Laryngeal diseases

Laryngitis, vocal cord nodules / polyps, Carcinoma larynx

 * LARYNX
• FRAMEWORK OF CARTILAGES
CONNECTED BY LIGAMENTS AND
MEMBRANES and moved by muscles, Laryngopharynx
lined by a mucous membrane.

• MIDLINE STRUCTURE in Neck.

• In front of laryngopharynx

HAVE A LOOK ON A SECTION

THROUGH THE INTERIOR OF
HUMAN LARYNX
You should read my anatomy lecture note
along with this -

True vocal cords are very poor in lymphatic drainage

 Some important pathological conditions
• Congenital • Acquired – non-neoplastic • Neoplastic
• Laryngomalacia • Infections • Benign
• Subglottic stenosis ✓Acute and chronic laryngitis Papilloma
• Vocal cord palsy ✓Acute epiglottitis
• Non-infective benign conditions • Malignant
✓Vocal polyp/ nodule/cyst/ granuloma (Commonly)
✓Reinke’s oedema carcinoma
 Laryngomalacia
https://youtu.be/DIA2YCn_CSI

• The epiglottis is small and curled on itself (omega-shaped).

Noisy breathing (stridor) — An audible wheeze

Difficulty feeding
Poor weight gain
Choking while feeding
• Apnea (breathing stoppage)
Pulling in neck and chest with each breath
Cyanosis (turning blue)
Gastroesophageal reflux
 Subglottic stenosis
• Subglottic stenosis (SGS) is a narrowing of
the airway below the vocal cords
(subglottis) and above the trachea.
• Acquired subglottic stenosis often occurs
after long periods of intubation and
ventilation for respiratory problems.
• Congenital subglottic stenosis

• Noisy breathing (stridor)

• Respiratory distress
Rx
• Dilatation of stricture
• Excision of scar tissue
• Tracheostomy, if needed.
 VOCAL CORD PARALYSIS (causes)

• Unilateral (Lt. side more com) / Bilateral • Causes in chest

Bronchogenic ca
• Central (less com.) / Peripheral (common)
Mediastinal growth or
metastatic node
• CAUSES IN NECK Ca oesophagus
✓ Ca Thyroid Enlarged heart
✓ Thyroid surgery ( Rt side common ) Pulm. TB / Fibrosis etc.
✓ Penetrating wound
• OTHERS
✓ Malignant disease metastasis
Viral neuritis
e.g. Ca oesophagus, Nasopharyngeal tumour Peripheral neuritis
Paralysis of Larynx
• 25% cases are IDIOPATHIC / viral
• Central—lesion in Cortex or medula
• Peripheral—Pressure or stretching
• Injury, malignant disease, infective or toxic neuritis, avitaminosis
• Paralysis may be unilateral / bilateral, Complete / incomplete
• Other causes -
✓Complication from endotracheal intubation
✓Tumors of the skull base, neck, and chest:
Vagus and
recurrent
laryngeal
nerves
(Rt. And Lt.)
VOCAL CORD PARALYSIS
• Left sided paralysis is more
common because of long
course of recurrent
laryngeal nerve in the
chest.
Paralysis of Larynx
Symptoms
• Voice changes: Hoarseness; breathy voice; extra effort on speaking;
excessive air pressure required to produce usual conversational voice;
and diplophonia (voice sounds like a gargle).
• Airway problems: Shortness of breath with exertion, noisy breathing,
and ineffective cough.
• Swallowing problems: Choking or coughing when swallowing food,
drink, or even saliva, and food sticking in throat, aspiration.
• Symptoms are actually variable, depend on the type of lesion.
• It is important to remember that cords paralysis of unknown cause
sometimes recover after 1 or 2 years of time.
Paralysis of Larynx
Signs
• Signs of the Primary Disease IN SENSORY PARALYSIS OF
e.g. Pulm. TB, Ca thyroid etc. LARYNX --
Local Vocal cord signs • Larynx is Insensitive to touch
• Bowing of cords • ↓ Cough reflex
• Slack wavy cord
• Sagging down at a lower level
• Little or no movement on
phonation.
How to see larynx? ▪ Videolaryngostroboscopy

