UPPER AIRWAY ANATOMY AND

FUNCTION
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.
Pharyngeal Anatomy

 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.
Pharyngeal Airway 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.
Laryngeal Anatomy

 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 cross-
sectional 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).
Muscles

 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.
Nerve 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.
Mucosal Cover
 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 Of
the 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 of Airflow
 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 in

maintaining patency of the pharyngeal
airway is the...
a. Cricothyroid muscle
b. Genioglossus muscle
c. Palatoglossus muscle
d. Posterior digastric muscle
e. 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
Soal B-1

1. The vocal folds are abducted by the....

a. Cricothyroid muscle
b. Thyroarytenoid muscle
c. Interarytenoid muscle
d. Lateral cricoarytenoid muscle
e. 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 supplies motor
fibers to the......
a. Superior pharyngeal contrictor muscle
b. Lateral cricoarytenoid muscle
c. Thyroarytenoid muscle
d. Cricothyroid muscle
e. Thyrohyoid muscle
 Answer: D
6. Laryngeal adductor muscle play a role in the
control of breathing by....
a. Decreasing the duration of inspiration
b. Increasing the duration of expiration
c. Decreasing functional residual capacity
d. Lengthening the pause between breaths
e. 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. Passavant’s 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.........