LARYNX Flashcards
location of larynx?
anteiror compartment of the neck
suspended from hyoid bone, opens superiorly in laryngopharynx, spans C3-C6 and then continues inferiorly with the trachea
boundaries of the larynx?
covered anteriroly by the infrahydois muscles, laterally by the thyroid lobes and posteriorly by oesophags
what is the internal cavity of the larynx lined by?
pseudostratified columnar epithelium
(other than true vocal cords which are lined by stratified squamous epithelium)
what are the 3 regions of the larynx?
supraglottis - from inferior epiglottis to vestibular folds
glottis
subglottis - from 1cm bellow glottis to inferior border of cricoid cartilage
vasculature of the larynx?
arterial - superior and inferior laryngeal arteries
venous - superior and inferior laryngeal veins
sensory and motor inervation to the larynx?
recurrent larngeal nerve provides motor innervation to all internal muscles except the cricothyroid + sensory innervation to infraglottis
superior laryngeal internal branch provides sensory innervation to supraglottis, and external branch provides motor innervation to the cricothyroud muscles
infrahyoid muscles?
omohyoid
sternohyoid
sternothyroid
thyrohyoid
suprahyoid muscles?
stylohyoid
digastric muscle
mylohyoid
gleniohyoid
how can we visualise the larynx?
laryngoscopy or videostroboscopy
what is videostroboscopy?
using an endoscope with a strobe light to create a series of images that appear to be slow motion vibration of the vocal folds. This helps assess how well the vocal cords are vibrating
physiology of vocal cord vibration?
intrinsic muscles bring vocal cords together to close the glottis
pressure against the closed vocal cords blows them apart
When the vocal folds vibrate, they alternately trap air and release it. Each release sends a little puff of air into the pharynx; each puff of air is the beginning of a sound wave
Physiology of vocal cords to raise the pitch?
Vocal cords vibrate faster so they get thinner by being stretched - done by extrinsic laryngeal muscles
What is laryngitis?
Inflammation or infection of the larynx and vocal cords
Most common causes of laryngitis?
Viral laryngitis is most common - rhinovirus, adenovirus, parainfluenza, influenza
Bacterial and fungal also possible
Can also be caused by trauma e.g. excessive voice use, chronic coughing etc
Symptoms of laryngitis?
Episodic coughing
Throat clearing behaviours
Hoarse voice
Dysphonia
Dysphagia
Fever
Systemic symptoms
Management of laryngitis?
Self-limiting so offer NSAIDs
When should you offer antibiotics for a sore throat?
Marked systemic upset
Unilateral features of peritonsillitis
PMHx of rheumatic fever
an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
What antibiotics should be given for a sore throat if indicated?
Phenoxymethylpenicillin for 7-10 days
(Clarithromycin if allergic)
What is the centor criteria?
Centor criteria: score 1 point for each (maximum score of 4).
Tonsillar exudate.
Tender anterior cervical lymphadenopathy or lymphadenitis.
History of fever (over 38°C).
Absence of cough.
A score of 0, 1 or 2 is thought to be associated with a 3-17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32-56% likelihood of isolating streptococcus.
What is the FeverPAIN criteria?
Score 1 point for each (maximum score of 5)
Fever (during previous 24 hours).
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (within 3 days after onset of symptoms).
Inflamed tonsils.
No cough or coryza.
A score of 0 or 1 is associated with a 13-18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34-40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62-65% likelihood of isolating streptococcus.
What most commonly causes acute sore throats?
Viruses - most commonly rhinovirus, coronavirus, parainfluenza virus, influenza virus
Strep, adenovirus, HSV 1, EBV, fusobacterium necrophorum
Whats the most common bacterial case of sore throat?
Group A beta-haemolytic strep (strep pyogenes)
What is scarlet fever?
A reaction to erythrogenic toxins produced by group A haemolytic strep (usually strep pyogenes)
Spread via resp route
Most common in children 2-6
Presentation of scarlet fever?
Fever for 24-48 hours
Malaise, headache
N&v
Sore throat
Strawberry tongue
Pinhead rash on torso most obvious in flexure with a rough sandpaper texture (desquamation occurs later around fingers & toes)
Compilations of strep pharyngitis/tonsilitis?
Scarlet fever
Otitis media
Acute sinusitis
Quinsy
More rare…
Acute rheumatic fever
Acute glomerulonephritis
Reactive arthritis
What is a quinsy?
A peritonsillar abscess that usually develops as a complication of bacterial tonsillitis
Presentation of a quinsy?
Severe throat pain lateralising to 1 side
Deviation of uvula to unaffected side
Trismus (difficulty opening mouth)
Reduced neck mobility
Management of quinsy?
Urgent ENT review
Needle aspiration or incision and drainage
IV antibiotics
Consider tonsillectomy for prophylaxis
Examination findings for pharyngitis?
