CHAPTER XLI
.
THE RESPIRATORY PASSAGES PROPER.
MALFORMATIONS OF THE RESPIRATORY PASSAGES.
The _congenital malformations_ of the upper respiratory passages pertain mainly to the nasal septum and the interior of the complicated nasal cavities, which are rarely symmetrically arranged, and which often differ considerably. The _nasal septum_ is frequently deviated or warped to one side, often to an extent making one nostril too restricted for easy breathing purposes. The _nostrils_ are occasionally seen to be abnormally retracted. Malformations of the _pharynx_ are of rare occurrence. The _soft palate_ is occasionally found to be more of a diaphragm than is natural, and _imperforation_ is sometimes seen. _Pharyngeal fistulas_ have been mentioned in connection with incomplete closure of branchial clefts. They occur more commonly on the right than on the left side, and are usually incomplete. A _fistula_ placed in the middle line and opening into the larynx or trachea is also occasionally seen, its inner opening being generally found on the side of the pharynx and just below the tonsil. This is not necessarily a persistent remains of the thyroglossal duct, but may have a different origin. _Cystic distentions_ not infrequently occur along these fistulous tracts. Malformations of the _larynx_ are rare and consist mainly of narrowings or stricture formations.
_Acquired malformations_ of the respiratory passages are common and are the result usually of previous disease or injury. They may assume the _obstructive type_, as when the tonsils or the other adenoid or lymphoid tissues of the nasopharynx become hypertrophied, or they may assume the _constrictive type_, as when strictures result from ulceration, produced either by disease or by caustics. Such diseases as diphtheria cause not only paralyses, through the nervous system, but cicatricial deformity in consequence of ulceration. The latter is also true of burns, while fractures may permanently displace parts, this being particularly true of the nose, but holding good also for the hyoid, and even for the larynx. Nearly all these malformations permit of more or less surgical improvement by operations, some of which are simple and easy of performance, while some will need the highest degree of trained skill.
=Ozena.=--Ozena is a general term applied to ulcerative lesions, especially involving the Schneiderian membrane in the nose, and causing more or less discharge of mucus, pus, and crusts, nearly always offensive, and accompanied by evidences of deeper ulceration, involving the fragile nasal bones or the nasal septum, and constituting expressions of caries or necrosis in this region. Ozena may be the consequence of a milder catarrhal inflammation, occurring in patients of vitiated constitution and bad habits of life, with insufficient attention or no care whatever. Another type of ozena is from the beginning of _syphilitic_ origin, and it is especially the syphilitic cases which present the most offensive types of lesions, yet which are the most satisfactory to treat, because of the relative certainty with which they yield to properly directed treatment. Any case characterized by profuse and offensive nasal discharge, in which by suitable illumination and examination ulcerations can be detected, should be considered ozena.
=Treatment.=--The treatment for all these cases should consist of local cleanliness, alkaline solutions in spray or by irrigation being especially indicated because of their cleansing properties. Warm sterilized salt solution may also be used for the same purpose. All visible ulcerations should be treated by local applications of mild silver nitrate solutions, or some other combined antiseptic and stimulant; or these may be alternated with local applications of an ointment of the yellow oxide of mercury in strength of 0.5 to 1 per cent. Local treatment, however, is but a part of that which should be instituted. In every case where the syphilitic element can be recognized, or where there is good reason for even suspecting it, vigorous antisyphilitic treatment should be begun and prosecuted. While these cases nearly always need one of the iodides, administered internally, there is no way of so quickly bringing them under the desired influence as by inunction with the ordinary mercurial ointment. Both measures should be carried along simultaneously until the combination proves to be too active, when the inunction may be discontinued.
In addition to these measures such cases need improvement of elimination and of nutrition, and the best restorative tonics may be combined to advantage with any other special medication which may seem to be indicated.
FOREIGN BODIES IN THE RESPIRATORY PASSAGES.
Nowhere, except perhaps in the ear, are foreign bodies more likely to find entrance, and become impacted, than in the respiratory passages. They are introduced either through the nose or the mouth. They consist of almost all imaginable substances, introduced either by accident or design, and belonging to all three kingdoms--animal, vegetable, and mineral. According to their nature, size, and lodging place, symptoms of more or less severity will ensue. Migratory bodies, especially small insects and parasites, may escape from the nasal cavity into one of the accessory sinuses, where they will give rise to great irritation, and necessitate perhaps serious measures for relief. The presence of a foreign body is not always promptly recognized. In some instances it is discovered only by accident, as when, having been present for some time, it has produced irritation, with or without ulceration and offensive discharge. Thus a shoe-button may have been pushed up the nose of a little child, and remain there undetected for some time, perhaps to be spontaneously extruded in the act of blowing the nose. The presence of a foreign body in the nasal passages, then, will be manifested by symptoms of obstructed nasal respiration and by other evidences of local irritation, with pain, tenderness, swelling, and discharge.
An object easily seen is ordinarily easily removed, unless it has some peculiar shape which impedes its easy withdrawal. Local cleanliness is the first prerequisite, and then in most instances local anesthesia, which may be produced with cocaine or one of its substitutes. After this a probe, bent into the shape of a blunt hook, or forceps of various patterns and shapes may be required, and will usually suffice for all ordinary cases which can be detected by inspection through the nostrils or with the rhinoscope. In more difficult and unusual cases the fluoroscope or the skiagram may be made to render great service. Should some larger object be found, particularly in the antrum, deeply within the cranium, then a more formal operation will be demanded, whose details should be made to suit the needs of each individual case. When a mass of inspissated secretion or of granulation tissue more or less conceals the outline of the foreign body, everything should be cleaned away with irrigating spray, or with cotton wrapped around a probe or held within the forceps.
=Calculi.=--A rare condition of _calculus formation_ is occasionally met with in the nose, the concretions being formed by precipitation of the mineral elements from the nasal mucus, and constituting the ordinary _rhinoliths_. These become, in effect, foreign bodies, and are to be recognized and treated as such. After syphilitic ulceration portions of bone may be loosened spontaneously, and dropped into locations where they are caught instead of being spontaneously expelled.
It is known, also, that, especially in tropical climates, there are several species of _insects_ which enter the nostrils and there deposit their _eggs_, which later are hatched into the resulting _larvæ_, the latter sometimes being expelled, or perhaps developing and burying themselves further within the nasal recesses. Any living organism may be killed by administration of chloroform or ether, and then expelled as an ordinary foreign body; or, in most cases, such larvæ or eggs can be washed away with an irrigating stream to which a little extract of tobacco should be added. Thus maggots have been found buried within the nasal mucosa, and requiring extraction by means of forceps. When larvæ have invaded the sinuses the case becomes more serious, for it will require free exposure by perhaps a somewhat formidable operation on the interior of the sinus, which should then be carefully cleansed and suitably drained. Living organisms within the nasal cavity or the sinuses will cause headache, lacrymation, sneezing, nasal discharge, perhaps with epistaxis, and almost every possible expression of local discomfort.
=Foreign Bodies in the Pharynx.=--Foreign bodies in the pharynx are usually, when small, lodged in the neighborhood of the tonsil, or caught in the lymphoid tissue of the tonsillar ring. According to their size they may become impacted at almost any point, and may even cause suffocation. They may be detected sometimes by the finger alone, or, at other times, only with good illumination and local anesthesia. The irritation which they produce leads to frequent acts of swallowing, the latter always exaggerating the former. Such objects as small fish-bones and the like, which may cause irritation, may easily escape or defy detection; moreover, such objects may be multiple.
For the sake of comfort pellets of ice may be frequently swallowed and cocaine may be used locally. Their _extraction_ should be promptly practised. In rare instances emergency may call for prompt tracheotomy, but this is rarely the case unless the object be impacted below the epiglottis. Curious instances of impaction in the nasopharynx, of strange foreign bodies, have required the administration of anesthetics and even serious cutting operations for their removal, by combined manipulation through the nostril and the oropharynx. Such bodies, however, can be in some way always removed.
Liquids may be aspirated through the nose, and cause strangling attacks of coughing. They are then more easily drawn into the larynx or trachea, where they will cause reflex phenomena and actual obstruction, according to their nature. Again by free inhalation of steam, natural or superheated, burns and scalds of the respiratory passages may be produced, which will be followed by edema of the glottis or by pneumonia. The inhalation of extremely strong vapors, like that of ammonia, may cause spasm of the glottis. The entrance of blood, as from rupture of an aneurysm, or of pus, as from a bursting abscess, or the escape of pus from one side of the chest into the other lung by way of the trachea, may cause serious symptoms or may produce actual suffocation. In operations for pyopneumothorax, for instance, with one side of the chest well filled with pus, one should be careful to avoid turning the patient in such a way that pus may run over into the other lung and thus suffocate him. I have seen death occur on the operating table from this cause, in spite of every precaution, when the accident itself had been anticipated.
Solid objects may be of all shapes, sizes, and materials; living insects are occasionally aspirated and may not be at once killed, the local irritation caused by their presence producing intense spasm of the glottis. I have personally known of two cases of suffocation in restaurants, where men eating hastily died as the result of impaction of pieces of meat within the rima glottidis. Again, bodies may pass beyond the glottis proper and enter the trachea, or even one of the great bronchi; shoe-buttons, for instance; and in one case in my knowledge a small hat-pin passed down and was only removed after a low tracheotomy and careful search, aided by a skiagram. Owing to the anatomical arrangement the right bronchus is more frequently entered than the left. Immediate danger of suffocation, of obstruction, or spasm having passed, there is still serious menace from _pneumonia_, with or without abscess or gangrene of the lung. Such condition occurring in a young child, in the absence of the history of passage of a foreign body, may cause some difficulty in diagnosis. The greatest help would be afforded by the use of the Röntgen rays, although the laryngoscope alone will sometimes be sufficient. To use the latter to advantage it will probably be necessary to allay local irritation with the cocaine spray. (See Figs. 476 and 477.)
