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Diseases of PharynxDiseases of Pharynx
and Larynxand Larynx
Anatomy of PharynxAnatomy of Pharynx
 Fibromuscular TubeFibromuscular Tube
 Base of Skull to C6 (12cm)Base of Skull to C...
NasopharynxNasopharynx
 Base of skull to the softBase of skull to the soft
palatepalate
 Key componentsKey components
 ...
OropharynxOropharynx
 Soft Palate to theSoft Palate to the
epiglottisepiglottis
 Key ComponentsKey Components
 Palatoph...
LaryngopharynxLaryngopharynx
 Epiglottis to the levelEpiglottis to the level
of cricoid cartilageof cricoid cartilage
 K...
Anatomy of PharynxAnatomy of Pharynx
 Blood supplyBlood supply
 Branches of many arteries (ascending pharyngeal,Branches...
LarynxLarynx
 Respiratory OrganRespiratory Organ
 Lying between pharynx and tracheaLying between pharynx and trachea
 B...
LarynxLarynx
 ComponentsComponents
 CartilagesCartilages
 Singular; thyroid, cricoid, epigolitticSingular; thyroid, cri...
CavitiesCavities
 Inlet +Inlet +
VestibuleVestibule
 Rima ofRima of
glottisglottis
 SubglotticSubglottic
spacespace
Layrnx - Intrinsic MembranesLayrnx - Intrinsic Membranes
 Quadrangular membraneQuadrangular membrane
 Arytenoid Cartilag...
Laryngeal Muscles - IntrinsicLaryngeal Muscles - Intrinsic
1. Those that alter size and shape of the inlet1. Those that al...
Laryngeal Muscles - IntrinsicLaryngeal Muscles - Intrinsic
2. Responsible for Phonation by moving vocal2. Responsible for ...
PhonationPhonation
 Pitch; Vibration of the folds through shorteningPitch; Vibration of the folds through shortening
and ...
LarynxLarynx
 Blood supplyBlood supply
 Superior and Inferior Laryngeal Branches from Superior andSuperior and Inferior ...
Nerve PalsiesNerve Palsies
 Recurrent Laryngeal NerveRecurrent Laryngeal Nerve
 Number of causesNumber of causes
 Left;...
Extrinsic MusclesExtrinsic Muscles
 ElevatorsElevators
 Indirectly;Indirectly;
 Mylohyoid, digastric, stylohyoid, genio...
 4 year old boy4 year old boy
 Pain in right ear and feversPain in right ear and fevers
 Recurrent ear infectionsRecurr...
Adenoid HypertrophyAdenoid Hypertrophy
 Occupies large area of nasopharynx age <6Occupies large area of nasopharynx age <...
 IxIx
 Nasopharyngeal ExamNasopharyngeal Exam
 Nasopharyngoscopic ExamNasopharyngoscopic Exam
 Lateral XrayLateral Xra...
AdenoidectomyAdenoidectomy
 Criteria for surgeryCriteria for surgery
 Chronic upper airway obstruction with OSA +/- corC...
TonsillitisTonsillitis
 Commonest area of infection of head and neckCommonest area of infection of head and neck
 Clinic...
TonsillitisTonsillitis
 Complications;Complications;
 Acute Otitis Media (most common)Acute Otitis Media (most common)
...
TonsillectomyTonsillectomy
 Indications for surgeryIndications for surgery
 AbsoluteAbsolute
 Airway obstructionAirway ...
PharyngitisPharyngitis
 AcuteAcute
 >70% Viral Cause, GAS>70% Viral Cause, GAS
 Supportive TreatmentSupportive Treatmen...
 64 Male recently Immigrated from Hong Kong64 Male recently Immigrated from Hong Kong
 Lump in right side of neckLump in...
Nasopharyngeal CarcinomaNasopharyngeal Carcinoma
 Rare in EuropeRare in Europe
 Common in Asian countriesCommon in Asian...
Nasopharyngeal CarcinomaNasopharyngeal Carcinoma
 Clinical;Clinical;
 Most commonly as lump in the neckMost commonly as ...
Nasopharyngeal CarcinomaNasopharyngeal Carcinoma
 Ix;Ix;
 Tissue sampling, CT/MRI, StagingTissue sampling, CT/MRI, Stagi...
Pathology of the LarynxPathology of the Larynx
 InfectiousInfectious
 InflammatoryInflammatory
 CongenitalCongenital
 ...
 5 Year old boy5 Year old boy
 Hx ofHx of
 3/7 Low grade fever and URTI Sx3/7 Low grade fever and URTI Sx
 1/7 history...
