Diseases of larynxDiseases of larynx

Dr. Manal BukhariDr. Manal Bukhari

King Saud University King Saud University OtolaryngologyOtolaryngology

Assistant professorAssistant professor consultant Phonosurgeon consultant Phonosurgeon King Abdulaziz University King Abdulaziz University

LarynxLarynx

Skeletomembranous framework of larynxSkeletomembranous framework of larynx

Thyroid cartilage Thyroid cartilage

Cricoid cartilageCricoid cartilage

paired arytenoids paired arytenoids cartilage cartilage

EpiglottisEpiglottis

Hyoid boneHyoid bone

Thyroid cartilageThyroid cartilage : :– Shield likeShield like

Cricoid cartilageCricoid cartilage : :– Signet ring shaped. Signet ring shaped. – the only complete skeletal ring the only complete skeletal ring

for the air way.for the air way.

♦♦Both thyroid and cricoid Both thyroid and cricoid cartilage cartilage ►► hyaline hyaline ►► calcification calcification

– Cricothyroid jointCricothyroid joint Synovial joint Synovial joint ►► hinge motion hinge motion

ArytenoidArytenoid cartilagecartilage : :– Pyramidal shapedPyramidal shaped

– Apex ,vocal &Apex ,vocal & muscular muscular process.process.

– Cricoarytenoid jointCricoarytenoid joint SynovialSynovial

rocking motion rocking motion

Corniculate and cuneiform Corniculate and cuneiform cartilage:cartilage:

Epiglottic cartilage :Epiglottic cartilage :Leaf like structure Leaf like structure

Elastic cartilage Elastic cartilage

– Thyroepiglottic ligamentThyroepiglottic ligament– Hyoepiglottic ligamentHyoepiglottic ligament– glossoepiglottic fold ► glossoepiglottic fold ►

valleculaevalleculae

Laryngeal membranes : Laryngeal membranes :

– Quadrangular membraneQuadrangular membrane..

Upper and lower border Upper and lower border

►►thickened thickened

aryepiglottic fold aryepiglottic fold

Vestibular foldVestibular fold

– Triangular membraneTriangular membrane (conus elasticus). (conus elasticus).

Medial and lateral border Medial and lateral border

is freeis free►► thickened thickened

►►vocal ligamentvocal ligament

Laryngeal mucosa :Laryngeal mucosa :

– All mucosa from trachea to All mucosa from trachea to aryepiglottic fold aryepiglottic fold ►ciliated ►ciliated columnar epitheliumcolumnar epithelium..

– ☼☼ except vocal cord and except vocal cord and aryepiglottic fold aryepiglottic fold ►►squamous epitheliumsquamous epithelium

Laryngeal musculatureLaryngeal musculature::

– Extrinsic depressors.Extrinsic depressors. (C1-C3)(C1-C3)

Sternohyoid sternothyroid Sternohyoid sternothyroid thyrohyoid, omhyoid.thyrohyoid, omhyoid.

– Extrensic elevators.Extrensic elevators. Genohyoid (C1), diagastric Genohyoid (C1), diagastric (CNV-CNVII) mylohyoid (CNV-CNVII) mylohyoid (v) stylohyoid (VII)(v) stylohyoid (VII)

Intrinsic musculature Intrinsic musculature

AbductorsAbductors : :

– posterior posterior cricoarytenoid cricoarytenoid (PCA)(PCA)

Adductors:Adductors:

– thyroarytenoid thyroarytenoid (TA) ,lateral (TA) ,lateral cricoarytenoid cricoarytenoid (LCA) ,cricothyroi(LCA) ,cricothyroid, interarytenoid d, interarytenoid

Histopathology Histopathology

– Vocal cord layersVocal cord layers

Histology:Histology: Squamous epitheliumSquamous epithelium

Lamina propria Lamina propria superficial layer superficial layer Reink’s spaceReink’s space

Intermediate layer.Intermediate layer.

Deep layer. Deep layer. – Intermediate + deep Intermediate + deep

layers =vocal layers =vocal ligamentligament

Vocalis Vocalis ((thyroarytenoid thyroarytenoid muscle)muscle)

Blood supply :Blood supply :– Superior and inferior laryngeal artery Superior and inferior laryngeal artery

and veins.and veins.

lymphatic drainagelymphatic drainage: : – above vocal cord above vocal cord ►► up deep up deep

cervical lymph node. cervical lymph node.

