ACUTE INFLAMMATIONSOF LARYNX

BY-KCSUDEEP,DR

Anatomy• Clinical subdivision

– Supraglottis: • from epiglottic tip to floor of laryngeal ventricle.

– Glottis: • ant. commissure, TVC, post commissure

– Subglottis: • at the inf. surface of TVC to inferior edge of cricoid

Diseases of the Larynx

• Inflammatory• Infectious• Granulomatous• Mucosal• Congenital• Neoplastic

Anatomy

ACUTE LARYNGITIS

• Acute laryngitis may be infectious or non- infectious.

AETIOLOGY

• Infectious type is more common and usually follows upper respiratory infection.

• To begin with, it is viral in origin but soon bacterial incasion takes place with sretp.pneumoniee, H.infuenzae and haemolytic streptococci or Staph. Aureus.

• Exanthematous fevers like measles, chickenpox and whooping cough are also associated with laryngitis.

• NON –INFECTIOUS TYPE– It is due to vocal abuse , allergy,

thermal or chemical burns to larynx due to inhalation or ingestion of various substances, or laryngeal trauma such as endotracheal intubation.

CLINICAL FEATURES

• SYMPTOMS are usually abrupt in onset and consists of : – Hoarseness which may lead to complete loss of voice – Discomfort or pain in throat, particularly after talking – Dry, irritating cough which is usually worse at night .– General symptoms of head , cold rawness or dryness of

throat, malaise and fever if laryngitis has followed viral infection of upper respiratory tract.

• Hoarseness which may lead to complete loss of voice.• Discomfort or pain in throat, particularly after talking.• Dry, irritating cough which is usually worse at night• General symptoms of head, cold, rawness or dryness of

throat, malaise and fever if laryngitis has followed viral infection of upper respiratory tract.

• Laryngeal appearance vary with severity of disease. • In early stages there is erythema and oedema of epiglottis,

aryepiglottic folds, arytenoids and ventricular bands, but the vocal cords appear white and near normal and stand out in contrast to surrounding mucosa, betraying the degree of hoarseness patient has.

• Later, hyperaemia and swelling increase. Vocal cords also become red and swollen. Subglottic region also gets involved. Sticky secretions are seen between the cords and interarytenoid region .

• In case of vocal abuse, submucosal haemorrhages may be seen in the vocal cords.

TREA

TMEN

• VOCAL REST • AVOIDANCE OF SMOKING AND

ALCOHOL• STEAM INHALATIONS• COUGH SEDATIVE • ANTIBIOTICS • ANALGESICS• STEROIDS

ACUTE MEMBRANOUS LARYNGITIS

• THIS CONDITION IS SIMILAR TO ACUTE MEMBRANOUS TONSILLITIS AND IS CAUSED BY PYOGENIC NON-SPECIFIC ORGANISMS.

• IT MAY BEGIN IN THELARYNX OR MAY BE AN EXTENSION FROM THE PHARYNX. IT SHOULD BE DIFFERENTIATED FROM LARYNGEAL DIPTHERIA.

STRIDOR

• INSPIRATORY– SUPRAGLOTTIC OR PHARYNX

• EXPIRATORY– LESION OF THORACIS TRACHEA, PRI.

OR SEC. BRONCHI• BIPHASIC

– GLOTTIS, SUBGLOTTIS AND CERVIAL TRACHEA

STRIDOR

• CONGENITAL– Laryngomalacia– Laryngeal web– Subglottic stenosis– Haemangioma– Vocal cord paralysis– Tongue and jaw abnormalities

• ACQUIRED– Afebrile

• Papillomatosis • Injury• Foreign body• Laryngeal oedema• Adenotonsillar hypertrophy

– Febrile • Epiglottis • Acute laryngitis• Laryngotracheitis• Diptheria• Retropharyngeal abscess• Infectious mononucleosis• Peritonsillar abscess

Diseases associated with acute stridor

COMMON• Acute laryngothracheitis.• Acute laryngotracheobronchitis.• Acute epiglottitis.• Bacterial tracheitis.• Foreign body. Uncommon• Peritonsillar abscess.• Retropharyngeal abscess.• Diphtheria

Viral Croup• Common respiratory illness in young children.

• Anglo-Saxon word Kropan; cry aloud.

• Hoarse voice; dry barking cough; inspiratory stridor; and variable amount of respiratory distress that develops over a brief period of time.

Croup Syndrome• Group of diseases that varies in anatomic

involvement and etiologic agents.

• Laryngotracheitis.• Spasmodic croup.• Bacterial tracheitis.• Laryngotracheobronchitis.• Laryngotracheobronchopneumonitis.

Croup(Acute laryngotracheo-bronchitis)

• Disease of viral origin causing subglottic & tracheal swelling.

