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"Learning the Larynx"

The document provides information about the anatomy and functions of the larynx. It is divided into sections covering location and functions, surface anatomy, cartilages and ligaments, relevant vessels, innervation, musculature, interior compartments, and clinical relevance. The user can click on underlined words and buttons to learn more about specific structures of the larynx. Images and self-assessment questions are included throughout to aid in learning the material.

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: The larynx has been broken down into sections. Choose the section that you would like to study by clicking on it Click if you wish to return to the home page at any time • UNDERLINED WORDS/BUTTONS: Click these to be taken to another page, where you can learn more about that structure Look out for Clinical Relevance buttons! • TEST YOURSELF! Observe the prosection photos throughout the package, and attempt to identify the structures before clicking to reveal the labels • Most sections have a self-assessment at the end to allow you to check how well you have revised!
LOCATION & FUNCTION SURFACE ANATOMY CARTILAGES & LIGAMENTS RELEVANT VESSELS INNERVATION MUSCULATURE INTERIOR COMPARTMENTS CLINICAL RELEVANCE THE “BELOVED” SPOTTER
• Situated in the anterior triangle of the neck • Extends from the tip of the epiglottis to the inferior border of the cricoid cartilage • It lies opposite the C3- C6 vertebrae • It’s bound by the Pretracheal layer of deep cervical fascia • It lies in the visceral compartment of the neck, along with the pharynx and oesophagus (posteriorly), thyroid, parathyroid glands and thymus and trachea (inferiorly) • Its location is relatively superficial so many of the laryngeal components are palpable! With permission from Moore & Agur (3rd ed.)
1. AIRWAY PROTECTION 2. PHONATION 3. RESPIRATION CLINICAL RELEVANCE
1. AIRWAY PROTECTION 2. PHONATION 3. •The most important function! • During swallowing the larynx should be •The epiglottis is pulled down to cover the laryngeal inlet and divert food into the pharynx during swallowing •The vocal folds => CLINICAL RELEVANCE
1. AIRWAY PROTECTION 2. PHONATION 3. RESPIRATION •To generate sound the larynx must be •The vocal folds must be •The appears • Force of expired air from lungs  causes vibration of vocal folds . . .generating sound! CLINICAL RELEVANCE
1. AIRWAY PROTECTION 2. PHONATION 3. RESPIRATION •To the larynx must be • This is achieved by of the vocal folds appears CLINICAL RELEVANCE
ISTHMUS OF THYROID GLAND CRICOTHYROID MEMBRANE 1ST TRACHEAL RING CRICOID CARTILAGETHYROID CARTILAGE (LARYNGEAL PROMINENCE) GREATER HORN OF HYOID BONE BODY OF HYOID BONE THYROID GLAND •BODY OF HYOID BONE •CRICOTHYROID MEMBRANE •CRICOID CARTILAGE •LATERAL LOBE OF THYROID GLAND •1ST TRACHEAL RING •ISTHMUS OF THYROID GLAND •THYROID CARTILAGE •GREATER HORN OF HYOID BONE ANTERIOR TRIANGLE With permission from Moore & Agur (3rd ed.) * Have a go at identifying the structures, and then click to reveal the labels *
C3 BIFURCATION OF THE COMMON CAROTID ARTERY SUPERIOR BORDER OF THYROID CARTILAGE C2 HYOID BONE C5 INFERIOR BORDER OF THYROID CARTILAGE C6 BEGINNING OF TRACHEA AND OESOPHAGUS (posteriorly) CRICOID CARTILAGE C4 VOCAL FOLDS (attach behind the laryngeal prominence) With permission from Moore & Agur (3rd ed.)
A term which refers to the supportive framework of the larynx, which is primarily responsible for maintaining the shape of the organ. It consists of nine cartilages joined by a series of ligaments and membranes, and reinforced by a selection of muscles HYOID BONE TRACHEA THYROID CARTILAGE CLINICAL RELEVANCE
• It’s not actually classified as part of the larynx but is still very important! • A horse-shoe shaped bone • It’s suspended in the neck by ligaments and muscles, and doesn’t articulate with any other bones or cartilages MAJOR HORNS MINOR HORNSBODY OF HYOID BONE ANTERIOR VIEW
CARTILAGES OF THE LARYNX Divided into 2 groups POSTERIOR VIEW EPIGLOTTIC THYROID ARYTENOIDS CRICOID •THYROID CARTILAGE •CRICOID CARTILAGE •EPIGLOTTIC CARTILAGE •ARYTENOID CARTILAGES •CORNICULATE CARTILAGES •CUNEIFORM CARTILAGES
• The largest cartilage in the laryngeal skeleton OBLIQUE LINE •Site for attachment for: •Thyrohyoid muscle, •Sternohyoid • Inferior constrictor of the pharynx. LARYNGEAL PROMINENCE • Formed by fusion of the laminae in the midline • Angle of approx. •90O in males •120O in females. • The vocal ligament attaches just behind this SUPERIOR HORN THYROID LAMINAE • 2 flat quadrilateral plates INFERIOR HORN Articulates with the cricoid cartilage at the CRICOTHYROID JOINTS Image adapted from Gray’s Anatomy for students
HYOID BONE THYROHYOID MEMBRANE CRICOID CARTILAGE CRICOTHYROID MEMBRANE INFERIOR HORN ATTACHMENT OF VOCAL FOLDS LARYNGEAL PROMINENCE INFERIOR THYROID NOTCH ANTERIOR VIEW POSTERIOR THYROID LAMINA SUPERIOR THYROID NOTCH SUPERIOR HORN •INFERIOR THYROID NOTCH •THYROID LAMINA •ATTACHMENT OF VOCAL FOLDS •INFERIOR HORN •SUPERIOR THYROID NOTCH •LARYNGEAL PROMINENCE * Have a go at identifying the structures, and then click to reveal the labels *
ARCH (anterior) The only cartilage to form a complete ring around the airway • Is both stronger and thicker than the thyroid cartilage •Signet-ring shaped LAMINA (posterior) •“signet” aspect is wider •the arytenoid cartilages sit on top FACETS (lateral aspects) Articulate with the Inferior horns of the thyroid cartilage The lobes of thyroid gland also attaches to it’s lateral surface1st TRACHEAL RING CRICOTRACHEA L MEMBRANE POSTEROLATERAL VIEW Image adapted from Gray’s Anatomy for students
ANTEROLATERAL VIEW POSTERIOR VIEW VOCAL PROCESSES (attachment of vocal ligaments) ARCH (anterior) LAMINA (posterior) ARYTENOID CARTILAGES •CRICOID ARCH •CRICOID LAMINA •VOCAL PROCESS •ARYTENOID * Have a go at identifying the structures, and then click to reveal the labels *
• A leaf-shaped elastic cartilage located posterior to the hyoid bone and the root of the tongue • Forms the superior margin of the laryngeal inlet The broad SUPERIOR ASPECT of the cartilage is free EPIGLOTTIC CARTILAGE attaches to: Thyroid cartilage via THYROEPIGLOTTIC LIGAMENT Hyoid bone via HYOEPIGLOTTIC LIGAMENT SAGITTAL SECTIONImage adapted from Clinical Voice Disorders 3rd ed. Arytenoid cartilages (posteriorly) via QUADRANGULAR MEMBRANE
CRICOARYTENOID JOINTS:- •These allow tilting,sliding and rotation of the arytenoid cartilages anteriorly, posteriorly, laterally and medially •Each movement causes a change in the length, tension and position of the vocal folds and therefore has an impact on laryngeal functionSAGITTAL SECTION • These triangular-based pyramidal structures have a posterior location, and sit on the lamina of the cricoid cartilage • Don’t be fooled by their small size- they’re very important structures! * EACH ARYTENOID HAS 4 SURFACES * BASE Articulates with the cricoid lamina at the cricoarytenoid joints Image adapted from Clinical Voice Disorders 3rd ed.
