inflammatory disorders of larynx dr. vishal sharma

Inflammatory Disorders of

LarynxDr. Vishal Sharma

A. Acute infection B. Chronic infection

Acute simple laryngitis Chronic laryngitis

Acute epiglottitis Tuberculosis

Viral LTB Scleroma

Bacterial LTB Candidiasis

Spasmodic croup Sarcoidosis

C. Laryngeal edema

D. Laryngo-pharyngeal reflux disease (LPRD)

Classification

Causes for laryngeal edema

Laryngeal infections

Retropharyngeal abscess / quinsy / Ludwig’s angina

Angio-neurotic edema; Reinke’s edema

Thermal / caustic burn

Trauma: accidental / intubation / endoscopy

Ca of larynx / pharynx; Post-irradiation

Nephritis / heart failure / myxedema / anasarca

Acute (simple) Laryngitis

• Viral infection (common cold)

• Vocal abuse

• Allergy / smoking / environmental pollution

• Gastro esophageal reflux disease

• Thermal / chemical burn due to inhalation

• Use of asthma inhalers

• Laryngeal trauma (endotracheal intubation)

• Undue physical or psychological stress

Etiology

• History of upper respiratory tract infection

• Hoarseness: high pitched husky voice

• Dry, paroxysmal cough, mainly at night

• Sore throat worsened by talking; fever, malaise

• Laryngoscopy: red, swollen supraglottic mucosa;

mild erythema / swelling of true vocal

cords; inspissated secretions b/w vocal

cords

Clinical Features

Flexible laryngoscopy

• Prevention: avoidance of cold fluids, cold air, smoking, alcohol consumption

• Absolute voice rest

• Tincture Benzoin steam inhalation & mucolytics

• Anti-tussives: dextromethorphan, codeine

• Pantoprazole for GERD; analgesics for pain

• Antibiotics: for secondary bacterial infections

• Steroid: for laryngeal edema

Treatment

Acute Epiglottitis

Synonym: Acute Supraglottitis

Supraglottic laryngitis

Definition: Rapidly developing inflammation of

epiglottis & adjacent tissues, due to bacterial

infection, may cause life-threatening airway

obstruction

Causative agents: Haemophilus influenzae type b

(Hib), Streptococcus pyogenes, Streptococcus

pneumoniae, Staphylococcus aureus

• Distress (respiratory)

• Dysphagia

• Drooling (due to inability to swallow)

• Severe sore throat / odynophagia

• Muffled voice

• Sudden onset & rapid progression in children (in

hours); Indolent course in adults (in days)

Symptoms

Examination

• Simply depressing child's tongue with

tongue depressor or indirect laryngoscopy

may visualize enlarged, cherry red epiglottis

in some situations

• These procedures may precipitate complete

airway obstruction, hence avoided

Tripod sign• Pt appears anxious

• Leans forward with

support of both

forearms

• Extends neck in an

attempt to maintain

an open airway

1. Flexible laryngoscopy: carried out only in ICU or

OT with intubation / tracheostomy set ready

2. Post-intubation direct laryngoscopy

3. Plain x-ray soft tissue of neck lateral view

4. Culture from epiglottis during intubation:

+ve in 15% cases of H. influenzae

5. Blood culture: +ve in 15% cases of H. influenzae

Investigations

Flexible laryngoscopy

• Inflamed cherry-red

epiglottis

• Thickened

aryepiglottic folds

• Edematous

arytenoid cartilages

Post-intubation direct laryngoscopy

X-ray soft tissue neck

Lateral view taken in erect position only

• Enlargement of epiglottis (thumb sign)

• Absence of well defined vallecula (Vallecula sign)

• Thickening of aryepiglottic folds (cause for stridor)

• Circumferential narrowing of subglottic portion of

trachea during inspiration (25% cases)

