Podcast
Questions and Answers
What is the boundary of the oropharynx superiorly and inferiorly?
What is the boundary of the oropharynx superiorly and inferiorly?
- Superiorly by soft palate, inferiorly by epiglottis (correct)
- Superiorly by Cricoid cartilage, inferiorly by arytenoid cartilage
- Superiorly by Hard palate, inferiorly by cricoid cartilage
- Superiorly by Epiglottis, inferiorly by thyroid cartilage
Which of the following nasal sinuses is divided into posterior, middle, and anterior cells and consists of numerous air cells?
Which of the following nasal sinuses is divided into posterior, middle, and anterior cells and consists of numerous air cells?
- Frontal sinus
- Ethmoid sinus (correct)
- Maxillary sinus
- Sphenoidal sinus
What is the function of the cricothyroid membrane?
What is the function of the cricothyroid membrane?
- Attaches the thyroid cartilage to the hyoid bone
- Provides a site for emergency airway access (correct)
- Allows for articulation between the cricoid and hyoid cartilages
- Separates the cricoid cartilage from the thyroid cartilage (correct)
What is the only complete cartilaginous ring in the larynx?
What is the only complete cartilaginous ring in the larynx?
Which of the following statements about the soft palate is true?
Which of the following statements about the soft palate is true?
Which nerve is responsible for the motor function of all muscles of the larynx except the cricothyroid muscle?
Which nerve is responsible for the motor function of all muscles of the larynx except the cricothyroid muscle?
What is the function of the posterior cricoarytenoid muscle?
What is the function of the posterior cricoarytenoid muscle?
What is the site used for an emergency airway access?
What is the site used for an emergency airway access?
What is the result of unilateral RLN injury?
What is the result of unilateral RLN injury?
What is the function of an oral airway (OPA) device?
What is the function of an oral airway (OPA) device?
Which nerve is responsible for the sensory function above the vocal cords?
Which nerve is responsible for the sensory function above the vocal cords?
What is the result of bilateral RLN injury?
What is the result of bilateral RLN injury?
Which of the following cartilages is NOT paired?
Which of the following cartilages is NOT paired?
What is the primary function of the arytenoid cartilage movement?
What is the primary function of the arytenoid cartilage movement?
What is the response to noxious stimuli that causes vocal cord closure?
What is the response to noxious stimuli that causes vocal cord closure?
What is the function of the thyroepiglottic ligament?
What is the function of the thyroepiglottic ligament?
What is the afferent limb of the gag reflex?
What is the afferent limb of the gag reflex?
What is the shape of the thyroid cartilage?
What is the shape of the thyroid cartilage?
What is the location of the cuneiform cartilages?
What is the location of the cuneiform cartilages?
Which of the following cartilages provides support for the aryepiglottic fold?
Which of the following cartilages provides support for the aryepiglottic fold?
Which of the following is the location of the vallecula?
Which of the following is the location of the vallecula?
Which of the following cartilages attaches to the tongue at the base of the hyoid bone?
Which of the following cartilages attaches to the tongue at the base of the hyoid bone?
Which of the following cartilages forms the laryngeal prominence?
Which of the following cartilages forms the laryngeal prominence?
Which of the following statements about the arytenoid cartilage is true?
Which of the following statements about the arytenoid cartilage is true?
Which of the following nasal sinuses is the largest and only present at birth?
Which of the following nasal sinuses is the largest and only present at birth?
At which level of the cervical spine is the oropharynx typically found?
At which level of the cervical spine is the oropharynx typically found?
What is the primary function of the soft palate?
What is the primary function of the soft palate?
Which of the following structures lies above the sphenoidal sinus in the sella turcica?
Which of the following structures lies above the sphenoidal sinus in the sella turcica?
What is the typical drainage point of the maxillary and frontal sinus?
What is the typical drainage point of the maxillary and frontal sinus?
Which muscle is responsible for the abduction of the airway?
Which muscle is responsible for the abduction of the airway?
Which nerve is responsible for the sensory function below the vocal cords?
Which nerve is responsible for the sensory function below the vocal cords?
What is the result of acute bilateral RLN injury?
What is the result of acute bilateral RLN injury?
Which muscle is responsible for the closure of the glottis?
Which muscle is responsible for the closure of the glottis?
What is the efferent response of the gag reflex obtained via?
What is the efferent response of the gag reflex obtained via?
What is the location of the cricothyroid membrane?
What is the location of the cricothyroid membrane?
What is the result of laryngospasm?
What is the result of laryngospasm?
What is the site used for an emergency airway access?
