Of all benign growths in the larynx papilloma is the most frequent. It may occur at any age of childhood and may even be congenital. The outstanding fact which necessarily influences our treatment is the tendency to recurrences, followed eventually in practically all cases by a tendency to disappearance. In the author's opinion multiple papillomata constitute a benign, self-limited disease. There are two classes of cases. 1. Those in which the growth gets well spontaneously, or with slight treatment, surgically or otherwise; and, 2, those not readily amenable to any form of treatment, recurrences appearing persistently at the old sites, and in entirely new locations. In the author's opinion these two classes of case represent not two different kinds of growths, but stages in the disease. Those that get well after a single removal are near the end of the disease. Papillomata are of inflammatory origin and are not true neoplasms in the strictest sense.
Methods of Treatment.—Irritating applications probably provoke recurrences, because the growths are of inflammatory origin. Formerly laryngostomy was recommended as a last resort when all other means had failed. The excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure; and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone, using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis. Thyrotomy for papillomata is mentioned only to be condemned. Fulguration has been satisfactory in the hands of some, disappointing to others. It is easily and accurately applied through the direct laryngoscope, but damage to normal tissues must be avoided. Radium, mesothorium, and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action. In my experience, however, I have never seen a cure of papillomata which could be attributed to the radiation. I have seen cases in which no effect on the growths or recurrence was apparent, and in some cases the growths seemed to have been stimulated to more rapid repullulations. In other most unfortunate cases I have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy. Possibly the disastrous results were due to overdosage; but I feel it a duty to state the unfavorable experience, and to call attention to the difference between cancer and papillomata. Multiple papillomata involve no danger to life other than that of easily obviated asphyxia, and it is moreover a benign self-limited disease that repullulates on the surface. In cancer we have an infiltrating process that has no limits short of life itself.
Endolaryngeal extirpation of papillomata in children requires no anesthetic, general or local; the growths are devoid of sensibility. If, for any reason, a general anesthetic is used it should be only in tracheotomized cases, because the growths obstruct the airway. Obstructed respiration introduces into general anesthesia an enormous element of danger. Concerning the treatment of multiple papillomata it has been my experience in hundreds of cases that have come to the Bronchoscopic Clinic, that repeated superficial removals with blunt non-cutting forceps (see Chapter I) will so modify the soil as to make it unfavorable for repullulation. The removals are superficial and do not include the subjacent normal tissue. Radical removal of a papilloma situated, for instance, on the left ventricular band or cord, can in no way prevent the subsequent occurrence of a similar growth at a different site, as upon the epiglottis, or even in the fauces. Furthermore, radical removal of the basal tissues is certain to impair the phonatory function. Excellent results as to voice and freedom from recurrence have always followed repeated superficial removal. The time required has been months or a year or two. Only rarely has a cure followed a single extirpation.
If the child is but slightly dyspneic, the obstructing part of the growth is first removed without anesthesia, general or local; the remaining fungations are extirpated subsequently at a number of brief seances. The child is thus not terrified, soon loses dread of the removals, and appreciates the relief. Should the child be very dyspneic when first seen, a low tracheotomy is immediately done, and after an interim of ten days, laryngoscopic removal of the growth is begun. Tracheotomy probably has a beneficial effect on the disease. Tracheal growths require the insertion of the bronchoscope for their removal.
Papillomata in the larynx of adults are, on the whole, much more amenable to treatment than similar growths in children. Tracheotomy is very rarely required, and the tendency to recurrence is less marked. Many are cured by a single extirpation. The best results are obtained by removal of the growths with the laryngeal grasping-forceps, taking the utmost care to avoid including in the bite of the forceps any of the subjacent normal tissue. Radical resection or cauterization of the base is unwise because of the probable impairment of the voice, or cicatricial stenosis, without in anyway insuring against repullulation. The papillomata are so soft that they give no sensation of traction to the forceps. They can readily be "scalped" off without any impairment of the sound tissues, by the use of the author's papilloma forceps (Fig. 29). Cutting forceps of all kinds are objectionable because they may wound the normal tissues before the sense of touch can give warning. A gentle hand might be trusted with the cup forceps (Fig. 32, large size.)
Sir Felix Semon proved conclusively by his collective investigations that cancer cannot be caused by the repeated removals of benign growths. Therefore, no fear of causing cancer need give rise to hesitation in repeatedly removing the repullulations of papillomata or other benign growths. Indeed there is much clinical evidence elsewhere in the body, and more than a little such evidence as to the larynx, to warrant the removal of benign growths, repeated if necessary, as a prophylactic of cancer (Bibliography, 19).
[207] CHAPTER XXIII—BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL TREE
Extension of papillomata from the larynx into the cervical trachea, especially about the tracheotomy wound, is of relatively common occurrence. True primary growths of the tracheobronchial tree, though not frequent, are by no means rare. These primary growths include primary papillomata and fibromata as the most frequent, aberrant thyroid, lipomata, adenomata, granulomata and amyloid tumors. Chondromata and osteochondromata may be benign but are prone to develop malignancy, and by sarcomatous or other changes, even metaplasia. Edematous polypi and other more or less tumor-like inflammatory sequelae are occasionally encountered.
Symptoms of Benign Tumors of the Tracheobronchial Tree.—Cough, wheezing respiration, and dyspnea, varying in degree with the size of the tumor, indicate obstruction of the airway. Associated with defective aeration will be the signs of deficient drainage of secretions. Roentgenray examination may show the shadow of enchondromata or osteomata, and will also show variations in aeration should the tumor be in a bronchus.
Bronchoscopic removal of benign growths is readily accomplished with the endoscopic punch forceps shown in Figs. 28 and 33. Quick action may be necessary should a large tumor producing great dyspnea be encountered, for the dyspnea is apt to be increased by the congestion, cough, and increased respiration and spasm incidental to the presence of the bronchoscope in the trachea. General anesthesia, as in all cases showing dyspnea, is contraindicated. The risks of hemorrhage following removal are very slight, provided fungations on an aneurismal erosion be not mistaken for a tumor.