

130 77/r Larvn.v 



regions ; a noisy passage of the air through the glottis ; and 



tress which is associated with laboured and ineffectual attempts at 



respiration. 



The simplest operation is that of passing a tube through the crico- 

 thyroid space, but in the child this interval is far too narrow to serve, 

 so that the trachea has to be opened instead tracheotomy always in 

 the child. Tracheotomy, moreover, is to be preferred in the adult 

 when the tube has to be left in permanently, as it is further away from 

 the vocal cords, and therefore less likely to set up inflammatory 

 thickening in that important region. Tracheotomy is also resorted to 

 in the adult when there is a foreign body below the cords. 



In laryng-otomy the shoulders are raised, and the head is thrown 

 back and held perfectly square to the middle line. The surgeon feels 

 for the thyroid cartilage, and, a little below its prominent inferior 

 border, the arch of the cricoid. He then makes an inch incision 

 down the middle line, beginning it \ in. above the bottom of the 

 thyroid, and traversing skin, superficial, and deep fascine. Thus the 

 crico-thyroid membrane is readily exposed ; on it is the small arterial 

 communication between the two superior thyroids, which is generally 

 cut, but it rarely gives any troublesome bleeding. The membrane is 

 incised across the middle line, so as to secure a more easy introduc- 

 tion for the tube. 



Thyrotomy. For the removal of a foreign body from the larynx, 

 or for the clearing away of a crop of warty growths which impede 

 respiration, or for the more efficient dealing with intra ; laryngeal epi- 

 thelioma, the thyroid cartilage may have to be split up the middle and 

 the halves turned asunder. 



Tracheotomy having been first performed, the skin and fasciae are 

 divided down the middle line of the pomum Adami, the wound being 

 continued into that which is already made for the tracheotomy. The 

 incision through the thyroid cartilage must be kept exactly in the 

 middle line, as it has to hit the narrow interval between the anterior 

 ends of the vocal cords. To make more room, the thyro-hyoid and 

 crico-thyroid membranes should also be cut. 



Removal of the entire larynx, a dangerous and unsatisfactory 

 operation, may be undertaken after a preliminary tracheotomy, due 

 provision having been made against the entrance of blood into the 

 trachea. 



A median incision through skin and fasciae is made from the hyoid 

 bone to the top of the trachea, and, at the top of this, a transverse one. 

 Then, with the blunt end of a pair of scissors, the sterno-thyroid and 

 thyro-hyoid and other soft tissues are torn through, raised from the 

 larynx, and turned back with the skin, fasciae, and the sterno-hyoid and 

 omo-hyoid. The trachea is cut across just above the wound made 

 for the silver tube, and the cricoid end of the larynx is drawn forward, 

 and cleared by division of the recurrent laryngeal nerve and branches 



