ANATOMY OF THE NOSE,

LARYNX AND TRACHEA

DR. HASSAN SHAIBAH

 SURFACE APPEARANCE
THE EXTERNAL NOSE

• HAVE A PYRAMIDAL SHAPE.

• NASAL ROOT LOCATED SUPERIORLY &
CONTINUOUS WITH FOREHEAD.
• APEX ENDS INFERIORLY IN A ROUNDED
‘TIP’.
• SPANNING BETWEEN THE ROOT & APEX IS
DORSUM OF THE NOSE.
• INFERIORLY TO APEX THE NARES; OPENINGS
INTO THE VESTIBULE OF THE NASAL
CAVITY.
• NARES BOUNDED MEDIALLY BY NASAL
SEPTUM, & LATERALLY BY ALA NASI (THE
LATERAL CARTILAGINOUS WINGS OF THE
NOSE).
 SKELETAL STRUCTURE

MADE OF BONY & CARTILAGINOUS

COMPONENTS:
• BONY COMPONENT – LOCATED
SUPERIORLY, COMPRISED OF
CONTRIBUTIONS FROM NASAL, &
MAXILLA BONES
• CARTILAGINOUS COMPONENT
LOCATED INFERIORLY, COMPRISED:
• 2 LATERAL CARTILAGES
• 2 ALAR CARTILAGES
• ONE SEPTAL CARTILAGE.
• SOME SMALLER ALAR CARTILAGES
 VESSELS AND LYMPHATICS

• EXTERNAL NOSE RECEIVES ARTERIAL SUPPLY

FROM
• BRANCHES OF THE MAXILLARY (INFRA ORBITAL)
• OPHTHALMIC ARTERIES ( DORSAL & EXTERNAL )

• THE SEPTUM & ALAR CARTILAGES RECEIVE

ADDITIONAL SUPPLY FROM ANGULAR ARTERY
& LATERAL NASAL ARTERY. THESE ARE
BOTH BRANCHES OF FACIAL ARTERY (DERIVED
FROM EXTERNAL CAROTID ARTERY).
• VENOUS DRAINAGE IS INTO THE FACIAL VEIN,
THEN IN TURN INTO INTERNAL JUGULAR VEIN.
• LYMPHATIC DRAINAGE FROM THE EXTERNAL
NOSE IS VIA SUPERFICIAL LYMPHATIC VESSELS
ACCOMPANYING THE FACIAL VEIN. THESE
VESSELS, LIKE ALL LYMPHATIC VESSELS OF THE
HEAD AND NECK, ULTIMATELY DRAIN INTO
THE DEEP CERVICAL LYMPH NODES.
 INNERVATION
• SENSORY INNERVATION OF THE EXTERNAL NOSE IS DERIVED FROM THE TRIGEMINAL
NERVE (CN V).
• EXTERNAL NASAL NERVE, A BRANCH OF OPHTHALMIC NERVE (CN V1), SUPPLIES THE SKIN
OF THE DORSUM OF NOSE, NASAL ALAE AND NASAL VESTIBULE.
• THE LATERAL ASPECTS OF THE NOSE ARE SUPPLIED BY THE INFRORBITAL NERVE, A BRANCH
OF THE MAXILLARY NERVE (CN V2).
 THE NASAL CAVITY

• THE MOST SUPERIOR PART

OF RESPIRATORY TRACT.
• EXTENDS FROM VESTIBULE TO THE
NASOPHARYNX, AND HAS THREE
DIVISIONS:
1. VESTIBULE – THE AREA SURROUNDING
ANTERIOR EXTERNAL OPENING TO NASAL
CAVITY.
2. RESPIRATORY REGION – LINED BY
CILIATED
PSUDEOSTRATIFIED EPITHELIUM, WITH
MUCUS-SECRETING GOBLET CELLS.
3. OLFACTORY REGION – LOCATED AT THE
APEX OF THE NASAL CAVITY. LINED BY
OLFACTORY CELLS & RECEPTORS.
 NASAL CONCHAE
• LATERAL WALLS OF THE NASAL CAVITY CURVED
SHELVES OF BONE. THEY ARE
CALLED CONCHAE (OR TURBINATES).
• 3 CONCHAE – INFERIOR, MIDDLE & SUPERIOR.
• PROJECT INTO NASAL CAVITY, CREATING
PATHWAYS FOR THE AIR TO FLOW. THESE
PATHWAYS ARE CALLED MEATUSES:
• INFERIOR MEATUS – BETWEEN THE INFERIOR
CONCHA AND FLOOR OF THE NASAL CAVITY.
• MIDDLE MEATUS – BETWEEN THE INFERIOR AND
MIDDLE CONCHA.
• SUPERIOR MEATUS – BETWEEN THE MIDDLE AND
SUPERIOR CONCHA.
• FUNCTION TO INCREASE THE SURFACE AREA OF
THE NASAL CAVITY – THIS INCREASES THE
AMOUNT OF INSPIRED AIR, SO THAT IT CAN
BE HUMIDIFIED.
 OPENINGS INTO THE NASAL CAVITY

