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The Larynx — Complete Clinical Reference

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1. Clinical Anatomy of the Larynx

• Supraglottis — includes the epiglottis (suprahyoid and infrahyoid), aryepiglottic folds, arytenoids, false vocal cords (vestibular folds), and ventricles
• Glottis — true vocal cords plus anterior and posterior commissures; lower boundary is 5 mm below the free margin of the cords
• Subglottis — from the lower glottic boundary to the inferior margin of the cricoid cartilage

• Thyroid cartilage — two quadrilateral hyaline cartilage laminae fused anteriorly; the laryngeal prominence ("Adam's apple") is the superior projection; superior and inferior horns project from posterior borders
• Cricoid cartilage — signet-ring shaped hyaline cartilage; the only complete cartilaginous ring in the airway; arch anteriorly, lamina posteriorly; the arytenoid articular surfaces sit on the superior laminar border
• Arytenoid cartilages — paired pyramids of hyaline cartilage; each has a muscular process (for muscle attachment) and a vocal process (for attachment of the vocal ligament)
• Epiglottis — leaf-shaped elastic cartilage; attached to the thyroid cartilage by its stalk; elastic cartilage does not ossify
• Corniculate and cuneiform cartilages — small elastic cartilages within the aryepiglottic folds

• Cricothyroid joint — between inferior horn of thyroid and the arch of cricoid; permits rotation that tenses the vocal ligament (cricothyroid muscle action)
• Cricoarytenoid joint — between arytenoid base and superior lamina of cricoid; permits rotation + gliding, opening/closing the rima glottidis

• Conus elasticus (cricovocal membrane) — spans the inner surface of the cricoid to the vocal ligaments; its anterior midline thickening is the median cricothyroid ligament, the surgical target for emergency cricothyrotomy (conicotomy)
• Quadrangular membrane — upper portion of fibroelastic membrane; free inferior margin = vestibular ligament (core of the false vocal cord)
• Thyrohyoid membrane — connects thyroid cartilage to hyoid; the superior laryngeal vessels and nerve pierce it

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2. Functions of the Larynx

Respiratory Function

Protective Function

• During swallowing, the epiglottis deflects food laterally into the pyriform sinuses; the laryngeal inlet narrows via aryepiglottic fold approximation; the true and false vocal cords adduct; the larynx is elevated under the base of the tongue
• The glottic closure reflex (bilateral superior laryngeal nerves) guards against aspiration — sustained spasm = laryngospasm
• The cough reflex opens the rima glottidis explosively to expel foreign material

Vocal (Phonatory) Function

1. Adduction and tensioning of the vocal ligaments (closing the rima)
2. Expiratory airflow forces the cords apart — they vibrate, producing sound
3. Pitch depends on vibration frequency (determined by cord length, thickness, and tension — regulated by cricothyroid and vocalis muscles)
4. Volume depends on the force of the airstream
5. Resonance and articulation are provided by supraglottic structures, oral cavity, and nasal sinuses

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3. Muscles of the Larynx

Extrinsic Laryngeal Muscles (move larynx as a whole)

Intrinsic Laryngeal Muscles

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4. Blood Supply of the Larynx

• Superior laryngeal artery — branch of the superior thyroid artery (from external carotid); passes with the internal branch of the superior laryngeal nerve through the thyrohyoid membrane; supplies supraglottic and most of the larynx
• Inferior laryngeal artery — branch of the inferior thyroid artery (from thyrocervical trunk); supplies subglottis and lower larynx

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5. Peculiarities of Laryngeal Innervation

Superior Laryngeal Nerve (SLN)

• Internal branch (sensory) — pierces the thyrohyoid membrane with the superior laryngeal artery; provides sensory innervation to the laryngeal mucosa down to and including the level of the vocal cords; mediates the glottic closure reflex
• External branch (motor) — supplies the cricothyroid muscle and the inferior pharyngeal constrictor

Recurrent Laryngeal Nerve (RLN)

• Right RLN — loops around the right subclavian artery, then ascends in the tracheo-oesophageal groove
• Left RLN — loops around the aortic arch (longer, more vulnerable), then ascends

