Bailey reading

U P P ER A IR W AY A N ATO M Y
A N D FU N C TIO N

Introduction
The upper airway includes the nasal and oral

cavities, the pharynx, and the larynx; the function

design is far from ideal because ingested food and
water must traverse the upper airway to reach the
alimentary tract.
The pharynx must serve two conflicting functions :

- rapidly constrict during swallowing,

- maintain patency during the negative pressure
generated by inspiration.
Breathing and speech must be interrupted during a

swallow.

PharyngealAnatom y
The pharynx is an irregularly tubular structure,

extending from the base of the skull to the

esophageal inlet (Fig. 49.1).
The pharynx has anterior openings into the nasal
and oral cavities, and inferiorly it opens into the
larynx and esophagus.
There are three segments: the nasopharynx, the
oropharynx, and the hypopharynx.
The nasopharynx can be sealed off from the
oropharynx by simultaneous elevation of the soft
palate and formation of a fold in the pharyngeal
walls, known as Passavant ridge.

 The pharynx must serve two conflicting

functions :
- rapidly constrict during swallowing,
- maintain patency during the negative
pressure
generated by inspiration.
The posterior and lateral walls of the pharynx

are composed of three pharyngeal constrictor

muscles attached to the cervical vertebrae
posteriorly:
1. superior constrictor
2. Middle constrictor
3. Inferior constrictor

 The superior constrictor is suspended from

the base of the skull, the medial pterygoid

plate, the pterygomandibular raphe, the
mylohyoid line of the mandible, and the
lateral tongue.
The middle constrictor attach anteriorly on
the hyoid bone and the stylohyoid ligament.
The inferior constrictor attaches to the
thyroid and cricoid cartilages.
Activation of these muscles constricts the
pharynx; there is no evidence to support the
concept that they contribute to stability of
the airway.

 Pharyngeal patency during the

negative pressure generated with

inspiration is maintained by muscles
that dilate the lumen by pulling the
base of the tongue or hyoid bone
anteriorly.
These muscles include: the
genioglossus, the geniohyoid, and
the anterior belly of the digastric
muscle.

PharyngealAirw ay Physiology
Maintenance of upper airway patency is a

peculiarly human problem. Some degree of airway

collapse occurs during sleep in all humans, and
obstructive sleep apnea (OSA) is extremely
common. Sleep-disordered breathing is extremely
rare in any other animal .
The instability of the human pharyngeal airway

seems to be a result of the inferior displacement of

the larynx during development (2). As a result, the
pliable pharyngeal walls are suspended from the
base of the skull and mandible with little skeletal
support.

 Otot-otot yg menjaga patensi, yaitu

otot genioglossus, geniohyoid, dan

digastric anterior sesungguhnya
adalah otot-otot dilatasi faring yang
distimulasi oleh tekanan negatif
airway
Pada pasien OSA dinding faring lebih
mudah kolaps.

 Karena dinding faring mudah kolaps (lentur), maka

pharynx berperan seperi/sebagai Starling resistor

mekanisme resistor yang dipengaruhi oleh :
Difference between the upstream and downstream
(i.e., intrapleural) pressures
Difference between the upstream pressure and the
collapsing forces (paling penting pengaruhnya).
Jadi bisa dikatakan bahwa jika tekanan udara inspirasi

dari hidung tidak cukup kuat untuk mencegah faring

kolaps dan tetap terbuka, maka tidak ada udara yang
akan masuk ke paru,meskipun otot-otot pernafasan
kontraksi hebat akibatnya timbul apnu obstruktif.

 Patency of the upper airway during

breathing depends on active

contraction of muscles that dilate the
pharynx and open the larynx.

LaryngealAnatom y
Epiglottis --the most superior portion of

the larynx , which projects posteriorly

into the pharynx.
The vallecula is the pouch between the
base of the tongue and the epiglottis.
Interiorly, the glottis is seen as a
roughly triangular opening during
inspiration and a narrow slit during
phonation.

 The true vocal folds comprise the anterior edges of

the glottis. Superior and lateral to the true vocal

folds are the false vocal folds.
The ventricle is a narrow space between the true and

false folds.
The posterior glottis is formed by the two arytenoid

cartilages and the intervening mucosa. The

arytenoids are the posterior attachments of both the
true and false vocal folds.
Opening and closing of the glottis is accomplished by

action of muscles that move the arytenoids.

