E.N.T.Acute laryngitis.(dr.usif chalabe)


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E.N.T.Acute laryngitis.(dr.usif chalabe)

  2. 2. Acute laryngitis <ul><li>It is swelling of the laryngeal mucosa and underlying tissue. </li></ul><ul><li>Caused by : </li></ul><ul><li>Infection (viral or bacterial). </li></ul><ul><li>Exogenous agents. </li></ul><ul><li>Autoimmune processes. </li></ul>
  3. 3. Clinical entities <ul><li>Acute simple laryngitis. </li></ul><ul><li>Acute laryngotracheobronchitis (croup). </li></ul><ul><li>Subglottic laryngitis (pseudocroup). </li></ul><ul><li>Acute epiglottitis. </li></ul><ul><li>Diphtheric laryngitis. </li></ul><ul><li>Membranous laryngitis. </li></ul><ul><li>Herps zoster of the larynx. </li></ul>
  4. 4. Acute (simple) laryngitis <ul><li>Aetiology </li></ul><ul><li>1. Infection . Airborne. </li></ul><ul><ul><li>- Viral influenza & adeno virus . </li></ul></ul><ul><ul><li>- Bacterial Moraxella catarrhalis, Streptococcus pneumoniae & H.influenza. </li></ul></ul><ul><ul><li>more in winter and early spring. </li></ul></ul><ul><li>Patients suffering from sinusitis, nasal obstruction, overuse of the voice, alcoholic and smokers are more prone . </li></ul>
  5. 5. <ul><li>2. Trauma (vocal abuse &/or endoscopic manipulation). </li></ul><ul><li>3. Irritation from inhaled fumes or gas, including tobacco smoke. </li></ul>
  6. 6. <ul><li>Pathology </li></ul><ul><li>The laryngeal mucosa shows all signs of acute inflammation: </li></ul><ul><li>Extravasation of fluid. </li></ul><ul><li>Infiltration by polymorphnuclear leucocytes. </li></ul><ul><li>Later plasma cells and lymphocytes predominates. </li></ul><ul><li>The underlying muscles, the perichondrium, and the cricoarytenoid joints may be affected. </li></ul><ul><li>The epithelium may be destroyed and exfoliated. </li></ul><ul><li>Full recovery is usuall. </li></ul><ul><li>Sometimes fibrosis will results leading to permanent damage to the laryngeal mucosa which can be the beginning of chronic laryngitis. </li></ul>
  7. 7. <ul><li>Pathological changes in the mucosa </li></ul><ul><li>Redness of the mucosa. </li></ul><ul><li>Oedema of the mucosa. </li></ul><ul><li>Sticky mucopurulant exudate . </li></ul><ul><li>Slight abrasions. </li></ul><ul><li>Purulent exudation in severe forms(septic laryngitis). </li></ul><ul><li>Fibrinous laryngitis in influenza, there are white plaques on the surface of the cords and the laryngeal inlet. </li></ul><ul><li>Perichondritis may follow the purulant form by H.streptococcus. </li></ul>
  8. 8. <ul><li>Clinical fearures </li></ul><ul><li>Hoarsness (high-pitched husky voice). </li></ul><ul><li>Discomfort in the throat. </li></ul><ul><li>Pain is slight or absent. </li></ul><ul><li>Dysphagia if epiglottis &/or arytenoid are markedly involved. </li></ul><ul><li>Dyspnoea in severe oedema. </li></ul><ul><li>Dry and irritant cough . </li></ul><ul><li>Generalized symptoms (malaise and fever , toxaemia is rare) more in bacterial infections. </li></ul><ul><li>Symmetrical redness &/or sticky secretions on both vocal cords, at indirect laryngoscopy . </li></ul><ul><li>The clinical coarse in children can be rapidly progressive. </li></ul>
  9. 9. <ul><li>Progress </li></ul><ul><li>Usually resolves in a few days. </li></ul><ul><li>The hoarsness may persist for as long as 2 weeks after apparent resolution. </li></ul><ul><li>A functional aphonia may follow specially in women. </li></ul><ul><li>In severe cases the inflammation spreads to the lung in aged patients. </li></ul>
  10. 10. <ul><li>Treatment </li></ul><ul><li>Local (supportive) </li></ul><ul><li>Voice rest (a quiet unforced whisper is allowed). </li></ul><ul><li>Steam inhalations. M enthol </li></ul><ul><li>loosen viscid secretions. </li></ul><ul><li>Aspirin. </li></ul><ul><li>Warm application to the neck. </li></ul><ul><li>Codeine to suppress dry cough. </li></ul>
  11. 11. <ul><li>General </li></ul><ul><li>Rest and sedatives. </li></ul><ul><li>Avoidance of alcohol and tobacco. </li></ul><ul><li>Systemic antibiotics in cases of bacterial infection </li></ul><ul><li>- Penicillin (Augmentin) 500 mg 4 times daily, </li></ul><ul><li>- Doxycycline 200 mg daily or </li></ul><ul><li>- Erythromycin 500 mg twice daily </li></ul>
