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Larynx

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  • 1. Disorders of the LarynxWinnie YeungFoundation Year 2
  • 2. Question 1All of the following muscles are supplied by the recurrentlaryngeal nerve except:A. Posterior cricoarytenoidB. Lateral cricoarytenoidC. CricothyroidD. ThyroarytenoidE. Mylohyoid
  • 3. Question 2Which virus is implicated in recurrent respiratorypapillomatosis:A. EBVB. HPVC. CMVD. VZVE. HIV
  • 4. Question 3A 37-year old opera singer comes to clinic, complaining of 2-weeks history of hoarseness which is interfering with herwork. On endoscopy, you see normal vibration of the vocalcords, but notice thickened areas at the anterior 1/3 of bothcords. The most likely diagnosis is:A. Vocal cord polypB. Vocal cord nodulesC. Vocal cord synechiaD. Vocal cord paralysisE. Carcinoma of the larynx
  • 5. Question 4A 5-year old child is brought to A&E by his concerned motherwith high fever and difficulty swallowing. On examination, thechild is sat up on the bed, you notice that stridor, quietshallow breathing and drooling. ‘Thumb-print sign’ is seen onXR. The most likely cause is:A. EpiglottitisB. CroupC. Peritonsillar abscessD. Retropharygeal abscessE. Foreign body
  • 6. Question 5A 17-year old comes to see her GP, presenting with a shorthistory of mild fever, fatigue and sore throat. She has vomitedonce at home today. On examination, there is splenomegaly.Which of the following treatment should the GP avoid:A. ClarithromycinB. DoxycyclineC. Co-trimoxazoleD. AmoxicillinE. Aciclovir
  • 7. Session Overview• Anatomy• Benign lesions▫ Nodules▫ Polyps▫ Cysts▫ Reinke’soedema• Inflammatory conditions▫ Laryngitis• Degenerative conditions▫ Presbylarynx• Neoplasia▫ Premalignant▫ Carcinoma• Neurological▫ Paralysis• Epiglottitis• Respiratory papillomatosis• Infectious mononucleosis
  • 8. • Cricothyrodectomy▫ Emergency airwayinvolves puncturing thecricothyroidmembrane.• Larynx skeleton made up of various cartilages:▫ Thyroid cartilage▫ Cricoidcartiage (complete ring)▫ Arytenoid cartilages (pyramid-shaped x2)
  • 9. Anatomy: Endoscopic view• All muscles of the larynx suppliedby the recurrent laryngeal nerve,from vagus.• EXCEPT cricothyroid muscle,innervated by the external branchof the superior laryngeal nerve.• Blood supply: Superior andinferior thyroid arteries.RimaGlottidis
  • 10. Function of the normal larynx• Appearance: Pearly-white true vocal cords, with surroundingstructure being light pink.• Function: Breathing and phonation.• Movement: Abducts and adducts against each other, meetingin the midline on phonation. There should be no gaps!
  • 11. Throat symptoms• Hoarseness• Stridor: High-pitched noise, in either inspiration or exhalation,due to upper airway obstruction.• Stertor: Heavy snoring inspiratory sound, occuring in coma ordeep sleep, sometimes due to obstruction and upper airways.• Pain: Not common, even in malignancy, but may be aprominent feature if pathology is inflammatory in nature,
  • 12. Benign: Nodules• Causes:Microtrauma, gastricreflux, repeated URTI.• Findings: Calluses occurs inpairs,preventing cords frommeeting in the midline. Hourglassdeformity.• Most commonly occuring inanterior 1/3 of vocal cords.• Common in children and femalepatients, singers, teachers.• Symptoms: Hoarseness, painfulphonation, frequent voice breaks,reduced vocal range.• Formed slowly over time.• Management: Intensive speechand voice therapy, uncommonlymicrolaryngeal surgery.
  • 13. Benign: Polyps• Causes: Isolated trauma, violentcoughing, screaming, LPR(Laryngopharyngeal reflux).• Findings:Single or paired lesionsoccuring at phonating margin(edge) of vocal cord.• Mostly in adult males.• Symtpoms: Hoarse, breathyvoice, tiring easily.• Management: Voice therapy,voice rest, sometimes surgery.
  • 14. Benign: Cysts• Causes: Poor draining or blockedsmall gland in vocal fold,preventing drainage. Unknownwhether vocal cord irritation orexcessive voice use contributes.• Findings:Single or paired lesions,collection of mucous fluid in sac-like structures.• Management: Poor response toconservative Mx. Surgicalremoval, followed by voice rest.
