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Vocal Cord and Voice Box

Overview
The vocal folds, also known as vocal cords, are located within the larynx (also colloquially known as the voice box) at the top of
the trachea. They are open during inhalation and come together to close during swallowing and phonation. When closed, the
vocal folds may vibrate and modulate the expelled airflow from the lungs to produce speech and singing.

A video displaying the anatomy of the vocal cords and voice box is provided below.

Airway endoscopy demonstrating the larynx of a 3-year-old child. The larynx is situated at the level of the base of tongue.
Separating the tongue from the larynx is the flaplike structure called the epiglottis. The larynx itself consists of 2 glistening
white vocal folds, which form a V-shaped structure. The glottic airway is between the vocal folds. Just superior to the vocal
folds are the false vocal folds. The posterior aspect of the larynx is lined by the arytenoids. The arytenoids form 2 "bumps" at
the posterior aspect of the vocal folds and are separated by the intra-arytenoid notch. Posterior to the larynx is the
esophageal inlet. Video courtesy of Dr. Ravi Elluru.

Gross Anatomy
The vocal cords are composed of mucous membrane infoldings that stretch horizontally across the middle laryngeal cavity. They
are attached anteriorly at the angle on the interior surface of the thyroid cartilage and project posteriorly to the arytenoid
cartilages on either side.

The vestibular folds, or false vocal cords, are formed by the superior layer of infolded membrane; the vocal folds, or true vocal
cords, are formed from the inferior layer of infolded membrane. The laryngeal ventricles extend laterally and are located
between the vestibular and vocal folds.[1, 2]

Vestibular folds (false vocal cords)

The quadrangular membrane extends between the lateral aspects of the epiglottis and the anterolateral surface of the arytenoid
cartilages on the each side. The free lower inferior margin of this ligament is thickened to form the vestibular ligament, which
forms the vestibular folds (false vocal cords) once covered by mucosa. The lower border of the vestibular folds forms the upper
boundary of the laryngeal ventricle.

The primary function of the vestibular folds is protection of the more delicate vocal folds that lie beneath. The vestibular folds
have a minimal role in phonation but may be used in the production of deep tones and screaming or throat singing.

Laryngeal ventricles

On either side of the middle laryngeal cavity, in between the vestibular and vocal folds, the mucosa bulges laterally to form
troughs known as the laryngeal ventricles. The laryngeal saccules are tubular extensions of each ventricle anterosuperiorly
between the vestibular fold and the thyroid cartilage. The walls of these saccules are thought to contain many mucous glands
that lubricate the vocal folds.

Vocal folds (true vocal cords)

The conus elasticus extends superiorly from the anterior arch of the cricoid cartilage and attaches to the thyroid cartilage
anteriorly and the vocal processes of the arytenoid cartilages posteriorly. The free superior margin of this submucosal
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membrane is thickened to form the vocal ligament, which forms the vocal folds (true vocal cords) once covered by mucosa. The
vocal folds also contain muscle fibers originating from the vocalis part of the thyroarytenoid muscle, which lies deep and inferior,
parallel with the vocal ligament to which it is attached at the posterior end. The main function of the muscle is fine tonal control
of the vocal cords.

The vocal folds differ in size and color between males and females. Adult males typically have larger, longer folds (due to the
sexually dimorphic laryngeal prominence), resulting in a lower-pitched voice. The vocal folds appear more pearly white in
women than in men.

Functional anatomy of the vocal cords

The larynx, or voice box, has multiple intrinsic muscles that control movement of the vocal folds. All of these muscles are
innervated by the recurrent laryngeal branch of the vagus nerve (CN X) except the cricothyroid muscles, which are innervated
by the external branch of the superior laryngeal nerve, which is also a branch of the vagus nerve.

The cricothyroid muscles function to elevate the anterior arch of the cricoid cartilage and depress the posterior portion of the
thyroid cartilage lamina. This produces tension and elongation of the vocal cords, resulting in higher-pitch phonation.

The posterior cricoarytenoid muscles function to rotate the arytenoid cartilages laterally, thereby abducting the vocal cords. Their
action opposes that of the lateral cricoarytenoid muscles.

The lateral cricoarytenoid muscles function to rotate the arytenoid cartilages medially, thereby adducting the vocal cords.

The main function of the transverse arytenoid muscle is adduction of the vocal cords.

The thyroarytenoid muscles function to draw the arytenoid cartilages forward, thereby relaxing and shortening the vocal cords,
while also rotating the arytenoid cartilage inward, thus adducting the vocal folds and narrowing the rima glottis. The vocalis part
of each thyroarytenoid muscle is contained within the vocal folds on each side.