What is the site used for an emergency airway access?
An OPA opens the larynx
An OPA opens the larynx
Laryngospasm may be provoked by airway instrumentation, pain, or visceral stimuli
Laryngospasm may be provoked by airway instrumentation, pain, or visceral stimuli
During which stage of anesthesia is laryngospasm a concern?
During which stage of anesthesia is laryngospasm a concern?
What are the signs and symptoms of laryngospasm?
What are the signs and symptoms of laryngospasm?
What is the primary treatment for laryngospasm?
What is the primary treatment for laryngospasm?
At which point is the airway narrowest in infants and children? (select 2)
At which point is the airway narrowest in infants and children? (select 2)
At what level is the airway narrowest in adults?
At what level is the airway narrowest in adults?
Why is the epiglottis significant in infants?
Why is the epiglottis significant in infants?
SLN injury is associated with respiratory distress
SLN injury is associated with respiratory distress
Unilateral RLN injury can result in complete paralysis of vocal cords
Unilateral RLN injury can result in complete paralysis of vocal cords
What is a potential cause of left recurrent laryngeal nerve (RLN) injury?
What is a potential cause of left recurrent laryngeal nerve (RLN) injury?
Is the soft palate capable of stretching and becoming more movable with age or obesity?
Is the soft palate capable of stretching and becoming more movable with age or obesity?
What is true about the hard palate?
What is true about the hard palate?
What is the correct description of corniculate cartilages?
What is the correct description of corniculate cartilages?
What is the function of Arytenoid cartilage movement in relation to vocal cords?
What is the function of Arytenoid cartilage movement in relation to vocal cords?
What do the vocal cords attach to anteriorly and posteriorly?
What do the vocal cords attach to anteriorly and posteriorly?
What is the correct order of airway structures from pharynx to carina?
What is the correct order of airway structures from pharynx to carina?
Trachea is anterior to the esophagus
Trachea is anterior to the esophagus
What is the correct range of the larynx?
What is the correct range of the larynx?
The base of which cartilage articulates with and rotates on cricoid cartilage?
The base of which cartilage articulates with and rotates on cricoid cartilage?
What lies behind the tongue and forms the superior part of the anterior wall of the larynx?
What lies behind the tongue and forms the superior part of the anterior wall of the larynx?
Which laryngeal cartilage is located most anterior and cephalad of all others?
Which laryngeal cartilage is located most anterior and cephalad of all others?
What is attached to the internal surface of the thyroid cartilage and projects over the pharynx, allowing the passage of air into the larynx, trachea, and lungs?
What is attached to the internal surface of the thyroid cartilage and projects over the pharynx, allowing the passage of air into the larynx, trachea, and lungs?
What cartilage has an inferior horn with a circular facet that allows it to articulate with the cricoid cartilage?
What cartilage has an inferior horn with a circular facet that allows it to articulate with the cricoid cartilage?
Which single cartilage lies mostly in the subglottic region?
Which single cartilage lies mostly in the subglottic region?
What provides sensory innervation to the trachea?
What provides sensory innervation to the trachea?
What is the direction of the carina, which is the last tracheal cartilage?
What is the direction of the carina, which is the last tracheal cartilage?
What is the function of extrinsic muscles in relation to the airway?
What is the function of extrinsic muscles in relation to the airway?
What is the function of the intrinsic muscles in the airway?
What is the function of the intrinsic muscles in the airway?
What does abduction refer to in the context of airway anatomy?
What does abduction refer to in the context of airway anatomy?
What nerve provides innervation to all intrinsic muscles of the airway except the cricothyroid muscle?
What nerve provides innervation to all intrinsic muscles of the airway except the cricothyroid muscle?
All intrinsic muscles play a role in adduction of airway except posterior cricoarytenoid which abducts airway
All intrinsic muscles play a role in adduction of airway except posterior cricoarytenoid which abducts airway
What is true about the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN)?
What is true about the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN)?
At what level of the spine does the Superior Laryngeal Nerve (SLN) arise from the vagus nerve?
At what level of the spine does the Superior Laryngeal Nerve (SLN) arise from the vagus nerve?
At which point does the Superior Laryngeal Nerve (SLN) divide into internal and external branches?
At which point does the Superior Laryngeal Nerve (SLN) divide into internal and external branches?
What muscle does the external branch of the superior laryngeal nerve (SLN) provide motor innervation to?
What muscle does the external branch of the superior laryngeal nerve (SLN) provide motor innervation to?
What is unique about the recurrent laryngeal nerve (RLN)?
