Anatomy of oropharynx maxilla mandible neck nodes

Anatomy of Oropharynx
Dr Samik Sharma

 The oropharynx consists of the tongue from the circumvallate papillae, posteriorly
to the epiglottis, the tonsils, the associated pharyngeal walls, and the soft palate.
 These structures have essential roles in swallowing and speech.
 The oropharynx has become the most common location for head and neck tumors.
 The oropharynx anteriorly connects to the oral cavity and joins the nasopharynx
with the larynx and hypopharynx.

INTRODUCTION
 Maxilla is the 2nd largest bone of
the face.
 The 2 maxillae form the whole of
the upper jaw.
 3 cavities: the roof of the mouth,
the floor & lateral wall of the nose
& the floor of the orbit.
.

2 fossae, the infratemporal&
pterygopalatine.
2 fissures, the inferior orbital&
pterygomaxillary.

DEVELOPMENT OF MAXILLA: PRENATAL
EMBROYOLOGY OFMAXILLA:
 4th week of IUL a prominent
bulge appears on the ventral
aspect of the embryo.
 Shallow depression primitive
mouth stomodeum
 Separated from the foregut by
the buccopharyngeal membrane
 5 branchial arches form in the
region.
 1st branchial arch is mandibular
arch – responsible for the
development of nasomaxillary
region.

The mesoderm covering the
developing forebrain proliferates
to form the frontonasal process.
The stomodeum is overlapped
superiorly by frontonasal process
& laterally by mandibular arches
of both sides.
Formation of nasal pits divides
frontonasal process into 2 parts :
a) The medial nasal process
b) The lateral nasal process

•The mandibular arch gives off a bud from its
dorsal end called the maxillary process which
grows ventro-medio-cranial to the mandibular
process.
•At this stage the stomodeum is overlapped
from above by the frontal process, below by
the mandibular process & on either side by
the maxillary process.
•The two mandibular processes grow
medially & fuse to form the lower lip & the
lower jaw.

•Maxillary process undergoes
growth, frontonasal process becomes
narrower so that 2 nasal pits come
closer.
•Line of fusion of maxillary process
& the medial nasal process
corresponds to the nasolacrimal
duct.

DEVELOPMENT OF
MAXILLARY SINUS:
The maxillary sinus forms
sometime around the 3rd month of
intrauterine life.
It develops by expansion of the
nasal mucous membrane into the
maxillary bone.
Later sinus enlarges by resorption
of the internal wall of maxilla.

POST-NATAL GROWTH OF MAXILLA
it influences the
Maxillary complex is attached to the cranial base
development of this region.
The growth of the maxilla is dependent on the spheno-occipital & spheno-
ethmoidal synchondroses.
The growth of the nasomaxillary complex is produced by the following
mechanisms:
 Displacement
 Growth at Sutures
 Surface Remodeling

Displacement
 Growth of the cranial base
passive /secondary displacement
of nasomaxillary complex in
downward & forward direction.
 As middle cranial fossa grows it
moves the nasomaxillary
complex to a more anterior
position.
 Growth of the maxillary
tuberosity primary type of
displacement in a forward
direction,due to the enlargement
of the bone itself.

Growth At Sutures:
Maxilla is connected to the cranium
& cranial base by a number of
sutures:
 The fronto-nasal suture
 The fronto-maxillary
suture
 The zygomatico-temporal
suture
 The zygomatico-maxillary
sututre
 The pterygo-palatine
suture

Anatomy of maxilla
BODY OFMAXILLA:
Body of maxilla is pyramidal in
shape, with its base directed
medially at the nasal surface, and
the apex directed laterally at the
zygomatic process.
It has four surfaces and encloses a
large cavity; the maxillary sinus.
(1)Anterior or facial
(2)Posterior or infratemporal
(3)Superior or orbital
(4) Medial or nasal

Four Processes of Maxilla:
 Zygomatic Process
 Frontal Process
 Alveolar Process
 Palatine Process

The Maxillary Sinus or Antrum of Highmore
(sinus maxillaris)
Large cavity in body of maxilla.
Pyramidal in shape, with base :
 Medially towards lateral wall of
nose
 Apex directed laterally into
zygomatic process of maxilla.
Roof formed by floor of orbit and
traversed by infraorbital canal.
The floor is formed by alveolar
process of maxilla ,lies about 1.2
cm below level of floor of nose.

