fieId for pIastic surgery. For exampIe, diIatation of the Iarynx, repair of tracheotomy wounds, adhesions of the posterior piIIars of the fauces to the phrayngea1 waI1, the proper remova of tonsiIs and adenoids in a patient with cIeft paIate, the cIosure of perforations of the nasa1 septum, the pIastic operation for either congenita1 or acquired atresia of the auditory cana1, can very we11 be remedied by the expert otoIaryngoIogist, with or without the assistance of the pIastic surgeon. To these procedures may be added the correction of prominent ears and the cIosure of deep clefts which often resuIt from a severe mastoid infection or from a mastoid wound which has been aIIowed to hea improperIy. It is my beIief that a11 of these procedures are we11 within the province of the otoIaryngoIogist, and the treatment of recent fractures of the nose may be added. MANAGEMENT PROCEDURES)
(INCLUDING OF
OPERATIVE
REPARATIVE
CITY
PRO-
CEDURES BY THE OTOLARYNGOLOGIST LARYNGEAL STENOSIS
REPAIR OF TRACHEOTOMY WOUNDS
Since the advent of direct Iaryngoscopy and bronchoscopy, many operative procedures resuIt in briIliant success. It is not
FrequentIy tracheotomy has to be performed as an emergency measure in cases of acute IaryngeaI obstruction, aris-
* From the Safian Pavilion for Plastic and Reconstructive Surgery, The; Park West HospitaI, New York City. Presented in abstract at Beth-E1 HospitaI, BrookIyn. 38
NEWSERIES VOL. xXx1,
NO. I
Hays-OtoIaryngoIogist,
of a foreign ing from the inhaIation body, an acute inff ammation, associated with an angina Ludovici or an angioneurotic edema, or from diphtheritic membrane in the larynx (not so often today). As a rule the tracheotomy tube does not have to remain in situ for a great Iength of time, so on remova1, the wound is aIIowed to close and the cosmetic resuIt is not unsightIy. However, in chronic stenosis of the Iarynx and in carcinoma of the Iarynx, where an intrinsic growth has been removed, the tracheotomy tube has to be worn for a considerabIe Iength of time. I am not taking into account those cases where a Iaryngectomy has to be performed for maIignancy; for in those cases the trachea1 wound may have to remain open permanentIy. In the type of case in which the tracheotomy tube may be removed after a short an unsightIy wound remains interval, which necessitates a cosmetic operation, for not onIy is the wound indented but there is an opening into the trachea which has to be cIosed. Operative Procedure. After thorough cIeansing of the parts, the skin and underlying tissues are anesthetized by injections of I per cent novacain and adrenalin. The edges of the wound are freshened and the trachea is separated from the superficial tissues. It is now possibIe in the majority of cases to cIose the trachea1 wound, and this may be done if there is assurance that no narrowing wiI1 fohow. The skin and deeper tissues are wideIy separated from the underIying parts. The edges of the oId wound are freshened and brought together horizontahy and then sutured with fine siIk. The wound heaIs rapidly and as a rule by primary intention. PHARYNGEAL
ADHESIONS
A congenita1 abnormality may occur but this is rare. Adhesions of the posterior piIIar or piIIars of the tons& to the pharyngea1 waI1 may resuIt from an improperIy performed tonsil and adenoid operation. Such accidents do not take pIace as often
PIastic
Surgeon
American JCW~
of Surgery
39
today as they did in former years but such cases are occasionalIy seen by the otoIaryngoIogist. I have seen many maIformations of the throat due to operations done by men who had no right to operate. These malformations extend from the moderate adhesion of one piIIar to the pharyngea1 wal1 to a compIete cIosure of the nasopharynx where the tissues have been so torn and mahreated that there are no remaining norma anatomica relationships. However, such a condition may result from tubercuIosis or syphiIis of the nasopharynx. In fact, considerabIe destruction of tissue, with adhesions, is associated with syphiIis. Symptoms of such a condition may be insignificant or may become so serious that they interfere with the norma vitality of the individua1. NasaI breathing is diffrcuIt or impossible, there may be difhculty in swallowing or the patient may compIain of a stiffness of the throat. One easiIy sees what the diffrcuIty is on IocaI examination of the patient. ParentheticaIIy it may be mentioned that extreme deformities of the throat, most often due to mutiIating operations, may give rise to no symptoms whatsoever. Years ago, at the New York Academy of Medicine, the question of tonsiI operations in singers was discussed. Many men had been of the opinion that distortion of the throat, adhesions after operation, etc. would interfere with the singing voice. The members of the LaryngoIogicaI Section brought together an array of professiona singers who had had tonsi operations and who had, as a resuIt, deformed throats, extending from an amputated uvuIa to definite adhesions between the pillars and the pharynx. In every instance the voice was as good as ever. Consideration for Operation. Examination of the throat reveaIs the extent of the deformity. Where there is fair breathing, the patient is in good physica condition, no aIteration in the voice, the patient is able to swaIIow normahy and has no feeIing of anything abnorma1, nothing should be done. In other words just seeing the ab-
40
American Journalof Surgery
Hays--OtoIaryngoIogist,
normal condition is no reason for performing an operation. I have one patient who has an opening into the nasopharynx no
FIG.
I.
SaddIe
back
FIG. IA. nose due to removal of too much
larger than the calibre of an ordinary lead pencil, and has no symptoms. At forty years of age, he is still perfectly normal. In other cases, it is absolutely essential that something be done. Operation for Pharyngeal Adhesions. It is of primary importance to map out a procedure in which the adhesions are freed and also to be able to cover the denuded surfaces with new mucous membrane, to avoid formation of new adhesions. As an anesthetic of preference the patient is given avertin by rectum, supplemented by a local anesthetic of novocain and adrenalin. The adhesions are freed by sharp dissection until one is sure that there is sufficient motility and nasal breathing space. The amount of denuded area may be considerable and the next problem is to find sufficient mucosa to cover the raw, denuded space. After it is properIy filIed in it is sutured into place with fine catgut or silk. This procedure is by no means easy and particuIar care must be taken that the denuded surface of the soft palate and the posterior pillars is covered. After this is
Plastic
Surgeon
JaNMW,1936
accomplished satisfactorily, attention must be given to the cheek wound. The edges of the cut mucosa are freed from the deeper
FIG.
septum.
(From
IB.
Safian’s
Corrective
Rhinoplastic
Surgery.)
tissues until they can be approximated without tension and then they are sutured with fine catgut. As a rule, the wounds heal readily. One continues to keep the mouth clean and antiseptic. Food is given by rectum for three days. Th.e patient is cautioned not to swallow any more than is necessary. The wounds are inspected daily. At the end of the fifth day the patient is free from any danger of infection. REMOVAL
OF
PATIENTS
TONSILS WITH
AND CLEFT
ADENOIDS
IN
PALATE
Infrequently patients with cleft palate have enlarged tonsils and sometimes adenoids which have to be removed. It is of the utmost importance that such an operation be performed with unusua1 care so that as little as possible of the soft tissues which surround the tons& be disturbed. There are two types of cases: (I) in very young individuals who have not had a cIeft palate operation performed and where one is contempIated; and (2) adults who have worn an obturator or prosthesis which fits
~~~ sERIEsvoL.XXXI, No. I Hays-OtoIaryngoIogist, properIy. If soft tissue is sacrificed by a poor operation, the denta pIate wiI1 not fit. I have taken care of both types of cases.
