MILLIKIN: Partially Bony Tumor of Orbit.
I69
CASE OF PARTIALLY BONY TUMOR OF ORBIT. REMOVAL; RECOVERY. BY B. L. MILIKIN, M.D., CLEVELAND, OHIO.
Hard tumors of the orbit are so unusual, whatever may be their nature, that one of any variety is worthy of record. The following case has been entirely unique in my own experience, and in looking up the matter in the literature at my disposal, I have found little definite information regarding it. Numerous cases of osteomata, hydatids, cysts, etc., more or less connected with the frontal sinus, occur in the literature of ophthalmology, but I find very few or no cases similar to this. Miss Jennie E. D., age i6, American, came to me on the 13th of June, I 8go, and gave me the following history: At the age of 6 years there was first noticed a small tumor located on the upper inner border of the left orbit. This was very hard, and the increase in size was very slow. There was no marked pain in the growth, occasionally a sharp shooting sensation in the region of it. Three years after this, or at the age of 9, an operation was performed upon it, but from the history of this and the cicatrix, I am not able to understand how extensive the operation was, only the wound continued to discharge from the time of the operation in April until the following September. Whatever it may have been, the growth has continued to increase ever since, and also has become quite painful at times. Condition at time of examination: The patient was a wellformed, good sized, healthy-looking girl, fair complexion, and had never been much ill. Her father died at 48 years of age, of "quick consumption," fifteen years ago, and her mother a *year later, at 38 years of age, of what disease she does not know. She has five brothers, all healthy. On examination, I found the vision of right eye 6/6, left eye 3/"30, T = n both eyes. Located in the left orbital region was a large growth of bony hardness, arising from the upper, inner portion of the orbit, and extending from the inner angle of orbit
170
MILLIKIN: Partially Bony Tumor of Orbit.
outward, along the orbital border to the junction of the middle and outer thirds, and downward on a line with the inner canthus, so that the lower border of the tumor was almost an inch below the line of the eyebrow, and projected forward full on a line with the superciliary ridge, which was itself somewhat thickened. As a result of this, the eye itself was protruded far forward, downward and outward, and the mlovements of the eyeball were greatly restricted in all directions. There was diplopia in nearly all portions of the field, and some droopilig of the upper lid. Vision in this eye was very defective, and the ophthalmoscope showed a small, somewhat atrophic disc, with small thread-like arteries of very much less caliber than the corresponding vessels of the opposite eye-ground. The tumor was uniformly smooth, with rounded'outlines, hard as bone, with only skin covering. That the tumor was of a bony nature, and was connected with the frontal sinus, was very evident -but an exact diagnosis of the difficulty was to me rather puzzling. My impression and expectation were that we had to deal with an osteoma of large size, and so intimately connected with the vault of the orbit that its removal might be attended with grave risk of injury to the membranes of the base of the brain. However, I advised operation as the only procedure offering any relief, and fully acquainted the friends with the possible serious nature of the undertaking. I confess I was not at all certain what would be found, and was greatly relieved when I discovered the real nature of the trouble, so far as the operation was concerned. On the I7th of June, in the presence, and with the assistance of Dr. H. S. Upson, and the House Staff of Charity Hospital, the following operation was performed: The patient being etherized, an incision was made extending from a point directly above the external angle of the orbit, on a line just above the eyebrow, to a point above the root of the nose, about 5 cm. long. From the inner extremity of this incision a second incision was made down the center of the nose to a point on a level with the internal canthus. These incisions were made to the bone, the flap with its subjacent periosteum was removed over the entire area of the tumor, when it was found that the tumor extended far back into the bottom of the
MILLIKIN: Partially Bony Tumor of Orbit.
