Professional Documents
Culture Documents
of Larynx
1
Introduction
• What is this sound? What is Voice?
What is this sound? What is Voice?
2
• Voice
Voice is sound created by voice box present
is sound created by voice box present
in neck along with assistance from structures
in throat & mouth
in throat & mouth.
• U
Unit 5: Study the anatomy & physiology and
i 5 S d h & h i l d
diseases of the larynx.
3
Anatomy & Physiology of larynx
Anatomy & Physiology of larynx
• Larynx, commonly called VOICE BOX
• Located in front, in the middle of the
neck.
neck
p
• Perched on the top of the trachea
(windpipe).
4
5
Location
• The
The position of the larynx in the neck varies
position of the larynx in the neck varies
with age, gender, head position and
swallowing.
swallowing
• The length of larynx is about 44 mm in an
adult male and 36 mm in an adult female
adult male and 36 mm in an adult female.
6
Biological functions
• Protection of the airway
Protection of the airway
• Building intra‐thoracic pressure for excretion
and carrying out strenuous physical activities
d i t t h i l ti iti
Non biological functions
• Speech
• Singing
7
Anatomy of larynx
Anatomy of larynx
• Made of a bone, cartilages, muscles,
membranes and joints
membranes and joints.
• Hyoid bone supports larynx.
Front View
8
Hyoid (Bone)
Hyoid (Bone)
• U shaped single bone present above the thyroid
cartilage.
cartilage
• It is not connected to any other bone directly.
• Hyoid bone is supported by many muscles & it
can make variety of movements. 9
10
Hyoid (Bone)
Hyoid (Bone)
• Hyoid has 3 parts: a body and 2 pairs of horns.
• The 2 pairs of horns attach the Hyoid bone to
The 2 pairs of horns attach the Hyoid bone to
the Thyroid cartilage.
11
NOTE: ligament vs. cartilage vs.
tendon
• Ligament: Fibrous tissue that connects bones to other
bones.
bones
• Cartilage: Stiff yet flexible connective tissue found in
many areas in the body including the joints between
many areas in the body, including the joints between
bones. It is not as hard and rigid as bone but is stiffer and
less flexible than muscle.
• Tendon: Tough band of fibrous connective tissue that
usually connects muscle to bone and is capable of
withstanding tension. Tendons are similar to ligaments
12
24.02.2010
13
Cartilages
• 3 unpaired & 3 paired cartilages in larynx.
Cartilage N b
Number Location
Epiglottis single Behind the hyoid bone and base of the
tongue
Thyroid single Front of the neck in the midline
Cricoid single Above the trachea; below thyroid cartilage
Arytenoids paired Rests on the back surface of cricoid
cartilage
C i l t
Corniculates paired
i d R t on th
Rests the arytenoid
t id cartilages
til
Cuneiform paired Embedded in aryepiglottic folds
16
Thyroid (Cartilage)
Thyroid (Cartilage)
• Biggest cartilage in larynx present
in front & sides
in front & sides.
• Protects voice box in the front.
• 2 laminas (quadrangular plates of
cartilage‐1 on right side & 1 on
left side)
• Laminas join at midline to form
j
the thyroid prominence (Adam’s
pp ) Felt or seen on
apple in men) ‐
surface of the neck in most men.
17
Thyroid (Cartilage)
• 2 big horn‐like structures (greater
h
horns) to attach to the hyoid bone.
) h h h id b
• 2 small horns (lesser horns) to
attachment with Cricoid cartilage.
• Lesser horns attach Thyroid to Cricoid
y
through the Cricothyroid ligament &
y ( )j j
Cricothyroid (CT) joints. CT joints are
important for changing the pitch.
18
Cricoid (Cartilage)
Cricoid (Cartilage)
• It forms base of larynx .
• Attached to thyroid above through
Att h d t th id b th h
Cricothyroid ligament, Cricothyroid joints
& trachea belo b Cricotracheal
& trachea below by Cricotracheal
ligament.
• Ring shaped cartilage
• Front surface is thin, narrow (called Arch)
& back surface (known as Lamina) is
broad, thick and wide. Arytenoids are
present on the lamina of Cricoid
19
Arytenoids (Cartilage)
Arytenoids (Cartilage)
• These are paired, pyramid shaped
cartilages present on upper
il
margins of lamina of Cricoid
cartilage.
il
• Each Arytenoid has a base, an
apex & 3 surfaces.
• Vocal process present on the
p p
medial surface is an important
structure, because they form the
, y
posterior 1/3rd of true vocal folds.