What is unique about the recurrent laryngeal nerve (RLN)?
What is triggered by sensory receptors in the glottis and subglottic mucosa, resulting in strong adduction of the vocal cords?
What is triggered by sensory receptors in the glottis and subglottic mucosa, resulting in strong adduction of the vocal cords?
The efferent response of the gag reflex is obtained via which nerve?
The efferent response of the gag reflex is obtained via which nerve?
Where does the gag reflex synapse?
Where does the gag reflex synapse?
What is the likely result of damage to the recurrent laryngeal nerve (RLN)?
What is the likely result of damage to the recurrent laryngeal nerve (RLN)?
What is the site used to perform a transtracheal block to anesthetize the recurrent laryngeal nerve (RLN)?
What is the site used to perform a transtracheal block to anesthetize the recurrent laryngeal nerve (RLN)?
What are the possible causes of recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) injury?
What are the possible causes of recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) injury?
Which cartilage(s) primarily facilitate vocal cord movement?
Which cartilage(s) primarily facilitate vocal cord movement?
Flashcards
Ethmoid sinus function
Ethmoid sinus function
A network of air cells in the ethmoid bone, divided into posterior, middle, and anterior cells.
Frontal sinus location
Frontal sinus location
Located in the frontal bone, draining into the middle nasal meatus.
Maxillary sinus size
Maxillary sinus size
Largest sinus, present at birth, found in the maxilla.
Maxillary sinus drainage
Maxillary sinus drainage
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Sphenoidal sinus location
Sphenoidal sinus location
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Oropharynx level
Oropharynx level
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Oropharynx boundaries
Oropharynx boundaries
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Mallampati classification
Mallampati classification
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Hard palate function
Hard palate function
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Soft palate function
Soft palate function
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RLN innervation
RLN innervation
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SLN innervation
SLN innervation
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Arytenoid cartilage shape
Arytenoid cartilage shape
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Cricothyroid membrane function
Cricothyroid membrane function
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Cricoid cartilage structure
Cricoid cartilage structure
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Epiglottis function
Epiglottis function
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Laryngeal prominence
Laryngeal prominence
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Bilateral RLN injury
Bilateral RLN injury
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Trachea location
Trachea location
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Vocal cord abduction
Vocal cord abduction
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Laryngospasm trigger
Laryngospasm trigger
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Cricothyrotomy site
Cricothyrotomy site
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Study Notes
Nasal Sinuses
- Ethmoid sinus: consists of numerous air cells, divided into posterior, middle, and anterior cells
- Frontal sinus: lies in the frontal bone, drains into the middle nasal meatus
- Maxillary sinus: largest sinus, present at birth, lies in maxilla on each side, drains into the middle nasal meatus
- Sphenoidal sinus: contained within sphenoid bone, pituitary gland lies above in sella turcica
Oropharynx
- Found at C2-C3 level
- Bound superiorly by soft palate, inferiorly by epiglottis
- Where we assess Mallampati classification
- Hard palate: immobile/stationary, covers anterior portion of oral cavity
- Soft palate:
- Covers posterior portion of oral cavity
- Rises when eating or drinking, preventing ingested substances from going to nose
- Can stretch and become more movable with age or obesity
- Blood supply to mouth primarily from branches of the external carotid artery
Pharynx and Larynx
- Pharynx and larynx are different structures
- Larynx begins with the epiglottis and extends to the cricoid cartilage
- OPA does not open the larynx, resolves occlusion usually from tongue or redundant tissue in pharynx
Cartilages of the Larynx
- Paired: arytenoids, corniculates, cuneiforms
- Arytenoids:
- Paired, flexible, pyramid-shaped cartilages
- Base articulates with and rotates on cricoid cartilage
- Vocal cords attach to arytenoid cartilages posteriorly and thyroid cartilages anteriorly
- Movement allows for tension and relaxation of vocal cords
