Laryngology Flashcards
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. V/VI
B. II
C. IV
D.III
Position of infant larynx related to cervical vertebrae vs adult
Infant: C1-C4
Adult: C4-C7 (by age 4)
Name intrinsic laryngeal muscles, function and innervation
- Cricothyroid: lengthens VF, external SLN
- Posterior cricoarytnoid: abducts, RLN
- Lateral cricoarytnoid: adducts, RLN
- Oblique arytenoid: adducts, RLN
- Transverse arytenoid: adducts
- Thyroarytnoid: relaxes, shortens and adducts; RLN
Describe sensation of the larynx
Internal branch of SLN above the glottis and RLN below glottis. Tip of epiglottis receives innervation from IX
Describe subtypes of laryngeal epithelium
- 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
Jitter
Cycle to cycle variation in frequency
Shimmer
Cycle to cycle variation in amplitude
GRABS scale
Grade Roughness Breathiness Asthenia (lack of power) Strain
0- no déficit, 1- mild, 2-moderate, 3- severe
Five aspects evaluated by stroboscopy
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
Common side effects of PPIs
Abdominal pain, diarrhea, nausea, osteoporosis, elevated liver function tests, headache, candidiasis
Vocal fold nodules
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
Vocal fold Nodules versus polyps
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.
Treatment of choice for vocal fold hemorrhage
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.
Vocal fold scar versus sulcus vocalis
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.
What benign lesion often occurs on the posterior vocal fold near the vocal process as either an ulcerative or nodular polypoid process?
Vocal fold granuloma
True or false the polypoid changes associated with Reinke Edema are permanent?
True however the degree of edema and turgidity may fluctuate with voice use and exacerbating factors
Intracortical vocal fold cysts
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)
A cyst involving which branchial cleft may involve the larynx
Third branchial cleft
Laryngeal saccule
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.
Anterior versus lateral saccular cysts
Anterior: Extend mediately into the laryngeal lumen between the true and false vocal folds
Lateral: Extends posteriorly and superiorly to involve the aryepiglottic fold
Laryngocele versus saccular cyst
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
Internal versus external/combined laryngocele’s
Internal: Contained within the thyroid cartilage
External: Extends through the thyrohyoid membrane
Treatment of laryngeal saccular cyst vs laryngocele
Saccular cyst: marsupialization or complete Excision
Laryngocele: complete excision vía endoscopic or external approach.
-Marsupialization not recommended
What is a laryngopyocele and how is it managed?
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.
Describe normal changes that occur in larynx with age and which physiologic changes contribute to “elderly voice”
Muscle atrophy, thinning of the vocal ligament, mucous glad degeneration, cartilage ossification, epithelial thickening.
Air escape, tremor, laryngeal tension
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?
Left. Toward the side of the weak cricothyroid muscle.
Three habits to limit or eliminate to improve laryngeal hygiene
Alcohol, tobacco, caffeine
Common symptoms associated with reflux laryngitis
Globus, hoarseness, cough, throat clearing
Fewer than 50% have GI symptoms of reflux
Laryngeal chondromas arise most commonly from what anatomical site?
Posterior cricoid plate
Cotton Myers Subglottic Stenosis grading system
Grade 1- 0-50%
Grade 2- 51-70%
Grade 3- 71-99%
Grade 4- 100%
Treatment for laryngeal chondromas
Complete excision to negative margins alone
Most common benign neurogenic laryngeal neoplasms
Laryngeal schwannoma (most common), neurofibroma, granular cell neoplasm
Schwannomas and neurofibromas most commonly arise from internal branch of SLN
Where do endolaryngeal neurofibromas commonly present
Arytenoid complex and AE fold
Which neurogenic laryngeal neoplasm is often associated with pseudoepitheliomatous hyperplasia of overlying mucosa, which can often be misdiagnosed as SCC?
Granular cell neoplasm
- Misdiagnosis due to insufficiently deep biopsy
- Most common site is middle to posterior part of TVF
- Treat with complete local excision
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?
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
What is the likely cell origin for granular cell tumors
Schwann cell
Most common benign neoplasm of larynx
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.
Describe structure of HPV
Pappilomavirus, non enveloped icosohedral capsid, double stranded DNA virus
True or False. Both cystic hygromas and cavernous/microcystic lymphangiomas respond well to surgical excision?
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.
Which side to laryngeal hemangiomas more commonly present in the larynx?
The left
How are laryngeal hemangiomas diagnosed and what is their natural history? Treatment?
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.
At what age to infantile hemangiomas typically begin to involute and at what age is involution likely to be complete?
Between 12-24months of age; 50% will be involuted by age 5 and 70% by age 7.
Viruses associated with acute viral laryngitis
RSV, parainfluenza, influenza, adenovirus, HSV, coronavirus
What med has been shown to improve discomfort with acute viral laryngitis?
