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HEAD AND NECK IX

Pharynx, Examination of Bisectioned Head


Dr. Lillian Nanney

2003 (1:00 pm)

November 25,

Moore & Dalley: Clinically-Oriented Anatomy, 4th ed.: pp: 1049-1061; Cases 8.7; 8.8, 8.9,
8.12; 8.20
Sauerland: Grants Dissector, 12th ed.: pp: 274-280
Dalley: Frank H. Netter, M.D., Atlas of Human Anatomy, 2nd ed. (book) /Interactive
Atlas (CD-ROM) and Clinical Atlas (CD-ROM): Plates 56-67; 69-70; 93; 120, plus in Clinical
Atlas, Plates C186-7; C208-9; C397; C400-405; C479-483 3rd ed: 5, 30-31, 33, 35, 48, 5869, 71, 119-120, 124-125
Weir & Abrahams: Imaging Atlas of Human Anatomy, 2nd or 3rd ed; 16a-d; 17e-h; 18a-d;
19a-d; 20a & c; 22a-d
Agur: Grants Atlas of Anatomy, 10th ed.: Figs. 8.33 8.38, 8.62 8.63
Clemente: Anatomy: A Regional Atlas, 4th ed.: Figs. 859, 888 - 896
Rohen, Yokochi & Ltjen-Drecoll: Color Atlas of Anatomy, 5th ed.: pp. 86, 161 - 165
As a result of attending the audiovisual presentations, reading/viewing the textbook, atlas
and notes, and participating in the laboratory exercise; VSM-1 students should understand
and be able to:

1. Describe the 3 arbitrary regions of the pharynx. Be familiar with the


formations, openings or communications associated with each.
2. Describe the organization of the pharyngeal musculature. Identify the
superior, middle and the inferior pharyngeal constrictor muscles,
describing their origins, insertions, and structures that pass through the
gaps between them.
3. Identify, demonstrate, and discuss the following:
Nerves that serve the pharynx
Arterial supply and venous drainage of the pharynx
Fascias and (potential) spaces related to the pharynx, their
significance both in terms of enabling pharyngeal movement and/or
the spread of infection/disease
Features of the pharynx as revealed by medical imaging
4. Identify components of the ring of tonsillar tissue surrounding the
superior portions of the pharynx (tonsillar ring of Waldeyer). Discuss
relevant clinical anatomy related to tonsillectomy and adenoidectomy,
including the bed of the palatine tonsils, blood supply and source of postoperative bleeding, adjacent structures at risk, and innervation.
5. Describe the role or action of the pharynx in swallowing, with attention
to:
Means of closure of the pharyngeal isthmus

The effect of swallowing on the auditory tube


Passavants ridge

6. Identify the major structures revealed on mid-sagittal sections through


the median aspect of the bisected head or transversely sectioned or
revealed in a sagittal or transverse median MRI.
In the G.I. tract, events usually occur slowly and often merge one into
the other. The exception is the pharyngeal stage of swallowing, in which
events can be measured in fractions of a second. The structure of the oral
and laryngeal pharynx thus reflects the functional demands of such rapid
movement and passage.
The Pharynx:
This musculomembranous tube is shared by the nasal and oral
cavities superiorly and the
respiratory and digestive channels inferiorly.

Curiously, the respiratory and digestive pathways actually cross each


other within the
pharynx.

The pharynx extends superiorly from the base of the skull to the lower
border of the cricoid cartilage at the level of the lower margin of the
6th cervical vertebra - level to remember for future recall.
Anteriorly, the pharynx is largely deficient; it lacks an anterior wall
owing to the fact that the right and left nasal cavities open into it as
does the oral cavity. It is deficient inferiorly since there are major
openings into the respiratory and digestive systems.
On the basis of these openings, the pharynx is topographically and
rather arbitrarily divided into:

the nasal pharynx (epipharynx/ nasopharynx)

the oral pharynx (oropharynx)

the laryngeal pharynx (hypopharynx/laryngopharynx)

A. The Nasal Pharynx:

Normally this upper portion has a predominantly respiratory


function.

