Salute

Vivamus 2023 | Central Philippine University | College of Medicine

Otolaryngology: S01L07


Anatomy

and Physiology of the Oral Cavity and the Pharynx

Dr. Melita Jesusa Uy | 10-15-2021 | F | 10:00-12:00 PM

OUTLINE
I. Division and boundaries E. Fascia of the
II. Oral cavity Pharynx
A. Lips F. Pharyngeal Spaces
B. Buccal Mucosa G. Arterial Supply
C. Alveolar Ridges H. Lymphatic Drainage
D. Floor of the Mouth I. Innervation
E. Retromolar Trigone IV. Nasopharynx/
F. Palate Epipharynx
G. Tongue A. Tubal Tonsils
H. Tongue Papillae B. Adenoids
I. Tongue Ventral C. Nasopharyngeal
Surfaces Bursa
J. Tongue Muscles D. Rathke’s Pouch
K. Extrinsic Muscles E. Passavant’s Ridge
L. Intrinsic Muscles F. Functions of
M. Innervations Nasopharynx
N. Embryology V. Oropharynx
III. Pharynx A. Boundaries of the
A. Pharynx Oropharynx
Attachments B. Vallecula
B. Pharyngeal Muscles C. Palatine Tonsils
C. Longitudinal D. Waldeyer’s Ring
Figure 1. Diagram of the Oral Cavity and the Pharynx
Muscles E. Lymphatic Drainage
D. Structure of the F. Functions
Pharyngeal Wall VI. References

I. DIVISIONS AND BOUNDARIES

• Oral cavity: anterior to soft palate, anterior tonsillar pillar and
base of tongue.
• Nasopharynx: extends from base of skull to the level of soft
palate
• Oropharynx

II. ORAL CAVITY

• Parts of the Oral Cavity
® Upper and lower lips Figure 2. Parts of the Oral Cavity
® Buccal mucosa
® Alveolar ridges A. LIPS
® Floor of the mouth
® Retromolar trigone
® Hard palate
® Anterior 2/3 of the oral tongue

Figure 3. Sagittal view of the orbicularis oris

ORBICULARIS ORIS
• Basically made up of the orbicularis oris internally, which
surround the mouth

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• It extends from the base of the nose cephalad and ends in the ® Located opposite to the second maxillary molar tooth on
mentalabial sulcus each side of the oral cavity
• It is a composite muscle that consist of 2 parts:
® larger peripheral part C. ALVEOLAR RIDGES
® smaller marginal part
• The orbicularis oris is not a simple sphincter muscle like the • The opposing surface of the maxillary and mandibular bone is
orbicularis oculi. the horseshoe-shaped alveolar ridges/bones
• It consists of numerous strata, muscular fibers sorrounding the • Contains sockets for the dentitions
orifice of the mouth but having different direction. • Covered by the gingiva which is a mucosa continuous with the
• It consists partly of fibers derived form the other facial muscles buccal mucosa as well as mucosa of the palate.
which are inserted into the lips and partly of fibers proper to the
lips. D. FLOOR OF THE MOUTH
• Externally to internally:
® Skin • Found between the base of the tongue and the inner aspect of
® subcutaneous tissue the mandible
® Muscle • Covered by mucosa which is continuous with the gingiva of the
® Mucosa mandibular ridge
• Functions of the orbicularis oris: • Surgically, it can be described as:
® Close the mouth ® Superficially: space of the mucosa
® Mastication ® Internally: myelohyoid muscle
® Lip pouting, twisting, pursing, and others • Structures found in the floor of the mouth:
® Facial expression and speech ® Lingual frenulum: thin fold in the midline formed by the
® Whistling or playing a wind instrument mucosa which attaches to the lower surface of the tongue
® Sublingual carancula: bumps on each side of the base of
the frenulum which houses the Warton’s duct of mandibular
NICE TO KNOW! gland
“Bilateral uniform contraction of the muscle will bring the lips together ® Sublingual fold: 2 oblique elevations found radiating
and close the mouth. This action is important for mastication as it laterally away from the lingual frenulum on either side of the
works in cooperation with the buccinator muscle and the tongue to caruncle which house the ducts from the sublingual salivary
prevent the food from escaping the teeth and accumulate in the oral gland
vestibule during eating. Isolated contraction of respective parts of the ® Geniohyoid muscle
muscle causes the movement such as lip pouting, twisting, pursing o found if you remove the mucosa and cut the tongue
and others. These movements greatly contribute to facial expression
and speech. In addition, the labial chords can act as vibrating strings o Underneath and in the sides is the myelohyoid muscle
that enable whistling and playing wind instruments.” ® Submandibular gland
-Doc Uy o found in the posterior edge of the myelohyoid muscle
o Its Wharton’s ducts going anteriorly opens in to the
• Innervation sublingual caruncle
® Buccal branch of the facial nerve (CN VII) ® Sublingual gland
• Blood supply o Gives numerous sublingual ducts own the sublingual fold
® Superior and inferior labial branches of the facial artery ® Lingual nerve
® Mental and infraorbital branches of the maxillary artery ® Hypoglossal nerve
® Transverse fascial branch of the temporal artery
E. RETROMOLAR TRIGONE
VERMILLION
• The vermillion meets at the • Also called the retromolar fossa
corners and is called the oral • Oral cavity subsite that consist of the mucosa posterior to the
commissures. last mandibular molar
• The mucosa in the inner • Triangular shaped area at the back of the teeth
portion form a ridge called the • The area that connects the upper third molar and the lower third
labial frenulum which molar
attaches to the adjacent • Extends superiority towards the maxilla along the anterior
gingiva. surface of the mandible
• Gingiva or mucosa covering the alveolar ridge posterior to the
last mandibular molar overlying the ramps of the mandible and
Figure 4. Vermillion of the mouth is defined as roughly triangular space
• The mucosa covering the retromolar trigone is rigid as it is
tightly adherent to the underlying alveolar bone
® It helps the malignant tumor infiltrate the mandible in a short
B. BUCCAL MUCOSA period of time in the early stages
• Also known as the anatomic crossroad where muscular and
• Lining at the lateral portion of the oral cavity nervous components converge
• Continuous with the gingiva of the maxillary and mandibullar • The lingual nerve is also positioned behind the retromolar
alveolar ridges trigone and medically placed which is the reason why there is
• Where the excretory duct or the Stenson’s duct of the parotid lingual nerve involvement seen in cancer of retromoar trigone.
opens
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• As it shared the borders of many vital structures like the tonsils, o Incisive fossa: depression in the midline of the bony plate
tongue, floor of the mouth and soft palate, in cases involving posterior to the central incisor teeth into which the incisive
the retromolar trigone, all these structures have a high chance canals open
of being invaded by the cancer. § The nasopalatine nerves pass from the nose through a
• The tumors from the surrounding structures also frequently variable number of incisive canals and foramina that open
extend into the trigone making it difficult to determine the into the incisive fossa
source of the tumor. o greater palatine foramen:
• It is a common location of carcinoma § Located medial to the 3rd molar tooth
• Innervation: § pierces the lateral border of the bony palate
® Branches of the glossopharyngeal and lesser palatine § the greater palatine vessels and nerves emerge from this
nerves foramen and run anteriorly on the palate
• Blood supply o lesser palatine foramina
§ Located posterior to the greater palatine foramen
® Artery
§ pierce the pyramidal process of the palatine bone
o Major: Tonsillar and ascending palatine branches of the
facial artery § transmits the lesser palatine nerves and vessels to the soft
o Minor: dorsolingual ascending pharyngeal and lesser palate and adjacent structures
o Palatine aponeurosis
palatine artery
§ Formed by the merging of the flattened tendons of the right
® Venous drainage
and left tensor belli palatine
o Pharyngeal plexus
o Common facial vein § Before they become flattened, each tendon uses the
pterygoid hamulus as a trochlea or pulley, directing its line
® Lymphatic drainage of pull approximately 90 degrees
o Upper jugular chain
§ Deep to the mucosa of the palate are mucus secreting
palatine glands. The openings of the ducts of these glands
F. PALATE give the palatine mucosa a pitted appearance.
o Incisive papilla
• Roof of the oral cavity § Located in the midline posterior to the incisor teeth
• Separates the oral § This elevation in the mucosa lies directly anterior to the
cavity from the nasal underlying incisive fossa
cavity above it
• Has 2 parts:
® Anterior: Hard/
Bony palate
® Posterior:
Soft/Muscular
palate

