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  #1 cause of acute laryngitis = viral  #1 cause of chronic laryngitis = reflux  Candidal laryngitis can occur in non immuno compromised  Even in setting of likely neoplasm, still consider infection

Laryngitis

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

Acute Laryngitis

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

 Supepithelial hemorrhage from phonotrauma

 Supepithelial hemorrhage of R VC polyp

Acute Laryngitis

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

Viral Laryngitis

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

Acute Laryngitis

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

Acute Bacterial Laryngitis

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

Acute Bacterial Laryngitis

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

Acute Laryngitis

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

Acute Fungal Laryngitis

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

Chronic Laryngitis

 Bacterial  Fungal  Mycobacterial  Non infectious

Chronic Bacterial Laryngitis

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

Chronic Bacterial Laryngitis

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

Chronic Laryngitis

 Bacterial  Fungal  Histoplasmosis  Blastomycosis  Cryptococcus  Coccidiomycosis  Mycobacterial  Non infectious

Histoplasmosis

Histoplasmosis SCCA

Histoplasmosis

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

Blastomycosis

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

Cryptococcus

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

Coccidiomycosis

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

Chronic Laryngitis

 Bacterial  Fungal  Mycobacterial  Non infectious

Mycobacterial Laryngitis

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

Chronic Laryngitis

 Bacterial  Fungal  Mycobacterial  Non infectious

Non Infectious Laryngitis

 Smoking  Pollution  Vocal Abuse  Rhinosinusitis  Laryngopharyngeal Reflux

LPR

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

LPR

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

Laryngeal and Tracheal Manifestations of Systemic Disease

 Key Points  Symptoms: hoarseness, cough, stridor, airway compromise  Mimic laryngeal carcinoma

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

Wegener’s Granulomatosis

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

Wegener’s Granulomatosis

Replapsing Polychondritis

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

Sarcoidosis

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

Sarcoidosis

Rheumatoid Arthritis

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

Pemphigus/Pemphigoid

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

Pemphigus/Pemphigoid

Amyloidosis

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