07/07/2015
Larynx (Voice Box)
Bismillah Membangun Generasi Khaira Ummah
Anatomi Larynx
Dr.H.Yani Istadi, M.Med.Ed
General principles of development
• The development of the larynx can be divided into
prenatal and postnatal stages.
• The larynx develops from the entodermal lining and the
adjacent mesenchyme of the foregut between the fourth
and sixth branchial arches.
• At 20 days' gestation, the foregut is first identifiable with
a ventral laryngotracheal groove. It continues to deepen
until its lateral edges fuse.
• This fusion occurs in the caudal-to-cranial direction, and
incomplete fusion results in development of persistent
communication between the larynx or trachea and the
esophagus
• Attaches to the hyoid bone and opens into the
laryngopharynx superiorly
• Continuous with the trachea inferiorly
• The three functions of the larynx are:
– To provide a patent airway
– To function in voice production
• Trachea becomes separated from the esophagus by the
tracheoesophageal septum with a persistent slit like
opening into the pharynx
• At birth, the larynx is located high in the neck between
the C1 and C4 vertebrae, allowing concurrent breathing
or vocalization and deglutition.
• By age 2 years, the larynx descends inferiorly; by age 6
years, it reaches the adult position between C4 and C7
vertebrae. This new position provides a greater range of
phonation (because of the wider supraglottic pharynx) at
the expense of losing this separation of function, i.e.,
deglutition and breathing.
1
 07/07/2015

The main changes occurring in the larynx postnatally are a change in

the axis, luminal shape, length, and proportional growth of the
laryngeal elements.

• The larynx grows rapidly during the first 3 years of life, • High position
while the arytenoids remain approximately the same
size. • Infant : C 1
• Beginning at age 18-24 months, the larynx descends in • 6 months: C 3
the neck to achieve its final position at vertebrae C4-C7
by age 6 years. • Adult: C 4-7
• The larynx elongates as the hyoid, thyroid, and cricoid • Anterior position
cartilages separate from each other
• The cricoid cartilage continues to develop during the first
decade of life, gradually changing from a funnel shape to
a wider adult lumen; therefore, it is no longer the
narrowest portion of the upper airway.

Framework of the Larynx

Narrowest point = cricoid cartilage • Cartilages (hyaline) of the larynx

ADULT INFAN – Shield-shaped anterosuperior thyroid cartilage
T
with a midline laryngeal prominence (Adam’s
apple)
– Signet ring–shaped anteroinferior cricoid cartilage
– Three pairs of small arytenoid, cuneiform, and
corniculate cartilages
• Epiglottis – elastic cartilage that covers the
laryngeal inlet during swallowing

2
 07/07/2015

Framework of the Larynx

3
 07/07/2015

Cartilages of Larynx (cont.):- Walls of the laryngeal cavity:-

Vestibular ligament :
(inferior free margin of
quadrangular
Vestibular fold membrane)

True vocal fold (Vocal cord) Vocal ligament:

(superior free margin
of conus elasticus)

Mucous Mucous
membrane membrane
intact on this removed on this
side side

Thyroid Cartilage Cricoid Cartilage

• Signet ring shaped
• Stronger than thyroid
cartilage.
• Lamina – 2 to 3 cm
• Shied shaped, open posteriorly, angulated from above
anteriorly downwards,
considerably broader
• Angulation more acute in males
than anterior arch.
• Its function is to shield larynx from injury and
provide an attachment to vocal cords

4
 07/07/2015

• Important from structural & functional point Epiglottis

of view • Thin leaf shaped fibro-cartilage,
– Base for entire larynx situated in midline
• Upper free end broad & rounded,
– Support to arytenoid
projects up behind base of tongue
– Attachment to intrinsic muscles • Narrow base called pitiole
– Only part of cartilagenous framework that forms • This attachment forms lower limit of
continuous 360 degree ring pre-epiglottis space
– Once injured or strictured , difficult to resect while
preserving laryngeal function

• Half of epiglottis • Infrahyoid portion has

projects above hyoid no free anterior surface
• This part has a • Forms posterior wall of
laryngeal and lingual PES (pre epiglottic
space)
surfaces
• Epiglottic cartilage
contains many pits filled
with mucous glands
• Little barrier between
infrahyoid portion and
PES

