uncomplicated nonspecific laryngitis, and specific diseases, premalignant
lesions, and tumors must be excluded.
Croup syndrome (laryngeal diphtheria)
Diphtheritic croup, beginning with laryngeal membranes and obstruction, is
presently rare. However, occasional endemic foci still persist in Western
Europe.
Diphtheritic laryngitis with greyish-white membranes occurring in isolation is
becoming less and less common. It is more commonly combined with lesions of the
oropharynx. Tracheotomy is required for increasing dyspnea.
The term pseudocroup includes a group of acute laryngotracheal diseases mainly
affecting children.
Acute subglottic laryngitis
(pseudocroup)
Symptoms. There is a previous common cold followed by dry barking cough rapidly
becoming worse, hoarseness, and inspiratory, expiratory, or mixed stridor
leading to severe respiratory obstruction depending on swelling of the mucosa
and site. There is indrawing of the suprasternal notch and intercostal spaces on
inspiration, cyanosis, perioral pallor, and worsening of the symptoms due to a
fear of asphyxia in children.
Pathogenesis. This is a very serious acute disease of early infancy, most common
between the 1st and 5th years of life. In a short time, life-threatening
narrowing of the relatively narrow child's airway due to inflammatory mucosal
swelling in the subglottic space or, in a descending infection, of the
tracheobronchial tree can develop. The disease is basically due to a viral
infection with accompanying secondary bacterial infection. Cool, damp, and foggy
autumn and winter weather appear to increase the morbidity. However, recurrent
infections in the nasopharynx and nasal obstruction due to chronically inflamed
hypertrophied adenoids and tonsils are important in the etiology. Whether air
pollution plays an important role in the pathogenesis of this disease remains
uncertain.
Diagnosis. The clinical picture is usually very typical. Laryngoscopy shows
glottic mucosal edema or crust formation.
Treatment. Mild cases, assessed on the degree of respiratory obstruction, may be
managed by the pediatrician. Reliable observation must be provided to ensure
that the effect of treatment is monitored.
Treatment of Acute Subglottic Laryngitis
Basic Principle: relief of both obstruction and distressing cough which impedes
circulation
Sedation of child (avoid respiratory depressive drugs)
Antihistamines
Steroids
Åphedrine
Euphylline
Antibiotics to prevent secondary infection
Croup tent with a high degree of humidity, high concentration of oxygen.
If these measures fail and there is increasing dyspnea, the child must be
admitted to the hospital as an emergency. There he is treated with oxygen
therapy and endotracheal intubation depending on the degree of dyspnea and the
results of blood gas analysis. Tracheostomy is carried out for severe
obstruction and when there is a progressive sicca-type crust formation.
Chronic laryngitis
Chronic nonspecific laryngitis must be distinguished from the group of specific
forms such as tuberculosis, amyloid, etc. Chronic nonspecific laryngitis
requires assessment and treatment by the otolaryngologist.
Symptoms. These persist for weeks or months in contrast to those of acute
laryngitis. They include hoarseness, deepening of the voice, and sometimes a dry
cough. The voice is less able to withstand stress, there is a globus sensation
in the larynx, a feeling of a need to clear the throat, but little or no pain.
Pathogenesis. This disease is mainly due to exogenous toxins such as cigarette
smoking, occupational air pollution, and climatic influences. Another cause is
vocal abuse in bartenders, construction workers, longdistance truck drivers, and
professional speakers. Nasal obstruction is also an important factor in
pathogenesis.
Laryngopathia gravidarum due to vocal cord edema with dysphonia and deepening of
the voice is sometimes observed in the second half of pregnancy. The hoarseness
almost always resolves spontaneously after delivery.
The administration of male sex hormones and anabolic steroids causes voice
change in women including deepening of the tone, disorders of the singing voice,
and reduction of the carrying power of the speaking voice. These disorders
persist because of the virilization of the laryngeal structures.
Diagnosis. There are several varieties:
Chronic Catarrhal Laryngitis.
