VOL. XXV, No.
296
THE PROTECTION OF THE LARYNGEAL AIRWAY
DURING SWALLOWING
By G. M. ARDRAN, M.D., D.M.R., and F. H. KEMP, M.B., Ch.B., M.R.C.P., D.M.R.
From the Nuffield Institute for Medical Research, University of Oxford
INTRODUCTION
A MONG the first to use X rays to investigate
* * the act of swallowing were the late Sir Arthur
Hurst of Guy's Hospital and Dr. A. E. Barclay, of
Manchester. Barclay's studies, begun in Manchester,
were continued in Cambridge and published in his
book The Digestive Tract (1933). He recognised that
while it is easy to demonstrate the act of swallowing
with the fluorescent screen, it is extremely difficult
to analyse certain phases of the movement as they
take place too quickly for the eye to follow. When he
came to Oxford he used kineradiographic apparatus
for this purpose, but was never satisfied with the
results obtained. Some of his 16 mm. films, taken
at the rate of 16 frames per second, are still in the
Nuffield Institute.
Janker in Bonn, Ramsey in Rochester, N.Y., and
Reynolds in London, also used indirect kineradio-
graphy, to demonstrate the act of swallowing. No
detailed account of their observations has been
published. Frenckner (1949) published a descrip-
tion by Holmgren of 16 mm. films taken at the rate of
16 frames per second, but it appears that the detail
obtained was not good enough to show what hap-
pened when movement occurs quickly.
The authors have already given a general account
of the mechanism of swallowing elsewhere (Ardran
and Kemp, 1951). The present paper is concerned
with the way in which the laryngeal airway is pro-
tected during swallowing.
The time-honoured theory that the epiglottis
turns down over the larynx to prevent food entering
the airway has been questioned, since it has been
shown that the tongue of the epiglottis can be re-
moved without apparent ill effects (Magendie, 1823),
and it is now held that the epiglottis serves little
useful purpose (Negus, 1949). Closure of the larynx
is attributed to strong elevation against the base of
the tongue. The thyro-arytenoid, lateral crico-
arytenoid and inter-arytenoid muscles are believed
to assist the closure of the superior laryngeal aper-
ture.
Our kineradiographic studies have shown that
these views are not entirely correct. We have found
406
that many safeguards exist to prevent food from
entering the lower air passages.
MATERIAL
About 500 examinations have been made of
swallowing in normal young European adults, of
both sexes, under 30 years of age. Observations were
made of swallowing varying consistencies and
quantities of barium emulsion. Kineradiographic
films were taken at a speed of 25 frames per second
on 35 mm. film with apparatus which has been des-
cribed by Ardran and Tuckey (1951-2).
RESULTS
General considerations
The larynx begins to rise as the bolus* descends
upon the back of the tongue; and as the thyroid
cartilage comes towards the body of the hyoid, the
epiglottis is pushed posteriorly against the posterior
pharyngeal wall (Fig. la) and the bolus is received
into the valleculae (Fig. lb). Here there is a moment-
ary pause; a little of the barium spills over the lateral
pharyngo-epiglottic folds into the lateral food
channels but the bulk of the bolus is held upon the
epiglottis (Figs, lb, lc, 7). At this stage the vesti-
bule of the larynx is usually open and in communica-
tion with air in the hypopharynx* (Fig. lc).
When a sufficient quantity of barium has entered
the mesopharynx-j- the larynx moves forward so that
the tongue of the epiglottis comes away from the
pharyngeal wall, allowing the bolus to pass (Fig. Id).
The bulk of the bolus then passes down on one or
* We have used this word to mean (1) a rounded mass of
food or fluid formed on the dorsum of the tongue in prepara-
tion for swallowing and (2) as a term to describe that which
is swallowed. After leaving the mouth the bolus becomes
elongated and sometimes may be said to have a head, body
and a tail.
t We have found difficulty in employing the conventional
nomenclature for the divisions of the pharynx. The pharynx
is divided into three chambers, an upper, middle and lower,
by the soft palate and the epiglottis. The upper chamber or
epipharynx is that part of the pharynx above the soft palate.
