clinical review of larynx upper resp tract

7/31/2019 Clinical Review of Larynx Upper Resp Tract

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Clinical Review of Larynx &Upper Respiratory Tract

Manny Trujillo, Jr., MDDepartment of Surgical Education

Spartanburg Regional Healthcare System04.16.12


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"Dispel from your mind the thought thatan understanding of the human body inevery aspect of its structure can be given inwords; the more thoroughly you describe

the more you will confuse... I advise younot to trouble with words unless you arespeaking to blind men."

Leonardo da Vinci


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Objectives

Enumerate the pertinent functions andanatomy of upper respiratory tract and

larynx

Familiarization with consequences of

alterations in normal function of upperrespiratory tract and larynx


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Upper Respiratory Tract

Nasal Cavity Main conducting airway for inhaled air Filtration, conditioning, olfaction, resonating

chamber contributing to sound production

Paranasal Sinuses Frontal, ethmoidal, sphenoidal, maxillary Conditioning, sound resonance, decrease skull weight

Pharynx Nasopharynx, Oropharynx, Laryngopharynx Air passage between nasal cavity and larynx Passageway for swallowed food and drink between

oral cavity and esophagus


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Upper Respiratory Tract

Sagittal depiction Paranasal Sinuses


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Rhinitis

Clinical manifestation of inflammatory response toinfection/allergy

Edema of mucosa (high vascularity) Infections of nasal cavities can spread to:

Anterior cranial fossa through cribiform plate

Nasopharynx and retropharyngeal soft tissues

Middle ear through pharyngotympanic tube Paranasal sinuses

Lacrimal apparatus and conjunctiva


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Nasal Fractures

Fracture of the nasal bones and/or cartilages

Often associated with other maxillofacial fractures

Must rule out concomitant airway, central nervous

system, visceral, and orthopedic injuries


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Nasal Fractures


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Epistaxis

Anterior (90%): Kiesselbachs plexus - anastomosis of the anterior

ethmoidal, greater palatine, sphenopalatine, andsuperior labial arteries

Treatment: Anterior packing

Posterior (10%): Woodruffs plexus anastomosis of pharyngeal,

posterior nasal, sphenopalatine, and posterior septalarteries

Treatment: Posterior packing, reduction of fractures,

embolization

Causes: trauma (#1), hypertension, infections


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Epistaxis


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Deviated Septum

Common occurrence

Variable presentations

Mild subclinical

Severe obstructive

Usually secondary totrauma in adolescence(minor incidencechildbirth)

Surgical correctioncurative


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Sinusitis

Etiologies:

Infection (viral MC!!) Allergy Autoimmune disease

Phases:

Acute New infection lasting up to 4 weeks

RecurrentAcute 4 or more separate episodes in one year

Subacute

Infection lasting between 4 and 12weeks Represents a transition between acute

and chronic infection Chronic

Signs and symptoms lasting more than12 weeks

Acute Exacerbation of Chronic

Exacerbation of chronic symptoms thatreturn to baseline after treatment

Treatment:

Acute Suspected viral

Supportive tx (analgesic, antipyretic,decongestant, intranasal corticosteroid,intranasal saline, mucolytic)

Suspected bacterial Immunocompromised or with severe

illness Antibiotics (10-14 days),Surgery consult

Immunocompetent nonseverewatchful waiting up to 7 days and

supportive tx

Chronic Antibiotics (3-4 weeks) Nasal saline irrigations Intranasal corticosteroids Functional Endoscopic Sinus Surgery

(FESS) reserved for failed medical

management

Inflammation of mucous membrane lining the paranasal sinuses


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Fulminant Fungal Sinusitis

24 hrs after presentation After debridement After partial closure


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Ethmoidal Sinusitis

Obstruction ofethmoidalinfundibulum to middlemeatus

Spread of infectionwith fracture oflamina papyracea

Proximity to optic canal

(optic nerve,ophthalmic artery) Complications include

optic neuritis andblindness

EthmoidalSinus

Pansinusitis with obstruction ofmiddle meatus


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CT scans used to evaluate persistence of chronic sinusitis

Pre-treatment Post-treatment

Sinusitis


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Tonsillitis

Waldeyers Ring

Pharyngeal tonsil(Adenoid)

Tubal tonsils Palatine tonsils

Lingual tonsils

Perfusion/Drainage

Tonsillar artery (viaFacial a.)

External Palatine vein


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Inflammation/infectionof tonsils

Etiologies: Viral (#1) Bacterial (#2)

GABHS

Allergic Neoplastic

Treatment: Non GABHS analgesics GABHS analgesics, ABX

x 10 days, corticosteroids Recalcitrant (>7/yr, >5/yr

x 2 yr, >3/yr x 3 yr) or withexacerbating factorsTonsillectomy

Tonsillitis

Culture-positiveStrep pharyngitis

with tonsillar exudates


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Nasopharyngeal Cancer

Rare in North America,more common in China

40% overall survival at 5years

Complete H&P, carefulotologic, neurologic,cervical and NP exams

Three WHO types - all from

NP epithelium Types II, III - better

prognosis, EBV assoc.

