Laryngeal Anomalies

Congenital Laryngeal Anomalies

1. Laryngomalacia.
• Most common

2. Congenital vocal cord palsy
• Second most common

3. Subglottic stenosis.
• Third most common

Laryngomalacia

• M/c congenital disorder of larynx

• Definition
• Excessive flaccidity of the epiglottis or supraglottis
• Due to immature cartilage, which matures with age

Important: Only inspiratory stridor present

• Most common cause of stridor in infants.

Stridor

Inspiratory stridor	No Stridor
• During inspiration • Supine position • During crying, feeding, agitation	• During expiration • Prone position

• Stridor may develop from 2 to 4 weeks.

Flexible laryngoscopy

• Omega-shaped epiglottis

• Loose and floppy

• Curled upon itself

Treatment

• Self-limiting disorder.

• Wait and watch until epiglottis matures

• Reassurance, Posture repositioning

• Epiglottopexy → surgery for severe stridor

• If progressive respiratory distress (15-20%)
• Supraglottoplasty

Congenital Vocal Cord Paralysis

• Most common congenital CNS abnormality causing Vocal Cord Paralysis
• Arnold Chiari malformation

Symptoms:

• Abductor palsy → Respiratory disturbance
• Bilateral → Stridor
• Unilateral → Dyspnea

• Adductor palsy → Voice issues, weak cry, aspiration

Treatment:

• No treatment if no major symptoms

• For stridor → tracheostomy → laryngeal surgery

• Laryngeal surgery → not done at birth (undeveloped larynx)

Subglottic Stenosis

• Definition:
• Subglottic narrowing from excessive thickening of the cricoid cartilage.

• Narrowest portion in children: Subglottis.

• Abnormal Diameter:
• Full-term neonate: <4mm.
• Preterm neonate: <3.5 mm.

Classification: Cotton Myer Classification (assesses stenosis amount).

Treatment:

• Grade I and II:
• No major symptoms: Wait and watch.

• Grade II
• Early: Balloon/laser dilatation.
• Late:
• Cricoid splitting + Graft placement
• f/b stent

• Grade III and IV:
• Laryngotracheal Resection.
• Cricotracheal reconstruction + End to end anastomosis
• Mitomycin C is given post-surgery to reduce fibrosis and recurrence.
• A Montgomery T-tube is used post-resection to keep the airway patent.

Laryngeal Web

• Cause:
• Incomplete fusion of the 4th and 6th arch

• Types:
• Partial web → partial obstruction
• Complete web → complete obstruction

• Symptoms:
• Depend on web location and thickness
• Most common level → glottis
• Partial obstruction → Dyspnoea, weak cry
• Complete obstruction → Stridor

• Treatment:
• Tracheostomy for cases with stridor to release the web

Inflammatory Conditions of the Larynx

Acute Epiglottitis

Case Scenario:

• 4-year-old

• Sore throat, difficulty swallowing, difficulty breathing

• High fever, tachypnoea

• Inspiratory stridor with recession

• No expiratory stridor
Suggests
extrapulmonary (extra-thoracic) obstruction → Acute epiglottitis

Benign Lesions of Vocal Cord

• Intubation granuloma
• posterior 1/3rd

Vocal Nodule

• Alternate names:
• Singer or screamer's nodule

• Cause:
• Chronic vocal abuse

• Location:
• Free edge of vocal cord
• Junction of anterior 1/3 and posterior 2/3

• Symptoms:
• Hoarseness
• Vocal fatigue

• Treatment:
• Initially → Voice rest
• If fails → Microscopic excision

• One-liner:
• Bilateral and symmetrical lesions are vocal nodules

Vocal Polyp

• Cause:
• Sudden vocal abuse

• Location:
• Same as vocal nodule

• Symptoms:
• Hoarseness
• Diplophonia
• Diplophonia seen in polyp > Reinke's edema

• Treatment:
• Micro laryngeal surgery is treatment of choice

• One-liners:
• Sessile → nodule,
• pedunculated → polyp

Reinke's Oedema

• Definition:
• Accumulation of tissue in Reinke's space

• Involvement:
• Anterior 2/3 (membranous portion) of vocal cord

• Causes:
• Smoking
• Reflux

• Clinical Features:
• Diplophonia
• Change in voice
• Dyspnea

• Treatment:
• Initially → Voice rest, anti-reflux medication, wait and watch
• Reduction glottoplasty
• Stripping of vocal cord / Decortication
• One cord followed by the other
• Prevent adhesions

Pseudosulcus

• H/o laryngopharyngeal efflux

• Infraglottic edema

Site:

• Vocal cords

Contact Ulcer/Pachyderma Laryngitis/Kissing Ulcer

• Lesion site
• Posterior part of larynx

• Causes
• Voice abuse
• Reflux

• Appearance
• Ulcer on one side and heaped-up epithelium on the other side
• Hypertrophic epithelium on one side
• Depression on the other side

• Nature
• Pseudo ulcer
• No true breech in epithelium
• Only paches - Pachyderma Laryngitis

• Differential diagnosis
• Tuberculosis
• Carcinoma

• HPE
• Hyperkeratosis
• Acanthosis

• Treatment
• Excisional biopsy

Keratosis of Larynx/ Leucoplakia of Vocal cord

• Appearance
• Whitish plaque-like lesion
• It is a premalignant condition

• Causes
• Smoking (most common)
• Tobacco chewing
• Excessive voice abuse
• Reflux

• Differential diagnosis
• Candidiasis

• Treatment
• Excisional biopsy
• Stripping of the vocal cord

Tuberculosis of Larynx

• Association: Often with pulmonary tuberculosis.

• Involvement:
• Commonly, posterior part of the larynx is involved first.
• Anterior part is involved last.

• Pain: Extremely painful condition ?????
• Not very painful, not painless

Earliest Signs:

• First sign: Hyperaemia, sluggish movement of vocal cords.

• Mamillated arytenoids.

• Mouse-bitten or moth-eaten appearance.

• Last sign: Turban epiglottis.

Diagnosis:

• Culture/histopathology/gene expert/molecular methods for TB.

Treatment:

• ATT (Anti-tuberculosis therapy).

Lupus of Larynx

• A low-grade infection of TB.

• Involvement:
• Affects the anterior part of the larynx;
• epiglottis is first involved.

Laryngeal Papilloma

• Definition: Finger-like projections.

• Cause: HPV 6, HPV 11.

Juvenile-Onset Laryngeal Papillomatosis

• Age: Infants, young children.

• Transmission: Mother to child during vaginal delivery.

• Location: True/false vocal cords, epiglottis, subglottis.

Presentation:

• Voice change

• airway obstruction

• respiratory distress

• stridor.

Recurrence:

• Aggressive recurrence is common.

Treatment:

• Tracheotomy is C/I
• Intubation preferred

• Microlaryngeal excision :
• Microdebrider (TOC) > CO2 laser.

To ↓ recurrence : ABC

• α interferon (Immunomodulator)

• Bevacizumab

• Cidofovir (Intralesional)

Adult-Onset Laryngeal Papillomatosis

• Age: 30-50 years.

• Transmission: Sexual.

• Single

• Location:
• Anterior half of the vocal cord or anterior commissure.

• Presentation:
• Voice change, airway obstruction, respiratory distress, stridor.

• Recurrence:
• Less aggressive;
• does not recur after excision.

• Treatment: Antivirals, interferons, debrider-assisted resection.

Voice and Speech Disorders

Dysphonia Plica Ventricularis

• Definition: Change in voice

• Causes:
• Organic pathology:
• True vocal cord pathology compensated by false cords.
• Functional: No cause.

• Mechanism: False cords adduct to produce sound instead of true cords.

• Result: Leads to hypertrophy of false cords.

• Seen in: Dubbing artist.

• Voice quality: Low-pitched voice.

• Treatment: Speech therapy, reduction of false cords.

Spasmodic Dysphonia

• Mechanism
• Spasm of a laryngeal muscle

• Association
• Neurological conditions
• Parkinsonism
• Alzheimer's disease
• Other dystonias
• Oromandibular dystonia
• Blepharospasm

Treatment

• Botulinum injection into affected muscle
• Adductor spasmodic dysphonia → thyroarytenoid muscle
• Abductor spasmodic dysphonia → posterior cricoarytenoid muscle

• Recurrence present

Puberphonia

• Definition
• Persistent adolescent, female-like voice after puberty
• More common in males

• Voice quality
• High-pitched voice

• Diagnostic test
• Gutzmann pressure test
• Pressure applied to thyroid cartilage during phonation
• If voice improves → diagnosis confirmed

• Treatment
• Speech therapy
• Type-3 thyroplasty (shortens vocal cords)



• Commonest RLN injured:
• Left RLN (longer course)

• Commonest cause bilateral RLN palsy:
• Surgical trauma (esp. Total thyroidectomy)

