DISEASES OF

LARYNX
 Anatomy and
Physiology of the
Larynx
1. m. digastric, anterior belly.
2. m. digastric, posterior belly.
3. hyodigastric membrane (sling).
4. m. mylohyoideus.
5. m. hyoglossus.
6. m. stylohyoid.
7. m. digastricus, posterior belly.
8. m. styloglossus.
9. m. stylopharyngeus.
10. m. middle pharyngeal constrictor.
11. m. inferior pharyngeal constrictor.
12. thyrohyoid membrane.
13. m. thyrohyoid.
14. m. sternohyoid.
15. m. sternothyroideus.
16. m. omohyoideus, superior belly.
17. m. omohyoideus, inferior belly.
18. m. omohyoideus, intermediate
tendon.
19. m. longus colli.
20. m. rectus capitis anterior major.
21. m. anterior scalene.
22. m. middle and posterior scalene.
23. m. levator anguli scapulae.
24. m. spenius capitis.
25. m. sternocleidomastoideus.
26. m. obliquus capitis superior.
27. m. obliquus capitis inferior.
28. m. trapezius (s. cucullaris).
29. m. deltoideus.
1. m. digastricus, anterior belly.
2. m. digastricus, posterior belly.
3. hyodigastric membrane.
4. m. mylohyoideus.
5. m. hyoglossus.
6. m. stylohyoid.
7. m. styloglossus.
8. m. stylopharyngeus.
9. m. geniohyoideus.
10. m. thyreohyoideus.
11. m. sternothyroideus.
12. m. inferior pharyngeal constrictor.
13. m. sternohyoideus.
14. m. omohyoideus, inferior belly.
15. m. omohyoideus, superior belly.
16. m. cricothyreoideus.
17. m. longus colli.
18. m. scalenus anterior.
19. m. scalenus medius.
20. m. scalenus posterior.
21. m. levator anguli scapulae.
22. m. splenius capitis.
1. m. orbicularis oris.
2. m. buccinator.
3. m. superior pharyngeal constrictor.
4. m. styloglossus.
5. m. stylopharyngeus.
6. m. middle pharyngeal constrictor
(ceratopharyngeus).
7. m. hyoglossus.
8. m. stylohyoideus.
9. m. thyreohyoideus.
10. m. inferior pharyngeal constrictor.
11. m. thyreohyoid membrane.
12. m. cricothyreoideus.
13. m. rectus capitis anterior major.
14. m. scalenus anterior.
15. m. scalenus media.
16. m. scalenus inferior.
17. m. levator anguli scapulae.
18. m. splenius capitis.
19. m. serratus posterior superior.
20. m. superior rhomboid.
21. m. trapezius.
22. m. supraspinatus.
23. m. sternothyreoideus.
1. subclavian artery.
2. internal thoracic artery.
3. transverse scapular artery.
4. transverse colli artery.
5. ascending cervical artery.
6. inferior thyroid artery.
7. common carotid artery.
8. superior thyroid artery.
9. maxillary artery.
10. inferior labial artery.
11. superior labial artery.
12. angular artery.
13. posterior nasal artery.
14. alares nasi arteries.
15. ophthalmic artery.
16. frontal artery.
17. supraorbital artery.
18. infraorbital artery.
19. deep temporal artery.
20. superficial temporal artery.
21. temporal artery, frontal branch.
• external jugular vein.
• occipital vein.
• ramus communicans
between
external and internal jugular
veins.
• internal jugular vein.
• anterior facial vein.
• labial vein.
• angular vein.
• temporal vein.
• ophthalmic vein.
• frontal vein.
• external carotid artery.
• posterior auricular artery.
• superficial temporal artery.
• transverse facial artery.
• Maxillary artery.
• submental artery.
• angular artery.
• frontal artery.
1. superior vena cava.
2. innominate vein.
3. right innominate vein.
4. right subclavian vein.
5. axillary vein.
6. external jugular vein.
7. internal jugular vein.
8. external cephalic vein.
9. internal cephalic vein.
10. middle jugular vein.
11. aortic arch.
12. innominate (brachiocephalic) artery.
13. right common carotid artery.
14. right subclavian artery.
15. axillary artery.
16. external carotid artery.
17. internal carotid artery.
18. superior thyroid artery.
19. lingual artery.
20. maxillary artery.
21. temporal artery.
22. posterior auricular artery.
23. occipital artery.
24. inferior thyroid artery.
25. transverse scapular artery.
26. transverse colli (cervicle) artery.
27. external thoracic artery.
1. common carotid artery.
2. internal carotid artery (s. cerebralis).
3. external carotid artery (s. facialis).
4. superior thyroid artery.
5. superior laryngeal artery.
6. lingual artery.
7. hyoid branch of lingual artery.
8. dorsal lingual artery.
9. maxillary artery.
10. sublingual artery.
11. deep lingual artery (s. artery ranina).
12. sphenopalatine artery.
13. superior palatine artery.
14. anterior ethmoidal artery.
15. posterior ethmoidal artery.
a) Frontal bone.
b) Nasal bone.
c) Lamina cribrosa.
d) Sphenoid sinus.
e) Hard palate.
f) Incisive canal.
g) Mandible.
h) Hyoid bone.
i) Superior concha.
k) Middle concha.
l) Inferior concha.
m) Auditory tube.
n) Soft palate (uvula).
o) Pharynx.
p) Tongue.
q) m. Genioglossus.
r) m. Geniohyoideus.
s) Epiglottis.
t) Superior thyreoarytenoid ligament.
u) Inferior thyreoarytenoid ligament.
v) Ventriculus larynges.
w) Thyroid cartilage.
x) Arytenoid cartilage.
y) Cricoid cartilage.
z) Esophagus.
LARYNGEAL EMBRYOLOGY

