5 Laryngology

Question 1

1 What embryologic structures give rise to the larynx?

Answer 1

The endodermal lining and splanchnic mesenchyme of the foregut formed by branchial arches IV through VI.

Question 2

2 Match the branchial arch with its laryngeal derivative:

1. Corniculate, arytenoid, and cricoid cartilages; some laryngeal muscles; RLN
2. Upper body of the hyoid bone and its lesser cornu
3. Epiglottis, thyroid cartilage, cuneiform cartilages, pharyngeal constrictors, some laryngeal musculature, SLN
4. Lower body of the hyoid bone and its greater cornu

Answer 2

1. V/VI
2. II
3. IV
4. III

Question 3

3 The anlagen of the larynx, trachea, bronchia, and lungs arise from what embryologic structure?

Answer 3

The tracheobronchial groove, a ventromedial diverticulum of the foregut

Question 4

4 What structure obliterates the ventral primitive laryngopharynx during embryologic development?

Answer 4

Epithelial lamina

Question 5

5 In the postnatal period, the larynx undergoes changes in axis, shape, length, and position. Describe the position of the larynx related to the cervical vertebra in an infant versus an adult.

Answer 5

• Infant: C1–C4
• Adult (by age 6 years): C4–C7

Question 6

6 What are the nine laryngeal cartilages?

Answer 6

Unpaired

1. Cricoid cartilage
2. Thyroid cartilage
3. Epiglottis

Paired

1. Arytenoid cartilages
2. Corniculate cartilages
3. Cuneiform cartilages

Question 7

7 Name the six intrinsic muscles of the larynx, and describe both their function and innervation. (▶Fig. 5.1; ▶Fig. 5.2)

Answer 7

1. Cricothyroid: Lengthens the vocal cord; external branch of the superior laryngeal nerve (cranial nerve [CN] X)
2. Posterior cricoarytenoid: Abducts the vocal cords; recurrent laryngeal nerve (CN X)
3. Lateral cricoarytenoid: Adducts the vocal cords; recurrent laryngeal nerve (CN X)
4. Oblique arytenoid: Adducts the vocal cords, recurrent laryngeal nerve (CN X)
5. Transverse arytenoid: Adducts the vocal cords; recurrent laryngeal nerve (CN X)
6. Thyroarytenoid: Relaxes, shortens, and adducts the vocal cords; recurrent laryngeal nerve (RLN; CN X)

Question 8

8 What nerve provides sensation to the larynx?

Answer 8

CN X via the internal branch of the superior laryngeal nerve above the glottis and the recurrent laryngeal nerve below the glottis Glottic sensation is mainly from the superior laryngeal nerve with some sensory innervation from the RLN as well.

Question 9

9 What are the extrinsic muscles of the larynx, and what is their function and innervation? (▶Fig. 5.3)

Answer 9

1. Sternohyoid: Caudal traction on the larynx; ansa cervicalis nerve
2. Sternothyroid: Caudal traction on the larynx; ansa cervicalis nerve
3. Omohyoid: Caudal traction on the larynx; ansa cervicalis nerve
4. Geniohyoid: Cephalad traction on the larynx; C1 via the hypoglossal nerve (CN XII)
5. Anterior belly of the digastric: Cephalad traction on larynx; nerve to the mylohyoid (V3)
6. Mylohyoid: Cephalad traction on the larynx; nerve to the mylohyoid (V3)
7. Stylohyoid: Cephalad traction on the larynx; facial nerve (CN VII)
8. Thyrohyoid: Caudal traction on larynx; ansa cervicalis nerve

Question 10

10 Describe the subtypes of the laryngeal epithelium.

Answer 10

• Lingual surface of the epiglottis: Stratified squamous epithelium
• Laryngeal surface of the epiglottis: Stratified squamous merging into pseudostratified columnar epithelium
• Supraglottis: Pseudostratified columnar epithelium (respiratory epithelium)
• Glottis: Stratified squamous epithelium
• Subglottis: pseudostratified columnar epithelium (respiratory epithelium)

Question 11

11 What are the layers of the true vocal folds, from superficial to deep? (▶Fig. 5.4)

Answer 11

1. Epithelium
2. Superficial lamina propria (SLP)
3. Intermediate lamina propria
4. Deep lamina propria
5. Thyroarytenoid muscle complex

Question 12

12 What layers form the vocal fold cover, ligament, and body, respectively, involved in the cover-body theory of voice production?

Answer 12

• Cover = epithelium + SLP ● Ligament = intermediate lamina propria + deep layers of the lamina propria ● Body = thyroarytenoid muscle

Question 13

13 True/False. A unilateral cortical stroke will always result in vocal-fold paralysis.

Answer 13

False. True vocal-fold motion is controlled by the brainstem via both pyramidal and extrapyramidal neural systems. The cell bodies of motor nerves reside within the nucleus ambiguus, whereas sensory nerves reside within the nodose ganglion. Therefore, cortical strokes rarely result in cord paralysis.

Question 14

14 Vascular insult to what structure(s) may result in loss of pain/temperature sensation in the ipsilateral face and contralateral body, ipsilateral facial pain, ataxia, nystagmus, vertigo, nausea, vomiting, dysphonia, dysphagia, and Horner syndrome? (▶Fig. 5.5)

Answer 14

Vertebral artery or posterior inferior cerebellar artery (Wallenburg syndrome)

Question 15

15 The superior laryngeal nerve branches off the vagus nerve just caudal to what important neural structure?

Answer 15

The nodose ganglion

Question 16

16 What are the three levels of laryngeal airway protection?

Answer 16

Epiglottis False vocal folds True vocal folds

Question 17

17 On physical examination, you note that a patient demonstrates a protective cough reflex with palpation of the tip of epiglottis but has no response to palpation of the lower laryngeal surface of the epiglottis or arytenoid mucosa. Which nerve is most likely injured?

Answer 17

Superior laryngeal nerve The tip of the epiglottis receives sensory innervation from the glossopharyngeal nerve (IX), and the lower epiglottis and arytenoid regions are innervated by the internal branch of the superior laryngeal nerve.

Question 18

18 The laryngeal closure reflex can be driven by several different stimuli. Name four.

Answer 18

● Thermal ● Mechanical ● Chemical ● Taste

Question 19

19 During intubation, what hemodynamic response may occur due to laryngeal irritation?

Answer 19

Bradycardia and hypotension; cardiovascular collapse Circulatory laryngeal reflex (superior laryngeal nerve [SLN], perhaps RLN as well) →central neurons →vagus →heart)

Question 20

20 What are the three types of laryngeal respiratory receptors?

Answer 20

● Negative pressure receptors: Maintain airway patency during inspiration ● Airflow receptors: Cold receptors, which are stimulated by air movement ● Respiratory drive receptors: Provide laryngeal proprioception

Question 21

21 What are three fundamental components of speech?

Answer 21

● Phonation: Vocal-fold vibration resulting in sound generation ● Resonance: Modulation of laryngeal phonation by induction of vibration within the vocal tract ● Articulation: Manipulation of the sound into words

Question 22

22 What is required for voice production?

Answer 22

● Power: Adequate breath support (lungs) ● Source of vibration: Larynx ● Resonator: Supraglottic vocal tract and pharynx Note: Normal phonation requires a good vibratory medium; normal vocal-fold shape; and the ability to modify the tension, length, and shape of the true vocal folds.

Question 23

23 How does injury to the superior laryngeal nerve impact voice production?

Answer 23

Loss of upper pitch register due to the loss of the motor innervation to the cricothyroid muscle via the external branch of the SLN, resulting in the inability to increase vocal tension

Question 24

24 The intensity or loudness of sound production is directly related to air pressure in what location?

Answer 24

Subglottis

Question 25

25 Describe the cover-body theory of voice production.

Answer 25

The cover (SLP) and body (thyroarytenoid muscle) move at different rates as air moves through the glottis because of their distinct masses and composition. This variation causes vibration, which results in a buzzing sound. The supraglottic vocal tract then modulates this sound to produce voice.

Question 26

26 Pitch (or frequency) can be altered by adjusting the length and tension of the vocal fold. If this is done by contraction of the thyroarytenoid or cricothyroid muscle, what nerves are involved?

Answer 26

● Thyroarytenoid: RLN ● Cricothyroid: External branch of the SLN Laryngology 177

Question 27

27 Given a constant volume of airflow through the vocal tract, the airflow velocity will increase at the level of the true vocal folds. Increased velocity results in decreased pressure and an inward movement of the vocal folds. What name is given to this effect?

Answer 27

Bernoulli effect

Question 28

28 Describe the myoelastic-aerodynamic theory of voice production.

Answer 28

This was an early model of voice oscillation, which postulated that the Bernoulli effect would function to close the vocal folds, whereas increasing pressure in the subglottis from the lungs would function to open the vocal folds. This would occur over short bursts, resulting in a single puff of air being released. Sound production was thought to be a compilation of these puffs, dependent on the intensity of the sound source, the frequency of the source signal, and the supraglottic laryngeal tract.

Question 29

29 What component of speech describes rhythm, repeated or prolonged syllables, rushes of speech, stress, and intonation?

Answer 29

Prosody

Question 30

30 One of the first patient-based, voice-specific outcome measures was the Voice Handicap Index. This is a 30-question assessment that focuses on which three domains?

Answer 30

Functional, physical, and emotional aspects of voice disorders

Question 31

31 Which voice-specific patient-reported outcome measure uses 10 questions to assess the physical functioning and social–emotional status of a patient with voice disturbance, and how is it measured?

