[210] CHAPTER XXV--ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX

The general surgical rule applying to individuals past middle life, that benign growths exposed to irritation should be removed, probably applies to the larynx as well as to any other epithelialized structure. The facility, accuracy and thoroughness afforded by skilled, direct, laryngeal operation offers a means of lessening the incidence of cancer. To a much greater extent the facility, accuracy, and thoroughness contribute to the cure of cancer by establishing the necessary early diagnosis. Well-planned, careful, external operation (laryngofissure) followed by painstaking after-care is the only absolute cure so far known for malignant neoplasms of the larynx; and it is a cure only in those intrinsic cases in which the growth is small, and is located in the anterior two-thirds of the intrinsic area. By limiting operations strictly to this cla.s.s of case, eighty-five per cent of cures may be obtained.* In determining the nature of the growth and its operability the limits of the usefulness of direct endoscopy are reached. It is very unwise to attempt the extirpation of intrinsic laryngeal malignancy by the endoscopic method, for the reason that the full extent of the growth cannot be appreciated when viewed only from above, and the necessary radical removal cannot be accurately or completely accomplished.

* The author's results in laryngofissure have recently fallen to 79 per cent of relative cures by thyrochondrotomy.

_Malignant disease of the epiglottis_, in those rare cases where the lesion is strictly limited to the tip is, however, an exception. If amputation of the epiglottis will give a sufficiently wide removal, this may be done en ma.s.se with a heavy snare, and has resulted in complete cure. Very small growths may be removed sufficiently widely with the punch forceps (Fig. 33); but piece meal removal of malignancy is to be avoided.

_Differential Diagnosis of Laryngeal Growths in the Larynx of Adults_.--Determination of the nature of the lesion in these cases usually consists in the diagnosis by exclusion of the possibilities, namely, 1. Lues.

2. Tuberculosis, including lupus.

3. Scleroma.

4. Malignant neoplasm.

In the Bronchoscopic Clinic the following is the routine procedure: 1. A Wa.s.sermann test is made. If negative, and there remains a suspicion of lues, a therapeutic test with mercury protoiodid is carried out by keeping the patient just under the salivation point for eight weeks; during which time no pota.s.sium iodid is given, lest its reaction upon the larynx cause an edema necessitating tracheotomy. If no improvement is noticed lues is excluded. If the Wa.s.sermann is positive, malignancy and the other possibilities are not considered as excluded until the patient has been completely cured by mercury, because, for instance, a leutic or tuberculous patient may have cancer; a tuberculous patient may have lues; or a leutic patient, tuberculosis.

2. Pulmonary tuberculosis is excluded by the usual means. If present the laryngeal lesion may or may not be tuberculous; if the laryngoscopic appearances are doubtful a specimen is taken. Lupoid laryngeal tuberculosis so much resembles lues that both the therapeutic test and biopsy may be required for certainty.

3. In all cases in which the diagnosis is not clear a specimen is taken. This is readily accomplished by direct laryngoscopy under local anesthesia, using the regular laryngoscope or the anterior commissure laryngoscope. The best forceps in case of large growths are the alligator punch forceps (Fig. 33). Smaller growths require tissue forceps (Fig. 28). In case of small growths, it is best to remove the entire growth; but without any attempt at radical extirpation of the base; because, if the growth prove benign it is unnecessary; if malignant, it is insufficient.

_Inspection of the Party Wall in Cases of Suspected Laryngeal Malignancy_.--When taking a specimen the party wall should be inspected by pa.s.sing a laryngoscope or, if necessary, an esophageal speculum down through the laryngopharynx and beyond the cricopharyngeus. If this region shows infiltration, all hope of cure by operation, however radical, should be abandoned.

_Radium and the therapeutic roentgenray_ have given good results, but not such as would warrant their exclusive use in any case of malignancy in the larynx operable by laryngofissure. With inoperable cases, excellent palliative results are obtained. In some cases an almost complete disappearance of the growth has occurred, but ultimately there has been recurrence. The method of application of the radium, dosage, and its screening, are best determined by the radiologist in consultation with the laryngologist. Radium may be applied externally to the neck, or suspended in the larynx; radium-containing needles may be buried in the growth, or the emanations, imprisoned in gla.s.s pearls or capillary tubes, may be inserted deeply into the growth by means of a small trocar and cannula. For all of these procedures direct laryngoscopy affords a ready means of accurate application. Tracheotomy is necessary however, because of the reactionary swelling, which may be so great as to close completely the narrowed glottic c.h.i.n.k. Where this is the case, the endolaryngeal application of the radium may be made by inserting the container through the tracheotomic wound, and anchoring it to the cannula.

The author is much impressed with Freer's method of radiation from the pyriform sinus in such cases as those in which external radiation alone is deemed insufficient.

The work of Drs. D. Bryson Delavan and Dougla.s.s M. Quick forms one of the most important contributions to the subject of the treatment of radium by cancer. (See Proceedings of the American Laryngological a.s.sociation, 1922; also Proceedings of the Tenth International Otological Congress, Paris, 1922.)

