Topography of the Auditory Region of the SkullFig. 251. Topography of the Auditory Region of the Skull.A, Point of trephining for a temporo-sphenoidal abscess;B, For a cerebellar abscess;C, Dotted line marking a portion of the lateral sinus.
1.Trephining.The trephine used should be three-quarters of an inch to one inch in diameter according as the patient is a child or an adult. Either the hand trephine or Macewen’s improved pattern mounted with a guard may be used. If available, the trephine may be worked by a motor, but in this case it should be remembered that the bone will be pierced more quickly than by the hand instrument.
Trephining for a temporo-sphenoidal abscess.The object of the operation is to expose the lowest portion of the middle fossa just above the roof of the antrum and tympanic cavity. The trephine, therefore, should be placed so that it is situated just above the suprameatal spine, its lowest margin being slightly above the zygomatic ridge (Fig. 251). After the disk of bone has been removed the exploration of the abscess is then carried out.
Trephining for a cerebellar abscess.The point at which the bone is trephined must be behind and below the curve formed by the transverse and sigmoid portion of the lateral sinus; that is, behind the mastoid process and below Reid’s base-line.
If the mastoid operation has not been performed, the centre pin of the trephine should be placed at a point 1¼ to 1½ inches behind the centre of the external auditory meatus, and an inch below Reid’s base-line (Fig. 251). If, however, the mastoid has already been opened and the lateral sinus exposed, the trephine should be placed so that its anterior border is just behind the sinus and its upper border well below Reid’s base-line.
2.After performing the mastoid operation.If this has been done already, the wound is reopened, and cleansed by filling it with hydrogenperoxide. After gently curetting away any granulations the wound cavity is irrigated and then packed in order to dry it. Under good illumination, careful inspection is made to see if a fistula or a tract of diseased bone extends in any direction. Whether the middle or posterior fossa should first be explored depends not only on the clinical symptoms but also on the condition found on opening the mastoid cavity.
Exploration for a Temporo-sphenoidal Abscess.Fig. 252. Exploration for a Temporo-sphenoidal Abscess.A, Above the tegmen tympani;B, Through the tegmen tympani. Occasionally these methods are combined; the bone between the openings being also removed.
Opening of a temporo-sphenoidal abscess.A temporo-sphenoidal abscess may be explored either through its lowest point, that is, through the roof of the antrum and floor of the middle fossa, or through its outer wall just above the zygomatic ridge. To obtain a view of the roof of the antrum and mastoid cavities, the head of the patient should lie almost flat on the operating table and be turned well over to the opposite side. The bony roof of the antrum and mastoid is removed by means of the gouge and mallet, and so expose the dura mater covering the floor of the middle fossa (Fig. 252). If a fistula communicates with the antrum cavity and the middle fossa, the bone surrounding it is first attacked. In removing the bone, it must be remembered that the tegmen tympani is exceedingly thin, and unless care is taken pieces of bone may be pressed inwards on to the overlying dura mater. Sufficient bone should be removed to determine whether the dura mater is normal or not. To do this it may be necessary to chisel away the tegmen tympani outwards until the squamous portion of the temporal bone is reached, after which a pair of bone forceps may be used until a sufficient opening is obtained.
The condition found on examination of the dura mater varies. Inmany cases it is congested or covered with granulations at the site of the infection, and usually it is adherent to the underlying bone. At other times it seems normal.
Increase of the intracranial pressure, as shown by the bulging outwards of the dura mater, and absence of pulsation are suggestive of an abscess. These signs, however, are not conclusive, as on the one hand increased intracranial pressure may be due to other causes and on the other it is quite possible to have pulsation if the abscess be small and deeply placed.
If an extra-dural abscess be present, the intracranial cavity should not be explored at once unless this is absolutely necessary, but this step of the operation should be delayed for at least twenty-four hours. If, however, immediate operation be necessary, special precautions must be taken to render the part as aseptic as possible, and a fine layer of gauze should be packed between the margin of the bone and the dura mater in order to prevent further infection of the brain or meninges. In an uncomplicated case only sufficient bone should be removed to permit of the insertion of a large drainage tube; that is, the dura mater should not be exposed over a larger area than the size of a shilling.
If there be disease of the tegmen tympani and the symptoms point to a temporo-sphenoidal abscess, the brain should be explored through this opening in the bone (Fig. 252), as the abscess is thus not only drained through its most dependent part, but also through its stalk.
If, however, the diagnosis be doubtful, the temporo-sphenoidal lobe may be explored through a fresh opening, just above the tegmen tympani. This will diminish the risk of septic infection from the mastoid cavity. After the dura mater has been exposed sufficiently a small incision is made in it, taking care to avoid wounding any of the vessels. With a pair of forceps the cut edge of the dura mater is drawn outwards and the incision is prolonged in each direction with a pair of blunt-pointed scissors. Similarly, the dura mater is cut through at right angles to the primary incision, so that four small flaps are made and turned back so as to expose the outer surface of the brain.
As a rule the dura mater, arachnoid, and pia mater are fused together by inflammatory adhesions, so that from a practical point of view they need hardly be considered as separate structures. Similarly, at the site of infection, the point of the so-called stalk of the abscess, the cerebral membranes are adherent to the underlying brain, especially if there has been any localized meningitis. For this reason it is sometimes necessary to peel away the dura mater from the brain, in order to expose the latter.
As a rule, very little fluid escapes: if present in considerable quantity,and if it escapes from between the dura mater and brain, it is an unfavourable sign, as it generally signifies early meningitis.
If meningitis be present, purulent lymph or secretion may be seen on the surface of the brain, either localized or spreading from the site of the infection.
If the intracranial pressure be great, the brain will bulge through the opening in the dura mater. If the abscess be very large and situated superficially, the thin layer of brain substance forming its outer wall may rupture as soon as an opening has been made in the dura mater. Sometimes, indeed, the pus may be seen to ooze through an opening in the dura mater, which may be found to communicate with the abscess cavity.
