Diseases of Larynx and Pharynx Flashcards
Sore throat
common causes
MC = viral
Group A strep (strep pharyngitis 15%)
EBV/Monoucleosis
Pharyngitis and Tonsillitis
50% of outpatient antibiotic use - inappropriate usually bc VIRAL cause
augmentin/ Amox MC used
Failure to recognize and treat Group A strep infection risk of
rheumatic fever and glomerulonephritis
May progress into a Peritonsillar abscess
Viral Pharyngitis
MC cause sore throat
Viral Pharyngitis - s/s
Odynophagia (painful swallowing)
F/muscle aches
tender/swollen lymph nodes
+/- exudates
cough!
nasal congestion/coryza/sneezing
Viral Pharyngitis - Dx
rapid strep test
throat culture
Viral Pharyngitis - Tx
conservative tx
Strep Pharyngitis (centor criteria)
- Fever >38
- tender ant. cervical adenopathy
- lack of cough
- pharyngo- tonsillar exudate
+/- 1 point for age
all 4 = strongly suggest GABHS
3/4 = sensitivity of rapid tests >90%
1/4 = GABHS unlikely
Strep Pharyngitis (CDC suggestions)
0-1 : no culture or test; no abx
2-3 : throat culture OR rapid test; + = abx
4 : high risk GABHS; tx w/o test
if hoarsness, cough or coryza present = NOT likely strep
Strep Pharyngitis - Dx
rapid strep test
culture
Strep Pharyngitis - Tx
Benzathine IM (painful)
Pen V
AMOX BID 10 days
erythro, azithro, cephalosporin if PCN allergy
Strep Pharyngitis - Complications
scarlet fever
glomerulonephritis,
abscess,
rheumatic fever
Strep Pharyngitis - s/s
Sudden onset sore throat
Fever
Tonsillopharyngeal &/or uvular edema
Anterior cervical adenitis
Scarlatiniform skin rash (scarlet fever)
Infectious Mononucleosis
EBV (HHV4) - blood test IgM, IgG
MC 12-19 y/o (but any age)
Infectious Mononucleosis - transmission
saliva
“kissing dz”
Infectious Mononucleosis - s/s
F
severe sore throat
POSTERIOR CERVICAL ADENOPATHY
tonsillar exudate
malaise
SPLENOMEGALY (about 50% cases)
photophobia
After effects of mono
Painful Cervical Adenopathy x weeks
large, firm cervical adenopathy – history is important!
unresolved after weeks - LN biopsy (FNA or excision is best) to rule out things like lymphoma
Infectious Mononucleosis - Dx
clinical!
Monospot
EBV test (IgM - acute; IgG - 4 weeks after)
Infectious Mononucleosis - Tx
95% improve w/o specific tx
NSAIDS, acetaminophen
salt water rinses/gargles
Infectious Mononucleosis - education
No contact sports until splenomegaly is resolved!
Reduce the risk of splenic rupture
Fever and sore throat resolve in 7-10 days
Lymphadenopathy and splenomegaly may persist >4 weeks
Significant fatigue for 2-3 months
Infectious Mononucleosis - complications
hepatitis
myocarditis,
encephalitis
Corynebacterium Diphtheriae
Diphtheria (Gram+, club shaped rod)
Transmitted via respiratory secretions
MC attacks resp tract
Corynebacterium Diphtheriae s/s
Nasal infxn = nasal discharge
Laryngeal infxn - upper airway and bronchial obstruction
Pharyngeal infxn - MC = tenacious gray membrane covering the tonsils/pharynx
Corynebacterium Diphtheriae - complications
Myocarditis
Neuropathy
Corynebacterium Diphtheriae - Dx
clinical
culture to confirm
Corynebacterium Diphtheriae - Tx
horse serum antitoxin must be given in all cases of diphtheria (CDC)
ENT (laryngoscopy) - remove membrane if airway obstruction
oral abx - PCN or erythro
Isolate until 3 - pharyngeal cultures
vaccine to prevent
Pharyngitis- Other Causes
N. Gonorrhea (STD of pharynx, direct contact)
HSV (very painful, “whitish” ulcerations post. oropharynx; gums gray and slough)
Coxsackie virus (Hand, Foot, Mouth) -
Abnormal Voice Sounds
Dysphonia
impairment in the ability to produce sound with the vocal organs
Any abnormal voice sounds = A GOOD H&P!
