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Lierature Reading

Upper Airway and Digestive Tract


Anatomy and Physiology
dr R. Isma Nurul A’Ini

Supervisor : dr. Bambang Purwanto, Sp.THT-


KL(K),.MM
DEPT. OF OTORHINOLARYNGOLOGY HEAD & NECK SURGERY

HASAN SADIKIN HOSPITAL


2017
INTRODUCTION

Upper Digestive Tract:


- Oral Cavity
- Pharynx
- Larynx
- Esophagus

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Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
ANATOMY
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The Oral Cavity

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Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
The Pharynx

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Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
The Larynx

Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
Esophagus
 Neuromuscular tube :
• laryngopharyng-cardiac
esophageal
• 25-30 cm
• Diameter  rest : 20 mm
Baby : 18 cm
1 yo : 20 cm
3 yo : 22 cm
6 yo : 25 cm
10 yo : 27 cm
14 yo : 34 cm
Adulth : 40 cm
Segment at Esophagus
Natural Constriction

Natural constriction :
- Cricopharyngeus
- Aorta & left bronchus
anteriorly cross
- LES
HISTOLOGY OF ESOPHAGUS

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Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
The Esophageal Mucosal Layer

*  Mucosa –
Stratified squamous

 Submucosa –
Blood vessels, Lymphatics,
myenteric plexus of Meissner
(parasympathetic ganglion
cells)

* *

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Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
Innervation :
N.vagus ( Parasympatic )
Thoracal and Cervical (sympatic)

Myenteric plexus of Auerbach,


responsible for peristaltic

Meissner's plexus 
•controls glandular secretions
•alters electrolyte and water transport
•regulates local blood flow

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Witmer LM. Clinical anatomy and histology of the upper gastrointestinal system. 2003.
PHYSIOLOGY
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Valve for Deglutition

1. Lips
2. Tongue
3. Velum to back of tongue (the glossopalatal valve)
4. Velopharynx
5. Larynx
6. Upper esophageal (cricopharyngeal) sphincter

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
DEGLUTITION

Three stages of deglutition :


1. The oral (voluntary) stage
2. The pharyngeal (involuntary) stage
3. The esophageal (involuntary) stage

 Regulated through the swallowing centre in the medulla

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
INNERVATION

Sensory information to the swallowing center is


carried along N. V, VII, IX, X

The motor respons from the swallowing center


are carried along N. V, VII, IX, X & XII and
also the ansa cervicalis (C-1 and C-2)

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
N. IX, X & XI

Nucleus
ambigus
Nucleus &
trac.solitarius
N. XII
SIX VALVES

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Oral Stage

Essential process :
Mechanical disruption of the food
Mixing with salivary bicarbonate & enzymes

Bolus is voluntary moved posteriorly

Pharynx

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Oral Stage

Once the food has been delivered to the


pharynx, the process become involuntary

The oral stage requires proper functioning of the


striated muscles of the tongue and pharynx

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Pharyngeal Stage

The food is passed from the pharynx

The Upper Esophageal Sphincter

The Proximal Esophagus

 Contraction & Relaxation

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Pharyngeal Stage
Food in the pharynx stimulates sensory receptors,
which send impulses to the swalowing center.
The CNS then initiates a series of involuntary
responses :
1. The soft palate is pulled upward and closes the
posterior nares
2. The palatopharyngeal folds are pulled
medially, limiting the opening through the
pharynx

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
3. The vocal folds are closed and the epiglottis
swings backward and down to close the
larynx

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
3. The larynx is pulled upward and forward by
the muscles atached to the hyoid bone ,
stretching the opening of the esophagus and
UES

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
4. The UES relaxes. Active
relaxation of the usually
tonic cricopharyngeus is
essential to permit the
passive opening of the UES
created by the movement of
the larynx

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
5. Peristaltic contraction of
the constrictor muscles
of the pharynx produces
the force that propels
food into the esophagus

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Esophageal Stage

Requires contraction of both the longitudinal and circular


muscular coats of the esophagus and relaxation of the
sphincters

Peristaltic wave
(Peristaltic clearing wave)

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Esophageal Stage
Circular muscle contraction  3 patterns
1. Primary peristalsis
- usual form of circular muscle
- requires 8-10 seconds to reach distal
esophagus
- The LES relaxes at the onset of the
swallow & remains relaxed untill it
contracts as a continuation of the
progressive peristaltic wave

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Esophageal Stage

2. Secondary peristalsis
- represent a peristaltic contraction of
the circular esophageal muscle without
central stimulation
- as a result of esophageal distention,
continuous until the esophagus is empty
- the mechanism for clearing ingested
and material refluxed from the stomach

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
The Esophageal Stage

3. Tertiary contractions
- identified during barium x-ray
- A nonperistaltic series of contractile waves that
appear as localized segmented indentations in the
barium column
- Has no known physiologic function

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
Importance of the Sphincters

Upper Esophageal Sphincters


- Maintains a constant clossure
- Normal pressure :
100 mmHg anteroposterior
50 mmHg laterally

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
Lower Esophageal Sphincter :
Pressure : 10-45 mmHg > intragastric
pressure

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
Two functions of the LES :
- Prevention of the
gastroesophageal reflux
- Its ability to relax to allow
movement of ingested
material to the stomach

Normal subjects : reflux occur during TLESRs (Transient


Lower Esophageal Sphincter Relaxation)
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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
Effects of bolus characteristics on the
oropharyngeal swallow
Various types of boluses : volumes and viscosities.

On swallow of small vol. (1 – 5 ml) : the oral stage


proceeds first, followed by the pharyngeal stage.

Larger volume (10 – 20 ml) : the oral and


pharyngeal stage occur essentially
simultaneously.

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
Effects of posture

Changing head position changes pharyngeal


dimensions and the direction of food flow.

When the patient is lying down, any residual food


simply adheres to the pharyngeal after the swallow
when the patient return to breathing.

Postural changes are often used as compensatory


strategies in the management of swallowing
disorders.

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Goyal R, Sivarao D. Functional anatomy and physiology of swallowing and esophageal motility. In: Castell D, Richter J, (eds) The esophagus,
Philadelphia: Lippincott Williams & Wilkins, 1999; 1–32.
Diamant N. Neuromuscular mechanisms of primary peristalsis. Am J Med 1997; 103:40S–43S.
SUMMARY

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Thank You

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