Apex- Airway Anatomy Flashcards
1
Q
Match the intrinsic muscle of the larynx with its action on the vocal cords
Thyroidarytenoid
Lateral cricoarytenoid
Cricothyroid
Posterior cricoarytenoid
Shortens
Elongates
Abducts
Adducts
A
Thyroidarytenoid
>Shortens “THey Relax”
Lateral Cricoarytenoid
>Adducts “Leaves Cords Alone”
Cricothyroid
>elongates “Cords Tense”
Posterior cricoarytenoid
>Abducts “Pulls Cords Apart”
2
Q
The RLN innervates all of the intrinsic laryngeal muscles except what?
What is that innervated by?
A
The cricothyroid muscle
- the external branch of the SLN
3
Q
All laryngeal muscles are classified as intrinsic or extrnisic, which are each responsible for?
A
Intrinsic- phonation (tension and position of cords)
Extrnsic- support the larynx and assist with swallowing
4
Q
The vocal cords attach to the __________anteriorly, and the _________posteriorly.
A
thyroid anteriorly
arytenoids posteriorly
5
Q
label
A
6
Q
label
A
label
7
Q
label
A
label
8
Q
label
A
label
9
Q
label
A
label
10
Q
label
A
label
11
Q
label
A
label
12
Q
What does the vocalis do?
A
Shorten (relaxes) the vocal cords
13
Q
Which laryngeal muscle has 2 functions and what are they?
A
Thyroarytenoid
- THey Relax > shortens (relaxes) VCs
- ADDucts (in ADDition to relaxing, they adduct the VCs) [close the glottis]
14
Q
What kind of muscles end in “-hyoid?”
A
Extrinsic muscles of the larynx
*Except digastiric
15
Q
What muscles tense/relax the vocal cords?
A
Tense = CricoThyroid “Cords Tense”
Relax = THyro aREtenoid “THey RElax”
16
Q
Which muscles Abduct vs Adduct the vocal cords?
A
Abduct = Posterior CricoAretynoids “Pulls Cords Apart”
Adduct = Lateral CricoAretynoids “Leaves Cords Alone”
17
Q
The SLN innervates (select 2):
- Cricothyroid muscle
- Trachea
- Posterior third of the tongue
- Underside of the epiglottis
A
- Cricothyroid
- Underside of the epiglottis
18
Q
What 4 nerves innervate the airway?
A
- Trigeminal (CNV)
- Glossopharyngeal (CNIX)
- SLN (internal and external)
- RLN
19
Q
What does the internal vs external branches of the SLN innervate?
A
internal branch = sensory
posterior side of epiglottis > top of the vocal cords
NO MOTOR
external branch = motor
cricothyroid muscle
NO SENSORY
20
Q
CN9 (GP) provides sensation from where to where
A
oropharynx down to the anterior side of the epiglottis
21
Q
What gives rise to the SLN?
A
Vagus (X)
22
Q
Trigeminal subsets and function:
V1:
V2:
V3:
A
V1: (opthalmic): SENSORY to nares and anterior 1/3 nasal septum
V2: (Maxillary): SENSORY to turbinates and nasal septum; anterior 2/3 tongue - sensory
V3: (Mandibular): muscles of mastication MOTOR
23
Q
What gives rise to the RLN and what does the RLN provide sensation to if anything?
A
Vagus nerve gives rise to RLN
sensation BELOW the elvel of the cords > trachea
24
Q
Most common cause of RLN injury (either side) and 3 other potential causes
A
*Thyroidectomy* (neck surgery)
- overinflation of ETT or LMA cuff
- tumor
- excessive neck stretching
25
What 4 things can cause injury to the LEFT RLN?
1. PDA ligation
2. Left atrial enlargement (Mitral stenosis)
3. aortic arch aneurysm
4. Thoracic tumor
26
What closes the laryngeal vestibule?
Aryepiglottic fold? sphincter?
27
What closes the posterior commisure of the glottis?