Laryngotracheitis (Croup)Laryngotracheitis (Croup)
 Inflammation of tissues of subglottic space +/-Inflammation of tissue...
Laryngotracheitis + EpiglottitisLaryngotracheitis + Epiglottitis
FeatureFeature LaryngotracheitisLaryngotracheitis Epiglot...
 18 month girl18 month girl
 ““Asthma Attack”Asthma Attack”
 WheezyWheezy
 ?trigger?trigger
 Family Hx of Asthma, Ecz...
Foreign BodyForeign Body
 Usually stuck at right main bronchusUsually stuck at right main bronchus
 Anything that’s smal...
Signs of Airway ObstructionSigns of Airway Obstruction
 Stretor; obstruction in the throat, low pitched chokingStretor; o...
Upper Airway Obstruction -Upper Airway Obstruction -
NeonatesNeonates
 Subglottic StenosisSubglottic Stenosis
 Congenita...
 44 Female44 Female
 6 week history of hoarse voice6 week history of hoarse voice
 Irritation and dryness in throatIrri...
Chronic LaryngitisChronic Laryngitis
 Most common cause is GORDMost common cause is GORD
 Recurrent Acute laryngitisRecu...
 35 year old35 year old
 Blunt trauma to neck 5 hours agoBlunt trauma to neck 5 hours ago
 Difficulty swallowing + Voic...
Laryngeal TraumaLaryngeal Trauma
 RareRare
 CausesCauses
 PenetratingPenetrating
 Blunt trauma; majority are MVA’s, cl...
Laryngeal InjuriesLaryngeal Injuries
 PresentationPresentation
 Significant cervical traumaSignificant cervical trauma
...
 33 year old male singing teacher33 year old male singing teacher
 Progressively hoarse voiceProgressively hoarse voice
...
Benign Vocal Fold LesionsBenign Vocal Fold Lesions
 Reactive nodules (singers nodules)Reactive nodules (singers nodules)
...
LaryngoceleLaryngocele
 Abnormal dilatation of the laryngeal ventricleAbnormal dilatation of the laryngeal ventricle
 Co...
Squamous PapillomaSquamous Papilloma
 Most common benign neoplasm of larynx (84%)Most common benign neoplasm of larynx (8...
Investigation and TreatmentInvestigation and Treatment
 Ix;Ix;
 LaryngoscopyLaryngoscopy
 Tx;Tx;
 CO2 LaserCO2 Laser
...
 55 year old male55 year old male
 History of GORD, cardiac diseaseHistory of GORD, cardiac disease
 Recurrent hoarse v...
Squamous Cell CarcinomaSquamous Cell Carcinoma
 Most common malignancy of larynxMost common malignancy of larynx
 Male>F...
Squamous Cell CarcinomaSquamous Cell Carcinoma
 Glottic SCC most common (60%) >Glottic SCC most common (60%) >
supraglott...
Squamous Cell CarcinomaSquamous Cell Carcinoma
 ManagementManagement
 Eradication of diseaseEradication of disease
 Res...
 www.surgical-www.surgical-tutortutor..orgorg.uk.uk
 Learning RadiologyLearning Radiology
 Clinical Cases and Osces in ...
