Complete Text (Part 22)

Fig. 63. Fig. 63.— Hyoid Bone and the Laryngeal Cartilages (Ellis) : G, body of the hyoid bone : R, large cornu; J, small cornu; A, epiglottis; B, thyroid cartilage; 0, arytenoid car- tilage ; D, cricoid cartilage ; E, upper cornu, and F, lower cornu of the thyroid cartilage. Fig. 64.— Vocal Apparatus, on a Vertical Section of the Larynx ( Ellis) : A, ventricle of the larynx; B, vocal cord; C, ventricular band; D, sacculus laryngis; E, arytenoid car- tilage; F, cricoid cartilage; G, thyroid cartilage ; H, epiglottis ; K, crico'-thyroid lig- ament ; L, thyro-hyoid membrane. The cartilages of Santorini are two small cartilages situated above the apices of the arytenoids. The cartilages of Wrisberg are imbedded in the ary-epiglottic folds. They terminate in two rounded projections above the cartilages of San- torini. THE LARYNX. 175 The ventricular bands, or false vocal conjs, are attached in front to the thyroid and posteriorly to the arytenoid cartilages (Fig. 64). The vocal cords are attached to the thyroid and arytenoid cartilages. Fig. 65. Fig. 66. w Fig. 65— View of the Internal Muscles of the Larynx (Ellis1! : 1, Crico-thyroideus detached ; 2, crico-arytenoideus posticus; 3, crico-arytenoideus lateralis ; 4, thyro-arytenoideus, superficial part; 5, depressor of the epiglottis; 6, thyro-hyoideus, cut; 8, deeper part of thyro-arytenoideus. Fig. 66.— Posterior View of the Larynx (Ellis): A, Superficial part of the arytenoideus muscle; B, deep part of the arytenoideus; C, crico-arytenoideus posticus. They are composed of yellow elastic tissue covered with mucous mem- brane. The ventricles of Morgagni are two pockets situated in the side walls of the larynx between the true and false vocal cords. 176 THE THROAT. The sacculus laryngis is a sac placed between the false vocal cord and the inner surface of the thyroid cartilage. The muscles are — I. The crico-arytenoidei postici, the abductors of the vocal cords. com Laryngoscopy Diagram, showing the vocal cords widely drawn apart, and the position of the various parts above and below the glottis, during quiet breathing (from Mackenzie) : ge, glosso-epiglottic folds; u, upper surface of epiglottis; I, lip or arch of epiglottis ; c, protuberance of epiglottis; v, ventricle of the larynx; ae, ary-epiglottic fold; c W, cartilage of Wrisberg; cS, cartilage of Santorini; com, arytenoid commissure; vc, vocal cord; w6, ventricular band; pv, processus vocalis; cr, cricoid cartilage; t, rings of trachea (Seiler). II. The crico-ar3'tenoidei laterales inward. III. The These rotate the processus vocales The arytenoideus approximates the arytenoid cartilages, IY. The thyro-arytenoidei, external and internal They draw the Fig Laryngoscopy Diagram, showing the approximation of the vocal cords and arytenoid cartilages, and the position of the various parts, during vocalization (from Mac- kenzie): fi, fossa innominata; hi, hyoid fossa; ch, cornu of hyoid bone; cW, cartilage of Wrisberg; cS, cartilage of Santorini ; a, arytenoid cartilages; com, arytenoid com- missure ; pv, processus vocalis and cartilages of Seiler (Seiler). arytenoid cartilages, together with the back part of the cricoid, forward toward the thyroid, and thus shorten and relax the vocal cords. LARYNGOSCOPY. 177 V. The crico-thyroidei draw the cricoid upward (its anterior part), thus producing tension of the cords. VI. The ary-epiglottici tend to bring the tips of the arytenoid carti- lages together and make the epiglottis curve inward at its edges. The arteries are the laryngeal branches from the superior and inferior thyroid. The nerves are the superior laryngeal and the inferior or recurrent laryngeal, both branches of the pneumogastric, with a few filaments from the sympathetic. The mucous membrane is continuous with that lining the mouth and the pharynx, and the epithelium is of the ciliated variety. The chief physiological formation is the production of voice ; it also has duties in reference to deglutition and respiration. By reference to Figs. 67 and 68 the larynx is seen during respiration and phonation. LARYNGOSCOPY. What is understood by laryngoscopy? and when is a laryngo- scopy examination made? Laryngoscopy is the art of examining the larynx. For this purpose Fig. 69. Laryngeal Mirror. are required — 1st, a laryngeal mirror (Fig. 69) ; 2d, a head reflector (Fig. 70) ; 3d, light. In making a laryngeal examination the patient is directed to hold out his tongue, which is grasped by means of a towel or handkerchief be- tween the thumb and index fingers. The laryngeal mirror is then held over the light and warmed, so as to prevent the condensation of moisture upon its reflecting surface. It is then introduced into the mouth, and as soon as the uvula is reached the back of the mirror is placed against it, and it is pushed upward and backward, and the handle of the mirror 12— Eye. 178 THE THROAT. gently depressed. By directing the patient to say "ah" or "eh" the epiglottis is raised, and a view of the larynx with the vocal cords is ob- tained. By reference to Fig. 71 the laryngeal mirror is seen held in the correct position, whilst Fig. 72 shows the mirror incorrectly held. Fig. 70. Head Reflector. What are the obstacles to a laryngoscopic examination ? 