A Case of Perichondritis of 
the Larynx ; Necrosis 
of the Cricoid. 
BY 
C. H. KNIGHT, M. D. 
REPRINTED PROM 
2TI)C Neto York ffle&tcal journal 
for January 1, 1887. Reprinted from the New York Medical Journal 
for January 1, 1887. 
A CASE OF 
PERICHONDRITIS OF THE LARYNX; 
NECROSIS OF THE CRICOID.* 
By C. II. KNIGHT, M. D. 
Destruction of the cartilages of the larynx, resulting 
from inflammation of their perichondrium, is by no means 
uncommon. Numerous instances have been recorded of its 
occurrence as a sequel of typhoid fever, as a complication 
of tubercular laryngitis, associated with malignant disease 
of the larynx, and in the course of syphilis. The opportu- 
nity of studying the condition in a pathological specimen 
may perhaps lend additional interest to the following his- 
tory: 
W. S. M., aged seventy-three, single, cabinet-maker, came to 
the Northern Dispensary in February, 1886, suffering from 
dyspnoea and dysphonia, which he said began about three 
months previous and had been gradually increasing. The ob- 
struction was obviously laryngeal and affected equally expira- 
tion and inspiration. The voice w'as remarkably low-pitched 
and raucous. There was occasional hoarse cough, with expec- 
toration of thin purulent sputa, which showed streaks of blood 
after an unusually violent paroxysm of cough. The breath was 
extremely foetid. There was no pain referable to the larynx, 
* Read before the American Laryngological Association at its eighth 
annual congress. 2 
PERICHONDRITIS OF THE LARYNX; 
except during phonation or deglutition and after coughing, but 
the patient complained of sensitiveness under external pressure, 
and when the larynx was moved from side to side. There was 
no apparent thickening, swelling, or oedema over the region of 
the larynx. The cervical glands were not enlarged. Examina- 
tion with the laryngoscope showed a diffuse, symmetrical oedem- 
atous swelling of the posterior wall of the larynx, the natural 
contour of the arytenoids being entirely effaced. Only a small 
portion of the anterior extremities of the vocal cords was visi- 
ble. They seemed to be normal. The epiglottis was congested 
and somewhat swollen. Oozing into the cavity of the larynx 
from its posterior wall appeared a small quantity of thin, white 
secretion. It was impossible to keep the laryngeal mirror in 
position more than a few seconds on account of the necessity of 
clearing the larynx. No ulceration could be seen, and the source 
of the secretion could not be precisely determined. Owing to 
the patient’s condition, no attempt was made to probe the larynx 
or to carry on a more extended examination. 
The general condition of the patient was extremely bad. Tie 
was very weak and much emaciated, having been able to take 
little or no solid food for three or four weeks. He had received 
no treatment whatever, except a series of cough mixtures, 
which, of course, gave him no relief. Stimulants and soft food 
were ordered, and the patient was directed to use every two 
hours a steam inhalation of compound tincture of benzoin. He 
was not seen again for four days, when lie reported in a very 
much improved condition. Still the tumefaction over the aryte- 
noids prevented a complete view of the cords. The amount of 
secretion in the larynx seemed to be less; its character was un- 
changed. Breathing was much easier, but the dysphagia was 
only little, if at all, diminished. Again the patient disappeared 
and was not seen for a week, when he returned in a very much 
worse condition than when he first applied for relief. His 
breathing was excessively labored and he was in a state of ex- 
treme exhaustion. He was at once ordered to the hospital, 
where it was my intention to perform tracheotomy, if neces- 
sary. Instead of following my instructions, he went to his 
home. The following morning he rose from his bed to light his NECROSIS OF THE CRICOID. 
3 
fire, fell on the floor, and died, before a friend, who occupied 
the room with him, could reach him. According to the best 
information obtainable, death seems to have occurred quietly, 
without struggle or sign of suffocation, apparently from as- 
thenia. 
The autopsy was made, with the assistance of Dr. Ilenriques, 
fourteen hours after death. The larynx, pharynx, and oesopha- 
gus were first removed intact. On section of the trachea, a 
small quantity of bloody pus was found on the mucous surface 
as far down as the bifurcation. The lungs showed numerous 
emphysematous areas and old pleuritic adhesions, but otherwise 
were normal. No trace of tubercular deposit was found and no 
syphilitic lesion could be discovered. The heart appeared to be 
normal; the pericardial sac contained about two drachms of 
perfectly clear serum. The specimen itself, which has been 
most carefully examined by Dr. Ferguson, of New York, con- 
sists of tho pharynx, larynx, and upper portions of the oesopha- 
gus and trachea. On the anterior wall of the laryngo-pharynx 
is an ulcer exposing the entire thickness of the partially ossified 
cricoid cartilage. It does not communicate with the larynx or 
trachea. Its edges are undermined to the extent of half an inch 
along the posterior surface of the cartilage. An ulcer involving 
the mucosa and the muscular tissue occupies the posterior wall 
of the pharynx at the level of the cricoid. The edges of both 
ulcers are elevated and very much thickened. There are super- 
ficial erosions of the vocal cords. There are numerous miliary 
masses on the mucous surface of the trachea composed of round 
and oval cells, granular detritus, bacteria, and micrococci. Nu- 
merous sections through the tissues surrounding the pharyngeal 
ulcers fail to discover tubercle bacilli or evidence of tumor de- 
velopment. Collections of small round cells are found, limiting 
small areas of degeneration, which give the appearance of tuber- 
cles. There are no giant cells. The fibrous tissue between the 
muscular bundles in the wall of the pharynx near the ulcers is 
increased and contains many groups of small round and spindle- 
form cells. Sections through the mucous membrane of the 
trachea show similar cells, and the stroma of the mucous glands 
is infiltrated with similar small round elements. 4 
PERICHONDRITIS OF THE LARYNX; 
So much has been written on the subject of laryngeal 
perichondritis that it is not worth while to detain yon with 
an extended review. The exhaustive article by von Ziems- 
sen in his “ Cyclopaedia ” (vol. ii, 814), where numerous 
valuable references may be found, and contributions by 
Tiirck, Mackenzie, Schroetter, Retslag, and others thor- 
oughly cover the ground. Perhaps the most important 
questions relate to diagnosis, and, secondarily, to prognosis. 