BONY PALATE
• Concave
• Mostly filled by the
tongue when it is at
rest

Figure 7. Incisive Papilla

o Rugae
§ Mediating laterally from the incisive papilla, are several
transverse palatine folds or rugged
§ These folds assist with manipulation of food during
mastication
o Palatine Raphe
§ Narrow, whitish streak passing posteriorly from the middle
of the palate from the incisive papilla
§ It may represent as a ridge anteriorly and a groove
posteriorly
§ Marks the site of fusion of the embryonic palatial
processes

Figure 6. Structure of the Bony Palate

• Anterior 2/3rds of the palate is a bony skeleton formed by the:

§ palatine process of the maxilla
§ horizontal plates of the palatine bone

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§ You can feel the transverse palatine folds and the palatine
raphe with your tongue
Figure 8. Palatine Raphe
o Mucosa of the hard palate is tightly bound to the underlying
bone consequently submucus injection in this area are
extremely painful
§ Superior lingual gingiva: part of the gingiva covering the
lingual surface of the teeth and the alveolar process is
continuous with the mucosa of the palate, therefore
injection of an aneasthetic agent in to the gingiva of a tooth
anesthesises the adjacent palatal mucosa
SOFT PALATE
o Attached to the posterior border of the palate
o Covered in its upper and lower surfaces by mucus membrane
o Composed of:
§ Muscle fibers
§ Aponeurosis
§ Lymphoid tissue
§ Glands
§ Blood vessels
§ Nerves
o It is the movable posterior third of the palate and is suspended
from the posterior border of the hard palate
o Has no bony skeleton, however, it’s anterior aponeurotic part
is strengthened by the palatine aponuerosis which attaches to
the posterior edge of the hard palate
o The aponeurosis is thick anteriorly and thin inferiorly
o Uvula – conical process that hangs in the curved free marginal
the soft palate
o When swallowing, the soft palate is initially tense to allow the
tongue to press against it, squeezing the bolus of food to the
back of the mouth
o The soft palate is then elevated posteriorly and superiorly
against the wall of the pharynx, thereby preventing the
passage of food into the nasal cavity
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o The palatal aponeurosis is a fibrous sheath attached to the
posterior border of the hard palate. It is an expanded tendon of
the tensor belli palatine and it splits to enclose the
musculoskeletal uvulae and gives origin to other palatine
muscles
• Innervation
Figure 9. Posterior part of the lateral wall of the nasal cavity. The perpendicular plate of the
palatine bone is removed to expose the palatine nerves and trace the ascending fossa
from the pterygopalatine canal
® Sensory nerve supply
o Maxillary nerve through its branches
§ Greater palatine nerve: supply the gingiva, mucus
membrane, and glands of most of the hard palate
§ Lesser palatine nerve: supplies the soft palate
§ Nasopalatine nerve: supplies the mucus membrane of
the anterior part of the hard palate
o Glossopharyngeal nerve supplies the soft palate
o Palatine nerve
§ Accompany the arteries through the greater and lesser
palatine foramina respectively
o Vagus nerve
§ Supply all muscles of the soft palate except the tensor
veil palatini
o Mandibular division of the trigeminal nerve
§ Supply the tensor veil palatini
• Blood supply
® Arteries
o Branches of the maxillary artery
§ Greater palatine
§ Lesser palatine
§ Sphenoplatine
o Ascending palatine branch of the facial artery
o Palatine branch of the ascending pharyngeal artery
o Maxillary, facial and ascending pharyngeal artery are all
branches that arise from the neck fromhe external carotid
artery
® Veins in the palate generally follow the artery and ultimately
drain into the pterygoid plexus and veins in the infra
temporal fossa or into another network of veins associated
with the palatine tonsil which drain into the pharyngeal
plexus of veins or directly in to the facial vein
® Lymphatic vessels of the palate
o Drain into the deep cervical nodes

