• General Objectives:– The study aims to help the students be critically

aware of the disease to help those who are affected by it, to help each of the family members to inform of this diseases. This study aims to gain knowledge facts about laryngitis and once knowledge is required, we shall disseminate this knowledge to the common people to help increase awareness of the disease.

• Specific Objectives– At the end of 3 hours case presentation our group will be able to:1.Identify its causes, predisposing and precipitating factor.2.Explain the pathophysiology of laryngitis.3.Provide a clear interpretation of its functions.4.Provide a brief and understandable description of the related structures.5.Provide a plan care with specific, measurable, attainable, realistic and time

bounded nursing care plan for the client.6.Attain a comprehensive drug study on the medications prescribed to the client.7.Provide client with the appropriate health teachings with regards to disease

process, self-care therapies and diet, and medication regimen.8.Present a well validated patient assessment.

• Prognosis of Laryngitis:– It is a minor ailment and clears up on its own

within a few days or weeks.– Prognosis for laryngitis is excellent. Recovery is

complete, and usually occurs within a week’s time.

– Laryngitis caused by a virus or vocal strain usually will disappear in a few days to a week. If the laryngitis is caused by a bacterial infection, the outlook depends on the type of bacterial involved.

INTRODUCTION• What is laryngitis?• The larynx is the voice box that allows us to speak, shout, whisper,

and sing. The larynx consists of a cartilage skeleton that houses the vocal cords, which are covered by a mucus lining. Muscles inside the larynx adjust the position, shape, and tension of the vocal cords, allowing us to make different sounds. Any change in the air flow (which is generated by the lungs) across the vocal cords will affect the voice and the quality of the sound.

• The larynx is located at the junction of the mouth and trachea and has a flap-like covering called the epiglottis, whose job it is to prevent food and saliva from entering the larynx during swallowing.

• Laryngitis (larynx + itis = inflammation) is an inflammation of the voice box, causing a hoarse or gravelly-sounding voice or even an inability to speak.

• What causes laryngitis?• Laryngitis is an inflammation of the vocal cords.

Most commonly, acute laryngitis is caused by an infection that inflames the vocal cords.

• In infants and young children, the classic signs and symptoms of an inflamed larynx include: croup, a hoarse barky cough, and fever.

• Similarly, in adults, a viral upper respiratory tract infection may be associated with:runny nose, dry cough, and a loss of voice.

• Rarely, since most people are immunized and protected against this infection, diphtheria may cause laryngitis-like symptoms.Laryngitis may also be caused by voice overuse with excess talking, singing, or shouting.Chronic laryngitis, often described as lasting for more than three weeks, may be caused by prolonged alcohol use, smoking, and excess coughing

THE LARYNX PART I: OVERVIEW AND CARTILAGES

• The Larynx serves a number of purposes. Though it may seem designed specifically for our speaking and singing, the larynx has evolved to allow us this control. It has other purposes too, ones that are essential to life. These purposes are called "biological", while speaking and singing are called "non-biological", as it is quite possible to survive without speech or singing. Witness those individuals who have had to have their larynges ( La - rin - jeeze,the plural of larynx) removed due to cancer and who talk through a process much like burping. Perhaps not very aesthetically pleasing, but possible.

• Biological Function: • to act as a valve to prevent air from escaping the

lungs, e.g. weightlifting • to prevent foreign substances from entering the

lungs, trachea and glottis, e.g. while swallowing, the epiglottis covers the opening to the larynx.

• to forcefully expell foreign substances which threaten the trachea, e.g. coughing

• Non-Biological Function: • the production of sound

Medical Management• Medical Care• Vaughan states that patients know that laryngitis treatment requires only

time and the common-sense avoidance of vocal excess and other irritants. The following measures can help lessen the intensity of the laryngitis while waiting for the condition to resolve:

• Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate.

