Perichondritis of the larynx. As a primary condition it is rare, almost always occurs secondary to trauma and irradiation. The infection compromises irrigation, and can lead to progressive and rebellious necrosis of the cartilaginous framework of the organ, especially at the level of the thyroid cartilage.
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- 1 Etiology
- 2 Pathological anatomy
- 3 Clinical manifestations
- 4 Complications
- 5 Treatment
- 6 Sources
Primary infection of the perichondrium and subperichondral spaces is rarely observed. Perichondritis is most often secondary to trauma . The most frequent causes of trauma are mechanical injuries due to high tracheotomies, automobile accidents, and irradiation.
Neoplastic invasion of cartilage can be associated with perichondritis. Perichondritis secondary to a general infection, such as typhoid fever, is rare . Any acute condition in the mouth or pharynx can be associated with perichondritis of the laryngeal cartilage.
Pyogenic infection of the perichondrium of the hyaline cartilages leads to a subperichondral collection of purulent substance. The progressive detachment of the perichondrium denudes the cartilage and decreases the already low blood supply that it has, causing necrosis. Thyroid cartilage involvement is the most frequent and is followed by cricoid and arytenoid cartilage. Elastic cartilage is rarely affected, because the perichondrium is firmly adherent.
Perichondritis and chondral necrosis secondary to irradiation are precipitated by decreased vascularization following irradiation. Initially, the process can be sterile , but the infection often develops after a laryngeal biopsy that causes contamination of the cartilage and causes the development of purulent perichondritis, therefore, to avoid this complication, the biopsy must be done under precise and careful indications in the case of the previously irradiated larynx .
Ankylosis of the cricoarytenoid joint may occur as a result of infection of the cricoid and arytenoid cartilages. A fibrous fixation is formed that immobilizes one or both vocal cords .
The pain is the most notorious system. It always exists, but is aggravated by swallowing and speech, which is why these patients refuse oral feeding almost entirely and their conversation is minimal. There is hoarseness or loss of voice . Inspiratory stridor and dyspnea are also frequent . It comes cough irritative and often unproductive and persistent.
Palpation of the neck reveals marked sensitivity of the larynx. It normally remains motionless during swallowing and appears to be fixed on the neck. The mucous covering of the larynx appears generally reddened and granular and edematous, with a considerable decrease in the size of the laryngeal lumen. Pus may exist in the larynx, and may even contain fragments of necrotic cartilage.
Vocal cords and arytenoids often fail to travel normally because of cricoarytenoid joint injury or soft tissue swelling. As the disease progresses , laryngeal obstruction increases, and even sudden and complete obstruction may even occur.
As with any infection , the patient may present with symptoms of generalized toxicity, such as fever , tachycardia , anorexia , nausea, and dehydration .
Perichondritis can be associated with early and late complications. As a result of inhaling pus, aspiration pneumonia , atelectasis, and lung abscess may occur secondarily . It is possible that mediastinitis appears as a consequence of the downward spread of the infectious process.
Late complications include chronic laryngotracheal stenosis and ankylosis of the cricoarytenoid joints.
Treatment is directed toward preventing suffocation and complications. A tracheostomy is required for suctioning the trachea , to bypass the obstruction, and to allow the larynx to rest. If the perichondritis is secondary to a high tracheostomy, the cannula should be immediately placed in the lowest appropriate position.
Since swallowing is usually impossible, parenteral fluid administration should be used until the acute inflammatory phase has subsided. Nasogastric cannula feeding during the acute phase is not advisable because it is very likely to lead to disease progression. In some patients, gastrostomy for feeding is advisable . The larynx must be in complete rest, with absolute prohibition of the use of the voice . Tracheostomy and gastrostomy help decrease laryngeal function. Antibiotics must be administeredat high doses, with the appropriate selection, whenever possible, according to bacterial sensitivity tests. The parenteral route will be used, except in the case of gastrostomy.
The infected and necrotic cartilage of the larynx should be removed as soon as feasible and any purulent collection will be drained. In general terms, except when it comes to simple drainage of the abscesses, it is convenient to wait for surgical debridement until the general signs of infection have been mastered and an improvement in the local signs of infection has been observed.
As soon as it is verified that the acute infection has already been controlled, it is advisable to proceed to the external examination of the larynx. Necrotic and infected cartilage should be completely identified and removed; at the same time, injury to the apparently healthy neighboring cartilage caused by overly vigorous exploration must be avoided .
Cartilage debridement should be done with great caution to respect the internal perichondrium. If we are forced to remove a considerable amount of cartilage, it is convenient to insert a stem into the larynx and carefully drain the surgical wound externally. The open wound is tamponade and frequent irrigations with 3% hydrogen peroxide to eliminate the necrotic remains.
The introduction of the stem will help prevent stenosis . The stem will be left in place until healing is well advanced, generally for about five to six weeks, however, when extensive destruction of the cricoid cartilage has occurred, there may already be stenosis, which will require secondary repair at a later date. In some cases, bilateral fixation of the cricoarytenoid joint occurs, which may become permanent. This situation is alleviated by an arytenoidepoxy or an arytenoidectomy, if the airway is not adequate after the active infection has dominated and fixation by palpation is demonstrated.
Particular attention should be paid to perichondritis secondary to irradiation. In addition to laryngeal disorders, perillaryngeal soft parts are affected by late post-irradiation disorders and skin necrosis , with the appearance of abscesses or fistulas, the place where the incision of these irradiated areas is to be chosen with great care , to avoid further necrosis; on the other hand, the incisions should, as far as possible, be horizontal.
When debridement of necrotic cartilage is performed, it is also convenient to dry the necrotic skin and subcutaneous tissue. The remaining defect can be repaired with non-irradiated tissue from the anterior aspect of the chest or other undamaged areas. Attempts to preserve laryngeal function should be reserved for situations where limited perichondritis is observed and it is assured that carcinoma will not persist .
When perichondritis and necrosis are extensive and the possibility of carcinoma persistence exists, total laryngectomy is indicated. This intervention is often complicated by the persistence of a large pharyngeal and skin defect (pharyngostoma), due to postoperative wound necrosis and poor healing. Its repair is achieved by rotating bilateral pedicle flaps in the acromiopectoral region, which will occlude the defect and allow the pharynx to be reconstructed in a two-stage operation.