1. a short frcennm linguae: 2. an unmanageable tongue; 3, hyper- trophy of the tonsils : 4, elongation of the uvula : 5. a faulty introduc- tion of the mirror on the part of the physician : 6, an overhanging epi- glottis : and 7. an irritable or sensitive pharynx. The latter can be overcome by painting the parts with a 4 per cent, solution of cocaine, administration of bromide of potassium, or gargling with ice- water. INFLAMMATIONS OF THE LARYNX. Give the etiology of acute laryngitis. Cold, sudden changes of temperature, inhalation of damp air, wet feet. etc.. may all give rise to an attack of acute laryngitis. It occurs not infrequently in clergymen, teachers, and singers after over-exertion INFLAMMATIONS OF THE LARYNX. 179 of the voice. Hot drinks, the inhalation of hot dry air and the vapors of various chemicals, as well as the excessive use of tobacco and alcohol, Fig. 71. Laryngeal Mirror in position, displaying the laryngeal image (Cohen). may cause an attack. It is often seen as a complication of measles, variola, typhoid and scarlet fever. Tubercular and syphilitic individ- 180 THE THROAT. uals are predisposed to it. It occurs in men more often than women, and in adults more than children. What is the pathology? There are hyperemia, swelling, and an increased and changed secretion. These vary in their intensity as well as in their extent. The catarrh may Fig. 72. Faulty Position of Laryngeal Mirror, with resultant laryngeal image (Seiler). confine itself to different portions, such as the entrance of the larynx, the interarytenoid space, etc. , or it may affect the entire larynx. There may be loss of epithelium, which rarely advances to true ulceration. The secretion is at first slight ; later it becomes increased in quantity and gelatinous, transparent, or grayish-yellow in color. INFLAMMATIONS OF THE LARYNX. 181 What are the symptoms? Acute laryngitis may occur without any prodromal symptoms, or be preceded by a slight chill, followed by some febrile disturbances. The first symptoms experienced by the patient are a sensation of pressure and dryness and a feeling of soreness. Cough is at first slight and dry, but becomes troublesome, owing to the exertions to clear the throat. When exudation occurs, it becomes loose. In children cough is more severe. The voice may be but slightly changed, but in most cases is usually rough and deep in quality. Difficulty of breathing is rare in adults, but in children it is marked and often assumes a serious nature. Pain is, as a rule, never severe, but there is a feeling of soreness. Expectoration is at first slight, of a mucous nature, and clear ; later it becomes more pro- fuse and yellowish. Swallowing is not painful unless the epiglottis or pharynx becomes involved. The laryngoscopic appearances vary ac- cording to the severity and extent of the inflammation. When this is slight, hypersemia of the mucous membrane is seen, involving different portions of the larynx or the entire larynx. Swelling is present in some cases, and slight erosions may be seen, though true ulceration is rare. What is the diagnosis? The diagnosis is easy, except perhaps in the case of young children, when the use of the laryngoscopic mirror is difficult. What is the prognosis? The prognosis is generally favorable ; when neglected it may become chronic. What is the treatment of acute laryngitis ? At the beginning of the attack a dose of calomel may be given; expectorants are also recommended. Locally steam inhalations are ser- viceable. The following has been found useful : R. Menthol, . 