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Muscles of Mastication & TMJ Dr. A. S.

D’ Souza 2006

Muscle Origin Insertion Action


Masseter Superficial layer- from the lower Muscle fibres pass [Deep It elevates the mandible to
border of anterior two third of the & Middle- vertical; close the mouth
zygomatic arch Superficial- downward & [Superficial fibres –
Middle fibres from the deep backward] downwards and protraction; deep fibres-
surface of the anterior two third are inserted into the outer retraction]
and lower border of the posterior aspect of the ramus of the
one third of the zygomatic arch mandible
Deep fibres from the deep surface
of the zygomatic arch
Temporalis Temporal fossa below the inferior Fibres converge to form a 1. It elevates the
temporal line [excluding the tendon which passes deep mandible
zygomatic bone] and from the to the zygomatic arch to 2. Posterior fibres –
overlying temporal fascia get inserted into the retract the mandible
coronoid process [its tip,
anterior border and medial
surface]
Lateral Upper head: arises from the infra- Pterygoid fovea [on the Depresses the mandible
pterygoid temporal surface and crest of the anterior surface of the to open the mouth.
greater wing of the sphenoid bone neck of the mandible] and Combined actions of
Lower head – lateral surface of to the anterior margin of lateral and the medial
the lateral pterygoid plate the articular disc and pterygoid muscles of both
capsule of the TMJ the sides protrude the
mandible
When the medial and
lateral pterygoid muscles
of one side act alternately
with the other side they
produce side to side
chewing movements
Medial Deep head: Medial surface of the Medial surface of the Elevation and protraction
pterygoid lateral pterygoid plate ramus and angle of the of the mandible
Superficial head: Tuberosity of mandible, below and [Also see lateral
the maxilla behind the mandibular pterygoid]
foramen and mylohyoid
groove

Nerve supply – branches from the anterior division of the mandibular nerve supply all the muscles of
mastication [developmentally derived from the mesoderm of the first pharyngeal arch].
These muscles move the mandible during mastication and speech.

Temporomandibular joint
The head of the mandible articulates with the temporal bone to form the TMJ.
Type – condylar variety of synovial joint

Articular surfaces
Superior – Articular tubercle and anterior part of the mandibular fossa of the temporal bone

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Inferior – Head or condylar process of the mandible
Articular surfaces are covered with fibro-cartilage. The joint cavity is divided into upper and lower
compartments by the articular disc.

Insertion of Lateral pterygoid & Articular disc


Articular disc
It is oval in shape and morphologically represents the degenerated primitive insertion of the lateral
pterygoid muscle. The disc is attached at the periphery to the fibrous capsule and anteriorly it blends with
the lateral pterygoid muscle. Posteriorly disc splits into an upper and a lower lamella [attached
respectively to the squamotympanic fissure and posterior surface of the neck of the mandible]. The upper
surface of the disc is concavo-convex and the lower surface is concave.

Ligaments of the joint


1. Capsular ligament
2. Lateral [TM] ligament
3. Sphenomandibular ligament
4. Stylomandibular ligament

Capsule
It is attached above to the articular tubercle in front, squamotympanic fissure behind. Below it is attached
to the neck of the mandible, in front it blends with the insertion of the lateral pterygoid.

Lateral ligament – Attached above to the articular tubercle and below to the postero-lateral aspect of the
neck of the mandible.

Sphenomandibular ligament
It is an accessory ligament of TMJ, developmentally derived from the first pharyngeal arch [Meckle’s
cartilage]. It is attached above to the spine of the sphenoid bone and below to the lingula of the mandible.
Near its lower end, the mylohyoid nerve and vessels pierce it.

Stylomandibular ligament
It is also an accessory ligament, formed by the thickening of deep cervical fascia and extends from the tip
of the styloid process to the angle of mandible. The ligament intervenes between the parotid and
submandibular salivary glands.

