Manual of Surgery Volume II Part 67

An examination of the lungs should be made in all cases of adductor paralysis, as this functional condition may be met with in early pulmonary tuberculosis.

#Dysphagia.#--Pain on swallowing, due to causes originating in the larynx, is usually a.s.sociated with ulceration of the mucous membrane covering the epiglottis, ary-epiglottic folds, or arytenoid cartilages, that is, in connection with those parts with which the food is brought into direct contact.

The most frequent causes of such ulceration are tuberculosis, syphilis, and malignant disease. The differential diagnosis is often difficult from local inspection alone. The Wa.s.serman test, the previous history, the state of the lungs and sputum, and the results of anti-syphilitic treatment may clear it up.

The _treatment_ of dysphagia, apart from that of the disease a.s.sociated with it, resolves itself into the use of local sedative applications, such as a weak cocain or eucain spray before meals, insufflations of acetate of morphin and boracic acid, and the use of a menthol spray. One of the best anaesthetic applications is orthoform powder, introduced by means of the ordinary laryngeal insufflator. Its action is more prolonged than that of any of the others, often lasting for from twenty-four to forty-eight hours.

Injection of the superior laryngeal nerve with a 60 per cent. solution of alcohol has been found satisfactory where other means have failed.

#Interference with Respiration.#--It is only necessary here to refer to such causes of interference with respiration as may call for surgical treatment.

The chief forms of _laryngitis_ to be considered in connection with the production of dyspna, are membranous or diphtheritic laryngitis and acute inflammatory dema.

#Diphtheria of the larynx# is described on p. 110, Volume I.

#Acute dema of the Larynx.#--dema of the larynx may be inflammatory or non-inflammatory in origin. The former is the more common, and may arise in connection with disease of the larynx, such as tuberculosis or syphilis, or it may be secondary to acute infective conditions at the base of the tongue, or in the fauces or pharynx; more rarely it results from infective conditions of the cellular tissue or glands of the neck. The non-inflammatory form may be a local dropsy in renal or cardiac disease, may be induced by pressure on the large cervical veins, and in some cases it appears to follow the administration of pota.s.sium iodide in the treatment of laryngeal affections.

The dema consists of an exudation into the loose submucous areolar tissue, which may be of a simple serous character or may become sero-purulent. The situations mainly involved are the glosso-epiglottic fossae between the base of the tongue and the epiglottis, the ary-epiglottic folds (Fig. 287), and the false cords.

If the infective process commences in front of the epiglottis this structure becomes swollen and rigid, and often livid in colour--points which are readily discerned on examination with the mirror, or even without its aid in some cases. The patient complains of great pain on swallowing, and has the sensation of a foreign body in the throat. Should the dema spread to the ary-epiglottic folds, either from the interior of the larynx or from the fauces and pharynx, dyspna becomes a prominent and grave symptom. The patient may rapidly become cyanosed, the inspirations a.s.sume a noisy, stridulous character, and great distress and imminent suffocation supervene. If laryngoscopic examination is possible, the ary-epiglottic folds may be found greatly swollen and the upper aperture of the larynx partly occluded. Digital examination may reveal the swollen condition of the parts. The urine should be examined for alb.u.min and tube casts.

[Ill.u.s.tration: FIG. 287.--Larynx from case of sudden death, due to dema of ary-epiglottic folds, _a_, _a_.

(From drawing lent by Dr. Logan Turner.)]

_Treatment._--In the milder forms, the sucking of ice, the inhalation of medicated steam, or spraying with a solution of adrenalin, and the application of poultices to the neck, may suffice to relieve the condition. Scarification of the epiglottis and ary-epiglottic folds with a knife, followed by free bleeding, may give complete relief.

Diaph.o.r.etic and purgative treatment should not be neglected. If suffocation is imminent, tracheotomy or intubation is called for.

