ANATOMY AND

PHYSIOLOGY OF
LARYNX
Mr. Girish. K. S
Assistant Professor in Speech Language Pathology,
JSSISH, Dharwad
 INTRODUCTION
◦ Voice box.
◦ Extends from laryngeal inlet to lower border of
cricoid cartilage .
◦ Opposite C3-C6 vertebrae.

MALE FEMALE
AP Diameter 36 mm 26 mm
Height 44 mm 36 mm
TD 43 mm 41 mm
VF Length
Child 8 mm 6 mm
Adult 17-23 mm 15-19 mm
 Composition of the Larynx
Skeletal framework:
◦ HYOID BONE
◦ UNPAIRED CARTILAGES
◦ Thyroid
◦ Cricoid
◦ Epiglottis
◦ PAIRED CARTILAGES
◦ Arytenoid
◦ Cuneiform
◦ Corniculate
HYOID BONE
U-SHAPED. It is situated just above the thyroid
cartilage.
BODY- Quadrilateral , anterior & posterior surface
with superior & inferior borders .

It is attached to mandible & skullbase by stylohyoid

ligament , digastric, mylohyoid, stylohyoid,
geniohyoid , hyoglossus muscles hence helping in
raising larynx during deglutition & phonation .
 IMPORTANCE
• Serves as a site of access to supraglottic larynx &
pharynx
• In Tracheal resection & anastomosis , tension free
closure of distal airway.
• Physiological functions – breathing, swallowing ,
speech & to keep airway open during sleep
Thyroid Cartilage
Hyaline cartilage, largest cartilage of larynx.
2 Lamina ; angle of 90 degree (male-adam’s apple ) & 120 degree
(female).
Ala ossification- begins at 25yrs , completes by 65 yrs.
The laryngeal skeleton consists of several cartilaginous structures,
the largest of which is the thyroid cartilage. The thyroid cartilage is
composed of two rectangular laminae that are fused anteriorly in
the midline.

The incomplete fusion of the two laminae superiorly forms the

thyroid notch. Attached to each lamina posteriorly are the superior
and inferior cornua.

The superior cornua articulate with the greater horns of the hyoid
bone, while the inferior cornua form a synovial joint with the
cricoid cartilage (the cricothyroid joint).
 IMPORTANCE
• Cartilage is divided in midline to expose endolarynx
for various
• procedures (eg.partial laryngectomy ,
laryngotracheoplasty,
• arytenoidectomy ).
• Cricothyroidotomy – emergency ventilation
Cricoid Cartilage
• Only complete cartilaginous ring in the upper airway.
• Signet ring shape.
• Narrow ARCH anteriorly , broad LAMINA posteriorly.
The cricoid cartilage articulates with the thyroid cartilage’s inferior
cornua on the cricothyroid joint facets. It joins the first tracheal ring
inferiorly via membranous attachments.

The face of the cricoid cartilage has a vertical height of only about
3–4 mm, while the lamina posteriorly stands about 20–30 mm high.

There is a steep incline from anterior to posterior of the superior

margin of the cricoid cartilage. This incline leaves an anterior
window where the cricothyroid membrane lies.
 IMPORTANCE
• The cricoid cartilage serves to maintain airway
patency, forms part of the larynx, and provides an
attachment point for key muscles, ligaments, and
cartilage, which function in the opening and closing the
vocal cords for sound production.
Epiglottis
• The epiglottis is an oblong, feather-shaped fibroelastic cartilage
that is attached, at its inferior end, to the inner surface of the
thyroid cartilage laminae just above the anterior commissure.

• It is attached inferiorly to the thyroid cartilage, just below the

thyroid notch in the midline, by the thyroepiglottic ligament.

• To the hyoid bone anteriorly by the hyoepiglottic ligament.

 IMPORTANCE
• The major function of the epiglottis is to help prevent
aspiration during swallowing. The epiglottis is
displaced posteriorly by tongue base contraction and
laryngeal elevation. This causes the superior free edge
of the epiglottis to fall over the laryngeal inlet, which,
in conjunction with sphincteric closure of the larynx at
the glottic and supraglottic level, closes off the
laryngeal vestibule.
Arytenoid Cartilage
• The arytenoid cartilages are paired, pyramidal cartilages that
articulate with the posterior lamina of the cricoid cartilage at the
cricoarytenoid joint.

