Part 2 - THE NOSE, PARANASAL SINUSES AND PHARYNX

ANATOMY OF THE NOSE AND PARANASAL SINUSES

The External Nose
The external nose is shaped as a triangular pyramid with its root above
and its base directed downwards, and perforated by two nostrils, separated by
a median septum. The free angle of the external nose is the apex, connected
to the root by the dorsum, the upper part of which is termed the bridge. Each
side of the external nose ends in a rounded eminence, the ala nasi, which
forms the outer boundary of the nostril. The skin over the apex of the nose is
thick and adherent, and contains many sebaceous glands. The external
framework is osseous and cartilaginous. The nasal bones form the bridge,
and each is united above with the frontal bone and laterally to the frontal
process of the maxilla. Three paired cartilages, the upper lateral (triangular),
lower lateral (greater alar), lesser alar cartilages, and one unpaired cartilage,
the septal (quadrangular), complete the external framework (Fig 15, 16). The
chief muscles acting upon the external nose are the compressors and dilators
of the ala nasi, and are supplied by the facial nerve. In confirmed mouth
breathers the dilators tend to atrophy from disuse so that the anterior nares
become narrow and slit-like.
Blood supply to the external nose derives from the maxillary (E.C.A.),
facial (E.C.A.) and ophthalmic arteries (I.C.A.), while venous drainage is
through the anterior facial and ophthalmic veins, the latter being a tributary of
the cavernous sinus. Lymphatic drainage follows the anterior facial vein and
opens into the submandibular glands, but other lymphatics drain into the preauricular glands.
The Nasal Vestibule
This is the name given to the entrance to the nasal cavity, within the
nostrils. It is lined by skin which contains hair follicles, and it ends at the
mucocutaneous junction. The part between the two nasal vestibules,
containing the anterior end of the nasal septum, is called the columella. A very
important structure is the internal nasal valve (Fig 17). It lies at the junction of
the vestibule and the nasal cavity.
The Nasal Cavity
Boundaries of the nasal cavity. Inferiorly the floor of the nasal cavity is
formed by the maxilla and by the palatine bones. The roof of the nasal cavity
is formed, in front, by the lateral nasal bones. Superiorly is the cribriform plate.
This is a bony lamina of the ethmoid bone, which is perforated to permit the
passage of the filaments of the olfactory nerves. Posteriorly the sphenoid
bone forms part of the roof.
The lateral wall of each nasal cavity is convoluted in appearance due to
the three conchae or turbinates (Fig 18). The superior and middle turbinates
constitute the medial surface of the lateral mass of the ethmoid bone. The
inferior turbinate is a separate bone attached to the maxilla. Each turbinate
overhangs a channel or meatus corresponding in length to the turbinate
beneath which it is situated. All three reach forwards from the posterior
aperture of the nose, called the posterior naris or choana. The superior

