PHARYNX, LARYNX, TONGUE AND PALATE PHARYNX o Pharynx is imusculomemiranous tube that extands from the bese of skull to the level of the sixth cervical vertebra, where itis continuous with esophagus. Pharyox is subdivided into 1) Nasopharynx Pert ofthe pharynx above the soft palate, ie from the bas of skull tothe soft palate™” 2) Oropharyns:-Extends fom the soft palate superotiy to the level of hye inferiorly 3) Hypopharymx - The hypopharynx includes thet portion ofthe pharynx below the level ofthe hyoid Nasopharynx 0 Tes the part of pharynx which tes behind the nose above the level of soft palate”. differs from the oral (oropharym) and laryngeal part hypepharynx) in thats cavity always remains patent. Boundaries ofnasopharynax ) Roof Basisphenoid & basioceipat i) Floor = Soft palate anteriorly; deficient posteriorly (nasopharyngeal istamus) through which nasopharynx communicate with oropharynx. ii) Posterior wail C1 vertebra wit prevertebral muscles and fascia iv) Anterior wal = Choanae ¥)_ Lateral wall - Pharyngeal opening of Eustachian tabefs situated 1.25 em behind the posteriar end of inferior turbinate°£s0, js bounded above and behind by an elevation called torus tubaris, ehind which i a recess called fossa of rosenmullar. Fossa of Rosenmullar corresponds to internal carotid nrtery"™"”, Shape and contents of nasopharynx 9 Nasopharynx can be divided into two sections or chambers: 2 Upper chamber = Large rectangular or ovoid (ovaly*9 a Lower chamber» Tubular 6 Contents of nasopharynx are: |) Adenoids / Nasopharyngeat tonsi!: Subepthelat collection of lymphoid tissue atthe junction of tof and posterior wall of nasopharynx ')Nasopharyngeat Bursa: Epithelial lined median recess extending fiom pharyngeal mucosa to the periosteum of basioccipt. Represens attachment of notochord to pharyngeal endoderm during embryonic life. Abscess of this bursa is called as Thornwald’s disease. i) Rake pouch : Reminiscent of buecal mucosa invagination to form the anterior lobe of pituitary. Represented bya dimple above adenoids 'v) Sinus of Morgagni : Space between base of skull and upper border of superior constrictor muscle, Through this pass auditory tube", levator patati muscle"*™ and ascending palatine artery © Oral par of pharynx reaches from the soft palate othe level ofthe hyoid bone. Major structures ofthe oropharynx are the palatine tonsils, soft palate and tongue base™™, Boundaties of oropharynx are i) Posterior wall Related 10 retropharyngeal space and lies opposite the C, & C, vertebrae. 8) Anterior wall: tis deficient above, where oropharynx communicates with fe oal cavity. Below anterior wall 2) Base of tongue b) Lingual tonsils 6). Valleclue cup shaped depression between the base of tongue and anterior suftee of epiglonts) ii) Lateral wall I presents - a) Palatine (faucial) tonsil ) Anterior pillar (palatoglossal arch) formed by the palatoglossus muscle ©). Posterior pillar (palatopharyngea ach) formed by the palatopharyageus muscle Hypopharynx (Laryngopharynx) © Laryngopharynx or laryngeal part of pharynx reaches from the hyoid bone to the lower border of ericoid cartilage, when itis continuous with the esophagus. Hypopharynx lies opposite the 3rd, 4th, 5th, 6th cervical vertebrae, Clinically, hypopharynx is subdivided into three regions :- 1) The pyriform sinus(? este 5D ji) Post-cricoid region’. ste iil) The posterior pharyngeal walt "saucy Jes of PI 1 Pharynx has two group of muscles =PHARYNX, LARYNX, TONGUE AND PLATE [297] 1) Imtrinsic museles :- Stylopharyngeous, salpingopharyngeous, palatopharyngeous. 