Lecture No. 19. Diseases of the larynx. Foreign bodies of the larynx

Objects that can be foreign bodies of the larynx are very diverse - from a fallen tooth and food items to small metal objects. They can lie freely or be introduced into the soft tissues of the larynx.

There are differences in the clinic of foreign bodies depending on their localization. Foreign bodies of the upper floor of the larynx, including vestibular folds and blinking of the ventricle, mainly lead to mucosal edema, stenosis is rare here, only in the case of laryngeal angina. A foreign body located at the level of the glottis can lead to acute stenosis due to spasm of the vocal muscles and closing of the vocal folds. This is especially common in children, because they have a narrowing in the subglottic space and the foreign body cannot fall into the trachea, as in adults.

The outcome of a foreign body of the larynx, as well as the pharynx, can be a natural rejection as a result of coughing, gagging, or a sharp exhalation, and, if necessary, with the help of indirect or direct laryngoscopy. In other cases, a foreign body is swallowed when it enters the esophagus or penetrates into the trachea, bronchi. In this case, death may occur as a result of asphyxia.

If a foreign body has fallen into the trachea, then the immediate danger of asphyxia, as a rule, does not arise. The danger lies in the possible blockage of the pulmonary or lobar bronchi, followed by atelectasis of the lung. Foreign bodies of the trachea and bronchi are removed by tracheobronchoscopy.

1. Acute laryngitis

Acute laryngitis is an inflammation of the mucous membrane of the larynx, which, as a rule, is affected a second time in acute respiratory infections, is less often an independent disease, while there is always inflammation of the mucous membrane of the trachea. In the first place are the defeat of the voice (dysphonia or aphonia), perspiration and burning in the larynx, cough, fever. On examination - hyperemia of the mucous membrane of the vocal folds, other parts of the larynx, sometimes - mucus in the folds.

Dysphonia is explained by swelling of the mucous membrane of the folds, swelling of the tissues of the blinking ventricles, which disrupts the free oscillations of the folds. Aphonia occurs with paresis of the vocal muscle, the glottis does not close completely, taking an oval shape during phonation.

With influenza, hemorrhagic laryngitis is observed when hemorrhages occur under the mucous membrane of the vocal folds. When conducting differential diagnosis, it is necessary to take into account the condition of the pharynx, since acute laryngitis in diphtheria, measles, scarlet fever is rarely isolated. The main method of treating acute laryngitis is inhalation: alkaline, alkaline-oil, inhalation with an individual inhaler (for example, Bioparox), according to indications, analgesics, antihistamines, vitamins are prescribed, and rarely antibiotics. Not bad help phonophoresis with hydrocortisone on the larynx or electrophoresis with potassium iodide, especially with aphonia. The infusion of various medicinal mixtures is also used with the help of a laryngeal syringe, which has a special long curved tip.

For example, equal parts of sea buckthorn oil, menthol oil and an alkaline mixture for inhalation are taken. Before infusion, the mixture is emulsified by adding 1-1,5 ml of emulsion. Under the control of indirect laryngoscopy during phonation, the mixture is applied to the vocal folds. The prognosis is favorable. The duration of the disease is 7-10 days.

Subglottic laryngitis (false croup). This type of acute laryngitis usually affects children. These features are explained by the structure of the larynx in children - the presence of loose fiber between the cricoid and thyroid cartilages outward from the mucous membrane of the larynx, which disappears with the growth of the larynx during puberty. This fiber is characterized by rapid (20-30 minutes) swelling with inflammation of the larynx, which occurs most often at night when the child is in a horizontal position. At the same time, the child wakes up in fear, rushes about, cries, stridor breathing appears, with a clear voice - a "barking" cough. When examining the larynx, there are, as it were, three floors of folds - vocal, vestibular, and below - swelling of the subglottic space in the form of third folds. During an attack of false croup, the child should be immediately picked up, giving him a vertical position, lower his legs into a hot bath (42-45 ° C), inhalation of a mixture of hydrocortisone and galazolin, mustard plaster on the chest, inside - antihistamines.