NSAIDs (Flurbiprofen lozenges)
Treatment of acute viral laryngitis
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.
Infectious agents causing epiglottitis in adults
Bacterial: H influenzae type B and other strains, Strep penumo, Staph aureus, B hemolytic strep
Viral: HSV, varicella zoster, prainfluenza, influenza, EBV
Fungal: candida
Most common cause of acute fungal laryngitis
Candida albicans
Causes of chronic fungal laryngitis
- 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
What is the most common subsite affected by laryngeal sarcoidosis?
Epiglottis
*Laryngeal sarcoidosis can occur in isolation without evidence of disease elsewhere in the body (1-5%)
What is the pathognomonic finding of laryngeal sarcoidosis during laryngoscopy?
Diffuse pale, edematous enlargement of the supraglottis
ACE level and sarcoid
Useful for monitoring disease but not recommended as diagnostic test due to low sensitivity (60%).
What % of patients with granulomatosis and polyangiitis will develop subglottis stenosis?
10-20%
Expected biopsy findings in a patient with granulomatosis with polyangiitis?
Necrotizing granulomas and necrotizing vasculitis of small arteries, arterioles, capillaries and venules
What will the flow volume loop look like in a patient with subglottic stenosis?
Flattened inspiratory and expiratory phases indicating a fixed obstruction.
What is most common laryngeal subsite affected by amyloidosis ?
True and false cords and ventricles
What autoimmune disorder results in episodic severe and progressive inflammation of cartilage most commonly within the ears, nose and laryngotracheobronchial tree?
Relapsing polychondritis
What is the most common manifestation of airway involvement in relapsing polychondritis?
Tracheobronchomalacia
What % of patients with RA develop cricoarytnoid joint involvement?
25-30%
What % of patients with RA have radiologic evidence of cricoarytnoid joint involvement?
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
Treatment for RA cricoarytnoid joint dysfunction
High dose corticosteroids or immune modulating meds.
Motor neurons for RLN originate in what brain stem nucleus?
Nucleus Ambiguous
Most common cause of unilateral true vocal fold paralysis.
Surgical iatrogenic injury
Most common malignant cause of unilateral true vocal fold paralysis?
Lung carcinoma
Imaging of what region should be obtained to evaluate unilateral true vocal Fold immobility of unknown cause
Skull base to upper chest to examine full course of recurrent laryngeal nerve
What meds are known to have neurotoxic effects that can lead to true vocal fold paralysis?
Vinca alkaloids (vincristine, vinblastine) and cisplatnum
After a high vagal injury, will the palate elevate away or toward the injured side?
Palate will elevate away from injured side
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?
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.
What is the role of laryngeal EMG in management of vocal fold immobility?
EMG Can differential paralysis from fixation and may provide prognostic information regarding potential for recovery.
Intermittent strangled or strained voice breaks during speech, particularly during words starting with vowels is suggestive of which diagnosis?
Adductor spasmodic dysphonia
Describe adductor spasmodic dysphonia vs muscle tension dysphonia during auditory perceptual evaluation?
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.
What muscle is injected with Botox during treatment of adductor spasmodic dysphonia?
Thyroarytenoid
Common adverse effects of Botox for ADSD?
Breathy voice, aspiration- usually self limited. Can last up to 2 weeks
Describe speech associated with abductor dysphonia?
Intermittent breathy voice breaks during speech, particularly following voiceless consonants.
Which muscle is injected with Botox for treatment of abductor spasmodic dysphonia?
Posterior cricoarytenoid
What spirometry finding is associated with paradoxical vocal fold motion?
Flat inspiratory portion of flow volume loop
Treatment for paradoxical vocal fold motion?
Voice therapy, relaxation and breathing exercises
What percentage of patients with essential tremor will develop vocal tremor?
10-20%
What muscles are selectively injected with botox during treatment of vocal tremor
strap muscles and or intrinsic laryngeal muscles may be injected, depends on muscles which appear most tremulous
What diagnosis should be considered in patient with Parkinson disease and vocal fold motion abnormalities?
Shy-Drager syndrome - form of multiple system atrophy, a Parkinson plus syndrome that may lead to life threatening sleep apnea. Tracheostomy may be required
What voice and speech characteristics are observed in ALS?
Harsh quality, low fundamental frequency, strained/strangled sound, pitch breaks resulting from injury of pyramidal and extrapyramidal tracts.
Injury to which structure results in flaccid dysarthria?
Damage to any cranial nerves involved in speech (V,VII, X, XII)
Describe speech pattern associated with ataxic dysarthria.
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.
Describe characteristic features of dysarthria associated with Parskinsons.
