4 laryngeal disorders

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Laryngeal Disorders Laryngeal Disorders Aiyun jiang

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Page 1: 4 laryngeal disorders

Laryngeal DisordersLaryngeal Disorders

Aiyun jiang

Page 2: 4 laryngeal disorders

Laryngeal DisordersLaryngeal Disorders

*Acute epiglottitis

Acute laryngitis

*Acute laryngitis in children

Chronic laryngitis, vocal polyp, vocal nodules

Paralysis of vocal fold

Laryngeal papilloma

Laryngeal carcinoma

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.

• Acute epiglottitis

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Case study Male, 42, businessman ,• Comlain : severe sore throat with a low fever for 10 hours. History: 10 hours ago the patient felt a slight pain in his larynx, and the pain became severe rapidly that he daren’t swallow. He has a slight fever and fells fatigue. 2 hours ago he felt it difficult to breath in.Examination: stridor, retraction of supraclavicular and

intercostal spaces, inspiratory dyspnea; Cyanos ;the epiglottis becomes hyperemia and swelling”,and looks like a ball

Question: (1)what’s the diagnosis? (2) How to treat the patient?

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Acute epiglottitisAcute epiglottitis

• Acute epilgottitis is a most dangerous condition . It is characterized by the abrupt onset of rapidly progressive respiratory obstruction due to a swollen, cherry-red epiglottis. Complete airway obstruction may occur in a few hours and cause death.

• Definition:– it is a localized inflammation of the supraglottic

larynx ,usually involve the mucous membranes of epiglottis.

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Etiology

– Infection usually Haemophilus nfluenzae

– allergic– others: trauma( physical or chemical),

etc.

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pathologypathology severe swelling of the epiglotic mucosa +/- phlegmon 3 pathologic types:① acute catarrh epiglottitis

– Only involve mucosa, diffuse hyperemia and swelling. The epiglottis becomes thicker than normal ones.

② acute edema epiglottitis – usually for allergy; epiglottis becomes “ball-

like”, and obstruct the laryngeal inlet for severity , causing laryngeal obstruction

③ acute anabrotic epiglottitis – Inflammation is severe in this condition.The

underlayer of the mucosa and the glands are involved. may cause laryngeal obstruction

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Clinical manifestationClinical manifestation general symptoms( fever, fatigue, anorexia, etc. )• Local symptoms:

Rapid onset of a severe sore throat (worse on swallowing,) the pain is so severe that the patient can’t swallow normally. Oral secretions increase and usually manifested as drooling.

Unclear speech:This kind of change is different from hoarseness caused by VC diseases. It sounds just like there is Sth in the patient’s mouth.

Dyspnea: stridor, retraction of supraclavicular and

intercostal spaces, difficult in inspiratory stage ( Dyspnea in asthma occurs in exspiratory stage)Cyanosis or even death

for child, usually severe and develop rapidly, maybe life threatening

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Physical examinationPhysical examination

• indirect or direct laryngoscopy: – the epiglottis becomes hyperemia and swelling;– maybe “ball-shape” or anabrotic;– Laryngeal obstruction

For child, laryngoscopy shouldn’t be admitted

lateral neck radiography --cherry-shaped epiglottic swelling (Thumb’s sign)

Induce laryngospasm

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Normal epiglottis

Acute epiglottis:Hyperemia and

swelling

laryngoscopylaryngoscopy

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X-rayX-ray - “Thumb’s sign”- “Thumb’s sign”

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Diagnosis and Differential Diagnosis and Differential DDiagnosisiagnosis• Diagnosis: indirect laryngoscopy important!!!!!!!!!!!!• according to typical history and clinical manifestation, a

diagnosis of AE can be confirmed. Remember , if the patient has an abrupt onset of severe sore throat, Don’t simply make a diagnosis of acute tonsillitis or acute pharyngitis. Indirect laryngoscope must be performed to observe the epiglottis. Misdiagnosis of AE may delay proper and prom treatment and may cause death!!

• Differential diagnosis– foreign body in the larynx– laryngeal tuberculosis– laryngeal edema

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TreatmentTreatment• Once the diagnosis of AE is confirmed ,the patient must be

hospitalized as an emergency measure because laryngeal obstruction may occur rapidly.

