LarynLaryngeal and voice geal and voice disordersdisorders

Yard.Doç.Dr.Müzeyyen DoğanYard.Doç.Dr.Müzeyyen Doğan

LARYNX

AdultAdult: between 3th and : between 3th and 6th cervical vertebra 6th cervical vertebra

İnfantİnfant: between 1st : between 1st and 4th cervical and 4th cervical vertebra vertebra

Attaches to the hyoid Attaches to the hyoid bone and opens into the bone and opens into the laryngopharynx laryngopharynx superiorlysuperiorly

Continuous with the Continuous with the trachea posteriorlytrachea posteriorly

Clinical subdivisionClinical subdivision of the larynx of the larynx

supraglottic space (also called the vestibule which is surrounded by the piriform fossa)

glottic space (which contains the

vocal folds) subglottic space (which

is the area below the true vocal folds).

Diseases of the LarynxDiseases of the Larynx

InflammatoryInflammatory InfectiousInfectious GranulomatousGranulomatous MucosalMucosal CongenitalCongenital Neoplastic Neoplastic

3 years old boy3 years old boy Presented with:Presented with:

Stridor: 1 dayStridor: 1 day Cough, barkingCough, barking Fever Fever Drooling??Drooling??

Inflammatory Inflammatory

Acute laryngotracheitisAcute laryngotracheitis (croup) (croup) viral infection, affects children < 5 years.viral infection, affects children < 5 years. lasts 3-7 days, seasonal, lasts 3-7 days, seasonal, in autumn & winter. in autumn & winter. parainfluenza 1, parainfluenza 3, influenza A, parainfluenza 1, parainfluenza 3, influenza A,

rhinovirus.rhinovirus. febrile URTI, followed by classic barky or croupy febrile URTI, followed by classic barky or croupy

cough (nonproductive and cough (nonproductive and at night. at night. self-limited, rarely self-limited, rarely edema & upper A/W obstruction. edema & upper A/W obstruction.

Dx: history + neck X-ray Dx: history + neck X-ray classic “steeple sign”. classic “steeple sign”. Tx: humidification & hydration. If symptoms worsen Tx: humidification & hydration. If symptoms worsen

racemic epinephrine & corticosteroids racemic epinephrine & corticosteroids

Acute epiglottitisAcute epiglottitis

Haemophilus influenzae type B Haemophilus influenzae type B Children between 2 - 4 years,Children between 2 - 4 years, winter and winter and

spring.spring. Rapid presentation over 2-6 hrs: fever, sore Rapid presentation over 2-6 hrs: fever, sore

throat, muffled voice, inspiratory stridor. Sitting throat, muffled voice, inspiratory stridor. Sitting upright, ill-appearing, &drooling, upright, ill-appearing, &drooling,

Examination of the epiglottis may precipitate Examination of the epiglottis may precipitate laryngospasm laryngospasm not recommended. not recommended.

Lateral X-ray Lateral X-ray classic “thumb” sign. classic “thumb” sign. Tx: operating room immediately to establish the Tx: operating room immediately to establish the

diagnosis and secure an airway diagnosis and secure an airway

Acute epiglottitisAcute epiglottitis

Treatment:Treatment:

1.1. Secure a safe airway (O-T Secure a safe airway (O-T tube, bronchoscope, trach)tube, bronchoscope, trach)

2.2. Antimicrobial (C/S) ampic Antimicrobial (C/S) ampic & chloramphenicol or 2& chloramphenicol or 2ndnd & 3& 3rdrd generation generation cephalosporin.cephalosporin.

3.3. Supportive care. Supportive care. Extubation usually Extubation usually possible after 48 to 72 possible after 48 to 72 hours hours

Acute epiglottitisAcute epiglottitis

Croup Vs EpiglottitisCroup 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

40 years old lady40 years old lady Globus pharyngeusGlobus pharyngeus Dryness of throatDryness of throat Frequent throat clearingFrequent throat clearing Nocturnal aspirationNocturnal aspiration Heart burnHeart burn

Gastroesophageal reflux Gastroesophageal reflux disease - GERDdisease - GERD

Most common cause of laryngitis.Most common cause of laryngitis. Acute & chronicAcute & chronic GERD GERD stenosis, recurrent spasm, C-A fixation, stenosis, recurrent spasm, C-A fixation,

dysphagia, globus pharyngeus, & laryngeal CA.dysphagia, globus pharyngeus, & laryngeal CA. Sx: Sx:

GI: regurgitation, heart burn.GI: regurgitation, heart burn. Larynx: hoarseness, globus pharyngeus, ch. Throat Larynx: hoarseness, globus pharyngeus, ch. Throat

clearing, cough, dysphagia.clearing, cough, dysphagia.

Gastroesophageal reflux Gastroesophageal reflux disease - GERDdisease - GERD

Examination:Examination: Grade I : Normal or Mild Grade I : Normal or Mild

Edema & Erythema Edema & Erythema

Grade II : Erythema / Grade II : Erythema /

Edema of posterior glottis.Edema of posterior glottis.

