congenital laryngomalacia

CongenitalCongenital
laryngomalacialaryngomalacia
先天性喉软化症先天性喉软化症
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CauseCause
 Congenital laryngeal stridor is a defectCongenital laryngeal stridor is a defect
that is present at birth. During fetalthat is present at birth. During fetal
development, the structures in the larynxdevelopment, the structures in the larynx
may not fully develop.may not fully develop.

CauseCause
 As a result, there is a weakness in theseAs a result, there is a weakness in these
structures at birth, causing them tostructures at birth, causing them to
collapse during breathing. In children,collapse during breathing. In children,
congenital laryngeal stridor is the mostcongenital laryngeal stridor is the most
common cause of chronic stridor. Sixtycommon cause of chronic stridor. Sixty
percent of infants born with congenitalpercent of infants born with congenital
laryngeal stridor will have symptoms in thelaryngeal stridor will have symptoms in the
first week of life. Most other infants willfirst week of life. Most other infants will
show symptoms by 5 weeks old.show symptoms by 5 weeks old.

symptomssymptoms
 The major symptom of this disorder is the stridorThe major symptom of this disorder is the stridor
that is heard as the infant breathes. The stridorthat is heard as the infant breathes. The stridor
is usually heard when the infant breathes inis usually heard when the infant breathes in
(inspiration), but can also be heard when the(inspiration), but can also be heard when the
infant breathes out (expiration). Otherinfant breathes out (expiration). Other
characteristics of the stridor may include:characteristics of the stridor may include:
 The stridor changes with activity.The stridor changes with activity.
 The stridor is usually less noisy when the child isThe stridor is usually less noisy when the child is
laying on his/her stomach.laying on his/her stomach.
 The stridor gets worse if the infant has an upperThe stridor gets worse if the infant has an upper
respiratory infection.respiratory infection.

diagnosediagnose
 a complete medical historya complete medical history
 and physical examinationand physical examination
 bronchoscopy of the airways - a procedurebronchoscopy of the airways - a procedure
which involves a tube being passed intowhich involves a tube being passed into
the airways to allow your child's physicianthe airways to allow your child's physician
to observe the airways during breathing.to observe the airways during breathing.

Treatment for congenitalTreatment for congenital
laryngomalacialaryngomalacia
Follow upFollow up
In most cases, congenital laryngeal stridor is a harmlessIn most cases, congenital laryngeal stridor is a harmless
condition that resolves on its own, without medicalcondition that resolves on its own, without medical
intervention. The condition usually improves by the timeintervention. The condition usually improves by the time
the infant is 18 months old and has no long-termthe infant is 18 months old and has no long-term
complications. In some cases, the stridor is apparentcomplications. In some cases, the stridor is apparent
until about the age of 5. Each child's case is unique.until about the age of 5. Each child's case is unique.
SurgerySurgery
A small percentage develop severe respiratory problemsA small percentage develop severe respiratory problems
which require medical and surgical interventions.which require medical and surgical interventions.

Acute laryngitisAcute laryngitis
急性喉炎急性喉炎
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 Laryngitis is an inflammation of the vocalLaryngitis is an inflammation of the vocal
cords causing speech to become hoarsecords causing speech to become hoarse
and/or whisperlike, and often inaudible.and/or whisperlike, and often inaudible.

CauseCause
 Viruses -- Influenza A and B, Adenovirus, Parainfluenza, andViruses -- Influenza A and B, Adenovirus, Parainfluenza, and
Rhinovirus are some of the viruses that may cause this condition.Rhinovirus are some of the viruses that may cause this condition.
 Bacteria such as Hemophilus influenzae, beta-hemolyticBacteria such as Hemophilus influenzae, beta-hemolytic
streptococcus, andstreptococcus, and
Moraxella catarrhalisMoraxella catarrhalis
 Inhalation of smoke, chemicals, and excessive use of voiceInhalation of smoke, chemicals, and excessive use of voice
 AcidAcid RefluxReflux
 AllergiesAllergies
 AgingAging

symptomssymptoms
 HoarsenessHoarseness
 Whisperlike voiceWhisperlike voice
 loss of voiceloss of voice

Bacterial laryngitis:Bacterial laryngitis:
 Sore throatSore throat
 FeverFever
 Painful swallowingPainful swallowing
 CoughCough

Viral laryngitisViral laryngitis
 General fatigueGeneral fatigue
 MalaiseMalaise
 Low-grade feverLow-grade fever
 General body achesGeneral body aches
 CoughCough
 Dry throatDry throat

allergic laryngitisallergic laryngitis
 Hoarseness that is worse during and severalHoarseness that is worse during and several
hours after exposure to the allergenhours after exposure to the allergen
 Itchy throatItchy throat
 Excess phlegm or mucous in the throatExcess phlegm or mucous in the throat
 Feeling of dry throatFeeling of dry throat
 CoughCough
 Itchy sensation in the throatItchy sensation in the throat
 SneezingSneezing

diagnosediagnose
 Throat check for pharyngitis (infection)Throat check for pharyngitis (infection)
 Neck checked for stridor (wheezing soundNeck checked for stridor (wheezing sound
heard by stethoscope)heard by stethoscope)

TreatmentTreatment
 Avoid loud speech, such as shouting or singingAvoid loud speech, such as shouting or singing
 Humidifiers (cool mist better) and steam (cool to warm, not hot) can help.Humidifiers (cool mist better) and steam (cool to warm, not hot) can help.
 Avoid smoking, recreational drugs, and alcoholAvoid smoking, recreational drugs, and alcohol
 Increase fluidsIncrease fluids
 If severe, physicians will often instruct a person not to speak at all for theIf severe, physicians will often instruct a person not to speak at all for the
next few days.next few days.
 If Hemophilus influenza or Moxarella catarrhalis are suspected, antibioticsIf Hemophilus influenza or Moxarella catarrhalis are suspected, antibiotics
will most likely be prescribed.will most likely be prescribed.
 Symptoms usually resolve in fewer than seven days in most individuals.Symptoms usually resolve in fewer than seven days in most individuals.