  12. 12. Acute simple laryngitis in children <ul><li>More serious because of: </li></ul><ul><li>Anatomical difference of infantile larynx. </li></ul><ul><li>Rich lymphatic drainage. </li></ul><ul><li>The neuromuscular mechanism is more easily upset and spasm more easily provoked. </li></ul><ul><li>The child is less liable to expel secretions by cough. </li></ul>
  13. 13. <ul><li>Clinical features </li></ul><ul><li>Cough . A laryngeal spasm (false croup) develops suddenly. </li></ul><ul><li>Dyspnoea , cyanosis, and stridor from laryngeal spasm and oedema. </li></ul><ul><li>laryngitis stridulosa is the name given to the condition when stridor is present. </li></ul><ul><li>3 . Hoarsness. </li></ul>
  14. 14. <ul><li>Treatment </li></ul><ul><li>The same as in adult. </li></ul><ul><li>In addition to oxygenation and securing the airway when there is stridor and cyanosis by intubation or tracheostomy. </li></ul>Home
  15. 15. Subglottic laryngitis (pseudocroup) <ul><li>Also called spasmodic cough. </li></ul><ul><li>Is common <3 years of age. </li></ul><ul><li>The symptoms are alarming. </li></ul><ul><li>The cause is unkown but is associated with influenza viruses infections. </li></ul><ul><li>There will be substantial swelling of the subglottic space. </li></ul>
  16. 16. <ul><li>Clinical features </li></ul><ul><li>Starts abruptly in a child with history of URTI. </li></ul><ul><li>The child wakes up with dry cough and increasing stridor. </li></ul><ul><li>No or mild fever. </li></ul><ul><li>Restless, nervous and crying child. </li></ul>
  17. 17. <ul><li>Treatment </li></ul><ul><li>Sedatives are given to the parents and never to the child. </li></ul><ul><li>Parenteral corticosteroids? </li></ul><ul><li>Taking the child to a room with moist ear (e.g bathroom). </li></ul><ul><li>In an emergency endotracheal intubation for 1-2 days. </li></ul>Home
  18. 18. Membranous laryngitis <ul><li>Rare, closely linked with croup , sometimes called (pseudomembranous croup). </li></ul><ul><li>Caused by : </li></ul><ul><li>*Pseudomonus aeruginosa. </li></ul><ul><li>*streptococci. </li></ul><ul><li>*Vincent’s organisms. </li></ul><ul><li>A confluent membrane covering the surface of the larynx and when removed no bleeding or ulceration occur. </li></ul><ul><li>The main site is the supraglottis. </li></ul>
  19. 19. <ul><li>Clinical features </li></ul><ul><li>Simillar to other forms of laryngitis. </li></ul><ul><li>The constitutional symptoms accompanied by anorexia and thirst. </li></ul><ul><li>Moderate fever. </li></ul><ul><li>Painfull swallowing. </li></ul><ul><li>Cough. </li></ul><ul><li>There may be stridor. </li></ul>
  20. 20. <ul><li>Diagnosis is established by by bacteriology. </li></ul><ul><li>Treatment </li></ul><ul><li>penicillins (Augmentin), 3 rd gen cephalosporen (ceftriaxon) or sulphonamides. </li></ul>Home
  21. 21. Acute epiglottitis <ul><li>Definition </li></ul><ul><li>special form of acute laryngitis, in which the inflammatory changes affect mainly the loosely attached mucosa of the epiglottis. </li></ul><ul><li>Pathology </li></ul><ul><li>Localized oedema may obstruct the airway. </li></ul><ul><li> - H.influenza is the usuall causative organism. </li></ul><ul><li>- B-Haemolytic streptococci rarely. </li></ul><ul><li>Submucous abscesses may form. </li></ul>
  22. 22. Acute epiglottitis
  23. 23. <ul><li>Incidence </li></ul><ul><li>1:17.000 children. </li></ul><ul><li>1:100.000 adults. </li></ul><ul><li>. Vaccination is reducing its incidence. </li></ul>
  24. 24. <ul><li>Clinical features </li></ul><ul><li>History is short and abrupt. </li></ul><ul><li>Fever >40 C. </li></ul><ul><li>Dyspnoea and stridor (progressive and alarming). </li></ul><ul><li>Pain on swallowing (commoner than respiratory obstruction in adults). </li></ul><ul><li>Drooling of saliva. </li></ul><ul><li>The patient is preferring the sitting position </li></ul>
  25. 25. Radiologically diagnosed by thump print sign on lateral view of neck X-ray
  26. 26. <ul><li>Treatment </li></ul><ul><li>Constant supervision in hospital when stridor is present. </li></ul><ul><li>Inhalation of moist air. </li></ul><ul><li>Throat swab and blood cultures. </li></ul><ul><li>IV antibiotics (Augmentin) or 3 rd gen. cephalosporen in high doses. </li></ul><ul><li>Endotrachial intubation , may be difficult. </li></ul><ul><li>Tracheostomy. </li></ul>Home
