Diseases of Pharynx and Larynx

Anatomy of Pharynx Fibromuscular Tube Base of Skull to C6 (12cm) Divided into three parts Nasopharynx Oropharynx Laryngopharynx 4 Layers Mucosal, submucosal (Fibrous), Muscular, Fascial layer (buccal pharyngeal)

Nasopharynx Base of skull to the soft palate Key components Pharyngeal Tonsil (Adenoids) Pharyngeal Recess (ICA) Opening of Auditory tube

Oropharynx Soft Palate to the epiglottis Key Components Palatopharyngeal and Palatoglossal arches Palantine Tonsil – project from tonsillar fossa Lingual Tonsil Valleculae – lie between epiglottis and posterior border of the tongue Floor of the tonsillar fossa is known as the bed and the glossopharyngeal nerve (CNIX) runs across this bed as well as tonsillar and ascending palantine arteries Waldeyers ring; Palatine, lingual, pharyngeal and tubal tonsils Valleculae; shallow pits. If crumb gets caught down wrong way will get lodged in and set about the coughing reflex

Laryngopharynx Epiglottis to the level of cricoid cartilage Key features Opening to the larynx Piriform recess (endoscope)

Anatomy of Pharynx Blood supply Nerve Supply Branches of many arteries (ascending pharyngeal, greater palantine, lingual, tonsilar) Nerve Supply Afferent; maxillary nerve, glossopharyngeal, internal and recurrent laryngeal nerves Motor; Pharyngeal Plexus (Vagus, glossopharyngeal, Cervical Sympathetic)

Larynx Respiratory Organ Function Lying between pharynx and trachea Becomes continuous with the trachea at the level of the cricoid cartilage (C6) Function Primary – protective sphincter at the inlet of the air passages Phonation Animals such as fish have a larynx.

Larynx Components Cartilages Joints Ligaments and Membranes Singular; thyroid, cricoid, epigolittic Paired; Arytenoid, corniculate, cuneiform Joints Cricothyroid, cricoarytenoid Ligaments and Membranes Intrinsic; Quandrangular membrane, Cricothyroid ligament (Vocal folds) Extrinsic; Thyrohyoid membrane, cricotracheal, hypoepiglottic, thyroepiglottic ligaments, cricothyroid Corniculate cartilage is the apex of the arytenoid cartilages

Cavities Inlet + Vestibule Rima of glottis Subglottic space

Layrnx - Intrinsic Membranes Quadrangular membrane Arytenoid Cartilage and epiglottis Lower border; vestibular folds (false cord) Upper border; aryepiglottic folds Cricovocal Membrane Formed from lateral part of cricothyroid ligament Upper thickened border forms cricovocal ligaement Vocal folds which bounds the glottis anteriorly

Apex of the arytenoid catilage is corniculate cartilage Cuneiform cartilage – elongated cartilage placed on each side of aryepiglottic folds in front of arytenoid cartilages

Laryngeal Muscles - Intrinsic 1. Those that alter size and shape of the inlet Aryepiglottic Muscles Oblique arytenoids Thyroepiglottic muscles Act as Sphincter for the inlet Provide valvular protection from above

Laryngeal Muscles - Intrinsic 2. Responsible for Phonation by moving vocal folds Abduction; Posterior Cricoarytenoids Adduction; Lateral cricoarytenoid and transverse arytenoid Lengthen; Cricothryroid Shorten; Thyroarytenoid, vocalis

Phonation Pitch; Vibration of the folds through shortening and lengthing of the volds Intensity; Pressure through the glottis Quality; Resonating chambers above the glottis Articulation; tongue, teeth and lips Phonation only possible when vocal cords are in contact with each other thus when they are adducted. Lengthening and shortening of the cords has no impact when the cords are open however when they are closed control the pitch of the voice. At rest the vocal cords are seprated as to allow for quite respiration. However during speech the cords are held together and air pressure causes vibrations of the folds giving rise to sound waves with a certain pitch. Intensity of the sound will vary with pressure through the glottis. Quality is dependent on the resonating chambers above the glottis such as vestibule of the larynx, pharynx, paranasal sinuses mouth and nose. Artibulation is dependent of breaking up the sound by use of tongue, teeth and lips.