The characteristic appearance is that the whole larynx, including the vocal
cords, is red and there are increased secretions. It looks rather like a
subacute laryngitis.
Chronic Hypertrophic Laryngitis.
In addition to redness, this type displays a hypertrophy in the supraglottis and
glottis. Laryngoscopy shows the vocal cords to be thick with rough edges in some
cases.
Chronic Atrophic laryngitis.
This condition is usually seen in laundry workers and cooks and is characterized
by an atrophy of all laryngeal structures including the mucous glands of the
supraglottis. The result of this is an excessive crusting within the larynx and
trachea.
Treatment. The duration of treatment is protracted. Elimination of exogenous
toxins such as tobacco is the mainstay of treatment. Voice rest is prescribed
and if necessary a deviated nasal septum is corrected to restore normal nasal
respiration. Antibiotics are given for accompanying inflammation, and a short
course of steroids, saline inhalations, and mucolytic agents are given. Infusion
of the solutions, which contains Ectericide, Hydrocortisone, ferments, into the
larynx by special laryngeal syringe is used.
Regular laryngoscopic check-ups are advisable in chronic laryngitis because of
the possibility of dysplasia. Microlaryngoscopy and biopsy should be performed
in every doubtful case. This is the only method of early detection of
malignancy.
VOCAL CORD PARALYSIS
Reccurent laryngeal nerve paralysis
(unilateral or bilateral)
All the internal laryngeal musculature is paralyzed on the affected side. Since
the cricothyroid muscle supplied by the external branch of the superior
laryngeal nerve still puts the paralyzed vocal cord under tension, the
paramedian position is adopted. The stroboscope is very useful in long-term
follow-up of vocal cord paralyses.
Unilateral recurrent nerve paralysis
Symptoms. These include dysphonia in the acute phase, with later improvement in
the voice. There is no appreciable respiratory obstruction except perhaps during
severe physical activity. The patient can no longer sing.
Diagnosis. Laryngoscopy shows the vocal cord to be immobile in the paramedian
position on one side. Thorough laryngologic, neurologic, and radiologic
investigation is indicated, whose objective is shown in Table 1.
Table 1
Unilateral or Bilateral Recurrent Nerve Paralysis
CAUSESDETAILS
ThyroidectomyMost frequent cause of a laryngeal muscle paralysis
Malignant goiter
Bronchial carcinomaParticularly common in tumors arising from the upper
and middle lobes and with involvement of the mediastinal lymph node
metastases
Esophageal carcinomaParticularly of the upper third
Mediastinal diseasesLymphogranulomas, non-Hodgkin’s lymphoma, metastases,
mediastinitis
Aneurysms of the aorta or the subclavian arteryCongenital or syphilitic
Operations on the hypopharynx or the esophagusFailure to display the
course of the nerve during resection of the hypopharyngeal diverticulum
Cardiomegaly of various causesMay also occur in Ortner’s syndrome
Pulmonary tuberculosis
Pleural plaques
Blunt or sharp cervical trauma
Infective-toxicInfluenza; herpes zoster; rheumatism; syphilis; tissue
toxins such as lead, arsenic, or organic solvents; quinine
Intubation anesthesiaStretching of the recurrent nerve by incorrect
position of the patient or pressure the tube
Neurologic diseasesWallenberg’s syndrome, poliomyelitis, bulbar paralysis,
multiple sclerosis, cerebral tumors
IdiopathicIt should be noted that a diagnosis of idiopathic recurrent
nerve paralysis should only be made after all other causes have been
excluded. In the great majority of these patients spontaneous recovery
occurs within 2 to 3 months. After a longer period the chances of recovery
become less.
Treatment. If the causal disease cannot be treated satisfactorily, the patients
are given proserine, euphylline, biostimulators, vitamins, speech therapy,
electrotherapy to achieve compensatory vocal cord closure by the action of the
still-functioning vocal cord.
Bilateral recurrent paralysis
Pathogenesis you can see in Table 1.
