Laryngeal infections

1. LARYNGEAL
INFECTIONS
Dr. Satinder Pal Singh

2. INTRODUCTION
• Laryngitis is one of the most common
conditions identified in the larynx.
Laryngitis, an inflammation of the larynx,
manifests in both acute and chronic forms.
• Acute laryngitis has an abrupt onset and is
usually self-limited. If a patient has
symptoms of laryngitis for more than 3
weeks, the condition is classified as
chronic laryngitis.

3. The etiology of acute laryngitis includes vocal
misuse, exposure to noxious agents, or
infectious agents leading to upper respiratory
tract infections. The infectious agents are most
often viral but sometimes bacterial.

6. INFECTIOUS:
Viral
Bacterial
NON INFECTIOUS
Inhaled fumes
Allergy
Polluted atmospheric conditions
Vocal abuse
Iatrogenic trauma
Gastroesophageal reflux
disease (GERD)
AETIOLOGY

7. Pathophysiology
1.The mucosa of the larynx becomes
congested and may become oedematous.
2.A fibrinous exudate may occur on the
surface.
3.Sometimes infection involves the
perichondrium of laryngeal cartilages
producing perichondritiis.

8. Predisposing factors
1.Smoking
2.Psychological strain
3.Physical stress

9. CLINICAL PRESENTATION
•Change or loss of voice;
• Difficulty in breathing/stridor;
• Sore throat and otalgia;
• Difficult or painful swallow;
• Tender larynx with/without cervical
lymphadenopathy.

10. Acute Laryngeal infections in
childhood
• Acute Epiglottitis
• Laryngotrachealbronchitis
• Bacterial
Laryngotrachealbronchitis
• Diphtheria
• Conditions which mimic laryngeal
infections

11. Acute Epiglottitis
• Most frightening pediatric emergency.
• If unrecognized it can lead to death of the
child.
• 6-23 per 100,000 in chlidren.
• Haemophilus influenzae type B , is the
causative organism in most cases.
• The disease is concentrated maximally on
the epiglottis but the inflammation may
involve whole supraglottic compartment.
• Most cases seen between 1 and 6 years of

12. Clinical features
• Classical features:
– A child c/o sore throat which intensifies, with
in half and hour dysphagia reported.
– Inspiratory stridor develops and within 2 hours
child becomes critical.
– Child sits up and leans forward
– Saliva is dribbling due to absolute dysphagia
– Voice is muffled
– As time goes child becomes quiet and
respiratory distress appears to lessen.
– An an ominous sign: respiratory & cardiac
arrest imminent

14. Epiglottitis Supraglottitis

15. Investigations
• Blood culture
• Throat awab culture
• WBC counts
• X ray plain lateral soft tissue neck.
• Computed tomography (CT) scans are
useful if there is a complication such as an
epiglottic abscess

16. Lateral X-ray of neck may show classical
‘thumb’ sign of swollen epiglottis
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17. Management
• It is a surgical emergency
• Admit and observe give i.v. antibiotics and
100% humidified oxygen.
• Examination of throat by tongue depressor
is particularly dangerous- sudden
respiratory obstruction may occur.
• If the clinical situation suggests that the
diagnosis is epiglottitis , there is no point
in confirming it what might turn out to be
fatal X-ray.

18. • The child is shifted to OT and
anesthetized in upright position
• Laryngoscope inserted & diagnosis
confirmed
• An appropriate size orotracheal tube
inserted
• Otherwise rigid bronchoscope used to
secure airway
• Tracheostomy / nasotracheal tube
• Culture swabs taken from epiglottis
• Nasogastric tube inserted for feeding

19. Best Clinical Practice
• Adults with suspected acute
epiglottitis should be admitted and
airway closely monitored
• Patients should be treated with I/V
second- or third-generation
cephalosporins and 100% humidified
oxygen
• Airway obstruction should be treated
early, ideally by intubation

20. Complications
1.Epiglottic abscess
2.Pulmonary oedema secondary to
relieving airway obstruction
3.Thrombosis of internal jugular vein

21. Laryngotracheobronchitis
(Croup)
• As name suggests it involves larger
proportion of respiratory tract
• Area of maximum impact is sub-glottis
• An acute illness with hoarseness, a
barking cough, stridor and varying
degree of respiratory distress
• Affects young children (6 months to 3
years)

22. • In most cases causative organism is
paramyxovirus, para-infleunza virus
type I and type II
• In adults it may also occur from herpes
simplex, cytomegalovirus & influenza
virus
• Adult croup is rare, more severe &
impaired immunity should always be
considered
• The key feature is sub-glottic oedema

23. Investigations
• Direct viral antigen detection by
sampling mucus from nasopharynx
• A plain neck radiograph may show
narrowing of the subglottis (steeple
sign) and ballooning of hypopharynx
• Chest X-ray to exclude collapsed lobes
or meditational shift

