It must be admitted that operations for the treatment of papillomata do not meet with any great measure of success. It seems probable, however, that the results obtained by endolaryngeal removal are better than those obtained by either tracheotomy or laryngo-fissure. To quote Killian[11]: 'Formerly, and especially from the standpoint of the surgeon, laryngotomy for laryngeal papillomata was very frequently done in little children in whom removal was impossible by endolaryngeal methods. In my judgment, direct laryngoscopy renders such a surgical procedure unnecessary. We can in all cases, with the aid of a tube-spatula under narcosis, remove papillomata, and the operation can be repeated as often as seems necessary.' These remarks express the general feeling of the present day, and the most important factor in determining the success of operative treatment is early diagnosis. Such diagnosis divides the cases into two cla.s.ses: those in which the growths are localized, and those in which they are diffuse. The first cla.s.s is easy to treat by endolaryngeal methods, and, given careful after-treatment, the prognosis is satisfactory. The second cla.s.s is serious, and far more difficult to treat; when Killian's method fails the prognosis is very bad. Finally, it must be borne in mind that, as recurrence may not occur for several months, a guarded prognosis must be given in every case.

[11] _Trans. Amer. Laryng. a.s.soc._, 1907, p. 127. Discussion of paper by C. G. Coakley on 'Removal of papillomata of larynx by direct instrumentation with the aid of Killian's tubes.'

The removal of other benign tumours and of foreign bodies, and the treatment of granulations, are conducted upon similar lines, and are attended with excellent results.

CHAPTER II

EXTRA-LARYNGEAL OPERATIONS

THYROTOMY

=Indications.= This operation is performed for two purposes:

(i) To obtain access to the cavity of the larynx when the diagnosis is uncertain, or as a preliminary to other operations.

(ii) As a method of eradicating certain diseases, of which the following are important:--

1. _Malignant tumours_, both carcinoma and sarcoma, in which an early diagnosis has been made, and so long as they remain intrinsic.

It is advisable to follow Krishaber in the separation of all forms of laryngeal cancer into two cla.s.ses, the _Intrinsic_ and the _Extrinsic_.

The term 'intrinsic' implies a growth springing from the vocal cords, the ventricular bands, the ventricles, or the subglottic s.p.a.ce, and the growth must lie entirely within the laryngeal cavity. 'Extrinsic' is the term used for a growth affecting the arytenoids, the posterior part of the cricoid cartilage, the aryteno-epiglottidean fold, or the epiglottis. Such a growth is not entirely limited to the larynx, but also involves some part of the pharynx.

2. _Extrinsic localized malignant tumours_ which are attached to the epiglottis, or to the aryteno-epiglottic fold.

3. _Innocent tumours_ which are too extensive for endolaryngeal operation or of a doubtful character. In either of these cases it is justifiable to perform an external operation, which may be thyrotomy, or occasionally, an atypical operation: thus Semon[12] removed a large fibromatous tumour of the larynx by submucous resection, without opening the cavity of the larynx.

[12] _Brit. Med. Journ._, 1905, vol. i, p. 6.

4. _Stenosis_ following syphilis, trauma, acute exanthemata, scleroma, and other rare diseases. C. Jackson has reported twenty-four cases falling under this head, nineteen of which lived for more than a year after the operation with useful voices. If the surgeon is satisfied that the disease is quiescent, he should point out to the patient that it may be possible to cure the obstruction by thyrotomy. It must, however, be remembered that tertiary syphilitic lesions may again become active as the result of operative interference. It is probable that slight cases of stenosis can be treated better by intubation than by thyrotomy.

Thyrotomy has also been suggested to relieve stenosis caused by double abductor paralysis of the vocal cords, but such cases are better treated by tracheotomy or intubation.

5. _Foreign bodies._ Thyrotomy is rarely necessary, and should be reserved for irregular or sharp-pointed bodies, such as tooth-plates or bones, which are so firmly jammed that removal by other methods is impracticable. If there has been much laceration of the soft parts, a tracheotomy tube should be retained for a few days until the swelling has subsided.