Inspection of the pharynx and larynx is necessary, although laryngoscopy in children is extremely difficult and sometimes fails. By itself, false croup is not dangerous, an attack sometimes goes away even without treatment when the patient is in an upright position, it is dangerous not to recognize diphtheria and not to inject serum on time. Enlarged cervical lymph nodes, a hoarse voice, epidemiological data (contact with a patient with diphtheria, consultation of an infectious disease specialist) speak in favor of diphtheria.

Throat angina (submucosal laryngitis). The disease is more often caused by vulgar flora with mechanical and thermal injuries, or with the transition of purulent processes from the tonsils, with pharyngeal processes.

Laryngeal angina has three forms: such as inflammatory edema, laryngeal abscess, phlegmon of the larynx.

With laryngeal edema, the general condition is slightly disturbed. With laryngoscopy, areas of vitreous edema are found, more often in the region of the epiglottis and (or) arytenoid cartilages. Swallowing is not difficult, moderately painful, breathing is free. However, with a sharp edema, there may be moderate disturbances in voice and breathing.

Timely therapy gives a good effect. Recommended are aspirin, antihistamines, a warming compress on the neck, dehydration therapy, such as intravenous infusions (prednisolone - 30 mg, 5% ascorbic acid solution - 5 ml, panangin solution, saline - 400 ml, lasix - 1,5-2 ml ).

The effect of treatment usually occurs quickly, the prognosis is favorable. However, in persons weakened, with reduced immunity, severe complications can occur.

Abscess of the larynx. Symptoms are similar to the previous disease, but much more pronounced. With laryngoscopy, one can see not only the epiglottis and arytenoid cartilages, but also the spread of edema to the vallecules, piriform sinuses. Salivation and aphonia are noted due to severe pain in swallowing and voice formation.

After 3-4 days from the onset of the disease, the formed abscess spontaneously opens, relief comes. Otherwise, the abscess is opened with a special laryngeal knife. Conservative treatment is the same as for edematous laryngitis.

Phlegmon of the larynx is a very serious and relatively rare disease. The process covers the submucosal tissue of the entire larynx. Against the background of a sharp fever, swallowing disorder is observed due to unbearable pain. Respiratory problems come to the fore. With laryngoscopy, infiltration and hyperemia of all walls of the larynx are determined.

In various places, purulent foci may open with the release of thick dark (hemorrhagic) pus. Fever occurs with a high temperature, it may be accompanied by dehydration due to the inability to swallow, therefore, such patients require parenteral nutrition and the introduction of saline solutions (for example, bisols, trisols). Due to the threat of asphyxia, an early tracheotomy is required.

Anti-inflammatory treatment is intensive: large doses of modern antibiotics, hormones, antihistamines, analgesics.

Fatal outcomes are rare, however, disability often occurs in the form of aphonia, cicatricial stenosis of the larynx, which then requires surgical interventions, since, along with other factors (specific infections, injuries, foreign bodies), phlegmon of the larynx can be the cause of chondroperichondritis of the cartilage of the larynx.

Along with trauma (blunt, acute, gunshot), a frequent cause was a long stay in the larynx of the endotracheal tube (more than 3-5 days) for mechanical ventilation. The result is persistent stenosis of the larynx, requiring surgical treatment.

2. Chronic laryngitis

The picture of chronic catarrhal laryngitis is similar to acute, but their symptoms can be smoothed out. They, as a rule, are combined with chronic pharyngitis, the course is undulating. Causes - chronic inflammatory diseases of the trachea, bronchi, lungs, sinusitis, vasomotor rhinitis, adverse environmental factors (frequent or constant cooling, impurities in the air, alcohol abuse).

In 100% of smokers, the larynx is affected (smoker's laryngitis), but passive smoking (presence in a smoky room) is also quite harmful. Chronic laryngitis is expressed in persistent dysphonia, fatigue of the voice, its hoarseness, coarsening (the voice of a smoker).

A kind of chronic laryngitis - atrophic, occurring with lakes, pharyngopathy; blanching and thinning of the mucous membrane are noted. Treatment is the same as for acute laryngitis, but preventive measures are of decisive importance: refusal of cold food and drink, bad habits, elimination of unfavorable factors of work and life, treatment of lung diseases.

Hypertrophic laryngitis is diffuse and (more often) limited. When diffuse, the vocal folds are not only enlarged, but also covered by enlarged vestibular folds, which close during phonation, forming a kind of voice timbre ("dog's voice").

