The pharynx

The pharynx is an incomplete

muscular tube, open anteriorly,
that extends from the base of
the skull to the inlet of the
esophagus at the level of the
sixth cervical vertebra.
 Traditionally, the pharynx is
subdivided into three parts:

The nasopharynx

the pharynx the oropharynx

the laryngopharynx
The nasopharynx
posterior to the
nasal complex

The oropharynx
posterior to the
oral cavity

The laryngophary
posterior to the
upper larynx
The nasopharynx

The oropharynx

The laryngophary
 The pharynx is lined internally
by a thick mucosa covered by
squamous epithelium that
contains discrete aggregates of
lymphoid tissue
The nasopharynx
In the vault of the
nasopharynx is the
adenoid ,which is a
mass of lymphoid
tissue with a central
segment and two
lateral bands. The
surface of the
adenoid is covered
by a respiratory-type
epithelium.
The adenoid
• The adenoid is present at birth, but its
size varies depending on age. The
adenoid grows slowly to a maximum
size around the age of 4 years and
thereafter slowly regresses .In the adult
the adenoid is usually only a
comparatively small mass of tissue.
The eustachian tubes

The
eustachian
tubes

The eustachian
tubes open into the
lateral walls of the
nasopharynx.
 The oropharynx
• The oropharynx is bounded anteriorly
by the oral cavity and the base of the
tongue. The pharyngeal tonsils are
present in its lateral walls. The
pharyngeal tonsils are large masses of
lymphoid tissue ,one on each side . The
size of the tonsils may vary
considerably between individuals.
The oropharynx
 The tonsils

The pharyngeal
tonsils are large
masses of lymphoid
tissue,the surface of
the tonsil is covered
by squamous
epithelium and
contains numerous
crypts.
 The tonsils

Epithelial debris and saprophytic

bacteria collect in these crypts and may
present as small, yellow masses
that should not be mistaken for
pustules.
The lingual tonsils are large aggregates
of lymphoid tissue on the base of the
tongue. They may be of considerable
size.other lymphoid aggregates are
scattered throughout the posterior wall
of the pharynx.
Waldeyer’s ring
• The adenoid,
pharyngeal tonsils,
lingual tonsils, and
lymphoid
aggregates form a
somewhat
continuous circle of
lymphoid tissue
around the lumen of
the pharynx that is
known as
Waldeyer’s ring.
 The valleculae

• The valleculae are two depressions

between the epiglottis and base of
the tongue, which are separated
from each other by a frenulum-like
fold of mucosa.
 The base of
the tongue

The
epiglottis
The
valleculae
 The laryngopharynx

• The laryngopharynx is a small but

important area that is bounded
anteriorly by the larynx and
posteriorly by the prevertebral
fascia,and inferiorly by the inlet of
the esophagus.
• The laryngopharynx extends
downward to two gutters (on
each side of larynx), which are
the pyriform sinuses. Each wall
of the pharynx contains
innumerable minor salivary
glands that keep the surface
constantly moist.
• The important anatomic
relationships of the pharynx
are as follows: laterally, the
common carotid and
external and internal carotid
arteries, vagus nerve, and
contents of the neck.
pyriform
sinuses
 Physiology of Pharynx

• The pharynx is a passage for inspired

and expired air. It also serves as
resonating chamber for the sound
produced in the larynx. But pernaps its
most important function is deglutition.
The pharynx is not a passive food-way,
but takes active part in deglutition.
Deglutition has got three stages:

• The oral stage.

• The pharyngeal stage .

• The esophageal stage.

• Food and fluids are received in the
oral cavity. Solids are minced fine
by the teeth. Saliva mixes with
food and serves three purposes:
first it starts the process of
digestion, secondly it lubricates
food and thirdly it brings
temperature of food to that of the
body.
• The sensory and the motor paths are
formed by the pharyngeal plexus. The
oropharynx opens into four cavities.
Above is the nasopharyngeal isthmus,
leading into the nasopharynx. Below
and infront is the aditus of the larynx
and below and behind is the esophagus.
Since the bolus has to pass into the
esophagus the other three apertures
must close.
• The function of the tonsils is not definitely
settled, but most workers believe that they
help in the manufacture of antibodies
against external invaders. They catch
bacteria from food, fluids and air. These
bacteria live in the crypts. Here they find
food ,warmth and moisture and multiply.
Some 0f them enter the blood stream;
others throw out their toxins.They are used
by the body defence mechanism to
manufacture antibadies.
The function of the pharynx maybe summed
up as under
• a. Passage for food and fluids (swallowing)
• b. Passage for respired air.
• c. Passage for lacrimal and nasal secretions.
• d. Passage for expectoration and vomitus.
• e. Resonance and speech.
• f .Taste.
1.Lymphoid tissue