20
Arytenoids (Cartilage)
Arytenoids (Cartilage)
• Arytenoids are attached to
the Thyroid in the front by
the Thyroid in the front by
Vestibular and Vocal
ligaments.
ligaments
• They are attached to Cricoid
through the Cricoarytenoid
h h h d
ligaments & joints.
• These ligaments & joints are
important for the opening &
closing of vocal folds.
21
22
Corniculates & Cuneiform
Corniculates & Cuneiform
• Corniculates: Small, paired, nodular structures
perched on apex of each arytenoids
perched on apex of each arytenoids.
• They may be 2 or even absent sometimes.
• Cuneiform: Small, paired, rod like structures
present above the Corniculates.
• Present in a few individuals
23
17 March 2010 CLASS
17 March 2010 CLASS
24
Joints/ ligaments of larynx
• C
Cartilages are connected to each other with the
til t dt h th ith th
help of joints, muscles and membranes.
25
Joints/ ligaments Connects Action
Cricothyroid Thyroid to Helps in changing the pitch of
ligament and joints Cricoid voice
26
Anatomy of vocal folds
Anatomy of vocal folds
• The
The important structures responsible for producing
important structures responsible for producing
voice (sound) are the vocal folds.
• There are 2 sets of vocal folds: Ventricular folds and
There are 2 sets of vocal folds: Ventricular folds and
True vocal folds.
• Their main function is protection of the lower
Th i i f i i i f h l
airway.
27
Ventricular folds/ False Vocal
Folds
• Pink
Pink in color & thick bands of mucous membranes
in color & thick bands of mucous membranes
with very few muscles, blood vessels & nerves.
• They start (originate) from the thyroid & attach
They start (originate) from the thyroid & attach
(insert) to the arytenoids cartilages at the back
through the Ventricular ligaments
through the Ventricular ligaments.
• Not suited for voice production as they are bulky
and do not have many muscles, blood vessels and
dd h l bl d l d
nerves.
28
True Vocal Folds/ Vocal folds
True Vocal Folds/ Vocal folds
• They are present just beneath the Ventricular folds.
• They originate from the Thyroid cartilage, in the
Th i i t f th Th id til i th
front and insert into the Arytenoid cartilages at the
back thro h the Vocal ligaments
back through the Vocal ligaments.
• The true vocal folds are light pink in color but on
laryngoscopy appear glossy white but the color
changes in clinical conditions.
• The space between the true vocal folds is called the
Glottis.
29
True Vocal Folds/ Vocal folds
True Vocal Folds/ Vocal folds
• VFs are made of mucous membranes, ligaments &
muscles ( blood vessels & nerve fibers)
muscles. ( blood vessels & nerve fibers)
• Under microscope, 5 different layers can be
identified:
identified
1. Epithelium
2. Superficial layer of Lamina propria (Reinke’s
space)
3. Intermediate layer of Lamina propria
4 Deep layer of Lamina propria
4. Deep layer of Lamina propria
5. Vocalis muscle 30
True Vocal Folds/ Vocal folds
Cross‐section
view
31
True Vocal Folds/ Vocal folds
True Vocal Folds/ Vocal folds
• Epithelium is the surface or the
is the surface or the "skin"
skin of the larynx
of the larynx
and it is continuous with the lining of mouth,
pharynx and trachea
pharynx and trachea.
•
• Lamina propria
L i i has 3 distinct layers, each with a
h 3 di i l h ih
different consistency. The Intermediate layer and
D
Deep layer of Lamina Propria forms the Vocal
l fL i P i f h V l
ligament.
32
True Vocal Folds/ Vocal folds
True Vocal Folds/ Vocal folds
• Superficial
Superficial layer
layer ‐ a jelly
a jelly‐like
like substance, close to the
substance close to the
surface
• Intermediate layer ‐
Intermediate layer an elastic, fibrous substance,
an elastic fibrous substance
like rubber bands
• Deep layer ‐
D l a thread‐like collagenous fiber layer
h d lik ll fib l
• Vocalis muscle is the main body of the vocal fold
and very stiff.
33
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34
Blood supply to Larynx
Blood supply to Larynx
• Blood
Blood supply is derived from laryngeal branches of
supply is derived from laryngeal branches of
superior & inferior thyroid arteries and cricothyroid
branch of the superior thyroid artery
branch of the superior thyroid artery.