Symptoms. (1) Dyspnea occurs with the possibility of asphyxia due to narrowing
of the glottic chink. Inspiratory stridor is particularly loud during sleep or
physical activity. (2) Initially, there is dysphonia which lasts for a variable
period, depending on the cause, and thereafter a weak, but only slightly hoarse
voice. (3) Feeble cough is also symptomatic.
Diagnosis. This is based on laryngoscopic findings. In bilateral paralysis the
vocal cords are in the paramedian position.
Treatment
1. Relief of the airway takes first priority. Immediate tracheotomy is often
necessary.
2. Cause removal.
3. Conservative treatment: proserine, euphylline, vitamins, biostimulators,
speech therapy, electrotherapy.
4. If remission does not occur, an operation to widen the glottis is indicated
at the earliest 10 to 12 months later if the patient wishes to be rid of his
tracheostomy tube.
Principles of surgery. An arytenoidectomy is carried out, and one of the
paralyzed vocal cords is moved laterally or superolaterally. The operation is
done endoscopically.
Speech therapy is used to supplement the operation.
The wider the glottic opening after operation the more unsatisfactory is the
voice.
Unilateral or bilateral paralysis
of the superior laryngeal nerve
Symptoms. These include aspiration of food and drink, loss of power of the
voice, and inability to sing in the higher part of the range, particularly in a
bilateral paralysis. Breathing is scarcely affected.
Pathogenesis. The paralysis affects the function of the cricothyroid muscle as
well as the sensory nerve supply to the supraglottic part of the larynx. The
paralysis is due to mechanical lesions of the nerve particularly after thyroid
gland operations, tumors, and viral infections.
Diagnosis. Laryngoscopy shows that the vocal cords are in the intermedian
position, the tension of the vocal cords is reduced so that the glottis does not
close completely on phonation, in unilateral paralysis, the ipsilateral vocal
cord is often shortened and lies lower than the nonparalyzed side.
Treatment. Corticosteroids should be tried, proserine, euphylline, vitamins,
biostimulators, electrotherapy and speech therapy is prescribed.
Combined lesions of the laryngeal nerves
Included are lesions of the superior laryngeal and recurrent laryngeal nerves.
Symptoms. Unilateral paralysis includes dysphonia and breathy voice due to air
loss. The healthy vocal cord compensates later. Aspiration occurs because of
absence of the sensory protection. In bilateral paralysis, there is dysphonia or
aphonia and almost always good respiration at rest. There is also aspiration and
a marked feeling of breath shortage during bodily exertion.
Pathogenesis. The basic cause is central or peripheral damage to the vagus nerve
causing a flaccid paralysis with immobility of the affected vocal cord in the
intermediate position. There is bilateral flaccid paralysis with bilateral
lesions.
Diagnosis. Laryngoscopy shows one or both of the vocal cords to be bowed and
paralyzed in the intermediate position.
Treatment. It is seldom possible to treat the cause of this paralysis, and the
mainstay of treatment is speech therapy.
If speech therapy for a unilateral atrophic vocal cord paralysis does not
succeed in producing compensation by movement of the healthy vocal cord across
the midline, the volume of the affected side of the larynx may be supplemented
to produce a satisfactory voice by injection of the affected vocal cord with
teflon paste.
Larynx stenosis
Larynx stenosis, a narrowing of larynx space, which leads to difficult
breathing, may be caused by the following causes:
1. Inflammatory edema of larynx (acute laryngotracheitis, phlegmonic laryngitis,
epiglottis abscess, suppurative processes in pharynx, parapharyngeal and
retropharyngeal spaces, in the region of the vertebra column cervical part, of
lingual root and soft tissues of the oral cavity floor).
2. Noninflammatory edema of larynx (allergologic, angioneurotic).
3. Larynx traumas (bullet, dull, shooting, cutting, thermal, chemical, after the
radiotherapy of the neck organs diseases, owing to the long intubation, long
superior tracheobronchoscopy).
