[300] CHAPTER XXXVIII—CHRONIC STENOSIS OF THE LARYNX AND TRACHEA
The various forms of laryngeal stenosis for which tracheotomy or
intubation has been performed, and the difficulties encountered in
restoring the natural breathing, may be classified into the following
types:
1. Panic
2. Spasmodic
3. Paralytic
4. Ankylotic (arytenoid)
5. Neoplastic
6. Hyperplastic
7. Cicatricial
(a) Loss of cartilage
(b) Loss of muscular tissue
(c) Fibrous
Panic.—Nothing so terrifies a child as severe dyspnea; and the memory of previous struggles for air, together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx, incites in some cases so great a degree of fear that it may properly be called panic, when attempts at decannulation are made. Crying and possibly glottic spasm increase the difficulties.
Spasmodic stenosis may be associated with panic, or may be excited by subglottic inflammation. Prolonged wearing of an intubation tube, by disturbing the normal reciprocal equilibrium of the abductors and adductors, is one of the chief causes. The treatment for spasmodic stenosis and panic is similar. The use of a special intubation tube having a long antero-posterior lumen and a narrow neck, which form allows greater action of the musculature, has been successful in some cases. Repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases. Very rarely a tracheotomy may be required; if so, it should be done low. The wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation. Corking the cannula with a slotted cork (Fig. 111) will now restore laryngeal breathing, after which the tracheotomic cannula may be removed.
[PLATE V—PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE—LARYNGEAL AND TRACHEAL STENOSES:
1, Indirect view, sitting position; postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration. (See Fig. 5.) 2, Indirect view, sitting position; posttyphoid cicatricial stenosis. Mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy. Cured by laryngostomy. (See Fig. 6.) 3, Indirect view, sitting position; posttyphoid infiltrative stenosis, left arytenoid destroyed by necrosis. Cured by laryngostomy; failure to form adventitious band (Fig. 7) because of lack of arytenoid activity. 4, Indirect view, recumbent position; posttyphoid cicatricial stenosis. Cured of stenosis by endoscopic evisceration with sliding punch forceps. Anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in Fig. 15. Ultimate result shown in Fig. 8. 5, Same patient as Fig. 1; sketch made two years after decannulation and plastic. 6, Same patient as Fig. 2; sketch made four years after decannulation and plastic. 7, Same patient as Fig. 3; sketch made three years after decannulation and plastic. 8, Same patient as Fig. 4; sketch made one year after decannulation, fourteen months after clearing of the anterior commissure to form adventitious cords. 9, Direct view, recumbent patient; web postdiphtheric (?) or congenital (?). "Rough voice" since birth, but larynx never examined until stenosed after diphtheria. Web removed and larynx eviscerated with punch forceps; recurrence of stenosis (not of web). Cure by laryngostomy. This view also illustrates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal illustrations. 10, Direct laryngoscopic view; postdiphtheric hypertrophic subglottic stenosis. Cured by galvanocauterization. 11, Direct laryngoscopic view; postdiphtheric hypertrophic supraglottic stenosis. Forceps excision; extubation one month later; still well after four years. 12, Bronchoscopic view of posttracheotomic stenosis following a "plastic flap" tracheotomy done for acute edema. 13, Direct laryngoscopic view; anterolateral thymic compression stenosis in a child of eighteen months. Cured by thymopexy. 14, Indirect laryngoscopic (mirror) view; laryngostomy rubber tube in position in treatment of post-typhoid stenosis. 15, Direct view; posttyphoid stenosis after cure by laryngostomy. Dotted line shows place of excision for clearing out the anterior commissure to restore the voice. 16, Endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis. Tracheotomy originally done for influenzal tracheitis. Cured by tracheostomy.]
Paralysis.—Bilateral abductor laryngeal paralysis causes severe stenosis, and usually tracheotomy is urgently required. In cadaveric paralysis both cords are in a position midway between abduction and adduction, and their margins are crescentic, so that sufficient airway remains. Efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves, have been failures. The operation of ventriculocordectomy consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope. Usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid. In some cases monolateral ventriculocordectomy is sufficient; in most cases, however, operation on both sides is needed. An interval of two months between operations is advisable to avoid adhesions. In almost all cases, ventriculocordectomy will result in a sufficient increase in the glottic chink for normal respiration. The ultimate vocal results are good. Evisceration of the larynx, either by the endoscopic or thyrotomic method, usually yields excellent results when no lesion other than paralysis exists. Only too often, however, the condition is complicated by the results of a faultily high tracheotomy. A rough, inflexible voice is ultimately obtained after this operation, especially if the arytenoid cartilage is unharmed. In recent bilateral recurrent paralysis, it may be worthy of trial to suture the recurrent to the pneumogastric. Operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition, this time being allowed for possible nerve regeneration, the patient being made safe and comfortable, meanwhile, by a low tracheotomy.
