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HISTORY
The anatomic and surgical history of the larynx is shown in Table 5-1.
Table 5-1. Anatomic and Surgical History of the Larynx
Aretaeus
ca. 100 The earliest reference to laryngeal cancer

A.D.
Galen
ca. 200 Described malignant ulceration of the throat. Stated that larynx has three cartilages: shield (thyroid), ladle (arytenoid), and ring
A.D.
(cricoid). Described strap muscles.
Leonardo Da
Vinci (14511519)
Sketched and described larynx
Fabricius of
Padua
1600
Discussed actions of intrinsic and extrinsic muscles of human and animal larynx
Casserius
1601
Wrote that the posterior cricoarytenoid muscles are considered to open the glottis
Boerhaave
1688
Described "cancerous angina"
Morgagni
1732
Reported two autopsy cases of laryngeal carcinoma
Dodart
17091719
Compared action of glottis to playing of oboe
Santorini
1724
Discovered corniculate cartilages (of Santorini)
Winslow
1732
Discussed action of laryngeal muscles
Ferrein
1741
First use of term "vocal cords"
Leverett
1743
Examined throat using bent mirror; used snare to remove polyps
Bertin
1745
Disagreed with Ferrein, naming structures "folds"
Camper
1767
Discovered cuneiform cartilages
Pelletan
1778
Split larynx to remove piece of meat
Wrisberg
1780
Claimed discovery of cuneiform cartilages (of Wrisberg)
Astley Cooper early

Removed large tumor of the epiglottis (supraglottic partial laryngectomy)
19th
century
Bozzini
1807
Claimed to visualize the larynx with a double cannula using an angled mirror, wax candle, and reflector
Caron
1808
Performed first successful tracheostomy in a child
Desault
1810
Performed or suggested a thyrotomy by transecting the midline of the larynx from within outward
Magendie
1822
Studied physiology of larynx
Babington
1829
Presented the first effective laryngoscope
Albers
1829
Experimented with total laryngectomy
Lauth
1835
Identified conus elasticus and several ligamentous bands
Trousseau &
Belloc
1837
Described 4 types of laryngeal phthisis (chronic laryngeal alterations)
Trousseau
1837
First to use tracheostomy for laryngeal cancer
Green
1846
Wrote A Treatise on Diseases of the Air Passages. Advocated application of silver nitrate solution for treatment of laryngeal diseases.
Pratt
mid
Successful resection of an epiglottic tumor
19th
century
Kronlein
mid
Promoted lateral subhyoid or suprahyoid pharyngotomy
19th
century
Buck
1851
Performed first laryngofissure in the United States
Garcia
1855
Visualized his own glottis; called "Father of Laryngology"
Krackowizer
1858
Introduced laryngoscopy to North America
Van Trck,
Czermak
1860
Introduced mirror laryngology
Lewin
18611862
Reported removal of laryngeal tumor by indirect laryngoscopy
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Avery

1862
Used a type of laryngoscope for 18 years
deSilva Solis- 1867

Cohen
Reported permanent cure of carcinoma by laryngofissure
Czerny
1870
Tested laryngectomies on dogs
Luschka
1871
Accurately described laryngeal anatomy
Mackenzie
1871
Developed surgical manipulation of the larynx with curved laryngeal forceps guided visually by mirror laryngoscopy
Billroth
1873
Performed first human laryngectomy for cancer
Bottini
1875
Performed first completely successful laryngectomy
Isambert
1876
Suggested classification into intrinsic, extrinsic, and subglottic varieties of laryngeal carcinoma
Cornil,
Ranvier
1876
Described laryngeal cancer as an extremely rare disease
Billroth
1878
Reported first vertical hemilaryngectomy
Krishaber
1879
Classified laryngeal tumors as intrinsic and extrinsic; recognized intrinsic are slow growing and extrinsic have a more malignant
course and early lymphatic invasion
Strk
1880
"[C]arcinoma is rarely found limited to the larynx and most frequently invades it from the mucous folds between the epiglottis and
the tongue, or the epiglottis and the esophagus."
Butlin
1883
Noticed that intrinsic carcinoma was more frequent than extrinsic and the most common origin was the true vocal cords.
Preponderance of intrinsic cancer was subsequently verified by Semon (136 of 212 cases), Chevalier Jackson (98 of 141), Tucker
(144 of 200), Schmiegelow (36 of 48).
Kobler
1884
Used cocaine as local anesthetic
Elsberg
1886
First to describe endoscopic removal of vocal cord carcinoma
Kirstein
1895
Used direct laryngoscopy
Fderl
1899
Performed first tracheohyoidoepiglottopexy
Semon
1903
Reported partial extirpation of the larynx
Crile
1906
Described radical surgical removal of neck lymphatic tissue
Gluck and
Sorenson
1911
Adopted Crile's technique.
1922
Performed 160 total laryngectomies.
Trotter
1913
Described partial practical pharyngolaryngectomy
Jackson
19151939
Created instrument that permitted examination of the larynx in toto. Stated that children do not outgrow chronic laryngeal stenosis.
Masson and
Berger
1924
First description of mucoepidermoid tumors
Suchanek
1925
First description of laryngeal Schwannoma
Abrikossoff
1926
First description of granular cell tumor of larynx
Lynch
1929
First description of pleomorphic adenoma
Colledge
1930
First description of laryngeal neurofibroma
Mackenty
1934
First description of malignant lymphoma of the larynx
Looper
1938
Described use of hyoid bone in cricoid framework expansion to treat subglottic stenosis
Watson
1942
Performed mediastinal dissection
Alonso
1947
Performed two-stage supraglottic laryngectomy
Hofmann
Saguez
1950
Described intravestibular horizontal partial laryngectomy
Lapido et al.
1968
Described successful animal use of thyrochondroplasty flap
Goldman et
al.
1969
Reported first carcinoid of larynx
Laitman and
Lieberman
19711982
Studied comparative upper respiratory anatomy of apes, hominids, and modern humans
Grahne
1971
Described Rthi procedure (vertical division of posterior lamina of cricoid cartilage)
Jako
1972
Described laser surgery on vocal cords of dogs
Fearon and
Cotton
1972
Used pedicled and free grafts of thyroid cartilage to expand arch of anterior lumen
Mozolewski
1975
Created arytenoid vocal shunt
Montgomery
1975
Sutured vocal cords to prevent aspiration (glottic closure procedure)
Singer and
Blom
1980,
1981
Developed tracheoesophageal puncture to restore voice after laryngectomy
Hirano
1981,
1991
Studied intrinsic laryngeal muscles
Holinger et al. 1987,

1989
Studied congenital subglottic stenosis and laryngomalacia
Quiney et al.
1989
Studied laryngeal papillomatosis
Kantor et al.
1991
Proposed videomicrolaryngoscopy
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Kantor et al.
1991
Proposed videomicrolaryngoscopy
Andrea and
Dias
1994
Introduced microendoscopy
History table compiled by David A. McClusky III and John E. Skandalakis.

References for History Table
Andrea M, Dias O. Atlas of Rigid and Contact Endoscopy in Microlaryngeal Surgery. Philadelphia: Lippincott-Raven, 1995.
Fink BR. A brief history of ideas about the larynx. In: Fink BR. The Human Larynx: A Functional Study. New York: Raven, 1975, pp. 1-15.
Kleinsasser O. Tumors of the Larynx and Hypopharynx. New York: Thieme, 1988.
Myer CM III, Cotton RT. Historical development of surgery for pediatric laryngeal stenosis. ENT Ear Nose Throat J 1995;74:560-562.
Silver CE. Historical aspects. In: Silver CE, Ferlito A. Surgery for Cancer of the Larynx and Related Structures (2nd ed). New York: Churchill Livingstone, 1996,
pp. 3-12.
Whicker JH, Devine KD. The commemoration of great men in laryngology. Arch Otolaryngol 1972;95:522-525.
Yanagisawa E, D'Agostino. The larynx. In: Lee KJ (ed). Essential Otolaryngology (7th ed). Stamford CT: Appleton & Lange, 1999, pp. 791-858.
EMBRYOGENESIS
Normal Development
The respiratory primordium appears in the floor of the foregut in the fourth week of gestational life. The larynx begins as a slitlike diverticulum of the
primitive pharynx (Fig. 5-1A).
Fig. 5-1.
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Development of the larynx. A, In the 4-week-old fetus, the larynx develops on the proximal end of the laryngotracheal groove. B, In the 5-week-old fetus,
paired arytenoid swellings are found lateral to the laryngeal aditus. The anterior midline swelling (the future epiglottis) is a derivative of the hypobranchial
eminence. C, In the 6-week-old fetus, the arytenoid swellings have migrated medially and toward the tongue, and the laryngeal aditus has become Tshaped. The laryngeal lumen is only a slit. D, In the 10-week-old fetus, the laryngeal cartilaginous and muscular structures have formed from the fourth and
sixth branchial arches. (From Moore KL, Persaud TVN. The Developing Human, 6th ed. Philadelphia: WB Saunders, 1998; with permission.)
Between the fifth and sixth weeks three swellings appear at the laryngeal aditus. An anterior swelling, which is probably a derivative of the
hypobranchial eminence from the fourth arch, forms the future epiglottis. Then two lateral arytenoid swellings appear (Fig. 5-1B). The arytenoid
swellings, which are derived from the sixth branchial arch, move medially and form a T-shaped aperture (Fig. 5-1C).2,3
The laryngeal lumen becomes occluded at 8 weeks gestational age as a result of epithelial proliferation. Recanalization occurs during the tenth week
(Fig. 5-1D).
The formation of the vocal and vestibular folds is related to condensation of mesenchyme. The laryngeal cartilages develop from the mesenchyme of
the branchial arches. The thyroid cartilage develops from the fourth arch as two lateral plates meet in the midline. The intrinsic laryngeal muscles
develop from the mesoderm of the fourth and sixth arches.2,4
We agree with O'Rahilly and Mller5 that possible relationships between the developing larynx and the pharyngeal arches and pouches are obscure.
For more information on the embryology of the larynx, please consult Embryology for Surgeons by Skandalakis and Gray.6
Congenital Anomalies
Certain congenital laryngotracheal anomalies occur because of problems during embryogenesis. These include laryngeal atresia, laryngeal webs,
subglottic stenosis, and laryngotracheal clefts.
Laryngeal atresia occurs if the endolarynx fails to recanalize. Immediate tracheotomy is required for survival.
Laryngeal webs occur when the epithelium partially fails to resorb. A weblike mass may appear at the glottic level, often with significant subglottic
extension.
Subglottic stenosis is a deformity in the development of the normal cricoid cartilage (sixth branchial arch).
Laryngotracheal cleft results from a failure to form the tracheoesophageal septum.
Immature teratomas of the larynx are very rare. They are composed of multiple tissues foreign to the part of the body in which they arise. Complete surgical
excision of the teratoma is advised because of the possibility of malignant degeneration.7
We quote from Sichel et al.8:

