The Larynx

Table of Contents
•  Functions
•  Anatomy
•  Subdivisions
•  Cartilages
•  Vocal Cords
•  Muscles
•  Nerves
•  Vessels
•  Special Cases
 Functions
Functions
Anatomy •  To produce voice
Subdivisions
•  To protect the airway,
Cartilages especially during swallowing
Vocal Cords
•  To keep the airway patent
Muscles
Nerves
Vessels
Special Cases
 Anatomy
Functions
Anatomy
•  The larynx is located at the point
Subdivisions
where the respiratory and
digestive tracts separate.
Cartilages
Vocal Cords •  The entrance to the larynx, or
Muscles laryngeal inlet, is in the anterior
Nerves
wall of the laryngopharynx.
Vessels •  Internally, the wall of the larynx is
Special Cases modified to form the vocal cords.
 Anatomy
Functions
•  The larynx lies in the
Anatomy mid-line of the neck,
Subdivisions deep to the
Cartilages strap muscles and
Vocal Cords
partly covered by the
thyroid gland.
Muscles
•  At roughly the C
Nerves vertebral level, the
Vessels larynx is continuous
Special Cases with the trachea.
 Subdivisions
Functions •  Vertically, the larynx is
Anatomy
divided into 3 regions:
•  1. Supraglottis –
Subdivisions
Includes the epiglottis,
Cartilages aryepiglottic folds,
Vocal Cords false vocal folds,
arytenoids, and
Muscles
ventricle
Nerves •  2. Glottis – true vocal
Vessels folds
Special Cases •  3. Subglottis –below
the true vocal folds to
the inferior border of
the cricoid cartilage
 Cartilages
Functions
•  Total of 9 cartilages
Anatomy •  3 single cartilages
Subdivisions –  Thyroid Cartilage
(green)
Cartilages
–  Cricoid (purple)
Vocal Cords –  Epiglottis (light
Muscles blue)
•  3 paired cartilages
Nerves –  Arytenoids
Vessels (orange)
–  Corniculates &
Special Cases Cuneiforms (black)
 Cartilages
Functions
Anatomy •  The hyoid bone
Subdivisions (yellow) and the
Cartilages cartilages are
Vocal Cords collectively
Muscles referred to as
Nerves the visceral
Vessels skeleton of the
Special Cases
neck.
 Thyroid Cartilage
Functions
•  Thyroid = shield-like
•  The largest cartilage
Anatomy
•  The two laminae
Subdivisions meet anteriorly at the
Cartilages
superior thyroid
notch (Adam's
Vocal Cords apple).
Muscles •  The inferior horns
articulate with the
Nerves cricoid cartilage at
Vessels the cricothyroid
joints.
Special Cases •  The thyroid cartilage
<- Cartilages suspended from the
hyoid bone by the
thyrohyoid
membrane.
 Cricoid
Functions •  Cricoid = ring-
Anatomy shaped
Subdivisions
•  The only
complete ring of
Cartilages
cartilage in the
Vocal Cords respiratory tract.
Muscles •  Cricoid pressure
Nerves is applied to the
esophagus during
Vessels intubation to
Special Cases prevent gastric
<- Cartilages contents from
refluxing into the
airway.
 Cricoid
Functions •  Anteriorly - a
Anatomy narrow arch.
Subdivisions •  Posteriorly -
enlarges to form
Cartilages
the lamina.
Vocal Cords
•  The cricoid lamina
Muscles articulates with
Nerves the inferior horns
of the thyroid
Vessels
cartilage at the
Special Cases crico-thyroid
joints.
<- Cartilages
 Epiglottis
Functions •  Guards the entrance
Anatomy of the larynx. It folds
posteriorly over the
Subdivisions
opening of the larynx
Cartilages during swallowing.
Vocal Cords •  Leaf-shaped, flexible,
elastic cartilage.
Muscles
•  It attaches to the back
Nerves of the thyroid cartilage
Vessels via the thyroepiglottic
ligament.
Special Cases
•  Unlike the other
cartilages, the
epiglottis remains
unossified.
<- Cartilages
 Arytenoids
Functions
Anatomy •  Paired and
Subdivisions
pyramidal in
shape.
Cartilages
Vocal Cords •  The base rests
Muscles
on the upper
surface of the
Nerves
cricoid and forms
Vessels
the crico-
Special Cases
arytenoid joint.
<- Cartilages
 Arytenoids
Functions
Anatomy •  Postero-laterally -
Subdivisions muscular process
Cartilages •  Anteriorly - vocal
Vocal Cords process provides
Muscles attachment for the
Nerves vocal cords.
Vessels •  Superiorly - apex
Special Cases

