The pharynx and Esophagus pdf - Head and Neck

634

CHAPTER 11

The Head and Neck

Sublingual Gland

glion. Postganglionic fibers pass directly to the gland.

nerve via the chorda tympani, and the submandibular gan

Parasympathetic secretomotor supply is from the facial

Nerve Supply

summit of the sublingual fold (Fig. 11.72).

(8 to 20 in number) open into the mouth on the

gual ducts

sublin

mucous acini, with the latter predominating. The

frenulum of the tongue (Fig. 11.86). It has both serous and

(sublingual fold) of the floor of the mouth, close to the

The sublingual gland lies beneath the mucous membrane

nasal part
of pharynx

oral part of
pharynx

laryngeal part of
pharynx

FIGURE 11.87

Sagittal section through the nose, mouth,

(Fig. 11.89).

tubal elevation

ridge of which is called the

the elevated

auditory tube,

lateral wall is the opening of the

the soft palate and the posterior pharyngeal wall. On the

The pharyngeal isthmus is the opening in the floor between

(Fig. 11.89).

pharyngeal tonsil

lymphoid tissue called the

(Fig. 11.87). In the submucosa of the roof is a collection of

This lies above the soft palate and behind the nasal cavities

the oral pharynx, and the laryngeal pharynx.

The pharynx is divided into three parts: the nasal pharynx,

Table 11.10.

and actions of the pharyngeal muscles are summarized in

The details of the origins, insertions, nerve supply,

sphincteric part, the cricopharyngeus.

propulsive part of the inferior constrictor and the lower

area on the posterior pharyngeal wall between the upper

Killian’s dehiscence

pharynx and act as a sphincter.

horizontally around the lowest and narrowest part of the

(Fig. 11.88). The fibers of the cricopharyngeus pass

muscle

cricopharyngeus

from the cricoid cartilage, is called the

The lower part of the inferior constrictor, which arises

outside the lower part of the middle constrictor (Fig. 11.88).

of the superior constrictor and the inferior constrictor lies

the middle constrictor lies on the outside of the lower part

The three constrictor muscles overlap each other so that

of the occipital bone of the skull down to the esophagus.

extends from the pharyngeal tubercle on the basilar part

yngeal wall to be inserted into a fibrous band or raphe that

The three constrictor muscles extend around the phar

direction.

whose fibers run in a somewhat longitudinal

geus muscles,

salpingopharyn

stylopharyngeus

direction, and the

pharynx, and larynx to show the subdivisions of the pharynx.

and

is the

Interior of the Pharynx

Nasal Pharynx

Sublingual Salivary Gland and Cyst Formation

The sublingual salivary gland, which lies beneath the sub-

lingual fold of the floor of the mouth, opens into the mouth

by numerous small ducts. Blockage of one of these ducts is

believed to be the cause of cysts under the tongue.

C L I N I C A L N O T E S

absence of ejection of saliva from the orifice of the duct of the

superior, middle, and inferior constrictor muscles

The muscles in the wall of the pharynx consist of the

brane is also continuous with that of the tympanic cavity.

larynx. By means of the auditory tube, the mucous mem

(choanae), the opening into the mouth, and the inlet of the

Here, it is replaced by the posterior openings into the nose

musculomembranous wall, which is deficient anteriorly.

gus opposite the 6th cervical vertebra. The pharynx has a

lower, narrow end becoming continuous with the esopha

shaped, its upper, wider end lying under the skull and its

The pharynx is funnel

laryngeal parts.

nasal, oral,

mouth, and the larynx (Fig. 11.87) and may be divided into

The pharynx is situated behind the nasal cavities, the

a result of a pathologic condition of the scalp, face, maxillary

affected gland. Frequently, the stone can be palpated in the

duct, which lies below the mucous membrane of the floor of

the mouth.

Enlargement of the Submandibular Lymph Nodes

and Swelling of the Submandibular Salivary Gland

The submandibular lymph nodes are commonly enlarged as

sinus, or mouth cavity. One of the most common causes of

painful enlargement of these nodes is acute infection of the

teeth. Enlargement of these nodes should not be confused

with pathologic swelling of the submandibular salivary gland.

