18/07/2012

Bismillah Membangun Generasi Khaira Ummah

Anatomi Larynx

Dr.H.Yani Istadi, M.Med.Ed

Larynx (Voice Box)

• 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

General principles of development

• The development of the larynx can be divided into
prenatal and postnatal stages.
• 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
 18/07/2012

• 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.

• Trachea becomes separated from the esophagus by the

tracheoesophageal septum with a persistent slit like
opening into the pharynx

• 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

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,

while the arytenoids remain approximately the same
size.
• Beginning at age 18-24 months, the larynx descends in
the neck to achieve its final position at vertebrae C4-C7
by age 6 years.
• The larynx elongates as the hyoid, thyroid, and cricoid
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.

2
 18/07/2012

• High position
• Infant : C 1
• 6 months: C 3
• Adult: C 4-7
• Anterior position

Narrowest point = cricoid cartilage

ADULT INFAN
T

3
 18/07/2012

Framework of the Larynx

• Cartilages (hyaline) of the larynx
– Shield-shaped anterosuperior thyroid cartilage
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

Framework of the Larynx

4
 18/07/2012

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

• Shied shaped, open posteriorly, angulated

anteriorly
• Angulation more acute in males
• Its function is to shield larynx from injury and
provide an attachment to vocal cords

5
 18/07/2012

Cricoid Cartilage
• Signet ring shaped
• Stronger than thyroid
cartilage.
• Lamina – 2 to 3 cm
from above
downwards,
considerably broader
than anterior arch.

• Important from structural & functional point

of view
– Base for entire larynx
– Support to arytenoid
– Attachment to intrinsic muscles
– Only part of cartilagenous framework that forms
continuous 360 degree ring
– Once injured or strictured , difficult to resect while
preserving laryngeal function

Epiglottis
• Thin leaf shaped fibro-cartilage,
situated in midline
• Upper free end broad & rounded,
projects up behind base of tongue
• Narrow base called pitiole
• This attachment forms lower limit of
pre-epiglottis space

6
 18/07/2012

• Half of epiglottis
projects above hyoid
• This part has a
laryngeal and lingual
surfaces

• Infrahyoid portion has

no free anterior surface
• Forms posterior wall of
PES
• Epiglottic cartilage
contains many pits filled
with mucous glands
• Little barrier between
infrahyoid portion and
PES

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
• Cx of laryngeal surface of
epiglottis readily spread
to PreEpiSpace

7
 18/07/2012

Reinke’s Space
• Mucosa over the vocal
ligament loosely attached
to ligaments
• Thus there is a
submucosal space along
most of the length of
truer VC

Supraglottis
• 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

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

8
 18/07/2012

Sub-glottis

• Begins about 5mm below free

margins of VC
• Consists of a mobile upper and
fixed lower part

Para-glottic space

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

9
 18/07/2012

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

Otot-otot larynx

10
 18/07/2012

Intrinsic muscles of the larynx:-

Perform 4 basic actions:

• Abduct the vocal cords.
• Adduct the vocal cords.
• Tense/relax the vocal cords.
• Close the laryngeal inlet.

31

• The intrinsic muscles of the larynx, all of

which are innervated by the recurrent
laryngeal nerve, include the:
–Posterior cricoarytenoid - the ONLY
abductor of the vocal folds.
–Functions to open the glottis by rotary
motion on the arytenoid cartilages.
–Also tenses cords during phonation.

Abductor of Larynx

11
 18/07/2012

• 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

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

Intrinsic muscles

12
 18/07/2012

Cricothyroid Muscle

Adductors of the Vocal Folds

Muscles that abduct the vocal cords :

Posterior crico-arytenoid muscles

Superior view

Posterior view

13
 18/07/2012

Muscles that adduct the vocal cords:

Lateral crico-arytenoid muscles & transverse arytenoid muscles.

Posterior view Side view

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

14
 18/07/2012

Muscles that close the laryngeal inlet:

Transverse arytenoid &

ary-epiglottic muscles

Transverse arytenoid

Transverse arytenoid - - only unpaired muscle

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

Persarafan Larynx

Motor:-
All intrinsic laryngeal muscles are
supplied by Recurrent laryngeal
nerve EXCEPT the cricothyroid

Supplied by external laryngeal
nerve.
Sensory:-
Above the level of the vocal cords:
Internal laryngeal nerve
Below the level of the vocal cords:
Recurrent laryngeal nerve.

15
 18/07/2012

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-
superior internal sensory.
– External -It supplies motor
function to the cricothyroid
muscle which tenses the vocal
cords and could cause
laryngopasm.

• 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
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.

Vascularisasi Larynx

16
 18/07/2012

ARTERIAL SUPPLY
• Sup. Laryngeal A. from
Sup. Thyroid artery
• Inf. Laryngeal A. from Inf.
Thyroid artery

lymphatic drainage:
– above vocal cord ► up deep cervical lymph node.

– Below vocal cord lower ►deep cervical node

Intrinsic Ligaments of larynx

• Quadrangular Membrane
• Conus Elasticus

17
 18/07/2012

Conus elasticus

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

18
 18/07/2012

Vocal Ligaments
• False vocal cords
– Mucosal folds superior to the true vocal cords
– Have no part in sound production

Sphincter Functions of the Larynx

• The larynx is closed during coughing, sneezing,
and Valsalva’s maneuver
• Valsalva’s maneuver
– 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

Kasus klinik

19
 18/07/2012

Impaired Movement of Vocal Folds

• Cricoarytenoid joint dysfunction
– Trauma associated with endotracheal intubation

• Recurrent laryngeal nerve damage

– Surgical injury and tumor compression

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)”

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.

20
 18/07/2012

Recurrent Laryngeal Nerve Damage

• The mechanism of recurrent laryngeal nerve
damage
– Direct injury or indirect compression of the nerve
or it proximal innervation (vagus nerve)

• Risk factors
– Injury, tumors, or surgery in the neck and upper
chest.

Unilateral Recurrent Laryngeal Nerve Injury

• Nonfunction of the intrinsic muscles of

the larynx on the affected side (loss of
abduction with intact adduction by
cricothyroid) cause the vocal cord to
assume a paramedian position.
• The voice is breathy but compensation
occurs, though rarely back to normal.
• The airway is adequate and may
become compromised only with
exertion.

Bilateral Recurrent Laryngeal Nerve Injury

• Usually result of damage to
both RLN.
• Cords lie in paramedian
position
• Voice is good
• Variable degree of stridor

21
 18/07/2012

Evaluation – Unilateral Paralysis

• Manual Compression Test

Inflammation of the larynx

Croup (laryngotracheobronchitis )

22
 18/07/2012

Malignant neoplasms of larynx

Intubation Technique

Effect Of Edema

Poiseuille’s law

23
 18/07/2012

TERIMA KASIH!

24