Inflammatory Conditions of Larynx Flashcards
What is laryngitis?
- Any inflammation to larynx
- Can be viral, bacterial or fungal infections; trauma, phonotrauma, smoking, allergies, reflux, XRT, autoimmune problems
- Can be acute, sub-acute or chronic
- Pediatric cases are mostly infections while in adults cause is primarily reflux, then smoking
- Acute: generally from infection and lasts ~10 days
What are the 4 symptoms of laryngitis?
hoarseness or aphonia
(Pain when talking) odynophonia/odynophagia
dysphagia
dyspnea
How does the larynx look?
redness, swelling, secretions, irregularities of folds, asymmetrical vibration, reduced mucosal wave and incomplete closure
Management for acute laryngitis?
ABT if bacteria inhalation of steam reduced phonation hydration/ avoid drying agents If severe swelling, medical referral to maintain airway
Symptoms of chronic laryngitis (a.k.a. laryngitic sicca) ?
chronic (more than 3 weeks)
significant hoarseness, low pitch, breathy and reduced loudness
What are causes of chronic laryngitis?
- Causes: smoking, alcohol abuse, voice overuse
* Also contributions from environmental pollutants, reflux, throat clearing/coughing, allergy
How does the laynx look when its chronic?
hyperkeratosis, thick mucus, fibrosis, scarring; may also see secondary effects: nodules, polyps
Management of chronic laryngitis?
identify and eliminate the irritants; vocal hygiene, voice therapy
Causes of GERD?
physiologic
diet
meds
smoking
How to assess for GERD?
clinical signs and symptoms
laryngeal exam
pH monitoring
Reflux Symptom Index
Tx for GERD?
- Team management for variety of symptoms
- Voice therapy important for LPR as often generally have dysphonia and develop maladaptive approach to phonation
- Diet/lifestyle changes
- Meds
- Surgery
What are autoimmune diseases that affect the voice?
Systemic Lupus Erythematosus (SLE):
Relapsing Polychonidritis (RP)
Rheumatoid Arthritis (RA)
Sjogren’s Syndrome
Symptoms of SLE and tx?
inflammation, infection, subglottic stenosis and epiglottitis. Treated with cortico-steroids
Symptoms of RP and tx?
swelling of connective tissues; serious when affects support of upper airway. Treated with cortico-steroids and immune system suppressants
Symptoms of RA and tx?
affects synovial joints, including cricoarytenoid and cricothyroid joints. When affected, see inflammation posteriorly, decreased arytenoid mobility and dysphonia. Patient may experience pain, sensation of globus, dysphagia, stridor and hoarseness
• Can mimic VF paralysis
• Treated with anti-inflammatory and pain meds
Symptoms of Sjorgen’s syndrome?
dryness of eyes and respiratory tract
• Body’s immune system attacks mucus-producing glands
• Larynx can be covered with thick, dry mucus
• Limited VF excursion and increased phonatory effort; can lead to hyperfunction
What are features of Paradoxical Vocal Fold Motion?
- Frequently misdiagnosed as asthma
- Features:
- vocal cords close as attempt to breathe (most on inhalation, but 10% with exhalation difficulty)
- usually no dysphonia but can hear breathy voice or weak to hoarse voice
- often hear STRIDOR
- may complain of difficulty swallowing, sore throat
- KEY PROBLEMS: air hunger and panic
What are the causes of PVFM?
- 1)Psychogenic/performance anxiety:
- May be primary (Koufman and Block feel rare) or secondary to fear of air hunger
- If primary, often have other psych history
- 2) Airway hyperreactivity:
- Probably most common and of these most have signs of LPR or GERD
- Also related to post-nasal drip, sinus drainage, exposure to gas, smoke, fumes, vapor, dust
- 3) Possible neurogenic: brain stem or vagal disturbance; episodic laryngeal dyskinesia or laryngeal dystonia (similar to SD but affects all breathing not just breathing for speech)
- 4) Pharmacologic: related to use of neuroleptic drugs and sometimes anesthesia
- Symptoms usually short-lived and reversible
- 50% estimated to have asthma in combination
Differences between Asthma and PVFM?
• Asthma: Bronchial constriction and inflammation Lower Airway Typical expiratory wheeze Slow onset and resolution Respond to bronchodilators • PVFM: Closure or adduction of vocal folds Upper airway Rapid onset and offset Not responsive to bronchodilators
What are the symptoms of PVFM?
