Larynx, laryngeal cartilages. The largest cartilage of the larynx. The structure of the human larynx and trachea. The larynx moves.

4.1. CLINICAL ANATOMY OF THE LARYNX

Larynx (Larynx) It is a hollow organ whose upper part opens into the laryngopharynx and the lower part passes into the trachea. The larynx is located under the hyoid bone on the front surface of the neck. The inside of the larynx is lined with a mucous membrane and consists of a cartilaginous skeleton connected by ligaments, joints and muscles. The upper edge of the larynx is located on the border of the IV and V cervical vertebrae, and the lower edge corresponds to the VI cervical vertebra. The outside of the larynx is covered with muscles, subcutaneous tissue and skin, which is easily displaced, allowing it to be palpated. The larynx makes active movements up and down when speaking, singing, breathing and swallowing. In addition to active movements, it passively shifts to the right and left, and the so-called crepitus of the laryngeal cartilages is noted. In the case of a malignant tumor, the active mobility of the larynx decreases, as well as its passive displacement.

In men, in the upper part of the thyroid cartilage, a protrusion or elevation is clearly visible and palpable - the Adam's apple, or Adam's apple. (prominentia laryngea, s. pomum Adami). In women and children it is less pronounced, soft and its palpation determination is difficult. In the lower part of the larynx in front, between the thyroid and cricoid cartilages, the area of ​​the conical ligament can be easily felt (lig. Conicum, s. cricothyreoideum), which is dissected (conicotomy) if it is necessary to urgently restore breathing in case of asphyxia.

Laryngeal cartilages. The skeleton of the larynx is made up of cartilage (cartilagines laryngis), connected by ligaments (Fig. 4.1 a, b). There are three single and three paired cartilages of the larynx:

Three singles:

1) cricoid cartilage (cartilago cricoidea);

2) thyroid cartilage (cartilago thyreoidea);

3) epiglottic cartilage (cartilago epiglotica) or epiglottis (epiglottis).

Rice. 4.1. Skeleton of the larynx:

a - front view; b - rear view: 1 - thyroid cartilage; 2 - cricoid cartilage; 3 - epiglottis; 4 - arytenoid cartilage; 5 - tracheal rings; b - hyoid bone

Three doubles:

1) arytenoid cartilages (cartilagines arytaenoidea);

2) horn-shaped cartilages (cartilagines corniculatae);

3) wedge-shaped cartilages (cartilagines cuneiformes, s. Wrisbergi).

Cricoid cartilage (cartilago cricoidea) is the basis of the skeleton of the larynx. In shape it really resembles a signet ring facing backwards. The narrow part facing forward is called the arc (arcus), and the extended back - with a signet or plate (lamina). The lateral surfaces of the cricoid cartilage have superior and inferior articular platforms for articulation with the arytenoid and thyroid cartilages, respectively.

Thyroid cartilage (cartilago thyreoidea), the largest cartilage of the larynx, located above the cricoid cartilage (Fig. 4.2). Thyroid cartilage confirms its name both by its appearance and its role in protecting the internal part of the organ. Two irregularly shaped quadrangular plates that make up the cartilage at the site of fusion

Rice. 4.2. Thyroid cartilage

in front along the midline they form a ridge, at the upper edge of which there is a notch (ta-sura thyreoidea). On the inner surface of the angle formed by the plates of the thyroid cartilage, there is an elevation to which the vocal folds are attached. At both sides

the posterior sections of the plates of the thyroid cartilage have processes extending upward and downward - the upper and lower horns (cornila). The lower ones - shorter ones - serve for articulation with the cricoid cartilage, and the upper ones are directed towards the hyoid bone, where they are connected to its large horns by the thyrohyoid membrane. On the outer surface of the plates of the thyroid cartilage there is an oblique line (linea oblique), running from back to front and from top to bottom, to which part of the external muscles of the larynx is attached.

Epiglottic cartilage (cartilago epiglottica), or epiglottis, is a leaf-shaped plate resembling a flower petal. Its wide part stands freely above the thyroid cartilage, is located behind the root of the tongue and is called the petal. Narrow lower part - stalk (petiolus epiglottis)- by means of a ligament it is attached to the inner surface of the angle of the thyroid cartilage. The shape of the lobe of the epiglottis varies depending on how much it is thrown back, elongated or curled, which is sometimes associated with errors during tracheal intubation.

Arytenoid cartilages (cartilagines arythenoideae) have the shape of triangular pyramids, the tops of which are directed upward, somewhat posteriorly and medially. The base of the pyramid articulates with the articular surface of the signet of the cricoid cartilage. To the anterointernal corner of the base of the arytenoid cartilage - the vocal process (processus vocalis)- the vocal muscle is attached, and to the anterior lateral (processus muscularis) - posterior and lateral cricoarytenoid muscles. The second part of the vocal muscle is fixed to the lateral surface of the pyramid of the arytenoid cartilage in the region of its anteroinferior third, where the oblong fossa is located.

Wedge-shaped cartilages (cartilagines cuneiformes, s. Wrisbergi) located in the thickness of the aryepiglottic fold.

Horn-shaped cartilages (cartilagines corniculatae) located above the apex of the arytenoid cartilages. Wedge-shaped and corniculate cartilages are small-sized sesamoid cartilages, not constant in shape and size.

Joints of the larynx. The larynx has two paired joints.

1. Cricothyroid joint (articulatio cricothyreoidea) formed by the lateral surface of the cricoid cartilage and the lower horn of the thyroid cartilage. By bending forward or backward at this joint, the thyroid cartilage thereby increases or decreases the tension of the vocal folds, changing the pitch of the voice.

2. Cricoarytenoid joint (articulatio cricoarytenoidea) formed by the lower surface of the arytenoid cartilage and the upper articular platform of the cricoid cartilage plate. Movements in the cricoarytenoid joint (forward, backward, medial and lateral) determine the width of the glottis.

Laryngeal ligaments (Fig. 4.3). The main ligaments of the larynx include:

Rice. 4.3. Laryngeal ligaments:

a - front view; b - rear view: 1 - lateral thyrohyoid, 2 - cricotracheal, 3 - cricothyroid, 4 - aryepiglottic fold

Thyrohyoid medial and lateral (tig. hyothyreoideum medium et lateralis);

thyroid-epiglottic (tig. thyreoepigtotticum);

sublingual-epiglottic (tig. hyoepigtotticum);

cricotracheal (tig. cricotracheate);

cricothyroid (tig. cricothyroideum);

aryepiglottic (tig. aryepigtotticum);

lingual-epiglottic medial and lateral (tig. gtossoepigtotticum medium et tateratis).

Thyrohyoid median and lateral ligaments are parts of the thyrohyoid membrane (membrana thyrohyoidea), with the help of which the larynx is suspended from the hyoid bone. The median thyrohyoid ligament connects the upper edge of the thyroid cartilage with the body of the hyoid bone, and the lateral ligament connects with the greater horns of the hyoid bone. The neurovascular bundle of the larynx passes through the hole in the outer part of the thyrohyoid membrane.

Thyroglottic ligament connects the epiglottis with the thyroid cartilage in the area of ​​its upper edge.

Hypoepiglottic ligament connects the epiglottis to the body of the hyoid bone.

Cricotracheal ligament connects the larynx with the trachea; located between the cricoid cartilage and the first ring of the larynx.

Cricoid or conical ligament connects the upper edge of the cricoid cartilage arch and the lower edge of the thyroid cartilage. The cricothyroid ligament is a continuation of the elastic membrane of the larynx (conus etasticus), which begins on the inner surface of the plates of the thyroid cartilage in the region of its angle. From here, the elastic bundles fan out vertically downwards towards the upper edge of the arch of the cricoid cartilage in the form of a cone, forming a conical ligament. The elastic membrane forms a layer between the inner surface of the cartilage and the mucous membrane of the larynx.

Vocal fold is the superior posterior bundle of the elastic cone; covers the vocal muscle, which is stretched between the inner surface of the angle of the thyroid cartilage in front and the vocal process (processus vocatis) arytenoid cartilage posteriorly.

aryepiglottic ligament located between the lateral edge of the epiglottis and the inner edge of the arytenoid cartilage.

Glossoepiglottic median and lateral ligaments They connect the middle and lateral parts of the root of the tongue with the anterior surface of the epiglottis; between them there are depressions - the right and left fossae of the epiglottis (valecula).

Muscles of the larynx (Fig. 4.4). All muscles of the larynx can be divided into two large groups:

1) external muscles involved in the movement of the entire larynx as a whole;

2) internal muscles that cause the movement of the cartilages of the larynx relative to each other; these muscles are involved in the functions of breathing, sound production and swallowing.

External muscles Depending on the place of attachment, they can be divided into two more groups:

Rice. 4.4. Muscles of the larynx:

a - external muscles: 1 - sternohyoid, 2 - geniohyoid, 3 - stylohyoid, 4 - digastric, 5 - sternothyroid, 6 - thyrohyoid, 7 - sternocleidomastoid, 8 - cricothyroid, 9 - omohyoid ; b - internal muscles: 1 - oblique arytenoid muscle, 2 - aryepiglottic, 3 - transverse arytenoid, 4 - posterior cricoarytenoid, 5 - cricothyroid

1 TO first group There are two paired muscles, one end of which is attached to the thyroid cartilage, and the other to the bones of the skeleton:

Sternothyroid (m. sternothyroideus);

thyrohyoid (m. thyrohyodeus).

2. Muscles second group attached to the hyoid bone and to the bones of the skeleton:

Sternohyoid (m. sternohyoideus);

omohyoid (m. omohyoideus);

stylohyoid (m. stylohyoideus);

Digastric (m. digastricus);

Geniohyoid (m. geniohyoideus). Internal muscles the larynx performs two main functions in the larynx

1. Change the position of the epiglottis during the act of swallowing and inhalation, performing a valve function.

The position of the epiglottis is changed by two pairs of antagonist muscles.

Arepiglottic muscle (m. aryepiglotticus) located between the apex of the arytenoid cartilage and the lateral edges of the epiglottis. Being covered with mucous membrane, this muscle forms the aryepiglottic fold in the area of ​​the lateral entrance to the larynx. During the act of swallowing, contraction of the aryepiglottic muscle leads to the retraction of the epiglottis backward and downward, due to which the entrance to the larynx is covered and food is displaced laterally into the pyriform fossa towards the entrance to the esophagus.

Thyroepiglotticus muscle (m. thyroepiglotticus) stretched on the sides of the thyroid epiglottis between the inner surface of the angle of the thyroid cartilage and the lateral edge of the epiglottis. When the thyroepiglottic muscle contracts, the epiglottis rises and the entrance to the larynx opens.

Lateral cricoarytenoid muscle (m. cricoarytenoideus lateralis)(paired) begins on the lateral surface of the cricoid

th cartilage and is attached to the muscular process of the arytenoid cartilage. When it contracts, the muscle processes move forward and down, and the vocal processes move closer together, narrowing the glottis.

Transverse arytenoid muscle (m. arytenoideus transverses) connects the posterior surfaces of the arytenoid cartilages with each other, which, when it contracts, come closer together, narrowing the glottis mainly in the posterior third.

Oblique arytenoid muscle (m. arytenoideus obliqus)(paired) begins on the posterior surface of the muscular process of one arytenoid cartilage and is attached to the apex of the arytenoid cartilage of the opposite side. Both oblique arytenoid muscles enhance the function of the transverse arytenoid muscle, located directly behind it, crossing each other at an acute angle.

Posterior cricoarytenoid muscle (m. cricoarytenoideus post. s. posticus) begins on the posterior surface of the cricoid cartilage and attaches to the muscular process of the arytenoid cartilage. When inhaling, it contracts, the muscular processes of the arytenoid cartilages rotate posteriorly, and the vocal processes, together with the vocal folds, move to the sides, expanding the lumen of the larynx. This is the only muscle that opens the glottis. When it is paralyzed, the lumen of the larynx closes and breathing becomes impossible.

Thyroarytenoid muscle (m. thyreoarytaenoides) begins on the inner surface of the plates of the thyroid cartilage. Going posteriorly and upward, it attaches to the lateral edge of the arytenoid cartilage. During contraction, the arytenoid cartilage rotates outward around its longitudinal axis and moves anteriorly.

Cricothyroid muscle (m. cricothyroideus) It is attached at one end to the anterior surface of the cricoid cartilage arch on the side of the midline, and at the other to the lower edge of the thyroid cartilage. When this muscle contracts, the thyroid cartilage bends forward, the vocal folds become tense, and the glottis narrows.

Vocal muscle (m. vocalis)- triceps, makes up the bulk of the vocal fold; begins in the region of the lower third of the angle formed by the inner surfaces of the plates of the thyroid cartilage, and is attached to the vocal process of the arytenoid cartilage.

A narrow strip of elastic connective tissue runs along the medial edge of the muscle; it plays a significant role in the formation of sound. When this muscle contracts, the vocal folds thicken and shorten, the elasticity, shape and tension of its individual sections change, which plays an important role in voice formation.

TOPOGRAPHY OF THE LARYNX

Larynx suspended from the hyoid bone by the thyrohyoid membrane; downwards it passes into the trachea, attached to it by the cricotracheal ligament. In front, the larynx is covered with skin, subcutaneous tissue, superficial fascia of the neck, and muscles. The fascia of the thyroid gland is attached to the lower part of the cricoid cartilage in front, the lateral parts of which cover the muscles (m. sternothyroideus et m. sternohyoideus). The anterolateral surface of the larynx is covered by the sternohyoid muscle, and under it are the sternothyroid and thyrohyoid muscles. At the back, the larynx borders the laryngeal part of the pharynx and the entrance to the esophagus. On the sides of the larynx lie neurovascular bundles.

Blood supply to the larynx carried out by two arteries:

Superior laryngeal (a. laryngea superior);

inferior laryngeal (a. laryngea inferior).

Superior laryngeal artery is a branch of the superior thyroid artery (a. thyreoidea superior), which, in turn, arises from the external carotid artery. The superior laryngeal artery is larger than the inferior one. As part of the neurovascular bundle of the larynx (a. laryngea superior, v. laryngea superior, ramus internus n. laryngei superior) the artery enters the larynx through an opening in the outer part of the thyrohyoid membrane. Inside the larynx, the superior laryngeal artery divides into smaller branches, where another branch arises from it - middle laryngeal artery (a. laryngea media), which anastomoses with the artery of the same name on the opposite side in front of the conical ligament.

Inferior laryngeal artery is a branch of the inferior thyroid artery (a. thyreoidea inferior), which originates from the thyrocervical trunk (truncus thyreocervicalis).

Venous drainage provided cranially through the superior thyroid vein (v. laryngea superior) into the internal jugular vein (v. jugularis interna), caudally - through the inferior thyroid vein (v. laryngea inferior) into the brachiocephalic vein (v. brachiocephalica).

Lymphatic system The larynx is divided into:

Upper section;

areas of the vestibular folds and laryngeal ventricles. From here, the lymph, converging with other lymphatic vessels, is directed along the neurovascular bundle of the larynx to the deep cervical lymph nodes located along the deep jugular vein.

Lymphatic vessels lower section pass under and above the cricoid cartilage, collecting in the preepiglottic lymph nodes. In addition, there is a connection with the deep cervical lymph nodes located along the deep jugular vein. Contralateral metastasis is possible here due to the existence of a connection with the pre- and paratracheal lymph nodes. The connection between the lymphatic system of the lower larynx and the mediastinal lymph nodes is of great clinical importance.

Innervation of the muscles of the larynx provided by two branches of the vagus nerve:

Superior laryngeal nerve (n. laryngeus superior);

inferior laryngeal nerve (n. laryngeus inferior s.n. recurrens).

Superior laryngeal nerve is mixed and originates from the vagus nerve in the region of the lower part of the vagus nerve ganglion (ganglion nodosum n. vagi). Posterior to the greater horn of the hyoid bone, the superior laryngeal nerve divides into two branches: the external branch (r. externus), motor, innervating the cricothyroid muscle, and the internal branch (r. internus), penetrating through the hole in the thyrohyoid membrane; it gives off sensitive branches to the mucous membrane of the larynx.

Inferior laryngeal nerve (n. recurens) mixed, innervates all the internal muscles of the larynx with the exception of the cricothyroid muscle and provides sensitive innervation to the mucous membrane of the lower floor of the larynx, including the area of ​​the vocal folds. The lower laryngeal nerves on different sides are continuations of the right and left recurrent nerves, which arise from the vagus nerve in the chest cavity at different levels. The right recurrent nerve departs from the vagus nerve at the level of the subclavian artery, the left - at the place where the vagus nerve bends around the aortic arch. Next, the recurrent nerves of both sides rise up to the larynx,

giving numerous branches to the trachea and esophagus on its way, while the right one is located on the side between the trachea and the esophagus, and the left one lies on the anterior surface of the esophagus on the left.

Sympathetic nerves arise from the superior cervical sympathetic cervicothoracic (stellate) ganglion (ganglion stellatum).

