LARYNGEAL INFECTIONS

Dr. Satinder Pal Singh

INTRODUCTION• Laryngitis is one of the most common

conditions identified in the larynx. Laryngitis, an inflammation of the larynx, manifests in both acute and chronic forms.

• Acute laryngitis has an abrupt onset and is usually self-limited. If a patient has symptoms of laryngitis for more than 3 weeks, the condition is classified as chronic laryngitis.

The etiology of acute laryngitis includes vocal misuse, exposure to noxious agents, or infectious agents leading to upper respiratory tract infections. The infectious agents are most often viral but sometimes bacterial.

http://www.gbmc.org/voice/images/bluetree/Larynx%20front.jpg

INFECTIOUS: Viral Bacterial NON INFECTIOUS Inhaled fumes Allergy Polluted atmospheric conditions Vocal abuse Iatrogenic trauma Gastroesophageal reflux disease (GERD)

AETIOLOGY

Pathophysiology1.The mucosa of the larynx becomes

congested and may become oedematous.2.A fibrinous exudate may occur on the

surface.3.Sometimes infection involves the

perichondrium of laryngeal cartilages producing perichondritiis.

Predisposing factors

1.Smoking2.Psychological strain3.Physical stress

CLINICAL PRESENTATION•Change or loss of voice;• Difficulty in breathing/stridor;• Sore throat and otalgia;• Difficult or painful swallow;• Tender larynx with/without cervical lymphadenopathy.

Acute Laryngeal infections in childhood

• Acute Epiglottitis• Laryngotrachealbronchitis• Bacterial

Laryngotrachealbronchitis• Diphtheria• Conditions which mimic laryngeal

infections

Acute Epiglottitis• Most frightening pediatric emergency.• If unrecognized it can lead to death of the child.• 6-23 per 100,000 in chlidren.• Haemophilus influenzae type B , is the

causative organism in most cases.• The disease is concentrated maximally on the

epiglottis but the inflammation may involve whole supraglottic compartment.

• Most cases seen between 1 and 6 years of age, peak incidence between ages 3 and 4.

Clinical features• Classical features:

– A child c/o sore throat which intensifies, with in half and hour dysphagia reported.

– Inspiratory stridor develops and within 2 hours child becomes critical.

– Child sits up and leans forward– Saliva is dribbling due to absolute dysphagia– Voice is muffled– As time goes child becomes quiet and

respiratory distress appears to lessen.– An an ominous sign: respiratory & cardiac arrest

imminent

Epiglottitis Supraglottitis

Investigations

• Blood culture• Throat awab culture• WBC counts• X ray plain lateral soft tissue neck.• Computed tomography (CT) scans are

useful if there is a complication such as an epiglottic abscess

Lateral X-ray of neck may show classical ‘thumb’ sign of swollen epiglottis

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Management

• It is a surgical emergency• Admit and observe give i.v. antibiotics and

100% humidified oxygen.• Examination of throat by tongue depressor

is particularly dangerous- sudden respiratory obstruction may occur.

• If the clinical situation suggests that the diagnosis is epiglottitis , there is no point in confirming it what might turn out to be fatal X-ray.

• The child is shifted to OT and anesthetized in upright position

• Laryngoscope inserted & diagnosis confirmed• An appropriate size orotracheal tube inserted• Otherwise rigid bronchoscope used to secure

airway• Tracheostomy / nasotracheal tube• Culture swabs taken from epiglottis• Nasogastric tube inserted for feeding• I/V line established

Best Clinical Practice• Adults with suspected acute epiglottitis

should be admitted and airway closely monitored

• Patients should be treated with I/V second- or third-generation cephalosporins and 100% humidified oxygen

• Airway obstruction should be treated early, ideally by intubation

Complications

1.Epiglottic abscess2.Pulmonary oedema secondary to

relieving airway obstruction 3.Thrombosis of internal jugular vein

Laryngotracheobronchitis (Croup)

• As name suggests it involves larger proportion of respiratory tract

• Area of maximum impact is sub-glottis • An acute illness with hoarseness, a

barking cough, stridor and varying degree of respiratory distress

• Affects young children (6 months to 3 years)

• In most cases causative organism is paramyxovirus, para-infleunza virus type I and type II

• In adults it may also occur from herpes simplex, cytomegalovirus & influenza virus

• Adult croup is rare, more severe & impaired immunity should always be considered

• The key feature is sub-glottic oedema

Investigations• Direct viral antigen detection by

sampling mucus from nasopharynx• A plain neck radiograph may show

narrowing of the subglottis (steeple sign) and ballooning of hypopharynx

• Chest X-ray to exclude collapsed lobes or meditational shift

• Narrowing of the subglottis (steeple sign)