Answer 31

The V-RQOL. Each question is given 1 to 5 points, with 5 representing a severe problem, and 1 representing no problem. An equation is then used to generate a score out of a total of 100, with a higher score representing better quality of life.

Question 32

32 Name three important voice parameters.

Answer 32

● Frequency (pitch) ● Intensity (loudness) ● Quality (i.e., timbre)

Question 33

33 What term refers to the number of repeating cycles per second (Hz) in the acoustic waveform?

Answer 33

Frequency

Question 34

34 Define the fundamental frequency of the voice and the ranges for adult men and women.

Answer 34

The predominant pitch component of speech ● Normal adult men into their 70s: 100 to 125 Hz ● Normal adult women: 190 to 225 Hz

Question 35

35 What describes the quality of a sound determined by its frequency (or fundamental frequency)?

Answer 35

Pitch

Question 36

36 What acoustic term defines the loudness, or sound pressure level, of speech?

Answer 36

Intensity (normally 70 dB for both male and female conversational speech)

Question 37

37 What factors most often influence loudness, or intensity?

Answer 37

Subglottic pressure, frequency, speech sample, glottal resistance, and airflow rate Type of equipment used, distance from the sound source, and ambient noise can also influence loudness measurements.

Question 38

38 In acoustic analysis of voice, what are the most common parameters used to assess frequency?

Answer 38

● Average speaking fundamental frequency ● Maximum phonational frequency range

Question 39

39 What describes the quality or character of voice, separate from pitch, intensity, and prosody?

Answer 39

Quality (timbre): Roughness, breathiness, and strain

Question 40

40 What is the perceptual correlate of the frequency of a sound wave?

Answer 40

Pitch (perceptual correlate of frequency)

Question 41

41 What is the perceptual correlate of the amplitude of a sound wave?

Answer 41

Volume is the perceptual correlate of amplitude.

Question 42

42 In acoustic analysis of voice, jitter is defined as cycle-to-cycle variation in what parameter?

Answer 42

Frequency of a wave (normal = 0.40%)

Question 43

43 In acoustic analysis of voice, shimmer is defined as cycle-to-cycle variation in what parameter?

Answer 43

Amplitude of a wave (normal = 0.50 dB).

Question 44

44 What are the most common measurements used to assess voice quality in acoustic analysis of voice?

Answer 44

Short-term perturbation measures (only reliable for nearly periodic signals): ● Jitter: Cycle-to-cycle variation in frequency ● Shimmer: Cycle-to-cycle variation in amplitude Note: No single test has been identified to reliably assess voice quality.

Question 45

45 The GRBAS scale is an assessment tool, which attempts to standardize the auditory perceptual evaluation of voice quality. What does GRBAS represent, and how is this assessment scored?

Answer 45

* G Grade: Overall severity * R Roughness: Psychoacoustic impression of irregular vocalfold vibration * B Breathiness: Psychoacoustic impression of air leakage through the glottis * A Asthenia: Weakness or lack of power in the voice * S Strain: Psychoacoustic impression of hyperfunctional state of phonation 0: No deficit in parameter 1: Mild deficit 2: Moderate deficit 3: Severe deficit

Question 46

46 What is the major weakness of the GRBAS scale?

Answer 46

It does not offer a specific protocol for administration or guidelines for analysis.

Question 47

47 Which auditory-perceptual evaluation tool uses a visual analog scale (100-mm line; increasing distance from the left indicates increasing severity) to assess six parameters of voice: overall severity, roughness, breathiness, strain, pitch and loudness, and how is it scored?

Answer 47

**Consensus Auditory-Perceptual Evaluation-Voice (CAPE-V):** The score is based on two sustained vowels, six standard sentences, and 20 or more seconds of natural running speech. The six parameters are evaluated for resonance differences and whether the parameter is constant or intermittent.

Question 48

48 Define the following terms: 1. Aphonia 2. Breathy voice 3. Diplophonia 4. Dysphonic 5. Flutter 6. Hoarse voice 7. Hypernasal (honky, nasal) 8. Hyponasal 9. Resonant 10. Strained (harsh, strangled) 11. Tremor

Answer 48

1. The inability to set the vocal folds into vibration either consistently or intermittently. Note: Arrest of phonation describes sudden stops. 2. Containing the sound of breathing (expiration) during phonation 3. Phonation with two independent pitches 4. Abnormal phonation 5. Phonation with amplitude or frequency modulations in the 8- to 12-Hz range 6. The combination of a rough and breathy voice 7. Voice quality when excessive acoustic energy is coupled to the nasal tract through opening of the velar port 8. Voice quality when inadequate acoustic energy is coupled to the nasal tract 9. A voice quality that rings on or "carries" well 10. A voice quality that appears effortful 11. A 1- to 15-Hz modulation of a cyclic parameter (e.g., amplitude or fundamental frequency), either neurologic in origin or interaction between neurologic and biomechanical properties

Question 49

49 An important adjunct to the auditory-perceptual evaluation of the dysphonic patient is the **visual perceptual evaluation**, which evaluates visible and physical facets of voice production related to cause, maintenance, or effect of dysphonia. What five categories are evaluated?

Answer 49

1. General appearance 2. Posture, breathing, musculoskeletal tension 3. Neurologic dysfunction 4. Physical dysmorphology 5. Clinical manifestations of disease

Question 50

50 When assessing a patient who has dysphonia suspicious of muscle tension or muscle misuse dysphonia, what tactile-perceptual tests can be completed in the office to provide a clinical assessment of dysfunction?

Answer 50

* Palpation of the suprahyoid, thyrohyoid, cricothyroid, and pharyngolaryngeal muscles both at rest and during phonation * Assessment of the thyrohyoid space for anterosuperior supraglottic compression * The clinician should assess for tension, muscle "knots," decreased space between thyroid cartilage and hyoid, or discomfort on mobilization.

Question 51

51 What is the aerodynamic assessment that measures the length of time a patient can sustain a vowel after having taken a maximum inspiration?

Answer 51

**Maximum phonatory time** (indicates breath support and phonatory efficiency The longest of **three** trials should be reported. Typically, adult **women** range between 15 and 25 seconds, adult **men** between 25 and 35 seconds.

Question 52

52 The subglottic air pressure (force/unit area) can be evaluated clinically by measuring the intraoral air pressure during a voiceless consonant. What influences the magnitude of normal pressure peak variation, and what are normative values for men and women?

Answer 52

Loudness, age, gender, consonant, and speech context * Men: 7.52cm H2O * Women: 6.43cm H2O

Question 53

53 What term describes the minimal subglottic pressure needed for vocal fold vibration?

Answer 53

Phonation threshold pressure

Question 54

54 Define transglottic airflow and its gender-specific ranges.

Answer 54

Transglottic airflow is **the volume of air that passes through the glottis during a specific period**. It can be traced during sustained phonation or connected speech and is associated with breathiness. * Men: 100 to 183 mL/second * Women: 91 to 156 mL/second

Question 55

55 What is the term given to the ratio of translaryngeal air pressure to translaryngeal airflow? What are the normative values in each gender, and what is the perceptual correlate?

Answer 55

Laryngeal airway resistance * Men: 25 to 45cm H2O/L/second * Women: 27 to 51 cm H2O/L/second Phonatory effort, vocal strength, strain

Question 56

56 What test measures the conductance of low frequency electrode signals between two surface electrodes on the neck to assess vocal fold vibration?

Answer 56

Electroglottography

Question 57

57 What is the maximum number of images the retina can distinguish per second, and how does this compare with the rate of vocal fold vibration?

Answer 57

* Retina: Five images per second (Talbot's law) * Vocal cords: 75 to 1,000 cycles per second Therefore, vocal-fold vibration cannot be seen by the naked eye.

Question 58

58 Videostroboscopy uses a xenon light with rapid on-and-off bursts to view the larynx in brief snapshots, fusing images, and "slowing" the motion of the vibration. This allows for visualization by the human retina. Why does videostroboscopy require a microphone?

Answer 58

The microphone is placed on the patient’s neck to sense laryngeal vibration, which in turn controls the rate of xenon light firing. **Light activation must be out of phase with laryngeal vibration to identify movement.**

Question 59

59 What five important criteria are used to grade videostroboscopy?

Answer 59

1. Symmetry 2. Periodicity 3. Amplitude 4. Mucosal wave 5. Closure

Question 60

60 Define the following terms: 1. Symmetry 2. Periodicity 3. Amplitude 4. Mucosal wave 5. Closure

Answer 60

1. Symmetry: Mirrorred appearance of the two vocal folds 2. Periodicity: Regularity of successive glottal cycles 3. Amplitude: Lateral excursion of the midmembranous cord 4. Mucosal wave: Vertical and horizontal movement of the cover (SLP) over the body (thyroarytenoid muscle) 5. Closure: Closure of the cartilaginous and membranous portions of the glottis

Question 61

61 During videostroboscopy on a normal patient, the mucosal wave will be seen traveling over what fraction of the superior portion of the true vocal fold?

Answer 61

From the inferior lip of the true vocal fold up the medial edge and across approximately one-half of the superior surface

Question 62

62 True or False. Videostroboscopy is an excellent tool in the evaluation of all voice pathologies, including those without periodic vibration of the true vocal folds.

Answer 62

False. Videostroboscopy can analyze only periodic vocal-fold vibration.

Question 63

63 What is the main advantage of videokymography over videostroboscopy?

Answer 63

Videokymography captures multiple images of a single glottic cycle, allowing for analysis of _aperiodic_ vocal-fold vibration. Videostroboscopy is effective only in the setting of periodic vocal-fold vibration and provides an averaging of images.