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
Diseases of-pharynx-and-larynx
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Diseases of-pharynx-and-larynx

  1. 1. Diseases of PharynxDiseases of Pharynx and Larynxand Larynx
  2. 2. Anatomy of PharynxAnatomy of Pharynx  Fibromuscular TubeFibromuscular Tube  Base of Skull to C6 (12cm)Base of Skull to C6 (12cm)  Divided into three partsDivided into three parts  NasopharynxNasopharynx  OropharynxOropharynx  LaryngopharynxLaryngopharynx  4 Layers4 Layers  Mucosal, submucosal (Fibrous), Muscular, FascialMucosal, submucosal (Fibrous), Muscular, Fascial layer (buccal pharyngeal)layer (buccal pharyngeal)
  3. 3. NasopharynxNasopharynx  Base of skull to the softBase of skull to the soft palatepalate  Key componentsKey components  Pharyngeal TonsilPharyngeal Tonsil (Adenoids)(Adenoids)  Pharyngeal Recess (ICA)Pharyngeal Recess (ICA)  Opening of Auditory tubeOpening of Auditory tube
  4. 4. OropharynxOropharynx  Soft Palate to theSoft Palate to the epiglottisepiglottis  Key ComponentsKey Components  Palatopharyngeal andPalatopharyngeal and Palatoglossal archesPalatoglossal arches  Palantine Tonsil – projectPalantine Tonsil – project from tonsillar fossafrom tonsillar fossa  Lingual TonsilLingual Tonsil  Valleculae – lie betweenValleculae – lie between epiglottis and posteriorepiglottis and posterior border of the tongueborder of the tongue
  5. 5. LaryngopharynxLaryngopharynx  Epiglottis to the levelEpiglottis to the level of cricoid cartilageof cricoid cartilage  Key featuresKey features  Opening to theOpening to the larynxlarynx  Piriform recessPiriform recess (endoscope)(endoscope)
  6. 6. Anatomy of PharynxAnatomy of Pharynx  Blood supplyBlood supply  Branches of many arteries (ascending pharyngeal,Branches of many arteries (ascending pharyngeal, greater palantine, lingual, tonsilar)greater palantine, lingual, tonsilar)  Nerve SupplyNerve Supply  Afferent; maxillary nerve, glossopharyngeal, internalAfferent; maxillary nerve, glossopharyngeal, internal and recurrent laryngeal nervesand recurrent laryngeal nerves  Motor; Pharyngeal Plexus (Vagus, glossopharyngeal,Motor; Pharyngeal Plexus (Vagus, glossopharyngeal, Cervical Sympathetic)Cervical Sympathetic)
  7. 7. LarynxLarynx  Respiratory OrganRespiratory Organ  Lying between pharynx and tracheaLying between pharynx and trachea  Becomes continuous with the trachea at the level ofBecomes continuous with the trachea at the level of the cricoid cartilage (C6)the cricoid cartilage (C6)  FunctionFunction  Primary – protective sphincter at the inlet of the airPrimary – protective sphincter at the inlet of the air passagespassages  PhonationPhonation
  8. 8. LarynxLarynx  ComponentsComponents  CartilagesCartilages  Singular; thyroid, cricoid, epigolitticSingular; thyroid, cricoid, epigolittic  Paired; Arytenoid, corniculate, cuneiformPaired; Arytenoid, corniculate, cuneiform  JointsJoints  Cricothyroid, cricoarytenoidCricothyroid, cricoarytenoid  Ligaments and MembranesLigaments and Membranes  Intrinsic; Quandrangular membrane, CricothyroidIntrinsic; Quandrangular membrane, Cricothyroid ligament (Vocal folds)ligament (Vocal folds)  Extrinsic; Thyrohyoid membrane, cricotracheal,Extrinsic; Thyrohyoid membrane, cricotracheal, hypoepiglottic, thyroepiglottic ligaments, cricothyroidhypoepiglottic, thyroepiglottic ligaments, cricothyroid
  9. 9. CavitiesCavities  Inlet +Inlet + VestibuleVestibule  Rima ofRima of glottisglottis  SubglotticSubglottic spacespace
  10. 10. Layrnx - Intrinsic MembranesLayrnx - Intrinsic Membranes  Quadrangular membraneQuadrangular membrane  Arytenoid Cartilage and epiglottisArytenoid Cartilage and epiglottis  Lower border; vestibular folds (false cord)Lower border; vestibular folds (false cord)  Upper border; aryepiglottic foldsUpper border; aryepiglottic folds  Cricovocal MembraneCricovocal Membrane  Formed from lateral part of cricothyroid ligamentFormed from lateral part of cricothyroid ligament  Upper thickened border forms cricovocal ligaementUpper thickened border forms cricovocal ligaement  Vocal folds which bounds the glottis anteriorlyVocal folds which bounds the glottis anteriorly
