Cryptococcus Neoformans

Cryptococcus neoformans laryngitis is a rare fungal infection of the larynx. The infection usually occurs as a primary pulmonary infection but can spread to other regions of the body. Common characteristics of cryptococcus neoformans include longstanding hoarseness, sore throat, or edema of the vocal cords. Cryptococcus neoformans laryngitis is treated with oral anti-fungal medications such as fluconazole.


Photos of cryptococcus neoformans:

Cryptococcus Infection of the Larynx

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Panoramic view (1 of 4)

Panoramic view of laryngeal vestibule in a man with very longstanding hoarseness and sore throat. Note intense redness and bumpy mucosal surface. Biopsy revealed Cryptococcus neoformans.

Closer view (2 of 4)

Closer view of the vocal cords shows similar intense inflammation and rough surface.

One year later (3 of 4)

After a one-year course of fluconazole, an oral anti-fungal medication. Symptoms are gone. The larynx is no longer inflamed, and the mucosal surface is smooth. White area of scarring (dotted surround), and scar band (parallel dotted lines).

One year later, close-up (4 of 4)

Close-up of the vocal cords shows similar resolution of redness and cobblestoned surface.

4 years later (5 of 6)

The patient has been lost to followup and re-presented with increased hoarseness and sore throat. Here, we see what appears to be recrudescence of the infection with granularity throughout the laryngeal vestibule.

Fungal re-growth (6 of 6)

At closer range, note the granularity of laryngeal petiole and false vocal cords. The vocal cords are in the distance, but also involved by the fungal re-growth.

Croup

Also known as laryngotracheitis or laryngotracheobronchitis, croup 1 is a primarily pediatric viral disease affecting the larynx and trachea. Though it may resemble a simple cold at first, the infection causes a loud barking cough and stridor (unusual, high-pitched breathing noises indicating partial airway obstruction). The majority of cases are caused by parainfluenza viruses (types 1, 2, and 3) but a variety of other viruses can lead to croup symptoms.

The central problem for patients with croup is the swelling of the subglottic region of the larynx, which is the narrowest part of the airway in children. It can vary in its severity and can last anywhere from three days to two weeks. Most patients do not require hospitalization, as home treatment or prescribed antibiotics or steroids are typically sufficient.


Croup, aka Laryngotracheitis:

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Croup, aka laryngotracheitis (1 of 4)

Though croup is most often seen in children, this woman developed a barking cough and mild, non-anxiety provoking stridor in the context of an upper respiratory infection. In this panoramic view note in particular the prominence and redness of the conus part of the vocal cords (indicated by white lines).

Croup, aka laryngotracheitis (2 of 4)

Closer view. Dotted lines signify normal airway diameter.

Croup, aka laryngotracheitis (3 of 4)

Even closer view showing redness and narrowing of the posterior subglottic airway.

Croup, aka laryngotracheitis (4 of 4)

View within the posterior subglottic narrowing.
References
  1. Meyer, Anna. “197. Pediatric Infectious Disease” Cummings Otolaryngology Head and Neck Surgery. Ed. Paul Flint. 6th ed. Vol. 3. Philadelphia, PA: Elsevier, 2015. 3045-3054.[]

Thyrohyoid Syndrome

A little-known inflammatory condition of the lateral thyrohyoid ligament and nearby tissues in the neck. The connective tissues in this area comprise in practical terms a floating “joint” that attaches the larynx to the hyoid bone. Inflammation of unknown cause can lead to a syndrome similar to tennis elbow, so that the point of attachment becomes chronically sore. Thyrohyoid syndrome is also known as hyoidynia, hyoid bursitis, or lateral thyrohyoid ligament syndrome. 1

A patient with this condition typically (but not always) has a history of placing stress on this connective tissue in his or her profession or activities—trumpet playing, for example. Diagnosis is confirmed with finger or thumb pressure to find a point of acute tenderness over the greater horn of the hyoid bone and sometimes the upper border of the thyroid cartilage. The clinician may find it helpful also, by way of comparison, to apply gentle pressure on the submandibular gland or carotid artery so as to confirm that the point of tenderness is truly greatest at the lateral thyrohyoid ligament, hyoid bone, or thyroid cartilage.

Treatment of thyrohyoid syndrome is typically supportive and may include reduction of percussive or aggressive use of voice, non-steroidal anti-inflammatory drugs, or (by far most effective) an injection of 0.5 ml of Kenalog 40 mg per ml at the lateralmost point of the hyoid and upper border of the thyroid cartilage 2, requiring care and experience, as this is just anterior to the carotid artery. This injection may cause soreness on top of the thyrohyoid syndrome pain for a day or two, followed by considerable, if not complete, relief for about three weeks. After this time, pain may return, though not usually to the original level. In some cases a single injection suffices; in others, a series of three injections, performed three or four weeks apart, is more effective.

