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HISTOLOGY OF RESPIRATORY TRACT (09-19-05, Rekasi)

Nasal cavity
nasal vestibule: skin (stratified keratinized squamous epithelium + sebaceous & sweat
glands, hairs (vibrissae))
limen nasi: stratified non-keratinizing squamous epithelium
nasal cavity proper (humidification and warming of air, turbulence, resonator:
respiratory region (extends to paranasal sinuses):
epithelium: pseudostratified ciliated + goblet cells
lamina propria: closely bond to periosteum, cavernous
vascular tissue (hormon sensitive) + mixed salivary
glands (lysozyme, lactoferrin, IgA),
olfactory region: pigmented pseudostratified epithelium:
olfactory receptor neurons: ciliated, bipolar - middle
zone
one neuron - expression of one type of receptor for
odorants
3 % of total genes (1000) for receptor expression in
1000 types of cells for 10000 different odours
sustentacular cells: barrier, pigmentation, phagocytosis -
superficial zone
basal cells: mitotic activity - basal zone
olfactory (Bowman’s) gland: solvent & binding protein for
odorant
Larynx
Mucous membrane: - epithelium: pseudostratified ciliated columnar + goblet
cells (taste buds may be present)
exceptions: ant. surface of epiglottis + vocal fold:
stratified non-keratinizing squamous
- lamina propria: loose (- edema!), lymphatic follicles,
mixed salivary glands
- in contrast to vestibular fold, the vocal fold (white in a
mirror) has:
- stratified non-keratinizing squamous epithelium
- no glands
- no skeletal muscle
- elastic membranes: in vestibule: quadrangular
membrane:
its upper margin: aryepiglottic fold; it lower margin:
vestibular lig.
in subglottic cavity: cricovocal lig. = conus elasticus
its anterior margin: ant. (median) cricothyroid lig.
= lig. conicum !!!; its upper margin: vocal lig.
Intrinsic skeletal muscle (inner: vocalis; outer thyroarytenoid)
Hyalin cartilage: lamina of thyroid cartilage (arch of cricoid or epiglottis may
be present)
Extrinsic skeletal muscle: cricothyroid
Lower conducting airways: Trachea - Bronchi (principal or primary bronchi, lobar or
secondary bronchi, segmental or tertiary bronchi, several successive dichotomous divisions,
terminal bronchi) - Bronchioli (lobular bronchioli, several successive dichotomous divisions,
terminal bronchioli) (except respiratory bronchioli, alveolar ducts, alveoli):
- mucosa: pseudostratified ciliated epithelium - mucociliary rejection current
ciliated columnar then cuboidal cells
goblet cells
basal cells: mitotic stem cells
neuroendocrine cells: paracrine effect
brush cells: slender, non-ciliated cells, sensory receptor function
Clara cells: cuboidal non-ciliated cells, surfactant production
lymphocytes: MALT
mast cells: histamine containing granules, release in response to
allergens
- submucosa: broad, longitudinal bands of elastin
submucosal glands: tubuloalveolar, seromucous, not present in
terminal bronchioli - production of lysozyme, lactoferrin, IgA, protease
inhibitors
- proportion of fibromuscular tissue and hyalin cartilage increases along bronchial tree
hyalin cartilage: incomplete rings, gradually discontinues,
not present in bronchioli
smooth muscle: contraction by parasympathetic innervation or local factors
(serotonin, histamine, leukotrienes released from mast cells) - bronchospasm
slight relaxation during inspiration
sympathetic stimulus: bronchodilatation (treatment of asthma!)
Respiratory surface (143m2):
- isolated patches of alveoli within the wall of respiratory bronchioli
- alveolar ducts with balloon-like alveolar sacs
- alveoli: pneumocytes type I (gas exchange) - simple squamous epithelium:
0.05-0.2 m thick, 90% of respiratory area,
pneumocytes type II(surfactant) - cuboidal epithelium, more than 50%
of cells but only 10% of respiratory area
- blood - air barrier (around 0.2 m thick): cytoplasm of squamous epithelium
basal lamina of squamous epithelium