  11. 11. Laryngeal Muscles - IntrinsicLaryngeal Muscles - Intrinsic 1. Those that alter size and shape of the inlet1. Those that alter size and shape of the inlet  Aryepiglottic MusclesAryepiglottic Muscles  Oblique arytenoidsOblique arytenoids  Thyroepiglottic musclesThyroepiglottic muscles  Act as Sphincter for the inletAct as Sphincter for the inlet  Provide valvular protection from aboveProvide valvular protection from above
  12. 12. Laryngeal Muscles - IntrinsicLaryngeal Muscles - Intrinsic 2. Responsible for Phonation by moving vocal2. Responsible for Phonation by moving vocal foldsfolds  Abduction; Posterior CricoarytenoidsAbduction; Posterior Cricoarytenoids  Adduction; Lateral cricoarytenoid and transverseAdduction; Lateral cricoarytenoid and transverse arytenoidarytenoid  Lengthen; CricothryroidLengthen; Cricothryroid  Shorten; Thyroarytenoid, vocalisShorten; Thyroarytenoid, vocalis
  13. 13. PhonationPhonation  Pitch; Vibration of the folds through shorteningPitch; Vibration of the folds through shortening and lengthing of the voldsand lengthing of the volds  Intensity; Pressure through the glottisIntensity; Pressure through the glottis  Quality; Resonating chambers above the glottisQuality; Resonating chambers above the glottis  Articulation; tongue, teeth and lipsArticulation; tongue, teeth and lips
  14. 14. LarynxLarynx  Blood supplyBlood supply  Superior and Inferior Laryngeal Branches from Superior andSuperior and Inferior Laryngeal Branches from Superior and Inferior Thyroid ArteryInferior Thyroid Artery  Nerve SupplyNerve Supply  Recurrent Laryngeal NerveRecurrent Laryngeal Nerve  All intrinsic Muscles except cricothyroidAll intrinsic Muscles except cricothyroid  Mucous Membranes below the foldsMucous Membranes below the folds  External Layngeal NerveExternal Layngeal Nerve  Cricothyroid muscleCricothyroid muscle  Internal Laryngeal NerveInternal Laryngeal Nerve  Mucous Membranes below the foldsMucous Membranes below the folds
  15. 15. Nerve PalsiesNerve Palsies  Recurrent Laryngeal NerveRecurrent Laryngeal Nerve  Number of causesNumber of causes  Left;Left;  Carcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surgCarcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surg  Left or Right;Left or Right;  Iatrogenic, Trauma, Thyroid diseaseIatrogenic, Trauma, Thyroid disease  Complete (Cadaveric Position)Complete (Cadaveric Position)  Half abducted position with arytenoid cartilage slightly in frontHalf abducted position with arytenoid cartilage slightly in front  Hoarse VoiceHoarse Voice  Bovine coughBovine cough  IncompleteIncomplete  Adducted position as posterior cricoarytenoid more susceptibleAdducted position as posterior cricoarytenoid more susceptible  External Laryngeal NerveExternal Laryngeal Nerve  Hoarse voice that recoversHoarse voice that recovers  Inability to hit high frequenciesInability to hit high frequencies
  16. 16. Extrinsic MusclesExtrinsic Muscles  ElevatorsElevators  Indirectly;Indirectly;  Mylohyoid, digastric, stylohyoid, geniohyoidMylohyoid, digastric, stylohyoid, geniohyoid  Directly;Directly;  Stlyopharyngeus, salingopharyngeus, palatopharyngeusStlyopharyngeus, salingopharyngeus, palatopharyngeus  DepressorsDepressors  Sternohyoid, omohyoid stenothyroidSternohyoid, omohyoid stenothyroid
  17. 17.  4 year old boy4 year old boy  Pain in right ear and feversPain in right ear and fevers  Recurrent ear infectionsRecurrent ear infections  Noisy breatherNoisy breather  OverweightOverweight  Examination – Sore right ear, hyperaemicExamination – Sore right ear, hyperaemic tympanic membrane, breathing with mouthtympanic membrane, breathing with mouth openopen
  18. 18. Adenoid HypertrophyAdenoid Hypertrophy  Occupies large area of nasopharynx age <6Occupies large area of nasopharynx age <6  Atrophies and by age 15 little remainsAtrophies and by age 15 little remains  Recurrent URTI or allergies can lead toRecurrent URTI or allergies can lead to hypertrophyhypertrophy  ClinicalClinical  Nasal Obstruction; Mouth breathing / AdenoidNasal Obstruction; Mouth breathing / Adenoid Facies, chest infections, pharyngeal infections,Facies, chest infections, pharyngeal infections, sinusitis, snoringsinusitis, snoring  Eustachian Tube; Recurrent Otitis Media, CSOMEustachian Tube; Recurrent Otitis Media, CSOM  Choanal Obstruction; OSA, chronic sinusitisChoanal Obstruction; OSA, chronic sinusitis
