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Chronic Diseases of the Larynx | Foreign Bodies of the Airway & Esophagus | Intubation & Tracheostomy

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I. CHRONIC DISEASES OF THE LARYNX

A. Noninfectious Chronic Laryngitis

1. Reflux Laryngitis (Laryngopharyngeal Reflux — LPR)

• Gastric acid, pepsin, and bile refluxate contact the laryngeal mucosa, causing epithelial and stromal injury
• Classic symptoms: hoarseness, chronic throat clearing, globus sensation, chronic cough, laryngospasm
• Pepsin has been identified within intracellular vesicles of laryngeal epithelium as a direct injurious agent
• Diagnosis: pH monitoring (>90% sensitivity/specificity); empiric PPI trial is widely used
• Treatment: behavioral (head-of-bed elevation, dietary changes, avoid fatty/spicy foods, caffeine, alcohol), PPIs, H₂ blockers

2. Laryngeal Tuberculosis

• May occur with or without disseminated pulmonary TB; ~15% have isolated laryngeal involvement, ~47% have active pulmonary disease
• Symptoms: hoarseness is nearly uniform
• Laryngoscopic findings: granulomatous or ulcerative lesions of the true and false vocal folds
• Diagnosis: tissue biopsy showing acid-fast bacilli and granuloma formation
• Treatment: multi-drug anti-TB regimens for extended periods

3. Autoimmune and Granulomatous Diseases

4. Laryngeal Stenosis (Subglottic Stenosis)

• Congenital: due to cricoid malformation (elliptical cricoid); may present as stridor at birth, recurrent croup, or failure to extubate
• Acquired: most commonly from prolonged intubation; exacerbated by GERD, eosinophilic esophagitis, and MRSA infection
• Classification — Cotton-Myer Grading System:
  • Grade 1: 0–50% stenosis
  • Grade 2: 51–70% stenosis
  • Grade 3: 71–99% stenosis
  • Grade 4: 100% (complete) obstruction
• Diagnosis: rigid laryngoscopy and bronchoscopy
• Management:
  • Treat co-morbidities (GERD, EE, MRSA)
  • Endoscopic: scar division, balloon dilation, steroid injection
  • Open laryngotracheal reconstruction (LTR): anterior/posterior cricoid splits with costal cartilage grafts; cricotracheal reconstruction (CTR); cervical slide tracheoplasty
  • Staging: single-stage (no tracheotomy at end) vs. double-stage (tracheotomy removed later)

5. Laryngoceles

• Formed by increased intraglottic pressure (horn players, glass blowers) or obstruction of the laryngeal ventricle by inflammation or neoplasm
• Internal: tracks superiorly within paralaryngeal fat, causing supraglottic compromise
• Mixed/External: extends through the thyrohyoid membrane, presenting as a neck mass

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II. FOREIGN BODIES OF THE LARYNX, TRACHEA, BRONCHI, AND ESOPHAGUS

A. Epidemiology

• ~1,000 deaths/year in the United States from foreign body aspiration
• Most common cause of accidental death in children <1 year
• 25% of airway foreign bodies have been present for >2 weeks before diagnosis

B. Location (in decreasing frequency — airway)

The right main bronchus is preferred because it is more vertical, shorter, and wider than the left. This anatomical relationship persists from fetal life through adulthood.

1. Upper esophageal sphincter (cricopharyngeus) — most common
2. Level of the aortic arch
3. Level of the mainstem bronchus
4. Lower esophageal sphincter

C. Symptoms by Location

D. Diagnosis

• AP and lateral chest X-ray: radiopaque foreign body visible in <25% of cases; may show mediastinal shift away from the foreign body, elevated contralateral hemidiaphragm, obstructive emphysema, pneumomediastinum, pneumothorax, or post-obstructive collapse
• Inspiratory/expiratory films or lateral decubitus views: the dependent lung should collapse but appears hyperinflated if a bronchial foreign body is present (specific but only 50% sensitive)
• CT scan: more sensitive than plain X-ray; reserved for negative bronchoscopy when symptoms persist, to locate subsegmental objects
• Barium esophagram: definitive for esophageal foreign bodies; CT is a useful adjunct

Note: calcification of laryngeal cartilage or the stylohyoid ligament can mimic foreign bodies on plain films; oblique projections help distinguish them.

E. Management

1. Rigid laryngoscopy and bronchoscopy under general anesthesia with spontaneous ventilation — preferred approach
2. Foreign body, forceps, and bronchoscope are removed as a single unit
3. Sharp objects: grasp the sharp end and keep it within the bronchoscope tip during withdrawal to minimize mucosal injury
4. If complete obstruction: push the object further into one bronchus to restore ventilation
5. Repeat bronchoscopy after removal to confirm no additional foreign bodies
6. Flexible bronchoscopy: useful for distal airway objects but provides less airway control
7. Tracheotomy or thoracotomy: rarely required for large or embedded objects

• Sharp, caustic, or button battery foreign bodies: urgent endoscopic removal
• Children <1 year, symptomatic, or >24 hours: urgent endoscopic removal
• Healthy asymptomatic older child, smooth midesophageal/distal object <24 hours: may observe 8–16 hours for spontaneous passage; ~25–30% will pass spontaneously
• Rigid esophagoscopy under general anesthesia with endotracheal intubation

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III. INTUBATION AND TRACHEOSTOMY

A. Endotracheal Intubation

• Mucosal injury to the subglottis (most common site of acquired stenosis)
• Granuloma formation at the vocal processes
• Subglottic cysts (from blocked mucous glands)
• Acquired subglottic stenosis — worsened by GERD, eosinophilic esophagitis, MRSA

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B. Tracheostomy

Indications and Contraindications

Techniques

• Open (surgical) tracheostomy: performed in the operating room
• Percutaneous Dilatational Tracheostomy (PDT): first described by Ciaglia in 1985; widely adopted for elective tracheostomy at the bedside in the ICU
  • Advantages: decreased wound infection, less clinically relevant bleeding, more cost-effective
  • Periprocedural mortality: <0.1–0.2%
  • Major complication rate (bedside PDT): ~0.15%
  • Safety aids: bronchoscopic guidance or semi-open technique with blunt dissection; preprocedure ultrasound to identify anatomy, crossing veins, and thyroid lobe

Timing

• Early (≤7 days) vs. late (>7 days): controversial; most studies show no mortality difference
• One RCT showed significant reduction in mortality, pneumonia, and ICU stay with early tracheostomy (48h vs. 14–16 days) in patients predicted to require >2 weeks ventilation
• In the largest UK RCT (>900 patients): no mortality difference; notably, >50% of late tracheostomy patients were liberated from ventilation without needing the procedure

Complications

• Perioperative: peristomal bleeding (anterior jugular veins, thyroid isthmus), posterior tracheal/esophageal laceration, false tract, loss of airway
• Long-term: tracheal stenosis (~6% clinically significant; ~40% subclinical); subclinical stenosis usually occurs early in the subglottic position
• COVID considerations: aerosol-generating procedure requiring airborne/droplet precautions; tracheostomy after 10–14 days of MV associated with shorter MV duration and ICU stay

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Summary Table

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