The middle chamber or mesopharynx extends from the
lower surface of the soft palate to the valleculae. The lower
chamber or hypopharynx extends from the valleculae to the
mouth of the oesophagus. The boundaries of these chambers
vary according to the positions of the soft palate and the
epiglottis.
 AUGUST 1952
The Protection of the Laryngeal Airway during Swallowing
both sides of the larynx (Fig. 2) and only a little and varies between individuals. If retraction of the
spills directly over the laryngeal entrance. The larynx forward is very pronounced, the epiglottis
extent to which the larynx moves forward depends may stand out in the channel beneath the bolus "like
upon the size and consistency of the bolus swallowed a rock under a waterfall".

FIG. 1.
Selected prints taken from a film of a normal individual swallowing a mouthful of barium emulsion. Lateral projection.
(a) 5th frame
The larynx slightly raised and arched backwards. The epiglottis touching the posterior pharyngeal wall. The bolus descend-
ing upon the dorsum of the tongue.
(b) 1th frame
"Vallecular arrest." The barium held on the epiglottis. A trace has passed into the lateral food channels.
(c) 8th frame
Further elevation and arching of the larynx. Narrowing of the lumen of the vestibule of the larynx; most pronounced at
the entrance. Barium has passed into the lateral food channels.
(d) Wth frame
The lumen of the larynx is obliterated. The epiglottis is withdrawn from the posterior pharyngeal wall and is projecting
into the stream.
407
VOL. XXV, No. 296
G. M. Ardran and F. H. Kemp
As the larynx is raised and moved forward, the
lumen of the vestibule is reduced to a narrow
(a) A still radiograph showing the valleculae and the lateral
food channels outlined by barium and partially distended
with air.
channel 2-3 mm. in diameter; at this stage, the
lumen is usually arched backward. When the larynx
is well arched, the epiglottis is bent to form a cowl-
like hood above the laryngeal entrance, the sides of
the hood serving to direct the bolus away from the
midline into the lateral food channels (Figs. 2a,
2d). The laryngeal entrance is well covered by the
overhanging epiglottis and sometimes further pro-
tection is offered by air trapped beneath the epi-
glottis. The arching of the larynx tips the vallecular
contents backwards.
The bolus descending the lateral food channels is
checked momentarily before it enters the oesophagus
and sometimes builds up in the hypopharynx
around the larynx.
The larynx continues to be drawn upwards as the
bolus is squeezed downwards. When the bolus has
passed through the mesopharynx forward retraction
of the larynx ceases. Then as the dorsum of the
tongue arches backward and the larynx moves back-
ward, the tongue of the epiglottis is carried down-
ward with the bolus as though it were being swal-
lowed (Fig. 4). At this stage the larynx is arched
nearly 90° backward and the tip of the epiglottis is
held in the region of the mouth of the oesophagus

FIG. 2.
The lateral food channels. Antero-posterior projections.
(b), (c) and (d) Three consecutive frames showing barium passing on either side of the larynx down the lateral food
channels.
408

The Protection of the Laryngeal Airway during Swallowing
FIG.
Barium spilling into the laryngeal vestibule.
(a) The subject swallowing a small fluid bolus. The larynx
has not been arched backwards. The epiglottis rests against
the posterior pharyngeal wall. Barium has spilled into the
vestibule—in this case passing into the laryngeal ventricle.
(b) The vestibule of the larynx has commenced to contract
from below and has squeezed some of the contents upwards.
(c) The vestibule is closed except at the superior orifice.
409
AUGUST 1952
(Figs. 4d, 4e, 4f). The lumen of the larynx, though
constricted, may still be patent, and it has fre-
quently been observed that a column of air is drawn
from the larynx and swallowed with the bolus. As
the bolus is squeezed out of the lower pharynx all
traces of air and barium are expressed from the
laryngeal vestibule and from beneath the down-
turned epiglottis (Figs. 3b, 3c), the lumen of the
3.
Tzvo frames taken from the films of another individual.