24. • Narrowing of the subglottis (steeple sign)

27. Management
• Oxygen, steroids and nebulized
epinephrine should be administered
• Monitor airway and oxygen saturation,
consider endotracheal intubation if
necessary
• Broad spectrum antibiotics to cover
secondary infection
• No evidence to support antiviral agents

28. Best Clinical Practice
• Adult croup is rare but rapidly progressive
• Once suspected patient should be
admitted
• Larynx inspected by flexible laryngoscope
• Broad-spectrum ABx to prevent bacterial
infection
• If the airway deteriorates patient should be
intubated and ventilated

29. Bacterial
Laryngotrachealbronchitis
• May be a separate disease or be caused
by secondary bacterial infection of viral
laryngotrachealbronchitis
• Also called bacterial tracheitis since it
involves trachea predominantly
• Much more severe illness and much less
common
• More severe respiratory obstruction and
artificial airway is often needed
• Tracheostomy preferred over intubation

30. Whooping cough or Pertussis
1.an acute illness that is usually caused by
Bordetella pertussis.
It is a notifiable communicable disease that
affects all age groups and is transmitted by
coughing and sneezing.
3.Most severe in children, particularly infants.
Adults generally have a milder disease.
Clinical features
•Runny nose,
•dry cough and mild pyrexia,
• similar to a common cold

31. •The cough occurs in prolonged paroxysms
after one to two weeks and is followed by
gasping and the characteristic whoop in
children.
•The disease is generally milder in adults and
presents as protracted cough rather than the
characteristic 'whooping cough' of children.
Investigations
confirmed by serum serology and
nasopharyngeal aspirate culture and assay by
(PCR).

32. M anagement•Pertussis is usually not diagnosed until the
cough has developed.
•A 7-14-day course of erythromycin is
recommended.
•Fluoroquinolones are also likely to be
effective in adults.
The cough should be treated symptomatically
with cough suppressants.

33. Diphtheria
• Caused by Corynebacterium
diphtheriae
• Spreads by droplet infection
• Affects non-immunised children and
susceptible adults particularly elderly
• Usual site of infection is the tonsils and
fauces but it can also occur in nasal
cavities or spread to larynx

35. Clinical Features
• Severe sore throat, malaise, pyrexia
• Examination of throat shows
characteristic grey membrane in
oropharynx which may spread to
larynx.
• Enlarged tender cervical lymph nodes

36. Investigations
• A swab from throat for C/S
• A sample of grey membrane for
screening

37. Management
• Treat with benzyl penicillin and
antitoxin
• Acute obstruction should be managed
with intubation
• Complications:
– The diffusible exotoxin has predilection
for cardiac and renal tissues
– Neurological complications soft palate
paralysis, diaphragm & EOM

38. Conditions which mimic laryngeal
infections in childhood
• Foreign bodies
• Peritonsillar abscess
• Retropharyngeal Abscess
• Infectious mononucleosis

39. Infectious mononucleosis
• A common disease often sub-clinical
or mild
• Caused by Epstein-Barr virus
• Spread is usually transfer of infected
saliva during kissing

40. Clinical Features
• Acute sore throat with large infected
tonsils
• Cervical lymphadenopathy with grossly
enlarged bilateral lymph nodes
• Fever, Malaise
• There may also be palatal petechiae,
oral ulceration, splenomegaly and
hepatomegaly

42. www.answers.com/topic/diphtheria

43. Investigations
• Full Blood count
• Heterophil antibody test: Heterophil antibodies are
antibodies that are stimulated by one antigen and react with an
entirely unrelated surface antigen present on cells from different
mammalian species
• Specific EBV serology
• HIV testing

44. Management
• I/V fluids
• Analgesia
• In serious infections antibiotics,
steroids and acyclovir should be
considered
• Ampicillin / amoxycillin are best
avoided for fear of inducing a
maculopapular rash

45. Complications
• Gross swelling of tonsils and adenoids
causes airway obstruction, but
inflammation and ulceration can also
extend to larynx
• The severity of laryngeal involvement
may be masked by upper airway
obstruction
• Splenic rupture
• CNS complications like encephalitis,
meningitis, CN palsies
• Immune deficiency and HIV status be

46. MYCOTIC LARYNGITIS
• Disease of both immunocompromised and
immunocompetent hosts
• May mimick leukoplakia or malignancy
– White or gray pseudomembrane on mucosa
– Mucosal erythema and edema (focal or
diffuse) surrounding white plaques
– Mucosal ulcerations
– Contact bleeding

47. Fungal laryngitis

48. Risk factors
•Risk factors: LPR, smoking, inhaled
steroids, prolonged antibiotic use, XRT
•DM, immunosuppressants, CA,
nutritional deficits
•Compromise mucosal barrier

49. Investigation
1.A chest radiograph.
2.Direct laryngoscopy and biopsy may be
necessary to confirm a diagnosis of fungal
laryngitis.
3.Tissue samples should be sent for special
fungal stains, such as methenamine silver
and periodic acid-schiff, to identify the
fungal hyphae.

