Laryngology laryngeal surgery

Question 1

What size ETT should be used during laryngeal

surgery?

Answer 1

The smallest ETT that will allow adequate ventilation and is

long enough to extend from the lips to the subglottis

Question 2

What are the four most common ventilation

techniques used during laryngeal surgery?

Answer 2

● Endotracheal intubation
● Jet ventilation
● Spontaneous breathing
● Apneic technique

Question 3

What are the three types of jet ventilation?

Answer 3

● Supraglottic
● Subglottic
● Transtracheal

Question 4

What is the most common major complication of

subglottic jet ventilation?

Answer 4

Air trapping leading to pneumothorax/pneumomediasti-

num

Question 5

What physical examination findings may be associated with difficult endotracheal intubation?

Answer 5

Long incisors, retrognathia, poor mandibular protrusion,
small interincisor distance, Mallampati grade 3 or 4, high
arched palate, short neck, thick neck, thyromental distance
less than three finger breaths, limited neck range of motion

Question 6

Describe the 4 modified Mallampati classes.

Answer 6

With the mouth fully open and the tongue protruded:
● Class 1: Tonsillar pillars, tonsils, and uvula visible
● Class 2: Uvula partially obscured by tongue base, upper
tonsils visible
● Class 3: Soft palate and base of uvula visible
● Class 4: Only hard palate visible

Question 7

What is the average duration of effect for deep true vocal-fold injection using the following materials: Gelfoam, bovine collagen, micronized Alloderm (Cymetra), fat, Teflon,calcium hydroxylapatite (Radiesse)?

Answer 7

● Gelfoam: 4 to 6 weeks
● Bovine collagen: 3 to 4 months
● Micronized Alloderm: 3 to 4 months
● Fat: Several years
● Teflon: Indefinite
● Calcium hydroxylapatite: 2 years, some longer

Question 8

The use of Teflon in true vocal-fold injection augmentation has been limited by what complication?

Answer 8

Teflon granuloma

Question 9

Patients with what finding on videostroboscopy
are less likely to benefit from true vocal-fold
injection augmentation?

Answer 9

Posterior glottic gap. Laryngeal framework surgery has a

higher chance of success.

Question 10

What test must be obtained before performing
true vocal-fold injection augmentation with bovine
collagen?

Answer 10

Allergy skin testing is required due to the risk of allergic

reaction to the material.

Question 11

What are the two different types of vocal fold injection augmentation?

Answer 11

● Superficial (intracordal)

● Deep injection augmentation

Question 12

What are the preferred needle-placement loca-
tions for deep true vocal-fold injection augmen-
tation?

Answer 12

The ideal location is at the intersection where a line drawn
laterally from the vocal process tip intersects the superior
arcuate line (transition from the superior surface of the
vocal fold to the ventricle). A second injection, if needed, is
often done along the superior arcuate line at the level of the
mid-membranous vocal fold.

Question 13

Define the superior arcuate line of the true vocal fold.

Answer 13

The superior arcuate line is the transition point from the

superior surface of the true vocal fold to the ventricle.

Question 14

What is the desired depth of injection for deep true vocal-fold injection augmentation?

Answer 14

3 to 5 mm into the thyroarytenoid muscle

Question 15

What are the three approaches used for trans-cervical true vocal fold injection augmentation?

Answer 15

● Thyrohyoid
● Cricothyroid
● Translaryngeal

Question 16

Define the desired effect on the true vocal folds in

each of the four types of thyroplasty.

Answer 16

● Type I: Medial displacement
● Type II: Lateral displacement
● Type III: Shortening/relaxing
● Type IV: Lengthening/tightening

Question 17

To avoid airway compromise after medialization
laryngoplasty, what should be true regarding the
contralateral true vocal fold?

Answer 17

It should be able to abduct completely during inspiration.

Question 18

What materials are commonly used for implantation in medialization laryngoplasty?

Answer 18

Silastic, hydroxyapatite, and Gore-Tex strips

Question 19

To avoid fracture of the thyroid cartilage after type I thyroplasty, what is the minimum width of
cartilage strut that must be left below the thyroplasty window?

Answer 19

3mm

Question 20

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

Answer 20

The inferior muscular tubercle of the thyroid cartilage must be completely exposed to define the plane of the inferior border of the thyroid cartilage, which parallels the long axis of the true vocal fold.

Question 21

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

Answer 21

The thyroid cartilage in men tends to have a more acute
anterior angle. The window is therefore placed more
posteriorly to avoid overmedialization of the anterior true
vocal fold.

Question 22

What are the indications for performing arytenoid

adduction in addition to type I thyroplasty?

Answer 22

Large posterior glottic gap or vocal-fold level mismatch

Question 23

What landmarks can be used to help identify the muscular process of the arytenoid during arytenoid adduction?

Answer 23

After a window has been created in the posterior thyroid
lamina and the pyriform sinus mucosa has been retracted,
the muscular process of the arytenoid must be identified.
This can be done by palpation, by following the fibers of the posterior cricoarytenoid muscle superiorly to their attachment to the muscular process, or by looking approximately 1 cm superior to the cricoarytenoid joint.

Question 24

During microflap excision of submucosal pathol-

ogy of the true vocal fold, where should the incision be located?

Answer 24

Directly over or just lateral to the pathology

Question 25

During microflap excision of submucosal pathology of the true vocal fold, what is the desired plane of elevation?

Answer 25

In the most superficial plane possible

Question 26

Describe the available techniques for laryngeal

reinnervation after injury to the RLN.

Answer 26

Primary RLN anastomosis, ansa cervicalis-to-RLN neuror-
rhaphy, ansa cervicalis-to-thyroarytenoid neuromuscular

pedicle, ansa cervicalis-to-thyroarytenoid neural implanta-
tion, hypoglossal nerve-to-RLN neurorrhaphy and cricothy-
roid muscle-nerve-muscle neurotization

Question 27

True or False: Laryngeal reinnervation procedures
restore normal movement of the true vocal fold in
unilateral true vocal-fold paralysis.

Answer 27

False. Laryngeal reinnervation procedures improve voice
and other symptoms of unilateral vocal-fold paralysis by
maintaining tone and bulk of the laryngeal adductor
muscles, not by restoring normal movement.

Question 28

What are the advantages of laryngeal reinnervation techniques relative to other procedures in the treatment of unilateral true vocal-fold paralysis?

Answer 28

● Avoiding thyroarytenoid muscle bulk loss
● Preservation of laryngeal anatomy to allow for additional
procedures if needed
● No alteration of vocal-fold vibratory potential
● The ability to perform the procedure under general
anesthesia

Question 29

What is the key principle in surgical repair of upper

airway stenosis?

Answer 29

Providing sufficient skeletal support

Question 30

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

Answer 30

● Laryngopharyngeal reflux
● Congestive heart failure
● Diabetes mellitus
● Stroke

Question 31

What are the indications for using an endolaryngeal stent in the repair of upper airway stenosis?

Answer 31

● Holding cartilage, bone grafts, or fragments in position
● Stabilizing epidermal grafts, separating denuded surfaces
● Maintaining a patent lumen when scar tissue is required

Question 32

What is the mechanism of action of mitomycin C?

Answer 32

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

Question 33

What is the preferred surgical technique for repair

of complete tracheal stenosis?

Answer 33

Resection and primary anastomosis

Question 34

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

Answer 34

50% (5–7 cm)

Question 35

What is the best surgical treatment for circumferential fibrous stenosis of the trachea with intact cartilage?

Answer 35

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