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Cummings Chapters 63 & 64

Cummings Chapters 63 & 64. Acute and Chronic Laryngitis Laryngeal and Tracheal Manifestations of Systemic Disease. Travis Shiba 12/6/13. Acute and Chronic Laryngitis. Key Points #1 cause of acute laryngitis = viral #1 cause of chronic laryngitis = reflux

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Cummings Chapters 63 & 64

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  1. Cummings Chapters 63 & 64 Acute and Chronic Laryngitis Laryngeal and Tracheal Manifestations of Systemic Disease Travis Shiba 12/6/13

  2. Acute and Chronic Laryngitis • Key Points • #1 cause of acute laryngitis = viral • #1 cause of chronic laryngitis = reflux • Candidal laryngitis can occur in non immuno compromised • Even in setting of likely neoplasm, still consider infection

  3. Laryngitis • Inflammation of the larynx • Can impair swallowing, phonating and breathing

  4. Acute Laryngitis • Phonotrauma • Viral Laryngitis • Acute Bacterial Laryngitis • Acute Fungal Laryngitis

  5. Supepithelial hemorrhage from phonotrauma

  6. Supepithelial hemorrhage of R VC polyp

  7. Acute Laryngitis • Phonotrauma • Viral Laryngitis • Acute Bacterial Laryngitis • Acute Fungal Laryngitis

  8. Viral Laryngitis • Pathogens: rhinovirus, parainfluenza, RSV, adenovirus, influenza, adenovirus… • SSx: dysphonia, hoarse voice, cough • Rx: supportive care: hydration, anti-inflam, voice rest, PPI +/- steroids • Croup: laryngotracheobronchitis • Typically parainfluenza 1,3 • Steeple sign

  9. Acute Laryngitis • Phonotrauma • Viral Laryngitis • Acute Bacterial Laryngitis • Acute Fungal Laryngitis

  10. Acute Bacterial Laryngitis • Supraglottitis (epiglottitis) • Pathogens: H influenza, Strep PNA, Staph Aureus, Beta hemolytic strep • Decreased incidence with h flu B vaccine • Rx: airway control. Humid air, IV antibiotics, monitored bed, steroids

  11. Acute Bacterial Laryngitis • Diptheria • Corynebacteriumdiptheria • SSx: acetone breath, thick grey membranous and friable plaque • Rx: airway via trach, diptheria anti toxins, PCN & clinda • Whooping cough • bordetellapertusis • Vaccine protects ~ 3 yrs • Rx: erythromycin to prevent spread

  12. Acute Laryngitis • Phonotrauma • Viral Laryngitis • Acute Bacterial Laryngitis • Acute Fungal Laryngitis

  13. Acute Fungal Laryngitis • Candiasis (moniliasis) • usually seen with oral/esophageal sx or in a pt taking oral inhaled steroids • White sessile plaques on erythematous base • Rx: Fluconazole

  14. Chronic Laryngitis • Bacterial • Fungal • Mycobacterial • Non infectious

  15. Chronic Bacterial Laryngitis • Rhinoscleroma • Klebsiellarhinoscleromatosis • Path: Mikulicz Cells • Rx: fluouroquinolones/TCN • Syphillis • Secondary: painless edema • Tertiary: gummas + cartil destruction • Rx: PCN

  16. Chronic Bacterial Laryngitis • Actinomycosis • Actinomycosisisraelii • Chronic suppurativeinfxn, rarely involves layrnx • Histo: • Sulfur Granules • Rx: PCN or Clinda

  17. Chronic Laryngitis • Bacterial • Fungal • Histoplasmosis • Blastomycosis • Cryptococcus • Coccidiomycosis • Mycobacterial • Non infectious

  18. Histoplasmosis Histoplasmosis SCCA

  19. Histoplasmosis • Histoplasmacapsulatum • Mississippi River Valley • Acute/Chronic, Pulmonary/systemic • Laryngeal Lesions: anterior larynx and epiglottis • Bx: poorly defined granulomas, multinucleated giant cells and pseudoepitheliomatous hyperplasia • Grows on Sabouraouds agar • Tx: Ampho/Azoles

  20. Blastomycosis • BlastomycesDermatitides • Central america/Midwest • Airborne to lung, to larynx hematogenously • Larynx involved 2% - exophytic/ulcerative mass usually on TVC • Histo: Broad based buds • Rx: ampho/azoles

