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Laryngology Flashcards

1
Q

Match the bronchial arch with it’s laryngeal derivative:
A. Corniculate, arytenoid and cricoid cartilages; some laryngeal muscles;RLN
B. Upper body of hyoid bone and less cornu
C. Epiglottis, thyroid cartilage, cuneiform cartilages, pharyngeal constrictors, some laryngeal musculature, SLN
D. Lower body of hyoid and greater Cornu

A

A. V/VI
B. II
C. IV
D.III

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2
Q

Position of infant larynx related to cervical vertebrae vs adult

A

Infant: C1-C4
Adult: C4-C7 (by age 4)

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3
Q

Name intrinsic laryngeal muscles, function and innervation

A
  1. Cricothyroid: lengthens VF, external SLN
  2. Posterior cricoarytnoid: abducts, RLN
  3. Lateral cricoarytnoid: adducts, RLN
  4. Oblique arytenoid: adducts, RLN
  5. Transverse arytenoid: adducts
  6. Thyroarytnoid: relaxes, shortens and adducts; RLN
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4
Q

Describe sensation of the larynx

A

Internal branch of SLN above the glottis and RLN below glottis. Tip of epiglottis receives innervation from IX

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5
Q

Describe subtypes of laryngeal epithelium

A
  • Supraglottis: pseudostratified columnar epithelium (respiratory epithelium)
  • Glottis: stratified squamous epithelium
  • Subglottis: pseudostratified columnar
  • Lingual surface of epiglottis: stratified squamous
  • Laryngeal surface of epiglottis: stratified squamous merging into pseudostratified columnar
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6
Q

Jitter

A

Cycle to cycle variation in frequency

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7
Q

Shimmer

A

Cycle to cycle variation in amplitude

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8
Q

GRABS scale

A 
Grade
Roughness
Breathiness
Asthenia (lack of power)
Strain

0- no déficit, 1- mild, 2-moderate, 3- severe

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9
Q

Five aspects evaluated by stroboscopy

A

Symmetry - appearance of VFs, symmetry of motion of one VF compared to the other
Periodicity - regularity of glottic cycles
Amplitude- lateral excursion of mid membranous cord, should be ~1/3 width of true VF
Mucosal wave- movement of the SLP
Closure- VF coming together

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10
Q

Common side effects of PPIs

A

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

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11
Q

Vocal fold nodules

A

Benign growth in the superficial layer of the anterior and middle third of the true vocal fold which can be either acute (edematous, erythematous, or vascular) or chronic (firm non-vascular secondary to scar deposition and fibrosis).

  • Seen at midportion of membranous VF (where shearing and collisional forces are greatest)
  • Bilateral
  • Tx: speech therapy followed by surgical removal if continued poor voice and persist nodules after > 3months of therapy
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12
Q

Vocal fold Nodules versus polyps

A

Nodules: Always bilateral,
composed of inflammatory tissue, respond to voice rest, have a broad range of appearances

Polyps: Unilateral or bilateral, full of either gelatinous material or blood, typically do not respond to voice rest.

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13
Q

Treatment of choice for vocal fold hemorrhage

A

This is a laryngologic emergency and the treatment is 7 to 14 days of total voice rest with follow up to ensure resorption of blood and identify a varix that could be treated. If the blood has not resolved chordotomy and a evacuation of blood are indicated.

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14
Q

Vocal fold scar versus sulcus vocalis

A

Vocal fold scar: the lamina propria is replaced with abnormally fibrous and disorganized tissue.

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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15
Q

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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16
Q

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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17
Q

Intracortical vocal fold cysts

A

Usually arise within the superficial lamina propria (although can 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, they are also commonly associated with a contralateral nodule. Two types: mucous retention cysts (wax and wane) and epidermoid/Keratin cysts (fairly stable)

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18
Q

A cyst involving which branchial cleft may involve the larynx

A

Third branchial cleft

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19
Q

Laryngeal saccule

A

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. It is responsible for lubricating the vocal folds.

