2. INFECTION OF THE LARYNX

3. Viral Laryngitis
• The most common viral pathogens in the
upper respiratory tract include rhinovirus,
influenza A. B, C, and parainfluenza viruses.
• normal duration of 5 to 7 days
• usually dysphonic
• Odynophagia
• laryngeal phonotory trauma (phonation and
coughing, pollutants)

4. • Patients with substantive
vocal fold edema from
viral laryngitis are at
increased risk of
repetitive phone trauma
leading to more
significant vocal fold
injury.
• Such as midmembranous
vocal fold lesions,
epithelial and
subepithelial trauma
ulceration, and scar

5. • Hydration
• Systemic corticosteroids
• Antibiotics are not indicated in patients
presenting with symptoms typical of viral
laryngitis
• Acute dysphonia lasting longer than 2 weeks
is unlikely to result from viral laryngitis, and
other etiologies should be investigated,
including a detailed laryngoscop~

6. Bacterial Laryngitis
• Clinical presentation may be similar to that
of viral laryngitis, but supraglottitis and
epiglottitis may result.
• As with the pediatric population, given the
potential for airway demise.
• Haemophilus injluenz.ae, Streptococcus
species, and Staphylococcus species.
• Haemophilus species remain the most
common but methicillin-resistant

7. Diagnosis relies on endoscopic
examination

8. Radiologic imaging
• Classic "thumb-print" sign of supraglottic
inflammation.

10. Treatment
• Medical treatment is targeted to the pathogen
identified by culture.
• Additional supportive measures such as hydration and
steroids are indicated (9).
• Though not common in the United States,
rhinoscleroma can also affect the larynx. Caused by
Klebsiella rhinoscleromatis, patients tend to have
laryngeal involvement (13/22 patients) and may need
emergent tracheotomy to maintain airway patency
(3/13 with laryngeal involvement)
• Pathologic examination demonstrates the gram-
negative coccobaccillus of Klebsiella on culture, as
well as Mikulicz cells on mucosal biopsy.

11. Fungal Infection
• Fungal laryngitis often occurs in
immunocompromised patients, such as
patients with systemic causes far
immunsuppression (HIV, chemotherapy,
diabetes, etc.)
• and individuals who are locally
imm.unocompromised because of steroid
inhaler use.

12. • Patients will present
with laryngopharyngeal
symptoms, such as
dysphagia and
dysphonia.
• Physical examination
demonstrates white
plaque-like epithelial
lesions of the mucosa
surfaces, which may be
focal or diffuse

13. • Though the majority of fungal infections are
Candida other fungal organisms, such as
blastomycosis, cocdioidomycosis, and
histoplasmosis
• These infections target immunocompromised
patients as seen with Candida sp. infections but
tend to occur in endemic geographic regions.
• Blastomycosis and stoplasmosis are prevalent in
the Mississippi and Ohio river valleys, and
coccidioidomycosis is endemic in the
outhwestern United States and Central America.

14. • Theatment involves long-term systemic
antifungal therapy with agents such as
amphotericin or triazole.
• topical antifungal

15. Mycobacterial Infection
• Laryngeal tubercular infection from Mycobacterium
tuberculosis is classically associated with active pulmonary
disease but can present as isolated laryngitis
• Laryngeal M. tuberculosis infections follow similar
natural history to pulmonary tuberculosis and most
commonly present as lesions in the posterior glottis.
• Patient factors include increased prevalence in
underdeveloped countries, areas of over-crowding and
communal living, and immunocompromised populations.
• While laryngeal infections present with similar symptoms
as pulmonary infections (cough, hemoptysis,
unintentional weight loss, fever, night sweats

16. • Patients may also present with laryngopharyngeal
symp-toms such as dysphonia, dysphagia, and
odynophagia.
• Physical examination can demonstrate exophytic
masses that mimic malignancy
• Pathologic examination demonstrates caseating
granulomas that are pathognomonic to M.
tuberculos1s infection.
• Treatment is targeted with multidrug regimens with
culture guidance,.
• as multidrug resistant M. tuberculosis strains are on
the rise.

