Chapter 20: Benign Laryngeal Disorders Flashcards
1
Q
Normal infant larynx
A
- Situated higher in the neck than that of the adult
- Softer, less rigid and more compressible by airway pressures
- At the level C2-C4. (Adult: C4-C6)
- 7 mm in the anteroposterior length and opens approximately 4mm in a lateral direction
2
Q
- Exaggeration of the soft, flabby state that is normal for newborns
- As the infant inhales, the soft larynx falls together, narrowing the inlet and stridor results
- Swallowing is unaffected
A
Laryngomalacia
3
Q
Direct examination of laryngmalacia
A
- Larynx fall together with inhalation
- Subglottic area is normal
- Stridor ceases if the larynx is held open with laryngoscope
4
Q
Most infants cease to have the stridor by the 12th to 15th month
A
Laryngomalacia
5
Q
Can be associated with a 2nd upper airway abnormality
A
Laryngomalacia
6
Q
Disorder of the trachea due to lack of rigidity of the tracheal cartilages
A
Tracheomalacia
7
Q
- Subglottic diameter less than 4 mm
- Presents with stridor shortly after birth or recurrent episodes of laryngotracheitis
- Mild cases: observation, most cases require tracheotomy
- Growth tends to resolve the relative stenosis, but laser excision or reconstructive surgery may be necessary
A
Congenital subglottic stenosis
8
Q
Congenital webs
A
- Glottic (75%)
2. Subglottic (12%)/Supraglottic (12%)
9
Q
Both the airway and the cry or voice are affected, with the symptoms beginning at birth
A
Congenital webs
10
Q
Congenital webs treatment
A
- Laser or surgical excision
- Repeated dilatation
- Tracheotomy
11
Q
- May have airway obstruction or simply do not grow
- Voice and swallowing and normal
- Arise from the base of the tongue, aryepiglottic folds or false cords
- If its possible: excision
- Not possible: aspiration or marsupialization
A
Congenital cysts
12
Q
- Occurs primarily in infants under 6 months of age
- Presence of external hemagioma plus stridor
- Tends to regress, usually by the age of 12 months
- Lateral xray: mass in the airway
- Endoscopic: smooth, compressible mass often on the posterior or lateral wall
- Tx: tracheotomy and allowing time for regression, laser excision
A
Hemagioma
13
Q
- Special type of congenital cyst that develops as s residual from a small appendix or saccus of the laryngeal ventricle
- Present at any age but its origin is congenital
A
Laryngocele
14
Q
- As the cyst begins, it first causes a bulging of the false vocal cord on that side
- With enlargement, the cyst dissects along the superior laryngeal nerve and vessels to present as mass in the neck
- As they enlarge, they encroach on the airway and may cause stridor and airway obstruction
A
Laryngocele
15
Q
Treatment for laryngocele
A
Dissection of the cyst using an external approach accompanied by a temporary tracheostomy
16
Q
Result of a failure of fusion of the dorsal portions of the cricoid cartilages
A
Laryngotracheoesophageal cleft
17
Q
There is an associated failure of closure of the tracheoesophaheal septum, thus creating a groove in the region of the cricoid cartilage
A
Laryngotracheoesophageal cleft
18
Q
- Infant may have cyanosis, respiratory distress and recurrent episodes of pneumonia
- Associated changes in the cry as well as inspiratory stridor
- Direct laryngoscopy: normal larynx
A
Laryngotracheoesophageal cleft
19
Q
Causes of vocal cord paralysis in infants
A
- Birth canal trauma
- Meningocele or mediatinal mass
- Increase ICP
20
Q
Unilateral vocal cord paralysis is more common on the…
A
Cleft
21
Q
Children with bilateral vocal cord paralysis can have a…
A
Normal cry
22
Q
Recovery of vocal cord paralysis
A
6-9 months but may take up to 14 months
23
Q
- Manifested by internal hematomas and occasionally by dislocation of the arytenoid cartilage
- Caused by some blunt object striking an extended neck
- Direct laryngoscopy: reduces the dislocated arytenoid cartilage
A
Mild contusions of the larynx
24
Q
Don not cause airway obstruction, since the pharynx is very wide at this level
A
Hyoid fractures
25
The greater cornu of the hyoid does not normally unite to the body until...
