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
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
14.
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
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
25.
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
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
