ANATOMY OF LARYNX AND

PHARYNX INCLUDING
CONNECTIVE TISSUE SPACES
AND THEIR IMPORTANCE IN
CANCER SPREAD
ANATOMY OF LARYNX
SITUATION AND EXTENT:
root of tongue---trachea
c3-c6
higher in female and children
Male-44mm
Female-36mm
INFANTfunnel shaped
collapsable
more submucosal tissue
epiglottis larger and folded on itself
SKELETON
9CARTILAGES
3PAIRED 3UNPAIRED
-ARYTENOID -THYROID
-CORNICULATE -CRICOID
-CUNEIFORM -EPIGLOTTIC
JOINTS--*CRICOTHYROID
*CRICOARYTENOID
LARYNGEAL LIGAMENTS AND
MEMBRANES
EXTRINSIC
-thyrohyoid membrane
-hyoepiglottic lig.
-cricotracheal lig.
-crico thyroid memb.
INTRINSIC
-quadrate memb.
-conus elasticus/cricovocal memb.
CAVITY OF LARYNX
INLET
VESTIBULE OF LARYNX
SINUS OF MORGAGNI/VENTRICLE
INFRA GLOTTIC PART
*rima vestibuli
*rima glottidis
-laryngocele
MUCOUS MEMBRANE-ciliated colomnar ep.
-strat.sq.ep.
<mucus glands absent over vocal cords>
MUSCLES OF LARYNX
INTRINSIC MUSCLES OF LARYNX
-cricothyroid
-post.cricoarytenoid
-lat.cicoarytenoid
-transverse arytenoid
-oblique arytenoid &ary epigotticus
-thyroarytenoid & thyroepiglottis
ACTIONS
*OPENING OF INLET-thyroepiglotticus
*CLOSING-aryepiglotticus,oblique arytenoids
*ABDUCT V.CORDS-only post.cricoarytenoids
*ADDUCT V.CORDS-lat.cricoarytenoids,transverse
arytenoids,cricothyroid,thyro arytenoids
*TENSE-cricothyroid
*RELAX-thyroarytenoid,vocalis
*ELEVATORS-1*--stylopharyngeus,salpingopharyngeus,palatopharyngeus,thyrohyoid
-2*--mylohyoid,digastric,stylohyoid,geniohyoid
*DEPRESSORS-sternohyoid,sternothyroid,omohyoid

NERVE SUPPLY-MOTOR-recc.laryngeal
n.,ext.laryngeal n.
SENSORY-int laryngeal n.,recc.laryngeal n.
BLOOD SUPPLY-above v.folds-sup.thyroid
a.&v.
Below v.folds-inf.laryngeal.a.&v
LYMPHATIC DRAINAGE-above v.folds-pierce
thyrohyoid memb-antero superior gr.og l.n
-below v.folds-pierce
cricothyroidprelaryngeal/pretracheallower
deep cervical nodesmediastinal nodes
SPEECH-expired
airvibratorsresonatorsarticulators
LARYNGOSCOPIC VIEW-
MOVEMENTS OF V.FOLDS-
ANATOMY OF PHARYNX
Conical fibromuscular tube,forming upper part of air &food passage.
WIDEST-3.5cm
NARROWEST-1.5cm at pharyngoesophageal junction.
BOUNDRIES-SUPERIORLY-base of skull,basilar part of ocipital
bone
INFERIORLY-continous with esophagus at c-6 corresponding to
lower border of cricoid
POST-prevertebral fascia
ANT-comm.nasal cavity,oralcavity,larynx
PARTS OF PHARYNX-oropharynx
-nasopharynx
-hypopharynx
NASOPHARYNX
BOUNDRIES
Cilliated columnar epithelium
Mucus memb.supplied by pharyngeal br. Of pterygopalatine
ganglion,other parts of pharynx supplied by cr.n.9,10
LATERAL WALL-auditory tubeopening
-tubal elevation
-salpingopharyngeal fold
-levator veli palatini
-pharyngeal recess/fossa of
rosenmullar
RATHKES POUCH
NASOPHARYNGEAL BURSATHORNWALDS DISEASE
OROPHARYNX
BOUNDRIES
WALDEYERS RING
-nasopharyngeal tonsil
-palatine tonsil
-lingual tonsil
-tubal tonsil
-lat.pharyngeal band
-nodules in ppw

