Posterior Commissure of the Human Larynx Revisited

*,John A. Tucker and *,Sean T. Tucker *yPhiladelphia, Pennsylvania

Summary: The existence of the posterior commissure (PC) of the human larynx has been disputed (Hirano M, Sato K,
et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:7075). The term posterior commissure has no relevance to anatomical structure. The term commissure means a joining together. The bilateral vocal folds never join at
their posterior ends. The posterior aspect of the glottis is a wall. The posterior lateral aspect of the posterior glottis is
also the lateral wall of the posterior glottis (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc.
1986;107:7075). This study is intended to clarify the development of anatomical and morphological aspects of the PC
in conjunction with a clinical classification of the larynx in sagittal view. This study uses human embryo and fetal
laryngeal sections from the Carnegie Collection of Human Embryos (the world standard) and whole organ laryngeal
sections from the Tucker Laryngeal Fetal Collection. Correlation of histologic and gross anatomical structure is
made with the Hirano et al atlas, the Vidic Photographic Atlas of the Human Body, and the ORahilly Embryonic Atlas.
Embryologic data clearly describe and illustrate the posterior union of the cricoid cartilage with formation of the PC.
The anatomical functional aspects of the posterior lateral cricoid lamina as the supporting buttress of the articulating
arytenoid cartilages are illustrated.
Key Words: StagesHistogenesis of cartilageInterstitial growthAppositional growth.

INTRODUCTION
The anterior commissure is easily recognized as the most anterior point of the glottic space,1,2 the most ventral attachment of
the true vocal folds to the thyroid cartilage, which is established
in the fourth and fifth months of development with completion
of the thyroid cartilage in the fetal period.
The concept of a posterior commissure (PC) has long been
a clinical impression based on the indirect and direct visual examination of the human larynx. The posterior glottic space is
clinically best visualized with the glottic larynx in abduction.
The posterior glottic and superior subglottic space then creates
an intraluminal v,2 that is, the median posterior wall (PC) and
the posterior lateral buttresses of the inner surface of the cricoid
cartilage. This, coupled with the abducted anterior glottic surface of the vocal processes and membranous vocal folds, creates the diamond glottic aperture.
The PC of the human larynx is represented anatomically by
the posterior union of the developing cricoid cartilage. It extends from the superior rim of the midposterior cricoid cartilage
through the glottic level to the lower limit of the posterior
portion of the cricoid lamina (Figure 1). Most organs are
formed of more than one germ layer. Interactions between
layers are necessary for successful morphogenesis.3
Prenatal development
In the Carnegie System of Classification, embryos are best
arranged in 23 stages in 8 weeks.4,5 Each stage is merely an
arbitrarily cut section through the time axis of the life of the

Accepted for publication December 9, 2008.

From the *Department of OtorhinolaryngologyHead and Neck Surgery, University of
Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and the yDepartment of
OtolaryngologyHead and Neck Surgery, Drexel University College of Medicine,
Philadelphia, Pennsylvania.
Address correspondence and reprint requests to John A. Tucker, Department of
OtolaryngologyHead and Neck Surgery, Drexel University College of Medicine,
219N, Broad Street, 10th Floor, Philadelphia, PA 19107. E-mail: office@phillyent.com
Journal of Voice, Vol. 24, No. 3, pp. 252-259
0892-1997/$36.00
2010 The Voice Foundation
doi:10.1016/j.jvoice.2008.12.006

organism. The embryonic period proper, the first eight postovulatory weeks of development is shown in relationship to the
fetal period (Graph 1). The fetus and older embryos are measured by their crown-rump lengths, which correspond to the
sitting height postnatally. The embryo, being approximately
30 mm in length at 8 weeks, is in the end of its embryonic
period. The fetal period originates during bone marrow production in the humerus.4,6
Cricoid development definitions
Primordium: the earliest discernible indication during
embryonic development of an organ or a part.
Accretionary growth: growth that causes increase in size
resulting from increase in the number of special cells by mitotic division.
Interstitial growth: growth occurring in the interior parts of
structures already formed or formingthe matrix.
Appositional growth: growth by addition at the periphery of
a particular structure or partthe perichondrium.
Commissure: a site of union of corresponding parts, a site of
junction, a joining together.
Histogenesis of cartilage
Embryologically, the entire connective tissue group arises from
morphologically similar mesenchymal cells. The cells secrete
the specialized components of the matrix which histologically
and biochemically characterize the tissue.
As cartilage first develops, the cells begin to separate from
one another by becoming active in secreting the fibers, mucopolysaccharides, and chondroitin sulfate, which characterize
the matrix cartilage. The accumulation of their secretion gradually forces them further and further apart until they come to
lie isolated from one another in the matrix they have produced. Such a method of increase or growth in humans is
known as interstitial growth. The formation of a matrix so
rigid that interstitial growth is limited takes place first centrally in an area of developing cartilage. When the center becomes too rigid for interstitial growth to continue,