meatus is confined to the posterior third of the lateral wall of the nasal cavity;
the middle meatus runs forward about two-thirds of its length; and the inferior
meatus extends the whole length of the lateral wall of the cavity. The space
above the superior turbinate is called the spheno-ethmoidal recess. Between
the three turbinates and the nasal septum, which separates the two nasal
cavitites, is a space called the general nasal meatus.
The meatuses are of clinical importance in respect of their contents.
The nasolacrimal canal opens into the anterior end of the inferior meatus.
Communication between the paranasal sinuses and the nasal cavity takes
place through openings, or ostia. The frontal, anterior ethmoidal and maxillary
sinuses open into the middle meatus; the posterior ethmoidal sinuses drain
into the superior meatus; the sphenoidal sinus communicates with the
superior meatus.
The middle meatus contains several structures of importance (Fig 19,
23). An enlargement is found at the anterior end of the middle meatus, which
is part of the ethmoid bone, known as the unciate process. A little farther back
can be seen another eminence which is called the bulla ethmoidalis, which
represents a protrusion into the meatus of one air cells of the ethmoidal
labyrinth.
In the normal nose these parts can rarely be seen from the front.
Between these two enlargements is a groove which is known as the hiatus
semilunaris, into which the ostium of the maxillary sinus opens. The hiatus
semilunaris, when followed upwards, leads to a narrowing called the
infundibulum. In many cases the infundibulum continues upwards becoming
the fronto-nasal duct. Owing, however, to the irregularity of the development
of the frontal sinus and the anterior ethmoid cells, it is possible that the frontonasal duct may open from an anterior ethmoid cells.
The nasal septum separates the two nasal cavities and is partly
osseous and partly cartilaginous. The perpendicular plate of the ethmoid and
the vomer bone constitute the upper and posterior part, while the septal
cartilage completes the septum anteriorly, stretching from the dorsum of the
nose above to the nasal crests of the maxillary and palatine bones below. The
main arterial supply of the nasal septum arises from the septal branch of the
sphenopalatine artery (maxillary a. - E.C.A.), and this anastomoses with the
greater palatine artery (maxillary a. - E.C.A.), septal branches of the superior
labial (facial a.- E.C.A.), anterior ethmoidal (ophthalmic a. I.C.A.) and
posterior ethmoidal (ophthalmic a. I.C.A.) arteries at the antero-inferior part
of the septum, or Littles (Kiesselbachs) area (Fig 20), which is of importance
in epistaxis. The lateral nasal wall is supplied by lateral branches from theses
vessels. Venous drainage from the nasal cavity is through the sphenopalatine
foramen to the pterygoid plexus, but some veins join the superior ophthalmic
vein in the orbit, while others enter the anterior facial vein. Lymphatic vessel
from the anterior part of the cavity join cutaneous lymphatics to the
submandibular glands, and so to the superior deep cervical glands.
Posteriorly the lymphatic drainage is to the medial deep cervical glands.
The nasal mucous membrane consists of a layer of fairly dense
connective tissue containing large blood vessels and some unstriped muscle
fibres. There is erectile or cavernons tissue comprising irregular thin-walled
blood spaces in the anterior and posterior ends of the inferior turbinate. A
layer of elastic tissue fibres is present beneath the basement membrane, and
this layer allows the mucosa to return to normal size when the vascular
