ief traumatic factors in chronic laryngeal stenosis
are: (a) prolonged presence of a foreign body in the larynx (b)
unskilled attempts at intubation and the wearing of poorly fitting
intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting
cannula; (e) war injuries; (f) attempted suicide; (g) attempted
homicide; (h) neglect of cleanliness and care of either intubation
tubes or tracheotomic cannulae allowing incrustation and roughening
which traumatize the tissues at each movement of the ever-moving
larynx and trachea.

_Treatment of Cicatricial Stenosis_.--A careful direct endoscopic
examination is essential before deciding on the method of treatment
for each particular case. Granulations should be removed. Intubated
cases are usually best treated by tracheotomy and extubation before
further endoscopic treatment is undertaken. A certain diagnosis as to
the cause of the condition must be made by laboratory and therapeutic
tests, supplemented by biopsy if necessary. Vigorous antiluetic
treatment, especially with protiodide of mercury, must precede
operation in all luetic cases. Necrotic cartilage is best treated by
laryngostomy. Intubational dilatation will succeed in some cases.

[FIG. 109.--Schema showing the author's method of laryngostomy. The
hollow upward metallic branch (N) of the cannula (C) holds the rubber
tube (R) back firmly against the spur usually found on the back wall
of the trachea. Moreover, the air passing up through the rubber tube
(R) permits the patient to talk in a loud whisper, the external
orifice of the cannula being occluded most of the time with the cork
(K). The rubber tubing, when large sizes are reached may extend down
to the lower end of the cannula, the part C coming out through a large
hole cut in the tubing at the proper distance from the lower end.]

_Laryngoscopic bouginage_ once weekly with the laryngeal bougies (Fig.
42) will cure most cases of laryngeal stenosis. For the trachea,
round, silk-woven, or metallic bougies (Fig. 40) are better.

[307] _Laryngostomy_ consists in a midline division of the laryngeal
and tracheal cartilages as low as the tracheotomic fistula, excision
of thick cicatricial tissue, very cautious incision of the scar tissue
on the posterior wall, if necessary, and the placing of the author's
laryngostomy tube for dilatation (Fig. 109). Over the upward branch of
the laryngostomy tube is slipped a piece of rubber tubing which is in
turn anchored to the