  19. 19.  IxIx  Nasopharyngeal ExamNasopharyngeal Exam  Nasopharyngoscopic ExamNasopharyngoscopic Exam  Lateral XrayLateral Xray  TxTx  SupportiveSupportive  AdenoidectomyAdenoidectomy
  20. 20. AdenoidectomyAdenoidectomy  Criteria for surgeryCriteria for surgery  Chronic upper airway obstruction with OSA +/- corChronic upper airway obstruction with OSA +/- cor pulmonalepulmonale  Chronic serous/suppurative otitis mediaChronic serous/suppurative otitis media  Recurrent acute otitis mediaRecurrent acute otitis media  Suspicion of nasopharyngeal malignancySuspicion of nasopharyngeal malignancy  Chronic sinusitisChronic sinusitis  ComplicationsComplications  Early HaemorrhageEarly Haemorrhage  Otitis mediaOtitis media  Regrowth of residual adenoid tissueRegrowth of residual adenoid tissue
  21. 21. TonsillitisTonsillitis  Commonest area of infection of head and neckCommonest area of infection of head and neck  Clinical; Sore throat and Odynophagia, Otalgia,Clinical; Sore throat and Odynophagia, Otalgia, headache, malaise, Fever, hyperaemic tonsils, cervicalheadache, malaise, Fever, hyperaemic tonsils, cervical lymphadenopathylymphadenopathy DDx;DDx;  ViralViral  Group A Streptococcus (20-30%)Group A Streptococcus (20-30%)  EBV; Palatal petechiaEBV; Palatal petechia  Diptheria; Unimmunised, grey membraneDiptheria; Unimmunised, grey membrane  Tx; Rest, paracetamol +/- ABxTx; Rest, paracetamol +/- ABx
  22. 22. TonsillitisTonsillitis  Complications;Complications;  Acute Otitis Media (most common)Acute Otitis Media (most common)  Peritonsillar abscess (Quinsy)Peritonsillar abscess (Quinsy)  GASGAS  Post Strep GNPost Strep GN  Rhuematic FeverRhuematic Fever  Scarlet Fever; Strawberry tongue and scarlitiform rashScarlet Fever; Strawberry tongue and scarlitiform rash  Recurrent TonsillitisRecurrent Tonsillitis  Tonsillar HypertrophyTonsillar Hypertrophy
  23. 23. TonsillectomyTonsillectomy  Indications for surgeryIndications for surgery  AbsoluteAbsolute  Airway obstructionAirway obstruction  Suspicion of malignancySuspicion of malignancy  RelativeRelative  Sleep apnoea, mouth breathing, difficulty swallowingSleep apnoea, mouth breathing, difficulty swallowing  Recurrent tonsillitis >5 episodesRecurrent tonsillitis >5 episodes  Any complicationsAny complications  ComplicationsComplications  Reactionary haemorrhageReactionary haemorrhage  Secondary haemorrhageSecondary haemorrhage  5-10 days post op5-10 days post op  Due to fibrinolysis aggravated by infectionDue to fibrinolysis aggravated by infection
  24. 24. PharyngitisPharyngitis  AcuteAcute  >70% Viral Cause, GAS>70% Viral Cause, GAS  Supportive TreatmentSupportive Treatment  ChronicChronic  Persistent mild soreness and drynessPersistent mild soreness and dryness  Predisoposing factors include; smoking, ETOH,Predisoposing factors include; smoking, ETOH, mouth breathing, chronic sinusitis, Industrial fumes,mouth breathing, chronic sinusitis, Industrial fumes, antiseptic throat lozengersantiseptic throat lozengers  Enlarged lymphoid tissue can be removedEnlarged lymphoid tissue can be removed
  25. 25.  64 Male recently Immigrated from Hong Kong64 Male recently Immigrated from Hong Kong  Lump in right side of neckLump in right side of neck  Progressive enlarged, non-painfulProgressive enlarged, non-painful  Exam; firm, fixed, solid mass lateral to midlineExam; firm, fixed, solid mass lateral to midline in posterior trianglein posterior triangle
  26. 26. Nasopharyngeal CarcinomaNasopharyngeal Carcinoma  Rare in EuropeRare in Europe  Common in Asian countriesCommon in Asian countries  20% of all malignancies in Hong Kong20% of all malignancies in Hong Kong  PathologyPathology  Squamous cell/undifferentiatedSquamous cell/undifferentiated  AietologyAietology  Unknown, however EBV plays a roleUnknown, however EBV plays a role  Others; ingestion of preserved foodsOthers; ingestion of preserved foods