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20
Q

Anterior versus lateral saccular cysts

A

Anterior: Extend mediately into the laryngeal lumen between the true and false vocal folds

Lateral: Extends posteriorly and superiorly to involve the aryepiglottic fold

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21
Q

Laryngocele versus saccular cyst

A

Laryngocele: Air filled dilation of the saccule that communicates with the laryngeal lumen

Saccular cyst: Fluid filled dilation of the saccule that does not communicate with the laryngeal lumen

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22
Q

Internal versus external/combined laryngocele’s

A

Internal: Contained within the thyroid cartilage

External: Extends through the thyrohyoid membrane

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23
Q

Treatment of laryngeal saccular cyst vs laryngocele

A

Saccular cyst: marsupialization or complete Excision

Laryngocele: complete excision vía endoscopic or external approach.

-Marsupialization not recommended

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24
Q

What is a laryngopyocele and how is it managed?

A

A saccular cyst filled with purulent debris. Can be a surgical emergency. Secure and airway and drain and culture. Either at the time of drainage or after acute infection complete excision of cyst. Medical management of acute episode with IV antibiotics, antipyretics and steroids.

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25
Q

Describe normal changes that occur in larynx with age and which physiologic changes contribute to “elderly voice”

A

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

Air escape, tremor, laryngeal tension

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26
Q

In a patient with paresis of 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.

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27
Q

Three habits to limit or eliminate to improve laryngeal hygiene

A

Alcohol, tobacco, caffeine

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28
Q

Common symptoms associated with reflux laryngitis

A

Globus, hoarseness, cough, throat clearing

Fewer than 50% have GI symptoms of reflux

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29
Q

Laryngeal chondromas arise most commonly from what anatomical site?

A

Posterior cricoid plate

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30
Q

Cotton Myers Subglottic Stenosis grading system

A

Grade 1- 0-50%
Grade 2- 51-70%
Grade 3- 71-99%
Grade 4- 100%

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31
Q

Treatment for laryngeal chondromas

A

Complete excision to negative margins alone

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32
Q

Most common benign neurogenic laryngeal neoplasms

A

Laryngeal schwannoma (most common), neurofibroma, granular cell neoplasm

Schwannomas and neurofibromas most commonly arise from internal branch of SLN

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33
Q

Where do endolaryngeal neurofibromas commonly present

A

Arytenoid complex and AE fold

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34
Q

Which neurogenic laryngeal neoplasm is often associated with pseudoepitheliomatous hyperplasia of overlying mucosa, which can often be misdiagnosed as SCC?

A

Granular cell neoplasm

  • Misdiagnosis due to insufficiently deep biopsy
  • Most common site is middle to posterior part of TVF
  • Treat with complete local excision
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35
Q

Because granular cell tumors present a risk for malignant conversion (2-3%) they should be resected. What confirmatory findings for benign tumor is seen on pathology?

A

Large polyhedral cells that may contain significant collagen, granular eosinophilic cytoplasm, centrally locates vesicular nuclei

+periodic acid Schiff (PAS), +S-100, + neuron specific enolase, + NK1-C3

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36
Q

What is the likely cell origin for granular cell tumors

A

Schwann cell

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37
Q

Most common benign neoplasm of larynx

A

Recurrent respiratory papillomatosis (RRP)

HPV 6 &11 are most common subtypes. 11 tends to be more aggressive requiring more frequent surgical intervention and higher incidence of airway obstruction.

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38
Q

Describe structure of HPV

A

Pappilomavirus, non enveloped icosohedral capsid, double stranded DNA virus

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39
Q

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

A

False

Cystic hygromas: composed of large cysts that are amenable to surgical excision.

Cavernous/microcystic lymphangiomas: composed of very small cysts difficult to resect and tend to recurr after surgery.

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40
Q

Which side to laryngeal hemangiomas more commonly present in the larynx?

A

The left

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41
Q

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

A

Seen on exam covered by thin, friable mucosa overlying a vascular stroma. T2 weighted MRI can be helpful to delineate extent. Most commonly seen in surpgalottis in adults and do not spontaneously regress. Hemangiomas in adults should not be actively treated unless symptomatic. Steroids or radiotherapy may be considered if necessary.

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42
Q

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

A

Between 12-24months of age; 50% will be involuted by age 5 and 70% by age 7.

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43
Q

Viruses associated with acute viral laryngitis

A

RSV, parainfluenza, influenza, adenovirus, HSV, coronavirus

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44
Q

What med has been shown to improve discomfort with acute viral laryngitis?

