Dissector Answers - Carotid Sheath, Pharynx, & Larynx

Learning Objectives:

Upon completion of this session, the student will be able to:

1. Review the arrangement, distribution and function of the cervical sympathetic trunk.
2. Review the carotid sheath and contents.
3. Identify, trace and describe the general functions of cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal
accessory), XII (hypoglossal).
4. Describe the pharynx, its anatomical architecture and action of its musculature during swallowing.
5. List the basic functions of the larynx.
6. Describe the anatomy of the interior of the larynx.
7. Identify the main cartilages and membranes that form the internal framework (skeleton) of the larynx.
8. Describe the actions of the intrinsic muscles of the larynx in tensing, relaxing, abducting or adducting the vocal folds.
9. Describe the innervation and vascular supply of the larynx.

Learning Objectives and Explanations:

1. Review the arrangement, distribution and function of the cervical sympathetic trunk. (WB 211-12; N 35, 128, 130, 131, 209, TG 7-
10, 7-15, 7-95)
The left and right cervical sympathetic trunks:

are a continuation of the thoracic sympathetic trunks

lie behind and medial to the carotid sheath and in front of prevertebral muscles
may be a solid trunk or strands connecting 2 or 3 cervical ganglia
cervical ganglia represent consolidation of the original 1 ganglion per cervical spinal nerve, which is the pattern in the
thorax. This consolidation of ganglia happens in areas where there are gray rami but no white rami, such as above T1 or
below L2.
there are only gray rami communicantes between the cervical trunk and spinal nerves C1-C8, because the highest level
for white rami is T1. This means that all of the preganglionic fibers of the cervical sympathetic trunk originated at T1 or
below (generally T1-T5). Postganglionic fibers in the cervical sympathetic trunk originate from one of the three cervical
ganglia (or thoracic ganglia).
much of the sympathetic innervation of the deep structures of the head occurs via perivascular sympathetic nerve
plexuses that follow branches of the external and internal carotid arteries.
The superior cervical ganglion sends gray rami to C1-C4 spinal nerves (variable) and also gives off other branches. It lies opposite the
transverse process of C2. Besides the gray rami to the spinal nerves, branches of the ganglion include:

external carotid nerve reaches external carotid artery to form the external carotid plexus. These perivascular fibers follow
branches of the external carotid to all the structures it supplies. For example, parotid gland sympathetic innervation comes
via the perivascular external carotid plexus (vasoconstriction reduces salivation).
internal carotid nerve, forming the perivascular internal carotid plexus to the brain, orbit, and forehead.
branches to the carotid body.
superior cervical cardiac nerve (accelerates heart rate and increases force of contraction).
sympathetic contributions to glossopharyngeal (CN IX), vagus (CN X), and hypoglossal (CN XII) nerves.
branches to join the pharyngeal plexus (along with glossopharyngeal and vagus).

The middle cervical ganglion (which may be absent) sends gray rami to C5-6 spinal nerves. It is at the level of the cricoid cartilage,
often close to where the inferior thyroid artery crosses the sympathetic trunk. Besides the gray rami, branches include:

middle cervical cardiac nerve, which has cardioaccelerator fibers, visceral afferent fibers to the heart, and fibers that go to
the thyroid.

The cervicothoracic or stellate ganglion, the fusion of the inferior cervical and first thoracic ganglia, sends gray rami to C6,7,8 and T1. It
lies anterior to the transverse process of C7 or the head of rib 1. Its other name, stellate ganglion, comes from the fact that its multiple
branches spread out like light rays from a star. Branches include:

inferior cervical cardiac n.

perivascular fibers to vertebral a. and from there into the brain, onto basilar, posterior cerebral, and cerebellar aa.
the ansa subclavia is a superficial strand that loops down from the middle cervical ganglion anteriorly around the
subclavian artery and joins the inferior cervical ganglion behind the artery.
this ganglion also receives a white ramus from T1.

Functions of the cervical sympathetic trunk:

recall that sympathetic nerves cause vasoconstriction, secretion (sweat glands), pilomotor functions, and contraction of
smooth muscle. Vasoconstriction can reduce output of glands like parotid by reducing blood flowing in. Specifically, the
cervical sympathetic trunk controls:
vasoconstriction of all the blood vessels of the brain and head (perivascular fibers)
blood vessels to salivary glands and other oral glands (external carotid n.)
acceleration of heart rate and strength of cardiac contraction through superior, middle, and inferior cervical cardiac nerves
innervation of hair muscles and sweat glands on the head
innervation of dilatator pupillae m. of the eye and superior tarsal m. of the eyelid. (Think about the eyes going wide with
fright, a sympathetic-stimulating emotion.)
Horner's syndrome involves a lesion of the sympathetic trunk. Two of the more noticeable signs of this syndrome are constriction of the
pupil and slight ptosis (drooping) of the eyelid.
2. Review the carotid sheath and contents. (WB 201,203,206; N 32, 33, 35, 125, 126, TG 7-17, 7-18, 7-13, 7-10)
The carotid sheath is a tube-shaped fascia wrapping the common carotid a., internal carotid a., internal jugular v., and vagus n. It lies
anterolateral to the cervical sympathetic trunk, behind the sternocleidomastoid muscle. The sheath blends with the thyroid fascia
anteromedially and with the deep surface of sternocleidomastoid anterolaterally. Posteriorly it is attached to prevertebral fascia along
the tips of the transverse processes of vertebrae. It ends at the base of the skull where it attaches around the jugular foramen and
carotid canal. It is here at the base of the skull that the internal carotid artery and internal jugular vein go their separate ways. Inferiorly,
the carotid sheath fuses with scalene fascia, adventitia of great vessels, and the fibrous pericardium.

Within the sheath, artery is medial, vein lateral, and nerve posterior and between the vessels.

The superior root of ansa cervicalis (from cervical plexus C1-2) lies draped over the anterior part of the carotid sheath.

The carotid sinus is the dilated terminal part of the common carotid artery, approx. 1 cm long. It is a baroreceptor in the elastic wall
which responds to changes in blood pressure. The carotid sinus is innervated by a branch of the glossopharyngeal nerve.