2). Extrinsic museles :- Superior constrictor, middle constrictor, inferior constrictor. © All mascles of pharynx are supplied by cranial accessory through branches of vagus via pharyngeal plexus except stylopharyngeus which is supplied by glossopharyngeal’ x7, © Inferior constrictor muscle has two parts: i) Thyropharyngeous with oblique fibres, and ii) Cricopharyngeous with transverse fibres. © Between these two parts of inferior constrictor exists a potential gap called Killan’s dehiscencet25", 11s also called the gateway 10 tear as perforation can occur at this site during esophagoscopy. It is also the site for herniation of pharyngeal mucosa in case of pharyngeal pouch. © Upper fibers of palatopharyngeus!"**."” constitute the Passavant's muscle” which on contraction raises a ridge called Passavant’s ridge'2 on posterior wall of nasopharynx, Gaps between pharyngeal maseles and structure passing through them ‘A) Between te base of skull and superior constrictor, i. above superior constrictor (Sinus of Morgagai) Levator veli palntini”°", auditory (eustachian) tube*"955?, Ascending palatine artery"°™, B) Between middle and superior constrictors :- Stylopharyngeus muscle, Glossopharyngeal nerve. ©, Between middie and inferior constrictors -- Internal laryngeal nerve, superior laryngeal vessels. D) Between inferior constrictor and esophagus (below inferior constrictor) :- Recurrent laryngeal nerve, inferior laryngeal vessels Waldeyer’s ring of lymphoid tissue © Waldeyer’s ring refers to the group of lymphatic organs that “guards” the oropharynx and nasopharynx in a roughly circular pattem, providing surveillance for pathogens or other foreign materials and mounting a defensive immunoresponse. © The right and left paladine ronsily™% 4%" attr Kook 9 fora tae most conspicuous parts ofthe waldeyer’s ring. The ring is completed below by the Jingual tonsils and above by pharyngeal tonsils #2599 (adenoids) and tubal fonsty 3 Se, ince the respiratory and oral cavities may be a site of entry for many pathogens, waldeyer’s ring maintains surveillance inthis critical region and is able to initiate the immune response before the pathogens invade deep into the body. TONSILS (PALATINE TONSIL, OR FAUCIAL TONSIL) © Palatine tonsils are masses of lymphoid tissue that can be seen on the left and right sides at the back of the throat. ‘There are two palatine tonsils, and each palatine tonsil (right or left) lis in the consilar sinus (tonsilar fossa) on the lateral wall of eropharynx. Tonsillar fossa bounded by the palacoglossal fold in front and the palatopharyngeal ‘fold behind. Tonsils are lined by non - keratinized stratified squamous epithelium 22-10, Medial surface ‘of each tonsil has 15-20 crypts, the largest of which is called Zntratonsillar cleft or crypta magna (which represents persistence of the ventral portion of the second pharyngeal pouch), 9 The plica triangularis#2° js a fold of mucous membrane covering the anteroinferior part of tonsil=2; Plica semilunaris is semiunar fold that may cross the upper part of tonsilar sinus © Tonsillar bed is formed from within - outwards by :- 1 Pharyngobasilar fascia Superior constrictor (above) 4" "1." and palatopharyngeus muscle @ Styloglossus (below) a Buccopharyngeal fascia Blood supply of tonsils The tonsil is supplied by five arteries :- 1) Tonsitiar branch of facial artery. Thisis the main artery‘, 2) Ascending pharyngeal artery from external carotid. 3) Ascending palatine", a branch of fcial artery. 4) Dorsal tinguae!