USLS COLLEGE OF MEDICINE b) Quadrangular

E. Laryngeal Folds
ANATOMY 1. Vocal or True
2. Vestibular or False
F. Laryngeal Muscles
Upper Respiratory Tract 1. Extrinsic
DATE: 11/04/20 a) Suprahyoid
LECTURER: Trinidad, MD (1) Stylohyoid
(2) Digastric
(3) Mylohyoid
(4) Geniohyoid
I. NOSE b) Infrahyoid
A. External Nose (1) Omohyoid
1. Muscles (2) Sternohyoid
a) Procerus (3) Thyrohyoid
b) Nasalis (4) Sternothyroid
c) Depressor Septi Nasi (5) Stylopharyngeus
2. Blood Supply 2. Intrinsic
3. Venous Drainage a) Cricothyroid
4. Lymphatic Drainage b) Thyroarytenoid
B. Nasal Cavity c) Posterior cricoarytenoid
1. Divisions d) Lateral cricoarytenoid
2. Nasal Conchae e) Transverse and Oblique arytenoids
3. Opening and Gateways f) Thyroepiglottic
4. Nerve Supply G. Arterial Supply
5. Arterial Supply H. Venous Drainage
6. Venous Drainage I. Nerve Supply
7. Lymph Drainage III. TRACHEOBRONCHIAL TREE
C. Paranasal Sinuses A. Trachea
1. Frontal 1. Anatomical Position
2. Sphenoid 2. Neurovascular Supply
3. Ethmoid B. Bronchi
4. Maxillary 1. Neurovascular Supply
II. LARYNX C. Bronchioles
A. Anatomical Structures
B. Cartilages
1. Unpaired
a) Thyroid
b) Cricoid
c) Epiglottis ● visible component of face, projecting over and allowing
2. Paired entrance into nasal cavity
a) Arytenoid ● have a pyramidal shape
b) Corniculate ● parts:
c) Cuneiform ○ Nasal Root
C. Joints ■ located superiorly
1. Cricothyroid ■ continuous with
2. Cricoarytenoid forehead
D. Membranes and Ligaments ○ Apex of the Nose
1. Extrinsic ■ ends inferiorly in a
a) Thyrohyoid rounded ‘tip’
(1) Median ○ Dorsum of the Nose
(2) Lateral ■ between root and apex
b) Hyo-epiglottic ○ Nares
c) Cricotracheal ■ immediately inferiorly to apex
d) Median cricothyroid ■ piriform openings into vestibule of nasal cavity
2. Intrinsic ■ bounded:
a) Cricothyroid ● medially​ - nasal septum

