00:01
Let's finish off the neck
by looking at the larynx.
00:05
We'll start with a
very clinical view.
00:08
So this would be the type
of view you have
of the opening into the larynx,
if you're doing a laryngeal scope.
00:17
Anteriorly,
we would have the tongue
Just behind that would
be the epiglottis,
a very important flap of tissue.
00:27
And there'd be a space between
the tongue and the epiglottis.
00:30
That's called the molecula.
00:34
Looking down into
the larynx itself,
we would see two folds.
00:38
One that's more pink and lateral,
and that will be
the vestibular fold,
also called the false vocal cords,
And then projecting more medially,
sitting below the
vestibular folds would be
the vocal folds,
also called the true vocal cord.
00:53
And it has this more
whitish appearance
because of its participation
in vocalization,
and the need for a
different type of mucosa.
01:05
The space between the vocal cords
is called the glottis.
01:08
In this case,
there is an open glottis
because we can see
through the vocal cords.
01:14
Posteriorly,
we have another set of depressions.
01:19
Here we call them
the piriform recess
back in the pharyngeal area.
01:26
Here's a sagittal cross section
to show the
various levels of the larynx.
01:32
Superiorly, we have
the supraglottic space.
01:35
In the area of the glottis
we have the transglottic space,
and then inferiorly
the subglottic space
before we enter the trachea.
01:45
Now let's look at what we
call the laryngeal skeleton,
which is composed of
several cartilages.
01:51
Although with age,
a lot of these cartilages
will actually ossify
in form partially at least bone.
01:58
Inferior to the larynx we have
the cartilages of the trachea.
02:03
Just before we reach the trachea
are inferior most
cartilage of the larynx
is the cricoid cartilage.
02:11
The largest is something
called the thyroid cartilage
Superiorly we have
attachments to the hyoid bone
Connecting the thyroid
cartilage and the hyoid bone
is this tough membrane called
the thyrohyoid membrane.
02:28
But it has a very important
opening or foramen
that allows a branch
of the superior laryngeal artery
and nerve to go into
that branch that pierces in
is the internal branch.
02:41
We also have a membrane connecting
the thyroid and cricoid cartilage
is called the
cricothyroid membrane.
02:47
And this is a soft
area within the larynx
that can be targeted
during a cricothyroidotomy.
02:55
Also in this area
connecting the two
is the cricothyroid muscle,
which is a very important muscle
in the process of vocalization.
03:04
Now, let's swing around
for a posterior view
of the laryngeal skeleton.
03:09
Here we can see the
thyroid cartilage
but we see that
the thyroid cartilage
doesn't go all the way around.
03:15
It really is just an
anterior structure
shaped somewhat like a shield,
which is actually what thyroid
means. Means shield like.
03:23
The cricoid, on the other hand,
is circumferential.
03:26
And does go all the way
around the airspace.
03:30
We also see the cartilage
of the epiglottis here.
03:33
As well as these pyramidal shaped
cartilages called the arytenoids
that sit on top of
the cricoid cartilage.
03:41
There are somewhat extended
by these smaller cartilages
the corniculate
and cuneiform cartilages
Here we see the cricoid cartilage.
03:51
Again, going all the way around
the airway. Unlike the thyroid.
03:56
Anteriorly, we have a small arch
and then posteriorly we have these
wider walls called the lamina.
04:03
At the top, we have these
little facets for articulation
with those arytenoid cartilages
and they're the ones
that are going to move
during the process of vocalization.
04:14
We also facet for articulation
with the inferior horn
of the thyroid cartilage.
04:20
Here is that thyroid cartilage
where it has some walls
called the right and left lamina.
04:26
And where they meet inferiorly
we have a notch called the
inferior thyroid knotch.
04:31
Similar one superiorly called
the superior thyroid notch.
04:35
And just below this,
at the anterior most projection
is something called
the laryngeal prominence.
04:41
Something that's often
palpable during physical exam
and sometimes also
called an Adam's apple.
04:48
Or posteriorly, we have a
superior and inferior tubercle
connected by an oblique line
to which many structures
will attach.
04:57
We also have that inferior horn
for an articulation with
the cricoid cartilage,
and a superior horn to which
ligaments will attach.
05:07
Here's a superior view
of the thyroid cartilage,
where we can again see
the inferior and superior horns.
05:14
And we see that the lamina form an
angle to call the thyroid angle.
05:18
And it varies between
90 to 120 degrees.