4. Foreign bodies in the larynx, esophagus superior part.
5. Disorders of larynx innervation (bilateral paralysis of the recurrent
laryngeal nerves).
6. Infectious diseases (diphtheria, measles, scarlet fever, chicken-pox).
7. Larynx tumors (in adults - more often carcinoma, in children papillomatosis),
infectious granulomas (scleroma, syphilis, tuberculosis).
8. Chronic atrophic laryngitis.
9. The diseases of cardiovascular system, which are accompanied by blood
circulation insufficiency and the kidneys diseases, complicated by uremia.
According to the development time the following kinds of larynx stenosis are
made out:
1. Lightning - like - develops during few seconds, minutes.
2. Acute - develops during few hours (up to twenty four hours).
3. Subacute - develops during few days (up to week)
4. Chronic - develops during weeks and more.
It is necessary to know 4 stages of larynx stenosis:
1 stage - of compensatory respiration
2 stage - of incomplete compensation of respiration
3 stage - decompensation
4 stage - terminal one
In cases of 3 and 4 stages the tracheostomy is indicated.
Tracheotomy, laryngotomy and intubation
Indications. Tracheotomy, laryngotomy and intubation are life-saving measures
which must often be carried out as emergency procedures.
Tracheotomy
Depending on the site of tracheal entry, tracheotomy may be divided into high
access, above the thyroid isthmus, middle access, after division of the isthmus,
and low access, below the isthmus. In urgent cases a high tracheotomy is usually
carried out, although a low tracheotomy is usually carried out in children.
Principle of the operation. The operation may be carried out under intubation
anesthesia using an endotracheal tube or the rigid bronchoscope or under local
anesthesia. A collar incision is made halfway between the suprasternal notch and
the superior border of the thyroid cartilage, or a median vertical incision may
be used. The trachea is dissected out in the midline, and a window is then
created through one or two rings. Hemostasis must be secured because of the
danger of aspiration of blood. A tracheotomy tube of suitable size is
introduced, and the wound is closed as far as possible.
Indications for Tracheotomy
The relief of upper respiratory obstruction remains important reason for
tracheostomy. Any condition of disease, oedema or obstruction by disease such as
carcinoma, may demand tracheostomy.
Aspiration of secretion. This is important part of treatment where secretions
are retained in the trachea and bronchi, particularly when the effort of
cleaning the secretions is exhausting the patient. Suction through a
tracheostomy opening can be life-saving. In patients with an acute exacerbation
of severe pulmonary disease, tracheostomy also serves to reduce the dead air
space.
Protection of the airway. In cases of neurological disease in which there is
anaesthesia of the larynx or in which the cough reflexes are inhibited because
of muscular paralysis, tracheostomy with a cuffed tube provides the necessary
protection of the airway from overflow and aspiration of secretions from the
pharynx into the tracheo-bronchial tree.
Comatose states, as form head injury or poisoning, will frequently benefit from
thracheostomy which can ensure airway protection and adequate ventilation.
Wounds and accidents involving the mouth or pharynx.
Assisted respiration can be carried out most conveniently through a cuffed
tracheostomy tube connected to a mechanical respirator in the patient with
respiratory paralysis.
Intubation
Short-term intubation, orotracheal intubation (i. e., less than 48 hours).
For respiration of patients under muscle relaxants, e. g. Intubation anesthesia
In acute obstructive respiratory insufficiency whose cause can probably be
relieved within 24-48 hours by minor operative procedures or antiinflammatory
measures such as steroids and antibiotics or which can be relieved in a short
period by assisted respiration, assisted respiration as a temporary emergency
measure; if a tracheotomy is impossible or contraindicated.
Long-term intubation, nasotracheal intubation, (i.e., for several days or
weeks).
Long-term intubation should not be undertaken in adults because of the great
danger of resulting scar tissue stenosis in the larynx or trachea. Also modern
forms of tubes and cuffed tubes do not reliably prevent the development of
stenosis which may only become manifest several months later. Patients with
infections of the airway, those taking steroids, those with hypotension, or
those under the influence of intoxicants are particularly at risk.