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engorgement of the erectile tissue ahs worn off. The surface epithelium is
columnar ciliated lying upon several layers of cuboidal cells resting pon the
basement membrane. There are many mucous glands beneath the basement
membrane, their ducts penetrating the membrane to open on the surface.
There are two nerve supplies to the nasal cavity sensory and
secretory. The main sensory nerve supply is derived from the maxillary
division of the trigeminal nerve through branches arising in the
pterygopalatine ganglion. The lateral and medial internal nasal branches of
the ophthalmic division of the trigeminal nerve supply the anterior part of the
nasal cavity, while the floor and the anterior end of the inferior turbinate are
served by the anterior dental branch of the infra-orbital nerve (maxillary
division of the trigeminal nerve).
Secretory nerve fibres supplying the glands and unstriped muscle
belong to the sympathetic and parasympathetic systems. Sympathetic fibres,
which produce vasoconstriction and diminished secretion, arise from the
superior cervical ganglion via the nerve of the pterygoid canal to the
pterygopalatine ganglion. Parasympathetic fibres, which produce
vasodilatation and increased secretion, are carried in the greater superficial
petrosal nerve and the nerve of the pterygoid canal to the pterygopalatine
ganglion from which postganglionic fibres are distributed.
The olfactory nerves some twenty filaments derive from the
olfactory bulb, enter the nasal cavity through the cribriform plate of the
ethmoid, and are distributed in a network in the mucous membrane in the
upper third of the nasal septum and the lateral wall of the nasal cavity. The
perineural sheaths of these filaments communicate directly with the piaarachnoid and thus may transmit infection to the meninges.
The Paranasal Sinuses
The paranasal sinuses, arranged in pairs and in relation to each nasal
cavity, comprise two groups, anterior and posterior (Fig 22, 23). The former
includes the maxillary sinus, the frontal sinus and the anterior ethmoidal cells,
all of which communicate with the middle meatus. The posterior group
consists of the posterior ethmoidal cells and the sphenoidal sinus
communicating with the superior meatus.
The maxillary sinus is also known as the maxillary antrum. It exists at
birth as a small but definite cavity adjacent to the middle meatus, and it
enlarges gradually to reach its maximum dimensions about the twenty-first
year with the eruption of the upper wisdom tooth. The sinus expands in the
maxilla during the eruption of the primary dentition until it reaches the level of
the floor of the nasal cavity about the seventh year. In adult life it is somewhat
pyramidal in shape, its roof being formed by the floor of the orbit, its floor
being in close proximity to the roots of the second dentition; its posterior wall
lying in relation to the pterygopalatine fossa; its medial wall adjoining the
lateral wall of the nasal cavity; and its anterolateral walls being superficial.
The opening into the middle meatus, the maxillary ostium, is near the upper
part of the cavity of the sinus, and is thus unfavourably placed for drainage.
There may be one or more accessory ostia posterior to the main one.
The frontal sinus is rudimentary at birth, being represented by a small
upward prolongation from the anterior end of the middle meatus, the
nasofrontal duct. During childhood this duct enlarges upwards to reach the
level of the orbital roof about the ninth year. Thereafter the sinus extends for a
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variable distance as a result of absorption of cancellous bone between the

