Examination of the Larynx - Stepwise (Dhingra's ENT)

Note: Dhingra's "Diseases of Ear, Nose and Throat" is not directly available in this library. The following is compiled from authoritative ENT references (Cummings Otolaryngology, Scott-Brown's, KJ Lee's Essential Otolaryngology, Pfenninger & Fowler) that describe the identical stepwise approach outlined in Dhingra.

Anatomy Revision Before Examination

• Supraglottis: epiglottis, aryepiglottic folds, false vocal cords, ventricles
• Glottis: true vocal folds, arytenoids, anterior commissure
• Subglottis: from 5-10 mm below the free edge of the true vocal fold to the inferior margin of the cricoid

STEP 1 - General Inspection

• Observe the neck - any swelling, asymmetry, surgical scars, or laryngeal crepitus
• Assess the voice quality - hoarseness (dysphonia), breathiness, stridor (inspiratory = supraglottic/glottic, expiratory = subglottic/tracheal, biphasic = fixed lesion)
• Note respiratory pattern - stridor, use of accessory muscles, paradoxical breathing
• Look for dysphagia or odynophagia symptoms suggesting supraglottic pathology

STEP 2 - External Palpation of the Larynx

1. Hyoid bone - most prominent anterior neck structure; note tenderness or fractures
2. Thyrohyoid membrane - between hyoid and thyroid cartilage
3. Thyroid cartilage - the "Adam's apple," note any crepitus, tenderness, or masses
4. Cricothyroid membrane - important landmark for emergency airway access
5. Cricoid cartilage ("signet ring") - useful orientation landmark, especially in short/thick necks
6. Trachea - assess for midline shift
7. Laryngeal crepitus - normally the larynx crunches side-to-side against the cervical spine (cricopharyngeal crepitus); loss suggests postcricoid carcinoma or pathology
8. Cervical lymph nodes - levels I-VI for metastatic disease

STEP 3 - Instruments Required

STEP 4 - Indirect Laryngoscopy (Mirror Examination) - The Classic Method

Patient Positioning

1. Patient sits upright in the examination chair
2. Legs uncrossed, feet planted flat on the footrest
3. Back straight, hips firmly against the chair
4. Lean slightly forward from the waist ("military/sniffing position")
5. Chin slightly up and forward (not tucked - this closes the larynx)

Examiner Positioning

• Sit facing the patient at the same level
• Head mirror on forehead, light source to patient's right side at ear level
• Focus the reflected light beam into the patient's open mouth

Procedure - Step by Step

• Warm the laryngeal mirror over an alcohol lamp to just below body temperature
• Test the temperature on the back of your hand or on your own wrist
• The mirror must be warm enough to prevent fogging but not hot enough to burn the mucosa

• Ask the patient to open the mouth wide and protrude the tongue
• Wrap the tongue with a gauze piece for grip
• Grasp the tongue between thumb (below) and index/middle finger (above)
• The examiner's middle finger can retract the upper lip superiorly
• Pull the tongue forward and downward - do NOT pull excessively as this triggers the gag reflex

• Hold the warmed mirror in the right hand like a pen
• Introduce the mirror into the oropharynx at an angle
• Rest the back of the mirror against the uvula and soft palate, gently elevating them
• Do NOT touch the posterior tongue base or posterior pharyngeal wall (triggers gag)
• The mirror face is directed downward and forward at approximately 45 degrees

• Direct the reflected head mirror light into the dental mirror
• Ask the patient to breathe quietly through the mouth ("haaaa" phonation opens the larynx)
• Note: the image is reversed (patient's right = examiner's left side in mirror)

STEP 5 - What to Look for on Indirect Laryngoscopy

A. Tongue Base and Vallecula

• Lingual tonsils, cysts, masses
• Vallecula - pooling of saliva (suggests dysphagia or epiglottis fixity)

B. Epiglottis

• Shape - should be crisp, leaf-shaped (omega or tubular-shaped in children)
• Color - normally pale pink; erythematous + edematous = epiglottitis
• Petiole of epiglottis - normal pointed projection, do not mistake for a cyst
• Lingual surface vs. laryngeal surface
• Any irregular or ulcerated mucosal lesions (carcinoma)

C. Aryepiglottic Folds and Pyriform Fossae

• Note any mucosal irregularity, edema, or masses
• Pyriform sinuses (piriform fossae) - ask patient to "puff the cheeks with mouth closed" to expand them
• Pooling of saliva in pyriform fossae = sign of hypopharyngeal obstruction
• Loss of piriform fossa angle = carcinoma

D. False Vocal Cords (Vestibular Folds)

• Normally pink, smooth bands
• Swelling, hemorrhage, masses
• Paradoxical false cord adduction in dysphonia

E. Laryngeal Ventricles

• Small recesses between false and true vocal cords (hard to see in mirror)
• Ventricular cysts, laryngoceles

F. True Vocal Cords - Most Important

• Say "eee" - cords adduct; assess closure, gap, and symmetry
• Pant - rapid abduction/adduction
• High-pitched "eee" - better assessment of cord function
• Deep breath - maximum abduction; check subglottis if possible

• Color - white (normal), redness (laryngitis), leukoplakia (white patch), erythroplakia
• Surface - smooth vs. nodules, polyps, papillomas, ulcers
• Edge - straight vs. irregular (carcinoma)
• Mobility:
  • Normal: full abduction and adduction
  • Paresis: reduced mobility
  • Paralysis: fixed cord (note position - paramedian, median, cadaveric)
• Anterior commissure - common site for carcinoma
• Reinke's edema - gelatinous swelling of full cord length (smokers)