MEDIAL SURFACE Smooth and covered with mucous membrane ANTEROLATERAL SURFACE Site for attachment of •Vestibular ligament •Thyroarytenoid and vocalis muscles POSTERIOR SURFACE attachment of • Transverse arytenoid • Oblique arytenoid muscles SUPERIOR VIEWTHYROID CARTILAGE VOCAL LIGAMENT CRICOID CARTILAGE
• Each Arytenoid cartilage has 3 KEY PROJECTIONS VOCAL PROCESS Site for posterior attachment of vocal ligament MUSCULAR PROCESS Site of attachment of • Lateral cricoarytenoid • Posterior cricoarytenoid muscles APEX •Articulates with the corniculate cartilages above • Attaches to the aryepiglottic fold. Image adapted from Clinical Voice Disorders 3rd ed. SAGITTAL SECTION
VOCAL PROCESSES APEX MUSCULAR PROCESSES Knowledge of these projections is key to understanding the actions of the intrinsic muscles involved in movement of the vocal folds CRICOID CARTILAGE SUPERIOR VIEW LATERAL VIEW POSTERIOR ANTERIOR * Have a go at identifying the structures, and then click to reveal the labels *
• These are the smallest cartilages and are of no major functional importance. CORNICULATES Lie on the apices of the arytenoid cartilages CUNEIFORMS Are suspended in the mucous membrane of the aryepiglottic folds ARY-EPIGLOTTIC FOLD
MEMBRANES OF THE LARYNX THYROHYOID CRICOTHYROID HYOEPIGLOTTIC & THYROEPIGLOTTIC QUADRANGULAR VOCAL LIGAMENT ARYEPIGLOTTIC LIGAMENT (superior) VESTIBULAR LIGAMENT (inferior)
• It attaches the superior border of the thyroid cartilage with the hyoid bone MEDIAN THYROHYOID LIGAMENT The thickened central portion of the membrane Penetrated by • superior laryngeal artery LATERAL THYROHYOID LIGAMENT The lateral aspect of the membrane Back to membranes Image adapted from Gray’s Anatomy for students
• It attaches. . . ANTERIORLY along the inferior border of the thyroid cartilage INFERIORLY along the superior border of the cricoid arch POSTERIORLY to the vocal processes of the arytenoid cartilages It’s thickened FREE UPPER MARGIN forms the VOCAL LIGAMENT; the skeleton of the vocal fold. It runs from the junction behind the laryngeal prominence to the vocal processes. The horizontal space between the 2 vocal folds = RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.) CLINICAL RELEVANCE Back to membrane s
Attaches the sides of the epiglottis  lateral aspects of the arytenoid cartilages It’s Free INFERIOR MARGINS VESTIBULAR LIGAMENTS VESTIBULAR FOLDS It’s Free SUPERIOR MARGINS ARYEPIGLOTTIC LIGAMENTS ARYEPIGLOTTIC FOLDS With permission from Moore & Agur (3rd ed.) Back to membran es
1. The cuneiform cartilages articulate with the corniculate cartilages 2. Only sliding movements of the arytenoid cartilages are possible at the cricoarytenoid joints. 3. In emergencies when there is obstruction of the larynx above the vocal folds, the thyrohyoid membrane can be punctured to allow air into the airways 4. The lateral lobes of the thyroid gland lie on the cricoid cartilage 5. The tip of the epiglottis extends above the hyoid bone FALSE  they actually are isolated, and don’t make contact with any cartilages or bony structures, instead they are suspended in the ary-epiglottic fold. FALSETRUE FALSETRUE FALSETRUE TRUE FALSE TRUE FALSE
ARTERIAL SUPPLY SUPERIOR LARYNGEAL ARTERY INFERIOR LARYNGEAL ARTERY VENOUS DRAINAGE INFERIOR LARYNGEAL VEIN SUPERIOR LARYNGEAL VEIN LYMPHATIC DRAINAGE INFERIOR DEEP CERVICAL NODES SUPERIOR DEEP CERVICAL NODES
SUPERIOR LARYNGEAL SUPERIOR THYROID EXTERNAL CAROTID COMMON CAROTID INFERIOR LARYNGEAL INFERIOR THYROID THYROCERVICAL TRUNKSUBCLAVIAN ARCH OF AORTA Ascends in the groove between the trachea and the oesophagus with the Recurrent Laryngeal nerve and then passes deep to the inferior constrictor of the pharynx Image adapted from Gray’s Anatomy for students
The venous drainage of the larynx is through the SUPERIOR and INFERIOR LARYNGEAL VEINS which accompany their respective arteries They ultimately drain into the the left and right INTERNAL JUGULAR VEIN  BRACHIOCEPHALIC VEINS
VOCAL FOLDS RIMA GLOTTIDIS= horizontal space between the two vocal cords THE GLOTTIS = the vocal apparatus of the larynx comprised by the VOCAL CORDS and RIMA GLOTTIDIS LYMPH VESSELS surrounding the vocal folds are sparse. As a result patients with CARCINOMA OF THE GLOTTIS often have a good prognosis as there is a reduced chance of metastasis through the lymphatics, and hoarseness is an early and easily identifiable symptom. The part of the larynx BELOW the VOCAL FOLDS drains into the INFERIOR DEEP CERVICAL NODES The part of the larynx ABOVE the VOCAL FOLDS drains into the SUPERIOR DEEP CERVICAL NODES
MEDULLA JUGULAR FORAMEN VAGUS (CNX) INFERIOR VAGAL GANGLION SUPERIOR VAGAL GANGLION COMMON CAROTID ARTERY INTERNAL JUGULAR VEIN SUPERIOR LARYNGEAL NERVE INTERNAL LARYNGEAL NERVE Provides fibres to the mucosa ABOVE the level of the VOCAL FOLDS Provides fibres to the cricothyroid muscle EXTERNAL LARYNGEAL NERVE The nerve supply to the larynx comes from the and the , both are branches of the Vagus (CNX) RECURRENT LARYNGEAL NERVE
• After looping, both RLNs ascend between the trachea and oesophagus • They pierce the inferior constrictor of the pharynx to enter the larynx • They continue as the inferior laryngeal nerves to provide the MOTOR SUPPLY to all the intrinsic muscles of the larynx except the Cricothyroid muscles •Provide SENSORY FIBRES to mucosa BELOW the VOCAL FOLDS. Loops under the Arch of the Aorta, posterior to the Ligamentum Arteriosum LEFT RLN RIGHT RLN Loops under the Subclavan Artery. POSTERIOR VIEW ANTERIOR VIEWImage adapted from Gray’s Anatomy for students
RLN Partially damaged Unilateral Bilateral Completely severed Unilateral Bilateral The action of the adductors overpower that of the single abductor muscle (SEMON’S LAW), this causes the affected vocal cord to adopt a MIDLINE ADDUCTED POSITION Both vocal cords will be adducted, and the patient will experience STRIDOR; harsh high-pitched wheezing The innervation to the intrinsic muscles supplied on one side is disrupted, resulting in paralysis of that vocal cord, which then adopts a PARAMEDIAN POSITION midway between adduction and abduction. Paralysis of both vocal cords results in complete loss of the voice (aphonia). Lack of muscle power to hold open the rima glottidis leads to breathing difficulties The RLN is at risk of damage during thyroid surgery. The left RLN is more prone to damage as it is longer and has a thoracic course.
