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ENT > Laryngology > Flashcards

Laryngology Flashcards

1
Q

Larynx anatomy: Framework (Cartilages, bone, traction)

A

Hyoid
4 cartilages (Cricoid, thyroid, 2x arytenoid)
– linked together by thyrohyoid and cricothyroid membranes
– supported by soft tissues
—Cephalad traction: mylo/genio/stylohyoid muscles +stylohyoid ligament
—Caudad pull: Inferior straps

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2
Q

Larynx anatomy: Base

A

Cricoid, only complete ring in larynx

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3
Q

Larynx Anatomy: Arytenoid position and function

A

Rest on cephalic rim of posterior cricoid

Anchors of the vocal cords

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4
Q

Larynx Anatomy: Arytenoid anatomy. 3 surfaces/projections with muscle insertions

A

i) Posterolateral projection=muscular process. Received insertions from lateral cricoarytenoid and poster cricoartytenoid muscle. Is a alever to amplify their actions
ii) Anterolateral face. Attaches to thyroarytenoid muscle
iii) Posteromedial surface=interarytenoid attachments

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5
Q

Larynx Anatomy: Corniculate and Cuneiform cartilages

A

a) Corniculate cartilages (of Santorini) rest atop the artenoid apices
b) Cuneiform cartilages (of Wrisberg) are along the superior rim of the AE folds

Fx unclear of corniculate and cuneiform

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6
Q

Larynx Anatomy: Fibroblastic support membranes (2)

A

i) Conus Elasticus= fibroblastic membrane from cricoid to glottis aperture (ligament)
(1) Defines the convergent shape of the sublottis. Imp for phonation

ii) Quadrangular membrane extends from AE folds to ventricular folds. Creates AE fold

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7
Q

Larynx Anatomy: Cricoarytenoid joint

A

principal articulation for VF ad- and abduction

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8
Q

Larynx Anatomy: Muscles: Abductors

A

Posterior cricoarytenoid

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9
Q

Larynx Anatomy: Muscles: Adductors

A

thyroarytenoid + lateral cricoarytenoid** (major) + smaller, unpaired interarytenoids

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10
Q

Larynx Anatomy: Muscles: VF Elongator

A

i) Cricothyroid m.
Increases pitch.
External ant cricoid to caudal rim of thyroid.
Antagonist of thyroarytenoid

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11
Q

Larynx Anatomy: Nerves: SLN

A

From Nodose ganglion (36mm below jug foramen)
Travels deep to ICA/ECA

External: innervates cricothyroid muscle
– lateral to inferior constrictor, moves anteriorly at inferior thyroid lamina

Internal: provides sensory innervation to glottis and above
– pierces thyrohyoid membrane w Superior Thyroid aa

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12
Q

Larynx Anatomy: Nerves: RLN course

A

Right sided: arises from main trunk of vagus, loops around right subclavian

Left sided: loops around aorta

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13
Q

Larynx Anatomy: Nerves: RLN Innervation

A

Sensory: Below glottis

All intrinsic muscles of larynx except cricothyroid

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14
Q

Larynx Anatomy: Nerves: Galen’s anastomosis

A

RLN to Internal SLN (mostly sensory)

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15
Q

Larynx Anatomy: Nerves: Human communicating n.

A

External SLN to RLN

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16
Q

Larynx Anatomy: Nerves: Interarytenoid plexus posterior

A

RLN communication with contralateral RLN.
Innervates interarytenoid muscle
Posterior glottic commissure mucosa

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17
Q

Physiology of phonation

A

a) Power- lungs, infraglottic focal tract
b) Oscillation: sound source- glottis (VFs)
c) Resonator: Supraglottic Vocal tract
d) ALL shape resonance
e) Glottis=space b/t vocal folds
f) Requirements for VF vibration= aerodynamic (glottis needs to be nearly closed) and myoelastic (pliable)

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18
Q

Vocal fold Histology layers

A

a) Strat squam epithelium
b) Attaches to lamina propria (1.5 mm)

i) Superficial- AKA Reinke’s space.
ii) Intermediate
iii) Deep
iv) Vocalis muscle.

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19
Q

Vocal fold Histology: Superficial

A

Where Reinke’s edema happens. Important in generating mucosal waves. Gelatinous. Least # of fibroblasts. Hyaluronic acids. Where most nodules form.

