The Larynx - JU Medicine · Laryngeal cavity • The central cavity of the larynx is tubular in...
Transcript of The Larynx - JU Medicine · Laryngeal cavity • The central cavity of the larynx is tubular in...
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TheLarynxProf. Dr.Mohammed Hisham Al-Muhtaseb
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TheLarynx
• ExtendsfromthemiddleofC3vertebratillthelevelofthelowerborderofC6
• ContinueasTrachea
• Aboveitopensintothelaryngo-pharynx
• Suspendedfromthehyoidboneaboveandattachedtothetracheabelowbymembranesandligaments
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Functions
• 1.actsasanopenvalveinrespiration
• 2.Actsasaclosedvalveindeglutition
• 3.Actsasapartiallyclosedvalveintheproductionofvoice
• 4.Duringcoughitisfirstclosedandthenopensuddenlytoreleasecompressedair
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Parts
• 1.Cartilage
• 2.Mucosa
• 3.Ligaments
• 4.Muscles
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Cartilage
• A.Single:EpiglottisCricoidThyroid
B.Pairs:ArytenoidCuneiformCorniculate
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Cricoidcartilage
• Themostinferiorofthelaryngealcartilages
• Completelyencirclestheairway
• Shapedlikea'signetring'
• Broadlaminaofcricoidcartilageposterior
• Muchnarrowerarchofcricoidcartilage circlinganteriorly.
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Cricoidcartilage• Posteriorsurfaceofthelaminahastwooval
depressionsseparatedbyaridge
• The esophagus isattachedtotheridge
• Depressionsareforattachmentoftheposteriorcrico-arytenoidmuscles.
• Hastwoarticularfacets oneachside
• Onefacetisontheslopingsuperolateralsurfaceandarticulateswiththebaseofanarytenoidcartilage;
• Theotherfacetisonthelateralsurfacenearitsbaseandisforarticulationwiththeinferiorhornofthethyroidcartilage
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Thyroidcartilage• Thelargestofthelaryngealcartilages
• Itisformedbyarightandaleftlamina
• Widelyseparatedposteriorly,butconvergeandjoinanteriorly
• Posteriormarginofeachlaminaiselongatedtoformasuperiorhorn andaninferiorhorn
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Thyroidcartilage• Mostsuperiorpointofthesiteoffusionbetweenthetwolaminaeisthelaryngealprominence ('Adam'sapple')
• Anglebetweenthetwolaminaeismoreacuteinmen(90°)thaninwomen(120°)
• Superiortothelaryngealprominence,thesuperiorthyroidnotch separatesthetwolaminae
• Superiorthyroidnotchandthelaryngealprominencearepalpable landmarksintheneck
• Lessdistinctinferiorthyroidnotch inthemidlinealongthebaseofthethyroidcartilage.
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Thyroidcartilage
• Themedialsurfaceoftheinferiorhornhasafacetforarticulationwiththecricoidcartilage;
• Thesuperiorhornisconnectedbya ligamenttotheposteriorendofthegreaterhornofthehyoidbone.
• Lateralsurfaceoflaminaismarkedbyaridge(theobliqueline),whichcurvesanteriorlyfromthebaseofthesuperiorhorntotheinferiormarginofthelamina.
• Endsoftheobliquelineareexpandedtoformsuperior andinferiorthyroidtubercles
• Theobliquelineisasiteofattachmentfortheextrinsicmuscles ofthelarynx(sternothyroid,thyrohyoid,andinferiorconstrictor).
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Epiglottis• Isa'leaf-shaped'cartilageattachedbyitsstemtotheangleofthethyroidcartilage
• Projectsposterosuperiorlyfromitsattachmenttothethyroidcartilage.
• Theattachmentisviathethyro-epiglotticligament inthemidlinebetweenthelaryngealprominenceandtheinferiorthyroidnotch
• Theuppermarginoftheepiglottisisbehindthepharyngealpartofthetongue.
