Disorders of the Throat and Larynx: Clinical Presentation and Management

To standardize the decision for surgery in cases of recurrent infection, clinicians utilize the Paradise Criteria. Surgery is indicated if a patient meets any of the following:

• $\ge 7$ episodes in the last year.
• $\ge 5$ episodes per year for at least 2 years.
• $\ge 3$ episodes per year for at least 3 years.

Post-operative management must monitor for complications such as bleeding, dehydration, and airway obstruction.

Laryngeal Disorders: Hoarseness and Stridor

The larynx is the primary organ for phonation, and its dysfunction often presents through two hallmark symptoms: hoarseness and stridor.

Hoarseness

Hoarseness results from abnormal vibration of the vocal folds.

• Acute Laryngitis: The most common cause of hoarseness, usually viral (90%). It is managed with vocal rest (7–10 days), hydration, and humidified air.
• Laryngopharyngeal Reflux (LPR): Chronic inflammation caused by gastric acid refluxing into the larynx. Patients may present with a "globus sensation" (feeling of a lump in the throat) or chronic throat clearing without classic heartburn. Management involves Proton Pump Inhibitors (PPIs) taken twice daily before meals.

Stridor

Stridor is a high-pitched, turbulent sound produced by airway narrowing.

• Inspiratory stridor usually indicates a lesion higher in the airway.
• Expiratory stridor usually indicates a lower airway lesion. Stridor is a medical emergency that warrants immediate airway evaluation.

Clinical Alert: Epiglottitis Epiglottitis is a life-threatening emergency involving inflammation of the epiglottis. Look for the "3 Ds": Dysphagia (difficulty swallowing), Distress, and Drooling. Patients often present in a "tripod position" (leaning forward to maintain airway). Diagnosis can be suggested by the "thumb sign" on a lateral neck X-ray. Treatment requires immediate hospitalization and airway stabilization (often intubation in the OR).

Vocal Fold Pathologies

Various lesions can affect the vocal folds, altering their ability to vibrate symmetrically.

Vocal Fold Paralysis

Paralysis results from damage to the recurrent laryngeal or vagus nerve, often due to iatrogenic causes (neck surgery), malignancy, or intubation injury.

• Unilateral Paralysis: Presents with a "breathy" voice and effortful phonation.
• Bilateral Paralysis: Can cause life-threatening inspiratory stridor, especially if the vocal folds are fixed in a closed position.

Malignancies and Emergencies

Laryngeal Squamous Cell Carcinoma (SCC)

SCC is the most common malignancy of the larynx and is almost exclusively associated with tobacco use. It is more common in men (9:1 ratio) and typically presents in patients aged 50–70.

• Symptoms: Persistent hoarseness, otalgia (ear pain), dysphagia, and weight loss (an ominous sign).
• Management: Early stages may be treated with radiation or partial laryngectomy; advanced disease may require total laryngectomy.

Foreign Body Aspiration

A significant risk in pediatric populations, foreign body aspiration can cause choking, wheezing, or localized unilateral breath sounds. While some objects like coins may pass into the trachea, others may lodge in the supraglottic airway.

• Gold Standard: Rigid bronchoscopy is the definitive method for both the diagnosis and removal of the foreign body.