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Larynx &Pharynx

Today we will continue about the larynx : Last time we spoke about the larynx, and as you remember we said that the larynx is made up from a group of cartilages, and those cartilages are 6 in number: -Three singles (3) -Three pairs (3) Those cartilages are connected together by membranes and ligaments: Membranes are Two Extrinsic : 1-The one connecting the thyroid up with hyoid bone is Thyrohyoid membrane 2- The one connecting the larynx down to the trachea Crico tracheal membrane Membranes Two Intrinsic 1- Superior membrane is from arytenoid all the way to the epiglottis ary epiglottis membrane or quadrangular membrane with it is upper folding forming the inlet to the larynx . 2-Inferior membrane, you can see it is upper margin, it is crico thyroid membrane and it is upper free margin forming the vocal cords. And we said that when you look to the larynx , you can see a space (Black color in the slide) called rema clottis and rema vestibularis beside it .

(These membranes are moving in order to produce the voice, and in order to move they need a skeletal muscle and now we want to speak about the muscles). -We have extrinsic muscles that moving the hall larynx together. - We have the intrinsic muscles that moving the larynx which are: * Supra hyoid group : elevate the larynx up as they elevate the hyoid bone.

(Stylopharyngeus and Salpingopharyngeus and Palatopharyngeus) * Infra hyoid group : depress the larynx down as they depressing the hyoid bone . The intrinsic muscles are between the cartilages Themselves, and they have to move the cartilages , so once they move them they will move the membrane connecting , in other word they will moving the vocal cords , either by tensing the cord or relaxing them . Or widening the cord (abducting them) or adding them together Now.. The intrinsic muscles are two groups : -Ones that move the cartilages to move the vocal cord , so these are either tensing the cord or relaxing them.or moving them away from each other abducting the cords or moving them close to each other reducing the rema clottis adding the cords . -Ones that move the laryngeal opening. So.there's a group related to movement of vocal cords and there's a group related to the laryngeal opening , so the laryngeal opening also has influence in the voice production The laryngeal opening as I told you determined by : Ant. epiglottis Lat.ary epiglottic fold Post. The Arytenoid

So Two muscles (one widening the inlet) and the other (narrowing it). Those two muscles are: The oblique Arytenoids m. This muscle is going obliquely from one Arytenoid towards the other , some muscle fibers of it will pass within the Ary epigllotis membrane as it folds , from arytenoid all the way to the epiglottis the oblique arytenoids extend from the muscular process of arytenoids cartilage all the way to the apex of arytenoids and corniculate cartilages in the opposite side part of the m. will continue within the aryepiglottic fold to the epiglottis , and we usually call it the Aryepiglottic m.

SO The aryepiglottic m. is a continuation of oblique arytenoids muscle , when it's contract in both sides it will narrowing the opening ( laryngeal inlet ) . Thyroepiclottic m. From thyroid cartilage Anteriorly all the way in to the Aryepiglottic fold so once this m. contract from both side , the inlet or opening will be widening .

NOW the other group of muscles 5 muscles(controlling the vocal cords),They extend from thyroid cartilage all the way to the vocal process of Arytenoid cartilage.

1St Muscle ( crico thyroid ) :


It's going from the outside of cricoid cartilage all the way up to the lower part of thyroid cartilage. Now when this m. contracts as they go posterior and Superior for thyroid , it will pull the thyroid cartilage Anteriorly ,When you look in a superior View , you will see the vocal cords become tensing . So the cricothyroid m. once it's contracts , it will pulls the thyroid cartilage forward then the vocal cartilages will become tense .

The second Muscle 2nd ( thyro arytenoid m. ) :


This m. relaxing the vocal cords, working against the cricothyroid muscle, this m. located within the cricothyroid itself. Another name vocalis m. because it accompany the vocal cords (joining them together ). NOW. When this m. contracts , it will return the thyroid cartilages back once it moves back then the vocal cords become relax . Cricothyroid : tensing the vocal cords

Thyroarytinoid : relaxing the vocal cords

Two other muscles from the muscular process of Arytenoid cartilages ( 3rd and 4th)
one goes to the lateral side of cricoid we call it lateralcricoarytinoid muscle and the other that goes to the posterior surface of cricoid post. Cricoarytinoid muscle