TreatmentTreatment
 If severe, physicians will often instruct a personIf severe, physicians will often instruct a person
not to speak at all for the next few days.not to speak at all for the next few days.
 If Hemophilus influenza or Moxarella catarrhalisIf Hemophilus influenza or Moxarella catarrhalis
are suspected, antibiotics will most likely beare suspected, antibiotics will most likely be
prescribed.prescribed.
 Symptoms usually resolve in fewer than sevenSymptoms usually resolve in fewer than seven
days in most individuals.days in most individuals.

Chorinic laryngitisChorinic laryngitis
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DefinationDefination
 Laryngitis is an inflammation of the larynx, theLaryngitis is an inflammation of the larynx, the
"voice box" that contains the vocal cords in the"voice box" that contains the vocal cords in the
upper portion of the neck. Laryngitis occurs inupper portion of the neck. Laryngitis occurs in
two forms, acute and chronic. Acute laryngitistwo forms, acute and chronic. Acute laryngitis
typically is a brief illness producing hoarsenesstypically is a brief illness producing hoarseness
and a sore throat. In most cases, an upperand a sore throat. In most cases, an upper
respiratory tract infection causes it. Chronicrespiratory tract infection causes it. Chronic
laryngitis is a more persistent disorder thatlaryngitis is a more persistent disorder that
produces lingering hoarseness and other voiceproduces lingering hoarseness and other voice
changes. It usually is painless and has nochanges. It usually is painless and has no
significant sign of infection.significant sign of infection.

CauseCause
 Cigarette smoke is chronically irritatingCigarette smoke is chronically irritating
to the laryngeal mucosa. At theto the laryngeal mucosa. At the
extreme, it can provoke cancer.extreme, it can provoke cancer.
 Ethanol contains many impurities, suchEthanol contains many impurities, such
as mycotoxins, tannins, aldehydes, andas mycotoxins, tannins, aldehydes, and
pesticides, which may cause cancer,pesticides, which may cause cancer,
either by direct contact with theeither by direct contact with the
mucosa or through a systemic effect,mucosa or through a systemic effect,
or may act as an irritant.or may act as an irritant.

 Gastroesophageal reflux diseaseGastroesophageal reflux disease
 InfectionsInfections
 The bacterium most commonly isolated in chronicThe bacterium most commonly isolated in chronic
infectious laryngitis isinfectious laryngitis is Staphylococcus aureus.Staphylococcus aureus.
Haemophilus influenzaeHaemophilus influenzae and pneumococcal speciesand pneumococcal species
may complicate the course of viral laryngitis.may complicate the course of viral laryngitis.
 Tuberculosis, caused by infection with the tubercleTuberculosis, caused by infection with the tubercle
bacillusbacillus Mycobacterium tuberculosis hominis,Mycobacterium tuberculosis hominis, was awas a
common disease of the larynx. Overall incidence hascommon disease of the larynx. Overall incidence has
declined. The hematogenous route and the infecteddeclined. The hematogenous route and the infected
sputum from pulmonary tuberculosis are the mostsputum from pulmonary tuberculosis are the most
likely sources of infection.likely sources of infection.

 Voice abuse can be pertinent to professionalVoice abuse can be pertinent to professional
singers and to occasional shouters. Lesionssingers and to occasional shouters. Lesions
can range from simple edema, in thecan range from simple edema, in the
occasional abuser, to hyperplastic reactionsoccasional abuser, to hyperplastic reactions
if the stimuli persist over time.if the stimuli persist over time.
 Allergic responses of immediate or delayedAllergic responses of immediate or delayed
hypersensitivity types can cause chronichypersensitivity types can cause chronic
laryngitis. Although the authors found nolaryngitis. Although the authors found no
data quantifying the exact number of peopledata quantifying the exact number of people
affected, current thought seems to indicateaffected, current thought seems to indicate
an increasing prevalence.an increasing prevalence.

 Environmental factors, such as dust,Environmental factors, such as dust,
fumes, chemicals, and toxins, canfumes, chemicals, and toxins, can
cause this condition.cause this condition.
 Systemic diseases, mostlySystemic diseases, mostly
autoimmune, may cause chronicautoimmune, may cause chronic
laryngitis.laryngitis.
 Wegener granulomatosis.Wegener granulomatosis.
 Amyloidosis.Amyloidosis.
 Relapsing polychondritis.Relapsing polychondritis.

 Chronic laryngitis may be associated withChronic laryngitis may be associated with
cutaneous diseases.cutaneous diseases. The larynx and theThe larynx and the
skin share similar microcharacteristicsskin share similar microcharacteristics
and macrocharacteristics.and macrocharacteristics.

 Neurologic causes may contribute to chronic laryngitis.Neurologic causes may contribute to chronic laryngitis.
 Spastic dysphonia is a discrete vocal disorder characterized bySpastic dysphonia is a discrete vocal disorder characterized by
strained, choked vocal attacks (laryngeal stuttering). The onsetstrained, choked vocal attacks (laryngeal stuttering). The onset
usually follows a stressful period in middle life. This conditionusually follows a stressful period in middle life. This condition
is probably a vocal expression of psychoneurotic behavior or ais probably a vocal expression of psychoneurotic behavior or a
CNS and/or proprioceptive disorder of the larynx.CNS and/or proprioceptive disorder of the larynx.
 Vocal folds atrophy and lose tension with age, causingVocal folds atrophy and lose tension with age, causing
changes in phonation. Loss of thyroarytenoid ligamentchanges in phonation. Loss of thyroarytenoid ligament
elasticity results in breathiness and loss of breath supportelasticity results in breathiness and loss of breath support
because of bowed vocal folds.because of bowed vocal folds.
 Muscular disorders may contribute to chronic laryngitis.Muscular disorders may contribute to chronic laryngitis.
Weakness of the larynx and the pharynx is present in one thirdWeakness of the larynx and the pharynx is present in one third
of patients with myasthenia gravis.of patients with myasthenia gravis.

symptomssymptoms
 Weak or absent voiceWeak or absent voice
 Sensation of a lump in the throat orSensation of a lump in the throat or
constant need to clear the throatconstant need to clear the throat
 Dry coughDry cough
 FeverFever

diagnosediagnose
 Diagnosis is based upon a combination ofDiagnosis is based upon a combination of
the clinical history and a physical exam.the clinical history and a physical exam.
Some physicians might wish to do aSome physicians might wish to do a
laryngoscopy (visualization of the vocallaryngoscopy (visualization of the vocal
cords).cords).

TreatmentTreatment
 IfIf laryngitislaryngitis is caused by a bacterial infection, antibioticsis caused by a bacterial infection, antibiotics
will be prescribed.will be prescribed.
 Some palliative measures that can be taken include:Some palliative measures that can be taken include:
 Avoid public speaking during recoveryAvoid public speaking during recovery
 Be aware that whispering puts greater strain on theBe aware that whispering puts greater strain on the
vocal cords than normal speakingvocal cords than normal speaking
 Inhale steam from a bowl of hot water or from a warmInhale steam from a bowl of hot water or from a warm
showershower
 Drink warm, soothing liquids (but do not drinkDrink warm, soothing liquids (but do not drink
alcoholic beverages)alcoholic beverages)
 Try a cool-mist humidifier; avoid air conditioningTry a cool-mist humidifier; avoid air conditioning
 Use throat lozenges to ease the discomfortUse throat lozenges to ease the discomfort
 Avoid cigarettes until the symptoms have subsidedAvoid cigarettes until the symptoms have subsided

Vocal Cord DisordersVocal Cord Disorders
vocal nodulesvocal nodules
vocal polypsvocal polyps
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 Vocal cord disorders are often caused byVocal cord disorders are often caused by
vocal abuse or misuse, such as excessivevocal abuse or misuse, such as excessive
use of the voice when singing, talking,use of the voice when singing, talking,
smoking, coughing, yelling, or inhalingsmoking, coughing, yelling, or inhaling
irritants. Some of the more common vocalirritants. Some of the more common vocal
cord disorders include laryngitis, vocalcord disorders include laryngitis, vocal
nodules, vocal polyps, and vocal cordnodules, vocal polyps, and vocal cord
paralysis.paralysis.

vocal nodulesvocal nodules ANDAND vocal polypsvocal polyps
 Vocal nodulesVocal nodules are benign (non-cancerous)are benign (non-cancerous)
growths on the vocal cords caused by vocalgrowths on the vocal cords caused by vocal
abuse. Vocal nodules are a frequent problem forabuse. Vocal nodules are a frequent problem for
professional singers. The nodules are small andprofessional singers. The nodules are small and
callous-like and usually grow in pairs (one oncallous-like and usually grow in pairs (one on
each cord). The nodules usually form on areaseach cord). The nodules usually form on areas
of the vocal cords that receive the most pressureof the vocal cords that receive the most pressure
when the cords come together and vibratewhen the cords come together and vibrate
(similar to the formation of a callous). Voice(similar to the formation of a callous). Voice
nodules cause the voice to be hoarse, low, andnodules cause the voice to be hoarse, low, and
breathy.breathy.

vocal nodulesvocal nodules ANDAND vocalvocal
polypspolyps
 A vocal polypA vocal polyp is a soft, benign (non-cancerous)is a soft, benign (non-cancerous)
growth, similar to a blister. A polyp usually growsgrowth, similar to a blister. A polyp usually grows
alone on one vocal cord and is often caused byalone on one vocal cord and is often caused by
long-term cigarette smoking. Other causes oflong-term cigarette smoking. Other causes of
vocal polyps include hypothyroidismvocal polyps include hypothyroidism
(underactive thyroid gland), gastroesophageal(underactive thyroid gland), gastroesophageal
reflux, and continuous voice misuse. Voicereflux, and continuous voice misuse. Voice
polyps cause the voice to be hoarse, low, andpolyps cause the voice to be hoarse, low, and
breathy. Vocal polyps are also called Reinke'sbreathy. Vocal polyps are also called Reinke's
edemas or polypoid degeneration.edemas or polypoid degeneration.

