DR MANPREET SINGH NANDA PROFESSOR ENT

1. Oral Cavity, Pharynx, Larynx, Oesophagus, Trachea,
Neck

2. Oral Cavity
 Sub sites (AJCC)
 Lip
 Buccal Mucosa
 Anterior two third tongue
 Hard Palate
 Alveolar ridges
 Floor of mouth
 Retro Molar Trigone
 EXTENSIONS

4. Lips
 Vestibule or Labial Cavity
 Vermilion border
 Non keratinized stratified sq epithelium
 2 mm dist between epithelium and muscle
 Orbicularis Oris
 Upper – pre auricular, parotid, submandibular lymph
nodes
 Lower- submental, submandibular lymph nodes
 Labial branch of facial artery

5. Oral Cavity proper (buccal cavity)
 Palate
 HARD PALATE ( Ant two third)
 Palatine process of maxilla
 Contains minor salivary glands, so site for tumours

6. Soft Palate
 Post one third
 Fibromuscular structure
 Palatine aponeurosis by extended tendon of tensor palati,
attached to it palatoglossus, palatopharyngeus, levator
palatini
 Midline – post margin forms uvula (musculus uvulae)
 Regulates the isthmus
 Ascending palatine branch of facial artery, palatine
branches of maxillary and ascending pharyngeal artery
 Deep facial vein
 Upper deep cervical lymph nodes
 Nerve – Pharyngeal plexus except tensor palati (V3)

7. Gums and Teeth
 Composed of dense fibrous tissue
 Gums (gingiva) surround teeth and cover alveolar
ridges
 Adult 2123
 Upper jaw – alveolar branch of maxillary nerve
 Lower jaw – inf alveolar br of mandibular nerve
 Submental and submandibular lymph nodes

8. Tongue
 Muscular organ
 Situation – floor of mouth, ant wall of pharynx
 Dorsum of tongue – subdivided by V shaped groove –
sulcus terminalis
 ANT two third – palatine part
 POST one third – pharyngeal part
 Foramen cecum at apex of sulcus terminalis

9.  Anterior tongue
 Median sulcus
 Mucous membrane has papillae
 Circumvallate ( parallel to sulcus terminalis)
 Fungiform – tip and margin, red (highly vascular)
 Filliform – dorsum
 Taste buds along papillae (flask shaped)

11.  Base of tongue – nodular elevations
 Lymphoid tissues
 Mucous and serous glands
 Lingual tonsil
 GLOSSO EPIGLOTTIC FOLDS
 Vallecula
 MUSCLES – Extrinsic ( geniglossus, hyoglossus,
styloglossus)
 Intrinsic – sup and inf longitudinal, transverse, vertical
 Connect to mandible, hyoid , styloid, soft palate, epiglottis,
floor of mouth)

12.  Lingual artery
 Internal jugular vein
 Lymphatics – apex – submental , margins –
submandibular , centre and base – deep cervical
 All muscles except palatoglossus (X) – hypoglossal
nerve (XII)
 Taste sensation – ant by chorda tympani, post (IX),
vallecula and epiglottis (X)

13. Floor of Oral Cavity
 Crescent shaped area
 undersurface of tongue
 Frenulum
 Sublingual papillae
 Opening of submandibular and sublingual glands
 Lymphatic drainage – submandibular, submental and
upper deep cervical lymph nodes

14.  Retromolar trigone
 Triangular area of mucous membrane
 Covers ant border of ascending ramus of mandible
 Behind third molar
 Buccal mucosa – buccinator muscle
 Submandibular lymph nodes

17. ANATOMY OF PHARYNX
 Fibromuscular membranous tube
 12 to 14 cm length
 Funnel shaped (width top 3.5 cm, bottom 1.5 cm)
 Extends from base of skull to lower border of cricoid
cartilage
 Continous with nasal cavity (chonae), oral cavity,
middle ear (ET), larynx(glottis), oesophagus
(cricopharynx)

