Lens-system ballooning gastroscopy may possibly afford additional information after all possible data from open-tube gastroscopy has been obtained. Care must be exercised not to exert an injurious degree of air-pressure. The distended portion of the stomach assumes a funnel-like form ending at the apex in a depression with radiating folds, that leads the observer to think he is looking at the pylorus. The foreshortening produced by the lens system also contributes to this illusion. The best lens-system gastroscope is that of Henry Janeway, which combines the open-tube and the lens system.
Gastroscopy for Foreign Bodies.—The great majority of foreign bodies that reach the stomach unassisted are passed per rectum, provided the natural protective means are not impaired by the administration of cathartics, changes in diet, etcetera. This, however, does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods, or by esophagoscopy, because a swallowed object lodged in the esophagus can always be returned through the mouth. Foreign bodies in the stomach and intestines should be fluoroscopically watched each second day. If an object is seen to lodge five days in one location in the intestines, it should be removed by laparotomy, since it will almost certainly perforate. Certain objects reaching the stomach may be judged too large to pass the pylorus and intestinal angles. These should be removed by gastroscopy when such decision is made. It is to be remembered that gastric foreign bodies may be regurgitated and may lodge in the esophagus, whence they are easily removed by esophagoscopy. The double-planed fluoroscope of Manges is helpful in the removal of gastric foreign bodies, but there is great danger of injury to the stomach walls, and even the peritoneum, unless forceps are used with the utmost caution.
[277] CHAPTER XXXVI—ACUTE STENOSIS OF THE LARYNX
Etiology.—Causes of a relatively sudden narrowing of the lumen of
the larynx and subjacent trachea are included in the following list.
Two or more may be combined.
1. Foreign body.
2. Accumulation of secretions or exudate in the lumen.
3. Distension of the tissues by air, inflammatory products, serum,
pus, etc.
4. Displacement of relatively normal tissues, as in abductor
paralysis, congenital laryngeal stridor, etcetera.
5. Neoplasms.
6. Granulomata.
Edema of the larynx may be at the glottic level, or in the supraglottic or subglottic regions. The loose cellular tissue is most frequently concerned in the process rather than the mucosal layer alone. In children the subglottic area is very vascular, and swelling quickly results from trauma or inflammation, so that acute stenosis of the larynx in children commonly has its point of narrowing below the cords. Dyspnea, and croupy, barking, cough with no change in the tone or pitch of the speaking voice are characteristic signs of subglottic stenosis. Edema may accompany inflammation of either the superficial or deep structures of the larynx. The laryngeal lesion may be primary, or may complicate general diseases; among the latter, typhoid fever deserves especial mention.
Acute laryngeal stenosis complicating typhoid fever is frequently overlooked and often fatal, for the asthenic patient makes no fight for air, and hoarseness, if present, is very slight. The laryngeal lesion may be due to cordal immobility from either paralysis or inflammatory arytenoid fixation, in the absence of edema. Perichondritis and chondritis of the laryngeal cartilages often follow typhoid ulceration of the larynx, chronic stenosis resulting.
Laryngeal stenosis in the newborn may be due to various anomalies of the larynx or trachea, or to traumatism of these structures during delivery. The normal glottis in the newborn is relatively narrow, so that even slight encroachment on its lumen produces a serious degree of dyspnea. The characteristic signs are inspiratory indrawing of the supraclavicular fossae, the suprasternal notch, the epigastrium, and the lower sternum and ribs. Cyanosis is seen at first, later giving place to pallid asphyxia when cardiac failure occurs. Little air is heard to enter the lungs, during respiratory efforts and the infant, becoming exhausted by the great muscular exertion, soon ceases to breathe. Paralytic stenosis of the larynx sometimes follows difficult forceps deliveries during which stretching or compression of the recurrent nerves occur.
Acute laryngeal stenosis in infants, from laryngeal perichondritis, may be a delayed result of traumatism to the laryngeal cartilages during delivery. The symptoms usually develop within four weeks after birth. Lues and tuberculosis are possible factors to be eliminated by the usual methods.
Surgical Treatment of Acute Laryngeal Stenosis.—Multiple puncture of acute inflammatory edema, while readily performed with the laryngeal knife used through the direct laryngoscope, is an uncertain measure of relief. Tracheotomy, if done low in the neck, will completely relieve the dyspnea. By its therapeutic effect of rest, it favors the rapid subsidence of the inflammation in the larynx and is the treatment to be preferred. Intubation is treacherous and unreliable except in diphtheritic cases; but in the diphtheritic cases it is ideal, if constant skilled watching can be had.