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236
CMDT 2025
CHAPTER 8
3. Squamous Cell Carcinoma of the Larynx
ESSENTIALS OF DIAGNOSIS
»
New and persistent (greater than 2 weeks’ duration) voice changes and hoarseness, especially in a
smoker.
»
Persistent throat pain, especially with swallowing;
weight loss; neck mass; hemoptysis.
»
Stridor or other symptoms of a compromised
airway.
» General Considerations
Squamous cell carcinoma of the larynx, the most common
malignancy of the larynx, occurs almost exclusively in
patients with a history of significant tobacco use. Prevalence
C. Biopsy
D. Tumor Staging
» Clinical Findings
A. Symptoms and Signs
Supraglottic carcinoma (false vocal folds, aryepiglottic
B. Imaging and Laboratory Studies
» Treatment
OTOLARYNGOLOGY DISORDERS
» When to Refer
• Specialty referral should be sought early for diagnosis
» When to Admit
• Airway compromise, hemorrhage, dehydration, signifi-
• To determine an effective pain management regimen
237
Long-term follow-up is critical in head and neck cancer
patients. In addition to the 3–4% annual rate of second
VOCAL FOLD PARALYSIS
recurrent laryngeal nerve involvement include thyroid
238
paralysis usually causes inspiratory stridor with deep
paralysis with inspiratory stridor at rest should be managed by a specialist immediately in a critical care environment. Causes of bilateral fold paralysis include thyroid
CMDT 2025
CHAPTER 8
As soon as it is apparent that the patient will require protracted ventilatory support, tracheotomy should replace the
endotracheal tube. Less frequent indications for tracheos-
CRICOTHYROTOMY & TRACHEOSTOMY
There are two primary indications for tracheotomy:
airway obstruction at or above the level of the larynx and
respiratory failure requiring prolonged mechanical ventilation.
º
FOREIGN BODIES IN THE UPPER
AERODIGESTIVE TRACT
FOREIGN BODIES IN THE
TRACHEA & BRONCHI
OTOLARYNGOLOGY DISORDERS
FOREIGN BODIES IN THE ESOPHAGUS
ingestion is a surgical emergency. If there is no concern
239
In adults over age 40, cancer is the most common cause of
persistent neck mass and should be definitively ruled out. A
CONGENITAL LESIONS PRESENTING
AS NECK MASSES IN ADULTS
1. Branchial Cleft Cysts
DISEASES PRESENTING AS NECK MASSES
2. Thyroglossal Duct Cysts
INFECTIOUS & INFLAMMATORY NECK MASSES
1. Reactive Cervical Lymphadenopathy
240
node with a necrotic center that is not associated with an
obvious infection should be further evaluated, especially if
the patient has a history of smoking, alcohol use, or prior
cancer. Other common indications for FNA biopsy of a
CMDT 2025
CHAPTER 8
2. Tuberculous & Nontuberculous
Mycobacterial Lymphadenitis
CANCER METASTASES
In older adults, 80% of firm, persistent, and enlarging neck
masses are metastatic in origin. The majority of these arise
3. Lyme Disease
biopsy should only be performed by head and neck surgeons
experienced in the management of head and neck cancer
since complications from open biopsy may make subsequent
formal neck dissections more challenging if cancer is detected.
LYMPHOMA
OTOLARYNGOLOGY DISORDERS
241
242
CMDT 2025
9
Pulmonary Disorders
Rime Abbas, MD
Mazen El Ali, MD
Meghan E. Fitzpatrick, MD
Belinda Rivera-Lebron, MD, MS, FCCP
º
DISORDERS OF THE AIRWAYS
Disorders of the airways can be classified as those that
involve the upper airways—those above and including the
vocal folds—and those that involve the lower airways.
DISORDERS OF THE UPPER AIRWAYS
Acute obstruction of the upper airway can be immediately life-threatening and must be relieved promptly to
avoid asphyxia. Causes of acute upper airway obstruction
include trauma to the larynx or pharynx, foreign body
aspiration, laryngospasm, laryngeal edema from thermal
injury or angioedema, infections (acute epiglottitis, Ludwig
angina, pharyngeal or retropharyngeal abscess), and acute
allergic laryngitis.
Chronic obstruction of the upper airway may be
caused by goiter, carcinoma of the pharynx or larynx,
laryngeal or subglottic stenosis, laryngeal granulomas or
webs, or bilateral vocal fold paralysis. Laryngeal or subglottic stenosis may become evident weeks or months after
endotracheal intubation. Laryngomalacia refers to the collapse of the supraglottic structures during inspiration.
