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5 Laryngology Flashcards

1
Q

1 What embryologic structures give rise to the larynx?

A

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

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2
Q

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

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

A

The tracheobronchial groove, a ventromedial diverticulum of the foregut

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4
Q

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

A

Epithelial lamina

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5
Q

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.

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

6 What are the nine laryngeal cartilages?

A

Unpaired

  1. Cricoid cartilage
  2. Thyroid cartilage
  3. Epiglottis

Paired

  1. Arytenoid cartilages
  2. Corniculate cartilages
  3. Cuneiform cartilages
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7
Q

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

A
  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)
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8
Q

8 What nerve provides sensation to the larynx?

A

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.

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9
Q

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

A
  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
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10
Q

10 Describe the subtypes of the laryngeal epithelium.

A
  • 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)
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11
Q

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

A
  1. Epithelium
  2. Superficial lamina propria (SLP)
  3. Intermediate lamina propria
  4. Deep lamina propria
  5. Thyroarytenoid muscle complex
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12
Q

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

A
  • Cover = epithelium + SLP ● Ligament = intermediate lamina propria + deep layers of the lamina propria ● Body = thyroarytenoid muscle
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13
Q

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

A

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.

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14
Q

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)

A

Vertebral artery or posterior inferior cerebellar artery (Wallenburg syndrome)

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15
Q

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

A

The nodose ganglion

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16
Q

16 What are the three levels of laryngeal airway protection?

A

Epiglottis False vocal folds True vocal folds

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17
Q

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?

A

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.

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18
Q

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

A

● Thermal ● Mechanical ● Chemical ● Taste

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19
Q

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

A

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

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20
Q

20 What are the three types of laryngeal respiratory receptors?

A

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

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21
Q

21 What are three fundamental components of speech?

A

● 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

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22
Q

22 What is required for voice production?

A

● 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.

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23
Q

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

A

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

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24
Q

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

A

Subglottis

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25
Q

25 Describe the cover-body theory of voice production.

A

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.

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26
Q

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?

A

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

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27
Q

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?

A

Bernoulli effect

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28
Q

28 Describe the myoelastic-aerodynamic theory of voice production.

A

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.

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29
Q

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

A

Prosody

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30
Q

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?

A

Functional, physical, and emotional aspects of voice disorders

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31
Q

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?

A

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.

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32
Q

32 Name three important voice parameters.

A

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

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33
Q

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

A

Frequency

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34
Q

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

A

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

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35
Q

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

A

Pitch

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36
Q

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

A

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

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37
Q

37 What factors most often influence loudness, or intensity?

A

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.

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38
Q

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

A

● Average speaking fundamental frequency ● Maximum phonational frequency range

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39
Q

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

A

Quality (timbre): Roughness, breathiness, and strain

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40
Q

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

A

Pitch (perceptual correlate of frequency)

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41
Q

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

A

Volume is the perceptual correlate of amplitude.

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42
Q

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

A

Frequency of a wave (normal = 0.40%)

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43
Q

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

A

Amplitude of a wave (normal = 0.50 dB).

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44
Q

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

A

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.

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45
Q

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?

A
  • 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

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46
Q

46 What is the major weakness of the GRBAS scale?

A

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

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47
Q

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?

A

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.

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48
Q

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
A
  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
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49
Q

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?

A
  1. General appearance
  2. Posture, breathing, musculoskeletal tension
  3. Neurologic dysfunction
  4. Physical dysmorphology
  5. Clinical manifestations of disease
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50
Q

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?

A
  • 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.
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51
Q

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

A

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.

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52
Q

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?

A

Loudness, age, gender, consonant, and speech context

  • Men: 7.52cm H2O
  • Women: 6.43cm H2O
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53
Q

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

A

Phonation threshold pressure

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54
Q

54 Define transglottic airflow and its gender-specific ranges.

A

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
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55
Q

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?

