Laryngeal edema

Laryngeal edema is inflammatory and non-inflammatory.

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

[1], [2],

Causes of laryngeal edema

Inflammatory swelling of the larynx, or edematous laryngitis in adults, is more common on the eve of the larynx, in children - in the under-storage space. The occurrence of this disease is mainly due to toxins produced by streptococci, they usually get sick people weakened by certain common diseases (diabetes, uremia, vitamin deficiency, cachexia of different origin), as well as a common infection (influenza, scarlet fever, etc.).

Edema occurs in the loose submucosal layer of the connective tissue, which is most developed on the lingual surface of the epiglottis, in the criburonal and gangled folds, in the area of the scyphoid cartilage and in the sub-basement space. Some of this fabric is contained in the folds of the vestibule.

[3], [4], [5], [6], [7], [8], [9]

Pathological anatomy

In edematous laryngitis, caused by over-acute diseases such as influenza, erysipelas, scarlet fever, etc., the edema develops quickly and covers almost the entire submucosal layer of the larynx or subsclip space It can also spread over paraminidal phlegmon, inflammation and abscess of lingual minus and the root of the tongue, trauma to the vestibule of the larynx with foreign bodies. With 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, leukocyte and lymphocytic infiltration of perivascular spaces, massive impregnation of submucous cellular elements with serous transudate. There is an increased activity of the mucous glands of the larynx. The only place where swelling of the mucous membrane and submucosal layer does not occur is the laryngeal surface of the epiglottis and the vocal folds. For the rest, the edema covers the laryngeal folds, lingual surface of the larynx. In some cases, it can be one-sided, simulating an abscess of the larynx. In the sub-storage space, edema from the top is limited to vocal folds, from below - the first or second tracheal ring. If the edema is localized in the area of the scyphoid cartilage, then it may be due to arthritis of the fingertip joint.

[10], [11], [12], [13]

Symptoms of laryngeal edema

When edematous laryngitis, in contrast to 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 fulminant, or it develops within 2-3 days, which depends on the virulence and toxigenicity of the pathogen. With the localization of edema at the pharyngeal-laryngeal "crossroads" the patient has a feeling of the presence of a foreign body and pain when swallowing and phonation. A dry paroxysmal cough increases pain and contributes to 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, their constancy, change in the tone of voice, deterioration of the general condition indicate the occurrence of complications in the form of phlegmon of the larynx. With significant laryngeal edema, significant impairment of voice function, up to aphonia, occurs. With a pronounced form of edematous laryngitis, the phenomena of respiratory insufficiency of the larynx increase, to the extent requiring urgent tracheotomy. The occurrence of inspiratory dyspnea, manifested during inhalation by retraction of the suprasternal, supraclavicular, epigastric regions in the intercostal space, indicates a growing stenosis in the rimae glottidis or cavitas infraglotticae.

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 stenoses. The latter fact is explained by the adaptation of the organism to the gradual narrowing of the respiratory fissure and the onset of oxygen deficiency.

The diagnosis of edematous laryngitis is established on the basis of the patient's history and complaints (sudden and transient onset with increasing signs of difficulty breathing, foreign body sensation, pain when talking, swallowing and coughing), increasing general clinical phenomena (fever, chills, general weakness) and data indirect and direct laryngoscopy. Direct laryngoscopy should be carried out carefully, since it is accompanied by worsening of breathing and can lead to a sudden spasm of the larynx, fraught with acute asphyxia and death. Difficulties in endoscopic examination may occur if it is carried out during an asphyxical crisis, with a trisma (jaw tightness), etc. In adults, it is possible to examine the edematous epiglottis when the root of the tongue is pulled downwards, in children, a direct laryngoscopy is performed - microlaryngoscopy or video rolaroscopy.

Differential diagnostics is performed primarily with noninflammatory laryngeal edema (toxic, allergic, uremic, in pregnant women with toxicosis), diphtheria, septic laryngotracheobronchitis, laryngeal foreign bodies, laryngospasm, traumatic laryngeal edema, hiccation of the larynx, laryngospasm, traumatic laryngeal edema (hurt, laryngotracheobronchitis, laryngeal spasm, laryngospasm, traumatic laryngeal edema, hurt, laryngitis, laryngotracheitis, laryngitis, laryngospasm, traumatic laryngeal edema, myopathies), with laryngeal lesions in case of specific infectious diseases (syphilis, tuberculosis), tumors, as well as respiratory failure in the case of disease heart and asthma.

Differentiating edematous laryngitis from abscess or phlegmon of the larynx is very difficult, and only further observation allows to establish the absence of the occurrence of these complications. In young children, differential diagnosis is most difficult due to the difficulties of physical examination and many other reasons that cause laryngeal stenosis in them. In this case, direct diagnosis is facilitated by information provided by parents, laboratory examination data (inflammatory changes in the blood) and direct micro-laryngoscopy.

