MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ LARYNX and HYPOPHARYNX ENT Clinic of Masaryk university, Brno Faculty St. Ann Hospital Head: Ass.prof. Gál Břetislav, MD, Ph.D. Pekařská 53, Brno , 656 91 Air passages ANATOMY of the larynx LARYNX - function Function: vital (respiration), social (phonation), protective of lower airways (reflexes: closure of aditus, glottis, cough reflex etc.) Frontal section through the larynx 1. Aryepiglottic fold, 2. recessus piriformis, 3. vocal cord, 4. anterior commisure, 5. thyroid cartilage, 6. cricoid cartilage, 7. thyroid gland, 8. trachea. (Taken from Becker, Neumann, Pfaltz. Ear, Nose and Throat Diseases 1989) Larynx 3 non-pair cartilages (thyroid, cricoid and epiglottis) 3 pair cartilages – arytenoidea, corniculatae (Santorini), cuneiformes (Wrisbergi) Laryngeal muscles Muscle moving larynx: infrahyoid (sternohyoideus, -thyreoideus, thyreoihyoideus, omohyoideus), suprahyoid Ones´own laryngeal muscles: Abductores (open) – m. cricoarytenoideus post. (POSTICUS) Adductores (close) – cricoaryteoideus lat., arytenoideus transversus Tensores (stretch) – m.cricothryeoideus (r. ext. N. laryngici sup.), m. vocalis Muscles moving aditus laryngis m. aryepiglotticus, thyreoepiglotticus Schema of function of laryngeal muscles A-cartilago arytenoidea C-cartilago cricoidea T-cartilago thyroidea 1.-m. thyreoarytenoideus /vocalis/ "internus" 2.-m. cricoarytenoideus lateralis 3.-m. crycoarytenoideus posterior "posticus" 4.-m. arytenoideus transversus "transversus" 5.-m. cricothyreoideus MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Internal ligaments and connective tissue membranes (membrana fibroelastica laryngis=quadrangularis + conus elasticus Conus elasticus History of laryngeal disorder Breathing disorder inspiratory stridor - stenosis localized upwards from bifurcation. Symptoms of usage of auxiliary breathing muscles (retraction of jugulum). There is longer inspirium as exspirium. General symptoms agitation with anxiety, loss of orientation, loss of conscience, tachycardy, usually bradypnoe. Auscultation the most noisy stridor above stenosis. Skin colour pale, then cyanotic. Growing exhaustion, alarm face. Voice disorder hoarseness – lasting longer then 14th days in male of risk group (smoker older 40 y) should by evaluated by otolaryngology. Dyspnoe Respiratory Extrathoracal origin Neuromuscular Psychogenic Cardiovascular Obstructive Restrictive Metabolic Uremy Hematologic Toxic Evaluation of dyspnoe ▪ Subjective scales ▪ (quasi) objective scales 0 10 no dyspnoe the vorst dyspnoe ⚫ no dyspnoe (0) ⚫ dyspnoe after greater physical labour than usually (1) ⚫ dyspnoe after usual physical labour (2) ⚫ dyspnoe at any physical action (3) ⚫ dyspnoe in no action (4) Pathophysiology of obstructive respiratory insufficiency ▪ inspiratory dyspnea ▪ stridor - 400-800 Hz, the most proximal stenosis, the lower frequency is ▪ Involvement of auxiliary breathing muscles ▪ dysphony ▪ cough, sometimes odynophagia. Stage of compensation – prolongation of regular inspiration, good blood supply, possible causal therapy Stage of decompensation– mild tachypnoea, motoric agitation, hypercapnia, anoxemia, respiratory acidosis, larynx in anteflex position, anxiety, exhaustion. Hypercapnia leads gradually to inhibition of breathing center Stage of suffocation – air flow with turbulence, decreased breath volume, reanimation is necessary Obstructive respiratory insufficiency 1. Larynx and superior part of trachea - „laryngeal“ dyspnea inspiratory stridor - stenosis localized upwards from bifurcation. Symptoms of usage of auxiliary breathing muscles (retraction of jugulum). There is longer inspiration as expiration. General symptoms - agitation with anxiety, loss of orientation, loss of conscience, tachycardia, usually bradypnea. Auscultation the most noisy stridor above stenosis. Skin color