Larynx Flashcards
Larynx extends from ……to …..
Laryngeal cartilage are ……in number.
How many are paired, how many unpaired?
C3-C6
9
3paired, 3 unpaired .
3 paired: 3unpaired
1. Arytenoid. Thyroid
2. Corniculate. Cricoid
3. Cuneiform. Epiglottis
…….(3) made up on hyaline cartilage
Thyroid
Cricoid
Basal part of arytenoid cartilage
Difference between hyaline and elastic cartilage
Hyaline: ossify after 25 years
Elastic : do not ossify.
Only complete ring of cartilage around trachea
Largest laryngeal cartilages
Cricoid cartilage
Thyroid cartilage
Thyrohyoid pierced by ….&……
2 synovial joints of laryngeal cartilages
SL vessels & ILN
Cricoarytenoid
Cricothyroid joints
Narrowest part of larynx in adults
In children
Prelaryngeal LN called ….
- Rima glottidis
- Subglottic region
Delphic nodes
Pre epiglottic space is ….
Space of boyer
Larynx in infants is different. How?
- Larynx is higher-C2-C4 and anterior
- Funnel shaped
- Tongue is larger
- Trachea is shorter
- Laryngeal cartilage are soft
- Epiglottis is omega shaped
- Arytenoids larger
- Thyroid cartilage flat
- Submucosal tissues- loose.
Different muscles of larynx
Cartilage that doesn’t alter with age;
Vocal cords: stratified squamous
Mucosa: ciliated columnar.
Epiglottis
Only intrinsic muscle in external aspect of larynx
It is ……
Supplied by ….
Cricothyroid
Tensor muscle
ELN- br of SLN
Only abductor of vocal cords
Safety muscle of larynx
Posterior cricoarytenoid
Posterior cricoarytenoid
Whispering muscle is …..
It is a ……..(abductor/adductor)
All muscles of larynx are paired except…
Transverse arytenoids.
Adductor muscle
Transverse arytenoid.
Sensory and motor nerve supply of larynx
Sensory :
1. Supraglottis- internal br of SLN-ILN
2. Subglottis: RLN
3. Glottis: both ILN & RLN
Motor supply of larynx:
All muscles :RLN except:
cricothyroid (ext br of SLN)
Right and left RLN
Right: turn around subclavian a
Left: turn around arch of aorta.
Left longer than right; paralysis of left 4times more than right.
Galen anastomosis is …..
Which is the human communicating nerve?
Connection between RLN and internal branch of SLN.
Anastomosis between external branch of SLN and distal RLN
Both SLN and RLN are branches of ……
Indirect laryngoscopy is done using ……..
How is process done?
Vagus nerve
Laryngeal mirror
Mirror warmed before use by placing glass surface on a flame.
Direct laryngoscopy is done using …….
Position used is …..
Rigid laryngoscopy
Boyce position or barking dog position.
What is micro laryngoscopy?
Combination of laryngoscopy and operating microscopy started by Kleinasser.
Blind areas that can’t be visualized on indirect laryngoscopy are : (5)
- Laryngeal surface of epiglottis/ infrahyoid epiglottis
- Ventricle of larynx
- Subglottis
- Anterior commissure
- Apex of pyriform fossa
Left is longer than right coz of ……
U/L RLN (abductor paralysis) sms.
Persistence of 6th arch artery- as ductus arteriosus which later fibrosis as ligamnetum arteriosum.
Affected cord lie close to midline- slight hoarseness of voice which improves over days.
Left RLN palsy caused by …(4)
Rx:
- Pancoast Tumor of lung
- Mitral stenosis
- Aneurysm of arch of aorta
- Apical TB
No Rx required.
What is ortner’s syndrome?
What happens in B/L RLN abductor paralysis? Rx
Paralysis of left RLN in cases of cardiomegaly.
Vocal cords come to the midline.
Normally we breathe with VC open and speak with VC closed.
So, in b/L abductor paralysis, speech is ok, but can’t breathe.
Rx: immediate tracheostomy —>6mo later:—-> type 2 thyroplasty.
What happens in B/L adductor paralysis ? Rx.
Both VC are in open / cadaveric position.
Sms: breathe is ok,but can’t speak,
Aspiration also.
Rx: wait for 6 months —> type 1 thyroplasty.
What is Bovine cough?
Cow-like cough- normal loss of explosive phase of normal coughing —> upon failure of cords to close the glottis.
Mc cause of vocal cord paralysis is….
Properties of cricothyroid. (2)
Iatrogenic (surgical )
- Adductor
- Tensor property
Cricothyroid is the main tensor, which gives quality of voice.
Branches of SLN
SLN: external br: cricothyroid
internal br: sensory supply - supraglottis
If SLN is damaged. Features (2)
- Poor quality of voice - main tensor of VC
- Aspiration- loss of sensory supply to supraglottis.
Thyroplasty types:
Type1: Medialization of Vc
Type 2: Lateralization of VC
Type 3: shortening of VC- lower pitch
Type 4: lengthening of VC- increase pitch
Gentle abduction of VC seen in ……
Full abduction of VC seen in ….
Quiet respiration, paralysis of adductors
Deep inspiration
Position of Vc in strong whisper
Types of Thyroplasty is introduced by …..
Paramedian position
Isshiki
Mc congenital abnormality of larynx is …..
In laryngomalacia, extensive flaccidity is in …..
Laryngomalacia
Supraglottic larynx
Stridor of laryngomalacia is ….
Rx.
- Since birth
- Increased crying - crying sounds normal
- Decreased stridor in prone position
- Inspiratory stridor
Rx: conservative , reassurance.
Conservative Rx for laryngomalacia is seen in ……(4)
- Laryngomalacia
- U/L vocal cord palsy
- CSF rhinorrhea
- Traumatic perforation of ear drum.
Direct laryngoscopy shows laryngomalacia is ……shaped
Tracheomalacia associated with …..
…..cough seen
Omega
TEF
Barking cough
What is laryngocele?
Affects …..professions
Dilatation of laryngeal saccule- arise from raised transglottic air pressure.
- Trumpet blowers
Glass blowers
Weight lifters
External laryngocele herniates through …..
What is Bryce’s sign?
Thyrohyoid membrane
Gurgling sound produced on pressing external laryngocele
Dx of laryngocele? Rx
Xray neck with valsalva
Rx: surgery
Mc cause of vocal nodules is …
2nd mc cause is ….
Always ……
Junction of …….
Vocal abuse
GERD
B/L
Jn of anterior 1/3 & posterior 2/3
Chief complaint of vocal nodules
Rx. (3)
Hoarseness of voice
Rx: voice rest + speech rx + PPI
What is keratosis larynx?
Rx. (3)
Seen in smokers
Vocal cord epithelium starts shedding faster —> keratinous debris on vocal cords
Surgery-
1. stripping vocal cord mucosa/decortication
2. Quit smoking
3. CO2 laser cordectomy.
Define Reinke’s space
What is Reinke’s edema?
Rx.
Vocal cord lined by stratified squamous epithelium. Below stratified squamous epithelium, there is submucosal connective tissue- Reinke’s space.
B/L diffuse swelling of VC- seen in smokers
Rx: surgery- decortication
Tb larynx is most commonly in …..
Mc affected part is …
Posterior VC than anterior
Inter arytenoid fold
Earliest symptom of tb vocal cord
First sign is …
Weakness of voice
Impaired adduction
Laryngoscopy finding of TB larynx (3)
- Mamillated appearance- swelling in inter arytenoid region
- Mouse nibbled appearance -ulceration of VC
- Turban epiglottis: pseudoedema of epiglottis
Acute laryngotracheobronchitis seen in ….
Cause is …
Age:
X-ray of acute laryngotracheobronchitis
Rx.
Croup
Viral parainfluenza
Age: 3 months to 3 years
Steeple sign- narrowing of subglottic area
Rx :
Humidifier O2+ bronchodilator + steroid + antibiotic — prevent secondary bacterial infection.
When false VC take over the function of true VC; it’s called?
Voice is ….
Dysphonia plica ventricularis
Rough, low pitched,unpleasant
Supraglottic larynx includes ….(5)
Epiglottis
False vocal cords
Ventricles
Aryepiglottic folds
Arytenoids
The glottis includes ….(2)
The subglottic region is ….
True VC
Anterior and posterior commissure
1cm below true vocal cords
Extends to cricoid cartilage or first tracheal ring.
Juvenile papilloma of larynx is ….
Seen in …… cause….
Sms.
Premalignant disease
Children
HPV 6,11.
Sms: warts on vocal fold —>trachea and bronchi—>chronic hoarseness +_ respiratory difficulty.
Rx for juvenile papilloma of larynx
Prognosis
CO2 laser surgery
Recurrence. Patient has multiple surgeries.
How to decrease recurrence rate of juvenile papilloma of larynx? (3)
- Intralesional Cidofovir
- IFN-gamma
- Bevacizumab
Mc site of juvenile papilloma of larynx
Risk factors for ca larynx (7)
Vocal folds
- Smoking
- Alcohol
- GERD
- Asbestos
- Wood dust
- Nitrogen mustard
- Ionizing radiation .
Age group of carcinoma larynx
Mc in ….
Mc type of ca larynx
40-70 yrs
Males
Squamous cell cancer
Mc type of cancer of larynx is …..next is ….
Least is …..
Glottic cancer
Supraglottic
Subglottic
Early presentation of glottic cancer is ….
Prognosis
Hoarseness
Best prognosis as LN involvement is late
Mc site for Supraglottic cancer is ….
Sms…
Sign…
Prognosis
Epiglottis
Pain on swallowing
Mass on neck
Poor-patient reports late and LN involvement occurs early.
Worst prognosis of ca larynx is ….
Presents with ….
Verrucous cancer caused by ….
Subglottis
Stridor
HPV 16,18
Highest incidence of distant mets with ca larynx is with …
Laryngofissure means….
Lungs
Opening of larynx/ thyroid cartilage in midline.
Stages of ca larynx
Type 1: only 1 named structure.
1 VC: T1A, 2 Vc= T1B
Rx: CO2 laser Rx > radiotherapy
Type 2: >1 named structure
Rx: radiotherapy
2nd option: if lung fn normal:
Partial laryngotomy
Type 3: VC is immobile and fixed.
Invasion of preglottic and paraglottic space
Rx: total laryngectomy +_ radical neck dissection—> radiotherapy
2nd option: concurrent chemoradio
Type 4: invasion of thyroid /extralaryngeal neck structures
Rx: total latyngectony +_radical neck dissection —>radiotherapy
2nd: concurrent chemoradiotherapy.
Best option for T3,T4:
Tracheoesophageo puncture device
Rehab for speech in ca larynx
…….helps restoration of olfactory sensation after larynectomy
Asai laryngoplasty technique
Best now : TEF speech
Polite yawning -yawning with mouth closed
Level or site of tracheostomy
High level: at first tracheal ring
Mid level:
at 2&3 tracheal rings -preferred method
Low level: at 4&5 tracheal rings
Structures seen while bronchoscopy: (6)
- Uvula
- Epiglottis
- Vocal cords
- Larynx
- Trachea , carina
- Segmental/ subsegmental bronchi
Intubation in child is done with …..
Straight blade and cuff tube- to decrease aspiration.
Complications of tracheostomy (3)
- Hemorrhage
- Surgical emphysema-
collection of air beneath skin
Coz of tight skin suture - Immediate complication
Apnea—>CO2 washout —> drive for respiratory centre gone.
………is associated with pan masala/ supari
2. Mc type of oral cancer
3. Mc site of oral cancer
Oral submucosal fibrosis of larynx
- Squamous cell ca
- Tongue
Mc site of oral cancer in india
Mc site of tongue cancer
Buccal mucosa
Lateral border
Mc site of lip cancer
……is investigation of choice for ca oral cavity
Vermilion of lower lip
MRI
Pathology of Ludwig’s angina
Molar/premolar caries —> infection to chin( cellulitis of submandibular space)
This causes glottic edema and painful airway compromise
Rx for Ludwig’s angina
Immediate antibiotic : cefuroxime+ metrogyl
If no response-drain submandibular triangles under local anesthesia
Infection from molar /premolar affecting angle of mouth, but no chin swelling. D/o
Egg shell crackling seen with ….
Cyst in mandibular are is ….
Parapharyngeal abscess
Dental cysts-at maxilla
Follicular cyst-dentigerous cyst
Xray s/o soap bubble /honeycomb appearance is ……
What is intubation granuloma?
Rx:
Adamanitoma
Results from traumatic endotracheal intubation-large granuloma arising from arytenoid
Prolonged intubation in ICU patients.
B/L disease
Surgery: microlaryngeal surgery
Cotton Meyer staging done for …..
What are the stages ?
Subglottic stenosis
Type1: 0-50% conservative
Type 2: 51-70% obst- laser /dilatation
Type 3: 71-90% obst-
Type 4: no lumen detected .
Type 3&4- rx : laryngotracheal reconstruction—> Montgomery’s silicon tracheal T tube.
Uses of mitomycin C (3)
- Laryngotracheal stenosis
- Prevent formation of synechiae in nose after surgery
- Surgery: choanal atresia mgt
- Site of vocal cord nodule:
- Site of intubation granuloma
- Ant 1/3, post 2/3
- Ant 2/3, post 1/3