John A. Tucker and Sean T. Tucker

Posterior Commissure of the Human Larynx

253

FIGURE 1. Gross illustration of the adult cricoid cartilage (Vidic

Collection).

appositional growth begins peripherally. This investing layer

of mesenchyme soon becomes specialized into a connective
tissue covering called the perichondrium. It is through the activity of the chondrogentic layer that the cartilage continues to
grow, peripherally by apposition. Thus, after interstitial
growth ceases in the matrix, the perichondrium becomes the
primary growth center.
Because cartilage is devoid of blood vessels and forms large,
compact masses, the nutritive fluid from the blood vessels in the
perichondrium must pass through the interstitial substance to
reach the cells. The interstitial substance is, thus, permeated
by the tissue fluids from the perichondrium. This appositional
ability of the perichondrium to form cartilage persists, although
latent, in the adult organism.
Posttraumatically or surgically, new cartilage in the adult
regenerates by metaplasia of the connective tissue. Further

GRAPH 1. The embryonic period properthe first eight postovulatory weeks of developmentis shown in relation to the fetal period.
Fetuses, and older embryos, are measured by their crown-rump length,
which corresponds to the sitting height postnatally. (Reprinted with
permission from Ref. 6 (p. 51).)

FIGURE 2. Median section through the pharyngeal region at stage

13 (4.5 mm). The respiratory diverticulum can be seen descending
from its origin in the foregut. Its close relationship with the heart is evident. The site of the tracheoesophageal septum is clearly visible. (Reprinted with permission from Ref. 5 (p. 520) [Carnegie Collection,
9297].)
metaplasia with ossification occurs with blood vessel and vascular connective tissue involvement of the cartilage.7
Laryngeal development
The respiratory primordium does not appear in the developing
human embryo before stage 11. In stage 13, a median section,

GRAPH 2. Graph showing several main features in laryngeal development during the second half of the embryonic period proper.
(Reprinted with permission from Ref. 15.)

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FIGURE 3. Stage 15: laryngeal primordium. Triangular condensation of undifferentiated mesenchyme around the respiratory canals
(Carnegie Collection, 8929).

Journal of Voice, Vol. 24, No. 3, 2010

FIGURE 5. Carnegie Collection: stage 19, 1390early union of the

dorsal ring and formation of the posterior commissure.
Materials
Carnegie Collection
Embryonic Stages

approximately 3 weeks old, with 4.5-mm crown rump length,

illustrates the respiratory diverticulum descending from its origin in the foregut. The tracheoesophageal septum is clearly
visible (Figure 2).

13
15
17
19
21

MATERIALS AND METHODS

This research is based on the examination of 12 serial section
specimens from the Carnegie Collection. Sections from nine
embryos, stages 1323, and four fetal specimens, 912 weeks,
were reviewed. In addition, 12 serial section fetal larynges from
the Tucker Collection, 1240 weeks, and one three-and-a-halfyear postnatal specimen were also studied. A total of 25 specimens were evaluated.
The stains of the Carnegie Collection included hemotoxin
and eosin, alum cocinal, azan and one treated with silver. The
Tucker fetal collection is unique in that many of the
celloidin-blocked specimens were specifically stained in
successive sections, not only with hemotoxin and eosin, but
also with elastic stains of Verhoff VanGeissen. The contrasting
specimens were then mounted side by side on the same
slide.
Of special importance are the stage 23 embryos of the Carnegie Collection that were previously studied in great detail by
Muller et al in 1980 through 1988.811 The Tucker Collection
has also been studied by G. Tucker Jr and J. Tucker, and multiple publication references are noted.2,6,10,12,13

