The document provides a comprehensive overview of the surgical anatomy of the pharynx and larynx, including their embryology, structure, and physiological functions. It details the anatomy and function of various anatomical components such as the walls of the pharynx, cartilages of the larynx, and their associated muscles, blood supply, and nerve innervation. Additionally, the document addresses applied clinical aspects including developmental anomalies and airway management techniques.

1. SURGICAL
ANATOMY OF THE
PHARYNX AND
LARYNX

2. CONTENTS
 Introduction
 Embryology of pharynx and larynx
 Anatomy of pharynx
 Anatomy of larynx
 Physiology of pharynx and larynx
 Examination
 Applied aspects
 Developmental anomalies
 Pharyngocutaneous fistula
 Laryngeal trauma
 Space infections
 Velopharyngeal insufficiency
 Obstructive sleep apnea
 Orthognathic surgery and pharyngeal space.
 Eagles syndrome.
 Zenker’s diverticulum.
Airway assessment and
management
Tracheostomy
Cricothyrotomy
Approaches to the
oropharynx
Conclusion
References

3. INTRODUCTION

4. PHARYNX

5. EMBRYOLOGY OF PHARYNX
 The primitive pharynx forms in the late
embryonic period as a dilation of the cranial
end of the foregut, lying between the
developing heart ventrally and the
chondrocranium rostrodorsally.
 The early pharynx is large relative to the
rest of the gut, is flattened ventrodorsally,
and gives rise to diverse structures from its
floor and side walls.
 The lateral aspects of the primitive pharynx
project a series of pouches between the
pharyngeal arches.
 The endodermal lining of the primitive
pharynx develops gradually from a
polyhedral cuboidal embryonic epithelium
into a respiratory mucous membrane.

6.  The cricothyroid and the constrictors
of the pharynx, palatopharyngeus
develop from occipital somites 2& 4.
 The third pharyngeal arch muscle ,
the stylopharyngeus, is derived from
seventh somitomere.
 The artery of the pharynx are derived
from the third arch artery.

7. Anatomy of pharynx
The wall of the pharynx
1. Mucosa & submucosa
2. Pharyngobasilar fascia
3. Longitudinal muscles
4. Circular muscles –
constrictors
5. Pharyngeal plexus of veins
& nerves
6. Buccopharyngeal fascia

8. Nasal part: the mucosa is
ciliated and resembles the
mucosa of the nose. It also
contains lymphoid nodules
that constitute the pharyngeal
tonsil (adenoids).
In the remainder of the
pharynx, the epithelium is
stratified squamous and the
mucosa is tightly attached to
the pharyngobasilar fascia
Mucous layer

9. MUSCLES OF PHARYNX
It consists of three
overlapping
constrictors:
Three
longitudinally
directed
muscles:

10. Origin: medial pterygoid plate,
pterygomandibular raphe, alveolar
process
Four parts-
Some fibers are attached to the
palatine aponeurosis and arise with
palatopharyngeal fibers. These fibers
as important in the formation of the
ridge of Passavant and they are
called the palatopharyngeal
sphincter.
The ridge of Passavant develops from
the passive folding of the pharyngeal
wall brought about by the elevation
of the pharynx through the
SUPERIOR CONSTRICTOR

11. MIDDLE CONSTRICTOR
Fan shaped muscle
Origin:
upper Fan-shaped border of the
greater cornu of the hyoid bone, from
the lesser cornu, and from the
stylohyoid ligament
Insertion:
Posterior median fibrous raphe
blending in the middle line with the
muscle of the opposite side.

12. INFERIOR CONSTRICTOR
Origin:
Thyropharyngeus arises from oblique line
of thyroid lamina, and by a small slip from
inferior cornu
Cricopharyngeus arises from the side of
the cricoid cartilage between attachment
of cricothyroid and articular facet for
inferior thyroid cornu
Insertion:
The upper part attaches to the median
raphe while the lower part forms a
circular band that lacks a median raphe

13. LONGITUDINAL MUSCLES
 Palatopharyngeus descends
from the sides of the palate and
runs longitudinally on the inner
aspect of constrictors.
 Salpingopharyngeus descends
from the auditory tube to merge
with the palatopharyngeus.
 Stylopharyngeus arises from
styloid process. Passes through
gap b/w sup. and middle
constrictor to run downwards on
the inner surface of middle and
inf. Constrictors

14. GAP BETWEEN PHARYGEAL MUSCLES &
STRUCTURES RELATED TO THEM
 SINUS OF MORGAGNI.
Structures- auditory tube, levator veli
palatine, ascending palatine artery.
 THE SUPERIOR AND MIDDLE
CONSTRICTORS:
Structures- Stylopharyngeus muscle and
glossopharyngeal N.
 THE MIDDLE AND INFERIOR
CONSTRICTOR muscle- internal
laryngeal N and superior laryngeal
vessels.

15. PARTS OF PHARYNX
 NASOPHARYNX: Lying behind
nasal fossae and above soft palate.
 OROPHARYNX: Lying behind
anterior pillars of fauces.
 LARYNGOPHARYNX: Lying behind
larynx.