  21. Cryptococcus Cryptococcus neoformans Bird droppings H&N Sx: meningitis (SNHL), membranous Npharyngitis; larynx (only TVC) Dx: india ink stain showing capsules Tx: ampho/azoles

  22. Coccidiomycosis • CoccidioidesImmitis • “valley fever” Southwest US and North Mexico • H&N: lesions (nodules/erosions) of skin, mucous membranes, epiglottis, trachea, salivary glands • Histo: “Sac with bugs” • Rx: ampho/azole

  23. Chronic Laryngitis • Bacterial • Fungal • Mycobacterial • Non infectious

  24. Mycobacterial Laryngitis • Tubercolosis • Direct from lungs or via blood • Dx: PPD/Quant/AFB • Tx: INH/Rifampin/voice rest • Leprosy (Hansen’s) • AFB and granulomas • Ulcerative supraglottis • Dx: foamy leprous cells • Rx: dapsone & CS

  25. Chronic Laryngitis • Bacterial • Fungal • Mycobacterial • Non infectious

  26. Non Infectious Laryngitis Smoking Pollution Vocal Abuse Rhinosinusitis Laryngopharyngeal Reflux

  27. LPR • Etiologies: acid/bile/pepsin • RF: obsity, EtOH, hiatial hernia, preg, scleroderma, feeding tube • SSx: Hoarse (am>pm), globus, dysphagia • Dx: trial of PPI/NP scope • Barium swallow • 24 hour dual pH probe • esophagoscopy

  28. LPR • Rx: • Behavioral: smoking cessation, elevate HOB, avoid late meals, overeating, avoid tight close/loose weight • Decrease caffiene, EtOH, mints, chocolate, • Avoid ASA, nitrates, CCB • Medications • PPI (usually 2x dose for LPR versus GERD) • H2 blockers • Surgery • Fundoplication

  29. Laryngeal and Tracheal Manifestations of Systemic Disease • Key Points • Symptoms: hoarseness, cough, stridor, airway compromise • Mimic laryngeal carcinoma

  30. Wegener’s Granulomatosis Relapsing Polychondritis Sarcoidosis Rheumatoid Arthritis Pemphigus/pemphigoid Amyloidosis

  31. Wegener’s Granulomatosis • Idiopathic necrotizing granulomatousvasculitis • Types: • Limited (no renal) • Systemic (pulm and renal) • Laryngeal SSx: subglottic mass, dyspnea, biphasic stridor • Rx: Steroids + cyclophosphamide then MTX/Azathiaprine

  32. Wegener’s Granulomatosis

  33. Replapsing Polychondritis • Idiopathic inflammation of cartilage • Laryngeal SSx: 14% present with laryngeal sx; 50% eventually have laryngeal sx • Radiology: non erosive arthopathy • Histo: non specific inflammation • Rx: steroids, dapsone, azathiaprine, cyclophosphamide, cyclosporine

  34. Sarcoidosis • Systemic granulomatosis • Laryngeal SSx (1-5%): suprglotticsubmucosal mass (“turbin like thickening”) • Dx: biopsy, incr ACE, hypercalcemia, hypergammaglobulinemia • Histo: noncaseatinggranulomas • Rx: endoscopic removal of mass if symptomatic • Systemic v injected steroids

  35. Sarcoidosis

  36. Rheumatoid Arthritis • Autoimmune • 25% Laryngeal involvement • Acute: tender/erythematous larynx • Chronic: cricoarytenoidankylosis, submucosal nodules • Increased RF, ESR; decreased C’ • Rx: steroids and antireflux

  37. Pemphigus/Pemphigoid • Autoimmune • Pemphigusvulgaris: anti desmosometonofilament • Intracellular bridges disrupted->intraepithelial blisters • BullousPemphigoid: anti basement membrane • Subepidermal blistering • Laryngeal SSx: can occur on the mucosa if other oral lesions. Usually does not extend to SG • Rx: corticosteroids

  38. Pemphigus/Pemphigoid

  39. Amyloidosis • Abnormal deposition of fibrillar protein and polysaccharide complexes • Laryngeal SSx: anterior subglottic mass • Dx: biopsy (congo red) • Rx: endoscopic removal

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