physician usually chooses between powder and solution. Powders are
usually propelled by a puff of air through a properly curved tube,
whether from a rubber ball, a reservoir of compressed air, or the
mouth. The mouth allows the most delicate and accurate application, but
the mouthpiece should be protected by a valve from receiving a return
current when the patient coughs. Solutions may be applied by means of
pipette, syringe, brush, cotton wad, or sponge, according to
indications. A fragment of sponge securely fastened to a properly-bent
rod or pair of forceps is the safest and most effectual material for
positive contact against a limited surface, and a brush the best for
painting larger surfaces. The use of the cotton wad involves a slight
risk of leaving a detached shred of fibre in the larynx, but renders
the manipulation less unpleasant to the patient than the use of the
sponge, and is less irritating to the mucous membrane. Spasm of the
larynx is usually excited the first time that a medicinal application
is made within it, and even death by suffocation has followed the
incautious use of powerful agents. Hence strong solutions should not be
used until the tolerance of the parts has been sufficiently tested by
weak or innocuous ones. The remedies which have been employed topically
for intra-laryngeal medication seem to include every available
medicinal agent that could be mentioned, from rose-water to the
incandescent cautery. The list of really useful ones is not very long.
Those upon which the most reliance is placed by the writer comprise
tannic acid (a saturated glycerite), zinc sulphate (thirty grains to
the ounce of rose-water), and silver nitrate (forty to sixty grains to
the ounce) in obstinate and protracted cases of simple chronic
laryngitis; iodine and carbolic acid, singly or in combination (one
grain or more to the ounce of glycerin), and chinoline tartrate or
salicylate (five or more grains to the ounce), in cases attended with
infiltration; iodoform (finely pulverized or in recent saturation in
sulphuric ether) in ulcerative or proliferative tuberculosis; and
iodoform and acid solution of mercuric nitrate (one part to ten or
twelve of water) in progressive ulcerative syphilis resisting
appropriate constitutional treatment. Other {127} astringents in the
simple varieties; resorcin in the glandular, hypertrophic, polypoid,
and tuberculous varieties; chromic acid and incandescent metal in the
circumscribed hypertrophic and in the polypoid varieties; and zinc
chloride and copper sulphate in the syphilitic varieties,--proffer
additional resources. These applications are to be made at intervals of
one day or more, according to results. Hyperæsthesia and pain, whether
of the larynx or of parts adjacent, can usually be subdued by the local
anæsthetic effect of solutions of erythroxyline hydrochloride (2 per
cent. or stronger) applied at intervals of a few hours, or even by the
fluid extract or a strong aqueous infusion of the erythroxylon-leaves.
Before the anæsthetic effect of this drug was known, morphine powder
(one-eighth to one-fourth of a grain, alone or associated with tannin
or with iodoform) or aqueous solutions of morphine salts and of aconite
were employed to relieve pain and obtund sensitiveness. The oleate of
morphine (2 to 4 per cent. solution) and the oleate of aconitine (2 per
cent. solution) are similarly useful. Morphine, by its constitutional
influence, is preferable to erythroxyline in some instances, though
less prompt in its effects. Where ulcerative processes at the top of
the larynx or thereabouts entail odynphagia, these preparations should
be used before administering nourishment. The use of erythroxylon
products may be entrusted to the nurse or to the patient with
comparative safety. Morphine and aconite should be applied only by a
medical attendant or an exceptionally skilled nurse. Before any
medicinal curative or reparative agent is applied the parts should be
thoroughly cleansed of suppurative and secretory products. This may be
done with sprays of alkaline solutions--five or more grains of sodium
borate or bicarbonate, for example--dissolved in pure water, in
tar-water, or in an emulsion of coal tar. An excellent agent,
especially in the presence of pus, is hydrogen dioxide, usually
furnished in a 10-volume solution which should be diluted with two or
more parts of distilled water. It is likewise disinfectant and gently
stimulant to mucous membrane. The manipulations by the physician
preparatory and medicatory should be performed laryngoscopically,
otherwise the entire procedure must be haphazard.