A

Laryngeal airway resistance

  • Men: 25 to 45cm H2O/L/second
  • Women: 27 to 51 cm H2O/L/second

Phonatory effort, vocal strength, strain

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56
Q

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

A

Electroglottography

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57
Q

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?

A
  • 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.

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58
Q

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?

A

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.

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59
Q

59 What five important criteria are used to grade videostroboscopy?

A
  1. Symmetry
  2. Periodicity
  3. Amplitude
  4. Mucosal wave
  5. Closure
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60
Q

60 Define the following terms:

  1. Symmetry
  2. Periodicity
  3. Amplitude
  4. Mucosal wave
  5. Closure
A
  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
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61
Q

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?

A

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

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62
Q

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.

A

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

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63
Q

63 What is the main advantage of videokymography over videostroboscopy?

A

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.

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64
Q

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

A

Dysphonia

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65
Q

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

A
  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
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66
Q

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

A
  1. Inspiratory 2. Inspiratory or biphasic 3. Biphasic 4. Expiratory
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67
Q

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

A

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.

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68
Q

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

A

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

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69
Q

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

A

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

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70
Q

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

A

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

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71
Q

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

A

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

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72
Q

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

A

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

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73
Q

73 Which asthma medications are associated with voice changes?

A

Inhaled and systemic steroids, β-agonists, and anticholinergics

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74
Q

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

A

Hypothyroidism may cause voice changes.

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75
Q

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

A

Lower fundamental frequency and increased roughness

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76
Q

76 Describe the difference between indirect and direct voice therapy.

A

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

Direct voice therapy focuses on improving voice production.

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77
Q

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

A

Lee Silverman voice therapy (LSVT)

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78
Q

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 _____?

A

Phonotrauma

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79
Q

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

A

Mid-membranous vocal fold

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80
Q

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)?

A

Vocal-fold nodules

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81
Q

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

A

Phonotrauma (ex: singing, screaming)

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82
Q

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

A

Voice therapy

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83
Q

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

A
  • Laryngopharyngeal reflux
  • Allergies
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84
Q

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

A

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.

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85
Q

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

A

When vocal impairment persists after an appropriate trial of voice therapy

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86
Q

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

A

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.

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87
Q

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

A

Phonotrauma and hemorrhage

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88
Q

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

A

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.

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89
Q

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?

A

Complete voice rest

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90
Q

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

A

Vocal-fold hemorrhage or unilateral hemorrhagic polyp

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91
Q

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

A

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.

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92
Q

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

A

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.

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93
Q

93 Describe the different types of sulcus vocalis.

A
  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
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94
Q

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

A
  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.

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95
Q

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

A

Stiffening of the superficial lamina propria of the true vocal fold

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96
Q

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

A

Vocal-fold granuloma

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97
Q

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

A

Arytenoid perichondrium

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98
Q

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

A
  • 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.
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99
Q

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

A
  • 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).

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100
Q

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?

A

Downsize his endotracheal tube (ETT).

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101
Q

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?

A

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

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102
Q

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

A

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

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103
Q

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

A

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

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104
Q

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

A

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

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105
Q

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

A

Smoking cessation, management of reflux, and reduction of phonotrauma

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106
Q

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

A

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

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107
Q

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

A
  1. Mast cell mediated
  2. Bradykinin induced
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108
Q

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

A

C1 esterase inhibitor level

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109
Q

109 Describe three types of laryngeal cysts.

A
  1. Saccular cysts
  2. Ductal cysts
  3. Intracordal vocal fold cysts
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110
Q

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?

A
  • Mucus-retention cysts (wax and wane)
  • Epidermoid/keratin cysts (fairly stable, more white)
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111
Q

111 What is the preferred management for intracordal cysts?

A

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

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112
Q

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

A

Third branchial cleft

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113
Q

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?

A

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

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114
Q

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?

A

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

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115
Q

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?

