Chapter III: Operations Upon the Trachea (2)

4. _Granulations._ The possible presence of granulations must always be borne in mind. I believe this condition is far less common than is generally supposed, and that in many cases the granulations are entirely limited to the neighbourhood of the wound, where they can be seen. It is doubtful whether they are responsible for the dyspnœa which occurs. Great ingenuity and patience are required for the treatment of this condition. The wound must be kept scrupulously clean and all source of irritation removed. A rubber canula should be substituted in place of a metal one; if it were possible it would be advisable to discard the tube altogether, but as yet no form of dilator has been devised which will take the place of the canula. If the granulations be large they should be removed either with a sharp spoon or with suitable forceps, the area having been anæsthetized previously by a small quantity of the novocaine and adrenalin mixture. When small, the use of silver nitrate is preferable. It may be necessary to repeat this after a few days, and as soon as seems advisable a further attempt should be made to dispense with the tube. At this stage time must be allowed for the various tissues to regain their normal condition. Should this treatment prove unsuccessful, a thorough investigation must be made under chloroform. The wound is enlarged as far upwards as the cricoid, bleeding being arrested with the mixture just described. By throwing a strong light into the wound, the condition of the mucous membrane can be inspected and granulations removed. If there be no granulations in the trachea, a tube speculum can be passed through the mouth to ascertain the condition of the larynx (see p. 480). Such a method of procedure is preferable to the passage of probes, forceps, sponges, and other articles through the larynx, in the hope that any obstruction may be removed. If ulceration or necrosis of cartilage be discovered, it is impossible to relieve the condition by surgical means without prolonged treatment with tubes and the constant use of antiseptics. Under these conditions it is advisable to consider the removal of the tracheotomy tube in favour of intubation. In the hands of many foreign authorities the use of intubation tubes covered with gelatine, in which antiseptic is introduced, has been attended with such conspicuous success that further attempts should be made in this country; there is little doubt that, as our knowledge of the treatment of such wounds improves, better results are daily attained. Whatever treatment is considered it is important first of all that the actual cause should be distinguished. This is now possible owing to the great advances made in methods of examining the larynx.

5. _Stenosis_ of the larynx or trachea occurs in old-standing cases, as the result of ulceration, after some cases of crico-tracheotomy, and especially where a tube has been worn for a very protracted period. Breathing through a tube, if continued for a long time, interferes with the natural growth of the air-passage above it. The child grows, but the larynx remains stationary. This condition is aggravated by the fact that some inflammation is constantly present, especially in the neighbourhood of the wound, so that the tissue become fibrous and hard. The fibrous tissue contracts and stenosis is caused. According to von Bruns, Kohl,[28] and others, constrictions of the trachea may in rare instances result from some kinking of its wall. Such conditions as a bulging of the posterior wall due to the approximation of the posterior ends of the cartilage secondary to the spreading of the anterior portions, inversion of the tracheal margins from too small an incision, overlapping of the tracheal wound, and cicatricial union between the thyreoid and cricoid, must be exceedingly rare. Here, again, a definite diagnosis can always be made by proper investigation, but treatment is more difficult. Dilatation must be attempted by either continuous or intermittent methods. If preferred, a short piece of rubber tubing can be passed upwards from the tracheotomy wound into the larynx and kept in place for several hours by two silk sutures, one passing out of the tracheal wound, the other out of the mouth; or a stenosis canula can be inserted with some form of hollow plug which passes upwards into the larynx (Fig. 272). The question whether the tracheotomy wound should be kept patent is difficult to answer. When stenosis is extreme there is no alternative, and the open wound allows of the constant passage of graduated bougies, which is more easily accomplished from below than from above. If treatment be persistent the prospect of a good result is not unfavourable, and there is every reason to believe that in the future the number of cases which require a permanent tracheotomy tube will be reduced to a minimum.

[28] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 270.

