LARYNX

The cervical viscera are composed of three layers, each named after
their primary function:
1. Endocrine layer: Contains the thyroid and parathyroid glands.
2. Respiratory layer: Contains the larynx and trachea.
3. Alimentary layer: Contains the pharynx and esophagus.

Respiratory Layer (Larynx and Trachea)

• The larynx and trachea are located in the respiratory layer. This
part of the cervical viscera routes air to the lungs and produces
voice, which makes each person’s voice unique. Thinking about
this can make one more aware of their own voice, especially while
speaking or recording.

Larynx Overview
• The larynx plays a dual role:
o It is responsible for voice production.
o It maintains an open airway, ensuring that air reaches the
trachea and lungs.
• The larynx is located in the anterior neck at the level of the C3 to
C6 vertebrae.
• It connects the inferior part of the pharynx with the trachea.
 • Contains the vocal cords (vocal folds), which are crucial for
phonation (voice production).

Skeleton of the Larynx

The larynx is supported by a framework of nine cartilages:
• Single cartilages:
1. Thyroid cartilage
2. Cricoid cartilage
3. Epiglottic cartilage
• Paired cartilages:
1. Arytenoid cartilages
2. Corniculate cartilages
3. Cuneiform cartilages

Thyroid Cartilage
• Largest cartilage in the laryngeal skeleton.
• The superior border of the thyroid cartilage lies opposite the C4
vertebra.
• The cartilage is formed by two plate-like laminae that unite
anteriorly to form the laryngeal prominence (commonly known as
the Adam’s apple).
 o The laryngeal prominence is more prominent in males due
to a sharper angle between the two laminae and is less
visible in females.
• Superior thyroid notch: Located above the laryngeal prominence,
where the laminae diverge to form a V-shaped notch.
• Inferior thyroid notch: A shallow indentation located in the
middle of the inferior border of the thyroid cartilage.
• Posterior borders of the laminae:
o Project superiorly as the superior horns.
o Project inferiorly as the inferior horns.
• The superior horns and superior border of the thyroid cartilage
are connected to the hyoid bone by the thyrohyoid membrane.
o This membrane has a thick median part known as the
median thyrohyoid ligament.
o The lateral parts of the membrane are called the lateral
thyrohyoid ligaments.
• The inferior horns of the thyroid cartilage articulate with the
cricoid cartilage at the cricothyroid joints, allowing the thyroid
cartilage to rotate and glide. This movement changes the length of
the vocal folds, affecting voice pitch.

Cricoid Cartilage
• The cricoid cartilage is shaped like a ring and is the only complete
ring of cartilage that encircles the airway.
 o Anterior part (arch): Thin band, attaches to the inferior
border of the thyroid cartilage via the median cricothyroid
ligament.
o Posterior part (lamina): Broad band, attaches inferiorly to
the first tracheal ring via the cricotracheal ligament.
• Key landmark at the level of C6 vertebra:
o The carotid artery can be compressed against the C6
vertebra at this level.
o Junction where:
▪ Larynx joins the trachea.
▪ Pharynx joins the esophagus.
o The recurrent laryngeal nerve enters the larynx at this level.

Arytenoid Cartilages
• The arytenoid cartilages are paired, pyramid-shaped, and
articulate with the superior border of the cricoid cartilage.
• Structure:
o Apex: Superior portion where the corniculate cartilages are
attached.
o Vocal process: Projects anteriorly and provides the posterior
attachment for the vocal ligament.
o Muscular process: Projects laterally and serves as a lever to
which the posterior and lateral cricoarytenoid muscles are
attached.
 • Cricoarytenoid joints: Between the base of the arytenoid
cartilages and the superior lateral surfaces of the cricoid cartilage
lamina. These joints allow the arytenoid cartilages to:
o Slide towards or away from each other.
o Tilt anteriorly or posteriorly.
o Rotate, affecting the tension, relaxation, and approximation
of the vocal cords.

