The Pharynx

Pharynx
The pharynx is 3 times larger than the larynx A funnel shaped fibromuscular tube extends from the base of skull & continues below with esophagus at the level of C6

Divided into 3 parts: Nasal: nasopharynx behind the nasal cavity Oral: oropharynx Behind the oral cavity Laryngeal: laryngeopharynx behind the larynx

Walls of Pharynx
Ant. : deficient communicates with the nose, the mouth and the larynx Lat. & Post. Walls: 1. mucous memb. 2. fibrous covering 3. Muscles

Muscles of Pharynx

(Read your text for origin, insertion, innervation & action of these muscles)
6 Muscles 3 constrictors: Sup., mid. & inf. - Run in circular direction & attached post. to pharyngeal raphe - The successive contraction of these muscles produces the action of swallowing Overlap each other in the direction of inferior to superior ( the inferior constrictor is covering the lower part of the middle constrictor and the middle constrictor is covering the lower part of the superior constrictor )

Additional slide
- The superior constrictor originate from the medial pterygiod plate and pterygomandibular raphe ( a ligament extending from the medial pterygoid plate the pterygoid hamulus all the way down to the posterior end of mylohyoid line on the mandible ) - The pterygomandibular ligament is a very important ligament in the dental clinical practice ( the origin of the superior constrictor muscle ) also providing an attachment for the buccinator muscle, because its the landmark to give the inferior dental block anaesthesia ( to anaesthesize the inferior alveolar nerve before it enters the mandible through the mandibular foramen ) , you have to but the needle lateral to the pterygomandibular raphe and medial to the ramus of the mandible ( you penetrate the buccinator muscle ), the needle can be inserted even to 2.5 cm because its a gap area - The pterygomandibular ligament providing attacments ( anteriorly to the buccinator muscle and posteriorly to the superior constrictor muscle)

Additional slide
The borders of the infratemporal fossa are the ramus of the mandible and the lateral pterygoid plate - In the infratemporal fossa the mandibular nerve will divide : - the most anterior branch lingual nerve - in the middle the inferior alveolar nerve - the posterior one the auriculotemporal nerve - Those are the three sensory branches of the posterior division of the mandibular nerve - You actually anaesthesize the ( inferior alveolar and the lingual nerves) , thats why when you give ID block always youll ask the patient if he has parasthaesia on the side of the tongue, this is an indication that the anaesthesia is working - You have to insert your finger to touch the ramus of the mandible and tense the mucosa ( to be very easy to find the pterygomandibular raphe )

Additional slide
The middle constrictor arises from the stylohyoid ligament and part of the greater horn of the hyoid bone The inferior constrictor ( the largest one ) arises from the oblique line of thyroid cartilage and from the cricoid cartilage 3 muscles are attaching to the oblique line those are : sternothyroid, thyrohyoid, and the inferior constrictor The upper part of the inferior constrictor muscle ( which arises from the oblique line ) , we refer to it as thyropharyngeus muscle and its helping in the action of swallowing The lower part of the inferior constrictor which is more horizontally going and arising from cricoid cartilage, we refer to it as cricopharyngeus The cricopharyngeus fibers once they contract they act as a sphincter, closing the pharynx and preventing the food from regurgitation

Killians Dehiscence
Dehiscence = gap Inferior constrictor m. consists of 2 parts: - Sup.: thyropharyngeus - Inf.: cricopharyngeus * A weak area presents between The 2 parts of inf. constrictor m. The clinical significance of Killians dehiscence : m.m. may protrude giving rise to a pharyngeal pouch sometimes, the very smooth food can stuck there producing uncomfortable sensation and difficulty in swallowing ( dysphagia )

3. Stylopharyngeus m.: styloid process post. Border of thyroid cartilage pass between superior and middle constrictor muscles Innervation : pharyngeal plexus 4. Palatopharyngeus m.: Palatal apon. post. Border of thyroid cartilage Palatopharyngeal fold 5. Salpingopharyngeus m.: Auditory tube (medial end) Salpingo = tube Blends with palatopharyngeus - Once it contracts it helps in the openinng of the pharyngeal orrifice for the Eustachian tube so the air can pass to the middle ear to balance the pressure on both sides of the tympanic membrane

