[307] Laryngostomy consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula, excision of thick cicatricial tissue, very cautious incision of the scar tissue on the posterior wall, if necessary, and the placing of the author's laryngostomy tube for dilatation (Fig. 109). Over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anchored to the tape carrier by braided silk thread. Progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber. Several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed. Painstaking after-care is essential to success. When dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall.
Intubational treatment of chronic laryngeal stenosis may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. The tube is a silver-plated brass one of large size (Fig. 110). A post which screws into the anterior surface of the tube prevents its expulsion. Over the post is slipped a block which serves to keep open the tracheal fistula. Detailed discussion of these operative treatments is outside the scope of this work, but mention is made for the sake of completeness. Before undertaking any of the foregoing procedures, a careful study of the complete descriptions in Peroral Endoscopy is necessary, and a practical course of training is advisable.
[FIG. 110.—The author's retaining intubation tube for treatment of chronic laryngeal stenosis. The tube (A) is introduced through the mouth, then the post (B) is screwed in through the tracheal wound. Then the block (C) is slid into the wound, the square hole in the block guarding the post against all possibility of unscrewing. If the threads of the post are properly fitted and tightly screwed up with a hemostat, however, there is no chance of unscrewing and gauze packing is used instead of the block to maintain a large fistula. The shape of the intubation tube has been arrived at after long clinical study and trials, and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape.]
[309] CHAPTER XXXIX—DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS
In order to train the patient to breathe again through the larynx it is necessary to occlude the cannula. This is best done by inserting a rubber cork in the inner cannula. At first it may be necessary to make a slot in the cork so as to permit some air to enter through the tube to supplement the insufficient supply obtainable through the insufficiently patulous glottis, new corks with smaller grooves being substituted as laryngeal breathing becomes easier. Corking the cannula is an excellent orthopedic treatment in certain cases where muscle atrophy and partial inflammatory fixation of the cricoarytenoid joints are etiological factors in the stenosis. The added pull of the posterior cricoarytenoid muscles during the slight effort at inspiration restores their tone and increases the mobility of all the attached structures. By no other method can panic and spasmodic stenosis be so efficiently cured.
[FIG. 111.—Illustration of corks used to occlude the cannula in training patients to breathe through the mouth again, before decannulation. The corks allow air leakage, the amount of which is regulated by the use of different shapes. A smaller and still smaller air leak is permitted until finally an ungrooved cork is tolerated. A central hole is sometimes used instead of a slot. A, one-third cork; B, half cork; C, three-quarter cork; D, whole cork.]
Following the subsidence of an acute laryngeal stenosis, it is my rule to decannulate after the patient has been able to breathe through the larynx with the cannula tightly corked for 3 days and nights. This rule does not apply to chronic laryngeal stenosis, for while the lumen under ordinary conditions might be ample, a slight degree of inflammation might render it dangerously small. In these cases, many weeks are sometimes required to determine when decannulation is safe. A test period of a few months is advisable in most cases of chronic laryngeal stenosis. Recurrent contractions after closure of the wound are best treated by endoscopic bouginage. The corks are best made of pure rubber cord, cut and ground to shape, and grooved, if desired, on a small emery wheel (Fig. 112). The ordinary rubber corks and those made of cork-bark should not be used because of their friability, and the possible aspiration of a fragment into the bronchus, where rubber particles form very irritant foreign bodies.
[FIG. 112.—This illustration shows the method of making safe corks for tracheotomic cannulae by grinding pure rubber cord to shape on an emery wheel. After grinding the taper, if a partial cork is desired, a groove is ground on the angle of the wheel. If a half-cork is desired half of the cork is ground away on the side of the wheel. Reliable corks made in this way are now obtainable from Messers Charles J. Pilling and Son.]
