The Upper Airways

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC 9781284430240_CH01_001_018.indd 1

© Golatckii Nikolai/Shutterstock. CHAPTER OBJECTIVES Airways Artificial Bronchoscopy Conditions ofthePharynxorLarynx The Larynx The Pharynx Conditions oftheOralCavity The OralCavity Conditions oftheNose The Sinuses The NoseandNasalCavity Breathing CHAPTER OUTLINE After completingthischapter, youwillbeableto: Muscles oftheLarynx ofthe Larynx Cartilages The Laryngopharynx The Oropharynx The Nasopharynx Swallowing andDeglutitionApnea 8. 7. 6. 5. 4. 3. 2. 1. NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

Identify different types of artificial airways. Identify different typesofartificial Discuss theuseofbronchoscopy. Describe thestructure andfunctionofthelarynx. nose, sinuses,oralcavity Provide examplesofabnormalphysiologicprocesses ofthe Describe thehistologyofupperairway. gases. Discuss thefiltration,humidification,andwarmingofinhaled Explain thedifference betweenbreathing andr of theupperairway Identify thestructures, physiologicprocesses, andfunctions © Jones&Bartlett Learning LLC,anAscendCompany. NOTFORSALEORDISTRIBUTION. NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC . , andpharynx. The UpperAirways espiration. CHAPTER 1 NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC nasal trumpets nasal septum nasal polyps nasal flaring nasal congestion nasal conchae nasal cavity nares larynx laryngospasm laryngoscope laryngopharynx laryngitis laryngeal edema intrinsic muscles hyperactive gagreflex extrinsic muscles epistaxis epiglottitis epiglottis endotracheal tubes dysphagia cuneiform cartilages cuboidal epithelium croup cricoid cartilage corniculate cartilages columnar epithelium ciliated epithelium cilia bronchospasm bronchoscopy breathing arytenoid cartilages ankyloglossia alar collapse edema airway KEY TERMS NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC Waldeyer’s ring vocal cord dysfunction vibrissae Valsalva maneuver vallecula epiglottis uvula upper airway tracheostomy tubes tonsillitis thyroid cartilage supraglottic airways stylet stratified squamous sinusitis simple squamous rhinitis respiration quinsy pseudostratified pharynx pharyngeal reflex peritonsillar abscess otitis media oropharynx oropharyngeal airways oral cavity oral candidiasis nose nasopharynx nasopharyngeal airways nasal vestibules nasal valvecollapse nasal turbinates (VCD) epithelium epithelium columnar epithelium 25/06/20 5:35 PM 1 2 CHAPTER 1 The Upper Airways

© Jones &Breathing Bartlett Learning, LLC © JonesAs air& Bartlettmoves into Learning, and out of the LLC body, it passes through the conducting airways to the lungs. The con- The natural act ofbreathing is simply moving air into NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ducting airways include the upper airway and lower and out of the body. Once inside the body, a series of airway. The upper airway includes the nose, nasal cavity, physiologic processes warm, filter, and humidify the air; oral cavity (mouth), and the pharynx, which is divided extract oxygen and nutrients; and eliminate carbon di- into the nasopharynx, oropharynx, and laryngophar- oxide and other by-products. The process of moving air ynx. The larynx, or voice box, is usually considered the involves a network of© nerves, Jones muscles, & Bartlett and tissues Learning, that LLC © Jones & Bartlett Learning, LLC demarcation between the upper and lower airways. The facilitate respiration,NOT or gas FOR exchange. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION lower airway includes the trachea, tracheobronchial tree, bronchioles, and the alveoli. The lower airway provides access to the lungs. The lungs are divided into five lobes, three lobes on the right of the body and two lobes CLINICAL© Jones FOCUS:& Bartlett Breathing, Learning, LLC on the left (©Figure Jones 1-1). & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Respiration, and Ventilation The Nose and Nasal Cavity Many people use the terms breathing, respiration, and ventilation interchangeably. However, in clinical The first portion of the anatomy that air encounters as it enters the body is the nose. Thenasal cavity extends practice the terms have distinct meanings. Breath- from the external opening of the nose to the oral cav- ing is the process of moving air into (inhaling) and © Jones & Bartlett Learning, LLC © Jonesity (i.e., & the Bartlett mouth). Learning,The opening LLCof the nose through NOT FOR SALEout of OR the bodyDISTRIBUTION (exhaling). Respiration is the pro- NOTwhich FOR air SALE enters ORthe body DISTRIBUTION is called the nostrils, or the cess of gas exchange at the cellular level by which nasal vestibules. Thenasal septum is the partition oxygen is made available to the cells of the body that separates the left and right sides of the nose and and carbon dioxide and other by-products are re- nasal cavity. It is composed of bones and cartilage. The moved. Ventilation is the mechanical movement of nares are the two openings at the end of the exterior air into and out of ©the Jones body. & Bartlett Learning, LLCof the nose and are separated© from Jones each other& Bartlett by the Learning, LLC NOT FOR SALE OR DISTRIBUTIONnasal septum. NOT FOR SALE OR DISTRIBUTION

Nasopharynx © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NasalNOT cavity FOR SALE OR DISTRIBUTION Oropharynx Pharynx Upper Mouth airway Epiglottis © Jones & Bartlett Learning, LLC © Jones & BartlettLaryngopharynx Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Trachea Larynx Apex of the lung Artery Alveolus

Lower Alveoli Bronchiole airway Bronchioles© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Main bronchiNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Vein

Base of the lung © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Diaphragm NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Capillary Carina network

FIGURE 1-1 The respiratory system is divided into the upper and lower airways, which can also be described as the © Jones & Bartlettconducting Learning, airways and LLC the respiratory zone, or nonconducting© Jonesairway. The & conducting Bartlett airways Learning, include all of LLCthe upper airway and the lower airway up until the alveoli. The respiratory zone includes the terminal bronchioles and the alveoli. Gas exchange NOT FOR SALEoccurs OR inDISTRIBUTION the respiratory zone. NOT FOR SALE OR DISTRIBUTION

9781284430240_CH01_001_018.indd 2 25/06/20 5:35 PM The Nose and Nasal Cavity 3

© Jones & BartlettIn addition Learning, to providing LLC sensory receptors for smell © Jonesinclude & the Bartlett inferior nasalLearning, conchae, LLC the middle nasal and aiding in speech, the nose and nasal cavity warm, NOTconchae, FOR SALE and the OR superior DISTRIBUTION nasal conchae. The largest of NOT FOR SALEhumidify, OR and DISTRIBUTION filter the incoming air. These structures these three sets of bones, the inferior nasal concha, is also provide access to the sinuses, a series of hollow located horizontally along the lateral wall of the nasal passages inside the head. The outer, or external, nose is cavity. This structure is responsible for directing the the part that most people see. It is made up of the nasal flow of air through the nasal cavity. By channeling the bones, the frontal processes© Jones of the & maxillae,Bartlett and Learning, five LLCair entering the nasal cavity via© theJones nose through& Bartlett the Learning, LLC cartilages—two lateralNOT nasal FOR cartilages, SALE the OR greater DISTRIBUTION and mucous membrane and cilia,NOT the inferior FOR nasal SALE concha OR DISTRIBUTION lesser alar cartilages, and the septal cartilage. The bones plays a primary role in filtering and humidifying the air of the nose include the ethmoid bone, palatine bones, as it enters the body. The middle conchae are smaller maxilla bone, vomer, and nasal conchae. The cribriform and sit just above the inferior conchae. They function as plate of the ethmoid bone forms the back interior (i.e., a protective structure for the sinuses. The superior nasal roof)© ofJones the nasal & cavity.Bartlett The Learning, palatine bone LLC posteriorly conchae, the© smallest Jones of & the Bartlett three sets Learning, of conchae bones, LLC andNOT the palatine FOR processSALE ofOR the DISTRIBUTION maxilla bone anteriorly sit just aboveNOT the middle FOR conchae.SALE ORThe DISTRIBUTIONsuperior nasal form the floor of the nasal cavity. The vomer serves as conchae protect a collection of olfactory nerve tissue the back wall of the cavity. where much of the information relating to the sense of Thenasal conchae, which are also called the nasal smell is processed. Figure 1-2 shows the anatomy of the turbinates, are thin bones that extend into the nasal nose, nasal cavity, and oral cavity. © Jones & cavity,Bartlett increasing Learning, the surface LLC area inside the nasal cavi-© JonesInside & Bartlett the nares, Learning,the front of the LLC nose is lined with vibrissae NOT FOR SALEties. By providingOR DISTRIBUTION a larger surface area for inhaled air NOThair FOR called SALE OR thatDISTRIBUTION capture large particles and to pass through, the conchae increase the ability of the prevent them from moving into the airways. Vibrissae nose to filter, warm, and humidify the air. There are are visible to the naked eye and should not be con- three sets of conchae bones within the nose, and they fused with cilia. Cilia are fine hairlike structures that

Hard palate

Pharyngeal tonsil © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONUpper lip NOT FOR SALE OR DISTRIBUTIONEntrance to auditory tube Cheek Soft palate Dorsum of tongue Uvula Lower lip Palatine tonsil Gingiva© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Oropharynx VestibuleNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Body of tongue Lingual tonsil Epiglottis Root of tongue © Jones & Bartlett Learning, LLC © Jones &Hyoid Bartlett bone Learning, LLC Larynx NOT FOR SALE OR DISTRIBUTION NOT FORLaryngopharynx SALE OR DISTRIBUTION Trachea Esophagus

NOT FOR SALE ORFIGURE DISTRIBUTION 1-2 Anatomy of the nose, nasal cavity, and oralNOT cavity. FOR SALE OR DISTRIBUTION