A

NSAIDs (Flurbiprofen lozenges)

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45
Q

Treatment of acute viral laryngitis

A

Supportive (hydration and voice rest). A single dose of dexamethasone (0.16mg/kg) has been shown to decrease severity of moderate to severe laryngotracheitis in peds during first 24hrs after injection.

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46
Q

Infectious agents causing epiglottitis in adults

A

Bacterial: H influenzae type B and other strains, Strep penumo, Staph aureus, B hemolytic strep
Viral: HSV, varicella zoster, prainfluenza, influenza, EBV
Fungal: candida

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47
Q

Most common cause of acute fungal laryngitis

A

Candida albicans

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48
Q

Causes of chronic fungal laryngitis

A
  • Blastomycoces (southern US): broad based budding yeast on pathology
  • Histoplasma (Ohio and Mississippi River Valley): typically seen in immunocompromised secondary to HIV, post transplant or diabetes
  • Coccidioides (SW US and Mexico - Valley fever)
  • Paracoccidioides: seen in South American male farm workers. Ulcerative and exophytic lesions seen on exam
  • Mycobacteria (South America, Africa, Asian subcontinent): true and false vocal folds most commonly affected sites
  • Cryptococcus
  • Candida
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49
Q

What is the most common subsite affected by laryngeal sarcoidosis?

A

Epiglottis

*Laryngeal sarcoidosis can occur in isolation without evidence of disease elsewhere in the body (1-5%)

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50
Q

What is the pathognomonic finding of laryngeal sarcoidosis during laryngoscopy?

A

Diffuse pale, edematous enlargement of the supraglottis

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51
Q

ACE level and sarcoid

A

Useful for monitoring disease but not recommended as diagnostic test due to low sensitivity (60%).

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52
Q

What % of patients with granulomatosis and polyangiitis will develop subglottis stenosis?

A

10-20%

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53
Q

Expected biopsy findings in a patient with granulomatosis with polyangiitis?

A

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

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54
Q

What will the flow volume loop look like in a patient with subglottic stenosis?

A

Flattened inspiratory and expiratory phases indicating a fixed obstruction.

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55
Q

What is most common laryngeal subsite affected by amyloidosis ?

A

True and false cords and ventricles

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56
Q

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

A

Relapsing polychondritis

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57
Q

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

A

Tracheobronchomalacia

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58
Q

What % of patients with RA develop cricoarytnoid joint involvement?

A

25-30%

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59
Q

What % of patients with RA have radiologic evidence of cricoarytnoid joint involvement?

A

54-72%. The common findings on CT are cricoarytnoid prominence, density, and volume change, subluxation, decreased joint space, and Pyriform sinus narrowing.

Radiologic involvement does not correlate with symptoms

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60
Q

Treatment for RA cricoarytnoid joint dysfunction

A

High dose corticosteroids or immune modulating meds.

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61
Q

Motor neurons for RLN originate in what brain stem nucleus?

A

Nucleus Ambiguous

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62
Q

Most common cause of unilateral true vocal fold paralysis.

A

Surgical iatrogenic injury

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63
Q

Most common malignant cause of unilateral true vocal fold paralysis?

A

Lung carcinoma

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64
Q

Imaging of what region should be obtained to evaluate unilateral true vocal Fold immobility of unknown cause

A

Skull base to upper chest to examine full course of recurrent laryngeal nerve

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65
Q

What meds are known to have neurotoxic effects that can lead to true vocal fold paralysis?

A

Vinca alkaloids (vincristine, vinblastine) and cisplatnum

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66
Q

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

A

Palate will elevate away from injured side

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67
Q

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 ipsilateral true vocal. Wallenberg syndrome or lateral medullary syndrome, dysphagia, loss of pain, and temperature sensation on the ipsilateral face and contra lateral body and ipsilateral Horner syndrome.

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68
Q

What is the role of laryngeal EMG in management of vocal fold immobility?

A

EMG Can differential paralysis from fixation and may provide prognostic information regarding potential for recovery.

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69
Q

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

A

Adductor spasmodic dysphonia

70
Q

Describe adductor spasmodic dysphonia vs muscle tension dysphonia during auditory perceptual evaluation?

A

ADSD is task dependent, MTD is not. MTD will have strained voice quality across all vocal tasks. ADSD will be worse during sentences rich in voiced consonants, will improve during sustained vowels In sentences with predominantly voiceless consonants.