35
(i) Superior thyroid artery
Branch of the superior thyroid
Branch
h of the superior thyroid
f th i th id
artery (branch of the external
carotid artery)
carotid artery)
• enters
enters the larynx through the
the larynx through the
thyrohyoid membrane (along
membrane (along
with the internal branch of the
superior laryngeal nerve)
superior laryngeal nerve)
• supplies the muscles and
supplies the muscles and
supplies the muscles and
mucous membranes in the
superior portion of the larynx
superior portion of the larynx
(ii) Inferior thyroid artery
(ii) Inferior thyroid artery branch of the inferior
branch of the inferior
thyroid artery (thyrocervical
thyroid artery ( thyrocervical trunk of the subclavian
trunk of the subclavian
artery)
• Ascends
Ascends on the trachea, together with the
on the trachea, together with the
recurrent
recurrent laryngeal nerve, and enters the larynx
laryngeal nerve and enters the larynx
from lower borders
• Supplies
S
Supplies the muscles and mucous membranes in
li the muscles and mucous membranes in
h l d b i
the lower part of the larynx
Blood supply to Larynx (Contd.)
Blood supply to Larynx (Contd.)
Figure in SLM
38
iii) Cricothyroid artery
iii)
iii) Cricothyroid
Branch of the superior
Branch of the superior
thyroid artery
thyroid artery
Passes across the superior
Passes across the superior
portion of the
portion of the cricothyroid
i f h cricothyroid
i h id
ligament
Lymphatic drainage
Lymphatic drainage
• The
The part of the larynx above the vocal folds is
part of the larynx above the vocal folds is
drained by vessels which accompany the superior
laryngeal vein pierce the thyrohyoid membrane
laryngeal vein, pierce the thyrohyoid membrane
and empty into the upper deep cervical lymph
nodes
• Whereas the zone below the vocal folds drains,
together with the inferior vein
together with the inferior vein.
40
ADDITIONAL INFORMATION
VENOUS DRAINAGE
superior and inferior laryngeal veins (follow the arteries in their course)
‐ superior drainage joins the superior and middle thyroid veins and then the
internal jugular
‐ inferior drainage joins the middle thyroid vein and the inferior thyroid vein,
inferior drainage joins the middle thyroid vein and the inferior thyroid vein,
which empties into the superior vena cava
LYMPHATIC DRAINAGE
larynx well supplied with lymphatics, with the exception of the free margins of the
vocal folds themselves
Superior group
‐ area of the larynx above the vocal cords is drained into the superior and middle
area of the larynx above the vocal cords is drained into the superior and middle
jugular nodes
Inferior group
‐ Drainage
Drainage is through the cricothyroid membrane to the middle and inferior jugular
is through the cricothyroid membrane to the middle and inferior jugular
nodes as well as to the paratracheal lymph nodes.
41
Nerve supply
Nerve supply
• It is from the Vagus by way of its superior and recurrent laryngeal branches.
• It descends lateral to the pharynx, behind the internal carotid, supply to the
cricothyroid muscle, divides into two main sensory and motor branches.
• External laryngeal nerve supplies the mucous membrane of the lower part of the
p y , pg
pharynx, epiglottis, vallecula and vestibule of the larynx, aryepiglottic fold, mucous
, y , y pg ,
membrane down to the level of vocal folds.
• Internal laryngeal nerve
ll l also carries fibers from neuromuscular spindles and other
l fb f l dl d h
stretch receptors in the larynx.
• Supplies the inferior constrictor muscle of the pharynx, and unites with an
g y g
ascending branch of the recurrent laryngeal nerve. This branch is called Gaten’s
anastomosis or loop and is purely sensory
• recurrent (inferior) laryngeal nerve on the right side leaves
the Vagus as the latter crosses the right subclavian artery and
then loops under the artery and ascends to the larynx,
between the oesophagus and trachea
• The nerve then divides into motor and sensory branches
• The motor branch supply all the intrinsic muscles of the
larynx with the exception of the cricothyroid
larynx with the exception of the cricothyroid.
• The sensory branch supplies the laryngeal mucous membrane
below the level of the vocal folds and also carries afferent
fib f
fibers from stretch receptors in the larynx.
h i h l
Membranes of larynx
Membranes of larynx
Laryngeal membranes Location
Mucous membrane (Ciliated Columnar Present in the entire larynx
Epithelium)
Cricovocal
C i l membrane
b (C
(Conus Originates
O i i t from
f Cricoid
C i id cartilage
til
Elasticus) and connects the Cricoid, Thyroid,
and Arytenoid cartilages together.
