A System of Operative Surgery, Volume 4 (of 4)

by Unknown

(a) When the epiglottis is involved, an extensive dissection of the thyreo-hyoid membrane can be made in order to expose and remove the growth thoroughly together with any soft parts or cartilage which appear to be involved. Branches of the superior thyreoid arteries, or the hyoid branch of the lingual artery, will be ligatured. The superior laryngeal nerves should always be preserved whenever possible, as loss of sensation increases the liability of food passing into the larynx.

(b) When the aryteno-epiglottidean fold is involved, a transverse incision can be made through the thyreo-hyoid membrane, immediately above the thyreoid cartilage on the same side, and the wound enlarged until the tumour is exposed. In this manner I was able to remove the large carcinoma shown in [Fig. 254], including the soft parts of the right half of the larynx, the right half of the epiglottis, the right arytenoid, and the wall of the pharynx in relation to the right pyriform fossa: the lymphatic glands were not removed. One year later the patient continued to enjoy good health with no signs of any recurrence. In this connexion it is important to emphasize that when the disease is very extensive, and particularly when the posterior portion of the cricoid and arytenoids is involved, such an operation is useless, and the surgeon must decide whether partial or complete laryngectomy should be performed. In rare instances the operation should be abandoned in favour of tracheotomy (palliative).

(c) When the tumour extends downwards into the subglottic region, it is necessary to split the cricoid anteriorly and divide the upper rings of the trachea, after which the tumour can be removed with as much of the structures as may be desirable.

(d) When the growth extends across the middle line in the anterior commissure, or when a second growth is situated directly opposite on the other side of the larynx, the whole disease must be removed regardless of damage to the tissues which are not affected.

(e) When the operation is performed for stenosis, it is necessary to remove freely all the fibrous tissue without attempting to preserve any part that is diseased. The hæmorrhage is generally severe and necessitates preliminary plugging of the trachea with a Hahn’s canula.

After-treatment. This must be conducted so as to prevent the chance of broncho-pneumonia and sustain the strength of the patient. With Butlin’s method the patient is placed on his side, or face downwards, with the head low and with only a small pillow, so that all secretions pass out of the air-passages through the external wound. This undoubtedly gives better drainage to the wound, and is less exhausting than the upright position during the early stages of convalescence. The dressings on the wound must be changed, especially in the early days, as often as they become soaked; it is also an advantage to insufflate an orthoform powder, or an antiseptic parolein preparation, with the object of cleansing the larynx. The tracheotomy tube should be retained, usually from ten to twenty days, until the patient can swallow well and as long as there is a flow of pus from the wound.

‘During the day of the operation nothing is swallowed, although fragments of ice may be kept in the mouth for the comfort of the patient. If there is fear of collapse and the patient is feeble and very old, brandy and beef-tea may be administered by the rectum. On the following morning the first attempt is made to swallow. The patient leans far forwards with the head down, and the dressing is taken off the wound, beneath which a basin is placed. Cold water is drunk out of a glass. If the experiment is successful, all the water passes down into the stomach; if it is only partially successful, some escapes into the larynx; but the posture of the patient ensures that the liquid runs out through the wound and does not pass into the air-passages. As soon as water can be readily swallowed, milk, beef-tea, and other liquids may be drunk, for the fear of “Schluck-pneumonie” is practically at an end. The wound is generally closed within ten or twelve days of the operation, and the patient is rarely confined to the house for more than ten days’ (Butlin). It is probable that the healing by this, which is called the ‘open’ method, is as rapid as with Moure’s, in which the whole length of the incision is closed; the open method would also appear to be safer and less often attended by complications.

Complications. (1) Broncho-pneumonia is most to be dreaded. Death from shock or collapse, from hæmorrhage, from septic conditions of the wound, or from iodoform poisoning, is now rarely met with and can more easily be prevented. Even pneumonia is uncommon, owing to more scientific methods of treatment. It is still to be feared in very old patients; in those who already suffer from bronchial catarrh at the time of the operation; in alcoholics; and in cases with old-standing renal, pulmonary, or heart affections. The improvement in this direction is due to greater antiseptic precautions, and to the prevention of aspiration of blood and septic secretion during and after the operation by free drainage of the wound.

(2) Stenosis. It sometimes happens that a considerable mass of granulation tissue appears in the anterior commissure, or upon the surface of the cartilage that has been bared by the operation; if this be left untreated it may gradually enlarge in size until a prominent cushion is produced, which reaches to the opposite side and thus causes stenosis with definite laryngeal obstruction. Such a swelling may be mistaken for recurrence, but is nearly always of inflammatory character. It is by no means certain what is the causation of this condition, which appears to occur more with some surgeons than with others; it has been suggested that the presence of sutures in the region of the anterior commissure may cause an irritation, especially if silk is used. It appears to me, having in mind similar conditions in other surgical wounds, that the cause is to be found in some form of sepsis, and that it can be prevented to a great extent by precautions at the operation and by proper after-treatment. If there be any obstruction to breathing, the larynx is inspected and the projecting granulations are removed by intralaryngeal forceps. The remainder of the mass generally shrinks and disappears. If the stenosis be troublesome (chiefly in syphilitic cases), the prolonged use of a laryngo-tracheal canula ([p. 540]), or of an intubation tube, or dilatation with bougies, may be necessary. In rare instances a permanent tracheotomy tube is required, with a valve to encourage expiration through the mouth.