• B/L RLN Palsy
• ⛔ Posterior Cricoarytenoid → Safety muscle of VC → Abductor
• Stridor, aphonia, breathlessness (Life threatening)
• Inability to extubate

ㅤ	U/L RLN injury	SLN Injury
Presentation	• Unilateral vocal cord paralysis • Hoarseness • Post-op dysphonia • Dyspnea • Difficulty in deglutition	• ILN → Aspiration → Absent cough reflex • ELN → Low pitch
Vocal cord appearance	• RLN injury = Paramedian	• RLN + SLN injury = Cadaveric/intermediate

Types of Vocal Cord Palsy



• Complete/adductor palsy
• SLN + RLN palsy
• VC in cadaveric/intermediate position (3.5 mm from midline)

• Incomplete/abductor palsy
• RLN palsy
• Cricothyroid intact
• VC in median/paramedian position (1.5 mm from midline)

Clinical Features





• Lateralisation of VC
• Kashima → Type 2 thyroplasty
• Woodmans → cordectomy + Arytenoidectomy

Surgical Trauma

Site of injury	Nerve injured
Base of skull	Complete vagus / SLN
Carotid triangle	ILN / ELN / SLN
Upper pole of thyroid	ELN ↳ most common injured in thyroid surgery
Lower pole of thyroid	RLN ↳ 2nd most common injured in thyroid surgery ↳ Rt > Lt
Mediastinal	Left RLN ↳ also in Ortner’s / cardiovocal syndrome

Normal VC position	during
Lateral	Deep inspiration
Paramedian	Rest
Median	Phonation

During total thyroidectomy for papillary carcinoma thyroid in a thirty-six-year-old lady, the
recurrent laryngeal nerve of right side was sacrificed for oncological safety. The next day, the patient complained of breathy voice. A fiberoptic laryngoscopy on the second post-operative day showed vocal cord paralysis of the right side. What would be the positions of the right and left vocal cords in this patient, on phonation?
(A) Right cadaveric, left intermediate
(B) Right intermediate, left intermediate
(C) Right paramedian, left median
(D) Right paramedian, left paramedian

ANS

C

Treatment of Vocal Cord Palsy

Isshiki’s thyroplasty types



• Type I (Medialisation/Proximalisation)
• Thyroid cartilage pushed medially
• Indication: U/L complete (adductor palsy)

• Type II (Lateralisation)
• Thyroid cartilage pulled laterally
• Indication: B/L RLN palsy

• Type III (Shortening)
• Part of thyroid cartilage cut
• Vocal cord shortened → pitch ↓
• Indication: Puberphonia
• Shorten the long man (shortening) who has guts (Gutzmann manoevre) but female sound (Puberphonia)

• Type IV (Tightening/Tensing)
• Indication: Androphonia
• Lengthen () the short female with male voice (androphonia)

Note

• Laryngeal inlet = epiglottis + arytenoid

• ILN injury → loss of cough reflex

Galen’s anastomosis:

• Between:
• Internal laryngeal nerve (from SLN)
• Recurrent laryngeal nerve (from RLN)

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Clinical Testing

• Hypoglossus (CN 12)
• Test: ask patient to protrude tongue
• If lesion present: tongue deviates towards the affected side (ipsilateral deviation)

• Glossopharyngeal N (CN 9)
• Test: pressure on soft palate/uvula
• Also supply Glossopharyngeus

• Circumvallate papillae
• Present in the anterior 2/3rd part of the tongue
• But special sensation carried by glossopharyngeal

• Jugular canal
• Carries the glossopharyngeal nerve (IX)
• Fracture of the jugular canal
• Loss of taste sensation in the posterior 1/3rd of the tongue

Phonasthenia

• Mechanism
• Weakness of thyroarytenoid and inter arytenoid muscles
• Leads to bowing of vocal cords

• Laryngoscopy

• Keyhole appearance of glottis / VC

• Mnemonic: Pass key through hole (Keyhole) to access phone (Phonasthesia)

Functional Aphonia

• Definition
• Patient is unable to speak

• Cause
• Emotionally labile individuals
• Stress / anxiety
• Sudden emotional shock

• Neurological deficit
• None

• Cough test
• Cough is normal

• Laryngeal examination
• Vocal cords adduct on coughing

• Treatment
• Refer to psychologists for counselling

LARYNGEAL CARCINOMA

Etiology

• Viral infection (HPV).

• Smoking.

• Alcohol.

• Tobacco.

• Genetic factors.

Incidence

• Mostly affects males.

Types of Laryngeal Carcinoma

• Divided by site of malignancy:
• Glottic > Supraglottic > Subglottic

• Squamous cell Ca.

