LARYNGITIS

LITERATURE READING
WIDYA W. HARTANTO

DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD&NECK SURGERY

MED.SCHOOL OF PADJADJARAN UNIVERSITY
HASAN SADIKIN GENERAL HOSPITAL
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 Laryngitis :

Acute/chronic, infectious/noninfectious, localizad/systemic process involving the larynx.

Bailey et.al., 2006

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 A. Childhood Laryngitis Noninfectious Laryngitis in Adult
- - Laryngopharyngeal Reflux
Common Viral Laryngitis
- - Trauma Laryngitis
Acute Laryngotracheitis (Croup)
- - Thermal Injury
Secondary Bacterial Laryngitis
- - Angiodema
Acute Supraglottitis
- - Allergic Laryngitis
Laryngeal Diphtheria
- - Relapsing Polychondritis
Laryngopharyngeal Reflux (LPR)
- - SLE
Spasmodic Croup
- Ephidermolysis Bullosa
- Amyloidosis

Laryngitis Chronic Granulomatous Laryngitis

- Tuberculosis
- Syphilis
- Leprosy
- Histoplasmosis
B. Adult Laryngitis - Blastomycosis
- Scleroma
- Sarcoidosis
- Viral Laryngitis - Wegener’s Granulomatosis
- Bacterial Laryngitis - Immunocompromised Host
- Radiation Laryngitis 3
Diagnosis :

Bailey et.al., 2006 4

 CHILDHOOD LARYNGITIS
 Common Viral Laryngitis
 Acute Laryngotracheitis (Croup)
 Secondary Bacterial Laryngitis
 Acute Supraglottitis
 Laryngeal Diphtheria
 Laryngopharyngeal Reflux
 Spasmodic Croup

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 Common Viral Laryngitis
Etiology :
Rhinovirus, parainfluenza,
adenovirus
Symptoms :
Low grade fever, mild dysphonia,
cough, or rhinitis
Diagnosis :
history + symptoms
Treatment :
Self limited
Hydration
Humidification
Antipyretic
Decongestant
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Acute Laryngotracheitis (Croup)
 Etiology
 Parainfluenza virus 1,2, influenza A, RSV
 Epidemiology
 Winter & autumn illness
 Incidences
 infants, under 5 years of age
 Subacute viral illness
 Fever, “barking” cough non productive
worseness at night, and stridor
 Lasts 3-7 days

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• Crucial factor
– Swelling in the subglottic
area
– Edema  complete
obstruction
– Fatal  mucous plug

• Diagnosis
History and on neck
radiographs “steeple sign”
(subglottic narrowing
due to edema)

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Management
• Hospitalization
• Humidification
• Aerosolized epinephrine
• Used of steroids  controversies :
- Doses dexamethasone > 0,3 mg /kg
- Single i.v injection 0,6 mg/kg  improvement at 12 to
24 hours
• Antibiotic

Failed in medication  intubation or tracheostomy

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Secondary Bacterial Laryngitis

 Difficult to differentiate with croup :

 Most common presenting symptom : stridor,
 Higher fever & leukocytosis
 Developed as a sequelae of croup

 Etiology
 Haemophilus influenzae, Pneumococcus, Streptococcus
haemoliticus

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Diagnosis
 Thick, purulent tracheal secretions
 Croup like symptoms not improved after several
days of medical management
 High fever or leukocytosis  bronchoscopy

management
 Cultures
 Hospitalization
 Antibiotic
 Tracheostomy /intubation

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Acute Supraglottitis

 Etiology
 Haemophilus influenza type B
 Insidence
 2-4 years
 Clinical features
 acute, often over 2-6 hours
 High temperature, drools, sniffing position,
stridor inspiration

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 Pathologies finding
 Inflammatory process  supraglottic
 Fiery, cherry red epiglottis
 Involved aryepiglottic fold and false cord

 Respiratory obstruction
 Swollen epiglottis and aryepiglottic fold
with supraglottic narrowing
 Excessive, thick, tenacious oral and
pharyngeal secretion due to odynophagia

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 Diagnosis
 History
 Clinical finding
 Radiology
 Differential Diagnosis
 Croup
 Foreign body
 Management
 Medical Management  Antibiotics :
 Ampicillin + chloramphenicol
 Cefamandole (2nd gen. cephalosporin)
 Cefuroxime / Ceftriaxone (3rd gen. cephalosporin)

