B5.049 Neck, Swallowing, Pharynx, and Larynx Flashcards
1
Q
what is investing fascia
A
outermost layer of deep cervical fascia
synonymous with deep fascia anywhere else in the body
surrounds sternocleidomastoid in the front and trapezius in back
2
Q
pretracheal fascia
A
begins in front of trachea but wraps around to cover trachea, thyroid gland, and esophagus on lateral sides
3
Q
what is inside the carotid sheath
A
common carotid
internal jugular
vagus nerve
4
Q
orientation of carotid sheath
A
artery = deep/medial vein = superficial/lateral nerve = posterior
5
Q
retropharyngeal space
A
potential space of loose connective tissue between prevertebral fascia and pretracheal fascia
continues down into mediastinum and may spread infections
6
Q
prevertebral fascia
A
surround vertebral column and deeper musculature of neck
7
Q
triangles of neck
A
formed by muscle
SCM separates posterior (lateral) from anterior
8
Q
what is congenital muscular torticollis
A
twisted neck/ wryneck condition in which an infant holds his or her head tilted to one side and has difficulty turning head 0.3%-2% incidence 75% of the time, right side more frequent in males presents at 2-4 wweks
9
Q
how does torticollis occur
A
tearing of SCM during passage through birth canal
shortens in response to being torn
10
Q
what is spasmotic torticollis
A
rare, sudden contraction of SCM
11
Q
anterior triangles of the neck
A
submandibular triangle carotid triangle submental triangle muscular triangle all separated by muscles that act on the hyoid bone
12
Q
carotid triangle
A
SCM
superior omohyoid
posterior digastric
13
Q
submandibular triangle
A
mandible
anterior digastric
posterior digastric
14
Q
muscular triangle
A
superior omohyoid
sternohyoid
SCM
15
Q
posterior triangle of neck
A
trapexius
posterior edge of SCM
clavicle
16
Q
2 zones of posterior triangle
A
carefree- superior, mostly muscle
careful- inferior, important nerves and vessels present
17
Q
components of careful/danger zone
A
accessory nerve (11)
brachial plexus
phrenic nerve anterior to anterior scalene
subclavian artery and vein behind omohyoid
18
Q
omohyoid muscle
A
inserts onto scapula and goes up to hyoid bone
passes through both anterior and posterior trangles
19
Q
platysma
A
muscle of facial expression
innervated by CN7
tightening occurs when one shaves the neck
20
Q
boundary between careful and carefree zones
A
spinal accessory nerve
innervates SCM and trapezius
21
Q
external jugular vein
A
partially behind platysma
crosses SCM and eventually pierces investing fascia, but not deep fascia, about 1/3-1/2 way up SCM
22
Q
clinical significance of external jugular
A
may fill in individuals suffering from CHF
23
Q
Erb’s point
A
nerve point of neck within posterior triangle
1/2 way up SCM near lower edge of mandible 3 cm from clavicle
24
Q
Erb’s point injection
A
used to block 4 cervical cutaneous nerves: lesser occipital greater auricular transverse cervical supraclavicular
25
lesser occipital nerve
serves region on top of occipital bone
| behind ear following SCM (C2,3)
26
greater auricular nerve
serves area around ear (C2,3)
27
transverse cervical nerve
anterior region under mandible and up the mandible
most of the anterior triangles
(C2,3)
28
supraclavicular nerves
branch out over clavicle (C3.4)
29
scalene muscles
originate in C1-C4 and attach onto rib 1 or 2
anterior/middle scalenes onto rib 1
posterior scalene onto rib 2
30
structures between the middle and anterior scalene
brachial plexus
| subclavian artery
31
structures anterior to anterior scalene
subclavian vein
| phrenic nerve
32
6 branches of external carotid
```
3 anterior:
-superior thyroid
-lingual
-facial
2 posterior:
-occipital
-posterior auricular
1 medial:
-ascending pharyngeal