<- Cartilages
 Corniculates & Cuneiforms
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles
Nerves
•  These small cartilages are both in the posterior
part of the aryepiglottic folds
Vessels
•  The corniculates attach to the apices of the
Special Cases arytenoid cartilages
•  The cuneiforms (not shown) do not directly
attach to any cartilages
<- Cartilages
 Vocal Cords
Functions
Anatomy
Subdivisions
False Vocal
Cartilages Epiglottis Cords
Vocal Cords
Muscles Ventricle
Aryepiglottic
Nerves Fold True
Vessels Vocal Cords
Special Cases Arytenoids
Glottis
 True Vocal Cords
Functions
•  Vocal folds (true vocal cords) control
Anatomy
sound production (tone). Each vocal
Subdivisions
fold includes:
Cartilages
Vocal Cords – Vocal ligament – elastic tissue that
Muscles is the thickened medial free edge
Nerves of the lateral cricothyroid ligament
Vessels (conus elasticus)
Special Cases – Vocalis muscle – fibres that form
the most medial part of the
thyroarytenoid muscle
<- Photo
 False Vocal Cords
Functions •  Vestibular folds (false vocal cords)
Anatomy extend between the thyroid and
Subdivisions arytenoids.
Cartilages
– Have little to no part in voice
Vocal Cords
production
Muscles
Nerves
– Serve a protective function
Vessels •  Vestibular folds are the mucous
Special Cases membrane covering the lower
border of the quadrangular
membrane
<- Photo
 Ventricle
Functions
Anatomy •  Between the true vocal
Subdivisions
cords and false vocal
Cartilages
cords, on each side, is a
Vocal Cords
Muscles
lateral depression, lined by
Nerves
mucous membrane, known
Vessels as the ventricle of the
Special Cases larynx.

<- Photo
 Glottis
Functions
Anatomy
•  Glottis (rima glottidis) -
Subdivisions
the opening between
the two true vocal cords
Cartilages
(or vocal folds).
Vocal Cords
Muscles
Nerves
Vessels
Special Cases

<- Photo
 Larynx – Sagittal View
Functions
Anatomy Aryepiglottic
Subdivisions Fold
Epiglottis
Cartilages Quadrangular
Vocal Cords Membrane
False Vocal
Muscles Arytenoids Cords
Nerves
Vessels Conus Ventricle
Special Cases Elasticus True
Vocal Cords
Cricoid Thyroid
Cartilage
 Larynx – Posterior View
Functions
Anatomy Epiglottis
Subdivisions
Hyoid Bone
Cartilages Thyrohyoid
Vocal Cords Membrane
Aryepiglottic
Muscles Fold Quadrangular
Nerves Membrane
Vessels Arytenoids Thyroepiglottic
Ligament
Special Cases
Cricoid Thyroid
Cartilage