23

Fetal
40 mm
41 mm
46 mm
54 mm

Embryo

Specimen Number

S
T
T
T
S
C
T
S
T
S

9297
8929
8789
1390
632
9614
9226
75
D122Silver
4525

S
T
S
T

6658
6361
1686
3990

Tucker Collection
Laryngeal Development
Sequence

Fetal

Fetal Age

LD8
LD9
LD18
LD2
LD51
LD5
LD25
LD7
LD48
LD20
LD29
LD52

C
S
C
S
C
T
C
C
S
C
C
C

12 wk
14 wk
16 wk
18 wk
20 wk
22 wk
24 wk
28 wk
30 wk
34 wk
38 wk
40 wk

Postnatal
LD50

312 y

Method of sectioning.
S Sagittal
T Transverse
C Coronal
FIGURE 4. Carnegie Collection: stage 17, 8789accretionary interstitial growth.

Method of staining.
Tucker Fetal Alternate H & E, V.G. was used for staining.

John A. Tucker and Sean T. Tucker

Posterior Commissure of the Human Larynx

255

FIGURE 6. Carnegie Collection: reconstruction of stage 20 with

dorsal union of the cricoid cartilage.
RESULTS
Cricoid cartilage
Cartilaginous development of the cricoid is prominent from
stages 15 through 23, weeks 48 (Graph 2). Stage 15 shows laryngeal primordium of poorly differentiated mesenchyme (Figure 3). The cricoid arises from a ventral blastomere in the area
of the future arch with condensation and accretionary interstitial growth at stage 17 (Figure 4), with lateral progression
through stage 18 to dorsal union of the ring with formation of
the PC of the cricoid at stage 19 (Figure 5). Furthermore, the
epithelial lamina is mature.11 The laryngeal inlet is closed.
A detailed reconstruction of stage 20 shows cricoid union in
the superior aspect of the cricoid lamina (Figures 6 and 7)
and histologic union of the cricoid lamina in coronal section
(stage 21). In stages 2122, interstitial and appositional peripheral growth is present within the cricoid and arytenoid cartilages (Figure 8).
Stage 23 is the end of the embryonic period proper. At the end
of the 8 weeks of the embryonic period, shifting of growth centers and appositional perichondral activity are well established
(Figure 9). At stage 23, in horizontal section and silver stain,

FIGURE 8. (A) Paramedian section of a stage 21 human embryo

(Carnegie Collection, 632). (B) Stage 21: lateral sagittal section of
the larynx. Both cartilaginous perichondral (appositional) growth
and interstitial cartilaginous growth are evident in the arytenoid and
cricoid cartilages of the larynx.

portions of the thyroid and cricoid cartilage as well as the thyroid gland are evident. On each side, the branching of the inferior laryngeal nerve is seen passing in the vicinity of the
cricothyroid joint and ending in the thyroarytenoid muscle
(Figure 10). The cricoid is the first and only laryngeal cartilage
to acquire adult form during the embryonic period proper
(Figure 11).4,5
Anatomical functional aspects of the cricoid
cartilage
The components of the larynx in sagittal view are summarized
in Graph 3.

FIGURE 9. Stage 23: end of the embryonic period proper. The body

FIGURE 7. Carnegie Collection: stage 21, 9614coronal section of

dorsal cricoid with union of the cricoid lamina.

of the hyoid, thyroid laminae, and cricoid cartilage are clearly visible,
as are the laryngeal cavity and the body of the laryngopharynx. The
submandibular and thyroid glands can be seen bilaterally. The thyrohyoid and sternothyroid muscles, and the oblique line of the thyroid
cartilage are indicated, as is the posterior cricoarytenoid muscle (transverse sections of No. 9226: Carnegie Collection). (Reprinted with permission from Ref. 5 (p. 520).)

