1. Inflammatory Disorders of Larynx
Dr. Vishal Sharma

2. 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)

3. 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

4. Acute (simple) Laryngitis

5. 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

6. 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

7. Flexible laryngoscopy

8. 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

9. Acute Epiglottitis

11. 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

12. 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)

13. 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

14. Tripod sign Pt appears anxious
Leans forward with support of both forearms
Extends neck in an attempt to maintain an open airway

15. 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

16. Flexible laryngoscopy
Inflamed cherry-red epiglottis
Thickened aryepiglottic folds
Edematous arytenoid cartilages

17. Post-intubation direct laryngoscopy

18. 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

19. X-ray soft tissue neck

20. X-ray soft tissue neck Red arrow = enlarged epiglottis
Yellow arrow = thickened ary-epiglottic folds

21. Ballooning of hypopharynx

23. 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

24. Methods of securing airway
Endotracheal intubation
Trans-nasal: preferred
Trans-oral
Percutaneous trans-laryngeal ventilation by needle cricothyrotomy
Tracheostomy: last resort for acute stridor

25. 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

26. Laryngo-Tracheo-Bronchitis (LTB)

27. 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

28. 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

29. 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

30. Church Steeple sign

33. 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

36. 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

37. 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.

38. 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

39. Chronic Laryngitis

40. 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

41. 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.

42. Chronic hyperemic laryngitis

43. 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

44. Chronic hyperplastic laryngitis

45. Chronic hyperplastic laryngitis

46. 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

47. 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

48. 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

49. Reinke’s edema

50. 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

51. Reinke’s space

52. 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

53. 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

54. Reinke’s edema

55. 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

56. Vocal cord stripping

57. Removal of edematous tissue

58. Trimming & re-draping

59. Pre-op vs. post-op

60. Angio-neurotic edema

61. 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

62. 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

63. 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

64. Laryngeal Tuberculosis

65. 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

66. 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

67. Symptoms History of pulmonary TB
Weakness of voice followed by hoarseness
Cough with hemoptysis
Throat pain
Referred earache
Dysphagia & odynophagia due to perichondritis

68. 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

69. Moth eaten ulcerations

70. Management Diagnosis Direct laryngoscopy & biopsy
Chest X-ray, P.A. view
Sputum for A.F.B.
Treatment
Anti-tubercular medication for 9 months

71. Laryngo-pharyngeal reflux disease (LPRD)

72. GERD vs. LPRD

73. 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

74. 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

75. Acid laryngitis

76. 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

77. 24 hour ambulatory double-probe pH monitoing

79. pH metry

80. 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

81. 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

82. 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

83. Thank You