Limited hypertrophic laryngitis is more common.

1) Singers' knots. Occurs with improper use of the voice, very often found in singers with an incorrectly delivered voice (hence the name), actors, lecturers, teachers and anyone who overloads the vocal apparatus. There is an overgrowth of the epithelium and connective tissue on the border of the middle and posterior thirds of the vocal folds, no larger than a millet grain. The glottis does not close completely.

2) Pachydermia - limited outgrowths in the form of nodules and tubercles in the posterior parts of the vocal folds or in the interarytenoid space.

3) Subglottic laryngitis - a symmetrical thickening in the subglottic space (as with false croup) without signs of suffocation, but only with a change in the timbre and sonority of the voice.

4) Prolapse of the Morganian ventricle - it can be one- and two-sided, when a roller is visible between the vestibular and vocal folds, sometimes obscuring the latter for inspection. Prevention and treatment are the same as for the forms of chronic laryngitis described above.

Myogenic and neurogenic paralysis of the larynx. The function of the muscles of the larynx can suffer from various infections, injuries, voice strain, congenital weakness.

In the first place among myogenic paralysis is the paralysis of the internal vocal muscle.

The folds do not close during phonation, an oval gap remains between them, which often happens in acute laryngitis. With damage to the lateral cricoarytenoid muscle, the anterior two-thirds of the glottis do not close, it looks like an irregular rhombus, and with paralysis of the interarytenoid muscles, they do not close in the posterior third of the glottis in the form of a triangle. With damage to the posterior vocalis muscle, which is the only dilator of the glottis, the vocal fold is motionless in the middle, the glottis expands only due to the opposite muscle.

When breathing, the glottis has the shape of a right triangle. Voice formation and breathing, however, are not disturbed. With bilateral paralysis of these muscles, there is a threat of asphyxia and a tracheotomy is required.

However, myogenic paralysis of these dilators of the glottis is very rare, usually due to damage to the recurrent nerve, the only one innervating this muscle, in contrast to the constrictor muscles that have cross-innervation.

The main causes of damage to the recurrent (lower laryngeal) nerve are pathology of the aorta, hypertrophy of the heart muscle, tumors of the mediastinum. More often, the left recurrent nerve, which passes through the mediastinum much lower than the right, to the level of the aortic arch, is affected. 2,5-3% of strumectomies performed by surgeons are accompanied by unilateral, less often bilateral lesions of the recurrent nerve.

With unilateral nerve damage, the fold is first located along the midline, then compensation of the respiratory function occurs due to the restructuring of the tone of the constrictors and the lateral shift of the affected fold by one third of the lumen. A healthy fold goes beyond the sagittal line during phonation, the arytenoid cartilage lies behind the paralyzed one.

Unilateral lesion does not require treatment. With a bilateral lesion, as a rule, a tracheostomy is applied, and then an operation is performed on the larynx with the removal of one or two folds to eliminate stenosis (chordectomy).

Stenosis of the larynx. Stenosis of the larynx and trachea lead to severe respiratory disorders (up to death from asphyxia). Laryngology studies only stenosis of the larynx and upper (cervical) trachea, while thoracic surgeons deal with stenosis of the thoracic region.

There are differences in both pathogenesis and clinics of acute and chronic stenoses of the larynx. Acute stenoses occur most often as a result of edema of the fiber in the region of the vestibule of the larynx, the blinking sinus, and in children - in the subglottic space, less often - due to a foreign body. Laryngeal tonsillitis (submucosal laryngitis) is a disease in which swelling of the vestibule of the larynx begins very quickly, and this is where Voyachek's tonsil is located. Edema can grow very quickly: from several hours to 2-3 days and even lead to sudden asphyxia. False croup (subglottic laryngitis) occurs only in children, since they have a diameter of the inner half-ring of the thyroid cartilage much larger than a ring, and this space is filled with loose fiber.

Edema develops here within 15-30 minutes, usually at night during sleep, when the child assumes a horizontal position. True croup - diphtheria of the larynx - is the second cause of stenosis - a foreign body of the larynx, since films are formed here as a result of necrosis of the mucous membrane, blocking the lumen of the larynx.

There are also "external" foreign bodies that outwardly injure the mucous membrane with subsequent edema or penetrate into the lumen of the larynx and trachea, narrowing it.

