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Chapter 41 Oral Cavity and Pharynx Anatomy and Physiology of the Pharynx “The RPE nds rom the bes of shalt theopper ond of the esophaguatthe level of the th cervical veriebra (Ege. luisa bromuscular structure condting ofthe following layers from without inward 1, air apr pon aeroge Muscle layer Pharyrgubeilat facia Moca ‘The pha dividd ito three pats: (0) nasopharynx, Gi) oropharynx, and (iii) laryngopharynx. NASOPHARYNX “The part of hati which ies above the oft palit andbehind the msal cavity called the nasophacynx Basisphenoid and basocciput form the rot of the naso- "The upper part ofthe posterior walls formed bythe terior arch of the all On the atera als aethe pharyngeal ‘openings of the eustachian tubes about 1.25 em behind the ord atte Sof palate Fig. 4.1: Sagial secon trough the upper ait pages and esophagus Posterior end ofthe inferior turbinate. Above and behind, the tubal opening is a deep recess which is commonly a site for ‘arcinoma and is called the fsa of Rovenuller, Nasopharyngeal Tonsil Itisa colletion of lymphoid tissue under the mucosa of the nasopharynx situated atthe junction of the roof and posterior wall of the natopharynx. The collection disappears asthe child starts growing. Hypertrophy of this lymphoid tissue is termed as adenoids. This lymphoid collection has no capsule. In the centre of the lymphoid mass isa depression called pharyngeal hres Thormald'c cst. develo frm the bre OROPHARYNX ‘This is that part of the pharynx which extends from the level of the soft palate tothe level of laryngeal inlet, below an imaginary horizontal line drawn at the level of the hyoid hone. ‘Anteriorly, the oropharynx opens in the buccal cavity a the ‘oropharyngeal isthmus formed by the faucal pillars Tonsil “Tonsils are organized lymphoid structures situated between the facial pillars. The tonsil fossa is formed by the palstogosal and palatopharyngeal folds and posterior part of these ofthe tongue. A fold of mucous membrane, pica semilunariseonnects the palatoglossal and palatopharyngeal folds superiosy. The pica triangularis is mother fold of mucous membrane which connects the palatoglossal and palatopharyngeal folds at the lower pole of the ton The tonsil is covered by stratified squamous epithelium. "The medial surface ofthe tonsil shows a numberof crypts. An intratonsllar cleft is seen atthe upper part ofthe tonsil and is «remnant of the second pharyngetl pouch, ‘The lateral surface of the tonsil is covered by a fibrous ‘capsule attached loosely tothe tonsillar bed. Tomsllar bed Wt is formed by loose areolar tissue, pharynge: basilar fascia, superior constrictor muscle and buccopharyn: [198 pa fsa. The item carotid Seton Blood supply of tonsil: Tonsillar branch of the facia artery isthe ‘main artery of supply. Branches of the following arteries also supply the tonsils ‘Ascending pharyngeal artery Descending palatine artery fil, Dorsalislinguae artery iw. Ascending palatine branch of faci ery lies one inch lateral to tery Veins: Veins emerge on the lateral surface and lower pole of the tonsil. Pratonsilla vein emerges on the lateral surface and pierces the superior constrictor muscle to end inthe common facial vein and pharyngeal plexus of veins. Lymphatic drainage: The efferent lymphatics emerge from the lateral aspect and end in the jugulodigastric group of deep cervical nodes, There are no afferent lymphatics, Wiakdever' Ring The lymphatic tissues of the pllaryiie and oral cavity are arranged ia ring-like panne around the oropharyngeal inet (Fig. A1.2-Te inner ring consists maa ofthe nasopharyngeal tonsil estaba Iymphoid tnwes faucal tonal and lingbal tonsil The fens from thisting rain to Iymph nods situated around the neck forming the outer ring. The lymphoid tissues have protective function. Fig. 41.2: Walder lymphatic rng and fs connections LARYNGOPHARYNX (HYPOPHARYNX) ‘This part of the pharynx lies behind the larynx and partly surrounds the larynx. Superior it communicates with the oro- pharyns and starts atthe level of the hyoid bone. Inferiory, extends upto the upper end ofthe esophagusatthelowerborder ofthe cicoid artilge. tis divided into theee parts: () pyrifoem sinus, (i) postcricoid region, and (i) posterior pharyngeal wal Pyrform Fossa ‘The pyriform fossa is a recess on each side of the larynx. Ii bounded medially by the aryepiglottic fold, laterally by the thyrohyoid membrane in the upper part and medial surface of the thyroid cartilage in the lowe part Superior, the fossa is separated from the vallecula bythe pharyngoepigiottc fol. “The fossa communicates below withthe upper end ofthe esophagus. Postercoid Region ‘The postctioid regions the lower part of the laryngopharynx and is formed by mucosa extending from the upper to lower border ofthe cricod cartilage. Posterior Pharyngea! Wall ‘This part of the hypopharynx extends from the level of the byoid bone down up to the upper end of the esophagus. The rest of the mucosa is included into the