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Early tuberculosis of the larynx
November 1937 EARLY
TUBERCULOSIS
89
TUBERCLE OF
TIII.;
L A R Y N X . By F. C. OR.xmgOD. l'roc. R] Soc. Med., ~937, xxx. 233. O f 65 cases of early tuberculosis of the larynx seen at the Brompton Hospital in x934, x~ had phthisis in both lungs ; 53 had phthisis in one lung ; 50 had positive sputum ; nine cases had infected tonsils, and six had nasal obstruction. In these early cases of laryngeal tuberculosis the lung disease was usually fairly advanced, most being in groups o or 3. A slight laryngeal condition does not necessarily mean slight disease in the chest, but a patient whose laryngeal condition is improving is likely to do well generally. A study of the site of the early lesions in different parts of the larynx in the 65 cases referred to, showed that in 41 the lesion was on the vocal cords (both cords in 21 of these) ; in 9 on the ventricular b a n d s ; in ~ on tim arytenoid processes ; in 9 in the interarytenoid space ; on the epiglottis in one, and there was paresis of the internal tensors in three. There is a type of early disease which begins in the ventricle and causes a swelling of the vcntricular band. As the vcntricular mucosa swells, it tends to present at the mouth of the ventricle and a fringe of infihrated mucous m e m b r a n c e can be seen overlapping the vocal cord. O f the 4~ cases with infiltration of the vocal cord, four died, eight became worse, x5 improved, Io were transferred to other sanatoria and their fate was not known. None of the nine cases of ventricular band involvement, and only three became worse. O f the nine cases of interarytenoid infiltration four died, four became worse, and only one remained in statu quo. L A R Y N G E A I , T U B E R C U L O S I S . By JoBso:q HORNE. Proc. R. Soc. Mcd., 1937, xxx. "31. The writer states that in his experience the earliest clinical evidence of laryngeal tuberculosis is not hoarseness, but dysphonia or transient aphoxla. 'l'he earliest change in the larynx is not acute laryngitis, but pallcr and impaired adduction of the vocal cords. In the earliest stage the laryngeal nfirror will reveal on the glottic aspect of the interarytenoid region a very fine crenulation. Post-mortem examination of larynges normal to the naked eye, but removed from bodies with pulmonary tuber-
culosis, showed under tim microscope a myositis in the intrinsic muscles. This myositis, in some cases very diffuse, might exist without occasioning any changes that could be observed clinically other than the various forms of paresis of the cords. A myositis in the interanytenoid muscle and a deposition of tubercle in tbe submucosa with distension of the superficial epithelium explained the impaired adduction of tim vocal cords and the resuhlng a p h o n i a ; also the crenulatinn so frequently present in the interarytenoid space. The disease in the larynx progresses pari pJssu with that in the lungs. The cervical glands are never involved in laryngeal tuberculosis, since the disease is always secondary to disease in the lung. When the disease in the lung is of the miliary type, as in childhood, the larynx is not affected.
AGRANULOCYTIC AND
ANGINA,
TUBERCULOUS
COMPLICATING
PUII.PURA,
LARYNGITIS
P U L M O N A R Y TUIII']R-
C U L O S I S . By A. B. TAYLOR, Lancet I937, IX, 73.
T h e writer describes tile case of a young woman, admitted to the King Edward V I I Sanatorium, Midhurst, with a large tuberculous cavity at the apex of the right lung, complicated by laryngeal tuberculo3is. Artificial pneumottmrax was instituted, but while collapse was being obtained a spread occurred into the left lower lobe, for which sanocrysin injections were given. After seven injections, with a total of i-o 5 gram, agranulocytie angina and purpura developed, and these were treated by .blood transfusion and injections of pcntnucleotide. From one of these injections a staptD, lodoceal abscess developed, and from that moment her blood picture and clinical condition began to improve. IIer l a r y n x recovered completely with voice rest and the galvano-cautery; and the lung gradually cleared, up under artificial pneunmthorax supplemented by phrenic crush and an upper thoraeoplasty. At the time of writing the pncumothorax was still being maintained, hut the patient had been discharged after i s months' treatment at the sanatorium, and was extremely fit, walking four miles daily and with n o symptoms.