5

Pre-Epiglottic Space
• Bound sup by hyo-
epiglottic ligament, ant by
thyrohyoid memb. &
thyroid cartilage and
posteriorly by epiglottis
• Filled with fat and areolar
tissue
• Continuous with para-
glottic space
Supraglottis (SG)
• Consists of ventricles, false
cords, laryngeal surface of
epiglottis, aryepiglottic folds
and the mucosal expanse.
• Posterior tapering shape
reduces area of mucosa in
posterior region
• So majority of SG tumors are
epiglottic
07/07/2015
Reinke’s Space
• Mucosa over the vocal
ligament loosely attached
to ligaments
• Thus there is a
submucosal space along
most of the length of true
VC
Glottis
• Consists of true cords, anterior
commissure and posterior
commissure
• Narrow triangular space
between the true cords is
called rima glottis
• Anterior 2/3 is membranous
• Posterior third consists of vocal
processes of arytenoids
• Posterior 1/3 of cords and
covering mucosa are called
posterior commissure
6
 07/07/2015

Sub-glottis Para-glottic space

• Begins about 5mm below free
margins of VC
• Consists of a mobile upper and
fixed lower part

Arytenoids
• Paired cartilages, pyramidal in
shape
• Base articulated with cricoid
• PCA (posterior cricoarythenoid)
& LCA (lateral cricoarythenoid)
muscles attach on muscular
process
• Anterior angle elongated into
vocal process which receives
insertion of vocal ligament

7
 07/07/2015

Mucosa
• Mucosa of glottic and Supraglottic regions is
stratified squamous epithelium.
• Mucosa of ventricles and sub-glottic regions is
pseudo-stratified ciliated epithelium Otot-otot larynx
• Supra and sub glottic regions particularly
ventricles are rich in submucosal mucous or
minor salivary glands while glottis is not.

Intrinsic muscles of the larynx:-

• The intrinsic muscles of the larynx, all of which are
innervated by the recurrent laryngeal nerve, include
Perform 4 basic actions: the:
• Abduct the vocal cords. – Posterior cricoarytenoid - the ONLY abductor of
• Adduct the vocal cords. the vocal folds.
• Tense/relax the vocal cords. – Functions to open the glottis by rotary motion on
the arytenoid cartilages.
• Close the laryngeal inlet. – Also tenses cords during phonation.

31

8
 07/07/2015

Abductor of Larynx

• Lateral cricoarytenoid - - functions to close

glottis by rotating arytenoids medially.
• Oblique arytenoid - - this muscle plus action of
transverse arytenoid function to close
laryngeal introitus during swallowing.

• Thyroarytenoid - - very broad muscle, usually Intrinsic muscles

divided into three parts:
– Thyroarytenoideus internus (vocalis) - adductor
and major tensor of free edge of vocal fold.
– Thyroarytenoideus externus - major adductor of
vocal fold
– Thyroepiglotticus - shortens vocal ligaments

9
 07/07/2015

Adductors of the Vocal Folds

Cricothyroid Muscle

Muscles that abduct the vocal cords : Muscles that adduct the vocal cords:
Lateral crico-arytenoid muscles & transverse arytenoid muscles.
Posterior crico-arytenoid muscles

Superior view

Posterior view
Posterior view Side view

10
 07/07/2015

Fig. 23.06

Muscles that tense& relax the vocal cords:

Cricothyroid muscles Thyro-arytenoid muscles

(Relax the cords)
(Tense the cords)

Relaxed muscle Contracted muscle

Muscles that close the laryngeal inlet:

Transverse arytenoid &

ary-epiglottic muscles
Persarafan Larynx

Transverse arytenoid

Transverse arytenoid - - only unpaired muscle

of the larynx. Functions to approximate bodies
of arytenoids closing posterior aspect of
glottis.

11
 07/07/2015

Nerve Supply: Derived from the Vagus

• Superior Laryngeal Nerve -It leaves
the vagus nerve high in the neck
– Internal -It provides sensation of
the glottis and supraglottis, which
includes the pharynx, underside of
the epiglottis and the larynx
above the cords. Remember: SIS-
Motor:-
superior internal sensory.
– External -It supplies motor
All intrinsic laryngeal muscles are
supplied by Recurrent laryngeal function to the cricothyroid
nerve EXCEPT the cricothyroid
muscle which tenses the vocal
Supplied by external laryngeal cords and could cause
nerve.
laryngopasm.
Sensory:-
Above the level of the vocal cords:
Internal laryngeal nerve
Below the level of the vocal cords:
Recurrent laryngeal nerve.

