LBM 5 THT SGD 15STEP 1

- INDIRECT LARYNGOSCOPY : is a from larynx+scopy. Is a medical procedure that is used to obtain of view of vocal folds and glottisLaryns examination that used larynx mirror

- HOARSENESS : generic term used to describe many kind of dysphonia. It is frequently used to define a vocal quality rough or harshAnabnormal change in the voice cause by a variety of condition, thyevoice may have change in pitch and volume, ranging from a deep harsh voice to a week and respy voice

- STRIDOR : is a high pitched wheezing sound resulting from turbulent airflow in the upper airway (larynx) and the lower airway (broncus)Is a abnormality voice because obstructing in the larynx

STEP 21. Anatomy of larynx?2. How is the phonation mechanism?3. Mechanism of chronic cough and complication?4. Why did she get hoarseness?5. Why the patient has a history of chronical cough, night sweating and weight loss for the

last 1 year?6. Why the physical examination reveals insipiratory stridor?7. Why indirect laryngoscopy shows hyperemic laryngeal mucosa and oedema?8. Is there any correlation between her work, age and onset with symptom?9. Is there any correlation between hoarseness with history of chronic cough, hight sweating

and weight loss for the last one year?10. DD

STEP 31. Anatomy of larynx?

Larynx terletak di region coli, setinggi vertebra cervical IV-VITerdapat cartilage pada larynxa. Sepasang : cartilage arytenoids, cuneiform dan corniculatab. Tunggal: cartilage thyroid, epiglottis dan cricoidsTampak sagital terdapat ruangan2 di dalam larynx:a. Vestibulum laringis : dari aditus larynx sampai plica vestibularisb. Ventriculuis laryngeus morgagni : dari plica vestibularis sampai plica vocalisc. Cavitas infraglotidis : dari bawah plica vocalis sampapi tepi bawah cartilage cricoidsMusculus di larynxa. Intrinsic : musculus yg menghubungkan antar cartilage laryngea

m. cricothyroid : untuk meregangkan lig.vocalism. thyroarythenoid : unt mengendorkan lig.vocalis

m. arythenoid obliq &transverses : unt menutupi rima glotidism. cricoarythenoid lateral : unt menutup rima glotidism. cricoarythenoid posterior : unt abduksi plica vocalis

b. Extrinsicm. mylohyoidm.stylohyoidm. thyrohyoidm. stylofaringm. palatofaringm. constrictor faring mediam. constrictor faring inferior

vascularisasi :a. Laryngea superior dan inferior merupakan cabanf dr a. thyroidea superior dan inferiorInnervasi : n. laryngeus superior inferior cab dr n.laryngeus reccurens cabang dr n.vagus

2. How is the phonation mechanism?Fonation take place as followEkspyratory airflow out of lung melewati daerah yg sempit (glotis) menimbulkan getaran pd glottis pd kondisi tertentubisa menghasilkan nada dasar suarasuara itu bergema mendasar baik di tenggorokan dan di saluran vocal

Proses bicara jg melibatkan system pernapasan, pusat khusus pengatur bicara di otak dlm cortex cerebri, pusat repirasi did lm batang otak dan struktur artikulasi serta resonansi dr mulut dan rongga hidung

Mekanisme berbisik : setengah dr plica abduksi, rima glotidis setengah membukaRespirasi normal : plica vocalis abduksi, rima glotidis membukaFonasi : rima glotidis menutup, plica vocalis adduksiUdara yg masuk akan menggetarkan plica vocalis yg dipengaruhi musculus2nya

Mekanisme fonasi :a. Ekspirasi. Ada otot2 yg bekerjab. Fibrasi. Yg menggetarkan plica vocalis dan udara melewati celah yg sempitc. Resonansi. Unt menguatkan suara yg dibantu sedikit fungsi larynx, rongga hidung

dan sinus paranasal. Seperti suara m,n,ngd. Artikulasi. Selain huruf m,n,ng

Jika ada palatoskisistdk bisa menempelkan lidahFungsi larynx sebagian besar unt fonasi. Tp larynx jg berfungsi sbg :- proteksi yg diperankan oleh epiglotis, reflex batuk krn ada reseptor batuk di larynx

- respirasi. Mengkondisikan agar udara masuk ke paru2 dg baik

- fonasi

3. Mechanism of chronic cough and complication?Terjadi reflex batuk. saat bakteri/kuman masuk pars konduksi dan sekitarnyamengeluarkan mucus. Krn di larynx ada reseptor batukbatukBila bakteri tidak matiberlanjut ke broncus. Di broncus jg ada reseptor di pergantian antara trachea dan broncus (karina)batukberlanjut teruske paru2menimbulkan komplikasi : s.pneumoni menyerang broncus, tbc menyebabkan kalsifikasi di paru2Gejala tbc :menimbulkan keringat dingin malam hari krn kuman tbc kerja pd malam hari. Juga disertai penurunan berat badanTbc bs menyebabkan tbc sekunder melalui vascular

Batuk kronis bisa disebabkan karena sinusitis kronis, bronchitis kronis

4. Why did she get hoarseness?Adanya iritasi pd pita suarasuara serak bisa disebabkan adanya radang, neoplasma, pasca operasiHoarsenenss adl gejala yg menunjukkan adanya penyakit pd tenggorokan khususnya di daerah larynxPenyebab umum :

- laryngitis akut krn infeksi di saluran napas atasdikaitkan dg pekerjaan pasien (sinden)penggunaan suara yg berlebihansuara serak

- Adanya polip/kista pd pita suara

- Gastoesophageal reflux

- Alergi

- Inhalasi iritasi saluran pernapasan

- Rokok

- Gangguan tiroid

- Terkait penyakit neurologis spt Parkinson dan stroke

- Ca larynx

5. Why the patient has a history of chronical cough, night sweating and weight loss for the last 1 year?Night sweating : kebanyak pd pasien infeksi tbc, neoplasma, hipoglikemia, hipertiroidWeight loss : bs trjd pd pasien neoplasma, infeksi tbc, nafsu makan turun krn tenggorokan sakit

Apakah neoplasma dan infeksi tbc bs terjadi bersamaan???Perbedaan penurunan bb pd neoplasma dan infeksi tbc???

6. Why the physical examination reveals insipiratory stridor?Sindensering nyanyibakteri/kuman masukinfeksi dan radang pd larynx, trakeaafonia, stridopr, batuk. Biasanya gejala pd malam hari dan menghilang pd pagi hariBisa jg karna neoplasma yg menyumbat jalan napasInflamasi pd daerah beronggamenghasilkan secret

Jika ada stridor saat ekspirasi terdapat kelainan dimana???

7. Why indirect laryngoscopy shows hyperemic laryngeal mucosa and oedema?Infeksi masukinflamasioedema dan hiperemis

8. Is there any correlation between her work, age and onset with symptom?Sindensering nyanyi pd nada tinggipenarikan pita suara kuatiritasi pd plica vocalisApalagi ditambah dengan infeksi yg masuk

Usia : 35thn. Mulai penurunan degenerative >40thnOnset 4 bulan : sudah kronis

9. Is there any correlation between hoarseness with history of chronic cough, hight sweating and weight loss for the last one year?

10. DD- LARINGITIS KRONIS

A. SPESIFIKB. NON SPESIFIK

- TUMOR LARINGA. JINAKB. GANAS

STEP 4

Symptom :Hoarseness (4bln)Chronic coughNight sweating

Suspect laryngitis chronis

Px. Penunjang

Ca larynxLaryngitis chronic TB

Sign :Weight lossStridor of inspiratoryHyperemic laryngeal mucosaLaryngeal edema

Singer

Diagnosis

Komplikasi

Terapi

STEP 71. Anatomy of larynx?The larynx is located within the anterior aspect of the neck, anterior to the inferior portion of the pharynx and

superior to the trachea. Its primary function is to protect the lower airway by closing abruptly upon mechanical stimulation, there by halting respiration and preventing the entry of foreign matter into the airway. Other functions of the larynx include the production of sound (phonation), coughing, the Valsalva maneuver, and control of ventilation, and acting as a sensory organ.

The larynx is composed of 3 large, unpaired cartilages (cricoid, thyroid, epiglottis); 3 pairs of smaller cartilages (arytenoids, corniculate, cuneiform); and a number of intrinsic muscles (see the images below). The hyoid bone, while technically not part of the larynx, provides muscular attachments from above that aid in laryngeal motion.[1, 2, 3, 4, 5]

Cartilages of the larynx

Cricoid cartilageThe cricoid cartilage is a ring of hyaline cartilage located at the inferior aspect of the larynx and is the only

complete ring of cartilage around the trachea. It has the shape of a "signet ring," with a broad portion posterior to the airway (lamina of cricoid cartilage) and a narrower portion circling anteriorly (arch of cricoid cartilage). The posterior surface of the lamina contains 2 oval depressions, which serve as attachment sites for the posterior cricoarytenoid muscles, separated by a vertical midline ridge that serves as an attachment to the esophagus.

At the junction of the lamina with the arch, small, round articular facets exist on the outer posterolateral surface of each side of the ring that articulate with the inferior horn of the thyroid cartilage. The lower border of the cricoid cartilage is connected to the first tracheal ring by the cricotracheal ligament. The upper border of the

cricoid cartilage gives attachment to the cricothyroid ligament on the anterior midline, the cricothyroid muscles on the lateral aspects, and the bases of a pair of arytenoid cartilages on both sides of the posterior aspect.

Thyroid cartilageThe thyroid cartilage is the largest of the laryngeal cartilages. It is formed by a right and a left lamina that are

separated posteriorly and joined together at an acute angle in the anterior midline, forming the laryngeal prominence, commonly known as the Adam’s apple. The laryngeal prominence is more apparent in men, because the angle between the 2 laminae is more acute in men (90°) than in women (120°).

The superior thyroid notch is a V-shaped notch immediately above the laryngeal prominence, while the inferior thyroid notch is less distinct and located in the midline along the base of the cartilage (see the image below). The 2 laminae are quadrilateral in shape and form the lateral surfaces of the thyroid cartilage that extend obliquely to cover each side of the trachea..

The posterior aspect of each lamina is elongated to form a superior horn and inferior horn. The medial surfaces of the inferior horns articulate with the outer posterolateral surface of the cricoid cartilage. The inferior border of the thyroid cartilage is attached to the cricoid cartilage by the cricothyroid membrane in the midline and the cricothyroid muscles on either side. The superior horn along with the entire superior edge of the thyroid cartilage is attached to the hyoid bone by the thyrohyoid membrane.

EpiglottisThe epiglottis is a leaf-shaped cartilage that moves down to form a lid over the glottis and protect the larynx

from aspiration of foods or liquids being swallowed. It is attached by its stem to the midline of the inner aspect of the thyroid cartilage, about halfway between the angle of the laryngeal prominence and the inferior notch.

It is attached via the thyroepiglottic ligament and projects posterosuperiorly to cover the superior opening of the larynx. The midline of the superior surface of the epiglottis is also attached to the body of the hyoid bone via the hyoepiglottic ligament. The mucous membrane covering the upper anterior part of the epiglottis reflects off the sides of the epiglottis, giving rise to the glossoepiglottic folds. The aryepiglottic folds are mucosal folds on the posterior surface of the epiglottis. The depressions on either side of the median fold, between the root of the tongue and the epiglottis, are called the valleculae epiglottica.

Arytenoid cartilagesThe arytenoid cartilages form the part of the larynx to which the vocal ligaments and vocal folds attach. They

are pyramidal in shape and have 3 surfaces, a base, and an apex. They are located superior to the cricoid cartilage in the posterior part of the larynx, with the base of the arytenoid cartilages articulating on either side with the posterior aspect of the upper border of the cricoid lamina. The anterior angle of the base of the arytenoid cartilage is elongated to form a vocal process for attachment of the vocal ligament, while the lateral angle is elongated to form a muscular process for attachment of the posterior and lateral cricoarytenoid muscles.

The posterior surface of the arytenoid cartilage gives attachment to the arytenoid muscle. The anterolateral surface has 2 depressions for attachment to the false vocal cord (vestibular ligament) and the vocalis muscle. The medial surface has a mucosal lining that forms the lateral aspect of the respiratory part of the glottis. The apex of the arytenoid cartilage is pointed and articulates with the corniculate cartilage.