[214] CHAPTER XXVI--BRONCHOSCOPY IN MALIGNANT GROWTHS OF THE TRACHEA

The trachea is often secondarily invaded by malignancy of the esophagus, thyroid gland, peritracheal or peribronchial glands.

Primary malignant neoplasms of the trachea or bronchus have not infrequently been diagnosticated by bronchoscopy. Peritracheal or peribronchial malignancy may produce a compressive stenosis covered with normal mucosa. Endoscopically, the wall is seen to bulge in from one side causing a crescentic picture, or compression of opposite walls may cause a "scabbard" or pear shaped lumen. Endotracheal and endobronchial malignancy ulcerate early, and are characterized by the bronchoscopic view of a bleeding ma.s.s of fungating tissue bathed in pus and secretion, usually foul. The diagnosis in these cases rests upon the exclusion of lues, and is rendered certain by the removal of a specimen for biopsy. Sarcoma and carcinoma of the thyroid when perforating the trachea may become pedunculated. In such cases aberrant non-pathologic thyroid must be excluded by biopsy.

Endothelioma of the trachea or bronchus may also a.s.sume a pedunculated form, but is more often sessile.

_Treatment_.--Pedunculated malignant growths are readily removed with snare or punch forceps. Cure has resulted in one case of the author following bronchoscopic removal of an endothelioma from the bronchus; and a limited carcinoma of the bronchus has been reported cured by bronchoscopic removal, with cauterization of the base. Most of the cases, however, will be subjects for palliative tracheotomy and radium therapy. It will be found necessary in many of the cases to employ the author's long, cane-shaped tracheal cannula (Fig. 104, A), in order to pipe the air down to one or both bronchi past the projecting neoplasm.

It has recently been demonstrated that following the intravenous injection of a suspension of the insoluble salt, radium sulphate, that the suspended particles are held in the capillaries of the lung for a period of one year. Intravenous injections of a watery suspension, and endobronchial injections of a suspension of radium sulphate in oil, have had definite beneficial action. While as yet, no relatively permanent cures of pulmonary malignancy have been obtained, the amelioration and steady improvement noted in the technic of radium therapy are so encouraging that every inoperable case should be thus treated, if the disease is not in a hopelessly advanced stage.

In a case under the care of Dr. Robert M. Lukens at the Bronchoscopic Clinic, a primary epithelioma of the trachea was r.e.t.a.r.ded for 2 years by the use of radium applied by Dr. William S. Newcomet, radium-therapist, and Miss Katherine E. Schaeffer, technician.

[216] CHAPTER XXVII--MALIGNANT DISEASE OF THE ESOPHAGUS

Cancer of the esophagus is a more prevalent disease than is commonly thought. In the male it usually develops during the fourth and fifth decades of life. There is in some cases the history of years of more or less habitual consumption of strong alcoholic liquors. In the female the condition often occurs at an earlier age than in the male, and tends to run a more protracted course, preceeded in some cases by years of precancerous dysphagia.

Squamous-celled epithelioma is the most frequent type of neoplasm. In the lower third of the esophagus, cylindric cell carcinoma may be found a.s.sociated with a like lesion in the stomach. Sarcoma of the esophagus is relatively rare (Bibliography 1, p. 449).

The sites of the lesion are those of physiologic narrowing of the esophagus. The middle third is most frequently involved; and the lower third, near the cardia, comes next in frequency. Cancer of the lower third of the esophagus preponderates in men, while cancer of the upper orifice is, curiously, more prevalent in women. The lesion is usually single, but multiple lesions, resulting from implantation metastases have been observed (Bibliography 1, p. 391). Bronchoesophageal fistula from extension is not uncommon.

_Symptoms_.--Malignant disease of the esophagus is rarely seen early, because of the absence, or mildness, of the symptoms. Dysphagia, the one common symptom of all esophageal disease, is often ignored by the patient until it becomes so marked as to prevent the taking of solid food; therefore, the onset may have the similitude of abruptness. Any well masticated solid food can be swallowed through a lumen 5 millimeters in diameter. The inability to maintain the nutrition is evidenced by loss of weight and the rapid development of cachexia.

When the stenosis becomes so severe that the fluid intake is limited, rapid decline occurs from water starvation. Pain is usually a late symptom of the disease. It may be of an aching character and referred to the vertebral region or to the neck; or it may only accompany the act of swallowing. Blood-streaked, regurgitated material, and the presence of odor, are late manifestations of ulceration and secondary infection. In some cases, constant oozing of blood from the ulcerated area adds greatly to the cachexia. If the recurrent laryngeal nerves are involved, unilateral or bilateral paralysis of the larynx may complicate the symptoms by cough, dyspnea, aphonia, and possibly septic pneumonia.

_Diagnosis_.--It has been estimated that 70 per cent of stenoses of the esophagus in adults are malignant in nature. This should stimulate the early and careful investigation of every case of dysphagia. When all cases of persistent dysphagia, however slight, are endoscopically studied, precancerous lesions may be discovered and treated, and the limited malignancy of the early stages may be afforded surgical treatment while yet there is hope of complete removal. Luetic and tuberculous ulceration of the esophagus are to be eliminated by suitable tests, supplemented in rare instances by biopsy. Aneurysm of the aorta must in all cases of dysphagia be excluded, for the dilated aorta may be the sole cause of the condition, and its presence contraindicates esophagoscopy because of the liability of rupture.