 There is a mucosal bridge between the

epiglottis and the arytenoid on each side,

known as the aryepiglottic fold. These folds
serve as levees between the swallowing
channels and airway, by separating the piriform
fossae from the glottis.
The piriform fossae are mucosal-lined spaces

lateral to the aryepiglottic folds but medial to

the laryngeal skeleton (Figs. 49.2, 49.3, and
49.4), and are the pathways by which ingested
food and liquid are conveyed to the esophagus.

Skeleton
The laryngeal skeleton is made up of several

cartilages and one bone strung together in

series and suspended from the skull base and
mandible (Fig. 49.5).
Laryngeal motion can be caused by both
intrinsic muscles, which arise and insert on
laryngeal cartilages, and extrinsic muscles,
which connect the larynx to other structures.
Descent of the trachea during inspiration
produces widening of the glottis. This
phenomenon is a result of the ligamentous
interconnections of the laryngeal skeleton.

 The hyoid
supports the larynx and stabilizes the hypopharynx,
is roughly U-shaped, with the two free ends

projecting posteriorly as the greater cornua and the

lesser cornua are two small bumps on the superior
anterior surface.
hyoid is connected to the thyroid cartilage by the
broad thyrohyoid membrane. A bursa in this
membrane enhances vertical mobility of the larynx.
Laterally, the edges of the membrane thicken to
form the thyrohyoid ligaments.

 The thyroid cartilage

is composed of two halves fusedanteriorly at a

sharp angle (90 degrees in males and 120

degrees in females).
The posterior border has superior and inferior
cornua: the superior cornu attaches to the
thyrohyoid ligament, whereas the inferior
articulates with the cricoid cartilage.
The thyroid cartilage begins to gradually ossify
after the age of 20 years. This process accounts
for many age-related changes in pitch and
resonance of the voice.

 The epiglottis
is 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.

 The cricoid cartilage

is the skeletal support of the subglottis.

- The subglottis is the only point in the airway with a

completely rigid diameter and has a smaller crosssectional area than the trachea
Anteriorly, the cricoid is about 1 cm high, with a
smooth curved surface. Posteriorly, it is 2 to 3 cm
high, and the superior surface is flattened centrally
to provide an area of articulation for the arytenoid
cartilages.
Posterolaterally, on each side, the cricoid articulates
with the inferior cornu of the thyroid cartilage to
form a visorlike apparatus, allowing rotation in a
sagittal plane, which opens or closes the anterior
cricothyroid space.

 arytenoid cartilage
is a somewhat pear-shaped mass.
The broad base articulates with the cricoid in a

complex synovial joint, allowing multiaxial

rotation but minimal translation (6).
The vocal process, an anterior and medial
projection of the arytenoid, is the posterior
segment off the vocal fold (Fig. 49.6). Two other
small sesamoid cartilages, the corniculate and
the cuneiform, are located superior to the
arytenoid and support the aryepiglottic fold.

 Two fibroelastic membranes are important

components of the larynx.

The conus elasticus provides support to the vocal

fold. From its lateral attachment to the cricoid, it
extends anteriorly to the midline lower edge of the
thyroid cartilage and posteriorly to the vocal process
of the arytenoid. Its free edge forms the vocal
ligament.
The qua-drangular membrane supports the
supraglottis. It connects the epiglottis with the
arytenoid and the corniculate cartilages. The superior
free edge is draped in mucosa to form the
aryepiglottic fold, whereas the inferior edge is a part
of the false vocal fold (Fig. 49.7).

M uscles
Motion of the vocal folds is affected primarily by

the intrinsic laryngeal muscles:

posterior cricoarytenoid muscle, the only
abductor of the glottis, origo:the posterior surface
of the cricoid, insertio: arytenoid. Contraction of
this muscle externally rotates the arytenoid,
displacing the vocal process superiorly and
laterally, resulting in abduction of the glottis (6).
The lateral cricoarytenoid is an adductor with
origin on the lateral cricoid and insertion on the
arytenoid. This muscle pulls the muscular process
forward, rotating the vocal process medially.

