ANATOMY OF LARYNX AND PHARYNX INCLUDING CONNECTIVE TISSUE SPACES AND THEIR IMPORTANCE IN CANCER SPREAD

ANATOMY OF LARYNXSITUATION AND EXTENT:root of tongue---tracheac3-c6higher in female and childrenMale-44mmFemale-36mmINFANTfunnel shaped collapsablemore submucosal tissue epiglottis larger and folded on itself

SKELETON9CARTILAGES3PAIRED 3UNPAIRED-ARYTENOID -THYROID-CORNICULATE -CRICOID-CUNEIFORM -EPIGLOTTICJOINTS--*CRICOTHYROID *CRICOARYTENOID

LARYNGEAL LIGAMENTS AND MEMBRANESEXTRINSIC-thyrohyoid membrane-hyoepiglottic lig.-cricotracheal lig.-crico thyroid memb.INTRINSIC-quadrate memb.-conus elasticus/cricovocal memb.

CAVITY OF LARYNXINLETVESTIBULE OF LARYNXSINUS OF MORGAGNI/VENTRICLEINFRA GLOTTIC PART *rima vestibuli *rima glottidis -laryngoceleMUCOUS MEMBRANE-ciliated colomnar ep. -strat.sq.ep.

MUSCLES OF LARYNXINTRINSIC MUSCLES OF LARYNX-cricothyroid-post.cricoarytenoid-lat.cicoarytenoid-transverse arytenoid-oblique arytenoid &ary epigotticus-thyroarytenoid & thyroepiglottisACTIONS*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.&vLYMPHATIC 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 airvibratorsresonatorsarticulatorsLARYNGOSCOPIC VIEW-MOVEMENTS OF V.FOLDS-

ANATOMY OF PHARYNXConical fibromuscular tube,forming upper part of air &food passage.WIDEST-3.5cmNARROWEST-1.5cm at pharyngoesophageal junction.BOUNDRIES-SUPERIORLY-base of skull,basilar part of ocipital boneINFERIORLY-continous with esophagus at c-6 corresponding to lower border of cricoidPOST-prevertebral fasciaANT-comm.nasal cavity,oralcavity,larynxPARTS OF PHARYNX-oropharynx -nasopharynx -hypopharynx

NASOPHARYNXBOUNDRIESCilliated columnar epitheliumMucus memb.supplied by pharyngeal br. Of pterygopalatine ganglion,other parts of pharynx supplied by cr.n.9,10LATERAL WALL-auditory tubeopening -tubal elevation -salpingopharyngeal fold -levator veli palatini -pharyngeal recess/fossa of rosenmullarRATHKES POUCHNASOPHARYNGEAL BURSATHORNWALDS DISEASE

OROPHARYNXBOUNDRIESWALDEYERS 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. -jugulodigastric node

LARYNGOPHARYNXBOUNDRIESPIRIFORM SINUS/FOSSA-medially-aefLaterally-thyroid cart.&thyrohyoid memb.*beneath the mucosa is theint.laryngeal.n.LYMPHATIC DRAINAGE-pyriform sinusthyrohyoid membupper jugular chainPpwdeep cervical nodesPost.cricoidparapharyngeal nodes.also,supraclavicular&paratracheal cahin.

WALL OF PHARYNX-mucosa -submucosa -pharyngobasilar fascia -muscular coat -buccopharyngeal fasciaMUSCLES OF PHARYNX- OUTER CIRCULAR-3-superior,middle,inf.constrictrINNER LONGITUDINAL-stylo,salpingo,palatopharyngeusORIGIN 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 aBetween sup.&middle-stlopharyngeus&glossopharyngealBetween middl&inf-int.laryngeal n.,sup.laryngeal vessels,(pierce thyrohyoid memb in the gap)Between inf&esophagus-recc.laryngeal n.,inf laryngeal vesselsKILLIANS 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.ganglionMOTOR-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 vagusNASOPHARYNX-maxillary n.,through pterygopalatine ganglion,softpalate&tonsil-lesser palatine &glossopharyngeal-taste sensation fro valleculla&epiglottic areaint.laryngeal.br.of vagusP.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-1ST STAGE-voulantry-oropharyngeal isthmus to oropharynx2ND STAGE-invoulantry-oropharynxlaryngopharynx3RD STAGE-invoulantry-laryngopharynxesophagusAUDITORY TUBE-m.ear with nasopharynx,4cm downwards,forwards,medially.45*saggitalplane,30*horizontal plane.lat,.1/3rd bony(12mm)medial2/3rd (25mm)Ascending pharyngeal,middle meningeal,a.of ptrygoid canalPharygeal&pterygoid plexus of v.Retropharyngeal nodes.

SPACES OF LARYNXPRE 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.foldsSpread locallyCa.of infrahyoid epiglottis&ant.ventricular band may extend into pre-epiglottic space&penetrate thyroid cart.Nodal metastasis occurs early-upper&middle deep cervical nodesb/l metastasis seen in epiglottic cancer.GLOTTIC CA.-m.c-upper surface of the free edgeoo ant.&middle 1/3rd 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 rapheCommunicates 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 boneStyloid 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.nParapharyngeal space communicates with retro pharyngeal,sub mandibular,parotid,carotid spaces.

CANCERS OF OROPHARYNXCA.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 commonCA.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 NASOPHARYNXM.c. sq.c.c& its variants.Commonest site-fossa of rosenmuller.Nodal metastasis 75% &about half with b/l nodes.

CANCER OF HYPOPHARYNXINFERIOR 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 spaceSpread mainly to jugularchain of nodes.POST.HYPOPHARYNXMetastatise 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.