Anatomy & physiology of larynx - The Medical Post

Anatomy & physiology of larynx - The Medical Post

Anatomy & Physiology of Larynx Dr. Vishal Sharma

Larynx (anterior) Larynx (posterior) Larynx (posterior)

Larynx (lateral) Larynx (superior)

Larynx (superior) Larynx (sagittal section) Larynx (sagittal section)

Larynx (coronal section) Vocal fold

Vocal fold Laryngeal Cartilages 3 single & 3 paired Single

Paired Epiglottis

Arytenoid Thyroid Corniculate (Santorini)

Cricoid Cuneiform (Wrisberg)

Cartilages (anterior) Laryngeal Cartilages Cartilages (posterior)

Cartilages (posterior) Cartilage Histology Elastic: Epiglottis, corniculate, cuneiform &

apex of arytenoid. Little or no calcification. Hyaline: Thyroid, cricoid & remaining arytenoid. Calcify as age advances. Ossification begins by 25-30 yr & is completed by 60 yr.

Indirect Laryngoscopy Flexible Laryngoscopy LEFT

RIGHT Laryngeal cavity 1. Laryngeal inlet 2. Laryngeal Vestibule

3. Laryngeal Ventricle 4. Rima glottis 5. Subglottis Pediatric Larynx

Conical in shape & subglottis is narrowest part Positioned high (C3-C4) Moves higher during swallowing allowing simultaneous breathing & feeding Loose sub-mucosal tissues (swell up easily)

Soft cartilages that collapse easily Membranes & Ligaments Extrinsic: connect thyroid cartilage & epiglottis with

hyoid bone; cricoid cartilage with trachea. Intrinsic: connect cartilages of larynx to each other. Extrinsic

Thyrohyoid membrane

Hyoepiglottic ligament

Cricotracheal ligament

Intrinsic Intrinsic Intrinsic

1. Quadrangular membrane Ary-epiglottic ligament Vestibular ligament 2. Crico-vocal membrane Vocal ligament Cricothyroid membrane 3. Thyro-epiglottic ligament

Oncological Divisions A. Supraglottis: laryngeal inlet to apex of ventricle B. Glottis: apex of

ventricle to 10 mm below C. Subglottis: lower glottic border to lower cricoid border

Subsites A. Supraglottis: 1. Epiglottis 2. Aryepiglottic folds 3. Ventricular bands 4. Laryngeal Ventricle B. Glottis:

1. True vocal cords 2. Anterior commissure C. Subglottis

3. Posterior commissure Intrinsic Muscles A. Acting on vocal cords

Abduction Posterior crico-arytenoideus Adduction Lateral crico-arytenoideus Transverse inter-arytenoideus Thyro-arytenoideus externa Tension + lengthening Cricothyroid

Relaxation + shortening Vocalis Intrinsic Muscles B. Acting on laryngeal inlet

Opener Thyro-epiglottic Closer Oblique inter-arytenoideus Ary-epiglottic

Extrinsic Muscles Primary Elevators Stylopharyngeus Secondary Elevators

Mylohyoid Salpingopharyngeus Stylohyoid Palatopharyngeus Thyrohyoid

Geniohyoid Digastric Depressors

Sternohyoid Sternothyroid Omohyoid Posterior cricoarytenoid Lateral cricoarytenoid

Transverse Inter-arytenoid Cricothyroid

Thyroarytenoid externa + Vocalis Oblique Inter-arytenoid Spaces of Larynx

Reinkes space Pre-epiglottic space

Para-glottic space Communications Shape of Glottis

Shape of Glottis Quiet Respiration Forced Inspiration

Inspiration Shape of Glottis Normal voice

Whisper Normal phonation

Whisper Mucous Membrane Stratified squamous epithelium: Epiglottis (anterior surface + upper half of

posterior surface), upper part of aryepiglottic folds & vocal cords Pseudo-stratified ciliated columnar (respiratory) epithelium: Rest of laryngeal mucous membrane

Nerve Supply Superior Laryngeal Nerve: Internal: sensation to supraglottis & glottis External: motor to cricothyroid muscle

