Pharynx anatomy and part and muscles. Tonsils and tonsilitis. Peritonsillar Abscess (Quinsy) FASCIA AND SPACE OF THE PHARYNX. Zenker diverticulum (pharyngeal pouch). Adenoid tonsils. pharyngitis. Sleep apnea. adenoids enlargement and surgical indications and contraindications. branchial cyst... and more...

1. THROAT
Hamzeh Yacoub
Medical student at AQU
2021

2. PHARYNX
The pharynx is a muscular tube that connects the oral and nasal
cavity to the larynx and oesophagus.
begins at the base of the skull, and ends at the inferior border of the
cricoid cartilage (C6).
Pharynx is composed of 3 parts:
Nasopharynx
Oropharynx
Laryngopharynx

3. NASOPHARYNX
Extend from the base of skull to the lower border of the soft palate
(C1).
lined by ciliated pseudostratified columnar epithelium.
Nasopharynx borders:
Anteriorly: communicates with nasal cavity through choanae.
Posteriorly: sphenoid body, occipital basilar part, anterior arch of
atlas.
Roof: Nasopharyngeal tonsils (adenoid) and pharyngeal hypophysis.
Inferiorly: oropharynx (through oropharyngeal isthmus).

4. OROPHARYNX
between the soft palate and the superior border of the epiglottis.
Contains the posterior 1/3 of tongue, lingual tonsils, palatine
tonsils, superior constrictor muscle.
The oropharynx is involved in the voluntary and involuntary phases
of swallowing.

5. LARYNGOPHARYNX
located between the superior border of the epiglottis and inferior
border of the cricoid cartilage (C6). It is continuous inferiorly with the
esophagus.
posterior to the larynx and communicates with it via the laryngeal
inlet.

6. PHARYNX INNERVATION
Motor and sensory innervation of the pharynx (except nasopharynx)
is by the pharyngeal plexus.
Pharyngeal plexus is formed by:
Pharyngeal branches of: Glossopharyngeal (IX)  sensory for
oropharynx and motor for stylopharyngeus muscle.
 Vagus (X)  sensory for laryngopharynx and for taste sensation.
Superior cervical sympathetic ganglion.
External laryngeal nerve.  supply motor for inferior constrictor
muscle
Cranial part of accessory nerve (XI).  motor for the whole pharynx
except stylopharyngeus muscle.

7. NASOPHARYNX INNERVATION
Superior and anterior Nasopharynx, sensory innervated by the
maxillary nerve (V2 of the trigeminal).
Nasopharynx motor innervation is by the accessory nerve branches
through vagus.

8. BLOOD SUPPLY TO THE PHARYNX
Pharynx is blood supplied by the external carotid artery branches:
Ascending pharyngeal artery.
Branches of facial artery: ascending palatine artery and tonsillar
artery.
Branches of lingual artery: dorsal lingual artery.
Branches of maxillary artery: pharyngeal artery, artery of pterygoid
canal, great palatine artery.

9. VENOUS AND LYMPH DRAINAGE OF
THE PHARYNX
Pharyngeal venous plexus drains to internal jugular vein.
Lymph drainage: for the deep cervical lymph nodes directly, or
indirectly by paratracheal nodes  deep cervical.

10. MUSCLES OF THE PHARYNX
Two main groups: circular and longitudinal.
Muscle Origin Insertion innervation Action
Superior
constrictor
pterygoid Median raphe
and
pharyngeal
tubercle of
skull
Middle
constrictor
Hyoid and
stylohyoid
lig.
Median raphe
Inferior
constrictor
Cricoid and
thyroid
cartilages
Median raphe
Stylopharyngeus Temporal
Styloid
process
Thyroid
cartilage
Palatopharyngeu Hard and Thyroid

11. TONSILS
Tonsils are large lymphoid tissue situated in the lateral wall of the
oropharynx.
They form lateral part of the Waldeyer's ring.
Tonsil occupies the tonsillar fossa between diverging palato-
pharyngeal and palatoglossal folds

12. TONSILS
Tonsil has two surfaces, medial and lateral; two borders anterior and
posterior; two poles upper and lower; two developmental folds plica
triangulris and plica semilumris; and one cleft intratonsillar cleft.
Medial surface is covered by squamous epithelium and presents 15-
20 crypts usually plugged with epithelial and bacterial debris.
Lateral surface extends deep to surrounding boundaries. It is coated
with a fibrous sheet, an extension of pharyngobasilar fascia called
capsule of the tonsil.
The capsule is loosely attached to the muscular wall but antero-
inferiorly it is attached firmly to the side of the tongue just in front of
insertion of palatoglossus and palatopharyngeus muscles

13. BLOOD SUPPLY OF TONSIL
Tonsillar branch of the dorsal lingual
Ascending palatine branch of facial artery
Tonsillar branch of facial artery
Ascending pharyngeal
Descending palatine

14. ACUTE TONSILLITIS
Mainly a disease of childhood but is also seen in adults.
May occur primarily as infection of the tonsils themselves or may
secondarily occur as a result of URTI following viral infection.
Causative bacteria: Beta-haemolytic streptococcus, Staphylococcus,
Haemophilus influenzae, Pneumococcus.

