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MD3001 > Week 7 > Flashcards

Week 7 Flashcards

1
Q

Understand the role of a medical history in making a clinical diagnosis

A

-Form a differential diagnosis and put health in
context
-Identify risk factors for conditions
- Red flags
-Direct further clinical examination
-Direct investigation and management
-Develop a rapport between patient and health care worker

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2
Q

To understand how different body systems inter-relate

A

Couple of questions to each remaining system as a quick screening tool

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3
Q

Causes of non-central chest pain?

A

Pleural:

  • Pneumonia/bronchiectasis/TB
  • Lung tumours/metastases/mesothelioma
  • PE
  • Pneumothorax

Chest wall

  • Muscular / rib injury
  • Costochondritis
  • Lung tumour / bony metastases/ mesothelioma
  • Shingles (herpes zoster)
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4
Q

Respiratory causes of dyspnoea?

A

– Airways e.g. asthma, COPD, bronchiectasis, cystic fibrosis, laryngeal tumour, foreign body, lung tumour
– Parenchyma e.g. pneumonia, pulmonary fibrosis, sarcoidosis, TB
– Pulmonary circulation e.g. PE
– Pleural e.g. neumothorax , pleural effusion
– Chest wall e.g. kyphoscoliosis, ankylosing spondylitis
– Neuromuscular e.g. myasthenia gravis, Guillain-Barre syndrome

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5
Q

Respiratory causes of dyspnoea?

A

– Airways e.g. asthma, COPD, bronchiectasis, cystic fibrosis, laryngeal tumour, foreign body, lung tumour
– Parenchyma e.g. pneumonia, pulmonary fibrosis, sarcoidosis, TB
– Pulmonary circulation e.g. PE
– Pleural e.g. neumothorax , pleural effusion
– Chest wall e.g. kyphoscoliosis, ankylosing spondylitis
– Neuromuscular e.g. myasthenia gravis, Guillain-Barre syndrome

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6
Q

Cardiovascular causes for dyspnea?

A

Cardiac failure, associated with angina/MI

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7
Q

Non cardio-respiratory causes f dyspnea?

A

Anaemia, obesity, hyperventilation, anxiety, metabolic acidosis

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8
Q

Non cardio-respiratory causes f dyspnea?

A

Anaemia, obesity, hyperventilation, anxiety, metabolic acidosis

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9
Q

Different types of cough?

A

Acute and chronic
Acute:
– Viral or bacterial infection / pneumonia / inhalation of foreign
body/ irritants

Chronic cough
– Common - gastro-oesophageal reflux / asthma/ COPD / smoking / post-nasal drip / occupational or other irritants /medication (ACEI)
– Less common – lung tumour / bronchiectasis / interstitial lung disease

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10
Q

Red flags for cough?

A

– Haemoptysis, breathlessness, weight loss, chest pain, smoker

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11
Q

Red flags for cough?

A

– Haemoptysis, breathlessness, weight loss, chest pain, smoker

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12
Q

Identify the common causes for the following characteristics of cough:

  • Productive
  • Persistent ‘moist’ cough worst in morning
  • Associated with wheeze
  • Pain
  • Harsh/barking
  • Chronic, dry cough
  • Persistent with haemoptysis
  • ‘Bovine’ cough (non-explosive cough)
A

Productive - Infection, Bronchiectasis
Persistent ‘moist’ cough worst in morning-COPD
Associated with wheeze-Asthma / COPD,
Painful-Tracheitis
Harsh/ barking-Laryngitis/ laryngeal tumour
Chronic, dry cough-Interstitial lung disease
Persistent with haemoptysis-Bronchial carcinoma
‘Bovine’ cough (non-explosive cough)-Left recurrent laryngeal nerve invasion, (secondary to malignancy), Neuromuscular disorders

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13
Q

Name the appearance and cause for the following types of sputum:

  1. Serous
  2. Mucoid
  3. Purulent
  4. Rusty
A
  1. Serous. Clear, watery, frothy, pink. Cause = Acute pulmonary oedema
  2. Mucoid. Clear, grey, white, viscid. Cause = COPD/asthma
  3. Purulent. Yellow, green, brown/ Cause= Infection
  4. Rusty. Rusty red. Cause= Pneumococcal pneumonia
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14
Q

6 cause of haemoptysis

A

Malignant, infective, vascular, cardiac, vasculitis

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15
Q

Why ensure accurate mediation history? 6

A
  • Improves patient safety
  • Reduces medication errors / near misses
  • Reduces missed doses in hospital
  • Reduces delays to treatment
  • Savings to NHS from prevented errors
  • Improves therapeutic outcomes
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16
Q

What are the issues with concordance?

A

Intentional non-concordance: Definite decision to not take medicines
Unintentional non-concordance. For example due to:
1. Physical dexterity
2. Reduced vision
3. Cognitive impairment
4. Poor understand

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17
Q

6 different types/forms of inhaler

A 
Mdi= Metered dose inhaler
Accuhaler
Autohaler
Easibreathe
Handihaler
Via spacer/aerochamber
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18
Q

What are the blue and brown inhaler?

A 
Blue= "reliever" e.g. salbutamol (beta-agonist)
Brown = "preventer" e.g. Beclomethasone (steroid)
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19
Q

Define Palliative Care

A

An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness
Through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems (physical, psychosocial and spiritual)

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20
Q

Discuss the principles of delivering good end of life care

A
  1. Open lines of communication
  2. Anticipating care needs and encouraging discussion
  3. Effective multidisciplinary team input
  4. Symptom control - physical and psycho-spiritual (=exacerbates physical symptoms)
  5. Preparing for death- patient and family
  6. Providing support for relatives both before and after death
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21
Q

What is advance and anticipatory planning?

Identify areas for discussion during advance and
anticipatory care planning

A

An ongoing process of discussion between the patient, those close to them and their care providers focusing on their wishes and preferences for their future

Discussion areas:

  1. Wises/preferences/fears about care
  2. Emergency preferences (DNR?)
  3. Preferred place of care
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22
Q

How are the wishes of a patient in advance care decisions formalized?

A

Formalising wishes:

  1. Advance statement:
  2. Advance decision
  3. Power of attorney
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23
Q

5 priorities of care for dying person

A
  1. The possibility that a person may die within the next few days/hours is recognized and communicated clearly
  2. Sensitive communication takes place between staff and patient/family
  3. Involvement of patient/family when making decisions about treatment/care
  4. The needs of families are actively explored, respected and met (if possible)
  5. Individual plan of care is agreed, co-ordinated and delivered with compassion
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24
Q

Aims of palliative care

A
  1. Whole person approach
  2. Focus on quality of life, including good symptom control
  3. Care encompassing the person with the life-threatening illness and those that matter to them
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25
Q

In formalizing the patients wishes, what are the features of an advance statement?

A
  • A statement that sets down your preferences, wishes, beliefs and values regarding your future care.
  • Will provide guidance if patient were to lose capacity
  • Although decisions not bound by statement.
  • Treatment must overall benefit to the patient
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26
Q

In formalizing the patients wishes, what are the features of an advance decision?