– Below vocal cord lower Below vocal cord lower ►►deep deep cervical nodecervical node

Nerve supplyNerve supply::– Superior laryngeal nerveSuperior laryngeal nerve

Internal branch (sensory) Internal branch (sensory) +superior laryngeal artery .+superior laryngeal artery .External branch External branch ►►cricothyroid musclecricothyroid muscle

– Recurrent laryngeal nerveRecurrent laryngeal nerve – RT sideRT side: crosses the : crosses the

subclavian artery subclavian artery

– LT sideLT side: arises on the arch : arises on the arch of the aorta deep to of the aorta deep to ligamentum arteriosum ligamentum arteriosum

– it is divided behind the it is divided behind the cricothyroid jointcricothyroid joint

Motor ►all the intrinsic Motor ►all the intrinsic muscles except ?muscles except ?Sensory Sensory

Pediatric airway anatomyPediatric airway anatomy

The neonates are obligate nasal breathers The neonates are obligate nasal breathers until 2 months .until 2 months .

The epiglottis at birth is omega The epiglottis at birth is omega ΏΏ shaped shaped

the infants have high larynx C1-C4the infants have high larynx C1-C4

Applied physiology of the larynx

Protection of the lower air passages

Phonation :

Respiration

Applied physiology of the larynxApplied physiology of the larynx

Protection of the lower air passagesProtection of the lower air passages– Closure of the laryngeal inlet Closure of the laryngeal inlet – Closure of the glottis Closure of the glottis – Cessation of respiration Cessation of respiration – Cough reflex (forced expiration is made Cough reflex (forced expiration is made

against a closed larynx against a closed larynx

Phonation :Phonation :Voice is produced by vibration of the vocal cord Voice is produced by vibration of the vocal cord

Source of energy is the airflow Source of energy is the airflow

Normal vocal fold vibration occurs vertically from Normal vocal fold vibration occurs vertically from inferior to superiorinferior to superior

The mouth ,pharynx ,nose ,chest (The mouth ,pharynx ,nose ,chest (resonating resonating chambers)chambers)

Respiration Respiration

Voice mechanismVoice mechanism

Speaking involve a Speaking involve a voice mechanism that voice mechanism that is composed of three is composed of three subsystems.subsystems.

Air pressure systemAir pressure system Vibratory systemVibratory system Resonating system Resonating system

The “spoken word” result The “spoken word” result from three components of from three components of voice production voice production ::

Voiced sound, resonance, and Voiced sound, resonance, and articulation articulation

Voiced sound Voiced sound :the basic sound produced :the basic sound produced by vocal fold vibration “buzzy sound”by vocal fold vibration “buzzy sound”

ResonanceResonance: voiced sound is amplified and : voiced sound is amplified and modified by the vocal tract resonators modified by the vocal tract resonators ( throat, mouth cavity ,and nasal passages ( throat, mouth cavity ,and nasal passages ))

ArticulationArticulation: the vocal tract articulators (the : the vocal tract articulators (the tongue ,soft palate, and lip) modify the tongue ,soft palate, and lip) modify the voiced sound voiced sound

Vocal fold vibrate rapidly in sequence of Vocal fold vibrate rapidly in sequence of vibratory cycles with a speed of about:vibratory cycles with a speed of about:

110 cycles per second (men)= lower pitch110 cycles per second (men)= lower pitch

180 to 220 cycles per second 180 to 220 cycles per second (women)=medium pitch(women)=medium pitch

300 cycles per second (children)= higher 300 cycles per second (children)= higher pitchpitch

Louder voice : increase in amplitude of Louder voice : increase in amplitude of vocal fold vibration vocal fold vibration

Vocal cord vibration Vocal cord vibration

Bernoulli effectBernoulli effect

Laryngeal sphinctersLaryngeal sphincters– True vocal cord True vocal cord – false vocal cordfalse vocal cord– Aryepiglottic sphincter Aryepiglottic sphincter

Evaluation of the dysphonic patientEvaluation of the dysphonic patient

HISTORY HISTORY – Dysphonia (hoarseness)Dysphonia (hoarseness)

URTI,fever ,cough ,(voice ,tobacco or alcohol abuse ), URTI,fever ,cough ,(voice ,tobacco or alcohol abuse ), dysphagia ,aspiration , breathing difficulty ,wt dysphagia ,aspiration , breathing difficulty ,wt lost ,GERD ,trauma , previous surgery .lost ,GERD ,trauma , previous surgery .

EXAMINATIONEXAMINATIONIndirect laryngoscope (mirror)Indirect laryngoscope (mirror)

Direct laryngoscopeDirect laryngoscope

Fibreoptic flexible scope Fibreoptic flexible scope

Stroboscopy Stroboscopy

Acoustic analysis Acoustic analysis

THANK YOUTHANK YOU

Disease of the larynxDisease of the larynx

Congenital abnormalities of the larynxCongenital abnormalities of the larynx : :

LaryngomalaciaLaryngomalacia– most common cause of stridor in neonate and infants most common cause of stridor in neonate and infants

Laryngeal findingLaryngeal finding : :– Inward collapse of aryepiglottic fold (short) into laryngeal inlet during inspiration .Inward collapse of aryepiglottic fold (short) into laryngeal inlet during inspiration .– Epiglottis collapses into laryngeal inlet.Epiglottis collapses into laryngeal inlet.

