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

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The lecture has been given on Apr. 11th, 2011 by Dr. Hiwa.

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

  1. 1. Prepared by Dr . Hiwa As’ad
  2. 2. COMMON LARYNGEAL LESIONS <ul><li>PHONOTRAUMA </li></ul><ul><li>VOCAL CORD NODULES </li></ul><ul><li>VOCAL CORD POLYPS </li></ul><ul><li>REINKE’S EDEMA </li></ul><ul><li>LARYNGEAL CYSTS </li></ul><ul><li>PAPILLOMATOSIS </li></ul><ul><li>VOCAL PROCESS GRANULOMAS </li></ul>
  3. 3. Phonotrauma <ul><li>Pathogenesis </li></ul><ul><li>The majority of vocal cord nodules, polyps, and the condition known as Reinke edema arise as a result of repetitive trauma to the vocal cords, which is known as phonotrauma . </li></ul><ul><li>Aberrant regeneration of either the lamina propria or basement membrane following injury leads to the development of vocal cord pathology. </li></ul>
  4. 4. VOCAL CORD NODULES <ul><li>Essentials of Diagnosis </li></ul><ul><li>1-Usually affects children or individuals who use their voices professionally. &quot;singers' nodules.&quot; </li></ul><ul><li>2-History of voice abuse common, such as frequent shouting in a young child. </li></ul><ul><li>3-people with vocal nodules often present with restricted pitch range& voice breaks </li></ul>
  5. 5. Clinical Findings <ul><li>Indirect laryngoscopy or flexible nasolaryngoscopy clearly shows the presence of small, well-defined vocal cord lesions. </li></ul><ul><li>These lesions are distinguishable from the normal vocal fold by their whitish hue, are generally bilateral, and are most commonly found at the junction of the anterior one third and posterior two thirds of the vocal fold. </li></ul>
  6. 6. Treatment <ul><li>SPEECH THERAPY </li></ul><ul><li>Speech therapy should be utilized as a first-line treatment. It is the mainstay of treatment in both children and adults. Photodocumentation of the nodules in voice clinic indicates the treatment progress and aids patient compliance during speech therapy. </li></ul><ul><li>MICROLARYNGOSCOPY </li></ul><ul><li>Microlaryngoscopy should be performed under the following circumstances: </li></ul><ul><li>the diagnosis is suspected in a child, but the age or noncompliance of the patient prevents examination; </li></ul><ul><li>(2) in adults, either when microsurgical excision of the nodules is considered or if the diagnosis is not clear. </li></ul>
  7. 7. SURGICAL EXCISION <ul><li>Formal excision of the nodules may be performed using appropriate microsurgical instruments, but other techniques, such as laser vaporization of the nodules using a pulsed CO 2 laser, may also be suitable. </li></ul><ul><li>The general principle of phonosurgery is to perform as limited a dissection as possible and under no account to dissect deep to the Reinke space. </li></ul>
  8. 8. VOCAL CORD POLYPS <ul><li>Essentials of Diagnosis </li></ul><ul><li>Usually unilateral, pedunculated lesions. </li></ul><ul><li>Occurring in the young to the middle aged group. </li></ul><ul><li>Located throughout the glottis, particularly between the anterior and middle thirds of the vocal folds. </li></ul><ul><li>Vocal cord polyps are most commonly found in men with a history of voice abuse and heavy smoking. </li></ul><ul><li>The treatment is most often surgical to confirm the diagnosis, exclude any coexisting malignant neoplasms, and provide resolution; conservative voice therapy is often not successful. </li></ul>
  9. 9. Clinical Findings <ul><li>Polyps are often pedunculated, unilateral lesions that are morphologically similar to the laryngeal epithelium. </li></ul><ul><li>They often occur on the true vocal folds and may have noticeable vascular markings. </li></ul>
  10. 10. Treatment <ul><li>The treatment involves a microlaryngoscopic examination of the larynx plus excision of the polyp both to confirm the diagnosis and exclude any other coexistent pathology. </li></ul><ul><li>A large polyp may conceal an occult, early laryngeal squamous cell carcinoma. </li></ul><ul><li>Excision is often performed using appropriate microsurgical instruments, but the vocal cord polyp can be removed using laser. </li></ul><ul><li>Patients can prevent recurrence by avoiding the risk factors for disease, including smoking and vocal abuse. </li></ul>
  11. 11. REINKE EDEMA <ul><li>Essentials of Diagnosis </li></ul><ul><li>Strong association with cigarette smoking and heavy voice use. </li></ul><ul><li>Occurring usually in the middle aged women </li></ul><ul><li>Diffuse polypoid changes of the vocal cords. </li></ul><ul><li>Usually bilateral. </li></ul><ul><li>There is little to distinguish this disorder morphologically and histologically from vocal cord polyps. </li></ul><ul><li>However, the diffuse nature of the swelling, which is an accumulation of fluid in the superficial layer of the lamina propria along the length of the vocal fold, is characteristic. </li></ul>
  12. 12. Clinical Findings <ul><li>Patients present with diffuse, sausage-shaped swelling of the vocal cords, which is usually bilateral. </li></ul><ul><li>On manipulation of the cords during microlaryngoscopy, they feel boggy and the swelling can be rolled beneath the instruments. </li></ul>