It also serves as a conduit for air passing to the Eustachian tubes


to equalize air pressure within the middle ear cavity.

In patients with allergic rhinitis, it serves as a conduit for


excessive secretions (post-nasal drip).

In patients experiencing nausea, it may inadvertently serve as a


conduit for gastric contents if the level of the patients head is not
optimally positioned.

This tube remains patent (its non-collapsable) due to its bony


framework.

1. Anterior Boundary: The choanae (posterior nares) with the


posterior border of the nasal septum interposed between them.
2. Lateral walls include:
a. the orifices of the pharyngotympanic (auditory; Eustachian) tubes:
The pharyngotympanic tubes:

allow communication between the nasopharynx


(external
environment) and the right and left tympanic cavities.

are inclined obliquely. This makes it possible to insert


either a blunt probe or flexible tube into the lumen. To
locate a tube, enter the nares, pass straight posteriorly
beneath the inferior nasal conchae then turn laterally.
This anatomical info is clinically useful if a physician
needs to open and introduce air into a blocked
Eustachian tube.
the levator veli palatini muscles:
produce a bulge or cushion in the lower circumference
of the orifice.
Expansion of this muscle belly during its contraction phase
pushes the long crus of the cartilaginous tube while the
tensor veli palatini muscle pulls on the short crus of tube.
This dilates the lumen of the tube. This is the natural
physiologic mechanism for ventilating the middle ear
(important in equalizing air pressure differences between
external environment and middle ear).
Normally several deliberate swallows move these
muscles of the posterior wall and milk air into the
tube.
Clinical Notes
1. Special nipples must be used in feeding infants
with a cleft lip and palate since milk from the oral
cavity can easily enter the nasopharynx and flow
into the middle ear cavity.
2. Bacterial/Viral pathogens from the
nasopharynx/oropharynx frequently travel down

this route to enter the middle ear cavity resulting


in otitis media.
b. Salpingopharyngeus Muscle - extends from the orifice of
the pharyngotympanic tubes downward where it inserts into
the laryngopharynx.
It produces a ridge of mucosa known as the
salpingopharyngeal fold.
c. Tubal tonsils:

There is an extensive collection of lymphatic tissue in the


mucous membrane guarding the orifice of the tube. This
raises a mound of tissue known as the torus tubarius.
This tonsillar material and all others sites within Waldeyers
ring reach their peak size at a mean age of approximately 6
yrs. Subsequently they undergo a steady reduction in size
that continues into young adulthood.
An inflammation (swelling) in this material hinders
ventilation of the middle ear. This is a condition that makes
it extremely painful to fly especially during rapid descent
when air pressures change rapidly. Wise parents feed their
young children during this period since the sucking
movement will stimulate muscles in the nasopharynx and
equalize air pressure.
3. Posterior wall/roof:

The mucous membrane in the midline at the posterior of the


nasopharynx is thrown into many variable folds. This focal
region of mucosa shows an accumulation of nodular and
diffuse lymphoid tissue that is known as the pharyngeal
tonsil (adenoids).
This lymphatic tissue also atrophies and shrinks with age.
Clinical note: Pharyngeal tonsils are accessible to view by
gazing upward from the oral cavity.
Clinical note: Enlargement of the pharyngeal tonsil impedes
the flow of air and is a leading contributor to snoring in the
young child.
Clinical note: Removal of the pharyngeal tonsil
(adenoidectomy) along with placement of tubes in the
tympanic membrane (myringotomy) is a common surgical
procedure that is indicated when a child is experiencing
repeated and/or continuous episodes of otitis media.
pharyngeal recesses

These spaces are located posterio-lateral to the orifices of


the auditory tubes.

The pharyngeal walls here are membranous only. This area


is located superior to the superior constrictor muscle; thus
there is no muscular component to reinforce this site in the
nasopharynx. One finds a pharyngobasilar fascia that is
lined internally with pharyngeal mucosa.