The Pharynx

and

Muscles of the Pharynx

(Fig.

fibers run in a somewhat circular

11.80A), whose

Basic Anatomy

635

sphenomandibular ligament

medial pterygoid

levator veli palatini

base of skull

fibrous layer of pharynx

nasal septum

nasal cavity

middle concha

auditory tube

uvula

tonsil

tongue

epiglottis

mandible

palatopharyngeal fold

aryepiglottic fold

posterior surface of

larynx

pharyngeal

raphe

superior
constrictor

stylopharyngeus

middle
constrictor

inferior
constrictor

cricopharyngeus

esophagus

trachea

esophagus

inferior constrictor

piriform

fossa

middle

constrictor

FIGURE 11.88

The pharynx seen from behind.

parts of the pharynx.

The greater part of the posterior wall of the pharynx has been removed to display the nasal, oral, and laryngeal

Note the three constrictor muscles and the position of the stylopharyngeus

muscles. B.

Muscles of the Pharynx

T A B L E 1 1 . 1 0

off nasal pharynx,

Aids soft palate in closing

hamulus, pterygomandibular

Medial pterygoid plate, pterygoid

Muscle

Origin

Insertion

Nerve Supply

Action

Superior constrictor

ligament, mylohyoid line of mandible

Pharyngeal tubercle of

occipital bone, raphe

in midline posteriorly

Pharyngeal

plexus

propels bolus downward

Middle constrictor

Lower part of stylohyoid ligament,

lesser and greater cornu of hyoid

bone

Pharyngeal raphe

Pharyngeal

plexus

Propels bolus downward

Inferior constrictor

Lamina of thyroid cartilage, cricoid

cartilage

Pharyngeal raphe

Pharyngeal

plexus

Propels bolus downward

Cricopharyngeus

Lowest fibers of inferior constrictor

muscle

Sphincter at lower end of

pharynx

Stylopharyngeus

Styloid process of temporal bone

Posterior border of

thyroid cartilage

Glossopharyngeal

nerve

Elevates larynx during

swallowing

Salpingopharyngeus Auditory tube

Blends with

palatopharyngeus

Pharyngeal

plexus

Elevates pharynx

Palatopharyngeus

Palatine aponeurosis

Posterior border of

thyroid cartilage

Pharyngeal

plexus

Elevates wall of pharynx,

pulls palatopharyngeal

arch medially

636

CHAPTER 11

palatine tonsil.

geal arches is occupied by the

cle. The recess between the palatoglossal and palatopharyn

of mucous membrane covering the palatopharyngeus mus

the mouth and pharynx. The palatopharyngeal arch is a fold

and marks the boundary between

oropharyngeal isthmus

interval between the two palatoglossal arches is called the

mucous membrane covering the palatoglossus muscle. The

between them (Fig. 11.89). The palatoglossal arch is a fold of

the palatopharyngeal arches or folds and the palatine tonsils

On the lateral wall on each side are the palatoglossal and

(Fig. 11.77).

vallecula

side of the median glossoepiglottic fold is called the

The depression on each

lateral glossoepiglottic fold.

side the

(Fig. 11.77), and on each

median glossoepiglottic fold

interval between the tongue and epiglottis. In the midline is

formed by the posterior one third of the tongue and the

This lies behind the oral cavity (Fig. 11.87). The floor is

Oral Pharynx

salpingopharyngeus muscle.

is a vertical fold of mucous membrane covering the

fold

salpingopharyngeal

wall behind the tubal elevation. The

is a depression in the pharyngeal

pharyngeal recess

The

The Head and Neck

the

-
-

The Lymphoid Tissue of the Pharynx

roof of the nasal part of the pharynx. Like the palatine tonsil, it

(quinsy) is caused by spread of infection

peritonsillar abscess

sillitis are best treated by tonsillectomy. After tonsillectomy, the

mon site of infection, producing the characteristic sore throat

At the junction of the mouth with the oral part of the pharynx, and

the nose with the nasal part of the pharynx, are collections of

lymphoid tissue of considerable clinical importance. The palatine

tonsils and the nasopharyngeal tonsils are the most important.

