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ANATOMY OF
LARYNX
MODERATOR: Dr.MANAS
PRESENTER:RAVINDRA.D
INTRODUCTION


The LARYNX is an
apparatus made up of
cartilage, ligaments,
muscles, and mucous
membrane, which
guards the entrance
to the lower
respiratory passages
(trachea, bronchi, and
lungs) and houses the
vocal cords.
DEVELOPMENT

OF LARYNX

Development of larynx
occur during the 4th
week of intra uterine life
 The respiratory
primordium appears in
the floor of the foregut
in the 4th week of
gestational life.
 The larynx begins as a
slit like
diverticulum(laryngotrac
heal groove ) in the
ventral wall of the
primitive pharynx .







The groove gradually
deepens and its edges
fuse to form a septum,
this septum separates
the laryngotracheal
tube from the pharynx
and oesophagus.

The process of this
fusion starts caudally
and extend cranially






Between 5th & 6th weeks,
— 3 swellings
appear at the laryngeal
aditus.
An anterior swelling , a
derivative of the
hypobranchial eminence
from 4th arch—forms
Epiglottis.
2 lateral arytenoid
swellings appear, derived
from the 6th branchial
arch, move medially and
form a T-shaped aperture


Laryngeal lumen— temporarily occluded at 8 weeks gestational
age as a result of epithelial proliferation.



By the 10th week of gestation, recanalization occurs and
consequently pair of laryngeal ventricles are formed.



The laryngeal ventricles are bound by mesenchyme tissue that
condense and progress into false and true vocal cords.



Laryngeal cartilages develop from the mesenchyme of the
branchial arches.



Thyroid cartilage-- from the 4th arch mesenchyme as two
lateral plates meet in the
midline.





Arytenoids , Corniculate , Cricoid & Tracheal cartilages-- 6th
branchial arch
Epiglottis — develops from Hypobranchial eminence
Intrinsic laryngeal muscles develop from the mesoderm of the
4th and 6th arches
EXTERNAL FEATURES










OF LARYNX

Larynx is located anterior to the
3rd, 4th, 5th, and 6th cervical
vertebrae.
Extends from the base of the
tongue to the proximal portion
of the trachea.
Laryngeal skeleton is suspended
from the hyoid bone by the
medial and lateral thyrohyoid
membrane.
The lateral lobes of the thyroid
gland lie anterolateral to the
thyroid and cricoid cartilage.
Isthmus of the thyroid gland
lies just below the cricoid
cartilage and often covers the
first 1 or 2 tracheal rings.
The carotid sheath and
its contents lie just
posterolateral to the
larynx.
 The recurrent laryngeal
nerve ascends in the
tracheoesophageal
groove and enters the
larynx just posterior to
the cricothyroid
articulation
 The 3rd to 6th cervical
vertebrae, prevertebral
muscles, and fascia lie
posterior to the larynx.

PRINCIPAL INTERNAL FEATURES OF THE LARYNX
The cavity of the larynx
extends
above – from the area
of the tip of the
epiglottis,aryepiglotti
c folds, and
interarytenoid folds
below — to the 1st
tracheal ring
INTERNAL CAVITY OF THE LARYNX
divided into 3 spaces:


Supraglottic,



Glottic, And



Subglottic spaces
DIFFERENCES BETWEEN ADULT & INFANT
LARYNX
7

S

1. Size- smaller in infants

2. Shape- funnel shaped in infants , cylindrical in adults
3 . Softness-laryngeal cartilages are softer in infants
4. Superiorly placed in infants
5 . Straighter and less oblique than in adults
6 . Sensitivity is greater in infants more prone to spasm
7 . Sub glottis is very narrow ,even a small swelling can lead
to airway obstruction in infants
Differences between adult & infant Larynx
Average measurements of larynx
SKELITAL ANATOMY
Laryngeal frame work consists of :
Cartilages
 Joints
 Ligaments
 Membranes
 Muscles
 Mucous membrane
 + Hyoid
Bone

HYOID












BONE

Described with the larynx
because of its anatomic
association with the
laryngeal apparatus.
located in front of the 3rd
cervical vertebra.
serves as an attachment for
the larynx via the
thyrohyoid membrane and
the extrinsic muscles of
the larynx.
The hyoid bone is suspended
from the skull base
(temporal bone) via the
stylohyoid ligaments
It is an U-shaped bone with
Body
2 lesser horns (cornua)
2 greater horns (cornua)
ATTACHMENTS TO THE HYOID BONE















Medial end of the middle
constrictor muscle and the
stylohyoid ligament attach to the
lesser cornu.
The middle constrictor and
hyoglossus muscles attach to the
greater cornu.
geniohyoid and genioglossus
attaches to the inner and upper
surfaces of the body
of the hyoid bone.

The mylohyoid attaches to the
anterior surface of the hyoid.
The tendon of the digastric
muscle attaches to the
anterolateral portion of the body.

sternohyoid, omohyoid, and
thyrohyoid attaches to the
inferior surface of body.
Each muscle acts to depress the
hyoid bone.
SURGICAL CONSIDERATIONS
In tracheal resection and anastomosis, a tension-free
closure of the distal airway is essential.
 The larynx can be released and "dropped" from the hyoid
bone to reduce tension on the distal suture line.
 This is accomplished by detaching the infrahyoid muscles
from the inferior surface of the hyoid bone body and
cutting the hyoid bone just lateral to the lesser cornua
 This releases the central body of the hyoid and larynx.
 Additional relaxation can be achieved by cutting the
suspensory ligament of the superior cornu of the thyroid
cartilage
 This can lower the larynx to a maximum of 4.5 cm.
 The hyoid bone serves as a site of access to the
supraglottic larynx and pharynx.

During the excision of a
thyroglossal duct cyst,


excising the entire
tract along with the
central body of the
hyoid bone (Sistrunk
procedure) reduces the
recurrence rate.
CARTILAGES OF LARYNX :















3
3

paired
unpaired

Paired :
Arytenoid
Corniculate
cunieform
Unpaired:
Thyroid
Cricoid
Epiglottic
THYROID CARTILAGE








located anterior to the
4th and 5th cervical
vertebrae.
formed by 2 laminae which
fuse ventrally in the
midline of the neck,
forming a protuberance,
the laryngeal prominence
or "Adam's apple,―
The 2 laminae meet at an
angle of 90° in the male
and 120° in the female.
The upper limit of fusion
of the two laminae forms
the superior thyroid notch










1.

2.
3.

Posterior border of each lamina
extends upward and downward
as hornlike projections,the
superior and inferior cornua
The cornua are characterized
further at their origins from
the thyroid laminae by superior
and inferior tubercles.
Both of the superior horns are
anchored to the tips of the
greater horns of the hyoid
bone;
both inferior horns articulate
with the cricoid cartilage.
On the lateral, external surface
of each thyroid lamina is—ridge
,called the oblique line,
attaches to 3 muscle
Sternothyroid,
Thyrohyoid,and
Thyropharyngeus (a portion of
the inferior pharyngeal
constrictor).
o











The thyrohyoid membrane and
median thyrohyoid ligament
are attached to the upper
border of the thyroid
cartilage.
The lateral thyrohyoid
ligaments attach to the
greater cornua of the thyroid
cartilage.
The cricothyroid ligaments
(cricothyroid membrane)
attach to the inferior border
of the thyroid cartilage
5 ligaments attach as one to
the posterior surfaces of the
thyroid laminae near the
union of the laminae (angle):
The median thyroepiglottic
ligament,
The 2 vestibular
ligaments,And
The 2 vocal ligaments.
SURGICAL CONSIDERATIONS
The thyroid cartilage is divided in the midline to
expose the endolarynx for various procedures
(for example, partial laryngectomy,
laryngotracheoplasty, and arytenoidectomy).
 The vocalis muscle and vocal ligaments attach to
the inner surface of the thyroid cartilage at the
anterior commissure
 On the external laryngeal surface in adult males
this point is halfway between the thyroid notch
and the inferior border of the thyroid cartilage.
It is slightly higher in adult females.
 In many laryngofissure approaches, it may be
beneficial to stay below the midpoint in order to
avoid dividing the anterior commissure.

