Laryngeal and voice disorders Yard.Doç.Dr.Müzeyyen Doğan.
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Transcript of Laryngeal and voice disorders Yard.Doç.Dr.Müzeyyen Doğan.
LarynLaryngeal and voice geal and voice disordersdisorders
Yard.Doç.Dr.Müzeyyen DoğanYard.Doç.Dr.Müzeyyen Doğan
LARYNX
AdultAdult: between 3th and : between 3th and 6th cervical vertebra 6th cervical vertebra
İnfantİnfant: between 1st : between 1st and 4th cervical and 4th cervical vertebra vertebra
Attaches to the hyoid Attaches to the hyoid bone and opens into the bone and opens into the laryngopharynx laryngopharynx superiorlysuperiorly
Continuous with the Continuous with the trachea posteriorlytrachea posteriorly
Clinical subdivisionClinical subdivision of the larynx of the larynx
supraglottic space (also called the vestibule which is surrounded by the piriform fossa)
glottic space (which contains the
vocal folds) subglottic space (which
is the area below the true vocal folds).
Diseases of the LarynxDiseases of the Larynx
InflammatoryInflammatory InfectiousInfectious GranulomatousGranulomatous MucosalMucosal CongenitalCongenital Neoplastic Neoplastic
3 years old boy3 years old boy Presented with:Presented with:
Stridor: 1 dayStridor: 1 day Cough, barkingCough, barking Fever Fever Drooling??Drooling??
Inflammatory Inflammatory
Acute laryngotracheitisAcute laryngotracheitis (croup) (croup) viral infection, affects children < 5 years.viral infection, affects children < 5 years. lasts 3-7 days, seasonal, lasts 3-7 days, seasonal, in autumn & winter. in autumn & winter. parainfluenza 1, parainfluenza 3, influenza A, parainfluenza 1, parainfluenza 3, influenza A,
rhinovirus.rhinovirus. febrile URTI, followed by classic barky or croupy febrile URTI, followed by classic barky or croupy
cough (nonproductive and cough (nonproductive and at night. at night. self-limited, rarely self-limited, rarely edema & upper A/W obstruction. edema & upper A/W obstruction.
Dx: history + neck X-ray Dx: history + neck X-ray classic “steeple sign”. classic “steeple sign”. Tx: humidification & hydration. If symptoms worsen Tx: humidification & hydration. If symptoms worsen
racemic epinephrine & corticosteroids racemic epinephrine & corticosteroids
Acute epiglottitisAcute epiglottitis
Haemophilus influenzae type B Haemophilus influenzae type B Children between 2 - 4 years,Children between 2 - 4 years, winter and winter and
spring.spring. Rapid presentation over 2-6 hrs: fever, sore Rapid presentation over 2-6 hrs: fever, sore
throat, muffled voice, inspiratory stridor. Sitting throat, muffled voice, inspiratory stridor. Sitting upright, ill-appearing, &drooling, upright, ill-appearing, &drooling,
Examination of the epiglottis may precipitate Examination of the epiglottis may precipitate laryngospasm laryngospasm not recommended. not recommended.
Lateral X-ray Lateral X-ray classic “thumb” sign. classic “thumb” sign. Tx: operating room immediately to establish the Tx: operating room immediately to establish the
diagnosis and secure an airway diagnosis and secure an airway
Acute epiglottitisAcute epiglottitis
Treatment:Treatment:
1.1. Secure a safe airway (O-T Secure a safe airway (O-T tube, bronchoscope, trach)tube, bronchoscope, trach)
2.2. Antimicrobial (C/S) ampic Antimicrobial (C/S) ampic & chloramphenicol or 2& chloramphenicol or 2ndnd & 3& 3rdrd generation generation cephalosporin.cephalosporin.
