[MUSIC] Welcome to Module 1.

In this first module, we're going

to talk about the basic anatomy and physiology of the speaking and
singing voice. Remember, anatomy is
a process of memorization. For those of you taking this course
without prior courses in anatomy, you may need to repeat
the video a few times to keep all of these concepts
straight within your head. The specific educational objectives of
this course are to describe the anatomy of the larynx and pharynx, important for
speaking and singing production. We'll describe the vocal fold histology,
the cellular structure, and the layered structure of the laryngeal
mucosa, or skin surface. And we're here to provide an understanding
of laryngeal vibration and physiology for voice production. These are concepts that
I have
developed over my 25 years of practice. Most vocal fold lesions are created
to inefficient voice use patterns. The initiation of efficient flow and
resonant voice use production techniques in speaking and
singing often eliminates the need for surgery because speaking
is a behavioral activity. I believe that optimal care is provided
through a multidisciplinary or interdisciplinary approach between
a speech language pathologist and a physician. The approach should be based on a
sound
understanding of a laryngeal anatomy, physiology and pathophysiology.
Pathophysiology is a fancy name for
disease state. I think it's important that the health
care professional understand the individuals local requirements. Let me present to
you some of my dogma. Surgery should never be
the initial treatment option for patients with voice disorders. Early surgery often
results in
irreversible scar tissue that causes permanent voice change. I think that surgery
is recommended only
when there is persistent troublesome difficulty speaking, after completing
work with a speech language pathologist, who has additional training
in voice therapy methods. It's important for
healthcare professionals to know that speech language
pathology is a broad field. Speech language pathologists deal
with difficulty in word finding, difficulty in articulation,
difficulty in sentence or grammar structure, difficulty in
swallowing and many other areas. For this reason, not all speech language
pathologists receive significant training in voice production techniques. It's
incumbent on the healthcare
professional, caring for patients with voice disorders to
identify speech language pathologists who have this additional interest and
training. Finally, dysphonia is really just defined
as the inability to meet vocal demands. Technically dysphonia is a symptom
of a change in voice quality. This change can be one of quality, or just
one of effort required to produce voice. So let's talk about how voice is produced.
This first from an anatomical standpoint,
the form of the larynx or voice box. And second from the physiology or
the function of the larynx or voice box. In the human voice,
the power supply is the lungs. The lungs exhale air and the air is driven
through the trachea past the vocal fold, this air then stimulates
the vocal folds into vibration. And this faint vibratory source is
resonated through the resonating chamber or the superglottic vocal tract.
Essentially, the area above the vocal
folds between the patient's vocal folds and lip. We're going to discuss
the Laryngeal Anatomy in terms of the the laryngeal framework or
structure. Then the muscles that
attach inside the larynx, also known as the intrinsic
laryngeal muscles. And the muscles that
attach outside the larynx, also know as the extrinsic
laryngeal musculature. Very simply, the laryngeal framework
consists of a series of bones and cartilage. The first bone is the hyoid bone. It
can be felt in our neck
just below our tongue base. Below that is the thyroid lamina. We often feel the
thyroid prominence or
Adam's apple in men, and just to either side of that
is the thyroid lamina. This is actually a cartilage
structure that becomes calcified in all patients as we age. Below the thyroid
lamina is the cricoid
ring, and below that is the trachea. The voice box itself is actually
defined as the cricoid ring plus the thyroid lamina
plus the hyoid bone. Within the thyroid lamina,
there are additional cartilages. The arytenoid complex of cartilages
includes the arytenoid, the main body. The corniculate cartilage, or a small crown-
like cartilage sitting
on top of the arytenoid body. And then the cuneiform cartilage. This cartilage
hangs within the fold
of tissue separating the voice box, or the vocal folds from the swallowing
tube, the pyriform sinuses. Lastly, within the thyroid lamina
is something called the epiglottis. The epiglottis is a type of cartilage
that's attached to the voice box with various ligaments. The purpose of the
epiglottis
is to help to steer food around the vocal folds during
the act of swallowing. Here is a clinical picture
of the inside of the larynx taken with a little mirror or
a Hopkins rod-lens telescope. At the very bottom of this screen,
we see the tongue base and the space between the tongue base and
the epiglottis. Down within the larynx itself, we see
these white structures that form a V. The V stands for voice, and these
white structures are the vocal folds. Above the vocal folds, we see the false
vocal fold, and between the false vocal fold and the true vocal fold,
we see a structure called the ventricle. Just above or outside of the false vocal
fold, we have the structure called the aryepiglottic fold that attaches
to the arytenoid complex of cartilages. We can see the bump or the prominence of
the cuneiform cartilage and then we can see the whole arytenoid body underneath
of the skin of the structure here. Down in the distance, we have the trachea. When
we swallow, food comes in over
the tongue base down at the bottom of the screen and
then is steered into vallecula and in through the pyriform sinuses
into the esophageal inlet. The aryepiglottic fold helps
to contain the food and steer it into the esophageal inlet
rather than letting it spill over into the voice box,
causing aspiration and coughing. The Larynx has three basic functions. It controls
respiration,
protects the airway during swallowing and creates the sound source for
voice production. By slightly opening and closing
the vocal folds during respiration, we can control how fast the air
comes in and out of the larynx. It helps us during physical activity,
it helps us during lifting. We can hold our breath and grunt so
we can get a stronger lift. During swallowing,
our laryngeal structures close down so that the food is steered toward
the outside of the larynx and through the pyriform sinuses and
then into the esophagus. The third function of the larynx is for
voice production. This involves vocal fold vibration. The larynx has different
groups of muscles. First, we have the extrinsic muscles, those muscles that attach
outside of
the larynx and are responsible for controlling the height of the larynx and
position of the larynx within the neck. And then we have the intrinsic muscles.