Laryngeal cavity (cavitas laryngis), shaped like an hourglass, narrowed in the middle section and widened upward and downward. According to clinical and anatomical characteristics, it is divided into three floors (Fig. 4.5):

upper- vestibule of the larynx (vestibulum laryngis)- located between the entrance to the larynx and the vestibular folds, has the appearance of a cone-shaped cavity, tapering downward;

Entrance to the larynx in front is limited by the epiglottis, behind - by the tips of the arytenoid cartilages and on the sides - by the aryepiglottis.

mi folds, in the lower part of which lie corniculate and wedge-shaped cartilages, forming tubercles of the same name. Between the aryepiglottic folds and the walls of the pharynx are located pear-shaped pockets (recessus piriformes), which behind the larynx pass into the esophagus. At the bottom of the pyriform sinus there is a fold of mucous membrane running posteriorly and downward, formed by the internal branch of the superior laryngeal nerve and the superior laryngeal

Rice. 4.5. Floors of the larynx: 1 - upper; 2 - average; 3 - lower

artery. The depressions between the median and lateral lingual-epiglottic folds, which connect the anterior surface of the epiglottis with the root of the tongue, are called lingual-epiglottic recesses, or valleculae (valleculae epiglotticae). At the level of the middle and lower third of the thyroid cartilage in the laryngeal cavity, on either side of the midline there are two pairs of horizontal folds of the mucous membrane. The top pair is called folds of the vestibule (plica vestibularis), lower - vocal folds (plica vocalis). The length of the vocal folds in newborns is 0.7 cm; for women - 1.6-2 cm; in men - 2-2.4 cm. On each side between the vocal and vestibular folds there are depressions - laryngeal(Morganii) ventricles (ventriculi laryngis), in which outward and anteriorly there is a pocket ascending upward. In the thickness of the mucous membrane of the laryngeal ventricles there is an accumulation of lymphadenoid tissue, which is sometimes called laryngeal tonsils, and when they are inflamed, accordingly, laryngeal tonsillitis. The width of the lumen (the glottis between the vocal folds in the posterior third) of the larynx in men is about 15-22 mm, in women - 13-18 mm, in a 10-year-old child - 8-11 mm.

The mucous membrane of the larynx is a continuation of the mucous membrane of the nasal cavity and pharynx and is covered mainly by multirow cylindrical ciliated epithelium. The vocal folds, the upper part of the epiglottis, the arytenoid folds and the laryngeal surface of the arytenoid cartilages are lined with stratified squamous epithelium, which is important to consider in the diagnosis of tumor diseases.

4.2. CLINICAL ANATOMY OF TRACHEA AND ESOPHAGUS

Trachea (tracheae) - this is a hollow cylindrical tube, which is a direct continuation of the larynx (Fig. 4.6). The trachea begins at the level of the body of the VII cervical vertebra and extends to the level of the bodies of the IV-V thoracic vertebrae, where it ends in a branching (bifurcation) into two main bronchi. The level of bifurcation is higher in young people. The length of the trachea is on average 10-13 cm. The wall of the trachea consists of 16-20 hyaline cartilages, shaped like a horseshoe, the arc of which faces forward, and the rear open ends are connected by a connective tissue membrane - the membranous part of the wall.

Rice. 4.6. Trachea skeleton

trachea ki (paries membranaceus tracheae). This membrane contains elastic and collagen fibers, and in deeper layers - longitudinal and transverse smooth muscle fibers. The width of the membranous wall ranges from 10 to 22 mm. Hyaline cartilage of the trachea (cartilagines trachealis) connected to each other by annular ligaments (lig. annularia). The inner surface of the trachea is lined with mucous membrane,

covered with columnar ciliated epithelium. In the submucosal layer there are mixed glands that produce a protein-mucosal secretion. On the inside of the trachea, at the point of its division into two main bronchi, a semilunar-shaped protrusion is formed - the junction of the medial walls of the main bronchi - the tracheal spur (carina trachea).

The right bronchus is wider, extends from the trachea at an angle of 15°, its length is 3 cm; the left one is at an angle of 45°, its length is 5 cm. Thus, the right bronchus is practically a continuation of the trachea, and therefore foreign bodies more often enter it.

TOPOGRAPHY OF THE TRACHEA

The trachea is attached superiorly to the cricoid cartilage by the cricotracheal ligament (lig. cricotrachaele). In the cervical part, the isthmus of the thyroid gland is adjacent to the anterior surface of the trachea, and its lobes are adjacent to the sides. Posteriorly, the trachea is adjacent to the esophagus. To the right of the trachea is the brachiocephalic trunk, to the left is the left common carotid artery (Fig. 4.7).

In the thoracic region in front of the trachea is the aortic arch. To the right of the trachea are the right pleural sac and the right vagus nerve, to the left are the aortic arch, left carotid and subclavian

Rice. 4.7. Topography of the trachea: 1 - thyroid gland; 2 - common carotid artery; 3 - aortic arch; 4 - thymus gland; 5 - vagus nerve

arteries, left recurrent nerve. In children under 16 years of age, the thymus gland is located in the thoracic region in front of the trachea.

Blood supply to the trachea carried out using the inferior thyroid (a. thyroidea inferior) and internal mammary arteries (a. thoracica interna), and also for

counting the bronchial branches of the thoracic aorta (rami bronchiales aortae thoracicae).

IN innervation of the trachea the recurrent and vagus nerves are involved (n. vagus) and tracheal branches of the inferior laryngeal nerve (n. laryngeus inferior). Sympathetic influence is represented by nerves arising from the sympathetic trunk (truncus sympathicus).

Lymph The trachea flows mainly into the lymph nodes located on both sides on its sides. In addition, the lymphatic system of the trachea has connections with the lymph nodes of the larynx, upper deep cervical and anterior mediastinal nodes.

Esophagus is a hollow organ in the form of a tube that connects the pharyngeal cavity with the stomach cavity. From above, the pharynx passes into the esophagus in the projection area of ​​the VI cervical vertebra at the level of the lower edge of the cricoid cartilage. Below, the junction of the esophagus with the stomach corresponds to the level of the XI thoracic vertebra. The length of the esophagus in an adult is on average 23-25 ​​cm, and the width is from 15 to 20 mm.

There are three sections in the esophagus:

Chest;

Abdominal.

Cervical region extends from the level of the VI cervical vertebra to the thoracic vertebra, its length ranges from 5 to 8 cm. The anterior border with the thoracic region is the level of the jugular notch.

Thoracic region has the greatest length - 15-18 cm and ends at the level of the X-XI thoracic vertebrae at the point of entry into the diaphragm through the esophageal opening (hiatus esophageus).

The abdominal section is 1-3 cm in length and ends in a slight expansion at the junction with the stomach.

Extending in front of the spine, the esophagus along its path has four bends (two in the sagittal and two in the frontal planes) and three narrowings. First narrowing located at the junction of the pharynx and the esophagus (15 cm from the upper edge of the incisors). The pressure of the aorta and the left main bronchus determines the existence second narrowing esophagus. Third narrowing- at the point of passage through hiatus esophageus(Fig. 4.8).

In the cervical region, on the sides, the common carotid arteries and recurrent laryngeal nerves are close to the esophagus. In the thoracic region, at the level of the IV-V thoracic vertebrae, the esophagus passes next to the aortic arch. In the lower third, the esophagus touches the pericardium and passes into the abdominal part, which is covered in front by the left lobe of the liver.

The wall of the esophagus has three layers: internal (mucous), middle (muscular) and external (connective tissue).

Innervation the esophagus is carried out by the esophageal plexus (plexus esophagealis).

Blood supply the esophagus in the cervical region is carried out by the lower thyroid gland

Rice. 4.8. Physiological narrowing of the esophagus

no artery (a. thyroidea inferior), in the thoracic region - esophageal and bronchial arteries (aa. esophageae, bronchiales), in the abdominal region - the left gastric artery (a. gastrica sinistra), inferior left renal artery (a. phrenica inferior sinistra).

4.3. CLINICAL PHYSIOLOGY OF THE LARRYNX, TRACHEA AND ESOPHAGUS

The larynx and trachea perform respiratory, protective and vocal functions.

Respiratory function- the larynx conducts air to the lower sections - the trachea, bronchi and lungs. When inhaling, the glottis expands, and the size of the glottis varies depending on the needs of the body. With a deep breath, the glottis expands more, so that even the bifurcation of the trachea is often visible.

The opening of the glottis occurs reflexively. The inhaled air irritates numerous nerve endings in the mucous membrane, from which impulses are transmitted along the afferent fibers of the upper laryngeal nerve through the vagus nerve to the respiratory center at the bottom of the fourth stomach. From there, motor impulses travel through efferent fibers to the muscles that expand the glottis. Under the influence of this irritation, the function of other muscles involved in the respiratory act, the intercostal and diaphragm muscles, increases.

Protective function larynx is associated with the presence of three reflexogenic zones of the mucous membrane of the larynx (Fig. 4.9):

The first of them is located around the entrance to the larynx (the laryngeal surface of the epiglottis, the mucous membrane of the aryepiglottic folds);

The third zone is located in the subglottic space on the inner surface of the cricoid cartilage. The receptors embedded in these areas have all types of sensitivity - tactile, temperature, chemical. When the mucous membrane of these areas is irritated, a spasm of the glottis occurs, due to which the underlying respiratory tract is protected from saliva, food and foreign objects.

Rice. 4.9. Reflexogenic zones of the larynx (indicated by arrows)

An important manifestation of the protective function of the larynx is also a reflex cough that occurs when the reflexogenic zones of the larynx and subglottic space are irritated. A cough expels foreign objects that enter the respiratory tract with air.

Finally, at the level of the entrance to the larynx, the respiratory and digestive tracts are separated. Here, in the figurative expression of V.I. Vojacek,

there is a smoothly functioning railway switch mechanism. During the act of swallowing, the larynx rises upward and anteriorly to the root of the tongue, the epiglottis bends backward and closes the entrance to the larynx, approaching the posterior wall of the pharynx. Food masses flow around the epiglottis on both sides and enter the pyriform sinuses, and then into the mouth of the esophagus, which at this moment opens. In addition, during swallowing movements, the vestibular folds close and the arytenoid cartilages bend forward.

All parts of the respiratory apparatus are involved in the mechanics of sound reproduction and speech formation: 1) lungs, bronchi and trachea (lower resonator); 2) vocal apparatus of the larynx; 3) the oral cavity, pharynx, nose and paranasal sinuses, in which sound resonates and which can change their shape by movements of the lower jaw, lips, palate and cheeks (upper resonator).

For sound to be produced, the glottis must be closed. Under the pressure of air from the lower resonator, the glottis opens due to the elasticity and elasticity of the vocal folds. Thanks to these forces, after stretching and upward deflection, the phase begins

return, and the glottis closes again. Then the cycle is repeated, during which the air stream vibrates over the vocal folds and at the same time the vocal folds themselves vibrate. They perform oscillatory movements in the transverse direction, inward and outward, perpendicular to the stream of exhaled air. The frequency of oscillatory movements of the vocal folds corresponds to the height of the emitted tone, i.e. sound is created. Wanting to pronounce a sound of a certain height, a person, contracting the laryngeal muscles in a certain way, reflexively gives the vocal folds the necessary length and tension, and the upper resonators a certain shape. The vibration pattern of the vocal folds is similar to the vibration of a steel plate in the form of a ruler, one end of which is clamped and the other is free. If you tilt and release its free end, it will vibrate and make a sound. In the larynx the same scheme occurs, only the force causing the oscillations (air pressure in the trachea) acts for an arbitrarily long time. All this relates to the normal formation of sound - chest register. The name comes from the fact that when pronouncing a sound, you can feel the trembling of the front wall of the chest with your hand.

In contrast to this, when falsetto The glottis does not completely close; a narrow gap remains, through which air passes with increasing force, causing only the edges of the folds close together to vibrate. Thus, if in the chest register the vocal folds are tense, thickened and closed, then in falsetto they appear flat, very stretched and not completely closed, so the sound is high, but weaker than the chest one.

Sound has its own characteristics and varies according to pitch, timbre and strength. The pitch of the sound is related to the frequency of vibration of the vocal folds, and the frequency, in turn, is related to their length and tension. As a person grows, the size of the vocal folds changes, which leads to a change in voice. A change in voice, or its fracture (mutation), occurs during puberty (between 12 and 16 years). For boys, the voice changes from treble or alto to tenor, baritone or bass, for girls - to soprano or contralto. Oral and nasal cavities,

being an upper resonator, they enhance some overtones of the guttural sound, as a result of which it acquires a certain timbre. By changing the position of the cheeks, tongue, lips, you can arbitrarily change the timbre of sounds, but only within certain limits. The characteristics of the timbre of each person’s voice, although they depend on gender and age, are exceptionally individual, so we recognize the voices of familiar people.

Physiological role of the esophagus- carrying food into the stomach. In the oral cavity, the food bolus is pre-crushed and moistened with saliva. The tongue pushes the prepared bolus of food to the root of the tongue, which causes the act of swallowing. At this time, the larynx rises upward. The entrance to the larynx is closed by the epiglottis, the return of food back to the oral cavity is blocked by the raised root of the tongue, and the food bolus, moving along the pyriform sinuses, enters the esophagus. The passage of food through the esophagus occurs as a result of its peristaltic movements: the section of the esophagus lying directly above the food bolus contracts, and the underlying section relaxes, the bolus is, as it were, pressed into the section of the esophagus that has opened in front of it. This passage of the lump through the esophagus to the stomach takes 4-5 seconds.

Swallowing is a complex reflex act. Contraction of the muscles of the swallowing apparatus is carried out reflexively with the participation of the cerebral cortex and the vagus nerve. A prerequisite for swallowing is stimulation of the receptors of the pharynx and the mucous membrane of the esophagus.

4.4. ACUTE INFLAMMATORY DISEASES OF THE LARYNX AND TRACHEA

Acute inflammatory diseases of the larynx and trachea often occur as a manifestation of acute inflammatory diseases of the upper respiratory tract. The cause may be a wide variety of flora: bacterial, fungal, viral, mixed.

4.4.1. Acute catarrhal laryngitis

Acute catarrhal laryngitis (laryngitis) - acute catarrhal inflammation of the mucous membrane of the larynx. As an independent disease, it occurs as a result of activation of flora,

saprophytic in the larynx under the influence exogenous and endogenous factors. Among exogenous factors such as hypothermia, irritation of the mucous membrane, exposure to occupational hazards (dust, gases, etc.), prolonged loud conversation in the cold, consumption of very cold or very hot food play a role. Endogenous factors: decreased immune reactivity, gastrointestinal diseases, allergic reactions, age-related atrophy of the mucosa. Acute catarrhal laryngitis often occurs during puberty, when voice mutation occurs. Among the various etiological factors Bacterial flora plays a role in the occurrence of this disease - B-hemolytic streptococcus, streptococcus pneumoniae, viral infections; influenza viruses (A and B), parainfluenza, coronavirus, rhinovirus, fungal flora. Mixed flora is often found.

Clinical picture characterized by the appearance of hoarseness, soreness, discomfort and a foreign body in the throat. The temperature is often normal, less often it rises to low-grade fever. Violations of the voice-forming function are expressed in the form of varying degrees of dysphonia. Sometimes the patient is bothered by a dry cough, which is subsequently accompanied by expectoration of sputum.

Pathomorphological changes are reduced to circulatory disorders, hyperemia, small cell infiltration and serous impregnation of the laryngeal mucosa. When inflammation spreads to the vestibular part of the larynx, the vocal folds may be covered by swollen, infiltrated vestibular folds. When the subglottic region is involved in the process, the clinical picture of false croup (subglottic laryngitis) occurs.

Diagnostics does not present any particular difficulties, since it is based on pathognomonic signs: acute onset of hoarseness, often associated with a specific cause (cold food, ARVI, colds, speech stress, etc.); a characteristic laryngoscopic picture is pronounced hyperemia of the mucous membrane of the entire larynx or only the vocal folds, thickening, swelling and incomplete closure of the vocal folds; absence of temperature reaction if there is no respiratory infection. Acute laryngitis should also include those cases when there is only marginal hyperemia of the vocal folds, since this is a limited process, like

diffuse, tends to become chronic. In children, laryngitis must be differentiated from the common form of diphtheria. Pathoanatomical changes in this case will be characterized by the development of fibrinous inflammation under the vocal folds with the formation of dirty gray films intimately associated with the underlying tissues (true croup).

Erysipelas of the laryngeal mucosa differs from the catarrhal process by its clearly defined boundaries and simultaneous disease of the skin of the face.