Congenital malformations of the larynx are relatively rare but may be life-threatening. The most common causes include laryngomalacia, vocal
cord paralysis, and subglottic stenosis. ...[S]urgical procedures...include supraglottoplasty for cases of severe laryngomalacia, in which relief of
respiratory symptoms has been shown to occur in excess of 80% of cases. Complication rate is low, although postoperative death has been
reported. Failure usually occurs in patients with concomitant airway abnormalities including pharyngomalacia. Vocal cord lateralization for vocal
cord paralysis with airway compromise is achieved by means of arytenoidopexy or arytenoidectomy, using the lateral approach.
Arytenoidectomy also can be performed using laryngofissure or endoscopic laser excision. Subglottic stenosis is the 3rd most common
congenital anomaly. Anterior or multiple cricoid splitting with cartilage graft interpositioning is usually performed. The success rates for these
procedures has been shown to be approximately 90%.
Table 5-2 provides additional details about the congenital anomalies of the larynx. Further discussion will be found in Embryology for Surgeons.6
Table 5-2. Anomalies of the Larynx
Anomaly
Prenatal Age at
Onset
First Appearance
Sex Chiefly
Affected
Relative
Frequency
Remarks
Atresia of the larynx
6th-10th weeks
At birth
Equal
Very rare
Fatal unless tracheostomy is performed

at once
Laryngeal "webs"
10th week?
At birth if large; asymptomatic

if small
Equal
Uncommon
Subglottic (cricoid) stenosis 10th week
At birth
Male
Rare
Laryngomalacia
At birth
Male
Common
Symptoms usually disappear by 2nd

year of life
At birth
Equal
Very rare
Familial tendency has been suggested
Laryngotracheoesophageal 6th week

cleft
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cleft
Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.
Wiatrak9 presented a comprehensive review of congenital anomalies of the larynx and trachea.
SURGICAL ANATOMY
Adult Larynx
From embryologic, anatomic, physiologic, and surgical standpoints, the larynx (Fig. 5-2) is one of the most complex organs of the human body. The
numerous cartilages, membranes, and muscles of the larynx and the singular hyoid bone are covered with mucosa and connective tissue, forming an
organ that at first inspection appears deceptively simple. All these parts function as an integral unit that cooperates beautifully with the cerebral
hemispheres in the production of speech and the regulation of respiration and deglutition.
Fig. 5-2.
Adult larynx. (Modified from Montgomery RL. Head and Neck Anatomy with Clinical Correlations. New York: McGraw-Hill, 1981; with permission.)
Principal Internal Features of the Larynx

The cavity of the larynx extends from the area of the tip of the epiglottis, aryepiglottic folds, and interarytenoid folds above to the first tracheal ring
below. The internal cavity of the larynx is divided into three spaces: the supraglottic, glottic, and subglottic spaces (Fig. 5-3).
Fig. 5-3.
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Internal cavity (coronal section) of larynx (semidiagrammatic). (Modified from Tucker HM, ed. The Larynx, 2nd ed. New York: Thieme Medical, 1987; with
permission.)
The entrance to the larynx is known as the laryngeal aditus (aditus laryngis). The aditus opens into the laryngeal vestibule or supraglottic space. This
space starts at the free edge of the epiglottis and the aryepiglottic folds. The inferior extent of the supraglottic space is the lower margin of the
false vocal folds (vestibular folds). Just below the false vocal folds is a paired diverticulum of the laryngeal mucosa referred to as the laryngeal
ventricle. This outpouching is located cranial to the true vocal folds at the summits of which are pearly white bands, the vocal cords (vocal
ligaments).
The space between the vocal cords is the rima glottidis or glottic space. Together the rima glottidis and the true vocal folds form the glottis.
The subglottic space extends below the glottis to the first tracheal ring.
Topography and Relations

The larynx is located anterior to the 3rd, 4th, 5th, and 6th cervical vertebrae. It extends from the base of the tongue to the proximal portion of the
trachea. The potential space known as the pharynx is closely related to the larynx.
The main cartilaginous structures of the larynx are the thyroid and cricoid cartilages (Fig. 5-4). The laryngeal skeleton is suspended from the hyoid
bone by the medial and lateral thyrohyoid membrane. The lateral lobes of the thyroid gland lie anterolateral to the thyroid and cricoid cartilage. The
isthmus of the thyroid gland lies just below the cricoid cartilage and often covers the first one or two tracheal rings.
Fig. 5-4.
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Topography of larynx proximally and distally. (Modified from Schwartz AW, Hollinshead WH, Devine KD. Laryngectomy: Anatomy and techniques. Surg Clin
North Am 43:1063-1079, 1963; with permission.)
The sternothyroid and sternohyoid muscles cover the thyroid cartilage, immediately subcutaneous. When these strap muscles are separated, the
midline structures, such as the thyroid notch and the median cricothyroid ligament, become visible.
The carotid sheath and its contents lie just posterolateral to the larynx. The recurrent laryngeal nerve ascends in the tracheoesophageal groove and
enters the larynx just posterior to the cricothyroid articulation. The palpable tip of the inferior horn of the thyroid cartilage serves as a landmark for
the entrance of the nerve.10 The 3rd to 6th cervical vertebrae, prevertebral muscles, and fascia lie posterior to the larynx.
Dimensions of the Larynx

The average measurements of the larynx are listed in Table 5-3. With increasing age, these diameters change. The larynx enlarges more in the male
than in the female, a difference particularly notable in the magnitude of growth of the thyroid cartilages, resulting in the formation of the "Adam's
apple."
Table 5-3. Average Measurements of the Larynx
Males
Females
Length
44 mm
36 mm
Transverse diameter
43 mm
41 mm
Sagittal diameter
36 mm
26 mm
Source: Bannister L. Respiratory system. In: Williams PL. Gray's Anatomy, 38th Ed. New York: Churchill Livingstone, 1995; with permission.
Skeletal Anatomy
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Skeletal Anatomy
HYOID BONE
For practical purposes the hyoid bone (Fig. 5-5) is described with the larynx because of its anatomic association with the laryngeal apparatus. It
serves as an attachment for the larynx via the thyrohyoid membrane and the extrinsic muscles of the larynx. The hyoid bone is suspended from the
skull base (temporal bone) via the stylohyoid ligaments.
Fig. 5-5.
Hyoid bone.
The hyoid bone, which is the first laryngeal structure to ossify, is partially calcified at birth and completely ossified by two years of age.11 It is a Ushaped bone with a body (Fig. 5-6) and two lesser and two greater horns (cornua) (Fig. 5-5). It is located in front of the 3rd cervical vertebra,
although it is quite mobile in the vertical plane. The greater cornua of the hyoid bone are in close proximity to the internal laryngeal nerve and
superior laryngeal artery and vein as they traverse the thyrohyoid membrane to enter the larynx.10
Fig. 5-6.
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Larynx. A, Disarticulated. B, Normal approximation. (Modified from Fried MP (ed). The Larynx: A Multidisciplinary Approach, 2nd ed. Boston: Little, Brown,
1996; with permission.)
Attachments to the Hyoid Bone

The medial end of the middle constrictor muscle and the stylohyoid ligament attach to the lesser cornu.
The middle constrictor and hyoglossus muscles attach to the greater cornu.
Tongue musculature (geniohyoid and genioglossus) attaches to the inner and upper surfaces of the body of the hyoid bone. The mylohyoid attaches to the
anterior surface of the hyoid. The tendon of the digastric muscle attaches to the anterolateral portion of the body.
The infrahyoid group (sternohyoid, omohyoid, and thyrohyoid) attaches to the inferior surface of body. Each muscle acts to depress the hyoid bone.12
Surgical Considerations
The hyoid bone serves as an elevator of the larynx. In tracheal resection and anastomosis, a tension-free closure of the distal airway is essential. The
larynx can be released and "dropped" from the hyoid bone to reduce tension on the distal suture line. This is accomplished by detaching the infrahyoid
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muscles from the inferior surface of the hyoid bone body and cutting the hyoid bone just lateral to the lesser cornua (Fig. 5-7A). This releases the central
body of the hyoid and larynx. Additional relaxation can be achieved by cutting the suspensory ligament of the superior cornu of the thyroid cartilage (Figs. 57B, C). This can lower the larynx to a maximum of 4.5 cm.13
The hyoid bone serves as a site of access to the supraglottic larynx and pharynx. A surgeon dissects directly over the superior portion or under the inferior
portion of the hyoid bone to reach the mucosa of the pharynx.
During the excision of a thyroglossal duct cyst, excising the entire tract along with the central body of the hyoid bone (Sistrunk procedure) reduces the
recurrence rate.14
Fig. 5-7.
Laryngeal release. A, Cutting the hyoid bone just lateral to the lesser cornua. B, Incising the inferior constrictor muscle to expose the thyroid cartilage
superior cornu. C, Cutting the superior thyroid cornu to release the larynx from its superior ligament. (From Dedo HH. Surgery of the Larynx and Trachea.
Philadelphia: BC Decker, 1990; with permission.)
CARTILAGES OF THE LARYNX
Thyroid Cartilage
The thyroid cartilage (Fig. 5-6, Fig. 5-8) is located anterior to the 4th and 5th cervical vertebrae. It is formed by two laminae which fuse ventrally in
the midline of the neck, forming a protuberance, the laryngeal prominence or "Adam's apple," which is visible and palpable. The two laminae meet at
an angle of 90 in the male and 120 in the female. This accounts for the more prominent notch in the male. The upper limit of fusion of the two
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laminae forms the superior thyroid notch (Fig. 5-6).

