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Treatment Of Cicatricial Stenosis





Category: DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

A careful direct endoscopic
examination is essential before deciding on the method of treatment
for each particular case. Granulations should be removed. Intubated
cases are usually best treated by tracheotomy and extubation before
further endoscopic treatment is undertaken. A certain diagnosis as to
the cause of the condition must be made by laboratory and therapeutic
tests, supplemented by biopsy if necessary. Vigorous antiluetic
treatment, especially with protiodide of mercury, must precede
operation in all luetic cases. Necrotic cartilage is best treated by
laryngostomy. Intubational dilatation will succeed in some cases.

[FIG. 109.--Schema showing the author's method of laryngostomy. The
hollow upward metallic branch (N) of the cannula (C) holds the rubber
tube (R) back firmly against the spur usually found on the back wall
of the trachea. Moreover, the air passing up through the rubber tube
(R) permits the patient to talk in a loud whisper, the external
orifice of the cannula being occluded most of the time with the cork
(K). The rubber tubing, when large sizes are reached may extend down
to the lower end of the cannula, the part C coming out through a large
hole cut in the tubing at the proper distance from the lower end.]

Laryngoscopic bouginage once weekly with the laryngeal bougies (Fig.
42) will cure most cases of laryngeal stenosis. For the trachea,
round, silk-woven, or metallic bougies (Fig. 40) are better.

[307] Laryngostomy consists in a midline division of the laryngeal
and tracheal cartilages as low as the tracheotomic fistula, excision
of thick cicatricial tissue, very cautious incision of the scar tissue
on the posterior wall, if necessary, and the placing of the author's
laryngostomy tube for dilatation (Fig. 109). Over the upward branch of
the laryngostomy tube is slipped a piece of rubber tubing which is in
turn anchored to the tape carrier by braided silk thread.
Progressively larger sizes of rubber tubing are used as the laryngeal
lumen increases in size under the absorptive influence of the
continuous elastic pressure of the rubber. Several months of wearing
the tube are required until dilatation and epithelialization of the
open trough thus formed are completed. Painstaking after-care is
essential to success. When dilatation and healing have taken place,
the laryngostomy wound in the neck is closed by a plastic operation to
convert the trough into a trachea by supplying an anterior wall.

Intubational treatment of chronic laryngeal stenosis may be tried in
certain forms of stenosis in which the cicatrices do not seem very
thick. The tube is a silver-plated brass one of large size (Fig. 110).
A post which screws into the anterior surface of the tube prevents its
expulsion. Over the post is slipped a block which serves to keep open
the tracheal fistula. Detailed discussion of these operative
treatments is outside the scope of this work, but mention is made for
the sake of completeness. Before undertaking any of the foregoing
procedures, a careful study of the complete descriptions in Peroral
Endoscopy is necessary, and a practical course of training is
advisable.

[FIG. 110.--The author's retaining intubation tube for treatment of
chronic laryngeal stenosis. The tube (A) is introduced through the
mouth, then the post (B) is screwed in through the tracheal wound.
Then the block (C) is slid into the wound, the square hole in the
block guarding the post against all possibility of unscrewing. If the
threads of the post are properly fitted and tightly screwed up with a
hemostat, however, there is no chance of unscrewing and gauze packing
is used instead of the block to maintain a large fistula. The shape of
the intubation tube has been arrived at after long clinical study and
trials, and cannot be altered without risk of falling into errors that
have been made and eliminated in the development of this shape.]





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