In many cases the laryngeal condition may escape the notice 
it deserves, since the constitutional disease provoking it or 
associated with it demands the larger share of attention. 
The prognosis must be considered grave, if not necessarily 
fatal, especially when the cricoid cartilage is involved. A 
case has been reported by Ruehle in which this cartilage 
became necrotic and was discharged entire. Cohen nar- 
rates an interesting case of chondritis of the cricoid in which 
he did tracheotomy, and opened several intra-laryngeal ab- 
scesses. There was apparent reproduction of the cartilage, 
“ the original one remaining necrosed in the cricoidal portion 
of the interior of the larynx as a foreign body ” (“ Diseases 
of the Throat and Nasal Passages,” p. 526 ; also, “ Trans, 
of the Path. Soc. of Phila.,” 1874, p. 148). The degree 
of deformity and consequent impairment of function de- 
pend upon what and how many cartilages may be involved. 
The difficulty of determining this point is often insurmount- 
able. A thorough examination may be impracticable, ow- 
ing to intolerance of the parts, or to the general condition 
of the patient; or, in case a laryngeal exploration is possible, 
the region may be so obscured and distorted by inflamma- 
tory thickening, ulceration, or oedema, that the usual land- 
marks can not be identified. 
The question of aetiology is of scarcely less interest and 
importance. Necrosis of laryngeal cartilages following ty- 
phoid fever has been especially observed by Trousseau, NECROSIS OF THE CRICORD. 
5 
Rokitansky, and Sestier. Liebermeister maintains that in 
these cases the affection of the cartilage is not primary, but 
is due to extension of ulceration from the mucous membrane. 
On the other hand, Sestier asserts that it may occur without 
ulceration, and the latter view is corroborated by Green- 
field. Tuberculosis, carcinoma, and syphilis have also been 
mentioned as prominent causes of laryngeal perichondritis. 
To these must be added variola and traumatism. Under 
the latter head should be included not only external vio- 
lence, but also the injudicious use of oesophageal bougies, 
especially in the aged. In this connection I may refer 
briefly to a case not yet reported which occurred in the 
service of Dr. Asch, at the Manhattan Eye and Ear Hos- 
pital : 
A woman, about forty years old, swallowed a plate of false 
teeth during an epileptic fit. The plate was dislodged from the 
pharynx with great difficulty. A few weeks later the woman 
came to the hospital with an abscess on the posterior wall of 
the larynx, which Dr. Asch opened. Subsequently the house 
surgeon did tracheotomy during an attack of acute cedema or 
spasm of the larynx. The patient recovered, with great deform- 
ity of the larynx and complete loss of voice. 
Unfortunately, we have not had the opportunity to ex- 
amine her recently, so that I am unable to describe her 
present condition. There is no doubt in my own mind that 
this was a case of traumatic perichondritis. Forcible and 
prolonged use of the voice, as in certain occupations, has 
been suggested as a cause by Flormann. Primary laryngeal 
chondritis, resulting from early ossification of the cartilage, 
may involve the perichondrium (Albers), and, finally, press- 
ure of an ossified cricoid cartilage against the vertebral 
column may develop a traumatic perichondritis (Dittrich). 
In some cases it may be very difficult to discover the origin 
of the lesion, as in one reported by Hall (“ Trans, of the Clin. 
Soc. of London,” 1882, xv, 195; 1884, xvii, 151). His patient 6 
PERICHONDRITIS OF THE LARYNX. 
died after the lapse of two years or more, and at the autopsy 
various lesions characteristic of syphilis were found. The 
conclusion was therefore adopted that syphilis had caused 
the necrotic changes in the larynx, which in the first in- 
stance had been attributed to a laryngitis accompanying an 
extensive bronchitis, no history and no signs of constitu- 
tional disease having been at that time discovered. In 
searching for the cause of the condition in the case which 
I have reported, it was learned that about one year ago the 
patient was violently seized by the throat in the course of 
an altercation and was nearly strangled. The immediate 
consequences of this incident were laryngeal pain and par- 
tial loss of voice, lasting nearly a week. No other trouble 
followed, except slight cough, which was supposed to be 
bronchial, until three months before the case came under my 
observation, when dyspnoea supervened, attended by marked 
change in the quality of the voice, and great pain and diffi- 
culty in swallowing. The patient had never had a serious 
illness since childhood, and positively denied syphilitic in- 
fection. He had never used liquor to excess; but it was 
found that his circumstances in life were such as to deprive 
him of proper nourishment, often for a very long period. 
It is quite evident that impairment of vitality due to this 
fact, combined with his extreme age and the condition of 
ossification of the cartilage, must have predisposed the pa- 
tient to the development of the affection. It would seem, 
therefore, that traumatism may be regarded as the imme- 
diate cause of the laryngeal lesion. The unusual site and 
extent of the ulceration, and the absence of pulmonary tu- 
berculosis and of tubercle bacilli in the sections examined 
microscopically, exclude the idea of tubercular laryngitis. 
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