01 Anatomy

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Section 1 Airway Management: Background and Techniques

Chapter
Anatomy

1 John Picard

Individual flowers may be pretty. But in a bouquet, it's Overenthusiastic openers of the mouth may some-
their relation to each other which makes the arrange- times find their jaw becomes stuck in subluxation (dur-
ment beautiful: context is key. The same is true of ing assessment for anaesthesia, for example). The
topological anatomy: context makes for clinical rele- patient is left phonating like a distant gargle, with the
vance. This chapter offers a selective account of the mouth wide open; to return the jaw to its joint, it
functional adult head and neck anatomy as it applies to suffices to push firmly on the mandible’s molars poster-
anaesthetic clinical practice. iorly and inferiorly.
Gape may be reduced by abnormal skin around
Mouth Opening and the mouth (e.g. scleroderma), by excessive tone in
masseter (e.g. induced by a neighbouring abscess) or
the Temporomandibular Joint by disease in the temporomandibular joint itself (e.g.
Cooking and cutlery both evolved after us; while our rheumatoid arthritis).
ancestors lived without tools or open fires, biting hard Mouth opening ability also depends on craniocervi-
and opening the mouth wide were both advantageous. cal flexion and extension. Head extension facilitates
A strong bite and a wide gape may seem to be opening. Normal humans extend about 26° from
conflicting ambitions. A firm bite, for instance, the neutral position at the craniocervical junction to
depends on a single, fused mandible, and on muscles achieve maximal mouth opening. If cervical extension,
inserting some way from the joint to gain greater from the neutral position, is prevented a subject can be
leverage, as in humans. (In snakes, in contrast, each expected to lose about one third of their normal inter-
of the two halves of the mandible and the maxilla dental distance. Patients with poor craniocervical exten-
move independently from the skull and from each sion therefore suffer a ‘double whammy’ in terms of
other, and their muscles insert close to the relevant airway management.
joints, to give an enormous gape, but a weak bite.) An
adequate gape is nevertheless achieved in most
humans by subluxation. When the jaw is closed, the The Oral Cavity and Oropharynx
head of the mandible rests in the mandibular fossa in The oral cavity is dominated by the tongue, and for
the temporal bone. But as the jaw opens, the head of anaesthetists, little else counts but its size. It may be
the mandible is pulled out of the fossa by the lateral swollen acutely (as in angioneurotic oedema) but is
pterygoids (Figure 1.1). Rather than turning on its also susceptible to disproportionate enlargement by
head, the mandible swivels on an axis which runs trisomy 21, myxoedema, acromegaly, tumours and
through the mandibular foramina (i.e. close to the glycogen storage diseases, among others.
insertion sites of temporalis and masseter). Angioneurotic oedema can cause such swelling as
This shift in the axis of rotation allows both strong to fill the entire pharynx, preventing both nasal and
bite and wide gape: at the limit of closure, as the molars mouth breathing and making a front of neck airway
meet, the jaw is turning on the temporomandibular joint, necessary for survival. Less dramatically, a large ton-
and masseter and temporalis are working with leverage. gue (relative to the submandibular space) can hinder
But at the jaw’s widest opening, it turns about the mus- direct laryngoscopy. That is, manoeuvred with rea-
cles’ insertion sites; they are not so passively stretched, sonable force, the laryngoscope blade should squeeze
and the bones of the joint do not so impinge on one the posterior tongue so as to achieve a direct view of
1
another. the glottis. If the tongue is too large, or the jaw

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Section 1: Airway Management: Background and Techniques