Question 64

64 What describes altered vocal quality, pitch, loudness, communication, or voice-related quality of life?

Answer 64

Dysphonia

Question 65

65 What are common risk factors for dysphonia (hoarseness)?

Answer 65

1. Upper respiratory tract infection 2. Recent or current infection 3. Significant voice use, misuse, or abuse 4. Recent neck trauma 5. Recent surgery (e.g., airway, neck or thoracic surgery) 6. Recent intubation 7. Tobacco and alcohol use 8. Reflux 9. Neurologic disorders 10. Psychiatric illness or stress 11. Hypothyroidism 12. Recent choking or foreign-body aspiration/ingestion

Question 66

66 What type of stridor would be seen in (1) supraglottic, (2) glottic, (3) subglottic, or (4) tracheobronchial airway obstruction?

Answer 66

1. Inspiratory 2. Inspiratory or biphasic 3. Biphasic 4. Expiratory

Question 67

67 When a suspected aspiration event has occurred, describe the most important aspects of the history and evaluation in a stable patient.

Answer 67

SPECS-R\* S: Severity of obstruction on clinical exam P: Progression of obstruction E: Eating difficulty, failure to thrive C: Cyanotic episodes S: Sleep disturbance - R - Radiographic abnormalities (only obtain if information will change management and patient is not in acute distress) \*Clinical suspicion: Witnessed aspiration, etc.

Question 68

68 When is voice therapy alone an appropriate treatment option for patients with dysphonia?

Answer 68

When medically and surgically treatable causes have been ruled out and a patient continues to have decreased voice related quality of life

Question 69

69 When should antireflux medications be prescribed for hoarseness (dysphonia)?

Answer 69

Only when there are signs or symptoms of reflux disease or chronic laryngitis

Question 70

70 True or False. Proton Pump Inhibitors (PPIs) may cause dysphonia in some patients.

Answer 70

True. PPI use can cause **laryngeal dryness** and **candidiasis leading to dysphonia**.

Question 71

71 Why should the histamine 2 (H2) receptor antagonists cimetadine and ranitidine be prescribed with caution in patients taking either tricyclic antidepressants or benzodiazepines?

Answer 71

**Cimetadine** and, to a lesser extent, **ranitidine** inhibit the cytochrome p450 enzymes that metabolize these medications and can lead to increased blood levels.

Question 72

72 What are the most common side effects of PPI therapy?

Answer 72

Abdominal pain, diarrhea, nausea, vomiting, elevated liver function tests, candidiasis, headache, **osteoporosis**

Question 73

73 Which asthma medications are associated with voice changes?

Answer 73

Inhaled and systemic steroids, β-agonists, and anticholinergics

Question 74

74 Why should thyroid hormone levels be monitored in professional voice users?

Answer 74

Hypothyroidism may cause voice changes.

Question 75

75 Describe the voice changes associated with hormonal therapy (androgens, estrogen, progesterone).

Answer 75

Lower fundamental frequency and increased roughness

Question 76

76 Describe the difference between indirect and direct voice therapy.

Answer 76

Indirect voice therapy focuses on improving vocal hygiene and decreasing phonotrauma. Direct voice therapy focuses on improving voice production.

Question 77

77 What voice therapy technique has been proven to improve speech and speech-related activities in patients with Parkinson disease?

Answer 77

Lee Silverman voice therapy (LSVT)

Question 78

78 Damage to the vocal folds resulting from voice abuse, misuse, and overuse can give rise to various vocal-fold lesions. This type of damage is called \_\_\_\_\_?

Answer 78

Phonotrauma

Question 79

79 What is the most common location of true vocal fold lesions resulting from voice abuse?

Answer 79

Mid-membranous vocal fold

Question 80

80 What is the term for benign growths in the superficial layer of the anterior and middle third of the true vocal fold, which can be either acute (edematous, erythematous, more vascular) or chronic (firm, nonvascular, thickened due to scar deposition and fibrosis)?

Answer 80

Vocal-fold nodules

Question 81

81 What is the most common cause of vocal fold nodules?

Answer 81

Phonotrauma (ex: singing, screaming)

Question 82

82 Before any surgical intervention for vocal-fold nodules, what is the first line of management?

Answer 82

Voice therapy

Question 83

83 In addition to voice therapy, what two contributing medical conditions should be optimized when treating a patient with vocal fold nodules?

Answer 83

* Laryngopharyngeal reflux * Allergies

Question 84

84 Describe the pathophysiologic sequence that gives rise to vocal fold nodules.

Answer 84

Excessive vibration causes trauma leading to vascular congestion and submucosal edema at the midmembranous cord. If the vocal trauma continues, hyalinization of the superficial lamina propria and epithelial thickening may occur.

Question 85

85 When is it appropriate to consider surgical removal of vocal-fold nodules?

Answer 85

When vocal impairment persists after an appropriate trial of voice therapy

Question 86

86 Describe the difference between a vocal-fold *nodule* and a vocal fold *polyp*.

Answer 86

**Nodules are always bilateral**, are composed of inflammatory tissue, and respond to voice rest. They have a broad range of appearances (hemorrhagic/edematous, pedunculated/ sessile, gelatinous/hyalinized). **Polyps** may be unilateral or bilateral, are full of either gelatinous material or blood, and typically do not respond to voice rest.

Question 87

87 What are the two most common etiologies for vocal fold polyps?

Answer 87

Phonotrauma and hemorrhage

Question 88

88 What is the treatment of choice for a symptomatic unilateral true vocal-fold polyp?

Answer 88

Voice therapy may be offered initially as a means of optimizing voice use. However, polyps only rarely respond to therapy alone, and microsurgical excision is usually necessary. Dissection should be subepithelial and just deep to the lesion within the involved SLP.

Question 89

89 After a patient undergoes microsurgical excision of a vocal-fold polyp, what amount of voice use is typically recommended in the immediate postoperative period?

Answer 89

Complete voice rest

Question 90

90 Sudden voice loss during maximal voice effort is most likely associated with what type of vocal-fold lesion?

Answer 90

Vocal-fold hemorrhage or unilateral hemorrhagic polyp

Question 91

91 What is the treatment of choice for vocal-fold hemorrhage?

Answer 91

This is a laryngologic emergency, and the treatment of choice is 7 to 14 days of total voice rest with follow-up to ensure resorption of blood and to identify a varix that could be treated. If the blood has not resorbed, cordotomy and evacuation of the blood are indicated.

Question 92

92 Describe the difference between vocal-fold scar and sulcus vocalis.

Answer 92

In vocal-fold scar, the lamina propria is replaced with abnormally fibrous and disorganized tissue. In sulcus vocalis, the lamina propria has degenerated or disappeared, leaving **an epithelial-lined depression down to the vocal ligament or deeper**.

Question 93

93 Describe the different types of sulcus vocalis.

Answer 93

1. Type I (physiologic sulcus): Longitudinal depression of the epithelium into the superficial lamina propria but not to the vocal ligament 2. Type II: Longitudinal depression of the epithelium down to the level of the vocal ligament or farther 3. Type III: Focal depression of the epithelium to or through the vocal ligament

Question 94

94 Describe the common surgical procedures used in the management of sulcus vocalis.

Answer 94

1. Cold instrument undermining and release of the base of the sulcus with redraping of the epithelium and superficial lamina propria 2. Laser undermining and redraping 3. Cold instrument excision 4. Coronal slicing to release the scar band 5. Fat, fascia, or alloderm implant 6. KTP (potassium-titanyl-phosphate) or PDL (pulsed dye laser) treatment Note: Surgical excision may improve symptoms, but techniques and results are highly variable.

Question 95

95 What is the cause of dysphonia secondary to vocal fold scar or sulcus vocalis?

Answer 95

Stiffening of the superficial lamina propria of the true vocal fold

Question 96

96 What benign lesion often occurs on the posterior vocal fold, near the vocal process, as either an ulcerative or nodular polypoid process?

Answer 96

Vocal-fold granuloma

Question 97

97 Vocal-fold granuloma/contact ulcer results from chronic irritation and inflammation of what structure?

Answer 97

Arytenoid perichondrium

Question 98

98 Describe the difference between vocal-fold granuloma related to intubation and vocal-fold granuloma not related to intubation.

Answer 98

* Intubation-related granuloma tends to resolve spontaneously within a few _months_ of extubation. * Vocal-fold granulomata not related to intubation are typically difficult to treat, requiring thorough evaluation to identify and eliminate causative factors such as reflux, voice abuse, chronic cough, or allergies.

Question 99

99 What is the treatment of choice for vocal-fold granuloma?

Answer 99

* Intubation-related granulomas will likely resolve spontaneously. * Non–intubation-related granulomas should be treated conservatively with primary voice therapy in addition to elimination of contributing factors (e.g., antireflux medication, possibly steroids to limit inflammatory response). Surgery is a last resort in both cases (e.g., large, pedunculated lesion).

Question 100

100 You are performing an interval airway examination on a 21-year-old man who survived a motorvehicle accident 10 days earlier. He suffered a tracheal laceration and polytrauma and has required ongoing sedation because of the extent of his neurologic injuries. He has an 8–0 endotracheal tube in place, and although his tracheal repair has healed nicely, you note the growth of a pedunculated lesion on his posterior true vocal fold and vocal process. What immediate intervention should you recommend?

Answer 100

Downsize his endotracheal tube (ETT).

Question 101

101 A patient has dysphonia. Laryngoscopy reveals bilateral pale, watery, sessile, mobile collections of fluid on the superior surface and margins of the true vocal folds. What is the most likely diagnosis?

