4 laryngeal disorders

Laryngeal DisordersLaryngeal Disorders

Aiyun jiang

Laryngeal DisordersLaryngeal Disorders

*Acute epiglottitis

Acute laryngitis

*Acute laryngitis in children

Chronic laryngitis, vocal polyp, vocal nodules

Paralysis of vocal fold

Laryngeal papilloma

Laryngeal carcinoma

.

• Acute epiglottitis

Case study Male, 42, businessman ,• Comlain : severe sore throat with a low fever for 10 hours. History: 10 hours ago the patient felt a slight pain in his larynx, and the pain became severe rapidly that he daren’t swallow. He has a slight fever and fells fatigue. 2 hours ago he felt it difficult to breath in.Examination: stridor, retraction of supraclavicular and

intercostal spaces, inspiratory dyspnea; Cyanos ;the epiglottis becomes hyperemia and swelling”,and looks like a ball

Question: (1)what’s the diagnosis? (2) How to treat the patient?

Acute epiglottitisAcute epiglottitis

• Acute epilgottitis is a most dangerous condition . It is characterized by the abrupt onset of rapidly progressive respiratory obstruction due to a swollen, cherry-red epiglottis. Complete airway obstruction may occur in a few hours and cause death.

• Definition:– it is a localized inflammation of the supraglottic

larynx ,usually involve the mucous membranes of epiglottis.

Etiology

– Infection usually Haemophilus nfluenzae

– allergic– others: trauma( physical or chemical),

etc.

pathologypathology severe swelling of the epiglotic mucosa +/- phlegmon 3 pathologic types:① acute catarrh epiglottitis

– Only involve mucosa, diffuse hyperemia and swelling. The epiglottis becomes thicker than normal ones.

② acute edema epiglottitis – usually for allergy; epiglottis becomes “ball-

like”, and obstruct the laryngeal inlet for severity , causing laryngeal obstruction

③ acute anabrotic epiglottitis – Inflammation is severe in this condition.The

underlayer of the mucosa and the glands are involved. may cause laryngeal obstruction

Clinical manifestationClinical manifestation general symptoms( fever, fatigue, anorexia, etc. )• Local symptoms:

Rapid onset of a severe sore throat (worse on swallowing,) the pain is so severe that the patient can’t swallow normally. Oral secretions increase and usually manifested as drooling.

Unclear speech:This kind of change is different from hoarseness caused by VC diseases. It sounds just like there is Sth in the patient’s mouth.

Dyspnea: stridor, retraction of supraclavicular and

intercostal spaces, difficult in inspiratory stage ( Dyspnea in asthma occurs in exspiratory stage)Cyanosis or even death

for child, usually severe and develop rapidly, maybe life threatening

Physical examinationPhysical examination

• indirect or direct laryngoscopy: – the epiglottis becomes hyperemia and swelling;– maybe “ball-shape” or anabrotic;– Laryngeal obstruction

For child, laryngoscopy shouldn’t be admitted

lateral neck radiography --cherry-shaped epiglottic swelling (Thumb’s sign)

Induce laryngospasm

Normal epiglottis

Acute epiglottis:Hyperemia and

swelling

laryngoscopylaryngoscopy

X-rayX-ray - “Thumb’s sign”- “Thumb’s sign”

Diagnosis and Differential Diagnosis and Differential DDiagnosisiagnosis• Diagnosis: indirect laryngoscopy important!!!!!!!!!!!!• according to typical history and clinical manifestation, a

diagnosis of AE can be confirmed. Remember , if the patient has an abrupt onset of severe sore throat, Don’t simply make a diagnosis of acute tonsillitis or acute pharyngitis. Indirect laryngoscope must be performed to observe the epiglottis. Misdiagnosis of AE may delay proper and prom treatment and may cause death!!

• Differential diagnosis– foreign body in the larynx– laryngeal tuberculosis– laryngeal edema

TreatmentTreatment• Once the diagnosis of AE is confirmed ,the patient must be

hospitalized as an emergency measure because laryngeal obstruction may occur rapidly.