Laryngeal development
 3rd week
Respiratory primordium is derived from primitive foregut
 4th -5th weeks
Tracheoesophageal (TE) septum forms by fusion of (TE) folds
LARYNGEAL EMBRYOLOGY

Larynx develops from the 4th & 5th arches

Primitive laryngeal aditus is T-shaped with 3 eminences
 Hyobranchial eminence becomes the epiglottis
 2nd & 3rd eminence develops into the arytenoids
 Laryngeal lumen obliterates & then recanalize by the 10th week
 LARYNGEAL ANATOMY
Differences in Adults vs
Infants
 1/3 size at birth
 Narrow dimensions of
subglottis and glottis
subglottis is the narrowest
(4-5mm in diameter)
 Higher in the neck
C4 at birth vs C6-7 at 15 y/o
 Epiglottis is narrower
ANATOMY OF THE LARYNX
LARYNGEAL CARTILAGES:
 3 unpaired cartilages:
Thyroid
Cricoid
Epiglottis
 3 paired cartilages:
Artytenoid
Corniculate (of Santorini)
Cuneiform (of Wrisberg)
ANATOMY OF THE LARYNX

Cartilages
ANATOMY OF THE LARYNX
ANATOMY OF THE LARYNX

Sagital section of larynx

showing cricovocal and
quadrangular membranes and
boundaries of the preepiglottic
space
a) Body.
b) Hyoid bone, greater horn.
c) Hyoid bone, lesser horn.
d) Middle thyrohyoid ligament.
e) Lateral thyrohyoid ligament.
f) Thyroid cartilage.
g) Laryngeal prominence.
h) Superior horn (s. majora).
i) Cricoid cartilage.
k) Middle cricothyroid ligament.
l) Lateral cricothyroid ligament.
m), n) Annular cartilaginous rings of the
trachea, I et II.
ANATOMY OF THE LARYNX
LARYNGEAL JOINTS:
 Cricoarytenoid joint
 Cricothyroid joint
LARYNGEAL MEMBRANES:
 Extrinsec membranes:
Thyrohyoid membrane
Cricothyroid membrane
Cricotracheal membrane
 Intrinsec membranes:
Cricovocal membrane
Quadrangular membrane
 CRICOARYTENOID JOINT
True synovial joint
ANATOMY OF THE LARYNX
Coronal section
of the larynx.
Lower free edge
of the
quadrangular
membrane lies in
the false cord
while upper free
edge of the
cricovocal
membrane forms
the vocal
ligament.
Note formation of
conus elasticus
by the cricovocal
membranes of
two sites
a) Body.
b) Hyoid bone, greater horn.
c) Hyoid bone, lesser horn.
d) Lateral thyrohyoid ligament.
e) Superior horn of thyroid cartilage.
f) Thyroid cartilage.
g) Cricoid cartilage.
h) Arytenoid cartilage.
i) Corniculate cartilage (s. Santoriniana).
k) Epiglottis, crest.
l) Aryepiglottic membrane.
m) Membranous posterior wall of trachea.
n) Hyothyroidmembrane.
ANATOMY OF THE LARYNX
MUSCLES OF THE LARYNX
 There are two types
 INTRINSEC MUSCLES
Abductors: Posterior cricoarytenoid
Adductors: Lateral cricoarytenoid, Interarytenoid, Thyroarytenoid
Tensors: Cricothyroid, Vocalis
Opens laryngeal inlet: Thyroepiglottic
