Types of laryngeal obstruction and their treatment

TYPES OF LARYNGEAL OBSTRUCTION AND THEIR TREATMENT LYMAN

RICHARDS,

Associate Professor of OtoIaryngoIogy, BOSTON,

S

Tufts CoIIege School of Medicine

MASSACHUSETTS

as the gateway to the Iower respiratory tract, the Iarynx occupies a commanding position with respect to the normaI passage of air into the Iungs. An adequate suppIy of oxygen is a prime requisite for Iife and any obstructive process interfering with this is at once manifested by a variety of signs and symptoms the appreciation of which is most important for a11 practicing physicians. In spite of the fact that the Iarynx is the narrowest portion in the entire respiratory tract, it is nevertheIess possibIe for some degree of obstruction to exist in it without serious embarrassment, but once this toIerated point is passed serious sequeIae may deveIop in an extremeIy short time. It is the purpose of this paper to consider the major causes of such obstructions and to outIine those forms of treatment which in the Iight of present knowIedge have been found to be most successfu1. TANDING

GENERAL

M.D.

CONSIDERATIONS

As in the case of obstruction to any narrow path through which air passes, the IocaIized manifestations of dbstruction in the airway, incIuding the Iower pharynx, Iarynx and upper trachea, are associated with the sound of air passing through a narrow orifice-commonIydesignated as stridor. This sound is most apparent on inspiration and resuIts from the passage of air between the waIIs of the Iarynx where, due to various forms of obstruction, it encounters resistance on its way to and from the Iower respiratory tract. This stridor can best be recognized by experience and by previous auditory contact, but exhibits certain characteristic types dependent on the initiating disease. 239

A high pitched crowing tone, associated most -commonIy with transitory approximation of the voca1 cords is seen commonIy in the infantiIe condition of congenita1 stridor or in the nervous dysfunction of spasmodic croup. Here the voca1 cords aIthough temporariIy in contact are not essentiaIIy abnorma1, present no roughened or inffamed area to the air passing through them and hence produce, in this manner, a tone of a reIativeIy smooth quaIity. InfI ammatory reactions, secretions, membrane or foreign body contained within the Iumen of the Iarynx and attached to or present at various points aIong its surface, add to the note of stridor a distinctIy harsh or roughened quaIity. The intensity of this inspiratory roughness varies greatIy with the extent of the obstruction and the character of the Iesion producing it. It may be audibIe across an entire room or perceptibIe onIy on appIying the ear to the mouth of the patient. Its earIy recognition is very important and the physician must be abIe not onIy to evaIuate any progressive change in its severity but to determine, insofar as means at his disposal wiI1 permit, the etioIogic factors underIying the obstruction. So Iong as the various possibiIities of the situation are appreciated, so Iong as the patient is kept under rigid surveiIIance unti1 the nature and course of the conditions underIying this stridor are known and so Iong as timeIy steps are taken to dea1 with evidences of increasing obstruction, the patient’s Iife wiI1 be safeguarded and the practitioner wiI1 be discharging a most serious obIigation. Stridor aIone, whiIe one of the most important indicative signs of IaryngeaI obstruction, is but one of a group of symp-

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toms which point the way toward its possibIe existence. Chief among the others is evidence of hyperactivity on the part of the thoracic cage to create negative pressure within the pIeiura1 cavity in an effort to compensate for a decreased oxygenation. This is manifested by an exaggerated expansion with distinct indrawing of the softer tissues of the chest at certain points, particuIarIy the supracIavicuIar spaces, the suprasterna1 notch and the epigastrium. These chest movements, coupIed with an increase in the respiratory rate are at once a most important indication of the diffIculty under which the patient is Iaboring. Such Iocalized retractions of the chest are particuIarIy obvious in infants and chiIdren in whom a more fIexibIe waII shows the effect of exaggerated pressure. The commonIy described and sometimes unduIy stressed sign of cyanosis, a symptom manifesting inadequate oxygenation of the bIood, has for so many years been a traditiona sign of high respiratory obstruction, that it has come to be regarded as a cIassic feature of this condition. In reality, however, severe and urgent obstruction can be present either with absence of cyanosis or more commonIy with an ashy gray coIor of the Iips and paIIor of the skiri which are equaIIy significant and indicative of the urgency of the situation. Cyanosis may appear only terminaIIy when a11 hope of recovery may we11 have passed, and shouId therefore never be awaited as confirmation of the need of immediate relief. Judged by the coIor of the Iips and mucous membrane, adequate oxygenation may be taking pIace, when in reaIity a severe form of IaryngeaI or trachea1 obstruction is wearing out a patient’s resistance minute by minute. AImost equaIIy significant and far more common than cyanosis is the symptom of genera1 restIessness on the part of a patient whose intake of oxygen is inadequate. Infants and chiIdren particuIarIy tend to exhibit this sign, moving restIessIy about, constantIy changing position, turning the head from side to side, and waving the

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arms in indication of genera1 discomfort and insuffIcient respiratory exchange. Lack of restIessness must, however, never Iead to the concIusion that reIief of obstruction is not urgent. Young chiIdren especiaIIy, exhausted by previous efforts to breathe, wiII eventuaIIy give up the struggIe and, with increasing cardiac faiIure, sIip into a termina1 unconsciousness quietIy unless the obstruction is immediateIy reIieved. Confirming aImost any form of respiratory embarrassment is a rise in the puIse rate, but eIevations in temperature wiI1 depend on the etiologic factor invoIved, being noted primariIy in the infectious diseases and absent in the mechanical forms of obstruction. In the face of these major signs of mild, moderate or severe upper respiratory obstruction, present often in combination or singIy, it behooves the practitioner carefuIIy to weigh their significance and, by frequent examination, to form an opinion as to whether the obstruction is increasing or decreasing. Above aII, he shouId never concIude because of the temporariIy miId manifestation of the condition, that nothing serious is in the offing, and shouId avoid the temptation to administer sedatives or hypnotics which, although for the moment apparentIy aIIeviating the symptoms and rendering the patient more comfortabIe, wiII in reality onIy mask vaIuabIe diagnostic signs. So far as possibIe one must determine the cause ‘of the obstruction, whether infectious or mechanica and whether essentiaIIy intra- or extraIaryngea1. SimuIating true intrarespiratory tract obstruction there wiII frequentIy be observed the rapid respiratory rate incident to pneumonia, the and embarrassment associated cyanosis with cardiac disease, the striking distress of the patient seized with a bad attack of asthma, and in infants, the puzzIing simiIarity between true IaryngeaI obstruction and so-caIIed capiIIary bronchitis. Any .of these conditions may produce disturbances of respiration and appropriate forms of physica examination must be

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FIG. I. Representative types of IaryngeaI obstruction. I. Bilateral abductor paralysis. Obstruction created by close approximation of the cords in the midline, with only a narrow air-space sufEcient to sustain life. 2. Acute streptococcus laryngitis. Marked edema and hyperemia of the arytenoid and false cords, overhanging the gIottis and restricting the airway. 3. Papillama. Benign growth, springing from the cord edges, graduaIIy enIarging unti1 encroaching on the lumen of the Iarynx. 4. Acute laryngo-tracbeo-bronchitis. SubgIottic accumutations of dry, inspissated secretions along the glottic walls with onIy the minimum of inflammatory reaction in the arytenoid and faIse cords. 5. Chronic cicntricial stenosis. The result of various inflammatory processes which hea with stenosing scar tissue, here a web in the anterior commissure. 6. Carcinoma qf the laryn~~. Malignant disease, advanced to a point at which the growth encroaches on the laryngeal airway.