• Theinferiorhalfoftheposteriorsurfaceoftheepiglottisisraisedslightlytoformanepiglottictubercle.
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Arytenoidcartilages
• Twoarytenoidcartilagesarepyramid-shapedcartilageswiththreesurfaces
• Baseofarytenoidcartilage andanApexofarytenoidcartilage
• The base ofarytenoidcartilageisconcaveandarticulateswiththefacetonthesuperolateralsurfaceofthecricoidcartilage;
• Theapexofarytenoidcartilagearticulateswithacorniculatecartilage;
• Themedialsurface ofeachcartilagefacestheother;
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Arytenoidcartilages
• Theanterolateralsurface hastwodepressions,separatedbyaridge,formuscle(vocalis) andligament(vestibularligament) attachment.
• Theanteriorangleofthebaseofarytenoidcartilageiselongatedintoavocalprocess towhichthevocalligament isattached
• Thelateralangleissimilarlyelongatedintoamuscularprocess forattachmentoftheposteriorandlateralcrico-arytenoidmuscles.
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CorniculateandCuneiform• Thecorniculatecartilagesaretwosmallconicalcartilages
• Basesarticulatewiththeapicesofthearytenoidcartilages
• Theirapicesprojectposteromediallytowardseachother.
• TheCuneiform aretwosmallclub-shapedcartilages
• Lieanteriortothecorniculatecartilages
• Suspendedinthepartofthefibroelasticmembranethatattachesthearytenoidtheepiglottis.
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Ligaments
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Extrinsicligaments
• Thyrohyoidmembrane
• Hyo-epiglotticligament
• Cricotrachealligament
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Thyrohyoidmembrane
• Toughfibroelasticligamentthatspansbetweenthesuperiormarginofthethyroidcartilagebelowandthehyoidbone
• Attachedtothethyroidlaminaeandadjacentanteriormarginsofthesuperiorhorns
• Ascendsmedialtothegreaterhornsandposteriortothebodyofthehyoidbonetoattachtothesuperiormarginsofthesestructures.
• Anaperture inthelateralpartofthethyrohyoidmembraneoneachsideisforthesuperiorlaryngealarteries,nerves,andlymphatics
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Thyrohyoidmembrane
• Theposteriorbordersofthethyrohyoidmembranearethickenedtoformthelateralthyrohyoidligaments.
• Alsothickenedanteriorlyinthemidlinetoformthemedianthyrohyoidligament.
• Occasionally,thereisasmallcartilage(triticealcartilage)ineachlateralthyrohyoidligament.
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Extrinsicligaments
• Cricotrachealligament runsfromthelowerborderofthecricoidcartilagetotheadjacentupperborderofthefirsttrachealcartilage.
• Thehyo-epiglotticligamentextendsfromthemidlineoftheepiglottis,anterosuperiorlytothebodyofthehyoidbone.
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Intrinsicligaments
• Thefibro-elasticmembraneoflarynxlinkstogetherthecartilagesandcompletesthearchitecturalframeworkofthelaryngealcavity
• Itiscomposedoftwoparts-alowercricothyroidligament andanupperquadrangularmembrane.
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Cricothyroidligament• Cricovocalmembraneorcricothyroidmembrane
• Attachedtothearchofcricoidcartilageandextendssuperiorly
• Endinafreeuppermargin withinthespaceenclosedbythethyroidcartilage
• Upperfreemarginattaches:
• Anteriorly tothethyroidcartilage;• Posteriorly tothevocalprocesses ofthearytenoid
cartilages.
• Thefreemarginisthickenedtoformthevocalligament,whichisunderthevocalfold (true 'vocalcord')ofthelarynx.