(d) Vallecular arrest. Barium has spilled into the lateral
food channels.
(e) Barium has filled the lateral food channels and spilled
into the entrance to the vestibule.
VOL. XXV, No. 296
G. M. Ardran and F. H. Kemp
vestibule being obliterated from below upward. A
small residue of barium remains on the upper sur-
face of the epiglottis (Fig. 4h). The tip of the epi-
glottis is ultimately folded forwards under the
arched larynx (Fig. 4e), a position which it holds
until the airway has been re-established, or until
another bolus is swallowed. The larynx remains
closed while the bolus is passing through the crico-
pharyngeal sphincter into the upper oesophagus.
Then relaxation takes place from above and below;
the larynx fills with air from below (Figs. 5a, 5b, 5c)
as it returns to its normal position of rest and the
pharynx fills with air from above. The epiglottis
sweeps upward to the erect position as the larynx
falls (Figs. 4f, 4g), and carries with it the residue of
barium remaining on its upper surface. When the
airway has been restored the subject resumes normal
respiratory movement.
Variations
The above account represents the usual sequence
of events. There may be modifications depending
upon the behaviour of the individual and the size
and consistency of the bolus swallowed. Though
there may be variations in timing and the degree to
which the different responses are made, the basic
pattern of the swallowing movement is always the
same.
The modifications which take place in response to
variations in the size and consistency of the bolus
swallowed are briefly as follows: when fluids are
passing, the superior aperture of the larynx and
lumen of the vestibule are reduced to a narrow
channel, whereas when thick pastes are swallowed
the lumen of the vestibule may be relatively wide
open. In this region fluids are swallowed more
quickly than pastes. Swallowing a small bolus usually
results in a smaller degree of closure of the vestibule
and less arching of the larynx than occurs when
swallowing a large bolus. Fluid is more apt than
paste to spill into the laryngeal vestibule. The effects
of taste and temperature have not been considered.
The entry offood into the larynx
A spill of food into the laryngeal vestibule takes
place frequently in nearly every normal individual.
It is most apt to occur with the first mouthful. The
spill penetrates to a varying depth into the vestibule,
often reaching the false cords, but seldom going
beyond. We have twice seen barium enter the laryn-
geal ventricle (Fig. 3a), but in normal individuals we
410
have never seen it penetrate the glottis. The total
amount entering the larynx is always very small, and
is conditioned by the reduced size of the vestibular
lumen. The commonest mode of spill usually occurs
early in swallowing, immediately after the stage of
vallecular arrest, just as the epiglottis is being with-
drawn from the posterior pharyngeal wall; at this
stage it is very liable to occur if the larynx has not
been arched backwards sufficiently (Fig. 3a) and
especially if the amount being swallowed is small.
A spill may also be observed to result by fluid
spreading over the moist undersurface of the epi-
glottis into the vestibule. This kind of spill may take
place even when the larynx has been well arched.
A third mode of laryngeal spill may occur a
fraction of a second later in the swallowing act. This
is because a transverse furrow is produced in the
hypopharynx by the forward retraction of the aryte-
noids upon the cricoid cartilage. A small column of
barium may be seen to pass along this furrow from
one or both lateral food channels towards the
entrance to the larynx and may enter the vestibule.
A fourth mode of spill occurs as a result of the
arrest of the bolus in the lateral food channels and is
due to the building up of a column of food in the
hypopharynx; when the column reaches the level of
the laryngeal orifice a spill may occur (Figs. 3d, 3e).
We have already explained that any trace of food
which enters the larynx is later expelled into the
pharynx when the last of the bolus is being expressed
into the oesophagus; the lumen of the vestibule is
obliterated from below upwards (Figs. 3b, 3c).
Our clinical observations suggest that certain
powders such as ginger, and oils such as cod liver oil,
are apt to enter the larynx and excite coughing after
swallowing. We have not been able to confirm this
observation radiographically, since it is extremely
difficult to reproduce the necessary conditions at the
time of taking the picture.