1 Closed monitoring2 Antiinflammatory

– broad spectrum antibiotic – +/- systematic steriod

3 Local treatment: – Inhalation of steriod– discission if necessary to maintain the airway unobstruc

ted– tracheostomy if necessary restlessness,stridor, cyanosis,and retraction of

supraclavicular and intercostal spaces are indications of immediate tracheostomy

Case study Male, 42, businessman ,• Comlain : severe sore throat with a low fever for 10 hours. History: 10 hours ago the patient felt a slight pain in his larynx, and the pain became severe rapidly that he daren’t swallow. He has a slight fever and fells fatigue. 2 hours ago he felt it difficult to breath in.Examination: stridor, retraction of supraclavicular and

intercostal spaces, inspiratory dyspnea; Cyanos ;the epiglottis becomes hyperemia and swelling”,and looks like a ball

Question: (1)what’s the diagnosis? (AE) (2) How to treat?( hospitalized, tracheostomy, antibiotic, systematic steriod, inhalation of steriod)

Acute laryngitisAcute laryngitis

Case sdudy • Female, 35, nurse• Complain: hoarseness for 3 days,aphonia for 2 hours.• History: 3 days ago the patient caught a “cold” and became hoarse. She had nonproductive cough and a tickling sensation in her larynx. Two hours ago she shouted very loudly to her naughty son and then lost her vioce (aphonia ).Physical examination: vocal folds are congestive and s

welling with stringy mucus between the cordsQuestion: (1)what’s the diagnosis?

(2) How to treat the patient?

definitiondefinition

• acute catarrhal inflammation of the laryngeal mucosa– usually a mild, self-limited inflammatory

condition – often a manifestion of a more diffuse

upper respiratory infection– More common in winter months

etiologyetiology

• Infection – the most common cause– almost always a virus upper respiratory infection, s

uch as: influenza, common cold• Bacterial invasion may be secondary.• Predisposed to by:

– vocal over-use.– smoking.– drinking of spirit.– irritant gas inhalation

Clinical manifestationClinical manifestation

• Symptoms – Hoarseness aphonia in severe case– cough, +/-fever– Throat pain, tenderness of the larynx– symptoms of a common cold for some cases

• Signs – redness and dry of the larynx, – vocal fold swelling with stringy mucus betwee

n the cords

Acute laryngitisAcute laryngitis

diagnosisdiagnosis

• according to :– the history– hoarseness – redness and edema of the mucosa of the voc

al cords.

Throat culture – rarely used, – only for prolong cases or in the face of a possible epidemic.

Differential diagnosis: hysteria

treatmenttreatment

1 Total voice rest– supreme important– even whisper should be avoided.

2 local treatment: Inhalations with steam

(steriod)

3 Anti inflammation– antibiotics + steroid

Case sdudy • Female, 35, nurse• Complain: hoarseness for 3 days,aphonia for 2 hours.

• History: 3 days ago the patient caught a “cold” and became hoarse. She had nonproductive cough and a tickling sensation in her larynx. Two hours ago she shouted very loudly to her naughty son and then lost her vioce (aphonia ).Physical examination: vocal folds are congestive and swelling wi

th stringy mucus between the cordsQuestion: (1)what’s the diagnosis? (AL)

(2) How to treat?(voice rest, antibiotics + steroid, Inhalations with steam )

.

Acute laryngitis in children

Case study • Boy, 2, hoarseness, fever 16 hours.• History: The boy had a fever and hoarseness for16 hours. His mother give him some Chinese to take, but his condition wasn’t improved. 2 hours ago it became even worse. The patient had a barking and dyspnea.Physical examination: stridor, cyanosis, retraction

of supraclavicular and intercostal spaces Question: (1)what’s the diagnosis? (2) How to treat the patient?

Acute laryngitis in childrenAcute laryngitis in children

– Dyspnea usually happen, for:

• Anatomic factors– narrow laryngeal cavity – soft cartilage– pultaceous connect tissue– richly supplied with lymphatic vessels

Low cough reflex ability– difficulty in eliminate the secretion

• the immature nerve system– Laryngospasm happens easily

• the immature immune system– Severe inflammation

Clinical manifestationClinical manifestation

• Symptoms:– hoarseness;– barking cough– inspiratory dyspnea– symptoms of upper respiratory infection: fever, fatigue,

et al

• Signs: – laryngeal stridor– retraction of supraclavicular and intercostal spaces

Acute laryngitis in childrenAcute laryngitis

diagnosisdiagnosis

• Differential diagnosis– foreign body in larynx;– upper respiratory infection or bronchitis; – Laryngeal spasm; – laryngeal diphtheria

hoarsenesshoarseness

barking coughbarking cough laryngeal stridorlaryngeal stridor

dyspneadyspnea

childrenchildren

consider the diagnosis confirm the diagnosis

treatmenttreatment• Should be treated as soon as possible!!!!