™S branches of lingual artery, 5) Descending palatine branch of maxillary artery. Nerve supply of tonsils © Lesser palatine branches”: of sphenopalatine ganglion and glossopharyngeal nerve (major supply)2"" £7. provide sensory nerve supply (othe tonsils. Glossopharyngeal nerve also gives sensory supply to middle earPHARYNX, LARYNX, TONGUE AND PLATE [298] (rough tympanic plexus). Therefore, pain from the tonsils can be referred to middle ear along glossopharyngeal hnervel™¥9% 07 faa), Lymphatic drainage © Lymphatics pass to jugulodigastr desir0 arn a7 059 (upper deep cervieal nodes”), Development © The tonsil develops from ventral part of second pharyngeal pouch 10-0, LARYNX 0 The lary is situated atthe crossroads of the air and food passages. It must serve not only asa conduit for air and ‘vaste gases to and from lungs but also asa valve to prevent the passage of secretions, of food and of other foreign ‘nateril into the upper respirstony tract. Larynx also serves as an organ of communication, therefore it isalso referred a5 organ of voice. Anatomy of adult larynx } The larymx is situated infront ofhypopharynx opposite to third to sith cervical vertebrae! and ends at the lower border of C6 vertebrae inaduls 6 The skeletal supports of larynx is provided by Six earlages, 3 ont of which are paired™**E"® (so there are total 9 cartilages!) + Thyroid, crieoid “Y*7™, epiglotts. i) Paired™!%§™ 5. Arytenoid®”*"*”, Cornieulate™”*¥#9.r010, co Larynx is larger in males than females. meiform 2.6099 Important features of individual laryngeal cartilages ‘Thyroid (unpaired) 6 It's the Zargest of all laryngeal cartilages. It is ‘Y” shaped with right and left lamina, Both laminae (alae) meet anteriorly forming an angle of 90° in males and 120” in females and forms laryngeal prominence", Vocal ‘cords are attached to the midale of thyroid angle. Upper border of thyroid cartilage lies at C.-C junction™=2 (at upper border of C2), Thyroid cartilage itself lies at C-Cs level, (Cricoid (unpaired) It is the only cartilage forming a complete ring ™*:", therefore is shaped like a ring. It articulates with arytenoid cartilage to form cricoarytenoid joint, a type of synovial joint, Ilies atthe level of Ce vertebra Zi? Epiglotts (unpaired) ‘o Itis eaf-shaped clastic cartilage (in adults). Itis omega shaped in children. I forms the anterior wal of faryngeal inlet. Itlies above glotis™=™, Arytenoid cartilage (paired) ‘9 Each Arytenoid cartilage is pyramidal in shape. Base articulates with cricoid cartilage, and apex supports the comiculate cartilage. A vocal process directed anteriorly and gives attachement to vocal cord. A muscular process directed laterally and gives attachment to intrinsic laryngeal muscles Corniculate cartilage (of Santorini) : Paired 9 Anticulates with apex of Arytenoid cartilage (Cuneiform cartilage (of Wrisberg) : Paired © Situated in aryepiglotic fold in front of comiculateeartitage. Histology of laryngeal cartilages : ‘Hyaline cartilages Elastic cartilages (do not ossify) © Thyroid eartilage’™”? o Etioglottisaucr rare © Cricoid cartilage”? © Cornieulate’™™? 9 Basal part of arytenoid cartilage © Cuneiform 9 Processes of arytenoid Muscles of larynx ‘9 Larynx has two types of muscles. ')_ Intrinsic muscles : Confined entirely to the larynx, ‘i)_ Extrinsic muscles : ~ Pass between the larynx and other structure around the larynx, Intrinsic muscles 1 Intrinsic museles act on vocal cord or laryngeal inlet.PHARYNX, LARYNX, TONGUE AND PLATE [299] 4) Acting on vocal eords Abductors (opening of glotis) Posterior ericoarytemoid! soe a ‘Adductors (Closure of glottis ™") jeoarytenoid’™™5"010.07 Tnterarytenoid (transverse arytenold™7) ‘Thyroarytenoid ™*® (external part) Cricothyroid™” Cricothyroigso Vocals (internal pat of thyroarytenoid) Tensors b)Acting on laryngeal inlet Openers of laryngeal inlet: Thyroepigiottic (part of thyroarytenoidy"™™ Closers of laryngeal inlet: Interarytenoid (oblique part), Aryepiglottc (posterior oblique part of interarytenoids), Extrinsic muscles ‘© These muscles connect the larynx to neighbouring structures. The muscles are : - Elevators : Primary elevators act directly as they are attached tothe