Anatomy of the Digestive system - Pharynx and Esophagus

Associate Professor Dr Farid Bin Ghazali School of Health Sciences

Embryology
Components of branchial/pharyngeal apparatus: 1) Pharyngeal arches 2) Pharyngeal pouches 3) Pharyngeal clefts/grooves

Pharyngeal (branchial) arches

Derived from neural crest cells Resemble fish gills (branchia) Begin to develop early in the 4th week By end of 4th week, four pairs of arches are visible on the surface (not 5th and 6th ) and a buccopharyngeal membrane ruptures forming communication between primitive oral cavity and foregut

Pharyngeal arches (cont.)

Contribute to the formation of the neck as well as the face. Visible structures at 42 weeks: 1st arch: mandibular prominence, maxillary prominences, and the frontonasal prominence

Pharyngeal arches (cont.)

Core of mesenchymal tissue covered by surface ectoderm (outside) and by endodermal epithelium (inside) Ectoderm -> skeletal Mesoderm -> muscles with accompanying nerve Arterial component (aortic arches) Therefore, each arch carries nerve, muscle, bone and blood supply

First pharyngeal arch

Maxillary process (dorsal)

Premaxilla,

maxilla, zygomatic bone, portion of temporal bone

Mandibular process (ventral)

Contains

Meckels cartilage which disappears except for dorsal end (incus & malleus) and mandible

First pharyngeal arch

Muscles of mastication, digastric (ant belly), mylohyoid, tensor tympani and tensor palatini Therefore, the accompanying motor nerve is the mandibular branch of trigeminal (V2) and sensory are V1, V2, and V3 1st aortic arch practically disappears but forms the maxillary artery

Second pharyngeal arch

Reicherts cartilage stapes, styloid process, stylohyoid ligament, lesser horn and upper part of the hyoid Muscles include: stapedius, stylohyoid, digastric (post belly), auricular, and those of facial expression Facial nerve (CN VII) 2nd aortic arch stapedial & hyoid arteries

Third pharyngeal arch

Cartilaginous contributions include greater horn and lower part of hyoid Sole muscle: stylopharyngeus CN IX (Glossopharyngeal nerve) 3rd aortic arch (quite large): common carotid, 1st portion of internal carotid (remainder dorsal aorta), and external carotid

Fourth & sixth pharyngeal arch

Cartilaginous contributions to larynx derived from fusion: thyroid, cricoid, arytenoid, corniculate, and cuneiform Muscles of 4th: cricothyroid, levator palatini, and pharyngeal constrictors are innervated by SLN (CN X) Muscles of 6th: intrinsics of larynx are innervated by RLN (CN X) 4th aortic arch: L->arch of aorta & R->subclavian 6th aortic arch: L & R pulmonary with ductus arteriosus on left

Pharyngeal pouches (5)

1st:tubotympanic recess-> middle ear & eustacian tube -> TM 2nd palatine tonsil/fossa 3rd: inferior parathyroid (dorsal), thymus (ventral) 4th: superior parathyroid 5th: ultimobranchial body -> calcitonin producing C cells (parafollicular)

Pharyngeal clefts/grooves (4)

1st: external auditory meatus 2nd-4th : epicardial ridge and cervical sinus (disappears)

The Pharynx
The pharynx is that part of the digestive tube which is placed behind the nasal cavities, mouth, and larynx. It is a musculomembranous tube, somewhat conical in form, with the base upward, and the apex downward, extending from the under surface of the skull to the level of the cricoid cartilage in front, and that of the sixth cervical vertebra behind. It is limited, superiorly above, by the body of the sphenoid and basilar part of the occipital bone; inferiorly (below), it is continuous with the esophagus; posteriorly, it is connected by loose areolar tissue with the cervical portion of the vertebral column, and the prevertebral fascia covering the Longus colli and Longus capitis muscles; anteriorly, it is incomplete, and is attached in succession to the medial pterygoid plate, pterygomandibular raph, mandible, tongue, hyoid bone, and thyroid and cricoid cartilages; laterally, it is connected to the styloid processes and their muscles, and is in contact with the common and internal carotid arteries, the internal jugular veins, the glossopharyngeal and vagus.