Corniculate cartilagesThe corniculate cartilages are 2 small, conical cartilages that articulate with the apices of the arytenoid

cartilages, serving to extend them posteriorly and medially. They are located in the posterior parts of the aryepiglottic folds of mucous membrane.

Cuneiform cartilagesThe cuneiform cartilages are 2 small, club-shaped cartilages that lie anterior to the corniculate cartilages in

the aryepiglottic folds. They form small, whitish elevations on the surface of the mucous membrane just anterior of the arytenoid cartilages.

Ligaments of the larynx

Extrinsic ligamentsThe thyrohyoid membrane is a broad fibroelastic ligament that spans between the superior border of the

thyroid cartilage and the hyoid bone above. It contains an aperture on the lateral surfaces of each side for the superior laryngeal arteries, nerves, and lymphatics.

The hyoepiglottic ligament extends from the midline of the superior surface of the epiglottis to the body of the hyoid bone, located anterosuperiorly. The cricotracheal ligament connects the lower border of the cricoid cartilage to the upper border of the first tracheal cartilage ring.

Intrinsic ligamentsThe conus elasticus, a submucosal membrane, extends superiorly from the anterior arch of the cricoid

cartilage and attaches to the thyroid cartilage anteriorly and the vocal processes of the arytenoid cartilages posteriorly. The free superior margin of the conus elasticus is thickened to form the vocal ligament, which forms the vocal folds (true vocal cords) once covered by mucosa.

The quadrangular membrane, another submucosal sheet, extends between the lateral aspects of the epiglottis and the anterolateral surface of the arytenoid cartilages on each side. The free lower inferior margin of this membrane is thickened to form the vestibular ligament, which forms the vestibular folds (false vocal cords) once covered by mucosa.

Cavities of the larynx

Laryngeal cavityThe laryngeal central cavity is tubular in shape and lined with mucosa. The superior aspect of the cavity

(laryngeal inlet) opens into the pharynx, inferior and posterior to the tongue. The inferior aspect of the cavity is continuous with the lumen of the trachea.

The laryngeal cavity may be divided into 3 major regions: the vestibule, the middle, and the infraglottic space. The vestibule is the upper portion of the cavity, in between the laryngeal inlet and the vestibular folds. The middle portion of the cavity, or the voice box, is formed by the vestibular folds above and the vocal folds below. The infraglottic space is the lower portion of the cavity, in between the vocal folds and inferior opening of the larynx into the trachea.

Laryngeal ventricles and sacculesOn either side of the middle laryngeal cavity, between the vestibular and vocal folds, the mucosa bulges

laterally to form troughs known as the laryngeal ventricles. The laryngeal saccules are tubular extensions of each ventricle anterosuperiorly between the vestibular fold and the thyroid cartilage. It is thought that the walls of these saccules contain many mucous glands that lubricate the vocal folds.

Rima vestibuli and rima glottidisThe rima vestibuli is the triangular-shaped opening between the 2 adjacent vestibular folds. The apex lies

anterior and the base is formed by the posterior wall of the laryngeal cavity. The rima glottidis is a narrower, triangular-shaped opening that lies beneath the rima vestibuli, formed by the 2 adjacent vocal folds.

Piriform recessesThe piriform recesses (piriform sinuses) are present on either side of the anterolateral wall of the

laryngopharynx. They are bounded medially by the aryepiglottic folds and laterally by the thyroid cartilage and thyrohyoid membrane. They are a common place for food to become trapped.

Muscles of the larynx

Cricothyroid musclesThe cricothyroid muscles are attached to the anterolateral surfaces of the arch of the cricoid cartilage and

expand superiorly and posteriorly to attach to the inferior border of the thyroid cartilage. They are the only laryngeal muscles supplied by the external branch of the superior laryngeal nerve, a branch of vagus nerve (cranial nerve [CN] X) below the base of the skull.

These muscles function to elevate the anterior arch of the cricoid cartilage and depress the posterior portion of the thyroid cartilage lamina. This produces tension and elongation of the vocal cords, resulting in higher-pitch phonation.

Posterior cricoarytenoid musclesThe posterior cricoarytenoid muscles extend from the oval depressions on the posterior surface of the cricoid

lamina on each side and extend upward to the muscular process of the arytenoid cartilage on the same side. These muscles function to rotate the arytenoid cartilages laterally, thereby abducting the vocal cords. Their action opposes that of the lateral cricoarytenoid muscles. The posterior cricoarytenoid muscles receive innervation from the recurrent laryngeal branch of the vagus nerve (CN X).

Lateral cricoarytenoid musclesThe lateral cricoarytenoid muscle on each side extends from the upper border of the arch of the cricoid

cartilage to the muscular process of the arytenoid cartilage on the same side. These muscles function to rotate the arytenoid cartilages medially, thereby adducting the vocal cords. The lateral cricoarytenoid muscles receive innervation from the recurrent laryngeal branch of the vagus nerve (CN X).

Transverse arytenoid muscleThe transverse arytenoid muscle is a single muscle that extends between the posterior surfaces of each

arytenoid cartilage. Its main function is adduction of the vocal cords, and it is innervated by both recurrent laryngeal branches of the vagus nerves (CN X).

Thyroarytenoid musclesThe thyroarytenoid muscles run from a vertical line on the interior surface of the thyroid cartilage angle and

adjacent to the external surface of the cricothyroid ligament to the anterolateral surface of the arytenoid cartilage. Each muscle consists of 2 parts: the vocalis and thyroepiglottic part.

The vocalis part lies deep and inferior, parallel with the vocal ligament to which it is attached at the posterior end. The thyroepiglottic part is occasionally described as a separate muscle; it lies superior and continues into the aryepiglottic fold, where some fibers extend to the margin of the epiglottis. These muscles function to draw the arytenoid cartilages forward, thereby relaxing and shortening the vocal cords, while also rotating the arytenoid cartilages inward, thus adducting the vocal folds and narrowing the rima glottis. The thyroarytenoid muscles receive innervation from the recurrent laryngeal branch of the vagus nerve (CN X).

Nerves of the Larynx

Superior laryngeal nerveThe superior laryngeal nerves arise from the inferior ganglia of the vagus nerve and receive a branch from the

superior cervical sympathetic ganglion on each side in the upper neck. They descend adjacent to the pharynx on either side, behind the internal carotid artery, and divide into internal and external branches.

The external branch (external laryngeal nerve) descends beneath the sternothyroid muscle and supplies the cricothyroid muscle. Injury to this nerve during thyroidectomy or cricothyrotomy causes hoarseness of the voice and an inability to produce high-pitched sounds.

The internal branch (internal laryngeal nerve) pierces the thyrohyoid membrane and supplies sensory innervation to the laryngeal cavity down to the level of the vocal folds. It is responsible for the cough reflex.

Recurrent laryngeal branch of the vagus nerve (CN X)The recurrent laryngeal branches of the vagus nerves ascend into the larynx within the groove between the

esophagus and the trachea. The left recurrent laryngeal nerve originates in the thorax, looping under the aortic arch before ascending, while the right recurrent laryngeal nerve originates in the neck.

These nerves are responsible for supplying sensory innervation to the laryngeal cavity below the level of the vocal folds, as well as motor innervation to all laryngeal muscles except the cricothyroid. Since the nerves run immediately posterior to the thyroid gland, they are at risk of injury during thyroidectomies. Unilateral nerve damage presents with voice changes, including hoarseness. Bilateral nerve damage may result in aphonia (inability to speak) and breathing difficulties.

Vessels of the Larynx

ArteriesThe superior and inferior laryngeal arteries supply the majority of blood to the larynx. The superior laryngeal

artery originates from the superior thyroid branch of the external carotid artery and enters the larynx with the internal branch of the superior laryngeal nerve through the lateral aperture of the thyrohyoid membrane. The inferior laryngeal artery originates from the inferior thyroid branch of the thyrocervical trunk, which is a branch of the subclavian artery. It ascends into the larynx within the groove between the esophagus and the trachea, along with the recurrent laryngeal branch of the vagus nerve (CN X).

VeinsThe superior and inferior laryngeal veins drain the larynx and share the same course as the arteries. The

superior laryngeal veins drain into the superior thyroid veins, which empty into the internal jugular veins. The inferior laryngeal veins drain into the inferior thyroid veins, which both empty into the left brachiocephalic vein.

LymphaticsThe lymphatic vessels that drain above the vocal folds travel along the superior laryngeal artery and drain to

the deep cervical lymph nodes at the bifurcation of the common carotid artery. The lymphatic vessels that drain below the vocal folds travel along the inferior thyroid artery and drain to the upper tracheal lymph nodes.

“Larynx Anatomy” Author: Rishi Vashishta George Washington University School of Medicine and Health Sciences from http://emedicine.medscape.com/article/1949369-overview

The Larynx, Basic AnatomyThe larynx, or voicebox, is an organ in the neck that plays a crucial role in speech and breathing. The larynx is

the point at which the aerodigestive tract splits into two separate pathways: the inspired air travels through the trachea, or windpipe, into the lungs, and swallowed food enters the esophagus and passes into the stomach.

Because of its location, the larynx has three important functions control of the airflow during breathing protection of the airway production of sound for speech

The larynx consisted of a framework of cartilage with surrounding soft tissue. The most prominent piece of cartilage is a shield-shaped structure called the thyroid cartilage. The anterior portion of the thyroid cartilage can be easily felt in thin necks as the "Adam's apple".

Superior to the larynx (sometimes considered part of the larynx itself) is a U-shaped bone called the hyoid. The hyoid bone supports the larynx from above and is itself attached to the mandible by muscles and tendons. These attachments are important in elevating the larynx during swallowing and speech.

The lower part of the larynx consists of a circular piece of cartilage called the cricoid cartilage. This cartilage is shaped like a signet ring with the larger portion of the ring in the back. Below the cricoid are the rings of the trachea.

In the center of the larynx lie the vocal folds (also known as the vocal cords). The vocal folds are one of the most important parts of the larynx, as they play a key role in all three functions mentioned above. The vocal folds are made of muscles covered by a thin layer called mucosa. There is a right and left fold, forming a "V" when viewed from above. At the rear portion of each vocal fold is a small structure made of cartilage called the arytenoid. Many small muscles, described below, are attached to the arytenoids. These muscles pull the arytenoids apart from each other during breathing, thereby opening the airway. During speech the arytenoids and therefore the vocal folds are brought close together. As the air passes by the vocal folds in this position, they open and close very quickly. The rapid pulsation of air passing through the vocal folds produces a sound that is then modified by the remainder of the vocal tract to produce speech. this process is described in more detail in the page on vocal fold vibration.

The diagram above on the left shows the folds in the open position. The folds should open like this during breathing. On the right, the folds are shown in the closed position as during speech.

Muscles of the larynxMovement of the larynx is controlled by two groups of muscles. The muscles that move the vocal folds and

other muscles within the larynx are called the intrinsic muscles. The position of the larynx in the neck is controlled by a second set call the extrinsic muscles.

The intrinsic muscles are shown in the illustrations above. The vocal folds are opened primarily by a pair of muscles running from the back of the cricoid cartilage to the arytenoid cartilage. This muscle is called the posterior cricoarytenoid muscle (almost all the muscles in the neck are named by stating where the originate and where the end).

Several muscles help to close and tense the vocal folds. The body of the vocal folds itself is made up of a muscle called the thyroarytenoid muscle. A muscle called the interarytenoid runs from on arytenoid to the other and brings together these two pieces of cartilage. The lateral cricoarytenoid muscle, like the posterior cricoarytenoid muscle, also runs from the arytenoid to the cricoid cartilage. However, as its name implies it attaches to the lateral portion of the cricoid cartilage and is felt to primarily close the larynx.

The cricothyroid muscle runs from the cricoid cartilage to the thyroid cartilage. When it contracts, the thyroid cartilage tilts forward, putting tension on the vocal folds and thereby raising the pitch of the voice.

The extrinsic muscles are also called the strap muscles (since they look like straps). They do not affect the movement of the vocal folds, but raise and lower the entire larynx. This movement is especially important for swallowing. Trained singers also develop fine control of these muscles to help improve the quality of their voices.