PhStiC
SUrgeOn
to the piIIars same position before.
American ~~~~~~~of Surgery
so that they maintain after operation as they
41
the did
FIG. 2. Saddle back nose due to removal of too much septum. (From S&an.)
In the former group of cases, the otoIaryngoIogist must regard the throat from the viewpoint of the surgeon who is to repair the palate cIeft. A thorough examination must be made of the reIationship of the anterior and posterior piIIars of the fauces to the tonsi1. The dissection must be made with the utmost care so that, after the tonsi1 is removed, the pihars hang IooseIy so that they may be utilized Iater. Care must aIso be used in removing the adenoids so that there is no opportunity for adhesions to form. In the second group of cases, when the obturator is removed, one can see high up in the vauIt of the nose. The tons& are not in a normal position; as a ruIe they hang IooseIy and extend down into the hypopharynx. There is a tendency to puI1 on the piIIars so that they are distorted and out of position. There is always a possibiIity that even with the most skiIfu1 operation, a Iaxity of the piIIars will take pIace so that the obturator wiI1 not fit properIy Iater. The tonsiIs must be removed, preferabIy by dissection; special attention must be paid
FIG. 3. Dropping of tip of nose due to improper septum operation. (From Safian.)
HARELIP
CASES
WITH
NASAL
OBSTRUCTION
Obviously the pIastic surgeon should operate upon the majority of patients. There are certain cases in which the cIeft extends into the nose so that one nostri1 is narrower and a definite nasa1 obstruction is made worse because of deviation of the septum to the distorted side. The hareIip operation should be performed at an early age, but the nasal obstruction shouId not be operated upon until after puberty if it is possible to wait that Iong. The obstruction is usuaIIy in the inferior meatus and is due to a disIodgement of the vomer from its norma groove at the time of birth. Metzenbaum of CIeveIand pointed out the fact that in many patients who do not have cIeft palate disIodgement of the septum occurs at birth. If one is aware of the fact that such an obstruction has taken pIace it can easiIy be corrected at that time. AI1 one has to do is to sIip one’s finger or
42
American Journal 0f
surgery Hays-OtoIaryngoIogist,
some duI1 instrument and Iift the septum groove.
into the affected side back into its norma
If the obstruction persists unti1 puberty, the otoIaryngoIogist can operate on the septum. We shaI1 take it for granted that the narrowed nostri1 has been enlarged, therefore only as much of the septum as is causing obstruction shouId be removed. As was stated, this defect is usuaIIy in the inferior meatus and forms a hard bony obstruction. After the underIying mucosa is freed, the bone is removed with a hammer, chise1 and sometimes a saw, and the mucosa then repIaced. Since there is a redundancy of mucosa it does not matter if some of it is destroyed. The utmost care shouId be taken to see that there are no denuded parts. DEFLECTION
Surgeon
OF THE
TRIANGULAR
CARTILAGE
This operation is so simpIe that very IittIe space is needed for its description. The offending nostri1 may be seen to be aImost, if not compIeteIy obstructed by the
JANUARY. 1936
cartiIage. The operation is preferabIy performed in a hospita1. AI1 hairs shouId be cut off. Iodine shouId be appIied to the part
FIG. 4~. FIG. 48. A. Appearance foIIowing automobile accident. Probe extending B. Case after operation by Dr. Joseph Safian. through nose.
FIG.4. Au Ithor’s-c :ase. (From Safian.) wound
PIastic
fl-0m exter ,naI
and then it shouId be anesthetized with novocaine. The incision shouId be made over the most prominent part and continued down to the cartiIage. The dissection behind and in front of this is not aIways easy because there are three to four Iayers of very adherent tissue but it can be accompIished with a sharp scaIpe1. After the cartiIage is denuded, an incision is made thrbugh it, the parts on the other side freed and the obstruction removed. In many instances one wiI1 see a deviation of the septum which couId not be seen before but this shouId be Ieft aIone if the breathing seems to be free. After the obstruction has been removed, the edges of the incision shouId be brought together with fine bIack siIk sutures which are aIIowed to remain in pIace for five days. If the wound is not sutured, a denuded area is apt to remain or a perforation of the septum may occur; for the mucosa on the opposite side is very thin.
~~~ sERIEsvoL.XXXI,No. I Hays-Oto1aryngoIogist,
PERFORATIONS
OF
THE
NASAL
SEPTUM
Such an accident is quite common and is frequentIy the resuIt of a septum operation. Primary perforations of the septum are most unusua1. This condition may arise from continuahy picking the nose to remove crusts, or may be due to disease, either tubercuIosis or syphiIis. Most septa1 perforations resuIting from septum operacan be attributed to occasiona tions, imperfectly performed operations, and other times because the mucosa is so thin that it tears, regardIess of the utmost care at the time of operation. Perforations divide themseIves into two main cIasses : the Iarge and the smaI1. Large perforations do not cause as much troubIe to the patients as smaI1 ones. The main compIaint is constant crusting of nasa1 secretions. It is seIdom possibIe to repair these large perforations. As suggested by SkiIIern, at times a Iarge opening in the septum is purposeIy made for certain types of sinus disease. The smaII perforation, from the size of a pin head to a centimeter in diameter, is a definite nuisance, mainIy because it causes a whistIing sound whenever the patient breathes through his nose. Operation. If these perforations are in the anterior portion of the septum, they are not extremeIy diffrcuIt to correct. After proper anesthetization, one attempts to separate the mucosa and underIying soft tissues, both anteriorIy and posteriorIy to the perforation. Then one penetrates the edges a11 around unti1 the tissues are free. The edges of the perforation are freshened and then coapted with fine sutures. The suturing is not very easy and has to be performed with a modified aneurysm needIe. The sutures may be removed at the end of five days. As a ruIe, no packing is necessary. In certain cases, in which there is tension of the tissues after they are freed, an incision of some extent may be made above and beIow the perforation. The denuded parts wil1 eventuaIIy hea1.