[Ill.u.s.tration: FIG. 259. INTRINSIC TUMOUR OF THE LARYNX. (_From Specimen No. 1649 in the Museum of St. Bartholomew's Hospital._)]

[Ill.u.s.tration: FIG. 260. EXTRINSIC TUMOUR OF THE LARYNX. (_From Specimen No. 1653 in the Museum of St. Bartholomew'[s] Hospital._)]

6. _Tubercle._ Thyrotomy has been successfully performed in such cases, mostly under the impression that the disease was malignant. The differential diagnosis between tuberculous and malignant growths is sometimes very difficult until the tumour has been explored. In cases that are known to be tuberculous, the feeling prevails that thyrotomy is not to be recommended. It should be remembered that the external wound is liable to become tuberculous.

=Instruments.= Scalpel, curved scissors, dissecting forceps, pressure forceps, aneurism needles, double hook retractors, bone shears (Waggett's) or bone scissors, tenaculum forceps, needles on handles, catgut in various sizes, a Hahn's tube, and tracheotomy equipment. A head-light is required for illumination of the deeper parts during removal of tumours.

=Operation.= In England, owing to the fact that the administration has been in skilled hands, chloroform is not considered dangerous, and the operation is well tolerated even for three or four hours (_e.g._ in laryngectomy). On the Continent, however, Kocher, von Bruns, and others advocate local anaesthesia with cocaine or novocaine. Jackson suggested rectal etherization as an alternative, but this has many dangers. In my opinion a general anaesthetic should be given, as it enables the operation to be performed more thoroughly and is followed by less shock.

It must nevertheless be borne in mind that, if the growth is intrinsic and of large size, it is difficult to administer chloroform, and the patient is liable to suffer from urgent dyspna. In such a case i[t] is advisable to perform preliminary tracheotomy with novocaine alone (see p. 544).

As regards the operation, the important question arises whether tracheotomy ought to be performed several days prior to the main operation, in order to accustom the patient to the tube and the new method of breathing. The following reasons are advanced in favour of this: the main operation is shortened, and relief is given to the larynx and lungs, so that congestion subsides and broncho-pneumonia is less likely to supervene. The objections are also important, namely, that there are two operations instead of one, and perhaps two anaesthetics (though this can be avoided if local anaesthesia is used for the tracheotomy); that the tracheotomy wound becomes septic, and infection of the trachea and bronchi is apt to occur, with consequent bronchitis; that the air which pa.s.ses into the lungs is devoid of moisture and heat; that the trachea becomes surrounded by adhesions; and that it is altogether unnecessary. The objections in my opinion outweigh the advantages claimed; it is better to perform tracheotomy as a first stage in the operation of removal, except in cases where there is great laryngeal obstruction, where dyspna is present, or where bronchitis fails to yield to other forms of treatment. In such cases tracheotomy should be performed first, and the second operation should be carried out a week or ten days later when all the conditions are favourable.

When operating upon the larynx the surgeon must use every precaution to prevent blood from running into the lower air-pa.s.sages, and this may be accomplished by a tampon in the trachea or by keeping the head of the patient lower than the body. The former method appears to me to be more reliable than the latter; and I prefer to use a Hahn's canula, although the sponge requires from ten to fifteen minutes to swell. This canula is more reliable than Trendelenburg's, whose inflated bag is apt to slip or collapse suddenly. As soon as the thyreoid cartilage has been opened, a second sponge should be inserted above the canula, and by this means the air-pa.s.sages are completely blocked.

If an ordinary tracheotomy tube be used, the operation must be performed either with the head lower than the body (Rose's position), or with the whole body inclined (Trendelenburg's position), or with a combination of the two; and in any case a sponge should be placed in the upper part of the trachea after the thyreoid has been opened. Many surgeons prefer the combined method. Under no conditions must blood be allowed to pa.s.s below the tube. Whatever form of canula is used, it should be fitted with a Hahn's tube and funnel (Fig. 266), so that the anaesthetist can give the chloroform without interfering with the surgeon. The patient should lie upon the back on a flat table, the head extended slightly over a small cushion in the position for tracheotomy.