  27. 27. Acute laryngotracheobronchitis (Croup) <ul><li>Aetiology </li></ul><ul><li>-Affects infants and small children up to the age of 7 . </li></ul><ul><li>-Caused by parainfluenza virus . </li></ul><ul><li>-secondary bacterial infection (haemolytic streptococcus) superimpose by the 3 rd day which makes the condition worse. </li></ul>
  28. 28. <ul><li>Clinical features </li></ul><ul><li>Hard ,dry, croupy cough and hoarsness . </li></ul><ul><li>Pyrexia (some time>41). </li></ul><ul><li>Dyspnoea and cyanosis. </li></ul><ul><li>Tenacious exudation and crusting. </li></ul><ul><li>Oedema of the larynx. </li></ul><ul><li>Atelactasis. caused by occlusion of the bronchi. </li></ul>
  29. 29. Narrowinng of the air column in the subglottic space (steeple sign) on x-ray of the neck AP view
  30. 30. <ul><li>The icreased muscular energy consumption required for breathing and coughing, with CO 2 retension leads to combination of metabolic and respiratory acidosis which paralyses the central regulation of respiration. </li></ul><ul><li>During the initial phase the child is restless and cyanotic, in the later stages there may be an apparent improvement when the child becomes tired and calm.the retension of CO 2 causes a change of colour from cyanotic to pale and it is the sign of imminent disaster. </li></ul><ul><li>A small child with a temp.>38.5 C and stridor should be admitted to hospital for observation </li></ul>
  31. 31. <ul><li>Treatment </li></ul><ul><li>Admission. </li></ul><ul><li>Rest and reasurance. </li></ul><ul><li>Systemic antibiotics (Augmentin or 3 rd gen cephalo) and anti-pyretics. </li></ul><ul><li>Humidification. </li></ul><ul><li>Oxygen preferably in a tent . </li></ul><ul><li>Fluid by mouth or IV. </li></ul><ul><li>IV steroids? </li></ul><ul><li>Nasotracheal tube or tracheostomy. </li></ul><ul><li>Removal of secretions by mucolytic agents (guafenecine containing syrup) </li></ul><ul><li>Bronchoscopy with removal of secretions by suction or forceps. </li></ul><ul><li>Tracheostomy with intermittent suction. </li></ul>Home
  32. 32. Diphtheric laryngitis <ul><li>Usually an extension of faucial infection. </li></ul><ul><li>Aetiology </li></ul><ul><li>corynbacterium diphtheriae . In children younger than 10 years of age and occasionally young adults. </li></ul><ul><li>It has been less frequent since universal immunization. </li></ul>
  33. 33. <ul><li>Clinical features </li></ul><ul><li>The onset is insidious. </li></ul><ul><li>Cough of a hoarse, croupy nature. </li></ul><ul><li>Stridor follows accompanied by cyanosis and recession of the chest wall. </li></ul><ul><li>Pyrexia rarely above 37.8 C. </li></ul><ul><li>Weak and rapid pulse. </li></ul><ul><li>Greyish-white membrane and bleeding when removed. </li></ul>
  34. 34. <ul><li>Diagnosis </li></ul><ul><li>By identifying the organism in swabs (KLB) from the membrane. </li></ul><ul><li>Treatment </li></ul><ul><li>Antitoxin injections IM or IV (20.000-100.000 units according to the age & severity). </li></ul><ul><li>Systemic penicillin. </li></ul><ul><li>Oxygen. </li></ul><ul><li>Tracheostomy. </li></ul>Home
  35. 35. Herpes zoster of the larynx <ul><li>Rare condition caused by a neurotrophic virus . The superior laryngeal branch of the vagus nerve and the pharyngeal plexus may be involved specially in debilitated persons. </li></ul>
  36. 36. <ul><li>Clinical features </li></ul><ul><li>Pain in the throat. </li></ul><ul><li>Dysphagia. </li></ul><ul><li>Fever and malaise. </li></ul><ul><li>Vesicles on the epiglottis, arytenoid, and ventricular bands (unilateral). </li></ul><ul><li>Palsies of the vocal cords from involvement of the motor branch to the cricothyroid muscle or of the recurrent laryngeal nerve. </li></ul>
  37. 37. <ul><li>Treatment </li></ul><ul><li>Oral acyclovir 800 mg 5 times daily for 1 week if a painful cord palsy is diagnosed within the first 3 days of onset. </li></ul>Home
  38. 38. Herpes zoster virus on electron microscopy close
  39. 39. Influenza virus on electron microscopy close
  40. 40. Smear of pus showing streptococci close
  41. 41. Blood agar culture showing beta haemolysis close
  42. 42. close Acute laryngitis Redness Oedema Sticky mucopurulant secretions Normal larynx
  43. 43. H.influenza close
  44. 44. close Diphtheric laryngitis (Grayish white membrane)
  45. 45. Acute laryngitis on indirect laryngoscopy close
  46. 46. H-influenza close
  47. 47. Oxygen tent close
  48. 48. Thank you