答案及解析：D.
Abovethevocalcords,thesensoryinnervationofthelarynxisviathesuperiorlaryngealnerve.Belowthevocalcords,sensoryinnervationisviabranchesoftherecurrentlaryngealnerve(RLN).Thevocalcordsthemselvesreceivedualinnervationfrombothnerves.Thetrigeminalnerve(choiceA)providestactilesensation,amongotherthings,totheanteriortwo-thirdsofthetongueandthenasalpassages.Theglossopharyngealnerve(choiceB)providestactileandgustatorysensationtotheposteriorone-thirdofthetongue.NoneofthechoicesexceptfortheRLNwouldbestimulatedduringanawaketracheostomy.在声带上方，喉的感觉神经是由喉上神经支配的。在声带下方，喉的感觉是由喉返神经的分支支配的。声带是由这两种神经共同支配。此外，三叉神经（选项A）为舌前三分之二和鼻道提供触觉。舌咽神经（选项B）提供舌头后三分之一的味觉和触觉。清醒状态下气管切开时，除了RLN，其他神经都不会被刺激。23.Oneofthefollowingstatementsregardingtheinnervationofairwaystructuresismostcorrect:
以下关于气道的神经支配的表述最正确的是：
A.TheafferentlimbofthegagreflexisprimarilycarriedbyfibersoftherecurrentlaryngealnerveB.TrigeminalnerveblockwouldfacilitateawakenasotrachealintubationC.Thesuperiorsurfaceoftheepiglottis（会厌）isprimarilyinnervatedbytheglossopharyngealnerveD.Tactilesensationfromtheposteriorone-thirdofthetongueiscarriedbythehypoglossal（舌下）nerve答案及解析：B.
Theophthalmic(V1)andmaxillary(V2)divisionsofthetrigeminalnerve(CNV)conveysensoryinformationfromthenasalmucosa.Blockadeofthesenerveswouldfacilitateawakenasotrachealintubation.Thegagreflexiselicitedprimarilybytactilestimulationoftheposteriorone-thirdofthetongue.Theafferentlimbofthisreflexiscarriedbytheglossopharyngealnerve(CNIX),nottherecurrentlaryngealnerve(choiceA)orthehypoglossalnerve(choiceD).Thesuperiorsurfaceoftheepiglottisisinnervatedbythesuperiorlaryngealnerve(SLN),nottheglossopharyngeal(choiceC).Ingeneral,theSLNprovidessensoryinnervationtoallstructuresofthelarynxabovethevocalcords,includingtheepiglottis.
三叉神经（CNV）的眼支（V1）和上颌支（V2）从鼻粘膜传递感觉信息。阻断这些神经有利于清醒状态下的经鼻插管。喉反射是由舌后三分之一处的触觉刺激引起的，这种感觉的传入神经为舌咽神经（CNIX），而不是喉返神经（选项A）和舌下神经（选项D）。会厌的上表面是由喉上神经（SLN）支配的，而不是舌咽神经（选项C）。一般来说，SLN提供的感觉神经声带以上喉的所有结构，包括会厌。24.Anasaltrumpetwouldbemostappropriateformanagementofanesthetic-inducedupperairwayobstructioninoneofthefollowingpatients:以下由于麻醉原因引起上呼吸道梗阻的病人中，最适合用鼻咽通气道的是：A.A25-year-oldpassengerejectedoutofamotorcyclenowwithGlasgowComaScale（Glasgow昏迷评分）of13andsomeperiorbital（眶周的）bruisingB.A32-year-oldtermparturient（孕产妇）,otherwisehealthyexceptforgestationalthrombocytopenia（血小板减少症）,whorequiresemergentcesareansectionundergeneralanesthesiaC.A45-year-oldfemalewithtemporomandibular（颞下颌）jointsyndromeandbreastcancerscheduledforbilateralmastectomyD.A65-year-oldmalewithamechanicalmitralvalveontherapeuticanticoagulationundergoingemergentcoronarycatheterizationforunstableangina答案及解析：C.