• Recurrent Laryngeal Nerve -It

provides sensation to the subglottic
area which includes the larynx
below the vocal cords and upper
esophagus. It provides motor
function to the intrinsic muscles of
the larynx.
• It branches from the vagus in the Vascularisasi Larynx
mediastinum and turns back up
into the neck. On the right, it
travels inferior to the subclavian
and loops up, and on the left it
travel inferior to the aorta and
loops up.

12
 07/07/2015

ARTERIAL SUPPLY lymphatic drainage:

• Sup. Laryngeal A. from – above vocal cord ► up deep cervical lymph node.
Sup. Thyroid artery
• Inf. Laryngeal A. from Inf. – Below vocal cord lower ►deep cervical node
Thyroid artery

Intrinsic Ligaments of larynx Conus elasticus

• Quadrangular Membrane
• Conus Elasticus

13
 07/07/2015

Vocal Ligaments
• Attach the arytenoid cartilages to the thyroid
cartilage
• Composed of elastic fibers that form mucosal
folds called true vocal cords
– The medial opening between them is the glottis
– They vibrate to produce sound as air rushes up
from the lungs

Vocal Ligaments Sphincter Functions of the Larynx

• The larynx is closed during coughing, sneezing,
• False vocal cords
and Valsalva’s maneuver
– Mucosal folds superior to the true vocal cords
• Valsalva’s maneuver
– Have no part in sound production
– Air is temporarily held in the lower respiratory tract
by closing the glottis
– Causes intra-abdominal pressure to rise when
abdominal muscles contract
– Helps to empty the rectum
– Acts as a splint to stabilize the trunk when lifting
heavy loads

14

Kasus klinik
Wegner and Grossman Theory
• “In the absence of cricoarytenoid joint
fixation, an immobile vocal cord in
paramedian position has total pure
unilateral recurrent nerve paralysis, and
an immobile vocal cord in lateral position
has a combined paralysis of superior and
recurrent nerves (the adductive action of
cricothyroid muscle is lost)”
07/07/2015
Impaired Movement of Vocal Folds
• Cricoarytenoid joint dysfunction
– Trauma associated with endotracheal intubation
• Recurrent laryngeal nerve damage
– Surgical injury and tumor compression
Cricoarytenoid Joint Dysfunction
• The mechanism of arytenoid dislocation
– motor reactions during endotracheal intubation, or direct
trauma to the cricoarytenoid joints leading to joint cavity
hemorrhage. The frequency has been reported to be 0.023%.
• Risk factors
– the use of lighted stylet, laryngeal mask airway and McCoy
laryngoscope, endotracheal intubation with double lumen
tube and cases of difficult intubation
• Mikuni I, et al. Br J Anaesth 2006, 96(1):136-138.
15
 07/07/2015

Recurrent Laryngeal Nerve Damage Unilateral Recurrent Laryngeal Nerve Injury

• The mechanism of recurrent laryngeal nerve • Nonfunction of the intrinsic muscles of

damage the larynx on the affected side (loss of
abduction with intact adduction by
– Direct injury or indirect compression of the nerve cricothyroid) cause the vocal cord to
or it proximal innervation (vagus nerve) assume a paramedian position.
• The voice is breathy but compensation
occurs, though rarely back to normal.
• Risk factors • The airway is adequate and may
– Injury, tumors, or surgery in the neck and upper become compromised only with
chest. exertion.

Bilateral Recurrent Laryngeal Nerve Injury

Evaluation – Unilateral Paralysis
• Usually result of damage to
both RLN. • Manual Compression Test
• Cords lie in paramedian
position
• Voice is good
• Variable degree of stridor

16
 07/07/2015

Inflammation of the larynx Croup (laryngotracheobronchitis )

Malignant neoplasms of larynx

Intubation Technique

17
 07/07/2015

Effect Of Edema

TERIMA KASIH!
Poiseuille’s law

18