positively recognized, from the peculiar pain if the laryngoscope (or,
in the rare case of thyroid perichondritis, palpation) reveals
enlargement of a part of the cartilaginous structure without much
injection of the mucous membrane. The presence of other symptoms
mentioned, and in the case of cricoid perichondritis the localized
pharyngeal reddening, make the diagnosis more probable. During the
suppurating and necrotic stages the diagnosis becomes certain from the
symptoms I have described, especially expectoration of fragments of
necrosed cartilage, together with direct examination. The laryngoscope
may show the abscess; sometimes the finger or a probe can detect
fluctuation, and frequently through an opening the probe detects the
necrosis. The movement of one or both vocal bands may be affected
either mechanically from purulent accumulation, or from articular
ankylosis, or from interference with muscular attachments or action, or
with innervation. In my hand, and in that of others, a probe introduced
through an external fistula has been seen in the larynx; others have
been able to inject colored fluid and find it in the interior.
PROGNOSIS.--Except in slight cases death is more apt to take place than
recovery. If tracheotomy has saved the patient from impending death,
ultimate prognosis is still unfavorable in severe cases. In idiopathic,
traumatic, and syphilitic cases the prognosis is of course better than
in others in which we have to face grave dangers of the underlying
disease as well. The {121} remaining laryngeal stenosis after recovery
makes the prognosis bad as to the doing away with the tracheotomy-tube,
although it is far more favorable at the present day than it was
previous to Schrötter's success with dilating measures.
TREATMENT.--Throughout the disease the patient's general health and
strength must be carefully attended to, tonics and stimulants used
according to circumstances, and the underlying condition of secondary
perichondritis, such as syphilis, etc., treated secundum artem.
Locally, the treatment during the first stage must be antiphlogistic,
by leeches, ice, etc., and soothing, especially by inhalations.
Afterward, abscesses must, if accessible by means of the laryngoscope,
be opened. Artificial feeding, through either an oesophageal or a
rectal tube, may become necessary. Schrötter's hard-rubber tubes may be
inserted to conduct air to the lungs, but tracheotomy, not laryngotomy,
must be performed if, in spite of this tubage, suffocation threatens.
The methodical dilatation of post-perichondritic laryngeal stenosis
requires special bougies, catheters, hard-rubber tubes, pewter plugs,
and dilators which are not to be found in the ordinary armamentarium of
a medical practitioner; but the proper and frequently successful use of
these can be acquired with patience and perseverance when a case of the
kind presents itself for treatment.
Chronic Laryngitis.
DEFINITION, SYNONYMS, AND CLASSIFICATION.--Under the name chronic
laryngitis are brought together a number of different diseases of the
larynx which have the character in common that they are more or less
inflammatory and chronic in their course. The various conditions of
chronic inflammation of the mucous membrane (chronic laryngeal catarrh)
prominently belong to this category, but the chronic inflammation of
every other constituent tissue of the larynx, except cartilage and
perichondrium, is included.
The synonyms refer mostly to individual etiological and other factors
not applicable to all cases, as clergymen's laryngitis, phthisical
laryngitis, and many of the designations of different classes.
Chronic laryngitis frequently involves more than one tissue, but
usually one prominently. Histologically, the following kinds of chronic
laryngitis have been distinguished: viz. catarrhal, when simply or
principally the mucous membrane is affected; granulous or glandular,
when the muciparous glands; submucous or parenchymatous, when the
connective tissues underneath the mucous membrane are prominently
implicated; and muscular, when there is chronic inflammation of the
muscular tissue. According to the seat, there will be supraglottic,
glottic, and infraglottic chronic laryngitis. There have also been
described atrophic, hypertrophic, and polypoid chronic laryngitis; dry
and blenorrhoeic or hypersecreting chronic laryngitis; simple, fetid or
ozænic, and ulcerative; phlebectasis laryngea, trachoma, etc.