Of note, the only muscles capable of separating the vocal cords for normal breathing are the posterior cricoarytenoid muscles.
Bilateral injury to the recurrent laryngeal branches of the vagus nerve (CN X) results in an inability to abduct the vocal folds and
causes difficulty breathing.

Microscopic Anatomy
The upper vestibular folds are covered with a pseudostratified ciliated columnar epithelium with goblet cells. The underlying
lamina propria contains an abundance of mixed serous and mucous glands, from which excretory ducts open onto the epithelial
surface.

The ventricle separating the vestibular folds and vocal folds is the site where the epithelium transitions from respiratory
epithelium to the stratified squamous epithelium on the vocal folds. The lamina propria within the laryngeal ventricles blends with
the perichondrium of the hyaline thyroid cartilage. No distinct submucosa exists.

The lower vocal folds are lined with a thick stratified squamous epithelium, which functions to protect the mucosa from abrasion
caused by the rapid movement of air when breathing and during phonation.

A thicker layer of connective tissue is located beneath the vocal fold epithelium and is subdivided into 3 layers: the superficial
lamina propria, the intermediate lamina propria, and the deep lamina propria.

The superficial lamina propria is composed of few elastic or collagenous fibers, resulting in an increased pliability; the
intermediate lamina propria is mainly composed of elastic fibers; and the deep lamina propria is composed of more collagenous
fibers. These elastic and collagenous fibers within the intermediate and deep layers form the vocal ligament. Beneath the deep
lamina propria, the skeletal muscle fibers of the vocalis muscle form the innermost layer and body of the vocal folds.

Natural Variants
The structure of adult vocal folds differs from the vocal fold structure in newborns. The infant lamina propria is only composed of
a single layer without a vocal ligament. The vocal ligament begins to appear at about 4 years of age. The formation of the 3
defined lamina propria layers occurs between the ages of 6 and 12 and are fully mature at the end of adolescence.

In old age, thinning of the superficial layer of the lamina propria and atrophy of the vocalis muscle occurs, which contributes to
the difficulty of speech seen with presbylarynx.

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Pathophysiological Variants
Spasmodic dysphonia

Spasmodic dysphonia is a voice disorder in which involuntary movements of one or more muscles of the larynx occur during
speech. Three types exist: adductor, abductor, and mixed.

In adductor spasmodic dysphonia, the vocal folds involuntarily slam together and stiffen. Words are often cut off or difficult to
start, causing speech to be choppy and sound similar to stuttering.

In abductor spasmodic dysphonia, the vocal folds open involuntarily. As a result, the voice sounds weak and whispery.

In mixed spasmodic dysphonia, elements of both adductor and abductor spasmodic dysphonia are present because of the
involuntary opening and closing of the vocal folds.

Vocal cord nodules and polyps

Vocal cord reactive nodules, also called polyps, are masses of tissue that grow on the vocal cords, typically on the anterior and
middle two thirds of the vocal fold. The nodules usually appear as symmetrical swellings on both sides of the vocal cords and
develop most commonly in heavy smokers or individuals who use strenuous or abusive voice practices.

Reinke edema

Swelling from abnormal accumulation of fluid that occurs within the superficial lamina propria (Reinke space) may cause the
vocal fold mucosa to appear floppy with excessive movement.

Contributor Information and Disclosures

Author

Rishi Vashishta, MD Resident Physician, Department of Anesthesiology, New York University School of Medicine

Rishi Vashishta, MD is a member of the following medical societies: American Society of Anesthesiologists

Disclosure: Nothing to disclose.

Coauthor(s)

Nisha Dhawlikar Boston University College of Arts and Sciences

Disclosure: Nothing to disclose.

Arjun S Joshi, MD Assistant Professor of Surgery, Division of Otolaryngology–Head and Neck Surgery, George Washington
University School of Medicine and Health Sciences

Arjun S Joshi, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-
Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association,
American Thyroid Association

Disclosure: Nothing to disclose.

Chief Editor

Thomas R Gest, PhD Professor of Anatomy, Foundational Sciences Discipline, Central Michigan University College of Medicine

Thomas R Gest, PhD is a member of the following medical societies: American Association of Clinical Anatomists

Disclosure: Nothing to disclose.

Acknowledgements

Medscape Reference thanks Ravindhra G Elluru, MD, PhD, Associate Professor, Department of Otolaryngology Head and Neck
Surgery, University of Cincinnati College of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Cincinnati
Children's Hospital Medical Center, for the video contribution to this article.

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