References
  1. Sinha P, Grindler DJ, Haughey BH. A pain in the neck: lateral thyrohyoid ligament syndrome. Laryngoscope. 2014;124(1):116-8.[]
  2. Kunjur J, Brennan PA, Ilankovan V. The use of triamcinolone in thyrohyoid syndrome. British Journal of Oral and Maxillofacial Surgery. 2002;40:450-451.[]

Rheumatoid Nodules

Rheumatoid nodules are white, fibrous submucosal nodules located on the vocal cords. They are sometimes described as “bamboo nodes,” because of the medial to lateral orientation of the submucosal lesion. Rheumatoid nodules in other areas of the body (elbows, knuckles, etc.) are almost always seen in the context of rheumatoid arthritis. In the larynx, they seem to occur with other autoimmune disorders, and sometimes as the first manifestation of an autoimmune disorder, before the patient has any other symptoms besides hoarseness.

The other entity in the differential diagnosis would be an epidermoid cyst, though distinguishing between the two is usually fairly simple on visual criteria alone. The key features for epidermoid cysts is that they are spherical rather than being oriented in a medial-to-lateral direction. If an epidermoid cyst begins to leak its contents, its shape can also become oval or oblong, but the axis of the submucosal white mass is anterior to posterior. Other distinguishing features of rheumatoid nodules are that they are routinely bilateral and sometimes even multiple as seen in some of the photo series below.


Photos of rheumatoid nodules:

Rheumatoid Nodules

Rheumatoid Nodules and Crohn’s Disease

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Woman with hoarseness (1 of 4)

Woman in middle age with very noticeable hoarseness. Standard light view not highly revealing.

White submucosal markings (2 of 4)

At very high pitch, one can see edge irregularity especially on the left side (right of photo). Note in addition faint white submucosal markings.

Submucosal lesions (3 of 4)

Under strobe light at high pitch, the medial-to-lateral white submucosal lesion on the left vocal cord (right of photo) is indicated by dotted lines. Additional mottled areas are not marked.

Remission from Crohn's (4 of 4)

At this high pitch, there is an independent vibrating segment involving the area of the brackets. A scratchy, diplophonic voice quality is heard at this pitch. Based upon these findings and additional questions, the patient revealed that she considers herself to be in remission from Crohn's Disease, after having been on Remicade and prednisone a year earlier.

Multiple Rheumatoid Nodules Under 3 Kinds of Light

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Standard light, submucosal lesions seen (1 of 4)

Young middle-aged woman with chronic severe hoarseness. In abducted (breathing) position under standard light, one can see irregular margins but more importantly, whitish submucosal lesions with the classic appearance of rheumatoid nodules.

Narrow band light, accentuated capillaries (2 of 4)

Under narrow band light, the overlying capillaries are accentuated, and submucosal masses remain obvious.

Strobe light, nodules (3 of 4)

During open (breathing) position, but under strobe light, another view of these classic, multiple, medial-to-lateral “bamboo” nodules.

Strobe light during phonation (4 of 4)

During phonation also under strobe light, the submucosal masses dramatically inhibit oscillatory flexibility of the mucosa, and prevent accurate margin match at the same time.

This Subtle, Submucosal Mass is made more Evident with High Pitch. It is likely a Rheumatoid Nodule

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Submucosal mass (1 of 4)

This young woman has abandoned her strong avocational interest in singing years earlier due to chronic and apparently unresolvable hoarseness. Speaking voice can pass for normal. Consistent with submucosal pathology, her swelling checks become abruptly (rather than gradually) impaired as she sings up the scale. Even in this breathing position, the left vocal cord (right of photo) appears to have a whitish submucosal mass.

Open phase (2 of 4)

At F#4 (370 Hz) under strobe light, open phase of vibration. The lesion remains indistinct.

Closed phase (3 of 4)

Closed phase of vibration, same pitch.

Much higher pitch (4 of 4)

At the much higher pitch of E5 (659 Hz), the mucosa is stretched and thinned so that the lesion is much more visible (right of photo). This is likely a rheumatoid nodule. The only other oval submucosal white lesion is an open epidermoid cyst, but the axis of the oval is always anterior-posterior rather than medial-lateral.

Post-surgical Laryngitis

Post-surgical laryngitis is inflammation of the larynx, not from infectious organisms, but from irritation caused by a surgical procedure. By analogy, think of the redness around a knuckle that has an abrasion but is not infected. Post-surgical laryngitis is typically transient and lasts only a few days following surgery. A typical time of recovery after nodule surgery is about four days, which explains why the suggested time of complete silence after surgery is four days, with gradually increasing amounts of voice use beginning on postoperative day four or five.