CRICOID CARTILAGE












Shaped like a signet ring.
signet-shaped portion of the
cricoid faces posteriorly
the arch is located anteriorly,
The cricoid cartilage is situated
at vertebral level C6
(occasionally reaching the middle
of C6), just below the thyroid
cartilage
The cricoid lamina has
2 superior facets– articulate
with the arytenoid cartilages
and attach to them by the
posterior cricoarytenoid
ligaments
2 lower lateral facets of the
lamina articulate with the
inferior horns of the thyroid
cartilage.
The lower border of the cricoid
cartilage is joined to the first
tracheal ring by means of the
thick cricotracheal ligament.
Arising from the arch of
the cricoid cartilage
anteriorly and externally
are the cricothyroid
muscles.
 The lamina has a midline
ridge for the tendinous
attachment of longitudinal
fibers of the esophagus.
 Lateral to this ridge are
the sites of origin for the
bilateral posterior
cricoarytenoid muscles.

SURGICAL CONSIDERATIONS










Injury to the cricoid cartilage from intubation or trauma
may result in perichondritis and lead to subglottic
stenosis.
Surgical approaches to repair long-standing subglottic
stenosis involve the expansion of the circumference of the
cricoid ring with autologous cartilage grafts.
Tracheotomies are usually performed at least one tracheal
ring below the cricoid cartilage (2nd or 3rd tracheal ring)
to avoid subglottic stenosis.
During an emergency cricothyroidotomy, the
tracheostomy tube is inserted through the median
cricothyroid ligament — the quickest and easiest access
to the airway.
To avoid permanent laryngeal stenosis —
cricothyroidotomy must be converted to a standard
tracheotomy within days.
ARYTENOID CARTILAGES













Almost pyramidal in
shape,
with
3 surfaces,
a base, and
an apex.
Each triangle-shaped base
articulates with the
cricoid cartilage by way
of a diarthrodial joint.
Base has 2 processes:
Anteromedially directed
vocal process – vocal
ligament is attached
Short, broad, laterally
projecting Muscular
process – lateral and
posterior cricoarytenoid
muscles are attached


1.

2.

3.






Arytenoid has 3
surfaces
Posterior surface —
Transverse and oblique
arytenoid muscles attach
Medial surface – covered
with mucous-secreting
laryngeal mucosa.
Anterolateral surface –
insertion of
thyroarytenoid muscle,
part of the vocalis
muscle,and
the vestibular ligament.
The apex of the arytenoid
cartilage supports the
corniculate cartilage
SURGICAL CONSIDERATIONS








Cricoarytenoid fixation may occur from arthritis or
perichondritis
(intubation
injury) and limit vocal fold mobility.
Cricoarytenoid subluxation during blind intubation
with a lighted stylet.
Arytenoidectomy through an external or endoscopic
approach may alleviate
arytenoid fixation or paralysis.
submucosal arytenoidectomy which preserves an
intact laryngeal mucosa
CORNICULATE CARTILAGES ( OF SANTORINI )
small fibroelastic nodules
that sit on the apices of the
arytenoid cartilages.
 It has little functional
importance in humans




CUNEIFORM CARTILAGES (OF
WRISBERG)

rod-shaped (like ancient
cuneiform script).
 situated in the
aryepiglottic folds anterior
to the corniculate cartilages,
 may be entirely absent.

TRITIATE
CARTILAGE
an occasional,
minute nodule.
 located in the
posterior margin of
the thyrohyoid
membrane

EPIGLOTTIS















Oblong leaf shaped
Located behind the root of the
tongue and the body of the hyoid
bone and in front of the laryngeal
entrance (laryngeal aditus or
vestibule).
It has:
2 ends— upper & Lower
2 surfaces— Anterior &
Posterior
2 Lateral borders
Upper end:broad
lower end: narrow –― petiolus /
stalk ‖ attaches to inner surface
of thyroid cartilage below
thyroid notch by the
thyroepiglottic ligament
It attaches to the posterior
body of the hyoid bone via the
hyoepiglottic ligament
it lies dorsal to the thyroid
cartilage and thyrohyoid
membrane, guarding the laryngeal
entrance.
The space between the anterior surface of the
epiglottis and the thyrohyoid membrane and
thyroid cartilage is called the preglottic space
 The epiglottis is attached to the thyroid
cartilage by the thyroepiglottic ligament.
 The aryepiglottic folds and the quadrangular
membranes attach to the lower
part of the
lateral margins of the epiglottis.

SURGICAL CONSIDERATIONS
Acute epiglottiditis, may cause airway
obstruction in children.
 To rule out foreign bodies, a lateral x-ray may
be ordered if the general condition of the child
permits.
 Laryngeal visualization must be done in the
operating room to avoid airway
occlusion, aspiration, and cardiac arrest.
 Intubation and tracheostomy are the procedures
of choice

LARYNGEAL LIGAMENTS

AND

MEMBRANES

Membranes — Extrinsic – Thyrohyoid membrane
Crico tracheal membrane
Intrinsic — Quadrangular
membrane
Conus elasticus

Ligaments & Folds
 Epiglottic ligaments
 Aryepiglottic fold
 Vestibular ligament (vestibular folds or false
vocal cords)
 Vocal ligaments

LARYNGEAL MEMBRANES
THYROHYOID
MEMBRANE








provides an extensive
connection between the
thyroid cartilage and the
hyoid bone bilaterally and
anteriorly.
Extending from the upper
border and the greater
horns of the hyoid bone to
the superior horns of the
thyroid cartilage and its
laminae
Thickens anteriorly,
forming the median
thyrohyoid ligament
Thickened posterior
margin on each side is
called the lateral
thyrohyoid ligament.
SURGICAL CONSIDERATIONS
The superior laryngeal
neurovascular bundle
may be injured by
surgical approaches to
the pharynx.
 One must observe
great care when
dissecting the greater
cornu of the hyoid
bone and the superior
horn of the thyroid
cartilage during various
pharyngotomy
approaches

THE CRICOTRACHEAL MEMBRANE



connects the most
superior tracheal
cartilage with the
inferior border of the
cricoid cartilage
INTRINSIC MEMBRANES
connect the laryngeal
cartilages with each
other to regulate
movement.
 There are 2
intrinsic membranes :
1.
Conus Elasticus
and
2. Quadrangular
membranes.

