Larynx ENT Lab. Asist. Univ. Dr.

Florentina Severin 2020

ANATOMY OF THE LARYNX

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

EXAMINATION OF THE LARYNX

1.Inspection

The thyroid cartilage prominence can be seen only at men. It moves upward on swallowing;
absence of this movement indicates fixation of the larynx by an infection or a tumor. Retracting of
the suprasternal notch on inspiration combined with inspiratory stridor points to laryngo-tracheal
obstruction by foreign body, tumour, oedema.

2.Palpation

The larynx is palpated by moving it lateral over the anterior vertebral bodies, producing
normal laryngeal crepitus. Palpation during swallowing allows on appreciation of the laryngeal
movement in deglutition. The thyroid lobes can be assessed by palpating them along on either side
of the trachea just below the larynx.

3.Laryngoscopy

a. Mirror examination – indirect laryngoscopy

The equipment required consists of a headlight (a head mirror or an external light source)
and a laryngeal mirror. The patient sits facing the examiner with a straight back, leaning slightly
forward at the waist. The laryngeal mirror is warmed and tested for temperature on the back on the
hand. The patient’s tongue is grasped using a compress, and the back of the mirror is used to elevate
the uvula. With the light focused on the mirror, the supraglottic and glottic structures can be
visualized. The patient is then asked to vocalize a sustained “i“ or “e”, thus tilting the epiglottis
forward and bringing the vocal folds into apposition.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

b.Endoscopic examination

Indirect laryngoscopy using rigid or flexible endoscopes provides superior visualization of

endolaryngeal structures, requires less compliance and facilitates documentation.

 Flexible fiber-optic laryngoscopy

After the patient’s nose has been decongested and anaesthetized, the tip of the instrument is
passed along the floor of the nose under permanent visualization into the nasopharynx. The patient
is asked to breathe through the nose and the endoscope is angled downwards, until the base of the
tongue and the supraglottic and glottic structures are visualized.

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 Rigid endoscopes
The technique of the procedure is identical to that of the indirect mirror examination.
Though it is performed more easily, it still requires patient cooperation. When applicable, indirect
laryngoscopy using rigid endoscopes offers an image quality superior to that of any other modality,
making it the best option for documentation purposes.

4.Direct laryngoscopy

Direct laryngoscopy aims the examination of the larynx by direct techniques in order to
evaluate the patient’s complaint or altered laryngeal function, to make a clinical diagnosis, either by
inspection or by biopsy a visible abnormality, and if possible to correct that complaint or to perform
a therapeutic procedure.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

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5.Stroboscopic examination

Stroboscopic examination shows an increase of the fundamental frequency with the

characteristic stop of the mucosal wave in the affected area, maintaining a normal wave progression
in the mucosa both anterior and posterior to it.

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6.Radiology examination

X-Ray examination

Plans views in the sagittal or lateral plane have limited value because of layered soft tissue
and bony shadows.

The X-Ray must be taken in full inspiration with the head in extension.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Imaging techniques - are becoming more precise and are now used routinely in conjunction
to complement the clinical and the endoscopic assessment of patients with laryngeal carcinomas.

CT scan

CT scan is currently the most useful imaging modality. The goal of CT scan is to accurately
assess the location and size of the primary cancer and to evaluate extension to the neck either
directly or through lymphatic metastasis.

Magnetic Resonance Imaging

MRI is used routinely, the advantage of a higher field strength being a better signal-to-noise
ratio and the possibility of faster sequencing. It is mandatory to use a receiving magnet of throat.
After contrast medium injection, all malignant tumors show a significant increase in signal in
comparison with the various surrounding structures because of the increased vascularization.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Fluorodeoxyglucose Positron Emission Tomography

To the morphological details depicted by CT, FDG-PET adds metabolic information.

Applied to patients suffering from malignant tumors of the upper aerodigestive tract, FDG-PET
allows depiction of even small malignant lesions.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

DYSPHONIA – CAUSES. Inflammatory diseases of the Larynx

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A. Acute laryngitis

A.1. Acute viral laryngitis

The larynx may became inflamed in isolation or as part of a general infectious process
which affects the whole respiratory tract.

When the larynx is only affected part, it may be due to vocal abuse or voice strain as well as
to exposure to irritant substances such as cigarette smoke or alcohol.

The symptoms are dysphonia, coughing and the sensation of globus.

A hoarse voice is the most common but on occasions there may be complete loss of voice
(aphonia).

The patients may also complain of pain on speaking and swallowing.

General malaise and slight pyrexia may be accompanying features.

Laryngoscopy shows the vocal cords to be red and swollen, often the whole larynx is
generally inflamed and also the neighboring pharyngeal or tracheal mucosa. Movements of the
cords are restricted but symmetrical, there is no paralysis.

