Acute and chronic laryngeal inflammations

Acute and chronic laryngeal inflammations

1. Acute and chronic
laryngeal inflammations
Dr. Krishna Koirala

2. Acute Laryngitis ( Simple laryngitis)
•Most common
•Occurs as a symptom of common cold
•Etiology
–Infection :
–Rhinovirus , Parainfluenza viruses, Respiratory
syncytial virus , Adenoviruses , Influenza viruses
–H. influenza, Strept. pneumoniae, Moraxella

3. •Gastroesophagealrefluxdisease
•Environmentalinsults(pollution)
•Vocaltrauma
•Unfavorableclimate
•Unduephysicalandpsychologicalstress

4. Clinical Features
•Symptoms
–HistoryofURTI
–Hoarseness-discomfortonspeech,highpitched
huskyvoice
–Discomfortandpaininthethroat
–Irritantparoxysmalcoughmainlyatnight
–Bodyache,malaise

5. •Signs
–Fever
–Congested posterior pharyngeal wall
–I/L or Flexible NPL
•Red and swollen mucosa of supraglottic
structures
•Mild swelling and congestion of true vocal
cords
•Inspissated mucous or purulent discharge

6. Swollen and
congested TVCs
Normal vocal cord
Mucopus

7. Treatment
•Supportive
–Voicerest
–Medicatedsteaminhalation
–Avoidanceofirritants:cold,draught,tobacco,
alcohol
•Mucolyticagents:Bromhexine,guaphenesin
•Analgesics
•Adequatehydration

8. •Codeine phosphate
•Proton pump inhibitors
•Antibiotics : Amoxicillin, Doxycycline, erythromycin
•Local anesthetic sprays
•Steroids
•Voice therapy if the problem persists

9. Acute Epiglottitis (Acute Supraglottitis,
Supraglottic laryngitis)
•Rapidlydevelopinginflammationoftheepiglottisand
adjacentsupraglottictissuesusuallyduetoabacterial
infection,thatcancauselife-threateningairwayobstruction
•M:F--3:1,meanage:3-5yrs
•Causativeorganisms
•Haemophilusinfluenzaetypeb(Hib)
•Streptococcuspyogenes,S.pneumoniae,Staph.Aureus
•Tubercularbacilli

10. •Morbidityandmortality
–Life-threateningairwayobstructionrequiring
intubation/tracheostomy
–Mortalityrate:around1%inchildren
•Course
–Suddenonsetandrapidprogressionwithearly
airwaycompromiseinchildren(hours)
–Indolentcourseinadults(days)

11. Clinical features
•Acute onset , rapid progression !
•Severe sore throat
•Odynophagia /Dysphagia
•Drooling (due to inability to swallow)
•Toxic look
•Respiratory Distress with Stridor (Inspiratory)

12. •Muffledvoice
•Childanxious,mayleanforward,extending
theneckinanattempttomaintainanopen
airway
•Tripodsign:Sittinguponhandswiththe
tongueoutandheadforward
•Cervicallymphadenopathy+

13. •ExaminationcarriedoutinICU/ERwith
intubation/tracheostomysetready
•Laryngealfindings
–Inflamedepiglottis,aryepiglotticfolds and
arytenoidcartilages
–Pusintheepiglottis

15. Investigations:
•Plainx-raysofttissueofnecklateralview
–Enlargedandswollenepiglottis(Thumbsign)
–Absenceofdeepwelldefinedvallecula(Vallecula
sign)
•Culturefromepiglottisduringintubation
•Bloodculture,throatswabs

16. Swollen epiglottis
Thickened AEF
Epiglottitis in elderly

17. •Parameters for diagnosing epiglottitis in adults
–Epiglottic height to width ratio >0.6
–Epiglottic to C4 vertebral body width ratio >0.33
–AE fold to C3 vertebral body width ratio >0.35
–Prevertebral soft-tissue to C4 vertebral body width
ratio >0.25
–Hypopharyngeal airway to C4 vertebral body width
ratio >1.5

18. Treatment
•Firstpriority-toensurepatient'sairway-intubationor
tracheostomyunderGAifrespiratorydistress/stridor
occur
•Mechanicallyventilateduntilswellingand
inflammationdecrease
•Carefulmonitoringandisolation-infectiousand
easilyspread

19. •Steroids(prednisolone1mg/kgstat)
•Antibiotics
–Ampicillin(200mg/kg/din4divideddoses)+
Chloramphenicol(100mg/kg/din4divideddoses)
–Ceftriaxone(100mg/kg/din2divideddoses)
–Cefuroxime(50-100mg/kgivBD)
•Sedation:Midazolam0.1mg/kgbolusandcontinuousi.v.
infusionifthechildisintubated
•Adequatehydration
•Oxygenation

20. Acute Laryngotracheobronchitis (Croup)
•Commonest infective cause of URT obstruction in
children ( 40 times more common than epiglottitis)
•Mean age 18 months
•Maximal effect in subglottic area
•Causative agents
–Parainfluenza virus type I, II and III
–Influenza virus, Respiratory syncytial virus,
Rhinovirus , Measles

