ACUTE & CHRONIC INFLAMMATIONS OF

LARYNX

ACUTE LARYNGITIS• INFECTIOUS*• Following URTI• Initially viral 2’ bacterial invasion

• Streptococcus pneumonia• H influenza• Hemolytic streptococco• Staphylococci

• Exanthematous fevers (measles, chicken pox,whooping cough)

• NON INFECTIOUS• Vocal abuse ,allergy,thermal /chemical burns (inhalation/ingestion)• Laryngeal trauma (endotracheal tube intubation)

CFs

• Symptoms• Hoarseness of voice • Discomfort / pain in throat after talking• Dry irritating cough (worse at night)• General symptoms

• Head cold• Rawness /dryness• Malaise • Fever (if viral infn of URT)

Laryngeal appearance

• In early stage • Erythema & edema of epiglottis ,aryeppiglotic folds , arytenoids & ventricular

bands• Vocal cord are white & normal (in comparison to surrounding structures)

• In late stage • ↑ hyperaemia & swelling• Vocal cord red & swollen• Subglottic region is also involved• Sticky secretions b/w vocal cords & interarytenoid region

• Vocal abuse • Submucosal hemorrhages in vocal cords

Treatment

• Vocal rest• Avoidance of smoking & alcohol• Steam inhalation with eucalyptus oil,pine,tr benzoin co• Cough sedative• Abx• Analgesics• Steroids following chemical; & thermal burns

Acute membranous laryngitis

• Pyogenic nonspecific organisms• May begin in laynx /as an extension fron pharynx• DD laryngeal diphtheria

Acute epiglottitis/supraglottic laryngitis• Inflammation of supraglottic structures (epiglottis,aryepiglottic

folds,arytenoids)• Marked edema obstrn

• Etiology • Children 2-7 yrs*• H influenza type B*

• CFs• Abrupt with rapid progression• Sore throat & dysphagia in adults• Stridor & dyspnea in children• Fever (d/t septicemia)

Examination

• Depress tongue with a tongue depressor• Edematous red & swollen epiglottis

• Indirect laryngoscopy• Edema & congestion of supraglottic structures• Not done for fear of precipitating complete obstruction

Lateral soft tissue xray of neck THUMB SIGN

Treatment

• Hospitalisation• Abx (ampicillin /3rd generation cephalosporins im/iv) • Steroids (hydrocortisone /dexamethasone im/iv ↓edema)• Adequte hydration (fluids)• Humidification & o2(mist tent & croupette)• Intubation & tracheostomy

Acute laryngo trachea bronchitis• Inflammation of Lx,trachea & bronchitis

• M>F• 6 months – 3 years children *• Para influenza type 1 & 2• 2’ bacterial invasion (gram +ve cocci)

Pathology

Edema of loose areolar tissue ↓Respiratory obstruction & stridor

Thick tenacious secretions & crusts↓

Complete occlusion

symptomatology

• URTI• Hoarseness of voice• Croupy cough• Fever 39-40*C• difficulty in breathing• Inspiratory type of stridor• Supra sternal & intercostal recession

treatment

• Hospitalisation • Abx ampicillin 50 mg/kg/day• Humidification• Parenteral fluids• Steroids hydrocortisone 100mg iv• Adrenaline} ↓ dyspnea• Intubation /tracheostomy

Laryngeal diphtheria

• 2’ to faucial diphtheria• Children <10 yrs

• Pathology • Pseudomembrane formation obstruction of lx• Exotoxin myocarditis & neurological

CFs

• General • Insidious • Low grade fever (100-101*F)• Sore throat• Malaise

• Laryngeal • Hoarse voice• Croupy cough• Respiratory stridor• Increasing dyspnea• Marked upper airway obstn

• Greyish white membrane on tonsil palate & pharynx • adherent bleeds on removal

Buul neck due to cervical lymphadenopathy

diagnosis

• Clinical • Smear & culture

treatment

• Diphtheria antitoxin • Based on severity & duration • 20,000-1,00,000 u

• Abx • Benzyl penicillin 5,00,000 u im qid *6days• Erythromycin

• Maintenance of airway • Tracheostomy• Direct larngoscopy removal of membrane & intubation• Complete bed rest

complications

• Air way obstructionAsphyxia & death• Toxic myocarditis & circulatory failure• Palatal paralysis nasal regurgitation• Laryngeal & pharyngeal paralysis

