Ann Otol Rhinol Laryngol 98:1989

ASYMMETRY OF THE LARYNGEAL FRAMEWORK: A MORPHOLOGIC

STUDY OF CADAVER LARYNGES

MiNORU HiRANO, M D SHIGEJIRO KURITA, M D

KEIICHIRO YUKIZANE, MD SEISHI H I B I , P H D
KuHUME, JAPAN

Asymmetry of the laryngeal framework was investigated with 50 excised human larynges, ten from newborns (five males, five
females), 20 from adults in their 20s (ten males, ten females), and 20 from adults in their 50s (ten males, ten females). All adults were right-
handed. The results are summarized as follows. 1) The laryngeal framework was asymmetric to a greater or lesser extent in all larynges. 2)
The degree of asymmetry did not differ among different age groups or between sexes. 3) In newborns, there was no directional
preponderance in asymmetry. 4) In older adults, there was a directional preponderance in asymmetry. The right thyroid lamina tended to
tilt laterally whereas the left lamina showed a tendency to tilt medially. The right cricoarytenoid joint tended to be located slightly more
laterally, posteriorly, and inferiorly than the left joint. The longitudinal axis of the thyroid cartilage was inclined to shift to the right
posteriorly against the axis of the cricoid cartilage. The thyroid cartilage as a whole tended to tilt to the right against the cricoid cartilage.
5) There must be some compensatory mechanisms for the asymmetric framework to keep the vocal fold edges relatively symmetric.
KEY W O R D S — asymmetry, laryngeal framework, normal variation.

It is well known that many people have an asym­ the anterior commissure ( D T A ) , width of the thy­
metric larynx. From a clinical point of view, it is ex­ roid lamina at the lower edge ( D T L ) , height of the
tremely important to determine whether a given thyroid lamina at the inferior tuberculum ( H T M ) ,
asymmetry of the larynx is within the range of nor­
mal variations or is a disordered condition. Honjo et
al' attributed a clinically observed group of asym­
metric false folds to an asymmetric thyroid cartilage
that was a normal variation. Asymmetries of the
cartilaginous framework of the larynx have been
described in some r e p o r t s . H o w e v e r , detailed
analyses of asymmetry are few. The purpose of this
study is to investigate asymmetry of the laryngeal
framework in a normal population of different age
groups.

METHODS
A total of 50 fresh Japanese cadaver larynges ob­
tained at the time of autopsy were included in this
study. Of the 50 larynges, ten were from newborns
(five males, five females), 20 were from adults in
their 20s (ten males, ten females), and 20 were from
adults in their 50s (ten males, ten females). All adults
were right-handed. None of the larynges had any
sign of disease and their structures appeared nor­
mal.
Following removal of the soft tissue, measure­ Fig 1. Measurements for thyroid cartilage. See Methods for
definition of additional abbreviations. TU — upper edge
ments of 17 selected dimensions and four selected at anterior midline, T A — level of anterior commissure at
angles of the laryngeal framework were taken. anterior midline, T L — lower edge at anterior midline,
IT — inferior tuberculum, SC — tip of superior cornu,
Thyroid Cartilage (Fig 1). The items selected for BSC — base of superior cornu, IC — tip of inferior cornu,
the measurements of the thyroid cartilage were BIC — base of inferior cornu, TNU — tip of superior
thyroid incisure, C L U — midpoint of cricoid lamina at
width of the thyroid lamina at the upper edge upper edge, C L L — midpoint of cricoid lamina at lower
( D T U ) , width of the thyroid lamina at the level of edge.

From the Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, Kurume, Japan.
Presented at the meeting of the American Laryngological Association, Palm Beach, Florida, April 23-25, 1988.
REPRINTS — Minoru Hirano, MD, Dept of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume
8 3 0 , Japan.

135

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136 Hirano et al, Asymmetry of Laryngeal Framework

Tl

Fig 2. Measurements for cricoid cartilage. See Methods for

definition of additional abbreviations. CAU — midpoint
of cricoid arch at upper edge, C L U — midpoint of cricoid
lamina at upper edge, JP — posterior end of facies ar-
ticularis arytenoidea.