17. Other Infections
• Less common infections of the larynx include
leprosy and syphilis. Mycobacterial leprae and
Mycobacterium lepromatosis, the causative infectious
agents of leprosy, cause dramatic systemic and
laryngeal epithelial changes.
• As with the other laryngeal infections, patients can
present with variable severity in symptoms, with the
most severe being occult aspiration or complete upper
airway obstruction requiring tracheotomy
• The World Health Organization recommends
multidrug treatment with combinations of dapsone
and rifampin with possible adjunctive clofazimine.

19. Syphilis
• Caused by 'Iteporl£ma pallidum infection and
generally presents in stages. The primary stage
generally presents to the otolaryngologist as a
painless oropharyngeal change.
• During the secondary stage, patients can
present with laryngeal manifestations, including
leukoplakia, exophytic mass( es ), and very
rarely, decreased vocal fold mobility .
• Diagnosis involves serologic studies (venereal
disease research laboratory or rapid .
• The mainstay of treatment is penicillin.

20. Idiopathic Ulcerative Laryngitis
• Idiopathic ulcerative laryngitis (IUL) was first
described in 2000 and a large clinical series was
presented in 2011
• This condition involves dysphonia and severe cough
following an upper respiratory tract infection and
ulceration of the midmembranous vocal fold.
• IUL appears to occur more in females than males
• An etiologic agent has not been identified and
medical therapy with antibiotics, antifungal, and
proton pump inhibitors are typically used but without
an obvious positive response.

21. INFILTRATION OF THE LARYNX

22. Wegener Granulomatosis
• Wegener granulomatosis is associated with
necrotizing granulomatous inflammation and
vasculitis of small blood vessels.
• The disease tends to affect the upper airway, the
lungs, and the kidneys
• nonhealing ulcers in the nasal cavity or,
• more rarely, subglottic airway stenosis.
• nasal and laryngeal endoscopy, and testing for
classical antineutrophil cytoplasm antibody (c-
ANCA).

23. • Medical management with systemic
corticosteroids and/or cyclophosphamide is used
to obtain remission, and medications such as
methotrexate, trimethoprim methoxazole, or
azathioprine are used for maintenance therapy .
• Surgical treatments include subglottic expansion
(subglottic releasing incisions with balloon or
rigid dilation)
• Subglottic stenting is generally avoided in favor of
tracheotomy for recalcitrant presentations
• intralesional injection of corticosteroids .

24. Rheumatoid Arthritis
• Rheumatoid arthritis affects millions of people
worldwide with a predilection for females.
• It affects the larynx in just over one-fourth of
cases
• Active rheumatoid arthritis tends to present with
a substantial laryngitis with erythematous
arytenoid mucosa
• Chronic rheumatoid arthritis also selectivdy
targets the arytenoid cartilages, but more
specifically seems to affect the cricoarytenoid
joint causing ankylosis and possible joint fixation

25. • Patients may also present with rheumatoid nodules,
also known as bamboo nodes, which are focal
subepithelial lesions, typically on the superior surface
of the membranous vocal fold.
• Theatment of rheumatoid arthritia relies upon
medical management with immnomodular and anti-
inflammatoty treatments.
• Surgical management may be indicated to manage
airway symptoms or to judiciously remove
rheumatoid nodules to improve phonation
• vocal fold steroid injections

27. Relapsing Polychondritis
• Relapsing polychondritis is characterized by intermittent
recurrent episodes and inflammation of cartilaginous
structures.
• While the ears and nose are most commonly affected,
the lacynx can also become involved.
• (MRI) and computed tomography can identify
cartilaginous changes.
• Patients with ear, nasal, and/or airway complaints such as
exertional dyspnea or stridor.
• Medical management is low dose corticosteroids and/or
methotrexate.
• Dapsone has also shown to be beneficial .
• Surgical intervention may be indicated to secure the
airway with tracheotomy.