1. Lesions of the left Recurrent Laryngeal nerve are more common than those of the right. 2. The internal laryngeal nerve is a continuation of the recurrent laryngeal nerves, that contains motor fibres 3. The inferior part of the larynx which lies below the vestibular folds is drained by the inferior deep cervical lymph nodes. TRUE FALSE TRUE FALSE TRUE FALSE TRUE  The left rln is longer and also has a thoracic course, (unlike the right rln, which stays within the neck) and is therefore more exposed and at greater risk of damage. FALSE  Remember, the VOCAL and not vestibular folds form the barrier between the two “lymphatic regions.” FALSE Don’t get confused between the internal and inferior laryngeal nerves. Remember internal is a branch of superior laryngeal nerve and enters the larynx superiorly through the thyrohyoid membrane, Inferior is the continuation of the RLN, it approaches the larynx inferiorly as indicated in the name.
4. The superior thyroid artery pierces the thyrohyoid membrane 5. Venous drainage of the larynx is via the superior and inferior laryngeal veins which accompany their respective arteries. FALSETRUE TRUE FALSE
•Attach at one end to a laryngeal cartilage and on the other to a bony structure that lies outside the larynx •Move the entire larynx as a whole unit •Originate from and insert into structures within the larynx •Move the individual laryngeal components that they attach to. •Responsible for movement of the vocal folds EXTRINSIC MUSCLES
Depress the hyoid/ larynxElevate the hyoid/larynx MYLOHYOID GENIOHYOID STYLOHYOID DIGASTRIC OMOHYOID STERNOTHYROI D THYROHYOID STERNOHYOID
MYLOHYOID GENIOHYOID ANTERIOR BELLY OF DIGASTRIC LARYNGEAL PROMINENCE POSTERIOR BELLY OF DIGASTRIC STYLOHYOID * Have a go at identifying the structures, and then click to reveal the labels *
STERNOHYOID STERNOTHYROID THYROHYOID OMOHYOID * Have a go at identifying the structures, and then click to reveal the labels *
ANTERIOR BELLY OF DIGASTRIC POSTERIOR BELLY OF DIGASTRIC OMOHYOID STERNOHYOID GENIOHYOID MYLOHYOID MANDIBLE HYOID BONE LARYNGEAL PROMINENCE ANSA CERVICALIS * Have a go at identifying the structures, and then click to reveal the labels *
•Originate from and insert into structures within the larynx •Responsible for movement of the vocal folds •Can be grouped according to this function TENSORS OF THE VOCAL FOLD HIGHER PITCH SOUND RELAXERS OF THE VOCAL FOLD LOWER PITCH SOUND ABDUCTORS OF THE VOCAL FOLD WIDER AIRWAY ADDUCTORS OF THE VOCAL FOLD NARROWER AIRWAY
ABDUCTORS OF THE VOCAL FOLD ADDUCTORS OF THE VOCAL FOLD TENSORS OF THE VOCAL FOLD RELAXERS OF THE VOCAL FOLD POSTERIOR CRICOARYTENOID MUSCLES TRANSVERSE ARYTENOID MUSCLE LATERAL CRICOARYTENOID MUSCLES CRICOTHYROID MUSCLES THYROARTENOID & VOCALIS MUSCLES OBLIQUE ARYTENOID MUSCLES
CRICOTHYROIDS ARE UNIQUE BECAUSE THEY ARE THE ONLY INTRINSIC MUSCLES THAT. . . • lie externally on the larynx (therefore seen on anterior view) •Stretch the vocal ligaments • Are innervated by the External Laryngeal nerve LATERAL VIEW Attaches the CRICOID ARCH (Anterolateral aspect)  INFERIOR BORDER and HORNS of the THYROID CARTILAGE ACTION: TILTS the thyroid cartilage DOWNWARDS and FORWARDS This action STRETCHES and TENSES the vocal ligament  generates a HIGHER-PITCHED sound With permission from Moore & Agur (3rd ed.) Intrinsic muscles
ACTION: ROTATE the ARYTENOIDS LATERALLY ABDUCTION OF THE VOCAL FOLDS OPENS the RIMA GLOTTIDIS * The ONLY ABDUCTORS of the vocal cords. * Bilateral paralysis of the PCAs (due to disruption of their nerve supply) Flaccid closure of the rima glottidis  SUFFOCATION! Attach the ARYTENOIDS (muscular processes) CRICOID LAMINA (posterior surface) During deep breathing or forced expiration, the PCAs abduct the vocal folds, rima glottidis is held widely open to allow passage of a greater volume of air through the larynx. With permission from Moore & Agur (3rd ed.)
ANTERIOR VIEW POSTERIOR VIEW CRICOTHYROI D MUSCLE POSTERIOR CRICOARYTENOID MUSCLES * Have a go at identifying the structures, and then click to reveal the labels *
Attach the ARYTENOIDS (muscular processes) ACTION: ROTATE the ARYTENOIDS MEDIALLY ADDUCTION OF THE VOCAL FOLDS This CLOSES the RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.) Intrinsic muscles
ARYEPIGLOTTIC MUSCLES - Continuations of the Qblique Arytenoids - Extend from the apices of the arytenoids to the epiglottic cartilage - They assist in pulling the epiglottis down to cover the laryngeal orifice and divert food into the pharynx during swallowing Attach the posterior aspect of one ARYTENOID BASE APEX of the CONTRALATERAL ARYTENOID ACTION: Cause the ARYTENOIDS to slide MEDIALLY ADDUCTION OF THE VOCAL FOLDS CLOSES the POSTERIOR RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.) Intrinsic muscles
This is the only unpaired muscle associated with the larynx •It lies deep to the OBLIQUE ARYTENOIDS and has the same action Attach the lateral aspect of one ARYTENOID Lateral aspect of the CONTRALATERAL ARYTENOID •PHONATION * •Sound production occurs when expired air from lungs passes through the vocal folds and causes them to vibrate, allowing the column of air directly above the folds to act as a resonating chamber • In order to generate a sound the vocal cords must be closely opposed, causing the rima glottidis to appear slit-like. The 3 adductor muscles achieve this. With permission from Moore & Agur (3rd ed.) Intrinsic muscles SUPERIOR VIEW
The Thyroarytenoid muscles form the main body of the vocal folds, and lies lateral to the vocal ligament Attaches posteriorly to the anterolateral surface of each arytenoid cartilage anteriorly, just behind the laryngeal prominence. ACTION: pulls the arytenoid cartilages FORWARD RELAX THE VOCAL LIGAMENT generate LOW-PITCHED SOUNDS VOCALIS- is the medial aspect of the Thyroarytenoid muscle- which is composed of finer fibres. - It inserts into the vocal fold along its length, and is thought to finely adjust the tension at these points to produce different tones. Functions in fine tuning of the sound produced. With permission from Moore & Agur (3rd ed.) Intrinsic muscles
1. The Cricothyroid muscle is classified as an extrinsic muscle 2. The Posterior Cricoarytenoids and the Lateral Cricoarytenoids attach to the same cartilages but have opposing functions 3. Vocalis is the lateral aspect of the Thyroarytenoid muscle that functions in fine tuning of the sound generated 4. The more taut the vocal cords the higher the pitch of the sound generated FALSE Don’t get confused between extrinsic and external. Remember what extrinsic actually means, and recall the fact that cricothyroid is intrinsic as it both originates from and inserts into laryngeal cartilages TRUE FALSE FALSETRUE TRUE FALSE FALSETRUE
• All the intrinsic muscles are innervated by the RECURRENT LARYNGEAL NERVE, except for the cricothyroid muscle, which is supplied by the EXTERNAL LARYNGEAL NERVE. • The Posterior Cricoarytenoid is the only ABDUCTOR of the vocal folds • The Thyroarytenoid forms the main body of the vocal folds and relaxes the vocal ligaments •The Cricothyroid is the only intrinsic muscles that lies externally on the larynx and that tenses the vocal ligaments 5. The Posterior Cricoarytenoid muscles abduct the vocal folds during forced expiration 6. The Sternothyroid muscles lie anterior to the sternohyoid muscles FALSETRUE TRUE FALSE
•The laryngeal cavity extends from the laryngeal inlet to the level of the cricoid cartilage • A coronal section of the larynx, shows the cavity to be hour-glass shaped • The constriction is formed from two folds; vestibular (superior) and vocal folds (inferior), which divide the cavity into 3 main compartments •VESTIBULAR FOLDS •VOCAL FOLDS •VESTIBULE •VENTRICLE •INFRAGLOTTIC CAVITY
Between the laryngeal inlet and the vestibular folds VESTIBULE VESTIBULAR FOLD VOCAL FOLD THYROID CARTILAGE VOCAL LIGAMENT THYROARYTENOID MUSCLE CRICOID CARTILAGE EPIGLOTTIS HYOID BONE CORONAL SECTION VENTRICLE The lateral recesses between the vestibular and vocal folds The region below the vocal folds INFRAGLOTTIC CAVITY Image adapted from Cunningham's Manual of practical anatomy. Vol. 2, Thorax, head and neck. 6th ed.
