1. Diseases of the Larynx

DISEASES OF DISEASES OF THE LARYNXTHE LARYNX

Prepared byPrepared by Dr. Muaid I. AzizDr. Muaid I. Aziz

Otolaryngologist–head & neck Otolaryngologist–head & neck surgeonsurgeon

M.B.Ch.B F.I.C.M.SM.B.Ch.B F.I.C.M.S

Inflammatory .Inflammatory . Benign laryngeal lesions.Benign laryngeal lesions. Malignant laryngeal lesions.Malignant laryngeal lesions. Vocal cord paralysisVocal cord paralysis Stridor Stridor TracheostomyTracheostomy Laryngeal traumaLaryngeal trauma

Inflammatory diseases of the larynxInflammatory diseases of the larynx

Acute laryngitis Its an acute inflammation of the Its an acute inflammation of the

larynx of V. or B. origin.larynx of V. or B. origin. Sx 2ndry to airway size.Sx 2ndry to airway size. Acute simple lary.Acute simple lary. = laryngo-tracheo-bronchitis = laryngo-tracheo-bronchitis

(ALTB)(ALTB) = epiglotitis = epiglotitis

Acute simple lary. Commonly occurs as a sequel to URTI of Commonly occurs as a sequel to URTI of

rhino virus origin .rhino virus origin .• Sx; Sx; fever , malaisefever , malaise voice changevoice change Pain , aggravates on swallowing or speechPain , aggravates on swallowing or speech CoughCough• SN;SN; Hyperaemic & edematous vcHyperaemic & edematous vc• R/R/ Voice rest , AB , analgesics, hydration , Voice rest , AB , analgesics, hydration ,

steam inhalation , steroids, cough steam inhalation , steroids, cough suppressants & expectorants .suppressants & expectorants .

Acute laryngo-tracheo-bronchitis(ALTB)

(croup) More sever condition affecting L.T.B, usually of viral More sever condition affecting L.T.B, usually of viral originorigin

Parainfluenza 1,2 & influenza AParainfluenza 1,2 & influenza A < 5 y< 5 y Boys > girlsBoys > girls More in winter but overall the yearMore in winter but overall the year feverfever Barky coughBarky cough StridorStridor may occur after 24-48 hrs may occur after 24-48 hrs Respiratory distress sn + bilateral coarse crepitationsRespiratory distress sn + bilateral coarse crepitations X-ray – neck AP X-ray – neck AP steeple snsteeple sn R;R; admission , Humidified O2 , hydration , AB , steroids admission , Humidified O2 , hydration , AB , steroids

, intubation or tracheostomy (agitation , cynosis , , intubation or tracheostomy (agitation , cynosis , lethargy, PR 140 , RR 80.)lethargy, PR 140 , RR 80.)

Plain radiographAP view

Croup

Narrowing of subglottis(Steeple sign)

Acute epiglotitisAcute epiglotitis Acute inflammation of the Epig.Acute inflammation of the Epig.

Common in childrenCommon in children H. Influenza B (others like s.p ,staph aureus)H. Influenza B (others like s.p ,staph aureus) SX;SX; Fever , Sore throat , odynophagia Fever , Sore throat , odynophagia Voice changeVoice change Breathing problem later on Breathing problem later on SN;SN; drooling child drooling child TripodTripod sign sign All exam . Should be done with extreme gentlenessAll exam . Should be done with extreme gentleness SUNRISESUNRISE Sign Sign (tongue depressor) (tongue depressor) IDL avoidedIDL avoided FLSFLS X-ray ; X-ray ; thumb printthumb print sign sign R;R; same of the croup. same of the croup.

Plain radiograph

of upper airway

)Lateral film(

Normal anatomy

T: tonsillE: epiglottisAE: ary ep.foldsA: arytenoidVC: vocal cordsV: ventricle

Plain radiograph

of upper airway

Lateral film

Acute epiglottitis

)open arrow( Epiglottis)short arrow( Aryep. Folds)long arrow( Ventricle)h( Hyoid bone

Acute epiglottitis(Thumb print sign)

Chronic laryngitisChronic laryngitis Chronic specific laryngChronic specific laryng.. = non = == non = = Its chronic inflam. of the larynx predominantly Its chronic inflam. of the larynx predominantly

involving v.c , may follow repeated attacks of involving v.c , may follow repeated attacks of acute laryngitis.acute laryngitis.

Causes :Causes : smoking smoking alcoholalcohol dust & chemicals exposuredust & chemicals exposure URT allergyURT allergy reflux oesophagitis reflux oesophagitis vocal abusevocal abuse chronic URT inf. (sinusitis)chronic URT inf. (sinusitis)

marked bymarked by long standing hoarsenesslong standing hoarseness dry irritative coughdry irritative cough sensation of sensation of cleaning of the throatcleaning of the throat ExaminationExamination Congested, hyperemic vcCongested, hyperemic vc (ch.simple (ch.simple

hyperemic laryng.”CSHL”).hyperemic laryng.”CSHL”). Thickening of the lary. EpithThickening of the lary. Epith.. (ch. (ch.

Hyperplastic laryng.”CHL”)Hyperplastic laryng.”CHL”)• R;R; 1ry cause1ry cause Voice restVoice rest Speech therapySpeech therapy Microlaryngeal surgery –stripping of the Microlaryngeal surgery –stripping of the

cordscords Ruling out GERD - PPIRuling out GERD - PPI

Inflammatory DiseasesInflammatory Diseases Candidiasis (as Candidiasis (as

leukoplakia of vocal leukoplakia of vocal cords)in cords)in immunocompromized ptimmunocompromized pt

Tuberculosis(+/_ pul.TB) , Tuberculosis(+/_ pul.TB) , as granular pathology as granular pathology ( biopsy , culture , cxr )( biopsy , culture , cxr )

SarcoidosisSarcoidosis SyphilisSyphilis

Epig. Is commonest site

S’ diff. from TB & fungal inf.