Blood supply – branches from the maxillary and superficial temporal arteries.
Nerve supply – Articular branches from the auriculotemporal and masseteric nerves
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Fig. To show the muscles acting on TMJ

Fig. Attachments of Temporalis Attachments of the masseter

Movements of the joint


1. Protrusion [protraction] and retraction.
2. Elevation and depression
3. Lateral or side-to-side movement.

In resting position a small space [about 2 - 3 mm] exists between the upper and lower jaws when the lips
are in contact. In occlusal position the teeth of both the jaws are in contact.
During protrusion mandible moves forward [for about 1cm] and the reverse takes place during retraction.
In slight opening of the mouth [depression] head of the mandilble moves on the under surface of the disc,
in wide opening [maximum 5cm] of the mouth, both head of the mandible and the articular disc glide
forwards towards the articular tubercle.
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Fig. Attachments of the pterygoid muscles
Muscles producing movements
Depression – Mainly by lateral pterygoid, assisted by digastric, geniohyoid and mylohyoid muscles.
Elevation – Masseter, temporalis and medial pterygoid muscles
Protrusion – Lateral and medial pterygoid muscles
Retraction – posterior fibres of temporalis, assisted by [middle and deep fibres of] masseter, digastric and
geniohyoid muscles.
Lateral and medial pterygoid muscles of both the sides acting alternatively produce side-to-side
movements.
Applied Anatomy
1. Dislocation of the mandible – During excessive opening of the mouth, the head of the mandible on
one or both the sides may slip in front into the infra-temporal fossa.

Mandibular nerve
It is the largest trigeminal division, supplies teeth and gums of the mandible, skin of the temporal region,
part of the auricle, lower lip, lower part of the face, mucosa of the anterior two thirds of the tongue,
mucosa of the floor of the oral cavity and the muscles of mastication. It has a large sensory root, which
arises from the trigeminal ganglion and a small motor root [arises from nucleus in the pons] that passes
under the ganglion. Both roots pass through the foramen ovale and just outside the skull join with each
other to form trunk of the mandibular nerve. The nerve descends between tensor veli palatini medially and
lateral pterygoid muscle laterally, in between the nerve and tensor palatini is the otic ganglion. After
giving a few branches the nerve divides into anterior [smaller- mainly motor] and posterior [larger –
mainly sensory] divisions

Branches
1. From the trunk – Meningeal, nerve to medial pterygoid
2. Anterior division – Buccal, masseteric, deep temporal and nerve to lateral pterygoid
3. Posterior division – Auriculo-temporal, Inferior alveolar and lingual

Meningeal branch [nervus spinosus]


It enters the skull through foramen spinosum along with the middle meningeal artery and divides into
anterior and posterior branches to supply meninges mainly of the middle cranial fossa.

Nerve to Medial pterygoid


It supplies medial pterygoid and provides a few branches to the otic ganglion [pass without interruption]
to supply tensor tympani and tensor veli palatini.
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Buccal nerve
It is the only sensory branch from the anterior division, passes between the two heads of lateral pterygoid
to pass anterior to the masseter. It supplies skin over the buccinator and buccal mucous membrane

Masseteric nerve
It passes laterally above the lateral pterygoid and then emerges through the mandibular notch [along with
masseteric vessels]. Nerve supplies the muscle from its medial aspect and gives a branch to the TM Joint.

Deep temporal nerves


Usually two anterior and posterior pass above the lateral pterygoid to supply the temporalis

Lateral pterygoid nerve – enters the deep surface of the muscle

Inferior alveolar nerve


It conveys sensory and motor fibres. It passes downwards and forwards between the mandibular ramus
and sphenomandibular ligament to enter the mandibular foramen along with inferior alveolar vessels.
Within the mandible the nerve runs in a canal and divides into incisive and mental nerves

Branches
1. To molar and premolar teeth and the adjoining gum
2. Incisive nerve – runs in the same canal and supplies canine and incisor teeth and the adjoining gum
3. Mental nerve – emerges through the mental foramen to supply the skin of the chin and lower lip
4. Mylohyoid nerve [motor] – arises from the inferior alveolar nerve before it enters the mandibular
foramen. The nerve pierces sphenomandibular ligament and is then lodged in a groove on the ramus
of mandible. It reaches the digastric triangle and supplies mylohyoid and anterior belly of digastric.

