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

PART I — CHRONIC DISEASES OF THE LARYNX

Overview

1. Chronic Bacterial Laryngitis

• Superinfection complicating intubation injuries
• Larynges damaged by relapsing polychondritis
• Purulent chondritis with prolonged hoarseness/stridor (>1 month)
• S. aureus is the most common pathogen

2. Chronic Fungal Laryngitis

Important: All fungal laryngitides can be misdiagnosed as laryngeal carcinoma due to pseudoepitheliomatous hyperplasia on biopsy.

3. Laryngeal Tuberculosis

• Accounts for <1% of TB cases
• True vocal cords and epiglottis are most affected
• Presents with hoarseness, odynophagia
• Histology shows caseating granulomas (H&E stain confirms)
• Treatment: standard antituberculous therapy

4. Autoimmune & Granulomatous Laryngitis

• Small/medium vessel vasculitis; ANCA-positive (c-ANCA/p-ANCA)
• 90% have head and neck manifestations; subglottic stenosis is the most common laryngeal finding (20%)
• Rx: endoscopic airway dilation or open resection; systemic immunosuppression

• Autoimmune; autoantibodies against type II collagen
• 25–50% have laryngeal dysfunction: hoarseness, pain, cough → lethal airway obstruction
• Rx: medical + surgical combined

• Up to 80% of pemphigus patients have otolaryngologic signs; 40% laryngeal
• Rx: high-dose corticosteroids + immunosuppressives

5. Laryngitis Associated with Systemic Disease

• Laryngeal involvement in <1% of patients
• Diffuse supraglottic/glottic edema (noncaseating granulomas)
• Rx: systemic corticosteroids; endoscopic resection + intralesional steroid injection for localized disease

• <1% of all benign laryngeal lesions
• Yellow/orange submucosal mass or nodule
• Rx: endoscopic resection for symptomatic/obstructing disease

6. Phonotrauma

• Vocal abuse, misuse, overuse → vocal fold hemorrhage, edema, molecular injury
• Exacerbated by dehydration (raises phonation threshold pressure)
• May result in nodules, polyps, or vascular lesions requiring phonosurgical intervention
• Rx: voice rest, voice therapy, phonosurgery for refractory lesions

7. Laryngopharyngeal Reflux (GERD-related)

• GERD causes extraesophageal manifestations including chronic laryngitis, hoarseness, and chronic cough
• Treatment: proton pump inhibitors/H2 blockers (also reduce post-injury scar formation in laryngotracheal stenosis)

PART II — FOREIGN BODIES OF LARYNX, TRACHEA, BRONCHI, AND ESOPHAGUS

A. Airway Foreign Bodies (Larynx, Trachea, Bronchi)

Epidemiology

• ~1,000 deaths/year in the USA
• Most common cause of accidental death in children <1 year
• 25% of airway foreign bodies have been present >2 weeks
• Children <6 years of age are at highest risk (lack molars to grind food)

Location Distribution

Right main bronchus predominates because it is wider, shorter, and more vertically oriented.

Symptoms by Level

Diagnosis

1. History — may be unwitnessed; any suspicion warrants investigation
2. X-ray (AP + lateral):
   • Radiopaque lesion seen in <25% of cases
   • Mediastinal shift away from the foreign body
   • Elevated contralateral hemidiaphragm
   • Postobstructive collapse (chronic)
   • Pneumomediastinum, pneumothorax
3. Inspiratory/expiratory or lateral decubitus films: Affected lung appears hyperinflated (air trapping); only positive in ~50%
4. CT scan: More sensitive than X-ray, less sensitive than bronchoscopy; use after negative bronchoscopy if symptoms persist
5. Rigid bronchoscopy: Gold standard for diagnosis and treatment

Management

• Rigid laryngoscopy and bronchoscopy with spontaneous ventilation
• Sharp-edged objects retrieved into the bronchoscope to minimize mucosal trauma
• Tracheotomy rarely required for very large foreign bodies
• Blind finger sweeping is contraindicated — may lodge foreign body deeper or in the esophagus causing tracheal compression

B. Esophageal Foreign Bodies

Sites of Lodgment

1. Cricopharyngeus muscle / thoracic inlet (cricopharyngeal level) — ~90% of pediatric esophageal foreign bodies
2. Aortic arch level
3. Tracheal bifurcation (carina)
4. Level of aortic arch
5. Gastroesophageal junction

Common Foreign Bodies

• Coins — most common in pediatric patients (>50%)
• Food bolus (meat), bones (fish, chicken)
• Button (disc) batteries, magnets, toys

Symptoms

• Dysphagia, drooling, retching, vomiting
• Odynophagia
• Chest/neck pain, anorexia
• Respiratory distress from extrinsic tracheal compression by upper esophageal foreign body (trachea lies directly posterior to esophagus)

Complications

• Esophageal erosion or perforation
• Mediastinitis
• Esophagus-to-airway or esophagus-to-vascular fistulae
• Retropharyngeal abscess
• Stricture formation

Button Battery — Special Danger

• Electrical current (liquefactive necrosis)
• Pressure necrosis
• Leakage of corrosive alkali
• Heavy metal poisoning

Timeline: mucosal damage begins within 1 hour. Esophageal button battery impaction = prompt emergency endoscopic removal.

Radiology

• Coin in trachea: seen in profile on lateral view (sagittal orientation with tracheal rings)
• Coin in esophagus: seen en face on lateral view (coronal orientation)
• Barium esophagram: definitive for occult esophageal foreign body
• CT: useful adjunct

Management

• Esophagoscopy (rigid or flexible) for removal
• Magill forceps + laryngoscope for proximal pharyngeal/esophageal objects

PART III — ENDOTRACHEAL INTUBATION

Complications of Prolonged Intubation

Pathophysiology

1. Cuff pressure → ischemic necrosis of tracheal mucosa
2. Mucosal ulceration + bacterial infection → perichondritis/chondritis
3. Cartilage resorption → acute stenosis from granulation tissue
4. Healing by secondary intention → submucosal fibrosis and scar contraction = chronic stenosis

Risk Factors for Post-intubation Stenosis

• Duration of intubation
• Inadequate sedation (excessive laryngeal movement)
• Diabetes mellitus
• Congestive heart failure
• History of stroke
• GERD / laryngopharyngeal reflux
• Hypothyroidism

Classification (Myer-Cotton)

PART IV — TRACHEOSTOMY

Indications and Contraindications

Tracheostomy is the most common surgical procedure in critically ill patients requiring prolonged mechanical ventilation. — Sabiston Textbook of Surgery

Techniques

• Can be performed safely at the bedside in the ICU
• Advantages vs open: decreased wound infection, less clinically relevant bleeding, more cost-effective
• Periprocedural mortality: <0.1%; major complication rate: 0.15%

Safety Measures

• Use of bronchoscopic guidance OR semiopen technique with blunt dissection to anterior trachea
• Preprocedure ultrasound to identify neck anatomy, detect crossing veins, enlarged thyroid, reduce bleeding risk
• Dedicated multidisciplinary tracheostomy teams → reduced time to decannulation, shorter LOS, fewer adverse events

Complications

• Tracheal stenosis (most common serious long-term complication): overall incidence ~6%; subclinical stenosis in 40%; usually early, at the subglottic position
• Bleeding, infection, subcutaneous emphysema, false passage
• Inadvertent decannulation

Timing

Summary Table