```
33
superior thyroid artery
supplies thyroid gland
34
lingual artery
tongue
35
facial artery
crosses mandible and can be palpated
36
occipital artery
pierces through investing fascia from SCM to the trapezius and eventually ends up behind ear
37
posterior auricular artery
passes behind and around ear
38
ascending pharyngeal artery
serves pharyna and part of nose
39
end of external carotid
splits into maxillary and superficial temporal arteries
40
suprahyoid muscles
```
4 total
pull the hyoid bone and larynx up
mylohyoid (CN V3)
geniohyoid (C1)
stylohyoid (CN7)
digastric (CNV3)
```
41
infrahyoid muscles
4 total
| pull hyoid bone and larynx down
42
ansa cervicalis
loop of the neck
innervates 4 infrahyoid muscles
arises from ventral rami off the cervical spinal levels of C1,2,3
surrounds carotid sheath
43
importance of carotid sinus massage
treats some forms of tachycardia
manually massaging carotid sinus to increase pressure within carotid artery
increases afferent feedback by CN 9 to increase parasympathetic outflow through CN X
slows heart
44
internal jugular vein
main vessel responsible for collecting blood from brain, superficial face, and neck
valve at the bottom in the thoracic region to stop blood from rushing out of thorax
45
why might a patient need a central line
caustic meds need to be given in large veins to avoid deterioration of endothelial lining
46
where are most central lines started
internal jugular
subclavian
femoral
47
process of central line placement
introduces a catheter which opens into the right atrium
48
middle approach to place a central line
internal jugular is lateral to common carotid
palpate SCM and locate apex of clavicular and sternal heads
push carotid medially and inject laterally at a 45 degree angle through the skin aiming towards ipsilateral nipple
49
how is US used in central line placement
probe can compress IJV while CA stays round
| helps tell the two apart and direct needle
50
placement of central line in subclavian vein
right side preferred
-supine position, head neutral, arm abducted
-shoulders neutral with mild retraction
junction of medial and middle third of the clavicle
site of needle insertion: 1 cm inferior to the clavicle, parallel to skin, aimed at supraclavicular notch
51
submental triangle
only triangle that crosses the midline
has submental lymph nodes which receive drainage from lower lip
common site of melanoma due to excess sun exposure
52
lower lip and tongue tumors
first metastasize to palpable submental lymph nodes
53
describe the general structure of the thyroid gland
2 major lobes (R and L) with a central isthmus across the trachea
small pyramidal lobe in 40% of people, remnant of embryonic thyroglossal duct
54
generally: where is aberrant thyroid gland tissue located
may occur anywhere along the course of the thyroglossal duct
| abnormal enlargements = goiter
55
specific locations of ectopic thyroid tissue
65% below thyroid bone and isthmus of thyroid gland at trachea ring 3-4
15% at/around hyoid
20% superior to hyoid, but not within tongue
1% within tongue
<1% caudal to isthmus of thyroid
56
thyroglossal duct
generally run posterior to hyoid bone, but can be anterior
57
thyroglossal duct cysts
```
midline masses below hyoid bone
may interfere w swallowing
65% between hyoid and thyroid
15% at hyoid
20% above hyoid
mass will rise when patient sticks out tongue
```
58
embryonic origin of thyroglossal cysts
originate from the junction of anterior 2.3 tongue with posterior 1/3 tongue at sulcus terminalis, specifically at foramen cecum
59
who gets thyroglossal cysts?
common in kids 2-10
| surgical treatment recommended unless infected (if infected antibiotics first)
60
how common is ectopic thyroid tissue?