Foreign body is to be excluded by history and roentgenographic study.

Spasmodic stenosis of the esophagus may or may not have a malignant origin. Esophagoscopy and removal of a specimen for biopsy renders the diagnosis certain. It is to be especially remembered, however, that it is very unwise to bite through normal mucosa for the purpose of taking a specimen from a periesophageal growth. Fungations and polypoid protuberances afford safe opportunities for the removal of specimens of tissue.

_The esophagoscopic appearances of malignant disease_, varying with the stage and site of origin of the growth, may present as follows:-- 1. Submucosal infiltration covered by perfectly normal membrane, usually a.s.sociated with more or less bulging of the esophageal wall, and very often with hardness and infiltration.

2. Leucoplakia.

3. Ulceration projecting but little above the surface at the edges.

4. Rounded nodular ma.s.ses grouped in mulberry-like form, either dark or light red in color.

5. Polypoid ma.s.ses.

6. Cauliflower fungations.

In considering the esophagoscopic appearances of cancer, it is necessary to remember that after ulceration has set in, the cancerous process may have engrafted upon it, and upon its neighborhood, the results of inflammation due to the mixed infections. Cancer invading the wall from without may for a long time be covered with perfectly normal mucous membrane. The significant signs at this early stage are: 1. Absence of one or more of the normal radial creases between the folds.

2. Asymmetry of the inspiratory enlargement of lumen.

3. Sensation of hardness of the wall on palpation with the tube.

4. The involved wall will not readily be made to wrinkle when pushed upon with the tube mouth.

In all the later forms of lesions the two characteristics are (a) the readiness with which oozing of blood occurs; and (b) the sense of rigidity, or fixation, of the involved area as palpated with the esophagoscope, in contrast to the normally supple esophageal wall.

Esophageal dilatation above a malignant lesion is rarely great, because the stenosis is seldom severely obstructive until late in the course of the disease.

_Treatment_.--The present 100 per cent mortality in cancer of the esophagus will be lowered and a certain percentage of surgical cures will be obtained when patients with esophageal symptoms are given the benefit of early esophagoscopic study. The relief or circ.u.mvention of the dysphagia requires early measures to prevent food and water starvation. _Bouginage_ of a malignant esophagus to increase temporarily the size of the stenosed lumen is of questionable advisability, and is attended with the great risk of perforating the weakened esophageal wall.

_Esophageal intubation_ may serve for a time to delay gastrostomy but it cannot supplant it, nor obviate the necessity for its ultimate performance. The Charters-Symonds or Guisez esophageal intubation tube is readily inserted after drawing the larynx forward with the laryngoscope. The tube must be changed every week or two for cleaning, and duplicate tubes must be ready for immediate reinsertion.

Eventually, a smaller, and then a still smaller tube are needed, until finally none can be introduced; though in some cases the tube can be kept in the soft ma.s.s of fungations until the patient has died of hemorrhage, exhaustion, complications or intercurrent disease.

_Gastrostomy_ is always indicated as the disease progresses, and it should be done before nutrition is greatly impaired. Surgeons often hesitate thus to "operate on an inoperable case;" but it must be remembered that no one should be allowed to die of hunger and thirst.

The operation should be done before inanition has made serious inroads. As in the case of tracheotomy, we always preach doing it early, and always do it late. If postponed too long, water starvation may proceed so far that the patient will not recover, because the water-starved tissues will not take up water put in the stomach.

_Radiotherapy_.--Radium and the therapeutic roentgenray are today our only effective means of r.e.t.a.r.ding the progress of esophageal malignant neoplasms. No permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. The combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has r.e.t.a.r.ded the progress of some cases.

The dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. Two fundamental points are to be considered, however.

The radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa.

The dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center.

If the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. It is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (Fig. 95)

Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer.

[221] CHAPTER XXVIII--DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX

The diagnosis of laryngeal disease in young children, impossible with the mirror, has been made easy and precise by the development of direct laryngoscopy. No anesthetic, local or general, should be used, for the practised endoscopist can complete the examination within a minute of time and without pain to the patient. The technic for doing this should be acquired by every laryngologist. Anesthesia is absolutely contraindicated because of the possibility of the presence of diphtheria, and especially because of the dyspnea so frequently present in laryngeal disease. To attempt general anesthesia in a dyspneic case is to invite disaster (see Tracheotomy). It is to be remembered that coughing and straining produce an engorgement of the laryngeal mucosa, so that the first glance should include an estimation of the color of the mucosa, which, as a result of the engorgement, deepens with the prolongation of the direct laryngoscopy.

_Chronic subglottic edema_, often the result of perichondritis, may require linear cauterization at various times, to reduce its bulk, after the underlying cause has been removed.

_Perichondritis and abscess_, and their sequelae are to be treated on the accepted surgical precepts. They may be due to trauma, lues, tuberculosis, enteric fever, pneumonia, influenza, etc.