Cerebrospinal Fluid (CSF) Rhinorrhea causes, symptoms, treatment, complications

A. Chronic non specific laryngitis:

(1) Hypertrophic

(a) Chronic diffuse hypertrophic laryngitis.

Etiology: 

• Repeated acute laryngitis 
• predisposing factors

Symptoms:

• Dysphonia.
• Cough & expectoration.
• Hemming (desire for frequent throat clearing).

Signs: 

• Congested thickened V.F
• In oedematous type (Reinke’s oedema) :polypoidal VF.

Treatment: 

• Remove predisposing factor.
• Like acute but no antibiotics.
• VF stripping: MLS or laser in resistant cases

(b) Chronic localized hypertrophic laryngitis.

	(i) Vocal cord nodules	(ii) Vocal cord polyp
Etiology	Voice abuse,Gastroesophageal reflux	Voice abuse
Incidence	More in females, children.	More in males
Pathology	Epithelial hyperplasia of free edge of V.F Fresh: soft& red Mature :hard& white	Localized subepithelial oedema or vascular engorgement followed by fibrosis
Symptoms	Hoarseness, weakness	Hoarseness Rarely stridor if large Chocking
Signs	Bilateral Small tiny nodules Sessile White or pink At free margin of V.F. At junction of ant 1/3 & post 2/3	Unilateral Small or large Usually pendunculated Grey, white or red From undersurface of V.F. Site as nodule
Treatment	Voice rest, avoid misuse Speech therapy +/- removal by MLS, or Laser Voice rest, avoid misuse Speech therapy	Removal by MLS or Laser

(iii) Leukoplakia

Definition: White patch on laryngeal mucosa.

Etiology: Irritation.

Pathology: Epithelial hyperplasia & hyperkeratinization.

Symptoms: Persistent hoarseness.

Signs: White patch on V.F. May appear as diffuse, villous, or verrucous.

Treatment: Excision by MLS or Laser, follow up as it is pre-cancerous.

(2) Atrophic.

Etiology: 

• Dusty atmosphere
• Industrial fumes
• Post irradiation therapy

Incidence: more in women.

Symptoms: hoarseness, offensive breath &dyspnea (crusts)

Signs: dry pale atrophic mucosa, & crusts.

Treatment: 

Avoid predisposing factors, moisture, menthol inhalation, laryngoscopy to remove crusts.

(B) Chronic specific laryngitis (Granuloma).

(1) Laryngoscleroma.

Definition: Chronic specific inflammation affecting upper respiratory tract.

Etiology: gram – ve bacilli; Klebsiella rhinoscleromatis.

Incidence: Endemic in Egypt. Usually 2ry to nasal scleroma may be 1ry.

Usually subglottic region.

Symptoms: 

• Stridor & dyspnea
• Hoarseness may be present
• Cough & expectoration

Signs: 

Pale pinkish smooth swelling on both side of subglottis covered by greenish crusts >> fibrosis & subglottic stenosis.

Investigations: 

• DL & biopsy
• CT for length & degree of stenosis.

Treatment:

• Medical as in rhinoscleroma.
• Voice rest & humidification.
• Tracheostomy, if severe distress.
• Treatment of stenosis by either: 

-Laser radial incisions and dilatation.

-External: graft & stent

-Resection anastomosis.

(2) T.B. laryngitis.

Etiology: 2ry to pulmonary T.B. Pathology: Affect posterior part of larynx.

Symptoms:

I- General: 1- T.B toxaemia: night fever, night sweat, loss of weight, loss of appetite.

2- Pulmonary T. B cough, expectoration, haemoptysis.

II- Local:

1- Hoarseness: progressive, phonoasthenia( weak voice.)

2- Stridor & dyspnea.

3- Pain & referred otalgia.

4- Odynophagia (marked).

Signs:

I- External: Tenderness due to perichondritis.

II- Indirect Laryngoscopy or flexible laryngoscopy:

1- T.B granulations on arytenoids.

2- T.B ulcer: thin undermined edge, yellow caseous floor.

3- Impaired V.F mobility.

Investigations:

1- DL & biopsy. 2- Chest X ray for T.B. 3- Tuberculin test: good negative test.

Treatment:

1- Tracheostomy in severe distress.

2- Antituberculous drugs e.g. rifampicin, PASA, streptomycin & pyrazinamide.

3- Local anesthetic spray before meals.

(3) Syphilis of the larynx.

Etiology: Treponema pallidum (spirochete). Incidence: Very rare.

Pathology: 1ry: chancre. 2ry: mucous patches. 3ry: gumma (commonest).

Symptoms: - Hoarseness.

- Stridor.

- Cough & discomfort (no pain).

Signs: Syphilis affects anterior part of larynx.

• Gumma of epiglottis appears swollen & ulcerated.
• Diffuse symmetrical infiltration without ulceration.

Investigations:

1- DL & biopsy. 2- Radiology. 3- Serology.

Treatment: 1- Tracheostomy if needed. 2- Penicillin.

(4) Lupus

Etiology: Attenuated T.B. Incidence: Mostly 2ry to nasal lupus.

Pathology: Apple jelly nodule.

Ulceration on one side.

Fibrosis, notched epiglottis.

Symptoms: vague discomfort.

Signs: see pathology.

Investigation: - DL & biopsy. - X ray chest.

Treatment: like T.B + vit. D.

(5) Leprosy

- Lepromatous or tuberculoid types.

- Nodules  ulceration  fibrosis.

- Treatment: Dapson and rifampicin.

(6) Fungal infection (mycosis).

(a) Candidiasis (moniliasis)

- Caused by candida albicans, whitish grey fibrinous membrane.

Treatment: Remove the underlying cause, topical nystatine or miconazole.

(b) Aspergillosis.

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