Treatment is primarily XRT

+/- chemo


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Laryngeal Anatomy

Cartilages(Unpaired, Paired)

Ligaments,Membranes, andSpaces

Musculature

Innervation andVasculature

Anterior View


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Functions of the Larynx

Respiration

Vocalization(Phonation)

Increasing intra-abdominal airpressure

Posterior View


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Vocalization (Phonation)

1. To phonate, the vocal folds must vibrate

2. To vibrate, they must be held close enough together

to impede the airflow through the glottis

3. Muscles bring them together & hold them there

4. The transglottal airflow itself sets them intovibration, and maintains the vibration

Myoelastic Aerodynamic Theory of Phonation(Elastic recoil and Bernoulli forces)


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Vertical views of the vocal folds

during one vibratory cycle

1

2

3

4

5

6

The folds are three-dimensional, and they vibratein three dimensions.

The pattern of vibration is likea wave travelling up them.

The lower sections part first,and come together first.

Cover (outer layer) and body

(inner layers) of folds are oftendistinguished, because theyvibrate fairly independently

After Stevens (1998) Acoustic Phonetics

(Baer, 1975)


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Myoelastic Aerodynamic Theory of

Vocal Fold Vibration

(van den Berg, 1950s)

1. Muscular activity rotates and rocks the arytenoid cartilages so thattheir vocal processes come together in the midline, thus positioningthe vocal folds close together or in actual contact.

2. Air pressure increases below the glottis until folds forced apart.(The subglottal pressure increase leads to a transglottal pressuredrop.)

3. Air travels faster through the glottis when it is narrow. This causesa local drop in air pressure (Bernoulli effect)whichcauses the

folds to be sucked towards each other.

4. The Bernoulli effect, together with the elastic recoil force exerted bythe displaced vocal folds, causes complete glottal closure again.

5. The process begins again at step 2


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Vocal Fold Vibration


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Nerves Supplying Larynx

Superior laryngeal nerve Internal branch sensation

to larynx External branchmotor

innervation to cricothyroidmuscle and anterior portionof cricopharyngeus muscle(posterior portion supplied

by ILN)

Inferior laryngeal nerve Terminal part of recurrent

laryngeal nerve Motor to ALL intrinsic

laryngeal muscles exceptcricothyroid

Nerve supply to larynx entirely from CN X (Vagus n.)


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Nerve of Galli-Curci

1882 - 1963

Italian opera singer

1935 Thyroidectomy forsymptomatic goiter

Continued voice

decline

Nerve of Galli-Curci


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Laryngeal Cancer

Any patient with hoarseness lastinglonger than 2 weeks should undergo

laryngeal examination

Most common cancer of the upperaerodigestive tract

Subtypes Glottic Cancer (59%) Supraglottic Cancer (40%) Subglottic Cancer (1%)

Most subglottic masses areextension from glottic carcinomas

Treatment depends on: Site of lesion Extent of spread Metastasis

Indications for total laryngectomy T3 or T4 unfit for partial Extensive involvement of thyroid

and cricoid cartilages Invasion of neck soft tissues Tongue base involvement beyond

circumvallate papillae


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Foreign Bodies in Laryngopharynx

3000 deaths/yearfrom foreign bodyaspiration (US)

Most in bronchus(80-90%) Larger objects

lodge in larynx

(10%) Emergent

interventionrequired


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Cricothyroidotomy

Needle Cricothyroidotomy

Large bore needle inserted throughcricothyroid ligamentto permit fast entry ofair

Temporizing procedure (CO2

retention)

Surgical Cricothyroidotomy

Incision with dissection to cricothyroidligament and placement of tracheotomy tube

Obstruction at the level of the vestibule of the larynx


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Cricothyroidotomy

Site ofcricothyroidotomy


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Prolonged intubation

Ventilation support

Manage bronchopulmonary secretion Upper airway obstruction

Obstructive sleep apnea

Bilateral vocal cord paralysis Inability to intubate

Major head & neck surgery or trauma

Indications for Tracheostomy


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Advantages Lower risk of

laryngotracheal injury Improved

comfort/mobility Improve airway

stabilization

Allows for oralnutrition Improved secretion

clearance

Tracheostomy


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Tracheostomy

ShoulderRoll

Transverse Incision

Sternal Notch

Incision through skin, fat, andmuscle


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Tracheostomy

Anteriorjugular vein

Sternohyoidmuscle

Isthmusof thyroid

Ligated anteriorjugular vein

Trachea palpatedby index finger

Pretrachealvenous plexus


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Tracheostomy

Index fingeron trachea

Incising thetrachea Knife spreading

the incision

Cruciateincision

Hook elevatingtracheal cartilage

Tape holding tracheotomytube in place


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To know truly is to know by

causes.

- Francis Bacon, De Augmentis Scientiarum

mgtr jillo@srhs com

clinical review of larynx upper resp tract

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