A

A decision you can make now to refuse specific treatments in the future
Used in the case that the patient is unable to express/communicate their decision
May be issues around life sustaining treatment (e.g. DNACPR)
Validity and applicability need to be considered.

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27
Q

How is the validity of the advance care plans assessed?

A 
Applicability?
Timing?
Capacity of patient at time of planning?
Informed decision?
Undue influences when plan made?
Withdrawn decision
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28
Q

4 pro’s and con’s for advance care plans?

A

PROS

  1. Enhances autonomy
  2. May encourage/improve discussions on end-of-life decisions
  3. Avoid breaching patient’s personal/religious beliefs
  4. Death with dignity

CONS

  1. May not be valid
  2. May not be applicable
  3. Attitudes may change with onset of serious illness
  4. May have been advances in medicine since being made
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29
Q

What is the Gold Standard Framework?

A

Systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by
generalist frontline care providers

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30
Q

4 principles of care for people in the last days and hours of life

A

Principle 1: Informative, timely and sensitive communication
Principle 2: Significant decisions about a person’s care are made on the basis of multidisciplinary
discussion
Principle 3: Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed
Principle 4: Consideration is given to the wellbeing of relatives or carers attending the person

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31
Q

What is the basic structure of a respiratory examination?

IIPPAC

A 
Introduction and explanation
Inspection: General and Close (hands, face, chest/neck)
Palpation
Percussion
Auscultation
Conclusion
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32
Q

What pathological signs should you look out for when performing the general and close inspection in a respiratory examination?

A

General:

  • Nebuliser/inhaler
  • Erythema nodosum

Close:
Hands- Flapping tremor, fine termor, tar staining, nail clubbing
Face- Central cyanosis, ruddy complexion due to polycythmaeia, Horner’s syndrome
Neck/chest- Scarring, kyphoscoliosis, SVC obstruction, JVP raised

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33
Q

What are the respiratory causes of clubbing?

A 
Bronchial carcinoma
Mesothelioma
Chronic suppurative lung disease
Pulmonary fibrosis
Cystic fibrosis
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34
Q

Horners syndrome:
Caused by?
Clinical features?

A

Caused by damage to cervical sympathetic nerves
Clinical features:
-Unilateral miosis
-Partial ptosis
-Loss of sweating on same side (ie facial anhidrosis)

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35
Q

What is the cause of fine tremor?

A

Excessive use of B-agonists

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36
Q

What is the cause of flapping tremor? Name 4 features

A

Due to severe ventilator failure with CO2 retention

Features:

  1. Hold hands outstretched
  2. Wrists cocked-back
  3. Jerky, flapping tremor
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37
Q

What are the areas inspected on the close inspection of the neck/chest in a respiratory exam?

A
  1. Scars – cardiac surgery, thoracotomy, chest drain scars
  2. Pattern of breathing
  3. Shape of chest
    – Symmetry
    – Deformity (kyphoscoliosis / pectus excavatum)
    – Increase in A-P diameter (‘barrel shaped’)
  4. Prominent veins on chest wall
    – SVC obstruction
  5. JVP
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38
Q

What are the different stages of palpation of the neck and chest?

A
  1. Lymph nodes: Patient sat forwards
  2. Subcutaneious emphysema: Crackling sensation, air in subcutaneous tissues
  3. Consider trauma/ underlying pneumothorax
  4. Mediastinal position: Check tracheal position and cardiac apex
  5. Chest expansion: Anterior/posterior, patient to breeze deeply, thumbs should move apart equally
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39
Q

How do you carry out the percussion section of the respiratory exam?

A
  • Anterior/posterior chest
  • Use middle finger/left hand
  • Apply firmly to patient’s chest
  • Strike it’s middle phalanx with the middle finger of righ hand
  • Percuss over intercostal spaces
  • Compare left and right
  • Listen to note produced
  • 7 on back, 6 on front
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40
Q

Name possible causes for the following percussion notes:

  1. Resonant
  2. Hyper resonant
  3. Dull
  4. Stony/ Very dull
A
  1. Resonant: Normal lung
  2. Hyper resonant: Emphysema/ pneumothorax
  3. Dull: Collapse/ consolidation/ fibrosis
  4. Stony/ Very dull: Pleural effusion
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41
Q

What is involved in the auscultation stage of the respiratory exam?

A
  • Use bell or diaphragm of stethoscope
  • Ask patient to breathe deeply through mouth
  • Listen through full inspiration and full expiration
  • Listen for breath sounds and added sounds
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42
Q

What are the breath sounds heard on auscultation?

A

Normal (vesicular)

  • Intensity of sounds relates to airflow
  • Diminished vesicular breath sounds (e.g. obesity, pleural effusion, pneumothorax, collapse, hyperinflation in COPD)

Bronchial (high pitched)
-Consolidation with patient bronchial system (e.g. pneumonia, top of pleural effusion, pulmonary fibrosis)

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43
Q

What are the added sounds heard on auscultation?

A

Crackles (crepitations)
-Caused by e.g. pulmonary oedema, pulmonary fibrosis, bronchial secretions, COPD, pneumonia, lung abcess, TB, bronchiolitis, bronchiectasis

Pleural rub

  • Usually associated with pleuritic pain
  • Caused by PE, pneumonia, vasculitis

Wheeze

  • Continuous oscillation of opposing airway walls
  • Musical quality
  • Implies airway narrowing
  • Louder in expiration
  • Caused by Asthma/COPD (if generalized) and lung tumour (if localized)

Silent check in severe airways obstruction

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44
Q

What is fremitus?

A

Fremitus refers to vibratory tremors that can be felt through the chest by palpation

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45
Q

How are the followed assessed:

  • Vocal fremitus?
  • Vocal resonance?
  • Increased resonance?
  • Decreased resonance?
A

Vocal fremitus: Use palm / ulnar border of hand

Vocal resonance :Use stethoscope

Increased resonance: Consolidation / fibrosis

Decreased resonance: Pleural effusion / collapse

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46
Q

What are the other areas to assess in a respiratory examination?

A

Ankle oedema

Sputum pot

Obs chart

Peak flow

Spirometry

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47
Q

Outline the key arguments often cited for/against the use of animals in research

A

Aspects to consider:

  • Benefits
  • Model
  • Sentience
  • Value
  • Moral agency
  • Spiritual/religious potential
  • Human achievement
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48
Q

Explain the three principles governing the use of animals in research (from the Home Office policy)

(3 R’s)

A

Replacement: e.g. alternative technologies
Reduction: e.g. better study design to allow use for fewer animals, better storage of data
Refinement: e.g. improve housing, minimize pain, improve welfare

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49
Q

Outline the regulatory role of the Home Office in animal research

A

Home Office: “Secretary of Sate weight the likely adverse effects on animals concerned against the benefit likely to accrue as a result of the programme”

Each local arena, animal ethics committee (reviews and monitors all eligible research, using ASPA and Home Office guidelines)
Licenses are granted: Site license, personal license, project license

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50
Q

Informed consent:
What is it?
Four criteria for valid consent?