6. _Paralysis._ In the larynx there may be paralysis of the sensory or of the motor nerves. In the former case food may enter into the trachea and cause troublesome coughing and possibly ‘Schluck-pneumonie’. When the motor nerves are affected, the paralysis is commonly abductor and may be unilateral or bilateral, the latter associated with inspiratory dyspnœa. ‘Complete paralysis of the recurrent laryngeal nerve may also occur, but is nearly always confined to one side’ (C. A. Parker[29]). Such paralyses may last from a few days to several months, and are very troublesome when associated with the passage of food into the trachea; when severe, nourishment should consist of fluids which can be administered by a nasal tube.

[29] _Nose and Throat_, 1906, p. 94.

Further complications arising during the after-treatment of tracheotomy:

7. _Broncho-pneumonia._ This occurs in the worst forms, and is accompanied by high temperature with definite signs in the lungs. The absence of septic discharge, the restlessness of the patient, and the rapidity of the breathing (in many instances accompanied by ‘recession’ not caused by obstruction in the tube) make the condition easy to recognize. There is no satisfactory treatment for septic broncho-pneumonia which has already developed, but it may be prevented. Within recent years it has become less common. This is due to better technique in the operation, and to careful attention during the after-treatment. The habit of passing feathers into the trachea has been abandoned with advantage to the patient. When possible the child should be removed from septic influences which are liable to infect the throat, for the occurrence of tonsil[l]itis as a sequel to tracheotomy is always to be feared in wards containing septic cases.

8. _Emphysema_ may occur in the neighbourhood of the wound, or in rare cases may be extensive and involve the whole of the face, neck, and chest. Champneys[30] was the first writer to call attention to this complication of tracheotomy. After a large number of observations and experiments, he was of opinion that emphysema of the anterior mediastinum occurs in a certain proportion of tracheotomies and is of frequent occurrence in cases that are fatal; that it may be associated with pneumothorax; and that the conditions which favour its production are a low division of the deep cervical fasciæ in the neighbourhood of the sternum, combined with obstruction of the air-passages and strong inspiratory efforts; artificial respiration, especially if improperly performed; and want of skill on the part of the operator; further, that the dangerous period of the operation is between the division of the deep cervical fascia and the efficient introduction of the tube. To this may be added those cases in which the tube slips out of the trachea into the cellular tissue above the sternum and thus causes more or less obstruction to breathing. It seems probable that the air is sucked into the cellular tissues beneath the pretracheal fascia, rather from the outside than from the trachea, and that with forced expansion of the chest it finds its way beneath the fascia into the mediastinum.

[30] _Trans. Med. Chirurg. Soc._, vol. lxv, p. 85; vol. lxvii, p. 102.

9. _Hæmorrhage_ may occur as the result of slipping of a ligature during an attack of vomiting or struggling after the operation; it is usually venous and requires nothing but passing notice. Secondary hæmorrhage may result from ulceration into one of the larger arteries or veins. Kocher[31] states that ‘the number of cases recorded is now about eighty-seven, of which fifty-six are associated with the innominate artery. Unfortunately it is not known how often in these cases inferior tracheotomy had been performed. Low tracheotomy was performed in my case because an excision of the larynx for cancer had been undertaken. Doubtless the danger of these fatal complications is much greater with inferior tracheotomy owing to the pressure of the canula.’ Von Bruns[32] also agrees that ‘the vast majority of fatal hæmorrhages were in cases of inferior tracheotomy. Of thirty-six cases in which the source of hæmorrhage was given, twenty-eight were traced to the innominate vein, two to the right carotid, and one each to the superior thyreoid, the left innominate, the right jugular and the left jugular.’ Bleeding is also recorded in cases of aneurism of the aorta, in which tracheotomy has been performed, as the result of erosion of the tracheal wall and the bursting of the sac. Further, troublesome oozing may take place from the mucous membrane of the trachea when this is inflamed, or when granulations are present, or when there is much sloughing of tissues, and especially after a metal tube has been worn for a considerable period. Hæmorrhage from an enlarged thyreoid isthmus is also described. When due consideration is given to the septic condition of the wounds and the close relation of large vessels, it is surprising to find that hæmorrhage proves so seldom fatal.

[31] _Chirurg. Operat._, 1907, p. 631.

[32] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 265.

