د. حسين جاسم
L.4 Other diseases of the larynx
  Mucous retention cysts:

 It's usually seen when mucous glands are abundant; on the epiglottis, the ventricular band and the upper part of the vestibule.
Treatment: by surgical resection or marsupialization.

Polypus of the larynx:
It’s a smooth sessile or pedunculated tumor of the vocal cord. It probably represents a localized area of chronic oedema in the lax tissue of the Reinke's easily stripped off endoscopically with a laryngeal forceps.
          Reinke's space: it’s a space lies immediately under the epithelia of the larynx and superficial to the elastic layer.

 Laryngocele
It's a bulbous air containing prolongation of the laryngeal ventricle and saccule. Its sometimes bilateral, and is more common in men with a peak incidence of 50-60 years old.
Types:
1. Internal: This type is confined to the interior of the laryngeal framework & present under the mucosa of the valleculae. The cyst can be uncapped endoscopically.
2.  External: here the enlarging herniation finds its way outside the laryngeal structures by piercing the thyrohyoid membrane. 
3.  Combined: (internal and external).
 The external type can be presents as a swelling in the thyrohyoid region which   expand on coughing & empties on digital pressure, while the internal type is seen as a smooth submucosal swelling in the valleculae with a muffled and hoarse voice.
Diagnosis:  radiographic examination delineates the air space during Valsalva maneuver.
Treatment: is required to relieve voice changes.

Oedema of the larynx:
 This term refers to an oedema of the laryngeal mucosa almost always above or bellows the true vocal cords but may occur in the subglottis or supraglottis.
Etiology:                                                                                                                              1. Infection: laryngitis (especially streptococcal or diphtheria) or spread of   infection from nearby source like in peritonsilliar abscess, Ludwig's angina or retropharyngeal abscess.
2. Trauma: foreign body & intubation.
3. Tumors and radiotherapy may cause oedema.
4.  Perichondritis.
5.  Allergy: Angioneurotic oedema or Quinke's oedema. 
6.  Intrathoracic diseases cause venous stasis.
7. Generalized diseases: Cardiac failure and renal diseases.
Clinical features:
1.	Dyspnoea and sometimes cyanosis.
2.	Inspiratory stridor.
3.	Hoarseness of voice.
4.	Oedema of the lax laryngeal tissues is seen on the indirect laryngoscopy.
Treatment:
1.	Rest in sitting position.
2.	Nebulised adrenaline, steam inhalation and oxygen with helium mixture may be helpful.
3.	Steroids: hydrocortisone 100 mg intravenously.
4.	Antibiotics.
5.	Adrenaline 1/1000 in a dose of 0.5 ml for adults and 0.1 ml for children subcutaneously.
6.	Tracheostomy may be done for respiratory distress.
                                                                                                                                                                                                             Laryngismus stridulus                                                                                                   an episode of a pyrexail laryngeal stridor in young children (first decade) usually in boys and it commonly begins in winter.                                                                                                      Etiology:                                                                                                                                                                1. it occurs more frequently in ill health or malnutrition which is prevalent in   children; also associated with Rickets.                                                                                           2. Infection: whooping cough and sepsis in the upper respiratory tract.                                                      3. Spasm in tetany & Calcium deficiency.                                                                                                               4. Passive obstruction by flabby soft tissue of the larynx.                                                                                        Clinical features:
There are stridor, cyanosis and carpopedal spasm but after a minute or more the attack suddenly ceases. Death has very rarely followed the breath the breath holding attack.                                  Treat ment:
- During the attack respiration can be stimulated by splashing with cold water & pulling the tongue forwards.
-Attention to the diet (vitamins) & exercise.

Paralysis of the larynx
Etiology: Paralysis of the motor nerves of the larynx maybe caused by:
1. Lesions in the central nervous system.
2. Lesions of the peripheral motor nerves to the larynx; these are the vagus trunk, the superior & recurrent laryngeal nerves. The condition is usually unilateral and the left side being more often affected owing to the longer course of the left recurrent laryngeal nerve.
Paralysis of these nerves results from:
1.  Pressure or stretching due to a disease.
2. Injury usually surgical.
    3. Malignant disease of the thyroid, esophagus, bronchial tree, nasopharynx, and lymph nodes.
     4.   Peripheral neuritis of infective or toxic form by chemical toxins (Lead), infective toxins as in diphtheria, typhoid fever, influenza or avitaminosis (leading to polyneuritis as in beriberi disease).
Clinical features:                                                                                                              A. Effect on the voice & respiration:
      Unilateral recurrent laryngeal nerve paralysis 
     - Respiration is unaffected.
   - The voice may be affected and hoarseness may occur.
  Bilateral recurrent laryngeal nerve paralysis 
 - Severe dyspnoea is produced. 
  - The voice may be good if the cords are paramedian.
  Superior laryngeal nerve paralysis 
    - Leads to slack wavy cord.                                                                                                       - The condition rarely occurs without a recurrent laryngeal nerve paralysis
   -  It may be unilateral or bilateral.
   - The voice is rough & tires quickly.
    - Respiration is unaffected but if associated with recurrent laryngeal nerve the vocal    cord is in lateral position and inhalation of food may occur.
B. effect on position of the cord:                                                                                  
      In recurrent laryngeal nerve paralysis:
       - Inc vocal cord is in median position either unilateral or bilateral.
     In combined paralysis of superior and recurrent laryngeal nerves:                                          - The vocal cord will be in cadaveric position (position midway between median and abduction position).
Treatment:
1.	In bilateral paralysis dyspnoea may occur so tracheostomy is indicated. 
2.	Arytenoidectomy is indicated in bilateral cases either endoscopically or by external approach. 
3.	In unilateral cases improving the voice by various phonosurgical procedures can be done. 
4.	 Spontaneous recovery may occur after the onset of the paralysis up to 2-years.

Functional paralysis (hysterical aphonia):
    Functional paralysis of the adductors during phonation occurs most often in emotionally unstable individuals particularly in young women.
Clinical features:
1.	Aphonia sometimes is complete but more often the voice is reduced to a whisper, onset and recovery is sudden. 
2.	Cough is normal.
Treatment:
1. Psychological assessment is indicated.
2. Speech therapy can be of value.

Dysphonia plica ventricularis
Etiology:
Ventricular hand voice is produced by the apposition of the false cords in phonation; this may be part of the attempt to compensate other vocal disabilities.
Clinical features:
 The voice is unpleasant producing a low rough sound.
Treatment:
1.	Voice rest is essential. 
2.	Speech therapy may help.