Diseases of Pharynx and Larynx

1. Diseases of Pharynx and Larynx

2. Anatomy of Pharynx • Fibromuscular Tube • Base of Skull to C6 (12cm) • Divided into three parts • Nasopharynx • Oropharynx • Laryngopharynx • 4 Layers • Mucosal, submucosal (Fibrous), Muscular, Fascial layer (buccal pharyngeal)

3. Nasopharynx • Base of skull to the soft palate • Key components • Pharyngeal Tonsil (Adenoids) • Pharyngeal Recess (ICA) • Opening of Auditory tube

4. Oropharynx • Soft Palate to the epiglottis • Key Components • Palatopharyngeal and Palatoglossal arches • Palantine Tonsil – project from tonsillar fossa • Lingual Tonsil • Valleculae – lie between epiglottis and posterior border of the tongue

5. Laryngopharynx • Epiglottis to the level of cricoid cartilage • Key features • Opening to the larynx • Piriform recess (endoscope)

6. Anatomy of Pharynx • Blood supply • Branches of many arteries (ascending pharyngeal, greater palantine, lingual, tonsilar) • Nerve Supply • Afferent; maxillary nerve, glossopharyngeal, internal and recurrent laryngeal nerves • Motor; Pharyngeal Plexus (Vagus, glossopharyngeal, Cervical Sympathetic)

7. Larynx • Respiratory Organ • Lying between pharynx and trachea • Becomes continuous with the trachea at the level of the cricoid cartilage (C6) • Function • Primary – protective sphincter at the inlet of the air passages • Phonation

8. Larynx • Components • Cartilages • Singular; thyroid, cricoid, epigolittic • Paired; Arytenoid, corniculate, cuneiform • Joints • Cricothyroid, cricoarytenoid • Ligaments and Membranes • Intrinsic; Quandrangular membrane, Cricothyroid ligament (Vocal folds) • Extrinsic; Thyrohyoid membrane, cricotracheal, hypoepiglottic, thyroepiglottic ligaments, cricothyroid

9. Cavities • Inlet + Vestibule • Rima of glottis • Subglottic space

10. Layrnx - Intrinsic Membranes • Quadrangular membrane • Arytenoid Cartilage and epiglottis • Lower border; vestibular folds (false cord) • Upper border; aryepiglottic folds • Cricovocal Membrane • Formed from lateral part of cricothyroid ligament • Upper thickened border forms cricovocal ligaement • Vocal folds which bounds the glottis anteriorly

12. Laryngeal Muscles - Intrinsic 1. Those that alter size and shape of the inlet • Aryepiglottic Muscles • Oblique arytenoids • Thyroepiglottic muscles • Act as Sphincter for the inlet • Provide valvular protection from above

13. Laryngeal Muscles - Intrinsic 2. Responsible for Phonation by moving vocal folds • Abduction; Posterior Cricoarytenoids • Adduction; Lateral cricoarytenoid and transverse arytenoid • Lengthen; Cricothryroid • Shorten; Thyroarytenoid, vocalis

14. Phonation • Pitch; Vibration of the folds through shortening and lengthing of the volds • Intensity; Pressure through the glottis • Quality; Resonating chambers above the glottis • Articulation; tongue, teeth and lips

15. Larynx • Blood supply • Superior and Inferior Laryngeal Branches from Superior and Inferior Thyroid Artery • Nerve Supply • Recurrent Laryngeal Nerve • All intrinsic Muscles except cricothyroid • Mucous Membranes below the folds • External Layngeal Nerve • Cricothyroid muscle • Internal Laryngeal Nerve • Mucous Membranes below the folds

16. Nerve Palsies • Recurrent Laryngeal Nerve • Number of causes • Left; • Carcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surg • Left or Right; • Iatrogenic, Trauma, Thyroid disease • Complete (Cadaveric Position) • Half abducted position with arytenoid cartilage slightly in front • Hoarse Voice • Bovine cough • Incomplete • Adducted position as posterior cricoarytenoid more susceptible • External Laryngeal Nerve • Hoarse voice that recovers • Inability to hit high frequencies

19. Extrinsic Muscles • Elevators • Indirectly; • Mylohyoid, digastric, stylohyoid, geniohyoid • Directly; • Stlyopharyngeus, salingopharyngeus, palatopharyngeus • Depressors • Sternohyoid, omohyoid stenothyroid

20. 4 year old boy • Pain in right ear and fevers • Recurrent ear infections • Noisy breather • Overweight • Examination – Sore right ear, hyperaemic tympanic membrane, breathing with mouth open

21. Adenoid Hypertrophy • Occupies large area of nasopharynx age <6 • Atrophies and by age 15 little remains • Recurrent URTI or allergies can lead to hypertrophy • Clinical • Nasal Obstruction; Mouth breathing / Adenoid Facies, chest infections, pharyngeal infections, sinusitis, snoring • Eustachian Tube; Recurrent Otitis Media, CSOM • Choanal Obstruction; OSA, chronic sinusitis

22. Ix • Nasopharyngeal Exam • Nasopharyngoscopic Exam • Lateral Xray • Tx • Supportive • Adenoidectomy

23. Adenoidectomy • Criteria for surgery • Chronic upper airway obstruction with OSA +/- cor pulmonale • Chronic serous/suppurative otitis media • Recurrent acute otitis media • Suspicion of nasopharyngeal malignancy • Chronic sinusitis • Complications • Early Haemorrhage • Otitis media • Regrowth of residual adenoid tissue