- Corniculate and cuneiforms:
- Corniculate cartilages are paired conical nodules resting on the arytenoid apex
- Cuneiform cartilages are paired cartilages that lie along the lateral edge of the arytenoids
- Both provide support for the aryepiglottic fold
- Single: epiglottis, thyroid, cricoid (ETC)
- Epiglottis:
- Curved leaf structure
- Located most anterior and cephalad of all laryngeal cartilages
- Lies behind tongue and forms superior part of the anterior wall of pharynx
- Attaches to tongue at the base of the hyoid bone and anteriorly by the hypoepiglottic ligament
- Extends down to the thyroid cartilage, attaching via the thyroepiglottic ligament
- Thyroid cartilage:
- Shield-shaped and largest cartilage
- Forms the laryngeal prominence (Adam’s apple)
- Attaches to the inferior laryngeal constrictors, sternothyroid, and thyrohyoid muscles
- Inferior horn of thyroid cartilage has a circular facet that articulates with the cricoid cartilage
- Attached to the hyoid bone via the thyrohyoid ligament and the cricoid via the cricothyroid membrane
- Cricothyroid membrane is our emergency airway because it’s beneath the vocal cords
- Cricoid cartilage:
- Single hyaline cartilage shaped like a ring
- Is the only complete cartilaginous ring
- Attaches to the thyroid cartilage and arytenoids
- Separated from the thyroid cartilage by the cricothyroid membrane
- Lies mostly in the subglottic region
- Trachea:
- Tubular structure from cricoid cartilage to carina
- Anterior to esophagus
- Cricoid cartilage is the only cartilage of trachea that is a complete ring
- Sensory innervation is from the RLN
- Carina is downward and backward projection of last tracheal cartilage
Innervation of the Airway
- Airway muscles:
- Extrinsic muscles: outside of the airway, provide gross motor movement to larynx
- Intrinsic muscles: inside of the airway, provide fine motor movement for sound production, phonation, and movement of vocal cords
- All intrinsic muscles innervated by RLN except the cricothyroid, which is innervated by SLN
- Abduction: opening of airway
- All intrinsic muscles play a role in adduction of airway except posterior cricoarytenoid, which abducts airway
- Transverse arytenoid and oblique arytenoid close glottis
- If there is damage to the RLN, there is unopposed adduction, causing potential airway problems
Cricothyrotomy and Emergency Airway
- Site used as an emergency airway because it’s below the vocal cords
- Attaches superior surface of cricoid cartilage to inferior edge of thyroid cartilage
- Can be identified 1-1.5 fingerbreadths below the laryngeal prominence
- Site used to perform transtracheal block to anesthetize the RLN
RLN and SLN Injury
- Damage causes vocal cord dysfunction
- Damage secondary to surgery, neoplasms, trauma
- Unilateral RLN injury:
- Paralysis of the ipsilateral vocal cord
- Vocal cords compensate by shifting to the uninjured side
- Causes hoarseness
- Left RLN injury can occur from mitral stenosis, dissecting aortic arch aneurysms
- Bilateral RLN injury affects both vocal cords
- Chronic bilateral RLN injury – patients compensate but have gruff speech and increased risk of aspiration
- Acute bilateral RLN injury:
- Causes unopposed tension and adduction of the vocal cords
- Stridor → respiratory distress → death
- SLN injury is not associated with respiratory distress
Laryngospasm
- Laryngospasm: response to noxious stimuli causing vocal cords to close
- Provoked by airway instrumentation/foreign body or vocal cord irritation
- May also result from pain or visceral stimuli
- Can cause partial or complete airway obstruction
- Can cause hypoxia and NPEE (negative pressure pulmonary edema), dysrhythmias, cardiac arrest, and death
- Concern in stage 2 (delirium/excitement) of general anesthesia
- Afferent limb and efferent limb???
- Inspiratory stridor
- Suprasternal and subclavicular retraction during inspiration
- Paradoxical appearance of chest wall
- Treatment:
- Remove stimulus
- O2 and PPV
- Deepen anesthetic
- Bilateral pressure at laryngospasm notch (Larson’s maneuver)
- Neuromuscular blocking agent
Nasal Sinuses
- Ethmoid sinus: consists of numerous air cells, divided into posterior, middle, and anterior cells
- Frontal sinus: lies in the frontal bone, drains into the middle nasal meatus
- Maxillary sinus: largest sinus, present at birth, lies in maxilla on each side, drains into the middle nasal meatus
- Sphenoidal sinus: contained within sphenoid bone, pituitary gland lies above in sella turcica
Oropharynx
- Found at C2-C3 level
- Bound superiorly by soft palate, inferiorly by epiglottis
- Where we assess Mallampati classification
- Hard palate: immobile/stationary, covers anterior portion of oral cavity
- Soft palate:
- Covers posterior portion of oral cavity
- Rises when eating or drinking, preventing ingested substances from going to nose
