- Reem Akiely. -Wardeh Al-Swalmeh. - Mohammad Al-Muhtaseb. 1 P a g e

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1 -2 - Reem Akiely -Wardeh Al-Swalmeh - Mohammad Al-Muhtaseb 1 P a g e

2 The palate: * Hard palate * Soft palate the Uvula: is a muscular structure present In the midline of the soft palate (اللهاة) The Hard palate: It is composed of 2 parts: *The palatine part *Maxillary part It is formed by 2 bones: Palatine process of maxilla (anteriorly) Horizontal plate of palatine bone(posteriorly) The mucosa is adherent by Dense connective tissue. Contains: 1-anteriorly: the incisive foramen that opens to the nasal cavity 2-on both sides: the greater and lesser palatine foramen [greater and lesser palatine nerve and vessels passes through it. The soft palate: The soft palate is a mobile fold attached to the posterior border of the hard palate. Its free posterior border presents in the midline a conical projection called the uvula. The soft palate is continuous at the sides with the lateral wall of the pharynx. The soft palate is composed of mucous membrane, palatine aponeurosis, and muscles. 2 P a g e

3 The mucous membrane covers the upper and lower surfaces of the soft palate. The Palatine aponeurosis: 1. It is a fibrous sheath attached to the posterior border of the hard palate. 2. It is an expansion on the tendon of Tensor veli palatini muscle. Muscles of the soft palate: There are 5 muscles; these muscles are closely related to the tendon of the tensor veli palatini muscle. Relations: two of these muscles are inserted in the tendon; the other three originate from the tendon. 1. Tensor veli palatini muscle. 2. Levator veli palatini muscle (elevates to the soft palate). 3. Palatopharyngeus muscle. 4. Musculus Uvulae Note: the palatopharyngeus muscle and the Uvulae do folds on both sides of the palatine tonsils. Innervation of the muscles The pharyngeal plexus EXCEPT, the tensor veli palatini muscle which is innervated by the stim of mandibular nerve. The movement of the soft palate The soft palate is present between the nasopharynx and the oropharynx. It is normally relaxed, hence to allow the air that comes from the nose to go directly to the pharynx and then to the larynx. And also, the air coming from the oral cavity goes to the pharynx and then to the larynx. However, the soft palate changes from relaxed in 2 cases: 3 P a g e

4 1. It shuts down and becomes contracted (مشدود) in: Mastication because we need high pressure in the oral cavity so it becomes closed and descends downwards 2. It is raised up in the case of vomiting, in order to prevent the vomit from getting out through the nose and instead to get out through the mouth, so it shuts the nasopharynx. 3. In the articulation for the pronunciation of certain letters that have a nasal sound. It lets the air reach the nose (not a complete closure) Example: when you pronounce N NOTE: The movements of the soft palate are important, you should know when it is relaxed, when it closes the oropharynx and when it closes the nasopharynx. Nerve supply of the soft palate: Branches of the maxillary nerve *Greater palatine nerve: it emerges through the greater palatine foramen (along with the greater palatine artery). *Lesser palatine nerve : emerges through the lesser palatine foramen. Blood Supply of the Palate: The greater palatine branch of the maxillary artery, the ascending palatine branch of the facial artery, and the ascending pharyngeal artery. Lymph Drainage of the Palate: Deep Cervical Lymph Nodes. 4 P a g e

5 Salivary gland We have 2 type of salivary glands : 1) Major salivary gland : parotid, submandibular, sublingual gland (we will talk about each of them in detail). 2) Minor salivary gland ( ) : each one has its own small duct which open directly into the oral cavity. For each one of these glands, we must know the site, type of secretion, nerve supply, blood supply, lymphatic drainage and relations of the gland. In addition, some of them have surface anatomy (for example, you must know the surface anatomy of the parotid duct). 1) Parotid gland : The largest salivary gland. Type of secretion: serous secretion Anatomical relations : lies in a deep hollow bellow the external auditory meatus, anteriorly it overlies the masseter muscle and the ramus of the mandible, posteriorly it overlies the sternocleidomastoid muscle, inferiorly it reach the angle of the mandible so it s large in size The parotid gland covered by 2 capsule (unlike other 2 glands which covered by only 1 capsule ) : the 1 st capsule (outer) is part of the deep investing fascia of the neck and the 2 nd is CT that divide the gland into lobes and lobules. this give the gland advantage for protection and disadvantage in 5 P a g e