I71
orbit. In separating the periosteum from the bone in the most prominent part of the tumor, the bone was found very thin, but hard, and broke down quite readily, disclosing a very large cavity filled with soft fibrous material, dark in color, well organized, no purulency. With the rongeur, chisels, bone forceps, burr, etc., the entire bony walls of the tumor below were removed, leaving a very large cavity. The floor wall of this cavity extended deep into the orbital cavity, and this was removed, so that it was left on a level with the surrounding orbital vault. Care was taken not to in;ure the roof of the cavity, which I should judge was thin, and perhaps pushed a little higher than normal. The whole cavity was rough, like cancellated bone tissue. This was all smoothed out with the ordinary surgeon's burr, as well as could be, and thoroughly washed out with a I-2000 solution of bichloride of mercury, the entire operation being done with strict antiseptic precautions. With the exception of the hemorrhage from the skin flap, the bleeding was almost nil. The arch of the orbit was much thickened, and this thickening was all torn and cut away with the rongeur and bone forceps. The eyeball, with the orbital contents, which had been previously separated from the tumor walls, were placed back in the cavity, and with a sponge, pressure was .made by the hand of an assistant until the sutures could be placed, silk being used for this purpose. I suspected, from a cavity of such dimensions and of such structure, that there would be a considerable amount of serous oozing, so I was led to insert a small drainage tube, allowing it to project from the most dependent portion of the incision upon the nose. The whole was then dressed by placing masses of bichloride gauze over the eyeball, care being taken that the eyelids were closed, over this pledgets of absorbent cotton, and the whole retained in place by flannel rollers put on rather tightly. There was much retching and vomiting from the effects of the ether, and a small quantity of blood was thus ejected,- the only indication of any connection of the tumor with the nasal cavity. I might say at this time there was no history or indication at any time in the progress of the case, indicating a possible nasal origin of the difficulty, so that I have no doubt the growth originated de novo, in the frontal
172
MILLIKIN: Partially Bony Tumor of Orbit.
sinus or possibly in the periosteum of this cavity. To keep the eyes as quiet as possible, both of them were closed after the operation. June igth. Since the operation, two days ago, the patient has ,done very well, the temperature at no time rising much over 100I F. To-day the dressings were removed for the first time, when it was found that the wound had entirely healed by primary union in every part, except where the drainage tube was inserted. Amount of discharge, very little. The drainage tube was removed and the wound redressed with iodoform and bichloride gauze, the sound eye being left open. June 2ISt. All the stitches were removed, and the wound was almost healed, and looks well. June 25th. Everything doing well. There is complete ptosis of the upper lid, but when this is raised, the vision seems about the same as before the operation, and the movements of the eyeball are of course limited. June 30th. Thirteen days after the operation everything was healed solid. The patient was recovering rapidly from the effects of the operation in a general way, and was permitted to go home. The amount of the scarring was not great, only a linear cicatrix along the border of the eyebrow, the most scar being on the root of the nose where the drainage tube had been placed. Since then I have occasionally seen the patient, and thus far, now nearly a year and a half, there. has been no indication of any return of the growth, nor has there been any special discomfort about it, except the cosmetic disadvantage. As time has gone on, the ability to raise the upper lid has increased, so that it now can be elevated nearly half, disclosing a portion of the eyeball. However, this I think, is no special disadvantage as the lid covers the eye, so as to shut off the annoyance of diplopia, which is very evident whenever the eyelid is raised. The movements of the eyeball in all directions are somewhat restricted, as I previously thought would be the case, owing-to the long and very great stretching of the muscles by the large size of the growth, and the consequent pressure upon them. The vision has remained in statu quo. A recent more careful examination of the refraction of the eye shows a high degree of
1ILLIKIN: Partially Boiny Tumor of Orbit.
173
astigmatism, about 50 D. cy. ax. goo, and with this glass, V=6/24, and the ophthalmoscope shows less of the atrophic condition than before the operation, the color of disc better, and the vessels larger. Now the eyeball moves pretty freely in all directions, but diplopia occurs in all portions of the field, the image of the eye seeming to be placed farther away than that of the sound eye. A photograph taken a few days ago shows the present appearance of the eye better than any de*scription, and I am only sorry we have no good photograph taken previous to the operation, for comparison. With reference to the operation and methods of performing it, I think there is little to be said. The removal by piecemeal is the only practical method, and was easily and quickly accomplished. The rongeur I found a most admirable instrument, it enabling me to cut away the bone very readily. In another operation of the kind I should omit the use of the drainage tube entirely, for in this case there is no doubt the union would have been prompt and complete without it, whereas with it, union was delayed. In fact, I believe that I should not again use a drainage tube in any operation about the orbit, unless there was some indication of suppurative trouble. I have given the tumor to Dr. W. H. Nevison of Cleveland, who has been kind enough to make sections from various portions of the growth, for microscopical examination, and pronounces it to be " a sarcoma of the small spindle-celled variety. Many points have undergone fatty degeneration, with the formation of small cyst-like cavities." Of course from the extent of the growth, it is impossible to say what was the exact origin of it, nor do I know how a more exact diagnosis could have been made without an exploratory incision.
