Otolaryngol Clin N Am

39 (2006) 1–10

Anatomy and Physiology of the Larynx

J. Pieter Noordzij, MD*, Robert H. Ossoff, DMD, MD
Vanderbilt Voice Center, Department of Otolaryngology, 7302 Medical Center East,
South Tower 1215, 21st Avenue South, Nashville, TN 37232-8783, USA

Assessing the function of vocal folds begins with a thorough understand-

ing of vocal fold anatomy (histologic and gross) and physiology. This
knowledge is important not only in understanding normal vibratory behav-
ior, but it is also critical in appreciating how alterations in normal structure
will adversely affect vibratory behavior and thereby voice. This article cov-
ers the latest understanding in vocal fold anatomy and physiology that
would be relevant to the practicing otolaryngologist.

Histologic anatomy
One key to understanding the vocal fold anatomy is to focus on vocal
fold histology. The covering of the free edge of the vocal fold is especially
adapted for phonatory vibration. This vocal fold epithelium is squamous
rather than respiratory and contains no mucous glands [1]. The arrangement
of connective tissue within the vocal fold allows the mucous membrane to
undulate with minimal restriction from the underlying vocalis muscle.
Histologically, the vocal fold consists of five layers (Fig. 1):
1. The squamous epithelium layer of the mucosa is very thin and helps to
hold the shape of the vocal fold. There are no mucous glands located
within this epithelium; therefore, mucoserous secretions covering the vo-
cal fold must travel from glands located superiorly, inferiorly, anteriorly,
and posteriorly to the edge of the membranous vocal fold.
2. The superficial layer of the lamina propria consists primarily of loose fi-
bers and matrix. Clinically, it is referred to as Reinke’s space. This layer
has the lowest concentration of both elastic and collagenous fibers. It of-
fers the least resistance to vibration and can be thought of as a soft

* Corresponding author.
E-mail address: jpnoordzij@pol.net (J.P. Noordzij).

0030-6665/06/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2005.10.004 oto.theclinics.com
2 NOORDZIJ & OSSOFF

Fig. 1. The three layers of the lamina propria of the vocal fold. (From Gray SD, Dove H, Bie-
lamowicz SA, et al. Experimental approaches to vocal fold alteration introduction to the mini-
thyrotomy. Ann Otol Rhinol Laryngol 1999;108:2; with permission.)

gelatinous mass. This layer, in particular, is vital for proper phonatory

function.
3. The intermediate layer of the lamina propria also consists of elastic and
collagenous fibers but at a higher concentration than the superficial
layer of the lamina propria.
4. The deep layer of the lamina propria consists primarily of a high con-
centration of collagen bundles. This deep layer is dense and fibrous
and together with the intermediate layer forms the vocal ligament.
The vocal ligament is the uppermost portion of the conus elasticus.
Some collagenous fibers of the deep layer of the lamina propria insert
into the muscle fibers of the vocalis muscle. The intermediate and
deep layers are not easily separated.
5. The vocalis (also known as thyroarytenoid) muscle provides the main
mass of the vocal fold. The muscle fibers run parallel to the free edge
of the vocal fold.
The vocal fold histologic characteristics described above are fairly consis-
tent along the length of the vocal fold with the following exceptions: at the
anterior-most portion of the vocal fold there is a mass of collagenous fibers
known as the anterior commisure tendon or Broyle’s tendon. These fibers
are attached to the inner thyroid perichondrium. The intermediate layer
of the lamina propria is thickened at the anterior and posterior ends of
the membranous vocal fold. These regions are known as the anterior and
 ANATOMY AND PHYSIOLOGY OF THE LARYNX 3