6 case of infection (mumps for example) because this capsule prevent swelling and cause very severe pain. Content of the parotid gland : 1) Fascial nerve : it divide the parotid gland into superficial and deep parts. The most superficial structure in the gland (The facial nerve is superficial in front of the ear and it divides inside the parotid gland into 5 branches) and this consider disadvantages. The 5 branch of the fascial nerve are : - Temporal, zygomatic above the parotid duct - Buccal, mandibular and cervical below the parotid duct Injury of the facial nerve: When it comes to surgeries, the facial nerve (the most superficial structure) is considered the most dangerous. The parotid gland may sometimes contain tumor or stones. The first structure that the surgeon encounters during the surgery is the facial n. and its branches. Any cut of any branch will lead to paralysis of the muscles innervated by that branch. Example: the temporal branch innervates orbicularis oculi. When injured, the patient will not be able to close his eyes at the affected side (but the other side will be normal). A common condition that is related to the facial nerve is Facial palsy (Bell's palsy): Paralysis of the facial nerve. Causes paralysis of all muscles in the affected half of the face. The most important signs of facial nerve palsy or paralysis: The patient cannot close his eye in the affected side. The patient cannot whistle because orbicularis oris is the muscle that causes the rounded shape of the mouth. Dripping of saliva from the angle of the mouth in the affected side. When the patient laughs, contraction will occur and the smile will be obvious in one side only, but the other side (the affected side) will be flat. Cervical branch run forward beneath the platysma in the neck and 6 P a gresponsible e for tightening of the skin of neck.

7 2) Retromandibular vein : formed by the union of superfiscial temporal and maxillary veins 3) External carotid artery and its terminal branches (superfiscial temporal and maxillary arteries ) 4) Parotid lymph nodes and lymphatic vessel 5) Auriculotemporal nerve :branch from the mandibular nerve, this nerve is sensory (transfer general sensation, pain, touch, temperature ) and secretomotor (parasympathhatic ) to the parotid gland. Parasympathatic of the glands consist of preganglionic parasympthatic fibers, parasympathatic ganglia and postganglionic parasympthatic fibers. In parotid gland : preganglionic parasympthatic fibers lesser petrosal nerve (branch of the glossopharyngeal nerve which originate from the inferior salivary nucleus in the medulla oblongata of the brain. parasympathatic ganglia the otic ganglia located directly below the foramen ovali in the base of the skull. postganglionic parasympthatic fibers oriculotemporal nerve. To sum up : inferior salivary nucleus glossopharyngeal nerve lesser petrosal nerve otic ganglia oriculotemporal nerve parotid gland. The duct of the parotid gland: - Length: about 5 cm. - Origin : anterior border of the parotid - It crosses the masseter muscle and pierces the buccinator to end in the vestibule of the mouth as it opens at the level of the upper second molar tooth. - This direction (crossing then piercing ) form angulation to prevent regurgitation of its secretion ( secretion in one direction to the vestibule of the mouth. - The surface anatomy of the parotid duct: it lies one finger below the zygomatic arch. 7 P a g e

8 2) Submandibular gland : Type of secretion : serous and mucous secretion (mixed ) Divided into superficial and deep part by mylohyoid muscle - The superficial part lies in the submandibular fossa of the mandible. - The deep part of submandibular lies between two muscles; mylohyoid and hyoglossus muscle. Submandibular duct : originate from the deep part and open in the sublingual papilla in both side of the frenulum under the tongue. Note : The sublingual gland has many ducts (around 8 to 10 or 12 small ducts) that also open into the submandibular duct or directly into the oral cavity. Innervation of the submandibular and sublingual gland are the same : - The origin of this parasympathetic innervation is the superior salivary nucleus (of the facial nerve) which is located in the medulla oblongata in the brain. - - After that, we have pre-ganglionic fibers through the chorda tympani. (Chorda tympani is a branch from the facial nerve and is considered pre- ganglionic. Before it participates in synapse, it joins the lingual nerve (its fibers run with the fibers of the lingual nerve) - Then, it participates in synapse in the submandibular ganglia that is 8 P a g e

9 located with the deep part of the submandibular gland between two muscles (mylohyoid and hyoglossus). - After synapse, the post- ganglionic fibers go directly to the gland or indirectly through the lingual nerve 3) Sublingual gland Type: mixed gland, mostly mucus. Location: lies under the tongue, and it covered by mucosa It has 8-20 ducts (small numerous ducts ) open either directly to the oral cavity or indirectly through submandibular duct Innervation : same as submandibular gland Note: in glands, we are concerned about the parasympathetic innervation, because the sympathetic innervation is for blood vessels to control vasoconstriction or vasodilation while parasympathetic is secretomotor. It is the one important for secretion. Therefore, it goes to the glands Important relation of the parotid gland : Parotid gland is pyramid in shape, has apex (deep toward the pharynx) and base (on the surface). Parotid gland has 2 deep surfaces : Anteromedial surface : related to 1) ramus of the mandible 2) Masseter muscle 3) Medial pterygoid muscle 9 P a g e

