E.N.T 5th year, 4th lecture (Dr. Hiwa)


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The lecture has been given on Apr. 4th, 2011 by Dr. Hiwa.

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E.N.T 5th year, 4th lecture (Dr. Hiwa)

  1. 1. Chronic laryngitis Prepared by: Dr.Hiwa As’ad
  2. 2. Chronic laryngitis <ul><li>Is the chronic inflamatory reaction of laryngeal mucosa and underlying tissue </li></ul><ul><li>Generally classified into: </li></ul><ul><li>Chronic non specific </li></ul><ul><li>Chronic specific </li></ul>
  3. 3. Clinical classification: <ul><li>Nonspecific chronic laryngitis: </li></ul><ul><li>Chronic simple laryngitis. </li></ul><ul><li>Hyper keratosis of larynx (keratosis or leukoplakia). </li></ul><ul><li>Pachydermia laryngis. </li></ul><ul><li>Contact granuloma. </li></ul><ul><li>Atrophic laryngitis. </li></ul><ul><li>Chronic specific laryngitis: </li></ul><ul><li>Tuberculous laryngitis </li></ul><ul><li>Syphilitic laryngitis. </li></ul><ul><li>Leprosy of the larynx. </li></ul><ul><li>Scleroma of the larynx. </li></ul><ul><li>Wegener’s (malignant) granuloma of the larynx. </li></ul><ul><li>Mycosis of the larynx. </li></ul>
  4. 4. <ul><li>Clinical entities </li></ul><ul><li>Chronic non specific laryngitis </li></ul><ul><li>Atrophic laryngitis </li></ul><ul><li>Pachydermia laryngitis </li></ul><ul><li>Hyperkeratosis of larynx </li></ul><ul><li>Tuberculous laryngitis </li></ul><ul><li>Perichondritis of larynx </li></ul><ul><li>Wegner’s granuloma of larynx </li></ul>
  5. 5. Chronic non-specific laryngitis: <ul><li>It may follow an acute attack of laryngitis but more often it arises insidiously due to: </li></ul><ul><li>Faulty use of voice (most important) </li></ul><ul><li>Infection in teeth,tonsils and sinuses especially when they result in excessive hawking or coughing </li></ul><ul><li>Excessive alcohol or tobacco </li></ul><ul><li>Dust or irritant fumes </li></ul>
  6. 6. Clinical features: <ul><li>Hoarseness is the most frequent and often the only symptom. It is intermittent at first and becomes less marked after use of voice </li></ul><ul><li>Cough slight ,dry and irritating may be present </li></ul><ul><li>Constant hawking and clearing of the throat with F.B sensation </li></ul><ul><li>Sore throat </li></ul><ul><li>Aphonia is rare </li></ul>
  7. 7. Laryngreal appearances: <ul><li>Three types of chronic nonspecific laryngitis: </li></ul><ul><li>1.Hyperaemic in which the cords are red or dull pink. There may be some loss of adduction due to myositis, flecks of vicid mucus may lie on the cords and in the interarytenoid space. </li></ul><ul><li>2.Hypertrophic in which there is thickening of the tissues of the cords , the ventricular bands, arytenoids and interarytenoid space </li></ul>
  8. 8. Normal larynx Chronic laryngitis hypertrophic ) )
  9. 9. <ul><li>3.Oedematous in which the true cords are swollen and pale .The condition may be of longstanding. </li></ul><ul><li>In all three types the larynx is nearly always affected bilaterally and symmetrically </li></ul>
  10. 10. Chronic laryngitis ( oedematous ) with polyp
  11. 11. Diagnosis: <ul><li>History </li></ul><ul><li>Laryngoscopy </li></ul><ul><li>Regular laryngoscopic follow ups are advisable in chronic nonspecific laryngitis because of possibility of dyplasia. </li></ul><ul><li>Microlaryngoscopy and biopsy should be performed in every doubtful case </li></ul>
  12. 12. Treatment <ul><li>Vocal rest </li></ul><ul><li>Speech therapy (faulty use) </li></ul><ul><li>Elimination of any URT infection (tonsillitis, sinusitis, dental infection) </li></ul><ul><li>Elimination of irritating factors such as dust and tobacco smoking </li></ul><ul><li>Inhalation of mentholated air </li></ul><ul><li>Mucolytic may give symptomatic benefit </li></ul><ul><li>Stripping of the vocal cords is performed endoscopically in resistant cases of chronic oedematous laryngitis </li></ul>