distance between the tips of the superior and in­

ferior cornua (Ητρ), length of the superior cornu
(Hsc), length of the inferior cornu (Hic), distance
of the tip of the superior thyroid incisure from the
posterior plane at the cricoid lamina (LTNU)* ('in­
dicates items measured on photographs), distance of
the base of the superior cornu from the midline of
the larynx ( W B S C ) * (the midline was defined as the
line between the anterior midpoint of the thyroid
Fig 3 . Measurements for cricothyroid complex. See Meth­
cartilage and the posterior midpoint of the cricoid ods for definition of additional abbreviations. T U — upper
lamina), distance of the base of the superior cornu edge of thyroid cartilage at anterior midline, CAU — mid­
from the frontal plane at the anterior edge ( L B S C ) * , point of cricoid arch at upper edge, C L U — midpoint of
cricoid lamina at upper edge, BSC — base of superior cor­
distance of the base of the inferior cornu from the nu, T L — lower edge of thyroid cartilage at anterior
midline of the larynx ( W B I C ) *, and distance of the midline, C A L — midpoint of cricoid arch at lower edge,
base of the inferior cornu from the frontal plane at C L L — midpoint of cricoid lamina at lower edge, BIC —
the anterior edge (LBIC) *. base of inferior cornu, BICP — posterior aspect of base of
inferior cornu, AC — anterior commissure, J P — posterior
end of facies articularis arytenoidea.
Cricoid Cartilage (Fig 2). The items selected for
measurement of the cricoid cartilage were height of
the cricoid lamina at the highest location ( H C L ) , tween the midpoint of the cricoid arch (CAL) and
distance of the posterior end of the facies articularis that of the cricoid lamina ( C L L ) .
arytenoidea ( J P ) from the midsagittal plane of the The angle of the thyroid cartilage against the cri­
cricoid cartilage (Wjp)*, distance of J P from the coid cartilage in the frontal plane ( A C T H ) * was de­
frontal plane at the anterior edge (LjP)*, and dis­ fined as the angle of the line between the bilateral
tance of J P from the anterior midpoint of the cricoid bases of the inferior cornua against the horizontal
arch (Djp)*. plane at the lower edge of the cricoid cartilage.
Cricothyroid Complex (Fig 3). The angle of the The distance between the anterior commissure
longitudinal axis of the thyroid cartilage against (AC) and the J P of the cricoid cartilage ( D j P C ) * was
that of the cricoid cartilage at the upper edge measured.
( A C T U ) * was measured. The longitudinal axis of the
thyroid cartilage was defined as the line between The angle of the line between the anterior com­
the midpoint of the upper thyroid edge (TU) and missure and the J P of the cricoid cartilage against
the midpoint between the bilateral bases of the su­ the midsagittal plane of the larynx ( A j P C ) * was
perior cornua (BSC). The longitudinal axis of the measured. This line was close to the location of the
cricoid cartilage was defined as the line between the vocal fold edge. The midsagittal plane of the larynx
midpoint of the cricoid arch (CAU) and that of the was defined as the plane that contained the AC and
cricoid lamina (CLU). the midpoint of the cricoid lamina.
The angle of the longitudinal axis of the thyroid The points of interest were marked with India ink
cartilage against that of the cricoid cartilage at the in order to facilitate exact measurements. The meas­
lower edge (ACTL) * was measured. The longitudi­ urements were conducted in one of the following
nal axis of the thyroid cartilage was defined as the two ways: a direct measurement with specimens by
line between the midpoint of the lower thyroid edge means of slide calipers and measurement on photo­
(TL) and the midpoint between the bilateral bases graphs. Measurements were repeated three times
of the inferior cornua (BIC). The longitudinal axis for each item and the median value was employed.
of the cricoid cartilage was defined as the line be- Measurements were accurate to 0.04 mm.

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 Hirano et al. Asymmetry of Laryngeal Framework 137
Female
•Male

. · Ι . •· m 50s . , 50·

: oo Sb ο<
:Ο
20'S
20's

Newborn
-0.10 -o:o5
- 1)
•
0.10
Λ Newborn
-0.2 -0.1
^
(1 0.1
0.05 0.3

ο φα:) οθο ο
caiD TD 9d ο α. c . ο ο οοφ
Ρ • ,—Η «« , «—, , » -^^h—·.—•—.—· ·»»

Oq. QD '3D Ο
OD Ο Ο Ο
»J—»-

«« Newborn Newborn.
-0.2 -0.1 0.1 0.2 -0.4 -0.3 -0.2 -0.1 0.1
-0.2 -0.1 Ο 0.1 0.2