According to the existing classification, stenoses are divided into:

1) lightning-fast with complete closure of the glottis;

2) acute I, II and III degrees, depending on the narrowing of the glottis, respectively, up to one third of the lumen, no more than two thirds and more than two thirds of the lumen.

Chronic stenosis of the larynx is not divided into degrees, because the patient's condition here largely depends on the compensation of the patient's respiratory function and adaptive mechanisms, their plasticity, therefore, with the same degree of stenosis, the condition of patients is very different.

This can be clearly seen with stenosis of the trachea, when respiratory failure during exercise, shortness of breath of the patient, and sometimes the doctor, is explained by heart failure, increased blood pressure, stagnation in the pulmonary circulation, while in a patient, a mediastinal tumor already compresses the trachea to the diameter of a ball-bearing rod. pens, only a thorough X-ray examination reveals the true cause.

In the etiology of chronic stenosis of the larynx and trachea are tumors of the larynx and trachea, trauma, infectious granulomas (scleroma, syphilis and tuberculosis of the larynx).

With compensated chronic stenosis, tracheotomy is rarely done, only if an acute process is added, leading to edema and a significant narrowing of the glottis.

A special type of stenosis of the larynx occurs as a result of paralysis of the vocal folds (unilateral or bilateral) due to damage to the lower laryngeal (recurrent) nerves, especially often occurs during strumectomy (in 2,5-4% of operated patients), which is explained by the passage of the recurrent nerve through the thyroid gland. Other causes of such a lesion are trauma, and the left recurrent nerve is syphilitic periortitis, since this nerve goes around the aortic arch.

There are conservative and surgical treatment of stenosis. The first includes the treatment of the underlying disease and the stenosis itself, as a rule, the parenteral use of drugs: diuretics, antihistamines, hormones.

With fulminant stenosis, a conicotomy is used - a horizontal dissection of the conical ligament connecting the thyroid and cricoid cartilages.

It is easily felt on the neck, and when it is cut, there is no bleeding, since there are no muscles and blood vessels, while the surgeon enters the subglottic space. Fulminant stenosis occurs when the larynx is blocked either at the level of the laryngopharynx, where a large foreign body gets stuck during swallowing and fixes the epiglottis in the lower position (they say - the person choked), or (more often in children) the foreign body enters the glottis, there is a spasm of the vocal folds in middle position. When a foreign body threatening asphyxia falls into the trachea, stenosis, as a rule, does not occur, but there is a danger of blockage of the bronchi and lung atelectasis. Foreign bodies are removed with a bronchoscope. If with acute stenosis of the first degree, tracheotomy is done extremely rarely, then, on the contrary, with stenosis of the third degree, tracheotomy is absolutely indicated.

Acute stenosis of the second degree requires a careful and balanced analysis to make a decision on tracheotomy, in order, on the one hand, to avoid unnecessary injury to a vital organ, and on the other hand, not to endanger the patient's life itself.

Tracheotomy - the imposition of a stoma on the trachea in three classic places - between the 2nd and 3rd tracheal rings (upper), between the 3rd and 4th - middle, between the 5th and 6th - lower. In the first and third cases, the isthmus of the thyroid gland is displaced up or down, and in the second case, the isthmus is dissected. The technique of tracheotomy is simple - a skin incision is made from the edge of the thyroid cartilage down, not reaching the jugular notch. Then the anterior muscles of the neck are bluntly stratified, while it must be remembered that the stratification should be exactly along the midline.

When approaching the trachea, the isthmus of the thyroid gland is determined, moved up or down, or crossed. The level of the tracheal incision is outlined. According to V. I. Voyachek, one of the ligaments between the cartilaginous rings of the trachea (transverse tracheotomy) is cut across, a tracheotomy tube is inserted here using a nasal mirror, the wound is not completely sutured in order to avoid emphysema of the neck tissue.

