Chronic inflammation of the epiglottis is usually the result of uncured acute epiglottitis or of laryngitis. The main symptom is dysphagia. The epiglottis is found swollen and more or less discolored. Not only tongue-spatula and laryngeal mirror, but also the finger carefully introduced into the mouth, may ensure the diagnosis, especially if the upper portion be affected: then the thickened epiglottis is seen and felt as a peculiar rounded tumor at the base of the tongue. Oedema is distinguishable from chronic inflammation by both sight and touch. As to prognosis, it must be observed that the process of restoration is slow and that there is always danger of acute exacerbation. The treatment consists in attention to the general health and habits and in local applications. The latter are indispensable, and should be made by means of an instrument (Elsberg's applicator or the like) carrying a little wad of cotton or sponge. Some prefer a brush: to such individual preference no objection need be made, but powders and sprays are not advisable. The remedies to be applied should be in liquid form, and belong pharmacologically to the class of alteratives. Iodine, iodoform, and silver nitrate in solution are most useful. In subacute inflammation (see above) potassium bromide and chlorate, respectively, in saturated aqueous solution, may be applied once a day, or a saturated solution of iodoform in sulphuric ether, or ten grains of crystallized silver nitrate dissolved in an ounce of water, every other day. In chronic epiglottitis the tincture or compound solution of iodine, the ethereal solution of iodoform, and the watery solution of silver nitrate, in degrees of concentration varying according to the severity of the case and the individuality of the patient (the choice of either of the three agents, the repetition of the same, or the change from one to the other depending upon the effect produced), should be accurately applied to the part affected by means of the laryngeal mirror or the tongue-spatula.
2. The most frequent, and at the same time the most neglected, morbid condition of the larynx is erosion of the free edge of the epiglottis. Louis has called attention to the epiglottic erosions in connection with tubercular phthisis: he found them present in about one-sixth of the patients who died of that disease, and they are caused, in his opinion, by the constant passage of pus over the part. Horace Green was the first who pointed out that they are also frequently met with independently of tubercular disease. According to him, "These instances, for the most part, have been found occurring in those cases in which a persistent, teasing cough, following chronic follicular disease or common catarrhal inflammation, has obstinately resisted all the ordinary measures for its arrestment. On depressing the tongue in such cases by means of the ordinary bent spatula or tongue-depressor, so as to bring the epiglottis into view, this cartilage has been found frequently inflamed, vascular, and its superior border marked at one or more points by distinct erosions. In much the largest proportion of cases these erosions make their first appearance on the left superior edge of the epiglottis. Next in frequency they will be found occupying its centre, and occasionally, but very rarely in comparison with the two preceding locations, they have been observed upon its right border. These erosions are not readily detected, at first, by the inattentive observer, as they are quite small, are only slightly depressed, with a pallid base, sometimes a little reddened, and with whitish, linear edges. The surrounding mucous membrane is generally inflamed, its delicate network of superficial vessels is red and injected, and the epiglottis itself more or less thickened." Sometimes epiglottic erosions exist without much cough, and certainly a cough can exist without erosions; but the two seem frequently to act interchangeably as cause and effect; and certain it is that a cough, from whatever cause, once firmly established, when such erosions have supervened rarely if ever yields so long as the erosions continue, and often stops when they are cured. According to my experience, the left and right sides of the upper border are affected with about the same frequency, and oftener than the centre. The erosions are catarrhal in their nature, even in tubercular subjects; in non-specific cases they degenerate exceedingly rarely into ulcers—i.e. they may exist for years without involving any tissue below the epithelium unless the patient is or becomes syphilitic or phthisical. They often produce symptomatically, especially in the beginning, more hemming than cough. The diagnosis is easy on thorough inspection of the epiglottis. Prognosis is generally favorable, except in phthisical cases; in others, although they sometimes prove exceedingly obstinate, they usually yield with surprising promptness to topical treatment. In specific cases, and even in chronic naso-laryngeal catarrh, they are apt to recur, however. A cotton wad dipped in a strong solution (gr. xxx–drachm j ad ounce j water) of either silver nitrate or gold chloride must be brought accurately into contact with the eroded spots once in twenty-four or forty-eight hours; ordinarily only a fortnight's treatment is necessary, except for the frequently accompanying (or underlying) catarrhal condition of a more or less large extent of the upper respiratory mucous membrane. In very severe cases a few applications at longer intervals of a still stronger solution (drachm j–drachm ij), or even of the solid silver or gold preparation, may be required.