G. TONGUE § Most numerous at the apex and margins of the
tongue
® Ventral – the inferior surface or underneath the tongue

H. TONGUE PAPILLAE

• Circumvallate papillae:
® Largest of the papilla, blunt-ended and cylindrical in papillae
® Vaginations in the tongue surface and there are only about
8-12 these in a single V-shaped lying immediately anterior
to the terminal sulcus of the tongue (Doc)
® Large, flat-top, lie directly anterior to the terminal sulcus,
arranged in a V- shaped row
® Surrounded by circular trenches, the walls of which are
studded with taste buds and the ducts of the serous glands
open into the trenches
• Fungiform papillae:
® Rounder in shape and larger than the filiform papilla (Doc)
® Bigger papillae,
Figure 10. Structure of the tongue ® Mushroom shaped pink-red spots scattered along the
filiform papilae,
• A mass of striated muscle covered with a mucus membrane ® Numerous at the tip and margin of the tongue
• Median septum – divide tongue to right and left haves • Filliform papillae:
• Has 3 parts: ® long and numerous
® Oral part – anterior 2/3 ® Contain nerve endings that are sensitive to touch
o Oriented in the horizontal plane ® Conical V-shaped on the dorsum of the tongue arranged in
® Pharyngeal part – posterior 1/3 rows parallel to sulcus terminalis except in the apex which
o Curves inferiorly and becomes oriented vertically are arranged transversely
® Tongue root/ base – attached to the mandible and hyoid ® Small,cone-shaped projections of the mucosa that end in
bone one arm or points (Doc)
• Terminal sulcus of the tongue: v-shaped sulcus that • Foliate: (VIVA TRANS)
separates the oral and pharyngeal part of the tongue
® small, lateral folds, not developed well in human
® Forms the inferior margin of the oropharyngeal isthmus
between the oral and the pharyngeal cavity I. TONGUE VENTRAL SURFACES
• Foramen cecum
® Depression in between the terminal sulcus
• Smooth: no papilla
® Marks the site in the embryo where the epithelium
• Lingual frenulum: midline fold from floor of the mouth to the
invaginated to form the thyroid gland
tongue
• Has 2 surfaces:
• Sublingual papilla: swelling at the base of frenulum; where you
® Dorsal surface – it is the superior surface of the tongue can find the opening of submandibular glands
where most of the papilla can be seen
• Fimbriated folds: lateral to lingual frenulum; represents the
o Oriented in the horizontal plane
location of lingual veins
o Midline groove – divides the anterior tongue into right and
left • Sublingual folds: are mucosal folds overlying and have opening
for sublingual salivary glands
o The mucosa of the anterior part of the tongue is relatively
thin and closely attached to the underlying muscle it is a
rough texture because of numerous small lingual papilla
§ Vallate
- large and flat top
- lies directly and anterior to the terminal sulcus and
arranged in a v shaped row
- surrounded by deep sulcular trenches
- the walls are studded with taste buds
§ Foliage
§ linear folds of mucosa on the sides of the tongue near
the terminal sulcus
§ poorly developed in humans
§ Filiform
- long, numerous and contain afferent nerve endings
that are sensitive to touch Fig. 11. Structures that we can see on the ventral side of the tongue

- pinkish gray and arranged in v-shaped rows that are

parallel to the terminal sulcus except at the apex J. TONGUE MUSCLES
where they tend to be arranged transversely
§ Fungiform • Two kinds of tongue muscles:
§ Mushroom shaped, pink-red spots scattered along ® Intrinsic
the filiform papilla ® Extrinsic
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FROM VIVA TRANS NICE TO KNOW!
® Stensen’s duct: opening of the parotid gland “Tongue rolling or twisting thought to be a genetic trait before. It was
® Wharton’s duct: opening of the submandibular gland the leading geneticist Alfred Sturtevant who suggested that in
1940’s that tongue rolling was a Mendelian trait. Meaning that it was
® Duct of Rivinus: opening of sublingual glands
inherited not as a blend of your parent gene but from one of your
parents. However, family studies have shown that tongue rolling is
K. EXTRINSIC MUSCLES OF THE TONGUE not a simple genetic character. Twin studies demonstrate that it is
influenced by both genetics and environment.”
• Connect the tongue to the surrounding structures; the soft
palate and the bones (mandible, hyoid bone and styloid - Doc Uy
process)
Table 1. External Muscles of the tongue
MUSCLES ORIGIN INSERTION ACTION
Genioglossus Genial tongue to its protrusion
tubercle of dorsal
the mandible surface
Styloglossus styloid lateral side of draws
process of tongue tongue
temporal superiorly
bone and
posteriorly
Hyoglossus greater or lateral side of depressed
lesser horns tongue the tongue
of hyoid bone
Palatoglossus inferior lateral side of depressed
surface of the tongue the soft
palatine palate and
\ aponeurosis elevates the
tongue
Fig. 12. Extrinsic Muscles of the Tongue Table 3. Extrinsic Muscles of the Tongue

