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The Periepiglottic Space: Topographic Relations and Histological Organisation

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The Periepiglottic Space: Topographic Relations and Histological Organisation J. Anat. (1996) 188, pp. 173-182, with 9 figures Printed in Great Britain 173 The periepiglottic space: topographic relations and histological organisation MARTINA MARIA REIDENBACH Institute of Anatomy, Rheinische Friedrich-Wilhelms-Universitat, Bonn, Germany (Accepted 10 July 1995) ABSTRACT Important aspects of histological organisation and topographic relations of the pre-epiglottic space are not fully understood. This region was therefore reinvestigated in plastinated serial sections of 19 human adult specimens. The cranial part of the pre-epiglottic space is homogenously filled with adipose tissue and extends around the epiglottis in a horseshoe fashion. Therefore, the term periepiglottic space (PES) is a more accurate description of this region. The cranial border of the PES is constituted by the hyoepiglottic membrane, which extends between the epiglottis and the tongue, and the hyoepiglottic ligament. The ligament consists of a cranial fibre layer anchored within the lingual muscles, and a caudal layer attached to the hyoid bone. Anterior to the lingual surface of the epiglottis, both fibre layers become apposed to form a dense collagenous mass, which may stabilise the epiglottis during deglutition. Contractions of the infrahyoid muscles will be transmitted to the thyrohyoid membrane anterior to the PES by numerous collagenous septa which originate from the membrane and radiate into the muscles. In contrast, the pre-epiglottic adipose tissue is not connected to the thyrohyoid membrane. The caudal part of the PES is subdivided by two paramedian sagittal collagenous septa. They include a medial compartment bordered by the epiglottis posteriorly and the thyroepiglottic ligament inferiorly. The two lateral subdivisions of the PES extend between the glands of the vestibular folds and towards the aryepiglottic folds, but a distinct confining collagenous layer is absent there. Posterolaterally, the PES is separated from the paraglottic space by the thyroarytenoid muscle and by a cranial extension of the fibrous sheet of the muscle. This collagenous tissue is often split into several layers and displays gaps which may facilitate the spread of malignancies. Key words-: Human larynx; deglutition; laryngeal carcinoma. epiglottic space is described as continuing into the INTRODUCTION adjacent laryngeal tissues. The hyoepiglottic mem- The term 'pre-epiglottic space' is not mentioned in the brane is also not mentioned in the Nomina Anatomica Nomina Anatomica (International Anatomical No- (International Anatomical Nomenclature Committee, menclature Committee, 1983, 1989), but it is defined 1983, 1989). According to recent investigations in the anatomical literature. According to Pernkopf (Vandaele et al. 1995), it is part of the submucosal (1952), Lanz & Wachsmuth (1955) and Zenker (1958), fascial tissue of the laryngopharynx and covers the the pre-epiglottic space has the following boundaries hyoepiglottic ligament cranially. This ligament (Fig. 1 a): anteriorly, the thyrohyoid membrane with connects the lingual surface of the epiglottis and the the thyrohyoid ligaments, and the cranial part of the hyoid bone (Williams et al. 1989). thyroid cartilage; superiorly, the hyoepiglottic mem- The pre-epiglottic space contains adipose tissue brane and the hyoepiglottic ligament; posteriorly, the (Pernkopf, 1952; Lanz & Wachsmuth, 1955; Anson & lingual surface of the epiglottis; inferiorly, the McVay, 1971; Williams et al. 1989), the 'corpus attachment of the epiglottis to the thyroid cartilage by adiposum pre-epiglotticum' of the Nomina the thyroepiglottic ligament. Laterally, the pre- Anatomica (International Anatomical Nomenclature Correspondence to Dr Martina Maria Reidenbach, Institute of Anatomy, Rheinische Friedrich-Wilhelms-Universitat, Nussallee 10, 53115 Bonn, Germany. 174 M. M. Reidenbach ~ ~~~~W.w. ..1W : -4r -1? Fig. 1. Schematic drawing ofmedian sagittal section oflarynx, viewed medially. (a) Topography ofthe pre-epiglottic space and its boundaries according to the literature. Asterisk, pre-epiglottic space, containing pre-epiglottic fat pad; arrow, hyoepiglottic membrane; 1, median hyoepiglottic ligament; 2, median thyrohyoid ligament; 3, thyroepiglottic ligament; 4, root of tongue; 5, epiglottis; 6, thyroid cartilage; 7, cricoid lamina; 8, cricoid arch; 9, hyoid bone; 10, transverse arytenoid muscle; 11, laryngeal ventricle. (b) Planes of horizontal (cf. Figs 3-7) and frontal (cf. Fig. 8) sections. Committee, 1989; not included in the earlier 1983 According to Sato et al. (1993), the posteroinferiot edition). During deglutition, this fat pad is deformed boundary is constituted by the thyroglottic ligament. and pressed against the epiglottis, causing it to descend This ligament was observed in a fetal larynx of 24 wk and partly close and protect the entrance of the larynx by Tucker & Smith (1962), who introduced the term (Passavant, 1886; Fink, 1975, 1976; Fink et al. 1979). 