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The larynx in tuberculosis
88
TUBERCLE
diseased larynx other than one with an ordinary catarrlml infection, as larynge+al tuberculosis, but this would, ofcourse, be a mistake in a slnall proportion of cases. Benign neoplasms on the vocal cords (fibrolnata, angeiomata) are generally easy to diagnose, and the writer has seen many of them in phythisical patients. In some cases of acute catarrhal laryngitis ulcerations resembling tuberculous lesions nmy be found on the vocal cords. Tiffs, however, is almost always symmetrical, and occurs most frequently in people who are susceptible to hoarseness on catching cold. Syphilitic mucus plaques on the vocal cords resemble the symmetrical ulcerations in acute laryngitis, but they are white and prominent, and are usually associated with other plaques in the mouth and phars'nx. Such plaques have a severe hypertrophic laryngitis, often difficult to distinguish from tuberculous tertiary syphilitic lesions, are generally much paler than tuberculous lesions and are painless, even in the presence of ulceration. Even microscopical examination may be inconclusive, and the patient should in doubtful cases be given antisyphilic treatment. Carcinoma of the vocal cords in an early stage may also be difficult to distinguish from tuberculosis, but biopsy in this region is a safe procedure and should be carried out in doubtful cases. Contrary to statements usually found in text-books, the writer believes that phthisical patients with laryngeal tuberculosis have not usually been previously susceptible to acute laryngitis. Suspicious symptoms inclflde: (1) obstinate catarrh or congestion limited to one part of the larynx ; (-o) paresis of the muscles of adduction and tension; (3) isolated redness of a vocal c o r d ; (4) swelling and soreness of the vocal process ; (5) prolapse of the ventricle o f * I o r g a g n i ; (6) swelling of the lower surface of the vocal cords--a symmetrical swelling which the writer has found as a symptom of incipient laryngeal tuberculosis in I6 3 cases ; (7) swelling of the mucus membrance in the inter-arytenoid region ; and (8) a l i t t l e red cushion beneath the commissure of the vocal cords, on the tracheal walh This affection is often found (o 7 cases) as a part of a widespread tuberculosis of the larynx, but it may also appear as the first visible localization of a laryngeal tuberculosis ('2..o certain and I x doubtful cases).
THE
LARYNX
IN TUBERCULOSIS.
By
L. S. T. BURRELL. I'roc. R. Soc. Mcd., x937, x~x. -o30. About one-third of the tuberculous patients referred to the throat det)artment for diagnosis
November
I937
on account of hoarseness or difficulty in spcmking are returned as non-tuberculous. This type of case ahvays seems to do well, and a follow-up has shown no greater incidence of tuberculous laryngitis among these than among other phthislcal patients. A tuberculous larynx responds very well to artificial pncumothorax, and where complete collapse of the lung has been obtained it is exceptional for the tuberculous laryngitis to continue. Ahhough early diagnosis is a question for the laryngologist rather than the physician, the question of early treatment somctimes arises. Smoking is injurious in this form of tuberculosis and should be forbidden to the patient.
I';ARI,Y
DIAGNOSIS
IN LARYNGEAL
TUBI';II.CULOSIS. By Sx. CLAIR Tno.~ISO.,,'. Proc. R. Soc. Med., I937, xxx. -o3 t. For early diagnosis of this condition, one inspection, even by a trained laryngologist, is not ahvays enough. Tile appearances of a larynx change to some extent from day to day, and under varying conditions, such as recent cough, pyrexla, or fatigue. Inspection after a period of silence will help to define a lesion, and inspections should ahvays be m a d e in a well darkened room. Any one-sided congestion or any irregularity should arouse suspicion. A second separate focus also demands attention, since a malignant growth spreads only from one centre. Tuberculosis, especially in the elderly, often simulates pachydcrmia, and it ought not to be forgotten tlmt tuherculcsis is far from being rare in the old. O n the other hand, t h e laryrgeal picture may look almost typical oftuberculosis, but the appearance may be misleading ; as in a case sent to MidImrst with this diagnosis and a family and personal history of tuberculosis, but tubercle bacilli were never fonnd in the sputum, and the case turned out to be one of infection with aspergillus fumigatus. The appearances, extension and progress of the laryngeal lesion are valuable in prognosis. O f .'2,000 patients seen by the writer in ten years, and who were reported upon ten years later, twice as m a n y were alive among those with a sound larynx as compared with those with a diseased larynx. During those years two out of every three patients with laryngeal tuberculosis were dead, while two out of every three of those with a sound larynx were alive. Tubcrculosis in the larynx is still a vcry serious discase, and the chicf hope lies in early diagnosis.