• Ballooning of hypopharynx

X-ray soft tissue neck

X-ray soft tissue neck

• Red arrow = enlarged epiglottis• Yellow arrow = thickened ary-epiglottic folds

Ballooning of hypopharynx

• Hospitalization, careful monitoring & isolation

• Hydration + humidification + oxygen tent therapy

• Secure airway in acute stridor → Mechanical

ventilation till swelling + inflammation subside

• IV Ceftriaxone: 100 mg/kg/d in 2 divided doses

• Hydrocortisone: 100 mg IV stat & 25 mg Q8H

• Rifampicin prophylaxis for household contacts

Treatment

Methods of securing airway

• Endotracheal intubation

– Trans-nasal: preferred

– Trans-oral

• Percutaneous trans-laryngeal ventilation by

needle cricothyrotomy

• Tracheostomy: last resort for acute stridor

Prevention• Hib vaccination for all children

• Rifampicin prophylaxis (20 mg/kg /day; max. 600 mg)

for 4 days should be given to all household contacts if:

a. child in household < 4 years, not received

appropriate doses of Hib vaccine

b. immuno-compromised child, despite vaccination

• Children > 2 years with epiglottitis do not need

vaccination as disease provides immune protection

Laryngo-Tracheo-Bronchitis (LTB)

• Commonest infective cause of stridor in children

• Mean age for presentation = 18 months

• Causative agents:

– Parainfluenza virus type I, II, III

– Influenza virus

– Respiratory syncytial virus

– Rhinovirus

– Measles

Acute viral LTB (Croup)

• Gradual onset preceeded by URTI of > 48 hrs

• Hoarseness

• Biphasic stridor, mainly at night

• Dry cough (like barking of seal)

• Low grade fever (< 102 F)

• Child prefers to lie down, but is restless

• Dysphagia & drooling absent

Clinical Features

• Plain X-ray soft tissue neck, AP view

a. Church steeple or pencil-point sign: squared

appearance of subglottic area replaced by cone

shaped narrowing just below vocal cords

b. Ballooning of hypopharynx

• Flexible laryngoscopy: narrowed subglottic area

Investigations

Church Steeple sign

• Hospitalization

• Humidification & mucolytic drugs

• Hydration with IV fluid

• Hydrocortisone: 100 mg IV stat & 25 mg Q8H

• Oxygen tent: es bronchospasm & pulm. edema

• Antibiotic (IV Ceftriaxone): 100 mg/kg/day

• Racemic adrenaline (1:1000) nebulization

• Intubation / Tracheostomy for acute stridor

Treatment

Synonym: pseudo-membranous croup

More severe than viral LTB

Causative agent: Staphylococcus aureus

Pathology: sloughing of respiratory epithelium

C/F: Hoarseness, biphasic stridor, dry cough, high

grade fever (> 102F), child supine but restless

X-ray neck, AP view: church steeple sign

Rx: moist air + oxygen + antibiotics

Bacterial LTB

Subglottic laryngitis• Synonym: spasmodic croup

• Etiology: unknown (? Influenza virus infection)

causing subglottic mucosal edema

• C/F: Child below 3 years with rapid onset of biphasic

stridor + barking cough + low grade fever

(< 102 F). Dysphagia & drooling are

absent.

• X-ray neck, AP view: church steeple sign

• Rx: Moist air + oxygen + supportive treatment. Rarely

endotracheal intubation. Avoid sedatives.

Acute epiglottitis

Viral croup Bacterial croup

Spasmodic croup

R.P. abscess

Age (yr) 3-7 1-3 1-8 1-3 1-3

Voice Normal or muffled

Hoarse Hoarse Hoarse Hoarse

Cough Absent Barking seal-like

Barking seal-like

Barking seal-like

Absent

Stridor Inspiratory Biphasic Biphasic Biphasic Inspiratory

Dysphagia + drooling

Severe Absent Absent Absent Severe

Fever > 102 F < 102 F > 102 F < 102 F > 102 F

Posture Quiet, sitting

Restless, supine

Restless, supine

Restless, supine

Restless, sitting

Chronic Laryngitis

Definition: Chronic non-specific inflammation

causing irreversible changes of laryngeal mucosa

Etiology of chronic laryngitis:

• Viral infection (common cold)

• Vocal abuse

• Allergy / smoking / environmental pollution

• Gastro esophageal reflux disease

• Thermal / chemical burn due to inhalation

• Laryngeal trauma (endotracheal intubation)

• Undue physical or psychological stress

Hoarseness (worse in morning) + dry cough for > 3 wk

Persistent clearing of throat

H/o previous URTI / GERD may be present

Laryngoscopy: hyperemic laryngeal mucosa

with sub-mucosal edema

Treatment: Voice test + medicated steam inhalation +

systemic antibiotic. Avoidance of alcohol & tobacco.

