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

PART 1 — CHRONIC DISEASES OF THE LARYNX

1.1 Chronic Laryngitis

• Chronic voice abuse / vocal overuse (teachers, singers)
• Tobacco smoking and alcohol
• Laryngopharyngeal reflux (LPR) — the most common cause today
• Chronic sinusitis with postnasal drip
• Occupational exposure (dust, chemical fumes)
• Mouth breathing

• Persistent hoarseness (dysphonia) — cardinal symptom
• Dry irritating cough
• Throat-clearing
• Globus sensation
• Vocal fatigue

• Diffuse mucosal erythema and edema
• Thickening of the vocal folds
• Interarytenoid congestion
• Posterior commissure hypertrophy (sign of LPR)

• Remove causative factors (stop smoking, voice rest)
• Proton pump inhibitors (PPIs) for LPR
• Voice therapy
• Steam inhalations, mucolytics
• Microlaryngoscopy + stripping for Reinke's edema if severe

1.2 Vocal Fold Nodules ("Singer's Nodes")

1.3 Vocal Fold Polyps

1.4 Laryngeal Leukoplakia & Keratosis

• Risk of malignant transformation: 5–10%
• Mandatory biopsy to exclude dysplasia or carcinoma-in-situ.
• Management: cessation of smoking, microlaryngoscopic stripping, laser excision; close endoscopic surveillance.

1.5 Laryngeal Tuberculosis

• Source: Almost always secondary to pulmonary TB via infected sputum.
• Sites: Posterior larynx (arytenoids, interarytenoid fold) > anterior larynx; contrast with syphilis which starts anteriorly.
• Symptoms: Hoarseness, odynophagia (severe, "can't swallow own saliva"), systemic TB symptoms.
• Laryngoscopy: Pale oedematous mucosa, "turban epiglottis," superficial ulceration, later scarring.
• Diagnosis: Laryngeal biopsy + AFB smear/culture; chest X-ray.
• Treatment: Standard anti-TB regimen (RHEZ for 2 months, then RH for 4 months).

1.6 Laryngeal Syphilis

1.7 Scleroma (Rhinoscleroma of the Larynx)

1.8 Laryngeal Cancer

• The most important chronic laryngeal disease; squamous cell carcinoma (SCC) accounts for >95%.
• Risk factors: Tobacco (primary), alcohol (synergistic), HPV-16/18.
• Classification: Glottic (most common, best prognosis), supraglottic, subglottic.
• Symptoms: Progressive hoarseness (early in glottic tumours), dysphagia, dyspnoea, neck mass (nodal metastasis).
• Diagnosis: Laryngoscopy + biopsy; CT/MRI for staging.
• Treatment: Early disease — radiotherapy or endoscopic laser resection (voice-preserving). Advanced disease — total laryngectomy ± neck dissection ± chemoradiotherapy. Proximal risk factors include tobacco and alcohol. — Goldman-Cecil Medicine

PART 2 — FOREIGN BODIES OF THE LARYNX, TRACHEA & BRONCHI

2.1 Epidemiology & Types

• Most common in children < 5 years (peanuts, seeds, small toys) and elderly (poorly fitting dentures, meat bolus).
• Adults: unusual; consider in anyone presenting with sudden onset cough, wheeze, or stridor.
• Most common object in adults and children: organic (peanuts, sunflower seeds, beans); these swell with time and are more hazardous.

2.2 Anatomy of Lodgement

2.3 Clinical Features

1. Initial (violent) stage — Sudden paroxysmal coughing, choking, gagging, stridor, cyanosis at the moment of aspiration. May be witnessed.
2. Asymptomatic (latent) stage — Object lodges, symptoms quiet down. This stage can last hours to weeks. Dangerous: the problem may be forgotten.
3. Symptomatic (complication) stage — Inflammation, infection, granulation tissue formation → recurrent pneumonia, atelectasis, bronchiectasis, abscess.

2.4 Radiology

• Plain X-ray (AP + lateral, including neck and chest):
  • Radiopaque FBs (coins, metals) are directly visible.
  • Most organic FBs are radiolucent — look for indirect signs: unilateral hyperlucency (obstructive emphysema), mediastinal shift away from the affected side on expiration, atelectasis, lobar consolidation.
  • Expiratory film or fluoroscopy is essential — demonstrates air-trapping on the affected side (mediastinum shifts to the opposite side on expiration = positive finding).
• CT chest: Best for near-soft-tissue-density FBs; defines location precisely.
• Radiographs may be completely normal — a high index of suspicion is paramount. — Murray & Nadel's Textbook of Respiratory Medicine

2.5 Management

• Conscious child: Heimlich manoeuvre (> 1 year) or back blows + chest thrusts (< 1 year).
• Unconscious: CPR protocol; finger-sweep only if FB is visible.

• Performed under general anaesthesia.
• Allows suction, forceps extraction, and ventilation simultaneously.
• Success rate: ~90% for flexible bronchoscopy, higher for rigid. — Murray & Nadel

• Preferred in adults, ICU patients on ventilators.
• Use retrieval forceps, baskets, balloon catheters.

• Reserved for failed endoscopy, impacted/deeply embedded FBs.

Key principle: Never delay — organic FBs absorb moisture, swell, and cause progressive inflammation and granulation tissue that makes extraction progressively more difficult.

