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Anatomy of larynx

DR SAURABH VIJAY
RSO ENT I
IMCHRC, INDORE
Introduction

 Larynx protects the lower respiratory tract, provides


controlled airway, allows phonation & helps
generating high intra-thoracic pressure for coughing
& lifting.
 The ability of larynx to allow speech is only found in
the humans.
Embryology
During 4th week
intrauterine
tracheobranchi
al diverticulum
appear in the
ventral wall of
primitive
pharynx just
below the
hypobrachial
eminence
•Edges of this
groove form
esophago- tracheal
septum which
fuses caudally,
leaving a slit like
aperture cranially
into the pharynx.
•The cranial end of
tube forms trachea
and larynx and
caudal end forms
lungs and bronchi.
 Arytenoid swelling appear both sides of the
tracheobrachial diverticulum
 as they enlarge epithelial wall of groove adhere to
each other and aperture of the larynx closes.
 By three months lumen is restored arytenoid
swelling grows upwards and deepen to produce
aryepiglottic folds.
 The hypobranchial eminence becomes epiglottis.
 Glottis forms just above the level of the primitive
aperture.
 The thyroid cartilage develops from the ventral end
of 4th pharyngeal arch cartilage and appear as two
lateral plates each with two chondrification centre.
 Cricoid cartilage and cartilage of trachea develops
from 6th arch during 6th week.
 Mesoderm of the each arch differentiates in to the
cartilage, muscle and vascular structure of the arch.
 Each arch has its own nerve supply in case of 4th and
6th arch superior and recurrent laryngeal nerve
branches of vagus supplies the larynx.
Primitive laryngeal
nerve passes below
the artery of the 6th
arch artery on left
side it remains as
ligamentum
arteriosus after
birth; on the right
side whole 5th arch
artery & dorsal
part of 6th arch
artery disappears
which leaves nerve
below 4th arch
artery ( subclavian
artery).
Anatomy of the Larynx

 Extend from laryngeal inlet to lower border of cricoid


cartilage.
 Opposite to c3 to c6 vertebrae in male,
 Slightly higher in female & children.
Measurements

 Until puberty there is little difference between male


& Female Larynx.
 After puberty male larynx undergo considerable
increase; thyroid cartilage becomes prominent-
Adam’s Apple.

Male Female
Length 44 mm 36 mm
Transverse diameter 43 mm 41 mm
A-P diameter 36 mm 26 mm
Circumference 136 mm 112 mm
Child larynx & adult larynx

Feature Difference
Size Smaller in paediatrics
Position Higher
Shape Curled epiglottis, shorter vocal cords
Mucosa More reactive and prone to obstruction
Vocal cord structure immmature
Division of the Larynx

 Antomically into three part by true and false vocal


cords
1) Supraglottic - epiglottis & aryepiglottic folds
2) Glottic - vocal cords ant commissure & post
commissure
3) Subglottic - cricoid region ends in trachea.
Frame work of Larynx

 1 bone
 9 cartilage
3 Paired
3 Unpaired
 8 muscles
Hyoid
•U shaped Bone.

•Provide upper
attachment of extrinsic
muscles & suspend the
larynx in the neck.

•Parts

• Body

•Greater cornua

•Lesser cornua
Thyroid
Cartilage
•Composed of two
lamina

•Fuse anteriorly in
midline which gives
laryngeal prominace

•Angle of fusion in male


is 90º & in female is
120 º.
•Posterior border of
each lamina is
prolonged above and
below to form superior
and inferior cornua.

•Superior lamina is long


narrow and curve
upwards , backwards
and medially ending in
conical extremity to
which lateral thyroid
ligament is attached
 Inferior cornua is shorter, thicker & and curve
downwards and medially.
 On medial surface of its lower end cricoid cartilage
articulate
 On external surface of each lamina an oblique line
curves downwards and forwards from the superior
thyroid tubercle, situated just in front of the root of
superior horn , to inferior thyroid tubercle on lower
border of lamina. This line marks the attachment of
the thyrohyoid, sternothyroid & inferior constrictor
muscle.
Attachment on inner aspect of thyroid cartilage

 On inner aspect In midline just below the thyroid notch


thyroepiglottic ligament is attached, below this and on
each side of midline, the vestibular and vocal ligament
and thyroarytenoid, thyroepiglottic, & vocalis muscle are
attached.
 The fusion of anterior end of the two vocal ligaments
produces the anterior commissure tendon.
 The remaining part of the inner lamina is smooth and
mainly covered by loosely attached mucous membrane.
 Superior border of each lamina gives attachment to the
thyrohyoid ligament and inferior border cricothyroid
ligament.
Cricoid cartilage

 Only complete cartilaginous ring in airway.


 Forms inferior part of the anterior and lateral wall
and most of the posterior wall of the larynx.
 Has deep broad lamina posteriorly and a narrow
arch anteriorly with a facet for articulation with
inferior cornu of the thyroid cartilage. Rotation of
the cricoid cartilage on thyroid cartilage can occur
about an axis passing transversely through both
joints.
 Vertical ridge in midline gives attachment to
longitudinal muscles of the oesophagus. And
posterior cricoarytenoid muscle
 Entire inner surface is lined with mucous membrane.
Arytenoid cartilages

 Irregular, three sided pyramid.