NOW The post. Cricoarytinoid muscle once it contracts , it moves the muscular process back ward , so it will rotate the arytenoid cartilages to the outside by this , it widening the rima glottis and moving the vocal cords away from each other ( abduct the vocal cords ) . The lateral one which going to anterior , once it's contracts , it will rotate the arytenoid inside rather than outside , by this the vocal cord will become closer to each other , so it will add them to each other ( adducting the vocal cord ). Post. Cricoarytinoid Abducts the vocal cords. Lateral Cricoarytinoid Adducts

The last One (Tranverse arytenoid muscle):


Btw The Two arytenoids , going Transversely from the post. Surface of one arytinoid to post. Surface of other arytinoid . Once this muscle going transversely contracts , it will bring the arytenoid toward each other , so it will close the post. Part of rima glottis.

SO THESE ARE THE FIVE M. YOU HAVE TO KNOW THEIR ORIGION , INSERTION , NERVE SUPPLY , ACTION. FROM YOUR TEXT BOOK .

BLOOD SUPPLY TO THE LARYNX


We divide blood supply to the larynx based on the vocal cords above and below it .

- Above the vocal cords : blood supply come from the sup. Laryngeal artery ,
which is a branch from the sup. Thyroid artery. The Sup. Laryngeal a.: as it branches from sup. Thyroid a., it will penetrate thyrohyoid membrane to get inside the larynx, provide blood supply to everything in the larynx above vocal cords.

- Below vocal cords : Blood supply comes from the inf. Laryngeal a. which is a
branch from the inf. Thyroid a.

Nerve supply
Above the vocal cord: it comes from the internal laryngeal branch of the sup. Laryngeal branch of vagus nerve. Sensory and motor innervations for the larynx specifically is from the vagus nerve, but depend on which branch.. There are two nerves : Sup. Laryngeal n. : penetrating the larynx from above , it starts from the thyroid ends at cricoid . as you see , the vagus n. as it descends down . It will give sup. Nerve , we call it sup. Laryngeal n. that reach the larynx from above . Recurrent n. : as the vagus n. descends down toward the thorax it will give a returning nerve that can loop around Subclavian a. in the right , this is called recurrent laryngeal n. , in the left side it will turns around the arch of aorta in the thorax and return back from the thorax cross the root of the neck all the way to the larynx .

NOW when it return back on each side it will pass through a groove btw trachea ant. And esophagus post. Until it reaches the larynx.

Everything regarding innervations of the larynx sensory or motor is from vagus nerve but which branch of vagus
We have Sup. Laryngeal n. and a Recurrent laryngeal n. On each Side.

- The Sup. Laryngeal n. before it reaches the larynx it divides in to: - Internal laryngeal n.: one that go inside the larynx penetrating the thyrohyoid membrane to get inside the larynx, which is totally sensory n. for everything above vocal cord in the larynx . * External laryngeal n. : one that can't get inside the larynx , which is a motor n. that provide motor innervations to one muscle crico thyroid m.

-recurrent laryngeal n. will pass back and get inside the larynx , it will give sensation to everything below vocal cords and it will give motor innervations to the remaining muscles of the larynx.

NOTE
all muscles of the larynx are innervated by recurrent laryngeal n. except cricothyroid which innervated by external laryngeal n. And both sup. Laryngeal and recurrent laryngeal n. are branches from vagus nerve . (10th cranial n. )

This is every thing about the larynx read it carefully

Now we move to the other part of our lecture which is the pharynx
The pharynx - The pharynx is 3 times larger than the larynx . - The larynx is at the level C4-C5-C6 but the pharynx from the base of the skull behind the nasal cavity all the way down to the C6. The pharynx at the C6 will become esophagus . - So the pharynx extend behind the nasal cavity this part behind the nasal cavity we will call it nasopharynx , the part behind the oral cavity we will call it the oropharynx and the part behind the larynx we will call it the laryngeopharynx . -So the pharynx is much larger than the larynx, it's divided into 3 part : 1- Nasopharynx behind the nose 2- Oropharynx behind the mouth 3- Laryngeopharynx behind the larynx . When we look to the wall of the pharynx are deficient anteriority that make sense because they are opening to or communicated with the nose, mouth and larynx, However posteriorly and laterally it's made up of muscles those muscles with their tendon fibrous covering and muscular covering and they cover by mucus membrane . The pharynx is funnel shape it's very wide superiorly and very narrow inferiorly until it reach the esophagus .so the narrowest part of pharynx it's meet the esophagus inferior but the widest part most superior . Why it's funnel shape!! because it's made of 3 muscles, the 3 muscles are actually funnel shape we call them the constrictors of the pharynx (Superior , middle , inferior ). =>The constrictor muscles: They pass posterior superior , and overlap with each other in direction inferior to superior. The inferior constrictor cover the lower part of the middle constrictor.

