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Clinical pharyngeal anatomy
The pharynx (pharynx) enters the initial section of the digestive tract and respiratory tract. It is a hollow organ formed by muscles, fascia and lined with mucous membrane from the inside. The pharynx connects the nasal and oral cavities with the larynx and esophagus, through the auditory tubes the pharynx communicates with the middle ear. The pharyngeal cavity is vertically projected onto the bases of the occipital and sphenoid bones, horizontally - onto the bodies of six cervical vertebrae. Three sections are distinguished in the pharynx: the upper one is the nasopharynx, the middle one is the oropharynx and the lower one is the larynxopharynx (Fig. 2.1).
1 - slope of the skull; 2 - the pharyngeal orifice of the auditory tube; 3 - nasopharyngeal pocket; 4 - stylohyoid muscle; 5 - pharyngeal orifice of the auditory tube; 6 - palatine curtain; 7 - posterior palatine arch (non-pharyngeal fold), 8 - lingual tonsil; 9 - the root of the tongue; 10 - pharyngeal-epiglottis fold; 11 - scooped palatine fold; 12 - the mucous membrane of the esophagus; 13 - trachea; 14 — esophagus; 15 - pear-shaped sinus; lb is the fold of the laryngeal nerve; 17 - entrance to the larynx; 18 - laryngopharynx (hypopharynx); 19 - epiglottis; 20 - oropharynx, (mesopharynx); 21 - tongue of the soft palate; 22 - nasopharynx (epipharynx); 23 - tube pharyngeal fold; 24 - opener; 25 — vagus nerve; 26 - internal carotid artery; 27 - internal jugular vein; 28 - Hoans.
However, the nasopharynx, or epipharynx, performs a respiratory function, its walls do not fall off and are motionless. At the top, the nasopharynx arch is fixed to the base of the skull, borders the base of the occipital bone and the anteroposterior sphenoid, the back with C and C, the front there are two choanas, funnel-like pharyngeal openings of the auditory tubes are located on the side walls at the level of the posterior ends of the lower nasal concha. Above and behind these openings are bounded by tubular ridges formed by protruding cartilaginous walls of the auditory tubes. From the posterior edge of the tubular roller, a fold of the mucous membrane, in which a muscle bundle (m.salpingopharyngeus) is located from the upper muscle compressing the pharynx, which is involved in the peristalsis of the auditory tube, goes downward. On the back of this fold and the mouth of the auditory tube, on each side wall of the nasopharynx there is a recess - the pharyngeal pocket, or the Rosenmüller fossa, in which there is usually an accumulation of lymphadenoid tissue. These lymphadenoid formations are called "tube tonsils" - the fifth and sixth tonsils of the pharynx.
At the border between the upper and posterior walls of the nasopharynx is the pharyngeal (third, or nasopharyngeal) tonsil.
The pharyngeal tonsil is normally well developed only in childhood (Fig. 2.2). Since puberty she
a - clinical picture: 1 - extended nose bridge; 2 - constantly open mouth; 3 - an elongated face (dolichocephaly), b - the location of adenoid vegetation in the nasopharynx: 4 - obstruction of the choan adenoids (sagittal section).
begins to decrease and by the age of 20 it appears as a small strip of adenoid tissue, which continues to atrophy with age. The boundary between the upper and middle parts of the pharynx is the plane of the hard palate, mentally extended posteriorly.
MEDIUM PARTICLES - Mesopharynx is involved in conducting both air and food; here the respiratory and digestive tract cross. In front, the oropharynx has an opening - a pharynx leading to the oral cavity (Fig. 2.3), its posterior wall borders on the Cg. The pharynx is bounded by the edge of the soft palate, the anterior and posterior palatine arches, and the root of the tongue. In the middle part of the soft palate there is an elongation in the form of a process, which is called the uvula (uvula). In the lateral sections, the soft palate splits and passes into the anterior and posterior palatine arches, in which the muscles are laid; when these muscles contract, the opposite arms come together, acting at the time of swallowing as a sphincter. A muscle is laid in the softest palate, which lifts it and presses it against the back wall of the pharynx (m.levator veli palatini), while contracting this muscle, the lumen of the auditory tube expands. The second muscle of the soft palate strains and stretches it to the sides, expands the mouth of the auditory tube, but narrows its lumen in the rest (m.tensor veli palatini).
Between palatine arches in triangular niches palatine tonsils (the first and second) are located. The histological structure of the lymphadenoid tissue of the pharynx is the same; between the connective tissue fibers (trabeculae) is a mass of lymphocytes, some of which are in the form of spherical clusters called follicles (Fig. 2.4). However, the structure of the tonsils has important features from the point of view of the clinic. The free, or yawning, surface of the palatine tonsils is turned into the pharyngeal cavity and is covered with a stratified squamous epithelium. Unlike other tonsils of the pharynx, each palatine tonsil has 16-18 deep gaps called lacunae, or crypts. The outer surface of the tonsils is connected to the side wall of the pharynx through a dense fibrous membrane (the intersection of the cervical and buccal fascia), which in the clinic is called the capsule of the tonsil.
Between the capsule of the tonsil and the pharyngeal fascia covering the muscles, there is a loose paratonsillar fiber, which facilitates the removal of the tonsil with tonsillectomy. A lot of connective tissue fibers pass from the capsule to the tonsil parenchyma, which are interconnected by beams (trabeculae), forming a densely looped network. The cells of this network are filled with a mass of lymphocytes (lymphoid tissue), which are sometimes formed into follicles (lymphatic or nodular tissue), forming a whole lymphadenoid tissue. Other cells are also found here - mast, plasma, etc. Follicles are spherical accumulations of lymphocytes in varying degrees of maturity.
Lacunae penetrate the thickness of the tonsils, have branches of the first, second, third and even fourth order. The walls of the gaps are lined with flat epithelium, which is rejected in many places. In the lumen of the gaps, along with the rejected epithelium, which forms the basis of the so-called amygdala plugs, microflora, lymphocytes, neutrophils, etc. are always contained.
An important factor from the point of view of pathology is that the emptying (drainage) of deep and tree-branched lacunae is easily broken due to their narrowness, depth and branching, as well as due to cicatricial narrowing of the mouths of the lacunae, some of which are also covered a flat fold of the mucous membrane (His fold), which is an expanded part of the anterior arch.
Above the upper pole of the tonsil is part of the tonsil
1 — hard sky; 2 - palatine curtain; 3 - upper nasal concha; 4 - "higher" nasal concha; 5 - anastomosis of the main sinus; 6 main sinus; 7 - choana; 8 - tube-palatal fold; 9 - pharyngeal orifice of the auditory tube; 10 - nasopharyngeal (pharyngeal) tonsil; 11 - pharyngeal pocket; 12 - tube roller; 13 - the handle of Atlanta (1 cervical vertebra); 14 - nasopharynx; 15 - tube pharyngeal fold; 16 - tongue of the soft palate; 17 - palatine-reed fold (anterior palatine); 18 - palatine tonsil; 19 - palatopharyngeal (posterior palatine) arch; 20 - oropharynx; 21 - epiglottis; 22 - throat-pharynx; 23 - cricoid cartilage; 24 - the esophagus; 25 - a trachea; 26 - thyroid cartilage (area of the corner of the Adam's apple); 27 - laryngeal cavity; 28 - the body of the hyoid bone; 29 - maxillary hyoid muscle; 30 - chin-hyoid muscle; 31 - chin-muscle; 32 - vestibule of the mouth; 33 - the oral cavity; 34 - lower nasal concha; 35 - the middle turbinate; 36 — frontal sinus.
The histological structure of the palatine tonsil
1 - crypt (lacuna); 2 - lymphoid follicles; 3 - connective tissue capsule; 4 - the mouth of the gap (crypt).
a facial niche filled with loose fiber, which is called the supramondial fossa (fossa supratonsillarae). The upper tonsil lacunae open in it. The development of paratonsillitis is often associated with structural features of this area. The above anatomical and topographic features create favorable conditions for the occurrence of chronic inflammation in the tonsils. The structure of the upper pole of the tonsil is particularly unfavorable in this regard; as a rule, it is here that inflammation most often develops.
Sometimes, in the region of the upper pole, the lobule of the palatine tonsil may lie in the softest palate above the tonsil (internal additional tonsil according to B.S. Preobrazhensky), which the surgeon should take into account when performing tonsillectomy.
Lymphadenoid tissue is also present on the posterior pharyngeal wall in the form of small (point) formations, called granules, or follicles, and behind the palatine arches on the lateral pharyngeal walls are the lateral ridges.
In addition, small accumulations of lymphadenoid tissue are located at the entrance to the larynx and in the piriform sinuses of the pharynx. At the root of the tongue is the lingual (fourth) tonsil of the pharynx, which through lymphoid tissue can be connected to the lower pole of the palatine tonsil (with tonsillectomy, this tissue must be removed).
Thus, lymphadenoid formations are located in the throat in the form of a ring: two palatine tonsils (the first and second), two trumpet (fifth and sixth), one pharyngeal (nasopharyngeal, third), one lingual (fourth) and smaller accumulations of lymphadenoid tissue. All of them combined and received the name "lymphadenoid (lymphatic) pharyngeal ring of Valdeira-Pirogov."
Hortan g h l o tk and - hortan g h l o tk a (hypopharynx). The border between the oropharynx and pharynx is the upper edge of the epiglottis and the root of the tongue; down the larynx, the funnel-shaped tapers and passes into the esophagus. The laryngeal part of the pharynx is located in front of the C, v — Cv cervical vertebrae. The front and bottom of the larynxopharynx opens the entrance to the larynx. On the sides of the entrance to the larynx, between it and the lateral walls of the pharynx, there are recesses that taper conically below, pear-shaped pockets (pits, sinuses) along which the food lump moves to the entrance to the esophagus (Fig. 2.5).
The main part of the lower part of the pharynx (larynx) is located behind the larynx so that its posterior wall is the front wall of the pharynx. With indirect laryngoscopy, only the upper part of the lower part of the pharynx is visible, to the lower part of the pear-shaped pockets, and below the anterior and posterior walls of the pharynx are in contact and only when food passes.
Endoscopic picture of the left piriform sinus
1 - pear-shaped sinus; 2 - epiglottis; 3 - scooped palatine folds; 4 — vocal folds; 5 - vestibular folds.
The wall is made up of four layers. Its basis is the fibrous membrane, which is covered by the mucous membrane from the inside of the pharyngeal cavity, and by the muscular layer from the outside. The muscles located outside are covered with a thinner connective tissue layer - adventitia, on which lies loose connective tissue, which provides mobility of the pharynx with respect to surrounding anatomical formations.
In the upper part, near the choanas, it is covered with a multilayer ciliated epithelium in accordance with the respiratory function of the nasopharynx, in the middle and lower parts it is multilayer flat epithelium. The mucous membrane of the pharynx, especially in the nasopharynx, on the pharyngeal surface of the soft palate, on the root of the tongue and tonsils contains many mucous glands.
The fibrous membrane of the pharynx at the top is attached to the main part of the occipital bone, the medial plate of the pterygoid process and to other bones of the base of the skull.
From top to bottom, the fibrous membrane becomes thinner and passes into a thin elastic membrane that attaches to the hyoid bone and plates of the thyroid cartilage. From the side of the pharynx, the fibrous layer is covered with a mucous membrane, and from the outside, with the muscle layer.
The muscular layer of the pharynx consists of striated fibers and is represented by circular and longitudinal muscles that compress and raise the pharynx. Three constrictors compress the pharynx - upper, middle and lower. These muscles are placed from top to bottom in the form of plates that cover each other in a tile-like manner. The upper muscle compressing the pharynx begins in front of the sphenoid bone and lower jaw, goes back to the midline of the posterior pharyngeal wall, where it forms the upper part of the median pharyngeal suture. The middle muscle compressing the pharynx starts from the horns of the hyoid bone and the stylohyoid ligament, goes fan-like posterior to the pharyngeal suture, partially covers the upper muscle compressing the pharynx, and below it is located under the lower muscle compressing the pharynx. This muscle starts from the outer surface of the cricoid cartilage, the lower horn and the posterior edge of the thyroid cartilage, goes posteriorly and forms a pharyngeal suture along the midline of the posterior pharyngeal wall. At the top, the lower muscle compressing the pharynx covers the lower part of the middle compressor of the pharynx, below its bundles function as a compressor of the esophagus.
The throat is lifted by two longitudinal muscles - stylo-pharyngeal (main) and palatopharyngeal, forming the posterior palatine arch. Contracting, the muscles of the pharynx carry out a movement such as peristaltic; the pharynx at the moment of swallowing rises, and thus the food lump moves down to the mouth of the esophagus. In addition, the upper compressor gives muscle bundles to the auditory tube and is involved in its function.
Between the mucous membrane of the posterior pharyngeal wall and the prevertebral fascia there is a pharyngeal space in the form of a flat gap filled with loose connective tissue. From the sides, the pharyngeal space is limited by fascial leaves that go to the pharyngeal wall from the prevertebral fascia. Starting from the base of the skull, this space passes down behind the pharynx to the esophagus, where its tissue passes into the posterior-esophageal tissue, and then into the tissue of the posterior mediastinum. The median septum the pharyngeal space is divided sagittally into two symmetrical halves. In children, near the median septum, there are lymph nodes into which lymph vessels flow from the tonsils, the posterior sections of the nasal and oral cavities; with age, these nodes atrophy; in children, they can suppurate, forming a pharyngeal abscess. On the sides of the pharynx there is a periopharyngeal space made of fiber (Fig. 2.6), in which the neurovascular bundle passes and the main lymph nodes of the neck are located.
The length of the pharynx of an adult from its arch to the lower end is 14 (12-15) cm, the transverse size of the pharynx is larger than the anteroposterior one and averages 4.5 cm. 2.6.
Topography of the periopharyngeal (parapharyngeal) space
I - chewing mouse; 2 - the lower jaw; 3 - internal alveolar artery; 4 - VII (facial) nerve; 5 - parotid gland. 6 - external carotid artery; 7 - posterior facial vein; 8 - parotid fascia; 9 - internal jugular vein and glossopharyngeal (IX) nerve; 10 - an additional (XI) nerve; II - internal carotid artery and vagus (X) nerve; 12 - upper cervical sympathetic ganglion; 13 - atlas with prevertebral fascia; 14 - a long muscle of the head and neck; 15 - sublingual (XII) nerve; 16 - palatine tonsil; 17 - styloid process; 18 - internal pterygoid muscle; 19 - periopharyngeal space.
The main throat of the pharynx comes from the pharyngeal ascending artery (a.pharyngica ascendens - branch of the external carotid artery - a.carotis externa), the ascending palatine artery (a.platina ascendens - branch of the facial artery - a.facialis, which also originates from the external carotid artery), descending palatine arteries (aa.palatina descendens - branches of the maxillary artery - a.maxillaris, the final branch of the external carotid artery). The lower part of the pharynx partially eats from the lower thyroid artery (a.thyreoidea inferior - branch of the subclavian artery - a.sub-clavia - on the left and brachiocephalic trunk - truncus brachiocephalicus - on the right). Blood supply to the tonsils is carried out from the external carotid artery system with various options (Fig. 2.7).
1 - common carotid artery; 2 - internal carotid artery, 3 - external carotid artery; 4 - superior thyroid artery; 5 - lingual artery; 6 - facial artery; 7 - ascending palatine artery; 8 - palatine tonsil; 9 - ascending pharyngeal artery; 10 - descending palatine artery; 11 - maxillary artery
Outflow from the pharynx occurs in the deep and posterior cervical lymph nodes (nodi lymphatici cervicales profundi et retropharyngeales). The pharyngeal lymph nodes are divided into lateral and median; they are, as a rule, only in young children. Lymphadenoid formations of the pharynx, including all the tonsils of the pharynx, do not have lymphatic vessels.
On the outer and inner surfaces of the middle muscle compressing the pharynx, its nerve plexus (plexus pharyngeus) is located, which is formed by the branches of the glossopharyngeal (n.glossopharyngeus), vagus (n.vagus) nerves and sympathetic trunk (truncus sympathicus). This plexus provides the motor and sensory innervation of the pharynx.
The upper part of the pharynx is innervated mainly by the glossopharyngeal nerve, the middle and lower parts - by the return (n.vagus branch of the vagus nerve).
Sensitive innervation of the upper part of the pharynx is carried out by the second branch of the trigeminal nerve (n.trigeminus), the middle - by the branches of the glossopharyngeal and lower - by the vagus nerve (the internal branch of the upper throat nerve).
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