Laryngotracheal disorders Flashcards
What are functions of the larynx?
Voice production, protect the airway from aspiration/cough;assist in swallowing, airway/breathing, increase in intrabdominal pressure for valsalva, defecation
What is the power source for vocal production?
Lungs
What is the oscillator/affects tone and pitch in vocal production
larynx
What is the resonator/shapes, resonates, and articulate sounds in an individual voice?
Pharynx/sinuses
What are the components of the vocal ligament?
intermediate lamina propria and deep lamina propria
What are the components of the vibratory microanatomy?
- Mucosa (epithelial cover-stratified squamous epithelium, spuerficial lamina propria-layer of surgical interest for benign pathologies)
- Intermediate and deep lamina propria
- Thyroarytenoid muscle
ABduction for the larynx is necessary for
breathing
ADduction of the larynx is necessary for
sound production, and during swallowing
What are some common causes of voice hoarseness
- Neurological injury (recurrent laryngeal nerve injury)
- Alterations of vocal fold lining
What are possible causes in non lesion alterations of vocal fold lining seen in voice hoarseness
- GERD/LPR
- Sinus disease/allergic rhinitis
- Dehydration
- General health and wellness
What are some possible causes for neurological injury that causes voice hoarseness?
- iatrogenic injury (MOST COMMON)
- Neoplasm
- Viral neuropathy
- Idiopathic Injury
What are some symptoms of unilateral vocal fold paralysis?
- Breathy
- Weak dysphonia
- Poor cough
- Dysphagia
The majority of laryngeal lesions that coase voice hoarseness involve which layers of the vocal cords?
The superficial layers of the vocal fold: Superficial lamina propria and epithelial cover
What are some types of benign vocal fold lesions?
- Nodules
- Polyps
- Cysts
- Hemorrhage
- Carcinoma
What is the most common cause of benign vocal fold lesions?
Phonotrauma (screaming)
What is the most common benign neoplasm of the larynx seen in children?
Recurrent respiratory papillomatosis
What is recurrent respiratory papillomatosis?
Exophytic airway lesions that may involve the entire aerodigestive tract
Does recurrent respiratory papillomatosis affect juveniles or children?
Both, but juvenile form is more aggressive
What is the etiology of recurrent respiratory papillomatosis?
Associated with Human Papilloma virus (HPV) types 6 and 11.
Childhood disease is linked to mom’s with genital HPV. While adult onset is possibly associated with oral-genital contact. Malignant transformation occurs in 1-7% of those for HPV11
Gardasil-9 protects against which HPVs?
6, 11, 16, 18, 31, 33, 45, 52, 58
Quadrivalent gardasil protects against which HPVs?
6, 11, 16, 18
Bivalent cervarix protects against which HPVs?
16 and 18
Treatment of vocal fold lesions includes what therapies?
A combination of medical treatment, speech therapy, and surgical therapy
The majority of larygneal carcinoma is what type of cancer?
> 90% are squamous cell carcinoma. The tumor typically arises from stratified epithelium or from respiratory epithelium that has undergone squamous metaplasia
What is the largest risk factor for laryngeal carcinoma?
Smoking is the largest risk factor, while alcohol use has synergistic effect
Is larygneal carcinoma curable?
Yes, it has excellent cure rates for early stage disease
Discuss the epidemiology regarding laryngeal cancer
- Common head and neck cancer mutations
- Prevalent over 40 years of age
- 4:1 male predilection
- More prevalent among lower socioeconomic class, in which it is diagnosed at more advanced stages
- 1/3 will die of their disease
What are the different types of laryngeal carcinomas?
- Supraglottic (above vocal folds)
- Glottic (In vocal cords): MOST COMMON
- Subglottic (below vocal folds): most rare
What is the most common symptom for layrgneal carcinomas. What are other symptoms?
Most common symptom is hoarseness.