25. Tonsillitis • Commonest area of infection of head and neck • Clinical; Sore throat and Odynophagia, Otalgia, headache, malaise, Fever, hyperaemic tonsils, cervical lymphadenopathyDDx; • Viral • Group A Streptococcus (20-30%) • EBV; Palatal petechia • Diptheria; Unimmunised, grey membrane • Tx; Rest, paracetamol +/- ABx

26. Tonsillitis • Complications; • Acute Otitis Media (most common) • Peritonsillar abscess (Quinsy) • GAS • Post Strep GN • Rhuematic Fever • Scarlet Fever; Strawberry tongue and scarlitiform rash • Recurrent Tonsillitis • Tonsillar Hypertrophy

28. Tonsillectomy • Indications for surgery • Absolute • Airway obstruction • Suspicion of malignancy • Relative • Sleep apnoea, mouth breathing, difficulty swallowing • Recurrent tonsillitis >5 episodes • Any complications • Complications • Reactionary haemorrhage • Secondary haemorrhage • 5-10 days post op • Due to fibrinolysis aggravated by infection

30. Pharyngitis • Acute • >70% Viral Cause, GAS • Supportive Treatment • Chronic • Persistent mild soreness and dryness • Predisoposing factors include; smoking, ETOH, mouth breathing, chronic sinusitis, Industrial fumes, antiseptic throat lozengers • Enlarged lymphoid tissue can be removed

31. 64 Male recently Immigrated from Hong Kong • Lump in right side of neck • Progressive enlarged, non-painful • Exam; firm, fixed, solid mass lateral to midline in posterior triangle

32. Nasopharyngeal Carcinoma • Rare in Europe • Common in Asian countries • 20% of all malignancies in Hong Kong • Pathology • Squamous cell/undifferentiated • Aietology • Unknown, however EBV plays a role • Others; ingestion of preserved foods

33. Nasopharyngeal Carcinoma • Clinical; • Most commonly as lump in the neck • Local; Nasal obstruction, blood stained discharge • Neurological; Invasion of skull base causing cranial nerve palsies (V, VI, IX, X, XII) • Otological; Serous otitis media • Metastasis to bone, lung, liver

34. Nasopharyngeal Carcinoma • Ix; • Tissue sampling, CT/MRI, Staging • Management • Radiotherapy with concominant chemotherapy • Poorly amendable to surgery due to anatomical location • DDx • Lymphoma, cystic adenocarcinoma, Infection

35. Pathology of the Larynx • Infectious • Inflammatory • Congenital • Mucosal • Malignancy

36. 5 Year old boy • Hx of • 3/7 Low grade fever and URTI Sx • 1/7 history Biphasic Stridor, barking cough • No obvious respiratory distress

37. Laryngotracheitis (Croup) • Inflammation of tissues of subglottic space +/- tracheobronchial tree • Mucopurulent exudate -> airway obstruction • Aetiology; Parainfluenza I (most common), II,III, influenza A,B, RSV • Presentation; night, inspiratory/biphasic stridor, barking cough • Beware loss of stridor, Decr SaO2 • DDx; FB, subglottic stenosis, Epiglottitis

38. Laryngotracheitis + Epiglottitis

40. 18 month girl • “Asthma Attack” • Wheezy • ?trigger • Family Hx of Asthma, Eczema • No stridor, but tachypnea, intercostal recession • Unilateral wheeze on Right with Decreased air entry in lower zones

42. Foreign Body • Usually stuck at right main bronchus • Anything that’s small enough • Presentation; • Stridor if at level of trachea • “Unilateral asthma” if bronchial • Complications • Atelectasis, lobar pneumonia, pneumothorax, mediastinal shift • Dx; • Inspiratory/Expiratory X-rays • Bronchoscopy

44. Signs of Airway Obstruction • Stretor; obstruction in the throat, low pitched choking noises • Stridor; High pitched, inspiratory, biphasic or expiratory depending on location • Accessory Muscle use • Pallor, diaphoresis, restlessness • Tachycardia • Cyanosis and altered concious state • Intercostal recession • Nasal Flaring • Exhaustion • Bradycardia – most dangerous sign

45. Upper Airway Obstruction - Neonates • Subglottic Stenosis • Congenital or Acquired (trauma, intubation) • Biphasic stridor, resp distress, recurrent croup • Diagnosis; CT, laryngoscopy • Tx; Soft tissue – laser and steroids Cartilage – Laryngotracheoplasty or tracheostomy (intubation) • Laryngomalacia • Soft immature cartilage Children or older patients with NM disorders • Inspiratory stridor at 1-2 weeks, worse supine + feeding difficulties • Dx; Bronchoscopy • Tx; Usually self resolves after 18-24months

46. 44 Female • 6 week history of hoarse voice • Irritation and dryness in throat • History of heartburn • Smoker • No history of weight loss, fatigue • Examination; Unremarkable

48. Chronic Laryngitis • Most common cause is GORD • Recurrent Acute laryngitis • Heavy smoking • Chronic infection of nasal sinuses • Mouth breathing from nasal obstruction • Clinically • Hoarseness or loss of voice • Spasmodic cough • DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis, TB • General; Voice resting, avoid smoking • Specific; eg. Lifestyle modifications, Medications

49. 35 year old • Blunt trauma to neck 5 hours ago • Difficulty swallowing + Voice changes • No history of LOC, resp distress, confusion • Examination showed midline tenderness of neck, subcutaneous emphysema