00 OCBOr _ , 8 0D 00 ο ο ο
. Hi • », - · — H —««•« , — ^
Fig 4. Asymmetry indices. A) DTU and
OaSDCOD I θ u t D Ο OKDO Ο Ο DTL. Two circles connected with line are
—β—·•··» from same larynx. B) HTM, C) HTP, D)
• I—4
LTNU, E ) WBSC, F ) LBSC, C ) WBIC, H)
LBIC.
0 0 ^ ° .. ^ ο
Newborn * Newborn ^ ^ο
-0.3 -0.2 -0.1 (I 0.1 0.2 0.3 -0.3 -0;2 -Oil 1 0.1 0.2 0.3 0.4
G Η

For the dimensions investigated, the degree of tween the sexes. In the following paragraphs, we
asymmetry was represented by the asymmetry in­ will focus chiefly on directional preponderance in
dex (Al), which was defined as asymmetry.
A I = - ^ Thyroid Cartihge. Figure 4A shows the Al for the
(R + L)I2 width of the thyroid lamina ( D T U and D T L ) . The
where R was the measured value for the right side distribution of the Al was also similar for D T A . The
and L was that of the left side. When the value is width was greater on the right side than on the left
the same for both sides, the Al becomes 0. When the side (positive Al values) in some larynges, whereas
measured value for the right side is greater than it was greater on the left (negative Al values) in the
that of the left side, the Al assumes a positive value, others. In other words, there was no directional
whereas it presents a negative value when the meas­ preponderance in asymmetry in any age group. The
ured value is greater on the left side. For the angles absolute value of the Al was less than 0.1 in almost
studied, the measured values were compared direct­ all cases. T h e Al value of 0.1 implies that the right-
ly and discussed. left difference in measured value is 1 0 % of the
mean of the value for the right side added to that for
the left side.
RESULTS
Since the purpose of this paper is to investigate The height of the thyroid lamina (HTM) was
asymmetry of the laryngeal framework, only those greater on the right side than on the left side (posi­
data that are related directly to asymmetry will be tive Al values) in the majority of the newborns,
presented. The measured values for each item will whereas H T M was greater on the left (negative Al
be reported elsewhere. values) in the majority of the adult larynges (Fig
4 B ) . The absolute value of the Al was less than 0.1
All dimensions and angles investigated differed to in all but two cases.
a greater or lesser extent between the right and left
sides in the majority of the larynges in all three age The distance between the tip of the superior cor-
groups. In other words, all larynges were more or nu and that of the inferior cornu (ΗΤΡ) was slightly
less asymmetric. The degree of asymmetry did not greater on the left (negative Al values) in the major­
differ systematically among the age groups or be­ ity of newborns, whereas in adults, the Al assumed

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138 Hirano et al, Asymmetry of Laryngeal Framework

J oScr. τ
^* ,• . . 1 t . 50'S 50's mm
Female
•Male
Fig 5. Asymmetry indices. A) Height of cri­
>oo ^O'X^: coid lamina at highest location. B) Distance
, 1.1. . 20s 20'S
of posterior end of facies articularis ary-
tenoidea from anterior midpoint of cricoid
arch.

-0.20 -0.10 -0.05 0.05 -0.15 -0.10 -0.05 0.05 0.10 0.15

A Β

both negative and positive values, demonstrating no The location of the bases of the superior and in­
directional preponderance in asymmetry (Fig 4 C ) . ferior cornua presented a unique pattern of asym­
The absolute value of the Al was less than 0.1 in metry in the adults, especially in the oldest age
many larynges, but in some it was greater than 0.1. group (Fig 4E-H). In the 50s age group, the Al for
The superior and inferior cornua of several larynges the distance of the base of the superior cornu from
showed marked right-left differences in length, pre­ the midline ( W B S C ) presented positive values (Fig
senting absolute values of the Al of greater than 0.2. 4 E ) , whereas the Al for the distance from the an­
Asymmetry for the superior and inferior cornua, terior frontal plane (LBSC) assumed negative values
however, did not show any directional preponder­ (Fig 4F) in most larynges. This indicated that the
ance in any age groups. upper edge of the right thyroid lamina tended to be
located more anterolaterally than that of the left
For the distance of the tip of the superior thyroid lamina. This tendency was not very marked in the
incisure from the posterior plane at the cricoid lam­ adults in their 20s or in the newborns. The absolute
ina (LTNU) , the Al assumed positive values in most value of the Al exceeded 0.1 in many larynges, indi­
adults in their 50s (Fig 4 D ) . In other words, the cating the existence of a considerable degree of
right tip of the superior thyroid incisure was located asymmetry.
anterior to the left tip. The same tendency was
noted also for the adults in their 20s, but to a lesser As for the base of the inferior cornu, the Al for
extent. The anteroposterior distance between the the distance from the midline ( W B I C ) showed nega­
bilateral tips varied. In some larynges, the right tip tive values (Fig 4G), whereas the Al for the distance
was located anterior to the left by 3 mm or more. from the anterior frontal plane (LBIC) assumed pos-

! § :
50S . ,
11 · ϊ · f f 11 · !