Benign laryngeal lesions.Benign laryngeal lesions.

Nodules Nodules PolypPolyp Polypoid corditis (Reinkes Polypoid corditis (Reinkes

edema)edema) CystCyst GranulomaGranuloma PapillomatosisPapillomatosis

V.C Nodules (Singers , V.C Nodules (Singers , teachers , screamers teachers , screamers

nodules) nodules) Small , greyish white, benign, firm Small , greyish white, benign, firm

swellings, occuring along the free margin swellings, occuring along the free margin of the TVC as a result of vocal trauma.of the TVC as a result of vocal trauma.

Ant.1/3 junction w post. 2/3Ant.1/3 junction w post. 2/3 UsuallyUsually bilateral.bilateral. Women more affectedWomen more affected HoarsenessHoarseness R; complete voice restR; complete voice rest MLSMLS speech therapyspeech therapy

PolypPolyp It’s a polypoidal mass forms along the memb. It’s a polypoidal mass forms along the memb.

part of the vcpart of the vc Size , Shape & tissue composition are variable Size , Shape & tissue composition are variable - - SessileSessile or or pedunculatedpedunculated - - Vascular , Fibrotic , or mixoidVascular , Fibrotic , or mixoid Commonest site is the ant. commissure or 3 Commonest site is the ant. commissure or 3

mm post. to ant. Comm. on subglottic surface mm post. to ant. Comm. on subglottic surface of the vc.of the vc.

Overlying epith. Is usually normalOverlying epith. Is usually normal Size:small:0-3 mmSize:small:0-3 mm medium:3-6 mmmedium:3-6 mm large:large:< < 6 mm 6 mm R;R; MLS MLS voice restvoice rest speech therapyspeech therapy

expiration inspiration

Polypoid corditis (Reinkes Polypoid corditis (Reinkes edema) edema) Difficult to diff. it from a polyp Difficult to diff. it from a polyp

histolog. & morphologically.histolog. & morphologically. Diffuse nature, sausage – shaped Diffuse nature, sausage – shaped

swelling v.c .swelling v.c . On manipulation during On manipulation during

microlaryngoscopy, feel Boggy & the microlaryngoscopy, feel Boggy & the swelling can be rolled beneath the swelling can be rolled beneath the instruments .instruments .

granulomagranuloma Majority arise in arytenoid regionMajority arise in arytenoid region Ususally exophytic with narrow Ususally exophytic with narrow

basebase Seen in pt. with GER & with Seen in pt. with GER & with

endotracheal intubatonendotracheal intubaton R/:voice therapy & antireflux R/:voice therapy & antireflux

therapytherapy Surg.resection :Surg.resection :

1.1. Conserv.management has failed Conserv.management has failed

2.2. Concern of malg.dis.Concern of malg.dis.

3.3. airway compromise airway compromise

papillomatosispapillomatosis Result from epithelial proliferation usually Result from epithelial proliferation usually

induced by human papilloma virus (HPV) induced by human papilloma virus (HPV) 6,11,166,11,16

of papova classof papova class

May involve entire aerodigestive tract, most May involve entire aerodigestive tract, most commonly effects the larynxcommonly effects the larynx

2 general forms: juvenile onset and adult onset2 general forms: juvenile onset and adult onset

Recurrent Respiratory Recurrent Respiratory PapillomasPapillomas

(RRP)(RRP)

Most common benign neoplasm of Most common benign neoplasm of the larynx in children and adultsthe larynx in children and adults

22nd nd most common cause of most common cause of hoarseness in childrenhoarseness in children

In children diagnosis occurs In children diagnosis occurs between 2-3 years of age, 75% are between 2-3 years of age, 75% are diagnosed before 5diagnosed before 5

Recurrent Respiratory Recurrent Respiratory PapillomasPapillomas

(RRP)(RRP)

JuvenileJuvenile

vaginal deliveryvaginal delivery

low socioeconomic low socioeconomic statusstatus

Adult onsetAdult onset

– more lifetime more lifetime sexual partnerssexual partners

– higher frequency of higher frequency of oral sexoral sex

Factors contributing to Factors contributing to RRPRRP

Child immune status Child immune status

Time in birth canalTime in birth canal

Viral load in birth canalViral load in birth canal

Local traumaLocal trauma

Signs and SymptomsSigns and Symptoms

Begins as an inspiratory stridor or Begins as an inspiratory stridor or mild hoarseness, progressing to mild hoarseness, progressing to worsening airway obstructionworsening airway obstruction

Cough, pneumonias, and dysphagiaCough, pneumonias, and dysphagia

Often misdiagnosed as asthma, Often misdiagnosed as asthma, croup, allergies, vocal nodules, or croup, allergies, vocal nodules, or bronchitisbronchitis

Surgical TherapySurgical Therapy

excision with phonomicrosurgical excision with phonomicrosurgical instruments instruments

Laser: COLaser: CO22

Laryngeal microdebrider shaverLaryngeal microdebrider shaver TracheostomyTracheostomy

Adjuvant Medical Adjuvant Medical TherapyTherapy

Interferon alphaInterferon alpha

Photodynamic Photodynamic TherapyTherapy

AcyclovirAcyclovir CidofovirCidofovir MethotrexateMethotrexate

Interferon AlphaInterferon Alpha

5 megaunits/m5 megaunits/m22/IM QD x 28 days, then /IM QD x 28 days, then 3x per week for 5 months, followed 3x per week for 5 months, followed by observation for 6 months.by observation for 6 months.