Larynx (Voice Box)

Attaches to the hyoid bone and opens into the

laryngopharynx superiorly

Continuous with the trachea posteriorly

The three functions of the larynx are:

 To provide a patent airway

 To act as a switching mechanism to route air and food into the

proper channels

 To function in voice production

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Anatomy of the Larynx ( I )

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Framework of the Larynx

Cartilages (hyaline) of the larynx

 Shield-shaped anterosuperior thyroid cartilage with a midline
laryngeal prominence (Adam’s apple)

 Signet ring–shaped anteroinferior cricoid cartilage

 Three pairs of small arytenoid, cuneiform, and corniculate

cartilages

Epiglottis – elastic cartilage that covers the

laryngeal inlet during swallowing

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Page 4
 Skeletal Structure of the Larynx

Laryngeal Cartilage

 Thyroid cartilage

 Cricoid cartilage

 Arytenoid cartilage

 Epiglottic cartilage

 Corniculate cartilage
on apex of the arytenoid

 Cuneiform cartilage
in aryepiglottic fold

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Page 6
 Anatomy of the Larynx ( III )
Anatomical Subdivision of the Larynx

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Anatomical Structure of the Larynx ( II )

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Framework of the Larynx

Figure 22.4a, b
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Vocal Ligaments

Attach the arytenoid cartilages to the thyroid

cartilage

Composed of elastic fibers that form mucosal folds

called true vocal cords
 The medial opening between them is the glottis

 They vibrate to produce sound as air rushes up from the lungs

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Vocal Ligaments

False vocal cords

 Mucosal folds superior to the true vocal cords

 Have no part in sound production

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Muscle
 Intrinsic muscles
Abductor L
Visor angle
– Posterior cricoarytenoid M (PCA) C
Adductor A
– Interarytenoid M (IA)
– Lateral cricoarytenoid M (LCA)
– Cricothyroid M (CT)

Tensor
– Cricothyroid M (CT)
– Vocalis (thyroarytenoid) M

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 Muscle

 Extrinsic Muscle
L
Suprahyoid (Oral diaphragm) C
Elevator group A

Infrahyoid (strap)
Depressor group

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 Nerve


 Superior
Superior laryngeal
laryngeal nerve
nerve
Internal
Internal br
br :: sensory
sensory in
in supraglottis
supraglottis

External
External br
br :: motor
motor to
to cricothyroid
cricothyroid M.
M.


 Inferior
Inferior (recurrent)
(recurrent) laryngeal
laryngeal nerve
nerve
Motor
Motor to
to intrinsic
intrinsic laryngeal
laryngeal M.
M. of
of

the
the same
same side
side except
except cricothyroid,
cricothyroid,

interarytenoid
interarytenoid M.
M.

Sensory
Sensory to
to glottis
glottis &
& subglottis
subglottis

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Lymphatics

Supraglottis
Extensive neurovascular bundle through thyrohyoid membrane

-->upper deep cervical L/N(jugulo-omohyoid)

Glottis
Free of lymphatics

Subglottis:
More variable

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Anatomic characteristics of the Larynx of the infant

1. Higher in neck (C4 at birth, C5 at 6yrs, C6-7 at adult)

2. More acute angle between the glottis and epiglottis
3. More soft, flabby and  less rigid epiglottis
4. Relatively longer epiglottis (omega shaped)
5. Redundant aryepiglottic  folds (closer to the midline)
6. Epithelium and underlying connective tissue are
more loosely attached (more easily induced serious edema)

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 Physiology

Function of the Larynx

 Airway protection as sphincter

 Respiration

 Phonation

 Deglutition(swallowing)

 Others: Fixation of the chest

Production of Voice
Source and Filter theory
Myoelastic Aerodynamic theory
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Vocal Production

Speech – intermittent release of expired air while

opening and closing the glottis

Pitch – determined by the length and tension of the

vocal cords

Loudness – depends upon the force at which the air

rushes across the vocal cords

The pharynx resonates, amplifies, and enhances

sound quality

Sound is “shaped” into language by action of the

pharynx, tongue, soft palate, and lips
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Sphincter Functions of the Larynx
The larynx is closed during coughing, sneezing, and
Valsalva’s maneuver

Valsalva’s maneuver
 Air is temporarily held in the lower respiratory tract by closing the glottis

 Causes intra-abdominal pressure to rise when abdominal muscles

contract

 Acts as a splint to stabilize the trunk when lifting heavy loads

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Page 20
Page 21
Movements of Vocal Cords

Figure 22.5
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Page 23
 Physical Examination

Indirect laryngoscopy

Flexible fiberoptic laryngoscopy

Telelaryngoscopy

Direct laryngoscopy

Laryngeal stroboscopy

Ventilating bronchoscopy

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Page 25
 Vessel

Artery
Superior laryngeal artery

from Superior thyroid A.