• Complete voice rest is suggested, although this recommendation is nearly impossible to follow. If the patient must speak, soft sighing phonation is best. Avoidance of whispering is best, as whispering promotes hyperfunctioning of the larynx.

• Prevailing data do not support the use of antihistamines and corticosteroids. If a patient uses these medications, he or she may have the false impression that the laryngitis is resolving and may continue to use his or her voice, leading to further insult. The drying effect of these medicines may also be deleterious.

• A patient who smokes must cease smoking in order to promote timely resolution of the acute laryngitis. If the patient's laryngitis is from an infectious etiology, continued smoking delays prompt resolution of the disease process.

• The most common etiology for acute laryngitis is an infectious source, usually a viral upper respiratory tract infection. In 1985, Schalen observed that, at the time of the acute laryngitic episode, many patients were carriers of bacterial infectious agents, the most common of which were Branhamella catarrhalis and Haemophilus influenzae.6 These patients experienced more severe dysphonia than patients with negative culture results.

• Despite the high isolation rate of organisms from the nasopharynx, a double-blind, placebo-controlled study of patients with acute laryngitis revealed that administration of penicillin V was not advantageous in the treatment of acute laryngitis.6 The study found that penicillin V administration did not decrease bacterial counts or alleviate symptoms. Schalen concluded that antibiotic treatment for otherwise healthy patients with acute laryngitis is currently unsupported; however, for high-risk patients and patients with severe symptoms, antibiotics may be considered. Others advocate the use of narrow-spectrum antibiotics only in the presence of an identifiable Gram stain and culture.2

• An excellent review from the Cochrane Database Systemic Review found no benefit in using antibiotics to treat acute laryngitis. They recommended that antibiotics should not be prescribed as a first-line treatment for acute laryngitis.7

• The treatment for gastroesophageal reflux disease (GERD)–related laryngitic conditions includes dietary and lifestyle modifications as well as antireflux medications. Antacid medications that suppress acid production, such as H2-receptor and proton pump blocking agents, are highly effective against gastroesophageal reflux. Of the various classes of medicines available to treat GERD, the proton pump inhibitors are the most effective.8 Patients on prolonged antireflux therapy or with a history of long-standing GERD should be evaluated by a gastroenterologist to ensure that serious sequelae of GERD, such as Barrett esophagitis, have not manifested or do not develop.

• Note that optimal timing of proton pump inhibitor intake increases its efficacy. For patients who require twice-a-day dosing, suggested dosing times that are 15-30 minutes before breakfast and dinner.9 Katz cautions that treatment durations may be longer for patients with reflux laryngitis than for patients with other extraesophageal manifestations of GERD (eg, asthma, cough, noncardiac chest pain).

• Diet• Dietary restrictions are recommended for patients with GERD. These include

avoidance of caffeine, fatty foods, chocolate, peppermint, and late meals (ie, <3 h before retiring).9 The patient should maintain hydration and fluid intake at a stress level to support requirements during the illness. The patient should drink at least 6-8 glasses (8 oz each) of water per day.

• Activity• Although not always possible, patients who use their voices professionally should

attempt complete vocal rest. If the patient must communicate, soft sighing use of the voice causes the least vocal trauma. Patients suspected of having GERD should avoid lying down after meals and should elevate the heads of their beds.

• A physician is often consulted to decide if a professional voice user should cancel or perform an engagement. A contraindication to performance is the presence of vocal fold hemorrhage or exudative laryngitis.2 If the patient has mild laryngitis, the physician's decision whether to allow the patient to perform becomes difficult. Vaughan's guiding principle is to do no harm because tomorrow is important, also. If the professional performer wants the show to proceed, he or she should adapt the show and vocal efforts during the performance to minimize vocal abuse.

• Medication• The goals of pharmacotherapy are to reduce morbidity and prevent

complications.• Proton pump inhibitors• These agents inhibit gastric acid secretion by inhibition of the

H+/K+/ATP-ase enzyme system in the gastric parietal cells. These agents are used in cases of severe esophagitis.