=Treatment.=--Treatment should be operative, although in some cases it is sufficient to invert the patient and slap him on the back. With an object impacted in the glottis relief may be afforded with the finger, but this may be exceedingly difficult, for in the later stages of suffocation the jaw may be convulsively shut and it will be almost impossible to effect entrance. In such case the jaw should be hastily pried open and the index finger carried down behind the base of the tongue, lifting the epiglottis and dislodging the object. If this fail and respiration have ceased, attempt should be made to hastily open the trachea, even with the blade of a penknife, and to follow this with artificial respiration. Under these circumstances the vessels of the neck will be engorged with venous blood, which will escape freely; this may, however, be disregarded, the primary indication being to get into the trachea, which may be held open by turning the knife-blade at right angles, while artificial respiration is practised, and until a couple of hair-pins, for instance, can be secured, bent into shape of blunt hooks and made to act as temporary retractors. This is an illustration of what may be done in emergencies.
[Illustration: FIG. 476
Toy-pin (actual size) removed by external pharyngotomy from pharynx and esophagus of a two-year-old child. Recovery. Skiagram by Dr. Plummer. (Buffalo Clinic.)]
[Illustration: FIG. 477
Skiagram of Fig. 476.]
On the other hand these operations should, when possible, be done deliberately and with local anesthesia. Foreign bodies should be located with the laryngoscope, after which they may be removed with the aid of the illumination thus afforded, or by mere sense of touch. _An object impacted in the larynx proper_ may be extracted by _thyrotomy_, whereas when it has passed below the larynx it will be necessary to open the trachea, perhaps even low down, making more than an ordinary opening for purposes of manipulation. Numerous forceps have been devised for these purposes. Roaldes reports having removed a piece of impacted iron from the bifurcation of the trachea, by means of a powerful _electromagnet_.
In the ensuing chapter there will be mentioned a method of exposing both the trachea and the esophagus by posterior incision or resection of the thoracic wall.
[Illustration: FIG. 478
Tack in bronchus of young child, removed after a low tracheotomy. Case of Dr. Parmenter’s. Skiagram by Dr. Plummer. (Buffalo Clinic.)]
INJURIES TO THE RESPIRATORY PASSAGES.
Besides those inflicted by _foreign bodies_ injuries may be produced here from external conditions, _gunshot wounds_, _fractures_, and a variety of causes which need not be specified. The inhalation or the entrance of violent _caustics_, either fluid or volatile, may produce edema at least, or actual destruction of tissue. The glottis, being the narrowest portion of the respiratory tract, offers the greatest danger under conditions of obstruction, and fatal dyspnea may ensue. Thus, for instance, _burns_ caused by inhaling _steam_, or hot vapors or _flame_, will be followed by most intense reaction, often extending beyond the trachea and to the air cells. Edema will be prompt, while pain, shock, dyspnea, and loss of voice will be instantly produced. If the patient survive the early complications he may succumb to pneumonia or other disastrous sequels in the lungs.
=Wounds of the Larynx.=--Wounds are nearly always complicated by other injuries of the neck or face, which may involve vessel or nerve trunks of primary importance. Moreover, such wounds are mostly infected and lead to extension of phlegmonous involvement, which may later cause mediastinal or deep cervical abscesses, and all sorts of septic and pyemic complications. Even when recovery ensues cicatricial contraction may produce laryngeal or tracheal stenosis, with defective voice, or sometimes _fistulas_, connecting usually with the trachea.
=Treatment.=--In the treatment of such wounds provision should be made for drainage, and it is seldom advisable to make too accurate a closure lest its very intent be thereby defeated. Unless the patient be suffocating the first indication is to check hemorrhage, then to cleanse the wound, and later to make such approximation of its surfaces as the case may permit. Occasionally in order to obtain a good result in the upper part of the respiratory tract it would be good practice to make a tracheotomy below. At other times an O’Dwyer tube may be inserted.
The occurrence of edema may be prevented, or at least its severity in a measure controlled, by the use of adrenalin solution, 1 to 10,000, while the local use of mild cocaine solutions will be frequently indicated, in order to check irritability and the reflex phenomena to which it will lead. Local symptoms may also be combated by inhalation of vapor, with soothing solutions, such as weak preparations of cocaine or of one of the opiates, followed by mild astringents and antiseptics--tincture of benzoin or oil of eucalyptus, or some of their equivalents, being nebulized and used in a spray. Opiates internally should be prescribed; while with delirious, drunken, or maniacal patients every effort should be made to secure physiological rest and to subdue restlessness or frenzy.
=Fracture of the Larynx.=--Fracture of the larynx is a somewhat uncommon accident, due to direct violence, which may instantly precipitate symptoms of the greatest severity. It may be simple or compound, the thyroid being obviously most often involved and the cricoid next. These injuries will occur more frequently in the aged, in whom the external cartilages of the larynx are prone to calcify and thus become more brittle. A fracture of the larynx precipitates extreme danger of suffocation, either from displacement or edema, and will usually require a prompt tracheotomy, which may be performed with a penknife in the absence of any better instrument. It may be indicated also by expectoration of bloody mucus, with froth, with stridulous respiration, dyspnea, pain--which is increased by pressure or motion, as in swallowing--and the local indications of injury. Thus death has occurred upon the field during a game of baseball, from a direct blow of the ball upon the larynx, no one who knew sufficient to perform it reaching the patient in time to do an emergency tracheotomy as above. Edematous laryngitis, which is not sufficiently serious to call for operation, is characterized by dyspnea, aphonia, dysphagia, cough, laryngeal irritability, and by more or less chemosis and congestion of the mucosa. The specialists treat certain of the milder forms of this condition by local scarification (_i. e._, with a knife made for the purpose), in order that by considerable local hemorrhage the vascular engorgement may be relieved.
NASAL DEFORMITIES.
These consist in large measure of deviations of the nasal septum, with or without turbinate hypertrophy, due to previous disease of the Schneiderian membrane, and followed by thickening and structural change. Nasal deviations are either of _congenital_ or _acquired origin_. An absolutely symmetrically arranged and divided nasal cavity is a rarity. Thus, though one side is rarely a replica of the other, deviations which are sufficiently marked to cause nasal obstruction are commonly the result of rapid or slow disease. They will be seen in connection with other body deformities by which the head is habitually held in an abnormal position, so that growth in one direction is thereby favored. Such conditions may be caused either by irregularities of vision, by enlarged tonsils, or by spinal deformities.
The _acquired deviations_ are frequently the result of injuries, not necessarily of those sufficiently severe to produce fractures. The nasal septum proper is made up of the cartilaginous or purely nasal portion, the vomer, and the perpendicular plate of the ethmoid, any one of which may be separated from its connections or warped from its perpendicular plane. Dislocation of the cartilages may also occur in the young, and, having once taken place, is rarely reduced unless treatment has been both prompt and scientific.
_Angular deviation_ to an extent which often produces a _spur_ is not necessarily of serious inconvenience unless it protrude sufficiently from its proper plane to come in contact with one of the turbinates, in which case a nearly complete obstruction may result, with symptoms of constant nasal irritation. Absolute symmetry being rare, and mild deviations being very common, it is only those which produce either visible deformity or local irritation which require surgical treatment. Obviously after injury to these parts attention should be given to overcome present and prevent further dislocation. This may be conveniently done by the introduction of small, tubular, nasal splints, of celluloid or caoutchouc, made for the purpose. In their absence short pieces of a stout, silk catheter may be used, one inserted on either side of the septum, and packed around with a light tampon of antiseptic gauze. All intranasal splints, no matter how made, will cause considerable local irritation, with tendency to discharge, and will need to be renewed every day or two.
Deviation having resulted in permanent deformity, no matter how produced, it can be relieved by operation. Except in the young this may be performed under local cocaine anesthesia. These measures fall under two heads--those made for _removal of projections_, or spurs, and those directed to _straightening of warped or deviated septa_, which do not show much thickening.
For the treatment of projections caustics and the actual cautery were formerly much in use. They have been now almost abandoned for the use of instruments, such as a strong knife, a small intranasal saw, or cutting forceps of various patterns, adapted for use within the nose. Only these latter means will be mentioned in this place. Cutting instruments may be actuated by hand or by electric motors. When the field of operation is small cocaine anesthesia is nearly always sufficient. Extensive operation involving both nasal cavities may often be better performed under a general anesthetic. The nasal cavity should have been previously thoroughly cleansed by the aid of irrigation with alkaline solutions, and then just previous to operation with hydrogen peroxide. Instruments should be absolutely clean and sterile. When local anesthesia is complete it is sufficient to seat the patient with the head supported, opposite to the operator, to illuminate the nasal cavity with the head mirror or some substitute therefor, and to introduce the knife, saw, or forceps in such a way that the removal may be effected with one movement, while injury to surrounding tissues is avoided. An intranasal saw should be blunt-pointed, and should never be pushed so as to touch the posterior wall of the pharynx. After division of bone the final detachment of the mucosa should be made with scissors or knife. Bleeding after these operations is rarely severe, although free at first, and may be controlled by a tampon made of a narrow, continuous strip of antiseptic gauze, either packing it into the nostril and occluding it, or inserting a nasal tube and packing snugly around it. Only in rare instances is it necessary to tampon the nose from the pharynx by the use of the Bellocq cannula. (See below.)
Warped and deviated septa, without angular projections, may be sometimes successfully treated by dividing the septum, either with knife or scissors, or with cutting forceps whose blades make a stellate incision, by which the curved surface is so much weakened that it can be pressed back into normal shape, where it is retained by tamponing the nostril on the affected side. The pressure required for this purpose is, however, sometimes irksome or even intolerable. A method of using a long pin, like a small hat-pin, has been suggested, it being passed through one nostril into and out of and again into the septum, in such a way that it serves as a splint, to keep it straight for a sufficient length of time. Later this pin may be removed without difficulty, its enlarged head lying meantime concealed within one of the nostrils.
SUBMUCOUS RESECTION OF THE NASAL SEPTUM.
This was first suggested by Killian as affording a method not subject to the objections of the older authorities. It may be performed under cocaine anesthesia, each side of the septum being swabbed with a 20 per cent. cocaine solution. A semilunar incision made through the mucous membrane and perichondrium on one side is the more convenient. Through this opening the coverings are separated from cartilage by means of a sharp and a plain elevator. Unless the perichondrium be itself elevated the mucous membrane will be torn in the pressure of loosening. The cartilage is then cut through with suitable instruments or burred away with a dental engine, the instrument being guarded by a finger in the opposite nostril, which acts as a guide, it not being desirable that the membrane on that side shall be cut through. In this way any spurs or ridges may be removed submucously with such instrument as the operator may select. The separated membranes then fall together and may be retained by light gauze packing without any suture.