• The narrowed airway is responsible for the hallmark of clinical picture.

• The cricoid ring in the upper trachea which is subglottic, has a narrow diameter which renders children vulnerable to inflammation.

Viral Croup( Acute laryngotracheobronchitis)

• Etiology: Respiratory viruses e.g. parainfluenza viruses 1,2,and

3, RSV, Influenza viruses A & B.

• Clinical picture: Age 6mths- 3 years, M>F, Fall & winter. Gradual onset of low grade fever,URTI, barking

cough, inspiratory stridor & respiratory distress. Hoarseness & aphonia may occur.

Croup, diagnosis & treatment

• Clinically• Lateral neck X-ray ( steeple sign).• Fluid intake• Cool mist/ hot steamy bathroom.• Aerosolized adrenaline.• Steroids( controversial)• Endotracheal intubation.• Helium-Oxygen Mixture.• Antibiotics

Acute epiglottitis, etiology

• Bacterial infection of the supraglottic structures( epiglottis, aryepiglottic folds & arytenoids soft tissues) causing rapid airway obstruction.

• Haemophilus Influenza type B in prevaccination era.

• Bacteria associated with epiglottitis in the Hib vaccine era include: HiA, Str. Pn, Staph aureus, ß-hemolytic streptococci Gps A,B,C,and F

Acute epiglottitis, clinical picture

Age usually 2- 7 years.

Sudden onset.

High fever.

Apprehensive, sitting forward, drooling saliva, hyperextended neck & protruded chin.

Stridor, dysphagia.

Acute epiglottitis, diagnosis

Direct visualization.

X-RAY; shows THUMB sign on Lat view

Blood cultures.

Latex agglutination of serum or urine.

Acute epiglottitis, treatment

HospitalizationTreatment is a medical emergency.Ventilatory support, intubation.Steroids for e.g. hydrocortisone 100mg i.v. may be

useful to relieve oedema.IV antibiotics, 2nd or 3rd generation cephalosporin's or

chloramphenicol till cultures & sensitivity are known.

Croup Vs Epiglottitis

Characteristics of Laryngotracheitis and Epiglottitis Feature Laryngotracheitis EpiglottitisAge <3 years >3 yearsOnset Gradual (days) Acute (hours)Cough Barky NormalPosture Supine SittingDrooling No YesRadiograph Steeple sign, narrowed subglottis Thumb sign, enlarged

epiglottis,dilated hypopharynxCause Viral BacterialTreatment Supportive (croup tent) Airway management (intubation or

tracheotomy), antibiotics

Diffuse tonsillar &

pharyngealErythema seen here as a non Specific finding that can be produced By a variety of pathogens

Intense erythema seen in associationWith acute tonsillar enlargement& palatal petichiae is highly suggestive Of Gp A beta-streptococcalInfection, though other pathogens Can produce these findings.

Exudative tonsillitisSeen with either Group A Beta hemolytic streptococcalOr EB virus infection.

Peritonsillar abscess

Photograph taken in the ORShows an intensely inflamedSoft palatal mass that obscuresThe tonsil & bulges forward &Toward the midline deviating The uvula .

Retropharyngeal abscess

This young child presentedWith high fever, drooling,Opisthotonous posture.Pharyngeal examination in The OR reveals an intenselyErythematous unilateral Swelling of the posterior Pharyngeal wall.

Retropharyngeal abscess, a lateral neck XR shows prominent Prevertebral swelling displacing the trachea forward.

Croup

This radiograph shows a long area of narrowing extending below the Normally narrowed area at the level of the vocal cords.

Croup Direct visualization revealed subglottic narrowing that was so severeOnly tracheostomy would enable establishment of an adequate airway.

EpiglottitisA 3 year old seen a few hours after Onset of symptoms.She was anxious but with no positionalPreference or drooling.

Epiglottitis

This 5 year old holds his neck Extended, head forward, is mouthBreathing, drooling, and shows Signs of tiring.

Epiglottitis

This 2-year old was in Severe distress and was Too exhausted to hold His head up.IN the OR the epiglottisAppears intensely red & Swollen.

?

Questions• A 12 yr old boy with 4 days of sore throat comes to

your office. Afebrile with rhinorrhea, cough, and one day diarrhea associated with his sore throat. Throat is mildly erythematous a with normal appearing tonsils. The best course of action is:

1. Swab the throat and give 10 days AB.2. Swab his throat and wait for results.3. Symptomatic Rx.4. AB without testing for gp A strept.

Question 2

• A 3 yr old fussy boy , febrile with proffuse rhinorrhea. Shallow ulcers are noted on the soft palate and vesicles are noted on one palm and both soles of the feet. The etiology of this infection is

1. Gp A strept2. Acranobacterium hemolyticum3. Coronavirus.4. Coxackie virus