  13. 13. Treatment <ul><li>Smoking cessation is the key to resolving Reinke edema. </li></ul><ul><li>In mild cases, speech therapy may also prevent the need for surgical treatment. </li></ul><ul><li>In sever cases treatment is surgery </li></ul>
  14. 14. LARYNGEAL CYSTS <ul><li>General Considerations </li></ul><ul><li>Cysts may occur throughout the larynx and may even be associated with similar lesions in the base of the tongue, vallecula, and oropharynx. </li></ul><ul><li>Dysphonia may not be the primary presenting symptom, particularly if the cysts are predominately supraglottic. </li></ul><ul><li>Dysphagia associated with a feeling either of discomfort or something lodged in the throat may be the primary feature. </li></ul><ul><li>Laryngeal cysts are either mucus-retention or epidermoid cysts . </li></ul><ul><li>Mucus-retention cysts often arise in the supraglottis, where the mucus-secreting glands are most abundant. </li></ul><ul><li>Embryonic cysts of the larynx can occur and may present in the newborn or adult. </li></ul>
  15. 15. Clinical Findings <ul><li>Laryngeal cysts vary in size from a few millimeters to several centimeters. In rare cases, laryngeal cysts are pedunculated and have an orange hue with small vessels obvious within their walls. </li></ul><ul><li>They may be single or multiple and on aspiration are found to contain viscous fluid. </li></ul><ul><li>A cyst is usually unilateral, although there may be a corresponding abnormal area on the opposite vocal cord. </li></ul><ul><li>This anomaly may appear as a depression. </li></ul><ul><li>Speech therapy will fail to correct the dysphonia. </li></ul>
  16. 16. Treatment <ul><li>An endoscopic examination of the larynx and pharynx is appropriate, using a microscope where necessary both for confirmation of the diagnosis and treatment with excision biopsy of the cyst. </li></ul>
  17. 17. PAPILLOMATOSIS <ul><li>Essentials of Diagnosis </li></ul><ul><li>Patient age at onset is usually 2–4 years. </li></ul><ul><li>Rare after the age of 30. </li></ul><ul><li>Multiple warty lesions of &quot;true&quot; and &quot;false&quot; vocal cords. </li></ul><ul><li>Although there is no curative treatment, spontaneous remission has been noted. </li></ul>
  18. 18. Pathogenesis <ul><li>Papillomas are papillary projections and hyper-vascular connective tissue covered with hyper-plastic squamous epithelium. </li></ul><ul><li>Studies have implicated the human papilloma virus (HPV6 and 11) in the pathogenesis of papillomatosis. HPV is a DNA virus that infects the cells of the mucosa of the larynx, resulting in benign epithelial proliferation. </li></ul><ul><li>These subtypes are also responsible for 90% of genital warts. </li></ul>
  19. 19. Clinical Findings <ul><li>Papillomatosis typically appears as multiple, friable, irregular warty growths in the larynx. </li></ul><ul><li>These lesions particularly affect the &quot;true&quot; and &quot;false&quot; vocal cords, but they are also found in other parts of the larynx and upper aerodigestive tract. </li></ul><ul><li>Patients typically present with dysphonia, but they can also have stridor and may complain of a cough, dyspnea, and dysphagia. </li></ul>
  20. 20. Treatment <ul><li>Although an overall cure of this disorder is usually not achieved, the aim of treatment is two fold: </li></ul><ul><li>(1) to permit the patient, often a child, to develop a satisfactory voice; and </li></ul><ul><li>(2) to preserve the structure and function of the vocal cords and avoid tracheostomy . </li></ul><ul><li>These treatment goals can best be achieved with the use of the CO 2 laser, which can vaporize the lesions while minimizing both damage to and scarring of the vocal cords. </li></ul><ul><li>Surgical techniques include injecting (Normal Saline+ Adrenalin) hydro-dissection & excising the mucosa en-bloc this giving lower recurrence rate although damaging the archetecture </li></ul>
  21. 21. Prognosis <ul><li>Spontaneous remission does occur, but a recurrence can arise many years later. </li></ul><ul><li>There is a small but definite risk of malignant change (2%), which is usually associated with more invasive papillomatosis, with seeding in the tracheobronchial tree. </li></ul>
  22. 22. VOCAL PROCESS GRANULOMAS <ul><li>Essentials of Diagnosis </li></ul><ul><li>Arise posteriorly </li></ul><ul><li>History of trauma to the larynx, usually intubation. </li></ul><ul><li>General Considerations </li></ul><ul><li>Vocal process granulomas mainly affect men and are associated with gastroesophageal reflux. </li></ul>
  23. 23. <ul><li>Clinical Findings </li></ul><ul><li>Patients present with dysphonia and a combination of other symptoms, including odynophagia, cough, and globus symptoms. </li></ul><ul><li>These lesions are either unilateral or bilateral and are related to the vocal processes of arytenoid cartilages. When there is no history of definite trauma, stroboscopic examination may show collision of the cartilages. </li></ul><ul><li>Treatment </li></ul><ul><li>The focus of treatment should be on conservative voice therapy. Diagnostic and therapeutic laryngoscopy can confirm the diagnosis and exclude any malignant neoplasm. </li></ul>

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