The larynx

Laryngeal Diseases

Dr.
Sa’ad Y. Sulaiman

Objectives:

Investigations of laryngeal disease
Symptoms of laryngeal disease
Hoarseness and its causes

Investigations of laryngeal diseases

History
General examination
Examination of the larynx
* Laryngeal mirror(indirect larygoscopy)
* Flexible laryngoscope
Laboratory & Radiological exam.
Direct laryngoscopy &Hypopharyngoscopy
* Diagnostic
* Therapeutic

Symptoms of Laryngeal Disease

Hoarseness
Stridor:
Inspiratory Larynx
Expiratory Below the larynx
Mixed Laryngeal+bronchial(Laryngotracheobronchitis)
Cough
Expectoration
Pain(local and referred)
Dysphagia







Hoarseness
For production of normal voice, vocal cords should:
• Be able to approximate properly with each other.
• Have proper size and stiffiness.
• Have the ability to vibrate regularly in response to air column.

Cause of Hoarseness

Congenital
Paralysis
Inflammation
Neoplastic

Singer's nodule (Screamer nodule)

Bilateral ,small, grayish-white nodules
at the junction of the anterior 1/3 with the posterior 2/3 of vocal cords ( max. vibration)
due to voice abuse
Trauma oedema&haemorrhage in submucosal space hyalinization and fibrosis
Treatment:
Small nodule; speech therapy.
Large nodule; endoscopic removal.

Vocal cord polyp

The most common laryngeal mass.
Aetiology is not well understood but it may be due to: * * Vocal abuse
* Allergy
* Smoking.
Mostly, it affects men in the age of 30-50.
Treatment is by endoscopic removal.

Acute laryngitis

Usually occurs as part of a generalized URTI.
Viral Bacterial
In young children respiratory obstruction.
Duration: 4-5 days.
C/O malaise, hoarseness & pain on speaking.
O/E redness and swelling of the laryngeal mucosa.
Treatment: symptomatic;
Voice rest, steam inhalation & avoidance of irritant
Analgesics.
Antibiotics?!

Chronic laryngitis

Non-specific laryngitis:
Causes:
URTI: e.g. chronic sinusitis, nasal polyps
LRTI: e.g. chronic bronchitis
Others: smoking, drinking and GERD.
Specific laryngitis: TB, Syphilis.

Laryngeal tumors

Benign Tumors
Papilloma
most common benign neoplasms of the larynx (84% of benign tumors).
In children it is multiple and recurrent
In adult it is single but it is a premalignant disease.
Treatment is endoscopic removal.
Chondroma and haemangioma rarely affect the larynx.

Malignant tumors

Carcinoma of the larynx
The larynx is the most common site for CA in the upper aerodigestive tract (5 per 100 000).

Squamous cell Carcinoma (SCCA) is the most common laryngeal Ca (>90%).

Sex: Male: female = 6:1.
Age: middle-aged and elderly.

Aetiology:

• Tobacco
• Alcohol
• Previous radiation to neck for benign lesions.
• Occupational exposure to asbestos, mustard gas and other chemical or petroleum product.
Site of origin:
Glottic SCCA: most common (60%) >
supraglottic SCCA (30%) >
subglottis SCCA (<10%).

Spread of malignancy

Local
Involves other divisions of the larynx
Spread beyond the larynx to involve tongue, trachea, pyriform sinus, oesophagus, thyroid etc.
Regional: To the cervical lymph nodes 18%
Supraglottis – 39%
Glottis - 05%
Subglottic - 13%
Distant: Lung, Liver, Brain and Bone

Clinical features- Symptoms

Progressive and unremitting dysphonia or hoarseness
Dyspnoea
Stridor
Pain / Referred pain
Dysphagia
Cough and irritation
Neck swelling
Haemoptysis, Anorexia, Cachexia.

Clinical Features- Signs

EXAMINATION OF LAYNX
External examination + Mobility
I.D.L.
Examination of the neck
Examination of ear, nose and throat
Systemic examination.

Treatment:

Radiotherapy:
Small tumors with no cervical lymph nodes
Has the advantage of preserving voice
Total laryngectomy +/- radical neck dissection +post op. radiotherapy
Large tumors with cervical LAP
Palliative treatment:
For advanced tumors

Paralysis of the vocal cords

The recurrent laryngeal nerve is the motor nerve to all the laryngeal muscles except the cricothyroid muscles which is supplied by the external branch of the superior laryngeal nerve.





The cricothyroid muscle has an adductor effect on the vocal cords, and thus a lesion which spares the superior laryngeal nerve will leave the cord lying nearer the midline than one which paralyses both the recurrent and superior laryngeal nerves.

Types of paralysis:

Incomplete: the abductor group is paralyzed; position of vocal cords is near the midline e.g. thyroid surgery.
Complete: both abductor and adductor muscles are paralyzed: position of vocal cords is half way (cadaveric position).




The chance is twice for the left recurrent nerve to be paralyzed than the right. Bronchogenic carcinoma is an important cause of left recurrent paralysis and should always be excluded by X-ray chest, bronchoscopy and biopsy.