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20
Q

Vocal fold Histology: Intermediate

A
  • it’s the largest. Elastic. Can tell the difference between superficial/intermediate but not intermediate/deep
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21
Q

Vocal fold Histology: Deep

A

– high propensity of fibroblasts. Provides strength via collagen

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22
Q

Vocal fold Histology: Muscle below VF

A

Medial aspect of thyroartenoid m.

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23
Q

Physiology of vocal vibration

A

(1) Inferior superior wave and then along superior surface
(2) Mucosal upheaval starts at infraglottis (mu point)
(3) Bernoulli principle snaps it back together

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24
Q

Vocal pitch and avg hertz

A

i) VF vibration speed=pitch (Hz)
(1) Guys avg Hz=100; Women avg Hz=200
(a) Superficial LP very delicate
(2) Singing=Middle C (C4)=256 Hz; High C (C6)=1024Hz

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25
Q

Vocal Vibration: Body-Cover theory

A

(1) Vibratory phenomena produced by difference in stiffness b/t body (vocalis) and cover (Epithelium and Superficial lamina propria). Separated by Intermediate and deep lamina propria= Vocal ligament
(2) VF vibration is mechanical, not neural

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26
Q

Components of good voice

A

A. Mucosal wave
B. Glottic closure

Important to think about when seeing dysphonic patients

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27
Q

How to eval mucosal wave

A

i) Stroboscopy (audiogram of laryngology)
(1) VF vibration too rapid for unaided human eye (human eye has 5 frames/sec limitation)
(a) Other imaging: videokymography, high speed digital imaging (HSDI)
(2) Mech principles
(a) Need to have consistent fundamental frequencies

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28
Q

Normal vibration variations

A

(1) Register
(2) Fundamental frequency
(3) Intensity

29
Q

Cause of Breathy phonation

A

Weak adductors, VF don’t close. (Maryln Monroe voice)

30
Q

Cause of Pressed phonation

A

High subglottic pressure, high adductor VF force, air flow low. Frequency low, compensatory muscle pattern may be abusive (get benign lesions)

31
Q

Cause of Flow phonation

A

Low subglottic pressure and adductory force. Increased amplitude of voice source fundamental. Increased 15 dB from pressed phonation

32
Q

Examining Endolarynx: FLL vs Oral rigid

A

i) FLL
(1) Able to talk while
(2) Helpful for gross motions (VF paralysis), functional dysphonia
(3) Dynamic: sing, speech, respiration
(4) More physiologic, well tolerated, biofeedback tool
(5) Cons: expensive, image qulity, invasive, angle sensitive

ii) Oral rigid
(1) Good for honing in on VF (lesions, scar)
(2) Great for mucosal wave
(3) Cons: Gag, benzocaine (methemoglobinemia- 2 sprays can set them off, cyanosis but normal pulse ox. Give methylene blue 2mg/kgs. Admit due to rebound effect)

33
Q

Using Stroboscopy: parameters and evaluation

A

i) Symmetry

ii) Closure- @MCPL open 2/3; closed 1/3.
(1) Hourglass- seen in bumps
(2) Elliptical- seen in atrophy, complete closure, normal in men
(3) Transglottic (VF paralysis)
(4) Posterior gap- normal in woman and some men
(5) Anterior gap
(6) Irregular

iii) Amplitude
(1) Medial lateral excursion of the superior surface during phonation

iv) Mucosal wave
(1) Start mu point
(2) Ends halfway across superior surface

v) Pitch
(1) Balance b/t pulm pressure and VF

34
Q

** Dysphonia vs Dysarthria vs Dystonia **

A

a) Dysphonia- problem of generation of sound or voice**
b) Dysarthria- problem of articulation (tx motor speech therapy)
c) Dystonia- movt d/o, uncontrolled muscle contraction

35
Q

Voice production reliant on what?

A

a) Voice production reliant on

Brain/lungs/larynx (VF)/pharynx/sinus/nose/mouth/ears

36
Q

Unilateral VF Paralysis features

A

VF paralysis=VF immobility from neurogenic origin

stil has movement=synkinesis, but no PURPOSEUL mvmt
Still has electrical activity, but incomplete recovery and reinnervation–>synkinesis

37
Q

Laryngeal reinnervation

A

Does not restore VF motion (but debatebly improves tone)

38
Q

Central vs Peripheral VF paralysis

A

a. Peripheral
i. Vagus
ii. Recurrent laryngeal nerve

b. Central
i. Wallenberg stroke

39
Q

Muscular tension dysphonia

A 
♣	squeeze of supragottic, trying to use false VC
♣	Clinical:
a.	Dyspnea on phonation “SOB w talking”
b.	Arytenoid tilted forward
c.	VC shortening
40
Q

Long term outcomes of Unilateral VF paralysis

A

“Rosen rule”

a. Key parameter: VF motion
i. If return of VF motion, ~80 have return to normal motion, average time 4.6mo
ii. If no return, 20% have return of normal voice

41
Q

Treatment of unilateral VF paralysis

A

a. No treatment
i. Observation as long as no aspiration
ii. Aversion to physicians (surgeon denying)
iii. No access to treatment

b. Static medicalization
i. VF injection
ii. Laryngeal framework surgery
iii. Laryngeal re-innervation?

c. Pro-active treatment?

