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BI, All Rights Reserved, 2005BI, All Rights Reserved, 2005 11

Part 2APart 2A Normal AnatomyNormal Anatomy

Upper airway and LarynxUpper airway and Larynx

Prepared ByPrepared By

Bronchoscopy InternationalBronchoscopy International

Contact us atContact us [email protected]@bronchoscopy.org

BRONCHATLAS

Series of Web-based Bronchoscopic Images

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The Upper AirwayThe Upper Airway

The upper airway starts :The upper airway starts :

At the nostrils, extends throughAt the nostrils, extends throughthe nasal conchae to thethe nasal conchae to thenasopharynx, over the uvula tonasopharynx, over the uvula to

the hypopharynx and larynx,the hypopharynx and larynx,or,or,

At the lips, extends through theAt the lips, extends through theoral cavity, over the tongue andoral cavity, over the tongue and

below the hard and softbelow the hard and softpalates, to the hypopharynxpalates, to the hypopharynxand larynx.and larynx.

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Upper Airway: From Pharynx to LarynxUpper Airway: From Pharynx to Larynx

Uvula

Epiglottis

Larynx

Midline guidance:

The uvula points to the epiglottis, the epiglottis leads into the larynx.

LingualTonsil

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The LarynxThe Larynx

The larynx is a 5The larynx is a 5--7 cm7 cmlong structure.long structure. Its upper boundary startsIts upper boundary starts

at the tip of the epiglottis,at the tip of the epiglottis,opposite the 3rd to 4th,opposite the 3rd to 4th,cervical vertebra.cervical vertebra.

Its lower end is at theIts lower end is at thelower border of thelower border of the

cricoid cartilage.cricoid cartilage. This lies opposite the 6thThis lies opposite the 6thcervical vertebra.cervical vertebra.

www.phon.ox.ac.uk

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Superior surface anatomy:Superior surface anatomy:

Major Landmarks IMajor Landmarks I

Base ofTongue

http://www.nyee.edu/top#top

SuperiorSurface ofEpiglottis

Posterior Wall ofHypopharynx(Leading toEsophagus)

LateralGlossoepiglottic

Folds

MedianGlossoepiglottic

Fold

Vallecula

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The Cricoid cartilageThe Cricoid cartilage

Cricoid Cartilage

Cricothyroid

membrane

Thyroid glandThyroid cartilage

Cricoid cartilage

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Time Out! Why is it so important toTime Out! Why is it so important torecognize the surface anatomy?recognize the surface anatomy?

As a bronchoscopist, we are responsible to report anyAs a bronchoscopist, we are responsible to report anynasal, oral, pharyngeal or laryngeal pathology that wenasal, oral, pharyngeal or laryngeal pathology that weobserve enobserve en--route to the lungs.route to the lungs.

We only know that we are correctly positioned and inWe only know that we are correctly positioned and inthe midline, when we knowthe midline, when we know exactly where we areexactly where we are..

During a difficult intubation, either with a bronchoscopeDuring a difficult intubation, either with a bronchoscopeor a rigid laryngoscope, knowledge of surface anatomyor a rigid laryngoscope, knowledge of surface anatomyensures timely intubation and saves a life.ensures timely intubation and saves a life.

In a variety of conditions, such as GERD, changes inIn a variety of conditions, such as GERD, changes inlaryngeal anatomy and structures, are the best clues tolaryngeal anatomy and structures, are the best clues topulmonary pathology.pulmonary pathology.

Shall we continue?Shall we continue?

