Acute and chronic laryngeal inflammations

1. Acute and chronic
laryngeal inflammations
Dr. Krishna Koirala

2. Acute Laryngitis ( Simple laryngitis)
• Most common
• Occurs as a symptom of common cold
• Etiology
– Infection :
– Rhinovirus , Parainfluenza viruses, Respiratory
syncytial virus , Adenoviruses , Influenza viruses
– H. influenza, Strept. pneumoniae, Moraxella

3. • Gastro esophageal reflux disease
• Environmental insults (pollution)
• Vocal trauma
• Unfavorable climate
• Undue physical and psychological stress

4. Clinical Features
• Symptoms
– History of URTI
– Hoarseness - discomfort on speech, high pitched
husky voice
– Discomfort and pain in the throat
– Irritant paroxysmal cough mainly at night
– Bodyache ,malaise

5. • Signs
– Fever
– Congested posterior pharyngeal wall
– I/L or Flexible NPL
•Red and swollen mucosa of supraglottic
structures
•Mild swelling and congestion of true vocal
cords
•Inspissated mucous or purulent discharge

6. Swollen and
congested TVCs
Normal vocal cord
Mucopus

7. Treatment
• Supportive
– Voice rest
– Medicated steam inhalation
– Avoidance of irritants: cold, draught, tobacco ,
alcohol
• Mucolytic agents : Bromhexine, guaphenesin
• Analgesics
• Adequate hydration

8. • Codeine phosphate
• Proton pump inhibitors
• Antibiotics : Amoxicillin, Doxycycline, erythromycin
• Local anesthetic sprays
• Steroids
• Voice therapy if the problem persists

9. Acute Epiglottitis (Acute Supraglottitis,
Supraglottic laryngitis)
• Rapidly developing inflammation of the epiglottis and
adjacent supraglottic tissues usually due to a bacterial
infection, that can cause life - threatening airway obstruction
• M:F -- 3:1 , mean age : 3 - 5 yrs
• Causative organisms
• Haemophilus influenzae type b (Hi b)
• Streptococcus pyogenes , S. pneumoniae, Staph. Aureus
• Tubercular bacilli

10. • Morbidity and mortality
– Life-threatening airway obstruction requiring
intubation / tracheostomy
– Mortality rate : around 1% in children
• Course
– Sudden onset and rapid progression with early
airway compromise in children ( hours)
– Indolent course in adults (days)

11. Clinical features
•Acute onset , rapid progression !
•Severe sore throat
•Odynophagia /Dysphagia
•Drooling (due to inability to swallow)
•Toxic look
•Respiratory Distress with Stridor (Inspiratory)

12. • Muffled voice
• Child anxious , may lean forward, extending
the neck in an attempt to maintain an open
airway
• Tripod sign : Sitting up on hands with the
tongue out and head forward
• Cervical lymphadenopathy +

13. • Examination carried out in ICU / ER with
intubation / tracheostomy set ready
• Laryngeal findings
–Inflamed epiglottis, aryepiglottic folds and
arytenoid cartilages
–Pus in the epiglottis

15. Investigations:
• Plain x-ray soft tissue of neck lateral view
– Enlarged and swollen epiglottis ( Thumb sign )
– Absence of deep well defined vallecula (Vallecula
sign)
• Culture from epiglottis during intubation
• Blood culture, throat swabs

16. Swollen epiglottis
Thickened AEF
Epiglottitis in elderly

17. • Parameters for diagnosing epiglottitis in adults
– Epiglottic height to width ratio >0.6
– Epiglottic to C4 vertebral body width ratio >0.33
– AE fold to C3 vertebral body width ratio >0.35
– Prevertebral soft-tissue to C4 vertebral body width
ratio >0.25
– Hypopharyngeal airway to C4 vertebral body width
ratio >1.5

18. Treatment
• First priority - to ensure patient's airway - intubation or
tracheostomy under GA if respiratory distress/ stridor
occur
• Mechanically ventilated until swelling and
inflammation decrease
• Careful monitoring and isolation - infectious and
easily spread

19. • Steroids (prednisolone 1mg/kg stat)
• Antibiotics
– Ampicillin (200 mg/kg/d in 4 divided doses) +
Chloramphenicol (100 mg/kg/d in 4 divided doses)
– Ceftriaxone (100 mg/kg/d in 2 divided doses)
– Cefuroxime (50 -100mg /kg iv BD)
• Sedation : Midazolam 0.1mg/kg bolus and continuous i.v.
infusion if the child is intubated
• Adequate hydration
• Oxygenation

20. Acute Laryngotracheobronchitis (Croup)
• Commonest infective cause of URT obstruction in
children ( 40 times more common than epiglottitis)
• Mean age 18 months
• Maximal effect in subglottic area
• Causative agents
– Parainfluenza virus type I, II and III
– Influenza virus, Respiratory syncytial virus,
Rhinovirus , Measles

