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Anatomy & Physiology of Larynx Dr. Vishal Sharma.

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1 Anatomy & Physiology of Larynx Dr. Vishal Sharma

2 Larynx (anterior)

3 Larynx (posterior)

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5 Larynx (lateral)

6 Larynx (superior)

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8 Larynx (sagittal section)

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10 Larynx (coronal section)

11 Vocal fold

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13 Laryngeal Cartilages 3 single & 3 paired SinglePaired Epiglottis Arytenoid ThyroidCorniculate (Santorini) CricoidCuneiform (Wrisberg)

14 Cartilages (anterior)

15 Laryngeal Cartilages

16 Cartilages (posterior)

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18 Cartilage Histology Elastic: Epiglottis, corniculate, cuneiform & apex of arytenoid. Little or no calcification. Hyaline: Thyroid, cricoid & remaining arytenoid. Calcify as age advances. Ossification begins by yr & is completed by 60 yr.

19 Indirect Laryngoscopy

20 Flexible Laryngoscopy LEFT RIGHT

21 Laryngeal cavity 1. Laryngeal inlet 2. Laryngeal Vestibule 3. Laryngeal Ventricle 4. Rima glottis 5. Subglottis

22 Pediatric Larynx Conical in shape & subglottis is narrowest part Positioned high (C3-C4) Moves higher during swallowing allowing simultaneous breathing & feeding Loose sub-mucosal tissues (swell up easily) Soft cartilages that collapse easily

23 Membranes & Ligaments Extrinsic: connect thyroid cartilage & epiglottis with hyoid bone; cricoid cartilage with trachea. Intrinsic: connect cartilages of larynx to each other.

24 Extrinsic Thyrohyoid membrane Hyoepiglottic ligament Cricotracheal ligament

25 Intrinsic

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27 1. Quadrangular membrane  Ary-epiglottic ligament  Vestibular ligament 2. Crico-vocal membrane  Vocal ligament  Cricothyroid membrane 3. Thyro-epiglottic ligament

28 Oncological Divisions A. Supraglottis: laryngeal inlet to apex of ventricle B. Glottis: apex of ventricle to 10 mm below C. Subglottis: lower glottic border to lower cricoid border

29 Subsites A. Supraglottis: 1. Epiglottis 2. Aryepiglottic folds 3. Ventricular bands 4. Laryngeal Ventricle B. Glottis: 1. True vocal cords 2. Anterior commissure 3. Posterior commissure C. Subglottis

30 Intrinsic Muscles A. Acting on vocal cords Abduction   Posterior crico-arytenoideus Adduction   Lateral crico-arytenoideus  Transverse inter-arytenoideus  Thyro-arytenoideus externa Tension + lengthening   Cricothyroid Relaxation + shortening   Vocalis

31 Intrinsic Muscles B. Acting on laryngeal inlet Opener   Thyro-epiglottic Closer   Oblique inter-arytenoideus  Ary-epiglottic

32 Extrinsic Muscles Primary ElevatorsSecondary Elevators  Stylopharyngeus  Mylohyoid  Salpingopharyngeus  Stylohyoid  Palatopharyngeus  Geniohyoid  Thyrohyoid  Digastric Depressors  Sternohyoid  Sternothyroid  Omohyoid

33 Posterior cricoarytenoid

34 Lateral cricoarytenoid

35 Transverse Inter-arytenoid

36 Cricothyroid

37 Thyroarytenoid externa + Vocalis

38 Oblique Inter-arytenoid

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41 Spaces of Larynx

42 Reinke’s space

43 Pre-epiglottic space

44 Para-glottic space

45 Communications

46 Shape of Glottis

47 Quiet RespirationForced Inspiration

48 Inspiration

49 Shape of Glottis Normal voiceWhisper

50 Normal phonation

51 Whisper

52 Mucous Membrane Stratified squamous epithelium: Epiglottis (anterior surface + upper half of posterior surface), upper part of aryepiglottic folds & vocal cords Pseudo-stratified ciliated columnar (respiratory) epithelium: Rest of laryngeal mucous membrane

53 Nerve Supply Superior Laryngeal Nerve: Internal: sensation to supraglottis & glottis External: motor to cricothyroid muscle Recurrent Laryngeal Nerve: sensation to subglottis motor to all intrinsic muscles but cricothyroid