CONUS ELASTICUS
Conus Elasticus connects the
cricoid cartilage with the thyroid
and arytenoid cartilages.
 composed of dense
fibroconnective tissue with
abundant elastic fibers.
 Having 2 parts
1 .Medial cricothyroid ligament —
connects the anterior part of the
arch of the cricoid cartilage with the
inferior border of the thyroid
membrane.
2. Lateral cricothyroid membranes
originate on the superior surface of
the cricoid arch and rise superiorly
and medially to insert on the vocal
process of the arytenoid cartilages
posteriorly, and to the interior
median part of the thyroid cartilage
anteriorly.
 Its free borders form the VOCAL
LIGAMENTS

QUADRANGULAR MEMBRANE






Extends from the sides
of the epiglottic cartilage
anteriorly to the
anterolateral surface of
the arytenoid cartilage
and posteroinferiorly to
the corniculate cartilage.
With its covering of
mucous membrane forms
the aryepiglottic fold
superiorly and vestibular
ligament inferiorly.
it forms the medial wall
of the piriform recess
The paired Quadrangular
Membranes connect the
epiglottis with the arytenoid
and thyroid cartilages.
 Course posteriorly downward
and attach to the corniculate
cartilages and the lateral
surfaces of the arytenoids.


The cuneiform cartilages are
embedded within the
aryepiglottic folds.
 The free inferior borders of
the quadrangular membranes
form the ventricular ligaments,
also known as the false vocal
folds.

LIGAMENTS & FOLDS OF LARYNX


Epiglottic ligaments



Aryepiglottic fold





Vestibular ligament (vestibular folds or false
vocal cords)
Vocal ligaments
1 . EPIGLOTTIC LIGAMENTS
FOLDS


Hyoepiglottic ligament



Thyroepiglottic ligament



Median glossoepiglottic
ligament





Lateral glossoepiglottic
or
pharyngoepiglottic fold,
attached between the base
of the epiglottic cartilage
and the pharyngeal wall at
the root of the tongue

AND
2 . ARYEPIGLOTTIC FOLDS






one on each side,
contain the aryepiglottic
muscles.
associated with the
superior border of the
quadrangular membrane.
Both aryepiglottic folds
constrict the entrance to
the larynx and protect
the respiratory pathway
by not permitting food,
liquids, and foreign bodies
to enter the larynx and
trachea.
3 . VESTIBULAR FOLDS
(FALSE VOCAL CORDS)









formed by the inferior edge of
the quadrangular membrane.
Attached in front to the
thyroid cartilage just below the
attachment of the epiglottic
cartilage
Connected behind to the
anterolateral surfaces of the
arytenoid cartilages.
The vestibular ligaments are
located just above the vocal
ligaments, separated from them
by bilateral ellipsoid spaces
called the laryngeal ventricles.
Overlap the true vocal folds
just prior to a cough or sneeze
— reinforcing the resistance
offered by the true vocal folds
against the internal expiratory
pressures.
4.VOCAL LIGAMENTS, VOCAL CORDS,
AND VOCAL FOLDS




The thickened,
ligamentous, upper
edges of the elastic
tissue of the conus are
the vocal ligaments or
vocal cords.
Extend from the medial
extremities of the
laminae of the thyroid
cartilage in the midline
anteriorly (forming the
anterior commissure) to
the apices of the vocal
processes of the
arytenoid cartilages on
each side posteriorly.
STRUCTURE OF VOCALCORD











Histologically 5 layers:
LAYER 1: is the squamous epithelial lining. It is very thin and helps to hold
the shape of the vocal fold. This layer doesnot contain any mucous glands.
LAYER 2: superfical layer of the lamina propria. It is composed of loose
fibers and matrix .
This layer contains only minimal elastic and collagenous fibers and offers
least resistance to vibration. The integrity of this layer is vital for proper
phonatory function.
LAYER 3: intermediate layer of lamina propria.
It contains a higher concentration of elastic and collagenous fibers when
compared to layer 2. This layer is thickened at the anterior and posterior
ends of the vocal folds. These thickened regions are known as anterior and
posterior macula flava. These structures provide protection to the vocal
folds from mechanical damage.
LAYER 4 : deep layer of lamina propria.
It contains a dense collection of elastic and collagenous fibers. This layer
along with the intermediate layer constitute the vocal ligament. Some of
the collagenous fibers present here gets inserted into the vocalis muscle.
LAYER 5: formed by the vocalis muscle. The fibers of this muscle run
parallel to the direction of the vocal fold.
anatomy of larynx by ravindra daggupati










Vocalis muscle is infact a portion of
thyro arytenoid muscle.
At the anterior most portion of the vocal
fold a mass of collagenous tissue is
present--known as the anterior
commissure tendon
or Broyle's ligament.
This ligament gets attached to the inner
area of thyroid cartilage which is
devoid of perichondrium.
Lacking a submucosa and blood vessels,
the vocal ligaments appear to be pearly
white and shiny.
The space between the true vocal cords
(the intermembranous space) is known as
the rima glottidis
RIMA GLOTTIDIS
Subdivided into 2 parts,




2/5 – intercartilaginous
part (respiratory
glottis,or interarytenoid
space), between the
arytenoid cartilages and
3/5 — the
intermembranous part
or glottis vocalis.
SURGICAL CONSIDERATIONS






The epithelium of the true vocal cords does not have
lymphatics. Therefore, metastatic disease is a rare
phenomenon.
The vocal folds are devoid of lymphatics, and it infact
clearly forms the watershed zone between the upper and
the lower group of lymphatics.
The pathway of metastasis of glottic cancer is via the
Delphian node or paratracheal nodes and finally nodes of
the superior mediastinum.
LARYNGEAL MUCOSA












Is mostly of the respiratory type called ciliated columnar
epithelium,

certain areas of the larynx covered with
stratified squamous epithelium are-

upper area of the anterior , dorsal epiglottic surfaces,
the ventral half of the aryepiglottic folds, and
the vocal cords.
Mucous membrane of the supraglottic larynx is a
downward continuation of the oropharyngeal mucosa.
Infraglottic region of the larynx is made of normal
respiratory mucosa
Mucous glands are found at the posterior surface of the
epiglottis, aryepiglottic fold, and laryngeal appendices.
LARYNGEAL SPACES




o

o




Internal laryngeal
spaces :
vestibule,
ventricles,
subglottic or
infraglottic spaces
External
laryngeal
spaces
Paraglottic space
pre-epiglottic. Space
INTERNAL SPACES (LARYNGEAL CAVITY)
VESTIBULE
 pyramid -shaped space
extends from the
laryngeal inlet or aditus
to the vestibular folds
(false vocal cords).
 Bounded ventrally by
the posteroinferior
surface of the
epiglottis, dorsally by
the corniculate
cartilages and apices of
the arytenoids, and
laterally by the
aryepiglottic folds and
the piriform recesses.
LARYNGEAL VENTRICLES








sinuses (of Morgagni), are
diverticula of the interval
between the false and true
vocal cords.
It is lined internally by
mucosa and covered
externally by a very thin
layer of elastic tissue and
the thin thyroarytenoid
muscle.
The anterior end of the
ventricle may possess an
additional external
expansion, the laryngeal
saccule,
This extends upward deep
to the internal face of the
thyroid cartilage.
SURGICAL CONSIDERATIONS.