In performing #tracheotomy#, a roller pillow is placed beneath the neck to put the parts on the stretch, and an incision is carried from the lower margin of the cricoid cartilage downwards for about 2 inches. The sterno-hyoids and sterno-thyreoids are separated; the cross branch between the anterior jugular veins, and any other veins met with, secured with forceps before being divided; and the trachea exposed by dividing transversely the layer of deep fascia which pa.s.ses from the cricoid to the isthmus of the thyreoid. If the isthmus cannot be pulled downwards sufficiently, it may be divided in the middle line. All active bleeding having been arrested, the larynx is steadied by inserting a sharp hook into the lower edge of the cricoid cartilage, and the trachea is opened by thrusting a short, broad-bladed knife through the exposed rings. The back of the knife should be directed downwards, and the opening in the trachea enlarged upwards sufficiently to admit the tracheotomy tube. In children it is sometimes found necessary to divide the cricoid for this purpose (_laryngo-tracheotomy_). The slit in the trachea is then opened up with a tracheal dilator, and the outer tube inserted and fixed in position with tapes. The inner tube is not fixed, so that it may be coughed out if it becomes blocked, and that it may be frequently removed and cleaned by the nurse. The tube should be discarded as soon as the patient is able to breathe by the natural channel.

_Intubation of the Larynx._--This procedure is employed as a subst.i.tute for tracheotomy, especially in children suffering from membranous and dematous forms of laryngitis. As experience is required to carry out the manipulations successfully, and as its use is attended with certain risks which necessitate that the surgeon should be constantly within call, the operation is more adapted to hospital than to private practice. O'Dwyer's apparatus is that most generally employed. The operation consists in introducing through the glottis, by means of a specially constructed guide, a small metal or vulcanite tube furnished with a shoulder which rests against the false vocal cords. The part of the tube which pa.s.ses beyond the true vocal cords is bulged to prevent it being coughed out.

In an emergency a gum-elastic catheter with a terminal aperture may be pa.s.sed, as recommended by Macewen and Annandale.

#Bilateral Abductor Paralysis.#--Both recurrent nerves may be interfered with by such conditions as enlargement of the thyreoid, tumour of the sophagus, or intra-thoracic tumour, or by injury in the course of operations for goitre. A gradually increasing inspiratory dyspna is developed, which at first is only noticed on exertion, when the desire for air is increased; later it becomes permanent, and even during sleep the stridor may be marked. Suffocation may become imminent. When the larynx is examined with the mirror, the vocal cords are seen to lie near each other, and on inspiration their approximation is still greater.

The _treatment_ is directed to removing the cause of pressure on the nerves. In the majority of cases tracheotomy is called for and the tube must be worn permanently.

#Syphilitic Affections of the Larynx.#--_Secondary syphilitic_ manifestations in the form of congestion of the mucous membrane, mucous patches, or condylomata, are occasionally met with, and give rise to a huskiness of the voice. These conditions usually disappear rapidly under anti-syphilitic treatment.

In _tertiary syphilis_, whether inherited or acquired, the most common lesion is a diffuse gummatous infiltration, which tends to go on to ulceration and to lead to widespread destruction of tissue. It usually attacks the epiglottis, the arytenoids, and the ary-epiglottic folds, but may spread and implicate all the structures of the larynx.

Syphilitic ulcers are usually single, deep, and crateriform; the base is covered with a dirty white secretion, and the surrounding mucosa presents an angry red appearance. When the perichondrium becomes invaded, necrosis of cartilage is liable to occur.

Hoa.r.s.eness, dyspna, and, when the epiglottis is involved, dysphagia, are the most prominent symptoms.

Cicatricial contraction leading to stenosis may ensue, and cause persistent dyspna.

The usual _treatment_ for tertiary syphilis is employed, but on account of the tendency of pota.s.sium iodide to increase the dema of the larynx, this drug must at first be used with caution. Intubation or tracheotomy may be called for on account of sudden urgent dyspna or of increasing stenosis. The stenosis is afterwards treated by gradual dilatation with bougies, which, if a tracheotomy has been performed, may conveniently be pa.s.sed from below upwards. An annular stricture causing occlusion may be excised, and the ends of the trachea sutured.

#Tuberculosis.#--The larynx is seldom the primary seat of tubercle. In the majority of cases the patient suffers from pulmonary phthisis, and the laryngeal mucous membrane is infected from the sputum. The disease may take the form of isolated nodules in the vicinity of the arytenoid cartilages, of superficial ulceration of the vocal cords and adjacent parts, or of a diffuse tuberculous infiltration of all the structures bounding the upper aperture of the larynx. The mucous membrane becomes dematous and semi-translucent. The nodules coalesce and break down, leading to the formation of multiple superficial ulcers. The parts adjacent to the ulcers are pale in colour. Perichondritis may occur and be followed by necrosis of cartilage and the formation of abscesses in the submucous tissue of the larynx or in the cellular tissue of the neck.