basal lamina of endothelium
cytoplasm of endothelium
interalveolar septa: elastic, collagen III fibers, cells
interalveolar pores (of Köhn): lined by pneumocytes type II
cross interalveolar septa
communications between alveoli
routes of migration of macrophages
alveolar macrophages: removal of small inhaled particles
also involved in the turnover of surfactant
pneumoconiosis, asbestosis - fibrosis
abnormal activation, release more proteases, damage the lung
alveolar surfactant (phospholipids): dipalmitoylphosphatidylcholine
and phosphatidylglycerol,
detergent-like properties reduce the surface tension
DEVELOPMENT OF THE RESPIRATORY TRACT (Rekasi 09-22-05)
Formation of larynx: copula (epiglottis), furcula (arytenoid), 4. & 5. (6.) arches (thyroid,
cricoid)
Formation of the trachea (epithelium from endoderm, rest of the wall from splanchnopleura)
- at stage 12 (approx 26 days) ventral outgrowth from the endodermal foregut into the
splanchnopleauric mesenchyme (control of branching pattern!)
- respiratory diverticulum
- laryngotracheal groove remains at constant level, and the trachea lengthens distally
Formation of the lungs
- at stage 15: lung buds project dorsally into the pericardioperitoneal canals
- at stage 16: lobar or secondary bronchi can be seen
- at stage 17 (approx 7 weeks): bronchopulmonary segments are present
- later stages: dichotomous division of the bronchial tree
Stages of lung development
- pseudoglandular stage (7-17 weeks)
development of lower conducting airways, acinar appearance
secretory activity identified
differentiation of epithelium and smooth muscle cells/cartilage from
endoderm and splanchnopleura, respectively
- canalicular stage (17-26 weeks)
3 generation of branching
increase and apposition of capillary network to pneumocytes
II. type of pneumocyte appears stem cell that produces I type of
pneumocyte then ultimately matures surfactant-producing cell
- saccular stage (24 weeks to birth)
terminal saccules appear
further decrease in the amount of interstitial tissues
elastin deposited
surfactant production matures (if not enough RDS in premature infant)
- alveolar stage (28 weeks to 8 years)- lung is mature by the 7th month (32nd
week)
expansion of distal airspaces
extensive double capillary net
Interactions of early lung development
- fibronectin is expressed in clefts and along the sides of developing bronchi
whereas tenascin is expressed on the budding and distal tips
- surfactant production (induced by fibroblast-pneumocyte factor)
cortisol stimulates the release of FPF,
androgens block the effect of cortisol!
- vimentin is replaced by desmin in cells differentiated into smooth muscle cells
Requirements for maturation of the lungs
- sufficient intrathoracic space
- normal fetal breathing movements
- sufficient amniotic fluid (renal factor) - mucous glands secrete lung fluid
Congenital malformations
Tracheomalacia & bronchomalacia
Tracheo-oesophageal fistulae - (poly)hydramnios
Agenesis & aplasia of the lungs
RESPIRATORY SYSTEM 1: LARYNX, VOCALIZATION (09-20-05, Rekasi)
Nasal cavity:
- nasal vestibule/ limen nasi/ - nasal cavity proper: common, sup., middle, inf. nasal meatus
- paranasal sinuses (sphenoidal, frontal, maxillary sinuses, ethmoidal air cells)
- blood supply: ant. ethmoidal a. (ophthalmic a.), sphenopalatine a. (maxillary a.), sup. labial. a.
(facial a.) - anastomosis (area of Kiesselbach) - pterygoid, pharyngeal venous plexus
- lymphatic drainage: submandibular & retropharyngeal ll. nn.
- innervation: ant. ethmoidal n. (ophthalmic n.), post. nasal rami or nasopalatine n. (maxillary
n.), infraorbital n. (maxillary n.)
- olfactory epithelium (roof, lat. & medial wall of nasal cavity) - olfactory n.
Laryngeal cartilages: - thyroid cartilage: - right & left lamina
(hyaline) - laryngeal prominence (Adam’s apple)
- superior thyroid notch
- sup. & inf. horns (cricoid articular facet)