18. Divisions
 Nasopharynx
 Oropharynx
 Laryngopharynx

19. Nasopharynx or Epipharynx
 Behind nasal cavity
 From skull base to nasopharyngeal isthmus
 Ant – choanae
 Post – C1 vertebrae
 Inf – soft palate
 Sup – Basi occiput , basi sphenoid
 Lateral wall – ET opening, tubal elevation (torus
tubaris), tubal tonsils
 Fossa of Rosenmuller (pharyngeal recess)- above and
behind tubal elevation, NP Cancer

20.  Roof and post wall – nasopharyngeal tonsils (adenoids)
6yrs
 Nasopharyngeal bursa – within adenoid mass (Tornwald’s
abscess)
 Rathke’s pouch – dimple above adenoids
(Craniopharyngioma)
 Sinus of morgagni – between skull base and upper border
of sup constrictor. Structures passing through it – ET,
Levator Palatini, Ascending Palatine artery
 Passavant’s ridge – made up of palatopharyngeus , post and
lat wall at nasopharyngeal isthmus

21.  Retropharyngeal, parapharyngeal and upper deep
cervical lymph nodes
 Palatine branches of facial, ascending pharyngeal and
maxillary artery

23. Oropharynx
 Lower border of soft palate to tip of epiglottis
 Sup
 Ant
 Post – C2 and C3 vertebra
 Anterior wall – Base of tongue
 Lateral wall – Tonsillar fossa
 Between palatoglossal and palatopharyngeal muscle
folds

24. Tonsils
 Ovoid lymphoid tissue
 Surfaces – medial and lateral
 Medial surface contain crypts 15 to 20
 Crypta magna or intra tonsillar cleft
 Secondary crypts
 Cheesy material – food, epithelial cells, bacteria
 Lateral surface – capsule, loose areolar tissue (less
vascular), bed of tonsil ( sup constrictor, IX CN,
styloglossus
 Poles – upper and lower, upper is free, lower has insertion
of palatoglossus

25. Blood supply

26.  Para tonsillar vein (haemorrhage)
 Jugulo digastric lymph nodes
 Ant tonsillar space or plica triangularis at lower pole.
mm fold
 Tonsillo lingual sulcus or plica semilunaris at upper
pole
 IX CN
 Approach to styloid process and IX CN

28.  Inf – glosso epiglottic folds
 Vallecula (retention cysts)
 Non keratinized stratified squamous epithelium
 Sup constrictor, palatoglossus, palatopharyngeus

29. Hypopharynx or Laryngopharynx
 From hyoid bone to lower border of cricoid cartilage

30.  Continous with oesophagus at cricopharyngeal sphincter
 Post wall – C3, C4, C5, C6
 Ant – Larynx
 Subsites –
 Pyriform fossa- from pharyngoepiglottic fold to upper end
of oesophagus, pear shaped, (FB), Rich lymphatics (Nodal
metastasis)
 Sup laryngeal N lies deep to MM of lateral wall (LA)
 Post cricoid area – from arytenoid catilage to lower border
of cricoid cartilage (Ca)
 Post pharyngeal wall

32. MALT(Mucosa Associated
Lymphoid Tissue)
 WALDEYER’S RING
 Around oropharyngeal inlet
 Has efferents, No afferents
 Inner ring-
 Palatine tonsils
 Adenoids
 Tubal tonsils
 Lingual tonsils
 Discrete nodules (Post pharyngeal wall)
 Lat pharyngeal bands
 Outer ring – lymph nodes around neck

33.  Functions – immunology ( antibody formation, plasma
cells and lymphocytes, protection of LRT, sentinels
against bacteria

