[Reprinted from the Transactions of the Medical and Chirurgical Faculty 
of Maryland, April, 1878 ] 
REMOVAL 
OF 
NASO-PHARYNGEAL POLYPUS 
BY 
Temporary Depression of loth Upper Jaws. 
BY 
L. McLANE TIFFANY, M. D., 
Professor Operative Surgery, University of Maryland. 
BALTIMORE: 
INNES & COMPANY, PRINTERS AND BINDERS. 
1878. [Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 
April, 1878.] 
REMOVAL OF NASO-PHARYNGEAL POLYPUS BY 
TEMPORARY DEPRESSION OF BOTH 
UPPER JAWS. 
L. McLANE TIFFANY, M. D., 
Professor Operative Surgery, University of Maryland, 
Charles Sorden, mulatto, aged 48 years, spare, rather under- 
sized, married; entered University Hospital, February 15, 1878, 
during my service. Previous history, as obtained from himself 
and wife, showed that for the past six years he has had trouble 
with his throat, while for the past five years he has been aware of 
the existence of a tumor “ behind his mouth.” Attention was 
first called to his throat by spitting of blood, then by profuse 
epistaxis at short intervals; later, ear-ache, very severe, was 
noticed, followed by greatly impaired hearing in right ear (1874). 
Right nostril closed completely in 1875. 
In April, 1877, he entered University Hospital, service Dr. J. 
J. Chisolm, who found a polypus growing from base of skull, 
occluding right nostril, etc. At this time the left nostril was free. 
Dr. Chisolm cast a wire around the base of the growth, and 
tightening the loop, removed the polyp in three days without 
haemorrhage. Hearing returned on right side, and he went home 
apparently well. In four months epistaxis recurred, renewal of 
the tumor was apparent, hearing on right side became impaired, 
right nostril became occluded, and in December, 1877, air could be 
no longer forced through the left one. Seen by me Feb. 16th; no 
deformity of face. The greater part of his posterior nares and 
pharynx was filled by a dark, tolerably firm growth, which rested 
on the soft palate, pressing it downwards and forwards almost 
upon the dorsum of the tongue; beyond and behind the tongue, 
for an inch, the growth extended uncovered by soft palate. The 2 
tumor rested against the bodies of the cervical vertebrae, but on 
either side and in front, by pulling the soft palate strongly for- 
ward, a finger could be passed around the mass. The attachment 
was made out to the internal plate of the right pterygoid process, 
its internal and posterior aspect, and to the adjacent basilar pro- 
cess of the sphenoid. The attachment was by a pedicle. The 
patient had been unable to sleep in the recumbent position for two 
or three weeks before admission to the hospital, owing to difficulty 
in breathing, and had passed his nights in a chair. Speech and 
deglutition greatly interfered with, fluids and very soft food only 
being swallowed. No appetite, great pain in throat, probably 
from pressure. Patient expectorates bloody mucus very frequently. 
Digital examination causes some bleeding from the tumor, on the 
surface of which certain veins are visible. The patient desires an 
operation performed for the cure of his affection, if possible, 
rather than a palliative procedure. 
Owing to the large size of the tumor, temporary depression of 
both upper maxillary bones was determined on, and for the same 
reason a provisional tracheotomy was judged to be proper. 
Feb. 19th, tracheotomy performed. An unexpected complica- 
tion nearly cost the patient his life, arising from the size of the 
tumor. The patient inhaled ether well, but when the stage of 
muscular relaxation was reached, at once the tumor, which rested on 
the soft palate, sank down and closed the opening of the trachea 
like a ball valve. Drawing the tongue forward was of course use- 
less, so fingers were thrust into the mouth to raise the tumor, and 
respiration was re-established. It was found, however, that the 
pressure of the fingers necessary to raise the tumor caused profuse 
bleeding from its surface, which rapidly passed into the now open 
glottis, and asphyxia was again imminent, indeed after a gasp or two 
respiration ceased. The patient was at once held up by the legs 
with his head to the floor, and in that position I rapidly opened 
his trachea, inserted the handle of the knife and turned it across, 
thus widely separating the lips of the wound. An ounce or so of 
blood gushed from within the trachea, and respiration commencing, 
went on regularly. A tube was inserted and the patient put to 
bed. On the morning of the 21st the tube was not in position, 
but was replaced in the trachea. 3 
February 25th, operation for removal of tumor. It being my 
intention to sever the pedicle with Paquelin’s thermo-cautery, 
chloroform was used as the anaesthetic. Chloroform was inhaled 
through the tracheotomy tube. To prevent the passage of blood 
into the air passages, instead of a complicated apparatus (i. e. 