42
Q

Types of laryngeal framework srugery

A

a. Medialization laryngoplasty AKA Thyroplasty

B. Crico-thyroid subluxation

43
Q

Thryoplasty

A

i. First done in 1911
ii. But popularized by Isshiki in 1970s
iii. Cartilage flap to medialize VF
iv. Silactic, Gore-Tex implants
v. Repositioning and augmenting VF via external implantation in paraglottic space
vi. Non-absorbable, alloplastic material
vii. Voice can be tuned since surgery is done w MAC
viii. Can be revised/reversible dependent on implant type, But should be considered permanent

44
Q

Thyroplasty indications

A
  1. Presbylaryngis
  2. Unilater or bilateral Paresis/paralysis/fixation
  3. Neurologic d/o
  4. VF soft tissue deficiency/scar
45
Q

Thyroplasty steps: Pre-Op

A

a. Steroids, Robinol, abx
b. Lidocaine/pontocaine nebulization
c. Use precedex gtt for anesthesia (less up and down than propofol). No amnesia effect so also useful to mix in a little versed to give some amnesia and fentanyl for pain

46
Q

Thyroplasty steps: OR pt 1. From start to mapping implant placement

A

a. Shoulder roll
b. Decon/anesthesia pledgets to nose
c. Lido w epi to skin
d. Horizontal incision over thyroid cartilage or cricoid
e. Retract strap
f. Elevate perichondrium
g. Map out where you want to put implant (Parallel to inferior border of thyroid cartilage**) 3mm above that line
i. Palpate inferior thyroid cartilage tubercle
ii. Needle localization
W flex scope, pass needle thyroid cartilage to see where you are. Don’t pass into airway

47
Q

Thyroplasty steps: OR pt 2

A

a. Make a window into the thyroid cartilage
b. Silastic implant: Probe VC and test voice. Allows you to identify position of VF w patients best voice

c. Rosen uses Gortex
i. 2x2mm window
ii. Medialize VC, don’t need to push arytenoid, push more anteriorly
iii. Implant placement:
1. Posterior toward muscle process
2. Inferior

48
Q

Crico-thyroid subluxation steps

A

i. Isshiki in 1974
ii. Release CT joint
iii. Rotate thyroid cartilage on cricoid
1. Disarticulare the joint
a. Pass suture around thyroid cartilage cornu(?) and then pass the cricoid posteriorly to put cartilage under tension
2. Moves anterior commissure away from side of paralysis
3. Increases distance from anterior commissure and arytenoid
iv. Adjunc to thyroplasty
v. Increase VF length?
vi. Increase post-op vocal range?

49
Q

VF injection vs Thyroplasty

A

a. Both tx bulk and position
i. Augment and medialize VF

b. Only arytenoid adduction addresses VF length and posterior commissure closure
c. Open vs minimal approach
d. Injection easier to treat both VFs
e. Unilateral VFP w contralateral VF atrophy
f. More 3D control w thyroplasty
g. Ease of revision
i. Easier to reduce w thyroplasty
ii. Easier to increase w injection

h. Patient factors
i. Prior neck surgery?
ii. Anti-coagulation status? Mechanical valve should get injection
iii. Direct vs indirect visualization of defect

50
Q

Signs of laryngoreflux of exam

A

a. Sulcis vocalis
On exam, VCs looks like there are two sets of TVCs. Extends posteriorly

b. Granuloma

51
Q

GERD v LPR

A

LPR:

i. LES and UES
ii. No heartburn (94%) possibly chronic destruction of nerve endings
iii. NO esophagitis (bx neg)
iv. Daytime and upright symptoms
v. Normal esophageal motility
vi. H2 blockers fail in 40%
vii. PPIs required?
viii. Non acid reflux
ix. Can be vagally mediated
x. Really nebulous symp