15. CATARRHAL TONSILLITIS
When tonsils are inflamed as part of the generalised infection of the
oropharyngeal mucosa it is called catarrhal tonsillitis

16. MEMBRANOUS TONSILLITIS
Some times exudation from crypts may coalesce to form a
membrane over the surface of tonsil, giving rise to clinical picture of
membranous tonsillitis.

17. PERITONSILLAR ABSCESS
(QUINSY)
A collection of pus between fibrous capsule of the tonsil usually at
its upper pole and the superior constrictor muscle of pharynx.
It usually occurs as a complication of the acute tonsillitis or it may
apparently arise de novo with no preceding tonsillitis.
Mixed flora with multiple organisms both aerobic and anaerobic
cause quinsy.

18. FASCIA AND SPACE OF THE
PHARYNX
Pharyngobasilar Fascia: Forms the submucosa of the pharynx and
blends with the periosteum of the base of the skull.
 Lies internal to the muscular coat of the pharynx; these muscles are
covered externally by the buccopharyngeal fascia.
Retropharyngeal Space: Is a potential space between the
buccopharyngeal fascia and the prevertebral fascia,
 extending from the base of the skull to the superior mediastinum.
 Permits movement of the pharynx, larynx, trachea, and esophagus
during swallowing

19. KILLIAN’S DEHISCENCE
A triangular area of weakness formed by the oblique fibers of the
inferior pharyngeal constrictor (thyropharyngeus) and the transverse
fibers of the inferior pharyngeal constrictor (cricopharyngeus).
Strong pharyngobasilar fascia forms the submucosal lining Internal
to the inferior constrictor, a relatively weaker buccopharyngeal fascia
forms the external lining of the inferior constrictor.
Killian’s dehiscence arises due to the descent of the larynx during
development.

21. ZENKER DIVERTICULUM
(PHARYNGEAL POUCH)
posterior outpouching of the hypopharynx, proximal to the upper
esophageal sphincter through the Killian dehiscence.
Results from herniation of mucosa and submucosa through the
Killian triangle
More than 50% of the affected patients present in 60-80 Y.O , rare
under 40 Y.O.
The entrapment of liquid / food within the diverticulum may result
in globus sensation, dysphagia, halitosis, regurgitation, chronic
chough, infection, aspiration pneumonia…

22. ZENKER’S DIVERTICULUM
DIAGNOSIS
Fluoroscopy:
Barium swallow examination is performed.
The outpouching may be transient and it is best identified during
swallowing and is best seen on the lateral view, on which the
diverticulum is typically noted at the C5-6 level.
X-Ray on next slide!

23. ZENKER’S DIVERTICULUM

24. ZENKER’S DIVERTICULUM
TREATMENT AND PROGNOSIS
patients with a Zenker diverticulum are at increased risk for
aspiration.
A Zenker diverticulum may be surgically treated with an endoscopic,
surgical diverticulectomy, or diverticulopexy (surgical obliteration or fixation of
a diverticulum)
Diverticulectomy is the cut of muscle.
But in Diverticulopexy: the diverticulum is inverted and sutured to
the prevertebral fascia.

25. a Diverticulectomy. b Diverticulopexy

26. ADENOID TONSILS
Also called pharyngeal tonsils, located at the posterior roof
of nasopharynx.
It is lobulated
 adenoids are part of the immune system and are made of
lymphoid tissue, they produce Antibodies (IgA locally, and
IgG/IgM systemically).
Its lobules or segments are arranged in a regular order like
separated segments of an orange. Lobules are arranged
around a central depression called bursa pharyngea.
Normal adenoids attain their maximum size between ages
of three and seven years, then they regress.

27. PHARYNGEAL BURSA (LUSCHKA
POUCH)
Median recess represents attachment of notochord to endoderm of
primitive pharynx.
Located in the posterior wall of nasopharynx.

29. PHARYNGITIS
Inflammation of the pharynx, resulting in a sore throat.
Pharyngitis is a symptom, rather than a condition. It is usually
caused by viral and/or bacterial infections, such as the common cold
and flu or by infection with the Streptococcus bacterium (strep
throat).
Fungal pharyngitis occurs in the setting of immunosuppression or
chronic steroid and antibiotic use.
Allergies, such as hay fever or allergic rhinitis, can cause sore throat.
Dry indoor air and chronic mouth breathing, especially in the winter,
can lead to recurrent sore throat.
 Gastroesophageal reflux disease (GERD) can lead to chronic sore
throat.

30. PHARYNGEAL ANGINA
The pharyngeal pain is usually caused by an inflammation or a
malignant disease. In some cases, anginal pain radiates to the
pharynx.
Patients with angina pectoris who suffer from pharyngeal pain
without chest pain are very rare.

31. APNEA
Apnea is when breathing stops for at least ten seconds while
sleeping.
Apnea types:
Obstructive apnea: continued or increased effort to breathe is noted,
the effort is due to an obstruction of the airway.
Central apnea: An apnea with no effort to breathe made during the
entire period, this is a neurological issue.
Mixed apnea: An apnea with no effort to breathe in the beginning of
the event followed by effort to breathe in the second part of the
event.