LARYNGEAL INLET VOCAL FOLDS VESTIBULAR FOLDS INFRAGLOTTIC CAVITY VESTIBULE LARYNGEAL VENTRICLE Borders: The epiglottis and the aryepiglottic folds Also known as the false vocal cords as they aren’t directly involved in phonation. The horizontal space between these 2 folds= RIMA VESTIBULI
A superior view of the larynx Pearly avascular appearance LARYNGEAL INLET VESTIBULAR FOLDS VOCAL FOLDS VALLECULAE ARYEPIGLOTTIC FOLDS EPIGLOTTIS Have a red vascular appearance CLINICAL RELEVANCE With permission from Moore & Agur (3rd ed.) RIMA GLOTTIDISRIMA VESTIBULI
1. The cavity that lies between the vestibular and vocal folds is called the 2. The (more inferior) vestibular folds appear pearly and avascular upon laryngoscopy. 3. The vestibular folds form the lateral borders of the laryngeal inlet 4. Identify the numbered structures on the coronal MRI section shown 1. Vestibule, 2. Vestibular fold 3. Laryngeal Ventricle, 4. Vocal fold, 5. Infraglottic cavity TRUE FALSE FALSE The lateral borders are formed by the aryepiglottic folds TRUE FALSE VESTIBULE VENTRICLE RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.)
• If you’re feeling confident move on to tackle the mock spotter. GOOD LUCK! • If you don’t feel quite ready, and want to review the material again, click here to return to the homepage
1. Name Structure A 2. How does this structure enter the larynx? 1. What is structure A’s origin? Left Recurrent Laryngeal Nerve It ascends in the groove between the trachea and the oesophagus and pierces the inferior constrictor of the pharynx to enter the larynx It is a branch of the Left Vagus A
1. Name structure B 2. What is it’s nerve supply 3. Describe structure B’s function Cricothyroid muscle External laryngeal nerve Cricothyroid muscles pull the thyroid cartilage forwards and downwards to stretch and tense the vocal ligament so a higher pitched sound is produced B
1. Name Structure C 2. Which vertebral levels does C lie opposite? 3. Name structure D 4. To which group of muscles does structure D belong Omohyoid muscle C3- C5 Thyroid Cartilage Infrahyoid musclesExtrinsic muscles C D
•A small transverse incision is made through the skin in the anterior neck, the infrahyoid muscles are moved laterally, and isthmus of thyroid gland is may need to be divided to gain access to the trachea. •A window is made in the 2nd and 3rd tracheal rings, to allow a tracheostomy tube to be inserted, and allow passage of air. • Tracheostomy are usually temporary, and the tube is removed after the required length of time. •However some patients require long-term or permanent tracheostomies. These patients are unable to vocalize as expired air will bypass the vocal folds.
RLN Partially damaged Unilateral Bilateral Completely severed Unilateral Bilateral The action of the adductors overpower that of the single abductor muscle (SEMON’S LAW), this causes the affected vocal cord to adopt a MIDLINE ADDUCTED POSITION Both vocal cords will be adducted, and the patient will experience STRIDOR; harsh high-pitched wheezing The innervation to the intrinsic muscles supplied on one side is disrupted, resulting in paralysis of that vocal cord, which then adopts a PARAMEDIAN POSITION midway between adduction and abduction. Paralysis of both vocal cords results in complete loss of the voice (aphonia). Lack of muscle power to hold open the rima glottidis leads to breathing difficulties The RLN is at risk of damage during thyroid surgery. The left RLN is more prone to damage as it is longer and has a thoracic course.
•The VALLECULAE and PIRIFORM FOSSAE are common sites for lodging of food on it’s passage to the pharynx. •Occasionally food or other foreign bodies may pass through into the laryngeal inlet, and become lodged above the vestibular folds. •This causes the laryngeal muscles to go into spasm, causing the vocal cords to tense and complete closure of the rima glottidis- preventing entry of air into the lungs. •Asphixiation will occur if the obstruction is not removed, so emergency action needs to be taken to open the airway. HEIMLICH MANOEVRE •This involves sudden compression of the patient’s abdomen, which elevates the diaphragm, causing compression of the air-filled lungs. This allows air to be expelled from the trachea • The force of this expired air is likely dislodge the obstruction
•Performed in emergency situations • If the airway is blocked above the level of the vocal folds by a foreign body, the membrane can perforated in the midline, to gain access into the infra-glottic cavity • This allows air (to bypass the obstruction) into the trachea and lower air passages. • Due it’s small size cricothyroid membrane puncture can only be a temporary intervention, it doesn’t allow for prolonged ventilation, and therefore should be followed by tracheostomy when possible or if needed
This procedure allows the interior of the larynx to be examined, and is useful in investigating problems of the voice, breathing , and swallowing. INDIRECT LARYNGOSCOPY:- • Relatively simple procedure that involves holding a laryngeal mirror against the soft palate at the back of the throat, allowing view through the inlet. DIRECT LARYNGOSCOPY • Fibre-optic laryngoscope is a flexible instrument that is usually inserted through the nose into the pharynx, useful when the mirror doesn’t give an adequate view. Can be used under local anaesthetic. • Rigid Laryngoscope is inserted into the mouth and larynx. It is used under general anaesthetic in operating theatres. The procedure allows for collection of tissue samples or removal of foreign bodies.
"Learning the Larynx"
"Learning the Larynx"

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"Learning the Larynx"

  • 2.
    : The larynxhas been broken down into sections. Choose the section that you would like to study by clicking on it Click if you wish to return to the home page at any time • UNDERLINED WORDS/BUTTONS: Click these to be taken to another page, where you can learn more about that structure Look out for Clinical Relevance buttons! • TEST YOURSELF! Observe the prosection photos throughout the package, and attempt to identify the structures before clicking to reveal the labels • Most sections have a self-assessment at the end to allow you to check how well you have revised!