Closes laryngeal inlet: Interarytenoid, Aryepiglottic
 EXTRINSEC MUSCLES
Elevators: stylopharyngeus, salpingopharyngeus, palatopharyngeus,
thyrohyoid, mylohioid, digastric, stylohyoid, geniohyoid
Depressors: sternohyoid, sternotyroid and omohyoid
 MUSCLES OF THE
LARYNX
a) Epiglottis.
b) Aryepiglottic fold.
c) Thyroid cartilage (cut through).
d) mm. Aryepiglottic.
e) Corniculate cartilage.
f) Cuneiform cartilage.
g) Cricoid cartilage lamina.
h) Lateral ceratocricoideum ligament.
i) m. Posterior cricoarytenoideus.
k) Posterior cricoarytenoideus ligament.
l) m. Arytenoideus, transverse.
m) m. Arytenoideus, oblique.
 MUSCLES OF THE
LARYNX
a) Epiglottis.
b) Thyroid cartilage (cut through).
c) Cricoid cartilage.
d) Tracheal cartilage.
e) Corniculate cartilage.
f) Accessory muscle fascicles.
g) mm. Cricothyroid and inferior constrictor of pharynx.
h) m. Posterior cricoarytenoideus.
i) m. Lateral cricoarytenoideus.
k) m. Thyroarytenoideus.
l) m. Thyroepiglotticus.
m) m. Thyroarytenoideus.
n) mm. Oblique and transverse arytenoids.
o) m. Superior thyroarytenoid.
p) m. Aryepiglotticus.
INTRINSIC MUSCULATURE
ABDUCTION
ADDUCTION
THYROARYTENOID
POSTERIOR CRICOARYTENOID
LATERAL CRICOARYTENOID
CRICOTHYROID
INTERARYTENOID
ANATOMY OF THE LARYNX
CAVITY OF THE LARYNX
 Inlet of the larynx
 Vestibule
 Ventricle (sinus of larynx)
 Subglottic space (infraglottic larynx)
 Vestibular folds (false vocal cords)
 Vocal folds (true vocal cords)
 Glottis (rima glottidis)
 Cavity of the
Larynx
Supraglottic
a) Epiglottis.
b) Hyoid bone.
c) Thyroid cartilage.
d) Cricoid cartilage.
e) Ventricular fold.
f) Vocal fold.
Glottic g) Ventricle.
h) Vocalis muscle.
Subglottic i) Trachea.
ANATOMY OF THE LARYNX
Mucous membrane of the larynx
 Epithelium
 Mucous glands
Lymphatic drainage
 Above the vocal cords
Lymphatics which pierce the thyrohyoid membrane and go to upper deep
cervical nodes
 Below the vocal cords
Lymphatics which pierce the cricothyroid membrane and go to prelaryngeal
and pretracheal nodes and to the lower deep cervical and mediastinal
nodes.

Nerve supply
Motor: recurrent laryngeal nerve
Sensory:
 internal laryngeal nerve (above the vocal cords)
 recurrent laryngeal nerve (below the vocal cords)
INNERVATION
 INNERVATION

Neuroanatomy
ANATOMY OF THE LARYNX
Spaces of the Larynx:
1. Pre-epiglottic space or space of Boyer
2. Paraglottic space
3. Reinke-s space
Paraglottic and pre-epiglottic spaces communicates with each
other
 LARYNGEAL FUNCTION
Sphincteric function
Respiration
Phonation
Other
 Stabilizes the thorax by preventing exhalation
during lifting
 Compresses abdominal cavity during
coughing or straining
 PHONATION