Reversible within few weeks.

Chronic hyperemic laryngitis

Chronic hyperemic laryngitis

Hoarseness (worse in morning) + dry cough for > 3 wk

Persistent clearing of throat

H/o previous URTI / GERD may be present

Laryngoscopy:

• Mild congestion of laryngeal mucosa

• Patches of epithelial thickening

• Broad based polypoid lesions

Chronic hyperplastic laryngitis

Chronic hyperplastic laryngitis

Chronic hyperplastic laryngitis

Chronic laryngitis histology

Kleinsasser’s classification:

• Grade I: simple squamous cell hyperplasia

or keratosis

• Grade II: squamous cell hyperplasia + atypia (mild

to moderate dysplasia)

• Grade III: carcinoma in situ with intact basal

membrane

Rx of hyperplastic laryngitisAbsolute voice rest for 48 hours

Systemic antibiotic

Tincture Benzoin steam inhalation

Analgesics & anti histamine-decongestant

Micro-laryngoscopic excision of lesion & HPE

• Grades I & II: no further treatment

• Grade III: total excision of lesion / radiotherapy

Prevention of recurrent attacks

• Avoid breathing polluted air

• Avoid tobacco in any form (chewing, smoking)

• Avoid recreational drugs like marijuana

• Avoid alcohol consumption

• Avoid talking or shouting at noisy places

• Avoid continuous throat clearing

• Avoid whispering loudly

Reinke’s edema

Introduction

• Accumulation of fluid in Reinke’s space

• Synonyms: Bilateral diffuse polyposis,

Smoker’s polyps, Polypoid corditis,

Polypoid degeneration of

vocal cords, Localized

hypertrophic laryngitis

• 10% of benign laryngeal lesions

Reinke’s space

Etiology

• Irritants: tobacco smoke, dry air, dust, alcohol

• Laryngeal allergy

• Infection: chronic sinusitis

• Idiopathic

Edema limited to superior surface of vocal cord

due to dense fibrous attachment to conus

elasticus on under surface of vocal cord

Clinical Features• Common in men b/w 30 – 60 years

• Hoarseness: monotonous low-pitch voice

• Diplophonia: in asymmetric cord involvement

• Stridor: in B/L gross edema

• Early cases: ed convexity of medial cord margin

• Late cases: Pale, watery bags of fluid on superior

surface of vocal cords, move to & fro on phonation

Reinke’s edema

Treatment

• Elimination of causative factors. Stop smoking.

• Vocal cord stripping (decortication) under MLS:

postero-anterior incision made on superior vocal

cord surface → edematous fluid sucked out →

edematous tissue removed with cup forceps

• Voice therapy: 1 wk before & 3 wks after surgery

Vocal cord stripping

Removal of edematous tissue

Trimming & re-draping

Pre-op vs. post-op

Angio-neurotic edema

Introduction• Recurring attacks of swelling of face, larynx &

extremities caused by edema due to vasodilatation &

increased capillary permeability

Types:

• Allergic: swelling with itching, laryngeal edema &

bronchospasm

• Hereditary: Non-pruritic swelling + laryngeal edema +

recurrent abdominal pain with vomiting &

diarrhea

• Atopy

• Food: nut, prawn, fish, egg, meat

• Drug: penicillin, NSAIDs, ACE inhibitors, Sulpha drugs

• Insect bites: bee, wasp

• Physical stimulus: cold air, smoke, pollution

• C1 esterase inhibitor deficiency → complement

pathway

activation

• Trauma: accidental, surgical

• Emotional stress, anxiety

Etiology

Treatment

Allergic: antihistamines + corticosteroids

Hereditary: IV purified C1 esterase inhibitor 36,000 U

for acute attacks & before surgery. Tranexemic

acid (anti-fibrinolytic) & Methyl- testosterone →

stimulate C1 esterase inhibitor

Life-threatening stridor: subcutaneous adrenaline +

aminophylline infusion + intubation / tracheostomy

Laryngeal Tuberculosis

• Commonly associated with pulmonary TB

• Posterior commissure arytenoids, vocal cords,

ventricular bands & epiglottis mainly affected

• Method of spread:

