Laryngeal edema

Edema of the larynx can be inflammatory or non-inflammatory.

The first are caused by a toxic infection, the second - by various diseases based on allergic processes, metabolic disorders, etc.).

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Causes of laryngeal edema

Inflammatory edema of the larynx, or edematous laryngitis in adults, is more often found in the vestibule of the larynx, in children - in the subglottic space. This disease is mainly due to toxins produced by streptococci, it usually affects people weakened by certain general diseases (diabetes, uremia, vitamin deficiency, cachexia of various origins), as well as general infection (flu, scarlet fever, etc.).

Edema occurs in the loose submucous layer of connective tissue, which is most developed on the lingual surface of the epiglottis, in the aryepiglottic folds, in the area of the arytenoid cartilages and in the subglottic space. Some of this tissue is also contained in the vestibule folds.

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Pathological anatomy

In edematous laryngitis caused by the super acute course of such diseases as influenza, erysipelas, scarlet fever, etc., the edema develops quickly and covers almost the entire submucosal layer of the vestibule of the larynx or subglottic space. It can also spread along the length with paratonsillar phlegmon, inflammation and abscess of the lingual tonsil and root of the tongue, trauma of the vestibule of the larynx by foreign bodies. In ulcerative forms of syphilitic or tuberculous laryngitis, radiation damage to the larynx, its edema develops slowly.

Edematous laryngitis is characterized by hyperemia of the mucous membrane, leukocytic and lymphocytic infiltration of the perivascular spaces, massive impregnation of the submucous cellular elements with serous transudate. Increased activity of the mucous glands of the larynx is noted. The only place where edema of the mucous membrane and submucous layer does not occur is the laryngeal surface of the epiglottis and the vocal folds. Otherwise, the edema covers the aryepiglottic folds, the lingual surface of the larynx. In some cases, it can be unilateral, simulating a laryngeal abscess. In the subglottic space, the edema is limited above by the vocal folds, below - by the first or second ring of the trachea. If the edema is localized in the area of the arytenoid cartilages, it can be caused by arthritis of the cricoarytenoid joints.

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Symptoms of laryngeal edema

In edematous laryngitis, unlike acute catarrhal laryngitis, the general condition is significantly worsened, the body temperature can reach 39 ° C and be accompanied by chills. The development of the disease can be rapid, almost lightning fast, or it develops over 2-3 days, which depends on the virulence and toxicity of the pathogen. When the edema is localized at the pharyngeal-laryngeal "crossroads", the patient experiences a sensation of a foreign body and pain when swallowing and phonation. Dry paroxysmal cough increases the pain and promotes the spread of infection to other parts of the larynx and the occurrence of purulent complications. A significant increase in pain radiating to the ear, its constancy, a change in the timbre of the voice, and a deterioration in the general condition indicate the occurrence of a complication in the form of phlegmon of the larynx. With significant edema of the larynx, significant disturbances of the voice function occur, up to aphonia. In severe cases of edematous laryngitis, symptoms of respiratory failure of the larynx increase, up to the point that urgent tracheotomy is required. The occurrence of inspiratory dyspnea, manifested by retraction of the suprasternal, supraclavicular, and epigastric regions into the intercostal space during inhalation, indicates increasing stenosis in the rimae glottidis or cavitas infraglotticae region.

In acute edematous laryngitis, the state of general hypoxia develops quickly, even if the phenomena of laryngeal stenosis are not so pronounced, while in subacute and chronic stenotic forms (tuberculosis, syphilis, tumor) hypoxia occurs only with very pronounced laryngeal stenosis. The latter fact is explained by the adaptation of the body to the gradual narrowing of the respiratory slit and the gradually occurring oxygen deficiency.

The diagnosis of edematous laryngitis is established based on the patient's history and complaints (sudden and rapid onset with increasing signs of difficulty breathing, sensation of a foreign body, pain when talking, swallowing and coughing), increasing general clinical phenomena (fever, chills, general weakness) and data from indirect and direct laryngoscopy. Direct laryngoscopy should be performed with caution, since it is accompanied by deterioration of breathing and can lead to sudden spasm of the larynx, fraught with acute asphyxia and death. Difficulties in endoscopic examination may arise if it is performed during an asphyxial crisis, with trismus (jaw clenching), etc. In adults, it is possible to examine the edematous epiglottis by pressing the root of the tongue downwards; in children, direct laryngoscopy is performed - microlaryngoscopy or video microlaryngoscopy.

Differential diagnostics are carried out primarily with non-inflammatory laryngeal edema (toxic, allergic, uremic, with toxicosis of pregnancy), diphtheria, septic laryngotracheobronchitis, foreign bodies of the larynx, laryngospasm, traumatic laryngeal edema (contusion, compression), neurogenic stenosis (neuritis or traumatic damage to the recurrent nerves, myopathy), with laryngeal lesions in specific infectious diseases (syphilis, tuberculosis), tumors, as well as with respiratory failure in heart disease and asthma.

It is very difficult to differentiate edematous laryngitis from abscess or phlegmon of the larynx, and only further observation allows us to establish the fact that the above complications do not occur. In small children, differential diagnostics is most difficult due to the difficulties of physical examination and many other causes of laryngeal stenosis. In this case, direct diagnosis is facilitated by information provided by parents, laboratory examination data (inflammatory changes in the blood) and direct microlaryngoscopy.

