Inoperable Sarcoma of the Nose. 
BY 
ROBERT LEVY, M. TX, 
Professor of Physiology and LafflJgology, Gross Medical 
College; Laryngologist to Arapahoe County, 
St. Luke's, and Deaconess’s Hospitals, 
Denver, Col. 
REPBINTED PROM THE 
Xeto 'STorft USe&tcal journal 
for March 17, 189b. Reprinted from the New York Medical Journal 
for March 17, 1891/,. 
INOPERABLE SARCOMA OF THE NOSE 
By ROBERT LEVY, M. D., 
PROFESSOR OF PHYSIOLOGY AND LARYNGOLOGY, GROSS MEDICAL COLLEGE ; 
LARYNGOLOGIST TO 
ARAPAHOE COUNTY, ST. LUKE’S, AND DEACONESS’S HOSPITALS, DENVER, COL 
Adopting Plicque’s * classification of malignant tumors 
of the nasal cavities, the following case is placed in the 
fourth or inoperable class : 
On September 21, 1898, J. L., male, aged sixty-two, by oc- 
cupation a farmer, was referred to me for examination and ad- 
vice by Dr. Wiest and Dr. Toplif, of Longmont, Col. 
In the family history of the patient there was nothing of in- 
terest. except that his mother died at the age of seventy of a 
“ tumor ” of the liver. He has always been healthy and strong; 
is the father of three children, one of whom died at the age 
of five weeks of “ scrofula ” and a “ troublesome sore on the 
neck.” He has been a sufferer from “catarrh” for twenty 
years, which he states has been gradually getting worse. 
Present illness dates back several years; the exact date of its 
origin is indefinite. Three years ago he first noticed that the 
discharge from his nose was becoming offensive. Several years 
ago he lost the sense of smell, which has not returned. In 
April, 1890, he began having intense pain in the forehead. In 
* A Study of the Diagnosis and Treatment of Malignant Tumors of 
the Nasal Fossae. Journal of Laryngology and Rhinology, May, 1890. 
Copyright, 1894, by D. Appleton and Company. 2 
INOPERABLE SARCOMA OF TIIE NOSE. 
August of the same year the region of the left superior maxil- 
lary and malar bones became swollen. There was a burning 
sensation in the region of the cavity of the antrum. About the 
same time there developed partial facial paralysis of motion, 
involving the superficial muscles from the lower lid to the 
upper lip upon the left side. There was slight loss of sensation 
of the upper lip. Since August his strength has been rapidly 
failing; his appetite has been nil; on account of the intense 
pain, he has been unable to obtain a night’s rest. The cliarac- 
ter of the pain has been lancinating, becoming more and more 
intense of late, radiating from the antrum to the left side and 
root of the nose and forehead, beiDg at times very intense in the 
occipital region. 
Upon examination, we find a large, well-developed man, 
somewhat emaciated, with an expression of intense suffering 
upon his face. A decided swelling exists over the middle and 
malar portions of the left superior maxillary bone and over the 
malar bone. The skin covering this region is tense and of a 
dusky hue. The eye is watery. Examination of the nose re- 
veals a small polyp springing from the under surface of the 
middle turbinate on the left side, and a considerable amount of 
thick, dark-green pus with an intensely foetid odor—the odor 
of necrotic tissue. The existence of the pain, the foetid odor, 
the purulent discharge, the swelling, and the presence of the 
nasal polyp, at once directed our attention to the probability of 
an existing, long-standing empyema of the antrum. The in- 
tensity of the symptoms and the odor pointed also to a syphilitic 
lesion or some form of malignant growth. The absence of any 
history of syphilis or of any previous symptom of that affec- 
tion led us to believe that the case was probably one of either 
cancer or long standing antrum abscess. Transillumination of 
the cavity of the antrum revealed characteristic and definite re- 
sults, and the advisability of opening the antrum was apparent. 
Upon gaining the patient’s consent, the antrum was opened by 
Dr. Bartleson through the alveolar process, when there was at 
once a profuse discharge of green, intensely foetid pus. A gold- 
plated tube was firmly fixed in the opening, antiseptic and 
stimulating solutions were given to the patient, and he was ad- INOPERABLE SARCOMA OF THE NOSE. 