_First stage._ A vertical incision is made in the middle line from the hyoid almost to the sternum, so as to expose the thyreoid cartilage and the pretracheal muscles; these are retracted, so that the anterior aspect of the trachea is exposed; the isthmus of the thyreoid gland is completely divided, and search made for bleeding points until the wound is quite dry. A large opening is made accurately in the middle line of the trachea; this will be at least two rings below the cricoid cartilage in order that the tube may be well away from the region of the growth.

In adults, if a Hahn's tube be employed, the section should include at least three rings of the trachea.

_Second stage._ The anterior aspect of the thyreoid cartilage, and the crico-thyreoid membrane, are freely exposed, the infrahyoid muscles being separated by at least one inch and, if necessary, retracted. Ten minutes after the tube has been inserted, the crico-thyreoid membrane is punctured, exactly in the middle line, in order to admit the inner blade of the bone forceps; the latter is pushed upwards, slowly and without force, between the posterior portions of the vocal cords, until the whole length of the thyreoid cartilage is included between the blades; the forceps are then forcibly closed, great care being taken that the outer blade is cutting exactly in the middle line. By quickly opening the cartilage in this manner, there is practically no danger of destroying the anterior attachments of the vocal cords, or cutting through the substance of one of them. The two halves of the larynx are forcibly separated and retained in this position by hooked retractors, so that the interior of the larynx is exposed. In order to give a free exposure, it is necessary, as a rule, to divide with a knife the crico-thyreoid membrane; but the thyreo-hyoid membrane should not be touched, nor should the attachments of the epiglottis be disturbed. The separation must be performed carefully in order to avoid a fracture of the cartilages. The pharynx is plugged with gauze, so that no saliva can enter the wound, and after all secretion has been removed from the larynx a small sponge or plug is inserted into the upper end of the trachea. Cocaine, 20%, is freely applied with a swab of wool to every part of the larynx in order to constrict the vessels; persistent haemorrhage can be controlled by plugging the cavity with wool soaked in cocaine; 'this fully suffices ... and the employment of adrenalin, as I have personally experienced in one case, increases the risk of secondary parenchymatous haemorrhage' (Semon). Further, and this is of importance, by the use of cocaine the irritability of the larynx and the laryngeal reflex are destroyed. The tumour can now be inspected; it must be thoroughly exposed by cutting through the soft or hard structures (cricoid if necessary) so that its limits can be determined, thus enabling the surgeon to decide whether it is possible to obtain a satisfactory result by local removal.

[Ill.u.s.tration: FIG. 261. THYROTOMY. Showing exposure of the larynx, and tube for the anaesthetic.]

_Third stage._ In the words of Butlin[13]: 'an incision is carried around it (the tumour) with knife or scissors, including more than half an inch of the surrounding apparently healthy tissues, without respect to the after use of the voice or any other consideration except the complete removal of the disease. The included area is cut out right down to the cartilage, which is laid bare and finally sc.r.a.ped absolutely bare with Volkmann's sharp spoon.' The cavity is then plugged for a few moments until the bleeding has been controlled. The haemorrhage is never serious, and can be controlled by catgut ligature if necessary. The wound must be completely dry. It is then dusted with a powder such as orthoform; the retractors are removed, and the alae of the thyreoid cartilage allowed to fall together. In relation to the removal of the tumour, Butlin has shown that there is 'little liability of malignant disease infiltrating the cartilage of the larynx', so that, as a general rule, the latter can be left if all the soft tissues, including the perichondrium, are removed from its surface; this is comparatively easy to accomplish in the case of the thyreoid, but more difficult with the arytenoids and cricoid cartilage. C. Jackson has criticized the use of a sharp spoon as likely to cause infection of the cartilage.

[13] _Op. Surg. Malig. Dis._, 2nd ed., p. 191.