The voice becomes hoa.r.s.e or may be lost, there is persistent and intractable cough, and in some cases dyspna supervenes. When the epiglottis is involved there is pain and difficulty in swallowing.

In the presence of advanced pulmonary phthisis the treatment is chiefly palliative, but if the disease in the lungs is amenable to treatment, and the laryngeal lesion limited, the electric cautery may be used. Tracheotomy may be called for on account of urgent dyspna.

#Tumours.#--The commonest form of simple tumour met with in the larynx is the _papilloma_. It may occur at any age, and is comparatively common in children. It most frequently springs from the vocal cords and adjacent parts, forming a soft, pedunculated, cauliflower-like ma.s.s of a pink or red colour, which may form a fringe hanging from the edge of the cord (Fig. 288), or may spread until it nearly fills the larynx. In children, the growths are frequently multiple and show a marked tendency to recur after removal. They sometimes disappear spontaneously about p.u.b.erty.

[Ill.u.s.tration: FIG. 288.--Papilloma of Larynx.

(From drawing lent by Dr. Logan Turner.)]

The most prominent symptoms are hoa.r.s.eness, aphonia, and dyspna, which in children may be paroxysmal.

The _treatment_ consists in removing the growth by means of laryngeal forceps or the snare, under cocain and adrenalin anaesthesia. For the removal of multiple papillomata, the removal of the growths through Killian's tubes or by suspension laryngoscopy has now taken the place of the external operation in children. In a certain number of cases it has been found that the tumour disappears after the larynx has been put at rest by the operation of tracheotomy.

#Cancer.#--_Epithelioma_ of the larynx is almost always primary, and usually occurs in males between the ages of forty and seventy. It is important to distinguish between those cases in which the growth first appears in the interior of the larynx--on the vocal cords, the ventricular bands, or in the sub-glottic cavity (_intrinsic cancer_)--and those in which it attacks the epiglottis, the ary-epiglottic folds, or the posterior surface of the cricoid cartilage (_extrinsic cancer_).

_Clinical Features._--In the great majority of cases of _intrinsic_ cancer the first and for many months the only symptom is huskiness of the voice, which may go on to complete aphonia before any other symptoms manifest themselves. When the larynx is examined in an early stage, the presence of a small warty growth on the posterior part of one vocal cord, or a papillary fringe extended along the free edge of the cord, should raise the suspicion of malignancy, especially if the affected cord is congested and moves less freely than its fellow.

Early diagnosis is essential in intrinsic cancer, and the absence of enlargement of lymph glands, or of ftor and cachexia, must in no way influence the surgeon against making a diagnosis of malignancy. The impaired mobility of the affected cord is an important point in determining the malignant nature of the growth.

Intrinsic cancer may spread over the upper boundaries of the larynx and become _extrinsic_, or the disease may be extrinsic from the outset.

In cases of _extrinsic_ cancer the early symptoms are much more marked, pain and difficulty in swallowing, and the secretion of frothy, blood-stained mucus being among the earliest manifestations.

The cervical glands are infected early, sometimes even before there are any symptoms of laryngeal disease. Difficulty of breathing is also an early symptom on account of the growth obstructing the entrance of air. Tracheotomy may therefore be called for. In other respects the course and terminations are similar to those of intrinsic cancer.

When the growth spreads into the tissues of the neck the patient's sufferings are greatly increased. The sophagus may be invaded with resulting dysphagia; the nerve-trunks may be pressed upon, causing intense neuralgic pains; the lymph glands become infected and break down, and the growth fungates through the skin. The general health deteriorates and death results, usually from septic pneumonia set up by the pa.s.sage of food particles into the air-pa.s.sages, from absorption of toxins, or from haemorrhage. The duration of this form of the disease varies from one to three years.

The _treatment_ consists in removing the growth. In early and limited forms of intrinsic cancer laryngo-fissure (thyreotomy) gives good results; in more advanced cases the entire larynx must be removed--_complete laryngectomy_--and at the same time, or after an interval, the a.s.sociated lymph glands are removed from the anterior triangle of the neck on both sides.

