CICATRICIAL STRICTURE OF PHARYNX CURED BY PLASTIC OPERATION.
It is well known how difficult of treatment and how liable to recurrence are the well-marked cases of cicatricial contrac tion of the pharynx, especially those which are the result of syphilitic ulceration. The authorities state that strictures in the lower division of the pharynx are less obstinate than those between the nose and mouth, but in the case reported below the tendency to recurrence under the most careful handling was striking, and the patient undoubtedly owes her life to the suc cess of the plastic operation.
Grace McT., single, twenty years of age, had had ulceration of the pharynx, due to inherited syphilis, from childhood. In 1895 she was regularly treated by Dr. L. A. Coffin with iodide of potash, and in January, 1898, the ulceration having healed with great cicatricial contraction, he made a series of energetic and patient attempts to divide the cicatricial bands and carry out the usual treatment by dilatation. For eighteen months these efforts were persevered in without success. Several times setons were passed through the hands, and were allowed to heal in so that the openings made were covered with epithelium on their edges, and then the tissue intervening between these openings and the pharynx were cut through. But even then, in spite of careful dilatation, recontraction occurred. Finally, she was re ferred to me and admitted to the General Memorial Hospital.
On admission, the patient, a slightly built, pale, somewhat emaciated girl, presented no other lesion than the cicatricial closure of the nasopharynx and the oropharynx. The opening upward from the mouth to the nose was less than one-eighth of an inch in diameter. The opening downward, through which she was compelled to swallow all her nourishment as well as to breathe, was only one-quarter of an inch in diameter. Her breathing was so stridulous as to be heard across a large room when she was at rest, and dyspncea came on when she walked vigorously. Her diet was restricted to fluids and semisolids. In spite of this serious interference with such vital necessities, she appeared to be in fairly good condition, owing to her naturally strong constitution and to her having been brought up in a healthy country. The lungs were sound, although the current of air was admitted so slowly that it was difficult to hear the respiratory murmur. Heart and kidneys also proved to be healthy.
May t3, 1899, under chloroform anaesthesia, tracheotomy was performed, and the anaesthesia continued through the tube. The head was then drawn over the end of the table and allowed to hang down backward (" Rose's position"). A transverse in cision was made above the hyoid bone, extending rather more to the left than to the right, and gradually deepened until the pharynx was opened on the left side between the epiglottis and the tongue. A careful examination showed that the lower pharynx was shut off from the upper by a membranous septum extending from the posterior pillar of the fauces and left side of the pharynx across to the base of the tongue. The right side was almost free from cicatricial tissue, and the septum was very thin at the margin of the opening (which lay to the right), but was very thick nearer its attachment to the left side of the pharynx. The mouth was kept open by a gag and the tongue drawn for ward by a thread which had been previously passed through its tip. With the finger in the wound below the septum, the edge of the membrane was divided from above through the mouth, a knife being used until the finger could be forced through, and the opening then forcibly stretched with the fingers until three of them could be passed freely up into the mouth. Only moderate haemorrhage followed.
The wound thus made upon the left side of the pharynx ex tended from below upward from the glosso-epiglottic fold of mucous membrane to the level of the hard palate, and from be fore backward from the tonsil to the posterior wall of the pharynx. The parts on the right side readily stretched out nearly to normal size, and the tongue regained its natural position. The epiglottis and larynx, and the neighboring pharyngeal mucous membrane, were healthy.
