Direct Laryngoscopy in Children.—The epiglottis in children is usually strongly curled, often omega shaped, and is very elusive and slippery. The larynx of a child is very freely movable in the neck during respiration and deglutition, and has a strong tendency to retreat downward during examination, and thus withdraw the epiglottis after the arytenoids have been exposed. In following down with the laryngoscope the speculum is prone to enter the hypopharynx. Lifting in this location will expose the mouth of the esophagus and shut off the larynx, and may cause respiratory arrest. Practice, however, will soon develop a technic and ability to recognize the landmarks in state of spasm, so that on exposing the approximated arytenoid eminences the endoscopist will maintain his position and wait for the larynx to open. The procedure should be done without any form of anesthesia for the following reasons: 1. Anesthesia is unnecessary. 2. It is extremely dangerous in a dyspneic patient. 3. It is inadmissable in a patient with diphtheria. 4. If anesthesia is to be used, direct laryngoscopy will never reach its full degree of usefulness, because anesthesia makes a major procedure out of a minor one. 5. Cocain in children is dangerous, and its application more annoying than the examination.
Inducing a Child to Open its Mouth (Author's Method).—The wounding of the child's mouth, gums, and lips, in the often inefficacious methods with gags, hemostats, raspatories, etcetera, are entirely unnecessary. The mouth of any child not unconscious can be opened quickly and without the slightest harm by passing a curved probe between the clenched jaws back of the molars and down back of the tongue toward the laryngopharynx. This will cause the child to gag, when its mouth invariably opens.
[91] CHAPTER VIII—DIRECT LARYNGOSCOPY (Continued)
Technic of Laryngeal Operations.—Preparation of the patient and anesthesia have been mentioned under their respective chapters. The prime essential of successful laryngeal operations is perfect mastery of continuous left-handed laryngeal exposure. The right hand must be equally trained in the manipulation of forceps, and the right eye to gauge depth. Blood and secretions are best removed by a suction tube (Fig. 9) inserted through the laryngoscope, or directly into the pharynx outside the laryngoscope.
For the removal of benign growths the author's papilloma forceps, Fig. 29, or the laryngeal grasping forceps shown in Fig. 17 will prove more satisfactory than any form of cutting forceps. These growths should be removed superficially flush with the normal structure. The crushing of the base incident to the plucking off of the growth causes its recession. By this conservative method damage to the cords and impairment of the voice are avoided. For growths in the anterior portion of the larynx, and in fact for the removal of most small benign growths, the anterior commissure laryngoscope is especially adapted. Its shape allows its introduction into the vestibule of the larynx, and if desired it may be introduced through the glottic chink for the treatment of subglottic conditions. It will not infrequently be observed that a pedunculated subglottic growth which is found with difficulty will be pulled upward into view by the gauze swab introduced to remove secretions. The growth is then often held tightly between the approximated cords for a few seconds—perhaps long enough to grasp it with forceps.
[92] Removal of Growth from the Laryngeal Ventricle.—After exposing the larynx in the usual manner, if the head is turned strongly to the right, the tip of the laryngoscope, directed from the right side of the mouth, may be used to lift the left ventricular hand and thus expose the ventricle, from which a growth may be removed in the usual manner (Fig. 57). The right ventricle is exposed by working from the left side of the mouth.
[FIG. 57.-Schema illustrating the lateral method of exposing a growth in the ventricle of Morgagni, by bending the patient's head to the opposite side, while the second assistant externally fixes the larynx with his hand. M, Patient's mouth; T, thyroid cartilage; R, right side; L, left. V, B, ventricular band. C, C, vocal cord. The circular drawing indicates the endoscopic view obtainable by this method. The tube, E, is dropped to the corner of the mouth, B, and the tube is inserted down to R. The lip of the spatula can then be used to lift the ventricular band so as to expose more of the ventricle. The drawing shows an unusually shallow ventricle.]
Taking a Laryngeal Specimen for Diagnosis.—The diagnosis of carcinoma, sarcoma, and some other conditions can be made certain only by microscopic study of tissue removed from the growth. The specimen should be ample but will necessarily be small. If the suspected growth be small it should be removed entire, together with some of the basal tissues. If it is a large growth, and there are objections to its entire removal, the edge of the growth, including apparently normal as well as neoplastic tissue, is necessary. If it is a diffuse infiltrative process, a specimen should be taken from at least two locations. Tissue for biopsy is to be taken with the punch forceps shown in Fig. 28 or that in Fig. 33. The forceps may be inserted through the tube or from the angle of the mouth; the "extubal" method (see Fig. 58).
[FIG. 58.—Schema illustrating removal of a tumor from the upper part of the larynx by the author's "extubal" method for large tumors. The large alligator basket punch forceps, F, is inserted from the right corner of the mouth and the jaws are placed over the tumor, T, under guidance of the eye looking through the laryngoscope, L. This method is not used for small tumors. It is excellent for amputation of the epiglottis with these same punch forceps or with the heavy snare.]
Removal of large benign tumors above the cords may be done with the snare or with the large laryngeal punch forceps. Both are used in the extubal method.