Lungs (Respiratory Diseases) PDF

LUNGS (RESPIRATORY DISEASES) hamper expansion and increase elastic recoil during expiration. Atelectasis lumiliit ang lungs Also known as collapsed lung, is loss of lung volume c...

LUNGS (RESPIRATORY DISEASES) hamper expansion and increase elastic recoil during expiration. Atelectasis lumiliit ang lungs Also known as collapsed lung, is loss of lung volume caused by inadequate expansion of air spaces. ACUTE LUNG INJURY it results in shunting of inadequately encompasses a spectrum of bilateral oxygenated blood from pulmonary arteries to pulmonary damage which can be initiated by veins, thus giving rise to a ventilation perfusion numerous conditions. imbalance and hypoxia. Manifests as:  potentially reversible and should be 1. acute onset dyspnea( shortness of breath) treated promptly. 2. hypoxemia (low levels of oxygen in the blood) 3. development of pulmonary infiltrates on the THREE FORMS OF ATELECTASIS chest It can progress to more severe Acute 1. Resorption Atelectasis Respiratory Distress Syndrome. (shows cyanosis Occurs when an obstruction prevents air from = becomes blue bc of lack of oxygen) (can lead to reaching distal airways. multi organ failure) (can be corrected 6-12 mos) nauubusan ng lung capacity The most common cause is obstruction of a ACUTE RESPIRATORY DISTRESS SYNDROME bronchus by a mucous or mucopurulent plug. Is a clinical syndrome cause by diffuse alveolar This frequently occurs postoperatively but also capillary and epithelial damage. may complicate: The usual course is characterized by rapid - Bronchial asthma onset of life threatening respiratory - Bronchiectasis insufficiency, cyanosis and severe arterial - Chronic Bronchitis hypoxemia that is refractory to oxygen therapy - Tumor and may progress the multisystem organ failure. Its Histological manifestation is Diffuse 2. Compression Atelectasis Alveolar Damage (DAD) Passive or Relaxation Atelectasis Usually associated with accumulation of Acute Respiratory Distress Syndrome fluid, blood, or air within the pleural cavity, Clinical Features which mechanically collapses the adjacent lung. - Approximately 85% of patients develop the fluid = less air clinical syndrome of Acute Lung Injury or ARDS This is a frequent occurence with pleural within 72 hrs of initiating insult. effusion, caused mostly commonly by congestive - The mortality rate for the 190,000 ARDS cases heart failure, occuring yearly decreased from 60% to 40% in Pneumotrax - Leakage of air into the pleural the last decade. cavity can also lead to - In most patients who survive the acute insult compression atelectasis and are spared the chronic sequelae, normal Basal Atelectasis resulting from the elevated respiratory function returns within 6-12 months. position of the diaphragm commonly occurs in bedridden patients, in patients with ascites and OBSTRUCTIVE VS.RESTRICTIVE PULMONARY during and after surgery. DISEASES Obstructive (Airway) Disease 3. Contraction Atelectasis Forced vital capacity (FVC) is either normal or Cicatrization slightly decreased. Atelectasis occurs when either local or Expiratory flow rate (FEV) is significantly generalized fibrotic changes in the lung or pleura decreased  Results from anatomic airway narrowing distal alveoli are spared. (central affected, distal (asthma) no changes) Loss of elastic recoil (emphysema) lesions more common in upper lobes 20 times more common than panacinar disease. Obstructive Lung (Airway) Diseases Emphysema Panacinar (Panlobular) Emphysema Chronic Bronchitis In panacinar (panlobular) emphysema, the Asthma acini are uniformly enlarged, from the level of Bronchoiectasis the respiratory bronchiole to the terminal blind alveoli This occur more commonly in the lower lung Restrictive Disease zones and is the type of emphysema that occurs Characterized by reduced expansion of lung in a1-antitrypsin deficiency. parenchyma accompanied by decreased total lung capacity. (700 normal nagiging 500 nd Distal Acinar (Paraseptal) Emphysema below) Least common 2 general conditions: In distal acinar (paraseptal) emphysema, the 1. chest wall disorders in the presence of normal proximal portion of the acinus is normal but the lungs. distal part is primarily involved. 