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Inflammatory Disorders of Larynx

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Presentation on theme: "Inflammatory Disorders of Larynx"— Presentation transcript:

1 Inflammatory Disorders of Larynx
Dr. Vishal Sharma

2 Classification 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)

3 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

4 Acute (simple) Laryngitis

5 Etiology 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

6 Clinical Features 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

7 Flexible laryngoscopy

8 Treatment 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

9 Acute Epiglottitis


11 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

12 Symptoms 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)

13 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

14 Tripod sign Pt appears anxious
Leans forward with support of both forearms Extends neck in an attempt to maintain an open airway

15 Investigations 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

16 Flexible laryngoscopy
Inflamed cherry-red epiglottis Thickened aryepiglottic folds Edematous arytenoid cartilages

17 Post-intubation direct laryngoscopy

18 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

19 X-ray soft tissue neck

20 X-ray soft tissue neck Red arrow = enlarged epiglottis
Yellow arrow = thickened ary-epiglottic folds

21 Ballooning of hypopharynx


23 Treatment 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

24 Methods of securing airway
Endotracheal intubation Trans-nasal: preferred Trans-oral Percutaneous trans-laryngeal ventilation by needle cricothyrotomy Tracheostomy: last resort for acute stridor

25 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

26 Laryngo-Tracheo-Bronchitis (LTB)

27 Acute viral LTB (Croup)
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

28 Clinical Features 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

29 Investigations 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

30 Church Steeple sign



33 Treatment 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



36 Bacterial LTB 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

37 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.

38 Acute epiglottitis Viral croup Bacterial croup Spasmodic croup R.P. abscess Age (yr) 3-7 1-3 1-8 Voice Normal or muffled Hoarse Cough Absent Barking seal-like Stridor Inspiratory Biphasic Dysphagia + drooling Severe Fever > 102 F < 102 F Posture Quiet, sitting Restless, supine Restless, sitting

39 Chronic Laryngitis

40 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

41 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: hyperemic laryngeal mucosa with sub-mucosal edema Treatment: Voice test + medicated steam inhalation + systemic antibiotic. Avoidance of alcohol & tobacco. Reversible within few weeks.

42 Chronic hyperemic laryngitis

43 Chronic hyperplastic 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

44 Chronic hyperplastic laryngitis

45 Chronic hyperplastic laryngitis

46 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

47 Rx of hyperplastic laryngitis
Absolute 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

48 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

49 Reinke’s edema

50 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

51 Reinke’s space

52 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

53 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

54 Reinke’s edema

55 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

56 Vocal cord stripping

57 Removal of edematous tissue

58 Trimming & re-draping

59 Pre-op vs. post-op

60 Angio-neurotic edema

61 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

62 Etiology 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

63 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

64 Laryngeal Tuberculosis

65 Introduction 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

66 Stages of laryngeal TB 1. 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

67 Symptoms History of pulmonary TB
Weakness of voice followed by hoarseness Cough with hemoptysis Throat pain Referred earache Dysphagia & odynophagia due to perichondritis

68 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

69 Moth eaten ulcerations

70 Management Diagnosis Direct laryngoscopy & biopsy
Chest X-ray, P.A. view Sputum for A.F.B. Treatment Anti-tubercular medication for 9 months

71 Laryngo-pharyngeal reflux disease (LPRD)

72 GERD vs. LPRD

73 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

74 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

75 Acid laryngitis

76 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

77 24 hour ambulatory double-probe pH monitoing


79 pH metry

80 Hoarseness & dysphagia Nocturnal (supine) reflux -
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

81 Treatment 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

82 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

83 Thank You

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