PART 3 — FOREIGN BODIES OF THE ESOPHAGUS

3.1 Sites of Lodgement

1. Cricopharyngeus muscle (UES) — most common (C5–C6 level)
2. Level of aortic arch — T4
3. Diaphragmatic hiatus (LES) — least common

3.2 Risk Groups

• Children (coins, toys, batteries)
• Elderly with loose dentures
• Psychiatric patients (intentional)
• Prisoners (deliberate ingestion)
• Patients with underlying esophageal pathology (stricture, ring, achalasia)

3.3 Clinical Features

• Dysphagia (solids > liquids)
• Odynophagia
• Hypersalivation ("drooling")
• Inability to swallow saliva (sign of complete obstruction)
• Chest/neck pain
• Regurgitation

Red flags: Fever, subcutaneous emphysema, mediastinal widening → perforation and mediastinitis.

3.4 Diagnosis

• Plain X-ray (lateral soft tissue neck + PA chest): Radiopaque FBs visible directly. Indirect signs of perforation: pneumomediastinum, prevertebral soft tissue swelling, gas in fascial planes.
• Important radiological point: A coin in the esophagus appears face-on (en face) on AP view (coronal orientation); a coin in the trachea appears on edge (sagittal) — because the tracheal rings hold it in a different plane.
• CT if radiographs are negative but clinical suspicion persists (superior for soft-tissue-density FBs like fish bones).
• Water-soluble contrast swallow if perforation suspected (not barium — barium causes mediastinal granuloma).
• Endoscopy is both diagnostic and therapeutic.

3.5 Management — by FB Type

Any FB in the esophagus must be removed — pressure necrosis with perforation may otherwise occur. Sharp or long FBs carry perforation risk of 15–35%. — Cummings Otolaryngology

PART 4 — ENDOTRACHEAL INTUBATION

4.1 Definition & Purpose

• Secure and protect the airway
• Enable mechanical ventilation
• Facilitate suction of secretions
• Administer anaesthetic gases

4.2 Indications

• Respiratory failure (apnoea, severe hypoxia)
• Airway protection (GCS ≤ 8, risk of aspiration)
• Upper airway obstruction (angioedema, trauma, epiglottitis — use with caution)
• General anaesthesia
• Cardiorespiratory arrest

4.3 Technique (Rapid Sequence Intubation — RSI)

1. Pre-oxygenation — 3–5 minutes of 100% O₂.
2. Pre-medication — Atropine (children), lidocaine (raised ICP).
3. Induction agent — Propofol, ketamine, or thiopentone.
4. Paralytic agent — Succinylcholine (fastest onset, 1–2 min) or rocuronium.
5. Cricoid pressure (Sellick's manoeuvre) — controversial but still used.
6. Laryngoscopy — Direct (Macintosh blade) or video laryngoscopy.
7. Tube placement — Cuffed ETT placed through cords; cuff inflated to 20–30 cmH₂O.
8. Confirmation: Capnography (gold standard), bilateral air entry, chest rise, misting of tube, CXR.

4.4 Complications of Intubation

• Failed intubation / oesophageal intubation (must confirm immediately with ETCO₂)
• Laryngospasm, bronchospasm
• Dental injury
• Hypoxia during attempts
• Haemorrhage
• Arytenoid dislocation

• Subglottic stenosis (prolonged intubation > 2 weeks; incidence historically 3–12% after tracheostomy)
• Laryngeal granulomas
• Tracheomalacia
• Sinusitis (nasotracheal)

Anterior neck trauma or possible laryngotracheal injury is a relative contraindication to orotracheal intubation; tracheostomy is preferred in such cases. — Pfenninger and Fowler's Procedures for Primary Care

PART 5 — TRACHEOSTOMY

5.1 Definition

5.2 Indications

• Upper airway obstruction from FB not amenable to intubation
• Severe laryngeal oedema (anaphylaxis, angioedema)
• Severe head/neck trauma with laryngeal fracture
• Failed intubation

• Prolonged mechanical ventilation (> 7–14 days)
• Bilateral vocal cord paralysis
• Laryngeal carcinoma (obstructing tumour)
• Obstructive sleep apnoea (severe, refractory)
• Neuromuscular diseases impairing airway protection (MND, Guillain–Barré)
• Post-laryngectomy (permanent stoma)

5.3 Types

5.4 Surgical Technique (Standard Open)

1. Position: Supine, neck extended (sandbag under shoulders).
2. Incision: Transverse incision in the lower third of the neck anteriorly (2 cm above the sternal notch).
3. Dissection: Strap muscles retracted laterally; thyroid isthmus divided if necessary.
4. Tracheal opening: Incision through the 2nd and 3rd tracheal rings (never above the 1st ring — risk of subglottic stenosis).
5. Tube insertion: Appropriate-sized cuffed tracheostomy tube inserted; cuff inflated.
6. Securing: Tube tied with tapes; first tube change at 5–7 days (tract established). — Gray's Anatomy for Students

5.5 Complications

• Haemorrhage (most common early complication)
• False passage / tube displacement
• Subcutaneous emphysema / pneumothorax
• Apnoea (over-sedation)
• Tube blockage with mucus

• Wound infection
• Tube displacement (life-threatening before tract is established)
• Tracheoinnominate artery fistula (rare, 0.3%; presents with herald bleed — surgical emergency)
• Aspiration / swallowing dysfunction

• Tracheal stenosis — historically 3–12% after tracheostomy; a common indication for tracheal reconstruction — Schwartz's Principles of Surgery
• Tracheomalacia
• Tracheo-oesophageal fistula
• Persistent stoma (>2 weeks after tube removed)
• Scarring / keloid

5.6 Decannulation

• Once the underlying problem resolves, the tracheostomy tube is simply removed.
• The stoma closes spontaneously without intervention in the vast majority of cases. — Gray's Anatomy for Students
• Progressive downsizing ("weaning") before decannulation.
• Patients with long-term tracheostomies cannot vocalise because no air passes through the vocal cords → a speaking valve (e.g., Passy-Muir valve) occludes the tube on expiration, directing airflow through the larynx.

Summary Table