LARGE CAVERNOUS ANGIOMA. INVOLVING THE INTEGUMENT OF AN ENTIRE AURICLE SUCCESSFULLY TREATED BY DISSECTION. FREE RESECTION OF DISEASED TISSUE, AND LIGATION OF THE AFFERENT TRUNKS IN SITU BY A SPECIAL METHOD. BY ' RUDOLPH CONSULTING SURGEON TO THE EYE, AND THROAT HOSPITAL, ETC., NEW ORLEANS, LA. FROM THE MEDICAL NEWS, December 24, 1892. [Reprinted from The Medical News, December 24, 1892.] LARGE CAVERNOUS ANGIOMA, INVOLVING THE INTEGUMENT OF AN ENTIRE AURICLE, SUCCESSFULLY TREATED BY DISSEC- TION, FREE RESECTION OF DIS- EASED TISSUE, AND LIGATION OF THE AFFERENT TRUNKS IN SITU BY A SPE/CIA L METHOD. I BY RUDOLPH MATAS, M.D., CONSULTING SURGEON TO THE EYE, EAR,"I«55ff, AND THROAT HOSPITAL, ETC., NEW ORLEANS, LA. An apology is scarcely needed for the presenta- tion of a case of cavernous angioma, involving the integument of the whole auricle. The treatment of angioma in general has been a source of worry to the surgeon from the remotest antiquity to the present day, and the therapeutic methods of election still remain a problem to be solved in individual cases. The extent and character of the lesion, especially whether limited to the superficial or the deeper tissues, or both; the region involved, and other complicating circumstances, profoundly affect the application of the fundamental principles of treatment. What is expected of the surgeon in all cases is, first, the eradication of the evil; and, second, if possible, the correction of the deformity; and any observation that will test the value of con- troverted methods of treatment, or that will aid in 2 formulating a plan of attack that will realize in the end either one or both of these desiderata, is worthy of consideration. The importance of the subject is accentuated when, as in the present instance, a tumor of this character presents itself in so conspicuous a locality as the auricle, and is allowed to ripen into the ful- ness of its most dangerous maturity, when life is threatened by spontaneous ulceration and hemor- rhage. Under these circumstances the difficulties in the way of an ideal conservative result cannot be overestimated. While an exhaustive discussion of the surgical treatment of cavernous angioma would be out of place in this report, a few remarks restricted to the consideration of auricular angioma may serve as a pertinent introduction to this clinical report. The auricle at first sight would appear, on ac- count of its isolation and semi-pedunculated attach- ment to the head, to be a most favorable field for the control of the vascular and other tumors that not infrequently develop in its tissues. But its abundant arterial supply from the branches of the carotid system, and the free collateral anastomoses that connect these with the subclavian artery, render the complete and permanent control of its arterial supply most difficult to effect. In addition to this, it should be remembered that an angioma is a neo- plasm, in which the process of neo-vascular forma- tion is progressive, and that the curative effect some- times obtained from the ligation of the direct afferent trunks in situ and of the parent trunks, at a dis- tance, is only operative in virtue of the diminished 3 nutrition consequent upon the anemia of ligation. Even a moderate collateral supply is, therefore, competent to reestablish the peculiar morbid histo- genesis that ends in neo-vascular formations. The condition is not simply varicose, cirsoid, or aneu- rismal, but is neoplastic. This understanding of the subject justifies the aggressive attitude of modern surgery that, when- ever practicable, adopts as an initial procedure the total extirpation of the morbid tissue. But the conspicuous and exposed position of the auricle, which is so important an appendix of the face, seriously interferes with the application of the more sweeping operative measures that would be unhesitatingly applied to tumors of this nature in less exposed regions. The unsightly mutilation produced by the amputation of the ear can only be permitted as an extreme measure, to be reserved almost strictly for malignant neoplasms. In the simple and early forms of nevoid disease that usually precede the more serious and progressive erectile-tissue growths, the ordinary methods of securing tissue-destruction or "perturbation" (Broca) may be utilized with advantage and excel- lent cosmetic result; but when the whole auricular integument has been involved by one immense growing pulsatile tumor, in which the skeletal framework participates, then it is impossible To destroy the evil without leaving marked traces of the destructive force employed. How to cure a generalized cavernous angioma of the auricle and still preserve this organ with some resemblance to its original normal appearance, is 4 the question. Many believe that this result maybe obtained with the aid of either thermic or electro- lytic cauterization, by potential caustics, or by inter- stitial injections of irritants or coagulants judiciously applied, etc. ; but experience has convinced me that in the cases of angioma in which the cirsoid or arterial element dominates, no reliance can be placed upon these methods, and that nothing short of the actual extirpation of the diseased tissue itself, after securing the preliminary ligation of the afferent trunks in situ, can secure a permanent result. One of the most instructive lessons gathered from the present case teaches that the auricle may be divested entirely of its cutaneous covering, and the cartilage itself be considerably remodelled without causing it to suffer necrotic changes. If this can be done with comparative ease