16.  Lies behind the nasal cavities, above the soft palate.
`` Roof :
 It is formed by body of the sphenoid and the basilar part of the
occipital bone.
 A collection of lymphoid tissue, called the pharyngeal tonsil is present
in the submucosa of this region.
 Anterior wall :shows posterior nasal apertures
 Posterior wall :the anterior arch of the atlas.
 Lateral wall:
 On each side has the pharyngeal opening of the auditory tube.
 The posterior margin of the tube forms an elevation called the tubal
elevation.
 The salpingopharyngeus muscle produces a vertical fold of mucous
membrane called the salpingopharyngeal fold
Floor :
 soft palate
 pharyngeal isthmus.
NASOPHARYNX

17. PHARYNGEAL RECESS
 It is a small depression
in the lateral wall
behind the tubal
elevation.
 A collection of lymphoid
tissue in the submucosa
behind the opening of
the auditory tube is
called the Tubal tonsil.

18. PHARYNGEAL TONSIL
 It is a collection of lymphoid tissue
present in the wall of the pharyngeal
recess and the roof of nasal pharynx.
 Seen in children and sometimes in
adults.
 Enlargement of the pharyngeal
tonsil may interfere with the
nasal breathing & speech.
 It may obstruct the auditory
tube and lead to deafness
because of subsequent
absorption of air from the
tympanic cavity.

19. OROPHARYNX
In front:
communicates with the oral cavity through
orophayngeal isthmus.
Below:
it opens into the laryngophaynx at the level
of the upper border of epiglottis.
lateral wall :
palatopharyngeal arch , palatoglossal arch
and palatine tonsil
Posteriorly:
level with second, and upper part of the
third, cervical vertebrae.

20. WALDEYER’S RING
 pharyngeal tonsil (or "adenoids"), are located on
the roof of the nasopharynx, under the sphenoid
bone.
 2 tubal tonsils on each side, where each
auditory tube opens into the nasopharynx
 2 palatine tonsils (commonly called "the tonsils"),
are located in the oropharynx
 1 group of lingual tonsil are located on the back
part of the tongue

21. Peritonsillar abcess (quinsy), is a
complication of tonsillitis and consists of a
collection of pus beside the tonsil (peritonsillar
space).
Piriform fossa:
The fossa present on each side of the
inlet of larynx
It is bounded medially by the aryepiglottic
fold, laterally by the thyroid cartilage and
the thyrohyoid membrane.

22. LARYNGOPHARYNX
Hypopharynx.
€ It has four walls:
 Anterior wall
 Posterior wall
 Two Lateral walls.
€ Anterior wall:
 Laryngeal inlet.
 Posterior surface of the larynx.
€ Posterior wall: C3, C4, C5, and C6
vertebrae.
€ Lateral wall: thyroid cartilage and
thyrohyoid membrane. On each side of
laryngeal inlet, lies the piriform fossa .

23. PIRIFORM RECESS
o It is a deep recess broad above
and is narrow down below in
anterior part of lateral wall of
laryngopharynx, on each side
of laryngeal inlet.
o These recesses are generated
because of bulging of larynx
into laryngopharynx.

24. SIGNIFICANCE
The malignant tumor of the laryngopharynx may grow
in the space supplied by the piriform fossa without
producing symptoms until the patient presents with
metastatic lymphadenopathy.
The ingested foreign bodies (fish bones, safety pins)
are occasionally lodged into the piriform fossa.
Piriform fossae are dangerous sites for perforation by an
endoscope.

25. KILLIAN’S DEHISCENCE
It is named after the German ENT
surgeon Gustav Killian
A triangular area in the wall of the
pharynx between the thyropharyngeus
and cricopharyngeus of the
inferior constrictor of the pharynx .
This weak part lies below the level of the
vocal folds or upper border of the
cricoid lamina & is limited inferiorly by a
thick cricopharyngeal sphincter.

26. BLOOD SUPPLY
From the External Carotid Artery
& its branches
1- Tonsillar artery (from Facial
Artery)
2-Ascending palatine artery (from
Facial Artery)
3-Ascending pharyngeal Artery
(from external carotid)
4-Descending palatine artery
( from Maxillary artery).
5-Dorsalis lingulae artery (from
Lingual artery)

27. VENOUS AND LYMPHATIC DRAINAGE
The veins of the pharynx form a plexus on the posterior wall , this plexus
communicates above with the pterygoid plexus of veins and below with the
superior thyroid and lingual veins or directly drains into internal jugular.
Lymphatic drainage
• Roof and most of the posterior wall of the pharynx -the lateral
pharyngeal node
• Tonsillar region -into the deep cervical nodes;
• Laryngeal part of the pharynx group together in the piriform recess,
pierce the thyrohyoid membrane, and unite with other lymphatics to
go to the deep cervical nodes.
• The drainage is via lymphatics which pierce the superior constrictor
muscle and pass to the nodes along the internal jugular vein,
especially the tonsillar or jugulodigastric node at the angle of the
jaw.

