Fig. 288.—Papilloma of Larynx.
(From drawing lent by Dr. Logan Turner.)
The most prominent symptoms are hoarseness, aphonia, and dyspnœa, which in children may be paroxysmal.
The treatment consists in removing the growth by means of laryngeal forceps or the snare, under cocain and adrenalin anæsthesia. For the removal of multiple papillomata, the removal of the growths through Killian's tubes or by suspension laryngoscopy has now taken the place of the external operation in children. In a certain number of cases it has been found that the tumour disappears after the larynx has been put at rest by the operation of tracheotomy.
Cancer.—Epithelioma of the larynx is almost always primary, and usually occurs in males between the ages of forty and seventy. It is important to distinguish between those cases in which the growth first appears in the interior of the larynx—on the vocal cords, the ventricular bands, or in the sub-glottic cavity (intrinsic cancer)—and those in which it attacks the epiglottis, the ary-epiglottic folds, or the posterior surface of the cricoid cartilage (extrinsic cancer).
Clinical Features.—In the great majority of cases of intrinsic cancer the first and for many months the only symptom is huskiness of the voice, which may go on to complete aphonia before any other symptoms manifest themselves. When the larynx is examined in an early stage, the presence of a small warty growth on the posterior part of one vocal cord, or a papillary fringe extended along the free edge of the cord, should raise the suspicion of malignancy, especially if the affected cord is congested and moves less freely than its fellow. Early diagnosis is essential in intrinsic cancer, and the absence of enlargement of lymph glands, or of fœtor and cachexia, must in no way influence the surgeon against making a diagnosis of malignancy. The impaired mobility of the affected cord is an important point in determining the malignant nature of the growth.
Intrinsic cancer may spread over the upper boundaries of the larynx and become extrinsic, or the disease may be extrinsic from the outset.
In cases of extrinsic cancer the early symptoms are much more marked, pain and difficulty in swallowing, and the secretion of frothy, blood-stained mucus being among the earliest manifestations. The cervical glands are infected early, sometimes even before there are any symptoms of laryngeal disease. Difficulty of breathing is also an early symptom on account of the growth obstructing the entrance of air. Tracheotomy may therefore be called for. In other respects the course and terminations are similar to those of intrinsic cancer.
When the growth spreads into the tissues of the neck the patient's sufferings are greatly increased. The œsophagus may be invaded with resulting dysphagia; the nerve-trunks may be pressed upon, causing intense neuralgic pains; the lymph glands become infected and break down, and the growth fungates through the skin. The general health deteriorates and death results, usually from septic pneumonia set up by the passage of food particles into the air-passages, from absorption of toxins, or from hæmorrhage. The duration of this form of the disease varies from one to three years.
The treatment consists in removing the growth. In early and limited forms of intrinsic cancer laryngo-fissure (thyreotomy) gives good results; in more advanced cases the entire larynx must be removed—complete laryngectomy—and at the same time, or after an interval, the associated lymph glands are removed from the anterior triangle of the neck on both sides.
In cases in which excision is impracticable, the sufferings of the patient may be alleviated by performing low tracheotomy, and by feeding with the stomach tube or by nutrient enemata. In some cases the difficulty of feeding the patient may make it necessary to perform gastrostomy.