( external carotid artery)

Inferior laryngeal artery

from Inferior thyroid A.
(Thyrocervical trunk)

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Clinical Examination of the Voice ( Vocal dynamic test )

Aerodynamic Study : MPT, PQ, MMFR, Pitch, Intensity

Vocal Fold Vibration study : Stroboscopy

Acoustic study : Sound Spectrogram

Neuromuscular study : EMG

Psychoacoustic analysis : GRBAS

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Mucosal Lining of the Larynx

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 Radiologic Examination

Plain X-ray
C-spine AP and Lateral
soft tissue technique
Laryngogram
CT
MRI

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Radiologic Examination

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Acute Laryngitis

Etiology
Viral URTI preceeding aphonia without or with the history of sore throat

Acute inflammation of the laryngeal mucosa

Symptom & Sign
Pain , Odynophagia , Fever

Physical Exam
Bilateral Vocal cord edema and erythema

Tx
Improves usually with resolution of URTI

Conservative treatment of voice rest

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 Acute epiglottitis ( 급성 후두개염 )

• Rapidly progressive acute bacterial infection

• H. influenza type B
• Usually betw. 2-7 yrs. Infant,child rarely adult
Sx
 Rapidly progressive dyspnea, esp. in children

– May be fatal within few hours

 Sore throat with dysphagia

 Hot potato voice (muffled voice)
 Wants to sit up (sitting position 을 취한다 )

P/E
 Swollen, bright red epiglottis obstructing the pharynx and airway

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Acute epiglottitis ( 급성 후두개염 )

Dx:
 Neck lateral radiography (thumb print sign)
 Oral exam. with tongue pressor --- very carefully

Tx
 Endotracheal intubation or tracheotomy
 ICU care with monitoring
 Hydration
 Ampicillin 200 - 400 mg/kg, Chloramphenicol 50 - 100 mg/kg

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 Acute laryngotracheobronchitis 급성후두염 ( 기관지염 )

• Mucosal inflammtion from larynx to subdivision of bronchial tree

• Viral infection
Sx :
Croupy cough
Inspiratory stridor with retraction
Hoarseness
Tx :
Ultrasonic humidification Antibiotics
Racemic epinephrine
Corticosteroid (100 mg hydrocortisone IM on admission)
Parenteral hydration
O2 with Timely nasotracheal intubation or tracheotomy
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 Laryngomalacia ( 후두연화증 )

• Congenital laryngeal stridor - most common

• Sx : inspiratory stridor soon after birth,
• worsen in supine position with normal crying
• Dx : Stridor improved in prone position
• Direct laryngoscopy :
Supraglottic larynx fall together with inhalation
Omega-shaped epiglottis & short aryepiglottic folds
• Px : stridor usually disappeares by 12 to 16 months of age

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Laryngeal nodule

• Etiology
•voice abuse
• Clinical feature
•more often in woman, children (boy>girl)
•hoarseness
•sites : junction of the ant. and
mid. third, usu. bilateral
•Tx :
•children : parent counselling with psychotherapy
•adult : voice rest and voice therapy
•microlaryngoscopic excision

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Laryngeal polyp

• may be related to vocal nodule

but differ from nodule
• usually more often in male &
rarely in children
• usually junction of the anterior
and middle third
• but appears anywhere in cords,
usually unilateral
• do not respond to voice therapy,
op is usually indicated.