28. NERVE SUPPLY
SENSORY
Nasopharynx,- by pharyngeal branch of
the pterygopalatine ganglion taking fibres
from maxillary division of trigeminal
nerve.
Oropharynx- glossopharyngeal nerve.
Laryngopharynx- Internal laryngeal nerve.
MOTOR
THE motor supply:
Derived from the cranial accessory N,
which via the branches of the vagus
to the pharyngeal plexus supply to
all the muscles of the pharynx.
Except,
Stylopharyngeus-glossopharyngeal
N.
the lower part of the inferior
constrictor- supplied by the recurrent
laryngeal branch of the vagus.

29. LARYNX

30. INTRODUCTION
 Lies in anterior midline of neck.
 From root of tongue to trachea.
 From laryngeal inlet upto lower
border of cricoid cartilage.
 Opposite to C3 to C6 vertebrae In
men.
 Slightly higher in female & children
 Until puberty there is little difference
b/w male & female larynx.
 After pubetry: Male larynx
undergoes considerable increase in
size; thyroid cartilage becomes
prominent called Adam’s apple

31. EMBRYOLOGY OF LARYNX
Cartilages are developed from 4th
and
6th
pharyngeal arch.
Hypoglossal cord derived from
occipital somites 1 to 4 contributes to
laryngeal muscle

32. ANATOMY OF LARYNX
9 Cartilages:
Connected by
Joints
Ligaments
Membranes
Moved by
8 muscles
Cavity- Mucous membrane

33. CARTILAGES OF LARYNX

34. HISTOLOGY OF LARYNGEAL CARTILAGES
Thyroid
Cricoid
Base of
arytenoids
Epiglottis
Cortniculate
Cuneiform
Process of
arytenoid
Hyaline cartilage
May ossify after 25yrs of age
Elasticus
Do not ossify

35. THYROID CARTILAGE
 Largest cartilage
 Shield shaped,open
posteriorly, angulated
anteriorly
 Protect larynx
 superior and inferior horn
 Inferior horn articulates via
synovial joint with cricoid
cartilage
 Laryngeal prominence i.e.
Adams apple – more
prominent in males

36. CRICOID CARTILAGE
Forms a complete ring around airway
Lies at the level of C 6 vertebra
Hyaline cartilage
Laminae gives attachment to fibers of
oesophagus and posterior
cricoarytenoid muscle
Cricothyroid and inferior constrictor
muscle take origin from arch.
The upper border of cricoid cartilage is
connected to thyroid cartilage by
cricothyroid membrane

37. EPIGLOTTIS
●Leaf shaped in adults and omega shaped in
children
●Stands vertically behind hyoid bone and
root of tongue
●Connected to body of hyoid and posterior
side of thyroid cartilage
●The anterior surface of epiglottis is
connected to tongue by a median
glossoepiglottic fold.
●The valleys on either side of glossoepiglottic
fold are termed as vallecula.

38. ARYTENOID CARTILAGE
Pyramid shaped
posterosuperior border of
the cricoid cartilage.
Has vocal process &
muscular process.
They influence the position
and tension of the
vocal folds.
More prone to damage
during laryngoscopy

39. CORNICULATE & CUNIEFORM
Corniculate cartilage –
Called as cartilage of
Santorini.
rests on apex of the
arytenoids
Cuneiform
cartilage(Wrisberg)
i. Lie in
aryepiglottic fold
Both these cartilages
strengthen arytenoids

40. JOINTS
CRICOTHYROID JOINT;
Rotatory movement around transverse
axis
CRICOARYTENOID JOINT:
Rotatory movement around vertical axis

41. MEMBRANES & LIGAMENTS OF LARYNX
EXTRINSIC:
 Thyrohyoid
membrane
 Hyoepiglottic
ligament
 Cricotracheal
ligament
INTRINSIC: FIBROELASTIC
MEMBRANE OF LARYNX
1. QUADRATE MEMBRANE
a)Aryepiglottic fold
b)Vestibular ligament
2. CRICOTHYROID LIGAMENT
a)Conus elasticus.

42. THYROHYOID MEMBRANE
Fibrous membrane that connects the
upper border of the thyroid cartilage
the lower border of the hyoid bone.
Its lateral portion is pierced by
The internal laryngeal nerve
Superior laryngeal artery
Serves as an anatomical
landmark for SLN block

43. EXTRINSIC
HYOEPIGLOTTIC
CRICOTRACHEAL

44. INTRINSIC
Part of fibro elastic membrane.
Lies just outside of mucous membrane.
FIBRO ELASTIC MEMBRANE divided into upper
& lower part by laryngeal ventricle
Quadrate membrane
Conus elasticus.

45. LARYNGEAL INLET

46. CAVITY OF LARYNX
Three distinct parts:
Supra glottis part/Vestibule
Glottic /Sinus/Ventricle
Infraglottic

47. VESTIBULE
Extends from the aditus to the vestibular
folds.
It is bounded by
 Epiglottis
 Aryepiglottic folds
 Arytenoid cartilages
 Arytenoid muscle.