CAUSESCAUSES
 vocal trauma (more specifically,vocal trauma (more specifically,
phonotrauma in the case of vocal foldphonotrauma in the case of vocal fold
polyps and vocal fold nodules)polyps and vocal fold nodules)

symptomssymptoms
 a voice change. Typical presentinga voice change. Typical presenting
symptoms include generalized andsymptoms include generalized and
persistent hoarseness, change in voicepersistent hoarseness, change in voice
quality, and increased effort in producingquality, and increased effort in producing
the voice. The laryngeal examination maythe voice. The laryngeal examination may
show either unilateral or bilateral lesions.show either unilateral or bilateral lesions.

diagnosediagnose
 Any hoarseness or change in voice that lastsAny hoarseness or change in voice that lasts
longer than two weeks should be brought to thelonger than two weeks should be brought to the
attention of your physician. (Sometimes theattention of your physician. (Sometimes the
hoarseness may be indicative of laryngealhoarseness may be indicative of laryngeal
cancer.)cancer.)
 a complete medical history and physicala complete medical history and physical
examinationexamination
 examine the vocal cords internally with a small,examine the vocal cords internally with a small,
long-handled mirror (indirect laryngoscopy) orlong-handled mirror (indirect laryngoscopy) or
laryngoscopylaryngoscopy

TreatmentTreatment
 eliminating the behavior that caused theeliminating the behavior that caused the
vocal cord disordervocal cord disorder
 a referral to a speech-languagea referral to a speech-language
pathologist who has specialized training inpathologist who has specialized training in
treating voice, speech, language, ortreating voice, speech, language, or
swallowing disorders that affectswallowing disorders that affect
communicationcommunication
 medicationmedication
 surgery to remove growthssurgery to remove growths

Acute laryngitis inAcute laryngitis in
childrenchildren
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CauseCause
 Laryngitis is a group of disorders in whichLaryngitis is a group of disorders in which
the inflammatory process covers thethe inflammatory process covers the
mucous membrane of all or particularmucous membrane of all or particular
levels of the larynx.levels of the larynx.
 These disorders have a different course inThese disorders have a different course in
children under 4 years old than in childrenchildren under 4 years old than in children
above 4 years old.above 4 years old.
 WHY?WHY?

specific variations of the structure ofspecific variations of the structure of
the larynx in children under 4 yearsthe larynx in children under 4 years
old AND above 4 years oldold AND above 4 years old
 The larynx of a small child is located higher,The larynx of a small child is located higher,
and the mucous is thicker and contains aand the mucous is thicker and contains a
large amount of soft tissue. This soft tissue islarge amount of soft tissue. This soft tissue is
mainly located under the mucous of themainly located under the mucous of the
aryepiglottic folds, and especially in thearyepiglottic folds, and especially in the
subglottic region.subglottic region.

 The specific reactivity of the mucousThe specific reactivity of the mucous
membrane in small children makes themmembrane in small children makes them
prone to infections, especially viral. Some ofprone to infections, especially viral. Some of
these infections may cause oedema of thethese infections may cause oedema of the
mucus. The respiratory tract in children ismucus. The respiratory tract in children is
relatively narrow in this region and therelatively narrow in this region and the
chondrous ring limits the size of the subglotticchondrous ring limits the size of the subglottic
region. So, oedema in this region may have aregion. So, oedema in this region may have a
dramatic course, leading even to acutedramatic course, leading even to acute
respiratory distressrespiratory distress

CauseCause
 viral infectionviral infection
 parainfluenza virusparainfluenza virus
 influenza virusinfluenza virus
 rubella virus and varicella-zoster virusrubella virus and varicella-zoster virus

symptomssymptoms
 dyspnoea,dyspnoea,
 inspiratory stridor,inspiratory stridor,
 hoarsenesshoarseness
 characteristic barking coughcharacteristic barking cough

diagnosediagnose
 general examinationsgeneral examinations
 laryngological examinationslaryngological examinations
 direct visualization of the larynxdirect visualization of the larynx
endoscopy, fiberoscopy and laryngoscopyendoscopy, fiberoscopy and laryngoscopy

Differential diagnosisDifferential diagnosis
 Foreign body of the larynx :Foreign body of the larynx :
The most general symptoms of laryngitis occur alsoThe most general symptoms of laryngitis occur also
in other disorders of the larynx which occur within other disorders of the larynx which occur with
dyspnoea like the foreign body of the larynx. So thedyspnoea like the foreign body of the larynx. So the
precise diagnosis is a good base for planning of furtherprecise diagnosis is a good base for planning of further
treatment.treatment.
 Congenital defect of the larynx:Congenital defect of the larynx:
When the symptoms of laryngitis occur at under 6When the symptoms of laryngitis occur at under 6
months of age or are prolonged or recurrent, amonths of age or are prolonged or recurrent, a
congenital defect of the larynx should be suspected, i.e.congenital defect of the larynx should be suspected, i.e.
laryngeal web or haemangioma of the larynx. In theselaryngeal web or haemangioma of the larynx. In these
cases direct examination of the larynx is an urgentcases direct examination of the larynx is an urgent
necessity, because the treatment of these disordersnecessity, because the treatment of these disorders
varies.varies.

