ACUTE ACUTE LARYNGITISLARYNGITIS

Acute laryngitisAcute laryngitis

It is swelling of the laryngeal mucosa and It is swelling of the laryngeal mucosa and underlying tissueunderlying tissue..

Caused byCaused by: :

Infection (viral or bacterial)Infection (viral or bacterial)..Exogenous agentsExogenous agents..Autoimmune processesAutoimmune processes..

Clinical entitiesClinical entities

1. Acute simple laryngitis.

2. Acute laryngotracheobronchitis (croup).(croup).

3. Subglottic laryngitis (pseudocroup).(pseudocroup).

4. Acute epiglottitis.

5. Diphtheric laryngitis.

6. Membranous laryngitis.

7. Herps zoster of the larynx.

Acute (simple) laryngitisAcute (simple) laryngitis

AetiologyAetiology

1. Infection1. Infection. Airborne.. Airborne.

--ViralViral influenza & adeno virus& adeno virus . .

--BacterialBacterial Moraxella catarrhalis, Moraxella catarrhalis, Streptococcus pneumoniae & & H.influenza.

more in winter and early spring. more in winter and early spring.

Patients suffering from sinusitis, nasal Patients suffering from sinusitis, nasal obstruction, overuse of the voice, alcoholic and obstruction, overuse of the voice, alcoholic and smokers are more pronesmokers are more prone..

22.. Trauma Trauma (vocal abuse &/or endoscopic (vocal abuse &/or endoscopic manipulation)manipulation)..

33.. Irritation Irritation from inhaled fumes or gas, from inhaled fumes or gas, including tobacco smokeincluding tobacco smoke..

PathologyPathology The laryngeal mucosa shows all signs of acute The laryngeal mucosa shows all signs of acute

inflammation:inflammation: Extravasation of fluid.Extravasation of fluid. Infiltration by polymorphnuclear leucocytes.Infiltration by polymorphnuclear leucocytes. Later plasma cells and lymphocytes predominates.Later plasma cells and lymphocytes predominates. The underlying muscles, the perichondrium, and the The underlying muscles, the perichondrium, and the

cricoarytenoid joints may be affected.cricoarytenoid joints may be affected. The epithelium may be destroyed and exfoliated.The epithelium may be destroyed and exfoliated. Full recovery is usuall.Full recovery is usuall. Sometimes fibrosis will results leading to permanent Sometimes fibrosis will results leading to permanent

damage to the laryngeal mucosa which can be the damage to the laryngeal mucosa which can be the beginning of chronic laryngitis.beginning of chronic laryngitis.

Pathological changes in the mucosa

1.1. RednessRedness of the mucosa.of the mucosa.

2.2. Oedema Oedema of the mucosa.of the mucosa.

3.3. Sticky mucopurulant exudateSticky mucopurulant exudate..

4.4. Slight abrasions.Slight abrasions.

5.5. Purulent exudationPurulent exudation in severe forms(septic in severe forms(septic laryngitis).laryngitis).

6.6. Fibrinous laryngitisFibrinous laryngitis in influenza, there are white in influenza, there are white plaques on the surface of the cords and the plaques on the surface of the cords and the laryngeal inlet.laryngeal inlet.

7.7. PerichondritisPerichondritis may follow the purulant form by may follow the purulant form by H.streptococcus.H.streptococcus.

Clinical fearuresClinical fearures

1.1. HoarsnessHoarsness (high-pitched husky voice). (high-pitched husky voice).2.2. DiscomfortDiscomfort in the throat.in the throat.3.3. PainPain is slight or absent. is slight or absent.4.4. DysphagiaDysphagia if epiglottis &/or arytenoid are if epiglottis &/or arytenoid are

markedly involved.markedly involved.5.5. DyspnoeaDyspnoea in severe oedema. in severe oedema.6.6. Dry and irritant Dry and irritant coughcough..7.7. Generalized symptomsGeneralized symptoms (malaise and fever , (malaise and fever ,

toxaemia is rare) more in bacterial infections.toxaemia is rare) more in bacterial infections.8.8. Symmetrical Symmetrical redness &/or sticky secretionsredness &/or sticky secretions on on

both vocal cords, at both vocal cords, at indirect laryngoscopy..9.9. The clinical coarse in children can be rapidly The clinical coarse in children can be rapidly

progressive.progressive.

