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LARYNX Flashcards

1
Q

location of larynx?

A

anteiror compartment of the neck
suspended from hyoid bone, opens superiorly in laryngopharynx, spans C3-C6 and then continues inferiorly with the trachea

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2
Q

boundaries of the larynx?

A

covered anteriroly by the infrahydois muscles, laterally by the thyroid lobes and posteriorly by oesophags

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3
Q

what is the internal cavity of the larynx lined by?

A

pseudostratified columnar epithelium
(other than true vocal cords which are lined by stratified squamous epithelium)

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4
Q

what are the 3 regions of the larynx?

A

supraglottis - from inferior epiglottis to vestibular folds
glottis
subglottis - from 1cm bellow glottis to inferior border of cricoid cartilage

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5
Q

vasculature of the larynx?

A

arterial - superior and inferior laryngeal arteries
venous - superior and inferior laryngeal veins

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6
Q

sensory and motor inervation to the larynx?

A

recurrent larngeal nerve provides motor innervation to all internal muscles except the cricothyroid + sensory innervation to infraglottis
superior laryngeal internal branch provides sensory innervation to supraglottis, and external branch provides motor innervation to the cricothyroud muscles

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7
Q

infrahyoid muscles?

A

omohyoid
sternohyoid
sternothyroid
thyrohyoid

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8
Q

suprahyoid muscles?

A

stylohyoid
digastric muscle
mylohyoid
gleniohyoid

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9
Q

how can we visualise the larynx?

A

laryngoscopy or videostroboscopy

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10
Q

what is videostroboscopy?

A

using an endoscope with a strobe light to create a series of images that appear to be slow motion vibration of the vocal folds. This helps assess how well the vocal cords are vibrating

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11
Q

physiology of vocal cord vibration?

A

intrinsic muscles bring vocal cords together to close the glottis
pressure against the closed vocal cords blows them apart

When the vocal folds vibrate, they alternately trap air and release it. Each release sends a little puff of air into the pharynx; each puff of air is the beginning of a sound wave

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12
Q

Physiology of vocal cords to raise the pitch?

A

Vocal cords vibrate faster so they get thinner by being stretched - done by extrinsic laryngeal muscles

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13
Q

What is laryngitis?

A

Inflammation or infection of the larynx and vocal cords

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14
Q

Most common causes of laryngitis?

A

Viral laryngitis is most common - rhinovirus, adenovirus, parainfluenza, influenza
Bacterial and fungal also possible
Can also be caused by trauma e.g. excessive voice use, chronic coughing etc

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15
Q

Symptoms of laryngitis?

A

Episodic coughing
Throat clearing behaviours
Hoarse voice
Dysphonia
Dysphagia
Fever
Systemic symptoms

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16
Q

Management of laryngitis?

A

Self-limiting so offer NSAIDs

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17
Q

When should you offer antibiotics for a sore throat?

A

Marked systemic upset
Unilateral features of peritonsillitis
PMHx of rheumatic fever
an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)

patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

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18
Q

What antibiotics should be given for a sore throat if indicated?

A

Phenoxymethylpenicillin for 7-10 days
(Clarithromycin if allergic)

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19
Q

What is the centor criteria?

A

Centor criteria: score 1 point for each (maximum score of 4).

Tonsillar exudate.
Tender anterior cervical lymphadenopathy or lymphadenitis.
History of fever (over 38°C).
Absence of cough.

A score of 0, 1 or 2 is thought to be associated with a 3-17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32-56% likelihood of isolating streptococcus.

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20
Q

What is the FeverPAIN criteria?

A

Score 1 point for each (maximum score of 5)

Fever (during previous 24 hours).
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (within 3 days after onset of symptoms).
Inflamed tonsils.
No cough or coryza.

A score of 0 or 1 is associated with a 13-18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34-40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62-65% likelihood of isolating streptococcus.

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21
Q

What most commonly causes acute sore throats?

A

Viruses - most commonly rhinovirus, coronavirus, parainfluenza virus, influenza virus

Strep, adenovirus, HSV 1, EBV, fusobacterium necrophorum

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22
Q

Whats the most common bacterial case of sore throat?

A

Group A beta-haemolytic strep (strep pyogenes)

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23
Q

What is scarlet fever?

A

A reaction to erythrogenic toxins produced by group A haemolytic strep (usually strep pyogenes)
Spread via resp route
Most common in children 2-6

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24
Q

Presentation of scarlet fever?