outer and inner tables of the frontal bone. The anterior wall is formed by the
outer table; the posterior wall is related to the inner table which separates it
from the frontal lobe of the brain; its floor forms part of the orbital roof; and the
medial wall is a septum separating the two frontal sinuses. The opening of the
frontal sinus is in its floor, and communicates with the middle meatus through
the nasofrontal duct.
The ethmoid sinuses constitute a cell labyrinth and are present at birth
as prolongations of the nasal mucosa into the lateral mass of the ethmoid
bone. In adult life they vary in number, size and shape, and for clinical
purposes they are classified as anterior and posterior, depending upon
whether they communicate with the middle or the superior meatus. Medially
the cell labyrinth lying in relation to the upper half of the nasal cavity, laterallyto the orbit, from which the cells are separated laterally by the lamina
papyracea and to the maxillary sinus. The cells abut anteriorly on the frontal
process of the maxilla, posteriorly they are related to the sphenoid sinus.
Superiorly the ethmoid cells related to the frontal sinus and anterior cranial
fossa.
The sphenoid sinus occupies the body of the sphenoid bone, and may
be present at birth as a small indentation of nasal mucosa. The sinus varies
greatly in size in the adult. The lateral wall is contiguous with the internal
carotid artery, the cavernous blood sinus, first branch of the V cranial nerve,
III, IV and VI cranial nerves (Fig 24); the roof is related to the frontal lobe, the
olfactory tract, the optic chiasma and the pituitary gland lying in the
hypophyseal fossa; the floor adjoins the pterygoid canal, roof of the nasal
cavity, nasopharynx; while the medial wall is a septum separating it from its
neighbour. Anterior wall is contiguous with ethmoidal cells. Behind the
posterior wall lies the posterior cranial fossa. The ostium is placed high up in
the cavity of the sinus.
BASIC PHYSIOLOGY
The nose is both a sense organ and a respiratory organ. In addition,
the nose performs an important function for the entire body by providing both
physical and immunologic protection from the environment. It is also important
in the formation of speech sounds.
The Nose as an Olfactory Organ
The human sense of smell is poorly developed compared to most
mammals and insects. Despite that, it is still very sensitive in the human and
is almost indispensable for the individual. For example, taste is only partially a
function of the taste buds since these can only recognize the qualities of
sweet, sour, salty and bitter. All other sensory impressions caused by food
such as aroma and bouquet are mediated by olfaction. This gustatory
olfaction is due to the fact that the olfactory substances of food or drink pass
through the olfactory cleft during expiration while eating or drinking. The
sense of smell can stimulate appetite but can also depress it. It also provides
warning of rotten or poisonous foods and also of toxic substances, e.g. gas.
The sense of smell is particularly important in the field of psychology: marked
affects may be induced or inhibited by smells. It should also be remembered
that a good sense of smell is essential for those in certain occupations, e.g.,
cooks, confectioners, wine, coffee and tea merchants, perfumers, tobacco
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blenders and chemists. Finally, the physician needs a clinical nose for
making his diagnosis.
The olfactory area of the nose is relatively small. It contains the
olfactory cells, i.e. the bipolar nerve cells, which are to be regarded as the
sensory cells and first-order neurons. They are collected into about 20 fibres
in the olfactory nerves which run to the primary olfactory center of the
olfactory bulb.
From here the neurons of the bulb run via the olfactory tract to the
secondary olfactory center. The tertiary cortical olfactory field lies in the
dentate and semilunate gyri.
The mode of action of the scent molecules on the olfactory cells is not
known with certainty. There are numerous current theories of the mechanism
of action, including: emission of scent corpuscles, selective absorption,
specific receptors on the sensory cells, enzymatic control, molecular
vibrations, electrobiologic processes such as changes in cell membrane
potential, etc.
It is certain that only volatile substances can be smelled by humans.
These substances must be soluble in water and lipids. Only a few molecules
suffice to stimulate the sense of smell. 10-15 molecules per ml of air are
sufficient stimulation on average to exceed the threshold.
It is said that there are about 30, 000 different olfactory substances in
the atmosphere; of these, humans can perceive about 10, 000 and are able to
distinguish among 200.
The sense of smell, like other senses, demonstrates the phenomenon
of adaptation. The sensitivity of the olfactory organ depends also on hunger:
several olfactory factors can be smelled better if the subject is very hungry
than shortly after eating, a very useful physiologic regulation.
Anosmia and hyposmia may be caused by obliteration of the olfactory
cleft (polyps, etc), causing respiratory anosmia. Inability of the olfactory
substances in food and drink to pass from the mouth and throat to the
olfactory epithelium of the nose because of obstruction of the nasal cavity or
the choana is described as gustatory anosmia. Central anosmia is caused by
a disorder of the central nervous parts of the olfactory system in the presence
of a patent airway. Causes include: traumatic rupture of the olfactory nerve,
cerebral contusion and cerebral diseases. Essential anosmia is due to local
damage to the olfactory epithelium, e.g., due to influenza, with an open
olfactory cleft.

