=Kyle, M. D., D. Braddon.—Initial Forms of Tubercular
Laryngitis.=—_Inter. Med. Mag._, March, 1900.
The enumeration and exact description of these prodromal symptoms are so
important that we copy them in full.
The following, which is a translation of an article by Monsarrat of
Paris (_Rev. Hebdom. Laryngol., d’Otol., et de Rhinol._, No. 43, October
28, 1899), covers the ground so thoroughly that it is worthy of
repetition:
“Laryngeal phthisis completely developed presents multiple and varied
symptoms, some more characteristic than others. In one patient are found
symptoms functionally grave, out of proportion to the lesions relatively
benign. In another, physical signs take first place; there may be an
ulceration completely obliterating one cord, or considerable œdema of
the arytenoids and vestibule, which closes the opening of the glottis.
Having reached the period when tuberculosis is easily recognized, the
various patients are able to date their laryngitis from diverse
pathologic beginnings. This one will present solely the history of a
cough, the other a raucous voice, in another pain will take precedence.
In mentioning these various modes of commencement we insist on the
connection which may exist between each of them and the localization at
the beginning of tuberculosis, on one or the other parts of that complex
organ known as the larynx. Let us divide the symptoms into the
functional and the laryngoscopic. The connection or antithesis between
them will be noticed.
“An initial symptom, quite frequent in tubercular laryngitis, is,
without a doubt, cough. This symptom, common to all maladies of the
respiratory tract, would have no diagnostic value, except that it is
characteristic. On it alone the diagnosis of laryngeal phthisis could
never be based. At the beginning, cough puts us on our guard, especially
when it is causeless; that is to say, when auscultation of the chest
fails to reveal anything abnormal. This cough is always persistent,
sometimes violent, hawking, and provoking.
“The physical signs of the chest do not correspond to the tenacity of
the cough; it is therefore possible for the larynx to be accused. As
regards this cough, the ‘hemming’ so often described, and which draws
attention most often to a possible rhinopharyngitis, may cause us to
think at the beginning of tuberculosis, but only after examination of
the rhinopharynx has established its integrity. There is a cough, well
known at the beginning of tubercular laryngitis, a little dry cough,
commencing insidiously, often at the moment when the patient is about to
speak, which the individual himself does not notice, but to which his
friends attach an importance too often justified by the outcome. The
cough may be hacking, followed or not by expectoration, and often
accompanied by vomiting. It is certainly right to consider it as a
symptom of the beginning of the disease.
“The speaking voice is often altered, dysphonia appears, and the patient
who is attacked presents little alteration in his larynx; no ulceration,
the cords accurately approximate, and they are very slightly congested;
the laryngeal image does not reveal anything by which this profound
alteration in the voice can be explained. There is no cough. There will
come a time in the disease, however, which will cause us to see that
this, too, is an initial form, and oblige us to give a prognosis
exceedingly guarded.
“The voice may be eunuchoid. Castex has noted it among the tuberculous.
The raucosity of the voice should also recall the statistics which
demonstrate the fact that a fifth of the cases of this condition are
tubercular. But these three symptoms, dysphonia, raucosity, eunuchoid
voice, are also found in other maladies of the larynx; conditions,
however, easily diagnosticated by the laryngoscope. If nothing justifies
these affections of the voice, one should think of tuberculosis. It is
these initial forms, apparently paradoxical, but analogous to that,
which we are going to mention under the subject of pulmonary lesion not
sufficient to provoke cough in the beginning if the larynx has not been
initially affected. The forms that are recognized in the mirror are
evidently very numerous. We will mention some: Congestion of the cords,
monocorditis, recurrent laryngitis, and a nodular form at the free
border of the vocal cords. We do not take into consideration any variety
of ulceration, no matter how insignificant, as for the most part the
velvety aspect of the cords leads us to think at once of laryngeal
phthisis. But this has not appeared at the beginning, and we are only
considering initial forms. The symptoms which we are attempting to
describe are those suggestive of tuberculosis, and we only say that
tuberculosis of the larynx may begin by a nodule, by a congestion, by a
monocorditis, etc.
“Congestion of the vocal cords, whose ætiology is difficult to explain,
often coincides with slight dysphonia, with cough. This congestion,
fugacious, if not tuberculous, disappears with rest, if it is not
aggravated by a chronic rhinopharyngitis. In the majority of cases the
patient returns. Despite a treatment, properly instituted, the
congestion persists; it extends on the cords; it may remain there, or it
may reach over the ventricular bands to the arytenoidal apophyses; this
is a form of commencing laryngeal phthisis, especially if, after a
period of calm, there is found in a patient a new congestion. It is
recurrent laryngitis, another form of initial tuberculosis more grave
than the first. Against laryngitis of this form treatment is of no
avail.
“Another variety of initial tuberculosis is monocorditis. The patient
becomes suddenly aphonic; laryngoscopic examination shows a cord
perfectly red, congestion of which is evident, not only by the color,
but by its altered volume. Contrast with the sound cord is often
striking. Movements of the affected cord may be observed, but it is
generally paretic. Acute monocorditis should cause us to think that it
is an initial form of tuberculosis. This monocorditis often corresponds
to the side of the lungs which is afterward or at that time attacked by
the bacillus. Certain authors admit that this relation is absolutely
constant, and their statistics allow no exception to the rule. On the
other hand, Bayle’s theory, setting forth the direct penetration of the
tubercular infection, becomes less often justified. It is the lymphatic
route which most often produces bacillary infection.
“Tubercular laryngitis may often begin by a nodule situated on the
border of the vocal cords. It is important not to confound it with
singers’ nodules, these latter being more conical and more rounded. The
tuberculous nodule may grow slowly, not ulcerate for a long time;
interfering so little with the speaking voice that the patient often
refuses any intervention. But the day comes when we see this nodule
desquamate, and we may observe the evolution of the tuberculous
ulceration which displaces it. We make no mention of the other forms of
commencement characterized by a congestion of the entire organ, by œdema
of the epiglottis, by a lividity quite characteristic which invades the
entire endolaryngeal mucosa, forms most usual for the tubercular
involvement of the larynx. A form especially noticeable is that which
begins with a sensation of a lump in the throat. It is true that this
variety is not observed except in the nervous; it is not, however, to be
compared to the globus hystericus. Tuberculous patients, in whom the
tuberculous process in the larynx begins with a sensation of a lump in
the throat, may be in very good health, but this particular impression
is often the first symptom which they observe in a laryngitis, which
finally becomes tuberculous. At the moment when the patient complains of
this symptom it may happen that laryngoscopic examination fails to
detect any lesion. It is useless to add that this form is especially met
with in the female. It most nearly resembles that form that begins with
a dysphagia that persists to the end; but at the beginning of tubercular
laryngitis this dysphagia alone is noted without any other symptoms.” So
it can be seen that laryngeal phthisis may begin by a variety of
symptoms, some common, the others rare. It is needless to insist upon
the importance of an early diagnosis.