Auriculotemporal nerve
It usually arises by two roots, which encircle the middle meningeal artery. The nerve then passes
backwards under cover of the lateral pterygoid and above the first part of the maxillary artery. The nerve
turns laterally posterior to TMJ and ascends behind the superficial temporal vessels to enter the temple
where it divides into branches.
It receives communicating branches from the otic ganglion that convey secretomotor fibres to the parotid
gland. Auriculotemporal nerve provides auricular branches to the upper part of the auricle, roof and
anterior wall of the meatus. It also gives articluar branches to the TMJ and superficial temporal branches
to the temple

Lingual nerve
It lies anterior to the inferior alveolar nerve, in between lateral pterygoid and tensor veli palatini. It
receives chorda tympani from behind and passes downwards and forwards to come in close contact with
the mandible medial to the third molar tooth. Here it lies between the origins of superior constrictor and
mylohyoid and is covered only by the mucous membrane of the gum [The nerve is palpable against the
mandible about 1cm below and behind the third molar tooth]
The nerve passes medially resting on the hyoglossus; the submandibular ganglion is suspended from the
lower border of the nerve. Lingual nerve winds round the submandibular duct, provides sensory branches
to the mucous membrane of the presulcal part of the tongue, floor of the mouth and mandibular gum.

Submandibular ganglion
¾ It is a peripheral parasympathetic ganglion, topographically connected to the lingual nerve, but
functionally connected to the facial nerve [chorda tympani]. It lies on the hyoglossus muscle below
the lingual nerve and above the deep part of the submandibular gland.
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¾ Parasympathetic root is the posterior root from the lingual nerve; preganglionic fibres arise from the
superior salivatory nucleus in the pons. Fibres pass successively through facial, chorda tympani, and
lingual nerves. The postganglionic fibres pass to the submandibular gland; some fibres join the
lingual nerve through the anterior root and supply the sublingual and anterior lingual glands.
¾ Sympathetic root is from the plexus around the facial artery [postganglionic fibres from the superior
cervical ganglion], fibres pass through the ganglion without interruption to reach the corresponding
glands

Maxillary artery
It is the larger terminal branch of the ECA, within the substance of the parotid gland behind the neck of
the mandible. It has a wide territory of distribution and supplies - External ear, middle ear, auditory tube,
duramater, upper and lower jaws, muscles of temporal and infra-temporal region, nose, para nasal sinuses,
palate and pharynx.

Course
Artery is divided into 3 parts by the lateral pterygoid muscle
1. First [mandibular] part – Passes between neck of the mandible and the sphenomandibular ligament.
2. Second [pterygoid] part – Runs either superficial or deep to the lower head of the lateral pterygoid
muscle.
3. Third [pterygopalatine] part – Through the pterygomaxillary fissure it enters the pterygopalatine fossa.

Branches
First part
1. Deep auricular artery – Supplies external auditory meatus, tympanic membrane and the TMJ.
2. Anterior tympanic artery – Supplies the middle ear.
3. Middle meningeal artery – refer later.
4. Accessory meningeal artery - Enters the skull through foramen ovale.
5. Inferior alveolar artery - See later.
Second part
1. Anterior and posterior deep temporal branches.
2. Pterygoid branches
3. Masseteric artery.
4. Buccal artery.
Third part
1. Posterior superior alveolar artery
2. Infra-orbital artery.
3. Greater palatine artery.
4. Pharyngeal artery.
5. Artery of the pterygoid canal.
6. Sphenopalatine artery.

Middle meningeal artery


It is a branch from the first part of the maxillary artery, given off in the infra-temporal fossa. It enters the
cranial cavity [middle cranial fossa] by passing through the foramen spinosum along with the meningeal
branch [nervus spinosus] of the mandibular nerve. It runs in the extradural space in a groove on the
squamous part of the temporal bone and divides into a frontal [anterior] and a parietal [posterior] branch.
Frontal branch is larger runs parallel to and a little in front of the central sulcus of the brain.

Branches
1. Ganglionic branches – to the trigeminal ganglion
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2. Petrosal branch
3. Superior tympanic branch
4. Temporal branches
Note: Middle meningeal artery supplies cranial bones more than the meninges.

Applied Anatomy
Middle meningeal artery may be damaged in head injuries resulting in extra-dural hemorrhage. Frontal
branch is more commonly involved, hematoma presses on the motor area resulting in hemiplegia of the
opposite side. Rarely parietal branch is involved leading to contra lateral deafness.

Inferior alveolar artery


It is accompanied by the corresponding nerve, enters the mandibular foramen, and runs within the
mandibular canal. It gives out branches to molar and premolar teeth and the adjoining gums before
dividing into mental and incisive branches. Before entering the mandibular canal, artery gives a lingual
and mylohyoid branches.