• Each arytenoid has both a vocal process medially and a muscular

process laterally. These processes act as the attachment sites for
the vocal ligament and the major intrinsic muscles of vocal fold
movement respectively.
Accessory Cartilages: Corniculate
• The corniculates are small conical, paired nodules, fibroelastic
cartilages that sit laterally to each of the arytenoids, and are
completely embedded within the aryepiglottic folds.

• These articulate through a synovial joint with the apices of the

arytenoid cartilages.

• These likely serve to provide additional structural support to the

aryepiglottic folds.
Accessory Cartilages: Cuneiform
• The cuneiform cartilages are two small elongated flakes of
fibroelastic cartilage, one in each margin of the aryepiglottic
fold.

• These paired elastic cartilages that sit on top of, and move with,
the corresponding arytenoid.

• The soft tissue of the aryepiglottic folds covers these cartilages.

 Laryngeal Joints: Cricothyroid

• The cricothyroid joint is a synovial joint formed from

the articulation of the inferior cornua of the thyroid
cartilage with facets on the cricoid lamina. The two
major actions at this joint are anteroposterior sliding
and rotation of the inferior thyroid cornu upon the
cricoid cartilage.
 IMPORTANCE
• Cricothyroid muscle contraction pulls the thyroid ala
anteriorly with respect to the cricoid cartilage and
closes the anterior visor angle between the thyroid and
the cricoid cartilage. This motion increases the
distance between the anterior commissure and the
vocal processes and serves to lengthen and tense the
vocal folds.
 Laryngeal Joints: Cricoarytenoid

• The cricoarytenoid joint is the primary moving

structure of the intrinsic larynx. The arytenoids
articulate with the cricoid cartilage forming multiaxial
joints. The action of movement at the cricoarytenoid
joints changes the distance between the vocal processes
of the two arytenoids and between each vocal process
and the anterior commissure.
Cricoarytenoid joint action in abduction (left) and
adduction (right). Note the lowering of the vocal
process as adduction occurs
IMPORTANCE
• The combined action of the intrinsic laryngeal muscles on the
arytenoid cartilages alters the position and shape of the vocal
folds. Each cricoarytenoid joint sits at a surprisingly steep 45°
angle with the horizontal plane on the cricoid cartilage and
permits motion in a rotatory and gliding fashion.
• (i) rotatory, in which arytenoid cartilage moves around a
vertical axis, thus abducting or adducting the vocal cord.
• (ii) gliding , in which one arytenoid glides towards the other
cartilage or away from it, thus closing or opening the posterior
part of glottis.
 LIGAMENTS & MEMBRANES
• EXTRINSIC MEMBRANES AND LIGAMENTS
a) Thyrohyoid membrane - It connects thyroid
cartilage to hyoid bone. It is pierced by superior
laryngeal vessels and internal laryngeal nerve.
b) Cricotracheal membrane - It connects cricoid
cartilage to the first tracheal ring.
c) Hyoepiglottic ligament - It attaches epiglottis to
hyoid.
d) Thyrohyoid ligaments
e) Cricotracheal ligament
 LIGAMENTS & MEMBRANES
• INTRINSIC MEMBRANES AND LIGAMENTS
a) Cricovocal membrane - It is a triangular
fibroelastic membrane. Its upper border is free and
stretches between middle of thyroid angle to the
vocal process of arytenoid and forms the vocal
ligament. Its lower border attaches to the arch of
cricoid cartilage. From its lower attachment the
membrane proceeds upwards and medially and
thus, with its fellow on the opposite side, forms
conus elasticus where subglottic foreign bodies
sometimes get impacted.
b) Quadrangular membrane - It lies deep to
mucosa of aryepiglottic folds. It stretches
between the epiglottic and arytenoid cartilages.
Its lower border forms the vestibular ligament
which lies in the false cord.
c) Cricothyroid ligament - The anterior part of
cricothyroid membrane is thickened to form the
ligament and its lateral part forms the
cricovocal membrane.
d) Thyroepiglottic ligament - It attaches epiglottis
to thyroid cartilage.
 Cavity of the Larynx
◦ Divided into 3 parts:
◦ Vestibule (supraglottic space)
◦ Ventricle (sinus of larynx)
◦ Infra-glottic cavity (subglottic space)
Vestibule
◦ Anterior: posterior surface of epiglottis
◦ Posterior: interval between arytenoid cartilages
◦ Lateral: inner surface of aryepiglottic folds and
upper surfaces of the false cord
Ventricle
◦ between the vestibular folds above and vocal folds below.
◦ The lateral walls of the middle part of the laryngeal cavity
bulge outward to form lateral recesses (laryngeal ventricle)
between the vestibular fold and the vocal fold.
◦ Each ventricle has an elongated blind tubular extension, the
laryngeal saccule, that projects antero-superiorly between the
vestibular fold and the thyroid cartilage.
◦ Each saccule is lined with mucus glands that produce mucus to
lubricate the vocal folds
Infra-glottic cavity
◦ The infra-glottic cavity is the portion of the larynx
below the laryngeal ventricles and the rima glottidis
(between vocal cords)till the lower border of the
cricoid cartilage.
 Muscles of the Larynx
◦ Extrinsic Laryngeal Muscles: These connect
laryngeal framework to adjacent structures & move laryngeal
skeleton as a whole, superiorly and inferiorly.
◦ Intrinsic Laryngeal Muscles: The intrinsic
laryngeal muscles act on the individual components of
the larynx. They control the shape of the rima glottidis
(opening between the vocal folds and the arytenoid
cartilages), and the length and tension of the vocal
folds.
Extrinsic Muscles
TWO Groups of Extrinsic Muscles:

◦ Suprahyoids – Attach to points above the Hyoid

(Jaw, Skull and Tongue) when they contract they
raise or elevate the Larynx. Eg: Swallowing

◦ Infrahyoids – Attach to points below the Hyoid (one

connects to the thyroid, however the others connect
to the sternum and the scapula) when they contract
they lower or depress the Larynx
 Extrinsic Muscles
Infrahyoids Suprahyoids
◦ Mylohyoid
◦ Sternohyoid
◦ Geniohyoid
◦ Sternothyroid
◦ Stylohyoid
◦ Thyrohyoid
◦ Digastric
◦ Omohyoid
◦ Stylopharyngeus
◦ Palatopharangeus
◦ Salphingopharyngeus
 Muscles Origin Insertion Action
Mylohyoid mylohyoid line of raphe and body of Raises and pulls hyoid
mandible hyoid bone anteriorly

Geniohyoid inferior mental body of hyoid Raises and pulls the hyoid
spine of mandible bone bone antero-superiorly.

Stylohyoid styloid process of body of hyoid elevates and retracts the

the temporal bone hyoid bone for swallowing
bone
Digastrics anterior belly: digastric intermediate Anterior belly pulls the hyoid
fossa of mandible; tendon to body anterior and up. posterior
posterior belly: mastoid and greater horn of belly pulls the hyoid
notch of temporal bone hyoid bone posterior and up.
 Muscles Origin Insertion Action
Stylopharyngeus Styloid process posterior and elevates the pharynx and
of temporal superior borders of larynx and expands the
bone thyroid cartilage sides of the pharynx
(side wall of
pharynx)

Palatopharynge hard palate lateral wall of tenses the soft palate and
us and palatine pharynx pulls the walls of the
aponeurosis pharynx superiorly,
anteriorly and medially
during swallowing

Salpingopharyn Eustachian tube posterior border of elevates the pharynx and

geus thyroid cartilage larynx and opens the
(side wall of orifice of the auditory
pharynx) tube during swallowing
Muscles Origin Insertion Action

Sternohyoid manubrium of sternum lower border of depresses/stabilizes the

and medial end of the hyoid bone
clavicle hyoid bone

Sternothyroid Posterior surface of Oblique line of Depresses the larynx

manubrium and edge the thyroid
of the costal cartilage lamina

Thyrohyoid oblique line of the lower border of elevates the larynx;

thyroid cartilage the depresses/stabilizes the
hyoid bone hyoid bone
Omohyoid superior border of inferior border depresses, retracts and
scapula near The of steadies the hyoid during
suprascapular notch hyoid bone swallowing and speaking
 Intrinsic Muscles
(a) Acting on laryngeal inlet:
• Openers of laryngeal inlet: Thyroepiglottic (part of
thyroarytenoid)
• Closers of laryngeal inlet: Interarytenoid (oblique part),
Aryepiglottic (posterior oblique part of interarytenoids)
(b) Acting on vocal cords:
• Abductors: Posterior cricoarytenoid
• Adductors: Lateral cricoarytenoid, Interarytenoid (transverse
arytenoid), Thyroarytenoid (external part)
• Tensors: Cricothyroid, Vocalis (internal part of thyroarytenoid
 Muscles Origin Insertion Action
Muscles controlling laryngeal inlet
Oblique Aretenoid Muscular Apex of the Narrows the inlet by
process of opposite aretenoid bringing the aryepiglottic
aretenoid cartilage folds together
cartilage