thyroid cartilage and include stylopharyngeus, salpingopharyngeus, palatopharyngeus and thyrohyoid"* %822, Secondary elevators act indirectly as they are attached to the hyoid bone and include mylohyoid22 (main), digastric", stylohyoid’“"™, geniohyoid, b)Depressors : They include stemohyoid, sternothyroid“"** 2 and omohyoid. aments/Membranes of Jaryax ‘0 Membranes/Ligamonts of larynx can be divided in to two groups :- ) Extrinsic: - On outer surface of the larynx. ii) Intrinsic :~ Inside the larynx: Extrinsic igaments/membranes ‘o These membranes/ligaments connect the laryngeal cartilages and epiglotts to neighbouring structure. a Thyrohyoid membrane (Thyroid cartilage to hyoid bone) |) Lateral thyrohyoid ligament“! i) Median Thyrohyoid ligament“ 2 Hyoepiglottic ligament “ (Epiglotts to body of hyoid). 2 Cricotracheal membrane “' (Cricoid tothe firstring of trachea), Greater horn ‘Superior nom: “Thyroid catage — Inferior nor Gricotrachoal igamont] = 16 cartlage ® Sr tracheal cartilage Clcothyrod joint Intrinsic Higament/ membranes ‘0 These membranes/Ligaments connect the laryngeal cartilage and epigltts with each other. 9 Quadrangular membrane ')Aryepielotic ligament (superior border of membrane) | 4) Vestibular ligament (Inferior border of membrane) 9 Triangular membrane (Cricovocal membrane) ') Vocal ligament (Superior end of membrane) / i) Cricothyroid ligament “™ (anterior part of membrane) © Median cricothyroid ligament | 6 Lateral cricothyroid ligament ' 2 Thyroepiglottic ligamentPHARYNX, LARYNX, TONGUE AND PLATE [ 300], Intrinsic ligaments and Membranes ‘Aryepigiotic igament “Thyroid cartlage ‘Arytonoid cartlage CCricoi cartlage ag] © The cavity of larynx extends from the laryngeal inlet (where it communicates with pharynx) to lower border of cricoid cartilage where its continuous with that of trachea. © There are two pairs of mucosal folds in laryngeal cavity :~ i) Vestibular folds ii) Yoeal fold (vocal cords) 9 These two pairs of folds divide the laryngeal cavity into three parts : = i) Vestibule: - Its the part of larynx which is above the vestibular folds, ic, it extends from laryngeal inlet to vestibular folds. ii) Vemtricle™ (sinus of larynx) : ~ It is the part of larynx between vestibular folds and vocal folds. The saccule”” isa diverticulum of mucous membrane which starts from the anterior part of ventricular cavity and extends upwards between vestibular fold and extends upward, When abnormally enlarged and distended, it may form a laryngocele, i¢.,an air containing sae which may present in the neck, ii) Subglotie space (infragiottic larynx) :- is he space of larynx below the vocal folds, ic.,it extends from vocal coords tothe lower border of cricaid cartilage. Inlet of larynx 9 It isan oblique opening bounded ; - })Amteriorly :- Free margins of epigtottis ji) On the sides : - Aryepiglomie folds" fi) Posteriorly :- Interarytenoid folds Vestibular folds (False vocal cords) «9 Two folds of mucous membrane extending anteroposteriorly across the laryngeal cavity. 0 It contains vestibular ligament, a few fibres of thyroarytenoides musice and mucous glands. Vocal folds (Vocal cords or true vocal cords) «9 Two pearly-white sharp fibrolastic bands extending from the middie of thyroid angle to voeal process of arytenoid. 9 They are formed by reflection of the mucosa over vocal ligaments. © They have stratified squamous epithelium with no submucous layer™, © Their blood supply is poor and are almost devoid of lymphatics, this gives vocal cord a pale apperance™”, 0 Vocal cords along with the upper part of the vestibule isthe only part of laryngeal mucous membrane which is lined by epithelium of stratified squamous ype ®°", Elsewhere in the larynx epithelluu of the mucous membrane is ciliated columnar type. Glottis (rima glottis) 0 Itis the opening between the true vocal cords (anteriorly). 