Other symptoms: Dysphagia, hemoptysis, throat pain, ear pain, airway compromise, aspiration, neck mass
What is the treatment for early stage layryngeal carcinoma? (I or II)
single modality therapy: Surgery OR Radiation therapy (85-95% local control rate)
What is the treatment for advanced stage laryngeal carcinoma? (III or IV)
Combined-modality therapy
- Primary surgery followed by radiation
- Concurrent chemoradiation therapy
- Primary CRT or RT with surgery for salvage
What are some complications that can develop from radiation treatment?
- Skin changes
- Mucositis
- Odynophagia
- Laryngeal edema
- Xerostomia
- Stricture and fibrosis
- Radionecrosis
- Hyperthyroidism
What are some of the types of surgical therapies for advanced laryngeal cancer?
- Transoral laser microsurgery
- Open partial laryngectomy
- Total laryngectomy
What is involved with a total larygnectomy?
Complete separation of the digestive and respiratory tracts. Tracheal stump attached to neck
What types of options are available for an individual with no voice box?
- Electrolarynx: Although has poor intelligiblity and is cumbersome in that it requires external device
- Pure esophageal speech: Forces a bolus through the cricopharngeus. The air bolus is then regurgitated through the pharyngoesophageal segment, which vibrates to produce sound
- Tracheoesophageal speech: Diversion of exhaled air into the pharynx by way of a permanent, surgically constructed tracheoesophageal fistula. The pharyngoesophageal segment above the fistula vibrates, producing a neovoice
What are some signs of pediatric obstructive sleep apnea
- Mouth breathing, snoring, snorting, gasping, apnea
- Dysphagia and choking on solid foods indicate obstructing tonsils, whereas hyponasal speech suggests enlarged adenoid tissue
- Poor sleep, enuresis, poor attention
There is a greater risk of OSA in patients with __ and __.
Decreased neuromuscular tone and craniofacial anomalies
How is OSA diagnosed?
Mostly clinical diagnosis is used, but definitive diagnosis by polysomnography. Routing use for diagnosis is not recommended in children
What might be demonstrated on a polysomnography test in a patient with OSA?
episodic hypoxia, intermittent hypercapnia, and sleep fragmentation
OSA occurs in __% of children, peaks in __ age, and is more prevalent in __ children.
2-3%, peaks in pre school age, more prevalent in obese children
What are some morbidities/ complications of OSA?
Failure to thrive, poor growth, learning diabilities, behavioral problems, cardiopulmonary issues, ADHD
What is the most common cause of upper airway obstruction in children?
Adenotonsillar hypertrophy
What are forms of treatment for pediatric OSA?
Surgical: Adenotonsillectomy
Non-surgical: CPAP and/or weight loss
What might be seen in a patient after having had their pediatric OSA surgically treated?
Improved height and weight and improved school performance
What is stridor?
High pitch breathing from turbulent airflow through the larynx or trachea caused by narrowing or obstruction. It can be inspiratory, expiratory or biphasic
What is stertor?
Used to described airway noise from nose, nasopharynx, and oropharynx. Low pitched, nonmusical, snoring
What is wheezing?
High pitched sound, indicating LOWER AIRWAY DISEASE; more commonly end expiratory noise
Where does inspiratory stridor generally come from?
From the supraglottis/glottis
Where does biphasic stridor generally come from?
Subglottis
Where does expiratory stridor generally come from?
From the trachea
Snoring occurs from an obstruction in which of the following? (Nasopharynx, larynx, trachea/bronchi, small airways)
Nasopharyx, and possibly the larynx in small babies
Stridor occurs from an obstruction in which of the following? (Nasopharynx, larynx, trachea/bronchi, small airways)
Nasopharynx, larynx, trachea/bronchi
Wheezing occurs from an obstruction in which of the following?
Larynx (severe obstruction, trachea/bronchi, small airways
Thumb sign is indicative of what condition? Is this an airway emergency?
Epiglottisi; it is an airway emergency
Epiglottitis or supraglottitis is more commonly seen in children or adults?
