6 - Larynx Flashcards
anatomy of larynx?
Pic on 5
Words on 6-9
Voice production is from?
Vocal cords/vocal folds
Description on 10
Pitch of voice?
Pitch - controlled by tension of the folds
Which cartilage is seen on nasopharyngeal endoscopy?
Arytenoid cartilage
Larynx is innervated by?
Vagal nerve
- recurrent laryngeal nerve
Dysphonia?
- Any abnormality in the speaking voice, such as hoarseness
- The primary symptoms of laryngeal disease are hoarseness and stridor
Hoarsness
- abnormal vocal quality caused by abnormal vibrations of the vocal coards
reflects a variety of complaints of voice
- tremor
- weakness
- fatigue
- altered pitch
- breathiness
- raspy, rough or strained voice
Types of voices?
Breathy - too much air
Harsh - stiff and vibrate irregularly
Heavy - edematous vocal folds produce a rough low pitched quality
Harsh voice can be?
Laryngitis
Malignancy
Stridor?
- high pitched
- inspiratory
- turbulent airflow through narrowed glottis
- warrant specialist exam
Rapid onset stridor?
Emergency
Stridor is narrowing but if above or below vocal cords it changes, describe
Above: inspiratory stridor
Below - expiratory or biphasic stridor
Hoarsness ddx?
Long list - slide 14
If hoarsness last longer than 2 weeks?
Refer fro complete otolaryngologic exam
- laryngeal cancer
- lung cancer
Worrisome symptoms w hoarseness?
Severe cough Hemoptysis Unilateral ear/throat pain Odynophagia/dysphagia Unexplained wt loss
Acute vs chronic laryngitis?
Acute: <3 weeks
- URi
- usually viral
- can by laryngopharyngeal reflux
Chronic: >3 weeks
- vocal cord lesions
- inhailed toxins
- GERD
- ETOH
- voice strain
MC cause of hoarseness?
Acute laryngitis
Acute laryngitis is?
Self limited inflammatory condition lasting < 3 weeks usually associated with:
- URI
- acute vocal strain
Tx for acute larygitis?
Education (the more you know ….)
Abx not recommended
Glucocorticoids reserved for pts who need their voice
Chronic laryngitis?
> 3 weeks
Usually caused by irritants , over time lead to laryngeal injury
Common irritants causing chronic laryngitis?
Inhaled toxins Reflux Chronic sinusitis w post nasal drip Chronic alcohol use Chronic vocal strain Tobacco smoke
How does tobacco smoke affect the vocal cords?
Irritates the vocal folds and can cause benign changes such as keratosis and polypoid corditis
Chronic laryngitis tx?
Remove the irritant
S/S of epiglottitis or supraglottitis?
Rapidly developing sore throat
Odynophagia out of proportion to exam findings
Drooling
Drooling is concerning bc?
Its a signal of impending airway compromise
Causes of epiglottitis/supraglottitis?
Viral or bacterial
Seen more in diabetics
Dx of epiglottitis or supraglottitis?
Adults:
- Indirect laryngoscopy
- lateral neck soft tissue x ray
Kids
- lateral neck soft tissue x ray
Looking for enlarged epiglottis (thumb sign)
Tx for epiglottitis/supraglottitis?
- Admit
- IV ceftriaxone
- IV dexmethasone
- Intubation (only 10% need this)
Once it calms down:
- Corticosteroid - 10 day taper
- PO abx
diagnosis for laryngopharyngeal reflux? (LPR)
Response to PPI is how diagnosis is made
What is LPR?
Gastroesophageal reflux into the larynx
Chronic hoarseness when other causes have been excluded by laryngoscopy
Presentation of LPR?
§ Hoarseness or voice quality change § Throat clearing or discomfort § Persistent cough § Sensation of post nasal drip § Esophageal spasm § Asthma (symptoms) § Half of patients lack heartburn and dyspepsia § Globus sensation (lump feeling in back of throat),
Gold standard test for LPR?
None
But typically diagnosis comes form empiric trial w PPI
- omeprazxol 40mg bid x 3 mo
Or
24hr pH monitoring of pharynx
- costly and difficult
What are recurrent respiratory papillomatosis?
Papillomas
- common lesions of larynx and other sites where ciliated and squamous epithelia meet
Generally benign
Recurrent respiratory papillomatosis is caused by?
HPV 6 and 11 are MC
Symptoms of recurrent respiratory papillomatosis?
Hoarseness
- progresses to stridor over weeks to months
Can extend to trachea and lungs
Multiple warty lesions on vocal cords
Tx for papillomatosis?
Repeated laser vaporizations or cold knife resections
- q 6 wks for airway patency
Cure is rare, goal is to keep their voice and avoid tracheotomy
Prevention of papillomatosos?
Gardasil 9
Traumatic (benign) lesions of. The vocal cords?
- vocal cord nodules
- vocal cord polyps
- vocal cord cysts
- polypoid corditis
Vocal fold nodules are aka?
Singer’s nodules - adults
Screamers nodules - kids
Common cause of hoarseness from vocal abuse
Describe vocal fold nodules?
Smooth, paired lesions that form at the junction of the anterior 1/3 and posterior 2/3 of the vocal folds
Tx for vocal fold nodules?