Tonsils and Tonsillitis

The palatine tonsils reach their maximum normal size in early

childhood. After puberty, together with other lymphoid tissues in

the body, they gradually atrophy. The palatine tonsils are a com-

and pyrexia. The deep cervical lymph node situated below and

behind the angle of the mandible, which drains lymph from this

organ, is usually enlarged and tender. Recurrent attacks of ton-

external palatine vein, which lies lateral to the tonsil, may be the

source of troublesome postoperative bleeding.

Quinsy

from the palatine tonsil to the loose connective tissue outside the

capsule (Fig. 11.90).

The nasopharyngeal tonsil or the pharyngeal tonsil consists

of a collection of lymphoid tissue beneath the epithelium of the

is largest in early childhood and starts to atrophy after puberty.

C L I N I C A L N O T E S

nasal cavity

hard palate

vestibule of nose

genioglossus muscle

mandible

geniohyoid muscle

mylohyoid muscle

hyoid bone

thyroid cartilage

aryepiglottic fold

epiglottis

palatopharyngeal
fold (arch)

body of axis

palatine tonsil

palatoglossal fold (arch)

soft palate

anterior arch of atlas

salpingopharyngeal fold

pharyngeal tonsil

inferior nasal concha

middle nasal concha

tubal elevation

FIGURE 11.89

Sagittal section of the head and neck, showing the relations of the nasal cavity, mouth, pharynx, and larynx.

(continued)

Basic Anatomy

637

Adenoids

cervical nodes

via the retropharyngeal or paratracheal nodes into the deep

Directly into the deep cervical lymph nodes or indirectly

Lymph Drainage of the Pharynx

and branches of maxillary and lingual arteries

Ascending pharyngeal, tonsillar branches of facial arteries,

The internal laryngeal branch of the vagus nerve

(around the entrance into the larynx):

Laryngeal pharynx

The glossopharyngeal nerve

Oral pharynx:

The maxillary nerve (V2)

Nasal pharynx:

(Fig. 11.88).

in the mucous membrane on each side of the laryngeal inlet

is a depression

piriform fossa

thyrohyoid membrane. The

The lateral wall is formed by the thyroid cartilage and the

This lies behind the opening into the larynx (Fig. 11.87).

Laryngeal Pharynx

the open mouth. The close relationship of the infected lymphoid

Marked hypertrophy blocks the posterior nasal openings and

enlarged; they are then commonly referred to as

Excessive hypertrophy of the lymphoid tissue, usually associ-

ated with infection, causes the pharyngeal tonsils to become

adenoids.

causes the patient to snore loudly at night and to breathe through

tissue to the auditory tube may be the cause of deafness and

recurrent otitis media. Adenoidectomy is the treatment of choice

for hypertrophied adenoids with infection.

The nasal part of the pharynx may be viewed clinically by a

mirror passed through the mouth (Fig. 11.91).

Sensory Nerve Supply of the Pharyngeal

Mucous Membrane

Blood Supply of the Pharynx

palatopharyngeus muscle

internal carotid arter y

external palatine vein

internal jugular vein

facial artery

palatine

tonsil

tonsilar capsule

ramus of

mandible

palatoglossus

muscle

vestibule of mouth

buccinator

muscle

lower lip

glossoepiglottic
fold

vallecula

enlarged tonsil

peritonsillar
abscess

internal carotid
artery

carotid sheath

superior constrictor muscle

tonsilar

artery

FIGURE 11.90

Horizontal section through the mouth and the oral pharynx.

carotid sheath. The opening into the larynx can also be seen below and behind the tongue.

The position of a peritonsillar abscess. Note the relationship of the abscess to the superior constrictor muscle and the

The normal palatine tonsil and its relationships.

Left.

Right.

638

CHAPTER 11

The Head and Neck

tubal elevation

soft palate

uvula

nasal septum

superior concha

middle concha

inferior concha

FIGURE 11.91

Structures seen in posterior rhinoscopy.

terior rhinoscopy.

larynx, and pharynx showing the position of the mirror in pos

Sagittal section through the nose, mouth,

Piriform Fossa and Foreign Bodies

The piriform fossa is a recess of mucous membrane situated

on either side of the entrance of the larynx. It is bounded medi-

ally by the aryepiglottic folds and laterally by the thyroid car-

tilage. Clinically, it is important because it is a common site

for the lodging of sharp ingested bodies such as fish bones.