Inspiratory stridor, intercostal retractions on inspiration, a
palpable inspiratory thrill over the larynx, and wheezing
localized to the neck or trachea on auscultation are characteristic findings. Flow-volume loops may show characteristic flow limitations. Soft-tissue radiographs of the neck
may show supraglottic or infraglottic narrowing. CT and
MRI scans can reveal exact sites of obstruction. Flexible
endoscopy may be diagnostic, but caution is necessary to
avoid exacerbating upper airway edema and precipitating
critical airway narrowing.
Vocal fold dysfunction (also known as inducible
laryngeal obstruction [ILO]) is characterized by transient,
reversible narrowing of the larynx due to paradoxical vocal
fold adduction during inspiration, expiration, or both. It
presents as dyspnea and wheezing that may mimic asthma
or exercise-induced asthma but may be distinguished by
the lack of response to bronchodilator therapy, normal
spirometry immediately after an attack, spirometric
evidence of upper airway obstruction in a flow-volume
loop, and a negative bronchial provocation test. However,
vocal fold dysfunction may coexist with asthma or may be
induced by exercise, inhalational irritant exposures (smoke,
fumes, cleaning chemicals), laryngopharyngeal reflux of
gastric contents, or psychological stress. Definitive diagnosis requires direct visualization of adduction of the vocal
folds on inspiration. Treatment consists of addressing
underlying precipitants (including psychogenic contributors), and speech therapy. Botulinum toxin injections have
been used in refractory cases to treat bilateral vocal fold
hypomobility, laryngeal dystonia, and inducible laryngeal
obstruction.
Koh J et al. A new paradigm for vocal cord dysfunction/
inducible laryngeal obstruction: swift diagnosis and streamlined management pathways. Respirology. 2023;28:911.
[PMID: 37612245]
Leong P et al. Diagnosis of vocal cord dysfunction/inducible
laryngeal obstruction: an international Delphi consensus
study. J Allergy Clin Immunol. 2023;152:899. [PMID:
37343843]
DISORDERS OF THE LOWER AIRWAYS
Tracheal obstruction may be intrathoracic (below the
suprasternal notch) or extrathoracic. Fixed tracheal
obstruction may be caused by acquired or congenital tracheal stenosis, primary or secondary tracheal neoplasms,
extrinsic compression (tumors of the lung, thymus, or
thyroid; lymphadenopathy; congenital vascular rings;
aneurysms; etc), foreign body aspiration, tracheal granulomas and papillomas, tracheal trauma, or idiopathic subglottic stenosis. Variable or dynamic tracheal obstruction
may be caused by tracheomalacia, foreign body aspiration,
and retained secretions.
Acquired tracheal stenosis is usually secondary to previous tracheotomy or endotracheal intubation. Daily endotracheal tube (ETT) care including monitoring cuff
pressure (ideally, 20–30 cm H2O) to avoid over inflation,
oral and endotracheal suctioning of secretions, and regular
ETT rotation may help prevent tracheal stenosis. Dyspnea,
PULMONARY DISORDERS
CMDT 2025
243
cough, and inability to clear pulmonary secretions occur
weeks to months after tracheal decannulation or extubation. Physical findings may be absent until tracheal diameter is reduced 50% or more, when wheezing, a palpable
tracheal thrill, and harsh breath sounds may be detected.
The diagnosis is confirmed by CT of the trachea or bronchoscopy. Management options include balloon dilation,
surgical resection with reconstruction, stent placement, or
laser. Tracheostomy may be considered in those with
refractory disease.
Bronchial obstruction may be caused by retained pulmonary secretions, aspiration, foreign bodies, bronchomalacia, bronchogenic carcinoma, compression by extrinsic
masses, and tumors metastatic to the airway. Clinical and
radiographic findings vary depending on the location of
the obstruction and the degree of airway narrowing. Symptoms include dyspnea, cough, wheezing, and, if infection is
present, fever and chills. A history of recurrent pneumonia
in the same lobe or segment or slow resolution (more than
3 months) of pneumonia on successive radiographs suggests the possibility of bronchial obstruction and the need
for bronchoscopy.
Radiographic findings include atelectasis (local parenchymal collapse), postobstructive infiltrates, and air trapping caused by unidirectional expiratory obstruction. CT
scanning may demonstrate the nature and exact location of
obstruction. Bronchoscopy is the definitive diagnostic
study, particularly if tumor or foreign body aspiration is
suspected. Management includes the use of bronchoscopic
electrocautery, argon plasma coagulation, and laser and
radiofrequency ablation.
