new infections of larynx

8/8/2019 New Infections of Larynx

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Infections of larynx

Drravikumar M.S(ENT)


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laryngitis

Acute laryngitis

Acute epiglottitis

Acutelaryngotracheobronchi

tis

Diphtheric laryngitis

Chronic laryngitis

tuberculosis

Scleroma Syphilis

leucoplakia


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Acute laryngitis Aetiology

Age

Infection or other URTI

Vocal misuse

Seasonal

Irritation

iatrogenic


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symptoms Hoarseness

Rawness

Pain

Cough

Stridor

Constitutional symptoms


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signs Congestion of vocal cords

Oedema

Exudate

White plaques-influenza

Movements of vocal cords


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Treatment Voice rest

Steam inhalation

Antibiotics

Anti-inflammatory drugs

Steriods

Endotracheal intubation


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Aetiology-

Age-2-7 years

Common organism-H.influenza B

Acute epiglottitis


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ACUTEEPIGLOTTITIS Classic symptoms-

abrupt onset ofhigh fever

sore throat, stridor, dysphagia, and

drooling, Usually no cough


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Acute epiglottitis P.E.- toxic-appearing, apprehensive, often

sits in tripod or sniffing position, voice

may be muffled, marked tenderness withpalpation ofhyoid


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investigations Blood exam-WBC RAISED

Predominance of polymorphonuclear leuco

Blood cultures


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investigations XRays- epiglottis is swollen thumbprint at

the base of the hypopharynx

Commonly vallecular space obscured Supraglottic ballooning


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X-ray


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EPIGLOTTITIS Airway Management- Try not to disturb

the patient!

Oxygen as needed Nebulized racemic epinephrine- decreases

airway edema

-for difficult airway mgt or respiratory failure

requires intubation &tracheostomy


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EPIGLOTTITIS Rx Management

2nd or 3rd cephalosporin +/- vancomycin

Oral ATBX for 7-10 days after extubation

Steroids remain controversial


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Viral Croup

(laryngotracheobronchitis) Most common cause of stridor after

neonatal period

Most affected are children 6 mo.- 3 y.o Peak incidence b/t 1-2 yrs of age

Narrowest part of airway is at cricoid cartilage

and inch

ildren 1 mm of airway edema may cross-sectional area 50-60%

Most cases occur late fall or early winter


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VIRAL CROUP Etiology-mostly viral

Parainfluenza virus type I,II,

Incubation 2-6 days, virus shed for about 2 weeks

Mycoplasma pneumoniae may present with

croup like syndrome


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VIRAL CROUP Signs & Symptoms

1-5 day prodrome ofcough, coryza, +/- low

grade fever and URI type symptoms Followed by 3-4 days of barking cough, worse

in late evening and night

+/- biphasic stridor: inspiratory component

greater than expiratory. Unaffected by position,worsened by agitation orcrying


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VIRAL CROUP Diagnosis- made clinically

X-rays: If othercauses being considered orin atypical or prolonged cases

Obtain lateral neck films and PA CXR

PA CXR in croup steeple sign


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Treatment

Continued

Racemic Epinephrine

Acts by vasoconstriction of mucosal vessels

0.5ml of 2.25%sol diluted in 3ml of saline

Recommended to watch patient for 3 hrs

before considering discharge


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Treatment

Continued

Dexamethasone

Steroids-used with moderate to severe episodes

ofcroup

Mild episodes controversial to tx with steroids


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VIRA

LC

ROUP-T

reatment Pulse ox, and humidified O2

Often improvement afterchild has been in cold night air ormoist air from shower

Antipyretics if fever present

Antibiotics not indicated IV fluid hydration only if necessary

Nebulized Albuterol

Stridor only with agitation- doesnt need epinephrine

Stridor at rest orchild in respiratory distress-tx with

epinephrine and steroids Intubation if respiratory failure or pending (use ETT 0.5 to

1.0 mm smaller than typically used)


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SPA

SM

ODIC

C

ROUP

Thought to be on continuum with acute

viral croup

Seen more commonly in atopicchildren No seasonal variation

Usually resolves within 6 hours of onset

Often recurrent and not associated withfever


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Epiglottitis Croup

Age Can occur in infants, olderchildren, or adults

Six months to six years

Onset Sudden Gradual

Location Supraglottic Subglottic

Temp High fever Low-grade fever

Dysphagia Severe Mild or absent

Dyspnea Present Present

Drooling Present Present

Cough Uncommon Chracteristiccough

Position Sitting forward with mouth open Comfortable in different

positionsRadiology Positive thumb sign* Positive steeple sign

.