• ONE OF THE FUNCTIONS OF THE NOSE IS TO DRAIN A VARIETY OF

STRUCTURES. MANY OPENINGS INTO NASAL CAVITY DRAINAGE
OCCURS.
• FRONTAL, MAXILLARY & ANTERIOR ETHMOIDAL SINUSES
OPEN INTO MIDDLE MEATUS. THE LOCATION OF THIS OPENING
IS MARKED BY THE SEMILUNAR HIATUS, A CRESCENT-SHAPED
GROOVE ON THE LATERAL WALLS OF THE NASAL CAVITY.
• MIDDLE ETHMOIDAL SINUSES EMPTY OUT ONTO A STRUCTURE
CALLED THE ETHMOIDAL BULLA.
• THE POSTERIOR ETHMOIDAL SINUSES OPEN OUT AT THE LEVEL
OF THE SUPERIOR MEATUS.
• THE ONLY STRUCTURE NOT TO EMPTY OUT ONTO THE LATERAL
WALLS OF THE NASAL CAVITY IS THE SPHENOID SINUS. IT
DRAINS ONTO THE POSTERIOR ROOF.
• IN ADDITION TO THE PARANASAL SINUSES, OTHER STRUCTURES
OPEN INTO THE NASAL CAVITY:
• NASOLACRIMAL DUCT –DRAIN TEARS FROM THE EYE. IT OPENS
INTO THE INFERIOR MEATUS.
• AUDITORY (EUSTACHIAN) TUBE – OPENS INTO THE
NASOPHARYNX AT THE LEVEL OF THE INFERIOR MEATUS. IT
ALLOWS THE MIDDLE EAR TO EQUALISE WITH THE ATMOSPHERIC
AIR PRESSURE.
 CLINICAL RELEVANCE: SPREAD OF
INFECTION

• AS THE AUDITORY TUBE CONNECTS THE MIDDLE EAR AND UPPER RESPIRATORY
TRACT, IT IS A PATH BY WHICH INFECTION CAN SPREAD FROM THE UPPER
RESPIRATORY TRACT TO THE EAR. INFECTION OF THE AUDITORY TUBE CAUSES
SWELLING OF THE MUCOUS LININGS, AND THE TUBE BECOMES BLOCKED. THIS
RESULTS IN DIMINISHED HEARING.
 VASCULATURE
INTERNAL CAROTID BRANCHES:
• ANTERIOR ETHMOIDAL ARTERY
• POSTERIOR ETHMOIDAL ARTERY

THE ETHMOIDAL ARTERIES ARE BRANCH OF

THE OPHTHALMIC ARTERY.
EXTERNAL CAROTID BRANCHES:
• SPHENOPALATINE ARTERY
• GREATER PALATINE ARTERY
• SUPERIOR LABIAL ARTERY
• LATERAL NASAL ARTERIES
• THESE ARTERIES FORM ANASTOMOSES WITH EACH
OTHER. THIS IS PARTICULARLY PREVALENT IN THE
ANTERIOR PORTION OF THE NOSE
• THE VEINS OF THE NOSE TEND TO FOLLOW THE
ARTERIES. THEY DRAIN INTO THE PTERYGOID PLEXUS,
FACIAL VEIN OR CAVERNOUS SINUS.
 CLINICAL RELEVANCE: EPISTAXIS

