1. SURGICAL ANATOMY OF THE NASOPHARYNX
Dr. Supreet Singh Nayyar, AFMC
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2. Layout General Description Layers Of The Nasopharyngeal Wall
Fascial Relations Of The Nasopharynx
Muscles Of The Nasopharynx
Blood Vessels Of The Nasopharynx
Lymphatics Of The Nasopharynx
Nerves Of The Nasopharynx
Imaging Of The Nasopharynx

3. General Description Development Dimensions Boundaries Anterior wall
The Floor
The roof and posterior wall
The lateral wall

4. Fossa of Rosenmuller Location- Depth- 2.5 cm Anatomical relationship

5. LAYERS OF THE NASOPHARYNGEAL WALL
The mucosa
- three types of epithelium
Lymphoid nodules – Waldeyer’s ring
The submucosa
The muscular layer
-outer circular & inner longitudinal muscle
The buccopharyngeal fascia

6. FASCIAL RELATIONS OF THE NASOPHARYNX
Cervical fascial layers
superficial and deep cervical fascia
Cervical fascial spaces
midline spaces: pharyngeal mucosal, retropharyngeal and prevertebral spaces
Paired lateral spaces: parapharyngeal, carotid, masticator and parotid spaces

7. Cervical fascial layers
Superficial cervical fascia
-Envelops platysma and muscles of facial expression
Deep cervical fascia
- Superficial layer
- middle layer
- deep layer

8. Pharyngeal mucosal space
Encloses the pharynx
Buccopharyngeal fascia
Sinus of morgagni
Buccopharyngeal fascia fuses

9. Retropharyngeal space
Location: buccopharyngeal fascia and prevertebral fascia
Extent: skull base to T2
Two compartments
Source of Infection: extension from para pharyngeal, masticator, parotid space

10. Prevertebral space Location: posterior to the prevertebral fascia
Extent: skull base to coccyx
Source of Infection: TB spine , penetrating trauma

11. Carotid space Extent: jugular foramen to the aortic arch
Location: lateral to the prevertebral

12. Masticator space Extent: skull base to lower border mandible
Location: superficial layer of deep cervical fascia
Source of Infection: 3rd molar

13. Parotid space
Location: lateral to the parapharyngeal space, anterior to carotid space and posterior to the masticator space
Extent: superficial layer of deep cervical fascia
Source of Infection: oral cavity via Stenson’s duct

14. Contents of the cervical fascial spaces
Pharyngeal mucosal space: mucosa, lymphoid tissue, muscles of pharynx, minor salivary glands
Retropharyngeal space: fat, lymph nodes
Prevertebral space: vertebrae and prevertebral muscles

15. Masticator space: mandible, muscles trigeminal nerve
Para pharyngeal space: fat, arteries veins, trigeminal nerve, salivary gland rests, lymph nodes
Carotid space: carotid artery, internal jugular vein, cranial nerves IX-XII lymph nodes, Sympathetic fibers
Masticator space: mandible, muscles trigeminal nerve
Parotid space: parotid gland, facial nerve, lymph nodes arteries veins

16. MUSCLES OF THE NASOPHARYNX
Pharyngeal muscles
Pre vertebral muscles
Palatal muscles
Masticator muscles

17. Pharyngeal muscles Superior constrictor - Quadrilateral muscle
- Arises from the lower part of the posterior margin of the medial pterygoid plate
-Sphincter that prevents reflux into the nasopharynx and has a peristaltic function during swallowing

18. Pharyngobasilar fascia
-lies in the gap between the superior constrictor and the skull base, the sinus of Morgagni, fuses with the buccopharyngeal fascia to form a single layer of fascia
-the auditory tube passes through this gap

19. Palatopharyngeal (velopharyngeal) sphincter
- a band of mainly superior constrictor muscle fibers
- arises from the upper surface of the palatine aponeurosis
-the band ridges the pharyngeal wall as Passavant’s ridge , seen when the soft palate is elevated

20. - elevates the upper lateral wall of the pharynx Prevertebral muscles
Salpingopharyngeus
-arises from the posterior region of the pharyngeal projection of the auditory tube
- elevates the upper lateral wall of the pharynx
Prevertebral muscles
- the longus capitis arises from the transverse processes of the cervical vertebrae and inserts into the inferior surface of the basilar part of the occipital bone
– separates the nasopharynx from the lower clivus and vertebrae

