E.N.T 5th year, 3rd lecture (Dr. Hiwa)

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The lecture has been given on Mar. 28th, 2011 by Dr. Hiwa.

The lecture has been given on Mar. 28th, 2011 by Dr. Hiwa.

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