its socket the better. If the root is clean, the tooth can
simply be put back in; if dirty, the root should first be
rinsed with saline or whole milk. A dentist will then be
able to splint the tooth in place. If a displaced tooth
cannot be immediately replaced, whole milk is the best
storage medium; a dental cavity exposed too long to
saline, or worse water, dies. Calcification of the peri-
odontal ligament is then inevitable, and the tooth will
become brittle and discoloured, and may fracture,
loosen or fall out again.
The stage’s side wings are formed by mucosal folds
running over palatoglossal and palatopharyngeal
muscles (from anterior posteriorly). Between the two
folds on each side lie the tonsils (which may be invi-
sible in adults, but in children may be so large as to
meet, ‘kiss’, in the midline, hampering laryngoscopy).
The glossopharyngeal nerve runs under the mucosa of
the base of the palatoglossal arch (towards the poster-
ior tongue) and can be blocked there. Just as in the
theatre, so in the oral cavity: confusion surrounds the
wings. Properly called the palatoglossal and palato-
pharyngeal arches, they are also commonly called
fauces and pillars. They are all the same thing.
Access to the stage’s flies is controlled by the soft
palate, a flap of soft tissue which can move up to
separate the nasopharynx from the mouth and orophar-
ynx (during swallowing), or move down to separate/
shield the pharynx from the mouth (during chewing).
The soft tissues which surround the pharyngeal
airway are themselves contained by bony structures
(the maxilla, the mandible, the vertebrae and the base
of the skull). When awake, tone in the pharyngeal
musculature maintains airway patency. But once
a patient is asleep, sedated or anaesthetised, muscular
tone falls, and airway patency may depend on the
relative sizes of these bones and of the soft tissues
Figure 1.1 (a) Mandible and muscle actions. (b) Mandibular
movement for opening the mouth wide.
within them. Patients with more soft tissue, a shorter
mandible or squatter cervical vertebrae may be at
particular risk of obstructive sleep apnoea.
hypotrophied, it may not be possible directly to see
the glottis over the compressed tongue. The Nose and Nasal Cavities
Within the oral cavity, the tongue is like a thrust The nasal cavities have evolved to humidify and warm
stage in a theatre. It is surrounded by two tiers of teeth air before directing it to the pharynx and thence
(stalls and royal circle), and a series of wings and flies towards the lungs; all roles likely to be subverted by
(Figure 1.2). anaesthetists. Nevertheless, the anatomies of both inside
Each tooth consists of calcified dentine, cementum and outside of the nose have anaesthetic relevance.
and enamel surrounding a cavity filled (if the tooth is The nose encases the two nasal cavities which each
alive) with vessels and nerves. Each tooth is held in its lead from nostril to nasopharynx. Each cavity is lined by
socket in the jaw by a periodontal ligament. If a tooth is a mucous membrane of peculiar vascularity; luxuriant
2 inadvertently knocked out, the sooner it is returned to perfusion limits local cooling and desiccation despite

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Chapter 1: Anatomy

Figure 1.2 The mouth.

evaporation. It also means minimal trauma can cause concha is larger than that between inferior and middle
profuse bleeding. conchae. Furthermore, the ostia (holes) through
The mucosa’s innervation is so complex as to which the sinuses drain into the nose are all cephalad
make topical anaesthesia the most practical option to the inferior concha. For both reasons, a tracheal
for even the most ardent regional anaesthetist (no tube which runs through the nasal cavity may be best
less than nine nerves innervate each cavity). That placed along its floor, being less likely to cause
said, simply pouring a local anaesthetic solution damage, or to obstruct drainage and cause sinusitis.
down the nostrils of a supine anaesthetised patient is On the other hand, an optical bronchoscope advanced
profoundly unanatomical: the medicine can be direc- between middle and inferior conchae may execute
ted to its target by gravity. Before functional endo- a gentler turn inferiorly toward the glottis.
scopic sinus surgery, for example, if the solution is to The damage that can be done by tubes passed
reach the cephalad reaches of the nasal cavity, the blindly through the nose is remarkable; entire con-
head must be tilted back (with Trendelenburg tilt chae have been amputated, and tubes passed into the
and a pillow below the shoulders). To direct solution brain through fractures in the skull base. Clearly tra-
along the projected path of an optical bronchoscope, cheal tubes should be of as small a diameter
less Trendelenburg is necessary. Moreover, some sen- as possible, while bleeding diatheses and basal
sory fibres pass through the contralateral sphenopa- skull fractures are important relative contraindica-
latine ganglion. It is therefore sensible to apply local tions to nasal intubation. If a tracheal tube is never-
anaesthetic to both nostrils, even if only one is to be theless to be directed through the nose, using a flexible
subjected to a foreign body. optical bronchoscope may reduce the risk of damage.
Each nasal cavity is divided by three turbinates The nose’s external profile also determines how
(more properly conchae) which extend medially tightly a face mask can fit. Given too large a nasal
from the cavity’s lateral wall (Figure 1.3). The space bone, gas escapes around the mask’s sides, and too
between the floor of the nasal cavity and the inferior small, gas escapes at the midline.
3

https://doi.org/10.1017/9781108303477.003 Published online by Cambridge University Press


Section 1: Airway Management: Background and Techniques

Ostium of sphenoidal sinus Figure 1.3 The lateral nose.