10 Posteromedial surface : also called parotid bed : structures that the parotid gland lies on : 1) Posterior belly of digastric muscle 2) Stylohyoid muscle 3) External carotid artery 4) Internal carotid artery 5) Internal jugular vein (a large vein) 6) last 4 cranial nerves; glossopharyngeal, vagus, accessory, and hypoglossal 7) fascial nerve before it enter the parotid and divide (the facial nerve exits the cranial cavity from the stylomastoid foramen at the base of skull. Immediately after it exits, it crosses the styloid process and enters the parotid gland in which it gives its 5 branches) 8) styloid process structures that lie between the mylohyoid muscle and the hyoglossus muscle the hyoglossus is more deep and goes to the tongue while the mylohyoid is more superficial and originate from the mylohyoid line of the mandible and form the floor of the mouth in both sides (mylohyoid muscle also called diaphragma oris ) Three submandibular structures the deep part of Submandibular gland. Submandibular duct. Submandibular ganglion. Two nerves (hypoglossal and lingual nerves) ( usually, there is a question in the exam about the previous five structures. Examples) 10 P a g e

11 Important relation to the submandibular gland There is a triple relationship between the lingual nerve and the submandibular duct: - At the beginning (near the origin of the duct): the lingual nerve is lateral. - The lingual nerve becomes below the duct. - At the end, the lingual nerve becomes medial to the duct. Remember the submandibular duct starts from the anterior border of the deep part of the submandibular gland. the lingual nerve has with it chorda tympani to reach the ganglion. Relations of the sublingual gland Lateral to sublingual gland is the sublingual fossa of the mandible. Medial to the sublingual gland are 1) submandibular duct 2) lingual nerve 3) genioglossus muscle 4) styloglossus muscle (both genioglossus muscle and styloglossus muscle go to the tongue) 5) lingual vessel (artery and vein ) 6) lymphatic 11 P a g e Clinical points : 1) infection of the parotid gland by MUMPS virus, this virus has important complication as it may cause infertility especially in male because when the gland is infected, the secretion decrease and the virus will proliferate and increase in number, reaching the blood then go to the testes and damage the spermatogenial cells. although its viral infection, the first line of treatment is complete rest to increase the immunity and prevent the viral proliferation, give vitamins and some analgesic to assist in rapid healing. Mumps accompanied with severe pain because the 2 capsule around the

12 parotid gland. 2) stone formation in the gland or duct, if it in the gland it cause stop secretion. important test to detect if the problem is stone in the parotid gland by giving the patient lemon, this stimulate the parotid gland to start secretion and because of the blockage in the duct this will result in swelling accompanied with painful sensation. Pharynx Muscular tube which open anteriorly (unlike esophygus which is completely muscular tube Divide into 3 parts : 1) nasopharynx lies behind the nasal cavity. 2) oropharynx lies behind the oral cavity. 3) laryngopharynx (hypopharynx) behind the inlet of the larynx length :5 inches. The pharynx is funnel shaped, its upper, wider end lying under the skull and its lower, narrow end becoming continuous with the esophagus opposite the sixth cervical vertebra. It lies in front of cervical vertebra the wall of the pharynx consist of the superior, middle, and inferior constrictor muscles whose fibers run in a somewhat circular direction, Each muscle overlaps the muscle superior to it (it looks as if the superior one inserts inside the one inferior to it) the pharynx has musculomembranous wall ( membranous mean that there is a mucosa which is stratified squamous non-keratinized epithelium ) It begins at the base of the skull where it starts below the sphenoid bone and the basiooccipital. It ends at the level of the lower border of the cricoid cartilage (the first part of the trachea) that is opposite to the 6th cervical vertebra. The end of pharynx: Posteriorly: 6th cervical vertebra. Anteriorly: lower border of the cricoid cartilage In front of the pharynx is the larynx and the trachea ( the trachea is the 12 P a g e