Department of Otolaryngology Head and Neck Surgery Eastern Virginia Medical School from http://www.evmsent.org/larynx.asp

2. How is the phonation mechanism?Phonation takes place as follows. First, expiratory air flows out of lungs, and passes through a narrow area

called glottis. Then self-excited oscillations are caused at glottis under particular conditions. And it makes fundamental tone of voice. At last the fundamental voice resonates in both the throat and the vocal tract, and is radiated from the mouth

Fundamentals of voice productionThe foundation for an effective voice is based on the coordination of three factors:• Breathing• Phonation• ResonanceBreathing air out of the lungs produces the power supply for the voice. This airflow from the lungs makes the

vocal folds (or vocal chords) in the larynx (or voice box) vibrate to make the basic sound of the voice; this process is called phonation. Because that sound made by the vocal folds is too weak to be heard, that basic sound is then modified into the sound we recognise as the human voice as it travels up from the larynx through the throat, mouth and nose; this transformation is known as resonance. Production of a natural, effective voice depends on how well we balance or coordinate these three fundamental components of breathing, phonation and resonance.

BreathingOur intention to produce voice is signalled to the parts of the body involved by impulses from the brain. The

first response of the body to these impulses is to breathe in so that there is enough air in the lungs to power the voice. The breath is taken in through the mouth and nose, passes down the trachea (or windpipe), and is inhaled into the lungs. For air to be inhaled into the lungs, the ribcage needs to expand and the dome-like diaphragm which forms the base of the chest, needs to flatten downwards. When we breathe in effectively, we feel most of this expansion in the area of the lower ribs.

Once the air has been inhaled into the lungs and they reach capacity, the elastic tissue of the lung recoils and the air is exhaled or breathed out. The exhaled air then returns up through the trachea and then through the larynx where it encounters the closing vocal folds.

PhonationWhen we breathe in and out without speaking, the vocal folds in the larynx are open to allow the air to pass

to and from the lungs easily. The impulses sent from the brain when we intend to speak, however, signal to the muscles of the larynx to close the vocal folds. When the air coming up from the lungs encounters the closed vocal folds, the pressure and flow of the air overcomes the resistance of the vocal folds and sets them into a pattern of rapid vibration. That is, the vocal folds open and close repeatedly, around 200 - 220 times per second for women and 100 - 120 times per second for men. This rapid vibration of the vocal folds produces the sound waves in the air which are the basic tones of our voices. The vocal folds are therefore the source of the human voice.

The larynx is located on the top of the trachea and is behind the Adam’s Apple. The two vocal folds in the larynx are approximately 20 mm in length and are stretched from just behind the

Adam’s Apple in the front of your neck to the back of the larynx. These vocal folds are complex structures made up of four main layers. The outer layer is the mucous membrane (or epithelium).

Directly under the mucous membrane is a soft, pliable layer filled with fluid; this layer is known as Reinke’s space. The mucous membrane and Reinke’s space are together known as the ‘cover’ of the vocal folds. This cover of the vocal folds must be kept moist and pliable so that it can move freely in a wave-like motion (the ‘mucosal wave’) over the deeper layers of the folds. If the cover of the vocal folds becomes dry or stiff, the voice will become rough and the person may experience throat discomfort.

Under the cover of the vocal folds is the vocal ligament. This ligament is made up of elastic tissue that allows the vocal folds to change shape easily when the deepest and least pliable layer of the vocal folds, the muscle, changes shape. The basic tone of the voice can be varied in many different ways, depending on the way in which we use the vocal folds and other parts of the voice mechanism.

The main aspects of the voice that can be varied are:• pitch• loudness• qualityPitch refers to how high or low the voice sounds. It is determined mainly by the speed of vibration of the

vocal folds, the thickness of the edge of the folds, and the length of the folds. The higher the voice, the faster is the rate of vibration of the vocal folds. The more elongated and thinner the edges of the vocal folds become, the higher the pitch will be. On the other hand, if the vibrating edges of the vocal folds become thicker and shorter, and the vocal folds vibrate at a slower rate, the pitch will be lowered. We use variations in pitch during speech to signal meaning and emotion and this is referred to as intonation.

Loudness refers to how loud or soft a voice is. It is dependent on the amount of air pressure from the lungs and the muscle tension in the vocal folds. The greater the air pressure and the more tense the vocal folds, the louder the sound will be. The lower the air pressure from the lungs is and the slacker the vocal folds are, the softer the voice will be. We also use variations in loudness during speech to signal meaning and emotion and this is referred to as stress. To emphasis the importance of a particular word, for example, we increase the loudness of voice on that word.

Quality refers to how clear the voice sounds. Voice quality is determined by many complex factors including how relaxed the muscles of the larynx are, how moist the cover of the vocal folds is, how smoothly the vocal folds vibrate, and whether or not the vocal folds are able to close sufficiently during phonation. If the muscles of the larynx are excessively tense, the cover is dry, the folds move in an irregular way, and/or the folds cannot close together, the voice quality will sound rough, strained and/or breathy.

ResonanceThe sound waves produced by the vocal folds in the larynx are too weak to be recognised as voice and so this

basic tone must be amplified or resonated as it travels up through the spaces of the throat, mouth and nose. The shape, size and muscle tension of these spaces will determine the eventual sound of the voice we will hear.

Because every person is built differently in the throat, mouth and nose, the basic voice tone is modified differently in each of us so that we will all have a recognisably unique timbre of voice. This process of resonance in our voices is similar to the way in which the shape and size of a musical instrument such as a trumpet gives the basic tone produced by the reed its unique sound. Just as the resonance process in a trumpet makes the sound of the trumpet carry throughout a concert hall, resonance in the human voice gives us the ability to control its carrying power or projection

Other physical factors influencing voiceWhile breathing, phonation and resonance are the basic building blocks of the voice, the effectiveness of our

voices is also affected by:• body posture • relaxation of the muscles of the body and the larynxBecause the parts of the body which contribute to voice production are connected to many other parts of the

body’s muscular and skeletal system, the way we align the whole body and the amount of muscle tension or relaxation in the body will influence the voice. Excess tension in the muscles of

the larynx, for example, can lead to a strained, harsh voice. Similarly, standing with the knees braced and the pelvis pushed forwards can lead to difficulty in coordinating relaxed breathing with phonation.

Voice Care for Teachers Program - Voice Production, Department of Education and Early Childhood Devwlopment, State Government of Victoria

3. Mechanism of chronic cough and complication?

Causes of Chronic CoughMost diagnostic workups for the cause of a cough differentiate between chronic cough in nonsmokers with a

normal chest x-ray (CXR) and chronic cough in smokers with or without an abnormal CXR. The most common causes for chronic cough in a nonsmoker with a normal CXR are postnasal drip syndrome,asthma, and gastroesophageal reflux disease (GERD). Medications called ACE inhibitors are another major cause of chronic cough. Common causes for chronic cough in smokers are bronchitis and lung cancer. Even though a chronic cough in a nonsmoker usually does not indicate problems as serious as these, it should be evaluated by a physician to exclude rare but serious causes.

Less common causes include: congestive heart failure, disorders of the upper airways, disorders of the pericardium, bronchogenic carcinoma, interstitial lung disease, chronic pulmonary infection (e.g., tuberculosis), cystic fibrosis, and psychogenic disorders.

Postnasal Drip Syndrome and Chronic CoughPostnasal drip syndrome is suggested by frequent nasal discharge, sensation of drainage in the back of the

throat, and frequent throat clearing. The syndrome is noted on physical examination by the rough appearance, termed cobblestoning, of the back of the throat. Sinus x-rays or sinus CT (computed tomography) scan may show evidence of sinusitis. Causes of postnasal drip include sinusitis, allergic rhinitis, and vasomotor rhinitis. Postnasal drip syndrome is the most common cause of chronic cough.

Chronic cough due to postnasal drip is generally treated with decongestants and antihistamines, with or without nasal steroid sprays. Treatment may also include a vasoconstrictor such as oxymetalazone, which should not be used for more than 5 days. Chronic cough due to postnasal drip may take a few weeks to a couple of months to resolve. Underlying sinusitis is treated with antibiotics.

Asthma and Chronic CoughAsthma that is asymptomatic except for cough is called cough-variant asthma. This condition is difficult to

diagnose because the physical examination and pulmonary function test results can be normal. The diagnosis may be suggested by caused by cold air, fumes, fragrances, or exercise. Coughing that starts after the initiation of a beta-blocker also suggests asthma. Beta-blockers are medications commonly used to treat high blood pressure, heart disease, migraines, palpitations, and other conditions. Beta-blockers are also used in eye drops for glaucoma and other eye problems. Beta-blocker eye drops can precipitate asthma symptoms, including cough.

Confirmation of the diagnosis of cough-variant asthma may include a breathing test called a methacholine bronchial challenge test.

See details on asthma.Gastroesophageal Reflux Disease (GERD) and Chronic CoughGERD is the third most common cause of chronic cough. The diagnosis may be obtained from the medical

history alone. Patients often present with classic symptoms of frequent heartburn or sour taste in the mouth. If these symptoms are present, therapy directed at GERD is initiated to resolve the cough. Forty percent of patients with GERD do not present with the classic symptoms. These patients may complain only of cough. In this case, a 24-hour esophageal pH probe—a small plastic catheter inserted through the nose and placed into the esophagus, above the stomach—may be performed to measure the pH (acid concentration) in the esophagus. If the pH in the esophagus falls below a certain level, acid is refluxing from the stomach.

Alternatively, therapy directed at reflux can be given as a diagnostic test. If the cough resolves with GERD therapy, the cough is attributed to GERD. This is reconfirmed if the cough returns with discontinuance of therapy.

The treatment for GERD includes elevation of the head of the bed; not eating or drinking 2 to 3 hours before bedtime; and avoiding certain foods, such as fatty foods, chocolate, alcohol, orange juice, and caffeine. Medications directed at reducing acid production in the stomach, such as proton pump inhibitors, are used as well.

ACE Inhibitors and Chronic Cough

ACE inhibitors can be excluded as the cause of chronic cough by discontinuing their use. The cough typically resolves in 1 to 4 days but can take up to 4 weeks. Therefore, eliminating the drug for a couple of days is not sufficient to exclude an ACE inhibitor as the cause. Further confirmation is made by the return of cough on resumption of the medication.

Other classes of medication need to be used if the cough is due to an ACE inhibitor.Bronchiectasis and Chronic CoughBronchiectasis (chronic dilation of the bronchi or bronchioles resulting from inflammatory disease or

obstruction) can be diagnosed by high resolution CT scan that shows the dilated airways. Once this diagnosis is established, the cause should be determined and, if possible, therapy initiated.

Chronic Bronchitis and Chronic CoughThe diagnosis of chronic bronchitis is obtained from a history of smoking and the production of sputum with

the cough most days of the week, for 3 months, in 2 successive years. Chest x-rays are obtained to exclude other pathology. In a smoker, any change in a chronic cough and any new cough warrant further evaluation.

Smoking cessation can resolve the cough associated with chronic bronchitis. Bronchodilators can help the cough as well.

Lung Cancer and Chronic CoughLung cancer is the cause of a chronic cough in less than 5% of patients with a normal CXR. It is suspected as a

cause of chronic cough most often when there is an abnormal CXR and a history of smoking. Abnormal CXR dictates that a biopsy be performed to obtain a sample of the abnormal tissue for analysis. When the CXR is normal and lung cancer is suspected, a CT scan of the chest may be obtained. Bronchoscopy is often the next diagnostic test in patients with normal radiographic studies. See details on lung cancer.

Foreign Body and Chronic CoughWhen a foreign body is suspected as the cause of chronic cough, fiberoptic bronchoscopy is usually performed.Nonspecific Therapy for Chronic CoughNonspecific therapy for cough may be employed to relieve symptoms until the therapy directed at the cause

becomes effective. The most commonly used cough suppressant is dextromethorphan. Dextromethorphan is chemically related to morphine but has no narcotic effect. Adverse effects, occuring in fewer than 1% of people, include drowsiness, dizziness, nausea, constipation, and abdominal discomfort. Dextromethorphan is contraindicated in a person taking a monoamine oxidase inhibitor (MAOI). Overdosage can occur and can lead to coma and respiratory depression. Codeine is another effective cough suppressant and may cause side effects similar to dextromethorphan, but with increased frequency. Dependency with prolonged use can occur with codeine.