TreatmentTreatment
 HospitaliseHospitalise
 systemic anti-inflammatory drugs,systemic anti-inflammatory drugs,
 humidification and cooling the air in the room.humidification and cooling the air in the room.
 hydrocortisone in high dose (10 mg per kg b. w.), preferably i.v., mayhydrocortisone in high dose (10 mg per kg b. w.), preferably i.v., may
be necessary.be necessary.
 Intubation:Only intubation is a good method which protects the childIntubation:Only intubation is a good method which protects the child
from asphyxiation.from asphyxiation.
 Formerly, tracheotomy was performed, but now it is not oftenFormerly, tracheotomy was performed, but now it is not often
performed in this disease.performed in this disease.
 Antibiotics are administrated in those patients in whom bacterialAntibiotics are administrated in those patients in whom bacterial
complications develop. It should be underlined that the antibioticscomplications develop. It should be underlined that the antibiotics
given for uncomplicated laryngitis in small children do not bringgiven for uncomplicated laryngitis in small children do not bring
improvement, so should be avoided.improvement, so should be avoided.
 In patients older than 4 years of age etiologic factors may beIn patients older than 4 years of age etiologic factors may be
different e.g. allergy. In these cases administration of anti-histaminicdifferent e.g. allergy. In these cases administration of anti-histaminic
drugs and calcium may be suitable.drugs and calcium may be suitable.

Acute epiglottitisAcute epiglottitis
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DefinitionDefinition
 A very rapidly progressive infectionA very rapidly progressive infection
causing inflammation of the epiglottis (thecausing inflammation of the epiglottis (the
flap that covers the trachea) and tissuesflap that covers the trachea) and tissues
around the epiglottis that may lead toaround the epiglottis that may lead to
abrupt blockage of the upper airway andabrupt blockage of the upper airway and
death.death.

CauseCause
 Infection:Infection:
H influenzaeH influenzae
Haemophilus parainfluenzaeHaemophilus parainfluenzae
Streptococcus pneumoniae,Streptococcus pneumoniae, and group A streptococci.and group A streptococci.
Less common infectious bacteria (eg,Less common infectious bacteria (eg, StaphylococcusStaphylococcus
aureus,aureus, mycobacteria,mycobacteria, Bacteroides melaninogenicus,Bacteroides melaninogenicus,
Enterobacter cloacae, Escherichia coli,Enterobacter cloacae, Escherichia coli,
Fusobacterium necrophorum, KlebsiellaFusobacterium necrophorum, Klebsiella
pneumoniae, Neisseria meningitidis, Pasteurellapneumoniae, Neisseria meningitidis, Pasteurella
multocidamultocida),),
herpes simplex virus (HSV), other viruses, infectiousherpes simplex virus (HSV), other viruses, infectious
mononucleosis,mononucleosis, CandidaCandida (in immunocompromised(in immunocompromised
patients), andpatients), and AspergillusAspergillus (in immunocompromised(in immunocompromised
patients).patients).

 Noninfectious factors:Noninfectious factors:
thermal causesthermal causes
crack cocaine smokingcrack cocaine smoking
marijuana smokingmarijuana smoking
throat burns affecting the epiglottis of bottle-fed infants)throat burns affecting the epiglottis of bottle-fed infants)
caustic insults (eg, automatic dishwasher soap ingestion)caustic insults (eg, automatic dishwasher soap ingestion)
foreign body ingestionforeign body ingestion
head and neck chemotherapy.head and neck chemotherapy.
Before widespread Hib vaccination,Before widespread Hib vaccination, H influenzaeH influenzae caused almostcaused almost
all pediatric cases.all pediatric cases.
AllergyAllergy

symptomssymptoms
 Sore throat (95%)Sore throat (95%)
 Odynophagia/dysphagia (95%)Odynophagia/dysphagia (95%)
 Muffled voice (54%)Muffled voice (54%)
 Usually, no prodromal symptoms occurUsually, no prodromal symptoms occur
in children. Adults may have precedingin children. Adults may have preceding
upper respiratory infection (URI)upper respiratory infection (URI)
symptoms.symptoms.

General symptomsGeneral symptoms
 FeverFever
 Drooling/inability to handle secretionsDrooling/inability to handle secretions
 Cervical adenopathyCervical adenopathy
 Stridor - A late finding indicating advanced airway obstructionStridor - A late finding indicating advanced airway obstruction
 Muffled voice (54%)Muffled voice (54%)
 Tripod position - Sitting up on hands with the tongue out and the headTripod position - Sitting up on hands with the tongue out and the head
forwardforward
 HypoxiaHypoxia
 Respiratory distressRespiratory distress
 Severe pain on gentle palpation over the larynxSevere pain on gentle palpation over the larynx
 Mild coughMild cough
 FeverFever
 IrritabilityIrritability
 TachycardiaTachycardia
 Toxic appearance of patientToxic appearance of patient

diagnosediagnose
 Differential DiagnosesDifferential Diagnoses
 Peritonsillar AbscessPeritonsillar Abscess
Retropharyngeal AbscessRetropharyngeal Abscess
Toxicity, Caustic IngestionsToxicity, Caustic Ingestions
 Other Problems to Be ConsideredOther Problems to Be Considered
 Airway obstructionAirway obstruction
Foreign body aspirationForeign body aspiration
Bacterial laryngotracheobronchitisBacterial laryngotracheobronchitis
LaryngotracheobronchopneumonitisLaryngotracheobronchopneumonitis
Retropharyngeal abscessRetropharyngeal abscess
Peritonsillar abscessPeritonsillar abscess
LaryngitisLaryngitis
Laryngeal diphtheriaLaryngeal diphtheria
Caustic ingestionsCaustic ingestions
Acute angioedemaAcute angioedema
SepsisSepsis