NEOPLASMS OF THE NASAL CAVITIES.
Of true neoplasms in the nose the most common are those myxomatous or fibromyxomatous developments from the Schneiderian membrane, which are called _nasal polypi_. Histologically most of these are of myxomatous character. Clinically, however, they seem to be in large degree products of inflammatory and irritative conditions. At all events they constitute sessile and later pendulous outgrowths, occupying different areas or occurring in clusters, those from the upper part of the nose being covered with columnar cells, while those of the lower pharynx are covered with flat epithelium. They are firm or soft, according to the amount of connective stroma which they contain. They are poorly supplied with blood and their contained fluid is largely composed of mucin. When involving a considerable area the condition is referred to as _polypoid degeneration_. They are observed at all ages and in both sexes. Their most common seat is the middle turbinate, toward its posterior extremity, and they also hang from the septum, but may be found in any part of the nasal cavity. From it they may spread to fill the adjoining accessory sinuses, even producing absorption of their bony walls by pressure. They also produce distortion of the nose, with such obstruction as to prevent nasal respiration. They may involve one side or both, and may hang so loosely attached that a flapping, valve-like sound is heard on respiration.
=Symptoms.=--They produce nasal obstruction, with irritation; more or less discharge of watery or acrid mucus, the latter sometimes leading to excoriation; while by pressure they produce headache, especially when located high in the nose, or deafness, as when they press upon the Eustachian outlets, or symptoms of sinusitis according as they invade one or other of the sinuses. Other reflex symptoms, such as facial neuralgia, reflex cough, lacrymation, and conjunctivitis, frequently accompany them, and mouth breathing and snoring are almost inevitable consequences. The voice becomes impaired, as does occasionally the sense of taste.
In most cases they are easily revealed by artificial illumination and exposure with the nasal speculum. In color they are usually pinkish, and may be seen to move with the respiratory effort. While it is usually easy to see at least some of them, when present, it is difficult to detect their exact point of origin. With the rhinoscopic mirror they may be seen projecting into the nasopharynx. Occasionally one will be detached by violent effort at sneezing or blowing the nose.
[Illustration: FIG. 479
Jarvis snare.]
Aside from the danger of retained secretion, which they may bring about, and that attending their extension into adjoining cavities, there is in elderly people at least an actual possible danger of their undergoing _malignant transformation_, although this is not common. There is, however, good reason for their removal, and none for allowing them to remain, for they are always both irritant and obstructive.
=Treatment.=--Almost every other method of treatment has yielded to that of removal by the Jarvis snare, or its equivalent, supplemented by the occasional use of forceps. In order, however, to expose them sufficiently to permit of removal it is often necessary to cut away a portion of the middle turbinate. In extensive polypoid disease this would be practically always required, and it should be done thoroughly, for nasal polypi tend usually to recur unless radically attacked. Local anesthesia is sufficient for the majority of cases, but an aggravated instance will call for complete anesthesia and thorough work, especially if the accessory sinuses have been infected.
The snare figured in Fig. 479 is a type of instrument which can be used to great advantage in dealing with these cases. When, however, it cannot be made effective by being applied around the actual base of each growth its use should be supplemented by that of the curette. No actual assurance can ever be given that there will be no subsequent development of polypi. Nevertheless it does not follow that new polypoid development is of the actual nature of recurrence. It may occur independently from the same causes that produced its first appearance.
It should hardly be necessary to insert here the caution that no operation of even this degree of simplicity should be effected without careful cleansing of the nasal cavity.
Of the other tumors that may occur within the nasal cavities none can be said to frequently occur here, but all varieties may be encountered. Of the more benign tumors the most common are the vascular growths and the fibromas, or mixed form of fibromas and papillomas. Epithelioma and sarcoma occur occasionally.
FIBROMA OF THE NASOPHARYNX.
Fibroma of the nasopharynx is much more common than in the nasal cavity proper. Here it assumes its usual characteristics as a more or less firm and dense tumor, growing slowly, sometimes from a large base and again in pedunculated form. A form occasionally met with springs from the periosteum of the base of the skull and slowly extends into the nasopharynx, causing in time a complete obstruction, with disappearance of the surrounding structure by its pressure effects. Some of these growths are of a considerable degree of vascularity. When arising from the base of the skull they become almost inoperable after obtaining considerable size. I have seen death upon the operating table, in one of the foreign clinics, from uncontrollable hemorrhage occurring during the removal of one of these growths. A growth thus situated should be attacked with extreme caution, and preferably after easier access has been made to it by division of the soft palate, and removal of a portion of the hard, or perhaps by a temporary or permanent resection of the upper jaw; the route being left in each case to the decision of the operator. Provisional ligation of the carotids may be also made.
The same is true of the other tumors of the nose and nasopharynx. The less malignant they are the more they justify radical attack. By the time a sarcoma or adenocarcinoma of deep origin has declared itself it is usually too late to justify its removal.
ADENOIDS OF THE PHARYNX.
A new-growth of different form, occurring in the vault or around the outlines of the pharynx, is frequently seen in the shape of great _hypertrophy or overgrowth of the lymphoid tissue_, already and elsewhere alluded to as composing a part of the original lymphoid ring which marks the site of the embryonic nasopharyngeal canal. This lymphoid hypertrophy, whose commencing expressions are seen in the tonsil, is referred to as _adenoid growth_. Associated with it occurs more or less hypertrophy of the other tissues, fibrous, etc., according to whose proportion the growths will be soft and spongy or more dense and resistant. The so-called _adenoids_ occupy more or less of the nasopharynx proper, reducing its dimensions, encroaching upon the vault of the pharynx, materially reducing the breathing space, thus leading to the establishment of the mouth-breathing habit, as well as to alteration of voice and the accompanying disagreeable features of increased secretion of the parts. It leads to characteristic appearances which may be recognized at a distance, consisting of a mouth habitually open, with more or less projecting teeth, pinched nostrils, Gothic roof of mouth, stooped shoulders, deformed thorax, loss of hearing, irritative cough, and possibly remote reflex effects, such as laryngeal spasm, general neuroses, chorea, and epilepsy. The effect of these changes is to give not merely an appearance of stupidity, but actually to interfere with mental development. Save in exceptional instances, a child with the mouth-breathing habit, and with that peculiarity of voice which indicates nasal obstruction, will nearly always be found to be defective in cerebral activity, if not actually stupid. The longer the condition is allowed to persist the greater the permanent alterations and damage permitted.
Pronounced degrees of the condition may be easily recognized by the habitually open mouth and the character of voice. A moment’s inspection will usually reveal the character and the degree of involvement. When adenoids in the nasopharynx attain a size sufficient to produce these results the tonsils are also usually involved, and the clinical picture is thereby made more pronounced. The rhinoscopic mirror, if it can be used, will give a picture of the condition, while the finger-tip passed upward behind the soft palate will give an idea as to the extent to which the cavity is filled.
By virtue of the interference with the vital function of respiration thus produced, and because of the retention of secretion and the greater exposure to irritation through the constantly open mouth, individuals with this condition are usually anemic, while many of them give evidence of the _status lymphaticus_, to which attention has been called in the preceding pages. _To such an extent is this true that the administration of an anesthetic is frequently attended by extra danger, and the operator should give the necessary relief only after careful preparation._ This should consist not only of general measures, by which the condition of the patient may be improved, but by local cleansing of parts; and finally, as a preparation for the anesthetic, of the local use of a weak cocaine solution, by which reflex excitability may be controlled. Just before administering the anesthetic in these cases it is well to spray into the nostrils and pharynx a weak cocaine solution, after which the anesthetic may be administered. In most instances it would be better to use ethyl chloride or ether than chloroform, not because the latter is necessarily more dangerous, but because one is placed less upon the defensive in case of accident, owing to the belief that it is not so safe as some other anesthetics. (See p. 164.)
=Operation.=--Local applications being of small avail in producing either condensation or resorption, the treatment of this condition is essentially surgical. With children an anesthetic is always necessary. With adults cocaine may be sufficient. The best position for the patient is that with the down-hanging head (Rose’s), as blood is not swallowed nor passed into the lungs, but may be removed as fast as it collects. The hemorrhage in these operations is generally profuse but of short duration.
Adenoids are removed either with a _snare_, the _curette_, or by special instruments constructed on the type of a tonsillotome, and having a concealed blade. The curette is also used as _forceps_. Two or three curettes and forceps are sufficient for nearly all purposes. In operating the instruments are guided entirely by the sense of touch and the operator’s knowledge of anatomy, for he relies upon his finger-tip for information as to whether the tissue has been completely removed or needs further attention. These instruments are used until the entire vault of the pharynx and its openings into the nasal cavities (choanæ) are freed from all hypertrophied tissue or excrescence. The posterior wall of the pharynx should be scraped until it is smooth. In addition the tonsils should be removed if it be necessary, while the lingual tonsil may be also removed with curette or forceps if it be involved. For a few moments there will be a free flow of blood through both nose and mouth. In some instances there will be indications for cutting away hypertrophied turbinates and removing nasal polypi. Hemorrhage, at first profuse, quickly subsides. A mixture of 1 per cent. cocaine solution with a little adrenalin is the best hemostatic for local use. The nostrils may be packed if the turbinate has been cut away, or the entire passage-way may be left open for the purpose of permitting the later use of an irrigating stream, by which blood clot may be washed away and antiseptics applied. While using and relying upon instruments for the greater part of this work there is no better curette for concluding the work than the finger-nail of the index finger. The finger being introduced recognizes the degree of relief afforded, and the finger-nail may be used to scrape away any remaining projecting tissue.
Various operators have devised formidable operations, varying from the temporary resection of one upper jaw to Cheever’s ingenious method of dividing and separating both upper jaws in one piece from the cranium, and thus exposing the nasopharynx from in front and above. Such operations are rarely performed.
