Cummings Chapters 63 & 64 Acute and Chronic Laryngitis Laryngeal and Tracheal Manifestations of Systemic Disease Travis Shiba 12/6/13

Acute and Chronic Laryngitis Key Points Key Points #1 cause of acute laryngitis = viral #1 cause of acute laryngitis = viral #1 cause of chronic laryngitis = reflux #1 cause of chronic laryngitis = reflux Candidal laryngitis can occur in non immuno compromised Candidal laryngitis can occur in non immuno compromised Even in setting of likely neoplasm, still consider infection Even in setting of likely neoplasm, still consider infection

Laryngitis Inflammation of the larynx Inflammation of the larynx Can impair swallowing, phonating and breathing Can impair swallowing, phonating and breathing

Acute Laryngitis Phonotrauma Phonotrauma Viral Laryngitis Viral Laryngitis Acute Bacterial Laryngitis Acute Bacterial Laryngitis Acute Fungal Laryngitis Acute Fungal Laryngitis

Supepithelial hemorrhage from phonotrauma Supepithelial hemorrhage from phonotrauma

Supepithelial hemorrhage of R VC polyp Supepithelial hemorrhage of R VC polyp

Acute Laryngitis Phonotrauma Phonotrauma Viral Laryngitis Viral Laryngitis Acute Bacterial Laryngitis Acute Bacterial Laryngitis Acute Fungal Laryngitis Acute Fungal Laryngitis

Viral Laryngitis Pathogens: rhinovirus, parainfluenza, RSV, adenovirus, influenza, adenovirus… Pathogens: rhinovirus, parainfluenza, RSV, adenovirus, influenza, adenovirus… SSx: dysphonia, hoarse voice, cough SSx: dysphonia, hoarse voice, cough Rx: supportive care: hydration, anti- inflam, voice rest, PPI +/- steroids Rx: supportive care: hydration, anti- inflam, voice rest, PPI +/- steroids Croup: laryngotracheobronchitis Croup: laryngotracheobronchitis Typically parainfluenza 1,3 Typically parainfluenza 1,3 Steeple sign Steeple sign

Acute Laryngitis Phonotrauma Phonotrauma Viral Laryngitis Viral Laryngitis Acute Bacterial Laryngitis Acute Bacterial Laryngitis Acute Fungal Laryngitis Acute Fungal Laryngitis

Acute Bacterial Laryngitis Supraglottitis (epiglottitis) Supraglottitis (epiglottitis) Pathogens: H influenza, Strep PNA, Staph Aureus, Beta hemolytic strep Pathogens: H influenza, Strep PNA, Staph Aureus, Beta hemolytic strep Decreased incidence with h flu B vaccine Decreased incidence with h flu B vaccine Rx: airway control. Humid air, IV antibiotics, monitored bed, steroids Rx: airway control. Humid air, IV antibiotics, monitored bed, steroids

Whooping cough Whooping cough bordetella pertusis bordetella pertusis Vaccine protects ~ 3 yrs Vaccine protects ~ 3 yrs Rx: erythromycin to prevent spread Rx: erythromycin to prevent spread Acute Bacterial Laryngitis Diptheria Corynebacterium diptheria SSx: acetone breath, thick grey membranous and friable plaque Rx: airway via trach, diptheria anti toxins, PCN & clinda

Acute Laryngitis Phonotrauma Phonotrauma Viral Laryngitis Viral Laryngitis Acute Bacterial Laryngitis Acute Bacterial Laryngitis Acute Fungal Laryngitis Acute Fungal Laryngitis

Acute Fungal Laryngitis Candiasis (moniliasis) Candiasis (moniliasis) usually seen with oral/esophageal sx or in a pt taking oral inhaled steroids usually seen with oral/esophageal sx or in a pt taking oral inhaled steroids White sessile plaques on erythematous base White sessile plaques on erythematous base Rx: Fluconazole Rx: Fluconazole

Chronic Laryngitis Bacterial Bacterial Fungal Fungal Mycobacterial Mycobacterial Non infectious Non infectious

Chronic Bacterial Laryngitis Rhinoscleroma Rhinoscleroma Klebsiella rhinoscleromatosis Klebsiella rhinoscleromatosis Path: Mikulicz Cells Path: Mikulicz Cells Rx: fluouroquinolones/TCN Rx: fluouroquinolones/TCN Syphillis Syphillis Secondary: painless edema Secondary: painless edema Tertiary: gummas + cartil destruction Tertiary: gummas + cartil destruction Rx: PCN Rx: PCN