• Motor — all intrinsic laryngeal muscles except the cricothyroid
• Sensory — laryngeal mucosa below the vocal cords and upper trachea

• Unilateral RLN injury → ipsilateral vocal cord paralysis in paramedian position → hoarseness, aspiration
• Bilateral RLN injury → complete adduction of both cords → stridor, acute respiratory distress
• SLN injury (e.g., thyroid surgery, neck dissection) → loss of pitch and projection (cricothyroid paralysis) + loss of protective glottic reflex → silent aspiration
• Risk of RLN injury: thyroid/parathyroid surgery, oesophageal surgery, aortic arch procedures (left)
• The sensory supply above the cords = SLN; below the cords = RLN — this is exploited in awake fiberoptic intubation with nerve blocks

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6. Methods of Examination of the Larynx

1. Indirect laryngoscopy — angled mirror placed in oropharynx; reflected light illuminates larynx; classic office technique
2. Direct laryngoscopy — rigid laryngoscope; used under anaesthesia; gold standard for operative procedures
3. Flexible nasopharyngolaryngoscopy (nasendoscopy) — fibre-optic or video endoscope passed transnasally; excellent for dynamic assessment of vocal cord movement, office-based
4. Video laryngoscopy — indirect video system for airway management; GlideScope, McGrath, Pentax-AWS
5. Microlaryngoscopy — operating microscope through direct laryngoscope for phonomicrosurgery
6. Stroboscopy — flashing light synchronised to vocal cord vibration; evaluates mucosal wave
7. Imaging — lateral neck X-ray (thumb-print sign of epiglottitis, "steeple sign" of croup), CT neck, MRI
8. Panendoscopy (triple endoscopy) — laryngoscopy + bronchoscopy + oesophagoscopy; for head and neck malignancy staging

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7. Technique of Indirect Laryngoscopy

1. Patient seated upright, neck slightly flexed, head extended ("sniffing position")
2. Patient protrudes tongue; examiner grasps it gently with gauze
3. Warm mirror briefly over flame; test temperature on examiner's hand
4. Mirror inserted to posterior oropharynx, mirror face angled inferiorly, touching the soft palate/uvula (NOT the posterior pharyngeal wall to avoid gag)
5. Patient breathes through mouth or says "eeee" (Valsalva) to elevate soft palate
6. Observe: epiglottis, aryepiglottic folds, arytenoids, false and true vocal cords, subglottis, pyriform fossae
7. Assess cord mobility: ask patient to say "eee" (adduction) and breathe deeply (abduction)
8. Note: the image is inverted — anterior structures appear at the top of the mirror image

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8. Technique of Direct Laryngoscopy

1. Patient supine; head in "sniffing position" (neck flexed, atlantooccipital joint extended)
2. Open mouth with right hand; blade inserted on right side of tongue, sweeping it leftward
3. Macintosh blade: tip placed in vallecula; upward lifting force (at 45°) elevates epiglottis indirectly
4. Miller (straight) blade: tip placed posterior to epiglottis; lifts it directly
5. Force directed along the blade handle axis (never lever against upper incisors)
6. Glottis identified; procedure performed or ETT passed under vision

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9. Causes of Acute Laryngeal Stenosis

• Acute epiglottitis (H. influenzae)
• Acute laryngotracheobronchitis (croup — parainfluenza virus)
• Bacterial tracheitis (S. aureus)
• Diphtheria (Corynebacterium diphtheriae — true croup)
• Laryngeal abscess, Ludwig's angina extension
• Measles laryngitis

• Anaphylaxis
• Angioedema (hereditary or allergic)
• Drug reactions (ACE inhibitors — bradykinin-mediated)

• Foreign body aspiration
• Post-intubation subglottic oedema/stenosis
• Laryngeal fracture (blunt neck trauma)
• Inhalation burns (smoke, steam, caustic agents)
• Iatrogenic (post-operative, post-radiotherapy)

• Rapidly growing laryngeal tumours
• Bilateral vocal cord paralysis (thyroid/oesophageal surgery, mediastinal mass)

• Laryngospasm (bilateral adductor muscle spasm, often from anaesthetic)

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10. Acute Laryngeal Stenosis — Stages, Clinic, Diagnosis, Treatment