tobacco use?
laryngeal CA?
lung CA w/ paralysis recurrent laryngeal n?
weight loss?
onset >2 weeks = ENT w/ laryngoscopy
Hoarseness
Abnormal vibration/flow of air past the vocal folds/cords
Hoarseness types
Breathy
Harsh
Rough, low-pitched
Hoarseness causes
Acute Laryngitis
Chronic Laryngitis
Overuse
Benign vocal fold lesions - nodules, polyps
Laryngeal cancer
Neurologic dysfunction
Hoarseness
Referral recommendations
Persistent symptoms > 2 weeks
OR if any concern for serious underlying cause
OR with any associated symptoms such as:
Hemoptysis
Dysphagia
Odynophagia
Otalgia
airway compromise
Stridor
high-pitched breath sounds produced by a narrowed or obstructed airway
timing and rapiditiy of onset KEY
ALL CASES NEED EVAL
must rule out foreign body
Inspiratory stridor
narrowing AT or ABOVE the vocal cords
Expiratory or mixed (biphasic) stridor
BELOW the vocal cords
Acute Laryngitis
Any inflammatory process that affects the larynx
Acute Laryngitis MC cause of
hoarseness (hallmark symptom)
Acute Laryngitis S/S
Hoarseness, Aphonia
Reduced vocal pitch
Associated URI symptoms- cough
Acute Laryngitis - Tx
Supportive therapy
Bacterial- oral antibiotics
Oral/IM steroids?
Laryngopharyngeal Reflux (LPRD)
Chronic laryngitis
GERD into larynx
Laryngopharyngeal Reflux (LPRD)
S/S
throat clearing, throat discomfort, chronic cough, postnasal drip, esophageal spasm
<50% heartburn
excess mucus in throat
increased rhinorrhea
Laryngopharyngeal Reflux (LPRD)
DX
ENT referral
laryngoscopy critical to exclude other causes hoarsness (tumors/ nodules)
+ response to empiric PROTON PUMP INHIB Therapy
decrease spicy foods, tomato based foods
Peritonsillar Abscess (Quinsy)
Dx
Imaging CT
Confirmed aspiration of pus = ENT
Peritonsillar Abscess (Quinsy)
Penetration of infection through the tonsillar capsule and into adjacent tissue
Peritonsillar Abscess (Quinsy)
S/S
severe sore throat
Trismus (limited ability to open mouth, due to spasm)
Muffled “hot potato” voice
deviation of soft palate and uvula (normal side)
Peritonsillar Abscess (Quinsy)
Tx
Abx
tolerate PO = oral abx
unable tolerate PO + more severe s/s = Admit + IV abx
Tonsillectomy if more than 2x - indicated for recurrence
Needle aspiration
I&D
Epiglottitis (supraglottitis)
Acute, rapidly progressive cellulitis of the epiglottis and surrounding tissue that can lead to airway compromise
MC in DM and kids (2-5 y/o)
Epiglottitis (supraglottitis)
cause
viral or bacterial
Epiglottitis (supraglottitis)
S/S
4 D’s
- Drooling
- Dysphagia
- Dyspnea
- Dysphonia (hot potato voice)
Tripod position
f/c
Epiglottitis (supraglottitis)
Dx
THUMB PRINT SIGN - lateral x-rays soft tissue
Laryngoscopy - ENT + anesthesia = spasm and airway compromise
Epiglottitis (supraglottitis)
Tx
Keep the patient comfortable!
DO NOT use a tongue depressor
respiratory distress, = intubate and secure the airway!