Age 35
26
Treatment of hyoid bone fractures
Expectant
27
Signs of laryngeal fracture
1. Hoarseness
2. Inspiratory or expiratory stridor
3. Hemoptysis
4. Subcutaneous emphysema
28
When laryngotracheal separation occurs, the trachea will retract into the lower neck
Emergency tracheostomy is required
29
Most likely fracture runs in a...
Vertical plane from the bottom of the thyroid notch to the lower border of the cartilage
30
Avulsion of the thyroid cartilage from the cricoid and trachea...
1. Facial pain
2. Aphonia
3. Subcutaneous emphysema
31
Required in anyone with a laryngeal fracture
1. Cervical spine films
| 2. Neurologic exam
32
Causes of laryngeal stenosis
1. Blunt or perforating trauma
2. High tracheostomy
3. Caustic ingestion
4. Gunshot wound
5. Irritation from an endotracheal tube cuff
33
Used to delineate laryngeal and subglottic stenosis
Ct scan
34
Treatment of chronic laryngeal stenosis is very complicated and must be individualized
1. Dilatation
2. Excision
3. Direct re-anastomosis
4. Skin grafting over a mo
5. Partial or total laryngectomy
35
1. Endotracheal tube abrades the vocal process of the arytenoid cartilage
2. Perichondritis develops and the healing process produces a raised polypoid lesion in the posterior portion of thr glottic chink (rima glottidis)
3. Not very hoarse but the voice is changed
4. Bilateral
Intubation granuloma
36
Treatment of intubation granuloma
Endoscopic surgical removal, often using the CO2 laser
37
1. Resulting in stridor and airway obstruction
2. Develop at any age even in adults
3. Most common in children under 6 years of age
Croup
38
Contain loose areolar tissue that is prone to swell when inflamed
1. Laryngeal surface of the epiglottis
| 2. Area just below the vocal cords in the larynx
39
Croup can be divided into:
1. Acute supraglottis (epiglottis)
| 2. Acute subglottic laryngitis
40
Signs and symptoms of croup
1. Restlessness
2. Apprehension
3. Stridor
4. Retraction
5. Cyanosis
41
1. More explosive
2. Tends to sit up with mouth open and chin forward, is not hoarse
3. Tends not to have a croupy a cough, but is more likely to have dysphagia
4. Painful to swallow, child may drool
5. Dysphagia may be a sign of impending collapse (results from the spread of inflammation into the adjacent esophageal inlet and means that the inflammatory process has swollen the epiglottis markedly)
Acute supraglottis (epiglotitis)
42
Hoarse with very croupy cough and usually want to lie down
Acute subglottic laryngitis
43
Management of croup
1. Rapid treated without long delay in the radiology or ED
| 2. Must not be upset or agitated
44
Soft tissue lateral xray in croup
Narrowing of the subglottic area or an enlarged epiglottis
45
Should not be done unless one is equipped to pass a bronchoscope or endotracheal tube
Depressing the tongue to see the epiglottis (may force the swollen epiglottis into the larynx like a cork)
46
Treatment of croup
1. IV fluid therapy is started in order to prevent dehydration and drying of secretions
2. Antibiotic therapy to actual Hemophilus or Staphylococcus is initiated
3. Steroids are given in large doses
4. Patient must be carefully observed and consideration given to intubation or tracheostomy
47
Evaluation of croup
Monitor
1. Pulse
2. Respiratory rate
3. Degree of restlessness
4. Apprehension
5. Use of accessory muscles of respiration
6. Degree of cyanosis
7. Degree of retraction
8. Overall fatigue
48
Indicate the need to support (croup)
1. RR over 40
2. PR over 160
3. Increasing restlessness and retraction
49
Can occur in 30-40 year old adults
Acute epiglotitis
50
Most cases of croup resolve in...