Catano J et al. Presentation, diagnosis, and management of sub-
glottic and tracheal stenosis during systemic inflammatory
diseases. Chest. 2022;161:257. [PMID: 34324839]
Ravikumar N et al. The role of bronchoscopy in the multidisci-
plinary approach to benign tracheal stenosis. J Thorac Dis.
2023;31:15:3998. [PMID: 37559626]
Russotto V et al. Intubation practices and adverse peri-intubation
events in critically ill patients from 29 countries. JAMA.
2021;325:1164. [PMID: 33755076]
ASTHMA
ESSENTIALS OF DIAGNOSIS
»
Respiratory symptoms such as wheeze, dyspnea,
or cough, which may be variable in time and
severity.
»
Variable limitation on expiratory airflow on
pulmonary function testing (PFT) or positive
bronchoprovocation challenge.
» General Considerations
Asthma is a common disease, affecting approximately
8–10% of the population. It is slightly more common in
male children (younger than 14 years) and in female adults.
There is a genetic predisposition to asthma. Prevalence,
hospitalizations, and fatal asthma have all increased in the
United States over the past 20 years. Each year, approximately 10 million office visits, 1.8 million emergency
department visits, and more than 3500 deaths in the
United States are attributed to asthma. Hospitalization
rates are highest among Black persons and children, and
death rates are consistently highest among Black persons
aged 15–24 years. The Global Initiative for Asthma (GINA)
report was updated in 2023 to provide a comprehensive
resource that addresses asthma diagnosis, assessment,
management, and evidence-based recommendations.
» Definition & Pathogenesis
Asthma is a chronic disorder of the airways that results in
an array of respiratory symptoms and signs and is characterized by variable levels of airway expiratory obstruction
and hyperresponsiveness. The most common pathogeneses
of asthma include airway inflammation with eosinophils,
neutrophils, and lymphocytes (especially T cells); goblet
cell hyperplasia; plugging of small airways with mucus; collagen deposition beneath the basement membrane; bronchial smooth muscle hypertrophy; airway edema; mast cell
activation; and denudation of airway epithelium. The
pathophysiology of asthma is heterogeneous, but a division
into T2-high and T2-low endotypes (marked by high and
low levels, respectively, of classic Th2 cytokines such as
interleukin [IL]-4, IL-5, and IL-13) has been shown to be
important in the selection of targeted biologic therapies.
Many clinical phenotypes of asthma have been identified. The most common is allergic asthma, which usually
begins in childhood and is associated with other allergic
diseases such as eczema, allergic rhinitis, or food allergy.
Exposure of sensitive patients to inhaled allergens may
cause symptoms immediately (early asthmatic response) or
4–6 hours after allergen exposure (late asthmatic response).
Common allergens include house dust mites (often found
in pillows, mattresses, upholstered furniture, carpets, and
drapes), cockroaches, cat dander, and seasonal pollens.
Allergic asthma, late-onset T2-high asthma, and aspirin/
NSAID-associated respiratory disease are T2-high phe-
notypes. T2-low asthma phenotypes include nonallergic
asthma, which tends to occur in adults and be marked by
neutrophilic inflammation and variable response to standard therapies. Asthma with persistent airflow limitation
is thought to be due to airway remodeling. Asthma with
obesity refers to prominent respiratory symptoms in
patients with obesity with little airway inflammation.
Nonspecific precipitants of asthma include upper
respiratory tract infections, rhinosinusitis, postnasal drip,
aspiration, gastroesophageal reflux, changes in the weather,
stress, and exercise. Exposure to products of combustion
(eg, tobacco, methamphetamines, diesel fuel, and other
agents) increases asthma symptoms and the need for medications and reduces lung function. Air pollution (increased
air levels of respirable particles, ozone, SO2, and NO2)
precipitates asthma symptoms and increases emergency
244
CMDT 2025
CHAPTER 9
department visits and hospitalizations. Selected individuals
may experience asthma symptoms after exposure to aspirin
(aspirin-exacerbated respiratory disease), NSAIDs, or tartrazine dyes. Other medications may precipitate asthma
symptoms (see Table 9–23). Occupational asthma is triggered by various agents in the workplace and may occur
weeks to years after initial exposure and sensitization.
Women may experience catamenial asthma at predictable
times during the menstrual cycle. Exercise-induced bron-
choconstriction begins during exercise or within 3 minutes after its end, peaks within 10–15 minutes, and then
resolves by 60 minutes. This phenomenon is thought to be
a consequence of the airways’ warming and humidifying an
increased volume of expired air during exercise. Cough-
variant asthma has cough instead of wheezing as the
predominant symptom of bronchial hyperreactivity.
