Transcript Diseases of Pharynx and Larynx - Surgical Students Society

Diseases of Pharynx
and Larynx
Anatomy of Pharynx
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Fibromuscular Tube
Base of Skull to C6 (12cm)
Divided into three parts
Nasopharynx
 Oropharynx
 Laryngopharynx
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4 Layers
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Mucosal, submucosal (Fibrous), Muscular, Fascial
layer (buccal pharyngeal)
Nasopharynx
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Base of skull to the soft
palate
Key components
Pharyngeal Tonsil
(Adenoids)
 Pharyngeal Recess (ICA)
 Opening of Auditory tube
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Oropharynx
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Soft Palate to the
epiglottis
Key Components
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Palatopharyngeal and
Palatoglossal arches
Palantine Tonsil – project
from tonsillar fossa
Lingual Tonsil
Valleculae – lie between
epiglottis and posterior
border of the tongue
Laryngopharynx
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Epiglottis to the level
of cricoid cartilage
Key features
Opening to the
larynx
 Piriform recess
(endoscope)
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Anatomy of Pharynx
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Blood supply
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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)
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Larynx
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Respiratory Organ
Lying between pharynx and trachea
 Becomes continuous with the trachea at the level of
the cricoid cartilage (C6)
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Function
Primary – protective sphincter at the inlet of the air
passages
 Phonation
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Larynx
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Components
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Cartilages
Singular; thyroid, cricoid, epigolittic
 Paired; Arytenoid, corniculate, cuneiform
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Joints
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Cricothyroid, cricoarytenoid
Ligaments and Membranes
Intrinsic; Quandrangular membrane, Cricothyroid
ligament (Vocal folds)
 Extrinsic; Thyrohyoid membrane, cricotracheal,
hypoepiglottic, thyroepiglottic ligaments, cricothyroid
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Cavities
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Inlet +
Vestibule
Rima of
glottis
Subglottic
space
Layrnx - Intrinsic Membranes
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Quadrangular membrane
Arytenoid Cartilage and epiglottis
 Lower border; vestibular folds (false cord)
 Upper border; aryepiglottic folds
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Cricovocal Membrane
Formed from lateral part of cricothyroid ligament
 Upper thickened border forms cricovocal ligaement
 Vocal folds which bounds the glottis anteriorly
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Laryngeal Muscles - Intrinsic
1. Those that alter size and shape of the inlet
Aryepiglottic Muscles
 Oblique arytenoids
 Thyroepiglottic muscles
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Act as Sphincter for the inlet
Provide valvular protection from above
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
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Phonation
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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
Larynx
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Blood supply
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Superior and Inferior Laryngeal Branches from Superior and
Inferior Thyroid Artery
Nerve Supply
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Recurrent Laryngeal Nerve
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External Layngeal Nerve
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All intrinsic Muscles except cricothyroid
Mucous Membranes below the folds
Cricothyroid muscle
Internal Laryngeal Nerve
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Mucous Membranes below the folds
Nerve Palsies
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Recurrent Laryngeal Nerve
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Number of causes
Left;
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Left or Right;
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Half abducted position with arytenoid cartilage slightly in front
Hoarse Voice
Bovine cough
Incomplete
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Iatrogenic, Trauma, Thyroid disease
Complete (Cadaveric Position)
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Carcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surg
Adducted position as posterior cricoarytenoid more susceptible
External Laryngeal Nerve
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Hoarse voice that recovers
Inability to hit high frequencies
Extrinsic Muscles
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Elevators
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Indirectly;
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Directly;
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Mylohyoid, digastric, stylohyoid, geniohyoid
Stlyopharyngeus, salingopharyngeus, palatopharyngeus
Depressors
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Sternohyoid, omohyoid stenothyroid
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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
Adenoid Hypertrophy
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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
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Ix
Nasopharyngeal Exam
 Nasopharyngoscopic Exam
 Lateral Xray
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Tx
Supportive
 Adenoidectomy
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Adenoidectomy
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Criteria for surgery
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Chronic upper airway obstruction with OSA +/- cor
pulmonale
Chronic serous/suppurative otitis media
Recurrent acute otitis media
Suspicion of nasopharyngeal malignancy
Chronic sinusitis
Complications
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Early Haemorrhage
Otitis media
Regrowth of residual adenoid tissue
Tonsillitis
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Commonest area of infection of head and neck
Clinical; Sore throat and Odynophagia, Otalgia,
headache, malaise, Fever, hyperaemic tonsils, cervical
lymphadenopathy
DDx;
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Viral
Group A Streptococcus (20-30%)
EBV; Palatal petechia
Diptheria; Unimmunised, grey membrane
Tx; Rest, paracetamol +/- ABx
Tonsillitis
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Complications;
Acute Otitis Media (most common)
 Peritonsillar abscess (Quinsy)
 GAS
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Post Strep GN
 Rhuematic Fever
 Scarlet Fever; Strawberry tongue and scarlitiform rash
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Recurrent Tonsillitis
 Tonsillar Hypertrophy
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Tonsillectomy
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Indications for surgery
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Absolute
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Relative
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Airway obstruction