1 Closed monitoring2 Antiinflammatory

– broad spectrum antibiotic – +/- systematic steriod

3 Local treatment: – Inhalation of steriod– discission if necessary to maintain the airway unobstruc

ted– tracheostomy if necessary restlessness,stridor, cyanosis,and retraction of

supraclavicular and intercostal spaces are indications of immediate tracheostomy

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Case study Male, 42, businessman ,• Comlain : severe sore throat with a low fever for 10 hours. History: 10 hours ago the patient felt a slight pain in his larynx, and the pain became severe rapidly that he daren’t swallow. He has a slight fever and fells fatigue. 2 hours ago he felt it difficult to breath in.Examination: stridor, retraction of supraclavicular and

intercostal spaces, inspiratory dyspnea; Cyanos ;the epiglottis becomes hyperemia and swelling”,and looks like a ball

Question: (1)what’s the diagnosis? (AE) (2) How to treat?( hospitalized, tracheostomy, antibiotic, systematic steriod, inhalation of steriod)

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Acute laryngitisAcute laryngitis

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Case sdudy • Female, 35, nurse• Complain: hoarseness for 3 days,aphonia for 2 hours.• History: 3 days ago the patient caught a “cold” and became hoarse. She had nonproductive cough and a tickling sensation in her larynx. Two hours ago she shouted very loudly to her naughty son and then lost her vioce (aphonia ).Physical examination: vocal folds are congestive and s

welling with stringy mucus between the cordsQuestion: (1)what’s the diagnosis?

(2) How to treat the patient?

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definitiondefinition

• acute catarrhal inflammation of the laryngeal mucosa– usually a mild, self-limited inflammatory

condition – often a manifestion of a more diffuse

upper respiratory infection– More common in winter months

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etiologyetiology

• Infection – the most common cause– almost always a virus upper respiratory infection, s

uch as: influenza, common cold• Bacterial invasion may be secondary.• Predisposed to by:

– vocal over-use.– smoking.– drinking of spirit.– irritant gas inhalation

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Clinical manifestationClinical manifestation

• Symptoms – Hoarseness aphonia in severe case– cough, +/-fever– Throat pain, tenderness of the larynx– symptoms of a common cold for some cases

• Signs – redness and dry of the larynx, – vocal fold swelling with stringy mucus betwee

n the cords

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Acute laryngitisAcute laryngitis

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diagnosisdiagnosis

• according to :– the history– hoarseness – redness and edema of the mucosa of the voc

al cords.

Throat culture – rarely used, – only for prolong cases or in the face of a possible epidemic.

Differential diagnosis: hysteria

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treatmenttreatment

1 Total voice rest– supreme important– even whisper should be avoided.

2 local treatment: Inhalations with steam

(steriod)

3 Anti inflammation– antibiotics + steroid

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Case sdudy • Female, 35, nurse• Complain: hoarseness for 3 days,aphonia for 2 hours.

• History: 3 days ago the patient caught a “cold” and became hoarse. She had nonproductive cough and a tickling sensation in her larynx. Two hours ago she shouted very loudly to her naughty son and then lost her vioce (aphonia ).Physical examination: vocal folds are congestive and swelling wi

th stringy mucus between the cordsQuestion: (1)what’s the diagnosis? (AL)

(2) How to treat?(voice rest, antibiotics + steroid, Inhalations with steam )

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.

Acute laryngitis in children

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Case study • Boy, 2, hoarseness, fever 16 hours.• History: The boy had a fever and hoarseness for16 hours. His mother give him some Chinese to take, but his condition wasn’t improved. 2 hours ago it became even worse. The patient had a barking and dyspnea.Physical examination: stridor, cyanosis, retraction

of supraclavicular and intercostal spaces Question: (1)what’s the diagnosis? (2) How to treat the patient?

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Acute laryngitis in childrenAcute laryngitis in children

– Dyspnea usually happen, for:

• Anatomic factors– narrow laryngeal cavity – soft cartilage– pultaceous connect tissue– richly supplied with lymphatic vessels

Low cough reflex ability– difficulty in eliminate the secretion

• the immature nerve system– Laryngospasm happens easily

• the immature immune system– Severe inflammation

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Clinical manifestationClinical manifestation

• Symptoms:– hoarseness;– barking cough– inspiratory dyspnea– symptoms of upper respiratory infection: fever, fatigue,

et al

• Signs: – laryngeal stridor– retraction of supraclavicular and intercostal spaces

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Acute laryngitis in childrenAcute laryngitis

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diagnosisdiagnosis

• Differential diagnosis– foreign body in larynx;– upper respiratory infection or bronchitis; – Laryngeal spasm; – laryngeal diphtheria

hoarsenesshoarseness

barking coughbarking cough laryngeal stridorlaryngeal stridor

dyspneadyspnea

childrenchildren

consider the diagnosis confirm the diagnosis

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treatmenttreatment• Should be treated as soon as possible!!!!