21. Palatal muscles The levator palati muscle The tensor palati muscle
The uvular muscle
The palatoglossus
The palatopharyngeus

22. -situated lateral to the choana
Levator palati muscle
-situated lateral to the choana
-arises within the pharynx from the inferior surface of the petrous part of the temporal bone
- inserts into the palatine aponeurosis
- opens the pharyngeal opening of the auditory tube and elevates the soft palate during swallowing

23. -situated lateral to the auditory tube and the levator palati
Tensor palati muscle
-situated lateral to the auditory tube and the levator palati
–arises from the scaphoid fossa at the base of the medial pterygoid plate
– inserts into the palatine aponeurosis
-actively opens the auditory tube and tenses the soft palate during swallowing

24. -elevates the pharynx during swallowing
The uvular muscle: -arises from the posterior nasal spine of the palatine bones and the palatine aponeurosis, and insert in the uvula -stiffen the soft palate
The palatoglossus: -arises from the soft palate aponeurosis and passes in front of the palatine tonsil to insert into the lateral side of the tongue acts as a constrictor of the fauces
The palatopharyngeus: -arises from the soft palate aponeurosis and the posterior border of hard palate
-elevates the pharynx during swallowing

25. Masticator muscles The lateral pterygoid:
-arises as two heads, one from the greater wing of the sphenoid and the other from the lateral surface of the lateral pterygoid plate
– inserts into the neck of the mandibular condyle
– opens the mouth and protrudes the mandible

26. The medial pterygoid:
-arises in the pterygoid fossa from the medial surface of the lateral pterygoid plate and maxillary tuberosity
-insert into the medial surface of the ramus and the angle of the mandible
-closes the mouth

27. BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES
The ascending palatine artery
-branch of the facial artery
-ascends towards the skull base on the external surface of the pharynx and then winds medially over the upper border of the superior constrictor muscle
-supplies the levator palati, the soft palate, the superior constrictor and the auditory tube

28. BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES
The ascending pharyngeal artery
-branch of the external carotid
-ascends vertically between the carotid sheath and the pharynx to the skull base
-supplies the lateral and posterior pharyngeal wall above the level of the palate

29. BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES
The ascending cervical artery
–arises from the thyrocervical trunk or from the inferior thyroid artery
–winds upwards behind the carotid sheath
-anastomoses with the ascending pharyngeal artery

30. BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES
The maxillary artery
–larger terminal branch of the external carotid
-travels through the parotid gland, passes between the ramus of the mandible and the sphenomandibular ligament, passes either deep or superficial to the lateral pterygoid muscle and enters the pterygopalatine fossa

31. BLOOD VESSELS OF THE NASOPHARYNX- ARTERIES
The maxillary artery – divided into three parts:
-mandibular
- pterygoid
-pterygopalatine

32. BLOOD VESSELS OF THE NASOPHARYNX - VEINS
submucosal plexus of veins communicates with an external pharyngeal plexus of veins
veins corresponding to all branches of the maxillary artery then drain into the pterygoid plexus
main drainage of the pterygoid plexus is into the internal jugular vein via the maxillary, retromandibular and common facial veins

33. LYMPHATICS OF THE NASOPHARYNX
The retropharyngeal lymph nodes
Medial retropharyngeal lymph nodes Lateral retropharyngeal lymph nodes ( nodes of Rouviere )
Upper jugular lymph node ( level IIb )

34. NERVES OF THE NASOPHARYNX
motor, sensory and autonomic nerve supply - pharyngeal plexus
lies medial to the buccopharyngeal fascia on the external surface of the constrictor muscle
supplies motor innervation to all muscles of the pharynx, except stylopharyngeus

35. NERVES OF THE NASOPHARYNX
Stylopharyngeus- supplied by the muscular branch of the glossopharyngeal
sensory supply is from the nasopharyngeal branches of the pharyngeal plexus, pharyngeal branches of the maxillary nerve and the glossopharyngeal nerve

36. IMAGING OF THE NASOPHARYNX

37. Surgical approaches Transpalatal Sublabial midfacial degloving
Lateral rhinotomy
Transfacial- maxillary swing
Mandibular swing
Infratemporal
Transnasal-maxillary

38. References
Last’s Anatomy Regional and Applied, editor Chummy S. Sinnatamby, 10th edition, Chapter 6, Part 13.
Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery , editor Michael Gleeson, 7th edition.
Stell and Maran’s Head and Neck Surgery, editor John C. Watkinson, 4th edition

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