<- Photo
 Quandrangular Membrane
(In more detail)
Functions
Anatomy
•  The quadrangular membrane is a
Subdivisions
sheet of fibrous connective tissue that
Cartilages
extends from the arytenoids to the
Vocal Cords
epiglottis.
Muscles •  The upper border, covered by mucous
Nerves membrane, is the aryepiglottic fold.
Vessels •  The lower border is the vestibular
Special Cases ligament.
•  The latter, together with its covering of
mucous membrane, is the vestibular
fold, or false vocal chord.
<- Diagram
 Conus Elasticus (In more detail)
Functions •  The conus elasticus attaches to
Anatomy the upper surface of the cricoid
Subdivisions arch.
Cartilages •  Its upper border is the vocal
Vocal Cords ligament which extends between
Muscles the vocal process of the arytenoid
Nerves cartilage and the thyroid lamina.
Vessels •  The vocal ligament, covered with
Special Cases mucous membrane, is the vocal
fold or true vocal chord.
•  The membrane between the
thyroid cartilage and cricoid is the
cricothyroid membrane.
<- Diagram
 Vocal Cords
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles
Nerves
Vessels
Special Cases

Abducted Adducted
Vocal Cord Abduction & Adduction
Functions
Anatomy
•  The vocal cords are abducted
Subdivisions
Cartilages
during breathing
Vocal Cords •  The vocal cords are tightly
Muscles adducted in straining efforts and
Nerves before a cough or sneeze.
Vessels
•  Voice production is the result of
Special Cases
the escape of small amounts of
air between the adducted vocal
cords.

<- Photos
 Phonation Physiology
Functions
Anatomy
Subdivisions •  Power source – Lungs & Diaphragm
Cartilages
•  Pitch & quality – Larynx
Vocal Cords
Muscles •  Articulation – Lips and Tongue
Nerves
Vessels
Special Cases

<- Photos
 Muscles
Functions •  The muscles of the larynx are classified
Anatomy as extrinsic or intrinsic
Subdivisions •  Extrinsic laryngeal muscles
Cartilages –  Move the larynx as a whole
–  Depress or elevate the hyoid bone & larynx
Vocal Cords
–  Infrahyoid strap muscles (omohyoid, sternohyoid,
Muscles sternothyroid, thyrohyoid)– depressors
Nerves –  Palato-pharyngeus & stylopharyngeus muscles –
elevators
Vessels
Special Cases •  Intrinsic laryngeal muscles
–  Move parts of the larynx
–  Control the length/tension and movements of the
vocal folds and may help in the closure of the
laryngeal inlet
 Extrinsic Muscles
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles
Nerves
Vessels
Special Cases
 Intrinsic Muscles – Posterior View
Functions
Epiglottis
Anatomy
Subdivisions
Hyoid Bone
Cartilages
Aryepiglottic
Vocal Cords Thyroid Muscle
Cartilage
Muscles
Nerves Arytenoids Interarytenoid
Vessels Muscle

Special Cases
Posterior
Cricoid
Cricoarytenoid
Muscle
 Intrinsic Muscles
Lateral View from Inside
Functions
Arytenoids
Anatomy
Subdivisions Quadrangular Membrane

Cartilages Thyroepiglottic Muscle

Vocal Cords
Muscles Aryepiglottic Fold

Nerves
Thyroid Cartilage
Vessels
Special Cases Thyroarytenoid Muscle

Lateral Cricoarytenoid
Muscle

Cricoid
 Intrinsic Muscles
Lateral View from Inside
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles Thyroid Cartilage
Nerves
Vessels
Special Cases Cricoid

Cricothyroid Muscle
 Posterior Cricoarytenoid Muscle
Functions
Anatomy
•  From the posterior surface of
Subdivisions the lamina of the cricoid, its
Cartilages fibres converge to insert into
Vocal Cords
Muscles
the muscular process of the
Nerves arytenoid.
Vessels •  The two posterior
Special Cases
cricoarytenoid muscles abduct
the vocal chords by both
rotating and separating the two
<- Diagram arytenoid cartilages.
 Interarytenoid muscle
Functions
Anatomy •  Consists of transverse and
Subdivisions oblique fibres which pass
Cartilages between the two arytenoid
Vocal Cords
Muscles
cartilages.
Nerves •  They adduct the vocal chords
Vessels
by drawing the two arytenoid
Special Cases
cartilages together.