3.3. Supportive care. Supportive care. Extubation usually Extubation usually possible after 48 to 72 possible after 48 to 72 hours hours
Acute epiglottitisAcute epiglottitis
Croup Vs EpiglottitisCroup Vs Epiglottitis
Characteristics of Laryngotracheitis and Epiglottitis Feature Laryngotracheitis EpiglottitisAge <3 years >3 yearsOnset Gradual (days) Acute (hours)Cough Barky NormalPosture Supine SittingDrooling No YesRadiograph Steeple sign, narrowed subglottis Thumb sign, enlarged
epiglottis,dilated hypopharynxCause Viral BacterialTreatment Supportive (croup tent) Airway management (intubation or
tracheotomy), antibiotics
40 years old lady40 years old lady Globus pharyngeusGlobus pharyngeus Dryness of throatDryness of throat Frequent throat clearingFrequent throat clearing Nocturnal aspirationNocturnal aspiration Heart burnHeart burn
Gastroesophageal reflux Gastroesophageal reflux disease - GERDdisease - GERD
Most common cause of laryngitis.Most common cause of laryngitis. Acute & chronicAcute & chronic GERD GERD stenosis, recurrent spasm, C-A fixation, stenosis, recurrent spasm, C-A fixation,
dysphagia, globus pharyngeus, & laryngeal CA.dysphagia, globus pharyngeus, & laryngeal CA. Sx: Sx:
GI: regurgitation, heart burn.GI: regurgitation, heart burn. Larynx: hoarseness, globus pharyngeus, ch. Throat Larynx: hoarseness, globus pharyngeus, ch. Throat
clearing, cough, dysphagia.clearing, cough, dysphagia.
Gastroesophageal reflux Gastroesophageal reflux disease - GERDdisease - GERD
Examination:Examination: Grade I : Normal or Mild Grade I : Normal or Mild
Edema & Erythema Edema & Erythema
Grade II : Erythema / Grade II : Erythema /
Edema of posterior glottis.Edema of posterior glottis.
Grade III : Pachydermia of Grade III : Pachydermia of
posterior glottis.posterior glottis.
Grade IV : Contact ulcer Grade IV : Contact ulcer
granulomagranuloma
GERDGERD
GERDGERD
Dx:Dx: HxHx ExaminationExamination 24-hour double 24-hour double
probe PH probe PH monitoring.monitoring.
Ba-swallow.Ba-swallow. GastroscopeGastroscope
GERDGERD
Treatment:Treatment: Dietary and Lifestyle modifications.Dietary and Lifestyle modifications. Antacids.Antacids. Systemic H2-blockers.Systemic H2-blockers. Prokinetic agents.Prokinetic agents. Mucosal cytoprotectants.Mucosal cytoprotectants. Proton pump inhibitors; OmebrazoleProton pump inhibitors; Omebrazole
Other inflammatory disease Other inflammatory disease
Granulomatous Conditions That May Affect the Larynx Disease Laryngeal InvolvementTuberculosis Posterior one-third of larynx involvedSyphilis Painless ulcers; positive syphilis serologyLeprosy Supraglottic involvementHistoplasmosis Anterior larynx involvedBlastomycosis Painless ulcers; microabscessesActinomycosis Draining sinuses; sulfur granulesRhinoscleroma Catarrhal stage, Mikulicz’s cellsSarcoidosis Supraglottic swelling, nodules, granulomasWegener’s Subglottic involvement; necrotizing vasculitis; pulmonary orgranulomatosis renal involvement
33 years old lady33 years old lady TeacherTeacher Hoarseness of voiceHoarseness of voice Cough mildCough mild Disappearance of voice sometimesDisappearance of voice sometimes No h/o URTINo h/o URTI
Mucosal disordersMucosal disorders
Benign mucosal disorderBenign mucosal disorder
Vocal noduleVocal nodule Fluid accumulation in the submucosa from Fluid accumulation in the submucosa from
acute abuse or overuse acute abuse or overuse mucosal swelling mucosal swelling (sometimes called "early nodules"): reversible. (sometimes called "early nodules"): reversible.
