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MRCS ENT/Dohns > Laryngology > Flashcards

Laryngology Flashcards

1
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A
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2
Q

What scoring system do we use to analyse voice?

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3
Q

VC Nodule management

A

SLT
Voice rest
Smoking cessation
+/- Surgery < 10%

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4
Q

What is Reinke’e oedema? What are the symptoms? Pathophysiology?

A

Expansion of subepithelial space (reinke’s space)

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5
Q

Causes of Reinke’e oedema?

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6
Q

Management of Reinke’e oedema?

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7
Q

What is phonatory gap, how is it cause?

A

Epithelium becomes adherent to muscle underneath and does vibrate in speech.
Hoarse voice
Voice fatigue

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8
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9
Q

Causes of Vocal process (medial aspect of arytenoid cartilage) granulomas

A

Intubation
Prolonged voice abuse
Aggressive coughig/throat clearing
Laryngopharyngeal reflux

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10
Q

If abductors are affected how will their voice sound?

A

Breathy

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11
Q

If adductors are affected how will their voice sound?

A

Strangulated, effortful voice

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12
Q

Management of VC Granulomas

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13
Q
A

Lindholm Laryngoscope
Glottis or supraglottis

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14
Q
A

Deedo-Pilling Laryngoscope
For Vocal cords or subglottis

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15
Q

How do you successfully set up for direct laryngoscopy?

A
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16
Q

What does LASER stand for ?

A

Light Amplification by Stimulated Emission of Radiation.

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17
Q

List TWO key differences between carbon dioxide and potassium titanyl phosphate laser ?

A

Wavelength and target chromophore

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18
Q

List the uses for laser in otolaryngology.

A

Recurrent respiratory papillomatosis
Leukoplakia
Vocal cord nodules
Laryngeal stenoses
Polypoid degeneration (Reinke’s oedema).
Laryngomalacia.
Oropharyngeal cancer resection (transoral laser surgery/transoral robotic surgery).
Hereditary haemorrhagic telengiectasia (recurrent, severe epistaxis)
Pharyngeal pouch procedures.
Otological surgery (e.g. residual cholesteatoma).

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19
Q

List the safety measures required for the use of laser in otolaryngology.

A

*Scarring and thermal damage to neighbouring tissue, including mucosal and facial burns.
* Airway (endotracheal tube) fire
*Eye protection.
*Controlled access (identifying a nominal ocular hazard area) e.g. using signs outside the operating theatre and closing doors.
*Care with flammable chemical and material use (e.g. drapes and skin preparation solutions).
*Testing and calibration of laser devices.
*Surgical plume management (e.g. appropriate ventilation and masks).
*Documentation, audit, education and training.

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20
Q

How does the anaesthetist ventilate the patient during laser airway surgery

A

Laser-safe endotracheal tube or jet ventilation.

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21
Q

What are the advantages of user Laser?

A
  • Precision
  • Unobstructed view of operating field
  • Minimal tissue manipulation
  • Better haemostasis
  • Increased sterility
  • Cost-effective - reduced hospital stay
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22
Q

Disadvantages of Lasers?

A

Increased staff numbers.
Training.
Opportunity cost of equipment and its depreciation and repair.
Additional safety elements.

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23
Q

Types of lasers and what do they selectively target?

A

Photoangiolytic (selectively target haemoglobin)
Potassium Titanyl Phosphate (KTP).
Pulsed die laser (PDL).
Cutting/ablating (selectively target water)
Carbon dioxide (CO2).
Thulium.

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24
Q

What is the target chromophore?

A

The substance that preferentially absorbs the energy , often haemoglobin or water.

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25
Q

What specifies the wavelength of a laser?

A

The laser medium (solid, liquid or gas) specifies the wavelength.

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26
Q

What is Gardasil?

A

HPV Vaccine covers for 9 diff types, incl 6,11,16,18

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27
Q

Complications of perc trache

A

Less per-operative bleeding
Reduced incidence of stomal infection
Lat displacement of tube v rare- flax bronchoscopy

28
Q

Early Complications of surgical trache

A

Bleeding
Air embolus
Surgical emphysema
Pnuemonia

29
Q

Late Complications of Perc and surgical trache

A

Tracheomalacia
Laryngotracheal stenosis
Tube migration
Innominate artery erosion
Persistent Traecheo-cutaneous Fistula
Trachea-oesophageal Fistula

30
Q

How do we protect our airway during Swallow

A

Closure of true cords
Closure of false cords
Laryngeal raise
Tongue retracts back
swallow occurs on Interrupted outbreath and subglottic pressure, so one can cough and clear throat if aspiration occurs

31
Q

Causes of dysphagia

A
32
Q

What is Presbyphagia?