Ankylosis.—Fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx. This, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endoscopic bouginage, and by partial corking of the tracheotomic cannula.
Neoplasms.—Decannulation in neoplastic cases depends upon the nature of the growth, and its curability. Cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation, provided recurrence has been ruled out. The stenosis produced by benign tumors is usually relieved by their removal.
Papillomata.—Decannulation after tracheotomy done for papillomata should be deferred at least 6 months after the discontinuance of recurrence. Not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments. It is the author's opinion that recurrent papillomata constitute a benign self-limited disease and are best treated by repeated superficial removals, leaving the underlying normal structures uninjured. This method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis.
Compression Stenosis of the Trachea.—Decannulation in these cases can only follow the removal of the compressive mass, which may be thymic, neoplastic, hypertrophic or inflammatory. Glandular disease may be of the Hodgkins' type. Thymic compression yields readily to radium and the roentgenray, and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents. Surgery will relieve the compression of struma and benign neoplasms, and may be indicated in certain neoplasms of malignant origin. The possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon. Monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy, even though the recurrent nerves have been in no way injured at operation. Probably a localized neuritis, a cicatricial traction, or inclusion of a nerve trunk accounts for most of these cases.
Hyperplastic and cicatricial chronic stenoses preventing
decannulation may be classified etiologically as follows:
1. Tuberculosis
2. Lues
3. Scleroma
4. Acute infectious diseases
(a) Diphtheria
(b) Typhoid fever
(c) Scarlet fever
(d) Measles
(e) Pertussis
5. Decubitus
(a) Cannular
(b) Tubal
6. Trauma
(a) Tracheotomic
(b) Intubational
(c) Operative
(d) Suicidal and homicidal
(e) Accidental (by foreign bodies, external violence, bullets,
etc.)
Most of the organic stenoses, other than the paralytic and neoplastic forms, are the result of inflammation, often with ulceration and secondary changes in the cartilages or the soft tissues.
[304] Tuberculosis.—In the non-cicatricial forms, galvanocaustic puncture applied through the direct laryngoscope will usually reduce the infiltrations sufficiently to provide a free airway. Should the pulmonary and laryngeal tuberculosis be fortunately cured, leaving, however, a cicatricial stenosis of the larynx, decannulation may be accomplished by laryngostomy.
Lues.—Active and persistent antiluetic medication must precede and accompany any local treatment of luetic laryngeal stenosis. Prolonged stretching with oversized intubation tubes following excision or cauterization may sometimes be successful, but laryngostomy is usually required to combat the vicious contraction of luetic cicatrices.
Scleroma is rarely encountered in America. Radiotherapy has been advocated and good results have been reported from the intravenous injection of salvarsan. Radium may be tried, and its application is readily made through the direct laryngoscope.
Diphtheria.—Chronic postdiphtheritic stenosis may be of the panic, spasmodic or, rarely, the paralytic types; but more often it is of either the hypertrophic or cicatricial forms. Only too frequently the stenosis should be called posttracheotomic rather than postdiphtheritic, since decannulation after the subsidence of the acute stenosis would have been easy had it not been for the sequelae of the faulty tracheotomy. Prolonged intubation may induce either a supraglottic or subglottic tissue hyperplasia. The supraglottic type consists in an edematous thickening around the base of the epiglottis, sometimes involving also the glossoepiglottic folds and the ventricular bands. An improperly shaped or fitted tube is the usual cause of this condition, and a change to a correct form of intubation tube may be all that is required. Excessive polypoid tissue hypertrophy should be excised. The less redundant cases subside under galvanocaustic treatment, which may be preceded by tracheotomy and extubation, or the intubation tube may be replaced after the application of the cautery. The former method is preferable since the patient is far safer with a tracheotomic cannula and, further, the constant irritation of the intubation tube is avoided. Subglottic hypertrophic stenosis consists in symmetrical turbinal-like swellings encroaching on the lumen from either side. Cautious galvanocauterant treatment accurately applied by the direct method will practically always cure this condition. Preliminary tracheotomy is required in those cases in which it has not already been done, and in the cases in which a high tracheotomy has been done, a low tracheotomy must be the first step in the cure. Cicatricial types of postdiphtheritic stenosis may be seen as webs, annular cicatrices of funnel shape, or masses of fibrous tissue causing fixation of the arytenoids as well as encroachment on the glottic lumen. (See color plates.)