50. Treatment of fungal
laryngitis
1. Fluconazole x 3wks
2. Nystatin swish and swallow (100,000
units/ml, 10ml tid).
3. Prevention spacers for inhaled
steroids oral rinse, gargle with water
after use.

51. Chronic Laryngitis
Is a chronic inflammation of the mucosa of
the larynx
Definition
Grade I Mild erythema, stasis of secretions, string
sign, piling u p of i nter-arytenoid mucosa
Grade II Diffuse oedema a nd mucosal thickening,
but with little erythema
Grade III Diffuse erythema, with granular friable
mucosa or Ulceration
Grade IV Discrete granuloma(s) with or without
oedema and erythema

52. Etiology
• Follows repeated acute attacks but
usually it arise insidiously due to :
• Faulty use of voice.
• Infection of teeth, tonsil, sinus, and
lower respiratory tract infection.
• Excessive alcohol consumption or
smoking.
• Dust or irritant fumes.

53. Clinical classification:
Chronic nonspecific laryngitis
1. Chronic simple laryngitis.
2. Hyper keratosis of larynx
(chronic keratosis or
leukoplakia).
3. Pachydermia laryngis.
4. Contact granuloma.
5. Atrophic laryngitis.
Chronic specific laryngitis
• Tuberculous laryngitis
• Syphilitic laryngitis.
• Leprosy of the larynx.
• Scleroma of the larynx.
• Wegener’s (malignant)
granuloma of the larynx.
• Mycosis of the larynx.

54. Simple chronic laryngitis
Pathology:
•Hyperaemia of vocal cord.
•Edema.
•Myositis occurs in the intrinsic muscles.
•Excessive secretion due to hyper activity of
the mucous gland.
•Hyperaemic and edematous stage often
passes to a hypertrophic one and rarely to an
atrophic one.
Clinical Features:
-Hoarseness (intermittent then persistent).
-Cough (slightly dry).
-Sore throat (very common).

55. Chronic laryngitis: there is hyperemia of mucus membrane.
Odema of the margins of the vocal cord(Rienkes edema

56. Laryngeal appearance
Three types:
1. Hyperaemic.
2. Hypertrophic.
3. Edematous.
In all types the larynx is always
affected bilaterally &
symmetrically.

57. Treatment:
•Vocal rest
•Elimination of irritating factors such as dust
and smoking.
•Systemic antibiotics.
•Carbocisteine ( a mucolytic ) when
secretion are thick.
•Stripping of the vocal cords is performed
endoscopically in persistent cases.

58. REINKE'S OEDEMA
1. Polypoid corditis
2. Proliferation of superficial lamina propria
chronic irritant exposure
Smoke, LPR, occupational exposures
3.Water-balloon outpouching from
membranous VF
4. characterized by oedema of the vocal
cords.

59. Reinke's oedema.

60. •Surgery
1. Airway compromise
2. Preserve some superficial lamina
propria and overlying epithelium
to preserve mucosal wave
•Stage for bilateral disease to prevent
anterior web
•Remove irritants and treat LPR
Treatment

61. Vocal cord polyp
•Polypoidal lesion of cords
•More in male
•localised vascular engorgement
and microhaemorrhage followed by
oedema.
•Gelatinous,fibrous,talengiectatic

62. Vocal cord polyp.

63. Effect of polyps on mucosal
waveAsymmetric mass produces more
chaotic vibrations and aperiodic
mucosal waves
Larger polyps cause decreased wave
amplitude
Excessive air egress during phonation
Fatigue
Frequent voice breaks
decreased vocal power

64. Treatment
•Conservative for small polyps
•Microsurgery mainstay of therapy
•Hemorrhagic polyps
Pulsed-dye lasers absorbed by hemoglobin
(585 nm) Lasers more effective for smaller
polyps.

65. Tuberculous laryngitis
•Almost always to secondary to
pulmonary TB
•Infected sputum
•Younger age group
•Tubercle formation is characteristic
•Infilteration stage followed by
proliferative stage
•Posterior part of larynx involved

66. The typical site and appearance of tuberculous
lesion involving the posterior commissure in
secondary-acquired tuberculous laryngitis.

67. To improve vocal hygiene
• Drinking lot of fluids - Drink 7-9 glasses of water
per day; also good are herbal tea and chicken
soup.
• maintaining good general health - Exercise
regularly.
• Avoiding smoking - They are bad for the heart,
lungs and vocal tract.
• Eating a balanced diet - Include vegetables, fruits
and whole grain foods.
• Avoid dry, artificial interior climates.
• Do not eat late at night - may have problems
when stomach acid backs up on the vocal cords.
• Use a humidifier to assist with hydration.

68. THANK
YOU