BIBLIOGRAPHY
The following list of publications of the author may be useful for reference: 1. Peroral Endoscopy and Laryngeal Surgery, Textbook, 1914. (Contains full bibliography to date of publication.) 2. Acromegaly of the Larynx. Journ. Amer. Med. Asso., Nov. 30, 1918, Vol. LXXI, pp. 1787-1789. 3. A Fence Staple in the Lung. A New Method of Bronchoscopic Removal. Journ. Amer. Med. Asso., Vol. LXIV, June 5, 1917, pp. 1906-7. 4. Amalgam Tooth-filling Aspirated into Lung During Extraction. Dental Cosmos, Vol. LIX, May, 1917, pp. 500-502. 5. Amalgam Filling Removed from Lung after a Seven Months' Sojourn: Case Report. Dental Cosmos, April, 1920. 6. A Mechanical Spoon for Esophagoscopic Use. The Laryngoscope, January, 1918, PP. 47-48. 7. An Anterior Commissure Laryngoscope. The Laryngoscope, Vol. XXV, Aug., 1915, P. 589. 8. Ancient Foreign Body Cases. Editorial. The Laryngoscope, Vol. XXVII, July, 1917, PP. 583-584. 9. An Esophagoscopic Forceps. The Laryngoscope, Jan., 1918, p. 49. 10. A New Diagnostic Sign of Foreign Body in Trachea or Bronchi, the "Asthmatoid Wheeze." Amer. Journ. Med. Sciences, Vol. CLVI, No. 5, Nov., 1918, p. 625. 11. A New Method of Working Out Difficult Mechanical Problems of Bronchoscopic Foreign-body Extraction. The Laryngoscope, Vol. XXVII, Oct., 1917, p. 725. 12. Arachidic Bronchitis. Journ. Amer. Med. Asso., Aug. 30, 1919, Vol. LXXIII, pp. 672-677. 13. Band of a Gold Crown in the Bronchus: Report of a Case. Dental Cosmos. Vol. LX, Oct., 1918, p. 905. 14. Bronchiectasis and Bronchiectatic Symptoms Due to Foreign Bodies. Penn. Med. Journ., Vol. XIX, Aug., 1916, pp. 807-814. 15. Bronchoscopic and Esophagoscopic Postulates. Annals of Otology, Rhinology and Laryngology, June, 1916, pp. 414-416. 16. Bronchoscopic Removal of a Collar Button after Twenty-six Years Sojourn in the Lung. Annals of Otology, Rhinology and Laryngology, June, 1913. 17. Bronchoscopy. Keen's Surgery, 1921, Vol. VIII. 18. Caisson Bronchoscopy in Lung-abscess Due to Foreign Body. Surg., Gyn. and Obstet., Oct., 1917, pp. 424-428. 19. Cancer of the Larynx. Is it Preceded by a Recognizable Precancerous Condition? Proceedings Amer. Laryngol. Soc., 1922. 20. Din. Editorial. The Laryngoscope, Vol. XXVI, Dec., 1916, pp. 1385-1387. 23. Endoscopie Perorale et Chirurgie Laryngienne. Arch. de Laryngol., T. XXXVII, No. 3, 1914, pp. 649-680. 24. Endoscopy and the War. Editorial. The Laryngoscope, Vol. XXVI, June, 1916, p. 992. 25. Endothelioma of the Right Bronchus Removed by Peroral Bronchoscopy. Amer. Journ. of Med. Sci., No. 3, Vol. CLII, March, 1917, p. 371. 26. Esophageal Stenosis Following the Swallowing of Caustic Alkalies, Journ. Amer. Med. Asso., July 2, 1921, Vol. LXXVII, pp. 22-23. 27. Esophagoscopic Radium Screens. The Laryngoscope, Feb., 1914. 28. Foreign Bodies in the Insane. Editorial. The Laryngoscope, Vol. XXVII, June, 1917, pp. 513-515. 29. Foreign Bodies in the Larynx, Trachea, Bronchi and Esophagus Etiologically Considered. Trans. Sec. Laryn., Otol. and Rhin., Amer. Med. Asso., 1917, pp. 36-56. 