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Major LandmarksMajor Landmarks -- IIII

Ventricle

PyriformSinus

LaryngealSurface ofEpiglottis

Posterior Wall ofHypopharynx(Leading toEsophagus)


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Major LandmarksMajor Landmarks -- IIIIII

Vallecula

Pyriform

Sinus

Epiglottis


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Major LandmarksMajor Landmarks -- IVIV


AryepiglotticFold

Posterior

Commissure

AnteriorCommissure

Ventricle

TrueVocalCords

FalseVocalCords

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Major LandmarksMajor Landmarks -- VV

AryepiglotticFold

Posterior Wall

Of Hypopharynx

Corniculate

Tubercle onArytenoidCartilage

CuneiformTubercle

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Major LandmarksMajor Landmarks -- VIVI

Arytenoid

Cartilage

True

VocalCords

FalseVocalCords

Ventricle

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Major LandmarksMajor Landmarksto look forto look for -- VIIVII

CartilaginousRings of

Trachea

TrueVocalCords

Vocal Cord

Sulcus (onTrue Vocal

Cords)

CricoidRing

False

VocalCords

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This is the..This is the..

A.A. The epiglottisThe epiglottis

B.B. The ventricleThe ventricle

C.C. The arytenoid cartilageThe arytenoid cartilage

D.D. The true vocal cordThe true vocal cord

E.E. The false vocal cordThe false vocal cord

Click for correct answer: B

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The Larynx: AnatomyThe Larynx: Anatomy

The structural rigidity of the larynxThe structural rigidity of the larynxis provided by the three medianis provided by the three mediancartilages:cartilages: The epiglottisThe epiglottis Thyroid cartilageThyroid cartilage Cricoid cartilageCricoid cartilage ,,

along with the hyoid bone.along with the hyoid bone.

The thyrohyoid membrane forms aThe thyrohyoid membrane forms aCC--shaped barrier around theshaped barrier around theanterior and lateral walls of theanterior and lateral walls of thesupraglottis, and inferiorlysupraglottis, and inferiorlybecomes confluent with thebecomes confluent with theconnective tissue in theconnective tissue in theperichondrium of the trachealperichondrium of the trachealcartilaginous rings.cartilaginous rings. www.throat-cancer-symptoms.com/

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The six smaller cartilages of theThe six smaller cartilages of thelarynx ( 3 pairs) are functionallylarynx ( 3 pairs) are functionallyinvolved with the movements ofinvolved with the movements ofthe vocal cords. These are:the vocal cords. These are: The arytenoidsThe arytenoids The corniculatesThe corniculates The cuneiformsThe cuneiforms

TheThe arytenoidarytenoid cartilages arecartilages arepyramidpyramid--shaped and articulateshaped and articulatewith the superior margin of thewith the superior margin of thecricoid lamina. On their summit,cricoid lamina. On their summit,are theare the corniculatecorniculate cartilages; oncartilages; ontheir anterior aspect, thetheir anterior aspect, thecuneiformcuneiform cartilagescartilages

www.polychondritis.com

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TheThe vocal ligamentsvocal ligaments, are, areattached posteriorly to the apex ofattached posteriorly to the apex ofthe arytenoids and corniculates.the arytenoids and corniculates.The cuneiforms extend laterally,The cuneiforms extend laterally,between the layers of the vocalbetween the layers of the vocal

cords, from the anterior aspect ofcords, from the anterior aspect ofthe arytenocorniculate complex.the arytenocorniculate complex.

TheThe epiglottisepiglottis is attached to theis attached to the

base of the tongue by a medianbase of the tongue by a medianand two lateral glossoepiglotticand two lateral glossoepiglotticfolds.folds.

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The Larynx: Critical StructuresThe Larynx: Critical Structures

The Larynx neighborsThe Larynx neighborsmajor critical structures:major critical structures:

Carotid arteries and jugularCarotid arteries and jugularveins, and the vagus nerveveins, and the vagus nerve

Superior and inferior thyroidSuperior and inferior thyroidarteriesarteries

Superior and recurrentSuperior and recurrentlaryngeal nerveslaryngeal nerves

www.yoursurgery.com

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The Larynx: Topical AnesthesiaThe Larynx: Topical Anesthesia

Bilateral nasalBilateral nasaladministration ofadministration of

anesthetic providesanesthetic providespartial posteriorpartial posteriorpharyngeal anesthesiapharyngeal anesthesiaby affecting theby affecting theSphenopalatine nerveSphenopalatine nervefibers, thus diminishingfibers, thus diminishingthe gag reflex.the gag reflex.