TONGUE MUSCLE MOVEMENTS M. INNERVATIONS OF THE TONGUE

• Protrusion: Genioglossus on both sides acting together
SENSORY NERVES
• Retraction: Styloglossus and hyoglossus on both sides acting
together • Lingual Nerve (CN V3)
• Depression: Hyoglossus and genioglossus on both sides ® Branch of the Mandibular Nerve of the Trigeminal Nerve
acting together ® General Sensation like touch and temperature
• Elevation: Styloglossus and palatoglossus on both sides ® Supplies the mucosa of the anterior 2/3 of the tongue
acting together • Chorda Tympani (CN VIII)
® Branch of Facial Nerve
L. INTRINSIC MUSCLES OF THE TONGUE ® Special sensation (taste)
® Supplies anterior 2/3 of the tongue except for vallate papilla
• Longitudinal Muscles (Superior and Inferior) ® Joins the Lingual Nerve in the Infratemoporal Fossa and
• Vertical Muscles runs anterior in its sheath
• Transverse Muscles • Glossopharyngeal Nerve (CN IX)
• Function: ® Supplies the mucosa of the posterior third of the tongue and
® Can alter the shape of the tongue vallate papilla (Lingual Branch)
® For general and special sensations
NICE TO KNOW! • Internal Laryngeal Nerve (CN X)
® Branch of Vagus nerve
“These muscles are confined to the tongue and have no bony ® Supply mostly general but some special sensation to a
attachment .” small area of the tongue just anterior to the epiglottis
- Doc Uy
NICE TO KNOW!
“ These mostly sensory nerves also carry parasympathetic secreto-
MUSCLES ORIENTATION FUNCTION motor fibers to serous glands in the tongue.”
Longitudinal antero-posteriorly Shortens the
Muscles tongue - Doc Uy

Vertical supero-inferiorly flatten and MOTOR NERVES

Muscles broaden the • All muscles of the tongue except the Palatoglossus receive
tongue motor innervation from the Hypoglossal Nerve (CN XIII)
• Palatoglossus is a palatine muscle supplied by the pharynges
Transverse horizontally Makes the plexus of the vagus nerve (CN X)
Muscles tongue
narrow FROM VIVA TRANS
Table 2. Intrinsic Muscles of the Tongue • Hypoglossal nerve: Intrinsic muscles
• Hypoglossal nerve, except palatoglossus: extrinsic muscles

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• Pharyngeal palatoglossus: pharyngeal plexus ® The ducts of mucus glands open into the bases of the
crypts, small isolated follicles also occurred beneath the
lingual mucosa
• Submental Nodes
® Drains the tip of the tongue
• Submandibular Nodes
® The rest of the 2/3 of the tongue
• Deep Cervical Lymph Nodes
® Drains mostly the posterior third of the tongue
® Drains the rest of the 2/3 of the tongue together with the
Submandibular Nodes

Fig. 13. Innervations of the Tongue
NICE TO KNOW!
“The chorda tympani nerve, which passes through the middle ear,
provides taste sensation to the anterior two thirds of the tongue.it
also carries parasympafibers to the submandibular gland.”
- Book ( Boie’s 6th edition)
NICE TO KNOW!
“Bear in mind that lymph vessels of the tongue cross midline and
lesions may spread to opposite side. The more central regions may
drain bilaterally and this must be bore in mind when planning to
remove malignant tumors of the tongue that are approaching the
midline. If the tumor has the propensity for lymphatics spread both
cervical chains may be involved.”
-Doc Uy
FUNCTIONS OF THE TONGUE
• Tongue is the most important articulator for speech production.
During speech, the tongue can make amazing range of
movements

BLOOD SUPPLY OF THE TONGUE

• Arteries of the Tongue are derived from:
® Lingual Artery
o Arises from the External Carotid Artery
o Upon entering the tongue, the lingual artery passes deep
to the hyoglossus muscle
o Gives off dorsal arteries which supply the root of the
tongue
o Further forward, it also branches to the deep lingual
arteries to supply the body of the tongue.
Fig. 14. Basic Tastes of the Tongue
§ The deep lingual arteries communicate with each other
near the apex of the tongue
§ It also forms the sublingual arteries and provide the • Primary Function:
blood supply to the floor of the mouth including the ® To provide a mechanism for taste
sublingual gland • Taste buds are located on different areas of the tongue that are
(FROM VIVA TRANS) generally found around the edges
® Tonsillar branch of Facial artery • Historically, gustatory receptors have been reported to detect 4
® Ascending pharyngeal artery main qualities of taste sensation
® Basic Taste:
• Veins of the tongue o Salt: NaCl
® Dorsolingual Veins o Sour: Acids
o Which accompany the lingual artery o Sweets: Sugars
® Deep lingual Veins o Bitter: Quinine
o Begin at the apex of the tongue which run posteriorly o Umami:5th basic taste which is recently identified
beside the lingual frenulum § A Japanese term for a delicious taste
• Sublingual Veins § Glutamate like receptor stimulated by
® In elderly, they are often varicosed or enlarged and turtuos MSG(monosodium glutamate)
• Internal jugular Vein
® Wherein some or all of the veins may drain; indirectly by DISTRIBUTION OF TASTE SENSATION
joining first to form a lingual vein that accompanies the initial • VII (Chorda Tympani): has more fibers that respond to sweet
part of the lingual artery • IX (Glossopharyngeal Nerve): has more fibers that respond to
bitter
LYMPHATIC DRAINAGE OF THE TONGUE • The papillae in general increase the area of contact between
• The mucosa of the pharyngeal part of the dorsal surface of the the surface of the tongue and the contents of the oral cavity
tongue contains many lymphoid follicles aggregated into dome-
shaped groups
• Lingual Tonsil
® Each group is arranged around a central deep crypt or
invagination which opens on to the surface epithelium