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utiIized in order to estabhsh a differentia1 diagnosis. It cannot be too strongIy stressed that any patient in whom respiratory obstruction is under diagnostic consideration shouId if possibIe be domiciled in a we11 equipped hospita1. Much can be Iearned as to the nature of the respiratory obstruction by a carefuI inquiry into the history of its onset. ReIativeIy rapid deveIopments wouId suggest an acute inflammatory process whiIe symptoms due to some new growth or sIow growing and compressing tumor wouId arise more graduaIIy. The presence of diphtheria in the visibIe portion of the throat wouId be strong presumptive evidence of IaryngeaI obstruction by this same process. Such obviousIy diagnostic points as the history of aspiration of a foreign body or even a suggestion of the possibihty of such an accident wiI1 prove invaIuabIe in Iocating the cause of IaryngeaI or trachea1 obstruction, provided that the physician wiI1 pay heed to what may, on the surface, seem an unIikeIy suggestion by the patient himself or his famiIy. The presence of fever, an eIevation in the white bIood count or the respiratory and pulse ‘rate, wil1 a11 prove heIpfu1 in estabIishing a causa1 reIationship in the face of infectious respiratory obstruction. LaryngeaI obstruction may heIpfuIIy be subdivided according to whether the etioIogic factor Iies outside (extraIaryngea1) or inside (intraIaryngea1) the Iarynx. EXTRALARYNGEAL

OBSTRUCTION

ExtraIaryngeaI pathoIogy may by mechanica1 pressure or inff ammatory edema encroach on the IaryngeaI Iumen and in this manner provoke obstruction. The chief Iocation of such pathoIogy is the area, just above the IaryngeaI orifice, through which air passes from the nasa1 chambers to the Iarynx. Inflammatory diseases in this pharyngea1 region may at times produce a suficient amount of sweIIing to encroach upon th‘e IaryngeaI airway, with resuItant respiratory embarrassment. Such inflammation is often associated

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with a IocaIized coIIection of pus, which may not be def?niteIy recognizabIe or surgicaIIy drainabIe unti1 respiratory obstruction is far advanced. OccasionaIIy acute tonsiIIitis, when invoIving aheady hypertrophied tons&, wiI1 produce such serious encroachment on the pharyngea1 airway, as to require immediate tons% Iectomy (one of the few situations in which this operation can in any way be caIIed urgent). PeritonsiIIar abscess, IinguaI or subIingua1 abscess, aIveoIar abscess and cervica1 adenitis wiI1 at times produce such marked sweIIing in the pharynx as to raise the question of the need of suppIementary measures for its reIief, entireIy apart from treatment of the IocaI condition, and any patient suffering from such pharyngea1 inffammation must aIways be carefuIIy watched for this possibihty. Drainage of IocaIized pus wiII often suffice to obviate further measures for the reIief of this respiratory obstruction. The thickness of the surrounding inffammatory waIIs of the abscess wiI1 diminish and an airway, temporariIy obstructed by such edema and sweIIing, may soon return to norma dimensions. On the other hand, surgica1 drainage may not be definiteIy indicated and impending respiratory obstruction must be deaIt with without deIay, no matter how desirous one may be of avoiding further surgery. PreIiminary tria1 wiI1, of course, have been made of a11 conservative procedures such as shrinking with astringents, hot irrigations, externa1 hot compresses and steam inhaIations, a11 designed to maintain a maximum patency of the airway in the face of threatened obstruction. Of particuIar importance in this connection is the condition of retropharyngea1 abscess, commonIy seen in infants and chiIdren up to the age of 3 years and often unsuspected as a cause of IaryngeaI obstruction. Its presence shouId be considered in any case of interference with norma respiratory exchange; a IateraI roentgenogram of the neck shouId be taken to confirm the diagnosis and the utmost

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care shouId be taken in the IocaI examination not to make undue pressure on the tongue with a tongue depressor or mouth gag. GentIe paIpation with the index finger wiI1 revea1 the characteristic eIastic fuIness of the posterior pharyngea1 waI1 usuaIIy to one side of the midIine and at times we11 beIow the point of visibiIity through the mouth. The treatment of IaryngeaI obstruction incident to retropharyngea1 abscess is incision and drainage of the abscess, the technique of which is beyond the scope of this paper. Attempts to dea1 with the Iarynx IocaIIy or by tracheotomy are IIIadvised when drainage of the abscess wiI1 suffice entireIy to reIieve the obstruction. INTRALARYNGEAL

OBSTRUCTION

The causes of intraIaryngea1 obstruction are such that the Iimitation in the airway is IikeIy to be more compIete and therefore to require more direct measures for its reIief than is the case in extraIaryngeaI obstruction. Since the Iarynx is anatomicaIIy the narrowest portion of the upper respiratory tract it foIIows that Iesser degrees of obstruction produce more serious effects in this region than in portions above or beIow it. ParticuIarIy is this true in chiIdren in whom the subgIottic space represents not onIy the narrowest area in the airway, but aIso the region in which inflammatory Iesions are most frequentIy encountered. Such IaryngeaI obstruction may be divided into two essentia1 categories, (I) inflammatory and (2) noninff ammatory. I. InfEammatory Obstruction. Any form of acute inflammation of the waIIs of the Iarynx can, as a resuIt of sweIIing of the mucous membrane or submucosa1 tissues, produce definite gIottic obstruction. Outstanding among such inflammatory causes, particuIarIy up unti1 the Iast five years, was diphtheria. This disease was formerly the cause of death of countIess chiIdren the worId over. It is fortunateIy becoming increasingIy rare as a resuIt, first, of the

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discovery of diphtheria anti-toxin as a therapeutic measure and more particuIarIy of Iate of the abiIity to immunize children sensitive to this disease by the administration of toxin-antitoxin. UnquestionabIy as time goes on the number of cases of pharyngea1 as we11 as IaryngeaI diphtheria wiI1 become increasingIy smaIIer and one may hopefuIIy Iook forward in a reIativeIy short time to its compIete eradication. NevertheIess, at present, one must stiI1 keep diphtheria in mind as a possibIe cause of IaryngeaI obstruction. The suspicion of its existence wouId be aroused by the discovery of diphtheritic membranes eIsewhere in the throat, aIthough IaryngeaI diphtheria may readiIy occur without such evidence and cannot therefore be ruIed out because of its absence. In the rarer instances in which the patient is a young aduIt the characteristic appearance of the membrane attached to the voca1 cord edges, wouId be seen in the IaryngeaI mirror. In chiIdren the diagnosis of IaryngeaI diphtheria can onIy be properIy substantiated by direct Iaryngoscopic examination of the Iarynx. This procedure reveaIs the typica membrane usuaIIy attached to the voca1 cord and at the same time offers the idea1 opportunity for the insertion of an intubation tube. WhiIe indirect intubation by the cIassica1 O’Dwyer method is stiI1 practical, particuIarIy where hospita1 faciIities are not avaiIabIe for direct endoscopy, the Iatter has so many advantages as to make it greatIy to be preferred. More recentIy there has been some enthusiasm for treating this condition by mechanica remova of the membrane by suction or forceps and foregoing the insertion of a tube unIess absoIuteIy necessary. This method obviousIy necessitates keeping the patient under cIosest surveiIIance, unti1, with the suppIementary administration of diphtheria antitoxin, the obstruction subsides. Acute streptococcic infections of the Iarynx are responsibIe for a Iarge number of instances of severe respiratory obstruction, particuIarIy in chiIdren. Infection is

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often secondary to a similar process higher up the respiratory tract and frequentIy foIIows such simpIe infections as an ordinary head coId or acute tonsiIIitis. The characteristic pathoIogic process is an inffammatory sweIIing of the mucous membrane and edema and hyperemia of the submucosa1 tissues, particuIarIy of the arytenoid cartiIage and the subgIottic walls. This sweIIing and edema are the essential causative agents in the obstructive process and, unIike diphtheria, are rarely accompanied by any definite membrane formation. Hoarseness, though frequentIy present, is not so pronounced a feature as in the case of diphtheria since the cord edges are often uninvoIved in the inffammatory process. The febriIe reaction is apt to be quite high with temperature eIevations up to 103’ or IO~‘F., but the outstanding sign is a graduaIIy increasing respiratory obstruction with restIessness and a rise in the puIse and respiratory rate, and, together with this, an intense and everincreasing genera1 toxicity which becomes in many instances an even more compeIIing factor in the necessity for aIIeviation of obstruction than the actua1 respiratory embarrassment itseIf. With such a picture in mind it is at once evident that the administration of antitoxin under the supposition that such a case is of diphtheritic nature is not onIy futiIe and misdirected treatment, but entaiIs grave risk to the Iife of the patient if such obstruction is not at once relieved. There is unfortunateIy as yet no treatment with the specificity which characterizes diphtheria antitoxin and antistreptococcic serum in genera1 has not proved particuIarIy efficacious in this form of acute IaryngeaI obstruction. Such a temporary and paIIiative measure as pIacement of the patient in a croup or oxygen tent, whiIe possibIy effective in miId cases of earIy acute catarrha1 laryngitis, cannot be reIied upon for any period of time beyond an earIy tria1 and, if ineffectua1 must at once be abandoned for other and more drastic

