Transcript 2012 Laryngeal and voice disorders

Laryngeal and voice disorders
Yard.Doç.Dr.Müzeyyen Doğan
LARYNX
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Adult: between 3th and
6th cervical vertebra
İnfant: between 1st and
4th cervical vertebra
Attaches to the hyoid
bone and opens into the
laryngopharynx superiorly
Continuous with the
trachea posteriorly
Clinical subdivision of the larynx
supraglottic space
(also called the vestibule
which is surrounded by
the piriform fossa)
 glottic space
(which contains the vocal
folds)
 subglottic space (which
is the area below the true
vocal folds).
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Diseases of the Larynx
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Inflammatory
Infectious
Granulomatous
Mucosal
Congenital
Neoplastic
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3 years old boy
Presented with:
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Stridor: 1 day
Cough, barking
Fever
Drooling??
Inflammatory
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Acute laryngotracheitis (croup)
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viral infection, affects children < 5 years.
lasts 3-7 days, seasonal,  in autumn & winter.
  parainfluenza 1, parainfluenza 3, influenza A,
rhinovirus.
febrile URTI, followed by classic barky or croupy
cough (nonproductive and  at night.
self-limited, rarely  edema & upper A/W
obstruction.
Dx: history + neck X-ray  classic “steeple sign”.
Tx: humidification & hydration. If symptoms worsen
 racemic epinephrine & corticosteroids
Acute epiglottitis
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Haemophilus influenzae type B
Children between 2 - 4 years, winter and
spring.
Rapid presentation over 2-6 hrs: fever, sore
throat, muffled voice, inspiratory stridor. Sitting
upright, ill-appearing, &drooling,
Examination of the epiglottis may precipitate
laryngospasm  not recommended.
Lateral X-ray  classic “thumb” sign.
Tx: operating room immediately to establish the
diagnosis and secure an airway
Acute epiglottitis
Acute epiglottitis
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1.
2.
3.
Treatment:
Secure a safe airway (O-T
tube, bronchoscope, trach)
Antimicrobial (C/S) ampic &
chloramphenicol or 2nd &
3rd generation
cephalosporin.
Supportive care. Extubation
usually possible after 48 to
72 hours
Croup Vs Epiglottitis
Characteristics of Laryngotracheitis and Epiglottitis
Feature
Age
Onset
Cough
Posture
Drooling
Radiograph
Laryngotracheitis
<3 years
Gradual (days)
Barky
Supine
No
Steeple sign, narrowed subglottis
Cause
Treatment
Viral
Supportive (croup tent)
Epiglottitis
>3 years
Acute (hours)
Normal
Sitting
Yes
Thumb sign, enlarged
epiglottis,dilated hypopharynx
Bacterial
Airway management (intubation or
tracheotomy), antibiotics
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40 years old lady
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Globus pharyngeus
Dryness of throat
Frequent throat clearing
Nocturnal aspiration
Heart burn
Gastroesophageal reflux disease
- GERD
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Most common cause of laryngitis.
Acute & chronic
GERD  stenosis, recurrent spasm, C-A fixation,
dysphagia, globus pharyngeus, & laryngeal CA.
Sx:
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GI: regurgitation, heart burn.
Larynx: hoarseness, globus pharyngeus, ch. Throat
clearing, cough, dysphagia.
Gastroesophageal reflux disease
- GERD
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Examination:
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Grade I : Normal or Mild
Edema & Erythema
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Grade II : Erythema /
Edema of posterior glottis.
Grade III : Pachydermia of
posterior glottis.
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Grade IV : Contact ulcer
granuloma
GERD
GERD
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Dx:
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Hx
Examination
24-hour double probe
PH monitoring.
Ba-swallow.
Gastroscope
GERD
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Treatment:
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Dietary and Lifestyle modifications.
Antacids.
Systemic H2-blockers.
Prokinetic agents.
Mucosal cytoprotectants.
Proton pump inhibitors; Omebrazole
Other inflammatory disease
Granulomatous Conditions That May Affect the Larynx
Disease
Tuberculosis
Syphilis
Leprosy
Histoplasmosis
Blastomycosis
Actinomycosis
Rhinoscleroma
Sarcoidosis
Wegener’s
granulomatosis
Laryngeal Involvement
Posterior one-third of larynx involved
Painless ulcers; positive syphilis serology
Supraglottic involvement
Anterior larynx involved
Painless ulcers; microabscesses
Draining sinuses; sulfur granules
Catarrhal stage, Mikulicz’s cells
Supraglottic swelling, nodules, granulomas
Subglottic involvement; necrotizing vasculitis; pulmonary or
renal involvement
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33 years old lady
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Teacher
Hoarseness of voice
Cough mild
Disappearance of voice sometimes
No h/o URTI
Mucosal disorders
Benign mucosal disorder
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Vocal nodule
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Fluid accumulation in the submucosa from acute
abuse or overuse  mucosal swelling (sometimes
called "early nodules"): reversible.