32. OBSTRUCTIVE SLEEP APNEA
Obstructive Sleep Apnea is the most severe form of Sleep disordered
breathing, affects quality of life and is potentially life threatening.
It is defined by AHI or RDI greater than 5 during sleep as revealed by
polysomnography.
OSA is caused by upper airway tissue collapse resulting in airway
obstruction.
AHA: Apnea Hypopnea Index. It’s the average number of combined
apneas and hypopneas per hour.
RDI: Respiratory Disturbance Index.

33. ADENOIDS ENLARGEMENT
Adenoids hypertrophy may occur due to acute upper respiratory
tract infection.
They can remain enlarged, even after the infection is gone.
Some children have enlarged adenoids from birth.
Allergies can also cause this enlargement.
The harmful effect of adenoids is not because their absolute size,
but due its relation to the nasopharynx.
The main infectious causes of adenoid enlargement due to viral
infections, such as the Epstein–Barr virus, or bacterial infections, such
group A Streptococcus.

34. ADENOIDS ENLARGEMENT
SYMPTOMS:
Adenoids enlargement produce impairment of nasal respiration,
causing:
snoring
hyponasal speech (as difficulty in pronounce the letter “m”) due to
the blocked, stuffy nose.
also forcing the child to inspire by mouth.
It has been demonstrated by radiological studies and by pressure
studies that adenoids can obstruct Eustachian tube openings, and
adenoidectomy can relieve this obstruction. So possible infections can
result (otitis media with effusion).
Sleep apnea.

35. ENLARGED ADENOIDS DIAGNOSIS
Take a full history of symptoms.
Use Nose endoscope (using a thin and slender illuminated
fiberoptic instrument) to view the adenoids.
X-Ray of the throat is useful for adenoids.
Sleep study for obstructive sleep apnea patients.
Sleep study: sleep overnight at a facility while their breathing
and brain activity are monitored using electrodes.
Nasopharyngeal endoscopy instrum

36. ENLARGED ADENOIDS (AND
TONSILS)
X-RAY

37. ADENOID FACE
The child with enlarged adenoids has a characteristic facial
appearance resulting from effect of nasal obstruction and mouth
breathing on the growth of maxilla. This facial appearance consists
of:
An open lip posture with prominent upper incisor teeth and a short
upper lip.
A thin nose, a hypoplastic narrow maxilla, narrow upper alveolus
and a high arched palate.
Teeth abnormalities as cross bite and open bite.

38. ADENOID FACE
Adenoid face child
High arched palate

39. ADENOID HYPERTROPHY
TREATMENT
Asymptomatic and may not require treatment.
 Bacterial infections will usually be treated with a specific antibiotic
course depending on the causative agent.
 Viral infections usually resolve themselves within 5 to 7 days.
Allergic causes can be treated with intranasal/oral corticosteroids, or
oral antihistamines.
Severe or persistent enlargement, surgical removal (Adenoidectomy)
may be required.

40. INDICATIONS FOR
ADENOIDECTOMY
Nasal obstruction proved by X-Ray.
Otitis Media with effusion (some cases require both adenoidectomy
and ventilation tubes insertion).
Recurrent acute Suppurative otitis media.
Obstructive Sleep apnea
Failure to thrive
Suspected malignancy
Adenoidectomy is usually performed at age between 1-7 years.

41. CONTRAINDICATIONS TO
ADENOIDECTOMY
A recent upper respiratory tract infection is an absolute
contraindication.
A suspected bleeding disorder (eg. hemophilia – factor VIII def.).
Active rheumatic fever.
Poliomyelitis epidemics.
Atlantoaxial joint laxity (in 10% of down syndrome) needs special
stabilization.
Adenoids should never be removed in a child who has had a cleft
palate repair, a congenitally short palate, or who has a submucous
cleft palate.
B/C, Adenoids assist soft palate in nasopharynx closure during

42. THE OPERATION OF
ADENOIDECTOMY
NASOPHARYNX PROCEDURE
General anesthesia is performed.
Adenoids are visualized by lifting the soft palate.
Palpate it with a finger to rule out any abnormal pulsation.
A St. Clair Thompson curette is inserted into nasopharynx, against
posterior surface of nasal septum and swept downwards. (too large
curette will damage Eustachian tube, and small curette will result in
incomplete removal).
There must be absolutely no bleeding from nasopharynx before
anesthesia is terminated.

43. THE OPERATION OF
ADENOIDECTOMY
OROPHARYNX PROCEDURE
General anesthesia is performed.
A St. Clair Thompson curette is inserted into oropharynx, and swept
upward.
There must be absolutely no bleeding before anesthesia is
terminated.
St. Clair Thompson
Curette
Adenoids specimen
2 cm wide and 1 cm
high.

44. Rhinoscopy, The adenoids
are in the center,
completely blocking the
choanae.
Rhinoscopy, the eustachian
tube orifice on the right, the
small adenoids on the
posterior superior wall of the
nasopharynx in the center.