• Thecricothyroidligamentisalsothickenedanteriorlytoformamediancricothyroidligament
• Inemergencysituations,themediancricothyroidligamentcanbeperforatedtoestablishanairway
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Quadrangularmembrane
• Runsbetweenthelateralmarginoftheepiglottisandtheanterolateralsurfaceofthearytenoidcartilage
• Attachedtothecorniculatecartilage
• Freeuppermarginandafreelowermargin
• Freelowermargin isthickenedtoformthevestibularligament underthevestibularfold (false 'vocalcord')
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Quadrangularmembrane
• Vestibularligamentisseparatedfromthevocalligamentbelowbyagap
• Whenviewedfromabovethevestibularligamentislateraltothevocalligament
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CartilageandLigaments
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Laryngealjoints
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Cricothyroidjoints• Betweentheinferiorhornsofthethyroidcartilageandthecricoidcartilage,aresynovial
• Surroundedbyacapsuleandisreinforcedbyassociatedligaments
• Enablethethyroidcartilagetomoveforwardandtiltdownwards onthecricoidcartilage
• Forwardmovementanddownwardrotationofthethyroidcartilageeffectivelylengthensandputstensiononthevocalligaments
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Crico-arytenoidjoints• Betweenarticularfacetsonthesuperolateralsurfacesofthecricoidcartilageandthebasesofthearytenoidcartilages
• Enablethearytenoidcartilagestoslideawayortowardseachotherandtorotate
• Thevocalprocessespivoteithertowardsorawayfromthemidline.
• Thesemovementsabductandadductthevocalligaments
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Cavityofthelarynx
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Laryngealcavity• Thecentralcavityofthelarynxistubularinshapeandislinedbymucosa
• Supportisprovidedbythefibro-elasticmembraneoflarynxandbythecartilagestowhichitisattached.
• Thesuperiorapertureofthecavity(laryngealinlet) opensintotheanterioraspectofthepharynxjustbelowandposteriortothetongue
• laryngealinletisoblique andpointsposterosuperiorly
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laryngealinlet
• Anteriorborderisformedbymucosacoveringthesuperiormarginoftheepiglottis
• Lateralbordersareformedbymucosalfolds(aryepiglotticfolds),
• Posteriorborderinthemidlineisformedbyamucosalfoldthatformsadepression(interarytenoidnotch)betweenthetwocorniculatetubercles
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• Aryepiglotticfolds
• Enclosethesuperiormarginsofthequadrangularmembranesandadjacentsofttissues
• Twotuberclesonthemoreposterolateralmarginsidemarkthepositionsoftheunderlyingcuneiformandcorniculate cartilages;
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Inferioropening• Inferioropeningofthelaryngealcavityiscontinuouswiththelumenofthetrachea
• Completelyencircledbythecricoidcartilage
• Horizontalinpositionunlikethelaryngealinlet
• Theinferioropeningiscontinuouslyopenwhereasthelaryngealinletcanbeclosedbydownwardmovementoftheepiglottis
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Divisionintothreemajorregions
• Thevestibularandvocalfolds,divideitintothreemajorregions-thevestibule,amiddlechamber,andthe infraglotticcavity
• Thevestibule istheupperchamberofthelaryngealcavitybetweenthelaryngealinletandthevestibularfolds
• Vestibularfoldsenclosethevestibularligamentsandassociatedsofttissues;
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Divisionintothreemajorregions
• Themiddlepart ofthelaryngealcavityisverythinandisbetweenthevestibularfoldsaboveandthevocalfoldsbelow
• Vocalfoldsenclosethevocalligamentsandrelatedsofttissuesbelow.
• Theinfraglotticspace isthemostinferiorchamberandisbetweenthevocalfoldsandtheinferioropeningofthelarynx;
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VocalFolds• Consistof:• Vocalligament
• Mucousmembrane(stratifiedsquamous)
• Vocalismuscle
• Nosubmucosa
• Nobloodvessels(whiteincolor)
• Oneachsideextendbetweenthevocalprocessofthearytenoidandthebackoftheanteriorlaminaofthyroid.
