1. 6/12/2016 Congenital Laryngeal Diseases Traumatic Laryngeal Diseases Lobna El Fiky, MD ORL, HNS Ain Shams University Learning without thought is labor lost… Thought without learning is perilous

2. 6/12/2016 OBJECTIVES Introduction: Introduction:  Anatomy and Physiology Congenital laryngeal Diseases Congenital laryngeal Diseases Traumatic Laryngeal Diseases Traumatic Laryngeal Diseases Examples of cases Examples of cases Be Passionate about your Life!!

3. 6/12/2016 Functions of the Larynx   Protection   Respiration   Phonation   Fixation of the chest

4. 6/12/2016 Anatomical Considerations Framework Cartilages   Unpaired Thyroid Cricoid Epiglottis   Paired Arytenoid Corniculate Cuneiform Membranes and Ligaments   Cricothyroid   Quadrangular membrane   Conus elasticus

5. 6/12/2016 Fun Fact! The speech skill is a wonder. To produce a phrase, about 100 muscles of the chest, neck, jaw, tongue and lips must collaborate!

6. 6/12/2016 Anatomical Considerations: Muscles Adductors: Adductors: Lateral cricoarytenoid muscle Inter-arytenoid

7. 6/12/2016 Anatomical Considerations: Muscles Tensors:   Cricothyroid   Thyroarytenoid (Vocalis)

8. 6/12/2016 Anatomical Considerations: Muscles Abductors:   Posterior cricoarytenoid

9. 6/12/2016 Fun Fact! The mass of the vocal fold is about ONE gram!

10. 6/12/2016 Cavity of the Larynx Glottic:   VF for phonation Subglottic:   only complete ring   Narrowest segment Supraglottic:   Developmentally related to pharynx   Opened posteriorly

11. 6/12/2016 Nerve Supply SENSORY:  Supraglottic: Superior laryngeal nerve Superior laryngeal nerve  Subglottic: Recurrent laryngeal nerve Recurrent laryngeal nerve MOTOR:  All muscles: Recurrent laryngeal nerve Recurrent laryngeal nerve  Cricothyroid: Superior laryngeal nerve Superior laryngeal nerve

12. 6/12/2016 Congenital Laryngeal Diseases Lobna El Fiky, MD ORL, HNS Ain Shams University

13. 6/12/2016 Congenital Laryngeal Diseases Congenital laryngeal anomalies are relatively rare Congenital laryngeal anomalies are relatively rare However, they may present with life- threatening respiratory problems However, they may present with life- threatening respiratory problems Associated problems with: Associated problems with:  Phonation  Swallowing  Failure of thriving

14. 6/12/2016 1. Laryngomalacia 60% to 75% of congenital laryngeal anomalies 60% to 75% of congenital laryngeal anomalies Supraglottic tissues of the larynx collapse into the airway during inspiration Supraglottic tissues of the larynx collapse into the airway during inspiration Contributing Factors: Contributing Factors:  Immature neuromuscular control and movement  Gastro esophageal Reflux Within the first weeks of life (Not at birth) Within the first weeks of life (Not at birth) Spontaneously resolves Spontaneously resolves More prominent when child is More prominent when child is  Supine  Agitated

15. 6/12/2016 1. Laryngomalacia Findings: Findings:  Redundant supraglottic mucosa prolapses  Shortened aryepiglottic folds  Posterior displacement of the epiglottis: Omega shaped  Anterior collapse of cuneiform and corniculate cartilage

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17. Severe Laryngomalacia 6/12/2016

18. 1. Laryngomalacia Treatment: Treatment:  Reassuring Position adjustments Position adjustments Consider reflux precautions Consider reflux precautions Frequent evaluation by pediatrician to assess: Frequent evaluation by pediatrician to assess: Growth Growth Feeding Feeding Breathing Breathing Surgery: Surgery:  Rarely necessary as condition is self- limiting  Severe symptoms are surgical indications: Life-threatening airway obstruction Life-threatening airway obstruction Inability to feed orally Inability to feed orally Cor pulmonale Cor pulmonale Failure to thrive Failure to thrive

19. 6/12/2016 2. Congenital laryngeal web Membrane between the VF: Membrane between the VF:  Thin, anterior 1/3 rd VF Weak, hoarse voice Weak, hoarse voice No respiratory problems No respiratory problems  Thick, Fibrous, extend to subglottis Hoarse voice, stridor Hoarse voice, stridor Some respiratory problems Some respiratory problems

20. 6/12/2016 Laser Division of Glottic web

21. 6/12/2016 3. Congenital Subglottic Stenosis Narrowing of the laryngeal lumen in the cricoid region: Narrowing of the laryngeal lumen in the cricoid region:  No history of intubation or surgical trauma An elliptic cricoid cartilage in which the transverse diameter was significantly smaller An elliptic cricoid cartilage in which the transverse diameter was significantly smaller  The transverse and anteroposterior luminal diameters at the midportion of the cricoid cartilage are normally equal Diameter of less than 3.5 mm in a newborn Diameter of less than 3.5 mm in a newborn

22. 6/12/2016 3. Congenital Subglottic Stenosis Submucosal thickening Submucosal thickening Abnormally shaped cricoid cartilage Abnormally shaped cricoid cartilage Presentation: Presentation:  range from mild dyspnea to severe airway obstruction In mild cases: In mild cases:  symptoms only during infections edema and thickened secretions further compromise the airway edema and thickened secretions further compromise the airway  Recurrent or persistent croup