A
33
Q

Ix that can used to assess swallow

A

Videofluoroscopy (Barium swallow etc)
Functional endoscopic evaluation of swallowing
High resolution Manometry

34
Q

Management of paroxysmal laryngospasm

A
35
Q

Causes of laryngospasm

A

Hypersensitised larynx
Secondary to Viral illness, Reflux, allergen or irritant exposure

36
Q

Management of laryngospasm

A
37
Q

Exercise Induced laryngeal obstruction management

A

Supraglottoplasty

38
Q
A
39
Q

What are the functions of the larynx?

A
  • Maintain an open airway
  • Vocalising
  • Coughing
  • Ventilation control
  • Sensory organ
  • Protect the lungs from noxious conditions
  • Protect the lungs from aspiration
  • Allowing leverage during a Valsalva manoeuvre to increase upper-body strength and ease defecation
40
Q

What is the Histology of the vocal cords?

A
  1. Stratified squamous epithelium
  2. Superficial layer (lamina propria, Reinke’s space)
  3. Vocal ligament underlying the true vocal folds
  4. Thyroarytenoid muscle (vocalis)
41
Q

Features of Cricoid

A
  • A complete ring of hyaline.
  • The cricotracheal ligament attaches to 1st tracheal ring.
  • The cricothyroid ligament attaches to the thyroid cartilage.
  • The cricothyroid muscles are found laterally.
  • The arytenoid cartilages are found posteriorly.
42
Q

Features of Thyroid

A
  • The anterior laryngeal prominence is around 90 degrees in men.
  • The inferior horn articulates with the cricoid cartilage.
  • The inferior border is attached to the cricothyroid membrane in the midline and the cricothyroid muscles laterally.
  • The superior horn/border attaches to the thyrohyoid membrane.
43
Q

Features of Epiglottis

A

*Attached to the thyroid cartilage via the thyroepiglottic ligament.
*Attached to the hyoid bone via the hyoepiglottic ligament.
*A reflection of mucous membrane creates the glossoepiglottic folds.
*The aryepiglottic folds represent mucosal folds on its posterior surface.
*The depressions between the base of the tongue and the epiglottis are the valleculae.

44
Q

Features of Arytenoids

A

*Pyramidal-shaped with a base and an apex.
*They are situated in the posterior larynx (an easy way to orientate views of the larynx).
*The vocal ligament attaches to them via their vocal process (medial part).
*They articulate with the cricoid at its base.
*They have a muscular process for the posterior and lateral cricoarytenoid muscles.
*Their posterior surfaces attach to the arytenoid muscles.
*Their anterolateral surfaces attach to the vocalis muscles and the vestibular ligaments (false cords).
*Their medial surfaces are lined with mucosa (which becomes the glottis).
*Their apices articulate with the corniculate cartilages.

44
Q
A

Corniculate
*They are minor cartilaginous structures. They articulate with the apices of the arytenoid cartilages.
Cuneiform
*corniculate cartilages lie in the aryepiglottic folds.

45
Q

All muscles of the larynx are supplied by the recurrent laryngeal nerve, except the…

A

cricothyroid muscles, which is supplied by the external branch of the superior laryngeal nerve from the vagus nerve (cranial nerve X).

46
Q

Course of the Recurrent laryngeal nerve

A

The vagal nucleus is the nucleus ambiguous of the medulla. The vagus descends in the carotid sheath. On the RIGHT-hand side it loops around the subclavian artery and forms the right recurrent laryngeal nerve.
On the LEFT-hand side is loops around the arch of the aorta at the ligamentum arteriosum and forms the left recurrent laryngeal nerve.
The right recurrent laryngeal nerve travels cephalad to the larynx as does the left, except the left lies in the tracheooesphageal groove. Both left and right recurrent laryngeal nerves travel deep to the inferior cornu of the thyroid cartilage and travel within the cricoid or thyroid space to innervate the intrinsic muscles of the larynx.