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The “thumb sign”  edematous epiglottis

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Laryngeal Diphtheria
Etiology
 Corynebacterium diphteriae

Incidence
 older than 6 year

Symptom
 febrile
 sore throat
 dysphonia
 progressive airway obstruction

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 Clinical feature
Exudative inflammatory  thick, gray
green, plaque like membranous exudate
over tonsils, pharynx, larynx & easy to bleed
 Diagnosis
 Cultures and smears

 Treatment
Diphteria antitoxin
Antibiotic : Erythromycin or Penicillin
 Establishing a safe airway tracheotomy

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Laryngopharyngeal Refluks

 Refluxgastric contents into laryngopharynx

 Associated w/
 Laryngomalacia
 Vocal nodules
 Polyps
 Granulomas
 Laryngeal and tracheal stenosis
 Laryngospasm

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Diagnostic test
 Ambulatory 24 hour double probe pH monitoring
 sensitive
 Barium esophagography
 Radionuclide scanning
 Lipid laden macrophage test
 Reflux finding score (>11  strongly suggestive LPR)

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Finding Score
(Source: Belafsky et al. , with permission from Lippincott, Williams and Wilkins.)
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2 = present
Subglottic edema
0 = absent
2 = partial
Ventricular obliteration
4 = complete
2 = arytenoids only
Erythema/hyperemia
4 = diffuse
1 = mild
2 = moderate
Vocal cord edema
3 = severe
4 = polypoid
1 = mild
2 = moderate
Diffuse laryngeal edema
3 = severe
4 = obstructing
1 = mild
2 = moderate
Posterior commissure hypertrophy
3 = severe
4 = obstructing
2 = present
Granuloma/granulation
0 = absent
2 = present
Thick endolaryngeal mucus/other
0 = absent
TOTAL

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Spasmodic Croup
 Non infectious form, related to allergy or reflux laryngitis,
associated with an URI
 1 to 3 years old
 Symptoms :
 “barky” cough at night, stridor and mild dyspnea  vomiting
 Asymptomatic during the day
 Laryngeal examination :
 Mildly erythematous laryngeal mucosa
 Subglottic edema

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Treatments  Humidification

Differential Diagnosis
 Diff. diagnosis of dysphonia, stridor and
airway obstruction :
 Laryngotracheitis (Croup)
 laryngospasme

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 ADULT LARYNGITIS
INFECTIOUS
• Viral Laryngitis
• Bacterial Laryngitis

NONINFECTIOUS CHRONIC GRANULOMATOUS

• Laryngopharyngeal Reflux LARYNGITIS
• Traumatic Laryngitis • Tuberkulosis
• Thermal Injury • Syphilis
• Angioedema • Leprosy
• Allergic Laryngitis • Histoplasmosis
• Relapsing Polychondritis • Blastomycosis
• Systemic Lupus Erythematosus • Scleroma
• Epidermolysis Bullosa • Sarcoidosis
• Amyloidosis • Wagener’s Granulomatosis
• Immunocompromised Host
• Radiation Laryngitis
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 Adult Laryngitis

 Usually less serious than children

 Etiology :
 Most cause  viral URI
 Smoking, LPR
 Can have chronic laryngitis  unrecognized

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Viral Laryngitis
 Etiology : viral URI
 Rhinovirus
 Symptoms :
 Generalized viral syndromes
 Dysphonia :
 voice breaks, episodic
aphonia, hoarse cough and
lowering of the vocal pitch
 Pathology :
 Laryngeal mucosa
 erythema and edema

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• TREATMENT g self limited

Humidification
Voicerest
Hydration
Smoking cessation
Cough suppressant
Expectorants

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Bacterial Laryngitis

 Etiology :
 H. influenza, staphylococcus aureus, ß hemolytic
streptococci
 Symptoms :
 Fever, sore throat, muffled voice, odynophagia and
dyspnea
 Symptoms progress rapidly over less than 24 hour  high
risk for airway compromise

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 Diagnosis, based on :
 History and laryngeal examination
 Neck soft tissue radiograph  swollen
epiglottis (thumbprint sign) or
supraglottis
 LFO  swollen, red supraglottis
structure

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Treatments :
Conservative : humidification, hydration
Corticosteroid
Intravenous antibiotics
Intubation or tracheostomy  airway
obstructive
Complications :
Epiglottic abscess

