Thyroid notch

Adam’s apple
(laryngeal
prominence)

The Nasopharynx extends along C1

Followed by the Oropharynx along C2 and C3
Followed by the Larynx from C4 to C6
Thyroid, cricoid and epiglottis are single cartilage
The epiglottis is a leaf-like cartilage with a free upper border
and an attached lower border to the midpoint of the posterior
side of thyroid cartilage, it is tasked to close the laryngeal
inlet when swallowing
The Larynx is covered by columnar epithelium except the
epiglottis which is stratified squamous epithelium
The epiglottis is the landmark of the larynx, when describing
lesions or anything we use the terminology, supraglottic,
subglottic or glottic
Epiglottis’ anterior surface contains seromucous glands, this
can sometimes spread cancer
 The cricoid cartilage is the only complete ring cartilage of the
trachea, the rest are C shaped
Arteynoid, corniculate and cuneiform are the paired cartilages
of the larynx
The larynx is supplied by Vagus nerve through superior
laryngeal N. that supplies (motor: cricothyroid M. + sensory:
all mucosa above vocal cords) Paralysis => aspiration + pitch
The other branch of Vagus that supplies the Larynx is
recurrent laryngeal N. that supplies (motor: all other muscles
except cricothyroid + sensory: mucosa below vocal cords)
The Larynx is supplied by superior and inferior laryngeal
arteries and is drained by superior and inferior laryngeal veins
#Superior laryngeal artery => Superior thyroid artery =>
External carotid artery
#Inferior carotid artery => Inferior thyroid artery =>
Thyrocervical trunk => Subclavian artery
Lymph drainage of the supraglottic parts of larynx is done by
upper deep cervical lymph nodes
Subglottic parts are drained by lower deep cervical which
drains to the paratracheal and mediastinal lymph nodes, so it
has very poor prognosis in cancer patients as it facilitates
lymphatic metastasis
The glottic area (vocal cords area) has no lymph drianage
hence it has very good cancer prognosis

Lined with Non-keratinized stratified squamous epithelium

There are 3 spaces in
Larynx which are
important clinically
because they are known
for being spread places of
tumors
These spaces are Reinke’s
space1, pre-epiglottic2
space and para-glottic3
space
#The layers of the vocal cords are important
 ‫الرسمة اللي الدكتور رسمها‬
‫في المحاضرة و اتكلم عنها‬
‫في الريكورد‬
Base of the tongue

Right Vallecula Left Vallecula

Petiol
Anterior commissure
(voice)

Posterior commissure
Aryepiglottic fold (breathing)

Cuneiform cartilage

Corniculate cartilage
Posterior Cricoid

Pyriform fossa

- The point where the true vocal cords meet anteriorly is called
the anterior commissure and they are located superior to the
esophagus, when it is affected with a pathology the main
symptom of the patient is “Hoarseness of voice”
- The point where they meet posteriorly is called the posterior
commissure and they are located superior to the trachea, when
it is affected with a pathology the main symptom is “Stridor”
- Hoarseness: harsh low pitch voice due to pathological effect on
vocal cord tension, vibration and adduction
- Stridor: is a noisy difficult respiration due to obstruction of
upper airway, can be inspiratory (glottic & supraglottic),
expiratory (wheezy chest) or biphasic (subglottic down to trachea)
#Click on the hyperlink on the word stridor to hear its sound
#Cricotracheal ligament cut is fatal, and it is what causes death
during execution in hanging punishment

Larynx muscles are

responsible for 3
actions (tension of
vocal cords - abduction
- adduction)
Tension:
Is what causes the
pitch “tune of voice”
Is done by cricothyroid
muscle and vocalis
muscle
#Crichothyroid is also responsible for some adduction
Abduction:
Abduction is responsible for breathing
Is done by posterior cricoartynoid muscle
Adduction:
is responsible for speaking and swallowing
Is done by lateral cricoartynoid, thyroartynoid & interartynoid
 Pitch adjustment by generating tension
Breathing by abduction of the posterior commissure
Swallowing and speaking by adduction of muscles
Protection of the airway from aspiration during swallowing by:
- Tracheal coverage of the epiglottis
- Elevation of the larynx
- Epiglottic fold, false cords and true cords closure
Fixation of chest by increasing intrathoracic tension during
closure, this happens in activities that require straining as
defecating, giving birth or carrying heavy stuff