34. Pharyngeal wall
 MM
 Pharyngeal aponeurosis
 Muscular layer
 Buccopharyngeal fascia
 MUSCLES
 Outer circular (horizontal)- sup, middle and inf
constrictor, overlap each other
 Inner longitudinal (vertical) – stylo, palato and
salpingopharyngeus
 Killian’s dehiscence – gap between two parts of inf
constrictor (thyro and cricopharyngeus) – perforation in
oesophagoscopy, herniation (pharyngeal pouch)

36. Nerve supply
 Pharyngeal plexus – IX, X, XI CN
 Vagus – muscles except stylopharyngeus (IX)
 Soft palate muscles except tensor palati (V3)
 GP – sensory
 Nasopharynx – maxillary nerve
 Deep cervical lymph nodes
 IJV
 ECA

37. Retropharyngeal Space
 2 spaces of gillete separated by midline fibrous raphe
 Behind pharynx
 Ant – buccopharyngeal fascia
 Post – prevertebral fascia
 Sup- skull base
 Inf- passes into post mediastinum (lincoln’s highway)
 Lat- parapharyngeal space
 Contains loose areolar tissue and lymph nodes
(rouvier, krause – 3-4yrs)
 Abscess – TB cervical spine, infants, unilateral

39. Parapharyngeal space
 Lateral pharyngeal or pharyngo maxillary space
 Triangular in cross section (pyramidal)
 On each side of pharynx
 Base- towards skull base, apex towards hyoid bone
 Anteromedially- buccopharyngeal fascia
 Posteromedially- cervical vertebra
 Superolaterally- ascending ramus of mandible, parotid gland,
pterygoid muscles
 Inferolaterally- scm muscle, strap muscles
 Two compartments (styloid process)-
 Anterior pre styloid –salivary gland tumours, dental abscess
 Post styloid – neurogenic tumours, contents- ICA, IJV, IX-XII
CN, upper deep cervical lymph nodes

40. Anatomy of Oesophagus
 Fibro muscular tube, 25 cms length, 2 cm diameter
 From lower border of cricoid cartilage (C6) to cardiac
orifice of stomach(T11)
 2 curves – 1st deviates to left at commencement
(cervical ), 2nd bends to left to cross descending
thoiracic aorta at lower end
 Costrictions – cricopharyngeal sphincter (15cm),
crossed by arch of aorta (25 cm), crossed by left main
bronchi (27 cm), lower oesophageal sphincter (40 cm)
 FB impaction, benign strictures

42. Wall of oesophagus
 Inner mucosal layer – MM, non keratinized stratified
squamous epithelium
 Submucosa – blood vessels, glands, meissner’s nerve
plexus
 Muscle coat – outer longitudinal, inner circular
 Upper one third- striated muscles, middle- both, lower
one third- non striated (smooth)
 Outer fibrous layer – loose layer

44.  Nerve supply
 Sympathetic – sympathetic trunk
 Parasympathetic – vagus nerve
 Blood supply
 Upper one third – Inf thyroid artery
 Thoracic part – descending thoracic artery
 Abdominal part – left gastric artery, inf phrenic artery
 Venous drainage
 Cervical – inf thyroid veins
 Thoracic- azygos and hemiazygos veins,
 Abdominal – left gastric vein

45.  Lymphatic drainage
 Cervical – lower deep cervical, paratracheal
 Thoracic- post mediastinal, tracheobronchial
 Abdominal – left gastric
 Oesophageal sphincters
 Upper – cricopharyngeus, 3-5 cm long
 Lower – has high raised pressure 8mm Hg than intra
gastric pressure, prevents regurgitation, 3-5 cm long,
can be affected by smoking , drugs

46. Anatomy of Larynx
 Framework of larynx- cartilage, joints, ligaments and
membranes of larynx
 Muscles of larynx
 Divisions of larynx
 Spaces in larynx
 Nerve supply, blood supply, lymphatic drainage of larynx
 LOCATION – midline of neck in front of laryngopharynx
between C3 – C6 vertebra
 Moves on phonation and swallowing
 Length – males 44 mm , females 36 mm