Chroinics caugh causes Review By: Stanley J. Swierzewski, III, M.D. Published: 01 Jun 2000 Last Modified: 23 May 2011on http://www.healthcommunities.com/chronic-cough/causes.shtml

Chronic cough is defined as lasting eight weeks or longer in adults, four weeks in children.While it can sometimes be difficult to pinpoint the problem that's triggering a chronic cough, the most common

causes are tobacco use, postnasal drip, asthma and acid reflux — the backflow of stomach acid that can irritate your throat. Chronic cough typically disappears once the underlying problem is treated.

An occasional cough is normal — it helps clear foreign substances and secretions from your lungs and prevents infection. But a cough that persists for weeks is usually the result of an underlying problem. In many cases, more than one cause is involved.

Major causes Postnasal drip. When your nose or sinuses produce extra mucus, it can drip down the back of your throat

and trigger your cough reflex. This condition is also called upper airway cough syndrome.

Asthma. An asthma-related cough may come and go with the seasons, appear after an upper respiratory tract infection, or become worse when you're exposed to cold air or certain chemicals or fragrances. In one type of asthma (cough-variant asthma), a cough is the main symptom.

Gastroesophageal reflux disease (GERD). In this common condition, stomach acid flows back into the tube that connects your stomach and throat (esophagus). The constant irritation can lead to chronic coughing. The coughing, in turn, worsens GERD — a vicious cycle.

Studies have shown that the above three causes, alone or in combination, are responsible for 90 percent of cases of chronic coughs.

Other causes Infections. A cough can linger long after most symptoms of a cold, influenza, pneumonia or other

infection of the upper respiratory tract have gone away. A not uncommon cause of a chronic cough in adults is pertussis, also known as whooping cough.

Blood pressure drugs. Angiotensin-converting enzyme (ACE) inhibitors, which are commonly prescribed for high blood pressure and heart failure, are known to cause chronic cough in some people.

Chronic bronchitis. This long-standing inflammation of your major airways (bronchial tubes) can cause congestion, breathlessness, wheezing and a cough that brings up discolored sputum. Most people with chronic bronchitis are current or former smokers.

Less common Aspiration Bronchiectasis Bronchiolitis Chronic bronchitis from an infectious disease COPD Cystic fibrosis Foreign body aspiration — children Laryngopharyngeal reflux Lung cancer Nonasthmatic eosinophilic bronchitis Sarcoidosis

4. Why did she get hoarseness?Hoarseness is a harsh, rough quality to the voice. Hoarseness is generally caused by irritation of, or injury to,

the vocal cords. The voice box, or larynx, is the portion of the respiratory (breathing) tract containing the vocal cords which produce sound. It is located between the pharynx and the trachea. The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in the neck.

We use the larynx when we breathe, talk, or swallow. Its outer wall of cartilage forms the area of the front of the neck referred to as the "Adams apple." The vocal cords are two bands of muscle that form a "V" inside the larynx.

Hoarseness can be caused by a number of conditions. The most common cause of hoarseness is inflammation of the vocal cords from virus infection. Hoarseness can also be caused by bacterial infection, overuse of the voice (such as from yelling or singing), inhalation of irritants (smoking, etc.), chronic sinusitis, reflux of acid from the stomach (GERD), tuberculosis, syphilis, and cancer of (or that has spread to) the larynx.

Cough suppressants are sometimes used to prevent recurrent irritation of the vocal cords from coughing. Hoarseness that persists for longer than two weeks should be evaluated by doctor.

Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008.

Causes Acid reflux (gastroesophageal reflux) Allergies Breathing in irritating substances Cancer of the throat or larynx Chronic coughing Colds or upper respiratory infections Heavy smoking or drinking, especially together Overuse or abuse of the voice (as in shouting or singing), which may cause swelling or growths on the vocal

cordsLess common causes include:

Injury or irritation from a bgreathing tube or bronchoscopy Damage to the nerves and muscles around the voice box (from trauma or surgery Foreign object in the esophagus or trachea Swallowing a harsh chemical liquid Changes in the larynx during puberty Thyroid or lung cancer

Underactive thyroid gland

Causes of hoarsenessFunctional dysphonia:

Where no organic cause is found - a diagnosis of exclusion. A common cause of hoarseness.[5] There are various forms (below).

Infections: Acute laryngitis (common), often with upper respiratory infection. Usually viral (may have secondary infection

with staphylococci or streptococci). Other infections - fungal or tuberculosis.

Benign laryngeal conditions (for details see last section 'Some specific voice disorders and their management'): Voice overuse - common. Benign lesions of the vocal cords, eg nodules (singer's nodes), polyps and papillomas.

Malignancy: Carcinoma of the larynx - smoking is major risk factor. Other neck or chest tumours, eg lung cancer, lymphoma, thyroid cancer.

Neurological: Laryngeal nerve palsy (see 'Some specific voice disorders and their management' below): this has various

causes including lung cancer, other tumours and thoracic aortic aneurysm. Stroke and other focal brain lesions. Parkinson's disease (voice change can be a presenting feature[6]). Motor neurone disease. Essential tremor. Myasthenia gravis.

Systemic: Endocrine: hypothyroidism, acromegaly. Rheumatoid arthritis affecting the cricoarytenoid joints.[2]

Granulomatous disease, eg sarcoid, tuberculosis, syphilis, Wegener's granulomatosis. Autoimmune disorders can affect the larynx.[6]

Causes in children:[4]

Congenital, eg laryngeal web, laryngomalacia, congenital cyst. Older children: vocal cord nodules, voice overuse, gastro-oesophageal reflux, papillomas (as for adults). Very rarely, malignancy.

Other causes: Various rare causes of hoarseness, from case reports, are described by Ulis.[6]

Contributing factors: Drying of the laryngeal mucosa, eg from low humidity, nasal obstruction, smoking, air pollution or medication,

eg antihistamines, inhaled steroids, and anticholinergics.

Upper respiratory tract infection. Voice overuse (see 'Some specific voice disorders and their management' below). Gastro-oesophageal reflux (reflux laryngitis or laryngopharyngeal reflux). Scarring, eg after prolonged intubation. Age-related loss of pliability (normal ageing of the voice).

1. Bossingham DH, Simpson FG ; Acute laryngeal obstruction in rheumatoid arthritis. BMJ. 1996 Feb 3;312(7026):295-6.

2. Carding P ; Voice pathology in the United Kingdom. BMJ. 2003 Sep 6;327(7414):514-5.3. Van Houtte E, Van Lierde K, D'Haeseleer E, et al Ulis JM, Yanagisawa E ; What's new in differential

diagnosis and treatment of hoarseness? Curr Opin Otolaryngol Head Neck Surg. 2009 Jun;17(3):209-15.

http://www.patient.co.uk/doctor/hoarseness

5. Why the patient has a history of chronical cough, night sweating and weight loss for the last 1 year?

Night sweating can arise from harmless situations or serious disease. If your bedroom is unusually hot or you are using too many bedclothes, you may begin to sweat during sleep - and this is normal. In order to distinguish night sweats that arise from medical causes from those that occur because one's surroundings are too warm, doctors generally refer to true night sweats as severe hot flashes occurring at night that can drench sleepwear and sheets, and that are not related to an overheated environment. It is important to note that flushing (a warmth and redness of the face or trunk) may also be hard to distinguish from true night sweats.There are many different causes of night sweats. Some of the known conditions that can cause night sweats are:

Menopause: The hot flashes that accompany the menopausal transition can occur at night and cause sweating. This is a very common cause of night sweats in women at or near menopause.

Idiopathic hyperhidrosis: a condition in which the body chronically produces too much sweat without any identifiable medical cause.

Infections: Classically, tuberculosis is the infection most notoriously associated with night sweats. However, bacterial infections, such as endocarditis (inflammation of the heart valves), osteomyelitis (inflammation within the bones), and abscesses all may result in night sweats. Night sweats are also a symptom of AIDS virus (HIV) infection.

Cancers: Night sweats are an early symptom of some cancers. The most common type of cancer associated with night sweats is lymphoma. However, people who have an undiagnosed cancer frequently have other symptoms as well, such as unexplained weight loss and fevers.

Medications: Taking certain medications can lead to night sweats. Antidepressant medications are a common type of medication that can lead to night sweats. All types of antidepressants can cause night sweats as a side effect, with a range in incidence from eight to 22% of persons taking antidepressant drugs. Other psychiatric drugs have also been associated with night sweats. Medicines taken to lower fever such as aspirin andacetaminophen can sometimes lead to sweating. Other types of drugs can cause flushing, which, as mentioned above, may be confused with night sweats. Some of the many drugs that can cause flushing include niacin (taken in the higher doses used \for lipid disorders), tamoxifen (Nolvadex), hydralazine(Apresoline), nitroglycerine, and sildenafil (Viagra). Many other drugs not mentioned above, including cortisone medications, such as prednisone andprednisolone, may also be associated with flushing or night sweats.

Hypoglycemia: Sometimes low blood glucose can cause sweating. People who are taking insulin or oral anti-diabetic medications may experience hypoglycemia at night that is accompanied by sweating.

Hormone disorders: Sweating or flushing can be seen with several hormone disorders, including pheochromocytoma, carcinoid syndrome, andhyperthyroidism.

Neurologic conditions: Uncommonly, neurologic conditions including autonomic dysreflexia, post-traumatic syringomyelia, stroke, and autonomic neuropathy may cause increased sweating and possibly lead to night sweats

Weight LossWeight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue. It can occur unintentionally due to an underlying disease or can arise from a conscious effort to improve an actual or perceived overweight or obese state.Unintentional weight loss may be a result of loss of fat, muscle atrophy, fluid loss or a combination of these. [1][2] It is generally regarded as a medical problem when at least 10% of an adult's body weight has been lost in six months[1] or 5% in the last month.[3] However less weight loss can be a cause for serious concern in a frail elderly person, for example.[4]

Unintentional weight loss can occur because of a diet lacking in adequate nutrition for a person's energy needs (generally called malnutrition). But it can also occur because of disease processes, changes in metabolism, hormonal changes, as an adverse effect of medication or other treatment, disease- or treatment-related dietary changes, or reduced appetite associated with a disease or treatment.[2][1][5][6][7] Serious weight loss may reduce quality of life, impair treatment effectiveness or recovery, worsen disease processes and be a risk factor for earlier mortality.[4][1]

Unintentional weight loss can be the characteristic leading to diagnosis of diseases such as cancer[1] and type 1 diabetes.[8]

Continuing weight loss may deteriorate into wasting, a vaguely defined condition called cachexia.[4] Cachexia differs from starvation because it involves a systemic inflammatory response.[4] It is associated with poorer outcomes.[4][1]

[5]

CausesDisease-relatedDisease-related malnutrition falls into four categories:[9]

Problem Cause

Impaired intake

Poor appetite can be a direct symptom of an illness, or an illness could make eating painful or induce nausea. Illness can also cause food aversion.Inability to eat can result from: diminished consciousness or confusion, or physical problems affecting the arm or hands, swallowing or chewing. Eating restrictions may also be imposed as part of treatment or investigations. Lack of food can result from: poverty, difficulty in shopping or cooking, and poor quality meals.

Impaired digestion &/or absorption

This can result from conditions that affect the digestive system.

Altered requirements

Changes to metabolic demands can be caused by illness, surgery and organ dysfunction.

Excess nutrient losses

Losses from the gastrointestinal can occur because of symptoms such as vomiting or diarrhea, as well as fistulae and stomas. There can also be losses from drains, including nasogastric tubes.Other losses: Conditions such as burns can be associated with losses such as skin exudates.

Weight loss issues related to specific diseases include: As chronic obstructive pulmonary disease (COPD) advances, about 35% of patients experience severe weight

loss called pulmonary cachexia, including diminished muscle mass.[5] Around 25% experience moderate to severe weight loss, and most others have some weight loss.[5] Greater weight loss is associated with poorer prognosis.[5]Theories about contributing factors include appetite loss related to reduced activity, additional energy required for breathing, and the difficulty of eating with dyspnea (labored breathing).[5]

Cancer, a very common and sometimes fatal cause of unexplained (idiopathic) weight loss. About one-third of unintentional weight loss cases are secondary to malignancy. Cancers to suspect in patients with unexplained weight loss include gastrointestinal, prostate, hepatobillary (hepatocellular carcinoma, pancreatic cancer), ovarian, hematologic or lung malignancies.