Neoplasmata and fungous growths may require removal should they
interfere with respiration. In the presence of stricture, surgical
interference by tracheotomy may become requisite. Elsberg, according to
the testimony of his assistant, Schweig, seems to have been
particularly favorable to the performance of this operation in
obstinate cases of ulcerative laryngitis of whatever character, and
even in protracted non-ulcerative cases, for the purpose of securing
physiological rest to the parts, although the procedure might not be
indicated to relieve any embarrassment in respiration. The writer's
experience in tracheotomy as a factor in producing rest has not been
favorable, such a result being usually defeated by the cough so
frequently following a tracheotomy, no matter how well-adjusted a tube
may have been inserted. His recommendation, therefore, is limited to
cases of embarrassment to respiration due to stricture or constriction
unamenable to intra-laryngeal interference.
Morbid Growths of the Larynx.
DEFINITION.--Neoplastic formations, benign and malign, in the interior
of the larynx, in its cartilaginous framework, in its
investment-tissues, or upon the exterior of the organ.
ETIOLOGY.--Inflammation of the mucous membrane, local irritation or
injury, ulceration, cell-proliferation, and excessive granulation seem
to be the exciting causes of benign neoplasms. They follow on
laryngitis, whether catarrhal, syphilitic, tuberculous, exanthematic,
toxic, or traumatic. They {128} are quite common, so to speak, several
thousands of cases being on record, and as many or more probably being
unrecorded. Heredity does not seem to play any special part in their
production. They are occasionally congenital, and may be developed at
any age; but they are encountered the most frequently in subjects
between the ages of thirty and sixty years, probably because of the
greater exposure to laryngitis attending the activity incidental to the
prime of life. Males are affected far more frequently than females,
probably on account of greater exposure to sources of laryngitis.
Benign growths are sometimes followed by malign growths in recurrence,
and are sometimes converted into malignity by irritation, whether
physiological, mechanical, or instrumental. Malign growths are
attributed to cold, chronic laryngitis, and traumatism as the initial
exciting causes. Butlin suggests a cryptogamic origin. They are far
more common in males than in females, and occur chiefly between the
ages of twenty-five and seventy, but they have been noted as occurring
exceptionally much later, and even as early as the first year.
PATHOLOGY AND MORBID ANATOMY.--By far the greater number of laryngeal
morbid growths belong histologically to the category of benign
neoplasms, but the important location they occupy often renders them
clinically malign. By far the greater number of benign growths are
papillomas, perhaps fully two-thirds, although Elsberg has reported
that but 163 instances were papillomas out of 310 seen in his own
practice.[7] This has been an exceptional experience. Then we have
fibromas, myxomas, adenomas, lymphomas, angeiomas, cystomas,
ecchondromas, lipomas, and composite neoplasms. Laryngeal morbid
growths, too, occasionally undergo the fatty, colloid, or amyloid
degenerations. Papillomas are frequently multiple, and most frequently
sessile, but the other benign neoplasms are most frequently single and
are more often pedunculated. All this class of morbid growths affect
the anterior half of the larynx more than the posterior. They are most
frequent on the vocal bands or very near to them, although they may
occupy any portion of the larynx. They vary in size from the smallest
protuberance to a bulk sufficient to block up the cavity of the larynx
and even project above it. The dimensions of the greater number of
papillomas vary from the size of a pea to that of a small mulberry.
Other benign neoplasms rarely reach the bulk attained by papillomas.
[Footnote 7: _Archives of Laryngology_, p. 1, New York, 1880.]
Malign growths are far less common than benign ones. They comprise both
sarcomas and carcinomas. Sarcomas occur in the varieties of
spindle-celled, round-celled, giant-celled, mixed-celled, fibrosarcoma,
lymphosarcoma, and myxosarcoma. Some attain only the size of small
beans, and few exceed the size of a pigeon's egg. The majority of them
are primary growths. Most of them originate in the interior of the
larynx, whence they may extend by contiguous infiltration, even
penetrating the laryngeal walls. The vocal band and the ventricular
band are the most frequent seat. The epiglottis is a common seat. These
growths appear either in irregular, smooth, spheroid masses, or
nodulated, mamillated, and dendritic. They are much the more common in
males, and occur chiefly in subjects between the ages of twenty-five
and fifty. Their growth is slow for a year or more, and then becomes
more rapid.