Management• Oxygen, steroids and nebulized

epinephrine should be administered• Monitor airway and oxygen saturation,

consider endotracheal intubation if necessary

• Broad spectrum antibiotics to cover secondary infection

• No evidence to support antiviral agents

Best Clinical Practice• Adult croup is rare but rapidly progressive• Once suspected patient should be

admitted• Larynx inspected by flexible laryngoscope• Broad-spectrum ABx to prevent bacterial

infection• If the airway deteriorates patient should be

intubated and ventilated

Bacterial Laryngotrachealbronchitis

• May be a separate disease or be caused by secondary bacterial infection of viral laryngotrachealbronchitis

• Also called bacterial tracheitis since it involves trachea predominantly

• Much more severe illness and much less common

• More severe respiratory obstruction and artificial airway is often needed

• Tracheostomy preferred over intubation

Whooping cough or Pertussis1.an acute illness that is usually caused by

Bordetella pertussis.It is a notifiable communicable disease that

affects all age groups and is transmitted by coughing and sneezing.

3.Most severe in children, particularly infants.Adults generally have a milder disease.Clinical features

•Runny nose, •dry cough and mild pyrexia,• similar to a common cold

•The cough occurs in prolonged paroxysms after one to two weeks and is followed by gasping and the characteristic whoop in children.•The disease is generally milder in adults and presents as protracted cough rather than the characteristic 'whooping cough' of children.Investigations

confirmed by serum serology and nasopharyngeal aspirate culture and assay by (PCR).

M anagement•Pertussis is usually not diagnosed until the cough has developed.•A 7-14-day course of erythromycin is recommended.•Fluoroquinolones are also likely to be effective in adults.The cough should be treated symptomatically with cough suppressants.

Diphtheria• Caused by Corynebacterium

diphtheriae• Spreads by droplet infection• Affects non-immunised children and

susceptible adults particularly elderly• Usual site of infection is the tonsils and

fauces but it can also occur in nasal cavities or spread to larynx

Clinical Features• Severe sore throat, malaise, pyrexia• Examination of throat shows

characteristic grey membrane in oropharynx which may spread to larynx.

• Enlarged tender cervical lymph nodes

Investigations

• A swab from throat for C/S• A sample of grey membrane for

screening

Management• Treat with benzyl penicillin and

antitoxin• Acute obstruction should be managed

with intubation• Complications:

– The diffusible exotoxin has predilection for cardiac and renal tissues

– Neurological complications soft palate paralysis, diaphragm & EOM

Conditions which mimic laryngeal infections in childhood

• Foreign bodies• Peritonsillar abscess• Retropharyngeal Abscess• Infectious mononucleosis

Infectious mononucleosis

• A common disease often sub-clinical or mild

• Caused by Epstein-Barr virus• Spread is usually transfer of infected

saliva during kissing

Clinical Features• Acute sore throat with large infected

tonsils• Cervical lymphadenopathy with grossly

enlarged bilateral lymph nodes• Fever, Malaise• There may also be palatal petechiae,

oral ulceration, splenomegaly and hepatomegaly

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Investigations

• Full Blood count• Heterophil antibody test: Heterophil antibodies are

antibodies that are stimulated by one antigen and react with an entirely unrelated surface antigen present on cells from different mammalian species

• Specific EBV serology• HIV testing

Management• I/V fluids• Analgesia• In serious infections antibiotics, steroids

and acyclovir should be considered• Ampicillin / amoxycillin are best avoided

for fear of inducing a maculopapular rash

Complications• Gross swelling of tonsils and adenoids

causes airway obstruction, but inflammation and ulceration can also extend to larynx

• The severity of laryngeal involvement may be masked by upper airway obstruction

• Splenic rupture• CNS complications like encephalitis,

meningitis, CN palsies• Immune deficiency and HIV status be looked

into

MYCOTIC LARYNGITIS

• Disease of both immunocompromised and immunocompetent hosts

• May mimick leukoplakia or malignancy– White or gray pseudomembrane on mucosa– Mucosal erythema and edema (focal or

diffuse) surrounding white plaques– Mucosal ulcerations– Contact bleeding

Fungal laryngitis

Risk factors •Risk factors: LPR, smoking, inhaled steroids, prolonged antibiotic use, XRT•DM, immunosuppressants, CA, nutritional deficits•Compromise mucosal barrier

Investigation1.A chest radiograph.2.Direct laryngoscopy and biopsy may be

necessary to confirm a diagnosis of fungal laryngitis.

