3 According to Sestier, the ary-epiglottic folds are affected in nearly every case, either alone or together with other parts.
4 In 90 cases Sestier found the infiltration serous 60 times, sero-gelatinous 6, sero-purulent 9, sero-purulent with plastic lymph 4, purulent 8 times, sero-sanguineous twice, and sanguineous once.
The mucous membrane covering the oedematous structures is tense and discolored; except in very inflammatory conditions it is yellowish, shimmering, and pallid. On cutting into the diseased parts often but little exudation takes place, and sometimes even squeezing between the fingers does not suffice to cause disgorgement.5 After the fluid is evacuated the parts collapse and the mucous membrane is left wrinkled and folded.
5 In 23 autopsies Sestier found that incisions into the oedematous structures made the liquid run out either without any or with slight pressure 10 times; with repeated pressure, with difficulty and only in small quantity, 6 times; and not at all, in spite of repeated incisions and pressure, 7 times.
DIAGNOSIS.—With the laryngoscope, the spatula, and the finger the seat, the degree, and often the nature of the infiltration can be determined. A successful laryngoscopical examination may sometimes require in such cases more than ordinary skill, and there is often so much tumefaction that the parts are not easily recognizable. The epiglottis may appear as a thick roundish tumor, or be of a more or less indistinct horse-shoe shape, overhanging the laryngeal aperture; the ary-epiglottic folds may be converted into large lateral cushions pressing against the arytenoid bodies, or be merged with the latter into huge, irregularly pear-shaped, oval, or globular masses; and the ventricular folds may be immensely tumefied, or else, by means of the swelling and the being pushed into a horizontal position of the whole lateral lining of the upper laryngeal cavity, may be obliterated altogether. Glottic oedema never occurs except with supraglottic, and the upper surface of the vocal bands may look elevated, arched, and bladder-like, even if only the thyro-arytenoid muscles are infiltrated. In infraglottic oedema there is usually neither epiglottic nor supraglottic oedema; pads are seen underneath the vocal bands, either ring-shaped or projecting from side to side toward the middle line, and fill up to a greater or less degree the rima glottidis. The oedematous parts have sometimes a pinkish, but usually a yellowish, translucent or semi-translucent aspect. Accumulation of pus lessens the translucency and sometimes makes the yellow more marked. Sanguineous infiltration shows a bluish-red or livid discoloration. In chronic oedema the color is lighter, sometimes a dirty gray.
I have already explained the proper method of using the spatula. It reveals in all cases, sometimes best during retching, the epiglottis, and in many cases the ary-epiglottic folds. With the finger these parts can be touched, and all the more easily when they are swollen; but great care must be exercised to avoid provoking by digital examination a suffocative paroxysm. When felt by the finger the peculiar elasticity or fluctuation present is unmistakable.
PROGNOSIS.—Laryngeal oedema is always a very dangerous condition—in a chronic case less so than in an acute one. The prognosis depends largely upon the causative or accompanying disease. The more local the oedema and the more promptly medical, and in most instances surgical, aid can be had, the more favorable is the prognosis, though uncertain even then. Sometimes a rapidly fatal attack supervenes in a mild, chronic, or apparently convalescing case. In abscess formation it is generally favorable unless the underlying disease makes it the reverse.
TREATMENT.—Antiphlogistic treatment of every sort has been recommended against this dread disease. Its frequently rapid course usually necessitates primarily topical measures. Even fifty years ago, when bleeding and tartar emetic were in vogue, Ryland entirely discountenanced these, and said: "Our chief reliance must be placed on the local detraction of blood by means of a large number of leeches applied in the vicinity of the larynx; on the use of blisters, which should never be put on the front of the neck, as their operation will interfere with the subsequent performance of tracheotomy should such a step be necessary, but on the back of the neck or the upper part of the chest; and on the internal administration of large doses of calomel, which, either by their purgative effect or by their specific action on the general system, tend to check the inflammation in the glottis and to promote the absorption of the effused fluids. These remedies can only be of use during the early stages of the disease, and experience shows but too plainly that even then we have far more reason to anticipate failure than success."
Many years ago it was proposed to catheterize the trachea for the purpose of allowing air to reach the lungs in this and other diseases in which the larynx is obstructed; and more recently Hack has shown the great benefit of using, under sight by means of the laryngoscopic mirror, Schrötter's dilating hard-rubber tubes in acute as well as chronic laryngeal oedema. According to him, they do good not only symptomatically, but also curatively.
Furthermore, we can employ, under the guidance of the mirror or of the finger, scarifications of the infiltrated structures by means of the laryngeal lancet, or in its absence of a long bent, sharp-pointed bistoury covered, except for a quarter of an inch or so from its point, with adhesive plaster. (For the epiglottis the ordinary gum lancet will often do.) An abscess is opened in the same way. When the bleeding following scarification is excessive we use ice internally or externally, or both; when bleeding is insufficient, steam inhalation, hot fomentations, etc. To promote absorption we make topical applications, either before or certainly after the scarification, of a saturated solution of iodoform in sulphuric ether (drachm ij ad ounce j), or of a strong watery solution of silver nitrate (scruple ij–drachm j ad ounce j). Astringents, especially tannin and alum, applied in the form of spray to parts that cannot otherwise be reached, are advisable; and antispasmodics and narcotics (potassium bromide and morphine) should not be omitted in cases complicated with muscular spasm, etc. The internal administration of fluid extract of jaborandi in drachm doses or the hypodermic injection of pilocarpine is highly lauded as promoting absorption; also diaphoretics, purgatives (salines and croton oil), etc. From the beginning the patient's general functions must be regulated and his strength supported by tonics and nutritives, and any underlying disease amenable to treatment must of course be attended to. The slow swallowing of pieces of ice is often of great benefit. In every case that does not visibly improve by the vigorous carrying out of the treatment hitherto detailed, especially the catheterization by means of Schrötter's tubular dilators, the ultima ratio—viz. tracheotomy, particularly inter-crico-thyroid laryngotomy—must be resorted to without waiting until the patient has lost much ground by the impediment to respiration. One of the lessons taught us by pathological investigation is that epiglottic, supraglottic, and glottic oedema does not extend beyond the upper surface of the vocal bands: therefore, while in infraglottic oedema, and when the two conditions supraglottic oedema and infraglottic coexist, tracheotomy should be performed, in the other cases the air-passage should be opened by introducing a tube through the inter-crico-thyroid membrane. This operation is, especially for the general medical practitioner, much easier, safer, and quicker of performance, and answers in those cases all purposes. This important lesson is not heeded by any of the recent authors on the subject. Indeed, Cohen expressly says: "The trachea is to be opened in preference to the larynx, as being at a greater distance from the seat of the disease and less liable to involvement, as well as for the reason that the disease occasioning the oedema may be extending low down in the larynx, and therefore exist at the very point usually selected for laryngotomy." Supraglottic oedema does not extend to the region of the inter-thyro-cricoid membrane, and the tube may therefore safely be there introduced.