Chronic Diseases of the Larynx — Foreign Bodies of the Larynx, Trachea, Bronchi, Esophagus — Intubation and Tracheostomy

PART 1: CHRONIC DISEASES OF THE LARYNX

1. Chronic Laryngitis

• Gastroesophageal/laryngopharyngeal reflux (most common chronic cause)
• Voice overuse, misuse, or abuse (phonotrauma)
• Tobacco smoke, dust, and polluted air
• Thermal and chemical irritants
• Chronic allergic reactions
• Prolonged use of inhaled corticosteroids (risk for fungal laryngitis)

2. Chronic Bacterial Laryngitis

3. Chronic Fungal Laryngitis

• The differential for white vocal fold lesions includes hyperkeratosis, thick mucus, malignancy, and Candida.
• Treatment: fluconazole (systemic for laryngeal involvement); itraconazole for resistant strains.

4. Laryngeal Tuberculosis

• Presentation: hoarseness, dysphagia, odynophagia, stridor
• Diagnosis: laryngoscopy + biopsy + AFB staining/culture
• Treatment: standard anti-TB therapy (isoniazid, rifampicin, pyrazinamide, ethambutol)

5. Autoimmune and Systemic Inflammatory Diseases of the Larynx

Granulomatosis with Polyangiitis (GPA / Wegener's)

• Small- and medium-vessel vasculitis; autoantibodies against proteinase 3 (c-ANCA)
• 90% have head and neck manifestations; subglottic stenosis is the most common laryngeal manifestation (20%)
• Treatment: endoscopic dilation or open resection + immunosuppression

Relapsing Polychondritis

• Autoimmune; autoantibodies against type II collagen
• 25–50% have laryngeal symptoms (hoarseness, cough, pain, potentially fatal airway obstruction)
• Treatment: medical and surgical combination

Pemphigus Vulgaris / Pemphigoid

• Up to 80% of pemphigus patients have ORL symptoms; 40% laryngeal
• Severe epithelial loss from intraepithelial (pemphigus) or subepithelial (pemphigoid) autoantibodies
• Treatment: high-dose corticosteroids + immunosuppressives

Sarcoidosis

• Laryngeal involvement in <1% of cases; usually supraglottic and glottic edema
• Diagnosis by histology (non-caseating granulomas)
• Treatment: systemic corticosteroids

6. Iatrogenic Laryngeal Injury (Intubation Granuloma / Stenosis)

7. Laryngocele

• Formed by increased intraglottic pressure (horn players, glass blowers) or obstruction of the laryngeal ventricle
• Internal laryngocele: tracks within the paralaryngeal fat, may be air- or fluid-filled
• External (mixed) laryngocele: extends through thyrohyoid membrane → presents as neck mass
• CT appearance: air- or fluid-containing structure within or adjacent to the larynx

8. Recurrent Respiratory Papillomatosis (RRP)

• Caused by HPV (types 6 and 11)
• Warty growths on the laryngeal mucosa
• Managed with endoscopic debridement; adjuncts include cidofovir, indole-3-carbinol
• Annual biopsies to rule out malignant transformation
• Quadrivalent and 9-valent HPV vaccines have decreased the incidence of RRP

9. Paradoxical Vocal Fold Movement

• Vocal fold adduction on inspiration, abduction on expiration (opposite of normal)
• More common in females with social stressors; often misdiagnosed as asthma
• Associated with laryngopharyngeal reflux
• Diagnosis: flexible nasopharyngoscopy (may require exercise testing)
• Treatment: panting exercises, PPI, voice therapy, biofeedback; severe cases — heliox, botox, anticholinergics

PART 2: FOREIGN BODIES OF THE LARYNX, TRACHEA, BRONCHI, AND ESOPHAGUS

Epidemiology and General Principles

• 80–90% of airway foreign bodies are found in the bronchi
• Tracheal or laryngeal foreign bodies are less common but more immediately dangerous
• A tracheal foreign body is more likely to cause complete airway obstruction and requires more urgent intervention than a bronchial foreign body

Foreign Body Aspiration (Larynx, Trachea, Bronchi)