The next step is to open the abscess. Formerly a trocar and canula were used. This method is no longer in favour for the following reasons:—If the wall of the abscess cavity be very thick, it may not be pierced; secondly, the trocar may pass through the abscess cavity and enter the brain substance beyond without draining it; and thirdly, even if the trocar enters the abscess cavity the pus may be so thick as to plug its lumen. For these reasons a fine pair of Lister’s sinus-forceps or a narrow-bladed bistoury is recommended. In the ordinary case Lister’s forceps can be used.
The direction in which the brain is explored depends upon the point at which this is done. Thus, if the procedure be carried out through the tegmen tympani, the brain is explored in an upward direction. The forceps are made to pierce the brain for about an inch; the blades are then slightly dilated and the forceps partly withdrawn. If a large abscess exists, the cavity is usually opened at once and pus flows out along the track of the forceps. If the abscess be small and deeply placed, its cavity may not be entered on the first thrust of the forceps. In this case they are closed and withdrawn. The brain is then explored by thrusting the forceps first upwards and forwards, then upwards and backwards, and finally upwards and inwards; in the latter case it is unwise to pierce the brain for more than an inch and a quarter for fear of entering the lateral ventricle.
If the brain be explored through the outer wall of the temporo-sphenoidal lobe, the first direction in which this is carried out is directly inwards. If this be not successful, the brain is further explored in a direction forwards, upwards, or backwards, the exploratory instrument at the same time pointing slightly inwards.
If exploration proves negative, it may also be necessary to explore the cerebellum. If, however, the surgeon be still convinced that a temporo-sphenoidal abscess exists, he may next pierce the brain with the bistoury, in case the forceps has failed to enter the abscess cavity,perhaps owing to its walls being very thick. If all efforts fail to find the abscess, the little finger may be inserted into the brain itself to see if the resistant wall of an abscess can be felt. This procedure, however, should be avoided if possible, as by doing so it causes destruction of a certain amount of brain tissue.
If an abscess be opened a varying quantity of pus escapes, usually evil smelling. In the more chronic cases it is thick and greenish; in the acute cases it may contain shreds of necrosed brain tissue or be intermixed with bubbles of gas. Sometimes there is also an escape of turbid cerebro-spinal fluid, which if excessive is suggestive either that the lateral ventricle has been opened inadvertently or that the abscess has already burst into it. In these cases the patient is usually comatose or in the state of muttering delirium at the time of the operation.
After the abscess has been opened, the forceps or bistoury should be retained in position until the pus has drained away. A large tube is then pushed into the abscess cavity along the line of the forceps or bistoury. It is only permissible to withdraw the instrument with which the abscess has been opened after the end of the tube is well within the cavity. The outer end of the tube should be flush with the surface of the wound. To prevent it slipping too far into the brain, it may be anchored to the edge of the skin wound by a silkworm-gut suture. If the abscess be drained through the tegmen tympani, it will be difficult to bring the tube out into the wound without kinking it. For this reason I prefer to incise the brain substance slightly outwards after the abscess cavity has been reached, so that a tube can be inserted obliquely upwards and inwards at a point corresponding to the angle between the tegmen tympani and the squamous portion of the temporal bone. If the exploratory puncture has been made above the tegmen tympani and an abscess discovered, the question arises whether another drainage tube should not also be inserted into the brain through an opening in the roof of the antrum so as to drain the abscess from below. This, however, I do not think necessary.
In addition to the rubber tube, many varieties of drainage tubes have been suggested, such as decalcified chicken bone, as originally used by Macewen, and glass or silver tubes; the object of the latter being to resist the pressure of the brain, which may compress a rubber tube. The rubber tube is the simplest form of drainage, and if sufficiently thick it should be employed. To make more certain of free drainage, some surgeons use two tubes placed side by side. I think, however, one large tube (half an inch in diameter) is better than two small ones.
Irrigation of the abscess cavity is still a matter of opinion. If the abscess be small and circumscribed, the best method is to open itwith as little disturbance as possible to the surrounding parts, insert a large drainage tube, and to do nothing further.
If, however, the abscess be large and irregular in shape, so that the drainage is not free, and especially if it be very septic and contains necrosed brain tissue, irrigation is justifiable if gently carried out. The best method is to insert a fine tube along the lumen of the large one and allow some warm saline solution to flow slowly along it into the abscess cavity, the fluid returning along the larger tube. If two tubes have already been inserted into the abscess cavity, the fluid injected through one will escape by the other. Whatever method is employed, care must be taken that there is free exit for the fluid, as otherwise the abscess cavity may become over-distended, and in consequence rupture of a portion of its wall may take place, especially the inner, which perhaps only consists of a thin layer of brain tissue separating the abscess from the lateral ventricle. During the act of irrigation there is a risk of some of the fluid, now loaded with septic particles, escaping between the surface of the brain and the dura mater and thus setting up a secondary meningitis.
Exploration for a Cerebellar AbscessFig. 253. Exploration for a Cerebellar Abscess.Abehind, andCin front of the lateral sinus;B, Lateral sinus.
Opening of a cerebellar abscess.The cerebellum may be explored from two different points, either in front or behind the lateral sinus. The posterior route is adopted if the abscess is superficial in the outer portion of the lateral lobe, usually the result of lateral sinus thrombosisor disease of the posterior mastoid cells. The anterior route is indicated if it is thought that the abscess is deeply placed in the anterior inferior portion of the cerebellum, that is, in those cases in which it is apparently a complication of labyrinthine suppuration, or the result of disease of the inner wall of the antrum and mastoid cavities (Fig. 253).
(a)Behind the lateral sinus.After exposure of the lateral sinus the bone is removed either by means of the gouge and mallet or by bone-forceps, until a considerable area of the dura mater is exposed behind and below the curve of the sinus (Fig. 253). The dura mater is then incised as already described.