21. Clinical features
•Symptoms
–AlmostalwaysprecededbyURTIusuallyatleast
48hrsduration
–Sorethroat,hoarseness
–Croupycough(musicalcoughofcrowingqualityor
barkofaseal)
–Respiratorydistressmainlyatnight
–Child prefers to lie down

22. •Signs
–Slightpyrexia
–Inspiratory / biphasic stridor
–Inflamed and ulcerated TVCs
–Edema and ulceration of subglottis
–Sloughing of trachea
–Rest of tracheobronchial tree may be affected

23. Bacterial Laryngotracheobronchitis (pseudo
membranous croup)
•More severe than acute laryngotracheobronchitis
•Causative agent : Staph. aureus
•Pathology
–Sloughing of resp. epithelium
•C/F
–Brassy cough with high fever

24. Investigations
•Plain X-ray soft tissue neck
AP view
–Narrow subglottis ( steeple
sign)
–Ballooning of hypopharynx
•Blood gas analysis
•Laryngeal findings during
intubation

26. Treatment
•Observation–Stridor,restlessness,bodycolour,
respiratoryandheartrate
•Reassurance–Calm,confident,reassuring
atmosphere
•Hydration–oralorIVfluids
•Humidification
•OxygenTherapy
–Decreasesreflexbronchoconstriction,sputum
retentionandpulmonaryedema

27. •Steroids
–Dexamethasone 0.6 mg/kg single dose
•Antibiotics
–IV Ceftriaxone 100 mg/kg/day
•Racemic adrenaline
–Nebulized and delivered by IPPV
•Endotracheal intubation / Tracheostomy
–Rarely

28. Chronic Laryngitis
•Chronicnonspecificinflammatoryprocess(>3wks)
leadingtoirreversiblealterationsofthelaryngeal
mucosa
•Etiology
–Endogenous:Short,heavybuiltpeople,diabetes,
hypothyroidism,vitaminAdeficiency
–Exogenous
•Physical-cigarette,inhaledirritants
•Chemicals
•Chronicinfectionsofupperorlowerrespiratorytract
•Chroniccough

29. History and Clinical symptoms
•Insidiousonset
•Hoarseness
–Worseinthemorning
–DrynessandfeelingofFBinthroat
–Decreasedvocalrange
–Painrarelypresent

30. Clinical Forms
•Simple diffuse chronic laryngitis
•Hyperplastic diffuse chronic laryngitis

31. Simple Diffuse Chronic laryngitis
•StartswithURTIandpersistsashoarsenessand
coughoveralongperiodoftime
•O/E
–Reddenedhyperemiclaryngealmucosa
–TVCspinkorred,glossy,submucosaledema
•Treatment
–Voicerest,steaminhalation
–Antibiotics(Amoxycillin,Co-amoxyclav)
–Avoidanceofalcoholandtobacco

32. Hyperplastic diffuse chronic laryngitis
•Contributingfactors
–Chronicinfectionofsinusesandlowerairway
–Tobaccoandalcohol
–Occupational,chemicalorphysicalirritants
–Mouthbreathing
•O/E
–TVCs lose their normal appearance (red, deep red or
grey)
–Patches of epithelial thickening and broad based
polypoid lesions

33. Reinke’s edema
•AccumulationoffluidundertheepitheliumofTVCs
•Etiology
–Precisecauseunknown
–Allergy,infection,localirritants(alcohol,tobacco)
•Clinicalfeatures
–Commoninfemalesmokersof30-60yrsofage
–Hoarsenesswithdeepenedandmonotonousvoice
–Drycoughandhabitofclearingofthroat
–Vocalcordsred,swollen,slightlytranslucent
–Fusiform,symmetrical,polypoidswellingofTVCs

34. •Treatment
–Eliminationofnoxiousagents
–Microsurgicalremovalofstripsof
vocalcordmucosabymicro
laryngoscopy(Decortication)
–Boththesidescanbetreatedatone
setting(don’textendtheincisionsto
anteriorcommissure)
–Absolutevocalrestfor1week
–Speechtherapy(after2-3wks)

35. Tuberculosis of larynx
•Commonly associatedwithpulmonary
tuberculosis
•Posteriorcommissure,arytenoidsandTVCs
mainlyaffectedb/ocontactoflarynxwith
sputumcontainingtubercularbacilli
•Hematogenousandlymphogenousinfection
(Moreacceptednowadays)

36. Pathology
Subepithelial infection
Exudation and hyperemia
Round cell infiltration
Tubercles (granulomatous reaction + Langhans giant cells +
caseation necrosis) (Turban epiglottis)
Sloughing with ulceration of epitheliumleading to shallow
ulcers with undermined edges involving the arytenoids and
epiglottis (moth eaten epiglottis)

37. •Clinicalfeatures
–HistoryofPTB,coughwithhoarseness
–Dysphagia
–Throatpainandreferredearache(outofproportiontothe
lesion)
–Mucosalhyperemia/edema
–Irregularitiesofmucosalsurface
–Granulomatousmassandulceration
–Swollenandturbanshapedepiglottis

38. •Diagnosis
–Directlaryngoscopyandbiopsy
–ChestX-rayP/Aview
–SputumAFB
•Treatment
–Antitubercularmedicationfor6-8mths
–2HRZE+6HR