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measures. The drug suIfaniIamide may well be worthy of a tria1 under these circumstances, but the fact must never be overIooked that no medication or form of generaIized therapy can ever be reIied upon in a case of impending asphyxiation and that when events are progressing unfavorabIy no procedure can be countenanced except mechanica reIief through by-passing of the obstruction at a Iower point. There remains, therefore, only the operative procedure of tracheotomy, the detaiIs of which wiI1 be discussed below. The utiIization of intubation under these circumstances, whiIe advocated by some, is in genera1 to be avoided and condemned, because, aIthough effective in temporary reIief of the obstruction, it entails subsequent dif%cuIties in extubation and possibIe residuaI IaryngeaI stenosis which mihtate very strongIy against its use. Another acute obstructive infection invoIving the Iarynx is commonIy designated as Iaryngo-trachea-bronchitis. Sometimes associated with epidemics of influenza, it gives rise within a remarkabIy short time to a high degree of respiratory obstruction which, aIthough beginning in the Iarynx itseIf, tends rapidIy to invoIve the trachea and upper bronchia tree. The pathoIogic feature is an accumuIation of thick, tenacious, aImost gIue-like secretion aIong the cord edges and waIIs of the Iarynx, particuIarIy in the subglottic region, producing increasing IaryngeaI obstruction but differing entireIy and hoarseness, from the type of true membrane found in diphtheria. AIthough post-mortem examinations show this condition to be essentiaIIy a streptococcic infection, there is Iacking at the outset the intense infiItration and edema of the arytenoids and supraglottic tissues which is seen so commonIy in true streptococcic Iaryngitis. Such cases, however, are marked by the same high degree of toxicity and systemic reaction as in the above described streptococcic infections and the prostration and gradual suffocation of these patients present an

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alarming picture which, once seen, can never be forgotten. AU avaiIabIe paIIiative measures designed to combat this infection have, in the author’s experience, proved futiIe, and tracheotomy, both from the standpoint of reIief of obstruction and from that of accessibility for remova of accumuIated and inspissated secretions from the trachea and bronchi, is absoIuteIy indispensabIe. The above described acute infections of the larynx are, of course, far more common in children than in aduIts, first because of the frequency of a11 respiratory infection in chiIdhood and second because the reIativeIy narrower IaryngeaI passages in the Iower age groups permit a Iesser degree of inff ammatory reaction to provoke a far greater obstruction. One must, however, never forget the possibiIity of simiIar IaryngeaI infections in aduIts. Their manifestations are more readily observed and diagnosed because of the possibiIity of direct mirror examination of the Iarynx, and other warning signs, particuIarIy hoarseness, are IikeIy to appear we11 in advance of serious obstruction. 2. Non-InJEammatory 0 b s t r u c t i o n. Those conditions arising within the Iarynx which produce varying degrees of obstruction, but which do not initiate from an infectious process, may be divided, according to their etioIogy, into three major groups : (a) Some form of spasm or paraIysis, arising from a neuromuscuIar disturbance, may resuIt in a temporary or permanent encroachment on the IaryngeaI airway. (b) A new growth, either benign or maIignant, may restrict the avaiIabIe space within the Iarynx. (c) The Iodgment of some form of foreign body inhaIed into the IaryngeaI box, through its interference with the passage of air, may produce varying degrees of obstruction. The varied mechanism underIying these three non-infectious processes may create a situation requiring immediate reIief if the patient’s Iife is to be saved, whereas,

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in other instances, the onset of symptoms is so sIow as to afford ampIe time for diagnosis and appIication of appropriate treatment. The former type is we11 exempIified by the sudden inspiration of a foreign body into the Iarynx, the Iatter by the gradual deveIopment of a maIignant tumor. As in other diagnostic problems, differentia1 diagnosis of such obstruction rests first on a detaiIed history of onset, second on the physica examination and, wherever possibIe, VisuaIization of the Iarynx by mirror examination or direct Iaryngoscopy. RareIy in adults wiI1 the dyspnea from IaryngeaI obstruction be so acute as to precIude this diagnostic mirror examination. In the case of chiIdren and infants, the probIem is a more diffIcuIt one. Certain chiIdren, between the ages of 5 and 6, wiI1 not infrequently coijperate suffIcientIy to permit a satisfactory mirror examination of the Iarynx. With younger chiIdren and with oIder ones who, for one reason or another, wiI1 not coaperate, the practitioner is denied the opportunity of this aII-important bit of evidence which can onIy be suppIied by resorting to direct Iaryngoscopy. LARYNGEAL

VERTIGO

Spasm of the IaryngeaI apperture resuIting in transient approximation of the true and faIse voca1 cords may resuIt from any irritant contacting the mucous membrane. This is essentiaIIy a protective mechanism, designed to keep intruding substances from gaining access to the Iower airways. It is exempIified by the result of water or food being swaIIowed the “wrong way,” by a drop of medication from a syringe striking the unanesthetized mucosa, or by the paroxysma obstruction seen in whooping cough. In a Iarynx unduIy irritated by vocal abuse the increased irritabiIity of the mucosa may Iead to spasm when a drop of nasa1 secretion strikes it, waking the patient up from a except in the sound sIeep. Hoarseness,

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presence of chronic irritation wiII not be present. The immediate attack can be terminated by raising the arms above the head, hoIding the nose and sIapping the patient on the back. Mirror examination between attacks wiII quickIy reveaI the essentia1 Iack of true obstructive pathoIogy. The essentia1 eIement in treatment is the discovery of the inciting factor, reassurance that an attack wiI1 not prove fata1, and advice designed to reIieve any IaryngeaI irritation which may be present. CROUP

A simiIar form of spasmodic IaryngeaI obstruction is croup, seen essentiaIIy in rachitic, undernourished and neurotic chiIdren with flabby IaryngeaI muscuIature. Often initiated by mouth breathing and the dropping into the Iarynx of secretions incident to an upper respiratory infection, it is not in itseIf an infectious process of the Iarynx. The onset of croup may be quite unexpected and for this reason is a11 the more terrifying to the chiId. For the moment its effect may appear extremeIy serious. Appropriate treatment, however, wiI1 usuaIIy resuIt in a cessation of at Ieast the immediate attack, foIIowed perhaps by a simiIar one within a variabIe time. It is important that croup, a seIfIimited and transitory affection, be not mistaken for some other more serious and proIonged form of IaryngeaI obstruction in yhich treatment for croup wiI1 not onIy prove ineffectua1 but may resuIt in a Iost opportunity to reIieve the basic cause. As a ruIe, temperature eIevation in true spasmodic croup is sIight, the patient’s voice during any interim between attacks is usuaIIy good and in spite of the apparent severity of the obstruction, the high pitched inspiratory stridor and the diffIcuIty in breathing, there is rareIy true cyanosis. A history of previous attacks is a most vaIuabIe key to the diagnosis though it is of course no guarantee that because a chiId has had previous attacks

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of croup it may not in a given instance be suffering from a far more severe and serious cause of IaryngeaI obstruction. If appropriate measures designed to relieve croup do not have a reasonabIy prompt effect, one shouId be suspicious of some more fundamenta1 condition and steps for meeting this situation shouId be undertaken without deIay. Prevention of subsequent attacks may be achieved by attention to genera1 heaIth, remova of diseased adenoids, incIusion of needed vitamins in the diet and avoidance of coId air in the sIeeping room. CIassicaI methods of treatment dictate the pIacement of the patient in a warm room fiIIed with steam from a hot water bath, with inhaIations through a paper funne1 of hot vapor medicated with such a drug as compound tincture of benzoin (one ounce to a pint) contained in a receptacIe which can be convenientIy kept hot. Ipecac, a time-honored remedy, carried just to the point of inducing vomiting to break up the muscIe spasm, is no Ionger favored by Ieading speciaIists. Much can be accompIished by reassurance of both the patient and the parent, and by drawing the tongue forward and inducing reguIar and reIaxed inspiration. An attack of true croup, aIarming as it often seems during its height, is rareIy serious, tends to subside under appropriate treatment and Ieaves no untoward effect behind. Its cIosest simuIator, the inspiratory stridor incident to whooping cough, is usuaIIy readiIy diagnosed by the history of associated cough. The practitioner shouId ever be on his guard not to make a diagnosis of croup unIess the signs and symptoms are present of transitory spasm in a patient otherwise quite weI1, often subject to previous attacks, and showing no essentia1 hoarseness or cyanosis. LARYNGEAL

PARALYSIS

Laryngeal Obstruction Due to Vocal Cord mechanism Paralysis. Th e neuromuscuIar of the Iarynx is so constituted that the norma gIottic opening, trianguIar in shape,

