Benign lesions of the larynx – swallowing disorders

SemmelweisUniversityDept.ofOtorhinolaryngologyHeadandNeckSurgery

Anatomy I. – the cartilageous trachea and larynx

Anatomy II. – the lumen of the larynx

Anatomy III. – the muscles of the larynx

• 1. „Outer muscles”: M. sternothyreoideus, m. thyreohyoideus, m. constrictor pharyngis inf.(m.thyreo- és cricopharyngeus)

• 2. „Inner” muscles: a: abductors – glottis opening b: adductors – glottis closure c: extensors – tense the vocal chords • 3. Muscles with no direct attachment to the larynx (m.

sternocleidomastoideus,...)

Muscles I. – the abductor

m. cricoarytenoideus posterior (m.posticus)

Muscles II. – the adductors

m.cricoarytenoideus lateralis m.interarytenoideus

m.thyreoarytenoideus internus (m.vocalis) és externus

Muscles III. - „tensors”

m.cricothyreoideus, m.vocalis

Movements

Examination I. – indirect laryngoscopy

Examination II. – direct laryngoscopy with flexible instument

Examination III. – direct laryngoscopy with flexible instrument

- minimal mucosal anaesthesia needed - can easily be performed - archivation - fiberoptic or „chip on the tip”

Examination IV. – direct laryngoscopy with rigid instrument

• betterpicturequality(comparedwithfiberoptic)• alittlebitlesstolerable• archivation

Examinations V. – Videostroboscopy

• Principle: the vocal chords are illuminated with a slightly differentfrequencyofpulsatinglightcomparedtotheirownactualfrequency,

• theperiodsofthevocalchordsseemtobesloweddown

Voice production (cover-body)

Examinations VI. – voice analysis

oscillogram

voice spectrum

Examinations VI. – voice analysis

Examinations VI. – voice analysis (jitter – shimmer)

Normal valuesPeriod-flutter (jitter) < 1.04%

< 83.2µsamplitude-flutter (shimmer) < 3.81%

< 0.35dB

Examinations VII. – laryngomicroscopy

Larynx

• airwayprotection• valsalva• phonation

• exhaledvolumeofair• phonatorysettingsandvibrationsofvocal

chords• softtissueabovetheglottis-theplaceof

articulation

Diseases affecting voice production

• congenitalmalformationsoftheupperairways• inflammatorydiseasesofthelarynx• injuries• benignandmalignantlesions• disordersofmutation• endocrindisorders• neurologicaldiseases• functionalproblems(psychic...)

Inflammatory diseases – laryngitis

Inflammatory diseases – cyst of the vocal chord

Inflammatory diseases – nodulus laryngis

Possible causes:

- deficient voice production

- overstrained voice

Inflammatory diseases – polypus ch.voc.

Overstrained vocal chord i.e. during acute laryngitis

Treatment: surgical removal

Papilloma laryngis

Inflammatory diseases – Reinke-edema

• typicalsmoker’sdisease,morefrequentamongwomen• edemaappearsunderthemucosaofthevocalchords• treatment:surgicalremoval

Intubation granuloma

Inflammatory diseases – atrophia of m.vocalis (spindle-shaped closure defect)

Cause:overstrained phonation in acute laryngitis

Treatment: vocal exercises

Closure defect in the posterior third of the glottis

Closure defect in the whole lenght of the glottis

Disorders of mutation

• delayed,long-lasting,early

• incomplete• perverted(women)• eunuchoidvoice(men)

Neurological diseases – multiple sclerosis

• monotonousspeech• weak,hoarsevoice

Neurological diseases – recurrent nerve palsy

• mostlyiatrogenic–afteroperationsofthethyroidgland• inunilateralcasesthehealthysidecompensatesthepalsy• thevoicetemporarilybecomesweak

Bilateral recurrent nerve plasy causing dyspnea

Neurological disorders – after cerebral hemorrhage

Regulatory (functional) disorders

dysplasia

SCC of the vocal chord

Voice rehabilitation after total laryngectomy

Esophageal speech

• about 2/3 of the patients ara able to learn the technique and 1/3 of these uses regularly