Answer 101

Reinke edema (also called bilateral diffuse polyposis or smoker's polyps)

Question 102

102 What is the mechanism leading to the voice changes observed in bilateral diffuse polyposis (Reinke edema) of the true vocal folds?

Answer 102

Accumulation of gelatinous material in the *superficial lamina propria* leading to increased vocal-fold mass

Question 103

103 What risk factors have been associated with the severity of Reinke edema?

Answer 103

Age, laryngopharyngeal reflux, vocal abuse, vocal hyperfunction, smoking, and hypothyroidism

Question 104

104 True or False. The polypoid changes associated with Reinke edema are permanent.

Answer 104

True. However, the degree of edema and turgidity may fluctuate with voice use and exacerbating factors.

Question 105

105 What is the initial treatment of choice for a patient with bilateral diffuse polyposis (Reinke edema) of the true vocal folds?

Answer 105

Smoking cessation, management of reflux, and reduction of phonotrauma

Question 106

106 If conservative therapy for a patient with Reinke edema fails, what is the primary surgical intervention?

Answer 106

Mucosal sparing microflap polyp reduction, which results in decreased postoperative voice dysfunction compared with vocal cord stripping

Question 107

107 What are the two mechanisms by which upper airway angioedema may occur?

Answer 107

1. Mast cell mediated 2. Bradykinin induced

Question 108

108 What laboratory test should be ordered if you suspect a diagnosis of **hereditary angioedema**?

Answer 108

C1 esterase inhibitor level

Question 109

109 Describe three types of laryngeal cysts.

Answer 109

1. Saccular cysts 2. Ductal cysts 3. Intracordal vocal fold cysts

Question 110

110 Intracordal vocal-fold cysts generally arise within the superficial lamina propria (although they may arise from the vocal ligament or epithelium). They may be open to the epithelium of the vocal fold and can be associated with a sulcus, and they are also commonly associated with a contralateral nodule. What are the two most common subtypes?

Answer 110

* Mucus-retention cysts (wax and wane) * Epidermoid/keratin cysts (fairly stable, more white)

Question 111

111 What is the preferred management for intracordal cysts?

Answer 111

For lesions that persist after conservative therapy, including a trial of voice therapy, microflap resection with preservation of the epithelium and superficial lamina propria, possibly followed by infusion of saline (or other substance, such as collagen) into the SLP

Question 112

112 A cyst arising from which branchial cleft may involve the larynx?

Answer 112

Third branchial cleft

Question 113

113 A large cyst is noted along the laryngeal surface of the epiglottis, resulting in partial obstruction. The cyst is covered in smooth mucosa and is round and slightly translucent. What is the best treatment?

Answer 113

Endoscopic incision and drainage followed by marsupialization (mucus-retention cyst)

Question 114

114 A patient with a history of having been intubated for less than 24 hours develops stridor and respiratory difficulty. A subglottic cyst is identified. What is the most likely cause for development of this lesion?

Answer 114

Acquired subglottic (ductal) cysts develop as a result of mucosal damage, which obstructs the duct of a mucous gland

Question 115

115 What structure consists of a blind sac between the false vocal fold and the thyroid cartilage, which opens into the anterior third of the laryngeal ventricle, is lined with ciliated respiratory epithelium and mucous glands, and is responsible for lubricating the vibrating vocal folds?

Answer 115

Laryngeal saccule (laryngeal appendix)

Question 116

116 When the saccular opening becomes blocked resulting in a mucous filled dilation within the false vocal fold, what pathologic condition results?

Answer 116

Saccular cyst

Question 117

117 What are the most common reasons for saccular cyst formation (obstruction of the saccular opening)?

Answer 117

Infection, recent intubation, cancer, or mass effect

Question 118

118 What type of saccular cyst extends posteriorly and superiorly to involve the aryepiglottic fold?

Answer 118

Lateral saccular cyst

Question 119

119 What type of saccular cyst extends medially into the laryngeal lumen between the true and false vocal folds?

Answer 119

Anterior saccular cyst

Question 120

120 What is the difference between an anterior and a lateral saccular cyst?

Answer 120

An anterior saccular cyst lies between the true and false vocal folds. A lateral saccular cyst lies between the false vocal fold and the aryepiglottic fold.

Question 121

121 What are the most common initial signs and symptoms associated with saccular cysts?

Answer 121

* Infants: Respiratory distress, cyanosis, stridor, difficulty feeding * Adults: Dysphonia, dyspnea, dysphagia, pain, neck mass

Question 122

122 What is the treatment of choice for saccular cysts?

Answer 122

Marsupialization or complete excision Biopsy should be performed in adults to rule out cancer.

Question 123

123 What are the medial and lateral boundaries of the laryngeal saccule?

Answer 123

The saccule is bordered medially by the **false vocal cord** and laterally by the **thyroid cartilage.**

Question 124

124 What results when the saccule becomes dilated or herniated, is filled with air, and maintains a patent orifice?

Answer 124

Laryngocele

Question 125

125 Describe the similarities and differences between a laryngocele and a saccular cyst.

Answer 125

Both laryngoceles and saccular cysts are dilations of the saccule. A **laryngocele** is an air-filled dilation that communicates with the laryngeal lumen. A **saccular cyst** is a fluidfilled dilation that _does not_ communicate with the laryngeal lumen.

Question 126

126 What type of laryngocele is confined to the larynx?

Answer 126

Internal laryngocele

Question 127

127 What type of laryngocele extends through the thyrohyoid membrane, laterally into the neck?

Answer 127

External or combined laryngocele

Question 128

128 Describe the difference between an internal laryngocele and an external or combined laryngocele.

Answer 128

* Internal laryngocele: Contained within the thyroid cartilage * Combined (external) laryngocele: Extends through the thyrohyoid membrane

Question 129

129 What are the most common symptoms associated with a laryngocele?

Answer 129

Most are asymptomatic. However, symptoms can include dysphonia, dyspnea, weak cry, and aphonia. External laryngoceles may manifest with an intermittent lump in the neck.

Question 130

130 How are internal laryngoceles treated?

Answer 130

Complete excision, either via endoscopic or external approaches. **Marsupialization is not recommended.**

Question 131

131 How should a large combined or external laryngocele be treated?

Answer 131

Generally, external approaches are recommended with complete excision through the thyrohyoid membrane and transection close to the orifice of the saccule. However, complete endoscopic excision has been successfully reported even for large lesions.

Question 132

132 What is the greatest risk associated with surgical repair of bilateral combined laryngoceles?

Answer 132

**Aspiration** secondary to bilateral injury to the internal branch of the superior laryngeal nerve

Question 133

133 When a saccular cyst is filled with purulent debris, what is it called?

Answer 133

Laryngopyocele

Question 134

134 How are laryngopyoceles managed?

Answer 134

A laryngopyocele can be a surgical emergency. Secure an airway, drain endoscopically, and culture. Either at the time of drainage or after resolution of the acute infection, complete excision either endoscopically or externally is indicated. Medical management of the acute episode includes IV antibiotics, antipyretics, and steroids.

Question 135

135 Describe the normal effect of advancing age on the fundamental frequency of the speaking voice.

Answer 135

In both men and women, the speaking pitch decreases with age to a point and then begins to increase.

Question 136

136 Describe the changes that occur in the larynx with age.

Answer 136

Muscle atrophy, thinning of the vocal ligament, mucous gland degeneration, cartilage ossification and epithelial thickening.

Question 137

137 Name three physiologic changes that contribute to the perception of a voice as sounding “elderly.”

Answer 137

* Air escape * Laryngeal tension * Tremor

Question 138

138 In a patient with paresis of the external branch of the left superior laryngeal nerve, which direction will the **petiole** of the epiglottis deviate during high-pitched phonation?

Answer 138

Left. Toward the side of the weak cricothyroid muscle

Question 139

139 True or False. Presbylaryngis is likely to be the sole cause of a voice complaint in an elderly patient.

Answer 139

False. Voice disorders in elderly patients are much more likely to be caused or confounded by diseases of aging and associated medications than by presbylaryngis alone. Presbylaryngis is a diagnosis of exclusion after all possible causes have been ruled out.

Question 140

140 How does chronic laryngitis differ from acute laryngitis?

Answer 140

Chronic laryngitis results in chronic dysfunction.

Question 141

141 What three habits should be limited or eliminated to improve laryngeal hygiene?

Answer 141

* Tobacco use * Alcohol use * Caffeine consumption

Question 142

142 What are the most common symptoms associated with reflux laryngitis?

Answer 142

* Hoarseness * Cough * Globus * Throat clearing Notably, fewer than 50% have gastrointestinal symptoms of reflux.

Question 143

143 Describe the key difference between laryngopharyngeal reflux (LPR) and gastroesophageal reflux. Patients with LPR are less likely to have esophagitis (25%) or heartburn (\< 40%) and are less likely to have prolonged periods of esophageal acid exposure or dysmotility.

Answer 143

Patients are more often "daytime" refluxers, and the cause is thought to be upper esophageal sphincter dysfunction.

Question 144

144 How is LPR diagnosed?

Answer 144

There is significant controversy regarding the best diagnostic criteria and tests to use. However, diagnosis is commonly made based on the following: * Clinical history: Reflux symptoms while upright, dysphonia/ hoarseness, cough, globus pharyngeus, throat clearing, and dysphagia * Symptomatic improvement with empiric treatment with PPIs as indicated by a patient’s reflux findings score * Laryngoscopy: Mucosal edema, injury, inflammation * Reflux events identified by use of a dual pH probe, oropharyngeal probe or impedence probe.