SSX:SSX:– intermittent inspiratory stridor that improve in prone position .intermittent inspiratory stridor that improve in prone position .

DX:DX:– HX and endoscopyHX and endoscopy

RX: RX: – observation observation – Epiglottoplasty Epiglottoplasty – Tracheostomy Tracheostomy

Subglottic stenosis :Subglottic stenosis :– Incomplete recanalization,small cricoid ring Incomplete recanalization,small cricoid ring

types:types:– membranousemembranouse– Cartilaginous Cartilaginous – mixed mixed

Grades: Grades: – I <70%I <70%– II 70-90%II 70-90%– III 91-99%III 91-99%– IV complete obstruction IV complete obstruction

SSX SSX :biphasic stridor ,failure to thrive .:biphasic stridor ,failure to thrive .

DXDX: chest and neck X-ray ,flexible endoscope : chest and neck X-ray ,flexible endoscope RX:RX: tracheotomy tracheotomy

– grade I - IIgrade I - II ; ; endoscope (endoscope (CO2 or excision with dilation )CO2 or excision with dilation )

Grade III –IVGrade III –IV: : open proceduresopen procedures::

Ant cricoid split Ant cricoid split LTR OR CTR LTR OR CTR

Laryngeal web:Laryngeal web:– incomplete decanalizationincomplete decanalization

Types:Types:– SupraglotticSupraglottic– GlottisGlottis– Subglottic Subglottic

SSX:SSX:– weak cry at birth ,variable degrees of respiratory weak cry at birth ,variable degrees of respiratory

obstruction obstruction DX:DX: flexible endoscope flexible endoscope Rx Rx ::

– no treatment no treatment – laser excision laser excision – open procedure+ tracheostomyopen procedure+ tracheostomy

Subglottic haemangiomaSubglottic haemangioma

Most common in subglottic space Most common in subglottic space – 50%50% of subglottic hemangiomas associated with cutaneous of subglottic hemangiomas associated with cutaneous

involvement involvement Types: Types:

– capillary (typically resolve)capillary (typically resolve)– Cavernous Cavernous

SSXSSX: biphasic stridor : biphasic stridor DX DX :endoscope:endoscope RX: RX:

– observationobservation– Crticosteroid Crticosteroid – CO2 LASER CO2 LASER

Traumatic conditions of the larynxTraumatic conditions of the larynx – Direct injuries (blows)Direct injuries (blows)– Penetration (open) Penetration (open) – Burns (inhalation , corrosive fluids)Burns (inhalation , corrosive fluids)– Inhalation foreign bodiesInhalation foreign bodies– Intubations injuries :Intubations injuries :

Prolonged intubation Prolonged intubation Blind intubation Blind intubation too large tube too large tube

– pathology :pathology :Abrasion ► granulomatous formation ….subglottic Abrasion ► granulomatous formation ….subglottic

stenosisstenosisSSX; hoarsness , dyspnoeaSSX; hoarsness , dyspnoeaRX: RX:

– voice rest voice rest – endoscopic removal endoscopic removal – prevention prevention

Vocal fold lesions secondary to vocal abuse and Vocal fold lesions secondary to vocal abuse and

traumatrauma Vocal nodules (singer’s nodulesVocal nodules (singer’s nodules))

– At junction of ant 1/3 and mid 1/3 At junction of ant 1/3 and mid 1/3 – RX :RX :

voice therapy voice therapy surgical excision surgical excision

Vocal fold polyp :Vocal fold polyp :– Middle and ant 1/3 , free edge , unilateral Middle and ant 1/3 , free edge , unilateral – Mucoid , hemorrhagic Mucoid , hemorrhagic – RX :RX :

surgical excisionsurgical excision

Vocal fold cyst ;Vocal fold cyst ;

– congenital dermoid cyst congenital dermoid cyst

– mucus retention cyst mucus retention cyst

– RX: RX: surgical excision surgical excision

Reinke’s edemaReinke’s edema– RX:RX:

voice rest ,stop smoking voice rest ,stop smoking surgical excisionsurgical excision

LaryngoceleLaryngocele

– Air filled dilation of the appendix of the Air filled dilation of the appendix of the ventricle ,communicates with laryngeal lumen ventricle ,communicates with laryngeal lumen

– congenital or acquired congenital or acquired

types :types :– External : through thyrohyoid membrane External : through thyrohyoid membrane – Internal :Internal :– Combined Combined

RxRx :marsupialization :marsupialization

Vocal cord paralysisVocal cord paralysis

Causes: Causes: – Adult Adult

Neoplastic Neoplastic Iatrogenic :Iatrogenic :Idiopathic Idiopathic TraumaTraumaNeurological Neurological infectious infectious systemic diseases systemic diseases ToxinsToxins

– children children Arnold chiari malformation Arnold chiari malformation Birth trauma Birth trauma

SSX:SSX:DysphoniaDysphonia

ChockingChocking

Stridor Stridor

Vocal cord position :Vocal cord position :Median ,paramedian ,cadMedian ,paramedian ,cad

averic averic

– Rx Rx ::Self limiting or permanent Self limiting or permanent

paralysisparalysis

– For medializationFor medialization : :Vocal cord injectionsVocal cord injections

– Gelfoam, fat, collagen, Gelfoam, fat, collagen, Teflon.Teflon.