48. Vocal fold or the true vocal cord
Lies inferior to the vestibular fold,
extends between thyroid cartilage and
the vocal process of the arytenoid
cartilage
Contains the
Vocal ligament
Vocalis portion of thyro artyenoid muscle
Functions to
Control flow of air through Rima glottidis
Produce sounds of speech

49. VENTRICULAR FOLD
The ventricle extends from the level of the vestibular
folds to the level of the vocal folds
The vocal folds are white and contain the vocal
ligaments.
The vocal folds and the slit between them constitute
the glottis.
The glottis is normally the narrowest portion of the
larynx, but its shape and size vary greatly with
movements of the arytenoids cartilages and the
vocal folds

50. SUBGLOTTIC/INFRAGLOTTIC
Lies between the vocal fold and the
lower border of the cricoid cartilage.
Is continuous inferiorly to the
cricothyroid membrane.
Note that an emergency airway made
through the cricothyroid membrane will
enter the airway below the vocal fold
where obstruction of the airway most
commonly occurs

51. RIMA GLOTTIDIS
Is the interval between the paired vocal folds
Is the narrowest part of the laryngeal cavity in
adults.
Opens and closes to regulate the passage of air
Note that the obstruction to the laryngeal airway at
the rima glottidis may result from
Aspirated food
Edema in the mucosa – resulting from an allergic
response

52. EXTRINSIC MUSCLES
The elevators and the depressors of
larynx
Elevators of the Larynx :
Stylohyoid
Mylohyoid
Digastric
Stylopharyngeus
Palatopharyngeus
Depressors of the Larynx:
Omohyoid
Sternohyoid
Sternothyroid

53. INTRINSIC MUSCLES
MUSCLES ACTING ON VOCAL CORDS
Length & tension
Cricothyroid
Thyroarytenoid
Abductor posterior cricoarytenoid
Adductor
Lateral cricoarytenoid
Thyroarytenoid
Transverse arytenoid
MUSCLES ACTING ON EPIGLOTTIS
Aryepiglotticus
Thyroepiglotticus

54. MUSCLES ACTING ON LARYNX
MOVEMENT MUSCLE
1.Elevation of larynx Thyrohyoid, mylohyoid
2.Depression Sternothyroid, sternohyoid
3.Opening of inlet of larynx Thyroepiglotticus
4. Closing inlet of larynx Aryepiglotticus
5.Abductor of vocal cord Post. cricoarytenoid
6. Adductor of vocal cord Lateral cricoarytenoid, transverse ,oblique
arytenoid
7.Tensor of vocal cord Cricothyroid
8. Relaxor of vocal cord Thyroarytenoid

55. NERVE SUPPLY
Sensory
Above the level of vocal fold- Internal laryngeal nerve
Below level of vocal fold- Recurrent laryngeal nerve
Motor
All intrinsic muscle- Recurrent laryngeal nerve
Cricothyroid- External laryngeal nerve

56. ARTERIAL & VENOUS SUPPLY

57. PHYSIOLOGY OF PHARYNX &
LARYNX

58. SPEECH

59. SWALLOWING

60. COUGHING

61. EXAMINATION

62. EXAMINATION OF NASOPHARYNX
Visualization :
Flexible fibreoptic telescope- assess the eustachian tube orifices, adenoids
and soft palate.
Radiographs :
Lateral neck radiographs
Contrast radiography
Videofluoroscopy – examine the palate and nasopharynx during the
evaluation of the velopharyngeal insufficiency.
CT, MRI – detect masses.

63. EXAMINATION OF HYPOPHARYNX
INDIRECT METHOD – LARYNGEAL MIRROR
DIRECT METHOD – LARYNGOSCOPE
CLINICAL EXAMINATION:
External palpation
Indirect laryngoscopy
COMPLETE EXAMINATION:
Direct laryngoscopy
Radiograph
Fiberoptic laryngoscopy

64. DIRECT METHOD
Direct method is - use of laryngoscope -visualize the glottis.
It consists of two parts: handle and the blade, which is available in two
basic styles- straight and curved.
The tip of the straight blade is placed under the tracheal surface of the
epiglottis during intubation.
The tip of the curved blade is placed in the vallecula, and elevation of the
surrounding tissues causes traction on the epiglottis, lifting it and thus
exposing the laryngeal aperture.

65. The handle is always held in the left hand the right hand should
contain a rigid suction device.
The patient’s mouth is cleared of any dentures and bridges if
present.
The blade is placed in the right side of the mouth. and should be
carefully advanced, displacing the tongue to the left.
Curved blades should be advanced gradually, while gentle lift is
applied along the axis of the handle, until the tip of the
epiglottis is seen.
Once this structure is seen, the tip of the blade is advanced into
the vallecula, revealing the vocal cords.

67. DEVELOPMENTAL ANAMOLIES
Laryngomalacia :
 Most common congenital laryngeal anomaly.
 May produce life- threatening obstructive
apnea, cor-pulmonale, and failure to thrive.
 It arises from a continued immaturity of the
larynx.
 Lesion resulting in collapse of the supraglottic
structures during inspiration, leading to airway
obstruction.
Supraglottic webs:
 Diaphragmatic growths of differing width that
partially occlude supraglottic lumen.
symptoms include voice changes and
dyspnea.