3ss; Tinct. benz. co., ^j. — M. Sig. A teaspoonful to a pint of boiling water, and inhale. In children the inhalation of steam from a kettle is recommended. Applications to the larynx should be avoided and children should be kept in-doors. Cold applied to the neck, or poultices, may be advised. Give the etiology of acute oedema of the larynx. Acute oedema of the larynx may be primary or secondary. It occurs frequently during the course of an acute laryngeal catarrh. It may occur as a secondary affection in other forms of inflammation of the larynx, such as syphilis, tuberculosis, perichondritis, in the laryngeal affections of diphtheria and the various exanthemata, in parotitis, in inflammations of the thyroid and cervical glands, and even the tonsils. It is seen in 182 THE THROAT. the acute inflammation of the larynx resulting from burns, wounds, scalds, and other injuries. By some it is said to occur as a complication of Bright' s disease. Among predisposing causes may be mentioned a low state of health and bodily fatigue. Give its pathology. (Edema of the larynx shows itself anatomically as a yellowish-white swelling (occasionally reddish). It occurs most frequently in the upper portions of the larynx ; the epiglottis, the ary-epiglottic folds, in the false vocal cords, in the mucous membrane of the arytenoid cartilages (seldom on the vocal cords) ; and consists of a transudation into the submucosa, which is usually serous, sero-purulent, or sanguineous. The histological appearances show distension of the muscles and the areolar tissue by the exudation. What are the symptoms? The chief symptom is dyspnoea, which at first is paroxysmal. As the oedema advances both expiration and inspiration are interfered with ; the dyspnoea becomes extreme, cyanosis develops, the eyeballs protrude, and the pulse becomes small and feeble. The voice is not affected to a marked degree. Cough may be present, but is usually due to efforts to clear the throat. Deglutition is painful, especially when the epiglottis is involved. With the laryngoscope the oedema is easily recognized. The epiglottis has the appearance of a semi-transparent body or shows swellings pressed against each other. -Where acute inflammation is present capillary injection is seen. The swellings of the ary-epiglottic folds are egg-shaped. They often prevent a view of the lower portion of the larynx. When the oedema is subglottic, two transparent swellings are seen apparently springing from the under surface of the vocal cords. What is the prognosis? The prognosis is, as a rule, bad, except, perhaps, where the oedema is partial. What is the treatment of acute oedema of the larynx ? Ice administered externally and internally, application of leeches, are measures which should be tried. When these fail, scarification should be performed by aid of the laryngoscope. Where this fails to give re- lief, tracheotomy then become necessary. Give the etiology of chronic laryngitis. It is often the sequel of an acute laryngitis. It occurs in teachers, clergymen, singers, etc., and especially in those who do not know how to use the voice. Those who live in an impure atmosphere are subject to this affection. The excessive use of tobacco and alcohol is a frequent cause of chronic laryngitis. In the case of alcoholic individuals who are suffering from chronic pharyngitis it is doubtless 1 ho result of accumu- lation of mucus, which, dropping during sleep from the pharynx into the INFLAMMATIONS OF THE LARYNX. 183 larynx, sets up irritation. An elongated uvula, by irritating the entrance of the larynx and epiglottis, is said to be a frequent cause. In boys con- tinued use of the voice when it is changing often results in a chronic laryngitis. It is a frequent complication of the various exanthemata, and is present in syphilis and tuberculosis. It is most frequent among adults, and more common in males than females. Give its pathology. There is dilatation of the vessels, hypertrophy of the mucous mem- brane, and a changed secretion. The_ mucous membrane is thickened, uneven, rough, and often covered with granulations. In some cases, where the affection has existed for some time, there is hyperplasia of connective tissue. The secretion is transparent, grayish, or muco-puru- lent ; sometimes it is dried in crusts. Erosions are often present, but true ulceration is rare. What are the symptoms ? The subjective symptoms are often slight. Pain is, as a rule, rare, except after vocal exertion. Instead, there is often a sense of constriction present, or the sensation as if a foreign body were in the throat. The voice is changed. Hoarseness is present, varying with the degree of in- flammation. Aphonia not infrequently occurs after continued use of the voice. _ Cough may be absent, unless there is bronchial-catarrh. Respi- ration is, as a rule, not affected. The secretion is scanty, grayish-white, and is