- oblique line (sternothyroideus, thyrohyoideus -
ant.; thyropharyngeus - post. )
- cricoid cartilage: - arch
(hyaline) - lamina
- thyroid articular facet
- arytenoid articular facet
- arytenoid cartilage: - apex & base
(hyaline + elastic) - posterior, medial & anterolateral surfaces
- muscular process
- vocal process (elastic)
- epiglottic cartilage: - lamina
(elastic) - petiolus
- epiglottic tubercle
- corniculate cartilage (of Santorini) (elastic)
- cuneiform cartilage (of Wrisberg) (elastic)
Laryngeal synovial joints: - cricothyroid - around a transverse axis
- cricoarytenoid - around a vertical axis
Laryngeal ligaments and membranes:
- extrinsic: - thyrohyoid membrane (foramen for sup. laryngeal a., v. & n.)
- median thyrohyoid lig.
- lateral thyrohyoid lig. (cartilago triticea)
- hyoepiglottic lig.
- thyroepiglottic lig.
- intrinsic: - quadrangular membrane (aryepiglottic fold - upper border,
vestibular lig. - lower border)
- anterior (median) cricothyroid lig. = lig. conicum !!!
- lat. cricothyroid lig. = cricovocal lig. = conus elasticus
(vocal lig. - upper border)
Laryngeal muscles: - extrinsic: - cricothyroid
- intrinsic: - posterior cricoarytenoid
- lateral cricoarytenoid
- transverse & oblique arytenoid
- aryepiglottic
- thyroarytenoid & vocalis
- thyroepiglottic
Cavity: - inlet (aditus) of larynx: - epiglottis
- aryepiglottic fold (cuneiform & corniculate tubercles)
- interarytenoid notch
- vestibule of larynx
- vestibular (ventricular) fold
- ventricle of larynx - saccule of larynx
- vocal fold (between two vocal folds: rima glottidis or glottis!!!)
- subglottic cavity
Actions of laryngeal muscles:
- alter glottis: - posterior cricoarytenoids - open the glottis
- lateral cricoarytenoids - close the glottis
(intermembranous part)
- transverse & oblique arytenoids - close the glottis
(intercartilaginous part)
- alter tension of vocal ligaments: - cricothyroids - stretch the vocal ligament
- posterior cricoarytenoids - tense the vocal lig.
- thyroarytenoids - relax vocal lig.
- vocalis -relax posteriorly, tense anteriorly
- modify laryngeal inlet: - aryepiglottics - constrict laryngeal inlet
- oblique arytenoids - constrict laryngeal inlet
- thyroepiglottics - widen laryngeal inlet
Movements of the vocal folds: - quiet respiration: intermembranous part - triangular,
intercartilaginous part - rectangular
- forced inspiration: intermembranous part - triangular,
intercartilaginous part - triangular (rhomboid)
- vocalization: vocal folds are adducted, both
intermembranous part and intercartilaginous part
are closed!!!, oscillated by expired air, the
frequency of sound depends on the tension of
vocal folds; amplified or dampened by resonators:
pharynx, nasal & oral cavities; articulatory organs
(teeth, lips, tongue soft palate) modify
- whispering: only intermembranous part is closed!!!
Blood supply: - sup. laryngeal a. & v. (sup. thyroid a. & v.) - above rima glottidis
- inf. laryngeal a. & v. ( inf. thyroid a. & v.) - below rima glottidis
Lymphatic drainage: - deep cervical lymph nodes - above rima glottidis
- pretracheal & paratracheal lymph nodes - below rima glottidis
Innervation of larynx: - superior laryngeal n. (vagus n.)
- internal r.: sensory & secretomotor innervation of mucous
membrane above rima glottidis
- external r.: motor innervation of cricothyroids (extrinsic m.)
- inferior laryngeal n. (= recurrent laryngeal n., vagus n.)
- sensory & secretomotor innervation of mucous membrane
below rima glottidis
- motor innervation of intrinsic muscles of larynx
Clinical anatomy of larynx: - laryngeal obstruction - edema or foreign body - coni(c)otomy
- hoarseness: desiccation and inflammation of vocal folds
- chronic hoarseness: functionless inf. laryngeal n. - tumor,
injury, aortic aneurysm
LUNGS, PLEURAE, ANATOMY OF BREATHING (DIAPHRAGMA, INTERCOSTAL
MUSCLES) (09-27-05, Rekasi)