ETIOLOGY.--Chronic laryngitis is caused in many ways. Frequently it
follows uncured or neglected acute laryngitis. It is apt to occur in
persons whose avocations or habits lead them to strain or otherwise
abuse their vocal organ, to work in an impure or irritating atmosphere,
or to use tobacco or alcohol excessively; and it may depend upon or be
an extension of chronic inflammation of either the naso-pharyngeal or
tracheo-bronchial mucous membrane. Secondarily, it accompanies all
long-continued laryngeal affections, such as phthisis, syphilis, lupus,
etc. Males suffer more often than females, and middle-aged persons more
often than either children or the very old. Boys at the time of puberty
are liable to become affected.
SYMPTOMATOLOGY.--The diseases comprised under the collective name of
chronic laryngitis give rise to various symptoms, of which the chief
are {122} morbid sensations in the region of the larynx and alteration
of the voice. Unless ulceration have occurred, the morbid sensations
hardly amount to pain, except on acute exacerbation from catching cold
or after long-continued use of the voice. They consist in a sense of
dryness or of pressure, in a tickling or in an unnatural feeling that
cannot be definitely described in words. Though not acute, they are
sufficient to make the patient constantly conscious of their existence
and to induce fruitless efforts at clearing the throat, etc. The
alteration of the voice varies from occasional unsteadiness or veiling,
or a loss of power or purity of tone, to different degrees of
hoarseness, dysphonia, and even aphonia. In singers and public speakers
the disease interferes sometimes with professional vocal efforts only,
ordinary conversation not being affected. The voice is best, sometimes
worst, after a night's rest, and in either instance changes after
moderate use for worse or better as the case may be; but long-continued
exercise is always harmful. The voice is comparatively easily fatigued,
and then the vocal organ becomes positively painful.
In addition to the two chief and constant symptoms there are others
that may or may not be present, and which sometimes assume even greater
prominence than the modification of the voice. Thus, secretion, which
in most cases is very slight, glassy grayish, and viscid, is
occasionally very abundant, yellowish, or darkish, or more rarely still
mixed with streaks of blood and in clumps, though not sticky or dried
into scabs, and is sometimes so fetid that the patient's breath is
exceedingly malodorous. Cough, which in most cases is either absent or
comparatively trifling, barking, or hacking, occasionally is the most
troublesome of all the symptoms. Dysphagia is sometimes present even in
simple or mild cases. In severer cases, in the later stages, especially
in syphilitic and phthisical chronic laryngitis, swallowing becomes
painful and difficult, or even impossible. Dyspnoea occurs only from
accumulations of phlegm in the larynx, and is then lessened after
expectoration, or it may depend upon the diminished lumen of the
laryngeal cavity on account of thickening of the walls, as it is
especially apt to do in subglottic chronic laryngitis, or on account of
so-called polypoid hypertrophies in simple cases, gummata or
cicatricial tissue in specific cases, etc. Dyspnoea may become so
urgent as to require tracheotomy.
PATHOLOGY AND MORBID ANATOMY.--In catarrhal chronic laryngitis there is
congestion of the mucous membrane, dilatation of the blood-vessels, and
altered secretion. The mucous membrane becomes, as a rule,
hypertrophied, tougher, and more firmly connected with the subjacent
tissues. Laryngeal venous congestion (so-called phlebectasis laryngea)
is occasionally, though rather rarely, met with; and still more rare is
a hemorrhage from the surcharged vessels in chronic cases. In granular
or glandular chronic laryngitis--_i.e._ when the muciparous glands are
prominently involved in the inflammatory process--they form elevations,
making the surface uneven, and the tissues become tenser and more
compact. When the submucous connective tissue takes much part in the
process the hypertrophy is still greater, and not only may the lumen of
the laryngeal cavity become greatly diminished, but projections of
various lengths (the so-called cellular polypi and papillary
excrescences) are apt to occur. The objective term tuberosa is
sometimes added to laryngitis or to the designation for inflammation of
a portion of the larynx; as, for example, that of the vocal bands--viz.
chorditis tuberosa, when small whitish, tumor-like elevations occur.