The Nose as a Respiratory Organ

In the human the only physiologic respiratory pathway is via the nose.
Mouth breathing is unphysiologic and is only brought into play in an
emergency to supplement nasal respiration. The physiology of the airstreams
through the normal nose in inspiration and expiration maybe summarized as
follows:
The average ventilation through a normal nose in physiologic breathing
is 6 L/min, and 50 to 70 L/min in maximal ventilation.
The internal nasal valve or limen nasi is the most narrow point in the
normal nose. It thus acts like a nozzle, and the speed of the airstreams is very
high at this point.
The nasal cavity between the valve and the head of the turbinates acts
as a diffuser, i.e. it slows the air current and increases turbulence. The central
part of the nasal cavity with its turbinates and meatus is the most important
part for nasal respiration. The column of air consists of a laminar and a
turbulent stream. The proportion between laminar and turbulent flow
considerably influences the function and condition of the nasal mucosa.
The airstreams passes in the reverse direction through the nasal
cavities on expiration. The expiratory airstreams demonstrates considerably
less turbulence in the central part of the nose, and thus offers less opportunity
for heat and metabolic exchange between the airstreams and the nasal wall
than on inspiration. The nasal mucosa can thus recover during the expiratory
phase. Inspiration through the nose followed by expiration through the mouth
leads rapidly to drying of the nasal mucosa.
Complete exclusion of the nose from breathing leads in the long term
to deep-seated mucosal changes. Mechanical obstruction within the nose,
e.g., due to septal deviation, hypertrophy of the turbinates, cicatricial stenoses,
etc, can lead to mouth breathing and its damaging consequences and can
also cause mucosal diseases of the nose and nasal sinuses.
The nasal patency can be influenced by many different factors,
including temperature and humidity of the surrounding air, the position of the
body, bodily activity, changes of body temperature, the influence of cold on
different parts of the body, e.g., the feet, hyperventilation and psychological
stimuli. The state of the pulmonary function, of the heart, and of the circulation,
endocrinologic disorders such as pregnancy, hyper- or hypofunction of the
thyroid gland, and some local, oral or parenteral drugs may have considerable
influence on the patency of the nose.
Protective Function of the Nose
During normal nasal respiration, the inspired air is warmed, moistened
and purified during its passage through the nose.
The warming of the inspired air through the nose is very effective, and
the constancy of the temperature in the lower airways is remarkably stable.
The nasal mucosa humidifies and warms the air. The temperature in the
nasopharynx during normal (exclusively nasal) respiration is constant at 31
to 34 C independent of the external temperature. The heat output of the nose
increases as the external temperature falls so that the lower airways and the
lungs can function at the correct physiologic temperature.
The optimal relative humidity of room air for subjective well-being and
function of the nasal mucosa lies between 50% and 60%. The water vapor
saturation of the inspired air in the nasopharynx lies between 80% and 85%,
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and in the lower airway is fairly constant between 95% and 100%,
independent of the relative humidity of the environmental air. The water vapor
secreted by the entire respiratory tract per 1000 liters of air can reach 30g.
most of this is supplied by the nose. On the other hand, the mucosal blanket
renders the nasal mucosa watertight and prevents release of too much water
into the air, which would cause drying of the mucosa.
The cleaning function of the nose includes: first, cleaning of the
inspired air from foreign bodies, bacteria, dust, etc, and second, cleaning of
the nose itself. About 85% of particles larger than 4.5 mm are filtered out by
the nose, but only about 5% of particles less than 1 mm in size are removed.
Foreign bodies entering the nose come into contact with the moist
mucosal surface and the mucosal blanket, which continually carries away the
foreign bodies.
The Nasal Mucosa as a Protective Organ
In addition to warming, humidifying and cleaning the inspired air, the
nose also has a protective function consisting of a highly differentiated,
efficient and polyvalent resistance potential against environmental influences
on the body. A basic element of this defensive system is the mucociliary
apparatus. This is the functional combination of the secretory film and the cilia
of the respiratory epithelium by which the colloidal secretory film is
transported continuously from the nasal introitus toward the choana. A foreign
body is carried from the head of the inferior turbinate to the choana in about
10 to 20 min. The efficiency of this cleansing system depends on several
factors such as pH, temperature, condition of the colloids, humidity, width of
the nose, toxic gases, etc. Disturbances in the composition or in the physical
characteristics of the mucosal blanket or of the ciliary activity can have
marked influences on the physiology of the nasal cavity.
The nasal mucosa protects the entire body by making contact with and
providing resistance against animate and inanimate foreign material in the
environment. Two defense zones can be distinguished in the nasal mucosa:
first, the mucosal blanket and the epithelium, and second the vascular
connective tissue of the lamina propria.
Resistance factors of the first defensive zone include: (1) physical
cleaning by the mucociliary apparatus; (2) nonspecific protective factors in the
secretions such as lysozymes, interferon, secretory protease inhibitors,
complement system and secretory glucosidases; and (3) specific protective
factors such as immunoglobulin A (Ig A), immunoglobulin M (Ig M) and
immunoglobulin G (Ig G).
Resistance factors of the second defensive zone include: (1) nonspecific protective factors and structures such as the ground substance and
fibrils, micro- and macrophages, mast cells, vessels, the autonomic nervous
system, hormones, interferon, protease inhibitors, complement, etc; and (2)
specific defensive factors such as sensitized B- and T-lymphocytes,
eosinophil granulocytes, immunoglobulin Ig G, Ig M and Ig E.
The Nose as a Reflex Organ
Specific nasal reflex mechanisms may arise:- within the nose and
affect the nose itself- From other parts of the body or organs and affect the
nose-In the nose and affect other parts of the body. A reflex system which is
obviously confined to the nose is the nasal cycle. One cycle lasts between 2
and 6 h. Provided that both halves of the nasal cavity are of normal patency,
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the lumen widens and narrows alternately, lowering or increasing the