• • Omeprazole (Prilosec)• Specifically suppress gastric acid secretion by potent inhibition of

the H+/K+ ATPase enzyme system at secretory surface of gastric parietal cell. This blocks the final step in gastric acid production. Effect is dose related and inhibits both basal and meal stimulated acid secretion.

Surgical Management• Normal Larynx •

• This is an example of a normal larynx. The true vocal folds are pearly white, they

meet in the midline on phonation, and the surrounding structures are light pink. As you view the following examples of diseases of the larynx, you can compare them to this example.

• Nodules •

• Nodules are calluses on the vocal folds that occur with improper voice use or

overuse. They are most common in children and females.They prevent the vocal folds from meeting in the midline and thus produce an hourglass deformity on closure resulting in a raspy, breathy voice. Most time,s these will respond to appropriate speech therapy. Occasionally (20% of the time), these may persist after intensive speech therapy and will require meticulous microlaryngeal surgery

Anatomy• Polyps •

• Polyps are benign lesions of the larynx, occurring mostly in adult males, that are

usually located on the phonating margin (edge) of the vocal folds and prevent the vocal folds from meeting in the midline. Polyps can interfere with voice production and may produce a hoarse, breathy voice that tires easily. These may respond to conservative medical therapy and intensive speech therapy. If the lesion fails to respond, meticulous microsurgery may be indicated. One of the cofactors in the cause of these lesions may be laryngeal reflux disease.

• Laryngitis sicca •

• Laryngitis sicca is caused by inadequate hydration of the vocal folds. Thick, sticky

mucus prevents the folds from vibrating in a fluid, uniform manner.

• Vocal fold hemorrhage •

• Vocal fold hemorrhage is a very rare occurrence that usually is

caused by aggressive or improper use of vocal folds (e.g. cheerleading). It is a result of rupture of a blood vessel on the true vocal fold, with bleeding into the tissues of the fold.

• Cancer • • • This is an example of a very early cancer of the vocal folds. If these

lesions are detected early, they can be treated with either radiation or surgery, with a cure rate approaching 96%.

• Impaired Vocal Fold Mobility, a condition where one or both of the vocal folds do not move appropriately, can be due to paralysis, paresis, scarring, or inflammation of the crico-arytenoid joint.

• • • Vocal fold paralysis or paresis results from a

lesion of the neural or muscular mechanism.

• Unilateral vocal fold paralysis can be caused by a variety of diseases or disorders that prevent movement in one vocal fold. When one weakened vocal fold does not move well enough to meet the other fold in the midline during speech, air leaks out too quickly. This causes the voice to sound breathy and weak, making it necessary for the speaker to take more frequent breaths during speech. After a full day of talking, someone with a weak vocal fold can feel exhausted due to the frequent breathing, and can experience choking and coughing on food or liquids.

• Bilateral vocal fold paralysis: When both vocal folds have movement problems, the situation can be much more serious. With both vocal folds paralyzed in the midline position, the person has difficulty breathing and a tracheotomy may be necessary to establish an airway. If both folds are paralyzed near the midline, although the voice may be good the airway may be compromised. If both folds are paralyzed far apart, there may be no voice.

• Vocal fold bowing, can result from neural, muscular, traumatic, congenital, or functional causes, with or without vocal fold atrophy, and can result in vocal weakness.

• • • Presbylaryngis is a condition that is caused by thinning of

the vocal fold muscle and tissues with aging. The vocal folds have less bulk than a normal larynx and therefore do not meet in the midline. As a result, the patient has a hoarse, weak, or breathy voice. This condition can be corrected by injection of fat or other material into both vocal folds to achieve better closure.

• Laryngeal Dystonia (Spasmodic Dysphonia) • Laryngeal dystonia, or spasmodic dysphonia

(SD) is a voice disorder caused by involuntary movements of one or more muscles of the larynx. There are two major types of spasmodic dysphonia: adductor and abductor, although most are a mixture of both types.