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Fig. 15. Distribution of Taste Sensation
NICE TO KNOW!
“Although it is commonly stated that particular areas of the tongue
are specialized to detect these different taste (basic tastes),
evidence indicates that all areas of the tongue are responsive to all
taste stimuli. Each afferent nerve fiber is connected to widely
separated taste buds and may respond to several different chemical
stimuli. Some respond to all 4 classic categories others are fewer or
only one. Within a particular class of taste receptors are also
differently sensitive to a wide range similar chemicals. Moreover,
taste buds alone are able to detect only a rather restricted range of
chemical substances in aqueous solution. It is difficult to separate
perceptions of taste and smell because the oral and nasal cavities
are continuous. Indeed, much of what is perceived taste is the result
of air borne odorants from the oral cavity that pass through the
nasopharynx to the olfactory area above it. Perceived sensation of
taste are the result of processing resumable central of a complex
pattern of responses from particular areas of the tongue.”
-Doc Uy
N. EMBRYOLOGY (VIVA)
FOREGUT
• Oral cavity, pharynx and esophagus
• Also gives rise to:
® Nasal Cavity
® Teeth
® Salivary Glands
® Anterior Pituitary
® Thyroid and Pharynx
® Trachea
® Bronchi
® Alveoli
• Mouth forms when primitive stomodeum, fusion of ectoderm
and endoderm, breaks down
• Upper lips are formed by medial and lateral nasal processes
and maxillary process
• Lower lips develop from mandibular processes.
® Muscles of the lips are derived from 2nd branchial region
and supplied by facial nerve
• Vermilion: characteristic bowed appearance
• Teeth are derived dental lamina.
• Development of human dentition thru milk teeth to final eruption
of adult third molar corresponds to the age of patient
® Supplied by branches of maxillary and mandibular
branches of trigeminal nerve.
• Palate 2 parts:
® Premaxilla: containing the incisor teeth and derived from
medial nasal process
® Posterior plate
• Pierre Robin Syndrome: palatal plates are lateral to the tongue
and if tongue does not descend, palatal plates cannot fuse.
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• Anterior tongue: derived from 1st branchial region; supplied by
lingual nerve.
• Glossopharyngeal nerve: supplies all sensation of posterior 3rd
of tongue
• Thyroid: arises from foramen cecum and migrates along the
thyroglossal duct into the neck.
III. PHARYNX
• It is divided into three divisions
® Superiorly: Nasopharynx
® Middle: Oropharynx
® Inferiorly: Hypopharynx/ Laryngopharynx
• It is 12-14 cm. long, musculomembranous tube shape like an
inverted cone
• Boundaries:
® Superiorly: Base of Skull including posterior part of the body
of sphenoid and the basilar part of the occipital bone
® Inferiorly: pharynx continues with esophagus at the level of
the 6th or 7th cervical vertebra/ lower border of cricoid cartilage
® Posteriorly: separated from the cervical part of the
vertebral column and the prevertebral fascia which covers
longus coli and longus capitis by loose connective tissue in
the retro pharyngeal space above and retro visceral space
below
® Anteriorly: communication with nasal cavity, oral cavity, and
larynx
® Laterally: it is attached to the medial pterygoid plane, the
pterygo mandibular raphi, mandible,tongue,hyoidbone
,thyroid and cricoid cartilages
• Also has communication with the middle ear through the
Eustachian tube or the pharyngo tympanic tube and it is also
related to the styloid process and muscles attached to it
• Common internal and external carotid arteries are also found
on each side of the pharynx
A. PHARYNX ATTACHMENTS
Fig. 16.
Attachments of the
Pharynx (the red
outline represents
the superior and
anterior margins of
the pharyngeal
wall)
• 2 sides of the pharyngeal wall
® Bounded posteriorly by a midline vertically oriented chord
like ligament called the pharyngeal raphe
o This connective tissue structure descends from the
pharyngeal tubercle on the base of the skull to the level of
the 6th cervical vertebra where the raphe blends with the
connective tissue in the posterior wall of the esophagus
• Irregular C shaped line of pharyngeal wall attachment on the
base of the skull
® The open arch of the C faces the nasal cavities
® Each arm of the C begins on the posterior margin of the
medial plate of the pterygoid process of the sphenoid bone
just inferior to the cartilaginous part of the Eustachian tube

Fig. 17. Vertical line of attachment for the lateral pharyngeal walls
• Structure that is related to the nasum,orum and larynx
• It is discontinuous and in 3 parts:
® 1st part
o on each side the anterior line of attachment of the lateral
pharyngeal wall begins superiorly on the posterior edge
of the medial pterygoid plate of the sphenoid bone just
inferior toward the pterygotympanic tube or the
Eustachian tube lies against its plate
o it continues inferiorly along the edge of the medial
pterygoid plate and onto the pterygoid hamulus
o From this point the line descends along the
pterygomandibular raphe to the mandible where this part
of the line terminates
§ Pterygomandibular raphe- is a linear cord like
connective tissue ligament that spans the distance
between the tip of the pterygoid hamulus and a
triangular roughening immediately posterior to the 3rd
molar of the mandible
® 2nd part: Related to the hyoid bone
o It begins on the lower aspect of the styloid ligament which
connects the tip of the styloid process of the temporal
bone to the lesser horn of the hyoid bone
o The line continues on to the lesser horn and then turns
and run posteriorly along the entire surface of the greater
horn of the hyoid where it terminates
® 3rd part: most inferior
o Begins superiorly on the superior tubercle of the thyroid
cartilage and descends along the oblique line to the
inferior tubercle
o From the inferior tubercle, the line of attachment
continues over the cricoid muscle along at tendinous
thickening of fascia to the cricoid cartilage where it
terminates
A. PHARYNGEAL MUSCLES
• Pharyngeal wall
® Formed by skeletal muscles and fascia
® Gaps between the muscles are reinforced by the fascia and
provide roots for structures to pass through the wall
• Muscles of the Pharynx are organized into 2 groups based on
the orientation of the muscle fibers
• Constrictor muscles: oriented in a circular direction
• Longitudinal muscles: oriented vertically
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• 3 constrictor muscles on each side are major contributors to the
structure of the pharyngeal wall and their name indicate their
position.
• Posteriorly: the muscles on each side are joined together by
the pharyngeal raphe
• Anteriorly: these muscles are attached to the bones and
ligaments related to the lateral margins of the nasal and oral
cavities and the larynx
• The constrictor muscles overlapped each other in a fashion
resembling the walls of three flower pots stacked one on the
other (e.g. Inferior constrictor overlapped the lower margins of
the middle constrictors and so on)
• Superior Constrictor
® Lies in the wall nasopharynx and oropharynx
® Wide Origin: muscles fan out posteriorly
o Post border of medial pterygoid plate and pterygoid
hamulus
o Pterygomandibular raphe
o Posterior end of mylohyoid line
o mucus membrane on side of tongue
® Palatopharyngeal sphincter which originates from the
anterolateral surface of the soft palate and circles the inner
aspect of the pharyngeal wall blending with the inner aspect
of the superior constrictor
® Lower part covered by middle constrictor
• Middle Constrictor: fans out posteriorly and attached to the
pharyngeal raphe
® Hypopharynx
® Origin: lower part of the stylohyoid ligament, lesser and
greater horn of hyoid bone
® Inferiorly overlapped by inferior constrictor
® Inferiorly: muscle fibers blend with and attach to the walls
of the esophagus
• Inferior Constrictor
® Thickest of the three constrictor muscles
® 2 Parts: Thyropharyngeus and Cricopharyngeus
o Thyropharyngeus
§ obliquely displaced
§ origin: oblique line of thyroid cartilage, inferior cornu
of thyroid
o Cricopharyngeus
§ Transversely displaced
§ Origin: anterior part of cricoid cartilage between
attachment of cricothyroid and articulation of inferior
cornu
o Act as a sphincter
§ Function: prevent the entry of air in the esophagus in
the interval between swallowing
§ Sphincter relaxes during swallowing and contracts in
between the acts of swallowing
• Killian’s Dehiscence
® A.k.a Killian’s Triangle or Gateway of Tears
® Triangular area in the wall of the pharynx between the
Cricopharyngeus and the Thyropharyngeus
® Potential gap between these 2 muscles predisposes this
site for herniation of pharyngeal mucosa in cases of
Pharyngeal pouch.

