L.

Surgical anatomy of the larynx

The larynx is situated in the midline from the level of the third to the sixth cervical
vertebrae.
It consists of a framework of cartilages connected by ligaments and lined by a mucous membrane;
in male the projection of the thyroid cartilage produces the Adam's apple.

Laryngeal cartilages:
Unpaired cartilages: These are three:
1. Thyroid cartilage:
Is the largest one and each half consists of:
- Ala (lamina) which meet in the midline forming an angle of about 90 degree in men and about
120 degree in women.
- Superior cornu: arises from the posterosuperior angle of the ala.
- Inferior cornu: arises from the posteroinferior angle of the ala and articulate with the cricoid
cartilage.
2. Cricoid cartilage:
Thicker and stronger than the thyroid cartilage, resembles a signet ring (narrow in front
and broad. behind), articulate with the arytenoids cartilages on the upper border of the cricoid
lamina.
3. Cartilage of epiglottis:
Rises up behind the tongue, it is leaf like sheet of elastic fibro cartilage the stem
directed downwards & is attached to the posterior surface of the thyroid ala at their
junction -while the upper free border directed upwards.
Paired cartilages: thesearethreepairs:
1.Arytenoid cartilages:
They are the largest, pyramidal-in shape, have the muscular process postero-laterally & the
vocal process anterolaterally, articulate inferiorly with the cricoid cartilage -while the apex,
curves backwards to articulate with the corniculate cartilage.
2. Corniculate cartilages (the cartilages of Santorini):
These are small articulate with the apices of the arytenoid cartilages and prolong
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 them backward and medially.
3. Cuneiform cartilages (the cartilages of Wrisberg):
These are small bars of yellow elastic cartilages in each ary-epiglottic fold.
Laryngeal joints:
There are two important joints in the larynx on each side.
1. Crico-thyroid joint:
It is between the inferior cornu of the thyroid cartilage and cricoid cartilage. It is a synovial
joint with two movements (rotation and gliding).
2. Crico-arytenoid joint:
It is also a synovial joint with the same two movements.

Laryngeal muscles:
These are two types:
I. Intrinsic (between the laryngeal cartilages):
- Abductors of the vocal cords:
There is only one on each side named the posterior crico-arytenoid muscles which opens the glottis.
- Adductors of the vocal cords: There are three on each side:
1. Lateral crico-arytenoid muscle.
2. Interarytenoid muscle.
3. Thyroarytenoid muscle.
- Tensors of the vocal cords: these are two on each side:
1. Cricothyroid muscle (external tensor).
2. Internal portion of the thyro-arytenoid (Vocalis, internal tensor).
II. Extrinsic (Between the larynx and the neighboring structures): There are two main groups:
1. Strap muscles of the neck: sternothyroid & thyrohyoid muscles.
2. Pharyngeal muscles: stylopharyngeus, palatopharyngeus & inferior constrictor muscles.

Membranes of the larynx

The elastic membrane is the fibrous framework of the larynx it lies beneath the laryngeal mucosa
and is divided into upper & lower parts by the ventricle of the larynx. Ventricular ligament is a
thickening of the free edge. The vocal ligament is the -free upper edge of this elastic membrane.

Cavity of the larynx

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It is divided into three parts by two folds of the mucous membrane:
1.False vocal cords:
These are the ventricular bands which are formed by the mucous membrane covering the
ventricular ligament.
2. True vocal cords:
These lies at a lower level than false vocal cords, the epithelium is closely bound down to the
underlying vocal ligament & their blood supply is poor hence the white appearance of the vocal
cords in life.
These mucosal folds divide the cavity into:
A. The vestibule: lies between the inlet of the larynx & the edges of the false cords.
B. Ventricle of the larynx: a recess between the false and the true vocal cords.
C. Subglottic space: lies between the true vocal cords and the lower border of the cricoid cartilage.
* Saccule: is a conical pouch which ascends from the anterior part of the ventricle.
* The glottis (rima glottides) is the interval between:
1. The true vocal cords in its anterior 3/5.
2. The vocal processes of the arytenoid cartilages in its posterior 2/5.
Its average length in the adult male is about 2.5 cm while in the adult female is about
1.6 cm.
* The lining mucous membrane of the larynx is ciliated columnar epithelium except at:
1. The true vocal cords.
2. The upper part of the vestibule of larynx. These are lined by stratified squamous
epithelium.

