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 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
Supraglottic
Glottic
Subglottic
Laryngomalacia
Vocal cord paralysis
Cong. Subglottic stenosis
Ductal retention cyst
Web and atresia
Subglottic hemangioma
Cystic hygroma
Interarytenoid web
Web & atresia
Bifid epiglottis
Posterior laryngeal cleft
Cysts
Saccular cyst
Cri-du-chat syndrome
Anterior laryngeal cleft

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.  Tx 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
Benign
Malignant
Papilloma
Squamous Cell Ca
Minor S.G. tumors
Neuroendocrine (e.g. carcinoid, melanoma)
Granular cell tumor
Chodrosarcoma
Chondroma
Rhabdomyosarcoma
Hemangioma
Lymphoma
Paraganglioma

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