Diseases of the larynx and Ca Larynx.pptx

Larynx pathology

1. Larynx By NIHLA & ENOCK

2. Brief intro. The larynx(voice box) is an organ located in Ant. Neck. It is primarily made of cartilage and held together by a series of ligaments and membranes. It is part of the respiratory tract and it is important in phonation, cough reflex and protection of the lower respiratory tract.

3. Brief Anatomy This Photo by Unknown Author is licensed under CC BY

4. Diseases of the larynx. Laryngotracheal Trauma Causes of Laryngotracheal Trauma automobile accidents when neck strikes against the steering wheel or the instrument panel. Blow or kick on the neck. Neck striking against a stretched wire or cable. Strangulation. Penetrating injuries with sharp instruments or gunshot wounds.

5. Symptoms of laryngotracheal injury Symptoms depend on the structures damaged and the severity of damage. They include: Respiratory distress. Hoarseness of voice or aphonia. Painful and difficult swallowing. This is accompanied by aspiration of food. Local pain in the larynx. More marked on speaking or swallowing. Haemoptysis , usually the result of tears in laryngeal or tracheal mucosa. External signs include: Bruises or abrasions over the skin. Palpation of the laryngeal area is painful. Subcutaneous emphysema due to mucosal tears. It may increase on coughing.

6. Cont … Flattening of thyroid prominence and contour of anterior cervical region. Thyroid notch may not be palpable. Fracture displacements of thyroid or cricoid cartilage or hyoid bone. Gap may be felt between the fractured fragments. Bony crepitus between fragments of hyoid bone, thyroid or cricoid cartilages may sometimes be elicited. Separation of cricoid cartilage from larynx or trachea.

7. Diagnosis and Management Diagnosis. Aside of history taking and physical exam; Indirect laryngoscopy. Direct laryngoscopy. X-rays. CT scan. Associated injuries

8. Management can be conservative or surgical Conservative; Patient should be hospitalized and observed for respiratory distress. Voice rest is essential. Humidification of inspired air is essential. Steroid therapy should be started immediately and in full dose. It helps to resolve oedema and haematoma and prevent scarring and stenosis. Antibiotics are given to prevent perichondritis and cartilage necrosis Surgical Tracheostomy Open reduction. it is done 3–5 days after injury and not delayed beyond 10 days. Fractures of hyoid bone, thyroid or cricoid cartilage can be wired and replaced in their anatomic positions. Miniplates made of titanium can be used for immobilization of cartilaginous fragments. Mucosal lacerations are repaired with catgut and any loose fragments of cartilage removed.

9. Conti… management. Epiglottis is anchored in its normal position and if already avulsed, may be excised. Arytenoid cartilages can be repositioned in their normal position or may be removed if completely avulsed. In laryngotracheal separation, end-to-end anastomosis can be done. Internal splintage of laryngeal structures may be required. It is done with a laryngeal stent, or silicone tube which may have to be left for 2–6 weeks on an average. Webbing of anterior commissure can be prevented by a silastic keel. COMPLICATIONS Laryngeal stenosis, which may be supraglottic, glottic or subglottic. Perichondritis and laryngeal abscess. Vocal cord paralysis

10. LARYNGITIS This is the inflammation of the voice box from overuse, irritation or infection. In this condition, the vocal cords become inflamed or irritated and this distorts the sound production hence hoarseness of voice. It is either; Acute Chronic

11. Acute Larygitis . This is inflammation of the larynx for <3 weeks . Common in children of 2-7 years. It can be; Infectious Commonly occurs as part of an upper respiratory tract infection Common: adeno virus, influenza virus Rarely: S. pneumonia, M. catarrharis, H. influenza non-infectious; this is due to vocal abuse, allergy, thermal or chemical burns to larynx due to inhalation or ingestion of various substances, or laryngeal trauma such as endotracheal intubation

12. Symptoms Of Acute Laryngitis Hoarseness which may lead to complete loss of voice. Discomfort or pain in throat, particularly after talking. Dry , irritating cough which is usually worse at night. General symptoms of head cold, rawness or dryness of throat, malaise and fever if laryngitis has followed viral infection of upper respiratory tract