'thyroglottic ligamdnt'. The authors applied it to a From a clinical standpoint, the pre-epiglottic space is collagenous layer fanning out between the anterior ofgreat interest, particularly with regard to the spread part of the vocal cord and the thyroid cartilage. of laryngeal carcinoma. Tumours arising cranial to Concerning the posterior boundary of the pre- the glottis frequently invade the pre-epiglottic space epiglottic space, Clerf (1944) pointed out that it is (Clerf, 1944; Bocca et al. 1968; Olofsson & van constituted by an elastic membrane, in addition to the Nostrand, 1973; Micheau et al. 1976; Kirchner, 1977; narrow lower part of the epiglottis. However, the Million, 1993). In the literature, there is no agreement author did not provide further information on this as to whether the pre-epiglottic space is subdivided by membrane. collagenous septa which may represent anatomical Altogether, important aspects of histological or- barriers against tumour growth. Some authors have ganisation and topographic relations of the pre- described a collagenous layer completely dividing the epiglottic space are still a matter of controversy. This pre-epiglottic space along the median sagittal plane physiologically and clinically interesting anatomical (Testut & Jacob, 1914; Testut, 1930; Guerrier & region has therefore been reinvestigated in the present Andrea, 1973). This septum is not mentioned else- study. The study is based on the examination ofwhole where (Pernkopf, 1952; Lanz & Wachsmuth, 1955; organ sections of human adult larynges and the Braus & Elze, 1956; Anson & McVay, 1971; Maguire adjacent pre-epiglottic regions. For tissue preparation, & Dayal, 1974; Williams et al. 1989). Dayal et al. the technique of plastination was applied, which is (1972) described a condensation of fibroelastic tissue advantageous for the examination both of the healthy in the midline of the pre-epiglottic space, but denied (Eckel et al. 1993) and diseased (Eckel, 1993) larynx. the existence of a sharply defined septum. It is not fully understood which anatomical structures border the pre-epiglottic space inferiorly and posteriorly. Periepiglottic space 175 MATERIALS AND METHODS RESULTS Terminology The anatomical structures which border the PES Maguire & Dayal (1974) found the pre-epiglottic cranially and ventrally can be defined easily. In space to extend around the epiglottis in a horseshoe contrast, the topographic relations of its posterior, fashion. They therefore suggested the term 'peri- inferior and lateral extensions are much more com- epiglottic space', which is more accurate and has been plicated. They depend on the level of investigation, as adopted in this work, abbreviated to PES. does the histological organisation of the contents of The material was taken from 19 human cadavers (9 the PES. males, 10 females) aged between 44 and 87 y (mean 65.8 y). The cause of death was unrelated to upper Cranial border of the PES airways or digestive tract disease or injury. The larynges with the PES and the thyrohyoid membrane, Cranially, the PES is bordered by several layers of the hyoid bone and the root of the tongue were collagen fibres, which are loosely apposed and extend removed en bloc. The specimens were fixed by in an anteroposterior direction (Fig. 2a). The cranial immersion in a 10% formaldehyde solution for at fibres radiate into the muscle tissue at the root of the least 3 months and were then subjected to a tongue, whereas the caudal fibre group is attached to plastination process (Fritsch, 1988, 1989a; Schmolke, the periosteum of the upper rim of the hyoid bone. A 1994). After rinsing in water for 48 h to remove the few of the cranial fibres course beneath the mucosal formaldehyde, the specimens were dehydrated in lining of the epiglottic valleculae and join the 100% acetone at -25 °C (Schwab & Hagens, 1981) perichondrium anterior to the free part of the changed weekly for 4 wk. This was followed by epiglottis. These fibres constitute the weak another 2 wk in 100 % acetone at room temperature hyoepiglottic membrane. The remaining collagen to dissolve the fat. Impregnation was then performed fibres of both the cranial and caudal layers interlace in a vacuum chamber (Hagens, 1985) with a mixture into the dense fibrous mass of the median of the epoxy resins Biodur E12 (2 parts) and Biodur hyoepiglottic ligament (Fig. 2a). This extends E6 (1 part), and the accelerator Biodur E600 caudalward at the lingual surface of the epiglottis and (0.2 vol %) over 2 wk. After another 2 wk of poly- contains numerous groups of glands. A few merisation at 50 °C, the epoxy
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