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Viral Laryngotracheitis. Viral laryngotracheitis is the most common infectious laryngeal disease. It is typically associated with upper respiratory infection, for example, by rhinoviruses and adenoviruses. Dysphonia is usually self-limiting but may create major problems for a professional voice user. The larger diameter upper airway in

Infectious Diseases and Inflammatory Conditions of the Larynx 33

adults makes airway obstruction much less likely than in children.

In a typical clinical scenario, a performer with mild upper respiratory symptoms has to carry on performing but complains of reduced vocal pitch and increased effort on singing high notes. Mild vocal fold edema and erythema may occur but can be normal for this patient group. Thickened, erythematous tracheal mucosa visible between the vocal folds supports the diagnosis.

Hydration and rest may be sufficient treatment. However, if the performer decides to proceed with the show, high-dose steroids can reduce inflammation, and antibiotics may prevent opportunistic bacterial infection. Cough suppressants, expectorants, and steam inhalations may also be useful. Careful vocal warmup should be undertaken before performing, and "rescue" must be balanced against the risk of vocal injury.

Other Viral Infections. Herpes simplex and herpes zoster infection have been reported in association with vocal fold paralysis (Flowers and Kernodle, 1990; Nishizaki et al., 1997). Laryngeal vesicles, ulceration, or plaques may lead to suspicion of the diagnosis, and antiviral therapy should be instituted early. New laryngeal muscle weakness may also occur in post-polio syndrome (Robinson, Hillel, and Waugh, 1998). Viral infection has also been implicated in the pathogenesis of certain laryn-geal tumors. The most established association is between human papillomavirus (HPV) and laryngeal papillomatosis (Levi et al., 1989). HPV, Epstein-Barr virus, and even herpes simplex virus have been implicated in the development of laryngeal malignancy (Ferlito et al., 1997; Garcia-Milian et al., 1998; Pou et al., 2000).

Bacterial Laryngitis. Bacterial laryngitis is most commonly due to Hemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, and beta-hemolytic streptococcus. Pain and fever may be severe, with airway and swallowing difficulties generally overshadowing voice loss. Typically the supraglottis is involved, with the aryepiglottic folds appearing boggy and edematous, often more so than the epiglottis. Unlike in children, laryngoscopy is usually safe in adults and is the best means of diagnosis. Possible underlying causes such as a laryngeal foreign body should be considered. Treatment includes intravenous antibiotics, hydration, humidification, and corticosteroids. Close observation is essential in case airway support is needed. Rarely, infected mucous retention cysts and epiglottic abscesses occur (Stack and Ridley, 1995). Tracheostomy and drainage may be required.

Mycobacterial Infections. Laryngeal tuberculosis is rare in industrialized countries but must be considered in the differential diagnosis of laryngeal disease, especially in patients with AIDS or other immune deficiencies (Singh et al., 1996). Tuberculosis can infect the larynx primarily, by direct spread from the lungs, or by hema-togenous or lymphatic dissemination (Ramandan, Tarayi, and Baroudy, 1993). Most patients have hoarse ness and odynophagia, typically out of proportion to the size of the lesion. However, these symptoms are not universally present. The vocal folds are most commonly affected, although all areas of the larynx can be involved. Laryngeal tuberculosis is often difficult to distinguish from carcinoma on laryngoscopy. Chest radiography and the purified protein derivative (PPD) test help establish the diagnosis, although biopsy and histo-logical confirmation may be required. Patients are treated with antituberculous chemotherapy. The laryngeal symptoms usually respond within 2 weeks.

Leprosy is rare in developing countries. Laryngeal infection by Mycobacterium leprae can cause nodules, ulceration, and fibrosis. Lesions are often painless but may progress over the years to laryngeal stenosis. Treatment is with antileprosy chemotherapy (Soni, 1992).

Other Bacterial Infections. Laryngeal actinomycosis can occur in immunocompromised patients and following laryngeal radiotherapy (Nelson and Tybor, 1992). Biopsy may be required to distinguish it from radio-necrosis or tumor. Treatment requires prolonged antibiotic therapy.

Scleroma is a chronic granulomatous disease due to Klebsiella scleromatis. Primary involvement is in the nose, but the larynx can also be affected. Subglottic stenosis is the main concern (Amoils and Shindo, 1996).

Fungal Laryngitis. Fungal laryngitis is rare and typically occurs in immunocompromised individuals. Fungi include yeasts and molds. Yeast infections are more frequent in the larynx, with Candida albicans most commonly identified (Vrabec, 1993). Predisposing factors in nonimmunocompromised patients include antibiotic and inhaled steroid use, and foreign bodies such as silicone voice prostheses.

The degree of hoarseness in laryngeal candidiasis may not reflect the extent of infection. Pain and associated swallowing difficulty may be present. Typically, thick white exudates are seen, and oropharyngeal involvement can coexist. Biopsy may show epithelial hyperplasia with a pseudocarcinomatous appearance. Potential complications include scarring, airway obstruction, and systemic dissemination.

In mild localized disease, topical nystatin or clo-trimazole are usually effective. Discontinuing antibiotics or inhaled steroids should be considered. More severe cases may require oral antifungal azoles such as keto-conazole, fluconazole, or itraconazole. Intravenous amphotericin is efficacious but has potentially severe side effects. It is usually used for invasive or systemic disease.

Less common fungal diseases include blastomycosis, histoplasmosis, and coccidiomycosis. Infection may be confused with laryngeal carcinoma, and special histo-logical stains are usually required for diagnosis. Long-term treatment with amphotericin B may be necessary.

Syphilis. Syphilis is caused by the spirochete Trepo-nema pallidum. Laryngeal involvement is rare but may occur in later stages of the disease. Secondary syphilis may present with laryngeal papules, ulcers and edema that mimic carcinoma, or tuberculous laryngitis. Tertiary syphilis may cause gummas, leading to scarring and stenosis (Lacy, Alderson, and Parker, 1994). Sero-logic tests are diagnostic. Active disease is treated with penicillin.

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