Fig. 5-8.
Cartilages and ligaments of the larynx from the front. (Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968; with
permission.)
The posterior border of each lamina extends upward and downward as hornlike projections, the superior and inferior cornua (Fig. 5-6, Fig. 5-8). The
cornua are characterized further at their origins from the thyroid laminae by superior and inferior tubercles. Both of the superior horns are anchored to
the tips of the greater horns of the hyoid bone; both inferior horns articulate with the cricoid cartilage.
On the lateral, external surface of each thyroid lamina is a slight ridge between the superior and inferior tubercles (Fig. 5-6, Fig. 5-8). This ridge,
called the oblique line, attaches to three muscles: the sternothyroid, thyrohyoid, and cricopharyngeus (a portion of the inferior pharyngeal
constrictor). The thyrohyoid membrane and median thyrohyoid ligament are attached to the upper border of the thyroid cartilage. The lateral
thyrohyoid ligaments attach to the greater cornua of the thyroid cartilage. The cricothyroid ligaments (cricothyroid membrane) attach to the inferior
border of the thyroid cartilage.10
Five ligaments attach as one to the posterior surfaces of the thyroid laminae (with internal surfaces covered by mucosa) near the union of the
laminae (angle): the median thyroepiglottic ligament (Fig. 5-9), the two vestibular ligaments, and the two vocal ligaments.
Fig. 5-9.
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Cartilages and ligaments of the larynx in sagittal section. (Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968;
with permission.)
Since the thyroid cartilage is so prominent and shields the major internal structures of the larynx, a useful approach to laryngeal surgery is the
laryngofissure technique. In this technique the thyroid cartilage is divided in the midline to expose the endolarynx for various procedures (for example, partial
laryngectomy, laryngotracheoplasty, and arytenoidectomy).
The vocalis muscle and vocal ligaments attach to the inner surface of the thyroid cartilage at a point known as the anterior commissure (Fig. 5-9). On the
external laryngeal surface in adult males this point is halfway between the thyroid notch and the inferior border of the thyroid cartilage. It is slightly higher
(2-3 mm) in adult females. In many laryngofissure approaches, it may be beneficial to stay below the midpoint in order to avoid dividing the anterior
commissure.
The adult thyroid cartilage can be displaced or fractured by a direct blow to its ventral surface (more prominent and obvious at the thyroid notch and along
the line of vertical midline fusion of the laminae). Similar fractures or displacements do involve the other laryngeal cartilages, but far less frequently.
Cricoid Cartilage
The cricoid cartilage (Fig. 5-6, Fig. 5-8, Fig. 5-9, Fig. 5-10) is shaped like a signet ring. The signet-shaped portion of the cricoid faces posteriorly;
the arch is located anteriorly, where it is usually easily palpable. The cricoid cartilage is situated at vertebral level C6 (occasionally reaching the
middle of C6), just below the thyroid cartilage.
Fig. 5-10.
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Cartilages and ligaments of the larynx from behind. (Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968; with
permission.)
The cricoid lamina possesses two superior facets that articulate with the arytenoid cartilages (Fig. 5-6, Fig. 5-9) and attach to them by the posterior
cricoarytenoid ligaments (Fig. 5-9, Fig. 5-10). The two lower lateral facets of the lamina articulate with the inferior horns of the thyroid cartilage. The
lower border of the cricoid cartilage is joined to the first tracheal ring by means of the thick cricotracheal ligament. This point is the end of the larynx
and pharynx and the beginning of the trachea. The lamina has a midline ridge for the tendinous attachment of longitudinal fibers of the esophagus.
Lateral to this ridge are the sites of origin for the bilateral posterior cricoarytenoid muscles, which insert upon the muscular process of each arytenoid
cartilage.
Arising from the arch of the cricoid cartilage anteriorly and externally are the cricothyroid muscles. These insert along the inferior border of the
thyroid laminae and are separated in the midline by the median cricothyroid ligament.
Injury to the cricoid cartilage from intubation or trauma may result in perichondritis and lead to subglottic stenosis.15
Surgical approaches to repair long-standing subglottic stenosis involve the expansion of the circumference of the cricoid ring with autologous
cartilage grafts.16
Tracheotomies are usually performed at least one tracheal ring below the cricoid cartilage (2nd or 3rd tracheal ring) to avoid subglottic stenosis. However,
during an emergency cricothyroidotomy, the tracheostomy tube is inserted through the median cricothyroid ligament. This is the quickest and easiest access
to the airway. To avoid permanent laryngeal stenosis, the cricothyroidotomy must be converted to a standard tracheotomy within several days.
Arytenoid Cartilages
The arytenoid cartilages (Fig. 5-6, Fig. 5-9, Fig. 5-10) are almost pyramidal in shape, with three surfaces, a base, and an apex. Each triangle-shaped
base articulates with the cricoid cartilage by way of a diarthrodial joint. The base has two processes:
The anteromedially directed vocal process to which the vocal ligament is attached
A short, broad, laterally projecting muscular process to which the lateral and posterior cricoarytenoid muscles are attached
The arytenoid has a posterior surface that is slightly concave, a medial surface, and an anterolateral surface. The arytenoid muscles (transverse and
oblique) attach to the posterior surfaces of both arytenoid cartilages. The medial surface is covered with mucous-secreting laryngeal mucosa. The
anterolateral surface is the site of insertion of the thyroarytenoid muscle, part of the vocalis muscle, and the vestibular ligament. The apex of the
arytenoid cartilage supports the corniculate cartilage.
The traditional view of arytenoid motion, which is expressed in many textbooks, is one of arytenoid rotation on the articular facet.17 In contrast, Fink
and Demerest demonstrated that the greatest movement of the arytenoid cartilage is a downward and lateral or upward and medial sliding motion.18
This is also accompanied by a lesser anterior-posterior rocking motion (Fig. 5-11).19
Fig. 5-11.
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Cricoarytenoid articulation, "sliding and rocking." (Modified from Dickson DR, Mave-Dickson W. Anatomical and Physiological Bases of Speech. Boston: Little,
Brown and Company, 1982; with permission.)
We quote from Prades et al.20:

The descriptive anatomy of the cricoarytenoid articulation provides an essential foundation for understanding disorders of mobility of the
larynx...The cricoid and arytenoid articular surfaces showed major intra- and inter-individual variations, causing dynamic asymmetry at the
glottic level. They were joined by a connective-elastic articular capsule bounding a cavity, characterized by a pseudo-meniscal synovial ridge
and deep peripheral blind recesses, indicative of great articular mobility. The cricoarytenoid ligament shares in stabilizing the articulation. The
posterior cricoarytenoid m. (abductor) and the lateral cricoarytenoid m. (adductor) have a motor innervation derived from the inferior laryngeal
nerve, which forms an endolaryngeal arch with a ventral concavity, in contact with the lateral articular recess. The cricoarytenoid articulation
thus appears as a diarthrosis possessing three degrees of liberty during movements of glottic abduction and adduction: an antero-posterior
rocking movement, an antero-medial shift of the arytenoid on the cricoid, and a less marked axial rotation.
Cricoarytenoid fixation may occur from arthritis or perichondritis (intubation injury) and limit vocal fold mobility.
Debo et al.21 reported cricoarytenoid subluxation during blind intubation with a lighted stylet.
Arytenoidectomy through an external or endoscopic approach may alleviate arytenoid fixation or paralysis.
Danino et al.22 proposed a submucosal arytenoidectomy which preserves an intact laryngeal mucosa. Further obstruction of the lumen by scar tissue and
granulation is avoided.
Corniculate Cartilages
The corniculate cartilages (of Santorini) (Fig. 5-6, Fig. 5-9, Fig. 5-10, Fig. 5-12) are small fibroelastic nodules that sit on the posteriorly bent apices
of the arytenoid cartilages. They are of little functional importance in humans.
Fig. 5-12.
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The quadrangular membrane and the larynx from behind. (Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968;
with permission.)
Cuneiform Cartilages
The cuneiform cartilages (of Wrisberg) (Fig. 5-12) are rod-shaped (like ancient cuneiform script). They are situated in the aryepiglottic folds anterior
to the corniculate cartilages, and may be entirely absent.
Tritiate Cartilage
The tritiate cartilage (sometimes referred to as triticeal) (Fig. 5-6, Fig. 5-9, Fig. 5-10), a bilateral mass, is an occasional, minute nodule. It may be
located in the posterior margin of the thyrohyoid membrane.
Epiglottic Cartilage
The epiglottic cartilage (Fig. 5-12), a thin, spoon-shaped or leaflike elastic movable cartilage, is located behind the root of the tongue and the body
of the hyoid bone and in front of the laryngeal entrance (laryngeal aditus or vestibule). The upper end of the cartilage is broad. The lower end is
considerably narrowed and referred to as the petiolus (Fig. 5-9) or stalk.
The epiglottic cartilage attaches to the posterior body of the hyoid bone via the hyoepiglottic ligament (Fig. 5-9). Therefore it lies dorsal to the
thyroid cartilage and thyrohyoid membrane, guarding the laryngeal entrance.
The space between the anterior surface of the epiglottis and the thyrohyoid membrane and thyroid cartilage is called the preglottic space (Fig. 5-9).
The epiglottis is attached to the thyroid cartilage by the thyroepiglottic ligament. The aryepiglottic folds and the quadrangular membranes (Fig. 5-12)
attach to the lower part of the lateral margins of the epiglottis.
Surgical Considerations. Acute epiglottiditis, an acquired phenomenon, may cause airway obstruction in children. To rule out foreign bodies, a lateral
x-ray may be ordered if the general condition of the child permits.
Laryngeal visualization must be done in the operating room to avoid airway occlusion, aspiration, and cardiac arrest. Intubation and tracheostomy are
the procedures of choice.
Laryngeal Ligaments and Membranes

There are several laryngeal ligaments, folds, and membranes. These include the:
Thyrohyoid membrane
Quadrangular membrane
Vestibular ligament (vestibular folds or false vocal cords)
Aryepiglottic fold
Cricothyroid ligament or conus elasticus
Vocal ligaments
Epiglottic ligaments
THYROHYOID MEMBRANE
The thyrohyoid membrane (Fig. 5-8, Fig. 5-13) provides an extensive connection between the thyroid cartilage and the hyoid bone bilaterally and
anteriorly. It forms a continuous sheet of tissue extending from the upper border and the greater horns of the hyoid bone to the superior horns of the
thyroid cartilage and its laminae.
Fig. 5-13.
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Thyrohyoid membrane, ligament, and superior laryngeal neurovascular bundle. (Modified from Tucker HM. The Larynx (2nd ed). New York: Thieme Medical
Publishers, 1993; with permission.)
The thyrohyoid membrane thickens anteriorly, forming the median thyrohyoid ligament (Fig. 5-9, Fig. 5-13). The thickened posterior margin on each
side is called the lateral thyrohyoid ligament. The tritiate cartilage (Fig. 5-9, Fig. 5-10) is often present within this lateral ligament, presumably adding
to its strength. The superior laryngeal artery and vein (Fig. 5-13) and internal laryngeal nerve penetrate the thyrohyoid membrane 4-5 mm anterior to
the superior horn of the thyroid cartilage.
The superior laryngeal neurovascular bundle (Fig. 5-13) may be injured by surgical approaches to the pharynx. One must observe great care when
dissecting the greater cornu of the hyoid bone and the superior horn of the thyroid cartilage during various pharyngotomy approaches.
QUADRANGULAR MEMBRANE
The quadrangular membrane (Fig. 5-12) extends from the sides of the epiglottic cartilage anteriorly to the anterolateral surface of the arytenoid
cartilage and posteroinferiorly to the corniculate cartilage. With its covering of mucous membrane, the quadrangular membrane forms the aryepiglottic
fold superiorly (Fig. 5-14) and the medial wall of the piriform recess of the laryngopharynx. Posteriorly, between the corniculate cartilages, there is a
mucosal interconnection characterized by a depression called the interarytenoid notch (Fig. 5-12) or incisure. The thickness of the quadrangular
membrane varies, being thinner superiorly. It is covered internally by the laryngeal mucosa and posterolaterally by a thin layer of muscle and the
mucosa of the pharynx.
Fig. 5-14.
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The interior of the larynx: vocal folds. (Modified from Montgomery RL. Head and Neck Anatomy with Clinical Correlations. New York: McGraw-Hill, 1981; with
permission.)
VESTIBULAR FOLDS (FALSE VOCAL CORDS)

The bilateral vestibular folds or ligaments (Fig. 5-9, Fig. 5-14) are formed by the inferior edge of the quadrangular membrane. These folds are
attached in front to the thyroid cartilage just below the attachment of the epiglottic cartilage. They are connected behind to the anterolateral
surfaces of the arytenoid cartilages. The vestibular ligaments are located just above the vocal ligaments, separated from them by bilateral ellipsoid
spaces called the laryngeal ventricles. The vestibular ligaments, which are also called false vocal folds, are covered by a thick mucosal membrane.
Like the true vocal folds, the vestibular folds approach each other during a Valsalva maneuver and help prevent expiration. They even overlap the
true vocal folds just prior to a cough or sneeze, reinforcing the resistance offered by the true vocal folds against the internal expiratory pressures.
This action helps also by resisting the incursion of foreign material into the larynx during swallowing. In addition, the vestibular folds may close as a
compensation for vocal cord adductor palsy.
The space between the two vestibular cords (folds) is called the rima vestibularis.
ARYEPIGLOTTIC FOLDS
The aryepiglottic folds (Fig. 5-2, Fig. 5-14, Fig. 5-15), one on each side, contain the aryepiglottic muscles. These muscles are associated with the
superior border of the quadrangular membrane. Contraction of the aryepiglottic muscles lifts the vestibular fold (false vocal fold) by elevating and
tensing the aryepiglottic folds. Both aryepiglottic folds constrict the entrance to the larynx and protect the respiratory pathway by not permitting
food, liquids, and foreign bodies to enter the larynx and trachea.
Fig. 5-15.
The larynx from above. (Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968; with permission.)
CRICOTHYROID LIGAMENT (CONUS ELASTICUS)