PIastic
SADDLE
Surgeon
NOSE
American ~~~~~~~of surgery
RESULTING
SEPTAL
FROM
43
IMPROPER
OPERATIONS
NaturaIIy the correction of such a deformity shouId be Ieft to the competent pIastic surgeon. The chief reason for bringing it to one’s attention here is to warn the otoIaryngoIogist that he shouId be unusuaIIy carefu1 in performing a septa1 operation so that such a disastrous deformity, does not take pIace. In studying the anatomy of the nose, one reaIizes that the septum is the main support of the nose and has a great dea1 to do with its externa1 appearance. The most prominent part is heId in pIace by the conformity of the cartiIaginous portion of the septum, particuIarIy the upper part. The bony portion of the septum can be mutiIated to a great extent without causing any troubIe. The tip of the nose may Iose its norma appearance by too extensive an operation on the trianguIar cartiIage (Figs. I and 2). The upper portion of this cartiIage hoIds up the tip of the nose; if this is removed, the tip wiI1 drop. Therefore, in performing this operation, care must be taken not to remove the upper portion of this cartiIaginous septum. We are mainIy concerned with saddIe nose. A saddIe nose of the extreme kind may resuIt from many causes, as injuries, syphiIis, etc. The sunk-in nose with which we are concerned is the depression which occurs in the Iower portion, just beIow the junction of the two nasa1 bones. This is aImost invariabIy caused by an improperIy performed septa1 operation. OtoIaryngoIogists must reaIize that a septa1 operation shouId be performed for two purposes onIy: to give proper breathing space and to give proper drainage to the sinuses. OnIy as much of the septum as is necessary shouId be removed and one shouId never make the attempt to remove the entire septum, particuIarIy the trianguIar portion. One may remove a11 he wishes of the Iower cartiIaginous portion of the septum but shouId beware of the
44
American
Journalof Surgery
Hays-OtoIaryngoIogist,
upper portion. It is surprising how the remova of any part of the supporting septum wiIl resuIt in a cave-in of the nose (Fig. 3). It is preferabIe to aIIow a smaI1, deviated part to remain than to excise too much and Ieave a nose which wiI1 sink within a short time and require pIastic repair. EXTERNAL
SINUS
OPERATIONS
WITH
DEFORMITY
The otoIaryngoIogist is mainIy concerned with getting the patient we11 and seIdom thinks of the marred features which wiI1 resuIt from the operation and which wiII be a constant embarrassment to the patient. Sometimes one cannot concern himseIf, but at other times, it is possibIe to pay more attention to the suturing process. Of main concern is the depression which arises from an extensive frontal sinus operation. This may be overcome in many instances by a thorough examination of the x-ray plates and adapting the procedures to the amount of bone invoIved. I have seen cases in which there was littIe disease of the external pIate and yet the entire bone was removed from the externa1 to the interna canthus. In such cases, onIy a smaI1 opening into the fronta sinus need be made. After the process of the disease has ceased, the external wound wiI1 hea without resulting scar, particuIarIy if the origina wound is made through the eyebrow. Where an extensive operation has been performed, particuIarIy if it is necessary to make a butterfly incision over both frontal sinuses, an unsightIy scar must necessariIy deveIop. Later a pIastic operation may be performed or a proper prosthesis appIied. ACUTE
NASAL
FRACTURES
Extreme deformities, the resuIt of severe injury to the nasa1 bones and often of the surrounding parts, may be cared for more properly by the pIastic surgeon. But he may not be available and very often such injuries wiIl have to be handIed by the genera1 practitioner.
PIastic
Surgeon
JANUARY, 1936
As a ruIe, it is wiser not to make any attempt to adjust the injured parts at the time of the immediate injury and particuIarIy so when there are externa1 wounds. The nasa1 hemorrhage is often severe and if there is a fracture of the septum there may be an extravasation of bIood on one or both sides of the septum. Such a hemorrhage must be stopped immediateIy both as a matter of convenience to the patient and because one must avoid the formation of a submucosa1“ bIood tumor” which may Iater cause a permanent obstruction. The usua1 procedures for arresting nasa1 hemorrhage shouId be applied. If packing one or both of the nasa1 cavities is necessary, it shouId be done with extreme care. Better resuIts are obtained if the nose is washed out thoroughIy with a hot saIine soIution (106-I I~‘F.) to which is added a small amount of suprarenaIin extract. In fact, the hemorrhage may cease, without packing, if the nose is properIy washed out. Attention shouId now be paid to the externa1 sweIIing. This is best reduced by the appIication of iced compresses. If external wounds are present, it is far better not to attempt suture for twenty-four hours so that infection may be ehminated. Then the edges should be carefuhy examined and, if possibIe, they shouId be caref&y approximated with line silk sutures. Two definite probIems present themseIves: (I) attention to intranasal injuries and (2) attention to externa1 deformity. If one finds a fracture of the septum, particuIarIy if there is a severe extravasation of bIood, resort to packing of the nose as soon as possibIe. The routine packing of the nose, usuahy with iodoform gauze, is crude and is often unskilfuIIy done. The best way to pack the nasa1 cavities is to take folds of J/4 inch gauze (iodoform, bismuth or pIain) about 2 inches long. Place the first packing in the inferior meatus and then appIy further foIds of gauze, one on top of the other, unti1 the cavity is tightIy filled. Care shouId be taken to exert pressure upon the septum in order to ehminate any tendency toward excessive hemorrhage.
NEW SEIUES Vor. XxX1,
No. r
Hays-OtoIaryngoIogist,
The actuaI fracture of the nasa1 bones themseIves must receive especia1 attention. Such fractures falI into a number of cIasses and the treatment given wiI1 depend upon the extent of the fracture and the resuIting deformity. The simpIest type is the comminuted fracture or greenstick fracture with no deformity. Very sIight or no crepitation will be feIt on palpation, and the fracture may be ascertained onIy by x-ray picture. No treatment to the fracture itseIf is necessary. Other types vary from the depressed fracture or one which causes the nose to be forced to one side, to that with externa1 wounds or compIete destruction of the nasa1 bones. After the external sweIIing has subsided to some extent, an attempt must be made to bring the bones into proper aIignment before there is an opportunity for the bones to “set” in a wrong position. The patient should be given a genera1 anesthetic. A blunt instrument is pIaced in the nasal cavity on the side of the depressed bone and the fragment elevated to its normal position. In many cases this is possibIe. If the entire nose has been forced to one side, forcible manipulation m.ay be necessary to adjust it properly. A smaII pad should be placed against the fractured bone and held in pIace with adhesive tape. At the same time, a nasa1 packing shouId be pIaced high up in the nose to hoId the fragment in pIace from the inside. This shouId be Ieft in pIace three to four days. GeneraIly, the nose wiII take care of itseIf after that. If there is stiI1 evidence of deformity, the patient shouId be referred to a pIastic surgeon of repute for further care. ACCIDENTAL
IN JURIES
Numerous types of injury of this kind are seen today, because of the automobiIe. The otolaryngologist, as well as the genera1 practitioner, must be in a position to take care of such patients. No genera1 or specific ruIes can be laid down. In many instances, immediate surgery is necessary-surgery
Plastic
Surgeon
American
which cannot attempt cosmetic resuIts.
~~~~~~~ Of surgery
to pay attention
45 to
One automobiIe accident case seen presented a fracture of the nose, the malar and fronta bones and injury to one eye (Fig. 4). There were numerous external wounds. Attention was paid to the injuries at the time of the accident. The wounds were sutured, the maIar and frontal bones lifted into position and an attempt made to bring together the fragments of nasa1 bones. The deformity, especiaIIy to the nose, was considerabIe. Dr. Safian performed a reparative operation at a Iater date. PROTRUDING
EARS
Very prominent ears, standing well out from the head, often need attention. The operation is comparativeIy simpIe and can readiIy be performed by the competent aurist. A semiIunar incision is made behind the ear, under either IocaI or genera1 anesthesia. Dissection of the soft tissues is carried down to the ear cana and backward under the scaIp until they are Ioose. The proper amount of soft tissue is excised and the free edges of the wound sutured. A bandage is kept on for a few days and then the sutures removed. The resuIts are uniformIy good. REPAIR
OF CAVITY
DEFECTS
AFTER
MASTOID
OPERATION
In former times, when mastoid wounds were packed and Ieft open, unsightIy cavities behind the ear often resulted. Such a condition also arises today in those cases where wounds wiI1 not hea properIy or where it is necessary to Ieave the mastoid cavity wide open because some compIication has occurred. The patient does not complain so much about the cavity as of the dirt which accumuIates in it and which has to be cIeaned out from time to time. In certain cases, a sinus Ieads down into the antrum and middle ear so that the cavity is constantIy moist from secretions which come up from the throat through the eustachian tube. This results in crust formation which is extremeIy annoying.
