Spasmodic stenosis may be associated with panic, or may be excited by subglottic inflammation. Prolonged wearing of an intubation tube, by disturbing the normal reciprocal equilibrium of the abductors and adductors, is one of the chief causes. The treatment for spasmodic stenosis and panic is similar. The use of a special intubation tube having a long antero-posterior lumen and a narrow neck, which form allows greater action of the musculature, has been successful in some cases. Repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases. Very rarely a tracheotomy may be required; if so, it should be done low. The wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation. Corking the cannula with a slotted cork (Fig. 111) will now restore laryngeal breathing, after which the tracheotomic cannula may be removed.
[PLATE V—PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE—LARYNGEAL AND TRACHEAL STENOSES:
1, Indirect view, sitting position; postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration. (See Fig. 5.) 2, Indirect view, sitting position; posttyphoid cicatricial stenosis. Mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy. Cured by laryngostomy. (See Fig. 6.) 3, Indirect view, sitting position; posttyphoid infiltrative stenosis, left arytenoid destroyed by necrosis. Cured by laryngostomy; failure to form adventitious band (Fig. 7) because of lack of arytenoid activity. 4, Indirect view, recumbent position; posttyphoid cicatricial stenosis. Cured of stenosis by endoscopic evisceration with sliding punch forceps. Anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in Fig. 15. Ultimate result shown in Fig. 8. 5, Same patient as Fig. 1; sketch made two years after decannulation and plastic. 6, Same patient as Fig. 2; sketch made four years after decannulation and plastic. 7, Same patient as Fig. 3; sketch made three years after decannulation and plastic. 8, Same patient as Fig. 4; sketch made one year after decannulation, fourteen months after clearing of the anterior commissure to form adventitious cords. 9, Direct view, recumbent patient; web postdiphtheric (?) or congenital (?). "Rough voice" since birth, but larynx never examined until stenosed after diphtheria. Web removed and larynx eviscerated with punch forceps; recurrence of stenosis (not of web). Cure by laryngostomy. This view also illustrates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal illustrations. 10, Direct laryngoscopic view; postdiphtheric hypertrophic subglottic stenosis. Cured by galvanocauterization. 11, Direct laryngoscopic view; postdiphtheric hypertrophic supraglottic stenosis. Forceps excision; extubation one month later; still well after four years. 12, Bronchoscopic view of posttracheotomic stenosis following a "plastic flap" tracheotomy done for acute edema. 13, Direct laryngoscopic view; anterolateral thymic compression stenosis in a child of eighteen months. Cured by thymopexy. 14, Indirect laryngoscopic (mirror) view; laryngostomy rubber tube in position in treatment of post-typhoid stenosis. 15, Direct view; posttyphoid stenosis after cure by laryngostomy. Dotted line shows place of excision for clearing out the anterior commissure to restore the voice. 16, Endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis. Tracheotomy originally done for influenzal tracheitis. Cured by tracheostomy.]
Paralysis.—Bilateral abductor laryngeal paralysis causes severe stenosis, and usually tracheotomy is urgently required. In cadaveric paralysis both cords are in a position midway between abduction and adduction, and their margins are crescentic, so that sufficient airway remains. Efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves, have been failures. The operation of ventriculocordectomy consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope. Usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid. In some cases monolateral ventriculocordectomy is sufficient; in most cases, however, operation on both sides is needed. An interval of two months between operations is advisable to avoid adhesions. In almost all cases, ventriculocordectomy will result in a sufficient increase in the glottic chink for normal respiration. The ultimate vocal results are good. Evisceration of the larynx, either by the endoscopic or thyrotomic method, usually yields excellent results when no lesion other than paralysis exists. Only too often, however, the condition is complicated by the results of a faultily high tracheotomy. A rough, inflexible voice is ultimately obtained after this operation, especially if the arytenoid cartilage is unharmed. In recent bilateral recurrent paralysis, it may be worthy of trial to suture the recurrent to the pneumogastric. Operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition, this time being allowed for possible nerve regeneration, the patient being made safe and comfortable, meanwhile, by a low tracheotomy.
Ankylosis.—Fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx. This, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endoscopic bouginage, and by partial corking of the tracheotomic cannula.
Neoplasms.—Decannulation in neoplastic cases depends upon the nature of the growth, and its curability. Cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation, provided recurrence has been ruled out. The stenosis produced by benign tumors is usually relieved by their removal.
Papillomata.—Decannulation after tracheotomy done for papillomata should be deferred at least 6 months after the discontinuance of recurrence. Not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments. It is the author's opinion that recurrent papillomata constitute a benign self-limited disease and are best treated by repeated superficial removals, leaving the underlying normal structures uninjured. This method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis.
Compression Stenosis of the Trachea.—Decannulation in these cases can only follow the removal of the compressive mass, which may be thymic, neoplastic, hypertrophic or inflammatory. Glandular disease may be of the Hodgkins' type. Thymic compression yields readily to radium and the roentgenray, and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents. Surgery will relieve the compression of struma and benign neoplasms, and may be indicated in certain neoplasms of malignant origin. The possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon. Monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy, even though the recurrent nerves have been in no way injured at operation. Probably a localized neuritis, a cicatricial traction, or inclusion of a nerve trunk accounts for most of these cases.
Hyperplastic and cicatricial chronic stenoses preventing
decannulation may be classified etiologically as follows:
1. Tuberculosis
2. Lues
3. Scleroma
4. Acute infectious diseases
(a) Diphtheria
(b) Typhoid fever
(c) Scarlet fever
(d) Measles
(e) Pertussis
5. Decubitus
(a) Cannular
(b) Tubal
6. Trauma
(a) Tracheotomic
(b) Intubational
(c) Operative
(d) Suicidal and homicidal
(e) Accidental (by foreign bodies, external violence, bullets,
etc.)
Most of the organic stenoses, other than the paralytic and neoplastic forms, are the result of inflammation, often with ulceration and secondary changes in the cartilages or the soft tissues.