The carotid body is an disc-shaped mass lying behind the bifurcation of the common carotid artery. It has a chemoreceptor sensitive to
blood oxygen concentration. The carotid body is innervated by the nerve to carotid sinus from glossopharyngeal nerve, and also
receives the nerve to carotid body, a branch of the vagus n. (CN X), as well as sympathetic fibers.
3. Identify, trace and describe the general functions of cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory), XII
(hypoglossal). (WB 91,205,206,218,239; N 118, N125, 127, 128, TG 7-90, 7-91, 7-93, 7-94)
I Olfactory Some Sensory
II Optic Say Sensory
III Oculomotor Money Motor
IV Trochlear Matters Motor
V Trigeminal But Both
VI Abducens My Motor
VII Facial Brother Both
VIII Vestibulocochlear Says Sensory
IX Glossopharyngeal Big Both
X Vagus Brains Both
XI Accessory Matter Motor
XII Hypoglossal Most Motor
Glossopharyngeal, CN IX, Both motor and sensory.
Emerges from medulla in the groove dorsal/lateral to the olive, passes through jugular foramen, passes along the posterior border of
stylopharyngeus m.

The short story:

Motor: innvervates stylopharyngeus m. (that's the only muscle it innervates)

Sensory: posterior 1/3 of tongue: general sensory (pain, etc) and special sensory (taste); sensory to pharynx via
pharyngeal plexus

The long story . . . Branches include:

Tympanic n. - parasympathetic fibers to otic ganglion, which supplies parotid gland (increases salivation) and mucous
membrane of the middle ear
Carotid sinus nerve, with branches to carotid sinus and carotid body
Pharyngeal branches which form the pharyngeal plexus (along with vagus and cervical sympathetics)
Branches to stylopharyngeus (the ONLY motor branches of this nerve)
Branches to tonsils
Lingual branches - afferent fibers from the tongue report taste sensations and somatic sensations from the posterior third
of the tongue

Vagus, X, Both motor and sensory.

Arises from the medulla, in the groove dorsal and lateral to the olive, in the same plane as glossopharyngeal (CN IX) and accessory
(CN XI). The vagus leaves the skull through the jugular foramen, descends through the neck in the carotid sheath behind and between
the internal carotid/common carotid and the internal jugular v.

The short story:

Vagus supplies all the muscles of the pharynx and soft palate and upper 2/3rds of esophagus EXCEPT stylopharyngeus
(from glossopharyngeal) and tensor veli palatini (from mandibular division of trigeminal V 3). It does this primarily through
the pharyngeal plexus. The inferior pharyngeal constrictor is innervated by the superior laryngeal external branch.
Vagus, through the superior and inferior laryngeal nerves, also supplies all muscles and sensory innervation of the larynx.
Motor: The inferior laryngeals (=recurrent laryngeals) supply all the muscles of the larynx EXCEPT cricothyroideus.
Superior laryngeal external branch supplies cricothyroideus.
Sensory: The inferior laryngeals supply sensory fibers to the larynx below the vocal folds, but their role is minor in
sensation. Superior laryngeal internal branch supplies sensory fibers to the larynx above the vocal folds. It is the principal
sensory nerve of the larynx, according to W+B.
 It also supplies fibers to the dura, trachea, heart, etc

The long story...

Branches include:

meningeal to posterior dura mater

auricular to back of external ear
pharyngeal, which contribute to the pharyngeal plexus. The pharyngeal plexus (from vagus, glossopharyngeal, and
cervical symp trunk) supplies the constrictor muscles
superior laryngeal n. Arises from the inferior ganglion of the vagus. Passes inferomedially toward the larynx. Has 2
branches.
o internal branch: sensory to the mucous membrane of epiglottis
o external branch: inferior pharyngeal constrictor m., cricothyroid m.
cervical cardiac
recurrent laryngeal
o right recurrent laryngeal loops under and behind the subclavian a.
o left recurrent laryngeal loops under aortic arch
o both recurrent laryngeals ascend between the esophagus and trachea and enter the larynx from under the inferior
constrictor muscle. Above the cricothyroid articulation, name changes to inferior laryngeal n.
o branches of the laryngeals include: cardiac, tracheal, esophageal, pharyngeal branch to inferior pharyngeal
constrictor m.
o inferior laryngeals innervate all intrinsic muscles of the larynx EXCEPT cricothyroideus

Accessory, CN XI, Motor nerve.

Arises from rootlets of C1-C5 which ascend within the vertebral column through foramen magnum. It then descends through the jugular
foramen, where it receives fibers from the cranial portion of the accessory nerve. Upon leaving through the jugular foramen, the
accessory nerve lies between the internal carotid and internal jugular veins. It travels laterally, piercing and innervating
sternocleidomastoid. It then passes through the muscle, goes dorsally under the superficial layer of deep cervical fascia to trapezius,
where it joins sensory branches of C3 and C4 to form the subtrapezial plexus.
Hypoglossal, CN XII, Motor nerve.
Motor nerve of the tongue arises from the medulla oblongata in the anterolateral sulcus between the pyramid and the olive. The rootlets
which form the hypoglossal unite in the hypoglossal canal. It emerges from the canal medial to carotid sheath, then goes lateral.
Travels for a short distance with the superior root of ansa cervicalis. Turns forward near angle of the mandible, loops around occipital
artery, enters the submandibular triangle deep to posterior belly of digastric, and goes superior to the greater horn of the hyoid bone.
Terminal branches distribute to styloglossus, hyoglossus, genioglossus, and intrinsic muscles of the tongue. Carries C1 and C2 fibers
that leave as the superior root of ansa cervicalis, and the nerves to the thyrohyoid and geniohyoid muscles.
4. Describe the pharynx, its anatomical architecture and action of its musculature during swallowing. (WB 235;
N 35, 63, 65, 66, 67, N125, 126, 130, TG 7-10A, 7-10B, 7-20, 7-21, 7-22, 7-24)
The pharynx is the multi-purpose chamber that connects the nasal and oral cavities superiorly with the esophagus and larynx inferiorly.
It is multi-purpose in that it is the common pipe for food, liquids, and air, and it is the job of the pharynx to see that these invaluable
items travel through the right pipe to the proper destination.

