ANATOMY OF PHARYNXANATOMY OF PHARYNX

BRIG MIRZA KHIZER HAMEEDBRIG MIRZA KHIZER HAMEED

PHARYNXPHARYNX• Muscular tube lying behind Muscular tube lying behind

the the nosenose, , oral cavity oral cavity && larynxlarynx

• Extends from the Extends from the base of base of the skull the skull to level of the to level of the 66thth cervical vertebracervical vertebra, where it , where it is continuous with the is continuous with the esophagusesophagus

• The anterior wall is The anterior wall is deficient and shows (from deficient and shows (from above downward):above downward): Posterior nasal aperturesPosterior nasal apertures Opening of the oral cavityOpening of the oral cavity Laryngeal inletLaryngeal inlet

PHARYNXPHARYNX SiteSite

MidlineMidline of the neck of the neckFrom From skull base skull base to to esophagusesophagusIn front of In front of upper 6 upper 6 Cervical vertebraCervical vertebra

Behind :Behind :The NoseThe Nose

The MouthThe MouthThe larynxThe larynx

Seen from behind

PHARYNXPHARYNX ShapeShape

Irregular Irregular Fibromuscular tube Fibromuscular tube lined by mucous lined by mucous membranemembrane

Length: 15 cmLength: 15 cm

PHARYNXPHARYNXStructureStructure

The wall is formed The wall is formed of 4 layersof 4 layers

1-Mucous membrane1-Mucous membrane

2- Pharyngeal aponeurosis2- Pharyngeal aponeurosis

3-Muscle layer3-Muscle layer

4-Bucco-pharyngeal fascia4-Bucco-pharyngeal fascia

Stratified squamous epithelium except the nasopharynx, it is Stratified squamous epithelium except the nasopharynx, it is pseudo-stratified with goblet cellspseudo-stratified with goblet cells

Loose connective tissue which contains lymphoid tissue that Loose connective tissue which contains lymphoid tissue that aggregates in some areas forming tonsils (Waldayer’s ring) aggregates in some areas forming tonsils (Waldayer’s ring)

Formed of 3 muscles, superior middle and inferior Formed of 3 muscles, superior middle and inferior constrictor musclesconstrictor muscles

A thin coat of connective A thin coat of connective tissuetissue

PHARYNXPHARYNX CompartmentsCompartments

• Pharynx is divided into three Pharynx is divided into three compartments:compartments: NasopharynxNasopharynx: :

Superior part, Superior part, communicates with the communicates with the nasal cavity through nasal cavity through posterior nasal aperturesposterior nasal apertures

OropharynxOropharynx: : Middle part, communicates Middle part, communicates

with the oral cavity through with the oral cavity through the the oropharyngeal isthmusoropharyngeal isthmus

HypopharynxHypopharynx: : Inferior part, communicates Inferior part, communicates

with the larynx through the with the larynx through the laryngeal inletlaryngeal inlet

PHARYNXPHARYNXCompartmentsCompartments

• NasopharynxNasopharynx

• OropharynxOropharynx

• HypopharynxHypopharynx

Seen from behind

• NasopharynxNasopharynx

• OropharynxOropharynx

• HypopharynxHypopharynx

Seen from lateral

PHARYNXCompartments

Nasopharynx Nasopharynx

--Behind the nasal cavityBehind the nasal cavity--Extends from skull base Extends from skull base

superiorly to the soft superiorly to the soft palate inferiorlypalate inferiorly

-Communicates -Communicates inferiorly with the inferiorly with the oropharynx through oropharynx through the velo-pharyngeal the velo-pharyngeal sphinctersphincter

-The nasopharyngeal -The nasopharyngeal tonsil lies in the rooftonsil lies in the roof

-The pharyngeal -The pharyngeal opening of ET lies in opening of ET lies in the lateral wallthe lateral wall

OropharynxOropharynx Behind the oral cavity (in Behind the oral cavity (in

front of 2front of 2ndnd&3&3rdrd Cervical Cervical vertebra)vertebra)

From the soft palate superiorly From the soft palate superiorly to tip of epiglottis inferiorlyto tip of epiglottis inferiorly

Communicates:Communicates: Anteriorly with the oral Anteriorly with the oral

cavitycavity Superiorly with the Superiorly with the

nasopharynxnasopharynx Inferiorly with the Inferiorly with the

hypopharynxhypopharynxThe palatine tonsils lie The palatine tonsils lie

laterallylaterallybetween the anterior and between the anterior and

posterior pillarsposterior pillars

The anterior pillar formed

by palatoglossus muscle The posterior pillar formed

by palatopharyngeus

muscle

The tonsils lie between the Two pillars

PALATINE TONSILSPALATINE TONSILS• Paired masses of Paired masses of

lymphoid tissuelymphoid tissue• Located in the Located in the

palatine fossa/sinus,palatine fossa/sinus, in the lateral wall of in the lateral wall of the oropharynxthe oropharynx

