Laryngeal Laryngeal disordersdisordersDR MAHIPAL DR MAHIPAL

REDDYREDDY

Laryngeal disordersLaryngeal disorders

BY/DR K BY/DR K SUBHASH.,DR SUBHASH.,DR SRIDHAR,DR SRIDHAR,DR SREEKANTH AND SREEKANTH AND ALL ENT SURGEONS ALL ENT SURGEONS OF IMAOF IMA

Pretest T or F Pretest T or F 1. Reurrent laryngeal nerve 1. Reurrent laryngeal nerve pure motor fiberpure motor fiber

larynx larynx

3. Acute laryngitis 3. Acute laryngitis

4.4. epiglottitis laryngospasmepiglottitis laryngospasm

5. Thumb’s sign 5. Thumb’s sign croupcroup

6. Vocal nodule 6. Vocal nodule unilateral massunilateral mass

7. Vocal granuloma 7. Vocal granuloma intubationintubation

8. Laryngeal trauma 8. Laryngeal trauma intubationintubation

9. Most common symptom 9. Most common symptom ของ ของ true vocal true vocal carcinoma carcinoma

neck node enlargementneck node enlargement

10. 10. acid refluxacid reflux

Laryngeal disordersLaryngeal disorders

ผศผศ..นพนพ..ยงยทธ วศ�นวงศ�ยงยทธ วศ�นวงศ�ภาคว�ชาจั�กษุ โสต นาส�กลาภาคว�ชาจั�กษุ โสต นาส�กลาริ�งซ์�ว�ทยาริ�งซ์�ว�ทยาคณะแพทยศาสตริ� คณะแพทยศาสตริ� มหาว�ทยาล�ยมหาว�ทยาล�ยศริ#นคริ�นทริว�โริฒศริ#นคริ�นทริว�โริฒ

Laryngeal disordersLaryngeal disorders

ObjectivesObjectives

1.1. AnatomyAnatomy

2.2. PhysiologyPhysiology

3.3. Common disordersCommon disorders

4.4. TreatmentTreatment

1. Anatomy1. Anatomy

FrameworkFramework

Muscles – intrinsicMuscles – intrinsic

- extrinsic- extrinsic

Innervation Innervation

VesselsVessels

FrameworkFramework

MusclesMuscles

Intrinsic Intrinsic – adductors ; – adductors ; thyroarytenoid thyroarytenoid (true (true vocal cord:TVC), vocal cord:TVC), cricoarytenoid, cricoarytenoid, interarytenoidinterarytenoid

- abductor ; - abductor ; post cricoarytenoidpost cricoarytenoid

ExtrinsicExtrinsic - - cricothyroidcricothyroid

InnervationInnervationInferior RLN Inferior RLN

motor - all muscles except..motor - all muscles except..

sensory- below TVCsensory- below TVC

Superior RLN Superior RLN

motor – cricothyroid musclemotor – cricothyroid muscle

sensory – above TVCsensory – above TVC

Blood supplyBlood supply

Arterial Arterial

sup. laryngeal arterysup. laryngeal artery

inf. Laryngeal arteryinf. Laryngeal artery

VenousVenous

sup. & inf. Thyroid veinssup. & inf. Thyroid veins

PhysiologyPhysiology

1.1. Airway protectionAirway protection2.2. Swallowing Swallowing

3.3. Voice productionVoice production

4.4. Air passageAir passage

ProtectionProtection

inspirationinspiration

phonationphonation

1. Inflammation- Acut e & chr oni c l ar yngi t i s, c roup, epiglottitis, ulcer,

2 . Tumor - benign, nodule, polyp, granuloma

- mal i gnancy 3 . Trauma - penetrating injury

- blunt injury- i at r ogeni c

4 . Congenital - cord paralysis, Laryngeal web, subglottic stenosis

5 . Miscellaneous- laryngopharyngeal reflux (LPR)

di sease

Laryngeal disordersLaryngeal disorders

Common laryngeal Common laryngeal disordersdisorders

1. Acute laryngitis1. Acute laryngitis

2. Croup2. Croup

3. Epiglottitis3. Epiglottitis

4. Vocal nodule4. Vocal nodule

5. Vocal polyp5. Vocal polyp

6. Vocal granuloma6. Vocal granuloma

7. Laryngeal carcinoma7. Laryngeal carcinoma

8. Laryngeal trauma8. Laryngeal trauma

9. Laryngopharyngeal reflux 9. Laryngopharyngeal reflux (LPR)(LPR)

Acute laryngitisAcute laryngitisPathogen - adenovirus, influenzaPathogen - adenovirus, influenza

Morexella catarrharisMorexella catarrharis

Hemophilus influenzaHemophilus influenza

Streptococcus pneumoniaeStreptococcus pneumoniae

Symptoms - hoarseness cough, +/- fever, malaise

Sign - TVC swelling

Acute laryngitisAcute laryngitisTreatment Treatment - voice rest- voice rest

- mucolytic, anticold- mucolytic, anticold

+/- antibiotic+/- antibiotic

Symptoms > 2 week, recurrent

DDx - chronic laryngitis

Croup Croup (acute (acute laryngotracheobronchitis)laryngotracheobronchitis)

- Severe respiratory infection- Severe respiratory infection

- - 6 months-2 yrs. Pathogen - parainfluenza*influenza, adenovirus

- follow by bacterial esp. H. influenzaSymptoms - early URI symptoms

- 2-3 days - barking cough, stridor- exhausted, lying down

Croup Croup (acute (acute laryngotracheobronchitis)laryngotracheobronchitis)