A

Fever for 24-48 hours
Malaise, headache
N&v
Sore throat
Strawberry tongue
Pinhead rash on torso most obvious in flexure with a rough sandpaper texture (desquamation occurs later around fingers & toes)

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25
Compilations of strep pharyngitis/tonsilitis?
Scarlet fever Otitis media Acute sinusitis Quinsy More rare… Acute rheumatic fever Acute glomerulonephritis Reactive arthritis
26
What is a quinsy?
A peritonsillar abscess that usually develops as a complication of bacterial tonsillitis
27
Presentation of a quinsy?
Severe throat pain lateralising to 1 side Deviation of uvula to unaffected side Trismus (difficulty opening mouth) Reduced neck mobility
28
Management of quinsy?
Urgent ENT review Needle aspiration or incision and drainage IV antibiotics Consider tonsillectomy for prophylaxis
29
Examination findings for pharyngitis?
Pharyngeal exudate Cervical lymphadenopathy Fever
30
Examination findings for tonsilitis?
Tonsillar exudate Enlargement and erythema of tonsils Anterior cervical lymphadenopathy Fever
31
What symptoms suggest viral rather than bacterial pharyngitis?
Rhinorrhoea Nasal congestion Cough
32
What symptoms suggest a strep infection of the throat?
Fever over 38.5 Exudate on pharynx or tonsils Anterior neck lymphadenopathy Absence of cough
33
What causes glandular fever?
EBV (HHV-4)
34
Classic triad of symptoms for glandular fever?
2-4 weeks of… Sore throat Lymphadenopathy Pyrexia (May also cause malaise, anorexia, headache, palatal petechia, splenomegaly, hepatitis, haemolytic anaemia, lymphocytosis)
35
What happens to pt if they take amoxicillin when they have glandular fever?
99% develop a maculopapular, pruritic rash
36
How do we diagnose glandular fever?
Monospot test (heterophil antibody test) - do in 2nd week of illness
37
Management of glandular fever?
Rest, fluids, avoid alcohol Simple analgesia Avoid playing contact sports for 4 weeks to reduce risk of splenic rupture
38
What no. Of episodes of tonsillitis would you be having for ENT to consider tonsillectomy?
>7 episodes for 1 year >5 episodes for 2 years >3 episodes for 3 years
39
What are the indications for a tonsillectomy?
Obstructive Sleep Apnoea / Sleep disordered breathing in Children Suspected Cancer Recurrent tonsillitis or Quinsy (abscess next to tonsil) Emergency Presentations (e.g. treatment of parapharyngeal abscess) Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous Acute and chronic renal disease resulting from acute bacterial tonsillitis As part of the treatment of severe guttate psoriasis Metabolic disorders where periods of reduced oral intake could be dangerous to health PFAPA (Periodic fever, Apthous stomatitis, Pharyntitis, Cervical adenitis)
40
What is dysphonia?
A disorder characterised by altered vocal quality, pitch, loudness or vocal effort that impairs communication Aka hoarseness
41
Causes of dysphonia
Malignancy - lung or laryngeal cancer gastro-oesophageal reflux Vocal cord nodules, cysts or papillomas Vocal cord palsy Trauma e.g. intubation or excessive use of voice Endocrine e.g hyothyroidism Infections e.g. laryngitis or candida Iatrogenic e.g recurrent laryngeal nerve palsy secondary to thyroid surgery Smoking or voice overuse
42
What is spasmodic dysphonia?
A rare, focal dystonia of the larynx that affects the laryngeal muscles and causes involuntary spasms Thought to be caused by damage to the basal ganglia Aka shaky voice
43
What are the 2 main types of spasmodic dysphonia and which is more common?
Adductor spasmodic dysphonia - most common (spasms in the muscles that bring the vocal cords together) Abductor spasmodic dysphonia
44
Symptoms of spasmodic dysphonia?
Hoarse or strained voice Uncontrollable pitch Voice breaks Fluctuating voice quality Tremor in voice
45
How do we treat adductor spasmodic dysphonia?
Injections of botulinum toxin type A to cause paralysis of the thyroarytenoid muscles = no vocal spasms
46
What are vocal cord granulomas?
Benign growths on the vocal cords Aka contact ulcers or arytenoid granulomas
47
What can cause vocal cord granulomas?
Chronic acid reflux Trauma from intubation Chronic mild trauma e..g throat clearing Excessive use of or strain on voice
48
Symptoms of vocal cord granulomas?
Hoarse voice Effortful voice Globus Frequent voice breaks Voice fatigue Throat pain
49
Treatment of vocal cord granulomas?
Voice exercises and may be SALT input Acid reflux treatment ENT may remove it surgically Botulinum toxin may be used
50
What usually causes vocal cord paralysis?
Damage to the recurrent or superior laryngeal nerve
51
Outline the anatomy of the laryngeal nerves?
The left recurrent laryngeal nerve has a long course which extends down into the chest and loops under the arch of the aorta to return to the larynx. The right recurrent laryngeal nerve is shorter and loops around the subclavian artery - thus the left nerve is more susceptible to disease than the right
52
What is Semon’s law?
In a progressive lesion of recurrent laryngeal nerve, the abductors are paralysed before the adductors. This means that in an incomplete paralysis, the cord will be brought to the midline by the adductors but in complete paralysis it falls away to the paramedical position.