The closure of the larynx
The lumen of the vestibule may be entirely
obliterated without the larynx being raised. Closure
may occur before swallowing has started, or at any
time during the act. Confirmation of this finding has
been obtained from a study of the behaviour of the
larynx during breathing (Ardran, Kemp and Manen).
It has been found that the lumen of the vestibule
may be closed without elevation of the larynx when
respiratory movements are suddenly arrested (Fig. 6).
 AUGUST 1952

The Protection of the Laryngeal Airway during Swallowing

FIG. 4.
A series of selected prints of a volunteer who had a small silver clip fixed to the tip of the epiglottis.
Figs, (a), (b), (c), (d), (e), (f) and (g) show the movement of the epiglottis while swallowing a mouthful of water.
(a) The larynx at rest before swallowing commenced. The epiglottis is (f) 2%th frame. Reinflation of the airways commencing. The epiglottis,
erect. which is still turned down, is outlined between air in the pharynx above
(b) 1th frame. After the commencement of swallowing. The larynx arched and air in the larynx below.
backwards. The lumen of the vestibule narrowed. The epiglottis tipped (g) 21th frame. The larynx is falling. Two images of the clip can be
backwards against the posterior pharyngeal wall. seen as the epiglottis sweeps upwards. At the 29th frame the epiglottis
(c) \9th frame. The lumen of the larynx obliterated. The epiglottis is had returned to its position of rest.
turning down. The two images of the clip indicate the distance travelled (h) A single frame taken from another film of the same individual, after
during the exposure. swallowing a mouthful of barium. The arrow indicates the clip on the
(d) 20th frame. Invertion of the tongue of the epiglottis now complete. tip of the down-turned epiglottis. A residue of barium is seen on the base
(e) 25th frame. The tip of the epiglottis has moved forwards under the of the epiglottis which would have been deposited over the mouth of the
arytenoids. larynx if the epiglottis had not been present. Compare with Fig. 8 (d).

411
 VOL. XXV, No. 296
G. M. Ardran and F. H. Kemp
Swallowing via the lateral food channels
It has been shown (Negus, 1949) that many lower
animals are provided with an efficient mechanism
whereby fluid is able to pass on either side of the
larynx without the danger of overflow into the air-
way. The existence of this mechanism in man is
accepted, but many authorities believe that it is only
used to transmit small quantities of fluid. We have
made many experiments in young adults with vary-
ing consistencies of barium paste and with various
added foodstuffs. In every case the bulk of the
material has always been diverted into one or both
of the lateral food channels (Fig. 2). It has already
been stated that in most cases some food passed
directly over the larynx, but this is only a small
fraction of the total swallowed (Fig. 2d).
The behaviour of the epiglottis
We have found that during swallowing the tongue
of the epiglottis turns down. This action takes place
late in the act of swallowing, after the bulk of the
bolus has passed. Confirmation that the movement
of the epiglottis is independent of gravity has been
obtained by taking films in the erect and supine
positions and with the subject suspended upside
down. Further proof was given by an experiment in
which our colleague, Mr. Ronald Macbeth, placed a
silver clip upon the tip of the epiglottis of a volun-
teer. No form of anaesthesia was used and the
subject was examined swallowing water and barium
emulsion (Kemp, 1950). From the cinematographic
records obtained it was easy to follow the movements
of the clip (Fig. 4). The speed of movement was
calculated at times to be of the order of 1 cm./20
milliseconds, which explains why previous observers
have encountered difficulty in obtaining satisfactory
records.

FIG. 5.
Reinflation of the larynx from below. Three consecutive frames.
(a) Complete obliteration of the lumen of the larynx and
pharynx following swallowing.
(b) Reinflation of the airways has commenced. The
laryngeal ventricle and the vestibule have filled with air
from below. No air has entered the airway from above.
(c) Further relaxation. Air has now passed from the vesti-
bule into the pharynx. The epiglottis is seen outlined
between air above and below.
Note—Reinflation of the larynx from below is usually
closely associated in timing with the entry of air into the
pharynx from above, but in some instances, one mode of air
entry preceded the other. The larynx always inflates from
below.