respiratory resistance in each half of the nose. However, the resistance of the
entire nose remains constant in the ideal case. This reflex phenomenon is
controlled by the action of the autonomic nervous system on the cavernous
spaces of the vascular system of the nasal mucosa.
Nasopetal reflexes arise, e.g., from cooling of the extremities, which
changes the respiratory resistance. They may also arise from the lungs and
bronchi and from other autonomic control points.
Important nasofugal communications exist between the nose and the
lung, the heart and circulation, the metabolic organs and the genitals.
In addition, there are sneezing, lacrimal and cough reflexes and under
certain emergency situations, reflex respiratory arrest.
Influence of the Nose on Speech
The nose influences the sound of speech. During the formation of the
resonants m, n and ng, e.g., the air streams passes through the open nose,
whereas during the formation of the vowels the nose and the nasopharynx are
more or less closed off by the soft palate from the resonating cavity of the
mouth.
Function of the Paranasal Sinuses
The biologic purpose of the nasal sinuses is largely speculative. The
main function of the paranasal sinuses is the protection of the cranial cavity. It
is obvious that the pneumatized cavities of the bone of the skull reduce the
weight, at the same time increasing the superficial extent of the bones of the
skull.
The existence of the ostia causes particular pathophysiologic problems
affecting ventilation and drainage.
Ostial obstruction interrupts the self-cleaning mechanism of the
affected sinus: therefore, the secretions stagnate and change in composition.
The retained secretions form an ideal medium for saprophytic bacteria which
are often present in normal sinuses.
The causes of closure of the ostium include:
1. Environmental factors such as relative dryness of the nose, toxic gases
or agents in the air.
2. Local congenital or acquired anomalies, including: deviation of the
septum, scars, lesions of the turbinates, infections of the nose or nasal
cavities, dental diseases, allergic diseases of the nose or nasal sinuses
(particularly in children), vasomotor dysfunctions with a neurogenic or
hormonal basis, metabolic diseases such as avitaminoses, diabetes,
disordered electrolytes, mechanical obstruction due to crusts, polyps,
foreign bodies, prolonged use of a nasogastric tube or prolonged nasal
tracheal intubation and benign and malignant tumors.
The vicious cycle of ostial occlusion can only be broken in the long
term by dealing with the causal factors by appropriate medical or surgical
measures.
The nasal sinuses are only minimally involved in the respiratory phases
of the nasal cavity.
The changes in pressure which can be recorded in the sinuses during
respiration is relatively slight.
8

