4. Granulations. The possible presence of granulations must always be borne in mind. I believe this condition is far less common than is generally supposed, and that in many cases the granulations are entirely limited to the neighbourhood of the wound, where they can be seen. It is doubtful whether they are responsible for the dyspnœa which occurs. Great ingenuity and patience are required for the treatment of this condition. The wound must be kept scrupulously clean and all source of irritation removed. A rubber canula should be substituted in place of a metal one; if it were possible it would be advisable to discard the tube altogether, but as yet no form of dilator has been devised which will take the place of the canula. If the granulations be large they should be removed either with a sharp spoon or with suitable forceps, the area having been anæsthetized previously by a small quantity of the novocaine and adrenalin mixture. When small, the use of silver nitrate is preferable. It may be necessary to repeat this after a few days, and as soon as seems advisable a further attempt should be made to dispense with the tube. At this stage time must be allowed for the various tissues to regain their normal condition. Should this treatment prove unsuccessful, a thorough investigation must be made under chloroform. The wound is enlarged as far upwards as the cricoid, bleeding being arrested with the mixture just described. By throwing a strong light into the wound, the condition of the mucous membrane can be inspected and granulations removed. If there be no granulations in the trachea, a tube speculum can be passed through the mouth to ascertain the condition of the larynx (see [p. 480]). Such a method of procedure is preferable to the passage of probes, forceps, sponges, and other articles through the larynx, in the hope that any obstruction may be removed. If ulceration or necrosis of cartilage be discovered, it is impossible to relieve the condition by surgical means without prolonged treatment with tubes and the constant use of antiseptics. Under these conditions it is advisable to consider the removal of the tracheotomy tube in favour of intubation. In the hands of many foreign authorities the use of intubation tubes covered with gelatine, in which antiseptic is introduced, has been attended with such conspicuous success that further attempts should be made in this country; there is little doubt that, as our knowledge of the treatment of such wounds improves, better results are daily attained. Whatever treatment is considered it is important first of all that the actual cause should be distinguished. This is now possible owing to the great advances made in methods of examining the larynx.
Fig. 271. Stenosis following Tracheotomy. (From Specimen No. 1659d in the Museum of St. Bartholomew’s Hospital.)
5. Stenosis of the larynx or trachea occurs in old-standing cases, as the result of ulceration, after some cases of crico-tracheotomy, and especially where a tube has been worn for a very protracted period. Breathing through a tube, if continued for a long time, interferes with the natural growth of the air-passage above it. The child grows, but the larynx remains stationary. This condition is aggravated by the fact that some inflammation is constantly present, especially in the neighbourhood of the wound, so that the tissue become fibrous and hard. The fibrous tissue contracts and stenosis is caused. According to von Bruns, Kohl,[28] and others, constrictions of the trachea may in rare instances result from some kinking of its wall. Such conditions as a bulging of the posterior wall due to the approximation of the posterior ends of the cartilage secondary to the spreading of the anterior portions, inversion of the tracheal margins from too small an incision, overlapping of the tracheal wound, and cicatricial union between the thyreoid and cricoid, must be exceedingly rare. Here, again, a definite diagnosis can always be made by proper investigation, but treatment is more difficult. Dilatation must be attempted by either continuous or intermittent methods. If preferred, a short piece of rubber tubing can be passed upwards from the tracheotomy wound into the larynx and kept in place for several hours by two silk sutures, one passing out of the tracheal wound, the other out of the mouth; or a stenosis canula can be inserted with some form of hollow plug which passes upwards into the larynx (Fig. 272). The question whether the tracheotomy wound should be kept patent is difficult to answer. When stenosis is extreme there is no alternative, and the open wound allows of the constant passage of graduated bougies, which is more easily accomplished from below than from above. If treatment be persistent the prospect of a good result is not unfavourable, and there is every reason to believe that in the future the number of cases which require a permanent tracheotomy tube will be reduced to a minimum.
Fig. 272. Tubes used in the Treatment of Stenosis of the Larynx. A, Lack’s; B, Störk’s; C, Schimmelbusch’s.
6. Paralysis. In the larynx there may be paralysis of the sensory or of the motor nerves. In the former case food may enter into the trachea and cause troublesome coughing and possibly ‘Schluck-pneumonie’. When the motor nerves are affected, the paralysis is commonly abductor and may be unilateral or bilateral, the latter associated with inspiratory dyspnœa. ‘Complete paralysis of the recurrent laryngeal nerve may also occur, but is nearly always confined to one side’ (C. A. Parker[29]). Such paralyses may last from a few days to several months, and are very troublesome when associated with the passage of food into the trachea; when severe, nourishment should consist of fluids which can be administered by a nasal tube.
Further complications arising during the after-treatment of tracheotomy:
7. Broncho-pneumonia. This occurs in the worst forms, and is accompanied by high temperature with definite signs in the lungs. The absence of septic discharge, the restlessness of the patient, and the rapidity of the breathing (in many instances accompanied by ‘recession’ not caused by obstruction in the tube) make the condition easy to recognize. There is no satisfactory treatment for septic broncho-pneumonia which has already developed, but it may be prevented. Within recent years it has become less common. This is due to better technique in the operation, and to careful attention during the after-treatment. The habit of passing feathers into the trachea has been abandoned with advantage to the patient. When possible the child should be removed from septic influences which are liable to infect the throat, for the occurrence of tonsil[l]itis as a sequel to tracheotomy is always to be feared in wards containing septic cases.