Treatment. With timely and adequate treatment, the disease ends within 10-14 days; a duration of more than 3 weeks most often indicates a transition to a chronic form. The most important and necessary therapeutic measure is compliance with the voice mode (silence mode) until the acute inflammatory phenomena subside. Failure to adhere to a gentle vocal regimen will not only delay recovery, but will also contribute to the process becoming chronic. Eating spicy, salty foods, alcoholic drinks, and smoking is not recommended. Drug therapy is mainly local in nature. Inhalation and irrigation of the laryngeal mucosa with combined preparations containing anti-inflammatory components (Bioparox, IRS-19, etc.), infusion into the larynx of medicinal mixtures of corticosteroids, antihistamines and antibiotics for 7-10 days are effective. Effective mixtures for infusion into the larynx, consisting of 1% oil solution of menthol, hydrocortisone emulsion with the addition of a few drops of 0.1% solution of adrenaline hydrochloride. In the room where the patient is located, it is advisable to maintain high air humidity.

For streptococcal and pneumococcal infections, accompanied by fever and intoxication of the body, general antibiotic therapy is prescribed: penicillin drugs (phenoxymethylpenicillin 1 million 4-6 times a day, amoxicillin 500 mg 2 times a day) or macrolides (for example, sumamed 500 mg 1 time per day).

Forecast favorable with appropriate treatment and compliance with the voice regime.

4.4.2. Infiltrative laryngitis

Infiltrative laryngitis (laryngitis infiltrativa) - acute inflammation of the larynx, in which the process is not limited to the mucous membrane, but spreads to deeper tissues. The process may involve the muscular system, ligaments, and perichondrium.

Etiological factor is a bacterial infection that penetrates the tissue of the larynx during injury or after an infectious disease. A decrease in local and general resistance is a predisposing factor in the etiology of infiltrative laryngitis. The inflammatory process can occur in a limited or diffuse form.

Clinic depends on the degree and prevalence of the process. At spilled form the entire mucous membrane of the larynx is involved in the inflammatory process, with limited- its individual sections: interarytenoid space, vestibular region, epiglottis, subglottic space. The patient complains of pain that intensifies when swallowing, severe dysphonia, high body temperature, and poor health. There may be a cough with expectoration of thick mucopurulent sputum. Against the background of these symptoms, respiratory dysfunction may occur. Regional lymph nodes are enlarged, dense and painful on palpation.

With irrational therapy or a highly virulent infection, acute infiltrative laryngitis can turn into a purulent form - phlegmonous laryngitis (laryngitis phlegmonosa). In this case, pain symptoms sharply intensify, body temperature rises, general condition worsens, breathing becomes difficult, up to asphyxia. Indirect laryngoscopy reveals an infiltrate, where a limited abscess can be visible through the thinned mucous membrane, which confirms the formation of an abscess. Laryngeal abscess may be the final stage of infiltrative laryngitis and occurs predominantly on the lingual surface of the epiglottis or in the area of ​​one of the arytenoid cartilages.

Treatment, usually performed in a hospital setting. Antibiotic therapy is prescribed to the maximum extent possible for a given age.

rasta dosage, antihistamines, mucolytics, and, if necessary, short-term corticosteroid therapy. Emergency surgery is indicated in cases where an abscess is diagnosed. After local anesthesia, the abscess (or infiltrate) is opened with a laryngeal knife. At the same time, massive antibiotic therapy, antihistamine therapy, corticosteroid drugs, detoxification and transfusion therapy are prescribed. It is also necessary to prescribe analgesics.

Usually the process stops quickly. Throughout the disease, you need to carefully monitor the condition of the lumen of the larynx and, without waiting for the moment of asphyxia, perform a tracheostomy.

In the presence of diffuse phlegmon spreading to the soft tissues of the neck, external incisions must be made with wide drainage of purulent cavities.

It is important to constantly monitor your breathing function. If signs of acute increasing stenosis appear, emergency tracheostomy is required, and if there is a danger of asphyxia, conicotomy is required.

4.4.3. Subglottic laryngitis (false croup)

False croup (laryngitis subchordalis, false croup) - acute laryngitis with a predominant localization of the process in the subglottic space. It is usually observed in children under the age of 5-8 years, which is associated with the structural features of the subvocal space: the loose tissue under the vocal folds in young children is highly developed and easily reacts to irritation by an infectious agent. The development of stenosis is also facilitated by the narrowness of the larynx in children and the lability of nervous and vascular reflexes. When the child is in a horizontal position, due to blood flow, the swelling increases, so the deterioration of the condition is more pronounced at night.

Clinical picture. The disease usually begins with inflammation of the upper respiratory tract, nasal congestion and discharge, low-grade fever, and cough. The general condition of the child during the day is quite satisfactory. At night, a sudden attack of suffocation, a barking cough, and cyanosis of the skin begin. Dyspnea is predominantly inspiratory, accompanied by

retraction of the soft tissues of the jugular fossa, supra- and subclavian spaces, and epigastric region. This condition lasts from several minutes to half an hour, after which profuse sweating appears, breathing returns to normal, and the child falls asleep. Such conditions may recur after 2-3 days.

Laryngoscopy picture subchordal laryngitis appears in the form of a roll-shaped symmetrical swelling, hyperemia of the mucous membrane of the subglottic space (RIS). These ridges protrude from under the vocal folds, significantly narrowing the lumen of the larynx and thereby making breathing difficult.

Diagnostics. It is necessary to differentiate from true diphtheria croup. The term “false croup” indicates that the disease is opposed to true croup, when there are fibrinous films under the vocal folds, i.e. diphtheria of the larynx. However, with subglottic laryngitis (false croup), the disease is paroxysmal in nature - a satisfactory condition during the day is changed by difficulty breathing and increased temperature at night. The voice with diphtheria is hoarse, with subglottic laryngitis it is not changed. With diphtheria there is no barking cough, which is characteristic of false croup. With subglottic laryngitis, there is no significant enlargement of regional lymph nodes; there are no films characteristic of diphtheria in the pharynx and larynx. However, it is always necessary to carry out bacteriological examination of smears of pieces of film from the pharynx, larynx and nose for diphtheria bacillus.

Treatment aimed at eliminating the inflammatory process and restoring breathing. Inhalation of a mixture of decongestant drugs is effective: 5% ephedrine solution, 0.1% adrenaline solution, 0.1% atropine solution, 1% diphenhydramine solution, hydrocortisone 1.0 and chymopsin. Antibiotic therapy is required, which is prescribed in the maximum dose for a given age, as well as antihistamine therapy and sedatives. The administration of hydrocortisone or prednisolone at a rate of 2-4 mg/kg of the child’s weight is also indicated. Drinking plenty of water has a beneficial effect: tea, milk, alkaline mineral waters, distracting procedures - foot baths, mustard plasters.

You can try to stop an attack of suffocation by quickly touching the back of the throat with a spatula, thereby causing a gag reflex.

In cases where the above measures are powerless and suffocation becomes threatening, it is necessary to resort to nasotracheal intubation for 3-4 days; if necessary, tracheotomy is indicated.

4.4.4. Laryngeal sore throat

Laryngeal sore throat (angina laryngis) is an acute infectious disease affecting the lymphadenoid tissue of the larynx, located in the Morganian ventricles, thicker than the mucous membrane of the aryepiglottic folds, at the bottom of the pyriform sinus, as well as in the area of ​​the lingual surface of the epiglottis. It is relatively rare and can occur under the guise of acute laryngitis.

Etiological factors causing the inflammatory process are a variety of bacterial, fungal and viral flora. Penetration of the pathogen into the mucous membrane can occur through airborne droplets or alimentary routes. Hypothermia and trauma to the larynx also play a role in the etiology.

Clinical picture is in many ways similar to the manifestations of tonsillitis of the palatine tonsils. I am worried about a sore throat, which gets worse when swallowing and when turning the neck. Dysphonia and difficulty breathing are possible. The temperature with laryngeal sore throat is high - up to 39 ° C, the pulse is rapid. On palpation, regional lymph nodes are painful and enlarged.

Laryngoscopy reveals hyperemia and infiltration of the mucous membrane of the larynx, sometimes narrowing the lumen of the respiratory tract, and individual follicles with pinpoint purulent deposits. With a prolonged course, an abscess may form on the lingual surface of the epiglottis, the aryepiglottic fold and other places where lymphadenoid tissue accumulates (Fig. 4.10).

Diagnostics. Indirect laryngoscopy with appropriate anamnestic and clinical data allows you to make the correct diagnosis. Laryngeal sore throat should be differentiated from diphtheria, which may have a similar course.

Treatment includes broad-spectrum antibiotics (augmentin, amoxiclav, cefazolin, kefzol, etc.), antihistamines (tavegil, fenkarol, peritol, claritin, etc.), mucolytics, analgesics, antipyretics. If signs of respiratory distress occur, short-term corticosteroid therapy is added to treatment for 2-3 days. If the stenosis is significant, emergency tracheotomy is indicated.

Rice. 4.10. Abscess of the epiglottis

4.4.5. Laryngeal edema

Laryngeal edema (oedema laryngis)- a rapidly developing vasomotor-allergic edematous process in the mucous membrane of the larynx, narrowing its lumen; As a rule, it is a secondary manifestation of any disease of the larynx, and not an independent nosological form.

Etiology. The causes of acute laryngeal edema may be:

Inflammatory processes of the larynx (subglottic laryngitis, acute laryngotracheobronchitis, chondroperichondritis, etc.);

Acute infectious diseases (diphtheria, measles, scarlet fever, influenza, etc.);

Tumors of the larynx (benign, malignant);

Laryngeal injuries (mechanical, chemical);

Allergic diseases;

Pathological processes in organs adjacent to the larynx and trachea (tumors of the mediastinum, esophagus, thyroid gland, retropharyngeal abscess, phlegmon of the neck, etc.).

Clinic. Narrowing of the lumen of the larynx and trachea can develop instantly (foreign body, spasm), acutely (infectious diseases, allergic processes, etc.) and chronically (against the background of a tumor). The clinical picture depends on the degree of narrowing of the lumen of the larynx and the speed of its development: the faster the stenosis develops, the more dangerous it is. With the inflammatory etiology of edema, pain in the throat that intensifies when swallowing, a sensation of a foreign body, and a change in voice are disturbing. The spread of edema to the mucous membrane of the arytenoid cartilages, aryepiglottic folds and subglottic space contributes to the appearance of acute laryngeal stenosis, which causes a severe picture of suffocation that threatens the patient’s life (see “Laryngeal stenosis”).

During laryngoscopic examination, swelling of the mucous membrane of the affected part of the larynx is determined in the form of a watery or gelatinous swelling. The epiglottis is sharply thickened; there may be elements of hyperemia, the process extends to

It is characteristic that with the inflammatory etiology of edema, reactive phenomena of varying degrees of severity, hyperemia and injection of mucosal vessels are observed; with non-inflammatory etiology, hyperemia is usually absent.

Diagnostics does not cause any difficulties. Respiratory impairment of varying degrees and a characteristic laryngoscopic picture make it possible to correctly identify the disease. It is more difficult to find out the cause of the swelling. In some cases, the hyperemic, edematous mucous membrane covers a tumor, foreign body, etc. in the larynx. Along with indirect laryngoscopy, in some cases it is necessary to do bronchoscopy, radiography of the larynx and chest, as well as other studies.

Treatment It is carried out in a hospital setting and is aimed primarily at restoring external respiration. Depending on the severity of clinical manifestations, conservative and surgical treatment methods are used.

Conservative methods are indicated for compensated and subcompensated stages of narrowing of the airways and include the following:

1) broad-spectrum antibiotics parenterally (cephalosporins, semisynthetic penicillins, macrolides, etc.);

2) antihistamines (0.25% solution of pipolfen IM, Tavegil, etc.);

3) corticosteroid therapy (hydrocortisone solution, prednisolone 3% - up to 120 mg IM); It is recommended to administer calcium gluconate 10% - 10 ml IM, glucose 40% - 20 ml simultaneously with 5 ml of ascorbic acid IV;

4) dehydration agents [furosemide (Lasix) 20-40 mg IM or IV; bumetanide 1-2 mg IV; hypothiazide, tab; veroshpiron, tab; And

The simultaneous administration of drugs containing antihistamines, corticosteroids and dehydration drugs (parenterally or intravenously) effectively eliminates signs of acute stenosis and improves breathing - drug destenosis.

If the swelling is severe and there is no positive dynamics, the dose of administered corticosteroid drugs can be increased. A faster effect is obtained by intravenous administration of 200 ml of isotonic sodium chloride solution with the addition of 90 mg of prednisolone, 10 ml of 10% calcium chloride, Lasix.

The lack of effect of conservative treatment and the appearance of decompensated stenosis require immediate tracheostomy. In case of asphyxia, an emergency conicotomy is performed, and then, after restoration of external respiration, a tracheostomy is performed.

4.4.6. Acute tracheitis

Acute tracheitis (tracheitis acuta) - acute inflammation of the mucous membrane of the lower respiratory tract (trachea and bronchi), rarely found in isolation; in most cases, acute tracheitis is combined with inflammatory changes in the upper respiratory tract - the nose, pharynx and larynx.

Etiology. The cause of acute tracheitis is infections, the pathogens of which saprophyte in the respiratory tract and are activated under the influence of various exogenous factors; viral infections, exposure to unfavorable climatic conditions, hypothermia, occupational hazards, etc.

Most often, when examining tracheal discharge, bacterial flora is detected: Staphylococcus aureus, H. influenzae, Streptococcus pneumoniae, Moraxella catarrhallis and etc.

Pathomorphology. Morphological changes in the trachea are characterized by hyperemia of the mucous membrane, edema, focal or diffuse infiltration of the mucous membrane, blood filling and dilation of the blood vessels of the mucous membrane.

Clinic. A typical clinical sign of tracheitis is a paroxysmal cough, especially at night. At the beginning of the disease, the cough is dry, then sputum of a mucopurulent nature, sometimes streaked with blood, appears. After a coughing attack

There are varying degrees of pain behind the sternum and in the larynx. The voice sometimes loses sonority and becomes hoarse. In some cases, low-grade fever, weakness, and malaise are observed.

Diagnosis is established on the basis of the results of laryngotracheoscopy, anamnesis, patient complaints, microbiological examination of sputum, and radiography of the lung.

Treatment. The patient must be provided with warm, moist air in the room. Expectorants (licorice root, mucaltin, glycyram, etc.) and antitussives (libexin, tusuprex, sinupret, bronholitin, etc.), mucolytic drugs (acetylcysteine, fluimucil, bromhexine), antihistamines (suprastin, pipolfen, claritin, etc.) are prescribed. ), paracetamol. The simultaneous administration of expectorants and antitussives should be avoided. The use of mustard plasters on the chest and foot baths has a good effect.

When body temperature rises, antibacterial therapy (amoxicillin, augmentin, amoxiclav, cefazolin, etc.) is recommended to prevent descending infection.

Forecast with rational and timely therapy, it is favorable and ends with recovery within 2-3 weeks. At the same time, the disease can take a protracted course or become chronic; sometimes complicated by descending infection: bronchopneumonia, pneumonia.

4.5. CHRONIC INFLAMMATORY DISEASES OF THE LARYNX

Chronic inflammatory disease of the mucous membrane and submucosal layer of the larynx and trachea occurs under the influence of the same reasons as in the case of acute diseases: exposure to unfavorable household, professional, climatic, constitutional and anatomical factors. Sometimes an inflammatory disease becomes chronic from the very beginning, for example in diseases of the cardiovascular and pulmonary systems.

There are the following forms of chronic inflammation in the larynx: catarrhal, atrophic, hyperplastic, diffuse or limited, subglottic laryngitis and pachyderma of the larynx.

4.5.1. Chronic catarrhal laryngitis

Chronic catarrhal inflammation of the laryngeal mucosa (laryngitis chronica catarrhalis) - the most common and mildest form of chronic inflammation. The main etiological role in this pathology is played by long-term stress on the vocal apparatus (singers, lecturers, teachers, etc.). The impact of unfavorable exogenous factors: climatic, professional and bad habits is also important.

Clinic. The most common symptom is hoarseness, a disorder of the voice-forming function of the larynx, fatigue, and a change in voice timbre. Depending on the severity of the disease, tickling, dryness, sensations of a foreign body in the larynx, and cough are also disturbing. There is a smoker's cough, which occurs against the background of prolonged smoking and is characterized by a constant, rare, mild cough.

During laryngoscopy moderate hyperemia, swelling of the mucous membrane of the larynx is determined, more in the area of ​​the vocal folds, and pronounced injection of the vessels of the mucous membrane.

Diagnostics is not difficult and is based on the characteristic clinical picture, medical history and data from indirect laryngoscopy.

Treatment. It is necessary to eliminate the influence of the etiological factor; it is recommended to maintain a gentle vocal regime (exclude loud and prolonged speech). Treatment is mainly local. During an exacerbation, infusion of an antibiotic solution with a suspension of hydrocortisone into the larynx is effective: 4 ml of isotonic sodium chloride solution with the addition of 150,000 units of penicillin, 250,000 units of streptomycin, 30 mg of hydrocortisone. This composition is poured into the larynx 1-1.5 ml twice a day. The same composition can be used for inhalation. The course of treatment is carried out for 10 days.