Other neoplasms in this region are _cysts_ and _dermoids_ of congenital origin--those involving the original craniopharyngeal canal, and those produced from pharyngeal diverticula. These produce only the ordinary manifestations of tumor and are of pathological rather than surgical interest.
EPISTAXIS (NOSE-BLEED).
The escape of a small amount of blood from the nose, especially in childhood, is a common occurrence, and may occur in consequence of slight traumatisms or even spontaneously. The so-called nose-bleeding of children, then, is scarcely of sufficient importance to justify consideration here, nor would it were it not for the fact that it may become severe and even dangerous. Children in whom it frequently recurs will lose sufficient blood to become anemic, while the effect of its frequent occurrence may bespeak a depraved condition of the blood as well as of the tissues which permit of its escape. A history of repeated nose-bleed should prompt an investigation into the general condition of the patient as well as a local examination of the nasal passages, where some explanation may be afforded. For instance, a polypus may be found whose removal will then be indicated, or an exceedingly spongy and vascular area may be revealed, which will call for a touch of the actual cautery or the use of the curette.
Besides the frequent expressions of this kind in childhood, some of which may occur during sleep, there are other forms of nasal hemorrhage. A vicarious menstruation is known to assume this type, individuals thus losing blood every month. This is a rare but well-known phenomenon. A plethoric individual may suffer serious epistaxis at any time, and this may be beneficial unless it be too extensive. Nasal hemorrhages may occur with certain fevers. Individuals with a hemorrhagic diathesis are peculiarly liable to it, and it is seen in connection with purpura hæmorrhagica. When this occurs in the debilitated or dissipated it may be fatal. Thus epistaxis may terminate fatally in spite of all that can be done. This statement requires some explanation. The nasal cavity may be tightly plugged, but such plugging cannot be made permanent because of decomposition of products thus retained and their absorption, with consequent septic infection. Nasal tampons should be removed every day or two, for the purpose of cleanliness, although their removal is contra-indicated when the necessity for physiological rest of the part is realized. The treatment, then, of epistaxis may be trying, at least, and in rare cases will prove absolutely disappointing and ineffectual. I have even been compelled to tie the common carotid to save life.
=Treatment.=--The ordinary nose-bleed of a young child will usually subside with the application of cold to the nose, elevation of the arms, or firm pressure upon the upper lip just below the nasal septum. It may be also checked by an irrigating stream of cold water, or by a spray of cocaine or weak adrenalin solution. A 5 per cent. antipyrine solution also makes an excellent styptic for the purpose. Within a day or two after a serious hemorrhage, after the remaining clots have been cleaned away, a thorough inspection of the nasal cavity should be made in order to reveal the source of the hemorrhage and permit local treatment.
Nasal hemorrhage may be subdued by _plugging the anterior nares_ with strips of gauze, or, better still, after the introduction of a tube through which air may pass freely, and around which packing may be firmly inserted. The ordinary dry styptics should not be used, for they may produce such a crusting of tampons as to make it difficult to remove them. More efficient materials can be used in solution. No tampon should be introduced into the nostrils which is not tied with a ligature of silk in such a way that it may be by it more easily withdrawn, and, at the same time, prevented from going too far. If the source of the bleeding be in the anterior part of the nasal cavity anterior packing may be sufficient. The surgeon should not, however, be deceived by the apparent cessation of bleeding, which cannot escape through the nostrils under these circumstances, but may continue into the nasopharynx, the patient swallowing the blood as it trickles down. Inspection of the pharynx should be made after the use of tampons. A much greater degree of safety is afforded by _posterior tamponing_ of each side of the nasal cavity, which is most easily effected by means of the little instrument known as _Bellocq’s cannula_, whose use is illustrated in Fig. 480.
[Illustration: FIG. 480
Plugging the nares with Bellocq’s cannula. (Fergusson.)]
It is, however, by no means necessary to have this special instrument in order to accomplish the purpose. A soft catheter may be passed backward through the nostril until its end appears in the nasopharynx, where it is caught with forceps and drawn into the mouth. Here, by means of a needle or knot, a piece of silk is fastened to this end. When the catheter is drawn out from the nose it pulls up after it and out through the nostril this bit of silk, to whose middle is tied a tampon, made of a sufficient amount of gauze or similar material, folded or rolled into the desired shape. By combined manipulation, as the silk thread is drawn upward and outward through the nostril, it pulls up the tampon into the nasopharynx, where it should be guided into its place by the tip of the index finger of the disengaged hand. If necessary this procedure is then repeated upon the other side, and thus a complete double tamponing can be effected. If the procedure be made difficult by the extreme sensitiveness of the part this can be overcome by local anesthesia. The tampon may be saturated with a weak adrenalin solution if desired. Ordinarily such a tampon can be easily disengaged and removed by again passing the finger up behind the soft palate and dislodging and withdrawing it, using curved forceps for the purpose of securing it. A tampon inserted for the control of hemorrhage should be left _in situ_ for at least forty-eight hours, possibly longer. The case should be watched for a while after its removal, lest it might require re-introduction. This maneuver is made easier by fastening the tampon in the middle of a long piece of silk as described; one end being brought out through the nostril is tied to the other portion, which is allowed to come out of the mouth. The latter will provoke some discomfort, and patients should be cautioned not to disturb it, its purpose being explained to them.
Mulford, of Buffalo, has suggested a method of dealing with cases of epistaxis by injecting two or three drops of reduced adrenalin solution into the tissues at the base of the upper lip, in close proximity to the course of the arteries which pass upward on either side and supply the septum. The injection should be made in the fold of the mucous membrane just beneath the septum of the nose.
RETROPHARYNGEAL ABSCESS.
This has already been referred to as the product of tuberculous disease in the upper cervical vertebræ, or in the neighboring lymph nodes, or as the possible sequel of more acute infections occurring in the upper portions of the neck, proceeding usually from infected tooth sockets or other lesions within the nose and mouth. Collections of pus in this location may be circumscribed or may be extensive and rapidly assume serious phases. A chronic abscess is essentially a tuberculous expression. Acute abscesses, either in the tissue behind the pharynx or to either side of it, may be seen in cachectic children and assume serious phases.
The first evidences in these cases are those of pharyngitis, but swelling and edema occur rapidly, septic indications become unmistakable, and, finally, almost complete nasopharyngeal obstruction may occur. The discovery by the palpating finger of a fluctuating swelling will make the presence of pus practically positive. If the operator be still in doubt he may use the exploring needle. The experienced practitioner will at once plunge the point of a knife into such a swelling, and, at the same time, plan his opening in such a way as to afford the best possible drainage.[48] For the purpose it may be necessary to have the patient in the position of down-hanging head, or, in extreme cases, the patient may be almost inverted in order that pus as it gushes forth may escape through the mouth rather than into the larynx or down the esophagus. The operation should be done without an anesthetic. The mouth may be opened with the O’Dwyer mouth-gag, or it may be forced and held open with the ordinary tongue depressor. When pus has travelled to such an extent as to give the case the importance and aspect of a deep cervical phlegmon, such as described in the chapter on the Neck, then anesthesia is necessary in order that by external, combined with internal, incision, escape of pus and provision for drainage may be permitted.
[48] Nevertheless in one instance an eminent American practitioner thus hastily incised a fluctuating intrapharyngeal swelling and found, to his dismay, that he had opened a carotid aneurysm, the patient dying within five minutes.
Two dangers attend inexcusable delay in such acute cases--one is of suffocation from pressure or from sudden spontaneous rupture of abscess; the other is of invasion of large blood trunks in the vicinity and possibility of hemorrhage after erosion, either into the abscess cavity or directly into the outer world.
THE UVULA AND SOFT PALATE.
ELONGATION OF THE UVULA.
As the result of constant irritation by coughing, or other reflex motions of the pharyngeal muscles produced by local irritation, the uvula frequently becomes elongated to a point which permits it to rest upon the base of the tongue and there to produce still more irritation and reflex phenomena. Patients suffering in this way will be noticed to make frequent attempts at swallowing and coughing, which may be depressing, and may lead to disturbed sleep and even an asthmatic form of breathing. The uvula is a useless organ when it has attained such dimensions, and its amputation, or at least its shortening, are indicated in all such cases as those above described. Local anesthesia is sufficient. Its tip is caught with a pair of forceps and it is clipped off, not too near its base, by long-handled and sharp scissors. This is a much neater and more expeditious method than to include it within the grasp of a wire snare and somewhat slowly crush it off.
Upon the uvula, as upon the soft palate, papular lesions of _syphilis_ are frequently seen, rarely the primary chancre, but very often mucous patches or the deeper ulcers, which characterize the secondary and tertiary lesions. _Gummas_ also may form within the thickness of the palatal tissues, which will in time break down and form ragged ulcers, while the destruction may extend to the bony portions, either of the nose or roof of the mouth, and then necrosis will be added to the evidences of ordinary ulceration. The rapidity with which these specific lesions will disappear under prompt and vigorous constitutional treatment, along with that local cleanliness which should include removal of necrotic tissue, is surprising and gratifying.
THE EPIGLOTTIS.
The epiglottis is composed of yellow elastic cartilage and it does not tend to calcify during the later years of life, as does the white or fibrocartilage of the balance of the larynx. Thus its elasticity and flexibility are fortunately maintained throughout life. It may be sometimes injured by the incised wounds elsewhere described under the term “cut-throat,” and is at least often thus exposed when not actually injured.
The epiglottis seems to be exempt from most of the primary diseases, but is occasionally involved in lesions of surrounding tissues, in which it may then participate. Thus it may be deformed by cicatricial tissue and unduly bound down, or it may succumb to advancing ulceration of syphilis, tuberculosis, or cancer. Injuries which break the laryngeal box rarely affect the epiglottis because of its elasticity.
While an extremely useful portion of the body, the epiglottis is not an absolute necessity, for even after its removal individuals can swallow, although the act requires some extra care. Should the epiglottis become involved in cancerous disease it should be removed with the rest of the diseased tissue, while syphilitic and tuberculous lesions will usually prove amenable to a combination of local and general treatment. New-growths in this region are extremely uncommon, but will prove relatively easy of removal when present.
THE LARYNX.