 The thyroarytenoid originates on thyroid

cartilage to insert on the vocal process of the

arytenoid. It exerts anterior traction on the vocal
process, increasing vocal fold tension, thickness,
and stiffness. In the absence of cricothyroid
muscle contraction, it also reduces tension in the
mucosal cover. The thyroarytenoid muscle is often
considered to be divided into two separate
muscles: the medial thyroarytenoid (vocalis) and
the lateral thyroarytenoid. The cricothyroid muscle
pulls the cricoid and thyroid cartilages together
anteriorly to increase the length and tension of the
vocal folds.

 The interarytenoid muscle, the

only unpaired laryngeal muscle,

adducts the vocal folds (Fig. 49.6).
The smallest laryngeal muscle, a
very small band of muscle fibers
between the epiglottis and arytenoid,
constricts the supraglottic inlet.

 Extrinsic laryngeal muscles include the

mylohyoid, digastric, and stylohyoid

muscles, which suspend the larynx
superiorly, and the cervical strap muscles:
the omohyoid, sternohyoid, sternothyroid,
and thyrohyoid.
Extrinsic muscles elevate or depress the

larynx or move it anteriorly or posteriorly.

Extrinsic muscle activity can indirectly
adduct, abduct, or tense the vocal folds or
constrict the supraglottis.

N erve Supply
The vagus nerve supplies the larynx through

two branches, the superior laryngeal nerve

and the recurrent laryngeal nerve. The
superior laryngeal nerve exits the vagus
below the nodose ganglion and branches into
two divisions. The internal branch is purely
sensory, carries afferent fibers from
supraglottis and vocal folds, and enters the
larynx laterally through the thyrohyoid
membrane. The external branch supplies
motor fibers to the cricothyroid muscle.

M ucosalCover
The mucosal cover of most of the upper airway

is respiratory epithelium, with numerous mucous

glands (Fig. 49.8).
Over the free edge of the vocal fold, mucosa is
adapted for periodic vibration with squamous
epithelium and no mucous glands.
A highly specialized lamina propria separates the
epithelium from underlying muscle (10). The
lamina propria serves as a shock absorber, or
impedance matcher, so that the epithelium can
vibrate freely, without restriction by the bulky
underlying muscle.

 The lamina propria of the vocal fold contains three

layers: superficial, intermediate, and deep.

Each layer has unique mechanical properties because
of varying densities of elastic and collagenous fibers.
The deep layer, or vocal ligament, is the stiffest, due
to a high concentration of collagen fibers.
Elastic fibers are most numerous in the intermediate
layer and gradually decrease toward the epithelium
and muscle.
The superficial layer of the lamina propria is often
referred to as Reinke space, although it is not actually
a potential space. This layer has the lowest
concentration of both elastic and collagenous fibers
and offers the least impedance to vibration.

Vocal fold mucosa

Respiratory Physiology O fthe

Larynx
The most primitive function of the larynx is

that of a sphincter, preventing the ingress

of anything other than air into the lungs.
Other functions include coughing, Valsalva
maneuver, and the regulation of airflow in
and out of the lungs.
The larynx also serves as a sensory organ
and contains receptors that influence the
control of breathing and even affect
cardiovascular function.

Cough
Cough ejects mucus and foreign matter from the lungs

and helps to maintain patency of the pulmonary alveoli

A cough has three phases: inspiratory, compressive,
and expulsive.
First, the larynx opens very widely to permit rapid and
deep inspiration. If the cough is voluntary, the degree
of glottal abduction and inspiratory effort is
proportional to the intended strength of the cough. The
compressive phase is produced by tight closure of the
glottis and strong activation of expiratory muscles.
During the expulsive phase, the larynx suddenly opens
widely, with a sudden outflow of air in the range of 6 to
10 L per second.

Valsalva Maneuver
Forced expiration against a tightly closed glottis
is known as the Valsalva maneuver.
The true vocal folds offer more resistance to
inspiratory than expiratory airflow. However,
very tight closure of both true and false vocal
folds enables the larynx to resist very strong
expiratory forces.
It is important in defecation because the
pressure is transmitted to the abdominal cavity.
Valsalva also serves to stabilize the thorax
during heavy lifting by the arms.