71
Q

What muscle is injected with Botox during treatment of adductor spasmodic dysphonia?

A

Thyroarytenoid

72
Q

Common adverse effects of Botox for ADSD?

A

Breathy voice, aspiration- usually self limited. Can last up to 2 weeks

73
Q

Describe speech associated with abductor dysphonia?

A

Intermittent breathy voice breaks during speech, particularly following voiceless consonants.

74
Q

Which muscle is injected with Botox for treatment of abductor spasmodic dysphonia?

A

Posterior cricoarytenoid

75
Q

What spirometry finding is associated with paradoxical vocal fold motion?

A

Flat inspiratory portion of flow volume loop

76
Q

Treatment for paradoxical vocal fold motion?

A

Voice therapy, relaxation and breathing exercises

77
Q

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

A

10-20%

78
Q

What muscles are selectively injected with botox during treatment of vocal tremor

A

strap muscles and or intrinsic laryngeal muscles may be injected, depends on muscles which appear most tremulous

79
Q

What diagnosis should be considered in patient with Parkinson disease and vocal fold motion abnormalities?

A

Shy-Drager syndrome - form of multiple system atrophy, a Parkinson plus syndrome that may lead to life threatening sleep apnea. Tracheostomy may be required

80
Q

What voice and speech characteristics are observed in ALS?

A

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

81
Q

Injury to which structure results in flaccid dysarthria?

A

Damage to any cranial nerves involved in speech (V,VII, X, XII)

82
Q

Describe speech pattern associated with ataxic dysarthria.

A

Ataxic dysarthria is associated with disorders of the cerebellum and is characterized by harsh, breathy voice with a strained tremulous quality and fluctuating pitch and volume. Tremulous laryngeal muscle contraction are noted during speech but not at rest.

83
Q

Describe characteristic features of dysarthria associated with Parskinsons.

A

Hypokinetic dysarthria, low volume, reduced pitch variation, rushed speech, reduction of articulation associated movements

84
Q

Key features of muscle tension dysphonia

A

Posterior glottic chink, high larynx, suprahyoid muscle tension, breathiness and glottal fry, tenderness to palpation of larynx, small thyrohyoid space, high hyoid bone and larynx, difficulty rotating larynx

85
Q

True or false - MTD is often the result of an unconscious attempt to compensate for glottic insufficiency?

A

True. Therefore treatment focuses initially on voice therapy.

86
Q

Dysphonia plica ventricularis

A

Or ventricular dysphonia, refers to phonation resulting from false vocal fold vibration as opposed to true vocal fold vibration. results in low pitched and hoarse voice with intermittent voice breaks and diplophonia (phonation with two independent pitches).

87
Q

Relative contraindications to cricothyrotomy

A
  • Child younger than 10-12 years
  • Inability to palpate landmarks (neck trauma)
  • Expanding cervical hematoma
  • Subglottic extension of known laryngeal disease
88
Q

Surgical steps of cricothyrotomy

A
  • Palpate landmarks, identify cricothyroid space
  • Stabilize larynx with non dominant hand and maintaining position of cricothyroid membrane with pointer finger
  • Vertical incision through skin
  • Horizontal incision through cricothyroid membrane
  • Spread space with instrument available
  • Place cuffed breathing tube
  • ## Can then work on controlling any bleeding
89
Q

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

A

reports range from 30min to 2 hours.

90
Q

Primary indications for tracheotomy

A
  • Prolonged intubation
  • Pulmonary toilet (management of tracheobronchial secretions)
  • Upper airway obstruction
  • Management associated with head and neck surgery or major head and neck trauma
91
Q

Nonemergent indications for surgical tracheotomy?

A
  • Pulmonary toilet: aspiration, inability to clear secretions (stroke, neurologic impairment)
  • Obstruction: malignancy, OSA
  • Prevent complications associated with prolonged intubation (subglottic stenosis, tracheal erosion…)
92
Q

what is the maximum pressure acceptable for an ETT or tracheostomy tube cuff?

A

30cm H20 so as not to excess mucosal capillary pressure

93
Q

Early and late complications of tracheostomy?