412

The Protection of the Laryngeal Airway during Swallowing
Through the kindness of Mr. F. Capps of St.
Bartholomew's Hospital, we have had an oppor-
tunity of examining one person from whom the
tongue of the epiglottis had been removed. Some
FIG. 6.
Two still radiographs showing complete closure of the
larynx with little elevation and without backward tilt.
(a) The airways in quiet respiration.
(b) During sudden arrest of respiration. The hyoid bone
has not moved. These two films demonstrate the vestibular
sphincteric mechanism.
three years earlier this patient had had the tongue of
his epiglottis removed for chronic ulceration. His
larynx was otherwise normal. He stated that since
the operation he had experienced no ill effects, but
413
AUGUST 1952
that his wife complained that he ate his meals very
slowly. Kineradiographic examination of this patient
showed that, on swallowing barium emulsion,
closure of the larynx was effected immediately the
bolus left the mouth (Fig. 8b); there was no arrest
in the vallecula and deviation of the fluid down the
lateral food channels occurred at a slightly lower
level than usual. There was considerable delay in re-
establishing the airway after the bolus had entered
the oesophagus, which appeared to be due to the
deposition of barium upon the closed superior
aperture of the larynx (Fig. 8d). The subject was
seen to make repeated attempts to open the airway
either from below or from above, each attempt being
FIG. 7.
The epiglottis acting as a true cover valve. The lumen of the
larynx is not arched backwards and is wide open. We have
only seen the epiglottis acting in this manner twice in over
500 records.
followed by another swallowing movement. Ulti-
mately the residue was removed and the airway re-
established. The patient was not conscious of any
difficulty, but each complete act of swallowing took
at least five times as long as the normal, the delay
being mostly due to the difficulty of re-establishing
the airway and not to the act of swallowing itself.
Closure of the larynx was performed satisfactorily
and no spill of barium into the vestibule occurred.
Protection was accomplished by instantaneous
closure of the vestibule by the muscular sphincter
before elevation had occurred. Unlike the normal
individual complete closure was maintained through-
out swallowing. On swallowing thick paste the
urgency for closure of the larynx was not so
great, but closure did occur whenever the barium
approached the laryngeal aperture.
VOL. XXV, No. 296
G. M. Ardran and F. H. Kemp
DISCUSSION and posteriorly by the apposed artenoids and the
The closure of the larynx ary-epiglottic folds. Similar appearances were
In 1892, Stuart, an Australian physiologist, observed when the subject was asked to make
investigated the mechanism of closure of the larynx expulsive efforts. Two Melbourne laryngologists
during swallowing by observing the behaviour of a confirmed these findings. Stuart also operated on a
man who had had a large part of the side wall of his number of species of animals and found that they

FIG. 8.
A series of frames from a patient who had the tongue of the epiglottis removed.
(a) Barium held in the mouth. The laryngeal airway is wide open. The tongue of the epiglottis has been excised near its base,
(b) Swallowing has commenced. The lumen of the vestibule is considerably narrowed but not arched backwards.
(c) The descent of the bolus through the pharynx. Barium fills the mouth of the closed larynx.
(d) The bolus has passed. The airway has not reinflated. A residue of barium lies over the mouth of the larynx. Compare
with Fig. 4h.
pharynx removed for carcinoma. He found that the too behaved in a similar manner. He explained the
entrance to the larynx is reduced to a T-shaped mechanism in the following words. "If, however, the
fissure. He stated that the vertical limb of this entrance is to be closed as a part of the act of
fissure, which is the shorter, is formed by apposition swallowing, then of course, the well-known move-
of the arytenoids; the transverse limb, which is con- ment of the entire larynx upwards and forwards
vex forwards, is formed anteriorly by the epiglottis ensues, and the tips of the arytenoids are seen to be
414

The Protection of the Laryngeal Airway during Swallowing
jammed firmly against the epiglottis. This is due
partly to the thyro-arytenoid vigorously rotating the
arytenoids inwards and pulling them downwards
and forwards, so that their tips come into contact
with the base of the epiglottis; partly, however, it is
due to the elevators of the larynx pulling the larynx
upwards and forwards against the base of the
tongue."