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is maintained by the tension of certain groups of muscIes designated as the abductors, which tend to keep the resting Iarynx suffIcientIy open to permit ampIe ingress and egress of air. These abductor muscIes are under the contro1 of the recurrent IaryngeaI nerves, branches of the vagus, which, Ieaving the parent nerve in the chest, Ioop around the aorta on the Ieft and the subcIavian artery on the right and ascend to reach the Iarynx. The triangular appearance of the gIottic opening with the cords in approximation anteriorIy just behind the thyroid notch and separated posteriorIy where they attach to the arytenoid cartilages, is the one commonIy seen in a mirror examination of the resting Iarynx. Interference with this abductor function may occur in such a way that one or both of the voca1 cords no Ionger retain their abducted position during quiet breathing but, puIIed toward the midIine by the action of the opposing adductor. muscIes, occupy a new position cIoseIy approximating the midline. When this takes pIace on onIy one side there occurs a so-caIIed uniIatera1 abductor paraIysis of the Iarynx. This restricts the gIottic airway to one haIf of its former capacity and resuIts in miId respiratory obstruction, never in itseIf severeIy embarrassing and noticed onIy by the patient on unusua1 efforts of exertion and activity. It requires no treatment so far as its obstructive features are concerned. The voice though weakened is essentiaIIy norma1 since the adductor function is unimpaired. Mirror examination shows the paraIyzed cord Iying verticaIIy in the midIine and the normaI cord abducted in the usual position. On a phonatory effort the norma cord not onIy approximates the paraIyzed cord in the midline, but as pointed out by Jackson actuaIIy moves or jostles it somewhat beyond the ‘center. This point is of importance in a differentiation between paraIysis and the inffammatory fixation of the arytenoid cartiIage, in which case there is compIete immobiIity of the affected cord on phonation.

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Such a uniIatera1 paraIysis may be the resuIt of pathoIogy in the chest or neck invoIving by pressure or inflammation the recurrent IaryngeaI nerve on the affected side. CIinicaI and x-ray search shouId be made for such a condition. BiIateraI paraIysis with a disturbance in the abductor function on each side creates a much more serious situation, resuIting either in urgent respiratory obstruction or, if the cord edges do not compIeteIy contact each other, in severe respiratory distress. The condition is most often the resuIt of inflammation, edema, or operative trauma in the neck, such as is occasionaIIy seen as a compIication after thyroidectomy. RareIy some chest pathoIogy wouId be so extensive as to invoIve both recurrent IaryngeaI nerves. In addition certain forms of centra1 nervous disease such as tabes and buIbar paIsy can aIso produce disturbances in the function of the recurrent IaryngeaI nerve, and shouId be ruIed out by compIete neuroIogic and seroIogic tests. In the case of inflammatory sweIIing or operative trauma, the paraIysis may come on quite suddenIy and create the need for immediate reIief of the resuItant obstruction. It is obvious that from an etioIogic standpoint the condition is far more common in aduIts than in chiIdren. Hence a diagnosis is most readiIy made by mirror examination of the Iarynx, which wiI1 revea1 the voca1 cords cIoseIy approximating the midIine with onIy a narrow chink between them. This is sufficient for sustaining Iife, but produces a high degree of stridor which must be reIieved in most instances in order to permit the patient to obtain an adequate respiratory exchange. An important diagnostic point under these circumstances is the fact that phonation is stiI1 possibIe and that there is absent the cIinica1 symptom of marked hoarseness which characterizes so many other pathoIogic conditions of the Iarynx. Th e probIem of permanent reIief of biIatera1 abductor paraIysis is a compIicated one which has taxed the ingenuity of genera1 surgeons and IaryngoIogists for

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a long period of time. Numerous operations have been devised with a view to restoration of the airway through either remova of portions of the voca1 cord, dissection of underIying tissue or attempts by pIastic operation to widen the gIottic space in an effort to provide more space. For purposes of immediate reIief of urgent obstruction there is onIy one procedure worthy of a moment’s consideration under the circumstances, nameIy tracheotomy, a detaiIed description of which wiI1 be found on a subsequent page. It wiI.I occasionaIIy be found that obstetrica trauma during diffIcuIt deIivery wiII so derange the recurrent IaryngeaI nerves as to produce a biIatera1 abductor paraIysis. Such a condition might easiIy be mistaken for an unexpIained or cardiac dyspnea (bIue baby). However, prompt reIief might prove a Iife saving measure if endoscopic confirmation were avaiIabIe. RareIy such biIatera1 abductor paraIysis wiI1 persist into chiIdhood. A transitory intermittent form of Iaryngea1 obstruction seen in the newborn and in infants is known as congenita1 IaryngeaI stridor. It appears in an otherwise perfectIy heaIthy chiId as a periodic high pitched inspiratory stridor with coIIapse of the gIottic waIIs due to a congenita1 weakness in the cartiIaginous structure with infoIding and indrawing of the epigIottis and arytenoid emminences which tend to approximate each other during inspiration. This stridor appears frequentIy with crying or exertion, and is usuaIIy absent during sIeep. The condition tends to right itseIf in due time without any essentia1 treatment, since, as the chiId grows oIder, the gIottis enIarges and the IaryngeaI waIIs become strengthened unti1 they no Ionger coIIapse under enforced inspiration. There is no cause for aIarm and no IikeIihood of serious consequences because of this condition so Iong as its nature is recognized and so Iong as the picture is not confused with some other fundamental and more serious cause of IaryngeaI obstruction in a newborn infant or chiId within this earIy age group.

Obstruction

OCTOBER, 1938

A form of this same condition, occurring in nocturna1 attacks, known as Iaryngismus striduIus is described in pediatric Iiterature as a compIication of tetany, associated with deficiency of bIood caIcium and abnorma1 function of the parathyroid gIands. NEW

GROWTHS

IN

THE

LARYNX

New growths springing from the Iaryngea1 waIIs tend, as they enIarge, to cause increasing respiratory obstruction. In the face of progressive symptoms some form of intraIaryngea1 pathoIogy shouId be suspected and confirmed by mirror Iaryngoscopy. Such growths arise either from the mucous membrane above the cord edges, from the cord edges themseIves or. from the subgIottic waIIs beIow the voca1 cords. They may be of benign nature, either in aduIts or in chiIdren, or may be maIignant, occurring most often between the ages of 30 and 60 years. When such tumors arise from the voca1 cords they wiI1 produce hoarseness Iong before they reach suficient size to provoke definite obstruction. If, however, they spring from the supragIottic or subgIottic region they may reach a considerabIe extent before they attract attention. For this reason symptoms of even miId Iaryngea1 obstruction merit a carefu1 mirror examination if the advantages of earIy diagnosis are to be secured. If negIected, obstruction from such growths eventuaIIy may be so severe as to require for its reIief the same urgent and drastic measures as those mentioned above. The treatment necessarily varies with the nature of the growth. PapiIIomata, seen oftenest in chiIdren and characterized by repeated recrudescence of the growths, are best removed by repeated and careful excision with bIunt cup forceps, great care being taken not to traumatize the adjacent normal mucous membrane. More recently some enthusiasm has been evinced for treatment by repeated exposure to smaI1 doses of x-ray, but to date this method has had Iimited and inadequate trial.

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The Iaryngeal surgery invoIved in deaIing with obstructing maIignant growths is beyond the scope of this paper. FOREIGN

BODIES

OF

THE

LARYNX

The aspiration into the Iarynx of some one of the manv forms of foreign body is an accident which may at any time befaI1 a chiId and more rareIy an adult. A wide range of objects pIaced in the mouth can, through the medium of sudden Iaughter, crying or coughing, be suddenIy inspired and if of such a size as to become Iodged within the structures of the Iarynx may create a varying degree of obstruction. That such an accident has taken pIace may be immediateIy recognized by the resuItant cough or interference with phonation because of impaction of the foreign body between or near the voca1 cords. Moreover, a chiId oId enough to reaIize what has happened wiI1 often report the accident to a parent or oIder individua1. If the obstruction is suffIcientIy severe, it wil1 at once manifest itseIf in the characteristic manner, depending on its completeness, with inspiratory stridor, indrawing of the substerna and suprasterna1 spaces and obvious signs of dyspnea. There may, however, be no eye witness to the accident itseIf and a child may be too young to reIate to older persons what has transpired. A diagnosis must then be made on the presenting signs and symptoms which vary greatIy according to the nature of the foreign body and the degree of obstruction which has been produced. Under these circumstances, it behooves every practitioner to bear in mind that any form of IaryngeaI pathoIogy, of which the actual cause is unknown, may conceivabIy be due to foreign body and to leave no stone unturned to determine the correctness of such a suspicion. Time and again either the patient himself or his parents have brought to a physician either a clear story, or at Ieast a definite suspicion, of possibIe aspiration of a foreign body. NevertheIess, because signs of obstruction in the Iarynx were incon-