A

Early: occlusion, granulation tissue, false passage, tube disgorgement, hemorrhage, wound infection, subcutaneous emphysema (possible pneumothorax or pneumomediastinum), post op pulmonary edema
Late: hemorrhage (tracheoinominate fistula), TE fistula, tracheal stenosis, persistent tracheocutaneous fistula (After decannulation)

94
Q

Three types of jet ventilation

A

Supraglottic, subglottic, transtracheal

95
Q

Most common complication of jet ventilation?

A

Air trapping leading to pneumothorax/pneomomediastinum

96
Q

Physical exam findings that my be associated with difficult endotracheal intubation?

A

Long incisors, retrognathia, poor mandibular protrusion, small interincisor distance (i.e decreased mouth opening), Mallampati 3+ , high arched palate, short neck, thick neck, thyromental distance less than three finger breadths, limited neck range of motion

97
Q

Mallampati classification

A

With mouth fully open and tongue protruded
Grade 1: Can see tonsillar pillars, tonsils and uvula
Grade 2: Uvula partially obscured by tongue base, upper tonsils visible
Grade 3: Can only see soft palate and base of uvula
Grade 4: Only hard palate visible

98
Q

Average duration of effect for the vocal fold injection via the following materials - gelfoam, bovine collagen, carboxymethycelulose (prolaryn gel), micronized alloderm (cymetra), fat, teflon, calcium hydroxyapatite (Radiesse/Prolaryn Plus)

A 
Gelfoam: 4-6 weeks
Bovine Collagen: 3-4 months
Carboxymethylcellulose: 2-3 months
Cymetra: 6-12 months
Fat: several years
Teflon: indefinite 
Calcium hydroxyapatite; 2+ years
99
Q

Teflon injection is limited by what complication?

A

Teflon granuloma

100
Q

Patients with what finding on videostroboscopy are less likely to benefit from true VF injection?

A

Posterior glottic gap. More likely to benefit from laryngeal framework surgery.

101
Q

What test must be obtained prior to injecting with bovine collagen?

A

Allergy skin testing due to risk of allergic reaction to material.

102
Q

What is the superior arcuate line of the true vocal fold?

A

The transition point from the superior surface of the true vocal fold to the ventricle

103
Q

Preferred needle placement for TVF injection

A

Anterior/lateral to the vocal process along arcuate line at a desired depth of 3-5mm

104
Q

Four types of thyroplasty

A

Type 1: Medialization (correct glottic insufficiency)
Type 2: Lateralization (used for SD)
Type 3: shortening/relaxing
Type 4: Lengthening/tightening

105
Q

What materials are commonly used for medialization laryngoplasty?

A

Gortex, silastic hydroxyapetite

106
Q

To avoid fracture of thyroid cartilage what is minimal width of cartilage strut that must be left below the thryoiplasty window in a type I thyroplasty?

A

3mm

107
Q

To externally determine the horizontal plane of the TVF within the thyroid cartilage, what anatomical landmark must be completely exposed along the inferior border of the thyroid cartilage?

A

Inferior muscular tubercle - parallels the long axis of the true vocal fold

108
Q

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

A

Men have a more acute anterior angle of the thyroid cartilage. Window is placed more posteriorly (7mm vs 5mm) to avoid overmedialization of the anterior TVF.

109
Q

Indications for performing an arytnoid adduction during type I thyroplasty

A

Large posterior glottic gap, vocal fold level mismatch, insufficient voice improvement with thyroplasty alone

110
Q

What landmarks can be used to help identify muscular process of arytnoid during ayrtnoid adduction?

A

After window has been created in posterior thyroid lamina and pyriform sinus mucosa has been retracted you can follow the fibers of the posterior CA muscle superiorly to their attachment to the muscular process or by looking approximately 1cm superior to the CA joint.

111
Q

During microflap surgery of submucosal pathology where should the incision be located?

A

Directly or just lateral to pathology

112
Q

During microflap surgery of submucosal pathology what is the desired plane of elevation?

A

As superficial as possible

113
Q

Available techniques for laryngeal reinnervation after injury to RLN

A

Primary RLN anastomosis, ansa cervicalis to RLN neurorrhaphy, ansa cervicalis to thyroarytnoid neuromuscular pedicle, ansa cervicalis to thyroarytnoid neural implantation, hypoglossal nerve to RLN neurorrhaphy and cricothyroid muscle nerve muscle neurotization

114
Q

True or false laryngeal reinnervation procedures restore normal movement of TVF in unilateral TVF paralysis?