As a rule, when a convalescent diphtheritic patient cannot be extubated two weeks after three negative cultures have been obtained the advisability of a low tracheotomy should be considered. If a convalescent intubated patient cough up a tube and become dyspneic a low tracheotomy is usually preferable to forcing in an oversized intubation tube.
Typhoid Fever.—Ulcerative lesions in the larynx during typhoid fever are almost always the result of mixed infection, though thrombosis of a small vessel, with subsequent necrosis is also seen. If the ulceration reaches the cartilage, cicatricial stenosis is almost certain to follow.
Trauma.—The chief traumatic factors in chronic laryngeal stenosis are: (a) prolonged presence of a foreign body in the larynx (b) unskilled attempts at intubation and the wearing of poorly fitting intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting cannula; (e) war injuries; (f) attempted suicide; (g) attempted homicide; (h) neglect of cleanliness and care of either intubation tubes or tracheotomic cannulae allowing incrustation and roughening which traumatize the tissues at each movement of the ever-moving larynx and trachea.
Treatment of Cicatricial Stenosis.—A careful direct endoscopic examination is essential before deciding on the method of treatment for each particular case. Granulations should be removed. Intubated cases are usually best treated by tracheotomy and extubation before further endoscopic treatment is undertaken. A certain diagnosis as to the cause of the condition must be made by laboratory and therapeutic tests, supplemented by biopsy if necessary. Vigorous antiluetic treatment, especially with protiodide of mercury, must precede operation in all luetic cases. Necrotic cartilage is best treated by laryngostomy. Intubational dilatation will succeed in some cases.
[FIG. 109.—Schema showing the author's method of laryngostomy. The hollow upward metallic branch (N) of the cannula (C) holds the rubber tube (R) back firmly against the spur usually found on the back wall of the trachea. Moreover, the air passing up through the rubber tube (R) permits the patient to talk in a loud whisper, the external orifice of the cannula being occluded most of the time with the cork (K). The rubber tubing, when large sizes are reached may extend down to the lower end of the cannula, the part C coming out through a large hole cut in the tubing at the proper distance from the lower end.]
Laryngoscopic bouginage once weekly with the laryngeal bougies (Fig. 42) will cure most cases of laryngeal stenosis. For the trachea, round, silk-woven, or metallic bougies (Fig. 40) are better.
[307] Laryngostomy consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula, excision of thick cicatricial tissue, very cautious incision of the scar tissue on the posterior wall, if necessary, and the placing of the author's laryngostomy tube for dilatation (Fig. 109). Over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anchored to the tape carrier by braided silk thread. Progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber. Several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed. Painstaking after-care is essential to success. When dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall.
Intubational treatment of chronic laryngeal stenosis may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. The tube is a silver-plated brass one of large size (Fig. 110). A post which screws into the anterior surface of the tube prevents its expulsion. Over the post is slipped a block which serves to keep open the tracheal fistula. Detailed discussion of these operative treatments is outside the scope of this work, but mention is made for the sake of completeness. Before undertaking any of the foregoing procedures, a careful study of the complete descriptions in Peroral Endoscopy is necessary, and a practical course of training is advisable.
[FIG. 110.—The author's retaining intubation tube for treatment of chronic laryngeal stenosis. The tube (A) is introduced through the mouth, then the post (B) is screwed in through the tracheal wound. Then the block (C) is slid into the wound, the square hole in the block guarding the post against all possibility of unscrewing. If the threads of the post are properly fitted and tightly screwed up with a hemostat, however, there is no chance of unscrewing and gauze packing is used instead of the block to maintain a large fistula. The shape of the intubation tube has been arrived at after long clinical study and trials, and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape.]