The intralaryngeal method, seen from the general surgeon’s view-point, can only be suitably applied to a limited class of cases which are recognized early, and may be best performed by an expert laryngologist, i. e., one accustomed to instrumentation within the pharynx and larynx. It includes the use of various instruments for the excision of small areas, for the application of the galvanocautery, etc. The writer agrees with Semon in regarding it as irreconcilable with the principles which should guide us in dealing with malignant growths, the fundamental one being the removal not only of the growth itself but of an area of surrounding tissue. This intralaryngeal method may then be satisfactory in the removal of benign growths, but will seldom appeal to the operating surgeon when he deals with cancer. Epithelioma may commence at the accessible tip of the epiglottis, but intrinsic cancer of the larynx should be dealt with in a more radical manner. Thyrotomy is the operation of choice, especially among the British laryngologists. It seems rational to believe that in cases where diagnosis is made early a thyrotomy, with removal of the growth and a wide area of surrounding tissue, including portions of cartilage, if necessary, may prove the ideal operation, while vocal results are better than after extirpation. It is necessary, however, that diagnosis should be made early and that operation be made thoroughly; while if, after opening the thyroid, it should appear that complete extirpation of the growth is otherwise impossible, then the operator should make a complete laryngectomy.
All of these operations are best preceded by use of a cocaine spray, by which extreme irritability of the interior of the larynx is allayed, and the reflex lowering of blood pressure prevented. (See [p. 178].)
Thyrotomy is performed as follows: The patient is preferably in the position with down-hanging head. An incision in the median line, about three inches in length, is made from the upper border of the thyroid cartilage down to a point below the cricoid. With but slight separation of the tissues it is made to extend directly down upon the abrupt ridge-like anterior border of the thyroid cartilage, below which will be exposed the cricothyroid membrane. Into this the knife may be inserted and made, with cutting edge up, to split the halves of the larynx exactly in the middle line, the blade passing between the vocal cords, unless they have been much distorted by the growth. In that case the dissection may be made more deliberately. The larynx being thus split, the cricoid should be divided, after which, with suitable retractors, the interior is exposed to such an extent as to permit both inspection and palpation. Through the opening thus afforded all suspicious tissue should be removed, from one side or both, the primary question being not what will be the resultant effect upon the voice, but how best to completely eradicate the cancerous tissue. With the patient’s head hanging downward there is less likelihood of the entrance of blood into the trachea. Nevertheless the tampon cannula should always be accessible so that it may be inserted should it be required. The tampon cannula is a trachea tube around which there is a small rubber bag, with a tube through which it may be inflated, so that after the cannula is introduced into the trachea it may be tamponed by air pressure in such a manner as to permit no passage of blood.
In the absence of one of these specially designed tubes an effective substitute may be made by the ordinary trachea tube wrapped with a covering of antiseptic gauze, the latter held in place by a few turns of fine silk or catgut.
The thyrohyoid membrane bears the superior laryngeal vessels and nerves, and it should be entered through the middle line in order not to disturb these. Whatever operation may be required upon the tissues within the laryngeal box may be conducted with knife, scissors, curette, and the fine point of the actual cautery. The interior of the larynx should be cleaned, leaving it simply as a part of the respiratory tube, without reference to what may become of the structures within it devoted to voice production. The cartilaginous shell, with or without a part of its previous contents, having been rid of the suspicious tissue within, it may be held together by one or two sutures of silver wire or by superficial sutures of chromic gut, while the trachea tube which may have been used may be left for a day or two, or removed at the time. Ordinarily the latter course will prove the better.
Laryngectomy, or total extirpation of the larynx, is the most severe procedure of all, but will be requisite when there is evidence of escape of malignant growth from within the true confines of the laryngeal box. Not only the larynx but more or less of the surrounding tissue may be removed, with infected neighboring lymphatics, the upper portion of the trachea, and the base of the tongue.