• Reaches its maximum Reaches its maximum size during early size during early childhood, but after childhood, but after puberty diminishes in puberty diminishes in size size

PALATINE TONSILSPALATINE TONSILS

• Lateral surface: Lateral surface: covered covered by a fibrous capsule by a fibrous capsule

• Medial surface:Medial surface:• Projects into the cavity Projects into the cavity

of oropharynxof oropharynx• Covered by mucous Covered by mucous

membranemembrane• Shows multiple Shows multiple

depressions, depressions, the the tonsillar cryptstonsillar crypts and one and one deep deep intratonsillar cleft intratonsillar cleft

HypopharynxHypopharynx

Behind the Larynx Behind the Larynx (in front (in front of 3of 3rdrd to 6th Cervical to 6th Cervical vertebra)vertebra)

From the tip of epiglottis From the tip of epiglottis superiorly to the lower border superiorly to the lower border of cricoid cartilage inferiorlyof cricoid cartilage inferiorly

Communicates:Communicates:

- Anteriorly with the LarynxAnteriorly with the Larynx

- Superiorly with the Superiorly with the oropharynxoropharynx

- Inferiorly with the esophagusInferiorly with the esophagus

The hypopharynx does not onlyThe hypopharynx does not only

lie behind the larynx BUT alsolie behind the larynx BUT also

Projects laterally on each side Projects laterally on each side of the larynxof the larynx

So it is formed of :So it is formed of :

- Postcricoid regionPostcricoid region ( behind ( behind the larynx)the larynx)

- Posterior pharyngeal wallPosterior pharyngeal wall

- Two pyriform fossaeTwo pyriform fossae (on (on each side of the larynxeach side of the larynx

Seen from behind

Cross section

HypopharynxHypopharynx

Waldeyer’s ringWaldeyer’s ring

• It is a It is a lymphoid tissue ring lymphoid tissue ring located in thelocated in the pharynxpharynx

• Consists of: Consists of: AdenoidsAdenoids (pharyngeal (pharyngeal

tonsils) tonsils) Tubal tonsil Tubal tonsil Palatine tonsil Palatine tonsil Lingual tonsilLingual tonsil Lateral pharyngeal bandsLateral pharyngeal bands Lymphoid follicles in post.Lymphoid follicles in post.

wallwall

Waldeyer’s ringWaldeyer’s ring

The lymphoid tissue in theThe lymphoid tissue in thepharyngeal aponeurosispharyngeal aponeurosisaggregates in some areasaggregates in some areasforming tonsilsforming tonsils::1-1-oneone nasopharyngealnasopharyngeal tonsil tonsil2- 2- twotwo palatinepalatine tonsils tonsils3- 3- twotwo linguallingual tonsils tonsils

Blood supplyBlood supplyFrom the External Carotid Artery & its From the External Carotid Artery & its

branchesbranches

1- 1- Tonsillar artery Tonsillar artery (from Facial Artery)(from Facial Artery)

2- 2- Ascending palatine artery Ascending palatine artery (from Facial Artery)(from Facial Artery)

3- 3- Ascending pharyngeal Artery Ascending pharyngeal Artery (from external (from external carotid)carotid)

4- 4- Descending palatine artery Descending palatine artery ( from Maxillary ( from Maxillary artery)artery)

5- 5- Dorsalis lingulae artery Dorsalis lingulae artery (from Lingual artery)(from Lingual artery)

Lymph DrainageLymph Drainage

• NasopharynxNasopharynx ------►►RetropharyngealRetropharyngeal

------►►Upper Deep Cervical L NUpper Deep Cervical L N

• OropharynxOropharynx ------►► Upper Deep Cervical L N Upper Deep Cervical L N

• HypopharynxHypopharynx ------► ► Upper Deep Cervical L NUpper Deep Cervical L N

Nerve SupplyNerve Supply

MotorMotor XX Except Except : :

Stylopharyngeus Stylopharyngeus IXIX

Tensor palatiTensor palati VV

SensorySensory NasopharynxNasopharynx VVOropharynxOropharynx IXIXLaryngopharynxLaryngopharynx

XX

AutonomicAutonomicSympathetic: SCGSympathetic: SCGParasympathetic: through Parasympathetic: through

VIIVII

ACUTE PHARYNGITISACUTE PHARYNGITIS

BRIG MIRZA KHIZER HAMEEDBRIG MIRZA KHIZER HAMEED

PharyngitisPharyngitis

– Inflammation of the Inflammation of the Pharynx secondary to Pharynx secondary to an infectious agentan infectious agent

– Most common Most common infectious agents are infectious agents are Group A Group A Streptococcus and Streptococcus and various viral agentsvarious viral agents