Grade III : Pachydermia of Grade III : Pachydermia of

posterior glottis.posterior glottis.

Grade IV : Contact ulcer Grade IV : Contact ulcer

granulomagranuloma

GERDGERD

GERDGERD

Dx:Dx: HxHx ExaminationExamination 24-hour double 24-hour double

probe PH probe PH monitoring.monitoring.

Ba-swallow.Ba-swallow. GastroscopeGastroscope

GERDGERD

Treatment:Treatment: Dietary and Lifestyle modifications.Dietary and Lifestyle modifications. Antacids.Antacids. Systemic H2-blockers.Systemic H2-blockers. Prokinetic agents.Prokinetic agents. Mucosal cytoprotectants.Mucosal cytoprotectants. Proton pump inhibitors; OmebrazoleProton pump inhibitors; Omebrazole

Other inflammatory disease Other inflammatory disease

Granulomatous Conditions That May Affect the Larynx Disease Laryngeal InvolvementTuberculosis Posterior one-third of larynx involvedSyphilis Painless ulcers; positive syphilis serologyLeprosy Supraglottic involvementHistoplasmosis Anterior larynx involvedBlastomycosis Painless ulcers; microabscessesActinomycosis Draining sinuses; sulfur granulesRhinoscleroma Catarrhal stage, Mikulicz’s cellsSarcoidosis Supraglottic swelling, nodules, granulomasWegener’s Subglottic involvement; necrotizing vasculitis; pulmonary orgranulomatosis renal involvement

33 years old lady33 years old lady TeacherTeacher Hoarseness of voiceHoarseness of voice Cough mildCough mild Disappearance of voice sometimesDisappearance of voice sometimes No h/o URTINo h/o URTI

Mucosal disordersMucosal disorders

Benign mucosal disorderBenign mucosal disorder

Vocal noduleVocal nodule Fluid accumulation in the submucosa from Fluid accumulation in the submucosa from

acute abuse or overuse acute abuse or overuse mucosal swelling mucosal swelling (sometimes called "early nodules"): reversible. (sometimes called "early nodules"): reversible.

Long-term voice abuse Long-term voice abuse hyalinization of hyalinization of Reinke's potential space, irreversible.Reinke's potential space, irreversible.

Tx: Tx: Medical: hydration, lubrication, GERD.Medical: hydration, lubrication, GERD. Voice therapyVoice therapy Surgery: >3months, fibrosis, symptomatic.Surgery: >3months, fibrosis, symptomatic.

Vocal noduleVocal nodule

Vocal fold polypVocal fold polyp

Vocal fold cystVocal fold cyst

Reinke’s edemaReinke’s edema

2 weeks old girl2 weeks old girl Inspiratory stridorInspiratory stridor No cyanosisNo cyanosis Normal cryNormal cry No chest infectionNo chest infection Aspiration with feedingAspiration with feeding

Congenital Congenital

Congenital disorders of the LarynxCongenital disorders of the Larynx

SupraglotticSupraglottic GlotticGlottic SubglotticSubglottic

LaryngomalaciaLaryngomalacia Vocal cord paralysisVocal cord paralysis Cong. Subglottic Cong. Subglottic stenosisstenosis

Ductal retention cystDuctal retention cyst Web and atresiaWeb and atresia Subglottic hemangiomaSubglottic hemangioma

Cystic hygromaCystic hygroma Interarytenoid webInterarytenoid web Web & atresiaWeb & atresia

Bifid epiglottisBifid epiglottis Posterior laryngeal cleftPosterior laryngeal cleft CystsCysts

Saccular cystSaccular cyst Cri-du-chat syndromeCri-du-chat syndrome

Anterior laryngeal cleftAnterior laryngeal cleft

Abnormal flaccidity of the laryngeal Abnormal flaccidity of the laryngeal tissues tissues inward collapse. inward collapse.

Resolve spontaneously (6-18 months).Resolve spontaneously (6-18 months). Sx: inspiratory stridor, intermittent Sx: inspiratory stridor, intermittent

upper a/w obstruction, normal cry, upper a/w obstruction, normal cry, normal general health and developmentnormal general health and development

Usually begins in the first few days or Usually begins in the first few days or weeks.weeks.

LaryngomalaciaLaryngomalacia

LaryngomalaciaLaryngomalacia

Dx: endoscopic exam. Dx: endoscopic exam. Tall, tubular, Tall, tubular, epiglotttis epiglotttis Large cuniform cartilage.Large cuniform cartilage. Short A-E foldsShort A-E folds Inward collapseInward collapse

TxTx Conservative:posturing, +/- Conservative:posturing, +/-

steroidssteroids Surgical: trach, intubation, Surgical: trach, intubation,

supraglottoplastysupraglottoplasty

Vocal cord paralysis (cong.)Vocal cord paralysis (cong.)

