Laryngostomy

LARYNGOSTOMY (from Greek larynx—larynx and stoma—mouth, opening), a method of surgical treatment for persistent stenosis of the larynx, consisting in the splitting of either the larynx alone or the larynx together with the upper rings of the trachea and maintaining this split for a long time, during which, in the presence of cicatricial strictures, gradual dilation is performed by inserting rubber tubes of increasing diameter; in the presence of other changes in the larynx, such as papillomas or submucous infiltrates, appropriate treatment of the open larynx is conducted. This method was thoroughly developed by Sargnon and Barlatier (1907) and is divided into four periods. The first period includes the splitting of the larynx and the elimination of those changes that are discovered during this process, followed by the postoperative course in the first few days with possible complications. The second period encompasses the methodical dilata

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tion of the larynx, the third is the control period during which it is observed how stable the resulting dilation of the laryngeal lumen is, and the fourth is the plastic closure of the remaining opening, the stoma. First period. The splitting of the larynx is performed under local anesthesia (for the technique of splitting, see Laryngofissure). Having opened the larynx, it is carefully examined, the changes located within it are determined, and action is taken in accordance with what is found: thus, abscesses and fistulous tracts are opened and curetted, soft and nodular infiltrates are excised, dense and smooth ones are removed submucosally or left untouched if they are not very large; cicatricial tissue is removed as much as possible. Submucosal removal of infiltrates consists in the mucous membrane being separated for a certain distance in a thin layer from the underlying tissue, which is removed with a knife or conchotome down to the cartilage, and the cartilage itself must not be exposed; then the separated flap of the mucous membrane is applied to its former place and secured with one or two sutures. Upon completion of the operation, a T-shaped rubber tube is inserted into the lumen of the larynx, and above it the upper part of the wound is sutured with a two-layer suture (catgut on the muscles, silk or staples on the skin) to such an extent that the tube can be freely removed and inserted. The postoperative course in the first few days varies depending on the extent of the wound during the operation: if it is not accompanied by the removal of large infiltrates, the temperature usually does not rise or rises by a few tenths of a degree, there is no pain upon pressure in the incision area; if the patient does not complain of pain during swallowing, if fluid when drinking does not get into the tube, and if there is no large discharge from the wound, the rubber tube is not removed for 2-4 days. If the splitting is accompanied by the removal of infiltrates or scars over a large area or the opening of abscesses, the temperature may rise quite high (39°), the edges of the wound swell, are painful upon pressure, and the discharge from the wound is abundant. In such cases, the tube is changed every day, the wound surface is cleaned and smeared with a 5% silver nitrate solution; then the discharge gradually decreases, the pain disappears, and the temperature returns to normal. Complications of the first period are 1) hemorrhages, which sometimes occur a few hours after the removal of bulky infiltrates along with the mucous membrane. The hemorrhages are usually diffuse; finding the bleeding vessel, applying forceps to it, or suturing it is usually not possible. Then it is necessary to remove the stitches, take out the rubber tube, and tightly tamponade the laryngeal cavity, inserting a tracheostomy cannula; the tamponade has to be changed several times; 2) formation of laryngeal abscesses. If a high temperature (39-40°) appears and persists for a long time after splitting; if along with this there is swelling and pain upon pressure of the skin and underlying tissues in the laryngeal region, as well as pain during swallowing, this indicates inflammation of the perichondrium and cartilages of the larynx. Such inflammation can, under the influence of warming compresses, either stop and regress or lead to the formation of pus, with pus accumulating either between the inner surface of the cartilages and the perichondrium with the mucous membrane (intralaryngeal abscesses) or on the outer surface between the cartilage and the muscles covering the larynx (extralaryngeal abscesses). Abscesses are opened, their cavity is smeared with iodine and tamponaded. Second period—the period of gradual, methodical dilation of the larynx, the period of shaping and modeling the larynx, when a new respiratory tube, unlike the previous normal one, has to be created from altered tissues. This period is the most difficult, prolonged, requiring unremitting attention from the doctor, inexhaustible patience, and implacable persistence. This restoration of the patency of the larynx and upper part of the trachea is achieved in two ways—by the long-term use of rubber tubes and the removal of infiltrates. Rubber tubes are mostly used T-shaped; the rubber must be red, soft, and elastic, and the wall thickness of the tube must not exceed 2 mm. The change of tubes is performed either daily or depending on the condition of the wound. At each change, the condition of the mucous membrane is carefully examined; places where the mucous membrane was removed along with the infiltrate are smeared with a 5% silver nitrate solution; if they granulate excessively, excess granulations are removed; if a grayish spot appears anywhere on the mucous membrane—a sign of incipient pressure sore—a thinner tube is inserted or instead a metal tracheostomy cannula is introduced for the healing of the pressure sore. Infiltrates of small size in the form of ridges or tubercles are removed with a double laryngeal curette or conchotome, more extensive ones—submucosally. When the condition of the mucous membrane remains satisfactory for some time, they switch to tubes of larger diameter and change them less frequently. When the edges of the stoma are covered with mucous membrane and skin and the discharge becomes negligible, the tube can be left unchanged for a long time. When, by such use of rubber tubes, it is possible to achieve a fairly wide laryngeal lumen, smooth and even walls, and free breathing with a closed stoma, then they proceed to attempts to leave the patient without a tube, i.e., they move on to the third, control period. Complications of the second period are: 1) pressure sores; they are superficial and deep. In the former, only the epithelium and partly the perichondrium perish, in the latter the cartilage is also affected. Replacing the rubber tube with a tracheostomy cannula and smearing with a silver nitrate solution (2-5%) rather quickly eliminates these pressure sores; 2) formation of abscesses (see above). Third period. When the lumen of the larynx and trachea is sufficiently wide and their walls are stable and do not collapse, the patient is left without a tube, but the opening (stoma) is closed with adhesive plaster to prevent the mucous membrane from being sucked in by the air escaping through the stoma during breathing. If patients with such a closed stoma breathe freely both day and night for many days, then the plaster is removed, the stoma is left free and covered only with a bandage; if even now the patient breathes freely through the mouth and nose for a week or two and upon examination the laryngeal lumen appears sufficiently wide, they proceed to suturing the stoma. Fourth period—closure of the stoma. If the stoma—a defect of the anterior wall of the larynx and trachea—is of significant size, then to close it one has to resort to plastic, sometimes quite complex operations with the formation of skin-cartilaginous and skin-bone flaps; if the stoma remains narrow, even if long, and if the respiratory tube within the stoma has not lost its rounded shape, then such a stoma is easily closed by simply approximating the freshened edges.