Direct Laryngoscopy In Diseases Of The Larynx

Categories: BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND BRONCHI
Sources: 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 contra ndicated 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

passages.



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.