Diagnosis - symptoms & signs- flexible scope- x-ray

norrowing of subglottis

“Pencil’s sign”

Pencil’s sign

NormalNormal

Croup Croup (acute (acute laryngotracheobronchitis)laryngotracheobronchitis)

Treatment - early detection- observe, admit- humidification, hydration, O2- antibiotic (penicillin)severe - steroid

- - intubation

EpiglottitisEpiglottitis

- infection of supraglottis >> epiglottis- infection of supraglottis >> epiglottis

- - 2-10 yr., adultPathogen - H. influenza type B

Symptoms - early URI symptoms- children > change very fast 6-12 hr.- high fever, pain in throat- น�&ง โน'มต�วมาข'างหน'า*

EpiglottitisEpiglottitis

Signs - epiglottis > swelling, inflam- ** laryngospasm เม)&อกดล�+น- fiberoptic

X-ray - “Thumb’s sign”

EpiglottitisEpiglottitis

Treatment- admit, closed monitoring- broad spectrum penicillin- hydration, humidification- +/- steriod- prepare for intubation

Vocal cord noduleVocal cord nodule

- vocal abuse, over-used- children, adult- fibrous formation

Symptoms - hoarsenessSign - nodule TVC> bilateral

> anterior 1/3

NoduleNodule

Treatment - voice rest- speech therapy- failed, recurrent > surgery

Vocal polypVocal polyp

- vocal abuse- vocal abuse

- - Reinke edema > capsule surrounding (polyp)

Symptoms - hoarseness > 2 wkSign - ant 1/3 TVC, unilateralTreatment - surgery

- follow by speech therapy

Reinke’s edema Reinke’s edema

Vocal polypVocal polyp

Both polyp, noduleBoth polyp, nodule

Vocal granulomaVocal granuloma

inflammation > ulcer > granulomainflammation > ulcer > granulomaetiology - intubation

- gastroesophageal reflux- partial laryngectomy

Symptoms - hoarseness 2-3 wk after extubation

Vocal granulomaVocal granuloma

Sign - arytenoid, unilateralTreatment - surgery

- follow by speech therapy- Rx acid reflux

CarcinomaCarcinomaChronic irritation Chronic irritation - smoking, alcohol,

pollution, acid reflux

Pathology - epithelial hyperplasia > dysplasia >

carcinoma insitu >carcinoma

CarcinomaCarcinoma

Symptoms > 2-3 weeks- glottis > hoarseness- supraglottis > dysphagia- subglottis > airway problems

others - referred otalgia, chronic cough, hemoptysis, lymphadenopathy, wt. loss

CarcinomaCarcinoma

DiagnosisDiagnosis - biopsy ; indirect or direct - biopsy ; indirect or direct

laryngoscopy laryngoscopy

- extension ; CT, MRI- extension ; CT, MRI

- metastasis ; CXR, LFT- metastasis ; CXR, LFT

TreatmentTreatment - depends on staging - depends on staging TNMTNM

- early > surgery or RT alone- early > surgery or RT alone

- stage 3, 4 > combined - stage 3, 4 > combined

surgery, RT, ChemoRxsurgery, RT, ChemoRx

Laryngeal traumaLaryngeal trauma

Most common -Car accidentMost common -Car accident

OthersOthers - athlete, penetrating, gun-- athlete, penetrating, gun-short short wound wound

S&SS&S >> location, severity>> location, severity

- stridor, bleeding, emphysema, - stridor, bleeding, emphysema, hemoptysis, dysphagia, hemoptysis, dysphagia,

crepitationcrepitation

- severe case > coma- severe case > coma

Laryngeal traumaLaryngeal trauma

ชนิ�ด การรกษาMinor- ม#hematoma, emphysema, - explore , แผล remove tureign body tear of cartilage - วางdrain

- reconstruction of frame work+ intubation

Major- multiple cartilage fracture - need intubation or tracheostomy- laryngo tracheal subluxation - exploration & reconstruction

+ intraluminal stent

Laryngopharyngeal reflux Laryngopharyngeal reflux (LPR)(LPR)

Laryngopharyngeal reflux Laryngopharyngeal reflux (LPR)(LPR)

Stomach acid > reflux to esophagus + Stomach acid > reflux to esophagus + others others

= gastroesophageal reflux (GER)= gastroesophageal reflux (GER)

reflux up to larynx = LPRreflux up to larynx = LPR

Etiology Etiology- relax sphincter, acid production- relax sphincter, acid production

food ; food ; chocolate, spicy, cola, alcohol, chocolate, spicy, cola, alcohol,

drugs ; drugs ; t heophyl i nt heophyl i n

ll - ife style- ife style ; ; eat late at nighteat late at night

Laryngopharyngeal reflux Laryngopharyngeal reflux (LPR)(LPR)

Symptoms Symptoms - feel lump in the throat,- feel lump in the throat,

chronic cough, chronic cough,

regurgitation, heartburnregurgitation, heartburn

SignsSigns - - arytenoid edema, TVC swelingarytenoid edema, TVC sweling

granuloma, ulcergranuloma, ulcer

>>> carcinoma>>> carcinoma

Laryngopharyngeal reflux Laryngopharyngeal reflux (LPR)(LPR)

Treatment Treatment - Lifestyle modification- Lifestyle modificationdiet, stress, avoid eating diet, stress, avoid eating

before bedtimebefore bedtime

- medication- medicationprotonpump inhibitor, protonpump inhibitor, H2 antagonist, antacid H2 antagonist, antacid+ prokinetic+ prokinetic

- surgery- surgery