68. Laryngocele:
Air filled sac produced in larynx due to
dilatation of laryngeal saccule .
Occur congenitally or due to raised
intrathoracic pressure.
Occurs in persons engaged in playing
windpipe instruments or weight
lifting

69. Zenker’s diverticulum

70. LARYNGEAL TRAUMA
● Laryngotracheal injuries, in general necessitate immediate attention not only as a
lifesaving measure but also to prevent delayed complications.
Classification:
● Depending on site
SUPRAGLOTTIC
GLOTTIC
SUBGLOTTIC
TRACHEAL
● According to Richardson: Depending on tissue injured
CARTILAGE
MUCOSA
LIGAMENTS
JOINTS
● According to Olson: Depending on severity
MILD
MODRERATE
SEVERE

71. Based on Etiology
External trauma
Open & Closed
Intubation
Tracheostomy and Cricothyrotomy
Burns and scalds
Radiation
Iatrogenic: endoscopy, laser, etc.
Miscellaneous
Nasogastric tube
Foreign bodies

72. Closed Injuries :
Blunt trauma to the larynx is
usually caused by
motor vehicle accidents, but it
may be sustained
in sports (e.g., karate, basketball,
or ice hockey)
or it may result from attempts at
strangulation or
hanging.

73. SYMPTOMS
voice change
pain
dyspnea
dysphagia
cough
hemoptysis
SIGNS
mild external bruising or
laceration
flattening of neck with loss of
thyroid prominance

74. INTUBATION INJURIES
•Acute
• Edema
• Laceration
• Hematoma
• Vocal cord avulsion
• Arytenoids cartilage dislocation
•Delayed
• Supraglottic Stenosis
• Glottic Edema
• Cricoarytenoid joint dysfunction
• Granuloma
• Vocal cord paralysis
• Interaryteniod fibrosis
• Subglottic Stenosis

75. Space infections

76. PARAPHARYNGEAL SPACE
Include lateral pharyngeal and retropharyngeal
spaces.
These are the major pathways for the spread of
head and neck infections.
These spaces form a “ring” around the pharynx;
and together form a pathway for the spread of
orofacial infections in the neck and mediastinum.
The parapharyngeal spaces communicate directly
with both submandibular space anteroinferior;
and retromandibular space posteriorly.

77. LATERAL PHARYNGEAL SPACE
Potential cone shaped space with its base at the
base of skull and its apex at the greater horn
of the hyoid bone
Space is divided into two by the styloid process,
as anterior and posterior compartments.
Infection of this space is extremely serious owing
to the intimate relationship with the carotid
sheath.

78. May result from – pharyngitis, parotitis, ootitis,
mastotitis, and dental infection.
Anterior compartment infected- pain, fever,
chills, medial bulging of lat. Phar. wall – deviation
of the uvula, dysphagia, trismus etc.
Post comp- absence of trismus and visible
swelling, but respiratory obstruction – major
sign.
Treatment- antibiotics, surgical drainage and
Tracheostomy.

79. Retropharyngeal space
This space lies between visceral division of middle layer of deep cervical fascia
around pharyngeal constrictors and alar division of deep layer of deep cervical
fascia posteriorly.
It extends from skull base to tracheal bifurcation around T2 where visceral and
alar divisions fuse.
It primarily contains retro pharyngeal lymphatics.
Painful deglutition, and if swelling is marked in lower portion of pharynx,
obstructive symptoms such as snoring, choking or even dyspnoea may occur.
Edema may eventually affect base of tongue, epiglottis and aryepiglottic fold.
In 3 to 5 days duration, mass becomes fluctuant and ruptures by pointing usually
through anterior tonsillar pillar.

80. Pharyngocutaneous lesion
It is an abnormal communication between the pharyngeal mucosa and skin.
Etiologic factors:
 Head and neck cancer patients
 Severe arteriosclerosis and diabetes
 Residual microscopic or gross tumor at the surgical site or at the resection
margins leads to disturbances in wound healing, early dehiscence, and the
appearance of fistulization.
 Technical errors in reconstruction of the surgical site also cause these fistulas,
such as tension on the mucosal closure line, inability to invert the mucosal edges
kinking of the suture line, and reduced vascular supply of the suture line.
 A radiation dose of more than 5000 rads administered within 6 months prior to
surgery has the potential for surgical complications involving the pharyngeal
closure and the survival of skin flaps.

81. VELOPHARYNGEAL INSUFFICIENCY
Velopharyngeal insufficiency (VPI) - is a disorder resulting in the improper closing of the
velopharyngeal sphincter (soft palate muscle in the mouth) during speech, allowing air to
escape through the nose instead of the mouth.
Velopharyngeal mechanism:
The Velopharyngeal mechanism is a complex sphincter encompassing the soft palate and
posterior pharyngeal wall as well as the lateral pharyngeal walls and accessory
structures.
The constrictor muscles of the lateral pharyngeal walls create lateral closure of the sphincter.
The adenoid pad, tonsils, and Passavant’s ridge contribute to the posterior wall.

