Anesthesiology Clin N Am 20 (2002) 733 745

Anatomy and physiology of the upper airway

Richard S. Isaacs, MD a,b,*, Jonathan M. Sykes, MD, FACS b
b

Kaiser-Permanente Medical Centers, Northern California, USA Department of Otolaryngology-Head and Neck Surgery University of California-Davis, Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817, USA

Normal respiration involves a highly detailed neurophysiologic process that results in the exchange of inspired and expired air through various anatomic structures. An understanding of these structures is important to the clinician involved in maintaining or reestablishing the normal airway. The following anatomic discussion focuses on the features crucial for the establishment and maintenance of a tracheal airway.

Nose The external nose is formed by the nasal bones, the upper and lower lateral cartilages, the cartilaginous portion of the nasal septum, and the skin. The surface anatomy and associated infrastructure of the nose are depicted in Figs. 1 and 2. The pliable portion of the nasal septum and columella separates the paired elliptical nostrils. The nose has a bony framework in its upper portion composed of the two nasal bones and the bones that form the posterior septum: the vomer (inferiorly) and the perpendicular plate of the ethmoid (superiorly). Lower and anterior portions of the nose are supported mainly by cartilage. Nasal cavity The nasal cavity is divided into two passages or fossae by the nasal septum. The nasal septum is a rigid partition formed by the perpendicular plate of the ethmoid, the vomer, and the septal cartilage (Fig. 3). Contained within its mucoperichondrial and mucoperiosteal envelope, the nasal septum, is normally a midline structure but can be deviated to one side.

* Corresponding author. Kaiser-Permanente Medical Centers, Northern California, USA. E-mail address: richard.isaacs@kp.org (R.S. Isaacs). 0889-8537/02/$ see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 0 8 8 9 - 8 5 3 7 ( 0 2 ) 0 0 0 1 7 - 2

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Fig. 1. Surface anatomy of the nose. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

Each nasal fossa is described as having a roof, a floor, a medial wall (nasal septum), and a lateral wall. Passages open anteriorly by way of the anterior naris, or nostril. Nasal passages open posteriorly by way of the posterior naris, or choana, into the nasopharynx. Anterior nares are located at the base of the nose and open anteriorly. Directly above each naris is the anterior aspect of the nasal cavity, which is termed the nasal vestibule. Nares and vestibule are bounded by the medial and lateral crura of the alar cartilage and surrounding fibrofatty tissue. The skin of the vestibule is thin and tightly adherent to the underlying lower lateral cartilages. The medial wall of the nasal vestibule contains the supporting structure of the anterior part of the cartilaginous septum and the connective tissue septum (ie, the columella). In the lateral portion of the vestibule, the skin contains course hairs (vibrissae) that guard the nasal entrance and assist in air filtration.

Fig. 2. Infrastructure of the nose. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

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Fig. 3. Schematic diagram of the nasal septum. Note that the septum is made up of the anterior nasal septal cartilage and the perpendicular plate of the ethmoid bone and the vomer. Other contributions include portions of the palatine bone and the maxilla. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

Lateral walls The lateral walls of the nasal passages are composed of irregular bony projections covered by soft tissue and mucous membrane (Fig. 4). These elevations, whose course is roughly parallel to the nasal floor, are the inferior, middle, superior, and supreme nasal conchae or turbinates. The space beneath each turbinate is called a meatus; its nomenclature corresponds to that of the adjacent turbinate (eg, the middle meatus is located directly beneath the middle turbinate). The ethmoid bone contributes to the structure of the supreme,

Fig. 4. Schematic diagram of the right lateral nasal wall of the nose (the left side of the nose and nasal septum have been removed). Arrows depict the course of the nasolacrimal duct, the nasofrontal duct, and the opening to the maxillary sinus through their corresponding bones. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

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superior, and middle turbinates. However, the inferior turbinate derives its structure from a separate bone. The lateral nasal wall also contains the ostia or openings of the paranasal sinuses and the nasolacrimal duct (Fig. 4). The inferior meatus lies between the floor of the nose and the insertion of the inferior turbinate. The inferior meatus does not contain a sinus ostium, but the opening of the nasolacrimal duct is located approximately 3 cm posterior to the external nasal opening. The middle meatus is located between the inferior and middle turbinates and contains the ostia of the nasofrontal duct, the anterior ethmoid cells, and the maxillary sinus. The superior meatus is located superior to the middle turbinate and contains the opening for the posterior ethmoid cells. The sphenoid ostium lies on the anterior wall of the sphenoid sinus in the area of the sphenoethmoidal recess. Posterior nares (choana) Each posterior naris or choana is oval and measures approximately 2.5 cm vertically and 1.5 cm horizontally. The posterior naris is completely bounded by bone covered by mucoperiosteum. The posterior portion of the septum is consistent and does not usually deviate in this region. There are, however, occasional cases of congenital choanal atresia and post-traumatic bony septal deviations. In these instances, posterior obstruction of the septum may occur. Function of the nose In addition to its role as a conduit to the lower respiratory tract, the nose has several important functions. Inspired air is warmed, humidified, and cleansed during its turbulent flow over the membranous lining of the nasal passages. The rich vascular supply of the turbinates allows the nasal airway to expand or contract according to the degree of vascular engorgement. Trauma to the nasal passages may result in profuse hemorrhage because of their rich blood supply. Other nasal functions include olfaction and phonation (the nose acts as an additional resonating chamber for certain consonants).