22ndnd common cause of congenital upper a/w common cause of congenital upper a/w obstruction. (10%)obstruction. (10%)

Unilateral VC paralysis > bilateralUnilateral VC paralysis > bilateral Causes: idiopathic, surgical trauma, neurological Causes: idiopathic, surgical trauma, neurological

abnormalities (e.g. meningomyelocele, bulbar abnormalities (e.g. meningomyelocele, bulbar palsy, Arnold-Chiary malformation.palsy, Arnold-Chiary malformation.

Sx: weak cry, aspiration, stridor.Sx: weak cry, aspiration, stridor. Tx: Tx:

Surgical: trach, transverse cordotomy, arytenoidectomy.Surgical: trach, transverse cordotomy, arytenoidectomy.

Subglottic stenosisSubglottic stenosis

Membranous and cartilaginous types.Membranous and cartilaginous types. Membranous: fibrous soft-tissue thickening Membranous: fibrous soft-tissue thickening

of the subglottic area of the subglottic area Cartilaginous: thickening or deformity of Cartilaginous: thickening or deformity of

the cricoid cartilage the cricoid cartilage shelf-like plate shelf-like plate   

Laryngeal webLaryngeal web

Subglottic stenosisSubglottic stenosis Tx:Tx:

Endoscopic: Endoscopic: mmembranous embranous stenosisstenosis

Surgery: Surgery: cartilaginous cartilaginous stenosisstenosis

Ant cricoid splitAnt cricoid split Ant. & post cricoid Ant. & post cricoid

division +/- division +/- augmentationaugmentation

Laryngeal HemangiomaLaryngeal Hemangioma

Infants Infants 50% associated 50% associated cutaneous hemangiomas. cutaneous hemangiomas.

Sx: stridor or Sx: stridor or "pseudocroup," within the "pseudocroup," within the first 6 months of life.first 6 months of life.

Dx: direct laryngoscopyDx: direct laryngoscopy Tx:Tx:    low-dose XRT, low-dose XRT,

tracheotomy + tracheotomy + observation, cryotherapy, observation, cryotherapy, sclerotherapy, CO2 laser, sclerotherapy, CO2 laser, steroid therapy (systemic steroid therapy (systemic or intralesional) & or intralesional) & interferone interferone -2a.-2a.

55 years old gentleman55 years old gentleman Hoarseness of voceHoarseness of voce Right otalgiaRight otalgia Mild dyspyagiaMild dyspyagia SmokerSmoker Alcohol drinkerAlcohol drinker

NeoplasmsNeoplasms

Laryngeal PapillomatosisLaryngeal Papillomatosis

The most common benign neoplasms of the The most common benign neoplasms of the larynx (84% of benign tumors).larynx (84% of benign tumors).

22ndnd mucosal infection by a papovavirus. mucosal infection by a papovavirus. Juvenile form: Juvenile form:

diffuse & extremely aggressive diffuse & extremely aggressive hoarseness and hoarseness and stridor. stridor.

Resistant to treatment Resistant to treatment frequent laryngoscopies. frequent laryngoscopies. Adult-onset form Adult-onset form

solitary or more localized, less aggressive solitary or more localized, less aggressive TX:TX: CO2 laser, cryotherapy, XRT, interferonCO2 laser, cryotherapy, XRT, interferon

Laryngeal PapillomaLaryngeal Papilloma

Neoplasms of the LarynxNeoplasms of the Larynx

BenignBenign Malignant Malignant PapillomaPapilloma Squamous Cell CaSquamous Cell Ca

Minor S.G. tumorsMinor S.G. tumors Neuroendocrine (e.g. carcinoid, Neuroendocrine (e.g. carcinoid, melanoma)melanoma)

Granular cell tumorGranular cell tumor ChodrosarcomaChodrosarcoma

ChondromaChondroma RhabdomyosarcomaRhabdomyosarcoma

HemangiomaHemangioma LymphomaLymphoma

ParagangliomaParaganglioma

Sqaumous cell CarcinomaSqaumous cell Carcinoma

Most common laryngeal Ca (>90%).Most common laryngeal Ca (>90%). Male:female = 6:1.Male:female = 6:1. Etiology:Etiology:

Tobacco: Tobacco: (related to number of cig.) (related to number of cig.) Alcohol: Alcohol: (x 2.2) (x 2.2) XRT, asbestose, wood dust, mustard gas.XRT, asbestose, wood dust, mustard gas. GERDGERD HPVHPV

Sqaumous cell CarcinomaSqaumous cell Carcinoma Glottic SCCA most Glottic SCCA most

common (60%) > common (60%) > supraglottic SCCA (30%) supraglottic SCCA (30%) > subglottic SCCA > subglottic SCCA (<10%).(<10%).

Sx: hoarseness, throat Sx: hoarseness, throat pain, cough, pain, cough, hemoptysis, referred hemoptysis, referred otalgia, dysphagia.otalgia, dysphagia.

Dx:Dx: Flexible laryngoscope, Flexible laryngoscope,

D.L. & biops.D.L. & biops. CT +/- MRICT +/- MRI