PHARYNX Dr. A. S. D’ Souza


Pharynx is a musculomembranous tube, extending between the base of skull and the sixth cervical
vertebra [lower border of cricoid cartilage], where it continues as the oesophagus.

It is situated behind the nasal cavity, oral cavity and larynx.


Divided into three parts
1. Nasopharynx
2. Oropharynx
3. Laryngopharynx.

Boundaries
Superior - base of the skull [body of the sphenoid and basilar part of the occipital bone]
Inferior - continuous with the oesophagus at the level of C6
Posterior - pharynx glides freely on the pre-vertebral fascia.
Anterior - wall is incomplete - communicates with nasal cavity, oral cavity and larynx.
On each side – communicates with the middle ear cavity through the auditory tube [pharyngotympanic or
Eustachian tube]. This maintains equilibrium of air pressure on both the sides of the tympanic membrane.

Measurements:
Length –12 to 14 cm
Width - Maximum at the roof 3.5 cm, minimum at the pharyngo-oesophageal junction 1.5 cm.

Nasopharynx
Nasopharynx is a respiratory passage, situated behind the nasal cavity. Its walls are rigid and non
collapsible and is lined by respiratory epithelium. Mucous membrane is supplied by the trigeminal nerve
[pharyngeal branch of pterygopalatine ganglion].

Features
Anteriorly- communicates with the nasal cavity through the posterior nasal apertures.
Inferiorly – communicates with the oropharynx by nasopharyngeal / pharyngeal isthmus [nasopharyngeal
isthmus is bounded by the lower border of the soft palate and posterior wall of the pharynx]. Elevation of
the soft palate and constriction of the palatopharyngeal sphincter close the isthmus during swallowing.

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Roof and posterior wall form a continuous sloping surface formed by the body of sphenoid, basilar part of
occipital bone and anterior arch of atlas. Under the mucous membrane opposite the basiocciput, there is a
collection of lymphoid tissue - pharyngeal tonsil.

Pharyngeal tonsil [Nasopharyngeal tonsil]


It is a collection of lymphoid tissue beneath the mucous membrane, projects downwards and forwards as a
conical mass. It is larger in children during 2 to 6 years of age and then starts diminishing in size
[involution and atrophy from the age of 8]. Inflammation and enlargement is adenoids, which causes
difficulty in nasal breathing. A median recess extending upwards and backwards into the substance of the
nasopharyngeal tonsil is pharyngeal bursa [of Luschka] – site of rostral end of the embryonic notochord.

Lateral wall - has the following features


¾ Pharyngeal opening of the auditory tube - slightly below and 1.2 cm behind the inferior nasal concha.
¾ Tubal elevation - guards the upper and posterior margins of the auditory tube opening, produced by
the underlying cartilaginous part of the auditory tube. Tubal tonsil overlies the tubal elevation.
¾ Salpingo pharyngeal fold – is a vertical fold of mucous membrane running downwards from the tubal
elevation. The underlying salpingopharyngeus muscle produces this fold. Salpingo palatine fold –
mucous fold below the tubal elevation to the soft palate, produced by the levator palati muscle.
¾ Pharyngeal recess - depression extending side ways, posterosuperior to the tubal elevation.

Oropharynx
It lies behind the oral cavity, communicating with it through the oropharyngeal isthmus. Below it
communicates with the laryngo pharynx at the level of upper border of the epiglottis. Posteriorly - bodies
of C2 & C3 support it. Lateral wall has the palatine tonsil, lodged in the tonsillar sinus [fossa].

Laryngopharynx
Lower part of the pharynx, situated behind the larynx, extends from the upper border of epiglottis to the
lower border of the cricoid cartilage. Posteriorly supported by the 4th, 5th and the 6th cervical vertebrae.
Lateral wall - presents a depression - the piriform fossa, on each side of the inlet of larynx.

Piriform fossa – bounded medially by the aryepiglottic fold; laterally by the thyroid cartilage and
thyrohyoid membrane. Deep to the mucous membrane lies the internal laryngeal nerve and superior
laryngeal vessels. Foreign body may be lodged in the piriform fossa and care to be taken during its
removal; damage to the nerve may cause anaesthesia in the supra-glottic part of the larynx.