and safety, then the way to the radical, and yet conservative and cosmetic treat- ment of auricular angioma, is clear and satisfactory. F. B., a German-American, aged thirty-two, ap- plied at my office for treatment, September n, 1890. He is a tall, thin, bub healthy man, who has an excellent family history and no record of cachetic or diathetic disease. He is married and the father of three very robust children. His pres- ent disease has been a source of worry to him since childhood. His mother has no recollection of any no- ticeable peculiarity in his ear as an infant, but when he grew older and was sent to school, he attracted the attention of his playmates by a peculiar red- dish discoloration of his right ear. This discolora- tion became more pronounced as he grew older; it assumed a darker hue and resembled a mother's mark. The abnormal color spread gradually over 5 the whole ear, which grew larger and more promi- nent than its fellow. He suffered no serious incon- venience, however, until about five or six years before his consultation with me. The disease appeared then to have become sud- denly more active. The color deepened to a dark purplish-red and the whole skin became thickened, so that the ear grew much larger, heavier, and de- formed. About this time also he began to notice that when lying with his head on his pillow at night the ear would throb and "hum " annoyingly. Any excitement or violent exertion would invariably aggravate the noise. About a week before consul- tation, the patient was awakened from his sleep by feeling himself bathed with blood, which, to his horror, he discovered spurting freely from a break in the cuticle of his ear. This spot had been no- ticed some days previously to have grown darker than the surrounding skin, and showed signs of ulceration ; in fact, this threatening appearance had decided him to submit to an operative procedure at the hands of one of the local surgeons whom he had consulted, when the unexpected hemorrhage occurred, which altered his plans and brought him to my hands. He was nearly unconscious from the bleeding when a physician arrived and stopped the hemorrhage by pressure and the free applica- tion of the tincture of the perchloride of iron. In consequence of this application the ear appears to have become very much inflamed and eczematous; so much so, that, when the patient called at my office, I feared he was suffering from acute erysip- elas, but a careful examination dispelled this im- pression. When the affected ear was uncovered, it instantly commanded attention because of its extraordinary appearance. Its elephantine size, dusky bluish 6 color, and visible pulsation made it remarkable. The normal left ear, from the tip of the helix to the extremity of the lobule, measured barely inches in length, and from the outer margin of the helix to the base of the tragus, inches in breadth. On the other hand, the abnormal ear measured inches in length, nearly 3 inches in breadth, and over 1 inch in thickness. The outline of the auricle was lost in many places, owing to the redundancy of the soft parts, which simulated the hypertrophy of elephantiasis; the color was dusky blue and purplish-red in places, and on the spot where the hemorrhage had taken place, corresponding to the anti-helix just above the concha, there was a black, superficial slough, surrounded by a red inflamed area. The whole ear pulsated visibly with the heart- beat, so that the pulse could be counted by looking at the ear. By palpation, a diffused pulsation and thrill could be detected over the whole ear, but the distinct throbbing of the larger afferent trunks could be felt in the upper and anterior portion near the tragus, corresponding to the situation of the anterior auricular branch of the temporalis, and posteriorly behind the concha, where the posterior auricular branches of the occipitalis enter the pinna. A distinct plexus of veins could also be detected and compressed as a soft mass lying in the zygomatic region, in front of the tragus and helix. It was also ascertained that the whole cartilage of the auricle had been much hypertrophied, though the outline of the chondral skeleton had been preserved. Pressure upon the common carotid immediately arrested all pulsation, diminished the color, and reduced the size of the ear. In view of this evidence, the diagnosis of cav- ernous angioma was established. The danger of secondary hemorrhage and the 7 advanced stage of the disease also decided me to adopt the ligation of the external carotid as the initial treatment. Two days after, the patient was removed to the Touro Infirmary, where, after careful antiseptic preparation, the external carotid was exposed and ligated.1 The control of the circulation of the ear by the external carotid was demonstrated before tying the knot. At the same time an incision was made in the pretragus, where a large venous plexus was exposed, and ligated in three places. Fine, twisted, sterilized silk ligatures were used for the arteries and veins. The wounds healed entirely perprimam and without any complication. In ten days the patient returned home. All the humming had ceased; the ear grew smaller, paler, and all pulsation was entirely arrested. The patient resumed his regular avocation (local solicitor for a brewing company), but was instructed to call at regular intervals for examination. For a period of over three months the patient enjoyed a total freedom from pulsation, and the ear appeared to diminish in size, but at the end of this time his vigilance was unhappily rewarded by the discovery of a slight pulsation in the fossa of the antihelix. Fifteen days after, this pulsation was decided and unmistakable; in a month, pulsation was also recognizable in the posterior surface of the concha. I concluded from this that a collateral circuit had been established, ist, through the temporal and facial branches of the opposite side; and, 2d, through the anastomoses of the profunda cervicis of the superior intercostal of the subclavian with the princeps cervicis of the occipital. The return of 1 Drs. P. E. Michinard and W. Schuppert and members of the resident staff assisted me in this operation. 