NICE TO KNOW!
“Zenker’s Diverticulum develops through the posterior pharyngeal
wall below the inferior constrictor and above the cricoid pharyngeus.”
- Book ( Boie’s 6th edition)

Fig. 18. Summary of Constrictor Muscles Fig. 19. Stylopharyngeus and Palatopharyngeus muscle

B. LONGITUDINAL MUSCLES
PALATOPHARYNGEUS MUSCLE
LONGITUDINA Oropharynx Nasopharynx KNOW!
NICE TO
L MUSCLES “Palatopharyngeus muscle starts at the superior surface of palatine
Stylo- • Medial aspect of • Glossopharynge and inserts at the posterior border of the thyroid cartilage
aponeurosis
pharyngeus styloid process al and pharyngeal wall. It acts to depress the palate and elevates the
• Gap between middle pharynx.”
and superior constrictor -Doc Uy

Palato- • Upper surface of • Pharyngeal

pharyngeus palatine aponeurosis plexus
as 2 fasiculi SALPHINGOPHARYNGEUS MUSCLE
• Moves along inner NICE TO KNOW!
aspect of the “Arises from the inferior part of the cartilage of the pharyngotympanic
constrictor membrane or the station 2 near its pharyngeal opening and passes
Salphingo- • Cartilage of the • Pharyngeal plexus downwards within the salphingopharyngeal fold to blend with the
pharyngeus auditory tube near the palatoharyngeus muscle. Vascular supply of the salphingopharyngeus
pharyngeal opening of muscle receives its arterial supply from the ascending palatine branch
it of the facial artery, the greater palatine branch of the maxillary artery
and the pharyngeal branch of the ascending pharyngeal artery. It is
innervated by the pharyngeal plexus. It elevates the pharynx and
Table 4. Summary of Longitudinal Muscles assists the tensor veli palatine to open the cartilaginous end of the
pharyngotympanic membrane during swallowing.
Note: All the 3 are inserted as a conjoint sheet at the post -Doc Uy

border of thyroid cartilage and lateral aspect of epiglottis

C. STRUCTURE OF THE PHARYNGEAL WALL
STYLOPHARYNGEUS MUSCLE
• From outwards:
NICE TO KNOW! ® Mucus Membrane: Stratified squamous epithelium
“A long, slender muscle symmetrical above, flat below. It arises from the ® Pharyngeal Aponeurosis/Pharyngobasilar Fascia: fibrous
medial side of the base of the styloid process, descends along at the layers lining the muscular coat
side of the pharynx at passes between the superior and middle ® Muscular Coat
constrictor to spread out beneath the mucus membrane. Some fibers
o Outer Circular Layer:
merge into the constrictors and the lateral glossoepiglottic pole. While
others join fibers of palatopharyngeus and are attached to the posterior § Superior
border of thyroid cartilage. The glossopharyngeal nerve curves around § Middle
the posterior border of the lateral side of the stylopharngeus and passes § Inferior Constrictor
between the superior and middle constrictors to reach the tongue. o Inner Longitudinal Layer:
Vascular supply of the stylopharyngeus receive its arterial supply from § Stylopharyngeus
the pharyngeal branch of the ascending pharyngeal artery. Elevation of § Salphingopharyngeus
the stylophryngeus is by the glossopharyngeal nerve. So the § Palatopharyngeus
stylopharyngeus elevates the pharynx and the larynx.”
-Doc Uy ® Buccopharyngeal Fascia: covers the outer surface of the
constrictor muscles

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o Anteriorly, by the posterior pharyngeal wall and
buccopharyngeal fascia
o Posteriorly by the cervical vertebra, their muscles and
fascia
o One on each side, and separated from parapharyngeal
space
o Contains retropharyngeal lymph nodes and connective
tissue

Fig. 20. Structure of the Pharyngeal Wall and Layers of Pharyngeal Fascia

OF THE PHARYNX
D. FASCIA

• Pharyngeal Fascia is separated into two layers
® Buccopharyngeal fascia
layer, coats the outside of muscular part of the wall
o a thin
Fig. 23. Retropharyngeal Space
® Pharyngobasilar fascia
o a much thicker layer, lines the inner surface ® Parapharyngeal Space:

o Present on each side of pharynx,
o contains vessels, jugular vein, last 4 cranial nerves,
sympathetic chain