  • 3.
  • 4.
    • Situated inthe anterior triangle of the neck • Extends from the tip of the epiglottis to the inferior border of the cricoid cartilage • It lies opposite the C3- C6 vertebrae • It’s bound by the Pretracheal layer of deep cervical fascia • It lies in the visceral compartment of the neck, along with the pharynx and oesophagus (posteriorly), thyroid, parathyroid glands and thymus and trachea (inferiorly) • Its location is relatively superficial so many of the laryngeal components are palpable! With permission from Moore & Agur (3rd ed.)
  • 5.
  • 6.
    1. AIRWAY PROTECTION 2. PHONATION 3. •The mostimportant function! • During swallowing the larynx should be •The epiglottis is pulled down to cover the laryngeal inlet and divert food into the pharynx during swallowing •The vocal folds => CLINICAL RELEVANCE
  • 7.
    1. AIRWAY PROTECTION 2. PHONATION 3. RESPIRATION •To generatesound the larynx must be •The vocal folds must be •The appears • Force of expired air from lungs  causes vibration of vocal folds . . .generating sound! CLINICAL RELEVANCE
  • 8.
    1. AIRWAY PROTECTION 2. PHONATION 3. RESPIRATION •To thelarynx must be • This is achieved by of the vocal folds appears CLINICAL RELEVANCE
  • 9.
    ISTHMUS OF THYROIDGLAND CRICOTHYROID MEMBRANE 1ST TRACHEAL RING CRICOID CARTILAGETHYROID CARTILAGE (LARYNGEAL PROMINENCE) GREATER HORN OF HYOID BONE BODY OF HYOID BONE THYROID GLAND •BODY OF HYOID BONE •CRICOTHYROID MEMBRANE •CRICOID CARTILAGE •LATERAL LOBE OF THYROID GLAND •1ST TRACHEAL RING •ISTHMUS OF THYROID GLAND •THYROID CARTILAGE •GREATER HORN OF HYOID BONE ANTERIOR TRIANGLE With permission from Moore & Agur (3rd ed.) * Have a go at identifying the structures, and then click to reveal the labels *
  • 10.
    C3 BIFURCATION OF THE COMMON CAROTIDARTERY SUPERIOR BORDER OF THYROID CARTILAGE C2 HYOID BONE C5 INFERIOR BORDER OF THYROID CARTILAGE C6 BEGINNING OF TRACHEA AND OESOPHAGUS (posteriorly) CRICOID CARTILAGE C4 VOCAL FOLDS (attach behind the laryngeal prominence) With permission from Moore & Agur (3rd ed.)
  • 11.
    A term whichrefers to the supportive framework of the larynx, which is primarily responsible for maintaining the shape of the organ. It consists of nine cartilages joined by a series of ligaments and membranes, and reinforced by a selection of muscles HYOID BONE TRACHEA THYROID CARTILAGE CLINICAL RELEVANCE
  • 12.
    • It’s notactually classified as part of the larynx but is still very important! • A horse-shoe shaped bone • It’s suspended in the neck by ligaments and muscles, and doesn’t articulate with any other bones or cartilages MAJOR HORNS MINOR HORNSBODY OF HYOID BONE ANTERIOR VIEW
  • 13.
    CARTILAGES OF THE LARYNX Dividedinto 2 groups POSTERIOR VIEW EPIGLOTTIC THYROID ARYTENOIDS CRICOID •THYROID CARTILAGE •CRICOID CARTILAGE •EPIGLOTTIC CARTILAGE •ARYTENOID CARTILAGES •CORNICULATE CARTILAGES •CUNEIFORM CARTILAGES
  • 14.
    • The largestcartilage in the laryngeal skeleton OBLIQUE LINE •Site for attachment for: •Thyrohyoid muscle, •Sternohyoid • Inferior constrictor of the pharynx. LARYNGEAL PROMINENCE • Formed by fusion of the laminae in the midline • Angle of approx. •90O in males •120O in females. • The vocal ligament attaches just behind this SUPERIOR HORN THYROID LAMINAE • 2 flat quadrilateral plates INFERIOR HORN Articulates with the cricoid cartilage at the CRICOTHYROID JOINTS Image adapted from Gray’s Anatomy for students
  • 15.
    HYOID BONE THYROHYOID MEMBRANE CRICOIDCARTILAGE CRICOTHYROID MEMBRANE INFERIOR HORN ATTACHMENT OF VOCAL FOLDS LARYNGEAL PROMINENCE INFERIOR THYROID NOTCH ANTERIOR VIEW POSTERIOR THYROID LAMINA SUPERIOR THYROID NOTCH SUPERIOR HORN •INFERIOR THYROID NOTCH •THYROID LAMINA •ATTACHMENT OF VOCAL FOLDS •INFERIOR HORN •SUPERIOR THYROID NOTCH •LARYNGEAL PROMINENCE * Have a go at identifying the structures, and then click to reveal the labels *
  • 16.
    ARCH (anterior) The onlycartilage to form a complete ring around the airway • Is both stronger and thicker than the thyroid cartilage •Signet-ring shaped LAMINA (posterior) •“signet” aspect is wider •the arytenoid cartilages sit on top FACETS (lateral aspects) Articulate with the Inferior horns of the thyroid cartilage The lobes of thyroid gland also attaches to it’s lateral surface1st TRACHEAL RING CRICOTRACHEA L MEMBRANE POSTEROLATERAL VIEW Image adapted from Gray’s Anatomy for students
  • 17.
    ANTEROLATERAL VIEW POSTERIORVIEW VOCAL PROCESSES (attachment of vocal ligaments) ARCH (anterior) LAMINA (posterior) ARYTENOID CARTILAGES •CRICOID ARCH •CRICOID LAMINA •VOCAL PROCESS •ARYTENOID * Have a go at identifying the structures, and then click to reveal the labels *
  • 18.
    • A leaf-shapedelastic cartilage located posterior to the hyoid bone and the root of the tongue • Forms the superior margin of the laryngeal inlet The broad SUPERIOR ASPECT of the cartilage is free EPIGLOTTIC CARTILAGE attaches to: Thyroid cartilage via THYROEPIGLOTTIC LIGAMENT Hyoid bone via HYOEPIGLOTTIC LIGAMENT SAGITTAL SECTIONImage adapted from Clinical Voice Disorders 3rd ed. Arytenoid cartilages (posteriorly) via QUADRANGULAR MEMBRANE
  • 19.
    CRICOARYTENOID JOINTS:- •These allow tilting,sliding and rotationof the arytenoid cartilages anteriorly, posteriorly, laterally and medially •Each movement causes a change in the length, tension and position of the vocal folds and therefore has an impact on laryngeal functionSAGITTAL SECTION • These triangular-based pyramidal structures have a posterior location, and sit on the lamina of the cricoid cartilage • Don’t be fooled by their small size- they’re very important structures! * EACH ARYTENOID HAS 4 SURFACES * BASE Articulates with the cricoid lamina at the cricoarytenoid joints Image adapted from Clinical Voice Disorders 3rd ed.
  • 20.
    MEDIAL SURFACE Smooth and covered with mucous membrane ANTEROLATERAL SURFACE Sitefor attachment of •Vestibular ligament •Thyroarytenoid and vocalis muscles POSTERIOR SURFACE attachment of • Transverse arytenoid • Oblique arytenoid muscles SUPERIOR VIEWTHYROID CARTILAGE VOCAL LIGAMENT CRICOID CARTILAGE
  • 21.