3.Tissue samples should be sent for special fungal stains, such as methenamine silver and periodic acid-schiff, to identify the fungal hyphae.

Treatment of fungal laryngitis

1. Fluconazole x 3wks2. Nystatin swish and swallow (100,000

units/ml, 10ml tid).3. Prevention spacers for inhaled

steroids oral rinse, gargle with water after use.

Chronic Laryngitis

Is a chronic inflammation of the mucosa of the larynx

Definition

Grade I Mild erythema, stasis of secretions, string sign, piling u p of i nter-arytenoid mucosa

Grade II Diffuse oedema a nd mucosal thickening, but with little erythema

Grade III Diffuse erythema, with granular friable mucosa or Ulceration

Grade IV Discrete granuloma(s) with or without oedema and erythema

Etiology• Follows repeated acute attacks but

usually it arise insidiously due to :• Faulty use of voice.• Infection of teeth, tonsil, sinus, and

lower respiratory tract infection.• Excessive alcohol consumption or

smoking.• Dust or irritant fumes.

Clinical classification:Chronic nonspecific laryngitis1. Chronic simple laryngitis.2. Hyper keratosis of larynx

(chronic keratosis or leukoplakia).

3. Pachydermia laryngis.4. Contact granuloma.5. Atrophic laryngitis.

Chronic specific laryngitis• Tuberculous laryngitis• Syphilitic laryngitis.• Leprosy of the larynx.• Scleroma of the larynx.• Wegener’s (malignant)granuloma of the larynx.• Mycosis of the larynx.

Simple chronic laryngitisPathology:

•Hyperaemia of vocal cord.•Edema.•Myositis occurs in the intrinsic muscles.•Excessive secretion due to hyper activity of the mucous gland.•Hyperaemic and edematous stage often passes to a hypertrophic one and rarely to an atrophic one.

Clinical Features:-Hoarseness (intermittent then persistent). -Cough (slightly dry). -Sore throat (very common).

Chronic laryngitis: there is hyperemia of mucus membrane. Odema of the margins of the vocal cord(Rienkes edema

Laryngeal appearanceThree types:1. Hyperaemic.2. Hypertrophic.3. Edematous.In all types the larynx is always

affected bilaterally & symmetrically.

Treatment:

•Vocal rest•Elimination of irritating factors such as dust and smoking. •Systemic antibiotics.•Carbocisteine ( a mucolytic ) when secretion are thick.•Stripping of the vocal cords is performed endoscopically in persistent cases.

REINKE'S OEDEMA

1. Polypoid corditis2. Proliferation of superficial lamina propriachronic irritant exposure Smoke, LPR, occupational exposures3.Water-balloon outpouching from

membranous VF4. characterized by oedema of the vocal

cords.

Reinke's oedema.

•Surgery1. Airway compromise2. Preserve some superficial lamina

propria and overlying epithelium to preserve mucosal wave

•Stage for bilateral disease to prevent anterior web •Remove irritants and treat LPR

Treatment

Vocal cord polyp•Polypoidal lesion of cords•More in male•localised vascular engorgement and microhaemorrhage followed by oedema.•Gelatinous,fibrous,talengiectatic

Vocal cord polyp.

Effect of polyps on mucosal waveAsymmetric mass produces more

chaotic vibrations and aperiodic mucosal wavesLarger polyps cause decreased wave amplitudeExcessive air egress during phonationFatigueFrequent voice breaksdecreased vocal power

Treatment•Conservative for small polyps•Microsurgery mainstay of therapy•Hemorrhagic polyps

Pulsed-dye lasers absorbed by hemoglobin (585 nm) Lasers more effective for smaller polyps.

Tuberculous laryngitis•Almost always to secondary to pulmonary TB•Infected sputum•Younger age group•Tubercle formation is characteristic•Infilteration stage followed by proliferative stage•Posterior part of larynx involved

The typical site and appearance of tuberculous lesion involving the posterior commissure in secondary-acquired tuberculous laryngitis.

To improve vocal hygiene• Drinking lot of fluids - Drink 7-9 glasses of water

per day; also good are herbal tea and chicken soup.

• maintaining good general health - Exercise regularly.

• Avoiding smoking - They are bad for the heart, lungs and vocal tract.

• Eating a balanced diet - Include vegetables, fruits and whole grain foods.

• Avoid dry, artificial interior climates. • Do not eat late at night - may have problems

when stomach acid backs up on the vocal cords. • Use a humidifier to assist with hydration.

THANK YOU