Radiotherapy.—Radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms. No permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. The combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has retarded the progress of some cases.
The dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. Two fundamental points are to be considered, however. The radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa. The dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center. If the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. It is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (Fig. 95)
Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer.
[221] CHAPTER XXVIII—DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX
The diagnosis of laryngeal disease in young children, impossible with the mirror, has been made easy and precise by the development of direct laryngoscopy. No anesthetic, local or general, should be used, for the practised endoscopist can complete the examination within a minute of time and without pain to the patient. The technic for doing this should be acquired by every laryngologist. Anesthesia is absolutely contraindicated because of the possibility of the presence of diphtheria, and especially because of the dyspnea so frequently present in laryngeal disease. To attempt general anesthesia in a dyspneic case is to invite disaster (see Tracheotomy). It is to be remembered that coughing and straining produce an engorgement of the laryngeal mucosa, so that the first glance should include an estimation of the color of the mucosa, which, as a result of the engorgement, deepens with the prolongation of the direct laryngoscopy.
Chronic subglottic edema, often the result of perichondritis, may require linear cauterization at various times, to reduce its bulk, after the underlying cause has been removed.
Perichondritis and abscess, and their sequelae are to be treated on the accepted surgical precepts. They may be due to trauma, lues, tuberculosis, enteric fever, pneumonia, influenza, etc.
Tuberculosis of the larynx calls for conservatism in the application of surgery. Ulceration limited to the epiglottis may justify amputation of the projecting portion or excision of only the ulcerated area. In either case, rapid healing may be expected, and relief from the odynphagia is sometimes prompt. Amputation of the epiglottis is, however, not to be done if ulceration in other portions of the larynx coexist. The removal of tuberculomata is sometimes indicated, and the excision of limited ulcerative lesions situated elsewhere than on the epiglottis may be curative. These measures as well as the galvanocautery are easily executed by the facile operator; but their advisability should always be considered from a conservative viewpoint. They are rarely justifiable until after months of absolute silence and a general antituberculous regime have failed of benefit.
Galvanopuncture for laryngeal tuberculosis has yielded excellent results in reducing the large pyriform edematous swellings of the aryepiglottic folds when ulceration has not yet developed. Deep punctures at nearly a white heat, made perpendicular to the surface, are best. Care must be exercised not to injure the cricoarytenoid joint. Fungating ulcerations may in some cases be made to cicatrize by superficial cauterization. Excessive reactions sometimes follow, so that a light application should be made at the first treatment.
Congenital laryngeal stridor is produced by an exaggeration of the infantile type of larynx. The epiglottis will be found long and tapering, its lateral margins rolled backward so as to meet and form a cylinder above. The upper edges of the aryepiglottic folds are approximated, leaving a narrow chink. The lack of firmness in these folds and the loose tissue in the posterior portion of the larynx, favors the drawing inward of the laryngeal aperture by the inspiratory blast. The vibration of the margins of this aperture produces the inspiratory stridor. Diagnosis is quickly made by the inspection of the larynx with the infant diagnostic laryngoscope. No anesthetic, general or local, is needed. Stridorous respiration may also be due to the presence of laryngeal papillomata, laryngeal spasm, thymic compression, congenital web, or an abnormal inspiratory bulging into the trachea of the posterior membranous tracheo-esophageal wall. The term "congenital laryngeal stridor" should be limited to the first described condition of exaggerated infantile larynx.