inflammatory disorders of larynx dr. vishal sharma
TRANSCRIPT
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