Chronic Bacterial Laryngitis Actinomycosis Actinomycosis Actinomycosis israelii Actinomycosis israelii Chronic suppurative infxn, rarely involves layrnx Chronic suppurative infxn, rarely involves layrnx Histo: Histo: Sulfur Granules Sulfur Granules Rx: PCN or Clinda Rx: PCN or Clinda

Chronic Laryngitis Bacterial Bacterial Fungal Fungal Histoplasmosis Histoplasmosis Blastomycosis Blastomycosis Cryptococcus Cryptococcus Coccidiomycosis Coccidiomycosis Mycobacterial Mycobacterial Non infectious Non infectious

Histoplasmosis Histoplasmosis SCCA

Histoplasmosis Histoplasma capsulatum Histoplasma capsulatum Mississippi River Valley Mississippi River Valley Acute/Chronic, Pulmonary/systemic Acute/Chronic, Pulmonary/systemic Laryngeal Lesions: anterior larynx and epiglottis Laryngeal Lesions: anterior larynx and epiglottis Bx: poorly defined granulomas, multinucleated giant cells and pseudoepitheliomatous hyperplasia Bx: poorly defined granulomas, multinucleated giant cells and pseudoepitheliomatous hyperplasia Grows on Sabouraouds agar Grows on Sabouraouds agar Tx: Ampho/Azoles Tx: Ampho/Azoles

Blastomycosis Blastomyces Dermatitides Blastomyces Dermatitides Central america/Midwest Central america/Midwest Airborne to lung, to larynx hematogenously Airborne to lung, to larynx hematogenously Larynx involved 2% - exophytic/ulcerative mass usually on TVC Larynx involved 2% - exophytic/ulcerative mass usually on TVC Histo: Broad based buds Histo: Broad based buds Rx: ampho/azoles Rx: ampho/azoles

Cryptococcus Cryptococcus neoformans Cryptococcus neoformans Bird droppings Bird droppings H&N Sx: meningitis (SNHL), membranous Npharyngitis; larynx (only TVC) H&N Sx: meningitis (SNHL), membranous Npharyngitis; larynx (only TVC) Dx: india ink stain showing capsules Dx: india ink stain showing capsules Tx: ampho/azoles Tx: ampho/azoles

Coccidiomycosis Coccidioides Immitis Coccidioides Immitis “valley fever” Southwest US and North Mexico “valley fever” Southwest US and North Mexico H&N: lesions (nodules/erosions) of skin, mucous membranes, epiglottis, trachea, salivary glands H&N: lesions (nodules/erosions) of skin, mucous membranes, epiglottis, trachea, salivary glands Histo: “Sac with bugs” Histo: “Sac with bugs” Rx: ampho/azole Rx: ampho/azole

Chronic Laryngitis Bacterial Bacterial Fungal Fungal Mycobacterial Mycobacterial Non infectious Non infectious

MycobacterialLaryngitis Tubercolosis Tubercolosis Direct from lungs or via blood Direct from lungs or via blood Dx: PPD/Quant/AFB Dx: PPD/Quant/AFB Tx: INH/Rifampin/voice rest Tx: INH/Rifampin/voice rest Leprosy (Hansen’s) Leprosy (Hansen’s) AFB and granulomas AFB and granulomas Ulcerative supraglottis Ulcerative supraglottis Dx: foamy leprous cells Dx: foamy leprous cells Rx: dapsone & CS Rx: dapsone & CS

Chronic Laryngitis Bacterial Bacterial Fungal Fungal Mycobacterial Mycobacterial Non infectious Non infectious

Non Infectious Laryngitis Smoking Smoking Pollution Pollution Vocal Abuse Vocal Abuse Rhinosinusitis Rhinosinusitis Laryngopharyngeal Reflux Laryngopharyngeal Reflux

LPR Etiologies: acid/bile/pepsin Etiologies: acid/bile/pepsin RF: obsity, EtOH, hiatial hernia, preg, scleroderma, feeding tube RF: obsity, EtOH, hiatial hernia, preg, scleroderma, feeding tube SSx: Hoarse (am>pm), globus, dysphagia SSx: Hoarse (am>pm), globus, dysphagia Dx: trial of PPI/NP scope Dx: trial of PPI/NP scope Barium swallow Barium swallow 24 hour dual pH probe 24 hour dual pH probe esophagoscopy esophagoscopy