  27. 27. Nasopharyngeal CarcinomaNasopharyngeal Carcinoma  Clinical;Clinical;  Most commonly as lump in the neckMost commonly as lump in the neck  Local; Nasal obstruction, blood stained dischargeLocal; Nasal obstruction, blood stained discharge  Neurological; Invasion of skull base causing cranialNeurological; Invasion of skull base causing cranial nerve palsies (V, VI, IX, X, XII)nerve palsies (V, VI, IX, X, XII)  Otological; Serous otitis mediaOtological; Serous otitis media  Metastasis to bone, lung, liverMetastasis to bone, lung, liver
  28. 28. Nasopharyngeal CarcinomaNasopharyngeal Carcinoma  Ix;Ix;  Tissue sampling, CT/MRI, StagingTissue sampling, CT/MRI, Staging  ManagementManagement  Radiotherapy with concominant chemotherapyRadiotherapy with concominant chemotherapy  Poorly amendable to surgery due to anatomicalPoorly amendable to surgery due to anatomical locationlocation  DDxDDx  Lymphoma, cystic adenocarcinoma, InfectionLymphoma, cystic adenocarcinoma, Infection
  29. 29. Pathology of the LarynxPathology of the Larynx  InfectiousInfectious  InflammatoryInflammatory  CongenitalCongenital  MucosalMucosal  MalignancyMalignancy
  30. 30.  5 Year old boy5 Year old boy  Hx ofHx of  3/7 Low grade fever and URTI Sx3/7 Low grade fever and URTI Sx  1/7 history Biphasic Stridor, barking cough1/7 history Biphasic Stridor, barking cough  No obvious respiratory distressNo obvious respiratory distress
  31. 31. Laryngotracheitis (Croup)Laryngotracheitis (Croup)  Inflammation of tissues of subglottic space +/-Inflammation of tissues of subglottic space +/- tracheobronchial treetracheobronchial tree  Mucopurulent exudate -> airway obstructionMucopurulent exudate -> airway obstruction  Aetiology; Parainfluenza I (most common),Aetiology; Parainfluenza I (most common), II,III, influenza A,B, RSVII,III, influenza A,B, RSV  Presentation; night, inspiratory/biphasic stridor,Presentation; night, inspiratory/biphasic stridor, barking coughbarking cough  Beware loss of stridor, Decr SaO2Beware loss of stridor, Decr SaO2  DDx; FB, subglottic stenosis, EpiglottitisDDx; FB, subglottic stenosis, Epiglottitis
  32. 32. Laryngotracheitis + EpiglottitisLaryngotracheitis + Epiglottitis FeatureFeature LaryngotracheitisLaryngotracheitis EpiglottitisEpiglottitis Inflammation Subglottic space Supraglottic spaceInflammation Subglottic space Supraglottic space AgeAge 4month-5 years4month-5 years 1-4 years1-4 years OnsetOnset Gradual (days)Gradual (days) Acute (hours)Acute (hours) Fever Low grade/afebrile High feversFever Low grade/afebrile High fevers Stridor Biphasic/inspiratory InspiratoryStridor Biphasic/inspiratory Inspiratory CoughCough BarkyBarky NormalNormal PosturePosture SupineSupine SittingSitting DroolingDrooling NoNo YesYes RadiographRadiograph Steeple signSteeple sign Thumb sign, enlarged epiglottisThumb sign, enlarged epiglottis Appearance Non-toxic Toxic/cyanoticAppearance Non-toxic Toxic/cyanotic CauseCause ViralViral BacterialBacterial TreatmentTreatment SupportiveSupportive Keep child calmKeep child calm O2, Adrenalin nebsO2, Adrenalin nebs Airway management -ETTAirway management -ETT Steroids ABx, IV hydration, Moist airSteroids ABx, IV hydration, Moist air
  33. 33.  18 month girl18 month girl  ““Asthma Attack”Asthma Attack”  WheezyWheezy  ?trigger?trigger  Family Hx of Asthma, EczemaFamily Hx of Asthma, Eczema  No stridor, but tachypnea, intercostal recessionNo stridor, but tachypnea, intercostal recession  Unilateral wheeze on Right with Decreased airUnilateral wheeze on Right with Decreased air entry in lower zonesentry in lower zones
  34. 34. Foreign BodyForeign Body  Usually stuck at right main bronchusUsually stuck at right main bronchus  Anything that’s small enoughAnything that’s small enough  Presentation;Presentation;  Stridor if at level of tracheaStridor if at level of trachea  ““Unilateral asthma” if bronchialUnilateral asthma” if bronchial  ComplicationsComplications  Atelectasis, lobar pneumonia, pneumothorax, mediastinalAtelectasis, lobar pneumonia, pneumothorax, mediastinal shiftshift  Dx;Dx;  Inspiratory/Expiratory X-raysInspiratory/Expiratory X-rays  BronchoscopyBronchoscopy