• g. Protective: 2.Mucous blanket

3.Cough reflex
 Clinical Symptom of the Pharynx

• Symptom

• There are three types of symptoms

from diseases of the throat:

• 1. General
• 2. Local
• 3. Distant
 General Symptoms

• Rise of temperature and pulse rate

from infective disorders.
• There may be cachexia and
anaemia from inability to ingest
food in sufficient quantity.
• Lymph node enlargement in the
neck.
 General Symptoms

• In infective conditions in children,

general symptoms are more
marked than local; whereas in
adults local symptoms are more
marked than general.
 Local symptoms

• A. Pain(sore throat ).
This is an important symptom in
infective conditions of the throat. It may
be slight or severe, so much so that it
may give rise to dysphagia and even
trismus. Whenever a patient complains of
pain in the throat, he should be critically
questioned whether he feels pain or is it
just a sense of irritation.
2
 A. Pain

• The former is typical of inflammation,

whereas the latter is met within allergy
of the throat and should be a warning
to the surgeon to refrain from surgery
on the throat unless clearly indicated
by the local condition of the tonsils.
 A. Pain

• The patient Should be questioned

regarding the total duration of pain and
whether it is continuous or intermittent
and if the latter, the duration of each
attack and the length of the intervals in
between.
 A. Pain

• The author's standard for

removing the tonsils is a total
duration of a minimum two
years, and the intervals in
between the attacks about
three month or less.
 A. Pain

• There should be acute pain,

preferably with rise of
temperature,enlargement of the
tonsillar lymph nodes and
responding to specific therapy.
Sometimes, pain is referred to the
ears.
 B. Cough
• B. Cough:
Cough from diseases of the pharynx
is usually unproductive and is
due to irritation in the throat on account
of infected tonsils or hypertrophy of the
lymph follicles under the mucous
membrane of the throat, i. e. granular
pharyngitis.
 B. Cough

Whenever a patient comes for

the relief of cough which
presumably he thinks is from the
throat, the surgeon should take
some pains to exclude other
causes of cough before embarking
upon removeal of tonsils.
 C. Dysphagia
• C. Dysphagia
In inflammatory condition of the
throat, the patient feels pain during
deglutition. In anaemias and atrophic
conditions of the pharyngeal
mucosa,there is dysphagia on account of
lack of secretion of mucous glands which
normally lubricates bolus.
 C. Dysphagia
In paralysis of the palate and the
pharynx, the food cannot be swallowed
properly and it may find its way into the
nose from inability of the palate to shut
off the nasopharynx from oropharynx.
This condition is called nasal
regurgitation.
 C. Dysphagia

The food may also find its way

into the larynx, if this cannot be shut
off adequately on attempted
swallowing there is a severe bout of
coughing
 C. Dysphagia

In growths of the pharynx, the

food gets obstructed on its way down
producing obstructive dysphagia.
Since pharynx is a very patulous
cavity, dysphagia in growths of the
pharynx is a late symptom.
 D. Speech defects

• D. Speech defects
As has already been mentioned the
pharynx is an important organ for
giving resonance to the speech. Thus
in cases of extreme hypertrophy of the
tonsils or a growth in the pharynx, the
speech will appear to be very full.
 D. Speech defects
In paralysis of the palate or in cases of
perforation in the palate, much air passes
out through the nose than is required for
proper speech production. The result is
that the patient's speech contains an
excess of nasal twang.
This condition is called rhinolalia
aperta(开放式鼻音).
 D. Speech defects

Conversely, if there is blockage in

the throat, the nasopharynx or the nose,
too little air may escape through the nose.
In this case the speech will contain an
abnormally low amount of nasal twang
and it will appear dull or toneless and
uninteresting. This condition is called
rhinolalia clausa（闭合式鼻音）.
 E.Dyspnoea

• E. Dyspnoea(呼吸困难)
For example in retropharyngeal
abscess and tumours of the
pharynx.
 F. Functional disorder

