UPPER AIRWAY DEFENSE MECHANISM UPPER AIRWAY DEFENSE MECHANISM

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UPPER AIRWAY DEFENSE MECHANISM UPPER AIRWAY DEFENSE MECHANISM

Umar S. Dharmabakti &

Retno S. Wardani Retno S. Wardani

Otorhinolaryngology Department Otorhinolaryngology Department

Faculty of Medicine University of Indonesia – Faculty of Medicine University of Indonesia –

Dr. Cipto Mangunkusumo Hospital Dr. Cipto Mangunkusumo Hospital

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ORGANIZATIONAL STRUCTURE ORGANIZATIONAL STRUCTURE

Head of Department: Dr. Umar S. Dharmabakti Head of Department: Dr. Umar S. Dharmabakti

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LEARNING OBJECTIVES LEARNING OBJECTIVES

• ANATOMYANATOMY of Ear Nose Throat region = Upper of Ear Nose Throat region = Upper respiratory tract region

respiratory tract region

• PHYSIOLOGIC FUNCTIONPHYSIOLOGIC FUNCTION of Upper of Upper Respiratory Tract

Respiratory Tract

• DEFENCE MECHANISMDEFENCE MECHANISM of Upper Respiratory of Upper Respiratory Tract

Tract

• COMMON PROBLEMSCOMMON PROBLEMS in ENT Region – Upper in ENT Region – Upper Respiratory Tract based on

Respiratory Tract based on SYMPTOMATOLOGY

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EAR NOSE THROAT = UPPER RESPIRATORY TRACT EAR NOSE THROAT = UPPER RESPIRATORY TRACT

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ENT ORGANS ENT ORGANS

• HearingHearing

• SpeechSpeech

• BalanceBalance

• SmellSmell

• TasteTaste

• SwallowingSwallowing

• RESPIRATIONRESPIRATION

EAR NOSE THROAT = UPPER RESPIRATORY TRACT EAR NOSE THROAT = UPPER RESPIRATORY TRACT

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EAR - NOSE EAR - NOSE

• Eustachian tube:Eustachian tube:

• Maintain effective impedance matching Maintain effective impedance matching to atmospheric pressure changes

to atmospheric pressure changes

• Connecting middle ear to nasopharynxConnecting middle ear to nasopharynx

 ADNEXA OF RESPIRATORIC ORGANADNEXA OF RESPIRATORIC ORGAN

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PHARYNX - ESOPHAGUS PHARYNX - ESOPHAGUS

The Waldeyer’s ring: series of lymphoepithelial organs called THE TONSILS:

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TONSILS

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LARYNX – TRACHEA – LARYNX – TRACHEA –

BRONCHUS BRONCHUS

Larynx:

• ORGAN OF PHONATIONORGAN OF PHONATION (vocal cords closed =

(vocal cords closed = phonation position) phonation position)

• AIRWAY AIRWAY (vocal cords open = (vocal cords open = respiratory position) respiratory position)

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INTEGRATION OF AIRWAY SYSTEM = INTEGRATION OF AIRWAY SYSTEM =

UNITED AIR UNITED AIR WAYS WAYS

Better understanding of Better understanding of

•Human airway Human airway FUNCTIONFUNCTION

•Patophysiology of the diseasesPatophysiology of the diseases

To offer To offer OPTIMAL MANAGEMENTOPTIMAL MANAGEMENT for many patientsfor many patients

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PHYSIOLOGIC FUNCTION OF PHYSIOLOGIC FUNCTION OF

THE UPPER AIRWAY TRACT

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Physiology of The Nose Physiology of The Nose

& Paranasal Sinuses & Paranasal Sinuses

 Respiration

 Static & mechanic

 Olfaction

 Phonetic

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Physiology of The Nose Physiology of The Nose

& Paranasal Sinuses & Paranasal Sinuses

 Respiration

 Static & mechanic

 Olfaction

 Phonetic

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Related Naso-Bronchial Physiology Related Naso-Bronchial Physiology

