ENT

BENIGN LARYNGEAL DISORDERS

Dr. Lazaro
091109
Mucosal flap creates the sound produced
Vibration of mucosal folds and through air
Laryngeal Anatomy
Differences in adults vs infants
o 1/3 size at birth
o Narrow dimensions of subglottis and
glottis

Subglottis us the narrowest (45mm in diameter)

o Higher in the neck

C4 at birth vs C6-c7 at 15 y/o

o Epiglottis is narrower
Laryngeal function
Breathing passage
Airway protection
Aid in the clearance of secretions
Vocalization
Symptoms of laryngeal anomalies
Airway obstruction
Feeding difficulties
Abnormalities of phonation
Airway Obstruction
Symptoms

Stridor

Increase work of breathing with

retraction, nasal flaring anf tachypnea

Apnea episodes, cyanosis and sudden

death
Stridor
o Inspratory stridor (supraglottic and
glottis)

Collapse during negative

inspiratory pressure
Airway
-

protection
1st level: epig, aryepig folds and arytenoids
2nd level: false
3rd: TVC
Anomalies
o Lead to aspiration and swallowing
dysfunction

Phonatory abnormality
Dependent on the level of abnormality
o Mufflec cry suggest supraglottic
obstruction
o High pith or absent cry suggest glottis
abnormality
Laryngomalacia
Most frequent cause of stridor in children
MC congenital laryngeal anomaly
Male predominance
Flaccidity o supraglottic laryngeal tissues

BENIGN LARYNGEAL DISORDERS

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Characterizsed by inward collapse of

supraglottic structures during inspiration

Anatomic Abnormalities
Epiglottis
o Long tubular
o Displaced posteriorly on inspiration
o Inferior collapse to the vocal folds
Short aryepiglottic folds
Inward collapse of aryepiglottic folds (primarily
cuneiform cartilages)
Anteromedial collapse of the arytenoids
cartilages
Symptoms
Airway obstruction
o Mild to mod obstn

Stridor exacerbated by exertion

Crying, agitation,
feeding or supine
o Severe

Substetrnal retraction

Pectus excavatum with chronic

severe obstruction
o Other complications

Feeding difficulties

GERD

Failure to thrive

Cyanosis, cardiac failure and

death
Stridor in Laryngomalacia
Inspiratory stride
o Intermittent low-pitched
Starts 1st 2 weeks of birth
Worsens in th 1st few most followed by gradual
improvement
Peak at 6months and most are symptom free
by 18-24 mos (75%)
Pathophysiology
Cause of collapse is unknown
o Theories

Derangement of supraglottic
anatomy

Laryngeal cartilage immaturity

Histopathology normal
microanatomy

Subepithelial edema
Neurologic involvement
o Assoc with central apnea, hypotonia,
MR, and early speech
o Abnormal neuromuscular control
Gastroesophageal Reflux
>50% of patients with laryngomalacia
Airway edema contributes to airway
compromise
Dx
-

Awake flexible fiberoptic laryngoscopy

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Fluoroscopy
Direct laryngoscopy and bronchoscopy
evaluate synchronous lesions (27%)

Treatment of Laryngomalacia
Observation most cases resolev
spontaneously
Medical mngt for GERd
Surgical mangt severe symptoms
o Supraglottoplasty
o Tracheotomy
o Iglauer amputation of epiglottic
redundant tissue with a wire snare
Supraglottoplasty complications
Aggressive approach
o Supraglottic stenosis
o Exacerbation of dysphagia with
aspiration
o Rare massive collapse of supraglottic
framework
Conservative excision minimizes complications
LARYNGOCELEs and SACCULAR CYST
Anatomy
Saccule cecal pouch of mucous membrane in
anterior roof of the laryngeal ventricle
Connection with tracheal area
Cyst: no connection with tracheal area
Laryngoceles
Dilation or herniation of the saccule
Communicates with the lumen of the larynx
Filled by air or mucous
Internal-extend posterosuperior into the
arypeiglottic fold
Saccular cyst
Congenital cyst of the larynx or laryngeal
mucocele
o No communication with the laryngeal
lumen
o Developmental failure to maintain
patency of the saccular orifice
Laryngoceles and Saccular Cyst
Acquired La
o Inc pressure on the laryngeal lumen
(player of wind instruments)
Acquired saccular cyst
o Occlusion of the ssaccular orifice

Inflame, trau, tumors

Laryngopyocele
Sx
-

Dx

Laryngocele
o Intermittent hoarseness and dyspnea
o Weak cry
Saccular cyst
o Respiratory distress wit inspuiratory
stridor

BENIGN LARYNGEAL DISORDERS

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Flexible and rigid laryngoscopy

Soft tissue neck x-ray (distended with air)
Combined laryngocele mass protrudes with
valsalva maneuver
Saccular cyst needle aspiration confirms the
dx