Enlargement of the laryngeal
saccule is often referred to
as a laryngocele.
Any obstruction of the
laryngeal ventricle, such as a
ventricular carcinoma, may
lead to the formation of a
laryngocele.
A laryngocele may bulge
through the aryepiglottic fold
and obstruct the endolarynx
( internal laryngocele ).
It may be present outside of
the thyrohyoid membrane (
external laryngocele ).
The enlargement may even be
a combined
internal and external
laryngocele
SUBGLOTTIC (INFRAGLOTTIC) SPACE








the distal part of the
laryngeal cavity.
extends from the glottis
to the inferior border of
the cricoid cartilage.
The subglottic space
begins below the curve
formed by the vocal fold
to the lower end of
cricoid cartilage
SURGICAL
IMPORTANCE :
Narrowest area in
infants , so edema
obstruction &
respiratory distress
occur early
EXTERNAL SPACES







Supraglottic laryngeal area is subdivided into 3
laryngeal spaces
Paired Lateral Paraglottic
One midline

Pre-Epiglottic

Spaces
Space
PARAGLOTTIC SPACES ( TUCKER’S
SPACE)
Bounded laterally by
the thyroid cartilage,
 inferomedially by the
conus elasticus,
 medially
by the
ventricle and the
quadrangular
membrane

PRE-EPIGLOTTIC SPACE ( BOAYER’S SPACE )







Bounded superiorly by the
hyoepiglottic ligament,
anteriorly by the thyrohyoid
membrane and ligament, and
Posteroinferiorly by the
epiglottis and
thyroepiglottic ligament.
The pre-epiglottic space
forms an inverted pyramid.
continuous with the superior
portion of the
paraglottic space.
contains abundant fat, blood
vessels, lymphatics,and
mucosal glands.
SURGICAL CONSIDERATIONS
Epiglottic (supraglottic) carcinoma may spread
through perforations in the epiglottis into the
pre-epiglottic space.
 Since the pre-epiglottic space communicates
laterally with the paraglottic spaces,
a
carcinoma is free to spread beyond the internal
boundaries of the larynx.
 Therefore, supraglottic laryngectomy may be
contraindicated

LARYNGEAL JOINTS








2 pairs of synovial joints
Between the major cartilages of the larynx:
the cricothyroid and
the cricoarytenoid.
1.CRICOTHYROID
JOINT








The joints between the
inferior cornua of the
thyroid cartilage and the
sides of the cricoid
cartilage are synovial
The primary movement at
the joint is rotation around
a transverse axis which
passes transversely through
both cricothyroid joints
The effect of these
movements is to lengthen
the vocal folds, provided the
arytenoid cartilages are
stabilized at the
cricoarytenoid joint.
This may also increase vocal
fold tension
2.CRICOARYTENOID JOINT
 The crico-arytenoid joints
between articular facets on
the superolateral surfaces
of the cricoid cartilage and
the bases of the arytenoid
cartilages enable the
arytenoid cartilages to
slide away or towards each
other and to rotate so that
the vocal processes pivot
either towards or away
from the midline. These
movements abduct and
adduct the vocal ligaments
3.ARYTINOCORNICULATE
JOINT
 Synovial or cartilaginous
joints link the arytenoid
and corniculate cartilages
LARYNGEAL MUSCLES





Extrinsic muscles — which move the entire
larynx,

Intrinsic muscles — which move the vocal cords.
EXTRINSIC MUSCLES





ELEVATORS OF THE PHARYNX
The Suprahyoid Muscles
 Digastric
 Stylohyoid
 Mylohyoid
 Geniohyoid
The Longitudinal Muscles of the
Pharynx
 Stylopharyngeus
 Salpingopharyngeus
 Palatopharyngeus
DEPRESSORS OF THE PHARYNX:



The Infrahyoid Muscles
 Sternohyoid
 Sternothyroid
 Omohyoid
INTRINSIC MUSCLES










The intrinsic muscles
are:
Cricothyroid
Posterior cricoarytenoid
Lateral cricoarytenoid
Arytenoid with its
transverse and oblique
fibers
Thyroarytenoid and its
thyroepiglottic and
components
MUSCLES CONTROLLING
INLET

Oblique arytenoid
 Aryepiglottic muscle


THE

LARYNGEAL
MOVEMENTS OF THE VOCAL CORDS
Adduction

Abduction

Glottis (space between folds)
Folds closed (adducted)

Folds open (abducted)

(View from above)
ADDUCTORS
 Lateral

OF THE

VOCAL CORDS

cricoarytenoid
 Transverse arytenoid
ABDUCTOR OF THE VOCAL CORDS
Posterior

cricoarytenoid
MUSCLE INCREASING
THE VOCAL CORDS
 Cricothyroid:

THE

LENGTH & TENSION

increases the
distance between the angle of
the thyroid cartilage & the
vocal processes of the
arytenoid cartilages, and
results in increase in the
length & tension of the vocal
cords

OF
MUSCLE DECREASING
VOCAL CORDS

 Thyroarytenoid

THE

(vocalis): pulls the
arytenoid cartilage
forward toward the
thyroid cartilage and
thus shortens and
relaxes the vocal
cords

LENGTH & TENSION

OF
SPHINCTERIC FUNCTION OF THE
LARYNX
There are two sphincters:
 At the inlet: used only
during swallowing
 At the rima glottis: used in
coughing and sneezing
SHAPE OF GLOTTIS
Quiet Respiration

Forced Inspiration
INSPIRATION
SHAPE OF GLOTTIS
Normal voice

Whisper
NORMAL PHONATION
WHISPER
BLOOD SUPPLY OF LARYNX :
ARTERIAL SUPPLY
 Upper Larynx
 External carotid artery
 Superior thyroid artery
 Superior laryngeal artery


Lower Larynx
 Subclavian artery
 Thyrocervical artery
 Inferior thyroid artery
 Inferior laryngeal artery

VENOUS
DRAINAGE
Upper Larynx
 Superior laryngeal
vein
 Superior thyroid vein
 Internal jugular vein


Lower Larynx
 Inferior laryngeal
vein
 Inferior thyroid vein
 subclavian vein

LYMPHATIC DRIANAGE
SUPRA GLOTTIC AREA
superior lymphatics drain to
the upper deep cervical
nodes, located at the level of
the carotid bifurcation.
 Some drainage passes to
prelaryngeal nodes.
 INFRA GLOTTIC AREA
drain to the pretracheal
lymph nodes of the proximal
trachea anteriorly
paratracheal nodes laterally
and then to the deep cervical
and superior mediastinal
nodes.

 GLOTIC AREA ( VOCAL FOLDS) is relatively
devoid of lymphatics.




The space deep to the thin mucosa of the true vocal
cords, which is called Reanke's space, has no direct
lymphatic drainage.
The spread of carcinoma is, likewise and fortunately,
retarded until an invasive process involves tissue
peripheral to the true vocal cord.

 DELPHIAN


NODE :

a midline prelaryngeal lymph node, adjacent to the
thyroid gland, enlargement of which is indicative of
metastasis from thyroid or laryngeal carcinoma.
SURGICAL IMPORTANCE








Elective dissection of node
levels II to IV for N-0
laryngeal and hypopharyngeal
carcinoma,
Bilateral selective dissection
is justified by the prevalence
of bilateral metastases in
midline and bilateral tumors.
The superior neurovascular
bundle may be injured during
anterior and lateral
pharyngotomy approaches to
the larynx.
Branches of the cricothyroid
artery may be accidentally
injured during emergency
cricothyroidotomy.
NERVE SUPPLY



1.
2.








