CHRONIC LARYNGEAL DISEASES 163 causing an acid mucositis in the interarytenoid area. Speech therapists, on the other hand, suggest that forceful voicing ('glottic attack') exposes bare cartilage on the vocal processes with a resulting formation of granulation tissue. The only symptom caused by pachydermia is hoarseness. The diagnosis by indirect laryngoscopy causes little problem since the characteristic red or grey tissue in the interarytenoid region is seen whether contact ulcers are present or not. In all cases this must be biopsied to exclude carcinoma, tuberculosis or granulation tissue at the mouth of a small cleft larynx. At endoscopy as much tissue as possible should be removed, and in this instance the microlaryngo- scopic scissors are very useful. The tissue on the vocal processes is trimmed at the same time. Several such procedures may be required before the condition resolves. PROLAPSE OF THE VENTRICLE This condition is of uncertain pathology. The mucosal lining of the ventricle is prolapsed so that it comes to lie on the vocal fold, where it appears as a smooth, pink, fleshy mass with a broad base. The cause of this condition is most probably the strain of coughing and the negative pressure which is exerted by the spasm. The condition may be simulated by tuberculosis, cysts and simple tumours. Hoarseness and cough are the main complaints. Diagnosis is made at direct laryngoscopy, when replacement of the prolapsed ventricle may be effected by the blade of the laryngoscope or by forceps. A biopsy of the tissue should be taken to establish the diagnosis. Endoscopic removal of the medial portion of the projection is the most satisfactory treatment. Diathermy puncture will cause fibrosis and prevent recurrence. TUBERCULOSIS OF THE LARYNX Over the past 20 years, not only has the incidence of this condition changed, but so has the clinical presentation. Formerly, laryngeal tuberculosis presented as part of a pulmonary tuberculosis affecting mainly the posterior part of the larynx. Oedema of the arytenoids and the epiglottis due to perichondritis was a feature, as was oedema and ulceration of the vocal cords. Of these cases that survived a proportion developed scarring and stenosis of the larynx. The chroniŁ.atteauated-iQrm of laryngeal tuberculosis is called lupus of the .jaryna and fr^cpntagious. It is usually secondary to well-marked lupus of the fgge, nosejjrj'frarynY and the epiglottis isjnost frequently involved. Since tuberculosis is so rare nowadays itTs unusual for the otolaryngologist to diagnose it from mirror examination alone. The appearances are in- distinguishable from those of carcinoma. There is .anjilcerative vocal cord, arytenoid oedema or a verruc^usjoyergrowjh in the. supiaglattis. It is noT ifivariably the case that tEeTpatielit has pulmonary tuberculosis also—in fact it is now more common for the laryngeal manifestation to be the only one. Each case must be examined at direct laryngoscopy and a biopsy taken to rule out carcinoma. When the diagnosis has been made treatment by chemo- thefapy~is"supervised by the tuberculosis specialist.