I69
CASE OF PARTIALLY BONY TUMOR OF ORBIT. REMOVAL; RECOVERY. BY B. L. MILIKIN, M.D., CLEVELAND, OHIO.
Hard tumors of the orbit are so unusual, whatever may be their nature, that one of any variety is worthy of record. The following case has been entirely unique in my own experience, and in looking up the matter in the literature at my disposal, I have found little definite information regarding it. Numerous cases of osteomata, hydatids, cysts, etc., more or less connected with the frontal sinus, occur in the literature of ophthalmology, but I find very few or no cases similar to this. Miss Jennie E. D., age i6, American, came to me on the 13th of June, I 8go, and gave me the following history: At the age of 6 years there was first noticed a small tumor located on the upper inner border of the left orbit. This was very hard, and the increase in size was very slow. There was no marked pain in the growth, occasionally a sharp shooting sensation in the region of it. Three years after this, or at the age of 9, an operation was performed upon it, but from the history of this and the cicatrix, I am not able to understand how extensive the operation was, only the wound continued to discharge from the time of the operation in April until the following September. Whatever it may have been, the growth has continued to increase ever since, and also has become quite painful at times. Condition at time of examination: The patient was a wellformed, good sized, healthy-looking girl, fair complexion, and had never been much ill. Her father died at 48 years of age, of "quick consumption," fifteen years ago, and her mother a *year later, at 38 years of age, of what disease she does not know. She has five brothers, all healthy. On examination, I found the vision of right eye 6/6, left eye 3/"30, T = n both eyes. Located in the left orbital region was a large growth of bony hardness, arising from the upper, inner portion of the orbit, and extending from the inner angle of orbit
170
MILLIKIN: Partially Bony Tumor of Orbit.
outward, along the orbital border to the junction of the middle and outer thirds, and downward on a line with the inner canthus, so that the lower border of the tumor was almost an inch below the line of the eyebrow, and projected forward full on a line with the superciliary ridge, which was itself somewhat thickened. As a result of this, the eye itself was protruded far forward, downward and outward, and the mlovements of the eyeball were greatly restricted in all directions. There was diplopia in nearly all portions of the field, and some droopilig of the upper lid. Vision in this eye was very defective, and the ophthalmoscope showed a small, somewhat atrophic disc, with small thread-like arteries of very much less caliber than the corresponding vessels of the opposite eye-ground. The tumor was uniformly smooth, with rounded'outlines, hard as bone, with only skin covering. That the tumor was of a bony nature, and was connected with the frontal sinus, was very evident -but an exact diagnosis of the difficulty was to me rather puzzling. My impression and expectation were that we had to deal with an osteoma of large size, and so intimately connected with the vault of the orbit that its removal might be attended with grave risk of injury to the membranes of the base of the brain. However, I advised operation as the only procedure offering any relief, and fully acquainted the friends with the possible serious nature of the undertaking. I confess I was not at all certain what would be found, and was greatly relieved when I discovered the real nature of the trouble, so far as the operation was concerned. On the I7th of June, in the presence, and with the assistance of Dr. H. S. Upson, and the House Staff of Charity Hospital, the following operation was performed: The patient being etherized, an incision was made extending from a point directly above the external angle of the orbit, on a line just above the eyebrow, to a point above the root of the nose, about 5 cm. long. From the inner extremity of this incision a second incision was made down the center of the nose to a point on a level with the internal canthus. These incisions were made to the bone, the flap with its subjacent periosteum was removed over the entire area of the tumor, when it was found that the tumor extended far back into the bottom of the
MILLIKIN: Partially Bony Tumor of Orbit.
