Multiple papillomata when very numerous are best removed by the author's "coring" method. This consists in the insertion of an aspirating bronchoscope with the mechanical aspirator working at full negative pressure. The papillomata are removed like coring an apple; though the rounded edge of the bronchoscope does not even scratch the tracheal mucosa. Many of the papillomata are taken off by the holes in the bronchoscope. Aspiration of the detached papillomata into the lungs is prevented by the corking of the tube-mouth with the mass of papillomata held by the negative pressure at the canal inlet orifice.
CHAPTER XXIV—BENIGN NEOPLASMS OF THE ESOPHAGUS
As a result of prolonged inflammation edematous polypi and granulomata are not infrequently seen, but true benign tumors of the esophagus are rare affections. Keloidal changes in scar tissue may occur. Cases of retention, epithelial and dermoid cysts have been observed; and there are isolated reports of the finding of papillomata, fibromata, lipomata, myomata and adenomata. The removal of these is readily accomplished with the tissue forceps (Fig. 28), if the growths are small and projecting into the esophageal lumen. The determination of the advisability of the removal of keloidal scars would require careful consideration of the particular case, and the same may be said of very large growths of any kind. The extreme thinness of the esophageal walls must be always in the mind of the esophagoscopist if he would avoid disaster.
[210] CHAPTER XXV—ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX
The general surgical rule applying to individuals past middle life, that benign growths exposed to irritation should be removed, probably applies to the larynx as well as to any other epithelialized structure. The facility, accuracy and thoroughness afforded by skilled, direct, laryngeal operation offers a means of lessening the incidence of cancer. To a much greater extent the facility, accuracy, and thoroughness contribute to the cure of cancer by establishing the necessary early diagnosis. Well-planned, careful, external operation (laryngofissure) followed by painstaking after-care is the only absolute cure so far known for malignant neoplasms of the larynx; and it is a cure only in those intrinsic cases in which the growth is small, and is located in the anterior two-thirds of the intrinsic area. By limiting operations strictly to this class of case, eighty-five per cent of cures may be obtained.* In determining the nature of the growth and its operability the limits of the usefulness of direct endoscopy are reached. It is very unwise to attempt the extirpation of intrinsic laryngeal malignancy by the endoscopic method, for the reason that the full extent of the growth cannot be appreciated when viewed only from above, and the necessary radical removal cannot be accurately or completely accomplished.
* The author's results in laryngofissure have recently fallen to 79 per cent of relative cures by thyrochondrotomy.
Malignant disease of the epiglottis, in those rare cases where the lesion is strictly limited to the tip is, however, an exception. If amputation of the epiglottis will give a sufficiently wide removal, this may be done en masse with a heavy snare, and has resulted in complete cure. Very small growths may be removed sufficiently widely with the punch forceps (Fig. 33); but piece meal removal of malignancy is to be avoided.
Differential Diagnosis of Laryngeal Growths in the Larynx of
Adults.—Determination of the nature of the lesion in these cases
usually consists in the diagnosis by exclusion of the possibilities,
namely,
1. Lues.
2. Tuberculosis, including lupus.
3. Scleroma.
4. Malignant neoplasm.
In the Bronchoscopic Clinic the following is the routine procedure: 1. A Wassermann test is made. If negative, and there remains a suspicion of lues, a therapeutic test with mercury protoiodid is carried out by keeping the patient just under the salivation point for eight weeks; during which time no potassium iodid is given, lest its reaction upon the larynx cause an edema necessitating tracheotomy. If no improvement is noticed lues is excluded. If the Wassermann is positive, malignancy and the other possibilities are not considered as excluded until the patient has been completely cured by mercury, because, for instance, a leutic or tuberculous patient may have cancer; a tuberculous patient may have lues; or a leutic patient, tuberculosis. 2. Pulmonary tuberculosis is excluded by the usual means. If present the laryngeal lesion may or may not be tuberculous; if the laryngoscopic appearances are doubtful a specimen is taken. Lupoid laryngeal tuberculosis so much resembles lues that both the therapeutic test and biopsy may be required for certainty. 3. In all cases in which the diagnosis is not clear a specimen is taken. This is readily accomplished by direct laryngoscopy under local anesthesia, using the regular laryngoscope or the anterior commissure laryngoscope. The best forceps in case of large growths are the alligator punch forceps (Fig. 33). Smaller growths require tissue forceps (Fig. 28). In case of small growths, it is best to remove the entire growth; but without any attempt at radical extirpation of the base; because, if the growth prove benign it is unnecessary; if malignant, it is insufficient.
Inspection of the Party Wall in Cases of Suspected Laryngeal Malignancy.—When taking a specimen the party wall should be inspected by passing a laryngoscope or, if necessary, an esophageal speculum down through the laryngopharynx and beyond the cricopharyngeus. If this region shows infiltration, all hope of cure by operation, however radical, should be abandoned.