A

False - they improve voice by maintaining tone and bulk of laryngeal adductor muscles

115
Q

Benefits of laryngeal reinnervation techniques relative to other procedures used to treat vocal cord paralysis?

A
  • avoid thyroarytenoid muscle loss
  • preservation of laryngeal anatomy to allow for additional procedures if necessary
  • no alternation of vocal fold vibratory potential
  • Ability to perform procedure under general anesthesia
116
Q

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

A

Laryngopharyngeal reflux, diabetes, stroke, congestive heart failure

117
Q

What are the indications for using 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

118
Q

Mechanism of action of mitomycin C

A

Mitomycin is both an antibiotic and an antineoplastic agent. Acts as an alkylating agent, causing DNA cross linking and inhibition of DNA and RNA synthesis. May lead to decreased cell division, decreasing fibroblast activity and protein production.

119
Q

Preferred surgical technique for repair of complete tracheal stenosis?

A

Resection and primary anastomosis

120
Q

What % of adult trachea can be resected and still allow for primary anastomosis?

A

50% (5-7cm)

121
Q

Best surgical treatment for circumferential fibrous stenosis of trachea with intact cartilage?

A

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

122
Q

Posterior cricoarytnoid

A
  • Only ABductor of the larynx
  • Attaches the cricoid to the muscular process of the arytenoid
  • Pulls muscular process posteriorly and caudally rotating the vocal process laterally and upward
123
Q

Cricothyroid

A
  • Only muscle not supplied by RLN, supplied by external branch of SLN
124
Q

Three components of sound creation

A
  • Power source: lungs
  • Vibratory source: the larynx
  • Resonator: supraglottal vocal tract, including the supraglottic larynx, pharynx, oral cavity, and potentially the nasal cavity
125
Q

Three histologic layers of the vocal fold?

A
  • Cover
  • Transition zone or vocal ligament
  • Body
126
Q

What are the components of the vocal fold cover?

A
  • Squamous epithelium
  • Superficial layer of the lamina propria (Reinke space - composed of fibroblasts that produce proteins and glycoproteins, forms an extracellular matrix of loose connective tissue
127
Q

Indirect methods to visualize the larynx

A
  • Mirror laryngoscopy
  • Rigid indirect laryngoscopy
  • Flexible indirect laryngoscopy
128
Q

Vocal fold closure patterns

A
  • Complete closure
  • Anterior or posterior gap: may be normal variant (women may have posterior gap), postsurgical defect, scar/sulcus
  • Spindle shaped: bowed cords from atrophy or prebylarynges
  • Hourglass: seen with vocal fold nodules, prenodular edema or a polyp/cyst with a reactive lesion
129
Q

Maximum phonation time (MPT)

A

Maximum time patient can sustain phonation

  • Normal 15-25 seconds in females
  • Normal 25-35 seconds in males
130
Q

Spasmodic dysphonia diagnostic features

A
  • Unstable voice that improves with whispering, singing or alcohol consumption
  • May worsen with stress
  • 16% of SD patients will have another dystonia; 10% of SD cases are familial
  • Consider Meige syndrome: dystonia of eyelid, tongue, floor of mouth and masseter with 25% laryngeal involvement
131
Q

Adductor spasmodic dysphonia

A
  • 87% of SD cases
  • choked, strangled strained voice with abrupt initiation/termination from thyroartenoids/lateral cricoartynoid dysfunction
  • More pronounced with voiced vowels “we eat eggs every Easter”
  • Tx: botox to one or both TA muscles
132
Q

Abductor spasmodic dyphonia

A
  • 12% of SD cases
  • breathy, effortful voice with breaks, whispered segments of speech from PCA dysfunction
  • Seen more in phrases with voiceless consonants: “ Harry’s happy hat”
  • Tx: botox to one or both PCA muscles
133
Q

Botox basics

A
  • Works by blocking presynaptic release of acetylcholine
  • Recovery because of new nerve terminals spouting and increase in postjunctional receptors
  • Contraindicated in myasethenia gravis, Eaton Lambort syndrome and pregnancy
134
Q

Vocal tremor

A
  • Tremoring persists with whisper, not sound specific, with vowel phonation
  • Rhythmic at 6-8 Hz
  • May have tremor elsewhere (hands, head)
  • 10-20% of patients with essential tremor will have vocal involvement
  • Tx: B blocker, primidone is considered first line therapy
135
Q

