benign lesions of the larynx – swallowing disorders€¦ · benign lesions of the larynx –...
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Benign lesions of the larynx – swallowing disorders
SemmelweisUniversityDept.ofOtorhinolaryngologyHeadandNeckSurgery
Anatomy I. – the cartilageous trachea and larynx
Anatomy II. – the lumen of the larynx
Anatomy III. – the muscles of the larynx
• 1. „Outer muscles”: M. sternothyreoideus, m. thyreohyoideus, m. constrictor pharyngis inf.(m.thyreo- és cricopharyngeus)
• 2. „Inner” muscles: a: abductors – glottis opening b: adductors – glottis closure c: extensors – tense the vocal chords • 3. Muscles with no direct attachment to the larynx (m.
sternocleidomastoideus,...)
Muscles I. – the abductor
m. cricoarytenoideus posterior (m.posticus)
Muscles II. – the adductors
m.cricoarytenoideus lateralis m.interarytenoideus
m.thyreoarytenoideus internus (m.vocalis) és externus
Muscles III. - „tensors”
m.cricothyreoideus, m.vocalis
Movements
Examination I. – indirect laryngoscopy
Examination II. – direct laryngoscopy with flexible instument
Examination III. – direct laryngoscopy with flexible instrument
- minimal mucosal anaesthesia needed - can easily be performed - archivation - fiberoptic or „chip on the tip”
Examination IV. – direct laryngoscopy with rigid instrument
• betterpicturequality(comparedwithfiberoptic)• alittlebitlesstolerable• archivation
Examinations V. – Videostroboscopy
• Principle: the vocal chords are illuminated with a slightly differentfrequencyofpulsatinglightcomparedtotheirownactualfrequency,
• theperiodsofthevocalchordsseemtobesloweddown
Voice production (cover-body)
Examinations VI. – voice analysis
oscillogram
voice spectrum
Examinations VI. – voice analysis
Examinations VI. – voice analysis (jitter – shimmer)
Normal valuesPeriod-flutter (jitter) < 1.04%
< 83.2µsamplitude-flutter (shimmer) < 3.81%
< 0.35dB
Examinations VII. – laryngomicroscopy
Larynx
• airwayprotection• valsalva• phonation
• exhaledvolumeofair• phonatorysettingsandvibrationsofvocal
chords• softtissueabovetheglottis-theplaceof
articulation
Diseases affecting voice production
• congenitalmalformationsoftheupperairways• inflammatorydiseasesofthelarynx• injuries• benignandmalignantlesions• disordersofmutation• endocrindisorders• neurologicaldiseases• functionalproblems(psychic...)
Inflammatory diseases – laryngitis
Inflammatory diseases – cyst of the vocal chord
Inflammatory diseases – nodulus laryngis
Possible causes:
- deficient voice production
- overstrained voice
Inflammatory diseases – polypus ch.voc.
Overstrained vocal chord i.e. during acute laryngitis
Treatment: surgical removal
Papilloma laryngis
Inflammatory diseases – Reinke-edema
• typicalsmoker’sdisease,morefrequentamongwomen• edemaappearsunderthemucosaofthevocalchords• treatment:surgicalremoval
Intubation granuloma
Inflammatory diseases – atrophia of m.vocalis (spindle-shaped closure defect)
Cause:overstrained phonation in acute laryngitis
Treatment: vocal exercises
Closure defect in the posterior third of the glottis
Closure defect in the whole lenght of the glottis
Disorders of mutation
• delayed,long-lasting,early
• incomplete• perverted(women)• eunuchoidvoice(men)
Neurological diseases – multiple sclerosis
• monotonousspeech• weak,hoarsevoice
Neurological diseases – recurrent nerve palsy
• mostlyiatrogenic–afteroperationsofthethyroidgland• inunilateralcasesthehealthysidecompensatesthepalsy• thevoicetemporarilybecomesweak
Bilateral recurrent nerve plasy causing dyspnea
Neurological disorders – after cerebral hemorrhage
Regulatory (functional) disorders
dysplasia
SCC of the vocal chord
Voice rehabilitation after total laryngectomy
Esophageal speech
• about 2/3 of the patients ara able to learn the technique and 1/3 of these uses regularly
• the patient can only tell short sentences
• poor, but understandable voice quality
Electrolarynx
Voice prosthesis
Swallowing disorders
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Phases of swallowing
• oral-(gyruspraecentr.,premot.cortex,tr.corticobulbaris)
• relaxedmandible• lipsreachingeachother• tipofthetongueininferiorposition• bodyofthetonguereachesthesoftpalate• nasalbreathing• closedteethandlips• tonguereachestheaveolararch• tonguepressedagainstthehardpalate• bodyofthetongueinlowestposition• bolusmovesposteriorly–reachesthetriggerpoint
Phases of swallowing
• pharyngeal(cca1s,med.obl.,n.X.)• velopharyngealclosure• hyoidboneelevates• laryngealclosure
• vocalchords• falsevocalchords• arytenoids,aryepiglotticfolds• retractionoftheradixepiglottisclosestheaditus
• pharyngealperistalsis• larynxelevates(cca.2cm),movesanteriorly,esophagusopens
• esophageal(cca.4-20s)
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Dysphagia
Difficultyin• oralpreparation• oral,pharyngealandesophagealtransport.
