Cummings Cummings Chapters 63 & 64Chapters 63 & 64

Acute and Chronic LaryngitisAcute and Chronic Laryngitis

Laryngeal and Tracheal Laryngeal and Tracheal Manifestations of Systemic Manifestations of Systemic

DiseaseDiseaseTravis ShibaTravis Shiba12/6/1312/6/13

Acute and Chronic Acute and Chronic LaryngitisLaryngitis

Key PointsKey Points #1 cause of acute laryngitis = viral#1 cause of acute laryngitis = viral #1 cause of chronic laryngitis = reflux#1 cause of chronic laryngitis = reflux Candidal laryngitis can occur in non Candidal laryngitis can occur in non

immuno compromisedimmuno compromised Even in setting of likely neoplasm, still Even in setting of likely neoplasm, still

consider infectionconsider infection

LaryngitisLaryngitis

Inflammation of the larynxInflammation of the larynx Can impair swallowing, phonating and Can impair swallowing, phonating and

breathingbreathing

Acute LaryngitisAcute Laryngitis

PhonotraumaPhonotrauma Viral LaryngitisViral Laryngitis Acute Bacterial LaryngitisAcute Bacterial Laryngitis Acute Fungal LaryngitisAcute Fungal Laryngitis

Supepithelial hemorrhage from Supepithelial hemorrhage from phonotraumaphonotrauma

Supepithelial hemorrhage of R VC Supepithelial hemorrhage of R VC polyppolyp

Acute LaryngitisAcute Laryngitis

PhonotraumaPhonotrauma Viral LaryngitisViral Laryngitis Acute Bacterial LaryngitisAcute Bacterial Laryngitis Acute Fungal LaryngitisAcute Fungal Laryngitis

Viral LaryngitisViral Laryngitis Pathogens: rhinovirus, Pathogens: rhinovirus,

parainfluenza, RSV, adenovirus, parainfluenza, RSV, adenovirus, influenza, adenovirus…influenza, adenovirus…

SSx: dysphonia, hoarse voice, SSx: dysphonia, hoarse voice, coughcough

Rx: supportive care: hydration, Rx: supportive care: hydration, anti-inflam, voice rest, PPI +/- anti-inflam, voice rest, PPI +/- steroidssteroids

Croup: laryngotracheobronchitis Croup: laryngotracheobronchitis Typically parainfluenza 1,3 Typically parainfluenza 1,3 Steeple signSteeple sign

Acute LaryngitisAcute Laryngitis

PhonotraumaPhonotrauma Viral LaryngitisViral Laryngitis Acute Bacterial LaryngitisAcute Bacterial Laryngitis Acute Fungal LaryngitisAcute Fungal Laryngitis

Acute Bacterial Acute Bacterial LaryngitisLaryngitis

Supraglottitis Supraglottitis (epiglottitis)(epiglottitis) Pathogens: H influenza, Pathogens: H influenza,

Strep PNA, Staph Aureus, Strep PNA, Staph Aureus, Beta hemolytic strepBeta hemolytic strep

Decreased incidence with Decreased incidence with h flu B vaccineh flu B vaccine

Rx: airway control. Humid Rx: airway control. Humid air, IV antibiotics, air, IV antibiotics, monitored bed, steroids monitored bed, steroids

Whooping coughWhooping cough bordetella pertusisbordetella pertusis Vaccine protects ~ 3 yrsVaccine protects ~ 3 yrs Rx: erythromycin to prevent spreadRx: erythromycin to prevent spread

Acute Bacterial Acute Bacterial LaryngitisLaryngitis

Diptheria Corynebacterium

diptheria SSx: acetone breath, thick

grey membranous and friable plaque

Rx: airway via trach, diptheria anti toxins, PCN & clinda

Acute LaryngitisAcute Laryngitis

PhonotraumaPhonotrauma Viral LaryngitisViral Laryngitis Acute Bacterial LaryngitisAcute Bacterial Laryngitis Acute Fungal LaryngitisAcute Fungal Laryngitis

Acute Fungal LaryngitisAcute Fungal Laryngitis

Candiasis (moniliasis)Candiasis (moniliasis) usually seen with oral/esophageal sx or usually seen with oral/esophageal sx or

in a pt taking oral inhaled steroidsin a pt taking oral inhaled steroids White sessile plaques on erythematous White sessile plaques on erythematous

basebase Rx: Fluconazole Rx: Fluconazole

Chronic LaryngitisChronic Laryngitis

BacterialBacterial FungalFungal MycobacterialMycobacterial Non infectiousNon infectious

Chronic Bacterial Chronic Bacterial LaryngitisLaryngitis

Rhinoscleroma Rhinoscleroma Klebsiella rhinoscleromatosisKlebsiella rhinoscleromatosis Path: Mikulicz CellsPath: Mikulicz Cells Rx: fluouroquinolones/TCNRx: fluouroquinolones/TCN