Bothnasotrachealintubationandnasaltrumpetinsertionarecontraindicatedinpatientswithfacialorskullinjuries(choiceA),withcoagulopathy(choiceB),andthoseonanticoagulation(choiceD).InchoiceA,thepatientsmechanismofinjuryandfindingsofperiorbitalbruisingsuggestanunderlyingskullfracture.Inadditiontoperiorbitalecchymoses,otherclassicsignsofabasilarskullfractureincludeleakageofbloodorcerebrospinalfluidfromthenares,ecchymosesontheskinoverlyingthemastoidprocess,andhemotympanumorbleedingfromtheears.Forapatientwithtemporomandibularjointdysfunctionwhohasnoneoftheabovecontraindications(choiceC),thenasaltrumpetwouldbeareasonablewaytobypassthepatientslimitedmouthopeningandrelieveupperairwayobstruction.
面部或颅骨的损伤（选项A）、凝血功能障碍（选项B）和抗凝治疗（选项D）的患者禁止鼻腔气管插管和放置鼻咽通气道。除了眼眶周围淤血外，颅底骨折的其他典型症状还包括：鼻孔漏血或脑脊液、鼓膜积血或耳出血。对于没有上述禁忌症的颞下颌关节障碍（选项C）的患者，鼻咽通气道可以避开患者张口度小的问题，缓解患者上呼吸道梗阻。图1（来源于《ClinicalAnesthesiology4thEdition》p）口咽通气道和鼻咽通气道的放置，在本章第2次推送中已有关于口咽通气道的放置的内容，鼻咽通气道大约比口咽通气道长2~4cm。25.A55-year-oldwomanwithsevereanxietyandrheumatoidarthritisisscheduledforthyroidectomyformedullarythyroidcancer.Herairwayexamintheuprightpositionisnotableforanonvisibleuvulawiththetongueprotruded,a2fingerbreadthsmouthopening,athyromentaldistanceof2.5fingerbreadths,andneckrange-of-motionattheatlanto-occipitaljointofabout70degrees.Examinationofherneckrevealsanenlarged,fixed,andnonmobilemassthatappearstobecontiguouswiththethyroidglandwhenthepatientswallows.Thetracheacannotbepalpated.Thepatientishighlyanxiousandtellsyouthatundernocircumstancewillsheletyouinserta“breathingtubeinsidemyairwaywhileI’mawake.”Thenextbeststepinanestheticmanagementis
55岁女性患者，患有严重的焦虑症和风湿性关节炎，因甲状腺髓样癌择期行甲状腺切除术。术前气道评估：站立位时，舌头伸出后看不见悬雍垂、张口度两指、颏甲距离2.5指、寰枕关节活动度约70°。颈部检查：颈部发现肿大、固定的肿块，当患者吞咽时，与甲状腺相连，不能触及气管。患者高度焦虑，并且表示任何情况下都不接受清醒状态下气管插管。麻醉管理的下一步是：A.InductionofgeneralanesthesiafollowedbyfiberopticbronchoscopyB.InductionofgeneralanesthesiafollowedbyrigidbronchoscopyC.Inductionofgeneralanesthesiafollowedbylaryngealmask（喉罩）airwayplacementD.Cancelthecase答案及解析：D.
Thispatienthasmultipleriskfactorsfordifficultintubation,includingMallampaticlass2,thyromentaldistance3fingerbreadths,mouthopening3fingerbreadths,andtotalatlanto-occipitalrange-of-motion80degrees.Patientswithinflammatoryrheumatoidarthritis(RA)haveanincreasedincidenceoftemporomandibularjointdisease(andassociatedlimitedmouthopening)andimmobilecervicalvertebra(associatedwithlimitedneckrange-of-motion).Additionally,patientswithRAcanhaveoccultairwayabnormalitiesnotapparentonphysicalexam,suchaslaryngealrotation,cricoarytenoidarthritis,andcervicalspineinstability.Thepatient’sthyroidmalignancymayresultinotherairwayabnormalitiesincludingtrachealdeviationand/or
