Congenital and Traumatic and Inflammatory diseases of the larynx

د.حسين جاسم

L.2 Congenital, Traumatic & Inflammatory diseases of the larynx

I. Congenital anomalies & causes of congenital laryngeal stridor

Laryngomalacia (congenital laryngeal stridor)
The larynx is of an exaggerated infantile type; the epiglottis is long, narrow & folded backwards at each lateral edge (Omega shaped, incomplete cylinder) so in each inspiration the edges are sucked inside the larynx.
Clinical features:

- Stridor is the only symptom and appears at or soon after birth, mainly inspiratory, diminished by rest and responsive to changes in posture but increased by exertion. It disappears between the second and first year of life.
- Cyanosis is rare and the -voice is unchanged.
Diagnosis:
1. Careful history and examination:
Inspiratory stridor without hoarseness is always suggestive when occurring soon or after birth.
2. Flexible fibroptic examination.
Treatment:
1. Reassurance is necessary.
2. Tracheostomy may rarely performed in very severe cases.
Subglottic stenosis:
There is inspiratory stridor, partially relieved by rest & worsened by exertion but unaffected by posture with failure to thrive.
Diagnosis:
By direct laryngoscopy and bronchoscopy.
Management:
Laser vaporization of the stenosis.
Subglottic hemangioma:
The clinical features are the same of the subglottic stenosis and the laser is very effective in treatment.
Laryngotracheal cleft:


Laryngeal cyst
Lead to muffled cry & sometimes stridor.
Laryngeal web
Web consist of a fibrous tissue stroma covered by epithelium in the anterior half of the glottis due to arrest in development, sometimes atresia may be complete.
Clinical features:
- Hoarseness.
- Inspiratory stridor.
Diagnosis:
- Fibroptic laryngoscopy or direct laryngoscopy.
Treatment:
1. No treatment in the milder forms.
2. Laser excision.
3. excision by laryngofissure, which may be advised later until the larynx developed fully.
Vocal cord palsy
This causes inspiratory stridor & hoarseness in neonate; diagnosed by fibroptic laryngoscopy, caused by damage to the recurrent laryngeal nerve in the neck or chest usually from, birth trauma.

Traumatic conditions of the larynx

Direct injuries (compression, closed)
As blows and strangulation, this may lead to:
1. Bruising of the skin.
2. Surgical emphysema, this may involve the neck, face, and chest.
5. Sub mucosal hemorrhage of any part of the interior of the larynx.
4. Adhesions, stenosis and perichondritis if infection supervenes.
5. Fracture of the laryngeal cartilages. Thyroid cartilage is more commonly involved while fracture of the cricoid cartilage is fatal because it leads quickly to subglottic swelling. The patient may complain from marked dyspnoea, pain, tenderness (may be elicited), crepitus and external swelling according to severity.
Diagnosis:
1. History and clinical examination.
2. Plain X-ray or CT scan may confirm the presence of fracture.
Treatment
1. The chief danger from asphyxia, so Tracheostomy may be urgently required.
2. Prophylactic systemic antibiotics.
3. Incision & drainage are needed if abscess developed.
4. Laryngofissure may be required for treatment of fracture.
Penetrating (open) wound
Usually fatal (involve the vital structures in the neck), these are caused by gunshot, stabs or cuts. The injury maybe:
1. Oblique wounds (usually involve the great vessels of the neck).
2. Anteroposterior wounds (may cause death from involvement of the cervical vertebrae).
3. Transverse wounds (may involve the larynx only).
Clinical features:
1. Respiratory obstruction (dyspnoea, asphyxia).
2. Severe hemorrhage into the larynx and tracheobronchial tree.
3. Fractures of the Laryngeal cartilages.
4. Mediastinal emphysema.
Treatment (must be immediate)
1. Clamping and ligation of the divided vessels.
2. Intubation and tracheostomy through the open wound may prevent asphyxia.
3. Removal of foreign Bodies & suturing of the mucosa.
4. Systemic antibiotics.
5. Laryngofissure at a later date if stenosis occurs.
6. No food by mouth. Feeding is through nasogastric tube or intravenous fluids.
Burns & Scalds
May lead to dyspnoea, pain, dysphagia, and oedema of the laryngeal inlet and vestibule may occur from:
1. Inhalation of irritant fumes or gases.
2. Swallowing of corrosive fluids.
3. Inhalation of steam.
Treatment:
1. Rest (voice and bed rest).
2. Steroids should be given.
3. Prophylactic antibiotics.
4. Analgesics.
5. Tracheostomy (in severe cases).
Inhaled foreign body
Most foreign Bodies entering through the mouth or nose are either held up in the upper part of the cervical esophagus or pass the glottis to the bronchi, but sharp objects such as pins or glass may be impacted in the larynx also large foreign bodies such as bolus of food maybe fatal when impacted in the larynx.
Clinical features:
1. Dyspnoea (may be urgent).
2. Cough.
3. Hoarseness or aphonia may appear.
Treatment
1. Heimlich's maneuver from behind with hands clasped just below the xiphisternum may expel the object with a gush of air.
2. Removal of foreign body by direct laryngoscope.
3. Tracheostomy may be necessary in an emergency.
4. Systemic antibiotic.
Acute submucosal hemorrhage
Hemorrhage is due to sudden violent and forceful approximation of the vocal cords as in coughing, shouting, weight lifting or injuries to the larynx.
Clinical features:
Hoarseness of voice occurs suddenly with pain after vocal strain, part or whole of the vocal cords may be involved by hemorrhage.
Treatment:
Voice rest is the most important part of treatment.
Singer's nodule
It is a condition occurring in persons who use their voice excessively with straining or faulty production.
Etiology:
Singers, actors, teachers, mothers of young children are frequently affected & it is more common in women.
Pathology:
Localized hyperkeratosis, the site is constant at the junction of the anterior third o£ posterior two thirds of the free edge of one or both vocal cords. The nodules never become neoplastic.
Clinical features:
- Increasing hoarseness and vocal fatigue.
- Nodules are more commonly bilateral and symmetrical.
Treatment:
1. Voice rest is essential & may cure some of the recent and small nodules.
2. Antibiotics should be given to eliminate any focal infection.
3. Removal by direct laryngoscopy with operating microscope is indicated if the condition persists.
4. Speech therapy.


