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Medical Science - Review Article

Whats special in a child’s larynx?
Manoharan Prakash, J. Carlton Johnny

Department of ENT, Sree ABSTRACT

Balaji Medical College
What’s special in a child’s larynx? Many of us know only a few specialties of the pediatric larynx, but there
and Hospital, Bharath
University, Chromepet,
are much more features, which are unique and often not highlighted. To understand the pediatric larynx, we
Chennai, Tamil Nadu, India have reviewed the development, the functions in‑utero and new born period and peculiarities.

Address for correspondence:

Dr. Manoharan Prakash,
E-mail: praky31@yahoo.com

Received : 31-10-14
Review completed : 31-10-14
Accepted : 09-11-14 KEY WORDS: Adult larynx, childs larynx, development of larynx

T here are certain modifications, which are seen in the

pediatric larynx and like the brain this remarkable organ
undergoes extensive modification in the structure as well as the
function to attain the attire of an adult larynx. These unique
modifications in the functional anatomy will not be clear
unless we study the development from utero and also compare
it with the adult larynx. This approach gives us a wholesome
knowledge about the different aspects of development.
Knowledge about these variations in age group is extremely
important in clinical aspects like intubation, direct, indirect
laryngosopy, tracheostomy, interpreting radiological images
based on anatomical landmarks and also fewer congenital
anomalies [Figure 1].[1,2]
Development of Larynx
The development of the larynx was first described by the
pioneering work of Soulie and Bardier,[3] Lisser,[4] Hast.[5] The
development takes origin from the median pharyngeal groove.
The differentiation of development takes place at about 25 days
from the ventromedial diverticulum of the forgut called as
tracheobronchial groove. This leads to the fact that the larynx is
also lined with the lining as the gut. Lateral furrows develop on
either side of the venteromedial diverticulum which later joins
to form the tracheo esophageal septum.[6] At about 33 days,
laryngeal primordial appear. The laryngeal aditus depends on
the relation with the primordium of the epiglottis anteriorly
and the precursors of the arytenoids cartilages on either side.
At 5–6 weeks, the tracheooesophageal septum reaches the
first tracheal cartilage. At 7th week the criciod is a complete
ring, hyoid is seen below the epiglottis. In the later stages,
there is only fine tuning in this structure and the acquirement
of neurogenic reflexes.[6] In 3rd month, the thyroid laminae
fuse, cartilaginous process of the arytenoids are seen, along
with the ventricle and saccule. Fetal breathing can be seen in
ultrasonogram by the 3rd month.[6] In the 4th month goblet cells
are seen in the sub mucosa. During 5th–6th month the cuneiform
and corniculate cartilages develop along with the development
of a mature laryngeal coordination[6] with swallowing, breathing.
During the third trimester, it gets ready to perform the uphill
tasks which are laid for it after birth.
Functions In‑utero

Access this article online Primitive swallowing ability develops by 11 weeks, and by
Quick Response Code: 18–20 weeks sucking movements appear. When full‑term
Website: gestation (37 completed weeks) is reached, the fetus can swallow
www.jpbsonline.org and circulate nearly 500 mL of amniotic fluid per day. Thus,
swallow‑induced peristaltic activity begins in fetal life, and
DOI: glottal airway and pharyngoesophageal functions are arranged
10.4103/0975-7406.155797 in series. Thus, the fetal larynx prevents aspiration under normal
conditions.[7]

How to cite this article: Prakash M, Johnny JC. Whats special in a child's larynx?. J Pharm Bioall Sci 2015;7:S55-8.