TUBERCLE
diseased larynx other than one with an ordinary catarrlml infection, as larynge+al tuberculosis, but this would, ofcourse, be a mistake in a slnall proportion of cases. Benign neoplasms on the vocal cords (fibrolnata, angeiomata) are generally easy to diagnose, and the writer has seen many of them in phythisical patients. In some cases of acute catarrhal laryngitis ulcerations resembling tuberculous lesions nmy be found on the vocal cords. Tiffs, however, is almost always symmetrical, and occurs most frequently in people who are susceptible to hoarseness on catching cold. Syphilitic mucus plaques on the vocal cords resemble the symmetrical ulcerations in acute laryngitis, but they are white and prominent, and are usually associated with other plaques in the mouth and phars'nx. Such plaques have a severe hypertrophic laryngitis, often difficult to distinguish from tuberculous tertiary syphilitic lesions, are generally much paler than tuberculous lesions and are painless, even in the presence of ulceration. Even microscopical examination may be inconclusive, and the patient should in doubtful cases be given antisyphilic treatment. Carcinoma of the vocal cords in an early stage may also be difficult to distinguish from tuberculosis, but biopsy in this region is a safe procedure and should be carried out in doubtful cases. Contrary to statements usually found in text-books, the writer believes that phthisical patients with laryngeal tuberculosis have not usually been previously susceptible to acute laryngitis. Suspicious symptoms inclflde: (1) obstinate catarrh or congestion limited to one part of the larynx ; (-o) paresis of the muscles of adduction and tension; (3) isolated redness of a vocal c o r d ; (4) swelling and soreness of the vocal process ; (5) prolapse of the ventricle o f * I o r g a g n i ; (6) swelling of the lower surface of the vocal cords--a symmetrical swelling which the writer has found as a symptom of incipient laryngeal tuberculosis in I6 3 cases ; (7) swelling of the mucus membrance in the inter-arytenoid region ; and (8) a l i t t l e red cushion beneath the commissure of the vocal cords, on the tracheal walh This affection is often found (o 7 cases) as a part of a widespread tuberculosis of the larynx, but it may also appear as the first visible localization of a laryngeal tuberculosis ('2..o certain and I x doubtful cases).
THE
LARYNX
IN TUBERCULOSIS.
By
L. S. T. BURRELL. I'roc. R. Soc. Mcd., x937, x~x. -o30. About one-third of the tuberculous patients referred to the throat det)artment for diagnosis
November
I937
on account of hoarseness or difficulty in spcmking are returned as non-tuberculous. This type of case ahvays seems to do well, and a follow-up has shown no greater incidence of tuberculous laryngitis among these than among other phthislcal patients. A tuberculous larynx responds very well to artificial pncumothorax, and where complete collapse of the lung has been obtained it is exceptional for the tuberculous laryngitis to continue. Ahhough early diagnosis is a question for the laryngologist rather than the physician, the question of early treatment somctimes arises. Smoking is injurious in this form of tuberculosis and should be forbidden to the patient.
I';ARI,Y
DIAGNOSIS
IN LARYNGEAL
TUBI';II.CULOSIS. By Sx. CLAIR Tno.~ISO.,,'. Proc. R. Soc. Med., I937, xxx. -o3 t. For early diagnosis of this condition, one inspection, even by a trained laryngologist, is not ahvays enough. Tile appearances of a larynx change to some extent from day to day, and under varying conditions, such as recent cough, pyrexla, or fatigue. Inspection after a period of silence will help to define a lesion, and inspections should ahvays be m a d e in a well darkened room. Any one-sided congestion or any irregularity should arouse suspicion. A second separate focus also demands attention, since a malignant growth spreads only from one centre. Tuberculosis, especially in the elderly, often simulates pachydcrmia, and it ought not to be forgotten tlmt tuherculcsis is far from being rare in the old. O n the other hand, t h e laryrgeal picture may look almost typical oftuberculosis, but the appearance may be misleading ; as in a case sent to MidImrst with this diagnosis and a family and personal history of tuberculosis, but tubercle bacilli were never fonnd in the sputum, and the case turned out to be one of infection with aspergillus fumigatus. The appearances, extension and progress of the laryngeal lesion are valuable in prognosis. O f .'2,000 patients seen by the writer in ten years, and who were reported upon ten years later, twice as m a n y were alive among those with a sound larynx as compared with those with a diseased larynx. During those years two out of every three patients with laryngeal tuberculosis were dead, while two out of every three of those with a sound larynx were alive. Tubcrculosis in the larynx is still a vcry serious discase, and the chicf hope lies in early diagnosis.