SyphillisSyphillis Secondary: painless edemaSecondary: painless edema Tertiary: gummas + cartil destructionTertiary: gummas + cartil destruction Rx: PCNRx: PCN

Chronic Bacterial Chronic Bacterial LaryngitisLaryngitis

ActinomycosisActinomycosis Actinomycosis israeliiActinomycosis israelii Chronic suppurative infxn, rarely Chronic suppurative infxn, rarely

involves layrnxinvolves layrnx Histo:Histo:

Sulfur Granules Sulfur Granules Rx: PCN or ClindaRx: PCN or Clinda

Chronic LaryngitisChronic Laryngitis

BacterialBacterial FungalFungal

HistoplasmosisHistoplasmosis BlastomycosisBlastomycosis CryptococcusCryptococcus CoccidiomycosisCoccidiomycosis

MycobacterialMycobacterial Non infectiousNon infectious

HistoplasmosisHistoplasmosis

Histoplasmosis SCCA

HistoplasmosisHistoplasmosis

Histoplasma capsulatumHistoplasma capsulatum Mississippi River ValleyMississippi River Valley Acute/Chronic, Pulmonary/systemicAcute/Chronic, Pulmonary/systemic Laryngeal Lesions: anterior larynx and Laryngeal Lesions: anterior larynx and

epiglottisepiglottis Bx: poorly defined granulomas, Bx: poorly defined granulomas,

multinucleated giant cells and multinucleated giant cells and pseudoepitheliomatous hyperplasiapseudoepitheliomatous hyperplasia

Grows on Sabouraouds agarGrows on Sabouraouds agar Tx: Ampho/AzolesTx: Ampho/Azoles

BlastomycosisBlastomycosis

Blastomyces Dermatitides Blastomyces Dermatitides Central america/MidwestCentral america/Midwest Airborne to lung, to larynx Airborne to lung, to larynx

hematogenouslyhematogenously Larynx involved 2% - Larynx involved 2% -

exophytic/ulcerative mass usually on exophytic/ulcerative mass usually on TVCTVC

Histo: Broad based budsHisto: Broad based buds Rx: ampho/azolesRx: ampho/azoles

CryptococcusCryptococcus

Cryptococcus neoformansCryptococcus neoformans Bird droppingsBird droppings H&N Sx: meningitis (SNHL), H&N Sx: meningitis (SNHL),

membranous Npharyngitis; larynx membranous Npharyngitis; larynx (only TVC)(only TVC)

Dx: india ink stain showing capsulesDx: india ink stain showing capsules Tx: ampho/azolesTx: ampho/azoles

CoccidiomycosisCoccidiomycosis

Coccidioides Immitis Coccidioides Immitis ““valley fever” Southwest US and North valley fever” Southwest US and North

MexicoMexico H&N: lesions (nodules/erosions) of H&N: lesions (nodules/erosions) of

skin, mucous membranes, epiglottis, skin, mucous membranes, epiglottis, trachea, salivary glandstrachea, salivary glands

Histo: “Sac with bugs”Histo: “Sac with bugs” Rx: ampho/azoleRx: ampho/azole

Chronic LaryngitisChronic Laryngitis

BacterialBacterial FungalFungal MycobacterialMycobacterial Non infectiousNon infectious

MycobacterialMycobacterial LaryngitisLaryngitis

TubercolosisTubercolosis Direct from lungs or via bloodDirect from lungs or via blood Dx: PPD/Quant/AFBDx: PPD/Quant/AFB Tx: INH/Rifampin/voice restTx: INH/Rifampin/voice rest

Leprosy (Hansen’s)Leprosy (Hansen’s) AFB and granulomasAFB and granulomas Ulcerative supraglottisUlcerative supraglottis Dx: foamy leprous cellsDx: foamy leprous cells Rx: dapsone & CSRx: dapsone & CS

Chronic LaryngitisChronic Laryngitis

BacterialBacterial FungalFungal MycobacterialMycobacterial Non infectiousNon infectious

Non Infectious LaryngitisNon Infectious Laryngitis

SmokingSmoking PollutionPollution Vocal AbuseVocal Abuse RhinosinusitisRhinosinusitis Laryngopharyngeal RefluxLaryngopharyngeal Reflux

LPRLPR

Etiologies: acid/bile/pepsinEtiologies: acid/bile/pepsin RF: obsity, EtOH, hiatial hernia, preg, RF: obsity, EtOH, hiatial hernia, preg,

scleroderma, feeding tubescleroderma, feeding tube SSx: Hoarse (am>pm), globus, SSx: Hoarse (am>pm), globus,

dysphagiadysphagia Dx: trial of PPI/NP scopeDx: trial of PPI/NP scope

Barium swallowBarium swallow 24 hour dual pH probe24 hour dual pH probe esophagoscopyesophagoscopy