The pharynx is the part of the digestive system posterior to the nasal and oral cavities, extending posteriorly and inferiorly past the
larynx. It extends to the inferior border of the cricoid anteriorly and the inferior border of C6 posteriorly. The posterior wall of the pharynx
lies against the prevertebral layer of deep cervical fascia.

In the pharynx the paths of food and air cross. Food travels from the mouth (anterior) to the esophagus (posterior). Air travels from the
choanae (posterior) to the trachea (anterior).

The interior of the pharynx is divided into 3 parts:

nasopharynx, most superior, is behind the nasal cavity and superior to the soft palate. It is strictly respiratory. Air enters
the nasopharynx through the posterior openings of the choanae, which are bisected by the posterior edge of the nasal
septum. At the upper posterior end of the nasopharynx is the pharyngeal tonsil, which is lymphoid tissue known as
adenoids when enlarged. The auditory tube to the middle ear opens into the lateral wall of the nasopharynx. Its opening is
covered by the torus tubarius. The salpingopharyngeal fold is a vertical fold of mucous membrane extending inferiorly
from the opening of the auditory tube.
oropharynx, the middle portion of the pharynx, is posterior to the oral cavity and connects with the nasopharynx above
and the laryngopharynx below. The dorsum of the tongue is anterior to the oropharynx. The inferior border of the
oropharynx is the epiglottis. Anteriorly it is continuous with the oral cavity at the palatopharyngeal folds or arches.
laryngopharynx, the most inferior part of the pharynx, lies below the oropharynx and posterior to the larynx. It extends
from the epiglottis superiorly down to the inferior border of the cricoid at C6. Its posterior and lateral walls are formed by
the middle and inferior pharyngeal constrictor muscles. Internally, the walls are formed by palatopharyngeus and
stylopharyngeus muscles. The laryngeal inlet connects the laryngopharynx with the larynx. (Aside: Lateral to the laryngeal
inlet are the piriform recesses, where foreign bodies can become lodged.) The laryngopharynx is continuous inferiorly with
the esophagus.

Structure of the pharynx:

The wall of the pharynx is composed of two layers of 3 muscles each. The external rings of circular constrictor muscles - the superior,
middle, and inferior constrictors - contract serially to push a bolus down to the esophagus. The internal ring of longitudinal muscles -
palatopharyngeus, stylopharyngeus, and salpingopharyngeus - elevate and widen the pharynx to accommodate a bolus during
swallowing. The fascia covering the outside of the posterior of the pharynx is the buccopharyngeal fascia. The interior fascia is the
pharyngobasilar fascia.
Innervation of the pharynx:
Motor:
Pharynx muscles are innervated by branches from pharyngeal plexus with 2 exceptions: stylopharyngeus (glossopharyngeal, CN IX)
and tensor veli palatini (supplied by mandibular division of trigeminal, V 3). Other than these two exceptions, the vagus is the source of
motor innervation to the pharynx. The inferior pharyngeal constrictor also receives innervation from the recurrent laryngeal and external
branch of the superior laryngeal (which are also derived from the vagus).

Sensory:
The glossopharyngeal sensory contribution to the pharyngeal plexus is connected to the mucosa of all three parts of the pharynx.
(Sensory nerve supply to the nasopharynx is primarily from the maxillary division of trigeminal, V 2)
The stages of swallowing (deglutition) (W+B 238)

Bolus begins to move from the mouth into oropharynx by action of muscles of tongue and soft palate. (voluntary)
The soft palate is elevated by the levator veli palatini and (to a lesser extent) tensor veli palatini muscles to seal off the
nasopharynx. (actions are involuntary from here down)
The salpingopharyngeus muscle (one of the internal longitudinal pharyngeal muscles) contracts drawing the lateral
pharyngeal walls upward.
As the bolus moves into the back of the pharynx, the palatopharyngeus and stylopharyngeus mm. (the other 2 longitudinal
muscles) elevate the larynx and pharynx causing the cavity to widen to receive the bolus.
After food passes the epiglottis, the superior, middle, and inferior pharyngeal constrictors - all circular muscles - contract,
one after the other, to push the bolus into the esophagus.

5. List the basic functions of the larynx.

The larynx connects the superior pharynx (oro- and naso-) with the trachea. It is specialized for producing voice, and a special part of
the larynx - the epiglottis - protects the airway during swallowing. To achieve these added functions, the larynx has additional cartilages,
muscles, ligaments, and mucous membranes.
6. Describe the anatomy of the interior of the larynx. (N 65, 66, 77, TG 7-22, 7-24, 7-27)
The laryngeal cavity extends superiorly from the laryngeal inlet at the border with the laryngopharynx to the inferior border of the cricoid.
It is covered with a mucous membrane, which is continuous with the pharynx above and trachea below. It has three parts.

The inlet and vestibule of the larynx are above the vestibular (false vocal) folds. The epiglottis, arytenoid cartilages,
cuneiform and corniculate cartilages, aryepiglottic folds, and piriform recesses are components here. Just below the inlet
is the widening called the vestibule, which ends below at the rima vestibuli, the aperture between the false vocal folds.
The lateral walls of the vestibule are formed by the quadrangular membranes. The free inferior margins of the
quadrangular membranes form the vestibular folds (or false vocal folds). The rima vestibuli, the opening between the
vestibular folds, is wider than the rima glottidis or glottis, the space between the true vocal folds, below.
The ventricle of the larynx is a cavity just below the vestibular folds and just superior to the true vocal folds. The ventricle
functions as a resonance chamber.
The infraglottic cavity extends from the glottis - the space between the vocal folds - to the beginning of the trachea below.
The true vocal folds, at the superior end of the infraglottic cavity, are two mucous-membrane-covered vocal ligaments
stretched between the vocal processes of arytenoids and the deep surface of the anterior angle of the thyroid cartilage.
Vocalis and thyroarytenoid muscles lie lateral, parallel, and adjacent to the vocal ligaments. These are the parts of the
larynx directly involved in making sound.
7. Identify the main cartilages and membranes that form the internal framework (skeleton) of the larynx. (N 78A, 78B, 78C, 78D, 78E,
TG 7-25, 7-28, 7-26, 7-27)
The larynx has nine cartilages (three unpaired and three paired):

