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Unit5:Anatomyandphysiology
ofLarynx
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inneckalongwithassistancefromstructures
.
Un t5:Stu yt eanatomy p ys o ogyan diseasesofthelarynx.
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Larynx,commonlycalledVOICEBOX
Locatedinfront,inthemiddleofthe.
Perchedontheto ofthetrachea(windpipe).
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withage,gender,headpositionand
.
The
length
of
larynx
is
about
44
mm
in
an
.
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Biologicalfunctions
Buildingintrathoracicpressureforexcretion
an carry ngou s renuousp ys ca ac v es
Nonbiologicalfunctions
S eech
Singing
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Madeofabone,cartilages,muscles,
.
Hyoidbonesupportslarynx.
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Ushapedsinglebone presentabovethethyroid
.
ssuspen e rom e pso
Styloid processes
of
the
Temporal
.
Itisnotconnectedtoanyotherbonedirectly.
Hyoidboneissupportedbymanymuscles&it
canmakevarietyofmovements. 9
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Hyoidhas3parts:abodyand2pairsofhorns.
theThyroidcartilage.
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NOTE:ligamentvs.cartilagevs.
tendon Ligament:Fibroustissuethatconnectsbonestoother
.
Cartilage:Stiffyetflexibleconnectivetissuefoundin,
bones.Itisnotashardandrigidasbonebutisstifferand
lessflexiblethanmuscle.
Tendon:Toughbandoffibrousconnectivetissuethatusuallyconnectsmuscletoboneandiscapableof
withstandingtension.Tendonsaresimilartoligaments
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3unpaired&3pairedcartilagesinlarynx.
um er
Epiglottis single Behind the hyoid bone and base of the
Thyroid single Front of the neck in the midline
Cricoid single Above the trachea; below thyroid cartilage
Arytenoids paired Rests on the back surface of cricoid
cartilage
orn cu ates pa re ests on t e aryteno cart agesCuneiform paired Embedded in aryepiglottic folds
14List of cartilages & location in larynx
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Itisleafshapedcartilage.
Attac e toupper,inner
surfaceofThyroid.
ItattachestoArytenoidsat
thebackbythe
Quadrilateralmembrane.
Theu ermar insare
formedbytheAryepiglottic
olds.
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food,water,salivaintotrachea.
swallowing.
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Biggestcartilageinlarynxpresent
.
Protectsvoiceboxinthefront.
2laminas(quadrangularplatesof
cartilage1onrightside&1on
leftside)
Laminas oinatmidlinetoform
thethyroidprominence(Adams
a leinmen Feltorseenon
17
surfaceoftheneckinmostmen.
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Thyroid(Cartilage)
2bighornlikestructures(greaterorns toattac tot e yo one.
2smallhorns(lesserhorns)to
attachmentwithCricoidcartilage.
LesserhornsattachTh roidtoCricoid
throughtheCricothyroidligament&
Cricoth roid CT oints.CT ointsare
importantforchangingthepitch.
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Itforms baseoflarynx.
ac e o yro a ove roug Cricothyroidligament,Cricothyroidjoints
rac ea e ow y r co rac ea
ligament.
Ringshapedcartilage
Frontsurfaceisthin,narrow(calledArch)
&backsurface(knownasLamina)is
broad,thickandwide. Arytenoidsare
19
presentonthelaminaofCricoid
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Thesearepaired,pyramidshapedcart agespresentonupper
marginsoflaminaofCricoid
cart age.
EachArytenoidhasabase,anapex&3surfaces.
Vocal rocess resentonthe
medialsurfaceisanimportant
structure,becausethe formthe
20
posterior1/3rd oftruevocalfolds.
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Arytenoidsareattachedto
VestibularandVocal
.
They
are
attached
to
Cricoid
t roug t eCricoarytenoi
ligaments&joints.
Theseligaments&jointsareimportantfortheopening&
closingofvocalfolds.21
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Corniculates:Small,paired,nodularstructures
.
Theymaybe2orevenabsentsometimes.
Cuneiform:Small,paired,rodlikestructurespresentabovetheCorniculates.
Presentinafewindividuals
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Bronchial Tree Model - Larynx - Sagittal View.flv
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Joints/ligamentsoflarynx ar agesareconnec e oeac o erw e
helpofjoints,musclesandmembranes.