4 difficulties that can arise in acquiring informed consent

A

Informed consent = First principle of Nuremberg Code

4 criteria for valid consent:

  1. Patient must have capacity
  2. Patient must give consent voluntarily
  3. Patient must be informed
  4. Consent must be continuing

Difficulties:

  • Participant feeling pressure into agreeing
  • The problem of incentives
  • Sufficient information
  • Vulnerable patients
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51
Q

Identify the different ethical issues raised by the:

  • Tuskegee Syphilis trial
  • The Guatemalan STD trial
  • The case of Henrietta Lacks
A

Tuskegee Syphilis trial

  • “a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks..”
  • No informed consent
  • Time span extended x80
  • Participants given incentives
  • No treatment given to treat syphilis or was allowed to be given

The Guatemalan STD trial

  • No consent was sought
  • Experiments on 5000+ soldiers, prisoners, psychiatric patients, orphans and prostitutes
  • Exposed participants to gonorrhea, syphilis or chancroid

The case of Henrietta Lacks

  • First immortal human cell line HeLa
  • After death her cells were used for research worldwide
  • No consent sought
  • Profit made from cells hasn’t gone to family
  • Justification: Material no longer “hers”, material would have been thrown away, for the common good
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52
Q

Name 3 types of transmission based precautions

A

Airborne, droplet, contact

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53
Q

Two strategies to measure quality of care?

A
  1. The Francis Report is leading to a paradigm shift in clinical care
  2. Health Improvement Scotland (HIS)
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54
Q

Two strategies to measure quality of care?

A
  1. The Francis Report is leading to a paradigm shift in clinical care
  2. Health Improvement Scotland (HIS)

Hospital acquired infections are one indicator of performance

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55
Q

Two strategies to measure quality of care?

A
  1. The Francis Report is leading to a paradigm shift in clinical care
  2. Health Improvement Scotland (HIS)

Hospital acquired infections are one indicator of performance

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56
Q

How can doctors taken measures to prevent HCAI?

A
  • Recognition of risk factors in patients
  • Behaviour and practice
  • Hand hygiene
  • Dress
  • PPE
  • Use isolation facilities correctly
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57
Q

How can doctors taken measures to prevent HCAI?

A
  • Recognition of risk factors in patients
  • Behaviour and practice
  • Hand hygiene
  • Dress
  • PPE
  • Use isolation facilities correctly
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58
Q

What is the chain of infection?

A
  1. Infectious agent
  2. Reservoir
  3. Portal of Exit
  4. Mode of transmission
  5. Portal of entry
  6. Susceptible host
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59
Q

3 different forms of mode of transmission?

A
  1. Direct/Indirect contact via fomites or ingestion e.g. Blood born viruses, diarrhea
  2. Droplet transmission e.g. N. meningitis, norovirus
  3. Aerosol (Airborne) transmission e.g. TB, chicken pox, influenza
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60
Q

For which patients should contact precautions be applied?

Name 4 contact precautions in HCAIs

A

For patients infected/colonized with organisms transmitted by direct or indirect contact e.g. C. difficile, MRSA

Precautions:

  • Single room if possible
  • Gloves
  • Aprons
  • Disposable masks/eye protection if at risk of splashes
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61
Q

For which patients should droplet precautions be applied?

Name 2 droplet precautions in HCAIs

A

For organisms transmitted in droplets (>0.5 microns). These travel only short distances e.g. N. meningitis, mumps, rubella

Precautions:

  • Single room if possible
  • Wear surgical mark when within touching distance (1 metre) of patient or cough inducing procedure
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62
Q

For which patients should airborne precautions be applied?

Name 5 airborne precautions in HCAIs

A

Particles <5microns. Can be widely dispersed e.g. TB, chickenpox, measles, FLU

Precautions:

  • Wear FFP3 masks for all aerosol generating procedure
  • Single room
  • Apron
  • Gloves
  • High efficiency filter mask
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63
Q

In hand decontamination, what are the 2 before and 3 after

A

Before:

  1. Touching patien
  2. Clean/aseptic procedure

After:

  1. Touching patient
  2. Touching patient surroundings
  3. Body fluid exposure risk
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64
Q

Patients with rash and photophobia….

A

Think measles

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65
Q

After examination of which patients should you use soap and water?

A

Patient with diarrhea and after removing gloves

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66
Q

What are the two main types of medical devices that could present risk of HCAI?

A

Invasive medical devices: Maybe long term and short term. All break the skin or mucous membrane barrier
e.g. Central venous catheters (CVC), PVC, urinary catheters

Indwelling prosthetic devices: Usually long term devices which are buried into tissue under the skin e.g. Heart valves, joints, pacing units etc

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67
Q

Two groups of antibiotic resistant organisms?

A

Gram positive organisms

  • MRSA
  • VRE (Vancomycin Resistant Enterococcus)

Gram negative enterobacteriaceae

  • ESBL producer
  • CRE (Carbapenem Resistant Enterobacteriaceae
  • Carbapenamase Producing pseudomonas
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68
Q

Explain why evidence based medicine is an important part of modern medicine

A

As it is the key to clinical effectiveness and decision making. Such as in the…
• Production of evidence through scientific research and review
• Production and dissemination of evidence
based clinical guidelines
• Implementation of evidence based, cost
effective practice through education and change management
• Evaluation of compliance with practice guidance through clinical audit

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69
Q

Define EBM

A

The conscientious, explicit and judicious use of current best evidence in marking nursing decisions about the care of individual patients

also

The systemic search for, and appraisal of, best evidence in order to make clinical decisions that might require changes in current practice, while taking into account the individual needs of the patient

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70
Q

List the key steps in the process of applying EBM

A

Use the best evidence in the scientific literature to provide the best care for an individual patient

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71
Q

Summarise the pros and cons of the EBM approach

A

Cons

  1. EBM is ‘old hat’
  2. EBM identifies statistically significant benefits which may be marginal in clinical practice
  3. EBM has generated a massive, unmanageable volume of evidence and guidelines
  4. EBM is the mindless application of population studies to the treatment of the individual
  5. Often no RTC or “gold standard” in the literature to address the clinical question

Pros

  1. Filters literature so that decisions are made based on “strong evidence”
  2. EBM should be one part of the process
  3. Produces expert judgement in a format that clinicians can understand
  4. Is the info applicable to specific patient
  5. Clinicians need to understand that there may be no good evidence to support clinical judgement
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72
Q

3 Principles of EBM

A
  1. High quality health care rests on objective and clinically relevant information
  2. There is a hierarchy of evidence where some types are stronger than others
  3. Scientific data alone is not a sufficient basis for making clinical decisions about individual patients
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73
Q

What questions are answered about drugs by EBM?