LPR Rx: Rx: Behavioral: smoking cessation, elevate HOB, avoid late meals, overeating, avoid tight close/loose weight Behavioral: smoking cessation, elevate HOB, avoid late meals, overeating, avoid tight close/loose weight Decrease caffiene, EtOH, mints, chocolate, Decrease caffiene, EtOH, mints, chocolate, Avoid ASA, nitrates, CCB Avoid ASA, nitrates, CCB Medications Medications PPI (usually 2x dose for LPR versus GERD) PPI (usually 2x dose for LPR versus GERD) H2 blockers H2 blockers Surgery Surgery Fundoplication Fundoplication

Laryngeal and Tracheal Manifestations of Systemic Disease Key Points Key Points Symptoms: hoarseness, cough, stridor, airway compromise Symptoms: hoarseness, cough, stridor, airway compromise Mimic laryngeal carcinoma Mimic laryngeal carcinoma

Wegener’s Granulomatosis Wegener’s Granulomatosis Relapsing Polychondritis Relapsing Polychondritis Sarcoidosis Sarcoidosis Rheumatoid Arthritis Rheumatoid Arthritis Pemphigus/pemphigoid Pemphigus/pemphigoid Amyloidosis Amyloidosis

Wegener’s Granulomatosis Idiopathic necrotizing granulomatous vasculitis Idiopathic necrotizing granulomatous vasculitis Types: Types: Limited (no renal) Limited (no renal) Systemic (pulm and renal) Systemic (pulm and renal) Laryngeal SSx: subglottic mass, dyspnea, biphasic stridor Laryngeal SSx: subglottic mass, dyspnea, biphasic stridor Rx: Steroids + cyclophosphamide then MTX/Azathiaprine Rx: Steroids + cyclophosphamide then MTX/Azathiaprine

Wegener’s Granulomatosis

Replapsing Polychondritis Idiopathic inflammation of cartilage Idiopathic inflammation of cartilage Laryngeal SSx: 14% present with laryngeal sx; 50% eventually have laryngeal sx Laryngeal SSx: 14% present with laryngeal sx; 50% eventually have laryngeal sx Radiology: non erosive arthopathy Radiology: non erosive arthopathy Histo: non specific inflammation Histo: non specific inflammation Rx: steroids, dapsone, azathiaprine, cyclophosphamide, cyclosporine Rx: steroids, dapsone, azathiaprine, cyclophosphamide, cyclosporine

Sarcoidosis Systemic granulomatosis Systemic granulomatosis Laryngeal SSx (1-5%): suprglottic submucosal mass (“turbin like thickening”) Laryngeal SSx (1-5%): suprglottic submucosal mass (“turbin like thickening”) Dx: biopsy, incr ACE, hypercalcemia, hypergammaglobulinemia Dx: biopsy, incr ACE, hypercalcemia, hypergammaglobulinemia Histo: noncaseating granulomas Histo: noncaseating granulomas Rx: endoscopic removal of mass if symptomatic Rx: endoscopic removal of mass if symptomatic Systemic v injected steroids Systemic v injected steroids

Sarcoidosis

Rheumatoid Arthritis Autoimmune Autoimmune 25% Laryngeal involvement 25% Laryngeal involvement Acute: tender/erythematous larynx Acute: tender/erythematous larynx Chronic: cricoarytenoid ankylosis, submucosal nodules Chronic: cricoarytenoid ankylosis, submucosal nodules Increased RF, ESR; decreased C’ Increased RF, ESR; decreased C’ Rx: steroids and antireflux Rx: steroids and antireflux

Pemphigus/Pemphigoid Autoimmune Autoimmune Pemphigus vulgaris: anti desmosome tonofilament Pemphigus vulgaris: anti desmosome tonofilament Intracellular bridges disrupted->intraepithelial blisters Intracellular bridges disrupted->intraepithelial blisters Bullous Pemphigoid: anti basement membrane Bullous Pemphigoid: anti basement membrane Subepidermal blistering Subepidermal blistering Laryngeal SSx: can occur on the mucosa if other oral lesions. Usually does not extend to SG Laryngeal SSx: can occur on the mucosa if other oral lesions. Usually does not extend to SG Rx: corticosteroids Rx: corticosteroids

Pemphigus/Pemphigoid

Amyloidosis Abnormal deposition of fibrillar protein and polysaccharide complexes Abnormal deposition of fibrillar protein and polysaccharide complexes Laryngeal SSx: anterior subglottic mass Laryngeal SSx: anterior subglottic mass Dx: biopsy (congo red) Dx: biopsy (congo red) Rx: endoscopic removal Rx: endoscopic removal