21. Clinical features
• Symptoms
– Almost always preceded by URTI usually at least
48 hrs duration
– Sore throat ,hoarseness
– Croupy cough ( musical cough of crowing quality or
bark of a seal)
– Respiratory distress mainly at night
– Child prefers to lie down

22. •Signs
–Slight pyrexia
–Inspiratory / biphasic stridor
–Inflamed and ulcerated TVCs
–Edema and ulceration of subglottis
–Sloughing of trachea
–Rest of tracheobronchial tree may be affected

23. Bacterial Laryngotracheobronchitis (pseudo
membranous croup)
• More severe than acute laryngotracheobronchitis
• Causative agent : Staph. aureus
• Pathology
–Sloughing of resp. epithelium
• C/F
– Brassy cough with high fever

24. Investigations
• Plain X-ray soft tissue neck
AP view
– Narrow subglottis ( steeple
sign)
– Ballooning of hypopharynx
• Blood gas analysis
• Laryngeal findings during
intubation

26. Treatment
• Observation – Stridor , restlessness , body colour,
respiratory and heart rate
• Reassurance – Calm, confident ,reassuring
atmosphere
• Hydration – oral or IV fluids
• Humidification
• Oxygen Therapy
– Decreases reflex bronchoconstriction, sputum
retention and pulmonary edema

27. • Steroids
–Dexamethasone 0.6 mg/kg single dose
• Antibiotics
–IV Ceftriaxone 100 mg/kg/day
• Racemic adrenaline
–Nebulized and delivered by IPPV
• Endotracheal intubation / Tracheostomy
–Rarely

28. Chronic Laryngitis
• Chronic non specific inflammatory process ( >3 wks)
leading to irreversible alterations of the laryngeal
mucosa
• Etiology
– Endogenous : Short, heavy built people, diabetes,
hypothyroidism, vitamin A deficiency
– Exogenous
•Physical - cigarette, inhaled irritants
•Chemicals
•Chronic infections of upper or lower respiratory tract
•Chronic cough

29. History and Clinical symptoms
• Insidious onset
• Hoarseness
– Worse in the morning
– Dryness and feeling of FB in throat
– Decreased vocal range
– Pain rarely present

30. Clinical Forms
•Simple diffuse chronic laryngitis
•Hyperplastic diffuse chronic laryngitis

31. Simple Diffuse Chronic laryngitis
• Starts with URTI and persists as hoarseness and
cough over a long period of time
• O/E
– Reddened hyperemic laryngeal mucosa
– TVCs pink or red, glossy, sub mucosal edema
• Treatment
– Voice rest, steam inhalation
– Antibiotics ( Amoxycillin , Co-amoxyclav)
– Avoidance of alcohol and tobacco

32. Hyperplastic diffuse chronic laryngitis
• Contributing factors
– Chronic infection of sinuses and lower airway
– Tobacco and alcohol
– Occupational ,chemical or physical irritants
– Mouth breathing
• O/E
– TVCs lose their normal appearance (red, deep red or
grey)
– Patches of epithelial thickening and broad based
polypoid lesions

33. Reinke’s edema
• Accumulation of fluid under the epithelium of TVCs
• Etiology
– Precise cause unknown
– Allergy, infection, local irritants (alcohol, tobacco)
• Clinical features
– Common in female smokers of 30 - 60 yrs of age
– Hoarseness with deepened and monotonous voice
– Dry cough and habit of clearing of throat
– Vocal cords red, swollen, slightly translucent
– Fusiform ,symmetrical, polypoid swelling of TVCs

34. • Treatment
– Elimination of noxious agents
– Microsurgical removal of strips of
vocal cord mucosa by micro
laryngoscopy (Decortication)
– Both the sides can be treated at one
setting (don’t extend the incisions to
anterior commissure)
– Absolute vocal rest for 1 week
– Speech therapy (after 2-3 wks)

35. Tuberculosis of larynx
• Commonly associated with pulmonary
tuberculosis
• Posterior commissure, arytenoids and TVCs
mainly affected b/o contact of larynx with
sputum containing tubercular bacilli
• Hematogenous and lymphogenous infection
( More accepted nowadays)

36. Pathology
Subepithelial infection
Exudation and hyperemia
Round cell infiltration
Tubercles (granulomatous reaction + Langhans giant cells +
caseation necrosis) (Turban epiglottis)
Sloughing with ulceration of epithelium leading to shallow
ulcers with undermined edges involving the arytenoids and
epiglottis (moth eaten epiglottis)

37. • Clinical features
– History of PTB, cough with hoarseness
– Dysphagia
– Throat pain and referred earache( out of proportion to the
lesion)
– Mucosal hyperemia /edema
– Irregularities of mucosal surface
– Granulomatous mass and ulceration
– Swollen and turban shaped epiglottis

38. • Diagnosis
– Direct laryngoscopy and biopsy
– Chest X - ray P/A view
– Sputum AFB
• Treatment
– Antitubercular medication for 6 - 8 mths
– 2 HRZE + 6HR