Supplied by Vagus nerve:
Superior laryngeal nerve
Internal branch (sensory) –
areas above the glottis
External branch (motor and
sensory)
Motor – Cricothyroid muscle
Sensory – Anterior
infraglottic larynx at level of
cricothyroid membrane
Inferior (recurrent)
laryngeal n.
Motor – all intrinsic laryngeal
muscles of SAME side
(except cricothyroid) and
interarytenoid muscle of
BOTH sides
Sensory – areas below the
glottis
anatomy of larynx by ravindra daggupati
BIBLIOGRAPHY
SCOTT&BROWN 6TH EDITION
 GRAY’S ANATOMY 40TH EDITION
 THE LARYNX -HUGH D. CURTIN

THANK YOU…

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anatomy of larynx by ravindra daggupati

  • 2. INTRODUCTION  The LARYNX is an apparatus made up of cartilage, ligaments, muscles, and mucous membrane, which guards the entrance to the lower respiratory passages (trachea, bronchi, and lungs) and houses the vocal cords.
  • 3. DEVELOPMENT OF LARYNX Development of larynx occur during the 4th week of intra uterine life  The respiratory primordium appears in the floor of the foregut in the 4th week of gestational life.  The larynx begins as a slit like diverticulum(laryngotrac heal groove ) in the ventral wall of the primitive pharynx . 
  • 4.    The groove gradually deepens and its edges fuse to form a septum, this septum separates the laryngotracheal tube from the pharynx and oesophagus. The process of this fusion starts caudally and extend cranially
  • 5.    Between 5th & 6th weeks, — 3 swellings appear at the laryngeal aditus. An anterior swelling , a derivative of the hypobranchial eminence from 4th arch—forms Epiglottis. 2 lateral arytenoid swellings appear, derived from the 6th branchial arch, move medially and form a T-shaped aperture
  • 6.  Laryngeal lumen— temporarily occluded at 8 weeks gestational age as a result of epithelial proliferation.  By the 10th week of gestation, recanalization occurs and consequently pair of laryngeal ventricles are formed.  The laryngeal ventricles are bound by mesenchyme tissue that condense and progress into false and true vocal cords.  Laryngeal cartilages develop from the mesenchyme of the branchial arches.  Thyroid cartilage-- from the 4th arch mesenchyme as two lateral plates meet in the midline.    Arytenoids , Corniculate , Cricoid & Tracheal cartilages-- 6th branchial arch Epiglottis — develops from Hypobranchial eminence Intrinsic laryngeal muscles develop from the mesoderm of the 4th and 6th arches
  • 7. EXTERNAL FEATURES      OF LARYNX Larynx is located anterior to the 3rd, 4th, 5th, and 6th cervical vertebrae. Extends from the base of the tongue to the proximal portion of the trachea. Laryngeal skeleton is suspended from the hyoid bone by the medial and lateral thyrohyoid membrane. The lateral lobes of the thyroid gland lie anterolateral to the thyroid and cricoid cartilage. Isthmus of the thyroid gland lies just below the cricoid cartilage and often covers the first 1 or 2 tracheal rings.
  • 8. The carotid sheath and its contents lie just posterolateral to the larynx.  The recurrent laryngeal nerve ascends in the tracheoesophageal groove and enters the larynx just posterior to the cricothyroid articulation  The 3rd to 6th cervical vertebrae, prevertebral muscles, and fascia lie posterior to the larynx. 
  • 9. PRINCIPAL INTERNAL FEATURES OF THE LARYNX The cavity of the larynx extends above – from the area of the tip of the epiglottis,aryepiglotti c folds, and interarytenoid folds below — to the 1st tracheal ring
  • 10. INTERNAL CAVITY OF THE LARYNX divided into 3 spaces:  Supraglottic,  Glottic, And  Subglottic spaces
  • 11. DIFFERENCES BETWEEN ADULT & INFANT LARYNX 7 S 1. Size- smaller in infants 2. Shape- funnel shaped in infants , cylindrical in adults 3 . Softness-laryngeal cartilages are softer in infants 4. Superiorly placed in infants 5 . Straighter and less oblique than in adults 6 . Sensitivity is greater in infants more prone to spasm 7 . Sub glottis is very narrow ,even a small swelling can lead to airway obstruction in infants
  • 12. Differences between adult & infant Larynx
  • 14. SKELITAL ANATOMY Laryngeal frame work consists of : Cartilages  Joints  Ligaments  Membranes  Muscles  Mucous membrane  + Hyoid Bone 
  • 15. HYOID         BONE Described with the larynx because of its anatomic association with the laryngeal apparatus. located in front of the 3rd cervical vertebra. serves as an attachment for the larynx via the thyrohyoid membrane and the extrinsic muscles of the larynx. The hyoid bone is suspended from the skull base (temporal bone) via the stylohyoid ligaments It is an U-shaped bone with Body 2 lesser horns (cornua) 2 greater horns (cornua)
  • 16. ATTACHMENTS TO THE HYOID BONE        Medial end of the middle constrictor muscle and the stylohyoid ligament attach to the lesser cornu. The middle constrictor and hyoglossus muscles attach to the greater cornu. geniohyoid and genioglossus attaches to the inner and upper surfaces of the body of the hyoid bone. The mylohyoid attaches to the anterior surface of the hyoid. The tendon of the digastric muscle attaches to the anterolateral portion of the body. sternohyoid, omohyoid, and thyrohyoid attaches to the inferior surface of body. Each muscle acts to depress the hyoid bone.
  • 17. SURGICAL CONSIDERATIONS In tracheal resection and anastomosis, a tension-free closure of the distal airway is essential.  The larynx can be released and "dropped" from the hyoid bone to reduce tension on the distal suture line.  This is accomplished by detaching the infrahyoid muscles from the inferior surface of the hyoid bone body and cutting the hyoid bone just lateral to the lesser cornua  This releases the central body of the hyoid and larynx.  Additional relaxation can be achieved by cutting the suspensory ligament of the superior cornu of the thyroid cartilage  This can lower the larynx to a maximum of 4.5 cm.  The hyoid bone serves as a site of access to the supraglottic larynx and pharynx. 
  • 18. During the excision of a thyroglossal duct cyst,  excising the entire tract along with the central body of the hyoid bone (Sistrunk procedure) reduces the recurrence rate.
  • 19. CARTILAGES OF LARYNX :           3 3 paired unpaired Paired : Arytenoid Corniculate cunieform Unpaired: Thyroid Cricoid Epiglottic
  • 20. THYROID CARTILAGE     located anterior to the 4th and 5th cervical vertebrae. formed by 2 laminae which fuse ventrally in the midline of the neck, forming a protuberance, the laryngeal prominence or "Adam's apple,― The 2 laminae meet at an angle of 90° in the male and 120° in the female. The upper limit of fusion of the two laminae forms the superior thyroid notch
  • 21.       1. 2. 3. Posterior border of each lamina extends upward and downward as hornlike projections,the superior and inferior cornua The cornua are characterized further at their origins from the thyroid laminae by superior and inferior tubercles. Both of the superior horns are anchored to the tips of the greater horns of the hyoid bone; both inferior horns articulate with the cricoid cartilage. On the lateral, external surface of each thyroid lamina is—ridge ,called the oblique line, attaches to 3 muscle Sternothyroid, Thyrohyoid,and Thyropharyngeus (a portion of the inferior pharyngeal constrictor).