Treatment
Sac aspiration or unroofing with cup forceps
Endoscopic excision
o Removing remnants CO2 laser
Open procedure for recurrence
o Lateral cervical approach
VOCAL CORD PARALYSIS
3rd MC laryngeal anomaly producing stridor
Unilateral and bilateral
Can have neurologic problem
Sym
-

Bilateral
o High-pitched inspiratory stridor
o Inspiratory cry
o Paradoxical function
Unilateral (less symptoms)
o Weak cry and occassionaly breathy
o Feeding difficulties

Dx
-

Awake flexible fiberoptic laryngoscopy

Direct laryngoscopy

Unilateral VC paralysis treatment

Watchful waiting
o 70% resolve spontaneously
o Most withing 6mo
o Feeding difficulties
Inc ICP
Bilateral VC
Tracheotomy may be necessary (50%)
Lateralizing one or both paralyzed VC
Excisional procedure
o Tissue removed from posterior glottis
CONGENITAL LARYNGEAL WEB-ATRESIA
Uncommon
Failure of recanalization
Most are glottis (75%)
Sx
o Vocal dysfunction

Hoarseness

Aphonia if severe
o Airway obstruction
Complete laryngeal atresia is incompatible with
life and need emergent tracheostomy
Dx
o Flexible laryngoscopy
o Direct laryngoscopy
Treatment
Thin anterior glttic web
o Incision or dilatin
Most significant glotic lesion

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Glotic Anomalies
Congenital high Upper airway obstruction
(CHAOS)
o UTZ with large lungs, flat diaphragms,
dilated airways, fetal ascites
Subglottic stenosis
2nd MC cause of stridor
Incomplete recanalizxation of laryngeal lumen
NB larynx <4mm
Congenital less sever than acquired
Membranous strenosis
Circumferential and soft
Less severe than cartilaginous
*7mm AP; lateral 4mm
Cartilaginous subglottic stenosis
Cricoid thickening
Sx
-

Upper airway obstruction

Inspiratory stridor
Mild to mod stenosis
o Asymptomatic
Severe obstruction
o Respiratory distress
o Intubation amy be needed

Diagnosis
DL and bronch
o Visualize the entire larynx
o Distinction of membranous vs
cartilaginous
o Synchronous lesions
Measurement of stenosis
o ET tube placement at sequential size
Classification
Gr 1 <50% obstruction
2 51-70
71-99
No detectable lumen
Tx gade 1
Watchful waiting for growth
>50% obstruction may require some intervention
Soft tissue acquired lesions
Dilation and laser
Tx grade 2-3
Multiple failed extubation
Tracheostomy may be neede
Anterior cricoids split
Horizontal skin incision over cricoids
Vertical miline incision
o Entire cricoids
o 1st 2 tracheal rings
Grade 3

BENIGN LARYNGEAL DISORDERS

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Laryngotracheal decompression
Reconstruction

Laryngeal and laryngotracheoesophageal clefts

Rare
Incomplete devt of Tracheoespohageal septum
Communicatioi iof posterior larynx and
esophagus
Strong association with other anomalies
o Aspiration
Laryngeal clefting
o Inerarytenoids only
Laryngotracheoesophageal clefts
Symptoms
Proportional to length
Can be asymptomatic
Inspiratory stridor
Feeding problem aspiration
Cyanotic episodes
Recurrent pneumonia
Diagnosis
CXR- pneumonia
Barium swallow contrasrt pill into trachea
Direct laryngoscopy- best single test
Tx
Supraglottic larynx
Conservative
Swallowing therapy
GERD evaluation
Surgical
Mortality
11 %, 46%
Intrathoracic 93%
SUBGLOTTIC HEMANGIOMA x
Benign vascular malformation
Histological endothelial hyperplasia
Female 2:1
Asymptomatic at birth
Stridor at 6 monhts
Ass cutaneous hemangioma (50% - x
Rapid growth at 1 year old followed by slow
resolution
Most complete resolution 5 yr
30-70% mortality if untreated
Priority- airway
Dx direct laryngsocopy
Systemic steroid dec size
Interferon alpha
Tracheostomy in Phils
Laser co2 and KTP
Surgical excision
ALLERGIES and INFECTION
Obstructive edema due to allergic response tx
with steroids or tracheostomy
Croup
Acute laryngitis
CROUP
Pathognomonic -stipple sign in CXR at AP view
BENIGN TUMORS OF LARYNX
Main complaint is hoarseness

ENT

Hoarseness perceived breathiness quality of

voice (bailey)
Rough or noisy quality of voice (Dorland)
Rough, harsh voice quality (Stedman)
Benign vocal fold mucosal disorders seem to
be caused by primarily by vibratory trauma
An expressive talkative personality
Occupational and lifestyle vocal demands
Cigarette smoking and liberal use of voice
Other secondary influences (infection, allergy,
acid reflux, insufficient fluid intake, certain
drying medications, systemic illnesses)
Benign vocal fold mucosal DO are common