8 pulsation was decidedly ominous, and I decided to interfere vigorously in loco before allowing the cir- culation to resume its primitive vigor. It was evident that the ligation of the opposite external carotid would be useless, as it could not affect the abundant supply from the right sub- clavian, the ligation of which would have been required to absolutely control the collateral supply. As the amputation of the ear always remained a last resort, the risk of so heroic a procedure as the liga- ture of the first portion of the subclavian was, of course, not to be entertained. The problem to solve was to save the ear and yet arrest the progress of the disease. The use of local coagulants naturally suggested itself, and the safety of electrolysis recommended this eminently con- servative procedure as a method of election. But the total failure of this method, after a careful and persistent trial, in a recent case of venous nevus of the cheek, followed by a brilliant and immediate cure by the injection of carbolic acid solution, de- cided me in favor of the latter agent. The aim here was not so much to coagulate the blood in the tumor, but to excite an aseptic inflammation in the peri-vascular and cavernous spaces of the angioma with the hope of compressing the afferent vessels with peri-arterial exudations and retractile tissue- proliferations, and of filling the areolae with similar products of inflammatory action. By using strong dilutions of carbolic acid this object had been suc- cessfully obtained in large venous nevi of the face in the practice of Professor Souchon, of this city, and in several small capillary nevi, in children, in my own clientele. The large, passive clots, which are so favorable to embolism, and which result from the injection of the iron salts, are not observed when dilute carbolic acid solutions are used in interstitial 9 injections, and it is largely due to this fact, no doubt, that the practice which is so general in this country, in the hands of the most irresponsible class of practitioners, of injecting hemorrhoids with car- bolic acid, is so rarely followed by disastrous conse- quences. At any rate, I began to inject the angioma in question with from io to 20 minims of solution thrown into the center of the foci of greatest pulsa- tion. At first solutions of 20 per cent, in water, with 2 per cent, cocaine hydrochlorate, were tried tenta- tively ; then these were increased to 30, 40, and 50 per cent, carbolic acid. After each injection, even of the weaker solutions, the pulsation in the area injected was very much diminished, but after the immediate effects of the injection had passed away, the pulsation returned, although not so vigorously. Two or three foci were injected at a time. The patient was thus treated at first every week, and then every two weeks. Beyond a stinging pain, no unpleasant accidents followed these injections, ex- cept on one occasion, when the almost pure acid was injected in a particularly rebellious spot over the antihelix. Here a small slough followed, but it was detached without any bleeding or other serious consequences. So much control over the growth was obtained by this mode of treatment, that the patient thought himself well, and did not return for several months. In March, 1892, he returned, however, complain- ing that the subjective pulsation and humming at night were returning. The ear was more tumefied, and approaching its earlier ugly appearance, and the pulsation had, indeed, returned. I was now seriously contemplating the advisability of ampu- tating the auricle, when I thought of a method of temporarily controlling the circulation of the pinna that had the double advantage of securing complete 10 local hemostasis as well as anesthesia, and that would allow of a direct attack upon the morbid tissues, and permit the ligation of the afferent trunks in situ. The patient was averse to any extended or ad- venturous operation, and rather inclined toward an amputation of the ear. The suggestion of a blood- less operation under cocaine anesthesia reassured him, and he consented. Of course, prolonged local anesthesia, with cocaine, could not be thought of without the aid of elastic constriction. This was secured in the following manner: The hair was cut short and shaved for a consid- erable area around the ear, and the skin thoroughly prepared by washing with soft soap, alcohol, and bichloride solution.1 Four punctures were made at approximately equidistant points in front, above, below, and behind the ear, through which a contin- uous circle or atmosphere of cocaine (4 per cent.) solution was created in the peri-auricular tissues. Four ordinary strong pins were then made to trans- fix the tissues at approximately equidistant points in the cocainized area; then a long, elastic thread was wound around each pin successively, and made to compress the root of the auricle very thoroughly. The pins thus served as binding-posts, and effectu- ally prevented the ligature from slipping. After winding the constrictor several times around the ear, the pulsations in the tumor were entirely arrested; the skin, however, presented a cyanosed appearance. An incision down to the cartilage of the ear was now made along the convex margin of the helix 1 This operation was performed at Eye, Ear, Nose, and Throat Hospital of this city, where every assistance was rendered by Dr. A. W. de Roaldes, surgeon-in-charge, and the painstaking members of the resident staff. 