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ● laterally ​- ala nasi (lateral cartilaginous wings of
nose) Clinical Notes:​ (​ not included in the lecture)
○ Philtrum Danger Triangle of the Face
■ groove between nasal septum all the way down the ● venous drainage of the nose and surrounding area - unique as a result of
upper border of the lip communication between the facial vein and cavernous sinus via ophthalmic
○ Alar Nasal Sulcus vein
■ lateral boundary of ala nasi ● as cavernous sinus lies within the cranial cavity: enables infections from nasal
○ Nasolabial Fold area to spread to brain
○ retrograde spread of infection - cause cavernous sinus thrombosis,
■ important landmark to understand symmetries of
meningitis or brain abscess
face
■ note: different from alar nasal sulcus
Clinical Notes:​ ​(not included in the lecture)
Saddle Nose Deformity ● superficial lymphatic vessels​ - along facial veins
● occurs primarily as a result of nasal trauma ○ drain into deep cervical lymph nodes
● septal support to the nose is lost, and subsequently the middle part of the nose
appears sunken
○ either a result of direct damage to the septal bone or cartilage, or a
consequence of nasal septal haematoma ● sensory innervation - ​trigeminal nerve (CN V) ​has ​3 major
● as cartilage has no blood supply of its own -> relies on oxygen and nutrients branches:
diffusing from blood vessels in the surrounding perichondrium ○ external nasal nerve (CN V1) - supplies ​bridge and ​apex of
● haematoma between these two structures -> destruction of the septum =
the external nose
deformity of the nose
○ infraorbital nerve (CN V2) - supplies the ​lateral sides of
nose
○ CN V3
● insert into external nose ● motor innervation - nasal muscles of facial expression is via
contributing to facial facial nerve (CN VII)
expression
● all are innervated by ● most superior part of the respiratory tract
branches of ​facial nerve (CN ● nose - olfactory and respiratory organ
VII) ● consists of nasal skeleton - houses the ​nasal cavity
1. Procerus ○ has 4 functions:
● O: fascia overlying the ■ Warms and humidifies the inspired air
nasal bone and lateral ■ Removes and traps pathogens and particulate matter
nasal cartilage from the inspired air
● I: inferior forehead ■ Responsible for sense of smell
● A: ■ Drains and clears the paranasal sinuses and lacrimal
○ depress the medial ducts
eyebrows
○ wrinkles the skin of the superior dorsum
○ brings down muscle to the forehead ● extends from the
○ assists Nasalis in flaring or enlargement of the naris vestibule of the nose to
2. Nasalis the nasopharynx, and has
● transverse part - assist Procerus 3 divisions:
● alar part ● Nasal vestibule -
○ O: maxilla surrounding the anterior
○ I: major alar cartilage external opening to the
● A: main driver for dilating or flaring or enlargement of the nasal cavity
naris ○ has hair follicles
○ assisted by Depressor septi nasi ○ Limen nasi ​- border
3. Depressor Septi Nasi ● Respiratory region
● small muscle inserting into septum internally ○ lined by ciliated
● as it pulls down the nostrils -> creates a tightening or psudeostratified
constrict the aperture of anterior naris epithelium,
interspersed with mucus-secreting goblet cells
○ lamina propia with many BVs - for warming of the air
● skin of the external nose - ​facial artery -> branches to ​angular ● Olfactory region​ – at the apex of the nasal cavity
artery​ and ​lateral nasal artery​ as it goes over the ala nasi ○ lined by olfactory cells with ​olfactory receptors

● skin of the nose - ​facial vein​ -> ​internal jugular vein

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ● Lateral wall
○ Superior meatus
■ posterior ethmoidal sinus
■ sphenoethmoidal recess
○ Middle meatus
■ sphenopalatine foramen - ​allows communication
between the nasal cavity and the pterygopalatine
fossa
■ paranasal sinuses’ drainage (semilunar hiatus) ​-
drain into the nasal cavity
■ ethmoidal bulla - bulge in the lateral wall formed by
middle ethmoidal sinus
○ Inferior meatus
■ nasolacrimal duct -​ drain tears from the eye
■ auditory or eustachian tube ​- allows middle ear to
equalise with atmospheric air pressure
■ incisive canal - pathway between the nasal cavity and
the incisive fossa of the oral cavity
● transmits nasopalatine nerve and greater
● conchae or ​turbinate - projecting out of the lateral walls of the palatine artery
nasal cavity are curved shelves of bone
○ 3 conchae – inferior, middle and superior
○ project into the nasal cavity creating 4 ​pathways or 1. Olfactory nerves (CN II) -
meatuses​ for the air to flow special sensory
■ Inferior meatus – between inferior concha and floor innervation (ability of nose
of the nasal cavity to smell)
■ Middle meatus​ – between inferior and middle concha ○ branches: run
■ Superior meatus – between middle and superior through the
concha cribriform plate to
■ Spheno-ethmoidal recess – superiorly and posteriorly provide special
to the superior concha sensory innervation
● function of the conchae: to the nose
○ increase the surface area of the nasal cavity –> increases 2. Nasopalatine nerve
the amount of inspired air that can come into contact with (branch of maxillary nerve) and ​nasociliary nerve (branch of the
the cavity walls ophthalmic nerve) - general sensory to ​internal (​septum and
○ disrupt the fast, laminar flow of the air -> making it slow lateral walls)
and turbulent 3. Trigeminal nerve (CN V) - general sensory to ​external skin of
the nose
■ air spends longer in the nasal cavity so that it can be
humidified 4. Facial nerve (CN VII) - parasympathetic to glands of respiratory
epithelium