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Journal of Voice, Vol. 24, No. 3, 2010

FIGURE 12. (A) Sagittal section of the fetus (Tucker Collection,

FIGURE 10. Stage 23: D122 (Carnegie Collection). Portions of
the thyroid and cricoid cartilages, as well as the thyroid gland, are evident. On each side, the anterior branch of the inferior laryngeal nerve
can be seen passing forward in the vicinity of the cricothyroid joint and
ending in the thyroarytenoid muscle.

14 wkLD9). (B) Adult gross specimen in sagittal section (Vidic Collection). The glottis is represented at the vocal process.

Transglottic structures
The arytenoid cartilage, cricoid cartilage, and thyroid cartilage
are all transglottic structures.
Supraglottis
The posterior supraglottis, the laryngeal inlet, or laryngeal vestibule is dominated by the interarytenoidus muscle, the superior
portion of the arytenoid cartilage and the aryepiglottic folds,
and epiglottis. Physiologically, the posterior supraglottis and
epiglottic complex are related to supraglottic closure with swallowing and squamous epithelium.

FIGURE 11. Stage 23: photograph of embryo (Carnegie

Glottis
The glottis is dominated by the anterior commissure to the
membranous portion of the vocal fold, the vocal process of
the arytenoid cartilage, the respiratory glottis, the mid-posterior
portion of the cricoid cartilage, and the wall (the PC). The PC is
a fixed site as is the anterior commissure and does not vary with
vocal fold mobility. In the sagittal section of the grossly
dissected adult larynx, it is clear that the arytenoid portion of
the glottis is represented by the vocal process (Figure 12).

Collection).

GRAPH 3. Sagittal view of larynx.

FIGURE 13. Sagittal section: four-month-old fetus (Carnegie Collection: 40 mm, 6658)the cricoid arytenoid articulation.

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Posterior Commissure of the Human Larynx

257

FIGURE 14. Newborn larynx. (A) Horizontal section midcricoid at level of inferior rim of thyroid ala illustrating the posterior V of the crytoid.
(B) Similar section at comparable levelpost intubation with pressure necrosis of the subglottic laryngeal mucosa. [Reprinted with permission from
Ref. 12 (pp. 8285).]

Subglottis
The cricoarytenoid joint is placed laterally in the superior portion of the subglottis resting on the cricoid lamina lateral to the
internal v of the dorsal union,2 the PC of the cricoid (Figure 13). The midsubglottis represents a thickened, posterior
lateral, supportive buttress of the cricoid arytenoid joint. Clinically, the internal surface buttress of the midsubglottis is the
most frequent site of endolaryngeal trauma and the eventual
potential subglottic stenosis (Figure 14).
The inferior subglottis has a more rounded to oval lumen
with a flattened lamina. The cricothyroid joint is placed laterally and externally and the arch is placed anteriorly. The inferior cricoid subglottis is a complete ring and, as such, is the
main supporting structure for the tracheal lumen. Further,
the cricoid lamina is also the origin of the supporting attachment of the laryngotracheal ligament and the tracheoesophageal septum.

This was an excellent and detailed, extensive study. The first

part was a photographic study of 20 specimens in neutral adduction and abduction. The second part was a histological evaluation of the structures of the posterior glottis in 28 specimens,
seven specimens in coronal section and three in sagittal section.
The number of specimens in transverse sections was not recorded. The authors pointed out that the anatomical definition
of the vocal folds, the structure between the anterior commissure and vocal process of the arytenoid, was well accepted.
The problem for the authors was to define the posterior glottis. Photographically, they included the arytenoid cartilage, the
wall, the cricoid cartilage, as well as the posterior and superior
structures, including the intraarytenoid muscles and other glandular, muscular, and mucosal elements (Figure 15).
By definition, the glottis is at the level of the vocal folds, and
therefore, is limited to that level from the anterior commissure
through the posterior wall of the cricoid. To include the

DISCUSSION
The existence of the laryngeal PC was questioned first by
Hirano et al in 1986. The title was The Posterior Glottis, an
anatomical study of excised human larynges.1

FIGURE 16. Fetus: Hirano, Atlasfetus weighing 3164 g found.

FIGURE 15. View of glottis from above during vocal fold abduction. AC, anterior commissure; TVPn, tip of vocal process in neutral
condition; TVP, tip of vocal process; PEVn, posterior end of ventricle
in neutral condition; MPW, midpoint of posterior wall. (Reprinted with
permission from Ref. 1 (p. 197).)