ADMIT
IV abx - cephalosporins
IV steroids - dexamethasone
Close airway obsevation
Continuous pulse ox
prep intubate
Vocal Cord Nodules
Smooth, PAIRED lesions at the junction of the anterior 1/3 and posterior 2/3
due to vocal abuse/ overuse
common cause of hoarsness
Vocal Cord Nodules - TX
Modification of voice habits (most resolve)
Referral to speech therapy
Do not resolve = surgery ?
Vocal Fold Polyps
UNILATERAL masses within the superficial lamina propria
Typically larger than nodules
due to vocal trauma (resolution of cord hemorrhage)
Vocal Fold Polyps - TX
Vocal rest, steroids for small polyps
Excision- larger polyps
Vocal Fold Cysts
Traumatic lesions from mucus-secreting glands on the inferior aspect of vocal folds
vary in size and degree of symptoms
Vocal Fold Cysts - tx
rarely resolve completely - often scar (permenant dysphonia)
Surgical intervention to prevent scarring by preserving the mucosal layer
Recurrent Respiratory Papillomatosis
benign, rare malign
symptomatic and causes hoarness
MC in kids
Recurrent Respiratory Papillomatosis
cause
HPV type 6 & 11
Recurrent Respiratory Papillomatosis
Tx
Failure to tx= distal spread and airway compromise
Tx: repeated laser vaporizations or resections
Severe cases = airway compromise in adults and may require treatment every 6 weeks
Polypoid Corditis
loss of …
elastin fibers and loosening of intracellular junctions within the lamina propria
= swelling of superficial lamina (REINKE EDEMA)
Polypoid Corditis strong assoc. w/
SMOKING
vocal abuse, chemicals, hypothyroid
Polypoid Corditis Tx
Surgical resection if stridor or airway obstruction
Vocal Cord Paralysis
lesion or damage to either the vagus or recurrent laryngeal nerve (RLN)
breathy dysphonia or effortful voicing
Vocal Cord Paralysis - diff types
Unilateral recurrent laryngeal nerve injury
Unilateral Vagus damage/lesions
BILATERAL fold paralysis = Medical Emergency!
Vocal Cord Paralysis
Dx
CT/MRI with contrast of brain and brainstem
Direct visualization with laryngoscope
Vocal Cord Paralysis
Tx
create safe airway with normal vocal ability
Vocal cord injections with ProLaryn (dermal filler)
Vocal cord prosthesis - Thyroplasty (Montgomery Implant)
Laryngeal Leukoplakia
Commonly associated with hoarseness in smokers
Histology = mild, moderate or severe dysplasia
35-60% with severe dysplasia = squamous cell carcinoma
Laryngeal Leukoplakia - tx
Proton Pump Inhibitors, regular surveillance, resection and/or radiation
Smoking cessation (mild/mod)
Squamous Cell Carcinoma of the Larynx
MC malign of larynx
Occurs almost exclusively in smokers
MEN, 50-70 y/o
Associated with HPV 16 and 18
Squamous Cell Carcinoma of the Larynx
S/S
Change in voice quality (new/persist hoarsness >2 weeks in smoker)
neck mass
throat/ear pain
Squamous Cell Carcinoma of the Larynx
Dx
Laryngoscopy with BIOPSY
Lung function and exercise tolerance should be evaluated prior to surgery due to risk of aspiration following procedure for resection
Squamous Cell Carcinoma of the Larynx
Staging
TNM - tumor, node, metastasis
Squamous Cell Carcinoma of the Larynx
Tx goals
Cure
Preserve swallowing and voice
Avoid permanent Tracheostoma
Squamous Cell Carcinoma of the Larynx
Modalities
Radiation
Chemo
Surgical resectino
Long term f/u
Laryngectomy
Removal of the larynx (voice box)
Laryngectomy - after
patients can eat by mouth
Permanent stoma – safest airway
Speech?
Tracheoesophageal Puncture + Prosthesis
Electrolarynx (robot voice from smokers commercial)