0 dis the narrowest part of larynx: in adults. Rima vestibuli 9 This the space between two vestibular folds natomical sites ‘© Conventionally, larynx is divided into :~ ) Supraglottc larynx!" "9 a Its the part of larynx above the vocal cords (vocal folds or true vocal cords). So, it includes vestibule of Tarynxas well as ventricle (sinus of larynx).. PHARYNX, LARYNX, TONGUE AND PLATE [301] 1 It consists of suprahyoid epiglotis (both lingual"? and laryngeal surface"), infrahsoid epiglottis, aryepiglottic folds") (only laryngeal aspect), false vocal cord"! (vestibular fold or ventricular band). ii) Glouis a Iris the part at the level of vocal cords. ii) Subglortic larynx a Its the part of larynx below the vocal cords and is continous with the trachea. supply of larvax ‘9 The main cranial nerve innervating the larynx isthe vagus nerve via its branches; superior laryngeal nerve (SLN) and recurrent laryngeal nerve (RLN)- Sensory supply of far ‘9 Above the level of vocal cords, larynx is supplied by internal laryngeal nerve" 7.0%", a branch of superior laryngeal nerve ‘9 Below the vocal cord, larynxis supplied by recurrent laryngeal nerve'™==?, Motor supply oflarynx. ‘9 All the intrinsic muscles of larynx are supplied by recurrent laryngeal nerve except for cricothyroid muscle" © Cricothyroid Is supplied by external laryngeal nerve, a branch of superior laryngeal nervel"™#~4*? 9880, TONGUE © Tongue is a muscular organ concemed with taste, speech, mastication and deglutition. It is partly situated in oral cavity proper and partly in oropharynx. The tongue has « roo, a tip apex) and a body. Body has an upper surfuce (dorsum) and an inferior surface. The dorsurn is divided into oral and pharyngeal paris by a V-shaped, the sulcus terminalis. The two limbs of *V" meet ata median pt, known as foramen eaeeum. The oral and pharyngeal pect differ in their development, opography, structure and function. Third par of tomgue (beside oral and pharyngeal parts) is, posterior most part, Thus tonguc has three parts: () Oral or papillary part, (i) Pharyngeal or lymphoid part, and (ii Posterior most part. Muscles of the tongue © Each half of tongue contains four intrinsic and four extrinsic muscles, 4) Imerinsie muscles :- Superior longitudinal, inferior longitudinal, transverse, vertical. ii) Exvinsic muscles += Genioglussus, hyoglossus, styloglossus and palatoglossus ‘0 Allmuscles of tongue are developed from occipital myotomes (somites), except palatoglossus. Palatozlossus develops from sixth arch mesoderm. © All muscles of tongue are supplied by hypoglossal nerve!” except palatoglossus which is supplied by cranial part of accessory nerve through pharyngeal plexus”™**!.e, vagoaccessory complex. Muscles ‘Action Extrinsic 9 Palatoglossus Elevates tongue, narrows oropharyngeal isthmus, 0 Styloglossus Retract and elevate the tongue. 9 Hyogiossus Depress the tongue, and retract the protruded tongue. 9 Genioglossus Protrude the tongue and deviates it to opposite side” ""*°, Prevents backward fall of tongue towards oropharynx. Itis called safety muscle of tongue™” (or life-saving muscle). Intrinsic 9 Superior longitudinal Shortens the tongue makes dorsum concave. Inferior longitudinal Shortens the tongue makes dorsum convex. o Transverse ‘Makes tongue narrow and elongated. Vertical ‘Makes tongue broad and flattened.PHARYNX, LARYNX, TONGUE ANDPLATE[302] * Nerve supply of tongue Part ‘Taste sensation General (Touch and temperattare) Anterior 2/3 (Chorda tympani". Lingual branch of mandibular (cxceptcizcumvallate papillae) division of trigeminal nerve Posterior 1/3 including Glossopharyngeal“?