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17192-LARYNX ANATOMY and PATOLOGY Dr. Bustelo.Pdf INDEX LARYNX: ANATOMY AND PATHOLOGIES LARYNX: ANATOMY AND PATHOLOGIES J Carlos Tortajada 1. Larynx Anatomy: Cartilages, membranes and ligaments 2. Larynx regions: Supra/glotis/sub Neuroradiology Department Vall d’Hebron Hospital. Barcelona (Spain) 3. Anatomical landmarks: [email protected] PEG, PGS, AC Cartilage invasión and other routes of tumor spreed 4. Laryngocele 5. Infections: Supraglottitis LARYNX LARYNX Structure FUNCTIONS 9 Airway 9 CARTILAGES 9 Phonation 9 MEMBRANES AND LIGAMENTS 9 Aspiration prevention 9 JOINTS LARYNX - CARTILAGES Epiglottis * epiglottis cricoid cricoid Post Fibroelastic leaf shaped cartilage o Suprahyod epiglottis (free) o Infrahyoid epiglottis (fixed) o Petiole : A stalk-like process of epiglottis (*) Protects airwaiy during swallowing Thyroid Cricoid Ant Ant • The largest laryngeal cartilage. 9 Complete ring. • 2 laminas that fuse in the midline (notch thyroidÆ Adam’s apple). Forming an angle of 90° in males and 120° in females. • 2 pairs of horns: 9 Posterior part Ælamina - The superior horns 9 Anterior part Æ arch. - The lower horns Arytenoidd Arytenoidd Post Cuniform cartilage Ant Post BaseÆ articulates with cricoid cartilage. BaseÆ articulates with cricoid cartilage. Muscular process, directed laterally to give attachment to intrinsic laryngeal muscles. Muscular process, directed laterally to give attachment to intrinsic laryngeal muscles. Vocal procesÆ attachment to vocal cord Vocal procesÆ attachment to vocal cord Apex Æ supports the corniculate cartilage. Apex Æ supports the corniculate cartilage. Arytenoidd LARYNX – MEMBRANES AND LIGAMENTS P M M R Q S N N O O Thyroarytenoid muscle BaseÆ articulates with cricoid cartilage. MEMBRANES AND LIGAMENTS Muscular process, directed laterally to give attachment to intrinsic laryngeal muscles. Extrinsic membranes and ligaments Intrinsic membranes and ligaments Vocal procesÆ attachment to vocal cord • Thyrohyoid membraneM • Quadrangular membrane R Apex Æ supports the corniculate cartilage. • Cricotracheal membrane. O • Cricothyroid or cricovocal membrane N Median and Lateral (conus elasticusS ) • Hyoepiglottic ligament. P • Thyroepiglottic ligament. Q LARYNX – MEMBRANES AND LIGAMENTS LARYNX REGIONS P M M Supraglottis: from the tip of the epiglottis R Q above to laryngeal ventricle below. S N N Glottis: contains true vocal cords O O Subglottis: from inferior border of the glottis to the inferior surface of the cricoid cartilage MEMBRANES AND LIGAMENTS JOINTS Extrinsic membranes and ligaments Intrinsic membranes and ligaments • Thyrohyoid membrane M • Quadrangular membrane R • Cricoarytenoid Joint • Cricothyroid Joint. • Cricotracheal membrane. O • Cricothyroid or cricovocal membrane N Median and Lateral (conus elasticusS ) • Hyoepiglottic ligament. P • Thyroepiglottic ligament. Q LARYNX REGIONS Glottic plane Supraglottis: from the tip of the epiglottis above to laryngeal ventricle below. Glottis: contains true vocal cords Subglottis: from inferior border of the glottis to the inferior surface of the cricoid cartilage X SUPRAGLOTTIS SUPRAGLOTTIS SUPRAGLOTTIS SUPRAGLOTTIS 331 331 331 331 4 4 4 4 2 2 2 2 2 2 2 2 5 5 5 5 * * * 1.Glossoepiglottic fold. * 1.Glossoepiglottic fold. 2.Pharyngonepiglottic 2.Pharyngonepiglottic fold. fold. 3.Vallecula 3.Vallecula 6 4.Epiglottis 6 4.Epiglottis 4 5.Ariepiglottic fold 4 5.Ariepiglottic fold 5 5 6.Preepiglottic space 5 5 6.Preepiglottic space * * * * 22 229 8 8 7.Paraglottic space. 