  • 22. o       The thyrohyoid membrane and median thyrohyoid ligament are attached to the upper border of the thyroid cartilage. The lateral thyrohyoid ligaments attach to the greater cornua of the thyroid cartilage. The cricothyroid ligaments (cricothyroid membrane) attach to the inferior border of the thyroid cartilage 5 ligaments attach as one to the posterior surfaces of the thyroid laminae near the union of the laminae (angle): The median thyroepiglottic ligament, The 2 vestibular ligaments,And The 2 vocal ligaments.
  • 23. SURGICAL CONSIDERATIONS The thyroid cartilage is divided in the midline to expose the endolarynx for various procedures (for example, partial laryngectomy, laryngotracheoplasty, and arytenoidectomy).  The vocalis muscle and vocal ligaments attach to the inner surface of the thyroid cartilage at the anterior commissure  On the external laryngeal surface in adult males this point is halfway between the thyroid notch and the inferior border of the thyroid cartilage. It is slightly higher in adult females.  In many laryngofissure approaches, it may be beneficial to stay below the midpoint in order to avoid dividing the anterior commissure. 
  • 24. CRICOID CARTILAGE         Shaped like a signet ring. signet-shaped portion of the cricoid faces posteriorly the arch is located anteriorly, The cricoid cartilage is situated at vertebral level C6 (occasionally reaching the middle of C6), just below the thyroid cartilage The cricoid lamina has 2 superior facets– articulate with the arytenoid cartilages and attach to them by the posterior cricoarytenoid ligaments 2 lower lateral facets of the lamina articulate with the inferior horns of the thyroid cartilage. The lower border of the cricoid cartilage is joined to the first tracheal ring by means of the thick cricotracheal ligament.
  • 25. Arising from the arch of the cricoid cartilage anteriorly and externally are the cricothyroid muscles.  The lamina has a midline ridge for the tendinous attachment of longitudinal fibers of the esophagus.  Lateral to this ridge are the sites of origin for the bilateral posterior cricoarytenoid muscles. 
  • 26. SURGICAL CONSIDERATIONS      Injury to the cricoid cartilage from intubation or trauma may result in perichondritis and lead to subglottic stenosis. Surgical approaches to repair long-standing subglottic stenosis involve the expansion of the circumference of the cricoid ring with autologous cartilage grafts. Tracheotomies are usually performed at least one tracheal ring below the cricoid cartilage (2nd or 3rd tracheal ring) to avoid subglottic stenosis. During an emergency cricothyroidotomy, the tracheostomy tube is inserted through the median cricothyroid ligament — the quickest and easiest access to the airway. To avoid permanent laryngeal stenosis — cricothyroidotomy must be converted to a standard tracheotomy within days.
  • 27. ARYTENOID CARTILAGES          Almost pyramidal in shape, with 3 surfaces, a base, and an apex. Each triangle-shaped base articulates with the cricoid cartilage by way of a diarthrodial joint. Base has 2 processes: Anteromedially directed vocal process – vocal ligament is attached Short, broad, laterally projecting Muscular process – lateral and posterior cricoarytenoid muscles are attached
  • 28.  1. 2. 3.     Arytenoid has 3 surfaces Posterior surface — Transverse and oblique arytenoid muscles attach Medial surface – covered with mucous-secreting laryngeal mucosa. Anterolateral surface – insertion of thyroarytenoid muscle, part of the vocalis muscle,and the vestibular ligament. The apex of the arytenoid cartilage supports the corniculate cartilage
  • 29. SURGICAL CONSIDERATIONS     Cricoarytenoid fixation may occur from arthritis or perichondritis (intubation injury) and limit vocal fold mobility. Cricoarytenoid subluxation during blind intubation with a lighted stylet. Arytenoidectomy through an external or endoscopic approach may alleviate arytenoid fixation or paralysis. submucosal arytenoidectomy which preserves an intact laryngeal mucosa
  • 30. CORNICULATE CARTILAGES ( OF SANTORINI ) small fibroelastic nodules that sit on the apices of the arytenoid cartilages.  It has little functional importance in humans   CUNEIFORM CARTILAGES (OF WRISBERG) rod-shaped (like ancient cuneiform script).  situated in the aryepiglottic folds anterior to the corniculate cartilages,  may be entirely absent. 
  • 31. TRITIATE CARTILAGE an occasional, minute nodule.  located in the posterior margin of the thyrohyoid membrane 
  • 32. EPIGLOTTIS           Oblong leaf shaped Located behind the root of the tongue and the body of the hyoid bone and in front of the laryngeal entrance (laryngeal aditus or vestibule). It has: 2 ends— upper & Lower 2 surfaces— Anterior & Posterior 2 Lateral borders Upper end:broad lower end: narrow –― petiolus / stalk ‖ attaches to inner surface of thyroid cartilage below thyroid notch by the thyroepiglottic ligament It attaches to the posterior body of the hyoid bone via the hyoepiglottic ligament it lies dorsal to the thyroid cartilage and thyrohyoid membrane, guarding the laryngeal entrance.
  • 33. The space between the anterior surface of the epiglottis and the thyrohyoid membrane and thyroid cartilage is called the preglottic space  The epiglottis is attached to the thyroid cartilage by the thyroepiglottic ligament.  The aryepiglottic folds and the quadrangular membranes attach to the lower part of the lateral margins of the epiglottis. 
  • 34. SURGICAL CONSIDERATIONS Acute epiglottiditis, may cause airway obstruction in children.  To rule out foreign bodies, a lateral x-ray may be ordered if the general condition of the child permits.  Laryngeal visualization must be done in the operating room to avoid airway occlusion, aspiration, and cardiac arrest.  Intubation and tracheostomy are the procedures of choice 
  • 35. LARYNGEAL LIGAMENTS AND MEMBRANES Membranes — Extrinsic – Thyrohyoid membrane Crico tracheal membrane Intrinsic — Quadrangular membrane Conus elasticus Ligaments & Folds  Epiglottic ligaments  Aryepiglottic fold  Vestibular ligament (vestibular folds or false vocal cords)  Vocal ligaments 
  • 36. LARYNGEAL MEMBRANES THYROHYOID MEMBRANE     provides an extensive connection between the thyroid cartilage and the hyoid bone bilaterally and anteriorly. Extending from the upper border and the greater horns of the hyoid bone to the superior horns of the thyroid cartilage and its laminae Thickens anteriorly, forming the median thyrohyoid ligament Thickened posterior margin on each side is called the lateral thyrohyoid ligament.
  • 37. SURGICAL CONSIDERATIONS The superior laryngeal neurovascular bundle may be injured by surgical approaches to the pharynx.  One must observe great care when dissecting the greater cornu of the hyoid bone and the superior horn of the thyroid cartilage during various pharyngotomy approaches 
  • 38. THE CRICOTRACHEAL MEMBRANE  connects the most superior tracheal cartilage with the inferior border of the cricoid cartilage
  • 39. INTRINSIC MEMBRANES connect the laryngeal cartilages with each other to regulate movement.  There are 2 intrinsic membranes : 1. Conus Elasticus and 2. Quadrangular membranes. 
  • 40. CONUS ELASTICUS Conus Elasticus connects the cricoid cartilage with the thyroid and arytenoid cartilages.  composed of dense fibroconnective tissue with abundant elastic fibers.  Having 2 parts 1 .Medial cricothyroid ligament — connects the anterior part of the arch of the cricoid cartilage with the inferior border of the thyroid membrane. 2. Lateral cricothyroid membranes originate on the superior surface of the cricoid arch and rise superiorly and medially to insert on the vocal process of the arytenoid cartilages posteriorly, and to the interior median part of the thyroid cartilage anteriorly.  Its free borders form the VOCAL LIGAMENTS 
  • 41. QUADRANGULAR MEMBRANE    Extends from the sides of the epiglottic cartilage anteriorly to the anterolateral surface of the arytenoid cartilage and posteroinferiorly to the corniculate cartilage. With its covering of mucous membrane forms the aryepiglottic fold superiorly and vestibular ligament inferiorly. it forms the medial wall of the piriform recess
  • 42. The paired Quadrangular Membranes connect the epiglottis with the arytenoid and thyroid cartilages.  Course posteriorly downward and attach to the corniculate cartilages and the lateral surfaces of the arytenoids.  The cuneiform cartilages are embedded within the aryepiglottic folds.  The free inferior borders of the quadrangular membranes form the ventricular ligaments, also known as the false vocal folds. 
  • 43. LIGAMENTS & FOLDS OF LARYNX  Epiglottic ligaments  Aryepiglottic fold   Vestibular ligament (vestibular folds or false vocal cords) Vocal ligaments
  • 44. 1 . EPIGLOTTIC LIGAMENTS FOLDS  Hyoepiglottic ligament  Thyroepiglottic ligament  Median glossoepiglottic ligament   Lateral glossoepiglottic or pharyngoepiglottic fold, attached between the base of the epiglottic cartilage and the pharyngeal wall at the root of the tongue AND
  • 45. 2 . ARYEPIGLOTTIC FOLDS     one on each side, contain the aryepiglottic muscles. associated with the superior border of the quadrangular membrane. Both aryepiglottic folds constrict the entrance to the larynx and protect the respiratory pathway by not permitting food, liquids, and foreign bodies to enter the larynx and trachea.
  • 46. 3 . VESTIBULAR FOLDS (FALSE VOCAL CORDS)      formed by the inferior edge of the quadrangular membrane. Attached in front to the thyroid cartilage just below the attachment of the epiglottic cartilage Connected behind to the anterolateral surfaces of the arytenoid cartilages. The vestibular ligaments are located just above the vocal ligaments, separated from them by bilateral ellipsoid spaces called the laryngeal ventricles. Overlap the true vocal folds just prior to a cough or sneeze — reinforcing the resistance offered by the true vocal folds against the internal expiratory pressures.
  • 47. 4.VOCAL LIGAMENTS, VOCAL CORDS, AND VOCAL FOLDS   The thickened, ligamentous, upper edges of the elastic tissue of the conus are the vocal ligaments or vocal cords. Extend from the medial extremities of the laminae of the thyroid cartilage in the midline anteriorly (forming the anterior commissure) to the apices of the vocal processes of the arytenoid cartilages on each side posteriorly.
  • 48. STRUCTURE OF VOCALCORD         Histologically 5 layers: LAYER 1: is the squamous epithelial lining. It is very thin and helps to hold the shape of the vocal fold. This layer doesnot contain any mucous glands. LAYER 2: superfical layer of the lamina propria. It is composed of loose fibers and matrix . This layer contains only minimal elastic and collagenous fibers and offers least resistance to vibration. The integrity of this layer is vital for proper phonatory function. LAYER 3: intermediate layer of lamina propria. It contains a higher concentration of elastic and collagenous fibers when compared to layer 2. This layer is thickened at the anterior and posterior ends of the vocal folds. These thickened regions are known as anterior and posterior macula flava. These structures provide protection to the vocal folds from mechanical damage. LAYER 4 : deep layer of lamina propria. It contains a dense collection of elastic and collagenous fibers. This layer along with the intermediate layer constitute the vocal ligament. Some of the collagenous fibers present here gets inserted into the vocalis muscle. LAYER 5: formed by the vocalis muscle. The fibers of this muscle run parallel to the direction of the vocal fold.
  • 50.      Vocalis muscle is infact a portion of thyro arytenoid muscle. At the anterior most portion of the vocal fold a mass of collagenous tissue is present--known as the anterior commissure tendon or Broyle's ligament. This ligament gets attached to the inner area of thyroid cartilage which is devoid of perichondrium. Lacking a submucosa and blood vessels, the vocal ligaments appear to be pearly white and shiny. The space between the true vocal cords (the intermembranous space) is known as the rima glottidis
  • 51. RIMA GLOTTIDIS Subdivided into 2 parts,   2/5 – intercartilaginous part (respiratory glottis,or interarytenoid space), between the arytenoid cartilages and 3/5 — the intermembranous part or glottis vocalis.
  • 52. SURGICAL CONSIDERATIONS    The epithelium of the true vocal cords does not have lymphatics. Therefore, metastatic disease is a rare phenomenon. The vocal folds are devoid of lymphatics, and it infact clearly forms the watershed zone between the upper and the lower group of lymphatics. The pathway of metastasis of glottic cancer is via the Delphian node or paratracheal nodes and finally nodes of the superior mediastinum.
  • 53. LARYNGEAL MUCOSA         Is mostly of the respiratory type called ciliated columnar epithelium, certain areas of the larynx covered with stratified squamous epithelium are- upper area of the anterior , dorsal epiglottic surfaces, the ventral half of the aryepiglottic folds, and the vocal cords. Mucous membrane of the supraglottic larynx is a downward continuation of the oropharyngeal mucosa. Infraglottic region of the larynx is made of normal respiratory mucosa Mucous glands are found at the posterior surface of the epiglottis, aryepiglottic fold, and laryngeal appendices.
  • 54. LARYNGEAL SPACES    o o   Internal laryngeal spaces : vestibule, ventricles, subglottic or infraglottic spaces External laryngeal spaces Paraglottic space pre-epiglottic. Space
  • 55. INTERNAL SPACES (LARYNGEAL CAVITY) VESTIBULE  pyramid -shaped space extends from the laryngeal inlet or aditus to the vestibular folds (false vocal cords).  Bounded ventrally by the posteroinferior surface of the epiglottis, dorsally by the corniculate cartilages and apices of the arytenoids, and laterally by the aryepiglottic folds and the piriform recesses.
  • 56. LARYNGEAL VENTRICLES     sinuses (of Morgagni), are diverticula of the interval between the false and true vocal cords. It is lined internally by mucosa and covered externally by a very thin layer of elastic tissue and the thin thyroarytenoid muscle. The anterior end of the ventricle may possess an additional external expansion, the laryngeal saccule, This extends upward deep to the internal face of the thyroid cartilage.