A

The effects of therapy
The utility of diagnostic tests
The prognosis of diseases
The etiology of disorders

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74
Q

How to practice EBM?

A
  1. Craft a clinical question (PICO)
  2. Search the medical literature (medical informatics)
  3. Find the study that will best answer the question
  4. Perform a critical appraisal (check for validity and bias)
  5. Determine how the results will help you care for your patient
  6. Evaluate the results in your patient or population
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75
Q

What is the pathway involved in air conditioning? What is it’s function?

A

Function: Moistens, warms, cleans/filters

  1. Nasal cavity
  2. Napsopharynx
  3. Oropharynx
  4. Larynx
  5. Trachea
  6. Main bronchi
  7. Lobar bronchi
  8. Segmental bronchi
  9. Terminal bronchioles
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76
Q 
Trachea:
Length/width?
Structure?
Start/end?
Muscle present?
Difference between RMB/LMB?
A

Length/width: 10-11cm long, 12mm wide internally
Structure: C-shaped rings of hyaline cartilage supporting a fibro-elastic and muscle air transport tube
Start: C6
End: T4/5 at carina
Muscle present: Trachealis alters tracheal diameter
Difference between RMB/LMB: RMB shorter, wider, more vertical

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77
Q

Major relations to trachea

A

On RHS: BCT, SVC, right vagus, azygos vein, right brachiocephalic vein, right upper lung lobe
On LHS: LCCA, Descending aorta, left upper lung lobe
Anterior: Thyroid gland, arch of aorta

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78
Q

What structures lies in the groove between the trachea and the oesophagus?

A

The left recurrent laryngeal nerve

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79
Q 
Trachea neurovascular supply:
Arteries?
Veins?
Lymph?
Nerves?
A

Arteries: Inferior thyroid and bronchial
Vein: Inferior thyroid
Lymph: Pre and para tracheal
Nerves: Vagi, recurrent laryngeal, sympathetic trunks

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80
Q

Each segmental bronchus passes to a…….

A

broncho-pulmonary segment

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81
Q

Each lobar bronchi supplies _ lung lobe

A

1

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82
Q

What are the names of the bronchopulmonary segments of the right lung? (10)

A

Upper lobe: Apical, anterior, posterior
Middle lobe: Medial, lateral
Lower lobe: Apical, anterior, lateral, posterior, medial

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83
Q

What are the names of the bronchopulmonary segments of the left lung? (10)

A

Upper lobe: Apical, anterior, posterior
Middle lobe: Superior, inferior
Lower lobe: Apical, anterior, lateral, posterior, medial

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84
Q

Bronchopulmonary segment:
Orientation on segments?
Separated by?

A

Orientation: Pyramid with its base on the surface of the lung, apex pointing to the hilum
Separated from each other by connective tissue

85
Q

Each respiratory bronchioles –> _____ alveolar ducts —> ____ alveoli

A

Each respiratory bronchioles –> 2-11 alveolar ducts —> 5-6 alveoli

86
Q

________ _______ are the smallest part of the purely conducting part of the tree. Beyond the terminal bronchioles the passages become increasingly involved in _______ exchange.
So Respiratory bronchioles will have a few ____ coming off their walls and there are no _____ _____ and the epithelium becomes _____. The respiratory bronchioles give rise to several alveolar ____ which branch into _____ sacs and finally alveoli

A

TERMINAL BRONCHIOLES are the smallest part of the purely conducting part of the tree. Beyond the terminal bronchioles the passages become increasingly involved in GASEOUS exchange.
So Respiratory bronchioles will have a few ALVEOLI coming off their walls and there are no GOBLET CELLS and the epithelium becomes CUBOIDAL. The respiratory bronchioles give rise to several alveolar DUCTS which branch into ALVEOLAR sacs and finally alveoli

87
Q

The first segmental bronchus to arise posteriorly passes to?

A

To the apical segments on the lower lobe. Leads to possible complication of pneumonia

88
Q

Lungs:
3 Borders?
3 Surfaces?
Fissures?

A

Borders: Anterior, posterior, inferior
Surfaces: Costal, diaphragmatic, mediastinal
Fissures: Oblique (spine of T4 to 6th rib), horizontal (rib 4 or 5)

89
Q

Phrenic Nerves pass _____ to the lung roots

Vagus nerves posterior

A

Phrenic Nerves pass anterior to the lung roots

Vagus nerves posterior

90
Q

Relations of lungs:
Mediastinum from right?
Mediastinum from left?

A

Mediastinum from right:

  • Phrenic nerve
  • Heart in pericardium
  • Azygos vein
  • Sympathetic truk
  • Vagus nerve
  • SVC

Mediastinum from left:

  • Heart in pericardium
  • Pulmonary veins
  • Bronchus
  • Aorta
  • Sympathetic trunk
  • Left vagus nerve
  • Recurrent laryngeal nerves
  • Phrenic nerve
91
Q

What is the arrangement of the vessels at the lung root/hilum?

A

Main bronchus is posterior (1L, 2 R)
Pulmonary artery is anterior and superior (1L, 2R)
2 pulmonary veins are anterior and inferior

Additional structures present: Lymphatics, hilar lymph nodes, nerves, bronchial vessels

92
Q

What is the pulmonary ligament and it’s function?

A

A fold of pleura

Allows hilar movement during respiration and vessel expansion

93
Q

At which point do the pulmonary arteries arise from the pulmonary trunk?

A

Pulmonary arteries arise from the pulmonary trunk just below the sternal angle (T4/5).

94
Q

Difference in the course of the right and left pulmonary artery?

A

Right is longer
Right passes anterior to the carina and right main bronchus. Lies posterior to the ascending aorta and SVC

Left is shorter
Left lies anterior to the descending aorta

95
Q

What vessels supply the tissue of the lung (e.g. walls of the bronchi)?

A

Bronchial arteries supply the tissue of the lung. They may anastomose with pulmonary arteries in the walls of the bronchioles.
Some blood supplied by bronchial arteries drains into the pulmonary veins.
Bronchial veins drain into the azygos system

96
Q

Lymphatic drainage of the lungs?

A
  • Deep lymphatic plexus running alongside the arteries and the dividing bronchial tree
  • Superficial or sub-pleural plexus of lymphatics

Both converge on Pulmonary nodes –> Bronchopulmonary nodes –> Inferior and superior Tracheobronchial nodes (at bifurcation of the trachea) –> Paratracheal nodes –> R+L Bronchomediastinal lymph trunks

The right usually joins the right lymphatic trunk.
The left usually joins the thoracic duct

97
Q

Nerve supply to the lungs and pleura?