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 NONINFECTIOUS LARYNGITIS
IN ADULT

• Laryngopharyngeal Reflux • Relapsing

Polychondritis
• Traumatic Laryngitis
• Systemic Lupus
• Thermal Injury
Erythematosus
• Angioedema
• Epidermolysis
• Allergic Laryngitis Bullosa
• Amyloidosis

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 Laryngopharyngeal Reflux
 Incidence :
 50 % patients with laryngeal complaints
 Associated :
 Acute, chronic or intermittent pattern of laryngitis,
wo/granulomas formation
 Implicated in the development of laryngeal carcinoma and
stenosis, recurrent laryngospasm, crycoarytenoid fixation
 Others : globus pharyngeus, cervical dysphagia,
bronchiectasis, asthma, chronic cough, subglottic stenosis

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Bailey et.al., 2006
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 Laryngeal examination :
 Posterior laryngitis
 Subglottic edema  “pseudosulcus vocalis”
 Diffuse erythema w/ granular, friable mucosa
and vocal process granuloma

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Ancillary test :
Ambulatory 24 hour double probe pH monitoring
 ‘gold standard’

Treatment :
• Dietary and lifestyle modification
• Antireflux medication, such as an H2 blocker
or proton pump inhibitor
• Failed  fundoplication

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Traumatic Laryngitis

 Etiology
 Vocal abuse
 Persistent coughing
 Muscle tension dysphonia Vocal abuse

 Direct endolaryngeal injury

MTD
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Symptoms
Dysphonia & odynophonia

Pathology
VC  hyperemic, edema within Reinke’s
space, sub mucosal hemorrhage

Therapy
Self limited
Voice rest, humidification

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 Thermal Injury
 Etiology
 Steam, smoke, very hot liquids or food
 Symptoms
 Dysphonia, odynophagia and odynophonia
 Pathology
 Supraglottic edema and erythema
 Tr e a t m e n t s
 Humidification
 Corticosteroids
 Larynx severely edematous  airway observation

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 Angioedema
 E t i o l o g y  causative agents
 Ty p e
 Acquired angioedema :
 Inflammatory reaction : vascular dilation and increased

vascular permeability
 Caused : variety of substance, ACE inhibitors

 Potentially life threatening

 Hereditary angioedema
 Autosomal dominant deficiency of C1 esterase inhibitor

 Recurrent attack of mucocutaneus edema

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 Symptoms
 May involve face, oral cavity, oropharynx or larynx
 Laryngeal involvement  dysphonia
 Diagnosis, based on history
 Tr e a t m e n t
 Aggressive, supplement O2
 Epinephrine, corticosteroids, antihistamin, aminophylline
 Progressive airway obstruction  intubation or
tracheostomy
 Chronic ‘pretreatment”  danazol

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 Allergic Laryngitis
 Controversial
 E t i o l o g y : triggering substances
 S y m p t o m : chronic & recurrent dysphonia
 Diagnosis :
History
Standard allergy evaluation
Challenge testing with the suspected triggering agent

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Treatment :

Optimizing vocal hygiene with hydration

Conservative voice use
Treating LPR, if present

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 Relapsing polychondritis
Characteristic

 Episodes of inflammation & fibrosis w/ subsequent destruction

of the cartilage of the ears, nose, larynx & tracheobronchial
tree
 Symptom : dysphonia, dysphagia & throat pain
 Treatment : dapsone, corticosteroid & other
immunosuppressive, tracheotomy

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Systemic Lupus Erythematosus

Symptom :
 Dysphonia & dyspnea
 Airway obstruction

E x a m i n a t i o n : edema, ulceration, VC paralysis

Tr e a t m e n t : systemic corticosteroid

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 Epidermolysis Bulosa
 Congenital autoimmune disorders  extraordinary skin
& mucous membrane fragility

 Symptoms
bullae or ulcerations appear in areas subject to even
slight trauma, dysphonia & stridor
 Findings
edema, raw mucosa, bullae, ulcers, webs, stenosis in
the larynx & trachea
 Tr e a t m e n t
tracheotomy, corticosteroid & immunosuppressive
therapy

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AMYLOIDOSIS
Etiology
unknown
Characterized
 Extracelluler deposition of fibrillar protein
Classification
 Primary amyloidosis  spontaneus deposits
 Localized
 Generalized