    • Each Arytenoidcartilage has 3 KEY PROJECTIONS VOCAL PROCESS Site for posterior attachment of vocal ligament MUSCULAR PROCESS Site of attachment of • Lateral cricoarytenoid • Posterior cricoarytenoid muscles APEX •Articulates with the corniculate cartilages above • Attaches to the aryepiglottic fold. Image adapted from Clinical Voice Disorders 3rd ed. SAGITTAL SECTION
  • 22.
    VOCAL PROCESSES APEX MUSCULAR PROCESSES Knowledge of theseprojections is key to understanding the actions of the intrinsic muscles involved in movement of the vocal folds CRICOID CARTILAGE SUPERIOR VIEW LATERAL VIEW POSTERIOR ANTERIOR * Have a go at identifying the structures, and then click to reveal the labels *
  • 23.
    • These arethe smallest cartilages and are of no major functional importance. CORNICULATES Lie on the apices of the arytenoid cartilages CUNEIFORMS Are suspended in the mucous membrane of the aryepiglottic folds ARY-EPIGLOTTIC FOLD
  • 24.
    MEMBRANES OF THE LARYNX THYROHYOID CRICOTHYROID HYOEPIGLOTTIC & THYROEPIGLOTTIC QUADRANGULAR VOCALLIGAMENT ARYEPIGLOTTIC LIGAMENT (superior) VESTIBULAR LIGAMENT (inferior)
  • 25.
    • It attachesthe superior border of the thyroid cartilage with the hyoid bone MEDIAN THYROHYOID LIGAMENT The thickened central portion of the membrane Penetrated by • superior laryngeal artery LATERAL THYROHYOID LIGAMENT The lateral aspect of the membrane Back to membranes Image adapted from Gray’s Anatomy for students
  • 26.
    • It attaches.. . ANTERIORLY along the inferior border of the thyroid cartilage INFERIORLY along the superior border of the cricoid arch POSTERIORLY to the vocal processes of the arytenoid cartilages It’s thickened FREE UPPER MARGIN forms the VOCAL LIGAMENT; the skeleton of the vocal fold. It runs from the junction behind the laryngeal prominence to the vocal processes. The horizontal space between the 2 vocal folds = RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.) CLINICAL RELEVANCE Back to membrane s
  • 27.
    Attaches the sides ofthe epiglottis  lateral aspects of the arytenoid cartilages It’s Free INFERIOR MARGINS VESTIBULAR LIGAMENTS VESTIBULAR FOLDS It’s Free SUPERIOR MARGINS ARYEPIGLOTTIC LIGAMENTS ARYEPIGLOTTIC FOLDS With permission from Moore & Agur (3rd ed.) Back to membran es
  • 28.
    1. The cuneiformcartilages articulate with the corniculate cartilages 2. Only sliding movements of the arytenoid cartilages are possible at the cricoarytenoid joints. 3. In emergencies when there is obstruction of the larynx above the vocal folds, the thyrohyoid membrane can be punctured to allow air into the airways 4. The lateral lobes of the thyroid gland lie on the cricoid cartilage 5. The tip of the epiglottis extends above the hyoid bone FALSE  they actually are isolated, and don’t make contact with any cartilages or bony structures, instead they are suspended in the ary-epiglottic fold. FALSETRUE FALSETRUE FALSETRUE TRUE FALSE TRUE FALSE
  • 29.
    ARTERIAL SUPPLY SUPERIOR LARYNGEAL ARTERY INFERIORLARYNGEAL ARTERY VENOUS DRAINAGE INFERIOR LARYNGEAL VEIN SUPERIOR LARYNGEAL VEIN LYMPHATIC DRAINAGE INFERIOR DEEP CERVICAL NODES SUPERIOR DEEP CERVICAL NODES
  • 30.
    SUPERIOR LARYNGEAL SUPERIOR THYROID EXTERNAL CAROTID COMMON CAROTID INFERIOR LARYNGEAL INFERIOR THYROID THYROCERVICAL TRUNKSUBCLAVIAN ARCH OF AORTA Ascendsin the groove between the trachea and the oesophagus with the Recurrent Laryngeal nerve and then passes deep to the inferior constrictor of the pharynx Image adapted from Gray’s Anatomy for students
  • 31.
    The venous drainageof the larynx is through the SUPERIOR and INFERIOR LARYNGEAL VEINS which accompany their respective arteries They ultimately drain into the the left and right INTERNAL JUGULAR VEIN  BRACHIOCEPHALIC VEINS
  • 32.
    VOCAL FOLDS RIMA GLOTTIDIS=horizontal space between the two vocal cords THE GLOTTIS = the vocal apparatus of the larynx comprised by the VOCAL CORDS and RIMA GLOTTIDIS LYMPH VESSELS surrounding the vocal folds are sparse. As a result patients with CARCINOMA OF THE GLOTTIS often have a good prognosis as there is a reduced chance of metastasis through the lymphatics, and hoarseness is an early and easily identifiable symptom. The part of the larynx BELOW the VOCAL FOLDS drains into the INFERIOR DEEP CERVICAL NODES The part of the larynx ABOVE the VOCAL FOLDS drains into the SUPERIOR DEEP CERVICAL NODES
  • 33.
    MEDULLA JUGULAR FORAMEN VAGUS (CNX) INFERIOR VAGAL GANGLION SUPERIOR VAGAL GANGLION COMMON CAROTID ARTERY INTERNAL JUGULAR VEIN SUPERIOR LARYNGEAL NERVE INTERNALLARYNGEAL NERVE Provides fibres to the mucosa ABOVE the level of the VOCAL FOLDS Provides fibres to the cricothyroid muscle EXTERNAL LARYNGEAL NERVE The nerve supply to the larynx comes from the and the , both are branches of the Vagus (CNX) RECURRENT LARYNGEAL NERVE
  • 34.
    • After looping,both RLNs ascend between the trachea and oesophagus • They pierce the inferior constrictor of the pharynx to enter the larynx • They continue as the inferior laryngeal nerves to provide the MOTOR SUPPLY to all the intrinsic muscles of the larynx except the Cricothyroid muscles •Provide SENSORY FIBRES to mucosa BELOW the VOCAL FOLDS. Loops under the Arch of the Aorta, posterior to the Ligamentum Arteriosum LEFT RLN RIGHT RLN Loops under the Subclavan Artery. POSTERIOR VIEW ANTERIOR VIEWImage adapted from Gray’s Anatomy for students
  • 35.
    RLN Partially damaged Unilateral Bilateral Completely severed Unilateral Bilateral The actionof the adductors overpower that of the single abductor muscle (SEMON’S LAW), this causes the affected vocal cord to adopt a MIDLINE ADDUCTED POSITION Both vocal cords will be adducted, and the patient will experience STRIDOR; harsh high-pitched wheezing The innervation to the intrinsic muscles supplied on one side is disrupted, resulting in paralysis of that vocal cord, which then adopts a PARAMEDIAN POSITION midway between adduction and abduction. Paralysis of both vocal cords results in complete loss of the voice (aphonia). Lack of muscle power to hold open the rima glottidis leads to breathing difficulties The RLN is at risk of damage during thyroid surgery. The left RLN is more prone to damage as it is longer and has a thoracic course.
  • 36.