posterior macula flava. These structures serve as a transition zone between

the stiff thyroid and arytenoid cartilage and the pliable membranous vocal
fold. These structures may cushion the vocal folds and provide protection
from mechanical damage caused by vibration [2].
The vocal fold epidermis is secured to the superficial lamina propria
through the basement membrane zone [3]. The basement membrane zone
is a collection of protein and nonprotein structures that, together, help
the basal cells of the epidermis secure themselves to the rather amorphous
mass of proteins present in the lamina propria. The basal cells have anchor-
ing filaments and fibers that attach themselves to laminar proteins in the
lamina propria (Fig. 2). This delicate and flexible anchoring system allows
the primarily cellular epidermis to adhere to the amorphous and gelatinous
lamina propria.
Any disruption in this anchoring system can have serious consequences in
voice production. For example, the number of anchoring fibers per unit area
appears to be genetically determined [4]. A person with fewer anchoring
fibers might be predisposed to the development of vocal fold nodules [3].
The lamina propria of the vocal fold can be categorized by its cellular and
noncellular (or extracellular) components [3]. The lamina propria contains
a variety of important cells including fibroblasts, myofibroblasts, and mac-
rophages. Macrophages are found in higher concentrations just below the
basement membrane zone and in the superficial layer of the lamina propria.
Their location suggests that these cells are present to combat inflammatory
agents crossing the epithelial layer. Fibroblasts are cells that replace dam-
aged proteins of the lamina propria. They are present in similar concentra-
tions throughout all layers of the vocal fold. Myofibroblasts are fibroblasts

Fig. 2. The basement membrane zone of the vocal fold. (From Gray SD, Pignatari SN, Harding
P. Morphologic ultrastructure of anchoring fibers in the normal vocal fold basement membrane
zone. J Voice 1994;8:48–52; with permission.)
4 NOORDZIJ & OSSOFF

that have differentiated into cells of repair [5], which are present when injury
has occurred and repair is needed. Myofibroblasts are found in most human
vocal folds and are found in a higher density in the superficial layer of the
lamina propria. It is speculated that their presence indicates that the human
vocal fold is constantly going through a cycle of minor injury and repair. It
is believed that the extent of this tissue injury is likely greatest in the super-
ficial lamina propria. By maintaining this constant presence of myofibro-
blasts, the vocal folds appear very capable of repairing minor injuries
efficiently, without significant compromise in vocal fold tissue or function.
However, the myofibroblasts must be given time to perform this repair. If
a patient develops a minor injury because of overuse, the voice must be res-
ted to allow the myofibroblasts the chance to perform needed repairs. This
typically happens in 2 to 3 days. Obviously, larger, more macroscopic inju-
ries would overwhelm the myofibroblasts and result in the degradation of
voice production.
The noncellular or extracellular component of the lamina propria is also
known as the extracellular matrix and refers essentially to the molecules
found between the cells [3]. The extracellular matrix contains a variety of
molecules, including fibrous and interstitial proteins and other interstitial
molecules such as carbohydrates and lipids [6,7]. The two most important
fibrous proteins are collagen and elastin. Collagen provides strength and
structure to the vocal fold. Elastin, on the other hand, is elastic in nature
and allows the vocal fold to be deformed and then return to its original
shape [3]. Interstitial proteins, also known as proteoglycans, include hyalur-
onic acid, decorin, fibromodulin, versican, heparin sulfate proteoglycan, and
aggregan biglycan [8]. Interstitial proteins affect tissue viscosity and bestow
a dampening or shock-absorbing property [9].
The extracellular matrix of the lamina propria is regulated by fibroblasts
and is influenced by age and gender. Older or damaged proteins in this ma-
trix are constantly being replaced by fibroblasts. With aging, the extracellu-
lar matrix turnover slows, that is, the collagen turnover decreases with age.
With age, collagen is older before being replaced or destroyed. In addition,
older proteins also undergo a process known as cross-linking. Cross-linking
results in less elastic elastin [10] and stiffer collagen [11]. As a result, the vo-
cal folds become less elastic and stiffer as the human body ages [3].

Gross anatomy
We now shift away from histologic anatomy to focus on the macroscopic
or gross anatomic features of the larynx. Vocal fold shape and movement
are primarily the result of intrinsic laryngeal muscle activity (Fig. 3). To
a lesser degree, extrinsic laryngeal muscles also affect vocal fold shape and
movement. The muscles that act to adduct or close the vocal folds are the
lateral cricoarytenoid, thyroarytenoid, and interarytenoid muscles. The lat-
eral cricoarytenoid muscle originates on the lateral aspect of the cricoid
 ANATOMY AND PHYSIOLOGY OF THE LARYNX 5

Fig. 3. The muscles of the larynx.

cartilage and inserts onto the muscular process of the arytenoid cartilage.
The thyroarytenoid muscle arises from the inner thyroid cartilage and in-
serts on the vocal process of the arytenoid cartilage.
The posterior cricoarytenoid muscle is the only muscle that abducts or
opens the vocal folds. It originates from the posterior surface of the cricoid
cartilage and inserts onto the muscular process of the arytenoid. When both
posterior cricoarytenoid muscles become denervated (eg, in bilateral recur-
rent laryngeal nerve injury from thyroidectomy surgery), serious airway ob-
struction can ensue. The cricothyroid muscle narrows the gap between the
thyroid and cricoid cartilages, thereby stretching of the vocal folds. Profes-
sional singers rely particularly on proper cricothyroid muscle control to
reach higher pitches while singing.
Compartmentalization of the intrinsic laryngeal muscles allows for ultra-
fine control of the vocal fold position. The posterior cricoarytenoid, cricothy-
roid, and thyroarytenoid muscles all have subdivisions, each with separate
nerve branches [12–14]. The division of the thyroarytenoid muscle into supe-
rior and inferior subcompartments, which appear to contract independently,
allows the human larynx to produce sounds with a variety of intensities, regis-
ters, and qualities that would not otherwise be possible [15].
6 NOORDZIJ & OSSOFF

The vagus nerve provides motor and sensory innervation to the larynx
through two branches, the superior and recurrent laryngeal nerves. The su-
perior laryngeal nerve has two branches, the external branch of the superior
laryngeal nerve, which provides motor innervation to the cricothyroid mus-
cle, and the internal branch of the superior laryngeal nerve, which provides
sensory innervation of the supraglottis and the glottis. The internal branch
of the superior laryngeal nerve enters the laryngopharynx through an open-
ing in the thyrohyoid membrane.
The recurrent laryngeal nerves provide motor innervation for the remain-
ing intrinsic laryngeal muscles (thyroarytenoid, lateral cricoarytenoid, poste-
rior cricoarytenoid, and interarytenoid) and sensory innervation to the upper
trachea and subglottis. The recurrent laryngeal nerves usually travel from the
skull base downward into the upper thorax before heading back superiorly
into the lower neck. The left recurrent laryngeal nerve travels around the
aortic arch before turning superiorly, whereas the right recurrent laryngeal
travels around the right subclavian artery. The left recurrent laryngeal nerve
travels more medially in the tracheoesophageal groove as it heads toward the
larynx compared with the right recurrent laryngeal nerve. Both left and right
recurrent laryngeal nerves may be nonrecurrent, meaning the nerve does not
travel into the thorax but rather directly from the skull base through the neck
into the larynx. This occurs on the right side in approximately 0.5% of cases
[16] and much less commonly on the left side. A nonrecurrent laryngeal nerve
has important surgical implications when operating along the external larynx
(eg, as in thyroidectomy).

Phonation
Physiologically, the human larynx is required for airway protection, res-
piration, swallowing, and phonation. This article focuses on phonation. Dur-
ing phonation, the vocal folds act as an energy transducer that converts
aerodynamic power generated by the chest, diaphragm, and abdominal mus-
culature into acoustic power that is heard as the voice [17]. This energy trans-
formation occurs primarily in the space between the vocal folds; however, it is
also influenced by subglottic and supraglottic parameters. For normal phona-
tion, adequate respiratory support, appropriate glottal closure, a normal
vocal fold cover, and control of vocal fold length and tension are required.
The vibratory motion of vocal folds is a complex cycle that results in
voice production (Fig. 4). The modulation (ie, glottal opening and closing)
of the air stream during phonation is what results in voice production. As
the subglottic pressure increases against closed vocal folds, this pressure
eventually opens the glottis. At its maximum opening, the upper lip of the
vocal fold continues to move laterally, while the lower lip begins to move
medially. Eventually the upper lip also begins to move medially. The medial
movement of the vocal folds results from a passive recoiling force (because
of an innate elasticity of the vocal folds), a drop in subglottic pressure, and
 ANATOMY AND PHYSIOLOGY OF THE LARYNX 7