Interarytenoid
| (RLN)
28
Which extrinsic muscles depress the larynx? (3)
**_SOS_**
_**S**tern_ oy*hoid*
**O**mo*hyoid*
_**S**tern_ot*hyroid*
(all other extrinsic muscles "-hyoid" elevate the larynx + the digastric)
29
What kind of nerve damage would result in one of the vocal cords being unable to abduct?
RLN damage
30
T/F: injury to b/l SLN's constitutes a respiratory emergency
FALSE
- B/L RLN -neither cord can abduct
- stridor/resp distress
31
Laryngospasm is a forceful, involuntary spasm of the laryngeal muscles caused by stimulation of what nerve?
the INTERNAL branh of the SLN
32
Sensory vs motor innervation for a laryngospasm
Sensory (afferent) innervation = internal branch of the SLN
Motor (efferent) innervation = external branch of the SLN (cricothyroid, cords tense)
AND RLN (Lat. cricoaretenoids & thyroaretynoids = adduct cords)
33
Hoarseness would be injury to SLN or RLN
RLN
-hoaRness
(SLN = Softness)
34
What 3 cranial nerves are responsible for innervation of the airway?
1. Trigeminal nerve (V)
2. Glossopharyngeal (IX)
3. Vagus (X)
\>SLN, RLN
35
Trigeminal V1, V2, V3 matching:
Lingual nerve
Anterior ethmoidal nerve
Sphenopalantine nerve
V1 = anterior ethmoidal
V2 = sphenopalantine
V3 = lingual nerve
36
What serves as the afferent nerve of the gag reflex
efferent nerve?
CN IX - glossopharyngeal (Sensory = affernt)
X = efferent limb/motor resposne of gagging
37
What provides motor innervation to the muscles of mastication (chewing)
V3 division of CNV
)
38
What provides motor inneration to the tongue?
CN 12 - hypoglossal nerve
39
CN 9 (GP) provides sensory innervation from the oropharynx to the anterior side of the epiglottis. What 6 structures are included?
1. Soft palate
2. **Oropharynx**
3. Tonsils
4. Posterior 1/3 of tongue
5. Vallecula
**6. Anterior side of the epiglottis**
40
CN 5 is mostly sensory, what is the exception?
Muscles of mastication innervated by V3 Mandibular/linguial nerve
(sensory of this is anterior 2/3 of tongue)
41
CN 9 is mostly sensory, what are the 2 exceptions?
swallowing and phonation
42
At the level of the \_\_\_\_\_\_, the SLN divides into internal and external branches
hyoid
43
The internal branch of the the SLN penetrates what membrane and between what two structures?
Thyohyoid membrane
Between the **greater cornu** of the hyoid bone
& the **superior horn** or the thyroid cartilage
44
The RLN branches off the vagus where?
inside the thorax
45
What does the right vs left RLNs loop under
right - loops under subclavian
left- loops under aortic arch
46
What landmark is identified for a SLN block?
A. Greater cornu of the hyoid bone
B. Suprior horn of the thyroid cartilage
C. Circothyroid membrane
D. Palatoglossal arch
A. Greater cornu of the hyoid bone
47
What 3 nerves must be blocked for an awake intubation?
1. Glossopharyngeal (B/L) (base of palatoglossar arch/anterior tonsillar pillar)
2. SLN (B/L) (inferior border greater cornu hyoid)
3. RLN (cricothyroid membrane)
48
Which block involves injecting the needle at the base of the palatoglossal arch?
AKA
depth
mls
5% risk of what?
Glossopharyngeal block
AKA anterior tonsillar pillar
0.25-0.5cm
1-2mls
5% risk of seizure from intracarotid injection
49
How to do a transtracheal block
What nerves are you trying to anesthesize?
insert needle through cricothyroid membrane in a caudal direction
ask pt to take a deep breath
inject 3-5mls of LA into the tracheal lumen
RLN
50
If your doing a glossopharyngeal nerve block and aispirate air, what does that mean?
too deep
51
If your doing a glossopharyngeal nerve block and aispirate blood, what does that mean?
What should you do?
withdraw needle and redirect medially (close to the carotid artery)
52
The adult larynx lies anterior to what spinal segments?