2. acute or chronic interstitial lung diseases This is localized to fibrous septa or to the pleura and lead to formation of bullae. The apical bullae may lead to spontaneous pneumothorax ( collection of air or gas in the space between the lungs and the chest that collapses the lungs that prevents it from inflating completely) Irregular emphysema, Most common so named because the acinus is irregularly involved, is almost invariably associated with scarring, such as that resulting from healed inflammatory diseases. Although clinically asymptomatic, this may be EMPHYSEMA the most common form of emphysema. Emphysema is characterized by abnormal permanent enlargement of the air spaces PATHOGENESIS distal to the terminal bronchioles. Exposure to toxic substances such as tobacco There are four major types of emphysema: smoke and inhaled pollutants induces ongoing (1) centriacinar, inflammation with accumulation of neutrophils, (2) panacinar, macrophages and lymphocytes in the lung. (3) distal acinar, and (4) irregular. CLINICAL FEATURES Dyspnea usually is the first symptom; it begins Centriacinar (Centrilobular) Emphysema insidiously but is steadily progressive. The distinctive feature of centriacinar In patients with underlying chronic bronchitis or (centrilobular) emphysema is the pattern of chronic asthmatic bronchitis, cough and involvement of the lobules: wheezing may be the initial complaints. The central or proximal parts of the acini, formed Most patients with emphysema demonstrate by respiratory bronchioles, are affected, while elements of chronic bronchitis concurrently, since cigarette smoking is an underlying risk factor for both; patients with pure emphysema a classic example of type / IgE-mediated are characterized as "pink puffers." hypersensitivity reaction Non-Atopic Asthma - Patients with nonatopic Conditions Related to Emphysema forms of asthma do not have evidence of allergen Compensatory emphysema sensitization, and skin test results usually are Obstructive overinflation negative. MAS DANGEROUS KASI U DON’T Bullous emphysema KNOW THE CAUSE Mediastinal (interstitial) emphysema Drug-Induced Asthma - Several pharmacologic agents provoke asthma, aspirin being the most striking example. Chronic Bronchitis Patients with aspirin sensitivity present with Chronic bronchitis is defined as persistent recurrent rhinitis and nasal polyps, urticaria, and productive cough for at least 3 consecutive bronchospasm. months in at least 2 consecutive years. Occupational Asthma -This form of asthma is Some studies indicate that 20% to 25% of men stimulated by fumes (epoxy resins, plastics), in the 40- to 65-year-old age group have the organic and chemical dusts (wood, cotton, disease. platinum, gases (toluene), and other chemicals. Cigarette smoking is the most important underlying risk factor; air pollutants also BRONCHIOECTASIS contribute. Bronchiectasis is the permanent dilation of bronchi and bronchioles caused by destruction PATHOGENESIS of the muscle and the supporting elastic tissue, The distinctive feature of chronic bronchitis is resulting from or associated with Obstructive hypersecretion of mucus, beginning in the large Lung (Airway) Diseases 471 chronic necrotizing airways. infections. MORPHOLOGY Chronic obstructive component largely results The conditional that most commonly from predispose to bronchiectasis include: small airway disease (chronic bronchiolitis) and Bronchial obstruction coexistent emphysema. > In cystic fibrosis, Histologic examination demonstrates > In immunodeficiency states, enlargement of > Kartagener syndrome (rare autosomal mucus-secreting glands, goblet cell metaplasia, recessive disorder related to impaired and bronchiolar wall fibrosis mucociliary clearance in airways leading to persistend infection and sterility of nails that ASTHMA reduces mobility of spermatozoa) Asthma is characterized by reversible Congenital or hereditary conditions