often expectorated in the form of hard crusts. What is seen on laryngoscopic examination? The laryngoscopic examination shows hyperemia and swelling, which vary according to the intensity and extent of the inflammation. The hyperemia may affect the mucous membrane of the larynx in its en- tirety or be confined to individual portions. The same can be said of the swelling. It seldom affects the whole larynx. The epiglottis is often thickened, especially in topers. Sometimes the false vocal cords are swollen to such a degree that very little can be seen of the true cords, and often the false cords meet during phonation, so that the voice has a hoarse sound. When swelling exists in the interarytenoid space it often prevents the complete closure of the glottis, and thereby also the_ move- ment of the cords. Lewin states that a thickening of the ary-epiglottic folds is often observed in preachers. Turck describes a roughened ap- pearance of the cords, which he designates as chorclitis tuberosa. _ Se- cretion is seen in J:he form of small pellets or forming small bridges which extend from one cord to the other, and motility may be disturbed. Erosions are often seen, especially in the vocal cords and in the arytenoid space. Give the diagnosis. A thorough laryngoscopic examination is the only method by which an accurate diagnosis can be made. Where chronic laryngitis has been 184 THE THROAT. present for some time there should be a careful examination of the lungs, as well as an inquiry concerning the family history and the general con- dition of the patient. What is the prognosis? Chronic laryngitis rarely terminates fatally. A cure may be often effected by persistent treatment and an avoidance of those causes which tend to keep up the condition. What is the treatment of chronic laryngitis ? The treatment consists chiefly in local applications to the larynx in the form of spray, powder, or applied by means of a brush or cotton-appli- cator. One of the best solutions is that of the chloride of zinc, in the strength of from 10-30 grs. to the ounce. Mackenzie recommends its application in the following manner : It should be made daily for the first seven days, on alternate days during the second and third weeks, twice in the fourth week, and so on at gradually increasing intervals until a cure is effected. Nitrate of silver, applied by means of a brush or cotton-applicator, is also recommended in solution from 4 to 10 per cent. Besides these are recommended iron, alum, zinci sulph., etc. Spray inhalations of tannin, 1-5 gr., chloride of zinc. 2-10 gr., are often useful. Steam inhalations of benzoin, pine oil, creasote, are beneficial. The general health of the patient should also receive attention. Where the disease is the result of a pharyngitis or nasal trouble, these should first receive treatment. Enlarged tonsils and obstructions in the nasal passages should all be removed. Over-exertion in those compelled to use the voice should be avoided, and as much rest as possible given to the voice during treatment. Application of wet compresses and the painting of the thyroid cartilage with tincture of iodine are recom- mended by Lennox-Browne. TUBERCULAR LARYNGITIS. Give the etiology of tuberculous laryngitis. It is usually a secondary manifestation of tuberculosis of the lungs. Whether it ever occurs as a primary affection is still a disputed question. A low state of vitality is a predisposing cause. It occurs more fre- quently in men than in women, and usually between the ages of twenty and forty. Give, briefly, the pathology. The first stage in the process is that of infiltration and swelling. This is, as a rule, situated in the interarytenoid space, on the coverings of one or both of the arytenoid cartilages and on the corresponding ary-epi- glottic fold, less frequently on the epiglottis. The swelling is seen to con- sist microscopically of a cellular infiltration into the subepithelial or sub- mucous cellular tissue, which is found to be made up of more or less TUBERCULAR LARYNGITIS. 185 circumscribed tubercles, consisting each of nuclei, detritus, giant-cells, and leucocytes. The glands become changed, either through an extension to them of the tubercular process or primarily through inflammation. A section of a blood-vessel shows an accumulation of round cells. As soon as the tubercular infiltration has reached the lowest boundary of the epi- thelial layer, this becomes lifted off from the basal membrane : perfora- tion ensues, which soon advances to ulceration, forming the typical tuber- culous ulcer. Caries and