82. Assessment of the velopharyngeal mechanism
Speech pathology
Clinical examination
Videofluoroscopy
Nasopharyngoscopy
TREATMENT
NON SURGICAL - Speech therapy,
Prosthetic manipulation
SURGICAL - Posterior wall Augmentation,
Sphincter pharyngoplasty
Superiorly based pharyngeal flap
surgeries ,Furlow palatoplasty ( z – plasty )

84. SPHINCTER PHARYNGOPLASTY
The goal of this treatment is the creation of a dynamic sphincter from the
musculature of the posterior tonsillar pillar.
Disadvantages:
The potential for taking functional, active musculature and creating
nonfunctioning bands of scar tissue.
 Incision -posterior surface of the posterior tonsillar pillar - right and
left side..
 A high transverse incision - posterior pharyngeal wall, connecting the
two previous incisions.
 An incision - anterior edge of the posterior tonsillar pillar, just
posterior to the tonsil on both sides.

85. The palatopharyngeus muscle bulk is dissected.
The tips of the two flaps are sutured to each other.
The two flaps are sutured into the transverse incision in the posterior
pharyngeal wall.
These flaps will be above the resting levels of the posterior soft palate
and uvula.

86. Obstructive sleep apnea
Definition : OSAS is characterized by repetitive episodes of upper airway
obstruction that occur during sleep usually in association with a reduction in
blood oxygen saturation.
According to Guilleminault
It is defined as, 30 or more apneic episodes that last more than 10seconds each
that occur within an 8-hr sleep period.
Prevalence
The prevalence of OSAS in the middle-aged population (30 to 60 years) is 4% in
men and 2% in women. However, prevalence rises dramatically with age

87. CLINICAL MANIFESTATIONS
• Obstruction of the upper airway, fragmented sleep, and the respiratory and
cardiovascular consequences of disordered breathing.
• Excessive daytime somnolence is a key feature of OSAS resulting from
disrupted sleep.
• Snoring, ranging in severity from mild to extremely loud, is invariably present.
Diagnosis is based on
 History
 clinical findings on examination
 Polysomnography – gold standard investigation for the diagnosis of OSAS.
 Radiology, cephalometry.
 Fluoroscopy, endoscopy.
 CT, MRI.

88. OSAS CAN BE MANAGED
NONSURGICALLY OR SURGICALLY.
SURGICAL MANAGEMENT
Tracheostomy was introduced for this
purpose in the 1970s.
Fujita and others first described the
use of the uvulopalatopharyngoplasty
(UPPP) for the treatment of OSAS in 1981.
This procedure involves shortening the soft
palate, amputating the uvula, and
removing redundant lateral and posterior
pharyngeal wall mucosa from the oral
pharynx.
Use of orthognathic surgery to treat OSAS
began toward the end of the 1970s, when
mandibular advancement was reported to
have reversed the symptoms of OSAS.
Non-surgical management:
The most successful non-surgical treatment is
continuous positive airway pressure (CPAP)
through the nose. Nasal cpap is administered
when patient is asleep by tight fitting mask
that is connected to compressor..
Oral appliances- removable anterior
repositioning splints, tongue retaining device,
klearway titrable appliance

89. ORTHOGNATHIC SURGERY
PHARYNGEAL AIRWAY DIMENSIONS &
OSAS
• Mandibular setback surgery produces a shift in oropharyngeal characteristics to a
morphology commonly associated with sleep apnea. In the longer term, this may
confirm a predisposition to sleep-disordered breathing, especially when these patients
reach middle age and are more likely to exhibit other risk factors for sleep apnea.
(Turnbull et al Journal of Orthodontics 2000)
• Reported two case-patients patients who underwent posterior repositioning of the
mandible for treatment of prognathism subsequently developed OSAS and concluded
that pts having undergone bilateral mand. prognathism can develop OSAS since it
causes airway narrow with change in tongue and hyoid position.. (Riley et al JOMS
1987)
• Study conducted on 23 female adults showed that set back surgery could possibly
predispose to the development of OSAS but in patients who have other risk factors
such as obesity, short neck, macroglossia, large uvula, and excessive soft tissue around
the nasopharyngeal region( FENGSHAN CHEN et al American Association of OMFS)

90. AIRWAY ASSESSMENT

91. Eagle’s syndrome
A nagging or aching sensation in the throat somewhat
similar to chronic pharyngitis.
The Pain may radiate to the middle ear or mastoid region.
Frequently a sensation of a foreign body having lodged in
the pharynx is noticed. There may be difficulty in swallowing .
Eagle’s syndrome is the term given to the symptomatic
elongation of the styloid process or mineralization of the
stylohyoid or stylomandibular ligament.
The normal length of the styloid process varies greatly, although
in the majority of patients it is 20 to 30 mm.