Thyroepiglottic Medial lateral margin of Widens the inlet by

surface of epiglottis and pulling the aryepiglottic
thyroid aryepiglottic folds folds apart
cartilage
Muscles Origin Insertion Action
Muscles controlling the movements of vocal folds
Cricothyroid Anterior arch of the inferior border of the draws the thyroid cartilage
cricoid thyroid cartilage forward, lengthening the
cartilage vocal ligaments, tenses
vocal cords

Thyroareteno inner surface of the lateral border of the relaxes and tenses the vocal
id (vocalis) thyroid cartilage arytenoid cartilage folds

Lateral Lateral part of the muscular process of Adducts the vocal cords
cricoaretynoi cricoid the arytenoid cartilage
d cartilage
Posterior posterior surface of muscular process of Abducts the vocal cords
cricoaretynoi the lamina of the the arytenoid cartilage
d cricoid cartilage

Transverse posterior surface of muscular process of Closes posterior part

aretynoid the arytenoid the arytenoid cartilage of rima glottidis by
cartilage approximating arytenoid
cartilages
 Abductors Adductors Tensors
• Posterior • Lateral • Cricothyroid
cricoarytenoid cricoarytenoid • Thyroaretenoid
• Transverse (Vocalis)
arytenoid
• Thyroarytenoid
(external part)
• Cricothyroid
 Nerve Supply
SENSORY:
◦ Supraglottis & upper surface of vocal cords – Internal
branch of superior laryngeal nerve.
◦ Subglottis & lower surface of vocal cords – Recurrent
laryngeal nerve.
MOTOR:
◦ INTRINSIC – All muscles except cricothyroid : recurrent
laryngeal nerve.
◦ Cricothyroid – External branch of superior laryngeal
nerve.
 Blood Supply

ARTERIAL-
◦ Superior laryngeal branch of superior thyroid artery.
◦ Inferior laryngeal branch of inferior thyroid artery.
◦ Cricothyroid branch of superior thyroid artery.
 Upper Larynx
External carotid artery
Superior thyroid artery
Superior laryngeal artery

 Lower Larynx
Subclavian artery
Thyrocervical artery
Inferior thyroid artery
Inferior laryngeal artery
Venous Drainage

◦ Upper Larynx
◦ Superior laryngeal vein
◦ Superior thyroid vein
◦ Internal jugular vein
◦ Lower Larynx
◦ Inferior laryngeal vein
◦ Inferior thyroid vein
◦ Innominate vein
Vocal Folds
The complex microanatomy of the true vocal fold
allows the loose and pliable superficial mucosal layers
to vibrate freely over the stiffer structural underlayers.

three major layers:

the mucosa,
the vocal ligament, and
the underlying muscle
• The most superficial layer (SLP) is mostly acellular and
composed of extracellular matrix proteins, water, and loosely
arranged fibers of collagen and elastin. The SLP is gelatinous in
nature.

• The potential space between the SLP and the intermediate layer
of lamina propria is Reinke’s space.

• The intermediate and deep layers of the lamina propria (ILP and
DLP) are composed mostly of elastin and collagen; the deepest
and most dense layer (DLP) is composed of tightly arranged
collagen fibers. The ILP and DLP together form the vocal
ligament.
• The gelatinous superficial layer of the lamina propria,
together with the squamous epithelium, moves freely
over the underlying vocal ligament and muscle to
form the vibrations that produce sound.

• The vocal fold mucosa and vocal ligament cover the

vocalis muscle and extend from the anterior
commissure to the vocal processes of the arytenoids.
PHYSIOLOGY OF LARYNX