ProgressProgress

Usually resolves in a few days.Usually resolves in a few days. The hoarsness may persist for as long as The hoarsness may persist for as long as

2 weeks after apparent resolution.2 weeks after apparent resolution. A functional aphonia may follow specially A functional aphonia may follow specially

in women.in women. In severe cases the inflammation In severe cases the inflammation

spreads to the lung in aged patients.spreads to the lung in aged patients.

TreatmentTreatment

1.1. LocalLocal (supportive) (supportive) Voice restVoice rest (a quiet unforced whisper is (a quiet unforced whisper is

allowed).allowed). Steam inhalations. MSteam inhalations. Menthol enthol loosen viscid secretions.loosen viscid secretions.

Aspirin.Aspirin. Warm applicationWarm application to the neck. to the neck. Codeine Codeine to suppress dry cough.to suppress dry cough.

2.2. GeneralGeneral RestRest and sedatives. and sedatives. AvoidanceAvoidance of alcohol and tobacco. of alcohol and tobacco. Systemic antibioticsSystemic antibiotics in cases of in cases of

bacterial infectionbacterial infection

- Penicillin (Augmentin) 500 mg 4 times - Penicillin (Augmentin) 500 mg 4 times daily,daily,

- Doxycycline 200 mg daily or- Doxycycline 200 mg daily or

- Erythromycin 500 mg twice daily- Erythromycin 500 mg twice daily

Acute simple laryngitis in childrenAcute simple laryngitis in children

More serious because of:More serious because of:

1.1. Anatomical difference of infantile larynx.Anatomical difference of infantile larynx.

2.2. Rich lymphatic drainage.Rich lymphatic drainage.

3.3. The neuromuscular mechanism is more The neuromuscular mechanism is more easily upset and spasm more easily easily upset and spasm more easily provoked.provoked.

4.4. The child is less liable to expel The child is less liable to expel secretions by cough.secretions by cough.

Clinical featuresClinical features

1.1. CoughCough . . A laryngeal spasm (false croup) A laryngeal spasm (false croup) develops suddenly.develops suddenly.

2.2. DyspnoeaDyspnoea, , cyanosis, and stridorcyanosis, and stridor from from laryngeal spasm and oedema.laryngeal spasm and oedema.

laryngitis stridulosalaryngitis stridulosa is the name given is the name given to the condition when stridor is present.to the condition when stridor is present.

33. . Hoarsness.Hoarsness.

Treatment Treatment

The same as in adult.The same as in adult.

In addition to oxygenation and securing the airway In addition to oxygenation and securing the airway when there is stridor and cyanosis by intubation or when there is stridor and cyanosis by intubation or tracheostomy.tracheostomy.

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Subglottic laryngitisSubglottic laryngitis(pseudocroup)(pseudocroup)

Also called Also called spasmodic cough.spasmodic cough. Is common Is common <3 years<3 years of age. of age.The symptoms are The symptoms are alarming.alarming.The cause is unkown but is The cause is unkown but is associated associated

with influenza viruseswith influenza viruses infections. infections.There will be substantial There will be substantial swelling of the swelling of the

subglottic space.subglottic space.

Clinical featuresClinical features

Starts abruptly in a child with history of Starts abruptly in a child with history of URTI.URTI.

The child wakes up with dry cough and The child wakes up with dry cough and increasing stridor.increasing stridor.

No or mild fever.No or mild fever.Restless, nervous and crying child.Restless, nervous and crying child.

TreatmentTreatment

Sedatives are given to the parents and Sedatives are given to the parents and never to the child.never to the child.

Parenteral corticosteroids?Parenteral corticosteroids?Taking the child to a room with moist ear Taking the child to a room with moist ear

(e.g bathroom).(e.g bathroom). In an emergency endotracheal intubation In an emergency endotracheal intubation

for 1-2 days.for 1-2 days.

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Membranous laryngitisMembranous laryngitis

Rare, closely linked with croup , sometimes Rare, closely linked with croup , sometimes called called (pseudomembranous croup).(pseudomembranous croup).

Caused by :Caused by : *Pseudomonus aeruginosa.*Pseudomonus aeruginosa. *streptococci.*streptococci. *Vincent’s organisms.*Vincent’s organisms.A confluent A confluent membrane membrane covering the surface covering the surface

of the larynx and of the larynx and when removed no bleedingwhen removed no bleeding or ulceration occur.or ulceration occur.

