Larynx - microscopic laryngoscopy

Dr. See - ENT

9.11.2020

3 ways to examine the larynx

1. Mirror laryngoscopy
- Size 4 - ideal size for laryngeal mirror
- Illusions
- patient is in front of the examiner
- patient's laterality is opposite of the examiner's
laterality - uses the vision of a microscope to do microlaryngeal
2. Endoscopic laryngoscopy surgery
1. 70 or 90-degrees Rigid laryngoscopy
- 70 or 90-degrees is the inclination of the lens at the > ENDOCAM
tip of the laryngoscope - allows visualization of the larynx via mobile devices
2. Flexible laryngoscopy
- inserted through the nose > Stroboscopy
- fiber optic lens - an instrument that allows the visualization of the motion
3. Direct laryngoscopy and vibration of the vocal cords
- uses a synchronized, flashing LED light of 60,000-80,000
per second

Normal Larynx Piriform

_
- patient is lying down
- patient's head is proximal to the examiner
- patient's feet is distal to the examiner
- laryngoscope -inserted through the mouth to create
> Structures that are visible:
space for visualization or manipulation of the laryngeal
- arytenoids
area
- piriform sinus - located at the posterolateral to either side of
- direct visualization of the larynx without aid of
the laryngeal opening
equipments (mirror, endoscope)
- vocal folds
- tracheal cartilage
- cricoid cartilage
- tracheal rings

- suspension laryngoscopy
- with endotracheal tube with balloon inflated to
avoid aspiration and to access airway
- do not suspend on the patient's chest because it
may cause post-op pain. suspend it on a mayo table. > PHONATION
- the vocal cords goes into the midline
- voice is produced through the vibration of the vocal cords
- laryngeal ADductor muscles
- group of muscles that acts on the vocal ligament to
produce phonation
1. Thyroarytenoid muscle (Dr.Po)
 2. Cricothyroid muscle (Dr. See) VOCAL CORD NODULE
3. Lateral Cricoarytenoid muscle
4. Interarytenoids
- laryngeal ABductor muscles
- Posterior Cricoarytenoid (PCA)
- moves the vocal cords on the lateral side
- for breathing

> HOARSENESS
- most common laryngeal chief complaint

LARYNGITIS
- the usual case associated with hoarseness
- Acute Laryngitis - <3 weeks duration - junction of the anterior 1/3rd of vocal cords and posterior
2/3rds Highest
- location of the highest tension in the vocal cords
- usual location of lesions
- benign lesion

VOCAL CORD PARALYSIS

- Vagus Nerve
- nerve supply to the larynx through the laryngeal nerve:
- Superior laryngeal nerve
- Inferior laryngeal nerve/Recurrent laryngeal nerve
- Left vagus nerve is the longest as it gives rise to the left
recurrent laryngeal nerve which hooks around the aortic
- (+) Inflamed Vocal Cords arch
- pinkish color of vocal cords (normally vocal cords should - upon assessing vocal cord paralysis check the head,
be white) neck, and chest.
- irregular, rough edges - Pulmonary Tuberculosis - causes compression of the
- swollen vocal cords recurrent laryngeal nerve via the hilar lymph nodes
- (+) hoarseness - Cardiomegaly secondary to chronic hypertension -
- the vocal cords cannot obtain the full coaptation the CM heart can pull the recurrent laryngeal nerve,
- management: injuring it.
- if acute - can be treated empirically/medically - Mediastinal tumors
- antibiotics - Trauma
- steroids
- mucolytics
- voice rest
- >3 weeks (chronic) despite empirical treatment -
examine the larynx
 > VOCAL CORD POSITIONS (not discussed, nice to know)

- UNILATERAL VOCAL FOLD PARALYSIS

- only one vocal fold moves
- normally, patient's vocal cord doesn't cross the midline.
In vocal fold paralysis, there will be a gap in between the
two vocal folds when it adducts.
- patient will have hoarseness since the vocal folds cannot
fully close in the midline. Air will leak out from the gap
between the two vocal folds during phonation.
- patient complains of hoarseness
- management: insertion of material (silicone/metallic) to
push to paralyzed vocal fold in the midline.

