PHARYNX

• 12- to 14-cm long musculomembranous tube shaped like an inverted cone

• Extends from the cranial base to the lower border of the cricoid cartilage (level of the sixth cervical vertebra)
• Limited superiorly by the posterior part of the body of the sphenoid and basilar part of the occipital bone and inferiorly with
the esophagus, to which it is continuous
• Lies behind and communicates with the nasal, oral, and laryngeal cavities via the nasopharynx, oropharynx, and hypopharynx
(laryngopharynx),
respectively; on this basis the pharynx is divided into three anatomic divisions including (from superior to inferior): (Fig. 8-
1)
m Nasopharynx

m Oropharynx

m Hypopharynx:

– Often included as part of the larynx but given differences in embryology from the larynx (see Section 5) and the inclusion of
hypopharyngeal cancers in the AJCC staging of pharyngeal cancers and not laryngeal cancers, the hypopharynx including the
piriform sinus is included in this section on the Pharynx rather than in Section 5, Larynx.

Pharyngeal lining mucosa is continuous with the mucosa lining the nasal cavity, oral cavity, pharyngotympanic
(eustachian) tubes, and larynx.

EMBRYOLOGY OF THE PHARYNX

• Primitive pharynx is derived from the foregut developing from the branchial arches and pharyngeal pouches:
m Epithelium and glands are of endodermal derivation.

m Tonsils develop from the second pharyngeal pouch.

m Tubotympanic recess (forms the eustachian tube and tympanic cavity) develops from the first pharyngeal pouch.

m Lymphoid tissues of the pharynx, including adenoids (pharyngeal tonsil), lateral pharyngeal lymphoid bands, and lingual

and palatine tonsils, arise from pharyngeal endoderm.

m Constrictor muscles derived from the fourth and sixth branchial arch

CONTENTS OF THE PHARYNX

Nasopharynx
• Nasopharyngeal tonsils (adenoids) lie along the posterior and lateral aspects of the nasopharynx.
• Orifice of eustachian tube lies along the lateral aspects of the nasopharyngeal wall.

Oropharynx
• Soft palate
• Base of tongue, including the lingual tonsils
• Tonsillar pillars
• Palatine tonsils
• Posterior tonsillar pillars
• Uvula
• Waldeyer tonsillar ring (Fig. 8-2) is formed by a ring or group of extranodal lymphoid tissues about the upper end of the
pharynx, which consists of the:
m Palatine tonsils

m Pharyngeal tonsils (adenoids)

m Base of tongue/lingual tonsils

m Adjacent submucosal lymphatics

ANATOMIC BORDERS OF THE PHARYNX
Nasopharynx
• Situated behind the nasal cavity and above the soft palate, it begins anteriorly at the posterior choana and extends along the
plane of the airway to the level of the free border of the soft palate.
• Anterior: continuous with the nasal cavities through the choanae
• Posterior: continuous with the roof and is further supported by first cervical vertebra (anterior arch of the atlas)
• Superior (roof): base of skull (occipital bone) and posterior part of the body of the sphenoid bone
• Inferior (floor): continuous with the oropharynx; during swallowing, the palate and uvula provide a functional floor
• Lateral: each side contains the pharyngeal orifice of the eustachian tube, which in the posterior portion has a submucosal
cartilaginous elevation called the torus tubarius, behind which is a shallow depression called the fossa of Rosenmüller.
Oropharynx
• Portion of continuity with the pharynx extending from the plane of the superior surface of the soft palate to the
superior surface of the hyoid bone (or floor of the ventricle)
• Anterior: continuous with the mouth through the oropharyngeal isthmus
• Posterior: on a level with the second and third cervical vertebrae
• Superior: horizontal plane of the palate
• Inferior: horizontal plane of the hyoid bone (upper border of the epiglottis)
• Lateral: palatopharyngeal arch