Larynx Blood supply Nerve Supply Superior and Inferior Laryngeal Branches from Superior and Inferior Thyroid Artery Nerve Supply Recurrent Laryngeal Nerve All intrinsic Muscles except cricothyroid Mucous Membranes below the folds External Layngeal Nerve Cricothyroid muscle Internal Laryngeal Nerve

Nerve Palsies Recurrent Laryngeal Nerve External Laryngeal Nerve Number of causes Left; Carcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surg Left or Right; Iatrogenic, Trauma, Thyroid disease Complete (Cadaveric Position) Half abducted position with arytenoid cartilage slightly in front Hoarse Voice Bovine cough Incomplete Adducted position as posterior cricoarytenoid more susceptible External Laryngeal Nerve Hoarse voice that recovers Inability to hit high frequencies Cadaveric position (2-3mm lateral to the laryngeal midline)

Extrinsic Muscles Elevators Depressors Indirectly; Directly; Mylohyoid, digastric, stylohyoid, geniohyoid Directly; Stlyopharyngeus, salingopharyngeus, palatopharyngeus Depressors Sternohyoid, omohyoid stenothyroid

4 year old boy Pain in right ear and fevers Recurrent ear infections Noisy breather Overweight Examination – Sore right ear, hyperaemic tympanic membrane, breathing with mouth open

Adenoid Hypertrophy Occupies large area of nasopharynx age <6 Atrophies and by age 15 little remains Recurrent URTI or allergies can lead to hypertrophy Clinical Nasal Obstruction; Mouth breathing / Adenoid Facies, chest infections, pharyngeal infections, sinusitis, snoring Eustachian Tube; Recurrent Otitis Media, CSOM Choanal Obstruction; OSA, chronic sinusitis  Open mouth/mouth breathing, Long elongated face, prominent incisors, Hypoplastic maxilla Short upper lip, Elevated nostrils, High arched palate,

Ix Tx Nasopharyngeal Exam Nasopharyngoscopic Exam Lateral Xray Supportive Adenoidectomy Diagnosis by enlarged adenoids on mirror nasopharyngeal exam or nasopharyngoscopic exam, enlarged adenoid shadow on X-ray

Adenoidectomy Criteria for surgery Complications Chronic upper airway obstruction with OSA +/- cor pulmonale Chronic serous/suppurative otitis media Recurrent acute otitis media Suspicion of nasopharyngeal malignancy Chronic sinusitis Complications Early Haemorrhage Otitis media Regrowth of residual adenoid tissue

Tonsillitis Commonest area of infection of head and neck Clinical; Sore throat and Odynophagia, Otalgia, headache, malaise, Fever, hyperaemic tonsils, cervical lymphadenopathy DDx; Viral Group A Streptococcus (20-30%) EBV; Palatal petechia Diptheria; Unimmunised, grey membrane Tx; Rest, paracetamol +/- ABx Penicillin + EBV Rash maculopapular rash on trunk

Tonsillitis Complications; Acute Otitis Media (most common) Peritonsillar abscess (Quinsy) GAS Post Strep GN Rhuematic Fever Scarlet Fever; Strawberry tongue and scarlitiform rash Recurrent Tonsillitis Tonsillar Hypertrophy

Tonsillectomy Indications for surgery Complications Absolute Relative Airway obstruction Suspicion of malignancy Relative Sleep apnoea, mouth breathing, difficulty swallowing Recurrent tonsillitis >5 episodes Any complications Complications Reactionary haemorrhage Secondary haemorrhage 5-10 days post op Due to fibrinolysis aggravated by infection

Pharyngitis Acute Chronic >70% Viral Cause, GAS Supportive Treatment Chronic Persistent mild soreness and dryness Predisoposing factors include; smoking, ETOH, mouth breathing, chronic sinusitis, Industrial fumes, antiseptic throat lozengers Enlarged lymphoid tissue can be removed