*All of these muscles help elevate the pharynx

All the muscles of the pharynx are innervated by the pharyngeal plexus except (the stylopharyngeus muscle - by the glossopharyngeal nerve) The pharyngeal plexus is a network of nerves formed by the cranial nerves IX, X and XI ( glossopharyngeal, vagus and accessory nerves ) on the wall of the pharynx The motor innervation to all muscles of the pharynx is from the pharyngeal plexus ( mainly from the vagus nerve ) Sensory supply - mainly glossopharyngeal In the gag reflex, when we work on the posterior teeth or when you try to place a denture, the patient tries to vomit once you touch the posterior part ( the oropharynx ) or the soft palate ( the roof of the oropharynx ), this touching will induce irritation this irritation will induce sensory signals in the glossopharyngeal nerve, from there this signal will go to the vagus nerve which will induce contraction in the constrictor muscles through the pharyngeal plexus, but this contraction will be opposite ( the inferior then the middle then the superior ) so they will push upwards rather than backwards

Nasopharynx
Post. To nasal cavity & above the soft palate Lined by respiratory epithelium Contains: - auditory tube: opens into the middle ear On the lateral walls of the nasopharynx - Tubal tonsil: aggregation of lymph nodules around the auditory tube - the microorganism can pass through the tube into the middle ear producing ( otitis media ) - Tubal elevation & Salpingopharyngeal fold

- Pharyngeal tonsil (adenoid): in the submucosa of the roof of the nasopharynx

Oropharynx
Post. To oral cavity & opens to it Through oropharyngeal isthmus Between the soft palate superiorly and the posterior 3rd of the tongue inferiorly At the level of C2 and C3 The floor is made by: post. 1/3 of tongue & the valleculae Contains: Palatine tonsils: between palatoglossal and palatopharyngeal folds over sup. Constrictor m. tonsillar bed

Oropharyngeal isthmus & Valleculae

Relations of Palatine Tonsils

Ant.: palatoglossal fold

Post.: palatopharyngeal fold

Sup.: soft palate

Inf.: posterior 3rd of the tongue

Medially: the cavity of the oropharynx Laterally: superior constrictor muscle

Tonsillitis & Tonsillectomy

Tonsillitis: inflammation of the tonsils (palatine) Acute (causes virus : EBR, influenza virus, herpes simplix virusthe tonsils are swollen and reddish lasts for a short period of time fever, sore throat & dysphagia) Vs. Chronic (cause bacterial ( hemolytic streptococcus group A in the thorax causes endocarditis) treatment : antibiotics ( most common : amoxycillin if the patient is allergic to penicillin he is given erythromycin) with pain relief ) - Acute : 6 days , chronic : can last for 3 weeks Tonsillectomy: removal of palatine tonsils * Some argue that tonsilectomy is unnecessary surgery & may be dangerous because: you remove one source of immunity Others argue that chronically inflamed tonsils are a site of recurrent infection. Inflammation of pharyngeal tonsil adenoiditis

Laryngeopharynx
From epiglottis to cricoid C. At vertebral level C4, C5 & C6 Lined by stratified squamous epithelium Contains: Piriform fossa ( Piriform = pear shaped ) A small depression or recess on each side of the laryngeal inlet

Piriform Fossa
A small recess (depression) on Each side of laryngeal inlet Bounded: Med.: qudrangular membrane Lat.: thyroid cartilage Fxn. : prevent swallowing of sharp and foreign objects

* Internal laryngeal n. pass In the fossa just beneath the m.m.

Innervation of The Pharynx

Sensory: Naso: maxillary nerve (V2) Oro: glossopharyngeal Laryngeo: vagus Motor: Pharyngeal plexus to all muscles of pharynx Except stylopharyngeus

Gag Reflex
Involved both sensory & motor innervations of pharynx working together Sensory stimulation of pharyngeal mucosa (via IX)

Contraction of pharyngeal musculature (from XI via X to pharyngeal plexus)

Relations of The Pharynx

Post.: retropharyngeal space & prevertebral fascia Lat.: carotid sheath IX Ant.:
1. 2. 3. 4. 5. 6.

Pharyngeal Gaps
4 gaps Above sup. Constrictor m.: Eustachian tube, ascending palatine artery ( branch from the facial atrery ), tensor velli palatine muscle, levator velli palatine muscle Between sup. & mid. Constrictor m.: stylopharyngeus muscle, glossopharyngeal nerve Between mid & inf. Constrictors: superior laryngeal artery, internal laryngeal nerve Below inf. Constrictor: inferior laryngeal artery, recurrent laryngeal nerve - Those gaps allow for structures to pass inside and outside of the pharynx

Above Sup. Constrictor M.

Waldeyers Tonsillar Ring

Pharyngeal Tonsil: single, roof of nasopharynx Tubal Tonsils: on lat. Walls of nasopharynx

Palatine Tonsils: on lat. Walls of oropharynx

Lingual Tonsil: single, floor of oropharynx (posterior 3rd of the tongue )

Done by : Muad Al-Zoubi Best wishes