Ask patient to inhale deeplythrough nostril

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Topical anestheticTopical anestheticusually affects theusually affects the

superior laryngeal nervesuperior laryngeal nerveand blocks sensoryand blocks sensoryinnervation to the baseinnervation to the baseof the tongue epiglottis,of the tongue epiglottis,

pyriform fossa, andpyriform fossa, andvalleculae.valleculae.

Click to continue

Click here to view video presentation

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The topical instillationThe topical instillationof Lidocaine with theof Lidocaine with the

Spray as you goSpray as you gomethod numbs themethod numbs thesubmucosal plexus ofsubmucosal plexus ofthe larynx, derivedthe larynx, derivedfrom the external andfrom the external andinternal branches ofinternal branches ofthe superior laryngealthe superior laryngealnerve.nerve. Click to continue


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Laryngeal function: Airway ProtectionLaryngeal function: Airway Protection

Open Closed

The glottis: open for inspiration and closed for swallowingThe glottis: open for inspiration and closed for swallowing

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Laryngeal function: PhonationLaryngeal function: Phonation

Adducted: Talking Abducted: Breathing

The vocal cords: Adducted for phonation; abducted forThe vocal cords: Adducted for phonation; abducted forinspirationinspiration

www.voice.northwestern.edu

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Laryngeal function: PhonationLaryngeal function: Phonation

The vocal cordsopen and closewhile talking

Click to continue


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Which of the following defends against aspiration?Which of the following defends against aspiration?

A.A. The epiglottisThe epiglottis

B.B. The false cordsThe false cords

C.C. The true cordsThe true cords

D.D. The ventricleThe ventricle

E.E. All of the aboveAll of the above

Click for correct answer: E

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This presentation is part of aThis presentation is part of acomprehensive curriculum forcomprehensive curriculum for

Flexible Bronchoscopy. Our goalsFlexible Bronchoscopy. Our goals

are to help health care workersare to help health care workersbecome better at what they do, andbecome better at what they do, andto decrease the burden ofto decrease the burden of

procedureprocedure--related training onrelated training onpatients.patients.

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A new curriculumA new curriculum

1.1. WebWeb--based Selfbased Self--learning study guide.learning study guide.2.2. ComputerComputer--based simulations, didactic lectures,based simulations, didactic lectures,

and image encyclopedia.and image encyclopedia.3.3. Bronchoscopy stepBronchoscopy step--byby--stepstep: Practical exercises,: Practical exercises,

skills and tasks, competency testing.skills and tasks, competency testing.4.4. Guided apprenticeship.Guided apprenticeship.5.5. Learning the art of Bronchoscopy.Learning the art of Bronchoscopy.

DEMOCRATIZATION ANDGLOBALIZATION OF KNOWLEDGE

BRONCHATLAS

Step by Step

Assured competency and proficiency

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Bronchoscopy International: BronchAtlasBronchoscopy International: BronchAtlas, an Electronic On, an Electronic On--LineLineMultimedia Slide Presentation.Multimedia Slide Presentation.

http://www.Bronchoscopy.org/Bronchatlas/htm. Published 2005http://www.Bronchoscopy.org/Bronchatlas/htm. Published 2005(Please add Date Accessed).(Please add Date Accessed).

All efforts are made by Bronchoscopy InternationalAll efforts are made by Bronchoscopy Internationalto maintain currency of online information. Allto maintain currency of online information. All

published multimedia slide shows, streaming videos,published multimedia slide shows, streaming videos,and essays can be cited for reference as:and essays can be cited for reference as:

BRONCHATLAS

Thank you

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