Bronchoscopy and Esophagoscopy Part 22

[304] _Tuberculosis_.--In the non-cicatricial forms, galvanocaustic puncture applied through the direct laryngoscope will usually reduce the infiltrations sufficiently to provide a free airway. Should the pulmonary and laryngeal tuberculosis be fortunately cured, leaving, however, a cicatricial stenosis of the larynx, decannulation may be accomplished by laryngostomy.

_Lues_.--Active and persistent antiluetic medication must precede and accompany any local treatment of luetic laryngeal stenosis. Prolonged stretching with oversized intubation tubes following excision or cauterization may sometimes be successful, but laryngostomy is usually required to combat the vicious contraction of luetic cicatrices.

_Scleroma_ is rarely encountered in America. Radiotherapy has been advocated and good results have been reported from the intravenous injection of salvarsan. Radium may be tried, and its application is readily made through the direct laryngoscope.

_Diphtheria_.--Chronic postdiphtheritic stenosis may be of the panic, spasmodic or, rarely, the paralytic types; but more often it is of either the hypertrophic or cicatricial forms. Only too frequently the stenosis should be called posttracheotomic rather than postdiphtheritic, since decannulation after the subsidence of the acute stenosis would have been easy had it not been for the sequelae of the faulty tracheotomy. Prolonged intubation may induce either a supraglottic or subglottic tissue hyperplasia. _The supraglottic type_ consists in an edematous thickening around the base of the epiglottis, sometimes involving also the glossoepiglottic folds and the ventricular bands. An improperly shaped or fitted tube is the usual cause of this condition, and a change to a correct form of intubation tube may be all that is required. Excessive polypoid tissue hypertrophy should be excised. The less redundant cases subside under galvanocaustic treatment, which may be preceded by tracheotomy and extubation, or the intubation tube may be replaced after the application of the cautery. The former method is preferable since the patient is far safer with a tracheotomic cannula and, further, the constant irritation of the intubation tube is avoided. _Subglottic hypertrophic stenosis_ consists in symmetrical turbinal-like swellings encroaching on the lumen from either side. Cautious galvanocauterant treatment accurately applied by the direct method will practically always cure this condition. Preliminary tracheotomy is required in those cases in which it has not already been done, and in the cases in which a high tracheotomy has been done, a low tracheotomy must be the first step in the cure. Cicatricial types of postdiphtheritic stenosis may be seen as webs, annular cicatrices of funnel shape, or ma.s.ses of fibrous tissue causing fixation of the arytenoids as well as encroachment on the glottic lumen. (See color plates.)

As a rule, when a convalescent diphtheritic patient cannot be extubated two weeks after three negative cultures have been obtained the advisability of a low tracheotomy should be considered. If a convalescent intubated patient cough up a tube and become dyspneic a low tracheotomy is usually preferable to forcing in an oversized intubation tube.

_Typhoid Fever_.--Ulcerative lesions in the larynx during typhoid fever are almost always the result of mixed infection, though thrombosis of a small vessel, with subsequent necrosis is also seen.

If the ulceration reaches the cartilage, cicatricial stenosis is almost certain to follow.

_Trauma_.--The chief traumatic factors in chronic laryngeal stenosis are: (a) prolonged presence of a foreign body in the larynx (b) unskilled attempts at intubation and the wearing of poorly fitting intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting cannula; (e) war injuries; (f) attempted suicide; (g) attempted homicide; (h) neglect of cleanliness and care of either intubation tubes or tracheotomic cannulae allowing incrustation and roughening which traumatize the tissues at each movement of the ever-moving larynx and trachea.

_Treatment of Cicatricial Stenosis_.--A careful direct endoscopic examination is essential before deciding on the method of treatment for each particular case. Granulations should be removed. Intubated cases are usually best treated by tracheotomy and extubation before further endoscopic treatment is undertaken. A certain diagnosis as to the cause of the condition must be made by laboratory and therapeutic tests, supplemented by biopsy if necessary. Vigorous antiluetic treatment, especially with protiodide of mercury, must precede operation in all luetic cases. Necrotic cartilage is best treated by laryngostomy. Intubational dilatation will succeed in some cases.

