Hoarseness and Laryngitis

2. Hoarseness and Laryngitis Dept of Otolaryngology BERJIS N, MD

3. Definition of Hoarseness • the perceived breathiness quality of the voice (Bailey) • a rough or noisy quality of voice (Dorland) • a rough, harsh voice quality (Stedman)

4. Symptom –vs- Diagnosis • Hoarseness is a symptom of a disease process • Although hoarseness appears on the ICD9 as a diagnosis (784.49): • it is really a symptom resulting from the underlying disease process • the underlying disease process is your diagnosis (ex. vocal nodules)

5. Anatomy: Laryngeal Cartilage

6. Anatomy: Laryngeal Muscles

7. Histology • Mucosal layer • Pseudostratified squamous epithelium superiorly and inferiorly • Nonkeratinizing squamous epithelium at contact surface of medial cord

8. Histology • Subepithelial tissues: three layered lamina propria • Superficial Layer (Reinke’s space) • Intermediate layer • Deep layer • the intermediate and deep layers make up the vocal ligament • Vocalis and thyroarytenoid muscle

9. Histology

10. Physical Examination • Laryngeal mirror • Advantages: fast, inexpensive, minimal equiptment • Disadvantages: gag, nonphysiologic, no permanent image capability

11. Physical Examination • Rigid Laryngoscopy (70 or 90-degree telescope) • Advantages: best optic image, magnifies, video documentation • Disadvantages: gag, nonphysiologic, expensive

12. Physical Examination • Flexible fiberoptic nasolaryngoscope • Advantages: well tolerated, physiologic, video documentation • Disadvantages: time consuming, expensive, resolution limited by fiberoptics

13. Physical Examination • Videostroboscopy • Advantages: allows apparent “slow motion” assessment of mucosal vibratory dynamics, video documentation • Disadvantages: time consuming, expensive

14. Surgical Treatment

15. Varices and Ectasias

16. Cysts • Treatment • Cold instrument resection • Subepithelial infusion of saline and epinephrine is helpful • Must retreive entire cyst wall to prevent recurrence • Preserve normal SLP • Microspot CO2 laser not as effective due to necessity of delicate tangential dissection

17. Cysts • Results • Mucosal wave usually improves • Does not return to normal if cysts has replaced substantial amount of SLP • SLP does not regenerate

18. Cysts

19. Granulomas • Results from hypertrophic inflammatory reaction due to traumatic mucosal disruption • Majority found in arytenoid region • Usually exophytic with narrow base • Typically arise in patients with LPR • Seen with endotracheal intubation

20. Granulomas • Treatment • Vocal therapy including antireflux management • Surgical resection • conservative management has failed • concern of a neoplastic process • airway compromise

21. Granulomas

22. Granulomas

23. Granulomas

24. Granulomas

25. Polypoid Corditis (Reinke’s Edema) • Extensive swelling of SLP • Usually on superior surface of musculo-membranous vocal fold • Typically bilateral but asymmetric volume • Multifactorial cause • Smoking • LPR • Vocal hyperfunction

26. Polypoid Corditis (Reinke’s Edema) • Treatment • Smoking cessation • Antireflux medication • Preoperative vocal therapy • Surgery • Epithelial microflap elevation with SLP contouring and reduction using either cold instruments, Microspot CO2 laser, or both • Vocal ligament should never be visualized • Both vocal folds can be treated in one procedure if flap is elevated on superior surface of vocal fold

27. Polypoid Corditis (Reinke’s Edema)

28. Papillomatosis • Human papillomavirus 6 and 11 • Confined to epithelium • Excision should preserve SLP • Most commonly found in musculo-membranous region, but may extend into arytenoid, ventricle, subglottis

29. Papillomatosis • Surgical treatment • Cold instruments • Microdebrider • Microspot CO2 laser • Resection of lesions inhibits recurrence in 30% of chronic patients

30. Papillomatosis

31. Physiology Airway protection Swallowing Voice production Air passage

32. inspiration phonation

33. Common laryngeal disorders 1. Acute laryngitis 2. Croup 3. Epiglottitis 4. Vocal nodule 5. Vocal polyp 6. Vocal granuloma 7. Laryngeal carcinoma 8. Laryngeal trauma 9. Laryngopharyngeal reflux (LPR)

34. Laryngitis • Laryngitis is inflammation of the vocal cords • Laryngitis can be acute (short term) or chronic (long term).

35. Short term laryngitis usually follows upper respiratory infections. • Long term laryngitis is most commonly caused by misuse, overuse and exposure to smoke, dust and other irritants, as well as acid reflux.

36. Acute laryngitis Pathogen - adenovirus, influenza Morexella catarrharis Hemophilus influenza Streptococcus pneumoniae Symptoms - hoarseness cough, +/- fever, malaise Sign - TVC swelling

38. Acute laryngitis Treatment - voice rest - mucolytic, anticold +/- antibiotic Symptoms > 2 week, recurrent DDx - chronic laryngitis

39. Croup (acute laryngotracheobronchitis) - Severe respiratory infection - 6 months-2 yrs. Pathogen - parainfluenza*influenza, adenovirus - follow by bacterial esp. H. influenza Symptoms - early URI symptoms - 2-3 days - barking cough, stridor - exhausted, lying down

40. Croup (acute laryngotracheobronchitis) Diagnosis - symptoms & signs - flexible scope - x-ray norrowing of subglottis “Pencil’s sign”

41. Pencil’s sign Normal

42. Croup (acute laryngotracheobronchitis) Treatment - early detection - observe, admit - humidification, hydration, O2 - antibiotic (penicillin) severe - steroid - intubation

43. Epiglottitis Signs - epiglottis > swelling, inflam - ** laryngospasm เมื่อกดลิ้น - fiberoptic X-ray - “Thumb’s sign”

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

45. Aetiology • Congenital • Traumatic • Inflammatory • Neoplastic • Functional

46. Congenital • Laryngomalacia (75%) - a “rough” cry associated with stridor which is worse when feeding and begins within a few weeks of birth

47. Congenital • Neurological (10%) - unilateral or bilateral recurrent nerve palsies (idiopathic or birth trauma)

48. Congenital • Other - laryngocoele (blind sac of the laryngeal ventricle) - haemangioma (site determines severity of dysphonia)

49. Laryngitis Sicca Laryngistis sicca is caused by inadequate hydration. The protective mucus normally needed for the vocal cords becomes too thick and they cannot open or close properly.