Long-term voice abuse Long-term voice abuse hyalinization of hyalinization of Reinke's potential space, irreversible.Reinke's potential space, irreversible.
Tx: Tx: Medical: hydration, lubrication, GERD.Medical: hydration, lubrication, GERD. Voice therapyVoice therapy Surgery: >3months, fibrosis, symptomatic.Surgery: >3months, fibrosis, symptomatic.
Vocal noduleVocal nodule
Vocal fold polypVocal fold polyp
Vocal fold cystVocal fold cyst
Reinke’s edemaReinke’s edema
2 weeks old girl2 weeks old girl Inspiratory stridorInspiratory stridor No cyanosisNo cyanosis Normal cryNormal cry No chest infectionNo chest infection Aspiration with feedingAspiration with feeding
Congenital Congenital
Congenital disorders of the LarynxCongenital disorders of the Larynx
SupraglotticSupraglottic GlotticGlottic SubglotticSubglottic
LaryngomalaciaLaryngomalacia Vocal cord paralysisVocal cord paralysis Cong. Subglottic Cong. Subglottic stenosisstenosis
Ductal retention cystDuctal retention cyst Web and atresiaWeb and atresia Subglottic hemangiomaSubglottic hemangioma
Cystic hygromaCystic hygroma Interarytenoid webInterarytenoid web Web & atresiaWeb & atresia
Bifid epiglottisBifid epiglottis Posterior laryngeal cleftPosterior laryngeal cleft CystsCysts
Saccular cystSaccular cyst Cri-du-chat syndromeCri-du-chat syndrome
Anterior laryngeal cleftAnterior laryngeal cleft
Abnormal flaccidity of the laryngeal Abnormal flaccidity of the laryngeal tissues tissues inward collapse. inward collapse.
Resolve spontaneously (6-18 months).Resolve spontaneously (6-18 months). Sx: inspiratory stridor, intermittent Sx: inspiratory stridor, intermittent
upper a/w obstruction, normal cry, upper a/w obstruction, normal cry, normal general health and developmentnormal general health and development
Usually begins in the first few days or Usually begins in the first few days or weeks.weeks.
LaryngomalaciaLaryngomalacia
LaryngomalaciaLaryngomalacia
Dx: endoscopic exam. Dx: endoscopic exam. Tall, tubular, Tall, tubular, epiglotttis epiglotttis Large cuniform cartilage.Large cuniform cartilage. Short A-E foldsShort A-E folds Inward collapseInward collapse
TxTx Conservative:posturing, +/- Conservative:posturing, +/-
steroidssteroids Surgical: trach, intubation, Surgical: trach, intubation,
supraglottoplastysupraglottoplasty
Vocal cord paralysis (cong.)Vocal cord paralysis (cong.)
22ndnd common cause of congenital upper a/w common cause of congenital upper a/w obstruction. (10%)obstruction. (10%)
Unilateral VC paralysis > bilateralUnilateral VC paralysis > bilateral Causes: idiopathic, surgical trauma, neurological Causes: idiopathic, surgical trauma, neurological
abnormalities (e.g. meningomyelocele, bulbar abnormalities (e.g. meningomyelocele, bulbar palsy, Arnold-Chiary malformation.palsy, Arnold-Chiary malformation.
Sx: weak cry, aspiration, stridor.Sx: weak cry, aspiration, stridor. Tx: Tx:
Surgical: trach, transverse cordotomy, arytenoidectomy.Surgical: trach, transverse cordotomy, arytenoidectomy.