• M/c in males, smokers

Comparison of Laryngeal Cancer Types

• Both supraglottic and glottic cancer have Referred Ear Pain (Vagus N)

Staging

N staging (Nodal status)

Investigation

• First line investigation:
• Contrast Enhanced CT scan (CECT).

• Most accurate test for cartilage/space involvement:
• MRI scan.

• Important:
• Perform radiology before biopsy
• to avoid a false picture from edema.

Total Laryngectomy

• Indications:
• T4a with thyroid cartilage invasion.
• Stage 3 and 4a patients intolerant to chemo-radiotherapy.
• Stage 3 and 4a recurrent tumours.
• Bilateral arytenoid involvement.
• T4b lesions with distant spread.
• Outer cortex of thyroid cartilage involvement.

Permanent tracheostomy

Indications of Tracheostomy

Mnemonic: Occupy Most Seats in Medical Association

• O → Obstruction: Above T₂–T₄

• M → prolonged Mechanical ventilation:
• Most common indication for elective tracheostomy

• S → Secretion removal / pulmonary toilet (coma, chest injury)

• M → Maxillofacial, head & neck surgeries

• A → Aspiration prevention (bilateral complete vocal cord palsy)

Tracheostomy Tube :

 

• High volume, low pressure.

• For air tight seal.

Position :

• Rose’s position :
• Extension at cervico-thoracic and atlanto-occipital joint.
• Rose has extension everywhere

Tracheal incision :

• 2, 3, 4 tracheal rings.

• Emergency
• Vertical incision :
• From lower border of cricoid to suprasternal notch

• Elective
• Horizontal incision/Skin crease incision :
• 2.5 cm above suprasternal notch

• High tracheostomy :
• Incision at T1
• Indication : Ca larynx.
• Complication : Laryngeal stenosis

• Low tracheostomy :
• Infections like Papillamatosis

Tube block :

• C/f of complete block : Stridor.

• Prevention : Saline/sodium bicarbonate suction.

• Management : Change tracheostomy tube.

Structures Injured During Tracheostomy

• Isthumus and below vessels
• Isthmus of thyroid gland
• Arteria thyroidea (Thyroid Ima artery)
• Inferior thyroid vein

• Surgical emphysema
• D/t tight sutures → injure nearby structures

Voice Rehabilitation

• Olfactory rehabilitation: Polite yawning
• Nasal airflow-inducing manoeuvre.

• Supraglottic prosthesis can’t be used
• Method for swallowing → to reduce Aspiration
• Indication : Dysphagia + aspiration.

Oesophageal Speech

Mechanism

• Patient swallows a gulp of air

• Air is held in oesophagus (as larynx absent)

• Air enters oesophagus via:
• Oropharynx
• Hypopharynx

• Pressure builds inside oesophageal lumen

• During phonation:
• Air currents hit Upper Esophageal Sphincter (UES)
• UES vibrates → produces acoustic waves
• Waves → pass through articulators → speech

Features

• Patient can speak 6–10 words, then must re-swallow

• Voice rough

• Voice loud and understandable

Tracheo-Oesophageal Speech

• Best

• Permanent tracheostomy present

• Fistula created between trachea and oesophagus

• Prosthesis inserted
• Blomsinger valve
• Provox prosthesis

Mechanism

• Patient closes tracheostomy with finger

• Air current from trachea → redirected into oesophagus

• Air strikes Upper Esophageal Sphincter (UES)

• UES generates acoustic waves

• Waves → pass through articulators → speech production

Features

• More air quantity available (lung residual capacity)

• Speech resembles normal speech more than oesophageal speech

• Patient can speak a few long sentences

Artificial Larynx

• An artificial sound source or vibrator is used.

• Examples: Electrolarynx, transoral pneumatic device.

Newer Techniques in Laryngeal Endoscopy

Contact endoscopy

• Lesion stained with Lugol’s iodine/methylene blue (Supravital stain)

• Visualized with Hopkin’s endoscope (Magnification: 60–120 times)

• First 3 layers of epithelium visualized:
• Cytological features.
• Microvasculature.

• Determines benign/malignant.

Autofluorescence

• Helps to identify benign/malignant.

• Light →
• Normal mucosa: Green fluorescence (Specific wavelength absorbed)..
• Neoplastic mucosa: Red‑violet fluorescence.

Narrow Band Imaging

• Filtered light → Visualization of neo‑angiogenic features.

• Longitudinal vessels: Benign.

• Pin‑shaped: Malignancy +.