23. 6/12/2016 3. Congenital Subglottic Stenosis Congenital subglottic stenosis becomes less critical as the larynx grows Congenital subglottic stenosis becomes less critical as the larynx grows Symptoms resolve by a few years of age in most cases Symptoms resolve by a few years of age in most cases A watch and wait approach is appropriate A watch and wait approach is appropriate severe cases of congenital subglottic stenosis, surgical intervention may be necessary: severe cases of congenital subglottic stenosis, surgical intervention may be necessary:  Laser resection  Laryngotracheoplasty  Laryngotracheal resection  Dilatation

24. 6/12/2016 4. Congenital vocal fold immobility VFI 10-20% of all congenital laryngeal anomalies 10-20% of all congenital laryngeal anomalies Causes: Causes:  Idiopathic  Birth trauma  CNS anomalies: hydrocephalus, encephalocele, leukodystrophy, spina bifida, cerebral palsy, and Arnold-Chiari malformation (ACM) hydrocephalus, encephalocele, leukodystrophy, spina bifida, cerebral palsy, and Arnold-Chiari malformation (ACM)  Peripheral nervous system disorders: myasthenia gravis, myopathy myasthenia gravis, myopathy  Cardiovascular anomalies: ventricular septal defect, Tetralogy of Fallot, cardiomegaly, double aortic arch, and patent ductus arteriosus ventricular septal defect, Tetralogy of Fallot, cardiomegaly, double aortic arch, and patent ductus arteriosus

25. 6/12/2016 4. Congenital vocal fold immobility VFI Unilateral: Unilateral:  Presents with a weak, breathy cry, feeding difficulties, and aspiration Bilateral: less common Bilateral: less common  Presents with biphasic stridor and a preserved cry

26. 6/12/2016 5. Subglottic Hemangiomas Rare (1.5%) congenital vascular lesions Rare (1.5%) congenital vascular lesions Undergo rapid growth in the first months after birth Undergo rapid growth in the first months after birth 50% of infants have cutaneous hemangiomas 50% of infants have cutaneous hemangiomas Recurrent croup and biphasic stridor Recurrent croup and biphasic stridor Most hemangiomas involute Most hemangiomas involute KTP Laser excision KTP Laser excision

27. 6/12/2016 Traumatic Laryngeal Diseases Lobna El Fiky, MD ORL, HNS Ain Shams University

28. 6/12/2016 Trauma to the Larynx External:   Blunt or penetrating cut throat, car accident Endolaryngeal:   Iatrogenic: Intubation   Chemical: corrosive   Physical: irradiation, steam FB Inhalation

29. 6/12/2016 External Trauma to the Larynx Presentation: Presentation:  Abnormal voice  Tenderness  Respiratory distress  Hematoma  Edema  Step deformities  Fractures  Mucosal tears  Exposed cartilages  Surgical emphysema

30. 6/12/2016 Evaluation Respiration: Respiration:  Observation, steroids, Oxygen  Obstruction necessitates tracheostomy vs intubation Other neck injuries: Other neck injuries:  Spine, esophagus and pharynx, Carotid  First aid measures Exploration and repair if needed is better than delayed intervention Exploration and repair if needed is better than delayed intervention

31. 6/12/2016 Sequelae STENOSIS: STENOSIS:  Level according to the site of injury  Can be glottic, supraglottic or subglottic  Can be laryngeal or tracheal or laryngotracheal stenosis:  Worst is the subglottic stenosis Patient may present later after trauma due to progressive fibrosis Patient may present later after trauma due to progressive fibrosis

32. 6/12/2016 Postcorrosive Supraglottic Stenosis

33. 6/12/2016 Laser excision of Supraglottic postcorrosive stricture

34. 6/12/2016 Foreign Body Inhalation Positive History Positive History Unilateral Chest Findings Unilateral Chest Findings

35. 6/12/2016 Bronchoscopic removal of Foreign Body

36. 6/12/2016 Good Luck Lobna El Fiky

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38. Pecularities of Larynx in children Both structural and functional differences exist between the pediatric and the adult larynx Both structural and functional differences exist between the pediatric and the adult larynx  Internal larynx at birth is approximately 1/3rd of its adult size  Infant larynx is smaller in proportion to the rest of the body  VF are 4.0 to 4.4 mm long at birth (14-18mm long in adults)  Thyroid cartilage is closer to the hyoid in the infant  larynx is positioned at 4th vertebra at birth (6 th or 7 th v at puberty)

39. 6/12/2016 Pecularities of Larynx in children The larynx of the infant is: The larynx of the infant is:  softer,  more easily displaced,  more easily irritated. The epiglottis: The epiglottis:  projects into the oropharynnx  Infantile: longer, narrower, and more tubular The cartilaginous framework of the larynx: The cartilaginous framework of the larynx:  Softer and less rigid  Less resistance to changing pressures Subglottis: Subglottis:  Mucosa & CT are loosely attached

40. 6/12/2016 Laryngeal Stridor The level of the obstruction can be suspected based on the characteristics of the stridor The level of the obstruction can be suspected based on the characteristics of the stridor Supraglottic or glottic obstruction = inspiratory stridor Supraglottic or glottic obstruction = inspiratory stridor Biphasic stridor = narrowing between the glottis & extrathoracic trachea. Biphasic stridor = narrowing between the glottis & extrathoracic trachea. Turbulent airflow in the distal trachea or main bronchi can produce expiratory stridor Turbulent airflow in the distal trachea or main bronchi can produce expiratory stridor

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