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Inflammatory Disorders of Larynx

Inflammatory Disorders of Larynx. Dr. Vishal Sharma. Classification. A. Acute infection B. Chronic infection  Acute s imple laryngitis  Chronic laryngitis  Acute epiglottitis  Tuberculosis  Viral LTB  Scleroma  Bacterial LTB  Candidiasis

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Inflammatory Disorders of Larynx

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  1. Inflammatory Disorders of Larynx Dr. Vishal Sharma

  2. Classification A. Acute infection B. Chronic infection  Acute simple laryngitis Chronic laryngitis  Acute epiglottitis Tuberculosis  Viral LTB Scleroma  Bacterial LTB Candidiasis  Spasmodic croup Sarcoidosis C. Laryngeal edema D. Laryngo-pharyngeal reflux disease (LPRD)

  3. Causes for laryngeal edema  Laryngeal infections  Retropharyngeal abscess / quinsy / Ludwig’s angina  Angio-neurotic edema; Reinke’s edema  Thermal / caustic burn  Trauma: accidental / intubation / endoscopy  Ca of larynx / pharynx; Post-irradiation  Nephritis / heart failure / myxedema / anasarca

  4. Acute (simple) Laryngitis

  5. Etiology • Viral infection (common cold) • Vocal abuse • Allergy / smoking / environmental pollution • Gastro esophageal reflux disease • Thermal / chemical burn due to inhalation • Use of asthma inhalers • Laryngeal trauma (endotracheal intubation) • Undue physical or psychological stress

  6. Clinical Features • History of upper respiratory tract infection • Hoarseness: high pitched husky voice • Dry, paroxysmal cough, mainly at night • Sore throat worsened by talking; fever, malaise • Laryngoscopy:red, swollen supraglottic mucosa; mild erythema / swelling of true vocal cords; inspissated secretions b/w vocal cords

  7. Flexible laryngoscopy

  8. Treatment • Prevention: avoidance of cold fluids, cold air, smoking, alcohol consumption • Absolute voice rest • Tincture Benzoin steam inhalation & mucolytics • Anti-tussives: dextromethorphan, codeine • Pantoprazole for GERD; analgesics for pain • Antibiotics: for secondary bacterial infections • Steroid:for laryngeal edema

  9. Acute Epiglottitis

  10. Synonym:Acute Supraglottitis Supraglottic laryngitis Definition:Rapidly developing inflammation of epiglottis & adjacent tissues, due to bacterial infection, may cause life-threatening airway obstruction Causative agents:Haemophilus influenzae type b (Hib), Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus

  11. Symptoms • Distress (respiratory) • Dysphagia • Drooling (due to inability to swallow) • Severe sore throat / odynophagia • Muffled voice • Sudden onset & rapid progression in children (in hours); Indolent course in adults (in days)

  12. Examination • Simply depressing child's tongue with tongue depressor or indirect laryngoscopy may visualize enlarged, cherry red epiglottis in some situations • These procedures may precipitate complete airway obstruction, hence avoided

  13. Tripod sign • Pt appears anxious • Leans forward with support of both forearms • Extends neck in an attempt to maintain an open airway

  14. Investigations 1. Flexible laryngoscopy:carried out only in ICU or OT with intubation / tracheostomy set ready 2. Post-intubation direct laryngoscopy 3. Plain x-ray soft tissue of neck lateral view 4. Culture from epiglottis during intubation:+ve in 15% cases of H. influenzae 5. Blood culture:+ve in 15% cases of H. influenzae

  15. Flexible laryngoscopy • Inflamed cherry-red epiglottis • Thickened aryepiglottic folds • Edematous arytenoid cartilages

  16. Post-intubation direct laryngoscopy

  17. X-ray soft tissue neck Lateral view taken in erect position only • Enlargement of epiglottis (thumb sign) • Absence of well defined vallecula (Vallecula sign) • Thickening of aryepiglottic folds (cause for stridor) • Circumferential narrowing of subglottic portion of trachea during inspiration (25% cases) • Ballooning of hypopharynx

  18. X-ray soft tissue neck

  19. X-ray soft tissue neck • Red arrow = enlarged epiglottis • Yellow arrow = thickened ary-epiglottic folds

  20. Ballooning of hypopharynx

  21. Treatment • Hospitalization, careful monitoring & isolation • Hydration + humidification + oxygen tent therapy • Secure airway in acute stridor → Mechanical ventilation till swelling + inflammation subside • IV Ceftriaxone: 100 mg/kg/d in 2 divided doses • Hydrocortisone: 100 mg IV stat & 25 mg Q8H • Rifampicin prophylaxis for household contacts

  22. Methods of securing airway • Endotracheal intubation • Trans-nasal: preferred • Trans-oral • Percutaneous trans-laryngeal ventilation by needle cricothyrotomy • Tracheostomy: last resort for acute stridor