92. TREATMENT
• The elongated styloid process syndrome can be managed either
conservatively or surgically.
• Conservative treatments include analgesics, antidepressant
medications, anticonvulsants, transpharyngeal injection of steroids
and lidocaine, diazepam, nonsteroidal anti-inflammatory drugs, and
the application of topical heat.
• The most effective treatment is the surgical shortening of the styloid
process either via an intraoral or external approach as it produces
better long-term results.

93. CARCINOMA OF LARYNX
AETIOLOGY
Smoking
Tobacco
Alcohol
Previous radiation
Occupational exposure
Hereditary
AJCC CLASSIFICATION
Supraglottic
Glottic
Subglottic
TREATMENT
Radiotherapy
Surgery – conservative / total
laryngotomy
Combined therapy
SYMPTOMS
Throat pain,Dysphagia,Referred ear
pain
Mass in the neck,Stridor, Hoarseness of
voice
CARCINOM
A

94. Airway assessment and
management

95. CRITICAL SITUATIONS IN WHICH AIRWAY
OBSTRUCTION OCCUR
1. Severe maxillofacial trauma
2. Chest injuries
3. Rapid loss of consciousness
4. Post extubation following orthognathic surgery- with IMF
5. Cervicofacial infection
6. Sudden obstruction during the surgical procedure
7. Induction of GA in patients with laryngeal tumors

96. Techniques available for airway
management

97. Airway Assessment
Specific tests :
Mallampatti test : The Mallampati classification correlates tongue size to
pharyngeal size.
This test is performed with the patient in the sitting position, head in a neutral
position, the mouth wide open and the tongue protruding to its maximum.
Classification is assigned according to the extent the base of tongue is able to mask
the visibility of pharyngeal structures into three classes:
Class I : Visualization of the soft palate, fauces; uvula, anterior and the posterior
pillars.
Class II : Visualization of the soft palate, fauces and uvula.
Class III : Visualization of soft palate and base of uvula.
In Samsoon and Young’s modification (1987)3 of the Mallampati classification, a
IV class was added.
Class IV: Only hard palate is visible. Soft palate is not visible at all.

98. Thyromental (T-M) distance (Patils test):It is defined as the distance
from the mentum to the thyroid notch while the patient’s anto-
occipital neck is fully extended.
This measurement helps in determining how readily the laryngeal
axis will fall in line with the pharyngeal axis when the atlanto-
occipital joint is extended.
Alignment of these two axes is difficult if the T-M distance is < 3
finger breadths or < 6 cm in adults;
6-6.5 cm is less difficult, while > 6.5 cm is normal.
Sterno-mental distance :
Savva (1948) estimated the distance from the suprasternal notch to
the mentum and investigated its possible correlation with
Mallampati class, jaw protrusion, inter-incisor gap, and
thyromental distance. It was measured with the head fully
extended on the neck with the mouth closed. A value of less than
12 cm is found to predict difficult intubation.
Mandibulo -hyoid distance: Measurement of length from chin (mental) to
hyoid should be at least 4 cm or three finger breadths. It was found
that laryngoscopy became more difficult as the vertical distance
between the mandible and hyoid bone increased.

99. LEMON AIRWAY ASSESSMENT METHOD
L- Look externally (facial trauma, large incisors, large
tongue)
E- Evaluate the 3-3-2 rule (incisor distance-3 finger
breadths, hyoid-mental distance-3 finger breadths,
thyroid-to-floor of mouth distance-2 finger breadths)
M- Mallampati (Mallampati score > 3).
O- Obstruction (presence of any condition like
epiglottis, peritonsillar abscess, trauma).
N- Neck mobility (limited neck mobility)
Patients in the difficult intubation group have higher LEMON
scores.

100. TRACHEOSTOMY
CONTRAINDICATIONS:
• In cases where the patient
airway can be safely secured
by other means
• In presence of expanding
hematoma.
INDICATIONS:
Tracheostomy needed to relieve respiratory
obstruction.
Needed to prevent aspiration of fluids, pus or
blood from the trachea.
Indicated in certain diseases which lead to
retention of secretion in lower respiratory
tract.
Indicated in certain conditions leading to
respiratory insufficiency.
Muscular spasm and recurrent laryngeal nerve
spasm as in tetanus .

101. COMPLICATIONS
●During surgery
●Postoperative complications:
●Surgical emphysema of neck & chest
●Displacement of tube
●High tracheostomy may damage
cricoid cartilage
●Damage to tracheal rings
●Pulmonary infection
●Fatal hemorrhage may occur due to
erosion of great vessels by tube end.
CARE FOR
TRACHEOSTOMY:
• Proper positioning of
tube & proper placement
• Removal of secretions.
• Cleaning of
tracheostomy tube.
• Wound is properly
dressed to avoid
infection
• If cuffed tube is used ,
should be periodically
deflated

102. Procedure
• Incisions : both horizontal and vertical
incisions are advocated.
• Vertical incision:
• Advocated in emergency conditions,
to maintain midline dissection and to
reduce the potential for anatomic
damage when the direction of the
incision is changed.
• It is made from inferior to the cricoid
cartilage to the suprasternal notch
and is carried through the
subcutaneous tissue and platysma
muscle before the dissection.