20S
. · t t i t t · · 1 · • · mm

Newborn | Newborn
-10 -5 0 5 10 -10 -5 (1 5 10
Degree Oegree
A Β

. ^ ' M r

20s 20S ' ψ f ^ f Ψ r

Newborn. | Newborn
-10 -5 -0.10 -0.05 0.05 0.10 -5
Degree Asymmetry Index Degree

Fig 6. Results for cricothyroid complex. A) Value in degrees of ACTU, Β) value in degrees of ACTL, C) value in degrees of ACTH,
D) asymmetry index for DJPC, E ) differences in degrees in AJPC between two sides. For ACTU and ACTL, positive values in­
dicate that axis of thyroid cartilage is shifted to right posteriorly against axis of cricoid cartilage by degree indicated, whereas
negative values indicate that thyroid axis is shifted to left posteriorly. For ACTH, positive values indicate that thyroid cartilage is
tilted to right against cricoid cartilage, whereas negative values imply that thyroid cartilage is inclined to left. Values for AjPC
were obtained by subtracting left AjPC value from right AjPC value. Therefore, positive values imply that angle is greater on
right side than on left side.

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 Hirano et al. Asymmetry oj Laryngeal Framework 139

Fig 7. Photographs of larynges demonstrating asymmetric frame­

work typical of older adults. Note lateralward tilt of right thyroid
lamina, medialward tilt of left thyroid lamina, right tip of
superior thyroid incisure (TNU) located anterior to left TNU,
right base of superior cornu (BSC) located more anterolaterally
than left BSC, shift of longitudinal thyroid axis from cricoid axis,
rightward incHnation of thyroid cartilage against cricoid cartilage
and fairly symmetric vocal fold edges. Ruler is graduated in
millimeters. A) View from above before removal of vocal folds
and arytenoid cartilages, B) view from above after removal of
vocal folds and arytenoid cartilages, C) view from back. TU —
upper edge at anterior midline, C L U — midpoint of cricoid lami­
na at upper edge, AC — anterior commissure, CAU — midpoint
of cricoid arch at upper edge, J P — posterior end of facies articu-
laris arytenoidea, BICP — posterior aspect of base of inferior cor-

itive values (Fig 4H) in the majority of the adults in JP from the midsagittal plane (Wjp) and that from
their 50s. In other words, the lower edge of the the anterior frontal plane (Ljp). This tendency was
right thyroid lamina was located more posteromedi- not marked in the newborns. The absolute value of
ally than that of the left lamina. This phenomenon the Al was less than 0.1 in most cases.
was noted also in the adults in their 20s, but with
more exceptions. Again, the absolute value of the Al These results indicate that the right cricoaryte­
was greater than 0.1 in many cases, indicating the noid joint tends to shift slightly downward, back­
existence of a marked asymmetry. ward, and lateralward with increasing age.

The results shown in Fig 4 D - H as a whole indi­ Cricothyroid Complex. The angles of the longi­
cate that with aging, the right thyroid lamina tends tudinal axis of the thyroid cartilage against that of
to tilt laterally while the left lamina tends to tilt the cricoid cartilage ( A C T U , A C T L ) are shown in Fig
medially. 6A,B. At the upper edge, the axis of the thyroid car­
tilage was shifted to the right posteriorly (positive
Cricoid Cartilage. The Al for the height of the A c T U values in Fig 6A) in most adult larynges. This
cricoid lamina (HCL) presented negative values in tendency was not consistent in newborns. The abso­
almost all adults of both age groups (Fig 5A). In lute value of AcTU was 5° or less in the majority of
other words, the cricoid lamina was higher on the the cases. At the lower edge, there was no direction­
left side than on the right side. This phenomenon al preponderance in the shift of the thyroid axis
was inconsistent in the newborns. The cricoid lami­ against the cricoid axis in any age group (Fig 6B).
na was highest at a location slightly medial to the The absolute value of A c T L varied greatly, and it
cricoarytenoid joint in most larynges. In some la­ exceeded 5° in some larynges.
rynges, it was highest at the JP. The absolute value
of Al was less than 0.1 in the majority of the laryn­ Figure 6C shows the angle of the thyroid cartilage
ges investigated. against the cricoid cartilage in the frontal plane
( A C T H ) . Most adult larynges presented positive
The location of the JP showed a unique pattern of values, indicating that the thyroid cartilage was
asymmetry. Its distance from the anterior midpoint tilted to the right against the cricoid cartilage. In
of the cricoid arch (Djp) was greater on the right side newborns, no directional preponderance in tilting
than on the left side in the majority of the adult la­ of the thyroid cartilage was observed. The absolute
rynges, presenting with positive Al values (Fig 5 B ) . value of A C T H varied. It was 5° or greater in some
The same tendency was noted for the distance of the larynges.