These, especially on the vocal bands, where they have been described by
Tuerck, Elsberg, Cohen, and others, are also called trachomata. In
cases to which the name muscular chronic laryngitis is given the
muscular tissue has been found prominently hypertrophied. Moura
Bourillou has recorded a case in which the striated fibres of the
posterior crico-arytenoid muscle were converted into fibrous tissue. In
many of {123} the common cases of catarrhal chronic laryngitis the
alteration of the voice depends upon paralysis of the
muscles--especially the thyroid arytenoid and the arytenoid--directly
caused by the transmitted inflammation and by thickening of the
overlying mucous membrane. In fetid chronic laryngitis there is usually
found excoriation of the mucous membrane, and atrophy. That
erosions--_i.e._ superficial ulcerations extending no deeper than the
epithelial layer--frequently occur in the course of catarrh is admitted
by everybody, but much unnecessary discussion has been indulged in
concerning the question whether deeper ulcerations of the mucous
membrane can ever take place under these circumstances. It has been
insisted upon that catarrhal ulcerations never occur. This is a
mistake, but it is true that catarrhal ulceration is rare unless the
patient is greatly debilitated or cachectic. Ulcerative chronic
laryngitis in the majority of cases depends upon some cachexia--_i.e._
tuberculosis, syphilis, lupus, lepra, etc.
Tuberculous chronic laryngitis--laryngeal phthisis proper--frequently
accompanies pulmonary consumption. Usually it follows, but occasionally
precedes, the latter. Unquestionably, it also occurs, though rarely,
without any disease in the lungs. Anæmia of the laryngeal mucous
membrane is present from the first, and usually persists throughout.
There is a low form of inflammation, swelling of the tissue, and then
ulceration, the ulcers being at first small, and afterward coalescing
to form larger ones. Much destruction may take place, and more or less
oedema is always present. Paralysis of some of the interior laryngeal
muscles may also occur, depending alike upon anæmia and oedematous
infiltration of the muscular substance, or upon compression of the
nerve-tracts by enlarged lymphatic glands (most frequently on the right
side) or upon involvement of the nerves--pleuritic adhesions,
tuberculous deposits, etc.
Syphilitic chronic laryngitis is a local manifestation occasionally of
hereditary, but usually of acquired, syphilis. It may vary from a
slight erythematous condition of the mucous membrane to intense
inflammatory thickening or destructive ulceration, may be accompanied
by laryngeal oedema and pericarditis, and may lead to dangerous
adhesions, cicatrizations, and stenosis. The chronic laryngitis
occurring in lupus and lepra and in malignant diseases of the larynx
partakes of the character of these processes, and is accompanied by
their peculiar thickenings, tuberosities, granulations, and
ulcerations.
DIAGNOSIS.--Chronic alteration of voice, local morbid sensation, and
other symptoms mentioned may lead us to suspect the presence of chronic
laryngitis, but are insufficient for diagnosis without mirror
examination. The diagnosis can be positively made only by means of the
laryngoscope, and even by this means requires care. It is of the utmost
importance that the physician make himself perfectly familiar with the
appearance of the healthy larynx by the particular illumination he uses
for examining patients.
A very able laryngoscopist, Carl Michel of Cologne, confesses[6] that
he has many times diagnosed chronic laryngitis when none existed, and
explains that with inadequate illumination the contours of the small
vessels run into one another and make the whole surface which they
traverse appear red. In simple chronic laryngitis the redness has a
somewhat livid look; in syphilitic chronic laryngitis it is darker and
more angry-looking; in phthisical cases it is duller, even though the
mucous membrane be congested, while usually it is pale. In both the
latter diseases the swelling is greater, the natural contour of the
parts more changed, and destruction more imminent than in the simple
chronic laryngitis. When oedema is present there is a peculiar
transparent or translucent appearance. In subglottic chronic
laryngitis, especially when {124} much hypertrophy has already taken
place, the color is often quite light grayish instead of red.
[Footnote 6: _Practische Beiträge zur Behandlung der Krankheiten des
Mundrachenhöhle und des Kehlkoffes_ (Leipzig, 1880).]