11 from its upper extremity to the lobule. The anes- thesia was complete. With this incision a consider- able gush of dark venous blood took place, and the turgid, erectile swelling collapsed. This hemor- rhage was due only to the escape of the blood actu- ally retained in the cavernous spaces; after the first gush the hemostasis was absolute. I then proceeded with the dissection of the skin, by which the whole cartilaginous skeleton of the pinna was exposed Fig. i.1 Fig. 2. 1 These cuts are intended to give a schematic representation of the author's method of elastic constriction with the aid of pins to secure local anesthesia and hemostasis in operations on the auricle. In total amputation of the auricle, this method is unreliable be- cause of the lack of cartilaginous support. The cocaine is in- jected first in the spots subsequently occupied by the pins. An atmosphere of cocaine solution is thus made to diffuse itself around the root of the auricle. The constricting elastic thread is then wound around the pins several times in the manner shown in Fig. i. Fig. 2 shows the pins and constrictor in relation to the auricle. The posterior pin should be nearer the concha than is shown in the diagram. As the elastic thread is wound around the root of the pinna, the ear becomes markedly pedunculated, and its outline more contracted and circular, the lobule being thrown up toward the helix. In all minor operations on the ears this method can be very easily and satisfactorily applied. 12 clearly to its perichondrium. A posterior flap, con- sisting of the whole skin covering the posterior sur- face of the auricle, and one anterior to the tragus, readily denuded the whole chondral framework. A careful search was now made for all recognizable afferent arteries at the points where previous obser- vation had shown that the supplying vessels entered. These visible vessels were now surprisingly few, and were all held by four artery-forceps, and were ligated with finest silk. In the meantime, the thinness of the collapsed angiomatous skin, and the shrinking of the whole ear were truly astonishing to those who had seen its quasi-elephantine proportions just be- fore the arrest of the circulation by the constrictor. It was evident from the dissection that there was very little subcutaneous tissue, indeed, and that the cavernous spaces now collapsed were lodged in the true skin, which was entirely involved in the angiec- tatic process. It also became evident from this that a radical removal of the diseased tissue could only be accomplished by the total excision of the tegu- mentary covering of the auricle. Such a procedure would have left a naked cartilaginous skeleton with- out any protecting skin-covering unless this was secured by grafting. • Without a precedent to guide me under the cir- cumstances, I hesitated to remove the angiomatous skin-flaps in their entirety for fear of chondral necrosis, and I decided simply to resect as much as possible of the redundant skin, of which there was certainly a great abundance. I also trimmed the whole outer margin of the hypertrophied cartilage, removing a strip corresponding to the whole length of the helix, and a large elliptical section of the much enlarged concha. This procedure reduced the skeleton of the auricle to the size of its normal fellow, and, furthermore, greatly dimished its un- 13 sightly and outstanding prominence. Having thus diminished the skeletal framework by at least one- half, it was also easy for me to excise over one-half of the superfluous skin that originally covered it, there- by removing a great portion of the diseased tissue. The operation was conducted thus far without pain or loss of blood, as the anesthesia and hemo- stasis were perfect, thanks to the elastic constrictor. The field was now carefully scanned for recogniz- able vessels, and a few additional ligatures applied at points where suspicious structures existed at the root of the auricle. Finally, to assure the control of all the afferent vessels, the elastic constrictor was removed. It was well that I did so, for no sooner was the elastic tension relieved than the thin, pale, and shortened flaps of skin became turgid and dis- colored, and numerous jets of blood instantly spurted in all directions from the stumps of the short skin-flaps, and immediately flooded the field of operation. The prompt application of a handful of dry sterilized gauze held over the bleeding flaps, firmly pressed with the palm of the hand, controlled the hemorrhage and allowed a more deliberate in- spection and gradual exposure of the bleeding- points. Fully ten forceps were at one time engaged in securing the bleeding-points, but owing to the promptness with which they were applied a final and complete hemostasis was secured, though only after much expenditure of time, during which the courage and endurance of the patient were being severely tried. There was no real physical pain, the anesthesia being maintained throughout in spite of the removal of the elastic constriction, but it was the mental distress which the possession of full con- sciousness and the appreciation of the proceedings caused the patient. After