Complete Text (Part 23)

necrosis of the cartilages not infrequently take place, and new growths have been observed accompanying tuberculous laryngitis. What are the symptoms? The patient, as a rule, in the beginning complains of peculiar sensa- tions in the throat ; the voice is easily tired and there is a tendency to hoarseness, or aphonia may be- present. Difficulty^ of swallowing is not always present, but where the epiglottis becomes involved or the ary- tenoids, then swallowing becomes very painful. Cough is usually a con- stant symptom, and is often very distressing. Shortness of breathing is occasioned by the lung affection, but where swelling leads to loss of mobility and the cords become thickened and ulcerated, then dyspnoea may ensue. What are the laryngoscopic appearances? The laryngoscopic appearances show in the early stage anaemia of the mucous membrane. When the process has farther advanced, infiltration is seen, which is most frequently situated in the jnterarytenoid space, next to this on the false vocal cords and arytenoid cartilages, and less frequently on the vocal cords, the ary-epiglottic ligament, and the epi- glottis. When the arytenoid cartilages are affected, they appear as pyriform swellings (see Fig. 1 , Plate II. ) , and when infiltration of the epiglottis is present, it loses its form, assuming a turban-like shape. When ulceration is seen it presents a worm-eaten, carious appearance. Paralysis of one or both vocal cords is often seen, and secretion is pres- ent, which is altered, being muco-purulent in character. (See Fig. 2, Plate II.) What is the prognosis ? The prognosis is unfavorable, though cures have been reported. The most that can be hoped for is to check the progress of the disease and alleviate the symptoms. Give the treatment of tubercular laryngitis. The treatment should be both constitutional and local. Appropriate internal remedies, such as the hypophosphites, cod-liver oil, creasote, etc., should be administered. The food should be nourishing, bland in quality, and non-irritating. Locally, steam inhalations of creasote, pine oil, and the compound tincture of benzoin are of service. Scarifi- 186 THE THROAT. cation is recommended by some and condemned by others. The insuf- flation of iodoform is advocated bySchnitzler-Krause of Berlin, who also advises the use of applications of lactic acid to ulcerations situated on the posterior portion of the larynx. A 20 per cent, solution of menthol in olive oil is recommended by Rosenberg. The use of sprays has also been found useful. Cocaine in a 2 per cent, solution, applied before eating', is useful for alleviation of the pain. When deglutition becomes impossible, Delavan's alimentation-bottle may be employed. When the dyspnoea becomes extreme, tracheotomy can be performed. SYPHILITIC LARYNGITIS. Give the etiology. It may occur as a secondary manifestation of syphilis in from a few weeks or months to two years after the primary infection. As a tertiary manifestation it may occur in from three to thirty years after. It is said to be more frequent in men than in women. Give the pathology. In the secondary form hyperemia may be present, complicated with ulcerations or condylomata. In the tertiary form hyperemia is the first manifestation, followed by progressive ulceration. The cartilages may become involved, and stenosis is not of infrequent occurrence as the result of cicatricial contraction. What are the symptoms? In secondary syphilis hyperemia with ulcerations or mucous patches is frequently observed. The voice is usually impaired, and may be completely lost, but soon returns. Difficulties of breathing are not, as a rule, present. Cough is not a prominent symptom, and is usually due to an effort to clear away the expectoration. On inspection with the laryngoscope congestion is noticed, and more especially the ulcerations of the vocal cords. (See Fig. 3, Plate II.) When mucous patches exist, they are seen most frequently on the ventricular bands, the interarytenoid space, and the epiglottis. Con- dylomata are sometimes seen. The secretion is scanty. In the tertiary form ulcerations, as a rule, begin in the epiglottis, and differ from the secondary ulcerations in that they are deep, covered with a whitish-yellow coating with elevated margins, and surrounded by an inflammatory areola. When the ulcerative process involves the carti- lages, necrosis is the result. If the blood-vessels become affected, hem- orrhage may ensue. What is the prognosis? In secondary stages the prognosis is favorable. In the tertiary stage the prognosis is also favorable if seen early, though death may result from oedema of the larynx or hemorrhage. NEUROSES OF THE LARYNX. 