– Bronchogenic: contact of larynx with sputum

containing tubercular

bacilli

– Hematogenous

Introduction

Stages of laryngeal TB1. Exudation + hyperemia in subepithelial layers

2. Mono-nuclear round cell infiltration of

subepithelial layers causing pseudo-edema

3. Tubercle formation: granuloma with epithelioid

cells + Langhans giant cells + caseation necrosis

4. Ulceration: shallow ulcers with undermined

edges involving arytenoids & epiglottis (moth

eaten or mouse nibbled appearance)

5. Cicatrization: ulcers heal by fibrosis

Symptoms• History of pulmonary TB

• Weakness of voice followed by hoarseness

• Cough with hemoptysis

• Throat pain

• Referred earache

• Dysphagia & odynophagia due to perichondritis

Laryngoscopic examination• Impairment of vocal cord adduction (first sign)

• Areas affected commonly are inter-arytenoid area,

posterior vocal cords + false cords + epiglottis

• Congestion of these areas with surrounding pallor

• Pseudo-edema mamillated appearance of

interarytenoid area + turban-shaped epiglottis

• Shallow, undermined ulcers

• Vocal cord palsy + perichondritis

Moth eaten ulcerations

Management

• Diagnosis

– Direct laryngoscopy & biopsy

– Chest X-ray, P.A. view

– Sputum for A.F.B.

• Treatment

– Anti-tubercular medication for 9 months

Laryngo-pharyngeal reflux disease (LPRD)

GERD vs. LPRD

Symptoms of LPRD• Hoarseness

• Persistent clearing of throat

• Difficulty in swallowing food

• Breathing difficulties or choking episodes

• Annoying cough after eating

• Sticking sensation or lump in throat

• Heartburn & indigestion absent

Laryngoscopic findings

• Erythema & swelling of inter-arytenoid area

• Erythema & swelling of arytenoids

• Posterior commissure mucosal hypertrophy

• Granulations / granuloma in posterior commissure

• Contact ulcer in posterior glottic commissure

Acid laryngitis

Diagnosis• Ambulatory 24-hour double-probe (esophageal &

pharyngeal) pH monitoring or pHmetry = gold

standard for diagnosis of

LPRD

• Distal probe = 5 cm above lower esophageal sphincter

• Proximal probe = 1 cm above upper esophageal

sphincter, in hypopharynx behind laryngeal

inlet

• LPRD = acidic pH in both probes

• GERD = acidic pH in distal probe only

24 hour ambulatory double-probe pH monitoing

pH metry

GERD LPRD

Heartburn ++++ +

Hoarseness & dysphagia + ++++

Nocturnal (supine) reflux ++++ -

Daytime (upright) reflux + ++++

ed lower esophageal pH ++++ ++

ed pharyngeal pH - ++++

Pantoprazole treatment 40 mg OD X 6 wk

40 mg BD X 6 mth

Level I: Antireflux therapy (ART)

A. Dietary modification

1. No eating or drinking within 3 hours of bedtime

2. Avoid overeating or reclining right after meals

3. No fried food; low-fat diet

4. Avoid coffee, tea, chocolate, mints, sodas

5. Avoid caffeine-containing foods & beverages

6. Avoid alcohol, especially in evening

7. Avoid other foods that cause reflux

Treatment

B. Lifestyle modification

1. Elevate head-end of bed by 4 to 6 inches

2. Avoid wearing tight-fitting clothing or belts

3. If you use tobacco, quit!

C. Liquid antacids: qid (1 tsf 1 hour after meal

& at bedtime)

Level II: Pantoprazole → 40 mg BD for 6 months

Level III: Fundoplication surgery

Thank You