Thyroid cartilage - largest, unpaired. Extends laterally but is not continuous posteriorly, so it doesn't form a complete ring
around the airway. Is composed of two quadrilateral laminae fused together in the anterior midline where there is a dip
called the superior thyroid notch. This dip projects anteriorly to form the laryngeal prominence (Adam's apple). Along the
lateral margins of the cartilage are the oblique lines running from the superior to inferior tubercles. The oblique line
provides a point of attachment for the sternothyroid and thyrohyoid muscles anteriorly and the inferior pharyngeal
constrictor muscle posteriorly. The superior border of the thyroid cartilage attaches to the hyoid bone by the thyrohyoid
membrane. Inferior horns of the thyroid cartilage articulate with the lateral surface of the cricoid at the cricothyroid joints.
The interior of the thyroid cartilage is covered by the mucous membrane of the interior of the larynx. The interior part of
the thyroid cartilage deep to the superior notch is the point of attachment for the stem of the epiglottis, the vocal and
vestibular ligaments, and three muscles: thyroarytenoid and its thyroepiglottic and vocalis parts.
Cricoid cartilage - is an unpaired signet-ring-shaped cartilage with the narrow band (the arch) facing anteriorly and the
broadened signet portion (the lamina) facing posteriorly. The cricoid is the only complete ring of cartilage to encircle the
airway. Cricoid attaches to the thyroid cartilage by the median cricothyroid ligament and to the trachea below by the
cricotracheal ligament. The cricothyroid muscle attaches to the anterior and lateral borders of the cricoid cartilage, and the
inferior pharyngeal constrictor attaches to its posterior border. The posterior superior aspect of the cricoid is notched, and
on either side of the notch are smooth surfaces for articulation with the bases of the 2 arytenoid cartilages. The inner
surface of the cricoid is lined with mucous membrane.
Arytenoid cartilages - paired, three-sided, pyramid-shaped bodies that lie on the superior margin of the cricoid lamina. The
anterior protrusion of the pyramid is the vocal process which is connected to the vocal ligament. The muscular process
protrudes laterally, to which are attached the posterior and lateral cricoarytenoid muscles. (Stretching between the
posterior surfaces of the two arytenoids are the transverse and oblique arytenoid muscles. Attached to the anterolateral
surface of the arytenoid are the thyroarytenoid muscle with its vocalis and thyroepiglottic parts.)
Corniculate cartilages - paired, small cartilages that sit on top of the apices of the arytenoids.
Cuneiform cartilages - paired, rod shaped bodies in the aryepiglottic fold lateral to the epiglottis.
Epiglottic cartilage - an unpaired, spoon-shaped cartilage which is attached (by the thyroepiglottic ligament) at its inferior
tapered end (tubercle of the epiglottis) to the superior thyroid notch. The superior end is free and curved anteriorly, while
the anterior surface is attached to the hyoid bone by the hyoepiglottic ligament. It is covered by mucosa. The posterior
surface of the epiglottis faces the vestibule of the larynx. It is pitted to accommodate small mucous glands.

Membranes of the larynx:

Thyrohyoid membrane - suspends the thyroid cartilage and thus the larynx from the hyoid bone above. The median
portion of this membrane is thickened, forming the median thyrohyoid ligament. Lateral thyrohyoid ligament on the sides
of the larynx extends between the superior horn of the thyroid cartilage and to the end of the greater horn of the hyoid
bone.
 Quadrangular membrane - above the vocal ligament is a thin sheet of connective tissue connecting the lateral part of the
epiglottic cartilage with the arytenoid. Its lower free margin, above the vocal ligament, is the vestibular ligament of the
false vocal (vestibular) folds.
Conus elasticus - is an elastic membrane hanging down like a sheet from the vocal ligament above to the cricoid cartilage
below. The lower attachment of this sheet stretches in a semicircle from the base of one arytenoid to the other. The
thickened superior margins of the conus - the vocal ligaments - attach the vocal processes of the arytenoids to the inner
surface of the laryngeal prominence, below the superior thyroid notch. This forms the V shape of the abducted vocal
ligaments when seen from above.
Hyoepiglottic and thyroepiglottic ligaments - attach the epiglottis to the hyoid bone and thyroid cartilage anteriorly.
Cricotracheal ligament - connects the inferior border of the cricoid to the first ring of the trachea.

8. Describe the actions of the intrinsic muscles of the larynx in tensing, relaxing, abducting or adducting the vocal folds.
(N 78C, 78D, 79, TG 7-26, 7-27, 7-28)

