Laryngeal Examination and Associated Conditions

CASE HISTORY

Complaints at OPD Level

  • Change in voice
  • Pain in laryngeal area
  • Respiratory obstruction
  • Cough and expectoration
  • Odynophagia (Painful swallowing)
  • Dysphagia (Difficulty in swallowing)
  • Foreign Body sensation in throat
  • Fever
  • Weight loss
  • Loss of appetite

Voice Disorders

Types of Voice Changes

Change in Voice Disorders
  • Hoarseness of Voice: Roughness of voice.
      - Causes: Acute inflammations, chronic inflammations, tumors, trauma, paralysis, fixation of cords, etc.
  • Aphonia: Inability to produce voiced sound.
      - Types of Aphonia:
        - Functional Aphonia/Hysterical Aphonia/Psychological Aphonia: More common in females (ages 15-30 years), characterized by sudden onset and absence of laryngeal symptoms.
        - Puberphonia/Mutational Falsetto Voice: Seen in boys who are emotionally immature.
        - Diplophonia/Dysphonia Plicae Ventricularis: Produces an unpleasant, rough, low-pitched voice, occurring due to false vocal cords; caused by unilateral complete paralysis of the vocal cord.
  • Phonasthenia: Weakness of voice due to abuse and misuse of voice, leading to fatigue of phonatory muscles (Thyroarytenoid & Interarytenoid).

Laryngeal Examination

Mogiphonia

  • Ordinary conversational voice remains unaffected, but professional speaking or singing becomes painful and impossible.
  • History Taking:
      - Duration
      - Onset (Gradual/Sudden):
        - Slow - Acute laryngotracheobronchitis
        - Insidious - Laryngeal diphtheria
      - Loud/Soft voice
      - Diurnal Variation: Patients may become aphonic toward the end of the day if they have chronic laryngitis.
      - Voice Characteristic (Clear/Husky/Hoarse/Hot Potato Voice)
      - Whether the voice is fatigable or not

Nasal Resonance Disorders

Hyponasality/Rhinolalia Clausa
  • Lack of nasal resonance for letters/words normally resonated in the nasal cavity.
      - Causes: Blockage of nose/nasopharynx (common cold, nasal allergy, nasal polyp, nasal growth, adenoids).
Hypernasality/Rhinolalia Aperata
  • Occurs when certain words that should not resonate through the nose are resonated through the nose.
      - Causes: Failure of the nasopharynx to separate from the oropharynx or abnormal communication between oral and nasal cavities.

Speech Disorders

Stuttering
  • Abnormal fluency of speech characterized by hesitation to start, repetition, prolongation, or blocks in speech flow.
Phonic Spasm
  • Occurs in adults who use their voice professionally, often linked to partial paralysis of the Superior Laryngeal Nerve (SLN) and Recurrent Laryngeal Nerve (RLN).
  • Speech becomes interrupted due to vocal cords pressed together after a few words, leading to sound emission.

Clinical Examination of the Larynx

Methods of Examination

  1. External Examination:
       - Inspect and palpate lymph nodes, Adam's apple, laryngeal crepitus.
  2. Internal Examination:
       - Techniques utilized include Indirect Laryngoscopy, Direct Laryngoscopy, Fibroptic Laryngoscopy, Rigid Laryngoscopy.
Imaging Techniques
  • X-ray of Neck, Larynx, Pharynx.
  • CT-scan, MRI, PET-CT & PET-MRI.

External Examination Details

  • Inspections: Neck for swelling or widening, shape of Adam's apple affected by laryngeal carcinoma.
  • Palpation of Cartilages: Tenderness, crepitus, abnormal movement checked on hyoid, thyroid, cricoid cartilages.
  • Lymph Nodes Examination: Performed while standing at patient's back with neck slightly flexed for muscle relaxation.
       - Levels in Cervical Lymph Node Classification:
         - Level 1A - Submental lymph nodes
         - Level 1B - Submandibular lymph nodes
         - Level 2 - Upper Jugular group nodes
         - Level 3 - Middle Jugular group nodes
         - Level 4 - Lower Jugular group nodes
         - Level 5A - Superior to cricoid cartilage
         - Level 5B - Inferior to cricoid cartilage
         - Level 6 - Anterior compartment from hyoid to suprasternal notch
         - Level 7 - Tracheoesophageal groove nodes and superior mediastinal nodes

Laryngeal Crepitus

  • Normal sound (grinding) when moving the thyroid cartilage side to side.
  • Absence (Trotter’s sign or Boeke's sign) indicates potential pathologies like postcricoid carcinoma or laryngeal trauma.

Indications for Examination

  • Diagnostic:
      - Change in voice, Foreign Body sensation, Odynophagia, Dysphagia, Throat Pain, Stridor, etc.
  • Therapeutic:
      - Foreign Body removal, Intubation, Biopsy of growth in hypopharynx or vocal cords, Placement of gastric tube.