bronchoconstriction caused by airway hyper Necrotizing, or suppurative, pneumonia responsiveness to a variety of stimuli. PATHOGENESIS Chronic Interstitial (Restrictive Infiltrative Atopic asthma is caused by a TH2 and IgE- Lung Disease) mediated immunologic reaction to Fibrosing Diseases environmental allergens and is characterized by Granulomatous Diseases acute-phase (immediate) and late-phase Pulmonary Eosinophilia reactions. The TH2 cytokines IL-4, IL-5, and IL- Smoking Related Interstitial Diseases 13 are important mediators. Fibrosing Diseases TYPES OF ASTHMA Idiopathic Pulmonary Fibrosis (IPF), also Atopic Asthma - This is the most common type known as cryptogenic fibrosing alveolitis of asthma, usually beginning in childhood, and is  It is characterized by patchy but progressive PULMONARY EOSINOPHILIA bilateral interstitial fibrosis, which in advanced A number of clinical and pathologic pulmonary cases results in severe hypoxemia and cyanosis. entities are characterized by an infiltration and  males are affected more than females activation of eosinophils, the latter by elevated levels of alveolar IL-5. Pneumoconioses Pneumoconioses encompass a group of chronic Simple Pulmonary Esinophilia fibrosing diseases of the lung resulting from Also called the = Loeffler syndrome – Transient exposure to organic and inorganic particulates, pulmonary lesions eosinophilia in the blood and most commonly mineral dust. (occupational benign clinical features. disease) the alveolar septa are thickened by infiltrate Pulmonary alveolar macrophages play a containing eosinophils and occasional giant cells central role in the pathogenesis of lung injury by promoting inflammation and producing reactive Tropical Eosinophilia oxygen species and fibrogenic cytokines. caused by infection with helminthic parasites processes: ASBESTOS EXPOSURE IS LINKED WITH SIX SMOKING-RELATED INTERSTITIAL DISEASES DISEASE PROCESSES: Desquamative interstitial pneumonia (DIP) and (1) parenchymal interstitial fibrosis respiratory bronchiolitis are the two related (asbestosis); examples of smoking-associated interstitial lung (2) localized fibrous plaques or, rarely, diffuse disease pleural fibrosis; RESPIRATORY BRONCHIOLITIS - Refers To (3) pleural effusions; Histologically Observed On Heavy Smokers And (4) lung cancer; Consisting Of Mild Chronic Inflammation And (5) malignant pleural and peritoneal Accumulation Of Pigmented Macrophages mesotheliomas; and (6) laryngeal cancer. PULMONARY DISEASES OF VASCULAR ORIGIN Pulmonary Embolism, Hemorrhage and infarction Granulomatous Diseases Pulmonary Hypertension - Cause = unknown Diffuse Alveolar Hemorrhage Syndrome Sarcoidosis is a multisystem disease of unknown etiology; the diagnostic is topathologic Pulmonary Embolism feature is the presence of noncaseating Almost all large pulmonary artery thrombi are granulomas in various tissues. (associated with embolic in origin, usually arising from the deep sicca syndrome iris inflammation, skin veins of the lower leg. problems) Risk factors include prolonged bedrest, leg Granuloma= collection of immune cells – surgery, severe trauma, CHF, use of oral histiocytes that forms as an attempt to wall off contraceptives (especially those with high substances but is unable to eliminate, only estrogen content), disseminated cancer, and accumulate. genetic causes of hypercoagulability. Clinical manifestations include lymph node enlargement, eye involvement and visceral Pulmonary Hypertension ( type of high bp that involvement. affects the arteries of the lungs and right side of Lung involvement occurs in 90% of cases, with the heart) formation of granulomas and interstitial fibrosis. The pulmonary circulation normally is one of Hypersensitivity pneumonitis is an low resistance; pulmonary blood pressures are immunologically mediated inflammatory lung only about one eighth of systemic pressures. disease that primarily affects the alveoli and is Pulmonary hypertension (when mean therefore often called allergic alveolitis. pulmonary pressures reach one fourth or more of systemic levels) is