Transcript SURGICAL ANATOMY OF THE NASOPHARYNX

SURGICAL ANATOMY OF THE
NASOPHARYNX
Dr. Supreet Singh Nayyar, AFMC
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Layout
 General Description
 Layers Of The Nasopharyngeal Wall
 Fascial Relations Of The Nasopharynx
 Muscles Of The Nasopharynx
 Blood Vessels Of The Nasopharynx
 Lymphatics Of The Nasopharynx
 Nerves Of The Nasopharynx
 Imaging Of The Nasopharynx
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General Description
Development
Dimensions
Boundaries
Anterior wall
The Floor
The roof and
posterior wall
The lateral wall
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Fossa of Rosenmuller
 Location-
 Depth- 2.5 cm
 Anatomical relationship
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LAYERS OF THE NASOPHARYNGEAL WALL
 The mucosa
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- three types of epithelium
Lymphoid nodules –Waldeyer’s ring
The submucosa
The muscular layer
-outer circular & inner longitudinal muscle
The buccopharyngeal fascia
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FASCIAL RELATIONS OF THE NASOPHARYNX
 Cervical fascial layers
superficial and deep cervical fascia
 Cervical fascial spaces
midline spaces: pharyngeal mucosal, retropharyngeal
and prevertebral spaces
Paired lateral spaces: parapharyngeal, carotid,
masticator and parotid spaces
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Cervical fascial layers
 Superficial cervical fascia
-Envelops platysma and
muscles of facial expression
 Deep cervical fascia
- Superficial layer
- middle layer
- deep layer
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Pharyngeal mucosal space
 Encloses the pharynx
 Buccopharyngeal fascia
 Sinus of morgagni
 Buccopharyngeal fascia fuses
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Retropharyngeal space
 Location: buccopharyngeal fascia and
prevertebral fascia
 Extent: skull base to T2
 Two compartments
 Source of Infection: extension from para pharyngeal,
masticator, parotid space
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Prevertebral space
 Location: posterior to the prevertebral
fascia
 Extent: skull base to coccyx
 Source of Infection: TB spine , penetrating
trauma
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Carotid space
 Extent: jugular foramen to the aortic arch
 Location: lateral to the prevertebral
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Masticator space
 Extent: skull base to lower border
mandible
 Location: superficial layer of deep cervical
fascia
 Source of Infection: 3rd molar
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Parotid space
 Location: lateral to the parapharyngeal space,
anterior to carotid space and posterior
to the masticator space
 Extent:
superficial layer of deep cervical fascia
 Source of Infection: oral cavity via Stenson’s duct
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Contents of the cervical fascial spaces
 Pharyngeal mucosal space: mucosa, lymphoid tissue,
muscles of pharynx, minor salivary glands
 Retropharyngeal space: fat, lymph nodes
 Prevertebral space: vertebrae and prevertebral muscles
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 Para pharyngeal space: fat, arteries veins, trigeminal nerve,
salivary gland rests, lymph nodes
 Carotid space: carotid artery, internal jugular vein, cranial
nerves IX-XII lymph nodes, Sympathetic fibers
 Masticator space: mandible, muscles trigeminal nerve
 Parotid space: parotid gland, facial nerve, lymph nodes
arteries veins
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MUSCLES OF THE NASOPHARYNX
 Pharyngeal muscles
 Pre vertebral muscles
 Palatal muscles
 Masticator muscles
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Pharyngeal muscles
 Superior constrictor
- Quadrilateral muscle
- Arises from the lower part of the posterior margin of the
medial pterygoid plate
-Sphincter that prevents reflux into the nasopharynx and
has a peristaltic function during swallowing
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 Pharyngobasilar fascia
-lies in the gap between the superior constrictor and the skull
base, the sinus of Morgagni, fuses with the buccopharyngeal
fascia to form a single layer of fascia
-the auditory tube passes through this gap
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 Palatopharyngeal (velopharyngeal) sphincter
- a band of mainly superior constrictor muscle fibers
- arises from the upper surface of the palatine aponeurosis
-the band ridges the pharyngeal wall as Passavant’s ridge , seen
when the soft palate is elevated
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 Salpingopharyngeus
-arises from the posterior region of the pharyngeal
projection of the auditory tube
- elevates the upper lateral wall of the pharynx
 Prevertebral muscles
- the longus capitis arises from the transverse processes of
the cervical vertebrae and inserts into the inferior surface of the
basilar part of the occipital bone
– separates the nasopharynx from the lower clivus and
vertebrae
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Palatal muscles
 The levator palati muscle
 The tensor palati muscle
 The uvular muscle
 The palatoglossus
 The palatopharyngeus
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 Levator palati muscle
-situated lateral to the choana