53
Causes of recurrent laryngeal nerve palsy’s?
Left recurrent nerve can be damaged in the chest - bronchial, oesophageal, mediastinal lymph node carcinomas. aortic aneurysm or surgery to heart/oseophagus Bulbar palsy Pseuodbulbar palsy Jugular foramen syndrome Thyroid surgery or carcinoma Penetrating wounds C-spine surgery
54
Symptoms of vocal cord palsy?
Bovine cough Hoarseness Change in quality of voice May be difficulties with breathing or swallowing
55
Management of vocal cord palsy?
Speech therapy Surgery
56
What is a bovine cough?
A non- explosive cough of someone unable to close their glottis E.g. recurrent laryngeal nerve palsy
57
What are vocal cord polyps?
Very common benign growths on the vocal cords - they tend to occur on 1 vocal cord
58
Symptoms of vocal cord polyps?
Hoarseness Throat discomfort Globus Vigorous throat clearing
59
What can cause vocal cord polyps?
Using voice too much or too loudly Smoking Reflux
60
Management of vocal cord polyps?
Voice therapy Surgery
61
What is a vocal cord Haematoma?
When a blood vessel in the vocal cords ruptures from foreceful or incorrect vocalisation and there is bleeding involving the superficial lamina propria
62
Symptoms of vocal cord haematomas?
Sudden hoarse voice
63
Management of vocal cord haematomas?
Vocal rest to prevent scarring Blood vessels can be cauatrised if necessary
64
What are vocal cord nodules?
Tiny bumps that occur on the edge of the vocal folds as a result of excessive friction. Overtime they develop into a swelling and then a nodule. They prevent the vocal folds coming together properly when you talk Usually form as a pair, 1 on each fold around the anterior 1/3rd of the fold
65
Symptoms of vocal cord nodules?
Hoarseness Throat discomfort Throat clearing Voice worsens with use
66
What causes vocal cord nodules?
Overusing voice, shouting, singing, excessive coughing or throat clearing, smoking, reflux
67
Treatment of vocal cord nodules?
Voice rest Good vocal hygiene Speech therapy Sometimes surgery by ENT
68
What is laryngeal papillomatosis?
Aka recurrent respiratory papillomatosis? A rare medical condition where papillomas form along the aerodigestive tract
69
What causes laryngeal papillomatosis?
HPV infection of the throat -> can cause tumours which may narrow the airway May also cause tumours elsewhere in the airways
70
Symptoms of laryngeal papillomatosis?
Hoarseness SOB Chronic cough Stridor (The juvenile version is often mistakes for asthma or croup in children)
71
Management of laryngeal papillomatosis?
Surgery
72
What is laryngopharyngeal reflux?
A group of upper respiratory tract symptoms secondary to irritation fron reflux of gastric contents
73
Symptoms of laryngopharyngeal reflux?
Hoarseness Throat clearing Chronic cough Globus - worse when swallowing saliva rather than eating or drinking Dysphagia May have heart burn
74
What questionnaire is commonly used for laryngopharyngeal reflux?
The reflux symptom index - a score of >13 = LPR
75
How can we diagnose laryngopharyngeal reflux?
Gold standard is a 24 hour dual probe pH manometry combine with intrlminal impedance studies Reflux symptoms index questionnaire Visualisation of larynx e.g. laryngoscopy Transnasal oesopahoscopy to exclude other causes
76
Treatment of laryngopharyngeal reflux?
Life style changes e.g. avoid food 3 hours before sleep, stop smoking, reduce alcohol, address obesity, avoid fizzy drinks, avoid throat clearing Speech therapy Alginates or PPIs to suppress acid (less evidence for PPI)
77
Which side is vocal cord palsy more common and why?
The left due to the nerve being longer
78
Consequences of a laryngectomy?
1-2 weeks not eating Won’t be able to speak if total laryngectomy
79
What can patients with laryngectomies be given to help them speak?
Trachyoesophageal voice prosthesis Learn to burp air up - SALT can teach this Electrolarynx
80
How does a tracheoesophageal prosthesis work?
Surgeon creates a hole between the trachea and oesophagus and implant a one-way valve so that when you cover your stoma and exhale you can re-direct air through the valve into your throat
81
How does an electrolarynx work?
This is a battery operated machine that produces vibrations so you can make sound
82
What fluid do we use for post-laryngectomy swallow?
Gastrografin swallow instead of barium swallow
83
What is laryngomalacia?
Congenital flaccidity of the supraglottic structures of the larynx Presents in the first 12 months of life with stridor
84
What are laryngoceles?
Uncommon, benign dilatation of the laryngeal saccule Often found in players of wind instruments
85
Presentation of laryngoceles?
Asymptomatic if small Sore throat, dysphagia, neck lump, airway obstruction
86
What is polypoid corditis?
Aka reinkes oedema or smokers polyps When polyps develop on the vocal cords due to chronic smoking
87
What is Globus pharyngeus/
The sensation of a lump, discomfort or foreign body in the throat A diagnosis of exclusion - linked to stress or anxiety

ENT (8 decks)

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