Cricothyroid muscles (paired) - On the external surface of the larynx. Arise from the anterior arch of the cricoid cartilage
and fibers travel backward and upward to insert into the inferior border of the thyroid cartilage. Action: pulls the thyroid
cartilage down and toward the cricoid. Result: increases the distance between the arytenoids and the thyroid cartilage,
tensing the vocal folds. Helps control pitch.
Posterior cricoarytenoid muscles (paired) - Lie on the dorsal surface of the cricoid cartilage. Fibers originate near the
posterior midpoint, and run laterally from there in both directions to attach to the back of the muscular processes of the
arytenoid cartilages. Action: when muscles contract, they pull the muscular processes posteriorly and the vocal processes
laterally. Result: Abduction of the vocal folds. These are the only abductors of the vocal folds. Without them, the vocal
folds adduct permanently, and you suffocate.
Lateral cricoarytenoid muscles (paired) - Originate from the upper anterior border of the cricoid cartilage. Fibers pass
posteriorly left and right and insert on the anterior aspect of the muscular processes of the arytenoid cartilages. Action:
Upon contraction, muscular processes are pulled anteriorly and vocal processes are pulled medially. Result: Adduction of
the vocal folds.
Arytenoid muscles (two, but unpaired) - These muscles, oblique and transverse, attach the posterior surfaces of the
arytenoids to one another. Oblique fibers are continuous with the aryepiglottic muscles, which help to pull epiglottis down
toward the larynx during swallowing. Action: Upon contraction, pulls the arytenoids medially (toward each other). Result:
Adduction of the vocal folds.
Thyroarytenoid muscles (paired) - Border the vocal ligaments. Arise from the anterior inner surfaces of the thyroid
laminae, deep to the laryngeal prominence, and insert on the lateral borders of the arytenoid cartilages. Action: they pull
the arytenoid cartilages closer to the thyroid cartilages, Result: reduced tension of the vocal ligament. In the process of
shortening, these muscles also thicken and this helps seal the glottis. Thus they are considered sphincters of the glottis.
Vocalis muscles (paired) - are composed of the fibers of thyroarytenoid muscles closest to the vocal ligaments. Each
vocalis attaches to the elastic tissue of the vocal ligament. Action: Contraction affects frequency of vibration of the vocal
ligaments. Result: Control of pitch and the fine adjustments required in vocalization.
9. Describe the innervation and vascular supply of the larynx. (N 76, 80, TG 7-26B, 7-26C, 7-28)
Innervation:

Vagus, through superior laryngeal and inferior laryngeal nerves, innervates the entire larynx.
o Superior laryngeal, internal branch: the principal sensory nerve of the larynx, sending fibers from the supraglottic
portion of the larynx; also sends parasympathetic fibers to the mucous glands of the interior of the supraglottic
portion of the larynx.
o Superior laryngeal, external branch: only innervates the cricothyroid muscle.
o Inferior laryngeal: Is the continuation of the left and right recurrent laryngeal nerves. It innervates all intrinsic
muscles of the larynx except cricothyroid.

Vascular supply:

Superior laryngeal artery, branch of the superior thyroid artery, pierces the thyrohyoid membrane along with the internal
branch of the superior laryngeal nerve.
Inferior laryngeal artery, branch of the inferior thyroid artery, passes under the inferior pharyngeal constrictor muscle along
with the inferior laryngeal nerve.

Questions and Answers:

10. Identify the ascending pharyngeal artery (a branch of the external carotid) distributing to the dorsal wall of the pharynx. Do you find
any lymph nodes (retropharyngeal)?
Retropharyngeal lymph nodes are usually present in the tissue between visceral and musculoskeletal parts of the neck, known as the
retropharyngeal space, but difficult to find unless they are enlarged by disease. They are associated with the deep cervical nodes found
in the carotid sheath just lateral to the space. (N 73, 136, TG 7-74)
11. Observe the pharyngobasilar fascia forming the pharyngeal wall above the superior pharyngeal constrictor. What tissue is it?
The wall of digestive and respiratory tracts, of which the pharynx is common to both, consists of a mucosal lining, a connective tissue
layer - the submucosa - and a muscular wall. The pharyngobasilar fascia is the submucosa of the pharyngeal wall. (N 67, TG 7-21)
12. Clear the stylopharyngeus muscle and trace to the pharynx. Between what two muscles does it pass?
The stylopharyngeus muscle passes between the superior and middle pharyngeal constrictors. (N 67, TG 7-21)
13. Consider the complete blood supply to pharyngeal constrictors. Innervation?
The pharynx is supplied by the ascending pharyngeal artery, branches of the facial, maxillary and inferior thyroid. The pharynx receives
nerves from the pharyngeal plexus which is composed of branches of the glossopharyngeal nerve (sensory), the vagus (motor and
parasympathetic motor to the glands of the mucosa) and the sympathetic trunk (vasomotor to the blood vessels of the pharynx).
(N 69, 75, 125, 126, 130, 131, 136, TG 7-22, 7-21, 7-20, 7-23, 7-24)
14. Define nasal, oral and laryngeal portions of pharynx. What boundaries separate these regions?
The nasopharynx extends from the choanae anteriorly to the soft palate inferiorly; it is the respiratory portion of the pharynx. The
oropharynx extends from the soft palate above to the epiglottis below and opens into the mouth anteriorly. The laryngopharynx extends
from the epiglottis to the beginning of the esophagus below. It opens into the larynx anteriorly.
14a. What structures lie immediately deep (lateral) to the palatine tonsil? Where is the lingual tonsil?
The superior pharyngeal constrictor muscle lies lateral to the palatine tonsil, along with the vessels supplying the tonsil. The lingual
tonsil is in the submucosa on the superior surface of the root of the tongue just behind the sulcus terminalis. It is a large collection of
lymphoid nodules that give the posterior one-third of the tongue its warty appearance.
15. The cartilages of the larynx along with their articulations and membranes constitute a separate, almost independent,
musculoskeletal entity. What structural features differ in male and female?
The thyroid cartilage in male and female are different in shape. In the female, the two thyroid laminae meet in an angle of about 120
degrees. In the male, the thyroid laminae meet at an angle of 90 degrees. Thus the laryngeal prominence (the so called "Adam's
apple") in the male is more obvious. The shape as well determines the length of the vocal cords and their consequent pitch; the cords
being shorter in women and thus a higher pitched voice.
16. What is the action of the cricothyroid joint?
The cricothyroid muscle brings the arch of the cricoid and the thyroid cartilage together with the pivot at this joint. During this action the
vocal folds become more tense and the pitch of the voice increases. Conversely paralysis of this muscle produces hoarseness of voice.
17. What is the glottis?
The glottis is defined as the space between the true vocal folds. It is also called the rima glottidis to differentiate it from the rima
vestibuli, the space between the vestibular or false vocal folds.
18. What is the source of the inferior laryngeal nerve and the inferior laryngeal artery?
The inferior laryngeal nerve is the terminal end of the recurrent laryngeal nerve. It is motor to the intrinsic muscles of the larynx, while
the recurrent laryngeal supplies the trachea and esophagus as well. The inferior laryngeal artery is a branch of the inferior thyroid
artery; it accompanies the nerve into the space deep to the piriform recess.
19. Identify two structures that perforate the thyrohyoid membrane: the internal branch of the superior laryngeal nerve and the superior
laryngeal artery. What is the source of each?
The internal branch of the superior laryngeal nerve is a sensory nerve to the interior of the larynx which arises from the vagus. The
superior laryngeal artery and vein arise as the first branches of the superior thyroid vessels. (N 69, 74, 126, TG 7-26, 7-28)
20. Does the external branch of the superior laryngeal nerve pass through or give off a branch to the inferior pharyngeal constrictor
muscle?
The external branch of the superior laryngeal nerve usually passes through the lower portion of the inferior constrictor muscle (this
portion a.k.a. cricopharyngeus m.) supplying it and the cricothryroid muscle. (N 74, 75, 76, TG 7-20, 7-26)
Clinical Cases - Carotid Sheath, Pharynx, & Larynx
A medical student was celebrating the end of midterm exams with her friends in a seafood restaurant when she started feeling a
prickling sensation in her neck after swallowing a large bite of smoked fish. The pain was getting worse, and attempts to clear it with
drinks failed. At the emergency room a plain X-ray of her neck showed a tiny fish bone lodged in the lower part of the pharynx. The
bone was quickly removed under general anesthesia, and the patient was discharged a few hours later.

