1. Diseases of Pharynx and Larynx

2. 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)

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

4. 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

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

6. 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)

7. 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.

8. 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

9. Cavities
Inlet + Vestibule
Rima of glottis
Subglottic space

10. 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

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

12. 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

13. 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

14. 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.

15. 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

16. 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)

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

20. 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

21. 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,

22. 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

23. 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

25. 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

26. 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

28. 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

30. 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

31. 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,

32. 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

33. 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

34. 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

35. Pathology of the Larynx
Infectious
Inflammatory
Congenital
Mucosal
Malignancy

36. 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

37. 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

38. 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

40. 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

42. 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

44. 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

45. 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

46. 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

48. 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

49. 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

51. 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.

54. 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

56. 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.

57. 33 year old male singing teacher
Progressively hoarse voice
Normal Cough
Non-smoker
No weight loss/fatigue

58. 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

60. 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

61. 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

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

63. 55 year old male
History of GORD, cardiac disease
Recurrent hoarse voice
Right otalgia
Smoker + ETOH abuse

64. 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

65. 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

67. 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

68.
Learning Radiology
Clinical Cases and Osces in Surgery. Ramachandran, Poole
Apleys Orthopaedics