Blood supply of the larynx

1. Laryngeal branches of the superior thyroid artery.
2. Laryngeal Branches of the inferior thyroid artery.

Nerve Supply of the larynx

The larynx is supplied by branches of the vagus nerves:
1. Superior laryngeal nerve which has two branches:
- Internal branch: entirely sensory, it supplies the cavity of the larynx as far down as the level
of the vocal cord.
- External branch: entirely motor, it supplies the cricothyroid muscle.

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2. Recurrent laryngeal nerve:
It has a much longer course on the left side than on the right. On the left side it turns round
the arch of the aorta, while on the right side it turns round the subclavian artery, both of them runs
upward on both sides between the trachea and esophagus, as they approach the larynx they supply all
the muscles of the larynx except the cricothyroid muscle, also they give sensation to the cavity of the
larynx below the level of the vocal cords.
Lymphatic drainage of the larynx
The edges of the vocal cords divide the lymphatic system of the larynx into two parts:
L Supraglottic above the vocal cords: the vessels drain into:
- Preglottic nodes.
- Upper deep cervical nodes.
2. Subglottic below the vocal cords: the vessels drain into:
-Prelaryngealandpretrachealnodes.
- Lower deep cervical nodes.
3. The vocal cords themselves have no lymphatic vessels.
Functions of the larynx
1. Protection of air passages.
2. Phonation.
3. Aspiration.
4. Fixation of the chest.
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Diseases of the larynx

I. Congenital anomalies & causes of congenital laryngeal stridor

Laryngomalacia (congenital laryngeal stridor)
The larynx is of an exaggerated infantile type; the epiglottis is long, narrow & folded
backwards at each lateral edge (Omega shaped, incomplete cylinder) so in each inspiration the edges are
sucked inside the larynx.
Clinical features:
- Stridor is the only symptom and appears at or soon after birth, mainly inspiratory,
diminished by rest and responsive to changes in posture but increased by exertion. It
disappears between the second and first year of life.
- Cyanosis is rare and the -voice is unchanged.
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Diagnosis:
1. Careful history and examination:
Inspiratory stridor without hoarseness is always suggestive when occurring soon or
after birth.
2. Flexible fibroptic examination.
Treatment:
1. Reassurance is necessary.
2. Tracheostomy may rarely performed in very severe cases.
Subglottic stenosis:
There is inspiratory stridor, partially relieved by rest & worsened by exertion but
unaffected by posture with failure to thrive.
Diagnosis:
By direct laryngoscopy and bronchoscopy.
Management:
Laser vaporization of the stenosis.
Subglottic hemangioma:
The clinical features are the same of the subglottic stenosis and the laser
is very effective in treatment.
Laryngotracheal cleft:

Laryngeal cyst
Lead to muffled cry & sometimes stridor.
Laryngeal web
Web consist of a fibrous tissue stroma covered by epithelium in the anterior half of
the glottis due to arrest in development, sometimes atresia may be complete.
Clinical features:
- Hoarseness.
- Inspiratory stridor.
Diagnosis:
- Fibroptic laryngoscopy or direct laryngoscopy.
Treatment:
1. No treatment in the milder forms.
2. Laser excision.
3. excision by laryngofissure, which may be advised later until the larynx developed fully.
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Vocal cord palsy
This causes inspiratory stridor & hoarseness in neonate; diagnosed by fibroptic
laryngoscopy, caused by damage to the recurrent laryngeal nerve in the neck or chest
usually from, birth trauma.