• Longerinmalewhichcausethedifferenceofthepitchofthevoicebetweengenders
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Vestibularfolds• Falsevocalcords
• Vestibularfoldsenclosethevestibularligamentsandassociatedsofttissues
• Vascularised(redincolor)
• Fixedandnotmovableunlikethevocalcord
• Superiortothevocalcord
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Laryngealventriclesandsaccules• Oneachside,themucosaofthemiddlecavitybulgeslaterallythroughthegapbetweenthevestibularandvocalligamentstoproducealaryngealventricle
• Tubularextensionofeachventricle(laryngealsaccule)projectsanterosuperiorlybetweenthevestibularfoldandthyroidcartilage
• Withinthewallsoftheselaryngealsacculesarenumerousmucousglands.
• Mucus secretedintothesacculeslubricatesthevocalfolds.
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Rimavestibuliandrimaglottidis
• Rimavestibuli isatriangular-shapedopeningbetweenthetwoadjacentvestibularfolds attheentrancetothemiddlechamber
• Apexoftheopeningisanterioranditsbaseisposterior
• TheRimaglottidisisformedbythevocalfolds(truevocalcords) andadjacentmucosa-coveredpartsofthearytenoidcartilages
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Rimavestibuliandrimaglottidis• Rimaglottidisopeningseparatesthemiddlechamberabovefromtheinfraglotticcavity
• Thebaseofitisformedbythefoldofmucosa(interarytenoidfold)atthebottomoftheinterarytenoidnotch
• Rimaglottisisthenarrowestpartofthelaryngealcavity
• Boththerimaglottidisandtherimavestibulicanbeopenedandclosedbymovementofthearytenoidcartilagesandassociatedmembranes.
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Muscles
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Intrinsicmuscles
• Adjusttensioninthevocalligaments,
• Openandclosetherimaglottidis,
• Controltheinnerdimensionsofthevestibule,
• Closetherimavestibuli
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Cricothyroidmuscles• Fan-shapedmuscles
• Attachedtotheanterolateralsurfacesofthecricoidcartilageandexpandsuperiorlyandposteriorlytoattachtothethyroidcartilage
• Eachmusclehasanobliquepartandastraightpart:
• Theobliquepart runsinaposteriordirectionfromthearchofthecricoidtotheinferiorhornofthethyroidcartilage
• Thestraightpart runsmoreverticallyfromthearchofthecricoidtotheposteroinferiormarginofthethyroidlamina
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Cricothyroidmuscles• Pullthethyroidcartilageforwardandrotate itdownrelativetothecricoidcartilage
• TheseactionsTensesvocalcords
• Aretheonlyintrinsicmusclesinnervatedbythesuperiorlaryngealbranches ofthevagusnerves
• Allotherintrinsicmusclesareinnervatedbytherecurrentlaryngealbranches ofthevagusnerves
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Posteriorcrico-arytenoidmuscles• Thereisarightandaleftposteriorcrico-arytenoid
• ThefibersofeachmuscleoriginatefromtheBackofcricoidcartilage,andrunsuperiorlyandlaterallytothemuscularprocessesofthearytenoidcartilage
• Abductsthevocalcords byrotatingarytenoidcartilage
• Innervatedbytherecurrentlaryngealbranchesofthevagusnerves
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Lateralcrico-arytenoidmuscles
• MuscleoneachsideoriginatesfromtheUpperborderofcricoidcartilage,andrunsposteriorlyandsuperiorlytoinsertonthemuscularprocessofthearytenoid
• Adductsthevocalcords byinternallyrotatingarytenoidcartilage
• Innervatedbytherecurrentlaryngeal
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Transversearytenoid
• OriginatesfromBackandmedialsurfaceofarytenoidcartilageandinsertintheBackandmedialsurfaceofoppositearytenoidcartilage
• Closesposteriorpartofrimaglottidis byapproximatingarytenoidcartilages
• Recurrentlaryngealnerve
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Thyroarytenoid(vocalis)
• FromtheInnersurfaceofthyroidcartilagetotheArytenoidcartilage
• Relaxesvocalcords
• Recurrentlaryngealnerve
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Obliquearytenoid
• FromtheMuscularprocessofarytenoidcartilagetotheApexofoppositearytenoidcartilage
• Narrowstheinlet bybringingthearyepiglotticfoldstogether
• Recurrentlaryngealnerve
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Thyroepiglottic(aryepiglotticmuscles)
• FromtheMedialsurfaceofthyroidcartilagetotheLateralmarginofepiglottisandaryepiglotticfold
• Widenstheinlet bypullingthearyepiglotticfoldsapart
• Recurrentlaryngealnerve
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Extrinsicmuscles• Elevatorsofthelarynx:• 1.Digastricmuscle• 2.Stylohyoid• 3.Myelohyoid• 4.Geniohyoid
• Thelarynxmovesupinswallowingbythesemusclesassistedby:• Stylopharngeus,Salpingo-pharngeus,AndPalatopharngeus.