Negus (1949) described the action of the intrinsic
muscles in bringing about closure of the superior
laryngeal aperture, and Keene and Whillis (1950)
considered that these muscles constitute a superior
laryngeal sphincter.
Very little is known of the changes which take
place in the interior of the larynx during deglutition.
Many text-books contain a diagram showing the
larynx closed at the superior laryngeal aperture and
the lumen opened below. It has always been con-
sidered that it is essential to keep food out of the
vestibule on the grounds that the vestibule is
extremely sensitive to mechanical irritation.
How is the vestibule controlled? The theory that
the larynx is closed during normal swallowing
entirely by its own strong elevation against the back
of the tongue has not been substantiated. We have
shown that the lumen of the vestibule can be
entirely obliterated without the larynx being raised,
indicating that the vestibule must be controlled by a
sphincteric girdle of muscle. This sphincter con-
tracts from below upward; relaxation also takes place
from below upward.
The elevation of the larynx undoubtedly results
in the lumen being narrowed and arched backward,
and also results in a relative narrowing of the superior
laryngeal aperture (Fig. lc). Closure of the larynx
by other means is thereby facilitated. The retraction
of the larynx forward in order to allow the bolus to
pass from the mesopharynx also helps to close the
vestibule. If the larynx moves forward a great deal,
as when an individual swallows a large bolus, or a
mass of thick paste, the lumen of the vestibule
usually closes and opens again as soon as the forward
movement ceases.
We can only deduce what is happening to the
lumen at the level of the false and true vocal cords
since we cannot clearly see the lumen at these levels
in all phases of swallowing. Obliteration of the lu-
men of the vestibule is always associated with
obliteration of the laryngeal ventricle; both true and
false cords are probably closed at this stage. We infer
415
AUGUST 1952
that the false cords are closed when we see that they
prevent entry of barium into the laryngeal ventricle.
During entry of barium into the vestibule the true
and false cords may be open. Presumably both true
and false cords must be open when air is aspirated
from the larynx in the final phase of swallowing.
Whether the false cords can ever close the larynx
during swallowing without closure of the vestibule
we do not know.
The function of the epiglottis
We have mentioned that it is considered that the
tongue of the epiglottis can be removed without
apparent ill effects (Magendie, 1823). The truth or
otherwise of this assertion is difficult to prove. We
have been unable to trace any detailed account of
observations on the behaviour of a patient from
whom the epiglottis has been removed. Enquiries
among laryngologists reveal that disease processes
solely confined to the tongue of the epiglottis are
seldom seen and operations for the removal of the
tongue of the epiglottis alone are rarely performed.
Stuart and McCormick (1892) stated, from their
observations on a patient with a pharyngostomy
stoma, that the epiglottis remained upright on
swallowing. Barclay (1933-36) stated that when a
bolus of barium was swallowed the epiglottis was
first pushed backward against the posterior pharyn-
geal wall and then retracted forward so that it
projected like a "rock under a waterfall". He was
unable to see what happened after the bolus had
passed, but concluded that the epiglottis did not
play any vital part in the act of swallowing or in
closing off the larynx. Negus (1949) came to the
same conclusion from anatomical and clinical studies.
On the other hand, Moscher (1927), who made
several radiographic studies of deglutition, stated
that the epiglottis turned down. Hegner (1936) came
to the same conclusion, though he doubted whether
the epiglottis covered the larynx completely.
Johnstone (1942) published excellent still radio-
graphs, showing beyond all doubt that the epiglottis
turned down. He referred to the findings of Welin
(1939) who believed that some cases of dysphagia,
having the sensation of something sticking in the
throat, were due to the slow return of the epiglottis
to the upright position. Johnstone considered that
it would be necessary to employ some form of kine-
radiography before a full understanding of the
sequences of movements could be obtained.
VOL. XXV, No. 296
G. M. Ardran and F. H. Kemp
Further reference to the paper by Stuart and
McCormick (1892) reveals that it is not a full report.