most often secondary to a PULMONARY INFECTION decrease in the cross-sectional area of the In the form of pneumonia are responsible for one pulmonary vascular bed, or to increased sixth of death in the US. pulmonary vascular blood flow. The causes of secondary pulmonary PNEUMONIA-defined as any infection in the hypertension include: lung; clinical presentation may be as an acute, Chronic obstructive or interstitial lung disease fulminant clinical disease or as a chronic Recurrent pulmonary emboli. disease. Antecedent heart disease, Acute bacterial pneumonias can manifest as one of two anatomic and radiographic, referred to as, Diffuse Alveolar Hemorrhage Syndrome bronchopneumonia and lobar pneumonia. Has a triad = hemomptysis (coughing up blood), anemia (low RBC count), diffuse Community Acquired Acute Pneumonia pulmonary infiltrates. Onset is usually abrupt, with high fever, shaking TRIAD MEANING WHEN YOU HAVE DAHS, YOU chils, pleuntic chest pain, and a productive WILL HAVE THE TRIAD SYMPTOMS mucopurulent cough., occasional patient may While there may be several "secondary" causes have homoplysis. of pulmonary hemorrhage (necrotizing bacterial S. Pnoumoniae is the most common cause. pneumonia, passive venous congestion, bleeding Pneumococcal pneumonia is the prototype for diathesis), the diffuse alveolar hemorrhage this subgroup. syndromes constitute a group of "primary" Streptococcus pneumoniae infections. immune-mediated diseases that manifest as the Occur with patients (1) with underlying triad of hemoptysis( coughing of blood) , anemia , chronic diseases such as CHF, COPD, or diabetes; and diffuse pulmonary infiltrates. (2) with either congenital or acquired immunoglobulin defects; (3) those with decreased or absent splenic function. Goodpasture Syndrome the prototype disorder of this group, is an uncommon but PNEUMONIAS CAUSED BY OTHER intriguing condition characterized by a IMPORTANT PATHOGENS proliferative, usually rapidly progressive, Haemophilus influenzae glomerulonephritis and hemorrhagic interstitial Both capsulated and encapsulated forms are pneumonitis. AFFECTS THE KIDNEY AND LUNGS important causes. Adult at risk for developing infections: with chronic pulmonary diseases such Idiopathic pulmonary hemosiderosis is a as chronic bronchitis, cystic fibrosis, and rare disease ofuncertain etiology that has bronchiectasis. pulmonary manifestations and histologic Encapsulated H. Influenzae type b was formerly features similar to those of Goodpasture an important cause of epiglottis and meningitis syndrome, but there is no associated renal in children disease or circulating anti-basement membrane antibody. Moraxella catarrhalis caused of pneumonia, especially in elderly Pulmonary Angiitis and Granulomatosis person. (Wegener Granulomatosis) along with S. Pneumoniae and H. Influenzae, M.  More than 80% of patients with wegener Catarrhalis constitutes one of the three most granulomatosis common of otitis media in children.  (WG) develop upper respiratory or pulmonary manifestations at some time in Staphylococcus Aureus the course of their disease. Usually affect children and elderly  Develop in upper respiratory Klebsiella Pneumoniae either while inconscious or during repeated most common cause of gram negative bacterial vomiting. pneumonia. aerobes more common that anaerobes commonly affects debilitated and malnourished  The resultant pneumonia is partly persons. chemical, resulting from the extremely thick and gelatinous sputum is characteristic. irritating effects of the gastric acid, and partly bacterial. Pseudomonas Aeruginosa  Although it is commonly assumed that most commonly seen in nosocomial setting. anaerobic bacteria predominate, more common in persons neutropenic, in victims of recent studies implicate aerobes more extensive burns, and patients requiring commonly than anaerobes. mechanical ventilation.  