27% of population have some ectopic thyroid gland tissue OR a pyramidal lobe
61
blood supply to thyroid gland
2 pairs of arteries
1. superior thyroid arteries (20% blood) off external carotid
2. inferior thyroid arteries (80% blood) off thyrocervical trunk
occasionally a 3rd, thyroid ima artery
62
prevalence of thyroid ima artery
10%
63
clinical significance of thyroid ima
possible presence is one of the reasons emergency tracheotomies are not done more frequently below the isthmus of the thyroid gland at the suprasternal notch
64
relationships of the pharynx
extends 14 cm from base of skull to the esophagus, at cricoid cartilage, vertebral level C6
widest at hyoid bone, narrowest at junction of esophagus
65
most likely spot for food to get stuck
junction of pharynx with esophagus
narrowest and least distensible portion (1.5 cm)
can cause reflex closure of glottis
66
Heimlich maneuver
forceful increase in the intra abdominal and intrathoracic pressure
may help expel stuck food
67
divisions of pharynx
nasopharynx
oropharynx
laryngopharynx
68
nasopharynx
posterior opening of nasal cavities (choanae)
pharyngeal openings of auditory (Eustachian) tubes on lateral walls
torus of auditory tube superior to opening
69
oropharynx
posterior to mouth
| separated from nasopharynx during swallow w soft palate
70
laryngopharynx
posterior inlet of larynx
71
3 "valves" to separate air and food pathways
soft palate- closes nasopharynx from oropharynx
epiglottis- covers inlet of larynx as food and water pass
glottis- vocal cords and apertures may be closed to prevent food from entering respiratory tract and to allow increased thoracic and abdominal pressure
72
pharyngeal constrictors
```
3 total
superior constrictor
middle constrictor
inferior constrictor
all innervated by CNX
```
73
pharyngeal elevators
3 total
palatopharyngeus (CN X)
salpingopharyngeus (CN X)
stylopharyngeus (CN IX)
74
prevalence of sleep apnea and snoring
24% of men, 13.8% of women
| increases susceptibility with advanced age
75
causes of snoring
1. drooping of tongue (overweight, common)
2. enlarged tonsils (palatine, younger)
3. drooping of soft palate into the oral pharynx, blocking normal airflow through now (older, overweight)
76
treatments for snoring
weight loss
| palatouvuloplasty: surgical shortening of soft palate, typically to prevent or reduce snoring
77
auditory tube opening
salphinopharyngeus and tensor palatine muscles pull on opposite sides of the cartilage of auditory tube to transiently open it during swallowing just as soft palate is raises, sealing oropharynx from nasopharynx
allows air from nasopharynx to move into middle ear
78
infant feeding recommendations
never allow infants to drink flat on their backs
fluid in oropharynx can reflux into nasopharynx as soft palate moves to neutral position between swallowing
fluid in nasopharynx can be pulled into auditory tube and lead to otitis media
79
lymphatics in CNS
channel found adjacent to superior sagittal dural sinus within dura matter in 2016
80
what is waldeyers tonsillar ring
lymphatic ring
| 4 tonsils in both nasal and oral pharynx to "protect" the entrances to the respiratory and digestive tracts
81
nasopharynx tonsils
1. pharyngeal (adenoids): single, midline at roof of nasopharynx
2. tubular: near opening of auditory tube, paired
82
oropharynx tonsils
1. lingual: base of tongue
2. palatine: layman tonsils, in palatopharyngeal arch formed by palatoglossus and palatopharyngeal muscles
superior constrictor of pharynx lies deep to the palatine tonsils
83
2 groups of head and neck lymph nodes
superficial
| deep cervical nodes
84
Virchow's node
signal node
firm, supraclavicular lymph node sufficiently enlarged so it is palpable
especially on left side
may be first recognized presumptive evidence for metastatic neoplasm of patient's viscera
85
structure of larynx
```
9 cartilages
3 unpaired:
-thyroid
-cricoid
-epiglottic
3 paired:
-arytenoid
-corniculated
-cuniform
all hyaline cartilage except epiglottis, which is elastic cartilage
```
86
thyroid cartilage
2 lateral plates (Laminae) which contain and oblique line and superior and inferior horns
attached to hyoid bone by thyrohyoid membrane
pierced by CNX and superior laryngeal artery
87
oblique line of thyroid cartilage
site of attachment for 3 muscles:
1. sternothyroid
2. thyrohyoid
3. inferior constrictor of pharynx
88
function of androgen receptors on thyroid cartilage
when exposed to rising levels of androgens during puberty, grows in size and lengthens vocal cords, deepening voice
89
male vocal cords
17.5-25 mm
90
female vocal cords
12.5-17.5 mm
91
spaces in larynx
```
vestibule (above cords)
vestibular fold = false cord
ventricle (between false and true cords)
vocal fold = true cord (space between = glottis)
infraglottic cavity