FUNCTIONS :
 Speech and voice resonance
 Reduce the weight of scull
 Filtration of inspired air
 Immunological barrier
 Regulation of intranasal pressure

Articulations of Maxilla
 Superiorly, it articulates with- 3 bones
1) Nasal
2) frontal
3) lacrimal.
 Medially : 5 bones
1) Ethmoid
2) Inferior nasal concha
3) Vomer
4) Palatine
5) Opposite maxilla

Laterally : 1 bone
1) Zygomatic bone

Age
Changes
 At birth :
 Transverse and anteroposterior diameters >vertical diameter;
 Frontal process is well marked
 Body consists of a little more than the alveolar process;
 The tooth sockets close to floor of orbit
 Maxillary sinus is a mere furrow on the lateral wall of the nose.
 In Adults:
 Vertical diameter is greatest due to developed alveolar process
 increase in the size of the sinus.
 In Old
 Infantile condition
 Its height is reduced as a result of absorption of the alveolar process.

INTRODUCTION
 The word mandible derived from Latin word mandibula-
"jawbone" or inferior maxillary bone.
 Only movable bone in the skull
 It consists of an anterior Horseshoe-shaped body, and of two
rami that project upwards from the posterior part of the body.
 It provides structural and protective support for the oral
cavity.
 The mandible is articulated in ball and socket fashion at the
condylar process.
 Strength resides in its dense cortical plates

embryology
 Mandible is the second bone after clavicle to
ossify in the body.
 Parts that ossify in cartilage includes: incisive
part below the incisor teeth, coronoid and
condyloid processes
 Upper half of ramus above the level of the
mandibular foramen
 A single ossification centre for each half of the
mandible arises in the 6th week of I.U. life in
the region of bifurcation of inferior alveolar
nerve into mental and incisive branches. As the
ossification continues, the meckel’s cartilage
become surrounded and invaded by bone.

partly membranous & partly
cartilaginous in ossification.
• Incisive part below symphysis
menti
• Coronoid
• Condyloid process
• Upper half of ramus
Cartilage
• Whole of body except lower incisive
part
• Lower half of ramus upto mandibular
foramen
Membrane

O
S
T
E
O
L
O
G
Y
BODY OF THEMANDIBLE
 Horseshoe-shaped BODY
 Has two surfaces EXTERNAL and INTERNAL surfaces ,
 Two borders UPPER and LOWER borders

FEATURES SEEN ON OUTER SURFACE OF THE BODY
 Symphysis Menti
 Mental Protuberance
 Mental Tubercles
 Mental foramen
 External Oblique line
 Incisive fossa

FEATURES ON THE INNER SURFACE OF THE BODY
 Genial tubercles
 Mylohyoid line
 Submandibular fossae
 Sublingual fossae
 Mylohyoid groove
 Upper alveolar border
 Lower border base
 Digastric fossae

SUPERIOR BORDER (ALVEOLAR BORDER)
It is hollowed into cavities for the reception of the teeth, these cavities are
sixteen in number, and vary in depth and size according to the teeth which
they contain.

INFERIOR BORDER (base of mandible)
Is rounded, longer than the superior,
and thicker in front than behind.

RAMUS OFMANDIBLE
Is quadrilateral
2 surfaces
Lateral
Medial
4 borders
Superior
Inferior
Anterior
Posterior
2 processes
Coronoid
Condylar

PROCESSES
CORONOID PROCESS
 Flat ,triangular
 Upward and forward projection
from anterolateral part of ramus
 Anterior border continuous with
anterior border of ramus
 Posterior border bounds the
mandibular notch

CONDYLAR PROCESS
 Upward projection from postero
superior part of ramus
 Apically enlarged as head of
condyle.
 Articulates with temporal bone’s
mandibular fossa to form
temperomandibular joint
 Lateral aspect palpable in front
of tragus
 Pterygoid fovea anterior to neck

ON THE LATERAL
SURFACE:
1.From The Oblique line :
Buccinator, and depressor anguli
oris below the mental foramen
2. Incisive fossa:
gives origin to MENTALIS mental
slips of ORBICULARIS ORIS.
3.Whole of lateral surface of
ramus except posterosuperior part
provides insertion to MASSETER.
4.Posterosuperior part : covered
by PAROTID GLAND

5.Lateral surface of the neck
provides insertion to the
LATERAL LIGAMENT OF
TMJ.
6.Parts of both the inner and
outer surfaces just below the
alveolar margins are covered by
mucous membrane of the
mouth.
7.PLATYSMA is inserted into
the lower border.
8.The deep cervical fascia (
investing layer) is attached to
the whole length of the lower
border.