Stages (Classic Four-Stage Classification)

Diagnosis

• Clinical: stridor, voice change, cough character, history
• Lateral neck X-ray: epiglottitis (thumbprint sign, thickened aryepiglottic folds), croup (steeple sign)
• Fibre-optic laryngoscopy (in cooperative patients without complete obstruction)
• Pulse oximetry, ABG

Treatment by Stage

• Stage I: Monitor, treat underlying cause (antibiotics, steroids, adrenaline)
• Stage II: Nebulised adrenaline (epinephrine), systemic corticosteroids (IV dexamethasone), humidified oxygen, prepare for intubation
• Stage III: Immediate tracheal intubation or tracheostomy; corticosteroids IV
• Stage IV: Emergency cricothyrotomy (conicotomy) → secure airway → CPR → definitive airway

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11. Acute Laryngeal Oedema — Cause, Clinic, Diagnosis, Treatment

Aetiology

• Allergic: anaphylaxis (bee stings, drugs, foods, latex), angioedema
• Hereditary angioedema (C1-esterase inhibitor deficiency — does NOT respond to adrenaline)
• Iatrogenic: post-intubation, post-radiotherapy, post-operative
• Inflammatory: acute epiglottitis, Ludwig's angina
• Inhalation injury: steam, smoke, chemicals
• Renal failure, cardiac failure (hypoproteinaemic states)

Clinical Features

• Inspiratory stridor (± biphasic in severe cases)
• Muffled or hoarse voice
• Dysphagia, drooling (if supraglottic)
• Progressive respiratory distress
• Rapid onset (minutes in anaphylaxis; hours in hereditary angioedema/inflammatory)

Diagnosis

• Clinical; direct/fibre-optic laryngoscopy shows pale, gelatinous supraglottic swelling
• Lateral neck X-ray shows enlarged epiglottis
• Lab: tryptase (anaphylaxis), C4/C1-inhibitor levels (hereditary angioedema)

Treatment

• Anaphylaxis: IM adrenaline (0.5 mg, 1:1000), IV hydrocortisone, IV chlorphenamine, IV fluid; early endotracheal intubation; may need surgical airway
• Hereditary angioedema: C1-inhibitor concentrate, icatibant, or tranexamic acid; NOT adrenaline/antihistamines
• Inflammatory: treat underlying infection; corticosteroids; airway protection
• All severe cases: oxygen, IV dexamethasone, nebulised adrenaline, early consideration of intubation or tracheostomy
• If airway lost: emergency cricothyrotomy → tracheostomy

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12. False Croup vs True Croup — Differential Diagnosis

False Croup (Viral Laryngotracheobronchitis)

• 1–3 day prodrome of mild fever and URI symptoms
• Barky ("seal-like") cough — pathognomonic
• Hoarse voice
• High-pitched inspiratory stridor
• Worse at night; aggravated by crying/agitation
• Duration 4–7 days; self-limiting

• Mild: barky cough, stridor only with agitation, minimal distress
• Moderate: stridor at rest, retractions, tachypnoea, fussy
• Severe: stridor at rest + severe retractions + agitation/lethargy/cyanosis

• Clinical; radiography if diagnosis uncertain
• CXR/neck X-ray: steeple sign (symmetric subglottic narrowing on AP view)

• Mild: single oral dose of dexamethasone (0.15–0.6 mg/kg); supportive, humidified air
• Moderate/severe: nebulised epinephrine (racemic or L-epinephrine) + dexamethasone
• Severe: intubation (use a smaller tube than expected), heliox as temporising measure
• Observation period of 2–4 hours after nebulised epinephrine before discharge

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True Croup (Laryngeal Diphtheria)

• Insidious onset; child appears toxic, pale
• Low-grade fever; sore throat → hoarseness → aphonia
• Barky cough
• Progressive stridor (subglottic membrane extension)
• Membranous exudate: tough grey/white membrane on tonsils, pharynx, larynx — bleeds on removal (pathognomonic)
• "Bull neck" — cervical lymphadenopathy + soft tissue oedema
• Systemic: myocarditis (arrhythmias, heart failure), late peripheral neuropathy

