INJURIES TO THE RESPIRATORY PASSAGES.
Besides those inflicted by foreign bodies injuries may be produced here from external conditions, gunshot wounds, fractures, and a variety of causes which need not be specified. The inhalation or the entrance of violent caustics, either fluid or volatile, may produce edema at least, or actual destruction of tissue. The glottis, being the narrowest portion of the respiratory tract, offers the greatest danger under conditions of obstruction, and fatal dyspnea may ensue. Thus, for instance, burns caused by inhaling steam, or hot vapors or flame, will be followed by most intense reaction, often extending beyond the trachea and to the air cells. Edema will be prompt, while pain, shock, dyspnea, and loss of voice will be instantly produced. If the patient survive the early complications he may succumb to pneumonia or other disastrous sequels in the lungs.
Wounds of the Larynx.
—Wounds are nearly always complicated by other injuries of the neck or face, which may involve vessel or nerve trunks of primary importance. Moreover, such wounds are mostly infected and lead to extension of phlegmonous involvement, which may later cause mediastinal or deep cervical abscesses, and all sorts of septic and pyemic complications. Even when recovery ensues cicatricial contraction may produce laryngeal or tracheal stenosis, with defective voice, or sometimes fistulas, connecting usually with the trachea.
Treatment.
—In the treatment of such wounds provision should be made for drainage, and it is seldom advisable to make too accurate a closure lest its very intent be thereby defeated. Unless the patient be suffocating the first indication is to check hemorrhage, then to cleanse the wound, and later to make such approximation of its surfaces as the case may permit. Occasionally in order to obtain a good result in the upper part of the respiratory tract it would be good practice to make a tracheotomy below. At other times an O’Dwyer tube may be inserted.
The occurrence of edema may be prevented, or at least its severity in a measure controlled, by the use of adrenalin solution, 1 to 10,000, while the local use of mild cocaine solutions will be frequently indicated, in order to check irritability and the reflex phenomena to which it will lead. Local symptoms may also be combated by inhalation of vapor, with soothing solutions, such as weak preparations of cocaine or of one of the opiates, followed by mild astringents and antiseptics—tincture of benzoin or oil of eucalyptus, or some of their equivalents, being nebulized and used in a spray. Opiates internally should be prescribed; while with delirious, drunken, or maniacal patients every effort should be made to secure physiological rest and to subdue restlessness or frenzy.
Fracture of the Larynx.
—Fracture of the larynx is a somewhat uncommon accident, due to direct violence, which may instantly precipitate symptoms of the greatest severity. It may be simple or compound, the thyroid being obviously most often involved and the cricoid next. These injuries will occur more frequently in the aged, in whom the external cartilages of the larynx are prone to calcify and thus become more brittle. A fracture of the larynx precipitates extreme danger of suffocation, either from displacement or edema, and will usually require a prompt tracheotomy, which may be performed with a penknife in the absence of any better instrument. It may be indicated also by expectoration of bloody mucus, with froth, with stridulous respiration, dyspnea, pain—which is increased by pressure or motion, as in swallowing—and the local indications of injury. Thus death has occurred upon the field during a game of baseball, from a direct blow of the ball upon the larynx, no one who knew sufficient to perform it reaching the patient in time to do an emergency tracheotomy as above. Edematous laryngitis, which is not sufficiently serious to call for operation, is characterized by dyspnea, aphonia, dysphagia, cough, laryngeal irritability, and by more or less chemosis and congestion of the mucosa. The specialists treat certain of the milder forms of this condition by local scarification (i. e., with a knife made for the purpose), in order that by considerable local hemorrhage the vascular engorgement may be relieved.