Subglottic stenosisSubglottic stenosis
Membranous and cartilaginous types.Membranous and cartilaginous types. Membranous: fibrous soft-tissue thickening Membranous: fibrous soft-tissue thickening
of the subglottic area of the subglottic area Cartilaginous: thickening or deformity of Cartilaginous: thickening or deformity of
the cricoid cartilage the cricoid cartilage shelf-like plate shelf-like plate
Laryngeal webLaryngeal web
Subglottic stenosisSubglottic stenosis Tx:Tx:
Endoscopic: Endoscopic: mmembranous embranous stenosisstenosis
Surgery: Surgery: cartilaginous cartilaginous stenosisstenosis
Ant cricoid splitAnt cricoid split Ant. & post cricoid Ant. & post cricoid
division +/- division +/- augmentationaugmentation
Laryngeal HemangiomaLaryngeal Hemangioma
Infants Infants 50% associated 50% associated cutaneous hemangiomas. cutaneous hemangiomas.
Sx: stridor or Sx: stridor or "pseudocroup," within the "pseudocroup," within the first 6 months of life.first 6 months of life.
Dx: direct laryngoscopyDx: direct laryngoscopy Tx:Tx: low-dose XRT, low-dose XRT,
tracheotomy + tracheotomy + observation, cryotherapy, observation, cryotherapy, sclerotherapy, CO2 laser, sclerotherapy, CO2 laser, steroid therapy (systemic steroid therapy (systemic or intralesional) & or intralesional) & interferone interferone -2a.-2a.
55 years old gentleman55 years old gentleman Hoarseness of voceHoarseness of voce Right otalgiaRight otalgia Mild dyspyagiaMild dyspyagia SmokerSmoker Alcohol drinkerAlcohol drinker
NeoplasmsNeoplasms
Laryngeal PapillomatosisLaryngeal Papillomatosis
The most common benign neoplasms of the The most common benign neoplasms of the larynx (84% of benign tumors).larynx (84% of benign tumors).
22ndnd mucosal infection by a papovavirus. mucosal infection by a papovavirus. Juvenile form: Juvenile form:
diffuse & extremely aggressive diffuse & extremely aggressive hoarseness and hoarseness and stridor. stridor.
Resistant to treatment Resistant to treatment frequent laryngoscopies. frequent laryngoscopies. Adult-onset form Adult-onset form
solitary or more localized, less aggressive solitary or more localized, less aggressive TX:TX: CO2 laser, cryotherapy, XRT, interferonCO2 laser, cryotherapy, XRT, interferon
Laryngeal PapillomaLaryngeal Papilloma
Neoplasms of the LarynxNeoplasms of the Larynx
BenignBenign Malignant Malignant PapillomaPapilloma Squamous Cell CaSquamous Cell Ca
Minor S.G. tumorsMinor S.G. tumors Neuroendocrine (e.g. carcinoid, Neuroendocrine (e.g. carcinoid, melanoma)melanoma)
Granular cell tumorGranular cell tumor ChodrosarcomaChodrosarcoma
ChondromaChondroma RhabdomyosarcomaRhabdomyosarcoma
HemangiomaHemangioma LymphomaLymphoma
ParagangliomaParaganglioma
Sqaumous cell CarcinomaSqaumous cell Carcinoma
Most common laryngeal Ca (>90%).Most common laryngeal Ca (>90%). Male:female = 6:1.Male:female = 6:1. Etiology:Etiology:
Tobacco: Tobacco: (related to number of cig.) (related to number of cig.) Alcohol: Alcohol: (x 2.2) (x 2.2) XRT, asbestose, wood dust, mustard gas.XRT, asbestose, wood dust, mustard gas. GERDGERD HPVHPV
Sqaumous cell CarcinomaSqaumous cell Carcinoma Glottic SCCA most Glottic SCCA most
common (60%) > common (60%) > supraglottic SCCA (30%) supraglottic SCCA (30%) > subglottic SCCA > subglottic SCCA (<10%).(<10%).
Sx: hoarseness, throat Sx: hoarseness, throat pain, cough, pain, cough, hemoptysis, referred hemoptysis, referred otalgia, dysphagia.otalgia, dysphagia.
Dx:Dx: Flexible laryngoscope, Flexible laryngoscope,
D.L. & biops.D.L. & biops. CT +/- MRICT +/- MRI