Pharyngeal exudate
Cervical lymphadenopathy
Fever
Examination findings for tonsilitis?
Tonsillar exudate
Enlargement and erythema of tonsils
Anterior cervical lymphadenopathy
Fever
What symptoms suggest viral rather than bacterial pharyngitis?
Rhinorrhoea
Nasal congestion
Cough
What symptoms suggest a strep infection of the throat?
Fever over 38.5
Exudate on pharynx or tonsils
Anterior neck lymphadenopathy
Absence of cough
What causes glandular fever?
EBV (HHV-4)
Classic triad of symptoms for glandular fever?
2-4 weeks of…
Sore throat
Lymphadenopathy
Pyrexia
(May also cause malaise, anorexia, headache, palatal petechia, splenomegaly, hepatitis, haemolytic anaemia, lymphocytosis)
What happens to pt if they take amoxicillin when they have glandular fever?
99% develop a maculopapular, pruritic rash
How do we diagnose glandular fever?
Monospot test (heterophil antibody test) - do in 2nd week of illness
Management of glandular fever?
Rest, fluids, avoid alcohol
Simple analgesia
Avoid playing contact sports for 4 weeks to reduce risk of splenic rupture
What no. Of episodes of tonsillitis would you be having for ENT to consider tonsillectomy?
> 7 episodes for 1 year
5 episodes for 2 years
3 episodes for 3 years
What are the indications for a tonsillectomy?
Obstructive Sleep Apnoea / Sleep disordered breathing in Children
Suspected Cancer
Recurrent tonsillitis or Quinsy (abscess next to tonsil)
Emergency Presentations (e.g. treatment of parapharyngeal abscess)
Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous
Acute and chronic renal disease resulting from acute bacterial tonsillitis
As part of the treatment of severe guttate psoriasis
Metabolic disorders where periods of reduced oral intake could be dangerous to health
PFAPA (Periodic fever, Apthous stomatitis, Pharyntitis, Cervical adenitis)
What is dysphonia?
A disorder characterised by altered vocal quality, pitch, loudness or vocal effort that impairs communication
Aka hoarseness
Causes of dysphonia
Malignancy - lung or laryngeal cancer
gastro-oesophageal reflux
Vocal cord nodules, cysts or papillomas
Vocal cord palsy
Trauma e.g. intubation or excessive use of voice
Endocrine e.g hyothyroidism
Infections e.g. laryngitis or candida
Iatrogenic e.g recurrent laryngeal nerve palsy secondary to thyroid surgery
Smoking or voice overuse
What is spasmodic dysphonia?
A rare, focal dystonia of the larynx that affects the laryngeal muscles and causes involuntary spasms
Thought to be caused by damage to the basal ganglia
Aka shaky voice
What are the 2 main types of spasmodic dysphonia and which is more common?
Adductor spasmodic dysphonia - most common (spasms in the muscles that bring the vocal cords together)
Abductor spasmodic dysphonia
Symptoms of spasmodic dysphonia?
Hoarse or strained voice
Uncontrollable pitch
Voice breaks
Fluctuating voice quality
Tremor in voice
How do we treat adductor spasmodic dysphonia?
Injections of botulinum toxin type A to cause paralysis of the thyroarytenoid muscles = no vocal spasms
What are vocal cord granulomas?
Benign growths on the vocal cords
Aka contact ulcers or arytenoid granulomas
What can cause vocal cord granulomas?
Chronic acid reflux
Trauma from intubation
Chronic mild trauma e..g throat clearing
Excessive use of or strain on voice
Symptoms of vocal cord granulomas?
Hoarse voice
Effortful voice
Globus
Frequent voice breaks
Voice fatigue
Throat pain
Treatment of vocal cord granulomas?
Voice exercises and may be SALT input
Acid reflux treatment
ENT may remove it surgically
Botulinum toxin may be used
What usually causes vocal cord paralysis?
Damage to the recurrent or superior laryngeal nerve
Outline the anatomy of the laryngeal nerves?
The left recurrent laryngeal nerve has a long course which extends down into the chest and loops under the arch of the aorta to return to the larynx. The right recurrent laryngeal nerve is shorter and loops around the subclavian artery - thus the left nerve is more susceptible to disease than the right
What is Semon’s law?
In a progressive lesion of recurrent laryngeal nerve, the abductors are paralysed before the adductors. This means that in an incomplete paralysis, the cord will be brought to the midline by the adductors but in complete paralysis it falls away to the paramedical position.
Causes of recurrent laryngeal nerve palsy’s?