Structure of the Pharynx


Composed of the following layers from within outwards
1. Mucosa.
2. Submucosa.
3. Pharyngobasilar fascia - fibrous sheet internal to the pharyngeal muscles. It is thickest in the upper
part where it fills the gap between base of the skull and the superior constrictor.
4. Muscular coat - consists of outer circular [made up of 3 pairs of constrictors] and an inner longitudinal
layer made up of the stylopharyngeus, palatopharyngeus and salpingopharyngeus.
5. Buccopharyngeal fascia - Covers the outer surface of constrictor muscles. Between the muscular coat
and the buccopharyngeal fascia are the pharyngeal plexus of nerves and veins.

Muscles of pharynx
1. Superior constrictor
Origin - from above downwards - pterygoid hamulus, pterygomandibular raphe, medial surface of the
mandible at the posterior end of the mylohyoid line and side of the posterior part of the tongue.
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2. Middle constrictor
Origin - a. Lower part of the stylohyoid ligament.
b. Lesser cornu of the hyoid bone.
c. Upper border of the greater cornu of the hyoid bone.

3. Inferior constrictor [thickest of the three] - Consists of two parts


a. Thyropharyngeal part - arises from the oblique line of the lamina of the thyroid cartilage and
inferior cornu of the thyroid cartilage.
b. Cricophararyngeal part arises from the side of the cricoid cartilage.

Fig. Median sagittal section to show the oral & nasal cavities & pharynx

Hypopharyngeal diverticula – pharyngeal mucosa that lies between the cricopharyngeus and
thyropharyngeus is relatively unsupported by pharyngeal muscles – dehiscence of Killan. A delay in
relaxation of cricopharyngeus, which can occur when the swallowing mechanism becomes discoordinated
can result in pulsion diverticulum [a pouch of prolapsing mucosa] at the level of C6.

Insertion of constrictors
All the constrictors are inserted into a median raphe on the posterior wall of the pharynx, upper end of
which reaches the base of the skull, where it is attached to the pharyngeal tubercle on the basilar part of
the occipital bone.

Stylopharyngeus
Origin: From the medial surface of the base of the styloid process
Insertion: Muscle enters the pharynx in the gap between the superior and middle constrictors, joins with
the palatopharyngeus and salpingopharyngeus and is inserted as a conjoint sheet to the posterior border of
the thyroid cartilage. Some fibres spread in the posterior wall of the pharynx and meet with similar fibres
of the opposite side across the median fibrous raphe.

Salpingopharyngeus
Arises from the cartilaginous part of the auditory tube, insertion is similar to that of stylopharyngeus.
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Palatopharyngeus
[Muscle raises a fold of mucous membrane – palatopharyngeal arch or fold].
Origin - from the palatine aponeurosis
Insertion - conjoined sheet to the lamina of the thyroid cartilage. Some fibres sweep backwards to form a
‘U’ shaped loop in the posterior wall of the pharynx [Passavant’s ridge].

Fig. To show the origin of constrictors

Nerve supply
The pharyngeal plexus (except stylopharyngeus – supplied by the glossopharyngeal nerve), supplies all
the muscles of the pharynx. The inferior constrictor muscle in addition receives fibres from external and
recurrent laryngeal nerves.

Pharyngeal plexus: Chiefly lie on the middle constrictor and is formed by the fibres of
1. Pharyngeal branch of vagus - carrying fibres of the cranial part of the accessory nerve [motor]
2. Pharyngeal branches of glossopharyngeal nerve [sensory in general except (motor) to stylopharyngeus]
3. Pharyngeal branches of superior cervical ganglion [sympathetic].

Actions of muscles
Constrictors contract during deglutition and induce a wave of peristalsis. Longitudinal muscles elevate
and shorten the pharynx during swallowing.

Gaps between the muscles and the structures related to them.


¾ Gap between the base of the skull and the upper border of the superior constrictor [sinus of
Morgagni], closed by the strong part of the pharyngobasilar fascia. Auditory tube, levator palatini and
ascending palatine artery pass though this.
¾ Gap between the superior and the middle constrictor - gives passage to stylopharyngeus and the
glossopharyngeal nerve.
¾ Internal laryngeal nerve and superior laryngeal vessels pierce the thyrohyoid membrane and pass
between the middle and the inferior constrictors.

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¾ Between the inferior constrictor and the oesophagus – pass recurrent laryngeal nerve and inferior
laryngeal vessels.