 Secondary  w/ other systemic diseases

(Rheumatoid arthritis or tuberculosis)
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Clinical features :
– Hoarseness, stridor
– Pathology :
• Smooth, pinkish gray masses lying
under intact epithelium
D i a g n o s i s  electron microscopy
– Interlacing mesh of nonbranching
fibrils
Tr e a t m e n t :
– Surgical excision
– Laser CO2

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 CHRONIC GRANULOMATOUS
LARYNGITIS

• Tuberkulosis
• Syphilis
• Leprosy
• Histoplasmosis
• Blastomycosis
• Scleroma
• Sarcoidosis
• Wagener’s Granulomatosis
• Immunocompromised Host
• Radiation Laryngitis
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Chronic Granulomatous Laryngitis

 Caused by a variety of uncommon organisms and disease

process
 May mimic laryngeal carcinoma
 Should elicit the patient’s past medical and travel history

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 TUBERCULOSIS
The areas were commonly
involved :
- posterior portion of the vocal cord
- the arytenoid cartilages
- the intraarytenoid space

Etiology
Mycobacterium
tuberculosis
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Symptom :
– hoarseness
– dysphagia or odynophagia
– cough
– weight loss
– fever
Diagnosis :
– sputum samples (+)
– characteristic finding on chest
radiograph
– biopsies positive for acid fast
bacilli

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Histopathology
 tubercles consisting of a homogenous
caseous center
 a periphery of pale epithelial cells
contains one or more giant cells
 an outer zone of lymphocytes

Tr e a t m e n t
 Isoniazide
 Ethambutol
 Rifampicin
 Streptomycin
 Para aminosalicylic acid

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 SYPHILLIS
Etiology
 Treponema pallidum
 congenital syphilis or acquired through sexual contact
Acquired syphilis
 primary stage
 secondary stage
 tertiary stage

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  Secondary syphilis
 diffuse laryngeal hyperemia,
 Supraglottic region : coalescing, maculopapular rash

 Te r t i a r y s y p h i l i s
 Diffuse, nodular, gummatous infiltrate
 May ulcerate or coalesce to form larger nodules

 Untreated syphilis
 Chondritis, fibrosis and scarring

Treatment :
 High i.m doses of penicillin
 Observed with repeat VDRL testing at 6-12 month

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 HANSEN’S DISEASE (LEPROSY)
Etiology
Mycobacterium Leprae
 Portal of entry : nasal mucosa
 Larynx  2nd most frequent site

Clinical features
 Erythematous or nodular edema of the supraglottis and
progresses to glottis
 Untreated  enlarge, ulcerate, and heal by scar
formation  stenosis and obstruction

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Diagnosis
 History, clinical findings, laryngeal
biopsy or nasal smear
 PA : edema with inflammatory
infiltrate + large foam cell
 Acid fast staining

Tr e a t m e n t
 Dapson or combination with
rifampicin

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HISTOPLASMOSIS
Via inhaled spores

E ti o l o g y
Histoplasma capsulatum
M a n i f e s t a ti o n
– Nodular superficial
granulomas
– Hepatosplenomegaly
Diagnosis
- culture

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 Histoplasmosis mimicking a squamous cell carcinoma

Treatment :

- DOC : Amphotericin B
GI Motility online (May 2006) - Laser excision
- Tracheostomy

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 BLASTOMYCOSIS

Etiology : Blastomyces dermatididis

Via inhaled spores
The most common site : the lung
Mimic a neoplastic process such as
verrucous or squamouse carcinoma
Symptoms : hoarseness

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Diagnosis
 biopsy :
micro abscess & giant cells
pseudo epitheliomatous
hyperplasia
 fungal stains : PAS or gomori’s
 laryngoscopy : scattered granular,
exophytic mases, ulcerative
Tr e a t m e n t
– i.v amphotericyn B
– oral ketoconazole

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 SCLEROMA
 Klebsiella rhinoscleromatis
 Sign and symptoms :
 Primarily involve nasal cavity
 Catarrhal stage :
 Purulent rhinorrhea with nasal crusting and obstruction
 Granulomatous stage :
 Nodular granulomas form within the URT
 Subglottic  most common involved
 Sclerotic stage :
 Manifested as fibrosis and scar formation
 Dysphonia and respiratory obstruction