45. ADENOIDECTOMY COMPLICATIONS
Hemorrhage.
Surgical trauma: as Injury to soft palate, ET injury or stenosis,
dislocation of cervical spine or anterior ligaments of cervical spine
infection and resulting instability of atlanto-occipital joint.
Hypernasality (contrast to hyponasality): excessive sound energy
from the nasal cavity (voice is not balanced).
A video on hypernasality suffering child :
https://youtu.be/KWz5_fpnZYc

46. TONSILLECTOMY INDICATIONS
Obstructive sleep apnea, failure to thrive, or abnormal dentofacial
growth; suspicion of malignant disease; hemorrhagic tonsillitis,
dysphagia, speech impairment, and halitosis. Otitis media and
recurrent or chronic rhinosinusitis.

47. THORNWALDT’S DISEASE
As I said before, adenoid is composed of lobules and a depressed
center called pharyngeal bursa.
The 2nd most common epithelial growth in nasopharynx next to
adenoids.
Cystic transformation with inflammation.
Thronwaldt’s disease is a rare congenital pathology characterized by
the formation of a pathological cavity in the nasopharynx. Discharge
accumulates inside the bursa, which in the future becomes inflamed
and a purulent discharge is formed.
Diagnosed by endoscopy, seeing central mass with yellowish color.
Treated by endoscopic removal of the cyst or by using a surgical
laser.

48. THORNWALDT’S DISEASE
(PHARYNGEAL BURSITIS) CLINICAL
FEATURES
Persistent post nasal discharge.
Nasal obstruction.
May result in serous otitis media.
Dull occipital headache.
Recurrent sore throat.
Low grade fever.

49. THORNWALDT’S DISEASE
DIAGNOSIS
A CT scan shows a solid mass of Tornwaldt's cyst and MRI shows a
glass-shaped lesion with fluid on the upper part of the posterior
nasopharyngeal wall.
A cystic mass in the upper part of the nasopharyngeal wall and
mucopurulent discharge from upper part of the mass can be seen on
nasal endoscopy.
Among them MRI is the best for diagnosing the Tornwaldt's cyst

50. THORNWALDT’S DISEASE MRI

51. LARYNX
the organ of voice production and the part of the respiratory tract between
the lower part of the pharynx and the trachea.
prevent the passage of food or drink into the airway in swallowing.
Regulates the flow of air to and from the lungs for vocalization.
Forms a framework of cartilage for the attachment of ligaments and
muscles.
situated : at the level of the C4-6, below the tongue & hyoid bone.
vocal cords lie at C5 level in adults, higher in female and children.
covered in front by the strap muscles & at the sides by the thyroid gland.

53. LARGYNGEAL FOLDS
The vestibular folds (false vocal cords):
lie superiorly to the true vocal cords.
They consist of the vestibular ligament covered by a mucous membrane, and
are pink in color.
They are fixed folds, which act to provide protection to the larynx.
The vocal Fold (true Vocal Cord):
mobile fold on each side of the larynx
Voice production.
White color, avascular.

55. LARYNGEAL CAVITY
laryngeal cavity is divided into three portions: the vestibule,
ventricle, and infraglottic cavity.
A. Vestibule: Extends from the laryngeal inlet to the vestibular folds.
B. Ventricles: Extend between the vestibular fold and the vocal fold.
C. Infraglottic Cavity: Extends from the rima glottidis to the lower
border of the cricoid cartilage

56. LARYNGEAL CAVITY
The gap between the vocal folds is called the rima glottidis
The glottis is the narrowest part of the larynx (2.5cm) but in
children, the lower part of larynx within the cricoid is the
narrowest.

57. LARYNGEAL CAVITY

58. THYROID CARTILAGE
Shied shaped, open posteriorly,
angulated anteriorly.
Angulation more acute in males.
Its function is to shield larynx
from injury and provide an
attachment to vocal cords.

59. CRICOID CARTILAGE
Signet ring shaped
Stronger than thyroid cartilage.
Base for entire larynx
Support to arytenoid
Attachment to intrinsic muscles

60. EPIGLOTTIS
Thin spoon shaped fibro-cartilage, situated in
midline.
Upper free end broad & rounded, projects up behind
base of tongue.
Narrow base attached to thyroid cartilage.
This attachment forms lower limit of pre-epiglottis
space.
All cartilages of the larynx are hyaline cartilage except
the epiglottis which is elastic cartilage.

61. ARYTENOID CARTILAGES
Paired cartilages, pyramidal in shape.
Base articulated with cricoid cartilage.
PCA & LCA muscles attach on muscular process.

62. LARYNX NERVE SUPPLY
Derived from vagus nerve.
Superior Laryngeal Nerve leaves the vagus nerve high in the neck
and divided into:
Internal laryngeal nerve: provides sensation of the glottis and
supraglottis, underside of the epiglottis and the larynx above the
vocal cords. ((SIS-superior internal sensory)).
External laryngeal nerve: supplies motor function to the cricothyroid
muscle which tenses the vocal cords and could cause laryngospasm.
Vagus branch  Recurrent laryngeal nerve : supplies larynx under
the level of vocal cords, and all intrinsic muscles of larynx except the
cricothyroid.