•Nasal challengeNasal challenge

induces mediators release induces mediators release

bronchoconstrictionbronchoconstriction

•The The post-nasal drippost-nasal drip

induce induce contractioncontraction of the bronchial of the bronchial smooth muscle

smooth muscle

inflammation inflammation of the lower airwaysof the lower airways

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Related Naso-Bronchial Physiology Related Naso-Bronchial Physiology

•Mouth breathing secondary Mouth breathing secondary to nasal obstruction

to nasal obstruction

a a common featurecommon feature

in asthmatics in asthmatics

play a role in the play a role in the severityseverity of asthma of asthma

•Nasobronchial reflex Nasobronchial reflex through trigeminal – through trigeminal – vagus nerve

vagus nerve

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Nasal Flow Nasal Flow

Physiology of The Nose & Paranasal Sinuses Physiology of The Nose & Paranasal Sinuses

• TURBULENCE FLOWTURBULENCE FLOW promotes contact promotes contact

between the air & the mucosa between the air & the mucosa  the inspired air is the inspired air is cleansedcleansed of particles, of particles,

humidifiedhumidified & & heatedheated or or cooledcooled

• LAMINAR FLOWLAMINAR FLOW provides movement of provides movement of

“safe air”

“safe air” toward the LRT tract. toward the LRT tract.

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Physiology of Physiology of

The Pharynx - Esophagus The Pharynx - Esophagus

• Resonance chamber for phonation Resonance chamber for phonation and articulation

and articulation

• Functional Importance of the Tonsils Functional Importance of the Tonsils in the Immune System

in the Immune System

• Swallowing FunctionSwallowing Function

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Swallowing Process

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Physiology Of The Larynx – Physiology Of The Larynx –

Trachea - Bronchus Trachea - Bronchus

• PhonationPhonation

• RespirationRespiration

• Complete reflex closure Complete reflex closure of the VOCAL CORDS &

of the VOCAL CORDS &

EPIGLOTTIS in response EPIGLOTTIS in response

to the pharyngeal phase to the pharyngeal phase

of swallowing of swallowing

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Cough reflex Cough reflex

if bolus transgress the glotic plane if bolus transgress the glotic plane

 induce another important induce another important mechanism

mechanism

 Deep reflex inspiration Deep reflex inspiration

 glottis closes tightly glottis closes tightly

 intrathoracic pressure rises intrathoracic pressure rises

 glottis opens widely & rapidly glottis opens widely & rapidly

forceful expulsion of the aspirated forceful expulsion of the aspirated materialmaterial

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DEFENCE MECHANISMS OF DEFENCE MECHANISMS OF UPPER RESPIRATORY TRACT UPPER RESPIRATORY TRACT

TO THE AIRWAY SYSTEM

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Cellular & Humoral Cellular & Humoral

Active Defence Mechanism Active Defence Mechanism

Aqueos layer (Sol phase) Aqueos layer (Sol phase) Gel layer (Mucus phase) Gel layer (Mucus phase)

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Cellular & Humoral Cellular & Humoral

Active Defence Mechanism Active Defence Mechanism

Aqueos layer (Sol phase) Aqueos layer (Sol phase) Gel layer (Mucus phase) Gel layer (Mucus phase)

Gel layer : albumin, glycoprotein, IgG, IgM, complemen factor

Aqueos layer: serous secretion, lactoferin, lysozym,

secretoric leucoprotease inhibitor, IgA secretoric

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Goblet Cells & Mucous Blanket

Gel layer (Mucus phase) Gel layer (Mucus phase)

Quality of Quality of

Mucocilliary Transport System

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Mucocilliary Transport System

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PND in the Pharynx

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Role of Nitric Oxide Role of Nitric Oxide

Lundberg, 1994 Lundberg, 1994

high levels of NO in

nasally exhaled air

 derives from the paranasal sinuses The levels of NO in nasal air are at least 100-fold higher than orally exhaled air

 transported into the lower airways.