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© Jones &occur Bartlett lower Learning, in the respiratory LLC tract. The nasal cavity ©is Jones & Bartlett Learning, LLC also lined with a mucous-producing membrane. This NOT FOR SALE OR DISTRIBUTION Frontal sinuses NOT FOR SALEmembrane OR is DISTRIBUTIONcontiguous throughout the nasal cavity and within the frontal, ethmoidal, sphenoidal, and Sphenoid sinuses maxillary sinuses. The membrane in the first third of the nasal cavity is lined by stratified squamous epithe- Ethmoid sinuses lium. These cells are© several Jones cell & layers Bartlett thick Learning,and lie LLC © Jones & BartlettMaxillary sinuses Learning, LLC on top of a layer of proliferativeNOT FOR cells SALE that ORare attached DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to a basement membrane. The remaining two-thirds of the nasal cavity is lined with pseudostratified columnar ciliated epithelium, which contains mucous- producing cells called goblet cells. This part of the membrane also lies on top of the basement membrane. FIGURE 1-3 The paranasal sinuses include the frontal sinuses, © Jones & Bartlett Learning, LLC sphenoid sinuses,© Jonesethmoid sinuses, & Bartlett and maxillary Learning, sinuses. LLC BeneathNOT the FOR basement SALE membrane OR DISTRIBUTION is the nasal sub- NOT FOR SALE OR DISTRIBUTION mucosa. This area contains nerves, capillaries, and mucous-producing cells. The mucus that is secreted by these membranes contains two layers, an upper gel layer and a lower sol layer. The cilia are located in the CLINICAL FOCUS : Is It a Sign or a © Jones & solBartlett layer and Learning, move in a wavelike LLC fashion to push out © JonesSymptom? & Bartlett Learning, LLC NOT FOR SALEthe mucous OR andDISTRIBUTION any captured particles or debris that NOT FOR SALE OR DISTRIBUTION have entered the airway. The terms signs and symptoms often are used to- Our ability to smell is a primary function of the nose gether. A sign is an objective indicator of an illness, and the olfactory receptor neurons it contains. The injury, or disease. It can be seen and measured, olfactory receptor neurons are embedded in the olfac- as with heart rate or blood pressure. In contrast, tory epithelium located© Jones on the roof & Bartlettof the nasal Learning, cavity LLCsymptoms are subjective measures© Jones of illness.& Bartlett They Learning, LLC approximately 7 cm NOTinside theFOR nose SALE from the OR nostrils. DISTRIBUTION are reported by an individual.NOT For example,FOR SALE whether OR DISTRIBUTION Humans have approximately 6 million olfactory recep- they feel hot or faint. tors in their nose and can distinguish at least 1 trillion different odors. In contrast, a dog has an estimated 300 million olfactory receptors in their nose. ©When Jones a person & Bartlett loses his orLearning, her ability toLLC smell it is are lined with© Jonespseudostratified & Bartlett ciliated Learning, columnar epi-LLC knownNOT as FOR anosmia. SALE This OR may DISTRIBUTIONbe a transient or perma- thelium andNOT drain FOReither directlySALE orOR indirectly DISTRIBUTION into the nent condition and can be caused by damage to the nose via the ostiomeatal complex (OMC) or ostiomeatal olfactory pathways between the nose and the brain, unit (OMU). aging, nasal and/or sinus disease, viral upper respiratory tract infections, and/or trauma. Hyposmia is a Conditions of the Nose © Jones & decreasedBartlett orLearning, reduced ability LLC to smell. This may oc- © Jones & Bartlett Learning, LLC cur as a result of allergies, nasal polyps, infection, or The nose plays an important role as the point at which NOT FOR SALEhead trauma. OR DISTRIBUTION Hyperosmia is an increased ability to NOTair FOR enters SALE and exits OR the DISTRIBUTION body. An understanding of the smell; it is associated with several medical conditions, function of the nose with respect to the rest of the body including pregnancy, migraines, autoimmune disease, can facilitate keeping the nose healthy and functioning and Lyme disease. properly. © Jones & Bartlett Learning, LLCThe mucous membranes ©of theJones nose secrete& Bartlett a pro- Learning, LLC The Sinuses tective gel-like substance that facilitates the removal of NOT FOR SALE OR DISTRIBUTIONparticles and debris that mayNOT be carried FOR into SALE the nose OR DISTRIBUTION The word sinus refers to a cavity within a bone or other during breathing. Nasal congestion occurs when the tissue. The body has many sinuses located throughout mucous layer inside the nose is overabundant. Nasal that serve a variety of functions. The paranasal sinuses congestion may interfere with an individual’s sense are© two Jones groups & of Bartlettair-filled spacesLearning, located LLCon each side of smell and© taste. Jones Congestion & Bartlett is usually Learning, a sign of a LLC of theNOT face FOR and skull. SALE They OR drain DISTRIBUTION into the nasal cavity, larger issueNOT and should FOR be SALE assessed OR before DISTRIBUTION starting any serving to lighten the weight of the head, acting as a res- treatment. Drying of the mucous membranes of the onance space for speech, and producing mucus that lu- nose can also occur and can be caused by exposure to bricates the nose. Each paranasal sinus is named for the environmental conditions, such as exposure to hot or bone upon which it is positioned and include the frontal cold dry air; diseases, such as Sjögren syndrome; or as © Jones & sinuses,Bartlett the Learning, ethmoid sinuses, LLC the maxillary sinuses, and© Jonesa side &effect Bartlett of medications, Learning, such LLCas antihistamines and Figure 1-3 NOT FOR SALEthe sphenoid OR DISTRIBUTIONsinuses ( ). The paranasal sinusesNOT decongestants. FOR SALE A OR dry DISTRIBUTIONnose may be uncomfortable but

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Normal nostrils Flared nostrils © Jones &is Bartlett usually self-limiting. Learning, Utilization LLC of a nasal moistur- © Jones & Bartlett Learning, LLC izer and/or a humidifier is often recommended for theNOT FOR SALE OR DISTRIBUTION NOT FOR SALEtreatment OR of dryDISTRIBUTION nose. However, an individual should consult their healthcare provider before starting any therapy. The nose is highly vascular, and the small blood vessels within the nose can© Jones rupture &and Bartlett cause bleeding Learning, LLC © Jones & Bartlett Learning, LLC epistaxis known as , orNOT a nosebleed. FOR SALE Nosebleeds OR DISTRIBUTIONcan oc- NOT FOR SALE OR DISTRIBUTION cur at any age, though they are most often seen in children aged 2 to 10 years and adults aged 50 to 80 years. They also are more common in the morning hours and during the winter when the air is dry. Nosebleeds can be classified© Jones according & Bartlett to their Learning, point of origin. LLC Anterior © Jones & Bartlett Learning, LLC nosebleedsNOT FOR are the SALE most commonOR DISTRIBUTION type and usually ori FIGURE 1-4 NasalNOT flaring FOR is most SALE commonly OR seen DISTRIBUTION in children and ginate from a blood vessel on the nasal septum. Trauma, infants, though it can occur at any age. It is characterized by the such as a blow to the nose or picking the nose, is a very nostrils widening while breathing and may be a sign of respiratory common cause of anterior nosebleeds. However, they distress. can also be caused by drying of the nose due to expo © Jones & sureBartlett to hot dryLearning, air, allergies, LLC nasal and sinus infections, © Jones & Bartlett Learning, LLC NOT FOR SALEvigorous OR nose DISTRIBUTION blowing, a foreign body inserted into theNOT FOR SALE OR DISTRIBUTION nose, a deviated or perforated nasal septum, or nasal Individuals with known or suspected posterior nose- surgery. Certain blood-thinning medications such as bleeds should seek medical attention. warfarin, low-molecular-weight heparin (LMWH), un- Nasal flaring occurs when the nostrils widen during fractionated heparin (UFH), direct oral anticoagulants breathing. Although it can occur at any age, nasal flar- (DOACs; apixaban, betrixaban,© Jones dabigatran,& Bartlett edoxaban, Learning, LLCing is most often used as an assessment© Jones in & newborns. Bartlett Learning, LLC and rivaroxaban), nonsteroidalNOT FOR anti-inflammatory SALE OR DISTRIBUTION drugs It may occur as a result of asthma,NOT nasal FOR obstruction, SALE OR DISTRIBUTION (NSAIDs), aspirin, and illegal drugs such as cocaine respiratory distress of the newborn, or pneumonia may cause anterior nosebleeds. Individuals with liver (Figure 1-4). disease, kidney disease, platelet disorders, and inherited Nasal polyps are noncancerous bead-shaped blood-clotting disorders may also experience nose- growths within the nasal cavity or sinuses. The etiol- bleeds.© Jones Hypertension & Bartlett (high blood Learning, pressure) LLC is some- ogy of nasal© polyps Jones is unclear; & Bartlett however, Learning, they may LLC timesNOT cited FOR as a sourceSALE of ORnosebleeds. DISTRIBUTION In most cases, be related toNOT chronic FOR inflammation, SALE OR asthma, DISTRIBUTION and al- hypertension may aggravate the condition, but it is not lergies. Some diseases, such as cystic fibrosis and the initial cause of the nosebleed. Churg-Strauss syndrome, may also be risk factors for Posterior nosebleeds occur in the larger vessels in the development of nasal polyps. Nasal polyps may be the back of the nasopharynx. They are more likely to oc- asymptomatic or they may be associated with a runny © Jones & curBartlett in the elderly Learning, but may LLC also affect children. Posterior© Jonesnose, congestion,& Bartlett postnasal Learning, drip, decreasedLLC or absent nosebleeds are most often related to bleeding disorders, sense of smell and/or taste, pain in the upper teeth, NOT FOR SALEmedication OR usage, DISTRIBUTION and nasal or sinus surgery. NOTsnoring, FOR SALE and facial OR pressure DISTRIBUTION or pain. If a large num- Ascertaining the difference between an anterior ber of polyps are present they may obstruct the nasal nosebleed and a posterior one can be challenging and passages and sinuses and should be evaluated by a may require a physical exam to identify the origin medical professional. Alar collapse of the bleeding. Home© Jonestreatment & ofBartlett anterior Learning,nose- LLC is the visible ©closing Jones of the & nostrilsBartlett dur- Learning, LLC bleeds includes having the individual sit upright and ing breathing. Nasal valve collapse occurs deeper in lean forward to preventNOT the FOR blood SALE from going OR DISTRIBUTIONdown the nose as a result of narrownessNOT and/or FOR weakness SALE ORat DISTRIBUTION the back of the throat. The nostrils may be pinched the nasal valve, the narrowest part of the nasal airway. together using the thumb and index finger for 5 to These conditions may be associated with snoring and 10 minutes. Effort should be made to ensure that sleep apnea. Treatment may include the utilization of the© individual Jones &is breathingBartlett throughLearning, his or LLC her mouth continuous© positive Jones airway & Bartlett pressure (CPAP)Learning, or a num- LLC andNOT in no FOR distress. SALE This ORprocess DISTRIBUTION can be repeated. If ber of surgicalNOT approaches. FOR SALE Proper OR identification DISTRIBUTION of the the bleeding does not stop or is excessive after 10 anatomic cause and location of the collapse is necessary minutes, the person should seek medical attention. to determine the correct treatment. This technique should not be used in cases of pos- Rhinitis is an inflammation of the mucous mem- terior nosebleeds. In cases of a posterior nosebleed, branes of the nasal cavity. It can be allergic, nonal- © Jones & pinchingBartlett the Learning, nose will cause LLC the blood to run down © Joneslergic, & or Bartlett related to Learning,an infection. ComplicationsLLC may NOT FOR SALEthe back OR of the DISTRIBUTION nasopharynx into the oropharynx. NOTinclude FOR SALEear infections, OR DISTRIBUTION nasal polyps, or sinusitis.