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Joints/ ligaments Connects Action
Cricothyroidligament and joints
Thyroid toCricoid
Helps in changing the pitch ofvoice
Cricoarytenoid joints
and ligaments
Cricoid to
Arytenoid
Important for opening and closing
of vocal folds
Vestibular ligaments Arytenoids
to Thyroid
Helps in changing the pitch of
voice
Vocal ligaments Arytenoidsto Thyroid
Helps in changing the pitch ofvoice
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voice(sound)arethevocalfolds.
Truevocalfolds.
T eirmain unctionisprotectiono t e owerairway.
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Ventricularfolds/FalseVocal
Folds
withveryfewmuscles,bloodvessels&nerves.
(insert)tothearytenoidscartilagesattheback
.
Notsuitedforvoice productionastheyarebulky
an onot avemanymusc es, oo vesse san nerves.
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TheyarepresentjustbeneaththeVentricularfolds.
eyor g na e rom e yro car age, n e
frontandinsertintotheArytenoidcartilagesatthe
ac roug e oca gamen s.
The
true
vocal
folds are
light
pink
in
color
but
on
laryngoscopyappearglossywhitebutthecolor
changesinclinicalconditions.
Thespacebetweenthetruevocalfoldsiscalledthe
Glottis.
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VFsaremadeofmucousmembranes,ligaments&
.
Undermicroscope,5differentlayerscanbe
en e :
1. Epithelium2. SuperficiallayerofLaminapropria (Reinkes
space)
3. IntermediatelayerofLaminapropria
.
5. Vocalis muscle 30
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TrueVocalFolds/Vocalfolds
Crosssection
view31
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" "
anditiscontinuouswiththeliningofmouth,
.
Laminapropria as3 istinct ayers,eac wit adifferentconsistency.TheIntermediatelayerand
eep ayero am na ropr a ormst e oca ligament.
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,
surface
, ,
likerubberbands
Deep ayer at rea i eco agenous i er ayer
Vocalismuscle isthemainbodyofthevocalfold
andverystiff.
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superior&inferiorthyroidarteries andcricothyroid
.
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(i)Superiorthyroidartery
ranc ranc o esuper or yro o esuper or yro artery(branchoftheexternalartery(branchoftheexternal
entersentersthelarynxthroughthethelarynxthroughthe
withtheinternalbranchofthewiththeinternalbranchofthe
ri r lar n al n rvri r lar n al n rv
mucousmembranesinthemucousmembranesintheri r rti n f th lar nxri r rti n f th lar nx
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thyroidartery(thyroidartery(thyrocervicalthyrocervical trunkofthetrunkofthesubclaviansubclavian
AscendsAscendsonthetrachea,togetherwiththeonthetrachea,togetherwiththe
,,
fromlowerbordersfromlowerborders
upp esupp est emusc esan mucousmem ranes nt emusc esan mucousmem ranes nthelowerpartofthelarynxthelowerpartofthelarynx
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38Figure in SLM
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BranchBranchofthesuperiorofthesuperior
PassesPassesacrossthesuperioracrossthesuperior
portiono t eportiono t ecricot yroicricot yroi
ligamentligament
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drainedbyvesselswhichaccompanythesuperior
,
andemptyintotheupperdeepcervicallymph
Whereasthezonebelowthevocalfoldsdrains,
.
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ADDITIONALINFORMATION
VENOUSDRAINAGEVENOUSDRAINAGE
superiorandinferiorlaryngealveinssuperiorandinferiorlaryngealveins (followthearteriesintheircourse)(followthearteriesintheircourse)
superiordrainagesuperiordrainage joinsthesuperiorandmiddlethyroidveinsandthenthejoinsthesuperiorandmiddlethyroidveinsandthenthe
internaljugularinternaljugular inferiordrainageinferiordrainagejoinsthemiddlethyroidveinandtheinferiorthyroidvein,joinsthemiddlethyroidveinandtheinferiorthyroidvein,
whichemptiesintothesuperiorvenacavawhichemptiesintothesuperiorvenacava
LYMPHATICDRAINAGELYMPHATICDRAINAGE
larynxwellsuppliedwithlymphatics,withtheexceptionofthefreemarginsofthelarynxwellsuppliedwithlymphatics,withtheexceptionofthefreemarginsofthe
vocalfoldsthemselvesvocalfoldsthemselves
SuperiorgroupSuperiorgroup
area of the lar nx above the vocal cords is drained into the su erior and middlearea of the lar nx above the vocal cords is drained into the su erior and middle
jugularnodesjugularnodesInferiorgroupInferiorgroup
nodesaswellastotheparatracheallymphnodes.nodesaswellastotheparatracheallymphnodes.