The cerebellum is explored by thrusting the instrument inward for about an inch. As a rule the abscess is found at once. If it be not discovered at the first attempt, the instrument should be directed forwards, upwards, and inwards towards the posterior surface of the petrous bone. Care, however, must be taken that it is not pushed in too far, otherwise it may pierce the anterior upper margin of the cerebellum, and if an abscess be present, the meninges may thus become infected. If the surgeon has exposed the dura mater by trephining, it is necessary to push the exploratory instrument at least two inches inwards and forwards in order to reach an abscess situated in the anterior inferior portion of the cerebellum. In such cases it is by no means difficult to miss a small abscess, and further, drainage is frequently incomplete when an abscess is discovered. For this reason, if the cerebellum be explored first behind the lateral sinus and no abscess is discovered, it should further be explored by the anterior route in front of the lateral sinus. If the cerebellar abscess be secondary to lateral sinus thrombosis, and if there be no doubt as to the diagnosis, the inner wall of the sinus should be made as aseptic as possible, and the dura mater forming it incised freely; the cerebellum being thus explored through the site of infection.
(b)In front of the lateral sinus.The lateral sinus is first exposed (Fig. 253). The triangular area of bone situated in front of it, between it and the semicircular canals, and forming the inner boundary of the antrum and mastoid cavities, is now removed with the gouge and mallet or with a suitable pair of forceps. If it be certain that internal-ear suppuration exists, or if the operation be secondary to opening of the labyrinth, the posterior wall of the petrous bone may be removed until the internal auditory meatus is almost reached. If, however, the labyrinth be intact, care must be taken not to chisel away too much bone for fear of encroaching on the posterior semicircular canal. On exposure of the dura mater an extra-dural abscess may be met with, usually the result of internal-ear suppuration. Even if no pus be seen, it is always a wise precaution,if internal-ear suppuration coexists, to separate the dura mater from the posterior wall of the petrous bone by means of an elevator in order to prevent any deeply situated extra-dural abscess being missed. After the dura mater has been exposed sufficiently it is opened by a crucial incision. In this region absence of increased tension within the brain and lack of bulging outwards of the cerebellar tissue do not necessarily imply the absence of an abscess; the cerebellum to all appearances may appear normal and flaccid, although a small abscess may be present.
The cerebellum is explored in various directions to a distance of not more than one inch. After the pus has been evacuated a tube is inserted as described above. In the majority of cases this method is far superior to opening the cerebellum behind the lateral sinus, especially as it is now recognized that the chief cause of cerebellar abscess is internal-ear suppuration.
After-treatment.This is similar to that of any ordinary abscess, but care must be taken that free drainage is maintained. The main part of the mastoid wound is lightly plugged with gauze, the tube inserted into the brain abscess being brought flush with the surface of the skin. The gauze filling the wound cavity should be arranged around the tube so that it rests comfortably within the wound and is not kinked. If the drainage tube be in its proper position, pus should be seen to ooze out of it.
Although the mastoid cavity itself need not be dressed daily, if necessary the outer dressings may be removed twice a day, in order to see that drainage of the abscess is continuous. After the first two or three days, the tube is gradually shortened. If the abscess be a recent one and not encapsuled, it becomes rapidly obliterated by pressure of the surrounding brain tissue, so that the tube may be forcibly ejected within a few days. On the other hand, if the abscess has existed for a considerable period and is bounded by a thick wall, which may be extremely resistant, the purulent discharge may continue for many days and necessitate the continuance of drainage. Generally speaking, the tube may be shortened every second or third day, and can usually be dispensed with by the end of the second week, if not before. It is, however, very necessary that the tube should not be withdrawn until it is certain that the abscess cavity has been obliterated completely.
The general treatment of the case in no way differs from that already described for the mastoid operation in which the wound has been left open posteriorly.
Complications.(i) On turning back the flaps of the dura mater, a hernia, consisting of friable congested brain tissue, may occur at once. This is extremely rare as a result of a simple abscess of the brain, butis significant of encephalitis frequently associated with meningitis (seep. 436). If an abscess be suspected, the brain should be explored as already described. If, however, no abscess be discovered, the treatment consists in removal of more bone and further incision of the dura mater, in order to permit of free drainage and to relieve tension.
(ii) Opening into the lateral ventricle. This may be due to rupture of its wall owing to the sudden diminution of pressure from too rapid drainage of the abscess cavity, or it may occur accidentally from thrusting in the exploratory instrument or drainage tube too deeply. Its occurrence is evidenced by the sudden gush of cerebro-spinal fluid. The ultimate danger is subsequent infection of the cavity, which, unfortunately, frequently occurs.
(iii) Cessation of breathing. This is more likely to occur in a cerebellar abscess in consequence of direct pressure on the medullary respiratory centres. The immediate treatment is to do artificial respiration and to open the cerebellar abscess by the quickest method possible. If this be successful, respiration probably will be restored.
Prognosis and subsequent progress.In an uncomplicated case a favourable prognosis may be expected, provided the abscess is successfully opened and drained without much disturbance of the surrounding parts. Many factors, however, may lead to a fatal result. With regard to recovery: in 100 cases taken from the records of the London Hospital during the last ten years, recovery took place in 20% operated on for cerebral and 10% for cerebellar abscess. Other statistics give a much higher percentage of recovery, but it must be remembered that in hospital patients a large number of the cases are only seen by the surgeon at a very late stage, when the brain abscess is complicated by other intracranial or suppurative lesions, and the patient is in an almost moribund condition; so that the operation may only be undertaken as a forlorn hope.