13. TREATMENT Vocal rest. Avoidance of smoking and alcohol. Steam inhalations. Cough sedative . Antibiotics. Analgesics. Steroids. Hospital admission in cases where the infection involves the supra

14. Acute epiglottitis Inflammation of the epiglottis Rapid onset inflection Common in children 2-10 yrs , rare in adults Causes Bacteria Commonest: H. influenza type b infection Others: S. pneumonia, S. pyogenes, S. aureus Trauma e.g. burns

15. Normal Vs Acute Epiglottitis

16. Diagnosis From history and examination Investigations Lateral neck x ray Thumb sign Laryngoscopy Swollen edematous epiglottis Blocking airway Lateral Neck X-ray >>>>

17. Laryngeal Diphtheria Mostly, it is secondary to faucial diphtheria affecting children below 10 years of age. Incidence of diphtheria in general is declining due to widespread use of immunization . CLINICAL FEATURES General symptoms. Onset is insidious with low-grade fever (100–101°F), sore throat and malaise but patient is very toxaemic with tachycardia and thready pulse. Laryngeal symptoms. Hoarse voice, croupy cough, inspiratory stridor, increasing dyspnoea with marked upper airway obstruction .

18. Membrane . Greyish white membrane is seen on the tonsil, pharynx and soft palate. It is adherent and its removal leaves a bleeding surface. Similar membrane is seen over the larynx and trachea. Cervical lymphadenopathy. Characteristic “bull-neck” may be seen DIAGNOSIS is always clinical but confirmed by smear and culture of Corynebacterium diphtheriae .

19. TREATMENT Diphtheria antitoxin. It neutralizes free toxin circulating in the blood . Antibacterial. Benzyl penicillin, 500,000 units i.m . every 6 h for 6 days, is effective against diphtheria bacilli. Erythromycin can be given to those who are allergic to penicillin. Maintenance of airway. Tracheostomy, Direct laryngoscopy to remove of diphtheritic membrane, Intubation can be done to relieve respiratory obstruction Complete bed rest for 2–4 weeks is essential to guard against effects of myocarditis

20. COMPLICATIONS OF L. DIPHTHERIA Asphyxia and death due to airway obstruction. Toxic myocarditis and circulatory failure. Palatal paralysis with nasal regurgitation. Laryngeal and pharyngeal paralysis

21. Chronic laryngitis Inflammation of the larynx for > 3 weeks Causes Smoking Infections e.g. TB, syphilis Allergies Acid reflux Auto immune e.g. sarcoidosis Voice abuse Diagnosis On laryngoscopy; Red, Edematous vocal cords Stiff vocal cords Secretions on vocal cords Other investigations Pus swab Tissue biopsies Antibody tests

22. Management Treat cause Acid reflux dietary changes PPIs e.g. omeprazole Allergic Antihistamines Inhaled corticosteroids Auto immune and granulomatous: Corticosteroids Tuberculosis: Anti TB treatment If symptoms persist REFER for further investigations direct laryngoscopy Biopsy Imaging investigations

23. Croup Aka laryngotracheobronchitis Inflammation of the larynx, trachea and bronchi causing airway narrowing Common paediatric infection 15% of children Is a viral infection commonly caused by; Para-influenza virus Influenza virus Respiratory Syncytial Virus (RSV) Symptoms Barking cough Stridor Hoarse voice Difficulty in breathing Fever Coryza Diagnosis From history and exam Neck X ray – steeple sign

24. management Admit Oxygen therapy If saturations < 92% Corticosteroids E.g. dexamethasone, budesonide Nebulised epinephrine

25. OTHER TYPES LARYNGITIS ATROPHIC LARYNGITIS (LARYNGITIS SICCA) It is characterized by atrophy of laryngeal mucosa and crust formation . Treatment is elimination of the causative factor and humidification . Tuberculosis Of Larynx. It is almost always secondary to pulmonary tuberculosis. Diagnosis; In addition to X-ray chest and sputum examination, biopsy of laryngeal lesion is essential to exclude carcinoma and differentiate it from other condition. Treatment is the same as for pulmonary tuberculosis. Voice rest is important.