54 Blood Supply Arterial supply: Laryngeal br. of superior & inferior thyroid Venous drainage: Superior thyroid vein  internal jugular vein Inferior thyroid vein  innominate vein

55 Lymphatic Drainage Supraglottis: via thyrohyoid membrane into upper deep cervical nodes & thyroid gland Subglottis: via cricothyroid membrane into pretracheal + lower deep cervical nodes Glottis: has no lymphatics

56 Functions of Larynx 1. Protection of lower airway 2. Phonation (voice production) 3. Passage of air into lungs for respiration 4. Chest fixation by glottic closure

57 Protection of lower airway a. 3-level below-upward closure of:  vocal cords  ventricular bands  aryepiglottic folds b. Cessation of respiration: mediated by glossopharyngeal nv & deglutition centre. c. Cough reflex

58 Voice Production 1. Voice activating air reservoir in lungs: affects voice intensity 2. Voice generation: affects voice pitch 3. Voice resonation: affects voice quality 4. Voice articulation: affects voice quality

59 Voice Production

60 Neuro-chronaxic theory (?) Vibration of vocal fold muscles due to impulses generated from recurrent laryngeal nerves. Speed is regulated by acoustic center in brain. Obsolete theory because: muscle contraction not so fast to produce vibrations even paralyzed vocal folds can produce phonation passive phonation occurs in excised larynges

61 Combined Aerodynamic & Myoelastic theory Proposed by Jan Willem van den Berg in 1958 Vocal cords kept approximated  Subglottic blast of air opens vocal cords from below upwards & causes their passive vibration, producing sound  Muscle tension + Bernoulli's effect closes vocal cords below upwards  Cycle repeated

62 Aerodynamic myoelastic theory (opening phase)

63 Aerodynamic myoelastic theory (closing phase)

64 Stroboscopic examination

65 Voice generation  High pitch = short, thin, tense, less elastic vocal cords  Low pitch = long, bulky, relaxed, more elastic vocal cords  Falsetto voice = tense vocal cords, only edge of vocal fold vibrates & body is relaxed, with small phonatory gap

66 Falsetto voice

67 Vocal cord cross-section

68 Normal phonation

69 Falsetto voice

70 Glottis state in phonation Voiceless (full air stream) Breathy voice (murmur) Slack voice Modal voice: maximum vibration, sweet spot Stiff voice Creaky voice (restricted air stream) Glottalized (blocked air stream)

71 Glottis state in phonation

72 Vocal Registers Vocal fry register: lowest vocal register Modal voice register: commonly used for speaking & singing Falsetto register: one octave higher than modal voice register Whistle register: highest voice register. Used by female singers

73 Musical notes & octaves

74 Guinness World records Georgia Brown (2006): Highest vocal range from G2 to G10 Highest vocal note (G10) Adam Lopez (2002): Highest vocal note for male (C8) Tim Storms (2002): lowest vocal note (8 Hz = two octaves below lowest B on a piano)

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76 Adam Lopez & Tim Storms

77 Voice resonation Oral & pharyngeal cavity  S Nasal cavity  M, N, Ng In rhinolalia clausa: M, N & Ng are uttered as B, D & G respectively In rhinolalia aperta: B, D & G are uttered as M, N & Ng

78 Organs of articulation

79 Places of articulation  Bilabial: both lips  Labio-Dental: lips + teeth  Dental: teeth + tip of tongue  Alveolar: alveolus + tip of tongue  Palatal: hard palate + tongue blade  Retroflex: tongue tip + hard palate  Velar: tongue base + soft palate  Glottal: produced in glottis

80 Places of articulation

81 Sound production  Bilabial  P, B, M, W  Labio-Dental  F, V;  Dental  T, D  Alveolar  T, D, N, L, S, Z  Palatal  Ch, Chh, J, Jh, Y  Retroflex  R, T, Th, D, Dh  Velar  K, Kh, G, Gh  Glottal  H, ?, uh-oh

82 Chest fixation Closure of glottis helps in raising intra-thoracic & intra-abdominal pressure required for: Coughing  Vomiting Defecation  Micturition Climbing  Weight-lifting Labour

83 Thank You


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