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Direct Laryngoscopy In Diseases Of The Larynx
Category: BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND BRONCHI
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
The diagnosis of laryngeal disease in young children, impossible with
the mirror, has been made easy and precise by the development of
direct laryngoscopy. No anesthetic, local or general, should be used,
for the practised endoscopist can complete the examination within a
minute of time and without pain to the patient. The technic for doing
this should be acquired by every laryngologist. Anesthesia is
absolutely contraindicated because of the possibility of the presence
of diphtheria, and especially because of the dyspnea so frequently
present in laryngeal disease. To attempt general anesthesia in a
dyspneic case is to invite disaster (see Tracheotomy). It is to be
remembered that coughing and straining produce an engorgement of the
laryngeal mucosa, so that the first glance should include an
estimation of the color of the mucosa, which, as a result of the
engorgement, deepens with the prolongation of the direct laryngoscopy.
Chronic subglottic edema, often the result of perichondritis, may
require linear cauterization at various times, to reduce its bulk,
after the underlying cause has been removed.
Perichondritis and abscess, and their sequelae are to be treated on
the accepted surgical precepts. They may be due to trauma, lues,
tuberculosis, enteric fever, pneumonia, influenza, etc.
Tuberculosis of the larynx calls for conservatism in the application
of surgery. Ulceration limited to the epiglottis may justify
amputation of the projecting portion or excision of only the ulcerated
area. In either case, rapid healing may be expected, and relief from
the odynphagia is sometimes prompt. Amputation of the epiglottis is,
however, not to be done if ulceration in other portions of the larynx
coexist. The removal of tuberculomata is sometimes indicated, and the
excision of limited ulcerative lesions situated elsewhere than on the
epiglottis may be curative. These measures as well as the
galvanocautery are easily executed by the facile operator; but their
advisability should always be considered from a conservative
viewpoint. They are rarely justifiable until after months of absolute
silence and a general antituberculous regime have failed of benefit.
Galvanopuncture for laryngeal tuberculosis has yielded excellent
results in reducing the large pyriform edematous swellings of the
aryepiglottic folds when ulceration has not yet developed. Deep
punctures at nearly a white heat, made perpendicular to the surface,
are best. Care must be exercised not to injure the cricoarytenoid
joint. Fungating ulcerations may in some cases be made to cicatrize by
superficial cauterization. Excessive reactions sometimes follow, so
that a light application should be made at the first treatment.
Congenital laryngeal stridor is produced by an exaggeration of the
infantile type of larynx. The epiglottis will be found long and
tapering, its lateral margins rolled backward so as to meet and form a
cylinder above. The upper edges of the aryepiglottic folds are
approximated, leaving a narrow chink. The lack of firmness in these
folds and the loose tissue in the posterior portion of the larynx,
favors the drawing inward of the laryngeal aperture by the inspiratory
blast. The vibration of the margins of this aperture produces the
inspiratory stridor. Diagnosis is quickly made by the inspection of
the larynx with the infant diagnostic laryngoscope. No anesthetic,
general or local, is needed. Stridorous respiration may also be due to
the presence of laryngeal papillomata, laryngeal spasm, thymic
compression, congenital web, or an abnormal inspiratory bulging into
the trachea of the posterior membranous tracheo-esophageal wall. The
term congenital laryngeal stridor should be limited to the first
described condition of exaggerated infantile larynx.
Treatment of congenital laryngeal stridor should be directed to the
relief of dyspnea, and to increasing the nutrition and development of
the infant. The insertion of a bronchoscope will temporarily relieve
an urgent dyspneic attack precipitated by examination; but this rarely
happens if the examination is not unduly prolonged. Tracheotomy may be
needed to prevent asphyxia or exhaustion from loss of sleep; but very
few cases require anything but attention to nutrition and hygiene.
Recovery can be expected with development of the laryngeal structures.
Congenital webs of the larynx require incision or excision, or
perhaps simply bouginage. Congenital goiter and congenital laryngeal
paralysis, both of which may cause stertorous breathing, are
considered in connection with other forms of stenosis of the air
Aphonia due to cicatricial webs of the larynx may be cured by
plastic operations that reform the cords, with a clean, sharp anterior
commissure, which is a necessity for clear phonation. The laryngeal
scissors and the long slender punch are often more useful for these
operations than the knife.
Next: Bronchoscopy In Diseases Of The Trachea And Bronchi