48-72 hours and the patient can be extubated
51
```
3-6 years
Onset hours
Voice clear
Dysphagia
Sitting up
Rarely recurs
Rapid course
Lateral xray: supraglottic edema
Hemophilus influenzae most common
Streptococcus or viral etiology less common
```
Supraglottitis
52
```
Under 3 years
Onset days
Hoarse
No dysphagia
No drooling
Recumbent
May recur
Days to weeks
Normal neck films
Viral etiology
```
Laryngotracheobronchitis (infraglottitis)
53
8-15 years
1-2 week period of respiratory infection with rapid deterioration
Barking cough
Inspiratory stridor
Recumbent
Intubation needed to remove secretions or pseudomembranes
Tracheal xray: irregular margins
Most typical: S. aureus
Less common: Streptococcus or H. influenzae
Bacterial tracheitis
54
```
1-5 years
Rapid onset, usually evening
No associated infection
Exposure to humidity or cold relieves
May be non inflammatory edema of subglottic area
```
Spasmodic croup
55
Produce acute laryngitis
1. Vocal abuse
2. Toxic fume inhalation
3. Infection
56
Most common causative organisms in acute laryngitis
1. Influenza virus
2. Adenovirus
3. Streptococci
57
Treatment of acute laryngitis
1. Voice rest
2. Antibiotics
3. Increased humidity
4. Cough suppressants
58
Advised in patient with acute laryngitis
1. Singers and voice professionals must be advised to let the inflammatory process subside before resuming their careers
2. Attempting to sing during the infection may result in hemorrhage in the larynx and the subsequent development of vocal cord nodules
59
1. Pain radiating to the ear
2. Dysphagia
3. Hoarseness
4. Arytenoid is edematous, erythematous and immobile
Vocal cord paralysis: joint should move passively
Arthritis: fixed
Acute cricoarytenoid arthritis
60
Early symptom of hypothyroidism due to deposition of mucopolysaccharides submucosally
Hoarseness
61
1. Supraglottic larynx is primarily involved as true cords ate spared
2. Present with hoarseness and dysphagia
3. Diffuse edema without ulceration of the supraglottic larynx
4. Noncaseating granulomas with giant cells
5. Tx: systemic steroids or direct intralesional injection of steroids
Obstructing: tracheostomy
Sarcoidosis
62
Cause simultaneous mucosal ulceration in the larynx and otal cavity
Histoplasmosis
63
Treatment of laryngeal pemphigus
| Cicatricial stenosis can result
Dapsone
| Steroid
64
More often involved in TB of larynx
Posterior aspect of the cords
65
Chronic granulomatous infections
TB
Syphilis
Leprosy
66
1. Variety of conditions that are all characterized by hoarseness
2. Repeated attacks of acute laryngitis
3. Exposed to irritating dust or smoke or may use their voices improperly in a neuromuscular sense
Chronic nonspecific laryngitis
67
Treatment of chronic nonspecific laryngitis
1. Removing the offending cause
2. Correcting treatable related disorders
3. Reeducating vocal habits through speech therapy
68
1. May be unilateral
2. Results from prolonged or improper use of the vocal cords
3. Soft, loosely edematous tumor to a firm, fibrous growth or a vascular lesion with many small vessels
4. Respond to vocal restraint and re education
Vocal nodules
69
1. Associated with prolonged vocal use, smoking and persistent inflammation
2. Surgical removal must be done on one side at a time to prevent the development of synechiae in the anterior commisure
Diffuse vocal cord polyposis
70
1. More likely to occur in male
2. Men forcefully bring the arytenoid cartilages together-->irritation forms a granuloma
3. Complaints of pain and notices only a slight vocal change
4. Heals slowly, over 2-3 months
5. Tx: speech therapy
Contact ulcer
71
1. Most common tumor of the larynx in children
2. Occurs in children between 18 months and 7 years of age, and involution often occurs at puberty
3.