1. Internal carotid artery

● branches​:
○ Anterior ethmoidal artery
○ Posterior ethmoidal artery
■ ethmoidal arteries - branch of the ophthalmic
artery
● descend into the nasal cavity through the
cribriform
plate
2. External carotid artery
● Medial wall ● branches:
○ superior - ​ethmoid ○ Sphenopalatine
○ postero-inferior - ​palatine​, ​crest​ and​ medial projections artery
○ inferior - ​vomer​, ​maxilla​ and ​crest ○ Greater palatine
○ septal cartilage - site of anastomoses of branches of artery
internal and external carotid arteries that supply the nose ○ Superior labial artery
○ Lateral nasal arteries

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ● form anastomoses with each other ○ anterior ethmoidal artery - branch of the
○ prevalent in the anterior portion of the nose internal carotid
2. Sphenoid Sinuses
● tend to follow the arteries ● within the body of the sphenoid bone
● drain into: ● drainage:
○ pterygoid plexus ○ open out into the nasal cavity in an area
○ facial vein supero-posterior to the superior cocha
○ cavernous sinus “spheno-ethmoidal recess”
● in some individual: few nasal veins join with the sagittal sinus (a ● nerve supply:
dural venous sinus) ○ posterior ethmoidal nerve - branch of the
○ represents a potential pathway by which infection can ophthalmic nerve
spread from the nose into the cranial cavity ○ branches of the ​maxillary nerve
● arterial supply:
Clinical Notes:​ (not included in the lecture)
○ pharyngeal branches of the maxillary arteries
Spread of Infection
● as the auditory tube connects the middle ear and upper respiratory tract ->
3. Ethmoidal Sinuses
path by which infection can spread from the upper respiratory tract to the ear ● divided into 3:
● infection of the auditory tube -> swelling of the mucous linings, and the tube ○ Anterior – opens onto the ​hiatus semilunaris
becomes blocked = diminished hearing (middle meatus)
Epistaxis ○ Middle – opens onto the lateral wall of the
● medical term for a nosebleed middle meatus
● rich blood supply of the nose - common occurrence ○ Posterior – opens onto the lateral wall of the
● most likely to occur in the anterior third of the nasal cavity “ Kiesselbach area”
superior meatus
● cause can be local (trauma) or systemic (hypertension)
Cribriform Plate Fracture
● nerve supply:
● can occur as a result of nose trauma ○ anterior and posterior ethmoidal branches of
○ either fractured directly by the trauma, or by fragments of the ethmoid the ​nasociliary nerve
bone ○ maxillary nerve
● can penetrate the meningeal linings of the brain -> leakage of cerebro-spinal ● arterial supply:
fluid ○ ​anterior and posterior ethmoidal arteries
○ exposing the brain to the outside environment -> increases the risks of 4. Maxillary Sinuses
meningitis, encephalitis and cerebral abscesses
● largest​ of the sinuses
● olfactory bulb - lies on the cribriform plate and can be damaged irreversibly by
the fracture ● laterally and slightly inferiorly to the nasal cavities
○ may present with anosmia (loss of smell) ● drainage:
○ nasal cavity at the hiatus semilunaris,
underneath the frontal sinus opening
○ potential pathway for spread of infection – fluid
● air-filled extensions of the nasal cavity draining from the frontal sinus can enter the
● lined by a ​ciliated ​pseudostratified epithelium​, interspersed maxillary sinus
with ​mucus-secreting goblet cells
● formed during development by the nasal cavity eroding into the
surrounding bones
● function​:
○ lightening the weight of the head
○ supporting immune defence of the nasal cavity
○ humidifying inspired air
○ increasing resonance of the voice
● 4 paired sinuses:
1. Frontal Sinuses
● within the frontal bone of the skull
○ most superior​ of the paranasal sinuses
● triangular in shape
● drainage:
○ via the frontonasal duct
○ opens out at the hiatus semilunaris, within the Clinical Notes:​ (​ not included in the lecture)
middle meatus of the nasal cavity Transsphenoidal Surgery
● sphenoid bone - shares a close anatomical relationship with the pituitary
● nerve supply: gland
○ supraorbital nerve - branch of the ophthalmic ○ pituitary - accessed surgically by passing instruments through the
nerve sphenoid bone and sinus “endoscopic trans-sphenoidal surgery (ETSS)”
● arterial supply: ■ usual treatment of choice for pituitary adenomas