Suspicion of malignancy
Sleep apnoea, mouth breathing, difficulty swallowing
Recurrent tonsillitis >5 episodes
Any complications
Complications
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Reactionary haemorrhage
Secondary haemorrhage
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5-10 days post op
Due to fibrinolysis aggravated by infection
Pharyngitis
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Acute
>70% Viral Cause, GAS
 Supportive Treatment
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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
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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
Nasopharyngeal Carcinoma
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Rare in Europe
Common in Asian countries
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Pathology
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20% of all malignancies in Hong Kong
Squamous cell/undifferentiated
Aietology
Unknown, however EBV plays a role
 Others; ingestion of preserved foods
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Nasopharyngeal Carcinoma
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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
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Nasopharyngeal Carcinoma
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Ix;
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Tissue sampling, CT/MRI, Staging
Management
Radiotherapy with concominant chemotherapy
 Poorly amendable to surgery due to anatomical
location
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DDx
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Lymphoma, cystic adenocarcinoma, Infection
Pathology of the Larynx
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Infectious
Inflammatory
Congenital
Mucosal
Malignancy
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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
Laryngotracheitis (Croup)
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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
Laryngotracheitis + Epiglottitis
Feature
Laryngotracheitis
Epiglottitis
Inflammation
Age
Onset
Fever
Stridor
Cough
Posture
Drooling
Radiograph
Appearance
Cause
Treatment
Subglottic space
4month-5 years
Gradual (days)
Low grade/afebrile
Biphasic/inspiratory
Barky
Supine
No
Steeple sign
Non-toxic
Viral
Supportive
O2, Adrenalin nebs
Steroids
Supraglottic space
1-4 years
Acute (hours)
High fevers
Inspiratory
Normal
Sitting
Yes
Thumb sign, enlarged epiglottis
Toxic/cyanotic
Bacterial
Keep child calm
Airway management -ETT
ABx, IV hydration, Moist air
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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
Foreign Body
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Usually stuck at right main bronchus
Anything that’s small enough
Presentation;
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Complications
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Stridor if at level of trachea
“Unilateral asthma” if bronchial
Atelectasis, lobar pneumonia, pneumothorax, mediastinal
shift
Dx;
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Inspiratory/Expiratory X-rays
Bronchoscopy
Signs of Airway Obstruction
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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
Upper Airway Obstruction Neonates
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Subglottic Stenosis
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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
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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
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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
Chronic Laryngitis
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Most common cause is GORD
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Clinically
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Recurrent Acute laryngitis
Heavy smoking
Chronic infection of nasal sinuses
Mouth breathing from nasal obstruction
Hoarseness or loss of voice
Spasmodic cough
DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis,
TB
General; Voice resting, avoid smoking
Specific; eg. Lifestyle modifications, Medications
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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
Laryngeal Trauma
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Rare
Causes
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Penetrating
Blunt trauma; majority are MVA’s, clothesline injuries, sporting
injuries
Manual strangulation
Inhaled flames
Swallowed poisons, foreign body
ETT
Injuries;
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Cricotracheal separation -> Asphyxia
Fractures of larynx, hyoid bone, joint disruption
Open wounds
Mucosal Tears
Laryngeal Injuries
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Presentation
Significant cervical trauma
 Hoarse voice, neck pain, dyspnea, hypoxia, aphonia
dysphasia
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Goals of treatment
Protect the airway; Intubation, tracheostomy
 Restoration of function; Surgical repair
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Complications
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Laryngeal stenosis; permanent tracheostomy
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33 year old male singing teacher
Progressively hoarse voice
Normal Cough
Non-smoker
No weight loss/fatigue
Benign Vocal Fold Lesions
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Reactive nodules (singers nodules)
Bilateral
 Smooth, rounded/pedunculated
 Small
 Located on true vocal folds
 Treatment;
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Voice training, re-education
 Rarely surgical if fibrosed, chronic
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Virtually never give rise to malignancy
Laryngocele
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Abnormal dilatation of the laryngeal ventricle
Contains air
Men>Women
Bilateral 25%
Aeitology;
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Acquired; Incr. Intraluminal pressure (musicians)
Congenital
SCC <15%
Hoarse voice, pain, dysphagia, lateral neck mass
Squamous Papilloma
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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
Investigation and Treatment
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Ix;
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Laryngoscopy
Tx;
CO2 Laser
 Surgical removal
 ?Antivirals
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55 year old male
History of GORD, cardiac disease
Recurrent hoarse voice
Right otalgia
Smoker + ETOH abuse
Squamous Cell Carcinoma
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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
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Squamous Cell Carcinoma
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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
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Squamous Cell Carcinoma
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Management
Eradication of disease
 Restoration of function; swallowing and speech
 Radiation treatment
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Especially early stage disease
 Cure rates equivalent to surgery
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Surgical Management
Emphasis on organ preservation
 Partial Larygectomy
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