Recurrent Laryngeal Nerve: sensation to subglottis motor to all intrinsic muscles but cricothyroid Blood Supply

Arterial supply: Laryngeal br. of superior & inferior thyroid Venous drainage: Superior thyroid vein internal jugular vein Inferior thyroid vein innominate vein

Lymphatic Drainage Supraglottis: via thyrohyoid membrane into upper deep cervical nodes & thyroid gland Subglottis: via cricothyroid membrane into

pretracheal + lower deep cervical nodes Glottis: has no lymphatics Functions of Larynx 1. Protection of lower airway

2. Phonation (voice production) 3. Passage of air into lungs for respiration 4. Chest fixation by glottic closure Protection of lower airway

a. 3-level below-upward closure of: vocal cords ventricular bands aryepiglottic folds b. Cessation of respiration: mediated by glossopharyngeal nv & deglutition centre.

c. Cough reflex Voice Production 1. Voice activating air reservoir in lungs: affects voice intensity

2. Voice generation: affects voice pitch 3. Voice resonation: affects voice quality 4. Voice articulation: affects voice quality Voice Production

Neuro-chronaxic theory (?) Vibration of vocal fold muscles due to impulses generated from recurrent laryngeal nerves. Speed is regulated by acoustic center in brain.

Obsolete theory because: muscle contraction not so fast to produce vibrations even paralyzed vocal folds can produce phonation passive phonation occurs in excised larynges

Combined Aerodynamic & Myoelastic theory Proposed by Jan Willem van den Berg in 1958 Vocal cords kept approximated Subglottic blast of air opens vocal cords from below upwards &

causes their passive vibration, producing sound Muscle tension + Bernoulli's effect closes vocal cords below upwards Cycle repeated Aerodynamic myoelastic theory

(opening phase) Aerodynamic myoelastic theory (closing phase)

Stroboscopic examination Voice generation High pitch = short, thin, tense, less elastic vocal cords

Low pitch = long, bulky, relaxed, more elastic vocal cords Falsetto voice = tense vocal cords, only edge of vocal fold vibrates & body is relaxed, with small phonatory gap

Falsetto voice Vocal cord cross-section

Normal phonation Falsetto voice Glottis state in phonation

Voiceless (full air stream) Breathy voice (murmur) Slack voice Modal voice: maximum vibration, sweet spot Stiff voice

Creaky voice (restricted air stream) Glottalized (blocked air stream) Glottis state in phonation

Vocal Registers Vocal fry register: lowest vocal register Modal voice register: commonly used for speaking & singing Falsetto register: one octave higher than modal

voice register Whistle register: highest voice register. Used by female singers Musical notes & octaves

Guinness World records Georgia Brown (2006): Highest vocal range from G2 to G10 Highest vocal note (G10)

Adam Lopez (2002): Highest vocal note for male (C8) Tim Storms (2002): lowest vocal note (8 Hz = two octaves below lowest B on a piano)

Adam Lopez & Tim Storms Voice resonation Oral & pharyngeal cavity S

Nasal cavity M, N, Ng In rhinolalia clausa: M, N & Ng are uttered as B, D & G respectively In rhinolalia aperta: B, D & G are uttered as M, N & Ng

Organs of articulation Places of articulation Bilabial: both lips

Labio-Dental: lips + teeth Dental: teeth + tip of tongue Alveolar: alveolus + tip of tongue

Palatal: hard palate + tongue blade Retroflex: tongue tip + hard palate Velar: tongue base + soft palate Glottal: produced in glottis

Places of articulation Sound production Bilabial P, B, M, W Labio-Dental F, V;

Dental T, D Alveolar T, D, N, L, S, Z Palatal Ch, Chh, J, Jh, Y

Retroflex R, T, Th, D, Dh Velar K, Kh, G, Gh Glottal H, ?, uh-oh Chest fixation

Closure of glottis helps in raising intra-thoracic & intra-abdominal pressure required for: Coughing Vomiting

Defecation Micturition

Climbing Weight-lifting Labour

Thank You

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