The cricothyroid ligament (Fig. 5-8, Fig. 5-9) has several alternative names, including cricovocal membrane, conus elasticus, and cricothyroid
membrane. The varied nomenclature is a result of its location and pathway, but the diversity sometimes causes confusion.
The cricothyroid ligament extends upward from the rim of the arch of the cricoid cartilage. Here it ends as a free border and forms the vocal
ligaments. The anterior part of the cricothyroid ligament thickens on either side of the midline to form the median cricothyroid ligament, the frequent
site for establishing an emergency airway. The cricothyroid ligament joins the arch of the cricoid cartilage to the thyroid cartilage, and to the
arytenoid cartilages via their vocal processes. We recommend reading the histology of the quadrangular membrane and conus elasticus which has
been beautifully described and illustrated by Reidenbach.23,24
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Little et al.25 dissected 34 cadavers and studied the vasculature of the area anterior to the cricothyroid ligament. They reported that 79% of the cadavers
had vascular structures within this area and 62% had vertically oriented arteries or veins that would be at risk during cricothyroidostomy.
According to Dover et al.26 the cricothyroid artery typically arises from the superior thyroid branch of the external carotid and passes obliquely toward the
median cricothyroid ligament. A branch then ascends deep to the thyroid lamina supplying muscles and connective tissues. Rich anastomoses across the
median cricothyroid ligament are very frequently present between the cricothyroid arteries of the two sides. In performing a cricothyroidotomy, a small artery
can be lacerated inadvertently and inverted into the airway, producing the risk of aspiration. The cricothyroid artery usually crosses the upper one-half of the
vocal ligament. Thus, it is preferable to enter the airway through the lower part of the ligament, using a transverse stab incision.
VOCAL LIGAMENTS, VOCAL CORDS, AND VOCAL FOLDS

For all practical purposes, the vocal ligaments (Fig. 5-9) are formed by the upper border of the conus elasticus. The conus elasticus is considerably
more distinct as a layer of submucosal elastic tissue than its superior laryngeal counterpart, the quadrangular membrane. Below, the conus elasticus
is attached to the upper margin of the arch of the cricoid (Fig. 5-8, Fig. 5-9).
The term "conus" describes this structure when viewed from its front. From this perspective, it resembles an inverted cone whose superiorly placed
apex has been cut off and whose posterior border is open vertically. Viewed from above and behind, the upper margin of the conus elasticus is
shaped like a horseshoe, the open end facing posteriorly. Anteriorly, the two sides of the conus are closely approximated as the median cricothyroid
ligament. Above this, they attach to the internal surface of the thyroid cartilage at a point called the anterior commissure (Fig. 5-9).
As stated above, it is the thickened, ligamentous, upper edges of the elastic tissue of the conus that are the vocal ligaments or vocal cords. They
extend from the medial extremities of the laminae of the thyroid cartilage in the midline anteriorly (forming the anterior commissure) to the apices of
the vocal processes of the arytenoid cartilages on each side posteriorly.
The vocal cords are covered by a layer of mucosa. Lacking a submucosa and blood vessels, the vocal ligaments appear to be pearly white and shiny.
The vocal cord forms the upper medial limit of a shelf of tissue, the vocal fold, about a centimeter thick vertically, and wider above than below. The
space between the true vocal cords (the intermembranous space) is known as the rima glottidis (Fig. 5-15).
Behind the attachments of the vocal ligaments and the space between the two arytenoid cartilages is a much smaller triangular interval. This
intercartilaginous or "respiratory" part of the rima glottidis forms two-fifths of the rima and is bounded posteriorly by the interarytenoid fold.
The rima glottidis is approximately 15-20 mm anteriorly to posteriorly. Approximately three-fifths of this length is attributable to the length of the
vocal cords. The length of the cords can increase by about one third during the production of high-pitched sounds.27
Below the periphery of the rima glottidis, the space between the vocal folds is the area termed the glottis. Finally, that part of the laryngeal cavity
inferior to the vocal fold is referred to as the subglottic space. This is normally the narrowest part of the larynx.
The true vocal cords are parallel with one another only when they are totally adducted (Fig. 5-14, bottom right); elsewhere, they form two sides of a
triangle whose apex is situated at their thyroid cartilage attachment. The length of the base of this triangle as well as the cross-sectional area of the
airway depends upon the degree to which the vocal processes of the arytenoid cartilages are abducted from one another. As they slide laterally,
they increase the cross-sectional area of the airway.
The epithelium of the true vocal cords does not have lymphatics. Therefore, metastatic disease is a rare phenomenon. The pathway of metastasis of
glottic cancer is via the Delphian node or paratracheal nodes and finally nodes of the superior mediastinum.
EPIGLOTTIC LIGAMENTS AND FOLDS
The epiglottic ligaments and folds include the:
Hyoepiglottic ligament (Fig. 5-9)
Thyroepiglottic ligament (Fig. 5-6, Fig. 5-9)
Median glossoepiglottic fold (Fig. 5-14, Fig. 5-15), attached in the midline to the back of the tongue
Lateral glossoepiglottic (Fig. 5-14) or pharyngoepiglottic fold, attached between the base of the epiglottic cartilage and the pharyngeal wall at the root of
the tongue
Epiglottic valleculae (Fig. 5-14, Fig. 5-15)
The valleculae are depressions (small "valleys") between the root of the tongue and the epiglottis on each side of the median plane. They are limited
by the median and lateral glossoepiglottic folds. The valleculae, together with the piriform recesses (Fig. 5-14, Fig. 5-16), are frequently the sites at
which foreign bodies become lodged. This entrapment may lead secondarily to partial or total airway obstruction.
Fig. 5-16.
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Larynx from above, laryngeal mirror view. (From Tucker HM. The Larynx (2nd ed). New York: Thieme Medical Publishers, 1993; with permission.)
Laryngeal Mucosa
The mucosa of the larynx is mostly of the respiratory type called ciliated columnar epithelium, and is the same as that of the trachea. However,
certain areas of the larynx are covered with stratified squamous epithelium. This includes the upper area of the anterior dorsal epiglottic surfaces, the
ventral half of the aryepiglottic folds, and the vocal cords.10 The mucous membrane of the supraglottic larynx is a downward continuation of the
oropharyngeal mucosa. The infraglottic region of the larynx is made of normal respiratory mucosa. Mucous glands are found at the posterior surface of
the epiglottis, aryepiglottic fold, and laryngeal appendices. Mucous glands are absent from the edge of the vocal cords.
Laryngeal Spaces
The various ligaments and skeletal structures form several potential spaces of the larynx and pharynx (Fig. 5-3). These include the internal laryngeal
spaces (vestibule, ventricles, and subglottic or infraglottic spaces) and the external laryngeal spaces (paraglottic and pre-epiglottic).
INTERNAL SPACES (LARYNGEAL CAVITY)
Vestibule
This pyramid-shaped space extends from the laryngeal inlet or aditus to the vestibular folds (false vocal cords). It is bounded ventrally by the
posteroinferior surface of the epiglottis, dorsally by the corniculate cartilages and apices of the arytenoids, and laterally by the aryepiglottic folds and
the piriform recesses.
Laryngeal Ventricles
The laryngeal ventricles, or sinuses (of Morgagni), are diverticula of the interval between the false and true vocal cords. They are lined internally by
mucosa and covered externally by a very thin layer of elastic tissue and the thin thyroarytenoid muscle. Contraction of the thyroarytenoid muscle
facilitates secretion of the local mucous glands.
The anterior end of the ventricle may possess an additional external expansion, the laryngeal saccule, appendix, or sinus. This extends upward deep
to the internal face of the thyroid cartilage. There is great variability in the size of the saccules.10 Freedman28 calls them the "oil can" of the vocal
cords.
Glottis and Rima Glottidis. By definition, the glottis is composed of the vocal folds and the rima glottidis, or the space between the true vocal cords.
The rima glottidis (Fig. 5-14, Fig. 5-15), the aperture of the larynx, is an elliptical slit. Dorsally it is located between the bases and the vocal
processes of the arytenoid cartilages. Ventrally it is located between the vocal cords. The rima glottidis is the most narrow area of the laryngeal
cavity, with a width of 23 mm in men, 18 mm in women, and 8-15 mm in children. Because of this, foreign bodies may lodge in it.
Surgical Considerations. An enlargement of the laryngeal saccule is often referred to as a laryngocele. Any obstruction of the laryngeal ventricle,
such as a ventricular carcinoma, may lead to the formation of a laryngocele. A laryngocele may bulge through the aryepiglottic fold and obstruct the
endolarynx (internal laryngocele). It may be present outside of the thyrohyoid membrane (external laryngocele). The enlargement may even be a
combined internal and external laryngocele (Fig. 5-17).
Fig. 5-17.
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Combined internal-external laryngocele. It is not sufficient to remove only the cervical portion of such a lesion, since the internal component will continue to
enlarge. (Modified from Tucker HM. The Larynx, 2nd ed. New York: Thieme Medical Publishers, 1993; with permission.)
Small internal laryngoceles are usually treated by endoscopic removal or marsupialization. External surgical removal, usually by lateral thyrotomy, is
the treatment of external and combined laryngoceles.
Subglottic (Infraglottic) Space

