Fig. 264. Infrathyreoid Laryngotomy. Position of the incision.
A tube introduced through the crico-thyreoid membrane lies in the subglottic space well below the vocal cords, and the latter should not be injured when the operation is performed with care. If inflammation supervenes, there may be a swelling of the subglottic region, making the tube difficult to manipulate; and for this reason the operation is particularly suited to cases which require a tube for a short period only, such as—
Indications. (i) Sudden laryngeal obstruction due to impaction of food or other foreign body. This is more common in adults: in children dyspnœa is rarely so urgent as to necessitate an operation.
(ii) Sudden œdema of the larynx caused by trauma, fracture, or acute inflammation, when the equipment for tracheotomy is not obtainable; or,
(iii) As a preliminary to major operations upon the upper air-passages, in order to prevent blood from passing down into the trachea.
This last method of treatment marks a distinct advance in the surgery of the throat. Attention was first directed to it by Bond[24], who has used the method for the past sixteen years with intent to make such operations less dangerous to life, and to increase, therefore, the number of cases that could be operated upon. His objects were to prevent respiration through the pharynx, thus obviating the coughing and struggling due to imperfect anæsthesia and making the anæsthetic easier and safer to administer; to shorten the operation and make it easier for the surgeon; and to get rid of preliminary tracheotomy whenever possible.
The value of this practice is well recognized by many surgeons. Butlin writes: ‘I do not know how many times I have employed this preliminary laryngotomy, but certainly more than a hundred times, so that I am now in a position to urge the importance of it on the profession.’ It has now been adopted at many of the hospitals in England before removal of tumours in the naso-pharynx, the upper and lower jaw, the tongue, palate, floor of mouth, and tonsil, in those cases where bleeding is likely to be severe.
In order to ascertain the feeling of my colleagues on this subject I have collected, with the assistance of Mr. Boyle, all the major operations performed upon the upper air-passages during the last six years at St. Bartholomew’s Hospital. These are tabulated below.
Table showing Operations upon the Upper Air-passages during the Years 1902–7 inclusive at St. Bartholomew’s Hospital
| Type of operation | With Laryngotomy. | Without Laryngotomy. | ||
|---|---|---|---|---|
| Cases. | Deaths. | Cases. | Deaths. | |
| Excision of Tongue | 20 | 03 | 13 | 2 |
| " " half Tongue | 25 | 02 | 46 | 1 |
| " " Floor of Mouth | 13 | 13 | 01 | |
| " " Tongue and Floor of Mouth | 05 | 01 | 01 | 1 |
| " " Palate | 08 | 01 | ||
| " " Upper Jaw | 12 | 13 | ||
| " " Lower Jaw | 01 | 09 | ||
| " " Tumour of Gums | 01 | |||
| " " Tonsil | 02 | 01 | ||
| " " Naso-pharyngeal Tumour | 03 | |||
| Total | 90 | 06 | 97 | 5 |