Laryngeal examination

When meeting a patient complaining of a sore throat or difficulty breathing, the doctor first assesses his general condition, the respiratory function of the larynx, predicts the possibility of stenosis and asphyxia and, if indicated, provides emergency care to the patient.

Anamnesis

When examining a patient with a laryngeal disease, important information can be obtained by questioning the patient. Often, from the very first words, based on the character of the patient's voice (nasal, hoarse, aphonic, rattling voice, shortness of breath, stridor, etc.), one can form an idea of the possible disease. Colds, allergic and post-traumatic diseases of the larynx are most easily identified. It is more difficult to diagnose specific diseases, especially those that at the initial stages manifest themselves with signs of banal pathological conditions of the upper respiratory tract (syphilitic enanthem, diphtheria, etc.). Particular difficulties arise in the differential diagnosis between peripheral and central lesions of the nervous apparatus of the larynx, manifested by disorders of its vocal and respiratory functions, as well as certain visually determined motor dysfunctions of the vocal folds.

When assessing the patient's complaints, attention is paid to their nature, duration, periodicity, dynamics, dependence on endo- and exogenous factors, and concomitant diseases.

Based on anamnestic data, it is possible to make a preliminary conclusion about the genesis of a given disease (organic or functional) and develop a working hypothesis about the patient’s condition, the confirmation or refutation of which is found in the data of an objective examination of the patient.

Particular difficulties in identifying neurogenic dysfunctions of the larynx arise in cases where the patient's complaints are confirmed by signs of damage to the nerve trunks or centers of the brain without the patient specifically indicating the causes of these complaints. In these cases, along with laryngeal endoscopy, special neurological research methods are used, including cerebral angiography, CT and MRI.

Information about the patient is of certain importance in diagnostics: age, gender, profession, presence of occupational hazards, past illnesses, working and living conditions, bad habits, presence of stressful domestic and industrial situations, etc.

An analysis of the causes of laryngeal diseases showed that the noted personal characteristics, which are, in essence, risk factors, can either initiate one or another functional or organic disease of the larynx, or sharply aggravate it.

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External examination of the larynx

The external examination covers the larynx area, which occupies the central part of the anterior surface of the neck, the submandibular and suprasternal areas, the lateral surfaces of the neck, and the supraclavicular fossa. During the examination, the condition of the skin, the presence of an increased venous pattern, the shape and position of the larynx, the presence of edema of the cellular tissue, unusual solitary swellings, fistulas, and other signs indicating inflammatory, tumor, and other lesions of the larynx are assessed.

Inflammatory processes revealed during examination may include perichondritis, phlegmon or adenophlegmon, and tumor processes may include neoplasms of the larynx and thyroid gland, conglomerates of fused lymph nodes, etc. Skin changes (hyperemia, edema, infiltration, fistulas, ulcers) may occur with tuberculosis and syphilitic infections, with suppurating cysts of the neck, etc. With mechanical trauma to the larynx (bruise, fracture, wound), signs of this trauma may appear on the anterior surface of the neck (hematomas, abrasions, wounds, traces of compression in the form of bruises during strangulation, strangulation grooves, etc.).

In case of injuries and fractures of the laryngeal cartilage, bleeding from the wound channel with characteristic bloody foam bubbling on exhalation (penetrating injury of the larynx) or internal bleeding with coughing up blood and signs of subcutaneous emphysema, often spreading to the chest, neck, and face, may be observed.

Palpation of the larynx and the anterior surface of the neck is performed both with the head in the normal position and with it thrown back, when individual elements of the palpated formations become more accessible.

Using this diagram, one can obtain additional information about the condition of the elements of the larynx, their mobility and the sensations that arise in the patient during superficial and deep palpation of this organ.

During superficial palpation, the consistency of the skin and subcutaneous tissue covering the larynx and adjacent areas is assessed, as well as their mobility by gathering the skin into folds and pulling it away from the underlying tissues; the degree of swelling of the subcutaneous tissue is determined by light pressure, and skin turgor is assessed.

With deeper palpation, examine the area of the hyoid bone, the space near the angles of the lower jaw, then go down the anterior and posterior edge of the sternocleidomastoid muscle, revealing enlarged lymph nodes. Palpate the supraclavicular fossa and the areas of attachment of the sternocleidomastoid muscle, the lateral and occipital surfaces of the neck and then move on to palpation of the larynx. It is grasped on both sides with the fingers of both hands and lightly pressed, as if sorting through its elements, guided by knowledge of their location, assess the shape, consistency, mobility, establish the possible presence of pain and other sensations. Then shift the larynx en masse to the right and left, assessing its overall mobility, as well as the possible presence of sound phenomena - crunching with fractures, crepitus with emphysema. When palpating the area of the cricoid cartilage and conical ligament, the isthmus of the thyroid gland covering them is often revealed. When palpating the jugular fossa, ask the patient to take a sip: if there is an ectopic lobe of the thyroid gland behind the manubrium of the sternum, its push can be felt.

Lymph nodes and infiltrates can be palpated on the surface of the thyrohyoid membrane, symptoms of fluctuation (abscess of the floor of the mouth), volumetric processes on the ventral surface of the root of the tongue and in the pre-epiglottic region can be detected. Pain during palpation of the thyrohyoid membrane area can be caused by lymphadenitis (and then these lymph nodes are determined by touch) or neuralgia of the superior laryngeal nerve, which penetrates the membrane.

Pain on palpation of the lateral areas of the larynx can be the result of many causes - laryngeal tonsillitis, inflammation of the thyroid gland, arthritis of the cricothyroid joint, perichoidritis of banal and tuberculous genesis, etc. Unlike the listed diseases, syphilitic damage to the larynx, even with significant destruction, is practically painless, pain occurs only with superinfection.

Palpation of the lymph nodes located along the internal jugular vein is performed with the head tilted forward and slightly to the side being palpated. This allows easier penetration of the fingers into the space located between the anterior edge of the sternocleidomastoid muscle and the lateral surface of the larynx. Difficulties in palpating the larynx arise in individuals with a short, thick and immobile neck.

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