On the other hand, in small children prolonged intubation using the correct
technique (transnasal-endotracheal) and inert soft materials often produces
fewer complications than a tracheotomy.
Technique. Intubation may be carried out without anesthesia in patients who are
already deeply unconscious, otherwise, a short intravenous anesthetic relaxant
is used. The operator must be able to ventilate the patient with a mask, which
should be available. The operator must have sufficient practical experience in
intubation.
Intubation technique. (1) The position of the patient must be such that the head
and neck are mobile and accessible. (2) The blade is introduced and the glottis
exposed. (3) The tube is introduced into the trachea through the glottis under
direct vision. (4) The tube is secured. Correct positioning of the tube is
assessed by the air flow. The tube is connected to a respirator and fixed with
adhesive plaster.
An indwelling tube to provide assisted respiration, e.g., in the intensive care
unit or after cervical injuries, etc., should not be retained for longer than 24
to 48 h and certainly for no more than 72 h. Otherwise, there is a danger of
scar tissue stenosis of the trachea. If assisted respiration is needed for
longer periods, the tube should be replaced by a tracheotomy. Infants are an
exception because experience has shown that a soft transnasal tube carries less
risk than a tracheotomy.
Increasing respiratory obstruction due to tracheal stenosis may not manifest
itself for several months.
Laryngotomy
This is an emergency procedure. It must be revised as rapidly as possible by a
regular tracheostomy because of the danger of laryngeal stenosis.
Principle of the operation. A skin incision is made just superior to the
prominent arch of the cricoid cartilage with the head extended. At this point
the cricothyroid ligament lies superficially under the skin, and there are no
large vessels at this site. The membrane is exposed and a horizontal incision is
made in it. The incision is held open with a tube or a spreading instrument.
Part 9
TUMOURS AND INFECTIOUS GRANULOMAS
OF THE UPPER RESPIRATORY TRACTS AND EAR
TUMOURS OF THE NOSE
Rhinophyma
This condition occurs almost exclusively in males past middle age in whom it may
cause considerable deformity, and thus distress, on account of the
disfigurement. It is due to hypertrophy of the sebaceous glands of the tip of
the nose, and produces a marked swelling of the nasal apex which becomes bulbous
in appearance. The skin is coarse and pitted, and has an oily appearance due to
the excessive secretion of the sebaceous material, and it is red or blue in
color due to vascular engorgement. Treatment consists in shaving off the excess
tissue to trim the nose to suitable size. Sufficient epithelial elements should
remain, so that skin grafting is not required.
Malignant tumours of the nose
Malignant tumours developing primarily in the sinuses usually originate in the
maxillary and ethmoidal sinuses, while primary nasal tumours arise more
frequently from the septum than from the lateral wall.
Pathology. The most common tumour is the squamous-cell carcinoma, which accounts
for 80% of the cases. Adenocarcinoma, adenoid cystic carcinoma and transitional
carcinoma, various types of sarcoma, fibrosarcoma, myxosarcoma, lymphosarcoma
and melanomas may also be found. The sarcomas tend to occur in younger people
and they act in a very malignant fashion.
Site of origin. Malignant tumours arise in the maxillary sinus, the ethmoidal
sinus, the frontal sinus and the sphenoidal sinus in that order of frequency,
the latter two being very rare. The site of origin within the sinus is often
difficult to determine as these tumours do not give rise to symptoms until they
have broken out of the bony sinus of origin. The majority arise at the junction
of the maxillary and ethmoidal sinuses. An exception to this is the
adenocarcinoma which is found in the ethmoidal cells of woodworkers in whom the
disease may be discovered early because, in certain areas, these workers are
screened at regular intervals for this tumour.