Trachea - bifurcation of trachea (Th4)


Right & left principal bronchi (right shorter, more vertical, larger - foreign objects)
Lung: apex - base
costal surface - costal impressions
diphragmatic surface
medial surface - mediastinal & vertebral parts
right lung: cardiac impression, groove for azygos v., groove for sup v. cava, groove
for right subclavian a.
left lung: cardiac impression, groove for aorta, groove for left subclavian a., groove
for left brachiocephalic v.
ant. border (cardiac notch & lingula on the left) and inf. border
pulmonary hilum (right: principal bronchus, r. pulmonary a., r. pulmonary vv. (vertical
sequence from above)
(left: l. pulmonary a., l. principal bronchus, l. pulmonary vv. (vertical
sequence from above)
pulmonary lig.: reflection of parietal & visceral pleura
lobes: 3 (right) sup., middle & inf.; - 2 (left) sup. & inf.
obliqua fissure & transverse (horizontal) fissure (latter persists on right lung only!)
bronchopulmonary segment: anatomical, functional, pathological unit
tip is facing to hilum, base is facing to surface
right lung: 3+2+5; left lung: 5+5 segments
in the middle: segmental bronchus, segmental branch of pulmonary a. (carries venous
blood, functional circulation), segmental branches of bronchial a.and v. (nutritive
circulation)
at the periphery: segmental branch of pulmonary vv. (carries arterial blood,
functional circulation)
Right & left pleura: - visceral pleura: adheres to lung surface and interlobar fissures
- parietal pleura: - costovertebral pleura
- diaphragmatic pleura
- mediastinal pleura (mediastinum?!)
- cupula of pleura
- pulmonary lig.: reflexion of parietal pleura & visceral pleura
- pleural cavity

Pleural recesses: reflexions of parietal pleural parts


- costodiaphragmatic recess
(projection: parastern., 7th costal cart.; midclav., 8th rib; midax., 10th
rib; scap., 11th rib; paravert., 12th rib, vertebra Th12)
- costomediastinal recess
- phrenicomediastinal recess

Diaphragm: trifoliate shape


- diaphragmatic attachments: - sternal part
- costal part
- lumbal part: - medial crus
- intermediate crus
- lateral crus (medial & lateral arcuate lig.)
- central tendon
- diaphragmatic apertures:
- central tendon: vena caval foramen (Th 8): inf. v. cava + right phrenic n.
- between med. crura: - aortic hiatus (Th12): thoracic/abdominal aorta + thoracic duct
- esophageal hiatus (Th 10): esophagus + vagus n. (l-front, r-behind)
- between med. & intermediate crura: azygos/hemiazygos v. (asc. lumb. v.) + splanchnic nn.
- between lat. & intermediate crura: sympathetic trunk
- between sternal & costal parts: sternocostal triangle: sup. epigastric a. & v.
- relations: lungs, heart, liver, stomach, spleen, kidneys, suprarenal glands (pancreas, duodenum)
- nerve supply: phrenic nerves (C3-C4-C5, cervical plexus)
- action: the main respiratory muscle
- herniations

Intercostals: - external (pass downward and forward) - raising of ribs


- internal (pass downward and backward ) - lowering of ribs
- innermost (intimus)
- nerve supply: intercostal nn. (= ventral rami of thoracic nerves)

Movements of respiration: - inspiration: diaphragm: vertical diameter of thoracic cage increases


During inspiration, the lowest ribs are fixed, and contraction of the diaphragm draws the central
tendon downwards, the curvature of the diaphragm altered. The cupolae move downwards which
associated with the downward displacement of the abdominal viscera permitted by the extensibility
of the abdominal wall. The limit of extensibility is soon reached. The central tendon, its motion
arrested by the abdominal viscera, then becomes a fix point from which the fibers of the diaphragm
continue to contract. This causes the second to tenth ribs to be elevated. sagittal (pump-handle
movement) and transverse (bucket-handle movement) diameters of thorax are increased. by
movements at costovertebral joints
ext. intercostals., accessory: sternocleidomastoid, scaleni, pectoralis major & minor, serratus ant.
- expiration: passive, recoil of lungs by elastic elements
- active expiration: int. intercostals, abdominal m. draw the ribs down
HISTOLOGY OF THE ORAL CAVITY (Rekasi, 09-26-05)