Auto-Immune Laryngitis

Inflammation of the vocal cords, especially of the layer just beneath the mucosa, caused by an auto-immune disorder. Auto-immune disorders that can potentially cause laryngitis (albeit infrequently) include rheumatoid arthritis, lupus erythematosus, Wegener’s granulomatosis, and combined auto-immune disorder. Some individuals develop an inflammatory picture of capillary prominence and mucosal edema which is unrelated to vibratory trauma; that is, these individuals do not have the profile of the “vocal overdoer.” Others form rheumatoid nodules of the vocal cords, aka “bamboo nodes.”

Bacterial Laryngitis (can be acute or chronic)

Bacterial laryngitis is an infection of the vocal cord mucosa by bacteria (not a virus or fungal organism). During this infection, mucus produced in the larynx is usually colored yellow, green, or brown. This can occur in any person as an acute, self-limited infection. It typically resolves on its own with supportive measures like hydration and relative voice rest. If the patient’s laryngitis continues unabated more than 5 days or so, or if there is a critical need for voice (such as for an upcoming performance), antibiotics can be prescribed. Definitive resolution of chronic bacterial laryngitis is more difficult.

Chronic Bacterial Laryngitis

Chronic bacterial laryngitis is seen in persons who have undergone radiotherapy or who have an immune defect. The laryngitis can often be improved with antibiotics, and hydration, when dryness is part of the problem. It often recurs when antibiotics are discontinued. Sometimes chronic antibiotic administration is needed. Or, motivated patients may learn how to do laryngeal irrigations.
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Bacterial infection? (1 of 5)

This young man has an autoimmune disorder and is taking a immunomodulator drug. He has been chronically hoarse for months. Is this further auto-immunity or a chronic bacterial infection?

Yellow mucus (2 of 5)

Notice yellowish mucus in the subglottis and the intense erythema of the subglottis. Culture shows staph aureus.

Improvement (3 of 5)

After several weeks of dicloxacillin, voice is dramatically improved, as is the laryngeal appearance (compare with photo 1).

Improved voice (4 of 5)

During voicing, excellent vibratory blur, correlating with his much improved voice.

Infection returns (5 of 5)

Some months after discontinuing antibiotics, hoarseness has returned along with infected mucus.

Viral Laryngitis

Infection or inflammation of the vocal cord mucosa, caused by viral infection. The mucosa becomes pink or red, and the normally thin mucus blanket increases in volume and can become more viscous. If the mucosa becomes sufficiently inflamed and edematous, an individual can lose his or her voice transiently (for one to three days, typically). An analogy for these tissue and secretional changes in the larynx is viral “pink-eye.” For treatment, antibiotics are of no benefit; instead, as the patient waits for the infection to pass, supportive measures such as voice rest and hydration are suggested.

Laryngitis Sicca

A condition of severe dryness in the larynx, almost always with crusting of mucus. Laryngitis sicca often makes the voice hoarse.

Causes of Laryngitis Sicca:

One cause of laryngitis sicca is the use of radiation therapy for cancer in the larynx. As the radiation therapy kills the tumor it is targeting, it may also damage or destroy the larynx’s mucus-producing glands. These damaged glands may then produce less mucus, and mucus that is more proteinaceous and consequently more viscous or thick and sticky. This viscous mucus can also be easily colonized by bacteria, and become crusted, especially in winter, when humidity indoors is lower.

A second kind of laryngitis sicca seems to accompany bacterial infection alone, apart from any use of radiation therapy. The mucus crusts become yellow or green, and the mucosa reddens with inflammation.

Treatment for laryngitis sicca:

Antibiotic therapy may improve or resolve the problem, though some cases seem stubbornly resistant to such treatment, even with several courses of broad-spectrum antibiotics. Improved hydration of the larynx may help somewhat, as may having the patient learn to irrigate his or her larynx and “gargle” in the larynx.


Photos:

Laryngitis Sicca

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Laryngitis sicca (1 of 2)

Laryngitis sicca, with crusting of dry, green mucus especially undersurface of the folds. Though a rare long-term complication, may be seen after laryngeal irradiation for cancer (Lab).

Laryngitis sicca (2 of 2)

Same patient, from slightly higher view (Lab).

Pachyderma, caused by laryngitis sicca: Series of 3 photos

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Heaped up Mucosa (1 of 3)

Pachyderma, here referring to the heaped up mucosa in the interarytenoid area, in a patient with laryngitis sicca.