A

Laryngeal saccule (laryngeal appendix)

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116
Q

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

A

Saccular cyst

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117
Q

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

A

Infection, recent intubation, cancer, or mass effect

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118
Q

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

A

Lateral saccular cyst

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119
Q

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

A

Anterior saccular cyst

120
Q

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

A

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.

121
Q

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

A
  • Infants: Respiratory distress, cyanosis, stridor, difficulty feeding
  • Adults: Dysphonia, dyspnea, dysphagia, pain, neck mass
122
Q

122 What is the treatment of choice for saccular cysts?

A

Marsupialization or complete excision

Biopsy should be performed in adults to rule out cancer.

123
Q

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

A

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

124
Q

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

A

Laryngocele

125
Q

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

A

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.

126
Q

126 What type of laryngocele is confined to the larynx?

A

Internal laryngocele

127
Q

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

A

External or combined laryngocele

128
Q

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

A
  • Internal laryngocele: Contained within the thyroid cartilage
  • Combined (external) laryngocele: Extends through the thyrohyoid membrane
129
Q

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

A

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

130
Q

130 How are internal laryngoceles treated?

A

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

131
Q

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

A

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.

132
Q

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

A

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

133
Q

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

A

Laryngopyocele

134
Q

134 How are laryngopyoceles managed?

A

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.

135
Q

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

A

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

136
Q

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

A

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

137
Q

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

A
  • Air escape
  • Laryngeal tension
  • Tremor
138
Q

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?

A

Left. Toward the side of the weak cricothyroid muscle

139
Q

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

A

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.

140
Q

140 How does chronic laryngitis differ from acute laryngitis?

A

Chronic laryngitis results in chronic dysfunction.

141
Q

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

A
  • Tobacco use
  • Alcohol use
  • Caffeine consumption
142
Q

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

A
  • Hoarseness
  • Cough
  • Globus
  • Throat clearing

Notably, fewer than 50% have gastrointestinal symptoms of reflux.

143
Q

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.

A

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

144
Q

144 How is LPR diagnosed?

A

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.
145
Q

145 What is the treatment for LPR?

A

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.

146
Q

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

A

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

147
Q

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

A
  • 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
148
Q

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

A

Hyperbaric oxygen therapy

149
Q

149 Laryngeal chondromas arise most commonly from what anatomical site?

A

Posterior cricoid plate

150
Q

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

A

Grade III

151
Q

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

A
  • 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.
152
Q

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

A

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%.

153
Q

153 What is the treatment for laryngeal chondromas?

A

When possible, complete excision to negative margins alone

154
Q

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

A

0.1 to 1.5%.

155
Q

155 What are the most common benign neurogenic laryngeal neoplasms?

A

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

156
Q

156 Where are endolaryngeal neurofibromas most commonly found?

A
  • Arytenoid complex and aryepiglottic fold
  • Although they can occur in patients with neurofibromatosis type I (von Recklinhausen disease), isolated laryngeal neurofibromas are more common.
157
Q

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

A

Granular cell neoplasm

158
Q

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?

A
  • 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
159
Q

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

A

Schwann cell

160
Q

160 How should benign neurogenic laryngeal neoplasms be managed?

A

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.
161
Q

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

A

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

162
Q

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

A

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

163
Q

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

A

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

164
Q

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

A

Surgical excision without damaging normal structures

165
Q

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

A

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

166
Q

166 What is a laryngeal lymphatic malformation?

A
  • A collection of lymph vessels filled with serous fluid centered in the larynx
  • Rarely confined solely to the larynx
167
Q

167 How do laryngeal lymphatic malformations present?

A
  • Asymptomatic versus stridor, dyspnea on exertion, and respiratory distress
  • Worse during infections
168
Q

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?

A

Lymphatic malformation

169
Q

169 What treatment options are available for laryngeal lymphatic malformations?

A

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.

170
Q

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

A

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.

171
Q

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

A

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

172
Q

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

A

True

173
Q

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

A

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.