Fig. Wall of the pharynx seen from behind


Blood supply of Pharynx
Arteries: 1. Ascending pharyngeal branch of external carotid artery.
2. Ascending palatine and tonsillar branches of the facial artery.
3. Dorsal lingual branches of lingual artery.
4. Greater palatine, pharyngeal and pterygoid branches of maxillary.

Veins form a plexus on the wall of the pharynx, which drains into the facial / internal jugular vein.

AUDITORY TUBE
Also known as pharyngotympanic or Eustachian tube, it communicates nasopharynx with the middle ear
cavity. It is 3.6 cm long, has got a bony [lateral one third] and a cartilaginous part [medial two thirds].

Bony part - Lies in the petrous part of the temporal bone, lateral end of which is wide and opens into the
anterior wall of the middle ear cavity. Medial end gives attachment to the cartilaginous part.
Cartilaginous part - Lies in a groove - sulcus tubae between the greater wing of the sphenoid and the
petrous part of the temporal bone. Medial end opens into the nasopharynx, after producing an elevation of
mucous membrane [tubal elevation].

Arterial supply: Branches from -1. Ascending pharyngeal 2. Middle meningeal 3. Artery of the
pterygoid canal.Veins drain into pharyngeal and pterygoid venous plexus. Lymphatics pass to the
retropharyngeal lymph nodes.

Nerve supply
1. Pharyngeal branch of pterygopalatine ganglion [maxillary nerve]
2. Nervous spinosus [mandibular nerve]
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3. Tympanic plexus [glossopharyngeal nerve]

Tube communicates middle ear cavity and the nasopharynx, equalizes air pressure on both sides of the
tympanic membrane. Tube is usually closed, opens during swallowing, yawning, sneezing etc. by the
action of tensor and levator palati muscles. Infections may pass from the throat to the middle ear cavity
through the tube, more common in children because the tube is shorter and straighter.

Waldeyer’s lymphatic ring – a circumpharyngeal lymphoid tissue, which surrounds the openings into the
respiratory and digestive tubes. It is made up of anteroinferiroly the lingual tonsil, laterally by the palatine
and tubal tonsils, and posterosuperiorly by the nasopharyngeal tonsil.

Palatine Tonsil
It occupies the tonsillar sinus between the palatoglossal and palatopharyngeal folds [arches], on the lateral
wall of the oropharynx.
It has – 2 borders - anterior and posterior, 2 surfaces - medial and lateral and 2 poles - upper and lower.

Medial surface - free bulges into the oropharynx, lined by stratified squamous non-keratinized epithelium.
This surface has 12 -15 small pits - tonsillar crypts, deepest of all is referred to as intratonsillar cleft [was
wrongly named supratonsillar fossa / cleft], represents the internal opening of the 2nd pharyngeal pouch.

Lateral surface - is covered by the capsule derived from the pharyngobasilar fascia.
Relations of the lateral surface [from medial to lateral] -1. Loose areolar tissue
2. Pharyngobasilar fascia.
3. Superior constrictor muscle of pharynx.
4. Buccopharyngeal fascia with pharyngeal plexus of nerves and vessels.

Anterior border - related to palatoglossal arch


Posterior border - related to palatopharyngeal arch
Upper pole - related to the soft palate
Lower pole - related to the tongue

Arterial supply
1. Main source is from the tonsillar branches of facial artery
2. Additional sources are from the tonsillar branches of ascending palatine [facial], dorsal lingual
[lingual], ascending pharyngeal [external carotid] and greater palatine arteries [maxillary].

Venous drainage – one or more veins [paratonsillar] leave the lower part of the deep surface of the tonsil,
pierce the superior constrictor and join the pharyngeal venous plexus.
Lymphatics pass to the jugulo-digastric lymph nodes [situated below and behind the angle of mandible, in
a triangular interval between the posterior belly of digastric and the junction of common facial vein and
internal jugular veins, enlarged in tonsillitis].

Nerve supply
The glossopharyngeal, greater and lesser palatine nerves supply tonsil.

Applied Anatomy
1. Tonsils are larger in children [start diminishing in size after puberty]. Tonsils are frequently sites of
infection called Tonsillitis. Tonsillitis may cause referred pain in the ear [same nerve supply].
2. Repeated infection, enlargement and abscess formation [peritonsillar abscess], may require surgical
removal [tonsillectomy].
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