Anatomy of the pharynx

Anatomy (cont.)
Extends from base of skull to inferior border of cricoid cartilage anteriorly and inferior border of C6 posteriorly Widest portion (5cm) at hyoid Narrowest portion (1.5cm) at caudal end Divided into 3 parts: nasopharynx, oropharynx, and laryngo(hypo)pharynx

Nasopharynx
Respiratory function Anterior: choana (posterior nasal aperture) Posterior: pharyngobasilar membrane and superior constrictor muscle Superior: basilar portion of occipital bone Inferior: soft palate

Oropharynx
Digestive function Anterior: anterior tonsillar pillar Posterior: superior constrictor Superior: soft palate Inferior: base of tongue, superior epiglottis Laterally: palatoglossal and palatopharyngeal arches

Hypopharynx
Lies posterior to the larynx Superior: superior border of epiglottis and pharyngoepiglottic folds Inferior: inferior border of the cricoid Posterior/lateral: middle & inferior constrictors, bodies of C4-C6 Anterior: laryngeal inlet

Pharyngeal muscles

Pharyngeal muscles

External circular and internal longitudinal (opposite in remainder of GI tract) External: 3 constrictors (CN XI via X and ELN/RLN for middle and inferior) function to constrict wall of pharynx during swallow Internal: palatopharyngeus and salpingopharyngeus (CN XI via X) and stylopharyngeus (CN IX) act to elevate pharynx and larynx during speech/swallow

Pharyngeal muscles
Tensor veli palatini (V3) tenses soft palate & opens Eustachian Tube during yawn/swallow Levator veli palatini (CN XI via X) elevates palate during swallow/yawn Palatoglossus (CN XI via X) approximates tongue and soft palate

Pharyngeal muscles

Pharyngeal lymphatic drainage

Oral cavity

I, II, III II, III, IV

Oro/hypopharynx
deep

Nasopharynx
II,

V, III

BLOOD SUPPLY TO PHARYNX: Mostly from External Carotid Artery 1. Ascending Pharyngeal Artery directly off the External Carotid. 2. Maxillary ------> Descending Palatine Artery 3. Facial Artery branches: Ascending Palatine Artery Tonsillar Branch going to tonsils 4. Lingual Arteries and Ascending Pharyngeal arteries -- minor contributions.

Pharyngeal vessels

Afferent innervation of pharynx

EUSTACHIAN TUBES: They equilibrate pressure between the middle ear and atmosphere, via the throat. 1.Openings of the eustachian tubes are found in the Nasopharynx, at the posterolateral aspect. 2.Torus Tubarius: The tissue surrounding the eustachian tube. TONSILS: WALDEYER'S RIM -- a "ring" of tonsils surrounding the naso and oropharynx. 1.Pharyngeal Tonsil -- Single lymph "node" on posterior of nasopharynx. It samples antigens breathed in through the air and triggers an immune response. ADENOID TONSILS: When enlarged or inflamed, it is termed an adenoid tonsil. 2.Palatine Tonsil -- between the palatoglossal and palatopharyngeal arches, on the posterior of the roof of the mouth. 3.Lingual Tonsil -- on posterior third of tongue 4.Tubular Tonsil: Tonsils near the opening of the Eustachian tubes. INFLAMED TONSILS: Glossopharyngeal Nerve can pick up referred pain from inflamed tonsils and send the sensory pain to the middle ear. DEEP CERVICAL LYMPH NODES: All tonsils of Waldeyer's Rim drain into deep cervical lymph nodes. ARCHES: The palatine tonsil is located between the two arches.

1.Palatoglossal Arch: More anterior and more visible. 2.Palatopharyngeal Arch: More posterior.