C3-C6 = Larynx
53
What is the only bone in the body that does not articulate with another bone?
Hyoid bone
54
What is the most caudal part of the larynx?
The criocid
55
What is the narrowest part of the ariway in the infant vs adult
infant = cricoid = narrowest "fixed" region; vocal cords = narrowest "dynamic region"
adult = glottis
56
3 paired vs unpaired cartlidges of the larynx
**_3 unpaired:_**
- epiglottis
- thyroid
- criocid
**_3 paired:_**
- arytenoids
- cornicutlates
- cuniforms
57
What is a laryngospasm?
Sustained, involuntary contraction of the laryngeal muscles, vocal cords slam shut and cant be opened
58
S/S of someone having a laryngospasm? (6)
1. Inspiratory stridor
2. Suprasternal or supraclavicular retraction during inspriation
3. "Rocking horse" apparence of chest wall (paradoxical movement)
4. Increased diaphrgamatic excursion
5. Low rib flailing
6. Absent or altered ETCO2
59
What are some things that can cause laryngospasm? (5)
1. manipulating the airway during light anesthesia
2. airway surgery
3. airway secretions
4. active or recent resp infection \<2 weeks
5. Age \< 1yo
60
5 steps in treating laryngospasm
1. 100% FIO2
2. Remove stimulus
3. Deepen anesthesia
4. Larson's maneuver, chin lift, and positive pressure (CPAP 15-20)
5. Sux
61
What is exhalation agaisnt a closed glottis called
valsalva's maneuver
62
What is muller's manuver?
INHALATION against a closed glottis
(where as valsava is EXHALATION agaisnt a closed glottis)
63
What would it be called if a patient bites down on the ETT and takes a deep breath?
Risk?
Muller's maneuver
Risk= supatmospheric pressure in the thorax \> negative pressure pulmonary edema
64
T/F: hypocapnia/hyperventillation increases risk for laryngospasm
True!
65
DOA of laryngeal lidocaine
30 minutes
66
IV dosing of SUX for adult or child vs infant or neonate
IM?
**_IV_**
adult 1-1.5
Kids 1.5-2
infant or neonate = 2-3mg/kg
**_IM_**
adult or child = 4mg/kg
infant or neonate = 5mg/kg (2+3 = 5)
67
What IM route of administration provides the fastest onset of sux to break a layngospasm?
Submental ....
68
you need to break a laryngospasm in a kid without an IV and has a contraindication to sux....now what?
ROC is the only other NMB that can be given IM
69
When adminsitering sux to kids \< \_\_\_\_\_, what should you administer with it, how much, and why?
kids \<5yo
Atropine 0.02mg/kg
prevent bradycardia
70
What borders the laryngospasm notch:
Anterior:
Posterior:
Superior:
**_Anterior:_** Ramus of the mandible
**_Posterior:_** Mastoid process
**_Superior:_** Skull Base
71
T/F: Laryngospasm notch is located jsut behind the earlobe
How should pressure be applied
True
Apply pressure BILATERALLY , TOWARDS the skull base (UP)
72
How long should you apply pressure to the laryngospasm notch?
3-5 seconds, release for 5-10 seconds and repeat until it breaks
KISS - 5 sec on, 5 sec off
73
Which maneuver puts the patient at risk for negative pressure pulmonary edema? Valsalva or Mullers?
Mullers- forced experation against a closed glottis
74
**Tensor palatine muscle** relaxation will MOST likely cause airway obstrution at which level?
A. Hard palate
B. Soft palate
C. Epiglottis
D. Tongue
B. Soft palate
75
Relaxation of the **hyoid muscles** contributes to upper airway obstruction from what structure?
**The epiglottis**
76
Relaxation of the **genioglossus muscle** contributes to upper airway obstruction from what structure?
**The tongue**
it's a genius!
