Transcript Inflammatory disorders of larynx

Inflammatory
Disorders of
Larynx
Dr. Vishal Sharma
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)
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
Acute (simple)
Laryngitis
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
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
Flexible laryngoscopy
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
Acute Epiglottitis
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
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)
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
Tripod sign
• Pt appears anxious
• Leans forward with
support of both
forearms
• Extends neck in an
attempt to maintain
an open airway
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
Flexible laryngoscopy
• Inflamed cherry-red
epiglottis
• Thickened
aryepiglottic folds
• Edematous
arytenoid cartilages
Post-intubation direct
laryngoscopy
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
X-ray soft tissue neck
X-ray soft tissue neck
• Red arrow = enlarged epiglottis
• Yellow arrow = thickened ary-epiglottic folds
Ballooning of hypopharynx
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
Methods of securing airway
• Endotracheal intubation
– Trans-nasal: preferred
– Trans-oral
• Percutaneous trans-laryngeal ventilation by
needle cricothyrotomy
• Tracheostomy: last resort for acute stridor
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
Laryngo-TracheoBronchitis (LTB)
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
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
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
Church Steeple sign
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
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
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.
Acute
Viral croup Bacterial
epiglottitis
croup
Spasmodic
croup
R.P.
abscess
Age (yr)
3-7
1-3
1-8
1-3
1-3
Voice
Normal or
muffled
Hoarse
Hoarse
Hoarse
Hoarse
Cough
Absent
Barking
seal-like
Barking
seal-like
Barking
seal-like
Absent
Stridor
Inspiratory
Biphasic
Biphasic
Biphasic
Inspiratory
Dysphagia
+ drooling
Severe
Absent
Absent
Absent
Severe
Fever
> 102 F
< 102 F
> 102 F
< 102 F
> 102 F
Posture
Quiet,
sitting
Restless,
supine
Restless,
supine
Restless,
supine
Restless,
sitting
Chronic Laryngitis
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
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.
Chronic hyperemic laryngitis
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
Chronic hyperplastic laryngitis
Chronic hyperplastic laryngitis
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
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
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
Reinke’s edema
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
Reinke’s space
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
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
Reinke’s edema
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
Vocal cord stripping
Removal of edematous tissue
Trimming & re-draping
Pre-op vs. post-op
Angio-neurotic edema
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
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
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
Laryngeal
Tuberculosis
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
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
Symptoms
• History of pulmonary TB
• Weakness of voice followed by hoarseness
• Cough with hemoptysis
• Throat pain
• Referred earache
• Dysphagia & odynophagia due to perichondritis
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
Moth eaten ulcerations
Management
• Diagnosis
– Direct laryngoscopy & biopsy
– Chest X-ray, P.A. view
– Sputum for A.F.B.
• Treatment
– Anti-tubercular medication for 9 months
Laryngo-pharyngeal
reflux disease (LPRD)
GERD vs. LPRD
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
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
Acid laryngitis
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
24 hour ambulatory double-probe
pH monitoing
pH metry
GERD
LPRD
Heartburn
++++
+
Hoarseness & dysphagia
+
++++
Nocturnal (supine) reflux
++++
-
Daytime (upright) reflux
+
++++
ed lower esophageal pH
++++
++
ed pharyngeal pH
-
++++
Pantoprazole treatment
40 mg OD 40 mg BD X
X 6 wk
6 mth
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
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
Thank You