AIDS can cause weight loss and should be suspected in high-risk individuals presenting with weight loss. Gastrointestinal disorders are another common cause of unexplained weight loss – in fact they are the most

common non-cancerous cause of idiopathic weight loss. Possible gastrointestinal etiologies of unexplained weight loss are celiac disease, peptic ulcer, inflammatory bowel disease (crohns disease and ulcerative colitis), pancreatitis, gastritis, diarrhea and many other GI conditions can cause weight loss.

Infection. Some infectious diseases can cause weight loss. These include fungal illness, endocarditis, many parasitic diseases, AIDS, and some other sub-acute or occult infections may cause weight loss.

Renal disease . Patients who have uremia often have poor or absent appetite, emesis and nausea. This can cause weight loss.

Cardiac disease . Cardiovascular disease, especially congestive heart failure, may cause unexplained weight loss.

Connective tissue disease Neurologic disease , including dementia [10] Stress can cause weight loss. However, recent research (Jastebott, Potenza et al. 2010) shows a correlation

between obesity and high levels of stress.[11]

Therapy-relatedMedical treatment can directly or indirectly cause weight loss, impairing treatment effectiveness and recovery that can lead to further weight loss in a vicious cycle.[1]

Many patients will be in pain and have a loss of appetite after surgery.[1] Part of the body's response to surgery is to direct energy to wound healing, which increases the body's overall energy requirements. [1] Surgery affects nutritional status indirectly, particularly during the recovery period, as it can interfere with wound healing and other aspects of recovery.[1][9] Surgery directly affects nutritional status if a procedure permanently alters the digestive system.[1] Enteral nutrition (tube feeding) is often needed.[1] However a policy of 'nil by mouth' for all gastrointestinal surgery has not been shown to benefit, with some suggestion it might hinder recovery.[12]

Early post-operative nutrition is a part of Enhanced Recovery After Surgery protocols. [13] These protocols also include carbohydrate loading in the 24 hours before surgery, but earlier nutritional interventions have not been shown to have a significant impact.[13]

Some medications can cause weight loss, while others can cause weight gain.[14]

Weight loss more than 4.5 kg or more than 5% of usual body weight over a period of 6 to 12 months is considered to be clinically important and should not be ignored. Further weight loss can affect the normal physiological functions of the body, and could even affect various organs.Malnutrition is a common cause of weight loss. Malnutrition is often due to social factors like poverty or unavailability of food. In other cases, malnutrition may occur due to inability or lack of inclination to eat, or a problem with absorption of nutrients from the intestines.Some of the health-related disorders that are associated with weight loss are listed below:

Cancer: Any person complaining of sudden and significant loss of weight should be evaluated for a hidden cancer, especially if no other cause is evident. Weight loss is a major symptom of cancer. Patients with cancer produce substances like cachectin and interleukins that are responsible for weight loss. Increased metabolism may be responsible for weight loss in patients with blood cancer.Hormonal Diseases: Hormonal diseases are also common causes of weight loss. Conditions like hyperthyroidism increase the metabolic rate. Less commonly, pheochromocytoma, adrenal insufficiency, hypercalcemia and hypopituitarism cause weight loss. A history of symptoms, a complete physical examination and blood tests are used to diagnose these conditions. Infection and Inflammation: Infections are commonly associated with weight loss due to an increase in metabolic rate accompanied by a decrease in appetite and calorie intake . Various infections like lung abscess, HIV, fungal diseases, and subacute bacterial endocarditis (infection of the heart) cause unintentional weight loss. Tuberculosis should be suspected in a patient with chronic cough, low-grade fever in the evenings and weight loss. These conditions are diagnosed through physical examination, blood tests and chest x-rays.Neurological Disorders: Brain injury and neurodegenerative diseases like Parkinson’s disease and Alzheimer’s disease may result in a neglect of regular eating and therefore result in loss of weight. In addition, the patient may suffer from other complications like constipation. The medications used in the treatment of these conditions could also interfere with regular eating patterns.Heart Diseases: Patients with cardiac diseases often experience decreased appetite and increased metabolism. Also, dietary restrictions in such patients may cause weight loss. Patients with severe congestive heart failure produce substances in the blood called cytokines, which result in symptoms like weight loss, wasting of muscle, and loss of appetite. Symptoms of cardiac disease are usually obvious in these patients.Lung Diseases: Besides lung infections, conditions like severe chronic obstructive pulmonary disease and breathlessness are also associated with weight loss. Symptoms of lung disease should be looked out for in a patient with weight loss.Digestive System Disorders: Digestive system disorders can reduce appetite and the absorption of nutrients from food, thereby resulting in weight loss. These disorders include stomach and intestinal ulcers, celiac disease and pancreatitis. In addition, dental problems may also be associated with reduced food intake and therefore weight loss. Worm infestations are common causes of weight loss or failure to gain weight in children despite adequate food intake.Kidney Diseases: Kidney diseases may be associated with weight loss due to loss of protein in the urine, and the associated nausea and vomiting. However, in later stages of kidney disease, the weight may increase due to accumulation of fluid.Medications and Alcohol: Medications are commonly associated with adverse effects like nausea, vomiting, loss of appetite, and altered taste. In addition, they could interfere with the absorption of certain nutrients or cause diarrhea, thus contributing to weight loss. Diuretics may cause weight loss by reducing the water content of the body. Alcohol impairs the body’s ability to absorb nutrients and vitamins and alters metabolism, resulting in weight loss.Psychological Disorders: Psychological disorders like depression and anxiety often result in decreased appetite and loss of interest in eating. Conditions like anorexia nervosa result in the patients starving themselves and vomiting out any excess food that they may eat. Social factors like isolation and financial hardship are also responsible for the weight loss.

Apakah neoplasma dan infeksi tbc bs terjadi bersamaan???Perbedaan penurunan bb pd neoplasma dan infeksi tbc??

TUBERCULOSISTuberculosis, or TB, is a serious infectious disease that primarily affects the lungs, but can affect any organ in the body. It is spread through droplets in the air from when an infected person speaks or coughs. Typically, close and prolonged contact with an infected person is required to spread the disease. Soaking night sweats, unexplained weight loss, fever and chills are common symptoms. A cough that produces thick, sometimes bloody mucus, and chest pain typically occur when tuberculosis affects the lungs. Other symptoms depend on the affected organ, such as back pain when tuberculosis occurs in the spine.

Unintentional weight loss can be a symptom of cancer, though vague and non-specific. Losing weight isn't a characteristic of a single type of cancer. The fact is that most people with cancer do lose some weight for a variety of reasons. Weight loss can be caused by the cancer itself, loss of appetite, or even emotional stress over the daily challenges of having cancer.

6. Why the physical examination reveals insipiratory stridor?Stridor is noisy breathing that occurs due to obstructed air flow through a narrowed airway. Stridor is not in and of itself a diagnosis but is a symptom or sign that points to a specific airway disorder.

What causes stridor?Stridor can be caused by any process that causes airway narrowing. In the infant, stridor usually indicates a congenital disorder (problem that your child is born with), including laryngomalacia, vocal cord paralysis or subglottic stenosis. In the toddler or older child, stridor may occur as a result of an infection such as croup or papillomatosis. In rare circumstances, stridor can occur secondary to trauma or foreign body aspiration.

What are the types of stridor?The timing and the sound of your child's noisy breathing provides clues to the type of airway disorder: Inspiratory stridor occurs when your child breathes in and it indicates a collapse of tissue above the vocal cords. Expiratory stridor occurs when your child breathes out and it indicates a problem further down the windpipe. Biphasic stridor occurs when your child breathes in and out, and it indicates a narrowing of the subglottis, the cartilage

right below the vocal cords.

How is stridor evaluated?The evaluation of stridor begins with a history and physical examination. Important history will include questions regarding the onset, duration and progression of stridor as well as associated feeding or voice disturbances.The physical examination begins with an assessment for signs of respiratory distress (nasal flaring, retractions, color change, etc.).Once the child is determined to be stable, the physician will evaluate specific features of the stridor (inspiratory, expiratory, biphasic) and voice.The airway doctor may recommend one or more of these diagnostic tests: Flexible laryngoscopy — A test in which the doctor passes a tiny tube with a camera and light at the end through the nose

and into the airway to look for problems. Plain X-ray, airway fluoroscopy, barium swallow, and CT scan of the chest — Films that can help the doctor further

evaluate the noisy breathing. Magnetic resonance imaging or magnetic resonance angiography — An imaging test that shows soft tissues in great

detail. MRI/MRA is rarely requested but it is helpful in diagnosing the presence of a vascular ring. A vascular ring is a rare birth defect in which a large blood vessel in the heart — the aortic arch — encircles and squeezes the trachea and esophagus.

How is stridor treated?Stridor treatment depends upon many factors, such as the cause of the noisy breathing and the severity of the condition. Your child's treatment will be tailored to meet her unique needs. Multidisciplinary care is often provided by a team of airway surgeons, speech pathologists, gastroenterologists, pulmonary physicians, social workers and nurses.Treatment options may include:

Observation — Indicated for patients who have minor degrees of obstruction such as laryngomalacia or mild subglottic stenosis.

Medications — Reflux medication and/or steroids to reduce airway swelling. Endoscopic surgery — To remove airway obstructions (i.e. foreign body or cyst) or expand the airway (i.e. for subglottic

stenosis) through the windpipe. In many cases, it is performed through a scope. Open surgery — To repair obstructions and scarring through an outside incision.

ReferencesBerg E., Naseri I. Sobol S. The role of airway fluoroscopy in the evaluation of children with stridor. Arch Otolaryngol Head Neck Surg. 2003 Mar;129(3):305-9.

Jika ada stridor saat ekspirasi terdapat kelainan dimana???

7. Why indirect laryngoscopy shows hyperemic laryngeal mucosa and oedema?

8. Is there any correlation between her work, age and onset with symptom?

9. Is there any correlation between hoarseness with history of chronic cough, hight sweating and weight loss for the last one year?

10. DDTabel perbedaan etiologi yang mendasari terjadinya laringitis akut dan kronis(6)

Common Causes of LaryngitisType of Laryngitis

Acute (Short-lived) Chronic (longer term)

InfectiousBacterial XViral XFungal X XContactReflux X XPollutants X XSmoking XInhaled Medications XCaustic Ingestions X XMedicalVocal misuse X XVocal abuse X

Trauma X XAllergicAllergies X XDryness (Laryngitis Sicca)Dehydration X XDry Atmosphere X XMouth Breathing X XMedications X XThermalClosed-Space Fire X XCrack Pipe X X

- LARINGITIS KRONISNon-Spesifik laringitis kronis

Sering merupakan radang kronis yang disebabkan oleh infeksi pada saluran pernapasan, seperti selesma, influensa, bronkhitis atau sinusitis. Akibat paparan zat-zat yang membuat iritasi, seperti asap rokok, alkohol yang berlebihan, asam lambung atau zat-zat kimia yang terdapat pada tempat kerja.Terlalu banyak menggunakan suara, dengan terlalu banyak bicara, berbicara terlalu keras atau menyanyi (vokal abuse). Pada peradangan ini seluruh mukosa laring hiperemis, permukaan yang tidak rata dan menebal.(15)

Gejala klinis yang sering timbul adalah berdehem untuk membersihkan tenggorokan. Selain itu ada juga suara serak. Perubahan pada suara dapat berfariasi tergantung pada tingkat infeksi atau iritasi, bisa hanya sedikit serak hingga suara yang hilang total, rasa gatal dan kasar di tenggorokan, sakit tenggorokan, tenggorokan kering, batuk kering, sakit waktu menelan. Gejala berlangsung beberapa minggu sampai bulan.(15)

Pada pemeriksaan ditemukan mukosa yang menebal, permukaannya tidak rata dan hiperemis. Bila terdapat daerah yang dicurigai menyerupai tumor, maka perlu dilakukan biopsi.(15)

Pengobatan yang dilakukan tergantung pada penyebab terjadinya laryngitis dan simtomatis. Pengobatan terbaik untuk langiritis yang diakibatkan oleh sebab-sebab yang umum, seperti virus, adalah dengan mengistirahatkan suara sebanyak mungkin dan tidak membersihkan tenggorokan dengan berdehem. Bila penyebabnya adalah zat yang dihirup, maka hindari zat penyebab iritasi tersebut. Dengan menghirup uap hangat dari baskom yang diisi air panas mungkin bisa membantu. Bila anak yang masih berusia batita atau balita mengalami langiritis yang berindikasi karahcroup, bisa digunakan kortikosteroid seperti dexamethasone. Untuk laringitis kronis yang juga berhubungan dengan kondisi lain seperti rasa terbakardi uluh hati, merokok atau alkoholik, harus dihentikan.(7)

Untuk mencegah kekeringan atau iritasi pada pita suara : (5)(6)(7)(15)

1. Jangan merokok, dan hindari asap rokok dengan tidak menjadi perokok tidak langsung. Rokok akan membuat tenggorokan kering dan mengakibatkan iritasi pada pita suara.