[14], [15]

Non-inflammatory swelling of the larynx

Noninflammatory laryngeal edema is the serous soaking of submucosal connective tissue, the fibers of which turn out to be disconnected accumulations of liquid transudate (unlike inflammatory edema, when exudate appears with a large number of blood cells, including erythrocytes).

Noninflammatory laryngeal edema is observed in a number of common diseases, for example, in patients suffering from cardiac decompensation, renal failure, nutritional or oncological cachexia, allergies, hypothyroidism, angiolymphogenous diseases, etc. For example, some renal diseases are sometimes accompanied by selective laryngeal edema without anasarca.

Congestion, entailing laryngeal edema, may be the result of mediastinal tumors, large aortic aneurysms, malignant and benign goiter, large neck tumors that squeeze large venous trunks, lower pharyngeal tumors, and many others. Others

General edema indicates a violation of water-salt metabolism in the body as a whole, localized or local occur as a result of fluid retention in a limited area of the body. The pathogenesis of total edema involves the complex mechanisms of excessive sodium and water retention by the kidneys. Of particular importance is the violation of the regulation of the metabolism of salts and water by hormones, in particular, with excessive production of vasopressin and aldosterone. The factors contributing to the violation of local water balance include an increase in hydrostatic pressure in the capillaries (for example, in case of heart failure), an increase in their permeability (cachexia, impaired filtration ability of the kidneys), and impaired lymphatic drainage.

Edema sometimes covers the entire larynx, but is usually more pronounced in areas of loose fiber. In contrast to inflammatory edema of the larynx, non-inflammatory edema is a low swelling of the gelatinous appearance, almost completely smoothing the internal contours of the larynx. It is often accompanied by general edema and localized edema of other parts of the body.

With edema of the epiglottis or the posterior wall of the larynx, the main symptoms are a feeling of restraint and awkwardness when swallowing, a sensation of a foreign body in the throat, gagging with food. Dysphagia is observed when the edema of the scyphoid cartilages, of the scapalae ganglia or of the epiglottis due to the arising insufficiency of the laryngeal function of the larynx. As BMMlechin (1958) notes, the edematous cherpalonadgortanic fold can go into the larynx lumen so that it completely closes it and causes stenosis. If the edema develops inside the larynx, then there is difficulty in breathing, hoarseness of the voice, difficulty and awkwardness during phonation with a change in the usual timbre of the voice, a feeling of bursting in the throat and cough. Noninflammatory edema usually develops slowly (except for edema in uraemia, which can occur within 1-2 hours, pushing doctors to an emergency tracheotomy). With the slow development of edema (3-5 days), the patient can adapt to the slowly increasing hypoxia, however, as long as the stenosis of the larynx remains compensated. Further development of edema can lead to rapid hypoxia.

Diagnosis and differential diagnosis carried out according to the same criteria as in acute inflammatory laryngeal edema.

The prognosis in most cases (with timely medical measures taken) is favorable.

[16], [17], [18]

Treatment of laryngeal edema

Treatment of diseases of this group includes pathogenetic and etiological - general, nonspecific and specific medical, differentiated, symptomatic and prophylactic.

Treatment for laryngeal edema can be distinguished by the genesis of this edema - is it inflammatory or non-inflammatory. However, it is often extremely difficult to differentiate these types of edema, even according to the endoscopic picture, so from the very beginning of the appearance of signs of laryngeal dysfunction and suspicion of the occurrence of its edema, all measures are taken to stop it. The patient is placed in a half-sitting or sitting position, prescribing high-speed diuretics (furosemide), antihistamines, sedatives and tranquilizers (sibazon) drugs, antihypoxants and antioxidants, hot foot baths, mustard plasters to the area of the calf muscles, oxygen. Some authors recommend swallowing pieces of ice and an ice pack on the larynx area, others, on the contrary, warming compresses on the neck area. One should refrain from this and the other, since cold, being a powerful vasoconstrictor, causing vasospasm, prevents the resorption of not only inflammatory infiltrates, but also non-inflammatory edema, besides cooling of the larynx can lead to activation of conditionally pathogenic microbiota and cause a secondary inflammatory reaction in the form catarrhal inflammation and its complications. On the other hand, a warming compress and other thermal procedures cause an expansion of blood vessels that are not justified by the pathogenesis of edema, a decrease in their permeability, and an increased blood flow, which cannot but enhance the edema. Among other measures, inhalations of epinephrine 1:10 000 solution, 3% solution of ephedrine hydrochloride, hydrocortisone are shown. The diet includes liquid and semi-liquid foods of vegetable character, at room temperature, devoid of spices, vinegar and other pungent spices. Limit drinking. In case of laryngeal edema caused by common diseases or intoxications, along with measures to rehabilitate the respiratory function of the larynx and medical antihypoxic treatment, provide adequate treatment of the disease that triggered the larynx as a risk factor.

For inflammatory edema, intensive antibiotic therapy is prescribed (penicillin, streptomycin, etc.). Sulfonamides are prescribed with caution, because they can adversely 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 danger of acute asphyxiation requiring immediate tracheotomy.