Seen in both, but is more common in children
What is the typical bacteria associated with epiglottitis or supraglottitis?
Haemophilus influenzae type b and streptococcus species
What is the treatment for epiglottitis or supraglottitis?
- Secure the airway
- FLexible fiberoptic nasotracheal intubation
- tracheotomy
- Cricothyrotomy
- ENT and anesthesia available
- IV abx and steroids
What is Croup?
Laryngotracheobronchitis; a common primarily pediatric viral respiratory illness
Croup affects __% of children 6 months-6years old
15%
With croup, there is a __ and __ lasting for 12 to 72 hours
prodromal period coryza and low grade fever
What are the common viruses seen in croup?
parainfluenzae, influenza, measles, adenovirus, RSV.
But can have bacterial superinfection
What are some symptoms of croup?
Barking cough, stridor, hoarseness, difficulty breathing. Swelling from inflammation leads to airway narrowing
What is a common sign on x-ray seen in croup?
Steeple sign
How serious is croup?
Not very? The majority recover with no sequelae. Mostly managed as outpatients, while small % require hospitalization
What is the treatment for croup?
- Steroids
- Nebulized racemic epinephrine (constricts arterioles, fluid resorption, and bronchodilation)
- Cool mist- moistens airway, decreases viscosity, and soothes inflamed mucosa
Compare and contrast epiglottis vs croup
Epiglottitis: Haemophilus influenzae B, 2-6 yrs old, rapid, no cough, severe dysphagia, inspiratory stridor, fever/drooling, tripod, muffled voice, thumbprint sign
Croup: Parainfluenza virus, <3 years old, slow, barking cough, no dysphagia, biphasic stridor, fever, lying back, hoarse voice, steeple sign
What is the most common cause of stridor in infants? Other causes of stridor in infants>?
Most common: Laryngomalacia
Other causes: Bilateral vocal fold paralysis, laryngeal web, laryngeal atresia, subglottic stenosis, subglottic hemangioma, recurrent respiratory papillomatosis
What is laryngomalacia?
Congenital abnormality of laryngeal cartilage; usually presents<2 months of life and resolves by 18 months
The floppy cartilage leads to collapse and inspiratory stridor. Worse when supine, feeding, and with exertion
What is the treatment for laryngomalacia?
- Mostly self limiting; observation
- In 10%, surgery (supraglottoplasty) may be indicated. Severe stridor, apnea, failure to thrive, pulmonary hypertension
What are some causes of laryngotracheal stenosis?
- Congenital
- Idiopathic
- Trauma (external, blunt, penetrating, thermal, or chemical burn. Intubation/tracheotomy. Radiation)
- Chronic inflammatory disease (Bacterial, fungal, TB, leprosy, sarcoidosis, RA. GERD)
- Benign neoplasms/malignant neoplasms
- Collagen vascular diseases (Granulomatosis with polyangitis, relapsing polycondritis)
What are some contributing factors for laryngotracheal stenosis?
Endotracheal tubes: Not typically recommended use >7-10 days. Or size of tube too large (7-8 mm ID for adult males, 6-7mm females)
How does laryngotracheal stenosis occur from endotracheal tubes?
Edema, ulceration, secondary infection, perichondritis, granulation tissue
Who are at increased risk for laryngotracheal stenosis from endotracheal tubes?
GERD, Chronic illness, Immunocompromised, Radiation, Diabetes
What are some symptoms of laryngotracheal stenosis?
- Shortness of breath with exertion
- High pitched inspiratory breathing or stridor
- No aid with use of inhalers
- Tightness in throat
What are some indications for tracheotomy?
- Bypass upper airway obstruction
- Prolonged intubation to avoid long term complications
- Cure for obstructive sleep apnea/hypercarbic hypobentilation syndrome
- Patients who need a ventilator long term
Rules for tracheotomy?
- Know the size
- Cuff or no cuff
- Keep clean and open airflow
