Inflammatory Disorders of Larynx Dr. Vishal Sharma

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)

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

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

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

Flexible laryngoscopy

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

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

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)

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

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

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

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

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)

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

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

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

Church Steeple sign

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

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

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 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

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

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.

Chronic hyperemic laryngitis

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

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 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

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

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

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

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

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

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

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

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

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

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