Trendelenburg’s), a sponge of proper size, having a piece of ligature 
silk tied to it to facilitate removal, was passed into the top of the 
larynx. This sponge was not pressed “ home ” until the patient 
was profoundly anaesthetized. An incision was carried down on 
each side of the nose, at the junction of the nose and cheek, then 
around the ala and through the middle line of the upper lip into 
the mouth. The cheeks were then freely dissected from the upper 
jaws as high as the nasal bones, infra-orbital foramina and malar 
bones. In this dissection the periosteum of the upper jaws was 
not disturbed. The nose was separated from the upper jaws and 
turned up toward the forehead. A fine saw was then made to cut 
each jaw from the malar process into the middle meatus of the 4 
nose, passing just beneath the infra-orbital foramen, upward and 
inward. The posterior wall of the upper jaw where in contact with 
the pterygoid process was not divided, lest the superior palatine 
artery should be injured. The septum of the nose and the vomer 
were cut with strong scissors. Both upper jaws were strongly 
depressed and sank down, hinging upon the pterygoid processes. 
The tumor was well exposed, and its attachment found as expected. 
The pedicle of the growth was divided by Paquelin’s cautery, and 
the root of the pterygoid process together with the basilar pro- 
cess of the sphenoid thoroughly scraped with the curved knife, 
hot, of the same instrument. The curve of this blade was suffi- 
cient to enable me to reach quite to the back of the pterygoid 
root. One or two bleeding points in the mucous membrane of the 
septum were touched with the cautery. Chloride of zinc in crystals 
was thoroughly applied to the bone from which the tumor grew. 
The pedicle at its site of attachment was about one half inch 
in diameter. There was no depression or perforation of bone at 
this point. 5 
Difficulty was experienced in extracting the polyp in conse- 
quence of its size, necessitating the use of the lithotomy forceps. 
Except upon the face, no vessels spouted, but there was a good 
deal of oozing. The wound was held open and the cut surfaces 
allowed to glaze. The jaws were replaced and held in position by 
a loop of wire passed through the cheeks near the outer angles of 
the orbits, and joined above the forehead by a rubber band. A 
celluloid plate was adapted to the teeth of the upper jaws and 
grooved, so as to hold the wire securely. The cheek flaps were 
then united to each other and to the nose by suture. Finally) 
the sponge was withdrawn from the larynx. The shock was 
great, and whiskey was given hypodermically to the extent of 
nearly an ounce. 
Just as the wound was being closed, respiration became very 
slow and feeble, the pulse disappearing. The poles of a battery 
were applied over the sterno-mastoid muscle, and over the epigas- 
trium, producing two or three strong, deep inspirations, after which 
all went well. The patient was put to bed and surrounded with 
hot bottles. 
The tumor was between three and four inches long, pear-shaped, 
six inches in circumference half an inch from the lower end. 
Weight not taken ; consistence moderately firm ; color pink, with 
here and there areas of dark red. 
Microscopical examination of the removed growth shows differ- 
ent tissues in different parts of the neoplasm. Large vessels, with 
sometimes sanguineous extravasions, well marked spindle cells in 
bands, newly formed mucous glands, lined with their characteristic 
epithelium, here the lumen filled with epithelium, there somewhat 
dilated with retained mucus so as to present the appearance of 
wide tubes, but at no point are epithelial-like elements found out- 
side of the glands ; finally, everywhere is apparent rapid prolifera- 
tion of the connective tissue elements. The growth is classed as 
adeno-sarcoma. 
The clinical history of the growth sustains this view. For five 
years the patient was aware of the existence of a tumor in his 
throat, yet after the lapse of so long a time, when he came under 
the charge of Dr. Chisolm, the left nostril was still free; yet nine 6 
months later, when he came under my care, both nostrils were 
occluded and almost the entire pharynx filled. Erichsen, in his 
last edition, calls attention to the clinical fact that an apparently 
benign polyp being removed may recur in malignant form, and 
the case in point seems to sustain such a view. A sarcoma being 
of the connective tissue type, it is not difficult to understand how, 
by pressure or other irritation, a simple outgrowth may have 
engrafted upon it undue and later malignant cellular tissue pro- 
liferation. Dr. Chisolm informs me that the diagnosis of malig- 
nancy was made when the case was under his care and return 
prognosticated. 
February 25th, evening.—Temp. 101°, pulse 99, respir. 20. 