Fig. 21. Layers of Pharyngeal Fascia

E. PHARYNGEAL SPACES
Fig. 24. Parapharyngeal Space
in relation to pharynx where abscess can form
• Potential spaces

• Parapharyngeal Space is divided into 2 smaller compartments
(styloid process and attached fascia of tensor veli palatini
® Pre-styloid

o Anterolateral
o Ends at hyoid
o Contains pterygoid and tensor veli palatini muscles, fat,
internal maxillary artery, maxillary nerve and tail of the
parotid glad
® Post-styloid
Fig. 22. Pharyngeal Space o Posteromedial
® Retropharyngeal Space: o Continues inferiorly to neck
from the base of the skull
o lies behind the pharynx, extend o Contains carotid artery, internal jugular vein, cervical
to bifurcation of trachea sympathetic chain and cranial nerves 9-12
o Between the buccopharyngeal fascia and prevertebral
fascia, which extends from the skull base to the upper part

of posterior mediastinum (T1,T2)
NICE TO KNOW!
“Veins of the pharynx form a plexus that drains superiorly into the
pterygoid plexus of the infratemporal fossa, and inferiorly into the facial
vein and internal jugular vein.”
-Doc Uy

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F. ARTERIAL SUPPLY

• Upper parts of the pharynx

® ascending pharyngeal
® ascending palatine
® tonsillar branches of
the facial artery
® numerous branches of
the maxillary and the
lingual artery
• Lower parts of the pharynx
® pharyngeal branches
from the inferior thyroid
artery which originates
Fig27. Innervation of Pharynx
from the subclavian
artery Fig.25. Arterial Supply of Pharynx

• Trigeminal Nerve (Tensor Veli Platini, etc)
G. LYMPHATIC DRAINAGE
TO KNOW!
NICE
“Nasopharynx is innervated by pharyngeal branch of maxillary nerve.

Oropharynx is innervated by the Glossopharyngeal nerve.
Laryngopharynx is innervated by the Vagus Nerve.”

-Doc Uy

IV. NASOPHARYNX/EPIPHARYNX

Fig26. Lymphatic Drainage of Pharynx

• Deep cervical nodes:
® Retropharyngeal
® Paratracheal
® Infrahyoid nodes
• Palatine tonsils:
jugulodigastric nodes (inferior to posterior belly of digastric Fig.28 Nasopharynx Fig.29 Structures seen in the Nasopharynx
muscle)

• Opens via posterior choanae
anteriorly into the nose
H. INNERVATION ® Superiorly: adenoid lies on the roof of nasopharynx
Bounded above and behind
® by an elevation called Torus
• Pharyngeal Plexus Tubarius (TT) raised by the cartilage of the tube
® Pharyngeal branch of the Vagus Nerve (X)
® Superior laryngeal branch of the vagus nerve ® Torus Tubarius(book): this reflection of the pharyngeal
® Pharyngeal branch of the glossopharyngeal nerve (IX) mucosa over the rounded protrusions of the cartilaginous
® Almost all of the nerve supply to the pharynx, whether motor portion of the Eustachian tubes projects as a thumblike
or sensory, is derived from the pharyngeal plexus intrusion in the lateral wall of the nasopharynx just above
® Formed by the pharyngeal branches of the the attachment of the soft palate
glossopharyngeal and vagus nerves with contributions from
the superior cervical symphathetic ganglion Aside from patency
® The pharyngeal branch of the vagus supplies all the of eustachian tube,
also check the
muscles of the pharynx
pharyngeal recess
® Excluding stylopharyngeus, which is supplied by because it can be
glossopharyngeal nerve obliterated in the
presence of small
submucosal
masses.

Fig.30 Torus Tubarius

Laterally: opening of eustachian tube occupies region

®
anterior to a recess called the Fossa of Rosenmuller

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o Fossa Rosenmuller also called the pharyngeal recess is D. RATHKE’S POUCH
one of the most common site of nasopharyngeal
carcinoma • A dimple above the adenoids
§ Malignant growth may infiltrate adjacent structures • Reminiscent of buccal mucosal invagination to form the
(e.g. brain, soft palate, auditory tube, nasal cavity) anterior lobe of pituitary
® Tensor veli palatini, muscle that tenses the palate and • Carcinopharyngioma may arise: since they have the same
opens the eustachian tube. embryology of the pituitary gland
® Supplied by mandibular nerve via otic ganglion
E. PASSAVANT’S RIDGE
A. TUBAL TONSILS

• Lining of the Torus tubarius

• Collection of subepithelial lymphoid tissue
• Continuous with adenoid tissue and forms a part of Waldeyer’s
ring
• When enlarged due to infection, it causes eustachian tube
occlusion
• First fat that will disappear: fats surrounding Eustachian
tube (we will experience Eustachian tube dysfunction)

B. ADENOIDS (PHARYNGEAL TONSILS)

Fig.33 Different Angles of Passavant’s Ridge

•A mucosal ridge raised by fibers of palatopharyngeus

• Forms a ring around post and lateral walls of nasopharyngeal

isthmus
• Passavant’s ridge: when soft palate is elevated the muscle

band appear as this ridge
• During act of swallowing palate and the ridge approximated

NICE TO KNOW!
“Passavant’s Ridge is estimated to be present at approximately 11-
Fig.31 Adenoids of the Nasopharynx 30% of normal patients, and approximately 9-41% on patients with
cleft palate. Its function is poorly understood but may aid in

• Sub-epithelial collection of lymphoid tissue at the junction of the preventing reflux of oropharyngeal contents into the nasopharynx.
Some argue that the ridge is too low, too slow, too inconsistent,
roof and posterior wall of the nasopharynx and too easily fatigued to be of essential importance in the normal
• It causes the overlying mucus membrane to be thrown into the speech mechanism.”
radiating poles - Doc Uy
• Tonsils in the nasopharynx
• Hypertrophied adenoids in pediatric age group are normal;
F. FUNCTIONS OF NASOPHARYNX
NICE TO KNOW!
“Adenoids usually increases in size up to the age of 6 years and
gradually disappears.” • Acts as a conduit for air between nose and larynx
- Doc Uy • Ventilates middle ear through Eustachian tube and equalizes
decreases during teenage years air pressure on both sides of TM
• Adult: adenoids are no longer appreciated unless you have • Cuts off nasopharynx from oropharynx with the help of
severe form of allergic rhinitis Passavant’s ridge
• Acts as a resonating chamber for voice production
C. NASOPHARYNGEAL BURSA • Acts as a drainage channel for mucus secreted by nasal and
nasopharyngeal glands
• Epithelial lined median recess found within adenoid mass
• Extends from pharyngeal mucus to periosteum of basiocciput
• Represents the attachment of
notochord to pharyngeal
endoderm during embryonic
development
• Infected → Pharyngeal
bursitis → post nasal
discharge or crusting
• Thornwaldt’s disease:
abscess in the bursa
Fig.32 Nasopharyngeal Bursa