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© Jones &Symptoms Bartlett includeLearning, runny LLC nose; nasal congestion; © Jonesfour premolars, & Bartlett and Learning,six molars in theLLC upper and lower watery, itchy, red eyes; sneezing; and cough. Opti- NOTjaws, respectively. FOR SALE OR DISTRIBUTION NOT FOR SALEmal treatment OR DISTRIBUTION should address the underlying cause The alveolar ridges are the bony portions of the jaw of the rhinitis and/or avoiding the allergen if it is behind the teeth that hold the tooth sockets. The ridges allergic rhinitis. can be felt in the roof of the mouth and in the front of Sinusitis is an inflammation of one or more of the si- the mouth behind the lower teeth. The tooth sockets nus cavities. The inflammation© Jones & may Bartlett be caused Learning, by a bac- LLCare called alveoli. This same ©word, Jones alveoli, & is Bartlett also used Learning, LLC terial, fungal, or viralNOT infection. FOR Sinusitis SALE can OR be DISTRIBUTIONeither to refer to the air sacs in the lowerNOT portion FOR SALEof the lungs OR DISTRIBUTION acute or chronic. An acute sinus infection lasts from where gas exchange occurs. 10 days up to 8 weeks. Symptoms include nasal obstruc- The tongue is the largest organ in the mouth tion or congestion; discolored nasal discharge; postnasal and plays a role in taste, speech, moving food, and drip; headaches; pain, tenderness, swelling, and pres- adding saliva during chewing. The tongue has ex- sure© around Jones the & eyes, Bartlett cheeks, Learning, nose, or forehead LLC that trinsic and ©intrinsic Jones muscles. & Bartlett The extrinsic Learning, muscles LLC worsensNOT when FOR bending SALE over; OR pain DISTRIBUTION in the jaw or teeth; include theNOT genioglossus FOR SALE muscle, ORthe hyoglossusDISTRIBUTION fatigue; and may or may not be accompanied by fever. muscle, the styloglossus muscle, and the palatoglos- Treatment should be directed toward the underlying sus muscle. These muscles allow the tongue to move cause of the infection and may also include medications in and out and from side to side. The four paired for symptom relief. intrinsic muscles of the tongue are the superior lon- © Jones & Bartlett Learning, LLC © Jonesgitudinal & Bartlett muscles, theLearning, inferior longitudinal LLC muscles, NOT FOR SALE OR DISTRIBUTION NOTthe FOR transverse SALE muscles, OR DISTRIBUTION and vertical muscles. These The Oral Cavity muscles allow the tongue to change shape and there- Theoral cavity, or mouth, includes the vestibule, teeth, fore play a role in speech, chewing, and swallowing. tongue, hard palate, soft palate, palatoglossal arch, pala- The tongue is connected to the floor of the mouth by tine tonsil, palatopharyngeal arch, uvula, and tongue. the lingual frenulum. The vestibule is the ©space Jones between & Bartlettthe lips, cheeks, Learning, LLCThe sense of taste primarily© Jones derives from& Bartlett the taste Learning, LLC gums, and teeth. NOT FOR SALE OR DISTRIBUTIONbuds located in the papillae NOTor bumps FOR under SALE the muOR- DISTRIBUTION The teeth define the separation between the vestibule cous membrane of the tongue. Although most of the and the main oral cavity. Children have 20 decidu- taste buds are located on the tongue, sensory cells ous teeth that are replaced by permanent teeth as they that detect taste may also be found in the nasal cav- grow older. The deciduous teeth include four incisors, ity, in the back of the throat, on the epiglottis, and in two© canines, Jones and & fourBartlett molars Learning, in the upper andLLC lower the upper part© Jones of the esophagus. & Bartlett Adults Learning, have between LLC jaws,NOT respectively. FOR SALE The adult OR teeth DISTRIBUTION are the 32 perma- 2000 and 4000NOT taste FOR buds. SALE Each tasteOR DISTRIBUTIONbud, in turn, nent teeth. These include four incisors, two canines, has between 10 and 50 sensory cells. These sensory

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECLINICAL OR DISTRIBUTION FOCUS: Histology of the RespiratoryNOT FORSystem SALE OR DISTRIBUTION Epithelium is the cellular lining or covering of a cavity. illusion that it has more than one layer of cells. Epithelium is classified based on the number of layers It can be ciliated or nonciliated. and the shape of the cells: Simple squamous epithelium: Epithelium with flat- Ciliated epithelium© Jones: Epithelium & Bartlett that has hairlike Learning, LLCtened platelike cells. © Jones & Bartlett Learning, LLC projections. NOT FOR SALE OR DISTRIBUTION Stratified squamous epitheliumNOT: Epithelium FOR SALE with OR DISTRIBUTION Cuboidal epithelium: Epithelium with cells that are square cells arranged in layers. Can be keratinized square in appearance (like little cubes). or nonkeratinized: Columnar epithelium: Epithelium that has cells that y Keratinized epithelium: Epithelium that has lay- are taller than they are wide (looks like it has rows ers of dead squamous cells and large amounts of © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC of columns). the protein keratin. This type of epithelium acts NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pseudostratified columnar epithelium: Epithelium as a dry covering capable of withstanding severe that has one layer of cells but because of the po- abrasive stresses. Also referred to as cornified sitioning of the cell nuclei looks uneven, giving the epithelium.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC y Nonkeratinized stratified squamous epithelium: Location Type of Epithelium NOT FOR SALE ThisOR typeDISTRIBUTION of epithelium does not have large NOT FOR SALE OR DISTRIBUTION amounts of keratin and serves as a wet lining First one-third of the nose Stratified squamous epithelium capable of withstanding relatively moderate abrasive stresses. Second two-thirds of the Pseudostratified columnar nose, including the trachea epithelium with goblet cells The epithelial lining© Jones changes & from Bartlett the upper Learning, to the LLCand bronchi © Jones & Bartlett Learning, LLC lower airways to meetNOT the FOR body’s SALE physiologic OR DISTRIBUTIONneeds. NOT FOR SALE OR DISTRIBUTION Figure 1-5 shows the different types of epithelial Bronchioles Cuboidal epithelium tissues associated with different parts of the respira- Alveoli Simple squamous epithelium tory tract. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

(C) (D) FIGURE 1-5© JonesThe respiratory & Bartlett epithelium. Learning, LLC © Jones & Bartlett Learning, LLC © Donna BeerNOT Stolz, PhD, FOR Center for SALE Biologic Imaging, OR University DISTRIBUTION of Pittsburgh Medical School. NOT FOR SALE OR DISTRIBUTION

cells© haveJones a pore & Bartlettin the top thatLearning, opens into LLC a chamber is not detected© Jones in the taste& Bartlett sensory cells,Learning, but rather LLC is linedNOT with FOR very fineSALE taste OR hairs DISTRIBUTION that detect the five produced viaNOT the FORpain pathway. SALE OR DISTRIBUTION basic tastes. The five taste sensations are sweet, sour, The main cavity of the mouth is located behind the salty, bitter, and umami (savory). The sensations of teeth. The hard palate forms the roof of the mouth and “spicy” and “peppery” are often called a taste, but is enclosed by the alveolar arches and gums. Another they are not. The peppery effect caused by capsaicin name for the gums is the gingiva. Behind the hard © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLCSuperior lip © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORSuperior DISTRIBUTION labial frenulum Central incisor Lateral incisor Canine Palatine raphe Premolars © Jones & Bartlett Learning, LLC Hard palate© Jones & Bartlett Learning, LLC NOT FORSoft SALE palate OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Palatoglossal arch Molars