13 continuation of the larynx and the esophygus is the continuation of the pharynx ) In the lateral wall of the nasopharynx we have auditory tube (Eustachian tube) which is responsible for the continuation between the pharynx and the middle ear. - The advantage : it is responsible for balance of air pressure on tympanic membrane ) االذن.(طبلة That s why when a person descends to low altitude (e.g. Al Ghor) or ascends to high altitude (e.g. in planes), pressure on the tympanic membrane increases sothe person should eat anything to swallow it so that air will enter from the Eustachian tube to the middle ear and maintain balance on the tympanic membrane - Disadvantage: Otitis media (infection of the middle ear) might occur, especially in infants. ER doctors should always examine the middle ear of children because the child might have Otitis media that came from the Eustachian tube (because sometimes when the child is laying on his back, he might vomit and some bacteria or particles might enter to the Eustachian tube then reach the middle ear causing Otitis media (the tympanic membrane is red and swelling due to infection ) Muscles of the pharynx 1) Superior pharyngeal constrictor muscle 2) Middle pharyngeal constrictor muscle 3) Inferior pharyngeal constrictor muscle 4) Stylopharyngeus muscle : its fiber is obliquely downward 5) Salpingopharyngeus muscle in the lateral wall of the nasopharynx above the eustichian tube (origin ) 6) 2 muscles around the palatine tonsils ; palatoglossus and palatopharyngeus the first 3 muscles are constrictors because they cause peristaltic movement (contraction and relaxation ) and aid in propelling of the bolus downward except the lowest part of the inferior constrictor muscle which is called cricopharyngeus muscle 13 P a g e

14 cricopharyngeus muscle : start from cricoid cartilage in the lower border of the pharynx or the upper boreder of the esophygus The fibers of the muscle are horizontal (circular). The function of the cricopheryngeus muscle is different from other constrictor muscles. This muscle always stays contracted. When the bolus reaches this muscle, the muscle opens so that the bolus would reach the esophagus It works as sphincter and prevent the enterance of the air to the esophygus ( both air and bolus of food enter the pharynx, but only the bolus should enter the esophygus and the air should go to the larynx it stays closed so that air can enter the larynx without entering the esophagus. It opens when the bolus directly stimulates it, the bolus will then enter the esophagus Important notes : all muscles innervate by pharyngeal plexus except stylopharyngeus muscle which innervate by the glossopharyngeal nerve all muscles act as constrictor ( propelling the bolus)except the cricopharyngeus muscle act as sphincter. Some muscle with oblique fibers cause elevation to the larynx Killian s dehiscence is the area on the posterior pharyngeal wall between the upper propulsive part of the inferior constrictor muscle and the lower sphincteric part; cricopheryngeus. Note that Killian s area is in the lower part of the inferior constrictor and above cricopheryngeus. This area is the most sensitive area. 14 P a g e

15 The muscle Origin Insertion Innervation Function/Act ion Pharyngeal tubercle of occipital bone, Superio r constric tor Middle constric tor Inferior constric tor Cricopheryng eus (Lowest fibers of inferior stylopharyngeu s salpingopharyng eus palatopharynge us Medial pterygoid plate, pterygoid hamulus, (these two are in the base of skull). pterygomandibular ligament, mylohyoid line of Lower part of stylohyoid ligament, lesser and greater cornu of hyoid bone Lamina of thyroid cartilage, cricoid cartilage raphe in midline Pharyngeal raphe Pharyngeal raphe Pharyngeal plexus Pharyngeal plexus Pharyngeal plexus Pharyngeal plexus Styloid process of temporal bone Auditory tube Palatine aponeurosis Posterior border of thyroid cartilage Blends with palatopharyngeu s Posterior border of thyroid cartilage Glossopharynge al nerve Pharyngeal plexus Pharyngeal plexus Aids soft palate in closing off nasal pharynx, propels bolus Propels bolus downward Propels bolus downward Sphincter at lower end of pharynx Elevates larynx and pharynx during Elevates swallowing pharynx Elevates wall of pharynx, pulls palatopharyng eal arch medially 15 P a g e

16 Interior of the pharynx The pharynx is divided into three parts: the nasal pharynx, the oral pharynx, and the laryngeal pharynx(epiglottis form the upper border of the inlet of the larynx ) 1) Nasopharynx : We have choanea (opening of the posterior nares to the nasopharynx, between them there is a bone called vomer The pharyngeal tonsil: Located in the roof of Nasopharynx. Clinical importance: in some children, it becomes enlarged if it gets infected. When it s enlarged, it s called: Adenoid. The Adenoid blocks the nasopharynx. The child would not be able to breathe from his nose; instead, he will use his mouth. This leads to characteristic effect on the face. Sometimes, the Ala of the nose becomes wide,short nose and thick lips. The condition is called "Adenoid face" Surgical treatment to remove the adenoid in the roof of the nasopharynx is needed. 2) Oropharynx : in both side of the oropharynx we have palatine tonsils which is prone to inflammationand its most common in children called tonsillitis 3) laryngopharynx : The region of the pharynx below the epiglottis The epiglottis is above and anterior to the opening of the larynx The inlet of the larynx prevent the enterence of any thing other than air to the larynx, enterence of any small particle will cause reflex of cough until the particle get out. 16 P a g e