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ■ allows for the surgical management of pituitary pathology without
the need for a more extensive craniotomy
Sinusitis
● as the paranasal sinuses are continuous with the nasal cavity -> upper 1. Thyroid Cartilage
respiratory tract infection can spread to the sinuses ● large, prominent structure -> easily visible in adult males
○ infection of the sinuses - causes inflammation (particularly pain and ● composed of 2 sheets (laminae)
swelling) of the mucosa “sinusitis” ○ anteriorly - form the laryngeal prominence (Adam’s
○ more than one sinus is affected: “pansinusitis”
apple)
● maxillary nerve - supplies both the maxillary sinus and maxillary teeth ->
inflammation of that sinus can present with toothache
○ posterior - project superiorly and inferiorly to form
the superior and inferior horns or cornu
■ superior horns - connected to the hyoid bone via
the lateral thyrohyoid ligament
● “voice box” ■ inferior horns - articulate with the cricoid
● in the ​anterior compartment of the neck, suspended from the cartilage
hyoid bone (​C3 - C6​) 2. Cricoid Cartilage​ - elastic
● relations: ● complete ring of hyaline cartilage
○ inferiorly​ - ​trachea ○ only complete circle of cartilage in the larynx or
○ superiorly​ - opens into laryngeal part of the ​pharynx trachea
○ anteriorly​ - covered by ​infrahyoid​ muscles ● completely encircles the airway
○ posterior​ - ​esophagus ○ marking the inferior border of the larynx at C6
○ laterally​ - lobes of the​ thyroid gland ● consists of:
● component of the respiratory tract ○ posterior​ - broad sheet
● important ​functions​: ○ anterior​ - much narrower arch (signet ring in shape)
○ phonation ● articulates with paired arytenoid cartilages posteriorly
○ cough reflex ● provides an attachment for the inferior horns of the
○ protection of the lower respiratory tract thyroid cartilage
● primarily cartilaginous 3. Epiglottis ​ - elastic
● held together by a series of ligaments and membranes ● leaf shaped​ plate of elastic cartilage
● internally: laryngeal muscles move components of the larynx ○ marks entrance to the larynx
for phonation and breathing ● ‘stalk’ - attached to the back of the anterior aspect of the
thyroid cartilage
Clinical Notes:​ ​(not included in the lecture) ● during swallowing: flattens and moves posteriorly to close
● during emergency intubation: as pressure can be applied to the cricoid
cartilage of the larynx to occlude the esophagus -> prevent regurgitation of
off the larynx and ​prevent aspiration
gastric contents “cricoid pressure or Sellick’s manoeuvre”

● internal cavity divided into 3 sections:

1. Supraglottis
● inferior surface of the
epiglottis to the vestibular
folds (false vocal cords)
2. Glottis ● situated bilaterally in
● contains vocal cords and the larynx
1cm below them 1. Arytenoid Cartilages
● opening between the vocal - hyaline
cords - ​rima glottidis (size of ● major
which is altered by the cartilaginous
muscles of phonation) structure
3. Subglottis ● pyramidal
● inferior border of the glottis shaped
to the inferior border of the structures that
cricoid cartilage sit on the cricoid cartilage
● interior surface of the larynx - lined by ​pseudostratified ciliated ● consist of: apex, base, 3 sides and 2 processes
columnar epithelium ● provides an attachment point for various key structures in
○ exception: true vocal cords - lined by a ​stratified the larynx:
squamous epithelium ○ Apex​ – articulates with the corniculate cartilage
○ Base – articulates with the superior border of the
cricoid cartilage

