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Home , Glottis, Infrahyoid muscles, Larynx, Oblique arytenoid, Trachealis muscle, Vestibular fold

Color Code Important , , and Bronchi Doctors Notes Notes/Extra explanation Please view our Editing File before studying this lecture to check for any changes. Objectives

By the end of the lecture, you should be able to: Describe the Extent, structure and functions of the larynx. Describe the Extent, structure and functions of the trachea. Describe the bronchi and branching of the bronchial tree. Describe the functions of bronchi and their divisions. NOTE: EXTENDS FROM C1 TO C6 WHILE LARYNX Larynx EXTENDS FROM C3 TO C6 *C6 AT THE LEVEL OF CRICOID . o The larynx is the part of the which contains the . o In adult it is a 2-inch-long tube. o It opens above into the laryngeal part of the pharynx. o Below, it is continuous with the trachea o The larynx has functions in: • Respiration (). • ( production). • Deglutition (). o The larynx is related to major critical structures in the .

Arteries Carotid : Jugular veins, Laryngeal nerves: (common, external (external & internal) (Superior laryngeal & and internal). recurrent laryngeal). arteries: Vagus . (superior & inferior thyroid arteries). Larynx 1- Cartilaginous o The cartilaginous skeleton is composed of 9 : The larynx consists of four basic components: 3 Single: -Arytenoid lies in 1- Cartilaginous skeleton. 1. Thyroid 2. Cricoid 3. the back of larynx. 3 Paired: 2- Membranes and . -Corniculate and 4. Arytenoid 5. Corniculate 6. Cuneiform Cuneiform are in 3- Mucosal lining. the Aryepiglottic fold. 4- Muscles (Intrinsic & extrinsic muscles). o All the cartilages, are hyaline except the epiglottis which is Elastic cartilage. o The cartilages are: • Connected by , membranes & ligaments. • Moved by muscles.

6 3 3 5 1 1 4 4 2 2 Larynx 2- Membranes & Ligaments - Thyrohyoid membrane - Cricothyroid membrane - Cricotracheal membrane - Hyoepiglottic - Thyroepiglottic ligament The thyrohyoid membrane is thickened in the median plane to form median thyrohyoid ligament and on both sides to form lateral thyrohyoid ligaments.

- Quadrangular membrane or (aryepiglottic membrane) : o It extends between the arytenoid and epiglottis. o Its lower free margin forms the vestibular ligament which forms the (false vocal cord). - Cricothyroid membrane (conus elasticus): o Its lower margin is attached to the upper border of . o Upper free margin forms Vocal ligament which forms the(true vocal cord) Larynx Laryngeal Inlet

o It is the upper opening of the larynx. o It faces upward and backward and opens into the laryngeal part of the pharynx (laryngopharynx). o Bounded by : • Anteriorly: by the upper margin of epiglottis (E) • Posteriorly & below by arytenoid cartilages (A) • Laterally by the Aryepiglottic folds (AEF) Larynx Laryngeal Cavity Rima A vestibuli o Extends from laryngeal inlet to lower border of the cricoid cartilage B

C o Narrow in the region of the vestibular folds (rima vestibuli) o Rima Narrowest in the region of the vocal folds (rima glottidis) glottidis o Divided into three parts: i. Supraglottic part or vestibule: it is the part above the vestibular folds. ii. Ventricle: it is the part between the vestibular folds & the vocal folds. The ventricle has an upward invagination called saccule which is rich in goblet cells. A iii. Infraglottic part: the part below the vocal folds. B C Larynx 3- Mucosal Lining 4- Muscles

Mucous Membrane o The cavity is lined with ciliated Laryngeal muscles are divided into 2 groups columnar except the surface of the vocal cords. Extrinsic muscles Intrinsic muscles Subdivided into 2 groups: Subdivided into 2 groups: o The surface of vocal folds, is covered with stratified squamous epithelium because of exposure to continuous Elevators of Depressors Muscles Muscles trauma during phonation. the larynx of the larynx controlling controlling the the laryngeal movements of o It contains many mucous glands, inlet the vocal more numerous in the region of the cords saccule (for lubrication of vocal folds). Larynx 4- Muscles (Extrinsic)

