| Fig. 259. Intrinsic Tumour of the Larynx. (From Specimen No. 1649 in the Museum of St. Bartholomew’s Hospital.) |
Fig. 260. Extrinsic Tumour of the Larynx. (From Specimen No. 1653 in
the Museum of St. Bartholomew’ |
It is advisable to follow Krishaber in the separation of all forms of laryngeal cancer into two classes, the Intrinsic and the Extrinsic. The term ‘intrinsic’ implies a growth springing from the vocal cords, the ventricular bands, the ventricles, or the subglottic space, and the growth must lie entirely within the laryngeal cavity. ‘Extrinsic’ is the term used for a growth affecting the arytenoids, the posterior part of the cricoid cartilage, the aryteno-epiglottidean fold, or the epiglottis. Such a growth is not entirely limited to the larynx, but also involves some part of the pharynx.
2. Extrinsic localized malignant tumours which are attached to the epiglottis, or to the aryteno-epiglottic fold.
3. Innocent tumours which are too extensive for endolaryngeal operation or of a doubtful character. In either of these cases it is justifiable to perform an external operation, which may be thyrotomy, or occasionally, an atypical operation: thus Semon[12] removed a large fibromatous tumour of the larynx by submucous resection, without opening the cavity of the larynx.
4. Stenosis following syphilis, trauma, acute exanthemata, scleroma, and other rare diseases. C. Jackson has reported twenty-four cases falling under this head, nineteen of which lived for more than a year after the operation with useful voices. If the surgeon is satisfied that the disease is quiescent, he should point out to the patient that it may be possible to cure the obstruction by thyrotomy. It must, however, be remembered that tertiary syphilitic lesions may again become active as the result of operative interference. It is probable that slight cases of stenosis can be treated better by intubation than by thyrotomy. Thyrotomy has also been suggested to relieve stenosis caused by double abductor paralysis of the vocal cords, but such cases are better treated by tracheotomy or intubation.
5. Foreign bodies. Thyrotomy is rarely necessary, and should be reserved for irregular or sharp-pointed bodies, such as tooth-plates or bones, which are so firmly jammed that removal by other methods is impracticable. If there has been much laceration of the soft parts, a tracheotomy tube should be retained for a few days until the swelling has subsided.
6. Tubercle. Thyrotomy has been successfully performed in such cases, mostly under the impression that the disease was malignant. The differential diagnosis between tuberculous and malignant growths is sometimes very difficult until the tumour has been explored. In cases that are known to be tuberculous, the feeling prevails that thyrotomy is not to be recommended. It should be remembered that the external wound is liable to become tuberculous.
Instruments. Scalpel, curved scissors, dissecting forceps, pressure forceps, aneurism needles, double hook retractors, bone shears (Waggett’s) or bone scissors, tenaculum forceps, needles on handles, catgut in various sizes, a Hahn’s tube, and tracheotomy equipment. A head-light is required for illumination of the deeper parts during removal of tumours.
Operation. In England, owing to the fact that the administration has been in skilled hands, chloroform is not considered dangerous, and the operation is well tolerated even for three or four hours (e.g. in laryngectomy). On the Continent, however, Kocher, von Bruns, and others advocate local anæsthesia with cocaine or novocaine. Jackson suggested rectal etherization as an alternative, but this has many dangers. In my opinion a general anæsthetic should be given, as it enables the operation to be performed more thoroughly and is followed by less shock. It must nevertheless be borne in mind that, if the growth is intrinsic and of large size, it is difficult to administer chloroform, and the patient is liable to suffer from urgent dyspnœa. In such a case i[t] is advisable to perform preliminary tracheotomy with novocaine alone (see [p. 544]).
As regards the operation, the important question arises whether tracheotomy ought to be performed several days prior to the main operation, in order to accustom the patient to the tube and the new method of breathing. The following reasons are advanced in favour of this: the main operation is shortened, and relief is given to the larynx and lungs, so that congestion subsides and broncho-pneumonia is less likely to supervene. The objections are also important, namely, that there are two operations instead of one, and perhaps two anæsthetics (though this can be avoided if local anæsthesia is used for the tracheotomy); that the tracheotomy wound becomes septic, and infection of the trachea and bronchi is apt to occur, with consequent bronchitis; that the air which passes into the lungs is devoid of moisture and heat; that the trachea becomes surrounded by adhesions; and that it is altogether unnecessary. The objections in my opinion outweigh the advantages claimed; it is better to perform tracheotomy as a first stage in the operation of removal, except in cases where there is great laryngeal obstruction, where dyspnœa is present, or where bronchitis fails to yield to other forms of treatment. In such cases tracheotomy should be performed first, and the second operation should be carried out a week or ten days later when all the conditions are favourable.