Left recurrent nerve can be damaged in the chest - bronchial, oesophageal, mediastinal lymph node carcinomas. aortic aneurysm or surgery to heart/oseophagus
Bulbar palsy
Pseuodbulbar palsy
Jugular foramen syndrome
Thyroid surgery or carcinoma
Penetrating wounds
C-spine surgery
Symptoms of vocal cord palsy?
Bovine cough
Hoarseness
Change in quality of voice
May be difficulties with breathing or swallowing
Management of vocal cord palsy?
Speech therapy
Surgery
What is a bovine cough?
A non- explosive cough of someone unable to close their glottis
E.g. recurrent laryngeal nerve palsy
What are vocal cord polyps?
Very common benign growths on the vocal cords - they tend to occur on 1 vocal cord
Symptoms of vocal cord polyps?
Hoarseness
Throat discomfort
Globus
Vigorous throat clearing
What can cause vocal cord polyps?
Using voice too much or too loudly
Smoking
Reflux
Management of vocal cord polyps?
Voice therapy
Surgery
What is a vocal cord Haematoma?
When a blood vessel in the vocal cords ruptures from foreceful or incorrect vocalisation and there is bleeding involving the superficial lamina propria
Symptoms of vocal cord haematomas?
Sudden hoarse voice
Management of vocal cord haematomas?
Vocal rest to prevent scarring
Blood vessels can be cauatrised if necessary
What are vocal cord nodules?
Tiny bumps that occur on the edge of the vocal folds as a result of excessive friction. Overtime they develop into a swelling and then a nodule. They prevent the vocal folds coming together properly when you talk
Usually form as a pair, 1 on each fold around the anterior 1/3rd of the fold
Symptoms of vocal cord nodules?
Hoarseness
Throat discomfort
Throat clearing
Voice worsens with use
What causes vocal cord nodules?
Overusing voice, shouting, singing, excessive coughing or throat clearing, smoking, reflux
Treatment of vocal cord nodules?
Voice rest
Good vocal hygiene
Speech therapy
Sometimes surgery by ENT
What is laryngeal papillomatosis?
Aka recurrent respiratory papillomatosis?
A rare medical condition where papillomas form along the aerodigestive tract
What causes laryngeal papillomatosis?
HPV infection of the throat -> can cause tumours which may narrow the airway
May also cause tumours elsewhere in the airways
Symptoms of laryngeal papillomatosis?
Hoarseness
SOB
Chronic cough
Stridor
(The juvenile version is often mistakes for asthma or croup in children)
Management of laryngeal papillomatosis?
Surgery
What is laryngopharyngeal reflux?
A group of upper respiratory tract symptoms secondary to irritation fron reflux of gastric contents
Symptoms of laryngopharyngeal reflux?
Hoarseness
Throat clearing
Chronic cough
Globus - worse when swallowing saliva rather than eating or drinking
Dysphagia
May have heart burn
What questionnaire is commonly used for laryngopharyngeal reflux?
The reflux symptom index - a score of >13 = LPR
How can we diagnose laryngopharyngeal reflux?
Gold standard is a 24 hour dual probe pH manometry combine with intrlminal impedance studies
Reflux symptoms index questionnaire
Visualisation of larynx e.g. laryngoscopy
Transnasal oesopahoscopy to exclude other causes
Treatment of laryngopharyngeal reflux?
Life style changes e.g. avoid food 3 hours before sleep, stop smoking, reduce alcohol, address obesity, avoid fizzy drinks, avoid throat clearing
Speech therapy
Alginates or PPIs to suppress acid (less evidence for PPI)
Which side is vocal cord palsy more common and why?
The left due to the nerve being longer
Consequences of a laryngectomy?
1-2 weeks not eating
Won’t be able to speak if total laryngectomy
What can patients with laryngectomies be given to help them speak?
Trachyoesophageal voice prosthesis
Learn to burp air up - SALT can teach this
Electrolarynx
How does a tracheoesophageal prosthesis work?
Surgeon creates a hole between the trachea and oesophagus and implant a one-way valve so that when you cover your stoma and exhale you can re-direct air through the valve into your throat
How does an electrolarynx work?
This is a battery operated machine that produces vibrations so you can make sound
What fluid do we use for post-laryngectomy swallow?
Gastrografin swallow instead of barium swallow
What is laryngomalacia?
Congenital flaccidity of the supraglottic structures of the larynx
Presents in the first 12 months of life with stridor
What are laryngoceles?
Uncommon, benign dilatation of the laryngeal saccule
Often found in players of wind instruments
Presentation of laryngoceles?
Asymptomatic if small
Sore throat, dysphagia, neck lump, airway obstruction
What is polypoid corditis?
Aka reinkes oedema or smokers polyps
When polyps develop on the vocal cords due to chronic smoking
What is Globus pharyngeus/
The sensation of a lump, discomfort or foreign body in the throat
A diagnosis of exclusion - linked to stress or anxiety