1.Digastric fossa: arises
ANTERIOR BELLY OF
DIGASTRIC
2.Genial tubercles: arises
GENIOGLOSSUS and
GENIOHYOID.
3.Mylohyoid line : arises
MYLOHYOID MUSCLE.
4.From an area above the
posterior end of mylohyoid line:
arises SUPERIOR
CONSTRICTOR OF PHARYNX.
5.Pterygomandibular raphe:
Attached immediately behind the
third molar tooth in continuation
with the origin of superior
constrictor
ON THE MEDIAL SURFACE

7.Below and behind the mylohyoid
groove: insertion of MEDIAL
PTERYGOID muscle .
8.At the apex of coronoid process :
TEMPORALIS is inserted ;extend
downwards on ant. Border of ramus.
9.Into the pterygoid fovea: insertion
of LATERAL PTERYGOID.
10.Sphenomandibular ligament : is
attached to the lingula.

BLOOD SUPPLY OF THE MANDIBLE
ARTERIALSUPPLY
Mainly by Maxillary artery,
Branch of external carotid
artery
By its branches, mainly
through inferior alveolar
artery

Venous supply of mandible
 Drains into
Internal jugular vein and external
jugular vein through maxillary vein,
facial vein and pterygoid plexus

Nerve supply of mandible
Mainly through the trigeminal nerve -
V cranial nerve
MANDIBULAR NERVE
 Main trunk
 Anterior trunk
 Posterior trunk

FORAMINA AND OTHER RELATIONS
 Mental foramina - mental nerve and
vessels
 Mandibular notch - massetric nerve
and vessels
 Medial side of neck - auriculo
temporal nerve
 Mylohyoid groove - mylohyoid nerve
and vessels
 Mylohyoid groove in front of ramus -
lingual nerve
 Mandibular canal and foramina -
inferior alveolar nerve and vessels

APPLIED ANATOMY OFMANDIBLE
 Parasymphysis region lateral to the mental prominence is a
naturally weak area susceptible for parasymphyseal fracture.
This is because of the presence of incisive fossa and mental
foramen
 The body of the mandible is considerably thicker than the
ramus and the junction between these two portions
constitutes a line of structural weakness.
 Strength of the lower jaw varies with the presence or absence
of teeth. The presence of impacted lower third molars or
excessive long roots of canines make the area more
vulnerable for fracture.

Introduction
The cervical group of lymph nodes extend from
Mandible & skull base superiorly
Clavicle inferiorly
Posterior triangle of neck laterally & posteriroly
Midline viscera anteriorly
LN groups are categorized acc to original
description by Memorial Sloan-Kettering Group

Levels of Neck Nodes
There are 7 levels of neck and most have
sublevels containing specific group of nodes
Level I – Submental & Submandibular
Level II – Upper Jugular
Level III – Middle Jugular
Level VI – Lower Jugular
Level V – Posterior Triangle
Level VI – Anterior/Central Compartment
Level VII – Superior Mediastinal

LEVEL I
2 groups of LN’s
Sublevel Ia – Submental
Sublevel Ib – Submandibular
Boundaries of Lvl I
Body of Mandible
Ant. Belly of C/L digastric muscle
Post. Belly of I/L digastric muscle
Stylohyoid muscle

Submental (Sublevel Ia)
LN’s in the triangular boundary formed by
Ant belly of digastric muscles
Hyoid Bone
Involved in pathology of
Floor of mouth
Anterior oral tongue
Anterior mandibular alveolar ridge
Lower lip

Boundary Clinical Radiologic Surgical
LEVEL
Ia
Superior
Inferior
Lateral
(Posterior)
Medial
Symphisis of
mandible
Body of Hyoid
N/A
N/A
Geniohyoid
Muscle,
Plane tangent to
inf. Border of
mandible
Body of Hyoid
Ant belly of I/L
digastric mus.
Ant belly of C/L
digastric muscle
Symphisis of
mandible
Body of Hyoid
Ant belly of I/L
digastric mus.
Ant belly of C/L
digastric muscle

Submandibular (Sublevel Ib)
LN’s in the triangular boundary formed by
Ant belly of digastric muscle
Stylohyoid & Post belly of digastric muscle
Body of Mandible
Oral Cavity
Anterior Nasal Cavity
Soft tissue structures of midface
Submandibular gland