<- Diagram
 Aryepiglottic muscle
Functions
Anatomy •  This muscle is an
Subdivisions extension of the oblique
Cartilages
interarytenoid muscle
Vocal Cords
Muscles along the
Nerves aryepiglottic fold to the
Vessels epiglottis.
Special Cases
•  It aids in pulling down the
epiglottis over the
laryngeal inlet during
<- Diagram swallowing.
 Lateral Cricoarytenoid Muscle
Functions
Anatomy
•  Originates from the upper
Subdivisions margin of the cricoid arch
Cartilages and inserts into the
Vocal Cords
muscular process of the
Muscles
Nerves arytenoid.
Vessels •  It adducts the vocal chord
Special Cases
by rotating the arytenoid
cartilage, so that the vocal
process swings towards the
<- Diagram mid-line.
 Cricothyroid Muscle
Functions •  Passes from the arch of the
Anatomy cricoid to the inferior margin
Subdivisions and inferior horn of the thyroid
Cartilages cartilage.
Vocal Cords
Muscles
•  It acts on the cricothyroid joint,
Nerves
causing an increase in the
Vessels
length, and/or tension of the
Special Cases
vocal chords.
•  This movement is opposed by
the thyroarytenoid muscle.
<- Diagram
 Thyroarytenoid Muscle
Functions
•  Passes between the
Anatomy
Subdivisions
arytenoid and thyroid
Cartilages
cartilages, on the lateral
Vocal Cords side of the vocal ligament.
Muscles •  It contracts to shorten the
Nerves vocal chord and/or
Vessels
decrease its tension.
Special Cases
•  This movement is opposed
by the cricothyroid muscle.
<- Diagram
 Thyroepiglottic Muscle
Functions
Anatomy
•  Some detached fibres of
Subdivisions the thyroarytenoid may
Cartilages extend up to the epiglottis
Vocal Cords as the thyroepiglottic
Muscles muscle.
Nerves
Vessels
•  This muscle aids in
Special Cases
depressing the epiglottis
and closing off the larynx
during swallowing.
<- Diagram
 Nerves
•  The larynx is innervated by branches of the
Functions vagus nerve (CN X).
Anatomy •  Sensory
Subdivisions –  For the laryngopharynx, the internal laryngeal
Cartilages branch of the superior laryngeal nerve
Vocal Cords
supplies sensation above the vocal chords
(supraglottis/glottis) and the
Muscles recurrent laryngeal nerve supplies sensation
Nerves below the vocal chords (subglottis).
Vessels •  Motor
Special Cases –  All intrinsic muscles are supplied by the
recurrent laryngeal nerve, except for the
cricothyroid which is supplied by the external
laryngeal nerve. The cricothyroid muscle
tenses the vocal folds.
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles
Nerves
Vessels
Special Cases
 Recurrent
Functions Laryngeal
Anatomy Nerve
Subdivisions
Cartilages
•  LEFT
Vocal Cords
–  Loops around
Muscles
aortic arch
Nerves
•  RIGHT
Vessels
Special Cases
–  Loops around
subclavian
artery
 Vessels
Functions
•  Arteries
Anatomy
Subdivisions –  Superior and inferior laryngeal
Cartilages arteries (from the superior and
Vocal Cords inferior thyroid arteries)
Muscles accompany the internal and
Nerves recurrent laryngeal nerves,
Vessels respectively.
Special Cases