▪ Direct laryngoscopy

Abductor palsy
• Inspiration Phonation VOCAL CORDS
WHEN PARALYSED

Treatment:
▪ According to cause
▪ Tracheostomy
▪ Voice therapy
▪ Ryle’s tube feeding
▪ Intralaryngeal surgeries/ procedures
▪ Vitamins
 ACUTE LARYNGITIS: Most common cause of acute hoarseness
• Short duration of
hoarseness
▪ Upper Resp. infection
Smoking/ tobacco
(bacteria, virus)
▪ Overuse of voice / TRAUMA
Reduced local
mucosal
resistance
Acute Laryngitis
Symptoms
• Sore throat
• Hoarseness
• Cough / hawking
• SOB Sometimes & other
• Constitutional features like
Fever, malaise etc.
• H/O attending a Party or
Travel
ACUTE LARYNGITIS
Inflammation and
oedema compromising
the airway
TREATMENT • SYMPTOMATIC /SUPPORTIVE
• STEAM INHALATION / MENTHOL INHALATION FOR
PLEASANT FEELING – SOOTHING EFFECT
• VOICE REST, FLUIDS, etc.
• ANTIBIOTIC, 02, IF NECESSARY
• REMOVE THE CAUSE OR PREDISPOSING FACTOR
• REASSURANCE

* IT SHOULD ALWAYS SETTLE DOWN WITHIN FEW WEEKS, IF NOT, IT IS NOT

SIMPLE LARYNGITIS AND SHOULD BE REFERRED TO AN OTOLARYNGOLOGIST.
ACUTE HAEMORRHAGIC LARYNGITIS
• Sudden violent and forceful approximation
Of vocal cords as in coughing, shouting, weight lifting etc.
Single or multiple haemorrhages

Fibrous nodule

Endoscopic removal

Vocal rest is the main part of treatment

Acute laryngitis
• May appear in the form of
• Acute Laryngotracheobrongchitis in infants and young children
(CROUP).
• Diphtheritic laryngitis
• Herpes zoster laryngitis and other forms as well.
• Special form of acute
Laryngitis affecting mainly
the loosely attached mucosa
of epiglottis.
Supraglottic structures, e.g. epiglottis,
• Short history, drooling of aryepiglottic folds and arytenoids
saliva, sitting posture of the
patient are evident.
• Progressive dyspnoea in
children may lead to death
within few hours.
• Pain on swallowing is more
common in adults
 Thumb print sign on lateral view
neck x-ray

BACTERIAL CAUSE Rx ANTIBIOTIC

CLOSE OBSERVATION
KIV STEROID, O2, PROPPED UP, IV INFUSION
 Chronic Laryngitis
Commonest cause of chronic hoarseness

• May follow an acute attack but usually follows an

insidious course.
• Exciting factors-
❑ Faulty use of voice
❑ Neighbouring infection as in tonsils, teeth, sinus etc.
❑ Excessive alcohol, tobacco
❑ Atmospheric pollutants such as dust, irritant fumes
etc.
❑ GERD
❑ Allergy
Chronic laryngitis
May be of specific type of infection like
Tubercular, Syphilitic etc.

• A patient with chronic hoarseness must be investigated for pulm. TB ,

at least a chest x-ray and sputum for AFB are mandatory.