4. Floor of the Nasopharyngeal Chamber:

The floor or lower portion of this chamber is largely open to


allow for the passage of air.
An incomplete partition is formed by the posterosuperior
surface of the soft palate. This flap delineates the level and
opening between the nasal and the oral pharynx. The opening
between the soft palate and posterior wall of the pharynx is
called the pharyngeal isthmus.
The Ridge of Passavant is a physiologic sphincter of
sorts. It is produced by the contraction of the superior
constrictor muscle where it meets the uvula during
deglutition. Thus every time a normal patient swallows, the
palatal muscles tense and lift up the soft palate. This
contracting mechanism closes the pharyngeal isthmus. If
there is a paralysis of the soft palatal muscles or spasticity,
this closure is deficient and food particles can enter the
nasal cavity. The patient is said to have velopalatal
incompetence (VPI). Normal people can mimic this
spasticity when they laugh and swallow at the same time.
Anyone willing to come down front and participate in a class
demonstration?
Clinical Notes: VPI can develop in adult patients. Examples
include patients with progressive neuromuscular
degeneration or a rapid onset in patients who have
experienced a stroke.
Clinical Notes: When the VPI problem is detected in small
children you may suspect a mental deficiency or a child
deprived of the opportunity to learn proper speech patterns.
Cerebral palsy is another cause of VPI.
Clinical Notes: In children, surgical corrections are possible
and frequent visits to a speech pathologist can work to
correct these problems.

B. The Oral Pharynx:


extends from the pharyngeal isthmus to the level of the
pharyngoepiglottic folds.
air & food pathways cross here

communicates with the oral cavity via the isthmus of the


fauces.
The isthmus of the fauces is formed between the
palatoglossal and palatopharyngeal arches of each side
of the oral cavity.
A tonsillar fossa which houses the palatine tonsils ("The
Tonsils") fills the concavity between the arches.
These are landmarks used in physical diagnosis. The mucosal
folds are also referred to as the anterior and posterior pillars.
If select a pediatric practice, the structures between these
landmarks may serve as the financial pillars of your early
clinical practice.

This fossa is the former location of the 2nd pharyngeal pouch.


These embryonic structures (one on each side) were lined with
endoderm and were small outpockets from the lateral walls of
the foregut tube that were secondarily invaded with
lymphocytic tissue.

A capsule separates the tonsil from the underlying wall of the


pharynx.
Clinical Note: In the pre-antibiotic era and for several more
decades, these were almost routinely removed during
childhood; hence, they're often missing in cadavers. This
tissue is another part of Waldeyers Ring of Tonsillar Tissue
that guards the opening of the body from foreign invaders.
The tonsillar tissue itself can swell to considerable size
(tonsillitis) or the pharyngeal tissue beneath it (a peritonsillar
abscess). The end result is fever, malaise and tonsillar tissue
that can nearly obstruct the oral cavity.
Adjacent Anatomical Structures:
Although numerous vital structures lie in the parapharyngeal
connective tissue at the level of the tonsil (e.g., int. carotid a.,
int. jug. v. and cranial nerves V3, IX, X, XI and XII), their

distance from the tonsillar fossa is great enough so that they


are not usually endangered during tonsillectomy or by
abscesses. (Only the facial artery may occasionally approach
closely, since its loops can be quite extensive.)
Blood supply of the palatine tonsil:
1. Arterial
The tonsillar a., a direct branch of the facial artery.
This is the main artery to the tonsil.
The tonsillar br. of the ascending pharyngeal a.
(br. of ext. carotid).
3. the tonsillar br. of the ascending palatine a. (br. of
facial artery).
4. the tonsillar br of the descending palatine a ( a br of
the maxillary a.)
5. the tonsillar br. of the dorsal lingual a. (a br. of the
lingual artery).
NOTE: Although the arterial supply is abundant, the extensive
hemorrhage that occasionally occurs following tonsillectomy
usually results from damage to the paratonsillar vein
(external palatine v.) -- a sometimes sizable tributary of the
facial v.
C. The Laryngeal Pharynx ( The Laryngopharynx):

The laryngeal pharynx imperceptibly begins at the lower end of


the oropharynx.