48. Framework of larynx
 Hyoid bone
 Raises the larynx
 Body ( central part – quadrilateral shape)- ant and post
surface
 Sup (hyoepiglottic and thyrohyoid membrane
attached here ) and inf border
 Lesser and greater horn on each side
 Hyoid bone attached to mandible and skull base by
muscles (geniohyoid, stylohyoid, mylohyoid and
digastric) and ligaments (stylohyoid)

49. Cartilages of Larynx
 3 unpaired – thyroid, cricoid, epiglottis
 3 paired – arytenoid, corniculate, cuneiform
 Hyaline – thyroid, cricoid and arytenoid (except tip)-
undergo ossification at 25 yrs and complete by 65 yrs
(1st to ossify – thyroid)
 Elastic – epiglottis, corniculate, cuneiform, tip of
arytenoid- don’t ossify, fibro elastic

50. Thyroid cartilage
 Largest hyaline cartilage
 2 wings ala meet anteriorly at thyoid angle (90 in
males, 120 in females
 Upper part of ala form v shaped notch – thyroid notch
 Vocal cords attached to thyroid angle
 Sup cornu and inf cornu arise from post sup angle of
ala and post inf angle of ala
 Atriculates with cricoid cartilage
 Cricothyoid and thyrohyoid membranes

52. Cricoid cartilage
 Thicker and stronger
 Signet ring (only cartilage with complete ring)
 Anterior arch – narrow front- cricothyoid membrane
 Posterior lamina – broad behind- upper fibres of
oesophagus, articulation with arytenoid cartilage at
upper border

53. Epiglottis
 Behind the tongue
 Ant wall of laryngeal inlet
 Ant surface – hyoepiglottic ligament
 Hyoepiglottic ligament – divides epiglottis into supra
hyoid and infra hyoid epiglottis
 Post surface contains mucous glands
 Petiole – a stalk like process of epiglottis

55. Arytenoid cartilage
 Pyramidal shaped
 Larger in males than females
 Base – articulate with cricoid cartilage
 Apex – supports the corniculate cartilage
 3 surfaces – medial , anterio lateral and posterior
 2 processes – vocal process (vocal cord), lateral
muscular process (cricoarytenoid)

56.  Corniculate cartilage
 Cartilage of santorini
 Conical shaped
 Present at apex of arytenoid cartilage
 Cuneiform cartilage
 Cartilage of wrisberg paired rod shaped
 Situated in front of corniculate cartilage in
aryepiglottic folds

57. Joints of larynx
 Simple synovial joints
 1 Cricothyroid joint – inf cornu of thyroid to articular
facet on cricoid, transverse axis movement
 2 Cricoarytenoid joint – base of arytenoid to facet on
upper border of cricoid lamina, rotatory and gliding
movements
 Rotation of arytenoids – adduction and abduction
 Gliding movement of arytenoids – closing or opening
of post part of larynx

58. Ligaments and membranes of
larynx
 Extrinsic – connect the larynx to hyoid and trachea
 Thyrohyoid ligament, cricotracheal ligament,
hyoepiglottic ligament
 Intrinsic – connect the cartilage to one another
 Cricothyoid ligament, conus elasticus, cricovocal
membrane, quadrangular membrane

59. Extrinsic
 Thyrohyoid ligament – thyrohyoid membrane (pierced
by sup laryngeal vessels and internal laryngeal nerve),
medial and lateral thyrohyoid ligament
 Cricotracheal ligament – connects cricoid to Ist
tracheal ring
 Hyoepiglottic ligament- form roof of pre epiglottic
space, barrier of invasion of supra glottis to tonge base

60. Intrinsic
 Cricothyroid ligament- medial and lateral cricothyroid
ligament, conus elasticus
 Conus elasticus – upper border of cricoid cartilage to vocal
ligament, ant condensation of conus elasticus leads to
cricothyoid ligament, sup condensation leads to vocal
ligament
 Cricovocal membrane – triangular fibroelastic connects
vocal ligament to arch of cricoid cartilage
 Quadrangular menbrane – between epiglottis and
arytenoid cartilage, upper border lies in aryepiglottic folds,
free lower border forms vestibular ligament (false cords)