In cases in which excision is impracticable, the sufferings of the patient may be alleviated by performing low tracheotomy, and by feeding with the stomach tube or by nutrient enemata. In some cases the difficulty of feeding the patient may make it necessary to perform gastrostomy.

#Sarcoma# of the larynx gives rise to the same symptoms as cancer, and can seldom be diagnosed from it before operation.

#Foreign Bodies in the Air-Pa.s.sages.#--Foreign bodies impacted _in the pharynx_ usually consist of unmasticated pieces of meat or large tooth-plates, and they occlude both the food and the air-pa.s.sages, frequently causing sudden death. They are considered with affections of the pharynx.

The bodies most frequently impacted _in the larynx_ are small tooth-plates in the case of adults, and b.u.t.tons, beads, sweets, coins, and portions of toys in children. These are drawn from the mouth into the air-pa.s.sage during a sudden inspiratory effort, for example while laughing or sneezing. If the glottis is completely blocked, rapidly fatal asphyxia ensues. If the obstruction is incomplete, the patient experiences severe pain, difficulty of breathing, and a terrifying sensation of being choked. The irritation of the foreign body causes spasmodic coughing and retching, and may induce spasm of the glottis, with threatening suffocation.

Small round bodies may lodge in the upper aperture or in one of the ventricles, and give rise to hoa.r.s.eness and repeated attacks of dyspna and spasmodic cough. Wherever the body is situated, the symptoms may suddenly become urgent from its displacement into the glottis, or from the onset of dema. The position of the body may often be ascertained by the use of the X-rays.

_Treatment._--If the symptoms are urgent, laryngotomy, which consists in opening the larynx below the glottis by dividing the crico-thyreoid membrane, or tracheotomy must be performed at once, and an attempt made to remove the foreign body thereafter. In less severe cases in adults, the throat should be sprayed with cocain, and the larynx examined with the mirror; in children, the direct method must be employed. In both instances an attempt should be made to extract the body by the direct method. As these manipulations are liable to induce sudden spasm of the glottis, the means of performing tracheotomy must be at hand. If it is found impossible to remove the body through the mouth, laryngotomy or tracheotomy should be performed, and the body extracted through the wound, or pushed up into the pharynx and removed by this route. In the case of small bodies, a strand of gauze pushed up from the tracheotomy wound, through the larynx and out of the mouth, catches the foreign body and carries it out (Walker Downie).

The foreign bodies that are most likely to become impacted _in the trachea_ are tooth-plates with projecting hooks, and small coins. The position of the foreign body may be ascertained by the use of Killian's tracheoscope, or by means of the X-rays. If the body remains movable in the trachea, it is apt to be displaced when the patient moves or coughs, and it may be driven up and become impacted in the glottis, setting up violent attacks of coughing and spasmodic dyspna.

Tracheotomy should be performed at once, and the edges of the tracheal wound held widely open with retractors, the patient being inverted, or coughing induced by tickling the mucous membrane with a feather. The foreign body is usually expelled, but it may be inhaled into one of the bronchi. One of Killian's tracheal tubes may be introduced through the tracheotomy wound and the body extracted by means of suitable forceps.

_Foreign Bodies in the Bronchi._--Rounded objects, which pa.s.s through the larynx, usually drop into one or other of the bronchi, usually the right, which is the more vertical and slightly the larger. The body may act as a ball-valve, permitting the escape of air with expiration, but preventing its entrance on inspiration, with the result that the portion of lung supplied by the bronchus becomes collapsed. The physical signs of collapse of a portion or of the whole lung may be recognised on examination of the chest. In some cases the body is dislodged and driven up into the larynx, causing severe dyspnic attacks and spasms of coughing. The irritation caused by the foreign body in the bronchus may set up bronchitis or pneumonia, and abscess of the lung may supervene. This has frequently followed the entrance of an extracted tooth into the air-pa.s.sage, and it may be a considerable time before pulmonary symptoms arise. Sometimes the tooth is ultimately coughed up and the symptoms disappear. In some cases the physical signs closely simulate those of pulmonary phthisis.

The _treatment_ consists in removing the body by the aid of Killian's or Jackson's tube pa.s.sed through the mouth. If this is not successful, low tracheotomy is performed and the tube is pa.s.sed through the tracheotomy opening.