Treatment consists on voice rest, analgesia, steam inhalations and gentle warmth applied to
the anterior neck. Linctus or cough suppressants may be soothing. Since viral infections are often
followed by secondary bacterial infection, antibiotics are indicated. Steroids are also indicated for
marked edema.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

A.2. Epiglottis

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It must be considered as a possible diagnosis in pyrexial children with a sore throat.

It affects the entire supraglottic area. The cherry-red swollen epiglottis, like a “thumb sign”,
leads to dysphagia, pain and increased temperature. Dyspnea and a sensation of stretching are
quickly very noticeable. The mouth falls open to allow the saliva that is too difficult to swallow to
dribble out.

Diagnosis is based on nasopharyngeal fibroscopy. In fact it corresponds to a septicaemia of

type B Haemophilus influenza, whose origin is to be found in the subglottic region.

This is an indication for urgent hospitalization. Intubation is indicated. Intravenous

antibiotherapy effective against Haemophilus influenza (cefotaxime) and steroid is given,
tracheotomy is rarely.

A.3. Croup/Acute Laryngotracheobronchitis

This condition is usually viral in origin but it is given by Staphylococcus, Haemophilus

influenzae, Streptococcus. It causes a diffuse inflammation of the airways. Often the child has had a
low grade upper respiratory tract infections.

Complication of subglottic laryngitis adds a septic status and dyspnea by obstructing the
larynx and trachea with pseudomembranes.

Aggravation of symptomatology consist in rising temperature, stridor associated with a

generalized deterioration status, and soon the child becomes toxic. High quality nursing and
continue monitoring are essential.

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A period of ventilation may be necessary, endotracheal intubation or temporary

tracheostomy may be required.

A.4. Spasmodic or stridulous laryngitis

There are various causes: allergy, inflammation, reflux or psychological influences. It occurs
mostly nocturnal, in short crises of dyspnoeic laryngitis, may be accompanied by a suffocating
cough with cyanosis. Oral corticotherapy may be used.

A.5. Laryngeal diphtheria

Today it's a rare disease. It is important to bear in mind as a different diagnosis since early
recognition and treatment with anatoxin and high class Penicillin or Erithromycin. The symptoms
are a hoarse voice, cough and later stridor which may progress to total airway obstructions. It may
also affect the oral cavity and pharynx with membrane formation, erythema and swelling of the
face. If there is any doubt in the diagnosis take a swab and treat as diphteria until proven otherwise.

A.6. Acute subglottic laryngitis

This is a very serious acute disease of early infancy, between the 1 st and 3rd years of age, is
the most frequent type of acute dyspnoeic laryngitis.

The disease is basically due to a viral infection (Parainfluenzae viruses, Rhinovirus,

Adenovirus and Echovirus), a bacterial origin is rare.

The diagnosis is clinical.

There is a previous common cold, followed by hoarseness, stridor leading to severe

respiratory obstruction depending on swelling of the mucosa and site, coughing will be raucous and
barking, cyanosis, perioral pallor and worsening of the symptoms due to a fear of asphyxia in
children.

Treatment should be started as soon as possible and it is based on oral corticotherapy. If

these measures failed over several days, and there is increasing dyspnoea, the child must be
hospitalized, emergency intubation or tracheotomy may be necessary.

B.Chronic laryngitis

Etiological factors are tobacco, alcohol, asbestos, nickel, wood dust, chrome, arsenic,
papilloma viruses.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

B.1.Chronic nonspecific laryngitis

Reinke's oedema

Presents hoarseness and deepening of the voice or diplophonia. The oedema can be found on
the upper face of the vocal cords, from the anterior commissure to the vocal processes, are generally
bilateral.

Patients with Reinke’s oedema are usually heavy smokers, vocal misusers and have a long
history of dysphonia.

Laryngoscopy shows a whitish, translucent aspect, fusiform oedema in both vocal cords.
Stroboscopic examination shows a complete glottic closure with asymmetric movement of the vocal
cords, and an overexpressed mucosal wave.

Recommended measures are to avoid irritants and follow speech therapy. In advanced cases
surgery is indicated.

B2. White laryngitis

Occurs in three types: leukoplakia, white pachydermia and horny papilloma in adults.

Leukoplakia

Leukoplakia is a clinical term covering lesions of various different histological grades. It

may be premalignant and requires histologic investigation. Symptoms are hoarseness, feeling or
foreign body in the throat and a desire of clear the throat.

Microlaryngoscopy shows the leukoplakic lesion (flat, like a candle-wax, of pearlescent or

grey color), mucosa of the vocal cords to be rough, thickened and altered in color.

Treatment is surgical.

