16th February 2025

The larynx

Disorders of the larynx may present with hoarseness, change in voice, difficulty breathing and chronic aspiration. The investigation may require flexible nasendoscopy (FNE) to visualise the larynx, which can be conducted in the ENT clinic.

Laryngitis

May be acute or chronic (lasting more than four weeks). Acute laryngitis is a common self-limiting illness causing hoarseness, usually caused by respiratory viruses. Chronic laryngitis is caused by irritants such as smoking, alcohol, gastro-oesophageal reflux, and chronic sinusitis with post-nasal drip. Chronic laryngitis can also complicate systemic diseases such as rheumatoid arthritis, pemphigoid, SLE and sarcoid.

Acute epiglottitis

This severe disease is most commonly caused by H. influenzae type B. It can cause life-threatening airway compromise, with a mortality of 7% in adults, but is now rare thanks to widespread vaccination. Presenting features include sepsis, sore throat, drooling, painful dysphagia, respiratory distress and stridor. Support should be sought from ENT and Anaesthetics, and the airway should only be examined where there are facilities to undertake endotracheal intubation. Treatment involves airway management and a third-generation cephalosporin such as ceftriaxone or cefotaxime.

Laryngeal cancer

This is predominantly squamous cell carcinoma related to smoking and alcohol and commonly presents with hoarseness. Flexible nasendoscopy (FNE) typically shows a white plaque-like lesion. Management is usually one or both of radiotherapy and surgery. Following a laryngectomy, it is important to be aware that the patient has no patent upper airway, as the trachea opens directly to the anterior neck.

Polypoid corditis (Reinke’s oedema)

This inflammatory, smoking-related condition of the larynx most commonly affects middle-aged women, presenting with a husky, low-pitched voice.

Vocal cord paralysis

This results from palsy of the vagus or recurrent laryngeal nerve. It presents with hoarseness and carries a risk of aspiration. It may be caused by multiple sclerosis, Lyme disease, Epstein-Barr virus, Herpes Simplex virus, and malignancy on the course of the nerves.

Systemic disease

Rheumatoid arthritis can give rise to vocal cord nodules and may also involve the cricoarytenoid joints, leading to vocal cord immobility. Tuberculosis involving the larynx may also give rise to vocal cord nodules.

References

• Chapman SJ, Robinson GV, Shrimanker R, Turnbull CD, Wrightson JM. Oxford handbook of respiratory medicine. 4th ed. London, England: Oxford University Press; 2021
• Bourke SJ. Respiratory medicine: Lecture notes, 10th edition: Lecture Notes. 10th ed. Hoboken, NJ: Wiley-Blackwell; 2022
• Bruch JM. Hoarseness in adults [Internet]. Kamani DV, editor. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/hoarseness-in-adults
• Woods CR. Epiglottitis (supraglottitis): Clinical features and diagnosis [Internet]. Edwards MS, Isaacson GC, Neuman MI, editors. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/epiglottitis-supraglottitis-clinical-features-and-diagnosis
• Pichichero ME. Complications of streptococcal tonsillopharyngitis [Internet]. Sexton DJ, Kaplan SL, editors. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/complications-of-streptococcal-tonsillopharyngitis
• Wald ER. Peritonsillar cellulitis and abscess [Internet]. Edwards MS et al., editors. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/peritonsillar-cellulitis-and-abscess
• Chow AW. Ludwig angina [Internet]. Durand ML, editor. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/submandibular-space-infections-ludwig-angina
• Barraso LF, Samuel Pegram P. Clinical manifestations, diagnosis, and treatment of diphtheria [Internet]. Sexton DJ, editor. UpToDate. 2022 [cited 2022 Dec 17]. Available from: https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-diphtheria