Dr.

Tahani Abualteen

The Larynx
Definition: A special part of the body consists of group of cartilages which are connected to each other by connective tissue membranes & ligaments and moved by skeletal muscles Functions: o Voice production (contains vocal cords/ligaments) o Protective sphincter " "for inlet of airway to the lungs that prevents foreign body entry into lungs Location: o Extends between C4 - C6 (where it ends and trachea begins ) ** Larynx = 1/3 of pharynx ** Pharynx is located posterior to larynx and extends between base of skull C6 (where it ends and esophageous begins ) ** Pharynx has a part behind nose (nasopharynx), and a part behind mouth (oropharynx), and a part behind larynx (laryngeopharynx) Components of Larynx: Cartilages Membranes & ligaments Muscles

Cartilages :

Thyroid cartilage: o Thyroid = like a shield "" o The largest cartilage o Single large shield of hyaline cartilage (solid cartilage) o Location: felt anterior in the neck and extends on both sides of the neck o Function: it shields/protects the whole larynx behind it (especially the vocal cords, part of epiglottis, arytenoid, Corniculate & cuneiform cartilages) o Consists of: 2 Laminae: Meet in a sharp angle in the midline anteriorly to form a laryngeal prominence called "Adams apple "
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On the lateral side of each lamina, there's a linear elevation that runs obliquely called the "Oblique line" - Oblique line represents a very important landmark on thyroid cartilage because some muscles attach to it - 2 Infrahyoid muscles sternothyroid & thyrohyoid - 1 pharyngeal constrictor Inferior constrictor of the pharynx (attached to posterior aspect of oblique line) ** These 2 laminae are just going anteriolaterally shielding the whole larynx behind them without being closed posteriorely (open backward) Superior Horn (cornu) goes superiorly Inferior Horn (cornu) goes inferiorly

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Cricoid cartilage : o o o o o Cricoid = like a ring "" Single small ring of hyaline cartilage (solid cartilage) This cartilage continues posteriorely (closed backward) Location: inferior to the thyroid cartilage Consists of: Anterior narrow arch Posterior wider lamina (on which arytenoid cartilages are resting)

Epiglottis: o Single leaf-shaped of elastic cartilage tissue covered with a mucus membrane (more movable) o Location: above the glottis (larynx) o Function: protects laryngeal inlet upon swallowing process (upon swallowing, this cartilage closes the laryngeal inlet, to prevent food entry into larynx & trachea) o Attachments Lower edge (stalk) attached to thyroid cartilage Sides attached to arytenoid cartilages (through a quadrangular membrane "aryepiglottic membrane") ** The upper margin of this membrane is free and called the aryepigottic fold ** The lower margin of this membrane is also free and called the vestibular fold ** Cuneiform cartilages are found in the aryepigottic fold to strengthen it Upper edge is free o Related with the tongue by glossepiglottic membrane (reflection of mucous membrane from epiglottis forward to the posterior surface of the tongue ) that consists of: Median fold elevation Lateral folds elevations Vallecula depression on either side of median fold that prevents swallowing of sharp foreign bodies into esophageous
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Arytenoid Cartilage: o Pair of small pyramidal-shaped cartilages in the posterior part of the larynx resting on the superior border of cricoid lamina o Arytenoid = like a pitcher "" Posterior cricoarytenoid muscle o Function: provide attachment for vocal ligaments (true vocal cords) o Consists of: Apex where Corniculate Cartilages are resting Base resting on cricoid lamina Vocal Process (goes anteriorly) provides attachment for vocal ligaments "true vocal cords" (which extend from vocal process of arytenoid cartilage posteriorly until thyroid cartilage anteriorly) Muscular Process (goes laterally) provides attachment for lateral cricoarytenoid muscle & posterior cricoarytenoid Lateral cricoarytenoid muscle muscle ** Between arytenoid & cricoid cartilages there's a plane synovial joint that allows for free range of movements Corniculate cartilages : o Corniculate = like a horn "" o Pair of small conical nodules at the apex of arytenoid cartilage Cuneiform Cartilages : o Cuneiform = like a wedge "" o Pair of small cartilages placed on either side, in the aryepiglottic fold o Function: exist within the aryepiglottic fold to strengthen it

