Airway/Larynx/Swallowing

Question 1

What region of obstruction is characteristic of inspiratory stridor?

Answer 1

Supraglottic/glottic

Question 2

What region of obstruction is characteristic of biphasic stridor?

Answer 2

Subglottic

Question 3

What region of obstruction is characteristic of expiratory stridor?

Answer 3

Tracheobronchial

Question 4

How do neonates breathe?

Answer 4

Obligate nasal breathers

Question 5

What is the typical presentation of nasal foreign bodies in young children?

Answer 5

Unilateral malodorous rhinorrhea

Question 6

What is the function of the larynx?

Answer 6

Conduit for ingested material into esophagus, protection of lower airways from aspiration, and intricate structures utilized in phonation

Question 7

What is the difference in position between the adult and neonatal larynx?

Answer 7

Neonatal larynx is at the level of C2 and contacts the palate and epiglottis directly (provides airway protection and helps with feeding), adult larynx lies at the C7 vertebral body

Question 8

What nerve provides sensory innervation tot he larynx? Muscle innervation?

Answer 8

Sensory: superior laryngeal

Motor: recurrent laryngeal

Question 9

What is the pathway of the recurrent laryngeal nerve?

Answer 9

It travels into the upper thorax from the skull base, loops around cardiovascular structures, and then goes back up to innervvate vocal cords

Question 10

What is the supraglottis? Glottis? Subglottis?

Answer 10

Supraglottis = area above vocal cords

Glottis = vocal cords

Subglottis = cricoid cartilage

Question 11

What is the function of the cricothyorid muscle?

Answer 11

Laryngeal tilting which stretches and tightens the vocal folds (inflection of voice)

Question 12

What is the function of the posterior cricoarytenoid muscle?

Answer 12

Actively abducts the larynx

Question 13

What is the laryngeal adductor reflex?

Answer 13

A reflux for adductor stimulus that leads to rapid closure of the laryngeal muscles to prevent penetration and aspiration into the airway

Question 14

Why is left vocal cord paralysis more common than right?

Answer 14

The left recurrent laryngeal nerve has a long course around the heart and is at high risk for injury

Question 15

What is the most common cause of stridor in neonates?

Answer 15

Laryngomalacia - immature supraglottic opening at birth (omega shaped epiglottis)

Question 16

What is subglottic stenosis?

Answer 16

Stenosis of the subglottic ring that can be congenital or acquired during intubation injury

Question 17

What is the most common subglottic tumor in neonates?

Answer 17

Subglottic hemangioma

Question 18

What is the presentation of subglottic hemangioma?

Answer 18

Usually presents with cutaneous hemangioma, worsens with crying, improves with calm and steroids, often mistaken for croup.

Treated with propanolol for 12 months

Question 19

What is a tracheosophageal fistula?

Answer 19

A congenital connection between the trachea and esophagus and is associated with esophageal atresia

Question 20

What is complete tracheal rings?

Answer 20

Results from failure of development of the trachealis muscle posteriorly, leading to a stenotic and rigid fully enclosed ring. Highly associated with cardiac anomalies.

Question 21

What is the epiglottis?

Answer 21

Laryngeal cartilage in oropharynx guarding the entry to larynx

Question 22

What is a valleculae?

Answer 22

Recesses in oropharynx anterior to the epiglottis on either side of the glosso-epiglottic fold at the back of the tongue

Question 23

What is the piriform recess?

Answer 23

Interval on each side of the laryngopharynx between the cricoid cartilage and posterior edge of thyroid cartilage of larynx

Question 24

What are vestibular folds?

Answer 24

False vocal folds that overlay true vocal folds

Question 25

What is the vestibule of the larynx?

Answer 25

Entryway into larynx between aryepiglottic folds above vestibular (false) folds below

Question 26

What is the ventricle of the larynx?

Answer 26

Compartment on each side between the false vocal cords above and the true vocal cords below

Question 27

What is the rima glottidis?

Answer 27

The space between the two vocal cords

Question 28

What is the quadrangular membrane?

Answer 28

Connective tissue wall of the vestibule (lower edge forms false vocal cords)

Question 29

What is the triangular membrane?

Answer 29

Conus elasticus bounding the infraglottic cavity, forms the cricothyroid ligament

Question 30

What are vocal ligaments?

Answer 30

Superior portion of the conus elasticus (focal fold is what vibrates)

Question 31

What is the function of the posterior cricoarytenoid?

Answer 31

Rotates the arytenoid cartilages laterally to pull the cords apart (abduction) during inspiration ## Footnote *only muscle that abducts*

Question 32

What is the function of the lateral cricoarytenoid muscle?

Answer 32

It rotates the arytenoid cartilages medially to adduct the vocal folds, closes airway to protect it (also aids with coughing)

Question 33

What is the function of the transverse arytenoid?

Answer 33

Pulls the arytenoid cartilages together for complete adduction

Question 34

What happens if lateral cricoarytenoids contract without transverse arytenoids?

Answer 34

The vocal cords close but not completely, leading to a whisper

Question 35

What are the functions of the cricothyroid muscle?

Answer 35

pulls thyroid cartilage down toward cricoid cartilage to stretch and tense vocal cords, raising pitch of voice

Question 36

What are the functions of the thyroarytenoid muscle?

Answer 36

Pulls the thyroid cartilage posteriorly toward the arytenoid cartilages to shorten and relax the vocal ligaments and folds, lowering pitch of voice

Question 37

What is the function of the thyroepiglottic muscle?

Answer 37

Pulls the epiiglottis forward to open the larynx

Question 38

What is the function of the aryepiglottic muscle?

Answer 38

It helps close the epiglottis

Question 39

What is A?