The pharynx The pharynx is a musculofascial tube that connects the nasal and oral cavities with the larynx and esophagus. The pharyngeal tube is composed of a thin outer fascial layer that thickens posteriorly to become the buccopharyngeal fascia. Inferiorly, this fascia becomes continuous with the adventitia of the esophagus, while superiorly it attaches to the skull base. Constrictor muscles The middle muscular layer is composed of the three pharyngeal constrictor muscles. The superior constrictor inserts at the base of the skull, the middle

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Fig. 5. Right posterior oblique view of the pharynx depicting the pharyngeal musculature. Note the overlapping of the pharyngeal constrictors and their insertion into the posterior midline as a tendinous raphe. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

constrictor muscle inserts into the hyoid bone, and the inferior constrictor muscle inserts into the cricoid cartilage (Fig. 5). The inferior constrictor contributes to a muscular band, the cricopharyngeus, which forms the upper esophageal sphincter. Each muscular segment is overlapped at its lower border by the adjacent inferior muscle segment. All muscle segments are inserted posteriorly into a tendinous median raphe (Fig. 5). Divisions of the pharynx The pharynx is divided into three sections: the nasopharynx, the oropharynx, and the hypopharynx (Fig. 6). The delicate muscular framework of the pharynx makes this structure prone to lacerations, retropharyngeal dissection, and the iatrogenic creation of false passages. Therefore, knowledge of these structures is critical for the practitioner before attempting endolaryngeal intubation. Nasopharynx The nasopharynx is situated directly behind the nasal cavity. Its inferior boundary is a line drawn transversely at the level of the soft palate. Five passages communicate with the nasopharynxthe two nasal choanae, the orifices of the two eustachian tubes, and the inferior outlet to the oropharynx. The roof of the nasopharynx is formed by the sphenoid and occipital bones of the skull base. The roof slopes gradually posteriorly and is continuous with the

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Fig. 6. Parasagittal view of the upper aerodigestive tract depicting the delineation of the nasopharynx, oropharynx, and hypopharynx. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

posterior nasopharyngeal wall. The posterior wall of the nasopharynx is separated from the spinal column by the tough prevertebral fascia, which covers the longus capitis muscle, the deep prevertebral musculature, and the arch of the first cervical vertebra. Each eustachian tube orifice is located medial to the lateral cartilaginous prominence called the torus tubarius. Above and behind the torus is a recess called the fossa of Rosenmuller. The eustachian tube functions to equalize middle ear and atmospheric pressure when pulled open by the specialized action of the palatal muscles. Mucous membranes of the roof and posterior walls of the nasopharynx contain lymphoid tissue termed the single pharyngeal or adenoid tonsil. Massive hypertrophy of the adenoid can result in chronic nasal airway obstruction. This condition may create difficulty in establishing a nasotracheal airway, or it may contribute to sleep apnea and altered arterial CO2 levels. The adenoid tonsil, however, typically involutes during puberty. Oropharynx The oropharynx lies directly posterior to the oral cavity and extends from the soft palate superiorly to the tip of the epiglottis inferiorly. The posterior wall consists of the prevertebral fascia and the bodies of the second and third cervical vertebrae. The lateral walls of the oropharynx contain the paired

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Fig. 7. Intraoral view of the open mouth depicting the tonsillar fossae and the corresponding tonsillar pillars. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