Transverse section, 2 mm below the glottis. Adult: Hirano, Atlas

57-year-old female: transverse section of posterior commissure at
the midpoint of cricoid laminae. (Reprinted with permission from
Hirano M, Sato K. Histological Atlas of the Human Larynx. Singular
Publishing Group, Inc.; 1993.)

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Journal of Voice, Vol. 24, No. 3, 2010

union of posterior cricoid laminae, the posterior commissure, the

cricoid spine. (G. Tucker, Jr., personal communication.) (Reprinted
with permission from Vidic Atlas of Human Body. CV Mosby; 1984.)

FIGURE 18. (A) Four-month-old fetussagittal section, illustrating

the laryngotracheal esophageal ligament (LTEL) just inferior to the
cricoid lamina (Carnegie Collection). (B) Seven-month-old fetus
sagittal section, X illustrating the laryngotracheal esophageal ligament.
(Reprinted with permission from Negus V. J Laryngol Otol. 1924.)

interarytenoidius muscle and supraglottis in the definition of the

posterior glottis is a misnomer as the interarytenoidius muscle
is anatomically a supraglottic structure. Hirano et als study
is, therefore, anatomically, a more inclusive and detailed evaluation of the entire posterior laryngeal inlet, both glottic and
supraglottic.
Histologic transverse sections of the cricoid cartilage clearly
illustrate the anatomical, PC, and intraluminal v of the posterior cricoid, glottic, and subglottic space (Figure 16).12

The median posterior wall is the point of union of the developing cricoid cartilage. Development occurs at stages 19
through 23, that is, 68 weeks of embryonic life. The PC itself
is fixed and extends to the height of the lamina of the cricoid
cartilage (Figure 17).
Dysgenesis of the cricoid cartilage at stages 1922 may create
a nonunion of the cricoid lamina and a partial or complete cricoid cleft.14,15 Extended clefts, laryngotracheal esophageal cleft
result with failure of the midline formation of the laryngotracheal

FIGURE 17. (A) Adult larynx posterior gross view. (B) Point of

FIGURE 19. (A) Transverse section of stage 23 embryo at the junction of the larynx and tracheasuperior to inferior-superior cricoid arch, tracheal
cartilage lumen, laryngotracheal esophageal ligament (X) and esophagus (Carnegie Collection: 9226). (B) Four year old. Endoscopic view of subglottic larynx cricoid arch and trachea, superior to inferior, cricoid arch, tracheal lumen, and laryngotracheal esophageal ligament (X).

John A. Tucker and Sean T. Tucker

Posterior Commissure of the Human Larynx

esophageal ligament, which extends to the upper one-third of the

tracheoesophageal septum and has its origin in the perichondrium
of the cricoid lamina16 (Figures 18 and 19).
In conclusion, the posterior end of the glottis is a wall (Hirano),1 the cricoid cartilage; the posterior median cricoid cartilage is also the developmental anatomical site of union of the
cricoid cartilage and the PC. It is a relevant, definitive, anatomical site, as is the anterior commissure and does not vary with
vocal fold mobility.
Acknowledgments
The authors wish to acknowledge the major contributions to
human laryngeal development by Professors Ronan ORahilly
and Fabiola Muller.
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Rhinol Laryngol. 1973;82:3-11.
3. ORahilly R, Muller F. Human Embryology and Teratology. Wiley-Liss Inc;
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4. ORahilly R, Tucker J. The early development of the larynx in staged
human embryos. Ann Otol Rhinol Laryngol. 1973;82(suppl 7):3-23.

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5. ORahilly R, Tucker J. Observations on the embryology of the human

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Staged Human Embryos and in Fetuses. Munich: Collegium, ORLAS;
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embryonic period proper: 2. The laryngeal cavity and the innervation of
its lining. Ann Otol Rhinol Laryngol. 1985;94:607.
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13. Tucker J, Tucker G, Vidic B. Clinical correlation of anomalies of normal human laryngeal development. Ann Otol Rhinol Laryngol. 1978;87:
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1984;93:422-427.
16. Fried M. The Larynx. Little Brown Co; 1988. 18 pp.