62. Muscles of Larynx
 INTRINSIC MUSCLES
 Connect the laryngeal cartilages
 All paired except transverse interarytenoides
 All by Rec LN except cricothyroid (Sup L N)
 Muscles affecting the laryngeal inlet –
 Openers – Thyroepiglottic, Closers – oblique
interarytenoid
 Muscles which move the vocal cord –
 Abductor – Post cricoarytenoid, Adductors – Lateral
cricoarytenoid (main), transverse interarytenoid,
thyroarytenoid (external part)
 Tensors – Thyroarytenoid (internal) known as vocalis

64. Extrinsic Muscles
 Connect laryngeal framework to adjacent structures
 Move laryngeal skeleton
 Elevators (primary) – attached to thyroid cartilage
(stylopharyngeus, palatopharyngeus and
salpingopharyngeus)
 Elevators (secondary) – attached to hyoid bone
(mylohyoid, stylohyoid, thyrihyoid, digastric)
 Depressors – sternohyoid, sternothyroid, omohyoid
 Tensors of vocal cords - cricothyroid

66. Interior of Larynx
 Lined by ciliated coumnar epithelium (resp)
 True vocal cords and parts of epiglottis lined by
stratified squamous epithelium
 No mucus glands seen on vocal folds
 LARYNGEAL INLET (oblique opening)
 Ant – free margins of epiglottis
 Post – interarytenoid region
 Lat – aryepiglottic folds

68. Divisions of Larynx
 Laryngeal inlet is divided by 2 folds (true and false
vocal cords) into 3 parts –
 Supraglottis
 Glottis
 Subglottis
 Lower limit of larynx is inf border of cricoid cartilage
 Vestibule – Region between laryngeal inlet and
vestibular folds

69. Supraglottis
 Epiglottis
 Aryepiglottic folds
 Arytenoids
 Vestibular folds (false vocal cords) – 2 in number
 Ventricles – between vestibular and vocal folds, called as
sinus of larynx
 Saccule- anterior ascending part of ventricle extending
between vestibular folds and thyroid lamina , contains
mucus glands laryngocele and retention cyst
 Lower limit – imaginary line through apex of
laryngeal ventricle

70. Glottis
 Anterior commissure – two vocal cords are attached to angle of
thyroid lamina.
 Posterior commissure - between two arytenoids
 Tue vocal cords or vocal bands- pearly white (less blood supply)
contain vocal ligament
 Rima glottidis
 Ant two third – membranous v.c
 Post one third –vocal process of arytenoids
 Length – males 24 mm, females 16 mm
 Narrowest part of larynx in adults
 Lower limit of glottis – horizontal line passing (1cm at ant
commissure, 0.5 cm at post commissure) below the free
margin of vocal cords

71. Structure of vocal fold
 3 layers
 Outer layer – epithelium
 Superficial layer of lamina propria contains loose
fibrous tissue (reinke’s space)
 Transition – intermediate and deep layers containing
elastic and collagenus fibres which form vocal
ligament
 Body – contains thyroarytenoid muscle

72. Subglottis
 From inferior margin of true vocal cords to lower
border of cricoid cartilage
 Narrowest part of larynx in children

74. Spaces of Larynx
 Pre epiglottic space or Boyer’s space
 Fat filled space between ant surface of infra hyoid epiglottis
and thyroid cartilage and thyrohyoid membrane also
containing areolar tissue and lymphatics.
 Supraglottic or tongue base carcinoma can easily spread
here
 Ant- upper part of thyroid cartilage and thyrohyoid
membrane
 Post – infrahyoid epiglottis, quadrangular membrane
 Sup – hyoepiglottic ligament, vallecula
 Lat – continous with paraglottic space