Membranes and ligament: 2 Extrinsic (connecting cartilages of larynx to outer structures): o Thyrohyoid membrane (connects thyroid cartilage with hyoid bone) Median thyrohyoid ligament Lateral thyrohyoid ligament o Cricotracheal ligament (connects cricoid cartilage with 1 st ring of trachea) 2 Intrinsic (connecting cartilages of larynx together): o Quadrangular membrane "aryepiglottic membrane" (connects arytenoid cartilage posteriorely with epiglottis cartilage anteriorly) o Cricothyroid membrane & ligament (triangular membrane connecting cricoid cartilage with thyroid cartilage)
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Thyrohyoid Membrane : o o o o Connects upper margin of thyroid cartilage To hyoid bone Thickened in midline to form median thyrohyoid ligament Thickened posterolaterally to form lateral thyrohyoid ligament Pierced on each side by: Superior laryngeal vessels (from superior thyroid artery of external carotid artery) & Internal laryngeal nerve (from superior laryngeal nerve of Vagus nerve )

Quadrangular Membrane "Aryepiglottic membrane": o Quadrangular in shape o Extends between arytenoid cartilage posteriorly & epiglottis cartilage anteriorly o Free lower Margin thickened to form vestibular fold (which is held within the vestibule of the larynx) ** The vestibular fold is a thickening of quadrangular membrane inferiorly that is located just above the vocal fold (true vocal cords) and thus sometimes mistakenly considered the vocal fold upon endoscoping the larynx from above and for this reason this fold is also called the false vocal cords which are fixed (not movable) because no muscle attaches to them o Free Upper margin folds to form Aryepiglottic fold o Cuneiform cartilage is found in the Aryepiglottic fold & serves to Strengthen it

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Cricothyroid membrane & ligaments: o Inferior Margin: attached to upper border of cricoid cartilage o Superior Margin: is a free margin on medial side of thyroid cartilage (within the space enclosed by Thyroid cartilage) ** The upper free margin is thickened to form the Vocal ligaments (true vocal cords) which are sheilded/protected by the thyroid cartilage and are tensed by having them attached through their anterior and posterior ends only (but their upper end is free) o Attached: Anteriorly to thyroid cartilage Posteriorely to vocal process of arytenoid cartilage

Structures found inside larynx: False Vocal cords: o Fixed vestibular folds inferior free margin of quadrangular membrane o Vascular & pink in color True Vocal Cords: o Mobile vocal ligaments superior free margin of Cricothyroid membrane o Avascular & white in color ** True vocal cords are whitish in comparison to false vocal cords for two reasons: 1. No blood supply (Avascular) 2. They always move and in continuous friction with air and this leads to change in epithelium from ciliated columnar epithelium (respiratory epithelium) into stratified Sequamous epithelium
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Rima Vestibularis fixed horizontal space between the two vestibular folds (false vocal cords) Rima Glottidis movable horizontal space between the two vocal folds (true vocal cords) Sinus of Larynx a small vertical recess extended from lateral sides of the larynx between vestibular folds above and vocal folds below

Cricothyroidotomy : An emergency incision through the skin and cricothyroid membrane to secure the airway during upper airway obstruction, when oral or nasal intubation is not possible ** Otomy = not complete ectomy just a cut in the skin between thyroid and cricoid cartilages in the cricothyroid membrane area ** In the anterior aspect of the neck, there's a very rigid area which is the thyroid cartilage , and at a certain distance from it inferiorly, there is a gap (soft area) which is the cricothyroid membrane, after which another rigid area is felt which is the arch of cricoid cartilage ** In the cricothyroid membrane there is nothing important (no arteries, nerves or even veins) so its very easy to penetrate this area to get into the airways ** Cricothyroidotomy is just an emergency incision that is NOT done routinely in the clinic

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Inlet of larynx: Looks upward and backward Borders o Upper epiglottis o Lateral aryepiglottic fold o Posterior and below membrane covers arytenoid cartilage Cavity of larynx: 3 Regions o Upper part (vestibule): Inlet vestibular fold (false vocal cords) o Middle part: Between vestibular & vocal folds (false & true vocal cords) Communicates laterally with sinus of larynx o Lower part: Vocal fold (true vocal cords) lower border of cricoid lamina Mucous membrane covering of larynx is ciliated columnar epithelium (respiratory epithelium) except at true vocal cords (stratified Sequamous epithelium)