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spicuous and the symptoms consistent with some other, perhaps more common the possibiIity of foreign expIanation, body has been dismissed and the patient aIIowed to continue to harbor the intruder until some one more shrewd and more wiIIing to Iend an attentive ear to the parents’ or patient’s suspicions has uItimateIy made the correct diagnosis, often after almost irreparabIe damage has been suffered through the sojourn of the foreign body within the Iarynx. Given the suspicion of such a IaryngeaI foreign body, an x-ray of this region, including the nasopharynx and the chest, shouId at once be taken in suffIcientIy varied positions to confirm or excIude this diagnostic possibiIity so far as it concerns opaque objects. A considerabIe number of such foreign bodies, particuIarIy toys, coins and pins, are opaque to the ray and wiI1 aImost invariabIy be shown in this manner. This wiI1, of course, not be true of the vegetabIe substances, grasses and a wide range of other foreign bodies. If such objects are definiteIy lodged within the Iarynx, signs and symptoms of this condition wiI1 usuaIIy be present which, if properIy interpreted, wiI1 at Ieast raise the suspicion of foreign body. It is surprising how reIativeIy Iarge a foreign body may occupy the confines of the larynx without producing sufficient interference with the airway to demand immediate relief. Coins, open safety pins, discs and a considerabIe number of ffat objects, such as thin pieces of bone, usuaIIy enter the Iarynx and become lodged in the anteroposterior position, Ieaving thus a reIativeIy Iarge airway avaiIabIe for respiration on either side. Strange as it may seem, even a considerabIe sojourn of such a foreign body in the larynx does not aIways resuIt in subsequent edema and sweIIing of the IaryngeaI tissues and hence this situation may go on for some time, manifested onIy by such reIativeIy miId symptoms as hoarseness or coughing, without attracting suff~cient attention to make direct observation

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of the Iarynx an obvious requirement for diagnostic purposes. It is in such instances as these that patients have been treated for diphtheria, chronic Iaryngitis, whooping cough, asthma and a variety of other genera1 conditions, with no suspicion of the possibiIity of IaryngeaI foreign body. WhiIe it is quite true that these conditions are far commoner causes of symptoms referabIe. to the Iarynx, nevertheIess the importance of retaining foreign body in the back of one’s mind as a possibIe diagnosis LntiI definiteIy excIuded by direct Iaryngoscopic examination, cannot be overstressed. So Iong as the physician maintains this attitude of mind with respect to such cases, particuIarIy in chiIdren, there is IittIe Iikelihood of such mistakes being made. As far as aduIts are concerned, aspiration of a IaryngeaI foreign body wiI1 aImost invariabIy be recognized at once by the patient and bring him to a physician, under which circumstances direct mirror Iaryngoscopy wiI1, in most instances, give the true diagnosis. As with chiIdren x-ray examination wiI1 afford heIpfu1 confirmation. The onIy appropriate treatment of foreign body in the Iarynx and the onIy positive means of its diagnosis is direct Iaryngoscopic examination. OnIy in this way can the foreign body be brought under direct vision and removed by appropriate operative measures. The Iatter do not faI1 within the province of the present articIe. Depending entireIy on the urgency of the situation a physician may at any time be caIIed upon to reIieve IaryngeaI obstruction without adequate opportunity for study and examination into the etioIogic factors invoIved. WhiIe direct Iaryngoscopic examination shouId, wherever possibIe, precede any mechanica by-passing of the obstruction if the most inteIIigent therapy is to be appIied, there wiI1 be occasions when Iack of faciIities or time these circumwiI1 precIude it. Under stances there are avaiIabIe two cIassic

Obstruction

OCTOBER,

1938

procedures, intubation and tracheotomy. The former is Iess in vogue today than formerIy and is considered appIicabIe chiefly to IaryngeaI diphtheria. The Iatter has a much more universa1 appIication and avoids certain disadvantages which render intubation a Iess desirabIe procedure. Discussion of measures for the relief of IaryngeaI obstruction wouId, however, not be compIete without some account of both intubation and tracheotomy. INTUBATION

The operation of intubation was first popuIarized by its inventor O’Dwyer, and was designed primariIy for the reIief of the obstruction incident to the presence of diphtheritic membranes within the IaryngeaI Iumen, most often in chiIdren, for whom it has, on countIess occasions, proved a Iife saving measure. The apparatus empIoyed is known as an intubation set and consists of a series of hoIIow tubes, either of hard rubber or meta of graduated sizes and of a shape to conform to the contour of the IaryngeaI Iumen. These tubes are affIxed to a socaIIed carrier, from which they can be disIodged by means of a spring slide when properIy pIaced within the Iarynx. The origina technique can be somewhat simpI&ed by eIiminating that portion of the instrument containing the spring and sIiding catch, the tube being maintained on the sIender obturator by tension on the string attached to the tube and heId by the fingers of the intubing hand. A second somewhat simiIar handIe is required for the subsequent remova of the tube when its presence is no Ionger required within the Iarynx. The procedure of introduction of such a tube is as foIIows: The patient is first secureIy wrapped in a bIanket to prevent the struggling, aIways to be coped with in any chiId suffering from respiratory embarrassment. Thus restrained, he is Iaid on a tabIe with the head heId firmly The proper sized tube, by an assistant. seIected according to the patient’s age

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is pIaced on the introducer, the handle of which is heId in the right hand with the physician standing on the patient’s right side, facing the head. WhiIe the mouth is heId open by a gag, the index finger of the Ieft hand is passed over the dorsum of the tongue unti1 the free edge of the epigIottis is paIpated. BeIow and sIightIy posterior can be feIt the two eminences of the arytenoid cartiIages. It is into the narrow gIottic space between the epigIottis and the arytenoid cartiIages, with the voca1 cords on either side that the intubation tube is to be introduced. With the Ieft finger as a guide, the intubation tube, heId in the introducer, is passed over the back of the tongue just above and behind the epigIottis and gentIy sIipped downwards and forward between the voca1 cords unti1 the upper Hanged surface of the tube comes to rest against the superior surface of the voca1 cords. When the tube is feIt to be definiteIy Iodged in the Iarynx and not, as sometimes happens, to have sIipped posterior to the arytenoid eminences and into the esophagus, it is disIodged by sIight downward pressure of the Ieft index finger on the flanges of the tube. The carrier is then withdrawn, the string being brought out and anchored to the side of the cheek. It is one of the dramatic experiences of any physician to note the amazing reIief which foIIows the introduction of such a tube in a chiId struggIing desperateIy from the respiratory embarrassment incident to IaryngeaI obstruction. If the tube is properIy pIaced a11 respiratory effort ceases and the chiId not infrequentIy dozes off into a quiet, restfu1 sIumber, with easy respiration contrasting markedIy with the previous vioIent efforts incident to the obstruction. Where such a happy outcome does not immediateIy foIIow the introduction of an intubation tube, the possibiIities are that by some mischance it has overridden the arytenoid cartiIages and sIipped into the esophagus, an accident usuaIIy due to faiIure either to make strong traction on

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the carrier anteriorIy or to eIevate the handIe as the end of the tube is introduced beIow the gIottic rim. More rareIy the obstruction may be so far beIow the Iarynx, in the trachea, that the tube does not overcome the diffIcuIty. In certain forms of IaryngeaI obstruction, particuIarIy those in which the difficuIty is due to accumuIated crusts, secretions or membranes aIong the IaryngeaI waIIs, the procedure of intubation is ideaIIy designed for reIief and avoids certain of the more unpIeasant features of tracheotomy. On the other hand, there are certain disadvantages associated with intubation. Among these is, first of aI1, the necessity of keeping constant and carefu1 watch of an intubated patient against the possibility that the tube wiI1 be suddenIy coughed up. Th is accident sometimes arises from the fact that too smaI1 a tube was used or from the gradua1 subsidence of the inflammatory sweIIing of the waIIs of the Iarynx, foIIowing the primary reIief of the obstruction. Some one capabIe of repIacing the tube must therefore remain at the patient’s bedside or within immediate caI1 unti1 further necessity of the tube in the Iarynx has passed. Furthermore, certain definite forms of IaryngeaI obstruction are not ideaIIy suited to this method of treatment. Thus in acute streptococci inflammation, marked sweIIing of the supragIottic tissues may render the introduction of the intubation tube extremeIy difficuIt and even if temporary reIief is afforded by its presence its withdrawa is immediateIy foIIowed by stiI1 further sweIIing with each necessary repIacement. Under such circumstances, secondary compIications in the form of IaryngeaI uIceration and chronic stenosis are aImost certain to Iead to unfortunate consequences. FinaIIy, the appIication of the procedure of intubation to IaryngeaI obstruction due to foreign bodies in the Iarynx is iIIogica1 since attempts to introduce such a tube wiI1 onIy drive the foreign body into a stiI1 more inacessibIe pIace or into a

