Post-tracheotomic vegetations may arise from the irritating pressure of a tracheotomy-tube, especially from the use of a fenestrated tube or a tube ill fitted to the patient. Some observers are of opinion that such tumors existed before the performance of the operation, and, indeed, led to it, even though the supposed reason may have been laryngeal or some other tracheal disease. While it cannot be denied that such may have been the case sometimes, there is no doubt that in other instances—and not only in those in which the vegetations "always grow from the cicatrix" (Petel)—they are truly caused by the operation, or by the wearing of the tube, especially if it be in any way unsuitable as to size, form, etc.
SYMPTOMATOLOGY.—The symptoms of tracheal tumors are local irritation; tickling or other morbid sensation, sometimes inducing and sometimes not inducing cough; and encroachment upon the breathing-space—dyspnoea—depending on their precise seat, size, and rapidity of growth. It is usually difficult for the patient to specify the beginning of his trouble, because, on account of the large size of the windpipe, dyspnoea generally comes on very gradually. An accidental catarrhal condition of the tracheal mucous membrane from a cold usually first arrests the patient's attention. The very great diminution of the calibre of the tube that the patient can bear when the tumor enlarges slowly is sometimes astonishing. Unless the tumor is pedunculated (so that expiratory efforts can throw it up into the larynx), which is generally not the case, expiration and inspiration are equally affected, both becoming gradually more and more labored and noisy. Sometimes the act of swallowing large morsels brings on an increased dyspnoea; sometimes respiration is accompanied by a sort of valvular sound. Cough is frequently, but not always, present, and depends, together with expectoration, upon either coincidental catarrhal condition or irritation from the tumor: in the latter case it is essential, dry, and persistent, and may vary with the position of the patient. Sputum may be bloody and even contain shreds of the tumor, as in similar cases of laryngeal growth. With increase of the tumor the voice becomes weak and suffers in extent of range, as in other cases of tracheal stenosis; the same is true of the diminished rising and falling of the larynx. The course and duration of the disease vary considerably with its nature. I have observed a tracheal fibroma to remain stationary for eight years, when the patient died from other causes and the diagnosis was confirmed post-mortem; and, on the other hand, a cancer to grow so rapidly that the patient died from suffocation within five months of its first causing the slightest symptom. If not relieved, suffocatory paroxysms, with or without consequent bronchitis and pneumonia, lead to a fatal termination.
PATHOLOGY.—As in the larynx, so in the trachea, the pathological character of neoplasmata is generally that of papilloma. Of my eight cases, all observed during life, four were papillomatous (two examined microscopically after successful extirpation, one post-mortem, and one in situ macroscopically only), one was a fibroma, microscopically examined, one an osteo-chondroma, one a sarcoma, and one a carcinoma, the three last having been examined post-mortem.
Of non-malignant tracheal tumors observed by others, the large majority were papillomata; next in number come fibromata. Aside from these two kinds of tracheal tumor, the cases recorded in literature are the following: Rokitansky more than thirty years ago described tracheal enchondromata found after death; and Cohen discovered in the corpse of a phthisical patient a number of small enchondromata on the central portions of the tracheal cartilages. Steudener, Demme, Wilks, Chiara, and Eppinger have observed, post-mortem, tracheal osteomata. Gibbs has described a tracheal cystic tumor2 seen with the laryngoscope; Müller, under the guidance of Gerhardt, a myxo-adenoma observed tracheoscopically and carefully studied during life and after death; and Eppinger has recorded a case of post-mortem tracheal adenomata and cysts, Simon having previously found three similar tumors on dissecting a new-born tigress. Virchow speaks of the occurrence of retro-tracheal retention-cysts, and Gruber has observed several; but there can be no doubt that at least some of the tumors thus described are nothing but circumscribed dilatations of the tracheal mucous membrane—practically, dilated mucous glands. As to malignant tumors, in addition to my two cases Schrötter has reported two cases of sarcoma, and Labus one of fibro-sarcoma, while Rokitansky, Klebs, Koch, Schrötter, Langhans, and Mackenzie have described cases of carcinoma.
2 Cohen questions whether this was a cyst or an abscess. It burst spontaneously.
Cases of cancer of the oesophagus, which involve the trachea—excluded, as before stated, from present consideration—are, comparatively speaking, by no means rare, and are apt to establish a fistulous communication between the two tubes.
DIAGNOSIS.—The symptoms mentioned are those common to nearly all cases of tracheal stenosis, and will be referred to again under that head. Tracheoscopy alone makes the diagnosis certain; unless when the seat of the disease is ascertainable without, its nature is shown by the expectoration of portions of the tumor. The first case of tracheal tumor ever diagnosed during the patient's life was observed by means of the mirror by Tuerck in 1861; but it is very difficult in the mirror to estimate distances as to depth, and unless the number of tracheal rings above a tumor can distinctly be counted, a growth in the lower cavity of the larynx may readily be mistaken for one in the trachea, and vice versâ. Catheterism of the trachea shows the distance at which the tumor is situated, sometimes very accurately, but it is dangerous unless performed under the guidance of the mirror, and even then requires great care. The introduction without the mirror of a probe or sound for the same purpose is still more dangerous and unjustifiable, while with the mirror it is perfectly safe in proper hands. Localized protrusion of the mucous membrane into the interior is the condition which most simulates tracheal tumor. (Compare [Fig. 32].)
| FIG. 31. |
| Papilloma of Trachea. |
The pathological nature of a tracheal tumor can sometimes be determined in situ with more or less probability. Without microscopical examination it is not always possible to say whether a growth is benign or malignant unless the mass has advanced to ulceration, and then specific disease must be excluded by the history and concomitant symptoms. Papillomata have a peculiarly uneven surface; fibromata are usually more smooth. With equally good illumination, tumors of the trachea resemble tumors of the larynx, and may be similarly differentiated. The former are almost always non-pedunculated, or at least none of those hitherto observed have had a long pedicle. Their seat is generally the posterior wall, or the cicatrix of the anterior wall after tracheotomy. In Fig. 31 is seen the tracheoscopic appearance of one of my cases of tracheal papilloma.