Diseases Of The Nose Throat And Ear

202 THE LARYNX, BRONCHI AND OESOPHAGUS

The principle of treatment is to remove the papillomata as they appear,
without damaging the larynx in the process, and to wait for the normal
resolution of the condition. It is also important to do everything possible to
prevent spread down the tracheobronchial tree and to this end avoidance of a
tracheostomy is of vital importance when one considers how the tumour is
implantable. If the tumour affects the tracheobronchial tree the patient is in
danger of death because of stenosis and scarring of that vital region.

Many treatments have been advocated over the years—administration of
oestrogens, cautery with podophyllin, trichloracetic acid or chromic acid,
ultrasonic therapy, irradiation, vaccine therapy and local idoxuridine. None
of these is as successful as careful and repeated local removal, aided by the
microscope, and regular 2-monthly follow-up of the patient until the condition
resolves some time in the late teens. This policy is safer than waiting until
respiration becomes embarrassed because by then so many landmarks have
disappeared that laryngeal damage and subsequent scarring are inevitable.

STENOSIS

Laryngeal atresia represents the ultimate in stenosis and is inconsistent with
life unless it is recognized at birth and a tracheostomy performed. It is, in fact,
a web filling the whole larynx and it is commonest in the subglottic region.

Congenital laryngeal web consists of a membrane lying between the vocal
cords always at the anterior part of the glottis (Plate VHI94). The membrane is
quite tough and the degree of stridor and aphonia is proportional to the size of
the web. A small web will cause little respiratory difficulty and may safely be
left until the larynx has stopped growing since it only causes slight dysphonia
and not dyspnoea. A large web, however, should be dealt with immediately
because the only alternative will be a permanent tracheostomy. The thyroid
cartilage is divided in the midline and the web is excised. If the larynx were to
be closed at this point, the raw anterior ends of the vocal cords would adhere
causing further glottic stenosis, and so it is necessary to close the larynx
over a McNaught keel (Fig. 98, p. 195). This is made of 0-18-mm thick
tantalum sheeting and it is left in place for at least 5 weeks. During this time
the patient breathes with a temporary tracheostomy. After 5 weeks the keel is
removed.

Medium size webs may be removed at microlaryngoscopy, the anterior ends
of the vocal cords being injected with steroid to try to prevent adhesions
forming.

Subglottic stenosis may be caused by a congenital narrowing of the cricoid
cartilage. It is said to be established if the internal diameter of the cricoid ring
is less than 3-5 mm. It can also be caused by an improperly performed high
tracheostomy.

STRUCTURAL ANOMALIES

Cleft larynx is really a high tracheo-oesophageal fistula. In its complete form,
where the cleft goes through the whole lamina of the cricoid cartilage and the
posterior wall of the trachea, death from aspiration of food and saliva is
inevitable. If the deft does not go completely through the cricoid lamina,
however, it can be repaired in layers and the cleft closed.