ENT Benign Laryngeal Disorders
ENT Benign Laryngeal Disorders
ENT Benign Laryngeal Disorders
Stridor
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
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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
Crying, agitation,
feeding or supine
o Severe
Substetrnal retraction
Feeding difficulties
GERD
Failure to thrive
Derangement of supraglottic
anatomy
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
-
ENT
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
Dx
Laryngocele
o Intermittent hoarseness and dyspnea
o Weak cry
Saccular cyst
o Respiratory distress wit inspuiratory
stridor
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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
-
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
ENT
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
-
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
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Laryngotracheal decompression
Reconstruction
ENT
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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
-
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
-
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
ENT
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
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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
-
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
-
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
ENT
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