• Depressorsofthelarynx:• 1.Sternothyroid• 2.Sternohyoid• 3.Omohyoid
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MusclesandCavity
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Functionofthelarynx
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Respiration• Duringquietrespiration,thelaryngealinlet,vestibule,rimavestibuli,andrimaglottidisareopen
• Duringforcedinspirationthearytenoidcartilagesarerotatedlaterally,mainlybytheactionoftheposteriorcrico-arytenoidmuscles.
• Asaresult,thevocalfoldsareabducted,andtherimaglottidiswidens intoarhomboidshape,effectivelyincreasesthediameterofthelaryngealairway.
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Phonation
• Whenphonating,thearytenoidcartilagesandvocalfoldsareadducted andairisforcedthroughtheclosedrimaglottidis
• Thisactioncausesthevocalfoldstovibrate againsteachotherandproducesounds
• Canthenbemodifiedbytheupperpartsoftheairwayandoralcavity
• Tension inthevocalfoldscanbeadjustedbythevocalisandcricothyroidmuscles.
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Effortclosure
• Effortclosureofthelarynxoccurswhenairisretainedinthethoraciccavitytostabilizethetrunk
• Forexampleduringheavylifting,oraspartofthemechanismforincreasingintra-abdominalpressure
• Therimaglottidisiscompletelyclosed,asistherimavestibuliandlowerpartsofthevestibule
• Theresultistocompletelyandforcefullyshuttheairway.
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Swallowing• Duringswallowing,therimaglottidis,therimavestibuli,andvestibuleareclosed andthelaryngealinletisnarrowed
• Thelarynxmovesupandforward
• Thisactioncausestheepiglottis toswingdownward toeffectivelynarroworclosethelaryngealinlet
• Theupandforwardmovementofthelarynxalsoopenstheesophagus
• Alltheseactionstogetherpreventsolidsandliquidsfromentryintotheairway
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BloodSupply
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Arteries
• Themajorbloodsupplytothelarynxisbythesuperiorandinferiorlaryngealarteries
• Thesuperiorlaryngealarteryoriginatesfromthesuperiorthyroidbranchoftheexternalcarotidartery,
• Accompaniestheinternalbranchofthesuperiorlaryngealnervethroughthethyrohyoidmembranetoreachthelarynx.
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Arteries
• Theinferiorlaryngealarteryoriginatesfromtheinferiorthyroidbranchofthethyrocervicaltrunkofthesubclavianartery
• Togetherwiththerecurrentlaryngealnerve,ascendsinthegroovebetweentheesophagusandtrachea
• Itentersthelarynxbypassingdeeptothemarginoftheinferiorconstrictormuscleofthepharynx;
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Veins
• Veinsdrainingthelarynxaccompanythearteries:
• Superiorlaryngealveinsdrainintosuperiorthyroidveins,whichinturndrainintotheinternaljugularveins
• Inferiorlaryngealveins drainintoinferiorthyroidveins,whichdrainintotheleftbrachiocephalicveins.