This type of pneumonia is often has a propensity to invade blood vessels at the necrotizing, and is a frequent cause of site of infection, with consequent death in persons predisposed to extrapulmonary spread aspiration. fulminant disease  In those who survive, abscess formation is a commas complications. COMMUNITY ACQUIRED ATYPICAL LUNG ABSCESS PNEUMONIA The causative organism maybe introduced into the term primary atypical pneumonia was the lung by any of the following mechanisms: applied to an acute febrile respiratory disease Aspiration of infective material from carious characterized by patchy inflammatory changes teeth or infected sinuses or tonsils. in the lungs, largely confined to the alveolar Aspiration of gastric contents. septa and pulmonary interstitium. As a complication of necrotizing bacterial Caused by a variety of organisms, Mycoplasma Clinical features pneumoniae being the most common. - The manifestation of a lung abscess are Mycoplasma infections are particularly common much like those of bronchiectasis and among children and young adults. They occur include a prominent cough that usually sporadically or as in local epidemics in closed yields copious amounts of foul-smelling, communities purulent, or sanguineous sputum, Other etiologic agents are viruses, including occasionally, hemoptysis occurs. influenza type A and B, the respiratory syncytial - Spiking fever and malaise are common. - Clubbing of the fingers, weight loss, and HOSPITAL ACQUIRED PNEUMONIA anemia may all occur.  most common with hospitalized persons - Secondary amyloidosis may develop in with severe underlying diseases, those chronic cases. who are immunosuppressed, or those on - Treatments includes antibiotic therapy prolonged antibiotic regimes. and, if needed surgical drainage.  Those on mechanical ventilation represent a particularly high-risk group, and infections acquired in this setting are Chronic pneumonia most often is a localized given the distinctive designation lesion in an immunocompetent person, with or ventilator-associated pneumonia. without regional lymph node involvement. There is typically granulomatous inflammation. ASPIRATION PNEUMONIA Tuberculosis is by far the most important when we drink and water flows in the wrong entity within the spectrum of chronic tube pneumonias. Aspiration pneumonia occurs in debilitated patients or those who aspirate gastric contents  Tuberculosis - communicable chronic Histoplasmosis, Coccidioidomycosis, and granulomatous disease caused by Blastomycosis mycobacterium tuberculosis Infections caused by the dimorphic fungi Epidemiology manifest either with isolated pulmonary Among medically and economically deprived involvement, as commonly seen in infected persons throughout the world, tuberculosis immunocompetent persons, or with remains a leading cause of death. disseminated disease in immunocompromised infection with M. tuberculosis typically leads to persons the development of delayed hypersensitivity, lesions evolve into small granulomas complete which can be detected by the tuberculin ( with giant cells and may develop central necrosis Mantoux) test. and later fibrosis and calcification. The clinical symptoms and signs resemble PRIMARY TUBERCULOSIS those of a "fulike" syndrome, most often self - form of disease that develops in a previously limited. unexposed and therefore unsensitized patient, elderly persons and profoundly Cytomegalovirus Infections immunosuppressed patients may lose their CMV is a member of the herpesvirus family sensitivity to the tubercle bacillus, so they may Cells infected by the virus exhibit gigantism of develop primary tuberculosis more than once. both the entire cell and its nucleus. Within the nucleus is an enlarged inclusion Etiology surrounded by a clear halo ("owl's eye"), which mycobacteria are slender rods that are acid- gives the name to the classic form of fast stain and subsequently stubbornly resist symptomatic disease that occurs in neonates- decolorization. cytomegalic inclusion disease. M. tuberculosis hominis is responsible for most cases of tuberculosis. Transmission of CMV Transmission is usually is direct, by inhalation Congenital CMV infection of airborne organisms in aerosols generated by Perinatal CMV infection expectoration or by