[FIG. 109.--Schema showing the author's method of laryngostomy. The hollow upward metallic branch (N) of the cannula (C) holds the rubber tube (R) back firmly against the spur usually found on the back wall of the trachea. Moreover, the air pa.s.sing up through the rubber tube (R) permits the patient to talk in a loud whisper, the external orifice of the cannula being occluded most of the time with the cork (K). The rubber tubing, when large sizes are reached may extend down to the lower end of the cannula, the part C coming out through a large hole cut in the tubing at the proper distance from the lower end.]

_Laryngoscopic bouginage_ once weekly with the laryngeal bougies (Fig.

42) will cure most cases of laryngeal stenosis. For the trachea, round, silk-woven, or metallic bougies (Fig. 40) are better.

[307] _Laryngostomy_ consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula, excision of thick cicatricial tissue, very cautious incision of the scar tissue on the posterior wall, if necessary, and the placing of the author's laryngostomy tube for dilatation (Fig. 109). Over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anch.o.r.ed to the tape carrier by braided silk thread.

Progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber. Several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed. Painstaking after-care is essential to success. When dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall.

_Intubational treatment of chronic laryngeal stenosis_ may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. The tube is a silver-plated bra.s.s one of large size (Fig. 110).

A post which screws into the anterior surface of the tube prevents its expulsion. Over the post is slipped a block which serves to keep open the tracheal fistula. Detailed discussion of these operative treatments is outside the scope of this work, but mention is made for the sake of completeness. Before undertaking any of the foregoing procedures, a careful study of the complete descriptions in Peroral Endoscopy is necessary, and a practical course of training is advisable.

[FIG. 110.--The author's retaining intubation tube for treatment of chronic laryngeal stenosis. The tube (A) is introduced through the mouth, then the post (B) is screwed in through the tracheal wound.

Then the block (C) is slid into the wound, the square hole in the block guarding the post against all possibility of uns.c.r.e.w.i.n.g. If the threads of the post are properly fitted and tightly screwed up with a hemostat, however, there is no chance of uns.c.r.e.w.i.n.g and gauze packing is used instead of the block to maintain a large fistula. The shape of the intubation tube has been arrived at after long clinical study and trials, and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape.]

[309] CHAPTER x.x.xIX--DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS

In order to train the patient to breathe again through the larynx it is necessary to occlude the cannula. This is best done by inserting a rubber cork in the inner cannula. At first it may be necessary to make a slot in the cork so as to permit some air to enter through the tube to supplement the insufficient supply obtainable through the insufficiently patulous glottis, new corks with smaller grooves being subst.i.tuted as laryngeal breathing becomes easier. Corking the cannula is an excellent orthopedic treatment in certain cases where muscle atrophy and partial inflammatory fixation of the cricoarytenoid joints are etiological factors in the stenosis. The added pull of the posterior cricoarytenoid muscles during the slight effort at inspiration restores their tone and increases the mobility of all the attached structures. By no other method can panic and spasmodic stenosis be so efficiently cured.

[FIG. 111.--Ill.u.s.tration of corks used to occlude the cannula in training patients to breathe through the mouth again, before decannulation. The corks allow air leakage, the amount of which is regulated by the use of different shapes. A smaller and still smaller air leak is permitted until finally an ungrooved cork is tolerated. A central hole is sometimes used instead of a slot. A, one-third cork; B, half cork; C, three-quarter cork; D, whole cork.]

Following the subsidence of an acute laryngeal stenosis, it is my rule to decannulate after the patient has been able to breathe through the larynx with the cannula tightly corked for 3 days and nights. This rule does not apply to chronic laryngeal stenosis, for while the lumen under ordinary conditions might be ample, a slight degree of inflammation might render it dangerously small. In these cases, many weeks are sometimes required to determine when decannulation is safe.

A test period of a few months is advisable in most cases of chronic laryngeal stenosis. Recurrent contractions after closure of the wound are best treated by endoscopic bouginage. The corks are best made of pure rubber cord, cut and ground to shape, and grooved, if desired, on a small emery wheel (Fig. 112). The ordinary rubber corks and those made of cork-bark should not be used because of their friability, and the possible aspiration of a fragment into the bronchus, where rubber particles form very irritant foreign bodies.

[FIG. 112.--This ill.u.s.tration shows the method of making safe corks for tracheotomic cannulae by grinding pure rubber cord to shape on an emery wheel. After grinding the taper, if a partial cork is desired, a groove is ground on the angle of the wheel. If a half-cork is desired half of the cork is ground away on the side of the wheel. Reliable corks made in this way are now obtainable from Messers Charles J.

Pilling and Son.]