Uvula Palatopharyngeal arch Oropharynx Palatine tonsil © Jones & Bartlett Learning,Tongue LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORMolars SALE OR DISTRIBUTION Frenulum linguae Duct of submandibular gland Sublingual papilla

Premolars (bicuspids) © Jones & Bartlett Learning, GingivaeLLC (gums) © Jones & Bartlett Learning,Canine (cuspid) LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORLateral DISTRIBUTION incisor Inferior labial frenulum Central incisor Inferior lip

FIGURE© 1-6 Jones Anatomy &of theBartlett mouth. Learning, LLC © Jones & Bartlett Learning, LLC © stockshoppe/Shutterstock. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

palate is the soft palate, which forms a partial septum CLINICAL FOCUS: Types of Muscles between the mouth and pharynx. Theuvula is a fleshy, conelike structure that extends from the center of the Muscles© Jones are fibrous& Bartlett tissue Learning,that allow our LLC bod- © Jones & Bartlett Learning, LLC soft palate (Figure 1-6). During swallowing, the soft iesNOT to move. FOR The SALE human OR body DISTRIBUTION has three types of NOT FOR SALE OR DISTRIBUTION palate and the uvula move upward and backward, clos- muscles: ing off the nasal cavity and preventing food and liquids Skeletal muscles are striated muscles that are at- from entering the nasopharynx. Coordinated move- tached to the bones and other structures, such ment of these structures also occurs during sucking, © Jones & Bartlettas the Learning,eyes, and allow LLC for movement. In most © Jonesblowing, & Bartlettand when enunciatingLearning, consonants LLC in certain NOT FOR SALEinstances, OR DISTRIBUTION the movement associated with these NOTlanguages. FOR SALE Five pairedOR DISTRIBUTION muscles play a role in the move- muscles is voluntary because they are under ment of the soft palate: the tensor veli palatine, levator veli palatine, palatopharyngeus, palatoglossus, and the conscious control. muscles of the uvula. Cardiac muscles are involuntary striated muscles The palatine arches are folds of soft tissue covered that are said to have© Jones autorhythmicity, & Bartlett or the Learning, LLCby a mucous membrane that ©passes Jones from &the Bartlett soft palate Learning, LLC ability to set their own contraction rate, and NOT FOR SALE OR DISTRIBUTIONto the side of the tongue and NOTforms theFOR anterior SALE margin OR DISTRIBUTION cause the heart to beat. of the tonsillar fossa. The innermost arch is the palato- Smooth muscles are involuntary nonstriated mus- pharyngeal arch. This arch covers the palatopharyngeal cles that line the walls of the blood vessels and or- muscle. The outer arch is the palatoglossal arch, and gans such as the stomach, intestine, and bladder. it encloses the palatoglossal muscle. Located between © Jones & Bartlett Learning, LLC these two arches© Jones and on & either Bartlett side of Learning, the oropharynx LLC In addition, muscles can be classified as either NOT FOR SALE OR DISTRIBUTION are the palatineNOT tonsils. FOR The SALE two ORpalatine DISTRIBUTION tonsils form extrinsic muscles because they are located su- part of Waldeyer’s ring. Although there are several dif- perficially, or on top, of a structure, or as intrinsic ferent tonsillar structures in Waldeyer’s ring, the pala- muscles, which are located deep within or inside of tine tonsils are the structures most often referred to as a structure. the tonsils. When inflamed they can obstruct the rear © Jones & Bartlett Learning, LLC © Jonesof the &oral Bartlett cavity. The Learning, palatine tonsils LLC may be seen in NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284430240_CH01_001_018.indd 8 25/06/20 5:36 PM The Oral Cavity 9

Swallowing and Deglutition Apnea © Jones & BartlettDid You Learning, Know? LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTDuring FOR theSALE complex OR act DISTRIBUTION of swallowing, breathing briefly Uvular and Alveolar Sounds and Speech stops as the mechanisms to protect the airway and Several languages use uvular sounds that are clas- prevent aspiration are initiated. This brief cessation of sified as uvular stops, fricatives, nasals, trills, or breathing is known as deglutition apnea. To better un- approximants. The sounds are articulated with the derstand this occurrence, the process of swallowing can © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC back of the tongue and throat moving against or be broken down into four phases: the oral preparatory phase, the oral transit phase, the pharyngeal phase, and near the uvula. UvularNOT consonants FOR SALE are extremely OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the esophageal phase (Figure 1-7). rare in English; they are more common in French, Catalan, German, Hebrew, Japanese, and Arabic. Examples of a uvular trill are the pronunciation of Nasal cavity the© Jonesletter r in & the Bartlett German wordLearning, rot (“red”) LLC and the © Jones & Bartlett Learning,Hard LLCpalate FrenchNOT wordFOR rue SALE (“street”). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Linguists also refer to alveolar sounds that are The oral preparatory Soft palate produced by placing the tongue on the alveolar phase and oral Blocked nasal ridge close to the back of the upper teeth. These transit phase. passage sounds occur in English. An example of an alveo- Bolus © Jones & Bartlettlar consonant Learning, is the pronunciation LLC of the zs in the © Jones & Bartlett Learning, LLC Pharynx NOT FOR SALEword pizzaOR .DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Epiglottis Larynx Trachea Esophagus (A) Did You Know?© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Waldeyer’s Ring Waldeyer’s ring, also known as nasal-associated The pharyngeal lymphoid tissue (NALT), was first described in phase. 1884© Jones by Heinrich & Bartlett Wilhelm Learning,Gottfried von LLC Waldeyer- © Jones & Bartlett Learning, LLC Hartz. A German anatomist, Waldeyer-Hartz NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION also coined the terms neuron for a nerve cell and chromosome for the smallest molecule of genetic material. Waldeyer’s ring is a circle of lymphoid tis- © Jones & Bartlettsue found Learning, in the nasopharynx LLC and oropharynx. © Jones(B) & Bartlett Learning, LLC NOT FOR SALEWaldeyer’s OR DISTRIBUTION ring includes the pharyngeal tonsils NOT FOR SALE OR DISTRIBUTION (adenoids) in the center rear of the nasopharynx, the two tubal tonsils near the opening of the eustachian tubes on either side, the two palatine tonsils on either side of the oropharynx, The esophageal phase. and the lingual tonsils© Jones on the &posterior Bartlett third Learning, of LLC © Jones & Bartlett Learning, LLC the tongue. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