Hoarseness of voice
Stridor
Pain
Swelling (tumor or enlarged lymph nodes)
Cough and Hemoptysis
#When writing a C/P of any laryngeal disease, write these 5
symps (all of them or what applies to the case) but remember to
order them from most relevant to the case to least relevant

Direct Laryngeal Endoscope (Laryngoscopy)

- Diagnostic use: in very uncooperative patient or biopsy
- Therapeutic: removal of tumor
#Done under general anaesthesia
Indirect Laryngoscopy
1- Using a heated mirror inserted in posterior pharyngeal wall,
done in places with poor equipment
2- Flexible “fibro-optic” useful for children, inserted in nose
3- Rigid (70 or 90 degree)
#All indirect laryngoscopes are done under local anaesthesia
CT scan with contrast
MRI
PET scan in case of tumor
Mild to moderate stridor:
- Put patient in semi-sitting position
- Oxygen mask
- Steroid to ease laryngeal edema
- Antibiotic
Severe stridor “patient is dying”:
- Endotracheal entubation or Tracheostomy
‫الالجات الجينرال ثابتة و لزم تتكتب في أي حالة لرنكس‬#

- Microscopic Laryngeal Surgery “MLS”

- Collapse of the larynx during inspiration due to softening of

cartilages in larynx and resolves on expiration
Etiology: Deficiency in Calcium and Vitamin D
Main complain: Stridor
Main diagnosis: Fibro-optic or rigid laryngoscopy
#The finding = definition
TTT:

- Calcium & vitamin D supplements

- MLS to remove redundant cartilage in some advanced cases
#95% of cases resolve spontaneously by age of 30 months old

- Fibrous bands in anterior commissure of vocal cords, can be

partial or complete = death
Main complain: Weak hoarseness cry
Main diagnosis: Fibro-optic laryngoscopy No rigid, it’s a neonate
#The finding = definition
TTT:

- MLS to destroy the web with laser or cut it with a scissors

- A large pink or red mass of blood vessels in the airway below
the vocal chords
Main complain: Biphasic Stridor
#Remember subglottic to tracheal lesion = biphasic
Main diagnosis: Fibro-optic or Rigid laryngoscopy
#The finding = definition
TTT:

- MLS to destroy the mass with laser or cut it with a scissors

- Narrowing of the airway just below the vocal cords < 3.5 mm
in the subglottic area, can be bony or soft tissue
Etiology:
- Bony: congenital narrowing
- Soft tissue: Iatrogenic injury, prolonged entubation -
granulomatous infections as rhinoscleroma
Main complain: Biphasic Stridor
Main diagnosis: Fibro-optic or Rigid laryngoscopy
#The finding = definition
TTT:

- MLS to excise the soft tissue with laser or cut it with a scissors
- In case of bony: MLS Laryngeal fissure

- Surgical as in tube or endoscopy

- Accidental: closed blunt trauma to neck - open cut/penetrating
as in corrosives
as in radiotherapy or hot steam inhalation
Complains
Stridor: Edema - Hemorrhage - Hematoma
Hoarseness of voice
Pain: Dysphagia
 Swelling: Hematoma
Cough and Hemoptysis
Surgical Emphysema
Shock (Neurogenic or hypovolemic)
TTT:

- Ligation of bleeding vessel

- Repair of cartilage and resection
- Antishock measures

- Metal as in coins, batteries and ‫دبوس الطرحة‬

- Organic: as in beans, seeds etc..
- Others
as vomit and blood
Stages
Initial: Sudden onset of cough, dyspnea, cyanosis
Latent: The foreign body is undetectable but later causes
inflammation (can stay for years)
Manifest: Lung collapse or emphysema
#Both collapse and emphysema have diminished air entry on
auscultation but collapse is dull on percussion but emphysema is
hyper-resonance
Diagnosis: CT chest - Layngoscopy - Bronchoscopy
TTT:

- Removal of foreign body with endoscope