10. _Cardiac paralysis_ may also complicate tracheotomy. When supervening in the acute stages of the disease, the patient becomes prostrate and vomiting is persistent, while the heart gradually fails. In other cases death occurs suddenly and unexpectedly, in mild as well as in severe disease; this may happen at any period, during the first days or later, during convalescence. Heart failure is more common in diphtheria than in any other infectious disease which is met with in this country.

=Prognosis.= It may be said that all cases of laryngitis caused by diphtheria are of a serious nature, and especially those which require tracheotomy (see Table, p. 517). The mortality amongst tracheotomized patients during five years was 31.5%, and the variations in each separate year were slight. Such results are far from satisfactory, but it must be remembered that in pre-antitoxin days less than 30% recovered after tracheotomy (Goodall[33]). The use of antitoxin, first suggested by Behring, is undoubtedly responsible for this remarkable decrease in the mortality. The sooner the serum is injected the better the prognosis with tracheotomy. A large dose should be given, 8,000 to 18,000 units, irrespective of age, and the dose may be repeated on the second day if required. Improvement generally commences between twelve and twenty-four hours after injection; the swelling of the mucosa subsides, and secretion is diminished; false membrane is not so copious, and rarely extends to the trachea and bronchi; crusts become less adherent, and are expelled by the patient. In this manner the whole area of the disease becomes clean, and there is less absorption of toxins. It is now generally agreed that serum should be used in all suspicious cases, and some authorities inject at once not only the patient, but also other children living in the same house. It is hoped by early injection to avoid the necessity for tracheotomy.

[33] _Brit. Med. Journ._, 1899, vol. i, p. 199, ‘On the Value of the Treatment of Diphtheria by Antitoxin.’

The age of the patient is very important, as the following table shows:

TABLE SHOWING TOTAL DIPHTHERIA TRACHEOTOMIES PERFORMED AT THE FEVER
HOSPITALS IN LONDON DURING 1902-6, INCLUDING THOSE IN WHICH
INTUBATION WAS PREVIOUSLY PERFORMED AND THOSE IN WHICH NO ANTITOXIN
WAS USED

+---------+----------+-----------+----------------+
| _Age._ | _Times._ | _Deaths._ | _Percentage of |
| | | | Deaths._ |
+---------+----------+-----------+----------------+
| Under 1 | 62 | 40 | 64.5 |
| 1-2 | 256 | 123 | 48.0 |
| 2-3 | 272 | 87 | 31.9 |
| 3-4 | 231 | 54 | 23.3 |
| 4-5 | 196 | 45 | 22.9 |
| 5-6 | 119 | 19 | 16.0 |
| 6-7 | 67 | 18 | 26.9 |
| 7-8 | 22 | 5 | 22.7 |
| 8-9 | 12 | 3 | 25.0 |
| 9-10 | 9 | 3 | 33.3 |
| Over 10 | 16 | 6 | 37.5 |
+---------+----------+-----------+----------------+
| Total | 1,262 | 403 | 31.9 |
+---------+----------+-----------+----------------+

From these figures it is apparent (1) that children less than one year of age rarely recover after tracheotomy; this is especially true of diphtheria, although in other forms of laryngeal obstruction cases of recovery have been reported in children of six months; (2) that in the early years of life tracheotomy is most commonly needed, especially between the ages of one and five years; (3) that the death-rate gradually decreases between the ages of one and six years, after which there is a rise.

In explanation of these facts it appears probable that after five years of age the larynx and trachea are increased in size, so that obstruction is only met with where there is a large amount of membrane, namely, in the worst cases; in patients over ten, the age which marks the change to the adult type of larynx, the air-passages become so large that obstruction seldom occurs even when much membrane is present; dyspnœa, in these cases, points to extension of the disease to the smaller tubes, and tracheotomy is unable to give the same relief.

In considering the prognosis, not only must the symptoms peculiar to the case be taken into account (as for instance the pulse, temperature, respiration and general condition), but also any complications that arise. It must be borne in mind that tracheotomy does not cure, although it can relieve, the patient; that nearly one-third of the cases die; that the disease, and not the operation, is responsible for most of the deaths. Moreover, the amount of toxæmia depends upon the virulence of the infection, which is variable in different epidemics; upon the area of mucous membrane infected; and upon the constitution of the patient. In so-called hæmorrhagic diphtheria the result is always fatal.