  • 57. SURGICAL CONSIDERATIONS.      Enlargement of the laryngeal saccule is often referred to as a laryngocele. Any obstruction of the laryngeal ventricle, such as a ventricular carcinoma, may lead to the formation of a laryngocele. A laryngocele may bulge through the aryepiglottic fold and obstruct the endolarynx ( internal laryngocele ). It may be present outside of the thyrohyoid membrane ( external laryngocele ). The enlargement may even be a combined internal and external laryngocele
  • 58. SUBGLOTTIC (INFRAGLOTTIC) SPACE      the distal part of the laryngeal cavity. extends from the glottis to the inferior border of the cricoid cartilage. The subglottic space begins below the curve formed by the vocal fold to the lower end of cricoid cartilage SURGICAL IMPORTANCE : Narrowest area in infants , so edema obstruction & respiratory distress occur early
  • 59. EXTERNAL SPACES    Supraglottic laryngeal area is subdivided into 3 laryngeal spaces Paired Lateral Paraglottic One midline Pre-Epiglottic Spaces Space
  • 60. PARAGLOTTIC SPACES ( TUCKER’S SPACE) Bounded laterally by the thyroid cartilage,  inferomedially by the conus elasticus,  medially by the ventricle and the quadrangular membrane 
  • 61. PRE-EPIGLOTTIC SPACE ( BOAYER’S SPACE )     Bounded superiorly by the hyoepiglottic ligament, anteriorly by the thyrohyoid membrane and ligament, and Posteroinferiorly by the epiglottis and thyroepiglottic ligament. The pre-epiglottic space forms an inverted pyramid. continuous with the superior portion of the paraglottic space. contains abundant fat, blood vessels, lymphatics,and mucosal glands.
  • 62. SURGICAL CONSIDERATIONS Epiglottic (supraglottic) carcinoma may spread through perforations in the epiglottis into the pre-epiglottic space.  Since the pre-epiglottic space communicates laterally with the paraglottic spaces, a carcinoma is free to spread beyond the internal boundaries of the larynx.  Therefore, supraglottic laryngectomy may be contraindicated 
  • 63. LARYNGEAL JOINTS     2 pairs of synovial joints Between the major cartilages of the larynx: the cricothyroid and the cricoarytenoid.
  • 64. 1.CRICOTHYROID JOINT     The joints between the inferior cornua of the thyroid cartilage and the sides of the cricoid cartilage are synovial The primary movement at the joint is rotation around a transverse axis which passes transversely through both cricothyroid joints The effect of these movements is to lengthen the vocal folds, provided the arytenoid cartilages are stabilized at the cricoarytenoid joint. This may also increase vocal fold tension
  • 65. 2.CRICOARYTENOID JOINT  The crico-arytenoid joints between articular facets on the superolateral surfaces of the cricoid cartilage and the bases of the arytenoid cartilages enable the arytenoid cartilages to slide away or towards each other and to rotate so that the vocal processes pivot either towards or away from the midline. These movements abduct and adduct the vocal ligaments 3.ARYTINOCORNICULATE JOINT  Synovial or cartilaginous joints link the arytenoid and corniculate cartilages
  • 66. LARYNGEAL MUSCLES   Extrinsic muscles — which move the entire larynx, Intrinsic muscles — which move the vocal cords.
  • 67. EXTRINSIC MUSCLES    ELEVATORS OF THE PHARYNX The Suprahyoid Muscles  Digastric  Stylohyoid  Mylohyoid  Geniohyoid The Longitudinal Muscles of the Pharynx  Stylopharyngeus  Salpingopharyngeus  Palatopharyngeus DEPRESSORS OF THE PHARYNX:  The Infrahyoid Muscles  Sternohyoid  Sternothyroid  Omohyoid
  • 68. INTRINSIC MUSCLES       The intrinsic muscles are: Cricothyroid Posterior cricoarytenoid Lateral cricoarytenoid Arytenoid with its transverse and oblique fibers Thyroarytenoid and its thyroepiglottic and components
  • 69. MUSCLES CONTROLLING INLET Oblique arytenoid  Aryepiglottic muscle  THE LARYNGEAL
  • 70. MOVEMENTS OF THE VOCAL CORDS Adduction Abduction Glottis (space between folds) Folds closed (adducted) Folds open (abducted) (View from above)
  • 71. ADDUCTORS  Lateral OF THE VOCAL CORDS cricoarytenoid  Transverse arytenoid
  • 72. ABDUCTOR OF THE VOCAL CORDS Posterior cricoarytenoid
  • 73. MUSCLE INCREASING THE VOCAL CORDS  Cricothyroid: THE LENGTH & TENSION increases the distance between the angle of the thyroid cartilage & the vocal processes of the arytenoid cartilages, and results in increase in the length & tension of the vocal cords OF
  • 74. MUSCLE DECREASING VOCAL CORDS  Thyroarytenoid THE (vocalis): pulls the arytenoid cartilage forward toward the thyroid cartilage and thus shortens and relaxes the vocal cords LENGTH & TENSION OF
  • 75. SPHINCTERIC FUNCTION OF THE LARYNX There are two sphincters:  At the inlet: used only during swallowing  At the rima glottis: used in coughing and sneezing
  • 76. SHAPE OF GLOTTIS Quiet Respiration Forced Inspiration
  • 78. SHAPE OF GLOTTIS Normal voice Whisper
  • 81. BLOOD SUPPLY OF LARYNX : ARTERIAL SUPPLY  Upper Larynx  External carotid artery  Superior thyroid artery  Superior laryngeal artery  Lower Larynx  Subclavian artery  Thyrocervical artery  Inferior thyroid artery  Inferior laryngeal artery 
  • 82. VENOUS DRAINAGE Upper Larynx  Superior laryngeal vein  Superior thyroid vein  Internal jugular vein  Lower Larynx  Inferior laryngeal vein  Inferior thyroid vein  subclavian vein 
  • 83. LYMPHATIC DRIANAGE SUPRA GLOTTIC AREA superior lymphatics drain to the upper deep cervical nodes, located at the level of the carotid bifurcation.  Some drainage passes to prelaryngeal nodes.  INFRA GLOTTIC AREA drain to the pretracheal lymph nodes of the proximal trachea anteriorly paratracheal nodes laterally and then to the deep cervical and superior mediastinal nodes. 
  • 84.  GLOTIC AREA ( VOCAL FOLDS) is relatively devoid of lymphatics.   The space deep to the thin mucosa of the true vocal cords, which is called Reanke's space, has no direct lymphatic drainage. The spread of carcinoma is, likewise and fortunately, retarded until an invasive process involves tissue peripheral to the true vocal cord.  DELPHIAN  NODE : a midline prelaryngeal lymph node, adjacent to the thyroid gland, enlargement of which is indicative of metastasis from thyroid or laryngeal carcinoma.
  • 85. SURGICAL IMPORTANCE     Elective dissection of node levels II to IV for N-0 laryngeal and hypopharyngeal carcinoma, Bilateral selective dissection is justified by the prevalence of bilateral metastases in midline and bilateral tumors. The superior neurovascular bundle may be injured during anterior and lateral pharyngotomy approaches to the larynx. Branches of the cricothyroid artery may be accidentally injured during emergency cricothyroidotomy.
  • 86. NERVE SUPPLY   1. 2.      Supplied by Vagus nerve: Superior laryngeal nerve Internal branch (sensory) – areas above the glottis External branch (motor and sensory) Motor – Cricothyroid muscle Sensory – Anterior infraglottic larynx at level of cricothyroid membrane Inferior (recurrent) laryngeal n. Motor – all intrinsic laryngeal muscles of SAME side (except cricothyroid) and interarytenoid muscle of BOTH sides Sensory – areas below the glottis
  • 88. BIBLIOGRAPHY SCOTT&BROWN 6TH EDITION  GRAY’S ANATOMY 40TH EDITION  THE LARYNX -HUGH D. CURTIN 