Internal Examination with Laryngoscopy

Common Indications
  • Indicated for chronic cough, laryngotracheal dyspnea, dysphonia, voice changes, persistent throat pain, swallowing problems, and aspiration symptoms.
  • Recommended for adult patients with recurring ear pain, hoarseness, and sore throat lasting over 2 weeks because of cancer risk.
  • High-risk patients (long-term tobacco/alcohol users) require careful examination.
Laryngoscopy Types
  • Indirect Laryngoscopy: Often uses mirrors to view vocal folds; less common today.
  • Flexible Laryngoscopy: Uses a flexible fiberoptic scope inserted through the nose after numbing; simple procedure taking a few minutes.
  • Direct Laryngoscopy: Performed under general anesthesia in an operating room; allows deep examination and possible tissue biopsy.

Emergency Laryngoscopy

  • Important for evaluating difficult airways in emergencies, performed in cases of angioedema, uncontrolled epistaxis, cervicofacial trauma, stridor, or suspected foreign body ingestion.

Angioedema and Stridor

  • Angioedema:
      - Rapid swelling of deep skin layers (face, lips, tongue, throat), potentially leading to breathing restrictions due to histamine or bradykinin triggers.

  • Stridor:
      - High-pitched or harsh sound indicating airway obstruction, most severe during inhalation and requiring immediate attention in emergencies.

Contraindications and Special Considerations

  • Laryngoscopic examination should be performed by skilled operators; inadvertent trauma can worsen swelling and risk respiratory arrest.
  • Children can undergo laryngoscopy, but tolerance may limit examination extent. Special caution is needed in cases of acute epiglottitis.

Indirect Laryngoscopy Technique

  • Equipment Required: Laryngeal mirror, adequate lighting, gauze sponges, and local anesthetic.
  • Procedure:
      - Conduct examination in a well-lit room using a headlight.
      - Prevent mirror fogging by warming the mirror.
      - Patient positioned upright; use gauze to hold the tongue.
      - Visualize larynx while ensuring not to induce gag reflex.
Structures to Examine
  • Median glosso-epiglottic fold, valleys, vocal folds, trachea, and other anatomical features.

Position and Movement of Vocal Cords

  • Observe position during different actions (rest, phonation, inspiration, coughing).
  • Types of vocal fold paralysis to assess: Unilateral incomplete, unilateral complete, bilateral incomplete, bilateral complete paralysis.

Other Diseases Affecting Vocal Cords

  • Viral Laryngitis: Presents as diffusely erythematous laryngeal mucosa.
  • Chronic Laryngitis: Shows reddened hyperemic laryngeal mucosa with loss of true vocal cord whiteness.
  • Keratosis: Thickening of squamous epithelium causes white appearance of vocal cords.
  • Vocal Nodules/Polyps: Characterized by benign swellings; polyps may appear as bumps or growths on vocal folds.

Flexible Fiberoptic Laryngoscopy

  • Modified direct laryngoscopy technique useful in challenging cases where mirror examination is ineffective.
  • A flexible fiberoptic scope provides a good view of larynx, laryngopharynx, subglottis, and upper trachea under local anesthesia.

Rigid Laryngoscopy

  • Utilizes a rigid fiberoptic telescope providing a clear, wide-angle view of the larynx and laryngopharynx.
  • Requires local anesthesia in patients with active gag reflex.

Stroboscopy

  • A crucial tool for assessing vocal fold vibration and health.
  • Utilizes stroboscopic light to "slow down" vocal fold vibration for assessment.
  • Equipment includes stroboscopic light source, microphone, and endoscope.
  • Important for observing pliability and vibratory function of vocal folds, with its imaging resembling a flipbook effect.

Imaging Techniques in Laryngeal Assessment

  • Utilized primarily for staging neoplasms, trauma evaluation, and soft tissue assessment.
      - Imaging Modalities:
        - X-Ray, CT, MRI, PET-CT, PET-MRI.
  • CT is favored for visualizing larynx/hypopharynx masses, while MRI complements when further detail is required.

Laryngeal Electromyography (LEMG)

  • Evaluation for vocal fold immobility and diagnosis of neuropathies.
  • Provides insights into neuromuscular conditions, differentiating nerve versus muscle disorders.
  • A needle electrode is inserted into specific laryngeal muscles to measure activity related to voice production, breathing, and swallowing.

Summary of Procedure Rationales

  1. Functionality: LEMG is not routine as standard exams address anatomy, while LEMG measures electrical activity in muscles, requiring suspicion of nerve damage.
  2. Invasiveness: The invasive nature requires specialized expertise, elevating complexity compared to standard examinations.
  3. Diagnostic Approach: LEMG focuses more on function (voice, swallowing) rather than identifying surface lesions or inflammation.

Conclusion

  • These comprehensive approaches to examining laryngeal conditions involve interdisciplinary understanding and careful evaluation to ensure accurate diagnosis and management of voice disorders, laryngeal diseases, and airway problems.