• the patient can only tell short sentences

• poor, but understandable voice quality

Electrolarynx

Voice prosthesis

Swallowing disorders

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Phases of swallowing

• oral-(gyruspraecentr.,premot.cortex,tr.corticobulbaris)

• relaxedmandible• lipsreachingeachother• tipofthetongueininferiorposition• bodyofthetonguereachesthesoftpalate• nasalbreathing• closedteethandlips• tonguereachestheaveolararch• tonguepressedagainstthehardpalate• bodyofthetongueinlowestposition• bolusmovesposteriorly–reachesthetriggerpoint

Phases of swallowing

• pharyngeal(cca1s,med.obl.,n.X.)• velopharyngealclosure• hyoidboneelevates• laryngealclosure

• vocalchords• falsevocalchords• arytenoids,aryepiglotticfolds• retractionoftheradixepiglottisclosestheaditus

• pharyngealperistalsis• larynxelevates(cca.2cm),movesanteriorly,esophagusopens

• esophageal(cca.4-20s)

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Dysphagia

Difficultyin• oralpreparation• oral,pharyngealandesophagealtransport.

• Symptoms• aspiration(pre-,intra-,postdeglutitive)

• withoutcoughing(silent)–neurogeniccause• slowchewing,swallowing• difficultyinforwardingthebolus• coughing• hoarsenessduringmeals(„wetvoice”)• weightloss• feverwithoutanyobviouscause

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Possible causes

• neurogenic• stroke• Parkinson’sdisease• ALS• multiplesclerosis• ICmalignancy• trauma• myastheniagr.,• toxicneuropathy,n.VII.paresis)

• local,organic• URTI• GOR• iatrogenic(intubation,laryngomicroscopy,irradiation)

• goiter,Zenker-div.• necktrauma• headandnecktu.

• psychogenic

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Examinations I.

• Generalexaminations• motoricfunction• breathing,phonation,articulation• ENTexamination• sluggishtonguemovement,salivation,foodremnantsintheoralcavity

• sensorytestoftheoralcavity,pharynx• muscletone• endoscopy

• velapharyngealclosure• garatizmokmozgása• szupraglottikus-,glottikuszár• colouredfoodinvarioussizesandviscosity

• esophagoscopy,pHmeasuring,esophagealmanometry,EMG

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Examination – X-ray

• esophagealphase• amountofaspiratedfluid• diagnosisbylocation

• Salivaaspirationcannotbeassessed

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Az aspiráció súlyossági fokozatai

I. megtartottköhögésireflex,alkalmankéntaspirálII. megtartottköhögésireflex,permanensaspirációv.alkalmankénti

aspirációköhögésireflexnélkül,dehatékonyakaratlagosköhögésselIII. permanensaspirációköhögésireflexnélkül,deeredményes

akaratlagosköhögésselIV. permanensaspirációköhögésireflexnélkül,ineffektívakaratlagos

köhögéssel

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Presbyphagy

• Causes• deformityofthecervicalspine• stroke• toothloss• deteriorationofsmelling• drymucosa• izomtevékenységgyengülése• bolusretencióaszájüregben,valleculakban,sin.piriformisban

• Treatingmethods• coldorhotmeals• seasoning• forcedswallowingtechnique

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Dysphagia Functional Therapy (DFT)• Restitutional-causaltherapy

• breathing(intendedglotticclosureandcoughing)• improvingtheorofacialregion’sfunction

• muscletone• cold,sourmaterials(tongue,buccalregion)• chewingpractices• keepingthelarynxinelevatedposition(Mendelsohn’smaneuver)

• Compensatoryswallowing• changingthepositionofthehead

• forward–afterepiglottectomy• rotationtowardstheaffectedside–paresisn.rec.• backwards–injuredtonguemotility

• varietyofswallowingtechniqes• forced• frequent• ...

• Adaptationmethods(oralprostheses,specialglas,NOstraw!)• Diet(temperature,consistency,energy...)

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Mészáros-Hacki