Elevators of the Larynx: Depressors of the Larynx: A- (MSGD) The : 1. Mylohyoid. oSternohyoid. 2. Stylohyoid. oSternothyroid. 3. Geniohyoid. oOmohyoid. 4. Digastric. B- The longitudinal muscles of the pharynx o Stylopharyngeus. o Salpingopharyngeus. o Palatopharyngeus. Larynx 4- Muscles (Intrinsic)

Muscles controlling the Laryngeal Inlet 1. 2. Aryepiglottic muscle Larynx 4- Muscles (Intrinsic) Muscles controlling vocal cords:

LENGTH AND TENSION ADDUCTION AND ABDUCTION 1. Thyroarytenoid (vocalis) muscle: 1. Adductors (close rima ) - Relax vocal cords - Lateral cricoarytenoid. - Decrease both length and tension of vocal cords - Transverse arytenoid. 2. Abductor (open rima glottis) 2. : - increase both length and tension of vocal cords - Posterior cricoarytenoid Remember: Cricothyroid is the only intrinsic muscle which found outside the larynx

TRANSVERSE ARYTENOID

POSTERIOR CRICOARYTENOID Larynx

Nerve Supply (very important): Blood Supply And Lymphatics: Sensory: Arteries: Above the vocal cords: Upper half: - Internal laryngeal nerve - Superior laryngeal - branch of the superior - branch of superior thyroid laryngeal of the . artery -Below the vocal cords: Lower half: - Recurrent laryngeal nerve of the vagus nerve. - Inferior laryngeal artery Motor: - branch of All intrinsic muscles supplied by Veins: the recurrent laryngeal nerve Accompany the corresponding except the cricothyroid arteries. للحفظ :بما أن سالفة arteriesمعقدة شوي يف الالرنكس ألن فيها نصف علوي و نصف سفل نقدر نقول :ال ذا ! The cricothyroid* is supplied ي :Lymphatics ( by the external laryngeal nerve (laryngeal & thyroidal مهم of superior laryngeal of vagus. The lymph vessels drain into the deep cervical lymph nodes. cross the rule :للحفظ * NB. recurrent laryngeal nerve is both sensory and motor SEMON’S LAW or damage of the RECURRENT LARYNGEAL NERVE Semon’s Law indicates the different effect between damage (surgical trauma) and of the recurrent laryngeal (قطع) transection nerve due to surgery in region of the neck Vocal cords lie in cadaveric (نفس وضع الجثة ) e.g. thyroidectomy or parathyroidectomy). position)

Median or paramedian position and air cannot pass Damage occurs to both sides of the nerve → patient may die Damage occurs to one side only → can be repaired incompletely Trachea (windpipe)

fibro cartilaginous tube, 5 inches long*, and 1 inch in, متحركة o Mobile diameter. o Begins: In the neck below the cricoid cartilage of the larynx (at lower border of cricoid cartilage at (C6). o Ends: In the thorax at the level of sternal angle (lower border of T4), by dividing into right and left principal (main,primary) bronchi.

زاوية االنقسام .o The ridge at the bifurcation from inside is called carina o It is the most sensitive part of the respiratory tract and is associated with the reflex.

*Note: Trachea = 5 inches Larynx = 2 inches

Extra (sternal angle) Anterior: 1. 2. ,(remains of thymus gland). 3. Left brachiocephalic . 4. Arch of aorta. 5. Origin of: Brachiocephalic artery and left .

Left side: 1. Arch of aorta. Relations in Right side: 2. Left common Carotid the Superior 1. Azygos vein artery Mediastinum 2. Right vagus nerve 3. Left subclavian artery 3. Pleura 4. Left vagus nerve 5. Left 6. Pleura Posterior: 1. 2. Left recurrent laryngeal nerve. Trachea

Nerve Supply: o Branches of the vagus nerve and recurrent laryngeal nerve give sensory fibers to supply the o Branches from the Sympathetic trunks supply the and the Blood vessels.

