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Anatomy of Larynx with Concept of Cancer Spread Dr Deepa Shivnani
Overview
Development of larynx (embryology) Paediatric v/s adult larynx Descriptive anatomy Cartilages of larynx Muscles of larynx Membranes Nerve supply / blood supply
/lyphatics Potential spaces Barriers of cancer spread
3
LaryngoTracheal GrooveForms in the ventral wall of Pharynx in 4th week
Development of larynx
Embryology
Embryology
6
Pharyngeal Arches - Derivatives
Paediatric v/s Adult
Pediatric Vs Adult larynx
8
Pediatric AdultSizeLuminal shape Conical / Funnel
ShapedCylindrical shaped
Position C1/C2 C3-C6Epiglottis Omega Leaf ShapedThyroid Flat Shield LikeArytenoid Large SmallMucosa and Submucosa
narrowest part
Lax
subglottis
Adherent
glottis
Descriptive anatomy
Located between 3rd to 6th vertebra in adults
Measures 44 x 43 x 36 mm in men
36 x 41 x 26mm in women
Important Dimensions of the Larynx
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MALE FEMALE-Av Length 44 mm 36mm-Transverse Diameter 43 mm 41mm-AP Diameter 36 mm 26mm
Vocal cord Length-Child 8 mm
6mm-Adult 17-23 mm
15-19mm
Larynx framework
3 unpaired cartilage Epiglottis Thyroid Cricoid 3 paired cartilage Arytenoid Corniculate(santorini) Cuneiform(wrisberg) Laryngeal muscles Laryngeal membrane
Larynx
3 regions : Supraglottic GlotticSubglottic
Laryngeal subdivisions
Sites Extent Subsites Supraglottis Tip of epiglottis to
laryngeal ventricleEpiglottis ,False cordsAryepiglottic folds Arytenoid cartilagesPreepiglottic spaceVestibule
Glottis From laryngeal ventricle to an imaginary plane 1cm below this level
True vocal cordsAnterior commissurePosterior commissure
Subglottis From undersurface of true cord to inferior surface of cricoid cartilage
ANATOMY OF LARYNX
Cartilage framework
Extrinsic membranes
Intrinsic membranes
Mucosal folds
Vocal foldsVestibular folds
Anterior 3/5th of vocal cord is called intermembranous part- phonatory part
Posterior 2/5th of VC is called inter cartilaginous part-resp. part
Height of the VF diminishes towards ant.commisure-as the inf. Edge of VF slopes upwards
No lymphatics in this plane of VF
Muscles Of Larynx
Extrinsic Muscles – connect larynx to neighboring structures Elevators Depressors
Intrinsic Muscles – Attach laryngeal cartilages to each other Acting on Vocal cords Acting on Laryngeal inlet
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Extrinsic musclesSUPRAHYOID (ELEVATORS) Primary
elevators:stylopharyngeous
Salpingopharyngeous Palatopharyngeous
Secondary elevators Digastric muscle Stylohyoid Mylohyoid Geniohyoid Hyoglossus
INFRAHYOID (DEPRESSOR) Sternohyoid Omohyoid Sternothyroid Thyrohyoid
Extrinsic Muscles
The intrinsic muscles of the larynx
Adjust tension in the vocal ligaments
Open and close the rima glottidis Open and Close the rima vestibuli Control the inner dimensions of the
vestibule Facilitate closing of the laryngeal
inlet.
Intrinsic muscles of larynx- acting on vocal cord
Abductors• Posterior
cricoarytenoid
Adductors• Lateral
cricoarytenoid
• Transverse arytenoid
• Thyroarytenoid(external part)
• Cricothyroid
Tensors• Cricothyroi
d• Vocalis
Intrinsic muscles of larynx – acing on laryngeal inlet
Openers of inlet Closers of inlet
Thyroepiglottic Interarytenoids
Intrinsic musclesMuscle Origin Insertion ActionLateral cricoarytenoid
Lat part of cricoid arch
Muscular process
Adductor
Posterior cricoarytenoid
Medial surface of cricoid lamina
Muscular process
Abductor
Vocalis Back of thyroid prominence
Muscular process
Tensor
Interarytenoid Muscular process
Muscular process(opp side)
Closure of inlet
Cricothyroid Ant arch of cricoid
Lower fibres – lesser cornu of thyroid cartilageAnt fibres – thyroid lamina
tensor
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Adductors of the Vocal Folds:
Abduction of Vocal Ligament
LAT.CRICOARYTENOID: It rotates the arytenoids medially and thus adducts the vocal cords. The vocal folds become thin and elongated. The edge becomes sharp and stiff. Transverse and oblique arytenoids also adduct the vocal folds.