• Clinical; throat swab with Loeffler's medium culture; Gram stain
• Albert stain shows metachromatic granules
• Elek test for toxin production

• Diphtheria antitoxin (DAT) — IV, URGENT (neutralises free toxin)
• Antibiotics: benzylpenicillin or erythromycin (eradicate organism)
• Airway management: gentle removal of membrane, intubation or tracheostomy if needed
• Isolation; cardiac monitoring for myocarditis
• Quarantine + contact tracing

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Differential Diagnosis: False vs True Croup

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13. Acute Epiglottitis (Supraglottic Laryngitis)

• Acute onset; high fever, intense sore throat, toxicity
• "3 Ds" — Drooling, Dysphagia, Distress
• Tripod/sniffing position: jaw forward, neck extended, leaning forward on hands
• Muffled "hot-potato" voice (but hoarseness typically absent — differentiates from croup)
• Cough absent or minimal
• Stridor — usually inspiratory; may be absent in very severe obstruction
• Rapid progression to complete airway obstruction (esp. in infants/young children)
• Older patients: sore throat out of proportion to pharyngeal findings; anterior neck tenderness

• Lateral neck X-ray: thumbprint sign — rounded, enlarged epiglottis; thickened aryepiglottic folds; lack of air in vallecula; hypopharyngeal overdistension
• Up to 70% may have normal X-ray
• Do NOT perform oropharyngeal examination in a child with suspected epiglottitis — may precipitate complete obstruction; examine only in OR with intubation equipment ready
• Blood cultures (positive in <10% of cases)

• Paediatric (≤12 yrs): immediate controlled intubation in OR under inhalation anaesthesia; surgeon scrubbed for emergency tracheostomy
• Adult: flexible nasendoscopy + fiberoptic intubation if needed; may manage conservatively with IV antibiotics + close monitoring
• IV antibiotics: 3rd-generation cephalosporin (ceftriaxone) ± MRSA cover
• IV dexamethasone
• Extubation after 24–48 hours when oedema resolved (confirm with direct laryngoscopy)

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14. Acute Laryngitis — Clinic, Diagnosis, Treatment

• Hoarseness or dysphonia (cardinal symptom)
• Dry irritating cough
• Throat discomfort/soreness
• Low-grade fever
• Mild dysphagia
• Laryngoscopy: erythema and oedema of vocal cords; mucosal secretions

• Voice rest (avoid whispering — increases cord strain)
• Humidification; adequate hydration
• Analgesics/anti-inflammatories
• Antibiotics only if bacterial secondary infection is confirmed
• Treat GORD if present
• Short-course systemic corticosteroids if rapid recovery needed (e.g., professional voice user)
• Resolution within 1–2 weeks

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15. Chronic Laryngitis — Clinic, Diagnosis, Treatment

Chronic Hyperplastic Laryngitis (Laryngitis Chronica Hyperplastica)

• Most common type
• Persistent hoarseness, rough voice, chronic cough
• Laryngoscopy: diffuse erythema; thickened, irregular vocal cord mucosa; surface leukoplakia (white patches) — must be biopsied to exclude dysplasia/carcinoma
• Treatment: eliminate causative factors; voice therapy; microlaryngoscopy and biopsy/laser vaporisation for resistant lesions; cessation of smoking is mandatory

Atrophic Laryngitis (Laryngitis Sicca)

• Often associated with atrophic rhinitis
• Dry, crusted, thick secretions on the cords → persistent dry cough, hawking, sensation of foreign body
• Laryngoscopy: dry, pale, thin mucosa; adherent brownish/greenish crusts
• Voice may be roughened, weak
• Treatment: humidification; alkaline saline sprays/irrigations; iodine-glycerine applications; mucophage agents; treat underlying atrophic rhinitis

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16. Foreign Bodies of the Larynx, Trachea, and Bronchi

• Laryngeal/tracheal foreign body: sudden choking; coughing/stridor; aphonia/dysphonia; cyanosis; may be life-threatening immediately
• Bronchial foreign body: Initial choking attack followed by apparent improvement; chronic phase: wheeze, unilateral reduced air entry, recurrent pneumonia in same lobe
• Classic triad: wheeze + unilateral reduced breath sounds + cough