Blood Supply: Arteries: Branches from the inferior thyroid and bronchial arteries (from descending thoracic aorta)

Veins: Drain to inferior thyroid veins.

Lymphatic Drainage: Into the pretracheal and paratracheal lymph nodes. Right Principal o About one inch long. o Wider, shorter and more vertical than the left. o Gives superior lobar bronchus before entering the hilum of the right . o On entering the hilum it divides into middle and inferior lobar bronchi.

Left Principal Bronchus o About two inches long. o Narrower, longer and more horizontal than the right. o Passes to the left below the aortic arch and in front of esophagus. o On entering the hilum of the left lung it divides into superior and inferior lobar bronchi. Bronchial Divisions (VERY IMPORTANT SLIDE) Within the lung, each bronchus divides and redivides into number of branches that can be divided into two groups: 4. Which muscle is responsible for opening the rima Questions glottidis? a. Lateral cricoarytenoid b. Posterior cricoarytenoid 1. Which of the following muscles controls the c. Transverse arytenoid laryngeal inlet? d. Both a and c a. Omohyoid b. Digastric c. Palatopharyngeus d. Aryepiglottic muscle Answer: B

Answer: D 5. All intrinsic muscles of the larynx are innervated by the recurrent laryngeal nerve except: 2. Which of the following muscles relaxes and shortens a. Thyroarytenoid the vocal cords? b. Cricothyroid a. Cricothyroid b. Oblique arytenoid c. Lateral cricoarytenoid c. Thyroarytenoid d. Sternothyroid d. Posterior cricoarytenoid

Answer: C Answer: B

3. The laryngeal muscle most responsible for stretching 6. In continuation of the previous question: which the vocal cords is the: nerve is it supplied by? a. Cricothyroid b. Oblique arytenoid c. Thyroarytenoid d. Sternothyroid Answer: External laryngeal nerve of the superior laryngeal branch of the vagus nerve. Answer: A 10.The mucous membrane of the trachea is innervated by: 7. Recurrent laryngeal nerves are sensory to: a. Recurrent laryngeal nerve a. Laryngeal cavity below the level of vocal cords b. Internal laryngeal nerve b. Laryngopharynx c. External laryngeal nerve c. All intrinsic muscles of the larynx d. Sympathetic nerve fibers d. Both a and c Answer: A Answer: A 8. According to Semon’s Law, the result of transection of 11.What happens to the trachea, or windpipe, before it the recurrent laryngeal nerve can cause: reaches the ? a. Adducted cords b. Inability to breath a. It branches in two directions c. Inability to speak d. Partial paralysis b. It branches in three directions Answer: C c. It vibrates and creates a sound d. It closes up so that no oxygen can escape 9. Following thyroid surgery, it was noted that a patient frequently aspirated fluid into her lungs. Upon Answer: A examination it was determined that the area above the vocal fold of the larynx was numb. What nerve 12.Which of the following statements is NOT true regarding may have been injured? the trachea? a. External branch of the a. Trachea rings are C-shaped b. Internal branch of the superior laryngeal nerve b. It splits into the right and left bronchi to supply air c. Recurrent branch of vagus nerve to the lungs d. None of the above c. Opening to the trachea is covered by epiglottis d. It lies posterior to the esophagus Answer: B Answer: D 13. Bronchi branch into tubes of smaller diameter 17. Quadrangular membrane forms : that are known as: A) vocal ligament. A) Microtrachea B) B) lateral thyrohyoid ligament. C) Alveolar sacs D) Respiratory bronchioles C) median thyrohyoid ligament. D) vestibular ligament. Answer: B Answer: D 14. All the larynx cartilages are EXCEPT : 18. Laryngeal Cavity Extends from laryngeal inlet to upper A) cricoid. B) epiglottis. border of the cricoid cartilage C) thyroid. D) Arytenoid A\ true. B\ false Answer: B, correct is: until lower border of crocoid cartilage Answer: B 19. Epithelium lining of vocal folds is : 15. How long is the larynx : A) ciliated columnar epithelium. A) 2cm. B) 2.5 inches. C) 2inches. D) 4cm B) simple squamous epi. Answer: C C) stratified squamous epi. D) simple cuboidal epi. 16. Laryngeal Inlet is bounded anteriorly by: A) upper margin of epiglottis. Answer: C B) . 20. Extrinsic muscles of Larynx subdivide into: C) Aryepiglottic folds. A) Elevators & depressors B) Controlling laryngeal inlet & vocal D) all of themed cavity C) none of the above D) all of the above. Answer: A Answer: A *All cartilages are hyaline, nerves Veins Arteries single paired except the epiglottis is Elastic cartilage Carotid arteries: Superior Jugular veins: 1.external Carotid 1.Thyroid 1.Arytenoid laryngeal 1.external 2.internal Carotid 2.Corniculate skeleton 2.Cricoid cartilaginous Jugular 3. Common Recurrent carotid 3.Epiglottis 3.Cuneiform laryngeal 2.internal Thyroid arteries: 1.superior Thyroid vagus nerve Jugular Relations 2.inferior Thyroid 1-Thyrohyoid membrane 2-Cricothyroid membrane *function in controlling the 3-Cricotracheal membrane larynx respiration,Phonation laryngeal inlet: 1-Oblique arytenoid