Phonatory dyspnea

A

When patient runs out of air while talking

136
Q

What does LASER stand for

A

Light amplification by stimulated emission of radiation

137
Q

Three properties of LASER

A
  • Monochromatic: single color, same wavelength
  • Collimated: emits organized light in the same direction
  • Coherent: in space and time
138
Q

Laser tissue interactions

A
  • reflection
  • absorption
  • transmission
  • scattering
139
Q

Argon laser

A
  • Blue green light 488-514nm
  • Transmitted through clear aqueous tissues (cornea, lens, vitreous humor)
  • Absorbed and reflected to varying degrees by tissues that are white in color (fat, skin, bone)
  • Absorbed by hemoglobin and pigmented tissues
  • Used in stapedotomy, port wine stains, hemangiomas, telangectasias, photodynamic therapy
  • Drawback: heat produced destroys epidermis and upper dermis
140
Q

Nd:YAG laser

A
  • Near infrared: 1064nm
  • Transmitted through clear liquids
  • Increased absorption in darkly pigmented tissues and charred debris
  • Strong scattering leads to a zone of thermal coagulation and necrosis of ~4m,
  • Clinical use: ablation of tracheobronchial and esophageal lesions, photocoagulation of vascular and lymphatic malformations
  • Benefit: control of hemorrhage is more secure because deep penetration of tissue
  • Drawback: lacks precision
141
Q

CO2 laser

A
  • 10600 nm
  • Absorbed by water
  • Tissue effect: carbonization, smoke and gas generation
  • Zone of thermal necrosis about 100um wide
  • Less postop edema likely because heat seals vessels
  • Clinical uses: stapedotomy, cosmetic skin treatment, laryngology, bronchoesophagology
  • Very precise with increased hemostasis and decreased intraoperative edema
142
Q

KTP laser

A
  • 532nm
  • Absorbed by hemoglobin, specifically oxyhemoglobin
  • Clinical use: otologic, rhinologic, laryngologic surgery, tonsillectomy, pigmented dermal lesions
143
Q

Pulsed dye laser

A
  • 585nm
  • Chromophore is oxyhemoglobin
  • Selectively absorbed by intraluminal blood of vascular lesions such as papillomas, vascular polyp, vocal fold ectasias, hemangiomas, port wine stains
  • Minimal scattering and absorption by melanin or other pigments
144
Q

Adjuvants used in treatment of RRP

A
  • Cidofovir
  • Bevacizumab
  • Interferon
145
Q

Laryngeal chondroma

A
  • Slow growing, dose not metastasize
  • Smooth, rounded mass in the subglottis: posterior aspect of cricoid
  • Treat with excision (commonly laryngofissure)
146
Q

Most common pathogens of viral layrngitis

A
  • Herpes zoster

- Coronavirus

147
Q

Klebsiella Rhinoscleromatis

A
  • Can involve nose, larynx and trachea
  • Histopath: Gram negative coccobacillus within macrophages (Mikulicz cells)
  • Treatment: fluroquinolones, tetracycline, airway management
148
Q

Relapsing Polychondritis

A
  • 25-50% demonstrate symptoms of laryngeal dysfunction
  • Most often affecting the cricoarytnoid joint
  • Pathology: inflammation in cartilages high in glycosaminoglycans
  • Autoantibodies directed against type II collagen
  • Diagnosis made clinically
149
Q

Sarcoidosis

A
  • Laryngeal manifestation occur in <1% of patients
  • Pulmonary, hepatic, cutaneous, cardiac and lymphatic system involvement is common
  • Supraglottis and glottis often involved in the form of diffuse edema
  • Pathology: noncaseating granulomas, possible elevated serum Ca and angiotensin converting enzyme levels
150
Q

Only laryngeal muscle with bilateral innervation

A

Interartyenoid muscle

151
Q

Modified barium swallow study (MBSS)

A
  • Can show past postcricoid region and upper esophageal sphincter
  • Can have concurrent esophogram
  • Will expose patient to radiation
  • Requires transport to radiology
152
Q

Flexible endoscopic evaluation of swallowing (FEES)

A
  • Allows indirect visualization of laryngeal and hypopharyngeal structures
  • Can perform at bedside
  • No radiation
  • Similar sensitivity/specificity as MBSS for aspiration
153
Q