Questions to consider:

1. Which are the most usual places for swallowed foreign bodies to be lodged?

The piriform recess and the valleculae on either side of the median glosso-epiglottic fold.

2. What is the piriform recess?

This is a small, pear-shaped depression of the laryngopharyngeal cavity on each side of the inlet of the larynx. It is
separated from the inlet by the aryepiglottic fold. Laterally the piriform recess is bounded by the medial surfaces of
the thyroid cartilage and the thyrohyoid membrane. The branches of the internal laryngeal and inferior laryngeal
nerves (continuation of recurrent laryngeal) lie deep to the mucous membrane of the piriform recess.

3. Fish bones and other foreign bodies may pierce the mucous membrane of the recess and cause injury to the internal
laryngeal nerve. What are the possible consequences of this injury?

Injury to the internal laryngeal nerve will result in anesthesia of the laryngeal mucous membrane as far inferiorly as the
vocal folds.
Practice Quiz - Carotid Sheath, Pharynx, & Larynx
Below are written questions from previous quizzes and exams. Click here for a Practical Quiz - old format or Practical Quiz - new
format.

1. Following thyroid surgery, it was noted that a patient frequently aspirated fluid into her lungs. Upon examination it was
determined that the area of the piriform recess above the vocal fold of the larynx was numb. What nerve may have been
injured?

External branch of the superior pharyngeal

Hypoglossal

Internal branch of the superior laryngeal

Lingual

Recurrent laryngeal

The correct answer is: Internal branch of the superior laryngeal

The internal branch of the superior laryngeal is a sensory nerve that pierces the thyrohyoid membrane along with the superior
laryngeal artery. It supplies sensory fibers to the mucous membrane of the larynx, superior to the vocal folds. Since this area lost
sensation, it appears that the internal branch of the superior laryngeal nerve must have been injured. The external branch of the
superior laryngeal nerve is a motor nerve that innervates the cricothyroid muscle--it does not provide any sensory innervation to
the larynx. The recurrent laryngeal nerve ascends from the thorax and provides motor innervation to the upper esophagus, lower
pharynx, and all the laryngeal muscles except cricothyroideus.

The hypoglossal nerve supplies motor innervation to the muscles of the tongue. The lingual nerve is a sensory nerve for the
anterior 2/3 of the tongue. These nerves are not important for innervating the larynx.
 2. The laryngeal muscle most responsible for stretching (elongating) the vocal ligament is the :

Posterior cricoarytenoid

Lateral cricoarytenoid

Thyroarytenoid

Arytenoid

Cricothyroid

The correct answer is: Cricothyroid

Cricothyroid draws the thyroid cartilage forward, tensing the vocal ligaments. This is the one muscle innervated by the external
branch of the superior laryngeal nerve. Posterior cricoarytenoid is a very important muscle; it's the only muscle that abducts the vocal
folds. This muscle is innervated by the inferior laryngeal nerve, which is a continuation of the recurrent laryngeal nerve. If this muscle is
denervated, the vocal folds may be paralyzed in an adducted position, which would prevent air from entering the trachea. Lateral
cricoarytenoid, thyroarytenoid, and arytenoid are all muscles that adduct the vocal folds. They are all innervated by the inferior laryngeal
nerve.

3. The muscle most responsible for the abduction of the vocal folds is the :

Arytenoid

Cricothyroid

Lateral cricoarytenoid

Posterior cricoarytenoid

Thyroarytenoid

The correct answer is: Posterior cricoarytenoid

The posterior cricoarytenoid is the only muscle that abducts the vocal folds. This muscle is innervated by the inferior laryngeal
nerve, which is a continuation of the recurrent laryngeal nerve. If this muscle is denervated, the vocal folds may be paralyzed in an
adducted position, which would prevent air from entering the trachea. Arytenoid, lateral cricoarytenoid, and thyroarytenoid all adduct the
vocal folds. Cricothyroid is the only laryngeal muscle innervated by the external branch of the superior laryngeal. It tenses the vocal
ligaments by tipping the thyroid cartilage forward relative to the cricoid cartilage.

4. The nerve that innervates all but one muscle of larynx is the:

Glossopharyngeal nerve, pharyngeal branch

Inferior laryngeal nerve

Superior laryngeal nerve, external branch

Superior laryngeal nerve, internal branch

Thyrohyoid nerve

The correct answer is: Inferior laryngeal nerve

The inferior laryngeal nerve is the continuation of the recurrent laryngeal nerve, superior to the inferior border of the cricoid
cartilage. It innervates the posterior cricoarytenoid muscle, which is responsible for abducting the vocal folds. The inferior laryngeal
nerve also innervates all of the other intrinsic muscles of the larynx, with the exception of the cricothyroid muscle. The pharyngeal
branch of the glossopharyngeal nerve provides sensory innervation to the pharynx, but not to the larynx. The glossopharyngeal nerve
only provides motor innervation to stylopharyngeus. The external branch of the superior laryngeal nerve innervates the cricothyroid
muscle, which is responsible for stretching the vocal ligaments. The internal branch of the superior laryngeal nerve is responsible for
providing sensory innervation to the mucosa of the larynx, superior to the true vocal fold. The thyrohyoid nerve is a branch of ansa
cervicalis-- it innervates the thyrohyoid muscle, which elevates the larynx and depresses the hyoid bone (or helps to fix the hyoid in
space, so that other muscles, such as tongue muscles, can work).