  23. Prevention • Hib vaccination for all children • Rifampicin prophylaxis (20 mg/kg /day; max. 600 mg) for 4 days should be given to all household contacts if: a. child in household < 4 years, not received appropriate doses of Hib vaccine b. immuno-compromised child, despite vaccination • Children > 2 years with epiglottitis do not need vaccination as disease provides immune protection

  24. Laryngo-Tracheo-Bronchitis (LTB)

  25. Acute viral LTB (Croup) • Commonest infective cause of stridor in children • Mean age for presentation = 18 months • Causative agents: • Parainfluenza virus type I, II, III • Influenza virus • Respiratory syncytial virus • Rhinovirus • Measles

  26. Clinical Features • Gradual onset preceeded by URTI of > 48 hrs • Hoarseness • Biphasic stridor, mainly at night • Dry cough (like barking of seal) • Low grade fever (< 102 F) • Child prefers to lie down, but is restless • Dysphagia & drooling absent

  27. Investigations • Plain X-ray soft tissue neck, AP view a. Church steeple or pencil-point sign: squared appearance of subglottic area replaced by cone shaped narrowing just below vocal cords b. Ballooning of hypopharynx • Flexible laryngoscopy:narrowed subglottic area

  28. Church Steeple sign

  29. Treatment • Hospitalization • Humidification & mucolytic drugs • Hydration with IV fluid • Hydrocortisone: 100 mg IV stat & 25 mg Q8H • Oxygen tent:es bronchospasm & pulm. edema • Antibiotic (IV Ceftriaxone): 100 mg/kg/day • Racemic adrenaline (1:1000) nebulization • Intubation / Tracheostomy for acute stridor

  30. Bacterial LTB Synonym:pseudo-membranous croup More severe than viral LTB Causative agent: Staphylococcus aureus Pathology: sloughing of respiratory epithelium C/F:Hoarseness, biphasic stridor, dry cough, high grade fever (> 102F), child supine but restless X-ray neck, AP view: church steeple sign Rx:moist air + oxygen + antibiotics

  31. Subglottic laryngitis • Synonym:spasmodic croup • Etiology:unknown (? Influenza virus infection) causing subglottic mucosal edema • C/F:Child below 3 years with rapid onset of biphasic stridor + barking cough + low grade fever (< 102 F). Dysphagia & drooling are absent. • X-ray neck, AP view:church steeple sign • Rx:Moist air + oxygen + supportive treatment. Rarely endotracheal intubation. Avoid sedatives.

  32. Chronic Laryngitis

  33. Definition:Chronic non-specific inflammation causing irreversible changes of laryngeal mucosa Etiology of chronic laryngitis: • Viral infection (common cold) • Vocal abuse • Allergy / smoking / environmental pollution • Gastro esophageal reflux disease • Thermal / chemical burn due to inhalation • Laryngeal trauma (endotracheal intubation) • Undue physical or psychological stress

  34. Chronic hyperemic laryngitis Hoarseness (worse in morning) + dry cough for > 3 wk Persistent clearing of throat H/o previous URTI / GERD may be present Laryngoscopy:hyperemic laryngeal mucosa with sub-mucosal edema Treatment:Voice test + medicated steam inhalation + systemic antibiotic. Avoidance of alcohol & tobacco. Reversible within few weeks.

  35. Chronic hyperemic laryngitis

  36. Chronic hyperplastic laryngitis Hoarseness (worse in morning) + dry cough for > 3 wk Persistent clearing of throat H/o previous URTI / GERD may be present Laryngoscopy: • Mild congestion of laryngeal mucosa • Patches of epithelial thickening • Broad based polypoid lesions

  37. Chronic hyperplastic laryngitis

  38. Chronic hyperplastic laryngitis

  39. Chronic laryngitis histology Kleinsasser’s classification: • Grade I:simple squamous cell hyperplasia or keratosis • Grade II:squamous cell hyperplasia + atypia (mild to moderate dysplasia) • Grade III:carcinoma in situ with intact basal membrane

  40. Rx of hyperplastic laryngitis Absolute voice rest for 48 hours Systemic antibiotic Tincture Benzoin steam inhalation Analgesics & anti histamine-decongestant Micro-laryngoscopic excision of lesion & HPE • Grades I & II: no further treatment • Grade III: total excision of lesion / radiotherapy

  41. Prevention of recurrent attacks • Avoid breathing polluted air • Avoid tobacco in any form (chewing, smoking) • Avoid recreational drugs like marijuana • Avoid alcohol consumption • Avoid talking or shouting at noisy places • Avoid continuous throat clearing • Avoid whispering loudly

  42. Reinke’s edema

  43. Introduction Accumulation of fluid in Reinke’s space Synonyms:Bilateral diffuse polyposis, Smoker’s polyps, Polypoid corditis, Polypoid degeneration of vocal cords, Localized hypertrophic laryngitis 10% of benign laryngeal lesions

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