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 Contact ulcer (Posterior laryngitis)
• Etiology
•vocal abuse, harsh coughing, esophageal reflux
• Clinical features:
•usually male
•ulceration : vocal process of arytenoid
•Treatment
•voice rest
•antibiotics
•steroid
•Antacid
• Diet control

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Intubation granuloma

• more in female
• Site
•vocal process of arytenoid
•Bilateral in 50% cases
•Tx
•excision when pedunculated
•sessile stage: antibiotics, steroid

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 Laryngeal papilloma

•Recurrent tumors of larynx

causing airway obsruction
•Associated with papilloma virus
•Tx:
•microlaryngeal surgical excision
or laser surgery
•immune therapy(interferon)
•Evaporation using CO2 laser

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Foreign Bodies ( 이물질 )

Page 41
Diffuse vocal polyposis (polypoid vocal fold, Reinke's edema)

Etiology:  Persistent vocal abuse

in hyperkinetic, smoking, extroverted
individuals
Pathology : The margins of the membranous
true vocal cords are diffusely involved
by edematous tissue masses .
The Reinke's space is widended & filled with
mucoid material almost devoid of cells,
fibrous tissue &blood vessel
Symptom : Severe hoarseness is constant
Treatment : Removal by laryngomicrosurgery
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Vocal cord paralysis ( 성대마비 )

Vocal cord paralysis is a sign of disease, not a diagnosis

Pathology : most peripheral nerve lesion & more in left side

(due to longer course of RLN)

Etiololgy : Tumor

Trauma ; Surgical trauma

Non-surgical truama

Pressure on the left RLN

Inflammation : pulm Tbc

Idiopathic
Vocal cord paralysis ( 성대마비 )
Diagnosis
 Symptoms and signs
 Indirect laryngoscopy
 Radiology
– chest X-ray
– CT(skull base to lung)
– thyroid scan
– esophagogram
 Panendoscopy

Treatment
 Observation for 6 months( unless cancer )
 Surgical therapy (see next slide)
 Thyroplasty by Isshiki(1989)

Type I : Medialization(medial displacement) Type II : Lateral displacement

Type III : to lower the high pitch sound Type IV : to elevate the low pitch sound in women
 Surgical Treatment of vocal cord paralysis

Vocal fold medialization by injection Endoscopic arytenoidectomy

for lateralization

Endoscopic laser cordotomy

Vocal fold injection using direct approach
for lateralization
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 Laryngeal trauma

A. Etiology

1. Mechanical injury 2. Burns of larynx

가 . Ext. : Car accidents 가 . Thermal burns :

   Other blunt neck injury Ingestion of hot food or liquid

   Surgical trauma                     Inhalation of hot air or gas

(Cx. of tracheotomy, 나 . Chemical burn : Lye, ammonia,

cricothyroidotomy) clorox etc.

나 . Int. : Endoscopic procedure 3. Irradiation injury

   Endotracheal intubation 4. Autogenous trauma(voice abuse)

  Indwelling nasogastric tube

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 Laryngeal trauma
B. Clincal manifestation & Symptoms
indicative of some derangement of larynx
Dyspnea & stridor
Dysphonia & aphonia
Cough
Hemoptysis & hematemesis
Neck pain
Dysphagia & hematemesis
Distintive signs of external mechanical injury
Deformity of the neck
Subcutaneous emphysema
Laryngeal tenderness with Bony crepitus
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Laryngeal Tumors 후두종양

Vocal nodule (Singer's nodule)

Vocal polyp

Contact ulcer (granuloma)

Intubation granuloma (after endotracheal intubation)

Papilloma

Malignant tumor of Larynx

Etiology

Tobacco

 relative risk : 6.0-15.8

 Quit smoking for 6 yrs (risk drammatically decreases),

 Quit smoking for 15yrs (same as non-smokers)

Alcohol, Radiation, Industrial exposure

Incidence : 2.3% of all malignancy in males,

0.4% in females

peak age: 55-65 yrs

Pathology

Squamous cell carcinoma

Verrucous squamous cell carcinoma

Lymphoepithelioma

Melanoma

Pseudosarcomatous carcinoma

Adenocarcinoma

Others : granular cell tumor

Modes of Spread

Direct infiltration

Hematogenic spread : uncommon

Lymphatic spread
Stage

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Radiology

Page 54
Treatment

Conservation surgery

 Partial laryngectomy

 Hemilaryngectomy

 Supraglottic laryngectomy

Total laryngectomy : sacrifice voice

 permanent tracheostoma

Chemotherapy

Radiation
Treatment ( Total Laryngectomy )

Page 56
Restoration of Voice

Esophageal voice

Tracheoesophageal shunt with prosthesis

 Amatsu

Tracheoesophageal shunt without prosthesis

 Panje button

 Provox II

External machine (Servox)

Page 58
Nerve

Page 59