Hypopharynx and larynx anatomy

Poster No.: C-0786

Congress: ECR 2016
Type: Educational Exhibit
Authors: 1 2
A. I. Fernández Martín , N. Delgado Ronda , E. Dominguez
3 4 5
Franjo , M. Martínez Martínez-Losa , N. Alegre Borge , J.
3 1 2
Martínez Salazar ; Arganda del Rey, MADRID/ES, Ávila/ES,
3 4 5
Arganda del Rey/ES, Madrid/ES, San Sebastián de los Reyes/
ES
Keywords: Education and training, eLearning, Education, MR, CT, Head and
neck, Anatomy
DOI: 10.1594/ecr2016/C-0786

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Learning objectives

Review the ct and mri anatomy of the hypopharynx and larynx

Correlate the images with the findings at endoscopy

Background

The thorough knowledge of Anatomy is crucial to read head and neck studies so we
intend to catch up this subject centered on hypopharynx and larynx subsites. The
correlation with the laryngoscopy images add an extra value to understand the Anatomy
itself and the otorhinolaryngologist point of view. For example, so we realize that the
laryngoscopy doesn´t depict the "outer" tissues of the airway, then Radiology takes over.
The approach to this subject from different points of views but complementaries involves
an integral cooperative job.

Findings and procedure details

HYPOPHARYNX

The hypopharynx extends from the vallecula to the inferior cricoid carilage
(cricopharyngeal muscle). It consists of three regions: pyriform sinus, postcricoid area or
prharygoesophageal junction and posterior hypopharyngeal wall.

• The pyriform sinus consists of an invaginaion of the aryepiglottic folds and the
thyroid cartilage. Its inferior tip (apex) is located at the level of the true vocal
cords.
• The postcricoid area or pharygoesophageal junction is the anterior wall of
the hypopharynx at the level of the cricoid and extends from the level of
cricoarytenoid joints to the lower border of the cricoid cartilage. It is an area
difficult to evaluate with CT or MRI.
• The posterior hypopharyngeal wall continuates the posterior oropharynx wall;
it is composed of mucosa and the constrictor muscle.

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LARYNX

The larynx is divided into three subsites: supraglottis, glottis and subglottis.

• The supraglottis extends from the tip of the epiglottis to the laryngeal
ventricles. It contais the vestibule, epiglottis, pre-epiglottic fat, aryepiglottic
folds, false vocal cords, paraglottic space, arytenoids cartilages and ventricles.

• The epiglottis is a leaf-shaped flexible cartilage situated into the

anterosuperior part of the laryx. It is seldom calcified. The epiglottis
acts as a lid, protecting the airway during swallowing and is divided
into the free margin (suprahyoid) and the fixed portion (infrahyoid). The
petiole or "stem of a leaf" attaches the epiglottis to the thyroid lamina
in conjunction with the thyroepiglottic ligament. Other connecting
structures are the glossoepiglottic fold, the hyoepiglottic ligament and
the pharyngoepiglottic folds that attacht the epiglottis to the tongue in
the midline, the hyoid bone and the oropharynx respendolectively.
• The pre-epiglottic space represents the fat tissue situated anterior to
the epiglottis and posterior to the hyoid bone.
• The aryepiglottic folds separate the epiglottis (supraglottis) from the
piriform sinuses (hypopharynx). They project from the superior tip of
arytenoid cartilages to inferolateral edge of epiglottis.
• The false vocal cords consist of mucosa lining the laryngeal vestibule.
The aryepiglottic folds are continuated inferiorly by the false vocal
cords, and these by the the paraglottic spaces.
• The paraglottic spaces contain the fat situated beneath false and vocal
cords. Superiorly, they blend with the pre-epiglotic space.
• The glottis includes exclusively the true vocal cords and anterior and posterior
commissures.

• The true vocal cords are formed by the thyroarytenoid muscles, whose
medial fibers are named "vocalis muscle".
• The point in which both vocal cords meet anteriorly is the anterior
commissure.
• The subglottis extends from the undersurface of the true vocal cords to
inferior surfaces of cricoid cartilage. This site comprises the mucosal surface
at the level of cricoid cartilage, which includes the conus elasticus and the
quadrangular membrane.

The cricoid, thyroid and arytenoids cartilages serve as a framework for the soft tissue
structures of the larynx.