2. Minum banyak air . Cairan akan membantu menjaga agar lendir yang terdapat tenggorokan tidak terlalu banyak dan mudah untuk dibersihkan.

3. Batasi penggunaan alkohol dan kafein untuk mencegah tenggorokan kering . Bila mengalami langiritis, hindari kedua zat tersebut diatas.

4. Jangan berdehem untuk membersihkan tenggorokan. Berdehem tidak akan berakibat baik, karena berdehem akan menyebabkan terjadinya vibrasi abnormal peda pita suara dan meningkatkan pembengkakan . Berdehem juga akan menyebabkan tenggorokan memproduksi lebih banyak lendir dan merasa lebih iritasi , membuat ingin berdehem lagi.

Pada laringitis kronis akibat alergi, pasien biasanya memiliki onset bertahap dengan gejala yang ringan. Pasien dapat mengeluhkan adanya akumulasi mukus berlebih dalam laring. Dalam pemeriksaan laringoskopi biasa dijumpai sekresi mukus endolaringeal tebal dalam kadar ringan hingga sedang, eritema dan edema lipatan pita suara serta inkompetensi glotis episodik selama fase fonasi.(5)(6)

Pada kasus laringitis kronis alergi, tatalaksana meliputi edukasi kepada pasien untuk menghindari faktor pemicu. Medikasi antihistamin loratadine atau fexofenadine dipilih karena tidak memiliki efek samping dehidrasi. Sekresi mukus yang tebal dan lengket dapat di atasi dengan pemberian guaifenesin. (7)(15)

Laringitis kronis spesifikLARINGITIS TUBERKULOSA

Penyakit ini hampir selalu sebagai akibat dari tuberkulosis paru. Sering kali setelah diberikan pengobatan, tuberkulosisnya sembuh tetapi laringitis tuberkulosanya menetap. Hal ini terjadi karena struktur mukosa laring yang sangat lekat pada kartilago serta vaskularisasi yang tidak sebaik paru, sehingga bila infeksi sudah mengenai kartilago, pengobatannya lebih lama. Infeksi kuman ke laring dapat terjadi melalui udara pernafasan, sputum yang mengandung kuman, atau penyebaran melalui aliran darah atau limfe. Tuberkulosis dapat menimbulkan gangguan sirkulasi. Edema dapat timbul di fossa inter aritenoid, kemudian ke aritenoid, plika vokalis, plika ventrikularis, epiglotis, serta subglotik.(4)(8)

Secara klinis, laringitis tuberkulosis terbagi menjadi 4 stadium yaitu : (4)

Stadium infiltrasi. Mukosa laring posterior mengalami pembengkakan dan hiperemis, kadang pita suara terkena juga, pada stadium ini mukosa laring tampak pucat. Kemudian di daerah sub mukosa terbentuk tuberkel, sehingga mukosa tidak rata, tampak bintik-bintik yang berwarna kebiruan. Tuberkel itu makin besar, serta beberapa tuberkel yang berdekatan bersatu, sehingga mukosa diatasnya meregang. Pada suatu saat, karena sangat meregang, maka akan pecah dan timbul ulkus. Pada stadium ini pasien dapat merasakan adanya rasa kering ditenggorokan, panas dan tertekan di daerah laring, selain itu juga terdapat suara parau.

Stadium ulcesari. Ulkus yang timbul pada akhir stadium infiltrasi membesar. Ulkus ini dangkal, dasarnya ditutupi oleh perkejuan, serta dirasakan nyeri waktu menelan yang hebat bila dibandingkan dengan nyeri karena radang (khas), dapat juga terjadi hemoptisis.

Stadium perikondritis. Ulkus makin dalam, sehingga mengenai kartilago laring, dan yang paling sering terkena ialah kartilago aritenoid dan epiglotis. Dengan demikian terjadi kerusakan tulang rawan, sehingga terbentuk nanah yang berbau, proses ini akan melanjut dan terbentuk sekuester. Pada stadium ini pasien dapat terjadi afoni dan keadaan umum sangat buruk dan dapat meninggal dunia. Bila pasien dapat bertahan maka proses penyakit berlanjut dan masuk dalam stadium fibrotuberkulosis.

Stadium fibrotuberkulosa. Pada stadium ini terbentuk fibrotuberkulosis pada dinding posterior, pita suara dan subglotik.Pemeriksaan fisik meliputi pemeriksaan umum dan pemeriksaan THT termasuk pemeriksaan laring tak

langsung untuk melihat laring melalui kaca laring, maupun pemeriksaan laring langsung dengan laringoskopi. Pemeriksaan penunjang seperti laboratorium dapat di temukannya tes BTA positif, dan patologi anatomi.(3)(8)

Penatalaksanaannya berupa pembeian obat antituberkulosis primer dan sekunder. Selain itu pasien juga harus mengistirahatkan suaranya. Beberapa macam dan cara pemberian obat antituberkulosa :(9)

Obat primer : INH (isoniazid), Rifampisin, Etambutol, Streptomisin, Pirazinamid. Memperlihatkan efektifitas yang tinggi dengan toksisitas yang masih dapat ditolerir, sebagian besar penderita dapat disembuhkan dengan obat-obat ini.

Obat sekunder : Exionamid, Paraaminosalisilat, Sikloserin, Amikasin, Kapreomisin dan Kanamisin.

LARINGITIS LUETIKA(3)(5)

Disebabkan oleh kuman treponema palidum, sudah sangat jarang dijumpai pada bayi ataupun orang dewasa. laring tidak pernah terinfeksi pada stadium pertama sifilis. Pada stadium kedua, laring terinfeksi dengan tanda-tanda adanya edema yang hebat dan lesi mukosa berwarna keabu-abuan. Sumbatan jalan nafas dapat terjadi karena adanya pembengkakan mukosa. Pada stadium ketiga, terbentuknya guma yang nanti akan pecah dan menimbulkan ulcerasi, perikondritis dan fibrosis.

Gejala klinis yang ditemukan adalah suara parau dan batuk yang kronis. Disfagia timbul bila gumma terdapat dekat introitus esofagus. Pada penyakit ini, pasien tidak merasakan nyeri, mengingat kuman ini juga menyerang saraf-saraf di perifer.

Pada pemeriksaan, bila guma pecah, maka ditemukan ulkus yang sangat dalam, bertepi dengan dasar yang keras, berwarna merah tua serta mengeluarkan eksudat yang berwarna kekuningan. Ulkus ini tidak menyebabkan nyeri dan menjalar sagat cepat, sehingga bila tidak terbentuk proses ini akan menjadi perikondritis.

Diagnosis dapat ditegakkan dengan tes serologi (RPR,VDRL, dan FTA-ABS) dan biopsi.Penatalaksanaan dengen pemberian antibiotika golongan penicilin dosis tinggi, pengengkatan sekuester,

bila terdapat sumbatan laring karena stenosis dapat dilakukan trakeostomi dan operasi rekonstruksi(8)

Prognosis pada penyakit ini kurang bagus pada gumma yang sudah pecah, karena menyebabkan destruksi pada kartilago dan bersifat permanenLaringitis Tuberkulosis2.3.1 Definisi

Laringitis tuberkulosis adalah proses inflamasi pada mukosa pita suara dan laring yang terjadi dalam jangka waktu lama yang disebabkan oleh kuman Mycobacterium tuberculosa.1 2.3.2 Etiologi

Laringitis tuberkulosis disebabkan infeksi laring oleh Mycobacterium tuberculosa yang hampir selalu akibat tuberkulosis paru aktif. Sering kali setelah diberi pengobatan, tuberculosis parunya sembuh tetapi laringitis tuberkulosanya menetap. Hal ini terjadi karena struktur mukosa laring yang sangat lekat pada kartilago serta vaskularisasi yang tidak sebaik paru, sehingga bila infeksi sudah mengenai kartilago, pengobatannya lebih lama.2

2.3.3 EpidemiologiSebagaimana insidensi dan prevalensi tuberkulosis paru yang mengalami penurunan, kejadian laringitis

tuberculosis juga mengalami penurunan, meskipun kecenderungan peningkatan kejadian laringitis tuberkulosis dalam beberapa tahun terakhir. 3

Dulu, dinyatakan bahwa penyakit ini sering terjadi pada kelompok umur usia muda, yaitu 20-40 tahun. Dalam 20 tahun belakangan ini, insidens penyakit ini pada penduduk yang berumur lebih dari 60 tahun jelas meningkat. Saat ini, tuberkulosis dalam semua bentuk dua kali lebih sering pada laki-laki dibanding dengan perempuan. Untuk pasien berumur di atas 50 tahun, perbandingan laki-laki dengan perempuan adalah 4:1. Gambaran ini juga terlihat pada insidens kelainan laring. Tuberkulosis laring lebih sering terjadi pada laki-laki usia lanjut, terutama pasien-pasien dengan keadaan ekonomi dan kesehatan buruk, banyak di antaranya adalah peminum alkohol.1

2.3.4 PatogenesisLaringitis tuberkulosis umumnya merupakan sekunder dari lesi tuberkulosis paru aktif, jarang merupakan

infeksi primer dari inhalasi basil tuberkel secara langsung. Secara umum, infeksi kuman ke laring dapat terjadi melalui udara pernapasan, sputum yang mengandung kuman, atau penyebaran melalui darah atau limfe. 1,2

Berdasarkan mekanisme terjadinya laringitis tuberkulosis dikategorikan menjadi 2 mekanisme, yaitu:a. Laringitis Tuberkulosis Primer

Laringitis tuberkulosis primer jarang dilaporkan dalam literatur medis. Laringitis tuberkulosis primer terjadi jika ditemukan infeksi Mycobacterium tuberculosa pada laring, tanpa disertai adanya keterlibatan paru. Rute penyebaran infeksi pada laringitis tuberkulosis primer yang saat ini diterima adalah invasi langsung dari basil tuberkel melalui inhalasi.

b. Laringitis Tuberkulosis SekunderLaringitis tuberculosis sekunder terjadi jika ditemukan infeksi laring akibat Mycobacterium

tuberculosa yang disertai adanya keterlibatan paru. Laringitis tuberculosis sekunder merupakan komplikasi dari lesi tuberculosis paru aktif.

2.3.5 Gambaran Klinis2

Secara klinis, laringitis tuberkulosis terdiri dari 4 stadium, yaitu:1. Stadium infiltrasi

Yang pertama-tama mengalami pembengkakan dan hiperemis adalah mukosa laring bagian posterior. Kadang-kadang pita suara terkena juga. Pada stadium ini mukosa laring berwarna pucat. Kemudian di daerah submukosa terbentuk tuberkel, sehingga mukosa tidak rata, tampak bintik-bintik yang berwarna kebiruan. Tuberkel ini makin membesar, serta beberapa tuberkel yang berdekatan bersatu, sehingga mukosa di atasnya meregang. Pada suatu saat, karena sangat meregang, maka akan pecah dan timbul ulkus.2. Stadium ulserasi

Ulkus yang timbul pada akhir stadium infiltrasi membesar. Ulkus ini dangkal, dasarnya ditutupi oleh perkijuan, serta sangat dirasakan yeri oleh pasien.3. Stadium perikondritis

Ulkus makin dalam, sehingga mengenai kartilago laring, dan yang paling sering terkena ialah kartilago aritenoid dan epiglotis. Dengan demikian terjadi kerusakan tulang rawan, sehingga terbentuk nanah yang berbau, proses ini akan berlanjut dan terbentuk sekuester (squester). Pada stadium ini keadaan umum pasien sangat buruk dan dapat meninggal dunia. Bila pasien dapat bertahan maka proses penyakit berlanjut dan masuk dalam stadium terakhir yaitu stadium fibrotuberkulosis.4. Stadium fibrotuberkulosis

Pada stadium ini terbentuk fibrotuberkulosis pada dinding posterior, piata suara dan subglotik.2.3.6 Gejala Klinis2

Tergantung pada stadiumnya, disamping itu terdapat gejala sebagai berikut:- Rasa kering, panas dan tertekan di daerah laring.- Suara parau berlangsung berminggu-minggu, sedangkan pada stadium lanjut dapat timbul afoni.- Hemoptisis - Nyeri waktu menelan yang lebih hebat bila dibandingkan dengan nyeri karena radang lainnya, merupakan

tanda yang khas.- Keadaan umum buruk- Pada pemeriksaan paru (secara klinis dan radiologik) terdapat proses aktif (biasanya pada stadium

eksudatif atau pada pembentukan kaverne)

2.3.7 DiagnosisTuberkulosis laring harus dibedakan dari kanker dan penyakit granulomatosis lain yang mirip secara klinis.