PALATINE TONSIL
-2ndpharyngeal pouch,ext.palatine v.
-BED OF TONSIL
*pharyngo basilar fascia
*sup.constrictor&palatopharyngeus
*buccopharyngeal fascia
*lower part of styloglossus
*glossopharyngeal n.<pain in ear>
-jugulodigastric node
LARYNGOPHARYNX
BOUNDRIES
PIRIFORM SINUS/FOSSA-medially-aef
Laterally-thyroid cart.&thyrohyoid memb.
*beneath the mucosa is theint.laryngeal.n.
LYMPHATIC DRAINAGE-pyriform
sinusthyrohyoid membupper jugular chain
Ppwdeep cervical nodes
Post.cricoidparapharyngeal
nodes.also,supraclavicular&paratracheal cahin.
WALL OF PHARYNX-mucosa
-submucosa
-pharyngobasilar
fascia
-muscular coat
-buccopharyngeal
fascia
MUSCLES OF PHARYNX- OUTER CIRCULAR-3-
superior,middle,inf.constrictr
INNER LONGITUDINAL-stylo,salpingo,palatopharyngeus
ORIGIN OF CONSTRICTORS-
INSERTION-al insert into the median raphe on post.wall of pharynx



GAPS BETWEEN PHARYNGEAL MUSCLES-
SINUS OF MORGAGNI-aud.tube
-levator veli palatini
-ascending palatine
a
Between sup.&middle-
stlopharyngeus&glossopharyngeal
Between middl&inf-int.laryngeal n.,sup.laryngeal
vessels,(pierce thyrohyoid memb in the gap)
Between inf&esophagus-recc.laryngeal n.,inf laryngeal
vessels
KILLIANS DEHISENCE-between
thyropharyngeus&cricopharyngeus

NERVE SUPPLY-pharyngeal plexus of n.(mainly on middle constrictor)
-pharyngeal br.of vagus
-phar.br.glossopharyngeal
-phar.br.sup.cervical symp.ganglion
MOTOR-cranial accesory n.through br. Of vagus supply all musclesexcept
stylopharyngeus(glossopharyngeal)
Inf.constrictor additional supply-ext.&recc.laryngeal n.
-plexus also supplies all muscles of softpalateexcept tensor veli
palatini(mandibular n.)
SENSORY-mainly glossopharyngeal,partly vagus
NASOPHARYNX-maxillary n.,through pterygopalatine
ganglion,softpalate&tonsil-lesser palatine &glossopharyngeal
-taste sensation fro valleculla&epiglottic areaint.laryngeal.br.of vagus
P.symp.secretomotor fibres to pharynx from greater petrosal n.&leser
palatine br. Of pterygopalatine ganglion.

A.SUPPLY-ascending pharyngeal br.of
ext.carotid
-ascending palatine&tonsillar br of fascial a.
-dorsal lingual br.of lingual a.
-gr.palatine,pharyngeal,pterygoid brs of
maxillary a.
VENOUS PLEXUS-postero lat.aspect of phrynx
drains to int jugular&fascial v.
LYMPHATICS-retropharyngeal&deep cervical
nodes.
DEGLUTATION-
1
ST
STAGE- voulantry-oropharyngeal isthmus to oropharynx
2
ND
STAGE-invoulantry-oropharynxlaryngopharynx
3
RD
STAGE-invoulantry-laryngopharynxesophagus
AUDITORY TUBE-m.ear with nasopharynx,4cm
downwards,forwards,medially.
45*saggitalplane,30*horizontal plane.
lat,.1/3
rd
bony(12mm)medial2/3
rd
(25mm)
Ascending pharyngeal,middle meningeal,a.of ptrygoid canal
Pharygeal&pterygoid plexus of v.
Retropharyngeal nodes.
SPACES OF LARYNX
PRE EPIGLOTTIC SPACE(BOYER)
PARAGLOTTIC SPACE-growth which invade this space
can present In the neck through cricothyroid space.
REINKES SPACE-junction of columnar&sq.ep.arcuate
lines(sup.&inf)
ANT.SUBGLOTTIC WEDGE-tumor then penetrates the
cricothyroid lig.
at the point of ant.commisure the v.c are very
narrow,so that the tumor which crosses the ant
comissure spreads readily into apex of the ant.part of the
subglottic space.mucosa has foramina for passage of
vessels,which provide easy route for cancer spread to
prelaryngeal tissues.