- Can stretch and become more movable with age or obesity
- Blood supply to mouth primarily from branches of the external carotid artery
Pharynx and Larynx
- Pharynx and larynx are different structures
- Larynx begins with the epiglottis and extends to the cricoid cartilage
- OPA does not open the larynx, resolves occlusion usually from tongue or redundant tissue in pharynx
Cartilages of the Larynx
- Paired: arytenoids, corniculates, cuneiforms
- Arytenoids:
- Paired, flexible, pyramid-shaped cartilages
- Base articulates with and rotates on cricoid cartilage
- Vocal cords attach to arytenoid cartilages posteriorly and thyroid cartilages anteriorly
- Movement allows for tension and relaxation of vocal cords
- Corniculate and cuneiforms:
- Corniculate cartilages are paired conical nodules resting on the arytenoid apex
- Cuneiform cartilages are paired cartilages that lie along the lateral edge of the arytenoids
- Both provide support for the aryepiglottic fold
- Single: epiglottis, thyroid, cricoid (ETC)
- Epiglottis:
- Curved leaf structure
- Located most anterior and cephalad of all laryngeal cartilages
- Lies behind tongue and forms superior part of the anterior wall of pharynx
- Attaches to tongue at the base of the hyoid bone and anteriorly by the hypoepiglottic ligament
- Extends down to the thyroid cartilage, attaching via the thyroepiglottic ligament
- Thyroid cartilage:
- Shield-shaped and largest cartilage
- Forms the laryngeal prominence (Adam’s apple)
- Attaches to the inferior laryngeal constrictors, sternothyroid, and thyrohyoid muscles
- Inferior horn of thyroid cartilage has a circular facet that articulates with the cricoid cartilage
- Attached to the hyoid bone via the thyrohyoid ligament and the cricoid via the cricothyroid membrane
- Cricothyroid membrane is our emergency airway because it’s beneath the vocal cords
- Cricoid cartilage:
- Single hyaline cartilage shaped like a ring
- Is the only complete cartilaginous ring
- Attaches to the thyroid cartilage and arytenoids
- Separated from the thyroid cartilage by the cricothyroid membrane
- Lies mostly in the subglottic region
- Trachea:
- Tubular structure from cricoid cartilage to carina
- Anterior to esophagus
- Cricoid cartilage is the only cartilage of trachea that is a complete ring
- Sensory innervation is from the RLN
- Carina is downward and backward projection of last tracheal cartilage
Innervation of the Airway
- Airway muscles:
- Extrinsic muscles: outside of the airway, provide gross motor movement to larynx
- Intrinsic muscles: inside of the airway, provide fine motor movement for sound production, phonation, and movement of vocal cords
- All intrinsic muscles innervated by RLN except the cricothyroid, which is innervated by SLN
- Abduction: opening of airway
- All intrinsic muscles play a role in adduction of airway except posterior cricoarytenoid, which abducts airway
- Transverse arytenoid and oblique arytenoid close glottis
- If there is damage to the RLN, there is unopposed adduction, causing potential airway problems
Cricothyrotomy and Emergency Airway
- Site used as an emergency airway because it’s below the vocal cords
- Attaches superior surface of cricoid cartilage to inferior edge of thyroid cartilage
- Can be identified 1-1.5 fingerbreadths below the laryngeal prominence
- Site used to perform transtracheal block to anesthetize the RLN
RLN and SLN Injury
- Damage causes vocal cord dysfunction
- Damage secondary to surgery, neoplasms, trauma
- Unilateral RLN injury:
- Paralysis of the ipsilateral vocal cord
- Vocal cords compensate by shifting to the uninjured side
- Causes hoarseness
- Left RLN injury can occur from mitral stenosis, dissecting aortic arch aneurysms
- Bilateral RLN injury affects both vocal cords
- Chronic bilateral RLN injury – patients compensate but have gruff speech and increased risk of aspiration
- Acute bilateral RLN injury:
- Causes unopposed tension and adduction of the vocal cords
- Stridor → respiratory distress → death
- SLN injury is not associated with respiratory distress
Laryngospasm
- Laryngospasm: response to noxious stimuli causing vocal cords to close
- Provoked by airway instrumentation/foreign body or vocal cord irritation
- May also result from pain or visceral stimuli
- Can cause partial or complete airway obstruction
- Can cause hypoxia and NPEE (negative pressure pulmonary edema), dysrhythmias, cardiac arrest, and death
- Concern in stage 2 (delirium/excitement) of general anesthesia
- Afferent limb and efferent limb???
- Inspiratory stridor
- Suprasternal and subclavicular retraction during inspiration
- Paradoxical appearance of chest wall
- Treatment:
- Remove stimulus
- O2 and PPV
- Deepen anesthetic
- Bilateral pressure at laryngospasm notch (Larson’s maneuver)
- Neuromuscular blocking agent
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