• Adductor SD, with spasms causing sporadic vocal fold closures, are identified by a strained, strangled voice.

• • • • • Listen• • • Audio• • • • Audio• • • Abductor SD, with spasms causing sporadic vocal fold closures, produces a voice with interruptions

of air

• PATHOPHYSIOLOGY• • • PREDISPOSING FACTORS• • Exposure to dust, chemical, smoke, other

pollutants• Exposure to sudden temperature changes• Dietary deficiencies• Malnutrition or immune suppression•

• Viral infectionBacterial infection

• • • •

Hoarseness or Aphomia / Complete loss of voice Strep throat

• Severe dry cough• Sore throat that worsens in the evening hours

• IDEAL NURSING CAREIdeal nursing care include resting the voice, avoiding

smoking, resting and inhaling cool steam or anaerosol. If the laryngitis is part of more extensive respiratory infection due to a bacterial organism or if it is severe, appropriate anti bacterial therapy is instituted.

For chronic laryngitis, the treatment includes resting the voice eliminating any primary respi-tract infection, eliminating smoking and avoiding second-hand smoke. Topical corticosteroids such as beclomentnasome dipropinate (vanceril) inhalation, may also be used. These preparations have no systemic or long-lasting effects in may reduce local inflammatory reaction.

• What is the Definition of Laryngitis?•

Laryngitis is an inflammation of the mucous membrane lining the larynx (voice box), which is located in the upper part of the respiratory tract.

• It causes hoarseness, and possibly a temporary loss of speech.

•

• Causes of Laryngitis•

Laryngitis may result from prolonged straining of the voice. It also may occur as an isolated local infection of the larynx as part of another, more serious underlying disorder, such as pneumonia or tuberculosis. In most cases, however, it is a minor ailment and clears up on its own within a few days or weeks.

• Acute laryngitis may result from excessive strain on the vocal cords, as occurs with activities such as yelling, cheering, singing, or public speaking.

• Postnasal drip, allergies, or inhalation of smoke fumes, or caustic chemicals can irritate the larynx and cause inflammation.

• Chronic laryngitis may be caused by excessive alcohol consumption, smoking, or constant exposure to dust or chemical irritants like paint remover.

• Chronic upper respiratory tract disorders such assinusitis, bronchitis, nasal polyps, and allergies can cause chronic laryngitis.

• Repeated episodes of acute laryngitis may eventually lead to chronic laryngitis.• Gastroesophageal reflux (heartburn) may ulcerate the larynx.•

• Symptoms of Laryngitis•

The major symptoms of laryngitis are:• Hoarseness• Sore throat• Weak or absent voice• Sensation of a lump in the throat or constant

need to clear the throat• Dry cough• Fever

• Diagnosis of Laryngitis•

Diagnosis is based upon a combination of the clinical history and a physical exam. Some physicians might wish to do a laryngoscopy (visualization of the vocal cords).

• Treatment for Laryngitis•

If laryngitis is caused by a bacterial infection, antibiotics will be prescribed.• Some palliative measures that can be taken include:• Avoid public speaking during recovery• Be aware that whispering puts greater strain on the vocal cords than

normal speaking• Inhale steam from a bowl of hot water or from a warm shower• Drink warm, soothing liquids (but do not drink alcoholic beverages)• Try a cool-mist humidifier; avoid air conditioning• Use nonprescription pain relievers and throat lozenges to ease the

discomfort• Avoid cigarettes until the symptoms have subsided• Above all, make sure that the underlying cause of chronic laryngitis has

been diagnosed and treated.

• What Questions to ask Your Doctor About Laryngitis?•

What is the cause of the laryngitis?Is there an underlying medical problem?

• Is there an infection present?• Is it caused by an upper respiratory problem?• Are antibiotics needed?• Can you identify a possible source of irritation of the

larynx?• How can the symptoms be relieved?•