TreatmentTreatment
 AntibioticsAntibiotics
 AntivirusAntivirus
 hydrocortisonehydrocortisone
 adequate airwayadequate airway
nasotracheal intubationnasotracheal intubation
intubationintubation
tracheostomytracheostomy
Skilled nursing care.Skilled nursing care.

Papilloma of larynxPapilloma of larynx
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CauseCause
 Most common benign tumor of the larynxMost common benign tumor of the larynx
and occurs in patients of all age.and occurs in patients of all age.
 The causative agent is thought to be HPV.The causative agent is thought to be HPV.
 Papillomas usually regress during puberty.Papillomas usually regress during puberty.

CauseCause
 Usually involving the true vocal cords butUsually involving the true vocal cords but
may affect supraglottic and subglotticmay affect supraglottic and subglottic
regions.regions.
 May also involve the trachea andMay also involve the trachea and
bronchus.bronchus.

CauseCause
 Papillomas in juveniles is more oftenPapillomas in juveniles is more often
multiple and recurs more frequently thanmultiple and recurs more frequently than
in adults.in adults.
 Papillomas in adults are usually single butPapillomas in adults are usually single but
may undergo malignant change (may undergo malignant change (HPV 16HPV 16 ，，
1818).).

symptomssymptoms
 Aphonia or weak cry is usually the firstAphonia or weak cry is usually the first
sign in infants.sign in infants.
 Dyspnea and stridor are seen.Dyspnea and stridor are seen.
 Hoarseness is the most commonHoarseness is the most common
symptom in adults.symptom in adults.

diagnosediagnose
 Laryngoscopic examinationLaryngoscopic examination ：：
 the tumor is pink or dark red in color. Thethe tumor is pink or dark red in color. The
surface of the tumor is rough andsurface of the tumor is rough and
papillary. The tumor is located in VC, falsepapillary. The tumor is located in VC, false
VC or subglottic area.VC or subglottic area.

TreatmentTreatment
 ⑴⑴ excision under microlaryngoscopy is the mostexcision under microlaryngoscopy is the most
commonly employed treatment modality.commonly employed treatment modality.
 Repeated operations are usually needed inRepeated operations are usually needed in
children.children.
 Co2 laser is favored because of its hemostaticCo2 laser is favored because of its hemostatic
properties and its precision allows forproperties and its precision allows for
vaporization of the lesion.vaporization of the lesion.

TreatmentTreatment
 ⑵⑵ Tracheotomy is occasionally indicatedTracheotomy is occasionally indicated
in children with dyspnea, but should bein children with dyspnea, but should be
avoided due to concern about subglotticavoided due to concern about subglottic
spread.spread.

TreatmentTreatment
 ⑶⑶ transfer factor, interferon andtransfer factor, interferon and
antivirotics.antivirotics. Cidofovir , a new antiviral agentCidofovir , a new antiviral agent
approved for ocular cytomegalovirus infections,approved for ocular cytomegalovirus infections,
has shown promise as a local injection inhas shown promise as a local injection in
adjuvant therapy.adjuvant therapy.
 ⑷⑷ Autogenous vaccine.Autogenous vaccine.

Carcinoma of the larynxCarcinoma of the larynx
Dong pinDong pin

EpidemiologyEpidemiology
 Accounts for 1% of all new cancers diagnosed in theAccounts for 1% of all new cancers diagnosed in the
U.S. and 0.75% of all cancer deaths.U.S. and 0.75% of all cancer deaths.
 Accounts for 30% in all head and neck cancers.Accounts for 30% in all head and neck cancers.
 More frequently happened in patients at 50~70 years ofMore frequently happened in patients at 50~70 years of
age.age.
 M:F ratio: 5~10:1 (foreign country)M:F ratio: 5~10:1 (foreign country) ，， 6.75:1(shanghai).6.75:1(shanghai).

EtiologyEtiology
 CigaretteCigarette
 Wine (combined smoking and alcohol abuseWine (combined smoking and alcohol abuse
increases the risk by 50% over the additive rate )increases the risk by 50% over the additive rate )
 air pollutionair pollution
 Virus (HPV)Virus (HPV)
 precancerous lesions (precancerous lesions (Leukoplakia, PapillomaLeukoplakia, Papilloma))
 sex hormonessex hormones

PathologyPathology
 Nearly 98% are squamous cell carcinoma.Nearly 98% are squamous cell carcinoma.
 adenocarcinoma and undifferentiatedadenocarcinoma and undifferentiated
carcinoma is rare.carcinoma is rare.