  35. 35. Signs of Airway ObstructionSigns of Airway Obstruction  Stretor; obstruction in the throat, low pitched chokingStretor; obstruction in the throat, low pitched choking noisesnoises  Stridor; High pitched, inspiratory, biphasic orStridor; High pitched, inspiratory, biphasic or expiratory depending on locationexpiratory depending on location  Accessory Muscle useAccessory Muscle use  Pallor, diaphoresis, restlessnessPallor, diaphoresis, restlessness  TachycardiaTachycardia  Cyanosis and altered concious stateCyanosis and altered concious state  Intercostal recessionIntercostal recession  Nasal FlaringNasal Flaring  ExhaustionExhaustion  Bradycardia – most dangerous signBradycardia – most dangerous sign
  36. 36. Upper Airway Obstruction -Upper Airway Obstruction - NeonatesNeonates  Subglottic StenosisSubglottic Stenosis  Congenital or Acquired (trauma, intubation)Congenital or Acquired (trauma, intubation)  Biphasic stridor, resp distress, recurrent croupBiphasic stridor, resp distress, recurrent croup  Diagnosis; CT, laryngoscopyDiagnosis; CT, laryngoscopy  Tx; Soft tissue – laser and steroidsTx; Soft tissue – laser and steroids Cartilage – Laryngotracheoplasty or tracheostomyCartilage – Laryngotracheoplasty or tracheostomy (intubation)(intubation)  LaryngomalaciaLaryngomalacia  Soft immature cartilage Children or older patients with NMSoft immature cartilage Children or older patients with NM disordersdisorders  Inspiratory stridor at 1-2 weeks, worse supine + feedingInspiratory stridor at 1-2 weeks, worse supine + feeding difficultiesdifficulties  Dx; BronchoscopyDx; Bronchoscopy  Tx; Usually self resolves after 18-24monthsTx; Usually self resolves after 18-24months
  37. 37.  44 Female44 Female  6 week history of hoarse voice6 week history of hoarse voice  Irritation and dryness in throatIrritation and dryness in throat  History of heartburnHistory of heartburn  SmokerSmoker  No history of weight loss, fatigueNo history of weight loss, fatigue  Examination; UnremarkableExamination; Unremarkable
  38. 38. Chronic LaryngitisChronic Laryngitis  Most common cause is GORDMost common cause is GORD  Recurrent Acute laryngitisRecurrent Acute laryngitis  Heavy smokingHeavy smoking  Chronic infection of nasal sinusesChronic infection of nasal sinuses  Mouth breathing from nasal obstructionMouth breathing from nasal obstruction  ClinicallyClinically  Hoarseness or loss of voiceHoarseness or loss of voice  Spasmodic coughSpasmodic cough  DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis,DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis, TBTB  General; Voice resting, avoid smokingGeneral; Voice resting, avoid smoking  Specific; eg. Lifestyle modifications, MedicationsSpecific; eg. Lifestyle modifications, Medications
  39. 39.  35 year old35 year old  Blunt trauma to neck 5 hours agoBlunt trauma to neck 5 hours ago  Difficulty swallowing + Voice changesDifficulty swallowing + Voice changes  No history of LOC, resp distress, confusionNo history of LOC, resp distress, confusion  Examination showed midline tenderness ofExamination showed midline tenderness of neck, subcutaneous emphysemaneck, subcutaneous emphysema
  40. 40. Laryngeal TraumaLaryngeal Trauma  RareRare  CausesCauses  PenetratingPenetrating  Blunt trauma; majority are MVA’s, clothesline injuries,Blunt trauma; majority are MVA’s, clothesline injuries, sporting injuriessporting injuries  Manual strangulationManual strangulation  Inhaled flamesInhaled flames  Swallowed poisons, foreign bodySwallowed poisons, foreign body  ETTETT  Injuries;Injuries;  Cricotracheal separation -> AsphyxiaCricotracheal separation -> Asphyxia  Fractures of larynx, hyoid bone, joint disruptionFractures of larynx, hyoid bone, joint disruption  Open woundsOpen wounds  Mucosal TearsMucosal Tears
  41. 41. Laryngeal InjuriesLaryngeal Injuries  PresentationPresentation  Significant cervical traumaSignificant cervical trauma  Hoarse voice, neck pain, dyspnea, hypoxia, aphoniaHoarse voice, neck pain, dyspnea, hypoxia, aphonia dysphasiadysphasia  Goals of treatmentGoals of treatment  Protect the airway; Intubation, tracheostomyProtect the airway; Intubation, tracheostomy  Restoration of function; Surgical repairRestoration of function; Surgical repair  ComplicationsComplications  Laryngeal stenosis; permanent tracheostomyLaryngeal stenosis; permanent tracheostomy