• Sometimes Fungus may cause hoarseness

Commonly by candida
 Clinical features
• Important signs are-
Hyperaemia, oedema of vocal cords
Excessive viscid secretion
SYMPTOMS-
• Hoarseness and vocal fatigue
• Chronic cough, on and off, and sore throat (hawking) are common
symptoms.
• In long run it may give rise to hypertrophic changes.
Hawking – constant attempt of clearing voice by expelling mucous or phlegm from throat
 After exclusion of any neoplasm (which is sometimes difficult),
treatment is mainly directed to
a) Avoidance of traumatizing agents e.g. smoking, gastritis etc.
b) Vocal rest, Speech therapy
c) Systemic antibiotic, if necessary etc.
d) Mucolytic agents and steam inhalation may be of some help.
e) Adequate hydration of throat, avoiding throat dryness.

Constant hawking may worsen the condition further

CONTACT ULCER
Kiss ulcer ( ? )
• Almost exclusively in male adults.
• Singers , street vendors etc.
WHY ?
Hammering of one vocal process of arytenoid cartilage against the
other.
FROM
Vocal abuse
The granuloma of one side fitting into the ulcer crater of
the other side like kissing to each other

• Hoarseness
• Vocal fatigue
• Coughing
are the predominant symptoms
VOCAL NODULE
Also called Singer’s node
• Nodular thickening at the free
edge of vocal cords ocurring in
persons who use their voice
excessively, with straining, or/&
faulty production.
VOCAL NODULE:
Susceptible groups -

• Hyperkinetic personality
• Singers, actors, teachers, mothers of
young children
• Persons talking to the deaf
• More common in women & singers who sing above their
natural tessitura(range)
• And also some high vocal LEADERS.
VOCAL NODULE
Pathology
• Localised hyperkeratosis
• Site is constant-
• Junction of ant. 1/3rd & posterior 2/3rds of the free edge of one or
both cords.
• Initially there may be a subepithelial haemorrhage with subsequent
organization.
• Never becomes neoplastic
VOCAL NODULE
Clinical features
• Increasing Hoarseness: sudden or insidious over weeks or months.
WHY ?
Failure of the cords to approximate properly
• Vocal fatigue/ easy fatiguability
• Commonly bilateral and symmetrical
• Size varies from a minute pin head to that of a grape pip
VOCAL NODULE
VOCAL NODULE
TREATMENT
General measures for any hoarseness
• Voice rest
• Avoidance of dust, smoke, alcohol, hawking etc.
• Elimination of focal sepsis
• Speech therapy
Specific for resistant cases
• Precise removal (excision & biopsy) is possible without damaging the
v. cords followed by speech therapy.
Vocal cord polyp

• Translucent sessile
polypoid mass near the
ant. commissure resulting
from the oedema of
subepithelial connective
tissue. May be due to
unresolved infection or
trauma.
• Rx Excision-biopsy
Benign growths
Granuloma e.g. TB, intubation
Fibroma
Retention cyst
papilloma
LAEYNGEAL TUMOURS
(BENIGN)
• Epithelial tumours are common
• and Papilloma is the commonest among them.

Single Multiple

Adult Child
Unknown etiology Viral
Usually ant. 1/3rd Can invade whole of the
Of v. cords/glottis Tracheobronchial tree.
Premalignant not so
No recurrence Recurrence common after removal

.
PAPILLOMA
Symptoms
Children
• Persistent and increasing hoarse voice is the usual symptom in
children and hoarse cry in infants.
• Difficulty in breathing is common.
• Sometimes acute dyspnoea
Adult
• Hoarseness and occasional cough
HYPERKERATOSIS LARYNX