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position in which it may produce stilI more com.pIete obstruction. Hence it is important that the physician have as accurate an idea as possibIe of the nature of the IaryngeaI obstruction before introducing an intubation tube and that he consider its use as idea1 principaIIy for cases of diphtheritic or membranous obstruction. It is because of the above objections that the procedure of indirect intubation is more and more giving way to the direct method in which the intubation tube is introduced into the Iarynx onIyafter the Iatter has been carefuIIy inspected by means of direct Iaryngoscopy, thus affording an opportunity for accurate diagnosis and the determination of the nature of the obstruction before consideration is given to the introduction of such a tube. Such “ visua1” intubation can be readiIy performed, if indicated, as part of the direct Iaryngoscopic examination. The Iength of time during which a tube shouId be Ieft in the Iarynx wiI1 depend entireIy on the nature of the case and the effect of such suppIementary treatment as the administration of diphtheria antitoxin. RemovaI is accomplished by a reversa1 of the technique of introduction, by insertion of the tip of the extubator into the Iumen of the tube. FoIIowing extubation cIose observation of the patient wiI1 be required before decision can be reached as to the safety of Ieaving the tube out. If symptoms of obstruction recur the tube must be reintroduced. If a third introduction proves necessary it is in genera1 better to abandon intubation entireIy and to resort to tracheotomy, lest further trauma to the larynx make uItimate extubation impossibIe and risk the deveIopment of uIceration with possibIe subsequent stenosis. A procedure somewhat anaIogous to indirect intubation, much favored by IaryngoIogists during the past few years, is the introduction of what is commonIy known as the Mosher Iife saver. This instrument consists of a Iong, hoIIow cannuIa with a bIunt pointed and distaIIy perfo-

Obstruction

O<:TOBEH, 1938

rated end, curved to fit the genera1 course of the upper airway and designed to be introduced in much the same manner as the O’Dwyer intubation tube. The Iife saver is carried over the back of the tongue, the epigIottis being identified as in intubation with the Ieft forefinger and the tip ,of the Iife saver passed between the voca1 cords into the IaryngeaI Iumen. Once introduced, it can, temporariIy, be Ieft in pIace with reIief of the IaryngeaI obstruction, affording time for further consideration as to proper means for management of the situation in hand. This life saver is extremeIy usefu1 in an emergency, particuIarIy because of its simpIicity; it shouId never be omitted from the physician’s ordinary daiIy equipment. It is made both in aduIt and chiIdren’s sizes. Its use, however is restricted by the same Iimitations aIready mentioned in connection with indirect intubation. TRACHEOTOMY

RivaIing intubation in its often dramatic effect and in many ways superior to it because of its aImost universa1 appIicabiIity to a11 forms of IaryngeaI obstruction, is the cIassic procedure known as tracheotomy. IndispensabIe for those anxious occasions when minutes onIy are avaiIabIe if the patient’s Iife is to be saved, tracheotomy has been carried out under the most adverse and trying circumstances, when no instrument other than the physician’s pen-knife was at hand to do the work. In such a situation, the one and onIy requisite is an opening into the trachea at a point we11 beIow the Iarynx, made with the maximum speed and with disregard of a11 other considerations. For the successfu1 achievement of socaIIed emergency tracheotomy certain fixed principIes of technique must be carried out even in the Iimited time avaiIabIe. These have been so cIassicaIIy described and repeatedIy emphasized by Chevalier Jackson, that one finds it impossibIe to improve on a summary and repetition of them as Iaid down by this master Iaryn-

gologist. Let it be said here that any practitioner who may unexpectedIy be faced with such a tracheotomy wiII do we11 to have aIways with him a simpIe yet adequate armamentarium, carefuIIy set aside, steriIized and packed in a convenient carrier, never to be disturbed except in such an emergency. A satisfactory group of instruments is as foIIows: I sharp scatpet I #I tracheotomy tube I #2 tracheotomy tube I #3 tracheotomy tube

I trachea1 dilator Mosher life saver (2 sizes) Gauze sponge Tracheal tape I

IZ smaI1 curved hemostats

Such a tracheotomy set shouId always include the above mentioned Iife-saver since it is in the execution of tracheotomy that this instrument finds one of its greatest fieIds of usefuIness. Once introduced into the Iarynx of a patient suffering from severe IaryngeaI obstruction, it affords a prompt and gratifying improvement in the patient’s condition and greatIy faciIitates the opening of the trachea and introduction of a. by-passing tracheotomy tube. The haste sometimes attendant on opening the trachea without such preIiminary intubation is thus eliminated together with the increased vascuIar congestion and resuItant bIeeding and obscuration of the field of operation. NevertheIess, the opportunity to insert such a life-saver cannot aIways be reIied upon and, for reasons mentioned above in connection with intubation its use is not aIways advisable. Hence, the practitioner must famiIiarize himseIf with the cardinal principles of procedure in executing an emergency tracheotomy without such suppIementary aid. To this end, the patient, restrained, if a chiId, as rapidIy as possible, shouId Iie supine on a tabIe, on an assistant’s Iap, or even on the physician’s own knee, with the head so extended toward the physician’s Ieft hand as to bring the trachea as prominentIy as possibIe to the anterior surface of the neck. With the knife heId in the right hand, the so-caIIed tracheo-

tomic triangle is located by placing the Ieft index finger over the trachea, just as it disappears behind the sternal notch, and the thumb and middIe finger just inside the anterior borders of each sternomastoid muscIe at the IeveI of the thyroid cartiIage. The position of these three fingers outlines thus a trianguIar area, the apex at the bottom toward the patient’s feet, the base toward the patient’s head. It is the purpose of the skin incision to bisect this triangIe, beginning just beIow the thyroid notch and extending almost to the suprasterna1 notch. There shouId be no hesitancy in making this incision of ampIe Iength and one must disregard entireIy the temporariIy copious bIeeding which results from incising the already engorged vesseIs which Iie beneath the skin in this pretrachea1 region. A singIe boId and uncompromising incision aIong this midIine shouId incIude the skin, superficia1 fascia and pretrachea1 muscIes down to the anterior trachea1 waI1. Timid and haIfway measures produce onIy bIeeding and avail nothing in the reIief of the obstruction. This initia1 incision must be suffrcientIy deep to permit the withdrawal of the index finger from its position at the sterna1 notch for the purpose of paIpation, in the depths of the wound, of the trachea1 corrugations. With this palpating finger as a guide to the knife, a second incision is made directIy through the trachea just beIow the index finger, which must protect from division the higher cricoid cartiIage. So Iong as this paIpating finger identifies the trachea1 rings before the second incision is made, no harm can come from false direction and faiIure of the knife to enter the trachea1 Iumen. With this second incision into the trachea, dividing two or even three trachea1 cartiIages, the principa1 object of the operation has been accompIished. For the moment, air can be admitted to the trachea by simpIe insertion into the incision of the handIe of the knife (as suggested by Jackson) thus spreading the edges of the trachea1 wound, and keeping

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it open to permit the unobstructed entrance of air to the Iungs. After this important end has been accomphshed ampIe time wiI1 be avaiIabIe to stop the active bIeeding from the incised superficia1 vesseIs and graduaIIy to restore order to a scene which, under the best of circumstances, may be somewhat hectic. There remains finaIIy the insertion of a tracheotomy tube of proper size for the individua1 patient and equipped with a cone-shaped obturator which is quickIy recovered or bIown out by the patient’s first active expiration. Tapes attached to the outer edges of the tube and tied behind the neck serve to maintain the tube in position after introduction. So critica may have been the patient’s condition and so severe the degree of obstruction that respiration may not immediateIy be resumed with opening of the trachea. Let no one be discouraged because of this fact since artificia1 respiration, begun immediateIy after tracheotomy, has, on numerous occasions, prdved uItimateIy successfu1 in restoring a Iife which htid apparentIy been Iost. During this process, effort shouId be made, if possibIe, to keep bIood from running into the tracheotomy tube and definite bIeeding vesseIs shouId be caught with hemostats, to be Iigated at Ieisure after respiration has again been resumed. So Iong as a heart beat can be detected, no effort at restoration of respiration shouId be abandoned, provided an unobstruction airway is afforded to the Iung. There is no gainsaying the fact that such a hasty and at times apparentIy futiIe operation vioIates many of the dictates of modern surgery. It may Iack a11 the aspects of asepsis, hemostasis and desirabIe surgica1 accessories but any physician who has deaIt with emergency IaryngeaI obstruction wiI1 recognize that otherwise essentia1 considerations must give way to the one and onIy important matter of the creation of an airway into the trachea, permitting oxygen to reach the Iung before death supervenes.