Comparison of the Features of Epiglottitis and Croup


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Laryngeal diphtheria Aetiology-secondary to faucial diphtheria

Age-below 10yrs


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Larynge

al diphtheri

a


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Pathogenesis and pathology

The organism produces a toxin that inhibits

cellular protein synthesis and is responsible

for local tissue destruction and

pseudomembrane formation.


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Clinical manifestations The incubation period of diphtheria is 2-4 days

(range, 1-7 days).

This disease can involve almost any mucous

membrane.


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Laryngeal diphtheria Laryngeal diphtheria can be either an

extension of the pharyngeal form (often) or

the only site involved (rarely).

Symptoms include mild fever (with little

absorption of toxin), dyspnea, hoarseness,

and a barking cough.

The pseudomembrane can lead to airway

obstruction, coma, and death.


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Clinical manifestations The major sign is pseudomembrane. The

typical pseudomembrane is adherent to the

tissue, and forcible attempts to remove it

cause bleeding.


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Laboratory findings Routine examination

Leukocytosis, 10~20 G/L, neutrophil is

dominant. Low platelet count (thrombocytopenia), rise

profiles of the serum enzyme tests and

proteinuria were found in serious cases.


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Laboratory findings

Bacteriological examinations

Smear and gram stain can found C.

diphtheriae, but can not identify from thediphtheroids.


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Laboratory findings

Bacteriological examinations

C. diphtheriae can be cultured from the

swabs from nose, pharynx or other sites.


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Laboratory findings

Immunological examinations

Schick test (not to be used any more),

positive result supports diagnosis Specific antibody detection. Positive results

deny the diagnosis since it is a protective

antibody.


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Diagnosis

Gram stain of material from the

pseudomembrane can be helpful when trying

to confirm the clinical diagnosis.


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Diagnosis

Culture of the lesion is even important to

confirm the clinical diagnosis. It is critical to

take a swab of the pharyngeal area, especially

any discolored areas, ulcerations, and

tonsillar crypts.


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Treatments

General measures

Relax on bed for more than 3 weeks, 4-6

weeks for patients with myocarditis.

Provide adequate energy and nutriments


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Treatments Diphtheriaantitoxin

Diphtheria antitoxin, produced in horses.

It will not neutralize toxin that is already

fixed to tissues, but will neutralizecirculating toxin.

Early use will prevent progression of

disease.

The earlier, the better.


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Treatments

Diphtheriaantitoxin

Dose: 3-5104 U for early (3-4d)

or grave patients; reduce in larynx diphtheria

1-2104 U is given intravenously and the restis given intramuscularly.


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Treatments Diphtheriaantitoxin

The patient must be tested for sensitivity

before antitoxin is given.

Respiratory support and airwaymaintenance should also be administered

as needed. (Pseudomembrane shedding

often happens during disintoxication)


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Treatments

Antibiotics

Prevention of further toxin production.

Control local infection.

Reduction of transmission.


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Treatments

Antibiotics

Procaine penicillin G daily, intramuscularly

(300,000 U/day for those weighing 10 kg or

less and 600,000 U/day for those weighing

more than 10 kg) for 7-10 days.

Erythromycin orally or by injection (40-50

mg/kg/day; maximum, 2 gm/day) for 14 days.


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treatment Pt allergic to pencillin G or erythromycin

can use rifampin orclindamycin

The disease is usually not contagious

48 hours after antibiotics are used.


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Complications Myocarditis

Present as abnormal cardiac rhythms and

can occur early in the course of the illness orweeks later, and can lead to heart failure and

abrupt deterioration (sudden death).

If myocarditis occurs early, it is often fatal.


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Complications Neuritis

Most neuritis often affect motor nerves and

usually recovers completely. Paralysis of the soft palate is most frequent

during the third week of illness.


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Complications Neuritis

Eye muscles, limbs, and diaphragm paralysis

can occur after the fifth week. Secondary pneumonia and respiratory failure

may result from diaphragmatic paralysis.


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Complications Other complications

Include otitis media and respiratory

insufficiency due to airway obstruction,especially in infants.


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Preventions

Management of infection sources

For close contacts, especially household

contacts, a diphtheria booster, appropriate

for age, should be given. Antitoxin 1000-2000

U, intramuscularly


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Preventions

Management of infection sources

Contacts should also receive antibiotics

benzathine penicillin G or a 7- to 10-day

course of oral erythromycin.


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Tuberculosis of larynx

Aetilogy-secondary to pulmonary TB

Pathology-

c/f-symptoms

Hoarseness

Dysphagia

Referred pain


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Laryngeal exam Hyperaemia of vocal cords

Swelling in interarytenoid

Ulceration of VC-mouse nibbed app

Pseudoedema of epiglottis-turban epiglottis


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diagnosis Blood exam

Chest x-ray

Sputum exam

Biopsy


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treatment ATT THERPHY-

Voice rest


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THEEN

D

new infections of larynx

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