epiglottitis acuta
Laryngitis acuta subglottica
Phonosurgical procedures
Michaela Máchalová
LF MU Brno, KDORL FN Brno
epiglottitis acuta
o life-threatening condition
o Bacterial infection – caused by
Haemophilus influenzae group B
o occurs in children 1 – 6 years old
o rapidly progressing phlegmona
epiglottis, septikemia
o predisposition – physiologically lower
immunity against encapsulated
bacteria in this age
epiglottitis acuta – clinical state
o sore throat
o swallowing difficulties, salivation
o Increasing dyspnoe
o paleness, forced forward bending
o subfebrilie event. febrilie
o silent voice, slight cough
o fast progression (during hours)
epiglottitis acuta - diagnostics
o Aspection epiglottis – laryngeal
mirror, examination using tongue
depressor (pressing of tongue root)
o epiglottis is edematous, enlarged,
reddish
o saliva (or mucus) accumulate
pathologically in hypopharynx
o do not lay the child down!
epiglottitis acuta - therapy
o careful transportation to hospital in
sitting position
o endotracheal intubation
o children ICU
o intravenous aplication of ATB –
cephalosporins of 2nd or 3rd
generation
o Taking of hemoculture
epiglottitis acuta - prevention
o Vaccination against Haemophilus
influenzae, group B – in CZ part of
hexa vaccine since 2001 => led to
elimination of this disease
Laryngitis acuta subglottica
o Swelling of tissue in suglottic region,
which is the thinnest part of lower airway in
small children (subglottic space in infants is about 4
mm in diameter reduction of 1 mm decreases lumen of
lower airways by 65% in comparison with adult)
o Caused by viruses (parainfluenza,
adenovirus, RS virus)
o This disease can be partly influenced by
allergens
o Frequent occurance in night, more in winter
o Usually affects infants and pre-school
children
Laryngitis acuta – clinical state
o Occurs suddenly in healthy people, or
follows infection in upper airways
o inspiratory dyspnoe with stridor
o Barking cough
o Rough voice or hoarseness
o Normal or slightly increased body
temperature – NO FEVER
o Retraction of jugulum, intercostal
spaces, epigastrium
o unrest, cyanosis, greyness of skin
Clinical state evaluation - Downes
score method
Symptom 0 point 1 point 2 points
auscultation Normal decreased,
crackles
silnece
Stridor none Inspiratory inspiratory
& expiratory
Breathing
effort
Free
breathing
Jugular
retraction
Retraction
of chest
cough none rough Barking, dry
Cyanosis none Air
breathing
O2
breathing
Downes score
o < 3 points – home care
o 3 - 4 points – hospitalization in
inpatient department
o 5 – 7 points – hospitalization in ICU
o > 7 points – if the patient’s state is
not improving after 20 min since drug
application – endotracheal intubation
is necessary – cannula diameter have
to be smaller than usually, artificial
pulmonary respiration
Laryngitis ac. - diagnostics
o assessment of children’s clinical state
o ORL examination – acpection of larynx –
direct or indirect laryngoscopy
o Dif. Diagnosis – necessary to exclude
epiglottitis ac. and tracheobronchitis
Laryngitis ac. - therapy
o Inspiration of cold gas mixture
o Inhalation of adrenaline (epinephrine)
(5mg in 5 ml 1/1 0,9% NaCl)
o Dexamethason i.v., i.m. 0,6 mg/kg
o Prednison p.r., p.o.
o antihistamines (Promethazin 1-
2mg/kg/day)
o Non-codeine antitussives (drugs not
leading to respiratory depression)
Laryngitis ac.
o Often recurrences
o Dif. diagnosis: exclude allergies, GER,
foreign body in lower airways
o In case of more than 3 recurrences in
a short period or atypical progression
laryngotracheobronchoscopy in GA is
indicated
Larynx, laryngeal muscles paresis
o MYOPATHIC – cancer- or
inflammation-induced damage
o NEUROPATHIC – damage can be on
level:
o cerebral
o bulbar
o peripheral - congenital or acquired
Paresis of laryngeal muscles
o N. LARYNGEUS SUP. – supplies m.
cricothyreoideus (vocal cord tensor),
sensitive innervation supraglottic
region
o N. LARYNGEUS INF. – RECURRENS –
motoric supply of the other internal
laryngeal muscles (abductors,
adductors, tensors), sensitive
innervation of glottis and subglottis
Voice disorders
o Suddenly occuring
o Gradually progressing
o Inflammations
o Tumors
o Innervation defects
o Permanent organic changes – scars
o Congenital abnormalities
o Malfunctions
Phonosurgical procedures
o Treatment methods of voice
malfunctions by surgical means
o developed in 1980’s
o Used in patients not responding to
conservative phoniatric treatment
o However co-operation of ENT-surgeon
and phoniatrician is still necessary!
Phonosurgical techniques
o TRANSORAL
PHONOMICROSURGERY
o Suspension microlaryngoscopy
(1960’s)
o Therapy of lesions in vocal cords
region (“singer” nodules, Reinke’s
oedema, polyps, leukoplakia)
Phonosurgical techniques
o METHODS USING VOLUME
ENLARGEMENT IN ATROPHIC/PARETIC
CORDS
o Atrophy of m. vocalis, in elderly people,
concave edge of vocal cords = gap between
vocal cords is present during phonation
o Paresis caused by lesion of n. laryngeus
recurrens – paramedial position of vocal
cord
o Volume enlargement by implantation of
adverse material (in past teflon, nowadays
autologous fat), irreversible, can be
performed ambulatory
Phonosurgical techniques
o SURGERY OF LARYNGEAL SKELETON
o Changes position or tonus of vocal cords
o 4 types of THYROPLASTY
o I. lateral compression of cord (causes shift
to medial position)
o II. lateral expansion of cord (causes shift to
lateral position)
o III. shortening of vocal cord
o IV. Prolongation of vocal cord
THYROPLASTY I
o lateral compression of vocal cord – in
paretic or atrophic cords (paramedial
position of cord – symptoms: hoarse voice,
dyspnoe, voice weakness),
o medialisation of vocal cord by implant,
which is inserted between cord and thyroid
cartilage through window in thyroid cart.,
size of implant is individually modified,
operation is reversible, performed in LA,
voice improvement by more than 90%
Change of voice pitch
o Thyroplasty III
o Lowering of voice pitch – in mutation
disorders, dysphonia caused by
increased stiffness of cords in
transsexual of female-to-male type
o Leads to shortening of vocal cords
and thus lowering of their tonus
Change of voice pitch
o THYROPLASTY IV
o Increase of voice pitch – virilization in
women, or in transsexuals male-to-
female
o Leads to prolongation of cords and
thus increasing their tonus
Reinnervation of n.laryngeus
recurrens
o Direct anastomosis end-to-end
o anastomosis using graft
o reinnervation using neuromuscular
junction
o technically difficult, in GA
o Effect of surgery is unsure, becomes
evident in 3-4 months
Spastic dysphonia
o Tonic or clonic spasm of vocal cords
adductors
o Symptoms: effortful, rough,
trembling voice
o purpose is to lower vocal cords tonus
o Botulotoxine injections into vocal
cords are used
o Temporary effect, can be repeated,
ambulatory technique
Methods in people after laryngectomy
o partial LE – relaxation and shift of
vestibular cord to the remainig vocal
cord
o total LE – implantation of voice
prosthesis to artificial
tracheoesophageal fistula – valve
enables one-way flow of air from
trachea to esophagus → pharynx →
mouth (in mouth occurs vocal
articulation)