3 
vised to return home and continue washing the antrum for a 
period of time. The polyp was removed with the cold snare. 
The result expected was either great improvement or, if the 
case proved one of malignant growth, it would rapidly pro- 
gress. Some relief to the pain and some correction to the odor 
were obtained. Soon the symptoms returned with increased 
violence, and on the 20th of October he pr. sented himself 
again. On the 19tli of October he had his first nosebletd, 
which was quite protuse. At this time also there was noticed 
difficulty in swallowing, especially liquids. Upon examining 
him the swelling over the cheek was seen to be slightly in- 
creased. The examination of the nose revealed a small grayish, 
irregular mass beneath the middle turbinated bone in the 
neighborhood of the ostium maxillare. From the rapid in- 
crease in the symptoms some form of malignant growth was 
quite definitely settled upon as a most likely diagnosis. This 
outgrowth appearing in the nose gave additional proof to the 
diagnosis, and a small portion removed with a cutting forceps 
was examined microscopically by Dr. Axtel. It proved to 
be, according to the doctor’s report, a large-celled sarcoma, in 
which were found many small round cells, embryonic blood- 
vessels, and a slight attempt at connective-tissue formation. 
On October 25th the patient discharged two large masses of 
necrosed tissue from the nose. There also appeared some diffi- 
culty in vision. An examination by Dr. Le Mond detected 
interference with the action of the internal rectus, causing 
diplopia. There was also considerable oedema of the ocular and 
palpebral conjunctiva of the lower lid. The pain continued to 
increase, becoming especially marked at the base of the brain. 
The difficulty of swmllowing rapidly increased, the patient’s 
strength soon failed, and he died of exhaustion November 24, 
1893. Unfortunately, an autopsy could not he obtained. ' 
At no time were any of the adjacent glands enlarged or 
affected. 
Passing over the interest attached to the existence of 
such rare growths in such still rarer situations, the case re- 
ported presents several points worthy of attention : 4 
INOPERABLE SARCOMA OF THE NOSE. 
1. The anatomical parts involved, as indicated by the 
subsequent train of symptoms, (a) Paralysis of'motion, 
involving the periphery of branches of the facial distributed 
over the superior maxillary bone, showing local pressure. 
(h) Paralysis of sensation due to pressure in the course of 
the second division of the fifth, (c) Paralysis of degluti- 
tion due to pressure upon Meckel’s ganglion, fr<jm which 
are derived the palatine nerves which supply muscles 
largely concerned in the act of swallowing, (o?) The pain 
in the face and eye, accounted for by pressure upon 
branches of the fifth. (e) The pain in the eye and that in 
the occipital region, accounted for by pressure in the neigh- 
borhood of the sphenoid bone. Finally, there is every 
reason to believe that from these pressure symptoms the 
tumor must have existed not only in the nose and in the 
antrum, but must have extended into the spheno-maxillary 
fossa, as well as into the body of the sphenoid bone. 
2. The presence of the nasal polyp. This brings us 
to the much discussed question of the relation of polypi to 
the development of malignant tumors. It is plain that in 
this case the polyp was simply coexistent. 
3. The necessity of determining the point of origin of the 
growth as well as its extent. This is particularly important 
in the matter of the treatment, for if it could bave been 
definitely determined that the growth began in the nose 
and extended only into the antrum and the adjacent supe- 
rior maxillary bone, an operation might have been under- 
taken. With the intensity of the symptoms referring us 
to extensive nerve pressure and the small amount of nasal 
disturbance, one might definitely conclude that the growth 
did not begin in the nose and that it extended into deep 
structures. 
4. The intensely foetid discharge from the antrum. 
This discharge was characteristic of necrosed tissue, and, INOPERABLE SARCOMA OF THE NOSK. 
5 
while in many cases of long standing empyema of the an- 
trum we have a foetid odor, still the difference between the 
odor from abscess of this cavity and the penetrating foetor 
found in malignant cases merits attention as a differential 
diagnostic feature. 
5. The severe pain in the forehead. This occurred 
early in the case reported above, and in the majority of 
cases of malignant tumors of the nose this appears as an 
early symptom. In an admirable report of five cases of 
malignant tumor of the nose by Neuman * this symptom is 
particularly noticeable. The New York Medical Journal. 
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