The tube has a shield for fixing on the neck with gauze turundas, and a cotton-gauze napkin with a slot is placed under the shield. If necessary, the tube is drained by suction. The transverse incision of the trachea is the prevention of chondroperichondritis of cartilage rings. There is also a method of longitudinal section of two cartilages of the larynx (longitudinal tracheotomy) with the subsequent introduction of the tube. In this case, the development of perichondritis, prolonged non-healing of the stoma after removal of the tube, cannula-carrier, when adequate breathing is not provided without a tube, are possible. The choice of the method of tracheotomy according to Björk is unsuccessful, when a U-shaped window is applied with parallel incisions of the tracheal rings and the interannular ligament, followed by the abduction of the flap down and its fixation with sutures to the skin.

Such an incision is made to exclude spontaneous prolapse of the tracheotomy tube and, in view of this, a new danger of suffocation. Such an incision leads to necrosis of the U-shaped flap of the trachea and the formation of persistent cicatricial stenosis with the need for further plastic surgery.

Elimination of cicatricial stenosis of the larynx is a rather complex intervention, which has its own rules, possibilities and difficulties.

3. Damage to the larynx

Injuries to the larynx are relatively rare. Distinguish between closed and open injuries, while closed are divided into internal and external. Internal injuries occur as a result of foreign bodies, medical manipulations (for example, tracheal intubation). Such injuries do not pose a particular danger, with the exception of the possibility of developing chondroperichondritis of the cartilage of the larynx, when the prognosis becomes serious. External closed injuries - bruises, compression of the larynx, fractures of cartilage, hyoid bone, tears of the larynx from the trachea. This can happen as a result of a blow to the larynx with hard objects, in a fight - with the edge of the palm.

The victim often loses consciousness, shock occurs, local hemorrhages, subcutaneous emphysema, which can be superficial, and if it spreads into the laryngopharyngeal tissue, there is a danger of asphyxia, in such cases a tracheostomy is required.

In addition to external examination, indirect laryngoscopy, radiography is of great importance in the diagnosis of larynx injury (not only for examining cartilage, but also for the spread of emphysema through internal cellular spaces).

The prognosis for contusions of the larynx, especially with cartilage fractures, is always serious. The patient is in danger of strangulation not only due to stenosis of the larynx, but also possible tamponade of the trachea and bronchi with outflowing and gore blood, and in the following days mediastinitis may develop due to the penetration of infection there. Tracheotomy in such cases is necessary not only to restore breathing, but also to suck blood from the bronchial tree.

Treatment of such patients is carried out exclusively in a hospital. If necessary, in case of significant crushing of the cartilage, a laryngofissure is performed to remove fragments, hemostasis. Patients are fed through a probe.

There are three types of open injuries of the larynx - cut, stab and gunshot (bullet and shrapnel).

Cut damage to the larynx occurs when the neck is cut, usually in a horizontal plane (from ear to ear), while depending on the height of the cut, the thyroid-hyoid membrane or conical ligament is cut.

In the first case, the wound gapes, the laryngopharynx is clearly visible, breathing is not disturbed, and with a low cut, breathing may be disturbed due to blood flow. The death of the wounded comes quickly only in the case of cutting the carotid arteries. If this does not happen, the prognosis depends on the severity of inflammation from the larynx and surrounding tissues.

Stab wounds of the neck with damage to the larynx are applied with thin, narrow, long objects and leave a narrow channel, which, when the injuring object is removed, is blocked along its length by the fascia of the neck (coulis syndrome), which contributes to the formation of emphysema and the development of mediastinitis, so such a channel has to be dissected.

With neck injuries of any origin, especially with damage to blood vessels and nerves, shock develops, which also requires adequate therapy.

Gunshot wounds of the larynx are most often combined, since other organs of the neck are also damaged. They are usually divided into through, blind and tangent.

With penetrating wounds, a wounding projectile (bullet) pierces both walls of the larynx and goes beyond it, with a blind wound, the bullet remains in the cavity of the larynx, moving further either into the pharynx or into the trachea. With a tangential wound, the bullet only hits the wall of the trachea without tearing it.

Medical measures are built in two stages - emergency care and subsequent rehabilitation. Emergency care includes providing breathing, stopping bleeding, treating a gunshot wound (if necessary, a laryngofissure), removing a foreign body (a wounding projectile), inserting a food probe. With a combined lesion, the participation of other specialists in the provision of emergency care is sometimes required (for example, a neurosurgeon, maxillofacial surgeon). The rehabilitation phase can be quite long, depending on the extent of the damage.

Authors: Drozdov A.A., Drozdova M.V.

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