Hypokinetic dysarthria, low volume, reduced pitch variation, rushed speech, reduction of articulation associated movements
Key features of muscle tension dysphonia
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
True or false - MTD is often the result of an unconscious attempt to compensate for glottic insufficiency?
True. Therefore treatment focuses initially on voice therapy.
Dysphonia plica ventricularis
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).
Relative contraindications to cricothyrotomy
- Child younger than 10-12 years
- Inability to palpate landmarks (neck trauma)
- Expanding cervical hematoma
- Subglottic extension of known laryngeal disease
Surgical steps of cricothyrotomy
- 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
How long can a patient be ventilated via transtracheal needle ventilation?
reports range from 30min to 2 hours.
Primary indications for tracheotomy
- Prolonged intubation
- Pulmonary toilet (management of tracheobronchial secretions)
- Upper airway obstruction
- Management associated with head and neck surgery or major head and neck trauma
Nonemergent indications for surgical tracheotomy?
- Pulmonary toilet: aspiration, inability to clear secretions (stroke, neurologic impairment)
- Obstruction: malignancy, OSA
- Prevent complications associated with prolonged intubation (subglottic stenosis, tracheal erosion…)
what is the maximum pressure acceptable for an ETT or tracheostomy tube cuff?
30cm H20 so as not to excess mucosal capillary pressure
Early and late complications of tracheostomy?
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)
Three types of jet ventilation
Supraglottic, subglottic, transtracheal
Most common complication of jet ventilation?
Air trapping leading to pneumothorax/pneomomediastinum
Physical exam findings that my be associated with difficult endotracheal intubation?
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
Mallampati classification
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
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)
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
Teflon injection is limited by what complication?
Teflon granuloma
Patients with what finding on videostroboscopy are less likely to benefit from true VF injection?
Posterior glottic gap. More likely to benefit from laryngeal framework surgery.
What test must be obtained prior to injecting with bovine collagen?
Allergy skin testing due to risk of allergic reaction to material.
What is the superior arcuate line of the true vocal fold?
The transition point from the superior surface of the true vocal fold to the ventricle
Preferred needle placement for TVF injection
Anterior/lateral to the vocal process along arcuate line at a desired depth of 3-5mm
Four types of thyroplasty
Type 1: Medialization (correct glottic insufficiency)
Type 2: Lateralization (used for SD)
Type 3: shortening/relaxing
Type 4: Lengthening/tightening
What materials are commonly used for medialization laryngoplasty?
Gortex, silastic hydroxyapetite
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?
3mm
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?
Inferior muscular tubercle - parallels the long axis of the true vocal fold
Why is the window for a silastic implant placed more posteriorly in men than in women during a type I thyroplasty?
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.
Indications for performing an arytnoid adduction during type I thyroplasty
Large posterior glottic gap, vocal fold level mismatch, insufficient voice improvement with thyroplasty alone
What landmarks can be used to help identify muscular process of arytnoid during ayrtnoid adduction?
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.
During microflap surgery of submucosal pathology where should the incision be located?
Directly or just lateral to pathology
During microflap surgery of submucosal pathology what is the desired plane of elevation?
As superficial as possible
Available techniques for laryngeal reinnervation after injury to RLN
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
True or false laryngeal reinnervation procedures restore normal movement of TVF in unilateral TVF paralysis?
False - they improve voice by maintaining tone and bulk of laryngeal adductor muscles
Benefits of laryngeal reinnervation techniques relative to other procedures used to treat vocal cord paralysis?
- 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
What systemic diseases have been shown to increase risk of laryngotracheal stenosis after endotracheal intubation?
Laryngopharyngeal reflux, diabetes, stroke, congestive heart failure
What are the indications for using endolaryngeal stent in the repair of upper airway stenosis?
Holding cartilage, bone grafts or fragments in position. Stabilizing epidermal grafts, separating denuded surfaces. Maintaining a patent lumen when scar tissue is required
Mechanism of action of mitomycin C
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.
Preferred surgical technique for repair of complete tracheal stenosis?
Resection and primary anastomosis
What % of adult trachea can be resected and still allow for primary anastomosis?
50% (5-7cm)
Best surgical treatment for circumferential fibrous stenosis of trachea with intact cartilage?
Staged partial excisions of fibrous tissue, spaced 2-4 weeks apart to prevent recurrence.
Posterior cricoarytnoid
- 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
Cricothyroid
- Only muscle not supplied by RLN, supplied by external branch of SLN
Three components of sound creation
- Power source: lungs
- Vibratory source: the larynx
- Resonator: supraglottal vocal tract, including the supraglottic larynx, pharynx, oral cavity, and potentially the nasal cavity
Three histologic layers of the vocal fold?
- Cover
- Transition zone or vocal ligament
- Body
What are the components of the vocal fold cover?