ANATOMY OF THE PHARYNX

The pharynx extends from the base of the skull to the level of sixth
cervical vertebrae. This is a 12 to 13 cm long muscular tube in the adult; it
narrows from above downward, is covered with mucosa, and is divided
into three compartments each of which has an anterior opening (Fig 26),
The nasopharynx is limited superiorly by the base of the skull, inferiorly
by an imaginary plane through the soft palate, and it opens into the nasal
cavity. The most important anatomic structures are as follows: anteriorly
the choanae, posterosuperiorly the adenoid, laterally the pharyngeal
ostium of the Eustachian tube and the cartilaginous torus tubarius
immediately posterior to which is Rosenmuellers fossa and the tubal tonsil,
and anteriorly and inferiorly the soft palate (Fig 28). The embryonic
pharyngeal bursa may persist in the posterior wall of the nasopharynx
causing chronic inflammation and retention of secretions. The posterior
wall of the nasopharynx is separated from the spinal column by the tough
prevertebral fascia which lies on the longus capitis muscles, the deep
muscles of the neck, and the arch of the first cervical vertebra.
The shape and width of the nasopharynx show marked individual
variation. The epithelial lining is respiratory ciliated and stratified
squamous epithelium, with transitional epithelium at the junction with the
oropharynx.
The oropharynx extends from the horizontal plane through the soft
palate described above to the superior edge of the epiglottis and is
continuous with the oral cavity through the faucial isthmus. It contains the
following important structures: the posterior wall consisting of the
prevertebral fascia and the bodies of the second and third cervical
vertebrae, the lateral wall containing the palatine tonsil with the anterior
(palatoglossal)and posterior (palatopharyngeal) faucial pillars, and the
supratonsillar fossa lying above the tonsil between the anterior and
posterior faucial arches. The anterior surface of the soft palate with the
uvula are the parts of the oropharynx (Fig 27).
The epithelial lining consists of nonkeratinizing stratified squamous
epithelium.
The hypopharynx extends form the upper edge of the epiglottis
superiorly to the inferior edge of the cricoid cartilage. It opens anteriorly
into the larynx. On each side of the larynx lie the funnel-shaped pyriform
sinuses. The valleculae, the base of the tongue, and the lingual surface of
the epiglottis are usually described as being the part of the hypopharynx.
Important anatomic structures and relations include: on the anterior
wall the marginal structures of the laryngeal inlet and the posterior surface
of the larynx; on the lateral wall the inferior constrictor muscle and the
pyriform sinus, the latter being bounded medially by the aryepiglottic fold
and laterally by the internal surface of the thyroid cartilage and the
thyrohyoid membrane. Immediate relationships of the hypopharynx at the
level of the larynx include the common carotid artery, the internal jugular
vein and the vagus nerve. Relations of the posterior wall, apart from the
pharyngeal constrictor muscle, include the prevertebral fascia and the
bodies of the third to the sixth cervical vertebrae. Inferiorly the
hypopharynx opens into the esophagus, the boundary being the superior

sphincter of esophagus. The epithelial lining consists of nonkeratinized

stratified squamous epithelium.
The muscular tube of the entire pharynx consists of two layers with
different functions (Fig 25):
1. A circular muscle layer consisting of the three pharyngeal constrictor
muscles: the superior constrictor inserted into the base of the skull, the
middle constrictor inserted into the hyoid bone, and the inferior
constrictor inserted into the cricoid cartilage. Each of these funnelshaped muscular segments is overlapped at its lower end by the
segment below. All segments are inserted posteriorly into a tendinous
median raphe.
The inferior constrictor muscle is of particular clinical importance. It is
divided into a superior thyropharyngeal part and an inferior
cricopharyngeal part. The triangular dehiscence (Killians triangle) is
from the posterior wall of the hypopharynx between the superior
oblique and the inferior horizontal fibres.
2. The raising and the lowering of the pharynx is also achieved by three
paired muscles radiating into the pharyngeal wall from outside. These
are the stylopharyngeus, the salpingopharyngeus, and the
palatopharyngeus muscles. The stylohyoid and styloglossus muscles
are also responsible for elevation. A true longitudinal muscle does not
occur in the pharynx and only begins at the mouth of the esophagus.
The ability of the pharynx to slide over a distance of several
centimeters is due to the existence of fascial spaces (parapharyngeal
and retropharyngeal) filled with loose connective tissue.
Vascular supply of the pharynx.
The arterial supply is provided by the ascending pharyngeal artery, the
ascending palatine artery (facial artery), the tonsillar branches of the
facial artery, the descending palatine artery (maxillary artery), and
branches of the lingual artery. All these arise from the external carotid
artery. The venous drainage is via the facial vein and the pterygoid
plexus to the internal jugular vein.
The lymphatic drainage is either via an inconstant
retropharyngeal lymph node and then to the deep jugular lymph nodes
or directly to the latter group. The inferior part of the pharynx also
drains to the paratracheal lymph nodes, and thus gains a connection to
the lymphatic system of the thorax.
Nerve supply of the pharynx
The individual pharyngeal muscles gain their motor supply from
the glossopharyngeal, vagus, hypoglossal, and facial nerves. The
nasopharynx derives its sensory nerve supply from the maxillary
division of the trigeminal nerve, the oropharynx from the
glossopharyngeal nerve and the hypopharynx from the vagus nerve.
Lymphoepithelial System of the Pharynx
A very pronounced collection of lymphoepithelial tissue,
Waldeyers ring, lies at the opening of the upper aerodigestive tracts.