187 What is the treatment? In the secondary form internal administration of mercury is indicated. Locally, astringents of nitrate of silver and chloride of zinc are service- able. Where there is ulceration or when condylomata are present, iodidt of potassium, with or without mercury, may be given. In the tertiary stage mercurial inunction is recommended, followed bj the administration of iodide of potassium. Local applications should not be neglected. Where ulceration exists, nitrate of silver should be applied. Iodoform is also recommended. When oedema is imminent tracheotomy is necessary. Where stenosis occurs as the result of cica- trization, dilatation by means of Schoetters tubes or those of O'Dwyer should be resorted to. Tracheotomy, however, often becomes necessary. NEUROSES OF THE LARYNX. Describe, briefly, the effects of lesions of the superior and recur- rent laryngeal nerves, and give some of the causes. When a lesion of the superior laryngeal nerve exists, there is some loss of sensation, the epiglottis can only be partially closed, the voice is hoarse and easily fatigued. Lesions of both nerves cause paralysis of the thyro- cricoid, thyroepiglottic, and ary-epiglottic muscles in the lateral half of the larynx. _ Aneurism, tumors of the pharynx, or enlarged glands may cause impairment of the function of the superior laryngeal nerve. It also occurs as a sequel of diphtheria. Lesions of the recurrent laryngeal nerve are the most frequent causes of paralysis of the larynx. Aneu- risms, pressure from bronchial glands, and mediastinal growths may cause impairment of the recurrent laryngeal nerve, as may also enlarge- ment of the thyroid gland. The effects are paralysis of all the muscles supplied by this nerve. Mention other causes which may bring about paralysis of the laryngeal muscles. An inflammatory condition of the muscular substance resulting from an inflammation of the larynx, atrophy or degeneration of the muscles, and various other conditions, such as ansemia, syphilis, rheumatism, and general poisoning by -means of various drugs, may be mentioned as fac- tors in the causation of motor paralysis. Treatment of these forms consists in treating any catarrhal condition of the nose, pharynx, or larynx which may exist, and in the administra- tion of tonics and faradization. Give a brief account of the paralysis of abduction. This consists in paralysis of one or both of the posterior crico-aryte- noid muscles. Bilateral paralysis is a serious affection, but is rare. As to its causation, cases have been reported occurring after typhoid fever, pneumonia, and erysipelas. New growths, aneurisms, by pressure upon both recurrents, may produce bilateral paralysis. The voice usually re- 188 THE THROAT. mains unimpaired, but may be slightly hoarse. Respiration is seriously interfered with, being noisy during inspiration, and suffocation is liable to take place. Expiration is normal. In unilateral paralysis the vocal cord is seen by aid of the laryngoscope to remain in the median line. The subjective symptoms are, as a rule, slight. The voice is rough and harsh in tone. Difficulty of breathing is not so marked in this as in the bilateral form on exertion ; however, dyspnoea is often experienced. Uni- lateral paralysis may be due to a lesion of the pneumogastric, to aneu- rism, enlarged bronchial glands, and hypertrophy of the thyroid gland. In the bilateral form, to relieve the extreme dyspnoea, tracheotomy often becomes necessary. In the unilateral form, where there exists any pathological conditions, such as enlarged glands, etc., appropriate treat- ment should be given. Faradization may be tried. Describe paralysis of adduction. This consists in paralysis of the lateral crico-arytenoid muscles. It may be bilateral or unilateral. The bilateral form is due to anaemia, and often occurs where there are great bodily weakness and hysteria. It may occur in women suffering from amenorrhoea Fig. 73. or dysmenorrhoea. In this condition the voice is lost j and the vocal cords in phonation do not approach the median line. Prognosis is favorable. The unilateral paralysis maybe due to chronic poisoning from lead and diphtheria: it may be the result of cerebral disease, cold, or muscular strain. It is met with after small-pox, constitu- tional syphilis, and in phthisis. The symptoms present are loss of voice or hoarseness. With the laryngoscope the cord af- fected is seen to remain in the cadaveric position, i and does not move. Paralysis of Left Vocal ., P^ogntmB is favorable when the cause is local in Cord (Cohen). its origin. Treatment of both forms consists in faradization, general tonics, and the administration of strychnine. Describe paralysis of the sphincters or tensors. This consists in paralysis of the thyro-arytenoidei, caused by over-ex- ertion of the voice, improper use of the voice, or hysteria. By the laryngoscope decreased approximation is seen to exist, and the cords ap- pear thinner than normal. What other forms of paralysis may exist ? Paralysis proper of the arytenoideus or as the result of catarrh. The prognosis as regards life is good. Treatment is the same as in the preceding forms. BENIGN TUMORS OF THE LARYNX. 