pale, then cyanotic. Growing exhaustion, alarm face. 2. Distal part of airways. Expiratory stridor - longer expiration Methods of investigation of larynx • Inspection • Palpation (crepitation, emphysema) • Indirect laryngoscopy • Direct laryngoskopy • Flexible • Rigid • Microlaryngoscopy sec Kleinsasser • Stroboscope (high frequency movies, allowing scientific analysis of the laryngeal function, especially of the vocal cords • Tomography • CT Laryngoscopy direct - flexible nose-endoscopy (laryngoskopy) Rigid endoskopy of the Larynx Rigid laryngoscopy (according to Stuckrad and Kleinsasser) Microlaryngoscopy sec. Kleinsasser • general anesthesia • chest holder • microscope Stroboscopy Tracheo-bronchoscopy rigid vs. flexible Transglottic cancer spreading into preepiglot. space, subglottic spread Congenital laryngeal anomalies Laryngomalacia – dyspnea, dysphonia, dysphagia. Unusual weakness of the supraglottic laryngeal skeleton Laryngoceles – lie within the larynx in the vestibular fold – dyspnoe, dysphonia Atresia and membranes Laryngitis acuta (restricted x diffused) Abscesus epiglottidis Acute supraglottic laryngitis - epiglottitis • Hemophilus influenzae • inspiratory stridor • dysphagia • Antibiotic treatment • steroids • tracheal intubation • tracheostomy Acute subglottic laryngitis • viral infection • rapid growth at night • cough • inspiratory stridor, inspiratory dyspnea • steroids, sedation, ATB, • Microclimate (steam inhalation) Angioneurotic swelling of larynx Laryngitis chronica Diphteria Laryngitis chronica hyperplastica Laryngeal polypus Polypus (granuloma) – right vocal cord Various benign findings on the vocal cord LARYNGITIS CHRONICA-OEDEMA REINCKE Oedema laryngis Papilomatosis laryngis, HPV virosis Intubation injury, granulomas • in voice proffesionals • microlaryngoscopy • strict voice rest Noduli cantatorii vocal abuse, dysphonia, pain on speaking Cystis epiglottidis Ca in situ bilat Ca spino plicae voc. l.sin. T1 Ca spino plicae voc. l.sin. T2 Ca spino plicae voc. l.sin. T3 Ca spino sinus piriformis Ca glottis Disorder of laryngeal motivity Seeman-Rosenbach rule – in insidious toxic influence on recurrent nerve - first damaged fibers phylogeneticly younger (for m. posticus) Laryngeal injury Laryngeal injury – external vs internal Commotio Contusion Fractures of laryngeal cartilages Symptoms – according to degree of laryngeal injury • Dyspnea • Dysphonia • Bleeding – not very extensive • Dysphagia – in connection to injury of pharyngeal and esophageal muscles Hematoma of the right vocal cord Fracture of laryngeal skeleton Laryngeal fracture with a mucosal hematoma and dislocation of the arytenoid Laryngeal fracture, neck emphysema External layngeal injury, first physician aid • Anti- shock treatment • care for airway • Management of bleeding Light injury (blunt trauma) conservative treatment- 1) antihistaminic, corticosteroids, antibiotics, analgesics', oxygen 2) cold compress on neck 3) in dyspnea – coniotomy, intubation, tracheotomy Tracheotomy Indication for tracheotomy „Classic“ – to bridge stenosis caused by inflammation, tumor, foreign body, injury, palsy „Prophylactic“ – if we suppose possible stenosis (big surgery, swelling, bleeding, irradiation…) „Anesthesiologic“ long term intubation of patient (prophylaxis of intubation injury, aspiration; reduction of dead space in airway, suction…etc.) Tracheotomy Position in tracheotomy Skin section – horizontal or vertical Thyroid gland isthm resection Trachea opening Punction, dilatation tracheotomy - Ciaglia (1985) PDT – Griggs (1990) Complication in tracheotomy During surgery bleeding, dyspnea, lost of orientation, Early post surgery emphysema, embolism, mediastinal emphysema, pneumothorax, inflammation bleeding, no corresponding opening in trachea and on the skin – problems with exchange o tracheal cannula Late post surgery stenosis