Physical act of sound production by

means of passive vocal fold interaction
with the exhaled airstream
Pitch
Quality
Volume
 SOUND PRODUCTION
 Contraction of expiratory muscles
 Rise in subglottic air pressure
 Escape through glottis
 Closure
 PHONATION
Glottal puff
 Release of air as upper margins of TVC
separate
Phase delay
 Delay of closure between upper and lower
margins of TVC
Mucosal wave
 Horizontal and vertical components
 PHYSICAL EXAMINATION
Laryngeal mirror
fast, inexpensive
minimal equipment
 PHYSICAL EXAMINATION
Rigid Laryngoscopy
(70 or 90-degree telescope)
best optic image
magnifies
video documentation
 PHYSICAL EXAMINATION
Flexible fiberoptic nasolaryngoscope
well tolerated
Physiologic
video documentation
 PHYSICAL EXAMINATION
Videostroboscopy
allows apparent “slow motion” assessment of mucosal
vibratory dynamics
video documentation
LARYNGOTRACHEAL TRAUMA
Etiology:
 Automobile accidents
 Blow or kick in the neck
 Neck striking
 Strangulation
 Penetrating injuries

Pathology
 Haematoma and edema
 Pharyngeal and laryngeal mucosa tears
 Dislocation of cricoarytenoid joint
 Dislocation of cricothyroid joint
 Fractures of hyoid bones, thyroid and cricoid cartilages
 Fractures of upper tracheal rings
 Trachea may separate from the cricoid cartilage and retract into the
mediastinum
 MECHANISM OF INJURY
BLUNT TRAUMA
Neck in fully extended
position
Direct crushing impact
sandwiches larynx
against C-spine
 MECHANISM OF INJURY
BLUNT TRAUMA
Result from
 differential densities of
hard and soft tissue
 rotation around fixed
points (ligaments)
 MECHANISM OF INJURY
BLUNT TRAUMA - PEDIATRIC

Larynx situated higher in the neck

 Better protection by mandible
Fracture less common due to elasticity of
cartilaginous skeleton
Loose attachments of mucous membranes
increase soft tissue damage
 MECHANISM OF INJURY
PENETRATING TRAUMA

Mostly knife and gunshot wounds

KE=mv2: Degree of injury directly related to
velocity and mass of source
Vascular injury most common cause of
death
Stab wounds: difficult to determine depth
of injury
Important to rule out esophageal injury
 MECHANISM OF INJURY
THERMAL AND CHEMICAL TRAUMA

Hot and/or caustic gases usually produce severe

and sudden edema
Can produce delayed laryngeal damage and
delayed edema
Long-term injuries: infection, chondritis, fibrosis
and loss of mucosal integrity
 MECHANISM OF INJURY
INTUBATION TRAUMA

Immediate: Delayed:
 Glottic edema  Granuloma
 Mucosal laceration  Glottic web
 Dislocation of  Cricoarytenoid
arytenoid ankylosis
 Acquired stenosis
 Vocal cord paralysis
LARYNGOTRACHEAL TRAUMA
Clinical features
Respiratory distress, hoarseness, painful and
difficult swallowing, local pain, haemoptysis
External signs: bruises or abrasions, palpation is
painful, subcutaneous emphysema, fracture
displacement of thyroid and cricoid cartilage or
hyoid bone, bony crepitus, separation of thyroid
cartilage from the larynx or tracheea
Diagnostic evaluation
Indirect laryngoscopy
Direct laryngoscopy
X-rays
CT scan
Associated injury
 MANAGEMENT
CLASSIFICATION OF INJURY
(SCHAEFER , 1982)
Group I: Minor endolaryngeal hematoma, without fracture

Group II: Edema, hematoma, minor mucosal disruption, no exposed

cartilage, non displaced fracture on CT

Group III: Massive edema, mucosal tears, exposed cartilage, cord

immobility

Group IV: As with group III, with more than 2 fracture lines, or
massive trauma laryngeal mucosa

Group V: Complete laryngotracheal separation

 MANAGEMENT
OPEN EXPLORATION
 MANAGEMENT
OPEN EXPLORATION
 MANAGEMENT
OPEN EXPLORATION
LARYNGOTRACHEAL TRAUMA
TREATMENT:
Conservative
 Hospitalization and observation, voice rest, air humidified,
steroid therapy, antibiotics

Surgical
 Tracheostomy
 Open reduction: ideally 3-5 days after the injury

COMPLICATIONS:
Laryngeal stenosis
Perichondritis / Laryngeal abscess
Vocal cord paralysis
LARYNGOTRACHEAL TRAUMA