46
* me&anJournal
of Surgery
Hays-OtoIaryngoIogist,
The probIem is to cIose this cavity, both for cosmetic reasons and to rid the patient of the annoyances. PreferabIy under avertin and IocaI anesthesia, the parts are thoroughIy cIeansed of a11 foreign materia1. The thin skin which Iines the mastoid cavity is carefuIIy dissected from the underIying bone. The soft tissues are compIeteIy freed anteriorIy and posteriorIy. The anterior dissection must be carried down to the posterior cana waI1. The posterior dissection is continued for at Ieast 1% inches. However if the tissues were then brought together there wouId be too much tension. Therefore a second incision is made in the scalp, at Ieast 134 inches behind the mastoid wound and carried down to the bone. This is made suffrcientIy Iong so that the section of scaIp can be sIid forward. The edges now overIying the mastoid cavity are sutured with some strong materia1. Dissection of the scaIp is then continued posteriorIy unti1 there is sufficient Ioose tissue to bring the edges of the second wound together without any tension. A reguIar mastoid bandage is appIied. HeaIing takes pIace in five to six days when the sutures may be removed. As a ruIe, the cosmetic resuIt is exceIIent and what pIeases the patient most is that there is no further secretion from the middIe ear. ATRESIA
OF
EAR
CANAL
Atresia of the ear cana may be either congenita1 or acquired. Atresia may be onIy of the cartiIaginous portion of the cana or may invoIve the bony structures. In cases of congenita1 atresia, it is necessary to determine whether the cIosure of the cana invoIves the bony structure or not and also whether any middIe ear is present, particuIarIy if marked deafness is aIso present. In congenita1 cases where the bony structures are definitely abnorma1, the condition cannot be corrected. Where the cIosure is in the anterior part of the canal invoIving onIy the soft structures, it is frequentIy possibIe to correct the condition. This is essentia1 in patients who have functioning middIe ears, because norma or
PIastic
Surgeon
JANUARY. 1936
nearIy norma hearing may be restored if the atresia is properIy corrected. Such atresia may be caused by a thin membrane which has deveIoped in the ear cana1, compIeteIy occIuding it. In these cases the operation is very simpIe because the membrane is easiIy excised. In other cases the cana is compIeteIy cIosed off by cartiIage, skin and inner Iming mucous membrane. A plastic operation has to be performed. An incision is made behind the ear and extended down to and through the posterior CartiIaginous cana waI1. As much of the obstruction as possibIe is removed unti1 one obtains a good view of the drum membrane. The type of reconstruction of the cana wiI1 depend upon the individua1 case. In every instance it is necessary to obtain flaps of cartiIage and skin to Iine the new cana1. After these are retained in pIace with catgut sutures, the ear cana is firmIy packed with gauze which is kept in pIace unti1 such time as definite adherence has occurred. Acquired atresia may resuIt from chronic eczema of the ear cana or muItipIe furuncles which resuIt in chronic inffammation. Such a condition may arise from an accident to the cana waI1 but most frequentIy a partia1 or compIete atresia resuIts from a mastoid operation in which too much of the bony posterior cana waII had been removed and permitted a proIapse of the membranous waI1 with a more or Iess compIete cIosure of the externa1 auditory apparatus. Operation may have to be performed to correct such a condition. Again an incision is made behind the ear and extended down unti1 the narrow part is brought into sight. The operation wiI1 vary according to the condition. One proceeds in the same manner as in making a pIastic ffap after a radica1 mastoid operation. An incision is made behind the ear and as much as possibIe of the underlying cartiIage is freed from the skin. This Ieaves a Ioose flap of tissue which can be sutured into pIace so that a new auditory canal can be made as Iarge as one wishes. In the course of time
NEW Seams VOL.XXXI, No.
I Hays-OtoIaryngoIogist,
the denuded parts are covered with granuIations and the externa1 appearance of the ear is not changed. CONCLUSION
AIthough one reaIizes the necessity for referring the majority of patients needing pIastic repair to the plastic surgeon, it wiI1 be seen from the procedures here outlined that there are certain definite cases which have to be attended by the otoIaryngoIogist and occasionaIIy by the genera1 practitioner. It is my sincere hope that I have made certain conditions suffkiently cIear to the reader so that he wiI1 be abIe to handIe such cases in an inteIIigent manner. REFERENCES BABCOCK, W. W. PIastic closure of Iaryngotomic fistuIas and enIargement of the Iumen of the trachea or Iarynx by impIantation of a chondrocutaneous Aap. Arch. Otolaryng., rg: 585-589, 1934.
PIas&
Surgeon
American ~~~~~~~ of surgery
47
BICKHAM, W. S. Operative Surgery. Phila., Saunders, 1924, 3: 305. (Closure of perforations, Hazeltine’s technique.) HARRIS, T. J. Adhesions after tonsiIIectomy. Laryngoscope, 30: 471, 1920. (Presentation of a-case.) JACKSON. _ C., and BABCOCK. W. W. PIastic closure of tracheotomic fistuIa. Surg. Clin. Nortb America, 14: rgg-202 (Feb.) 1934. (Adhesions of posterior pillars to pharyngea1 waI1 after tonsiIIectomy. Operations for same.) KEELER, J. C. Modern OtoIogy. PhiIa., Davis, 1930, pp. 149: 152. KOPETZKY, S. J. OtoIogic Surgery. Ed. 2. N. Y., Hoeber, 1929, pp. 46-5 I. LISCHKOFF, M. A., and HEINBERG, C. J. A new procedure for the cIosure of non-soecibc oerforations of the nasal septum. Arch. Otolaryng., 14: 342, 1926. MACKENTY, J. E. NasopharyngeaI atresia. Arch. Otolaryng., 6: I (July) 1927. (Operation for cIosure of peifoiations of n&a1 septum.) RICHARDS. L. ConeenitaI atresia of the external auditory meatus. “Ann. Otol., Rbinol. & Laryngol., 42: 692-71 I, 1933. (BibIiog.) SAFIAN, J. Corrective RhinopIastic Surgery, N. Y., Am. J. Surg., 1934. SEWALL. E. C. Perforations of the seotum. In: Jackson. C., ‘The Nose, Throat and Ear and Their Diseases: PhiIa., 1930, pp. 77-79. TOD, H. F. Operations upon the ear. In: Oxford LooseLeaf Liv. Surg., 4: 327-510, 1920. (Atresia, pp. 354-355; illus. p. 426.) I
I
OTOLARYNGOLOGIST
AND THE PLASTIC SURGEON*
HAROLD
HAYS, M.D.
F.A.C.S.