I71
orbit. In separating the periosteum from the bone in the most prominent part of the tumor, the bone was found very thin, but hard, and broke down quite readily, disclosing a very large cavity filled with soft fibrous material, dark in color, well organized, no purulency. With the rongeur, chisels, bone forceps, burr, etc., the entire bony walls of the tumor below were removed, leaving a very large cavity. The floor wall of this cavity extended deep into the orbital cavity, and this was removed, so that it was left on a level with the surrounding orbital vault. Care was taken not to in;ure the roof of the cavity, which I should judge was thin, and perhaps pushed a little higher than normal. The whole cavity was rough, like cancellated bone tissue. This was all smoothed out with the ordinary surgeon's burr, as well as could be, and thoroughly washed out with a I-2000 solution of bichloride of mercury, the entire operation being done with strict antiseptic precautions. With the exception of the hemorrhage from the skin flap, the bleeding was almost nil. The arch of the orbit was much thickened, and this thickening was all torn and cut away with the rongeur and bone forceps. The eyeball, with the orbital contents, which had been previously separated from the tumor walls, were placed back in the cavity, and with a sponge, pressure was .made by the hand of an assistant until the sutures could be placed, silk being used for this purpose. I suspected, from a cavity of such dimensions and of such structure, that there would be a considerable amount of serous oozing, so I was led to insert a small drainage tube, allowing it to project from the most dependent portion of the incision upon the nose. The whole was then dressed by placing masses of bichloride gauze over the eyeball, care being taken that the eyelids were closed, over this pledgets of absorbent cotton, and the whole retained in place by flannel rollers put on rather tightly. There was much retching and vomiting from the effects of the ether, and a small quantity of blood was thus ejected,- the only indication of any connection of the tumor with the nasal cavity. I might say at this time there was no history or indication at any time in the progress of the case, indicating a possible nasal origin of the difficulty, so that I have no doubt the growth originated de novo, in the frontal
172
MILLIKIN: Partially Bony Tumor of Orbit.
sinus or possibly in the periosteum of this cavity. To keep the eyes as quiet as possible, both of them were closed after the operation. June igth. Since the operation, two days ago, the patient has ,done very well, the temperature at no time rising much over 100I F. To-day the dressings were removed for the first time, when it was found that the wound had entirely healed by primary union in every part, except where the drainage tube was inserted. Amount of discharge, very little. The drainage tube was removed and the wound redressed with iodoform and bichloride gauze, the sound eye being left open. June 2ISt. All the stitches were removed, and the wound was almost healed, and looks well. June 25th. Everything doing well. There is complete ptosis of the upper lid, but when this is raised, the vision seems about the same as before the operation, and the movements of the eyeball are of course limited. June 30th. Thirteen days after the operation everything was healed solid. The patient was recovering rapidly from the effects of the operation in a general way, and was permitted to go home. The amount of the scarring was not great, only a linear cicatrix along the border of the eyebrow, the most scar being on the root of the nose where the drainage tube had been placed. Since then I have occasionally seen the patient, and thus far, now nearly a year and a half, there. has been no indication of any return of the growth, nor has there been any special discomfort about it, except the cosmetic disadvantage. As time has gone on, the ability to raise the upper lid has increased, so that it now can be elevated nearly half, disclosing a portion of the eyeball. However, this I think, is no special disadvantage as the lid covers the eye, so as to shut off the annoyance of diplopia, which is very evident whenever the eyelid is raised. The movements of the eyeball in all directions are somewhat restricted, as I previously thought would be the case, owing-to the long and very great stretching of the muscles by the large size of the growth, and the consequent pressure upon them. The vision has remained in statu quo. A recent more careful examination of the refraction of the eye shows a high degree of
1ILLIKIN: Partially Boiny Tumor of Orbit.
173
astigmatism, about 50 D. cy. ax. goo, and with this glass, V=6/24, and the ophthalmoscope shows less of the atrophic condition than before the operation, the color of disc better, and the vessels larger. Now the eyeball moves pretty freely in all directions, but diplopia occurs in all portions of the field, the image of the eye seeming to be placed farther away than that of the sound eye. A photograph taken a few days ago shows the present appearance of the eye better than any de*scription, and I am only sorry we have no good photograph taken previous to the operation, for comparison. With reference to the operation and methods of performing it, I think there is little to be said. The removal by piecemeal is the only practical method, and was easily and quickly accomplished. The rongeur I found a most admirable instrument, it enabling me to cut away the bone very readily. In another operation of the kind I should omit the use of the drainage tube entirely, for in this case there is no doubt the union would have been prompt and complete without it, whereas with it, union was delayed. In fact, I believe that I should not again use a drainage tube in any operation about the orbit, unless there was some indication of suppurative trouble. I have given the tumor to Dr. W. H. Nevison of Cleveland, who has been kind enough to make sections from various portions of the growth, for microscopical examination, and pronounces it to be " a sarcoma of the small spindle-celled variety. Many points have undergone fatty degeneration, with the formation of small cyst-like cavities." Of course from the extent of the growth, it is impossible to say what was the exact origin of it, nor do I know how a more exact diagnosis could have been made without an exploratory incision.