Diagnosis tergantung dari ditemukannya basil tahan asam pada dahak pasien, bilasan lambung atau bahan biopsi. Riwayat penyakit dan penemuan klinis mengingatkan dan merupakan indikasi untuk pemeriksaan sputum dan bahan bilasan lambung dengan pewarnaan Ziehl Neelsen. Pada beberapa pasien, kuman ini mungkin sedikit sekali dan harus diulangi beberapa kali. Bahan dapat ditingkatkan dengan mencampurkan Clorox dan dilakukan pemusingan untuk mengumpulkan kuman tersebut. Kultur pada media Dubos dan inokulasi pada marmut perlu dilakukan pada kasus yang dicurigai, jika basil tahan asam tidak ditemukan pada dahak. Bilasan lambung sering menolong dalam menemukan apusan posited daripada dahak.

Foto Rontgen toraks hampir selalu memperlihatkan kelainan dan harus dilakukan sejak mula pada kasus yang dicurigai untuk menghindarkan penularan yang tidak perlu pada petugas.

Laringoskopi langsung dan biopsi harus dilakukan pada semua kasus untuk menegakkan diagnosis tuberculosis dan untuk menyingkirkan ada tidaknya karsinoma atau penyakit lain. Karsinoma terjadi cukup sering berkaitan dengan tuberculosis paru dan adakalanya dengan tuberculosis laring. Oleh karena itu, kehadirannya tidak dapat disingkirkan dengan menemukan foto toraks yang abnormal dan dahak yang mengandung basil tahan asam saja. Beberapa pasien mungkin mempunyai dahak sedikit sekali dan foto toraks cukup normal, dan pemeriksaan bahan biopsi dengan pewarnaan khusus mungkin perlu untuk menemukan basil tuberkulosa.2.3.8 Diagnosis Banding

1. Laringitis leutikaLaringitis leutika seringkali memberikan gejala yang sama dengan laringitis tuberkulosis. Akan tetapi,

radang menahun ini jarang ditemukan. Laringitis leutika terjadi pada stadium tersier dari sifilis, yaitu stadium pembentukan guma. Apabila guma pecah, maka timbul ulkus. Ulkus ini mempunyai sifat yang khas, yaitu sangat dalam, bertepi dengan dasar yang keras, berwarna merah tua serta mengeluarkan eksudat yang berwarna kekuningan. Ulkus tidak menyebabkan nyeri dan menjalar sangat cepat, sehingga bila tidak terbentuk proses ini akan menjadi perikondritis.1,2,4,5,6

2. Karsinoma laringKarsinoma laring memberikan gejala yang serupa dengan laringitis tuberkulosa. Serak adalah gejala

utama karsinoma laring, namun hubungan antara serak dengan tumor laring tergantung pada letak tumor. Untuk diagnosis pasti sebaiknya dilakukan pemeriksaan patologi anatomi.1,2

2.3.9 Tatalaksana1

Pengobatan pada dasarnya ditujukan terhadap penyakit parunya. Obat-obat anti tuberkulosis seperti isoniazid yang dikombinasikan dengan rifampisin atau etambutol paling sering digunakan untuk mencegah timbulnya kuman yang resisten. Kombinasi yang berisikan isoniazid paling bermanfaat dan obat ini biasanya digunakan dengan rifampisin atau etambutol untuk terapi permulaan pada kebanyakan kasus paru. Ketiga jenis obat digunakan pada penyakit yang sangat lanjut, pada saa pembedahan atau bila terdapat kuman yang resisten. Pasien dengan penyakit laring biasanya menderita penyakit paru lanjut, sehingga perlu diberikan terapi ketiga obat sekaligus. Dosis yang biasa diberikan ialah isoniazid 300-400 mg/hari, rifampisin 10 mg/kgBB/hari dan etambutol 15-25 mg/kgBB/hari. Obat-obat ini diberikan sekurang-kurangnya selama enam bulan setelah dahak dan bilasan lambung tidak mengandung basil tahan asam lagi.

Respon penyakit laring terhadap pengobatan biasanya cepat. Jika ada rasa nyeri, biasanya akan menghilang dalam beberapa hari dan ulkus akan smebuh dalam beberapa minggu. Istirahat suara total harus dipertahankan selama fase aktif penyakit laring.2.3.10 PrognosisTergantung pada keadaan sosial ekonomi pasien, kebiasaan hidup sehat serta ketekunan berobat. Bila diagnosis dapat ditegakkan pada stadium dini maka prognosisnya baik.

- TUMOR LARINGA. JINAKB. GANAS

Tumor laring terbagi atas 3 bagian, yaitu : 1

a.Tumor supraglotis: terbatas pada daerah mulai dari tepi atas epiglotis sampai batas atas glotis termasuk pita suara palsu dan ventrikel laring.

b.Tumor glotis : mengenai pita suara asli.

c.Tumor subglotis : tumbuh lebih dari 10 mm dibawah tepi bebas pita suara asli sampai batas inferior krikoid.

2.3. EPIDEMIOLOGIKekerapan tumor ganas laring di beberapa tempat di dunia ini berbeda-beda. Di Amerika Serikat

pada tahun 1973 – 1976 dilaporkan 8,5 kasus karsinoma laring per 100.000 penduduk laki-laki dan 1,3 kasus karsinoma laring per 100.000 penduduk perempuan. Tumor ganas laring lebih sering mengenai laki-laki dibanding perempuan dengan perbandingan 5 : 1 dan terbanyak pada usia 56-69 tahun.2,3

Di RSUP H. Adam Malik Medan, Februari 1995 – Juni 2003 dijumpai 97 kasus karsinoma laring dengan perbandingan laki dan perempuan 8 : 1. Usia penderita berkisar antara 30 sampai 79 tahun. Dari Februari 1995 – Februari 2000, 28 orang diantaranya telah dilakukan operasi laringektomi total.2

2.4. ETIOLOGIBelum diketahui pasti penyebabnya, namun beberapa penelitian epidemiologi menggambarkan

beberapa hal yang dapat meningkatkan risiko terjadinya tumor laring, beberapa diantaranya yaitu :1,6,7

1. Umur

Insiden tumor ganas laring meningkat pada usia diatas 55 tahun.2. Jenis kelamin

tumor laring 4x lebih sering mengenai laki-laki dibandingkan perempuan3. Ras

Meningkat pada ras kulit hitam dibandingkan kulit putih4. Merokok

Kebiasaan merokok meningkatkan resiko terjadinya tumor ganas laring5. Alkohol

Orang yang mengkonsumsi alkohol berkemungkinan lebih besar terkena tumor laring dibandingkan orang yang tidak mengkonsumsi alkohol.

6. Riwayat keganasan pada kepala dan leherSatu dari empat orang yang pernah menderita tumor pada kepala dan leher berisiko tinggi terkena untuk kedua kalinya.

7. PekerjaanPekerja-pekerja yang terpapar uap asam sulfat,nikel dan asbes akan beresiko tinggi menderita tumor laring

8. Faktor-faktor lain seperti virus, makanan rendah vitamin A dan gastroesophageal reflux disease ( GERD ).

2.5 HISTOPATOLOGI Karsinoma sel skuamosa meliputi 95 – 98% dari semua tumor ganas laring, dengan derajat

differensiasi yang berbeda-beda. Jenis lain yang jarang kita jumpai adalah karsinoma anaplastik, pseudosarkoma, adenokarsinoma dan sarkoma.1,2

Karsinoma verukosa adalah satu tumor yang secara histologis kelihatannya jinak, akan tetapi klinis ganas. Insidennya 1 – 2% dari seluruh tumor ganas laring, lebih banyak mengenai pria dari wanita dengan perbandingan 3 : 1. Tumor tumbuh lambat tetapi dapat membesar sehingga dapat menimbulkan kerusakan lokal yang luas. Tidak terjadi metastase regional atau jauh. Pengobatannya dengan operasi, radioterapi tidak efektif dan merupakan kontraindikasi. Prognosanya sangat baik.1,2

Adenokarsinoma. Angka insidennya 1% dari seluruh tumor ganas laring. Sering dari kelenjar mukus supraglotis dan subglotis dan tidak pernah dari glotis. Sering bermetastase ke paru-paru dan hepar. Two years survival rate-nya sangat rendah.Terapi yang dianjurkan adalah reseksi radikal dengan diseksi kelenjar limfe regional dan radiasi pasca operasi.1,2

Kondrosarkoma, adalah tumor ganas yang berasal dari tulang rawan krikoid 70%, tiroid 20% dan aritenoid 10%. Sering pada laki-laki 40 – 60 tahun. Terapi yang dianjurkan adalah laringektomi total.1,2

2.6. GEJALA KLINIS DAN SUMBATAN LARING AKIBAT TUMOR LARING2.6.1 Gejala klinis dari tumor ganas laring yaitu :1,2,8 a. Serak

Merupakan gejala utama karsinoma laring, merupakan gejala dini tumor pita suara. Hal ini disebabkan karena gangguan fungsi fonasi laring. Kualitas nada sangat dipengaruhi oleh besar celah glotik, besar pita suara, ketajaman tepi pita suara, kecepatan getaran, dan ketegangan pita suara.

Pada karsinoma laring,pita suara gagal berfungsi secara baik disebabkan oleh ketidakaturan pita suara, oklusi atau penyempitan celah glotik, teserangnya otot-otot vokalis, sendi dan ligamen krikoaritenoid, dan kadang-kadang menyerang saraf. Adanya tumor di pita suara akan mengganggu

gerak maupun getaran kedua pita suara tersebut. Serak menyebabkan kualitas suara menjadi kasar, mengganggu, sumbang dan nadanya lebih rendah dari biasa. Kadang-kadang bisa afoni karena nyeri, sumbatan jalan napas, atau paralisis komplit.