```
92
saccule
rare continuation of ventricle space between false and true cords
93
posterior cricoarytenoid muscles
paired
largest and most important muscles of larynx
only major abductor of the vocal cords, responsible for opening the airway during inspiration
all other intrinsic muscles help close the rima glottis (opening between vocal cords)
94
vocal cord paralysis
bilateral paralysis of posterior cricoarytenoid muscles
| may require surgical cricothyrotomy, cricotomy tracheostomy, or intubation to allow air into lungs
95
transverse arytenoid muscle
adducts vocal cords
| pulling arytenoid cartilages together
96
oblique arytenoid muscle
extends superiorly into aryepiglottic folds and forms aryepiglottic muscle
helps close vestibule of larynx during swallowing
pull epiglottic cartilage down
97
action of crycothyroid muscle
increases tension on the true vocal cords
helps hit high notes
innervated by external laryngeal nerve, branch of superior laryngeal nerve, CN X
98
what are hiccups
diaphragmatic spasm which causes a sudden inhalation of air which is interrupted by a reflex closure of the glottis
99
what causes hiccups
large mean
| alcoholic or carbonated beverages
100
treatment for persistent hiccups
crushing one of the phrenic nerves to result in temporary paralysis of one hemidiaphragm
101
why must fetuses hiccup
get amniotic fluid into lungs
102
extrinsic muscles of larynx
have one attachment to the larynx and another to external structures
2 groups
1. suprahyoid
2. infrahyoid
103
contraction of thyrohyoid muscle
causes laxity of hypoepiglottic membrane, allowing epiglottis to close over laryngeal inlet during swallow
104
mucosa of interior of the larynx
primarily respiratory epithelium: pseudostratified columnar epithelium
105
when does the mucosa convert to stratified squamous epithelium in the larynx?
over true vocal cords, epiglottis, and edge of laryngeal inlet
due to air turbulence in these areas`
106
laryngeal cancer
13,000 americans annually
25% of head and neck cancers
increased risk at vocal cords, where one epithelial type transitions to another
95% of laryngeal cancers arise from squamous epithelial cells
107
cure of laryngeal cancer
radiation and laryngeal preservation surgery can cure a high proportion of patients with early stages
5 year survival > 90% for stage 1
108
epiglottitis
rare
inflammation of epiglottis
may interfere with breathing and present as a medical emergency
presentation: abnormal breathing sounds, difficulty swallowing
109
treatment of epiglottitis
hospitalization
IV antibiotics
intubation
110
laryngitis
inflammation of vocal cords
due to viral infection of resp epithelium within the larynx
common
111
other causes of laryngitis
shouting/straining voice
breathing harsh chemicals
acid reflus
112
appearance of vocal cords in laryngitis
white to red and thickened due to edema
| loosens ones voice due to impaired vibration
113
innervation of the larynx
supraglottic: internal laryngeal nerve (CN X)
infraglottic: recurrent laryngeal nerve (CN X)
114
function of recurrent laryngeal nerve
mixed, both sensory and motor
| motor to all intrinsic muscles of the larynx except cricothyroid
115
innervation of cricothyroid
external laryngeal nerve, branch of superior laryngeal ( CN X)
116
superior laryngeal nerve damage
unilateral damage to superior laryngeal nerve causes unilateral paralysis of cricothyroid and unilateral loss of sensation to supraglottic mucosa
weak, rough, easy fatiguing voice
loss of ability to sing high pitched
117
recurrent laryngeal nerve damage
most common traumatic neurolaryngological lesion
unilateral damage = immediate flaccidity of ipsilateral vocal cords, loss of abduction and adduction, severe dysphonia to complete aphonia, and frequent aspiration
118
treatment of permanent loss of recurrent laryngeal nerve
injections to place vocal cords in a fixed, paramedian position
may allow return of some voice and breathing
119
loss of all innervation to laryngeal muscles
passive closure of the glottis necessitating intubation to keep glottis open
120
vocal cord nodules
callous like
thicken the stratified squamous epithelium
typically due to overuse of voice
121
tracheostomy
emergency airway below cricoid cartilage
cranial to isthmus of thyroid gland, through trachea
bypasses larynx
122
tracheotomy
incising the trachea
| below isthmus of thyroid gland
123
cricothyroidotomy
incision through skin and cricothryroid membrane caudal to thyroid cartilage & cranial to cricoid cartilage
easiest to locate and perform
124
Kah sound
soft palate elevation
CN X
forces air out of mouth
125
La sound
test of tongue function
| CN XII
126
Ma sound
test of opening of mouth
CN VII
building oral pressure that is released when mouth is opened
CN X raises soft palate