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V. OROPHARYNX • Lateral wall
® Palatine tonsil
® Anterior pillar:
palatoglossus muscle
® Posterior pillar:
palatopharyngeus
muscle
• Tonsillar fossa
® A triangular depression
b/w the anterior and the
posterior pillars
® Lodges palatine tonsils Fig.36 Structures of the Oropharynx

B. VALLECULA

• Cup shaped depressions

• Lying between the base of the
tongue and anterior surface of
epiglottis
Fig.34 Oropharynx • Bounded medially by the
median glossoepiglottic fold
• Middle portion of the pharynx • Laterally by pharyngoepiglottic
• Behind mouth and 2/3 of the tongue fold
of the soft palate to
• Bounded superiorly by the inferior border • Where foreign bodies usually
the lingual surface of the epiglottis get lodged (aside from
• Common to both respiratory and digestive systems Smuggler’s fossa in pyriform
• Oropharyngeal isthmus sinus)
• Posterior wall is smooth Fig.37 Vallecula

• Lateral walls shows palatine tonsils between palatoglossal and C. PALATINE TONSILS
palatopharyngeal arches

• Tonsils is between anterior and posterior pillar
® Anterior Pillar: Palatoglossus
® Posterior: palatopharyngius
• Review:
® Pharyngeal tonsils: Adenoids
® Oropharyngeal: Palatine

Fig. 38 Palatine Tonsils

• Venous drainage
® Peritonsillar plexus which drains into the lingual and
pharyngeal veins and in to the IJV

NICE TO KNOW!
“Each tonsil is on ovoid mass of tissue situated in the lateral wall of
Fig.35 Structure of the Oropharymx the oropharynx. Size varies according to age, individuality, and
pathological status (tonsils may be hypertrophied or inflamed). It is
A. BOUNDARIES OF THE OROPHARYNX therefore difficult to define the normal appearance of the palatine
tonsils. For the first 5-6 years of life, the tonsils increase rapidly in
size. Reaches maximum in puberty with the average of 20-25mm
• Posterior wall in vertical and 10-15mm in transverse diameters. And they project
® Related to retropharyngeal space conspicuously into the oropharynx.”
® Lies opposite the second and upper part of third cervical
vertebrae “Its medial free surface usually presents a pitted appearance. The
10-20 crypts formed by the invagination of the free surface mucosa
• Anterior wall
are narrow tubular epithelial diverticula that often branch within the
® Deficient above tonsil and frequently are packed with plugs of shed epithelial cells,
® Below, it present: lymphocytes and bacteria which may calcify.’
o Base of the tongue, posterior to circumvallate papillae
o Lingual tonsils -Doc Uy
o Valleculae

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BLOOD SUPPLY OF PALATINE TONSILS

• Tonsillar branches of 5 arteries

® Dorsal lingual artery (of the lingual artery)
® Ascending palatine artery (of the facial artery)
® Tonsillar branch (of the facial artery)
® Ascending pharyngeal artery (of the external carotid artery)
® The lesser palatine artery (of the descending palatine
artery)
• Venous drainage
® Peritonsillar plexus which drains into the lingual and
pharyngeal veins and in to the IJV

D. WALDEYER’S RING

• Acts as 1st line of defense against microbes that enters the

body by nasal and oral routes
• Circumferential ring of oropharyngeal lymphoid tissue within
pharynx that includes:
® Nasopharynx (Adenoids)
® Tubal tonsils (Tonsils of Gerlach)
o Tonsils surrounding Eustachian tube
® Oropharynx (Palatine/Faucial tonsils)
® Hypopharynx (Lingual tonsils)

E. LYMPHATIC DRAINAGE

• Oropharynx
® Upper jugular chain, particularly jugulodigastric
(tonsillar) node
• Soft palate, lateral and posterior pharyngeal walls and base of
tongue
® Retropharyngeal and parapharyngeal nodes

F. FUNCTIONS

• Conduit passage for air and food

• Helps in pharyngeal phase of deglutition
• Forms part of vocal tract, help in speech
• Helps in appreciation of taste
• Provide local immunity and defense against harmful intruders

VI. REFERENCES
• Doc Uy’s Lecture
• Boie’s 6th Edition page 273-281
• ViVa Trans

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 Muscles Origin Insertion Innervation Action
Tensor veli palatini Spine of the forms palatine
mandibular tenses the soft palate,
sphenoid; aponeurosis nerve via opens the pharyngotympanic
auditory tube branch to tube
the medial
pterygoid
muscle
Levator veli palatini petrous temporal superior surface of vagus nerve only muscle to elevate the soft
bone, auditory the palatine palate above the neutral position
tube, palatine aponeurosis
aponeurosis
Palatoglossus inferior surface Lateral margin of Vagus nerve depresses soft palate; elevates the
of the the tongue tongue to cause narrowing of the
palatine oropharyngeal isthmus
aponeurosis
Palatopharyngeus Superior surface posterior border Vagus nerve Elevates wall of the pharynx
of the of the thyroid Depresses soft palate,
palatine cartilage and Moves palatopharyngeal arch
aponeurosis pharyngeal toward midline
wall
Musculus uvulae Posterior nasal connective tissue Vagus nerve elevates and retracts the uvula,
spine of the hard of the uvula thickens central region of the
palate soft palate

Table 4. OINA of the Muscles of the Soft Palate

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