  13. 13. Atrophic laryngitis (laryngitis sicca) : <ul><li>A rare entity characterized by atrophic changes in the respiratory mucosa with loss of the mucus-producing glands </li></ul><ul><li>it is usually associated with atrophic rhinitis and pharyngitis caused by klebsiella ozaenae </li></ul><ul><li>the most common sites involved in larynx are the false cords, the posterior region, and the subglottic region </li></ul>
  14. 14. <ul><li>Aetiology: </li></ul><ul><li>Aggravating factors include dusty atmospheres, industreal fumes . </li></ul><ul><li>Chronic infection in paranasal sinuses . </li></ul><ul><li>More common in women. </li></ul><ul><li>Clinical features : </li></ul><ul><li>An irritable cough and hoarseness are the most important features. </li></ul><ul><li>Excessive crusts formation which are sometimes bloodstained with foul odour. </li></ul><ul><li>The crusting usually extends into the trachea. </li></ul>
  15. 15. <ul><li>The crusts can be seen in the larynx and are the most important diagnostic feature </li></ul><ul><li>hoarseness and sore throat both of which are improved temporarily by hawking and coughing up the crust. Some times there will be dyspnea. </li></ul><ul><li>On examination the mucosa will be dry and atrophic, crusts different sizes lie over the mucosa which may be excoriated when they are removed. </li></ul><ul><li>If the nose and sinuses show similar abnormality the diagnosis is more easier </li></ul>
  16. 16. <ul><li>Treatment: </li></ul><ul><li>Eradication of associated lesions in the nose and paranasal sinuses </li></ul><ul><li>Change of atmospheric condition </li></ul><ul><li>Removal of crust will give some local relief </li></ul><ul><li>{Inhalations of menthol } for softening of </li></ul><ul><li>crusts </li></ul><ul><li>Mucolytic agents </li></ul><ul><li>Hormones (results are uncertain) </li></ul>
  17. 17. Hyperkeratosis of larynx <ul><li>A localized form epithelial hyperplasia characterized by white “leucoplakic” raised patches on the vocal cords. it is of unknown aetiology. </li></ul><ul><li>Pathology: </li></ul><ul><li>There is a hperplastic change in the epithelium leading to excessive cornification. The basement membrane remains intact. </li></ul>
  18. 18. Clinical features <ul><li>Hoarseness of gradual onset ,is persistent </li></ul><ul><li>White raised patches appear on one or both vocal cords on laryngoscopy. </li></ul><ul><li>The anterior and middle thirds are usually involved. </li></ul><ul><li>Mobility of the cords is not impaired. </li></ul>
  19. 19. Leucoplakia of the left true vocal cord
  20. 20. Treatment & prognosis: <ul><li>Septic foci in the mouth,throat and nose must be treated but response is uncertain. </li></ul><ul><li>Biopsy of suspicious areas is essential and may require repetition during follow up . </li></ul><ul><li>Constant supervision is essential to detect early malignant change demanding radical removal . </li></ul><ul><li>Stripping of the cords . </li></ul><ul><li>Radiotherapy is not indicated . </li></ul><ul><li>The condition must be considered precancerous and carcinoma in-situ . it tends to persist in spite of conservative treatment. </li></ul>
  21. 21. Perichondritis of larynx <ul><li>An inflammation of the perichondrium of the laryngeal cartilages </li></ul><ul><li>Aetiology: </li></ul><ul><li>There are several causes: </li></ul><ul><li>1. Inflamation: </li></ul><ul><li>from T.B and syphlitic infection,acute septic laryngitis as in typhoid fever and diphtheria or from spread of infection from sepsis in the mouth </li></ul>
  22. 22. <ul><li>2. Traumatic: </li></ul><ul><li>from cut throat wounds , impacted F.B and high tracheostomy tubes . </li></ul><ul><li>3. Neoplastic : </li></ul><ul><li>from advanced carcinoma with secondary infection. </li></ul><ul><li>4 . Complication of irradiation in carcinoma of larynx (most common cause nowadays). </li></ul>