The main site is the The main site is the supraglottis.supraglottis.

Clinical featuresClinical features

Simillar to other forms of laryngitis.Simillar to other forms of laryngitis. The constitutional symptoms accompanied The constitutional symptoms accompanied

by anorexia and thirst.by anorexia and thirst.Moderate fever.Moderate fever.Painfull swallowing.Painfull swallowing.Cough.Cough.There may be stridor.There may be stridor.

DiagnosisDiagnosis is established by by bacteriology. is established by by bacteriology.

Treatment Treatment

penicillins (Augmentin), 3penicillins (Augmentin), 3rdrd gen gen cephalosporen (ceftriaxon) or cephalosporen (ceftriaxon) or sulphonamides.sulphonamides.

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Acute epiglottitisAcute epiglottitisDefinitionDefinition

special form of acute laryngitis, in which the special form of acute laryngitis, in which the inflammatory changes affect mainly the loosely inflammatory changes affect mainly the loosely attached mucosa of the epiglottisattached mucosa of the epiglottis..

PathologyPathology Localized oedema may obstruct the airwayLocalized oedema may obstruct the airway..

-H.influenza is the usuall causative organismis the usuall causative organism..

-B-Haemolytic streptococci rarelyrarely..

Submucous abscesses may formSubmucous abscesses may form..

Acute epiglottitis

IncidenceIncidence 1:17.0001:17.000 childrenchildren..

1:100.0001:100.000 adultsadults..

. .Vaccination is reducing its incidenceVaccination is reducing its incidence..

Clinical featuresClinical features

1.1. History is short and abrupt.History is short and abrupt.

2.2. Fever >40 C.Fever >40 C.

3.3. Dyspnoea and stridor (progressive and Dyspnoea and stridor (progressive and alarming).alarming).

4.4. Pain on swallowing (commoner than Pain on swallowing (commoner than respiratory obstruction in adults).respiratory obstruction in adults).

5.5. Drooling of saliva.Drooling of saliva.

6.6. The patient is preferring the sitting positionThe patient is preferring the sitting position

Radiologically diagnosed by thump print sign on lateral view of neck X-ray

TreatmentTreatment

1.1. Constant supervision in hospital when Constant supervision in hospital when stridor is present.stridor is present.

2.2. Inhalation of moist air.Inhalation of moist air.

3.3. Throat swab and blood cultures.Throat swab and blood cultures.

4.4. IV antibiotics (Augmentin) or 3IV antibiotics (Augmentin) or 3rdrd gen. gen. cephalosporen in high doses.cephalosporen in high doses.

5.5. Endotrachial intubation , may be difficult.Endotrachial intubation , may be difficult.

6.6. Tracheostomy.Tracheostomy.

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Acute laryngotracheobronchitisAcute laryngotracheobronchitis(Croup)(Croup)

AetiologyAetiology

- - Affects infants and small Affects infants and small children up to the age of children up to the age of 77..

- - Caused by Caused by parainfluenza parainfluenza virusvirus..

- - secondary bacterial infection secondary bacterial infection (haemolytic streptococcus)(haemolytic streptococcus) superimpose by the superimpose by the 33rdrd day day which makes the condition which makes the condition worseworse..

Clinical featuresClinical features

1.1. Hard ,dry, croupy Hard ,dry, croupy cough and hoarsnesscough and hoarsness..

2.2. Pyrexia Pyrexia (some time>41).(some time>41).

3.3. DyspnoeaDyspnoea and cyanosis. and cyanosis.

4.4. TenaciousTenacious exudation and crusting. exudation and crusting.

5.5. OedemaOedema of the larynx. of the larynx.

6.6. Atelactasis.Atelactasis.caused by occlusion of the caused by occlusion of the bronchi.bronchi.

Narrowinng of the air column in the subglottic space(steeple sign) on x-ray of the neck AP view

The icreased muscular energy consumption required The icreased muscular energy consumption required for breathing and coughing, with COfor breathing and coughing, with CO2 2 retension leads retension leads to combination of metabolic and respiratory acidosis to combination of metabolic and respiratory acidosis which paralyses the central regulation of respiration.which paralyses the central regulation of respiration.

During the initial phase the child is restless and During the initial phase the child is restless and cyanotic, in the later stages there may be an cyanotic, in the later stages there may be an apparent improvement when the child becomes tired apparent improvement when the child becomes tired and calm.the retension of COand calm.the retension of CO2 2 causes a change of causes a change of colour from cyanotic to pale and it is the sign of colour from cyanotic to pale and it is the sign of imminent disaster.imminent disaster.