Regulation ofAirfl
ow
The larynx is ideally located to regulate the flow of air in and

out of the lungs

Observations of laryngeal movement demonstrate that the
glottis widens during inspiration and narrows during expiration,
Opening, or abduction of the larynx, facilitates breathing by
decreasing resistance to airflow.
Two forces contribute to inspiratory opening of the larynx:
longitudinal tension on the laryngeal skeleton, caused by the
descent of the trachea, and contraction of the posterior
cricoarytenoid muscle.
Active laryngeal abduction is a primary action of breathing,
because the posterior cricoarytenoid muscle consistently begins
to contract before the diaphragm.
The larynx opens more widely during inspiration with increasing
effort of breathing and in response to negative upper airway
pressure.

 Expiratory adduction of the larynx is sometimes a

passive phenomenon, but laryngeal abductor

activity can decrease the rate of breathing by
prolonging expiratory duration.
With very strong respiratory demand, the posterior
cricoarytenoid muscle continues contracting during
expiration, after the diaphragm has relaxed. This
results in decreased resistance and faster outflow of
air, which shortens the duration of expiration and
increases the rate of breathing.
During most conditions of breathing, respiratory
rate is primarily controlled by varying the rate of
exhalation.

 In addition to dynamic control of airflow,

the static larynx exerts mechanical

influences on airflow. At any given glottic
aperture, resistance to airflow in the
inspiratory direction is much greater than
resistance to expiratory flow. Because of
this, conditions that cause laryngeal
obstruction, such as edema, papillomas,
or laryngeal paralysis, usually produce
inspiratory stridor before expiration is
impaired.

Sensory Input to Respiratory Control

The larynx is not only an effector organ; it is also

richly supplied with a variety of sensory receptors

that exert influences on breathing and
cardiovascular function
Three major types of laryngeal receptors are
activated by the process of breathing and have an
influence on the central control of breathing:
negative pressure receptors; airflow (cold)
receptors; and drive receptors, which are
probably proprioceptors that respond to
respiratory motion of the larynx. Laryngeal
receptors also respond to touch and chemical
stimuli.

Circulatory Reflexes
Stimulation of the larynx can produce changes in

heart rate and blood pressure as seen during

general anesthesia and OSA.
When upper airway patency is not maintained
during sleep, the resulting increase in negative
airway pressure can stimulate receptors in the
larynx so strongly that cardiac arrhythmias
occur.
The direct result of laryngeal stimulation on
blood pressure is hypertension. However, if
laryngeal stimulation produces significant
bradycardia or ectopy, the indirect result can be
hypotension.

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, resonance, and articulation.
Phonation is the generation of sound by vibration of the
vocal folds. Resonance is the induction of vibration of
the rest of the vocal tract to modulate and amplify
laryngeal output. Articulation is the shaping of the
voice into the words that characterize human speech.

Phonation
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, and volitional control of vocal fold length and tension.
Just before phonation, the vocal folds are approximated in the
midline. Exhalation then causes subglottic pressure to rise until the
vocal folds are pushed apart. This separation produces a rapid
decrease in subglottic pressure. The vocal folds then return to the
midline as a result of sudden decrease in pressure, elastic forces in
the vocal fold, and the Bernoulli effect. Pressure in the trachea
builds once more, and the cycle is repeated. During modal
phonation, the vocal fold essentially vibrates as two masses, with
the upper edge lagging behind the lower edge. This results in a
traveling wave, from caudal to rostral, known as the mucosal wave.

Resonance
Phonatory output is modulated by resonance, the

induction of vibration in the chest, pharynx, and head

with selective amplification of certain component
frequencies.
Resonance not only gives the voice its characteristic
acoustic pattern but can also amplify the voice. Vocal
training, for singing and acting or public speaking,
concentrates heavily on refining and maximizing
resonance, so that the loudest and most pleasing
sound can be produced with the least amount of strain
or pressure on the larynx. Resonance is controlled by
altering the shape and volume of the pharynx, by
raising or lowering the larynx, by moving tongue or
jaw position, or by varying the amount of sound
transmission through the nasopharynx and nose.

Soal-soal

Soal-soal (B-II)
1. The muscle which is most important

a.
b.
c.
d.
e.

in maintaining patency of the

pharyngeal airway is the...
Cricothyroid muscle
Genioglossus muscle
Palatoglossus muscle
Posterior digastric muscle
Superior pharyngeal constrictor

 Answer : B
Pharyngeal patency during the

negative pressure generated with

inspiration is maintained by muscles
that dilate the lumen by pulling the
base of the tongue or hyoid bone
anterior include: the genioglossus, the
geniohyoid, and the anterior belly of
the digastric muscle.