Modify voice habits
Speech therapist
Behavior modifications
Excision of recalcitrant nodules
What are vocal fold polyps?
Unilateral masses that form with the superficial lamina propria of the vocal fold
- related to vocal trauma (yelling)
Tx for vocal fold polyps?
Small polyps
- conservative tx,
- vocal rest
- corticosteroids
Large polyps
- irreversible
- operative removal
Vocal fold cysts are?
True cyst w epithelial lining or pesudocyts
Formed in the mucous-secreting glands on the inferior aspect of the vocal folds
Tell tale sign of vocal fold cysts?
Fluctuate in size from week to week and are common cause of harseness
Problem with Tx for vocal fold cyst?
They rarely resolve completely
- if do leave a scar/sulcus
Reinke’s edema is?
Polypoid corditis
Polypoid corditis is?
- Loss of elastin fibers
- loosening of the intracellular junctions w/in the lamina propria
- swollen and floppy vocal folds
- respiratory symptoms (maybe)
Polypoid corditis is associated w?
Smoking
Vocal abuse
Chemical irritants
Hypothyroidism
- middle age woman who complains of a husky, low-pitched voice
Tx for polypoid corditis
Smoking cessation
Reflux management
Voice therapy
W stridor or airway obstruction
- Surgical debulking/reconturing
What is laryngeal leukoplakia?
Larynx mass
- Hoarseness in smokers
May be benigh, precancer, or cancer
Laryngeal leukoplakia tx?
Stop smoking PPI (mainstay) Laryngovideostroboscopy Serial resection External beam radiation therapy
Presentation of squamous cell carcinoma of larynx
New (>2 weeks) hoarseness in smoker Persistent throat/ear pain esp w: - swallowing - neck mass - hemoptysis - stridor - compromised airway
MC malignancy of larynx?
SCC
SCC of larynx pt population?
50-70yo men w hx of
- tobacco
- ETOH
- HPV 16,18 (MC in non-smokers)
S/s of SCC of larynx?
- Change in voice quality
- persistent hoarseness
- throat/ear pain
- neck mass
- hemoptysis
- stridor
- wt loss
Dx for SCC or larynx?
Complete head and neck exam
- Laryngoscopy w biopsy (by ent)
- CT/MRI
- PET/CT-PET for metastasis
METS of SCC are common in? Not common in?
Common in supraglottic carcinoma
- false vocal folds,
- aryepiglottic folds
- epiglottis
Not common in
- true vocal cords if cords are mobile
Goals of tx for SCC?
Cure
Preserve swallowing
Preservation of voice
Avoid permanent tracheostoma
Tx for SCC
?
Early glotic/supraglottic cancer
- radiation
Later, large tumor or mets
- multimodal therapy
Causes of vocal cord paralysis?
Lesion or damage to vagus
unilateral recurrent laryngeal nerve
- surgeries
- mediastinal/apical lung ca
- skull base tumors
Common MCC cause of unilateral vocal cord paralysis?
2 is idiopathic
Iatrogenic injury
Describe vocal cord paralysis presentation
Breathy dysphonia or effortful voicing
Pts with vocal cord paralysis need?
CN exam
CT w contrast
MRI (if cranial neuropathy present)
What nerve runs on either side of the trachea?
Right/Left recurrent laryngeal nerve
unilateral recurrent laryngeal nerve injury?
True vocal cord rests in paramedial position
Contralateral vocal fold to compensate
Glottal incompetence - risk of aspiration
Why does RLN make coughs ineffectual?
They require transient tight glottic closure
Tx for unilateral vocal cord paralysis
Early surgy indications
- aspiration pneumonia
- disabling breathy hypophonia
- ineffective cough
- disabling dyspnea
Mild sx
- voice/speech therapy
- evidence of little activity on laryngeal electromyography
Surgery for unilateral vocal cord paralysis?
surgical procedures can reposition the immobile vocal fold to achieve adquate glottal closure
What causes bilateral vocal fold paralysis?
Total thyroidectomy
- usually w re-operations
Symptoms of bilateral vocal fold paralysis?
Position dependent
- narrow glottic aperture
- resp function compromised
- dyspnea or inspiratory stridor
- respiratory distress
Voice is usually spared
Tx for bilateral vocal fold paralysis?
Preserve airway
- intubation
- Tracheostomy
Permanent bilateral vocal cord paralysis
- posterior cordectomy
- laser surgery (restore air flow)
What is vocal cord dysfunction (VCD) or paradoxical vocal fold movement (PVFM)
Syndrome of acute and chronic upper airway obstruction characterized by paradoxical cord adduction
Sudden or gradual
VCD triggers?
GERD Inhaled allergens Post nasal drip Exercise Neurological conditions Psychosocial d/o and stress
Key features of vocal cord dysfunction?
Dyspnea and wheezing
Co-occurs w asthma (40%)
Dont respond to bronchodilator
VCD is often confused w?
Asthma
Diagnosis of VCD?
Direct visualization of vocal cords showing adduction w both inspiration and expiration (abnormal)
Spirometry - evidence of upper airway obstruction
Bronchial provocation test = normal
VCD tx?
stop unnecessary tx
- steroids
- asthma meds
Acute
- CPAP
- Breathing exercises
Chronic
- speech therapy
- botox
- tracheotomy
What do you call a pony w a sore throat?
A little horse
