Presentation is loading. Please wait.

Presentation is loading. Please wait.

Diseases of Pharynx and Larynx

Similar presentations

Presentation on theme: "Diseases of Pharynx and Larynx"— Presentation transcript:

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

Download ppt "Diseases of Pharynx and Larynx"

Similar presentations

Ads by Google