174
Q

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

A

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

175
Q

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

A

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

176
Q

176 What viruses have been associated with acute viral laryngitis?

A

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

177
Q

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

A

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.

178
Q

178 Should steroids be given for acute viral laryngitis?

A

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.

179
Q

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

A
  • Immunocompetent: Mild upper respiratory tract infection
  • Immunocompromised: Pneumonia (can be fatal)
180
Q

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

A
  • 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).
181
Q

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

A

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.

182
Q

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?

A

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.

183
Q

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?

A

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

184
Q

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

A

Candida albicans

185
Q

185 How do you confirm the diagnosis of candidal laryngitis?

A

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

186
Q

186 What fungal strains are responsible for chronic fungal laryngitis?

A

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.

187
Q

187 What are risk factors for fungal laryngitis?

A

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

188
Q

188 How is fungal laryngitis treated?

A

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.

189
Q

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

A

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

190
Q

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

A

Epiglottis

191
Q

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

A

True (1 to 5%)

192
Q

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

A

Diffuse pale, edematous enlargement of the supraglottis

193
Q

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

A

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%).

194
Q

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

A

10 to 20%

195
Q

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

A

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

196
Q

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?

A

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

197
Q

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

A

The true and false cords and the ventricles

198
Q

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

A

Amyloid light chain

199
Q

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

A

Relapsing polychondritis

200
Q

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

A

Two mechanisms are possible:

  1. Airway narrowing secondary to fibrosis
  2. Airway collapse secondary to cartilage destruction and fibrosis.
201
Q

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

A

Tracheobronchomalacia

202
Q

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

A

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.

203
Q

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

A

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.

204
Q

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

A

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.

205
Q

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

A

Nucleus ambiguous

206
Q

206 How can neuronal injuries be classified?

A

Sunderland and Seddon injury table with neurosensory impairment and recovery potential

207
Q

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

A

Bilateral innervation of the interarytenoid muscle

208
Q

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

A

Surgical iatrogenic injury

209
Q

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

A

Lung carcinoma

210
Q

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

A

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

211
Q

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

A

Aspiration of liquids

212
Q

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

A

Incomplete glottic closure leading to air escape during speech

213
Q

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

A

Vinca alkaloids (vincristine, vinblastine) and cisplatinum

214
Q

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

A

The palate will elevate away from the injured side.

215
Q

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

A

Increased amplitude on the paralyzed side

216
Q

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?

A

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.

217
Q

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

A

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

218
Q

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

A

Improving the airway while preserving voice and swallowing

219
Q

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

A
  1. Endotracheal intubation
  2. Suture lateralization
  3. Botox injection
220
Q

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?

A

59 to 100%

221
Q

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

A

Adductor spasmodic dysphonia

222
Q

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

A

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.

223
Q

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

A

Thyroarytenoid muscles

224
Q

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

A

Breathy voice and aspiration of fluids, which are usually selflimiting

225
Q

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.

A

True

226
Q

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

A

Intermittent breathy voice breaks during speech, particularly following voiceless consonants

227
Q

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

A

Posterior cricoarytenoid muscles

228
Q

228 Describe paradoxical vocal-cord motion.

A

Inappropriate adduction of the true vocal folds during inspiration

229
Q

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

A

Flat inspiratory portion of the flow-volume loop

230
Q

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

A

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.

231
Q

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

A
  • Voice therapy
  • Relaxation and breathing exercises, such as laryngeal control therapy
232
Q

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

A

10 to 20%

233
Q

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

A

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

234
Q

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

A

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.

235
Q

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

A

Monotonous hoarse voice with hypernasal and dysarthric speech

236
Q

236 Describe the distinctive vocal features of spastic dysarthria.

A

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

237
Q

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

A

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

238
Q

238 Describe the speech pattern associated with ataxic dysarthria.

A

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.

239
Q

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

A

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

240
Q

240 Describe the key features of muscle tension dysphonia.

A

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

241
Q

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

A

True. Therefore, treatment focuses initially on voice therapy.

