Oral Cavity and Pharynx

Anatomy
 Oral Cavity
o Above and postero-lateral bounded by edge of soft palate
o Inferior – tongue
o Roof – hard palate
o Greater palatine foramen – located at postero-lateral corners of the hard palate where greater palatine vessels and nerves
pass
o Behind and lateral to the hard palate – medial and lateral pterygoid plates
o Hamulus – bony spine palpable behind 3rd upper molar
o Fibrous Pterygo-mandibular raphe – stretches form the hamualus to the mandible
o Lips, cheeks, tongue and soft palate – muscular structure enclosing the mouth
o Lower strucrual support of the mouth – mandible
o Orbicularis oris – lip bulk
o Buccinator – origin – molar regions of the maxilla and mandible and pterygo-mandibular raphe. Insertion: orbicularis oris.
Controls cheek motion
o Facial nerve – nuerve supply
o Fibrous soft palate aponeurosis – anteriorly attach to the hard palate joined by tensor veli palatine
o Tensor veli palatine – origin: sphenoid bone, medial pterygoid plate and medial end of cartilaginous ET (Eustachian tube)
insertion: palatine aponeurosis
Opens ET and tenses the palate. Supplied by maxillary branch of trigeminal
o Palatoglossus – anterior pillars
o Palatopharyngeus – posterior pillars
o Innervation – pharyngeal plexus (vagus)
o Levator veli palatini – palatine bulk. Origin: base of the skull between carotid canal and ET. Motion: elevates the palate
o Rhinolalia aperta – hypernasalvoice due to incompetent palate
o Rhinolalia clausa – hyponasal voice due to scarring
o Sublingual salivary glands and wharton’s duct on either side of the lingual frenulum found in the floor of the mouth
o Lingual nerve – taste sensation and aparsympathetic efferents to the sublingual and submandibular glands
o Tongue – made up of extrinsic and intrinsic muscles
 Extrinsic muscles – for movement of the tongue out of the mouth
 Intrinsic muscles – for the shape changes of the tongue
 Tongue is the prime organ of taste and sensation of foreign bodies in the mouth
 Essential in mastication, deglutination and speech
 Motor innervation – hypoglossal nerve
 Mouth is lined by non-keratinizing squamous epithelium
 Koplik’s spots – swollen mucous and serous glands lining the buccal mucosa; measles
 Circumvallate papillae – forms a “V” separates anterior 2/3’s from posterior 1/3 of the tongue
 Obliterated opening – foramen cecum
 Fungiform papillae
 Blood supply –
 Terminal branches
 Facial and internal maxillary arteries supplies the soft palate and cheeks.
 ___

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 Pharynx
o Upper, Middle, Lower
o Nasopharynx oropharynx and hypopharynx
o Posterior pharyngeal wall – consist of fascia, muscle and mucosa overlying the base of the skull and cervical vertebra
o Superior, middle and inferior pharyngeal constrictors innervated by pharyngeal plexus (vegus) encircles the pharynx
o Superior constrictor – from the pterygoid hamulus, pterygo-mandibular raphe and posterior part of the mandible
interdiitates in the midline attached to a vertical fibrous band – pharyngeal raphe
o Styolopharyngeus – from the styloid
 Nasopharynx
o Roof – base of the skull and upper cercical vertebrae
o Floor – oropharynx and soft palate
o Front – nares and nasal cavity
o Back – choanae and cervical vertebrae
o Sides – ET and rossenmuller fossae
o Continous with the nasal airway at the posterior choanae
o ET – located in the later nasopharygeal wall posterior to ___
o ___
o Pharyngeal bursae – sac-like depression in the posterior wall
o Rossenmuller fossae – site of carcinoma
o Jugular foramen – where CN IX, X, XI, internal jugular vein, inferior petrosal sinus and meningeal branches from the
occipital and ascending pharyngeal arteries passes
o Hypoglossal foramen – CN XII pas
o Ciliated respiratory epithelium lines the nasopharynx
o Procedure to examine the nasopharynx – posterior rhinoscopy

 Oropharynx
o Roof – choanae and soft palate
o Floor – base of tongue and epiglottis
o Front – mouth back – cervical vertebrae
o Sides – palatine tonsils between the anterior and posterior pillers and lateral pharyngeal bands
o Middle pharyngeal constrictors – form the greater and lesser cornu of the hyoid extending back to interdigitate with the
opposite muscle along the pharyngeal raphe
o Mucosa of the oropharynx – stratified squamous epithelium
o Tonsillar ring of waldeyer – lymphoid tissues in the nasal and oropharynx
 palatine tonsils, adenoids, lingual tonsils, lateral pharyngeal bands and guerlach tonsils (rosenmuller fossa)
 Tonsil – lymphoid masss supported by a framework of connective tissue reticulum
o adenoids – lymphoid arrangement in folds
o faucial tonsils – has crypt-like formation with 5 arterial supply: dorsalis linguae from lingual artery, ascending pharyngeal
from external carotid and descending palatine from internal maxillary artery

 Laryngopharynx
o Roof – base of the tongue and epiglottis
o Floor – cricoid
o Front – larynx with 3 sided channels called piriform sinuses
o Sides – lateral glosso-epiglottic folds
o Antero-medial wall of each piriform sinus – arythenoids and aryepiglottic folds
o Anatomical pill pocket – vallecullae