– Sufficient antibiotic, + systemic steroid for severe cases

– Inhalations with steam (steroid + adrenaline)– Management of laryngeal obstruction: stridor, cyanosis,and retraction of supraclavicular

and intercostal spaces are indications of immediate tracheostomy

• Supporting therapy– sedation,– be sure of water-electrolyte balance

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Case study • Boy, 2, hoarseness, fever 16 hours.• History: The boy had a fever and hoarseness for16 hours. His mother give him some Chinese to take, but his condition wasn’t improved. 2 hours ago it became even worse. The patient had a barking and dyspnea.Physical examination: stridor, cyanosis, retraction of

supraclavicular and intercostal spaces Question: (1)What’s the diagnosis? (AL in children)

(2) How to treat ? hospitalized, Closed monitoring

antibiotic, systematic steriod, inhalation of steriod)

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ChronicChronic laryngitislaryngitis

non-specificity chronic inflammation of the larynx

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etiologyetiology

• Every factor that can affect the vocal folds (physical, chemical, infection)– Excessive vocal use– Vocal misuse, Habitual shouting– Long-term inhalation of irritative gas( smoking,

et al)– Chronic airway infection( bronchitis, sinusitis) – Acute laryngitis procrastinating

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high risk grouphigh risk group

• Occupation required frequent vocal use

• Irritable character

• Pollution envirenment

• chronic upper respiratory inflammation

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Clinical manifestationClinical manifestation

• Symptoms:– Hoarseness– Vocal fatigues easilly– Discomfort and a tendency to clear the throat

constantly

– Cough (with white sputum)

• Signs: three kinds of laryngeal changes– Chronic simple laryngitis– Chronic hypertrophy laryngitis– Chronic atrophy laryngitis

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• 。

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diagnosisdiagnosis

• NEVER MAKE A DIAGNOSIS OF CHRONIC LARYGITIS UNTIL OTHER LESIONS CAUSING HOARSENESS HAVE BEEN CAREFULLy EXCLUDED!!!!!!!!!!!!!!!

• Differential diagnosis: – laryngeal tuberculosis and syphilis; – laryngeal carcinoma; – vocal cord paresis; – hysteria

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treatmenttreatment

1. Removal of the cause , voice rested, correct vocal use,etc

2. Steam inhalation

3. Chinese medicine

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Vocal fold nodulesVocal fold nodules

• Etiology: – excessive or improper vocal use.

• Clinical manifestation: – Symptoms:

• hoarseness– Signs:

• small smooth nodule of the anterior 1/3 of the free edge of each cord,

• usually bilateral, • symmetric

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• edema types:– vocal rest– speech therapy– medicine

• Fibrosis types– surgery

• CAUTION: no surgery for children

Vocal fold nodulesVocal fold nodulesTreatmentTreatment

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surgery for vocal fold nodules

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Vocal polypVocal polyp

• Etiology  – vocal abuse; – improper vocal use

• Clinical manifestation:– symptoms

–hoarseness(persistent)

– signs• smooth neoplasm at anterior 1/3 VC, • unilateral

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Vocal polyp

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• Differential diagnosis  – laryngeal fibroma ,– neurofibroma ;– papilloma; – carcinoma

• Treatment  – surgery:

• indirect laryngoscope; • fiber laryngoscope;• Selfretaining laryngoscope

– follow by speech therapy

Vocal polypVocal polyp

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diseases of laryngeal motor nerve diseases of laryngeal motor nerve ( laryngeal paralysis)

– disturbance of the motor n.( superior laryngeal n.

and recurrent laryngeal n.) of laryngeal muscle that cause the TVC motion disorder.

• etiology – centric disorder – peripheral disorder

• trauma; tumor; inflammation; intoxication;

left rignt﹥

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Clinical manifestationClinical manifestation

• voiced function disorder

• 4 types:– Incomplete recurrent laryngeal n. paralysis– Complete recurrent laryngeal n. paralysis– Superior laryngeal n. paralysis– Mix laryngeal n. paralysis

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.. .