 Forward projection, the vocal process attached to
vocal folds and lateral projection attached to
posterior cricoarythenoid and lateral cricothyroid
muscle.
 In between these two processes anterolateral surface
is irregular and divided into two fossa by a crest
running from apex.
 Upper triangular fossa gives attachment to the
vestibular ligament and lower to the vocalis and
lateral cricoarythenoid muscle.
 Apex is curved backwards and medially and attched
to corniculate cartilage.
 Base is concave and have a smooth surface for
articulation with cricoid lamina, this is synovial joint
with lax capsular ligament allowing both rotatory
movement and lateral gliding movement.
 Posterior cricoarythenoid ligament prevents forward
movement of arytenoid cartilage.
Corniculate & Cuneiform cartilage

 Corniculate cartilages are two small conical nodule of


elastic fibrocartilage which articulate through a
synovial joint with apices of arytenoid cartilage.
 They are situated in post part of aryepiglottic fold
 The Cuneiform cartilage are two small elongated
flakes of fibroelastic cartilage, one in each margin of
aryepiglottic fold.
Epiglottis

 Thin, leaf like, elastic fibrocartilage; projects upward behind


the tongue and body of hyoid bone.
 Attached inferiorly to thyroid cartilage just below the thyroid
notch in midline by thyroepiglottic ligament & to the hyoid
anteriorly by hyoepiglottic ligament.
 The space in between ligament form pre- epiglottic space.
 Posterior surface of the cartilage is indented by numerous
small pits into which mucous glands project.
 Anterior surface of epiglottis is covered is covered with
mucous membrane superiorly and forms the posterior surface
of vallecula.
 Mucous membrane reflected on the base of tongue
glossoepigottic folds.
Ligaments & membranes of the Larynx

 Extrinsic ligaments
 Intrinsic ligaments
 Extrinsic ligaments
 connects laryngeal cartilage to hyoid above and to
trachea below.
 Superiorly thyrohyoid membrane stretch from upper
border of thyroid cartilage & posterior surface of the
body and greater cornua of hyoid.
 The membrane is composed of fibroelastic tissue,
reinforced by fibrous tissue un midline as thyrohyoid
ligament & lateral thyrohyoid ligament posteriorly.
 Lateral thyrohyoid ligament connects the superior
cornua of thyroid cartilage to the posterior end of
greater cornua of the hyoid.
 The membrane is pierced by internal branch of
superior laryngeal nerve an by superior laryngeal
vessels.
 Cricotracheal ligament unites the lower border of
cricoid cartilage with 1st tracheal ring.
Intrinsic Ligaments

 Connects the laryngeal cartilage together, strengthen


the intercartilaginous joint and forms a broad sheet
of fibroelastic tissue, which lies beneath mucous
membrane of larynx forming internal framework.
 Fibroelastic membrane is divided into upper & lower
part by laryngeal ventricle.
 Upper quadrilateral cartilage extends between lateral
border of epiglottis and arythenoid cartilage.
 Upper margin forms framework of the aryepiglottic
fold and lower margins thickened to form vestibular
ligament underlying vestibular folds (false VC).
 Lower part is thicker containing many elastic fibers.
 Also known as cricovocal ligament, cricothyroid ligament
or conus elasticus.
 It is attached to upper border of the cricoid cartilage and
above it is stretched between inner surface of the
midpoint of the laryngeal prominence of thyroid cartilage
anteriorly in midline & vocal process of arythenoid
posteriorly.
 Free upper border of the membrane constitute vocal
ligaments the frame work of vocal cord.
 Anteriorly a thickening of membrane cricothyroid
ligaments connects the thyroid & cricoid cartilage in
midline.
Muscles of the larynx

 Extrinsic muscles attach the larynx to neighbouring


structure & maintain the position of the larynx in
neck.
 Infrahyoid muscle oppose the elevators of larynx by
paying out rope during contraction of the suprahyoid
elevators.
 Descent of the larynx is due to elastic recoil of the
trachea.
 Intrinsic muscles are all paired and move the
cartilage in larynx & regulate the mechanical
properties of the larynx.
 They control the position & shape of the vocal folds &
control the elasticity and viscosity of each layer.
 Supplied by recurrent laryngeal nerve except
cricothyroid which is supplied by the external branch
of the superior laryngeal nerve.
 Abductor post cricothyroid
 Adductor lateral cricothyroid. Interarytenoid,
thyroarytenoid.
The glottis

 Lies between the false & true vocal cord which cover
vestibular & vocal ligaments respectively.
 Laterally a horizontal slit opens into elongated
recess, the laryngeal ventricle.
 From the anterior part of the ventricle, the saccule of
the larynx ascends between the vestibular ligament
and inner surface of the thyroid cartilage.
 The vestibular folds are two thick folds of mucous
membrane each enclosing the fibrous tissue band,
vestibular ligament which is lower limit of upper
qudrilateral membrane.
 It is fixed in front at the angle of thyroid cartilage
just below the attachment of epiglottic cartilages and
behind the anterolateral surface of arytenoid
cartilage just above the vocal process.
 Vocal folds extend from the middle of the angle of
thyroid cartilage to the vocal process of arytenoid
cartilage & underlying them is upper border of conus
elasticus.
 Each fold has is layered structure consists of a
superficial layer of non keratinizing stratified
squamous epithelium and beneath this lamina
propria.
 This has three distinct layer superficial layer (Rinke’s
space) contain fibrous substance, which has
characteristics of gelatin.
 The intermediate layer contains fibrous layer.
 Deep layer contains collagen fibers.
 Intermediate and deep layer make up the vocal
ligament.
 The vocalis muscle forms the main body of the vocal
folds lies laterally.
 The layered structure of the vocal cord is not uniform
in its entire length.
 At the anterior end a mass of collagen fibres present
which connect the inner perichondrium of the
thyroid cartilage and to the deep layer of the lamina
propria posteriorly.
 Adjacent to this collagen fibres layer a mass of elastic
fibres continue with the intermediate layer of lamina
propria called macula flava.
 Similar structure is also present in the posterior part
of the vocal folds.
 These structure serve as the cushion to protect the
ends of the vocal folds from mechanical damage
caused by vocal fold vibrations.
 Anterior three fifth of the vocal cord is between the vocal
folds and is called the inter membranous part of the cord.
 Posterior two fifths are between vocal process of the
arytenoid and are called inter cartilagenous part.
 The height of the vocal folds diminishes towards anterior
commissure mainly because inferior edge of vocal cord
slopes upwards.
 At the anterior commissure the lower edge of the vocal
folds form the apex of triangular fixed part of the
epiglottis, so tumour involving anterior commissure
involve the subglottic.
Mucous membrane of Larynx

 Closely attached over posterior surface of the


epiglottis, the corniculate & cuneiform cartilages and
over the vocal ligament. Elsewhere it is loosely
attached and prone to oedema.
 Most of the larynx is lined by pseudo-stratified
ciliated columnar epithelium.
 The upper half of the post surface of epiglottis, the
upper part of the arythenoid fold, the posterior
glottis and vocal folds are covered with non
keratinizing stratified squamous epithelium.
 Mucous glands are freely distributed in throughout
the mucous membrane.
 The vocal folds do no contain any mucous gland, and
mucous membrane get lubricated by the glands
present in the saccule.
 This makes VC prone to desiccation if these gland
cease to function as post radiation.
Spaces within the larynx

 Preepiglottic space
 Paraglottic space
Preepiglottic space

 Wedge shaped with point of wedge inferiorly.


 Anteriorly thyrohyoid ligament and hyoid bone.
 Posteriorly epiglottis.
 Superiorly hyoepigottic ligament connect hyoid and
epiglottis.
 Tumour may spread into this area through
perforation in epiglottis or via hyoepiglottic
ligament.
 This space is continuous laterally with paraglottic
space.
Paraglottic space

 Laterally thyroid cartilage


 Medially conus elasticus and quadrangular
membrane.
 Posteriorly by piriform fossa mucosa
 It encompasses laryngeal ventricles and sacules.
Nerve supply

 Motor & sensory nerve supply of the larynx is


derived from Vagus. By superior & inferior laryngeal
nerve.
 Recurrent laryngeal nerve on right side leaves the
Vagus as it crosses the right sub clavian artery and
loops under the artery ascending in
tracheoesophageal groove to reach the larynx.
 Left side nerve originate from Vagus as it crosses the
aortic arch, it then passes under the arch and
ligamentum arteriosum to reach tracheoesophageal
groove.
 In the neck both nerve follow same path and pass
upwards accompanied by laryngeal branch of
inferior thyroid artery.
 They enter the larynx behind cricothyroid joint.
 After entering nerve divides into motor & sensory
branches.
 Motor branch supplies all the intrinsic muscle of
larynx except cricothyroid.
 Sensory branch supply laryngeal mucosa below the
level of vocal folds.
 The relationship between RLN and inferior thyroid
artery is variable, nerve may be in front or behind
the artery or may pass between terminal branches of
artery.
 On right side this relation is more variable while on
left side nerve mostly lie posterior to artery.
Laryngeal vasculature

 Supplied by laryngeal branches of the superior &


inferior thyroid artery and crico thyroid branches of
superior laryngeal artery.
 Venous supply accompanies the arteries.
 Superior laryngeal vein drains into the superior
thyroid or facial vein which drains into internal
juglar vein.
 Inferior laryngeal vein drains into inferior thyroid
vein which drain into brachiocephalic vein.
Lymphatic Drainage

Upper deep cervical group of


LN Upper drainage group

• VOCAL FOLDS- No lymphatic


drainage in this plane

Prelaryngeal group of LN &


Pretracheal group of LN
Lower drainage group