If the operation is going to be successful, the head symptoms quickly disappear. Even if the patient was comatose before operation, the recovery may be so rapid that his mental condition may be almost normal within twenty-four hours. In many cases, if the abscess be a large one, convalescence will be tedious or prolonged; sometimes, indeed, complete restoration of the mental faculties, in spite of a most successful operation, will not be obtained. The chief relief to the patient is the cessation of the terrible headaches from which he has been suffering.
Unfavourable symptoms are the sudden onset of pyrexia accompanied by delirium usually the result of diffuse meningitis, or of infection of the lateral ventricles. In the latter case there is a rapid termination in drowsiness, coma, and death.
Although the brain abscess may be draining freely, the patient for some days may lie in a semi-comatose condition as a result of œdema or inflammation of the surrounding brain tissue; in such cases prognosis is difficult, but hope of recovery may be entertained if the pulse and temperature keep practically normal.
Recurrence of symptoms.This may take place within the first few days after the operation as a result of infective cerebritis, the presence of another abscess, or faulty drainage; or at a much later period, owing to the formation of another abscess or to a cyst within the brain at the site of the former abscess.
1. If the recurrence of the symptoms appears immediately after the operation, the wound should be inspected carefully, if necessary under an anæsthetic. If drainage be not free, the tube should be removed and a pair of forceps inserted along the track leading into the abscess, their blades being then slightly opened and withdrawn. On doing this an accumulation of pus may escape. The cavity may then be irrigated gently with saline solution and a larger tube inserted.
If, however, this procedure does not give a satisfactory result, the finger may be inserted into the brain to feel if the abscess is loculated. By this means any existing septa may be broken through; or if a feeling of resistance suggests the presence of another abscess, this part of the brain can also be explored. It must also be remembered that although a temporo-sphenoidal abscess has been opened successfully and is draining well, the continuance of the symptoms may be due to a coexisting abscess of the cerebellum, orvice versa; in other cases, in spite of all care, the patient gradually sinks, partly from exhaustion and partly from general toxæmia, the result of infective cerebritis.
2. Recurrence of symptoms at a later period. The occurrence of a fresh abscess is usually owing to the fact that the primary focus of the disease has not been completely removed at the first operation; for instance, if the surgeon only trephined and drained the abscess without performing the mastoid operation.
A cyst is usually the result of the abscess having been encapsulated and its wall not having been removed at the first operation. If a cyst be discovered on exploring the brain in consequence of these symptoms, its wall should be removed if possible.
Apart from symptoms of intracranial pressure, the patient may suffer from attacks of Jacksonian epilepsy from time to time, presumably due to the post-operative adhesions. If they continue in spite of conservative treatment, it may become necessary to operate in order to remove this source of irritation (see Vol. III).
SECTION IVOPERATIONS UPON THE LARYNX AND TRACHEABYW. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital
Indications.(i)Tumours.Tumours of the larynx are more often innocent than malignant. Sir F. Semon5collected 12,297 cases seen between 1862 and 1888 by 107 laryngologists, and of these 10,747 (or 88%) were benign and 1,550 (or 12%) were malignant. Of the innocent forms, papilloma, either simple or multiple, occurred in 39%; fibroma, sessile or pedunculated, was next in frequency; cystic tumours were not nearly so common; and other forms, including myxoma, angeioma, adenoma, lipoma, and enchondroma, were rare. The period during which these tumours are most common is between the ages of 20 and 40 years, but they are also frequent during childhood.
Malignant growths occur at a later age, mostly between the ages of 40 and 60, and attack males more than females. Carcinoma is far more common than sarcoma, and is generally of the squamous-celled variety. Endothelioma has not often been discovered.
The importance of distinguishing innocent from malignant tumours is greater now than in former years, since it is agreed that endolaryngeal operations are preferable for the eradication of the former, while the latter are better treated by extra-laryngeal methods. Moreover, the differential diagnosis has steadily improved, owing to the more general use of the laryngoscope and the introduction of recent methods of examination. Thus, by direct laryngoscopy it is possible to investigate children as easily as adults. Microscopical examination of fragments removed with laryngeal forceps is of great value in confirming the clinical diagnosis; the sections can be made by freezing, or in paraffin, the latter method requiring, with recent improvements, not more than twenty-four hours. Semon, who has done more than any other man to improve the early diagnosis of malignant disease of the larynx, is strongly in favour of such examinations. It must be remembered, however, that the result is sometimes inconclusive, for it is difficult to be certain that the actual growth has been removed. In cases that are thought to be malignant, it is better to open the thyreoid6cartilage than to rely upon endolaryngealoperation, as there is a danger of stimulating the growth to greater activity, especially by repeated interference. When the thyreoid cartilage has been opened, the whole disease can be explored thoroughly and a fragment selected from which to make a frozen section. In the majority of cases a definite diagnosis can thus be arrived at, and even when it is necessary to examine several fragments the amount of time lost is small.
As regards the value of skiagraphy, Walsham and myself have found that photographs can be made of tumours of the larynx which in some instances determine accurately the position and extent of the disease.
Skiagram showing a Tumour of the LarynxFig. 254. Skiagram showing a Tumour of the Larynx.A, Tumour;B, Body of hyoid;C, Greater cornu of hyoid;D, Epiglottis;E, Posterior plate of cricoid;F, Vocal cord;G, Trachea;H, Œsophagus.
Fig. 254 is a photograph showing a cancer of the upper opening of the larynx, lying above the vocal cords, the position of which was proved to be accurate by later operation upon the patient. It is, however, doubtful whether the method will eventually assist in the differential diagnosis between innocent and malignant growths.
(ii)Tuberculosis.Endolaryngeal operations are successfully performed for chronic conditions such as ulceration or tumour, and, rarely, in acute forms such as abscess, necrosis, and the like. Removal of a portion of the epiglottis occasionally gives great relief to a patient who is suffering from dysphagia.
(iii)Stricturesresulting from trauma, from the ulcerations of syphilis, diphtheria, and other inflammatory diseases, or caused by congenital webs.