Its Contents and Boundaries include:

Anteriorly An epiglottis that is connected to the root of the


tongue via lateral epiglottic (glossoepiglottic) folds and the
median epiglottic fold, between which lie small indentations
(valleculae). Saliva collects in the valleculae between swallows.
Food particles do usually not slip over the epiglottis and gain
entrance to the larynx, nor does the epiglottis completely "close"
over the laryngeal aperture like a trap door. Instead, the flow of
food and liquids is deflected to either side of the epiglottis. During
swallowing, the epiglottis is elevated along with the rest of the
visceral feeding tube (the tongue, hyoid bone, thyroid cartilage
and associated musculature). This does lower the epiglottis over
the opening to the larynx. The bolus of food/liquid slides around

the aperture laterally through the piriform recesses and onward


and downward into the esophagus. The epiglottis mostly acts like
a rock in the middle of the rapids. It deflects the flow.
Clinical note: Piriform recesses are lateral pockets where pills, fish
bones, and improperly chewed food can become caught. Patients
may present to the ER for an extraction procedure.
Mucosal folds in the piriform recesses are formed by the internal
laryngeal nerve which passes underneath this area.

Posterio-laterally, the laryngeal pharynx is enclosed by the


inferior constrictor musculature. Laterally there is a gap in the
muscle that is filled with the thyrohyoid membrane. This
membrane is pierced by the internal laryngeal nerve accompanied
by the internal laryngeal artery.

The mucous membrane in the laryngeal pharynx contains


plexiform venous networks (the pharyngeal venous plexus),
which are especially dense at the entrance of the esophagus.
Congestive swelling due to an acute inflammatory response in
glottis edema brings the danger of acute asphyxiation.
The loose texture of the submucosa in this area contributes
considerably to
the ease with which the edema tends to spread. As you can
imagine, it you procrastinate before you intubate a patient
who is developing this problem, the anatomic blockage can
make it impossible to pass the tube through this area.

These veins drain directly into the internal jugular vein.


Malignant cells in this area spread quickly into deep cervical
lymphatic chains.

D. Pharyngeal Musculature

The spatial arrangement is unique in this area compared to the


rest of the digestive tube.
Muscles are composed of the striated skeletal variety.
In contrast to the intestine, the longitudinal muscles (ex:
salpingopharyngeus, glossopharyngeus, thyroepiglottic) lie
internally and the circular muscles (constrictors) lie externally.
This necessitates a structural rearrangement of the muscle
layers at the transition to the esophagus: The oblique fibers of
the inferior constrictor regroup to form the outer longitudinal
muscle of the esophagus.

A triangular area (Laimer's triangle) at the beginning of the


esophagus often remains free of or thinly covered by
muscular tissue and favors the formation of diverticula.
This is yet another recess where pills can accumulate with
life-threatening consequences.
The three pharyngeal constrictors originate from anterio-laterally
placed structures:
Superior Constrictor:
Origins: pterygomandibular raphe, pterygoid hamulus,
buccinator ridge of the mandible
Insertion: The right and left muscles sweep posteriorly and
superiorly. In the midline the superior attachment is to the
pharyngeal tubercle on the base of the skull and the
remaining muscle meets its companion muscle from the
opposite side to form a mid-line pharyngeal raphe.
Middle Constrictor:
Origins: from the hyoid bone, stylohyoid ligament
Insertion: meets its partner to contribute to the pharyngeal
raphe.
The pharyngeal raphe will be apparent on those cadavers
where the prevertebral cut has been performed and the
pharynx is viewed from behind.
Inferior Constrictor:
Origins: from the oblique line on the cricoid and thyroid
cartilages
often described as having two components:
thryopharyngeus
cricopharyngeus
diverticula may develop in the relatively weak area
(Killian's dehiscence) between the two components.
Insertion: meets its partner to contribute to the mid-line
posterior raphe
muscle fibers of the lower cricopharyngeus--which are horizontal-pass as an uninterrupted muscular band completely around
laryngopharynx
serve as the major component of the upper esophageal
("pharyngoesophageal") sphincter which keeps the
esophagus closed between swallows.
Because pharyngeal constructors blend together posteriorly to
form a continuous circular (oblique) muscle, it is difficult to
distinguish them from this approach. They are most readily
distinguished by following them to their
origins, or on the basis of structures which pass over or between
their borders:
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As mentioned above, the lateral portions of each constrictor


