Treatment of congenital laryngeal stridor should be directed to the relief of dyspnea, and to increasing the nutrition and development of the infant. The insertion of a bronchoscope will temporarily relieve an urgent dyspneic attack precipitated by examination; but this rarely happens if the examination is not unduly prolonged. Tracheotomy may be needed to prevent asphyxia or exhaustion from loss of sleep; but very few cases require anything but attention to nutrition and hygiene. Recovery can be expected with development of the laryngeal structures.
Congenital webs of the larynx require incision or excision, or perhaps simply bouginage. Congenital goiter and congenital laryngeal paralysis, both of which may cause stertorous breathing, are considered in connection with other forms of stenosis of the air passages.
Aphonia due to cicatricial webs of the larynx may be cured by plastic operations that reform the cords, with a clean, sharp anterior commissure, which is a necessity for clear phonation. The laryngeal scissors and the long slender punch are often more useful for these operations than the knife.
[224] CHAPTER XXIX—BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND BRONCHI
The indications for bronchoscopy in disease are becoming
increasingly numerous. Among the more important may be mentioned:
1. Bronchiectasis.
2. Chronic pulmonary abscess.
3. Unexplained dyspnea.
4. Dyspnea unrelieved by tracheotomy calls for bronchoscopic search
for deeper obstruction.
5. Paralysis of the recurrent laryngeal nerve, the cause of which is
not positively known.
6. Obscure thoracic disease.
7. Unexplained hemoptysis.
8. Unexplained cough.
9. Unexplained expectoration.
Contraindications to bronchoscopy in disease do not exist if the bronchoscopy is really needed. Serious organic disease such as aneurysm, hypertension, advanced cardiac disease, might render bronchoscopy inadvisable except for the removal of foreign bodies.
Bronchoscopic Appearances in Disease.—The first look should note the color of the bronchial mucosa, due allowance being made for the pressure of tubal contact, secretions, and the engorgement incident to continued cough. The carina trachealis normally moves slowly forward as well as downward during deep inspiration, returning quickly during expiration. Impaired movement of the carina indicates peritracheal and peribronchial pathology, the fixation being greatest in advanced cancer. In children and in the smaller tubes of the adult, the lengthening and dilatation of the bronchi during inspiration, and their shortening and contraction during expiration are readily seen.
Anomalies of the Tracheobronchial Tree.—Tracheobronchial anomalies are relatively rare. Congenital esophagotracheal and esophagobronchial fistulae are occasionally seen, and cases of cervicotracheal fistulae have been reported. Congenital webs and diverticula of the trachea are cited infrequently. Laryngoptosis and deviation of the trachea may be congenital. Substernal goitre, aneurysm, malignant growths, and various mediastinal adenopathies may displace the trachea from its normal course. The emphysematous chest fixed in the deep voluntary inspiratory position produces in some cases an elevation of the superior thoracic aperture simulating laryngoptosis (Bibliography r, pp. 468, 594).
Compression Stenosis of the Trachea and Bronchi.—Compression of the trachea is most commonly caused by goiter, substernal or cervical, aneurysm, malignancy, or, in children, by enlarged thymus. Less frequently, enlarged mediastinal tuberculous, leukemic, leutic or Hodgkin's glands compress the airway. The left bronchus may be stenosed by pressure from a hypertrophied cardiac auricle. Compression stenosis of the trachea associated with pulmonary emphysema accounts for the dyspnea during attacks of coughing.
The endoscopic picture of compression stenosis is that of an elliptical or scabbard-shaped lumen when the bronchus is at rest or during inspiration. Concentric funnel-like compression stenosis, while rare, may be produced by annular growths.