• Plain X-ray: radiopaque objects visible; radiolucent objects → unilateral hyperinflation (air trapping), mediastinal shift away from obstruction on expiratory film
• CT chest: sensitive for non-opaque foreign bodies
• Bronchoscopy: definitive — both diagnostic and therapeutic

• Immediate choking (witnessed): Heimlich manoeuvre (abdominal thrusts); back blows in infants
• Complete obstruction: emergency Heimlich; emergency cricothyrotomy
• Bronchoscopy: rigid bronchoscopy under GA — procedure of choice for removal; flexible bronchoscopy has a role in adults
• Antibiotics if post-obstructive pneumonia

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17. Foreign Bodies of the Oesophagus

1. Upper oesophageal sphincter (cricopharyngeus) — most common (C5–6)
2. Level of aortic arch (T4)
3. Lower oesophageal sphincter

• Dysphagia (solids > liquids)
• Drooling/hypersalivation
• Retrosternal pain
• Regurgitation
• Neck pain; torticollis (vertebral penetration)
• In children: refusal to feed, distress

• Plain X-ray neck/chest: radiopaque objects; cervical soft tissue swelling
• Coins in oesophagus = frontal (en face); coins in trachea = lateral (edge-on)
• Barium swallow (if X-ray negative and high suspicion)
• Oesophagoscopy: definitive

• Rigid oesophagoscopy: gold standard for removal
• Flexible endoscopy: option for soft food boluses, non-sharp objects in cooperative adults
• Glucagon IV (relaxes LOS for food bolus)
• Sharp objects, batteries: urgent removal (batteries cause liquefactive necrosis within hours)
• Perforation: IV antibiotics, surgical drainage/repair

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18. Indications and Technique of Tracheostomy

Indications

1. Upper airway obstruction (unrelieved or anticipated) — laryngeal stenosis, bilateral cord palsy, tumour, trauma
2. Prolonged mechanical ventilation (>7–14 days)
3. Need to bypass upper airway (obstructive sleep apnoea; neuromuscular disease)
4. Pulmonary toilet — facilitation of tracheal suctioning in patients with poor cough
5. Prophylactic (pre-operatively before major head/neck surgery)

Types of Tracheostomy

• Emergency (high) tracheostomy: above isthmus of thyroid — used in acute obstructive emergencies
• Standard (low) tracheostomy: below isthmus (between 2nd and 4th tracheal rings) — standard elective procedure
• Percutaneous dilational tracheostomy (PDT): bedside technique using Seldinger technique + serial dilators; increasingly used in ICU

Technique (Standard Surgical Tracheostomy)

1. Patient supine; shoulder roll to extend neck; local anaesthesia ± GA
2. Transverse or midline incision 2 cm below cricoid (2 finger-widths)
3. Divide platysma; separate strap muscles in midline
4. Thyroid isthmus: divide and suture-ligate if it overlies the trachea
5. Identify trachea; confirm with needle aspiration of air
6. Make incision into trachea between 2nd–4th rings (avoid 1st ring to prevent subglottic stenosis):
   • Window (H or U flap); or
   • Vertical midline incision (in emergency)
   • Stay sutures placed lateral to incision for emergency retrieval
7. Insert appropriately-sized tracheostomy tube; confirm with capnography and chest auscultation
8. Secure tube with ties around neck; suture flange to skin

Complications of Tracheostomy

• Haemorrhage (anterior jugular veins, thyroid vessels)
• False passage
• Apnoea (loss of hypercapnic drive in chronic CO2 retainers)
• Tube misplacement (subcutaneous/paratracheal)
• Cardiorespiratory arrest

• Tube displacement/decannulation
• Surgical emphysema
• Wound infection
• Obstruction of tube (secretions, crusting)
• Pneumothorax, pneumomediastinum

• Tracheomalacia (cartilage destruction)
• Subglottic/tracheal stenosis (most important late complication)
• Tracheo-innominate artery fistula (life-threatening haemorrhage ~day 7–10 — tube erodes into innominate artery)
• Tracheo-oesophageal fistula
• Persistent tracheocutaneous fistula after decannulation
• Difficulty swallowing (reduced laryngeal elevation)
• Cosmetic scarring

