Laryngeal disorders ผศ.นพ.ยงยุทธ วศินวงศ์

Laryngeal disorders ผศ.นพ.ยงยุทธ วศินวงศ์ ภาควิชาจักษุ โสต นาสิกลาริงซ์วิทยา คณะแพทยศาสตร์ มหาวิทยาลัยศรีนครินทรวิโรฒ

Pretest T or F 1. Reurrent laryngeal nerve เป็น pure motor fiber 2. การทำงานของ larynx ไม่เกี่ยวข้องกับการกลืน 3. Acute laryngitis เกิดการการติดเชื้อไวรัสเป็นส่วนใหญ่ 4. การกดลิ้นใน epiglottitis ทำให้เกิด laryngospasm ได้ 5. Thumb’s sign พบในโรค croup 6. Vocal nodule มักเป็น unilateral mass 7. Vocal granuloma มักเกิดจากการ intubation 8. Laryngeal trauma ควร intubation ทุกราย 9. Most common symptom ของ true vocal carcinoma คือ neck node enlargement 10. การดื่มสุราเป็นปัจจัยกระตุ้นให้เกิด acid reflux

Laryngeal disorders ผศ.นพ.ยงยุทธ วศินวงศ์ ภาควิชาจักษุ โสต นาสิกลาริงซ์วิทยา คณะแพทยศาสตร์ มหาวิทยาลัยศรีนครินทรวิโรฒ

Objectives Anatomy Physiology Common disorders Treatment Laryngeal disorders Objectives Anatomy Physiology Common disorders Treatment

Framework Muscles – intrinsic - extrinsic Innervation Vessels 1. Anatomy Framework Muscles – intrinsic - extrinsic Innervation Vessels

Framework

Muscles Intrinsic – adductors ; thyroarytenoid (true vocal cord:TVC), cricoarytenoid, interarytenoid - abductor ; post cricoarytenoid Extrinsic - cricothyroid

Innervation Inferior RLN motor - all muscles except.. sensory- below TVC Superior RLN motor – cricothyroid muscle sensory – above TVC

Blood supply Arterial sup. laryngeal artery inf. Laryngeal artery Venous sup. & inf. Thyroid veins

Airway protection Swallowing Voice production Air passage Physiology Airway protection Swallowing Voice production Air passage

Protection inspiration phonation

Laryngeal disorders 1. Inflammation - Acute & chronic laryngitis, croup, epiglottitis, ulcer, 2. Tumor - benign, nodule, polyp, granuloma - malignancy 3. Trauma - penetrating injury - blunt injury - iatrogenic 4. Congenital - cord paralysis, Laryngeal web, subglottic stenosis 5. Miscellaneous - laryngopharyngeal reflux (LPR) disease

Common laryngeal disorders 1. Acute laryngitis 2. Croup 3. Epiglottitis 4. Vocal nodule 5. Vocal polyp 6. Vocal granuloma 7. Laryngeal carcinoma 8. Laryngeal trauma 9. Laryngopharyngeal reflux (LPR)

Acute laryngitis Pathogen - adenovirus, influenza Morexella catarrharis Hemophilus influenza Streptococcus pneumoniae Symptoms - hoarseness cough, +/- fever, malaise Sign - TVC swelling

Treatment - voice rest - mucolytic, anticold +/- antibiotic Acute laryngitis Treatment - voice rest - mucolytic, anticold +/- antibiotic Symptoms > 2 week, recurrent DDx - chronic laryngitis

Croup (acute laryngotracheobronchitis) - Severe respiratory infection - 6 months-2 yrs. Pathogen - parainfluenza*influenza, adenovirus - follow by bacterial esp. H. influenza Symptoms - early URI symptoms - 2-3 days - barking cough, stridor - exhausted, lying down

Croup (acute laryngotracheobronchitis) Diagnosis - symptoms & signs - flexible scope - x-ray norrowing of subglottis “Pencil’s sign”

Pencil’s sign Normal

Croup (acute laryngotracheobronchitis) Treatment - early detection - observe, admit - humidification, hydration, O2 - antibiotic (penicillin) severe - steroid - intubation

Epiglottitis - infection of supraglottis >> epiglottis - 2-10 yr., adult Pathogen - H. influenza type B Symptoms - early URI symptoms - children > change very fast 6-12 hr. - high fever, pain in throat - นั่ง โน้มตัวมาข้างหน้า*

Epiglottitis Signs - epiglottis > swelling, inflam - ** laryngospasm เมื่อกดลิ้น - fiberoptic X-ray - “Thumb’s sign”

Epiglottitis Treatment - admit, closed monitoring - broad spectrum penicillin - hydration, humidification - +/- steriod - prepare for intubation

- vocal abuse, over-used - children, adult - fibrous formation Vocal cord nodule - vocal abuse, over-used - children, adult - fibrous formation Symptoms - hoarseness Sign - nodule TVC > bilateral > anterior 1/3

Nodule Treatment - voice rest - speech therapy - failed, recurrent > surgery

- vocal abuse - Reinke edema > capsule surrounding (polyp) Vocal polyp - vocal abuse - Reinke edema > capsule surrounding (polyp) Symptoms - hoarseness > 2 wk Sign - ant 1/3 TVC, unilateral Treatment - surgery - follow by speech therapy

Reinke’s edema Vocal polyp Both polyp, nodule

Vocal granuloma inflammation > ulcer > granuloma etiology - intubation - gastroesophageal reflux - partial laryngectomy Symptoms - hoarseness 2-3 wk after extubation

Vocal granuloma Sign - arytenoid, unilateral Treatment - surgery - follow by speech therapy - Rx acid reflux

Carcinoma Chronic irritation - smoking, alcohol, pollution, acid reflux Pathology - epithelial hyperplasia > dysplasia > carcinoma insitu > carcinoma

Carcinoma Symptoms > 2-3 weeks - glottis > hoarseness - supraglottis > dysphagia - subglottis > airway problems others - referred otalgia, chronic cough, hemoptysis, lymphadenopathy, wt. loss

Carcinoma Diagnosis - biopsy ; indirect or direct laryngoscopy - extension ; CT, MRI - metastasis ; CXR, LFT Treatment - depends on staging TNM - early > surgery or RT alone - stage 3, 4 > combined surgery, RT, ChemoRx

Laryngeal trauma Most common -Car accident Others - athlete, penetrating, gun-short wound S&S >> location, severity - stridor, bleeding, emphysema, hemoptysis, dysphagia, crepitation - severe case > coma

Laryngeal trauma

Laryngopharyngeal reflux (LPR)

Laryngopharyngeal reflux (LPR) Stomach acid > reflux to esophagus + others = gastroesophageal reflux (GER) reflux up to larynx = LPR Etiology - relax sphincter, acid production food ; chocolate, spicy, cola, alcohol, drugs ; theophylin life-style ; eat late at night

Laryngopharyngeal reflux (LPR) Symptoms - feel lump in the throat, chronic cough, regurgitation, heartburn Signs - arytenoid edema, TVC sweling granuloma, ulcer >>> carcinoma

Laryngopharyngeal reflux (LPR) Treatment - Lifestyle modification diet, stress, avoid eating before bedtime - medication protonpump inhibitor, H2 antagonist, antacid + prokinetic - surgery