103. • Horizontal incisions:
• This is done for improved cosmetic results.
• A 4 to 5-cm incision is made approximately
2cm below the cricoid cartilage. the
incision is carried through the
subcutaneous tissue and platysma muscle
until the superficial layer of the deep
cervical fascia is identified.
• Two principles must adhere for entrance into
the trachea:
• Cricoid cartilage and the first tracheal ring
must not be cut or injured.
• The incision into the trachea must not
extend below the fourth tracheal ring.

104. • A Tracheostomy hook is placed between the first
and the second tracheal rings to elevate the trachea
into the surgical area.
• An appropriate tracheostomy tube is selected to
occupy 2/3 to ¾ of the tracheal lumen diameter and
is inserted through the 2nd
and 3rd
tracheal rings.
• Complications of tracheostomy:
• Hemorrhage
• Aspiration
• Vocal cord paralysis
• Infection.

105. CRICOTHYROTOMY
Indications :
a. Obstruction of the airway from massive facial trauma is the most
common indication.
b. Oropharyngeal obstruction; edema secondary to infection;
foreign body, and mass lesions.
c. Conditions in which tracheal intubation is contraindicated.
Contraindications :
d. Age – in children << than 11yrs.
e. Crush injury to the larynx.
f. Preexisting laryngeal or tracheal pathology.

106. Approaches to pharynx
Approaches through the oral cavity:
The transoral approach
Median labio-mandibulo glossotomy,
Mandibulectomy
Approaches to the oropharynx through the neck/ transcervical:
Anterior pharyngotomy
High lateral pharyngotomy
Combination of Pharyngotomy with partial or total
Laryngotomy :
Suprahyoid supraglottic laryngotomy

107. TRANSORAL APPROACH
It is appropriate for lesions of the faucial
arches, tonsils, and upper posterior
pharyngeal wall.
It is recommended that only small lesions
(1.5 cm or less) of the posterior wall be
approached transorally, as deep
margin dissection can be difficult with
larger lesions.

108. MEDIAN LABIO-MANDIBULO GLOSSOTOMY
Trotter’s procedure
It is useful for lesions of the base of tongue,
upper posterior pharyngeal wall, soft palate,
and nasopharynx.
It is performed by exposing the mandible via a
lip-splitting incision.
The entire tongue can be split to access more
posterior lesions.
This approach preserves all sensation and has
minimal postoperative morbidity.
It is best for midline lesions as it allows little
lateral exposure

109. LIP SPLIT MANDIBULOTOMY / MANDIBULAR
SWING
● This procedure provides excellent
exposure for lesions of the entire
tongue, soft palate, posterior
pharyngeal wall, and tonsillar
fossae.
● After the mandible has been split
the lingual floor of mouth mucosa
on the side of the lesion is incised.
● The mylohyoid and digastric
muscles are divided, leaving a cuff
of tissue on either side for
reapproximation.

110. ANTERIOR PHARYNGOTOMY
 The suprahyoid approach to the
oropharynx is best used for exposure of
lesions of the tongue-base, faucial
arches, suprahyoid epiglottis, and low
posterior pharyngeal wall lesions that
cannot be excised transorally.
 Flap is raised and the hyoid bone
identified.
 The hyoid is grasped and retracted
inferiorly.

111.  The intrinsic muscles of the tongue are dissected from the hyoid and the
hyoepiglottic ligament. This is the point of precise entry into the oropharynx.
 Once the initial pharyngotomy has been made, it can be widened so that the
lesion may be respected under direct vision.

112. CONCLUSION
The pharynx and larynx perform vital functions, which may be affected
pre or post operatively. Hence it is essential to have a sound knowledge
of the surgical anatomy of pharynx and larynx before carrying out any
surgical procedure in this region.

113. REFERENCES
 Anatomy for surgeons – Hollinshead
 Gray’s Anatomy - 39th
Edition
 Oral anatomy – Sicher
 Oral and Maxillofacial trauma – Vol.1 – Fonseca
 Oral and Maxillofacial surgery – Vol 6 – Fonseca
 Otorhinolaryngology – Head and Neck surgery – 15th
edition – Ballenger.
 Last’s anatomy: regional and applied
 Complications of head and neck surgery – Krespi and Osoff
 Otorhinolaryngology – Vol.3, 3rd
Edition.
 Paediatric orotlaringology – Vol.2
 Head and Neck Surgical pathology – Ben Z. Pilch
 Oral and Maxillofacial infections – 4th
Edition – Topazian
 Human embryology – Inderbir Singh.
 Maxillofacial injuries – Rowe and Williams Vol 1
 Comprehensive surgical atlas in otolaryngology and head and neck surgery
 Atlas of the Oral and Maxillofacial Surgery Clinics of North America – 2003

114. THANK YOU

115. SURGICAL
ANATOMY OF THE
PHARYNX AND
LARYNX
MODERATOR PRESENTER
DR. AMITH HADHIMANE DR. PIYUSH DALMIA