189 BBNIG-N TUMORS OF THE LARYNX. Give the etiology. Hyperemia, catarrh, and the inhalation of certain irritating vapors may give rise to the formation of a new-growth in the larynx. Constant use of the voice, as also syphilis, may be mentioned as predisposing causes. These tumors occur usually in adults, and are more frequent in males than in females. What are the symptoms? The symptoms vary with the size, situation, and consistency of the growth. The voice is, as a rule, impaired. Double voice is said to oc- cur in a certain proportion of cases, especially if the growth be small. Dyspnoea is only present when the growth is of so large a size that it interferes with respiration. Cough may be present, and is usually due to a desire to clear the throat. Pain, as a rule, is absent, nor is there any difficulty in swallowing unless the growth be situated on the epi- glottis. "What are the growths usually met with? Papillomata, fibromata, angiomata, myxomata, and cysts. 4 and 5, Plate II.) (See Fi^ What is the treatment of benign growths in the larynx ? They should be either destroyed by means of caustics or removed. Caustics should only be employed where the growth is of small size. Of these, nitrate of silver, chromic acid, and the galvano-cautery are the ones chiefly recommended. For their removal forceps are generally used. Mackenzie's forceps (Fig. 74) and Schroetter's are effective for Fig. 74. Mackenzie's Laryngeal Forceps. this purpose. Where the growth is situated on the epiglottis, Jarvis's snare may be employed. 190 THE THROAT. MALIGNANT GROWTHS IN THE LARYNX. What are the malignant growths which occur in the larynx ? Sarcoma and carcinoma. "What are the symptoms? Hoarseness with severe pain, difficulty in swallowing, and disturb- ances in respiration as the growth increases in size. When ulceration occurs, pain becomes more intense and hemorrhage may occur. The breath has a foetid odor. The laryngoscopy appearances vary. Sar- coma often resembles a papilloma or fibroma. In carcinoma when the growth is an epithelioma it has a grayish-red color ; ulceration is pres- ent, surrounded by vegetations, which soon break down to become in turn ulcerated. In encephaloid cancer vegetations are seen on the sur- face of the ulcer. Scirrhus is hard to the touch at first, but soon becomes inflamed and ulcerates. What is the treatment of malignant growths of the larynx ? Attempts at endolaryngeal removal are recommended by some, con- demned by others. Excision of the larynx, total or partial, has met with some success, as has also thyrotomy, followed by removal of the growth. Tracheotomy often prolongs the life of the patient. Cocaine, 4 per cent, solution, and insufflations of morphia, gr. il, for the relief of pain are often useful. SUCCESSFUL CASES ALIVE AFTER THREE YEARS. THYROTOMY. Case No. 1. Died 4 years after operation, of cerebral apoplexy. 2. Well 8 3. " 20 PARTIAL EXCISION. 1. Well 3\ Years after operation. 2. " 4 3. " 4 4. Died 5 " " of cerebral apoplexy. TOTAL EXCISION. 1. Well 3J years after operation. 2. " 4 3. " 4 4. " 4\ 5. Died U 6. Well 5 7. " 5| " 8. "9 Total, 15 cases. FOREIGN BODIES IN THE LARYNX. 191 DEATHS DUE TO OPERATIONS FOR INTRINSIC CARCINOMA (IMMEDIATE). Cases. Deaths. Thyrotomy 28 3 Partial excision - 23 7 Total excision _51 16 102 operations. 26 deaths. CAUSES OF DEATH. Accident 1 Hemorrhage 1 Paralysis of heart 2 Exhaustion . . r 3 Pleurisy 1 Pneumonia, broncho-pneumonia, pleuropneumonia. 6 Sepsis 9 Not ascertained 3 Total 26 FOREIGN BODIES IN THE LARYNX. What are the foreign bodies found in the larynx? Give the treatment. Various articles of food, such as fish-bones, pieces of meat and bread ; also buttons, pins, etc. often find their way into the larynx. The symptoms they give rise to are violent attacks of coughing, and when not dislodged, and the body is of large size, the face becomes livid, with protrusion of the eyeballs, and even unconsciousness may ensue. When the body is of such size as to prevent the entrance of air into the lungs, suifocation ensues, and the patient dies in a very short space of time. When the foreign body is small, the above symptoms do not show themselves, but instead fits of coughing. Fig. 75. Seller's Universal Tube-forceps and Guillotine. 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