lateral pharyngel wall. MUSCLES OF PHARYNX “Two layers of muscles form the pharyngeal wall. The circular layer is formed by the superior, middle and inferior constrictors: which form the side and posterior wal ofthe pay. The Tong! mc lier formed bythe plstopharynges ded srlophuryogsis mel, Twe placyged meses hoa deghtiion. Whe the longitudinal muscles clean the ya, the circular group bel in propelling the bolus down NERVE SUPPLY Pharynit is supplied through pharyngeal plexus which lies rainly on the middle constrictor muscle. Ths is formed by the pharyngeal branches of the vagus and glossopharyngeal nerves and sympathetic fibers around the vessels. The vagus supplies the motor fibers through its cranial accessory nerve “The glossopharyngeal isthe main sensory nerve but supplies motor fibers tostylopharyngeus. The recurrent laryngeal nerve sends aeanch tothe inferior constrictor. Soft Palate Itisa fibromuscular structure attached tothe posterior edge of the hard palateby the palatine aponeuross, which is formed by the expanded tendons of tensor palati muscles, ther muscles hich take partinits formation ar lrior pla palatloens, Falatopharyogeus and muscalosuvuae Laterally, the soft palate is attached to the pay Posterony iti fe. [NERVE SUPPLY Allthe musclesof the soft palate except tensor palat are supplied by the cranial root of the accessory through the vagus. Tensor supplied by the mandibular division ofthe trigeminal ‘The soft palate plays nasopharyngeal isthmus and speech. PASSAVANT'S RIDGE OR BAR ‘Thisis a rounded ridge which appears on the posterior pharyn- ‘gel wall during closure of the nasopharyngeal isthmus. The ree horde of the soft palate cones in contact with this ridge to close the nasopharynx during degluttion. The ridges raised by the contraction of upper fibers of the superior «constrictor and the palatopharyngeus muscle. Physiology of the Pharynx important role in closure of the 1, therefore, helps in deglutition [a RR ore lowing pros 1, Beene aad Wd foe A Apepueal gee el ee i is frlitimushones protective role 3. Phang mca re important for degton, ‘The OMIM plays an importa role i speech 1 ts tes reonstoc of the vr, Bsn the BIGGE » t foc various sete snd led fo the opening of te cain aoa. FUNCTIONS OF THE PHARYNGEAL LYMPHOID TISSUES “The exact functions of the subepithelial lymphoid tsnues are sot very clear. These probably playa dfensiverole. Thestategic location of the faucal tonsils and nasopharyngeal lymphoid tises suggests that these structures are concerned with sampling of airand food and thus constantly monitor the bacteria flora Antibodies are formed against these microorganisms and thus haelpin the body's defence mechanism, Sines, these lymphoid structures atrophy with the growth it appears that this defence ‘mechanism is mainly ative during childhood. Deglutition Degluttion isa process by which food passes from the oral cavity into the stomach through the esophagus. Ths process involves three stages: Fi ag (lary: fr he fod a mand and mde Ct fol Ge oe oe eat pape ibeieccsepetea name canse as oie ‘Second stage (pharyngeal stage): In this stage, food passes from pegeoeeinai a uote uropaa ec ahaa itased on rope csed to prover od fom going into the trachea. Retroversion of the epiglottis helps to ee nce meen Bese he tape pel ere el The idol tad parygpop hapa eon op Motor bss etch pled So Oy re a theca ude of Third stage (esophageal stage): Ths stage consist of passage of food down the esophagus. Once the ricopharynx opens, the food passes into the esophagus tis carried down by peristaltic waves. The cardia sphincter opens in response othe peristaltic ‘waves and food thus enters the stomach. Inaddition, deglutition also serves the following functions. i. Disposal of dust and bacteri-laden mucus conveyed by ciliary action to the from nasal passages, sinuses, tympanic cavities, larynx and tracheobronchial tre. ii, Opening of the pharyngeal ostia of pharyngotympanic tubes, to establish equalization of pressure on the outer and inner surfaces ofthe tympanic membranes. ‘The resting intrapharyngeal pressure is equal to the atmospheric pressure, During swallowing, there ia transitory rise of about 40 mm Hi pressure at the pharyngoesophageal junction. There occur a region of raised pressure about 3 em in length. During swallowing this pressure falls abruptly just before the pharyngeal peristaltic wave reaches this rome. This indicates a relaxation of the sphincter. Immediately after the bolus has passed the sphincter contracts strongly with arise of pressure to 50 to 100 mm Hy This abrupt closure coincides With the arrival ofthe pharyngeal peristaltic wave and has the function of preventing reflux while peristalsis is occurring in the upper esophagus. When the bolus has passed further down the esophagus, the pressure in the pharyngoesophageal zone returns to normal thesphincter returns to the normal state of tonic contraction ‘SOUNDS DURING DEGLUTITION ‘Two sounds can be heard on auscultation over the esophagus