Laryngitis &
Laryngeal
Obstruction
dr. Ricky Yue, Sp. THT-KL
ENT-HNS Department
AtmaJaya Catholic University
Anatomical Framework
Anatomical Framework
LARYNGEAL OBSTRUCTION in Children,
Congenital in origin
Congenital Laryngeal Defects
Congenital Webs
● Most commonly anteriorly based.
● Path : incomplete recanalization at
8th week of embriological
development.
● Types : supraglotic (2%), glottic
(75%), subglottic (7%)
● SSx : weak cry at birth, aphonia,
variable degree of obstruction
(inspiratory stridor).
● Dx : Flexible endoscopy, DL
● Rx : endoscopic laser excision, open
surgical procedure
Congenital Subglottic Stenosis
● < 4mm in newborn
● 3rd most common anomaly.
● Path : incomplete recanalization,
small diameter cricoid cartilage.
● Types :
1. Membranous
2. Cartilaginous
3. Mixed
● Grade I-IV
● SSx : Biphasic stridor, recurrent or
prolonged croup, barking cough,
failure to thrive.
● Dx : endoscopy, Chest x-ray, neck
plain film, flexible endoscopy
Congenital Subglottic Stenosis
• Management :
– Secure airway → tracheostomy
– Medical → reflux regimen,
corticosteroid ( controversies)
– Surgical : laser excision or open
procedures (LTR,PCTR)
Laryngomalacia
● Most common (~60%) congenital laryngeal anomaly.
● Most common source of stridor in newborns.
● Male to female ratio 2:1.
● Inward collapse of supraglottic structures on inspiration.
● High-pitched fluttering inspiratory stridor exacerbated
by crying, feeding, agitation and supine position.
● Path : immature cartilage, abnormal calcium metabolism.
● Self-limiting condition:
● Onset: 2–4 weeks after birth
● Progression: up to 6–8 months after birth
● Resolution: 18 (range: 12–24) months after birth
● Diagnosis made using awake transnasal flexible
laryngoscopy (TNFL): Three main types of obstruction
• Associated gastro-oesophageal reflux in up to 80 % of cases.
• Severity of the disease:
– Mild to moderate in 80 % of cases
– Severe in 15 % of cases; supraglottoplasty required
– Very severe in 1–3 % of cases; tracheotomy required
• Rx : Observation → resolve with growth
Surgical removal of the excess tissue
Correct GERD if present
Tracheotomy or intubation → very rare
Laryngeal Cleft
• Path : Posterior cricoid lamina does not fuse or
tracheoesophageal septum does not develop.
• Associated w/ TE fistula, laryngomalacia, congenital hearth
defect, cleft lip/palate, down syndrome, others.
• SSx : inspiratory stridor, pneumonia, aspiration
• Dx :Chest X-ray → non-specific signs of aspiration pneumonia are
possible, esophagoram with water-soluble contrast → spillover
into larynx and trachea, direct rigid
laryngo-tracheo-bronchoscopy and SML in general anaesthesia →
probing of posterior cleft.
• Classification types : I – IV
• Rx : consider tracheostomy, endoscopic repair ( I,II), open surgical
procedures.
LARYNGEAL OBSTRUCTION in Children due
to Infection
Laryngeal Inflammation
( infection )
• Stridor→ A high pitched sound that produced due
to upper airway obstruction.
– Inspiratory
– Expiratory
– Both
• Specific
• Vs
• Non-Specific
Acute Viral Laryngitis
• Pathogens : Rhinovirus (most common), parainfluenza,
respiratory syncytial virus, adenovirus, influenza virus,
pertussis.
• SSx : dysphonia, low-grade fever, hoarseness, cough, rhinitis,
postnatal drip.
• Dx : Clinical history & PE
• Rx : Symptomatic therapy.
AB not indicated unless suspect 2nd bacterial infection
Laryngeal inflammation related Stridor
in Children
• Virus Vs Bacteria infection
– Acute Laryngotracheobronchitis
– Acute Epiglotitis
– Bacterial Tracheitis
– Acute Spasmodic Laryngitis
Acute Laryngotracheobronchitis
● Synonyms :
● Croup, Acute Subglotic laryngitis
● Viral infection
● Parainfluenza virus (1,2,3)→ most common
● Influenza, rhinovirus, adenovirus, respiratory syncytial
virus
● Epidemiology :
● Children → 6 mo – 3 yr (90%)
● Etiopathogenesis : droplet infection
Develops gradually (1-3days) during the course of URTI
• Symptoms :
– Hoarseness
– Barking cough
– Low grade fever
– Stridor during inspiration( at night or few hour’s
sleep)→ biphasic
• In severe case → sianosis
DIAGNOSIS
• Indirect laryngoscopy :
– Inflammation especially
subglottic area
• Blood examination : (-)
leukocytosis
• X-ray : Steeple sign
Treatment
• Airway humidification
• Adequate fluid intake
• Steroid systemic
• Inhalation therapy using epinephrine in case with
pronounced stridor & dyspnea
• Antibiotic → if can’t rule out the bacterial
infection
• Symtomatic treatment
• In severe case → intubation
Bacterial tracheitis
• Epidemiology : most common in infant & small
children
• Ethiopathogenesis: bacterial superinfection of
the viral URTI.