LEVEL
Ib
Superior
Inferior
Lateral
(Posterior)
Medial
Body of mandible
Plane through
Hyoid bone
Ant border of SCM
N/A
Mylohyoid Mus,
Body of mandible
Inferior edge of
hyoid bone
Post edge of
Submandibular Gl.
Ant belly of
digastric muscle
Body of mandible
Digastric tendon
attachment to
hyoid bone
Post edge of
Submandibular Gl
Ant belly of
digastric muscle

Many of these lymph nodes lie in close proximity to
submandibular gland, and it is removed to ensure
thorough exenteration of all lymph nodes with in this
traingle
Perifacial LN’s – drain Lip, buccal musoca, ant
nasal caity & soft tissue of neck, sometimes get
involved along with the Level I LN groups.
ND’s performed for nodal disease asso with
primary lesions of these sites should be modified to
encompass perifacial nodes

LEVEL
II
Contain Upper Jugular LN’s
2 groups – Sublevel IIa & IIb
LN’s are located around upper third of internal
jugular vein & adjacent spinal accessory nerve
Extent
Superiorly - Skull base
Inferirly - Inf border of Hyoid bone
Ant (medial) boundary – stylohyoid mus
Post (lateral) boundary – posterior border of SCM

Sublevel IIa nodes are located anterior (medial) to
vertical plane defined by spinal accessory nerve,
whereas sublevel IIb nodes are located posterior
(lateral) to the vertical plane defined by spinal
accessory nerve
Oral cavity, Nasal Cavity
Nasopharynx, Oropharynx, Hypopharynx
Larynx
Parotid gland

LEVEL
IIA
Superior
Inferior
Lateral
(Posterior)
Medial
Mastoid process
Horizontal plane
defined by the
inferior border of
hyoid bone
N/A
N/A
Skull base, Caudal
edge of C1 lateral
process
Horizontal plane
defined by the
inferior border of
hyoid bone
Post. border of IJV
Post. edge of
submandibular
gland
Skull base
Carotid bifurcation
Vertical plane
defined by Spinal
acc. nerve
Post. edge of
submandibular
gland

LEVEL
IIB
Superior
Inferior
Lateral
(Posterior)
Medial
Mastoid process
Horizontal plane
defined by the
inferior border of
hyoid bone
Lateral border of
SCM
N/A
Skull base, Caudal
edge of C1 lateral
process
Horizontal plane
defined by the
inferior border of
hyoid bone
Lateral border of
SCM
Medial edge of
ICA, paraspinal
(lev. scapulae)
mus
Skull base
Carotid bifurcation
Lateral border of
SCM
Vertical plane
defined by Spinal
acc. nerve

AHNS Committee recommends – perpendicular
plane formed by posterior aspect of submandibular
gland as radiologic marker of this boundary

LEVEL
III
Contains Middle Jugular LN’s Group
Located around middle third of IJV
Extent
Superiorly – Carotid bifurcation / Inferior aspect of
body of hyoid bone
Inferiorly – Junction of Omohyoid mus with IJV / lower
border of cricoid arch(cartilage)
Medially – Lateral border of sternohyiod muscle
Laterally – Post border of SCM muscle

Oral cavity
Nasopharynx, Oropharynx, Hypopharynx
Larynx
 AHNS Committee recommends – Lateral border of CCA serves as
Radiologic marker for medial boundary

LEVEL
III
Superior
Inferior
Lateral
(Posterior)
Medial
Horizontal plane
defined by the
inferior border of
hyoid bone
Horizontal plane
defined by the
inferior border of
cricod cartilage
Lateral border of
SCM
Medial border of
SCM
Horizontal plane
defined by the
inferior border of
hyoid bone
Horizontal plane
defined by the
inferior border of
cricod cartilage
Lateral border of
SCM
Medial edge of
ICA, paraspinal
(lev. scapulae)
mus
Carotid bifurcation
Omohyoid muscle
Sensory branches
of cervical plexus
Sternohyoid
muscle

LEVEL
IV
Contains Lower Jugular LN’s Group
Located around lower third of IJV
Extent
Superiorly – Junction of Omohyoid mus with IJV /
lower border of cricoid arch(cartilage)
Inferiorly – Clavicle
Medially – Lateral border of sternohyiod muscle
Laterally – Post border of SCM muscle

Hypopharynx
Thyroid
Cervical Esophagus
Larynx
 AHNS Committee recommends – Lateral border of CCA serves as Radiologic
marker for medial boundary