2. The intrinsic laryngeal muscle that

opens the glottis is the....
a. Thyrohyoid musle
b. Cricothyroid muscle
c. Interarytenoid muscle
d. Lateral cricoarytenoid muscle
e. Posterior cricoarytenoid muscle

 Answer : E

3. Laryngospasm, in response to
mechanical stimulation of the larynx,
is most likely to occur under which of
the following condition?
a. Hypoxia
b. Deep sleep
c. Hypercarbia
d. Light anesthesia
e. Strenuous exercise

 Answer : D

4. Mechanical stimulation of the larynx

results in...
a. Bronchodilation
b. Tachycardia
c. Hypertension
d. Valsava maneuver
e. disphoresis

 Answer: C

5. Which of the following is

requirement for normal phonation?
a. Normal lamina propia
b. Normal vital capacity
c. Divergent glottal tract
d. Tight glottal closure
e. Sense vocal ligament

 Answer: A

SoalB-1
1. The vocal folds are abducted by
a.
b.
c.
d.

e.

the....
Cricothyroid muscle
Thyroarytenoid muscle
Interarytenoid muscle
Lateral cricoarytenoid muscle
Posterior cricoarytenoid muscle

 Answer: E

2. Anterior displacement of the

muscular process of the arytenoid
has the following effect on the vocal
fold
a. Adduction
b. Abduction
c. Shortening
d. Decrease in tension
e. Inferior displacement

 Answer: A

3. A muscle that does not contribute to

maintaining patency of the upper
airway patency is the..
a. Digastric
b. Geniohyoid
c. Genioglossus
d. Posterior cricoarytenoid
e. Superior pharyngeal constrictor

 Answer: E

4. The mucosa of the vibratory edge of

the vocal fold is unique because of
its specialized....
a. Columnar epithelium
b. Basement membrane
c. Lamina propria
d. Mucus gland
e. Cilia

Answer: C

5. The superior laryngeal nerve

a.
b.
c.
d.
e.

supplies motor fibers to the......

Superior pharyngeal contrictor
muscle
Lateral cricoarytenoid muscle
Thyroarytenoid muscle
Cricothyroid muscle
Thyrohyoid muscle

 Answer: D

6. Laryngeal adductor muscle play a

a.
b.
c.
d.
e.

role in the control of breathing by....

Decreasing the duration of
inspiration
Increasing the duration of expiration
Decreasing functional residual
capacity
Lengthening the pause between
breaths
Increasing the rate of respiration

 Answer : B

7. A direct cardiovascular effect of

mechanical stimulation of the larynx
is..
a. Hypertension
b. Tachycardia
c. Ventricular ectopy
d. Peripheral vasodilatation
e. Increased cardiac output

 Answer: A

8. Excess subglottic pressure would be

required for phonation in the
presence of..
a. Vocal nodules
b. Vocal fold paralysisi
c. Abductor muscle spasm
d. Adductor muscle spasm
e. Vocalis muscle atrophy

 Answer: D

9. Elevation of vocal pitch with

increasing age is due to....
a. Vocal fold edema
b. Descent of the hyoid bone
c. Atrophy of thecricothyroid muscle
d. Thinning of the vocal fold mucosa
e. Calcification of thyroid cartilage

 Answer: E

10. The structure around which the left

recurrent laryngeal nerve courses
before ascending back to the larynx
is the........
a. Aortic arch
b. Pulmonary artery
c. Innominate artery
d. Subclavian artery
e. Ligamentum arteriosum

 Answer: E

11. The medial border of the pyriform

fossa is partially formed by the.....
a. Vallecula
b. Hyoid bone
c. Conus elasticus
d. Thyroid cartilage
e. Aryepiglottic fold

 Answer: E

12. The feature of upper airway that is

unique to human is
a. Passavants ridge
b. The laryngeal ventricle
c. Descent of the larynx during
development
d. Complete glottal closure with
phonation
e. Contact of the uvula with the
epiglottic

 Answer: C

13. Laryngeal edema is most likely to

result in
a. Hyperpnea
b. Reflex apnea
c. Inspiratory stridor
d. Expiratory wheezing
e. Prolonged exhalation

 Answer: C

Thank you.........