29. Pemphigus and Pemphigoid
• Pemphigus and pemphigoid are related autoimmWle
conditions differentiated by the target of their
autoantibodies.
• While both conditions lead to a robust/хүчтэй/
infflammatory reaction that can possibly lead to epithelial
injury, pemphigus autoantibodies are directed against
intraepithelial targets while pemphigoid autoantibodies
target subepithelial antigens.
• ImmWlofiuorescence of tissue biopsy is used to identify
the characteristic autoantibodies for definitive diagnosis.
• Patients may present with signs of disease within the nasal
cavity or the larynx. The prevalence of laxyngeal
involvement seems to differ between the diseases for
unknown reasons.

30. • One study demonstrated that 21 of 53 ( 40%) patients with head
and neck manifestations pemphigus had laryngeal involvement {
45).
• However a separate study of pemphigoid patients demonstrated
that 10 of 38 (26%) patients with head and neck symptoms had
laryngeal involvement
• Other studies have demonstrated relatively similar prevalence in
pemphigus
• Both pemphigus and pemphigoid appear to have a predilection for
supraglottic mucosa (Fig. 67 .S).
• High-dose corticosteroids are utilized to control active disease and
are decreased for maintenance therapy.
• Other immunomodulators, such as azathioprine.
cyclophosphamide, and cyclosporine, have also been utilized for
medical management.
• Surgical intervention is limited to diagnostic biopsy and for ait:way
intervention, such as tracheotomy or less invasive airway surgery:
(dilation) to provide a stable airway.

32. External Beam Radiation
• As the role of external beam radiation has increased for
the treatment of head and neck malignancies, many of
these patients later present with laryngopharyngeal
complaints, such as dysphonia, dysphagia. and globus
sensation post treatment.
• Electron beam radiation induces gradual, dose dependent
fibrotic changes to include muscle atrophy and fibrosis in
the larynx as well as desiccation of mucosa
• Fibrosis within the lamina propria can be appreciated
as decreased mucosal pliability on stroboscopy.
• Patients will exhibit atrophy that is disproportionate to
their expected age-related vocal fold volume loss.

33. • Vocal fold hypervascularity is a
common finding due to prior vasculitis
incurred during radiation therapy.
• Improvement in voice is commonly
reported following laryngeal radiation
for early lacyngeal cancar but voice
outcomes associated with late radiation
:fibrosis of the vocal folds uncertain
(50,51). A prior report of postradiation
vocal
• quality suggests that vocal fold
stripping or exdsional
• biopsy rather than limited biopsy for
initial diagnosis and
• continued tobacco smoking after
treatment are significantly associated
with an increased risk of perceived
worse voice quality after treatment
• As radiation oncologists develop
more sophisticated techniques to avoid
collateral damage to uninvolved
structures, the extent of radiation
changes may decrease.

34. BENIGN NEOPLASIA OF THE
LARYNX

35. Hamartoma
• Hamartomas are rare, benign lesions that can present as
congenital malformations or lesions later in life.
• They are generally loosely oiganized neoplasms with
multiple types of tissue, all of which are native to the
affected subsite of the larynx.
• Hamartomas can be incidentally identified or cause
significant airway symptoms, especially in a young child.
• Presentation and symptomatology are related to the
location of the neoplasm, and hamartomas have been
mostly commonly identified in the supraglottis and
subglottis
• Exisional biopsy is both diagnostic and curative if
resection is complete

36. Chondroma
• Chondromas are benign tumors consisting of cartilaginous cells.
• They are slow-growing lesions that do not metasta-size, and they
generally present as a smooth, submucosal lesion. Laryngeal
chondromas may be difficult to differentiate from low-grade
chondrosarcomas and clinically follow a similar courSe.
• While the bulk of these tumors present within the posterior
cricoid cartilage, lesions have been found within other subsites of
the larynx as well as the hyoid bone .
• Patients may be relatively asymptomatic. but lesions can cause
airway obstruction or external neck masses .
• cr is generally the preferred imaging modality to define the crtent
of the lesion .
• Surgical excision is the treatment of choice for chondromas.