the torsion of some and the ligation of the 14 majority of the bleeding-points the skin was re- adjusted over the cartilaginous auricle and the wound closed by sutures, and a typical dry aseptic dressing applied. Apart from the nervous tension, which almost threw the patient into a fit of hys- terics, there was no remarkable immediate sequel to the operation. On the third day the patient was able to leave the hospital (March, 1892) and drive home. Here, however, he did not do so well. A week had elapsed, and the wound was healing rapidly, when an attack of erysipelas (due to con- tamination from exposure of the wound) was in- augurated in the operated ear, and prostrated the patient. The erysipelas assumed the ambulating type, and for four weeks the disease travelled all over his body, beginning in the head and only ending when it had reached the toes. The fever, delirium, and general exhaustion consequent upon this disastrous complication nearly killed the patient, but he finally rallied and recovered, and is at pres- ent in excellent health. Present condition of the ear. Notwithstanding the liberal pruning of the hypertrophied cartilage, and large resection of the angiomatous skin, the ear is still larger than its fellow. The partial excision of the helix is now noticeable because the outline of the cartilage is not hidden by the mass of redundant and turgescent integument that first covered it. The color of the ear is its most disfiguring charac- teristic. It is of a dusky bluish-red, but thin and adherent to the underlying cartilage; a slight varix stands in relief on the anterior border of the helix ; posteriorly, the skin is in some places puffy, thick, and compressible, showing the persistence of erec- tile tissue. But the great difference that is at once perceived between the present and past condition, is the total absence of all diffused or localized pul- 15 sation. The last operation was performed in March, 1892, and since that time (eight months) the auricle has remained the same in size and ap- pearance and freedom from pulsation. The patient attends to his usual work, and considers himself well. _ This long period of quiescence encourages me to believe that the disease has been finally con- trolled, and will not recur. In reviewing the history of this case the salient features that are most noticeable are : 1. The sudden transformation of an innocent nevoid spot into a voluminous and rapidly growing angioma. 2. The extent of the disease, which involved the entire tegumentary covering of the auricle. 3. The preponderance of arteriectasis in the mor- bid tissues. 4. The participation of the entire thickness of the skin in the angiomatous process. 5. The hypertrophy of the cartilage from hyper- nutrition. The therapeutic lessons to be derived from the study of the case are : 1. The advantage of early and radical interfer- ence in all nevoid diseases, before the advent of the later and more formidable erectile-tissue stage. 2. The danger of ulceration and hemorrhage from neglecting advanced cavernous angiomata, an urgent condition that interferes with the choice of thera- peutic methods when ulceration has been established. 3. The inability of ligature of the external carotid to control permanently the circulation of the auricle, on account of the early reestablishment 16 of the collateral circulation through the opposite carotid and corresponding subclavian branches. 4. The inability of interstitial or parenchymatous injections of carbolic acid to control extensive cavernous angiomata in which the arterial preponder- ates over the venous ectasis. 5. The facility with which prolonged local anes- thesia with cocaine and hemostasis of the auricle may be obtained by means of elastic constriction, applied by the method adopted in this case. 6. The possibility of permanently arresting the progress of advanced cavernous angiomata of the auricle by ligating the afferent arteries in situ, pro- vided this be done deliberately under the prophy- lactic hemostasis of elastic constriction. 7. In all cases of cutaneous angioma, as in the present instance, in which the skin is diseased throughout, it is utterly impossible to restore the parts to their normal appearance without complete excision. The progress of the disease may be arrested, but the cosmetic result will remain poor. 8. The entire cartilaginous framework of the auricle may be bared of all tegumentary covering and fully resected without seriously compromising its vitality, provided the connections of the concha with the temporal auditory cartilage are maintained. Finally, profiting by the light of present experi- ence, if called again to operate on this or a similar case, I would proceed as follows: 1. Ligate the external carotid on the correspond- ing side. 2. After waiting for the wound of ligation to heal, and before the collateral circulation is reestablished, 17 anesthetize the patient and control the circulation of the ear by the method previously described, and resect the whole angiomatous skin, leaving only those areas in which the normal tissues remain. If necessary, remove the whole cutaneous envelop of the auricle, and cover the raw surface immediately with Thiersch grafts. 3. Before applying grafts ligate all afferent trunks in the auricular skin-stumps, before and after renew- ing the elastic constrictor. 4. Dress the wound with a typical aseptic dress- ing. The advantages of such a procedure are obvious. Not only would the diseased area be radically removed, and thus the possibility of re- currence eliminated, but the cosmetic result would be much more satisfactory.