ConsuIting Oto-Laryngologist, Safian Pavilion for PIastic Surgery, The Park West HospitaI; Medical Director, The Park West and The Park East HospitaIs NEW YORK
T
HE
diffrcuIt for the bronchoscopist to remove any type of growth from the Iarynx, frequentIy under IocaI anesthesia. PoIypi beIow or above the voca1 cords, papilIomata on the cords, cysts, etc., are excised with precision and frequentIy an intrinsic maIignant growth is removed from one cord, x-ray or radium appIied and the patient is cured. Such procedures wouId need no discussion here if it were not for the fact that a stenosis of the Iarynx may resuIt, particuIarIy after inff ammatory processes folIowing diphtheria or the inhaIation of some strong irritant. The surgeon must confine his attention to two factors: first, the restoration of breathing and secondly, if possible, a restoration of the voca1 cords so that the patient may be abIe to speak. Such operations are preferabIy performed intra-oraIIy, If indicated, operative procedures are done but in the majority of cases, a11 that is necessary is repeated diIatation of the interIaryngea1 space by the introduction of obturators of increasing size which have an opening in the center so that the patient is abIe to breathe. CompIete diIatation may take pIace, with or without permanent injury to the voca1 cords. In certain cases, the voca1 cords themseIves may be repaired by proper interna or externa1 operation.
plastic or reconstruction surgeon is primariIy interested in reparative operations upon the exterior of the body and the restoration of functioning parts, such as repair to injuries of tendons and nerves. This Ieaves a special fieId for pIastic surgery. For exampIe, diIatation of the Iarynx, repair of tracheotomy wounds, adhesions of the posterior piIIars of the fauces to the phrayngea1 waI1, the proper remova of tonsiIs and adenoids in a patient with cIeft paIate, the cIosure of perforations of the nasa1 septum, the pIastic operation for either congenita1 or acquired atresia of the auditory cana1, can very we11 be remedied by the expert otoIaryngoIogist, with or without the assistance of the pIastic surgeon. To these procedures may be added the correction of prominent ears and the cIosure of deep clefts which often resuIt from a severe mastoid infection or from a mastoid wound which has been aIIowed to hea improperIy. It is my beIief that a11 of these procedures are we11 within the province of the otoIaryngoIogist, and the treatment of recent fractures of the nose may be added. MANAGEMENT PROCEDURES)
(INCLUDING OF
OPERATIVE
REPARATIVE
CITY
PRO-
CEDURES BY THE OTOLARYNGOLOGIST LARYNGEAL STENOSIS
REPAIR OF TRACHEOTOMY WOUNDS
Since the advent of direct Iaryngoscopy and bronchoscopy, many operative procedures resuIt in briIliant success. It is not
FrequentIy tracheotomy has to be performed as an emergency measure in cases of acute IaryngeaI obstruction, aris-
* From the Safian Pavilion for Plastic and Reconstructive Surgery, The; Park West HospitaI, New York City. Presented in abstract at Beth-E1 HospitaI, BrookIyn. 38
NEWSERIES VOL. xXx1,
NO. I
Hays-OtoIaryngoIogist,
of a foreign ing from the inhaIation body, an acute inff ammation, associated with an angina Ludovici or an angioneurotic edema, or from diphtheritic membrane in the larynx (not so often today). As a rule the tracheotomy tube does not have to remain in situ for a great Iength of time, so on remova1, the wound is aIIowed to close and the cosmetic resuIt is not unsightIy. However, in chronic stenosis of the Iarynx and in carcinoma of the Iarynx, where an intrinsic growth has been removed, the tracheotomy tube has to be worn for a considerabIe Iength of time. I am not taking into account those cases where a Iaryngectomy has to be performed for maIignancy; for in those cases the trachea1 wound may have to remain open permanentIy. In the type of case in which the tracheotomy tube may be removed after a short an unsightIy wound remains interval, which necessitates a cosmetic operation, for not onIy is the wound indented but there is an opening into the trachea which has to be cIosed. Operative Procedure. After thorough cIeansing of the parts, the skin and underlying tissues are anesthetized by injections of I per cent novacain and adrenalin. The edges of the wound are freshened and the trachea is separated from the superficial tissues. It is now possibIe in the majority of cases to cIose the trachea1 wound, and this may be done if there is assurance that no narrowing wiI1 fohow. The skin and deeper tissues are wideIy separated from the underIying parts. The edges of the oId wound are freshened and brought together horizontahy and then sutured with fine siIk. The wound heaIs rapidly and as a rule by primary intention. PHARYNGEAL
ADHESIONS
A congenita1 abnormality may occur but this is rare. Adhesions of the posterior piIIar or piIIars of the tons& to the pharyngea1 waI1 may resuIt from an improperIy performed tonsil and adenoid operation. Such accidents do not take pIace as often
PIastic
Surgeon
American JCW~
of Surgery
39
today as they did in former years but such cases are occasionalIy seen by the otoIaryngoIogist. I have seen many maIformations of the throat due to operations done by men who had no right to operate. These malformations extend from the moderate adhesion of one piIIar to the pharyngea1 wal1 to a compIete cIosure of the nasopharynx where the tissues have been so torn and mahreated that there are no remaining norma anatomica relationships. However, such a condition may result from tubercuIosis or syphiIis of the nasopharynx. In fact, considerabIe destruction of tissue, with adhesions, is associated with syphiIis. Symptoms of such a condition may be insignificant or may become so serious that they interfere with the norma vitality of the individua1. NasaI breathing is diffrcuIt or impossible, there may be difhculty in swallowing or the patient may compIain of a stiffness of the throat. One easiIy sees what the diffrcuIty is on IocaI examination of the patient. ParentheticaIIy it may be mentioned that extreme deformities of the throat, most often due to mutiIating operations, may give rise to no symptoms whatsoever. Years ago, at the New York Academy of Medicine, the question of tonsiI operations in singers was discussed. Many men had been of the opinion that distortion of the throat, adhesions after operation, etc. would interfere with the singing voice. The members of the LaryngoIogicaI Section brought together an array of professiona singers who had had tonsi operations and who had, as a resuIt, deformed throats, extending from an amputated uvuIa to definite adhesions between the pillars and the pharynx. In every instance the voice was as good as ever. Consideration for Operation. Examination of the throat reveaIs the extent of the deformity. Where there is fair breathing, the patient is in good physica condition, no aIteration in the voice, the patient is able to swaIIow normahy and has no feeIing of anything abnorma1, nothing should be done. In other words just seeing the ab-
40
American Journalof Surgery
Hays--OtoIaryngoIogist,
normal condition is no reason for performing an operation. I have one patient who has an opening into the nasopharynx no
FIG.
I.
SaddIe
back
FIG. IA. nose due to removal of too much
larger than the calibre of an ordinary lead pencil, and has no symptoms. At forty years of age, he is still perfectly normal. In other cases, it is absolutely essential that something be done. Operation for Pharyngeal Adhesions. It is of primary importance to map out a procedure in which the adhesions are freed and also to be able to cover the denuded surfaces with new mucous membrane, to avoid formation of new adhesions. As an anesthetic of preference the patient is given avertin by rectum, supplemented by a local anesthetic of novocain and adrenalin. The adhesions are freed by sharp dissection until one is sure that there is sufficient motility and nasal breathing space. The amount of denuded area may be considerable and the next problem is to find sufficient mucosa to cover the raw, denuded space. After it is properIy filIed in it is sutured into place with fine catgut or silk. This procedure is by no means easy and particuIar care must be taken that the denuded surface of the soft palate and the posterior pillars is covered. After this is
Plastic
Surgeon
JaNMW,1936
accomplished satisfactorily, attention must be given to the cheek wound. The edges of the cut mucosa are freed from the deeper
FIG.
septum.
(From
IB.