the© back Jones of the & throat Bartlett between Learning, the two arches. LLC They are © Jones & Bartlett Learning, LLC linedNOT by stratified FOR SALE nonkeratinized OR DISTRIBUTION squamous epithelium. NOT FOR SALE OR DISTRIBUTION The pharyngeal tonsils, also known as the adenoids, are located in the rear of the nasopharynx. When enlarged, (C) they may cause nasal airway obstruction. The pharyn- FIGURE 1-7 Swallowing and deglutition apnea. (A) The oral preparatory geal tonsils are lined with pseudostratified ciliated co- phase and oral transit phase. (B) The pharyngeal phase. (C) The © Jones & lumnarBartlett epithelium. Learning, LLC © Jonesesophageal & Bartlett phase. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Phase 1: Oral Preparatory Phase © Jones & Bartlett Learning, LLC © Jonesleft untreated, & Bartlett ankyloglossia Learning, can result LLC in difficulties in breastfeeding, speaking, and swallowing. Treatment is NOT FOR SALE1. FoodOR isDISTRIBUTION taken into the mouth. NOT FOR SALE OR DISTRIBUTION 2. The tongue positions the food on the teeth usually a surgical procedure called a frenulectomy to for mastication and repositions the food, as release the tongue. necessary. Cold-stimulus headaches (“ice cream” headaches) are 3. The tongue mixes food with saliva during characterized by a sharp, stabbing pain in the forehead mastication. © Jones & Bartlett Learning, LLCfollowing exposure to sudden© extreme Jones cold & orBartlett by hav- Learning, LLC 4. This process NOTcontinues FOR until SALE a bolus OR or ball DISTRIBUTION of ing something cold move acrossNOT the FOR roof of SALE the mouth. OR DISTRIBUTION food is formed. The physiologic cause of these headaches is unknown. 5. Breathing continues through the nose, and the Treatment is to allow the body to stabilize and adapt to pharynx and larynx are at rest. the temperature change. Oral candidiasis, commonly known as thrush, is Phase© Jones 2: Oral &Transit Bartlett Phase Learning, LLC an infection© caused Jones by the& Bartlettfungus Candida Learning, albicans LLC. NOT1. FOR SALE OR DISTRIBUTION Symptoms includeNOT FOR white lesionsSALE inside OR DISTRIBUTIONthe mouth. Risk As the tongue moves the bolus of food toward factors for the development of oral candidiasis include a the back of the mouth, the soft palate raises to weakened immune system, diabetes, and the use of cer- prevent nasal regurgitation. 2. tain medications, such as prednisone, inhaled cortico- Sensory receptors in the oropharynx and steroids, or antibiotics. Treatment focuses on improved tongue stimulate the pharynx and swallowing is oral hygiene and antifungal medications. © Jones & Bartlettinitiated. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Phase 3: Pharyngeal Phase The Pharynx 1. The soft palate is tensed by the tensor palatini Thepharynx , more commonly known as the throat, muscles and then elevated by the levator palatini extends from the back of the nasal cavity down to the muscles to close© Jones the nasopharynx & Bartlett and preventLearning, LLClarynx. Anatomically, the pharynx© Jones begins & at Bartlettthe base of Learning, LLC food from entering the nasal cavity. This ac- NOT FOR SALE OR DISTRIBUTIONthe skull and extends to the cricoidNOT cartilage.FOR SALE It can ORbe DISTRIBUTION tion also opens the eustachian tubes to equalize divided into three sections: the nasopharynx, the oro- the pressure between the nasopharynx and the pharynx, and the laryngopharynx. middle ear. The pharynx has two types of muscles: circular and 2. The hyoid bone and larynx are elevated and longitudinal. The circular muscles form partial or in- © Joneslifted anteriorly & Bartlett to protect Learning, the airway. LLC complete ringlike© Jones structures & Bartlett that contract Learning, to move foodLLC 3. The palatoglossus, intrinsic muscles of the tongue, NOT FOR SALE OR DISTRIBUTION from the oralNOT cavity FOR into theSALE esophagus. OR DISTRIBUTION They include and the styloglossus close the oropharynx. the superior pharyngeal constrictor in the oropharynx; 4. The stylopharyngeus, salpingopharyngeus, and the middle pharyngeal constrictor in the laryngophar- palatopharyngeus muscles lift the pharynx and ynx; and the inferior pharyngeal constrictor, also in the pull it forward to receive the bolus. laryngopharynx. These muscles are innervated by the 5. In the larynx, the lateral cricoarytenoids and the © Jones & Bartlett Learning, LLC © Jonesvagus nerve& Bartlett (CN X). Learning, LLC oblique and transverse arytenoids close the vo- The longitudinal muscles lift the larynx and widen NOT FOR SALE calOR cords. DISTRIBUTION It is at this stage that breathing stops NOTthe FOR pharynx SALE during OR swallowing. DISTRIBUTION These muscles include briefly and deglutition apnea occurs. the stylopharyngeus, which is innervated by the glos- 6. The bolus is moved toward the esophagus by a sopharyngeal nerve (CN IX), and the palatopharyngeus series of sequential contractions called pharyn- and salpingopharyngeus muscles, which are innervated geal peristalsis.© Jones & Bartlett Learning, LLCby the vagus nerve (CN X). The© Jones salpingopharyngeus & Bartlett Learning, LLC muscle also opens and closes the eustachian tubes to Phase 4: EsophagealNOT Phase FOR SALE OR DISTRIBUTIONequalize the pressure in the middleNOT earFOR with SALE atmo OR DISTRIBUTION 1. The food bolus enters the esophagus and moves spheric pressure. downward toward the stomach at a rate of 3 to 5 cm per second. The Nasopharynx 2. © JonesBreathing & Bartlettresumes when Learning, this is completed. LLC Thenasopharynx © Jones provides & Bartlett a passage fromLearning, the back LLC NOT FOR SALE OR DISTRIBUTION of the nasalNOT cavity FORto the softSALE palate. OR The DISTRIBUTION pharyngeal tonsils, commonly known as the adenoids, are located Conditions of the Oral Cavity in the upper-rear portion of the nasopharynx. When A variety of conditions may affect the oral cavity. enlarged, they may cause nasal airway obstruction. Ankyloglossia (tongue-tied) is a condition in which The nasopharynx and the pharyngeal tonsils are lined © Jones & theBartlett lingual frenulumLearning, is unusually LLC short or thick. It is © Joneswith pseudostratified & Bartlett Learning, ciliated columnar LLC epithelium. NOT FOR SALEmost often OR diagnosed DISTRIBUTION and treated in infants. When NOTWhile FOR not SALE technically OR DISTRIBUTIONa portion of the nasopharynx, the

9781284430240_CH01_001_018.indd 10 25/06/20 5:36 PM The Larynx 11

© Jones &eustachian Bartlett tubesLearning, (also called LLC pharyngotympanic tubes)© JonesThe laryngopharynx & Bartlett Learning, is lined with LLCnonciliated stratified are canals that link the nasopharynx to the middle ear. NOTsquamous epithelium. FOR SALE OR DISTRIBUTION NOT FOR SALEThese tubes OR DISTRIBUTIONmay be divided into two sections: a bony portion arising from the anterior wall of the tympanic The Larynx cavity and a fibrocartilaginous portion closer to the entry point of the nasopharynx. In an infant, the eu- The larynx, or voice box, provides protection for the stachian tubes are approximately© Jones & 18 Bartlett mm in length, Learning, LLCairways during swallowing, assists© Jones in airway & Bartlett patency, Learning, LLC and supports vocalization. Considered the transition whereas in an adult theyNOT are FOR approximately SALE OR 36 mm DISTRIBUTION in NOT FOR SALE OR DISTRIBUTION length. In addition to equalizing pressure between the point from the upper airways to the lower airways, the atmosphere and the inner ear, the eustachian tubes also larynx is positioned in the anterior portion of the protect the middle ear from nasopharyngeal secretions neck, beneath the hyoid bone, and between the third and drain middle ear secretions into the nasopharynx. and sixth cervical (C3 and C6) vertebrae. The inlet of At its© Jonesopening in& theBartlett nasopharynx, Learning, the eustachian LLC tube the larynx is© called Jones the aditus& Bartlett and is borderedLearning, anteri LLC- orly by the epiglottis, on each side by the aryepiglottic is linedNOT by FOR pseudostratified SALE OR columnar DISTRIBUTION epithelium with NOT FOR SALE OR DISTRIBUTION goblet cells. The pseudostratified columnar epithelium folds, and inferiorly and posteriorly by an interaryte- lining transitions to a type of lining called the middle noid fold. Primarily cartilaginous, the larynx is made ear mucosa as the tubes progress toward the bony por- up of three single cartilages—the thyroid, cricoid, and tion nearest the tympanic cavity. epiglottic cartilages—and three paired cartilages—the © Jones & Bartlett Learning, LLC © Jonesarytenoid, & Bartlett corniculate, Learning, and cuneiform LLC cartilages. The The Oropharynx cartilages are controlled by both intrinsic and extrinsic NOT FOR SALE OR DISTRIBUTION NOTligaments FOR SALE and muscles. OR DISTRIBUTION The intrinsic ligaments and Theoropharynx is the portion of the pharynx that pro- muscles of the thyroid cartilage are the cricothyroid ceeds from the soft palate to the superior border of the ligament and the cricothyroid muscle, thyroarytenoid epiglottis. This section of the pharynx can be easily seen muscle, posterior cricoarytenoid muscles, lateral cri- via the oral cavity. The© Jonestwo palatine & Bartlett tonsils and Learning, the lin- LLCcoarytenoid muscles, and the© transverse Jones &and Bartlett oblique Learning, LLC gual tonsils are technically located in the oropharynx. arytenoid muscles. The extrinsic ligaments of the When inflamed, theNOT palatine FOR tonsils SALE can obstruct OR DISTRIBUTION the thyroid cartilage are the medianNOT thyrohyoid FOR SALE ligament, OR DISTRIBUTION rear of the oral cavity. The oropharynx is lined by non- lateral thyrohyoid ligament, hyoepiglottic ligament, ciliated stratified squamous epithelium. cricotracheal ligament, and the median cricothyroid In the back of the oral cavity, posterior to the root of ligament. The extrinsic muscles of the thyroid cartilage the© tongue Jones between & Bartlett the median Learning, and lateral LLC glossoepi- are the suprahyoid© Jones group & andBartlett the infrahyoid Learning, group LLC glottic folds, is a small groove or indentation called the (Figure 1-8). valleculaNOT epiglottisFOR SALE. The ORword valleculaDISTRIBUTION is derived from The insideNOT cavity FOR of the SALE larynx ORcan DISTRIBUTIONbe divided into the Latin valles meaning “valley.” The vallecula epiglot- three sections: the supraglottis; the glottis, which con- tis groove is an important reference landmark that is tains the vocal folds (vocal cords); and the subglottis used when placing a breathing tube into the trachea. (Figure 1-9). The glottis has two pairs of vocal folds. The procedure for placing a breathing tube through the The upper pair is known as the false vocal cords be- © Jones & oropharynxBartlett Learning, is called intubation LLC . It can be done manu- © Jonescause they& Bartlett do not play Learning, a role in speech. LLC The lower NOT FOR SALEally with OR a laryngoscope DISTRIBUTION or with the assistance of a NOTpair FOR is known SALE as ORthe true DISTRIBUTION vocal cords. The opening fiberoptic scope. between the vocal cords is called the rima glottides. The interior cavity of the larynx is lined by ciliated The Laryngopharynx columnar epithelium. laryngopharynx © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The is the passage that extends from Cartilages of the Larynx the superior border ofNOT the epiglottis FOR SALE to the inferiorOR DISTRIBUTION bor- NOT FOR SALE OR DISTRIBUTION der of the cricoid cartilage, where it becomes continu- The larynx has multiple cartilages. Thethyroid ous with the esophagus. This portion of the pharynx is cartilage, more commonly known as the Adam’s apple, also known as the hypopharynx. The laryngopharynx is the largest cartilage in the larynx. It is composed of plays a crucial role in preventing aspiration; that is, two rectangular laminae that are fused in the midline stopping© Jones food and& Bartlett liquid particles Learning, from entering LLC the and anteriorly.© Jones The position & Bartlett of these Learning,internal laryngeal LLC airway.NOT In FOR the lower SALE portion OR of DISTRIBUTION the laryngopharynx is structures toNOT the thyroid FOR SALEcartilage OR is an DISTRIBUTION important land- the piriform recess. Also called the piriform sinus, this mark in surgical planning. area is located on either side of the opening to the lar- Thecricoid cartilage is located below the thyroid ynx. It is bounded medially by the aryepiglottic fold, cartilage. The cricoid cartilage is the only laryngeal and laterally by the thyroid cartilage and the thyrohy- cartilage to completely encircle the airway. Shaped © Jones & oidBartlett membrane. Learning, This recess LLC is an important anatomic © Joneslike a signet& Bartlett ring, this Learning, cartilage joins LLC the first tra- NOT FOR SALEmarker whenOR DISTRIBUTION discussing cancer staging and treatment. NOTcheal FOR ring SALE inferiorly OR via DISTRIBUTION membranous attachments.