*"4™sH — Glossopharyngeal”*/mes9 circumvallae papillae Posterior most part {Internal laryngeal branch of vaus Internal laryngeal branch of vagus Lymphatic drainage of tongue ‘© Tip ofthe tongue drains into swhmental nodes", anterior2/3 drains into submandibular nodes, and posterior 13 into jugulodigastric nodes. « Finally all Iymphaties drain into jugulomohyoid nodes, aiso known as lymph nodes of tongue. Development of tongue 1. Eplihelium a) Ant2/3_- lingual swellings of Ist arehi@#2£"%™ and tuberculum impar b) Post 13 - large dorsal part of hypobranchial eminence ie. 3rd arch. ©) Posterior most part -small dorsal pat of the bypobranchial eminence, ie. 4th atch 2. Muscles From occipital myotomes”2 except palatoglossus which is derived from the Gth arch. PALATE ‘0 Palate forms the roof of mouth and flour of nasal cavity and consists of an anterior hard palate and a posterior soft palate, It forms anterior four-fifth of palate. It is @ partition between nasal and oral cavities, It is formed by palatine processes of maxillae”@ (anterior 2) and horizontal plates of palatine bones (postertor 2/3). Inferior surface is covered by mucosa and receives sensory Ianervation from greater palatine and nasopalatine nerves and blood supply from greater palatine vessel, © Soft palate isa mobile, fibromuscular curtain attached to posterior border of hard palate and forms posterior one fifth ‘of palate It separates oropharynx from nasopharynx. Uvula is a median conical projection from the posterior free border of sof palate © Soft palate encloses palatine aponeurosis, palatine muscles, vessels, nerves, lymphoid tissue and mucous glands. Anterior oral surfaceis covered by nonkeratinising stratified squamous epithelium and posterior nasopharyngeal surface is covered by respiratory epithelium. ‘9 Muscles of soft palate are: (i) tensor palati (tensor vei palatni, (ji levator pata (levator vel palatini) (ii) musculus ‘uvulae, (iv) palatoglosus and (v) palatopharyngcus. All mustles of palate (exeept tensor vel paiatini) are supplied by cranial part of accessory nerve=""" via vagus ¢hrough pharyngeal plexus. Tensor vell palatin is supplied by mandibular nerve a branch of trigeminal". Upper fibers of palatopharyngeus 822°” constitute the passavants musele"°™” which on contraction raises ridge, passavant’s ridge an posterior wall of nasopharynx, internal fo superior constrictor, ‘0 Nerve supply of soft palate is as follows |. Motor supply All muscles of soft palate except the tensor veli palatini are supplied by the cranial part of accessory nerveA#) through pharyngeal plexus. The fibers of this plexus are derived from cranial part of accessory nerve®2 through the vagus. Tensor veli palatini is supplied by mandibular nerve, a branch of trigeminal nerve", 2 Sensory (General) i) Lesser palatine nerves (middle and posterio), branches of maxillary nerve through plerygopalatine ganglion i) Glossopharyngeal nervePHARYNX, LARYNX, TONGUE AND PLATE [303] 43,Sensory (Special) 1 Taste (gustatory) sensations from the oral surface of soft palate are conveyed by lesser palatine nerve, The fibers travel through the greater petrosal nerve to geniculate ganglion of facial nerve/#™5*S-/ and then to nucleus of tractus solitarius. 4 Secretomotor ‘a Contained in lesser palatine nerve, derived from the superior salivary nucleus and travel through the greater petrosal nerve, Blood supply of soft palate © Arterial supply of soft palate is as follows ') Greater palatine branch of descending palatine artery"*™, which in tum isa branch of maxillary artery. ii) Ascending palatine branch of facial artery”*™. ii) Palatine branch of ascending pharyngeal artery", iv) Lesser palatine artery a branch of descending palatine artery, which i a branch of maxillary artery