_The effect on after-life._ It was stated by Landouzy at the Berlin Tuberculosis Congress in 1899 that, judging by the rarity of the scar, few tracheotomized children reach adult life, but inquiries in Germany showed that this was incorrect. H. W. L. Barlow, in reviewing the literature of the subject, concludes that ‘in the large majority of cases the cure is permanent and complete’. In cases where a tracheotomy tube has been retained for a long period, however, complications are liable to arise; these include stenosis of the larynx or trachea, bronchitis, pneumonia, and possibly tuberculosis (see p. 485).

TRACHEOTOMY IN CONDITIONS OTHER THAN DIPHTHERIA

The indications for tracheotomy in conditions other than diphtheria have already been described. Although local anæsthetics are of little practical value in children, their use is much preferred where adults are concerned. The three drugs most commonly used at the present time are eucaine, cocaine, and novocaine, and of these novocaine is unquestionably to be preferred for subcutaneous injection as being less toxic, less irritant to the tissues, and at least as efficient in producing anæsthesia. Whichever drug is chosen, a small quantity of chloride of sodium should be added in order to make the solution isotonic with the blood serum, and thus to render it practically non-irritant. Many surgeons add adrenalin to contract the vessels in the injected area and so to prevent the drug from being absorbed into the general circulation: owing to the large size of the vessels and their proximity to the heart this is important, but it must also be remembered that with strong solutions there is great contraction of vessels, and that when the effects have disappeared there is a slight danger of recurrent hæmorrhage. Semon has drawn attention to this danger in connexion with operations upon the larynx, and after minor operations in other regions of the body it is not uncommon to find a small hæmatoma which necessitates reopening the wound.

In order to ensure the full effects of local anæsthesia with the least possible disadvantage, the drug should be used in weak solution, and the injection should be made at least a quarter of an hour before the operation is commenced. It is only necessary to prick the skin at one point, namely, at the upper end of the proposed incision; a small quantity of the fluid should be expelled, after which the needle may be withdrawn. After a short interval it is possible to reinsert the needle (or a larger one if preferred) and to push it deeper, until the whole length of the incision has been injected, without distress to the patient.

The following solution will be found effective:

‘Novocaine, 4% solution ɱ x = 1.3%
Sodium chloride, 4% solution ɱ vj = 0.8%
Adrenalin, 1-1,000 ɱ i = 0.003%
Distilled water to ɱ xxx

[Transcriber’s note: ɱ (approximation to symbol in the text) is
thought to mean drops, minims, or parts by volume;
hence ɱ x = 10 parts/drops, ɱ vj = 6 parts/drops, ɱ i = 1 drop
made up to a total of 30 parts/drops with distilled water]

‘These local anæsthetics are all, more or less, rapidly decomposed
and rendered inactive in the presence of even traces of an alkali or
alkaline carbonate. If boiling is resorted to in order to sterilize
the syringe, great care must be taken that no soda is
present.’--LANG.

Moreover, the finished solution cannot be boiled without decomposing the adrenalin, and it is customary therefore to add thymol or Ol. Gaultherii (0.1%), which keeps the solution antiseptic without being irritant.

The operation, which is often required in adults, must be carried out upon the lines already described. The enlargement of the thyreoid and cricoid cartilages, the small amount of fat, the small size of the thyreoid isthmus and of the pretracheal vessels after puberty, make the trachea easy to find. Difficulties, however, arise and are determined by the urgency of the case and the nature of the disease. Thus, with inflammation, the neck may be so swollen that the trachea is many inches from the surface; with tumours the trachea may be displaced, or the obstruction may be in the thorax. Under such conditions it is important to note the probable position of the trachea before the operation is commenced, and to be prepared for serious hæmorrhage.

The after-treatment also corresponds to that which is adopted in diphtheria. It is important to keep the tube clean and to prevent it from irritating the trachea. The time for removal of the canula varies according to the condition. Thus, when tracheotomy is performed for a foreign body, the tube may be removed as soon as the object has been extracted; on the other hand, when treating stenosis of the larynx it may be necessary to advise permanent wearing of the canula.