-arises within the pharynx from the inferior surface of the
petrous part of the temporal bone
- inserts into the palatine aponeurosis
- opens the pharyngeal opening of the auditory tube and
elevates the soft palate during swallowing
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 Tensor palati muscle
-situated lateral to the auditory tube and the levator palati
–arises from the scaphoid fossa at the base of the medial
pterygoid plate
– inserts into the palatine aponeurosis
-actively opens the auditory tube and tenses the soft palate
during swallowing
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 The uvular muscle: -arises from the posterior nasal spine
of the palatine bones and the palatine aponeurosis, and insert
in the uvula
-stiffen the soft palate
 The palatoglossus: -arises from the soft palate
aponeurosis and passes in front of the palatine tonsil to
insert into the lateral side of the tongue
-acts as a
constrictor of the fauces
 The palatopharyngeus: -arises from the soft palate
aponeurosis and the posterior border of hard palate
-elevates the pharynx during swallowing
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Masticator muscles
 The lateral pterygoid:
-arises as two heads, one from the greater wing of the sphenoid
and the other from the lateral surface of the lateral pterygoid
plate
– inserts into the neck of the mandibular condyle
– opens the mouth and protrudes the mandible
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 The medial pterygoid:
-arises in the pterygoid fossa from the medial surface of the
lateral pterygoid plate and maxillary tuberosity
-insert into the medial surface of the ramus and the angle of
the mandible
-closes the mouth
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BLOOD VESSELS OF THE
NASOPHARYNX- ARTERIES
 The ascending palatine artery
-branch of the facial artery
-ascends towards the skull base on the external surface of
the pharynx and then winds medially over the upper border
of the superior constrictor muscle
-supplies the levator palati, the soft palate, the superior
constrictor and the auditory tube
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BLOOD VESSELS OF THE NASOPHARYNXARTERIES
 The ascending pharyngeal artery
-branch of the external carotid
-ascends vertically between the carotid sheath and the pharynx to
the skull base
-supplies the lateral and posterior pharyngeal wall above the level
of the palate
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BLOOD VESSELS OF THE NASOPHARYNXARTERIES
 The ascending cervical artery
–arises from the thyrocervical trunk or from the inferior thyroid
artery
–winds upwards behind the carotid sheath
-anastomoses with the ascending pharyngeal artery
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BLOOD VESSELS OF THE NASOPHARYNXARTERIES
 The maxillary artery
–larger terminal branch of the external carotid
-travels through the parotid gland, passes between the ramus of
the mandible and the sphenomandibular ligament, passes either
deep or superficial to the lateral pterygoid muscle and enters the
pterygopalatine fossa
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BLOOD VESSELS OF THE NASOPHARYNXARTERIES
 The maxillary artery – divided into three
parts:
-mandibular
- pterygoid
-pterygopalatine
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BLOOD VESSELS OF THE NASOPHARYNX - VEINS
 submucosal plexus of veins communicates with an external
pharyngeal plexus of veins
 veins corresponding to all branches of the maxillary artery then
drain into the pterygoid plexus
 main drainage of the pterygoid plexus is into the internal jugular
vein via the maxillary, retromandibular and common facial veins
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LYMPHATICS OF THE NASOPHARYNX
 The retropharyngeal lymph nodes
Medial retropharyngeal lymph nodes
Lateral retropharyngeal lymph nodes
( nodes of Rouviere )
 Upper jugular lymph node ( level IIb )
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NERVES OF THE NASOPHARYNX
 motor, sensory and autonomic nerve supply - pharyngeal
plexus
 lies medial to the buccopharyngeal fascia on the external
surface of the constrictor muscle
 supplies motor innervation to all muscles of the pharynx,
except stylopharyngeus
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NERVES OF THE NASOPHARYNX
 Stylopharyngeus- supplied by the muscular branch of the
glossopharyngeal
 sensory supply is from the nasopharyngeal branches of the
pharyngeal plexus, pharyngeal branches of the maxillary
nerve and the glossopharyngeal nerve
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IMAGING OF THE NASOPHARYNX
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Surgical approaches
 Transpalatal
 Sublabial midfacial degloving
 Lateral rhinotomy
 Transfacial- maxillary swing
 Mandibular swing
 Infratemporal
 Transnasal-maxillary
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References
 Last’s Anatomy Regional and Applied, editor Chummy S.
Sinnatamby, 10th edition, Chapter 6, Part 13.
 Scott-Brown’s Otorhinolaryngology, Head and Neck
Surgery , editor Michael Gleeson, 7th edition.
 Stell and Maran’s Head and Neck Surgery, editor John C.
Watkinson, 4th edition
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Thank You
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