Inserts into the true vocal folds
44
Muscles of Larynx
Muscles of Larynx
• Extrinsic
Extrinsic muscles connect the larynx to the
muscles connect the larynx to the
surrounding structures. Intrinsic muscles
connect the laryngeal cartilages to each other
connect the laryngeal cartilages to each other.
Muscle Origin Insertion Action
Posterior Back surface of Back surface of the opens the glottis by
cricoarytenoid
y Cricoid lamina muscular pprocess of opening
p g the vocal folds
(PCA) Arytenoids
Lateral upper border of the Front surface of the closes the glottis by
cricoarytenoid Cricoid arch muscular process of the closing the vocal folds
(LCA) Arytenoids
Cricothyroid Front and sides of Thyroid lamina and Increases the length
(CT) the Cricoid arch lower horns of thyroid and tension of the vocal
folds
Vocalis inner surface of the Front surface and vocal Increases tension of
Thyroid process of Arytenoid vocal folds
Transverse Muscular process Muscular process closing the vocal folds
arytenoid of one Arytenoid of the opposite
y
Arytenoid
Oblique Muscular process Muscular process closing the vocal folds
arytenoid of one Arytenoid of the opposite
Arytenoid
Thyroarytenoi inner surface of the Front surface and vocal Relaxes the vocal folds
d Thyroid process of Arytenoid
Next Class
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47
Congenital disorders of larynx
Congenital disorders of larynx
Includes
1)) respiratory obstruction
b
2) Stridor
3) weakened or abnormal cry,
4) Dyspnea (shortness of breath)
(shortness of breath)
5) Tachypnea (rapid shallow breaths)
6)) Aspiration
i i
7) episodes of cyanosis (blue coloration due
deoxygenated hemoglob)
48
8) sudden death.
Laryngeal Stridor
Laryngeal Stridor
• High pitched sound resulting from turbulent air flow
in upper airway(inspiration)
in upper airway(inspiration).
• Indicative of serious airway obstruction from severe
conditions s ch as epi lottitis a forei n bod
conditions such as epiglottitis, a foreign body.
• During fetal development, the structures in the
larynx may not fully develop.
• Stridor is indicative of a potential medical
emergency and should always command attention
• It can resolves on its own, without medical
,
intervention (apparent until about the age of 5)
49
Laryngomalacia
• common anomaly (cause is unknown)
• due to a partial or complete collapse of supraglottic
due to a partial or complete collapse of supraglottic
structures on inspiration
• Symptoms:
9Stridor during inspiration which
worsens in the supine position,
feeding, agitation with Normal Phonation
g g
9 The symptoms may increase but usually resolves by
18‐24
18 24 mths of life without treatment.
mths of life without treatment.
9Tracheotomy ‐ in place for 2 years spont. recovery50
Vocal Fold Paralysis
Vocal Fold Paralysis
• Symptoms vary depending on whether unilateral or
p y
bilateral vocal cords paralyzed.
• Bilateral VC paralysis: CNS immaturity, lesions in
CNS, hydrocephalus, and birth trauma.
CNS, hydrocephalus, and birth trauma.
• Symptoms :
9I i t
9Inspiratory stridor at rest that worsens upon
t id t t th t
agitation in children
9Progressive airway obstruction
9Aspirations resulting in recurrent chest infections
p g
and a failure to thrive
51
Vocal Fold Paralysis
Vocal Fold Paralysis
• Unilateral Vocal Cord Paralysis: usually idiopathic,
tumors or vascular malformations iatrogenic injury
tumors or vascular malformations, iatrogenic injury
to the left recurrent laryngeal.
• Unilateral VC paralysis may manifest during the first
Unilateral VC paral sis ma manifest d rin the first
few weeks of life, or it may go unnoticed.
• Symptoms:
9Hoarse, breathy cry that is aggravated by agitation,
9Feeding difficulties
9Aspiration may occur
9Aspiration may occur
52
Congenital Subglottic Stenosis
Congenital Subglottic Stenosis
• Incomplete development during the third month of
gestation leads to different degrees of congenital
gestation leads to different degrees of congenital
subglottic stenosis
• Symptoms
9Respiratory stridor
(during inspiration &expiration)
9Barking cough
9Barking cough
9Cry is usually normal
9
9Prognosis is usually good. Most symptoms fade as
i i ll d f d
the baby matures. 53
Congenital Laryngeal Webs
Congenital Laryngeal Webs
• rare congenital anomalies due to Incomplete
development of the laryngotracheal tube during the
development of the laryngotracheal tube during the
third month of gestation
• Anter.ior margins of the true vf
Anter ior margins of the true vf’ss
• Symptoms:
• Stridor
• Aphonia, or mild hoarse or breathy cry that is
aggravated by agitation
• Feeding difficulties
Feeding difficulties
• Aspiration & Obstructive cyanosis 54
Vocal Nodules
• N
Nodules are tiny swellings on both the VFs.
d l ti lli b th th VF
• Excessive talking, shouting, screaming, constant
throat clearing, imitation of others voices
• noticed in children and women
• prevent the VFs from meeting in the midline &
cause air leak through the vocal folds.
cause air leak through the vocal folds.