A

Lungs:

  • Supplied by pulmonary plexuses that lie anterior to the main bronchi
  • PS fibres from vagus synapse in the plexuses. Postganglionic fibres are bronchoconstrictor, vasodilator, secretomotor
  • Sympathetic synapse in the sympathetic ganglia: Postganglionic fibres are bronchodilator, vasoconstrictor
  • Pain fibres travel with sympathetic

Pleura

  • Visceral pleura has no general sensory supply
  • Parietal pleura has sensory fibres from the intercostal and phrenic nerves
98
Q

What are the symptoms that can occur by a tumour developing on either side of respiratory system?

vice versa for LHS only

A

On both sides:

  1. Tumour may impinge upon the phrenic nerve to cause paralysis of the diaphragm on the affected side
  2. Tumour may impinge upon the sympathetic trunk and embarrass sympathetic supply to the head, causing Horner’s Syndrome (drooping eyelid, constricted pupil, dry/flushed face on affected side)

LHS only: Tumour may impinge upon the recurrent laryngeal nerve to cause hoarseness of the voice

99
Q

What are the components of the thoracic wall?

A

12 pairs of ribs and costal cartilages
Sternum
12 thoracic vertebrae
3 layers of intercostal msucele s

100
Q

Sternum:
3 parts?
Sternal angle of Louis at which position? Joint type?
Articulates which ribs?

A

3 parts: Manubrium, body, xiphoid process
Sternal angle of Louis at T4/5 and 2nd CC. A secondary cartilaginous joint (symphysis). (The bony articular surfaces are covered with hyaline cartilage, and a fibrocartilaginous disc connects the articulation bones)
Articulates ribs 1-7

101
Q

Features of a typical rib?

A
  1. Head, neck, tubercle, angle and body/shaft of the rib, joins to the costal cartilage (1y cartilaginous joint with costal cartilage)
  2. Costal groove on the inner surface and close to the inferior border
  3. Inferior border sharper than the superior border
  4. 2 articular demi-facets a the rib head. Articulates with own vertebrae and one above.
  5. Tubercle has a facet
102
Q

What 4 features are present on the first rib that aren’t on the other ribs?

A
  1. Scalene tubercle for the attachment of scalenus anterior
  2. Groove (upper surface, anterior to scalene tubercle) for subclavian vein
  3. Groove for subclavian artery and lower trunk of brachial plexus
  4. Head of rib 1 articulates only with T1 vertebra, not the one above. The tubercle articulates with the transverse process of T1 = rib 1 lies horizontal
103
Q

What structures could be affected by cervical ribs and what symptoms may arise?

A
  1. Trauma to the subclavian artery: Obstruction and possible thrombo-emboli to the forarm. Leads to ischeamia and pallor of forearm
  2. Compression of the lower trunk of the brachial plexus: Weakness of small muscles of the hand and sensory disturbance to the medial forearm (C8) and arm (T1)
104
Q

Typical thoracic vertebrae

A
  1. Heart shaped body and circular vertebral canal
  2. Long overlapping spinous processes
  3. Body with superior and inferior demifacets for articulation with the heads of the 2 pairs of ribs
  4. Transverse processes that articulate with the tubercles of the pair of ribs
  5. Superior and inferior facets that allow some rotation (no flexion)
105
Q

During osteoporotic fracture (collapse) of the vertebral body and facet joint arthritis, what structure is at risk?

A

Spinal nerve leading to local and spinal (intercostal) nerve pain

106
Q

Ribs 2-10 articules with the costal facet joints of which vertebra?

A

Articulates with:

  • Superior costal facet of its own number vertebra
  • Inferior costal facet of the vertebra above

FORMS COSTOVERTBERAL JOINT

107
Q

Costovertebral joint type?

A

Synovial, supported by capsule and ligament

108
Q

The tubercle of ribs 1-10 articules with its own….

A

Transverse process

109
Q

How do the costotransverse processes of the joints vary?

A

Costotransverse joints 1 to 7 have curved facets, allowing rotatory movement
Costotransverse joints 8-10 have flat facets, allowing gliding movement
(Key in respiratory movements of the thoracic wall)

110
Q

What are the anterior articulations of the thoracic wall?

A

All ribs articulate anteriorly with a CC via primary cartilaginous (hyaline) oint

TRUE RIBS (1-7) Articulate directly with the sternum via synovial joints to allow movment (except CC1 with is 1y cartilaginous, more stable for thoracic inlet)

FALSE RIBS (8-10) Articulate with the costal cartilage above to form the costal margin

FLOATING RIBS 11+12 have no anterior articulation

(As the rib number increases, the obliqueness also increase. Key to respiratory movements)

111
Q

What structure overly the intercostal spaces anteriorly?

A

Anterior: Pec maj, serratus anterior, pec minor, breast (opposite ribs 2-6)

112
Q

Intervertebral neurovascular bundle, components and location?

A

Made up of: Intercostal vein, artery and nerve (VAN)

Location: Costal groove at the inferior edge of the rib, between internal and innermost intercostal muscle

113
Q

3 layers of intercostal muscle?

A

External
Inner
Innermost

114
Q

Intercostal muscles:
Function?
Nervous supple?

A

Function: Support the intercostal space and prevent indrawing during inspiration
Nervous supply: Supplied by intercostal nerves T1 to T11

115
Q

External intercostal:
Fibre direction?
Anteriorly?
Function?

A

Fibre direction: Pass downwards and medially
Anteriorly: External intercostal membrane
Function: Raise ribs, inspiration

116
Q 
Internal intercostal:
Fibre direction?
Anteriorly?
Posteriorly?
Function?
A

Fibre direction: Pass downward and laterally
Anteriorly: External intercostal
Posteriorly: Internal intercostal memebrane
Function: Aids elastic recoil by moving ribs inferiorly in expiration

117
Q

What are the 3 parts of innermost intercostal muscles?

A
  1. Subcostales
  2. Innermost intercostal
  3. Transversus thoracis
118
Q

What supplies the anterior arterial supply to the intercostal space?

A

Internal thoracic artery:

  • Branch of the first part of the L+R subclavian artery
  • Lies along the margins of the sternum
  • Terminates as the superior epigastric and musculophrenic arteries
  • Supplies medial 1/2 of the breast

Anterior intercostal arteries:

  • 2 per space (ICS 1-6)
  • 7-10 from the musculophrenic
  • 11+12 have no anterior supply
119
Q

What supplies the posterior arterial supply to the intercostal space?

A

1st part of the subclavian arterty: Costocervical trunk supplies the 1st two spaces via the supreme intercostal artery

Thoracic aorta:

  • 9 pairs of posterior intercostal arteries
  • 2 per space in spaces 3-11 (passing with the intercostal nerves and their collateral branches)
  • 12th branch is the subcostal artery

Anterior and posterior arteries anastomose in the space

120
Q

In the incident of coarctation of the aorta anastomoses between which vessels forms a collateral circulation/

A

Anterior intercostals (from Internal thoracic) and posterior intercostals (from aorta)

121
Q

What vessels are involved in the venous drainage of the intercostal space?

A

Anterior intercostal veins: -Venae comitantes of the internal thoracic artery and its anterior intercostal arteries drain.
-Drains to internal thoracic vein

Posterior intercostal veins:

  • Venae comitantes of the posterior intercostal arteries
  • 1st space drains to the BCV
  • 2nd and 3rd veins form superior intercostal vein
  • On the right it drains to the arch of the azygos and on the left it drains to the LBCV
  • All others drain to the azygos system
122
Q

What is the lymphatic drainage of the thoracic wall?