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Non-inflammatory laryngeal edema

Non-inflammatory edema of the larynx is a serous impregnation of the submucosal connective tissue, the fibers of which turn out to be disconnected accumulations of liquid transudate (in contrast to inflammatory edema, when exudate appears with a large number of formed elements of the blood, including erythrocytes).

Non-inflammatory laryngeal edema is observed in a number of common diseases, such as in patients suffering from cardiac decompensation, renal failure, alimentary or oncological cachexia, allergies, hypothyroidism, angiolymphogenic diseases, etc. For example, some renal diseases are sometimes accompanied by selective laryngeal edema without anasarca.

Congestion, which leads to swelling of the larynx, can be a consequence of tumors of the mediastinum, large aortic aneurysms, malignant and benign goiters, large tumors of the neck that compress large venous trunks, tumors of the lower pharynx, and many others.

General edema indicates a violation of water-salt metabolism in the body as a whole, localized or local ones occur as a result of fluid retention in a limited area of the body. Complex mechanisms of excessive sodium and water retention by the kidneys participate in the pathogenesis of general edema. Particular importance is given to the violation of the regulation of salt and water metabolism by hormones, in particular with excessive production of vasopressin and aldosterone. Factors contributing to the violation of local water balance include increased hydrostatic pressure in the capillaries (for example, in heart failure), increased permeability (cachexia, impaired filtration capacity of the kidneys), and impaired lymph flow.

The swelling sometimes covers the entire larynx, but is usually more pronounced in areas where loose tissue accumulates. Unlike inflammatory swelling of the larynx, non-inflammatory swelling is a slightly hyperemic swelling of a gelatinous appearance, almost completely smoothing out the internal contours of the larynx. It is often accompanied by general swelling and localized swelling of other parts of the body.

In case of edema of the epiglottis or the back wall of the larynx, the main symptoms are a feeling of tightness and awkwardness when swallowing, a sensation of a foreign body in the throat, and choking on food. Dysphagia is observed with edema of the arytenoid cartilages, aryepiglottic folds, or epiglottis due to the resulting insufficiency of the locking function of the larynx. As noted by B.M. Mlechin (1958), an edematous aryepiglottic fold can protrude so far into the lumen of the larynx that it completely closes it and causes stenosis. If edema develops inside the larynx, then difficulty breathing, hoarseness of the voice, difficulty and awkwardness in phonation with a change in the usual timbre of the voice, a feeling of fullness in the throat, and coughing occur. Non-inflammatory edema usually develops slowly (except for edema in uremia, which can occur within 1-2 hours, prompting doctors to perform an emergency tracheotomy). With slow development of edema (3-5 days), the patient can adapt to slowly increasing hypoxia, but only as long as the laryngeal stenosis remains compensated. Further development of edema can lead to rapid hypoxia.

Diagnosis and differential diagnosis are carried out according to the same criteria as for acute inflammatory edema of the larynx.

The prognosis in most cases (with timely treatment) is favorable.

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Treatment of laryngeal edema

Treatment of diseases in this group includes pathogenetic and etiological - general medication, non-specific and specific, differentiated, symptomatic and preventive.

Treatment for laryngeal edema can be differentiated by the genesis of this edema - whether it is inflammatory or non-inflammatory. However, it is often extremely difficult to differentiate these types of edema, even by the endoscopic picture, therefore, from the very beginning of the appearance of signs of laryngeal dysfunction and suspicion of its edema, all measures are taken to relieve it. The patient is given a semi-sitting or sitting position, fast-acting diuretics (furosemide), antihistamines, sedatives and tranquilizers (sibazon) drugs, antihypoxants and antioxidants, hot foot baths, mustard plasters to the calf muscles, oxygen are prescribed. Some authors recommend swallowing pieces of ice and an ice pack on the larynx, others, on the contrary, warming compresses on the neck. It is necessary to refrain from both, since cold, being a powerful vasoconstrictor, causing vascular spasm, prevents the resorption of not only inflammatory infiltrates, but also non-inflammatory edemas, in addition, cooling the larynx can lead to the activation of opportunistic microbiota and cause a secondary inflammatory reaction in the form of catarrhal inflammation and its complications. On the other hand, a warming compress and other thermal procedures cause vasodilation not justified by the pathogenesis of edema, a decrease in their permeability, increased blood flow, which cannot but contribute to an increase in edema. Other measures include inhalation of adrenaline solution 1:10,000, 3% ephedrine hydrochloride solution, hydrocortisone. The diet includes liquid and semi-liquid food of plant origin, at room temperature, devoid of spices, vinegar and other hot seasonings. Limit drinking. In case of laryngeal edema caused by general diseases or intoxications, along with measures to rehabilitate the respiratory function of the larynx and drug antihypoxic treatment, adequate treatment is carried out for the disease that provoked, as a risk factor, laryngeal edema.

In case of inflammatory edema, intensive antibacterial therapy is prescribed (penicillin, streptomycin, etc.). Sulfonamides are prescribed with caution, since they can negatively affect the excretory function of the kidneys.

Often, acute inflammatory and non-inflammatory laryngeal edema develops very quickly, sometimes with lightning speed, which leads to the risk of acute asphyxia, requiring immediate tracheotomy.