26. Other diseases. LUPUS OF THE LARYNX. It is an indolent tubercular infection associated with lupus of nose and pharynx. Lupus of larynx is a painless and often an asymptomatic condition and may be discovered on routine laryngeal examination in cases of lupus of nose. There is no pulmonary tuberculosis. Treatment is antitubercular drugs. Prognosis is good.

27. Syphilis Of The Larynx It is a rare condition now. It may occur in any part of the larynx and present as a smooth swelling which may later ulcerate. Diagnosis is only on biopsy and serological tests. Laryngeal stenosis is a frequent complication.

28. Leprosy Of The Larynx It is a rare condition and is often associated with leprosy of the skin and nose. It presents as diffuse nodular infiltration of epiglottis, aryepiglottic folds and arytenoids. Lesions may ulcerate. It is associated with nasal leprosy. Diagnosis is made on biopsy from the lesion. Deformity of the laryngeal inlet and stenosis are the end results of this disease after healing

29. SCLEROMA OF THE LARYNX It is a chronic inflammatory condition caused by Klebsiella rhinoscleromatis. Laryngeal involvement may be seen occasionally with or without a nasal lesion. Typically , it presents as a smooth red swelling in the subglottic region. Hoarseness of voice, wheezing and dyspnoea may be the presenting symptoms in addition to the nasal lesion.

30. Diagnosis is made on biopsy. Treatment is by streptomycin or tetracycline, often combined with steroids to prevent fibrosis. Subglottic stenosis is a frequent complication requiring subsequent reconstructive surgery.

31. Laryngeal Mycosis Fungal infections such as candidiasis, histoplasmosis and blastomycosis may rarely affect the larynx. Diagnosis is usually made on biopsy and on finding a similar lesion in other parts of the body

32. Congenital Lesions Of Larynx Laryngomalacia (congenital laryngeal stridor) - It is characterized by excessive flaccidity of supraglottic larynx which is sucked in during inspiration producing stridor and sometimes cyanosis. Usually disappears by 2 years of age. Congenital vocal cord paralysis - It results from birth trauma when recurrent laryngeal nerve is stretched during breech or forceps delivery or can result from anomalies of the central nervous system Congenital subglottic stenosis - It is due to abnormal thickening of cricoid cartilage or fibrous tissue seen below the vocal cords .

33. Laryngeal web - It is due to incomplete recanalization of larynx. Presenting features are airway obstruction, weak cry or aphonia dating from birth. Subglottic haemangioma - Patient may present with stridor but has a normal cry . Laryngo-oesophageal cleft - . It is due to failure of the fusion of cricoid lamina. Patient presents with repeated aspiration and pneumonitis. Coughing, choking and cyanosis are pres ent at the time of feeding.

34. Laryngocele - It is dilatation of laryngeal saccule and extends between thyroid cartilage and the ventricle. Laryngeal cyst - fluid-filled smooth swelling in the supra glottic larynx. Needle aspiration or incision and drainage of cyst provide an emergency airway. Treatment is deroofing the cyst or excision with CO2 laser.

35. Causes of a stridor

36. Stridor Causes

37. Laryngeal Paralysis CLASSIFICATION OF LARYNGEAL PARALYSIS: Recurrent laryngeal nerve. Superior laryngeal nerve. Both recurrent and superior laryngeal nerves (combined or complete paralysis ). And this can be unilateral or bilateral.

38. TREATMENT Tracheostomy Gastrostomy Epiglottopexy - It is a reversible folding of epiglottis. Vocal cord plication Total laryngectomy. May be needed in those where cause is progressive and irreversible and speech is unserviceable . Laryngectomy will prevent repeated aspiration and lung infections . Diversion procedures. Trachea is separated at third or fourth rings and its upper segment ( laryngotracheal ) is anastomosed to oesophagus while the lower end is brought out as tracheostome for breathing. Aspirated material now finds its way to oesophagus . This operation is done in intractable aspiration

39. Tumors

40. Tumors

41. Neoplastic benign SQUAMOUS PAPILLOMAS - they most common benign neoplasm of the larynx in children. It is viral in origin and is caused by human papilloma DNA virus type 6 and 11. It is presumed that affected children got the disease at birth from their mothers who had vaginal human papilloma virus disease. They can be divided into; ( i ) juvenile (3 and 5)years ( ii) adult-onset types

42. Juvenile. Diagnosis is made by flexible fibreoptic laryngoscopy and confirmed by direct laryngoscopy and biopsy. Papillomas are known for recurrence but rarely undergo malignant change. Treatment is by microlaryngoscopy and CO2 laser excision avoiding injury to vocal ligament . Aim of care is to maintain a good airway, preserve voice and avoid recurrence Check out the role of Vaccination in the mangement of these papillomas Papillomas mostly affect supraglottic and glottic regions of larynx but can also involve subglottis, trachea and bronchi Seeding. (stromal involvement incase of a tracheostomy) Reoccurrence. Patient, presents with hoarseness or aphonia with respiratory difficulty or even stridor

43. Carcinoma of the larynx Risk factors Smoking Alcohol intake HPV infection Presentation Horse voice Difficulty in breathing Cough Difficulty swallowing Cervical lymphadenopathy Diagnosis Biopsy on laryngoscopy CT scan MRI Treatment Depends on stage Surgery Radiotherapy Chemo-radiotherapy

44. Cancer larynx ten times more common in males than in females. Recently, its incidence in females has increased in western countries due to more women taking to smoking. Disease is mostly seen in the age group of 40–70 years but younger people in thirties may occasionally be affected . Both tobacco and alcohol are well-established risk factors in laryngeal cancer. Cigarette smoke contains benzopyrene and other hydrocarbons which are carcinogenic in man. Combination of alcohol and smoking increases the risk 15-folds compared to each factor alone (2–3 folds ).

45. About 90–95% of laryngeal malignancies are squamous cell carcinoma with various grades of differentiation. Cordal lesions are often well-differentiated while supraglottic ones are anaplastic. The rest 5–10% of lesions include verrucous carcinoma, spindle cell carcinoma, malignant salivary gland tumours and sarcomas

46. SUPRAGLOTTIC CANCER Supraglottic cancer is less frequent than glottic cancer. Majority of lesions are seen on epiglottis, false cords followed by aryepiglottic folds, in that order. Spread . Cancer of supraglottic region may spread locally and invade the adjoining areas, i.e. vallecula , base of tongue and pyriform fossa . Cancer of infrahyoid epiglottis and anterior ventricular band may extend into pre- epiglottic space and penetrate the thyroid cartilage. Nodal metastases occur early . Upper and middle jugular nodes are often involved. Bilateral metastases may be seen in cases of epiglottic cancer .

47. Symptoms. Supraglottic growths are often silent. Hoarse ness is a late symptom. Throat pain, dysphagia and referred pain in the ear or mass of lymph nodes in the neck may be the presenting features. Weight loss Respiratory obstruction halitosis

48. GLOTTIC CANCER In vast majority of cases , laryngeal cancer originates in the glottic region . Free edge and upper surface of vocal cord in its anterior and middle third is the most frequent site. Spread can be Locally , the lesion may spread anteriorly to anterior commissure and then to the opposite cord; posteriorly to vocal process and arytenoid region; upward to ventricle and false cord; and downwards to subglottic region. Vocal cord mobility is unaffected in early stages . Fixation of vocal cord indicates spread of disease to thyro -arytenoid muscle and is a bad prognostic sign . There are few lymphatics in vocal cords and nodal metastases are practically never seen in cordal lesions unless the disease spreads beyond the region of membranous cord.

49. Symptoms. Hoarseness of voice is an early sign because lesions of cord affect its vibratory capacity. It is because of this that glottic cancer is detected early. Increase in size of growths with accompanying oedema or cord fixation may cause stridor and laryngeal obstruction .

50. SUBGLOTTIC CANCER (1–2%) Subglottic region extends from glottic area to lower border of cricoid cartilage. Lesions of this region are rare. Spread . Locally , Growth starts on one side of subglottis and may spread around the anterior wall to the opposite side or downwards to the trachea. Upward spread to the vocal cords is late and that is why hoarseness is not an early symptom. Subglottic growths can invade cricothyroid membrane, thyroid gland and ribbon muscles of neck. Lymphatic metastases go to prelaryngeal , pretracheal , paratracheal and lower jugular nodes.

51. Symptoms. The earliest presentation of subglottic cancer may be stridor or laryngeal obstruction but this is often late and by this time disease has already spread sufficiently to encroach the airway. Hoarseness in subglottic cancer indicates spread of disease to the undersurface of vocal cords, infiltration of thyroarytenoid muscle or the involvement of recurrent laryngeal nerve at the cricoarytenoid joint. Hoarseness is a late feature of subglottic growth

52. DIAGNOSIS OF LARYNGEAL CANCER History . Symptomatology of glottic , subglottic and supra glottic lesions would vary and is described under appropriate heads. It is a dictum that any patient in cancer age group having persistent or gradually increasing hoarseness for 3 weeks must have laryngeal examination to exclude cancer . Indirect laryngoscopy; (a ) Appearance of lesion. Appearance of lesion will vary with the site of origin. Vocal cord mobility. Impairment or fixation of vocal cord indicates deeper infiltration into thyroarytenoid muscle , cricoarytenoid joint or invasion of recurrent laryngeal nerve and is an important sign. Extent of disease. Spread of disease to vallecula , base of tongue and pyriform fossa should be noticed . Flexible fibreoptic or rigid laryngoscopy or video laryngoscopy. Examination of neck. It is done to find; Extralaryngeal spread of disease and Nodal metastasis. Search should be made for metastatic lymph nodes, their size and number; and also if they are mobile or fixed, unilateral, bilateral or contralateral.

53. Radiography (X-ray chest, computed tomography (CT) scan and magnetic resonance imaging (MRI )).CT scan. It is a very useful investigation to find the extent of tumour , invasion of pre- epiglottic or paraglot tic space, destruction of cartilage and cervical lymph node involvement. Direct laryngoscopy. It is done to see; the hidden areas of larynx ( include infrahyoid epiglottis, anterior commissure, subglottis and ventricle) extent of disease. Microlaryngoscopy . For small lesions of vocal cords, laryngoscopy is done under microscope to better visualize the lesion and take more accurate biopsy specimens without damaging the cord. Supravital staining and biopsy .

54. TREATMENT OF LARYNGEAL CANCER It depends upon; the site of lesion extent of lesion presence or absence of nodal and distant metastases. Treatment consists of; Radiotherapy. Surgery; Conservation laryngeal surgery. Total laryngectomy. Combined therapy. Surgery with pre- or postoperative radiotherapy. Endoscopic CO2 laser excision. Organ preservation

55. Vocal Rehabilitation After Total Laryngectomy After laryngectomy, patient loses his speech completely. Various methods by which communication can be established; Oesophageal speech. In this, patient is taught to swallow air and hold it in the upper oesophagus and then slowly eject it from the oesophagus into the pharynx. Patient can speak six to ten words before reswallowing air. Voice is rough but loud and understandable . Artificial larynx. It is used in those who fail to learn oesophageal speech . Electrolarynx . Transoral pneumatic device. Tracheo-oesophageal speech. Here attempt is made to carry air from trachea to oesophagus or hypopharynx by the creation of skin-lined fistula or by placement of an artificial prosthesis. The vibrating column of air entering the pharynx is then modulated into speech. This technique has the disadvantage of food entering the trachea. These days prosthesis ( Blom -Singer or Panje ) are being used to shunt air from trachea to the esophagus. They have inbuilt valves which work only in one direction thus preventing problems of aspiration.

56. References; DISEASES OF EAR NOSE & THROAT HEAD & NECK SURGERY 6TH EDITION DHINGRA. Atlas of human anatomy.