TRANSFIXION OF THE LEFT ARYTENOID CARTILAGE BY 
A FISH-BONE—LOSS OF MOTION IN THE COR- 
RESPONDING HALF OF THE LARYNX- 
ABSCESS; RECOVERY. 
BY JOHN N. MACKENZIE, M. D., 
Late House Physician in Bellevue Hospital, N ew York, and Chef-de-Clinique at the London 
Hospital for Diseases of the Throat and Chest, Golden Square, W. / 
The literature of foreign bodies in 
the air-passages goes back to the time 
when Anacreon perished by the grape 
which made his songs immortal. Sub- 
stances in almost infinite variety, 
even the larynx itself,* have found 
their way into the windpipe; and their 
modes of entrance, the various phe- 
nomena to which they give rise, and 
the methods devised for their extrac- 
tion, have furnished the material for 
separate treatises which abound in in- 
teresting reading and instructive detail. 
As the following case, for which I 
am indebted to my friend, Dr. Whistler, 
of London, presents some features of 
unusual interest, I am induced to place 
it on record: 
In the summer of 1879, while in 
charge of Dr. YV.’s clinic at the Hos- 
pital for Diseases of the Throat and 
Chest, a young man applied to me 
on account of great difficulty of 
breathing and loss of voice, which 
had come on suddenly during his mid- 
day meal, and which he accordingly 
attributed to the impaction of a for- 
eign substance in the throat. In the 
act of swallowing a mouthful of fish 
he had experienced an acute pain in 
the lower part of the throat and a 
convulsive sense of constriction, which 
lasted for some time and during which 
he was unable to “fetch his breath,” as 
he inelegantly observed. After the 
violence of the paroxysm had subsided, 
he found that he was unable to swal- 
low, and that his respiration had be- 
come seriously embarrassed. The 
*Burow (Braithwaite’s Retrospect, American 
edition, 1850, 21, p. 203, from Caspar’s Wochen- 
schrift) tells of a boy who inhaled the larynx of 
a goose while blowing through it in play. 
Strangulation took place, with a clear, whistling 
noise in breathing, followed at each expiration 
by “a hoarse noise not unlike that of the voice 
of a goose.” Tracheotomy was performed and 
the larynx with difficulty extracted. 2 
dyspnoea increased rapidly in severity, 
and the patient in great alarm sought 
relief at the hospital. 
When he arrived at the clinic, some 
hours after the accident, his respira- 
tion had become labored and stridu- 
lous, exquisite pain in the throat pre- 
cluded attempts at deglutition, and 
the voice was almost completely gone. 
The tissues external to' the larynx 
were somewhat swollen, and manipu- 
lation of the organ itself gave rise to 
intense suffering. Nothing noticeable 
was observafelel in the oio-pharynx, 
nor could any foreign substance be 
detected in the glosso-epiglottic or 
pyriform sinuses. The left latero- 
posterior pharyngeal wall was greatly 
swollen and oedematous. Owing to 
the irritable state of the pharynx and 
the nervous condition of the patient, 
but especially to a large overhanging 
epigjottis, laryngoscopic examination 
was accomplished with great difficulty, 
and only after a number of unsuccess- 
ful attempts was a view finally obtained 
of the laryngeal cavity. The whole 
mucous membrane and both vocal 
cords were intensely hyperaemic—the 
left ventricular band greatly swollen 
and the corresponding cord immova- 
ble. The mucous membrane of the 
left ary-epiglottic ligament and that 
clothing the arytenoid cartilage of the 
same side were cedematous,the oedema 
of the cartilage giving rise to a large, 
globular swelling which diminished 
considerably the lumen of the larynx. 
No foreign body could be seen in the 
larynx or lower pharynx. 
The oedematous portions of the 
larynx and pharyngeal wall were free- 
ly scarified with Mackenzie’s laryn- 
geal lancet with great and immediate 
relief to the patient. Probes and in- 
struments of various kinds and sizes 
were next introduced into the oesopha- 
gus; but the most careful exploration 
failed to determine the presence of a 
foreign body. The introduction of 
forceps and hooks deep into the gullet 
was likewise negative in result; and, 
as the scarification had placed the 
man out of immediate danger, it was 
decided to abandon, for the time, the 
search for the foreign body. The 
patient was accordingly given a 
phoretic mixture and a soothing in- 
halation, with instructions to keep 
cracked ice constantly in the back of 
the throat and to return the following 
day. The next morning he reported 
great relief from his suffering, and a 
good night’s rest; but deglutition con- 
tinued painful and impossible. The 
pharyngeal wall was still slightly 
cedematous. The oedema of the ary- 
epiglottic fold and arytenoid cartilage 
had subsided; but on the posterior 
surface of the latter a small, round, 
intensely red tumor had developed, 
which, when touched with the probe, 
gave rise to acute pain. Thinking 
that a small bone had penetrated the 
cartilage behind and produced sup- 
puration, the abscess was freely lanced 
with the guarded laryngeal knife. A 
few drops of blood and pus followed 
the incision but no foreign body could 
be detected. 