76. Paraglottic space
 Antsup – continous with pre epiglottic space
 Ant lat – thyroid cartilage, cricothyroid membrane
 Post – pyriform fossa
 Sup med – ventricle, glottis, quadrangular membrane
 Inf med – conus elasticus
 If space involved – fixation of vocal cords

78. Reinke’s space
 Sup – Epithelium
 Inf – vocal ligament
 Ant – anterior commissure
 Post – vocal process of arytenoids
 Extends from sup arcuate line to inf arcuate line
 Oedema of this space known as reinke’s oedema causes
swelling of vocal cords

79. Blood Supply
 Sup thyroid artery (ECA)
 Inf thyroid artery ( subclavian artery )
 LYMPHATIC DRAINAGE
 Above vocal cords – upper deep cervical lymph nodes
 Vocal cords- no lymphatics (water shed area)
 Ant commissure – pre laryngeal LN (delphian LN)
 Below vocal cords – pretracheal, paratracheal,
prelaryngeal, sup mediastinal lymph nodes

80. Nerve Supply
 Above vocal cords –
 Sensory – Internal laryngeal branch of sup laryngeal nerve
 Below vocal cords – Recurrent Laryngeal N
 Muscles – Rec Laryngeal N except cricothyroid (external
laryngeal nerve br of sup laryngeal nerve)
 Sup L N – at greater cornu of thyroid divide into external
and internal branches
 Rec LN – left side longer as loops over arch of aorta, right
side loops over right subclavian artery
 Strap muscles supplied by ansa cervicalis ( branch of
hypoglossal nerve

82. Anatomy of Tracheobronchial tree
 Membranocartilaginous tube, dynamic organ(contracts
and expands)
 Lower border of cricoid cartilage (C6) to carina (T5)
 10 to 12 cm long, 2 to 2.5 cm wide
 16 to 20 incomplete rings (U shaped hyaline cartilage
deficient posteriorly – flat), 4mm wide, 1 mm thick
 Intervenous membranous tissue
 Post made up of fibro membranous tissue and trachealis
 Cervical (6 to 7 rings) and thoracic trachea
 Ciliated columnar epithelium

84. Relations
 Cervical
 Ant – strap muscles, thyroid Isthmus (2-4 ring),
innominate artery
 Lat – thyroid gland, CCA, IJV, X CN
 Post – oesophagus, rec laryng nerve
 Thoracic
 Ant – sternum, arch of aorta, left brachiocephalic vein
 Lat – pleura, X CN
 Post – oesophagus
 BLOOD SUPPLY – ITA, thyroid venous plexus
 Nerve supply – X CN
 Lymphatic drainage – level VI lymph nodes

85. Bifurcation
 At T5 vertebra 25 cm from upper incisor teeth
 Carina – Ridge or spur like projection (keel) of lowest
tracheal ring at point of separation into two main
bronchi
 Trachea – main lobe bronchus – segmental bronchus –
bronchioles - terminal bronchioles
 Right lobe bronchus – wider, short, more vertical , FB
lodge, straight placed
 Left lobe bronchus – narrow, longer, more horizontal,
oblique placed

87.  Right main bronchi – (passes over right pulmonary
artery)
 Upper lobe bronchi – apical, posterior, anterior segments
 Middle lobe bronchi – lateral, medial
 Lower lobe bronchi – apical, sub apical, medial, anterior,
lateral and posterior basal
 Left main bronchi – (passes under left pulmonary artery)
 Upper lobe bronchi – apical, posterior, anterior segments,
lingular segment (superior and inferior)
 Lower lobe bronchi – apical, sub apical, anterior, lateral
and posterior basal