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19. Technique of Conicotomy (Cricothyrotomy)

1. Patient supine; neck extended
2. Stabilise thyroid cartilage between thumb and middle finger of non-dominant hand
3. Identify cricothyroid membrane with index finger (soft depression between two hard cartilages)
4. Transverse stab incision through skin and membrane — 1.5 cm wide, in the LOWER half of the membrane to avoid the cricothyroid artery
5. Hook the cricoid cartilage downward; insert tracheal dilator or curved haemostat; insert small cuffed tracheostomy tube (6.0 or 6.5 mm)
6. Confirm: capnography, bilateral chest auscultation

• 14G IV cannula through membrane; attach oxygen via Y-connector or improvised Luer-lock; jet insufflation 15 L/min
• Buys up to 30–45 minutes in adults; preferred in infants/small children (surgical cricothyrotomy challenging due to small membrane)

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20. Tracheal Intubation — Indications and Technique

Indications

• Protection of airway (aspiration risk, impaired consciousness)
• Mechanical ventilation
• Upper airway obstruction (stages III–IV laryngeal stenosis)
• Facilitation of general anaesthesia
• Pulmonary toilet

Technique (Direct Laryngoscopy)

1. Pre-oxygenation — 100% O₂ × 3–5 min; allows denitrogenation
2. Induction — IV anaesthetic ± muscle relaxant
3. Sniffing position (neck flexed at C7, head extended at atlantooccipital joint)
4. Blade inserted as above; glottis identified
5. ETT passed through vocal cords under direct vision; cuff inflated
6. Confirmation: capnography (gold standard); bilateral chest auscultation; CXR
7. Cuff pressure maintained <25 mmHg to prevent tracheal mucosal ischaemia

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21. Chronic Hyperplastic Laryngitis — Clinical Picture

• Persistent hoarseness; rough, low-pitched voice; vocal fatigue
• Chronic nonproductive cough; throat clearing
• Laryngoscopy: diffuse hyperaemia; mucosal thickening of cords; irregular surface; leukoplakia (white patches) on the cords — dysplastic potential
• Pachydermia: warty thickening of interarytenoid mucosa
• Risk factors: smoking, alcohol, GORD, vocal abuse, chronic sinusitis
• Key concern: leukoplakia → mandatory microlaryngoscopy biopsy to exclude carcinoma in situ or SCC
• Treatment: eliminate causative factors; CO₂ laser stripping/microlaryngoscopy; strict follow-up for leukoplakia

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22. Atrophic Laryngitis (Laryngitis Sicca) — Clinical Picture

• Usually co-exists with atrophic rhinitis and pharyngitis ("ozaena complex")
• Dry, harsh, weak voice; persistent tickling cough
• Sensation of foreign body in the throat; constant hawking
• Laryngoscopy: pale, dry, thin mucosa; adherent yellowish-green or brownish crusts covering the vocal cords and subglottis; wide rima glottidis; atrophic-looking cords
• Voice worsens with talking; improves after crust removal
• Pathology: squamous metaplasia; gland atrophy; reduced mucus production
• Treatment: humidification; alkaline-saline irrigations; iodine-glycerine; vitamin A; treat atrophic rhinitis; reassurance (not malignant)

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23. Laryngeal Tuberculosis — Clinical Features

• Persistent progressive hoarseness
• Odynophagia (marked pain on swallowing — differentiates from carcinoma)
• Chronic non-productive or productive cough (sputum may be acid-fast bacilli positive)
• Stridor (late/stenosis)
• Systemic TB: weight loss, night sweats, haemoptysis, fever
• "Pale oedematous" appearance of laryngeal mucosa (vs red, irregular carcinoma)
• May simulate carcinoma — biopsy essential

• Laryngoscopy + biopsy: caseating granulomata with Langhans giant cells; ZN stain / culture for AFB
• CXR / chest CT (primary pulmonary focus)
• Sputum AFB; Mantoux/IGRA

• Standard anti-TB regimen (RIPE): rifampicin + isoniazid + pyrazinamide + ethambutol × 2 months, then continuation phase
• Corticosteroids for severe oedema/stenosis
• Voice rest