When using drugs locally, antibiotics can be changed after culture of the flora and detection of sensitivity to antibiotics. You can also exclude hydrocortisone from the composition, and add chymopsin or fluimucil, which have secretolytic and mucolytic effects.

The administration of aerosols for irrigation of the laryngeal mucosa with combined preparations, which include an antibiotic, an analgesic, an antiseptic (bioparox,

IRS-19). The use of oil and alkaline oil inhalations must be limited, since these drugs have a negative effect on the ciliated epithelium, inhibiting and completely stopping its function.

A major role in the treatment of chronic catarrhal laryngitis belongs to climatotherapy in conditions of a dry sea coast.

Forecast relatively favorable with proper therapy, which is repeated periodically. Otherwise, the disease may transition into hyperplastic or atrophic forms.

4.5.2. Chronic hyperplastic laryngitis

Chronic hyperplastic (hypertrophic) laryngitis (laryngitis chronica hyperplastica) characterized by limited or diffuse hyperplasia of the laryngeal mucosa. The following types of hyperplasia of the laryngeal mucosa are distinguished:

Pachyderma of the larynx;

Chronic subglottic laryngitis;

Prolapse, or prolapse, of the Morganian ventricle.

Clinic. The patient's main complaint is varying degrees of severe persistent hoarseness, voice fatigue, and sometimes aphonia. During exacerbations, the patient is bothered by soreness, a sensation of a foreign body when swallowing, and a rare cough with mucous discharge.

Diagnostics.Indirect laryngoscopy and stroboscopy make it possible to detect limited or diffuse hyperplasia of the mucous membrane, the presence of thick mucus both in the interarytenoid and in other parts of the larynx.

At diffuse form hyperplastic process, the mucous membrane is thickened, pasty, hyperemic; the edges of the vocal folds are thickened and deformed throughout, which prevents their complete closure.

At limited form (singing nodules) the mucous membrane of the larynx is pink without any significant changes; on the border between the anterior and middle thirds of the vocal folds, on their edges there are symmetrical formations in the form of connective tissue outgrowths (nodules) on a wide base with a diameter of 1-2 mm.

At pachyderma of the larynx in the interarytenoid space, the mucous membrane is thickened, on its surface there are limited epidermal outgrowths that externally resemble small tuberosities; there may be granulations on the posterior third of the vocal folds and the interarytenoid space. In the lumen of the larynx there is scanty viscous discharge and crusts in places.

Prolapse (prolapse) of the Morganian ventricle occurs as a result of prolonged voice overstrain and inflammation of the ventricular mucosa. During forced exhalation, phonation, and coughing, the hypertrophied mucous membrane protrudes from the ventricle of the larynx and partially covers the vocal folds, preventing complete closure of the glottis, causing the hoarse sound of the voice.

Chronic subglottic laryngitis with indirect laryngoscopy, it resembles a picture of false croup, while there is hypertrophy of the mucous membrane of the subglottic space, narrowing the glottis. Anamnesis and endoscopic microlaryngoscopy and biopsy can clarify the diagnosis.

Differential diagnosis. Limited forms of hyperplastic laryngitis must be differentiated from specific infectious granulomas, as well as neoplasms. Appropriate serological reactions and biopsy followed by histological examination help in making the diagnosis. Clinical experience shows that specific infiltrates do not have a symmetrical localization, as in hyperplastic processes.

Treatment. It is necessary to eliminate the impact of harmful exogenous factors and mandatory adherence to gentle vocal

Rice. 4.11. Limited form of hyperplastic laryngitis (singing nodules)

th mode. During periods of exacerbation, treatment is carried out as for acute catarrhal laryngitis.

In case of hyperplasia of the mucous membrane, targeted shading of the affected areas of the larynx is performed after 2-3 days with 10-20% lapis solution for 2 weeks. Significant limited hyperplasia of the mucous membrane is an indication for endolaryngeal removal followed by histological examination of the biopsy specimen. The operation is performed using local topical anesthesia with lidocaine 10%, cocaine 2%, dicaine 2%. Currently, such interventions are performed using endoscopic endolaryngeal methods.

4.5.3. Chronic atrophic laryngitis

Chronic atrophic laryngitis (laryngitis chronica atrophica)- the disease is in isolated form and is rare. The cause of the development of atrophic laryngitis is most often atrophic rhinopharyngitis. Environmental conditions, occupational hazards (dust, hot air gases, etc.), diseases of the gastrointestinal tract, and lack of normal nasal breathing contribute to the development of atrophy of the laryngeal mucosa.

Clinic. The leading complaints with atrophic laryngitis are a feeling of dryness, soreness in the larynx and a sensation of a foreign body in the larynx, as well as dysphonia of varying severity. When coughing up, there may be streaks of blood in the sputum due to a violation of the integrity of the epithelium of the mucous membrane at the time of the cough impulse.

During laryngoscopy, the mucous membrane is thinned, smooth, shiny, and in places covered with viscous mucus and crusts. The vocal folds are somewhat thinned. During phonation, they do not close completely, leaving an oval-shaped gap, in the lumen of which there may also be crusts.

Treatment. Rational therapy includes eliminating the cause of the disease. It is necessary to avoid smoking and eating irritating foods. A gentle voice mode should be observed. Medications are prescribed to help thin mucus and facilitate its easy expectoration: pharyngeal irrigation and inhalation with isotonic sodium chloride solution (200 ml) with the addition of 5 drops of 10% iodine tincture. Procedures are carried out according to

2 times a day, using 30-50 ml of solution per session, in long courses for 5-6 weeks. Inhalations of 1-2% menthol solution in oil are periodically prescribed. An oil solution of menthol 1-2% can be poured into the larynx daily for 10 days. To enhance the activity of the glandular apparatus of the mucous membrane, 30% potassium iodide solution is prescribed, 8 drops 3 times a day orally for 2 weeks (before prescribing, it is necessary to determine iodine tolerance).

In case of an atrophic process simultaneously in the larynx and nasopharynx, a good effect is achieved by submucosal infiltration into the lateral sections of the posterior pharyngeal wall of a solution of novocaine and aloe (2 ml of 1% novocaine solution with the addition of 2 ml of aloe). The composition is injected under the mucous membrane of the pharynx, 2 ml in each direction at a time. Injections are repeated at intervals of 5-7 days; only 7-8 procedures.

4.6. ACUTE AND CHRONIC LARRYNAL STENOSIS

AND TRACHEA

Stenosis of the larynx and trachea is expressed in the narrowing of their lumen, which prevents the passage of air into the underlying respiratory tract, which leads to insufficiency of external respiration, expressed to varying degrees, up to asphyxia.

The general phenomena for stenosis of the larynx and trachea are almost the same, treatment measures are also similar, so it is advisable to consider laryngeal and tracheal stenoses together. Acute or chronic stenosis of the larynx and trachea is not a separate nosological unit, but a symptom complex of a disease of the respiratory tract and adjacent areas. This pathology can develop quickly or slowly, accompanied by severe disturbances in the vital functions of the respiratory and cardiovascular systems, requiring emergency assistance. Often, delay in providing it can lead to the death of the patient.

4.6.1. Acute stenosis of the larynx and trachea

Acute laryngeal stenosis is much more common than tracheal stenosis. This is explained by the more complex anatomical and functional structure of the larynx, a more developed vascular network and submucosal tissue. Acute narrowing of the airways in the area of ​​the larynx and trachea immediately causes severe impairment

all basic life support functions, up to their complete shutdown and death of the patient. Acute stenosis occurs suddenly or in a relatively short period of time, which, unlike chronic stenosis, does not allow the body to develop adaptive mechanisms.

The main clinical factors that are subject to immediate medical assessment in acute stenosis of the larynx and trachea are:

Degree of external respiration insufficiency;

The body's response to oxygen starvation.

With stenosis of the larynx and trachea, adaptive(compensatory and protective) and pathological mechanisms. Both of them are based on hypoxia and hypercapnia, which disrupt the trophism of tissues, including the brain and nervous, which excites the chemoreceptors of the blood vessels of the upper respiratory tract and lungs. This irritation is concentrated in the corresponding parts of the central nervous system and, as a response, the body’s reserves are mobilized.

Adaptive mechanisms have less opportunity to form during the acute development of stenosis, which can lead to depression up to complete paralysis of one or another vital function.

Adaptive reactions include:

Respiratory,

Hemodynamic,

Bloody;

Fabric.

Respiratory manifested by shortness of breath, which leads to an increase in pulmonary ventilation; in particular, breathing deepens or increases, and additional muscles are recruited to perform the respiratory act: the back, shoulder girdle, and neck.

TO hemodynamic compensatory reactions include tachycardia, increased vascular tone, which increases the minute volume of blood by 4-5 times, accelerates blood flow, increases blood pressure, and removes blood from the depot. All this enhances the nutrition of the brain and vital organs, thereby reducing oxygen deficiency and improving the removal of toxins caused by laryngeal stenosis.

Blood and vascular adaptive reactions are the mobilization of red blood cells from the spleen, an increase in pro-

vascular permeability and the ability of hemoglobin to be completely saturated with oxygen, increased erythropoiesis. The ability of the tissue to absorb oxygen from the blood increases, and a partial transition to the anaerobic type of metabolism in cells is noted.

All these mechanisms can, to a certain extent, reduce hypoxemia (lack of oxygen in the blood), hypoxia (in tissues), as well as hypercapnia (increased carbon dioxide in the blood). Insufficiency of pulmonary ventilation can be compensated provided that a minimum volume of air enters the lung, which is individual for each patient. An increase in stenosis, and therefore hypoxia, under these conditions leads to the progression of pathological reactions, the mechanical function of the left ventricle of the heart is disrupted, hypertension appears in the pulmonary circle, the respiratory center is depleted, and gas exchange is sharply disrupted. Metabolic acidosis occurs, the partial pressure of oxygen drops, oxidative processes decrease, hypoxia and hypercapnia are not compensated.

Etiological factors acute stenosis of the larynx and trachea can be endogenous and exogenous. Among the first: local inflammatory diseases- swelling of the larynx and trachea, subglottic laryngitis, acute laryngotracheobronchitis, chondroperichondritis of the larynx, laryngeal tonsillitis. Non-inflammatory processes- tumors, allergic reactions, etc. Among the latter (exogenous) the most common are foreign bodies, injuries of the larynx and trachea, conditions after bronchoscopy, intubation. General diseases of the body- acute infectious diseases (measles, diphtheria, scarlet fever), heart disease, vascular disease, kidney disease, etc., endocrine diseases.

Clinic. The main symptom of acute stenosis of the larynx and trachea is shortness of breath, noisy, intense breathing. Depending on the degree of narrowing of the airways, upon examination, retraction of the supraclavicular fossa, retraction of the intercostal spaces, and disturbance of the respiratory rhythm are observed, which is associated with an increase in negative pressure in the mediastinum during inspiration. It should be noted that with stenosis at the level of the larynx, shortness of breath is inspiratory in nature, the voice is usually changed, and with narrowing of the trachea, expiratory shortness of breath is observed, the voice is not changed. A patient with severe stenosis develops a feeling of fear, motor agitation (he rushes about, tries to run), facial hyperemia occurs, sweating occurs, cardiac activity, secretory and motor functions are impaired.

function of the gastrointestinal tract, urinary function of the kidneys. If the stenosis continues, increased heart rate and cyanosis of the lips, nose and nails occur. This is due to the accumulation of carbon dioxide in the body.

There are 4 stages of airway stenosis:

I - compensation;

II - subcompensation;

III - decompensation;

IV - asphyxia (terminal stage).

IN compensation stages due to a drop in oxygen tension in the blood, the activity of the respiratory center increases, and, on the other hand, an increase in the carbon dioxide content in the blood can directly irritate the cells of the respiratory center, which is manifested by a slowdown and deepening of respiratory excursions, shortening or loss of pauses between inhalation and exhalation, and a decrease in the number of pulse beats . The width of the glottis is 5-6 mm. At rest there is no lack of breathing; shortness of breath appears when walking and physical activity.

IN subcompensation stages The phenomena of hypoxia deepen, the working capacity of the respiratory center becomes strained. Already at rest, inspiratory shortness of breath appears (difficulty inhaling) with the inclusion of auxiliary muscles in the act of breathing, while there is retraction of the intercostal spaces, soft tissues of the jugular, as well as supra- and subclavian fossae, swelling (fluttering) of the wings of the nose, stridor (breathing noise), pale skin, restless state of the patient. The width of the glottis is 4-5 mm.

IN stages of decompensation stridor is even more pronounced, the tension of the respiratory muscles becomes maximum. Breathing becomes frequent and shallow, the patient takes a forced semi-sitting position, tries to hold on to the headboard of the bed or other objects with his hands, which improves support for the auxiliary respiratory muscles. The larynx makes maximum excursions. The face becomes pale bluish in color, a feeling of fear, cold sticky sweat, cyanosis of the lips, tip of the nose, and nail phalanges appear, and the pulse becomes frequent. The width of the glottis is 2-3 mm.

IN stages of asphyxia with acute laryngeal stenosis, breathing is wheezing, intermittent, of the Cheyne-Stokes type. Gradually, the pauses between breathing cycles increase and stop completely.

The width of the glottis is 0-1 mm. There is a sharp drop in cardiac activity, the pulse is frequent, threadlike, blood pressure is not determined, the skin is pale gray due to spasm of small arteries, the pupils dilate. Loss of consciousness, exophthalmos, involuntary urination, defecation are observed, and death quickly occurs.

Diagnostics stenosis is based on the described symptoms, data from indirect laryngoscopy, tracheobronchoscopy. It is necessary to find out the causes and location of the narrowing. There are a number of clinical signs to distinguish between laryngeal and tracheal stenosis. With laryngeal stenosis, it is mainly inhalation that is difficult, i.e. shortness of breath is inspiratory in nature, and when tracheal - exhalation (expiratory type of shortness of breath). The presence of an obstruction in the larynx causes hoarseness, while with a narrowing in the trachea, the voice remains clear. Acute stenosis should be differentiated from laryngospasm, bronchial asthma, and uremia.

Treatment carried out depending on the cause and stage of acute stenosis. In compensated and subcompensated stages, it is possible to use drug treatment in a hospital setting. For laryngeal edema, dehydration therapy, antihistamines, and corticosteroids are prescribed. For inflammatory processes in the larynx, massive antibiotic therapy and anti-inflammatory drugs are prescribed. For diphtheria, for example, it is necessary to administer specific anti-diphtheria serum.

The most effective way to carry out drug destenosis - combinations of antihistamines, corticosteroids and dehydration drugs, the scheme of which is outlined in the relevant sections on the treatment of laryngeal edema.

In the decompensated stage of stenosis urgent tracheostomy is required and in the stage of asphyxia it is urgently performed conicotomy, and then tracheostomy.

It is worth noting that, if indicated, the doctor is obliged to perform these operations in almost any conditions and without delay.

In relation to the isthmus of the thyroid gland, depending on the level of the incision, there are upper tracheotomy - above the isthmus

thyroid gland(Fig. 4.12), the lower one under it and the middle one across the isthmus with its preliminary dissection and dressing. It should be noted that this division is conditional. As a rule, 2-3 half rings of the trachea are dissected.

More acceptable is the division depending on the level of the tracheal rings incision. For an upper tracheotomy, 2-3 rings are cut, for a middle tracheotomy, 3-4 rings, and for a lower tracheotomy, 4-5 rings.

Operation technique(upper tracheotomy). The patient's position is usually supine; a cushion must be placed under the shoulders to protrude the larynx and facilitate orientation. Sometimes, with severe stenosis, when breathing worsens while lying down, the operation is performed in a semi-sitting or sitting position, in severe cases of asphyxia - even without anesthesia. Local anesthesia: 1% novocaine mixed with a solution of adrenaline 1:1000 (1 drop per 5 ml). The hyoid bone, thyroid notch and cricoid tubercle are palpated. For orientation, you can use brilliant green to mark the midline and level of the cricoid cartilage. A layer-by-layer incision of the skin and subcutaneous tissue is made from the lower edge of the cricoid cartilage 6 cm vertically downwards strictly along the midline. The superficial fascia is dissected, under which the white line is found - the junction of the sternohyoid muscles. The latter is incised and the muscles are bluntly pulled apart. After this, the isthmus of the thyroid gland is examined, which is brown-red in color and soft to the touch. Then, along the lower edge of the cricoid cartilage, an incision is made into the capsule of the gland that fixes the isthmus; the latter is folded downward and held with a blunt hook. Then the tracheal rings, covered with fascia, become visible. Careful hemostasis is necessary before opening the trachea. To fix the larynx, the excursions of which are significantly pronounced during asphyxia, a sharp hook is inserted into the thyrohyoid membrane and fixed upward. To avoid severe coughing, a few drops of 2-3% dicaine solution are injected into the trachea through a needle. Using a pointed scalpel, the 2nd and 3rd rings of the trachea are opened. The scalpel must not be inserted too deeply (0.5 cm),

Rice. 4.12. Tracheostomy:

a - midline skin incision and separation of the wound edges; b - exposure of the tracheal rings; c - dissection of the tracheal rings; d - formation of tracheostomy

so as not to injure the posterior wall of the trachea, which is devoid of cartilage, and the adjacent anterior wall of the esophagus. The edges of the hole in the trachea are spread apart using a Trousseau dilator and an appropriately sized tracheotomy tube is inserted, which is fixed with a gauze bandage on the neck.