• Symptoms• aspiration(pre-,intra-,postdeglutitive)
• withoutcoughing(silent)–neurogeniccause• slowchewing,swallowing• difficultyinforwardingthebolus• coughing• hoarsenessduringmeals(„wetvoice”)• weightloss• feverwithoutanyobviouscause
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Mészáros-Hacki
Possible causes
• neurogenic• stroke• Parkinson’sdisease• ALS• multiplesclerosis• ICmalignancy• trauma• myastheniagr.,• toxicneuropathy,n.VII.paresis)
• local,organic• URTI• GOR• iatrogenic(intubation,laryngomicroscopy,irradiation)
• goiter,Zenker-div.• necktrauma• headandnecktu.
• psychogenic
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Examinations I.
• Generalexaminations• motoricfunction• breathing,phonation,articulation• ENTexamination• sluggishtonguemovement,salivation,foodremnantsintheoralcavity
• sensorytestoftheoralcavity,pharynx• muscletone• endoscopy
• velapharyngealclosure• garatizmokmozgása• szupraglottikus-,glottikuszár• colouredfoodinvarioussizesandviscosity
• esophagoscopy,pHmeasuring,esophagealmanometry,EMG
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Mészáros-Hacki
Examination – X-ray
• esophagealphase• amountofaspiratedfluid• diagnosisbylocation
• Salivaaspirationcannotbeassessed
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Az aspiráció súlyossági fokozatai
I. megtartottköhögésireflex,alkalmankéntaspirálII. megtartottköhögésireflex,permanensaspirációv.alkalmankénti
aspirációköhögésireflexnélkül,dehatékonyakaratlagosköhögésselIII. permanensaspirációköhögésireflexnélkül,deeredményes
akaratlagosköhögésselIV. permanensaspirációköhögésireflexnélkül,ineffektívakaratlagos
köhögéssel
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Presbyphagy
• Causes• deformityofthecervicalspine• stroke• toothloss• deteriorationofsmelling• drymucosa• izomtevékenységgyengülése• bolusretencióaszájüregben,valleculakban,sin.piriformisban
• Treatingmethods• coldorhotmeals• seasoning• forcedswallowingtechnique
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Mészáros-Hacki
Dysphagia Functional Therapy (DFT)• Restitutional-causaltherapy
• breathing(intendedglotticclosureandcoughing)• improvingtheorofacialregion’sfunction
• muscletone• cold,sourmaterials(tongue,buccalregion)• chewingpractices• keepingthelarynxinelevatedposition(Mendelsohn’smaneuver)
• Compensatoryswallowing• changingthepositionofthehead
• forward–afterepiglottectomy• rotationtowardstheaffectedside–paresisn.rec.• backwards–injuredtonguemotility
• varietyofswallowingtechniqes• forced• frequent• ...
• Adaptationmethods(oralprostheses,specialglas,NOstraw!)• Diet(temperature,consistency,energy...)
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Mészáros-Hacki