THE GLOTTIS

Contouring Accuracy Program

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 Outline
1. Refresher Course on the Glottis
A. What is the glottis?
B. Functions
C. Tissue types
D. “Did you know?” Fun Fact
2. Locating the Glottis in medical images
A. Identifying the axial slice range (superior and inferior limits)
B. Contouring the glottis on axial images
3. Special considerations for radiation therapy
A. Radiosensitivity
B. Resources, publications, and links

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 1A. What is the Glottis?
Glottis [glot´is] (pl. glot´tides) (Gr.)
“The vocal apparatus of the larynx, consisting
of the true vocal cords (vocal folds) and the
opening between them.”
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and
Allied Health

The term glottis in radiation therapy is

generally used to define the exact region
(about 5 mm thick) plus the anterior and
posterior commissures down to 5 mm below
free margin of vocal cords.
The glottis may also be referred to as the
“glottic larynx.”

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 1B. The Functions of the Glottis
The glottis is essential in phonation, or voicing, as the vocal folds vibrate to
produce certain sounds.
Muscles in the larynx control the opening and closing of the glottis. The glottis
closes to a small slit in order to prepare for sound production. The glottis opens
(in a triangular shape) when we breathe, allowing air to flow in and out of the
lungs. Folds of skin protect the glottis when we swallow.

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 1C. The Histoanatomy of the Glottis
Taken directly from Wikipedia:
 The glottis is composed of an intermembranous portion or anterior glottis,
and an intercartilaginous portion or posterior glottis.
 The border between the anterior and posterior glottises is defined by an
imaginary line drawn across the vocal fold at the tip of the vocal process of
the arytenoid cartilage.
 The anterior glottis is the primary structure of vocal fold vibration for
phonation and the posterior glottis is the widest opening between the vocal
folds for respiration.
 There are gradual changes in stiffness between the pliable vocal fold and
hard, hyaline cartilage of the arytenoid.
 The vocal processes of the arytenoid cartilages form a firm framework for the
glottis but are made of elastic cartilage at the tip. Therefore, the vocal
process of the arytenoid bends at the elastic cartilage portion during
adduction and abduction of the vocal folds.

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 1D. “Did You Know…?”
Glottal control is an essential skill of
the expert player of the Australian
FUN
instrument called the didgeridoo. FACTS
A study1 was published in the journal
Nature where the authors found that:
“Experienced players are
subconsciously using their glottis to
accentuate the instrument's tonal
variation.”
1Tarnopolsky et al. “Acoustics: The
vocal tract and the sound of a
didgeridoo,” Nature 436, 39 (7 July
2005)

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 2A. Superior and Inferior Limits

Arytenoid Cartilage

5 mm below free
margin of vocal
cords, near top of
cricoid

The superior-inferior dimension is

typically on the order of 1.0 cm
thick, and not more than 1.5 cm.

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 2B. Contouring the Glottis

Steps for Contouring

1. Find the level of the arytenoids (superior border)
2. Contour outward giving something shaped like a
slice of pie.
- Anterior: Anterior commissure
- Posterior: Posterior of cricoid
- Lateral: Paraglottic space
- Do not extend beyond the thyroid cartilage

3. Continue inferiorly about 5 mm below free margin

of the vocal cords, to near the top of the cricoid.

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 3A. Radiosensitivity
QUANTEC Dose Limits
Organ Volume Side effect Dose or Dose/Vol Rate Notes

Larynx Whole Organ Vocal Dmax <66Gy < 20% With chemotherapy,
dysfunction based on a single study

Larynx Whole Organ Aspiration Dmean <50Gy <30% With chemotherapy,

based on a single study

Larynx Whole Organ Edema Dmean <44Gy <20% Without chemotherapy,

based on a single study
in patients without
larynx cancer

Larynx Whole Organ Edema V50 <27% <20% Without chemotherapy,

based on a single study
in patients without
larynx cancer

All data taken from L.B. Marks et al, Use of Normal Tissue Complication Probability Models in the Clinic,
IJROBP, Vol 76, Supplement 2010, pp. S15 -S18

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 3A (cont). Radiosensitivity
Organ Endpoint Rate% Dose Volume Dmean (Gy)
Parameter

Larynx Grade >2 Edema 20% V50 <27% <44Gy

Tolerance of Normal Tissue to Therapeutic Radiation. Dr Emami B. Department of Radiation

Oncology, Loyola University Medical Center, Maywood, Illinois, USA

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 3B. Resources, publications and links
 NCCN Guidelines
- https://www.nccn.org/professionals/physician_gls/f_guidelines.a
sp

 Quantitative Analyses of Normal Tissue Effects in the Clinic

(QUANTEC)
- International Journal of Radiation Oncology-Volume 76, Issue 3,
Supplement, S1-S160

 Tolerance of Normal Tissue to Therapeutic Radiation

- journals.sbmu.ac.ir/rro/article/viewFile/4316/3851

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