Question 145

145 What is the treatment for LPR?

Answer 145

A combination of diet and behavior modifications is recommended. The use of PPIs and H2 blockers, although recommended by the American Academy of Otolaryngology– Head and Neck Surgery (AAO-HNS) consensus statement, is still somewhat controversial for isolated LPR.

Question 146

146 What are the most common risk factors for developing laryngeal chondronecrosis (radionecrosis)?

Answer 146

Radiation dose/timing, infection, poor vascular health (i.e., smoker, diabetic, and such conditions)

Question 147

147 Describe the Chandler classification system for laryngeal radionecrosis and the corresponding treatment recommendations.

Answer 147

* Grade I: Slight hoarseness/dryness; slight edema, telangiectasias; symptomatic care: humidification, antireflux medication, smoking cessation * Grade II: Moderate hoarseness/dryness; similar signs and treatment * Grade III: Severe hoarseness with dyspnea, moderate odynophagia, and dysphagia; Severe impairment of vocal-cord mobility or fixation of one cord, marked edema, skin changes; symptomatic care, steroid, antibiotics, tracheostomy or laryngectomy, if necessary * Grade IV: Respiratory distress, severe odynophagia, weight loss, dehydration; fistula, fetor oris, fixation of the skin to the larynx, airway obstruction, fever; tracheostomy, laryngectomy

Question 148

148 In addition to symptomatic care, antibiotics, and steroids, what additional conservative measure can be tried before laryngectomy for laryngeal chondronecrosis and radionecrosis?

Answer 148

Hyperbaric oxygen therapy

Question 149

149 Laryngeal chondromas arise most commonly from what anatomical site?

Answer 149

Posterior cricoid plate

Question 150

150 According to the Myers-Cotton grading system, what grade is a subglottic stenosis with 90% obstruction of the tracheal lumen? (▶Table 5.1)

Answer 150

Grade III

Question 151

151 What is the mechanism of injury for laryngotracheal stenosis caused by endotracheal intubation?

Answer 151

* Ischemic necrosis of the mucosa secondary to pressure of the cuff or the tube itself * Healing by secondary intention leads to fibrosis and scar contraction.

Question 152

152 True or False. Approximately 80% of cartilaginous tumors of the larynx are chondromas.

Answer 152

False. Chondroma was initially thought to represent approximately 80% of cartilaginous laryngeal tumors, but this was later determined to be an overestimation resulting from misdiagnosed low-grade chondrosarcoma. The true number of cartilaginous tumors that are chondromas is much less than 80%.

Question 153

153 What is the treatment for laryngeal chondromas?

Answer 153

When possible, complete excision to negative margins alone

Question 154

154 Approximately what percentage of all benign laryngeal lesions are neurogenic in origin?

Answer 154

0.1 to 1.5%.

Question 155

155 What are the most common benign neurogenic laryngeal neoplasms?

Answer 155

Laryngeal schwannoma (most common), neurofibroma, and granular cell neoplasms. Schwannomas and neurofibromas most commonly arise from the **internal branch of the superior laryngeal nerve.**

Question 156

156 Where are endolaryngeal neurofibromas most commonly found?

Answer 156

* Arytenoid complex and aryepiglottic fold * Although they can occur in patients with neurofibromatosis type I (von Recklinhausen disease), isolated laryngeal neurofibromas are more common.

Question 157

157 Which neurogenic laryngeal neoplasm is often associated with pseudoepitheliomatous hyperplasia of the overlying mucosa, which can often be misdiagnosed as squamous cell carcinoma?

Answer 157

Granular cell neoplasm

Question 158

158 Because granular cell tumors present a risk for malignant conversion (2 to 3%), they should be resected. What confirmatory findings for benign tumor should be looked for on pathology?

Answer 158

* Large polyhedral cells that may contain significant collagen, granular eosinophilic cytoplasm, and centrally located vesicular nuclei * (+) periodic acid-Schiff (PAS), (+) S-100, (+) neuron specific enolase, (+) NK1-C3

Question 159

159 What is the likely cell of origin for granular cell tumors?

Answer 159

Schwann cell

Question 160

160 How should benign neurogenic laryngeal neoplasms be managed?

Answer 160

Endoscopic evaluation and biopsy * Small lesion: complete endoscopic resection * Large lesion: complete resection via an external approach These are benign lesions; therefore, conservative complete excision with voice preservation should be the goal.

Question 161

161 What is the most common benign neoplasm of the larynx?

Answer 161

Recurrent respiratory papillomatosis (RRP). Also the most common benign neoplasm of the larynx in children.

Question 162

162 Of the most common human papillomavirus (HPV) subtypes causing RRP, which has a more aggressive clinical course?

Answer 162

HPV 11: More frequent surgical intervention and a higher incidence of airway obstruction. HPV subtypes 6 and 11 are the most common in RRP.

Question 163

163 Does juvenile- or adult-onset RRP tend to have a more aggressive course?

Answer 163

Juvenile RRP tends to be more diffuse, exophytic, and often recurs rapidly after intervention.

Question 164

164 What is the standard of care for treatment of symptomatic RRP?

Answer 164

Surgical excision without damaging normal structures

Question 165

165 Describe the type and structure of the virus responsible for RRP.

Answer 165

HPV is a papillomovirus of the Papovavirus family, with a **nonenveloped icosahedral capsid** and a **double-stranded circular DNA genome**.

Question 166

166 What is a laryngeal lymphatic malformation?

Answer 166

* A collection of lymph vessels filled with serous fluid centered in the larynx * Rarely confined solely to the larynx

Question 167

167 How do laryngeal lymphatic malformations present?

Answer 167

* Asymptomatic versus stridor, dyspnea on exertion, and respiratory distress * Worse during infections

Question 168

168 Laryngoscopy shows a soft, smooth, painless, compressible mass in the larynx. Imaging shows fluid filled areas enveloped by connective tissue. What is the likely diagnosis?

Answer 168

Lymphatic malformation

Question 169

169 What treatment options are available for laryngeal lymphatic malformations?

Answer 169

For symptomatic or disfiguring lesions, surgical debulking is the treatment of choice. Sclerotherapy may be considered for macrocystic lesions. Up to 50% of patients with extensive disease of the head and neck will require tracheostomy.

Question 170

170 True or False. Both cystic hygromas and cavernous/ microcystic lymphangiomas respond well to surgical excision.

Answer 170

False. **Cystic hygromas** are composed of large cysts that are amenable to surgical excision. **Cavernous/microcystic lymphangiomas**, however, are composed of very small cysts that are difficult to resect and tend to recur after surgery.

Question 171

171 Although laryngeal hemangiomas in adults are rare, how do they manifest?

Answer 171

Airway symptoms including bleeding, stridor, dysphonia, mild dyspnea, dysphagia, and snoring

Question 172

172 True or False. Laryngeal hemangiomas are more common on the left side of the larynx than on the right.

Answer 172

True

Question 173

173 How are laryngeal hemangiomas diagnosed, and what is their natural history?

Answer 173

They are seen on examination covered by thin, friable mucosa overlying a vascular stroma. T2-weighted MRI can be helpful to delineate extent. These are most commonly seen in the **supraglottis** in adults and generally do not spontaneously regress.

Question 174

174 What is the treatment of choice for an asymptomatic laryngeal hemangioma in an otherwise healthy adult patient?

Answer 174

Hemangiomas in adults should not be actively treated unless they are symptomatic. Corticosteroids or radiotherapy may be considered if necessary.

Question 175

175 At what age do infantile hemangiomas typically begin to involute, and at what age is involution likely to be complete?

Answer 175

Infantile hemangiomas begin to involute between 12 and 24 months of age; 50% will have involuted by age 5 and 70% by age 7.

Question 176

176 What viruses have been associated with acute viral laryngitis?

Answer 176

Rhinovirus, parainfluenza, influenza, adenovirus, respiratory syncytial virus, herpes simplex virus (HSV), coronavirus

Question 177

177 What medication has been shown to significantly improve discomfort associated with acute viral laryngitis?

Answer 177

Nonsteroidal anti-inflammatory drugs (NSAIDs) In a prospective, double-blinded study, flurbiprofen lozenges were shown to significantly improve sore throat associated with acute viral laryngitis compared with placebo.

Question 178

178 Should steroids be given for acute viral laryngitis?

Answer 178

Treatment is primarily supportive (hydration and voice rest) with escalation for evidence of airway compromise (steroids, PPI, antibiotics for secondary infection, humidification). However, **a single dose of dexamethasone (0.16 mg/ kg)** has been shown to decrease overall severity of moderate to severe laryngotracheitis in pediatric patients during the first 24 hours after injection.

Question 179

179 Describe the clinical manifestations of parainfluenza virus infection in adults.

Answer 179

* Immunocompetent: Mild upper respiratory tract infection * Immunocompromised: Pneumonia (can be fatal)

Question 180

180 What infectious agents are potential causes of epiglottitis in adults?

Answer 180

* A broad range of bacterial (H. influenzae type b[Hib]], other Haemophilus strains, Streptococcus pneumonia, Staphylococcus aureus, β-hemolytic streptococci, etc.), viral (HSV type 1, varicella zoster virus, parainfluenza virus type 3, influenza B virus, Epstein-Barr virus), and fungal (candida) infections * Noninfectious causes are also possible (thermal, mechanical, or chemical injury).