The next day pus was discovered 
welling up from the oesophagus and 
posterior border of the arytenoid 
which had been incised the day before. 
The left ventricular band presented 
posteriorly a small, circumscribed 
swelling streaked on its surface with 
fine red lines. On attempted phona- 
tion, no motion could be detected in 
the corresponding side of the larynx. 
Under the guidance of the laryngeal 
mirror, a probe was introduced into 
the opening of the oesophagus and 
directed against the cartilage, where 
it impinged on a small, hard, project- 
ing body. Attempts were then made 
with forceps and other instruments to 
dislodge it; but only with partial 
success, and I determined to defer the 
attempt at extraction until the suppura- 
tive process should render the object 
looser and easier of manipulation. 
The following day suppuration had 
increased and efforts at extraction 3 
were repeated. After succeeding in 
loosening the body and accomplish- 
ing partial extraction, the patient was 
seized with a convulsive action of the 
muscles of the throat, and, finally, at 
the end of the paroxysm, expelled the 
foreign body—a fish bone about one- 
half an inch long and two or three 
lines in breadth—covered with blood 
and pus. The extremity of the bone, 
which had evidently been buried in 
the larynx, was sharp, rugged and 
more or less pointed; the other smooth 
and rounded. After its expulsion, the 
patient coughed up a small quantity 
of purulent matter much to his relief 
and satisfaction. 
The throat was thoroughly cleansed 
with disinfectant solutions, the wound 
treated with stimulating applications, 
the larynx placed at perfect rest and 
the patient placed upon iced milk. 
With the removal ofthe bone, motion 
returne 1 gradually in the left side cf 
the larynx, the dysphagia and injec- 
tion of the laryngeal mucous mem- 
brane disappeared, and at the end of 
a fortnight, the excursions of the vocal 
cord were apparently perfect. The 
arytenoid cartilage was left in a some- 
what thickened state and scarred on 
its posterior aspect from the cicatriza- 
tion of the abscess cavity, and the 
swelling on the ventricular band re- 
mained (although the injection had dis- 
appeared); but the larynx performed 
its functions with perfect ease, and 
the patient was discharged from the 
clinic cured. 
The points of interest in the case 
may be briefly summarized as follows: 
I. The situation and mode of entrance 
of the foreign body. The bone had in 
all probability fallen lengthwise across 
the opening of the oesophagus, with 
its sharp, jagged end in front, and had 
been driven forcibly into the larynx 
in the convulsive acts of deglutition 
which followed its introduction with 
the food. It had doubtless passed 
along the lateral border of the ary- 
tenoid, partially transfixing the cartil- 
age, through the muscular fibres of the 
thyro-arytenoideus externus, and 
buried its point in the left upper pos- 
terior wall of the ventricle, as indica- 
ted by the swelling and injection of 
the left ventricular band. The crico- 
arytenoid joint had apparently es- 
caped uninjured. 
2. 7 lie loss of motion on the corre- 
sponding side of the larynx. This was 
obviously due to the transfixion of 
the laryngeal structures in the path 
of the bone, and to the abrogation of 
muscular action induced partially, 
doubtless, by reflex spasm, partially 
by inflammatory action. 
3 The failure, at first, to detect its 
presence after careful examination, due 
to the accompanying inflammatory 
swelling and oedema, and the very 
unusual depth to which the bone had 
penetrated the laryngeal tissues. 
4. The method of expulsion (by sup- 
puration) and the happy termination of 
the case; and 5, finally, the obvious im- 
portance of laryngoscopic examination 
in all cases where a foreign body has 
gained admission to the throat. It 
seems superfluous to dilate upon the 
dangers which must follow the rough 
manipulation to which the oesophagus 
and even the larynx are subjected 
without an intelligent appreciation 
of the situation derived from ocular-* 
inspection. In the above case, with- 
out such aid, scarification would not 
have been indicated or carried out, the 
patient would have been placed in 
peril, and the incautious use of in- 
struments unguided by the eye would 
have almost certainly increased the 
oedema and precipitated tracheotomy. 
Without inspection with the mirror 
the oesophagus, and even the stomach, 
have been roughly invaded, while the 
offending substance nestles, secure 
from arrest, in the pyriform sinus. 
Even with its aid, the difficulty of ex- 
traction when the foreign body has 
been buried in the tissues can only be 
appreciated by those who have had 
some experience in their removal.