  23. 23. <ul><li>Clinical features : </li></ul><ul><li>Sudden or insidious in onset. </li></ul><ul><li>Malaise , fever even rigor in the acute form. </li></ul><ul><li>Local pain is always present and often radiates to the ears. </li></ul><ul><li>Enlargement of the laryngeal contour by inspection and palpation. </li></ul><ul><li>Swelling of the neck caused by abscess which may burst to form a sinus or fistula. </li></ul><ul><li>Tenderness,hoarseness,cough and dysphagia. </li></ul><ul><li>Dyspnea which increases. </li></ul>
  24. 24. Diagnosis & finding: <ul><li>Laryngoscopic picture reveals pale mucosal oedema particularly on the epiglottis and the arytenoid cartilages. </li></ul><ul><li>There is intra and extra-laryngeal swelling and may be fistula. </li></ul>
  25. 25. Perichondritis of larynx
  26. 26. Treatment <ul><li>Absolute rest both general and local in the acute stage. </li></ul><ul><li>Systemic antibiotics . </li></ul><ul><li>High dose of steroid for 1 week with tapering. </li></ul><ul><li>Tracheostomy is indicated when dyspnea marked and should be made as low as possible. </li></ul><ul><li>Incision of abscess externally or internally. </li></ul><ul><li>Laryngeal spray of ephedrine 0.5%. </li></ul>
  27. 27. <ul><li>In perichondritis due to irradiation in Ca . larynx is very difficult situation to manage because to take deep biopsies in a search for cancer is a certain way to make the perichondritis worse . </li></ul><ul><li>It is better to treat the perichondritis with Ampicillin and diuretics and to delay the biopsy for as long as possible. </li></ul><ul><li>If the larynx is still swollen 6 months after the radiation therapy a total laryngectomy should be performed even if the biopsies are negative </li></ul>
  28. 28. Prognosis <ul><li>Depends chiefly on the condition causing the perichondritis. </li></ul><ul><li>Laryngeal obstruction, inhalation pneumonia or abscess and septicemia are the common immediate dangers . </li></ul><ul><li>Laryngeal stenosis and permanent hoarseness are late results. </li></ul>
  29. 29. Pachydermia laryngis <ul><li>A form of chronic hypertrophic laryngitis affecting the epithelium and subepithelium of the posterior part of the larynx i.e the posterior half of the cords , the vocal process, and the interarytenoid region </li></ul><ul><li>The exact aetiology is unknown but alchol, tobacco, and acid from oesophageal reflux (acid laryngitis) may be considered as aggravating factors </li></ul><ul><li>Neoplastic change does not occur </li></ul>
  30. 30. Clinical features <ul><li>Hoarseness : the voice is usually husky but may occasionally be normal </li></ul><ul><li>Irritation or discomfort sometimes </li></ul><ul><li>Laryngeal appearance is variable from reddening to hypertrophy( bilateral and symmetrical ) in the epithelium &subepithelial connective tissue of the interarytenoid area . </li></ul><ul><li>Gross thickening can extend to the vocal processes where as a result of trauma the altered epithelium can break down causing contact ulcer . </li></ul><ul><li>Any unilateral condition must be reguarded as neoplastic until proved otherwise </li></ul>
  31. 31. Normal larynx Contact ulcer
  32. 32. Treatment <ul><li>H2 antagonist and antiacid at night ( acid laryngitis ) with advices on weight and posture </li></ul><ul><li>( Of unknown aetiology ) the treatment is similar to that for simple chronic laryngitis . Surgical removal diathermy of the mass give little relief and are inadvisable . Systemic steroid may help </li></ul>
  33. 33. Tuberculous laryngitis <ul><li>It is almost always secondary to pulmonary lesion </li></ul><ul><li>Most infections are sputogenic, few are haematogenous and rarely by lymph stream </li></ul><ul><li>Often persons between 20-40 years of age are affected </li></ul><ul><li>Can infect the intact laryngeal mucosa especially the posterior third of larynx </li></ul>