Clinical classification:Clinical classification:
 Glottic (60%)Glottic (60%) ：： well differentiated, latewell differentiated, late
metastasismetastasis
 Supraglottic (30%)Supraglottic (30%) ：： poor differntiated,poor differntiated,
early metastasisearly metastasis
 Subglottic (6%)Subglottic (6%) ：： poor differentiated,poor differentiated,
early metastasisearly metastasis

Spread of tumorSpread of tumor
 ⒈⒈ Direct spreadDirect spread
 Supraglottic cancer→ epiglottis, pre-①Supraglottic cancer→ epiglottis, pre-①
epiglottic space, vallecula, and tongueepiglottic space, vallecula, and tongue
base. piriform sinus, lateral wall of②base. piriform sinus, lateral wall of②
hypopharynx. paraglottic space,③hypopharynx. paraglottic space,③
ventricle or the VC.ventricle or the VC.

 Glottic cancer→ anteriorly, contralateral①Glottic cancer→ anteriorly, contralateral①
VC. posteriorly, arytenoid cartilage② ③VC. posteriorly, arytenoid cartilage② ③
superiorly, supraglottic area. inferiorly,④superiorly, supraglottic area. inferiorly,④
paraglottic space and subglottic area.paraglottic space and subglottic area.

 Subglottic cancer→ superiorly, glottis.①Subglottic cancer→ superiorly, glottis.①
anteriorly and laterally, strap muscle② anteriorly and laterally, strap muscle②
and thyroid gland. posteriorly,③and thyroid gland. posteriorly,③
esophagus.esophagus.

 ⒉⒉ Lymph nodes metastasesLymph nodes metastases
 Supraglottic cancer →have a propensity toSupraglottic cancer →have a propensity to
spread to cervical lymph nodes bilaterallyspread to cervical lymph nodes bilaterally
at the early stages.at the early stages.
 Generally, the risk of occult or actualGenerally, the risk of occult or actual
metastases from T1, T2, T3 and T4metastases from T1, T2, T3 and T4
tumors is 20, 40, 60, and 80%.tumors is 20, 40, 60, and 80%.

 Glottic cancer →CV is virtually devoid ofGlottic cancer →CV is virtually devoid of
lymphatics, involvement of cervical nodeslymphatics, involvement of cervical nodes
at the early stages is not common.at the early stages is not common.
 ＜＜ 8% of patients with T1 and T2 tumors8% of patients with T1 and T2 tumors
will have nodal involvement.will have nodal involvement.

 Glottic cancer →Only at the later stages,Glottic cancer →Only at the later stages,
prelaryngeal nodes, paratracheal nodesprelaryngeal nodes, paratracheal nodes
and other cervical nodes could beand other cervical nodes could be
involved.involved.

 Subglottic cancer →tend to spread toSubglottic cancer →tend to spread to
paratracheal lymphatics and then toparatracheal lymphatics and then to
superior mediastinual nodes.superior mediastinual nodes.

 ⒊⒊ Distant metstases via bloodDistant metstases via blood
 Distant metastasis only occurs in the veryDistant metastasis only occurs in the very
later stage of laryngeal carcinoma .later stage of laryngeal carcinoma .

symptomssymptoms
 Supraglottic carcinomaSupraglottic carcinoma ：：
 Might be asymptomaticMight be asymptomatic
 Foreign body sensationForeign body sensation
 Pain while swallowingPain while swallowing
 Throat burnsThroat burns
 Enlargement of cervical lymph nodesEnlargement of cervical lymph nodes

symptomssymptoms
 Glottic carcinomaGlottic carcinoma ：：
 Hoarsenenss is the early symptomHoarsenenss is the early symptom
 Respiratory obstruction will happen in lateRespiratory obstruction will happen in late
stagestage

symptomssymptoms
 SubgSubglottic carcinomalottic carcinoma ：：
 There are no definitive symptoms in theThere are no definitive symptoms in the
early stage.early stage.
 Dyspnea and lymph nodes metastasis isDyspnea and lymph nodes metastasis is
the late symptomsthe late symptoms

diagnosediagnose
Physical examinationPhysical examination
 Laryngoscopic examination can find aLaryngoscopic examination can find a
mass on one or both vocal cordsmass on one or both vocal cords
 fixation of the vocal cords is commonfixation of the vocal cords is common
 mass in the neckmass in the neck

Differential diagnosisDifferential diagnosis
 Tuberculosis of the larynxTuberculosis of the larynx ：： chest X-raychest X-ray
filmfilm
 Papilloma of the larynxPapilloma of the larynx
 Syphilis of the larynxSyphilis of the larynx

TreatmentTreatment
 Early laryngeal carcinoma (T1/T2) is usuallyEarly laryngeal carcinoma (T1/T2) is usually
managed with single modality of treatment andmanaged with single modality of treatment and
responds well to radiation, transoral laserresponds well to radiation, transoral laser
resection,or partial laryngeal surgery.resection,or partial laryngeal surgery.
 Primary cure rates of 80 to 85% are expected.Primary cure rates of 80 to 85% are expected.

TreatmentTreatment
 The management of advanced laryngealThe management of advanced laryngeal
carcinoma is more controversial.carcinoma is more controversial.
 The aim is to optimize disease-free andThe aim is to optimize disease-free and
overall survival while preserving quality ofoverall survival while preserving quality of
life.life.

TreatmentTreatment
 Generally, combined therapy is widelyGenerally, combined therapy is widely
used, as it shows better survival rates thanused, as it shows better survival rates than
single-modality treatment.single-modality treatment.
 Surgery + radiotherapy or radiotherapy +Surgery + radiotherapy or radiotherapy +
surgery are two commonly usedsurgery are two commonly used
modalities.modalities.