exposure to contaminated Through saliva secretions of infected persons. Venereal route, fecal-oral route, and oropharyngeal and intestinal tuberculosis respiratory secretions contracted by drinking milk contaminated with latrogenic transmission mycobacterum bovis infection. Cytomegalovirus Mononucleosis Nontuberculous Mycobacterial Disease the disease is nearly always asymptomatic mimicking TB an infectious mononucieoss-a with fever, Nontuberculous mycobacteria most commonly atypical lymchecyton lymphad cause chronic but clinically localized pulmonary accompar disease in immunocompetent persons. nied by abnormal hoe et result, suggesting mid Manifest as upper lobe cavitary disease, hegen mimicking tuberculosis, especially in patients The virus remains latent win leukoyse with a long history of smoking or alcohol abuse. Concomitant chronic pulmonary disease (COPD, cystic fibrosis, pneumoconiosis) is often LUNG TUMORS present. Primary lung cancer is also a common disease. Strains implicated most frequently include: Roughly 95% of lung tumors are carcinomas; the 1. Mycobacterium aviumintracellulare (M. avium remaining 5% constitutes a miscellaneous group complex) that includes carcinoids mesenchymal 2. Mycobacterium kansasii malignancies, lymphomas, and a few benign 3. Mycobacterium abscessus. lesions.  Most common benign tumor: hamartoma, Presence of fluid in the pleural space shows up a so called coin lesion on the chest Hydrothorax - condition in which the pleural radiographs. fluid is transudate Pleuritis - pleural fluid is exudate The four major histologic types of carcinomas *4 Principal Causes of Pleural Exudate of the lung are adenocarcinoma, squamous cell 1. microbial invasion through either direct carcinoma, small cell carcinoma and large cell extension of a pulmonary infection or blood- carcinoma. borne seeding. Recently, carcinoma of the lungs were classified 2. Cancer into two broad groups, Small cell lung cancer 3. Pulmonary infarction (SCLC), and non-small cell lung cancer (NSCLC), 4. Viral pleuritis with the latter including adenocarcinomas and squamous and large cell carcinomas. PNEUMOTHORAX Presence of air or other gas in the pleural sac. All SCLC have metastasized by the time of A ball-valve leak may create a tension diagnosis and hence are not curable by surgery. pneumothorax that shifts the mediastinum. Squamous cell carcinomas are more common in Simple or Spontaneous Pneumothorax - may men. occur in young, apparently healthy adults, they tend to arise centrally in major bronchi usually men without any known pulmonary and eventually spread to local hilar nodes. disease. Adenocarcinomas may occur as central lesions Secondary Pneumothorax - result of some like thoracic or lung disorder. the squamous cell variant but usually are more - consequence of rupture of any pulmonary peripherally located, many with a central scar. It lesion situated close to the pleural surface is the most common type of lung cancer in pleural cavity. women and nonsmokers. HEMOTHORAX Large cell carcinomas are undifferentiated The collection of whole blood in the pleural malignant epithelial tumors that lack cytologic cavity, is a complication of a ruptured features of small cell carcinoma and have no intrathoracic aortic aneurysm that is almost glandular or squamous differentiation. The cells always fatal. typically have large nuclei, prominent nucleoli, Blood clots within the pleural cavity. and a moderate amount of cytoplasm. Small cell lung carcinomas generally appear as CYLOTHORAX pale gray, centrally located masses with A pleural collection of a milky lymphatic fluid extension into the lung parenchyma and early containing microglobules of lipid. involvement of the hilar and mediastinal nodes. It implies obstruction of the major lymph ducts, usually by an intrathoracic cancer. Clinical course Carcinomas of the lung are silent, insidious MALIGNANT MESOTHELIOMA lesions that in many cases have spread before a rare cancer of mesothelial cells they produce symptoms, arising in the parietal or visceral pleura, and Chronic cough and