The laryngeal cartilages, save the epiglottis, are composed of white fibrocartilage which manifests a tendency in the later years of life to undergo calcification. This makes the organ less elastic, changes the tonal qualities of the voice, and makes it more brittle and subject to possible fracture by external violence. _Fractures_ of the organ, as of the adjoining _hyoid bone_, have been elsewhere discussed, with the indications which may make an emergency tracheotomy necessary because of hemorrhage or edema of the narrow laryngeal passage.
Of the inflammatory affections of the cartilages _chondritis_ and _perichondritis_ are most common. These are usually seen in connection with other expressions of tuberculous, syphilitic, and malignant disease. Nevertheless they are known to occur as sequels of the exanthems and ordinary infectious fevers. They may be followed by destructive ulceration, which will lead to a necrosis of the cartilage corresponding closely to death of bone under similar circumstances. In due time there may form a cartilaginous sequestrum, and this will require removal as though it were bone. Dangers attend these lesions in two peculiar directions. The very condition which produces the destructive inflammation may also produce either _hemorrhage_ or _edema_, with suffocation which can usually be prevented by an emergency tracheotomy. On the other hand, when repair follows spontaneous recovery or successful treatment, it may be accompanied by such cicatricial contraction as shall materially change the shape and impair or possibly destroy the function of the larynx itself. In this case either thyrotomy, tracheotomy, or laryngotomy may be called for, the opening thus made being expected to permanently remain.
STRICTURES OF THE LARYNX.
Various forms of _stricture of the larynx_ may be similarly produced. Such strictures, then, are due to previous disease or to injuries, and here as elsewhere stricture is a consequence rather than itself a disease. It occurs in consequence of syphilis and of the destruction following laryngeal diphtheria.
What is, in this respect, true of the larynx is also true, though less often, of the trachea, where constrictions may occur at various points, with reduction of caliber or such distortion of shape as to produce partial or even finally complete obstruction. The peculiar scabbard-shape which the trachea may be made to assume by compression between the lobes of a growing goitre has been elsewhere described. While the trachea itself is in this case free from disease the obstruction is none the less pronounced. Similar effects are produced by pressure, as from aneurysms or tumors, even at a distance. Loss of voice, shown to be due to paralysis of one or both vocal cords, should always prompt an examination of the chest, in order that the presence of an aneurysm or other tumor making pressure upon the recurrent laryngeal may not be overlooked.
=Symptoms.=--Symptoms of laryngeal and tracheal stricture comprise (1) those of the primary and active disease which produces them; (2) those of obstruction; (3) those of suffocation in emergency cases. The earlier symptoms are those of increasing _dyspnea_, which may vary in rapidity and extend over weeks and months, or which may become most pronounced within a few hours. There is also a change in the character and sometimes complete loss of voice, hoarseness of the speaking voice changing into a whisper. The condition is frequently complicated by attacks of serious dyspnea, often at night, which are due to an added spasmodic feature, and in which death may suddenly occur. Usually, however, with asphyxia comes muscular relaxation, and individuals may pass through a large number of these attacks, which are accompanied with extreme mental and physical suffering, in which death is only avoided by final relaxation. Again the heart may suddenly give out, and then the case becomes practically hopeless. In recognition of causes and location of such troubles it may be held that when hoarseness precedes dyspnea the lesion is in the larynx; when the reverse, it is in the trachea. Careful auscultation of the chest and thorough laryngoscopic examination will usually enable the lesion to be recognized. The lower the location of the stenosis the worse the prognosis, because of its inaccessibility. So long as the trachea below the stricture can be opened life may be prolonged indefinitely; but when due to a mediastinal tumor or an enlarged thymus, the case assumes desperate aspects and may baffle the best-directed efforts.
=Treatment.=--Strictures in the larynx proper may be treated by dilatation, as by the introduction of intubation tubes of increasing size, a method which ordinarily gives satisfactory results. Nevertheless such laryngeal strictures manifest an almost permanent tendency to recontract, and whatever measures are addressed to them have to be frequently and thoroughly practised and over a long period. Fortunately, however, these patients are able to wear an O’Dwyer tube nearly all the time. When these internal operative methods fail there remains only an external opening, which may be made through the larynx proper (thyrotomy), or a low tracheotomy, which may require the insertion of short or long tubes, according to circumstances. Long trachea tubes are made, their lower portion being composed of rings fastened together in such a way as to cause them to be called lobster-tailed, and such a long tube may be passed through a low tracheotomy opening and made to extend beyond the point of pressure produced by an extrathoracic or an intrathoracic tumor. By the use of such an expedient life may be prolonged, although the exciting cause may prove fatal.
TUBERCULOSIS OF THE LARYNX.
Tuberculosis of the larynx may appear in a generally disseminated form, involving nearly all the structures, or in circumscribed localized form, as a tuberculous ulcer, which may produce symptoms depending upon its exact location. Laryngeal tuberculosis may, moreover, be but a local expression of the disease, apparently primary, or as often happens, it may be an accompaniment of pulmonary tuberculosis, the laryngeal trouble appearing as a local infection, taking place by the constant passage over the surface of tuberculous sputum which the patient is expectorating at frequent intervals. Thus, clinically, we may have a miliary, an ulcerative, or a gummatous form of the disease.
The condition is frequently referred to as _laryngeal phthisis_, and is mainly to be distinguished from syphilitic laryngitis, or occasionally from commencing malignant disease. _Local symptoms_ include those of chronic laryngeal catarrh, with hoarseness, impairment of voice, sensation of dryness within the larynx, and frequent short, hacking, unsatisfying cough. To these features are later added more or less pain, especially in deglutition, while aphonia will finally succeed dysphonia. When the epiglottis and the structures near it are involved there are more irritation and pain. Dyspnea is a measure of the encroachment upon the breathing space left by the progress of the disease. Infiltration of all the parts within and later of those around the larynx finally takes place, and with further implication nervous reflex symptoms are added to those above mentioned. Cough is usually a distressing feature; the sputum varies in amount; saliva is increased in flow, and the expectoration is frequently streaked with blood. In advanced disease the sufferings of the patient become excessive, while constitutional symptoms keep pace with those of the local disease. Thus anemia, emaciation, debility, insomnia, and general malaise cause the patient great discomfort, and, coupled with his terminal local symptoms, make death an absolute relief.
With the laryngoscope varying pictures may be seen, either of ulceration or of general involvement of the entire interior of the larynx, which will be tumefied, irregularly swollen, ulcerating here and there, while the vocal bands show thickening and roughenings as well as ulcerations. Gummatous outgrowths may be seen at almost any point and in various stages of ulceration. A more distinctly _lupoid form_ of tuberculosis is also occasionally seen in the larynx, where it assumes more of the nodular appearance characteristic of lupus, the nodules coalescing or disappearing by ulceration, which may leave a dense, cicatricial tissue after healing. Primary lupus of the larynx is rare.
Tuberculous lesions of the larynx are mainly to be recognized with the laryngoscope, but they, like all other local diseases in this location, produce alteration and final loss of voice, with difficulty of breathing, reflex cough, and are accompanied by general constitutional symptoms, according as the disease is purely local or an expression of a general affection.
=Treatment.=--Treatment should be both local and general. The latter may be summarized by stating that all measures, including proper climatic environment, which are found to be of advantage in ordinary tuberculous disease, will prove of equal advantage here. There should be avoidance of exposure to all irritation--coal gas, tobacco smoke, vitiated air, etc.--while absolute rest of the vocal organs should be prescribed and all attempts at singing or unnecessary speaking be prohibited. All measures regarded as of value in general tuberculosis will find an equally wide field for their activities.
_Local treatment_ is directed toward amelioration of discomfort and improvement of local lesions. The former may be afforded by steam inhalations with some soothing, volatile antiseptic added to the spray, such as methol, oil of eucalyptus, some gentle opiate, or anything that may give local anodyne effect. Cough may also be treated by the milder anodynes, of which cocaine or heroine will serve for most instances. Sleep is to be secured by some of the ordinary hypnotics. Local applications may be made by an applicator guided by the laryngoscopic mirror, by the medical attendant, or through watery or oleaginous solutions in a spray. For absolute local relief a mild cocaine solution, followed by the use of a very weak solution of silver nitrate, lactic acid (C. P.), or even the more thorough treatment of local ulceration by means of the laryngeal curette or touching with the point of the galvanocaustic loop, may give relief. The treatment of laryngeal tuberculosis rarely comes within the domain of surgery proper, until the disease has reached a degree necessitating some radical measure, such as thyrotomy, with erasion of the affected tissue, or possibly a laryngectomy, with complete removal of an organ which is too thoroughly diseased to warrant hope of repair.
SYPHILIS OF THE LARYNX.
Syphilis of the larynx is more common than tuberculosis, the lesions usually belonging to the later stages of the diseases, including especially mucous patches, and the ulcerative expressions, with or without the formation of small gummatous tumors. The loss of voice is rarely as pronounced, and the entire course of the disease is accompanied by less irritative and offensive features than is tuberculosis. Diagnosis will be materially assisted by the discovery of suggestive expressions of syphilis, either in adjoining or distant parts. Thus if mucous patches appear within the larynx they will also be seen within the mouth. Ulcers which are produced by syphilis have well-defined edges, and are rarely multiple; while those produced by tuberculosis are more often multiple, are seated upon an anemic base, produce more distortion of laryngeal structures, and more residue of cicatricial tissue at points where healing has occurred.
=Treatment.=--The treatment of laryngeal syphilis is essentially constitutional, for nearly every local expression will clear up under the influence of properly directed remedies. However, when local symptoms are uncomfortable or depressing they may be treated as are those of tuberculosis, by soothing sprays and the local application of anesthetics, astringents, and the like.
INTRALARYNGEAL AND INTRATRACHEAL TUMORS.
Within the larynx tumors may occupy the space beneath the glottis, where they are referred to as _subglottic_; they may grow from the structure of the vocal cords and become _intraglottic_, or they may spring from above the glottis and from the aryteno-epiglottic fold. Certain forms of benign tumor are relatively common in this location, while others are almost unknown. The former include cysts, papillomas, fibromas, angiomas, and adenomas, as well as the ordinary granulomas.
