UPPER AIRWAY

ANATOMY 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 Surgery

School of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2015
1

Introduction
The upper airway includes :
- Nasal Cavity
- Oral cavity
- Pharynx
- Larynx

Nasal
Nasal Skeleton
-Bone
-Cartilage

Jhonson T.J. et al . 2014. Baileys 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 Cavity
Nasal Septum
- Bone : vomer,
perpendicular plate of
etmoid, maxillary crest,
palatine bone
-Cartilage :
quadrangular cartilage

Lateral Nasal Wall

Three turbinates
(inferior, middle,
superior)
Meatus : inferior meatus
middle meatus
superior
meatus

Artery blood supply

External nose :
- External carotid artery to facial
artery
- Superior labial artery
- Angular artery
Nasal 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

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

Artery blood supply

Kiesselbachs plexus
anastomosis of septal
branch of sphenopalatine
artery, anterior ethmoidal
artery branches, greater
palatine artery, and septal
branches of superior labial
artery anastomose
Woodrufs plexus
anastomosis of posterior
nasal, posterior ethmoid,
sphenopalatine, and
ascending pharyngeal
arteries
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Oral 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

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

PHARYNGEAL
ANATOMY
irregularly tubular
structure from the base
of the skull to the
esophageal inlet
3 segments
-Nasopharynx
-oropharynx
-Hypopharynx

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.

PHARYNGEAL ANATOMY

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Blood Suply
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

11

Nerve
Supply
Motor, sensory and
autonomic innervation
from the pharyngeal
plexus, which in turn
receives fibers from
the Glossopharyngeal
(CN IX) and Vagus
nerves (CN X)
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Lymphayic Drainage
Retropharyngeal lymph
nodes, while the lower
portions drain to the
parapharyngeal or deep
cervical nodes.

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LARYNGEAL ANATOMY
Laryngeal
Framework : Bone
Cartilages
Bone: Hyoid
Cartilages:
-Thyroid
-Cricoid
-Arytenoids
-Epiglottis
-Sesamoid cartilages
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.

LARYNGEAL 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.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.
Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006. Ch17. p337-384

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LARYNGEAL ANATOMY
Thyroid Cartilage Greek
Name meaning Sheild
like
Thyroid cartilage :
o Superior horn
thyrohyoid ligament
o Inferior horn cricoid
cartilage
To gradually ossify after
the age of 20 age-related
changes of the voice
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.
Probst, Rudolf, et all. Basic Otorhinolaringology. Thieme, 2006. Ch17. p337-384

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LARYNGEAL 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
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.

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LARYNGEAL 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.
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5 th ed. Pennsylvania.. Lippincot Williams & Wilkin

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Fibroelastic
Membranes
Two important components
:
The quadrangular
membrane
o supports the supraglottis.

The conus elasticus

o provides support to the vocal
fold.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

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LARYNGEAL ANATOMY

LARYNGEAL 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

Netter F. Atlas Clinical Anatomy. Electronic version.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

21

LARYNGEAL 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
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin.

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LARYNGEAL ANATOMY

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

Ch17. p337-384

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

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Nerve supply to the

larynx
Supplied by :
Internal and External branches
of the superior laryngeal nerve
(SLN)
the recurrent laryngeal nerve
(RLN)

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

Ch17. p337-384

24

Blood supply to the larynx

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.

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

Ch17. p337-384

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MUCOSAL 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)
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

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Respiratory
physiology of the
Larynx
Main function of the larynx a sphincter
preventing anything other than air into the lungs
Another functions :
- Coughing
- Valsalvas 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. inspiratory
2. compressive
3. expulsive.
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

28

Valsalvas 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.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

29

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.

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

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 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.
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

31

Respiratory
Physiology
Strong respiratory demand, the posterior
cricoarytenoid muscle continues contracting during
expiration, after the diaphragm has relaxed.
decreased resistance and faster outflow
of air
shortens the duration of
expiration
increases the rate of
breathing

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

32

Respiratory
Physiology
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.
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

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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.
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

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Circulatory 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.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

35

Speech
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

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

36

Speech
Phonation
Soundisproducedbythelarynxwhenexpiratoryairflowinduces
vibrationoffreeedgesofthevocalfoldsasaresultoftheinteraction
ofaerodynamicandmyoelasticforces.
Fiveconditionsmustbemettosupportnormalphonation:
appropriatevocalfoldapproximation
adequateexpiratoryforce
sufficientvibratorycapacityofthevocalfolds
favorablevocalfoldcontour
volitionalcontrolofvocalfoldlengthandtension
Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

37

Resonance

Speech

Gives the humans voices 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.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

38

Speech
Articulation
formation of consonants and vowels
largely controlled by the lips, tongue, palate, and
pharynx.

Jhonson T.J. et al . 2014. Baileys Head and Neck Surgery Otolaryngology.5th ed. Pennsylvania.. Lippincot Williams & Wilkin

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THANK YOU

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