For conditions such as these tracheotomy is better than intubation, and, as the swelling may extend into the trachea, the high operation is not advised. Although the operation should not be undertaken until other treatment has been tried, it is well to remember that collapse of the lung, broncho-pneumonia, and complications, are likely to arise when the obstruction is allowed to persist.
(iv) Syphilis. In the tertiary stages of either acquired or congenital syphilis (rare) the larynx may be affected, and in long-standing cases of over ten years, when the mucosa is much thickened, there is a danger of obstruction. Even when energetic antisyphilitic treatment has been advised the disease may become acute. Tracheotomy may be necessary for the relief of (a) œdema, likely to occur suddenly with necrosis, perichondritis, or the breaking down of gummata; (b) fibrous stenosis, which may cause a gradual increase of dyspnœa or become suddenly acute from spasm or œdema (iodides?); (c) adhesions, whether simple bands or webs; or (d) fixation of the vocal cords in the middle line, resulting from inflammation of the laryngeal joints or from paralysis of the abductor muscles.
(v) Tubercle. This rarely causes true laryngeal obstruction, excepting in those acute cases where subglottic œdema, abscess, or sequestrum is present. Tracheotomy was at one time used in certain cases in order to give complete rest to the larynx, but this has been abandoned as unsatisfactory; it should not be performed unless there is urgent laryngeal obstruction, since ‘it has many and grave disadvantages. It materially diminishes the efficiency of the cough, the secretion from the lungs is apt to accumulate in the bronchi and alveoli, and set up miliary tuberculosis. Again, the patient can often ill withstand even this slight operation; his power of speaking is diminished or lost and his mental anxiety is increased. Not rarely also, the tracheotomy wound becomes infected with tubercle. For these reasons tracheotomy should never be performed in phthisis except for severe dyspnœa’ (Lack[26]).
(vi) Certain nervous diseases, such as abductor paralysis. Urgent dyspnœa may occur in (a) advanced bilateral abductor paralysis, or (b) unilateral abductor paralysis associated with pressure upon the trachea by tumours. In the bilateral form it is difficult to determine when to operate; but the danger of suffocation, increased during the night, makes it necessary to overrule the objections of the patient. Tracheotomy (or intubation) may be performed merely as a temporary relief where the paralysis results from diphtheria, syphilis, toxic neuritis, &c.; in more serious cases the tube must be worn permanently, unless total recurrent paralysis supervenes (as it may do, though rarely in tabes) accompanied by cadaveric position of the cords and the restoration of free breathing. This latter condition can be induced by total division of both recurrent laryngeal nerves, but the operation, which has been performed on one or two occasions, has not been attended with satisfactory results. In cases of long duration the tube may be plugged during the day, or a valve may be added to the canula, so that the patient can speak by expiration through the larynx.
(vii) Tracheal compression by tumours of the neck or mediastinum, of the thyreoid or thymus, or by aneurism, or by tuberculous bronchial glands. In these conditions inspiration and expiration are equally affected, and if the obstruction is low down, a long canula (such as König’s, Kocher’s, or Salzer’s) will be required in order to relieve the dyspnœa. The pressure of such tubes may cause ulceration of the wall of the trachea, and hæmorrhage may occur. This danger is especially to be feared when an aortic aneurism presses upon the trachea (see [p. 542]).
Tracheotomy should, therefore, be reserved for extreme cases, where it is impossible to remove the cause of the obstruction: on the other hand, dyspnœa caused by tumours of the neck which are removable (e.g. thyreoid tumours) should be relieved by radical operation without tracheotomy.
(viii) Congenital laryngeal stridor, glottic spasm, laryngismus stridulus, epilepsy, congenital webs and diseases of the crico-arytenoid joint such as ankylosis (true or false) or luxation. In these cases tracheotomy is rarely necessary, but when the operation is advisably undertaken the dyspnœa may require a permanent tracheotomy tube or prolonged intubation unless a radical removal of the disease can be effected.
(ix) Cut-throat. Tracheotomy is advised as a preliminary to further plastic operations in all cases where any part of the air-passages has been opened, in order to avoid the danger of suffocation and to prevent hæmorrhage into the trachea.
(x) Fracture of either the hyoid, thyreoid, or cricoid cartilage, that of the thyreoid being the most common, and of the cricoid the most serious. These fractures are always associated with hæmorrhage and œdema of the mucous membrane, sometimes with emphysema; and the swelling thus caused within the larynx may be so great that tracheotomy or laryngotomy becomes urgently necessary for the relief of dyspnœa. Theoretically it is advisable to expose the fracture, so that it may be sutured or wired in its proper position, but, even in those instances where this is attempted, it is advisable to retain the tracheotomy tube for a few days until all swelling has subsided.