Methods Of Treatment

Categories: BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL TREE
Sources: 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).