– Staphylococcus
– Pneumococcus
– Streptococcus
– Haemophilus influenzae
● Symptoms :
● Gradual onset of rhinitis & pharyngitis
● Biphasic stridor
● Pulmonary complications
● In severe case→ obstruction of the lower airway
due to viscous mucous.
● Diagnosis :
● Indirect laryngoscopy : mucosal redness upper & lower
airway
● Moderately elevated temperature
● Leucocytosis
● Laryngoscopy & Tracheoscopy → C&S
THERAPI
• Antibiotic therapy→
absolute
• Similar to croup
• In severe case→
intubation or
tracheostomy
Supraglotitis
• Synonym : Acute epiglotitis
• Most common in children (2-8yr)
• Incidence ↓ because of HIB vaccine
• Causative agent : Bacterial infection→
Haemophilus Influenza (type B)
• Other organisms : streptococcus piogenes, s.
Pneumonia, s. aureus
• Symptoms :
– High grade fever
– Inspiratory stridor
– Odynophagia & dysphagia
– “Hot potato” voice
– Sitting upright
– In severe case → inspiratory retraction & dyspnea
• One of the emergency in ENT-HNS
• Mortality rate 5-10%
Diagnosis
• Indirect laryngoscopy :
swelling and erythematous
of epiglottis
• X-ray : thumb sign
• Leucocytosis
Inspection should be done with extreme
care to prevent a laryngeal spasm causing
total airway obstruction
Therapy
• Secure airway
– Intubation or tracheostomy
• Parenteral antibiotic : sephalosporin 3rd gen
• Systemic corticosteroid
Acute Spasmodic Laryngitis
• Synonym : spasmodic croup
• Epidemiology : male infant & small children 1-3
yo
• Ethiopathogenesis: not fully understood.
Non-infection, chronic and intermiten associated
with croup symptoms.
• Some possible etiology :
– Bronchial hyperactivity
– Allergic reaction
– GERD
• Symptoms :
– URTI w/o fever
– Wake up at night with extremely coughing, stridor
and dyspnea
– Completely subside after a few hours
• Treatment :
– Observation
– Optimum humidification
– Symptomatic treatment
Chronic Laryngitis
• Common etiologies : multifactorial.
• SSx : hoarsness, pain, edema, dysphagia, respiratory compromise.
• Dx : flexible nasopharyngoscopy, endoscopy → thick
erythematous vocal folds.
• Rx : address etiologies, humidification, mucolytic, consider short
course Corticosteroid.
TB Laryngitis
● 2nd to pulmonary TB
● Histopathology : cellular inflammation, granuloma in
subepithelium, perichondritis.
● Lesion : Granulation & ulcerative tissue in posterior
glottis (posterior interarytenoids most common,
laryngeal surface of epiglottis, vocal folds)
● Rx : Anti-TB, voice rest, analgetic
Syphilitic Laryngitis
• Rare manifestation of oropharyngeal syphilis.
• 2nd stage SSx : Temporary mild edema, painless.
• 3rd stage SSx : Gummas may break down cartilage.
• Rx : Penicillin, tetracycline, erythromycin.
Diptheria Laryngitis
• <<<< since immunization
• Pathogen → corynebacterium diptheria
• Risks : nonimmunized children > 6 y.o
• SSx : sore throat, progressive airway obstruction, thick
gray-green plaques, membranous, friable exudate on tonsils,
pharynx and larynx, low grade fever.
• Dx : endoscopic examination, culture & smears
• Complication : nephritis, airway obstruction, death.
• Rx : establish airway via tracheostomy, Avoid intubation , ADS,
AB (penicillin / erytromycin )
Fungal Laryngitis
• Risks : Imunocompromised (uncontrolled diabetes, AIDS, chronic
corticosteroid, etc), radiation, poor nutrition status, debilitating
illness, long-term AB.
• SSx : odynophagia, mucositis, dysphonia, cough, dyspnea,
aspiration.
• Dx : endoscopy & Biopsy ( r/o malignancy)
• Rx : establish airway, antifungal regimen.
• Pathogens :
– Candidiasis (moniliasis) : adherent, friable, chessy, white plaque; spread
from oral cavity.