In some cases, in pediatric practice for stenosis caused by diphtheria of the larynx and trachea, naso(oro)tracheal intubation with a flexible tube made of synthetic material is used. Intubation is performed under the control of direct laryngoscopy, its duration should not exceed 3 days. If a longer period of intubation is necessary, a tracheotomy is performed, since a long stay of the endotracheal tube in the larynx causes ischemia of the mucous membrane, followed by ulceration, scarring and persistent stenosis of the organ.

4.6.2. Chronic stenosis of the larynx and trachea

Chronic stenosis of the larynx and trachea - long-term gradual pathological narrowing of the lumen of the larynx and trachea, causing hypoxemia and hypoxia in the body. Persistent, usually voluminous, morphological changes in the larynx and trachea or in areas adjacent to them narrow their lumen, developing slowly over a long time.

The causes of chronic stenosis of the larynx and trachea are varied. The most common are:

1) scarring after surgery and trauma or prolonged tracheal intubation (over 5 days);

2) benign and malignant tumors of the larynx and trachea;

3) traumatic laryngitis, chondroperichondritis;

4) thermal and chemical burns of the larynx;

5) prolonged presence of a foreign body in the larynx and trachea;

6) dysfunction of the lower laryngeal nerves as a result of toxic neuritis, after strumectomy, compression by a tumor, etc.;

7) congenital defects, scar membranes of the larynx;

8) specific diseases of the upper respiratory tract (tuberculosis, scleroma, syphilis, etc.).

Often in practice, the development of chronic laryngeal stenosis is associated with the fact that tracheotomy is performed with a gross violation of the surgical technique: instead of the second or third rings of the trachea, the first is cut, and the tracheotomy tube touches the lower edge of the cricoid cartilage, which always quickly causes chondroperichondritis with subsequent severe stenosis of the larynx. Prolonged wearing of a tracheotomy tube and its incorrect selection can also cause chronic stenosis.

Clinical picture depends on the degree of narrowing of the airways and the cause of the stenosis. However, a slow and gradual increase in stenosis provides time for the development of the body's adaptive mechanisms, which allows one to maintain life support functions even in conditions of insufficient external respiration. Chronic stenosis of the larynx and trachea has a negative effect on the entire body, especially children, which is associated with oxygen deficiency and changes in reflex influences emanating from receptors located in the upper respiratory tract.

Impaired external respiration leads to sputum retention and frequent recurrent bronchitis and pneumonia, which ultimately leads to the development of chronic pneumonia with bronchiectasis. With a long course of chronic stenosis, these complications are accompanied by changes in the cardiovascular system.

Diagnostics based on characteristic complaints, history and symptoms. The examination of the larynx to determine the nature and localization of stenosis is carried out through indirect and direct laryngoscopy, using bronchoscopy and endoscopic methods that make it possible to determine the level of the lesion, its extent, the thickness of the scars, the appearance of the pathological process, and the width of the glottis.

Treatment. Minor scar changes that do not interfere with breathing do not require special treatment, but observation is necessary, since as the scar ages, it shrinks and stenosis increases. Scar changes that cause persistent stenosis require appropriate treatment.

For certain indications, expansion, stretching (bougienage) of the larynx with bougies of increasing diameter and special dilators is sometimes used for 5-7 months. If there is a tendency to narrowing and long-term dilatation is ineffective, the lumen of the airways is restored surgically. Surgical plastic interventions on the upper respiratory tract are performed, as a rule, in an open manner and represent various options for laryngopharyngotracheofissure. These surgical interventions are complex and multi-stage in nature.

4.7. DISEASES OF THE NERVOUS APPARATUS OF THE LARYNX

Among the diseases of the nervous system of the larynx there are:

Sensitive and

Movement disorders.

Depending on the location of the main process, disorders of the innervation of the larynx can be of central or peripheral origin, and in nature - functional or organic.

4.7.1. Sensitivity disorders

Laryngeal sensitivity disorders can be caused by central (cortical) and peripheral causes. Central disturbances, caused, as a rule, by a violation of the ratio of excitation and inhibition processes in the cerebral cortex, are bilateral in nature. Violations of the sensitive innervation of the larynx are based on neuropsychic diseases (hysteria, neurasthenia, functional neuroses, etc.). Hysteria, according to I.P. Pavlov, is the result of a breakdown of higher nervous activity in people with insufficient coherence of the signaling systems, expressed in the predominance of the activity of the first signaling system and the subcortex over the activity of the second signaling system. In easily suggestible individuals, dysfunction of the larynx, which arose under the influence of nervous shock or fear, can become fixed, and these disorders can take on a long-term character. Sensitivity disturbances appear hyposthesia(decreased sensitivity) of varying severity, up to anesthesia, or hyperesthesia(increased sensitivity), and parasthesia(perverted sensitivity).

Hypostesthesia, or anesthesia, larynx is more often observed with traumatic injuries of the larynx or upper laryngeal nerve, during surgical interventions on the organs of the neck, with diphtheria, and anaerobic infection. Decreased sensitivity of the larynx usually causes minor subjective sensations in the form of sore throat, awkwardness in the throat, and dysphonia. However, against the background of a decrease in the sensitivity of the reflexogenic zones of the larynx, there is a danger of pieces of food and liquid getting into the respiratory tract and, as a consequence, the development of aspiration pneumonia, impaired external respiration, even asphyxia.

Hyperesthesia can be of varying severity and is accompanied by a painful sensation when breathing and talking, often there is a need to cough up mucus. With hyperesthesia, examination of the oropharynx and larynx becomes difficult due to a pronounced gag reflex.

Paresthesia is expressed by a wide variety of sensations in the form of tingling, burning, sensation of a foreign body in the larynx, spasm, etc.

Diagnostics based on medical history, patient complaints and laryngoscopic picture. Can be used in diagnostics

method for assessing the sensitivity of the larynx during probing: touching the mucous wall of the hypopharynx with a probe with cotton wool causes an appropriate response. Along with this, consultation with a neurologist or psychotherapist is necessary.

Treatment carried out jointly with a neurologist. Since sensitivity disorders are based on disorders of the central nervous system, therapeutic measures are aimed at their elimination. Sedative therapy, pine baths, vitamin therapy, and sanatorium treatment are prescribed. In some cases, novocaine blockades are effective, both in the area of ​​nerve nodes and along the conduction pathways. Physiotherapeutic agents for peripheral lesions include intra- and extralaryngeal galvanization and acupuncture.

4.7.2. Movement disorders

Motor disorders of the larynx manifest themselves in the form of partial (paresis) or complete (paralysis) loss of its functions. Such disorders can arise as a result of inflammatory and regenerative processes in both the muscles of the larynx and the laryngeal nerves. They can be central and peripheral origin. Distinguish myogenic and neurogenic paresis and paralysis.

Central (cortical) paralysis the larynx develops with traumatic brain injuries, intracranial hemorrhages, multiple sclerosis, syphilis, etc.; can be unilateral or bilateral. Paralysis of central origin is often associated with damage to the medulla oblongata and is combined with paralysis of the soft palate. Peripheral paralysis and paresis of the larynx are associated with damage to the nerve pathways in the neck and chest cavity (trauma, tumors, abscesses).

Clinical symptoms characterized by speech disorders, sometimes breathing, and may be accompanied by convulsions. Movement disorders of central origin often develop in the last stage of severe brain disorders, the cure of which is difficult to hope for.

Diagnostics based on the characteristic symptoms of the underlying disease. With indirect laryngoscopy, a violation of the mobility of one or both halves of the larynx is observed.

Treatment aimed at eliminating the underlying disease. Local disorders in the form of difficulty breathing sometimes require

surgical intervention (tracheostomy is performed). In some cases, it is possible to use physiotherapy in the form of electrophoresis of drugs and electrical stimulation of the laryngeal muscles. Climatic and phonopedic treatment has a beneficial effect.

Peripheral laryngeal paralysis, as a rule, unilateral and are caused by a violation of the innervation of the upper laryngeal and mainly recurrent nerves, which is explained by the topography and proximity of these nerves to many organs of the neck and chest cavity, diseases of which can cause dysfunction of the nerve.

Paralysis of the upper laryngeal and recurrent nerves is most often caused by tumors of the esophagus or mediastinum, enlarged peribronchial and mediastinal lymph nodes, syphilis, and cicatricial changes in the apex of the lung. With diphtheria neuritis, paralysis of the larynx is accompanied by paralysis of the velum palatine. The causes of recurrent nerve palsy can be an aortic arch aneurysm for the left nerve and an aneurysm of the right subclavian artery for the right recurrent nerve, as well as surgical interventions. The left recurrent nerve is most often affected, particularly during strumectomy or a tumor in the mediastinum.

Clinic. Hoarseness and weakness of the voice of varying severity are characteristic functional symptoms of laryngeal paralysis. With bilateral recurrent nerve palsy, laryngeal stenosis occurs because the vocal folds are in a midline position and do not move, while the voice remains sonorous.

During laryngoscopy, characteristic disturbances in the mobility of the arytenoid cartilages and vocal folds are determined, depending on the degree of motor disorders. In the initial stage of unilateral paresis of the recurrent nerve, the vocal fold is somewhat shortened, but retains limited mobility, moving away from the midline during inspiration. In the next stage, the vocal fold on the affected side becomes motionless and is fixed in the middle position, occupying the so-called cadaveric position. Subsequently, compensation appears on the side of the opposite vocal fold, which closely approaches the vocal fold of the opposite side, which maintains a sonorous voice with a slight hoarseness.

Diagnostics. If the innervation of the larynx is impaired, it is necessary to identify the cause of the disease. X-ray examination and computed tomography of the chest organs are performed to identify the volumetric process. To exclude syphilitic neuritis, it is necessary to examine the blood according to Wasserman. Vocal fold paralysis accompanied by spontaneous rotatory nystagmus on one side indicates damage to the bulbar part of the medulla oblongata.

Treatment for motor paralysis of the larynx, it is aimed at treating the causative disease. For paralysis of inflammatory etiology, anti-inflammatory therapy and physiotherapeutic procedures are carried out. For toxic neuritis, for example syphilis, specific therapy is carried out. Persistent disorders of laryngeal mobility caused by tumors or scar processes are treated promptly. Plastic surgeries are effective - removal of one vocal fold, excision of vocal folds, etc. With bilateral laryngeal paralysis, third degree stenosis occurs, which requires immediate tracheostomy.

Myopathic paralysis caused by damage to the muscles of the larynx. In myopathic paralysis, the constrictors of the larynx are predominantly affected. Paralysis of the vocal muscle is most common. With bilateral paralysis of these muscles during background-

Rice. 4.13. Motor disorders of the larynx:

tion, an oval-shaped gap is formed between the folds (Fig. 4.13 a). Paralysis of the transverse interarytenoid muscle is laryngoscopically characterized by the formation of a triangular space in the posterior third of the glottis due to the fact that when this muscle is paralyzed, the bodies of the arytenoid cartilages do not come together completely along the midline (Fig. 4.13 b). Damage to the lateral cricoarytenoid muscles causes the glottis to take on a diamond shape.

Diagnostics based on medical history and laryngoscopic picture.

Treatment aimed at eliminating the cause that caused paralysis of the laryngeal muscles. Physiotherapeutic procedures (electrotherapy), acupuncture, gentle food and voice regimens are used locally. To increase the tone of the muscles of the larynx, faradization and vibration massage have a positive effect, as well as phonopedic treatment, in which the speech and respiratory functions of the larynx are restored or improved with the help of special sound and breathing exercises.

Laryngospasm - convulsive narrowing of the glottis, in which almost all muscles of the larynx are involved; occurs more often in childhood. The cause of laryngospasm is hypocalcemia, a lack of vitamin and the calcium content in the blood decreases to 6-7 mg%, instead of the normal 9.5-11 mg%. Laryngospasm can be of a hysteroid nature.

Clinic. Laryngospasm usually occurs suddenly after a strong cough or fright. Initially, there is a noisy, uneven long breath, followed by intermittent shallow breathing. The child's head is thrown back, the eyes are wide open, the neck muscles are tense, and the skin is cyanotic. Cramps of the limbs and facial muscles may appear. After 10-20 seconds, the respiratory reflex is restored. In rare cases, an attack may result in death due to cardiac arrest. Due to increased muscle excitability, surgical intervention is performed: adenotomy, opening of a retropharyngeal abscess, etc.; In such children, laryngospasm is associated with complications.

Diagnostics. Glottic spasm is recognized based on the clinical picture of the attack and the absence of any changes in the larynx in the interictal period. At the time of an attack, with direct laryngoscopy, you can see a collapsed epiglottis, aryepiglottis,

The tan folds converge along the midline, the arytenoid cartilages are brought together and everted.

Treatment. Laryngospasm can be eliminated by any strong irritant of the trigeminal nerve: an injection, a pinch, pressing on the root of the tongue with a spatula, spraying the face with cold water, etc. For prolonged spasm, intravenous administration of 0.5% novocaine is beneficial.

In threatening cases, tracheotomy or conicotomy should be resorted to.

In the post-attack period, restorative therapy, calcium and vitamin supplements and exposure to fresh air are prescribed. With age (usually by the age of five), these phenomena disappear.

4.8. INJURIES OF THE LARRYNX AND TRACHEA

Injuries to the larynx and trachea, depending on the damaging factor, can be mechanical, thermal, radiation and chemical.

Injuries to the larynx and trachea are relatively rare in peacetime. They are divided into open and closed.

Open injuries or wounds of the larynx and trachea, As a rule, they are of a combined nature: not only the larynx itself is damaged, but also the organs of the neck, face, and chest. There are cut, stab and gunshot wounds. Incised wounds occur as a result of damage caused by various cutting instruments. Most often they are inflicted with a knife or razor for the purpose of murder or suicide (suicide). Based on the level of the incision, there are:

1) wounds located under the hyoid bone, when the thyrohyoid membrane is cut;

In the first case, due to the contraction of the cut neck muscles, the wound, as a rule, gapes wide, thanks to which the larynx and part of the pharynx can be examined through it. With such wounds, the epiglottis always moves upward, breathing and voice are preserved, but speech with a gaping wound is absent, since the larynx becomes disconnected from the articulatory apparatus. If in this case the edges of the wound are moved, thereby closing its lumen, speech is restored. When food is swallowed, it comes out through the wound.

Clinic. The general condition of the patient is significantly impaired. Blood pressure drops, pulse quickens, and body temperature rises. When the thyroid gland is injured, significant bleeding occurs. Consciousness, depending on the degree and nature of the injury, can be preserved or confused. When the carotid arteries are injured, death occurs immediately. However, the carotid arteries are rarely crossed in suicidal wounds; suicides throw their heads back strongly, protruding their necks, while the arteries are displaced backwards and are not damaged.

Diagnostics presents no difficulties. It is necessary to determine the level of the wound. Examination through the wound and probing allows you to determine the condition of the cartilaginous skeleton of the larynx, the presence of edema, and hemorrhages.

Treatment surgical, includes stopping bleeding, ensuring adequate breathing, replenishing blood loss and primary wound treatment. Particular attention should be paid to respiratory function. As a rule, a tracheostomy is performed (preferably lower).

If the wound is located in the area of ​​the thyrohyoid membrane, the wound should be sutured in layers with the obligatory suturing of the larynx to the hyoid bone with chrome-plated catgut. Before suturing the wound, it is necessary to stop the bleeding most carefully by ligating the vessels. To reduce tension and bring the edges of the wound closer together, the patient’s head is tilted anteriorly while suturing. If the walls of the larynx are damaged and deformed, it may be sutured, a laryngostomy is formed, and a T-shaped tube is inserted. To protect against infection, the patient's nutrition is provided using a gastric tube inserted through the nose or mouth. At the same time, anti-inflammatory and restorative treatment is prescribed, including the administration of massive doses of antibiotics, antihistamines, detoxification drugs, hemostatic agents, and anti-shock therapy.

Gunshot injuries to the larynx and trachea are rarely isolated. More often they are combined with damage to the pharynx, esophagus, thyroid gland, blood vessels and nerves of the neck, spine, spinal cord and brain.

Gunshot wounds of the larynx and trachea are divided into through, blind, tangent (tangential).

With a through wound there are two holes - entrance and exit. It must be taken into account that the entrance hole rarely coincides with the course of the wound canal, the site of damage to the larynx and the exit hole, since the skin and tissue on the neck are easily displaced.

In blind wounds, a fragment or bullet gets stuck in the larynx or in the soft tissues of the neck. Once in the hollow organs - larynx, trachea, esophagus - they can be swallowed, spat out, or aspirated into the bronchus.

With tangential (tangential) wounds, the soft tissues of the neck are affected without violating the integrity of the mucous membrane of the larynx, trachea, and esophagus.