17 The process of swallowing (deglutition ) 1) Masticated food is formed into bolus on the dorsum of the tongue, then you make deglutition ( voluntarily pushed the bolus upward and backward against the undersurface of the hard palate) 2) Soft palate move upward and the pharyngeal wall move forward this cause blocking of the nasopharygeal isthmus 3) As the bolus move, it push the epiglottis downward and the larynx will move upward with contraction of the aryepiglottis fold and aryepiclotticus muscle causing complete closure to the inlet of the larynx 4) Bolus will move to esophygus Piriform fossa: wide space anterolateral to the laryngopharynx and posterolateral to the larynx. Clinical imporatance : Sometimes, foreign bodies especially fish bones descend down and lodge in the piriform fossa of the esophagus. When the doctor uses the Gastro-scope, he enters the oral cavity by the scope. When he reaches the larynx, he passes it and examines the piriform fossa to see if there is any obstruction in it by foreign bodies. Innervation of the pharynx : Nasal pharynx: The maxillary nerve (V2) Oral pharynx: The glossopharyngeal nerve Laryngeal pharynx (around the entrance into the larynx): The internal laryngeal branch of the vagus nerve 17 P a g e

18 Blood supply : Ascending pharyngeal, tonsillar branches of facial arteries, and branches of maxillary and lingual arteries All are branch of the external carotid artery Lymph Drainage of the Pharynx Directly into the deep cervical lymph nodes or indirectly via the retropharyngeal or paratracheal nodes into the deep cervical nodes Structure pass between constrictor muscles : (the doctor didn t mention this structures but ask to know them ) structures pass between the superior and middle constrictors. 1) Stylohyoid ligament 2) Glossopharyngeal nerve. 3) Stylopharyngeus muscle Internal laryngeal nerve : pass between the inferior and middle constrictor muscle Palatine tonsils : The palatine tonsil is a lymphoid tissue on both sides of the oropharyngeal isthmus, covered by capsule (thick laterally and thin medially ) Boundaries: Superiorly: uvula and soft palate. Floor: posterior third of the tongue Repeated tonsillitis will cause crypts in the medial side of tonsils Children commonly get tonsillitis They must be treated. We are usually afraid of acute tonsillitis becoming chronic tonsillitis which might cause infection in the joints (arthritis) or the 18 P a g e

19 heart (pericarditis) or kidneys (glomerulonephritis). These are complications of chronic tonsillitis. That s why in the case of repetitive infection (3-4 times a year), it is advised to remove the palatine tonsils of the child (tonsillectomy). Tonsillectomy On the medial surface of the palatine tonsils, we find what is called "crypts" of tonsils ( (بؤر that result from repetitive infections. On the other hand, tonsils from the lateral sides are covered by capsule (fibrous tissue surrounding the tonsils). During the tonsillectomy operation, surgeons open the capsule on the lateral side of the tonsil then they enucleate (remove) the tonsil. Cut and ligation of the tonsillar artery and the vein must be carried out during this operation. Palatine Tonsils in adults are rudimentary (shrunk in size). Always after the tonsillectomy operation, the patient is kept under observation. Why? Because the surgeon would be afraid of bleeding from the vein (external palatine vein from upward and pierce the superior constrictor muscle of the pharynx -not the artery- due to the fact that the vein pierces the superior constrictor muscle. Release of ligation of the vein may occur when the muscle contracts leading to bleeding. This does not occur in the case of the artery. What is important during the operation is the lateral relations of the tonsil: Carotid sheath which contain the carotid artery, jugular vein, vagus nerve, tonsilar branch of facial artery 19 P a g e

20 Blood Supply of the palatine tonsiles : The tonsillar branch of the facial artery. The veins pierce the superior constrictor muscle and join the external palatine, the pharyngeal, or the facial veins. Lymph Drainage of the Tonsil :The upper deep cervical lymph nodes, just below and behind the angle of the mandible Waldeyer s Ring of Lymphoid Tissue The fauces (the posterior opening of the oral cavity) is surrounded by lymphoid tissue. Part of this lymphoid tissue is the pharyngeal tonsil (adenoid) Roof Lingual tonsil Floor Palatine tonsil On both sides Tubal tonsil On both sides (on the tubal elevation). The purpose of the ring: filtration of bacteria and viruses 20 P a g e

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