Topography and constriction

Pharyngoesophag eal junction

General structure of the digestive tract

A hallow tube with a lumen whose diameter varies Surrounded by a wall made up of 4 principle layers Mucosa layer / Mucous membrane Contained epithelial layer and lamina propria Submucosa layer Composed of dense connective tissues, Blood vessels and lymph vessels and Meissner's nerve plexus Muscularis layer Thin inner circular layer smooth muscle cells Myenteric or Auerbachs nerve plexus Outer longitudinal layer smooth muscle cells Serosa / Adventitia layer Thin layer of loose connective tissue, rich in blood vessels and a simple squamous covering epithelium (mesothelium)

The esophagus or gullet is a muscular canal, about 23 to 25 cm. long, extending from the pharynx to the stomach. It begins in the neck at the lower border of the cricoid cartilage, opposite the sixth cervical vertebra, descends along the front of the vertebral column, through the superior and posterior mediastinum, passes through the diaphragm, and, entering the abdomen, ends at the cardiac orifice of the stomach, opposite the eleventh thoracic vertebra. The general direction of the esophagus is vertical; but it presents two slight curves in its course. At its commencement it is placed in the middle line; but it inclines to the left side as far as the root of the neck, gradually passes to the middle line again at the level of the fifth thoracic vertebra, and finally deviates to the left as it passes forward to the esophageal hiatus in the diaphragm. The esophagus also presents antero-posterior flexures corresponding to the curvatures of the cervical and thoracic portions of the vertebral column. It is the narrowest part of the digestive tube, and is most contracted at its commencement, and at the point where it passes through the diaphragm.

Musculature Histology Has an internal circular and external longitudinal layer of muscle.

In the superior third, the external

layer is skeletal muscle. The inferior third is composed

of smooth muscle.
The middle third is made up of both types of muscle.

Blood supply of the Esophagus

cervical part inferior thyroid branch of the thyrocervical trunk thoracic part branches of the descending aorta, bronchial arteries abdominal part branches of the left gastric artery and the inferiorphrenic artery

Nerve supply of the Esophagus

Nerve supply
Cervical part parasympathetic - the recurrent laryngeal nerves sympathetic - the cervical sympathetic trunks via the plexus around the inferior thyroid artery Thoracic part parasympathetic - vagus nerve via oesophageal plexus sympathetic - sympathetic trunk via greater splanchnic nerves Abdominal part parasympathetic - vagus nerve via anterior and posterior gastric nerves sympathetic - thoracic sympathetic trunk via greater and sometimes

1.

Connects pharynx & stomach Represents a transition

2. Muscularis mucosae replaces elastic layer of pharynx 3. Muscularis more regular

Esophagus upper portion

Stratified Squamous Epithelium

Lamina propria Muscularis mucosae

(Smooth muscle)

Submucosa

Tunica muscularis (longitudinal)

Tunica adventitia

Skeletal muscle

Tunica musclularis (circular)

Esophagus - high
Submucosa lax, elastic; 7 10 longitudinal folds; deep esophageal glands
Muscularis 2 layers: inner = circular, outer = longitudinal; upper = skeletal, not regular; middle = mix skeletal/smooth; lower third = smooth (extent variable)

Epithelium stratified squamous (25 cell layers tall papillae indent lower surface

Adventitia loose, fibrous; blood vessels & nerves

Lamina propria - areolar C.T. poor elasticity; superficial glands (extreme upper & lower ends mucous compound tubular)

Muscularis mucosae - smooth muscle

Normally have four constrictions 1. At its beginning, 15 cm from the incisor teeth caused by the cricopharyngeus muscle (upper esophageal sphincter). 2.Where it is crossed by the arch of aorta, 22.5cm from the incisor teeth. 3.Where it is crossed by the left main bronchus, 27.5 cm from the incisor teeth.

4. Where it is passes through the

diaphragm, approximately 40 cm from the incisor teeth.