64 Male recently Immigrated from Hong Kong Lump in right side of neck Progressive enlarged, non-painful Exam; firm, fixed, solid mass lateral to midline in posterior triangle DDx; Malignancy, Reactive lymphadenopathy, including TB, Branchial Cysts,

Nasopharyngeal Carcinoma Rare in Europe Common in Asian countries 20% of all malignancies in Hong Kong Pathology Squamous cell/undifferentiated Aietology Unknown, however EBV plays a role Others; ingestion of preserved foods 80% of lateral neck lumps are malignant

Nasopharyngeal Carcinoma Clinical; Most commonly as lump in the neck Local; Nasal obstruction, blood stained discharge Neurological; Invasion of skull base causing cranial nerve palsies (V, VI, IX, X, XII) Otological; Serous otitis media Metastasis to bone, lung, liver

Nasopharyngeal Carcinoma Ix; Tissue sampling, CT/MRI, Staging Management Radiotherapy with concominant chemotherapy Poorly amendable to surgery due to anatomical location DDx Lymphoma, cystic adenocarcinoma, Infection Axial (cross sectional), contrast enhanced, T1 weighted MRI through the nasopharynx and skull base. This scan demonstrates a right sided (on your left) nasopharyngeal squamous cell carcinoma with deep invasion

Pathology of the Larynx Infectious Inflammatory Congenital Mucosal Malignancy

5 Year old boy Hx of 3/7 Low grade fever and URTI Sx 1/7 history Biphasic Stridor, barking cough No obvious respiratory distress

Laryngotracheitis (Croup) Inflammation of tissues of subglottic space +/- tracheobronchial tree Mucopurulent exudate -> airway obstruction Aetiology; Parainfluenza I (most common), II,III, influenza A,B, RSV Presentation; night, inspiratory/biphasic stridor, barking cough Beware loss of stridor, Decr SaO2 DDx; FB, subglottic stenosis, Epiglottitis

Laryngotracheitis + Epiglottitis Feature Laryngotracheitis Epiglottitis Inflammation Subglottic space Supraglottic space Age 4month-5 years 1-4 years Onset Gradual (days) Acute (hours) Fever Low grade/afebrile High fevers Stridor Biphasic/inspiratory Inspiratory Cough Barky Normal Posture Supine Sitting Drooling No Yes Radiograph Steeple sign Thumb sign, enlarged epiglottis Appearance Non-toxic Toxic/cyanotic Cause Viral Bacterial Treatment Supportive Keep child calm O2, Adrenalin nebs Airway management -ETT Steroids ABx, IV hydration, Moist air

18 month girl “Asthma Attack” Wheezy ?trigger Family Hx of Asthma, Eczema No stridor, but tachypnea, intercostal recession Unilateral wheeze on Right with Decreased air entry in lower zones

Foreign Body Usually stuck at right main bronchus Anything that’s small enough Presentation; Stridor if at level of trachea “Unilateral asthma” if bronchial Complications Atelectasis, lobar pneumonia, pneumothorax, mediastinal shift Dx; Inspiratory/Expiratory X-rays Bronchoscopy

Signs of Airway Obstruction Stretor; obstruction in the throat, low pitched choking noises Stridor; High pitched, inspiratory, biphasic or expiratory depending on location Accessory Muscle use Pallor, diaphoresis, restlessness Tachycardia Cyanosis and altered concious state Intercostal recession Nasal Flaring Exhaustion Bradycardia – most dangerous sign

Upper Airway Obstruction - Neonates Subglottic Stenosis Congenital or Acquired (trauma, intubation) Biphasic stridor, resp distress, recurrent croup Diagnosis; CT, laryngoscopy Tx; Soft tissue – laser and steroids Cartilage – Laryngotracheoplasty or tracheostomy (intubation) Laryngomalacia Soft immature cartilage Children or older patients with NM disorders Inspiratory stridor at 1-2 weeks, worse supine + feeding difficulties Dx; Bronchoscopy Tx; Usually self resolves after 18-24months Soft immature cartilage that collapses during inspiration Laryngeal Webs Laryngeal Cysts Vascular ring