A

Anteriorly:

  • Drains to parasternal nodes
  • These lie alongside internal thoracic artery and drains into the Bronchomediastinal trunks

Posteriorly:

  • Drains to intercostal nodes
  • These lie on the heads of ribs and drain to thoracic duct (inf) OR to Bronchomediastinal trunks (sup)

[NOTE Skin, breast and superficial muscles drain to Axillary nodes]

123
Q

Breast:
Arterial supply?
Lymph drainage?

A

Arterial supply:

  • Mainly from branchs of Axillary artery (sup thoracic, thoraco-acromial + laterial thoracic)
  • Also: Internal thoracic, anterior intercostal

Lymph: Axillary nodes mainly, also to internal thoracic

124
Q

Intercostal nerves:
Arise from…
Position?
Branches?

A

Arise from spinal nerve in intervertebral foramen.

Position: At inferior border of the rib between the internal and innermost intercostal muscles

Branches:

  • Lateral and anterior branches to overlying skin
  • Collateral branches that run at the upper border of the rub
125
Q

T1 spinal nerve, supplies??

A

The ventral ramus mainly goes to the Brachial Plexus to supply:

  • Small muscles of the hand, skin of medial aspect of the arm/forearm.
  • Sends a branch to supply the muscles of the 1st intercostal space
126
Q

The ventral rami of T2-T11 are the intercostal nerves and carry…

A

Carry:

  • Motor fibres to intercostal muscles
  • Sensory fibres from skin and parietal pleura
  • Sympathetic fibres to body wall structures via WRC (1y/Pre-ganglionic) and GRC (2y/post-ganglionic)
127
Q

What is the ventral ramus of T12?

A

The Subcostal nerve

128
Q

T2 gives a large cutaneious branch that supplies what?

What is this branch called?

A

Supplies:

  • Thorax wall in axilla
  • Upper, medial part of UL

Called the Intercostobrachial Nerve

129
Q

The ventral rami of T2-11 gives ___ _____ ____ at the angle of the rib which gives mainly motor to intercostal muscles

A

The ventral rami of T2-11 gives SMALL COLLATERAL BRANCH at the angle of the rib which gives mainly motor to intercostal muscles

130
Q

What dermatome level are the following structures:
Xiphoid process?
Umbilicus?

A

Xiphoid process: T6

Umbilicus: T10

131
Q

What is the treatment of a pneumothorax?

A

Presenting problem: The air is in the wrong place preventing the lung from expanding.

Treatment: A needle is inserted just above the rib to avoid damage to the neurovascular bundle that runs just inferior to each rib. Aim to go above/below and lateral to breast tissue.

Need passes through: Skin, pec major ( + pec minor?), 3 layers of intercostal muscles ( external, internal, innermost), endothoracic fascia, parietal pleura.

132
Q

Function of the nose and nasal cavity?

A

Warm, humidify and filter inhaled air. Sense of smell

133
Q

`What 3 cartilages support the nostrils/nares anteriorly?

A

Septal
Lateral
Alar (Lesser and Greater)

134
Q

What is the function of the muscles around the nostrils? and what are they?

A

Act as sphincters/dilators to control the diameter of the nares and adjust air flow.
Muscles: Procerus, Nasalis, Levator Labii Superoiris Alaeque Nasi (muscles of facial expression)

135
Q

Where are vibrissae located? and what is their function?

A

Location: On the skin of the nasal vestibule
Function: First air filters

136
Q

What two structures are present on the lateral wall of the nasal cavity?

A 
3 conchae (aka turbinates). Superior and middle from Ethmoid bone. Inferior from separate bone.
Meati (area between overhanging conchae and cavity lateral wall).

[Adjacent paranasal air sinuses open into the meatu]

137
Q

What bones make up the lateral wall of the nasal cavity?

A

Nasal, maxilla, macrimal, ethmoid, palatin, med. pterygoid plate of sphenoid

138
Q

What bones make up the roof the nasal cavity?

A

Nasal, frontal, ethmoid, sphenoid

139
Q

What is the function of conchae? What are they covered by?

A

Function: Increase surface area and create turbulence in the inhaled air.
Covered by highly vascular mucous membrane lined with respiratory epithelium (i.e. pseudostratified, ciliated, columnar with goblet cells)

140
Q

What are the three skeletal elements of the medial wall- midline septum?

A
  1. Perpendicular plate of ethmoid
  2. Vomer
  3. Septal cartilage
141
Q

Air passes through the ______ conchae (vom_, medial perpendicular plate of ____) into the nasopharynx

A

Air passes through the posterior conchae (vomer medial perpendicular plate of sphenoid) into the nasopharynx

142
Q

The septum is ____ posteriorly and ________ anteriorly

A

The septum is bone posteriorly and cartilage anteriorly

143
Q

The floor of the nasal cavity is horizontal and made up of the…….

A

Hard palate

144
Q

What are the main components that make up the ethmoid bone?

A
  1. Superior, middle concha
  2. R + L ethmoidal labyrinth
  3. Perpendicular plate
  4. Bulla ethmoidalis
  5. Crista galli
  6. Cribriform plate
145
Q

Fracture of the cribriform plate may cause ….

A

CSF rhinorrhoea

146
Q

What structures lie immediately superior and later to the nasal cavity?

A

Superior: Cranial cavity
Lateral: 2 orbits

147
Q

What sinus opens into middle meatus?

A

Maxillary sinus

[M=M]

148
Q

What two structures bulge into the middle meatus?

A

Bulla ethmoidalis

Middle ethmoidal air cells

149
Q

What epithelium detects smell? Where is it located?

A

Olfactory epithelium

Restricted to the cavity roof and the adjacent lateral wall and septum

150
Q

The mucus from the sinuses and the tears from the eye empty into the _____, via the _______

A

The mucus from the sinuses and the tears from the eye empty into the meati, via the nasolacrimal duct

151
Q

Nasal cavity and sinuses require what types of nervous supply?

A

General sensation and PS

Secretomotor supply to the mucous membrane

152
Q

Cranial nerves arise in the _______ and emerge from _____ in the skull

A

Cranial nerves arise in the brainstem and emerge from foramina in the skull

153
Q

What two cranial nerves provide sensory and parasympathetic (secretomotor) fibres?

A

The Trigeminal Nerve (Cranial V) is sensory. Has ophthalmic (V1) and maxillary (V2) divisions.

The Facial Nerve (Cranial VII) carries PS fibres that hitch-hike with divisions on trigeminal.

–> Divisions of the Trigeminal are distribution both the sensory and PS fibre

154
Q

Where in the nasal cavity is olfaction restricted to?

A

The roof and over the superior concha

[Olfactory nerves are capable of regeneration]

155
Q

Anterior/superior nasal nerves supplying the lateral wall of nasal cavity arise from?