- Not generally associated with voice problems but may have mild hoarseness or breathy, weak phonation
- Shortness of breath
- Throat tightness (not chest)
- Cough, wheeze
- Inspiratory stridor
- Some with consistent airway obstruction, some paradoxical: as attempt to inhale, get adduction or as attempt to exhale, get closure(10%)
- Some experience as many as 25 episodes/day while others only once a month
How does the larynx look during PVFM?
- During spasm, true and possibly false cords adduct
- When non-episodic, exam is normal
- May attempt to trigger event by having patient run or exercise
- High percentage now found to have tissue changes consistent with reflux
Assessment of PVFM?
1) Medical
*Inhale helium/oxygen mix (heliox)
*If related to excess tissue, excise
*Ipratropium (anticholinergic aerosol)
2) SLP
a.eval
b.flexible endoscopy
) c. Some recommend pulmonary function testing, especially spirometry
• d) Reflux Symptom Index
• e) Patient Education
Attenuate fear, increase awareness
Explain anatomy/physiology
Explain control
Teach relaxation technique
Teach low breathing (A/D) pattern
Teach breathing recovery exercise to practice daily
Request journal
TX for PVFM?
Probably requires 3-5 additional sessions
Counseling and exercises
• Preparation when relaxed for dealing with episodes
• Diaphragmatic breathing exercises
• Wide open throat breathing
• Focus on exhalation
• Take ownership of the training sequence
• Interrupt the effortful breathing
What’s the blager sequence?
- Hand on abdomen
- Know the breathing pattern
- Inhale with relaxed throat while tongue relaxed on floor of mouth, lips relaxed/closed
- Exhale on /s/
- Use at any sign of problem and 5 reps several times per day
What the PVFM recovery breathing?
DEEP SNIFF w/shoulders and neck relaxed- practice until reliable
- One deep sniff or 2-3 quick sniffs to open folds
- Pair sniff with low breathing (sniff down to belly button) no shoulders!
- Add slow exhale on any of these: s, sh, f
- Get all air out
- Train until automatic then teach to use when first sign of impending event
Whats the Sandage and Zelazny sequence for PVFM?
goal not so much relaxation and heightening awareness of subtle changes establish low breathing: often develop neck/shoulder tightness and high chest, shallow breathing
commonalities of PVFM tx?
- 1) attention on technique and away from panic
- 2) patient in control
- 3) attention exhalation relaxes the system
- 4) nasal breathing gives increased glottal space
- 5) make sequence automatic so can use in stress
- 6) identify early and start sequence to prevent
Chronic cough
cough that lasts more than 3 weeks, not related to active infection, dry, non-productive
Accompanied by fatigue, social avoidance, poor sleeping
Management of chronic cough?
- First step: medical assessment to r/o pulmonary disease, asthma, extra-thoracic obstruction
- Evaluation for post-nasal drip, reflux
- When all ruled out and post-nasal drip, reflux managed, begin behavioral intervention
SLP tx of chronic cough?
Intervention program:
1) Improve the environment of the larynx: eliminate exacerbating agents like menthol cough drops, gargling, dry environment
Add hydration and wet snacks (fruit).
Breathe through nose
Avoid reflux foods: caffeine, chocolate, spicy, fried, carbonated beverages, alcohol
• Avoid tight clothing
• Avoid eating less than 3-4 hours before bed
• Avoid strenuous exercise after eating
2) Recalibrate the sensitivity threshold:
Teach client to delay or eliminate the cough before it starts; before can do that, must train sensitivity
Once aware of precursory feeling, substitute one of following: ice chip or cold water, swallow hard, swallow hard with laryngeal re-positioning or nasal inhalation
3) follow-up at one week, one month intervals as needed to refine plan and facilitate carryover
SLP assessment of chronic cough?
• Case history: careful, detailed! Especially re: nature of cough and pattern
What is sulcus vocalis?
Indentation of the mucosal covering of vf
-associated with scarring
Hat are symptoms of scarring and sulcus vocalis?
Glottal insuffiency like Breath unless Roughness Low pitch range Low volume Vocal fatigue Effortfull phonation Voice breaks Aphonia
If false vf are used to phonate what are the symptoms?
Strained low pitch