White pachydermia

The lesion has a tumor-like aspect, surface is irregular. It is of a chalky greyness with clearly
defined limits. The suppleness of the vocal cords may be altered and it feels hard when palpated.
Horny papilloma

The distinction between horny papilloma and pachydermia is most often histological
(exophytic, spicular surface is characteristic). The free edge of the vocal cord may be affected,
showing a sawtoothed aspect.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

B.3. Specific forms of chronic laryngitis

Laryngeal tuberculosis

It generally occurs as a condition secondary to a pulmonary infection. The pulmonary

infection may pass unnoticed.

Symptoms are hoarseness and coughing persisting and pain on swallowing radiating to the
ear.

Laryngoscopy and microlaryngoscopy shows monocorditis characterized by redness and

thickening, with small ulcerations of different parts of the larynx, exudative oedema of the vocal
cords.

Treatment is antituberculous drugs.

Laryngeal syphilis

It's a manifestation of oropharyngeal syphilis in the secondary generalized stage of the

disease. It is caused by Treponema pallidum.

Mucous plaques or hoarseness and mucosal swelling at laryngoscopy.

The cartilage is destroyed in a gumma in stage III.

Treatment is a dermatological ones.

Scleroma of the Larynx

Laryngoscopy shows pale-red swellings and granulations with crusts develop mainly in the
subglottic space.

Hoarseness, cough and increasing stridor.

Treatment is tracheotomy followed by treatment of laryngo-tracheal stenosis.

Laryngeal amyloid

Tumorous, polypoid lesions covered by smooth mucosa appears in the larynx in this
dysproteinemia. Hoarseness and respiratory obstruction.

Laryngoscopy shows the lesions on the vocal cords and the subglottic space.

Surgical removal is required.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

TRACHEOTOMY

A hole is made in the front wall of the trachea and a tube maintains the airway. Most
commonly, this is performed as an elective procedure in patients who require long term assisted
ventilation or as a part of head and neck or airway operation.

Indications for tracheotomy

1. Mechanical airway obstruction due to:

 tumors or congenital anomalies of the upper respiratory or digestive tract;

 trauma of the larynx and trachea;
 bilateral recurrent nerve paralysis;
 aspiration of a foreign body;
 inflammation causing oedema of the larynx, trachea.

2. Obstruction of the airway by secretions or inadequate respiration or both:

 retention of secretions, ineffective coughing and self during or after thoracic or abdominal
surgery, vomiting or aspiration of stomach contents, coma;
 alveolar respiratory insufficiency, during or after drug intoxication and poisoning, paralysis
of the respiratory musculature, chronic obstructive lung diseases;
 retention of secretions with alveolar respiratory insufficiency in central nervous diseases,
eclampsia, postoperative neurosurgical coma, air or fat embolus.

Tracheotomy reduces the dead space by 70 to 100 ml.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Complications are hemorrhage by venous congestion or by goiters or tumors overlying the

trachea. Damage to the cricoid cartilage causes a cricoid stenosis. Damage to the pleura causes
pneumothorax.

Other complications are emphysema, tracheal stenosis, cervical cellulitis, difficulty with
decannulation.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

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How to perform a temporary tracheostomy:

1. First pass an endotracheal tube if it is possible.

2. Hyperextend neck by placing something beneath the
shoulders.
3. Horizontal or vertical skin incision centered two finger below
thyroid cartilage and two finger breadths above sternal notch.
4. By blunt dissection open a vertical plane in the midline
between the strap muscles.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

5. Retract strap muscles.

6. If thyroid isthmus is in the way, either retract it or divide between two clamping forceps.
7. Secure hold on trachea with temporary suture.
8. Divide trachea transversely between the second and third or third and fourth tracheal
cartilages. Alternatively at the children, a vertical incision can be made.
9. Aspirate blood and mucus from trachea.
10. Insert tracheostomy tube.
11. Tie retaining tracheostomy tapes with the neck flexed.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

In recent years percutaneous tracheostomy has become more frequent for the anesthetists
working in intensive treatment units.

The technique involves passing a needle into the tracheal lumen through which is passed a
guide wire. Dilators of increasing size are passed over the wire until a tracheostomy tube can be
inserted.

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

TRACHEOSTOMY TECHNIQUE

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Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

TRACHEOSTOMY CARE

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 Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

LARYNGOTOMY

A hallow tube is introduced into the lumen of the larynx via a percutaneous route. The
easiest and most commonly available instrument at least in the hospital setting, is a wide bore
intravenous cannula. This is inserted into the neck, in the midline through the cricothyroid
membrane. Its position can be confirmed when bubble will be seen. Once in position it should be
secured with tape and oxygen supply attached.

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Larynx ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

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