Muscles of The Larynx: Extrinsic Muscles: o Move the whole organ of the larynx up or down during swallowing o Extrinsic muscles = hyoid related muscles mainly (supra & infra ones) ** When hyoid bone is elevated/depressed through the action of muscles attached to it, then the whole larynx will be elevated/depressed too because the hyoid bone is attached to the thyroid cartilage through the thyrohyoid membrane and so many of the hyoid movements are actually accompanied by movements of the whole organ of the larynx o Elevators: 4 Suprahyoid muscles (mylohyoid, stylohyoid, digastric and Geniohyoid) 3 pharyngeal muscles (Stylopharyngeus, Salpingopharyngeus and Palatopharyngeus) ** These muscles are known as the pharyngeal elevators and once they elevate the pharynx upon swallowing, the elevate the larynx too because the pharynx is attached to the larynx anteriorly o Depressors: 3 Infra hyoid muscles (sternohyoid, sternothyroid and omohyoid) EXCEPT thyrohyoid muscle (because it represents a connection between hyoid bone and thyroid cartilage and when this muscle contracts, it depresses the hyoid bone but doesn't depress the whole larynx)

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Intrinsic muscles: o 2 groups Control Laryngeal inlet "Protective sphincter for inlet of airway to the lungs" (2 muscles): Oblique arytenoid ( action narrows the laryngeal inlet) Thyroepiglottic (action widens the laryngeal inlet) Move vocal folds "voice production" (5 muscles): Cricothyroid tenses vocal cords Thyroarytenoid (vocalis) relaxes vocal cords Lateral cricoarytnoid adducts vocal cords Posterior cricoarytnoid abducts vocal cords Transverse arytenoid approximates arytenoid cartilages Origin = Muscular process of one arytenoid cartilage Insertion = Apex of the opposite arytenoid cartilage This muscle runs in an oblique way Some fibers continue in the aryepiglottic fold as the aryepiglottic muscle ** Aryepiglottic muscle = continuation of the oblique arytenoid muscle and so both muscles contract together Action = Narrows laryngeal inlet by approximating arytenoid cartilages together Origin = Inner surface of thyroid cartilage Insertion = Lateral Epiglottis & aryepiglottic fold Action = Widens laryngeal inlet by pulling arytenoid cartilages apart

o Oblique arytenoid:

o Thyroepiglottic Muscle :

o Cricothyroid: Origin = anteriolateral part of cricoid cartilage Insertion = inferior margin and inferior horn of thyroid cartilage This muscle seen from lateral aspect of larynx This muscle has horizontal part (moves thyroid cartilage forward) and oblique part (moves thyroid cartilage forward downward) Action = tenses vocal cords

o Thyroarytenoid (also called "vocalis"): Origin = inner surface of thyroid cartilage

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Insertion = vocal process of arytenoid cartilage This muscle accompanies and is found on either side of true vocal cords Action = relaxes vocal cords by pulling thyroid cartilage backward and keeping the arytenoid cartilage in a fixed position over the cricoid cartilage

o Lateral cricoarytnoid: Origin = arch of cricoid cartilage Insertion = muscular process of arytenoid cartilage Action = adducts vocal cords by rotating arytenoid cartilage inside o Posterior cricoarytnoid: Origin = posterior surface of cricoid lamina Insertion = muscular process of arytenoid cartilage Action = abducts vocal cords by rotating arytenoid cartilage outside o Transverse arytenoid: Origin = one arytenoid cartilage Insertion = opposite arytenoid cartilage Action = closes posterior part of rima glottidis

Blood supply: Upper half of larynx (above vocal fold) superior laryngeal branch of superior thyroid artery (which is an anterior branch of external carotid artery) Lower half of larynx (below vocal fold) inferior laryngeal branch of the inferior thyroid artery (which is a branch of thyrocervical trunk) Nerve supply: Nerve supply to the larynx comes from the Vagus nerve (the tenth cranial nerve which descends from the skull through the jugular foramen) and as it descends it will give two nerves to the larynx

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One goes to the larynx from above and thus called the superior laryngeal nerve , and the other one goes to the larynx from below but isn't called the inferior laryngeal because when it goes down, it rotates and make a loop around an artery and then ascends up to the larynx and thus it is called the recurrent laryngeal nerve ** In the right it loops around the subclavian artery and in the left it loops around the arch of aorta Superior laryngeal nerve before it enters the larynx it will divide into two nerves; the first one is located inside the larynx by penetrating the thyrohyoid membrane and called the internal laryngeal nerve and the second one is located outside the larynx and called the external laryngeal nerve Sensory o Above vocal fold internal laryngeal branch of superior laryngeal branch o Below vocal fold recurrent laryngeal nerve Motor o Recurrent laryngeal nerve supply all intrinsic muscles except cricothyroid muscle which is supplied by external laryngeal branch of superior laryngeal nerve

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