63. LARYNX BLOOD SUPPLY AND
LYMPH DRAINAGE
Sup. Laryngeal Artery from Sup. Thyroid artery.
Inf. Laryngeal Artery from Inf. Thyroid artery.
Veins correspond to arteries..
Lymph Drainage of the Larynx
Above vocal folds: antero-superior group of deep cervical nodes.
Below vocal folds: postero-inferior group of deep cervical nodes
through prelaryngeal & pretracheal nodes.

64. MUSCLES OF THE LARYNX
The muscles of the larynx are divided into two groups:
Extrinsic muscles: produce the movements of the hyoid bone. These
are the infrahyoid (sternohyoid, omohyoid, sternothyroid, thyrohyoid)
and suprahyoid muscles (stylohyoid, digastric, mylohyoid,
geniohyoid)
Intrinsic muscles: which move the vocal cords in order to produce
speech sounds. They are functionally divided into adductors (lateral
cricoarytenoid, transverse arytenoid), abductors (posterior
cricoarytenoid), sphincters (transverse arytenoid, oblique arytenoid,
aryepiglottic), muscles that tense the vocal cords (cricothyroid), and
muscles that relax the vocal cords (thyroarytenoid, vocalis).

65. MUSCLES OF THE LARYNX

66. CRICOTHYROID
stretches and tenses the vocal ligaments, and so is important for the
creation of forceful speech.
Originates from the anterolateral aspect of the cricoid cartilage, and
attaches to the inferior margin and inferior horn of the thyroid
cartilage.
Innervated by the external laryngeal nerve.

67. THYROARYTENOID
Originates from the inferoposterior aspect of the angle of the thyroid
cartilage, and attaches to the anterolateral part of the arytenoid
cartilage.
Actions: Relaxes the vocal ligament.
Innervated by the inferior laryngeal nerve.

68. POSTERIOR CRICOARYTENOID
Originates from the posterior surface of the cricoid cartilage, and
attaches to the muscular process of the arytenoid cartilage.
Actions: Abducts vocal folds.
Innervation: Inferior laryngeal nerve (branch of recurrent laryngeal).

69. LATERAL CRICOARYTENOID
Originates from the arch of the cricoid cartilage, and attaches to the
muscular process of the arytenoid cartilage.
Actions: Adducts the vocal folds.
Innervated by the Inferior laryngeal nerve.

70. TRANSVERSE AND OBLIQUE
ARYTENOIDS
Spans from one arytenoid cartilage to the opposite arytenoid.
Actions: Adducts the arytenoid cartilages.
Innervated by the inferior laryngeal nerve.

72. LARYNGOMALACIA
 Most common congenital laryngeal anomaly.
 Accounts for approximately 60 percent of laryngeal problems in the
newborn.
 2 Males : 1 Female.
 It is usually a self-limiting condition, but when severe may produce:
Life-threatening obstructive apnea,
Cor pulmonale,
Failure to thrive.

73. LARYNGOMALACIA
delay of maturation of the supporting structures of the larynx.
dynamic lesion resulting in collapse of the supraglottic structures
during inspiration, leading to airway obstruction.
Noted in the first few weeks of life and is characterized by fluttering,
high-pitched inspiratory sounds.
Stridor (noisy breathing) typically worsens in the supine position.

76. LARYNGOMALACIA TREATMENT
In the past, tracheostomy was the surgical procedure of choice for
severe cases.
Now Supraglottoplasty has proven successful for the correction of
supraglottic obstruction (the surgical procedure of choice).
Supraglottoplasty is done through the mouth by laser or surgical
instruments to remove obstructive tissue in the upper larynx.

77. Supraglottoplasty

78. LARYNGOCELE
Dilated sac filled with air (ventricle)
Internal vs. external
May present at birth.
Difficult to diagnose.
Endoscopic or open procedures for treatment.
Symptoms:
intermittent hoarseness + stridor.
dyspnoea that increases with crying.
Neck mass in adults

79. LARYNGOCELE TYPES
Internal laryngocoeles are within the larynx itself and do not cross
the thyrohyoid membrane.
External laryngocoeles penetrate the thyrohyoid membrane at the
neurovascular bundle.
Mixed laryngocoeles are dilated in both segments.

80. STRIDOR
Stridor is a respiratory noise produced by turbulent airflow in the
airway.
It is not a diagnosis or a disease but a symptom indicates narrowing
or obstruction of the upper airway.
It is a harsh, high-pitched noise that can resemble a squeak or a
whistle.

81. STRIDOR TYPES
1) Inspiratory stridor reflects airflow impairment above or at the level
of the vocal cords. It is generally high pitched when occurring at
the vocal cords and may be low pitched (stertor) when obstruction
is above the vocal cords (pharynx or supraglottic larynx).
2) Expiratory stridor is classically caused by obstruction in the distal
trachea or bronchi. It gives rise to a more prolonged, sonorous
sound and a prolongation of the expiratory phase of respiration.
3) Biphasic stridor has both an inspiratory and expiratory component
and is suggestive of a fixed lesion. This typically suggests a
narrowing of the subglottic region, though fixed narrowing in
other locations can also result in this sound.