(iv)Foreign bodiesimpacted in the larynx.
(v)Œdemaof the mucous membrane due to trauma or inflammation, local abscess, necrosis, and other allied conditions, in which obstruction is likely to supervene.
The operation may be performed either by indirect or by direct laryngoscopy.
It being essential that the patient should be tolerant, this method is chiefly applicable in the case of adults. The operation may require a course of instruction, but this presents no difficulty if given with discretion. The employment of cocaine, novocaine, and adrenalin is of the greatest importance to both surgeon and patient. Cocaine, which is generally to be preferred, may be used in strong solutions—10 or even 20%—if applied to the mucosa by a small swab of wool; but, if used as a spray, weaker solutions are employed (4%). With neurotic patients cocaine must be applied cautiously, as a sense of suffocation is sometimes produced. It is necessary first to treat the soft palate, the uvula, base of the tongue, pharynx, and epiglottis; secondly, with the help of a laryngeal mirror, the interior of the larynx must be cocainized; this can be accomplished by expelling a few drops of the solution from a laryngeal syringe or by means of a swab attached to a suitable wool-carrier. Fifteen to twenty minutes must be allowed to gain the full effect of anæsthesia. The patient must be instructed on no account to swallow the saliva. The secret of successful intralaryngeal operations lies in the thorough application of these principles, and in not attempting the operation until the patient is able to tolerate the presence of an instrument within the larynx. The surgeon must be experienced in the use of laryngeal instruments, and must be provided with a complete equipment, including forceps (Mackenzie’s, Whistler’s, Grant’s, &c.), which must be of different lengths to suit the patient, snares, galvano-cautery, curettes, probes, and other instruments for the application of drugs. Proper illumination is also very important.
Horsford’s Instrument for transfixing the Epiglottis.Fig. 255. Horsford’s Instrument for transfixing the Epiglottis.
When removing an intralaryngeal growth, the surgeon sits facing the patient. The mouth is opened to the fullest extent, and the tongue drawn well forward and held by the patient’s right hand. The mirror is introduced in such a way that the tumour is distinctly seen. If the epiglottis overhangs, it can be drawn forward with the forceps; or, in rare instances, a special instrument (Fig. 255) can be used for transfixingits upper margin with a thread, the latter being grasped by a pair of pressure forceps, which, being allowed to hang, will automatically raise the obstruction.
The forceps, having been warmed, are taken in the right hand when the tumour is on the right side of the larynx and in the left hand when the tumour is on the left, thus allowing a clearer view than when the same hand is employed irrespective of the position of the disease. It is introduced as follows: firstly, the handle is directed towards the patient’s left ear until the point of the forceps has passed beyond the back of the tongue and lies behind the epiglottis; secondly, the instrument is quickly rotated so that the handle lies below the chin; thirdly, the hand is raised so that the point is directed forwards; fourthly, the whole instrument is quietly lowered and the beak of the forceps directed towards the growth. This manipulation is made more difficult by the laryngeal image being reversed in an antero-posterior direction.
When the point is seen to rest upon the growth, the instrument is opened, and the tumour grasped and avulsed: with careful manipulation there is little danger of wounding the normal mucosa, and hæmorrhage is insignificant. When dealing with multiple growths the patient must understand that it may be necessary to repeat the operation, either immediately or after an interval. Given suitable instruments, sufficient experience, and a tolerant patient, it is possible to remove, with the help of cocaine, the majority of simple tumours. Operations upon cysts, the scarification of mucous membrane with a guarded knife, the curettement of tuberculous ulcers, and cauterization of the larynx, are all conducted upon similar lines. Foreign bodies can generally be removed with forceps; thus, F. A. Rose7reported a case in which part of the breastbone of a chicken, measuring 1 inch in length and over ¾ of an inch in width, was removed after having been impacted in the larynx for nearly forty-eight hours. In rare instances such an operation is not successful;e.g.with a foreign body firmly impacted, multiple papillomata, or an intolerant patient, general anæsthesia may be required, and removal may have to be effected through a tube-spatula or by external incision.
After-treatment.Intralaryngeal wounds generally heal well, but every effort should be made to prevent infection of the parts, to allay any inflammation that may arise, and to avoid catarrh and swelling of the mucosa. It is advisable to order complete vocal rest until the redness has subsided, and the patient should refrain from coughing; the sucking of ice, or the inhalation of benzoin or other medicated steam, has a sedative action upon the parts. If the larynx becomes septic or filled with irritating discharge, the use of sprays or powders is indicated; in such a case the patient may be given a parolein spray, with menthol, eucalyptus, or other antiseptic, for constant use; or a powder such as orthoform, the latter being sucked into the larynx through a warmed glass tube (Leduc’s insufflator), or applied by the surgeon. In the later stages the patient may be treated by the local application of caustic fluids, or by galvano-cautery, as occasion requires. The success of such operations depends largely upon the skill of the surgeon; if attention be given to the after-treatment the results are very good, and the voice is generally recovered. As Semon has shown conclusively, there is no practical danger of the occurrence of malignant degeneration through the influence of instrumentation.
(Killian’s Method)
Multiple Papillomata of the LarynxFig. 256. Multiple Papillomata of the Larynx.(From Specimen No. 1647 in the Museum of St. Bartholomew’s Hospital.)
Indications.(i)Multiple papillomata.These tumours occur most commonly during the early years of life, and operations for their removal present great difficulties, first, in their removal, and, secondly, owing to their inveterate tendency to recurrence whatever operation is performed; moreover, in some instances operation seems to stimulate the growths to greater activity. The case reported by Stoker is a well-known instance. He was consulted by a man thirty years of age who had suffered from papilloma for twenty-three years, during which period one surgeon had performed 100, and a second 120 operations.
(ii)Benign tumoursother than papillomata, which are not amenable to operation by indirect laryngoscopy.