Safian’s
Corrective
Rhinoplastic
Surgery.)
tissues until they can be approximated without tension and then they are sutured with fine catgut. As a rule, the wounds heal readily. One continues to keep the mouth clean and antiseptic. Food is given by rectum for three days. Th.e patient is cautioned not to swallow any more than is necessary. The wounds are inspected daily. At the end of the fifth day the patient is free from any danger of infection. REMOVAL
OF
PATIENTS
TONSILS WITH
AND CLEFT
ADENOIDS
IN
PALATE
Infrequently patients with cleft palate have enlarged tonsils and sometimes adenoids which have to be removed. It is of the utmost importance that such an operation be performed with unusua1 care so that as little as possible of the soft tissues which surround the tons& be disturbed. There are two types of cases: (I) in very young individuals who have not had a cIeft palate operation performed and where one is contempIated; and (2) adults who have worn an obturator or prosthesis which fits
~~~ sERIEsvoL.XXXI, No. I Hays-OtoIaryngoIogist, properIy. If soft tissue is sacrificed by a poor operation, the denta pIate wiI1 not fit. I have taken care of both types of cases.
PhStiC
SUrgeOn
to the piIIars same position before.
American ~~~~~~~of Surgery
so that they maintain after operation as they
41
the did
FIG. 2. Saddle back nose due to removal of too much septum. (From S&an.)
In the former group of cases, the otoIaryngoIogist must regard the throat from the viewpoint of the surgeon who is to repair the palate cIeft. A thorough examination must be made of the reIationship of the anterior and posterior piIIars of the fauces to the tonsi1. The dissection must be made with the utmost care so that, after the tonsi1 is removed, the pihars hang IooseIy so that they may be utilized Iater. Care must aIso be used in removing the adenoids so that there is no opportunity for adhesions to form. In the second group of cases, when the obturator is removed, one can see high up in the vauIt of the nose. The tons& are not in a normal position; as a ruIe they hang IooseIy and extend down into the hypopharynx. There is a tendency to puI1 on the piIIars so that they are distorted and out of position. There is always a possibiIity that even with the most skiIfu1 operation, a Iaxity of the piIIars will take pIace so that the obturator wiI1 not fit properIy Iater. The tonsiIs must be removed, preferabIy by dissection; special attention must be paid
FIG. 3. Dropping of tip of nose due to improper septum operation. (From Safian.)
HARELIP
CASES
WITH
NASAL
OBSTRUCTION
Obviously the pIastic surgeon should operate upon the majority of patients. There are certain cases in which the cIeft extends into the nose so that one nostri1 is narrower and a definite nasa1 obstruction is made worse because of deviation of the septum to the distorted side. The hareIip operation should be performed at an early age, but the nasal obstruction shouId not be operated upon until after puberty if it is possible to wait that Iong. The obstruction is usuaIIy in the inferior meatus and is due to a disIodgement of the vomer from its norma groove at the time of birth. Metzenbaum of CIeveIand pointed out the fact that in many patients who do not have cIeft palate disIodgement of the septum occurs at birth. If one is aware of the fact that such an obstruction has taken pIace it can easiIy be corrected at that time. AI1 one has to do is to sIip one’s finger or
42
American Journal 0f
surgery Hays-OtoIaryngoIogist,
some duI1 instrument and Iift the septum groove.
into the affected side back into its norma
If the obstruction persists unti1 puberty, the otoIaryngoIogist can operate on the septum. We shaI1 take it for granted that the narrowed nostri1 has been enlarged, therefore only as much of the septum as is causing obstruction shouId be removed. As was stated, this defect is usuaIIy in the inferior meatus and forms a hard bony obstruction. After the underIying mucosa is freed, the bone is removed with a hammer, chise1 and sometimes a saw, and the mucosa then repIaced. Since there is a redundancy of mucosa it does not matter if some of it is destroyed. The utmost care shouId be taken to see that there are no denuded parts. DEFLECTION
Surgeon
OF THE
TRIANGULAR
CARTILAGE
This operation is so simpIe that very IittIe space is needed for its description. The offending nostri1 may be seen to be aImost, if not compIeteIy obstructed by the
JANUARY. 1936
cartiIage. The operation is preferabIy performed in a hospita1. AI1 hairs shouId be cut off. Iodine shouId be appIied to the part
FIG. 4~. FIG. 48. A. Appearance foIIowing automobile accident. Probe extending B. Case after operation by Dr. Joseph Safian. through nose.
FIG.4. Au Ithor’s-c :ase. (From Safian.) wound
PIastic
fl-0m exter ,naI
and then it shouId be anesthetized with novocaine. The incision shouId be made over the most prominent part and continued down to the cartiIage. The dissection behind and in front of this is not aIways easy because there are three to four Iayers of very adherent tissue but it can be accompIished with a sharp scaIpe1. After the cartiIage is denuded, an incision is made thrbugh it, the parts on the other side freed and the obstruction removed. In many instances one wiI1 see a deviation of the septum which couId not be seen before but this shouId be Ieft aIone if the breathing seems to be free. After the obstruction has been removed, the edges of the incision shouId be brought together with fine bIack siIk sutures which are aIIowed to remain in pIace for five days. If the wound is not sutured, a denuded area is apt to remain or a perforation of the septum may occur; for the mucosa on the opposite side is very thin.
~~~ sERIEsvoL.XXXI,No. I Hays-Oto1aryngoIogist,
PERFORATIONS
OF
THE
NASAL
SEPTUM
Such an accident is quite common and is frequentIy the resuIt of a septum operation. Primary perforations of the septum are most unusua1. This condition may arise from continuahy picking the nose to remove crusts, or may be due to disease, either tubercuIosis or syphiIis. Most septa1 perforations resuIting from septum operacan be attributed to occasiona tions, imperfectly performed operations, and other times because the mucosa is so thin that it tears, regardIess of the utmost care at the time of operation. Perforations divide themseIves into two main cIasses : the Iarge and the smaI1. Large perforations do not cause as much troubIe to the patients as smaI1 ones. The main compIaint is constant crusting of nasa1 secretions. It is seIdom possibIe to repair these large perforations. As suggested by SkiIIern, at times a Iarge opening in the septum is purposeIy made for certain types of sinus disease. The smaII perforation, from the size of a pin head to a centimeter in diameter, is a definite nuisance, mainIy because it causes a whistIing sound whenever the patient breathes through his nose. Operation. If these perforations are in the anterior portion of the septum, they are not extremeIy diffrcuIt to correct. After proper anesthetization, one attempts to separate the mucosa and underIying soft tissues, both anteriorIy and posteriorIy to the perforation. Then one penetrates the edges a11 around unti1 the tissues are free. The edges of the perforation are freshened and then coapted with fine sutures. The suturing is not very easy and has to be performed with a modified aneurysm needIe. The sutures may be removed at the end of five days. As a ruIe, no packing is necessary. In certain cases, in which there is tension of the tissues after they are freed, an incision of some extent may be made above and beIow the perforation. The denuded parts wil1 eventuaIIy hea1.
