Dysphagia is due to a growth at the top of the larynx or on some portion of its pharyngeal surface. It is quite frequent in carcinoma, preceding dysphonia in the extrinsic varieties. It may be associated with regurgitation of food, drink, or saliva into the larynx, provocative of paroxysms of suffocation. Cough is due to growths which project from the vocal bands or press upon them, or to hemorrhage or accumulation of secretory or suppurative products. Hemorrhage, cough, and expectoration of bloody and fetid masses are indicative of carcinoma. Pain is usually due to intercurrent conditions. Aches in the part and sensations of the presence of a foreign substance are more frequent. Intense pain is exceptional in benign neoplasmata; it is often an early symptom in carcinoma, in which it is apt to radiate toward the ears and along the neck. Epileptic seizures and vertigo are sometimes occasioned by reflex influence. Exceptionally, large growths may produce change in the external configuration of the larynx. The general health is not much involved in benign growths, unless they interfere seriously with important physiological functions. Impaired health is far less manifest in sarcoma than in carcinoma. Emaciation, pyresis, and marasmus eventually occur as constitutional manifestations of malign growths.
DIAGNOSIS.—Laryngoscopic inspection usually reveals the growth and furnishes the best means of diagnosis. Intra-ventricular and subglottic growths may elude detection. Palpation is sometimes available, especially with children. Palpation with probes under laryngoscopic inspection is sometimes requisite to determine the mobility of a growth, its form and seat of attachment, and even its size. It seems, too, to discriminate a neoplasm from an eversion of a ventricle. While the histological character of a growth cannot be definitively decided by laryngoscopic inspection, the varieties present a series of characteristics sufficiently pronounced for approximative discrimination. Papillomata are often multiple, usually sessile, and usually racemose or dendritic. Some are white, but the majority are red, and the tinge varies from one extreme of the tint to the other. Some are as small as the smallest seeds; most of them have a bulk varying from that of a pea to that of a berry; some of them are so extensive as to appear to fill the larynx or even project above its borders. They are far the most frequent in the anterior portion of the larynx, and are often located upon a vocal band. Fibromata are most frequently single, smooth and pedunculated, and red. Some are white or gray. Some are vascular. When fully developed they vary in size from small peas to large nuts. They are more frequent upon a vocal band. Their development is slower than that of papillomata. Myxomata are usually single, smooth, pyriform, and pedunculated. They are usually red or reddish. Their ultimate size varies from that of grains of rice to that of Lima beans. They are most frequent at the commissure of the vocal bands. Angeiomata are usually single, reddish or bluish, vary in size from that of small peas to that of berries, and are most frequent on the vocal bands. Cystomata are usually globular, sessile, translucent, and white or red. They are most frequent in a ventricle or on the epiglottis. Their size varies from that of hempseed to that of peas. Ecchondromata are usually developed in the posterior portion of the larynx. Other benign growths are very rare, and do not seem to present special features for recognition by laryngoscopic inspection. Sarcomata are usually present as sessile, hard, well-circumscribed growths, smooth or lobulated. Some are dendritic on the surface, but not to the extent noticed in papillomata, and their location at the posterior portion of the larynx would suggest their true character, for papillomata rarely occupy this position except in tuberculosis. Superficial ulceration occurs in some cases, but is not extensive. There is no peculiarity in the color of the mucous membrane, which may be paler or redder than is normal. The lymphatic glands are not involved.10 Carcinomata present first as diffuse tumefactions in circumscribed localities, gradually undergoing transformation into well-formed growths, then nodulation, and then ulceration. Meanwhile, especially in extrinsic varieties, the submaxillary and the cervical lymphatic glands become successively involved and tumefied. Squamous-celled carcinoma becomes pale, wrinkled, and nodulated, and sometimes dendritic. Large spheroidal-celled carcinoma becomes nodulated, dark, and irregularly vascular, and finally ulcerated, perhaps at a number of points. In the ulcerative stage of carcinoma of the epiglottis and of the interior of the larynx discrimination is requisite from syphilis and from tuberculosis. In all cases of doubt as to malignancy, laryngoscopic inspection should be supplemented by microscopic examination of fragments detached for the purpose. The early detection of sarcoma may lead to surgical measures competent to save life—a remark applicable, perhaps, in a far more limited degree to intrinsic carcinoma.