(iii)Foreign bodies.Direct laryngoscopy is advised for patients who are intolerant (e.g.young children), or when the object is firmly impacted, or when other methods of treatment have failed. Thus in one of my cases a man presented himself with a long pin impacted transversely above the vocal cords; it was found impossible to remove it by indirect laryngoscopy without serious injury to the parts. An anæsthetic was therefore given and a large tube-spatula passed into the larynx: with strong forceps the pin was bent upwards and removed with ease.
(iv)Granulations,ulcers,necrosis, and otherinflammatory conditionssuch as are caused by diphtheria, tubercle, syphilis, and many other diseases.
(v)For diagnostic purposes.There can be little doubt that direct laryngoscopy has a great future before it as a means of determining the nature of doubtful laryngeal conditions. If the upper parts of the larynx be swollen, if there be any stenosis such as follows ulceration, or if the patient be intolerant, the air-passages cannot be thoroughly examined with the laryngoscope alone. With the newer method many of these difficulties have disappeared, and it is now possible for the surgeon to diagnose with certainty many conditions which would otherwise have remained doubtful.
The apparatus requiredconsists of:
Figure 257, Part a
Figure 257, Part b
Figure 257, Part c
Fig. 257. Tube-spatulæ used for Laryngoscopy.A, Killian’s. B, Bruenings’.A, Handle;B, Collar to allow rotation;C, Fixation spring;D, Switch;E, Socket for lamp;F, Focus;G, Lamp;H, Lens;I, Aperture for eye;K, Reflector.
(a) Thetube-spatulæ. The tube originally suggested by Killian was made of straight metal and circular in section, the distal end being cut obliquely with the projecting portion fashioned like a spatula. A strong handle, at right angles to the tube, was used for manipulation. Different sizes were required for children and adults. Various modifications of these tubes are now in use, notably those of Mosher and Bruenings: the instrument recommended by the latter is easier to manipulate and gives a better view than the earlier forms described.
(b) Thelampfor illumination. Different forms of head-lamp (Killian’s, Kirstein’s) and hand-lamp (Caspar’s) have been devised for illumination from the outside, and Chevalier Jackson has invented a lamp which is sufficiently small to pass to the distal end of the tube, where it lies in a compartment of its own lest it should be broken and fall into the trachea. Recently these electroscopes have been improved upon by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful and is attached to the handle in such a manner that it can be easily swung into positionwhen required. A condensing lens has also been added and the light can be focused to any desired distance. If preferred, an ordinary forehead-mirror reflecting the light from a powerful Nernst lamp (100 c.p.) can be employed.
(c) Theinstrumentsfor operation. Various forms of forceps for removal of tumours have been devised by Killian, von Eicken, Bruenings, Patterson, and others. In any form that is employed it is necessary, in order to allow of clear vision, that the handle should be set at an angle with the shaft. For foreign bodies, hooks of different shapes are also useful. Other requirements include a gag for opening the mouth, a tongue depressor, tongue forceps, suitable cotton-wool carriers, the requisites for tracheotomy, and a darkened room.
Operation.The operation can be performed with local or general anæsthesia. With patients who are intolerant chloroform is more reliable, and is preferable to other drugs, which tend to excite secretion. Chloroform should always be employed for children. It should be givenslowly and in the smallest possible quantity, the head of the patient being kept lower than the body to allow blood and mucus to drain away from the trachea. To make the parts more tolerant, cocaine can also be applied to the vocal cords, or a dose of morphine (codeine is advised in children) can be given half an hour before the operation. The importance of a skilled anæsthetist cannot be too strongly emphasized. With chloroform, the patient should lie upon the back or right side, with the head projecting beyond the end of the table, so that the neck can be extended as required. With cocaine the upright position is often preferred, and the patient should sit on a low stool facing the surgeon. When the patient is recumbent, the surgeon should sit or kneel behind the head (Fig. 258). He should observe the strictest antiseptic precautions, and should introduce no instrument which has not been properly sterilized; further, the tubes should be previously warmed to prevent ‘fogging’, and oiled with sterilized liquid paraffin before introduction. There should be two assistants, one (the chloroformist) to support the head and watch the respiration and pulse, the other to help with instruments.
Removal of Multiple Papillomata by Direct LaryngoscopyFig. 258. Removal of Multiple Papillomata by Direct Laryngoscopy
In order to examine the larynx, the mouth is opened by a gag, and the tube-spatula is passed to the upper border of the epiglottis; when this has been inspected the spatula is pushed behind it, and the upper portion of the cricoid plate is examined; the tongue is then pulled forward and the tube tilted so that the larynx can be seen. The examination should be methodical, and should include the vocal cords, ventricular bands, and openings of the ventricles. The whole manipulation can be performed with great delicacy, and is entirely guided by the eye, so that there is little fear of injury even in young children.
In this and the further technique the chief difficulties are caused by: (a)The prominence of the upper teeth.This may seriously interfere with the easy passage of a straight tube, even when the neck is fully extended. The difficulty can be overcome by turning the head laterally, so that the tube passes through the opposite angle of the mouth. (b)The mucus, which collects in the tube and obstructs the vision. This must be overcome by using a secretion aspirator, by frequent sponging, or, as suggested by Ingals, by giving a previous dose of atropin[e]. (c)Intolerance of the parts, which can be counteracted by the judicious use of cocaine (10%). It may be noted that this combination of chloroform and cocaine is not dangerous, even in young children, so long as the cocaine is prevented from running into the pharynx.