The subglottic space (Fig. 5-3) is the distal part of the laryngeal cavity. It extends from the glottis to the inferior border of the cricoid cartilage.
The subglottic space begins below the curve formed by the vocal fold, that is, where the sides of the lumen begin to be parallel, and to the lower end
of cricoid cartilage, where the subglottic space is located. Ferlito and Rinaldo29 commented on the ongoing controversy concerning the anatomic
boundaries of the subglottic region in the staging of laryngeal tumors.
We quote from Reidenbach:30
A precise definition of clinically important laryngeal regions and compartments is still a matter of controversy...The superior border of the
subglottic region is defined by the transition of squamous stratified epithelium covering the vocal cords into the respiratory epithelium of the
caudal airways. It is found at the inferior margin of the vocal fold at a variable distance from the free edge of the vocal cord and bears a high
risk of carcinogenesis. The anterior border of the subglottic region is the cricothyroid space between the thyroid cartilage and cricoid arch.
Medially, it is bridged by the median cricothyroid ligament. Laterally, the gap between the thyroid and cricoid cartilage is filled by adipose tissue
in most cases. This provides a broad connection of intra-and extralaryngeal connective tissue. There, cancer may escape the larynx. The
conus elasticus is often regarded as a firm fibroelastic membrane within the subglottic region, but its structure may be disturbed by piercing
blood vessels or age-related changes, facilitating cancerous spread. The cricoid lamina representing the dorsal border of the subglottic space
ossifies preferentially in its superior part, which is often attacked by tumor invasion. The inferior border of the subglottic region is defined at
the inferior rim of the cricoid cartilage. At this level, the endocricoid submucosal tissue contains loosely arranged collagenous fibers, which
probably do not act as an anatomic barrier.
EXTERNAL SPACES
The supraglottic laryngeal area is subdivided into three laryngeal spaces (Fig. 5-3):
Paired lateral paraglottic spaces
One midline pre-epiglottic space (Fig. 5-9)
Paraglottic Spaces
The paraglottic spaces (Fig. 5-3) are bounded laterally by the thyroid cartilage, inferomedially by the conus elasticus, and medially by the ventricle
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and the quadrangular membrane.12
Pre-Epiglottic Space
The single midline pre-epiglottic space (Fig. 5-9) is bounded superiorly by the hyoepiglottic ligament, anteriorly by the thyrohyoid membrane and
ligament, and posteroinferiorly by the epiglottis and thyroepiglottic ligament. The pre-epiglottic space forms an inverted pyramid. It is contiguous with
the superior portion of the paraglottic space. This space contains abundant fat, blood vessels, lymphatics, and mucosal glands.
Epiglottic (supraglottic) carcinoma may spread through perforations in the epiglottis into the pre-epiglottic space. Since the pre-epiglottic space
communicates laterally with the paraglottic spaces, a carcinoma is free to spread beyond the internal boundaries of the larynx. Therefore,
supraglottic laryngectomy may be contraindicated.
Laryngeal Joints
There are two pairs of synovial joints between the major cartilages of the larynx: the cricothyroid and the cricoarytenoid.
CRICOTHYROID JOINT
The cricothyroid joint (Fig. 5-12) is formed between the side of the cricoid cartilage and the inferior horn of the thyroid cartilage. The thyroid
cartilage rotates around a horizontal axis that unites both cricothyroid joints. The primary movement of the cricothyroid joint is rotation. The
cricothyroid muscle can cause subluxation if it moves the lamina of the cricoid downward when the thyroid cartilage is fixed and the cricopharyngeus
muscle is relaxed.
CRICOARYTENOID JOINT
The cricoarytenoid joint is formed between the upper border of the lamina of the cricoid cartilage (Fig. 5-10) and the base of the arytenoid cartilage.
This bilateral joint permits downward and lateral or upward and medial sliding and rocking of the arytenoid on the cricoid18,19 (Fig. 5-11). When the
arytenoid cartilage is pulled forward by the lateral cricoarytenoid, the vocal process turns medially, resulting in adduction of the vocal cord.
When the posterior cricoarytenoid draws the muscular process backward and medially, the vocal process turns laterally, producing abduction of the
vocal cord. The arytenoid cartilage will slide downward and laterally on the cricoid lamina. The distance between the apex of the arytenoid cartilage
and the thyroid lamina anteriorly is also increased by a posterior rocking motion19 (Fig. 5-11). This tenses the vocal cord. The arytenoid cartilage
glides anteromedially on the superior facet of the cricoid lamina.
A study by Reidenbach31 found the following:
Contrary to the descriptions in the literature, no fibers of the cricoarytenoid ligament join the vocal cord. Especially, the medial part of the
ligament is important for controlling abduction and adduction of the vocal cord. Voice disturbance may result from structural asymmetry of the
cricoarytenoid ligament.
Laryngeal Muscles
The larynx includes extrinsic muscles, which move the entire larynx, and intrinsic muscles, which move the vocal cords.
EXTRINSIC MUSCLES
The extrinsic muscles are often referred to as "strap" muscles (Fig. 5-18).
Fig. 5-18.
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Extrinsic laryngeal, or strap, muscles. (From Tucker HM. The Larynx, 2nd ed. New York: Thieme Medical Publishers, 1993; with permission.)
Extrinsic muscles serving as elevators of the larynx are:

Thyrohyoid
Stylohyoid
Mylohyoid
Digastric
Stylopharyngeus
Palatopharyngeus
Extrinsic muscles depressing the larynx are:

Omohyoid
Sternohyoid
Sternothyroid
The larynx elevates during expiration and deglutition. It falls during inspiration and after deglutition.
INTRINSIC MUSCLES
The intrinsic muscles (Fig. 5-19 A,B) are:
Cricothyroid
Posterior cricoarytenoid
Lateral cricoarytenoid
Arytenoid with its transverse and oblique fibers
Thyroarytenoid and its thyroepiglottic and vocalis components
Fig. 5-19.
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Internal muscles of the larynx. A, From behind, after removal of the pharynx and esophagus. B, From the side, after partial removal of the thyroid cartilage.
(Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968; with permission.)
Cricothyroid Muscle
The cricothyroid muscle arises from the lateral surfaces of the cricoid arch. It inserts upon the anterior border of the inferior horn and the posterior
part of the lower border of the lamina of the thyroid cartilage.
When stimulated by the external laryngeal nerve to contract, the cricothyroid tilts the thyroid cartilage forward or causes the lamina of the cricoid
cartilage to descend. This results in increased length and tension of the vocal cords and elevation of pitch. Its contraction also results in adducting
the cords. During phonation the cricoid cartilage is held in position against the vertebral column by the cricopharyngeus. The thyroid cartilage tilts
forward and downward in the sagittal plane when the cricothyroid contracts. During swallowing, the cricoid cartilage tilts forward as the
cricopharyngeus relaxes.
Posterior Cricoarytenoid Muscle

The posterior cricoarytenoid muscle is the only true abductor of the vocal cords. The muscle arises from the posterior surface of the lamina of the
cricoid cartilage. There is a midline raphe between the paired posterior cricoarytenoid muscles. The fibers pass laterally and upward to insert on the
muscular process of the arytenoid cartilage. It pulls the muscular process of the arytenoid cartilage posteriorly and medially, thereby rotating the
vocal process laterally with the posterior end of the vocal ligament. This widens both the intermembranous and intercartilaginous spaces. By the
orientation of its fibers, the posterior cricoarytenoid also draws the arytenoid cartilages backward, assisting the cricothyroid to increase the tension
of the ligament.
Lateral Cricoarytenoid Muscle

The lateral cricoarytenoid arises from the upper and outer surface of the cricoid cartilage. It inserts on the anterior surface of the muscular process
of the arytenoid and causes the vocal process to rotate medially, adducting the vocal ligaments.
Arytenoid Muscle
The arytenoid interconnects the posterior surfaces of the two arytenoid cartilages. The transverse fibers that form the deep part of the muscle draw
the two cartilages closer together. This adducts the vocal ligaments and closes the posterior part of the rima glottidis, the intercartilaginous portion.
The oblique fibers pass from the posterior part of the muscular process of one arytenoid cartilage to the apex of the other arytenoid and into the
opposite aryepiglottic fold. They assist in narrowing the intercartilaginous space. Together with the aryepiglottic muscle fibers in the free margin of
aryepiglottic folds, they also cause a sphincteric narrowing of the laryngeal inlet when they contract.
Thyroarytenoid and Vocalis Muscles

The thyroarytenoid, a thin, flat, broad muscle, arises from the internal surface of the median cricothyroid ligament and the lower half of the thyroid
cartilage anteriorly. Passing posteriorly, most of the fibers of the thyroarytenoid insert upon the anterolateral surface of the arytenoid cartilage, its
base, and the lateral surface of the vocal process. The deeper and lower fibers run lateral and adjacent to the vocal process, forming the vocalis
muscle. Many of the more posterior fibers attach directly to the vocal ligament.
Oblique fibers of the thyroarytenoid ascend toward the aryepiglottic fold as they pass posteriorly. Some continue acutely upward to the epiglottic
cartilage and form the thyroepiglotticus muscle. This muscle causes widening of the laryngeal aditus and draws the aryepiglottic folds apart. A thin
lamina of the thyroarytenoid passes lateral to that part of the quadrangular membrane that bounds the laryngeal saccule.
Suspension of the Larynx

Several important points about the suspension of the larynx follow:
The stylohyoid ligaments attach between the temporal bones and the lesser horns of the hyoid bone.
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Several muscles, including the digastric, stylohyoid, and mylohyoid, assist in supporting and elevating the hyoid bone and larynx.
The medial and lateral parts of the thyrohyoid membrane connect the upper border of the thyroid lamina and superior horns of the thyroid cartilage to the
body and to the greater horns of the hyoid bone.
The cricothyroid ligament (conus elasticus or cricovocal membrane) suspends the cricoid cartilage.
The quadrangular membrane suspends the vestibular ligament from the epiglottis and arytenoid cartilage.
The cricotracheal ligament connects the larynx and the trachea.
Glottic Motion and Pitch

The motion of the vocal cords during speech and respiration is a very complex process involving the finely coordinated activities of both extrinsic and
intrinsic laryngeal muscles. The posterior cricoarytenoid, which is the only abductor of the larynx, acts to slide the arytenoid cartilage laterally and
rock it backwards. Controlled by the medullary respiratory center, the posterior cricoarytenoid functions mainly during inspiration. However, action of
the posterior cricoarytenoid may contract the adductor muscles during phonation. In fact, three posterior cricoarytenoid muscle bellies have been
described.32 The medial belly, which is composed of mostly slow-twitch fibers, may be most important for the tonic activities of phonation. The
lateral cricoarytenoid, thyroarytenoid, arytenoid, and cricothyroid muscles act to adduct the vocal cords during phonation. Furthermore, the
cricothyroid muscle may tilt the cricoid lamina backward and tense the vocal cords, thereby raising the pitch. In addition, the action of the vocalis
muscle may produce changes in the tenseness of the vocal cords.33
Voice pitch and tone are regulated by both extrinsic and intrinsic muscles. The infrahyoid and the suprahyoid muscles alter pitch by changing the
position of the thyroid cartilage. Elevation of the larynx lengthens the subglottic space which yields higher tones, while depression results in lower
tones27 (Fig. 5-20). In addition, the intrinsic laryngeal muscles regulate pitch by varying the length and tenseness of the vocal cords (Fig. 5-21).
Fig. 5-20.
Semischematic line drawings indicating the changes in position of the larynx between (A) humming a low tone, and (B) humming a high tone. Note the
upward and forward movement of the pharynx and larynx and the lengthening of the vocal cords in (B). Red, pharynx; blue, larynx; green, supraglottic and
infraglottic cavities. (Modified from Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968; with permission.)
Fig. 5-21.
Schema indicating the production of a longer and thinner vocal cord by tilting the cricoid cartilage. Vocal ligament is shown in black for illustrative purposes.
(Modified from Hollinshead WH. Anatomy for Surgeons, 2nd ed. Philadelphia: Harper and Row, 1968.)
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(Modified from Hollinshead WH. Anatomy for Surgeons, 2nd ed. Philadelphia: Harper and Row, 1968.)
Vascular System
ARTERIES
The superior laryngeal artery (Fig. 5-22) originates from the superior thyroid artery, a branch of the first segment of the external carotid. Together
with veins, lymphatics, and the internal laryngeal nerve, the superior laryngeal artery penetrates the lateral aspect of the thyrohyoid membrane.
Fig. 5-22.
The arterial blood supply of the larynx. (From Tucker HM. The Larynx, 2nd ed. New York: Thieme Medical Publishers, 1993; with permission.)
The inferior laryngeal artery originates from the inferior thyroid artery, a branch of the thyrocervical trunk of the subclavian artery. Together with its
vein and the recurrent laryngeal nerve, the inferior laryngeal artery penetrates the cricothyroid ligament deep to the lower border of the inferior
constrictor muscle.
The cricothyroid artery is a branch of the superior thyroid artery. It distributes twigs to the subglottic laryngeal area via the cricothyroid ligament and
the tissues deep to the thyroid cartilage. There, it anastomoses with the superior laryngeal arteries. Free anastomoses also exist between the
superior and inferior laryngeal arteries and therefore between the supraglottic and subglottic areas. The cricothyroid artery usually reaches the
median cricothyroid ligament close to the thyroid cartilage. It should be avoided, if possible, when establishing an emergency airway.
VEINS
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VEINS
Venous blood passes by way of the superior laryngeal vein (Fig. 5-23) into the superior thyroid venous tributary. Drainage is to the internal jugular
vein above and into the inferior thyroid vein to reach the brachiocephalic veins below.
Fig. 5-23.
Venous drainage from larynx. (From Tucker HM. The Larynx, 2nd ed. New York: Thieme Medical Publishers, 1993; with permission.)
LYMPHATICS
The lymphatics of the larynx pass to supraglottic (superior) and subglottic (inferior) nodes (Fig. 5-24), as well as to the right and left cervical lymph
chains. The superior lymphatics drain through the thyrohyoid membrane to the upper deep cervical nodes, located at the level of the carotid
bifurcation. Some drainage passes to prelaryngeal nodes. The inferior lymphatics drain to the pretracheal lymph nodes of the proximal trachea
anteriorly and paratracheal nodes laterally and then to the deep cervical and superior mediastinal nodes.
Fig. 5-24.
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Lymphatic drainage of larynx. (From Tucker HM. The Larynx (2nd ed). New York: Thieme Medical Publishers, 1993; with permission.)
We quote from Sergei and Chilingaridi34 on their cadaveric investigations:

Lymphatics of the vestibule of the larynx appear to emerge along with the superior laryngeal artery in 66%, in 29% along with lingual artery,
and along the pharyngeal branches of thyrocervical axis in 4.5%; lymphatics of the infraglottic cavity in 2.3% emerge through the thyrohyoid
membrane. Lymphatics of the larynx and tongue supply the superior internal jugular node located superior to the site of confluence of the facial
vein and internal jugular vein; the prelaryngeal node located on the plate of thyroid cartilage superior to the superior thyroid artery; the node
of the medium group of the internal jugular chain in the site of confluence of the medium thyroid vein and internal jugular vein.
Pressman et al.35 stated that the vocal folds are relatively devoid of lymphatics. The space deep to the thin mucosa of the true vocal cords, which is
called Ranke's space, has no direct lymphatic drainage. Thus, fluid collections there diminish slowly by diffusion. The spread of carcinoma is, likewise
and fortunately, retarded until an invasive process involves tissue peripheral to the true vocal cord.
The relatively poor lymphatic drainage of the glottis results in a very low incidence of cervical lymphatic spread of glottic carcinoma. Therefore, cervical
lymphadenectomy is rarely indicated for glottic carcinoma.36 The Delphian lymph node is the most likely to be involved with glottic carcinoma.
According to Kaplan et al.,37 carcinoma of the glottic larynx with unimpaired vocal cord mobility is treated with radiation. With immobility of the cord, surgery
and radiation are the treatments of choice. Advanced cancer, a multisystem disease, requires individualization of treatment.
The regional lymphatic drainage, which is based on the branchial arch system, justifies conservative laryngeal surgery.
Buckley and MacLennan 38 propose elective dissection of node levels II to IV for N0 laryngeal and hypopharyngeal carcinoma, with the inclusion of level VI
nodes for tumors invading the subglottis, piriform fossa apex, and postcricoid region. Bilateral selective dissection is justified by the prevalence of bilateral
metastases in midline and bilateral tumors. Pending further study, selective neck dissection may suffice for small palpable metastases.
The mucosal lining of the larynx is intimately fixed to the vocal ligaments, serving to retard the production of edema in the vicinity of the vocal cords.
Therefore, repeated vocal cord injury may result in Reinke's edema.
The superior neurovascular bundle may be injured during anterior and lateral pharyngotomy approaches to the larynx.
Branches of the cricothyroid artery may be accidentally injured during emergency cricothyroidotomy. Injury can cause problematic bleeding.
Innervation
The nerve supply to the larynx can be summarized as follows (Fig. 5-25, Fig. 5-26):
General sensory supply:
Glossopharyngeal nerve (C9)
Vagus nerve (C10)
Parasympathetic supply:
Internal laryngeal branch of superior laryngeal from vagus
Recurrent (inferior laryngeal) branch of vagus
Sympathetic supply
Skeletal motor supply:
External laryngeal branch of superior laryngeal from vagus
Recurrent branch of vagus
Fig. 5-25.
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Nerve supply of larynx. Also note inferior constrictor muscle. (From Tucker HM. The Larynx (2nd ed). New York: Thieme Medical Publishers, 1993; with
permission.)
Fig. 5-26.
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One type of distribution of the inferior (recurrent) laryngeal nerve. (Modified from Hollinshead WH. Anatomy for Surgeons, 2nd ed. Philadelphia: Harper and
Row, 1968.)
VAGAL NERVE SUPPLY TO THE LARYNX

Almost all of the larynx receives its sensory, parasympathetic, and skeletal motor nerve supply from branches of the vagus nerve (Fig. 5-25). The
superior laryngeal nerve arises from the vagus at, or just slightly below, the inferior sensory ganglion of the vagus. This location is just beneath the
base of the skull and the jugular foramen, through which the vagus leaves the skull. Near the superior cornu of the hyoid and the bifurcation of the
common carotid artery, the superior laryngeal nerve divides into external and internal branches.
The external laryngeal nerve is apparently entirely skeletal motor in composition except, perhaps, for proprioceptive fibers from skeletal muscles. It
provides motor supply for the cricothyroid and the inferior pharyngeal constrictor (the cricopharyngeal part of the inferior constrictor). The
cricopharyngeus is the lowest part of the pharyngeal musculature under voluntary control. The motor fibers of the external laryngeal nerve arise in
the midbrain in the nucleus ambiguus.
The internal laryngeal nerve is a mixed nerve. It innervates the laryngeal mucosa down to the vocal folds. The internal laryngeal nerve passes through
the thyrohyoid membrane, thereafter giving off branches to the mucosa of the piriform recess and to the interior of the larynx to the true vocal folds.
A few sensory fibers for the sense of taste supply the area of the laryngeal aditus. General sensory fibers and preganglionic parasympathetic fibers to
mucosal glands supply the laryngeal vestibule and the region of the ventricle. The sensory fibers have their cell bodies in the sensory ganglia of the
vagus. The preganglionic parasympathetic fibers arise in the dorsal motor nucleus of the vagus. The postganglionic parasympathetic cell bodies are
found in terminal ganglia associated with the mucosal lining of the larynx.
The recurrent laryngeal nerve innervates all the intrinsic muscles of the larynx except the cricothyroid. It branches to provide skeletal motor, general
sensory, and parasympathetic supply to the laryngeal mucosa at and below the vocal folds. The locations of the cell bodies of these motor fibers are
similar to those described for the superior laryngeal nerve. Beginning near the subglottis and continuing downward into the trachea, the vagus
provides general visceral (fibers for poorly localized sensation) and parasympathetic branches to the airway with motor fibers for the tracheal
musculature.
The recurrent laryngeal nerve runs upward in the groove between the trachea and the esophagus, giving off branches to these structures. The nerve
lies close to the inferior thyroid artery and enters the larynx just behind the cricothyroid joint, dividing into two branches. The anterior branch
innervates the adductor muscles and the posterior branch innervates the posterior cricoarytenoid (Fig. 5-26).
We quote from Yoshida et al.39:
The pharyngeal mucosa from the eustachian cushion to the middle level of the aryepiglottic fold, except the laryngeal surface of the epiglottis,
was supplied by the glossopharyngeal sensory fibers, whereas the laryngeal sensory fibers innervated between the apex of the epiglottis and
the level of the first tracheal ring in the larynx and between the middle level of the aryepiglottic fold and the caudal end of piriform sinus in the
pharynx. Most areas of the mucosa, except the subglottis, had unilateral innervation. The subglottis, including the caudal aspect of the vocal
fold and the posterior glottis, had bilateral supply with ipsilateral predominance. The density of sensory fibers in the vestibule of the larynx
involving the posterolateral aspect of the arytenoid eminence was much heavier than the other parts. Sensory nerve fibers around the caudal
pole of the palatine tonsil, and in the root of the tongue and the hypopharyngeal wall were also dense.
Mu and Sanders40 provided further insight on the sensory nerve supply:
[T]he sensory innervation of the human pharynx is organized into discrete primary branches that innervate specific areas, although these areas
are often connected by small neural anastomoses. The density of innervation varied, with some areas receiving almost no identifiable nerve
supply (e.g., posterior wall of the hypopharynx) and certain areas contained much higher density of sensory nerves: the posterior tonsillar
pillars; the laryngeal surface of the epiglottis; and the postcricoid and arytenoid regions. The posterior tonsillar pillar was innervated by a
dense plexus formed by the pharyngeal branches of the IX and X nerves. The epiglottis was densely innervated by the internal superior
laryngeal nerve and IX nerve. Finally, the arytenoid and postcricoid regions were innervated by the internal superior laryngeal nerve. The
postcricoid region had higher density of innervation than the arytenoid area...The data would be useful for further understanding swallowing
reflex and guiding sensory reinnervation of the pharynx to treat neurogenic dysphagia and aspiration disorders.
The internal laryngeal nerve is rarely identified by the surgeon. It is only seen where there is a greatly enlarged superior pole of the thyroid gland rising
above the superior border of the thyroid cartilage.
The external laryngeal nerve, together with the superior thyroid vein and artery, passes under the sternothyroid muscles. The nerve then passes
beneath the blood vessels and then divides into an anterior branch for the cricothyroid and a posterior branch for the cricopharyngeus.
In most patients, the blood vessels lie within the visceral compartment of the neck beneath the pretracheal fascia. The external laryngeal nerve lies
between the fascia and the inferior pharyngeal constrictor muscle. There is thus a plane of dissection between the vessels and the nerve. One must
remember the proximity of the external laryngeal nerve when the superior thyroid vessels require ligation. In about 25 percent of individuals, the nerve
lies beneath the fascia, together with the vessels,41 and can be quite difficult to expose.
Exposure of the recurrent laryngeal nerve during any procedure on the thyroid gland is a sound surgical principle and should be done whenever possible in
procedures related to the regional cervical viscera, such as the thyroid and larynx. If the nerve cannot be found readily, the surgeon must avoid the areas in
which it might be hidden.
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At one time the recurrent nerve was considered to be so delicate that, "if a recurrent laryngeal nerve is seen during thyroidectomy, it is injured."42 At
the other extreme are those who would require demonstration of the nerve by direct stimulation during laryngoscopic observation of the vocal
cords.43 We believe that visual identification, with avoidance of traction, compression, or stripping of the connective tissue, is all that is necessary.
Complete anatomic dissection is not required, but simple exposure will not destroy the recurrent laryngeal nerve.
It should be kept in mind that the vagus nerve receives arterial supply segmentally from adjacent vessels, all the way from the base of the skull and
carotid supply to tiny branches from the inferior thyroid artery. Unnecessary manipulation of the vagus can cause avulsion of tiny arterial radicals,
resulting in seeming injury to the vagus nerve or its branches, including the motor branches of the recurrent laryngeal nerve. Thus, simple avoidance
of the recurrent nerve may not entirely preclude the possibility of paralysis of laryngeal muscles.
The recurrent laryngeal nerve forms the medial border of the triangle bounded superiorly by the inferior thyroid artery and laterally by the carotid
artery. On the left side, the recurrent nerve passes superiorly in the groove between the trachea and the esophagus. The nerve can be identified
where it enters the larynx just posterior to the inferior cornu of the thyroid cartilage.44 In the lower portion of its course, the nerve can be palpated
as a tight strand over the tracheal surface. There is more connective tissue between the nerve and the trachea on the right than on the left.
If the recurrent nerve is not found, the presence of a nonrecurrent inferior laryngeal nerve should be suspected, especially on the right side. Remember that
a nonrecurrent laryngeal nerve occurs most commonly in the presence of a retroesophageal right subclavian artery, due to the embryologic interrelationships
of development of the subclavian artery and recurrent nerve. When present, a nonrecurrent laryngeal nerve can have a nearly transverse course from its
parent vagus nerve to the region of the inferior pole of the thyroid gland.
The upper laryngeal mucosa is richly innervated and very sensitive; thus, any irritation may produce coughing.
SYMPATHETIC SUPPLY TO THE LARYNX