37. • Surgical excision is the treatment of choice
for chondromas.
• Surgery has been traditionally performed
via open procedures involving
laryngofissure, but, more recently,
endoscopic ablation techniques have been
shown to be successful
• Comparative efficacy between open and
endoscopic surgical excision is unknown.

38. Respiratory Papillomatosis
• Though primarily seen in the pediatric population,
adult-onset recurrent respiratory papillomatosis (RRP)
is not an uncommon presentation.
• For further information regarding juvenile onset RRP,
please refer to Chapter 94.
• Caused by human papillomavirus (HPV) subtypes 6
and 11, RRP occurs most commonly at the level of
the vocal folds.
• The virus can be transmitted vertically or by sexual
transmission. RRP can present anywhere within the
upper aerodigestive tract from the nasal vestibule to
the bronchioles with a predilection for areas of
transition from pseudostratified columnar to stratified
squamous epithelium.

39. • Lesions can be relatively small, noticeable only because of
resultant dysphonia from decreased vocal fold mucosal
wave propagation, dysphonia related to mass-effect that
impairs glottal closure, or variable degrees of airway
obstruction
• Though benign, they do have significant morbidity and
have the potential for malignant transformation
• A recent study including 54 adults demonstrated that
dysplasia was identified in 50% of patients, and dysplasia
was diagnosed on biopsy specimens at an average of
16.2 months from initial diagnosis.
• Of the initial 54 patients, 3 progressed to carcinoma in situ
while 1 patient progressed to squamous cell carcinoma

40. • Use of inhaled corticosteroids, increasing
number of procedures, distal spread of
disease, and previous exposure to cidofovir
have been implicated as risk factors for
dysplastic reaction .
• In addition, history of radiation therapy,
cigarette smoking, and systemic
immunosuppression have been implicated in
malignant transformation.

42. • lhe verrucous papillomatous growth of the lesions are pathognomonic.
• lhough. multiple treatment modalities are available. conservative
removal of disease is the firstline treatment.
• If cold instrumentation is to be utilized, careful attention must be
dedicated to only removing the
• papilloma and leaving the superficial lamina propria undisturbed.
Ablation with CO2 or potassium titanyl phosphate (KI'P) Jasen has also
been shown to be a successful treatment modality for both initial and
subsequent treatments
• A great benefit of fiber-based laser treatment is that it can be performed
in an awake patient using a channeled endoscope through which the
fiber am be advanced. Awake procedures decrease use of operative
resources and eliminate the need and dangers of general anesthetic.
• Regardless of the surgical technique utilized, the physician must avoid
deepithelialized surfaces in juxtaposition to avoid anterior glottic
webbing and/or posterior glottic stenosis.

44. • While swgical removal of lesions remains the first-line
teatment for RRP, other adjuvant therapies have
been developed.
• Cidofovir is an antiviral shown to deaease disease
burden in both intralesional injection and inhaled
forms .
• Both treatment modalities have been shown safe.
but hepatotoxicity has been identified with the
injected form.
• Interferon-alpha and indole-3-carbinol an extract
found in auciferous vegetables) have both been
used to control disease propagation

45. • The United States Food and Drug Administration
{FDA) approved Gardasil.. a vaccination against HPV
subtypes 6, 11, 16, and 18, in June of 2006 as a means
of potentially preventing cervical cancer.
• While cervical cancer is mainly caused by HPV
subtypes 16 and 18, the vaccination against subtypes
6 and 11, could drastically affect the prevelence and
presentation of RRP.
• Currently, there is no definitive association between
vaccination and disease modulation, thus vaccination is
not presently indicated in patients with prior
exposure .

