Laryngeal involvement in miscellaneous causes.

ANGIONEUROTIC EDEMA
  • It is essentially an anaphylaxis limited to the skin and subcutaneous tissues and can be due to drug allergy, insect stings or bites, desensitization injections or ingestion of certain foods (particularly eggs, shellfish or nuts)
  1. It is characterized by a diffuse and painful swelling of loose subcutaneous tissue, e.g. dorsum of hands or feet, eyelids, lips, genitalia and mucous membrane.
  2. Edema of the upper airways-especially larynx may produce respiratory distress and the stridor may be mistaken for asthma.
  • If acute angioedema is recurrent progressive, painful rather than pruritic and not associated with urticaria, a hereditary enzyme deficiency should be considerd.
  • Hereditary angioneurotic edema occurs due to deficiency of C1 esterase inhibitor (regulatory protein)
  • Treatment
  1. Epinephrine should be the first treatment for acute pharyngeal or laryngeal angioedema.
  2. This may be supplemented, by a nebulized agonist (e.g. albuterol) and an I.V. antihistamine (diphenhydramine).
  3. This is usually sufficient to prevent airway obstruction but intubating or performing a tracheostomy might be necessary.
REFLUX LARYNGITIS
Reflux laryngitis may have the following sequlae:
  1. Bronchospasm
  2. Chemical pneumonitis
  3. Refractory subglottic stenosis
  4. Refractory contact ulcer
  5. Peptic laryngeal granuloma
  6. Acid laryngitis (Heart burn, burning pharyngeal discomfort, nocturnal chocking due to interarytenoid pachydermia)
  7. Laryngeal Carcinoma .
  8. Laryngopharyngeal Reflux
  • Here classical GERD symptoms are absent.
  1. Patients have more of daytime/upright reflux without the nocturnal/supine reflux of GERD.
  2. In laryngopharyngeal reflux esophageal motility and lower esophageal sphincter is normal, while upper esophageal sphincter is abnormal.
  3. The traditional diagnostic tests for GERD are not useful in LPR.
  • Symptoms: Chronic or Intermittent dysphonia, vocal strain, foreign body sensation, excessive throat mucus, Postnasal discharge and cough.
  • Laryngeal findings in LPR:
  1. Vocal cord granuloma
  2. Interarytenoid bunching
  3. Posterior laryngeal hypertrophy
  4. Laryngeal edema and erythema
  5. Cobblestoning
  6. Subglottic edema
  7. Posterior Laryngitis
  8. Posterior commissure bar
  9. Pseudosulcus : edema of the under surface of vocal cords giving a false impression of a sulcus vocalis; due to acid reflux into the larynx in laryngopharyngeal reflux (LPR). Sequelae of Laryngopharyngeal Reflux
  • Subglottic stenosis
  1. Carcinoma larynx
  2. Contact ulcer/granuloma
  3. Cricoarytenoid joint fixity
  4. Vocal nodule/polyp
  5. Sudden infant deaths
  6. Laryngomalacia (Association)
Treatment is in similar lines as GERD, but we need to give proton pump inhibitors at a higher dose and for a longer duration (at least 6-8 months). 
 LARYNGEAL AMYLOIDOSIS 
  •  The larynx is the most common site in the respiratory tract for amyloid deposition. Patient presentation is characterized by the presence of a submucosal mass, which may arise anywhere in the larynx and may impair vocal cord mobility.
LARYNGEAL SARCOIDOSIS
  • One to five percent of patients with sarcoidosis present with lesions within the larynx.
  • The epiglottis is the most common site of involvement.
SCLEROMA OF LARYNX
  • It is a chronic inflammatory condition of the larynx caused by klebsiella rhinoscleromatis . Treatment is with streptomycin or tetracycline often combined with steroids to prevent fibrosis.
  • Subglottic stenosis is a common complication.
INVOLVEMENT OF LARYNX IN BURNS
  • Inflammatory and circulatory changes in burn patient produce a net flow of water, solutes and proteins from the intravascular to extravascular space.
  • This flow occurs over the first 36 hours after the injury.
  • As the burn size approaches 10-15% of the total body surface area (TBSA), the loss of intravascular fluid can cause a level of circulatory shock Once burned, the linings of nose, mouth, tongue, palate and larynx will start to swell.
  • After a few hours, they may start interfere with the larynx and may completely block the airway(which may lead to death), if action is not taken to secure an airway. Physical burn injury to the airways below the larynx is a rare injury
Exam Question
  • 29-year-old male with episodic abdominal pain and stress-induced edema of the lips, the tongue, and occasionally the larynx is likely to have low functional or absolute levels of C1 esterase inhibitor.
  • The most probable diagnosis in a man taking peanut and developing stridor, neck swelling, tongue swelling and hoarseness of voice is Angioneurotic Edema.
  • C1 esterase inhibitor deficiency is causative in a patient presenting with history of episodic painful edema of face and larynx.
  • Laryngopharyngeal reflux is the cause of pseudosulcus in the larynx in an alcoholic presenting with globus sensation in throat, cough and hoarseness.
  • Scleroma of larynx is caused by Klebsiella,Subglottic stenosis is a common complication,Treatment may include steroids.
  • Larynx is the most common site in respiratory tract for amyloidosis.
  • Epiglottis is the most common site in larynx for sarcoidosis.
  • Reflux laryngitis produces subglottic stenosis and Ca larynx.
  • A patient with burns die within 24 hours. Physical burn injury to the airways above the larynx could be the most probable cause.

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