82. REGIONS OF THE NECK
Anterior Triangle: bounded by sternohyoid muscle, the digastric
muscle, and the sternomastoid muscle.
Posterior Triangle: bounded by the cleidomastoid muscle, the
clavotrapezius muscle, and the clavicle.

83. ANTERIOR NECK TRIANGLE
Bounded by the anterior border of the sternocleidomastoid, the
anterior midline of the neck, and the inferior border of the mandible.
 Has a roof formed by the platysma and the investing layer of the
deep cervical fascia.
 Is further divided by the omohyoid anterior belly and the digastric
anterior and posterior bellies into the digastric (submandibular),
submental (suprahyoid), carotid, and muscular (inferior carotid)
triangles.

84. ANTERIOR NECK TRIANGLE
Thyroid Gland
Common Carotid Arteries and Branches:
- cranial thyroid artery (CTA)
- muscular branch (lateral to the CTA)
- internal and external carotid arteries (passes deep to the digastric
muscle).
INTERNAL JUGULAR VEIN runs with the common carotid artery in the
anterior triangle.
The HYPOGLOSSAL NERVE (CN XII) runs with the sublingual artery.
The SPINAL ACCESSORY NERVE (CN XI) innervates the cleidomastoid and
trapezius muscles.
VAGUS NERVE (CN X) runs with the common carotid artery and is joined by
the SYMPATHETIC TRUNK

85. POSTERIOR TRIANGLE
Bounded by the posterior border of the sternocleidomastoid muscle, the
anterior border of the trapezius muscle, and the superior border of the clavicle.
 Has a roof formed by the platysma and the investing (superficial) layer of the
deep cervical fascia.
 Has a floor formed by the splenius capitis and levator scapulae muscles and
the anterior, middle, and posterior scalene muscles.
 Contains the accessory nerve, cutaneous branches of the cervical plexus,
external jugular vein, transverse cervical and suprascapular vessels, subclavian
vein (occasionally) and artery, posterior (inferior) belly of the omohyoid, and
roots and trunks of the brachial plexus.
 Also contains the nerve to the subclavius and the dorsal scapular,
suprascapular, and long thoracic nerves.
 Is further divided into the occipital and subclavian (supraclavicular or
omoclavicular)
triangles by the omohyoid posterior belly.

86. POSTERIOR NECK TRIANGLE
EXTERNAL JUGULAR VEIN runs obliquely across this triangle.
The SPINAL ACCESSORY NERVE (the only structure found in both
triangles).
The SUBCLAVIAN ARTERY and vein are found deep to the clavicle.

87. NECK TRIANGLES

88. DEEP NECK SPACES
Deep neck spaces are suprahyoid, infrahyoid, or span the entire
length of the neck.
1) Suprahyoid: Peritonsillar, Parapharyngeal, Submandibular.
Sublingual.
2) Infrahyoid: visceral
3) Span entire length of neck:
Retropharyngeal: nasal cavity, paranasal sinuses, nasopharynx,
vertebral bodies
Prevertebral: hematogenous spread from vertebrae and
intervertebral discs
Danger space: parapharyngeal, retropharyngeal space infections

89. DANGER SPACE
The danger space is bound by the alar fascia anteriorly and the
prevertebral fascia posteriorly. It extends from the skull base to the
thoracic cavity, providing an unrestricted path for spread of infection
into the mediastinum, causing mediastinitis.
 Infections of the parapharyngeal, retropharyngeal, and prevertebral
space can easily extend to this space.

90. NECK SPACES

91. NECK SWELLINGS (HISTORY
TAKING)
Ask about:
Onset, Duration, Pain, Difficulty in swallowing/ mastication,
Dyspnea/ nasal obstruction
Change of voice
Weight loss, Night sweating, Fever
Past Medical History: Surgery, liver disease, smoking …etc
Family history.

92. NECK SWELLINGS EXAMINATION
Site: in which triangle?
Relation to muscles: If the lump is deep to a muscle, it will become
impalpable when the muscle contracts.
Relation to the trachea: Swellings that are fixed to the trachea will
move when the trachea moves (pulled up by swallowing).
Relation to the hyoid bone: Ask the patient to protrude their tongue.

93. NECK SWELLINGS EXAMINATION
Check the following:
Solitary/ multiple
Solid/ cystic
Effect of swallowing/ tongue protrusion
Complete exam of head, neck, oral and upper aero-digestive tract.