It is quite clear that they were unable to keep the
epiglottis under observation in all phases of swallow-
ing, a point which is borne out by the report of
Iredell, a laryngologist, quoted in the subsequent
paper by Stuart (1892). Moreover, Johnstone (1942)
contradicted their findings, stating that he observed
a similar patient with an open pharynx and saw the
epiglottis turn over.
Why should the tongue of the epiglottis be turned
down during swallowing? In only two instances in
over 500 examinations have we seen the down-
turned epiglottis acting as a true cover valve, i.e. as a
flap covering the entrance to the wide open larynx, so
preventing the entrance of a bolus into the larynx
(Fig. 7). In a previous paper (Kemp, 1950), it was
suggested that the epiglottis acts as a valve to
prevent particles of food being swept into the larynx
during the phase of reaeration of the airways, after
swallowing has been completed. In support of this
theory it has been noted that there was frequently
a residue retained upon the upper surface of the
epiglottis, which if the epiglottis had not been
present, would presumably have been deposited over
the mouth of the larynx (Fig. 4b). The behaviour
of Capps' patient appears to confirm this theory.
As a result of these investigations we now feel
that we can claim that the epiglottis is not a useless
structure. It serves a very useful purpose during the
act of swallowing, by assisting in the protection of
the airway. It first acts as a ledge to receive the bolus
into the mesopharynx, and so obviates the necessity
for early closure of the larynx. Then after the phase
of vallecular arrest it becomes folded on itself, as a
hood over the entrance to the larynx; the sides form
chutes sloping into the lateral food channels and
guide the bolus away from the laryngeal entrance.
Though it does not normally act as a cover valve in
the old sense of the word, it does project over the
entrance to the larynx when the larynx is tilted back-
wards. Finally, it acts as a cover to prevent the
deposition of a residue of food over the mouth of the
larynx and fouling of the larynx during re-establish-
ment of the airway. Without the epiglottis man is at
a considerable disadvantage, even though he is able
to swallow without difficulty.
ACKNOWLEDGMENTS
We wish to acknowledge the help of our assistants, Miss
E. Emrys Roberts and Mr. M. S. Tuckey, without whom
this work could not have been carried out. Our thanks are
416
extended to the many members of the Staffs of the Radcliffe
Infirmary and Institute of Social Medicine and others who
acted as volunteers. We are also grateful for the help and
encouragement of Mr. Ronald Macbeth, and for assistance
afforded by Dr. Graham Weddell and Mr. F. Capps.
We are grateful to the editor of the Proceedings of the
Royal Society of Medicine for permission to reproduce
Figs, lb, 3a, 4a, 4d, 4f.
SUMMARY
The protection of the larynx during swallowing depends
upon a number of factors:
(1) The epiglottis acts as a ledge to check the descent of
the bolus, thereby obviating the necessity for early closure
of the larynx.
(2) Elevation of the larynx results in the lumen of the
laryngeal vestibule being narrowed and arched backward.
(3) The bulk of the bolus is normally deviated to one or
both sides of the larynx, down the lateral food channels.
(4) When the bolus is passing down the lateral food
channels, the vestibule may be still open and in communi-
cation with air in the hypopharynx. Barium often enters the
vestibule at this stage.
(5) The epiglottis is bent downward to form a hood over
the entrance to the larynx, but is not closely applied to the
entrance to the larynx until the last of the bolus leaves the
pharynx.
(6) Closure of the larynx is effected by contraction of the
sphincteric girdle of muscle which surrounds it, and can
occur without the need for the larynx being raised. The
larynx may be closed at any stage during the act of swallow-
ing. Complete closure is always effected when the last of the
bolus leaves the pharynx; any barium which has entered the
vestibule of the larynx is squeezed out at this stage.
(7) The epiglottis prevents the deposition of a residue of
food over the entrance to the larynx and upon reinflation of
the airway carries the residue upwards into the vallecula.
(8) If the epiglottis be removed reinflation of the airway
is delayed until all traces of food have been removed from
the entrance to the larynx by repeated acts of swallowing.
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