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ItisfromtheVagusbywayofitssuperiorandrecurrentlaryngealbranches. Itdescendslateraltothepharynx,behindtheinternalcarotid,supplytothe
cricothyroid
muscle,
divides
into
two
main
sensory
and
motor
branches.
Externallaryngealnerve suppliesthemucousmembraneofthelowerpartofthehar nx e i lottis valleculaandvestibuleofthelar nx ar e i lotticfold mucous
membranedowntothelevelofvocalfolds.
Internallaryngealnerve alsocarriesfibersfromneuromuscularspindlesandotherstretchreceptorsinthelarynx.
Suppliestheinferiorconstrictormuscleofthepharynx,anduniteswithanascendin branchoftherecurrentlar n ealnerve. ThisbranchiscalledGatens
anastomosis
or
loop
and
is
purely
sensory
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recurrent(inferior)laryngealnerve ontherightsideleavestheVagusasthelattercrossestherightsubclavianarteryand
thenloopsunderthearteryandascendstothelarynx,betweentheoesophagusandtrachea
Thenervethendividesintomotorandsensorybranches
Themotorbranchsupplyalltheintrinsicmusclesofthe.
Thesensorybranchsuppliesthelaryngealmucousmembranebelowthelevelofthevocalfoldsandalsocarriesafferent
ers romstretc receptors nt e arynx.
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Laryngeal membranes Location
Epithelium)
r covoca mem rane onus
Elasticus)
r g na es rom r co car age
and connects the Cricoid, Thyroid,
and Arytenoid cartilages together.Inserts into the true vocal folds
Quadrangular membrane Connects Epiglottis and Thyroid to
e ry eno car ages a e
back
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surroundingstructures. Intrinsicmuscles
.
Muscle Origin Insertion Action
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Posterior
cricoar tenoid
Back surface of
Cricoid lamina
Back surface of the
muscular rocess of
opens the glottis by
o enin the vocal folds
(PCA) Arytenoids
Lateral
cricoarytenoid
upper border of the
Cricoid arch
Front surface of the
muscular process of the
closes the glottis by
closing the vocal folds
(LCA) Arytenoids
Cricothyroid(CT)
Front and sides ofthe Cricoid arch
Thyroid lamina andlower horns of thyroid
Increases the lengthand tension of the vocal
folds
Vocalis inner surface of the
Thyroid
Front surface and vocal
process of Arytenoid
Increases tension of
vocal folds
Transverse
arytenoid
Muscular process
of one Arytenoid
Muscular process
of the opposite
Ar tenoid
closing the vocal folds
Obliquearytenoid
Muscular processof one Arytenoid
Muscular processof the opposite
Arytenoid
closing the vocal folds
Thyroarytenoi
d
inner surface of the
Thyroid
Front surface and vocal
process of Arytenoid
Relaxes the vocal folds
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Includes
1 respiratoryo struction
2) Stridor
3) weakenedorabnormalcry,
5) Tachypnea (rapidshallowbreaths)
6 Aspiration7) episodesofcyanosis(bluecolorationdue
deoxygenatedhemoglob)
8 suddendeath.48
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Highpitchedsoundresultingfromturbulent airflow
.
Indicativeofseriousairway obstructionfromsevere
con onssuc asep g o s,a ore gn o y.
Duringfetaldevelopment,thestructuresinthe
larynxmaynotfullydevelop.
Stridorisindicativeofapotentialmedical
emergency andshouldalwayscommandattention Itcanresolvesonitsown withoutmedical
intervention(apparentuntilabouttheageof5)49
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commonanomaly(causeisunknown)
structuresoninspiration
Stridorduringinspirationwhich
worsensinthesupineposition,
feeding,agitationwithNormalPhonation
Thesymptomsmayincreasebutusuallyresolvesby
Tracheotomy
in
place
for
2
years
spont.
recovery50
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Symptomsvarydependingonwhetherunilateralor
bilateralvocalcords aral zed.