• Peanut oil is chemically irritating → causes chemical bronchitis and pneumonia
• Vegetable/organic matter is associated with higher complication rates due to swelling and inflammatory response
• Solid foreign body causes air trapping → hyperlucency of affected lobe (especially on expiration)

• Initial cough or choking episode while eating, often followed by an asymptomatic interval
• Unilateral wheeze on auscultation (often misdiagnosed as asthma)
• Total respiratory obstruction if in trachea (rare but emergent)

• CXR: radiopaque FB seen directly; for radiolucent FB (nuts, seeds, plastic) → hyperexpansion of affected lobe on expiratory film or fluoroscopy
• CT chest (if diagnosis uncertain)
• Rigid bronchoscopy = gold standard for diagnosis and treatment

• Rigid bronchoscopy with optical forceps — may be simple or very difficult
• Epinephrine injection into mucosa if foreign body has been present long term (minimizes bleeding)
• Rarely: bronchiectasis from repeated infection may require partial/total lobe resection

Foreign Bodies of the Esophagus

1. Coins (most common in children)
2. Small toy parts
3. Fish bones, meat boluses (adults)

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

• Often asymptomatic period after ingestion initially
• GI symptoms: dysphagia, drooling, dehydration
• Respiratory symptoms (if prolonged): cough, stridor, wheezing — may mimic upper respiratory infection

• CXR: diagnostic for coins (coronal plane — coin faces forward in esophagus vs. sagittal in trachea)
• Contrast swallow or esophagoscopy for non-radiopaque FB

PART 3: INTUBATION

Endotracheal Intubation — Complications

• Pharyngeal or laryngeal lacerations
• Cricoarytenoid joint dislocation
• Neuropraxia of lingual, hypoglossal, and laryngeal nerves
• Arytenoid dislocation

• Granulation tissue, fibrotic scar
• Arytenoid fixation
• Subglottic stenosis — particularly dangerous in children; there is no duration of intubation below which this cannot occur

PART 4: TRACHEOSTOMY

Definition and Indication Categories

1. Upper airway obstruction (difficult airway, maxillofacial trauma, angioedema, tumors)
2. Prolonged mechanical ventilation
3. Neurologic condition preventing safe extubation (brain injury, spinal cord injury, severe agitation, altered mental status)

Indications and Contraindications

Techniques

1. Open (Surgical) Tracheostomy

• Performed in the operating room
• Standard technique with direct visualization

2. Percutaneous Dilatational Tracheostomy (PDT)

• First described by Ciaglia (1985)
• Now widely performed at the bedside in the ICU
• Compared to open tracheostomy: decreased wound infection and clinically relevant bleeding; more cost-effective
• Periprocedural mortality: <0.2%
• Major complication rate: 0.15%
• Safety confirmed in >3000 consecutive procedures
• Guidance: bronchoscopic or semi-open technique with blunt dissection — both minimize loss of airway

Timing

• Controversial in predicted prolonged ventilation
• Most studies show no mortality difference between early (<7 days) vs. late (>7 days)
• One RCT showed significant benefit of early tracheostomy at 48h vs. 14–16 days (↓ mortality 32% vs. 62%, ↓ pneumonia)
• The largest RCT (TracMan, UK; >900 patients) showed no mortality difference between early (within 4 days) vs. late (after 10 days); >50% of late group never needed tracheostomy

Complications of Tracheostomy

• Peristomal bleeding (anterior jugular veins or thyroid isthmus)
• Posterior tracheal wall laceration or esophageal injury
• Extraluminal placement (false tract)
• Loss of airway

• Tracheal stenosis (especially after emergency cricothyroidotomy in children)
• Tracheomalacia
• Persistent stoma

Tracheostomy Tube Sizing (Jackson Scale)

Special Considerations

• COVID-19: Aerosol-generating procedure — airborne/droplet precautions required. Timing after 10–14 days of ventilation associated with shorter ventilation and ICU stay.
• ECMO patients: Tracheostomy can be safely performed, but complications (mostly bleeding) are higher; no difference between open and percutaneous technique.

Summary Table: Foreign Body Management