5. The vocalis muscle is most responsible for the fine control of phonation because of its attachment into the:

Arytenoid cartilage

Cricoid cartilage

Thyroid cartilage

Vestibular ligament

Vocal ligament
 The correct answer is: Vocal ligament

Vocalis represents the innermost fibers of the thyroarytenoid muscle, from the inner surface of the thyroid cartilage. Because
vocalis inserts on the vocal ligament, it can relax very specific segments of the vocal ligament to adjust the pitch. Although there
are many muscles that insert on the other pieces of cartilage listed, vocalis is the only one that can provide for such fine control
of tone because it is inserting right on the vocal ligament.

6. The constrictor muscles of the pharynx receive their motor nerve supply from the:

Glossopharyngeal nerve

Hypoglossal nerve

Spinal accessory nerve

Sympathetic trunk

Vagus nerve

The correct answer is: Vagus nerve (CN X)

The vagus nerve supplies motor innervation to the muscles of the larynx and pharynx, with the exception of stylopharyngeus
(innervated by the glossopharyngeal nerve). It also supplies motor innervation to the palate muscles, with the exception of tensor veli
palatini (innervated by the V3 division of the trigeminal nerve). The glossopharyngeal nerve (CN IX) provides the sensory, but not motor,
innervation to the pharynx. The hypoglossal nerve (CN XII) provides motor innervation to the muscles of the tongue. The accessory
nerve (CN XI) provides motor innervation to the trapezius and the sternocleidomastoid. Finally, the sympathetic trunk supplies
sympathetic innervation to the head and neck.
 7. Twenty-four hours following a partial thyroidectomy where the inferior thyroid artery was also ligated (tied off), the patient now
spoke with a hoarse voice (whisper), and had difficulty in breathing. Which nerve was injured?

Internal branch of superior laryngeal

Ansa cervicalis

Ansa subclavia

Recurrent laryngeal

External branch of superior laryngeal

The correct answer is: Recurrent laryngeal

The recurrent laryngeal nerve runs with the inferior thyroid artery toward the lower lobes of the thyroid. This means that the
recurrent laryngeal nerve would be at risk in any surgery involving the inferior thyroid artery or the inferior poles of the thyroid. The
recurrent laryngeal nerve becomes the inferior laryngeal nerve at the inferior border of cricoid cartilage, and this nerve continues on to
innervate all the muscles of the larynx with the exception of cricothyroid. So, an injury to the recurrent laryngeal nerve might lead to
hoarseness and difficulty breathing (due to a laryngeal spasm).

The internal branch of superior laryngeal runs with the superior laryngeal artery and pierces the thyrohyoid membrane. Ansa
cervicalis is a branch of the cervical plexus which hangs in front of the internal jugular vein. It innervates the strap muscles, not the
laryngeal muscles. Ansa subclavia is part of the sympathetic trunk which loops around the subclavian artery. Finally, the external
branch of the superior laryngeal nerve runs with the superior thyroid artery. This is the artery and nerve that might be damaged when
removing the superior lobe of the thyroid.
 8. In performing a thyroidectomy, caution should be exercised when ligating (tying) the inferior thyroid artery, as it lies in a very
close relationship to which nerve?

ansa cervicalis

hypoglossal

phrenic

recurrent laryngeal

vagus

The correct answer is: recurrent laryngeal

The recurrent laryngeal nerve crosses the inferior thyroid artery near the lower lobe of the thyroid. This means that the recurrent
laryngeal nerve would be at risk in any surgery involving the inferior thyroid artery or the inferior poles of the thyroid. The recurrent
laryngeal nerve becomes the inferior laryngeal nerve at the inferior border of cricopharyngeus, and this nerve continues on to innervate
all the muscles of the larynx with the exception of cricothyroid. So, you really need to take care to protect the recurrent laryngeal nerve--
injuring this structure could lead to hoarseness, permanent loss of voice, or even death due to a laryngeal spasm.

None of the other listed nerves are related to the inferior thyroid artery. Ansa cervicalis is a branch of the cervical plexus which
hangs in front of the internal jugular vein. It innervates the strap muscles. The hypoglossal nerve winds behind the internal jugular vein,
then sweeps around lateral to the carotid vessels and into the floor of the mouth, where it innervates the tongue muscles. The phrenic
nerve lies on top of the anterior scalene muscles--it then travels through the thorax to innervate the diaphragm. Finally, the vagus is
found in the carotid sheath--it is associated with the common carotid and the internal carotid arteries.
 9. A 60-year-old man has occasional blackouts and light-headedness. Studies reveal atherosclerotic plaques within the common
carotid arteries and the bifurcation of the vessels. A carotid endartectomy is undertaken. Which nerve bundle running vertically
within the carotid sheath must the surgeon be careful not to injure?

Accessory

Cervical sympathetic trunk

Glossopharyngeal

Hypoglossal

Vagus

The correct answer is: Vagus

In a carotid endarterectomy, surgeons enter the carotid artery and excise the diseased endothelium and media of the artery so
that the lumen is left with a smooth lining. To do this, the surgeons must enter the carotid sheath, which means that any structure within
that sheath or near that sheath might be injured. This question specifically asks which structure in the sheath could be injured, so the
correct answer is the vagus nerve. The carotid sheath contains 2 nerves: the vagus and the superior ramus of ansa cervicalis. It also
contains 3 vessels: internal carotid, common carotid, and internal jugular vein. Any of these structures could be damaged during the
procedure.