Carcinoma is much more common than sarcoma. It is most frequently
primary, and primarily limited to the larynx, but occurs likewise in
extension of carcinoma of the tongue, palate, pharynx, oesophagus, or
thyroid gland. It rarely extends to the oesophagus or penetrates the
laryngeal walls.
Squamous-celled carcinoma or epithelioma is the commonest variety,
large spheroidal-celled or encephaloid being much less frequent, and
small spheroidal-celled and cylindrical-celled occurring still more
rarely. Intrinsic {129} laryngeal carcinoma is usually unilateral at
first, and most frequently in the left side. Its most frequent seat is
at the vocal band. It rarely occurs below this point, and when it does,
as in the five cases analyzed by Butlin,[8] it seems to be at some
point just beneath. Extrinsic laryngeal carcinoma usually begins in the
epiglottis, and sometimes occupies that structure only. It may begin in
a cicatrix in the skin.[9] Carcinoma is the more common in males,
chiefly in subjects between the ages of fifty and seventy. It has
occurred within the first year, at three years, and as late as at
eighty-three years. Carcinoma is liable to extend by infiltration of
tissue and destroy all the contiguous and overlying tissues, so that it
may extend into the pharynx or even externally; the large
spheroidal-celled variety presenting the most frequently progressive
ulceration into contiguous tissue, and the squamous-celled, intrinsic
ulceration. Hemorrhage is frequent. Perichondritis, abscess, necrosis,
and fistula take place in old cases.
[Footnote 8: _On Malignant Disease of the Larynx_, p. 36, London,
1883.]
[Footnote 9: Cohen, _Transactions American Laryngological Association_,
p. 113, 1883.]
SYMPTOMATOLOGY.--Small growths in localities where they neither provoke
cough nor interfere with voice or respiration may run their course for
a long time without giving rise to any symptoms at all. Growths of
larger size, pedunculated growths, and growths located upon important
structures give rise to interference with voice, respiration, or
deglutition as may be--to cough, and even to pain. Dysphonia is due to
mechanical interference with vibrations of the edges of the vocal
bands; aphonia, to mechanical interference with their approximation;
diphthonia, to mechanical interference at an acoustic node. These
manifestations may be permanent or intermittent. Dysphonia is one of
the earliest symptoms of carcinoma, and is usually continuous for a
number of months before any other indication. Aphonia in carcinoma is
often due to nerve-lesion. Dyspnoea is due to some considerable
mechanical occlusion of the respiratory tract, whether by the growth
itself or in consequence of oedema or of intercurrent tumefaction. It
is inspiratory rather than expiratory, and subject to aggravation at
night. As with the dysphonia, it varies with the size, location, and
mobility of the growth and the position of the head and neck. It may be
intermittent or permanent; be slight or severe; or it may terminate in
apnoea by spasm, by mechanical occlusion of the calibre of the larynx,
or by impaction of the growth at the chink of the glottis. Marked
encroachment on the breathing-space is not accompanied with as marked
dyspnoea as in acute processes, the parts seeming to acquire tolerance
during the slow growth of neoplasms.
Dysphagia is due to a growth at the top of the larynx or on some
portion of its pharyngeal surface. It is quite frequent in carcinoma,
preceding dysphonia in the extrinsic varieties. It may be associated
with regurgitation of food, drink, or saliva into the larynx,
provocative of paroxysms of suffocation. Cough is due to growths which
project from the vocal bands or press upon them, or to hemorrhage or
accumulation of secretory or suppurative products. Hemorrhage, cough,
and expectoration of bloody and fetid masses are indicative of
carcinoma. Pain is usually due to intercurrent conditions. Aches in the
part and sensations of the presence of a foreign substance are more
frequent. Intense pain is exceptional in benign neoplasmata; it is
often an early symptom in carcinoma, in which it is apt to radiate
toward the ears and along the neck. Epileptic seizures and vertigo are
sometimes occasioned by reflex influence. Exceptionally, large growths
may produce change in the external configuration of the larynx. The
general health is not much involved in benign growths, unless they
interfere seriously with important physiological functions. Impaired
health is far less manifest in sarcoma than in carcinoma. Emaciation,
pyresis, and marasmus eventually occur as constitutional manifestations
of malign growths.