Vocal Ligaments and Conus Elasticus

• The vocal ligaments are the free superior borders of the conus
elasticus and form the submucosal skeleton of the vocal folds.
• The conus elasticus has two components:
1. Lateral cricothyroid ligaments: Extends laterally between
the vocal folds and superior border of the cricoid cartilage.
2. Median cricothyroid ligament: Forms the anterior part of
the conus elasticus, blending with the lateral parts.
• The conus elasticus closes the tracheal inlet, leaving an opening
called the rima glottidis, which is located between the vocal folds.

Epiglottic Cartilage
• The epiglottic cartilage lies posterior to the root of the tongue and
hyoid bone, and anterior to the laryngeal inlet.
o It forms the superior part of the anterior wall and the
superior margin of the laryngeal inlet.
 • Consists of elastic cartilage, which provides flexibility to the
epiglottis.
• The epiglottis is heart-shaped and covered with a mucous
membrane.
o Its main function is to act as a valve: It closes the superior
opening of the larynx during swallowing, preventing food
and liquids from entering the airway.
• The stalk of the epiglottis (inferior end) is attached to the angle of
the thyroid laminae via the thyroepiglottic ligament.

Laryngeal Cavity (Including Laryngeal Ventricles)

• The laryngeal cavity extends from the laryngeal inlet, which
communicates with the laryngopharynx, down to the inferior
border of the cricoid cartilage, where it continues with the
tracheal cavity.
• The cavity is divided into three regions:
1. Laryngeal vestibule: The area between the laryngeal inlet
and the vestibular folds.
2. Middle part of the laryngeal cavity: Located between the
vestibular folds (false vocal cords) and vocal folds (true vocal
cords). This part is considered the central cavity of the
larynx.
▪ Laryngeal ventricles: These are small lateral recesses
that extend laterally between the vestibular and vocal
folds.
 ▪ Laryngeal saccules: Outpouchings from each laryngeal
ventricle that are lined with mucosal glands. These
glands are responsible for lubricating the vocal folds,
aiding in vocal cord movement during phonation.
3. Infraglottic cavity: This extends from the vocal folds to the
inferior border of the cricoid cartilage and continues into the
lumen of the trachea.

Vocal Folds and Glottis

• Vocal folds: Consist of vocal ligaments and vocalis muscles.
o Vocalis muscles: Slender muscle slips located lateral to the
vocal ligaments, containing fine fibers.
o The vocal folds produce vibrations for sound during
phonation when air is pushed through from the lungs.
o When fully closed, the vocal folds prevent air from entering
the lungs.
• Glottis: Includes the vocal folds and the rima glottidis.
o The shape of the rima glottidis changes with different
actions:
▪ Normal breathing: The rima is narrow and wedge-
shaped.
▪ Forced respiration: The rima becomes wide and
trapezoidal.
▪ Phonation: The rima is slit-like.
 o Changes in voice pitch are due to variations in the tension,
length of the vocal folds, and expiratory effort.
▪ After puberty, the male voice becomes deeper because
the vocal folds increase in length.

Vestibular Folds
• The vestibular folds (false vocal cords) extend between the
thyroid and arytenoid cartilages.
o Their primary role is protective, as they do not participate in
sound production.
• Each vestibular fold contains the vestibular ligament enclosed in a
thick fold of mucous membrane.

Quadrangular Membrane
• Connects the arytenoid cartilages to the epiglottic cartilage.
• Aryepiglottic ligament: The superior margin of the quadrangular
membrane, covered by mucosa to form the aryepiglottic fold.
• Vestibular ligament: The inferior margin of the quadrangular
membrane, covered by mucosa to form the vestibular fold.
 Laryngeal Muscles
The muscles of the larynx are divided into two groups: extrinsic muscles
and intrinsic muscles.
Extrinsic Muscles
• Function: Move the larynx as a whole, changing its position in the
neck (e.g., during swallowing).
• Muscles:
o Infrahyoid muscles: These muscles depress the hyoid bone
and larynx. They include:
▪ Sternohyoid: Pulls the hyoid bone downwards.
▪ Omohyoid: Depresses the hyoid and also helps keep
the internal jugular vein open.
▪ Sternothyroid: Depresses the larynx specifically.
 ▪ Thyrohyoid: Depresses the hyoid or elevates the larynx
depending on the action.
o Suprahyoid muscles: These muscles elevate the hyoid bone
and indirectly the larynx during swallowing and speaking.
They include:
▪ Mylohyoid: Elevates the floor of the mouth, aiding in
swallowing.
▪ Geniohyoid: Pulls the hyoid bone anteriorly and
superiorly.
▪ Digastric: Assists in elevating the hyoid bone.
▪ Stylohyoid: Elevates and retracts the hyoid bone.
o Stylopharyngeus: Elevates both the larynx and the pharynx
during swallowing.

