Amputation of the epiglottis for palliation of odynophagia or dysphagia in tuberculous or malignant disease, is of benefit when the ulceration is confined to this region; though as to tuberculosis the author feels rather conservatingly inclined. Early malignancy of the extreme tip can be cured by such means. The function of the epiglottis seems to be to split the food bolus and direct its portions laterally into the pyriform sinuses, rather than to take any important part in the closure of the larynx. Following the removal of the epiglottis there is rarely complaint of food entering the larynx. The projecting portion of the epiglottis may be amputated with a heavy snare, or by means of the large laryngeal punch forceps (Fig. 33).
Endoscopic Operations for Laryngeal Stenosis.—Web formations may be excised with sliding punch forceps, or if the web is due to contraction only, incision of the true band may allow its retraction. In some instances liberation of adhesions will favor the formation of adventitious vocal cords. A sharp anterior commissure is a large factor in good phonation.
Endoscopic evisceration of the larynx will cure a few cases of laryngeal cicatricial stenosis, and should be tried before resorting to laryngostomy. A sliding punch forceps is used to remove all the tissue in the larynx out to the perichondrium, but care should be taken in cicatricial cases to avoid removing any part of either arytenoid cartilage. In cases of posticus paralysis the excision may include portions of the vocal processes of the arytenoids. Ventriculocordectomy is preferable to evisceration. The ventricular floor is removed with punch forceps (Fig. 33) first on one side, then after two months, on the other.
Vocal Results.—A whispering voice can always be had as long as air can pass through the larynx, and this may be developed to a very loud penetrating stage whisper. If the arytenoid motility has been uninjured the repeated pulls on the scar tissue may draw out adventitious bands and develop a loud, useful, though perhaps rough and inflexible voice.
Galvano-cauterization is the best method of treatment for chronic subglottic edema or hyperplasia such as is seen in children following diphtheria, when the stenosis produced prevents extubation or decannulation. The utmost caution should be used to avoid deep cauterizations; they are almost certain to set up perichondritis which will increase the stenosis. Some of the most difficult cases that have come to the author have been previously cauterized too deeply.
Galvano-cautery puncture of tuberculous infiltrations of the larynx at times yields excellent results in cases with mild pulmonary lesions, and has quite replaced the use of the curette, lactic acid, and other caustics. The direct method of exposing the larynx renders the application of the cautery point easy and accurate. In severely stenosed tuberculous larynges a tracheotomy should first be done, for though the reaction is slight it might be sufficient to close a narrowed glottis. The technic is the usual one for laryngeal operations. Local anesthesia suffices. The larynx is exposed. The rheostat having been previously adjusted to heat the electrode to nearly white heat, the circuit is broken and the electrode introduced cold. When the point is in contact with the desired location the current is turned on and the point thrust in as deeply as desired. Usually it should penetrate until a firm resistance is felt; but care must be used not to damage the cricoarytenoid joint. The circuit is broken at the instant of withdrawal. Punctures should be made as nearly as possible perpendicular to the surface, so as to minimize the destruction of epithelium and thus lessen the reaction. A minute gray fibrous slough detaches itself in a few days. Cautery puncture should be repeated every two or three weeks, selecting a new location each time, until the desired result is obtained. Great caution, as mentioned above, must be used to avoid setting up perichondritis. Many cases of laryngeal tuberculosis will recover as quickly by silence and a general antituberculous regime.
Radium, in form of capsules or of needles inserted in the tissues may be applied with great accuracy; but the author is strongly impressed with pyriform sinus applications by the Freer method.
After-care of endolaryngeal operations includes careful cleansing of the teeth and mouth; and if the extrinsic area of the larynx is involved in the wound, sterile liquid food and water should be given for four days. The patient should be watched for complications by a special nurse who is familiar with the signs of laryngeal dyspnea (q.v.). Complications during endolaryngeal operations are rare. Dyspnea may require tracheotomy. Idiosyncrasy to cocain, or the sight or taste of blood may nauseate the patient and cause syncope. Serious hemorrhage could occur only in a hemophile. The careless handling of a bite block might damage a frail tool or dental fixture.
Complications after endolaryngeal operations are unusual. Carelessness in asepsis has been known to cause cervical cellulitis. Emphysema of the neck has occurred. Edema of the larynx occasionally occurs, and might necessitate tracheotomy. Serious bleeding after operation is very rare except in bleeders. Hemorrhage within the larynx can be stopped by the introduction of a roll of gauze from above, tracheotomy having been previously performed. Morphin subcutaneously administered, has a constricting action on the vessels which renders it of value in controlling hemorrhage.