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 Diagnosis :
 Isolated organisms from tissues or via
immunohistochemical studies
 Histologically :
 Foamy vacuolated histiocytes (Mikulicz cells)

 Degenerated plasma cells (Russel bodies)

 Tr e a t m e n t :
 Tetracycline, fluoroquinolone or clofazimine
 Laryngeal endoscopic laser resection
 Tracheotomy during the sclerotic phase

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Fig. 38.6 Scleroma involving the subglottic region of the trachea, as seen on AP (A) and lateral (B) contrast laryngography. There
is thickening of the tracheal wall due to granulomatous infiltration which narrows the tracheal lumen (arrow). The valleculae and
pyriform sinuses are normal. (Courtesy of the late Dr. Benjamin Felson.)
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 SARCOIDOSIS

E t i o l o g y  unknown
I n c i d e n c e  young adults, women and black
P r e d i l e c t i o n  most : lymph nodes
Clinical features :
 Respiratory complaints
 Larynx involve : 3-5 %, usually of the epiglottis
 1st laryngeal involvement : painful lesions, hoarseness and
partial airway obstruction

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Pathology
 Initially : relatively benign  white or brown nodules on
mucosa  produce pale, edematous epiglottis
 Microscopic : miliary tubercles  epitheloid cells,
macrophages, and giant cells
Tr e a t m e n t :
 Long term oral steroids
 Intralesional steroid injection
 Low doses radiotherapy

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LARYNGEAL SARCOIDOSIS

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WEGENER’S GRANULOMATOSIS

Unknown etiology
Characterized  triad necrotizing granuloma of :
 Respiratory system
 Necrotizing vasculitis
 Glomerulonephritis

Figure 8 Crusting granulation tissue seen in the larynx and subglottis

of a patient with Wegener's granulomatosis.
GI Motility online (May 2006)

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Clinical features :
Chronic sinusitis and mucosal lesion of the
nasopharynx
Laryngeal involvement  8,5 %

Tr e a t m e n t :
Medical therapy (cyclophosphamide or steroid)
Surgical excision

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IMMUNOCOMPROMISED HOST

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 May present with symptoms and physical findings
consistent with acute or chronic laryngitis
 Mimic nonspesific laryngitis and carcinoma
 Failure to improve rapidly with empiric therapy 
early direct laryngoscopy and biopsy

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 RADIATION LARYNGITIS
 R a d i a t i o n t h e r a p y  dysphonia, dysphagia, pain or
globus pharyngeus
 Laryngeal examination :
 Erythematous, swollen larynx with exudate and crusting
 Tr e a t m e n t :
 Hydration and humidification
 Acid suppression
 Steroid and antibiotics

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 HIGHLIGHTS
 Laryngitis is not a synonym for hoarseness but rather refers
to an inflammatory condition of the larynx

 Laryngitis is more serious in infants and small children

because the airway is smaller and more easily compromised
by swelling and edema

 Differentiation between severe laryngo-tracheitis and

supraglottitis must be made in the operating room
Radiographs and diagnostic steps should be done after the
airway is secured
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 HIGHLIGHTS
 Laryngopharyngeal reflux in children :
- chronic cough
- aryngospasm
- exacerbation of reactive airway disease
- laryngeal stenosis
- subglottic stenosis
- associated with sudden infant death syndrome

 In adults, common causes of laryngitis :

- viral upper respiratory infection
- laryngopharyngeal reflux
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 HIGHLIGHT
 Laryngopharyngeal reflux may cause
- dysphonia
- cough
- frequent throat clearing
- globus sensation

 Traumatic laryngitis :
- self-limited
- managed conservatively w/ voice rest, hydration, and
humidification
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 HIGHLIGHTS
 Angioedema involving the larynx requires :
aggressive treatment  suppressed inflammatory response &
considered possible precipitating agents (drugs)

 The incidence of laryngeal tuberculosis is increasing

Should be strongly considered :
- laryngitis and systemic symptoms
- immunosuppressed patients
- patients who immigrated from endemic areas

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 HIGHLIGHTS
 The granulomatous disorders best diagnosed by biopsy
and special staining and culture techniques

 Immunocompromised patients with laryngitis must have

close follow-up. Failure of empiric treatment requires
biopsy and appropriate cultures

 Radiation laryngitis must be differentiated from

recurrent cancer, laryngopharyngeal reflux,
radionecrosis, and hypothyroidism

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THANK YOU

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