• F. Functional disorder
Some hysterical patients
complain of a feeling of fullness in
the throat, or the feeling of a ball in
the throat giving rise to obstruction
during swallowing.
 Distant symptoms
• Disease happens particularly in
inflammatory disease of the tonsil. The
tonsils are situated in between the
pharyngeal muscles and due to the
continuous action of the these muscles,
infection in the tonsillar crypts keeps being
expressed out. It does not collect in the
tonsils in sufficient amount to produce local
symptoms. Nevertheless bacteria enter the
• general circulation from the tonsils to
produce distant manifestations.
 Distant symptoms
• A. Ear: Eustachian catarrh, otitis media.
B . Nose: rhinitis, sinusitis.
C . Eye:conjunctivitis
D . Respiratory system: broncho-
pneumonia, lung abscess.
E . Gastrointestinal system:dyspepsia.
F . Cardiovascular: anaemia.
G . Locomotor system: arthritis.
H . Kidneys
I . Skin
j . General:state of ill health
The examination

tongue
depressor
 The examination

Indirect
Indirect
laryngoscop
nasopharyngoscopy
y mirror
mirror
 The examination

Bull's Eye Frontal head

lamp mirror
 The general examination

• The oropharynx is best examined with

Bull's Eye lamp and the frontal head
mirror. The patient sits on the chair
facing the examiner direct. There
should be no twist on the neck, The
light is thrown on to the patient’s throat
who is instructed to open the mouth
and breath calmly and quietly.
 The general examination
• In many patients, a view of the interior of the
throat can be obtained without the use of any
instruments, but mostly it will be found that
the dome of the tongue hides the view. If so
there should be no hesitation in using a
tongue depressor. The examiner catches
hold of a Lack's tongue depressor, which
should rather be broad than narrow and first
examines the oral cavity by retracting the
cheeks from the gums.
 Examination of the oral cavity

• The teeth should be counted and the

cheeks, the gums, the teeth, the tongue
and the floor of the mouth should be
inspected for any lesions. The patient
is asked to say AAH and the
movements of the palate are noted. The
colour of the mucous membrane of the
palate is also seen.
 Examination of the throat

• the patient is instructed to keep the

tongue in the mouth which in this
condition stays limp and loose near the
floor of the mouth, It is further
depressed with a tongue depressor
which is placed gently but deliberately
on the dorsum of the tongue.
 Examination of the throat

• The tongue depressor should not be

introduced into the mouth too far, in
any case it should not touch the
posterior third of the tongue. This part
of the tongue is supplied by the ninth
nerve which takes part in the formation
of the pharyngeal plexus and if irritated,
sets up the. deglutition reflex.
 Examination of the throat

• Having depressed the tongue in this

way, the examiner looks at the
anterior pillars ,the tonsils, the
posterior faucial pillars and the
posterior pharyngeal wall.Some
part of base of the tongue can also
be seen.
 Examination of the throat

• A note is made of the general colour of

the pharynx; any ulcers are noted, any
growth is also seen and the state of the
mucous glands is also assessed by
noting the wet or dry state on the
mucous membrane. About the tonsils,
their size, colour and surface are
noticed.
 Examination of the throat

• From the tonsils, use is made of two

tongue depressors one for depressing
the tongue and the other for pressing
the tonsils through the anterior pillars.
For the left tonsil, the depressor in the
right hand presses the anterior pillar
and that in the left hand presses the
tongue, whereas for the right tonsil the
hands are changed.
Examination of the laryngopharynx

The laryngolpharynx cannot be

seen by throwing light directly into
the oropharynx. For examining the
laryngopharynx, use must be made
of the indirect laryngoscopy mirror.
 Examination of the laryngopharynx

• Indirect laryngoscopy mirror is taken

and warmed in a spirit lamp flame on
the minor side. Then its temperature is
tested by the examiner on his hand,
first on the palmar surface and then on
the dorsal surface .If it is too hot,its
temperature is brought down by waving
it in the air.
Examination of the laryngopharynx

• Before introducing it in the

patient's throat, it should be
lightly swayed on the patient’s
palm or cheek to ressure him
that it is not too hot.
 Examination of the laryngopharynx

• The light is thrown on the patient's

throat, who is asked to put out the
tongue. The tip of the patient's tongue
is held by the examiner by means of a
tongue cloth between his left index
finger and the thump and the patient's
upper lip is retracted by the examiner's
left middle
 Examination of the laryngopharynx

• As the tip of the tongue is held by the

examiner, the warmed mirror is introduced
into the mouth far enough to lift the uvula on
the back of the mirror. The stem of the mirror
should be in the left angle of the patient's
mouth. The beam light falls on the mirror,
gets reflected downwards and lights up the
aditus-ad-larynis and the hypopharynx.
Examination of the laryngopharynx

With the help of this mirror the

base of the tongue, epiglottis,
pyriform fossae are seen.