NASO- OR RETRO-PHARYNGEAL GROWTHS. 
BY 
J. EWING HEARS, M.D., 
PHILADELPHIA. 
Transactions of the American Surgical Association, iBqj. 
Reprinted from the NASO- OR RETRO-PHARYNGEAL GROWTHS. 
BYj. EWING MEARS, M.D., 
PHILADELPHIA. 
I desire to place on record an operation the performance of 
which I believe to have been sufficiently rare to make the re- 
port of it of interest. From my knowledge of surgical records, 
based upon observation and an acquantance with the current 
literature, I can recall but two recorded cases in this country. 
The operation to which I allude is that for the removal of 
naso- or retro-pharyngeal tumors. 
With regard to these growths I wish first to say a few words 
relating to their nomenclature. An examination of surgical 
text-books, even of those most recently issued, shows that the 
term “ retro-pharyngeal ” does not, as applied to tumors, find a 
place in the index. Retro-pharyngeal abscesses are indicated 
and described, but not retro-pharyngeal tumors. Tumors of 
the pharynx and naso-pharyngeal polyps appear in the indices, 
and both are fully discussed by Professor Gross, whilst Professor 
Agnew gives but a brief account of the former with a full dis- 
cussion of the latter. In my study of the subject, incidental 
to the operations which I performed, I was led to the conclusion 
that, possibly, without unnecessarily refining nomenclature, the 
position of these growths could be more definitely stated, and 
thus the nature of the operation to be performed more accurately 
determined by limiting the application of the term naso-pharyn- 
geal to those which take their origin from the structures in 
immediate relation to the posterior openings of the nares, as the 
posterior surface of the vomer, which forms the posterior por- 
tion of the septum narium ; the inner surfaces of the internal 
pterygoid plates of the pterygoid processes of the sphenoid 2 
HEARS, 
. 0 . 
bone; the walls of that part formed by the pterygoid processes 
and the palate bone; the pterygo-palatine space. The natural 
tendency of growths taking origin from these parts is to become 
more largely nasal than pharyngeal; growing into openings 
which offer little or no resistance they finally, by increased 
growth, produce by pressure, absorption of adjacent bony struc- 
tures, and work their way into the cavities in relation with the 
nasal cavities, as the antra, producing a peculiar distortion of 
the face. 
These tumors are, by reason of their anatomical and surgical 
relations, more readily accessible through the nasal passages, 
or, where these do not afford sufficient space for operative pro- 
cedures, through the mouth or by osteo-plastic resection of the 
upper jaw. Therefore, in a given case, the diagnosis having 
been made by reason of the presence largely of symptoms 
relating to the nares, the operation should be conducted through 
these cavities or from the front, by any method which may be 
selected. 
The tumors of the character under discussion which take 
origin from the petro-occipital suture, the under surface of the 
basilar process of the occipital bone, or from the anterior sur- 
faces of the upper cervical vertebrae, are apt to become, as they 
grow, more largely pharyngeal than nasal, and may, with a 
view to localize them, be designated as occipito-pharyngeal or 
vertebro-pharyngeal tumors. 
These are not so readily accessible from the front—that is, 
through the nasal or oral cavities, or even by osteo-plastic 
resection of the upper jaw—as the naso-pharyngeal growths, 
but are easily reached through the upper region of the antero- 
lateral surface of the neck by incision and resection of the 
lower jaw. Again, as above, in a given case, the diagnosis 
having been made by reason of the presence largely of symp- 
toms relating to that portion of the pharynx designated the 
oro-pharynx, the operation should be made preferably from the 
side and below, through and behind the pharyngeal walls, 
section of the lower jaw opening up a route, short and marvel- 
lously free from danger in the field of operation. NASO- OR RETRO-PHARYNGEAL GROWTHS. 
3 
In the case of a lad, twelve and a half years of age, the sub- 
ject of an occipito-pharyngeal tumor, I performed the operation 
of osteo-plastic resection of the upper jaw, and subsequently 
the operation by incision through the neck, section of the lower 
jaw and incision through the pharyngeal walls. The first 
method of operation was selected under the belief that the 
growth was naso-pharyngeal in character, in accord with the 
designation I have given above of growths belonging to that 
class—that it had originated from the structures in immediate 
relation with the posterior openings of the nasal cavities, and 
that while it could not be removed through these cavities or 
through the oral cavity, it could be removed from the front by 
osteo-plastic resection of the upper jaw. When the operation 
was made the region about the posterior nares was fully 
exposed, but the growth was found to have its attachment so 
far back toward the posterior wall of the pharynx that its 
complete removal could not be accomplished by this method. 
The result of this operation led me to study more closely 
the symptoms presented in the case, and I was then forcibly 
impressed with the marked absence of those relating to the 
nasal cavities. There was no discharge from the nose; there 
had been no epistaxis; there was no obstruction of the right 
nasal cavity, and although the tumor occupied the left region 
of the pharynx the left nasal cavity was but partially ob- 
structed. There had been what was described as a “ nasty 
spit” for some time. Audition in the left ear was absent, due 
in all probability to closing of the left Eustachian tube by the 
tumor. Inspection of the mouth, which could not be fully 
opened, revealed the presence of a tumor which lay in close 
contact with the posterior surface of the soft palate, and 
extended downward into the pharynx. It could not be com- 
pletely outlined by the finger. Manipulation produced slight 
hemorrhage into the mouth. To my mind, these symptoms 
confirmed what the operation had revealed, the attachment of 
the tumor far back to the under surface of the basilar process 
of the occipital bone. From the effects of the operation the 4 
HEARS, 
lad made a prompt recovery, and in three weeks left my private 
hospital and went to the suburban residence of his father. 