  42. 42.  33 year old male singing teacher33 year old male singing teacher  Progressively hoarse voiceProgressively hoarse voice  Normal CoughNormal Cough  Non-smokerNon-smoker  No weight loss/fatigueNo weight loss/fatigue
  43. 43. Benign Vocal Fold LesionsBenign Vocal Fold Lesions  Reactive nodules (singers nodules)Reactive nodules (singers nodules)  BilateralBilateral  Smooth, rounded/pedunculatedSmooth, rounded/pedunculated  SmallSmall  Located on true vocal foldsLocated on true vocal folds  Treatment;Treatment;  Voice training, re-educationVoice training, re-education  Rarely surgical if fibrosed, chronicRarely surgical if fibrosed, chronic  Virtually never give rise to malignancyVirtually never give rise to malignancy
  44. 44. LaryngoceleLaryngocele  Abnormal dilatation of the laryngeal ventricleAbnormal dilatation of the laryngeal ventricle  Contains airContains air  Men>WomenMen>Women  Bilateral 25%Bilateral 25%  Aeitology;Aeitology;  Acquired; Incr. Intraluminal pressure (musicians)Acquired; Incr. Intraluminal pressure (musicians)  CongenitalCongenital  SCC <15%SCC <15%  Hoarse voice, pain, dysphagia, lateral neck massHoarse voice, pain, dysphagia, lateral neck mass
  45. 45. Squamous PapillomaSquamous Papilloma  Most common benign neoplasm of larynx (84%)Most common benign neoplasm of larynx (84%)  Found on true vocal cordsFound on true vocal cords  Caused by HPV 6 and 11Caused by HPV 6 and 11  Soft Raspberry like appearanceSoft Raspberry like appearance  May ulcerate resulting in haemoptysisMay ulcerate resulting in haemoptysis  Usually Single in AdultsUsually Single in Adults  Multiple in Children (Laryngeal Papillomatosis) withMultiple in Children (Laryngeal Papillomatosis) with extended growth and recurrenceextended growth and recurrence  Malignant transformation extremely rareMalignant transformation extremely rare
  46. 46. Investigation and TreatmentInvestigation and Treatment  Ix;Ix;  LaryngoscopyLaryngoscopy  Tx;Tx;  CO2 LaserCO2 Laser  Surgical removalSurgical removal  ?Antivirals?Antivirals
  47. 47.  55 year old male55 year old male  History of GORD, cardiac diseaseHistory of GORD, cardiac disease  Recurrent hoarse voiceRecurrent hoarse voice  Right otalgiaRight otalgia  Smoker + ETOH abuseSmoker + ETOH abuse
  48. 48. Squamous Cell CarcinomaSquamous Cell Carcinoma  Most common malignancy of larynxMost common malignancy of larynx  Male>Female 6;1xMale>Female 6;1x  2.5% all cancers in men2.5% all cancers in men  AeitologyAeitology  Tobacco:Tobacco: ↑↑↑↑  Alcohol:Alcohol: ↑↑ (x 2.2)(x 2.2)  Radiation, asbestosRadiation, asbestos  GORDGORD  HPVHPV
  49. 49. Squamous Cell CarcinomaSquamous Cell Carcinoma  Glottic SCC most common (60%) >Glottic SCC most common (60%) > supraglottic SCC (30%) > subglottic SCCsupraglottic SCC (30%) > subglottic SCC (<10%).(<10%).  Sx: hoarseness, throat pain, cough, hemoptysis,Sx: hoarseness, throat pain, cough, hemoptysis, referred otalgia, dysphagiareferred otalgia, dysphagia  Diagnosis;Diagnosis;  Laryngoscopy with FNALaryngoscopy with FNA  CT/MRICT/MRI
  50. 50. Squamous Cell CarcinomaSquamous Cell Carcinoma  ManagementManagement  Eradication of diseaseEradication of disease  Restoration of function; swallowing and speechRestoration of function; swallowing and speech  Radiation treatmentRadiation treatment  Especially early stage diseaseEspecially early stage disease  Cure rates equivalent to surgeryCure rates equivalent to surgery  Surgical ManagementSurgical Management  Emphasis on organ preservationEmphasis on organ preservation  Partial LarygectomyPartial Larygectomy
  51. 51.  www.surgical-www.surgical-tutortutor..orgorg.uk.uk  Learning RadiologyLearning Radiology  Clinical Cases and Osces in Surgery.Clinical Cases and Osces in Surgery. Ramachandran, PooleRamachandran, Poole  Apleys OrthopaedicsApleys Orthopaedics

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