46. Hemangioma
Laryngeal hemangiomas are more prevalent in the
pediatric population, and this is presented in Chapter 104.
In contrast to pediatric hemangiomas, which usually
present in the subglottis, adult laryngeal hemangiomas
present in the supraglottis (Fig. 67.10) (72).
• Hemangiomas are usually asymptomatic but can cause
airway obstructive symptoms
• As these are incredibly rare tumors, no standardized
treatment exists.
• A conservative approach emphasizing medical
management with either corticosteroids or radiation
therapy was historically advocated.

47. • Though successful in the pediatric population,
laser ablation was initially avoided in adults for
concern that the vasculature would exceed C02
laser coagulation capacity.
• However, a repon of four laryngeal
hemangiomas ablated without incident calls that
initial theory into question
• Propanolol has also been successful in treating
laryngeal hemangiomas in children, but there are
no repons of its use in the adult population .

49. Fibroma
• Laryngeal fibromas are exceedingly rare with fewer than a
dozen cases reported. Histologic examination
demonstrates abundant extracellular matrix with
interspersed paucicellular areas, and the extracellular
matrix tends to be composed of •cytologically bland
spindle cells.“
• The reported cases all appear to be isolated lesions that
presented with dysphonia and cough (77).
• Radiographic imaging ( cr and MRI) can delineate the
full extent of the lesion in planning for surgical
resection.
• Excision with margins is advocated to minimize chance of
recurrence

50. Schwannoma
• Schwannomas arise from ner:ve sheath fibers and account for less
than 1% of all laryngeal tumon~.
• The endoscopic appearance may be mistaken for a laryngocele and
commonly appear as smooth submucosal mass within the
pyriform sinus or aryepiglottic space
• Patients may present with globus sensation, dysphagia. dysphonia.
and if luge, airway obstruction (SO). Imaging with Cf and/or MRI
help to plan surgical resection.
• Histopathologic examination demonstrates the classic Antoni A
and Antoni B area seen with other schwannomas.
• The associated nerve was not identified in the available case
reports.
• Some patients have postoperative dysphonia and vocal fold
paresis, possibly implying recurrent laryngeal involvement {79).

51. LARYNGOCELES AND SACCULAR CYSTS
• While laryngoceles and saccular cysts are not neoplasms, they
present as benign appearing masses in the larynx.
• The laryngealsacalle is a mucous gland containing appendage that
lies between the false vocal fold and the thyroid cartilage.
• It is an out pouching of the normal laryngeal ventricle and
atends as a blind-ended sac posterolateral to the edge of the
laryngeal surface of the epiglottis.
• The function of the sacullar is unknown although it has been
theorized that it may represent a vestigial air sac.
• Both laryngoceles and sacallar cysts involve expansion of the
saccule to form a mass.
• LaJ:yngoceles by definition must have air contained within their
lumen, while saccular cysts are strictly fluid filled masses.

52. • Laryngoceles contain air due to patent commWlication
• with the laryngeal lumen. Further classification of laryn-
• goceles depends on their location. They can be defined as
internal, externaL or combined. Internal laryngoceles are
• strictly confined within the Thyroid cartilage.
extemallary:goceles lie exclusively outside the
cartilaginous I~
• framework. and combined lar:yngoceles span bo1h the
inside
• and outside of the thyroid cartilage (82,83) (Fig. 67.11).

55. To underline
• Multiple infections, inflammatory, and benign processes can affect the
larynx. Each has its own unique presentation and treatment
considerations.
• Infectious laryngitis is most commonly viral in etiology. and should be
initially treated with voice rest and supportive measures in most cases.
Bacterial, fungal, and mycobacterial infection is considerably more rare.
• Inflammatory and infiltrative processes of the larynx can occur from
Wegener granulomatosis (typically subglottic involvement), sarcoidosis
(typically supraglottic involvement), amyloidosis, and autoimmune
processes (such as rheumatoid arthritis, SLE, and
pemphigus/pemphigoid)
• The most common benign neoplasm of the larynx is laryngeal
papillomatosis. Laryngeal chondromas, hamartomas, schwannomas,
fibromas, pleomorphic adenomas, and granular cell tumors are far
more rare.