9781284430240_CH01_001_018.indd 11 25/06/20 5:36 PM 12 CHAPTER 1 The Upper Airways

Epiglottis © Jones & Bartlett Learning,Hyoid LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONbone NOT FOR SALE OR DISTRIBUTIONEpiglottis

Cuneiform Ventricular fold cartilage Thyroid (false vocal cord) cartilage Arytenoid Thyroid cartilage © Jones & Bartlett Learning,cartilage LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION VocalNOT cord FOR SALE OR DISTRIBUTION Cricoid cartilage Cricoid Tracheal cartilage cartilages Tracheal © Jones & Bartlett Learning, LLC © Jones & Bartlettcartilages Learning, LLC NOT FOR SALE OR DISTRIBUTIONLarynx LarynxNOT FOR SALE OR DISTRIBUTION (anterior view) (sagittal view)

FIGURE 1-8 The larynx.

Epiglottis

Aryepiglottic fold © Jones & BartlettPyriform Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALErecess OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Cuneiform cartilage Trachea

NOT FOR SALE OR DISTRIBUTIONFIGURE 1-9 The vocal cords as seen withNOT an open FOR glottis. SALE OR DISTRIBUTION

A cricothyrotomy is a procedure that places a tube The corniculate cartilages are accessory cartilages that through an incision via© Jonesthe cricothyroid & Bartlett membrane Learning, to LLCaid in the opening and closing© of Jones the glottis & andBartlett sound Learning, LLC establish an airway for oxygenation and ventilation. production. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Theepiglottis is a piece of cartilage positioned be- Thecuneiform cartilages are two rod-shaped nod- hind the root of the tongue and the hyoid bone and just ules that are positioned at the edge of the aryepiglottic above the aditus of the larynx. The purpose of the epi- folds, above and anterior to the corniculate cartilages. glottis is to prevent aspiration during swallowing. They are classified as accessory cartilages that provide ©The Jonesarytenoid & cartilagesBartlett areLearning, two pyramid-shaped LLC support to the© Jones vocal folds & andBartlett the lateral Learning, aspects of LLC the cartilagesNOT FORthat have SALE an apex, OR a DISTRIBUTIONbase, three sides, a vocal epiglottis. NOT FOR SALE OR DISTRIBUTION process medially, and a muscular process laterally. Vo- cal ligaments and intrinsic muscles that coordinate the Muscles of the Larynx movements of the vocal folds attach to these processes. The corniculate cartilages are two small conical car- A number of intrinsic and extrinsic muscles support © Jones & tilagesBartlett that areLearning, also known LLC as the cartilages of Santorini.© Jonesthe functions & Bartlett of the Learning,larynx. The intrinsic LLC muscles in- NOT FOR SALEThey are OR positioned DISTRIBUTION above each of the arytenoid carti- NOTclude FOR the SALE cricothyroid OR DISTRIBUTION muscle, thyroarytenoid muscle, lages and are embedded within the aryepiglottic folds. posterior cricoarytenoid muscles, lateral cricoarytenoid

9781284430240_CH01_001_018.indd 12 25/06/20 5:37 PM Conditions of the Pharynx or Larynx 13

© Jones &muscle, Bartlett oblique Learning, arytenoid LLC muscles, and the transverse © Jonesairway & edema Bartlett should Learning, be regarded LLCas a potentially life- arytenoid muscle. The cricothyroid muscle originates NOTthreatening FOR SALE condition. OR DISTRIBUTION NOT FOR SALEin the anterolateral OR DISTRIBUTION aspect of the cricoid cartilage and Croup, also known as inspiratory stridor, is an infec- attaches to the inferior margin and inferior horn of the tion of the vocal cords, trachea, and/or bronchial tubes. thyroid cartilage. This muscle tightens and thins the The infection can be either viral or bacterial in origin, vocal folds and increases their resonant frequency in but is most often caused by human parainfluenza vi- speech. © Jones & Bartlett Learning, LLCruses (HPIVs). Children between© Jones 6 months & andBartlett 3 years Learning, LLC The thyroarytenoidNOT muscle FOR originates SALE in OR the DISTRIBUTIONinfero- of age are at highest risk for developingNOT FOR croup SALE due toOR DISTRIBUTION posterior angle of the thyroid cartilage and attaches to the small diameter of their airways. The infection may the arytenoid cartilage. Its primary action is to relax the begin with coldlike symptoms and progress to a barking vocal ligaments. cough. Symptoms usually last for 3 to 5 days. Parents The posterior cricoarytenoid muscles originate in and caregivers should seek immediate medical atten- the© posterior Jones surface& Bartlett of the Learning,cricoid cartilage LLC and at- tion if a child© developsJones stridor& Bartlett (high-pitched Learning, breathing LLC tachNOT to the FOR arytenoid SALE cartilage. OR DISTRIBUTION These muscles rotate sounds), hasNOT excessive FOR drooling, SALE has OR difficulty DISTRIBUTION swal- the arytenoid cartilages laterally, thereby abducting lowing, is anxious and agitated or fatigued and listless, the vocal folds and opening the rima glottidis. These shows an increased respiratory rate or difficulty breath- muscles are used as a landmark for arytenoid adduc- ing, or develops cyanosis. tion surgery, which is a procedure to treat vocal cord Dysphagia, or difficulty swallowing, can also cause © Jones & paralysis.Bartlett Learning, LLC © Jonesproblems & Bartlett with airway Learning, functioning. LLC Dysphagia may NOT FOR SALEThe lateralOR DISTRIBUTION cricoarytenoid muscles originate in the NOTbe FOR related SALE to a physical OR DISTRIBUTION obstruction of the pharynx or arch of the cricoid cartilage and attach to the arytenoid esophagus, diseases of the muscles of the pharynx or cartilage. These muscles rotate the arytenoid cartilages esophagus, or other diseases/conditions that alter the medially, thereby adducting the vocal folds and closing swallowing process such as a stroke or degenerative dis- the rima glottides. eases of the brain. The oblique arytenoid© Jones muscles & Bartlettoriginate on Learning, the pos- LLCEpiglottitis is an inflammation© Jones of the epiglottis.& Bartlett This Learning, LLC terior surface and muscularNOT FOR process SALE of the arytenoidOR DISTRIBUTION is a potentially life-threateningNOT condition FOR because SALE the OR DISTRIBUTION cartilage and attach to the arytenoid cartilage on the op- swelling may obstruct the airway. The condition may posite side inside the aryepiglottic fold. They move the occur at any age and can be caused by a variety of trig- vocal folds either closer together or farther apart. gers, including trauma or infection. Common causes of The transverse arytenoid muscle originates from the epiglottitis in adults include infections with Streptococ- arytenoid© Jones cartilage & Bartlett on one side Learning, and inserts LLCin the ary- cus pneumoniae© Jones and groups & Bartlett A, B, and Learning, C streptococcus LLC. tenoidNOT cartilage FOR onSALE the opposite OR DISTRIBUTION side. It pulls the aryte- The most commonNOT FOR cause SALE of epiglottitis OR DISTRIBUTION in children is noid cartilages and the vocal folds together, closing the infection with Haemophilus influenzae type b (Hib). Im- rima glottides. munization with the Hib vaccine is recommended for The extrinsic muscles of the larynx include the su- children beginning at 2 months of age. prahyoid group and the infrahyoid group of muscles. Laryngitis is an inflammation of the larynx. Acute © Jones & TheBartlett suprahyoid Learning, group of musclesLLC are four sets of mus- © Joneslaryngitis & Bartlett may be caused Learning, by either LLC viral or bacterial cles that work together with the longitudinal muscles infection or by vocal strain. Chronic laryngitis, lasting NOT FOR SALEof the pharynx, OR DISTRIBUTION specifically the stylopharyngeus, to lift NOTlonger FOR than SALE 3 weeks, OR mayDISTRIBUTION be caused by inhalation of the hyoid bone and widen the esophagus during swal- irritants, allergens, or smoke; conditions such as gastro- lowing. The infrahyoid group of muscles are four sets of esophageal reflux disease (GERD) or sinusitis; smoking; muscles that depress the hyoid bone and larynx during or excessive overuse of the voice. Laryngeal edema swallowing and speech.© Jones & Bartlett Learning, LLC , the abnormal© Jones accumulation & Bartlett of Learning, LLC fluid in the larynx, is a common cause of airway ob- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Conditions of the Pharynx struction after the removal of an endotracheal tube. The condition may result from trauma to the larynx by the or Larynx endotracheal tube. Postextubation stridor (PES), defined Several conditions that may affect the pharynx or larynx as a high-pitched sound produced by airflow through can© have Jones a negative & Bartlett impact on Learning, ventilation. LLCFor example, a narrowed© airway, Jones is a &clinical Bartlett indicator Learning, of laryngeal LLC edema,NOT by FOR definition, SALE is anOR abnormal DISTRIBUTION accumulation of edema followingNOT extubation. FOR SALE Treatment OR DISTRIBUTION of the condition fluid in the tissues or cavities of the body. It most often varies based on the severity of the edema. manifests as swelling. In the airways, edema may be- Laryngospasm is a spasm or contraction of the vocal come life-threatening if it obstructs airflow and makes cords. It may be triggered by trauma, gastroesophageal breathing difficult. Airway edema has a variety of eti- reflux disease (GERD), anxiety, or stress. Laryngo- © Jones & ologies,Bartlett including Learning, allergic LLC response, trauma, infection, © Jonesspasm & should Bartlett not be Learning, confused with LLC bronchospasm, NOT FOR SALEinhalation OR of DISTRIBUTIONtoxic or noxious gases, or hereditary con-NOTwhich FOR is SALE contractions OR DISTRIBUTIONof the muscles in the walls of ditions, such as hereditary angioedema (HAE). Upper the bronchioles.