• EPISTAXIS IS A NOSEBLEED. DUE TO THE RICH BLOOD SUPPLY OF THE NOSE, THIS
IS A COMMON OCCURRENCE. IT IS MOST LIKELY TO OCCUR IN THE ANTERIOR
THIRD OF THE NASAL CAVITY – THIS AREA IS KNOWN AS THE KIESSELBACH
AREA.
• THE CAUSE CAN BE LOCAL (SUCH AS TRAUMA), OR SYSTEMIC (SUCH AS
HYPERTENSION).
 INNERVATION

• CAN BE FUNCTIONALLY DIVIDED

INTO SPECIAL AND GENERAL INNERVATION.
• SPECIAL SENSORY SMELL. BY OLFACTORY
NERVES.
• GENERAL SENSORY INNERVATION TO THE SEPTUM
AND LATERAL WALLS IS DELIVERED BY
THE NASOPALATINE NERVE (BRANCH OF
MAXILLARY NERVE) & THE NASOCILIARY
NERVE (BRANCH OF THE OPHTHALMIC NERVE).
• INNERVATION TO THE EXTERNAL SKIN OF THE
NOSE IS SUPPLIED BY THE TRIGEMINAL NERVE.
 THE LARYNX

CARTILAGINOUS STRUCTURE IN THE NECK THAT GUARDS THE ENTRANCE TO THE TRACHEA

HAS 3 BASIC FUNCTIONS; IN ORDER OF IMPORTANCE:

1. AIR PASSAGE: CARTILAGINOUS STRUCTURE ENSURES PATENCY OF AIRWAY

2. SPHINCTER: REGULATES AIR & FOOD PASSAGES TO ENSURE COORDINATED BREATHING &
SWALLOWING. PROVIDES VALVULAR BLOCKADE FOR BUILD-UP OF INTRA-THORACIC & INTRA-
ABDOMINAL PRESSURE IMPORTANT FOR FUNCTIONS SUCH A COUGHING, SNEEZING, MICTURITION,
PARTURITION, ETC.

3. ORGAN OF PHONATION (VOICEBOX): PRODUCES SOUND BY INTERMITTENT RELEASE OF HIGH

PRESSURE AIR BETWEEN CLOSED VOCAL FOLDS CAUSING THEIR VIBRATION
 ANATOMICAL STRUCTURE
• IS FORMED BY A CARTILAGINOUS SKELETON,
WHICH IS HELD TOGETHER BY LIGAMENTS AND
MEMBRANES. THE LARYNGEAL MUSCLES
ANATOMICALLY, THE INTERNAL CAVITY OF THE
LARYNX CAN BE DIVIDED INTO THREE SECTIONS:
• SUPRAGLOTTIS – FROM THE INFERIOR SURFACE
OF THE EPIGLOTTIS TO THE VESTIBULAR FOLDS
(FALSE VOCAL CORDS).
• GLOTTIS – CONTAINS VOCAL CORDS AND 1CM
BELOW THEM. THE OPENING BETWEEN THE
VOCAL CORDS IS KNOWN AS RIMA GLOTTIDIS,
THE SIZE OF WHICH IS ALTERED BY THE MUSCLES
OF PHONATION.
• SUBGLOTTIS – FROM INFERIOR BORDER OF THE
GLOTTIS TO THE INFERIOR BORDER OF THE
CRICOID CARTILAGE.
 CARTILAGES

PRINCIPLE CARTILAGES (hyaline

cartilage):

• Thyroid cartilage

• Cricoid cartilage

• Arytenoid cartilages (2)

(These cartilages are made of hyaline cartilage and

may calcify with age starting with the thyroid cartilage
at ~ 25 yrs.)
SECONDARY CARTILAGES:

• Epiglottis

• Corniculate cartilages (2)

• Cuneiform cartilages (2)

(These cartilages are made of elastic fibrocartilage & do not usually calcify)
 MUSCLES OF THE LARYNX

1. EXTRINSIC MUSCLES:

Join cartilages of the larynx to neighboring structures in the neck. Divided into:

Suprahyoid muscles (elevators) & infrahyoid muscles (depressors) of the larynx

2. INTRINSIC MUSCLES:

Regulate length and tension of the vocal folds and aperture of the glottis

All intrinsics supplied by CN XI via X (vagus: external & recurrent laryngeal nerves)

