LARYNX

ANATOMY
Larynx (voice box) is divided into three
areas:
Supraglottic area epiglottis to
vestibule
glottic area - in between vocal
folds
subglottic area- 1 cm below true
vocal fold
*Larynx has a skeletal framework, mucosa
and muscles.
*True vocal fold - is the only squamous
epithelium
*Rest of larynx - respiratory epithelium
(ciliated
pseudostratified
columnar
epithelium)
CARTILAGES
Thyroid and Cricoid cartilage
Cricothyroid joint
Cricothyroid ligament area
for esophageal tracheostomy.
Arytenoids
Corniculate
Cuneiform cartilage
Hyoid Bone
Epiglottis
connected
to
thyroid
cartilage via thyroepiglottic ligament
Two joints of larynx
Cricothyroid joint
Cricoarytenoid joint - basis for
the key movement of the vocal fold
(Abduction and adduction of vocal
fold).
Cricothyroid membrane: location where
emergency tracheostomy is performed
(clinically); avascular.
2nd -4th tracheal ring:
elective tracheostomy.

location

for

MUSCLES
Two groups of muscles in larynx
I. Intrinsic - closes and opens the larynx,
regulates pitch of voice
Occur IN PAIRS
of interest in this topic
1) Posterior Cricoarytenoid Muscle

Ask the patient to sniff. It is maximally

stimulated when inhaling deeply and
opens up the glottis.
2) Lateral Cricoarytenoid Muscle
main adductor of larynx. Important when
you cough. Because before you cough,
you inhale, the vocal fold closes, and then
when
pressure
in
subglottic
area
overcomes the force of this muscle, this
opens up.
3)
Interarytenoid
(oblique
and
transverse arytenoids muscles)
4) Thyroarytenoid Muscle
5) Cricothyroid Muscle
- Lengthens the vocal folds, Increases
the pitch.
In transsexuals, mimic the action
of muscle. Suture the cricoid and
thyroid, and mimics the action of
this muscle increase the pitch by
a bit.
But the true vocal fold is elastic so
after sometime it would reverse to
original voice
(Refer to Table 17.1)
IMPORTANT POINTS
posterior cricoarytenoid muscles only abductor muscle (opens the glottis).
The rest are adductors (closes the glottis).
Main intrinsic muscle of the larynx during
inhalation.
cricothyroid muscle - only pair of
muscles innervated by Superior Laryngeal
nerve. The rest innervated by recurrent
laryngeal nerve. When it contracts it pulls
the thyroid cartilage anteriorly thereby
lengthening the vocal fold hence increase
in pitch.
interarytenoid muscle - only muscle
innervated
bilaterally
by
recurrent
laryngeal nerve. Other muscles are
innervated unilaterally
thyroarytenoid muscle (vocalis
muscle) main muscle for speech; when it
contracts. It makes the vocal cord thicker
therefore making the pitch lower
II. Extrinsic
- elevates and depresses the larynx

NERVE SUPPLY

Superior Laryngeal nerve

External
branch

innervates
cricothyroid muscle
Internal branch - sensory to the
larynx.
Recurrent Laryngeal nerve
- innervates the rest of intrinsic
muscles of
the larynx.
Cricothyroid cartilage emergency site of
tracheostomy
Cricoarytenoid joint
1) upward, lateral and posterior movement
2) Moves the vocal folds
Glottal tongue sound from larynx without
articulation; aah
BLOOD SUPPLY

Supraglottic and Glottic levels Superior

Laryngeal Artery
Subglottic level Inferior Laryngeal Artery
Venous Drainage: Inferior Thyroid Vein
SOUND PRODUCTION
***Phonation + articulation= speech
Phonation
- Function of larynx
- Production of raw sound
Articulation
- function of (vocal tract) lips. tongue, uvula,
palate. pharyngeal
muscle
- Molding of sound into words
How does the larynx produce sound?
- Sound is produced by vibration of vocal
cords.
- Must have two opposing forces
opening and closing of glottis
- thru actions of muscles and nerve of larynx
5 Steps
1) Vocal cords will approximate
2) Subglottic pressure increases leading to...
3) Opening of the glottis (it opens inferior to
superior)

4) Vocal cords close again as the pressure of

subglottic are drops due to the steady
stream of air that passes
5) The closing of vocal cords is due to:
a. vibration
b. elasticity of vocal cords
DIAGNOSTIC TESTS AND PE
DIAGNOSTICS
Indirect laryngoscopy
- open up mouth, examiner grasps the
protruded tongue, insert laryngeal mirror
- downside if the px has strong gag reflex, it
will be hard to do
Laryngeal telescope
- advantage: easier, brighter, view is
magnified;
- downside if the px has strong gag reflex, it
will be hard to do
- laryngeal telescope cost 2000$
Flexible fiberoptic laryngoscope
- flexible scope insert thru the nose
- flexible scope cost 10,000$
Direct microlaryngoscopy
- Main indication taking out nodules and
cyst in larynx
- px is put to sleep and the laryngoscope is
inserted thru the mouth.
- Under general anesthesia
- done for surgery of vocal cord and larynx
Laryngeal videostroboscopy
- observe the vibration of the vocal fold
through flashes of light.

- early lesions are detected

History and physical examination
Complaint or PE Laryngeal problem
findings
Hoarseness
because of problem
in phonation (think
of
structures involved
in phonation)
Difficulty of
breathing;
problem in
inspiration

due to the larynxs

anatomical function
in
airway protection

Cherry red
epiglottis
Dryness

Check hydration
history
Medications that
may cause dryness

Voice handicap index

- a questionnaire by which a px can rate the
severity of voice
problem
** Observe great care in PE to avoid spasm
GENERAL RULE IN MEDICINE: Function of
organ dictates its S/Sx