PATHOLOGY AND MORBID ANATOMY.—In catarrhal chronic laryngitis there is congestion of the mucous membrane, dilatation of the blood-vessels, and altered secretion. The mucous membrane becomes, as a rule, hypertrophied, tougher, and more firmly connected with the subjacent tissues. Laryngeal venous congestion (so-called phlebectasis laryngea) is occasionally, though rather rarely, met with; and still more rare is a hemorrhage from the surcharged vessels in chronic cases. In granular or glandular chronic laryngitis—i.e. when the muciparous glands are prominently involved in the inflammatory process—they form elevations, making the surface uneven, and the tissues become tenser and more compact. When the submucous connective tissue takes much part in the process the hypertrophy is still greater, and not only may the lumen of the laryngeal cavity become greatly diminished, but projections of various lengths (the so-called cellular polypi and papillary excrescences) are apt to occur. The objective term tuberosa is sometimes added to laryngitis or to the designation for inflammation of a portion of the larynx; as, for example, that of the vocal bands—viz. chorditis tuberosa, when small whitish, tumor-like elevations occur. These, especially on the vocal bands, where they have been described by Tuerck, Elsberg, Cohen, and others, are also called trachomata. In cases to which the name muscular chronic laryngitis is given the muscular tissue has been found prominently hypertrophied. Moura Bourillou has recorded a case in which the striated fibres of the posterior crico-arytenoid muscle were converted into fibrous tissue. In many of the common cases of catarrhal chronic laryngitis the alteration of the voice depends upon paralysis of the muscles—especially the thyroid arytenoid and the arytenoid—directly caused by the transmitted inflammation and by thickening of the overlying mucous membrane. In fetid chronic laryngitis there is usually found excoriation of the mucous membrane, and atrophy. That erosions—i.e. superficial ulcerations extending no deeper than the epithelial layer—frequently occur in the course of catarrh is admitted by everybody, but much unnecessary discussion has been indulged in concerning the question whether deeper ulcerations of the mucous membrane can ever take place under these circumstances. It has been insisted upon that catarrhal ulcerations never occur. This is a mistake, but it is true that catarrhal ulceration is rare unless the patient is greatly debilitated or cachectic. Ulcerative chronic laryngitis in the majority of cases depends upon some cachexia—i.e. tuberculosis, syphilis, lupus, lepra, etc.
Tuberculous chronic laryngitis—laryngeal phthisis proper—frequently accompanies pulmonary consumption. Usually it follows, but occasionally precedes, the latter. Unquestionably, it also occurs, though rarely, without any disease in the lungs. Anæmia of the laryngeal mucous membrane is present from the first, and usually persists throughout. There is a low form of inflammation, swelling of the tissue, and then ulceration, the ulcers being at first small, and afterward coalescing to form larger ones. Much destruction may take place, and more or less oedema is always present. Paralysis of some of the interior laryngeal muscles may also occur, depending alike upon anæmia and oedematous infiltration of the muscular substance, or upon compression of the nerve-tracts by enlarged lymphatic glands (most frequently on the right side) or upon involvement of the nerves—pleuritic adhesions, tuberculous deposits, etc.
Syphilitic chronic laryngitis is a local manifestation occasionally of hereditary, but usually of acquired, syphilis. It may vary from a slight erythematous condition of the mucous membrane to intense inflammatory thickening or destructive ulceration, may be accompanied by laryngeal oedema and pericarditis, and may lead to dangerous adhesions, cicatrizations, and stenosis. The chronic laryngitis occurring in lupus and lepra and in malignant diseases of the larynx partakes of the character of these processes, and is accompanied by their peculiar thickenings, tuberosities, granulations, and ulcerations.
DIAGNOSIS.—Chronic alteration of voice, local morbid sensation, and other symptoms mentioned may lead us to suspect the presence of chronic laryngitis, but are insufficient for diagnosis without mirror examination. The diagnosis can be positively made only by means of the laryngoscope, and even by this means requires care. It is of the utmost importance that the physician make himself perfectly familiar with the appearance of the healthy larynx by the particular illumination he uses for examining patients.
A very able laryngoscopist, Carl Michel of Cologne, confesses6 that he has many times diagnosed chronic laryngitis when none existed, and explains that with inadequate illumination the contours of the small vessels run into one another and make the whole surface which they traverse appear red. In simple chronic laryngitis the redness has a somewhat livid look; in syphilitic chronic laryngitis it is darker and more angry-looking; in phthisical cases it is duller, even though the mucous membrane be congested, while usually it is pale. In both the latter diseases the swelling is greater, the natural contour of the parts more changed, and destruction more imminent than in the simple chronic laryngitis. When oedema is present there is a peculiar transparent or translucent appearance. In subglottic chronic laryngitis, especially when much hypertrophy has already taken place, the color is often quite light grayish instead of red.
6 Practische Beiträge zur Behandlung der Krankheiten des Mundrachenhöhle und des Kehlkoffes (Leipzig, 1880).
Phlegm found in the larynx may have come from the bronchial tubes or the trachea; when it is cleared away by cough or otherwise, the larynx may prove to be unaffected. In all cases of suspected secondary chronic laryngitis, phthisical, syphilitic, etc., the state of the lungs and whole respiratory tract, as well as the general health in every respect, hereditary tendencies, and past diseases, must be carefully inquired into.
PROGNOSIS.—The prognosis of chronic laryngitis is good as to life except in broken-down constitutions, neglected exacerbations, and grave underlying affections; but, even with these exceptions, it can be said to be favorable as to cure only with expert local treatment and if no severer tissue-alterations, usually hypertrophic, have as yet taken place. If the latter have taken place—especially if the submucous tissues are prominently involved—the organ can seldom be restored to perfect integrity. For persons in ordinary vocations and situations in life the recovery that can generally be secured may be entirely satisfactory, but more exacting demands on the speaking and singing voice require special measures, including hygienic precautions, to be carried out carefully, and sometimes to be long continued.
BY J. SOLIS COHEN, M.D.