upper airway

UPPER AIRWAYUPPER AIRWAY

ANATOMY AND FUNCTIONANATOMY AND FUNCTION

LITERATURE READING

Igor T. Hutabarat

Supervisor : dr. Agung D Permana, M.Kes., Sp.T.H.T.K.L

Department of Otorhinolaryngology-Head & Neck SurgerySchool of Medicine Padjadjaran University

Hasan Sadikin General HospitalBandung

20151

IntroductionIntroductionThe upper airway includes :

- Nasal Cavity

- Oral cavity

- Pharynx

- Larynx

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Nasal Nasal

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Nasal Skeleton -Bone-Cartilage

Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.Lee, K.J. 2008. Essential Otolaryngology Head and Neck Surgery . 8th ed. Connecticut. McGraw-Hill.

Nasal CavityNasal Cavity

Nasal Septum- Bone : vomer, perpendicular plate of etmoid, maxillary crest, palatine bone-Cartilage : quadrangular cartilage

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Lateral Nasal WallLateral Nasal Wall

• Three turbinates (inferior, middle, superior)

• Meatus : inferior meatus middle meatus

superior meatus

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Artery blood supplyArtery blood supplyExternal nose : - External carotid artery to facial

artery- Superior labial artery- Angular arteryNasal cavity- External carotid artery internal

maxillary artery sphenopalatine artery, descending palatine artery, greater palatine artery

- Internal carotid arteryophthalmic artery anterior ethmoid artery, posterior ethmoid artery

6Lee, K.J. 2008. Essential Otolaryngology Head and Neck Surgery . 8th ed. Connecticut. McGraw-Hill.

Artery blood supplyArtery blood supplyKiesselbach’s plexus anastomosis of septal branch of sphenopalatine artery, anterior ethmoidal artery branches, greater palatine artery, and septal branches of superior labial artery anastomoseWoodruff”s plexus anastomosis of posterior nasal, posterior ethmoid, sphenopalatine, and ascending pharyngeal arteries

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Oral cavityOral cavity- Food intake- Taste- Phonation and Articulation :

With the pharinx, nose and paranasal sinuses and in forming the supraglottic vocal tract wich plays a role in the coordination of vocal sounds

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Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006.

PHARYNGEAL PHARYNGEAL ANATOMYANATOMY

9Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.

irregularly tubular structure from the base of the skull to the esophageal inlet

3 segments-Nasopharynx-oropharynx-Hypopharynx

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PHARYNGEAL ANATOMYPHARYNGEAL ANATOMY

Blood SuplyBlood Suply

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external carotid artery (branches of the facial artery, maxillary artery, ascending pharyngeal artery, lingual artery, and superior thyroid artery). The veins of the pharynx drain into the internal jugular vein

Nerve Nerve SupplySupply

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Motor, sensory and autonomic innervation from the pharyngeal plexus, which in turn receives fibers from the Glossopharyngeal (CN IX) and Vagus nerves (CN X)

Lymphayic DrainageLymphayic Drainage

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Retropharyngeal lymph nodes, while the lower portions drain to the parapharyngeal or deep cervical nodes.

LARYNGEAL ANATOMYLARYNGEAL ANATOMYLaryngeal

Framework : Bone

Cartilages

Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.

Bone: HyoidCartilages: -Thyroid-Cricoid -Arytenoids-Epiglottis-Sesamoid cartilages

LARYNGEAL ANATOMYLARYNGEAL ANATOMY• Hyoid supports the

larynx and stabilizes the hypopharynx o U shaped, o two greater horn o Two lesser horn

• Hyoid connected to the thyroid cartilage the broad thyrohyoid membrane.

15Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006. Ch17. p337-384


LARYNGEAL ANATOMYLARYNGEAL ANATOMY• Thyroid Cartilage – Greek

Name meaning ‘Sheild like’

• Thyroid cartilage : o Superior horn

thyrohyoid ligamento Inferior horn cricoid

cartilage• To gradually ossify after

the age of 20 age-related changes of the voice



LARYNGEAL ANATOMYLARYNGEAL ANATOMY• Cricoid Cartilage – Greek

Name meaning ‘ring like• Cricoid cartilage : the

skeletal support of the subglottis completely rigid diameter.

• Smaller cross-sectional area than the trachea

• A single foreign body that is small enough to pass through the subglottis does not cause total airway obstruction


LARYNGEAL ANATOMYLARYNGEAL ANATOMY

• Epiglottis : a fibroelastic cartilage

• Attached anteriorly in the midline to the inner surface of the thyroid cartilage and supported by the hyoepiglottic ligament.

• The free end of the epiglottis projects into the hypopharynx.

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Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

Fibroelastic Fibroelastic MembranesMembranes

Two important components :

• The quadrangular membrane o supports the supraglottis.

• The conus elasticus o provides support to the vocal

fold.

19Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

LARYNGEAL ANATOMYLARYNGEAL ANATOMY• Intrinsic

o Posterior cricoarytenoid the only abductor of the glottis

o Lateral cricoarytenoid adductor of the glottis

o Thyroarytenoid increasing vocal fold tension, thickness, and stiffness

• medial thyroarytenoid • lateral thyroarytenoid

o Cricothyroid increase the length and tension of the vocal folds

o Interarytenoid adducts the vocal folds

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Netter F. Atlas Clinical Anatomy. Electronic version.



• True vocal folds anterior edges of the glottis.

• Posterior glottis : two arytenoid cartilages and the intervening mucosa.

• Arytenoids : posterior attachments of both the true and false vocal folds.