Page 3 of 21
 • The thyroid cartilage is composed of two laminae that meet anteriorly at an
acute angle with a notch in the anterior superior aspect. It acts as a protective
shield. The superior and inferior horns strecht out from the posterior part of
the laminae to articulate with the hyoid and cricoid cartilages respectively. The
thyrohyoid ligaments attacht to the superior horns.
• The cricoid cartilage has a ring shape, only completed at the level of
endolarynx. It consists of a posterior lamina and an anterior arch and its lower
border separates the larynx above and the trachea below.
• The paired pyramidal arytenoid cartilages sit on top of the posterior cricoid
cartilage (lamina) and move the vocal cords during phonation. Their vocal
processes serve for the attachement of the posterior part of vocal cords. Their
ossification begins by the age of 20.

And as a "picture is worth a thousand words"...let´s convert into images the theoretical
knowkedge!

• The CT and plain radiograph images: Fig. 1 on page 4 , Fig. 2 on page

5 , Fig. 3 on page 6 , Fig. 4 on page 7 , Fig. 5 on page 8 ,
Fig. 6 on page 9 , Fig. 7 on page 10 & Fig. 8 on page 11
• The laryngoscopy images: Fig. 9 on page 12, Fig. 10 on page 13, Fig.
11 on page 14, Fig. 12 on page 15, Fig. 13 on page 16 & Fig. 14
on page 17
• And MR-laryngoscopy images correlation: Fig. 15 on page 18, Fig. 16 on
page 19

Images for this section:

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Fig. 1: Axial CT image of the neck at the level of high supraglottic level of larynx

© UCR

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Fig. 2: Axial CT image of the neck at a lower level than the previous image. The
aryepiglottic folds depict the border between larynx and hypopharynx.

© UCR

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Fig. 3: Axial CT neck image at the level of the true vocal cords.

© UCR

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Fig. 4: Axial CT image of the neck at the level of the subglottis. This level starts when the
cricoid cartilage is visible and no arytenoid cartilages are noted. Any soft tissue density in
the subglottis is pathological and therefore suspicious of tumor extension into this level.

© UCR

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Fig. 5: coronal reformatted ct image of the airway from the nasopharynx to larynx-trachea.

© UCR

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Fig. 6: Saggital reformation obtained from CT images.

© UCR

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Fig. 7: Plain film that depicts the airway. We usually tend to feel unconfortable with this
technique, however it is exactly the same as the reformatted ct previous image!

© UCR

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Fig. 8: A serie of axial CT images of the neck that depict the position of the nasogastric
tube (as a marker of the hypopharynx and esophagus). The NGT is highlighted with
a red arrow. For a better understanding, the hypopharynx-larynx crossroad can be
conceptualised as a pair of trousers, in wich both share a common part and then each
one takes its own way.

© UCR

Page 12 of 21
Fig. 9: Image obtained from laryngoscopy.

© "Department of Otorhinolaryngology, Hospital del Sureste/Spain 2015 "

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Fig. 10: Image (same image as the previous one) obtained from laryngoscopy, but with
the signs.

© "Department of Otorhinolaryngology, Hospital del Sureste/Spain 2015

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Fig. 11: Image obtained from laryngoscopy at the level of epiglotis.

© "Department of Otorhinolaryngology, Hospital del Sureste/Spain 2015

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Fig. 12: Image obtained from laryngoscopy that depicts the level of the false and true
vocal cords.

© "Department of Otorhinolaryngology, Hospital del Sureste/Spain 2015

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Fig. 13: Image obtained from laryngoscopy that depicts the true vocal cords abducted.

© "Department of Otorhinolaryngology, Hospital del Sureste/Spain 2015

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Fig. 14: Image obtained from laryngoscopy during phonation (adducted true vocal cords).

© "Department of Otorhinolaryngology, Hospital del Sureste/Spain 2015

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Fig. 15: Axial T2 image - laryngoscopy image correlation. This latter image is turned
"upside-down" regarding the position the otorhinolaryngologist sually would see it.

© - Arganda del Rey/ES

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Fig. 16: Axial T2 image - laryngoscopy image correlation. This latter image is turned
"upside-down" regarding the position the otorhinolaryngologist sually would see it.

© - Arganda del Rey/ES

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Conclusion

The anatomy landmarks are the mainstay to read a head and neck study, so its
deepest knowledge is needed to make the correct diagnosis. Furthermore, the correlation
between the ct/mri images and those seen by the otorhinolaryngologist are helpful to
perform this task.

Personal information

References

1. Spiral and Multislice Computed Tomography of the Body, Mathias Prokop,

Michael Galanski and cols., Thieme 2003
2. Diagnostic and Surgical Imaging Anatomy, Harnsberger, Osborn,
Macdonald, Ross et cols,, Amirsys, first edition, January 2011

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