  34. 34. <ul><li>Pathology: </li></ul><ul><li>With sputogenic type of infection the tubercle bacillus can infect the intact laryngeal mucosa. </li></ul><ul><li>The submucosal layer becomes infected. One or more surface nodules soon appear which caseate and lead to ulceration. </li></ul><ul><li>Later on there will be formation of granulation tissue and cellular swellings which is called pseudo-edema </li></ul>
  35. 35. Clinical features <ul><li>Weakness of voice with periods of aphonia </li></ul><ul><li>Hoarseness </li></ul><ul><li>Cough is a prominent symptom </li></ul><ul><li>Pain on swallowing in advanced lesions </li></ul><ul><li>Referred otalgia is common </li></ul><ul><li>Dyspnea and localized tenderness are rare symptoms unless perichondritis is present </li></ul>
  36. 36. Laryngeal appearances <ul><li>Slight impairment of adduction </li></ul><ul><li>Marked injection of one vocal cord may involve the whole cord or the posterior part of it </li></ul><ul><li>Ulceration of the edge of the cord (mouse-nibbled) </li></ul><ul><li>Granulations in the interarytenoid region or the vocal process of arytenoid cartilage </li></ul><ul><li>Oedema of the mucosa of the ventricle which mimics the prolapse </li></ul><ul><li>Perichondritis </li></ul><ul><li>Pseudo-edema of the epiglottis and arytenoids (turban larynx) of a pale sausage-like appearance, with occasional small bluish superficial ulcers </li></ul><ul><li>Vocal cord paralysis may occur from apical pulmonary disease .it affect right side more than left </li></ul>
  37. 37. Diagnosis <ul><li>Early manifestations need careful investigation </li></ul><ul><li>Chest x-ray must always be taken when there is persistent laryngeal symptoms </li></ul><ul><li>Sputum will usually contain tubercle bacilli </li></ul><ul><li>Biopsy is essential in any doubt laryngeal lesion especially ulcerative type </li></ul><ul><li>Treatment : </li></ul><ul><li>Is the treatment of the primary lung disease. </li></ul>
  38. 38. Chronic Specific Laryngitis Syphilitic laryngitis: <ul><li>Congenital </li></ul><ul><li>Acquired </li></ul>
  39. 39. Chronic Specific Laryngitis Syphilitic laryngitis: Congenital Syphilis: <ul><li>Rarely affect the larynx. Organism is the spirochaete Treponema pallidum </li></ul><ul><li>Early form : occur in the first few months of life, perichondritis is the main lesion. Acute laryngeal obstruction may be caused by the resulting edema. </li></ul><ul><li>Late form : occurs between the ages of 2 and 10 years. Mucosal hyperplasia with granulation is the commonest lesion. </li></ul>
  40. 40. Chronic Specific Laryngitis Syphilitic laryngitis: Acquired Lesions: <ul><li>Usually tertiary lesion affect the larynx. </li></ul><ul><li>Gumma: the commonest lesion and is most frequently seen on the epiglottis. </li></ul><ul><li>Diffuse infiltration without ulceration is common and affects any part or all of the larynx. </li></ul><ul><li>Ulceration occurs in one of two forms: </li></ul><ul><ul><li>Small superficial ulcer on the epiglottis or arytenoid (chancre). </li></ul></ul><ul><ul><li>Deep punched out ulcers usually on the epiglottis as the result of gumma . </li></ul></ul>
  41. 41. <ul><li>Perichondritis leads to edema and sequestration of the cartilage. </li></ul><ul><li>Scar tissue and adhesions which causes laryngeal stenosis. </li></ul><ul><li>Clinically the patient may suffer from hoarseness and dyspnea. Stridor also may follow. </li></ul><ul><li>Treatment: Systemic penicillin, tracheostomy may be needed. </li></ul>
  42. 42. Wegner’s granuloma <ul><li>It is a rare disease of the larynx affect the glottic and subglottic region . </li></ul><ul><li>It is due to periartritis and associated with lung and kidney changes . </li></ul><ul><li>It is associated with threatening asphyxia . </li></ul><ul><li>The antipolymorpholeucocytic antibody test is +ve. </li></ul>
  43. 43. Treatment <ul><li>1- Tracheostomy . </li></ul><ul><li>2- steroids and high dose of cyclophosphamide. </li></ul>
  44. 44. <ul><li>Thanks </li></ul>