» Clinical Findings
Symptoms and signs vary widely among patients as well as
within individuals over time. The level of asthma control is
assessed by the frequency of day and nighttime symptoms
and need for reliever medications as listed in Table 9–1.
A. Symptoms and Signs
Asthma is characterized by episodic wheezing, shortness of
breath, chest tightness, and cough. Symptoms vary over
time and in intensity and are often worse at night or in the
early morning. Asthma symptoms may occur spontaneously or be precipitated or exacerbated by many different
triggers, as discussed above.
Some physical examination findings increase the probability of asthma. Nasal mucosal swelling, increased secretions, and polyps are often seen in patients with allergic
asthma. Eczema, atopic dermatitis, or other allergic skin
disorders may also be present. Wheezing, a prolonged
expiratory phase, or both during normal breathing are suggestive of airflow obstruction; wheezing during forced
expiration does not. Chest examination may be normal
between exacerbations in patients with mild asthma. During severe asthma exacerbations, airflow may be too limited to produce wheezing, and the only diagnostic clue on
auscultation may be globally reduced breath sounds with
prolonged expiration. Hunched shoulders and use of accessory muscles of respiration suggest an increased work of
breathing.
B. Laboratory Findings
ABG measurements may be normal during a mild asthma
exacerbation, but respiratory alkalosis (with low Pa2)
and an increase in the alveolar-arterial oxygen difference
(A–a–DO2) are common. During severe exacerbations,
hypoxemia develops and the Pa2 returns to normal due
to retention. The combination of an increased Pa2 and
respiratory acidosis may indicate impending respiratory
failure and the need for mechanical ventilation.
C. Pulmonary Function Testing
Pulmonary function testing with either spirometry or PEF
measurements are important for the diagnosis and management of patients with asthma.
Important spirometry measurements include FEV1,
FVC, and FEV1/FVC before and after the administration of
a short-acting bronchodilator. These measurements help
determine the presence and extent of airflow obstruction
and whether it is immediately reversible. Airflow obstruction is indicated by a reduced FEV1/FVC ratio, generally
below 0.7 or the lower limit of normal. Significant reversibility of airflow obstruction was previously defined by an
increase of 12% or more and 200 mL in FEV1 or FVC after
inhaling a short-acting bronchodilator. Based on 2022
guidelines, bronchodilator response is defined by an
increase in FEV1 or FVC of greater than 10% relative to the
predicted value. A positive bronchodilator response supports the diagnosis of asthma, but a lack of responsiveness
does not preclude response to a clinical trial of bronchodilator therapy. Severe airflow obstruction results in significant air trapping, with an increase in residual volume and
consequent reduction in FVC, resulting in a pattern that
may mimic a restrictive ventilatory defect.
Bronchoprovocation testing with inhaled histamine or
methacholine may be useful when asthma is suspected
despite nondiagnostic spirometry. Bronchial provocation is
not recommended if the FEV1 is less than 65% of predicted.
A positive methacholine test is defined as a fall in the FEV1
Table 9–1. Assessing asthma control.
Classification of Asthma Control
Components of Asthma Control
Daytime asthma symptoms > 2 ×/week
Nighttime awakenings due to asthma
Interference with normal activity due to asthma
Reliever medication needed for asthma
symptoms > 2 ×/week
Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management
of Asthma. National Institutes of Health Pub. No. 08-4051. Bethesda, MD, 2007, and Global Initiative for Asthma. Global Strategy for Asthma
Management and Prevention 2022. Available at https://ginasthma.org
Well Controlled Partly Controlled Not Controlled
None of these components
within past 4 weeks
1 or 2 of these components
within past 4 weeks
3 or 4 of these components
within past 4 weeks
PULMONARY DISORDERS
CMDT 2025
245
of 20% or more at exposure to a methacholine concentration of less than or equal to 8 mg/mL. A negative methacholine test has a negative predictive value for asthma of
95%. Exercise challenge testing may be useful in patients
with symptoms of exercise-induced bronchospasm.
PEF meters are handheld devices designed as personal
monitoring tools. PEF monitoring can establish peak flow
variability, quantify asthma severity, and provide both
patient and clinician with objective measurements on
which to base treatment decisions. Comparison with reference values is less helpful than comparison with the
patient’s own baseline. PEF shows diurnal variation; it is
generally lowest on first awakening and highest several
hours before the midpoint of the waking day. PEF should
be measured in the morning before the administration of a
bronchodilator and in the afternoon after taking a bronchodilator. A 20% change in PEF values from morning to
afternoon or from day to day suggests inadequately controlled asthma. PEF values less than 200 L/minute indicate
severe airflow obstruction.