in general:
mucosa
-epithelium: non-keratinized stratified squamous epithelium (keratinized in gingiva and on
the filiform papillae of dorsal lingual mucosae)
- lamina propria: - loose connective tissue (but gingiva is attached firmly to periosteum with
the exception of its upper free end)
- highly vascularized – red color (gingiva - pink)
submucosa: minor salivary glands
lip
- cutaneous part: keratinized stratified sqamous epithelium with hair follicles, sweat &
sebaceous glands
- intermediate part (rubor labii): thin keratinized stratified squamous epithelium,
no glands, important papillae, color of blood in capillary network refers to the degree of
oxygenisation
- mucous part: non-keratinized stratified sqamous epithelium, seromucous glands
tongue: body– root
dorsal lingual mucosa (papillary part & follicular part)
inferior surface
papillae: filiform – tactile
fungiform – taste
circumvallate – taste (serous gland – of von Ebner)
foliate – taste
taste buds – receptor cells – sustentacular cells – basal cells
4 basic tastes + metallic and umami (monosodium glutamate)
lingual tonsil: not deep crypts
numerous mucous glands
skeletal muscles in 3 different dimensions
salivary glands (merocrine) - minor & major
- major: parotid gland – only serous, well elaborated glandular ducts
submandibular gland – seromucous, more serous secretory units
sublingual gland - seromucous, more mucous secretory units
glandular ducts: - intralobular - intercalated duct (squamous, then cuboidal epithelium)
- striated duct (columnar) - ion exchange (Na+/K+)
- interlobular - excretory duct (pseudostratified)
saliva: 1-1.5L/day, 70% submandibular gland, 25% parotid gland, 5% sublingual gland
glycoproteins, proteoglycans
lysozyme, lactoferrine,
IgA (produced by plasma cells)
amylase
ESOPHAGUS & STOMACH (Rekasi Z., 10-06-2005)

Esophagus
Constrictions (from the incisor teeth, with regard to the passage of instruments):
Cricoid: 15 cm
Aortic: 22.5 cm
Bronchial: 27.5 cm
Diaphragmatic: 40 cm
Skeletal topography:
Commences: C6
Traverses the diaphragm: Th10
Ends: Th11
Syntopy:
Cervical part: anterior: trachea, recurrent laryngeal n. (vagus n.)
posterior: vertebral column
lateral: common carotid a., post. part of thyroid gland
Thoracic part (first in the superior then in the posterior mediastinum):
anterior: trachea, below the bifurcation (Th 4) left atrium of the heart
posterior: vertebral column, thoracic duct, azygos and hemiazygos
veins, aorta (near the diaphragm)
(left) lateral: aortic arch, thoracic duct, recurrent laryngeal n., vagus
n., descending aorta
Abdominal part (covered by peritoneum – gastrophrenic lig.):
anterior: left lobe of the liver, left vagus n.
posterior: left crus of the diaphragm, right vagus n.
Blood supply:
arteries: inf. thyroid a. (subclavian a.), aorta, left gastric a. (coeliac trunk)
veins: inf. thyroid v. (subclavian v.), azygos, hemiazygos v. (sup. v. cava), left gastric v. (v.
coronaria ventriculi) anastomosis between portal and azygos veins
Lymphatic drainage: deep cervical l.n., post. mediastinal l.n.
Innervation: parasympathetic (vagus n.) – sympathetic

Stomach (J or steer-horn shape)