Contact ulcer & granuloma
It is uncommon condition that occurs almost exclusively in male adults. It occurs in singers and street vendors, this result from hammering of one vocal process of the arytenoid cartilage against the other as in coughing or vocal abuse.
Pathology:
Thickening of the tissues over one vocal process of the arytenoid with saucer like depression over the other, the epithelium is not broken so it is not true ulcer.
Clinical features:
1. Discomfort in the throat and vocal fatigue.
2. Referred otalgia.
3. Duskiness of voice.
Treatment:
1. Voice rest for 2-3 weeks.
2. Steroids may be given.
3. Direct laryngoscopy & removal of granuloma.

Inflammations of the larynx

Acute simple laryngitis
It is an acute superficial inflammation of the laryngeal mucous membrane.
Etiology:
1. Infection: these forms are commonly viral more common in winter and early spring,
2. Vocal abuse or trauma from intubation.
3. Irritation from inhaled fumes or gases including tobacco smoke.
Pathology:
1. Oedema with infection may occur.
2. Sticky mucopurulent exudate may cover the surface.
3. Perichondritis may occur in severe cases.
Clinical features:
1. Hoarseness or aphonia.
2. Discomfort in the throat, pain and dysphagia.
3. Dyspnoea is absent unless oedema occurs in severe cases.
4. Cough, generalized malaise and fever.
Treatment
1. Local:
- Voice rest is essential.
- Steam inhalation with tincture benzoate combination or menthol helps to loosen viscid secretions.
- Warm applications to the neck.
- Codeine to suppress dry cough.
2. General:
- Rest in a room with equable temperature.
- Avoidance of alcohol and tobacco.
- Systemic antibiotics.
* Acute laryngitis in children is more serious condition than in adults because stridor may develop due to oedema and the child is less able to expel the secretions by coughing.


Acute epiglottitis
The inflammatory changes affect mainly the loosely attached mucosa of the epiglottis.
Pathology:
1. Localized oedema may obstruct the airway especially in children.
2. Haemophilus influeuzae type B is the usual causal organism.
3. Submucosal abscesses may form.
Clinical features:
1. Dyspnoea maybe progressive and alarming especially in children in whom death may occur within few hours.
2. Pain on swallowing.
Treatment:
1. Admission of the patient to hospital.
2. Throat swab and blood cultures before antibiotics.
3. Intravenous antibiotics.
4. Endotracheal intubation and tracheostomy may become urgently necessary.