5 5 5 5 8.Vestibular folds (False * * * * vocal cords) 6 6 9.Ventricle 7 7 8 8 5 5 * Piriform sinus 5 5 * Piriform sinus * * * * GLOTTIS GLOTTIS AC AC 1. Vocal cords (TVC) TVC 2 2. Anterior commissure (AC) TVC 3. Posterior commisusre 1 1 4 (PC) PC 4 4. Cuniform tuberculum 5 3 5 5. Corniculate tuberculum PC - The glottis larynx essentially consists of the TVC and their mucosal covering. - The glottis larynx essentially consists of the TVC and their mucosal covering. - Anterior commissure. - Anterior commissure. - Posterior commissure Æthe mucosal surface between the arytenoid cartilages, anterior to the cricoid. - Posterior commissure Æthe mucosal surface between the arytenoid cartilages anterior to the cricoid. GLOTTIS Supraglottis Glottis 1 1 1 1 1 2 2 2 2 2 1. Vestibular folds (False vocal cords) 2. Ventricle 3. TVC SUBGLOTTIS ANATOMICAL LANDMARKS IN THE STAYING ANATOMICAL LANDMARKS: • Full thickness commisure evaluation - Pre-epiglottic space - Thyro-epiglottic space - Anterior thyro-crycoid membrane • Full thickness evaluation off the anterior PGS and thyroid cartilage • Posteiror PGS / CAU evaluation • TAM invasion AC- Anterior Comisure AC Classical AC: Insertion of the glottic level excluding thyroid 1.intermediate lamina of thyroid cartilage, 2.vocal ligament, 3.vocal muscle cartilage. (thyroarytenoid muscle), 4.high density collagen fibers of the glottic commissure, 5.internal perichondrium, “Developmental” AC: 3 levels of insertion: glottic, supraglottic 6.submucosal glands and infraglottic, including intermediate thyroid lamina. 1 Epiglottic Broyles tendon, 2 right vocal fold, 3 supraglottic median hollow, 4 subglottic level, 5 laryngeal ventricle, 6 left ventricular fold. Prades JM, Peoüh M ,Pectu C,Karkas A,Dumollard JM,GavidM.The anterior commissure of the human larynx revisited. SurgRadiol Prades JM, Peoüh M ,Pectu C,Karkas A,Dumollard JM,GavidM.The anterior commissure of the human larynx revisited. SurgRadiol Anat .2017;39(8):871-6. Anat .2017;39(8):871-6. AC PES-Preepiglottic Space T3T3 9 Broyle’s ligament Hyo-epiglottic ligament 9 Quadrangular membranes 9 Conoid ligamet Thyrohyoid membrane 9 Thyroid inner perichondrium Thyroepiglottic ligament 9 Thyroid laminas PGS-Paraglottic Space T3 PGS-Paraglottic Space ANT /POST T3 PGS : volume fille with adipose and loose connective tissue with ill defined boundaries Magic Plane Confined by: - Thyroid cartilage (laterally) - Quadrangular lamina, ventricle and T3+T posterior paraglottic tyrohyoid m (mediality) sapaces - Conus eslasticus (inferiorly) - Piriform sinus (posteriorly) Ravanelli M, Paderno A, Del Bon F, Montalto N, Pessina C, Battocchio S, Farina D, Nicolai P, Maroldi R, Piazza C. Prediction of Posterior Paraglottic Space and Cricoarytenoid Unit Involvement in Endoscopically T3 Glottic Cancer with Arytenoid Fixation by Magnetic Resonance with Surface Coils. Cancers (Basel). 2019 Jan 10;11(1):67. doi: 10.3390/cancers11010067. Neoplastic cartilage invasion Neoplastic cartilage invasion Erosion/lysis T3 SclerosisÆ Sensitive but not specific Extracartilaginous spread T4 variations in the laryngeal cartilage ossification Routes of tumor spread out from the larynx through Neoplastic cartilage invasion- MRI areas of inherent weakness T4 Yes Via the thyrohyoid membrane No Kuno H, Onaya H, Fujii S, Ojiri H, Otani K, Satake M. Primary staging of laryngeal and hypopharyngeal cancer: CT, MR imaging and dual- energy CT. Eur J Radiol. 2014 Jan;83(1):e23-35. doi: 10.1016/j.ejrad.2013.10.022. T1: hypointense T2: “evil gray”, moderately hyperintense T1 + Gd: moderate enhancement Via the inferior pharyngeal constrictor Via the cricothyroid membrane muscle LARYNGOCELE LARYNGOCELE MIXED INTERNAL SUPRAGLOTTITIS secondary laringocele Emergency Upper airway obstruction CT - If Laryngoscopy is not posible - Abscess Cause? 9 Continuous increases of the intralaryngeal pressure: excessive cough, playing wind instruments, glass blowing. 9 Valve mechanism: squamous carcinoma. CLOSING REMARKS Thank you CT Glottic plane. Laryngeal neoplasm, pay attention: -PGE - PGS: Posterior PGS may be T3+ - Spread routes: PGS, AC - Extralaringeal extension: not only cartilages... also membranes Secondary Laryngocele in neoplasm. SupraglottitisÆ can rapidly develop airway compromise..
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