Clinic depends on the depth, degree, type and forward force of the wounding projectile. The severity of the wound may not correspond to the size and force of the wounding projectile, since concomitant organ contusion, disruption of the integrity of the skeleton, hematoma and swelling of the internal lining aggravate the patient’s condition.

The wounded are often unconscious, shock is often observed, since the vagus and sympathetic nerves are injured and, in addition, when large vessels are injured, large blood loss occurs. An almost constant symptom is observed - difficulty breathing due to damage and compression of the airways by edema and hematoma. Emphysema occurs when the wound opening is small and quickly sticks together. Swallowing is always impaired and accompanied by severe pain; food entering the respiratory tract contributes to coughing and the development of inflammatory complications in the lung.

Diagnostics based on medical history and examination. The cervical wound is mostly wide, with torn edges, with significant loss of tissue and the presence of foreign bodies -

metal fragments, pieces of fabric, particles of gunpowder in the wound, etc. When wounded at close range, the edges of the wound are burned, and there is hemorrhage around it. In some wounded people, soft tissue emphysema is detected, which indicates penetration of the wound into the cavity of the larynx or trachea. Hemoptysis may also indicate this.

Laryngoscopy (direct and indirect) in a wounded person is often practically impossible due to severe pain, inability to open the mouth, fractures of the jaw, hyoid bone, etc. In the following days, during laryngoscopy, it is necessary to determine the condition of the area of ​​the vestibule of the larynx, glottis and subglottic space. Hematomas, ruptures of the mucous membrane, damage to the cartilage of the larynx, and the width of the glottis are detected.

The X-ray method of examination and computed tomography data are informative in diagnosis, with the help of which you can determine the condition of the skeleton of the larynx, trachea, the presence and localization of foreign bodies.

Treatment for gunshot wounds includes two groups of measures:

1) restoration of breathing, stopping bleeding, primary wound treatment, combating shock;

2) carrying out anti-inflammatory, desensitizing, restorative therapy, anti-tetanus (possibly other) vaccinations.

To restore breathing and prevent further impairment of respiratory function, as a rule, a tracheotomy is performed to form a tracheostomy.

Bleeding is stopped by applying ligatures to the vessels in the wound, and if large vessels are damaged, the external carotid artery is ligated.

The fight against painful shock involves the administration of narcotic analgesics, transfusion therapy, and single-group blood transfusions; cardiac drugs.

Primary surgical treatment of the wound, in addition to stopping bleeding, includes gentle excision of crushed soft tissues and removal of foreign bodies. In case of extensive damage to the larynx, a laryngostomy should be formed with the introduction of a T-shaped tube. After emergency measures, it is necessary to enter according to the scheme

antitetanus serum (if serum was not previously administered before surgery).

The second group of measures includes the prescription of broad-spectrum antibiotics, antihistamines, dehydration and corticosteroid therapy. Patients are fed through a nasoesophageal tube. When inserting a probe, you should be careful not to get it into the respiratory tract, which is determined by coughing and difficulty breathing.

Closed injuries of the larynx and trachea occur when various foreign bodies enter the laryngeal cavity and subglottic space. Often the mucous membrane of the larynx is injured by a laryngoscope or endotracheal tube during anesthesia. At the site of injury, an abrasion, hemorrhage, and disruption of the integrity of the mucous membrane are detected. Sometimes swelling appears at the site of the injury and around it, which can spread, and then it poses a threat to life. If an infection occurs, a purulent infiltrate may appear at the wound site; the possibility of developing phlegmon and chondroperichondritis of the larynx cannot be ruled out.

With prolonged (more than 3 days) or rough exposure of the endotracheal tube to the mucous membrane, in some cases a so-called endotracheal granuloma is formed. The most common location for it is the free edge of the vocal fold, since in this place the tube is most intimately in contact with the mucous membrane.

Clinic. With a closed injury to the mucous membrane of the larynx and trachea by a foreign body, sharp pain, aggravated by swallowing, and cough occur. Swelling and tissue infiltration develop around the wound, which can lead to difficulty breathing. Due to severe pain, the patient cannot swallow saliva or eat food. The addition of a secondary infection is characterized by the appearance of pain on palpation of the neck, increased cough and pain when swallowing, and increased body temperature. With external blunt trauma, swelling of the soft tissues of the larynx on the outside and swelling of the mucous membrane, often in its vestibular region, are noted.

Diagnostics consists of anamnesis and objective research methods. During laryngoscopic examination, you can see swelling, hematoma, infiltrate or abscess at the site of injury. In the pyriform sinus or vallecula on the affected side, it can accumulate -

saliva in the form of a “lake”. Radiography in frontal and lateral projections, as well as using contrast agents, allows in some cases to detect a foreign body and determine the level of damage.

Treatment. The tactics of patient management depend on the examination data of the patient, the nature and area of ​​damage to the mucous membrane, the state of the lumen of the respiratory tract, the width of the glottis, etc. If there is an abscess, it is necessary to open it with a laryngeal (hidden) scalpel, after preliminary application of anesthesia. In case of severe breathing disorders (stenosis of II-III degree), emergency tracheostomy is necessary.

In case of edematous forms, drug destenosis (corticosteroids, antihistamines, dehydration drugs) is prescribed to eliminate stenosis.

In all cases of closed laryngeal injuries occurring against the background of a secondary infection, antibacterial therapy, antihistamines and detoxification agents are necessary.

4.9. CHONDROPERICHODRITIS OF THE LARRYNX

Chondroperichondritis (hondroperihondritis) - inflammation of the perichondrium and cartilage of the larynx. As a rule, the perichondrium is the first to be affected; in the near future, the cartilage is also involved in the inflammatory process. Clinically distinguished spicy And chronic chondroperichondritis, as well as purulent And sclerosing(fibrous) of its form. The purulent form occurs during injuries, infectious processes, the sclerosing form develops during chronic inflammatory processes ending in secondary cicatricial (fibrous) changes.

Etiology. One of the most common etiological factors of chondroperichondritis is trauma. In wartime, gunshot injuries predominate; in peacetime, cuts, stabs, and blunt injuries to the larynx predominate, as a result of which the cartilage is damaged and infection occurs. Inflammation of the cartilage of the larynx can also occur as a result of damage to the mucous membrane of the larynx during bronchoscopy, during bougienage of the esophagus, after intubation and tracheotomy.

In some cases, after radiation therapy for blastomatous processes, early or late chondroperichondritis of the larynx may occur.

Inflammation of the perichondrium and cartilage in infectious diseases (tonsillitis, erysipelas, typhoid) is possible through contact and hematogenous routes.

With tuberculous ulcers and infiltrates penetrating to the perichondrium and cartilage, both specific and non-specific chondroperichondritis can develop due to a secondary infection.

Clinic. Clinical manifestations of laryngeal chondroperichondritis depend on its etiology and location. Typically, the inflamed area of ​​cartilage becomes hard, painful on palpation, and soft tissue infiltration occurs. Laryngoscopy identifies areas of infiltration and swelling of the mucous membrane, narrowing the lumen of the larynx. The course of the disease is usually long-term; it can last several months and end with cartilage necrosis.

Chondroperichondritis of the thyroid cartilage characterized by the appearance of a painful hard-elastic swelling in the area of ​​cartilage projection on the affected side. The skin at the site of inflammation is hyperemic, thickened, and the cervical lymph nodes are enlarged. During laryngoscopy, almost no changes in the mucous membrane are noted. Damage to the inner side of the thyroid cartilage is accompanied by swelling of the mucous membrane, in this place it is hyperemic and edematous. As a rule, the aryepiglottic fold is involved in inflammation. The inflammatory infiltrate can cover the glottis and cause suffocation.

With chondroperichondritis of the epiglottis there is a sharp thickening, rigidity, swelling and infiltration, most often of the laryngeal surface. In this condition, choking occurs when swallowing due to food particles entering the larynx. Painful symptoms are especially pronounced when the arytenoid cartilages are affected. In this case, the area of ​​the affected cartilage becomes like a ball. Edema can spread to the aryepiglottic fold, pyriform sinus, and respiratory and voice-forming functions are impaired.

For inflammation of the cricoid cartilage the process is localized in the subglottic space, where there is fiber. At this point, a pronounced narrowing of the lumen of the larynx occurs, resulting in impaired respiratory function. To eliminate the stenosis, urgent tracheostomy is required.

Inflammation of the cricoid cartilage occurs after tracheotomy, when the tracheotomy tube is adjacent to the lower edge of the cricoid cartilage and injures it.

When all cartilages of the larynx are affected hyperemia and swelling of the soft tissues of the entire larynx occurs. The entrance to the larynx is sharply narrowed; at the anterior commissure, granulations and a fistula are often visible, from which pus is released. When laryngopharyngeal tissues are involved in the inflammatory process, a forced position of the patient's head is noted.

The development of the described symptoms is accompanied by general intoxication of the body, an increase in body temperature to fibril levels.

Diagnostics is based on data from anamnesis, examination of the patient, instrumental, radiological and endoscopic research methods. Indirect laryngoscopy is not always successful in cases of severe inflammation of the cartilage of the larynx. It is necessary to differentiate from acute thyroiditis, paresis and paralysis of the larynx, rheumatic ankylosis of the laryngeal joints.

Treatment. In case of acute chondroperichondritis of the larynx, anti-inflammatory therapy is prescribed; antibiotics (cefazolin, keyten, augmentin, sumamed, tarivid, etc.), sulfonamide drugs, antihistamines (claritin, fencarol, etc.), detoxification therapy, analgesics, symptomatic drugs.

Treatment of chondroperichondritis of the cricoid cartilage that occurs after tracheotomy due to pressure on the cartilage of the tracheotomy tube must begin with moving the tracheostomy to a lower section of the trachea.

In order to increase the overall reactivity of the body, autohemotherapy, biostimulants, and vitamin therapy are indicated.

In the future, when acute phenomena subside, physiotherapeutic interventions are recommended (UHF, laser therapy, phonoelectrophoresis with anti-inflammatory drugs, electrophoresis with potassium iodide, calcium chloride, etc.).

In case of abscess formation, surgical intervention is indicated to empty the abscess and remove necrotic tissue. The presence of fistulas is also an indication for surgery, which is performed to open and drain the fistula.

The choice of surgical intervention method depends on the nature, location, and extent of the process. For internal perichondritis, you can start with endolaryngeal operations; for external perichondritis, an external surgical approach is required. Fenestrated (submucosal) fenestration of the larynx has become widespread as a gentle method of draining purulent inflammation of the cartilage of the larynx. In cases where there is persistent stenosis of the respiratory tract, preliminary tracheostomy or laryngostomy is necessary.

Forecast. The disease is severe. In the early stage of the disease, the effectiveness of treatment is greatest. With purulent lesions, the prognosis for life is favorable, but doubtful from the point of view of complete restoration of the functions of the larynx.

4.10. FOREIGN BODIES OF THE LARRYNX, TRACHEA AND BRONCHI

A sage will rather avoid diseases than choose remedies against them.

T. More

Foreign bodies of the larynx, trachea and bronchi are common, but more often in children, which is associated with insufficiently developed protective reflexes. Foreign bodies can be any small objects: fruit seeds, grains, coins, small parts of toys, buttons, pins, etc. In adults, foreign bodies enter the respiratory tract more often during alcohol intoxication. Dentures, pieces of food, vomit, etc. may enter the respiratory tract.

Foreign bodies that enter the respiratory tract are usually not coughed out. This is due to the fact that as soon as an object slips through the glottis, a reflex spasm occurs and the vocal folds close tightly. In some cases, a foreign body can either penetrate the tracheal wall or lodge in its lumen. When inhaling, the foreign body rushes deeper and passes more often into the right bronchus, since the latter is wider than the left and is practically a continuation of the trachea.

Clinical picture. Depends on the level of penetration, the degree of obstruction of the respiratory tract and the nature of the foreign body. When a foreign body is inserted into the wall of the larynx, pain, a feeling of a lump in the throat, cough, and difficulty swallowing occur.

Small objects can enter the bronchi, causing obstruction. The latter can be of three types:

Through;

Valve;

At end-to-end view a foreign object partially fills the lumen of the bronchus and does not cause significant respiratory disturbances. At valve blockage, air can enter the lung when inhaling, but when exhaling, the lumen of the bronchus narrows somewhat and the foreign body tightly obstructs the airway. As a result of such breathing, the amount of air in the lung increases all the time and emphysema develops. Finally, when complete blockage respiratory tract, obstructive atelectasis of a certain segment of the lungs occurs.

Sharp, thin foreign bodies can wedge into the wall of the larynx or trachea, causing coughing and severe pain symptoms. Subsequently, an inflammatory process and, in rare cases, sclerosis with subsequent encapsulation of the foreign body may develop at the injection site.

An important sign of a foreign body in the trachea is the symptom of flapping (balloting), which is heard using a phonendoscope on the chest wall. It occurs during the cough reflex when a foreign body hits the lower surface of the vocal folds. Another important sign is a cough, which occurs in paroxysms and is accompanied by cyanosis.

Diagnostics based on medical history and instrumental examination of the larynx. If the bronchus is blocked, it is necessary to auscultate the lungs and compare the respiratory excursion of both halves of the chest during a visual examination. An X-ray examination of the patient is required, and if indicated, tracheobronchoscopy.

Treatment. Sometimes a foreign body can be removed using direct laryngoscopy. If there is a foreign object in the trachea and bronchi, removal is carried out through natural routes - upper tracheobronchoscopy is performed using general anesthesia. In case of deep occurrence and long-term presence of foreign matter

body, severe impairment of external respiration, as well as in case of unsuccessful attempts at upper bronchoscopy, an urgent tracheotomy is performed. Further attempts to remove the foreign object are made through the tracheotomy opening, i.e. lower tracheobronchoscopy.

4.11. BURNS OF THE LARRYNX AND TRACHEA

There are two types of burns to the larynx and trachea:

Thermal and

Chemical.

Thermal burns occur when accidentally swallowing hot liquids (water, milk, etc.), getting steam or hot air into the mouth. With thermal burns, the face, eyes and other parts of the body usually suffer simultaneously, which worsens the general condition.

Chemical burns occur due to ingestion or inhalation of concentrated chemical solutions. Of the acids, the most severe burns are caused by sulfuric, hydrochloric, nitric, and chromic. Most often, the vestibular part of the larynx (epiglottis, aryepiglottic and vestibular folds, arytenoid cartilages) is affected. At the site of contact of the chemical agent with the mucous membrane, a local burn reaction of the tissue occurs in the form of hyperemia, edema, and fibrinous plaque is formed.

Clinic. The course of burns varies depending on their degree, localization of the process, and general condition of the body.

First degree burns are characterized by uneven whitening of the mucous membrane, followed by hyperemia and desquamation of the epithelium. There is practically no general intoxication of the body. From the third day, the whitened surface layers of the epithelium begin to be rejected, exposing hyperemic tissue.

With second-degree burns, severe intoxication of the body occurs; on the mucous membrane there are exfoliated epidermis of varying lengths and burn bullae with transudate. On days 7-8, the epidermis is rejected with the formation of erosions, which heal with virtually no scars.

With a third degree burn, intoxication is especially severe; there is tissue necrosis with the formation of ulcers, granulations, followed by scarring and arrosive bleeding.

Immediately after a burn, there are characteristic burn marks on the lips, mucous membrane of the oral cavity and pharynx. The patient experiences severe pain, a burning sensation, salivation, attacks of vomiting and coughing with shortness of breath and a feeling of lack of air. Difficulty breathing is accompanied by a change in voice up to aphonia. Painful symptoms increase with swallowing and coughing movements. Third degree burns, as a rule, are accompanied by damage to parenchymal organs, primarily the kidneys, which is usually the cause of death of the patient.

Diagnostics is based on anamnesis, eyewitness accounts of the incident, characteristic examination data, traces of a burn, and the time that has passed since the burn. Sometimes in the first hours the substance that caused the burn is recognized by the odor from the mouth, characteristic of burns with acetic acid, ammonia, phenol, etc. For a forensic medical report, it is important that the substance that caused the burn can be determined in saliva and vomit in the first hours after the burn. Already on the second day, the burned areas and their discharge lose their specific features. From the first hours of the disease, the condition of the kidneys and liver is monitored.

Treatment(see esophageal burns) should begin immediately after the burn. Gastric lavage with neutralizing solutions is necessary. For burns from alkalis, the throat and stomach are washed with 3-4 glasses of table vinegar or lemon juice diluted halfway with water. For acid burns, use water with the addition of magnesium carbonate and table soda (sodium bicarbonate). In the absence of the required medications, water with the addition of half the amount of milk and the whites of raw eggs (10-15 pieces) is used to rinse the mouth and throat, and lavage the stomach. The amount of liquid used for washing should be significant - 3-4 liters.