Edema of larynx

• Supra glotttic & sub glottis region *(abundant subepithelial connective tissue)• Vocal cords rare(sparse connective tissue)

etiology

• Infections • a/c epiglottitis , laryngo trachea bronchitis, tuberculosis or syphilisnof larynx• Infection in neighbourhood }

• Peritonsillar abscess,retropharyngeal abscess,ludwings angina

• Trauma : • Surgery of tongue , laryngeal trauma,fb,endoscopy , inhalation ,irritant gases, thermal ,

chemical burns, intubation

• Neoplasm • Ca of lx, laryngopharynx often ass with deep ulceration

• Allergy• Angioneurotic edema,anaphylaxis

• Radiation • Systemic diseases

Symptoms & signs

• Airway obstruction• Inspiratory stridor• Indirect laryngoscopy• Edema of supraglottic & subglottic region

• Treatment

• Intubation/tracheostomy• Steroids(thermal/chemical)• Adrenaline (1:1000) 0.3-0.5 ml im repeated evey 15 minute (allergic)

Chronic laryngitis

• Chronic laryngitis with out hyperplasia (chronic hyperaemic laryngitis)• Chronic hypertrophic laryngitis

Chronic laryngitis with out hyperplasia (chronic hyperaemic laryngitis)

• Diffuse & symmetrical involvement of whole of larynx• (true cords ,ventricular bands , inter arytenoid region , root of

epiglottis)

Etiology

• Incompletely resolved a/c simple laryngitis/its recurrent attacks• Presence of c/c infn in paranasal sinuses , teeth & tonsil & chest• Occupational } dust & fumes • Smoking & alcohol• Vocal abuse• Persistent trauma of cough as in c/c lung disease

Clinical features

• Hoarseness • Easily gets tired & patient becomes aphonic by the end of the day

• Constant hawking • Dryness & intermittent tickling } repeated clearing

• Discomfort in throat• Dry & irritating cough

Laryngeal examination

• Hyperaemia of laryngeal structures• Vocal cord } dull red & rounded• Fleks of viscid mucus in interarytenoid in the vocal cords

Treatment

• Eliminate URTI & LRTI (sinusitis,tooth,c/c chest infection)• Avoidance of irritating factors (smoke,dust,alcohol)• Voice rest & speech therapy• Steam inhalation• Expectorant

Chronic hypertrophic laryngitis

• Present either as• Diffuse & symmetrical• Localised (like a tumour)

• Dysphonia plica ventricularis• Vocal nodules• Vocal polyp• Reinkes edema• Contact ulcer

Etiology

• Same as Chronic laryngitis with out hyperplasia

Pathology

Hyperaemia, edema & cellular infiltration of submucosa

EPITHELIAL CHANGES • PSEUDOSTRATIFIED SQUAMOUS TYPE• SQUAMOUS EPITHELIM OF VOCAL

CORDS • HYPERTROPHY & KERATINISATION

HYPERTROPHY OF MUCUS GLANDSATROPHY LATER (diminished secretion & dryness

Starts in glottic regionVentricular bandsBase of epiglottis Even subglottis

CFs

• Hoarseness • Easily gets tired & patient becomes aphonic by the end of the day

• Constant hawking • Dryness & intermittent tickling } repeated clearing

• Discomfort in throat• Dry & irritating cough

Laryngeal examination

• On examination, changes are often diffuse and symmetrical.• 1. Laryngeal mucosa } dusky red and thickened.• 2. Vocal cords } red and swollen. Their edges lose sharp demarcation

and appear rounded. In late stages, cords become bulky and irregular giving nodular appearance.• 3. Ventricular bands } red and swollen• 4. • oedema and infiltration, • later due to muscular atrophy • arthritis of the cricoarytenoid joint.

Mobility of cords gets impaired

Treatment

• Conservative• Same as for chronic laryngitis without hyperplasia.

• Surgical• Stripping of vocal cords, removing the hyperplastic and oedematous mucosa,

may be done in selected cases.• Damage to underlying vocal ligament should be carefully avoided. One cord is

operated at a time.

POLYPOID DEGENERATION OF VOCAL CORDS (REINKE'S OEDEMA)

• b/l symmetrical swelling of the whole of membranous part of the vocal cords, • in middle-aged men and women. • due to oedema of the subepithelial space (Reinke's space) of the vocal

cords.