88. Anatomy of Neck
 Floor of mouth ant, skull base post – first rib and T1 vertebra
 Sternocleidomastoid muscle
 Divides neck into anterior and posterior triangles
 Origin- Sternal head (thick tendinous), Clavicular head
(muscvular)
 Insertion – lateral aspect of mastoid
 Relations – IJV, carotid sheath, lymph nodes, XI CN, cervical
plexus
 Action – IL Flexion, rotation of head opposite side
 Blood supply – STA (ECA)
 Trapezius muscle – elevates the shoulder
 XI CN, cervical plexus (C2,3,4)

89. Triangles of neck

90. Anterior triangle
 SCM, inf border of mandible, cervical midline
 Divided further by ant belly of digastic, post belly of
digastric, sup belly of omohyoid into –
 Submental triangle – 2 side ant digastric , hyoid, contains
lymph nodes
 Submandibular triangle – lower border of mandible, ant
digastric, post digastric, contains – lymph nodes, glands,
facial nerve and vessels
 Carotid triangle – SCM, post digastric, sup omohyoid,
contains – lymph nodes, carotid sheath
 Muscular triangle – SCM, sup omohyoid, cervical midline.
Contains – thyroid, parathyroid, larynx, trachea,
laryngopharynx, strap muscles, oesophagus

92. Posterior triangle
 SCM(post border), clavicle (middle third), trapezius
(ant border)
 Divided by inferior belly of omohyoid into
 Occipital triangle – SCM, trapezius, inf omohyoid.
Contains – lymph nodes, XI CN, cervical plexus nerves
 Supraclavicular triangle (subclavian) – SCM, inf
omohyoid, clavicle. Contains – branchial plexus,
subclavian vessels, thyrocervical trunk, cervical pleura

94. Cervical fascia
 Superficial fascia and deep fascia
 Superficial fascia (Tela Subcutanea)
 Single layer of fibrofatty tissue
 Thin, beneath skin
 Invests platysma, muscles of facial expression
 Space between superficial and deep fascia contains
adipose tissue, external and anterior jugular veins,
superficial lymphatics and sensory nerves

95. Deep cervical fascia
 Superficial investing layer
 Middle visceral layer
 Deep prevertebral layer

96. Outer investing layer
 Surrounds whole of neck
 Encloses SCM, trapezius, masseter
 Encloses submandibular and parotid glands
 1 to 3 cm superior to sternum forms 2 spaces – suprasternal
space of burns and supraclavicular space
 Attachments
 Ant – hyoid bone
 Post – ligamentum nuchae and cervical spine
 Sup – mastoid tip, mandible, nuchal ridge, external
occipital protuberance
 Inf – acromion of scapula, clavicle, sternum

97.  At mandible and parotid this layer splits into two
lamina –
 External lamina – covers masseter and parotid gland.
Attaches to zygomatic arch
 Internal lamina – covers medial surface of pterygoids
to skull base, styloid process. Forms stylomandibular
ligament

98. Middle visceral layer
 Surrounds middle compartment of neck
 Attachments
 Sup – hyoid bone, thyroid cartilage
 Post – forms ant wall of retropharyngeal space
 Inf – sternum, clavicle and scapula
 Continous with pericardial layer
 Divisions – muscular layer and visceral layer
 Muscular layer - surrounds strap muscles
 Visceral layer – envelops trachea (pre tracheal layer),
thyroid (pre thyroid layer), pharynx, larynx, oesophagus

99. Deep prevertebral fascia
 Divisions – anterior alar layer and posterior prevertebral layer
 Alar fascia layer
 Forms post wall of retropharyngeal space and ant wall of danger space
 Prevertebral layer
 Forms post wall of danger space
 Splits and encloses vertebral muscles, vertebral vessels, phrenic nerve
and brachial plexus
 CAROTID SHEATH
 Formed from condensation of all 3 layers
 Extends from skull base to clavicle
 Present deep to SCM
 Contains
 IJV, CCA, ICA, X CN, 80% neck lymph nodes
 All in separate sheaths