The condition of the larynx having been thoroughly examined, the operation can proceed. The method of removing multiple papillomata will first be described. In some cases it will be found that betterexposure of the tumours is obtained if the end of the tube is placed above the epiglottis rather than in the larynx itself. The position of the growths having been determined, a suitable forceps is selected and introduced through the tube. The papillomata are seized and avulsed separately, without injury to the normal tissues. To arrest the bleeding it may be necessary to apply cocaine and adrenalin mixture, and to raise the foot of the table so that the blood drains away from the field of operation. As far as possible, all the growths should be removed; it may be difficult to attack those which are situated in the anterior commissure or subglottic region, but this difficulty may be overcome by the use of specially devised instruments; thus, von Eicken has invented a tube which is long enough to pass through the larynx and into the trachea, the portion lying in the larynx being provided with a lateral window which can be turned in any direction, so that a growth can be made to project into the tube, where it can be easily removed.
At any moment during this operation the surgeon may be called upon to perform tracheotomy.
After-treatment.This must be carried out upon the same lines as those already suggested; everything must be done to relieve congestion and irritation. Killian advises internal administration of arsenic for a period of several months, and, if this fails, potassium iodide in large doses. It should be remembered that in some instances syphilis seems to play an important part in the causation of these conditions. Ingersole suggests that X-rays prevent recurrence, and may even cause shrinkage of existing growths.
Recurrence occurs in most cases in some degree, and requires further operation; this may be carried out after an interval of a week or longer, according to the case. At these secondary operations it may not be necessary to use the forceps; local applications such as absolute alcohol, salicylic acid in absolute alcohol (2–10%), solutions of silver nitrate or chromic acid, and many other drugs, have been advised by different surgeons. Wylie is strongly in favour of the galvano-cautery, and is of opinion that the technique is more reliable and the liability of local infectivity diminished. If the latter method be employed, very little should be done at one sitting, otherwise great inflammatory reaction may be set up, entailing tracheotomy. A tracheotomy tube may be required for a short time while such treatment is being carried out; some surgeons, with whom the author does not agree, always perform preliminary tracheotomy, and claim that the papillomata are less likely to recur if complete rest is thus given to the larynx.
Results.In discussing the value of the above method it is necessary to refer to the results obtained by other operations, such as—
(i)Tracheotomy(seep. 522). This operation has been advocated as a method of curing papillomata. It has been noted that by giving rest to the larynx the congestion is relieved, the papillomata decrease in size, and in some cases completely disappear. Mackenzie8published seven cases which he had had under observation for a minimum of two years, with four recoveries, the canula having been worn for periods varying from six to fifteen months. He also mentioned thirteen other cases in which good results had been obtained by other surgeons, and was of opinion that the method was most successful with ‘virgin’ cases. There are, however, many objections to this form of treatment. For instance, it is often necessary to retain the tube for a prolonged period, two years or longer, and even then the result is doubtful; moreover, the prolonged use of a canula is disastrous to the larynx, not only in retarding development, but also in the production of stenosis; there is also a danger of bronchitis, of broncho-pneumonia, and possibly of tuberculosis. In regard to the last, G. A. Wright,9in reporting a case in which tubercle supervened, argues that ‘presumably there is more risk of this happening to the wearer of a tracheotomy tube than when breathing in a normal way through the mouth or nose’. Further, the line of treatment is difficult to enforce on account of the aversion shared by most parents to the performance of tracheotomy.
(ii)Laryngo-fissure(seep. 487). Under this head are included thyrotomy, or complete division of the thyreoid cartilage; partial thyrotomy, where a small portion of the upper or lower part of the thyreoid cartilage is left intact (an operation which does not give a good exposure of the larynx); infrathyreoid laryngotomy, which is only applicable to adults; cricotomy, with division of the cricoid cartilage and crico-thyreoid membrane; and subhyoid pharyngotomy. Of the above, thyrotomy is the most satisfactory operation, because it gives the best exposure of the parts and facilitates removal of the growths; recurrence, however, is frequent, permanent injury to the voice is common, and stenosis may result.
The results of these operations, especially during childhood, are by no means satisfactory. In the statistics carried up to 1896, collected by Rosenberg and von Bruns,10laryngotomy was performed 143 times on 109 children; 11 were operated upon twice, 3 children three times, and 1 child seventeen times. 52 of the children were under four years of age; 20 died, principally from suffocation with recurrent papillomata;43 showed recurrences after repeated operation; 40 were cured (i.e.36%), and of these 10 showed disturbance of voice.
It must be admitted that operations for the treatment of papillomata do not meet with any great measure of success. It seems probable, however, that the results obtained by endolaryngeal removal are better than those obtained by either tracheotomy or laryngo-fissure. To quote Killian11: ‘Formerly, and especially from the standpoint of the surgeon, laryngotomy for laryngeal papillomata was very frequently done in little children in whom removal was impossible by endolaryngeal methods. In my judgment, direct laryngoscopy renders such a surgical procedure unnecessary. We can in all cases, with the aid of a tube-spatula under narcosis, remove papillomata, and the operation can be repeated as often as seems necessary.’ These remarks express the general feeling of the present day, and the most important factor in determining the success of operative treatment is early diagnosis. Such diagnosis divides the cases into two classes: those in which the growths are localized, and those in which they are diffuse. The first class is easy to treat by endolaryngeal methods, and, given careful after-treatment, the prognosis is satisfactory. The second class is serious, and far more difficult to treat; when Killian’s method fails the prognosis is very bad. Finally, it must be borne in mind that, as recurrence may not occur for several months, a guarded prognosis must be given in every case.
The removal of other benign tumours and of foreign bodies, and the treatment of granulations, are conducted upon similar lines, and are attended with excellent results.
Indications.This operation is performed for two purposes:
(i) To obtain access to the cavity of the larynx when the diagnosis is uncertain, or as a preliminary to other operations.
(ii) As a method of eradicating certain diseases, of which the following are important:—
1.Malignant tumours, both carcinoma and sarcoma, in which an early diagnosis has been made, and so long as they remain intrinsic.
Intrinsic Tumour of the LarynxFig. 259. Intrinsic Tumour of the Larynx.(From Specimen No. 1649 in the Museum of St. Bartholomew’s Hospital.)