muscle is discontinuous. This leaves gaps between the
musculature. These areas serve to permit passages for structures
that enter and leave the pharynx.
1. Gap #1 - Structures passing over the superior border of the
superior pharyngeal constrictor:
a. cartilaginous portion of the pharyngotympanic tube.
b. The levator veli palatini muscles.
c. The ascending palatine arteries
d. The pharyngeal branch of the ascending pharyngeal
arteries
2. Gap #2 - Structures passing in the lateral gap between the
origins of the superior and middle pharyngeal constrictors:
a. Stylopharyngeus m.

This muscle is derived from the material that moves the


3rd pharyngeal arch cartilages. It runs between the
styloid process superiorly and inserts onto the thyroid
cartilage.

b. Glossopharyngeal (IX) nerve This nerve wraps around the


stylopharyngeus muscle (innervates it) and moves forward
toward the oropharynx and tongue.
c. stylohyoid ligament This is a remnant of the 2nd
pharyngeal arch cartilage. It runs between the styloid
process and the superior horn of the hyoid bone.
3. Gap #3 - Structures passing between the middle and inferior
pharyngeal constrictors:
a. This gap is spanned by the thyrohyoid membrane.
b. It is pierced by the internal laryngeal br. of superior
laryngeal n. (X).
c. sup. laryngeal br. of superior thyroid artery and vein

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4. Gap #4 - Structures passing under (deep to) the inferior border of


the inferior pharyngeal constrictor:
a. recurrent (inferior) laryngeal nerve (X).
b.

branches of the inferior thyroid artery.

E. Space

Infections from the tonsillar materials, abscessed teeth if


untreated can eventually penetrate posterior to the constrictor
muscles and gain access to the region posterior to the pharyngeal
tube. This area is known as the retropharyngeal space. It is
lined on its pharyngeal surface with retropharyngeal or visceral
fascia that is continuous with the pretracheal fascia. This layer
completely encompasses the central visceral tube. Posterior to the
retropharyngeal space are the cervical neck muscles and nerves of
the cervical plexuses that are encased in a prevertebral fascial
sheath.

Infections that gain access to the retropharyngeal space are


limited in their upward spread by the base of the skull. Infections
spread downward due to gravity. They can move downward
through the thoracic outlet and into the posterior mediastinal
area.

F. Vessels and Nerves of the Pharynx:


1. Arteries:
a. Ascending pharyngeal a. (ext. carotid a.).
b. Ascending palatine a. (facial a., supplies mainly upper
portions of
pharynx as well as auditory tube, tonsils, etc.)
2. Veins:

accompanying the above listed arteries and their branches,


plus:
a. the pterygoid venous plexus
b. the external palatine vein (paratonsillar vein)

3. Lymph vessels:
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a. drainage mainly into upper deep cervical nodes.

4.

b. nasal cavity, nasopharynx ---> retropharyngeal node (part


of upper deep cervical group).
Nerves:
a. Sensory:
i. upper portions: Glossopharyngeal (IX) n.
ii. lower portions: Vagus (X) (int. laryngeal br. of sup.
laryngeal n.)
b. Motor:

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pharyngeal plexus -- It is most probable that the


motor fibers come from the cranial portion of the
accessory (XI) nerve, which are carried to the
pharyngeal plexus via the vagus (X) nerve.
Exception: stylopharyngeus--supplied by
glossopharyngeal (IX) n.