PIastic
SADDLE
Surgeon
NOSE
American ~~~~~~~of surgery
RESULTING
SEPTAL
FROM
43
IMPROPER
OPERATIONS
NaturaIIy the correction of such a deformity shouId be Ieft to the competent pIastic surgeon. The chief reason for bringing it to one’s attention here is to warn the otoIaryngoIogist that he shouId be unusuaIIy carefu1 in performing a septa1 operation so that such a disastrous deformity, does not take pIace. In studying the anatomy of the nose, one reaIizes that the septum is the main support of the nose and has a great dea1 to do with its externa1 appearance. The most prominent part is heId in pIace by the conformity of the cartiIaginous portion of the septum, particuIarIy the upper part. The bony portion of the septum can be mutiIated to a great extent without causing any troubIe. The tip of the nose may Iose its norma appearance by too extensive an operation on the trianguIar cartiIage (Figs. I and 2). The upper portion of this cartiIage hoIds up the tip of the nose; if this is removed, the tip wiI1 drop. Therefore, in performing this operation, care must be taken not to remove the upper portion of this cartiIaginous septum. We are mainIy concerned with saddIe nose. A saddIe nose of the extreme kind may resuIt from many causes, as injuries, syphiIis, etc. The sunk-in nose with which we are concerned is the depression which occurs in the Iower portion, just beIow the junction of the two nasa1 bones. This is aImost invariabIy caused by an improperIy performed septa1 operation. OtoIaryngoIogists must reaIize that a septa1 operation shouId be performed for two purposes onIy: to give proper breathing space and to give proper drainage to the sinuses. OnIy as much of the septum as is necessary shouId be removed and one shouId never make the attempt to remove the entire septum, particuIarIy the trianguIar portion. One may remove a11 he wishes of the Iower cartiIaginous portion of the septum but shouId beware of the
44
American
Journalof Surgery
Hays-OtoIaryngoIogist,
upper portion. It is surprising how the remova of any part of the supporting septum wiIl resuIt in a cave-in of the nose (Fig. 3). It is preferabIe to aIIow a smaI1, deviated part to remain than to excise too much and Ieave a nose which wiI1 sink within a short time and require pIastic repair. EXTERNAL
SINUS
OPERATIONS
WITH
DEFORMITY
The otoIaryngoIogist is mainIy concerned with getting the patient we11 and seIdom thinks of the marred features which wiI1 resuIt from the operation and which wiII be a constant embarrassment to the patient. Sometimes one cannot concern himseIf, but at other times, it is possibIe to pay more attention to the suturing process. Of main concern is the depression which arises from an extensive frontal sinus operation. This may be overcome in many instances by a thorough examination of the x-ray plates and adapting the procedures to the amount of bone invoIved. I have seen cases in which there was littIe disease of the external pIate and yet the entire bone was removed from the externa1 to the interna canthus. In such cases, onIy a smaI1 opening into the fronta sinus need be made. After the process of the disease has ceased, the external wound wiI1 hea without resulting scar, particuIarIy if the origina wound is made through the eyebrow. Where an extensive operation has been performed, particuIarIy if it is necessary to make a butterfly incision over both frontal sinuses, an unsightIy scar must necessariIy deveIop. Later a pIastic operation may be performed or a proper prosthesis appIied. ACUTE
NASAL
FRACTURES
Extreme deformities, the resuIt of severe injury to the nasa1 bones and often of the surrounding parts, may be cared for more properly by the pIastic surgeon. But he may not be available and very often such injuries wiIl have to be handIed by the genera1 practitioner.
PIastic
Surgeon
JANUARY, 1936
As a ruIe, it is wiser not to make any attempt to adjust the injured parts at the time of the immediate injury and particuIarIy so when there are externa1 wounds. The nasa1 hemorrhage is often severe and if there is a fracture of the septum there may be an extravasation of bIood on one or both sides of the septum. Such a hemorrhage must be stopped immediateIy both as a matter of convenience to the patient and because one must avoid the formation of a submucosa1“ bIood tumor” which may Iater cause a permanent obstruction. The usua1 procedures for arresting nasa1 hemorrhage shouId be applied. If packing one or both of the nasa1 cavities is necessary, it shouId be done with extreme care. Better resuIts are obtained if the nose is washed out thoroughIy with a hot saIine soIution (106-I I~‘F.) to which is added a small amount of suprarenaIin extract. In fact, the hemorrhage may cease, without packing, if the nose is properIy washed out. Attention shouId now be paid to the externa1 sweIIing. This is best reduced by the appIication of iced compresses. If external wounds are present, it is far better not to attempt suture for twenty-four hours so that infection may be ehminated. Then the edges should be carefuhy examined and, if possibIe, they shouId be caref&y approximated with line silk sutures. Two definite probIems present themseIves: (I) attention to intranasal injuries and (2) attention to externa1 deformity. If one finds a fracture of the septum, particuIarIy if there is a severe extravasation of bIood, resort to packing of the nose as soon as possibIe. The routine packing of the nose, usuahy with iodoform gauze, is crude and is often unskilfuIIy done. The best way to pack the nasa1 cavities is to take folds of J/4 inch gauze (iodoform, bismuth or pIain) about 2 inches long. Place the first packing in the inferior meatus and then appIy further foIds of gauze, one on top of the other, unti1 the cavity is tightIy filled. Care shouId be taken to exert pressure upon the septum in order to ehminate any tendency toward excessive hemorrhage.
NEW SEIUES Vor. XxX1,
No. r
Hays-OtoIaryngoIogist,
The actuaI fracture of the nasa1 bones themseIves must receive especia1 attention. Such fractures falI into a number of cIasses and the treatment given wiI1 depend upon the extent of the fracture and the resuIting deformity. The simpIest type is the comminuted fracture or greenstick fracture with no deformity. Very sIight or no crepitation will be feIt on palpation, and the fracture may be ascertained onIy by x-ray picture. No treatment to the fracture itseIf is necessary. Other types vary from the depressed fracture or one which causes the nose to be forced to one side, to that with externa1 wounds or compIete destruction of the nasa1 bones. After the external sweIIing has subsided to some extent, an attempt must be made to bring the bones into proper aIignment before there is an opportunity for the bones to “set” in a wrong position. The patient should be given a genera1 anesthetic. A blunt instrument is pIaced in the nasal cavity on the side of the depressed bone and the fragment elevated to its normal position. In many cases this is possibIe. If the entire nose has been forced to one side, forcible manipulation m.ay be necessary to adjust it properly. A smaII pad should be placed against the fractured bone and held in pIace with adhesive tape. At the same time, a nasa1 packing shouId be pIaced high up in the nose to hoId the fragment in pIace from the inside. This shouId be Ieft in pIace three to four days. GeneraIly, the nose wiII take care of itseIf after that. If there is stiI1 evidence of deformity, the patient shouId be referred to a pIastic surgeon of repute for further care. ACCIDENTAL
IN JURIES
Numerous types of injury of this kind are seen today, because of the automobiIe. The otolaryngologist, as well as the genera1 practitioner, must be in a position to take care of such patients. No genera1 or specific ruIes can be laid down. In many instances, immediate surgery is necessary-surgery
Plastic
Surgeon
American
which cannot attempt cosmetic resuIts.