– Sufficient antibiotic, + systemic steroid for severe cases

– Inhalations with steam (steroid + adrenaline)– Management of laryngeal obstruction: stridor, cyanosis,and retraction of supraclavicular

and intercostal spaces are indications of immediate tracheostomy

• Supporting therapy– sedation,– be sure of water-electrolyte balance

Case study • Boy, 2, hoarseness, fever 16 hours.• History: The boy had a fever and hoarseness for16 hours. His mother give him some Chinese to take, but his condition wasn’t improved. 2 hours ago it became even worse. The patient had a barking and dyspnea.Physical examination: stridor, cyanosis, retraction of

supraclavicular and intercostal spaces Question: (1)What’s the diagnosis? (AL in children)

(2) How to treat ? hospitalized, Closed monitoring

antibiotic, systematic steriod, inhalation of steriod)

ChronicChronic laryngitislaryngitis

non-specificity chronic inflammation of the larynx

etiologyetiology

• Every factor that can affect the vocal folds (physical, chemical, infection)– Excessive vocal use– Vocal misuse, Habitual shouting– Long-term inhalation of irritative gas( smoking,

et al)– Chronic airway infection( bronchitis, sinusitis) – Acute laryngitis procrastinating

high risk grouphigh risk group

• Occupation required frequent vocal use

• Irritable character

• Pollution envirenment

• chronic upper respiratory inflammation

Clinical manifestationClinical manifestation

• Symptoms:– Hoarseness– Vocal fatigues easilly– Discomfort and a tendency to clear the throat

constantly

– Cough (with white sputum)

• Signs: three kinds of laryngeal changes– Chronic simple laryngitis– Chronic hypertrophy laryngitis– Chronic atrophy laryngitis

• 。

diagnosisdiagnosis

• NEVER MAKE A DIAGNOSIS OF CHRONIC LARYGITIS UNTIL OTHER LESIONS CAUSING HOARSENESS HAVE BEEN CAREFULLy EXCLUDED!!!!!!!!!!!!!!!

• Differential diagnosis: – laryngeal tuberculosis and syphilis; – laryngeal carcinoma; – vocal cord paresis; – hysteria

treatmenttreatment

1. Removal of the cause , voice rested, correct vocal use,etc

2. Steam inhalation

3. Chinese medicine

Vocal fold nodulesVocal fold nodules

• Etiology: – excessive or improper vocal use.

• Clinical manifestation: – Symptoms:

• hoarseness– Signs:

• small smooth nodule of the anterior 1/3 of the free edge of each cord,

• usually bilateral, • symmetric

• edema types:– vocal rest– speech therapy– medicine

• Fibrosis types– surgery

• CAUTION: no surgery for children

Vocal fold nodulesVocal fold nodulesTreatmentTreatment

surgery for vocal fold nodules

Vocal polypVocal polyp

• Etiology 　– vocal abuse; – improper vocal use

• Clinical manifestation:– symptoms

–hoarseness(persistent)

– signs• smooth neoplasm at anterior 1/3 VC, • unilateral

Vocal polyp

• Differential diagnosis 　– laryngeal fibroma ，– neurofibroma ；– papilloma; – carcinoma

• Treatment 　– surgery:

• indirect laryngoscope; • fiber laryngoscope;• Selfretaining laryngoscope

– follow by speech therapy

Vocal polypVocal polyp

diseases of laryngeal motor nerve diseases of laryngeal motor nerve ( laryngeal paralysis)

– disturbance of the motor n.( superior laryngeal n.

and recurrent laryngeal n.) of laryngeal muscle that cause the TVC motion disorder.

• etiology – centric disorder – peripheral disorder

• trauma; tumor; inflammation; intoxication;

left rignt﹥

Clinical manifestationClinical manifestation

• voiced function disorder

• 4 types:– Incomplete recurrent laryngeal n. paralysis– Complete recurrent laryngeal n. paralysis– Superior laryngeal n. paralysis– Mix laryngeal n. paralysis

.. .

