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Median Osteotomy of the Hyoid Bone. Vallas has devised an excellent means of gaining access to the lower part of the pharynx and the vestibule of the larynx. The operation is indicated for the removal of foreign bodies, of benign neoplasms, of epiglottal cancers, and for the treatment of syphilitic strictures. Tumors of the base of the tongue and even the whole of that organ may be removed by this method. Preliminary tracheotomy, at first thought neces sary, has been given up.

Make a vertical median incision from the symphyses menti to the superior angle of the thyroid cartilage. Separate the fibres of the mylohyoid muscle in the middle line. Expose and divide the hyoid bone in its middle. Retract the two halves of the bone laterally along with the mylohyoid muscles. A space one and one-half inches wide is thus easily exposed. The lower part of the wound is only separated from the pharynx by the thyrohyoid membrane, the upper part by the buccal mucosa. If the object of the procedure is to reach the lower pharynx, cut downward through the thyrohyoid membrane ; if the root of the tongue is the objective, cut upward. The wound is closed by sutures. Drainage of the lower part of the wound is proper.

When excising the tongue, Vallas first ligates both lingual arteries, and through the same incisions removes the submaxil lary glands. He then performs hyoid osteotomy as above de scribed, but does not divide the thyrohyoid membrane. The sub mental wound is only separated from the mouth by the mucosa. An assistant opens the mouth with a suitable gag, and the sur geon, through the mouth, divides the fraenum, the floor of the mouth, and the inferior and lateral connections of the tongue, including the anterior pillars of the fauces. The tongue is manip ulated by a traction suture placed through it or by volsellum for ceps. The tongue is now connected with the body by the hyo glossus muscles alone. Place the patient in a sitting posture with the head inclined forward, and proceed with the next step rapidly for fear of asphyxia. Pull the tongue out through the submental wound until the epiglottis appears. With the finger passed over the tongue feel for and recognize the two halves of the hyoid bone. With the scissors hugging the upper margin of the hyoid, divide the insertions of the hyoglossus muscle. This completes the operation. Closure of the wound, etc., is accomplished on ordinary surgical principles.

tongue, wound, hyoid and lower