Answer 39

Epiglottis

Question 40

What is B?

Answer 40

Aryepiglottic fold

Question 41

What is C?

Answer 41

Aryepiglottic muscle

Question 42

What is D?

Answer 42

Oblique arytenoid muscles

Question 43

What is E?

Answer 43

Transverse arytenoid muscle

Question 44

What is F?

Answer 44

Posterior cricoarytenoid muscle

Question 45

What is G?

Answer 45

Oblique part of cricothyroid muscle

Question 46

What is H?

Answer 46

Straight part of cricothyroid muscle

Question 47

What is I?

Answer 47

Thyrohyoid membrane

Question 48

What is J?

Answer 48

Opening for internal laryngeal nerve

Question 49

What is the function of the thyrohyoid?

Answer 49

Elevates the larynx with the superior hyoid muscles (helps with swallowing)

Question 50

What is the function of the sternothyroid?

Answer 50

Pulls thyroid cartilage down towards the cricoid cartilage, helping stretch vocal cords and raise pitch of voice

Question 51

What is the function of the external laryngeal nerve?

Answer 51

Branchiomotor to cricothyroid muscle

Question 52

What is the function of the internal laryngeal nerve?

Answer 52

Pierces thyrohyoid membrane to provide visceral sensory and parasympathetic innervation to all of the larynx above vocal cords

Question 53

What is the function of the inferior laryngeal nerve?

Answer 53

Visceral sensory and parasympathetic to the larynx below the vocal folds, branchiomotor to all muscles of larynx except cricothyroid ## Footnote *comes from the vagus nerve*

Question 54

What is the ramus communicans?

Answer 54

A communicating sensory branch from the inferior laryngeal nerve to the superior laryngeal nerve

Question 55

What primordia does the mucosa of the larynx come from?

Answer 55

Pharyngeal arches four and six

Question 56

What larynx structures come from pharyngeal arch four?

Answer 56

Most of epiglottis, most of thyroid cartilage

Question 57

What larynx structures come from pharyngeal arch 6?

Answer 57

Cricoid and arytenoid

Question 58

What is the only laryngeal muscle that can maximally open the airway by abducting the vocal folds? a) thyroarytenoid b) lateral cricoarytenoid c) cricothyroid d) posterior cricoarytenoid e) transverse arytenoids

Answer 58

d) posterior cricoarytenoid

Question 59

What laryngeal nerve is the sensory limb of the cough reflex? a) external b) superior c) internal d) recurrent e) inferior

Answer 59

c) internal

Question 60

Where does food often get trapped? a) piriform recess b) vestibule c) valleculae d) infraglottic cavity e) ventricle

Answer 60

a) piriform recess

Question 61

A deformed or undersized thyroid cartilage might be the result of deficient population of ectomesenchyme in which pharyngeal arch? a) 1 b) 2 c) 3 d) 4 e) 6

Answer 61

d) 4

Question 62

What are the three phases of swallowing?

Answer 62

Oral, pharyngeal, and esophageal phases

Question 63

What occurs in the oral phase of a swallow?

Answer 63

Lips seal bolus in oral cavity --\> tongue transports bolus to oropharynx

Question 64

What occurs in the pharyngeal phase of a swallow?

Answer 64

Nasopharynx is sealed by soft palate contact to superior pharyngeal constrictor --\> bolus propeled through the pharynx (tongue base and posteiror pharyngeal wall) while larynx is sealed off to prevent aspiration

Question 65

What occurs in the esophageal phase of swallowing?

Answer 65

Bolus tranpsorted to cervical esophagus through upper esophageal sphincter

Question 66

What nerual signals lead to an oropharyngeal swallow?

Answer 66

It is under control of a central pattern generator

Question 67

What is the difference in nerve control between primary and secondary peristalsis?

Answer 67

Primary = dependent on extrinsic innervation, secondary = dependent on an intramural nerve network (myenteric plexus)

Question 68

What is the most likely cause of dysphagia associated with coughing or aspiration?

Answer 68

Oropharyngeal

Question 69

What is the most likely cause of dysphagia associated with chest pain?

Answer 69

Esophageal

Question 70

What is the most likely cause of dysphagia associated with only solid food?

Answer 70

Mechanical cause (ex. stricture)

Question 71

What is the most likely cause of dysphagia associated with solids and liquids?

Answer 71

Motor disorder

Question 72

What are the two main tools to evaluate oropharyngeal dysphagia?

Answer 72

Viddeofluoroscopy (aka MBS), fiberoptic endoscopic evaluation of swallowing (FEES)

Question 73

Dysphagia, or impaired swallowing is: a) a symptom of larger impairment b) unique to *only* older adults c) limited inetiology, usually only to those with neurological impairment d) synonymous with aspiration

Answer 73

a) a symptom of larger impairment

Question 74

When discussing invasion of food or liquid into the airway, _______ is defined as ingested material below the level of the true vocal cords, whereas ______ is defined as ingested material above the level of true vocal cords. a) penetration; aspiration b) aspiration; penetration c) aspiration; dysphagia d) aspiration; superficial aspiration

Answer 74

b) aspiration; penetration

Question 75

A 64 y.o. man with a history of DLBCL diagnosed 2 years ago presents with weight loss, hypernasality, fluxuating voice changes, low-grade fever. Imaging is remarkable for new cranial nerve lesions impacting CN X, XII. Chest x-ray on admission is notable for bilateral lower lobe infiltrates. Patient denies difficulty swallowing. What is notable about this patient's history and complaints that would be concerning for possible dysphagia?

Answer 75

- involvement of CN X and XII may interfere with oral and pharyngeal phases of sawllowing - fever and bilateral lower lobe infiltrates - weight loss could be secondary to swallowing impairment