Phlegm found in the larynx may have come from the bronchial tubes or
the trachea; when it is cleared away by cough or otherwise, the larynx
may prove to be unaffected. In all cases of suspected secondary chronic
laryngitis, phthisical, syphilitic, etc., the state of the lungs and
whole respiratory tract, as well as the general health in every
respect, hereditary tendencies, and past diseases, must be carefully
inquired into.
PROGNOSIS.--The prognosis of chronic laryngitis is good as to life
except in broken-down constitutions, neglected exacerbations, and grave
underlying affections; but, even with these exceptions, it can be said
to be favorable as to cure only with expert local treatment and if no
severer tissue-alterations, usually hypertrophic, have as yet taken
place. If the latter have taken place--especially if the submucous
tissues are prominently involved--the organ can seldom be restored to
perfect integrity. For persons in ordinary vocations and situations in
life the recovery that can generally be secured may be entirely
satisfactory, but more exacting demands on the speaking and singing
voice require special measures, including hygienic precautions, to be
carried out carefully, and sometimes to be long continued.
BY J. SOLIS COHEN, M.D.
TREATMENT.--Whatever the grade or stage of a chronic laryngitis, the
constitutional condition or proclivity of the patient always requires
suitable hygienic, dietetic, and therapeutic management. The repair of
regional or local morbid conditions may often be confidently entrusted
to such constitutional measures; and it is only when these morbid
conditions resist the influence of systemic treatment, or are of some
special character obviously insusceptible to such influence, that
topical medication or actual surgical procedure becomes requisite in
addition. The accessibility of the interior of the larynx to
instrumental manipulation under laryngoscopic guidance offers great
temptations for topical interference. The result is, that the diseased
larynx is sometimes submitted to unnecessary, and even injurious,
direct attack at the hands of a dexterous manipulator untrained in
general practice, and consequently ignorant of the beneficial influence
of purely constitutional measures upon many local morbid conditions.
While it is highly proper, therefore, to utter a few words of caution,
it is equally proper to assert that many local conditions are entirely
beyond the control of systemic measures, and require topical treatment.
Constitutional Treatment.--Simple or catarrhal chronic laryngitis,
unassociated with special diathesis, is often admirably influenced by
the prolonged administration of some preparation of cubeb; the
oleoresin being preferred by the writer in doses of from fifteen to
twenty-five minims for the adult, three times a day on crushed sugar.
This drug being eliminated in part by the bronchial tract, it seems
especially adapted to exert upon chronic inflammatory conditions of the
aërial mucous membrane that healing process which it is known to exert
on mucous membrane elsewhere. Among other useful constitutional
remedies from which similar service can be expected may be enumerated
compound tincture of benzoin in doses of from thirty to sixty minims
for the adult, three or more times daily; fermented infusion of tar or
tar beer, several ounces daily; and petroleum mass, one to two grains
for the adult, three or four times daily, with pulverized extract of
glycyrrhiza in pill or capsule. In cases with deficient secretion
ammonium chloride is indicated. In cases associated with impaired
digestion, with excess of acidity, the {125} prolonged use of alkaline
mineral waters is advisable; preferably, if convenient, at their
sources. In cases associated with chronic diarrhoea the mineral acids
are indicated. Cod-liver oil, hydrated chloride of calcium, and
preparations of iodine and of arsenic are useful in patients of the
scrofulous diathesis. Iodoform, one grain for the adult, rubbed up with
glucose or some other excipient, in pill or capsule, three times a day,
is often useful in patients with the tuberculous diathesis. Specific
remedies are required for syphilis. In like manner, any constitutional
abnormality is to be systematically attacked.
The functions of skin, kidneys, and intestine are to be maintained as
nearly normal as may be, or even a little in excessive action from time
to time for derivative purposes. Abstinence is to be enjoined from all
exposures or indulgences deleterious to the parts diseased; with as
sparing a use of the voice as is compatible with ordinary domestic or
social demands, and absolute rest for prolonged periods of days at a
time whenever unusual demands have resulted in exacerbating the malady.
Under such treatment many cases of simple catarrhal or glandular
chronic laryngitis may get well, as has been intimated, without any
special local measures.
Topical Treatment.--The difficulty of impressing patients with the
necessity of submitting to these hygienic measures and to dietetic
restrictions, and for avoidance of occupations or habits which favor or
maintain the condition of chronic inflammation, renders topical
treatment necessary in many instances. Direct instrumental medication
requires the personal attention of the medical attendant. Medication by
inhalation or insufflation may be entrusted to the patient or the nurse
in most instances. In instituting a course of topical treatment several
things must be taken into consideration, such as the condition of
hyperæsthesia, hypersecretion, insufficient secretion, congestion,
hemorrhagic infiltration, hemorrhage, hypertrophy of tissue or
tissue-elements, erosion, fissure, ulceration, and excessive
granulation. The first three of these furnish the clue to the nature of
the home-treatment, the remainder to that required at the hands of the
physician. The home-treatment is to be directed to keeping the parts
clean and comfortable; the manipulation of the physician is to be
directed toward overcoming special pathological conditions.
Should secretion be defective, alkaline sprays inhaled at regular
intervals, for a few minutes at a time, tend to augment secretion and
to facilitate the detachment of adherent mucus. For the purpose choice
may be made of the following drugs in the proportion of about five
grains to the ounce for the adult, dissolved in distilled water or
tar-water, with the addition of a sedative when the parts are
hyperæsthetic, or an opiate when they are painful: ammonium chloride,
sodium borate, sodium bicarbonate, sodium chloride, sodium chlorate,
sodium iodide, potassium iodide, potassium chloride. The spray should
be propelled by means of compressed air, with what is known as the
hand-ball atomizer, in preference to steam, the effect of which is too
relaxing in most instances. A few drops of some aromatic or balsamic
product will render the spray more agreeable in many instances. Should
these agents fail, pyrethrum or jaborandi may be found more
serviceable, in the proportion of from one to five minims of the fluid
extract to the ounce of water.
Should secretion be excessive, astringents are indicated; and choice
may be made from alum, five grains to the ounce of rose-water; tannic
acid, two or three grains; zinc sulphate or zinc sulphocarbolate, two
grains; lead acetate, two grains; ferric chloride, one grain; and
silver nitrate, half a grain to the ounce. Personal supervision of the
initial inhalations is requisite to ensure proper use of the spray.
Whether the medicament is to be propelled directly into the larynx by
means of a tube with a vertical tip to be passed beyond the tongue, or
to be inhaled by efforts of inspiration from spray projected
horizontally, will depend upon the skill of the individual using it.
Hard-rubber {126} spray-producers are furnished with series of tips, so
that either method may be employed. When the horizontal tip is used,
the instrument should be held some distance from the mouth, so that the
spray may be deflected into the larynx by the act of inspiration. When
the tube is placed within the mouth most of the spray becomes condensed
upon the pharynx, and very little can be drawn down into the larynx. As
metallic tubes are liable to become reduced by certain
remedies--ammonium chloride, for instance--tubes of glass or of hard
rubber are to be preferred.
Should a steam apparatus be employed, the patient should remain housed
for half an hour after inhalation, except in very warm weather. In
cases of hyperæsthetic mucous membrane the home inhalation of volatile
remedies daily is often useful. Compound tincture of benzoin,
camphorated tincture of opium, oil of pine, oil of turpentine,
terebene, eucalyptol, creasote, carbolic acid, may be inhaled from a
bottle containing hot water or from a special inhaler, a few drops of
chloroform being advantageously added when there is a good deal of
irritative cough. A few drops of the more pungent volatile substances,
such as terebene, eucalyptol, and creasote, may be dropped on the
sponge supplied with the perforated zinc respirator of Yeo of London,
and the apparatus be worn for an hour or longer continuously. In cases
with excessive secretion and in syphilis, ethyl iodide is indicated as
a remedy appropriately administered by this method. When the parts are
very irritable, a respirator of this kind or some similar contrivance,
or a fold or two of woollen or silk gauze worn in front of the mouth
and nose while in the open air, will often protect the tissues from too
cool an atmosphere, and enable the patient to bear exposure with
comfort.