Symptoms. The presenting symptom depends upon the direction of spread of the
tumour. Inferior spread will give rise to symptoms in the palate-swelling or
erosion, loosening of teeth or, if the patient is edentulous, widening of the
alveolar ridge giving rise to ill-fitting dentures. Lateral spread will give
rise to swelling and redness of the cheek with obliteration of the buccal
sulcus. If the tumour spreads upwards and laterally it will give rise to eye
symptoms, epiphora from blockage of the nasolacrimal duct, diplopia due to
fixation of the inferior oblique or the inferior rectus muscle, and proptosis
with lateral displacement of the globe. Tumours spreading medially give rise to
nasal obstruction with an offensive purulent serosanguineous discharge from the
nose. Posterior spread towards the pterygoid plates causes spasm of the
masticatory muscles with trismus, and spread to the base of the skull causes
intense headaches. In later disease pain is a prominent feature. Spread to lymph
nodes occurs late.
Clinical features. Anterior rhinoscopy shows invasion of the nasal cavity by a
friable granular tumour mass which bleeds readily.
Radiographic examination, including tomography, is important in assessing the
extent of the tumour before contemplating treatment. The most important areas to
assess are the superior spread to the anterior cranial fossa and the posterior
spread to the pterygoid plates which, if involved, means that curative surgical
removal is impossible.
Biopsy should be carried out under general or local anaesthetic.
Treatment. The best results are obtained from the combination of a full course
of external irradiation followed by radical surgery. The latter consists at the
very least of maxillectomy with the fitting of an obturator, and before
embarking on such major treatment, it is important to select only patients who
are likely to have a reasonable chance of survival. To this end, the elderly,
those who are infirm from other disease, those with trismus, cervical glandular
enlargement, evidence of erosion of the base of the skull, or evidence of
distant metastases should not be submitted to this major treatment regime.
Radiation consists of a full course of 6000 rads delivered by a linear
accelerator. Six weeks later surgery takes place. All patients should be warned
pre-operatively of the possibility that their eye may have to be sacrificed to
obtain clearance of the tumour. The extent of surgery depends upon the position
and the size of the growth. In localized antero-inferior neoplasms, removal of
the maxilla with preservation of the orbital floor is possible, the resulting
palatal defect being filled with an obturator attached to the upper dentures.
With more superior growths the whole maxilla is removed, as are any involved
ethmoidal cells. The eye may require to be sacrificed if the orbit is involved.
If the soft tissues of the cheek are infiltrated by tumour, this area will have
to be included in the resection.
Palliative treatment for those unsuitable for the above regime, or for those
suffering from recurrent tumour, is limited to general nursing care,
psychological support and adequate relief of pain. There is no evidence that
chemotherapy plays a useful role in the control of nasal and sinus tumours of
epithelial origin, although it is very useful in the control of lymphomatous
tumours.
Prognosis. Various classifications have been used over the years to gauge
prognosis. In general, a better prognosis is likely if the tumour arises from
the anterior and inferior part of the maxillary sinus, and the outlook is poorer
the more superior the origin of the growth.
The outlook is grave in children and young adults who tend to have very
malignant sarcomas. The prognosis is better for the common squamous carcinomas
where a 5-year survival of 30% is expected. Tumours of salivary gland origin,
like adenoid cystic carcinoma, have a better short-term prognosis, but many of
these patients die with recurrent tumours many years later.
TUMOURS OF THE PHARYNX
Benign tumours of the nasopharynx
Benign tumors of the nasopharynx are rare. The most frequent is the
nasopharyngeal angiofibroma. This occurs exclusively in the male, beginning
about the age of 20-25, but this is not true of all cases.
Symptoms. These include increasing nasal obstruction, purulent rhinosinusitis
due to obstruction of the nasopharynx, severe spontaneous bleeding from the nose
or pharynx, rhinolalia clausa, headaches, obstruction of the ostium of the
eustachian tube causing conductive deafness, middle ear catarrh, and purulent
otitis media. Posterior rhinoscopy shows occlusion of the nasopharynx by a
smooth greyish-red tumor which may be lobulated and have offshoots penetrating
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