Disorders of the LarynxWinnie YeungFoundation Year 2

Question 1All of the following muscles are supplied by the recurrent

laryngeal nerve except:

A. Posterior cricoarytenoidB. Lateral cricoarytenoidC. CricothyroidD. ThyroarytenoidE. Mylohyoid

Question 2Which virus is implicated in recurrent respiratory

papillomatosis:

A. EBVB. HPVC. CMVD. VZVE. HIV

Question 3A 37-year old opera singer comes to clinic, complaining of 2-

weeks history of hoarseness which is interfering with her work. On endoscopy, you see normal vibration of the vocal cords, but notice thickened areas at the anterior 1/3 of both cords. The most likely diagnosis is:

A. Vocal cord polypB. Vocal cord nodulesC. Vocal cord synechiaD. Vocal cord paralysisE. Carcinoma of the larynx

Question 4A 5-year old child is brought to A&E by his concerned mother with

high fever and difficulty swallowing. On examination, the child is sat up on the bed, you notice that stridor, quiet shallow breathing and drooling. ‘Thumb-print sign’ is seen on XR. The most likely cause is:

A. EpiglottitisB. CroupC. Peritonsillar abscessD. Retropharygeal abscessE. Foreign body

Question 5A 17-year old comes to see her GP, presenting with a short

history of mild fever, fatigue and sore throat. She has vomited once at home today. On examination, there is splenomegaly. Which of the following treatment should the GP avoid:

A. ClarithromycinB. DoxycyclineC. Co-trimoxazoleD. AmoxicillinE. Aciclovir

Session Overview• Anatomy

• Benign lesions▫ Nodules▫ Polyps▫ Cysts▫ Reinke’s oedema

• Inflammatory conditions▫ Laryngitis

• Degenerative conditions▫ Presbylarynx

• Neoplasia▫Premalignant▫Carcinoma

• Neurological▫Paralysis

• Epiglottitis• Respiratory papillomatosis• Infectious mononucleosis

• Cricothyrodectomy▫ Emergency airway

involves puncturing the cricothyroid membrane.

• Larynx skeleton made up of various cartilages:▫ Thyroid cartilage▫ Cricoid cartiage (complete ring)▫ Arytenoid cartilages (pyramid-shaped x2)

Anatomy: Endoscopic view• All muscles of the larynx supplied

by the recurrent laryngeal nerve, from vagus.

• EXCEPT cricothyroid muscle, innervated by the external branch of the superior laryngeal nerve.

• Blood supply: Superior and inferior thyroid arteries.Rima Glottidis

Function of the normal larynx• Appearance: Pearly-white true vocal cords, with surrounding

structure being light pink.• Function: Breathing and phonation.• Movement: Abducts and adducts against each other, meeting

in the midline on phonation. There should be no gaps!

Throat symptoms• Hoarseness

• Stridor: High-pitched noise, in either inspiration or exhalation, due to upper airway obstruction.

• Stertor: Heavy snoring inspiratory sound, occuring in coma or deep sleep, sometimes due to obstruction and upper airways.

• Pain: Not common, even in malignancy, but may be a prominent feature if pathology is inflammatory in nature,

Benign: Nodules• Causes: Microtrauma, gastric

reflux, repeated URTI.

• Findings: Calluses occurs in pairs, preventing cords from meeting in the midline. Hourglass deformity.

• Most commonly occuring in anterior 1/3 of vocal cords.

• Common in children and female patients, singers, teachers.

• Symptoms: Hoarseness, painful phonation, frequent voice breaks, reduced vocal range.

• Formed slowly over time.

• Management: Intensive speech and voice therapy, uncommonly microlaryngeal surgery.

Benign: Polyps• Causes: Isolated trauma, violent

coughing, screaming, LPR (Laryngopharyngeal reflux).

• Findings: Single or paired lesions occuring at phonating margin (edge) of vocal cord.

• Mostly in adult males.

• Symtpoms: Hoarse, breathy voice, tiring easily.

• Management: Voice therapy, voice rest, sometimes surgery.

Benign: Cysts• Causes: Poor draining or blocked

small gland in vocal fold, preventing drainage. Unknown whether vocal cord irritation or excessive voice use contributes.

• Findings: Single or paired lesions, collection of mucous fluid in sac-like structures.

• Management: Poor response to conservative Mx. Surgical removal, followed by voice rest.

Reinke’s Oedema• Aka ‘Polypoid Degeneration’ or

‘Polypoid Corditis’.

• Findings: Enlargement of upper layer of vocal cord covering, ‘Reinke’s space’, with accumulation of gelatinous fluid.