A small child with a temp.>38.5 C and stridor should A small child with a temp.>38.5 C and stridor should be admitted to hospital for observationbe admitted to hospital for observation

TreatmentTreatment 1.1. Admission.Admission.2.2. Rest and reasurance.Rest and reasurance.3.3. Systemic antibiotics (Augmentin or 3Systemic antibiotics (Augmentin or 3rdrd gen cephalo) gen cephalo)

and anti-pyretics.and anti-pyretics.4.4. Humidification.Humidification.5. Oxygen preferably in a tent..6.6. Fluid by mouth or IV.Fluid by mouth or IV.7.7. IV steroids?IV steroids?8.8. Nasotracheal tube or tracheostomy.Nasotracheal tube or tracheostomy.9.9. Removal of secretions by mucolytic agents Removal of secretions by mucolytic agents

(guafenecine containing syrup)(guafenecine containing syrup) Bronchoscopy with removal of secretions by suction Bronchoscopy with removal of secretions by suction

or forceps.or forceps. Tracheostomy with intermittent suction.Tracheostomy with intermittent suction.

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Diphtheric laryngitisDiphtheric laryngitis

Usually an extension of faucial Usually an extension of faucial infection.infection.

AetiologyAetiology

corynbacterium diphtheriaecorynbacterium diphtheriae. In . In children younger than 10 years of children younger than 10 years of age and occasionally young age and occasionally young adults.adults.

It has been less frequent since It has been less frequent since universal immunization.universal immunization.

Clinical featuresClinical features

The onset is insidious.The onset is insidious.1.1. Cough of a hoarse, croupy nature.Cough of a hoarse, croupy nature.2.2. Stridor follows accompanied by cyanosis and Stridor follows accompanied by cyanosis and

recession of the chest wall.recession of the chest wall.3.3. Pyrexia rarely above 37.8 C.Pyrexia rarely above 37.8 C.4.4. Weak and rapid pulse.Weak and rapid pulse.5.5. Greyish-white membrane and bleeding when Greyish-white membrane and bleeding when

removed.removed.

Diagnosis Diagnosis By identifying the organism in swabs By identifying the organism in swabs

(KLB) from the membrane.(KLB) from the membrane.

Treatment Treatment 1.1. Antitoxin injections IM or IV (20.000-Antitoxin injections IM or IV (20.000-

100.000 units according to the age & 100.000 units according to the age & severity).severity).

2.2. Systemic penicillin.Systemic penicillin.3.3. Oxygen.Oxygen.4.4. Tracheostomy.Tracheostomy. Home

Herpes zoster of the larynxHerpes zoster of the larynx

Rare condition caused by a neurotrophic Rare condition caused by a neurotrophic virus. The virus. The superior laryngeal branch of superior laryngeal branch of the vagus nerve and the pharyngeal the vagus nerve and the pharyngeal plexusplexus may be involved specially in may be involved specially in debilitated persons.debilitated persons.

Clinical featuresClinical features

1.1. Pain in the throat.Pain in the throat.2.2. Dysphagia.Dysphagia.3.3. Fever and malaise.Fever and malaise.4.4. Vesicles on the epiglottis, arytenoid, and Vesicles on the epiglottis, arytenoid, and

ventricular bands (unilateral).ventricular bands (unilateral).5.5. Palsies of the vocal cords from Palsies of the vocal cords from

involvement of the motor branch to the involvement of the motor branch to the cricothyroid muscle or of the recurrent cricothyroid muscle or of the recurrent laryngeal nerve.laryngeal nerve.

Treatment Treatment

Oral acyclovir 800 mg 5 times daily for 1 Oral acyclovir 800 mg 5 times daily for 1 week if a painful cord palsy is diagnosed week if a painful cord palsy is diagnosed within the first 3 days of onset.within the first 3 days of onset.

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Herpes zoster virus on electron microscopy

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Influenza virus on electron microscopy

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Smear of pus showing streptococci

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Blood agar culture showing beta haemolysis

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Acute laryngitisRednessOedemaSticky mucopurulant secretions

Normal larynx

H.influenzaclose

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Acute laryngitis on indirect laryngoscopy

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H-influenza

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Oxygen tentclose