upper airway
DESCRIPTION
united airwayTRANSCRIPT
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
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
Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.
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
16Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006. Ch17. p337-384
Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.
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
17Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.
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.
Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
LARYNGEAL ANATOMYLARYNGEAL ANATOMY
• 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
22Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.
LARYNGEAL ANATOMYLARYNGEAL ANATOMY
• 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.
25Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006. Ch17. p337-384
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)
26Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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.
28Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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.
29Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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.
31Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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
Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
Respiratory Respiratory PhysiologyPhysiology
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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.
34Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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.
35Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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
36Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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
37Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
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.
38Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin
SpeechSpeechArticulation
• formation of consonants and vowels
• largely controlled by the lips, tongue, palate, and pharynx.
39Jhonson T.J. et al . 2014. Bailey’s Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin