The Larynx

Anatomy

By Dr. Nixon See

Supporting structures
Laryngeal musculature
o Extrinsic
o Intrinsic
Innervation
Arterial supply
Anatomic Region
o Supraglottis
Bounded by tip of epiglottis up to level of true cord
o Glottis
level of true cord to 1 cm below it
o Subglottis
1 cm below the glottis up to level of inferior border of cricoid
cartilage

Anatomy
o Supporting structures
Cartilage
Thyroid cartilage
o shield-like structure, when you cut it open, you
will see vocal ligament, arytenoids, cuneiform and
corniculate cartilages
Cricoid
o complete ring
o Site for emergency
o Below thyroid cartilage
Artyenoid
Corniculate
Cuneiform
Epiglottis
Quad membrane
Conus elasticus
Single bone hyoid
***all of the supporting structures are membranous and cartilaginous except
the hyoid bone.
***all of them are incomplete except cricoid cartilage which is the only
complete ring.
***epiglottis attached to the inner surface of anterior boundary of thyroid
cartilage
***main structure of larynx is behind thyroid cartilage
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The Larynx
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***anterior view: thyrohyoid membrane, cricothyroid membrane;
cricothyrotomy perforate the cricothyroid membrane; tracheostomy done
below the 2nd tracheal ring
o Laryngeal musculature
Extrinsic moves larynx grossly as a whole
Depressors (strap muscles) in front of laryngeal
musculature
o Omohyoid
o Sternohyoid
o Sternothyroid
e.g. when it contracts, it shorten the
diameter, pull the cartilage downward
Elevators
o Mylohyoid floor of the oral cavity
o Geniohyoid
o Genioglossus
o Hyoglossus
o Digastric
o Stylohyoid
o Thyrohyoid
Intrinsic movement of the vocal folds
Abductor (moves folds away from each other)
o Posterior cricoarytenoid
Origin: posterior part of cricoid cartilage
attaching t posterior part of arytenoid
muscle
When it contracts, shortening of diameter,
pull the arytenoid inward,
Adductors (pulls cords to close aperture):
o Interarytenoid
o lateral cricoarytenoid
from lateral surface of cricoid cartilage
attaching itself to lateral of aytenoid
when it contracts, it pivot inward, causing
adduction
o cricothyroid
lateral posterior belly adduct the vocal
ligament inward
Tensors:
o cricothyroid (two bellies on this muscle)
anterior belly shorten the anterior and
posterior distance of vocal ligament
o vocalis
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The Larynx
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o thyroartenoid
main bulk of vocal ligament
when it contracts, it will shorten the
anterior, posterior diameter of vocal cord
***cricothyroid both adductor and tensor
o Blood Supply
Superior thyroid artery and vein superior laryngeal artery
and vein
Inferior thyroid artery and vein inferior laryngeal artery and
vein
o Lymphatic Drainage
Supraglottic upper LN (deep cervical chain)
Glottic none; cancer does not metastasize quickly, no need
for surgery
o Innervation
Derived from CN X longest CN
Superior Laryngeal Nerve
Motor to cricothyroid external branch
o (only one not from recurrent laryngeal)
Sensory to suproglottis internal branch
Can also change voice, aspiration if damaged
Inferior/Recurrent Laryngeal
Motor to rest of intrinsic laryngeal muscles
Sensory to subglottis and upper trachea
Subglottic
Pretracheal nodes
Lower deep cervical nodes
Supraclavicular
Superior mediastinal
***all intrinsic muscles are located internally except cricothyroid muscle
***all intrinsic muscles are innervated by recurrent laryngeal nerve except
cricothyroid muscle

Laryngeal Phsyiology
o Protection of airway
Acting as a sphincter, the larynx prevent the entrance of
anything but air into the lung
Function of posterior cricoarytenoid muscle
Closure of the laryngeal inlet
Closure of the glottis
By adductor muscles
Cessation of respiration
Cough refle, expulsion of secretions and foreign body

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The Larynx
By Dr. Nixon See

o Respiration
By posterior cricoarytenoid muscle
Governed by active muscular dilation
Acid base balance
o Phonation action of intrinsic muscles
o Effort Closure
By adductor muscles
Closure of glottis helps to increase intrathoracic and
intraabdominal pressure
Example: weight lifting, during pooping, peeing, puking,
birthing
Diagnostic Methods
o Indirect laryngoscopy
Mirror laryngoscopy
Expensive
Illusions
Lateral reversal
o e.g patient in front of examiner, whatever you see
in your right is actually the left of examiner
AP reversal
o e.g. epiglottis appears to be more posterior than
arytenoid
Depth perception illusion
o e.g. true cord appears to be at the same level as
the false cord
o Endoscopic laryngoscopy no more illusions
Rigid
Flexible do not touch the larynx;
o Direct Laryngoscopy
In ER or OR b/c you might induce laryngospasm
o Ancillary Procedures
Soft tissue radiograph
CT Scan trauma
MRI soft tissue disorders
o Exam
100 w incandescent bulb/LED headlights
Uncomfortable chair
Sit to either side of patients legs

Congenital Anomalies
o Pediatric larynx not a tiny adult
Basic differences
Pediatric larynx

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Adult larynx
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The Larynx
By Dr. Nixon See
Level of C2-C4
AP 7 mm.
Glottis: 4 mm
Soft, compressible

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C4-C6
1.2-1.4 mm.
I cm. or higher

Laryngomalacia
Congenital laryngeal stridor
o Most common cause of stridor in infants
Stridor from wheezes
Stridor obstruction is higher
(inspiratory)
Wheezes much lower (expiratory)
o Benign, self limiting
o Exaggerated softness, flaccidity of the laryngeal
structures (cartilages)
o Inspiratory stridor, good cry
o Good prognosis
May cause sternal retraction and pectum excavatum
Start when infants is several weeks old and disappear in
12-15 months
Diagnosis
o Direct endoscopic examination during inspiration
o Epiglottis maybe abnormal
o During inspiration: supraglottic structures are
sucked into the larynx
o During expiration: blown up and out
Management
o Active treatment is unnecessary
o Most infants with laryngomalacia gain weight and
mature normally
o Put patient in prone position, not supine
Congenital Subglottic Stenosis
Inadequate recanalization of laryngeal lumen
Subglottic diameter < 4 mm
Membranous cartilaginous
Mild to severe
Treatment: surgery vs laser
Congenital Laryngeal Web
Membranous to fibrous can easily be excised
o Glottis 75% - MC
o Subglottis 12%
o Supraglottis 12%
Congenital Laryngeal Cyst
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The Larynx
By Dr. Nixon See
Arises from the base of the tongue, aryepiglottic fold or
false vocal cord
o If located in tongue part epiglottic cyst in
lingual side (found incidentally)
o If located in larynx epiglottic cyst in laryngeal
side presents with obstruction
Fluid filled cyst
Usually voice and swallowing are normal
Stridor and airway obstruction
Treatment: excision or marsupialization
Hemangioma
Subglottic area
Stridor
Regression at 12 months
Symptom is more obstruction not because of bleeding
Treatment
o laser excision
o surgery
o systemic steroid therapy
o new treatment: beta-blocker use
Laryngocele/Saccular Cyst
Arises from saccule of the laryngeal ventricle
o Ventricle/saccule potential space between true
cord and false cord
Laryngocele: air-filled dilatation
Saccular cyst: mucus filled dilatation; Surgical treatment
Often in wind-instrument musicians
If cyst is located internally called internal
laryngocele/saccular cyst
If it perforates thyrohyoid membrane external
laryngocele/saccular cyst
Laryngotracheoesphageal Cleft
Failure of fusion of dorsal or posterior part of cricoid
cartilage
Associated closure defect
Feeding problems and respiratory distress secondary to
repeated aspiration
o Neurogenic Disorders in the Newborn
Traumatic birth
Associated CN disorder and chest disorder
Unilateral or bilateral
Diagnostic evaluation
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The Larynx

By Dr. Nixon See

Clinical presentation
o Weak, breathy cry
o Often aspiration of pharyngeal secretions
o Cyanotic attack
o Chokes during feeding
Laryngoscopic examination
Direct laryngoscopy
o Vocal cord/cricoarytenoid joint mobility
Management
Spontaneous resolution of paralysis sometimes occurs
Paralysis often recovers 6-9 months
Tracheostomy is virtually always necessary
o Bilateral cord paralysis
o Unilateral cord paralysis with stridor
o Partial airway obstruction or troublesome
aspiration

***laryngeal examination must be done if hoarseness persists for >3 weeks

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