Obstruction

OCTOBER, 1938

Far more frequentIy the physician wiI1 be confronted with a state of affairs in which there is ampIe time not onIy for carefu1 examination of the patient to determine the nature of the IaryngeaI obstruction, but aIso for a consideration as to the advisabiIity of tracheotomy, either as a preIiminary or as the chief therapeutic procedure. The patient, whiIe not urgentIy dyspneic, nevertheIess presents signs and symptoms which indicate that unIess some direct measures can be appIied to the cause of the IaryngeaI obstruction itseIf, by-passing the Iatter wiI1 prove the most effective means of avoiding the necessity for an emergency tracheotomy at a Iater time when the situation for executing this may be far Iess favorabIe. Thus, in a tracheotomy deIiberateIy pIanned and tranquiIIy carried out, time is usuaIIy avaiIabIe for transfer of the patient to a hospita1 where a11 the faciIities for a surgica1 operation are at hand. Under these circumstances, the physician is exposed onIy to the temptation of postponing tracheotomy unti1 the most favorabIe time for its execution has passed. In spite of the feeIing that sooner or Iater the procedure wiI1 be necessary, there is inevitabIy an inborn desire to hope that perhaps it may be avoided. The physician must first of a11 make up his mind as def?niteIy as possibIe as to the intrinsic cause of the IaryngeaI obstruction and as to whether the condition is in any way IikeIy to resoIve spontaneousIy without surgica1 intervention. Once convinced that tracheotomy wiI1 sooner or Iater be required, vaIuabIe time wiI1 onIy be Iost in postponing it and increasing diff%uIty in its execution wiII inevitabIy resuIt. ParticuIarIy in those cases in which the cause of obstruction is an inffammatory Iesion in the Iarynx, associated with edema of the IaryngeaI tissues, tracheotomy is invariabIy the procedure of choice. Likeinstances of Iaryngeal wise, in those foreign body, in which, for one reason or another, means for its remova are not

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readily avaiIabIe, tracheotomy as a preIiminary procedure has much to recommend it and the attendant disadvantages are as nothing compared with those which may resuIt from its deIay or omission. The insidious but ever increasing obstruction due to some form of new growth, either benign or malignant, such as papiIIoma or carcinoma, is in genera1 best treated by prehminary tracheotomy. In recent years numerous authors have stressed the great advantage of the passage of a smaI1 bronchoscope into the trachea preIiminary to eIective tracheotomy. This must, of course, be preceded by direct Iaryngoscopy which permits inspection of the Iarynx and so facilitates a correct diagnosis as to the cause of the obstruction. Even if this is of an inflammatory nature there wiI1 usuaIIy be avaiIabIe suff~cient space to pass a smaI1 bronchoscope or “life saving” tube into the trachea to be left unti1 tracheotomy is compIeted. With such a tube in pIace a free airway is maintained, the patient’s struggIes are aImost entireIy eIiminated and the operation can proceed with a tranquiIiIty to be secured in no other manner. With the opening of the trachea the tube can be withdrawn and repIaced by the customary trachea1 cannula. Properly executed in an operating room with carefu1 attention to anatomic and surgica1 detaiIs, tracheotomy is, a11 things considered, the most dependabIe method of reIief of impending IaryngeaI obstruction. The patient should be pIaced supine on the tabIe, preferabIy with a sandbag under the shouIders and the head gentIy but firmly supported by an assistant with the chin directIy in the midIine. ChiIdren wiI1 require further restraint by being firmIy wrapped in a blanket. The operation shouId be performed under IocaI anesthesia, since even in cases of miId dyspnea, a genera1 anesthetic is fraught with some risk. ExceIIent anesthesia in a11 patients can be secured by infiItration of the skin with I per cent novocaine, starting at the sterna1 notch and carrying a Iine of wheaIs up to

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the thyroid cartiIage. Deeper injections can then be made into the subcutaneous tissues, passing sIightIy IateraIIy to the trachea from beIow upward, care being taken that the needIe is not inserted beIow the depth of approximateIy I cm. from the surface. A midIine incision in the skin, starting just beIow the thyroid cartilage, is extended to the suprasterna1 notch. There is a temptation at first to make this skin incision too short with the resuIt that as one goes deeper toward the trachea, the wound area narrows in a funne1 fashion unti1, when the trachea is fInaIIy exposed, an inadequate extent of trachea1 waI1 must be deaIt with. FoIIowing incision of the skin, the subcutaneous fat and superficia1 fascia are divided, exposing various smaI1 veins which cross the midIine. These are readiIy cIamped, Iigated and divided before carrying the dissection farther down between the pretrachea1 muscIes, which can be separated by a midIine incision and drawn IateraIIy, exposing the pretrachea1 fascia. If required, further anesthesia can be secured by introducing a smaI1 amount of novocaine beneath the Iatter. At this point there comes into view the one structure which may in any way cause diffIcuIty, nameIy, the isthmus of the thyroid gIand. This wiI1 appear as a smooth, dark red mass Iying across the midIine, just beneath the pretrachea1 fascia. In genera1 it is most satisfactory to incise this fascia and then to retract the thyroid isthmus upward. At times, this may Iie so Iow that it is easier to cIamp it on either side, cut directIy across it and Iigate the stumps of the gIand thus exposed. In either case, displacement or remova of the isthmus Ieaves no obstructing tissue between the operator and the anterior trachea1 surface. It is highIy important that this surface be accurateIy identified by the paIpating finger and that the distinct trachea1 rings be feIt before incision is made through them. IdeaIIy, the trachea1 waI1 is best entered through the second, third or fourth trachea1

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rings. Above all, it is important to incise the trachea beIow the crieoid cartiIage and the first trachea1 ring. It is the so-caIIed high tracheotomy with incision through this upper danger zone which has resulted so frequentIy in subsequent trachea1 stenosis and against which so much has been said by Jackson and other Ieading Iaryngologists. It is often heIpfu1, just before actua1 incision through the anterior trachea1 waI1, to insert a hypodermic needIe between two of the rings and inject into the trachea1 Iumen a few drops of I per cent cocaine and in this manner greatIy to reduce the unavoidabIe cough incident to the norma irritabiIity of the trachea1 mucous membrane. A thin-bladed sharp knife is then used to divide two or three of the exposed trachea1 rings and the intervening fibrous tissue between them. Great care shouId be taken in this incision that the posterior trachea1 waI1 is not traumatized as the knife enters the lumen. At this moment there wiI1 be an immediate passage of air through the incision, with slight bIeeding from the edges of the wound. Operators vary in their preference as to the type of trachea1 incision, some favoring a simpIe Iinear incision with suffIcientIy wide spreading of the edges of the wound to permit introduction of the tracheotomic cannuIa. Others prefer to make a crucia1 incision, the first verticaIIy through the second and third trachea1 rings, the second transverseIy between two adjacent cartiIaginous rings. Such a crucia1 incision immediateIy affords a somewhat wider opening with greater ease of introduction of the trachea1 cannuIa. StiII others, foIIowing such an incision, advocate the remova1, with some form of ring punch, of the four corners created by the crucia1 incision, Ieaving an aImost circuIar opening in the trachea. This is stiI1 more suitabIe for accommodation of the trachea1 cannuIa and has been found by experimenta work not to Jead to any tendency, after its

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removal, towards a stenosis or cicatricial obstruction of the trachea1 Iumen. With the trachea thus opened, an appropriate sized tracheotomic cannuIa is introduced. The diameter of the cannuIa shouId be onIy sIightIy Iess than that of the trachea1 Iumen, thus permitting air to pass around the tube and if possible through the Iarynx. It is usuaIIy inadvisabIe to attempt to cIose any portion of the skin wound foIIowing tracheotomy, barring, possibIy, the most extreme edges above and beIow. Such wounds usuaIIy hea promptIy and cIeanIy, but attempts at cIose suturing entai1 danger of infection in the deeper portion of the wound. A singIe foIded gauze pad is carried about the trachea1 cannuIa and the Iatter is heId in pIace by tapes passed through the sIotted edges and around the back of the neck. Any accumulation of bIood which may have entered the trachea during the procedure, is readiIy removed by means of suction appIied through a AexibIe catheter introduced into the tracheotomy tube and passed into the Iower portion of the trachea. The normaIIy present cough reflex shouId not be duIIed by the administration of sedatives since on it depends to a great extent the patient’s abiIity to rid himseIf of subsequent trachea1 secretions. To blunt and obtund this reffex onIy deprives him of his own natura1 defenses against possibIe puImonary compIications. Above aI1, the physician must reaIize that from this moment on, the patient is a candidate for the most carefu1 nursing care avaiIabIe and, if possible, shouId be pIaced in the hands of a nurse who has at Ieast some fundamenta1 training in such care. The outstanding principIe to be foIIowed is the constant maintenance of an unobstructed airway through the tracheotomy tube, and of a toiIet and cIeanIiness of the wound, tube and dressing which avoids any tendency to irritation or infection. In this connection, a factor of prime importance is the care of the socaIIed inner cannuIa. This tube, held in

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place by a small catch at its upper edge, can readiIy be removed at any time and shouId be repeatedIy cIeansed as often as there is the shghtest indication of blood or secretions having become dried within its Iumen. This cIeansing is carried out by introducing through one end of the inner cannula a bent piece of wire passed through to the other end of the tube, on which is threaded a smaII foIded piece of gauze. This gauze is then drawn back through the entire Iength of the tube, thus freeing it compIeteIy of accumuIated bIood and secretions. During the first twenty-four or forty-eight hours foIIowing tracheotomy, it is often necessary to clean this inner cannuIa at Ieast every fifteen minutes. With such a free tuba1 airway, there should, under norma circumstances, be no audibIe sound to the patient’s breathing, which shouId be tranqui1, comfortable, and, unIess there are puImonary compIications aIready present, unmarked by any essentia1 rise in respiratory rate. Any change in this situation shouId at once attract attention and shouId be reported promptIy to the physician as indicative of some further obstruction at a point beIow the tracheotomy tube for which prompt and often specialized treatment may be necessary. The outer tracheotomy tube should, by preference, be changed once a day, at Ieast during the first week, and this onIy by the physician himseIf, aided by good iIIumination and diIatation of the trachea1 wound. The outer cannuIa is introduced with the obturator in place, we11 Iubricated by an externa1 appIication of alboIene, facilitating the insertion of the tube within the tracheotomic wound. So far as possible, the newly inserted tube shouId be an absoIute dupIicate of the origina1, thus avoiding any change in the contour and irritation from contact of the tube end with the trachea1 waIIs, The avoidance of this trauma wiI1 prevent any tendency to bIeeding and formation of granuIation tissue aIong the trachea1 mucous membrane.

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STENOSIS

The above described conditions which IaryngeaI obstruction are esproduce sentiaIIy acute, though varying somewhat in the time before reIief becomes urgent. In most instances the Iarynx was norma before the onset of the disease and with the recovery of the patient after appropriate treatment the Iarynx returns to an approximateIy norma state. At times, however, the damages created by certain processes is such that permanent changes structures take pIace in the Iaryngeal which are beyond any reparative effort of nature. The cartiIaginous framework of the Iarynx may, as the resuIt of pathologic processes, be so deformed and soft tissues may be so repIaced by scar tissue, as to resuIt in serious deformity in the IaryngeaI architecture. Aside from disturbances in voice production with subsequent hoarseness, these cicatricial contractions may Iead to a varying degree of laryngeal stenosis and respiratory obstruction. Such conditions as perichondritis, fixation of the arvtenoid cartiIages, tubercuIosis and syph8is may a11 produce changes which even with the compIete arrest of the actua1 disease Ieave behind a varying degree of restriction of the IaryngeaI airway. Of a somewhat different etioIogy but productive of chronic stenosis are a wide range of congenita1 IaryngeaI deformities of which the commonest is a web in the anterior commissure. In most instances a11these Iesions wiI1 have required previous tracheotomy, but they differ from the group of cases of acute IaryngeaI obstruction in that it is impossible, without further attention to the stenosis, to decannuIate them. Such stenosis may stiI1 Ieave a residual but greatIy restricted IaryngeaI Iumen, or the Iatter may be so narrowed as to constitute an actua1 atresia. Such IaryngeaI stenosis may, moreover, be the direct resuh of a tracheotomy for acute IaryngeaI obstruction in which, through haste or inexpert execution, the

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opening was pIaced too high. As Jackson has so often reiterated, a high tracheotomy, encroaching on the subgIottic region or damaging the cricoid cartiIage, carries with it grave risk of producing chronic IaryngeaI stenosis, making it impossibIe to decannuIate the patient and condemning him to a life of proIonged disabiIity unIess measures are adopted for restoration of the Iumen of the Iarynx. The treatment of chronic IaryngeaI stenosis varies greatIy with the etioIogy and duration of the condition. In those cases in which tracheotomy for acute obstruction is foIIowed by difEcuIty or impossibiIity of decannuIation because of high tracheotomy, the first procedure is the repIacement of the tube. This shouId be done by a separate trachea1 incision, not communicating with the origina1, Iowering the tube to a new Iocation and permitting the former trachea1 opening to cIose. In miId cases this procedure wiI1 be su& cient, the subgIottic sweIIing resuIting from the maIpIaced tube wiI1 subside and subsequent decannuIation wiII be easiIy accomplished. In cases of stenosis due to cicatricia1 disease in the Iarynx itseIf much depends on the etioIogica1 factor. In syphiIis and tubercuIosis systemic treatment is necessary to contro1 the underIying pathoIogy in the body as a whoIe irrespective of its IocaI manifestations. Once heaIed the stenosing Iesions resuIting from traumatic and inff ammatory conditions wiI1 progress no further and the probIem is essentiaIIy one of mechanica and surgica1 ingenuity. Much depends on the age of the patient. In chiIdren with chronic IaryngeaI stenosis there is present the norma factor of growth which tends constantIy to aid attempts to restore the IaryngeaI Iumen. In aduIts in whom this growth factor is no Ionger present and in whom there is no residua1 fIexibiIity of the IaryngeaI cartiIages, the d&uIties are proportionateiy greater. The simpIest form of procedure in restoration of the IaryngeaI Iumen in chronic stenosis is endoscopic diIatation, carried out

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usuaIIy from above, sometimes by retrograde methods through the tracheotomic opening. During such diIatation, particuIarIy in chiIdren, efforts shouId be made to induce the patient to use what IaryngeaI space he has by judicious partia1 cIosure of the tracheotomy tube. Jackson has caIIed attention to the fact that such attempts to use the Iarynx are of great importance in its growth and the restoration of the norma airway. DiIatation, to be successfu1, often requires a Iong period of time and taxes the patience both of the surgeon and the patient. In certain cases the degree of scar tissue as the resuIt of previous trauma or inflammation wiI1 be such that simpIe diIatation wiI1 be insuffIcient to achieve success. Under these circumstances it was formerIy customary to resort to more compIicated measures such as the operation of Iaryngoscopy in which, after externa1 opening of the Iarynx and remova of scar tissue, some compIicated diIating apparatus was pIaced in the Iarynx in conjunction with specia1 forms of tracheotomy tube. Such operative procedure is at best a tedious and diffIcuIt affair, requiring the utmost surgica1 ski11 and necessitating proIonged hospitaIization of the patient. DetaiIed description of its execution is beyond the scope of this paper. More recentIy Jackson has advocated the somewhat simpIer procedure of diIatation of a chronic Iaryngeal stenosis by the use of rubber core mouIds. These mouIds, shaped Iike an intubation tube to conform to the norma IaryngeaI Iumen, are inserted in progressiveIy increasing sizes, and by the steady expansiIe effect of the rubber, graduaIIy create a new and normaIIy shaped airway. The mechanica probIems associated with these methods are by no means simpIe and invoIve detaiIs excIuded by the restrictions of this paper. SUMMARY

AND

CONCLUSIONS

I. The cardina1 signs of IaryngeaI struction are an increasing respiratory

oband

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puke rate, stridor, indrawing of the supracIavicuIar, and epigastric suprasternal, spaces, restIessness and paIIor or cyanosis. 2. Acute inff ammatory disease, new growths benign or maIignant, muscuIar spasm or paraIysis, externa1 pressure, and foreign body account for the majority of cases of acute IaryngeaI obstruction.

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3. HeaIed inffammatory disease and fauIty tracheotomy are the cause of most cases of chronic IaryngeaI obstruction. 4. Severe acute IaryngeaI obstruction demands prompt and adequate reIief either by intubation or tracheotomy. Chronic stenosis requires either diIatation or pIastic reconstruction.

IT has been said that the status of a hospita1 can be judged with accuracy by the character of its department of pathoIogy. . . . Young men seeking internships have been advised to seIect a hospita1 IargeIy on the basis of its autopsy percentage. From-“The Postmortem Examination” by Sidney Farber (Thomas).