BilateralVCparalysis:CNS immaturity,lesionsin, , .
Symptoms:
nsp ratorystr oratrestt atworsensupon
agitationinchildren
Progressiveairwayobstruction
Aspirationsresultinginrecurrentchestinfections
andafailuretothrive51
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UnilateralVocalCordParalysis:usuallyidiopathic,
,
totheleftrecurrentlaryngeal.
n a era para ys smayman es ur ng e rs
fewweeksoflife,oritmaygounnoticed.
Symptoms:
Hoarse,breathycrythatisaggravatedbyagitation,
Feedingdifficulties
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Incompletedevelopmentduringthethirdmonthof
subglotticstenosis
Symptoms
Respiratory
stridor
(duringinspiration&expiration)
Cryisusuallynormal
Prognosisisusua ygoo . Mostsymptoms a eas
thebabymatures.53
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rarecongenitalanomaliesduetoIncomplete
thirdmonthofgestation.
Symptoms:
Stridor
Aphonia,ormildhoarseorbreathycrythatis
aggravatedbyagitation Feedin difficulties
Aspiration &Obstructivecyanosis
54
Vocal Nodules
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VocalNodules o u esare nyswe ngson o e s.
Excessivetalking,shouting,screaming,constant
throatclearing,imitationofothersvoices
noticedinchildrenandwomen
preventtheVFsfrommeetinginthemidline&
cause air leak throu h the vocal folds.
Symptoms:
rea yvo ce oarsevo ce
tirednessontalkingforafewminutes
noduleswilldisappearwhenvoicerest&voice
therapy55
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Polypsarebenignlesionsofthelarynx(mostlyin
locatedontheoutermostsurfaceofthevocal
Symptoms
Breathyvoice&/Hoarsevoice
Feelingoftirednessontalkingforafewminutes
Voicetherapyaftersurgeryisnecessary.
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Contactulcersarewearingawayofthemucous
membraneovertheVFs
causedbyvoiceabuse,pressedvoice,hyperacidity,.
Symptoms:
oarsevo ce
Painwhileswallowing
Painwhilephonation/speaking
condition.57
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Laryngitisisinflammation(tenderness,redness,&
Duetoviralinfectionorvocalabuse/overuse.
Symptoms:
Change
in
voiceHoarsevoice
Dependingonthecause,treatmentvaries.
Voicerest,coughsuppressants,andsteam
inhalationsrelievesymptoms.58
Dysphonia Plica Ventricularis
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DysphoniaPlica Ventricularis
(VentricularDysphonia) WhenthefunctionsofthetrueVFsareaffected,
ventr cu ar o s a se o s v rate
Paralysisoftruevocalfolds,vocalabuse,andsevere
laryngitiscauseventriculardysphonia.
S m tomsHarshvoice
Voicerestandvoicetherapycanrelievethesymptoms.
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Causedbyinvoluntarymovementsofoneormore
Causeisunknown,oftennoticedafterURTI,
3majortypesofSD:
1. Adductortype(spasmoftheVFscausesstrained,strangledandeffortfulvoice)
2. Abductortype(laryngealspasmsresultsinsudden
spurtsofwhispered/breathyvoice)
3. Mixedtype(laryngealspasmscausessuddenstrained,
strangulatedvoicealongwithspurtsofbreathiness) 60
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Causedbytheabnormalrefluxofthestomachacid
Mucosaofthepharynxandlarynxmaybedamaged
Symptoms:
Heartburn
Swallowingdifficulties
Regurgitationofstomachacid
Hoarse/
Harsh
voice61
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Cancer candevelopinanypartofthelarynx.
3
anatomic
regions:
the
glottis,
the
supraglottis
Mostlaryngealcancersoriginateintheglottis.
Hoarsevoice&Sorethroat
Swallowing
difficulties
LumpEarpain
PersistentcoughwithStridor62
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Surgicalremovalofthelarynxdue
.
typesTotallaryngectomy:completeremovalofthelarynx
Hemi
laryngectomy:
partial
removal
of
the
larynx Alaryngectomee istaughttospeakusingeither,an
artificial lar nx
treachoesophegeal speechor
esop agea speec .
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