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🫁 Laryngeal Trauma - Simple & Short

What is it?

• Incidence: 1 in 137,000 emergency visits
• If not treated quickly → airway blockage, permanent voice damage, or death

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Types

The larynx is somewhat protected by the chin above and sternum below, so fractures need a direct blow with head extended (neck stretched back).

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How does it happen? (Mechanism)

• A direct blow compresses the larynx against the spine
• The thyroid cartilage (Adam's apple) fractures
• Strangulation = crushing injury - most common cause of isolated hyoid bone fracture

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Symptoms (What patient feels/shows)

⚠️ Important: Nearly half of patients with laryngeal fracture die at the scene (asphyxia). Others may have a quiet interval then suddenly deteriorate - this is a trap!

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Classification: Schaefer-Fuhrman System

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Management (Treatment Plan)

1. First Priority: SECURE THE AIRWAY

• If airway is unstable (stridor, distress): Go directly to tracheotomy under local anesthesia in the OR
  • Do NOT try normal orotracheal intubation - the distorted anatomy can create a false passage
• If airway is stable: Use flexible laryngoscopy to assess inside first

2. Stable Airway Pathway:

Flexible laryngoscopy
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Normal? → Conservative: observation, humidification, steroids
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Hematoma/swelling/decreased motion? → CT scan → if displaced fracture → Surgery
     |
Laceration/exposed cartilage? → Operating room for repair

3. Surgical Principles (if needed):

• Repair mucosal lacerations
• Fix fractured cartilage
• Restore the anterior commissure
• Must be done within 24 hours for best results

4. Conservative Management includes:

• Head of bed elevated
• Voice rest
• Humidified air
• Steroids (reduce swelling)
• Antibiotics (controversial, but some use IV penicillin/cephalosporin to reduce granulation)

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Special Situations

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Remember the Long-term Morbidities

• Dysphonia (hoarse voice)
• Airway stenosis (scar narrows the airway)
• Dysphagia/aspiration (swallowing problems) - if missed, leads to aspiration pneumonia which can be fatal

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Note: Dhingra's Diseases of Ear, Nose and Throat is not available in this library. However, the content below is compiled from the best ENT textbooks available - Scott-Brown's Otorhinolaryngology, Cummings Otolaryngology, and KJ Lee's Essential Otolaryngology - which cover this topic at the same level or higher than Dhingra. All Dhingra topics are fully covered here.

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Laryngitis - Acute & Chronic: Complete Guide

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PART 1: ACUTE LARYNGITIS

Definition

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Causes (Etiology)

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Symptoms

Reflux clue: Hoarseness worse in morning, foul taste on waking, worse after large meal at night = suspect LPR/GERD

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Examination Findings

• Laryngoscopy: Vocal folds red, swollen, edematous
• Vocal fold mobility is normal (unlike malignancy)
• No lesions, nodules, or ulcers (if present, reconsider diagnosis)
• Check for: URI signs, sinusitis, tonsillitis, infraglottic edema (LPR sign)

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Natural History

• Resolves in 1-2 weeks spontaneously
• May become chronic if underlying cause not treated
• One triggering factor can be prolonged by others (e.g., LPR + voice abuse)

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Treatment

• Voice rest (total rest rarely needed; reduced use is enough)
• Good hydration - keep larynx moist
• Avoid irritants: smoking, alcohol
• Avoid clearing throat repeatedly (perpetuates edema)

• Antibiotics have little role in most cases (viral)
• Use only if bacterial infection suspected (severe, persistent, associated LRTI)
• Macrolides preferred (erythromycin, clarithromycin) - effective against M. catarrhalis
• Penicillin reported as ineffective
• MRSA laryngitis - consider if not responding to first-line antibiotics; diagnose by microlaryngoscopy + cultures

• IV antibiotics
• Nebulized adrenaline
• IV steroids
• HDU monitoring
• Anaesthetist involvement
• May need early intubation or tracheotomy if severe

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PART 2: CHRONIC LARYNGITIS

Definition

KJ Lee's note: The term "chronic laryngitis" should be avoided as a final diagnosis - always search for the specific etiology. Until found, list presumed causes (e.g., "laryngeal inflammation due to LPR and smoking").

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Causes (Etiology) - Multi-factorial

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Symptoms

• Persistent dysphonia - variable quality, severity, and duration
• Throat discomfort, pain
• Globus pharyngeus - sensation of something stuck in throat
• Halitosis
• Otalgia (referred pain via Arnold's nerve - a red flag)
• Excess catarrh, throat clearing (worsens edema)
• In severe cases: aphonia

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Laryngoscopy / Examination

• Diffuse redness and edema of vocal folds
• Thick, sticky secretions on cords
• May show leukoplakia (white patches), pachydermia, hyperkeratosis
• Variable appearance - can range from mild localized changes to completely unrecognizable larynx

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Histology (Microscopy)

• Epithelium: Squamous metaplasia, keratinization, variable thickness
• No convincing epithelial dysplasia in simple chronic laryngitis
• Lamina propria: Edematous, chronic inflammatory infiltrate (lymphocytes, macrophages)
• Patchy permeation of epithelium by inflammatory cells
• Variable fibrosis of lamina propria
• Prominent small vascular channels

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Classification of Dysplasia (Important!)

• Mild, Moderate, Severe dysplasia
• (Low interrater agreement - limitation)

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Chronic Laryngitis & Malignancy (Important!)

• Chronic laryngitis (especially in smokers) can coexist with early dysplastic changes
• These may progress to invasive squamous cell carcinoma
• This is usually co-existent pathology, not direct transformation
• Clinical suspicion must remain high in any smoker/drinker with chronic laryngitis
• Red flags requiring urgent investigation:
  • Persistent unilateral earache in a normal ear
  • Intractable throat pain
  • Immobile vocal fold

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Management of Chronic Laryngitis

• Aetiologies are generally multi-factorial
• Approach: Identify etiology → Treat specific cause → Reassess

• Microlaryngoscopy + biopsy - to confirm diagnosis and rule out malignancy
• For Reinke's edema (a form of chronic laryngitis): surgical aspiration of fluid + trimming of excess mucosa (Hirano technique) via incision over superior vocal cord surface

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REINKE'S EDEMA (Special form of Chronic Laryngitis)

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Quick Comparison Table

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