The presence of such a foreign body immediately causes the

patient to gag violently. Once the object has become jammed,

it is difficult for the patient to remove it without a physician’s

assistance.

Pharyngeal Pouch

Examination of the lower part of the posterior surface of the

inferior constrictor muscle reveals a potential gap between

the upper oblique and the lower horizontal fibers (cricopha-
ryngeus). This area is marked by a dimple in the lining mucous

C L I N I C A L N O T E S

(continued)

membrane. It is believed that the function of the cricopharyn

pharynx as the result of the successive contraction of the

entrance into the larynx, and reaches the lower part of the

The bolus moves downward over the epiglottis, the closed

aryepiglottic, oblique arytenoid, and thyroarytenoid muscles.

enoid cartilages are pulled forward by the contraction of the

the approximation of the aryepiglottic folds, and the aryt

larynx is closed. The laryngeal entrance is made smaller by

posterior surface of the epiglottis, and the entrance into the

muscles. The main part of the larynx is thus elevated to the

salpingopharyngeus, thyrohyoid, and palatopharyngeus

pulled upward by the contraction of the stylopharyngeus,

The larynx and the laryngeal part of the pharynx are

vents the passage of food and drink into the nasal cavities.

the contraction of the palatopharyngeus muscles. This pre

by the upper fibers of the superior constrictor muscle, and

the pulling forward of the posterior wall of the pharynx

oral part of the pharynx by the elevation of the soft palate,

The nasal part of the pharynx is now shut off from the

the process of swallowing becomes an involuntary act.

bolus backward into the pharynx. From this point onward,

and backward. The palatoglossus muscles then squeeze the

cles on both sides, which pull the root of the tongue upward

is brought about by the contraction of the styloglossus mus

backward against the undersurface of the hard palate. This

sum of the tongue and voluntarily pushed upward and

Masticated food is formed into a ball or bolus on the dor

which covers the outer surface of the constrictor muscles.

wall of the pharynx. The pus then tracks laterally and down

Pus arising from tuberculosis of the upper cervical vertebrae

ward, usually on the left side. The presence of the pouch filled

posteriorly because of the vertebral column, it turns down

enlarge and fill with food with each meal. Unable to expand

geus is to prevent the entry of air into the esophagus. Should

the cricopharyngeus fail to relax during swallowing, the inter-

nal pharyngeal pressure may rise and force the mucosa and

submucosa of the dimple posteriorly, to produce a diverticu-

lum. Once the diverticulum has been formed, it may gradually

with food causes difficulty in swallowing (dysphagia).

Cervical Tuberculous Osteomyelitis and the

Pharynx

is limited in front by the prevertebral layer of deep fascia. A

midline swelling is formed and bulges forward in the posterior

ward behind the carotid sheath to reach the posterior triangle.

Here, the fascia, which forms a covering to the muscular floor

of the triangle, is weaker, and the abscess points behind the

sternocleidomastoid. Rarely, the abscess may track down-

ward behind the prevertebral fascia to reach the superior and

posterior mediastina in the thorax.

It is important to distinguish this condition from an abscess

involving the retropharyngeal lymph nodes. These nodes lie in

front of the prevertebral layer of fascia but behind the fascia,

Such an abscess usually points on the posterior pharyngeal

wall and, if untreated, ruptures into the pharyngeal cavity.

The Process of Swallowing (Deglutition)

Basic Anatomy

639

superior, middle, and inferior constrictor muscles. Some of

(Fig. 11.90). The capsule is separated from the supe

capsule

fibrous

The tonsil is covered on its lateral surface by a

tonsillar crypts.

openings that lead into the

into the pharynx. The surface is pitted by numerous small

by mucous membrane, and its free medial surface projects

palatopharyngeal arches (Fig. 11.90). Each tonsil is covered

oral part of the pharynx between the palatoglossal and

each located in the depression on the lateral wall of the

The palatine tonsils are two masses of lymphoid tissue,

Palatine Tonsils

geus muscle) relaxes and the bolus enters the esophagus.

