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Methods Of TreatmentCategory: BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL TREE Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery Irritating applications probably provoke recurrences, because the growths are of inflammatory origin. Formerly laryngostomy was recommended as a last resort when all other means had failed. The excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure; and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone, using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis. Thyrotomy for papillomata is mentioned only to be condemned. Fulguration has been satisfactory in the hands of some, disappointing to others. It is easily and accurately applied through the direct laryngoscope, but damage to normal tissues must be avoided. Radium, mesothorium, and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action. In my experience, however, I have never seen a cure of papillomata which could be attributed to the radiation. I have seen cases in which no effect on the growths or recurrence was apparent, and in some cases the growths seemed to have been stimulated to more rapid repullulations. In other most unfortunate cases I have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy. Possibly the disastrous results were due to overdosage; but I feel it a duty to state the unfavorable experience, and to call attention to the difference between cancer and papillomata. Multiple papillomata involve no danger to life other than that of easily obviated asphyxia, and it is moreover a benign self-limited disease that repullulates on the surface. In cancer we have an infiltrating process that has no limits short of life itself. Endolaryngeal extirpation of papillomata in children requires no anesthetic, general or local; the growths are devoid of sensibility. If, for any reason, a general anesthetic is used it should be only in tracheotomized cases, because the growths obstruct the airway. Obstructed respiration introduces into general anesthesia an enormous element of danger. Concerning the treatment of multiple papillomata it has been my experience in hundreds of cases that have come to the Bronchoscopic Clinic, that repeated superficial removals with blunt non-cutting forceps (see Chapter I) will so modify the soil as to make it unfavorable for repullulation. The removals are superficial and do not include the subjacent normal tissue. Radical removal of a papilloma situated, for instance, on the left ventricular band or cord, can in no way prevent the subsequent occurrence of a similar growth at a different site, as upon the epiglottis, or even in the fauces. Furthermore, radical removal of the basal tissues is certain to impair the phonatory function. Excellent results as to voice and freedom from recurrence have always followed repeated superficial removal. The time required has been months or a year or two. Only rarely has a cure followed a single extirpation. If the child is but slightly dyspneic, the obstructing part of the growth is first removed without anesthesia, general or local; the remaining fungations are extirpated subsequently at a number of brief seances. The child is thus not terrified, soon loses dread of the removals, and appreciates the relief. Should the child be very dyspneic when first seen, a low tracheotomy is immediately done, and after an interim of ten days, laryngoscopic removal of the growth is begun. Tracheotomy probably has a beneficial effect on the disease. Tracheal growths require the insertion of the bronchoscope for their removal. Papillomata in the larynx of adults are, on the whole, much more amenable to treatment than similar growths in children. Tracheotomy is very rarely required, and the tendency to recurrence is less marked. Many are cured by a single extirpation. The best results are obtained by removal of the growths with the laryngeal grasping-forceps, taking the utmost care to avoid including in the bite of the forceps any of the subjacent normal tissue. Radical resection or cauterization of the base is unwise because of the probable impairment of the voice, or cicatricial stenosis, without in anyway insuring against repullulation. The papillomata are so soft that they give no sensation of traction to the forceps. They can readily be scalped off without any impairment of the sound tissues, by the use of the author's papilloma forceps (Fig. 29). Cutting forceps of all kinds are objectionable because they may wound the normal tissues before the sense of touch can give warning. A gentle hand might be trusted with the cup forceps (Fig. 32, large size.) Sir Felix Semon proved conclusively by his collective investigations that cancer cannot be caused by the repeated removals of benign growths. Therefore, no fear of causing cancer need give rise to hesitation in repeatedly removing the repullulations of papillomata or other benign growths. Indeed there is much clinical evidence elsewhere in the body, and more than a little such evidence as to the larynx, to warrant the removal of benign growths, repeated if necessary, as a prophylactic of cancer (Bibliography, 19). Next: Benign Growths Primary In The Tracheobronchial Tree Previous: Papillomata Of The Larynx In Children
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