False this form of laryngitis there appear sometimes in the night, sudden and unexpected attacks of asphyxia, as a result of most acute inflammatory swelling of the subglottic region (accumulated mucus in sleep, obstructed breathing and passive congestion). The sudden onset, absence of aphonia, the relatively comfortable condition before and after the attack, all argue against its being diphtheria.
Inflammation of the Lower Vocal is a form of laryngitis in which a great amount of (edema may develop in the sub glottic region. The onset and course strongly resemble primary laryn geal diphtheria so that the distinction is only possible by bacteriologic examination.
CEdema of the to the laryngeal mucous mem brane by foreign bodies, burns, caustics, as well as intra- or perilaryngeal inflammatory and suppurative processes may easily cause an acute cedema leading to stenosis. The history, inspection of the mouth and pharynx and laryngoscopic examination usually render the diagnosis certain.
Thrush in the very rare cases thrush may descend to the larynx and trachea, perhaps by aspiration, and the yellowish brown thrush fungi may be found in abundance (Alassei, quoted by Spiegel berg). The diagnosis is made by examination of the masses removed artificially or spontaneously.
Papillomas of the larynx, the most common tumors of child hood, are congenital, or acquired as the result. of laryngeal inflamma tion of long duration. They may, according to their position, size and number bring about a slowly increasing stenosis, or they may only occa sionally close the lumen of the larynx in a valve-like fashion. In the latter instance, if a catarrhal laryngitis coexists, the condition may be mistaken for an attack of membranous croup. Of importance in the
differential diagnosis is the congenital or at any rate the longstanding hoarseness.
(c) Hyperplasia of the Thymus A well-developed thymus, extending deeply along the sternum, may cause great stenosis in infants, because it presses directly on the bifurcation of the trachea, where the tracheal rings arc wide apart and the membranous part is extensive, so that slight pressure suffices to coin press the trachea. Diseases causing active or passive congestion may accidentally aggravate the condition and through ignorance of the pre vious history diphtheria may be suspected. Examination with the Rontgen rays will establish the diagnosis.
(d) Enlargement of the Thyroid Gland Even in the first weeks of life enlargement of the thyroid gland may act like enlargement of the thymus, if the gland is situated much deeper than usual. The stenotic riles vary in intensity according to the position of the head, that is, according as the contraction or relaxation of the sternohyoid muscles press the gland against the trachea.
(e) Tuberculosis of the Bronchial Gland Masses of tuberculous lymph-nodes in the region of the trachea and of the bronchi may also exert pressure on the air-passages and cause stenosis. The symptoms described by Variot, Guinon and Marfan are very characteristic: dyspncea, sucking in of the soft parts, and a loud hollow sound, especially on inspiration, which is muffled when the child is lying down. The long duration of the trouble, the weak but—so long as a recurrent nerve is not compressed—clear voice, the hoarse but not silent cough, finally the absence of false membranes, exclude diphtheria.