Journal of Pharmacy and Bioallied Sciences April 2015 Vol 7 Supplement 1 S55 
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Prakash and Johnny: Whats special in a child’s larynx?
Figure 1: Cross section of both the adult and paediatric larynx
At the First Cry
In‑utero, the main function of the larynx was just to maintain
respiration, but soon after its first cry it has to perform three
contradictory tasks of maintain respiration, protect the lower
airway from contamination and produce the first cry.[6] To
perform these functions, there are certain unique modifications.
The pharynx is vertically short, and it lies in the cervical area.
The inferior margin of the cricoids cartilage lies at C4 vertebra
level, and the tip of the epiglottis lies at C1 level. The opposition
of the epiglottis and soft palate helps to perform the dual
function of respiration and sucking, which helps in obligate
nasal breathing of the child. The framework of the larynx is
more vertical when compared to the adult larynx. The thyroid
cartilage is within the hyoid arch and inferior to it. The vocal
cords are more transverse when compared to the adults, the
epiglottis is short and the aryepiglottic folds are thick and bulky
along with comparatively large arytenoids. The larynx is well
supported by soft tissue which helps in prolonged intubation
and prevents sub‑glottic injury.[6] The trachea of new born tends
to collapse as its compliance is 3 times that of a 1‑year‑old and
6 times of an adult. The resistance to prevent collapse is partially
due its cartilages and smooth muscle of the posterior wall.[8]
Reflexes Learnt for Life
There are some vital reflexes which are acquired by the pediatric
laryngeal complex which are:
Vocal cord closure (laryngeal adductor reflex)
Glottic dynamics encompasses three tiers of laryngeal closure
during the act of swallowing.
• Tire 1: Closure of the vocal cords is the initial action and
anatomically the most caudal portion of the tiers, and
the duration of vocal cords closure has been reported to
be ~1.7 s[9]
• Tire 2: Laryngeal elevation follows in the majority of
instances with an upward and forward movement; the vocal
cords start to close during this time in a minority of instances
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• Tire 3: It consists of the sphincteric function of the glottis,
which occurs due to laryngeal muscle activation and
completes laryngeal closure.[7]
Esophago‑glottal closure reflex
The esophago‑glottal closure reflex (EGCR) is most likely the
primary airway protective mechanism during retrograde transit
of gastric contents associated with belching, regurgitation,
vomiting, and acid reflux events. When a large volume of gatric
contents reflux into the esophagus, the esophagus becomes
distended at various levels that in turn stimulates the EGCR
that causes reflex adduction of the vocal cords to prevent the
entry into the trachea.[7]
The response time for esophageal reflexes was 3.8 ± 1.8 s.[10]
Pharyngoglottal closure reflex
Injection of small amounts of water into the pharynx induces
brief vocal cord closure. Slow introduction of graded amounts
of fluid into the pharynx causes partial adduction of the vocal
cords while rapid injection of water causes complete closure of
the vocal cords.[10,11] Frequency, response latency, and duration
of glottal closure with spontaneous swallows were 100%,
0.27 ± 0.1 s, and 1 ± 0.22 s, respectively.
The frequency, response latency, and duration of glottal closure
with pharyngoglottal closure reflex were 100%, 0.56 ± 0.13 s,
and 0.52 ± 0.1 s, respectively.[12]
Whats the Radiolosgists View
A study where computed tomography, magnetic resonance
imaging of the pediatric larynx concluded that pediatric larynx
differs from the adult larynx in four aspects: Consistency, size,
position, and shape. Except for the hyoid bone, the laryngeal
cartilaginous structures are not ossified in the pediatric larynx
and appear featureless. This may mislead an inexperienced
radiologist to think that it is a tumor. The airway is narrowest at
the infraglottic portion. The supraglottic airway is triangular and
oval, the glottic level has a teardrop shape, and the sub‑glottic
level is oval. The pediatric larynx is positioned higher in the
neck, at the C2–C3 level, and is seen behind the mandible.[13]
Whats the Histologists Contribution
In new born and children, the membranous portion of the vocal
fold makes less contribution to the total vocal fold length. The vocal
fold mucosa is thinner in new born and young children, the ratio
of mucosa to the length of the membranous portion of vocal fold
is higher when compared to the adults. The different layers in the
structure are not clearly seen in new born and young children. There
is no ligamentous structure seen in the pediatric vocal fold and the
first appearance is seen at 1–4 years after which it is clearly visible.
It is also seen that there is a greater percentage of collagen in the
pediatric vocal fold muscle and it is deficient in the anterior and
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Prakash and Johnny: Whats special in a child’s larynx?