Both the superior and inferior laryngeal nerves contain postganglionic sympathetic fibers that most likely arise from the superior cervical ganglion and
possibly also the middle cervical sympathetic ganglia. It is uncertain whether some sympathetic fibers may also enter the larynx with the vessels
supplying it. The preganglionic sympathetics arise from cell bodies in the upper four thoracic segments of the intermediolateral cell column of the
spinal cord.
FUNCTIONAL CHANGES WITH NERVE INJURY
Unilateral and total injury of the recurrent laryngeal nerve will produce paralysis of all ipsilateral intrinsic laryngeal muscles. The only exception is the
cricothyroid, which is supplied by the superior laryngeal nerve (external branch). Paralysis of one recurrent nerve will usually result in significant hoarseness,
which may diminish over time as the contralateral vocal cord compensates by crossing the midline. Table 5-4 and Figure 5-27 describe and illustrate the
consequences of laryngeal nerve injury.
The cricothyroid muscle, having an intact innervation and being unopposed, will tense the vocal cord. This moves the vocal cord toward a median or
paramedian position and results in a hoarse voice.
A bilateral recurrent nerve injury will usually result in airway obstruction and significant respiratory distress, especially if both vocal cords remain in the
paramedian position. Tracheotomy is usually required. Arytenoidectomy or some type of vocal cord lateralization procedure is required to restore a normal
airway, but the voice may become quite breathy.
After unilateral injury of the external branch of the superior laryngeal nerve, the cricothyroid on the affected side is paralyzed. This results in partial paresis
of the posterior segment of the true vocal cord and transient weakness of voice and hoarseness. The anterior commissure rotates downward and toward the
side of the injury.
Injury to the main trunk of the superior laryngeal nerve will produce the following results:
Cricothyroid paralysis with transient weakness of phonation
Sensory changes in the laryngeal mucosa resulting in accumulation of secretions in the airway and piriform recesses
Loss of sensation in the piriform recesses and inability to perceive the presence of foreign bodies
Bilateral injury of the main trunk of both branches of the superior laryngeal nerve results in bilateral paralysis of the cricothyroid muscles (with reduction of
tension of the vocal folds) and sensory loss of the upper laryngeal mucosa. With bilateral injury the problems with lack of sensation in the laryngeal mucosa
are severe. As previously noted, airway secretions accumulate, and because the presence of foreign bodies in the piriform recesses is not easily detected by
the patient there is a tendency to aspirate foreign material.
Table 5-4. Signs and Symptoms of Laryngeal Nerve Injury*

Voice
Glottic Close
Airway
Unilateral
Weak
Weak
Good
Bilateral
Normal
Adequate
Poor
Recurrent
External branch, superior

Unilateral
Lowered Weakened
Bilateral
Lowered Loss of reflex Good
Combined injury
Good
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Combined injury
Unilateral
Weak
Poor
Good
Bilateral
Weak
Weak
Adequate
*Before compensatory cord changes occur.

Source: Newsome HH Jr. Complications of thyroid surgery. In: Greenfield LJ (ed). Complications in Surgery and Trauma. Philadelphia: JB Lippincott, 1984, pp.
601-611; with permission.
Fig. 5-27.
The various types of laryngeal nerve injury as they appear on laryngoscopy. (Modified from Newsome HH Jr. Complications of thyroid surgery. In: Greenfield
LJ. Complications in Surgery and Trauma, 2nd ed. Philadelphia: Lippincott, 1984, pp. 649-659; with permission.)
Pediatric Larynx
Anatomic Differences
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The pediatric larynx differs dramatically from the adult larynx. There are significant differences in the size, shape, location, and consistency of the
pediatric larynx.
Compared with the adult larynx the pediatric larynx is considerably smaller.45 The infant subglottic airway is only 5-6 mm in diameter compared to 1214 mm in the adult. Therefore, the area of the airway is reduced 32% by only 1 mm of mucosal edema.3,46
The child's larynx also differs in shape; the infant larynx is funnel-shaped (Fig. 5-28). As a result, the subglottis is the smallest portion of the
pediatric larynx. In the adult the glottis is the narrowest portion of the airway.
Fig. 5-28.
The infant larynx (left) compared with the adult larynx. The infantile larynx is funnel shaped. As a result, its narrowest portion is the subglottic region, which
is 5-7 mm in the newborn. The adult larynx is wider at the base; the glottis is the narrowest portion of the adult airway. (Modified from Cotton RT.
Management and prevention of subglottic stenosis in infants and children. In: Bluestone CD, Stool SE, Kenna MA, eds. Pediatric Otolaryngology (3rd ed).
Philadelphia: WB Saunders, 1996; pp. 1373-1389; with permission.)
In comparison with the adult larynx, the infant larynx is much more cranial relative to the pharynx; the free edge of the epiglottis is at the C1 level. It
descends to C3 by adolescence.45,47 Because of the position of the larynx the infant favors nasal breathing and can breathe during suckling.
The pediatric larynx is completely cartilaginous. Because of its soft consistency and high location, it is not susceptible to fractures after blunt
cervical trauma.
The small size of the pediatric airway means that trauma to the glottis and subglottis should be avoided. Trauma can result in significant edema and airway
obstruction. Specialized optical instruments have been developed to perform pediatric endoscopy.
Because of its high location and cartilaginous consistency, the pediatric larynx is not susceptible to fractures with blunt trauma. The larynx is protected by
the mandible.
Advances in neonatology have resulted in an increased survival of critically ill newborns. But because of the narrowness of the subglottic airway, the
incidence of acquired subglottic stenosis caused by intubation is much higher in the pediatric population.48
It is difficult to locate the cricothyroid space in the infant and small child. Therefore, an emergency cricothyroidotomy should not be performed. The airway
should be established endoscopically if at all possible.
HISTOLOGY
The epithelium of the mucosa of the larynx is primarily of the ciliated columnar type, the same as that of the pharynx above and the trachea below.
Stratified squamous epithelium is present on the upper half of the posterior surface of the epiglottis, the superior borders of the vestibular folds, and
on the vocal folds.
For all practical purposes, the secretions of the numerous mucous glands of the respiratory epithelium (particularly on the anterior surfaces of the
arytenoid cartilages and lining the laryngeal ventricles) bathe the interior of the larynx and the surfaces of the vocal folds. This protects them from
drying and hoarseness.
According to Montgomery,49 there are three groups of mucous glands: anterior, middle, and posterior. The anterior group is located on the anterior
and posterior surfaces of the epiglottis. The middle group is located in the vicinity of the vestibular fold. The posterior group is located anterior to the
transverse arytenoid muscle. Montgomery stated that there are no glands in the immediate vicinity of the true vocal folds.
The mucosal lining of the larynx is fixed intimately to the vocal ligaments. It serves to retard the production of edema in the vicinity of the vocal cords.
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The mucosal lining of the larynx is fixed intimately to the vocal ligaments. It serves to retard the production of edema in the vicinity of the vocal cords.
The upper laryngeal mucosa is richly innervated and very sensitive. Any irritation may produce coughing.
The occurrence of laryngeal edema is attributable to the rich, loose submucosal stratum.
The lack of lymphatic vessels draining the mucosal region of the true vocal folds deters the spread of cancer from the cords until adjacent tissues have been
invaded.
PHYSIOLOGY
It is not within the scope of this chapter to elaborate on laryngeal physiology and the anatomy of speech. The interested student will find an
abbreviated, but excellent synopsis of these topics in the 38th edition of Gray's Anatomy.50 However, a few notes on the function of the larynx will
be helpful.
The larynx serves five essential functions:
It provides a controlled passageway for normal respiration. During inspiration there is a rhythmic abduction of the glottis, resulting in an increase in the
airway area. During expiration there is adduction of the vocal cords.
It protects the lower airway from the entry of liquids, solids, and foreign bodies, and assists in the expulsion of these by initiating coughing. Laryngeal
protection occurs at several levels. During swallowing the epiglottis is brought down over the glottis. The true vocal cords adduct together. The laryngeal
mucosa is very sensitive and has many cough receptors. Stimulation of these receptors results in glottic and supraglottic closure. This is followed by an
explosive cough.
The larynx produces sounds by imposing vibrations upon the column of air expelled from the lungs, bronchi, and trachea. This is the result of a wondrous
synergism of anatomic entities concurrently increasing (widening) or decreasing (narrowing) the size of the air space in the region of the rima glottidis
(phonation).
It alters the pitch of the voice by changing the tension upon segments of the vocal cords.
As a prime agent in the Valsalva maneuver, the larynx facilitates urination, defecation, parturition, and physical efforts. Closing the airway completely after
inspiration, the larynx causes the trunk to be a stable fulcrum for efforts involved in such activities. Opening the forcibly compressed vocal folds after deep
inspiration, as in coughing, assists greatly in expulsion of fluids and solids in the airway.
ANATOMIC COMPLICATIONS
Complications Secondary to Intubation

Some problems of intubation include abrasions and contusions of the laryngeal mucosa with secondary edema, perhaps airway obstruction in the cricoid
area, or chronic ulcerations over the mucosa of the arytenoid cartilages. Pressure necrosis from an over-sized endotracheal tube can result in severe mucosal
and submucosal ulceration. This can lead to cartilage exposure and possible perichondritis of the cricoid cartilage, which is the only complete tracheal ring.
Healing can result in remodeling of cartilage and excessive scar tissue formation. This leads to subglottic or glottic stenosis.48 Avoid the use of over-sized
endotracheal tubes and limit endotracheal intubation to two weeks in adults. In addition, avoid excessive endotracheal tube motion and traumatic
intubations.
Arytenoid dislocation may occur during intubation or endoscopy. The arytenoid is usually displaced anteriorly and medially into the airway. Early endoscopic
reduction is essential.
Complications of Laryngoscopy (Direct Diagnostic, Therapeutic, or Laser)

Direct injury to the anterior commissure may result in the formation of an anterior glottic web. To avoid this complication, one must avoid lasering the
anterior commissure during endoscopic laser procedures such as the ablation of laryngeal papillomas.
Avoid injury to the upper teeth when inserting the laryngoscope.
Edema may occur from poor technique and lead to airway obstruction.
Avoid injury to the vocalis muscle during stripping of the vocal cords. Safety can be assured by superficial removal of mucosa. Dissection should be
performed in Reinke's space.
Excessive use of the laser in the subglottic space may lead to subglottic stenosis. If a laser is used, avoid allowing the laser beam to reach the subglottic
area or the proximal trachea. This reduces the likelihood of inducing stenotic changes.
Complications of Cricothyroidotomy
Perform an accurate midline incision to avoid injuring the cricothyroid muscles and blood vessels.
Avoid injury of the vocal cords and small cricothyroid vessels by keeping the incision close to the cricoid.
Convert to tracheotomy as soon as possible to avoid subglottic or glottic stenosis.
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Complications of Tracheotomy
Pneumothorax or pneumomediastinum can result from excessively lateral dissection. It is important to stay in the midline and avoid the lung apices,
especially in children.
Esophageal injury may result from improper identification of the midline trachea. Overzealous insertion of the tracheostomy tube may result in a
tracheoesophageal fistula. A fistula may also result from pressure necrosis of the posterior tracheal wall due to an over-inflated tracheostomy tube cuff.
Cricoid injury and subglottic stenosis may result from high placement of a tracheostomy tube. It is important to stay at least one tracheal ring below the
cricoid cartilage.
Complications of Conservative Laryngeal Surgery