SUPRAGLOTTIC cancer-
epiglottisfalsecordsa.e.folds
Spread locally
Ca.of infrahyoid epiglottis&ant.ventricular band may
extend into pre-epiglottic space&penetrate thyroid cart.
Nodal metastasis occurs early-upper&middle deep
cervical nodes
b/l metastasis seen in epiglottic cancer.
GLOTTIC CA.-m.c-upper surface of the free edgeoo
ant.&middle 1/3
rd
of v.c.
Hoarseness is early symptom.(detected early)
SUB-GLOTTIC CA.-earliest presentation
stridor/laryngeal obst.(1-2%)
SPACES OF PHARYNX:
RETRO PHARYNGEAL SPACE-behind pharynx from base of skull to bifurcation of
trachea.
Divided into 2 lat.comp.(space of gillette)by afibrous raphe
Communicates with parapharyngeal space.
PREVERTEBRAL SPACE-between vertebral body&prevertebral fascia ant.from skull
to cocyx.
PARAPHARYNGEAL/PHARYNGOMAXILLARY/LAT.PHARYNGEAL SPACE-
pyramidal shaped,base at base of skull.
Apex-hyoid bone
Styloid process&muscles attached to it divide parapharyngeal space into ant.&post.
Compartments.
Through post.compcarotid a.
jugular v.
9,10,11,12 cr.n.
sympathetic trunk.
upper deep cervical l.n
Parapharyngeal space communicates with retro pharyngeal,sub
mandibular,parotid,carotid spaces.
CANCERS OF OROPHARYNX
CA.B.O.T-usually asymptomatic,cervical node+(70%jugulodigastric
node)
Local spread-epiglottis,pre epiglottic space,hypopharynx.
CA.TONSIL&TONSILLAR FOSSA-local spread to soft
palate,pillars,pharyngeal wall,hypopharynx,pterygoid
m.(trismus),parapharyngeal space.
50%lymphatic spread(jugulodigastric)
CA.PALATINE ARCH-late nodal-upper deep cervical,submaxillary
nodes.
CA.PPW&LPW-60%l.n,b/l node involvement common
CA.PYRIFORM SINUS-cx node metastasis early,upper&middle gr.
Of deep cervical nodes.
CA.POSTCRICOID REGION-ulcerate &local spread in annular
fashion.lymphatic paratracheal l.n.
CANCER OF NASOPHARYNX
M.c. sq.c.c& its variants.
Commonest site-fossa of rosenmuller.
Nodal metastasis 75% &about half with b/l
nodes.
CANCER OF HYPOPHARYNX
INFERIOR HYPO(PIRIFORM SINUS)
If origin is lateralthrough thyroid cart.to extralaryngeal structures.
Lesions of med.&ant wall extend medially into larynx.
Easy spread to paraglottic space
Spread mainly to jugularchain of nodes.
POST.HYPOPHARYNX
Metastatise to retropharyngeal&jugular chain.
POST.CRICOID.CA.-females(plummer vinson syndrome)
Tendancy for paratracheal &lower deep cervical nodes.
SUPERIOR HYPOPHARYNX.
Similar to oropharyngeal tumors,with poorly diff.&metastatise to
cervical l.n.