– Aspergillosis : allergic, non-invasive, or invasive form.
– Blastomycosis : red laryngeal ulcersor miliary nodules on VF
– Histoplasmosis : Ulcerative lesions ( anterior & epiglottis)
– Coccidiomycosis : nodular laryngeal mass
LARYNGEAL OBSTRUCTION in Children due
to Benign Neoplasm
Recurrent Respiratory Papillomatosis
● 2nd most common cause of hoarseness in children.
● 2/3 < 15 yo, regress by puberty.
● Extremely rare malignant change.
● Pathox : HPV type 6 & 11 (similar to genital warts)
● Risks : younger, first time mothers (longer 2nd stage of delivery in the
birth canal), lower socioeconomic status, 50% born from mother w/
condyloma acuminata, oral sex, multiple sex partner
● Lesion : wart like, irregular, exophytic lesion between an epithelial
transition.
● Type : Juvenile Vs Senile
● Symptoms : Hoarsness → stridor → dypsnea → dysphagia
● Dx : Endoscopic examination w/ biopsy
● Management : Surgical w/ laser excision (CO2 laser) w/ biopsy to r/o
malignancy.
● Post-op → chest x-ray yearly→ r/o pulmonary involvemant
interval endoscopies → 2-4 weeks after initial treatment
● Adjuntive treatment : α interveron, antiviral.
Hemangioma
• Most common head & neck neoplasm in children
• Typically present by 6 months old then involutes by 2 years of age.
• Most common laryngeal site L posterior lateral quadrant of subglottis.
• 50% of subglottic hemangiomas associated w/ cutaneous involvement.
• Pathox : abnormal blood vessel growth.
• Type : infantile ( typical subglttic), adult onset
Capillary (>>> infantile type→ resolve )
Cavernous (enlarge rapidly → no regression)
• SSx : polypoid / sessile lesions, biphasic stridor, worse w/ crying
(hemangiomas become engorged w/ blood), dysphonia, dysphagia, seldom
cause bleeding in larynx.
• Dx : endoscopy
• Management : observe if asymtomatic , embolization, CS or interveron
α-2A, endoscopic CO2 laser excision / open excision, radiotherapy (
controversies)
LARYNGEAL OBSTRUCTION in Adult
Malignancy
• 1–5% of all malignancies
• Second most common site for head and neck malignancy
• SSx: hoarseness, aspiration, dysphagia, odynophagia, sore throat,
hemoptysis, airway obstruction (stridor), referred otalgia, weight
loss, globus sensation.
• Risk Factors: smoking and alcohol use; radiation exposure;
history of juvenile papillomatosis (HPV), Plummer-Vinson
syndrome; exposure to metal, plastics, paint, wood dust, and
asbestos
• Ussually SCCA ( glottic)
• Rx : Surgical removal w/ free margin excision w/w.o combination
Chemo/RT
Other Laryngeal Lesions
Laryngeal Edema (Angioedema)
● Types :
1. Acquired Angioedema: histamine mediated inflammation (Urticaria) secondary
to a variety of substances.
2. Congenital (Hereditary) Angioedema: deficiency in C1 esterase inhibitor
(controls the complement pathway)
● Common Causes of Acquired Angioedema: medications (ACE inhibitors, ASA,
antibiotics, NSAIDs), food allergies (eggs, peanuts), insect bites, transfusions,
infections (Hepatitis B, viral infections), emotional, other allergens
● SSx; rapid onset of facial, oropharyngeal, or laryngeal edema, “hot potato
voice,” stertor or stridor, pruritis, hoarseness
● Dx: clinical history, flexible nasopharyngoscopy, C1 esterase inhibitor serum
levels
● Rx :
1. Evaluate airway, severe and progressive symptoms may require fiberoptic
intubation versus an urgent surgical airway.
2. Epinephrine, parenteral corticosteroids, H1 and H2 blockers, aminophylline.
3. consider prophylactic Danazol for Hereditary Angioedema (increases C1 esterase
inhibitor) → not avaiable
Reinke’s Space Edema (Polypoid Degeneration)
● Reinke’s space: superficial layer of the lamina propria,
loose connective tissue (susceptible to fluid accumulation)
● Risks: GERD, smoking, hypothyroidism, vocal abuse,
chronic throat clearing, chronic cough
● Not associated with increased risk of laryngeal cancer
● Dx: indirect mirror exam, flexible nasopharyngoscopy,
endoscopy, videostroboscopy.
● Rx :
1. evaluate and manage for hypothyroidism and GERD
(antireflux medications).
2. voice rest, smoking cessation.
3. consider microlaryngoscopy and excision with removal of
gelatinous material in Reinke’s space