Parts: Cardiac orifice–Body-Fundus (part of the body of the stomach above the level of the cardiac
orifice)-Pyloric part (pyloric antrum and pyloric canal)-pyloric orifice
Lesser and greater curvatures
Anterior and posterior surfaces
Cardiac and angular notches
Skeletal topography (located in the epigastrium and the left hypochondrium):
Cardia: Th11 or 7th costal cartilage 2 cm to the left of the midline
Fundus: left 5th rib
Pylorus: L1 2 cm to the right of the midline (supine body and empty stomach)
Syntopy:
anterior: left (cardia, body along the lesser curvature, part of fundus) and quadrate (pylorus)
lobe of the liver, diaphragm, left costal arch, abdominal wall (? for feeding)!
posterior: left kidney and suprarenal gland, omental bursa, pancreas
(left) lateral: spleen
superior: liver and diaphragm
inferior: transverse colon and mesocolon
Peritoneal relations (intraperitoneal organ)
along the lesser curvature: hepatogastric lig. (part of lesser omentum derived from mesogastrium
ventrale)
along the greater curvature: gastrophrenic (phrenicogastric) and gastrosplenic lig. (derived
from mesogastrium dorsale), greater omentum, gastrocolic lig. (attached to transverse
mesocolon and colon)
Blood supply:
arteries (branches of the coeliac trunk):
to the lesser curvature: right and left gastric a.
to the greater curvature: right and left gastroepiploic a.
fundus: short gastric a.
veins (to portal vein):
from the lesser curvature: right and left gastric v. = v. coronaria ventriculi
from the greater curvature: right and left gastroepiploic v.
Lymphatic drainage:
from the lesser curvature: upper: left gastric n.l. (metastasis to post. mediastinal l.n.
and left supraclavicular l.n. /of Virchow/), lower: pyloric l.n. (metastasis to hepatic
l.n.)
from the greater curvature: upper: pancreaticosplenic l.n., lower: right gastric
l.n.
Innervation: parasympathetic (vagus n.) – sympathetic (from coeliac ggl.)

GENERAL MICROSTRUCTURE OF GI TRACT:


Mucosa
- epithelium mucosae
- lamina propria: connective tissue (glands, vessels, lymphoid follicles, nerve fibers)
- lamina muscularis mucosae: mainly longitudinal smooth m.
Submucosa – loose connective t. (vessels, glands, lymphoid follicles, submucosal /Meissner’s/
plexus)
Muscularis externa – inner circular/outer longitudinal smooth m. (myenteric /Auerbach’s/ plexus)
Serosa (subserosa)/adventitia – visceral peritoneum and/or loose connective tissue -vessels

Esophagus:
Mucosa
- epithelium mucosae: non-keratinized stratified squamous epithelium
- lamina propria: mucous glands only in its upper and lower regions
- lamina muscularis mucosae: well-developed
Submucosa – longitudinal ridges of mucosa- mucous and serous oesophageal glands
Muscularis externa – upper quarter is skeletal, below gradually replaced by smooth muscle
Serosa (subserosa) or adventitia – covered by peritoneum in abdominal part only

Stomach:
Mucosa
- epithelium mucosae: simple columnar mucus secreting epithelium – gastric pits with
surface mucous cells – neutral mucus – protection*
- lamina propria: gastric glands
- cardiac: simple or branched tubular – mucus secreting cells predominate
- principal (in body/fundus): branched tubular – isthmus, neck, base – occupied about 2/3s of the
mucosal depth
- mucous cells: numerous at the neck– acidic mucin – (Golgi apparatus)
- parietal cells: mainly in the apical part – HCl, intrinsic factor of v. B12 (intracellular canaliculi,
tubulo-vesicular system, microvilli – H+/K+ ATPase antiporter channels, abundant mitochondria)
- chief (zymogen) cells: predominate at the base - pepsinogen – abundant citoplasmic RNA in
endoplasmic reticulum – basophilic
- stem cells: undifferentiated mitotic cells – replacement of other cells (surface mucous secreting
cells have limited lifespan – about 3 days)
- neuroendocrine cells: G-cells – gastrin; D-cells – somatostatin; ECL-cells-histamine
- pyloric: simple convoluted tubular - occupied about 1/3 of the mucosal depth - mucus secreting
cells predominate
- lamina muscularis mucosae: third external circular layer of smooth m.
Submucosa
Muscularis externa – inner oblique, middle circular, outer longitudnal smooth m.
Serosa (subserosa) or adventitia – peritoneum covers the entire surface except at the attachment of
ligaments along the curvatures

* Press Release: The 2005 Nobel Prize in Physiology or Medicine


3 October 2005
The Nobel Assembly at Karolinska Institutet has today decided to award
The Nobel Prize in Physiology or Medicine for 2005
jointly to
Barry J. Marshall and J. Robin Warren
for their discovery of
"the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease"