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Dr. Supreet Singh Nayyar, AFMC For more presentations, visit www.nayyarENT.comwww.nayyarENT.com SURGICAL ANATOMY OF THE NASOPHARYNX 22-07-2012 www.nayyarENT.com 1

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Layout 22-07-2012 2 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 www.nayyarENT.com

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General Description 22-07-20123 Development Dimensions Boundaries Anterior wall The Floor The roof and posterior wall The lateral wall www.nayyarENT.com

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Fossa of Rosenmuller Location- Depth- 2.5 cm Anatomical relationship 22-07-20124www.nayyarENT.com

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LAYERS OF THE NASOPHARYNGEAL WALL 22-07-2012 5 The mucosa - three types of epithelium Lymphoid nodules Waldeyers ring The submucosa The muscular layer -outer circular & inner longitudinal muscle The buccopharyngeal fascia www.nayyarENT.com

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FASCIAL RELATIONS OF THE NASOPHARYNX 22-07-2012 6 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 www.nayyarENT.com

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Cervical fascial layers 22-07-2012 7 Superficial cervical fascia -Envelops platysma and muscles of facial expression Deep cervical fascia - Superficial layer - middle layer - deep layer www.nayyarENT.com

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Pharyngeal mucosal space 22-07-2012 8 Encloses the pharynx Buccopharyngeal fascia Sinus of morgagni Buccopharyngeal fascia fuses www.nayyarENT.com

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Retropharyngeal space 22-07-2012 9 Location: buccopharyngeal fascia and prevertebral fascia Extent: skull base to T2 Two compartments Source of Infection: extension from para pharyngeal, masticator, parotid space www.nayyarENT.com

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Prevertebral space 22-07-2012 10 Location: posterior to the prevertebral fascia Extent: skull base to coccyx Source of Infection: TB spine, penetrating trauma www.nayyarENT.com

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Carotid space 22-07-2012 11 Extent: jugular foramen to the aortic arch Location: lateral to the prevertebral www.nayyarENT.com

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Masticator space 22-07-2012 12 Extent: skull base to lower border mandible Location: superficial layer of deep cervical fascia Source of Infection: 3 rd molar www.nayyarENT.com

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Parotid space 22-07-2012 13 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 Stensons duct www.nayyarENT.com

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Contents of the cervical fascial spaces 22-07-2012 14 Pharyngeal mucosal space: mucosa, lymphoid tissue, muscles of pharynx, minor salivary glands Retropharyngeal space: fat, lymph nodes Prevertebral space: vertebrae and prevertebral muscles www.nayyarENT.com

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22-07-2012 15 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 www.nayyarENT.com

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MUSCLES OF THE NASOPHARYNX 22-07-2012 16 Pharyngeal muscles Pre vertebral muscles Palatal muscles Masticator muscles www.nayyarENT.com

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Pharyngeal muscles 22-07-2012 17 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 www.nayyarENT.com

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22-07-2012 18 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 www.nayyarENT.com

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22-07-2012 19 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 Passavants ridge, seen when the soft palate is elevated www.nayyarENT.com

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22-07-2012 20 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 www.nayyarENT.com

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Palatal muscles 22-07-2012 21 The levator palati muscle The tensor palati muscle The uvular muscle The palatoglossus The palatopharyngeus www.nayyarENT.com

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22-07-2012 22 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 www.nayyarENT.com

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22-07-2012 23 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 www.nayyarENT.com

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22-07-2012 24 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 www.nayyarENT.com

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Masticator muscles 22-07-2012 25 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 www.nayyarENT.com

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22-07-2012 26 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 www.nayyarENT.com

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BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES 22-07-2012 27 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 www.nayyarENT.com

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BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES 22-07-2012 28 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 www.nayyarENT.com

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BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES 22-07-2012 29 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 www.nayyarENT.com

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BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES 22-07-2012 30 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 www.nayyarENT.com

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BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES 22-07-2012 31 The maxillary artery divided into three parts: -mandibular - pterygoid -pterygopalatine www.nayyarENT.com

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BLOOD VESSELS OF THE NASOPHARYNX - VEINS 22-07-2012 32 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 www.nayyarENT.com

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LYMPHATICS OF THE NASOPHARYNX 22-07-2012 33 The retropharyngeal lymph nodes Medial retropharyngeal lymph nodes Lateral retropharyngeal lymph nodes ( nodes of Rouviere ) Upper jugular lymph node ( level IIb ) www.nayyarENT.com

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NERVES OF THE NASOPHARYNX 22-07-2012 34 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 www.nayyarENT.com

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NERVES OF THE NASOPHARYNX 22-07-2012 35 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 www.nayyarENT.com

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IMAGING OF THE NASOPHARYNX 22-07-201236www.nayyarENT.com

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Surgical approaches 22-07-2012 37 Transpalatal Sublabial midfacial degloving Lateral rhinotomy Transfacial- maxillary swing Mandibular swing Infratemporal Transnasal-maxillary www.nayyarENT.com

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References 22-07-2012 38 Lasts Anatomy Regional and Applied, editor Chummy S. Sinnatamby, 10 th edition, Chapter 6, Part 13. Scott-Browns Otorhinolaryngology, Head and Neck Surgery, editor Michael Gleeson, 7 th edition. Stell and Marans Head and Neck Surgery, editor John C. Watkinson, 4 th edition www.nayyarENT.com

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Thank You 22-07-2012 www.nayyarENT.com 39 For more presentations, visit www.nayyarENT.comwww.nayyarENT.com