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24. Laryngomalacia (Laryngeal Stridor) — Aetiology, Clinic, Diagnosis, Treatment

• Onset: 1st–2nd week of life (may be present from birth)
• Inspiratory stridor — high-pitched, fluctuating; worst when supine, feeding, crying; better prone or with neck extension
• Stridor worsens 4–8 months (peak) then gradually resolves by 18–24 months in 90%
• Feeding difficulties; prolonged feeding times; failure to thrive in severe cases
• Cyanotic episodes (severe)
• No voice change (unlike croup)

• Flexible nasopharyngolaryngoscopy — shows dynamic supraglottic collapse on inspiration (omega-shaped, elongated epiglottis; short aryepiglottic folds; prolapsing arytenoid mucosa)
• Also rules out other causes of neonatal stridor (vocal cord paralysis, subglottic stenosis, haemangioma)

• Mild–moderate: reassurance; prone positioning; anti-reflux therapy (ranitidine/PPI + thickened feeds); parental education; spontaneous resolution expected
• Severe (failure to thrive, severe desaturation, apnoea): supraglottoplasty — CO₂ laser or cold steel division of aryepiglottic folds ± excision of redundant arytenoid mucosa; success rate >90%
• Tracheostomy rarely required for refractory cases

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25. Classification of Laryngeal Paralysis

By Side

• Unilateral (more common) — usually tolerated; hoarse, breathy voice; mild aspiration
• Bilateral — potential life-threatening airway emergency; usually presents with stridor ± dyspnoea

By Level of Lesion (Anatomical)

• Peripheral (RLN) — paralysis of all intrinsic laryngeal muscles except cricothyroid; cord in paramedian position; most common
• Superior laryngeal nerve — cricothyroid paralysis only; pitch and projection affected; loss of protective reflex → silent aspiration
• Combined (vagus nerve trunk) — paralysis of both RLN and SLN; cord in cadaveric (lateral) position
• Central — upper motor neuron lesion; bilateral; cortical, brainstem, or skull base pathology

By Cord Position (Semon & Rosenbach)

• Median position — complete adduction; both cords together (bilateral adductor paralysis — rare)
• Paramedian position — just off midline; most common in RLN palsy; reasonable voice, impaired airway
• Intermediate position — mid-abduction
• Cadaveric position — full abduction; poor voice; good airway

By Cause

• Surgical: thyroidectomy (most common cause), parathyroid, oesophageal, cardiac, aortic arch
• Neoplastic: lung apex (left RLN), thyroid, oesophageal, mediastinal
• Neurological: CVA, multiple sclerosis, syringomyelia, bulbar palsy
• Idiopathic: post-viral
• Traumatic: intubation injury, external laryngeal trauma

• Unilateral: observe 6–12 months for recovery; voice therapy; medialization thyroplasty or injection augmentation if persistent
• Bilateral (acute): intubation/tracheostomy for airway; later, arytenoidectomy or posterior cordotomy to widen the glottic aperture (sacrifices some voice)

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26. Reinke's Oedema (Polypoid Degeneration of Vocal Cords)

Pathogenesis

• Smoking (most important — present in >90%)
• GORD
• Hypothyroidism
• Vocal abuse

Clinical Features

• Predominantly in middle-aged women who smoke
• Progressive deepening and roughening of the voice — characteristic low, "whisky voice"
• Chronic hoarseness; vocal fatigue
• Occasional mild stridor (if extensive)
• Laryngoscopy: bilateral translucent, pale, gelatinous-appearing swellings occupying the entire cord; "water-bag" appearance; worse anteriorly
• Endoscopy (Fig. 66.6B in Miller's Anesthesia) shows characteristic bilateral cord swelling

Treatment

• Mandatory: cessation of smoking (treatment fails without it); treat GORD; voice therapy
• Surgical (if voice or airway affected): microlaryngoscopy under GA — microsurgical cordotomy (longitudinal epithelial incision at the superior surface) → suck out gelatinous fluid → redraped epithelium; CO₂ laser can also be used
• Staged bilateral procedures (never strip both cords simultaneously — risk of anterior commissure web)
• Hypothyroidism: thyroid replacement alone may partially resolve oedema

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Summary Differential — Upper Airway Obstruction in Children

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