These muscles attach inside the larynx and
are important for controlling vocal fold opening,
abduction and vocal fold closing, or adduction,
for coughing and voice production. The intrinsic laryngeal muscles
control vocal fold motion. They're divided into two groups,
the muscles that close, or adduct the vocal folds, and the muscles
that open, or abduct the vocal folds. There are three different muscles that
are responsible for closing, or adducting, the vocal folds. The thyroarytenoid
muscle,
the lateral cricoarytenoid muscle, and the interarytenoidius muscle. The
thyroarytenoid on the lateral
cricoarytenoid muscle are paired. There's one on the left side and
one on the right side. The interarytenoidius muscle, however,
attaches between the body of the arytenoid cartilages, and contracts to pull the
body
of the arytenoid cartilages together during voice production and
during swallowing. Vocal fold opening or abduction is controlled by
the postier cricoarytenoid muscle. This is a single-paired muscle
that is roughly equal in mass to the entire thyroarytenoid muscle and
lateral cricoarytenoid muscle together. Here, we see a cartoon of vocal
fold opening for respiration. As the posterior cricoarytenoid
muscle contracts, it pulls on the back bottom portion
of the arytenoid cartilage. As it pulls back here, the vocal process
and the vocal folds are pulled open. This is our typical clinical view,
and we appreciate the two-dimensional motion of the arytenoid cartilage on
the cricoid ring and of the vocal fold. When we look at this
lateral cut-away over here, however, we can see that as the posterior
cricoarytenoid muscle contracts, it pulls down slightly on the back
portion of the arytenoid body, as it pulls down the vocal
process not only open in the horizontal plane, but
it's pulled upward in the vertical plane. We, as clinicians, need to remember
that the vocal folds move in three dimension and must open and close in three
dimension, but typically we're limited to this superior view,
which only gives us appreciation for the opening and closing motion, and not
the horizontal motion that we see here. Similarly, vocal fold closure,
or adduction for speaking and coughing is controlled by the lateral
cricoarytenoid, thyroarytenoid, and interarytenoid muscles. During speaking, or
bringing the vocal folds together,
the lateral cricoarytenoid muscle and thyroarytenoid muscles seen here on
the left, bring the vocal folds together. They attach to the body of the arytenoid
cartilage in the front for the thyroarytenoid muscle and
to the posterior or back portion of the arytenoid for
the lateral cricoarytenoid muscle. Seen on the left in the superior view,
we can appreciate the horizontal or two-dimensional
image of these vocal folds moving. However, when we look at the lateral cut
away on the right, we can appreciate that is the thyroarytenoid muscle and the
lateral cricoarytenoid muscle contract. The vocal process or the back portion
of the vocal fold is lowered slightly. The cricoarytenoid muscle attaches on the
front of the cricoid ring seen down here, and then on the bottom
of the thyroid lamina. As it contracts, it pulls the thyroid lamina forward in
relationship
to the cricoid ring. When we look at the lateral cutaway, we can see how this
action then stretches
the vocal folds, and specifically, the vocal ligament, which is attached
to the front of the thyroid cartilage. This action is important because it tenses
the vocal fold and the vocal ligament and vocal fold mucosa,
as the cricothyroid muscle contracts. This helps us elevate pitch, so
we can speak in a low pitch and then a higher pitch. All of these intrinsic
laryngeal
muscles are under control of branches of the tenth cranial nerve. Cranial nerves
are nerve that
come out of the brainstem and go through the skull base to
the muscles of the upper neck. There are 12 of them. The tenth nerve also called
the vagus
nerve is the nerve that's responsible for innovating the larynx and the pharynx. To
innovate the larynx, the tenth
cranial nerve has two specific branches. The recurrent laryngeal nerve and
the superior laryngeal nerve. The superior laryngeal nerve is further
broken down into an internal branch and an external branch. The recurrent laryngeal
nerve
comes off of the vagus nerve below the level of the voice box, and
then recurves up to the voice box. It sends small branches to the trachea,
and to the inside of the laryngeal lumen,
laryngeal airway, to give sensation. It also sends branches to
the vocal fold muscles, the thyroarytenoid, and
lateral cricoarytenoid, and the posterior cricoarytenoid,
to control vocal fold motion. The superior laryngeal nerve
sends an internal branch that gives sensation to all of the skin of the
larynx above the level of the vocal folds. It also sends an external branch
to the cricothyroid muscle. That controls vocal fold lengthening for
alterations and vocal fold pitch. We now know that gallons of anastomosis or
nerve branches between the superior laryngeal nerve and
the recurrent laryngeal nerve, exist. They exist with different degrees
of variability in patients. Some patients have more and
some patients have less. Originally, Galen's anastomosis was
thought to be only a sensory nerve, but we now know that it contains motor fibers.
The extrinsic laryngeal musculature,
also known as the strap muscles, are important because they
control the height of the larynx with regard to the mandible and
the clavicles. We'll see later in module 2
why this height is important. These muscles are more important for
swallowing, and they're under control of the 12th cranial
nerve, also called the hypoglossal nerve, and branches of the 12th cranial
nerve called the ansa cervicalis. These muscles are innervated by
the 12th cranial nerve, which starts in a very close area to the 10th
cranial nerve within the motor and sensory cortex within the brain. It's therefore
no wonder that patients,
when they're speaking and swallowing, trying to control the height of
the larynx within the neck, and vocal fold opening and closing often
have overlap of these functions. [MUSIC]