TreatmentTreatment
 Partial laryngectomyPartial laryngectomy
 Total laryngectomyTotal laryngectomy
 Rehabilitation of speech after total laryngectomyRehabilitation of speech after total laryngectomy
Blom- Singer valveBlom- Singer valve
Esophageal speechEsophageal speech
Electrical larynxElectrical larynx
 Neck dissectionNeck dissection

Laryngeal obstructionLaryngeal obstruction
Dong pinDong pin

CauseCause
InfectionInfection
TumorsTumors
Foreign bodiesForeign bodies
TraumaTrauma
AllergyAllergy
MalformationMalformation
Laryngeal paralysisLaryngeal paralysis

symptomssymptoms
 inspiratory dyspneainspiratory dyspnea
 inspiratory stridorinspiratory stridor
 depression of suprasternal fossa,depression of suprasternal fossa,
intercostal and supraclavicular space orintercostal and supraclavicular space or
epigastrium while inspirationepigastrium while inspiration
 hoarseness and even cyanosishoarseness and even cyanosis

classification:classification:
 ⅠⅠ°°there is no symptoms at rest. But slightthere is no symptoms at rest. But slight
inspiratory dyspnea and stridor may occurinspiratory dyspnea and stridor may occur
during crying or on exertionduring crying or on exertion

 ⅡⅡ°°slight inspiratory dyspnea during quietslight inspiratory dyspnea during quiet
respiration, and exaggeration on exertion.respiration, and exaggeration on exertion.
Sleeping and taking the meal is nearlySleeping and taking the meal is nearly
normal , no evidence of hypoxia.normal , no evidence of hypoxia.

 ⅢⅢ°° ：： with marked inspiratory dyspnea,with marked inspiratory dyspnea,
loud stridor, depression of suprasternalloud stridor, depression of suprasternal
and supraclavicular fossae and intercostaland supraclavicular fossae and intercostal
spaces, cyanosis, restless and strugglesspaces, cyanosis, restless and struggles
for air hunger, with quick pulse, high bloodfor air hunger, with quick pulse, high blood
pressure and refuse meals.pressure and refuse meals.

 ⅣⅣ°° ：： extremely dyspneic, restless,extremely dyspneic, restless,
sweating, cyanoticsis. Pulse is rapid,sweating, cyanoticsis. Pulse is rapid,
irregular, weak and thready. B.P. drops.irregular, weak and thready. B.P. drops.
Finally circulatory collapse may occur orFinally circulatory collapse may occur or
may die of asphyxia or cardiac failure.may die of asphyxia or cardiac failure.

TreatmentTreatment
ⅠⅠ°° ：： etiological treatment, antibiotics andetiological treatment, antibiotics and
corticosteroid.corticosteroid.

TreatmentTreatment
ⅡⅡ°° ：： etiological treatment .etiological treatment .
in case of tumors of the larynx,in case of tumors of the larynx,
trauma, bilateral vocal cords paralysis,trauma, bilateral vocal cords paralysis,
tracheotomy is indicated.tracheotomy is indicated.

TreatmentTreatment
ⅢⅢ°° ：： If the laryngeal obstruction is causedIf the laryngeal obstruction is caused
by inflammation, medical treatment can beby inflammation, medical treatment can be
administrated under close observation.administrated under close observation.
Tracheotomy should be prepared. IfTracheotomy should be prepared. If
dyspnea is not relieved, tracheotomydyspnea is not relieved, tracheotomy
should be performed immediately.should be performed immediately.

TreatmentTreatment
 ⅣⅣ°° ：： TracheotomyTracheotomy

TracheotomyTracheotomy
Dong pinDong pin

 Tracheotomy is a surgical procedure inTracheotomy is a surgical procedure in
which an opening is made in the anteriorwhich an opening is made in the anterior
wall of the trachea to establish an airway.wall of the trachea to establish an airway.

 Tracheotomy is often temporary andTracheotomy is often temporary and
reversible if the patient is able to breathereversible if the patient is able to breathe
through an unobstructed upper airwaythrough an unobstructed upper airway

AnatomyAnatomy
 22ndnd
-4-4thth
ring of trachearing of trachea

IndicationIndication ：：
⒈⒈ Laryngeal obstructionLaryngeal obstruction
⒉⒉ Secretion obstructed in lower respiratorySecretion obstructed in lower respiratory
tract (coma)tract (coma)
⒊⒊ Before some major head & neck surgeryBefore some major head & neck surgery

ComplicationsComplications
 HemorrhageHemorrhage
 Subcutaneous emphysemaSubcutaneous emphysema
 PneumothoraxPneumothorax
 Difficulty of decannulationDifficulty of decannulation
 Laryngeal or tracheal stenosisLaryngeal or tracheal stenosis

CCricothyrotomyricothyrotomy
 Employed in first-aid cases.Employed in first-aid cases.
 Making an opening in the membraneMaking an opening in the membrane
between the cricoid cartilage and thyroidbetween the cricoid cartilage and thyroid
cartilage and insert a cannula.cartilage and insert a cannula.
 After the situation becomes stable,After the situation becomes stable,
ordinary tracheotomy should beordinary tracheotomy should be
performed.performed.

congenital laryngomalacia

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