•  Vein
–  Venous drainage is by
corresponding veins.
Functions
Special Cases
Anatomy
Subdivisions •  Child’s Larynx
Cartilages
Vocal Cords
•  Laryngeal Carcinoma
Muscles •  Tracheostomy
Nerves
Vessels
•  Epiglottitis
Special Cases •  Cricothyrotomy
•  Spasmodic Dysphonia
 Child’s Larynx
Functions There are several
Anatomy differences
Subdivisions between an adult
Cartilages and child’s larynx
Vocal Cords and airway:
Muscles •  More anterior and
Nerves cephalad larynx
Vessels •  Short trachea and
Special Cases neck. Beware of
right mainstem
bronchus intubation
•  Proportionally
larger head and
tongue
 Child’s Larynx
Functions Narrowest point in the
Anatomy pediatric airway is
Subdivisions the cricoid cartilage,
Cartilages while in the adults, it
Vocal Cords is the vocal cords.
Muscles Use an uncuffed
Nerves tube to intubate
Vessels children.
Special Cases Long, floppy epiglottis, “U
shaped”. Use a
straight blade for
intubation
 Laryngeal Carcinoma
Functions
Anatomy
This laryngeal
Subdivisions
Cartilages
carcinoma,
Vocal Cords shown in black,
Muscles is obstructing
Nerves the airway. A
Vessels tracheostomy
Special Cases was done to
secure the
patient’s airway
Functions
Laryngeal Carcinoma
Anatomy
Subdivisions •  The most common head & neck cancer
Cartilages •  5% of all malignancies diagnosed
Vocal Cords annually
Muscles
•  20,000 new cases in US annually
Nerves
Vessels •  Mean age: 60-62 years
Special Cases •  Predisposing factors: smoking & alcohol
•  Most are squamous cell carcinomas
(>95%)
 Laryngeal Carcinoma
Functions •  Presenting symptoms: hoarseness,
Anatomy dysphagia, odynophagia, sore throat,
Subdivisions referred otalgia, globus sensation,
Cartilages weight loss, and neck mass.
Vocal Cords
•  Laryngeal tumors arise in the glottis
Muscles
(67%), supraglottis (31%), and
Nerves
subglottis (2%)
Vessels
Special Cases
•  Early cancers (T1/T2) are treated with
single-modality treatment (surgery or
radiation), while late cancers (T3/T4)
are treated with multimodality
treatment (surgery with postoperative
radiation or organ preserving therapy)
 Tracheostomy
Functions
Anatomy
A tracheostomy
Subdivisions
Cartilages
is an opening
Vocal Cords is made into
Muscles the anterior
Nerves wall of the
Vessels trachea to
Special Cases establish an
airway
 Indications for Tracheostomy
•  Upper airway obstruction
Functions –  Due to burns or corrosive injury, laryngeal
Anatomy dysfunction, foreign bodies, infections,
Subdivisions inflammatory conditions, neoplasms, OSA
Cartilages •  Inability of patient to manage
Vocal Cords secretions
Muscles –  Due to aspiration or excessive
Nerves bronchopulmonary secretions
Vessels •  Prolonged intubation
Special Cases
•  Facilitation of ventilation support
•  Inability to intubate
•  Adjunct to major head & neck surgery
•  Adjunct to management of major head
& neck trauma
 Tracheostomy
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles
Nerves
Vessels Airway
Special Cases Obstruction

