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Anatomy of the Larynx and Tracheobronchial Tree
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
The cricoid cartilage is the only complete cartilaginous ring in the airway (Figure 58.5). It forms the inferior part of the anterior and lateral walls and most of the posterior wall of the larynx. It has a deep broad lamina posteriorly and a narrow arch anteriorly with a facet for articulation with the inferior cornu of the thyroid cartilage, near the junction of the arch and lamina. Rotation of the cricoid cartilage on the thyroid cartilage can take place about an axis passing transversely through both joints. The lamina has sloping shoulders on which the articular facets for the arytenoid cartilages are found. A vertical ridge in the midline of the lamina gives attachment to the longitudinal muscle of the oesophagus and produces a shallow concavity on each side for the origin of the posterior cricoarytenoid (PCA) muscle. The entire inner surface of the cricoid cartilage is lined with mucous membrane. The importance of the cricoid in laryngeal health and disease cannot be overemphasized. The luminal mucosa is at risk of necrosis and circumferential scarring, which results in debilitating subglottic stenosis. The cricoarytenoid joint – together with an associated functional PCA muscle—is regarded as a key functional unit of the larynx, facilitating vocal fold motility to ensure a patent airway when abducted and airway protection when adducted.
Stridor
Published in John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed, Paediatrics, The Ear, Skull Base, 2018
Laryngeal examination with the endotracheal tube removed provides a superior view and, by using a probe to move the arytenoids independently, the mobility of the cricoarytenoid joints can be assessed. If an interarytenoid scar is present, the arytenoids will not move independently. A posterior laryngeal cleft is excluded by passing the probe between the arytenoids, comparing the lower limit of the interarytenoid groove with that of the posterior commissure. Finally, great care should be taken to pass through the vocal cords if a rigid endoscope is used to inspect the subglottis.
Connective Tissue Diseases: ENT Complications
Published in John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie, Basic Sciences Endocrine Surgery Rhinology, 2018
Stridor: Arthritis of the synovial joints of the cricoarytenoid joint with an emergency presentation of vocal cord dysfunction. Occurs in rheumatoid arthritis, ankylosing spondylitis, juvenile idiopathic arthritis and gout. Osteoarthritic changes have also been described.Mucosal inflammation and swelling in GWP, Churg-Strauss vasculitis, rheumatoid arthritis, SLE, extranodal mucosal disease with lymphoid hyperplasia as in lymphomas.Myaesthenia gravis including neonatal disease with transplacental transfer of anti-Musk antibodies.
Update on the diagnosis and management of pediatric laryngotracheal stenosis
Published in Expert Review of Respiratory Medicine, 2022
Matthew M Smith, Lauren S Buck
The most important tools in the evaluation of laryngotracheal stenosis are microlaryngoscopy and bronchoscopy (MLB) and flexible bronchoscopy in the operating room under general anesthesia. Similar to the awake flexible fiberoptic evaluation, flexible bronchoscopy allows the physician to assess for the presence of dynamic airway collapse. Following flexible bronchoscopy, a rigid MLB is performed to assess for possible stenoses at the level of the supraglottis, glottis, subglottis, trachea, and mainstem bronchi. At the level of the supraglottis, it is important to look for the presence of laryngomalacia, prolapsed and obstructive arytenoids (dynamic or static), or a prolapsed epiglottic petiole. At the glottis, it is important to palpate the cricoarytenoid joints and posterior glottis with an endoscopic forceps to determine the presence of fixation and scar. This allows the physician to make the diagnosis of posterior glottis stenosis if the cricoarytenoid joints are fixed. If the cricoarytenoid joint(s) and vocal fold(s) are mobile on palpation but immobile on awake endoscopy, then the patient has vocal fold paralysis. It is important to examine the anterior commissure for the presence of a laryngeal web and to palpate posteriorly for the presence of a laryngeal cleft. At the subglottis, the narrowest portion of the pediatric airway, it is important to look for narrowing and determine the size.
Regularity of voice recovery and arytenoid motion after closed reduction in patients with arytenoid dislocation: a self-controlled clinical study
Published in Acta Oto-Laryngologica, 2020
Tingting Zheng, Zhewei Lou, Xiaxia Li, Yaoshu Teng, Yun Li, Xiaojiang Lin, Zhihong Lin
Another objective of this study was to observe the relationship between vocal fold movement and voice improvement after treatment. Comparing with the laryngoscopy, examined before the onset, immediately after the last reduction and one week after the last reduction (Figures 2 and 3), we observed another phenomenon that the vocal cords on the side of the dislocation started to move after successful reduction, the bilateral arytenoid cartilage were almost symmetrical, but the affected vocal cord adduction did not reach the median during phonation, and the cleft glottis is still present when the glottis is closed. The voice improved but not up to the normal. At this point, performing closed reduction again might result in the redislocation of the reduced arytenoid cartilage, so an appropriate strategy is probably just observation. It will take some time before the voice recover completely. This is probably because that the glottic cleft is completely closed when the inflammatory exudation in the cricoarytenoid joint capsule absorbed and then the arytenoid cartilage fully activated. In this study, the duration between the last closed reduction and recovering normal voice is with a mean of 4.65 ± 0.57 days, a time window between 4.08th and 5.22th day (at a confidence level of 95%). We assume that this time window may be the period required for the joint capsule to absorb the exudates.
Diagnosis and management of laryngotracheal stenosis
Published in Expert Review of Respiratory Medicine, 2018
Matthew M Smith, Robin T Cotton
The most important tools in the evaluation of laryngotracheal stenosis are microlaryngoscopy and bronchoscopy (MLB) and flexible bronchoscopy in the operating room. Similar to the awake flexible fiberoptic evaluation, flexible bronchoscopy allows the physician to assess for the presence of dynamic airway collapse. Following flexible bronchoscopy, a rigid MLB is performed to assess for possible stenoses at the level of the supraglottis, glottis, subglottis, trachea, and mainstem bronchi. At the level of the supraglottis, it is important to look for the presence of laryngomalacia, prolapsed and obstructive arytenoids (dynamic or static), or a prolapsed epiglottic petiole. At the glottis, it is important to palpate the cricoarytenoid joints and posterior glottis with an endoscopic forceps to determine the presence of fixation and scar. This allows the physician to make the diagnosis of posterior glottis stenosis if the cricoarytenoid joints are fixed. If the cricoarytenoid joint(s) and vocal fold(s) are mobile on palpation but immobile on awake endoscopy, then the patient has vocal fold paralysis. It is important to examine the anterior commissure for the presence of a laryngeal web and to palpate posteriorly for the presence of a laryngeal cleft. At the subglottis, the narrowest portion of the pediatric airway, it is important to look for narrowing and determine the size. Following evaluation of the larynx, the trachea is evaluated for the presence of complete tracheal rings, tracheobronchomalacia, or external tracheal compression.