Children also have a shorter trachea, which makes right mainstem bronchus intubation more likely. These features contribute to the more acute angle between the epiglottis and glottis of children, which makes vocal cord visualization more difficult when using a laryngoscope. The child’s larynx is also more cephalad and anterior compared to adults. The larger tongue in children more easily obstructs the airway. Applying a shoulder roll to extend the head can overcome neck flexion. Compared to an adult, a child’s head is proportionally larger, leading to a flexed position of the neck when supine. These anatomic landmarks can also be identified in a child with some special considerations. This ligament helps lift the epiglottis anteriorly during intubation to expose the vocal cords. The hyoepiglottic ligament attaches the hyoid bone to the larynx, and it inserts at the base of the vallecula. The cricoid cartilage is ring-shaped and sits inferior to the cricothyroid membrane, which is the landmark for emergent cricothyrotomy. Identification of the cricoid cartilage and manipulation of the airway often facilitates vocal cord visualization during intubation. These vagal fibers contribute to circulatory changes with direct laryngoscopy. Superior to the vocal cords, the larynx is innervated by the superior laryngeal branch of the vagus nerve, which provides afferent innervation at the base of the tongue and vallecula. The obtuse angle between the trachea and the right mainstem bronchus makes it more prone to right mainstem intubation if the endotracheal tube is advanced too distally. The angle between the trachea and the left mainstem bronchus is more acute, making foreign object dislodgement into the left mainstem less likely. At the fifth thoracic spine, the trachea bifurcates into the right and left mainstem bronchi. These features are important clinical markers that differentiate the trachea from the esophagus and allow for the utilization of a bougie for intubation. Adult tracheal diameters vary between 15 mm and 20 mm. The trachea is soft and membranous posteriorly with cartilaginous rings anteriorly. The trigeminal nerve provides sensory innervation to the mucous membranes of the nasopharynx, while the facial nerve and glossopharyngeal nerve innervate the oropharynx. These structures humidify and warm the air and derive their blood supply from the external and internal carotid arteries. The upper airway consists of the oral cavity and pharynx, including the nasopharynx, oropharynx, hypopharynx, and larynx.
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