subclavian artery to inferior thyroid artery to inferior laryngeal artery
Larynx venous blood drainage
inferior laryngeal vein to brachiocephalic vein to SVC
3 single cartilages of the larynx
epiglottic, thyroid, cricoid
3 paired cartilages of the larynx
arytenoids, corniculate, cuneiform
What forms the Adam's apple?
thyroid cartilage
largest of the laryngeal cartilages
Thyrohyoid membrane
Attaches thyroid cartilage to the hyoid bone
Narrowest part of the pedi airway
cricoid cartilage
cricothyroid ligament
Attaches cricoid cartilage to the thyroid ligament
First cartilage seen on DL
epliglottic
List the following structures from cephalad to caudad: cricotracheal ligament, thyroid cartilage, 1st tracheal ring, thyrohyoid membrane, cricoid cartilage, cricothyroid membrane, hyoid bone
hyoid bone
thyrohyoid membrane
thyroid cartilage
cricothyroid membrane
cricoid cartilage
cricotracheal ligament
1st tracheal ring
Where is a trach usually placed?
Mid way btw the thyroid notch and the suprasternal notch
A vertical incision is made thru the 2nd and 3rd tracheal rings with the thyroid isthmus divided and retracted
Narrowest part of adult airway
glottis
Position of the rims glottidis
-resting
-forced respiration
-phonation
resting= narrow and wedge shaped
forced respiration= wide and kite shaped
phonation= slit like as VC are closely approximated
rima glottidis
opening btw the VC
What are the 3 functions of the larynx?
protect airway
respiration
vocalization
How does the larynx protect the airway?
Involuntary reflex function
glottis closes by a reflex activated by swallowing
primitive reflex elicited by stimulation of the superior laryngeal nerve
Function of the extrinsic laryngeal muscles
move the larynx as a whole
extrinsic laryngeal muscles
how many?
2 main groups?
8
infrahyoid and suprahyoid
function of the infra hyoid laryngeal muscles
depress hyoid and larynx
function of the supra hyoid laryngeal muscles
elevate hyoid and larynx
function of the intrinsic muscles of the larynx
move laryngeal parts
make changes in length and tension of the VC
open and close the glottis essentially
VC should be ____ during swallowing and ____ during inspiration
closed
open
4 classifications of intrinsic laryngeal muscles
adductors and abductors
sphincters
tensors
relaxers
All but one of the _____ laryngeal muscles are supplied by the _____.
intrinsic
RLN
Only the ______ is innervated by the external laryngeal nerve. All the other intrinsic muscles are supplied by the ____.
cricothyroid
RLN
The RLN is a branch of what CN?
10th CN, vagus
Major tensor intrinsic laryngeal muscles
cricothyroid muscles
tense and elongate the VC, this causes voice pitch to rise
Abductor intrinsic laryngeal muscle
posterior cricoarytenoid
open VC by widening the rims rims
Major adductor intrinsic laryngeal muscle
lateral cricoarytenoid
close VC
work with transverse arytenoid muscles
air gets pushed thru rims glottides to cause vibration of vocal ligaments and to cause phonation
The transverse arytenoid muscles cause
adduction, work with the lateral cricoarytenoid muscles
Thyroarytenoid muscle function
relaxer
relax VC and lower the voice
intrinsic muscles that fall into the category of sphincters
lateral cricoarytenoid
oblique arytenoids
transverse arytenoids
aryepiglottic muscles
What nerves supply the larynx?
Vagus, RNL, and superior LN
What is the only intrinsic laryngeal muscle NOT innervated by the RNL?
the cricothyroid muscle
What supplies sensory innervation of larynx down to the VC?
Internal branch of the superior LN
Function of the external branch of the superior laryngeal nerve
motor
innervates cricothyroid muscle and inferior pharyngeal muscle
What nerve provides sensory innervation of the larynx below the VC?
RLN
Thyroid or parathyroid surgery has the potential to cause damage to what nerve?
RLN
Unilateral RLN injury
cord on the injured side will assume a paramedian position
hoarse and weak voice
increased risk of aspiration
What occurs with bilateral ischemia of the RLN?
Laryngospasm causing complete airway obstruction
What causes laryngospasm?
What nerve is involved
Spasm of glottic muscles
superior LN
The VC are at the level of the?
laryngeal prominence
cricoid cartilage is at the level of the ___ vertebra
C6
Why is the cricoid cartilage an important landmark?
-site where carotid artery can be compressed against the transverse process of C6
-junction of larynx and trachea
-site where pharynx and esophagus join
-point where RLN enters larynx
-narrowest part of the pedi airway
3 parts of the pharynx
nasopharynx- posterior to nose and superior to soft palate
oropharynx- posterior to mouth
laryngopharynx- posterior to larynx
T or F, the pharynx extends from the base of the skull to below the level of the body of C6 where it becomes continuous with the esophagus
T
Anesthesia goals r/t microlaryngoscopy
Atraumatic intubation (minimize bleeding for surgical visualization)
Protect tracheal with cuffed ETT
Adequate oxygenation and ventilation (surgeon wants smallest ETT possible- as small as 4.5 mm)
Minimize secretions- glyco often requested, minimize coughing in response to secretions
Prompt wake up with return of protective reflexes
T or F, MR is typically NOT required for microlaryngoscopy
F
Why is microlaryngoscopy associated with 1.5-4% incidence of Mi or ischemia?
suspended laryngoscope is stimulating
can cause HTN, tachycardia, arrythmias
Possible techniques used to perform microlaryngoscopy
apneic- alternate mask ventilation with surgical incision, use TIVA
spontaneous breathing with deep anesthesia (tricky)
jet ventilation
How does jet ventilation work?
Utilizes the Venturi effect, Bernouli's theory
VC must be relaxed
Jet gas must be allowed to exit freely
Use 100% O2, but air is entrained, so actual FiO2 < 100%
Contraindications / risks of jet ventilation
pedi, obesity, emphysematous bullae
risk= barotrauma
Laser
light amplification by simulated emission of radiation
CO2 laser
most commonly used laser
suitable for removing lesions on VC and larynx
produces radiation with a wavelength of 0.01 mm
YAG and ARGON laser
deep and penetrating effects
suitable for detached retinas
shorter wl than CO2 laser
Major anesthesia considerations r/t laser use
airway fire and eye protection (for all in room!!)
Strategies to avoid an airway fire
fill cuff with NS or methylene blue
avoid N20 (combustable)
FiO2 <= 30%
Steps to take if an airway fire does occur
First step = D/C O2
Remove ETT
re-intubate trachea
flush pharynx with cold NS
rigid broch to check for damage and presence of foreign bodies
possibly steroids, humidified gas, abx
T or F, the nasal mucosa has minimal blood supply
F, rich blood supply
considerations r/t pts undergoing nasal or sinus surgeries
pre-op nasal obstruction
nasal polyps are associated with asthma and CF
max dose of cocaine
3 mg / kg
SE of cocaine
HTN and ectopic ventricular activity
cocaine inhibits reuptake of NE
Why are the eyes not taped for FESS?
Surgeon may want to periodically check for eye movement during dissection due to close proximity of the sinuses and the orbit
Is TIVA or volatile anesthesia preferred for nasal / sinus surgeries?
TIVA, propofol and remi are associated with less bleeding, better visualization, less coughing on emergence, decreased PONV
Why is MR preferred for FESS
movement could cause neuro or opthalmic damage
Major complications associated with FESS
incidence