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ○ Vocal process – provides attachment for the vocal
ligament ● holds cartilages of the larynx together as one functional unit
○ Muscular process – provides attachment for the internally
posterior and lateral cricoarytenoid muscles 1. Cricothyroid ligament
2. Corniculate Cartilages​ - elastic ○ originates from
● minor cartilaginous structures the cricoid
● articulate with the apices of the arytenoid cartilages cartilage
3. Cuneiform Cartilages​ - elastic ○ extends
● within the aryepiglottic folds superiorly where
● no direct attachment it terminates
● strengthen the folds with an ​free
(unattached)
● 2 pairs of synovial joints: upper margin ->
○ cricothyroid joint - between ​inferior cornu of thyroid forms ​vocal
cartilage​ and​ lateral side of the cricoid cartilage ligament
○ cricoarytenoid joint - between ​base of the arytenoid ○ relations​:
cartilage​ and ​superior border of lamina of cricoid cartilage ■ anteriorly​ - ​thyroid​ cartilage
■ helps with changing the tension of vocal cords ■ posteriorly​ - ​arytenoid​ cartilage
● each joint allows multiaxial movements of rotation and gliding 2. Quadrangular membrane
○ movements occur simultaneously or independently ○ between anterolateral arytenoid cartilage and lateral
aspect of the epiglottis
○ has a free upper margin and lower margi
● laryngeal membranes and ligaments - support cartilaginous ■ lower margin thickened to become ​vestibular
skeleton of larynx ligament
Clinical Notes:​ (not included in the lecture)
● attach components of the larynx to external structures (eg. Cricothyroidotomy
hyoid and cricoid cartilage) ● an emergency procedure to provide a temporary airway
1. Thyrohyoid membrane ● used in situations where there is an obstruction at or above the larynx
○ between superior aspect of thyroid cartilage and (e.g foreign body, angioedema or facial trauma), and intubation has been
hyoid bone unsuccessful
○ pierced laterally by the ​superior laryngeal vessels and ● to perform the technique: thyroid cartilage is palpated in the neck –
below which there is a depression representing the cricothyroid ligament
internal laryngeal nerve (branch of the superior ○ small incision is made in the midline of this ligament
laryngeal nerve) ○ endotracheal tube is inserted to secure the airway
a. Median thyrohyoid ligament
■ anteromedial​ thickening of the membrane
b. Lateral thyrohyoid ligaments
■ posterolateral​ thickenings of the membrane ● crucial role in protection
2. Hyo-epiglottic ligament of the airway, breathing,
○ connects hyoid bone to anterior aspect of the and phonation
epiglottis ● 2 important soft tissue
3. Cricotracheal ligament folds located within the
○ connects cricoid cartilage to trachea larynx
4. Median cricothyroid ligament 1. Vocal Fold
○ anteromedial thickening of the cricothyroid ligament ● true vocal
○ connects thyroid and cricoid cartilages cords - more
important
● * ​avascular ->
white​ in colour
● space between
the vocal folds -
rima glottidis
● under control of the muscles of phonation:
○ abducted
○ adducted
○ relaxed and tensed to control the pitch of the
sound created
● histologically (superficial to deep)
○ Non-keratinised stratified squamous epithelium