Question 181

181 How does adult supraglottitis (epiglottitis) differ from pediatric epiglottitis?

Answer 181

Manifestation is often less dramatic, with the most common initial symptoms and signs including **sore throat**, dysphagia, fever, and dyspnea. **Airway intervention is required in less than 20% of cases**.

Question 182

182 In an adult with epiglottitis demonstrating mild respiratory distress, \< 50% obstruction of the laryngeal inlet, without stridor, drooling, or cyanosis, what is the management strategy of choice?

Answer 182

Close monitoring in the intensive care unit (ICU) with an emergency airway cart available is preferred, as well as empiric antibiotics including a third-generation cephalosporin and an anti-staphylococcal antibiotic with activity against MRSA (methicillin-resistant Staphylococcus aureus). Glucocorticoids can be considered but are not routinely recommended.

Question 183

183 Primary infection of the laryngeal cartilage can occur after trauma, radiation, intubation, tracheostomy, or foreign body aspiration. Cancer and relapsing polychondritis are also risk factors. Such an infection is called what?

Answer 183

Chondritis (primarily impacting the cartilage) or perichondritis (impacting the perichondrium + /- underlying cartilage)

Question 184

184 What organism is the most common cause of acute fungal laryngitis?

Answer 184

Candida albicans

Question 185

185 How do you confirm the diagnosis of candidal laryngitis?

Answer 185

**Tissue biopsy** is generally done to rule out carcinoma or **swab and fungal stains** (not routinely performed).

Question 186

186 What fungal strains are responsible for chronic fungal laryngitis?

Answer 186

Blastomycoces (Southern United States), Histoplasma (Ohio and Mississippi River valleys), Coccidioides (southwestern United States and Mexico), Paracoccidioides, and Cryptococcus spp. Candidal laryngitis is more commonly acute, but it can be chronic as well.

Question 187

187 What are risk factors for fungal laryngitis?

Answer 187

Laryngopharyngeal reflux, immunosuppression, systemic or inhaled steroid use, broad-spectrum antibiotic therapy, and smoking

Question 188

188 How is fungal laryngitis treated?

Answer 188

Systemic antifungals (i.e., amphotericin B, ketoconazole, itraconazole, fluconazole, nystatin). Topical therapy can also be used in the form of troches or lozenges (i.e., miconazole, clotrimazole, nystatin); however, this therapy is not recommended for invasive or systemic infections and often does not lead to long-term control.

Question 189

189 What risk factors predispose a person to developing chronic bacterial laryngitis?

Answer 189

Previous prolonged intubation, relapsing polychondritis, history of recent viral laryngitis, compromised immune status, reflux

Question 190

190 What is the most common subsite affected by laryngeal sarcoidosis? (▶Fig. 5.6)

Answer 190

Epiglottis

Question 191

191 True or False. Laryngeal sarcoidosis can occur in isolation without evidence of disease elsewhere in the body.

Answer 191

True (1 to 5%)

Question 192

192 What is the pathognomonic finding of laryngeal sarcoidosis during laryngoscopy?

Answer 192

Diffuse pale, edematous enlargement of the supraglottis

Question 193

193 True or False: An ACE (angiotensin-converting enzyme) level is the test of choice for diagnosing sarcoidosis.

Answer 193

False. An ACE level is useful for **monitoring** disease in patients with sarcoidosis but is not recommended as a diagnostic test due to low sensitivity (60%).

Question 194

194 What percentage of patients with granulomatosis and polyangitis (Wegener) will develop subglottic stenosis?

Answer 194

10 to 20%

Question 195

195 What are the expected biopsy findings in a patient with granulomatosis with polyangiitis (Wegener)?

Answer 195

Necrotizing granulomas and necrotizing vasculitis of small arteries, arterioles, capillaries, and venules

Question 196

196 In a patient with symptomatic subglottic stenosis secondary to granulomatosis with polyangiitis (Wegener), what will be found on flow-volume loops during pulmonary function testing?

Answer 196

Flattening of both inspiratory and expiratory phases, indicating a **fixed airway obstruction**

Question 197

197 What site within the larynx is most commonly affected by amyloidosis?

Answer 197

The true and false cords and the ventricles

Question 198

198 What is the most common type of amyloid protein deposit found in the larynx?

Answer 198

Amyloid light chain

Question 199

199 What autoimmune disorder results in episodic, severe, and progressive inflammation of cartilage most commonly within the ears, nose, and laryngotracheobronchial tree?

Answer 199

Relapsing polychondritis

Question 200

200 What is the mechanism of respiratory distress in relapsing polychondritis?

Answer 200

Two mechanisms are possible: 1. Airway narrowing secondary to fibrosis 2. Airway collapse secondary to cartilage destruction and fibrosis.

Question 201

201 What is the most common manifestation of airway involvement in relapsing polychondritis?

Answer 201

Tracheobronchomalacia

Question 202

202 What percentage of patients with rheumatoid arthritis develop cricoarytenoid joint involvement (i.e., arthritis, ankylosis, etc)?

Answer 202

25 to 30%. May also see cricothyroid joint dysfunction or rheumatoid nodules on the true vocal folds, but these are less common in the literature. May see tenderness on palpation of the larynx.

Question 203

203 What percentage of patients with rheumatoid arthritis have radiologic evidence of cricoarytenoid joint involvement?

Answer 203

54 to 72%. The most common findings on CT are cricoarytenoid prominence, density and volume change, subluxation, decreased joint space, and pyriform sinus narrowing. However, radiologic involvement does not always correlate with symptoms.

Question 204

204 How is cricoarytenoid joint dysfunction associated with rheumatoid arthritis treated?

Answer 204

Mild symptoms: High-dose corticosteroids or immune modulating medications used for rheumatoid arthritis. If this fails, corticosteroid injection of the cricoarytenoid joint can be considered. For acute airway obstruction (rare), consider tracheostomy, arytenoidectomy, or arytenoidopexy.

Question 205

205 The motor neurons of the recurrent laryngeal nerve originate in what brainstem nucleus?

Answer 205

Nucleus ambiguous

Question 206

206 How can neuronal injuries be classified?

Answer 206

Sunderland and Seddon injury table with neurosensory impairment and recovery potential

Question 207

207 What accounts for the small amount of continued vocal fold adduction that may exist after transection of the ipsilateral recurrent laryngeal nerve?

Answer 207

Bilateral innervation of the **interarytenoid muscle**

Question 208

208 What is the most common cause of unilateral true vocal-fold paralysis

Answer 208

Surgical iatrogenic injury

Question 209

209 What is the most common malignant cause of unilateral true vocal-fold paralysis?

Answer 209

Lung carcinoma

Question 210

210 Imaging of what region(s) should be obtained to evaluate unilateral true vocal-fold immobility of unknown cause?

Answer 210

Skull base to the upper chest to examine the full course of the recurrent laryngeal nerve. CT or MRI is most commonly used.

Question 211

211 What is the most common swallowing problem associated with unilateral true vocal-fold immobility?

Answer 211

Aspiration of liquids

Question 212

212 Unilateral true vocal-fold immobility may cause dyspnea by what mechanism?

Answer 212

Incomplete glottic closure leading to air escape during speech

Question 213

213 What medications are known to have neurotoxic effects that can lead to true vocal-fold paralysis?

Answer 213

Vinca alkaloids (vincristine, vinblastine) and cisplatinum

Question 214

214 After a high vagal nerve injury, will the palate elevate toward or away from the injured side?

Answer 214

The palate will elevate away from the injured side.

Question 215

215 What mucosal wave finding on videostrobosopy is associated with unilateral vocal-fold paralysis?

Answer 215

Increased **amplitude** on the paralyzed side

Question 216

216 A patient is evaluated for hoarseness and aspiration after suffering a known stroke involving the posterior inferior cerebellar artery. What is likely to be seen on flexible laryngoscopy?

Answer 216

Paralysis of the ipsilateral true vocal fold in **Wallenberg syndrome**, or **lateral medullary syndrome**, results in hoarseness secondary to true vocal-fold paralysis, dysphagia, loss of pain and temperature sensation on the ipsilateral face and contralateral body, and ipsilateral Horner syndrome.

Question 217

217 What is the role of laryngeal electromyography (EMG) in management of vocal-fold immobility?

Answer 217

EMG can differentiate paralysis from fixation and may provide prognostic information regarding the potential for recovery of mobility.

Question 218

218 What is the primary goal of surgical intervention for bilateral true vocal-fold paralysis?

Answer 218

Improving the airway while preserving voice and swallowing

Question 219

219 What options, other than tracheotomy, exist for management of airway compromise secondary to bilateral true vocal-fold paralysis in the early postinjury period?

Answer 219

1. Endotracheal intubation 2. Suture lateralization 3. Botox injection

Question 220

220 For a patient who is tracheostomy dependent as a result of bilateral true vocal-fold paralysis, what is the chance of decannulation after transverse cordotomy and medial arytenoidectomy?

Answer 220

59 to 100%

Question 221

221 Intermittent strangled or strained voice breaks during speech, particularly during words starting with vowels, is suggestive of which diagnosis?

Answer 221

Adductor spasmodic dysphonia

Question 222

222 Describe the difference between adductor spasmodic dysphonia (ADSD) and muscle-tension dysphonia (MTD) during auditory – perceptual evaluation?

Answer 222

ASD is task dependent, whereas MTD is not. Patients with both disorders may have a strangled or strained voice quality, but in MTD this will be constant across all vocal tasks. In ADSD, symptoms will be worse during sentences rich in voiced consonants and during connected speech and will improve during sustained vowels and sentences with predominantly voiceless consonants.

Question 223

223 Which laryngeal muscles are selectively injected during botulinum toxin treatment of adductor spasmodic dysphonia?

Answer 223

Thyroarytenoid muscles

Question 224

224 What are the most common adverse effects of botulinum toxin injection for ADSD?

Answer 224

Breathy voice and aspiration of fluids, which are usually selflimiting

Question 225

225 True or False. Breathy voice and aspiration of liquids after botulinum toxin injection for adductor spasmodic dysphonia are likely to last up to 2 weeks and then resolve spontaneously.

Answer 225

True

Question 226

226 Describe the voice and speech characteristics associated with abductor spasmodic dysphonia.

Answer 226

Intermittent breathy voice breaks during speech, particularly following voiceless consonants

Question 227

227 Which laryngeal muscles are selectively injected during botulinum toxin treatment of abductor spasmodic dysphonia?

Answer 227

Posterior cricoarytenoid muscles

Question 228

228 Describe paradoxical vocal-cord motion.

Answer 228

Inappropriate adduction of the true vocal folds during inspiration

Question 229

229 What spirometry finding is associated with paradoxical vocal-fold motion?

Answer 229

Flat inspiratory portion of the flow-volume loop

Question 230

230 How can you test for suspected exercise-induced paradoxical vocal-fold motion in the office?

Answer 230

Provocation testing. Ask the patient to exercise until he or she becomes symptomatic, and then immediately perform flexible fiberoptic laryngoscopy. The diagnosis will be confirmed with observation of adduction of the vocal folds during inspiration.

Question 231

231 What is the treatment of choice for paradoxical vocal-fold motion?

Answer 231

* Voice therapy * Relaxation and breathing exercises, such as laryngeal control therapy

Question 232

232 What percentage of patients with essential tremor will develop vocal tremor?

Answer 232

10 to 20%

Question 233

233 What muscles are selectively injected with botulinum toxin in the treatment of vocal tremor?

Answer 233

The strap muscles and/or intrinsic laryngeal muscles may be injected, based on which muscles appear most tremulous on examination.

Question 234

234 What diagnosis must be considered in a patient with Parkinson disease and vocal-fold motion abnormalities?

Answer 234

Shy-Drager syndrome, a form of multiple-system atrophy, is a Parkinson-plus syndrome that may lead to life-threatening sleep apnea. Tracheotomy may be required.

Question 235

235 What are the voice and speech characteristics observed in amyotrophic lateral sclerosis?

Answer 235

Monotonous hoarse voice with hypernasal and dysarthric speech

Question 236

236 Describe the distinctive vocal features of spastic dysarthria.

Answer 236

Harsh quality, low fundamental frequency, strained/ strangled sound, and pitch breaks resulting from injury of the pyramidal and extrapyramidal tracts

Question 237

237 Injury to what structure(s) results in flaccid dysarthria?

Answer 237

Damage to any of the cranial nerves involved in speech (V, VII, X, XII) results in flaccid dysarthria.

Question 238

238 Describe the speech pattern associated with ataxic dysarthria.

Answer 238

Ataxic dysarthria is associated with disorders of the cerebellum and is characterized by a harsh, breathy voice with a strained tremulous quality and fluctuating pitch and volume. Tremulous laryngeal muscle contractions are noted during speech but not at rest.

Question 239

239 Describe the characteristic features of dysarthria associated with Parkinson disease.

Answer 239

Hypokinetic dysarthria: Low volume, reduced pitch variation, rushed speech, and reduction of articulation-associated movements

Question 240

240 Describe the key features of muscle tension dysphonia.

Answer 240

Posterior glottic chink, high larynx, suprahyoid muscle tension, breathiness, and glottal fry

Question 241

241 True or False. Muscle tension dysphonia is often the result of an unconscious attempt to compensate for glottic insufficiency.

Answer 241

True. Therefore, treatment focuses initially on voice therapy.

Question 242

242 What physical examination findings are associated with excessive laryngeal muscle tension?

Answer 242

Pain on palpation of the larynx and extrinsic laryngeal muscles, small thyrohyoid space, high hyoid bone and larynx, difficulty rotating the larynx

Question 243

243 Describe the voice characteristics associated with dysphonia plica ventricularis.

Answer 243

Ventricular dysphonia, or dysphonia plica ventricularis, refers to phonation resulting from false vocal-fold vibration as opposed to true vocal-fold vibration. The resulting voice is characteristically low pitched and hoarse, with intermittent voice breaks and diplophonia.

Question 244

244 What are the indications for a surgical airway?

Answer 244

* More than three failed attempts at intubation by an experienced laryngoscopist * \> 10 minutes since initiation of induction * O2 saturations \< 65% during the first or second intubation attempt * Difficulty or inability to mask ventilate * Experienced airway staff decides that additional intubation attempts would be unsuccessful

Question 245

245 In an emergent “can’t intubate, can’t ventilate” situation, what is traditionally the preferred surgical airway approach?

Answer 245

Cricothyrotomy (Some studies report that in practice tracheotomy may be used more often than cricothyrotomy.)

Question 246

246 Describe the relative contraindications to cricothyrotomy.

Answer 246

* Child younger than 10 to 12 years * Inability to palpate landmarks (neck trauma) * Expanding cervical hematoma * Subglottic extension of known laryngeal disease

Question 247

247 Describe the surgical steps involved in cricothyrotomy.

Answer 247

1. Palpate landmarks (correctly identify cricothyroid space) and stabilize the larynx in your nondominant hand, maintaining the position of the cricothyroid membrane with your pointer finger. 2. Make a vertical incision through skin to, but not through, the laryngeal cartilaginous framework. 3. Horizontal incision through the cricothyroid membrane 4. Spread open the space using a clamp, back end of the scalpel, or other available instrument. 5. Carefully place cuffed breathing tube (tracheostomy or ETT).

Question 248

248 When is needle cricothyrotomy or transtracheal needle ventilation indicated?

Answer 248

* It is indicated only in unique emergency settings in which intubation and surgical airway are not possible or in pediatric patients in whom a surgical airway is considered unsafe because of compressibility of the laryngeal cartilage framework. * It is used as a temporizing measure until a secure airway is possible. In adults, this is seen more in the prehospital setting. However, staff must be comfortable putting the equipment together and ventilating through this approach, which can be challenging.

Question 249

249 How long can a patient be ventilated via transtracheal needle ventilation?

Answer 249

Reports range from 30 minutes to 2 hours.

Question 250

250 Describe the technique of needle cricothyrotomy and subsequent ventilation.

Answer 250

1. Connect a 12- or 14-gauge angiocatheter to a 3-mL syringe filled partially with saline or a commercially available needle cricothyrotomy device such as the Ravussin catheter. 2. After identifying the cricothyroid space, the needle is advanced at a 0- to 30-degree (caudal) angle while pulling back on the plunger. Once air is aspirated, the catheter is inserted over the needle at a 30- to 45-degree angle. 3. The angiocatheter is then connected to 100% oxygen at 50 psi using a Luer-Lok connector or oxygen tubing containing a y-connection attached to a jet insufflator and oxygen source (preferred). If this is not available, the angiocatheter can be connected to a bag-valve system via a 3.5-mm ETT connector, a 3-mL syringe without the plunger, and a 7.0 ETT connector, a 10-mL syringe without the plunger, and a 7.0 ETT inserted into the syringe with the cuff inflated or via cut IV infusion tubing connected to a 2.5 ETT connector. 4. Ventilation is most effective with a jet ventilation system: however, the airway may be temporized with a bag-valve system.

Question 251

251 Describe the primary indications for tracheotomy

Answer 251

1. Prolonged endotracheal intubation 2. Upper airway obstruction 3. Management of tracheobronchial secretions (pulmonary toilet) 4. Airway management associated with head and neck surgery 5. Management of major head and neck trauma

Question 252

252 What are the nonemergent indications for surgical tracheotomy?

Answer 252

P Pulmonary toilet: Aspiration, inability to clear secretions (e.g., stroke, neurologic impairment, etc.) O Obstruction: Malignancy, obstructive sleep apnea (not amenable to noninvasive treatment) P Prevent complications associated with prolonged intubation (e.g., subglottic stenosis, tracheal erosion, etc.)

Question 253

253 Tracheotomy should be performed after how many days of endotracheal intubation?

Answer 253

Although tracheotomy is generally performed after 14 days, there is no specific rule regarding optimal timing and should be individualized based on risk of continued intubation (i.e., subglottic stenosis) versus the likelihood of extubation.

Question 254

254 At what level should the tracheal incision be made during open tracheostomy?

Answer 254

Between the second and third tracheal rings (or third and fourth if necessary)

Question 255

255 What are the basic steps in open surgical tracheotomy?

Answer 255

1. A horizontal incision is placed between the sternal notch and cricoid cartilage at approximately the level of the second tracheal ring. 2. Dissection through the subcutaneous tissue to the strap musculature 3. Division of the midline raphe between the sternohyoid and sternothyroid muscles 4. Division (electrocautery or clamp and tie) or displacement of the thyroid isthmus 5. Identification of the cricoid cartilage and tracheal rings 6. Horizontal incision between rings 2–3 or 3–4 7. Creation of a Bjork flap using scalpel or heavy scissors and fixation of flap to subcutaneous tissue and or skin 8. Withdrawal of the ETT, suctioning, if needed, and placement of the desired tracheostomy tube 9. Inflate the cuff and secure tracheostomy with sutures to skin and tracheostomy tie. Note: Minimal lateral dissection around the trachea will limit disruption of the vascular supply to the trachea and resultant stenosis as well as injury to the recurrent laryngeal nerves.