• A localised form of
epithelial hyperplasia
characterised by white
leucoplakic raised
patches on the vocal
cords.
• Premalignant condition
• Hoarseness of gradual
onset and persistent.
LARYNGEAL TUMOURS:
Malignant
• Epithelial tumours are commoner than non-epithelial ones.
• Practically all malignant tumours are squamous cell
carcinoma while others are extremely rare.
• Pathological range from highly keratinized to anaplastic
types.
LARYNGEAL TUMOURS
Malignant
Topographically 3 types
• Supraglottic
• Glottic - most common in Europe
• Subglottic - least common .
• Trans-glottic – extending from one region to another.
• Hoarseness is early and prominent feature for Glottic Ca whereas in
other types it appears relatively late.
LARYNGEAL TUMOURS Malignant
LARYNGEAL TUMOURS
Some important notes
• Common in male smokers & Heavy Drinkers.
• Cure rate with Radiotherapy is High for smaller lesion. Hence, early
diagnosis is very important .
• The larger the tumour the less effective is Radiotherapy with
maximum side effects.
• Glottic Ca spreads late less than 4% because of insignificant lymphatic
drainage of vocal cords.
• Carcinoma of the larynx in Malaysia.
• Sani A1, Said H, Lokman S.
• Author information
• Abstract
• A retrospective study of cases with carcinoma of the larynx seen in the Universiti Kebangsaan Malaysia
(UKM) and General Hospital Kuala Lumpur (GHKL) between 1981 to 1988 was performed. The aim was
to document the distribution and the pattern of behaviour of this tumour amongst our patients. There
were 137 cases, the majority of whom were Chinese (54%). The peak incidence was in the seventh
decade and the male to female ratio was 7.6:1. The most common symptom at presentation was
hoarseness (90%). The most common histological type was squamous cell carcinoma (87%) whilst by
site, transglottic involvement was commonest (55%). The overall 3 year survival rate was 68%.
Supraglottic carcinoma behaved differently in that a significantly large number presented with
dysphagia (33.3%) and neck nodes (42%). Compared to tumours of other sites of the larynx, they had
the poorest 3 year survival rate of 50%. Amongst the T2 and T3 tumours, the results of surgery
appeared better than primary radiotherapy. Considering that 26% of patients presented with stridor,
20% with neck nodes and 55% with multiple site involvement, it can be concluded that our patients
present themselves late.
LARYNGEAL TUMOURS (carcinoma)

https://slideplayer.com/slide/10407138/
LARYNGEAL TUMOURS
Common presentation
• Dyspnoea – shortness of breath not fully relieved by bronchodilators
• Hoarseness – persistant and progressive
• Severe stridor in advanced cases.
• Neck swelling. May be tumour itself or metastatic node.
• Difficulty in swallowing
• Cough
• Systemic features
• Metastatic features
 Investigations
INDIRECT / DIRECT LARYNGOSCOPY
BIOPSY FOR HPE
X-RAY/ CT / MRI OF NECK/ CHEST

DIRECT LARYNGOSCOPY

INDIRECT LARYNGOSCOPY
Staging - TNM
TREATMENT
• Each patient should be assessed • Partial or total laryngectomy
individually
• Main options are -
• Radiotherapy – good for small
tumours (T1, T2)
• Surgery: good for big tumour
and also for recurrent tumours.
• Sometimes, both of these Trachea is open here -
• Chemotherapy can be combined tracheostoma
with other modality as an
adjunct.
No larynx in this pt. after total laryngectomy
 Post-laryngectomy voice restoration
• Oesophageal speech – air is swallowed • Artificial larynx
into the stomach and then
regurgitated into the pharynx. This
causes vibration of the pharyngo-
oesophageal segment.
• Tracheo-oesophageal puncture –
artificial communication is made
during surgery between trachea and
pharynx to divert the breathing air into
the pharyngo-oesophageal segment.
• Artificial larynx – held firmly on
patient’s neck, floor of mouth or cheek
that causes these tissues to vibrate.
Case note (1)
• Mr. Chin Kui Len i.c. 490604-12-5192
• Age- 50 + years
• Presented with hoarseness for 1 month
• Attended ENT Clinic, between 1992 and 1995
• Diagnosed as a case of Sq. cell ca of vocal cord. And underwent
radiotherapy 6000 rads over 6 weeks.
• She was fully cured and visited our clinic in a good condition after 20
years
Here are some conditions
detected by laryngoscopy.
Can you differentiate these
conditions?