Supraglottic (Horizontal Partial) Laryngectomy
Because of the loss of the protective mechanisms of the supraglottic structures, aspiration of oral feedings (especially thin liquids) is an expected
complication of supraglottic laryngectomy. For this reason careful patient selection, including adequate pulmonary capacity to expel aspirated
material, is essential prior to embarking on this type of procedure.
The severity of aspiration increases with extensions of supraglottic laryngectomy to include partial excision of the base of the tongue, hypopharynx,
or an arytenoid. Johnson51 considers patients with cancer confined to the supraglottic larynx without involvement of either arytenoid or with
involvement of one arytenoid and/or the vallecula and tongue base to be suitable candidates for supraglottic laryngectomy. Ogura and Thawley52
report that glottic stenosis or glottic incompetence can be avoided by reducing the amount of, or avoiding, excision of the arytenoid cartilage or base
of the tongue.
Remember, with glottic stenosis respiratory function is compromised, but phonation and deglutition may be within normal limits. However, glottic
incompetence is associated with problems of deglutition and phonation, while respiration is not affected in most cases.
Swallowing therapy after supraglottic laryngectomy is aimed at reducing the volume of aspirated material and improving or controlling tracheal
clearance. Palliative measures include using a supraglottic swallow technique, providing thickened or pureed food, avoiding thin liquids, and prescribing
procedures to improve overall pulmonary function. Removal of the tracheostomy tube is essential prior to initiating swallowing in these patients.
Some patients, especially those who are undergoing or who have undergone radiation therapy, may require prolonged supplemental nasogastric or
gastrostomy tube feedings. Prolonged use of a cuffed tracheostomy tube may be necessary in rare instances. If refractory aspiration persists, total
laryngectomy or Lindemann procedure (laryngotracheal separation) should be considered.
Vertical Hemilaryngectomy
Complications in vertical hemilaryngectomy (lateral, frontal, frontolateral, and extended frontolateral) increase with more extensive resections.
Complications include glottic stenosis with inability to decannulate the tracheostomy tube, and foreshortening of the glottis.
GLOTTIC STENOSIS
Glottic stenosis may result for many reasons. First, ensuring that the contralateral vocal cord has normal mobility is essential to avoid stenosis. In
addition, reconstructive flaps should not be overly bulky such that they cause narrowing of the glottic inlet. This is especially important when using
unipedicled or bipedicled strap muscle flaps for reconstruction of the vocal cords. If stenosis occurs then endoscopic laser or open debulking is
necessary to relieve airway obstruction.
FORESHORTENING OF THE GLOTTIS
Foreshortening of the glottis is a particular risk in procedures involving the anterior commissure. It can be remedied by reattaching the membranous
vocal cords to the anterior thyroid cartilage remnant or by reconstructing the anterior thyroid lamina and vocal folds with an epiglottic flap.
Complications of Total Laryngectomy

Fistula Formation
According to Ogura and Thawley,52 fistula formation depends on the type of surgery, radiation prior to surgery, and surgical technique. Fistulas can
occur not only with total laryngectomy but also with other procedures such as partial laryngopharyngectomy and removal of large tumors of the
piriform recess. It is likely that the amount of mucosa remaining, not the amount of mucosa removed for a good cancer operation, is responsible for
the genesis of this complication. If possible, preserve the lateral wall of the piriform recess. If the lateral and posterior pharyngeal walls are removed,
the mucosal closure is compromised. This results in the formation of fistulas because of the excessive tension and necrosis on the suture line.52
Since most fistulas will close spontaneously, treatment is usually conservative and requires drainage and diversion away from skin flaps and vital
structures (for example, the great vessels). A myocutaneous flap, such as the pectoralis major flap, may be necessary if a fistula is persistent. If
hypopharyngeal stenosis occurs, reconstruction of the pharynx with a pedicled myocutaneous flap or free jejunal tissue may be necessary. The latter
requires microvascular techniques.
Pharyngocutaneous fistulas resulting from excessive tension at the mucosal closure occur early in the postoperative course. Other causes include
poor wound healing from underlying medical problems (for example, diabetes or malnutrition), distal obstruction (such as stenosis or foreign body),
infection, or recurrent tumor.
Neopharyngeal Stenosis
Neopharyngeal or neoesophageal stenosis results from excision of too much pharyngeal mucosa during total laryngectomy or from circumferential
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scarring, such as occurs after radiation therapy. Since the three fundamental physiologic actions (glottic closure, laryngeal apposition at the base of
the tongue, and pharyngoesophageal patency) are compromised, swallowing is inadequate. Treatments include dilatations and myocutaneous and free
tissue transfer reconstructions.
Tracheal Stomal Stenosis

According to Ogura and Thawley,52 tracheal stomal stenosis is preventable "by beveling the remaining trachea posteriorly in a superior fashion so that
the surface area of the tracheal stoma is increased." The postoperative tracheal stenosis may be corrected with such rotating flaps as Y-to-V
advancement flaps.
Bleeding
The superior laryngeal vessels and the vascular base of the tongue are responsible for bleeding. It is important to identify the superior laryngeal
vascular pedicle during surgical approaches to the larynx and pharynx. In addition, the carotid artery is at risk for erosion and severe hemorrhage
after radical neck dissection and pharyngolaryngeal procedures. Whenever the pharynx is entered in conjunction with the surgical dissection of the
carotid artery (radical or modified radical neck dissection), the artery is unprotected from erosion via a salivary fistula. It is essential to protect the
carotid artery by covering the exposed vessel with a dermal graft or muscle flap. Otherwise a carotid blowout may require emergent surgical ligation
with potential neurological sequelae.
Voice Loss
In total laryngectomy the voice loss is not, for all practical purposes, an anatomic complication, but it is a "complicated disability."
The Singer-Blom technique of voice restoration53 for the total laryngectomy patient, with the shunting of air from the trachea into the hypopharynx
without aspiration, has produced very good results.54,55
Affleck et al.56 stated that resection of the larynx, hypopharynx, and cervical esophagus with pharyngogastric anastomosis could be carried out with
acceptable levels of voice rehabilitation.
Complications of Laryngotracheal Reconstruction

Granulation Tissue
The formation of granulation tissue is the most frequent complication after tracheal resection and anastomosis.13 Granulation tissue occurs because
of excessive tissue reaction at the site of anastomosis. The cause may be local infection or reaction to absorbable sutures. The granulation tissue
may obstruct the airway. It may be removed endoscopically with the laser or optical cup forceps. It is best to avoid highly reactive suture materials.
Nerve Injury
Accidental nerve injury may occur during blind dissections in the region of major nerves. For instance, during cricotracheal resection and anastomosis,
one must identify the recurrent laryngeal nerve in order to avoid injury. Injury to one or both recurrent nerves during such an airway procedure may
result in significant airway compromise despite an adequate airway lumen.
Wound Separation
A high-tension closure may result in separation at the site of anastomosis. This will result in subcutaneous air and severe respiratory distress. This
problem requires immediate intervention that may include endoscopy, repair with vascularized tissue, additional relaxation, drainage, and possible
stenting with synthetic endotracheal tubes. Stenosis may result at the suture line.
It is best to avoid this rare complication by providing a tension-free anastomosis. A laryngeal release may provide up to 4.5 cm of relaxation.
Mobilization of the mediastinal trachea may provide additional relaxation.13 In addition, immobilization at the suture line may be provided by suturing
the patient's chin to the chest during the healing period (10-14 days).
LARYNGEAL TRAUMA
Blunt or penetrating external laryngeal trauma is a rare but life-threatening injury. We quote from O'Mara and Hebert 57:
Injuries may range from small endolaryngeal hematomas or lacerations to complete laryngotracheal separation. Proper airway management is of
utmost importance and is one of the most controversial aspects of treatment of laryngeal trauma. Flexible fiberoptic laryngoscopy and high
resolution computed tomography scanning of the larynx has greatly enhanced the evaluation of these injuries. Treatment options range from
conservative, nonsurgical observation to evaluation in the operating room. Surgical intervention may involve endoscopy, open surgical
exploration, and possibly laryngeal stenting. Long-term goals are aimed at maintaining voice, airway, and swallowing ability.
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Skandalakis' Surgical Anatomy > Chapter 5. Larynx >

ca. 100 The earliest reference to laryngeal cancer

Sketched and described larynx

Described "cancerous angina"

Reported two autopsy cases of laryngeal carcinoma

Compared action of glottis to playing of oboe

Discovered corniculate cartilages (of Santorini)

Discussed action of laryngeal muscles

First use of term "vocal cords"

Examined throat using bent mirror; used snare to remove polyps

Disagreed with Ferrein, naming structures "folds"

Discovered cuneiform cartilages

Split larynx to remove piece of meat

Claimed discovery of cuneiform cartilages (of Wrisberg)

Astley Cooper early

Performed first successful tracheostomy in a child

Studied physiology of larynx

Presented the first effective laryngoscope

Experimented with total laryngectomy

Identified conus elasticus and several ligamentous bands

Described 4 types of laryngeal phthisis (chronic laryngeal alterations)

First to use tracheostomy for laryngeal cancer

Performed first laryngofissure in the United States

Visualized his own glottis; called "Father of Laryngology"

Introduced laryngoscopy to North America

Introduced mirror laryngology

Reported removal of laryngeal tumor by indirect laryngoscopy

Print: Chapter 5. Larynx

Used a type of laryngoscope for 18 years

deSilva Solis- 1867

Reported permanent cure of carcinoma by laryngofissure

Tested laryngectomies on dogs

Accurately described laryngeal anatomy

Performed first human laryngectomy for cancer

Performed first completely successful laryngectomy

Described laryngeal cancer as an extremely rare disease

Reported first vertical hemilaryngectomy

Used cocaine as local anesthetic

First to describe endoscopic removal of vocal cord carcinoma

Used direct laryngoscopy

Performed first tracheohyoidoepiglottopexy

Reported partial extirpation of the larynx

Described radical surgical removal of neck lymphatic tissue

Adopted Crile's technique.

Performed 160 total laryngectomies.

Described partial practical pharyngolaryngectomy

First description of mucoepidermoid tumors

First description of laryngeal Schwannoma

First description of granular cell tumor of larynx

First description of pleomorphic adenoma

First description of laryngeal neurofibroma

First description of malignant lymphoma of the larynx

Performed mediastinal dissection

Performed two-stage supraglottic laryngectomy

Described intravestibular horizontal partial laryngectomy

Described successful animal use of thyrochondroplasty flap

Reported first carcinoid of larynx

Described Rthi procedure (vertical division of posterior lamina of cricoid cartilage)

Described laser surgery on vocal cords of dogs

Created arytenoid vocal shunt