A flap was then cut from the skin of the left side of the neck, its base at the angle of the jaw, its apex directed downward and forward, its anterior (superior) margin corresponding with the incision made in opening the pharynx, and the posterior (in ferior) margin parallel with the latter. This flap included the skin and subcutaneous tissue, and was about five inches long and two inches broad. When it had been dissected up, three silk sutures were passed through its distal margin, being left untied and their ends passed into the pharynx, drawing after them the flap. The flap was reflected upward so that its raw surface lay in contact with the wound on the left of the pharynx, and its epithelial surface was turned to the cavity of the pharynx. By means of a curved needle the three sutures already mentioned were in turn passed through the edge of the mucous membrane at the upper end of the raw surface on the left side of the pharynx. The introduction and tying of these sutures was the most diffi cult part of the entire operation. The flap having been fastened thus, it was further secured by sutures of very fine silk passed at intervals along its margins. The upper pharynx was then packed with gauze so as to still further press the flap into place, and a sterile dressing applied to the neck. The operation was rather long, two hours in all, but the patient bore it well and soon reacted from the shock.
Rectal feeding was at once instituted, and was continued for seven days. No infection occurred ; the flap healed well in place, and the patient's highest temperature was we F. on the second day after the operation. After the first week she was fed by introducing a stomach-tube cautiously through the mouth. On the tenth day, under local anwsthesia, the flap was divided trans versely, where it adjoined the mucous membrane of the pharynx. On the fourteenth day the patient was allowed out of bed.
June 6, twenty-four days after the first operation, again in chloroform anwsthesia, the opening in the pharynx was closed by suture. The opening barely admitted two fingers at that time, and the cut edge of the transplanted skin had retracted well up into the pharynx. The remaining portion of the flap (towards its base) was dissected back from the edge of the opening, the numerous folds in it being straightened out, and it was turned down over the raw surface on the side of the neck, covering about one-half of it. The edges of the mucous membrane of the pharynx on the inner side of the opening into that cavity were dissected free and united with sutures of fine silk. The retraction of the transplanted skin had drawn it up above this opening. The skin on the external margin of the opening was dissected up and its edges also united with silk sutures. The remainder of the raw surface on the side of the neck was covered with Thiersch grafts taken from the thigh. Rectal feeding was maintained for four days, the stomach-tube was used for one day, and then the pa tient was allowed to swallow some fluid by mouth. This was quite difficult at first, but the function was soon restored. I should have preferred using the stomach-tube for feeding a few days longer, but was forced to give it up because the patient objected so strenuously, and was so nauseated by the tube, perhaps be cause of the sutures having altered the position of the epiglottis, for she had been fed in this manner without bad results ever since the first operation, and had formerly appeared thoroughly accus tomed to the tube. The wound healed rapidly and almost com pletely by primary union. The tracheotomy-tube was removed a few days after the last operation.
She was discharged from the hospital with all wounds healed June 24, and given a No. 4 soft rubber Wales rectal bougie, about three-quarters of an inch in diameter, with instructions to pass it at regular intervals, and at least once a week for some months. She had regained some flesh and color in spite of her prolonged rectal feeding, and was able to swallow and breathe with perfect freedom. She made little use of the bougie, but, in spite of that fact, there has been very little recontraction. At present the bougie passes, although with some difficulty. The transplanted skin in the pharynx has assumed the appearance of mucous mem brane, as is usual with skin transplanted into the mouth. The external scars are sound and not greatly disfiguring, as the widest parts are beneath the collar. There are no fistulae or sinuses. She swallows well, and the respiration is only noisy on exertion, as it must still be carried on through the mouth. Her general health has improved.
A hasty search through the literature reveals no similar operation, although I can hardly doubt that some one has em ployed this method. Mesny reports thirty-four cases of cica tricial stricture at this level, and states that there is little ten dency to recontraction (These de Bordeaux, 1893, quoted in Heymann's " Handbuch der Laryngologie and Rhinologie," Wien, 1899, II, p. 446). But there are several of these cases on record in which dilatation with small incisions failed to cure or caused serious accidents, such as haemorrhage so severe as to require ligation of the carotid to control it. Park has reported (International Medical Magazine, July, 1893, p. 550) a case similar to mine in which tracheotomy and gastrostomy were done as life-saving operations because of a low pharyn geal stricture with a lumen one-quarter of an inch in diameter, the patient being too irresponsible to allow systematic treat ment by dilatation. It is for these serious cases that the operation here described is recommended.