Juvenile papilloma
72
Initial symptoms of juvenile papilloma
Hoarseness and abnormal cry
73
1. Croup is suspected, no response to treatment
2. Enlarged to cause airway obstruction and present as an emergency requiring tracheostomy
3. Can be hormone-dependent, regressing with pregnancy and puberty
4. Viral etiology
Juvenile papilloma
74
Treatment for juvenile papilloma
1. Surgical removal, using microscope with a CO2 laser
2. Tetracycline
3. Steroids
4. Smallpox vaccine
5. Autologous vaccine
6. Alpha N1 interferon
75
Repeated surgical excision of juvenile papilloma can lead to
Laryngeal scarring or webbing
76
1. Tend to occur in tongue and larynx
2. Main symptom is hoarseness
3. Mucosa over may show pseudoepithelial hyperplasia
Granular cell myoblastoma
77
1. Slow-growing tumors of hyaline cartilage arising from the cricoid, thyroid, arytenoid or epiglottic cartilages
2. Main symptoms are hoarseness and dyspnea
3. Tx: surgical
Chondroma
78
1. Persistent irritation of the larynx, particularly by smoking may lead to the development of whitish area or may appear reddened
2. Biopsy: hyperkeratosis, carcinoma in situ or frank carcinoma
3. Tx: total endoscopic removal
Leukoplakia or Erythroplakia
79
Five positions of the vocal cord
1. Median
2. Paramedian
3. Intermediate
4. Slight abduction
5. Full abduction
80
Positions are designated by observing the size of the glottic chink
Paralysis is bilateral
81
Observer must 1st estimate the true midline midline position and then relate the cordal position to that
Paralysis is unilateral
82
Any lesion along the course of the recurrent laryngeal nerve can cause...
Laryngeal paralysis
83
Vocal cord opening of median position
Both cords in midline
84
Vocal cord opening in median position
Both cords in midline
85
Vocal cord opening in paramedian position
3-5 mm
86
Vocal cord opening in intermediate postion
7 mm
87
Vocal cord opening in slight abduction position
14 mm
88
Vocal cord opening in full abduction position
18-19 mm
89
Paralysis of cricothyroid muscle; sensory loss in half of larynx
Superior laryngeal paralysis
90
Effect of superior laryngeal paralysis
Loss of pitch; aspiration
91
Anterior commissure looks tilted to side of lesion; arytenoid on that side tilts in
Superior laryngeal paralysis
92
Paralysis of all intrinsic muscles in that side
Unilateral recurrent nerve paralysis
93
Effect of unilateral recurrent nerve paralysis
Hoarse; good airway except in small children; breathy voice; poor cough
94
Cord in paramedian position; no lateral motion
Unilateral recurrent nerve paralysis
95
Paralysis of all intrinsic muscles
Bilateral recurrent nerve paralysis
96
Effect of bilateral recurrent nerve paralysis
Good voice; poor airway, especially on exertion
97
Vocal cords do not move laterally; some patients adapt and exists with decreased exercise tolerance
Bilateral recurrent nerve paralysis
98
Vagus nerve lesion above the superior laryngeal nerve; may be unilateral or bilateral
Complete paralysis
99
Effect of complete paralysis
Similar to corresponding lesions of recurrent paralysis; more likely to aspirate
100
Cords are immobile but in intermediate position due to loss of adduction by cricothyroid muscle
Complete paralysis
101
Strained, hoarse voice, often staccato-like, due to hyperadduction of the true and false cords
Spastic dysphonia
102
This tension larynx usually starts in young adults, who become very self-conscious and may change occupation to avoid speech
Spastic dysphonia
103
Best therapy for spastic dysphonia
Surgical section of the right recurrent laryngeal nerve
104
Patient may complain of a total inability to talk
Psychogenic aphonia
105
1. Phonation with the false cords vibrating instead of the true vocal cords produces a husky voice
2. Larynx appears normal, but the false cords seem to overhang or cover the true cords
Dysphonia plicae ventricularis
106
1. Complain of vocal weakness
2. Voice lacks its usual tone and vigor
3. The voice breaks or drops in pitch
4. Examination: vocal cords appear slightly bowed
Vocal weakness