Schaefer Classification of Laryngeal Trauma

A

Level I: minor hematoma/lacerations and no fractures
Level II: moderate edema, lacerations, mucosal disruptions without exposed cartilage and nondisplaced fractures
Level III: massive edema, displaced fractures and cord immobility
Level IV: massive edema, >2 displaced fractures, cord immobility, instability and anterior commissure involvement
Level V: complete laryngotracheal separation

154
Q

Alkali vs acid ingestion

A
  • Alkali is worse resulting in liquefactive necrosis with injury worsening over time
  • Acid results in coagulative necrosis
155
Q

Grading of esophageal injuries after caustic injury

A

First degree: mucosal erythema
Second degree: erythema with noncircumferential exudation
Third degree: circumferential exudation
Fourth degree: circumferential exudation with esophageal wall perforation

156
Q

Normal flow volume loop

A
  • Expiratory flow indicated by positive deflection

- Inspiratory flow indicated by negative defelction

157
Q

Flow volume loop in bilateral vocal cord paralysis

A
  • Normal expiratory limb

- limited inspiratory

158
Q

Flow volume loop in fixed obstruction

A
  • Decreased inspiratory and expiratory limbs
159
Q

Factors associated with poor outcome with endoscopic repair of airway stenosis

A
  • Circumferential stenosis with scar contracture
  • Scarring wider than 1cm in vertical dimension
  • Tracheomalacia with loss of cartilage
  • Previous history of severe bacterial infection associated tracheostomy
  • Posterior laryngeal inlet scarring with arytnoid fixation
160
Q

At what pressure does capillary blood flow cease

A

20-40 mmHg

161
Q

Ambulatory 24hr pH probe basics

A
  • abnormal pH level is < 4.0
  • pH level at which pepsin is activated: < 4.0
  • considered abnormal if > 4.35% of time with pH <4.0
162
Q

CREST syndrome

A
  • Limited cutaneous form of systemic sclerosis
  • C: calcinosis
  • R: Raynaud phenomenon
  • E: esophageal dysmotility
  • S: sclerodactly
  • T: telangiectasia
  • Esophogram will show dilated distal esophagus and manometry will be normal
163
Q

Esophageal involvement with polymyositis and dermatomyositis

A
  • Pharyngeal weakness with upper esophageal weakness

- May see dilated upper esophagus on esophagogram

164
Q

Diffuse Esophageal Spasm

A
  • See high pressure nonperistaltic contractions
  • Esophogram: corkscrew esophagus
  • Manometry: disorganized high pressure contractions
  • Treatment; nitrates and calcium channel blockers
165
Q

Killians triangle

A
  • Site of Zenker’s diverticulum
  • Area of weakness between the inferior constrictor and the cricopharyngeus (thyropharyngeus is a muscle that makes up the inferior constrictor)
166
Q

Killian Jameson dehiscense

A

Area of weakness between the oblique and transverse cricopharyngeus fibers
- Follows the course of the RLN

167
Q

Laimer triangle

A

Area of weakness between the cricopharyngeus and the superior esophageal wall circular muscles

168
Q

Traction and Pulsion diverticula

A

Pulsion: result from pressure from within the esophaugs causing the esophageal mucosa and submucosa to be herniated through an area of weakness

Traction: result of pulling forces external to the esophagus (inflammatory, neoplastic, or following spine surgery)

169
Q

Common symptoms of Zenker’s diverticulum

A
  • Progressive dysphagia
  • Regurgitation of food even hours after a meal
  • Unprovoked aspiration
  • Noisy deglutition
  • Belching
  • Halitosis
  • Choking/coughing
  • Globus
  • Weight loss
  • Recurrent respiratory infections
170
Q

Treatment options for Zenker diverticulum

A
  • Diet modification
  • G tube
  • Endoscopic diverticulotomy with cricopharyngeal myotomy
  • Open cricopharyngeal myotomy
171
Q

Number of lobes and lobules of each lung

A

Right lung: 3 lobes, 10 lobules

Left lung: 2 lobes, 9 lobules

172
Q

How does vocal cord tissue content change with aging?

A

Increased collagen (type I and III fibers) and decreased elastin (vocal cords are stiffer affecting the mucosal wave)

in service exam (16 decks)

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