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pharyngeal reflex © Jones & BartlettThe Learning, , LLCalso known as the gag reflex,© Jonescan be & taken Bartlett during Learning,this procedure. LLC Bronchoscopes is a contraction of the back of the laryngopharynx trig-NOTmay FOR also SALE be used OR to facilitate DISTRIBUTION endotracheal intubation in NOT FOR SALEgered by OR an object DISTRIBUTION or particle touching the back of the some instances. hard or soft palate or an area of the oropharynx. This reflex is intended to protect the individual from choking Artificial Airways or aspirating food. A hyperactive gag reflex is a height- Sometimes it becomes necessary to bypass the upper ened pharyngeal reflex© Jones that may & or Bartlett may not beLearning, a learned LLC © Jones & Bartlett Learning, LLC response. airways in order to prevent or relieve obstruction of NOT FOR SALE OR DISTRIBUTIONthe airway, to allow access forNOT suctioning FOR or SALE removal OR of DISTRIBUTION Otitis media is an infection of the middle ear. Symp- toms may include pain, fever, bulging or erythema of mucous, to prevent aspiration, or to provide a route for the tympanic membrane, and middle ear effusion (fluid mechanical ventilatory support. Several devices, known behind the eardrum). Treatment may include antibiotic as artificial airways, are available to safely and effectively therapy and symptom relief for the pain. bypass the upper airways. © Jones & Bartlett Learning, LLC Nasopharyngeal© Jones airways & Bartlett, also called Learning, nasal trumpets LLC, A peritonsillar abscess is caused by an infection of NOT FOR SALE OR DISTRIBUTION are flexible,NOT soft tubelike FOR SALEdevices thatOR haveDISTRIBUTION a flared end the palatine tonsils that spreads and forms an abscess in Figure 1-10 the surrounding tissue. Infection of the palatine tonsils ( ). They are usually lubricated and inserted can also cause deviation of the uvula, which is called via the nares. Although nasopharyngeal airways may be quinsy. A diagnosis of quinsy is usually considered a used to relieve upper airway obstruction, they are most medical emergency, because the deviation may obstruct often used to prevent damage to the nasal passages © Jones & Bartlett Learning, LLC © Joneswhen frequent& Bartlett suctioning Learning, is needed LLC to keep the airway NOT FOR SALEthe airway OR or DISTRIBUTION alter swallowing, resulting in aspiration NOT FOR SALE OR DISTRIBUTION of particles into the lungs and infections. Treatment is clear. They are available in a variety of sizes, from pedi- atric to adult. usually intravenous antibiotics and incision and drain- Oropharyngeal airways age of the abscess. are curved plastic devices with a flange that rests against the teeth when inserted. Tonsillitis is an infection of the palatine tonsils caused by either a bacteria or virus. The condition can be acute They are inserted into the mouth and used to maintain © Jones & Bartlett Learning, LLCa patent airway in an unconscious© Jones patient & who Bartlett is at risk Learning, LLC or chronic. ConcurrentNOT infection FOR ofSALE the adenoids OR DISTRIBUTION may NOT FOR SALE OR DISTRIBUTION also occur. Treatment includes antibiotics or surgical re- of his or her tongue obstructing their airway. These moval with a tonsillectomy and/or an adenoidectomy. airways may also be used to facilitate suctioning via the oral cavity in an unconscious or semiconscious patient The Valsalva maneuver involves forcibly exhaling air against a closed airway to normalize middle-ear pres- and/or prevent him or her from biting his or her tongue. sure. It is usually done by pinching the nose, closing The two most common oropharyngeal airways are © Jones & Bartlett Learning, LLC the Berman© airway Jones and &the Bartlett Guedel airway. Learning, The Berman LLC theNOT mouth, FOR and exhaling.SALE ORThe DISTRIBUTIONmaneuver can be used NOT FOR SALE OR DISTRIBUTION when ambient pressure changes, as in diving or air airway has two open channels, one along each side of the airway, and the Guedel airway has a single closed travel, cause discomfort in the inner ear. However, the Figure 1-11 maneuver also has cardiac ramifications. Intrathoracic channel down the center ( ). Other types of pressure changes that occur during the Valsalva ma- oropharyngeal airways include the Williams airway intubator, Ovassapian airway, and the Berman intubating © Jones & neuverBartlett may Learning, initiate changes LLC in heart rate and/or blood © Jones & Bartlett Learning, LLC pressure. airway. These airways are most often used during bronchoscopy and intubation. NOT FOR SALEVocal OR cord DISTRIBUTION dysfunction (VCD) is characterized by NOT FOR SALE OR DISTRIBUTION paroxysmal adduction of the vocal cords, resulting in Oropharyngeal airways come in a variety of sizes. airway restriction, and is often misdiagnosed as asthma. With an appropriately sized oropharyngeal airway, Correct diagnosis is usually confirmed by direct visu- the flange should be approximately at the level of the teeth when the airway is placed against the patient’s alization of vocal cord© movement.Jones & The Bartlett treatment Learning, of LLC © Jones & Bartlett Learning, LLC choice is usually speech therapy. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Bronchoscopy A bronchoscopy is a procedure where a fiberoptic scope© Jones with a camera & Bartlett and light Learning, are used to visualizeLLC the © Jones & Bartlett Learning, LLC upperNOT airways FOR and SALE lungs. ORThe DISTRIBUTIONprocedure is performed NOT FOR SALE OR DISTRIBUTION using either a flexible bronchoscope or a rigid bronchoscope that is passed through the nose or mouth into the trachea, bronchi, and bronchioles of the lungs. Flexible bronchoscopy is performed more often than © Jones & rigidBartlett bronchoscopy Learning, and usually LLC does not require general© Jones & Bartlett Learning, LLC NOT FOR SALEanesthesia. OR In DISTRIBUTION addition to providing visualization of theNOT FIGURE FOR 1-10SALE Nasopharyngeal OR DISTRIBUTION airways. airways, tissue samples and bronchial lavage samples © Jones & Bartlett Learning. Courtesy of MIEMSS.

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(A) (B)

(C) (D) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR(E) SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 1-11 Several types of oropharyngeal airways are available. (A) The Berman airway has two lateral air channels or grooves that open to the oral cavity and promote air passage. (B) The Guedel airway has one internal tubelike passage that allows for air movement. (C) The Williams airway intubator has an enclosed upper channel and an open lower channel and is often used as an aid in fiberoptic intubations. (D) The Ovassapian airway has a closed upper portion and a curved open portion and is used during intubation and bronchoscopy. The bronchoscope or endotracheal© Jones tube &can Bartlett fit inside the Learning,open central portion, LLC allowing for some air passage around© Jones the airway. & (BartlettE) The Berman Learning, intubating airway LLC has a large central channel that permits air passage. It is primarily used during fiberoptic intubation and bronchoscopy. (A) ©NOT deepspacedave/Shutterstock; FOR SALE (B) CourtesyOR DISTRIBUTIONof Intersurgical Ltd/Wikimedia Commons; (C) Courtesy of SunMed; (DNOT) Courtesy FORof Teleflex; SALE(E) Reproduced OR with permissionDISTRIBUTION from CareFusion.

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© Jones &cheek Bartlett and the Learning, opposite end LLC should extend to the angle© Jonesend of & the Bartlett tube. When Learning, inflated this LLC cuff cushions the of the jaw. Improperly sized oropharyngeal airways NOTairway FOR andSALE provides OR aDISTRIBUTION seal to prevent gas from escap- NOT FOR SALEcan obstruct OR DISTRIBUTIONthe airway. Oropharyngeal airways are ing during mechanical ventilation. A double-lumen usually not well tolerated in conscious patients, as tube, called a Carlen’s tube, has two pilot balloons, and they tend to stimulate the gag reflex at the back of the is used to perform independent ventilation of the right oropharynx. and left lung. Endotracheal tubes used in infants and Supraglottic airways© Jones are used & to Bartlettdeliver manual Learning, ven- LLCchildren are usually uncuffed.© JonesMost endotracheal & Bartlett tubes Learning, LLC tilation using a resuscitationNOT FOR bag. TheySALE may OR be DISTRIBUTIONused in have a slight curvature that followsNOT FOR the natural SALE curva OR- DISTRIBUTION place of intubation with an endotracheal tube, when in- ture of the upper airways. However, preformed tubes tubation attempts have failed, or when bag-valve-mask are available that have a sharp U-shaped curve. These ventilation has failed. Supraglottic devices include the tubes are most often used in the operating room. En- laryngeal tube, the Cobra perilaryngeal airway (PLA), dotracheal tubes come in several sizes to suit infants the© Elisha Jones airway, & theBartlett supraglottic Learning, airway laryngopha- LLC through adults.© Jones & Bartlett Learning, LLC stylet ryngealNOT tube FOR (SALT), SALE and ORthe streamlined DISTRIBUTION liner of the A isNOT a thin, FOR flexible SALE rod that OR mayDISTRIBUTION be inserted pharynx airway (SLIPA) (Figure 1-12). A similar device inside an endotracheal tube during intubations to pro- is the laryngeal mask airway (LMA). The designs and vide stability to the tube. The stylet should not extend utilization of each of these devices differ, and training is beyond the end of the tube and is removed immediately required before safely and effectively using them. after the intubation. Similar to a stylet, a gum-elastic © Jones & BartlettEndotracheal Learning, tubes are LLC firm, yet flexible curved © Jonesbougie & or Bartlett “introducer” Learning, is a flexible LLC rod that is used as NOT FOR SALEtubes that OR are DISTRIBUTION inserted via the nose or mouth, passed NOTa FOR guide forSALE intubation OR DISTRIBUTION of a difficult airway. This device through the vocal cords, and extended into the trachea is passed into the airway and an endotracheal tube (Figure 1-13). The placement of an endotracheal tube, threaded over it, and then the introducer is removed. also known as intubation, is indicated to maintain A laryngoscope is used to visualize the larynx airway patency, facilitate mechanical ventilation, and/ and insert the endotracheal tube via the mouth or prevent aspiration.© SeveralJones varieties & Bartlett of endotracheal Learning, LLC(Figure 1-14). The laryngoscope© Jones has three & Bartlettparts: a light Learning, LLC tubes are available. TheNOT tubes FOR most SALE often ORused DISTRIBUTIONin adults source, a handle, and a blade.NOT The FORmost common SALE bladesOR DISTRIBUTION have an inflatable pilot balloon, or cuff, at the distal are a curved blade known as a Macintosh blade and a