CRICOTHYROID : It rotates the cricoid cartilage lengthens the vocal cords by increasing the distance between the thyroid angle
and the arytenoids. The vocal fold thus becomes long and thin and the edges become sharp and
stiffened
Nerve supply of the larynx-SUPERIOR LARYNGEAL NERVE
Nerve supply of the larynx
.
Nerve supply of the larynx
The upper branch supplies the mucous membrane of the lower part of the pharynx, epiglottis, vallecula, vestibule of the larynx and the lower branch descends in the medial wall of the piriform fossa beneath the mucous membrane and supplies the aryepiglottic fold and the mucous membrane of the larynx .
Recurrent laryngeal nerve
Enters larynx behind cricothyroid joint, divides into motor and sensory branches
Motor branch – all intrinsic muscles except cricothyroid
Sensory – mucosa below level of vocal cords, afferents from stretch receptors
Right LeftArises from vagus where it crosses subclavian loops under it, ascends in the TE groove
Arises at aortic arch, passes under it, ascends in the TE groove
Galen’s anastomosis
– internal branch of SLN ends by piercing inferior constrictor where it unites with a branch of RLN. It’s a purely sensory loop
Blood supply
Superior laryngeal artery – branch of sup.thyroid artery.
Inferior laryngeal artery – branch of inf.thyroid artery.
VENOUS DRAINAGE Follow A Sup laryngeal V enter IJV via sup thyroid & facial V. Inf laryngeal V drain into inf thyroid V-brachiocephalic V. Some drain into middle thyroid - IJV
Lymphatic drainageSpread to lymph nodes
Supraglottis – level II, III(upper deep cervical LN)
Subglottis – Level IV, VI
Histology
Supraglottis /sub glottis -respiratory pseudostratified columnar epithelium.
Glottic -stratified non keratinized squamous epithelium.
Vocal foldsExtend from
thyroid cartilage to arytenoids
Superficial layer – Reinke’s layer, loose fibrous
tissue
Intermediate layer, elastic
fibresDeep layer, collagenous
fibres, fibroblasts
Mucosa
Stratified squamous
Lamina propria
Muscle
Histology of the vocal cord
Laryngeal barriers to tumor spread
Laryngeal barriers to tumor spread
Laryngeal development, Anatomic barriers, Enzymatic activity. focal areas of vulnerability -
ossified cartilage and natural interruptions in the perichondrium.
Embryology barriers
supraglottis -midline buccopharyngeal anlage with rich bilateral lymphatics.
subglottis -propensity for extralaryngeal extension
Glottis - midline fusion of lateral tracheobronchial primordium
Anatomic barriers tumour spread is bounded by the ligaments ,connective tissue membranes and laryngeal cartilages and facilitated by the soft tissue spaces and musclesFibrous barriers ---”Tucker and smith “found the elastic and dense connective tissue to be relatively resistant to the tumour invasion
Effective barriers includes sub mucosal elastic layers---Conus elasticus---Quadrangular membrane---Ventricular connective tissue.---Hyoepiglottic ligament---Glossoepiglottic ligament---Vocal ligament tendon---Perichondrium
Other vulnerable area
Soft tissue space Venous structure-lacks elastic fibers. Muscle Anterior commissure- Broyles -devoid of a true inner perichondrium.
Chemical activatorsTumor growth -requires the formation of new capillaries tumour releases the tumour angiogenesis factor. enzymatic activity of the collagenase -activated by inflammation.Proteolytic enzymes -cleave type 4 collagen -tumor invasion.
Potential tissue spaces Reinke’s space Sub mucosal space between mucosa and vocalis muscle . Very early glottic cancer remain superficial ,rarely
penetrating the deeper tissue.
Paraglottic space: Between mucosa of larynx and thyroid cartilage . It contains thyro-arytenoid muscle .
Pre epiglottic space: Fat filled space lying between the hyoid bone and
thyrohyoid membrane anteriorly and infrahyoid epiglottis posteriorly.
PRE EPIGLOTTIC SPACE
Reinke’s space Submucosal space between
the mucosa of glottis and underlying vocalis muscle
This act as bursa allowing the mucosa to slide over the underlying tissues producing fluency in normal speech
Very early glottic ca remain superficial rarely penetrating deeper tissue
Mucosa of VC can therefore be stripped off without causing damage to underlying soft tissues with no alteration in voice
Paraglottic spaceBounded laterally - thyroid
cartilage and thyrohyoid membrane
superomedially - quadrangular membrane
inferomedially - conus elasticus
posteriorly - medial wall of piriform fossa.
This space contains thyroarytenoid muscle- infiltration of this space causes fixity of VC
Ossification of Laryngeal Cartilages hyaline cartilage-thyroid, cricoid, and
arytenoid Thyroid cartilage- (male) age 20 ( female) a
few years later Neoplastic invasion of the laryngeal
cartilages generally takes place in the ossifi ed portion of the cartilage.
THANK YOU