Reacts slowly from operation. Milk § i.; brandy § ss. every half 
hour. Restless. Swallows easily. 
26th, morning.—Temp. 102.5°, pulse 108, respir. 24. Surface 
warm, suffers no pain, bowels moved, urine free. Iced milk § ij.; 
brandy § ss. every hour. 
26th, evening.—Temp. 103.5°, pulse 110, respir. 25. Perspiring 
freely ; urine free ; no complaint of pain. Milk ad. lib.; brandy 
diminished one-half. 
27th, morning.—Temp. 103.5°, pulse 99, respir. 21. Bowels 
moved during night twice ; urine free; perspiring freely. No 
complaint of pain. Union of face wound. Iced milk ad. lib.; 
brandy 5 j. every hour in milk. Cinchonid sulph. gr. v. t. i. d. 
Tracheotomy tube removed. 
27th, evening.—Temp. 99.5°, pulse 99, respir. 21. Drinks 
milk in quantity. Doing well in all respects. 
28th, morning.—Temp. 101.5°, pulse 99, respir. 18. Slight 
oedema of left eyelid. Nourishment continued. The oedema sug- 
gesting erysipelas, tinct. ferri muriat 3 ss. every two hours. 
28th, evening.—Temp. 103°, pulse 90, respir. 16. Treatment 
continued. 
29th, morning.—Temp. 98.5°, pulse 88, respir. 15. Oedema 
gone. 
From this time the record shows nothing of moment. Union of 
the skin wound took place without suppuration, except at the 
right ala nasi, where a small point granulated, and the same 7 
occurred at the upper end of the incision on the left side, a space 
not larger than the head of a large pin. The wires were removed 
from the cheeks on the eighth day, an inter-dental splint being 
substituted, at which time the patient began to go about his 
room. 
March 15th.—Patient was discovered eating beef and potatoes, 
and acknowledged having used his jaws in eating for three days. 
The union between the bony surfaces, which had previously been 
stiff, was now much more loose, so the wires were again inserted, 
and the patient cautioned. 
March 23d.—Patient returned home, still wearing the wires. 
The connection between the jaws much stiffer than one week pre- 
viously ; every prospect of good union. The mutilation of the 
face is very slight, since the incisions which healed without suppu- 
ration, except at the points mentioned, lie in the natural furrows 
on either side of the nose. The cicatrice through the upper lip 
will be concealed by a moustache. 
Extirpation of one upper jaw was, I believe, first performed in 
1820, the late Dr. Jameson of this city being the operator; his 
patient recovered. Osteo-plastic resection of one upper jaw was 
devised and first practised by Langenbeck in 1859, and has since 
been successfully repeated by himself and others. Temporary de- 
pression, osteo-plastic resection, of both upper jaws has been 
attempted, so far as I am aware, but once, by Cheever, of Boston. 
His patient succumbed one hundred and twenty hours after the 
operation, never having rallied beyond the stage of “ prostration 
with excitement.” In the case now reported the incisions were 
made as in Cheever’s, but operative measures upon the upper jaw 
were preceded by a tracheotomy. To this latter provision I am 
largely inclined to attribute the successful issue, as thereb}'- free 
respiration was assured, and danger of any foreign substance enter- 
ing the air passages removed. The prostration following the opera- 
tion was great, yet reaction came on as usual after severe measures, 
and subsequently all conditions were very favorable, the tempera- 
ture on two occasions only rising to 103.5°, and the pulse but once 
reaching 110. With the exception of the third day, February 
28th, when pufliness of one eyelid was noticed, erysipelas feared 8 
and iron administered, convalescence was uninterrupted. For 
twenty-four hours after the operation the mucous membrane of the 
upper jaws was less florid than that of the lower ; by the second 
day the eye could detect no difference in color. The absence of 
pain was a noticeable feature, no opium or other hypnotic was ad- 
ministered at any time. 
The method employed to prevent the passage of blood into the 
trachea is worthy of notice, as infinitely more simple than any 
other, while nothing could be more efficacious. For one hour the 
sponge remained in position, giving rise to no cough, yet entirely 
plugging the top of the larynx. The sponge was conical, two 
inches long, tapering from one-half inch to two inches in diameter, 
and was passed into the larynx between the epiglottis and arytenoid 
cartilages. After removal, the lower intra-laryngeal end was 
scarcely tinged with blood, showing how perfect the protection 
afforded to the air passages had been. The tracheotomy wound 
was thoroughly healed when patient left hospital.