As the method of operation varied from that devised by 
Langenbeck in 1859, it may be of interest to describe it briefly. 
In Langenbeck’s operation the incisions of the soft structures 
and sections of the jaw are so made as to permit the segment 
to be “ moved as on a hinge upon the sutures between it and 
the nasal and frontal bones.” It is, therefore, elevated. In the 
method I employed, following to some extent that practised by 
Dr. Cheever, of Boston, in the remarkable case in which he 
divided both bones and depressed them with the palate bones 
on the pterygoid processes of the sphenoid, I made an incision 
of the soft tissues in the same manner as that employed in 
uncovering the jaw when excision of the bone is performed. 
The saw was placed over the posterior or zygomatic surface of 
the bone, and carried across into the nose. The central incisor 
of the left side was then removed, and the hard palate sawn 
through. The bone was then readily depressed, and the field 
of operation exposed. After removal of the growth the seg- 
ment of the jaw was replaced and wire sutures were introduced 
through the divided malar and nasal processes, the ends of the 
wires being brought out through the incision in the soft tissues, 
and the points covered with shot. A. wire ligature was placed 
around the incisor teeth, thus holding the bone firmly in place. 
In four days the skin sutures were removed, and in four weeks 
those in the bone, the jaw being firmly united, and the patient 
was able to use it two weeks later in the mastication of soft 
food. Two months after the operation sensation returned in 
the teeth of the jaw resected, as manifested by the patient’s 
ability to appreciate the presence of food between them and 
those of the lower jaw. 
A number of enlarged lymphatic glands occupying the left 
side of the neck were not disturbed at this time, as it was desired 
by the parents that an effort might be made to remove them by 
medical treatment. No effect was produced by medical treatment, 
and the patient was again admitted into my hospital. On exami- 
nation, I found the glands had greatly increased in size, and also NASO- OR RETRO-PHARYNGEAL GROWTHS. 
5 
that the pharyngeal tumor had recurred. I therefore determined 
to attack it from the neck by an operation which would at the 
same time permit of removal of the enlarged glands. A cres- 
centic incision, with the convexity downward, was made on 
the left side from a point midway between the mastoid process 
and angle of the jaw to a point one inch in front of the anterior 
inferior angle of the masseter muscle. In order to delay a 
necessary division of the facial artery, the tissues of the pos- 
terior portion of the incision were divided to a sufficient depth 
to permit of the enucleation of the enlarged cervical glands. 
Six glands of varying size were removed, and the anterior por- 
tion of the wound then deepened, dividing the facial artery, vein, 
and the external jugular vein, each of which was ligatured. The 
mylo-hyoid muscle was now divided, and the inner surface of the 
jaw uncovered; the external surface was likewise uncovered by 
dissection of the tissues upward, the periosteum incised in an 
oblique direction just in front of the inferior angle of the mas- 
seter muscle. The jaw was drilled on each side of the incision, 
and strong silver wire introduced for the purpose of holding the 
segments apart after section, and uniting them on completion of 
the operation. The bone was divided and the portions held 
apart. The dissection was now carefully conducted, largely by 
the handle of the knife, without opening the cavity of the 
mouth. Neither nerves nor bloodvessels were seen. The index 
finger of the left hand was now passed into the mouth, carried 
to the position of the tumor, and pressure made upon it, 
which forced it into the wound, so that it could be readily 
felt. The tissue overlying the tumor—the pharyngeal walls 
—were now carefully divided, the index finger introduced 
through the opening, and the tumor separated from the 
enveloping tissues. When it was entirely freed it was found 
to be attached by a broad base to the under surface of the 
basilar process. The tumor was now seized with the volsellum 
forceps, and firm traction made, whilst the periosteal elevator 
was used to separate it from its bony attachment. This was 
accomplished gradually, in order to avoid tearing the growth 
and leaving portions adherent. After its removal the surface 6 
NASO- OR RETRO-PHARYNGEAL GROWTHS. 
was thorough!).’ scraped with the Volkmann spoon and perios- 
teal elevator. The efforts at the removal provoked but little 
hemorrhage, and that which occurred was not arterial. The 
gustatory nerve was not seen, nor were any large arterial trunks 
seen or felt in the field of operation. The wound in the 
pharyngeal walls was not sutured. The dressing was completed 
by packing the cavity loosely with 5 per cent, iodoform gauze; 
wiring the divided bone with two strong silver wires, the ends 
of which were brought out between the edges of the wound and 
shot clamped on them; suturing the soft tissues and covering 
the surface with iodoform gauze, boric acid cotton, and a 
roller. On the third day following the operation the dressings 
were removed. For a few days subsequently fluids escaped by 
the opening in the pharynx. This was overcome by turning 
the head to the side opposite the wound. Gradually the 
opening closed, and deglutition became normal. The sutures 
in the soft structures were removed on the fourth day, and those 
uniting the bone in the sixth week. Slight necrosis has occurred 
at the point of section of the bone, and possibly some exfolia- 
tion will take place. The patient now uses the jaw in mastica- 
tion, and opens the mouth to the extent of three-fourths of an 
inch. 
With regard to the operation, I join Dr. Cheever, who I 
believe devised it, in the expression of surprise at the ease with 
which it may be made, and the absence of complications in a 
region the path through which would, from an anatomical 
point of view, seem to be beset with many and great dangers.