• Movement of the arytenoids Opening and closing of the glottis



• The laryngeal cavity is divided into 3 parts in relation to the glottis : o Supraglottis

• Laryngeal inlet sinus morgagni

o Glottis • Vocal fold +/- 1 cm

o Subglottis • Lower border of glotis

lower border of cricoid

23Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006.

Ch17. p337-384

Nerve supply to the Nerve supply to the larynx larynx

Supplied by : • Internal and External branches of the superior laryngeal nerve

(SLN) • the recurrent laryngeal nerve

(RLN)

24Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006.

Ch17. p337-384

Blood supply to the Blood supply to the larynxlarynx

Supplied by : superior thyroid arteries

(branch of the external carotid artery)

inferior thyroid arteries. (branch of the thyrocervical trunk from the subclavian artery)

Drained by : superior and middle thyroid

veins internal jugular vein inferior thyroid vein left

brachiocephalic vein. Lymphatic drainage :

laterally the deep cervical and paratracheal lymph nodes

medially the prelaryngeal and pretracheal lymph nodes.


MUCOSAL COVERMUCOSAL COVER Vocal folds above :

(nonkeratinized stratified squamus epithelium)

• Below vocal folds : (pseudo-stratified ciliated columnar

epithelium) Lamina propria shock absorber

Three layers : Superficial (Reinke's space) lowest

concentration of both elastic and collagenous fibers

Intermediate Elastic fibers are most numerous

Deep the stiffest (collagen fibers)


Respiratory Respiratory physiology of the physiology of the

LarynxLarynx• Main function of the larynx a sphincter preventing anything other than air into the lungs• Another functions : - Coughing - Valsalva’s maneuver - The regulation of airflow in and out of the lungs.- Control of breathing - Affect cardiovascular function.

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Cough• ejects mucus and foreign matter from the lungs • helps to maintain patency of the pulmonary alveoli.

Cough may be voluntary but more often occurs in response to stimulation of receptors in the larynx or lower respiratory tract.

A cough has three phases: 1. inspiratory2. compressive3. expulsive.


Valsalva’s Maneuver

• Forced expiration against a tightly closed glottis

• The true vocal folds offer more resistance to inspiratory airflow.

• enables the larynx to resist very strong expiratory forces.

• important in defecation the pressure is transmitted to the abdominal cavity

• serves to stabilize the thorax during heavy lifting by the arms.


Regulation of Airflow

• The larynx regulate the flow of air in and out of the lungs

• Two forces contribute to inspiratory opening of the larynx:

longitudinal tension on the laryngeal skeleton

(descent of the trachea)

contraction of the posterior cricoarytenoid muscle.

30Tortora, Gerard J. Principles of Anatomy and Physiology. Wiley, 2006. p854

• Active laryngeal abduction is a primary action of breathing

posterior cricoarytenoid muscle consistently begins to contract before the diaphragm with each inspiration.

• The larynx opens more widely during inspiration with increasing effort of breathing and in response to negative upper airway pressure.


Respiratory Respiratory PhysiologyPhysiology

• Strong respiratory demand, the posterior cricoarytenoid muscle continues contracting during expiration, after the diaphragm has relaxed.

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decreased resistance and faster outflow of air

shortens the duration of expiration

increases the rate of breathing


Respiratory Respiratory PhysiologyPhysiology


glottic aperture

resistance to airflow in inspiratory much greater than resistance to expiratory flow.

laryngeal obstruction (edema, papillomas, laryngeal

paralysis)

produce inspiratory stridor before expiration is impaired.

Sensory Input to Respiratory Control

• The larynx is richly supplied with a variety of sensory receptors that exert influences on breathing and cardiovascular function.

• laryngeal receptors activated by breathing & influence on the central control of breathing by:

negative pressure receptors, airflow (cold) receptors

“drive” receptors (proprioceptors that respond to respiratory motion of the

larynx)• Laryngeal receptors also respond to touch and

chemical stimuli.


Circulatory ReflexesCirculatory Reflexes• Stimulation of the larynx can produce changes in heart rate

and blood pressure (induction of general anesthesia in response to endotracheal intubation)

• It may also occur in natural circumstances such as obstructive sleep apnea. upper airway patency is not maintained during sleep

increase in negative airway pressure

stimulate receptors in the larynx

cardiac arrhythmias

• The direct result of laryngeal stimulation on blood pressure is hypertension.

• If laryngeal stimulation produces significant bradycardia, the indirect result can be hypotension.


SpeechSpeech• The human voice results from the coordinated

interaction of the larynx, lungs, diaphragm, abdominal muscles, throat, neck muscles, lips, tongue, buccinators, and soft palate.

• Speech consists of three component processes: • Phonation vibration of the vocal folds• Resonance vibration of the rest of the vocal

tract • Articulation shaping of the voice into the

words by the lips, tongue, palate, and pharynx


SpeechSpeechPhonation

• Sound is produced by the larynx when expiratory airflow induces vibration of free edges of the vocal folds as a result of the interaction of aerodynamic and myoelastic forces.

• Five conditions must be met to support normal phonation:

appropriate vocal fold approximation

adequate expiratory force

sufficient vibratory capacity of the vocal folds

favorable vocal fold contour

volitional control of vocal fold length and tension


SpeechSpeechResonance

• Gives the human’s voice’s characteristic

• Amplify the voice.

• Vocal training refining and maximizing resonance

• Controlled by :

o altering the shape and volume of the pharynx

o raising or lowering the larynx,

o moving tongue or jaw position,

o varying the amount of sound transmission through the nasopharynx and nose.


SpeechSpeechArticulation

• formation of consonants and vowels

• largely controlled by the lips, tongue, palate, and pharynx.


THANK YOU

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upper airway

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