_Fourth stage._ In some instances it is possible partially to unite the divided mucous membrane, and so to lessen the granulating area: when this is done it is of the utmost importance that the lumen of the larynx should not be constricted, as any constriction will increase the danger of stenosis. In many instances it is not advisable to attempt to repair the wound that has been produced.

In suturing the external wound the alae of the thyreoid are brought accurately into the position which they occupied before division, in order that the anterior attachments (if left) of the vocal cords should heal at their proper level. In some instances the cartilages fall naturally into the desired position, especially if one or two catgut sutures are inserted into the thyreo-hyoid membrane; in other cases it may be advisable to insert one or two similar sutures through the cartilage itself and thus obtain correct apposition. These sutures should lie on the outer aspect of the mucosa, so as not to traverse the cavity of the larynx itself. In cases where only the anterior portion of a vocal cord has been removed, Semon recommends that the divided end be sutured to the ventricular band; it is reasonable to suppose that, by attention to this detail, a better voice will be afterwards obtained.

The infrahyoid muscles are approximated with one or two catgut sutures in the upper part of the wound; the skin is united with a continuous silk suture, as far downwards as the lower part of the thyreoid cartilage. The lower part of the wound is left open, to procure free drainage through the crico-thyreoid and tracheal openings. The whole of this lower wound is packed very loosely with gauze, so that discharges are not retained. It is necessary to emphasize the importance of not plugging the cavity of the larynx. The Hahn's tube is removed as soon as the operation is completed, and replaced by a tracheotomy canula; the whole wound is covered by a loose pad of antiseptic gauze, which is kept in position by tapes or loosely applied bandages. No dissection for removal of lymphatic glands is required.

The above may be called the typical operation for malignant disease in which the growth is intrinsic; it gives a better exposure of the parts than other operations such as transverse laryngotomy (division of the thyreoid cartilage at the level of the ventricles), subhyoid pharyngotomy, partial thyrotomy, cricotomy, and crico-tracheotomy; the removal of tumours is therefore easier, and better after-results are obtained. If the growth be found more extensive, it may be necessary to modify the procedure. For example:

(_a_) When the epiglottis is involved, an extensive dissection of the thyreo-hyoid membrane can be made in order to expose and remove the growth thoroughly together with any soft parts or cartilage which appear to be involved. Branches of the superior thyreoid arteries, or the hyoid branch of the lingual artery, will be ligatured. The superior laryngeal nerves should always be preserved whenever possible, as loss of sensation increases the liability of food pa.s.sing into the larynx.

(_b_) When the aryteno-epiglottidean fold is involved, a transverse incision can be made through the thyreo-hyoid membrane, immediately above the thyreoid cartilage on the same side, and the wound enlarged until the tumour is exposed. In this manner I was able to remove the large carcinoma shown in Fig. 254, including the soft parts of the right half of the larynx, the right half of the epiglottis, the right arytenoid, and the wall of the pharynx in relation to the right pyriform fossa: the lymphatic glands were not removed. One year later the patient continued to enjoy good health with no signs of any recurrence. In this connexion it is important to emphasize that when the disease is very extensive, and particularly when the posterior portion of the cricoid and arytenoids is involved, such an operation is useless, and the surgeon must decide whether partial or complete laryngectomy should be performed. In rare instances the operation should be abandoned in favour of tracheotomy (palliative).

(_c_) When the tumour extends downwards into the subglottic region, it is necessary to split the cricoid anteriorly and divide the upper rings of the trachea, after which the tumour can be removed with as much of the structures as may be desirable.

(_d_) When the growth extends across the middle line in the anterior commissure, or when a second growth is situated directly opposite on the other side of the larynx, the whole disease must be removed regardless of damage to the tissues which are not affected.

(_e_) When the operation is performed for stenosis, it is necessary to remove freely all the fibrous tissue without attempting to preserve any part that is diseased. The haemorrhage is generally severe and necessitates preliminary plugging of the trachea with a Hahn's canula.

