Anatomy of larynx, trachea and bronchial tree

Susan Baker CT2 Anaesthetics

Structure of presentation

Larynx
Surface anatomy Cartilages Membranes / ligaments Muscles Innervation and blood supply Changes with age

Trachea Bronchial tree

The larynx

Larynx surface anatomy

Thyroid cartilage (C4) Cricoid cartilage (C6)

Larynx surface anatomy

C3 - Hyoid C4 - Thyroid C6 - Cricoid

Laryngeal cartilages

3 unpaired
Epiglottis Thyroid Cricoid

3 paired
Arytenoid Cuneiform Corniculate

Epiglottis
Superior border of the larynx (C3) Leaf shaped

Thyroid
Largest of laryngeal cartilages C4-5 level

Superior horn Superior thyoid notch

Laryngeal prominence
Inferior horn

Cricoid
Signet ring shaped (widest posteriorly) Only complete tracheal ring

Arytenoid
Sit on top of cricoid Key site of attachment of intrinsic muscles

Cuneiform and corniculate cartilages

Cuneiform and corniculate cartilages at laryngoscopy

Cricothyroid ligament
Joins outer edge of cricoid to anterior thyroid cartilage and arytenoids Superior border forms the vocal cords

Quadrangular membrane

Forms the false vocal cords / vestibular folds

Intrinsic muscles

Key role in controlling vocal cords (and laryngeal inlet):

Abduction Adduction Tensing

Protective mechanisms (important in cough reflex) Role in deep breathing Valsalva Phonation

Muscles cont...
Muscle Cricothyroid Post. cricoarytenoid Lat cricoarytenoid Transverse arytenoid Oblique arytenoid Vocalis Thyroarytenoid Function Tenses vocal cords Abducts arytenoids and thus cords Adducts arytenoids and thus cords Adducts arytenoids and thus cords Narrows inlet by pulling arytenoids together Increases thickness of cords Narrows inlet Innervation Superior* Recurrent** Recurrent Recurrent Recurrent Recurrent Recurrent

* External laryngeal nerve, a branch of the superior laryngeal nerve ** Recurrent laryngeal nerve

Innervation

Sensory
Above epiglottis is glossopharyngeal (including valecula) Internal laryngeal nerve (branch of superior laryngeal nerve above vocal cords Recurrent laryngeal nerve below cords

Motor
Cricothyroid external laryngeal nerve (branch of superior) Others recurrent laryngeal nerve

Recurrent Laryngeal Nerve

Superior Laryngeal Nerve

Blood supply
Superior laryngeal artery, a division of the superior thyroid artery (branch of external carotid) Inferior laryngeal artery, a division of the inferior thyroid artery (branch of thyrocervical trunk) The arteries travel alongside the nerves

Differences with young age

Head and pharynx

Larger head with more prominent occiput Large tongue, so obligate nasal breathers

Larynx
Higher C2 to C3 (normally C4) Greater angulation, so appears more anterior Narrower U shaped epiglottis Cricoid is narrowest part of trachea, and being a complete cartilaginous circle, pressure at this point may easily lead to tissue necrosis

Trachea
Short trachea increases risk of accidental endobronchial or extubation

Trachea
12cm in length, 1.6 - 2cm diameter Descends from C6 to T4 15-20 incomplete cartilaginous rings, bordered by trachealis posteriorly Bifurcation angle <90 (>90 classically suggests mitral stenosis) Percutaneous and surgical tracheostomies are typically performed between 2nd and 3rd rings

The carina

Tracheobronchial tree
23 generations of divisions First 16 generations contribute to anatomical deadspace The right main bronchus is 1-2mm wider than the left, and angled more inferiorly The right upper lobar bronchus is extrapulmonary, all others arise intrapulmonarily

Tracheobronchial tree

Questions...