4-Hyoepiglottic ligament - deglutition structures

Intrinsic Intrinsic 2-Aryepiglottic

5-Thyroepiglottic ligament muscles: muscle 6-Quadrangular membrane Muscles controlling the -laryngeal cavity lined with Extrinsic movements of the muscles: vocal cords ciliated columnar epithelium 1-decreasing Length & except The vocal folds surface Elevators Tension of Vocal Depressors(The S:Mylohyoid, Stylohyoid Cords with stratified squamous Infrahyoid Muscles): Thyroarytenoid Geniohyoid ,Digastric. Sternohyoid, epithelium. Mucosal lining 2- increasing Length L:Stylopharyngeus, Sternothyroid, -contains mucous glands. & Tension of Vocal Salpingopharyngeus, Omohyoid. Cords: Cricothyroid. Palatopharyngeus. laryngeal arteyr laryngeal ​I half​: Lower artery laryngeal ​ half: Upper Accompany the Accompany corresponding corresponding drain into the into drain Lateralcricoarytenoid deep cervical cervical deep lymph nodes lymph Transverse arytenoid Transverse Lymphatics Arteries arteries Veins Superior Superior nferior nferior cricoarytenoid cricoarytenoid Adductors Abductor Posterior​ Posterior​ : vagus oflaryngeal superior ​of external nerve laryngeal the by supplied ​ is which ​cricothyroid the except laryngealnerve recurrent the by ​supplied are - nerve laryngeal ​Recurrent cords vocal theBelow nerve laryngeal Internal cords: vocal theAbove Sensory: Motor Motor All intrinsic muscles, intrinsic All relations N erves erves movment cords vocal : bronchioles and bronchioles zone branches:zone Respiratory Respiratory below Bronchial Bronchial Divisions bronchioles and bronchioles zone brancheszone Conduction Trachea Terminal above : and paratracheal and I nto Pretracheal Pretracheal nto lymph nodes lymph Lymphatics drain to inferior inferior to drain thyroid vein thyroid Veins supply supply trachealis the recurrent laryngeal recurrent sympathetic trunks sympathetic nerve give sensorygive nerve mucus membrane 2 1 muscle and blood blood muscle and vagus nerve and and nervevagus fibers to supply supply fibers to - - bronchial arteries arteries bronchial andthyroid inferior the from branches Branches of the the of Branches the of Branches vessels nerves Arteries Leaders: Members: Nawaf AlKhudairy Alanoud Abuhaimed Jawaher Abanumy Alanoud Alsaikhan Ameera Niazi Dania Alkelabi Deena AlNowiser Lama Alfawzan Lara Alsaleem [email protected] Maha Alissa

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