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Role of Nitric Oxide Role of Nitric Oxide

NO produced by the upper airways NO produced by the upper airways

 PROTECTIVE ROLEPROTECTIVE ROLE for the entire for the entire respiratory tree

respiratory tree

•strong strong ANTIVIRAL & BACTERIOSTATICANTIVIRAL & BACTERIOSTATIC activity

activity

•improves improves OXYGENATIONOXYGENATION

•exerts exerts BRONCHODILATORYBRONCHODILATORY effects effects

•

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Effect Of Phonation On Levels Effect Of Phonation On Levels

Of Nitric Oxide

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Breathing Technique Breathing Technique

Prana = life, Yama = control, regulation, mastery Prana = life, Yama = control, regulation, mastery

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Tonsil – An Immune Organ Tonsil – An Immune Organ mucosa-associated lymphatic tissue mucosa-associated lymphatic tissue

(MALT) (MALT)

• Significant role in the defense against URT Significant role in the defense against URT infections

infections

• Active phase of immune initiation last until Active phase of immune initiation last until 8-9 years

8-9 years

extreme tonsilar hyperplasia extreme tonsilar hyperplasia

narrowing oropharynx narrowing oropharynx

eating difficulties & obstructed breathing eating difficulties & obstructed breathing

respiratory dysfunction w/apnea (OSA)respiratory dysfunction w/apnea (OSA)

cor pulmonalecor pulmonale

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Protecting The Airway Protecting The Airway

While Swallowing While Swallowing

Swallowing reflex Swallowing reflex

• The The VELUMVELUM is elevated to close off is elevated to close off nasopharynx

nasopharynx

• The larynx is sealed off by elevation of The larynx is sealed off by elevation of the the EPIGLOTTISEPIGLOTTIS

• ADDUCTIONADDUCTION reflex of the reflex of the VOCAL CORDSVOCAL CORDS

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Microaspiration

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Protection Function of Protection Function of

the Airway System

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COMMON PROBLEMS OF COMMON PROBLEMS OF

RESPIRATION IN ENT

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ENT Symptomatology of ENT Symptomatology of

Respiration Disorder Respiration Disorder

Ear: eustachian tube Ear: eustachian tube

dysfunction =

dysfunction = ear fullness, earache ear fullness, earache

Nasal symptoms Nasal symptoms

• SneezingSneezing

• RhinorrheaRhinorrhea

• Nasal obstructionNasal obstruction

Pharynx – Larynx Pharynx – Larynx

• CoughCough

• HoarsenessHoarseness

• StridorStridor

• ChokingChoking

• SnorringSnorring

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Ear Fullness - Earache Ear Fullness - Earache

Eustachian Tube Inflammation

 vasodilatation of blood vessels vasodilatation of blood vessels

 negative negative

pressure of middle ear pressure of middle ear

 increase increase transudation transudation 

secretion accumulation secretion accumulation

 bacterial growth bacterial growth  pus pus

Otitis Media

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Sneezing Sneezing

Sneezing is a complex reflex Sneezing is a complex reflex

• begins with an begins with an IRRITATIONIRRITATION of the nose lining. of the nose lining.

• the impulses travel to the brain – the impulses travel to the brain –

• which reacts by controlling the muscles around which reacts by controlling the muscles around the abdomen, chest, diaphragm, neck, face,

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Qin Juren once suffered from RHINORRHEA Qin Juren once suffered from RHINORRHEA with turbid discharge. It smells terrible and with turbid discharge. It smells terrible and is disgusting. Even his wife and children is disgusting. Even his wife and children disliked him. Although he had visited many disliked him. Although he had visited many doctors and had taken a lot of drugs, it doctors and had taken a lot of drugs, it didn’t work. He was hopelessness and didn’t work. He was hopelessness and

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Rhinorrhea

( (

excessive mucous secretion from the nose) excessive mucous secretion from the nose)

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Nasal Obstruction Nasal Obstruction

The disturbance of normal The disturbance of normal

turbulent & laminar airflow pattern turbulent & laminar airflow pattern

• ..

