Laryngology

Question 1

What muscle attaches to the vocal process of the larynx?

Answer 1

vocal process: thyroarytenoid

Question 2

What structure(s) attach to the muscular process?

Answer 2

muscular process: LCA, PCA

Question 3

Motion of the CA joint and impact on vocal process position?

Answer 3

CA joint - rotation of arytenoids outward leads to elevation and lateral displacement of the vocal process. rotation inwards leads depression and medial displacement.

Question 4

Motion of the cricothyroid joint and function?

Answer 4

Cricothyroid joint - hinge/visor like movement anteriorly; lengthens VF

Question 5

Where are the quadrangular membrane and conus elasticus located relative to VF?

Answer 5

quadrangular membrane is superior, runs between epiglottis and false VF

conus elasticus is inferior to that — superior border on conus elasticus is vocal process/vocal ligament; inferior is cricoid cartilage

Question 6

What is the only abductor of the larynx? What is its effect on the muscular process? The vocal process? Arytenoids?

Answer 6

PCA - muscular process depression and posterior. vocal process elevation and lateral deviation. arytenoids lateral rotation.

Question 7

The only unpaired muscle of the larynx?

Answer 7

interarytenoid

Question 8

Innervation of the cricothyroid muscle? Impact on length and tension in vocal cords? How does it accomplish this?

Answer 8

superior laryngeal nerve; increases length and tension in the vocal cords by causing anterior closure of the cricothyroid space

Question 9

Define: vestibule, ventricle, rima glottidis

Answer 9

vestibule - space in the supraglottis from inlet to the false VF, ventricle - invagination/recess between FVF and TVF; rima glottitidis - space between the TVF

Question 10

Histology: cell type in the vocal fold/upper vestibule? cell type everywhere else in larynx?

Answer 10

Stratified squamous epithelium; ciliated columnar squamous epithelium everywhere else. NOTE: false vocal folds are pseudostratified.

Question 11

Layers of the membranous vocal fold?

Answer 11

Epithelium, superficial/middle/deep layers of the superficial lamina propria, vocalis muscle.

Question 12

General description of the layers of the lamina propria?

Answer 12

Superficial to deep gets progressively denser. hyaluronic acid in superficial layer, cross-linked collagen in deep.

Question 13

Course of the left RLN? Course of the right RLN?

Answer 13

Left RLN wraps around ligamentum arteriosum, RLN wraps around the subclavian.

Question 14

Course of a non-recurrent right RLN and associated developmental anomaly?

Answer 14

Non-recurrent right RLN comes off of vagus and directly to TE groove; a/w retroesophageal subclavian.

Question 15

Associated developmental anomaly in the rare event of a non-recurrent left RLN?

Answer 15

Non-recurrent left RLN a/w situs inversus.

Question 16

Origin of the superior thyroid artery vs the inferior thyroid artery?

Answer 16

superior thyroid artery comes off of external carotid. inferior thyroid artery comes off of thyrocervical trunk.

Question 17

Lymphatic drainage of the supraglottis, infraglottis, and glottis?

Answer 17

supraglottis - upper jugular, infraglottis - lower jugular/pretracheal; glottis - no significant lymphatic drainage

Question 18

Position of the larynx (relative to cervical vetebrae) at birth vs adults? When does this descent occur?

Answer 18

Birth - C2-3, adult - C5, descent occurs around 6-8 years old in both genders; second descent at puberty in men

Question 19

Branchial cleft embryology of the larynx: a) which arch develops into cricothyroid muscle? which nerve associated? b) which arch develops remainder of laryngeal muscles? which nerve associated?

Answer 19

a) 4th arch; superior laryngeal nerve. b) 6th arch; recurrent laryngeal nerve

Question 20

Cause/Management of nodules

Answer 20

phonotrauma/“overuse”, voice therapy.

Question 21

Cause/management of VF polyp

Answer 21

like a mucocele/outpouching of mucosa, treatment is surgery.

Question 22

Cause/management of granuloma/contact ulcer

Answer 22

often trauma- intubation or phonotrauma, GERD. medical management +PPI unless obstructive, then surgery with high recurrence rate

Question 23

Contrast cyst vs sulcus vs pseudocyst: a) location b) management

Answer 23

cyst - epithelial lined. surgery but significant risk of persistent voice change. sulcus - deep invagination of the vocal fold w/wo epithelial lining. surgery or injection (with variable results). pseudocyst - submucosal; surgery.