    1. Lesions ofthe left Recurrent Laryngeal nerve are more common than those of the right. 2. The internal laryngeal nerve is a continuation of the recurrent laryngeal nerves, that contains motor fibres 3. The inferior part of the larynx which lies below the vestibular folds is drained by the inferior deep cervical lymph nodes. TRUE FALSE TRUE FALSE TRUE FALSE TRUE  The left rln is longer and also has a thoracic course, (unlike the right rln, which stays within the neck) and is therefore more exposed and at greater risk of damage. FALSE  Remember, the VOCAL and not vestibular folds form the barrier between the two “lymphatic regions.” FALSE Don’t get confused between the internal and inferior laryngeal nerves. Remember internal is a branch of superior laryngeal nerve and enters the larynx superiorly through the thyrohyoid membrane, Inferior is the continuation of the RLN, it approaches the larynx inferiorly as indicated in the name.
  • 37.
    4. The superiorthyroid artery pierces the thyrohyoid membrane 5. Venous drainage of the larynx is via the superior and inferior laryngeal veins which accompany their respective arteries. FALSETRUE TRUE FALSE
  • 38.
    •Attach at oneend to a laryngeal cartilage and on the other to a bony structure that lies outside the larynx •Move the entire larynx as a whole unit •Originate from and insert into structures within the larynx •Move the individual laryngeal components that they attach to. •Responsible for movement of the vocal folds EXTRINSIC MUSCLES
  • 39.
    Depress the hyoid/ larynxElevatethe hyoid/larynx MYLOHYOID GENIOHYOID STYLOHYOID DIGASTRIC OMOHYOID STERNOTHYROI D THYROHYOID STERNOHYOID
  • 40.
    MYLOHYOID GENIOHYOID ANTERIOR BELLY OF DIGASTRIC LARYNGEAL PROMINENCE POSTERIOR BELLYOF DIGASTRIC STYLOHYOID * Have a go at identifying the structures, and then click to reveal the labels *
  • 41.
    STERNOHYOID STERNOTHYROID THYROHYOID OMOHYOID * Have ago at identifying the structures, and then click to reveal the labels *
  • 42.
    ANTERIOR BELLY OF DIGASTRIC POSTERIOR BELLYOF DIGASTRIC OMOHYOID STERNOHYOID GENIOHYOID MYLOHYOID MANDIBLE HYOID BONE LARYNGEAL PROMINENCE ANSA CERVICALIS * Have a go at identifying the structures, and then click to reveal the labels *
  • 43.
    •Originate from andinsert into structures within the larynx •Responsible for movement of the vocal folds •Can be grouped according to this function TENSORS OF THE VOCAL FOLD HIGHER PITCH SOUND RELAXERS OF THE VOCAL FOLD LOWER PITCH SOUND ABDUCTORS OF THE VOCAL FOLD WIDER AIRWAY ADDUCTORS OF THE VOCAL FOLD NARROWER AIRWAY
  • 44.
    ABDUCTORS OF THE VOCALFOLD ADDUCTORS OF THE VOCAL FOLD TENSORS OF THE VOCAL FOLD RELAXERS OF THE VOCAL FOLD POSTERIOR CRICOARYTENOID MUSCLES TRANSVERSE ARYTENOID MUSCLE LATERAL CRICOARYTENOID MUSCLES CRICOTHYROID MUSCLES THYROARTENOID & VOCALIS MUSCLES OBLIQUE ARYTENOID MUSCLES
  • 45.
    CRICOTHYROIDS ARE UNIQUE BECAUSETHEY ARE THE ONLY INTRINSIC MUSCLES THAT. . . • lie externally on the larynx (therefore seen on anterior view) •Stretch the vocal ligaments • Are innervated by the External Laryngeal nerve LATERAL VIEW Attaches the CRICOID ARCH (Anterolateral aspect)  INFERIOR BORDER and HORNS of the THYROID CARTILAGE ACTION: TILTS the thyroid cartilage DOWNWARDS and FORWARDS This action STRETCHES and TENSES the vocal ligament  generates a HIGHER-PITCHED sound With permission from Moore & Agur (3rd ed.) Intrinsic muscles
  • 46.
    ACTION: ROTATE the ARYTENOIDS LATERALLY ABDUCTIONOF THE VOCAL FOLDS OPENS the RIMA GLOTTIDIS * The ONLY ABDUCTORS of the vocal cords. * Bilateral paralysis of the PCAs (due to disruption of their nerve supply) Flaccid closure of the rima glottidis  SUFFOCATION! Attach the ARYTENOIDS (muscular processes) CRICOID LAMINA (posterior surface) During deep breathing or forced expiration, the PCAs abduct the vocal folds, rima glottidis is held widely open to allow passage of a greater volume of air through the larynx. With permission from Moore & Agur (3rd ed.)
  • 47.
    ANTERIOR VIEW POSTERIOR VIEW CRICOTHYROI DMUSCLE POSTERIOR CRICOARYTENOID MUSCLES * Have a go at identifying the structures, and then click to reveal the labels *
  • 48.
    Attach the ARYTENOIDS (muscularprocesses) ACTION: ROTATE the ARYTENOIDS MEDIALLY ADDUCTION OF THE VOCAL FOLDS This CLOSES the RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.) Intrinsic muscles
  • 49.
    ARYEPIGLOTTIC MUSCLES - Continuationsof the Qblique Arytenoids - Extend from the apices of the arytenoids to the epiglottic cartilage - They assist in pulling the epiglottis down to cover the laryngeal orifice and divert food into the pharynx during swallowing Attach the posterior aspect of one ARYTENOID BASE APEX of the CONTRALATERAL ARYTENOID ACTION: Cause the ARYTENOIDS to slide MEDIALLY ADDUCTION OF THE VOCAL FOLDS CLOSES the POSTERIOR RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.) Intrinsic muscles
  • 50.
    This is theonly unpaired muscle associated with the larynx •It lies deep to the OBLIQUE ARYTENOIDS and has the same action Attach the lateral aspect of one ARYTENOID Lateral aspect of the CONTRALATERAL ARYTENOID •PHONATION * •Sound production occurs when expired air from lungs passes through the vocal folds and causes them to vibrate, allowing the column of air directly above the folds to act as a resonating chamber • In order to generate a sound the vocal cords must be closely opposed, causing the rima glottidis to appear slit-like. The 3 adductor muscles achieve this. With permission from Moore & Agur (3rd ed.) Intrinsic muscles SUPERIOR VIEW
  • 51.
    The Thyroarytenoid musclesform the main body of the vocal folds, and lies lateral to the vocal ligament Attaches posteriorly to the anterolateral surface of each arytenoid cartilage anteriorly, just behind the laryngeal prominence. ACTION: pulls the arytenoid cartilages FORWARD RELAX THE VOCAL LIGAMENT generate LOW-PITCHED SOUNDS VOCALIS- is the medial aspect of the Thyroarytenoid muscle- which is composed of finer fibres. - It inserts into the vocal fold along its length, and is thought to finely adjust the tension at these points to produce different tones. Functions in fine tuning of the sound produced. With permission from Moore & Agur (3rd ed.) Intrinsic muscles
  • 52.
    1. The Cricothyroidmuscle is classified as an extrinsic muscle 2. The Posterior Cricoarytenoids and the Lateral Cricoarytenoids attach to the same cartilages but have opposing functions 3. Vocalis is the lateral aspect of the Thyroarytenoid muscle that functions in fine tuning of the sound generated 4. The more taut the vocal cords the higher the pitch of the sound generated FALSE Don’t get confused between extrinsic and external. Remember what extrinsic actually means, and recall the fact that cricothyroid is intrinsic as it both originates from and inserts into laryngeal cartilages TRUE FALSE FALSETRUE TRUE FALSE FALSETRUE
  • 53.