FUNCTIONS:
• Respiration
• Swallowing (deglutition)
• Coughing
• Protection of tracheobronchial tree
• Phonation
• To increase intrathoracic pressure (effort
closure)
 SWALLOWING (Deglutition)
Primary function – to prevent food & liquid entering
airway.
Acts as a sphincter:
◦ Closure of the laryngeal inlet
◦ Closure of the glottis
◦ Cessation of respiration
◦ Cough reflex, expulsion of secretions and foreign bodies
 SWALLOWING (Deglutition)
ORAL STAGE: Food bolus is manipulated by tongue & broken
down by teeth before being propelled towards oropharynx.
PHARYNGEAL STAGE: reflex activity which is initiated as
the bolus reaches the back of the tongue.
During this phase, the glottis is closed by adduction of the
arytenoids and contraction of the lateral cricoarytenoid muscles,
false vocal folds and true vocal folds.
 SWALLOWING (Deglutition)
Epiglottis covers the laryngeal entrance and directs/allow the
bolus to enter the oesophagus.
Rapid laryngeal elevation occurs during the pharyngeal phase of
the swallow and appears to be essential for normal swallowing.
Oral and pharyngeal
stages of a normal
swallow:
(a)Oral phase, food is
reduced and the bolus
prepared
(b)Bolus is moved to the
posterior part of the
tongue
(c)Bolus contacts the
trigger points in the
oropharynx and the
pharyngeal phase is
initiated
(d)Bolus is moved past
the closed larynx
(e)Bolus enters the
oesophagus.
 COUGHING
Coughing is a common reflex action that clears your throat of
mucus or foreign irritants
1. Preceded by rapid inspiration
2. Forceful closure of both the vocal and vestibular folds
3. Air pressure builds up below the adducted folds as the
diaphragm ascends spasmodically
4. The folds separate explosively and mucus or foreign material
is expelled
Laryngeal and supralaryngeal area
 EFFORT CLOSURE
Laryngeal structure has evolved in order to contain intrathoracic
pressure, so as to provide a stable fulcrum for the upper limbs.
Expiratory effort against a closed glottis is known as the Valsalva
manoeuvre.
During any form of exertion involving use of the arms, the vocal
folds are firmly adducted preventing expulsion of air and collapse
of the chest walls, thus providing a fixed origin for the arm and
shoulder muscles.
To increase intrathoracic pressure : Fixation of chest by glottic
closure essential for straining , climbing etc.
 PHONATION
INITIATION OF VOICE :
Pre-phonatory inspiratory phase
Vibrator – vocal folds
Excitor- exhaled air
Vocal fold oscillation
Phonation threshold pressure
◦ Immediately before phonation, the vocal folds rapidly abduct to
allow the intake of air.
◦ Vocal folds are adducted by the contraction of the lateral
cricoarytenoid muscles.
◦ The vocal note is generated by pulmonic air (air from the lungs)
as it is exhaled between the adducted vocal folds.
◦ Subglottic air pressure increases below the adducted vocal folds
until it reaches a level which overcomes their resistance and
blows them apart, thus setting in motion the vibratory cycles
which result in phonation.
VIBRATORY CYCLE

◦ 3 PHASES:
◦ ADDUCTION
◦ AERODYNAMIC SEPARATION
◦ RECOIL
◦ As the increased subglottic pressure overcomes the
resistance of the adducted vocal folds at the onset of
phonation, the vocal folds peel apart from their inferior
border.
◦ When they finally separate at their superior margin, a
puff of air is released.
◦ The resulting negative pressure in the glottis, caused
by the Bernoulli effect, results in the vocal folds
closing rapidly as they are sucked together, the inferior
vocal fold margins closing first.
◦ The Bernouilli effect is a drop in pressure dependent on particle
velocity.
◦ In relation to the vocal tract, when air passes from one large
space to another (e.g. from lung to pharynx), through a
constriction (the glottis), the velocity will be greatest and the
pressure least at the site of the constriction.
◦ As a result of the drop in pressure at the glottis, the vocal fold
mucosa is drawn into space between the vocal folds.
◦ Contact between the vocal folds increases until the subglottic air
pressure is high enough to blow the vocal folds apart again, and
the cycle recommences.
 COVER/ BODY THEORY
Hirano, 1974
◦ Each cycle of adduction, separation and recoil is the
manifestation of a mucosal wave travelling from the inferior
to the superior surface of each vocal fold.
◦ The process by which this undulating wave of movement of
the mucous membrane occurs is dependent on what is known
as the cover/body theory.
◦ Vocalis muscle provides the firm body of the vocal fold over
which the mucous membrane cover of the vocal fold is blown
by the expiratory air stream.
Vibratory cycle can be classified into 4 phases

PHASE DESCRIPTION
CLOSING The vocal folds begin to close rapidly from
their lower margin.
CLOSED The medial edges of the vocal folds are in full
contact.
OPENING The vocal folds begin to separate from their
lower margin and gradually peel apart. The
superior margin remains in contact until the
end of this phase.
OPEN The vocal folds are separated, the longest part
of a normal vibratory cycle.
VOCAL REGISTERS
◦ Hollien's suggestion that registers should be defined in terms of
laryngeal behaviour, rather than in acoustic terms, as registers are
governed by the degree of contraction of the vocalis muscle.

◦ LOFT REGISTER
◦ MODAL REGISTER
◦ PULSE REGISTER

They describe the vibratory pattern of the vocal folds and the
acoustic parameters being produced.