From the first day, the patient is prescribed adequate analgesics, broad-spectrum antibiotics, corticosteroid drugs, cardiac drugs, and symptomatic medications. Eating food by mouth is very difficult for the patient, so it is necessary to establish parenteral nutrition and nutritional enemas. To combat dehydration, massive transfusion therapy and blood transfusions are prescribed.

As shortness of breath increases, a tracheotomy becomes necessary. To prevent concomitant cicatricial processes of the esophagus, long-term bougienage is indicated.

Forecast in mild cases favorable. In severe cases, when concentrated acid or alkali enters the stomach, the patient dies from kidney failure within a few days.

In surviving patients, extensive cicatricial stenoses of the pharynx, larynx, and esophagus develop, requiring long-term treatment, including surgery.

4.12. FOREIGN BODIES OF THE ESOPHAGUS

The entry of foreign bodies into the esophagus is mostly accidental: along with poorly chewed food, or during careless, hasty eating. This can be facilitated by the absence of teeth and wearing dentures, alcohol intoxication, bad habits - holding nails, needles, coins, etc. with teeth. Foreign bodies may be intentionally ingested by mentally ill people.

The nature of foreign objects can be very diverse: small fish, bird bones, pieces of meat, coins, fragments of toys, dentures, etc.

Foreign bodies get stuck in the esophagus in places of physiological narrowing, most often in the cervical narrowing. Powerful striated muscles cause strong reflex contractions of the esophagus in this section. The second place in the frequency of foreign body stuckness is thoracic region and finally, third - cardiac.

Clinic for foreign bodies of the esophagus is determined by their size, surface topography, level and location in relation to the esophagus. The patient is bothered by pain in the chest, which intensifies when swallowing food, as well as a sensation of a foreign body. In some cases, the passage of food is disrupted. The forced position of the torso is characteristic: the head is pushed forward, turns along with the torso, and there is an expression of fear on the face. The general condition of the patient may not be affected.

Diagnostics. The examination must begin with an examination of the laryngopharynx. Sometimes a foreign body may end up in the palatine tonsils, the root of the tongue, or in the pyriform sinus.

With indirect laryngoscopy, an important sign of a foreign body or injury can be detected in the first narrowing of the food -

water - accumulation of foamy saliva in the pyriform sinus on the affected side. Swelling and infiltration of the arytenoid cartilage can be observed. When pressing on the area of ​​the larynx or trachea, pain is sometimes noted.

An X-ray examination of the esophagus with contrast is informative, allowing to identify not only foreign objects, but also narrowing or blockage of the esophagus. In the presence of perforation of the esophagus caused by a foreign body, radiography may reveal the accumulation of air in the peri-esophageal tissue in the form of a light spot between the spine and the posterior wall of the lower pharynx. Flow of contrast material into the mediastinum, detected on radiography, is also a sign of perforation.

The final conclusion about the presence of a foreign body and its characteristics is given by esophagoscopy using Brunings, Mesrin, Friedel bronchoesophagoscopes, and flexible fiberscopes.

Treatment. Esophagoscopy is the main method for examining the esophagus and removing foreign bodies. The technique of esophagoscopy is described in the chapter “Methods for examining ENT organs.”

Complication. A sharp object, wedging into the wall of the esophagus, causes disruption of the integrity of the mucous membrane and its infection. The resulting infiltration involves the muscular wall of the esophagus, and then, possibly, the mediastinal tissue. Since the wall of the esophagus does not have a capsule or fascia on the outside, but is surrounded only by fiber, foreign bodies can immediately cause through perforation with the development of mediastinitis. If perforation occurs in the upper parts of the esophagus, subcutaneous emphysema and soft tissue crepitus immediately appear on the neck.

Purulent periesophagitis and mediastinitis, the absence of positive dynamics in the first hours against the background of massive anti-inflammatory therapy are an indication for surgical intervention and drainage of the peri-esophageal tissue, which, depending on the level of damage to the esophagus, can be transcervical and thoracic.

Larynx- This is a kind of musical instrument of the human body that allows you to speak, sing, express your emotions in a quiet voice or a loud cry. As part of the respiratory tract, the larynx is a short tube with dense cartilaginous walls. The rather complex structure of the walls of the larynx allows it to generate sounds of different heights and volumes.

Structure of the larynx

The larynx is located in the anterior region of the neck at the level of the IV-VI cervical vertebrae. With the help of ligaments, the larynx is suspended from the hyoid bone, as a result of which it lowers and rises with it during swallowing. From the outside, the position of the larynx is noticeable by the protrusion, strongly developed in men and formed by the thyroid cartilage. In common parlance, this protrusion is called “Adam’s apple”, or “Adam’s apple”. Behind the larynx is the pharynx, with which the larynx communicates; large vessels and nerves pass along the side. The pulsation of the carotid arteries can be easily felt in the neck on the sides of the larynx. Below, the larynx passes into the trachea. In front of the trachea, reaching the larynx, is the thyroid gland.

The hard skeleton of the larynx consists of three unpaired cartilages - the thyroid, cricoid and epiglottis - and three paired ones, the most important of which are the arytenoids. The cartilages of the larynx are connected to each other by joints and ligaments and can change their position due to the contraction of the muscles attached to them.

The base of the larynx forms the cricoid cartilage, which resembles a horizontally lying ring: its narrow “arch” faces forward, and its wide “signet” faces back. The lower edge of this cartilage connects to the trachea. The thyroid and arytenoid cartilages join the cricoid cartilage from above. The thyroid cartilage is the largest and is part of the anterior and lateral walls of the larynx. It distinguishes two quadrangular plates, connected to each other at a right angle in men, forming an “Adam’s apple,” and at an obtuse angle (about 120°) in women.

The arytenoid cartilages are pyramid-shaped, their triangular base is movably connected to the plate of the cricoid cartilage. From the base of each arytenoid cartilage a vocal process extends forward, and a muscular process extends to the side. The muscles that move the arytenoid cartilage around its vertical axis are attached to the latter. This changes the position of the vocal process to which the vocal cord is connected.

The top of the larynx is covered by the epiglottis, which can be compared to a “lifting door” above the entrance to the larynx (see Fig. 1). The lower pointed end of the epiglottis is attached to the thyroid cartilage. The wide upper part of the epiglottis descends with each swallowing movement and closes the entrance to the larynx, thereby preventing food and water from entering the respiratory tract from the pharynx.

All cartilages of the larynx are hyaline and can undergo ossification, except for the epiglottis and the vocal process of the arytenoid cartilage, which are formed by elastic cartilaginous tissue. As a result of ossification, which sometimes occurs before the age of 40, the voice loses flexibility and acquires a hoarse, creaky tone.

For the production of sound, the vocal cords, which are stretched from the vocal processes of the arytenoid cartilages to the inner surface of the angle of the thyroid cartilage, are of utmost importance (Fig. 2). Between the right and left vocal cords there is a glottis through which air passes during breathing. Under the influence of muscles, the cartilages of the larynx change their position. The muscles of the larynx are divided into three groups according to their function: they expand the glottis, narrow the glottis, and change the tension of the vocal cords.

The cavity of the larynx is lined with a mucous membrane, which is extremely sensitive: the slightest touch of a foreign body to it reflexively causes a cough. Covers the mucous membrane of the larynx, excluding only the surface of the vocal cords, ciliated epithelium with a large number of glands.

Under the mucous membrane of the larynx lies a fibroelastic membrane. The laryngeal cavity is shaped like an hourglass: the middle section is strongly narrowed and limited above by the folds of the vestibule (“false vocal folds”), and below by the vocal folds (Fig. 3). On the lateral walls of the larynx between the fold of the vestibule and the vocal fold, rather deep pockets are visible - the ventricles of the larynx. These are the remains of voluminous “voice sacs” that are well developed in apes and apparently serve as resonators. Under the mucous membrane of the vocal fold are the vocal cord and vocal muscle, under the mucous membrane of the vestibular fold is the fixed edge of the fibroelastic membrane.

Functions of the larynx

It is customary to distinguish four main functions of the larynx: respiratory, protective, phonatory (voice-forming) and speech.

• Respiratory. When you inhale, air from the nasal cavity enters the pharynx, from it into the larynx, then into the trachea, bronchi and lungs. When you exhale, air from the lungs travels all the way through the respiratory tract in the opposite direction.
• Protective. The movements of the cilia covering the mucous membrane of the larynx continuously clean it, removing the smallest particles of dust that enter the respiratory tract. Dust surrounded by mucus is released as phlegm. Reflex cough is an important protective device of the larynx.
• Phonatornaya. The occurrence of sound is associated with vibration of the vocal cords during exhalation. The sound may vary depending on the tension of the ligaments and the width of the glottis. A person consciously regulates this process.
• Speech. It should be emphasized that only the formation of sound occurs in the larynx; articulate speech occurs when the organs of the oral cavity work: the tongue, lips, teeth, facial and masticatory muscles.

The first is the voice, the second is the melody

A person’s ability to produce sounds of different strength, pitch and timbre is associated with the movement of the vocal cords under the influence of a stream of exhaled air. The strength of the sound produced depends on the width of the glottis: the wider it is, the louder the sound. The width of the glottis is regulated by at least five muscles of the larynx. Of course, the force of exhalation itself, caused by the work of the corresponding muscles of the chest and abdomen, also plays a role. The pitch of the sound is determined by the number of vibrations of the vocal cords in 1 second. The more frequent the vibrations, the higher the sound, and vice versa. As you know, tightly stretched ligaments vibrate more often (remember a guitar string). The muscles of the larynx, in particular the vocal muscle, provide the necessary tension to the vocal cords. Its fibers are woven into the vocal cord along its entire length and can contract either as a whole or in separate parts. Contraction of the vocal muscles causes the vocal cords to relax, causing the pitch of the sound they produce to decrease.

Having the ability to vibrate not only as a whole, but also in individual parts, the vocal cords produce additional sounds to the main tone, the so-called overtones. It is the combination of overtones that characterizes the timbre of the human voice, the individual characteristics of which also depend on the condition of the pharynx, oral cavity and nose, movements of the lips, tongue, and lower jaw. The airways located above the glottis act as resonators. Therefore, when their condition changes (for example, when the mucous membrane of the nasal cavity and paranasal sinuses swells during a runny nose), the timbre of the voice also changes.

Despite the similarities in the structure of the larynx of humans and apes, the latter are not able to speak. Only gibbons are capable of producing sounds that are vaguely reminiscent of musical sounds. Only a person can consciously regulate the force of exhaled air, the width of the glottis and the tension of the vocal cords, which is necessary for singing and speech. The medical science that studies the voice is called phoniatry.

Even in the time of Hippocrates, it was known that the human voice is produced by the larynx, but only 20 centuries later Vesalius (16th century) expressed the opinion that sound is produced by the vocal cords. Even now, there are various theories of voice formation, based on individual aspects of the regulation of vocal cord vibrations. Two theories can be cited as extreme forms.

According to the first (aerodynamic) theory, voice formation is the result of vibrational movements of the vocal folds in the vertical direction under the influence of an air stream during exhalation. The decisive role here belongs to the muscles involved in the exhalation phase and the muscles of the larynx, which bring the vocal cords together and resist the pressure of the air stream. Adjustment of muscle function occurs reflexively when the mucous membrane of the larynx is irritated by air.

According to another theory, the movements of the vocal folds do not occur passively under the influence of an air stream, but are active movements of the vocal muscles, carried out by command from the brain, which is transmitted along the corresponding nerves. The pitch of the sound, associated with the frequency of vibration of the vocal cords, thus depends on the ability of the nerves to conduct motor impulses.

Some theories cannot fully explain such a complex process as voice formation. In a person who has speech, the function of voice formation is associated with the activity of the cerebral cortex, as well as lower levels of regulation, and is a very complex, consciously coordinated motor act.

Larynx in nuances

A specialist can examine the condition of the larynx using a special device - a laryngoscope, the main element of which is a small mirror. For the idea of ​​this device, the famous singer and vocal teacher M. Garcia was awarded the title of honorary doctor of medicine in 1854.

The larynx has significant age and gender characteristics. From birth to 10 years of age, the larynx of boys and girls is virtually no different. Before the onset of puberty, the growth of the larynx in boys increases sharply, which is associated with the development of the gonads and the production of male sex hormones. At this time, the boys’ voice also changes (“breaks”). Voice mutation in boys lasts about a year and is completed at the age of 14-15. In girls, the mutation occurs quickly and almost imperceptibly at the age of 13-14 years.

A man's larynx is on average 1/3 larger than a woman's, and the vocal cords are much thicker and longer (approximately 10 mm). Therefore, the male voice, as a rule, is stronger and lower than the female one. It is known that in the XVII-XVIII centuries. in Italy, 7-8 year old boys who were supposed to sing in the papal choir were castrated. Their larynx did not undergo any special changes during puberty and retained its child size. This achieved a high tone of voice, combined with masculine strength of performance and a neutral timbre (between childish and masculine).

Many organs and systems of the body take part in the formation of the voice, and this requires their normal functioning. Therefore, voice and speech are an expression not only of the normal activity of individual organs and systems, including the human psyche, but also of their disorders and pathological conditions. By changes in voice one can judge a person’s condition and even the development of certain diseases. It must be especially emphasized that any changes in hormonal levels in the body (in women - the use of hormonal drugs, menstruation, menopause) can lead to changes in voice.

The sound energy of the voice is very small. If a person talks continuously, it will take only 100 years to produce the amount of thermal energy needed to brew a cup of coffee. However, the voice (as a necessary component of human speech) is a powerful tool that changes the world around us!

Larynx, larynx, - located in the anterior region of the neck at the level of the IV-VI cervical vertebrae. In front of the larynx are the muscles lying below the hyoid bone; on the sides - vessels and nerves forming the neurovascular bundle of the neck; behind - the oral part of the pharynx; above is the hyoid bone, to which the larynx is suspended; below - the thyroid gland, as well as the trachea, into which the larynx directly passes. The larynx is a sound producing organ. It is built on the principle of an organ of movement, that is, it has: a skeleton formed by cartilage; cartilage connections - joints; ligaments; muscles that provide active mobility of cartilage.
Laryngeal cartilages, cartilagines laryngis, represented by three odd and three paired cartilages.
Thyroid cartilage, cartilago thyroidea, - unpaired, largest in size, hyaline, consists of two plates (right and left), lamina dextra et sinistra, connected in front at an angle. In men, the angle is acute (60-70°), due to which a protrusion of the larynx, prominentia laryngea, is formed. In women and children, this angle is rounded, due to which the protrusion is not expressed. In the middle of the upper and lower edges of the cartilage there are the upper and lower thyroid notches, incisura thyroidea superior et inferior. The thickened posterior edge of each plate continues up and down, forming the upper and lower corner, cornu superius et inferius. The latter has a surface from below from the inside for connection with the cricoid cartilage. On the outer surface of each plate there is an oblique line, linea obliqua, - the place of fixation of the sternothyroid and thyrohyoid muscles.
Cricoid cartilage, cartilago cricoidea, - unpaired, hyaline, has the shape of a ring consisting of an arc, arcus cartilaginis cricoideae, and a plate, lamina cartilaginis cricoideae, facing backwards. The upper outer corner of the plate contains arytenoid articular surfaces, fades articularis aiytenoidea, for connection with the arytenoid cartilages, and on the posterolateral surfaces of the arch there are thyroid articular surfaces, fades articularis thyroidea.
Epiglottis, epiglottis, - unpaired, elastic, has the shape of a leaf-shaped plate. Its anterior surface faces the base of the tongue and is connected to the hyoid bone, and its edges to the arytenoid cartilages. The posterior surface faces the entrance to the larynx. The lower part of the epiglottis is narrowed in the form of a stalk, petiolus epiglottidis, attached to the inner surface of the upper edge of the thyroid cartilage. In the lower part of the posterior surface a protrusion is formed, which is called the epiglottic tubercle, tuberculum epiglotticum.
Arytenoid cartilage, cartilago arytenoidea, - paired, elastic, shaped like a pyramid, the base of which, basis cartilaginis arytenoideae, is associated with the plate of the cricoid cartilage, and the apex, apex cartilaginis arytenoideae, is directed upward. There are three surfaces - medial, fades medialis, posterior, fades posterior and anterolateral, fades anterolateral. The latter contains a tubercle, colliculus. An arched ridge, crista arcuata, runs from it along the entire surface, which divides the surface into two pits - the upper triangular, fovea triangularis, and the lower oblong, fovea oblonga.
Two processes extend from the base of the cartilage - the lateral muscular, processus muscularis, and the anterior vocal, processus vocalis.
Corniculate cartilage, cartilago comiculata, - paired, elastic, located at the apex of the arytenoid cartilage.
Sphenoid cartilage, cartilago cuneiformis, - paired, located in front of the corniculate in the thickness of the aryepiglottic ligaments.
Between the cartilages of the larynx there are two pairs of joints that provide mobility of the cartilages and change the tension of the vocal cord.
Cricothyroid joint, articulatio cricothyroidea, - located between the lower horns of the thyroid cartilage and the thyroid articular surfaces of the cricoid. It has a frontal axis of movement. The thyroid cartilage moves in this joint, changing its position relative to the arytenoid. In this case, the vocal cord, located between these cartilages, either tenses or relaxes.
Crico-arytenoid joint, articulatio cricoarytenoidea, - located between the base of the arytenoid cartilage and the arytenoid articular surface of the cricoid. It has a vertical axis of movement around which the arytenoid cartilage rotates. In this case, the vocal processes of both cartilages either come closer or move away from each other. In addition, it is possible for the arytenoid cartilages to slide towards each other and in the opposite direction.
The corniculate cartilages are connected to the apices of the arytenoids through synchondrosis.
There are a number of syndesmoses between the cartilages of the larynx, as well as between the larynx and other organs:
1. Thyroglossal membrane, membrana thyrohyoidea, - consists of the median thyroid hyoid ligament, ligamentum thyrohyoideym medianum, which stretches between the body of the hyoid bone and the upper edge of the thyroid cartilage (in the area of ​​the superior thyroid notch) and the paired lateral thyroid hyoid ligament, ligamentum thyrohyoideym laterale, which runs between the large angle hyoid bone and the upper edge of the plate of the thyroid cartilage, including the upper angle. In the thickness of the last ligament lies granular cartilage.
2. Hypoepiglottic ligament, ligamentum hyoepiglotticum, - located between the body and horns of the hyoid bone and the middle of the anterior surface of the epiglottis.
3. Thyroepiglottic ligament, ligamentum thyroepiglotticum, - between the thyroid cartilage and the stem of the epiglottis.
4. Cricothyroid ligament, ligamentum cricothyroideum, - between the arch of the cricoid cartilage and the inferior notch of the thyroid. Consists of elastic fibers.
5. Cricotracheal ligament, ligamentum cricotracheale, - between the lower edge of the arch of the cricoid cartilage and the first ring of the trachea.
6. Cric-arytenoid ligament, ligamentum cricoarytenoideum, - a pair connecting the cricoid and arytenoid cartilages, constitutes a lateral extension of the cricothyroid ligament.
7. Cricopharyngeal ligament, ligamentum ciicopharyngeum, - located between the plate of the cricoid cartilage and the pharynx.
8. Vocal cord, ligamentum vocale, - steam room, consists of elastic fibers. Connecting the middle of the inner surface of the thyroid cartilage. In fact, this ligament constitutes the upper free edge of the elastic cone.
9. Ligament of the vestibule, ligamentum vestibulare, - steam room, located in the thickness of the fold of the same name above the vocal cord and parallel to it.
Muscles of the larynx, musculi laryngis, are divided into three groups:
- Compressors - narrow the glottis or laryngeal cavity;
- Dilators - expand the glottis or laryngeal cavity;
- Muscles that change the tension of the vocal cords.