expectoration call attention to less commonly in the peritoneum and still localized, resectable disease. By the time pericardium. hoarseness, chest pain, superior vena cava related to occupational exposure to asbestos in syndrome, pericardial or pleural effusion or the air. persistent segmental atelectasis or pneumonitis Asbestos fibers preferentially gather near the makes its appearance prognosis is grim. mesothelial cell layer, where they generate reactive oxygen species, which cause DNA PLEURAL LESIONS damage with potentially oncogenic mutations. Pleural Effusion  Histological patterns of mesotheliomas: 6. Acute laryngitis - result from inhalation of 1. Epithelial - Most common pattern. Cuboidal irritants or may be caused by allergic reactions. cells line tubular and microcystic spaces, into * 2 forms of laryngitis: Tuberculosis & Diptheritic which small papillary buds project 7. Laryngotracheobronchitis - commonly 2. Sarcomatous - spindled and sometimes known as croup. cause frightening inspiratory fibroblastic-appearing cells grow in stridor and harsh, persistent o / a o cough. nondistinctive sheets Caused by parainfluenza virus. 3. Biphasic - both sarcomatous and epithelial areas Il. Nasopharyngeal Carcinoma a rare neoplasm that merits comment because of (1) the strong epidemiologic links to EBV LESIONS OF THE UPPER RESPIRATORY (2) the high frequency of this form of cancer TRACT among the Chinese, which raises the possibility 1. Acute Infections of viral oncogenesis on a background of genetic II. Nasopharyngeal Carcinoma susceptibility III. Laryngeal Tumors a striking influx of mature lymphocytes often can be seen. I. Acute Infections invade locally, spread to cervical lymph nodes, most Frequently manifesting as the "common and then metastasize to distant sites. cold." most common in children Clinical features: nasal congestion accompanied III. Laryngeal Tumors by watery discharge; sneezing; scratchy, dry sore A variety of non-neoplastic, benign, and throat; and slight increase empe taure that is sint malignant neoplasms of epithelial and pronounced in young children. mesenchymal origin common pathogens are rhinoviruses, but the most common presenting feature is coronaviruses, respiratory syncytial viruses, hoarseness. parainfluenza and influenza viruses, A. Nonmalignant Lesions adenoviruses, enteroviruses, and sometimes B. Carcinoma of the Larynx even group A B-hemolytic streptococci have been implicated. A. Nonmalignant Lesions 1. Vocal Cord Nodules - "polyps" are smooth, 1. Acute Pharyngitis - manifesting as a sore hemispherical protrusions occur chiefly in heavy throat, more severe forms with tonsillitis, smokers or singers. associated with marked hyperemia and - The nodules are composed of fibrous tissue and exudates. covered by stratified squamous mucosa that 2. Streptococcal tonsillitis - associated usually is intact but can be ulcerated from potential for development of peritonsillar contact trauma with the other vocal cord abscesses ("quinsy") or for progression to poststreptococcal glomerulonephritis and acute B. Carcinoma of the Larynx rheumatic fever. It most commonly occurs after age 40 years 3. Coxsackievirus A infection - may produce and is more common in men than in women pharyngeal vesicles and ulcers occur in smokers, and alcohol and asbestos 4. Infectious mononucleosis - "kissing disease" exposure may also play roles caused by Epstein-Barr virus About 95% of laryngeal cancers are typical 5. Acute bacterial epiglottitis - a syndrome squamous cell carcinomas. predominantly affecting young children who The tumor develops directly on the vocal cords have an infection of the epiglottis caused by (glottic tumors) in 60% to 75% of cases, but it H. influenzae, in which pain and airway may arise above the cords (supraglottic; 25% to obstruction are the major findings. 40%) or below the cords (subglottic; less than 5%).  Begin as in situ lesions that later appear as pearly gray, wrinkled plaques on the mucosal surface, ultimately ulcerating and fungating manifests itself clinically with persistent hoarseness