The next slide is a summary of these muscles…

 SUMMARY OF EXTRINSIC MUSCLES OF THE LARYNX
(Nerve supply in parentheses) Digastric (ant. belly: CN V3; post. belly: CN VII)

Stylohyoid (CN VII) Suprahyoid

muscles
ELEVATORS
Geniohyoid (C1)
OF
LARYNX
Stylopharyngeus (CN IX)

Palatopharyngeus (CN XI via X)

EXTRINSIC

MUSCLES
Sternothyroid (ansa cervicalis)

Sternohyoid (ansa cervicalis) Infrahyoid (strap)

DEPRESSORS muscles
OF LARYNX Omohyoid (ansa cervicalis)

Thyrohyoid (C1)

Inf. pharyngeal constrictor (XI via X)

 SUMMARY OF INTRINSIC MUSCLES OF THE LARYNX
(All intrinsics supplied by XI via X)
Abductors Posterior cricoarytenoid
MUSCLES VARYING
Lateral cricoarytenoid
APERTURE OF GLOTTIS
Adductors Transverse arytenoid

Oblique arytenoid

Cricothyroid

MUSCLES REGULATING Thyroarytenoid

INTRINSIC TENSION OF VOCAL
LIGAMENTS Vocali
MUSCLES s
Posterior cricoarytenoid

Aryepiglotticus

Oblique arytenoid
MUSCLES MODIFYING
LARYNGEAL INLET
Thyroepiglottics

Thyroarytenoid
INTRINSIC MUSCLES OF THE LARYNX
Superior view

Transverse arytenoid muscle

Posterior cricoarytenoid muscle
Arytenoid cartilage
Lateral cricoarytenoid muscle

Glottis (rima glottidis)

Cricothyroid muscle
Vocal ligament

Cricoid cartilage Thyroarytenoid muscle

Thyroid cartilage Vocalis muscle

Laryngeal prominence

Anterior
BLOOD SUPPLY OF THE
LARYNX
Superior and inferior laryngeal arteries:

From superior and inferior thyroid arteries

respectively

Sup. thyroid from ext. carotid; inf. thyroid from

thyrocervical trunk (subclavian)
NERVE SUPPLY OF THE LARYNX

Mostly through branches of the vagus nerve (CN X):

• Internal & external laryngeal (from superior laryngeal nerve)

• Recurrent laryngeal nerve

Can divide into:

1. Motor innervation (vagus nerve)

2. Sensory innervation (vagus nerve)

3. Autonomic innervation (sympathetic and parasympathetic)

MOTOR INNERVATION:
• ALL INTRINSIC MUSCLES SUPPLIED BY BRANCHES OF THE VAGUS NERVE

•EXTERNAL LARYNGEAL NERVE (BRANCH OF SUP. LARYNGEAL N. FROM

VAGUS)  CRICOTHYROID M.

•RECURRENT LARYNGEAL NERVE  ALL REMAINING INTRINSIC MUSCLES

SENSORY INNERVATION:

• ABOVE VOCAL FOLDS  INTERNAL LARYNGEAL NERVE (SENSORY BR. OF

SUP. LARYNGEAL N.)

• BELOW VOCAL FOLDS  RECURRENT LARYNGEAL NERVE

 THE TRACHEA
ANATOMICAL POSITION
• MARKS THE BEGINNING OF THE TRACHEOBRONCHIAL
TREE. IT ARISES AT THE LOWER BORDER OF CRICOID
CARTILAGE IN THE NECK, AS A CONTINUATION OF THE
LARYNX.
• TRAVELS INFERIORLY INTO THE SUPERIOR
MEDIASTINUM, BIFURCATING AT THE LEVEL OF THE
STERNAL ANGLE (FORMING THE RIGHT AND LEFT MAIN
BRONCHI). AS IT DESCENDS, THE TRACHEA IS LOCATED
ANTERIORLY TO THE ESOPHAGUS,
STRUCTURE
• THE TRACHEA,, IS HELD OPEN BY CARTILAGE – HERE IN C-
SHAPED RINGS. THE FREE ENDS OF THESE RINGS ARE
SUPPORTED BY THE TRACHEALIS MUSCLE.
• AT THE BIFURCATION OF THE PRIMARY BRONCHI, A RIDGE
OF CARTILAGE CALLED THE CARINA CAN BE SEEN ON
BRONCHOSCOPY.
 NEUROVASCULAR SUPPLY