Acute laryngotracheobronchitis

Etiology
- Affect infants & young children.
- Causative organism is usually parainfluenza virus type 1.
- Secondary infection by third day of infection is common and makes the condition worse.
Clinical features:
1. Hard, dry and croupy cough with hoarseness occurs after cold or influenza.
2. Pyrexia.
3. Dyspnoea and cyanosis.
4. Tenacious exudation and crusting are characteristic.
5. Oedema of the larynx.
6. Atelactasis caused by occlusion of the bronchi by secretion or crusts.
Differential diagnosis
1. Acute simple laryngitis (less severe and no physical signs in the chest).
2. Diphtheria.
3. Bronchopneumonia (no crusting).
4. Bronchial foreign Body.
Treatment:
1. Admission to the hospital for supervision.
2. Rest and reassurance.
3. Systemic antipyretic and antibiotics.
4. Humidification of inspired air.
5. Oxygen may have to be given in a tent.
6. Fluids must be given by I. V. line or mouth to prevent dehydration.
7. Intubation or tracheostomy may be necessary in severe cases.


Chronic non-specific laryngitis

Etiology:

1. Faulty use of the voice, overstraining or excessive force is the most important factor.
2. Infection in teeth, tonsils and sinuses, especially when the result in excessive hawking or coughing.
3. Excessive alcohol or tobacco.
4. Dusts or irritant fumes.
Pathology:
1. Hyperaemia of the vocal cords is marked.
2. Oedema and excessive viscid secretion (hypertrophic or atrophic stage).
Clinical features
1. Hoarseness is intermittent at first then become less marked after use of voice.
2. Cough, dry and irritating with constant hawking and clearing of the throat.
3. Soreness in the throat.
Examination of the Larynx may show:
1. Hyperaemia: in which the cords are injected or dull pink with secretions.
2. Hypertrophic changes: thickening of the tissues of the vocal cords, ventricular bands and arytenoids.
3. Oedematous changes: in which the cords are swollen & pale.
* In all these types the vocal cords are affected bilaterally and symmetrically.
Treatment:
1. Voice rest.
2. Speech therapy may correct faulty use of voice.
3. Systemic antibiotics.
4. Elimination of irritating factors such as dust and smoking.
5. Mucolytics may be given when secretions are thick.
6. Direct laryngoscopy & stripping of the vocal cords in resistant cases.


Hyperkeratosis of the larynx (leukoplakia):
It is a localized form of epithelial hyperplasia with raised patches on the vocal cords.
Etiology:
More commonly occurs in men associated with chronic inflammation of the larynx.
Clinical features
1. Hoarseness of gradual onset.
2. White raised patches on one or both vocal cords c£ mobility is not impaired.
3. The condition must be considered precancerous.
Treatment
1. Treatment of septic foci in the mouth or throat.
2. Biopsy is essential with constant supervision to detect early malignancy.
3. Stripping of the cords can be done 6y direct laryngoscopy.
4. Removal of the affected cords.
5. Radiotherapy is not indicated.

Specific infection of the larynx:

1. Tb.
2. Syphilis.
3. Leprosy.
4. Mycoses of the larynx (Blastomycosis, Candidiasis).
5. Wegner's granuloma (Non-healing granuloma).
Perichondritis of the larynx
It is an inflammation of the perichondrium of the laryngeal cartilages.
Etiology:
1. Inflammatory: from TB, syphilis, diphtheria and acute laryngitis in the exanthema.
2. Traumatic: from cut throat wounds c£ foreign body.
3. Neoplastic: from advanced Ca with infection.
4. Radiotherapy: during treatment of laryngeal tumors.
Pathology:
The perichondrium becomes infected & start to separate from the cartilage, accompanied by exudation leading to subperichondrial abscess & necrosis of cartilage, resolution if occur will lead to deformity and stenosis.
Clinical features
The condition may be of sudden or insidious onset, presented by:
1. Malaise, fever and even rigors occur in acute form.
2. Local pain and tenderness.
3. Enlargement of laryngeal contour and swelling of the neck.
4. Cough, hoarseness, dysphagia & and dyspnoea which increases.
Treatment
1. Absolute rest both general and local in the acute phase.
2. Systemic antibiotics.
3. Tracheostomy is indicated when dyspnoea is marked.
4. Drainage of the abscess if developed & necrotic cartilages are removed.
5. Laryngectomy is indicated when marked necrosis has occurred specially following radiotherapy.