Head and Neck Anatomy Lecture#22 Hi all, it is my pleasure to write again for our class.

In the previous lecture Dr. Allouh talked about the larynx and its relation with the trachea. In this lecture, we will cover the fundamentals in addition to the details concerning the pharynx and its relation with the esophagus. Briefly explained, the pharynx has a cone like appearance or is funnel shaped. That is why it is wide superiorly and is narrow inferiorly. This cone or funnel is made of skeletal muscles and fibrous tissue that extends from the base of the skull moving all the way inferiorly to merge with the esophagus at the level of C2. It is important to note that the pharynx is much larger than larynx. Keep in mind that we have previously mentioned that the larynx is located along C4, C5 and C6 only. Firstly, the pharynx is divided into 3 main regions: 1- Nasopahrynx: it is the part posterior to the openings of the nasal cavity that we refer to as the nasal part of the pharynx. 2- Oropharynx: it is the area posterior to oral cavity located behind a narrow passage that we call Oropharyngeal Isthmus. 3- Laryngopharynx: it is the part posterior to the opening or inlet of the larynx. REMEMBER that all of these parts are continuous with each other.

Secondly, the formation of the pharynx is: 1- It has no anterior boundary because it communicates with the oral cavity, nasal cavity and larynx from the front.

2- Laterally and posterioraly is made of skeletal muscles that fuse

together and form a fibrous band that we call the pharyngeal raphe. They are covered by a mucous membrane of epithelial cells. These skeletal muscles contributing to the pharynx are six in number: - Three of them are the constrictors of the pharynx. They pass in a circular way forming the wall (tube) of the pharynx. - Three of them are smaller and more vertical. They function in elevating the pharynx. Lets talk about the main three skeletal muscles namely the constrictor muscles. The first is the superior constrictor which is the highest. The second is the middle constrictor which is in the middle. The third is the inferior constrictor. The main function of the constrictor muscles is that of swallowing. They propel food down into the esophagus. (You must know the insertion, origin, innervations, and function). The constrictor muscles work as follows: the superior constrictor contracts, pushing the soft palate to the posterior wall of the pharynx preventing food from going up. So food goes from the oral cavity downwards rather than upwards. The middle constrictor contracts causing the food to move more inferiorly. Then the inferior constrictor contract expelling the food into the esophagus. These muscles overlap each other from the bottom to the top. The inferior covers the lower part of the middle, and the middle covers the lower part of the superior > eventually forming a funnel. Thats why they all work in a coordinated way. The superior constrictor is attached anteriorly to the medial pterygoid plate (narrower than lateral pterygoid because 1 muscle is attached to it).Also it is attached to a ligament that extends from the pterygoid process (humulus) to the end of mylohyoid line of the mandible that we call pteryo-mandibular raphe. It is very important in dentistry; this ligament (raphe) forms the boundary or the border line where you do the ID block anesthesia to the inferior alveolar nerve. First you have to determine the anterior border of the Mandibular Ramus, and then you insert the needle lateral to the pterygo-mandibular raphe. REMEMBER lateral to the pterygo-mandibular raphe. - The middle constrictor is attached to the lower part of stylo-hyoid ligament and greater horn of hyoid bone.
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The inferior constrictor muscle is very large muscle it has 2 important attachments: A-the upper attachment is to the oblique line of thyroid cartilage which also is a place where the sternothyroid and thyrohyoid are attached. This muscle is referred to as the thyro-pharyngeous muscle. B-Inferiorly, it is attached to cricoid cartilage (the lower part of thyroid cartilage). We refer to it as crico-pharyngeous muscle. The thyro-pharyngeous muscle fibers are directed upward to facilitate the action of swallowing, while the crico-pharyngeous muscle fibers are directed horizontally in a circular way. Accordingly, it doesnt help in swallowing but act as an esophageal sphincter preventing food from going backwards. There is a very small space located at the junction of these 2 muscles. This space is referred to as dehiscence and it represents a point of weakness because in this region the fibers of the 2 muscles change their direction: one goes upwards and the other goes horizontally. For example, when you are very hungry to the point where you will eat anything, and then you find a big dish of Mansaf covered with a mountain of meat, you will throw the food in your mouth without chewing it. While you are overwhelmed with joy eating meat, this delicious piece of meat reaches this area and it will exert a big pressure on it. Eventually, the mucous membrane penetrates this area and produces a pouch we refer to as pharyngeal pouch. In the end you will still be hungry, not just that, but also with time this pouch will accumulate food in it leading to dysphagia. So try to eat slowly especially Mansaf.
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The other three muscles are: 1- stylo-pharyngeus: it extends from the posterior part of the styloid process to posterior border of thyroid cartilage (the largest cartilage that contributes to the larynx). Also it passes in the gap between the 2 constrictor muscles; the superior and inferior ones. It is innervated by the Glossopharyngeal nerve.
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* There are gaps between the constrictor muscles where different structures can pass through like nerves, muscles, blood vessels, etc... All the pharyngeal muscles are innervated from the pharyngeal plexus mainly from the vagus and cranial root of accessory nerves except stylopharyngeus muscle. As you can observe that in every region there is an exception, for example in the tongue area all the muscles are innervated by the hypoglossal nerve except one the palatoglossus muscle it is innervated from the pharyngeal plexus. Another example is the muscles of the palate which are all innervated by the pharyngeal plexus except one; the Tensor Palatini. The Tensor Palatini is innervated by the mandibular nerve. Do you ever wonder why these exceptions happen? - Because of the different developmental origins of these muscles. 2-Palato-pharyngeus: it extends from the soft palate (palatine Aponeurosis) all the way to the posterior border of thyroid cartilage. It is covered by a mucous membrane that we call the palato-pharyngeal fold which demarcates the posterior border of palatine tonsils. 3- Salpingo-pharyngeus: it is a tiny muscle that extends from the medial end of the auditory tube or Eustachian tube (which is a tube that connects the middle ear to the nasal part of the pharynx) and merges with palato-pharyngeous muscle. This muscle is covered by a fold of mucous membrane that we call salpingo-pharyngeus fold. If you mistakenly go to the lab you will see it. *We are finished with the formation of the pharyngeal wall and now we are going to speak about the cavity. As we said, it has three main parts. In this section, were going to speak about them in details:
1- Naso-pharynx: it is posterior to the nasal cavity and superior or above

