Traumatic disorders of the larynx and trachea diphtheria

							Traumatic disorders of the
    larynx and trachea



                             1
Foreign body inhalation




                          2
Incidence:
It occurs more in children aged 1 – 5 years.
The most common inhaled foreign body is watermelon
seeds and peanuts.
It is more in right bronchus as it is wider and in line with
the trachea




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Symptoms
1. Initial stage: violent fit of cough, chocking, dyspnea and
   cyanosis
2. Latent stage: symptomless
3. Manifest stage: collapse or emphysema
    Collapse: complete obstruction  dullness and shift of
     mediastinum to same side (because the FB prevents air
     flow both during inspiration and expiration).
    Emphysema: partial valvular obstruction 
     hyperresonance and shift of mediastinum to other side
     (due to partial obstruction because the FB acts as a
     one-way valve allowing air in but not out of the lung as
     the bronchi constricts during expiration.
                                                                4
Signs:
     1. Suspect FB inhalation in children with persistent
        non resolving cough even with negative history
        of FB inhalation
     2. Stridor and cyanosis
     3. Dullness and shift of mediastinum to same side in
        case of collapse
     4. Hyperresonance and shift of mediastinum to
        other side in case of emphysema.
     5. Wheezes and cripitaions



                                                        5
Investigations:
1. X-ray chest




2. Bronchoscopy
                  6
Treatment: Bronchoscopic removal
Note

1. Normal chest X-Ray does not role out FB inhalation
2. All that wheezes is not asthma
3. Don't turn a non-obstructing FB into an obstructing one
4. Don't miss the second FB




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                    Trauma of larynx

Incidence:
It is a rare but serious condition
The larynx is protected by:
Mandible
Sternum
The flexion mechanism of neck




                                       8
Type of trauma:
•Blunt trauma (car accidents)
•Penetrating trauma (knife, bullet)
In blunt trauma (larynx becomes crashed between anterior aspect of
cervical spine and the object {steering wheel or dashboard} )

Aetiology
Mechanical:
   •Accidental: blows, gunshot or stab wounds
   •Surgical: high tracheostomy, laryngoscopy and endotracheal
   intubation
   •Self-inflected
Physical: inhalation of steam or irritating gases, irradiation
Chemical: swallowing of corrosives
                                                                 9
Symptoms
Dyspnea and stridor
Hoarseness of voice
Pain in the larynx and during swallowing

Signs:
Swelling: oedema, haematoma and surgical emphysema
Tenderness
Crepitus




                                                     10
Investigations:
CT scanning to asses the extent of the injury
Direct laryngoscopy
Treatment
1. Voice rest,
2. Raised bed head
3. Steroids to reduce edema
4. antibiotics to avoid secondary bacterial infection
5. Endotracheal intubation or tracheostomy when needed.
6. Microlaryngoscopic evacuation of large or persistent
   hematoma.
7. Larngofissure for open reduction of fractured cartilages.


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Inflammatory disorders of the
           larynx




                                12
   Definition:
   Inflammation of the mucosal lining of the larynx.

   Types:
I) Acute laryngitis
   1. Acute non-specific laryngitis.

       a) Acute laryngitis in adults

       b) Acute laryngitis in children (false croup)

       c) Acute laryngo-tacheo-bronchitis (true croup)

       d) Acute epiglottitis

   2. Acute specific laryngitis

        a) Diphtheritic laryngitis                       13
II) Chronic   laryngitis
   1. Chronic non-specific laryngitis
             a) Diffuse chronic laryngitis
             b) Vocal nodules
             c) Vocal polyps
             d) Leukoplakia
   2. Chronic specific laryngitis
             a) Laryngoscleroma
             b) Tuberculosis
             c) Syphilis




                                             14
Acute laryngitis in adults




                             15
Aetiology:
Usually secondary to viral upper respiratory tract infection as
coryza that may be followed by bacterial infection by strept.
haemolyticus or strept. peumoniae.