• Causes: Smoking, never seen in non-smokers.

• Symptoms: Lower-pitched voice due to slower vibrations. SOB.

• Management: Surgery. Smoking cessation is key, as may reoccure post-surgery is continued.

• Have some malignant potential.

Inflammatory: Laryngitis • Irritation and swelling of vocal

cords, acute vs. chronic.

• Causes: LPR, infection, smoking and inhalation of noxious fumes.

• Findings: Swollen cords, resulting in limited mucosal waves and incomplete closure. May look dry.

• Management: Seek and treat underlying course. If persists >2 weeks, consider expert advice.

Presbylarynx• Causes: Thicking of vocal cord muscles and

tissues with aging.

• Findings: Reduced bulk, not meeting in midline.

• Symptoms: Hoarse, weak, breathy voice.

• Management: Injection of fat or other material to achieve complete closure.

Malignancy: Carcinoma of the Larynx

• Causes: Smoking, alcohol, LPR.

• Classification: Supraglottic, glottic, subglottic.

• Pre-malignant: Leukoplakia on vocal cords, may develop into cancer if untreated.

• Symptoms: Horaseness, but may be insidious, presenting with acute airway obstruction. SOB, neck lump, blood in spit.

• Management: Surgery, cessation of smoking, alcohol, anti-reflux medication.

Vocal Cord Paralysis• Causes: Iatrogenic, malignant

invasion.

• Findings: Cord abducted on ipsilateral side, no movement/vibration

• Symptoms: Adduction failure results in weak, breathy voice.

• Management: Voice therapy, surgery with sialistic block to displace affect cord medially.

Epiglottitis• CT: ‘Halloween sign’ excludes

acute epiglottitis.

• C-spine XR: ‘Thumb-print’ sign

• Causes: Infection from Haemophilus influenzae.

• Uncommon since Hib vaccine.

• Symptoms: Potentially life-threatening upper respiratory obstruction.

• Young child, anxious, quiet shallow breathing, drooling +++.

• Managment: Protecting and securing airway, antibiotics.

Recurrent papillomatosis• Causes: Associated with HPV,

vertical transmission.

• Symptoms: Wart-like lesions in respiratory tract, causing recurrent obstruction.

• Young patients with stridor.

• Managment: No definitive cure, repeat microdebridement or CO2 laser to manage recurrent lesions.

Infectious mononucleiosis• Glandular fever (aka ‘kissing disease).

• Causes: Epstein-Barr virus.

• Symptoms: Fever, sore throat, malaise, sometimes vomiting and petichiae.

• Signs: Lymphadenopathy in posterior cervical, axillary and inguinal regions. Splenomegaly.

• Investigations: >50% lymphocytes, 10% with enlarged, typical nuclei, Monospot test (heterophile antibody test).

• Differentials: CMV, tonsillitis, flu, leukaemia, diptheria.

• Management: Symptomatic and supportive. Generally self-limiting,

• Avoid penicillins Rash.

Review: Question 1All of the following muscles are supplied by the recurrent

laryngeal nerve except:

A. Posterior cricoarytenoidB. Lateral cricoarytenoidC. CricothyroidD. ThyroarytenoidE. Mylohyoid

Correct answer: C

Review: Question 2Which virus is implicated the development of recurrent

respiratory papillomatosis:

A. EBVB. HPVC. CMVD. VZVE. HIV

Correct answer: B

Review: Question 3A 37-year old opera singer comes to clinic, complaining of 2-weeks history of

hoarseness which is interfering with her work. On endoscopy, you see normal vibration of the vocal cords, but notice thickened areas at the anterior 1/3 of both cords. The most likely diagnosis is:

A. Vocal cord polypB. Vocal cord nodulesC. Vocal cord synechiaD. Vocal cord paralysisE. Carcinoma of the larynx

Correct answer: B

Question 4A 5-year old child is brought to A&E by his concerned mother with high fever

and difficulty swallowing. On examination, the child is sat up on the bed, you notice that stridor, quiet shallow breathing and drooling. ‘Thumb-print sign’ is seen on XR. The most likely cause:

A. EpiglottitisB. CroupC. Peritonsillar abscessD. Retropharygeal abscessE. Foreign body

Correct answer: A

Question 5A 17-year old comes to see her GP, presenting with a short history of mild

fever, fatigue and sore throat. She has vomited once at home today. On examination, there is splenomegaly. Which of the following treatment should the GP avoid:

A. ClarithromycinB. DoxycyclineC. Co-trimoxazoleD. AmoxicillinE. Aciclovir

Correct answer: D

‘ Nothing can surpass the ability of the voice for soulful expression of the human experience.’