the soft palate. It is lined by respiratory epithelium because it is a passageway for air only. It contains many structures: A-Eustachian tubes open into the lateral walls of the nasopharynx. They are used to equalize air pressure within the middle ear and the tympanic membrane. B- Aggregation of lymph nodes which are covered by a tubal elevation we call them tubal tonsils because they are located around the opening of the Eustachian tube. C- Pharyngeal or adenoid tonsils and they are found at the roof of the nasopharynx.
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In the Oropharynx we have the linguinal tonsils and the palatine tonsils (the most common to be inflamed) These 4 groups of tonsils form a ring we call it the Wilder tonsil ring (not sure!!), and they are the first line of defense against microbes because they are found at the area exposed to the outside environment. 2-Oro-pharynx: is located posterior to the oral cavity at the level of C2 and C3 and opens into it by the oropharyngeal Isthmus. It located between the soft palate superiorly and the posterior third of the tongue inferiorly along with the Valleculae (the depression between the epiglottis and the posterior third of the tongue and at the mid line it turns into an elevation we call it Glosso-epiglottic fold of mucous membrane), they help in preventing sharp objects from being swallowed like fish bone, and they contribute to floor of the Oro-pharynx. It contains: o Palatine tonsils: they are usually found between the Palatoglossal fold (it covers the Palatoglossus muscle) and Palatopharyngeal fold (covers the Palatopharyngeus muscle). These 2 muscles are innervated by the pharyngeal plexus. So it is between the palatoglossal and palatopharyngeal folds and located over the superior constrictor muscle. The area where these tonsils are located is called the tonsillar bed. In this bed you can see the tonsillar artery (branch from Facial artery) and the Peritonsillar vein. *What are the Boundaries of the Oropharyngeal Isthmus? (This question must be answered by each student individually) Thats what Dr.alloh said! But there is no harm in cooperation sometimes. So here is the answer: Anteriorly: the posterior 1/3 of the tongue Posteriorly: the pharyngeal palatine and it is covered by the Palatoglossus and Palatopharyngeus muscles which act in narrowing this isthmus. -Boundaries of the palatine tonsils: Anteriorly: the Palatoglossal fold. Posteriorly: the Palatopharyngeal fold. Posterior superior: the soft part of the palate.