94. THYROGLOSSAL CYST
Midline neck swelling that arises from the remnant of the
thyroglossal tract.
Often located below or near the hyoid bone.
children in the first decade of life are the most affected.
Failure of thyroglossal tract obliteration after thyroid reaches its
destination.
It may remain asymptomatic until fluid dilation leads to the
development of a cyst.
Almost 50% of these cysts occur close to or just below the body of
the hyoid bone.
may also be found at the base of the tongue or close to the thyroid

95. THYROGLOSSAL CYST

96. THYROGLOSSAL CYST SYMPTOMS
AND EXAM
Midline swelling.
moves upwards on swallowing and on tongue protrusion due to its
attachment to hyoid bone.
If the cyst is large enough, it will transilluminate.
The infected cyst may rupture into the overlying skin of the neck.

97. THYROGLOSSAL CYST DIAGNOSIS
Thyroid imaging (ultrasound, CT scan) and thyroid function tests
should be carried out to delineate the anatomy of the normal thyroid
gland and thyroglossal cyst.
Thyroid scintigraphy (Radioactive iodine or technetium) or high-
resolution ultrasonography, for identifying ectopic thyroid tissue.
The fine needle aspiration (FNA) to remove fluid from the cyst help to
identify the diagnosis.
Differentials: Lymph nodes, Goiter, Dermoid cyst, Lipomas, Branchial
cleft cyst, Enlarged lymph node, Ectopic thyroid anomalies which are
odontogenic in origin

98. THYROGLOSSAL CYST TREATMENT
incision of the entire thyroglossal tract, a procedure known as the
Sistrunk’s operation.
Sistrunk’s operation: resection of the central portion of the hyoid
bone, together with the thyroglossal cyst, with extent of the
dissections occurring as far as the back of the tongue.
Surgery indications:
Occurrence of any complications (ex. Thyroglossal cyst carcinoma,
infection, thyroglossal fistula…).
Cosmetic purposes.

99. LYMPHADENOPATHY
Causes of lymphadenopathy:
Throat infection: Upper deep cervical, size 1-2 cm, mildly tender,
inflamed tonsil.
Tuberculous: Upper & middle cervical, mildly tender, firm to cystic,
overlying skin- normal temp., purplish or normal color.
Primary tumors: Ant./post. triangles, smooth, discrete, non-tender,
rubbery, not fixed.
Metastatic: hard, non-tender, tethered.

100. CERVICAL LYMPHADENOPATHY
The most common cause of a swelling in the neck.
Enlargement of the cervical lymph glands.
Causes include:
Infection: non-specific tonsillitis, glandular fever, tuberculosis, cat-
scratch fever.
Metastatic tumor: from the head, neck, chest and abdomen.
primary reticuloses – lymphoma, lymphosarcoma, reticulosarcoma.
sarcoidosis.

101. LYMPHOMA
The most common primary tumour of lymphoid tissue is malignant
lymphoma.
Lymphoma is a malignancy of lymphocytes (B cells and T cells).
They're enlarged painless lymph nodes.
Lymphoma is diagnosed by mass biopsy.
Divided into Hodgkin’s and non-Hodgkin’s lymphoma.

102. BRANCHIAL CYST
Remnant of a branchial cleft, usually the second cleft, it lies behind
the anterior edge of the upper third of the sternomastoid and bulges
forwards.
Lined with squamous epithelium, but there are often patches of
lymphoid tissue in the wall that are connected with the other lymph
tissue in the neck and can become infected.
The overlying skin may be reddened and tender if the cyst is
inflamed.
Most branchial cysts are between 5 and 10 cm long with smooth
surface

103. BRANCHIAL CYST

104. CAROTID BODY TUMOUR
A rare tumour of the chemoreceptor tissue in the carotid body.
commonly appear in patients between 40-60 Y.O.
painless, slowly growing lump, the lump may pulsates, and transient
cerebral ischemia may occur.

105. NECK MASSES DIFFERENTIAL
Congenital neck masses are those that are present at birth and
secondary to defects occurring in embryology.
Infectious neck masses are those that present due to an infection
and typically resolve with treatment of the infection
Inflammatory masses that do not have a known infectious cause,
such as those associated with Kawasaki’s disease.
Neoplastic lesions of the neck including benign and malignant
processes. These malignant lymphadenopathy, benign and malignant
salivary gland tumors, benign and malignant thyroid tumors, and
tumors originating from neurologic, muscular, vascular, lymphatic, or
osseus tissues.
Vascular malformations.

106. MOST COMMON NECK MASS
CHILDREN
An enlarged lymph node is the most common reason that a child
presents with a neck mass.
The most common cause of enlarged lymphadenopathy is infection,
either viral or bacterial.
Viral causes of lymphadenopathy include adenovirus, rhinovirus, and
enterovirus, which can all occur with a viral upper respiratory
infection.
Bacterial causes of an enlarged lymph node most commonly include
infections due to Staphylococcus aureus and Streptococcus pyogenes.

107. UNILATERAL CAROTID BODY
TUMOR

108. TRACHEOSTOMY
An opening created at the front of the neck so a tube can be
inserted into the cervical trachea, to help in breath.
It is most often performed in patients who have had difficulty
weaning off a ventilator, followed by those who have suffered trauma
or a catastrophic neurologic insult.
Between second and third tracheal rings.