~~~~~~~ Of surgery
to pay attention
45 to
One automobiIe accident case seen presented a fracture of the nose, the malar and fronta bones and injury to one eye (Fig. 4). There were numerous external wounds. Attention was paid to the injuries at the time of the accident. The wounds were sutured, the maIar and frontal bones lifted into position and an attempt made to bring together the fragments of nasa1 bones. The deformity, especiaIIy to the nose, was considerabIe. Dr. Safian performed a reparative operation at a Iater date. PROTRUDING
EARS
Very prominent ears, standing well out from the head, often need attention. The operation is comparativeIy simpIe and can readiIy be performed by the competent aurist. A semiIunar incision is made behind the ear, under either IocaI or genera1 anesthesia. Dissection of the soft tissues is carried down to the ear cana and backward under the scaIp until they are Ioose. The proper amount of soft tissue is excised and the free edges of the wound sutured. A bandage is kept on for a few days and then the sutures removed. The resuIts are uniformIy good. REPAIR
OF CAVITY
DEFECTS
AFTER
MASTOID
OPERATION
In former times, when mastoid wounds were packed and Ieft open, unsightIy cavities behind the ear often resulted. Such a condition also arises today in those cases where wounds wiI1 not hea properIy or where it is necessary to Ieave the mastoid cavity wide open because some compIication has occurred. The patient does not complain so much about the cavity as of the dirt which accumuIates in it and which has to be cIeaned out from time to time. In certain cases, a sinus Ieads down into the antrum and middle ear so that the cavity is constantIy moist from secretions which come up from the throat through the eustachian tube. This results in crust formation which is extremeIy annoying.
46
* me&anJournal
of Surgery
Hays-OtoIaryngoIogist,
The probIem is to cIose this cavity, both for cosmetic reasons and to rid the patient of the annoyances. PreferabIy under avertin and IocaI anesthesia, the parts are thoroughIy cIeansed of a11 foreign materia1. The thin skin which Iines the mastoid cavity is carefuIIy dissected from the underIying bone. The soft tissues are compIeteIy freed anteriorIy and posteriorIy. The anterior dissection must be carried down to the posterior cana waI1. The posterior dissection is continued for at Ieast 1% inches. However if the tissues were then brought together there wouId be too much tension. Therefore a second incision is made in the scalp, at Ieast 134 inches behind the mastoid wound and carried down to the bone. This is made suffrcientIy Iong so that the section of scaIp can be sIid forward. The edges now overIying the mastoid cavity are sutured with some strong materia1. Dissection of the scaIp is then continued posteriorIy unti1 there is sufficient Ioose tissue to bring the edges of the second wound together without any tension. A reguIar mastoid bandage is appIied. HeaIing takes pIace in five to six days when the sutures may be removed. As a ruIe, the cosmetic resuIt is exceIIent and what pIeases the patient most is that there is no further secretion from the middIe ear. ATRESIA
OF
EAR
CANAL
Atresia of the ear cana may be either congenita1 or acquired. Atresia may be onIy of the cartiIaginous portion of the cana or may invoIve the bony structures. In cases of congenita1 atresia, it is necessary to determine whether the cIosure of the cana invoIves the bony structure or not and also whether any middIe ear is present, particuIarIy if marked deafness is aIso present. In congenita1 cases where the bony structures are definitely abnorma1, the condition cannot be corrected. Where the cIosure is in the anterior part of the canal invoIving onIy the soft structures, it is frequentIy possibIe to correct the condition. This is essentia1 in patients who have functioning middIe ears, because norma or
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JANUARY. 1936
nearIy norma hearing may be restored if the atresia is properIy corrected. Such atresia may be caused by a thin membrane which has deveIoped in the ear cana1, compIeteIy occIuding it. In these cases the operation is very simpIe because the membrane is easiIy excised. In other cases the cana is compIeteIy cIosed off by cartiIage, skin and inner Iming mucous membrane. A plastic operation has to be performed. An incision is made behind the ear and extended down to and through the posterior CartiIaginous cana waI1. As much of the obstruction as possibIe is removed unti1 one obtains a good view of the drum membrane. The type of reconstruction of the cana wiI1 depend upon the individua1 case. In every instance it is necessary to obtain flaps of cartiIage and skin to Iine the new cana1. After these are retained in pIace with catgut sutures, the ear cana is firmIy packed with gauze which is kept in pIace unti1 such time as definite adherence has occurred. Acquired atresia may resuIt from chronic eczema of the ear cana or muItipIe furuncles which resuIt in chronic inffammation. Such a condition may arise from an accident to the cana waI1 but most frequentIy a partia1 or compIete atresia resuIts from a mastoid operation in which too much of the bony posterior cana waII had been removed and permitted a proIapse of the membranous waI1 with a more or Iess compIete cIosure of the externa1 auditory apparatus. Operation may have to be performed to correct such a condition. Again an incision is made behind the ear and extended down unti1 the narrow part is brought into sight. The operation wiI1 vary according to the condition. One proceeds in the same manner as in making a pIastic ffap after a radica1 mastoid operation. An incision is made behind the ear and as much as possibIe of the underlying cartiIage is freed from the skin. This Ieaves a Ioose flap of tissue which can be sutured into pIace so that a new auditory canal can be made as Iarge as one wishes. In the course of time
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the denuded parts are covered with granuIations and the externa1 appearance of the ear is not changed. CONCLUSION
AIthough one reaIizes the necessity for referring the majority of patients needing pIastic repair to the plastic surgeon, it wiI1 be seen from the procedures here outlined that there are certain definite cases which have to be attended by the otoIaryngoIogist and occasionaIIy by the genera1 practitioner. It is my sincere hope that I have made certain conditions suffkiently cIear to the reader so that he wiI1 be abIe to handIe such cases in an inteIIigent manner. REFERENCES BABCOCK, W. W. PIastic closure of Iaryngotomic fistuIas and enIargement of the Iumen of the trachea or Iarynx by impIantation of a chondrocutaneous Aap. Arch. Otolaryng., rg: 585-589, 1934.
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BICKHAM, W. S. Operative Surgery. Phila., Saunders, 1924, 3: 305. (Closure of perforations, Hazeltine’s technique.) HARRIS, T. J. Adhesions after tonsiIIectomy. Laryngoscope, 30: 471, 1920. (Presentation of a-case.) JACKSON. _ C., and BABCOCK. W. W. PIastic closure of tracheotomic fistuIa. Surg. Clin. Nortb America, 14: rgg-202 (Feb.) 1934. (Adhesions of posterior pillars to pharyngea1 waI1 after tonsiIIectomy. Operations for same.) KEELER, J. C. Modern OtoIogy. PhiIa., Davis, 1930, pp. 149: 152. KOPETZKY, S. J. OtoIogic Surgery. Ed. 2. N. Y., Hoeber, 1929, pp. 46-5 I. LISCHKOFF, M. A., and HEINBERG, C. J. A new procedure for the cIosure of non-soecibc oerforations of the nasal septum. Arch. Otolaryng., 14: 342, 1926. MACKENTY, J. E. NasopharyngeaI atresia. Arch. Otolaryng., 6: I (July) 1927. (Operation for cIosure of peifoiations of n&a1 septum.) RICHARDS. L. ConeenitaI atresia of the external auditory meatus. “Ann. Otol., Rbinol. & Laryngol., 42: 692-71 I, 1933. (BibIiog.) SAFIAN, J. Corrective RhinopIastic Surgery, N. Y., Am. J. Surg., 1934. SEWALL. E. C. Perforations of the seotum. In: Jackson. C., ‘The Nose, Throat and Ear and Their Diseases: PhiIa., 1930, pp. 77-79. TOD, H. F. Operations upon the ear. In: Oxford LooseLeaf Liv. Surg., 4: 327-510, 1920. (Atresia, pp. 354-355; illus. p. 426.) I
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