Laryngostomy

LYRINGOSTOMY (from Greek larynx-throat and stoma-mouth, opening), a method of surgical treatment for persistent stenosis of the larynx, consisting of splitting either only the larynx or the larynx together with the upper rings of the trachea and maintaining this splitting for a long time, during which, in the presence of scar strictures, gradual expansion is performed by inserting rubber tubes of progressively larger diameters; if there are other changes in the larynx, such as papillomas or submucosal infiltrates, appropriate treatment of the open larynx is carried out. This method was thoroughly developed by Sargnon and Barlatier (1907) and consists of four periods. The first period includes splitting the larynx and eliminating the changes found during this procedure, followed by the postoperative course in the immediate days with possible complications. The second period covers the systematic expansion of the larynx, the third is the control period, during which the stability of the achieved expansion of the laryngeal lumen is observed, and the fourth is the plastic closure of the remaining opening-the stoma. First period. Splitting of the larynx is performed under local anesthesia (technique of splitting see Laryngofissure). After opening the larynx, it is carefully examined, the changes present in it are determined, and appropriate action is taken based on findings: 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 too large; scar tissue is removed as completely as possible. Submucosal removal of infiltrates consists in separating the mucosa over a certain length as a thin layer from the underlying tissue, which is removed with a knife or conchotome down to the cartilage, without exposing the cartilage itself; the separated mucosal flap is then applied back in place and secured with one or two sutures. At the end of the operation, a T-shaped rubber tube is inserted into the lumen of the larynx, and the upper part of the wound is sutured with a two-layer suture (catgut on muscles, silk or clips on the skin) just enough to allow free removal and insertion of the tube. The postoperative course in the immediate days varies depending on the extent of injury during the operation: if it is not accompanied by removal of large infiltrates, the temperature usually does not rise or rises by a few tenths of a degree, there is no tenderness on pressure in the area of the incision; if the patient does not complain of pain when swallowing, if fluid does not enter the tube when drinking, 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 removal of infiltrates or scars over a large area or opening of abscesses, the temperature may rise quite high (39°), the edges of the wound swell, are tender on pressure, and discharge from the wound is abundant. In such cases, the tube is changed daily, the wound surface is cleaned and coated with a 5% solution of argyrol; then the discharge gradually decreases, tenderness disappears, and the temperature returns to normal. Complications of the first period are: 1) bleeding, which sometimes occurs several hours after removal of voluminous infiltrates together with the mucosa. Bleeding is usually diffuse; it is usually not possible to find the bleeding vessel, apply a hemostat to it, or suture it. Then the sutures have to be removed, the rubber tube taken out, and the laryngeal cavity tightly packed by inserting a tracheotomy cannula; the packing has to be changed several times; 2) formation of laryngeal abscesses. If after splitting a high temperature (39-40°) appears and persists for a long time; if along with this there is swelling and tenderness on pressure of the skin and underlying tissues in the area of the larynx, as well as pain when swallowing, this indicates inflammation of the perichondrium and cartilages of the larynx. Such inflammation may, under the influence of heating compresses, stop and regress or lead to the formation of pus, with the pus accumulating either between the inner surface of the cartilages and the perichondrium with the mucosa (intralaryngeal abscesses) or on the outer surface between the cartilage and the muscles covering the larynx (extralaryngeal abscesses). Abscesses are opened, their cavity is coated with iodine, and packed. The second period is the period of gradual, systematic expansion of the larynx, the period of formation, modeling of the larynx, when a new respiratory tube has to be created from the changed tissues, unlike the previous normal one. This period is the most difficult, prolonged, requiring from the doctor constant attention, inexhaustible patience, and unwavering persistence. This restoration of patency of the larynx and upper part of the trachea is achieved in two ways-prolonged use of rubber tubes and removal of infiltrates. Rubber tubes are mostly T-shaped; the rubber should be red, soft, and elastic, and the wall thickness of the tube should not exceed 2 mm. Changing of tubes is done either daily or depending on the condition of the wound. At each change, the condition of the mucosa is carefully examined; areas where the mucosa was removed together with the infiltrate are coated with a 5% solution of argyrol; if they granulate excessively, excessive granulations are removed; if a grayish spot appears anywhere on the mucosa-a sign of beginning decubitus, a thinner tube is inserted or a metal tracheotomy cannula is introduced instead to allow the decubitus to heal. Small infiltrates in the form of ridges or nodules are removed with a double laryngeal curet or conchotome, more extensive ones submucosally. When the condition of the mucosa remains satisfactory for some time, transition is made to tubes of larger diameter and they are changed less frequently. When the edges of the stoma are covered with mucosa 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 that the lumen of the larynx becomes quite wide, the walls even, smooth, and breathing with the stoma closed is free, then attempts are made to leave the patient without a tube, i.e., transition is made to the third, control period. Complications of the second period are: 1) decubitus; they are superficial and deep. In the first, only the epithelium and partly the perichondrium die, in the second, the cartilage is also affected. Replacing the rubber tube with a tracheotomy cannula and coating with a solution of argyrol (2-5%) quite quickly eliminates these decubiti; 2) formation of abscesses (see above). Third period. When the lumen of the larynx and trachea becomes sufficiently wide and their walls are stable, non-collapsible, the patient is left without a tube, but the opening (stoma) is covered with an adhesive plaster to prevent the mucosa 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 open and covered only with a dressing; if now the patient breathes freely through the mouth and nose for another week or two and upon examination the lumen of the larynx is sufficiently wide, suturing of the stoma is undertaken. Fourth period-closure of the stoma. If the stoma-a defect of the anterior wall of the larynx and trachea-is of considerable size, then plastic, sometimes rather complex operations with the formation of skin-cartilage and skin-bone flaps have to be resorted to for its closure; if the stoma remains narrow, even if long, and if the respiratory tube within the stoma has not lost its round shape, then such a stoma can be easily closed by simple approximation of the freshened edges.