47
Q

Sensation of the larynx

A

Sensation of the larynx is supplied by the internal branch of the superior laryngeal nerve and is sensory down to the level of the vocal cords. This is the afferent limb of the cough reflex.

48
Q

Motor Innervation of the larynx

A

All muscles of the larynx are supplied by the recurrent laryngeal nerve, except the cricothyroid muscles, which is supplied by the external branch of the superior laryngeal nerve from the vagus nerve (cranial nerve X).

49
Q

Arterial supply of the larynx

A

*External carotid artery -> superior thyroid -> superior laryngeal via thyrohyoid membrane.
*Subclavian -> thyrocervical trunk -> inferior thyroid -> inferior laryngeal with recurrent laryngeal via tracheo-oesophageal groove.

50
Q

Venous drainage of the larynx

A

*Superior laryngeal -> superior thyroid -> internal jugular vein.
*Inferior laryngeal -> inferior thyroid -> left brachiocephalic

51
Q

Lymphatic drainage of the larynx

A

Above the vocal folds
*Deep cervical lymph nodes at common carotid artery bifurcation
Below the vocal folds
*Upper tracheal lymph nodes

52
Q

Unilateral vocal cord palsy causes

A

Iatrogenic
* Thyroid/parathyroid surgery
* Anterior cervical disc surgery
* Carotid surgery
* Mediastinal surgery
* Endotracheal tube overinflated or too cephalad
Neoplastic (invasion/compression)
* Skull base
* Thyroid
* Lung
* Oesophageal
* Mediastinal metastasis
Trauma
* Neck or chest
* Idiopathic (this could actually be viral or inflammatory)

53
Q

Symptoms Unilateral vocal cord palsy

A

*Breathy, weak, low-pitched dysphonia, although can be high-pitched if compensated.
*Neck or throat pain after voice use from excessive muscle tension.
*Dysphagia (usually liquids more than solids) due to glottal incompetence. This can lead to aspiration, especially if high vagal lesion leading to recurrent and superior laryngeal palsy. The explanation for this is pharyngeal anaesthesia(insensate larynx)
*Dyspnoea from air wasting due to glottal incompetence (versus any negative pulmonary physiology).
*Weak cough.

54
Q
A

The classical appearance is a foreshortened, lateralised and flaccid affected vocal cord with compensatory muscle tension and compensatory contralateral cord

55
Q

What muscles cause abduction of the vocal folds.

A

Posterior cricoarytenoid muscles

55
Q

Function of cricothyroid

A

lengthen VCs, high pitch

55
Q

Function of Posterior cricoarytenoid muscles

A

These are the only muscle pair to cause abduction of the vocal folds.

56
Q

What is the Wagner and Grossman theory?

A

If there is a recurrent laryngeal nerve palsy per se then the vocal cords adopt the paramedian position due to cricothyroid muscle adducting the cords

57
Q

When do we see the the cadaveric position of vocal cords

A

In a high vagal lesion where the the superior external laryngeal nerve is affected causing loss of adduction from the cricothyroid.

57
Q

What is the innervation of the Cricothyroid?

A

superior external laryngeal nerve

58
Q

What Investigations would you perform for unilateral RLN Palsy?

A

Chest X-ray
*Pancoast tumour
*Mediastinal mass
*Massive cardiomegaly (Ortner syndrome)
*Computed tomography base of skull to mediastinum (arch of aorta)
Laryngeal electromyography
*Useful for prognostication of recovery
*Can distinguish between vocal fold immobility (from cricoarytenoid joint pathology) versus a true vocal fold paralysis
*Best undertaken 6 weeks to 6 months after onset of symptoms

58
Q

What does the superior external laryngeal nerve supply?

A

Cricothyroid muscles, the are responsible for stretching the VC, increasing the pitch of voice

59
Q

What is Ortner’s syndrome?

A

Cardiovocal syndrome or Ortner’s syndrome is hoarse voice due to left recurrent laryngeal nerve palsy caused by mechanical compression of the nerve from enlarged cardiovascular structures

60
Q

What is the management for unilateral RLN Palsy?

A

MRCS ENT/Dohns (11 decks)

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