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140 Hirano et al, Asymmetry of Laryngeal Framework

There was no directional preponderance in dif­ The left thyroid lamina is higher than the right at
ferences between the right and left sides for the dis­ the inferior tuberculum. The cricoid lamina also is
tance between the AC and the J P (DjPC) (Fig 6 D ) . higher on the left side than on the right side. The
The absolute value of the Al for DjPC was less than right cricoarytenoid joint is located slightly more
0.1 in all cases. The angle of the line between the laterally, posteriorly, and inferiorly than the left
AC and the J P against the midsagittal plane of the joint. The thyroid cartilage is tilted to the right rela­
larynx (AjPC) was different between the right and tive to the cricoid cartilage.
left sides in most larynges (Fig 6 E ) . As described
earlier, this line was close to the vocal fold edge. No It should be noted that all adults investigated
directional preponderance was noted in the differ­ were right-handed. Two questions remain for fur­
ences of AjPC between the two sides. The absolute ther studies. Is the pattern of asymmetry observed
value of the right-left difference of AjPC was less in the older adults attributed to the right-handed­
than 5° in most larynges. ness? If so, how does it occur? The asymmetry of the
thyroid cartilage of older men reported by Honjo et
Figure 7 shows photographs of a larynx with the al' appears to be basically the same as that observed
typical pattern of framework asymmetry for older in the present study. They did not report the hand­
adults. edness of their subjects. Since the majority of Japa­
nese people are right-handed, the subjects in their
DISCUSSION paper, at least most of them, are presumed to be
right-handed. A systematic study of the laryngeal
Asymmetry of the cartilaginous framework of the
framework of left-handed adults is required in or­
larynx has been described previously.'* It has,
der to generalize the relationship between handed­
however, not been investigated systematically.
ness and the direction of asymmetry of the laryngeal
The results of the present study are summarized framework.
as follows. The laryngeal framework is asymmetric
to a greater or lesser extent in all larynges in all age There were some exceptional cases in which
groups. In newborns, there is no directional pre­ asymmetry of the framework was not very marked
ponderance in any pattern of asymmetry. or the laryngeal framework was deformed to the
opposite direction. The reasons for this await fur­
In older adults, there is a directional preponder­ ther investigation.
ance in the pattern of asymmetry. The right thyroid
lamina tends to tilt laterally, whereas the left thy­ It should be noted that the line between the AC
roid lamina shows a tendency to tilt medially. As a and the J P of the cricoid cartilage, which was close
result, the right tip of the superior thyroid incisure to the location of the vocal fold edge, did not show
is located anterior to the left tip, the base of the directional preponderance in asymmetry. Further­
right superior cornu is placed more anterolaterally more, the degree of asymmetry was not very great.
than that of the left superior cornu, the base of the This indicates that there must be some compensa­
right inferior cornu is situated more posteromedial- tory mechanisms that keep the edges of the bilateral
ly than that of the left inferior cornu, and the lon­ vocal folds relatively symmetric. Further studies of
gitudinal axis of the thyroid cartilage at the upper the djmamics in excised larynges and living subjects
edge shifts to the right posteriorly against the longi­ are required to elucidate the compensatory mecha­
tudinal axis of the cricoid cartilage. nisms.
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1. Honjo I, Tanaka S, Tanabe M. Pathogenesis of protruded (Warsz) 1967;26:118-28.
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2. Minnigerode B. Messungen iiber die Lage einiger auf den adult human larynx. Arch Otolaryngol 1971;94:432-9.
Schildknorpel projizierter Teile des Kehlkopfinneren. HNO 1955;
5:51-6. 5. Hiramoto M. Functional anatomy of the larynx. Pract
Otol (Kyoto) 1977;2:177-97.
3. Malinowski A. The shape, dimensions and process of
calcification of the cartilaginous framework of the larynx in rela­ 6. Kahane J C . A morphological study of the human prepu­
tion to age and sex in the Polish population. Folia Moφhol bertal and pubertal larynx. Am J Anat 1978;151:11-20.

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