  • 15. Reinke’sOedema• Aka ‘PolypoidDegeneration’ or‘PolypoidCorditis’.• Findings: Enlargement of upperlayer of vocal cord covering,‘Reinke’s space’, withaccumulation of gelatinous fluid.• Causes: Smoking, never seen innon-smokers.• Symptoms: Lower-pitched voicedue to slower vibrations. SOB.• Management: Surgery. Smokingcessation is key, as may reoccurepost-surgery is continued.• Have some malignant potential.
  • 16. Inflammatory: Laryngitis• Irritation and swelling of vocalcords, acute vs. chronic.• Causes: LPR, infection, smokingand inhalation of noxious fumes.• Findings: Swollen cords, resultingin limited mucosal waves andincomplete closure. May look dry.• Management: Seek and treatunderlying course. If persists >2weeks, consider expert advice.
  • 17. Presbylarynx• Causes: Thicking of vocal cord muscles andtissues with aging.• Findings: Reduced bulk, not meeting inmidline.• Symptoms: Hoarse, weak, breathy voice.• Management: Injection of fat or othermaterial to achieve complete closure.
  • 18. Malignancy: Carcinoma of the Larynx• Causes: Smoking, alcohol, LPR.• Classification:Supraglottic, glottic, subglottic.• Pre-malignant: Leukoplakiaon vocal cords, maydevelop into cancer if untreated.• Symptoms: Horaseness, but may be insidious,presenting with acute airway obstruction. SOB,neck lump, blood in spit.• Management: Surgery, cessation of smoking,alcohol, anti-reflux medication.
  • 19. Vocal Cord Paralysis• Causes: Iatrogenic, malignantinvasion.• Findings: Cord abducted onipsilateral side, nomovement/vibration• Symptoms: Adduction failureresults in weak, breathy voice.• Management: Voice therapy,surgery with sialistic block todisplace affect cord medially.
  • 20. Epiglottitis• CT: ‘Halloween sign’ excludesacute epiglottitis.• C-spine XR: ‘Thumb-print’ sign• Causes: Infection fromHaemophilusinfluenzae.• Uncommon since Hib vaccine.• Symptoms: Potentially life-threatening upper respiratoryobstruction.• Young child, anxious, quietshallow breathing, drooling +++.• Managment: Protecting andsecuring airway, antibiotics.
  • 21. Recurrent papillomatosis• Causes: Associated with HPV,vertical transmission.• Symptoms:Wart-like lesions inrespiratory tract, causingrecurrent obstruction.• Young patients with stridor.• Managment: No definitive cure,repeat microdebridement or CO2laser to manage recurrentlesions.
  • 22. Infectious mononucleiosis• Glandular fever (aka ‘kissing disease).• Causes: Epstein-Barr virus.• Symptoms: Fever, sore throat, malaise,sometimes vomiting and petichiae.• Signs: Lymphadenopathy in posteriorcervical, axillary and inguinal regions.Splenomegaly.• Investigations: >50% lymphocytes,10% with enlarged, typical nuclei,Monospot test (heterophile antibodytest).• Differentials: CMV, tonsillitis, flu,leukaemia, diptheria.• Management: Symptomatic andsupportive. Generally self-limiting,• Avoid penicillinsRash.
  • 23. Review: Question 1All of the following muscles are supplied by the recurrentlaryngeal nerve except:A. Posterior cricoarytenoidB. Lateral cricoarytenoidC. CricothyroidD. ThyroarytenoidE. MylohyoidCorrect answer: C
  • 24. Review: Question 2Which virus is implicated the development of recurrentrespiratory papillomatosis:A. EBVB. HPVC. CMVD. VZVE. HIVCorrect answer: B
  • 25. Review: Question 3A 37-year old opera singer comes to clinic, complaining of 2-weeks history ofhoarseness which is interfering with her work. On endoscopy, you seenormal vibration of the vocal cords, but notice thickened areas at theanterior 1/3 of both cords. The most likely diagnosis is:A. Vocal cord polypB. Vocal cord nodulesC. Vocal cord synechiaD. Vocal cord paralysisE. Carcinoma of the larynxCorrect answer: B
  • 26. Question 4A 5-year old child is brought to A&E by his concerned mother with high feverand difficulty swallowing. On examination, the child is sat up on the bed,you notice that stridor, quiet shallow breathing and drooling. ‘Thumb-print sign’ is seen on XR. The most likely cause:A. EpiglottitisB. CroupC. Peritonsillar abscessD. Retropharygeal abscessE. Foreign bodyCorrect answer: A
  • 27. Question 5A 17-year old comes to see her GP, presenting with a short history of mildfever, fatigue and sore throat. She has vomited once at home today. Onexamination, there is splenomegaly. Which of the following treatmentshould the GP avoid:A. ClarithromycinB. DoxycyclineC. Co-trimoxazoleD. AmoxicillinE. AciclovirCorrect answer: D
  • 28. ‘ Nothing can surpass the ability of the voice forsoulful expression of the human experience.’