tonsillar fossae (Fig. 7). These fossae are formed by the palatoglossal (anterior pillar) and palatopharyngeal (posterior pillar) folds and contain the palatine tonsils. Directly medial to the tonsillar fauces lies the posterior aspect, or base, of the tongue. The tongue base is anterior to the laryngeal inlet and attaches to the epiglottis by the paired lateral glossoepiglottic folds and by the single median glossoepiglottic fold. Glossoepiglottic folds bind two spaces, the epiglottic valleculae. The posterior dorsal tongue surface is irregularly contoured because of the lingual tonsils. In some children, the palatine tonsils may reach considerable size and actually obstruct exposure of the larynx during intubation. As is commonly seen with the adenoid tonsil, the palatine tonsils usually involute after puberty. Fig. 8 demonstrates the parasagittal view of the oropharynx with emphasis on the musculature of the tongue and the floor of the mouth. The tongue is composed of a specialized group of paired muscles that provide it with extreme mobility. The tongue musculature is divided into two groupsmuscles that are attached to fixed points (styloglossus, genioglossus, hyoglossus, and palatoglossus) and muscles that run freely in the body of the tongue (transverse, superior, and inferior longitudinal muscles and vertical muscles). The floor of the mouth is supported mainly by the paired mylohyoid muscles, which arise from the mandible and insert into the hyoid bone. Cellulitis of the submandibular and submental spaces can involve the floor of the mouth, located superiorly to the mylohyoid muscle. This process, known as Ludwigs angina, usually follows a dental extraction or infection. Tongue muscles are usually involved and become edematous and displaced posteriorly. Rapid progression of the infection can produce airway obstruction. Tracheotomy is commonly required to secure the airway before incision and wide drainage of the floor of the mouth are performed.

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Fig. 8. Parasagittal view of the muscles of the floor of the mouth with their corresponding insertions into the tongue, mandible, and hyoid bone. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

Hypopharynx The hypopharynx extends inferiorly from the upper edge of the epiglottis to the inferior edge of the cricoid cartilage and communicates with the oropharynx, the laryngeal inlet, and the esophagus. On each side of the larynx are the funnel-shaped piriform recesses. These recesses are bound superiorly by the lateral glossoepiglottic folds, and they lie between the aryepiglottic folds and the internal lining of the thyroid cartilage (Fig. 9). The piriform recesses function to divert the food bolus laterally and away from the larynx in transit to the esophagus. The posterior border of the hypopharynx comprises the buccopharyngeal and prevertebral fascia and deep prevertebral musculature. The hypopharynx is located approximately at the level of the fourth through sixth cervical vertebrae.

The larynx Functions of the larynx The larynx is continuous with the trachea and has a specialized constrictor dilator mechanism in the airway. The sphincteric, protective function

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Fig. 9. Right posterior oblique view of the open pharynx depicting the relation of the aryepiglottic folds, larynx, epiglottis, and piriform recesses. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

is the oldest phylogenetic function of the larynx, having developed from aquatic amphibian predecessors. The constrictor mechanism of the larynx results in an effective and rapid closure that prevents food, liquid, and other foreign material from entering the lower airway. In addition, the vocal cords have a vibratory effect on the expiratory air column and produce the sound used in voice production. Placement of a tracheal tube through the larynx interferes with these laryngeal functions. The intubated patient experiences loss of voice and possible aspiration of foreign material into the airway. In addition, the presence of the tube prevents the production of an adequate protective cough.

Laryngeal skeleton Thyroid cartilage, cricoid cartilage, and hyoid bone form the laryngeal skeleton (Fig. 10). These structures are readily palpated in the anterior midline of the neck. The thyroid cartilage is responsible for the visible bulge (especially in male patients) known as the Adams apple. Thyroid cartilage is composed of two superior horns that aid in its suspension from the hyoid bone. The two horns join in the midline and remain open posteriorly. This forms an effective shield (Greek thyrus, shield) for the opening of the airway and supports most of the soft tissue folds in the larynx. Two downward projections, inferior horns, articulate with the cricoid cartilage below.

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Fig 10. (A) Right anterolateral view of the laryngeal skeleton. (B) Parasagittal view of the laryngeal skeleton showing the relation of the epiglottis, thyroid and cricoid cartilages, and glottis. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

Cricoid cartilage Cricoid cartilage (Greek cricos, ring) is the only complete ring in the larynx and serves to support the posterior laryngeal structures. The anterior portion of the cricoid is short, 5 to 7 mm in height, and the posterior portion of the cricoid is taller, 2 to 3 cm in height. The posterior lamina is marked by a posterior ridge that