D. Additional Testing
Routine CXRs in patients with asthma are usually normal
or only show hyperinflation. Chest imaging is indicated
when pneumonia, which may mimic asthma, or a complication of asthma such as pneumothorax is suspected.
Skin or in vitro testing, including total serum IgE and
allergen-specific IgE, to assess sensitivity to environmental
allergens can identify atopy in patients with persistent
asthma who may benefit from therapies directed at their
allergic diathesis. Evaluations for paranasal sinus disease or
gastroesophageal reflux should be considered in patients
with persistent, severe, or refractory asthma symptoms. An
absolute eosinophil count can identify patients eligible for
anti–IL-5 therapy to manage eosinophilic airway disease.
» Complications
Complications of asthma include exhaustion, dehydration,
airway infection, tussive syncope, and, rarely, pneumothorax. Acute hypercapnic and hypoxemic respiratory failure
occurs in severe disease.
» Differential Diagnosis
Patients who have atypical symptoms or poor response to
therapy may have one of several conditions that mimic
asthma. Upper airway disorders that mimic asthma
include vocal fold paralysis, vocal fold dysfunction syndrome, narrowing of the supraglottic airway, and laryngeal
masses or dysfunction. Lower airway disorders include
foreign body aspiration, tracheal masses or narrowing,
tracheobronchomalacia, airway edema (eg, angioedema or
inhalation injury), nonasthmatic COPD (chronic bronchitis or emphysema), bronchiectasis, allergic bronchopulmonary aspergillosis (mycosis), cystic fibrosis, eosinophilic
pneumonia, hypersensitivity pneumonitis, sarcoidosis, and
bronchiolitis obliterans. A systemic vasculitis with pulmonary involvement may have an asthmatic component, such
as eosinophilic granulomatosis with polyangiitis. Cardiac
disorders include HF (“cardiac asthma”), and pulmonary
hypertension. Psychiatric causes include conversion disor-
ders (“functional” asthma), emotional laryngeal wheezing,
or episodic laryngeal dyskinesis. Rarely, Münchausen syndrome or malingering may explain a patient’s symptom
presentation.
» Approach to Management
Personalized asthma management is a continuous cycle
that involves assessment, treatment adjustment, and periodic review with the goals of optimal symptom control;
minimization of future risks, including exacerbations; and
prevention of asthma-related deaths, as recommended in
the updated 2023 GINA report for asthma. Asthma assess-
ment includes the level of asthma control, risk factors for
exacerbations, asthma severity, treatment adjustment, and
periodic lung function testing.
1. Asthma control—Level of control is assessed by evaluating symptoms. Patients are asked about their past 4 weeks
including frequency of symptoms (days per week), awakening from sleep, and use of reliever therapy (short-acting
beta-agonist (SABA), inhaled corticosteroid (ICS)formoterol, or ICS-SABA) for symptom relief (Table 9–1).
Patients should also be asked about activity limitation.
2. Risk factors for exacerbations—Poor symptom control
increases risk of exacerbations. Other risk factors include
more than one exacerbation in the previous year; inadequate inhaled corticosteroid (ICS) use (due to undertreatment, poor adherence, or incorrect inhaler technique);
and other comorbidities, such as chronic sinusitis, GERD,
obesity, and smoking.
3. Asthma severity—Severity is evaluated retrospectively
from the level of treatment needed to control symptoms and
exacerbations. Table 9–2 describes the step therapy in a
personalized asthma management plan. Typically, mild
asthma responds to Step 1 or 2 treatments, moderate asthma
to Step 3 treatment, and severe asthma to Step 4 or 5 treatments. It is important to distinguish between uncontrolled
and severe asthma in patients who are using Step 4 or Step 5
treatments. The clinician must assess inhaler technique,
medication adherence, comorbidities such as obstructive
sleep apnea or GERD, and ongoing exposure to allergens as
causes of poor asthma control (“uncontrolled” asthma). If
the patient still requires Step 4 or 5 therapy after these issues
have been addressed, then the patient has “severe” asthma
and should be referred to a pulmonary or asthma specialist.
Serial lung function testing is beneficial at time of diagnosis,
3–6 months after treatment initiation, and periodically
thereafter but is not necessarily needed at every visit.
4. Treatment adjustment—The goals of asthma therapy
are to minimize chronic symptoms that interfere with normal activity (including exercise), prevent recurrent exacerbations, reduce or eliminate the need for emergency
department visits or hospitalizations, and maintain normal
or near-normal pulmonary function. A multidisciplinary
approach using pharmacologic and nonpharmacologic
strategies is best to address disease pathogenesis and modifiable risk factors. Pharmacologic agents that satisfy the
patient’s expectations of asthma care with the fewest