A nodular lesion seen upon the vocal cords, especially in singers, which is hyperplastic in character, irritative in origin, and often called “_singer’s node_,” is frequently found upon the edges of the cords, either as a single or bilateral lesion. The adjoining structures are usually quite vascular. These lesions occur in those who abuse their voices, as, for instance, in amateur singers and newsboys. The nodules themselves vary in size from that of a pin’s head to that of a split pea. The condition produces hoarseness and impairment of the voice, is recognized with the laryngoscope, and is amenable to treatment, which should consist in absolute rest from vocal effort and gentle astringent and stimulating applications. If the node project very far it may be removed by the intralaryngeal guillotine.
_Laryngeal polypi_ include the forms of benign tumor above mentioned, most of which assume in time a polypoid form, and cause impairment of function according to their location.
[Illustration: FIG. 481
Multiple papilloma of larynx. (Bergmann.)]
_Papilloma_ is by all means the most common of these growths, and may present either the vascular type, bleeding easily and growing rapidly, or the firmer and denser type from admixture with fibromatous tissue. It occurs frequently in the young, and may even be present in the newborn. Here it can scarcely be detected with the laryngoscope, but may be felt with the finger. _Cysts_ take their origin from the mucosa, save those which, possibly of embryonic character, protrude into or encroach upon the larynx from without (Fig. 481).
=Symptoms.=--The symptoms of benign intralaryngeal growths are largely irritative, including cough, with hoarseness and change of voice, and going on to production of dyspnea in proportion to the size which they attain. Later complete aphonia, with spasm of the glottis, may be the result of their presence, while pedunculated growths, or polypi with long pedicles, may cause aggravated symptoms by circumstances of position, the patient being much of the time relatively free. Hoarseness, dyspnea, and cough, without other evidences of inflammation or epidemic disease, should always lead to careful inspection with the laryngoscope, and this will reveal the size and situation of the growth. These examinations can be made with cocaine and give satisfactory information. Only in young children are they difficult, or sometimes impossible. Even in an infant with a hoarse cry and spasmodic or suffocative attacks the condition may be suspected.
=Prognosis.=--The prognosis will depend upon the character of the tumor and the local conditions--_i. e._, size, fixation, location, etc. In the young it is serious because of the danger attending its removal. Rational adults can be usually put in excellent condition for endolaryngeal operation by the aid of local anesthesia, and expert specialists become dexterous in their manipulation of the specially shaped forceps, curettes, and the like which are required for removal of these growths. As elsewhere a truly innocent tumor in this location does not recur after complete extirpation.
MALIGNANT TUMORS OF THE LARYNX AND TRACHEA.
Of these tumors the most common is _epithelioma within the larynx_. _Sarcoma_ occasionally originates from the vocal bands, true or false, and will usually form a nodular tumor, of rugose surface, until it begins to ulcerate. Once it begins to break down it is difficult to distinguish from the other varieties without the aid of the microscope; but epithelioma may be met with in any part of the larynx, generally arising from the ventricular bands. Here, as ordinarily upon mucous surfaces, it begins as a small nodule with a definite zone of infiltration about it; if seen early it may be mistaken for innocent papilloma. As infiltration progresses the hoarseness resulting from its presence will change to loss of voice, because of the fixation of the tissues whose mobility is essential to voice production. Pain may be an early feature, depending upon ulceration and exposure of sensory nerve endings. Later when the ulcerated surface has become deep, irregularly covered with fetid discharge, and more or less concealed by edematous surroundings, the picture is more complete in one respect, although the details may be obscure. From the mucous and softer tissues the disease will spread and invade the cartilages themselves, as well as the tissues outside, and so with the progress of the cancer the entire larynx becomes fixed in a bed of infiltrated tissue extending in all directions, involving the upper part of the trachea, the epiglottis, and the base of the tongue. Meantime the loss of voice, the distressing cough, and the other evidences of local invasion will have kept pace with the progress of the disease, and dyspnea will come on sooner or later as the passage-way becomes blocked, while from sudden, violent efforts at coughing acute attacks of edema, which may result fatally, are liable to occur.
_Tumors of the trachea_ proper are far less common. They may be benign or malignant. In either event they will prove to be of about the same type as those already discussed above as occurring within the larynx. They cause less interference with speech, but as much or even more difficulty in respiration.
When tracheotomy was a frequent resort in croup and diphtheria a peculiar form of new formation in the trachea was occasionally encountered, resulting from the irritation of the trachea tube, whose presence sometimes provokes excessive formation of granulation tissue, whose subsequent contraction brings about not only the formation of a dense granuloma, but cicatricial contraction. Hence in the older literature references to _granulation stenosis_ were common. Now that intubation has almost completely replaced tracheotomy for these purposes the latter is rarely performed, and tubes are seldom left more than a day or two _in situ_, so that this kind of local provocation, with its consequences, is rarely encountered.
It may be possible by expert use of the laryngoscope to see a tumor located within the trachea. If the patient cannot tolerate its use the parts may be made tolerant by the use of a weak cocaine spray. Such a growth, if accessible from above, may be removed through the glottis by forceps. Most operators, however, prefer to make an opening through the trachea and thus profit by the larger surgical opportunities thus afforded. Such an operation should be made with the patient’s head low in order that blood may gravitate to the pharynx rather than to the lungs.
OPERATIONS UPON THE LARYNX.
Cancer of the larynx was regarded, until the last quarter of the previous century, as an absolutely hopeless condition for which nothing could be done until it became necessary to do a tracheotomy, this simply affording relief from some of the distressing features, but aiding nowise to check the progress of the growth. The first demonstration of the possibility of successful removal of the larynx was made by Czerny, in 1870, upon dogs. Watson, of Edinburgh, had removed a syphilitic larynx _in toto_ in 1866, but this summary operation only became known to the world through a publication of Foulis in 1881. Meantime, Czerny’s experiments were so successful that Billroth was induced to attempt the removal of the entire larynx in a case of cancer, with results which astonished the profession of that day. Thus introduced, nevertheless, the mortality rate was great, the principal cause of death being inspiration pneumonia--that is, rapid infection of the lung through the widely opened trachea and the entrance of saliva and fluids from the mouth. Hahn, of Berlin, undertook the improvement of the technique and was able to reduce the mortality from this cause. Meantime another radical method--namely, _thyrotomy_, _i. e._, opening the laryngeal box--had not fared much better than the measure just mentioned. Thus until about twenty-five years ago the radical treatment of laryngeal cancer stood in an unpleasant light, partly because diagnostic methods were unsatisfactory and our general knowledge of the disease incomplete, partly because operation was always delayed until late, and because operative measures had yet to be much improved. Tremendous impetus was given to the whole subject by the celebrated case of the Emperor Frederick, and the acrimonious criticisms concerning its conduct were not without benefit, since they led to a careful re-study of the whole situation, with its numerous subsidiary questions, among which was the possibility of transformation of a benign into a malignant tumor. At present, largely through the labors of Hahn and Billroth, in Germany, and Semon, in London, the question of operative procedures is fairly settled, everyone now believing that the disease should be radically attacked at the earliest possible moment, opinions differing only in regard to the route which the surgeon should adopt, _i. e._, whether he should make an intralaryngeal operation, as is now favored in Germany; a thyrotomy, as preferred in Great Britain, or a laryngectomy, as some of the general surgeons in all parts of the world prefer.
The different methods of attack upon the larynx for cancer may then be summarized as including _intralaryngeal extirpation_ through the natural passages, _thyrotomy_, and partial or complete _laryngectomy_.
The _intralaryngeal method_, seen from the general surgeon’s view-point, can only be suitably applied to a limited class of cases which are recognized early, and may be best performed by an expert laryngologist, _i. e._, one accustomed to instrumentation within the pharynx and larynx. It includes the use of various instruments for the excision of small areas, for the application of the galvanocautery, etc. The writer agrees with Semon in regarding it as irreconcilable with the principles which should guide us in dealing with malignant growths, the fundamental one being the removal not only of the growth itself but of an area of surrounding tissue. This intralaryngeal method may then be satisfactory in the removal of benign growths, but will seldom appeal to the operating surgeon when he deals with cancer. Epithelioma may commence at the accessible tip of the epiglottis, but intrinsic cancer of the larynx should be dealt with in a more radical manner. Thyrotomy is the operation of choice, especially among the British laryngologists. It seems rational to believe that in cases where diagnosis is made early a thyrotomy, with removal of the growth and a wide area of surrounding tissue, including portions of cartilage, if necessary, may prove the ideal operation, while vocal results are better than after extirpation. It is necessary, however, that diagnosis should be made early and that operation be made thoroughly; while if, after opening the thyroid, it should appear that complete extirpation of the growth is otherwise impossible, then the operator should make a complete laryngectomy.
All of these operations are best preceded by use of a cocaine spray, by which extreme irritability of the interior of the larynx is allayed, and the reflex lowering of blood pressure prevented. (See p. 178.)
_Thyrotomy is performed as follows_: The patient is preferably in the position with down-hanging head. An incision in the median line, about three inches in length, is made from the upper border of the thyroid cartilage down to a point below the cricoid. With but slight separation of the tissues it is made to extend directly down upon the abrupt ridge-like anterior border of the thyroid cartilage, below which will be exposed the cricothyroid membrane. Into this the knife may be inserted and made, with cutting edge up, to split the halves of the larynx exactly in the middle line, the blade passing between the vocal cords, unless they have been much distorted by the growth. In that case the dissection may be made more deliberately. The larynx being thus split, the cricoid should be divided, after which, with suitable retractors, the interior is exposed to such an extent as to permit both inspection and palpation. Through the opening thus afforded all suspicious tissue should be removed, from one side or both, the primary question being not what will be the resultant effect upon the voice, but how best to completely eradicate the cancerous tissue. With the patient’s head hanging downward there is less likelihood of the entrance of blood into the trachea. Nevertheless the _tampon cannula_ should always be accessible so that it may be inserted should it be required. The tampon cannula is a trachea tube around which there is a small rubber bag, with a tube through which it may be inflated, so that after the cannula is introduced into the trachea it may be tamponed by air pressure in such a manner as to permit no passage of blood.
In the absence of one of these specially designed tubes an effective substitute may be made by the ordinary trachea tube wrapped with a covering of antiseptic gauze, the latter held in place by a few turns of fine silk or catgut.
