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Overview of Respiratory tract and pharynx

Case Based LearningBy

Dr. Abdul Waheed AnsariChairperson &Prof. Anatomy,

RAKCOMS.

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Learning outcomes of the CBL are as follows:-• Able to relate the clinical condition of respiratory system with the

disturbed anatomy in upper and lower respiratory tracts.• Gross anatomy of nose, nasal cavity and paranasal sinuses.• Gross anatomy of larynx and pharynx.• Gross anatomy of lungs and pleurae.

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A clinical case of epistaxis

• A 34 year old female presents to ED at 2am, post waking up with blood all over her pillow, and a continuous ooze of blood from her right nostril.

• On examination the patient is alert and oriented, BP 110/60, pulse 95, respiratory rate 22, and has no past medical history. The patient reports having a sinus infection of late which she’s has been using an antihistamine nasal spray to treat.

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Epistaxis is a clinical term to describe the bleeding from nose. • Nose is an olfactory and respiratory organ. It

has a root, dorsum, alae and nostrils.• The floor of nose forms the roof of oral

cavity. The first cranial nerve arises from the roof of nose from olfactory epithelium.

• The Fila olfactoria enters the anterior cranial fossa passing through cribriform plate of ethmoid bone.

• An injury at the root/roof of nose may damage these olfactory nerves and there will be drainage of CSF associated with loss of (smell) olfactory sensation-anosmia.

• Nose also has a median nasal septum and lateral wall of nose having three conchae and meatuses.

• The paranasal sinuses drain in these meatuses.

• The paranasal sinuses provide humidification and resonance to the voice.

• Infection of these sinuses are called as sinusitis.

• Our first patient was having sinusitis. It is one of the reasons for epistaxis.

• The blood supply of nose comes from internal carotid and external carotid branches.

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Gross anatomy of lateral wall of nose

• Sp=supreme concha• S= superior concha• M= middle concha• I=inferior concha• Ss= sphenoid sinus• F=frontal sinus• Et= Eustachian tube• V= vestibule

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The median nasal septum is partly bony, cartilaginous and mucocutaneous septum, deflection to one side is one of the cause for sinusitis- DNS( Deflected Nasal septum)

DNS

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A clinical case of maxillary sinusitis

• A 24 year old medical student, presents to the office in August complaining of ongoing upper respiratory cold symptoms for almost 2 weeks now.

• She has used over-the-counter medication without significant benefit.

• She has also taken a few antibiotic pills his roommate had laying around last week. This also provided little benefit.

• She lists her specific symptoms as runny nose, worsening nasal congestion, mildly productive cough, sore throat, headache, subjective fever and chills, decreased appetite, and overall malaise.

• Her radiograph of head indicates bilateral maxillary sinusitis.

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There are paired and unpaired paranasal sinuses arising from the nasal cavity. They provide air conditioning and humidification, resonance to voice and lessen the weight of the skull.

• The paired sinuses are• Ethmoidal air cells anterior/middle and

posterior groups; they are lodged in the bony labyrinth-ethmoid.

• Frontal sinuses are present in the frontal bone.

• Maxillary sinuses are present in the maxillary bone

• The sphenoidal sinus is present in the sphenoid bone, below pituitary fossa. It is unpaired sinus.

• The mastoid air cells are connected with the middle ear cavity through nasopharynx. The mastoid air cells are present in the mastoid process of temporal bone.

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The larynx is the voice box and it is made up of paired and unpaired cartilages, muscles, membranes and folds. It is lined by respiratory epithelium. Laryngitis is the inflammation of larynx.

• Male larynx is longer when compared to female larynx.

• The cartilages are:-• Thyroid, cricoid, epiglottis, arytenoids,

corniculate and cuneiforms.• The muscles of larynx are intrinsic and

extrinsic.• All intrinsic muscles are supplied by

recurrent laryngeal nerves except- cricothyroid-that is supplied by external laryngeal nerve.

• The extrinsic muscles are supplied by ansa cervicalis.

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Endoscopic view of larynx

• 1=true vocal cord• 2=vestibular fold/false vocal cord• 3=epiglottis• 4=arypeiglottic fold• 5=arytenoid• 6=piriform fossa• 7= dorsum of tongue

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Movements of vocal cord are adduction, abduction

• It is completely closed in adduction as seen during swallowing.

• The vocal cords are abducted widely when we breath quietly.

• The vocal cords vibrate when we talk.

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Clinical case of vocal cord damage• A female elementary school music teacher

in her 40s notes two years of loss of singing capabilities for five months after school starts.

• She has definite improvement over the summer when she uses her voice less.

• She has had problems with high soft singing for a longer period.

• She has voice fatigue.• On a previous ENT exam, a physician told

her that she had nodules and recommended Speech therapy.

• This did not help according to patient.

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Birds have syrinx instead of larynx

• Syrinx is the name for the vocal organ of birds. Located at the base of a bird's trachea

• Unlike humans, parrots do not have vocal cords. Instead, they learn to control the movement of the muscles in their throat to direct the airflow in a way to reproduce certain tones and sounds.

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The pharynx

• The oral cavity leads to pharynx.• It has three parts associated with

tongue, nose and larynx.• Oropharynx , nasopharynx and

laryngopharynx.• Oropharynx is that part of pharynx

which lies posterior to the tongue. It contains tonsillar pillars and palatine tonsils- member of Waldeyer’s ring of lymphoid tissue around the oral cavity.

• The nasopharynx lies posterior to posterior nares, having pharyngeal opening of Auditory tube/pharyngotympanic tube or Eustachian tube.

• The laryngopharynx lies posterior to the larynx. It continues as esophagus.

• The musculature of pharynx are constrictors of pharynx.

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Palatine tonsils

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Nasopharynx

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The trachea is the wind pipe below cricoid cartilage, it divides at the sternal angle in to two principal bronchi• The right principal bronchus is wide

and in line of the trachea. • Foreign bodies inhaled will enter the

right bronchus.• The thyroid gland and parathyroid

glands are encircling the trachea and enclosed in pretracheal fascia.

• Internal carotid, common carotid arteries and internal jugular vein and sympathetic chain and vagus nerves are related lateral to the trachea.

• The primary bronchus divides into secondary bronchi and enters into each lobe of lung.

• The tertiary bronchi along with the lung parenchyma constitute the BP segments.

• Each lung has 10 Broncho pulmonary segments.

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References

• Essential Clinical Anatomy-4th Edition- Keith Moore. • (pages 573-577)• ( pages 623-635)• (pages 71-79)