Etiology

• Chronic irritation of vocal cords • due to misuse of voice,• heavy smoking, • chronic sinusitis and • laryngopharyngeal reflex

• myxoedema

CFs

• Hoarseness• Low pitched & rough voice(d/t use of false vocal cords)

• On indirect laryngoscopy• Vocal cords are fusiform pale translucent look• Ventricular folds hyperaemic & hypertrophic and hides

true vocal cords

Treatment

• Decortication of vocal cords• Removal of strip of epithelium is done first on one side & 3-4 wks later on

other side

• Voice rest

• Speech therapy for proper voice production

Pachydermia laryngis

• Form of c/c hypertrophic laryngitis • Affecting posterior part of larynx in the region of inter arytenoid &

posterior part of vocal cords

Etiology • Uncertain • Alcohol & smoking• Forceful talking• Gastro esophageal reflux disease (where postr part of lx is constantly washed

with acid juices)

CFs

• hoarseness or husky voice and irritation in the throat. • Indirect laryngoscopy • heaping up of red or grey granulation tissue in the interarytenoid region and

posterior thirds of vocal cords; the latter sometimes showing ulceration due to constant hammering of vocal processes as in talking, forming what is called the 'contact ulcer'. • bilateral & symmetrical.• It does not undergo malignant change.

• biopsy of the lesion • differentiate the lesion from carcinoma and tuberculosis.

Treatment

• Removal of granulation tissue under operating microscope• Control of acid reflux• Speech therapy

Atrophic laryngitis

• Atrophy of laryngeal mucosa & crust formation• Ass with atrophic rhinitis & pharyngitis• Women*

• CFs• Hoarseness of voice improving on coughing & removal of crusts• Dry irritating cough• Dyspnea(obstructing crusts)

• Examination • Atrophic mucosa covered with foul smelling crusts• Expulsion of crusts excoriation & bleeding

• treat,ment • Elimination of causative factor & humidification• Laryngeal sprays with glucose in glycerine /pine oil } loosen the crusts• Trt ass nasal & pharyngeal conditions• Expectorants to loosen the crusts

Tuberculosis of larynx

• Always 2’ to pulmonary tuberculosis• Hematogenous • Bronchogenic

• Males in middle age grp

• Pathology • Posterior >anterior• Parts = inter arytenoid fold ,ventricular fold , vocal cords , epiglottis

• Bronchogenic spread From bronchi (Tubercle bacilli carried by sputum)

↓Penetrate intact laryngeal mucosa (particularly inter arytenoid region)

↓Formn of submucosal tubercles

↓Ulceration & caseation

• Laryngeal mucosa } red & swollen ( pseudo edema due to cellular infiltration)• Perichondritis & cartilage necrosis

• Symptoms & signs• Weakness of voice hoarseness of voice• Ulceration – pain radiating to ears• Dysphagia

Laryngeal examination

• Hyperaemia of the vocal cord • In its whole extent• Or its posterior part with impairement of adduction (first sign)

• Mamillated swelling in interarytenoid region• Ulceration of larynx } mouse nibbled appearance• Superficial ragged ulceration in arytenoid & interarytenoid region• Granulation tissue in interarytenoid /vocal process of arytenoid• Pseudoedema of epiglottis (turban epiglottis)• Swelling of ventricular bands & aryepiglottic folds• Marked pallor of surrounding mucosa

• Diagnosis• X ray chest • Sputum examin• Biopsy of laryngeal lesion

• Treatment • Same as pulmonary TB

Lupus of the larynx

• Indolent tubercular infn ass with lupus of nase & pharynx• No pulmonary tb• Painless asymptomatic• Posterior >anterior• Epiglottis aryepiepiglottic folds v entricular bands• Trt anitubercular drugs

Syphilis of larynx

• Rare • Gumma of Tertiary stage any where in larynx• Smooth swelling which may ulcerate later• Complication laryngeal stenosis

Leprosy of larynx

• Rare• Leprosy of skin & nose• Diffuse nodular infiltration of epiglottis, aryepiglottic folds &

arytenoids• Dx : biopsy• Complication : laryngeal stenosis

• Deformity of laryngeal inlet

Scleroma of larynx

• c/c inflammatory condition by klebsiella rhinoscleromatis• Nasal involvement +/-

• smooth red swelling in the subglottic region.• Hoarseness of voice, • wheezing and• dyspnoea .

• Dx biopsy.• Treatment streptomycin or tetracycline + steroids to prevent fibrosis.

Subglottic stenosis is a frequent complication requiring subsequent reconstructive surgery.

• LARYNGEAL MYCOSIS• Fungal infections such as candidiasis, histoplasmosis and

blastomycosis may rarely affect the larynx. Diagnosis is usually made on biopsy and• on finding a similar lesion in other parts of the body.