• Symptoms:
9B th
9Breathy voice &/ Hoarse voice
i &/ H i
9tiredness on talking for a few minutes
9nodules will disappear when voice rest & voice
therapy 55
Vocal Polyps
Vocal Polyps
• Polyps are benign lesions of the larynx (mostly in
adult males)
adult males)
• located on the outer most surface of the vocal
folds & prevent the VFs from meeting in midline
folds & prevent the VFs from meeting in midline
• Symptoms
9Breathy voice &/ Hoarse voice
9Feeling of tiredness on talking for a few minutes
9Most polyps must be surgically removed
9Most polyps must be surgically removed
9Voice therapy after surgery is necessary. 56
Contact Ulcers
Contact Ulcers
• Contact ulcers are wearing away of the mucous
membrane over the VFs
• caused by voice abuse, pressed voice, hyperacidity,
respiratory ventilation.
respiratory ventilation.
• Symptoms:
9H
9Hoarse voice
i
9Pain while swallowing
9Pain while phonation/ speaking
9Voice
Voice rest of a longer duration will improve the
rest of a longer duration will improve the
condition. 57
Laryngitis
• Laryngitis is inflammation (tenderness, redness, &
swelling)
• Due to viral infection or vocal abuse/overuse.
• Symptoms:
9Change in voice
9Hoarse voice
9Decreased loudness
9Decreased loudness
9Depending on the cause, treatment varies.
• Voice rest, cough suppressants, and steam
inhalations relieve symptoms. 58
Dysphonia Plica Ventricularis
(Ventricular Dysphonia)
• When the functions of the true VFs are affected,
ventricular folds (false folds) vibrate
i l f ld (f l f ld ) ib
• Paralysis of true vocal folds, vocal abuse, and severe
laryngitis cause ventricular dysphonia.
• Symptoms
y p
9Harsh voice
9Excessive low pitched voice
9Excessive low pitched voice
• Voice rest and voice therapy can relieve the
symptoms.
t
59
Spasmodic Dysphonia (SD)
Spasmodic Dysphonia (SD)
• Caused by involuntary movements of one or more
muscles of the larynx
muscles of the larynx
• Cause is unknown, often noticed after URTI
infections vocal abuse and/ stress
infections, vocal abuse and/ stress
• 3 major types of SD:
1. Adductor type (spasm of the VFs causes strained,
strangled and effortful voice)
2. Abductor type (laryngeal spasms results in sudden
spurts of whispered/breathy voice)
3. Mixed type (laryngeal spasms causes sudden strained,
strangulated voice along with spurts of breathiness) 60
Gastro Esophageal Reflux Disorder
Gastro Esophageal Reflux Disorder
• Caused by the abnormal reflux of the stomach acid
contents into the pharyngeal region
contents into the pharyngeal region
• Mucosa of the pharynx and larynx may be damaged
causing various symptoms
causing various symptoms
• Symptoms:
9 Heart burn
9Swallowing difficulties
9Regurgitation of stomach acid
9Nausea & Chest pain
9Nausea & Chest pain
9Hoarse/ Harsh voice 61
Laryngeal cancer
Laryngeal cancer
• Cancer can develop in any part of the larynx.
• 3 anatomic regions: the glottis, the supraglottis
(less common) and the subglottis (least frequent).
(less common) and the subglottis (least frequent).
Most laryngeal cancers originate in the glottis.
• Symptoms:
9Hoarse voice & Sore throat
9 Swallowing difficulties ‐ Lump
9Ear pain
9Persistent cough with Stridor
62
Laryngectomy
• Surgical removal of the larynx due
to cancer is termed as laryngectomy
to cancer is termed as laryngectomy.
• types
9 Total laryngectomy: complete removal of the larynx
9Hemi laryngectomy: partial removal of the larynx
• A laryngectomee is taught to speak using either, an
artificial larynx,
artificial larynx,
treacho‐esophegeal speech or
esophageal speech.
h l h
63
THANK YOU
THANK YOU
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