Acute and Chronic Laryngitis

ACUTE LARYNGITIS

• Acute laryngitis is a common inflammatory clinical condition.

• Can be infectious or non infectious
• Can also occur secondary to infections of upper and lower respiratory tracts
Etiology

• INFECTIOUS TYPE: usually viral in origin but there may be superadded bacterial
infection (Sterptococcus pneumoniae, Hemophilus influenzae and haemolytic
streptococci or Staphylococcus aureus, Moraxella catarrhalis.

• Immunocompromised patients can also present with mycotic laryngitis.

• NON INFECTIOUS TYPE: smoking; allergy; rhinosinusitis; voice abuse;
laryngopharyngeal reflux; thermal or chemical burns to larynx; laryngeal trauma
during intubation
CLINICAL FEATURES

• Majority cases are self limiting and resolve within couple of weeks
• Hoarseness which may lead to complete loss of voice
• Discomfort or pain in throat; particularly after vocalising
• Dry, irritating cough which is worse at night
• General symptoms of head cold, rawness or dryness of throat, malaise and fever
• Stridor in severe cases
DIAGNOSIS

• Microlaryngoscopy and culture ( considered in cases which ar not responding to first

line treatment )

• Laryngeal appearance vary with severity of disease

• Early stages : erythema and oedema of epiglottis, aryepiglottic folds, arytenoids,
ventricular bands but the vocal cords appear white and near normal

• Late stages: vocal cords also get involved, sticky secretions are seen between the cords
and interarytenoid region. In case of vocal abuse, submucosal hemorrhages can be
seen.
MANAGEMENT

• Vocal hygiene measures

• Analgesics/ anti inflammatory
• Avoidance of irritants (smoking and alcohol)
• Maintaining good hydration of larynx
• Cough sedatives
• Choice of antibiotic depends on associated infections ( macrolides- erythromycin and
Clarithromycin)

• Early intubation and ventilation should be considered in patients with stridor

• Tracheostomy is rarely indicated
CHRONIC LARYNGITIS

• Chronic inflammation of the laryngeal structures, most commonly affecting the

laryngeal mucosa and to certain extent the sub mucosa

• Can be due to infectious or non infectious causes

Aetiological factors

• Smoking
• Voice abuse
• Reflux disease (laryngopharyngeal or gastro oesophageal)
• Occupations: excess noise at work; asbestos workers; cement workers; solvents; shoe workers;
hair dressers and glass blowers

• Allergens
• Infective organisms: candidates infections in immunocompromise, diabetes mellitus, after
chemo radiative therapy or following prolonged antibiotic administration.
• Co existent disease :
• Previous radiation therapy for head and neck malignancy
• Immuno-suppressed
• Tuberculosis
• Sarcoidosis
• Granulomatosis with polyangitis
Clinical Presentation
CHRONIC LARYNGITIS WITHOUT HYPERPLASIA

• Diffuse inflammatory condition symmetrically involving entire larynx

• Etiology:
• Incompletely resolved acute simple laryngitis
• Chronic infection of Paranasal sinuses, teeth,tonsil, chest
• Occupational factors
• Smoking and alcohol
• Persistent trauma of cough in chronic lung diseases
• Vocal abuse
CLINICAL FEATURES
Chronic Hyperemic Laryngitis

• Alteration in voice quality in form of hoarseness ( rough and coarse voice with
reduced pitch)

• Constant hawking
• Difficulty in swallowing
• Foreign body sensation
• Persistent non productive cough
• Halitosis
• Unusual taste or bitter taste
• Otalgia
• Water brash
• Indigestion
ASSESSMENT

• Severity of dysphonia (harshness and breathy components)

• Strained intonation of voice
• Examination of ears and hearing
• Nasal abnormalities ( leading to persistent obstruction or mouth breathing )
• Examination of larynx in resting neutral state: fibreoptic nasendoscopy
• More detailed examination: per oral rigid laryngoscopy
• Principal Aim : Microlaryngoscopy under general Anesthesia
• Laryngeal examination:
• Red arytenoids and piled up into the arytenoid mucosa
• Diffuse oedema, including Reinke’s space, mucosal thickening but possibly minimal
erythema

• Diffuse oedema with granular friable mucosa

• Discreet granuloma, with or without, oedema and erythema
OPERATIVE ASSESSMENT

• Suspicious with regard to dysplastic changes or overt malignancy

• Co existent pathology: vocal cord polyp
• Presence of crusting of secretions
• Failure to respond to medical treatment
• MICROLARYNGOSCOPY: detailed assessment and subsequent appropriate biopsy
without traumatising the inflamed larynx
Histological features

• Squamous epithelium of variable thickness with a tendency to keratinisation

• Lamina propria may be edematous
• Chronic inflammatory infiltrates
• Variable degree of fibrosis of lamina propria
TREATMENT

• Eliminate infection of upper or lower respiratory tract

• Avoidance of irritating factors
• Voice rest and speech therapy
• Steam inhalation
• Expectorants
CHRONIC HYPERTROHIC LARYNGITIS
SYN. Chronic hyperplastic laryngitis

• Can be diffuse and symmetrical or localised

• Localised variety: dysphonia pelican ventricularis, vocal nodule, vocal polyp, reinke’s
oedema, contact ulcer
PATHOLOGY

• Starts in glottis region later extends to ventricular band and subglottis

• Hyperaemia, oedema, cellular infiltration in submucosa
• This changes pseudostratified ciliates epithelium to squamous type
• Then squamous epithelium of vocal cord to hyperplasia and keratinisation
• Mucous glands initially hypertrophy but later atrophy with diminished secretion and
dryness of larynx
CLINICAL FEATURES

• Males (8:1)
• 30-50 years
• Hoarseness, constant tiredness and discomfort in throat when speaking for extended
period
Examination

• Laryngeal mucosa is dusky red NS thickened

• Vocal cords are red and swollen; in late stages they become bulky and irregular giving
nodular appearance

• Ventricular bands are red and edematous and may be mistaken for prolapse or eversion
of ventricle

• Mobility of cords are impaired due to edema and later due to muscular atrophy or
arthritis OD cricoarytenoid joint
TREATMENT

• CONSERVATIVE
• SURGICAL : Stripping of vocal cord
REINKE’S OEDEMA

• Bilateral symmetrical of membranous part of vocal cord

• Middle aged men and women
• Due to edema of subepithelial space (Reinke’s space) of vocal cord
• Polyploidal degeneration and hypertrophy
AETIOLOGY

• Chronic misuse of voice

• Heavy smoking
• Chronic sinusitis
• Laryngopharyngeal reflux
CLINICAL FEATURES

• Hoarse voice as the patient uses false vocal cord for voice production which gives a
low pitched and roughy voice

• Indirect laryngoscopy: fusiform swelling with pale translucent look, ventricular band
hyperemia and hypertrophy
TREATMENT

• Decortication of vocal cord: removal of strip of epithelium

• Hirano’s technique: incision made on mucosa overlying the superior aspect of TVC
then Reinke’s space is entered and contents aspirated and excess mucosa trimmed
( cold steel or CO2 laser )

• Voice rest
• Rehabilitation
CHONIC LARYNGITIS AND
MALIGNANCY
• Chronic laryngitis can progress to invasive squamous cell carcinoma
• Early dysplastic changes latter transform to invasive malignancy
• Level of clinical suspicion should be always high