The middle constrictor cover the lower part of superior constrictor. Anterior to each one there is an opening that's why the anterior wall is deficient. We cut opposite the nose, opposite to oral cavity and a cut opposite to the larynx . Now what's happing between these constrictor why it's made like this ! Because the (successive) sequential contraction of these 3 muscle will produce the action of swallowing , as will you swallow the food , the food bolus first when it get inside into the first part of pharynx the superior constrictor will contract once it contract the bolus will go down the middle will contract so pushing the bolus more down and the inferior will contract pushing the bolus of food into the esophagus producing the action of swallowing superior then middle then inferior that's why it's funnel shape because it's made of funnel shape muscle , 3 muscles that overlap each other and the main function is producing the action of swallowing . So the pharynx is made of 6 muscles. The main 3 ones that forming the pharynx actually complete wall of the pharynx are the constrictor (superior , middle , inferior ) , they run in a circular direction with their fibrous and they are attached posteriorly in one tendon so we call it the (pharyngeal tendon) or (pharyngeal raphe). The successive contraction of these muscle produce the action of swallowing (The contraction of the muscle the sup, middle , inf ) They overlap each other from inferior to superior . The other 3 muscles there attachment and origin: 1- The superior one usually originate from the medial pterygoid plate (Now u know why we have the medial pterygoid plate ) we have the narrow (medial) pterygoid plate and wide (lateral) pterygoid plate . The lateral pterygoid plate wider because we have 2 muscle of mastication attach to it lateral and medial pterygoid , but the medial pterygoid plate narrower because we have one muscle attach to it which is the superior constrictor of the pharynx , it's coming up form medial pterygoid plate from pterygomandiblular raphe.( it's a ligament extending from medial pterygoid plate (pterygoid hamulus) all the way down onto the posterior end of mylohyoid line on the mandible )

It's very important ligament in our practice because this ligament it's actually the origin of superior constrictor and also it's providing an attachment of another muscle of facial expression the buccinators , so this raphe provide an attachment laterally to buccinators muscle ( it's go all the way and enter the cheek fascia and skin ) and posteriorly to superior constrictor muscle . It's going from pterygomandiblular plate to the mandible (posterior end of mylohyoid line ) Pterygomandiblular raphe u can see it in oral cavity , back to the pterygomandiblular raphe should be the mucus membrane covering the superior constrictor and anterior to pterygomandiblular raphe the membrane covering the buccinators . Pterygomandiblular raphe is very important because it's your land mark to give the inferior dental bock Anastasia , when u gain a work in posterior teeth u have to Anastasias them , for filling and extraction (ID BLOCK Anesthesia) The ID block: is the Anesthesia that u give to inferior alveolar nerve before it enters into the mandible through the mandibular foramen, you anesthetize the whole nerve so the you can work on the whole teeth on this side getting the Anesthesia so this is called block the whole teeth .

Procedure of ID Block
you have to put the needle lateral to pterygomandiblular raphe because this is your mark line, and just put your finger( index) at the ramus of the mandible, So u have to put the needle lateral to pterygomandiblular raphe and medal to the anterior border of the ramus of the mandible . so that's why pterygomandiblular raphe is your key mark in the oral cavity for (ID block)because the needle have to be always lateral to pterygomandiblular raphe , which muscle u penetrating here ?? The buccinators , penetrating the buccinators passing all the way backward toward the medial surface of the ramus of the mandible .

The border of infratemporal fossa The lateral pterygoid plate and The ramus of the mandible.

In the infratemporal fossa the mandibular nerve will divide into 3 sensory branches: 1-The most anterior one : lingual nerve 2-The middle one: inferior alveolar nerve 3-The posterior one: auriculotemporal nerve

When we do ID block (inferior dental block) we anesthetize the inferior alveolar nerve before it inters to the mandible through the mandibular foramen .