109. TRACHEOSTOMY INDICATIONS
Congenital anomaly (eg, laryngeal hypoplasia, vascular web).
Upper airway foreign body that cannot be dislodged with Heimlich and
basic cardiac life support maneuvers.
Supraglottic or glottic pathologic condition (eg, infection, neoplasm,
bilateral vocal cord paralysis).
Neck trauma that results in severe injury to the thyroid or cricoid
cartilages, hyoid bone, or great vessels.
Subcutaneous emphysema.

110. TRACHEOSTOMY INDICATIONS
Facial fractures that may lead to upper airway obstruction
(comminuted fractures of the mid face and mandible).
Upper airway edema from trauma, burns, infection, or anaphylaxis.
Prophylaxis (as in preparation for extensive head and neck
procedures and the convalescent period).
Severe sleep apnea not amendable to continuous positive airway
pressure devices or other less invasive surgery

111. TRACHEOSTOMY PROCEDURE
The patient’s neck is extended over a shoulder roll (unless there is a
contraindication).
The anesthesiologist stands at the head end of the bed and under
direct laryngoscopy positions the endotracheal tube (ETT) so that the
cuff is midway at the vocal cord level.
Inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.
A horizontal or vertical incision centered on the inferior border of the
cricoid cartilage may be used. a 3-4 cm vertical incision is routinely
used.

112. TRACHEOSTOMY PROCEDURE
A minimal dissection is performed onto the pretracheal tissue in
order to push the thyroid isthmus downward.
The larynx is stabilized and pulled cephalad with the operator’s left
hand.
A bronchoscopy is then performed and the light reflex is used to
select the best site for the introducer needle.
Placing the needle at the inferior edge of the light reflex, the tip of
the needle is directed caudad into the tracheal lumen avoiding the
posterior tracheal wall at all cost.

113. TRACHEOSTOMY TUBE
A tracheostomy tube is loaded onto the dilator
Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to
the 26 FR dilator
Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the
28 FR dilator
The dilator is then loaded on the safety ridge of the stylet and
placed into the tracheal lumen under direct visualization.

114. TRACHEOSTOMY

115. TRACHEOSTOMY VS.
TRACHEOTOMY
Tracheotomy is any procedure that cuts an opening into the trachea.
Tracheostomy is technically a term for a more permanent tract that is
formed from trachea to skin.
Tracheostomy can be performed at the time of a tracheotomy by
suturing skin to the trachea, thus allowing a more stable airway in
case of accidental decannulation.
These terms are often used interchangeably.

116. TRACHEOSTOMY VS.
TRACHEOTOMY

117. INDICATIONS FOR TRACHEOSTOMY
Emergent upper airway obstruction or inability to intubate.
Prolonged intubation/ventilatory support.
Glottic/supraglottic obstruction (including tumor, infection, trauma,
surgical changes).
Pulmonary toilet (hygiene): helps to clear your airways of mucus and
other secretions.
Chronic aspiration (relative indication).
Severe sleep apnea not controlled by CPAP or less-invasive surgery.

118. TRACHEOTOMY
CONTRAINDICATION
The only absolute contraindication for tracheostomy is skin infection
and prior major neck surgery.

119. POSTOPERATIVE COMPLICATIONS OF
TRACHEOTOMY
Bleeding and/or tracheo-innominate fistula
Mucus plugging
Accidental decannulation
False passage during placement of tracheotomy tube

120. SKULL DEVELOPMENT
 Cranial base develops mainly by endochondral ossifi cation.
 Cranial vault and facial skeleton develop by intramembranous ossifi
cation.
 Sutures are important sites of growth and allow bones to overlap
(molding) during birth.

121. FACE EMBRYOLOGY
At the end of the fourth embryonic week, neural crest derived facial
prominences appear from the first pair of pharyngeal arches.
Maxillary prominences are found laterally.
The frontal nasal prominences develop into the forehead and frontal
nasal process.
On either side of the frontal nasal prominences are local thickenings
that form nasal placodes which invaginate to form nasal pits and
ultimately ridges of tissue that can be divided into a lateral nasal
prominence and medial nasal prominences.

122. FACE EMBRYOLOGY

123. NOSE EMBRYOLOGY
In the 7th week embryo, five facial prominences contribute to the
formation of the nose: the frontal nasal prominence, the paired
medial nasal prominences, and the paired lateral nasal prominences.
The frontal nasal prominence forms the nasal bridge, the medial
nasal prominences fuse and form the nasal tip and columella, and the
lateral nasal prominence forms the nasal alae.

124. ORAL MANIFESTATIONS OF
SYSTEMIC DISEASES

125. ORAL MANIFESTATIONS OF
SYSTEMIC DISEASES

127. WALDEYER’S RING
Waldeyer was an anatomist who described the lymphoid tissue in the
posterior nasopharynx and oropharynx.
The ring is composed of the lingual tonsils, pharyngeal tonsils
(adenoids), and palatine tonsils.
This ring of the immune system samples pathogens that enter the
upper aerodigestive pathway, and is involved in the synthesis of
humoral immunoglobulins and production of lymphocytes.

128. WALDEYER’S RING

129. THE END
Thank you so
much…