Upper Airways & Larynx

Question 1

What are the components of voice production? (3)

Answer 1

Source (pulmonary/infraglottic – diaphragm, intercostal musculature) Vibratory production (laryngeal – extrinsic and intrinsic muscles) Resonance (supraglottic and oral phase)

Question 2

True or False: Scoliosis and other msk issues can make a difference in voice production

Answer 2

True

Question 3

What is special about the cricoid cartilage?

Answer 3

It’s the only complete ring in your airway. Scar tissue or calcification developed at this level causes issues

Question 4

Which muscle is the only muscle that opens your vocal folds?

Answer 4

Posterior cricoarytenoid muscle

Question 5

What happens if you have one side of your vocal folds not moving? What about both sides?

Answer 5

One side not moving–you can still breathe but sound crappy. Both sides not moving–you can’t breathe

Question 6

True or False: Skull based lesions can cause difficulty swallowing

Answer 6

True. The innervation for vocal folds and swallowing is incredibly complicated and take a combination of signals from the cerebral cortex.

Question 7

If a patient presents with a hoarse voice, what cancers should you be concerned about?

Answer 7

Thyroid and lung because of the pathways of the recurrent laryngeal nerves

Question 8

What does the superior laryngeal nerve control?

Answer 8

Pitch changes in voice and sensation. So, for vital functions, the recurrent laryngeal nerve is more important (breathing and vocal production)

Question 9

Descent of the ____ leads to lower vocal pitch

Answer 9

Larynx. In children, their larynx is higher up which causes a higher pitched voice. As the larynx descends with age, their voices get lower in pitch (due to laxity of musculature, etc).

Question 10

What shapes the way that a voice sounds?

Answer 10

Supraglottic larynx, lips, teeth, tongue, palate, pharynx, nasal cavity, and sinuses

Question 11

True or False: Vocal tract length effects frequency of voice

Answer 11

True. Shorter tract = higher fundamental frequencies. Adult males have lower pitch (longer tract) than children and females.

Question 12

What is hoarseness?

Answer 12

Abnormal voice changes, breathy, raspy, strained, and weak

Question 13

What is dysphonia?

Answer 13

General alteration of voice quality, usually a laryngeal source

Question 14

What is dysarthria?

Answer 14

Defect in rhythm, enunciation, articulation of voice. This typically indicates a neurological or muscular problem

Question 15

What is stridor?

Answer 15

Large airway noise from obstruction

Question 16

What is stertor?

Answer 16

snoring sound from nose, nasopharynx, throat

Question 17

What does inspiratory stridor indicate?

Answer 17

Supraglottic or extrathoracic problem

Question 18

What does expiratory stridor indicate?

Answer 18

Tracheal or large bronchi intrathoracic problem

Question 19

What does biphasic stridor indicate?

Answer 19

Laryngeal or immediate subglottis problem

Examples: Stenosis of the cricoid cartilage

Posterior glottic scar band

Cancer holding vocal cords in place

Question 20

What are some causes of inspiratory stridor? (3)

Answer 20

1. In neonates, their epiglottis can be floppy and can fold over the airway during inspiration causing stridor. They will grow out of this. 2. Epiglottitis, from edema or infection 3. Epiglottic cancer

Question 21

What is the thumb sign?

Answer 21

With epiglottitis, there is a thumb sign which shows the epiglottis pinching off the airway.

Question 22

What is subglottic stenosis, what kind of physical exam finding will you get, and what kinds of things cause it?

Answer 22

Subglottic stenosis is stenosis of the cricoid cartilage. This can be caused by prolonged entubation and causes biphasic stridor. It can also be caused by autoimmune disorders or idiopathically.

This is a life-long problem. If you try to cut it, it just heals back. You can operate on patients every 6mo to a year.

Question 23

What is a posterior glottic scar band?

Answer 23

This scar band can form intubation. The vocal cords are stuck together at the back.

Question 24

What is croup?

Answer 24

Croup is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the wind pipe, which interferes with normal breathing and produces the classic symptoms of “barking” cough, stridor, and a hoarse voice. It causes subglottic inflammation and edema which leads to biphasic stridor.

This is more often seen in kids but can also be found in adults.

Question 25

What is the most common cause of acute voice hoarseness? how about for chronic?

Answer 25

Viral laryngitis (acute)

Laryngeal reflux (chronic)

This is typically self-limiting and has other viral symptoms too

Question 26

What can cause voice hoarseness?

Answer 26

• Viral laryngitis
• Reflux
• vocal abuse
• allergies
• chronic cough
• nodules
• polyps
• trauma
• age
• neurological disorders
• smoking
• malignancies
• other

Question 27

When should a patient with hoarseness see an otolaryngologist?

Answer 27

If the hoarseness lasts longer than 2-3 weeks.

If the hoarseness is associated with

• pain (ear pain radiation possible)
• coughing up blood
• difficulty swallowing
• a lump in the neck
• complete loss or severe change in voice lasting longer than a few days

Question 28

What’s going on here?

Answer 28

Vocal nodules

These are basically calluses that sit on the vocal folds. These are common and can happen with people who scream too often (think cheerleaders, loud families, etc). This are treated by changing the behavior that causes them. If you just take them off, they will be back with more of the same behavior.

*note, in the picture it’s not the big pink things… it’s the small pink things that are stuck right on the vocal folds.

Question 29

What’s going on here?

Answer 29

Vocal fold cysts.

You take it out and the patient needs to be quiet for a couple days for it to heal.

Question 30

What can be used to partially paralyze muscles?

Answer 30

Botox.

It can be injected through the neck into the vocal folds if the vocal folds bumping against each other are causing granulomas to form.

Question 31

What is this?

Answer 31

Reinke’s edema

This is caused by smoking.

These patients get have a proliferation of their lamina propria in their vocal cords. Treatment is to take out some of the fluid but not all of it as they need some to keep their vocal cords able to vibrate.

Question 32

What can cause vocal fold hemorrhage? What is the problem with vocal fold hemorrhage?

Answer 32

Can becaused by cough or strain.

If healed incorrectly and develops fibrous tissue instead of lamina propria, the hoarse voice lasts forever.

Question 33

What is presbyphonia and vocal fold bowing?

Answer 33

These are structural changes in the larynx and vocal cords that happen as you get older. Older people will develop weaker voices.

Question 34

What is a vocal complication of post-radiation therapy?

Answer 34

Radiation kills cells that divide rapidly which includes your mucosa and salivary glands. This will cause patients to have thick mucus in their upper airway which can make it difficult for the vocal folds to vibrate.

Question 35

What are the arytenoids? What can cause dislocation of an arytenoid?

Answer 35

The arytenoid cartilages are a pair of small three-sided pyramids which form part of the larynx, to which the vocal folds (vocal cords) are attached. These allow and aid in the vocal cords’ movement.

Traumatic intubation (from placing the endotracheal tube) can dislocate an arytenoid. This is often not noticed until weeks later and doesn’t move too well even if you pop it back in place.

Question 36

What can be done to help a one-sided paralyzed vocal fold?

Answer 36

One-sided paralyzed vocal folds can be partially corrected by a procedure that pushes the paralyzed fold more towards the center.