TIONS OF THE LARYNX ACCOMPANIED BY STENOSIS The diagnosis of a laryngeal diphtheria is very easy when it occurs in the course of a pharyngeal diphtheria, but it may be very difficult if it develops after the disappearance of a mild, unobserved pharyngeal diphtheria, or if it starts primarily in the larynx, does not mount to the pharynx and if at the time of observation no loosening and expectora tion of membrane have occurred. The possibility then exists of con founding the condition with a nondiplitheritic infection of the naso pharynx, larynx and trachea which may arise from some inflammatory or mechanical cause and go on to the development of dyspncea, and even to a high degree of stenosis with attacks of asphyxia. For diphtheria, there speaks the onset with a rapidly developing catarrhal process, in crease of the initial hoarseness even to complete aphonia; steadily ad vancing stenosis even to the maximum with attacks of asphyxia; after the attack, incomplete relief; continuation of the dyspna,sa with a slight degree of increase.
In all doubtful cases, digital examination, but preferably la-ryngo scopic examination if possible, is to be made; sometimes the question is settled by bacteriologic examination of the pharyngeal mucus. A negative result of this is not sufficient to exclude diphtheria; the secre tion on the coughed-up or extracted tube—in case intubation has been necessary because of asphyctic attacks—is to be examined (Malian); if no diphtheria bacilli arc found in it, diphtheria may be excluded with reasonable certainty.
(a) Nondiphtheritic Affections of the Nasopharynx Pharyngeal inflammation and swelling of the pharyngeal tonsil is of frequent occurrence in newborn and young in fants. Nasal breathing is interfered with or absolutely prevented and a watery secretion flows down the posterior pharyngeal wall. In sleep it collects near the entrance to the larynx and may cause temporary obstruction to respiration. The very short duration and frequent repe titions of the attacks which do not appear when the child is awake and sitting up, as well as the usually perfectly clear voice, prevent mista-king it for diphtheria.
Retropharyngeal and Retrolaryngeal geal abscess is seen rather frequently in infancy. It may be a suppu rative lymph-node or a penetrating abscess. The primary cause in nurs lings may be a lesion of the mucosa by an infected finger of the nurse. The abscess lies ordinarily at the level of the third or fourth cervical vertebrce and compresses the entrance to the larynx. There are dys phagia, regurgitation of fluids, snoring respiration and finally a high degree of dyspncea; a swelling may also be seen externally in the cor responding region of the neck. The deep, gurgling ring to the voice (von B 'kay) and digital examination separate this from laryngeal diphtheria.
Macroglossia.--Lymphangioma of the. tongue, the so-called macro glossia, as seen in cretinism and myxcedema, may when inflamed cause considerable obstruction to respiration.
(b) Nondiphtheritic Diseases of the Larynx epiglottis of the newborn is normally rather deeply grooved. This peculiarity is often so strongly developed that the free edges become movable to such a degree as to narrow quite de cidedly the lumen of the glottis. A congenital stridor then develops, with a gurgling sound on inspiration and difficulty on breathing amount ing to attacks of stenosis when excited. The history that the symptoms have been present from birth removes all doubt about the nondiphther itic nature of the affection, which disappears toward the end of the second year of life, with the unfolding of the epiglottis.
In very rare cases there is seen a congenital adhesion of the anterior commissure of the vocal cords. The glottis is therefore narrowed and so a simple laryngitis may cause a severe stenosis. Such children have from birth a muffled, hoarse voice.
differential diagnosis of this concerns only the first stage of laryngeal diphtheria. The in symptoms in both cases are cough and hoarseness, but their development shows characteristic differences. In laryngitis, voice and cough are loud, in diphtheria they grow steadily weaker, almost to silence. In addition, diphtheria is accompanied by increasing dyspncva and swelling of the glands.