Tracheostomy

http://www.nlm.nih.gov/medlineplus/ency/presentations/100043_4.htm
 Epiglottitis
Functions
•  Acute inflammation of the
Anatomy
Subdivisions
epiglottis and the supraglottic
Cartilages
structures surrounding it
Vocal Cords •  Can be a severe, life-
Muscles threatening disease of the
Nerves upper airway
Vessels
Special Cases
•  Haemophilus influenzae was
the predominant organism.
–  Hib vaccine has decreased the
incidence of epiglottitis
•  Age: 1-6 years old
 Epiglottitis
Functions
•  Clinical triad of the 3 Ds:
Anatomy
Subdivisions – Drooling
Cartilages
Vocal Cords
– Dysphagia
Muscles – respiratory Distress
Nerves
Vessels
•  Rapid onset of fever and sore
Special Cases throat
•  Patient anxious and toxic
looking
 Epiglottitis
Functions •  “Hot potato" muffled voice
Anatomy –  supraglottic
Subdivisions
Cartilages
•  May have inspiratory stridor
Vocal Cords –  Inspiratory – supraglottic or glottic
Muscles –  Biphasic – subglottic
Nerves –  Expiratory – distal tracheobronchial tree
Vessels •  “Sniffing position" with their nose
Special Cases
pointed superiorly, head forward,
sitting erect to maintain an adequate
airway.
•  Cough is rare
 Epiglottitis
Functions
Anatomy
Subdivisions
•  Secure the AIRWAY first before
Cartilages any tests
Vocal Cords – ENT/Anesthesia consults
Muscles
– May need to intubate in the OR
Nerves
Vessels •  Do not agitate the child in any way
Special Cases – e.g. iv, tests
•  Administer humidified oxygen
•  iv Antibiotics to cover causative
agents X 7-10 d
 Epiglottitis
Functions
Anatomy
Subdivisions
•  After the airway
Cartilages is secure,
Vocal Cords lateral neck
Muscles radiographs
Nerves may show an
Vessels enlarged
Special Cases epiglottis called
the thumb sign
 Cricothyrotomy
Functions
Anatomy •  Emergency incision through the
Subdivisions skin and cricothyroid membrane to
Cartilages secure a patient's airway during
Vocal Cords
certain emergency situations
Muscles
Nerves •  Easier and faster than a
Vessels tracheostomy
Special Cases •  Only used when oral or nasal
intubation is not possible
•  A cricothyrotomy is a temporary
airway, while a tracheostomy is a
definitive airway
 Cricothyrotomy
Functions
Anatomy
Subdivisions
Cartilages
Vocal Cords
Muscles
Nerves
Vessels
Special Cases

http://www.fotosearch.com/comp/LIF/LIF141/NU304004.jpg
 Adductor Spasmodic Dysphonia
Functions
Anatomy •  Sudden involuntary muscle
Subdivisions movements or spasms cause the
Cartilages
Vocal Cords
vocal cords to slam together and
Muscles stiffen.
Nerves
•  Speech may be choppy and sound
Vessels
Special Cases
similar to stuttering. The voice is
commonly described as strained or
strangled and full of effort.
 Abductor Spasmodic Dysphonia
Functions
Anatomy •  Sudden involuntary muscle
Subdivisions movements or spasms cause the
Cartilages
Vocal Cords
vocal folds to open.
Muscles •  The vocal folds can not vibrate
Nerves
when they are open.
Vessels
Special Cases •  The open position of the vocal folds
also allows air to escape from the
lungs during speech.
•  The voices sounds weak, quiet and
breathy or whispery.
 Spasmodic Dysphonia
Functions
Anatomy •  With both abductor and adductor
Subdivisions spasmodic dysphonia, the spasms are
Cartilages often absent during activities such as
Vocal Cords laughing or singing
Muscles
•  Stress often makes the spasms worse
Nerves
Vessels •  There is no cure
Special Cases •  The most effective treatment for
reducing symptoms is injections of very
small amounts of botulinum toxin
(Botox) directly into the affected muscles
of the larynx
 References
•  Essential Clinical Anatomy
•  ENT Secrets
•  Wikipedia® - the Free encyclopedia
http://en.wikipedia.org/wiki/Larynx
http://en.wikipedia.org/wiki/
Spasmodic_dysphonia#Adductor_spasmodic_dysphonia
•  Dr. Peter Haase’s Laryngeal Anatomy lecture notes for first
year medicine, UWO
•  Dr. Kevin Fung’s Hoarseness lecture notes for first year
medicine, UWO
•  Amira 4.1
•  Netters
•  http://www.nlm.nih.gov/medlineplus/ency/presentations/
100043_4.htm - trach photo
•  http://www.fotosearch.com/comp/LIF/LIF141/NU304004.jpg -
cricothyrotomy photo