– Often co-exists with Often co-exists with tonsillitis tonsillitis

EtiologyEtiology

• 30%-65%: idiopathic30%-65%: idiopathic• 30%-60%: viral30%-60%: viral• 5%-10%: bacterial5%-10%: bacterial• Group A beta-hemolytic: most Group A beta-hemolytic: most

common bacterial pathogencommon bacterial pathogen– 15%-36%: pediatric cases15%-36%: pediatric cases– 5%-10% : adult pharyngitis5%-10% : adult pharyngitis– Disease of childrenDisease of children

EtiologyEtiology

BacterialBacterial• Strep.AStrep.A• Corynebacterium Corynebacterium

diphteriaediphteriae• GonococcusGonococcus

FungalFungal• Candida albicansCandida albicans

OthersOthers• ToxoplasmosisToxoplasmosis

ViralViral• RhinovirusRhinovirus• InfluenzaInfluenza• ParainfluenzaParainfluenza• EBVEBV• CytomegalovirusCytomegalovirus• HIVHIV

Clinical manifestationsClinical manifestations

• Differ in severityDiffer in severity

• FeverFever

• Sore throatSore throat

• HeadacheHeadache

• GI symptomsGI symptoms

• ErythemaErythema

• ExudatesExudates

• Enlarged tonsilsEnlarged tonsils

• Anterior cervical Anterior cervical adenopathy adenopathy

• Prominent lymphoid Prominent lymphoid follicles on Post. follicles on Post. WallWall

• Edema of UvulaEdema of Uvula

Suppurative Complications of Suppurative Complications of Group A Streptococcal Group A Streptococcal PharyngitisPharyngitis• Otitis mediaOtitis media

• SinusitisSinusitis

• Peritonsillar and retropharyngeal Peritonsillar and retropharyngeal abscessesabscesses

• Suppurative cervical adenitisSuppurative cervical adenitis

Nonsuppurative Complications Nonsuppurative Complications of Group A Streptococcusof Group A Streptococcus

• Acute rheumatic feverAcute rheumatic fever– follows only streptococcal pharyngitis follows only streptococcal pharyngitis

(not group A strep skin infections)(not group A strep skin infections)

• Acute glomerulonephritisAcute glomerulonephritis– May follow pharyngitis or skin May follow pharyngitis or skin

infection (pyoderma)infection (pyoderma)– Nephritogenic strainsNephritogenic strains

CourseCourse

• Group A strep pharyngitis naturally Group A strep pharyngitis naturally self-limitingself-limiting

• Resolve spontaneously in 3-4 days w/ Resolve spontaneously in 3-4 days w/ or w/o antibioticsor w/o antibiotics

• Rapid test or throat culture: reduces Rapid test or throat culture: reduces unnecessary antibiotic use by unnecessary antibiotic use by identifying those whom antibiotic identifying those whom antibiotic therapy is justifiedtherapy is justified

DiagnosisDiagnosis

• HistoryHistory

• Throat cultureThroat culture

• Rapid antigen detection test (RADT)Rapid antigen detection test (RADT)

Diagnostic toolsDiagnostic tools

• History: History: – FeverFever– Tonsillar exudatesTonsillar exudates– Swollen or tender lymph nodesSwollen or tender lymph nodes– Lack of coughLack of cough

– unreliableunreliable

Diagnostic toolsDiagnostic tools

• Throat culture: Throat culture: gold standard for gold standard for dxdx– Sensitivity 90%, Sensitivity 90%,

specificity 99%specificity 99%– For adult patients For adult patients

to confirm clinical to confirm clinical diagnosisdiagnosis

Diagnostic toolsDiagnostic tools• Rapid antigen detection test (RADT)Rapid antigen detection test (RADT)

– When throat culture is impractical or When throat culture is impractical or inappropriateinappropriate•Extensive contact with othersExtensive contact with others•Work full-time jobsWork full-time jobs•Difficult to reachDifficult to reach

– Sensitivity 80%-90%, specificity 70%-95%Sensitivity 80%-90%, specificity 70%-95%

– Helps selects true positives thus avoiding Helps selects true positives thus avoiding

unnecessary use of antibioticsunnecessary use of antibiotics

– (+) RADT- start antibiotic therapy (+) RADT- start antibiotic therapy

TreatmentTreatment

• AntibioticAntibiotic

• Bed restBed rest

• Plenty of fluidsPlenty of fluids

• Analgesics/ AntipyreticsAnalgesics/ Antipyretics

• Warm saline garglesWarm saline gargles

• DecongestantsDecongestants

Antibiotic therapyAntibiotic therapy

• PenicillinPenicillin

• Ampicillin, amoxicillinAmpicillin, amoxicillin

• CephalosporinsCephalosporins

• MacrolidesMacrolides

Thank You