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ETIOLOGY OF IRRITATION – ETIOLOGY OF IRRITATION –

RHINORRHEA & NASAL OBSTRUCTION RHINORRHEA & NASAL OBSTRUCTION

OF THE NASAL MUCOSA OF THE NASAL MUCOSA

• AllergenAllergen

• Irritant - PollutantIrritant - Pollutant

• Cigarette smokeCigarette smoke

• InfectionInfection

• ViralViral

• BacteriaBacteria

• FungiFungi

Find the Find the

pathogenesis pathogenesis

• IgE MediatedIgE Mediated

• Non IgE MediatedNon IgE Mediated

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Nasal Bleeding = Epistaxis Nasal Bleeding = Epistaxis

• ANTERIOR EPISTAXISANTERIOR EPISTAXIS

• anterior CAUDAL SEPTUManterior CAUDAL SEPTUM

• Kiesselbach plexus / Little’s areaKiesselbach plexus / Little’s area

• POSTERIOR EPISTAXISPOSTERIOR EPISTAXIS

• posterior middle turbinate: posterior middle turbinate:

foramen sphenopalatine foramen sphenopalatine

• Sphenopalatine arterySphenopalatine artery

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Cough Cough

Triggered by Triggered by

• presence of presence of CHEMICAL RECEPTORSCHEMICAL RECEPTORS in the larynx and in airways larger in the larynx and in airways larger

than bronchioles.

• serotonin, adenosine triphosphate (ATP), serotonin, adenosine triphosphate (ATP), acetylcholine, acid, and bradykinin

acetylcholine, acid, and bradykinin

• MECHANICAL RECEPTORSMECHANICAL RECEPTORS in the in the lungs as the respond to the

lungs as the respond to the

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Hoarseness Hoarseness

( (

abnormal voice changesabnormal voice changes

) )

• the voice may sound the voice may sound

• breathy, raspy, strained breathy, raspy, strained

• there may be changes in there may be changes in

• volume (loudness) volume (loudness)

• pitch (how high or low the pitch (how high or low the voice is)

voice is)

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When should I see an When should I see an

otolaryngologist (ENT doctor)?

• If hoarseness lasts If hoarseness lasts longer than 2-3 wks

longer than 2-3 wks

• If hoarseness is associated If hoarseness is associated with:

with:

• Pain not from a cold / flu Pain not from a cold / flu

• Coughing up blood Coughing up blood

• Difficulty swallowing Difficulty swallowing

• A lump in the neck A lump in the neck

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Stridor Inspiratory Stridor Inspiratory

• the audible symptom ofthe audible symptom of

• rapid, turbulent flow of air through a rapid, turbulent flow of air through a

narrowed segment of the respiratory tract narrowed segment of the respiratory tract

• more specifically from more specifically from the large airways: the large airways:

larynx, upper trachea, or hypopharynx larynx, upper trachea, or hypopharynx. .

• It is often the most prominent symptom of It is often the most prominent symptom of AIRWAY OBSTRUCTION

AIRWAY OBSTRUCTION

• STERTORSTERTOR: low-pitched inspiratory : low-pitched inspiratory snoring snoring sound

sound produced by produced by nasal or nasopharyngeal nasal or nasopharyngeal obstruction.

obstruction.

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Holinger's "Laws" of Airway Obstruction

I. Awake v. Sleep

A. Obstruction worse asleep is pharyngeal*

– especially tonsils and adenoids

B. Obstruction worse awake is laryngeal, tracheal, or bronchial – exacerbated by exertion

II. Inspiratory v. Expiratory

A. Inspiratory obstruction is extrathoracic 1. Occasionally nasal or pharyngeal

2. Usually larynx – laryngomalacia

– bilateral vocal fold paralysis

B. Expiratory obstruction is intrathoracic 1. Mimics asthma

2. Trachea, bronchi

– tracheomalacia, bronchomalacia – vascular rings, extrinsic compression

*Exceptions occur. Early symptoms of airway obstruction due to recurrent respiratory papillomatosis in the larynx are likely to occur during sleep.

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Choking Choking

• coughing spasm and sputtering coughing spasm and sputtering

 

complete blockage complete blockage of the

of the LARYNXLARYNX by solid & liquid by solid & liquid material

material

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Snoring & Obstructive Sleep Apnea Snoring & Obstructive Sleep Apnea

• repetitive repetitive UPPER AIRWAY UPPER AIRWAY OBSTRUCTION

OBSTRUCTION during sleep during sleep as a result of narrowing as a result of narrowing

of the respiratory of the respiratory

passages passages

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CONCLUSION

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