• THE TRACHEA RECEIVES SENSORY INNERVATION FROM THE RECURRENT

LARYNGEAL NERVE.
• ARTERIAL SUPPLY COMES FROM THE TRACHEAL BRANCHES OF THE INFERIOR
THYROID ARTERY, WHILE VENOUS DRAINAGE IS VIA THE BRACHIOCEPHALIC,
AZYGOS AND ACCESSORY HEMIAZYGOS VEINS.
 BRONCHI

• AT THE LEVEL OF THE STERNAL ANGLE, THE

TRACHEA BIFURCATES INTO THE RIGHT AND
LEFT MAIN BRONCHI.
• UNDERGO FURTHER BRANCHING TO THE
SECONDARY BRONCHI.
• EACH SECONDARY BRONCHI SUPPLIES A
LOBE OF THE LUNG, AND GIVES RISE TO
SEVERAL SEGMENTAL BRONCHI.
• ALONG WITH BRANCHES OF THE
PULMONARY ARTERY AND VEINS, THE MAIN
BRONCHI MAKE UP THE ROOTS OF THE
LUNGS.
 STRUCTURE

THE RIGHT PRINCIPAL BRONCHUS IS SHORTER, WIDER

AND MORE VERTICAL THAN THE LEFT; THEREFORE
INHALED (ASPIRATED) OBJECTS TEND TO LODGE
MORE FREQUENTLY IN THE RIGHT LUNG COMPARED
TO THE LEFT.
• EACH SECONDARY BRONCHI
SUPPLIES A LOBE OF THE
LUNG, THUS THERE ARE 3
RIGHT LOBAR BRONCHI AND 2
LEFT.
• THE LOBAR BRONCHI THEN
BIFURCATE INTO
SEVERAL SEGMENTAL
(TERTIARY) BRONCHI, EACH
OF WHICH SUPPLIES
A BRONCHOPULMONARY
SEGMENT.
Bronchopulmonary segments are
subdivisions of the lung lobes,
and act as the functional unit of
the lungs.
 Bronchioles

The segmental bronchi undergo further

branching to form numerous smaller airways –
the bronchioles. (The smallest airways,
bronchioles do not contain any cartilage )

bronchioles then eventually end as terminal

bronchioles. These terminal bronchioles branch
even further into respiratory bronchioles,
which are distinguishable by the presence
of alveoli extending from their lumens.
Alveoli are tiny air-filled
pockets with thin walls (simple
squamous epithelium), and are
the sites of gaseous exchange in
the lungs. Altogether there are
around 300 million alveoli in
adult lungs, providing a large
surface area for adequate gas
exchange.
 THE TRACHEA AND
BRONCHIAL TREE
The right principal bronchus is shorter, wider and more
vertical than the left; therefore inhaled (aspirated) objects tend
to lodge more frequently in the right lung compared to the Cross section of trachea:
left.
Incomplete hyaline
Esophagus cartilage ring

Trachealis (smooth)
muscle posteriorly
Trachea
Related posteriorly
Right Left to esophagus
lung
lung Left main (principal)
Right main (principal) bronchus  2 lobar bronchi
bronchus  3 lobar (superior & inferior)
bronchi (superior, middle
& inferior) Tracheal bifurcation
at T4/5 vertebral level
(internal aspect of bifurcation
known as carina)

The lobar bronchi divide into segmental bronchi, each supplying a bronchopulmonary
are 10 bronchopulmonary segments in each lung (see next slide). The segmental br
divisions into progressively smaller airways called bronchioles, and terminal and resp
 NEUROVASCULAR SUPPLY

• THE BRONCHI DERIVE INNERVATION

FROM PULMONARY BRANCHES OF
THE VAGUS NERVE (CN X).
• BLOOD SUPPLY TO THE BRONCHI IS
FROM BRANCHES OF
THE BRONCHIAL ARTERIES, WHILE
VENOUS DRAINAGE IS INTO
THE BRONCHIAL VEINS.