The thyrohyoid membrane bears the superior laryngeal vessels and nerves, and it should be entered through the middle line in order not to disturb these. Whatever operation may be required upon the tissues within the laryngeal box may be conducted with knife, scissors, curette, and the fine point of the actual cautery. The interior of the larynx should be cleaned, leaving it simply as a part of the respiratory tube, without reference to what may become of the structures within it devoted to voice production. The cartilaginous shell, with or without a part of its previous contents, having been rid of the suspicious tissue within, it may be held together by one or two sutures of silver wire or by superficial sutures of chromic gut, while the trachea tube which may have been used may be left for a day or two, or removed at the time. Ordinarily the latter course will prove the better.
_Laryngectomy, or total extirpation of the larynx_, is the most severe procedure of all, but will be requisite when there is evidence of escape of malignant growth from within the true confines of the laryngeal box. Not only the larynx but more or less of the surrounding tissue may be removed, with infected neighboring lymphatics, the upper portion of the trachea, and the base of the tongue.
The operation may be preceded by a low tracheotomy or otherwise. If necessary this should be done several days in advance, in order that the patient may have become tolerant of the tube and of the new method of breathing. If requisite the ordinary trachea tube may be substituted for the tampon tube above described, in which case it will not be necessary to lower the patient’s head. Otherwise the operation is perhaps best performed with the head and neck in the Rose position.
The incision is a long median division of tissues from above the hyoid to an inch or more below the cricoid cartilage. Through it the anterior border of the thyroid should be easily exposed. It is then necessary to separate on either side the sternohyoid and sternothyroid muscles, the lateral mass of the thyroid body being drawn to either side along with the musculature, the isthmus having been previously doubly ligated and divided for this purpose. Now as rapidly as may be the larynx is completely isolated from all the structures around it, the dissection being bluntly made. After freeing it on both sides it is drawn forward, first to one side, then to the other, so that on either side the superior laryngeal artery may be exposed and secured, the superior laryngeal nerve being necessarily divided. The cricothyroid branches need also to be secured, as well as any other vessels which may spurt blood. Circumferential isolation of the larynx is now completed by dividing the inferior constrictor of the pharynx and separating it from the side of the thyroid, keeping close to the cartilage. After this isolation is completed the surgeon has the choice of first dividing the respiratory tube either above or below the larynx. This will depend largely upon his own choice, but usually the procedure is easier when the first division is made either through the cricothyroid membrane or between the cricoid and the upper ring of the trachea or even below this point, if necessary. With a low division first the patient will immediately begin to breathe through the opening thus made unless a previous tracheotomy has been done. Ample time will be afforded for the introduction of a trachea tube and protection around it to prevent entrance of blood, when the larynx may be lifted and separated with knife or scissors from the tissues remaining attached. The esophagus begins at the level of the cricoid cartilage, and if the cricoid is to be removed the esophagus should be separated from it; otherwise it is not disturbed. Last of all, in this order, the thyrohyoid membrane will require division, and then the extirpation is completed.
The wound is large, the communication with the oropharynx is unobstructed, and there will be constant escape into the newly formed cavity of secretions from the nose and mouth. At first the patient will be unable to swallow, although there may be constant desire to reflex attempts in this direction. The questions to be decided are the management of the wound in gross and the suitable treatment of the upper end of the trachea, as well as of the esophagus, if this has been touched. The greatest danger is that of inspiration pneumonia. Other consideration should be secondary to that of prevention of the escape of fluids down the trachea and the consequent production of pneumonia. General experience is rather to the effect that the best results are obtained with a minimum of sutures, the large cavity being lightly packed with absorbent material, while the upper end of the trachea should be sewed to the skin as high as possible on either side, the esophagus being allowed to take care of itself. The patient should wear a trachea tube for several days after the operation. Through the exposed upper end of the esophagus a tube may be passed three or four times a day, and sufficient nourishment be thus introduced into the stomach. The patient may be kept lying upon the side for the greater part of the time, so that saliva may escape from the mouth.
The question comes up later as to what substitute, if any, may be afforded for the lost larynx. Gussenbauer devised an improvement on what was called the “artificial larynx,” devised originally by Foulis and then modified by Hahn, which afforded an ingenious mechanical substitute for the larynx, permitting the production of voice by vibration of a metallic reed, such tone as it produced being, like that produced by the vocal cords, modified by the vocal organs above into perfectly intelligible speech, but always in a monotone. It consisted of a tracheal tube through whose external opening another tube could be passed upward to a point where it lay beneath the epiglottis, if this were left _in situ_, or behind the base of the tongue, if the epiglottis had been removed. Through this the patient could breathe under ordinary circumstances. By a little device at the external opening the touch of the finger upon a spring would throw into the air current a thin, metallic reed, by whose vibrations tone was produced, to be modified as mentioned above. This was the principle of the _artificial larynx_ which was worn by many patients and which in many gave good results. One patient of my own wore one for seven years, although he discontinued using the reed because the peculiarity of the tone attracted more attention than did the loud “stage whisper” which he had cultivated. Around the instrument there is always more or less moisture or discharge, and there are many disagreeable features attending its use, even though it permit the act of swallowing without any difficulty.
Solis Cohen introduced a method of treating these cases by fastening the trachea to the external wound and permitting the cavity above to close as rapidly as possible. In this way the trachea is permanently terminated in the middle of the neck and patients breathe through this opening. It has been found that with practice they can retain sufficient air in the mouth and pharyngeal cavity to permit them to whisper several words at a time. This simplifies the procedure, and is now usually adopted after extirpation of the larynx.
_Partial laryngectomies_ have been practised through external openings, one lateral half or more of the larynx being removed. These operations have been few in number and often unsatisfactory. They should be reserved for cases with favorable indications. When required they are performed on the same principles as those already outlined, only the extirpation is incomplete. Certain modifications have been proposed by individuals, as, for instance, the suggestion made by Gluck, to suture the opening in the trachea to a buttonhole opening made in the overlying skin, by which means he thought to prevent inspiration pneumonia.
OPERATIONS UPON THE TRACHEA.
Tracheotomy is the general term made to cover any opening into the lower air passages between the larynx proper and the upper end of the sternum. Laryngotomy, cricotracheotomy, tracheotomy, etc., may be described as implying by these names the exact location of the opening. The principle is, however, the same, and the details of the operation vary but little.
[Illustration: FIG. 482
Position of patient for tracheotomy. (Wharton.)]
Tracheotomy as a deliberate operation is different from tracheotomy as it was formerly practised for diphtheria, and as it is yet done in emergencies, some cases being so serious that suffocation will occur if the opening be not promptly afforded. In the former case preparations can be made; in the latter, operation may have to be done with the blade of a penknife. It makes considerable difference also whether an anesthetic can be used. To administer chloroform to a child with a heart already weakened by the toxins of diphtheria is almost to invite disaster, and yet to do the operation without an anesthetic is perhaps impossible.
The _middle line is the line of safety_ in all of these operations. The danger of heart failure from the anesthetic, or of suffocation from tardiness of relief, being passed, the other principal danger is that of hemorrhage. The isthmus of the thyroid may be divided, but always with preliminary ligatures, or it should be caught between the blades of pressure forceps on either side before dividing it. A patient with a short, fat neck, whose cervical veins are dilated and engorged with venous blood owing to partial asphyxia, makes a difficult and undesirable subject. The trachea lies nearer the surface at its laryngeal end than in its lower portion--_i. e._, if the operation be low in the neck deep search will have to be made for the tube. The first incision should be made sufficiently long, never less than two inches, and should be so planned as to bring the operator down upon the tracheal rings. By this time sufficient engorged veins may have been divided to cause a serious oozing of dark, venous blood, by which the field of vision is much obscured. Except in emergencies the surgeon may wait for this engorgement to be relieved. The trachea, being recognized by the finger-tip, is seized with a tenaculum, by which it may be held forward, and then at least two of its rings divided with the knife-blade. The instant the opening is made, if the patient be still breathing, bloody foam and frothy blood will be ejected, and for a moment or two the bleeding may be uncontrollable. Under these circumstances the normal blood color soon returns. Artificial respiration should be practised at the same time. Supposing this to be an emergency case, with little or almost nothing at hand, sutures should be passed through the tracheal opening and through the skin margin on either side. If no other retractor be at hand the suture materials may be left long and tied behind the back of the neck, sufficient tension being made to prevent the wound edges from coming together. Formerly when the surgeon was called to do this operation with little or no help the writer has extemporized a couple of retractors out of hair-pins, bent for the purpose, hooked into the tracheal wound, then tied with tapes, which were united behind the neck, while the wires were kept from being pulled out of place by a skin suture on each side. There is now less occasion for these crude methods since the introduction of O’Dwyer’s intubation.
With _tracheotomy done deliberately_, and at the point of election, usually above the thyroid isthmus, with or without division of the cricoid, the vessels may be secured as they are exposed or bleed, and the trachea should not be opened until all oozing from its exterior has been checked. For this purpose the patient is placed upon the back, the shoulders raised, the head thrown backward, and the neck exposed, a pillow being placed beneath. (See Fig. 482.) The operation may be done under cocaine local anesthesia or with a general anesthetic. Incision in the middle line, below the lower border of the thyroid cartilage, is made two inches or so downward, the fascia beneath being divided in the same line and the tissues retracted to either side from this median exposure. Thus one makes access to the cricothyroid membrane, the cricoid, the upper tracheal rings, and the thyroidal isthmus. According to the size and location of the latter (it usually lies in front of the second tracheal ring) it may be retracted or doubly ligated and divided in the middle. The difficulty now afforded is from the upward and downward play of the larynx, which may occur during forced efforts at respiration. To steady it a tenaculum should be introduced just above the cricoid, a little to one side of the middle line, firmly fastening it. With this held in the left hand, thus steadying the parts, a sharp-pointed knife is so employed as to divide the cricoid and one or two upper rings of the trachea, being cautious not to wound the posterior wall. The opening thus made should be about one-half inch in length. Through it a second hook is now passed into the other side of the cricoid and the incision held open by their agency while the trachea tube is introduced.