GERD:

i. LES relaxation
ii. Classic symp: +Heartburn, globis, indigestion, regurgitation
iii. TX: Elevate HOB, don’t eat before bed, H2 blockers
iv. Often a/w esophageal dysmotility

52
Q

LPR “Symptoms”

A

a. Dysphonia/hoarseness
b. Chronic throat clearing
c. PND
d. Globus

53
Q

Issues in LPR

A

a. Wide array of complaints attributed
b. Diagnosed clinically (subjective)
i. Based upon hx/NPO
ii. Neither specific or sensitive
iii. Rarely confirmed by testing
iv. No std diagnosis

54
Q

Reflux symptom index (RSI)

A

score up to 45

a. If above 11 = + but is not diagnostic.
- ->Use for monitoring symptom improvement
b. Not great bc Allergic rhinitis and paradoxical VF monitoring can also obscure diagnosis

55
Q

LPR Dx

A

a. pH probe; impedance monitoring
i. Proves do NOT have reflux
ii. Poor correlation to symptoms
iii. No normative data

b. Practically
i. Empiric tx w PPI
ii. Reflux precautions

Studies not useful: a. Restech probe

b. Barium swallow
c. EGD w bx
d. Single probe pH studies (false neg 40%)

56
Q

LPR empirical treatment

A

a. Behavior modification
b. PPI (half life 18hrs)
c. QD? BID? Start at QD dosing
d. Symptoms at a specific time of day?
e. If they forget to take 30 min before biggest protein meal, have them take it when they remember
f. H2 blocker at night?? If having night time symptoms or morning phlegm
g. 2-4 month trial of PPI

57
Q

PPIs names

A 
Lansoprazole (Prevacid)
Omeprazole (prilosec)
Rabeprazole (aciphex)
Esomeprazole (nexium)
Dexlansoprazole (dexilant)
58
Q

Lansoprazole (Prevacid)

A

i. Only one approved in kids

ii. Adults 15 half dose, 30 full dose

59
Q

Omeprazole (prilosec)

A

i. 20 and 40mg dosing

60
Q

Rabeprazole (Aciphex)

A

i. 20mg dosing, equivalent to 40 of Nexium or 30 of prevacid

ii. Least GI SE

61
Q

Esomeprazole (nexium)

A

i. Most GI SE

ii. 20/40 dosing

62
Q

Dexlansoprazole (Dexilant)

A

i. Very expensive but very good

ii. Don’t have to time it with PO food

63
Q

PPI Interactions

A

a. CYP2C19 metabolizers
b. Clopidogrel competitively inhibits CYP2C19 metbolism not converted to active form less antiplatelet effect
c. Decreased Warfarin metab (increased INR)
d. Decreased metabolism of Digoxin, phenytoin, diazepam increased levels

64
Q

PPI Complications

A

a. Osteoporosis
i. Small potential increase in Spine/hip especially in smokers. Really chronic use

b. Kidney issues
i. Not dose dependent, usually resolves

c. C-diff
d. Alzheimers/dementia
e. B12 deficiency

f. Pneumonia
i. Not CAP but more in HCAP

65
Q

PPI Wean

A

a. Avoid rebound
b. Wean with H2 blockers
c. RF for unsuccessful wean: elevated BMI

66
Q

Alginates for LPR

A

a. Calcium alginate suspension =seaweed
b. Creates a barrier to prevent reflux through LES
c. Have to order it online
d. Gaviscon ADVANCE 10mL TID (30 min after meals)
i. Regular gaviscon is like tums
e. “Poor man’s Nissen procedure”

67
Q

Dietary and Lifestyle modifications for LPR

A

a. Weight loss, tobacco cessation, no late eating, HOB elevation highly effective
b. Low acid diet
i. Really good for motivated patients “Dropping Acid the reflux diet by Koufman” book for it
c. Canned foods have artificially lowered pH to preserve it. Increases acid intake

68
Q

Role of H2 Blockers for LPR

A

a. Nocturnal acid breakthrough
i. Drop in gastric pH <4 for a hour or more
ii. Typically 7 hours after evening dose
iii. Occurs in 70% of patients on PPIs twice daily
iv. Actual LPR a/w NAB? Unknown
v. May explain failure of PPIs in LPR (up to 20%)

69
Q

H2 Blocker meds

A

a. Zantac (ranitidine)
i. 150mg or 300 mg at night
ii. 3 mg/kg in kids
b. Pepcid (famotidine)
i. 40 mg =300 of zantac
c. Tagomet
i. 800mg

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