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Lymphatics
• Lymphaticsdrainregionsaboveandbelowthevocalfolds:
• Thoseabovethevocalfoldsfollowthesuperiorlaryngealarteryandterminateindeepcervicalnodes
• Thosebelowthevocalfoldsdrainintodeepnodesassociatedwiththeinferiorthyroidartery
• Orwithnodesassociatedwiththefrontofthecricothyroidligamentoruppertrachea.
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Innervations
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Superiorlaryngealnerves
• Thesuperiorlaryngealnervesoriginatefromtheinferiorvagalgangliahighintheneck
• Theydescendmedialtotheinternalcarotidarteryanddivideintointernalandexternalbranches abovethehyoidbone
• Theexternalbranch(externallaryngealnerve)descendsalongthelateralwallofthepharynxtosupplytheinferiorconstrictorofthepharynxandendsbysupplyingthecricothyroidmuscle;
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Superiorlaryngealnerves
• Theinternallaryngealnervepassesanteroinferiorlytopenetratethethyrohyoidmembrane
• Internalnerveismainlysensory andsuppliesthelaryngealcavitydowntothelevelofthevocalfolds.
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Recurrentlaryngealnerves
• Therecurrentlaryngealnervesare:
• Sensorytothelaryngealcavitybelowthelevelofthevocalfolds;
• Motortoallintrinsicmusclesofthelarynxexceptforthecricothyroid.
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Recurrentlaryngealnerves
• Theleft recurrentlaryngealnerveoriginatesinthe thoraxwhereastheright recurrentlaryngealnerveoriginatesintherootoftheneck
• Bothnervesgenerallyascendintheneckinthegroovebetweentheesophagusandtrachea
• Enterthelarynxdeeptothemarginoftheinferiorconstrictor
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Relationsofthelarynx
• Oneachside:
• Carotidsheath(contents),andlaterallobeofthethyroidgland
• Posterior:• Pharynxandtherightrecurrentlaryngealnerve
• Anterior:
• Skin,fasciaanditscontents,4infra-hyoidmuscles
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Clinicalnotes
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Thyroidoctomy
• Sectioningoftheexternallaryngeal nervemighthappeninthyroidoctomy
• Duetothecloserelationshipbetweentheexternallaryngealnerveandthesuperiorthyroidartery.
• Producesweaknessinvoice sincethevocalcordscannotbetensed(criciothyroidM.).
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SectionoftheRecurrentlaryngealnerve
• 1.Unilateralcompletesection:
• Onevocalfold(ontheaffectedside)inthepositionmidwaybetweenabductedandadducted
• Speechnotgreatlyaffectedastheothervocalcordcompensatefortheaction.
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SectionoftheRecurrentlaryngealnerve
• 2.Bilateralcompletesection:
• Bothvocalfoldsinpositionmidwaybetweenabductedandadducted
• Breathingisimpairedsincetherimaglottisispartiallycloseandspeechislost
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SectionoftheRecurrentlaryngealnerve
• 3.Unilateralpartialsection:
• Thisresultsinagreaterdegreeofparalysisoftheabductormusclesthanoftheadductor.
• Thereforetheaffectedcordisintheadductedmidlineposition
• Hoarsenessofthevoice(theothervocalfoldcompensatestheaction)
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SectionoftheRecurrentlaryngealnerve
• 4.Bilateralpartialsection:
• Thisresultsinbilateralparalysisoftheabductormuscles
• Thereforethevocalfoldsareadductedtogetherinthemidline
• Acutebreathlessness(Dyspnea)andstridorfollow
• Leadtosuffocationsotracheostmyisnecessary
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Thankyou