Inferiorly:

posterior 1/3 of the tongue Medially: the Cavity of Oro-Pharynx. Laterally: the superior constrictor muscle. Tonsillitis: It is the inflammation of the palatine tonsils. Usually it is the inflammation of any tonsil there, but generally the main ones to be inflamed are the palatine tonsils. Tonsillectomy: it is the removal of the palatine tonsils. Adenoiditis: it is the inflammation of the Pharyngeal tonsils. 3-Laryngo-pharynx: it extends from the epiglottis to the cricoids cartilage at the level of C4, C5 and C6 (same as larynx), and it is lined with digestive epithelium. It contains important structures: a- The piriform fossa (recess): it is a recess (depression) on each side of the laryngeal inlet; it is bounded laterally by thyroid cartilage and medially by aryepiglottic fold. It functions in preventing sharp objects from being swallowed like fish bone. b- The Internal laryngeal nerve: it is a branch from the vagus nerve, it innervates the larynx (sensory), usually pass in the piriform fossa just beneath its mucous membrane. It is very dangerous and sensitive area because any sharp object that tears this mucous membrane will lead to injury in the internal laryngeal nerve. **Reminder of some innervations: I. Nasopharynx innervated by maxillary nerve (sensory)

II. Posterior of the tongue and Oropharynx innervated by glossopharyngeal nerve (CN#9). III. Larynx innervated by the vagus nerve(CN#10) All muscles of the pharynx are innervated (motor) by the pharyngeal plexus except STYLOPHARYNGEUS.
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Gag Reflex: it happens between the posterior 1/3 of the tongue and the Uvula, and it involves both motor and sensory innervations of the Oropharynx. First, sensory stimulation of the Pharyngeal mucosa by the glossopharyngeal nerve , then this stimulation goes all the way to the brain which in turn gives signals through the cranial root of accessory and vagus (by the way we dont have something called cranial root of accessory only spinal root of accessory). This signal is received by the pharyngeal plexus where it orders the pharyngeal muscles to contract, specifically the constrictors which in the end results in Gag reflex. Simply if you put your finger inside your mouth pushing it all the way inside to reach the posterior 1/3 of the tongue you will achieve the Gag reflex. Relations of the pharynx: o Posteriorly: Retropharyngeal space, along with the privertebral fascia of deep cervical fascia. o Anteriorly: Nasal cavity, Soft palate, Oral cavity, posterior 1/3 of the tongue, epiglottis and the laryngeal inlet. o Laterally: The Carotid sheath

***The following is very important so study it well. -Pharyngeal gaps and the structures that pass through them:
Above the superior constrictor there are 2 muscles of the palate which

are the Tensor veli Palatini and Levator veli Palatini. They both extend from the base of the skull. Also we have the Eustachian tube and an artery. Do you know what we call it?!(This is also a question that you must answer by yourselves. Doctor Allouh said: If I dont give you homework to do you will never find it so apparently Im the one who should do the homework. Dont I deserve extra credit?). Here is the answer:

Ascending palatine artery. It divides near the levator veli palatini muscle into two branches: one follows the course of this muscle, and winding over the upper border of the superior pharyngeal constrictor, supplies the soft palate and the palatine glands, anastomosing with its fellow of the opposite side and with the descending palatine branch of the maxillary artery; the other pierces the superior pharyngeal constrictor and supplies the palatine tonsil and auditory tube, anastomosing with the tonsillar branch of the facial artery and the ascending pharyngeal artery. Between the superior and middle constrictors passes the stylopharyngeus muscle and the glossopharyngeal nerve. Between the middle and the inferior constrictors we have the superior laryngeal artery that provides blood supply to the upper half of the larynx, which is a branch of superior thyroid artery. Also we have the internal laryngeal nerve a branch from the vagus nerve. Below the inferior constrictor we have the returning blood vessels and nerves of the larynx. Which nerve gives innervations to the lower half of the larynx? The recurrent laryngeal nerve that passes between the trachea inferiorly and the esophagus posteriorly, and we have the inferior laryngeal artery that provide blood supply to the lower half of the larynx, which is a branch of inferior thyroid artery. You MUST know these relations because we will be asked about them for sure! The End
Please allow me this opportunity to share with you a unique story that I like. The reason why I would like you to consider this brief yet meaningful story is this: Failure is the road to success. What do I mean by that? I dont mean go and fail all of your exams. This story will illustrate what I exactly mean: Thomas Edison, the inventor of the light bulb, was asked by a reporter after 1,000 unsuccessful attempts at inventing the light bulb How did it feel to fail 1,000 times? Edison replied I didnt fail 1000 times. I have eliminated 1000 ways, combinations and elements that did not work. Thanks to all my friends especially Fadya, Suzan, and Heba. Thanks to Mutaz and Aya sawalmeh for their hard work.

Done by: Tarek Salfity

Edited By: #11

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