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Anatomy- Vagus. N. ambiguus: Motor - skeletalDorsal nucleus: paraysmpathetic to smooth muscle of bronchi, gut, heartN. solitarius: afferent from pharynx, larynx, and esophagus. Anatomy - Vagus. Jugular foramina - superior ganglion, nodose ganglion (inferior)Meningeal branches, auricular branchPhar. Constrictors, soft palate (most)SLN - int.- sensation to supraglottic larynx - ext- over inf const to cricothyroidRLN - all other laryngeal musclesBranches to carotid bulb, heart, others.9457
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1. Evaluation of the Hoarse Patient Herve’ LeBoeuf, MD
3. Anatomy - Vagus Jugular foramina - superior ganglion, nodose ganglion (inferior)
Meningeal branches, auricular branch
Phar. Constrictors, soft palate (most)
SLN - int.- sensation to supraglottic larynx
- ext- over inf const to cricothyroid
RLN - all other laryngeal muscles
Branches to carotid bulb, heart, others
4. Anatomy - Vagus Right - ant to subclavian, RLN loops SA and ascends in TE groove to C-T membrane
May branch with sensory fibers to glottis and
subglottis, some variability
Left - RLN in thorax, loops aorta post to L.A.
Ascends in TE groove
Non-recurrent nerve in 1% ?
5. Anatomy - skeleton Cartilages - thyroid, cricoid, arytenoid, epiglottic
Inferior thyroid horns - cricoid…synovial
Arytenoids articulate with upper lateral border of the cricoid lamina
Pyramidal - base = synovial, slide , rock, or rotate on cricoid, laterally = muscular process, anteriorly = vocal process to cords
7. Anatomy - Intrinsic Musculature Post C-A - only aBductor of the cords, opens glootis by rotary motion on arytenoids, tenses cords during phonation
Lat C-A - Closes glottis by rotating on aryt. Medially
Transv C-A - unpaired, approximates arytenoid bodies to close post glottis
Obl. Aryt - Closes laryngeal introitus during swallowing
8. Anatomy - Musculature Thyroarytenoid - three parts:
Vocalis - adductor and major tensor of cord
Thyroarytenoideus externus - major adductor
Thyroepiglotticus - shortens vocal ligaments
Cricothyroid - extrinsic as innervated by ext br of SLN, increases tension of cords, esp at upper range of pitch and loudness
9. Histology Outermost layer - pseudostratified squamous epithelium superior and inferior to contact margin
Contact surface - non keratinizing squamous
Lamina propria - 3 layers
- Reinke’s space - few fibroblasts, scant elastic and collagenous fibers
- Intermediate - mainly elastic fibers, mod. Fibroblasts
- Deep layer - collagenous fibers
Thyroarytenoid muscle
11. Physiology Hoarseness: Sx, not Dx
Laryngeal functions:
- Respiration
- Phonation
- Airway protection
- Fixation of the chest during respiration
Hoarseness = problem with phonation
12. Physiology - Speech Pulmonary phase - lung inflation and air expulsion into trachea
Laryngeal phase - column of air vibrate cords according to proximity and tension = fq
Oral phase - sound fq amplified by resonating O/P, O/C, N/P, then modified into speech by lips, pharynx, tongue, teeth
Hoarseness = pathology of laryngeal phase
13. Physiology Intr. adductors tense and approximate cords
Arytenoids remain immobile/ approximated
Air escapes through hiatus from increased subglottic pressure generated from lungs
Mucosal margins everted, then elasticity causes them to return to midline - thyroarytenoid and cords don’t move
Sustained subglottic pressure causes rapid repetition = “mucosal wave”
14. Physiology Frequency = speed of mucosal vibration
Glottic hiatus size/ shape = differing fq
If disrupted (cord lesion, incomplete cord adduction), causes hoarseness
If mucosa elasticity decreased by edema, thickening, then changes fq = hoarseness
FVC flatten laterally, if not then alters air column, alters fq, and causes hoarseness (dysphonia plica ventricularis)
15. Physiology Pitch - altered by fq of mucosal vibration
As TVCs lengthened and tightened, vibration fq increases, and pitch increases
Damping - Cricothyroid compresses cords further together until vibration ceases, post to ant, decreasing hiatal size, and increasing force of air column = vibration fq increases, and pitch increases
Pitch break = neurologic disruption of damping, may cause hoarseness
16. History Hoarseness - rough, scratchy sound - mucosal irregularity
Breathiness - incomplete closure, air hisses through TVC gap
- paralysis, large mass, CA joint problem
Distinguish from articulation/resonance (oral phase), and volume (pulmonary phase)
17. History Geriatric - vocal atrophy, poor conditioning of abdominal and pulmonary musculature
Toxic exposure - tob, etoh, pollutants, pollens directly toxic, increase mucus/ throat clearing
Voice use/ abuse - occupation, poor posture during abuse, compensatory mechanisms injurious
Chronic - nodules - voice rehab
Acute severe - polyps/cysts - surgery
18. History Respiratory
Hormonal - thyroid, estrogen - edema of lamina propria = decreased elasticity
Medications - androg hormones - permanent
Asprin, NSAIDS, antihistamines, diuretics
Food products - milk - casein
GERD - mucosal edema = hoarseness, halitosis, dry mouth….worse in am heartburn absent in half pts
19. History Neurologic
Psychiatric
Surgical history - laryngeal, abdominal, thoracic
20. Exam Complete ENT exam for every new patient with emphasis on IDL, Neck
1854 - larynx examined in vivo - IDL
1980s - fiberoptics = machida
flex end v. rigid end v. strobe
(v. IDL )
IDL not always able to see piriforms to apex
21. Exam - Larynx Evaluate changes in cord mucosa, and appearance of cord in aBd, and aDd
Est glottic gap, (mass, atrophy, poor mobility)
Arytenoid mobility - hypermobile, paretic, paralyzed …..Cancer, CA joint, RLN lesions, masses, neurologic diseases, etc.
22. Ancillary Testing Labs: TSH, LFT
Plain films: CXR, Lat neck
CT scan: cancer, unk dx, persistent or recurrent pain and hoarseness, trauma, foreign body?
MRI - multiple cranial neuropathies - evaluate skull base and brainstem
Modified Ba, Ba swallow,
25. Consultations Speech, Speech, Speech
GI med - ph probes
Pulmonary
Neurology
Psychiatry
26. Strobe Oertel - 1878
Late 1980s - fiberoptics, video
Mechanism
Allows recording of voice and video together = good for f/u to tx and patient education
Glottic closure/gap, precise cord motion, supraglottic funxn, better look at ? masses, mucosal elasticity, cord stiffness, functional disorders, ……fewer DLs
27. EMG/ EGG EGG: whether cords open or closed and rapidity of cord closure
limited if cords don’t approximate well
EMG: determine if paralyzed cord permanent, assisting surgical planning, guiding botox injections for spasmodic dysphonia, CA joint fixation/dislocation v TVC paralysis, RLN paralysis v. complete vocal cord paralysis
28. Panendo Indications Biopsy suspicious lesion
Laryngeal cancer - tumor extent, second primary
Hoarse patients without dx at end of w/u
Persistent or recurrent vocal symptoms …..may need to repeat
Patients with prior cancers with new onset hoarseness