The operation may be preceded by a low tracheotomy or otherwise. If necessary this should be done several days in advance, in order that the patient may have become tolerant of the tube and of the new method of breathing. If requisite the ordinary trachea tube may be substituted for the tampon tube above described, in which case it will not be necessary to lower the patient’s head. Otherwise the operation is perhaps best performed with the head and neck in the Rose position.
The incision is a long median division of tissues from above the hyoid to an inch or more below the cricoid cartilage. Through it the anterior border of the thyroid should be easily exposed. It is then necessary to separate on either side the sternohyoid and sternothyroid muscles, the lateral mass of the thyroid body being drawn to either side along with the musculature, the isthmus having been previously doubly ligated and divided for this purpose. Now as rapidly as may be the larynx is completely isolated from all the structures around it, the dissection being bluntly made. After freeing it on both sides it is drawn forward, first to one side, then to the other, so that on either side the superior laryngeal artery may be exposed and secured, the superior laryngeal nerve being necessarily divided. The cricothyroid branches need also to be secured, as well as any other vessels which may spurt blood. Circumferential isolation of the larynx is now completed by dividing the inferior constrictor of the pharynx and separating it from the side of the thyroid, keeping close to the cartilage. After this isolation is completed the surgeon has the choice of first dividing the respiratory tube either above or below the larynx. This will depend largely upon his own choice, but usually the procedure is easier when the first division is made either through the cricothyroid membrane or between the cricoid and the upper ring of the trachea or even below this point, if necessary. With a low division first the patient will immediately begin to breathe through the opening thus made unless a previous tracheotomy has been done. Ample time will be afforded for the introduction of a trachea tube and protection around it to prevent entrance of blood, when the larynx may be lifted and separated with knife or scissors from the tissues remaining attached. The esophagus begins at the level of the cricoid cartilage, and if the cricoid is to be removed the esophagus should be separated from it; otherwise it is not disturbed. Last of all, in this order, the thyrohyoid membrane will require division, and then the extirpation is completed.
The wound is large, the communication with the oropharynx is unobstructed, and there will be constant escape into the newly formed cavity of secretions from the nose and mouth. At first the patient will be unable to swallow, although there may be constant desire to reflex attempts in this direction. The questions to be decided are the management of the wound in gross and the suitable treatment of the upper end of the trachea, as well as of the esophagus, if this has been touched. The greatest danger is that of inspiration pneumonia. Other consideration should be secondary to that of prevention of the escape of fluids down the trachea and the consequent production of pneumonia. General experience is rather to the effect that the best results are obtained with a minimum of sutures, the large cavity being lightly packed with absorbent material, while the upper end of the trachea should be sewed to the skin as high as possible on either side, the esophagus being allowed to take care of itself. The patient should wear a trachea tube for several days after the operation. Through the exposed upper end of the esophagus a tube may be passed three or four times a day, and sufficient nourishment be thus introduced into the stomach. The patient may be kept lying upon the side for the greater part of the time, so that saliva may escape from the mouth.
The question comes up later as to what substitute, if any, may be afforded for the lost larynx. Gussenbauer devised an improvement on what was called the “artificial larynx,” devised originally by Foulis and then modified by Hahn, which afforded an ingenious mechanical substitute for the larynx, permitting the production of voice by vibration of a metallic reed, such tone as it produced being, like that produced by the vocal cords, modified by the vocal organs above into perfectly intelligible speech, but always in a monotone. It consisted of a tracheal tube through whose external opening another tube could be passed upward to a point where it lay beneath the epiglottis, if this were left in situ, or behind the base of the tongue, if the epiglottis had been removed. Through this the patient could breathe under ordinary circumstances. By a little device at the external opening the touch of the finger upon a spring would throw into the air current a thin, metallic reed, by whose vibrations tone was produced, to be modified as mentioned above. This was the principle of the artificial larynx which was worn by many patients and which in many gave good results. One patient of my own wore one for seven years, although he discontinued using the reed because the peculiarity of the tone attracted more attention than did the loud “stage whisper” which he had cultivated. Around the instrument there is always more or less moisture or discharge, and there are many disagreeable features attending its use, even though it permit the act of swallowing without any difficulty.