Question 24

Management of leukoplakia/keratosis: a) possible etiologies b) conservative management options

Answer 24

both are premalignant. a) smoking, GERD, chronic phonotrauma, vitamin deficiencies b) if low suspicion for malignancy can initially watch closely with smoking cessation/PPI/voice therapy -> DL/excision with subsequent serial follow-up

Question 25

RRP: a) implicated HPV subtypes? b) management? adjunctive options?

Answer 25

a) serotypes 6&11. b) management is surgery. Adjunctive therapies include cidofovir, laser/photodynamic, cryotherapy

Question 26

VF paralysis: surgical options for unilateral?

Answer 26

injection, medialization +/- arytenoid adduction.

Question 27

most common cause for bilateral VF paralysis ? surgical options for bilateral?

Answer 27

most common cause for bilateral is THYROIDECTOMY. Surgical options include cordotomy/cordectomy, tracheotomy, arytenoid abduction. Innervation for either.

Question 28

Laryngeal reinnervation procedure: expected impact on function/outcome?

Answer 28

restore bulk/tone position, does not restore function; does not restore abductor function

Question 29

Spasmodic dysphonia, adductor vs abductor: a) which one more common? b) what type of words have breaks? c) options for management?

Answer 29

a) adductor more common; b) sixties/puppy for abductor spasmodic dysphonia, eighties/elephant for ADductor spasmodic dysphonia; c) botox injection to TA or lateralization thyroplasty for adductor. medialization thyroplasty for abductor.

Question 30

Classic X-ray finding for epiglottitis vs croup?

Answer 30

epiglottitis - thumb sign; croup - steeple sign

Question 31

Histological difference between pemphigus and pemphigoid?

Answer 31

pemphigus = intraepithelial blisters, pemphigoid = subepithelial blisters

Question 32

Systemic conditions that can affect the larynx based on buzzwords: non-caseating granulomas? what site(s) most commonly affected?

Answer 32

sarcoidosis; supraglottis, especially epiglottis.

Question 33

Systemic conditions that can affect the larynx based on buzzwords: cricoarytenoid joint fixation? what other conditions can cause this?

Answer 33

RA. Also SLE, TB, Crohn’s, syphilis, gonorrhea.

Question 34

Systemic conditions that can affect the larynx based on buzzwords: waxy gray or orange lesions on the epiglottis, nonspecific findings on H&E? What kind of stain needed to make the diagnosis?

Answer 34

amyloidosis; congo-red with birefrigence.

Question 35

Systemic conditions that can affect the larynx based on buzzwords: necrotizing granulomatous subglottic process and capillary thrombosis?

Answer 35

Wegener’s/PGA

Question 36

Systemic conditions that can affect the larynx based on buzzwords: oral ulcers that progress caudally to involve the larynx with 15% mortality?

Answer 36

pemphigoid

Question 37

Systemic conditions that can affect the larynx based on buzzwords: relapsing polychondritis - what site of dysfunction in the airway?

Answer 37

tracheal stenosis

Question 38

How to manage an acute unstable airway in laryngeal fracture? What is the one “exception” to this?

Answer 38

tracheotomy UNLESS complete cricotracheal separation — in which case theoretically attempt fiberoptic but may be extremely difficult and end up with slash trach anyway

Question 39

How to approach workup for a stable airway in laryngeal fracture?

Answer 39

If stable and no fracture suspected - observe. If stable but scope shows significant hematoma/fracture suspected - CT first, possible OR pending results. If stable but scope shows exposed cartilage/significant mucosal injury -> OR.

Question 40

Surgical treatment options for supraglottic, glottic, and subglottic stenosis?

Answer 40

Supraglottic - supraglottic laryngectomy most effective, other targeted expansion/stenting high risk for recurrence. Glottic - can attempt cordotomy/cordectomy, possible trach. Issue is posterior VF usually fixed so need static opening but sacrifices voice. Subglottic - can try endoscopic interventions but often may need tracheal resection

Question 41

Laryngeal cleft staging?

Answer 41

type 1 - interarytenoid cleft, does not pass TVF. type 2 - past TVF, into but not through cricoid. type 3 - through cricoid into cervical trachea, not into thoracic inlet. type 4 - into thoracic inlet/thoracic trachea

Question 42

X-ray findings on inspiration vs expiration for bronchial foreign body?

Answer 42

inspiration - atelectasis. expiration - hyperinflation