101. Lymph Nodes of Head and Neck
 75 nodes on each side of neck
 Nodes of upper horizontal chain
 Submental – 2 to 8. lie on mylohyoid muscle
 Submandibular
 Parotid – preauricular, infraauricular, intraglandular
 Postauricular (mastoid)
 Occipital – apex of posterior triangle
 Facial – along facial vessels

102.  Lateral cervical lymph nodes
 Superficial group – along EJV
 Deep group –
 Internal jugular lymph nodes (upper, middle, lower)
 Spinal accessory group – along XI CN
 Transverse cervical (supraclavicular) – lower posterior
triangle
 Scalene lymph nodes (virchow) – medial group of
supraclavicular lymph nodes. Afferents from breast,
lung, stomach, colon, ovary and testis

103.  Anterior cervical lymph nodes
 Anterior jugular chain – along ant jugular vein
 Juxtavisceral lymph nodes – prelaryngeal (delphian),
pretracheal and paratracheal
 Lymph nodes not clinically palpable
 Retropharyngeal lymph nodes – lateral(nodes of
rouviere) and medial
 Sublingual lymph nodes – along lingual vessels
 ALL LYMPH NODES OF NECK DRAIN INTO IL
LOWER DEEP CERVICAL LN

105. Oncological classification
 I A – SUBMENTAL
 I B – SUBMANDIBULAR
 II – UPPER JUGULAR (between skull base and hyoid bone)
II A – inferomedial to accessory nerve, II B – sup lateral
 III – MIDDLE JUGULAR (between hyoid bone and upper
border of cricoid cartilage)
 IV – LOWER JUGULAR (between upper border of cricoid
cartilage to clavicle)
 V – POSTERIOR V A – above cricoid cartilage, V B – below
cricoid cartilage

106.  VI – ANTERIOR COMPARTMENT (medial to carotid between hyoid bone to
suprasternal notch) prelaryngeal, pretracheal, paratracheal, prethyroid
 VII – SUPERIOR MEDIASTINAL LYMPH NODES

107. Embryology of Head and Neck
 Branchial apparatus (4th and 5th week)
 Consists of
 Branchial arches (pharyngeal)
 Clefts or groove on outer aspect
 Pouches on inner aspect
 Cervical and occipital myotomes

108.  Ist pharyngeal arch (mandibular arch) meckel’s cartilage
 Nerve – V3
 Bones – malleus, incus, maxilla, pre maxilla, temporal bone,
stylomandibular ligament
 Muscles – mastication, ant digastric, mylohyoid, tensor tympani,
tensor palati,
 IInd arch (hyoid arch) reichert’s cartilage
 Nerve – VII
 Bones – stapes, styloid process, hyoid ( lesser horn, upper body),
stylohyoid ligament
 Muscles – stapedius, post digastric, muscles of facial expression,
stylohyoid

109.  III rd arch – hyoid bone – lower body and greater
horn,Stylopharyngeus muscle and IX CN
 IV th arch – thyroid cartilage, all muscles of palate
except tensor palati and all muscles of pharynx except
stylopharyngeus, cricothyroid muscle, superior
laryngeal nerve
 V th arch – lost
 VI th arch – cartilages of larynx, all intrinsic muscles of
larynx, Recurrent laryngeal nerve

111.  I st pouch – middle ear, eustachian tube
 II nd pouch – palatine tonsils, lingual tonsils, adenoids
 III rd pouch – thymus gland, inf parathyroid gland
 IV th pouch – sup parathyroid gland
 V th pouch – ultimobranchial body
 I st cleft – EAC , TM (along with 1st pouch)
 II – IV th cleft – cervical sinus which disappears later
 Cervical myotome – SCM, trapezius, XI CN
 Occipital myotome – XII CN, all muscles of tongue
except palatoglossus

112.  Tongue – anterior two third – I st arch, post one third
III rd arch
 Larynx – hypobranchial eminence between II, III and
IV th branchial arches forms primitive epiglottis
 Tracheobronchial groove forms trachea and larynx