Contractor muscles

Extender muscles

Muscles that change vocal cord tension

Age-related features of the larynx

X-ray anatomy of the larynx

The larynx is located on the front surface of the neck at the level of the V-VI cervical vertebrae. It is part of a breathing tube, the upper end of which opens into the pharynx and through the latter communicates with the oral and nasal cavity, and the lower end passes into the windpipe (trachea).

From above, the larynx is connected to the hyoid bone using a special ligament.

The skeleton of the larynx is made up of cartilage (Fig. 28, 29), connected to each other by ligaments. The muscles of the larynx, attaching to certain points of the cartilage, when they contract, change the relative position of the latter.

Rice. 28. Larynx (front).
1 - epiglottis; 2 and 3 - hyoid bone; 4, 10 and 12 - sublingual-thyroid membrane; 5 - thyroid cartilage; 6 and 7 - tracheal cartilage; c - cricoid cartilage; 9 - conical ligament; II - fat body.

Rice. 29. Larynx (back).
1 and 7 - epiglottis; 2 - hyoid bone; 3 and 6 - thyroid cartilage; 4 - arytenoid cartilage; 5 - cricoid cartilage; 8 - sublingual-thyroid membrane.

The basis of the larynx, on which all its cartilages are located, is the immobile cricoid cartilage. Its shape resembles a ring, with its “signet” facing backward and its narrow part facing forward.

The upper, right and left halves of the “signet” have an articular surface; on it there are movable arytenoid cartilages, which are driven by muscles. The thyroid cartilage is located on the cricoid cartilage, forming a protruding part on the front surface of the neck.

The thyroid cartilage consists of two plates placed at an angle to each other. This part of the thyroid cartilage can be easily felt under the skin, and in men it protrudes sharply on the neck (“Adam’s apple”). Both plates of the thyroid cartilage have processes above and below - the upper and lower horns. The upper ones connect to the hyoid bone, and the lower ones rest against the ring of the cricoid cartilage. A functionally important part of the larynx is the arytenoid cartilages; The vocal cords are attached to them.

These muscles are cords of triangular prismatic shape, lying horizontally in the lumen of the larynx and going from each scoop to the thyroid cartilage at the angle of connection of the plates. Above the true vocal cords, two folds of the mucous membrane run in the same direction - the so-called false vocal cords.

The approximation or removal of the arytenoid cartilages in relation to each other or the rotation of each arytenoid cartilage around a vertical axis, which is associated with a displacement of the vocal processes, leads to a narrowing or widening of the glottis.

The glottis has the shape of a triangle during quiet breathing. With deep breathing, it expands significantly. When pronouncing a sound, the free edges of the vocal cords tense and come together so much that only a narrow gap remains between them. In this case, vibrations of the free edges of the vocal cords can be observed.

If you press down firmly on the root of the tongue, sometimes you can see with your eye a raised formation that is closely connected to the root of the tongue.

In shape, this formation resembles a plant leaf, half folded longitudinally. This cartilaginous formation is called the epiglottis. During the act of swallowing, the latter covers the entrance to the larynx, preventing the entry of food, drink, and mucus.

All cartilages of the larynx, in addition to the joints, are connected to each other by numerous ligaments.

Thus, the entire larynx is a tube suspended on the hyoid bone and consisting of cartilages interconnected into one whole.

The direct continuation of the larynx is the trachea. It consists of 16-20 cartilaginous half-rings. The posterior wall of the trachea is membranous. The trachea ends at the level of the V thoracic vertebra, where it is divided into two primary bronchi - right and left.

The muscles of the larynx are divided into external and internal. Extrinsic muscles connect the larynx to other parts of the skeleton. By the action of these muscles, the larynx rises and falls or is fixed in a certain position.

The internal muscles do not extend beyond the larynx and carry out its respiratory and voice-forming functions. According to these functions, they are divided into muscles that expand and narrow the glottis.

The larynx is innervated by two branches of the vagus nerve - the superior and inferior laryngeal nerves. The superior laryngeal nerve, mainly sensory, innervates the entire mucous membrane of the larynx.

The muscles of the larynx, which take part in the narrowing of the glottis, are innervated by the branches of the inferior laryngeal nerve, with the exception of one - the anterior one, innervated from the superior laryngeal nerve.

One of the anatomical structures of the upper respiratory tract is the larynx. To the average person, it appears to be a movable tube, which somewhere in its depth contains the vocal cords involved in the formation of the voice. Usually this is where knowledge ends. In reality, things are a little more complicated. Therefore, it is worth talking about this in more detail.

Topography

The larynx is located opposite the IV, V and VI cervical vertebrae, starting immediately behind and passing along the anterior surface of the neck. Behind it is the pharynx. It communicates with the larynx through the entrance to the larynx, but in order to prevent food from entering the lungs and air from entering the stomach, nature has provided such an important detail as the epiglottis, which blocks the lumen of the pharynx during inhalation and moves the larynx during swallowing, separating thus the functions of these organs.

On the sides of the larynx there are large neurovascular bundles of the neck, and in front all this is covered by muscles, fascia and the thyroid gland. From below it passes into the trachea, and then into the bronchi.

In addition to the muscle component, there is also a cartilaginous component, represented by nine half-rings, ensuring the reliability and mobility of the organ.

Features in men

A characteristic feature of the structure of the larynx in representatives of the stronger sex is the presence of an Adam's apple, or Adam's apple. This is a part that, for unknown reasons, is stronger in men than in women. Although it would be more logical to assume the opposite situation, because the muscular frame of the neck, which should cover the cartilage, is weaker in women.

Anatomy

The larynx is a cavity, which is covered from the inside with smooth and moist tissue - the mucous membrane. Conventionally, the entire organ cavity is divided into three sections: upper, middle and lower. The upper one is the vestibule of the larynx, they are narrowed downwards in the shape of a funnel. The middle is the gap between the false and true vocal folds. The lower part serves to connect with the trachea. The most important and complex department in structure is the middle one. Here are the cartilages and ligaments of the larynx, thanks to which the voice is formed.

Voice education

The space between is called the glottis. Contraction of the laryngeal muscles changes the tension of the ligaments, and the configuration of the gap changes. When a person exhales, air passes through the glottis, causing the vocal cords to vibrate. This is what produces the sounds we pronounce, particularly vowels. In order to pronounce a consonant sound, the participation of the palate, tongue, teeth and lips is also necessary. Their coordinated work allows them to speak, sing, and even imitate the sounds of the environment and imitate the voices of other people or animals. The rougher one is explained by the fact that anatomically their ligaments are longer, which means they vibrate with a greater amplitude.

Ontogenesis

Depending on the age of a person, the structure of the larynx may change. This is partly why men experience voice loss after puberty. Newborns and infants have a short and wide larynx, it is located higher than that of an adult. It does not contain carotid cartilages and thyrohyoid ligaments. It will take its final form only by the age of thirteen.

Laryngeal wall

If we consider from a topographical point of view, then from the outside to the inside its layers are arranged like this:

• Leather.
• Subcutaneous tissue.
• Cartilage, ligaments, muscles.
• Fibrous-elastic membrane (represented by connective tissue).
• The mucosa is a multinucleated ciliated epithelium and fibers of unformed connective tissue that grow together with the previous layer.
• The outer connecting plate is elastic and covers the cartilage of the larynx.

Rigid laryngeal frame

As mentioned above, there is a phylogenetically formed apparatus that supports the larynx. The cartilages of the larynx are dense half rings that hold the remaining tissues of this part of the neck and give the organ the appearance of a hollow tube. They are connected to each other by ligaments. There are single and paired cartilages of the larynx.

Single cartilages

In the anatomy of the organ, there are three cartilages that do not have twins. The unpaired cartilages of the larynx are located along the same axis, one above the other.

1. The epiglottis, or epiglottis, is a thin plate shaped like a leaf or flower petal. The wide part is located above the thyroid cartilage, and the narrow part, also called the stalk, is attached to its inner corner.
2. The thyroid is the largest cartilage of the larynx, located between the epiglottis and the cricoid cartilage. Its name corresponds to both the form and function of this part of the organ. The thyroid cartilage of the larynx serves to protect its internal part from trauma. It is formed by two quadrangular plates merging in the middle. At this point, a ridge is formed, at the top of which there is an elevation to which the vocal cords are attached. On the sides of the plates there are paired processes - horns (upper and lower). Those at the bottom articulate with the cricoid cartilage, and those at the top articulate with the hyoid bone. On the outer side of the cartilage there is an oblique line to which the external muscles of the larynx are partially attached.
3. The cricoid cartilage of the larynx is an organ. Its shape fully corresponds to its name: it looks like a man’s ring, turned backwards with a signet. On the sides there are articular surfaces for connection with the arytenoid and thyroid cartilage. This is the second major cartilage of the larynx.

Paired cartilages

There are also three of them, since nature loves symmetry and strives to show this love in every possible case:

1. Cherpalovdnye. The arytenoid cartilage of the larynx is shaped like a triangular pyramid, the apex of which faces back and slightly toward the center of the body. Its base is part of the joint surface with the cricoid cartilage. Muscles are attached to the corners of the pyramid: in front - the vocal muscles, and in the back - the posterior and anterior cricoarytenoid muscles.
2. The corniculates are located above the tips of the arytenoid cartilages.
3. The wedge-shaped ones are usually located in the aryepiglottic folds. The last two pairs of cartilages belong to the sesamoids and can vary in shape and location.

All these formations give shape to an organ such as the larynx. The cartilages of the larynx perform functions necessary to maintain normal human functioning. This is especially noticeable in relation to voice formation.

Joints

As mentioned above, cartilage is connected to each other through ligaments and joints. There are two paired joints in the larynx:

1. Between the cricoid and thyroid cartilage. They are formed by the lateral surfaces of the cricoid cartilage, which are adjacent to the lower horn of the thyroid. When moving in this joint, the tension of the ligaments changes, and therefore the pitch of the voice.
2. Between the cricoid and arytenoid cartilages. It is formed by the articular surfaces (lower parts of the pyramid) of the arytenoid cartilages and the articular platform of the cricoid cartilage. Moving relative to each other, these anatomical formations change the width of the glottis.

Ligaments

Being a mobile organ, the ligaments have a great influence on how the larynx is structured. The cartilages of the larynx are maintained in dynamic balance with the help of connective tissue cords:

1. The thyrohyoid ligament is part of the large thyrohyoid membrane, with which the entire larynx is attached to the hyoid bone. A neurovascular bundle passes through it, feeding the organ.
2. The thyroid epiglottis ligament serves to connect the epiglottis to the thyroid cartilage.
3. Hypoepiglottic ligament.
4. The cricotracheal ligament connects the larynx with the trachea and is attached to the first cartilage of the larynx.
5. The conical ligament unites the cricoid and thyroid cartilages. In fact, it is a continuation of the elastic membrane running along the inner surface of the larynx. It is a layer between cartilage and mucous membrane.
6. The vocal fold is also part of the elastic cone covering the vocal muscle.
7. The aryepiglottic ligament.
8. The lingualepiglottic ligaments connect the root of the tongue and the anterior surface of the epiglottis.

Muscles

There are two larynxes. The first is functional. She divides all muscles into:

• Constrictors, which narrow the glottis and laryngeal cavity, making it difficult for air to pass through.
• Dilators are necessary to widen the larynx and glottis, respectively.
• Muscles that can change the tension of the vocal cords.

According to the second classification, they are divided into external and internal. Let's talk about them in more detail.

External muscles

The external muscles seem to wrap the larynx. The cartilages of the larynx are supported not only from the inside, but also from the outside. Conventionally, anatomists divide the outer group into two more: the first includes those muscles that are attached to the thyroid cartilage, and the second - those attached to the bones of the facial skeleton.

First group:

• sternothyroid;
• thyrohyoid.

Second group:

• sternohyoid;
• scapular-hyoid;
• stylohyoid;
• digastric;
• geniohyoid.

Internal muscles

Necessary to change the position of the epiglottis and help it perform its functions, as well as to change the configuration of the glottis. These muscles include:

• The aryepiglottic, which forms the aryepiglottic fold. During swallowing, the contraction of this muscle changes the position of the epiglottis so that it blocks the entrance to the larynx and prevents food from entering there.
• The thyroid epiglottis, on the contrary, when contracting, pulls the epiglottis towards itself and opens the larynx.
• The lateral cricoarytenoid regulates the width of the glottis. When it contracts, the ligaments come closer together and the glottis becomes narrower.
• The posterior cricoarytenoid contracts during inhalation, and the vocal folds diverge, pulling back and to the sides, allowing air to pass further into the respiratory tract.
• The vocal muscle is responsible for the characteristics of the vocal cords, how long or short they are, tense or relaxed, whether they are equal in relation to each other. The timbre of the voice, its aberrations, and vocal abilities depend on the work of this muscle.

Functions of the larynx

The first function, of course, is respiratory. And it consists in regulating the air flow passing through the respiratory tract. Changing the width of the glottis prevents air from entering the lungs too quickly during inspiration. Conversely, air cannot leave the lungs too quickly until gas exchange has taken place.

The ciliated epithelium of the laryngeal mucosa takes on its second function - protective. It manifests itself in the fact that small particles of dust and food do not enter the lower respiratory tract thanks to the well-coordinated work of the cilia. In addition, the nerve endings, which are present in large numbers on the mucous membrane, are very sensitive to foreign bodies and, when irritated, provoke a coughing attack. At this moment, the epiglottis blocks the entrance to the larynx, and nothing foreign gets in there. If the object does get into the larynx, the cartilages of the larynx reflexively interact with each other, and the glottis is blocked. This, on the one hand, prevents food and other bodies from entering the bronchi, and on the other hand, it blocks the access of air. If help does not arrive quickly, the person dies.

The last one on our list is voice-forming. It completely depends on the anatomical structure of the larynx and on how much a person controls his vocal apparatus. As people grow and develop, they learn to speak, sing, recite poetry and prose, imitate animal voices or environmental sounds, and sometimes even imitate other people. The higher the level of control over one’s body, the more opportunities a person has.

This is, in brief, the normal topographic anatomy and physiology of the larynx. From the article you learned about the important function it performs in the activities of the human body and that the cartilages of the larynx play an important role here. Thanks to her, we breathe normally, speak and don’t choke every time we eat something. Unfortunately, she is more susceptible to infectious diseases and tumor processes than others.