- BILATERAL VOCAL FOLD PARALYSIS

- when the patient breaths, there is limitation in the
abduction of the bilateral vocal folds.
- when the patient phonates, the bilateral vocal folds
doesn't move or adduct.
- usually associated with post-op bilateral thyroidectomy
- patient has near normal voice but there will be a change
in the quality of the voice
- patient complains of easy fatigability due to shortness of
breath.
- patient's problem is in the limitation of abduction of the
vocal folds, compromising the airway. (image)
- management: pull one arytenoid laterally to increase
> VOCAL CORD COMPENSATION airway but the patient will have poor voice
- the unaffected, normal vocal cord crosses the midline
and touches the affected, paralyzed vocal cord. Produces
less normal to normal voice
VOCAL CORD MASS LARYNGEAL CYST

> benign smooth mass

LARYNGOMALACIA

- in pediatric patients, the larynx is very compressible

- when the patient lies down, there is a flapping motion of
> exophytic mass
the arytenoids to the epiglottis
- associated with patients who smokes
- (+) stridor
- laryngeal cancer is divided into three: supraglottic cancer,
- stridor vs wheezes
glottic cancer, subglottic cancer
- timing of the noise
- if the mass is confined to the glottic area, the cancer rarely
- stridor - upper respiratory
metastasize because the glottis area have no lymphatic
- air failing to get inside the lungs (timing is
drainage.
inspiratory)
1. Supraglottic - upper
- wheezes - alveolar level
LN
- air failing to get out of the lungs (expiratory)
2. Glottic - none
3. Subglottic:
INTUBATION GRANULOMA
- pretracheal LN
- lower deep cervical
nodes
- supraclavicular
nodes
- superior
mediastinal nodes

- In glottic cancers, biopsy the mass and administer

radiotherapy
- glottic cancers have good prognosis - Conversion tracheostomy
- if patient requires intubation for >3-5 days in adults
- if patient requires intubation for >7-10 days in
children
 TONSILLAR GRADING

- Subglottic granuloma - in some cases, the granuloma can

be inferior the vocal cords

EPIGLOTTITIS Grade Description

1 Tonsils are within the tonsilar
bed

2 Tonsils reach the tonsilar bed,

palatoglossus and
palatopharyngeus

3 Tonsils goes beyond the

tonsilar pillar and obstructs
75% of the oral cavity

4 Tonsils are in the midline or

touches each other (Kissing
tonsils)

Ap Lateral
Upright waters view - head
FOREIGN BODY

- Inflamed epiglottis
- airway is partially compromised

- Laryngeal vs Esophageal FB
- anatomically, the opening of the esophagus is horizontal
- the opening of the larynx is vertical
 - structures visible:
- frontal sinus
- ethmoid air cell
- rim of orbit
- maxillary sinus
- Classic Waters View
- patient is placed on a prone position
- significant in checking air-fluid levels in the sinus

- maxillary sinus air-fluid levels

- FB: Upper Denture

UPRIGHT WATERS VIEW

- (+) air-fluid level on the Left maxillary sinus, (-) Right air-fluid
level, (+) Right mucoperiosteal thickening
- Mucoperiosteal thickening
- density on the poster- lateral border
- indicative of recurrent, chronic sinusitis

- a.k.a "nose-chin" radiographic examination

- the plate is placed on the tip of the nose and on the chin
- the x-ray tube is at the back
SKULL FRACTURES

- nasal bone fracture

- Zygomatic fracture
BRAIN ABSCESS

- (+) Chronic Otitis Media with purulent foul-smelling

discharge
- (+) Cholesteatoma leading to brain abscess as complication
- tripod fracture
to chronic OM
- (+) Headache
- Town's view - bilateral ear x-ray view of the mastoid
HEAD AND NECK SURGERY
RECONSTRUCTIVE SURGERY

- Malignant Melanoma
- Excision requires 0.5-1mm margin on all sides
- In closing the excision, wait for the pathologist to confirm
that the margin are clean of malignancy

- Rotational flap
- from the diameter of the lesion, you harvest skin from
the posterior at a length multiplied by 4 and pull it
anteriorly

- wait for 4-6 weeks until the donor site is accepted by the
recipient bed
- cut the remaining skin and return it to the forehead

- Midline forehead flap

- get tissue from the forehead and rotate it toward the
defect
- 2-stage procedure:
- post-op midline forehead flap

- delto-pectoral flap
- 2-stage procedure
- same procedure with midline forehead flap

- pectoralis major myocutaneous flap

- 1-stage procedure
- do not include the nipple
- the blood supply of the pectoralis major is included in
the flap
- END OF LECTURE -