Symptoms:
General symptoms; fever, headache, anorexia and malaise.
Laryngeal symptoms:
Rapid onset of hoarseness of voice
Throat discomfort especially on talking
Dry cough


                                                            16
Signs:
General signs; fever
Laryngeal signs;
Hyperaemia and edema of the laryngeal mucosa mainly the vocal
folds.




                                                           17
Treatment:
General treatment:
1. Antibiotics
2. Supportive and symptomatic measures as rest, ample fluids, and
   anti-inflammatory drugs

Local treatment:
1. Voice rest
2. Avoid laryngeal irritation by smoking
3. Steam inhalation as Tincture Benzoin composite.




                                                              18
Acute laryngitis in children




                               19
Aetiology:
Similar to acute laryngitis in adults. Usually starts as
  acute rhino-pharyngitis that descends to involve the
  larynx.

Symptoms:
General symptoms;
Fever, headache, anorexia and malaise
Laryngeal symptoms:
1. Rapidly progressive, and potentionally fatal bi-phasic
   stridor.
2. Dry cough that may be associated with laryngeal
   spasm.
3. Hoarseness of voice.                                20
Signs:
General signs;
High grade fever
Laryngeal signs;

Hyperaemia and edema of the laryngeal mucosa
especially the subglottis.




                                          21
Treatment:
The condition should be treated carefully and hospitalization
  is essential as it is a life threatening condition.
General treatment:
1. Antibiotics
2. Steroids to reduce the laryngeal edema.
3. Bed rest in sitting position to facilitate coughing.
4. Humidification of the inspired air to liquefy the secretions.
5. Supportive and symptomatic measures as rest, ample
   fluids, and anti-inflammatory drugs
Local treatment:
1. Oxygen inhalation through a face mask
2. Endotracheal intubation of tracheostomy when necessary.
                                                        22
Acute epiglottitis




                     23
Aetiology:
Age: More common in children than adults.
Causative organism: haemophilus influenzae type B

Symptoms:
General symptoms;
Rapid onset of fever, headache, anorexia and malaise.
Laryngeal symptoms:
Rapidly progressive and potentially fatal inspiratory stridor.
Rapidly progressive painful swallowing (odenophagia) the
patient is unable to swallow his own saliva.
Hot potato muffled voice.

                                                                  24
Signs:
General signs;
High fever. The child prefers to sit up rather than lie down.
Laryngeal signs;

Marked hyperaemia and edema of the epiglottis.




Investigations:
                                                                 25
Plain X-ray of the neck shows swollen epiglottis
If you think the patient provisional diagnosis is epiglottitis, do
not examine his mouth using tongue depressor because the
patient may go in severe stridor on pressing his tongue and
try to do plain X-ray lateral view neck and if thumb sign is
there, it is a case of epiglottitis

Treatment:
Similar to acute laryngitis in children




                                                               26
Diphtheritic laryngitis




                          27
Aetiology:
Most commonly secondary to pharyngeal diphtheria.

Symptoms:
General symptoms;
Similar to pharyngeal diphtheria
Laryngeal symptoms:
Stridor secondary to laryngeal obstruction by diphtheritic
membrane and edema.
Hoarseness of voice.




                                                        28
Signs:
General signs;
Similar to pharyngeal diphtheria
Laryngeal signs;
The laryngeal mucosa is covered by dirty grayish membrane.

Treatment:
Similar to pharyngeal diphtheria
Tracheostomy when needed




                                                        29
Diffuse chronic laryngitis



                             30
Aetiology:
   1. Repeated attacks of acute laryngitis.
   2. Prolonged exposure to laryngeal irritants as smoking
      and dust.
   3. Prolonged voice abuse.
   4. Gastro-esophageal reflux.
   5. Allergy.

Symptoms:
1. Hoarseness of voice.
2. Sensation of throat irritation leading to frequent hemming
   and hawking.


                                                         31
Signs:
Bilateral symmetrical thickening of the vocal fold. This may be;
   a) Whitish
   b) Reddish
   c) Pale and edematous (called Reinke’s edema)




                                                                   32
Vocal (singer’s) nodules




                           33
Aetiology:
Prolonged voice abuse

Incidence:
More   common     in     children   (screamer’s     nodules)   and
professional voice users as teachers, singers and Quran
reciters.