Long-term voice abuse  hyalinization of Reinke's
potential space, irreversible.
Tx:
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Medical: hydration, lubrication, GERD.
Voice therapy
Surgery: >3months, fibrosis, symptomatic.
Vocal nodule
Vocal fold polyp
Vocal fold cyst
Reinke’s edema
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2 weeks old girl
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Inspiratory stridor
No cyanosis
Normal cry
No chest infection
Aspiration with feeding
Congenital
Congenital disorders of the Larynx
Supraglottic
Glottic
Subglottic
Laryngomalacia
Vocal cord paralysis
Cong. Subglottic
stenosis
Ductal retention cyst
Web and atresia
Subglottic hemangioma
Cystic hygroma
Interarytenoid web
Web & atresia
Bifid epiglottis
Posterior laryngeal cleft
Cysts
Saccular cyst
Cri-du-chat syndrome
Anterior laryngeal cleft
Laryngomalacia
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Abnormal flaccidity of the laryngeal tissues
 inward collapse.
Resolve spontaneously (6-18 months).
Sx: inspiratory stridor, intermittent upper
a/w obstruction, normal cry, normal
general health and development
Usually begins in the first few days or
weeks.
Laryngomalacia
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Dx: endoscopic exam. 
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Tall, tubular,  epiglotttis
Large cuniform cartilage.
Short A-E folds
Inward collapse
Tx
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Conservative:posturing, +/steroids
Surgical: trach, intubation,
supraglottoplasty
Vocal cord paralysis (cong.)
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2nd common cause of congenital upper a/w obstruction.
(10%)
Unilateral VC paralysis > bilateral
Causes: idiopathic, surgical trauma, neurological
abnormalities (e.g. meningomyelocele, bulbar palsy,
Arnold-Chiary malformation.
Sx: weak cry, aspiration, stridor.
Tx:
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Surgical: trach, transverse cordotomy, arytenoidectomy.
Subglottic stenosis
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Membranous and cartilaginous types.
Membranous: fibrous soft-tissue thickening of
the subglottic area
Cartilaginous: thickening or deformity of the
cricoid cartilage  shelf-like plate
Laryngeal web
Subglottic stenosis
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Tx:
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Endoscopic:
membranous stenosis
Surgery: cartilaginous
stenosis
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Ant cricoid split
Ant. & post cricoid
division +/augmentation
Laryngeal Hemangioma
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Infants  50% associated
cutaneous hemangiomas.
Sx: stridor or "pseudocroup,"
within the first 6 months of
life.
Dx: direct laryngoscopy
Tx: low-dose XRT,
tracheotomy + observation,
cryotherapy, sclerotherapy,
CO2 laser, steroid therapy
(systemic or intralesional) &
interferone -2a.
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55 years old gentleman
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Hoarseness of voce
Right otalgia
Mild dyspyagia
Smoker
Alcohol drinker
Neoplasms
Laryngeal Papillomatosis
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The most common benign neoplasms of the
larynx (84% of benign tumors).
2nd mucosal infection by a papovavirus.
Juvenile form:
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Adult-onset form
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diffuse & extremely aggressive  hoarseness and
stridor.
Resistant to treatment  frequent laryngoscopies.
solitary or more localized, less aggressive
TX: CO2 laser, cryotherapy, XRT, interferon
Laryngeal Papilloma
Neoplasms of the Larynx
Benign
Malignant
Papilloma
Squamous Cell Ca
Minor S.G. tumors
Neuroendocrine (e.g. carcinoid,
melanoma)
Granular cell tumor
Chodrosarcoma
Chondroma
Rhabdomyosarcoma
Hemangioma
Lymphoma
Paraganglioma
Sqaumous cell Carcinoma
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Most common laryngeal Ca (>90%).
Male:female = 6:1.
Etiology:
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Tobacco:  (related to number of cig.)
Alcohol:  (x 2.2)
XRT, asbestose, wood dust, mustard gas.
GERD
HPV
Sqaumous cell Carcinoma
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Glottic SCCA most
common (60%) >
supraglottic SCCA (30%)
> subglottic SCCA
(<10%).
Sx: hoarseness, throat
pain, cough, hemoptysis,
referred otalgia,
dysphagia.
Dx:
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Flexible laryngoscope, D.L.
& biops.
CT +/- MRI