Mix left laryngeal n. paralysis

treatment

• Etiological treatment

• Symptomatic treatment:– local injection,

– surgery( neuro-muscular-pedical grafting, neuroanastomosis, medial or lateral cordopexy, partial cricoidectomy)

• Voice training• Tracheotomy (bilateral incomplete recurrent

laryngeal n. paralysis)

CASECASEbilateral incomplete recurrent n. paralysisbilateral incomplete recurrent n. paralysis

male, 41yrsbilateral incomplete

recurrent n. paralysis for laryngeal trauma,with laryngeal obstruction

Tracheotomy

Satisfied vioce

Endotracheal anethesia

Arytenoidectomy

Successfully extubate

.

. .

incomplete bilateral recurrent laryngeal n. paralysis

.

Neoplasms of the larynxNeoplasms of the larynx

.Benign ：

amyloid tumor

papilloma

angioma

fibroma

Laryngeal papillomaLaryngeal papilloma

• Cause: HPV-6 ， HPV-11 infection

• Pathology: – epithelioma, – no basic membrane infiltrated

• Clinical manifestation:

– Progressive hoarseness, inspiratory dyspnea

(1)Adults: unifocal, may recurrent , cancerate(2)Children:

• multifocal, any position of the larynx, may in trachea• Fast grow, easily recurrent, seldom cancerate

treatmenttreatment

• surgery – mostly via edoscopy, often need more than once– Laryngofissure for some adults

• Antivirus

• Immunotherapy– Transfer factor– interferon

Laryngeal papilloma of children

Laryngeal papilloma of adult

Carcinoma of larynxCarcinoma of larynx

Carcinoma of Carcinoma of larynxlarynx

• Etiology– Smoking,alcohol abuse– Virus infection– Enviroment factors– Sexual hormone

• Pathology – 93~99% squamous cell carcinoma

• Classification of tumor sides: – supraglottic carcinoma– Glottic carcinoma– Subglottic carcinoma– Transglottic carcinoma

classification

Clinical manifestationClinical manifestation

• Supraglottic carcinoma– Maybe no symptoms for early stage– Layngalgia, bloody sputum for some cases

• Glottic carcinoma– Hoarseness 　　　　　 at early stage– Apnea

• Subglottic carcinoma– No symptoms for early stage– Difficult to detect

• Trans-glottic carcinoma– No symptoms for early stage– Hoarseness following

Missed diagnosis

Carcinoma of larynx

route of metastasis(1)route of metastasis(1)

1 、 direct metastasis

• Barrier for restricting metastasis– Tendon of anterior commissure– The space between supraglottic and infraglottic area– Vocal process of arytenoid cartilage– Pyriform sinus– Thyroid cartilage

route of route of metastasis(1)metastasis(1)

• Supraglottic carcinoma– Anteriad preepiglottic space, extrinsic muscles– Astern layngopharynx– Downward vocal folds

• glottic carcinoma– Anteriad preepiglottic space, contralateral vocal thyroid cartilage– upward vestibule, ventricle– Downward infraglottic area

• Subglottic carcinoma– Upward vocal folds– Downward trachea– Anteriad thyroid– Astern esophagus

direct metastasis

route of metastasis(2)route of metastasis(2)

2. Lymphatic metastasis• Supraglottic carcinoma: easy• Glottic carcinoma: seldom • Subglottic carcinoma:

3. Hematogenous metastasis– For some advaned stage cases

Carcinoma of Carcinoma of larynxlarynx

• diagnosis

hoarsenesshoarseness Laryngoscopy Laryngoscopy

Laryngeal massLaryngeal mass

biopsybiopsy

• Differential diagnosis:Differential diagnosis: 1.laryngeal tuberculosis2.Laryngeal syphilis3.Laryngeal papilloma

treatmenttreatment

• Surgery

• Radiotherapy

• Others – Chemotherapy– Hyperthermia– Photoradiative Therapy– Immune modulation

surgery

• Via laryngendoscope or microscope for early stage

• Partial laryngectomy– Acording to the location and the bound of the tumor– The principle is: 1 、 to remove the tumor completely

2 、 function reservation

• Total Laryngectomy• Neck dissection

treatmenttreatment

radiotherapy

• Radical radiotherapy– Carcinoma in situ or T1

• Combine with surgery– Before or after the surgery

• Radiotherapy alone as palliation

treatmenttreatment