Pachyderma (2 of 3)

Adducted (voicing) position. Note that the pachyderma does not interfere with closure of the cords. In this case, it does not directly affect the patient’s voice, which is typical, but the more generalized inflammatory condition (see the redness of the cords) does.

Stippled Vascular Markings (3 of 3)

Narrow-band lighting. This shows some stippled vascular markings, often seen with chronic inflammation or HPV infection.

Acid reflux and sicca syndrome: Series of 4 photos

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Acid reflux (1 of 4)

This man has obvious clinical symptoms of acid reflux such as heartburn, excessive morning mucus, husky morning voice. Note classic interarytenoid pachyderma, diffuse pinkness.

Prominent capillaries & mucus (2 of 4)

Here we see loss of color differential between true and false cords. Capillaries are prominent (like bloodshot eyes) on the true cords. There is also adherent mucus.

Closer view (3 of 4)

Closer view of the prominent capillaries.

Redness and inflammation (4 of 4)

Even the upper trachea shows evidence of redness and inflammation. This is not seen that often except with truly severe nocturnal acid reflux/ LPR.

Sicca laryngitis with micro-crusts: Series of 3 photos

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Laryngitis (1 of 3)

This 50-something man complains of chronic laryngitis of unknown cause. This distant view shows some small crusts, but closer viewing reveals more detail...

Closer view (2 of 3)

...in this closer view, small crusts are seen more clearly, but an even closer visualization....

"Micro-crusts" (3 of 3)

...shows not just small, but also "micro-crusts" rather than the thin and wet mucus layer that should be slowly streaming upwards from the undersurface of the vocal cords. Tiny dots added to show these micro-crusts.

Radiation Mucositis

Inflammation of mucosa caused by cancer-treating radiation. Mucositis is to mucosa as dermatitis is to skin. This inflammation appears reddish with patches of greyish superficial necrosis or ulceration. Typically, radiation mucositis fully resolves four to six weeks after the last radiation treatment.


Photos:

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Prior to start of radiation (1 of 4)

Patient with vocal cord carcinoma, primarily of the right true cord (left of picture). This is before radiation therapy began, so there is not yet any radiation mucositis.

Radiation mucositis, 1 week after radiation (2 of 4)

One week after the end of radiation therapy. The tumor has disappeared. Radiation mucositis is evident from the patches of grey (arrows), which are superficial ulceration.

Radiation mucositis, 4 weeks after radiation (3 of 4)

Almost four weeks after the end of radiation therapy. Note that the mucositis has begun resolving, especially on the right cord (left of picture).

Disappearing radiation mucositis, 10 weeks after radiation (4 of 4)

Almost ten weeks after the end of radiation therapy. The mucositis is virtually gone.

Laser Removal of Vocal Cord Cancer with Bilateral Disease

For treatment of early vocal cord cancer, both laser excision and radiotherapy are in competition as good treatment modalities. See also Early Vocal Cord Cancer: Remove with a Laser, or Radiate? Often, radiation is used when disease is bilateral, in the interest of preserving voice. This is an example of the ability to do fairly extensive laser surgery bilaterally, yet preserving good voice. This man had a friend who had severe difficulty with radiation, and he was therefore opposed to that option.

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Vocal cord cancer (1 of 10)

This 70-something man is a longterm smoker. Here you see an obvious cancer of his left vocal cord (biopsy-proven), but disease on the right side as well that is more superficial.

Stippling (2 of 10)

At higher magnification and using narrow band light, some of the vascular abnormality (stippling) is better seen (arrows).

Granulation (3 of 10)

A week after definitive excision of his cancer. Typical early wound appearance, with a suggestion of granulation on the left side (right of photo).

Reparative Granuloma emerges (4 of 10)

Six weeks later, healing is nearly complete other than a typical reparative granuloma on the left (right of photo).

Granuloma interferes with voicing (5 of 10)

During voicing, the granuloma interferes with closure, explaining in part his ongoing severe hoarseness. Note also the typical medial-to-lateral capillary reorientation.

Granuloma fades away (6 of 10)

Now 3 months postop, the granuloma is smaller. Classic capillary reorientation is again seen.

Closer view (7 of 10)

Under strobe light, closed phase of vibration. Voice is highly functional, since the granuloma no longer interferes with closure.

Granuloma cleft (8 of 10)

Open phase of vibration under strobe light shows the bilobed, clefted nature of the granuloma, where the right vocal fold “fits into” the granuloma (arrows at cleft).

Blood tattoo (9 of 10)

At nearly 5 months postop, the granulation tissue has auto-detached, leaving only a small “blood tattoo.” Here, under strobe light and closed phase of vibration.

Open phase of vibration (10 of 10)

Voice is somewhat hoarse but highly serviceable, and “better than it has been in years,” according to the patient.