Both Branches (the lingual and the inferior alveolar nerves ) are anesthetized by the ID block and thats why when we give ID block to the patient we ask him if he has Numbness on his tongue because it is an indication that the anesthesia is working on the inferior alveolar and the lingual nerve => So the proper way to do ID block : 1- insert your finger (index) and palpate the ramus of mandible and handle it. 2- tense the mucosa to make easier to find the Pterygomandiblular raphe 3- insert the needle always lateral to the outside of the raphe.
Recall that we have 3 muscles attached to the oblique line of the thyroid cartilage : 1- sternothyroid m. 2- thyrohyoid m.
3- inferior constrictor muscle

The Inferior constrictor muscle:


it is a very large muscle attached to the oblique line of thyroid cartilage and cricoids cartilage

* It consists from two parts : 1- The upper part : which arises from the thyroid cartilage , we call it thyropharyngeus and it helps in the swallowing process because it has a successive contraction . it's fibers are going upward and backward and involved in the swallowing 2- The lower part : Which arises from the cricoids cartilage , we call it cricopharengeus its fibers are going horizontally.

so once it contract it acts as a sphincter to make sure that the bullas of the food wont return back so once it contract it will close the pharynx preventing the food from regurgitation.

We can see a gap between the two parts (thyropharyngeus and the cricopharyngeas ) ; because of the difference in the fiberes direction of these two parts this small tearing will develop we call it Killains Dehisence

Killains Dehisence : - located in the inferior constrictor muscle . - week area presents between the two parts of the inferior constrictor muscle: sup : thyropharyngeus muscle. inf : cricopharyngeus muscle. - Clinical significant If the tearing was big the mucus membrane in some patient can protrude in this gap and make a pouch there (pharyngeal pouch ) so sometimes the very smooth food can stick there producing uncomfortable feeling and difficulty in swallowing dysphasia So these are the main 3 muscles in the pharynx whose fibers run in a circular direction , and we still have to talk about the other 3 muscles whose fibers run in a longitudinal direction and these are ( stylopharyngeus , salpingopharyngeus and the palatopharyngeus ) .

4- stylopharyngeus : -Arises from styloid process all the way to the posterior border of the thyroid cartilage . - passes between two muscles which are the (superior constrictor and middle constrictor). Innervated by the glossopharyngeal nerve. All the muscles of the pharynx are innervated by the pharyngeal plexus which is a network of nerves formed by cranial nerves IX,X,XI ( glossopharyngeal (sensory) / vegus(motor)/ accessory respectively ) EXCEPT: Stylopharyngeus muscle which is innervated by the glossopharyngeus #9 only .

Gag reflex : when we work on the posterior teeth and touch the soft palate or when we try to place a denture once we try to touch the posterior part of the oropharynx we will induce an irretation there , this irretation will induce sensory signals in the glossopharyngeal nerve these signals now will go to the vegus as an action potential inducing contractions there ( in the constrictor muscles ) but this contraction will be inverted so the inferior constrictor will contract first then the middle then the superior one pushing upward not downward .
Remember: All the muscles of the larynx are innervated by the recurrent laryngeal nerve except the cricothyroid which innervated by the external laryngeal nerve .

5- palatopharyngeus : Extend from the soft palate (palatal aponeurosis) to the posterior border of the thyroid cartilage . Part of the palate and the pharynx . The palatopharyngeus is covered by a mucus membrane to become palatopharyngeus fold which demarcating the posterior end of the tensile bed .

6- salpingopharyngeus : Descends from the medial end of the Eustachian tube ( auditory tube) all the way down to be merge with the palatopharyngeus muscle .

Action : Once it contract it opens the pharyngeal orifice ( for the auditory tube ) so the air can pass to the middle ear to balance the pressure on both sides on the tympanic membrane . Auditory tube : A tube that communicates with the pharynx all the way posteriolaterally with the middle ear .

Forgive us for Any mistake wish you all the best in the exam.( Study well) Happy Easter for you guys <3 Enjoy it with Head&Neck Done by : Ramz rabadi Areej ra2ed

Edited by C.W.T Happy Easter