Of the inflammatory affections of the cartilages chondritis and perichondritis are most common. These are usually seen in connection with other expressions of tuberculous, syphilitic, and malignant disease. Nevertheless they are known to occur as sequels of the exanthems and ordinary infectious fevers. They may be followed by destructive ulceration, which will lead to a necrosis of the cartilage corresponding closely to death of bone under similar circumstances. In due time there may form a cartilaginous sequestrum, and this will require removal as though it were bone. Dangers attend these lesions in two peculiar directions. The very condition which produces the destructive inflammation may also produce either hemorrhage or edema, with suffocation which can usually be prevented by an emergency tracheotomy. On the other hand, when repair follows spontaneous recovery or successful treatment, it may be accompanied by such cicatricial contraction as shall materially change the shape and impair or possibly destroy the function of the larynx itself. In this case either thyrotomy, tracheotomy, or laryngotomy may be called for, the opening thus made being expected to permanently remain.
STRICTURES OF THE LARYNX.
Various forms of stricture of the larynx may be similarly produced. Such strictures, then, are due to previous disease or to injuries, and here as elsewhere stricture is a consequence rather than itself a disease. It occurs in consequence of syphilis and of the destruction following laryngeal diphtheria.
What is, in this respect, true of the larynx is also true, though less often, of the trachea, where constrictions may occur at various points, with reduction of caliber or such distortion of shape as to produce partial or even finally complete obstruction. The peculiar scabbard-shape which the trachea may be made to assume by compression between the lobes of a growing goitre has been elsewhere described. While the trachea itself is in this case free from disease the obstruction is none the less pronounced. Similar effects are produced by pressure, as from aneurysms or tumors, even at a distance. Loss of voice, shown to be due to paralysis of one or both vocal cords, should always prompt an examination of the chest, in order that the presence of an aneurysm or other tumor making pressure upon the recurrent laryngeal may not be overlooked.
Symptoms.
—Symptoms of laryngeal and tracheal stricture comprise (1) those of the primary and active disease which produces them; (2) those of obstruction; (3) those of suffocation in emergency cases. The earlier symptoms are those of increasing dyspnea, which may vary in rapidity and extend over weeks and months, or which may become most pronounced within a few hours. There is also a change in the character and sometimes complete loss of voice, hoarseness of the speaking voice changing into a whisper. The condition is frequently complicated by attacks of serious dyspnea, often at night, which are due to an added spasmodic feature, and in which death may suddenly occur. Usually, however, with asphyxia comes muscular relaxation, and individuals may pass through a large number of these attacks, which are accompanied with extreme mental and physical suffering, in which death is only avoided by final relaxation. Again the heart may suddenly give out, and then the case becomes practically hopeless. In recognition of causes and location of such troubles it may be held that when hoarseness precedes dyspnea the lesion is in the larynx; when the reverse, it is in the trachea. Careful auscultation of the chest and thorough laryngoscopic examination will usually enable the lesion to be recognized. The lower the location of the stenosis the worse the prognosis, because of its inaccessibility. So long as the trachea below the stricture can be opened life may be prolonged indefinitely; but when due to a mediastinal tumor or an enlarged thymus, the case assumes desperate aspects and may baffle the best-directed efforts.
Treatment.
—Strictures in the larynx proper may be treated by dilatation, as by the introduction of intubation tubes of increasing size, a method which ordinarily gives satisfactory results. Nevertheless such laryngeal strictures manifest an almost permanent tendency to recontract, and whatever measures are addressed to them have to be frequently and thoroughly practised and over a long period. Fortunately, however, these patients are able to wear an O’Dwyer tube nearly all the time. When these internal operative methods fail there remains only an external opening, which may be made through the larynx proper (thyrotomy), or a low tracheotomy, which may require the insertion of short or long tubes, according to circumstances. Long trachea tubes are made, their lower portion being composed of rings fastened together in such a way as to cause them to be called lobster-tailed, and such a long tube may be passed through a low tracheotomy opening and made to extend beyond the point of pressure produced by an extrathoracic or an intrathoracic tumor. By the use of such an expedient life may be prolonged, although the exciting cause may prove fatal.
TUBERCULOSIS OF THE LARYNX.
Tuberculosis of the larynx may appear in a generally disseminated form, involving nearly all the structures, or in circumscribed localized form, as a tuberculous ulcer, which may produce symptoms depending upon its exact location. Laryngeal tuberculosis may, moreover, be but a local expression of the disease, apparently primary, or as often happens, it may be an accompaniment of pulmonary tuberculosis, the laryngeal trouble appearing as a local infection, taking place by the constant passage over the surface of tuberculous sputum which the patient is expectorating at frequent intervals. Thus, clinically, we may have a miliary, an ulcerative, or a gummatous form of the disease.