30. Gold Three-tooth Molar Bridge Removal from the Right Bronchus: Case Report. Dental Cosmos, Oct., 1919. 31. High Tracheotomy and Other Errors the Chief Causes of Chronic Laryngeal Stenosis. Surg., Gyn. and Obstet., May, 1921, pp. 392-398. 32. Inducing a Child to Open Its Mouth. Editorial. The Laryngoscope, Vol. XXVI, Nov., 1917, p. 795. 33. Intestinal Foreign Bodies. Editorial. The Laryngoscope, Vol. XXVI, May, 1916, p. 929. 34. Laryngoscopic, Esophagoscopic and Bronchoscopic Clinic. International Clinics, Vol. IV, 1918. J. B. Lippincott Co. 35. Local Application of Radium Supplemented by Roentgen Therapy (Discussion). Amer. Journ. of Roentgenology. 36. Localization of the Lobes of the Lungs by Means of Transparent Outline Films. Amer. Journ. Roent., Vol. V, Oct., 1918, p. 456. Also Proc. Amer. Laryn., Rhin. and Otol. Soc., 1918. 37. Mechanical Problems of Bronchoscopic and Esophagoscopic Foreign Body Extraction, Journ. Am. Med. Assn., Jan. 27, 1917. 38. Observation on the Pathology of Foreign Bodies in the Air and Food Passages Based on the Analysis of 628 Cases. Mutter Lecture, 1917, Surg. Gyn. and Obstet., Mar., 1919, pp. 201-261. 39. Orthopedic Treatment by Corking. Journ. of Laryn. and Otol., London, Vol. XXXII, Feb., 1917. 40. Peroral Endoscopy. Journ. of Laryn. and Otol., Edinburgh, Nov., 1921. 41. Peroral Endoscopy and Laryngeal Surgery. The Laryngoscope, Feb., 1919. 42. Postulates on the Cough Reflex in Some of its Medical and Surgical Phases. Therapeutic Gazette, Sept. 15, 1920. 43. Prognosis of Foreign Body in the Lung. Journ., Amer. Med. Asso., Oct. 8, 1921, Vol. LXXVII, pp. 1178-1181. 44. Pulsion Diverticulum of the Esophagus. Surg., Gyn. and Obstet., Vol. XXI, July, 1915, PP. 52-55. 45. Radium. Editorial. The Laryngoscope, Vol. XXVI, Aug., 1916, pp. 1111-1113. 46. Reaction after Bronchoscopy. Penn. Med. Journ., April, 1919. Vol. XXII P. 434. 47. Root-canal Broach Removed from the Lung by Bronchoscopy. The Dental Cosmos, Vol. LVII, March, 1915, p. 247. 48. Safety Pins in Stomach, Peroral Gastroscopic Removal without Anesthesia. Journ. Amer. Med. Asso., Feb. 26, 1921, Vol. LXXVI, pp. 577-579. 49. Symptomatology and Diagnosis of Foreign Bodies in the Air and Food Passages. Am. Journ. Med. Sci., May, 1921, Vol. CLXI, No. 5, p. 625. 50. The Bronchial Tree, Its Study by Insufllation of Opaque Substances in the Living. Amer. Journ. Roentgenology, Vol. 5, Oct., 1918, p. 454. Also Proc. Amer. Laryn., Rhinol. and Otol. Soc., 1918. 51. Thymic Death. Editorial. The Laryngoscope, Vol. XXVI, May, 1916, p. 929. 52. Tracheobronchitis Due to Nitric Acid Fumes. New York Med. Journ., Nov. 4, 1916, PP. 898-899. 53. Treatment of Laryngeal Stenosis by Corking the Tracheotomic Cannula, The Laryngoscope, Jan., 1919. 54. Ventriculocordectomy. Proceedings Amer. Laryngol. Soc., 1921. 55. New Mechanical Problems in the Bronchoscopic Extraction of Foreign Bodies from the Lungs and Esophagus. Annals of Surgery, Jan., 1922. 56. The Diaphragmatic Pinchcock in So-called Cardiospasm. Laryngoscope, Jan., 1922.