3. Epiglottic ulcerations differ from erosions in the fact that the latter are confined to the epithelium, while the former involve also deeper structures. It has been asserted by some observers that an erosion is always the first stage of an ulceration, and by others that the one never passes into the other. I believe that both of these extreme assertions are incorrect; but if it were possible to distinguish, clinically or pathologically, every case of superficial ulceration from erosion, I might incline to agree with the latter. Histologically, epiglottic ulceration affects the mucous membrane, glands, or cartilage. Most frequently it seems to originate in the follicles. As Horace Green has long ago pointed out, "At first an enlarged or pimple-like follicle appears on the border of the epiglottis, surrounded by an inflamed and highly-injected portion of mucous membrane. Soon the follicle softens, and degenerates into an ulcer with irregular edges and an inflamed and reddened circumference. In many instances these ulcers remain for some time superficial, destroying only the mucous membrane; in others they penetrate deep into the fibro-cartilage, and occasionally they result in the total destruction of the epiglottis." Sometimes the ulcer seems to originate in the superficial layer of the mucous membrane, the molecular death proceeding from the surface downward; these are the cases which in the beginning cannot be distinguished from erosions. Both these kinds of ulceration of the epiglottis occur without, and with, grave constitutional affections, but the cartilaginous tissue usually, though not invariably, remains intact except in phthisis, syphilis, and cancer. Lupus, lepra, and glanders also give rise to ulceration, and sometimes to much accompanying thickening of the epiglottis. The seat of the ulcers is, as a rule, on the upper border and laryngeal surface of the epiglottis, only exceptionally on the lingual. Together with ulcers on the laryngeal face those on the lingual face are found, but not vice versâ. Ulcers of the epiglottis are usually small, but numerous, worm-eaten in appearance, and frequently pass to other laryngeal structures. Though occasionally resulting from tuberculosis, syphilis, and other constitutional affections, they also occur as primary disease due to catarrh and local injury, but may become the antecedents, and in many instances the exciting cause, of other grave maladies. Indeed, I quite agree with Horace Green that they are often "not only among the earliest manifestations of thoracic diseases, but are themselves in many instances the true exciting cause of these affections; and furthermore, this postulate once established, that we have it in our power, by timely topical medication, to arrest, positively, cases of disease which otherwise would, and in many instances which do, terminate fatally."
The symptoms vary with the seat and extent of ulceration. Cough and the sense of irritation in the throat are usually present. "In several instances all the prominent rational signs, with some of the earlier physical manifestations, of pulmonary disease have been observed to follow long-continued ulceration of the epiglottis; all of which symptoms have been seen to disappear after these lesions have been healed." When the upper border is extensively affected, and still more when either surface, especially the lower portion of the laryngeal surface, be involved, there is difficulty of swallowing; the pain is due often as much to surrounding inflammation as to the epiglottic lesion. In some cases the voice also is affected.
The diagnosis of the existence of an ulcer is easily made when the epiglottis can be seen not only with the spatula, but also with the laryngeal mirror. Its origin and nature are, however, not always easily recognized, and the patient's general condition and history, as well as the appearance of the ulcer, must be taken into account. The diagnosis of catarrhal epiglottic ulceration must be made only after other underlying conditions, as phthisis, syphilis, malignant disease, lupus, lepra, and glanders (see the articles on those subjects), have been excluded. The prognosis is good, except in cases of phthisis, syphilis, etc., or in which already a great deal of the cartilage has been destroyed; and even in these cases appropriate treatment will often give the patient much comfort. Appropriate constitutional treatment must be instituted in all cases in which the constitution is affected.
Topical treatment consists in the application of alteratives, astringents, stimulants, or sedatives, as the case may call for. Some cases may require once or more times touching with solid silver nitrate; watery solution of this remedy, varying in strength from gr. x to drachm ij to the ounce; solution of gold chloride of similar strength; of iron pernitrate and perchloride drachm ss–drachm j to the ounce; of zinc chloride (gr. x–drachm ss to the ounce); a solution of iodine in olive oil (gr. x–xxv ad ounce j with a few grains of potassium iodide), or of iodoform in sulphuric ether (drachm i–drachm ij ad ounce j); carbolic acid in glycerin (gr. v ad ounce j) or Magendie's solution of morphine, or a mixture of morphine and syrup of tolu (gr. 1/8–½ to a few drops),—have most frequently been beneficial in my hands. In many cases in which the pain on swallowing has been so great as to make deglutition almost impossible, I have succeeded in temporarily anæsthetizing the parts before a meal by applying, after cleansing them, a watery solution of cocaine hydrochloride (gr. xx ad ounce j). If, in spite of all, the difficulty of swallowing threatens the patient with starvation, feeding with the oesophageal tube must be resorted to.
Laryngeal Oedema.
DEFINITION.—Infiltration of a fluid or semi-fluid into the submucous connective tissue of the larynx.
SYNONYMS.—Oedema of the glottis (often incorrectly so called, as will presently be seen), Oedematous laryngitis, Phlegmonous laryngitis, Submucous laryngitis, Dropsy of the larynx, Angina laryngis infiltrata, Angina laryngea oedematosa, Angine infiltro-laryngée, etc.
CLASSIFICATION.—Cases of laryngeal oedema are classified as to their occurrence into acute and chronic, corresponding generally to inflammatory and non-inflammatory; as to the nature of the infiltration, into serous, purulent, sanguineous, sero-purulent, sero-sanguineous, etc.; as to the extent of the infiltration, into diffuse and circumscribed (the latter often leading to abscess-formation, and then called laryngeal abscess rather than laryngeal oedema, differing, however, from perichondric abscess); and as to the seat, into epiglottic, supraglottic, infraglottic, and glottic. When epiglottic, it implicates, besides the upper border, often the glossal, hardly ever the laryngeal, surface; in supraglottic, the ary-epiglottic folds, arytenoid region, ventricular folds, or ventricles are involved; in glottic, the interfibrillar connective tissue of the thyro-arytenoid muscle is infiltrated, very exceptionally, if ever, the submucous tissue of the vocal bands themselves;1 and in infraglottic, the submucous connective tissue down to the first ring of the trachea. Glottic oedema occurs extremely seldom, but the designation oedema glottidis is often used, no matter what portion of the larynx is affected. Laryngeal oedema usually affects both sides; occasionally one side more than the other, still more rarely one side exclusively.