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ■ stratified layer - provides extensive ○ Branches of the ​occipital artery
protection against foreign bodies which ○ Branches of the ​lingual artery
may accidentally enter the larynx 1. STYLOHYOID - thin muscular strip superiorly to the
○ Reinke’s space posterior belly of the digastric muscle
■ watery, amorphous layer - rich in ● O: styloid process of the​ temporal bone
glycosaminoglycans ● I: lateral aspect of the hyoid bone
■ due to its fluidity -> epithelium is able to ● N: Stylohyoid branch of the facial nerve (CN VII)
vibrate freely arises proximally to the parotid gland
○ Vocal ligament ● A: initiates swallowing action by pulling the hyoid
■ lies at the free upper edge of the bone in a posterior and superior direction
cricothryoid ligament 2. DIGASTRIC - ​consists of 2 muscular bellies connected by a
○ Vocalis muscle tendon (in some cadavers: this tendon can be seen to
■ exceptionally fine muscle fibres that lie pierce the stylohyoid muscle)
lateral to the vocal ligaments ● O:
2. Vestibular Folds ○ anterior belly​: digastric fossa of mandible
● False vocal cords ○ posterior belly: ​mastoid process of temporal
● lie superiorly to the bone
true vocal cords ● I: 2 bellies are connected by an intermediate
● consist of: tendon attached to the hyoid bone via a fibrous sling
○ vestibular ● N:
ligament (free ○ anterior belly​: inferior alveolar nerve - branch of
lower edge of the mandibular nerve (derived from the
the quadrangular membrane) - covered by a trigeminal nerve,​ CN V​)
mucous membrane ○ posterior belly: digastric branch of the facial
○ *​vascular​ -> ​pink​ in color nerve
● fixed folds -> provide protection to the larynx ● A: Depresses the mandible and elevates the hyoid
bone
3. MYLOHYOID - broad, triangular shaped muscle, forms
floor of the oral cavity and supports floor of the mouth
● O: Mylohyoid line of the mandible
● I: Hyoid bone
● N: Inferior alveolar nerve - branch of the
mandibular nerve (which is derived from the
trigeminal nerve
● A: Elevates hyoid bone and floor of the mouth
4. GENIOHYOID - ​close to the midline of the neck, deep to
the mylohyoid muscle
● O: Inferior mental spine of the mandible
● I: Hyoid bone
● N: C1 nerve roots - run within ​hypoglossal nerve
● A: Depresses mandible and elevates hyoid bone
● elevate or depress the larynx​ during swallowing Infrahyoid Muscles
● SUPRAHYOID​ and ​INFRAHYOID​ - both attach to the ​hyoid bone ● inferiorly to the
○ bound to the larynx by strong ligaments hyoid bone in the
■ allowing the whole of the larynx to be moved as one neck
unit ● arterial supply:
● note: ○ superior and
○ SUPRAHYOID​ & ​STYLOPHARYNGEUS​ - ​elevate​ the larynx inferior
○ INFRAHYOID​ - ​depress​ the larynx thyroid
Suprahyoid Muscles arteries
● superior to the hyoid ● divided into 2
bone​ of the neck groups:
● elevate​ the hyoid bone ○ Superficial plane​ – omohyoid and sternohyoid muscles
○ action involved in ○ Deep plane​ – sternothyroid and thyrohyoid muscles
swallowing Superficial:
● arterial supply: 1. OMOHYOID MUSCLE - thin muscular strip located
○ Branches of the superiorly​ to the posterior belly of the digastric muscle
arterial artery ● O:

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: T​EACH​ M​E​ A​NATOMY
 ○ Inferior belly​: ​scapula the ​superior laryngeal nerve (derived from the vagus
○ Superior belly​:​ clavicle by the deep cervical nerve)
○ fascia 1. CRICOTHYROID - ​stretches and tenses the vocal ligaments
● I: ● important in creation of forceful speech
○ Inferior belly​: runs superomedially underneath ● also has a role in altering the tone of voice (along
the sternocleidomastoid muscle with the thyroarytenoid muscle) -> ‘singer’s muscle’
○ Superior belly:​ hyoid bone ● O: anterolateral aspect of cricoid cartilage
● N: Anterior rami of C1-C3 - carried by a branch of ● I: inferior margin and inferior horn of thyroid
the ansa cervicalis cartilage
● A: Depresses​ hyoid bone ● N: External laryngeal nerve
2. STERNOHYOID MUSCLE ● A: Stretches and ​tenses vocal ligament
● O: sternum and sternoclavicular joint 2. THYROARYTENOID
● I: hyoid bone ● O: Inferoposterior aspect of the angle of thyroid
● N: Anterior rami of C1-C3 - carried by a branch of cartilage
the ansa cervicalis ● I: anterolateral part of arytenoid cartilage
● A: Depresses​ hyoid bone ● N: Inferior laryngeal nerve
Deep​: ● A: Relaxes vocal ligament
1. THYROHYOID MUSCLE - ​short band of muscle, 3. POSTERIOR CRICOARYTENOID - sole abductors of the
continuation of the sternothyroid muscle vocal folds -> only muscle capable of widening the rima
● O: thyroid cartilage of the larynx glottidis
● I: hyoid bone ● O: posterior surface of cricoid cartilage
● N: Anterior ramus of C1 - carried within the ● I: muscular process of arytenoid cartilage
hypoglossal nerve ● N: Inferior laryngeal nerve
● A: Depresses​ hyoid ● A​: ABDUCTS​ vocal folds
○ If hyoid bone is fixed: can elevate larynx 4. LATERAL CRICOARYTENOID - major adductors of the vocal
2. STERNOTHYROID MUSCLE - ​wider and deeper than the folds
sternohyoid, located within the deep plane ● narrows the rima glottidis, modulating the tone and
● O: manubrium of the sternum volume of speech
● I: thyroid cartilage ● O: arch of the cricoid cartilage
● N: Anterior rami of C1-C3 - carried by a branch of ● I: muscular process of the arytenoid cartilage
the ansa cervicalis ● N: Inferior laryngeal nerve
● A: Depresses​ thyroid cartilage ● A: Adducts the vocal folds
5. TRANSVERSE AND OBLIQUE ARYTENOIDS - ​adduct the
STYLOPHARYNGEUS arytenoid cartilages, closing the posterior portion of rima
● O: Medial base of styloid process of ​temporal bone glottidis -> narrows the laryngeal inlet
● I: Blends with pharyngeal constrictors, lateral ● O & I​: from one arytenoid cartilage to the opposite
glossoepiglottic fold, posterior border of thyroid arytenoid
cartilage ● N: Inferior laryngeal nerve
● N: Glossopharyngeal nerve ● A: Adducts arytenoid cartilages
● A: Elevates​ pharynx and larynx 6. THYROEPIGLOTTIC
● A: widens inlet (aryepiglottic folds)
● control shape of the
rima glottidis 1. Superior laryngeal artery
(opening between ● branch of the superior thyroid artery
the vocal folds and ○ derived from the external carotid
the arytenoid ● follows the internal branch of the superior laryngeal nerve
cartilages) and length into the larynx
and tension of the ● Inferior laryngeal artery
vocal folds ○ branch of the inferior thyroid artery
● all (except the ■ derived from the thyrocervical trunk
cricothyroid) - ○ follows the recurrent laryngeal nerve into the larynx
innervated by the inferior
laryngeal nerve (terminal ● Superior laryngeal vein - drains to the internal jugular vein via
branch of the recurrent the superior thyroid
laryngeal nerve, a branch of ● Inferior laryngeal vein - drains to the left brachiocephalic vein
the vagus nerve) via the inferior thyroid vein
○ cricothyroid - innervated
by the external branch of