Extrinsic Tumour of the LarynxFig. 260. Extrinsic Tumour of the Larynx.(From Specimen No. 1653 in the Museum of St. Bartholomew’[s] Hospital.)
It is advisable to follow Krishaber in the separation of all forms of laryngeal cancer into two classes, theIntrinsicand theExtrinsic. The term ‘intrinsic’ implies a growth springing from the vocal cords, the ventricular bands, the ventricles, or the subglottic space, and the growth must lie entirely within the laryngeal cavity. ‘Extrinsic’ is the term used for a growth affecting the arytenoids, the posterior part of the cricoid cartilage, the aryteno-epiglottidean fold, or the epiglottis. Such a growth is not entirely limited to the larynx, but also involves some part of the pharynx.
2.Extrinsic localized malignant tumourswhich are attached to the epiglottis, or to the aryteno-epiglottic fold.
3.Innocent tumourswhich are too extensive for endolaryngeal operation or of a doubtful character. In either of these cases it is justifiable to perform an external operation, which may be thyrotomy, or occasionally, an atypical operation: thus Semon12removed a large fibromatous tumour of the larynx by submucous resection, without opening the cavity of the larynx.
4.Stenosisfollowing syphilis, trauma, acute exanthemata, scleroma, and other rare diseases. C. Jackson has reported twenty-four cases falling under this head, nineteen of which lived for more than a year after the operation with useful voices. If the surgeon is satisfied that the disease is quiescent, he should point out to the patient that it may be possible to cure the obstruction by thyrotomy. It must, however, be remembered that tertiary syphilitic lesions may again become active as the result of operative interference. It is probable that slight casesof stenosis can be treated better by intubation than by thyrotomy. Thyrotomy has also been suggested to relieve stenosis caused by double abductor paralysis of the vocal cords, but such cases are better treated by tracheotomy or intubation.
5.Foreign bodies.Thyrotomy is rarely necessary, and should be reserved for irregular or sharp-pointed bodies, such as tooth-plates or bones, which are so firmly jammed that removal by other methods is impracticable. If there has been much laceration of the soft parts, a tracheotomy tube should be retained for a few days until the swelling has subsided.
6.Tubercle.Thyrotomy has been successfully performed in such cases, mostly under the impression that the disease was malignant. The differential diagnosis between tuberculous and malignant growths is sometimes very difficult until the tumour has been explored. In cases that are known to be tuberculous, the feeling prevails that thyrotomyis not to be recommended. It should be remembered that the external wound is liable to become tuberculous.
Instruments.Scalpel, curved scissors, dissecting forceps, pressure forceps, aneurism needles, double hook retractors, bone shears (Waggett’s) or bone scissors, tenaculum forceps, needles on handles, catgut in various sizes, a Hahn’s tube, and tracheotomy equipment. A head-light is required for illumination of the deeper parts during removal of tumours.
Operation.In England, owing to the fact that the administration has been in skilled hands, chloroform is not considered dangerous, and the operation is well tolerated even for three or four hours (e.g.in laryngectomy). On the Continent, however, Kocher, von Bruns, and others advocate local anæsthesia with cocaine or novocaine. Jackson suggested rectal etherization as an alternative, but this has many dangers. In my opinion a general anæsthetic should be given, as it enables the operation to be performed more thoroughly and is followed by less shock. It must nevertheless be borne in mind that, if the growth is intrinsic and of large size, it is difficult to administer chloroform, and the patient is liable to suffer from urgent dyspnœa. In such a case i[t] is advisable to perform preliminary tracheotomy with novocaine alone (seep. 544).
As regards the operation, the important question arises whether tracheotomy ought to be performed several days prior to the main operation, in order to accustom the patient to the tube and the new method of breathing. The following reasons are advanced in favour of this: the main operation is shortened, and relief is given to the larynx and lungs, so that congestion subsides and broncho-pneumonia is less likely to supervene. The objections are also important, namely, that there are two operations instead of one, and perhaps two anæsthetics (though this can be avoided if local anæsthesia is used for the tracheotomy); that the tracheotomy wound becomes septic, and infection of the trachea and bronchi is apt to occur, with consequent bronchitis; that the air which passes into the lungs is devoid of moisture and heat; that the trachea becomes surrounded by adhesions; and that it is altogether unnecessary. The objections in my opinion outweigh the advantages claimed; it is better to perform tracheotomy as a first stage in the operation of removal, except in cases where there is great laryngeal obstruction, where dyspnœa is present, or where bronchitis fails to yield to other forms of treatment. In such cases tracheotomy should be performed first, and the second operation should be carried out a week or ten days later when all the conditions are favourable.
When operating upon the larynx the surgeon must use every precaution to prevent blood from running into the lower air-passages, and this may be accomplished by a tampon in the trachea or by keeping the head ofthe patient lower than the body. The former method appears to me to be more reliable than the latter; and I prefer to use a Hahn’s canula, although the sponge requires from ten to fifteen minutes to swell. This canula is more reliable than Trendelenburg’s, whose inflated bag is apt to slip or collapse suddenly. As soon as the thyreoid cartilage has been opened, a second sponge should be inserted above the canula, and by this means the air-passages are completely blocked.
If an ordinary tracheotomy tube be used, the operation must be performed either with the head lower than the body (Rose’s position), or with the whole body inclined (Trendelenburg’s position), or with a combination of the two; and in any case a sponge should be placed in the upper part of the trachea after the thyreoid has been opened. Many surgeons prefer the combined method. Under no conditions must blood be allowed to pass below the tube. Whatever form of canula is used, it should be fitted with a Hahn’s tube and funnel (Fig. 266), so that the anæsthetist can give the chloroform without interfering with the surgeon. The patient should lie upon the back on a flat table, the head extended slightly over a small cushion in the position for tracheotomy.