05:23
And actually the narrower angle
creates more of an elongation
and that is actually
what will have an effect
on the overall depth
or pitch of a voice.
05:36
Here we see those pyramidal
shaped arytenoid cartilage
sitting on top of the cricoid.
05:42
They have a broad base inferiorly
and a pointy aspect
superiorly called the apex.
05:50
Anteriorly, we have a projection
called the vocal process
because it will interact
with the vocal cords,
then posteriorly a muscular process
because that's where we're
going to have attachments
for these laryngeal muscles.
06:03
Here's another superior view
of the laryngeal skeleton
showing our thyroid
cartilage anteriorly
and the cricoid posteriorly.
06:12
They're connected
at least anteriorly
by this cricothyroid membrane.
06:17
We have the
arytenoid cartilages sitting
on top of the cricoid cartilage.
06:23
And here we find
this ligament running
from the arytenoids
to the thyroid cartilage
called the vocal ligaments.
06:30
Superior to which are a
different set of ligaments
called the vestibular ligaments.
06:38
Here we have another
cross section view
where we see
the epiglottis, the hyoid,
the thyroid cartilage anteriorly,
the cricoid cartilage
circumferentially,
and the membrane between the two
the cricothyroid membrane.
06:54
Again, the arytenoid sit superior
to the cricoid cartilage.
07:00
The superior fold is
the false vocal cord
why the inferior one
is the true vocal cord.
07:07
The one that actually
produces vocalization.
07:11
Let's look at the muscles
that produce that vocalization.
07:15
First of all, we have the
posterior cricoarytenoid muscle,
which is very descriptive
in where it is.
07:22
We have lateral cricoarytenoid,
transverse arytenoids,
oblique arytenoids.
07:30
The vocalis running more
anterior to posterior,
as well as the thyroid retinoids
which are also running more or
less in that same direction.
07:40
Further laterally, we have muscle
called the aryepiglotticus.
07:45
We also have the thyroepiglotticus.
07:49
When it comes to the movement,
vocal cords can be abducted
or brought away from
the midline or adducted.
08:01
Here we see them abducting or
opening versus adducting or closing.
08:10
When it comes to
the cricothyroid muscle,
it's actually drawing down
that thyroid cartilage
and an anterior inferior direction
which is actually tensing
those vocal cords
creating a higher pitch.
08:28
Here we see the
posterior cricoarytenoids
which are very important
because they're really
the only muscles
that cause abduction
of the vocal cords.
08:39
And that's important not so
much in terms of vocalization,
but in terms of
opening up the airway,
because closed vocal cords
would block air from getting down
into the trachea and lungs.
08:52
We also have the
lateral cricoarytenoids
which are going to cause abduction.
09:01
the transverse arytenoids
which are also going
to cause abduction.
09:06
Then we have the vocalis
and thyroid arytenoid
which are oriented
very differently.
09:12
They're more of an anterior
posterior orientation
along the length
of the vocal cords.
09:18
And so they're going to adjust
the tension in these vocal folds.
09:25
Now let's look at the
blood supply of the larynx.
09:30
Here we see the superior
laryngeal artery and vein
and the inferior laryngeal artery,
as well as the
inferior laryngeal vein.
09:39
These are all branches off of
the corresponding
thyroid arteries and veins.
09:45
Innervation of the
larynx really comes from
cranial nerve X,
or the vagus nerve.
09:50
And there is a bit of asymmetry
between left and right.
09:52
So we'll start by looking
at the left vagus nerve.
09:55
The vagus nerve has a branch called
the superior laryngeal nerve,
which will form an internal branch
that will become
internal by piercing
through the thyrohyoid membrane.
10:07
And then we'll have
an external branch.
10:09
And that external branch is going to
innervate the cricothyroid muscle.
10:15
Here, we also see the relationship
of the common carotid artery
as it comes off of the
arch of the aorta directly.
10:23
And that's a bit of a symmetry
because the arch of the aorta
is something of a
leftward structure.
10:29
And because it's on the left side,
the recurrent laryngeal nerve
has to arch under
the arch of the aorta
much further down than it
does on the right side.
10:41
Once it does,
it will come back upwards
and provide the motor innervation
for the remainder of
the laryngeal muscles.
10:51
On the right, we see,
again the right vagus nerve.
10:55
But on the right side,
the right recurrent laryngeal nerve
will recur underneath
the right subclavian artery.
11:03
So it will make that turn
much more superiorly
than it does
on the left side of the body.