242
Q

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

A

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

243
Q

243 Describe the voice characteristics associated with dysphonia plica ventricularis.

A

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.

244
Q

244 What are the indications for a surgical airway?

A
  • 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
245
Q

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

A

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

246
Q

246 Describe the relative contraindications to cricothyrotomy.

A
  • Child younger than 10 to 12 years
  • Inability to palpate landmarks (neck trauma)
  • Expanding cervical hematoma
  • Subglottic extension of known laryngeal disease
247
Q

247 Describe the surgical steps involved in cricothyrotomy.

A
  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).
248
Q

248 When is needle cricothyrotomy or transtracheal needle ventilation indicated?

A
  • 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.
249
Q

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

A

Reports range from 30 minutes to 2 hours.

250
Q

250 Describe the technique of needle cricothyrotomy and subsequent ventilation.

A
  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.
251
Q

251 Describe the primary indications for tracheotomy

A
  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
252
Q

252 What are the nonemergent indications for surgical tracheotomy?

A

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.)

253
Q

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

A

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.

254
Q

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

A

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

255
Q

255 What are the basic steps in open surgical tracheotomy?

A
  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.

256
Q

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

A

30cm H2O; must not exceed mucosal capillary pressure

257
Q

257 When should a tracheostomy tube cuff be deflated?

A

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

258
Q

258 What are early and late complications of tracheostomy?

A
  • 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)
259
Q

259 When should a tracheostomy tube be removed?

A
  • 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
260
Q

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?

A

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

261
Q

261 What size ETT should be used during laryngeal surgery?

A

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

262
Q

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

A
  • Endotracheal intubation
  • Jet ventilation
  • Spontaneous breathing
  • Apneic technique
263
Q

263 What are the three types of jet ventilation?

A
  • Supraglottic
  • Subglottic
  • Transtracheal
264
Q

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

A

Air trapping leading to pneumothorax/pneumomediastinum

265
Q

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

A

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

266
Q

266 Describe the 4 modified Mallampati classes.

A

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
267
Q

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)?

A
  • 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
268
Q

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

A

Teflon granuloma

269
Q

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

A

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

270
Q

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

A

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

271
Q

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

A
  • Superficial (intracordal)
  • Deep injection augmentation
272
Q

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

A

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.

273
Q

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

A

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

274
Q

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

A

3 to 5mm into the thyroarytenoid muscle

275
Q

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

A
  • Thyrohyoid
  • Cricothyroid
  • Translaryngeal
276
Q

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

A
  1. Type I: Medial displacement
  2. Type II: Lateral displacement
  3. Type III: Shortening/relaxing
  4. Type IV: Lengthening/tightening
277
Q

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

A

It should be able to abduct completely during inspiration.

278
Q

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

A

Silastic, hydroxyapatite, and Gore-Tex strips

279
Q

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?

A

3mm

280
Q

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?

A

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.

281
Q

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

A

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.

282
Q

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

A

Large posterior glottic gap or vocal-fold level mismatch

283
Q

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

A

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.

284
Q

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

A

Directly over or just lateral to the pathology

285
Q

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

A

In the most superficial plane possible

286
Q

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

A

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

287
Q

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

A

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.

288
Q

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

A
  • 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
289
Q

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

A

Providing sufficient skeletal support

290
Q

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

A
  • Laryngopharyngeal reflux
  • Congestive heart failure
  • Diabetes mellitus
  • Stroke
291
Q

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

A
  • Holding cartilage, bone grafts, or fragments in position
  • Stabilizing epidermal grafts, separating denuded surfaces
  • Maintaining a patent lumen when scar tissue is required
292
Q

292 What is the mechanism of action of mitomycin C?

A

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.

293
Q

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

A

Resection and primary anastomosis

294
Q

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

A

50% (5–7 cm)

295
Q

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

A

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

Oto (15 decks)

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