Complications are less common than with tracheotomy for diphtheria. Under favourable conditions there is little danger of pneumonia unless the wound becomes infected, as may happen when the operation is undertaken for the relief of septic inflammations.

Although tracheotomy is in itself a slight operation, it should be reserved for cases that demand it. The mortality of the operation under favourable conditions is probably very small; on the other hand, in acute septic conditions and in patients suffering from bronchitis there are grave dangers of complications.

TRACHEO-FISSURE AND RESECTION OF THE TRACHEA

Although these operations are very rarely performed, advance has been made in their technique during recent years.

=Indications.= (i) _Tumours of the trachea._ These are uncommon. Thiesen[34] in 1906 collected from literature 135 cases, of which 89 were innocent and 46 malignant. The majority of the former were papilloma (25), fibroma (24), enchondroma (17), and intratracheal struma (10). Of the latter, carcinoma (28) was more common than sarcoma (18). More than half of these tumours were situated high up in the trachea. These cases were collected from a period covering seventy-five years, which proves that they are extremely rare as compared with tumours of the larynx.

[34] _Trans. Amer. Laryng. Assoc._, 1906, p. 264, ‘Tumours of the Trachea.’

(ii) _Stenosis due to previous inflammation._ Stenosis may be caused by diphtheria or other fevers, syphilis, the presence of a foreign body, or the inhalation of corrosive acids or chemical fumes. Such cases are generally treated by endotracheal methods (see p. 559).

(iii) _Cut-throat, or injury._ An operation may be necessary after crushing or bullet wounds, or, in later stages, owing to the development of stenosis.

The diagnosis of these conditions is now comparatively easy, and with the help of direct laryngoscopy and X-ray photography the exact condition can, in many cases, be determined. In some instances the tumour may be removed by endotracheal operation, especially if the growth is innocent.

=Tracheo-fissure= is more reliable, and should always be performed when there is any suspicion of malignancy. The preliminary stages are similar to those of tracheotomy. A section of the trachea is first made in the region of the tumour, and the opening is enlarged so that the growth can be thoroughly explored; this can be better accomplished when the trachea is illuminated by a good electric lamp, in some instances a Killian’s tube being required. When possible, a tampon canula is inserted into the lower part of the trachea. When the growth is low down, the patient is placed in the Trendelenburg position in order to prevent the inspiration of blood. Should the diagnosis be uncertain, a portion of the tumour can be excised and a frozen section made. If proved to be innocent, the growth can then be freely excised with scissors or galvano-cautery. The bleeding is arrested, and the tracheotomy tube is retained for several days. The after-treatment must be conducted on lines similar to those laid down for laryngectomy, the patient being turned on the face in order to prevent pneumonia. ‘Up to the present time about two dozen operations of this sort have been reported. The author has removed in this manner four intratracheal thyreoids with permanent result’ (von Bruns).[35]

[35] Bergmann, E. von. _Sys. Pract. Surg._, vol. ii, p. 249.

=Resection.= If the tumour be malignant, the surgeon must first decide whether its removal is practicable or whether palliative tracheotomy is preferable. In the former case the trachea is isolated laterally and divided transversely well below the growth. Whenever possible the lower end is then brought outwards and temporarily attached to the lower part of the incision above the sternum. The resection of the trachea is then carried out, so that the growth is freely removed, care being taken to preserve the recurrent laryngeal nerves. ‘Where the section of the trachea to be removed is limited to 4 centimetres or less, the two ends can generally be approximated and united, restoring the calibre of the tube and normal mouth respiration’ (Brewer).[36] This is accomplished by numerous catgut sutures some of which include the entire thickness of the tube. The muscles can be approximated so as to cover the incision, and the wound can be drained freely. On the other hand, the lower end of the trachea may be permanently fixed in the wound as described under laryngectomy (see p. 498). Von Bruns has removed a cancer on the posterior wall of the trachea with six tracheal rings, thus giving the patient six years of life. He remarks: ‘operative treatment in tumours of the trachea shows brilliant results. Untreated the condition leads to death from suffocation. In seven cases operated upon by me, the results were all favourable.’

[36] _Keen’s Surgery_, 1908, p. 510.