44 Female 6 week history of hoarse voice Irritation and dryness in throat History of heartburn Smoker No history of weight loss, fatigue Examination; Unremarkable

Chronic Laryngitis Most common cause is GORD Clinically Recurrent Acute laryngitis Heavy smoking Chronic infection of nasal sinuses Mouth breathing from nasal obstruction Clinically Hoarseness or loss of voice Spasmodic cough DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis, TB General; Voice resting, avoid smoking Specific; eg. Lifestyle modifications, Medications

35 year old Blunt trauma to neck 5 hours ago Difficulty swallowing + Voice changes No history of LOC, resp distress, confusion Examination showed midline tenderness of neck, subcutaneous emphysema

Laryngeal Trauma Rare Causes Injuries; Penetrating Blunt trauma; majority are MVA’s, clothesline injuries, sporting injuries Manual strangulation Inhaled flames Swallowed poisons, foreign body ETT Injuries; Cricotracheal separation -> Asphyxia Fractures of larynx, hyoid bone, joint disruption Open wounds Mucosal Tears Strangulation – mucosal tears, haematoma, multiple fractures and cartilaginous displacement.

Access to the laryngeal cartilage. Transvere incision in the neck Access to the laryngeal cartilage. Transvere incision in the neck. (strap muscles, sternohyoid, thyrohyoid, sternothyroid) dissected

Laryngeal Injuries Presentation Goals of treatment Complications Significant cervical trauma Hoarse voice, neck pain, dyspnea, hypoxia, aphonia dysphasia Goals of treatment Protect the airway; Intubation, tracheostomy Restoration of function; Surgical repair Complications Laryngeal stenosis; permanent tracheostomy Suspect upper-airway injury in any patient who has signs of cervical trauma. Common presenting symptoms in patients with laryngeal trauma include hoarseness, neck pain, dyspnea, dysphonia, aphonia, dysphasia, odynophonia, and odynophagia. Often not direct injury which can be lethal but the delayed oedema, haematoma can lead to airway obstruction. Many of those with laryngeal trauma have significant injuries elsewhere and are already intubated.

33 year old male singing teacher Progressively hoarse voice Normal Cough Non-smoker No weight loss/fatigue

Benign Vocal Fold Lesions Reactive nodules (singers nodules) Bilateral Smooth, rounded/pedunculated Small Located on true vocal folds Treatment; Voice training, re-education Rarely surgical if fibrosed, chronic Virtually never give rise to malignancy

Laryngocele Abnormal dilatation of the laryngeal ventricle Contains air Men>Women Bilateral 25% Aeitology; Acquired; Incr. Intraluminal pressure (musicians) Congenital SCC <15% Hoarse voice, pain, dysphagia, lateral neck mass

Squamous Papilloma Most common benign neoplasm of larynx (84%) Found on true vocal cords Caused by HPV 6 and 11 Soft Raspberry like appearance May ulcerate resulting in haemoptysis Usually Single in Adults Multiple in Children (Laryngeal Papillomatosis) with extended growth and recurrence Malignant transformation extremely rare

Investigation and Treatment Ix; Laryngoscopy Tx; CO2 Laser Surgical removal ?Antivirals

55 year old male History of GORD, cardiac disease Recurrent hoarse voice Right otalgia Smoker + ETOH abuse

Squamous Cell Carcinoma Most common malignancy of larynx Male>Female 6;1x 2.5% all cancers in men Aeitology Tobacco:  Alcohol:  (x 2.2) Radiation, asbestos GORD HPV

Squamous Cell Carcinoma Glottic SCC most common (60%) > supraglottic SCC (30%) > subglottic SCC (<10%). Sx: hoarseness, throat pain, cough, hemoptysis, referred otalgia, dysphagia Diagnosis; Laryngoscopy with FNA CT/MRI

Squamous Cell Carcinoma Management Eradication of disease Restoration of function; swallowing and speech Radiation treatment Especially early stage disease Cure rates equivalent to surgery Surgical Management Emphasis on organ preservation Partial Larygectomy

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