Inflamatory diseases of the larynx_035404.pptx

Undergraduate essentials

1. Inflamatory diseases of the larynx Acute Laryngitis Gen part of an upper airway disease Common in occupations where there is overuse of voice (armed forces, teachers, singers, preachers) Symptoms Hoarseness to complete loss of voice Severity of hoarseness corresponds to severity of disease Pain on swallowing Freq painful cough edema of glottic components Hyper-secretion causing urge to cough/clear throat

2. Treatments (ABC), analgesics, rehydration, steam inhalation, warm saline gargles Acute Epiglottitis - arise from a rapidly progressing acute laryngitis to involve the epiglottis - rare in adults but common in children aged about 2 – 7yrs

3. symptoms Rapidly progressing dyspnoe, esp in children, that can be fatal within hrs of onset (it is a medical emergency) Dysphagia starting with sore throat, then refusal of oral feeds Dehydration, fever, tachycardia, restlessness, exhaustion with respiratory collapse Patient prefers the upright position and leaning slightly forwards (don’t force to lie down) Swollen, red epiglottis obstructing the pharynx at the base of tongue

4. NB: infection remains supra-glottic Examination using tongue depressor is contraindicated except when preparations have been made for intubation or tracheostomy ( pat. can develop abrupt total airway obstruction Examinations done only in presence of a team of pediatrician, anaesthesiologist and otorhinolaryngologist Treatment in ICU with beta lactamase stable ABC, steroids to reduce inflammation/oedema, and extubation done 1 – 2 days later

5. Because obstruction can occur suddenly, intubation or tracheostomy should be performed immediately after diagnosis is confirmed If patient present < 8 hrs of onset, intubation or tracheostomy should be done If patient presents > 8 hrs of onset, patient should be observed on medication (in ICU)

6. Acute laryngo-tracheo-bronchitis (LTB) An acute infection of the lower respiratory passages extending into the bronchial system Etiology probably viral but Haemophilus influenza is commonly cultured Occur especially in children aged 1 – 3 yrs Infection remains sub-glottic A descending inflammation of the mucus membrane followed by edema, congestion, and exudation of thick tenacious secretion

7. Symptoms Onset is like a cold but there is cough Hoarseness of voice follows thereafter Retraction occurs, cyanosis then reduced breath sounds (need for emergency airway now) In early stages anorexia, fever are common together with restlessness, dehydration, & exhaustion Raised pulse & agitation hence raised carbon dioxide concentration

8. Treatments Hospitalization and close observation Humidification ABC as for acute epiglottitis Corticosteroids Parenteral fluids Timely endotracheal intubation or (tracheostomy) – *when in doubt, do it *

9. Tuberculosis laryngitis Almost always secondary to pulmonary TB, from coughed up sputum with TB germs Affect mostly the posterior commissure Bloody sputum and hoarseness of voice Rx is same as for active TB Syphilitic laryngitis Effect felt in secondary stage Lesion usually in the anterior commissure Serology for diagnosis, Rx is by ABC

10. Diphtheria laryngitis Rarely seen these days Has symptoms of hoarseness of voice, cough, followed by stridor and spasms Grayish white membrane appears on the larynx, removal of membrane causes bleeding Treatment by anti-toxin, penicillin, tracheostomy Candidiasis White patch on a red mucosa In prolonged corticosteroids, immuno-suppressed, prolonged chemotherapy Treatment is by topical anti-fungal +/- oral antibiotic

11. Chronic Diseases of the Larynx a) Chron Laryngitis Results from freq repeated attacks of acute form not adequately treated TB & syphilis must always be excluded Acute symptoms are persistent Complete investigation of the other ENT systems necessary Rx guided by exam findings

12. b) Contact Ulcer Hypertrophic changes in the vocal cord as a result of vocal abuse, non-lingual laryngeal trauma (harsh coughing, throat clearing), gastric reflux and ET – tubes for long periods Treatment is by total voice rest, vocal education, and treatment of other causes c) Vocal nodules Are localized hypertrophy on vocal cord lining due to over use or cig smoking (e.g. in singers)

13. d) Leukoplakia e) Intubation granuloma f) Laryngocele air filled dilation of ventricles as seen in wind instrument players f) GERD/GERL g) Laryngeal stenosis Each of the three parts Caused by inhalation of caustic gases, trauma Webs Nerve paralysis h) Laryngotracheomalacia

14. Tumours of the larynx Benign Papilloma Benign tumour arising from the free edges of the vocal cords Recurs frequently May be single or multiple

15. b) Vocal cord polyps May result from infection or trauma or haemangioma May affect both cords –Reinke’s edema Are usually along the whole length of the cords Other benign laryngeal tumours include; -granuloma from protracted intubation -singers nodules

16. Malignant Laryngeal tumours Ca larynx may be located in any of the three laryngeal subdivision a) Supraglottic ca rarely affects vocal cords (no hoarseness) spread to pre-epiglottic areas are diagnosed late b) Glottic ca are restricted to glottic structures (poor LN system)

17. Always present with hoarseness of voice May involve both supra- and sub-glottic regions – then referred to as transglottic Direct laryngoscopy (DL) is method of diagnosis c) Subglottic ca Involves the glottis and cause hoarseness Respiratory obstruction if Tu is lower in subglottis Neither surgery nor irradiation give good results