Frontal sinus
Superior
Tubal elevation Middle concha
Inferior

Opening of Atrium
auditory tube

Vestibular area

Position of pharyngeal tonsil

Figure 1.4 Anatomical specimen of


adult human larynx.
Epiglottis

Aryepiglottic fold
Ventricular fold
Glottis Vocal fold
Cuneiform cartilage
Corniculate cartilage
Arytenoid cartilage

the more it can frustrate direct laryngoscopy. Given


Glottis and Epiglottis adequate anaesthesia, the tip of a laryngoscope placed
The human larynx is often declared the organ of speech in the vallecula and drawn anteriorly will generally also
(Figure 1.4). More extraordinary still, it allows singing. pull the epiglottis sufficiently far anteriorly to reveal the
Its intrinsic musculature is accordingly complex, but not glottis. But if an anaesthetised patient is in the supine
always relevant to the anaesthetist simply aiming for the position, and the epiglottis is long and flaccid, it may
cavity the muscles surround. That said, a naming of the fall to hide the cords unless it too is scooped above the
parts seen on laryngoscopy allows accurate description laryngoscope’s blade (Figure 1.5). Alternatively, the tip
of abnormality. Just as for a glutton before fancy cho- of a McCoy laryngoscope blade can be deployed to
colates, only a few details of the box are relevant; the key apply anterior pressure at the root of the epiglottis.
is to get in, past the epiglottis and past the cords them- Conversely, if the tissue around the epiglottis is incom-
selves, without doing undue damage on the way. pliant (after radiotherapy, for instance), deploying the
The epiglottis has evolved to shield the glottis not McCoy blade’s tip may simply push the laryngoscope’s
from anaesthetists, but from nutrients headed towards blade posteriorly, hindering direct laryngoscopy rather
the oesophagus. It works like the flexible lid of a pedal than making it easier (see Chapter 14). A Miller
bin. Generally, it is half open, to allow breathing. But straight blade can be placed posteriorly to a flaccid
on swallowing the epiglottis and larynx come together. epiglottis to lift it out of the way.
Like the lid closing on the bin, the larger and more A hypertrophied lingual tonsil or a tumour at the
4
flexible the epiglottis, the better it can fit the glottis, but root of the tongue may also push the epiglottis

https://doi.org/10.1017/9781108303477.003 Published online by Cambridge University Press


Chapter 1: Anatomy

(in laryngospasm) to protect the trachea from aspira-


tion or to thwart the anaesthetist. With force, an
arytenoid may be knocked off the cricoid cartilage –
a remediable hoarse voice and sore throat are the
results.