LPRLPR

Rx: Rx: Behavioral: smoking cessation, elevate HOB, Behavioral: smoking cessation, elevate HOB,

avoid late meals, overeating, avoid tight avoid late meals, overeating, avoid tight close/loose weightclose/loose weight Decrease caffiene, EtOH, mints, chocolate, Decrease caffiene, EtOH, mints, chocolate, Avoid ASA, nitrates, CCBAvoid ASA, nitrates, CCB

MedicationsMedications PPI (usually 2x dose for LPR versus GERD)PPI (usually 2x dose for LPR versus GERD) H2 blockersH2 blockers

SurgerySurgery FundoplicationFundoplication

Laryngeal and Tracheal Laryngeal and Tracheal Manifestations of Systemic Manifestations of Systemic

DiseaseDisease Key PointsKey Points

Symptoms: hoarseness, cough, stridor, Symptoms: hoarseness, cough, stridor, airway compromiseairway compromise

Mimic laryngeal carcinomaMimic laryngeal carcinoma

Wegener’s Wegener’s GranulomatosisGranulomatosis

Relapsing Relapsing PolychondritisPolychondritis

SarcoidosisSarcoidosis Rheumatoid Rheumatoid

ArthritisArthritis Pemphigus/Pemphigus/

pemphigoidpemphigoid AmyloidosisAmyloidosis

Wegener’s Wegener’s GranulomatosisGranulomatosis

Idiopathic necrotizing granulomatous Idiopathic necrotizing granulomatous vasculitisvasculitis

Types:Types: Limited (no renal)Limited (no renal) Systemic (pulm and renal)Systemic (pulm and renal)

Laryngeal SSx: subglottic mass, Laryngeal SSx: subglottic mass, dyspnea, biphasic stridordyspnea, biphasic stridor

Rx: Steroids + cyclophosphamide Rx: Steroids + cyclophosphamide then MTX/Azathiaprinethen MTX/Azathiaprine

Wegener’s Wegener’s GranulomatosisGranulomatosis

Replapsing Replapsing PolychondritisPolychondritis

Idiopathic inflammation of cartilageIdiopathic inflammation of cartilage Laryngeal SSx: 14% present with Laryngeal SSx: 14% present with

laryngeal sx; 50% eventually have laryngeal sx; 50% eventually have laryngeal sxlaryngeal sx

Radiology: non erosive arthopathyRadiology: non erosive arthopathy Histo: non specific inflammationHisto: non specific inflammation Rx: steroids, dapsone, azathiaprine, Rx: steroids, dapsone, azathiaprine,

cyclophosphamide, cyclosporinecyclophosphamide, cyclosporine

SarcoidosisSarcoidosis

Systemic granulomatosisSystemic granulomatosis Laryngeal SSx (1-5%): suprglottic Laryngeal SSx (1-5%): suprglottic

submucosal mass (“turbin like submucosal mass (“turbin like thickening”)thickening”)

Dx: biopsy, incr ACE, hypercalcemia, Dx: biopsy, incr ACE, hypercalcemia, hypergammaglobulinemiahypergammaglobulinemia

Histo: noncaseating granulomasHisto: noncaseating granulomas Rx: endoscopic removal of mass if Rx: endoscopic removal of mass if

symptomaticsymptomatic Systemic v injected steroidsSystemic v injected steroids

SarcoidosisSarcoidosis

Rheumatoid ArthritisRheumatoid Arthritis

AutoimmuneAutoimmune 25% Laryngeal involvement25% Laryngeal involvement

Acute: tender/erythematous larynxAcute: tender/erythematous larynx Chronic: cricoarytenoid ankylosis, Chronic: cricoarytenoid ankylosis,

submucosal nodulessubmucosal nodules Increased RF, ESR; decreased C’Increased RF, ESR; decreased C’ Rx: steroids and antirefluxRx: steroids and antireflux

Pemphigus/PemphigoidPemphigus/Pemphigoid

AutoimmuneAutoimmune Pemphigus vulgaris: anti desmosome tonofilament Pemphigus vulgaris: anti desmosome tonofilament

Intracellular bridges disrupted->intraepithelial blistersIntracellular bridges disrupted->intraepithelial blisters Bullous Pemphigoid: anti basement membraneBullous Pemphigoid: anti basement membrane

Subepidermal blisteringSubepidermal blistering

Laryngeal SSx: can occur on the mucosa if Laryngeal SSx: can occur on the mucosa if other oral lesions. Usually does not extend to other oral lesions. Usually does not extend to SGSG

Rx: corticosteroidsRx: corticosteroids

Pemphigus/PemphigoidPemphigus/Pemphigoid

AmyloidosisAmyloidosis

Abnormal deposition of Abnormal deposition of fibrillar protein and fibrillar protein and polysaccharide complexespolysaccharide complexes

Laryngeal SSx: anterior Laryngeal SSx: anterior subglottic masssubglottic mass

Dx: biopsy (congo red)Dx: biopsy (congo red) Rx: endoscopic removalRx: endoscopic removal