Anatomy and physiology

Anatomy most relevant to the benign vocal fold
mucosal DO is the microarchitecture of voca
folds
Vocalis muscle- not participant in production of
mucosal wave
reinkes space superficial layer of L.propia
chief oscillator of phonation
Myoelastic-aryeodynamic theory
closed vocal folds
pressure build p
folds blown apart
vocal fold mucosal vibration
Evaluation of px
skillful Hx
Asses vocal capabilities and limitations
Hi quality laryngeal exam

BENIGN LARYNGEAL DISORDERS

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Small- 0-3
Medium- 3-6
Large - >6 mm

NODULES
occurs at boys and women
vocal overdoses
children with cleft palates develop nodules
freq. presumably form using glottal stops to
compensate for velopharyngeal incompetence
vary in size.contour, symmetry, color
nodules do not unilaterally
polyps- unilateral
-

vibration too forceful or prolonged causes

localized vascular congestion with edema
fluid accumulation in the sub mucosa
hyalinization of renkes potential space

MNgment
good laryngeal lubrication through hydration
manage allergies and nighttime reflux of
stomach acid into larynx
behavior voice therapy
nodules regress if px not singer
Surgical if nodules persist and voice impaired
After adequate trial of therapy
Micro dissection techniques

Hx
Benign
-

Onset and duration of symptoms

Patient beliefs causes exacerbating influences
Common symptoms complexes
Talkativeness
Vocal commitments
Patient perception of severity of DO
Vocal aspirations
Risk factors smoking

Post surg
Patient is asked not to speak for 4 days
After 4 days, px progress to full voice use
Early return to nonstressful voice use seems to
promote dynamic healing and preserve a
degree of mucosal freedom
As long as certain management principles are
followed in the majority of cases

Polyps
Nodules
Varices
cyst

VArices
-

and ectasia
Excessive blood
Happens because of idlated capillaries.
Frequent in women
Repeated vibratory micro trauma lead to
capillary angiogeneses
Inc mucosas vulnerability to vibratory trauma
Most often in female singers
Abn dilatation of long archades of capillaries
Cappillay lake

POLYPS
result of trauma to the SLP and
microvasculature
size, shape, and tissue composition is variable
commonly found at middle portion of musculomembranous region
not uncommon to find smaller traumatic
fibrovascular lesion on contralateral vocal fold
epi is normal
Sessile epi microflap
-sub epi resection of polyp contents
Pedunculated retraction and amputations

Size

Surgical

Medical anticoagulant effects stops used

It increase severity of bruising
Behavioral
-vocal overdoses
- px warned about sudden explosive use of
voice

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Pathophy
Capillary rupture
Resolution of the bruise may be complete
within 2 weeks
Alter the margin contour
Abrupt onset
Laryngeal exam
Unilateral lesion
Usually dark or very red
Surgical
Evacuation of blood through a tiny incision
Vocal overuse
Mucus retention or epidermoid inclusion type

Mucus retention (ductal) cysts

Mucus gland plugged
Epidermoid cysts
Accumulation of keratin
Theories
From previous injury
Or from birth and recurred
Cysts may rupture spontaneously. Opening is small in
relation to the overall size of the cyst
-

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Microsurgery
Spot-coagulated lasers routinely involutes
within a few weeks

Vibratory ..
MC in men
Hx of aspirin or other anticoagulant use

CYST
-

BENIGN LARYNGEAL DISORDERS

Mucus retention cyst may just come and go

Laryngeal eacx
Originate below the free margin of the fold
Cyst on examination
Medical mngt
Voice rest
Hydration
Beh mngt
Voice therapy
Surgery
Small incision
Glottic sulcus
Ruptured cyst

GRANULOMA
Contact grnuloma or ulceration
Due to trauma
o Intubation granuloma MC
Most common in males
o Lawyers, ministers
Pathophy
Thin mucosa of glottis become inflamed
Overly forceful apposition (slamming together)
Hx
-

Caffeine and alcohol use and late-noght eating

habits
Acid reflux symptoms
Speaking voice may sound normal or slightly
husky
Held-back quality, habitual coughing or throat
clearing

Laryngeal exam
Depressed ulcerated areas with whitish
exudates
Mngt
-

Antireflux
Steroidal injections
Voice rest
Stop coffee

REINKERs EDEMA
Middle-aged woman
Smoking and voice abuse
Smokers polyps may complain of being called
sir
Increasing hoarseness during the day
Phonate though the voice of a bass singer
Due to fluid retention
Mangt
Stop smoking
Thyroid function tests can be done if
hypothyroidism is suspected
Surgical: microsurgery
POSTSURGICAL DYSPHONIA
Scarred stiff vocal fold cover, phonatory
mismatch of the vocal fild margins
Degree of freedom of the mucosa from the
iunderlying vocal ligament is lost
Mucosal injury due to previous laryngeal
surgery
Impact on identity and communication and their
commonness
Good hx, vocal capability elicitation and
laryngeal examination

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BENIGN LARYNGEAL DISORDERS

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