LEVEL
IV
Superior
Inferior
Lateral
(Posterior)
Medial
Horizontal plane
defined by the
inferior border of
cricod cartilage
Clavicle
Lateral border of
SCM
Medial border of
SCM
Horizontal plane
defined by the
inferior border of
cricod cartilage
2cm cranial to
sternoclavicular
joint
Lateral border of
SCM
Medial edge of
CCA, paraspinal
(scalenus) mus
Omohyoid muscle
Clavicle
Sensory branches
of cervical plexus
Sternohyoid
muscle

LEVEL
V
Contains Posterior Triangle LN’s Group
Located along the lower half of spinal accessory
nerve & transverse cervical artery
Extent
Superiorly (Apex) – convergence of SCM & trapezius
muscle
Inferiorly – Clavicle
Medially – Post border of SCM muscle
Laterally – Anterior border of trapezius muscle

2 groups – Sublevel Va & Vb
The Va is separated from Vb by a horizontal plane
marking the inferior border of the anterior cricod arch
Sublvl Va includes – Spinal accessory nodes
Sublvl Vb includes – nodes following transverse
cervical vessels & supraclavicular nodes (not
Virchow’s Nodes – they are located in Level IV)

Nasopharynx
Oropharynx
Cutaneous structures of posterior scalp
Neck

LEVEL
Va
Superior
Inferior
Lateral
(Posterior)
Medial
Apex of
convergence of
SCM & trapezius
muscle
Horizontal plane
defined by the
inferior border of
cricod cartilage
Anterior border of
Trapezius muscle
Lateral border of
SCM
Apex of
convergence of
SCM & trapezius
muscle
Horizontal plane
defined by the
inferior border of
cricod cartilage
Anterior border of
Trapezius muscle
Lateral border of
SCM
Apex of
convergence of
SCM & trapezius
muscle
Horizontal plane
defined by the
inferior border of
cricod cartilage
Anterior border of
Trapezius muscle
Sensory branches
of cervical plexus

Boundary Clinical Radiologic surgical
LEVEL
Vb
Superior
Inferior
Lateral
(Posterior)
Medial
Horizontal plane
defined by the
inferior border of
cricod cartilage
Clavicle
Anterior border of
Trapezius muscle
Lateral border of
SCM
Horizontal plane
defined by the
inferior border of
cricod cartilage
Clavicle
Anterior border of
Trapezius muscle
Lateral border of
SCM
Horizontal plane
defined by the
inferior border of
cricod cartilage
Clavicle
Anterior border of
Trapezius muscle
Sensory branches
of cervical plexus

LEVEL
VI
Contains LN’s of Anterior compartment of the
neck
They surround the midline visceral structures of
the neck
Extent
Superiorly – Hyoid Bone
Inferiorly – Suprasternal Notch
Laterally (on each side) – Medial border of Carotid
sheath

LN groups in the compartment are –
Pretracheal N
Paratracheal N
Precricoid (Delphian) N
Perithyroidal N
LN’s along Recurrent Laryngeal Nr
Thyroid Gland
Glottic & Subglottic Larynx
Apex of pyriform sinus
Cervical esophagus

LEVEL
VI
Superior
Inferior
Lateral
(Posterior)
Medial
Hyoid Bone
Superior edge of
manubrium sterni
CCA
CCA
Hyoid Bone
Superior edge of
manubrium sterni
Medial Aspect of
CCA
Medial Aspect of
CCA
Hyoid Bone
Superior edge of
manubrium sterni
CCA
CCA

LEVEL
VII
Contains Superior Mediastinal group of LN’s
The LN are an extension of the paratracheal LN
chain extending inferiorly below the suprasternal
notch along each side of cervical trachea to the level
of the innominate artery
Extent
Superiorly – Superior edge of manubrium
Inferiorly – superior border of arch of aorta
Laterally (Left side) – CCA
Laterally (Right side) – Innominate Artery

LEVEL
VII
Superior
Inferior
Lateral
(Posterior)
Medial
Superior edge of
manubrium sterni
N/A
N/A
N/A
Superior edge of
manubrium sterni
Innominate Artery
Innominate Artery
& Left CCA
Innominate Artery
& Left CCA
Superior edge of
manubrium sterni
Innominate Artery
Innominate Artery
& Left CCA
Innominate Artery
& Left CCA

Anatomy of oropharynx maxilla mandible neck nodes

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