Intrinsic Muscles
• Function: These muscles move individual components of the
larynx, altering the shape and tension of the vocal folds to control
sound production, as well as opening and closing the rima glottidis
(space between the vocal cords).
• Divided into Functional Groups:
1. Abductors and Adductors: Move the vocal folds to open and
close the rima glottidis.
2. Sphincters: Close the laryngeal inlet to protect the airway
during swallowing.
3. Tensors: Tighten the vocal folds to raise the pitch of the
voice.
 4. Relaxers: Loosen the vocal folds to lower the pitch of the
voice.

Functional Groups of Intrinsic Laryngeal Muscles

1. Abductors and Adductors
• Abductors: Open the vocal folds to allow air passage, widening
the rima glottidis.
o Only Abductor:
▪ Posterior cricoarytenoid muscles:
▪ Origin: Posterior surface of the cricoid cartilage
lamina.
▪ Insertion: Vocal process of arytenoid cartilage.
▪ Action: Rotate the arytenoid cartilages laterally,
moving the vocal folds apart (important during
breathing, especially forced respiration).
• Adductors: Close the vocal folds, bringing them together and
narrowing the rima glottidis.
o Main Adductors:
▪ Lateral cricoarytenoid muscles:
▪ Origin: Arch of cricoid cartilage.
▪ Insertion: Vocal process of arytenoid cartilage.
▪ Action: Pull the muscular processes anteriorly,
rotating arytenoid cartilages to bring vocal folds
together.
 ▪ Transverse arytenoid muscles (single muscle):
▪ Origin: One arytenoid cartilage.
▪ Insertion: Contralateral arytenoid cartilage.
▪ Action: Pull arytenoid cartilages together to
adduct vocal folds, crucial for phonation.
▪ Oblique arytenoid muscles (paired):
▪ Origin: One arytenoid cartilage.
▪ Insertion: Contralateral arytenoid cartilage,
crossing each other to form an "X" shape.
▪ Action: Assist the transverse arytenoid muscles in
adducting the arytenoid cartilages.
o Sphincter Function:
▪ The arytenoid and lateral cricoarytenoid muscles work
together as a protective reflex sphincter. When foreign
objects (liquids or solids) approach the laryngeal
vestibule, they bring the aryepiglottic folds together
and close the laryngeal inlet. This prevents aspiration
into the airway, a vital protective mechanism—
especially when swimming or drinking.
• Phonation:
o When the adductors bring the vocal folds together, air is
pushed through, causing vibrations that produce sound
(phonation).
o When the transverse arytenoid muscle is inactive, the vocal
folds don’t fully close, allowing for a whispering voice since
only part of the vocal folds vibrate.
2. Tensors
• Cricothyroid muscles:
o Origin: Anterolateral cricoid cartilage.
o Insertion: Inferior margin and inferior horn of thyroid
cartilage.
o Action: Tilt the thyroid cartilage anteriorly and inferiorly
toward the cricoid cartilage, elongating and tightening the
vocal ligaments. This action increases the tension in the
vocal folds, raising the pitch of the voice (important in high-
pitched sounds during speech or singing).
3. Relaxers
• Thyroarytenoid muscles:
o Origin: Lower half of the posterior aspect of the thyroid
cartilage and cricothyroid ligament.
o Insertion: Anterolateral surface of arytenoid cartilage.
o Action: Pull the arytenoid cartilages anteriorly, relaxing the
vocal ligaments and reducing tension. This causes the pitch
of the voice to lower.
4. Tensor and Relaxer (Vocalis Muscle)
• Vocalis muscle:
o Location: Lies medial to the thyroarytenoid muscles and
lateral to the vocal ligaments within the vocal folds.
o Origin: Lateral surface of the vocal process of the arytenoid
cartilage.
o Insertion: Ipsilateral vocal ligament.
 o Action: Acts during speech and singing to adjust tension on
the vocal ligaments in specific sections. This allows fine-
tuning of pitch and modulation of voice quality. It can
simultaneously tense and relax different parts of the vocal
ligaments, which is crucial in creating variations in tone
during animated speech and singing.

