5. The silver tube can be changed for one of rubber, and this can be shortened daily until nothing remains but the shield.
If these various methods have been tried with no success it is probable that the case is abnormal, but before this can be conceded it is necessary to repeat that, in the large majority of cases, the difficulty of removing the tube is due not so much to definite stenosis of the larynx as to the bad habit acquired by the patient.
Complications arising after tracheotomy and preventing removal of the tube:—
Fig. 270. Trachea showing Ulceration caused by a Badly Fitting Tube. A, Tracheotomy opening; B, Ulcer caused by the end of the tube. (From Specimen No. 1659a in the Museum of St. Bartholomew’s Hospital.)
1. Wound infection. This rarely occurs at the present time, and diphtheritic wounds are seldom seen. Some inflammation of the wound is natural under the conditions, and may be associated with œdema of the surrounding tissues; this generally yields to antiseptic treatment in a few days. In very weakly children suffering from a virulent form of disease the healing of the wound may be slow, and septic conditions are apt to arise ending in cellulitis of the neck or even typical erysipelas. Owing to the disposition of the fasciæ there is a tendency for the infection to spread in a downward direction, and for mediastinal inflammation or suppuration to occur: this appears to be more common after low tracheotomy. The prognosis in such cases is not good, and every endeavour should be made to prevent the possibility of their occurrence by absolute cleanliness at the operation and by suitable after-treatment of the wounds.
2. Septic conditions of the trachea are less common since the introduction of antitoxin, but occur in cases where false membrane is abundant. There may be swelling of the mucosa, or copious discharge which persists for long periods.
3. Ulceration may be due to sepsis or to pressure from a badly fitting tube, especially when the latter has been worn for a protracted period (Fig. 270). It may cause perforation and localized abscess either in front of the trachea or in the neighbourhood of the œsophagus, and may result in a communication with the latter. In the region of the cricoid, ulcers are liable to cause necrosis. The signs of such ulceration are: continuance of purulent discharge, discoloration of the tube, bleeding from the wound, and, above all, difficulty in removing the tube.
At the first indication of ulceration the cause of irritation should be removed. It is advisable to discard a metal in favour of a rubber tube, or, if possible, to remove the tube altogether. Strenuous efforts must then be made to disinfect the trachea by the insufflation of antiseptics, either as powders or in solution. The healing of such ulcers is very slow, and granulations are apt to form resulting in obstruction and preventing removal of the tube. In later stages contraction of fibrous tissue causes stenosis; this is more common in the neighbourhood of the cricoid, especially when the latter has been divided at the time of the operation.