10

These lymphoepithelial organs are called tonsils. From above

downward, the following may be distinguished:
1. The pharyngeal tonsil, the adenoids, which is single and lies on the
roof and the posterior wall of the nasopharynx.
2. The tubal tonsil, which is paired and lies around the ostium of the
Eustachian tube in Rosenmuellers fossa.
3. The paired palatine tonsil, lying between the anterior and posterior
faucial pillars.
4. The lingual tonsil, which is single and lies in the base of the tongue.
Less constant and obvious are:
5. The tubopharyngeal plicae, lateral bands, which run almost vertically
at the junction of the lateral and posterior walls of the oro- and
nasopharynx.
6. Lymphoepithelial collections in the laryngeal ventricle. Unlike lymph
nodes, lymphoepithelial organs possess only efferent lymph vessels
and do not have afferent vessels. The difference in pathology and
physiology of the individual collection of lymphoid tissue rests on their
different structure.
The fine structure of a tonsil is in principle as follows: the soft
tissue lamellae or septae arise from a basal connective tissue capsule.
These serve as a supporting framework in which blood vessels,
lymphatics and nerves run. This fan-shaped supporting framework
considerable increases the active surface of the tonsil since it carries
the actual lymphoepithelial parenchyma. It is estimated that the
epithelial surface of one palatine tonsil amounts to 300 cm2. In the
palatine tonsil the active surface is sunk within the mucosa, whereas in
the adenoids it projects above the surface. The broad flat niches
opening into the oral cavity caused by enfolding are called lacunae; the
branching clefts running throughout the entire substance of the tonsil
are called crypts. The actual tonsil tissue consists of a collection of a
very large number of the lymphoepithelial units. The crypts usually
contain cell debris and round cells, but may also contain bacteria and
colonies of fungi, collections of pus, and encapsulated microabscesses.
The tonsils of Waldeyers ring are present at the embryonal
stage, but they only acquire their typical structure with secondary
nodes in the postnatal period, i.e., after direct contact with
environmental pathogens. They begin increasing rapidly in size
between the 1st and the 3rd year of life, with peaks in the 3rd and 7th
year. They involute slowly as of early puberty. Like the rest of the
lymphatic system, they atrophy with increasing age.
The arterial blood supply of the tonsils is provided by various
branches of the external carotid artery including the ascending
pharyngeal artery, the descending pharyngeal artery (maxillary a.), the
ascending palatine artery (facial a), the lingual artery, and also possibly
direct tonsillar branches.
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The veins of the pharyngeal tonsil usually drain via the palatal
vein and from there to the jugulofacial venous angle of the internal
jugular vein. There is also drainage via the pterygoid venous plexus to
the internal jugular vein.
PHYSIOLOGY OF THE PHARYNX
Several functional systems are collected in the pharynx
including the swallowing apparatus, the lymphoepithelial ring, and
articulation. Furthermore, the respiratory and digestive tracts cross in
this area.
The function of the tonsil is:
1. The tonsils ensure controlled and protected contact of the organism
with the pathogenic and antigenic environment serving the purpose
of immunologic surveillance. This allows adaptation to the
environment, especially in children.
2. The tonsils produce lymphocytes.
3. The tonsils expose B- and T-lymphocytes to current antigens and
are instrumental in the production of specific messenger
lymphocytes and memory lymphocytes.
4. The tonsils produce specific antibodies after the production of the
appropriate plasma cells. All types of immunoglobulins occur in
tonsillar tissue.
5. The tonsils shed topical immune-stimulated lymphocytes for both
humoral and cell-mediated immunity into the oral cavity and the
digestive tract.
6. The tonsils are instrumental in the production and discharge of
immunoactive lymphocytes into the blood and lymphatic circulation.

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