Question 256

256 What pressure is the maximum pressure acceptable for any endotracheal or tracheostomy tube cuff and why?

Answer 256

30cm H2O; must not exceed mucosal capillary pressure

Question 257

257 When should a tracheostomy tube cuff be deflated?

Answer 257

When the patient no longer needs mechanical ventilation and is not aspirating

Question 258

258 What are early and late complications of tracheostomy?

Answer 258

* Early: Tracheostomy tube occlusion, granulation tissue formation, false passage, tube dislodgement, hemorrhage, wound infection, subcutaneous emphysema (possible pneumothorax or pneumomediastinum), postoperative pulmonary edema * Late: Hemorrhage (e.g., tracheoinnominate fistula), tracheoesophageal fistula, tracheal stenosis, persistent tracheocutaneous fistula (after decannulation)

Question 259

259 When should a tracheostomy tube be removed?

Answer 259

* Resolution of original indication for tracheostomy * Successfully corked/capped for 24 to 72 hours. * No anticipated need for general anesthetic or tracheostomy ventilation in the near future * Patient has adequate pulmonary toilet * No evidence for tracheal granulation tissue or other potentially compromising lesions

Question 260

260 Your patient has met the criteria for tracheostomy decannulation. After removing the tube, cleaning the wound, and removing any stitch (i.e., from the Bjork flap), what type of dressing should be placed?

Answer 260

Occlusive dressing (changed once a day, when saturated, or when no longer sticking)

Question 261

261 What size ETT should be used during laryngeal surgery?

Answer 261

The smallest ETT that will allow adequate ventilation and is long enough to extend from the lips to the subglottis

Question 262

262 What are the four most common ventilation techniques used during laryngeal surgery?

Answer 262

* Endotracheal intubation * Jet ventilation * Spontaneous breathing * Apneic technique

Question 263

263 What are the three types of jet ventilation?

Answer 263

* Supraglottic * Subglottic * Transtracheal

Question 264

264 What is the most common major complication of subglottic jet ventilation?

Answer 264

Air trapping leading to pneumothorax/pneumomediastinum

Question 265

265 What physical examination findings may be associated with difficult endotracheal intubation?

Answer 265

Long incisors, retrognathia, poor mandibular protrusion, small interincisor distance, Mallampati grade 3 or 4, high arched palate, short neck, thick neck, thyromental distance less than three finger breaths, limited neck range of motion

Question 266

266 Describe the 4 modified Mallampati classes.

Answer 266

With the mouth fully open and the tongue protruded: * Class 1: Tonsillar pillars, tonsils, and uvula visible * Class 2: Uvula partially obscured by tongue base, upper tonsils visible * Class 3: Soft palate and base of uvula visible * Class 4: Only hard palate visible

Question 267

267 What is the average duration of effect for deep true vocal-fold injection using the following materials: Gelfoam, bovine collagen, micronized Alloderm (Cymetra), fat, Teflon,calcium hydroxylapatite (Radiesse)?

Answer 267

* Gelfoam: 4 to 6 weeks * Bovine collagen: 3 to 4 months * Micronized Alloderm: 3 to 4 months * Fat: Several years * Teflon: Indefinite * Calcium hydroxylapatite: 2 years, some longer

Question 268

268 The use of Teflon in true vocal-fold injection augmentation has been limited by what complication?

Answer 268

Teflon granuloma

Question 269

269 Patients with what finding on videostroboscopy are less likely to benefit from true vocal-fold injection augmentation?

Answer 269

Posterior glottic gap. Laryngeal framework surgery has a higher chance of success.

Question 270

270 What test must be obtained before performing true vocal-fold injection augmentation with bovine collagen?

Answer 270

Allergy skin testing is required due to the risk of allergic reaction to the material.

Question 271

271 What are the two different types of vocal fold injection augmentation?

Answer 271

* Superficial (intracordal) * Deep injection augmentation

Question 272

272 What are the preferred needle-placement locations for deep true vocal-fold injection augmentation?

Answer 272

The ideal location is at the intersection where a line drawn laterally from the vocal process tip intersects the superior arcuate line (transition from the superior surface of the vocal fold to the ventricle). A second injection, if needed, is often done along the superior arcuate line at the level of the mid-membranous vocal fold.

Question 273

273 Define the superior arcuate line of the true vocal fold.

Answer 273

The superior arcuate line is the transition point from the superior surface of the true vocal fold to the ventricle.

Question 274

274 What is the desired depth of injection for deep true vocal-fold injection augmentation?

Answer 274

3 to 5mm into the thyroarytenoid muscle

Question 275

275 What are the three approaches used for transcervical true vocal fold injection augmentation?

Answer 275

* Thyrohyoid * Cricothyroid * Translaryngeal

Question 276

276 Define the desired effect on the true vocal folds in each of the four types of thyroplasty.

Answer 276

1. Type I: Medial displacement 2. Type II: Lateral displacement 3. Type III: Shortening/relaxing 4. Type IV: Lengthening/tightening

Question 277

277 To avoid airway compromise after medialization laryngoplasty, what should be true regarding the contralateral true vocal fold?

Answer 277

It should be able to abduct completely during inspiration.

Question 278

278 What materials are commonly used for implantation in medialization laryngoplasty?

Answer 278

Silastic, hydroxyapatite, and Gore-Tex strips

Question 279

279 To avoid fracture of the thyroid cartilage after type I thyroplasty, what is the minimum width of cartilage strut that must be left below the thyroplasty window?

Answer 279

3mm

Question 280

280 To externally determine the horizontal plane of the true vocal fold within the thyroid cartilage, what anatomical landmark must be completely exposed along the inferior border of the thyroid cartilage?

Answer 280

The inferior muscular tubercle of the thyroid cartilage must be completely exposed to define the plane of the inferior border of the thyroid cartilage, which parallels the long axis of the true vocal fold.

Question 281

281 Why is the window for placing a Silastic implant during type I thyroplasty placed more posteriorly in men than in women?

Answer 281

The thyroid cartilage in men tends to have a more acute anterior angle. The window is therefore placed more posteriorly to avoid overmedialization of the anterior true vocal fold.

Question 282

282 What are the indications for performing arytenoid adduction in addition to type I thyroplasty?

Answer 282

Large posterior glottic gap or vocal-fold level mismatch

Question 283

283 What landmarks can be used to help identify the muscular process of the arytenoid during arytenoid adduction?

Answer 283

After a window has been created in the posterior thyroid lamina and the pyriform sinus mucosa has been retracted, the muscular process of the arytenoid must be identified. This can be done by palpation, by following the fibers of the posterior cricoarytenoid muscle superiorly to their attachment to the muscular process, or by looking approximately 1cm superior to the cricoarytenoid joint.

Question 284

284 During microflap excision of submucosal pathology of the true vocal fold, where should the incision be located?

Answer 284

Directly over or just lateral to the pathology

Question 285

285 During microflap excision of submucosal pathology of the true vocal fold, what is the desired plane of elevation?

Answer 285

In the most superficial plane possible

Question 286

286 Describe the available techniques for laryngeal reinnervation after injury to the RLN.

Answer 286

Primary RLN anastomosis, ansa cervicalis-to-RLN neurorrhaphy, ansa cervicalis-to-thyroarytenoid neuromuscular pedicle, ansa cervicalis-to-thyroarytenoid neural implantation, hypoglossal nerve-to-RLN neurorrhaphy and cricothyroid muscle-nerve-muscle neurotization

Question 287

287 True or False: Laryngeal reinnervation procedures restore normal movement of the true vocal fold in unilateral true vocal-fold paralysis.

Answer 287

False. Laryngeal reinnervation procedures improve voice and other symptoms of unilateral vocal-fold paralysis by maintaining tone and bulk of the laryngeal adductor muscles, not by restoring normal movement.

Question 288

288 What are the advantages of laryngeal reinnervation techniques relative to other procedures in the treatment of unilateral true vocal-fold paralysis?

Answer 288

* Avoiding thyroarytenoid muscle bulk loss * Preservation of laryngeal anatomy to allow for additional procedures if needed * No alteration of vocal-fold vibratory potential * The ability to perform the procedure under general anesthesia

Question 289

289 What is the key principle in surgical repair of upper airway stenosis?

Answer 289

Providing sufficient skeletal support

Question 290

290 What systemic diseases have been shown to increase the risk of laryngotracheal stenosis after endotracheal intubation?

Answer 290

* Laryngopharyngeal reflux * Congestive heart failure * Diabetes mellitus * Stroke

Question 291

291 What are the indications for using an endolaryngeal stent in the repair of upper airway stenosis?

Answer 291

* Holding cartilage, bone grafts, or fragments in position * Stabilizing epidermal grafts, separating denuded surfaces * Maintaining a patent lumen when scar tissue is required

Question 292

292 What is the mechanism of action of mitomycin C?

Answer 292

Mitomycin is both an antibiotic and an antineoplastic agent. It acts as an alkylating agent, causing DNA cross-linking and inhibition of DNA and RNA synthesis. This may lead to decreased cell division, decreasing fibroblast activity and protein production.

Question 293

293 What is the preferred surgical technique for repair of complete tracheal stenosis?

Answer 293

Resection and primary anastomosis

Question 294

294 What percentage of the adult trachea can be resected and still allow for primary anastomosis?

Answer 294

50% (5–7 cm)

Question 295

295 What is the best surgical treatment for circumferential fibrous stenosis of the trachea with intact cartilage?

Answer 295

Staged partial excisions of the fibrous tissue, spaced 2 to 4 weeks apart to prevent recurrence.