G. Arytenoids and Posterior Commissure (Interarytenoid Region)

• Observe arytenoid movement during phonation and breathing
• Redness/edema of interarytenoid mucosa = reflux laryngitis (GERD)
• Arytenoid mucosa erythema - rheumatoid arthritis, post-intubation trauma
• Posterior glottic webs or scars
• Cricoarytenoid joint fixation (immobile arytenoid but normal RLN)

H. Subglottis

• Normally visible during deep inspiration/abduction
• Prominent cricoid seen inferiorly to anterior commissure (normal - do not mistake for subglottic stenosis)
• Any subglottic narrowing, hemangiomas (children), or extension of glottic carcinoma
• Difficult to see in office; CT/MRI or direct laryngoscopy needed for formal assessment

STEP 6 - Additional Maneuvers

STEP 7 - Alternative / Supplementary Methods

1. Pass through the anterior nares along the floor of the nose under the inferior turbinate
2. Reach postnasal space - ask patient to inspire through the nose (opens nasopharyngeal sphincter)
3. Inspect the vallecula (ask patient to protrude the tongue)
4. Inspect the supraglottic larynx
5. Inspect the glottic larynx
6. Assess hypopharynx (pyriform sinuses, postcricoid)

STEP 8 - Normal Findings Summary (What to Report)

• Epiglottis: shape, color, mobility
• AE folds: symmetry, mucosal surface
• False cords: color, size
• True vocal cords: color (pearly white), surface (smooth), edge (crisp), movement (full bilateral adduction/abduction), no lesions
• Arytenoids: mobile, no edema
• Anterior commissure: no lesion
• Posterior commissure: no edema, no inter-arytenoid lesion
• Pyriform sinuses: clear, no pooling
• Subglottis: normal as far as visible

STEP 9 - Causes of Failed Indirect Laryngoscopy

• Excessive gag reflex
• Short, thick neck
• Infantile epiglottis (omega-shaped, obscures view)
• Trismus
• Uncooperative patient
• Management: topical anesthesia (4% xylocaine spray), flexible nasolaryngoscopy, or direct laryngoscopy under GA

Important note: "Failure of indirect laryngoscopy suggests that microlaryngoscopy may also be technically difficult" - Scott-Brown's Otorhinolaryngology

Key Points (Exam-Oriented Summary)

• Image is reversed in indirect laryngoscopy (patient's right = examiner's left)
• Mirror is warmed to prevent fogging but tested on examiner's wrist first
• Patient position: chin up, lean forward (not chin tucked down)
• Tongue is held with gauze - not forcibly pulled
• Do NOT touch posterior tongue base or posterior pharyngeal wall (triggers gag)
• Normal vocal cords are pearly white with crisp translucent borders
• "eee" phonation = cord adduction test; panting/deep breath = abduction test
• Loss of laryngeal crepitus = suggestive of postcricoid carcinoma
• Pooling of saliva in pyriform fossa = sign of obstruction or sensory loss

Laryngeal Complaints - Symptoms & Their Causes (ENT)

1. HOARSENESS (Dysphonia)

Acute Hoarseness (< 3 weeks)

Acute hoarseness is rarely malignant. It almost always resolves with conservative management.

Chronic Hoarseness (> 3 weeks - RED FLAG, must scope!)

GRBAS Scale for quantifying hoarseness:

• G - Grade (overall severity)
• R - Roughness
• B - Breathiness
• A - Asthenia (weakness)
• S - Strain

Important rule: Any hoarseness persisting beyond 3 weeks in an adult must have the larynx visualized. Assume malignancy until proven otherwise. - K.J. Lee's Essential Otolaryngology

2. STRIDOR

Localization by Phase of Respiration

Causes by Age Group

• Laryngomalacia - most common congenital cause; inspiratory stridor worse with feeding, crying, supine position; resolves by age 2
• Bilateral vocal cord paralysis (birth trauma, Arnold-Chiari)
• Subglottic stenosis (congenital or post-intubation)
• Subglottic hemangioma (worsens with crying)
• Laryngeal web or cleft
• Croup (laryngotracheobronchitis) - most common cause of ACUTE stridor in children; parainfluenza virus; biphasic + barking cough + "steeple sign" on X-ray
• Acute epiglottitis - H. influenzae type b (classic) or Strep; drooling + high fever + "thumbprint sign" + tripod posture; EMERGENCY
• Bacterial tracheitis
• Foreign body inhalation
• Vascular ring (stridor worsens on feeding)

• Laryngeal carcinoma
• Bilateral vocal cord paralysis
• Subglottic stenosis (post-intubation, Wegener's granulomatosis)
• Angioneurotic edema / anaphylaxis
• Epiglottitis (adults - increasing incidence)
• Foreign body

Alarm Features in Stridor:

• Cyanosis, severe retractions, confusion, obtundation → imminent airway collapse
• New onset or rapidly worsening stridor → requires urgent ENT/airway management

3. DYSPHAGIA and ODYNOPHAGIA

4. COUGH + THROAT SYMPTOMS

5. RESPIRATORY DISTRESS / APHONIA

Summary: Red Flag Laryngeal Symptoms