=After-treatment.= This must be conducted so as to prevent the chance of broncho-pneumonia and sustain the strength of the patient. With Butlin's method the patient is placed on his side, or face downwards, with the head low and with only a small pillow, so that all secretions pa.s.s out of the air-pa.s.sages through the external wound. This undoubtedly gives better drainage to the wound, and is less exhausting than the upright position during the early stages of convalescence. The dressings on the wound must be changed, especially in the early days, as often as they become soaked; it is also an advantage to insufflate an orthoform powder, or an antiseptic parolein preparation, with the object of cleansing the larynx. The tracheotomy tube should be retained, usually from ten to twenty days, until the patient can swallow well and as long as there is a flow of pus from the wound.

'During the day of the operation nothing is swallowed, although fragments of ice may be kept in the mouth for the comfort of the patient. If there is fear of collapse and the patient is feeble and very old, brandy and beef-tea may be administered by the r.e.c.t.u.m. On the following morning the first attempt is made to swallow. The patient leans far forwards with the head down, and the dressing is taken off the wound, beneath which a basin is placed. Cold water is drunk out of a gla.s.s. If the experiment is successful, all the water pa.s.ses down into the stomach; if it is only partially successful, some escapes into the larynx; but the posture of the patient ensures that the liquid runs out through the wound and does not pa.s.s into the air-pa.s.sages. As soon as water can be readily swallowed, milk, beef-tea, and other liquids may be drunk, for the fear of "Schluck-pneumonie" is practically at an end. The wound is generally closed within ten or twelve days of the operation, and the patient is rarely confined to the house for more than ten days'

(Butlin). It is probable that the healing by this, which is called the 'open' method, is as rapid as with Moure's, in which the whole length of the incision is closed; the open method would also appear to be safer and less often attended by complications.

=Complications.= (1) _Broncho-pneumonia_ is most to be dreaded. Death from shock or collapse, from haemorrhage, from septic conditions of the wound, or from iodoform poisoning, is now rarely met with and can more easily be prevented. Even pneumonia is uncommon, owing to more scientific methods of treatment. It is still to be feared in very old patients; in those who already suffer from bronchial catarrh at the time of the operation; in alcoholics; and in cases with old-standing renal, pulmonary, or heart affections. The improvement in this direction is due to greater antiseptic precautions, and to the prevention of aspiration of blood and septic secretion during and after the operation by free drainage of the wound.

(2) _Stenosis._ It sometimes happens that a considerable ma.s.s of granulation tissue appears in the anterior commissure, or upon the surface of the cartilage that has been bared by the operation; if this be left untreated it may gradually enlarge in size until a prominent cushion is produced, which reaches to the opposite side and thus causes stenosis with definite laryngeal obstruction. Such a swelling may be mistaken for recurrence, but is nearly always of inflammatory character.

It is by no means certain what is the causation of this condition, which appears to occur more with some surgeons than with others; it has been suggested that the presence of sutures in the region of the anterior commissure may cause an irritation, especially if silk is used. It appears to me, having in mind similar conditions in other surgical wounds, that the cause is to be found in some form of sepsis, and that it can be prevented to a great extent by precautions at the operation and by proper after-treatment. If there be any obstruction to breathing, the larynx is inspected and the projecting granulations are removed by intralaryngeal forceps. The remainder of the ma.s.s generally shrinks and disappears. If the stenosis be troublesome (chiefly in syphilitic cases), the prolonged use of a laryngo-tracheal canula (Fig. 540), or of an intubation tube, or dilatation with bougies, may be necessary. In rare instances a permanent tracheotomy tube is required, with a valve to encourage expiration through the mouth.

HEMI-LARYNGECTOMY

This operation is suitable for certain cases of malignant disease which is strictly limited to one half of the larynx. The requirements and _first and second_ stages of the operation are similar to those for thyrotomy (see pp. 490, 491).

_Third stage._ A transverse incision is made on the side affected along the upper border of the thyreoid cartilage, through the skin and fasciae; and, if necessary, a second transverse incision is made at the level of the lower border of the cricoid so that a skin flap can be turned back.