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receives longitudinal fibers of the esophagus. The cricoid has two surfaces that articulate with the thyroid cartilage. First tracheal ring The first tracheal ring attaches to the cricoid cartilage by a dense cricotracheal ligament. Thyroid cartilage is attached above to the hyoid bone by the thyrohyoid membrane and below to the cricoid cartilage by the cricothyroid membrane. Because of the relatively superficial location of the laryngotracheal complex, the cricothyroid membrane may be penetrated (cricothyroidotomy) to establish an airway in an emergency. Epiglottis and arytenoid cartilages Two additional cartilages contribute to the laryngeal skeleton. The epiglottic cartilage forms the anterior border of the laryngeal inlet and is attached to the hyoid bone and thyroid cartilage by several ligaments. The epiglottis is composed of cartilage and a covering mucous membrane. The bulk of the epiglottis projects posteriorly to the tongue and into the pharynx. The anterior surface of the epiglottis is concave; this feature, combined with laryngeal elevation, aids in airway protection during deglutition. Arytenoid cartilages are pyramidal and articulate with the posterior parts of the cricoid cartilage. The intricate muscles of voice control are attached to the two arytenoid cartilages, and the vocal cords project anteriorly from the arytenoid cartilages to the thyroid cartilage. Movement of the cricoarytenoid joints from the action of the laryngeal muscles causes a change in size of the opening between the vocal cords. Vocal cords The vocal cords are also called the true vocal cords or the vocal folds. They are composed of muscle, ligament, submucosal soft tissue, and mucous membrane covering. The vocal cords extend from the arytenoid cartilages posteriorly to the thyroid cartilage anteriorly. The laryngeal cavity begins at its entrance, the laryngeal aditus, and is bound by the aryepiglottic folds. The laryngeal aditus leads to the vestibule, which in turn leads to the rima vestibuli. Two mucosal folds that are parallel and above the vocal cords bind the rima vestibuli; these are called the ventricular folds, or false vocal cords. The lateral spaces between the ventricular and vocal folds are called the ventricles. The narrow space between the vocal folds is called the rima glottides, while the term glottis is used to refer to the rima glottides and the adjacent true vocal cords. The space that leads from the rima glottidis to the trachea is the infraglottic cavity or subglottis. Muscles of the larynx Intrinsic muscles of the larynx include the posterior cricoarytenoid (the only abductor of the vocal cords), lateral cricoarytenoid, transverse arytenoid,

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Fig. 11. Right posterior oblique view of the larynx showing the origin and insertion of the intrinsic and extrinsic laryngeal musculature. (From Applied Anatomic Considerations in Airway Management. In: Hanowell, Leland H, editors. Airway Management. Lippincott-Raven, 1996, with permission.)

oblique arytenoid, and thyroarytenoid and the aryepiglottic muscles (Fig. 11). The intrinsic muscles and the solitary extrinsic muscle, the cricothyroid muscle, act synergistically and antagonistically to control the specialized functions of the larynx. Nerve supply of the larynx At the level of the hyoid bone, the vagus nerve gives off the superior laryngeal nerve, which immediately divides into internal and external laryngeal nerves. The larger internal laryngeal nerve pierces the thyrohyoid membrane and supplies sensory fibers to the laryngeal mucosal down to the level of the vocal folds. The external laryngeal nerve courses on the lateral surface of the middle and inferior parts of the pharyngeal constrictor and finally reaches the level of the cricoid cartilage, where it supplies the cricothyroid muscle. The recurrent laryngeal nerve supplies the remainder of the intrinsic laryngeal muscles. On the right, the recurrent laryngeal nerve arises from the vagus nerve at the level of the right subclavian artery, and on the left the recurrent laryngeal nerve arises from the vagus nerve at the level of the aortic arch. A branch of the recurrent laryngeal nerve penetrates the cricothyroid membrane and supplies sensory fibers to the subglottic larynx up through the level of the vocal folds. The false vocal cords, when viewed from above, overlap and parallel the course of the true vocal cords. These cords are not as highly developed as the true vocal cords and do not approximate completely during phonation. They can close together, however, and act as a sphincter to protect the laryngeal inlet. When in spasmodic contraction, the false vocal folds obscure the view of the true vocal cords and glottis from above.

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Pediatric larynx The infant larynx differs greatly from the adult larynx in appearance, location, and morphology. Several important differences should be noted. Anatomy The infant larynx is characterized by a funnel-shaped lumen whose point of greatest narrowing is approximately 1 cm below the cords. A tracheal tube that penetrates the glottis may be too large for the trachea. This funnel shape gradually disappears as the child grows and matures. The cartilaginous framework of the infant larynx is softer than its adult counterpart. In fact, the laryngeal cartilages undergo ossification throughout life, with resultant bony characteristics in adulthood. The pediatric epiglottis is proportionally narrower and longer, and in some infants the immature epiglottic cartilage may form an omega-shaped epiglottis. This configuration brings the aryepiglottic folds closer to the midline, narrows the laryngeal inlet, and increases the possibility of airway obstruction. Position The location of the larynx is higher in the neck of children than it is in adults. The tip of the epiglottis can frequently be seen through the open mouth of an infant. The epiglottis may be in contact with the soft palate, which contributes to the neonatal obligatory nasal respiration and assists the infant in swallowing while it maintains a nasal airway. Mucous membranes Laryngeal soft tissues and mucous membranes are loosely attached in the child. Loose attachment of the laryngeal soft tissues predisposes to swelling (edema), with resultant airway obstruction when the larynx is traumatized or infected. The insertion of an endotracheal tube or laryngeal manipulation with a laryngoscope may create edema that obstructs the upper airway. This obstruction is most marked in the subglottic region, where the narrow lumen and the restrictive cricoid ring can produce dangerous airway obstruction.