10 Butlin, op. cit., p. 14.
PROGNOSIS.—The prognosis is usually good in benign growths submitted to proper surgical treatment. Left to themselves or treated medicinally, the prognosis is bad both as to function and to life. Such growths are occasionally expectorated after detachment during cough or emesis. Some occasionally undergo spontaneous absorption. Some remain without change for years. Most of them enlarge and compromise life as well as function. Recurrence occasionally follows thorough removal, and this recurrence is occasionally malign in character. Repullulation frequently follows incomplete removal. The prognosis is favorable in sarcomata, provided thorough eradication can be accomplished by surgical procedure. Incomplete removal is followed by repullulation or recurrence. Unsubmitted to operation, sarcoma will destroy life either mechanically by apnoea or physiologically by asthenia.
The prognosis is unfavorable in carcinoma. Recurrence takes place as the rule despite the best devised resources of surgery. Intrinsic carcinoma offers some hope of success to the surgeon; extrinsic carcinoma, little if any. Life is shortest in the large spheroidal-celled, and longest in the small spheroidal-celled variety, other conditions being equal. Death may take place by apnoea or asthenia, as in sarcoma, or by hemorrhage, collapse, or pyæmia. Submitted to tracheotomy at the proper moment in cases in which death is threatened by occlusive dyspnoea, life is prolonged and suffering mitigated. The fresh lease of life is longest in the squamous-celled variety.
TREATMENT.—The essential treatment is surgical, and to surgical works the reader must be referred for details. Suffice it to say that when a benign growth is small and does not embarrass respiration, it need not be attacked at all, unless its interference with the voice deprives the patient of his means of livelihood. The majority of benign growths are accessible to instruments passed through the mouth. Some require external incision into the larynx, whether partial or complete. The intra-laryngeal procedures in vogue include cauterization, both chemical and by incandescence, incision, abscission, crushing, brushing, scraping, and evulsion. According to the character and location of the growth, direct access from the exterior is practised by infra-hyoid pharyngotomy, by partial or complete thyroid laryngotomy, mesochondric laryngotomy, cricoid laryngotomy, complete laryngotomy, laryngo-tracheotomy, or tracheotomy, as may be indicated.
The thorough eradication of sarcomata usually requires a direct access by section of the thyroid cartilage or even of the entire larynx. This procedure failing or appearing insufficient, partial or even complete laryngectomy may be necessary. Temporizing is of no avail.
The treatment of carcinoma is palliative, unless it be decided advisable to attempt eradication, which may offer some chance of success in intrinsic carcinoma still confined to the larynx. Laryngectomy may be unilateral in some instances, and must be bilateral in others. Unilateral laryngectomy is the more hopeful. Eradication proffers no hope in cases of extrinsic carcinoma in which the growth has passed the boundaries of the larynx. After recovery from the laryngectomy an artificial appliance may be adjusted to the parts for the purpose of supplying a mechanical method of producing sound in the larynx for speaking purposes. Should no radical procedures be instituted, treatment is relegated to general principles, with prophylactic performance of tracheotomy in the presence of dangerous occlusion of the larynx. The voice should be used but little. All sources of laryngitis should be avoided. Ergot or hamamelis may be given to restrain hemorrhage, and morphine to relieve pain and secure sleep. Sprays can be used to keep the parts free from morbid products. Erythroxyline may be applied to produce local anæsthesia as required. Semi-detached portions of growth may be removed from time to time. Nourishment may be given by the bowel when necessary, and so on as in other diseases of the larynx in which the functions of respiration and deglutition are seriously impaired. Medicinally, arsenic may be given in the early stages, as that drug is conceded to possess some slight retarding influence on the growth of carcinoma.
Lupus of the Larynx.