LYRING]

rene laryngii, third-control period, during which they observe how stable the achieved expansion of the laryngeal lumen is, and fourth-plastic closure of the remaining opening-stoma. First period. Splitting of the larynx is performed under local anesthesia (technique of splitting see Laryngofissure). After opening the larynx, it is carefully examined, the changes present in it are determined, and appropriate action is taken based on findings: 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 too large; scar tissue is removed as completely as possible. Submucosal removal of infiltrates consists in separating the mucosa over a certain length as a thin layer from the underlying tissue, which is removed with a knife or conchotome down to the cartilage, without exposing the cartilage itself; the separated mucosal flap is then applied back in place and secured with one or two sutures. At the end of the operation, a T-shaped rubber tube is inserted into the lumen of the larynx, and the upper part of the wound is sutured with a two-layer suture (catgut on muscles, silk or clips on the skin) just enough to allow free removal and insertion of the tube. The postoperative course in the immediate days varies depending on the extent of injury during the operation: if it is not accompanied by removal of large infiltrates, the temperature usually does not rise or rises by a few tenths of a degree, there is no tenderness on pressure in the area of the incision; if the patient does not complain of pain when swallowing, if fluid does not enter the tube when drinking, 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 removal of infiltrates or scars over a large area or opening of abscesses, the temperature may rise quite high (39°), the edges of the wound swell, are tender on pressure, and discharge from the wound is abundant. In such cases, the tube is changed daily, the wound surface is cleaned and coated with a 5% solution of argyrol; then the discharge gradually decreases, tenderness disappears, and the temperature returns to normal. Complications of the first period are: 1) bleeding, which sometimes occurs several hours after removal of voluminous infiltrates together with the mucosa. Bleeding is usually diffuse; it is usually not possible to find the bleeding vessel, apply a hemostat to it, or suture it. Then the sutures have to be removed, the rubber tube taken out, and the laryngeal cavity tightly packed by inserting a tracheotomy cannula; the packing has to be changed several times; 2) formation of laryngeal abscesses. If after splitting a high temperature (39-40°) appears and persists for a long time; if along with this there is swelling and tenderness on pressure of the skin and underlying tissues in the area of the larynx, as well as pain when swallowing, this indicates inflammation of the perichondrium and cartilages of the larynx. Such inflammation may, under the influence of heating compresses, stop and regress or lead to the formation of pus, with the pus accumulating either between the inner surface of the cartilages and the perichondrium with the mucosa (intralaryngeal abscesses) or on the outer surface between the cartilage and the muscles covering the larynx (extralaryngeal abscesses). Abscesses are opened, their cavity is coated with iodine, and packed. The second period is the period of gradual, systematic expansion of the larynx, the period of formation, modeling of the larynx, when a new respiratory tube has to be created from the changed tissues, unlike the previous normal one. This period is the most difficult, prolonged, requiring from the doctor constant attention, inexhaustible patience, and unwavering persistence. This restoration of patency of the larynx and upper part of the trachea is achieved in two ways-prolonged use of rubber tubes and removal of infiltrates. Rubber tubes are mostly T-shaped; the rubber should be red, soft, and elastic, and the wall thickness of the tube should not exceed 2 mm. Changing of tubes is done either daily or depending on the condition of the wound. At each change, the condition of the mucosa is carefully examined; areas where the mucosa was removed together with the infiltrate are coated with a 5% solution of argyrol; if they granulate excessively, excessive granulations are removed; if a grayish spot appears anywhere on the mucosa-a sign of beginning decubitus, a thinner tube is inserted or a metal tracheotomy cannula is introduced instead to allow the decubitus to heal. Small infiltrates in the form of ridges or nodules are removed with a double laryngeal curet or conchotome, more extensive ones submucosally. When the condition of the mucosa remains satisfactory for some time, transition is made to tubes of larger diameter and they are changed less frequently. When the edges of the stoma are covered with mucosa 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 that the lumen of the larynx becomes quite wide, the walls even, smooth, and breathing with the stoma closed is free, then attempts are made to leave the patient without a tube, i.e., transition is made to the third, control period. Complications of the second period are: 1) decubitus; they are superficial and deep. In the first, only the epithelium and partly the perichondrium die, in the second, the cartilage is also affected. Replacing the rubber tube with a tracheotomy cannula and coating with a solution of argyrol (2-5%) quite quickly eliminates these decubiti; 2) formation of abscesses (see above). Third period. When the lumen of the larynx and trachea becomes sufficiently wide and their walls are stable, non-collapsible, the patient is left without a tube, but the opening (stoma) is covered with an adhesive plaster to prevent the mucosa 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 open and covered only with a dressing; if now the patient breathes freely through the mouth and nose for another week or two and upon examination the lumen of the larynx is sufficiently wide, suturing of the stoma is undertaken. Fourth period-closure of the stoma. If the stoma-a defect of the anterior wall of the larynx and trachea-is of considerable size, then plastic, sometimes rather complex operations with the formation of skin-cartilage and skin-bone flaps have to be resorted to for its closure; if the stoma remains narrow, even if long, and if the respiratory tube within the stoma has not lost its round shape, then such a stoma can be easily closed by simple approximation of the freshened edges.