Laryn geal and voice disorders

1. Laryngeal and voice disorders Yard.Doç.Dr.Müzeyyen Doğan

2. LARYNX • 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

4. 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).

5. Diseases of the Larynx • Inflammatory • Infectious • Granulomatous • Mucosal • Congenital • Neoplastic

6. 3 years old boy • Presented with: • Stridor: 1 day • Cough, barking • Fever • Drooling??

7. Inflammatory • Acute laryngotracheitis (croup) • 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

8. Acute epiglottitis • 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

9. Acute epiglottitis

10. Acute epiglottitis • 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

11. Croup Vs Epiglottitis Characteristics of Laryngotracheitis and Epiglottitis Feature Laryngotracheitis Epiglottitis Age <3 years >3 years Onset Gradual (days) Acute (hours) Cough Barky Normal Posture Supine Sitting Drooling No Yes Radiograph Steeple sign, narrowed subglottis Thumb sign, enlarged epiglottis,dilated hypopharynx Cause Viral Bacterial Treatment Supportive (croup tent) Airway management (intubation or tracheotomy), antibiotics

12. 40 years old lady • Globus pharyngeus • Dryness of throat • Frequent throat clearing • Nocturnal aspiration • Heart burn

13. Gastroesophageal reflux disease - GERD • Most common cause of laryngitis. • Acute & chronic • GERD  stenosis, recurrent spasm, C-A fixation, dysphagia, globus pharyngeus, & laryngeal CA. • Sx: • GI: regurgitation, heart burn. • Larynx: hoarseness, globus pharyngeus, ch. Throat clearing, cough, dysphagia.

14. Gastroesophageal reflux disease - GERD • Examination: • Grade I : Normal or Mild Edema & Erythema • Grade II : Erythema / Edema of posterior glottis. • Grade III : Pachydermia of posterior glottis. • Grade IV : Contact ulcer granuloma

15. GERD

16. GERD • Dx: • Hx • Examination • 24-hour double probe PH monitoring. • Ba-swallow. • Gastroscope

17. GERD • Treatment: • Dietary and Lifestyle modifications. • Antacids. • Systemic H2-blockers. • Prokinetic agents. • Mucosal cytoprotectants. • Proton pump inhibitors; Omebrazole

18. Other inflammatory disease Granulomatous Conditions That May Affect the Larynx Disease Laryngeal Involvement Tuberculosis Posterior one-third of larynx involved Syphilis Painless ulcers; positive syphilis serology Leprosy Supraglottic involvement Histoplasmosis Anterior larynx involved Blastomycosis Painless ulcers; microabscesses Actinomycosis Draining sinuses; sulfur granules Rhinoscleroma Catarrhal stage, Mikulicz’s cells Sarcoidosis Supraglottic swelling, nodules, granulomas Wegener’s Subglottic involvement; necrotizing vasculitis; pulmonary or granulomatosis renal involvement

19. 33 years old lady • Teacher • Hoarseness of voice • Cough mild • Disappearance of voice sometimes • No h/o URTI

20. Mucosal disorders

21. Benign mucosal disorder • Vocal nodule • 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: • Medical: hydration, lubrication, GERD. • Voice therapy • Surgery: >3months, fibrosis, symptomatic.

22. Vocal nodule

23. Vocal fold polyp

24. Vocal fold cyst

25. Reinke’s edema

26. 2 weeks old girl • Inspiratory stridor • No cyanosis • Normal cry • No chest infection • Aspiration with feeding

27. Congenital

28. Congenital disorders of the Larynx

29. Laryngomalacia • 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.

30. Laryngomalacia • Dx: endoscopic exam.  • Tall, tubular,  epiglotttis • Large cuniform cartilage. • Short A-E folds • Inward collapse • Tx • Conservative:posturing, +/- steroids • Surgical: trach, intubation, supraglottoplasty

32. Vocal cord paralysis (cong.) • 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: • Surgical: trach, transverse cordotomy, arytenoidectomy.

33. Subglottic stenosis • Membranous and cartilaginous types. • Membranous: fibrous soft-tissue thickening of the subglottic area • Cartilaginous: thickening or deformity of the cricoid cartilage  shelf-like plate

35. Laryngeal web

36. Subglottic stenosis • Tx: • Endoscopic: membranous stenosis • Surgery: cartilaginous stenosis • Ant cricoid split • Ant. & post cricoid division +/- augmentation

37. Laryngeal Hemangioma • 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.

39. 55 years old gentleman • Hoarseness of voce • Right otalgia • Mild dyspyagia • Smoker • Alcohol drinker

40. Neoplasms

41. Laryngeal Papillomatosis • The most common benign neoplasms of the larynx (84% of benign tumors). • 2nd mucosal infection by a papovavirus. • Juvenile form: • diffuse & extremely aggressive  hoarseness and stridor. • Resistant to treatment  frequent laryngoscopies. • Adult-onset form • solitary or more localized, less aggressive • TX:CO2 laser, cryotherapy, XRT, interferon

42. Laryngeal Papilloma

45. Neoplasms of the Larynx

46. Sqaumous cell Carcinoma • Most common laryngeal Ca (>90%). • Male:female = 6:1. • Etiology: • Tobacco:  (related to number of cig.) • Alcohol:  (x 2.2) • XRT, asbestose, wood dust, mustard gas. • GERD • HPV

47. Sqaumous cell Carcinoma • Glottic SCCA most common (60%) > supraglottic SCCA (30%) > subglottic SCCA (<10%). • Sx: hoarseness, throat pain, cough, hemoptysis, referred otalgia, dysphagia. • Dx: • Flexible laryngoscope, D.L. & biops. • CT +/- MRI