Subglottic Airway: Cricothyroid


Epiglottis Puncture and Tracheostomy
‘If you cannot go through it, go round it’: if teeth,
tongue, epiglottis or glottis obstruct the path to the
cords, then it may be easier to reach the trachea
directly through skin, either by cricothyroid puncture
or by tracheostomy.
As the trachea must run posteriorly from the glottis
to reach the carina in the mediastinum, it is most super-
ficial at its start. Indeed, the defect between the thyroid
and the cricoid cartilages is easily palpable in a slim
normal neck, and is covered only by skin, loose areolar
tissue and the fibrous cricothyroid membrane (Figure
Figure 1.5 The laryngoscope.
1.6). So, in theory, a needle or cannula can be passed
into the trachea here without risk of haemorrhage from
posteriorly to obstruct the glottis, just as a bin’s lid may anterior structures. The cricoid cartilage is the only ring-
be pushed down. While asymptomatic and impercep- shaped cartilage in the upper airway and the posterior
tible during a standard examination, such an enlarged part is broader than the anterior part, thus to some
tonsil may severely hamper airway control (see extent preventing a needle or scalpel from penetrating
Chapter 14). into the oesophagus at the level of the cricothyroid
The mucosa of the larynx above the cords is sup- membrane.
plied by the internal laryngeal nerve, which branches More caudally a larger tube can be passed into the
off the superior laryngeal nerve just lateral to the trachea without undue force (either surgically or with
greater cornu of the hyoid bone. It then plunges deep a percutaneous technique). But again, the oesophagus
to the thyrohyoid membrane. It can be blocked by local runs directly behind the trachea, where the cartilages
anaesthetic injected through a needle gingerly walked are C-shaped instead of complete rings, and can be
off the hyoid and then passed through the perceptible damaged through the posterior wall in a percutaneous
resistance of the membrane. As it is purely sensory, it approach. Moreover, the trachea is far from subcuta-
can be blocked without fear of attendant paresis. neous as it approaches the sternum: the thyroid isth-
But below the cords, the mucosa is innervated by the mus lies over the second, third and fourth tracheal
recurrent laryngeal nerve, which also supplies almost all rings; from there the inferior thyroid veins drain the
the intrinsic muscles of the larynx. Transection of the gland, running close to the midline towards the
recurrent laryngeal nerve partially adducts the cord, chest – and in a short neck, the left brachiocephalic
and – worse – less extreme surgical damage of the vein and artery may poke above the sternum as they
nerve can cause the cord to adduct more extremely, cross the trachea. The position of these vessels, and
across the midline. So, anatomy dictates that the mucosa indeed the trachea and the cricothyroid membrane,
below the cords is anaesthetised topically, if at all. can usefully be identified by ultrasound before cri-
The ends of the vocal cords themselves are fixed cothyroidotomy or tracheostomy.
anteriorly to the thyroid cartilage. But their posterior
ends each attach to an arytenoid complex which Trachea and Bronchial Tree
moves like a cam on the cricoid cartilage. A few Like a jetliner’s wing, the trachea’s apparent simplicity
degrees’ turn tightens the cord to raise the voice’s belies its complexity. It is held open by the tracheal
pitch; more extreme movements adduct the cords cartilages. These are shaped like a C, with the curve 5

https://doi.org/10.1017/9781108303477.003 Published online by Cambridge University Press


Section 1: Airway Management: Background and Techniques

Anterior belly of digastric Hyoid bone Figure 1.6 Thyroid gland and the front of
Submandibular gland Thyrohyoid
the neck.
Facial artery Mylohyoid
Facial vein
Parotid gland

Stylohyoid
Thyrohyoid membrane Superior belly of omohyoid
Laryngeal prominence Sternohyoid
External jugular vein Superior thyroid artery
Arch of cricoid cartilage Cricothyroid
Isthmus of thyroid gland Middle thyroid vein
Sternocleidomastoid Internal jugular vein
Inferior thyroid veins Transverse cervical artery
Anterior jugular vein Suprascapular nerve
Sternothyroid Suprascapular artery
Trachea
Phrenic nerve on
scalenus anterior
Recurrent laryngeal nerve

Common carotid artery


Lateral lobe of thyroid gland

facing anteriorly; their corrugations distinguish the


trachea from the smooth oesophagus. Not only do
Right main
the rings help disorientated bronchoscopists, it also
enables the tracheal bore to vary. The two ends of each
C are joined by the trachealis muscle, which forms the Apicoposterior
posterior wall of the trachea. If the muscle tightens the
trachea’s radius is reduced (as the points of the C are
drawn together), airway resistance rises and the Left upper
volume of the dead space falls; conversely, airway Right upper
resistance falls and the dead space swells as the muscle
Right main
relaxes. So, just as in a wing, the trachea’s shape can be Left main
Right middle
optimised for different flow rates.
As the bronchial tree ramifies beyond the trachea
(Figure 1.7), its initial divisions are crucially asym- C
Left lower
metric. The carina itself is on the left of the midline;
the left main bronchus is narrower and runs off closer Right lower
to the horizontal than the right; all conspire to send
Figure 1.7 Main, lobar and segmental bronchi.
aspirated material towards the right main bronchus.
Moreover, in an adult the left main bronchus is some
4.5 cm long while the right main bronchus runs just
2.5 cm, or less, before giving off the bronchus to the stimulate the carina or even pass into a bronchus if
right upper lobe. Clearly a larger target is easier to hit. the neck is flexed.
It is therefore easier to isolate the lungs without
occluding a lobar bronchus, if the left rather than Cervical Spine
the right main bronchus is the target (see Chapter 27). As in owls, so in humans: our two eyes face in the
The trachea is shortened by cervical flexion and same direction, so our cervical spines have evolved
lengthened by cervical extension. If a tracheal tube is particular mobility and strength to bear the heavy
anchored at the mouth, and rests above the carina head, and allow it to turn relative to the body, while
6 when the neck is in the neutral position, it may protecting the spinal cord within.