Mix left laryngeal n. paralysis

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treatment

• Etiological treatment

• Symptomatic treatment:– local injection,

– surgery( neuro-muscular-pedical grafting, neuroanastomosis, medial or lateral cordopexy, partial cricoidectomy)

• Voice training• Tracheotomy (bilateral incomplete recurrent

laryngeal n. paralysis)

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CASECASEbilateral incomplete recurrent n. paralysisbilateral incomplete recurrent n. paralysis

male, 41yrsbilateral incomplete

recurrent n. paralysis for laryngeal trauma,with laryngeal obstruction

Tracheotomy

Satisfied vioce

Endotracheal anethesia

Arytenoidectomy

Successfully extubate

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.

. .

incomplete bilateral recurrent laryngeal n. paralysis

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.

Neoplasms of the larynxNeoplasms of the larynx

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.Benign :

amyloid tumor

papilloma

angioma

fibroma

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Laryngeal papillomaLaryngeal papilloma

• Cause: HPV-6 , HPV-11 infection

• Pathology: – epithelioma, – no basic membrane infiltrated

• Clinical manifestation:

– Progressive hoarseness, inspiratory dyspnea

(1)Adults: unifocal, may recurrent , cancerate(2)Children:

• multifocal, any position of the larynx, may in trachea• Fast grow, easily recurrent, seldom cancerate

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treatmenttreatment

• surgery – mostly via edoscopy, often need more than once– Laryngofissure for some adults

• Antivirus

• Immunotherapy– Transfer factor– interferon

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Laryngeal papilloma of children

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Laryngeal papilloma of adult

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Carcinoma of larynxCarcinoma of larynx

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Carcinoma of Carcinoma of larynxlarynx

• Etiology– Smoking,alcohol abuse– Virus infection– Enviroment factors– Sexual hormone

• Pathology – 93~99% squamous cell carcinoma

• Classification of tumor sides: – supraglottic carcinoma– Glottic carcinoma– Subglottic carcinoma– Transglottic carcinoma

classification

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Clinical manifestationClinical manifestation

• Supraglottic carcinoma– Maybe no symptoms for early stage– Layngalgia, bloody sputum for some cases

• Glottic carcinoma– Hoarseness       at early stage– Apnea

• Subglottic carcinoma– No symptoms for early stage– Difficult to detect

• Trans-glottic carcinoma– No symptoms for early stage– Hoarseness following

Missed diagnosis

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Carcinoma of larynx

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route of metastasis(1)route of metastasis(1)

1 、 direct metastasis

• Barrier for restricting metastasis– Tendon of anterior commissure– The space between supraglottic and infraglottic area– Vocal process of arytenoid cartilage– Pyriform sinus– Thyroid cartilage

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route of route of metastasis(1)metastasis(1)

• Supraglottic carcinoma– Anteriad preepiglottic space, extrinsic muscles– Astern layngopharynx– Downward vocal folds

• glottic carcinoma– Anteriad preepiglottic space, contralateral vocal thyroid cartilage– upward vestibule, ventricle– Downward infraglottic area

• Subglottic carcinoma– Upward vocal folds– Downward trachea– Anteriad thyroid– Astern esophagus

direct metastasis

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route of metastasis(2)route of metastasis(2)

2. Lymphatic metastasis• Supraglottic carcinoma: easy• Glottic carcinoma: seldom • Subglottic carcinoma:

3. Hematogenous metastasis– For some advaned stage cases

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Carcinoma of Carcinoma of larynxlarynx

• diagnosis

hoarsenesshoarseness Laryngoscopy Laryngoscopy

Laryngeal massLaryngeal mass

biopsybiopsy

• Differential diagnosis:Differential diagnosis: 1.laryngeal tuberculosis2.Laryngeal syphilis3.Laryngeal papilloma

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treatmenttreatment

• Surgery

• Radiotherapy

• Others – Chemotherapy– Hyperthermia– Photoradiative Therapy– Immune modulation

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surgery

• Via laryngendoscope or microscope for early stage

• Partial laryngectomy– Acording to the location and the bound of the tumor– The principle is: 1 、 to remove the tumor completely

2 、 function reservation

• Total Laryngectomy• Neck dissection

treatmenttreatment

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radiotherapy

• Radical radiotherapy– Carcinoma in situ or T1

• Combine with surgery– Before or after the surgery

• Radiotherapy alone as palliation

treatmenttreatment

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