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Methods Of Treatment
Category: 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
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).
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