HYPOPHARYNX
Anatomic Borders
• Superior border: just above the level of the hyoid bone
• Inferior border: lower border of the cricoid cartilage
• Anterior border: mucosa on the medial surface of the thyroid cartilage
• Posterior and lateral border: no markings; lateral walls attach to the hyoid bone and thyroid cartilage
• Medial border: larynx and its appendages
• Piriform sinus: (Fig. 8-3)
m Represents part of the hypopharynx that expands bilaterally and forward around the sides of the larynx and

lies between the larynx and the thyroid cartilage

m Synonymous with piriform recess and piriform fossa

m Piriform means pear-shaped from Latin pirum, “pear,” and forma, “shape.”

m Pyriform means flame-shaped from Greek pyra, “fire.”

m Piriform sinus is pear shaped and not flame shaped; although both spellings have been used for this anatomic

site, the correct spelling based on anatomic shape is piriform.

Innervation
• Both motor and sensory innervation are primarily supplied from the pharyngeal plexus formed by branches of
cranial nerves IX (glossopharyngeal) and X (vagus).

Vascular Supply and Lymphatic Drainage

• Arteries and veins:
m Naso- and oropharyx:

– Arterial supply comes from branches of the external carotid artery, including the ascending pharyngeal,
facial, lingual, maxillary, and superior thyroid arteries.

Veins form a plexus that drains into the internal jugular and facial veins directly or via a
communication with the pterygoid venous plexus.
m Hypopharynx:
– Arterial supply from branches of the superior and inferior thyroid artery branches of the carotid artery and
the subclavian artery, respectively
– Venous plexus communicates with the pterygoid plexus above and the superior thyroid and lingual veins
below or directly with the facial vein or the internal jugular vein.
• Lymphatics:
m Nasopharynx:

– Directly to the upper deep cervical lymph nodes

m Oropharynx, including the tonsil and base of tongue:

– Upper deep cervical lymph nodes particularly to the jugulodigastric and jugulo-omohyoid group of lymph
nodes
m Hypopharynx:
 – Drain to the lymph nodes of the deep cervical chain

HISTOLOGY OF THE PHARYNX

Nasopharynx (Fig. 8-4)
• Epithelium varies from stratified squamous in the lower and posterior regions to ciliated pseudostratified
(respiratory) columnar type near the choanae and adjacent roof of the nasopharynx to intermediate (“transitional”)
type in the junctional zones in the roof and lateral walls:
m Intermediate (“transitional”) epithelium seen at junction between squamous and respiratory type epithelium

(similar epithelium identified in the larynx)

m Basaloid nuclei with minimal cytoplasm may raise concern for intraepithelial dysplasia:

– Presence of smooth rather than coarse nuclear chromatin, smooth rather than irregular nuclear contours, and
generally limited nuclear pleomorphism and absence of increased mitotic activity should allow distinction
from intraepithelial dysplasia.
– Isolated focus or foci of intraepithelial dysplasia occurring in the absence of an invasive carcinoma is rarely
seen:
■ Unlike the oral cavity and glottic portion of the larynx, where intraepithelial dysplastic lesions may result

in clinical symptoms warranting biopsy, intraepithelial dysplasia(s) of the pharynx typically does not
engender clinical symptoms, so it is extremely uncommon for the pathologist to identify isolated
intraepithelial dysplastic alterations of the pharynx without its being seen in association with invasive
carcinoma.
■ More likely, when confronted with histologically suspicious foci for intraepithelial dysplasia in a routine

specimen from a structure in the nasopharynx, it is likely intermediate (“transitional”) epithelium.

• Although these types of epithelia may be associated with a specific part of the nasopharyngeal region, this is not
constant so that any site may be covered by any type of epithelium.
• Submucosa contains minor salivary glands as well as a prominent lymphoid component.
• Nasopharyngeal tonsils, also known as the adenoids, represent extranodal lymphoid tissues characterized by:
m Epithelium infiltrated by many small lymphoid cells (so-called lymphoepithelium, Fig. 8-5) expanding and

disrupting the epithelium to produce a reticulated pattern:

– Blurred interface between epithelium and submucosa, including lymphoid cells
– Basaloid-appearing cells with uniform, vesicular nuclei
– Typically lack keratinization but abrupt areas of keratinization may be present
– Epithelial component is cytokeratin positive
– In nonendemic populations, normal nasopharyngeal mucosa is typically negative for the presence of
Epstein-Barr virus
m Presence of germinal centers but absence of a capsule, sinusoids, or epithelial crypts

Oropharynx (Figs. 8-6 and 8-7)

• Epithelium throughout is a stratified squamous epithelium, which normally does not have a keratin layer.
• Submucosa contains:
m Minor salivary glands, which are mixed seromucous glands but are predominantly mucous

m Scattered lymphoid component

• Palatine and lingual tonsils, like the adenoids, contain:

m A prominent lymphoid component, including germinal centers but does not have a capsule or sinusoids

m Unlike the adenoids, the palatine and lingual tonsils have 10 to 20 (tonsillar) crypts formed by invagination of the

free surface mucosa, are narrow tubular epithelial diverticuli branching within the tonsils, and are frequently packed
with plugs of shed epithelial cells, lymphocytes, and bacteria, which may calcify:
– Actinomycotic colonies (Actinomyces israelii) are commensal microorganisms that may be found within
tonsillar crypts.
m Tonsillar crypts are lined by specialized stratified squamous epithelia known as reticulated epithelia, which:

– Lack the orderly laminar structure of the surface-stratified squamous epithelia of the tonsils, including loss
of cellular polarity and surface maturation
 – As stratified squamous epithelium of the tonsillar surface extends into the tonsillar crypts a dense lymphoid
infiltrate, as well as macrophages, penetrates the reticulated epithelium obscuring junction between epithelial
and lymphoid components:
■ Basal lamina of reticulated epithelium is discontinuous and therefore porous, facilitating migration of

lymphocytes and dendritic cells, the latter representing potent antigen processing cells.
■ Intimate association of epithelial cells and lymphocytes facilitates direct transport of antigen (e.g., HPV,

HIV) from external environment to the tonsillar lymphoid cells:

□ Reticulated epithelial cells are functionally similar to microfold (M) cells of the gut.

□ Lymphoid tissue elsewhere depends on direct antigen delivery through afferent lymphatic vessels but

such afferent vessels are absent from the tonsils.

■ Total surface area of the reticulated epithelium is very large owing to the complex branched nature of the

tonsillar crypts.
■ Reticulated epithelium is characterized by numerous (intraepithelial) blood vessels that can be further

delineated by vascular endothelial cell immunomarkers (e.g., CD31, others).

NOTE: The discontinuous basal lamina of the reticulated epithelium coupled to the numerous intraepithelial blood
vessels assist in explaining the facts that:
m Any carcinoma arising from the crypt epithelium should be interpreted as invasive carcinoma rather than carcinoma

in situ.
Metastatic carcinomas to the cervical neck may originate from very small crypt carcinomas that histologically
appear to be wholly confined to the crypt epithelium without apparent evidence of invasion into the submucosa.
– Reticulated epithelial cells are basaloid appearing with vesicular nuclei, increased nuclear-to-cytoplasmic
ratio, absence of keratinization, absence of intercellular bridges, and loss of distinct cytoplasmic border.
– HPV-associated squamous cell carcinomas originating from tonsillar crypt epithelium are nonkeratinizing
and may be viewed as “poorly differentiated”; however, such cancers are in fact differentiated, originating
and recapitulating the features of its cell of origin being that of the specialized tonsillar crypt reticulated
epithelium.
– p16 immunoreactivity may be seen in normal (non-neoplastic) tonsillar crypt epithelium and is not
evidence for the presence of HPV-associated intraepithelial dysplasia and/or carcinoma.
m Minor salivary glands of the palatine tonsils (as well as the uvula and soft palate) are mixed seromucous but

are predominantly mucous and can be seen embedded in the underlying muscle.
m Minor salivary glands at the lingual tonsils/base of the tongue are pure mucous type.

Hypopharynx
• Epithelium is nonkeratinizing stratified squamous epithelium.
• Seromucous glands are seen throughout the submucosa.
• Not characterized by “lymphoepithelium” or reticulated epithelium