Fig. 4. Vocal fold vibration showing a coronal view of a complete glottal cycle.

the negative pressure caused by the Bernoulli effect. This negative pressure
pulls the vocal folds toward each other. The initial recontact occurs at the
lower lip of the vocal folds. The contact area of the vocal folds increases until
the subglottic pressure becomes high enough to push the vocal folds apart.
This aeromechanical cycle is repeated over and over and results in phonation.
This glottal cycle results in the occurrence of a traveling wave of mucosa
from the inferior to superior surface of the vocal folds, known as the muco-
sal wave. This mucosal wave is present only if there is a pliable mucous
membrane covering the vocal fold. The speed at which the mucosal wave
travels is increased with the vocal fold lengthening [18,19], greater airflow
[18], greater subglottic pressure [20], and laryngeal muscle contraction,
which is associated with increased fundamental frequency [20].
8 NOORDZIJ & OSSOFF

Normal vocal folds can produce three typical vibratory patterns: falsetto,
modal voice, and glottal fry. In the falsetto or light voice, no complete glot-
tal closure takes place. During this high-pitched voice, only the upper edge
of the vocal fold vibrates. In the modal voice, complete glottal closure oc-
curs and results in the majority of the midfrequency range voice. During
the modal phonation, the vocal fold mucosa vibrates independently of the
underlying vocalis muscle. Glottal fry, or very low-frequency phonation,
is characterized by a closed phase, which is relatively long compared with
the open phase. During glottal fry, the mucosal cover and underlying muscle
vibrate as a unit.
Knowledge of videostroboscopic vibratory parameters is important for
the clinician when assessing videostroboscopic images of the larynx. The
first such parameter is fundamental frequency, which describes the modal
or basic frequency at which a person phonates. The fundamental frequency
for an adult male is approximately 120 Hz (number of vibratory cycles
per second), whereas for an adult female, the frequency is approximately
200 Hz. Another major parameter is the horizontal (or lateral) excursion
of the vocal fold edge. The vocal fold edge is the medial-most part of the
vocal fold, and this is not a fixed point on the vocal fold. Rather, the
medial-most portion of the vocal fold is at varying vertical points along
the vocal fold, depending on where the vocal fold is in its glottal cycle
(see Fig. 4). The horizontal displacement of the vocal folds is called ampli-
tude. The distance between the vocal folds is known as the glottal width.
The area between the two vocal fold edges (when viewed from above) is
called the glottal area.
The vibratory cycle is divided into the open and closed phases [21]. The
open phase denotes the time at which the vocal folds are at least partially
open. The closed phase denotes the time at which the membranous vocal
folds are fully closed. The open phase is further divided into the opening
and closing phases. The opening phase is defined as the time when the vocal
folds are moving away from each other, whereas the closing phase is defined
as the time when the vocal folds are moving together.
There are several other important vocal fold physiologic parameters that
should be assessed when visually examining the vocal folds. One parameter
is the mucosal wave of the vocal fold, which represents an undulation of the
mucous membrane during the glottal cycle. During normal phonation, the
mucosal wave travels in an inferior-to-superior direction. The speed of
the mucosal wave ranges from 0.5 to 1 m per second [21]. The symmetry
of vocal fold vibratory behavior is another important parameter to assess.
Any asymmetry of vocal fold excursion (one vocal fold compared with
the other) represents a pathologic process. Finally, the periodicity of the
glottal cycles also should be assessed. Periodicity denotes a regular repeti-
tion of vibratory cycles such that each cycle is the same in amplitude and
duration. Any deviation from periodic vibratory cycles is known as
aperiodicity.
 ANATOMY AND PHYSIOLOGY OF THE LARYNX 9

Summary
A sound understanding of laryngeal anatomy and physiology is crucial
when managing patients with vocal complaints. This article covers the basics
in vocal fold anatomy (histologic and gross) and vocal fold physiology. A
better understanding of the lamina propria and the basement membrane
zone and of the fine neuromuscular control of laryngeal muscles may result
in improved treatments of dysphonia in the future.

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