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ● receives motor and sensory
innervation via branches of the
● marks the beginning of the tracheobronchial tree
vagus nerve:
● arises at ​C6 - lower border of ​cricoid cartilage ​as continuation
○ sensory
of the larynx
■ Recurrent laryngeal
● ends​ at ​T4-T5​ - superior mediastinum and carina
nerve
● relations:
● infraglottis
○ anterior:
■ internal branch of
■ thyroid isthmus
Superior laryngeal
■ inferior thyroid veins
nerve
■ thyroidea ima
● supraglottis
■ sternothyroid and sternohyoid muscles
○ motor
■ jugular arch
■ Inferior laryngeal nerve
■ right common carotid artery
- terminal branch of
■ ascending arota
recurrent laryngeal
○ posterior​:
nerve - ​internal muscles
■ esophagus
of larynx except
■ vertebral column
cricothyroid
○ lateral:
■ external branch of Superior laryngeal nerve ​-
■ thyroid lobes
cricothyroid
■ inferior thyroid artery
Clinical Notes: ■ left common carotid artery
Vocal Cord Paralysis ■ recurrent laryngeal nerves
● vocal cords - responsible for the production of speech ■ vagus nerve
○ movement is controlled by the ​intrinsic muscles of the larynx
■ majority - ​innervated​ by the ​recurrent laryngeal nerve
● susceptible to damages due to its long course ● C-shaped rings
■ an exception: cricothyroid muscle - innervated by the external ○ trachea is held open by this cartilage
laryngeal ● Trachealis Muscle
nerve ○ supports the free ends of C-shaped rings
● Causes of ​RLN palsy​: ● Goblet Cells
○ Apical lung tumour
○ Thyroid cancer
○ interspersed the ciliated ​pseudostratified columnar
○ Aortic aneurysm epithelium​ lining of the trachea and bronchi
○ Cervical ○ produces mucus
lymphadenopathy ● Mucociliary Escalator
○ Iatrogenic - ○ formed by the combination of sweeping movements by
particularly during the cilia and mucus from goblet cells
thyroid surgery due to the close relationship with the inferior thyroid ○ trap inhaled particles and pathogens, moving them up out
artery of the airways to be swallowed and destroyed.
● in unilateral RLN palsy: one vocal cord is paralysed
○ other vocal cord tends to compensate, and speech is not affected to a
● Carina
great degree, although the patient may experience hoarseness of voice ○ at the bifurcation of the primary bronchi
● in bilateral palsy: both vocal cords are paralysed in a position between ○ ridge of cartilage that runs anteroposteriorly between the
adduction and abduction openings of the two bronchi
○ Breathing is impaired, and phonation cannot occur ○ most sensitive area of the trachea-triggers cough reflex
● in where nerves are only partially damaged: vocal folds become paralysed in ○ seen on bronchoscopy
a fully adducted position
○ if occurs bilaterally: rima glottidis (space between the vocal cords) is
completely closed, and emergency surgical intervention is required to ● Inferior Thyroid Artery - ​tracheal arteries
restore the airway ● Superior and Middle Bronchial Artery
● Brachiocephalic, Azygos and Accessory Hemiazygos Veins -
venous drainage
● system of airways that allow passage of air into lungs ● Recurrent Laryngeal Nerve - ​sensory innervation
● where gas exchange occurs
● located in the neck and thorax ● main bronchi branch further
● consist of: into secondary bronchi
○ trachea ● supplies a lobe of the lung
○ bronchi ● gives rise to segmental
○ bronchioles bronchi