{130} DIAGNOSIS.--Laryngoscopic inspection usually reveals the growth
and furnishes the best means of diagnosis. Intra-ventricular and
subglottic growths may elude detection. Palpation is sometimes
available, especially with children. Palpation with probes under
laryngoscopic inspection is sometimes requisite to determine the
mobility of a growth, its form and seat of attachment, and even its
size. It seems, too, to discriminate a neoplasm from an eversion of a
ventricle. While the histological character of a growth cannot be
definitively decided by laryngoscopic inspection, the varieties present
a series of characteristics sufficiently pronounced for approximative
discrimination. Papillomata are often multiple, usually sessile, and
usually racemose or dendritic. Some are white, but the majority are
red, and the tinge varies from one extreme of the tint to the other.
Some are as small as the smallest seeds; most of them have a bulk
varying from that of a pea to that of a berry; some of them are so
extensive as to appear to fill the larynx or even project above its
borders. They are far the most frequent in the anterior portion of the
larynx, and are often located upon a vocal band. Fibromata are most
frequently single, smooth and pedunculated, and red. Some are white or
gray. Some are vascular. When fully developed they vary in size from
small peas to large nuts. They are more frequent upon a vocal band.
Their development is slower than that of papillomata. Myxomata are
usually single, smooth, pyriform, and pedunculated. They are usually
red or reddish. Their ultimate size varies from that of grains of rice
to that of Lima beans. They are most frequent at the commissure of the
vocal bands. Angeiomata are usually single, reddish or bluish, vary in
size from that of small peas to that of berries, and are most frequent
on the vocal bands. Cystomata are usually globular, sessile,
translucent, and white or red. They are most frequent in a ventricle or
on the epiglottis. Their size varies from that of hempseed to that of
peas. Ecchondromata are usually developed in the posterior portion of
the larynx. Other benign growths are very rare, and do not seem to
present special features for recognition by laryngoscopic inspection.
Sarcomata are usually present as sessile, hard, well-circumscribed
growths, smooth or lobulated. Some are dendritic on the surface, but
not to the extent noticed in papillomata, and their location at the
posterior portion of the larynx would suggest their true character, for
papillomata rarely occupy this position except in tuberculosis.
Superficial ulceration occurs in some cases, but is not extensive.
There is no peculiarity in the color of the mucous membrane, which may
be paler or redder than is normal. The lymphatic glands are not
involved.[10] Carcinomata present first as diffuse tumefactions in
circumscribed localities, gradually undergoing transformation into
well-formed growths, then nodulation, and then ulceration. Meanwhile,
especially in extrinsic varieties, the submaxillary and the cervical
lymphatic glands become successively involved and tumefied.
Squamous-celled carcinoma becomes pale, wrinkled, and nodulated, and
sometimes dendritic. Large spheroidal-celled carcinoma becomes
nodulated, dark, and irregularly vascular, and finally ulcerated,
perhaps at a number of points. In the ulcerative stage of carcinoma of
the epiglottis and of the interior of the larynx discrimination is
requisite from syphilis and from tuberculosis. In all cases of doubt as
to malignancy, laryngoscopic inspection should be supplemented by
microscopic examination of fragments detached for the purpose. The
early detection of sarcoma may lead to surgical measures competent to
save life--a remark applicable, perhaps, in a far more limited degree
to intrinsic carcinoma.
[Footnote 10: Butlin, _op. cit._, p. 14.]
PROGNOSIS.--The prognosis is usually good in benign growths submitted
to proper surgical treatment. Left to themselves or treated
medicinally, the prognosis is bad both as to function and to life. Such
growths are occasionally expectorated after detachment during cough or
emesis. Some {131} occasionally undergo spontaneous absorption. Some
remain without change for years. Most of them enlarge and compromise
life as well as function. Recurrence occasionally follows thorough
removal, and this recurrence is occasionally malign in character.
Repullulation frequently follows incomplete removal. The prognosis is
favorable in sarcomata, provided thorough eradication can be
accomplished by surgical procedure. Incomplete removal is followed by
repullulation or recurrence. Unsubmitted to operation, sarcoma will
destroy life either mechanically by apnoea or physiologically by
asthenia.
The prognosis is unfavorable in carcinoma. Recurrence takes place as
the rule despite the best devised resources of surgery. Intrinsic
carcinoma offers some hope of success to the surgeon; extrinsic
carcinoma, little if any. Life is shortest in the large
spheroidal-celled, and longest in the small spheroidal-celled variety,
other conditions being equal. Death may take place by apnoea or
asthenia, as in sarcoma, or by hemorrhage, collapse, or pyæmia.
Submitted to tracheotomy at the proper moment in cases in which death
is threatened by occlusive dyspnoea, life is prolonged and suffering
mitigated. The fresh lease of life is longest in the squamous-celled
variety.
TREATMENT.--The essential treatment is surgical, and to surgical works
the reader must be referred for details. Suffice it to say that when a
benign growth is small and does not embarrass respiration, it need not
be attacked at all, unless its interference with the voice deprives the
patient of his means of livelihood. The majority of benign growths are
accessible to instruments passed through the mouth. Some require
external incision into the larynx, whether partial or complete. The
intra-laryngeal procedures in vogue include cauterization, both
chemical and by incandescence, incision, abscission, crushing,
brushing, scraping, and evulsion. According to the character and
location of the growth, direct access from the exterior is practised by
infra-hyoid pharyngotomy, by partial or complete thyroid laryngotomy,
mesochondric laryngotomy, cricoid laryngotomy, complete laryngotomy,
laryngo-tracheotomy, or tracheotomy, as may be indicated.
The thorough eradication of sarcomata usually requires a direct access
by section of the thyroid cartilage or even of the entire larynx. This
procedure failing or appearing insufficient, partial or even complete
laryngectomy may be necessary. Temporizing is of no avail.
The treatment of carcinoma is palliative, unless it be decided
advisable to attempt eradication, which may offer some chance of
success in intrinsic carcinoma still confined to the larynx.
Laryngectomy may be unilateral in some instances, and must be bilateral
in others. Unilateral laryngectomy is the more hopeful. Eradication
proffers no hope in cases of extrinsic carcinoma in which the growth
has passed the boundaries of the larynx. After recovery from the
laryngectomy an artificial appliance may be adjusted to the parts for
the purpose of supplying a mechanical method of producing sound in the
larynx for speaking purposes. Should no radical procedures be
instituted, treatment is relegated to general principles, with
prophylactic performance of tracheotomy in the presence of dangerous
occlusion of the larynx. The voice should be used but little. All
sources of laryngitis should be avoided. Ergot or hamamelis may be
given to restrain hemorrhage, and morphine to relieve pain and secure
sleep. Sprays can be used to keep the parts free from morbid products.
Erythroxyline may be applied to produce local anæsthesia as required.
Semi-detached portions of growth may be removed from time to time.
Nourishment may be given by the bowel when necessary, and so on as in
other diseases of the larynx in which the functions of respiration and
deglutition are seriously impaired. Medicinally, arsenic may be given
in the early stages, as that drug is conceded to possess some slight
retarding influence on the growth of carcinoma.
{132} Lupus of the Larynx.
Lupus is rare in the larynx. It usually occupies the structures above
the vocal bands. It is most frequent in females, and usually associated
with cutaneous lupus.
ETIOLOGY.--Scrofulosis and syphilis seem to be the predisposing causes.
Climate may have some influence. The reason of the special proclivity
of the female is undetermined. Of 9 reported cases, records of which
are before the writer, 8 were in females.
PATHOLOGY AND MORBID ANATOMY.--Laryngeal lupus is usually an extension
of the disease from the upper lip or the nose, extending along the
nasal passages, pharynx, and palate. Destructive ulceration takes
place, with irregular cicatrization and the formation of hard nodules
of hyperplastic tissue of irregular conformation, varying from the size
of hempseeds to that of small peas, similar to the cutaneous buccal and
pharyngeal nodules.
SYMPTOMS.--These include dysphonia, dyspnoea, dysphagia, and cough.
Pain is exceptional.
DIAGNOSIS.--Laryngoscopic inspection reveals the characteristic
nodulation, the nature of which is inferred from the coexistence of
external lupus. The disease may be confounded with lepra, syphilis,
tuberculosis, or carcinoma. Discrimination from syphilis is the most
difficult, and is predicated chiefly on its slow progress and on the
absence of constitutional manifestations.
PROGNOSIS.--This is unfavorable. The reported cures seem to have
occurred only under the influence of antisyphilitic treatment.