18. Glottal tumour

19. Classification of malignant tumours By site: Glottic (most common) Supraglottic Subglottic (least common) Prognosis for isolated laryngeal cancer is better than any other cancer type as it is less likely to spread: there are no lymphatic vessels in the vocal folds

20. TRACHEOSTOMY • This is a surgical artificial opening in the anterior wall of the cervical trachea to keep patent airway . Cf tracheotomy/tracheostomy Indicated in three groups of patients With mechanical obstruction With secretory obstruction Needing prolonged artificial ventilation Indications for mechanical obstruction Laryngeal obstruction: causes of stridor

21. Indications of tracheostomy 1. Upper respiratory tract obstruction ( mechanical obstruction ): • Laryngeal obstruction: causes of stridor. • Supralaryngeal obstruction: Retropharyngeal abscess . Ludwig's angina. Tumours of the tongue base. • Infralaryngeal obstruction : Malignant thyroid. Cellulitis in the neck.

22. 2. Lower respiratory tract obstruction ( secretory obstruction ): • Any condition causing abolished or weak cough reflex leads to accumulation of secretions inside the alveoli. This prevents gas exchange leading to hypoxia and acidosis. The patient is said to be drowned in his own secretions.

23. Causes of secretory obstruction: • Coma: as in Cerebro-vascular accidents: e.g thrombosis and hemorrhage . Trauma : head injuries and fracture base. Toxins: − Exogenous e.g barbiturate poisoning. − Endogenous e.g uraemia and diabetic coma. Tumours: of the brain.

24. Failure of chest muscles: as in Paralysis of chest muscles: diphtheria and poliomyelitis. Trauma : multiple fracture ribs. Myopathies: Myasthenia gravis. 3. Preoperative indications:- Before bloody operations in the mouth and pharynx to prevent aspiration of blood. Examples are nasopharyngeal fibroma, glossectomy and maxillectomy As a step in total laryngectomy and laryngofissure

25. Types of tracheostomy according to site in trachea 1 . High tracheostomy: • Done in the 1st and 2nd tracheal rings, above the thyroid isthmus. • Indicated in malignant thyroid and in urgent cases. • Disadvantages : it causes perichondritis of cricoid cartilage and permanent stenosis. 2 . Mid tracheostomy: • Done in the 3rd and 4th tracheal rings, behind the thyroid isthmus and it is the operation of choice. 3 . Low Trachesotomy: • Done in the 5th and 6th tracheal rings, below the thyroid isthmus. • Indicated in subglottic extension of cancer larynx.

26. Types of tracheostomy tubes according to its materials: • May be metallic or plastic. • Composed of inner and outer tubes. The inner tube is longer than the outer so that it is easily removed for cleaning if obstructed while the outer tube is left in place. • Plastic tube with cuff.

27. Steps of tracheostomy. 1. Anaesthesia: • No anaesthesia: in unconscious patient. • Local anaesthesia: in emergency cases. Usually xylocaine solution 2 % is used with adrenaline 1 / 1000 . • General anaesthesia: in elective cases. 2 . Position : • Supine with a pillow under the shoulders to allow extension of the neck. 3 . Incision: •

28. 4. Steps : • Incision of the skin and fascia down to the strap muscles which are retracted laterally. • The isthmus is divided and transfixed to avoid bleeding and leakage of thyroxin. • The pretracheal fascia is cut and cleard from the trachea . • A cricoid hook is applied to fix and elevate the trachea. • An incision is done in the 3rd and 4th tracheal rings; a tracheal dilator is inserted to widen the opening and a suitable tracheostomy tube is inserted. • The tube is fixed by ribbons around the neck and the wound is closed without tension.

29. Post operative care : • Position: semi-sitting to help easy breathing and effective coughing. • Room atmosphere should be humidified with steam to compensate for the moisture lost. • Observation of respiration with the tracheostomy tube by: Movement of a piece of cotton or condensation of water vapour over a mirror placed in front of the tube. The patient can not speak. • Broad specturm antibiotics. • Care of the tube : §Repeated suction through the tracheostomy to avoid tube blocking.

30. cont Repeated removal of the inner tube to clean it. • Decannulation: i.e removal of the tube after treatment of the cause. • The tube is closed with a cork as a test and the patient is observed for 2 days.

31. 3. Incision: • Vertical incison: from the upper border of cricoid cartilage to suprasternal notch. It is usually done in emergency cases and gives rapid exposure of the trachea but it is not cosmetic. • Transverse incision: midway between cricoid cartilage and suprasternal notch. It is usually done in elective cases and is more cosmetic but takes more time than the vertical one.

32. 3- congenital abnormalities like laryngeal web, atresia 4- trauma to larynx, maxillofacial areas 5- bilateral vocal cord paralysis 6- foreign bodies 7- sleep apnoea Indications for secretory obstruction 1- retained secretion 2- coma states e.g. in DMs, septicaemia 3- alveolar hyperventilation

33. Complications of tracheostomy Apnoea and hypertension Displacement of tube Tube obstruction Subcutaneous emphysema/pneumothorax Tracheal stenosis Difficulty decannulation Fistula formation Pulmonary infection Haemorrhage Tracheitis and crusting