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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● branches of pulmonary artery and veins + main bronchi = ​roots Clinical Notes:
of the lungs A boy swallowed a
● Right Main Bronchus - ​starts at ​T5​ (higher) coin. Is it in the
Esophagus or the
Trachea​? Why?
● answer: it is in
the ​Esophagus
○ trachea
is not a
full circle
of
cartilage
-> a C-ring
○ open end of the C of the C-ring cartilage of the trachea faces your back
○ find the C below
● in normal anatomy (from the chest to back): trachea (which leads to the
lungs ahhh AIR) sits on top of the esophagus (which leads to the stomach
ahhh food)
● with almost 100% certainty a large coin will follow the path of least
resistance if it happens to go down your esophagus
● in the esophagus (like in this patient): face of the coin will sit flat against the
flatter C-ring portion of the abutting trachea just like below
○ an xray from the front to the back and from side to side - it will look
like the figure on top
○ wider​, ​shorter​ and descends more vertically ● in the trachea: coin in the xrays (above) will be switched
○ results in a higher incidence of foreign body inhalation ○ it will sit end to end on the front to back view (AP) of the chest x-ray
○ where right superior lobar bronchus arises
● Left Main Bronchus ​- starts at ​T6
○ narrow​, ​longer
○ passes inferiorly to the arch of aorta
○ anteriorly to the thoracic aorta and esophagus in order to
reach the hilum of the left lung
● Cartilage Rings
○ main bronchi​ - completely encircle the lumen
○ smaller lobar and segmental bronchi​ - crescent shapes

● Bronchial Arteries - ​arterial supply

● Bronchial Veins - ​venous drainage
● Vagus Nerve (CN X) - ​innervation

● numerous smaller airways resulted from further branching of

the segmental bronchi

● do not contain any cartilage or goblets cells Asthma ​(not included in the lecture)
● Club Cells ● chronic inflammatory
○ produce a surfactant lipoprotein which prevents sticking of disorder of the airways
● characterised by
walls during expiration
hypersensitivity,
● Conducting Bronchioles reversible outflow
○ transport air but lack glands obstruction and
○ not involved in gas exchange bronchospasm
○ end as ​terminal bronchioles ● remodelling of the
■ branch further into ​respiratory bronchioles small airways -> increased smooth muscle thickness around the bronchioles,
● presence of alveoli extending from their lumens damaged epithelium and a thickened basement membrane
● Alveoli ● “Asthma attacks” - acute exacerbations of the condition whereby a trigger
(e.g. allergens, exercise) causes sudden inflammation and contraction of the
○ tiny air filled pockets with thin walls (simple squamous
smooth muscle around bronchioles (bronchospasm)
epithelium) ○ narrows the airways -> difficulty in breathing and wheezing
○ sites of gaseous exchange in the lungs (characteristic feature of asthma)
○ adult lungs​: 300 million alveoli

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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End of Transcription

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
11
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