A

From V1, mainly via the anterior ethmoidal nerve

156
Q

Posterior/inferior nasal nerves supplying the lateral wall of nasal cavity arise from?

A

V2 mainly via the greater palatine nerve

157
Q

Anterior/superior nasal nerves supplying the medial wall of nasal cavity arise from?

A

From V1

158
Q

Posterior/inferior nasal nerves supplying the medial wall of nasal cavity arise from?

A

From V2 mainly via the nasopalatine nerve (enters the nasal cavity via the sphenopalatine foramen)

159
Q

What artery accompanies and the following nerves and what do they branch from:

  • Maxillary nerve (V2) branches?
  • Ophthalmic nerve (V1) branches
A
  • Branches of the Maxillary nerve (V2) are accompanied by branches of the maxillary branch of the external carotid artery
  • Branches of the Ophthalmic nerve (V1) are accompanied by branches of the ophthalmic branch of the internal carotid artery
160
Q

What nerve passes through the incisive canal to supply the anterior plate?

A

Nasopalatine nerve

161
Q

Epistaxis, define?

A

Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx

162
Q

What is the arterial supply of the:

  • Anterior lateral nasal wall?
  • Posterior lateral nasal wall?
A

Anterior:
-Anterior, superior branches from the anterior and posterior ethmoidal branches of the Ophthalmic Artery

Posterior:
-Posterior, inferior
branches from the
greater palatine and sphenopalatine branches of the Maxillary Artery

163
Q

What is the one difference between the nervous and arterial supply of the nasal cavity?

A

The nasopalatine nerve is accompanied by the sphenopalatine artery

164
Q

What is a key site of epistaxis?

A

Littles/Kiesselbach’s area on the septum as it is highly vascular

165
Q

What features of the venous drainage of the nasal cavity increases likelihood of infection spread?

A

Connections to intracranial venous sinuses

  • Nasal vein in foramen caecum
  • Drainage to cavernous sinus in cranial cavity
  • Also connects to cavernous sinus
166
Q

What are the 3 paranasal sinuses?

A

Frontal sinuses
Ethmoidal cells
Sphenoidal sinuses
Maxillary sinuses

167
Q

Entry of the sinuses and nasolacrimal duct?

A

Most enter the middle meatus

  • Front sinus drains via the frontonasal duct and infundibulum (with anterior ethmoidal cells) to hiatus semilunaris
  • Hiatus semilunaris inf. to bulla and extending to the infundibulum
  • Maxillary sinus opens into the hiatus semilunaris (posteriorly)
  • Bulla ethmoidalis with the openings of the middle ethmoidal air cells
168
Q

What are the two pathologies that could lead to sinusitis?

A

Infection: The maxillary sinus opening is high in its medial wall and clearance of mucus is dependent upon ciliary action (which may be compromised by infection)

Deviated septum: Also predisposes to sinusitis

169
Q

Which sinuses do NOT open into the middle meatus?

A

The posterior ethmoidal cells open into the superior meatus

The sphenoid sinus opens into the spheno-ethmoidal recess

The nasolacrimal duct opens into the inferior meatus

170
Q

Arterial and nervous supply of the sinuses:

  • Frontal, ethmoid and sphenoid?
  • Maxillary?
A

The frontal, ethmoid and sphenoid sinuses are supplied by supra-orbital and ethmoidal branches of the Ophthalmic Nerve (V1) and Ophthalmic Artery

The maxillary sinus by branches of the Maxillary Nerve (V2) and Maxillary Artery

171
Q

Posterior and anterior lymph drainage of the nasal cavity?

A

Anterior: Drains to submandibular nodes

Posteriorly: To upper cervical nodes via the retropharyngeal nodes

[Jugulodigastric is palpable if inflamed]

172
Q

Describe the journey of inhaled air from nasal cavity to laynx

A

Inhaled air passes from the nasal cavity to the nasopharynx, which has protective, tonsillar tissue on its roof (adenoid), then past the soft palate to the oropharynx before entering the larynx

173
Q

What is the larynx?

A

Protective sphincter that prevents foreign bodies entering the airway

174
Q

What are tonsils?

A

Protective clusters of lymphoid tissue, the mucous membrane forms crypts
Adenoid/pharyngeal tonsil: On the roof and posterior wall of the nasopharynx

Tubal tonsil: Around the opening of the pharyngotympanic tube

+ Palatine and Lingual tonsils (below soft palate in oropharynx)

175
Q

Enlargement/swelling of the following tonsils leads to:

  • Pharnygeal tonsil?
  • Tubal tonsil?
A

Inflammation and swelling of the pharyngeal tonsil may obstruct the airway and lead to mouth breathing

Enlargement of the tubal tonsil may obstruct the pharyngotympanic tube and cause middle-ear infections

176
Q

Tonsillar lymph drainage is to the ??

A

Tonsillar lymph drainage is to the jugulodigastric node,
palpable behind
the angle of the
mandible

177
Q

What structure separates the nasopharynx and oropharynx?

A

The soft palate

178
Q

What is the larynx?

A

Amounts to a membranous (fibro-elastic) tube suspended between cartilages (the positions of which are controlled by muscles)
The laryngeal diameters may be altered to allow the passage of AIR ONLY, and also control airflow for SPEECH and raising INTRA-ABDOMINAL PRESSURE

179
Q

What are the 4 laryngeal cartilages? ETAC

A

Epiglottic (elastic) - Most sup
Thyroid
Arytenoid
Cricoid (The only complete ring) - Most inf

[All hyaline cartilage except epiglottis]

180
Q

What is the site of emergency access to the airway?

A

Median cricothyroid ligament (midline thickening of cricothyroid membrane)

181
Q

5 features of the cricoid structure?

A
  1. Signet ring with the lamina posteriorly
  2. Articulates with the arytenoids and the thyroid
  3. “Sloping shoulder” on the lamina for arytenoid articulation
  4. Ridge for attachment of the oesophagus
  5. Depression for attachment of posterior crico-arytenoid muscle
182
Q

Describe the lamina of the thyroid?

A

Left and right laminae
Each has superior and inferior horn (inf articulates with the cricoid)
The laminae fuse anteriorly as the laryngeal prominence, with superior notch above

[Prominence more obvious in males]

183
Q

Epiglottis:
Attached to which other laryngeal cartilage?
Position?
Function?

A

Attaches to the thyroid cartilages
Position: Projects upwards into the pharynx, behind the posterior part of the tongue
Function: Laryngeal elevation during swallowing pushes the epiglottis backwards and downwards (closes laryngeal inlet). Spring back after swallowing

184
Q

Arytenoid cartilage:

  • Shape
  • Articulates with…
  • Topped by which cartilages?
  • Contains which vocal structure?
A

Pyramidal shape. 3 sides and a base which articulates with the sloping shoulders of the cricoid lamina
Topped by corniculate and cuneiform cartilages
Vocal process anteriorly for attachment of the vocal ligament/fold

185
Q

What are the laryngeal membranes?

A
  1. Extrinsic thyrohyoid membrane

2. Intrinsic: Quadrangular and Cricovocal/cricothyroid

186
Q

The extrinsic thyrohyoid membrane:
Spans what area?
Thickenings?

A

Spans the space:

  • FROM the upper edges of the thyroid lamina + superior
  • TO the upper edges of the body + greater horn of the hyoid

Thickened anteriorly and posteriorly = Median and lateral thyrohyoid ligaments

187
Q

What are the two intrinsic membranes/ligaments?

A
  1. Quadrangular: From arytenoid to thyroid + epiglottis. Forms Aryepiglottic ligament on upper edge.
  2. Cricovocal/cricothyroid from the cricoid + arytenoid to the thyroid. Forms the conus elasticus, median cricothyroid ligament and vocal ligament
188
Q

How are the ligaments of the larynx turned onto folds?

A

Internal covering of mucous membrane

External muscle covering

189
Q

What are the following folds formed over:

  • Aryepiglottic fold?
  • Vestibular fold?
  • Vocal fold?
A

Aryepiglottic Fold: formed over the aryepiglottic ligament (upper edge of quadrangular membrane)

Vestibular Fold: formed over the vestibular ligament (lower edge of quadrangular membrane)

Vocal Fold: formed over the vocal ligament (upper edge of cricovocal (cricothyroid) membrane

190
Q

Where is the laryngeal inlet found and what controls it’s opening/closure?

A

Formed by the aryepiglottic folds on each side of the quadrangular membrane

Closure via the elevation of the larynx and muscles within folds

191
Q

What forms the folds of the laryngeal inlet?

A

False vocal / Vestibular folds on each side are the lower edge of the quadrangular membrane

Vocal folds (cords/ligaments) on each side are the upper edge of the cricovocal/cricothyroid membrane

192
Q

Vocal folds control laryngeal diameter for??
Vital for which processes?
What muscles are involved in altering the diameter?

A

The vocal folds control laryngeal diameter for: speech, coughing, sneezing and raising the intra-abdominal pressure, which is vital in parturition, micturition, defecation and lifting heavy objects.

Muscles: Rima glottis/glottidis

193
Q

The ventricle of the larynx is between the ______ and vocal folds and leads to the ______, which is to provide lubricating mucus for the ______ folds.

A

The ventricle of the larynx is between the VESTIBULAR and vocal folds and leads to the SACCULE, which is to provide lubricating mucus for the VOCAL folds.

194
Q

Muscles involved in closing and opening the aryepiglottic folds i.e. the laryngeal inlet?

A

Closure:

  1. Elevation of the larynx and pharynx by extrinsic muscles from skull
  2. Aryepiglotticus: A continuation of oblique arytenoid
  3. Thyro-epiglotticus: Draws the epiglottis and arytenoids towards each other.

Open:
-Descent of larynx (and pharynx) mainly by elastic recoil

195
Q

What action happens at the cricothyroid joint that lengthens/shortens the vocal folds?

A

The thyroid cartilage rocks backwards and forwards at the cricothyroid joint

196
Q

What movements combine to separate the vocal folds and open the rima glottidis?

A

The arytenoid cartilages both swivel (or externally rotate) and glide laterally down the shoulders of the cricoid lamina

197
Q

What is the only muscle that opens the rima glottis?

A

The posterior crico-arytenoid

198
Q

What muscles are responsible for closing the rima glottis?

A

The arytenoids are pulled back up the cricoid shoulders towards each other (adduction) by TRANSVERSE ARYTENOID. and they cords are swivelled towards each other by LATER CRICO-ARYTENOID

199
Q

What muscles are involved in lengthening and shortening the vocal folds to alter tension?

A

Shorten folds by rocking thyroid back towards the arytenoids: thyro-arytenoid

Lengthen folds by rocking thyroid forwards: cricothyroid

Increase in tension = Increase in voice pitch (vice versa)

200
Q

What is the difference between rima glottis in quiet and forced inspiration?

A

Quiet: Triangular rima, all folds opens, all cords abducted

Forced: Rima more forcefully/widely opened by posterior crico-arytenoid

201
Q

What is phonation/

A

When vocal folds are adducted to close the rima glottis and air is forced through, causing vibration.
Cord length and tensions are altered by an interplay between cricothyroid, thyro-arytenoid and vocalis

202
Q

Laryngeal innervation?

A 
The vagus (cranial X) sends the superior laryngeal nerve. Passes with the superior thyroid artery until it divides into the internal and external branches
Internal branch: Sensation of larynx down to vocal folds
External branch: Cricothyroid innervation
203
Q

Recurrent laryngeal branch of the vagus:
Pathway?
Supplies?

A

Pathway:

  1. Passes inferior to aortic arch of the left, or subclavian artery on the right
  2. Ascends between the trachea and oesophagus
  3. intermingles with branches of the inferior thyroid artery close to the gland
  4. enters the larynx

Supplies: All the muscles of the larynx (except cricothyroid) and sensation to the vocal cords and larynx below

204
Q

Laryngeal nerves may be at risk during…

A

Thyroid surgery

205
Q

What are the different effects of nerve lesions:

  • Complete paralysis of recurrent laryngeal
  • Partial paralysis of RL
  • Paralysis of external laryngeal
A
  • Complete paralysis of the recurrent laryngeal – the vocal fold lies in a semi-abducted position. The fold vibrates so respiration is noisy, the voice is hoarse, but there is compensation by extra movement of the opposite fold
  • Partial paralysis of the recurrent laryngeal causes the vocal fold to move into the midline and even cross it, therefore bilateral partial paralysis is life threatening
  • Paralysis of the external laryngeal nerve may not be noticed, or there may be some hoarseness of the voice. Recovery is good due to hypertrophy of the opposite cricothyroid
206
Q

What is the vascular supply and lymph drainage of the larynx?

A

Above vocal cords:

  • Superior laryngeal branch of the superior thyroid artery
  • Venous drainage to superior thyroid vein
  • Lymph: Upper cervical nodes

Below vocal cords:

  • Inferior thyroid artery
  • Veins drain to the inferior thyroid vein
  • Lymph: Lower deep cercial nodes
207
Q

The inferior thyroid veins are at risk in….

A

The inferior thyroid veins are at risk in tracheostomy as they descend to the left brachiocephalic vein

208
Q

What structures make up the:

  • Conducting pathway?
  • Respiratory pathways?
A

Conducting: Nasal cavity and mouth, larynx into the trachea, RMB and LMB, lobar bronchi, segmental bronchi
Respiratory: Respiratory bronchioles, alveolar duct, alveoli

209
Q

The walls of the bronchioles and alveolar ducts are composed of….

A
  1. Ciliated cuboidal epithelium becoming simple
  2. Squamous epithelium
  3. Elastic fibres
  4. Smooth muscle

NB there is no cartilage and no bronchial glands

MD3001 (12 decks)

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