77
The upper airway extends from where to where?
mouth and nose \> cricoid cartilage
78
Airway resistance is \_\_\_x higher in the nasal passage compared to the mough
2x
79
Primary functions of the upper airway (3)
1. warming and humidfying inspired air
2. filtering particulate matter
3. preventing aspiration
80
How can you reduce the risk of airway trauma when instrumenting the nasal cavity?
direct the device between the inferior turbinate and the floor of the nasal cavity
&
orient the bevel towards the septum
81
What muscle opens the:
Nasopharnyx:
Oropharnyx:
Hypopharnyx:
**_Nasopharnyx:_** Tensor Palatine
**_Oropharnyx:_** Genioglossus
**_Hypopharnyx:_** Hyoid muscles (epiglottis)
82
When compared to the trachea, which factor is **GREATER** in the _terminal bronchioles?_
A. Total cross-sectional area
B. Airflow velocity
C. Amount of cartilage
D. Quantity of goblet cells
**_A. Total cross-sectional area_**
83
Where does the lower airway begin and end?
Begins at the trachea \> alveoli
84
Where does the trachea begin and end?
beings at the inferior border of the cricoid cartilage and ends at the carina (T4-5)
85
What spine processes does the carina correlate with?
What is this called?
T4-T5
The Angle of Louis
(just think when you tickle that carina those cardiac acclerates (T4) go wild as the pt starts coughing and carrying on) - dumb idk
-tickle Louis's carina
86
Does neck flexion make the distance from the mouth to the carina longer or shorter?
Shorter \*rember tube follows the nose , felxed neck = more likely to come out
87
Length and projections of:
Left bronchus vs Right bronchus
**_Left bronchus:_**
5cm
45 degree takeoff
**_Right bronchus:_**
2.5cm
25 degree take off
88
in children up to \_\_\_yo, both bronchi take off at \_\_\_\_degrees
3 years old
55 degrees
89
Type 1 vs Type 2 pneumocytes
Type 1 provide surface for gas exchange
Type 2 produce surfactant and type 1 pneumocytes
90
The trachea is \_\_\_\_cm wide
& \_\_\_\_\_cm long
2.5cm wide
10-13cm long
91
Sensory innervation to the trachea
Vagus
92
Match:
Trachea, Mainstem bronchi, Alvoli
Cuboidal epithelium, ciliated columnar epithelium, squamous epithelium
Trachea = ciliated columnar (duh, it's got the cilia to keep shit out)
Mainstem = cuboidal
Alveoli = squamous
93
What allows for air movement between the alveoli?
Pores of Kohn
94
What are type 3 pneumocytes responsible for?
fighting infection and eliciting an inflammatory response
95
The lower airway begins as a single tube (the traceha) but the ncontinues to bifurcate along ____ generations/divisions
23 (bitrhday bronchioles! yay0
96
What 2 things increase as the airway bifurcates?
1. # of airways
2. Total cross-sectional area
\*everything else decreases: airflow velocity, amount of cartilage, goblet cells (produce mucous), ciliated cells (clear mucus)
97
What vertebral level corresponsds with the adult trachea?
C6
lower airway STARTS at C6
98
Which structures are anesthetized by injecting lidocaine at the base of the palatoglossal arch (select 2)
- Posterior side of the epiglottis
- Anterior 2/3 of the tongue
- Oropharynx
- Vallecula
-Oropharynx & Vallecula
This is a CN9 block- anesthesizes soft palate, oropharynx, tonsils, posterior 1/3 of tongue, vallecula, and anterior side of the epiglottis
Anterior 2/3 of the tongue is innervated by the mandibular branch (V3) (lingual nerve) of the trigeminal nerve (CN 5)
The posterior side of the epiglottis is innervated by the internal branch of the superior laryngeal nerve
99
Contraction of which muscles widens the glottic aperture:
Cricothyroid
Thyroarytenoid
Vocalis
Posterior cricoarytenoid
Posterior cricoarytenoid
"Pulls Cords Apart"
100
Calculate the dose of IM sux for a 12kg patient
kids and adults IM = 4mg/kg
4x12 = **48mg**
101
A patient bites down on the ETT during emergence. Pink frothy sputum is noted inside the breathing circuit. Which maneuver explains the pathphys of this complication?
A. Valsalva
B. Muller
C. Larson
D. Beck
B. Muller
