Treatment Of Cicatricial Stenosis


Categories: DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS
Sources: 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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