    • All theintrinsic muscles are innervated by the RECURRENT LARYNGEAL NERVE, except for the cricothyroid muscle, which is supplied by the EXTERNAL LARYNGEAL NERVE. • The Posterior Cricoarytenoid is the only ABDUCTOR of the vocal folds • The Thyroarytenoid forms the main body of the vocal folds and relaxes the vocal ligaments •The Cricothyroid is the only intrinsic muscles that lies externally on the larynx and that tenses the vocal ligaments 5. The Posterior Cricoarytenoid muscles abduct the vocal folds during forced expiration 6. The Sternothyroid muscles lie anterior to the sternohyoid muscles FALSETRUE TRUE FALSE
  • 54.
    •The laryngeal cavityextends from the laryngeal inlet to the level of the cricoid cartilage • A coronal section of the larynx, shows the cavity to be hour-glass shaped • The constriction is formed from two folds; vestibular (superior) and vocal folds (inferior), which divide the cavity into 3 main compartments •VESTIBULAR FOLDS •VOCAL FOLDS •VESTIBULE •VENTRICLE •INFRAGLOTTIC CAVITY
  • 55.
    Between the laryngealinlet and the vestibular folds VESTIBULE VESTIBULAR FOLD VOCAL FOLD THYROID CARTILAGE VOCAL LIGAMENT THYROARYTENOID MUSCLE CRICOID CARTILAGE EPIGLOTTIS HYOID BONE CORONAL SECTION VENTRICLE The lateral recesses between the vestibular and vocal folds The region below the vocal folds INFRAGLOTTIC CAVITY Image adapted from Cunningham's Manual of practical anatomy. Vol. 2, Thorax, head and neck. 6th ed.
  • 56.
    LARYNGEAL INLET VOCAL FOLDS VESTIBULARFOLDS INFRAGLOTTIC CAVITY VESTIBULE LARYNGEAL VENTRICLE Borders: The epiglottis and the aryepiglottic folds Also known as the false vocal cords as they aren’t directly involved in phonation. The horizontal space between these 2 folds= RIMA VESTIBULI
  • 57.
    A superior viewof the larynx Pearly avascular appearance LARYNGEAL INLET VESTIBULAR FOLDS VOCAL FOLDS VALLECULAE ARYEPIGLOTTIC FOLDS EPIGLOTTIS Have a red vascular appearance CLINICAL RELEVANCE With permission from Moore & Agur (3rd ed.) RIMA GLOTTIDISRIMA VESTIBULI
  • 58.
    1. The cavitythat lies between the vestibular and vocal folds is called the 2. The (more inferior) vestibular folds appear pearly and avascular upon laryngoscopy. 3. The vestibular folds form the lateral borders of the laryngeal inlet 4. Identify the numbered structures on the coronal MRI section shown 1. Vestibule, 2. Vestibular fold 3. Laryngeal Ventricle, 4. Vocal fold, 5. Infraglottic cavity TRUE FALSE FALSE The lateral borders are formed by the aryepiglottic folds TRUE FALSE VESTIBULE VENTRICLE RIMA GLOTTIDIS With permission from Moore & Agur (3rd ed.)
  • 59.
    • If you’refeeling confident move on to tackle the mock spotter. GOOD LUCK! • If you don’t feel quite ready, and want to review the material again, click here to return to the homepage
  • 60.
    1. Name StructureA 2. How does this structure enter the larynx? 1. What is structure A’s origin? Left Recurrent Laryngeal Nerve It ascends in the groove between the trachea and the oesophagus and pierces the inferior constrictor of the pharynx to enter the larynx It is a branch of the Left Vagus A
  • 61.
    1. Name structureB 2. What is it’s nerve supply 3. Describe structure B’s function Cricothyroid muscle External laryngeal nerve Cricothyroid muscles pull the thyroid cartilage forwards and downwards to stretch and tense the vocal ligament so a higher pitched sound is produced B
  • 62.
    1. Name StructureC 2. Which vertebral levels does C lie opposite? 3. Name structure D 4. To which group of muscles does structure D belong Omohyoid muscle C3- C5 Thyroid Cartilage Infrahyoid musclesExtrinsic muscles C D
  • 63.
    •A small transverseincision is made through the skin in the anterior neck, the infrahyoid muscles are moved laterally, and isthmus of thyroid gland is may need to be divided to gain access to the trachea. •A window is made in the 2nd and 3rd tracheal rings, to allow a tracheostomy tube to be inserted, and allow passage of air. • Tracheostomy are usually temporary, and the tube is removed after the required length of time. •However some patients require long-term or permanent tracheostomies. These patients are unable to vocalize as expired air will bypass the vocal folds.
  • 64.
    RLN Partially damaged Unilateral Bilateral Completely severed Unilateral Bilateral The actionof the adductors overpower that of the single abductor muscle (SEMON’S LAW), this causes the affected vocal cord to adopt a MIDLINE ADDUCTED POSITION Both vocal cords will be adducted, and the patient will experience STRIDOR; harsh high-pitched wheezing The innervation to the intrinsic muscles supplied on one side is disrupted, resulting in paralysis of that vocal cord, which then adopts a PARAMEDIAN POSITION midway between adduction and abduction. Paralysis of both vocal cords results in complete loss of the voice (aphonia). Lack of muscle power to hold open the rima glottidis leads to breathing difficulties The RLN is at risk of damage during thyroid surgery. The left RLN is more prone to damage as it is longer and has a thoracic course.
  • 65.
    •The VALLECULAE andPIRIFORM FOSSAE are common sites for lodging of food on it’s passage to the pharynx. •Occasionally food or other foreign bodies may pass through into the laryngeal inlet, and become lodged above the vestibular folds. •This causes the laryngeal muscles to go into spasm, causing the vocal cords to tense and complete closure of the rima glottidis- preventing entry of air into the lungs. •Asphixiation will occur if the obstruction is not removed, so emergency action needs to be taken to open the airway. HEIMLICH MANOEVRE •This involves sudden compression of the patient’s abdomen, which elevates the diaphragm, causing compression of the air-filled lungs. This allows air to be expelled from the trachea • The force of this expired air is likely dislodge the obstruction
  • 66.
    •Performed in emergencysituations • If the airway is blocked above the level of the vocal folds by a foreign body, the membrane can perforated in the midline, to gain access into the infra-glottic cavity • This allows air (to bypass the obstruction) into the trachea and lower air passages. • Due it’s small size cricothyroid membrane puncture can only be a temporary intervention, it doesn’t allow for prolonged ventilation, and therefore should be followed by tracheostomy when possible or if needed
  • 67.
    This procedure allowsthe interior of the larynx to be examined, and is useful in investigating problems of the voice, breathing , and swallowing. INDIRECT LARYNGOSCOPY:- • Relatively simple procedure that involves holding a laryngeal mirror against the soft palate at the back of the throat, allowing view through the inlet. DIRECT LARYNGOSCOPY • Fibre-optic laryngoscope is a flexible instrument that is usually inserted through the nose into the pharynx, useful when the mirror doesn’t give an adequate view. Can be used under local anaesthetic. • Rigid Laryngoscope is inserted into the mouth and larynx. It is used under general anaesthetic in operating theatres. The procedure allows for collection of tissue samples or removal of foreign bodies.

Editor's Notes

  • #17 mAYBE DELETE THE THYROID CARTILAGE/ CT MEMBRANE LABEL
  • #21 May want to delete
  • #54 Delete the first section?