The accessory nerve is most closely associated with the posterior triangle of the neck. It cuts through this triangle to innervate
sternocleidomastoid and trapezius and lies posterior to the carotid vessels The cervical sympathetic trunk lies in front of the
prevertebral muscles in the prevertebral fascia. The glossopharyngal nerve comes out of the jugular foramen and divides into 2
branches--pharyngeal and lingual branches. This nerve sweeps near the carotid sheath, but it's not in the carotid sheath. The
hypoglossal nerve travels lateral to the carotid vessels before entering the floor of the mouth. It crosses the carotid artery, but it's not in
the sheath.
 10. A 55-year-old woman has difficulty swallowing and frequently aspirates fluids while drinking. She is diagnosed as having a skull
base tumor occupying the space behind the jugular foramen. Involvement of which structure is responsible for the findings?

Ansa cervicalis

Cervical sympathetic trunk

Accessory nerve

Hypoglossal nerve

Vagus

The correct answer is: Vagus

The vagus nerve, which exits the skull through the jugular foramen, is the motor nerve to the pharynx. So, it allows for swallowing.
This patient's symptoms and the location of the tumor clearly point to an injury of the vagus nerve. The accessory nerve also exits the
skull through the jugular foramen--it could be injured from this tumor, but the symptoms are not suggestive of an accessory nerve injury.
If her accessory nerve was damaged, the patient's sternocleidomastoid and trapezius would be denervated, which means the acromion
of her shoulder would sag. The other nerve that comes through the jugular foramen is the glossopharyngeal nerve--this nerve might
also be damaged by the tumor.

The other nerves listed do not come from the jugular foramen, so they would not be the first nerves injured by the tumor. Ansa
cervicalis is a branch of the cervical plexus that innervates the strap muscles in the anterior neck. The cervical sympathetic trunk is the
structure that provides sympathetic innervation to the head and neck. If this trunk was disrupted, the patient would have Horner's
syndrome. The symptoms of Horner's syndrome include: ptosis, constricted pupil, lack of sweating on the affected side, flushing on the
affected side, and enophthalmos (sunken-in eye). Finally, the hypoglossal nerve exits the skull through the hypoglossal canal, providing
motor innervation to the muscles of the tongue. An injury to the hypoglossal nerve would cause the tongue, when protruded, to point to
the side of the face with the injured nerve.
 11. While doing a postoperative physical on a patient who has undergone carotid endarterectomy on the right side, it was noted that
the tongue deviated toward the right when the patient was asked to point the tongue outward. What nerve crossing the carotid
artery must have been injured?

Glossopharyngeal

Hypoglossal

Inferior alveolar

Lingual

Vagus

The correct answer is: Hypoglossal

The hypoglossal nerve crosses the carotid artery before diving into the floor of the mouth, so it might get injured during this
procedure. This nerve innervates the muscles of the tongue. When the hypoglossal nerve is injured and a patient sticks out the tongue,
the tongue points to the side with the injured nerve. So, this patient, who had the right side endarctectomy, has an injury to the right
hypoglossal nerve. The symptoms that you see in this case should point you toward suspecting damage to the hypoglossal nerve.

The glossopharyngeal nerve crosses around the internal carotid artery and the stylopharyngeus muscle--it could theoretically be
injured in this procedure, but the symptoms are not consistent with an injury to this structure. The inferior alveolar nerve and lingual
nerves are branches of the mandibular division of the trigeminal nerve. They are not associated with the carotid vessels. The vagus
nerve is found in the carotid sheath. This nerve can be easily injured by an endarterectomy, although damage to the vagus would cause
problems with swallowing, not with tongue movements.

12. Any manipulation of the superior thyroid artery must be undertaken with care not to damage its small companion nerve, the:

Cervical sympathetic trunk

External branch of the superior laryngeal

Inferior root of the ansa cervicalis

Internal branch of the superior laryngeal

Recurrent laryngeal
The correct answer is: External branch of the superior laryngeal

The external branch of the superior laryngeal nerve runs with the superior thyroid artery--this artery and nerve might be damaged
when removing the superior pole of the thyroid. If this nerve was damaged, the cricothyroid muscle would be paralyzed, and a patient
would be unable to tense the vocal cords. The internal branch of the superior laryngeal nerve runs with the superior laryngeal artery
and provides sensory innervation to the mucous membrane of the larynx, superior to the vocal fold. The recurrent laryngeal nerve
crosses the inferior thyroid artery, near the lower pole of the thyroid. This means that the recurrent laryngeal nerve would be at risk in
any surgery involving the inferior thyroid artery or the inferior poles of the thyroid. The recurrent laryngeal innervates all the muscles of
the larynx with the exception of cricothyroid. So, an injury to the recurrent laryngeal nerve might lead to hoarseness and dificulty
breathing.

The cervical sympathetic trunk lies in front of the prevertebral muscles in the prevertebral fascia--it would not be near the
structures involved with thyroid surgery. The inferior root of ansa cervicalis is a branch of the cervical plexus. It innervates the strap
muscles. Ansa cervicalis hangs in a loop over the carotid vessels; it is not associated with the thyroid gland.

13. The carotid body is innervated by a branch of the:

Glossopharyngeal nerve

Hypoglossal nerve

Spinal accessory nerve

Sympathetic trunk

Vagus nerve

The correct answer is: Glossopharyngeal nerve (CN IX)

The carotid body is innervated by the carotid branch of the glossopharyngeal nerve. It is a small, reddish-brown ovoid mass that
lies on the medial side of the carotid bifurcation, serving as a chemoreceptor that monitors the level of carbon dioxide in the blood. The
hypoglossal nerve (CN XII) innervates the muscles of the tongue. The spinal accessory nerve is a motor nerve that innervates the
sternocleidomastoid and the trapezius. The sympathetic trunk provides sympathetic innervation to the head and neck. Finally, the
vagus nerve supplies motor innervation to the muscles of the pharynx and larynx, with the exception of stylopharyngeus, and the
muscles of the palate, with the exception of tensor veli palatini.