(A) FIGURE 1-13 Endotracheal tubes. © Jones & Bartlett Learning, LLC© Jones & Bartlett Learning. Courtesy of MIEMSS.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

(B) © Jones & FIGUREBartlett 1-12 Learning,(A) Supraglottic LLCairway laryngopharyngeal tube (SALT)© Jones & Bartlett Learning, LLC and (B) a laryngeal mask airway (LMA). FIGURE 1-14 Laryngoscopes come in a variety of styles and sizes. NOT FOR SALE(A) Courtesy ofOR Ecolab; DISTRIBUTION (B) © Jones & Bartlett Learning. Courtesy of MIEMSS. NOT© FOR Jones & Bartlett SALE Learning. OR Courtesy DISTRIBUTION of MIEMSS.

9781284430240_CH01_001_018.indd 16 25/06/20 5:37 PM Review Questions 17

© Jones & Bartlett Learning, LLC © JonesSummary & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTThe FOR upper SALE airway OR is theDISTRIBUTION first place where atmo- spheric air comes into contact with the interior of the human body. Air moves into and out of the body via the conducting airways to the lungs. The conducting airways include the upper airway and lower © Jones & Bartlett Learning, LLCairway. The upper airway includes© Jones the nose,& Bartlett nasal Learning, LLC NOT FOR SALE OR DISTRIBUTIONcavity, oral cavity or mouth, andNOT the FOR pharynx, SALE which OR DISTRIBUTION is divided into the nasopharynx, oropharynx, and laryngopharynx. The larynx or voice box is usually con- (A) sidered the demarcation between the upper and lower airways. Through a complex interaction of nerves, © Jones & Bartlett Learning, LLC muscles, cartilage,© Jones and bones,& Bartlett the sense Learning, of smell, hear LLC- NOT FOR SALE OR DISTRIBUTION ing, and taste,NOT as well FOR as chewingSALE andOR swallowing DISTRIBUTION and speech, all take place in the same physiologic space that comprises the upper airways. Understanding the physiology of this compact and highly active portion of the body is the first step in understanding the © Jones & Bartlett Learning, LLC © Jonesrespiratory system. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

(B) Case Study FIGURE 1-15 Tracheostomy© Jones tubes. (A ) &A cuffed Bartlett tracheostomy Learning, tube. LLCA 9-year-old male presents© to Jones his primary & Bartlett care pro- Learning, LLC (B) An uncuffed tracheostomy tube. (B) © praisaeng/iStockPhoto. NOT FOR SALE OR DISTRIBUTIONvider with fever, a sore throat,NOT chills, FOR and SALE conges- OR DISTRIBUTION tion. His mother states that the symptoms began approximately 4 days ago and have gotten progres- sively worse. He also complains of intermittent straight© Jones blade known& Bartlett as a Miller Learning, blade. When LLC utilizing pain in his© right Jones ear. Upon & Bartlett examination, Learning, the provider LLC suspects tonsillitis. a MacintoshNOT FOR blade, SALE the tip OR of the DISTRIBUTION blade is placed in the NOT FOR SALE OR DISTRIBUTION vallecula, shifting the tongue forward and lifting the 1. Which tonsils is the provider most likely refer- epiglottis, thereby permitting visualization of the vocal ring with regards to suspicion of tonsillitis? cords. When using a Miller blade, the tip of the blade is Where are these tonsils located? inserted beneath the epiglottis, depressing the tongue During the examination, the provider notes a © Jones & andBartlett permitting Learning, visualization LLC of the vocal cords. Miller © Jones2. & Bartlett Learning, LLC and Macintosh laryngoscope blades are available in slight deviation of the uvula. What is this con- NOT FOR SALEinfant through OR DISTRIBUTION adult sizes. Fiberoptic or video laryngo-NOT FORdition SALE called? OR DISTRIBUTION scopes also are available, though they are less common. 3. How should this condition be treated? These laryngoscopes permit indirect visualization of the larynx and the feeding of the endotracheal tube via a video monitor. Regardless© Jones of the & type Bartlett of laryngoscope Learning, LLC © Jones & Bartlett Learning, LLC selected, all intubation procedures carry the risk of airway or dental traumaNOT and FOR should SALE not be ORattempted DISTRIBUTION Review Questions NOT FOR SALE OR DISTRIBUTION without proper training. 1. The conducting airways include: Tracheostomy tubes are inserted through a surgi- a. the upper airways. cal incision into the trachea to facilitate ventilation or b. the lower airways. to clear© Jones secretions & Bartlett (Figure 1-15 Learning,). The opening LLC in the c. both© the Jones upper and& Bartlett lower airways. Learning, LLC tracheaNOT that FOR is visible SALE on theOR individual’s DISTRIBUTION neck is known d. the NOTnasal ca FORvity and SALE the oropharynx. OR DISTRIBUTION as the stoma. The tracheostomy tube can be plastic or 2. The mucus secreted by the mucous membranes metal and is shorter than an endotracheal tube. They of the nose contains two layers. The lower layer is come in several sizes to suit infants through adults. Like known as the: an endotracheal tube, tracheostomy tubes can be either a. bronchial mucosa. © Jones & cuffedBartlett or uncuffed.Learning, When LLC the tracheostomy tube is no © Jonesb. &olfactor Bartletty mucosa. Learning, LLC NOT FOR SALElonger needed, OR DISTRIBUTION it may be capped, or it may be replaced NOT FORc. gelSALE layer .OR DISTRIBUTION with a speaking valve. d. sol layer.

9781284430240_CH01_001_018.indd 17 25/06/20 5:37 PM 18 CHAPTER 1 The Upper Airways

© Jones & Bartlett3. During Learning,swallowing, the LLC soft palate is tensed by the © JonesBibliography & Bartlett Learning, LLC tensor palatini and then elevated by the levator NOT FOR SALE OR DISTRIBUTION NOTBeachey FOR W.SALE Respiratory OR care DISTRIBUTION anatomy and physiology: foundations palatini to close the: for clinical practice, 4th ed. New York, NY: Elsevier; 2017. a. nasopharynx. Des Jardins T. Cardiopulmonary anatomy and physiology: essentials b. oropharynx. for respiratory care, 7th ed. Independence, KY: Cengage Learning; c. laryngopharynx. 2019. Hess DR, MacIntyre NR, Galvin WF. Respiratory care: principles and d. larynx. © Jones & Bartlett Learning, LLCpractice, 3rd ed. Burlington, MA: ©Jones Jones & Bartlett & Learning; Bartlett 2016. Learning, LLC 4. Forcibly exhalingNOT against FOR a closed SALE airway OR to DISTRIBUTIONnormal- Mason RJ, Ernst JD, King Jr. TE, MurrayNOT JF,FOR Nadal SALE JA, Slutsky OR AS, DISTRIBUTION ize middle-ear pressures is also known as: Gotway MB. Murray and Nadel’s textbook of respiratory medicine, a. the Valsalva maneuver. 6th ed. New York, NY: Elsevier; 2015. b. vocal cord dysfunction. Moini J. Anatomy and physiology for health professionals, 3rd ed. Bur- lington, MA: Jones & Bartlett Learning; 2020. c. the pharyngeal reflex. Standring S (Ed.). Gray’s anatomy: the anatomical basis of clinical prac- ©d. Jones laryngo &spasm. Bartlett Learning, LLC tice, 41st ed.© New Jones York, NY: & Elsevier; Bartlett 2015. Learning, LLC 5. NOTThe tongueFOR SALEis onnectedc OR to DISTRIBUTION the floor of the mouth Volsko TA, ChatburnNOT RL.FOR Equipment SALE for respiratoryOR DISTRIBUTION care. Har/Psc ed. by the: Burlington, MA: Jones & Bartlett Learning; 2014. a. alveoli. West JB, Luks AM. West’s respiratory physiology: the essentials, 10th ed. New York, NY: Wolters Kluwer; 2015. b. columnar epithelium. West JB, Luks AM. West’s pulmonary pathophysiology, 9th ed. c. keratin. New York, NY: Wolters Kluwer; 2017. © Jones & Bartlettd. lingual Learning, frenulum. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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