ThyroplastyThyroplasty

– For lateralizationFor lateralization:: cordotomy cordotomy ThyroplastyThyroplastytracheotomytracheotomy

Inflammation of the larynxInflammation of the larynx Acute viral laryngitisAcute viral laryngitis::

– Rhinovirus, parainfluenza Rhinovirus, parainfluenza SSX:SSX:

– dysphonia , fever coughdysphonia , fever cough Rx:Rx:

– conservative conservative

Acute epiglottis :Acute epiglottis :– Haemophilis influnzae BHaemophilis influnzae B– 2-6 years2-6 years

SsxSsx::– fever , dysphagia ,drooling ,dyspnea, sniffing position , no cough, normal voice.fever , dysphagia ,drooling ,dyspnea, sniffing position , no cough, normal voice.

DXDX : :– x-ray (thumbprint sign)x-ray (thumbprint sign)

Rx:Rx: – do not examine the child in ERdo not examine the child in ER– Intubation in OR Intubation in OR – IV abx IV abx – corticosteroid corticosteroid

Croup (laryngotracheobronchitisCroup (laryngotracheobronchitis ) )

– Primary involves the subglotticPrimary involves the subglottic– Parainfluenza 1-3Parainfluenza 1-3– 1-5 years 1-5 years

SSX: SSX: – biphasic stridor, fever , brasssy cough , hoarseness , no biphasic stridor, fever , brasssy cough , hoarseness , no

dysphagia dysphagia DX: DX:

– x-ray ,steeple sign x-ray ,steeple sign RX: RX:

– humidified oxygen,racmic epinephrine ,steroidhumidified oxygen,racmic epinephrine ,steroid

Diphtheritic laryngitis Diphtheritic laryngitis

Causes:Causes:– Corynebacterium diphtheriae Corynebacterium diphtheriae

Ssx:Ssx:– Cough ,stridor ,dysphonia , feverCough ,stridor ,dysphonia , fever– Greyish –white membraneGreyish –white membrane

Treatment:Treatment:– Antitoxin injection Antitoxin injection – Systemic pencillinSystemic pencillin– Oxygen Oxygen – tracheostomytracheostomy

Fungal laryngitis :Fungal laryngitis :Immunocompromised Immunocompromised candidiasis ,aspergillosis candidiasis ,aspergillosis

– Ssx: Ssx: dysphonia ,cough odynophagia dysphonia ,cough odynophagia

– RX:RX: antifungal regimenantifungal regimen

Recurrent respiratory papillomatosis:Recurrent respiratory papillomatosis:

– 2/3 before age 15 2/3 before age 15 – rarely malignant change rarely malignant change – HPV 6-11HPV 6-11

Risks:Risks:– younger first time mother (condyloma acuminata)younger first time mother (condyloma acuminata)– Lesions: wart like (cluster of grapes )Lesions: wart like (cluster of grapes )– Types :Types :

juvenilejuvenile SenileSenile

– SSX:SSX: Hoarseness stridorHoarseness stridor

– RX;RX; laser excision ,microdebrider laser excision ,microdebrider Adjunctive therapy: acyclovir , interferon …Adjunctive therapy: acyclovir , interferon …

Malignant neoplasms of the larynxMalignant neoplasms of the larynx 1-5 % of all malignancies 1-5 % of all malignancies All are squamous cell carcinomas ;All are squamous cell carcinomas ; Ssx:Ssx:

– Hoarseness ,aspiration, dysphagia , stridor , wight lost Hoarseness ,aspiration, dysphagia , stridor , wight lost risks:risks:

– Smoking ,alcohol ,radiation exposure .Smoking ,alcohol ,radiation exposure .

Classification :Classification : Supraglottic :Supraglottic :

– 30-40-% of laryngeal Ca 30-40-% of laryngeal Ca – 25-75% nodal metastasis 25-75% nodal metastasis

Glottic:Glottic:– 50-75% 50-75% – Limtted regional metastasis Limtted regional metastasis

Subglottic :Subglottic :– Rare Rare – 20% regional metastasis 20% regional metastasis

RX RX ::– Radiotherapy Radiotherapy – hemilaryngectomy . Total laryngectomy + neck dissection hemilaryngectomy . Total laryngectomy + neck dissection