Pathology:
Localized   epithelial    hyperplasia   and   /or     subepithilial
organized microhematomas of the vocal folds.

                                                                 34
Symptoms:
1. Hoarseness of voice.

2. Phonasthenia.




Signs:
Bilateral small sessile smooth swellings.

They occur at the junction of the anterior 1/3 and posterior
  2/3 of the vocal folds (middle of membranous vocal folds).
  This is because this is the site of maximum contact of the
  vocal folds during phonation (maximum trauma)
                                                          35
Treatment:
1. Voice rest.
2. Voice therapy: This is the treatment of choice. It is
   usually successful.
3. Micro- laryngeal excision by laser or              surgical
   instruments in case of failure of voice therapy.
4. Management of gastro-esophageal reflux.




                                                             36
Vocal polyp




              37
Aetiology:
Unknown. May be voice abuse

Pathology:
Localized     sub-epithilial   edema   (edematous   poly),   vascular
engorgement (vascular poly) or fibrosis (fibrotic polyp) of the
vocal fold.




                                                                    38
Symptoms:
Hoarseness of voice.



Signs:
Unilateral variable sized sessile or pedunculated smooth
  swelling. It occurs on the anterior part of the vocal fold. It
  may be grayish (edematous polyp), reddish (vascular
  polyp) or whitish (fibrotic polyp).

Treatment:
1. Micro- laryngeal excision by laser or surgical instruments.
2. Voice therapy: to avoid recurrence.
                                                              39
Leukoplakia




              40
Aetiology:
Unknown. May be prolonged exposure to laryngeal irritants
as smoking and dust.

Pathology:
Localized subepithilial hyperplasia and keratinization with or
without cellular dysplasia of the vocal folds. The basement
membrane remains intact. It is considered as carcinoma in
situ (preinvasive).




                                                           41
Symptoms:
Hoarseness of voice.

Signs:
Unilateral or bilateral irregular white raised patches of the
vocal fold (s).




Prognosis:
Precancerous.                                             42
Treatment:
1. Micro- laryngeal excision by laser or surgical
   instruments.    Histopathological   examination is
   mandatory to confirm the diagnosis.
2. regular follow up is essential because it is precancerous.




                                                            43
Laryngoscleraoma




                   44
Aetiology:
Most commonly secondary to rhinoscleroma.

Pathology:
Scleromatous granulation in the subglottis.

Symptoms:
1. Biphasic stridor is the main symptom
2. Cough
3. Hoarseness of voice.




                                              45
Signs:
Granulations covered with greenish crusts.

Complications:
Healing by fibrosis leading to laryngeal stenosis and stridor.

Treatment:
1) Ciprofloxacin 250 mg twice daily for 6 – 8 weeks
2) Tracheostomy in severe stridor
3) Laser or laryngofissure removal of mass




                                                             46
Laryngeal T.B.




                 47
Aetiology:
It occurs usually secondary to pulmonary T.B.

Symptoms:
1. Hoarseness of voice,
2. Stridor
3. Pain
4. Cough

Signs:
Granulations in posterior half of larynx ( interarytenoid area)
  with ulceration  perichondritis  necrosis  fibrosis



                                                                  48
Investigations:
1. Sputum for T.B.
2. X-ray chest

Treatment
1. Anti-T.B. ( rifampicin, isoniazid, P.A.S.)
2. Tracheostomy in severe stridor




                                                49
Laryngeal syphilis




                     50
Aetiology:
The patient presents in the tertiary stage

Symptoms:
1. Hoarseness of voice
2. Stridor

Signs:
Gumma usually affects the anterior half of larynx especially
  the epiglottis  ulceration  perichondritis  necrosis
   fibrosis  laryngeal stenosis



                                                            51
Investigations:
Wasserman Reaction, Kahn’s test

Treatment:
1) Antisyphilitic: penicillin
2) Tracheostomy in severe stridor




                                    52