posterior macula flava fibers which in turn leads to less anchoring gradually as the child grows there is a gradual drop in the
strength to the laryngeal architecture[14] [Figures 2 and 3].[2] pitch and reaches 286 Hz by 7 years of age. Till the puberty,
the vocal features are similar to both boys and girls only
Features Seen in Laryngoscopy during puberty the change in voice depends on the sex of
the child[6] [Figure 5].
The larynx is displaced anteriorly, highly positioned, and the
arytenoids are prominent and the membranous portion of the
vocal fold is short. It lies in the first and third cervical level and
continues to descend throughout childhood till adult level
of sixth and seventh cervical vertebrae.[2] Epiglottis is omega
shaped in 50% of the population.[15] New born glottis is 7 mm
in anteroposterior diameter and 4 mm in transverse diameter.[6]
The subglottis is the narrowest part of the airway that is around
4–5 mm when compared to the glottis that is the narrowest part in
adults.[6] There is no vertical laryngeal prominence (Adam’s apple)
seen in the thyroid cartilage and does not occur till substantial
changes happen in vocal fold at around 10–14 years.[16]

Infantile Reflex

After birth closure reflex is seen, this prevents aspiration of

food contents into the lungs. The infantile glottis also closes
Figure 2: Posterior view of both adult and pediatric larynx
in response to tactile, thermal, chemical stimulation of the
laryngeal inlet, trachea or distal esophageal afferents. The larynx
must open after the stimulus is withdrawn if not it is called
as laryngospasm.[17] This has been postulated in the origin of
sudden infant death syndrome.[18,19]

Evolution during Childhood

In new born, the length of the vocal cord is 2.5–3.0 mm, and

it grows throughout childhood. The difference in vocal cord
length is seen around 10–14 years of age when it reaches adult
female 11–15 mm and male 17–21 mm.[14] The position,
structure and function of the larynx changes throughout
childhood. By two years the lower border of the cricoids has
descended to the neck at about the C5 vertebra, and it reaches
C6 by 5 years of age. The final position of C6–C7 is reached by
15 years.[20] The overlapping thyroid cartilages separate. The
pattern of growth is Figure 3: Anterior view of both adult and pediatric larynx

Birth ¾¾¾
rapid
® 3years ¾¾¾
slow
® puberty

The various aspects of the laryngeal growth is linear, that is,

same in all aspects. Thus the configuration of the larynx is
maintained to a great extent. Later the epiglottis increases
in curvature till 3 years then flattens. About 60–75% of vocal
fold length is due to the vocal process of the arytenoids at
birth. At 3 years, the membranous part of vocal fold is the
dominant size.[21] All through child hood the level of true
vocal folds is halfway between the thyroid notch and the
lower border of the thyroid cartilage. The upper border of
the cricoid maintains an angle of 30 degree with the true
vocal cords[22] [Figure 4].[4]

Changes in Vocal Spectrum

At birth, the pitch of the new born cry is 500 Hz and Figure 4: Shape of both adult and pediatric larynx

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Prakash and Johnny: Whats special in a child’s larynx?
Figure 5: Vocal frequency as the child grows
Clinical Application
The trachea, pharyngeal and laryngeal inlet must be aligned.
The back of the head of the infant should be slightly elevated to
help in this alignment. Too much flexion or improper elevation
may cause difficulty in passing the scope.[2] For laryngoscopy,
the flexible scope must be around 2.7–3.0 mm. Other important
procedures, which involve adequate care and knowledge, are
foreign body removal and tracheostomy in children.
Conclusion
We have reviewed the various aspects from the development of
the larynx, morphology at birth to the changes it acquires during
child hood. The clinical applications which are based on these
concepts are very remunerating for many departments such as
the neonatology, pediatrics, emergency medicine, anesthesiology
and ENT. If proper knowledge of these aspects is not there, we
have many chances of iatrogenic injury of many structures and
cause long term morbidity. It is also recommended to stress
about the pediatric anatomy of the neck along with simulation
classes for training to prevent many iatrogenic complications.
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Source of Support: Nil, Conflict of Interest: None declared.