TUBERCULOSIS
89
TUBERCLE OF
TIII.;
L A R Y N X . By F. C. OR.xmgOD. l'roc. R] Soc. Med., ~937, xxx. 233. O f 65 cases of early tuberculosis of the larynx seen at the Brompton Hospital in x934, x~ had phthisis in both lungs ; 53 had phthisis in one lung ; 50 had positive sputum ; nine cases had infected tonsils, and six had nasal obstruction. In these early cases of laryngeal tuberculosis the lung disease was usually fairly advanced, most being in groups o or 3. A slight laryngeal condition does not necessarily mean slight disease in the chest, but a patient whose laryngeal condition is improving is likely to do well generally. A study of the site of the early lesions in different parts of the larynx in the 65 cases referred to, showed that in 41 the lesion was on the vocal cords (both cords in 21 of these) ; in 9 on the ventricular b a n d s ; in ~ on tim arytenoid processes ; in 9 in the interarytenoid space ; on the epiglottis in one, and there was paresis of the internal tensors in three. There is a type of early disease which begins in the ventricle and causes a swelling of the vcntricular band. As the vcntricular mucosa swells, it tends to present at the mouth of the ventricle and a fringe of infihrated mucous m e m b r a n c e can be seen overlapping the vocal cord. O f the 4~ cases with infiltration of the vocal cord, four died, eight became worse, x5 improved, Io were transferred to other sanatoria and their fate was not known. None of the nine cases of ventricular band involvement, and only three became worse. O f the nine cases of interarytenoid infiltration four died, four became worse, and only one remained in statu quo. L A R Y N G E A I , T U B E R C U L O S I S . By JoBso:q HORNE. Proc. R. Soc. Mcd., 1937, xxx. "31. The writer states that in his experience the earliest clinical evidence of laryngeal tuberculosis is not hoarseness, but dysphonia or transient aphoxla. 'l'he earliest change in the larynx is not acute laryngitis, but pallcr and impaired adduction of the vocal cords. In the earliest stage the laryngeal nfirror will reveal on the glottic aspect of the interarytenoid region a very fine crenulation. Post-mortem examination of larynges normal to the naked eye, but removed from bodies with pulmonary tuber-
culosis, showed under tim microscope a myositis in the intrinsic muscles. This myositis, in some cases very diffuse, might exist without occasioning any changes that could be observed clinically other than the various forms of paresis of the cords. A myositis in the interanytenoid muscle and a deposition of tubercle in tbe submucosa with distension of the superficial epithelium explained the impaired adduction of tim vocal cords and the resuhlng a p h o n i a ; also the crenulatinn so frequently present in the interarytenoid space. The disease in the larynx progresses pari pJssu with that in the lungs. The cervical glands are never involved in laryngeal tuberculosis, since the disease is always secondary to disease in the lung. When the disease in the lung is of the miliary type, as in childhood, the larynx is not affected.
AGRANULOCYTIC AND
ANGINA,
TUBERCULOUS
COMPLICATING
PUII.PURA,
LARYNGITIS
P U L M O N A R Y TUIII']R-
C U L O S I S . By A. B. TAYLOR, Lancet I937, IX, 73.
T h e writer describes tile case of a young woman, admitted to the King Edward V I I Sanatorium, Midhurst, with a large tuberculous cavity at the apex of the right lung, complicated by laryngeal tuberculo3is. Artificial pneumottmrax was instituted, but while collapse was being obtained a spread occurred into the left lower lobe, for which sanocrysin injections were given. After seven injections, with a total of i-o 5 gram, agranulocytie angina and purpura developed, and these were treated by .blood transfusion and injections of pcntnucleotide. From one of these injections a staptD, lodoceal abscess developed, and from that moment her blood picture and clinical condition began to improve. IIer l a r y n x recovered completely with voice rest and the galvano-cautery; and the lung gradually cleared, up under artificial pneunmthorax supplemented by phrenic crush and an upper thoraeoplasty. At the time of writing the pncumothorax was still being maintained, hut the patient had been discharged after i s months' treatment at the sanatorium, and was extremely fit, walking four miles daily and with n o symptoms.