Innervation of Laryngeal Muscles

• All intrinsic muscles of the larynx are innervated by branches of
the vagus nerve (CN X).
o Recurrent laryngeal nerve: Innervates all intrinsic muscles
except the cricothyroid.
o External laryngeal nerve: Innervates the cricothyroid
muscle.
o Mnemonic: "External is for motor"—remember that the
external laryngeal nerve provides motor innervation to the
cricothyroid muscle, while the internal laryngeal nerve
provides sensory innervation.

Blood Supply to the Larynx

• Arterial Supply:
1. Superior laryngeal artery:
▪ Source: Branch of the superior thyroid artery.
▪ Course: Accompanies the internal branch of the
superior laryngeal nerve through the thyrohyoid
membrane.
 ▪ Supply: Internal surface of the larynx above the vocal
folds.
2. Inferior laryngeal artery:
▪ Source: Branch of the inferior thyroid artery.
▪ Course: Accompanies the inferior laryngeal nerve.
▪ Supply: Mucous membrane and muscles in the inferior
part of the larynx.

• Venous Drainage:
1. Superior laryngeal vein:
▪ Joins the superior thyroid vein, draining into the
internal jugular vein.
2. Inferior laryngeal vein:
▪ Joins the inferior thyroid vein or venous plexus,
draining into the left brachiocephalic vein.

Innervation of the Larynx

• Superior laryngeal nerve (branch of vagus nerve):
o Divides into two terminal branches:
1. Internal laryngeal nerve:
▪ Course: Passes through the thyrohyoid
membrane with the superior laryngeal artery.
▪ Function: Sensory innervation to the laryngeal
mucosa above the vocal folds, including the
laryngeal vestibule and middle cavity.
 2. External laryngeal nerve:
▪ Course: Descends with the superior thyroid
artery, posterior to the sternothyroid muscle.
▪ Function: Provides motor innervation to the
cricothyroid muscle.
• Inferior laryngeal nerve:
o Continuation of the recurrent laryngeal nerve, after its
course in or near the tracheo-esophageal groove.
o Function: Motor innervation to all intrinsic muscles (except
the cricothyroid) and sensory innervation to the mucosa
below the vocal folds (infraglottic cavity).

The Trachea
• Start: Begins at the inferior end of the larynx (C6 vertebra level).
• End: Ends by bifurcating into the right and left main bronchi at the
level of the sternal angle (T4-T5 vertebra level).
• Structure:
o Cartilaginous rings: 16 to 20 C-shaped rings of hyaline
cartilage that maintain the patency of the trachea and
prevent collapse during breathing.
o Trachealis muscle: Smooth muscle connecting the posterior
ends of the cartilage rings, allows flexibility during
swallowing and regulates the diameter of the trachea.
o Mucosa: Lined by pseudostratified columnar epithelium with
cilia that move mucus upward toward the pharynx for
expectoration or swallowing (the "mucociliary escalator").
o Blood Supply: Branches of the inferior thyroid arteries.
o Venous Drainage: Drains into the inferior thyroid venous
plexus.
o Nerve Supply: Branches of the recurrent laryngeal nerves for
motor and sensory innervation.