Hubungan antara serak dengan tumor laring tergantung pada letak tumor. Apabila tumor tumbuh pada pita suara asli, serak merupakan gejala dini dan menetap. Apabila tumor tumbuh di daerah ventrikel laring, di bagian bawah plika ventrikularis atau di batas inferior pita suara, serak akan timbul kemudian. Pada tumor supraglotis dan subglotis, serak dapat merupakan gejala akhir atau tidak timbul sama sekali. Pada kelompok ini, gejala pertama tidak khas dan subjektif, seperti perasaan tidak nyaman, rasa ada yang mengganjal di tenggorok. Tumor hipofaring jarang menimbulkan serak, kecuali tumor eksentif. Fiksasi dan nyeri menimbulkan suara bergumam ( Hot potato voice ).b. Dispnea dan stridor

Merupakan gejala yang disebabkan oleh sumbatan jalan napas dan dapat timbul pada tiap tumor laring.Gejala ini disebabkan oleh gangguan jalan napas oleh massa tumor, penumpukan kotoran atau sekret, maupun oleh fiksasi pita suara. Pada tumor supraglotik atau transglotik terdapat kedua gejala tersebut. Sumbatan yang terjadi secara perlahan-lahan dapat dikompensasi oleh pasien. Pada umumnya dispnea dan stridor adalah tanda prognosis yang kurang baik.c. Nyeri tenggorok

Keluhan ini dapat bervariasi dari rasa goresan sampai rasa nyeri yang tajam.d. Disfagi

Merupakan ciri khas tumor pangkal lidah, supraglotik, hipofaring, dan sinus piriformis. Keluhan ini merupakan keluhan yang paling sering pada tumor ganas post krikoid. Rasa nyeri ketika menelan ( odinofagi )menandakan adanya tumor ganas lanjut yang mengenai struktur ekstra laring.e. Batuk dan hemoptisis

Batuk jarang ditemukan pada tumor ganas glotik, biasanya timbul dengan tertekannya hipofaring disertai sekret yang mengalir ke dalam laring. Hemoptisis sering terjadi pada tumor glotik dan tumor supraglotik.f. Gejala lain

Berupa nyeri alih di telinga ipsilateral, halitosis, batuk, hemoptisis dan penurunan berat badan menandakan perluasan tumor ke luar laring atau metastasis jauh. Pembesaran kelenjar getah bening dipertimbangkan sebagai metastasis tumor ganas yang menunjukkan tumor pada stadium lanjut. Nyeri tekan laring adalah gejala lanjut yang disebabkan oleh komplikasi supurasi tumor yang menyerang kartilago tiroid dan perikondrium.2.6.2 Gejala Sumbatan laring

Gejala dan tanda sumbatan laring yang tampak adalah :4

1. Sesak napas ( dispnea ).2. Stridor ( napas berbunyi ) yang terdengar pada waktu inspirasi.3.Cekungan yang terdapat pada waktu inspirasi di suprasternal, epigastrium, supraklavikula, interkostal. Cekungan itu terjadi sebagai upaya dari otot-otot pernafasan untuk mendapatkan oksigen yang adekuat.4. Gelisah karena pasien haus udara ( air hunger ).5. Warna muka pucat dan terakhir menjadi sianosis karena hipoksia.

Jackson membagi sumbatan laring yang progresif dalam 4 stadium dengan tanda dan gejala :4

1. Stadium 1 : cekungan tampak pada waktu inspirasi di suprasternal, stridor pada waktu inspirasi dan pasien masih tenang.2. Stadium 2 : cekungan pada waktu inspirasi di daerah suprasternal makin dalam, ditambah lagi dengan timbulnya cekungan di daerah epigastrium. Pasien sudah mulai gelisah. Stridor terdengar pada waktu inspirasi.3. Stadium 3 : cekungan selain didaerah suprasternal, epigastrium juga terdapat di infraklavikula dan sela-sela iga, pasien sangat gelisah dan dispnea. Stridor terdengar pada waktu inspirasi dan ekspirasi.4. Stadium 4 : cekungan- cekungan diatas bertambah jelas, pasien sangat gelisah, tampak sangat ketakutan dan sianosis. Jika keadaan ini berlangsung terus maka pasien akan kehabisan tenaga, pusat pernapasan paralitik karena hiperkapnia. Pasien lemah dan tertidur, akhirnya meninggal karena asfiksia.2.7. DIAGNOSIS

Diagnosis ditegakkan berdasarkan :1,2 1. Anamnesis.

Didapatkan keluhan berupa suara serak, nafas berbunyi, sulit bernafas, nyeri tenggorokkan, batuk berdarah, sulit menelan dan kadang – kadang ditemukan bau mulut, penurunan berat badan. 2. Pemeriksaan THT rutin .3. Laringoskopi direk.

Pemeriksaan ini untuk memastikan lokasi tumor dan menilai penyebaran tumor.4. Radiologi foto polos leher dan thorak .

Foto toraks diperlukan unuk menilai keadaan paru, ada atau tidaknya proses spesifik dan metastasis di paru.5. Pemeriksaan radiologi khusus separti CT-Scan, MRI.

CT-Scan laring dapat memperlihatkan keadaan tumor dan laring lebih seksama, misalnya penjalaran tumor pada tulang rawan tiroid dan daerah pre-epiglotis serta metastasis kelenjar getah bening leher. 6. Pemeriksaan hispatologi dari biopsi laring sebagai diagnosa pasti.

Diagnosis pasti ditegakkan dengan pemeriksaan patologi anatomik dari bahan biopsi laring dan biopsi jarum halus pada pembesaran kelenjar getah bening di leher. Dari hasil patologi anatomik yang terbanyak adalah karsinoma sel skuamosa.

Klasifikasi dan stadium tumor berdasarkan UICC 1988 : 1. Tumor primer ( T ) Supraglotis : T is : tumor in situ T 1 : tumor terdapat pada satu sisi suara atau pita suara palsu ( gerakan masih baik ). T 2 : tumor telah meluas ke satu dan dua sisi daerah supraglotis dan glotis masih bisa bergerak ( tidak terfiksir ). T 3 : tumor terbatas pada laring dan sudah terfiksir atau meluas ke daerah krikoid bagian belakang, dinding medial dari sinus piriformis, dan kearah rongga pre-epiglotis.T 4 : tumor sudah meluas ke luar laring, menginfiltrasi orofaring jaringan lunak pada leher atau sudah merusak tulang rawan tiroid.Glotis : T is : tumor in situ.

T 1 : tumor mengenai satu atau dua sisi pita suara, tetapi gerakan pita suara masih baik, atau tumor sudah terdapat pada komisura anterior atau posterior.T 2 : tumor meluas ke daerah supraglotis atau subglotis, pita suara masih dapat bergerak atau sudah terfiksasi ( impaired mobility ). T 3 : tumor meliputi laring dan pita suara sudah terfiksir. T 4 : tumor sangat luas dengan kerusakan tulang rawan tiroid atau sudah keluar dari laring. Subglotis : T is : tumor in situ T 1 : tumor terbatas pada subglotis . T 2 : tumor sudah meluas ke pita, pita suara masih dapat bergerak atau sudah terfiksasi. T 3 : tumor sudah mengenai laring dan pita suara sudah terfiksasi.T 4 : tumor yang luas dengan destruksi tulang rawan atau perluasan keluar laring atau dua-duanya.2. Pembesaran kelenjar getah bening leher (N) N x : kelenjar tidak teraba. N 0 : secara klinis tidak teraba kelenjar. N 1 : klinis teraba kelenjar homolateral dengan diameter = 3 cm.N 2 : klinis teraba kelenjar tunggal, ipsilateral dengan diameter 3 – 6 cm. N 2a : klinis terdapat satu kelenjar ipsilateral dengan diameter > 3 cm dan tidak >6 cm. N 2b : klinis terdapat kelenjar ipsilateral multipel dengan diameter tidak lebih dari 6 cm.N 2c : metastasis bilateral atau kontralateral, diameter tidak lebih dari 6 cm.N 3 : metastase kelenjar limfe lebih dari 6 cm.3. Metastase jauh ( M ) Mx : tidak terdapat / terdeteksi.M 0 : tidak ada metastase jauh. M 1 : terdapat metastase jauh. 4. Stadium : Stadium I : T1 N0 M0 Stadium II : T2 N0 M0 Stadium III : T3 N0 M0

T1/T2/T3 N1 M0 Stadium IV : T4 N0/N1 M0

T1/T2/T3/T4 N2/N3 T1/T2/T3/T4 N1/N2/N3 M1

2.8 DIAGNOSIS BANDING Tumor ganas faring dapat dibanding dengan : 1. TBC laring 2. Sifilis laring 3. Tumor jinak laring 4. Penyakit kronis laring

2. 9 PENATALAKSANAAN

2.9.1 Penatalaksanaan tumor laringSecara umum ada 3 jenis penanggulangan karsinoma laring, yaitu :1,2,8

1.PembedahanTindakan operasi untuk keganasan laring terdiri dari :

1. Laringektomi : a. Laringektomi parsial Laringektomi parsial diindikasikan untuk karsinoma laring stadium I yang tidak memungkinkan dilakukan radiasi, dan tumor stadium II. b. Laringektomi total Adalah tindakan pengangkatan seluruh struktur laring mulai dari batas atas ( epiglotis dan os hioid ) sampai batas bawah cincin trakea. 2. Diseksi leher radikal

Tidak dilakukan pada tumor glotis stadium dini ( T1 – T2 ) karena kemungkinan metastase ke kelenjar limfe leher sangat rendah. Sedangkan tumor supraglotis, subglotis dan tumor glotis stadium lanjut sering kali mengadakan metastase ke kelenjar limfe leher sehingga perlu dilakukan tindakan diseksi leher. Pembedahan ini tidak disarankan bila telah terdapat metastase jauh.2. Radioterapi

Radioterapi digunakan untuk mengobati tumor glotis dan supraglotis T1 dan T2 dengan hasil yang baik ( angka kesembuhannya 90% ). Keuntungan dengan cara ini adalah laring tidak cedera sehingga suara masih dapat dipertahankan. Dosis yang dianjurkan adalah 200 rad perhari sampai dosis total 6000 – 7000 rad.

Radioterapi dengan dosis menengah telah pula dilakukan oleh Ogura, Som, Wang, dkk, untuk tumor-tumor tertentu. Konsepnya adalah untuk memperoleh kerusakan maksimal dari tumor tanpa kerusakan yang tidak dapat disembuhkan pada jaringan yang melapisinya. Wang dan Schulz memberikan 4500–5000 rad selama 4–6 minggu diikuti dengan laringektomi total.3. Kemoterapi

Diberikan pada tumor stadium lanjut, sebagai terapi adjuvan ataupun paliativ. Obat yang diberikan adalah cisplatinum 80–120 mg/m2 dan 5 FU 800–1000 mg/m2.Rehabilitasi suara

Rehabilitasi setelah operasi sangat penting karena telah diketahui bahwa tumor ganas laring yang diterapi dengan seksama memiliki prognosis yang baik. Setelah laringektomi dilakukan rehabilitasi suara dengan pertolongan alat bantu suara yakni vibrator yang ditempelkan didaerah submandibula atau menggunakan esophageal speech dimana suara dihasilkan dari esofagus melalui proses belajar.1,2 2.9.2 Penatalaksanaan sumbatan laring

Dalam penanggulangan sumbatan laring prinsipnya diusahakan supaya jalan nafas lancar kembali. Tindakan konservatif dengan medikamentosa dilakukan pada sumbatan laring stadium 1. Tindakan operatif atau resusitasi yang dilakukan pada stadium 2 dan 3 yaitu intubasi endotrakea dan trakeostomi sedangkan krikotirotomi dilakukan pada stadium 4.4

Intubasi endotrakeaIndikasi intubasi endotrakea yaitu 4:

1. Untuk mengatasi sumbatan saluran nafas atas

2. Membantu ventilasi3. Memudahkan mengisap sekret dari traktus trakeobronkial4. Mencegah aspirasi sekret di rongga mulut atau yang berasal dari lambung

Ukuran pipa endotrakea harus sesuai dengan ukuran trakea pasien dan umumnya untuk dewasa dipakai yang diameter dalamnya 7 – 8,5 mm. Pipa endotrakea tidak boleh lebih dari 6 hari dan selanjutnya dilakukan trakeostomi. Trakeostomi

Merupakan tindakan membuat lubang pada dinding depan / anterior trakea untuk bernafas. Menurut letak stroma, trakeostomi dibedakan letak yang tinggi dan letak yang rendah dan batas letak ini adalah cincin trakea ke tiga. Indikasi trakeostomi yaitu 4:

1. Mengatasi obstruksi laring2. Mengurangi ruang rugi di saluran nafas atas3. Mempermudah pengisapan sekret dari bronkus4. Untuk memasang respirator5. Untuk mengambil benda asing dari subglotis

KrikotirotomiKrikotirotomi merupakan tindakan penyelamat pasien dalam keadaan gawat nafas dengan cara

membelah membran krikotiroid. Tindakan ini harus dikerjakan cepat walaupun persiapannya darurat. Kontraindikasi krikotirotomi pada anak dibawah 12 tahun, tumor laring yang sudah meluas ke subglotis dan terdapat laringitis.4 2. 10. PROGNOSIS

Tergantung dari stadium tumor, pilihan pengobatan, lokasi tumor dan kecakapan tenaga ahli. Secara umum dikatakan five years survival pada karsinoma laring stadium I adalah 90 – 98%, stadium II adalah 75 – 85%, stadium III adalah 60 – 70% dan stadium IV adalah 40 – 50%. Adanya metastase ke kelenjar limfe regional akan menurunkan five years survival rate sebesar 50%.1,2