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Chapter 1: Anatomy

• The transverse band of the cruciform ligament –


said to be the strongest ligament in the body – runs
behind the peg from one side of atlas to the other –
it stops atlas moving anteriorly over axis.
• The tectorial membrane runs as a fibrous sheet
from the back of the body of the peg to insert
around the anterior half of the foramen magnum –
running anterior to the axis around which the
head nods, it tightens as the head is extended.
Below the axis, in the ‘subaxial’ spine, the vertebrae
assume a more conventional form. They articulate at
the zygoapophyseal joints (‘facet joints’) between each
bone’s facets. Flexion is limited by the ligaments
between the posterior parts of the vertebrae; extension
by the anterior longitudinal ligament and the inter-
vertebral disc capsules.
Direct laryngoscopy is classically facilitated by bring-
ing oral, pharyngeal and laryngeal axes into line. In
practice, that means extension at the occipito-atlanto-
axial complex and very moderate flexion in the subaxial
cervical spine. A normal spine and cord will typically
tolerate the forces applied by a gentle anaesthetist.
Figure 1.8 Atlas and axis. But after trauma, or with disease or malformation,
the cervical spine may be either fixed or abnormally
Both the mobility and strength are crucial to mobile. Ankylosing spondylitis, surgical fusion, or
anaesthetic practice: if pathology limits mobility, fixation may (for example) all frustrate the anaesthe-
management of the airway is typically hampered; if tist hoping to align the oral, pharyngeal and laryngeal
the cervical spine is weakened, inappropriate manage- axes, and so indicate the need for more artful manage-
ment of the airway may catastrophically damage the ment of the airway.
cord. At the other extreme, trauma or ligamentous lax-
The three most cephalad bones together form the ity may make the cervical spine so especially mobile as
occipito-atlanto-axial complex (Figure 1.8). Most of the to jeopardise the spinal cord or medulla. Here anat-
neck’s movement occurs between these three bones, omy is paramount, determining which manoeuvres
both in normal life and during direct laryngoscopy. are safe, and which dangerous. For example, in rheu-
Working caudad, the occipital condyles rest on the matoid arthritis, the cruciform ligament may become
lateral masses of atlas like the rails of a rocking chair lax; flexion of the occipito-atlanto-axial complex is
stuck in tram tracks: the head can flex forward at the then especially dangerous (atlas may move anteriorly
joint (until the odontoid hits the skull) and extend on axis, impaling the cord between the peg and the
backwards; some abduction is possible, but rotation is posterior arch of atlas). But if the peg is fractured at its
not. Atlas, however, turns around the axial odontoid base, atlas is freer to move relative to axis, and both
peg which occupies the anterior third of the space extension and flexion of the occipito-atlanto-axial
within the axis. Posterior movement of atlas over complex will be dangerous.
axis is limited by the axial anterior arch impinging Similarly, turning a patient from the supine position
on the peg. to prone will expose the patient to different dangers
Otherwise ligaments are responsible for the stabi- according to anatomy. Generally, the volume of the
lity of the joints: vertebral canal is increased in flexion, easing pressure
• The alar ligaments run from the sides of the peg to on a cord compressed by, for example, ligamentous
the foramen magnum – depending on which way hypertrophy. But in bilateral facet fracture dislocation,
the head is turned, one or other tightens and so flexion can precipitate anterior subluxation of the
limits rotation. cephalad vertebra, disastrously guillotining the cord. 7

https://doi.org/10.1017/9781108303477.003 Published online by Cambridge University Press


Section 1: Airway Management: Background and Techniques

Summary the trachea, though the posterior arch of the cricoid


cartilage may protect at the level of the cricothyroid
Gentle subluxation of the temporomandibular joint
membrane. Anatomy determines what manoeuvres
facilitates passive mouth opening. Direct laryngo-
will be especially dangerous in cervical instability.
scopy entails extension of the intricate occipito-
atlanto-axial joint. Passage through the cricothyroid
membrane offers the easiest percutaneous access to Acknowledgements
the airway in an emergency. The oesophagus lies Christian Ulbricht and Peter and Ellie Clarke nobly
behind the trachea at this level, and it may be punc- and generously improved an earlier draft; all remain-
tured by a needle or scalpel passed posteriorly through ing mistakes are mine alone.

https://doi.org/10.1017/9781108303477.003 Published online by Cambridge University Press

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