Finally, the lower part of the pharyngeal wall (the cricopharyn

piriform fossae.

into the larynx, that is, down through the

the food slides down the groove on either side of the entrance

rior constrictor muscle by loose areolar tissue (Fig. 11.90),

the respiratory and digestive systems forms a ring. The

The lymphoid tissue that surrounds the opening into

Waldeyer’s Ring of Lymphoid Tissue

behind the angle of the mandible.

The upper deep cervical lymph nodes, just below and

Lymph Drainage of the Tonsil

tine, the pharyngeal, or the facial veins.

the superior constrictor muscle and join the external pala

The tonsillar branch of the facial artery. The veins pierce

hood, but after puberty it diminishes considerably in size.

The tonsil reaches its maximum size during early child

the loop of the facial artery, and the internal carotid artery.

the superior constrictor muscle lie the styloglossus muscle,

in this tissue to join the pharyngeal venous plexus. Lateral to

and the external palatine vein descends from the soft palate

Blood Supply

lateral part of the ring is formed by the palatine tonsils
and tubal tonsils (lymphoid tissue around the opening
of the auditory tube in the lateral wall of the nasopharynx).

Posteriorly:

chea and the esophagus (Fig. 11.49).

ascend one on each side, in the groove between the tra

The trachea; the recurrent laryngeal nerves

Anteriorly:

rax is described on page 100.

neck, it inclines to the left side. Its further course in the tho

commences in the midline, but as it descends through the

tilage, opposite the body of the sixth cervical vertebra. It

11.13 and 11.88). It begins at the level of the cricoid car

long, extending from the pharynx to the stomach (Figs.

The esophagus is a muscular tube about 10 in. (25 cm)

of the tongue forms the lower part.

the upper part, and the lingual tonsil on the posterior third

The pharyngeal tonsil in the roof of the nasopharynx forms

The Esophagus

Relations in the Neck

■

The prevertebral layer of deep

ical

cerv

fascia, the longus colli, and the vertebral column
(Fig. 11.49)

is the area of the nasal cavity lying just inside the nostril

nasal vestibule

nose opens into the nasopharynx. The

behind, where the

choanae

posterior nasal apertures

The nasal cavity extends from the nostrils in front to the

Nasal Cavity

maxillary nerve (CN V) (see page 608).

thalmic nerve (CN V) and the infraorbital branch of the

The infratrochlear and external nasal branches of the oph

plied by branches from the facial artery.

skin of the ala and the lower part of the septum are sup

ophthalmic and the maxillary arteries (see page 598). The

The skin of the external nose is supplied by branches of the

formed of plates of hyaline cartilage (Fig. 11.92).

the nasal part of the frontal bone. Below, the framework is

the nasal bones, the frontal processes of the maxillae, and

The framework of the external nose is made up above by

rounded and mobile.

(Fig. 11.92). The lateral margin, the

septum

which are separated from each other by the

trils,

The external nose has two elliptical orifices called the

External Nose

halves.

both of which are divided by a septum into right and left

The nose consists of the external nose and the nasal cavity,

and from the sympathetic trunks.

The nerves are derived from the recurrent laryngeal nerves

The lymph vessels drain into the deep cervical lymph nodes.

Lymph Drainage in the Neck

rior thyroid veins.

drain into the infe

veins

the inferior thyroid arteries. The

of the esophagus in the neck are derived from

arteries

The

and the carotid sheath (Fig. 11.49)

On each side lie the lobe of the thyroid gland

Laterally:

■

Blood Supply in the Neck

Nerve Supply in the Neck

The Respiratory System in the Head

and Neck

The Nose

nos-

nasal

ala nasi, is

Blood Supply of the External Nose

Nerve Supply of the External Nose

(Fig. 11.93). The nasal cavity is divided into right and left

and a medial or septal wall.

Each half of the nasal cavity has a floor, a roof, a lateral wall,

Walls of the Nasal Cavity

vomer.

ethmoid,

vertical plate of the

septal cartilage,

made up of the

(Fig. 11.92). The septum is

nasal septum

halves by the

the

and the