- 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
Indirect methods to visualize the larynx
- Mirror laryngoscopy
- Rigid indirect laryngoscopy
- Flexible indirect laryngoscopy
Vocal fold closure patterns
- 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
Maximum phonation time (MPT)
Maximum time patient can sustain phonation
- Normal 15-25 seconds in females
- Normal 25-35 seconds in males
Spasmodic dysphonia diagnostic features
- 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
Adductor spasmodic dysphonia
- 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
Abductor spasmodic dyphonia
- 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
Botox basics
- 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
Vocal tremor
- 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
Phonatory dyspnea
When patient runs out of air while talking
What does LASER stand for
Light amplification by stimulated emission of radiation
Three properties of LASER
- Monochromatic: single color, same wavelength
- Collimated: emits organized light in the same direction
- Coherent: in space and time
Laser tissue interactions
- reflection
- absorption
- transmission
- scattering
Argon laser
- 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
Nd:YAG laser
- 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
CO2 laser
- 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
KTP laser
- 532nm
- Absorbed by hemoglobin, specifically oxyhemoglobin
- Clinical use: otologic, rhinologic, laryngologic surgery, tonsillectomy, pigmented dermal lesions
Pulsed dye laser
- 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
Adjuvants used in treatment of RRP
- Cidofovir
- Bevacizumab
- Interferon
Laryngeal chondroma
- Slow growing, dose not metastasize
- Smooth, rounded mass in the subglottis: posterior aspect of cricoid
- Treat with excision (commonly laryngofissure)
Most common pathogens of viral layrngitis
- Herpes zoster
- Coronavirus
Klebsiella Rhinoscleromatis
- Can involve nose, larynx and trachea
- Histopath: Gram negative coccobacillus within macrophages (Mikulicz cells)
- Treatment: fluroquinolones, tetracycline, airway management
Relapsing Polychondritis
- 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
Sarcoidosis
- 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
Only laryngeal muscle with bilateral innervation
Interartyenoid muscle
Modified barium swallow study (MBSS)
- Can show past postcricoid region and upper esophageal sphincter
- Can have concurrent esophogram
- Will expose patient to radiation
- Requires transport to radiology
Flexible endoscopic evaluation of swallowing (FEES)
- Allows indirect visualization of laryngeal and hypopharyngeal structures
- Can perform at bedside
- No radiation
- Similar sensitivity/specificity as MBSS for aspiration
Schaefer Classification of Laryngeal Trauma
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
Alkali vs acid ingestion
- Alkali is worse resulting in liquefactive necrosis with injury worsening over time
- Acid results in coagulative necrosis
Grading of esophageal injuries after caustic injury
First degree: mucosal erythema
Second degree: erythema with noncircumferential exudation
Third degree: circumferential exudation
Fourth degree: circumferential exudation with esophageal wall perforation
Normal flow volume loop
- Expiratory flow indicated by positive deflection
- Inspiratory flow indicated by negative defelction
Flow volume loop in bilateral vocal cord paralysis
- Normal expiratory limb
- limited inspiratory
Flow volume loop in fixed obstruction
- Decreased inspiratory and expiratory limbs
Factors associated with poor outcome with endoscopic repair of airway stenosis
- 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
At what pressure does capillary blood flow cease
20-40 mmHg
Ambulatory 24hr pH probe basics
- 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
CREST syndrome
- 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
Esophageal involvement with polymyositis and dermatomyositis
- Pharyngeal weakness with upper esophageal weakness
- May see dilated upper esophagus on esophagogram
Diffuse Esophageal Spasm
- See high pressure nonperistaltic contractions
- Esophogram: corkscrew esophagus
- Manometry: disorganized high pressure contractions
- Treatment; nitrates and calcium channel blockers
Killians triangle
- 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)
Killian Jameson dehiscense
Area of weakness between the oblique and transverse cricopharyngeus fibers
- Follows the course of the RLN
Laimer triangle
Area of weakness between the cricopharyngeus and the superior esophageal wall circular muscles
Traction and Pulsion diverticula
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)
Common symptoms of Zenker’s diverticulum
- Progressive dysphagia
- Regurgitation of food even hours after a meal
- Unprovoked aspiration
- Noisy deglutition
- Belching
- Halitosis
- Choking/coughing
- Globus
- Weight loss
- Recurrent respiratory infections
Treatment options for Zenker diverticulum
- Diet modification
- G tube
- Endoscopic diverticulotomy with cricopharyngeal myotomy
- Open cricopharyngeal myotomy
Number of lobes and lobules of each lung
Right lung: 3 lobes, 10 lobules
Left lung: 2 lobes, 9 lobules
How does vocal cord tissue content change with aging?
Increased collagen (type I and III fibers) and decreased elastin (vocal cords are stiffer affecting the mucosal wave)