This procedure may be modified in accordance with any local indications, and may be made according to the needs of the case. When the opening is made into the trachea below the isthmus it is called a low tracheotomy. Here the anterior part of the trachea lies free from the skin, but may be covered with a plexus of veins connecting with the inferior thyroid. Farther down the _arteria thyroidea ima_ may be encountered. There is always reason for operating as high as the case will permit. The trachea may itself be displaced by the growth which compresses it and necessitates the operation. Thus it may be crowded to one side, other anatomical relations being disturbed, or it may be compressed into scabbard shape, and thus be difficult to find or to open.
The moment the trachea is open more or less marked expulsive efforts will drive blood and foam in all directions, and may for a moment obscure the field of vision. Every precaution should be taken to prevent the entrance of blood into the trachea. Pressure of the tracheal walls against the tube to be inserted may check hemorrhage from its margins. The operator should be ready to suspend all other procedures and make artificial respiration, and he should also be prepared to open the trachea suddenly, should impending suffocation require it.
In a general way, then, the _indications for tracheotomy_ are symptoms of rapidly or slowly threatening obstruction to respiration from causes either within the larynx--_e. g._, diphtheria, foreign bodies, tumors, and the like--or causes external to it, such as tumors, phlegmons, cicatrices, etc. Any cause which interferes with the free play of air through the respiratory tube, which can be either relieved or atoned for by the operation, will always justify it.
_Tracheotomy tubes_ are mechanical devices for not only keeping the tracheal wound open but permitting the unobstructed passage of air. They are made of various materials, of which silver is the most satisfactory, as aluminum is too easily acted upon by the fluids of the body, and rubber occupies too much space. The tracheotomy tube is a double tube, the inner one slipping easily into and out of the outer, and being necessitated by the ease and abundance with which secretions may collect and dry, and thus obstruct. Were it necessary to remove the entire tube for each cleansing, difficulty might be met in re-introducing it, whereas the inner tube is easily removed, quickly cleansed, and restored to place within the outer without disturbance or pain to the patient.
Aside from the tracheal tubes ordinarily used there are others made exceptionally _long_, and with flexible lower ends, which may be used in case of tumor low in the neck or high in the mediastinum--for instance, in cases of enlarged thymus, where it is necessary to go beyond an obstruction.
In the _after-care_ of these cases it should be remembered that air passes directly into the lung without being warmed, or moistened, by passage over the mucous membrane of the upper respiratory tract. The patient, therefore, should be kept in a warm room, and the air should be kept moist by the use of a croup kettle or a spray machine. The inner tube should be kept unobstructed, the length of time during which it should remain depending on the nature of the case. So soon as its usefulness is passed it should be removed. A tracheotomy wound kept open but for a day or two will quickly close, but one which has remained open for weeks may close with difficulty, and then there may be trouble from granulation stenosis or cicatricial contraction. (See above under Stricture.) In instances where a permanent opening is to be maintained it is desirable to remove the tube as early as circumstances may permit.
INTUBATION.
The perfection by Joseph O’Dwyer of a method, at which others had worked, of substituting intubation of the larynx for the old tracheotomy, not only shed the greatest luster upon his own name, but has afforded a speedy and bloodless method of accomplishing much more than had been previously possible by the older procedure. The method comprises the emplacement of a suitably sized and shaped tube within the larynx, by a manipulation guided almost entirely by the sense of touch, for the relief of suffocative symptoms due to disease at this level, and leaving the tube _in situ_ for a sufficient time to permit morbid activity to subside and justify its removal.
It is advisable to have a half-dozen tubes, varying in size from 1¹⁄₂ inches to 2¹⁄₂ inches in length, and of corresponding increase in other dimensions, each of which affords a passage-way for respiratory purposes, and is also provided at its upper end with a flange, which shall rest upon the false vocal cords and prevent the descent of the tube into the trachea below. The complete set of instruments as now furnished by all the manufacturers provides an assortment of these tubes, with a scale indicating which one to use upon a patient of a given age, and includes a mouth-gag, which may be used for many purposes, and two handled instruments--one intended for the introduction, the other for the extraction of the metal tubes.
[Illustration: FIG. 483
O’Dwyer’s laryngeal tube and introducer.]
[Illustration: FIG. 484
Mouth-gag.]
[Illustration: FIG. 485
Extractor.]
[Illustration: FIG. 486
Intubation of the larynx.]
[Illustration: FIG. 487
The tube in the pharynx.]
A suitable tube having been selected, a strong thread is passed through a small opening near its head, thus affording means for withdrawing it should there be need before it is finally left in its resting place. The particular obturator meant for the tube to be used is then firmly fastened upon the handle and over it the tube is slipped. The instrument should then be tested to make sure that disengagement of the tube will easily take place. Everything being ready, the patient is then held in the arms and on the lap of an assistant, in the position indicated in Fig. 486. The individual holding the patient should be perfectly reliable in the matter of presence of mind and self-control, for a great deal depends upon having a child firmly and properly held during the moment of intubation. The arms and hands of the patient should be well wrapped with a towel and firmly held by the side of the chest, for the temptation is inevitable to put the hand to the mouth and interfere with the operator. A second assistant should stand above and behind, holding the mouth-gag in position, as represented, and steadying it as well as the head. It is necessary that the mouth-gag be held firmly in place, for if it should become disengaged the child may bite the operator’s finger.
[Illustration: FIG. 488
The tube penetrates the larynx. (Lejars.)]
[Illustration: FIG. 489
The stem is withdrawn while the finger fixes the tube. (Lejars.)]
Standing in front of the patient the operator identifies the tip of the epiglottis with the forefinger of the left hand in the pharynx, this finger being used at the same time to raise and fix the epiglottis and also to serve as a guide to the tip of the tube, which is passed downward alongside it, by a maneuver similar to that by which the laryngoscopic mirror is used in the pharynx (Fig. 487). When the tip of the tube reaches the location behind the epiglottis the finger may be passed a little farther downward, plugging the entrance to the esophagus, while at the same time the handle of the instrument is so manipulated as to bring the tube forward. With gentle movement in the right direction it passes into the larynx (Fig. 488). It is then pressed downward until the flanged upper end has passed the epiglottis, after which the tube is disengaged, the handle and the obturator withdrawn, and the upper end of the tube pressed gently into place by the finger which still rests in the pharynx (Figs. 488, 489 and 490). During the manipulation there is almost complete obstruction of the glottis for two or three seconds. The effort, therefore, should be to shorten the procedure, and at no time should it occupy more than two or three seconds. If the landmarks are not easily recognized, and the tube is not placed at the expiration of three seconds, the operator should discontinue for a few more seconds in order that a few inspirations may be taken, after which he should try again.
[Illustration: FIG. 490
The finger pushes the tube into place. (Lejars.)]
[Illustration: FIG. 491
Withdrawal of the thread. (Lejars.)]
When the tube is in place there will come ease of respiration, at the same time violent coughing efforts, because of the irritation thus suddenly produced. So soon as it is apparent, both to the finger in the pharynx and from the relief of obstructive symptoms, that the tube is in its proper place, the finger may be once more passed into the pharynx, the tube pressed down, while the silk thread is withdrawn, since it is not intended to leave it for more than the time necessary to be assured that the tube will not have at once to come out again (Fig. 491). Before removing the thread the gag should be removed for a few moments, so that the effect of the excitement may pass, after which it may be re-introduced for the purpose of withdrawing the thread.
The procedure is by no means a simple nor necessarily easy one, and it should be practised with the instruments upon the cadaver before resorting to it on the living child.
The tube being placed it will remain to be decided by the subsequent course of events how long it should be allowed to remain--in some cases a few hours, in others a few days. With young children it should remain for at least a week. The time having arrived for its _removal_, the procedure is similar to that required for its introduction. The assistants hold the child in the same position as before, while the operator substitutes the extractor, guiding its tip again by the sense of touch along the left index finger, which, passed down into the pharynx, is made to discover and identify the upper end of the metallic tube. So soon as the point of the extractor is engaged within the tube the blades are separated and it is then drawn out, while the finger is withdrawn along with it in order to make its removal easier and to prevent its loss should it slip off the instrument. Unless the patient struggles violently the whole procedure should be conducted so as to scarcely cause the slightest staining of the expectoration with blood.
_Various causes may require abrupt removal of the tube._ Thus it is possible for its caliber to be become occluded with tenacious secretion. This may produce a violent fit of coughing, during which there may occur spontaneous expulsion of the tube. At any time, when it is seen that asphyxia is increasing, or when violence of respiratory effort would indicate obstruction within the tube, it should be removed, cleaned, and re-introduced. After its introduction and removal the operator should remain within easy reach for a short time, to be sure that no unpleasant effects result and that no re-introduction may be suddenly required. Should obstructive efforts occur the child should be held head downward and be slapped vigorously upon the chest. This may loosen membrane or it may permit dislodgement of the tube and its spontaneous expulsion. The latter may also occur during the act of vomiting.
The above description is meant especially to apply to intubation as performed upon young children for the relief of the laryngeal obstruction consequent upon diphtheria. It has given better results than tracheotomy, which was the only resort previous to O’Dwyer’s device. It is usually performed easily, and is devoid of the horrors frequently attendant upon an emergency tracheotomy. But intubation is not necessarily limited to children nor to cases of diphtheria. The emplacement of such a tube may be called for at any time in cases of threatening or actual _edema of the glottis_, as, for instance, from inhalation of steam or flame. It may be advisable in other forms of intralaryngeal disease, both acute and chronic, while individuals suffering from laryngeal stricture or stenosis find that they can wear an O’Dwyer tube almost constantly, not only with relief, but that they are thereby saved from the more serious measure of opening the trachea or removing the larynx.
Impending suffocation having been relieved by intubation, the question of feeding arises. The principal disadvantage attendant upon the use of the tube is partial or complete inability to swallow, for the epiglottis does not always easily close over the tube and prevent entrance of fluid into the larynx. It is necessary to feed patients, especially the young, with extreme care. For this purpose there is no food better than ice-cream, while little children should be placed upon their backs, with the head lower than the body, and made to swallow in this position, at least until they have been accustomed to the presence of the tube and instinctively learn how to avoid irritation by involuntary regulation of the act of swallowing.
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