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 o Epiglottis – inferior to the vallecullae with it’s action to protect the glottis and prevents aspiration, works with the ventricular
bands (folds vocal cords)
 Pharyngeal Blood Supply – external carotid
o Brancehs of internal maxiallary artery, tonsillar branch of external maxillary artery, dorsal lingual branch of the lingual
artery and branch of superior thyroid artery
o Sensnory nerve supply to the nasopharynx, oropharynx and base of the tongue – pharyngeal plexus of glossopharngeal
nerve
o Lower pharynx – innervated by vagus via the superior larngal
o Lymphatics - __

 Pharynx function
o Upper respiratory tract – voice resonance, articulation and deglutination
o Deglutition has 3 stages:
 Oral stage (voluntary movement of food from mouth to the pharynx)
 Pharyngeal stage – involuntary transport of food of the pharynx
 Esophageal stage – involuntary
o Starts when the good is positioned in the middle 1/3 of tongue as it elevates together with the soft alate it forces the food to
the orophyarnx
o Contraction of the intrinsic laryngeal muscles prevents aspiration
o As the inferior pharyngeal constrictor contracts and the cricophargeus releaxs guiding the food into the stomach
o ___

 Embryology
o Primitive mouth and foregut separated by buccopharngeal membrane lined by ectoderm and endoderm anterior and
posteriorly
o Ectoderm of the primitive mouth provides the oral mucosa and it’s derivative (dental enamel and salivary glands)
o Anterior part of the primitive foregut becomes the pharynx and the esophagus
o Mesodermal tissue int eh lateral wall of the pharynx develops into 5 paried branchial arches which becomes prominent by
the 5th week
o Adjacent achers are separated by ____
o Cysts and fistulas
o ET and middle ear from the 1st pouch
o Tonsillar fossa – 2nd pouch
o Thymus – 3rd pouch
o Parathyroids – 3rd and 4th pouches
o Upper lips – median and lateral nasal processes
o Lower lips – mandibular process
o Dental lamina – gives rise to dentue, enamel and cementum
o Anterior tongue – from the 1st branchial region
o Tongue muscle – from the post-branchial region
o Tongue muscles – from the post-branchial myotomes migrating forward arising from the floor of the primitive pharynx
o Thyroid – arising from the foramen cecum migrating along the thyroidglossal duct
o Salivary glands – outpoucing of the epithelium of the mouth in close promximity of CN VII
o 1st branchial arch – meckles or mandibular cartilage – the maleus, incus and sphenomandibular ligament are derived
o 2nd branchial arch – hyoid or reichert’s cartilage – upper body
o _____

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Special Dx procedures
 MRI
o Exquisite soft tissue contrast for soft tissue tumors
 CT – scintillation
o Delineating fraction, infection, tumor
 Nasopharyngeal endoscopy – rigid or fiberoptic
o Nasal cavity , naso, oro and hypopharynx
 Rhinoscopy
o Anterior – nasal speculum; evaluate the presence of nasal cavity using a nasal speculum evaluating the presence of nasal
discharge or polyps
o Polyps are pale fleshy masses arising from the ethmoid and in nasal allergy with the presence of pale and boggy
turbinates with watery discharge
 Examination of the Oral Cavity and Oropharynx – using a tongue depressor asking the patient to open the mouth and screening the
oral cavity prior to examining the pharynx by pressing the tongue only up to the middle 1/3 so as not to make the patient gag
 Masses in the oral cavity should be palpated bimanually
 Posterior rhinoscopy – examining the posterior part of the nasal cavity and nasopharynx with the use of a small laryngeal mirror
inserted carefully into the oropharynx without making the patient gag, done in cases of epitaxis, neck masses, unilateral serous otitis
media which is persistent, a sinus infection and antrochoanal polyp
 Nasal and pharyngeal endoscopy – uses a telescope inserted in the nsoe and oropharynx for direct visualization and screening

Congenital Anomalies
 Oral Tori
o Bony exostosis within the oral cavity
o Torus palatinus – nodular or lobular bony outgrowths in the hard palate note din 25% of females 15% of males
o Torus mandibularis – single or multiple unilateral or bilateral bony outgrowth in the lingual aspect of the mandible usually in
the region of the premolar
o Tx – osteotome – drill or surgical chisel

 Micrognathia
o Dimunition in the size of the jaw
o Can be acquired as sequel to trauma or infection
o Congenital
o Due to failure in the growth center of the condyle
o Mandibular micrognathia is an isolated polygenic trait while maxillary micrognathia is seen in trisomy 21, apert’s syndrome
and crouzon’s syndrome
o Surgical correction done by a maxillofacial surgeon after growth of the jaws is completel.

 Prognathism
o Ant placement of the lower jaw maybe absoluate or relative and is a multifactoral __

 Macroglossia
o Congenitally due to hemagloma, lymphangioma or hemagiolymphangioma
o Also seen in type 2 gloscogen stoage disease (pompe and deease) and in the macroglossianomphalocoele syndrome
o Ddx is neurofibromatosis
o In the adult, maybe seen with primary amyloidosis
o Tx – surgery via debulking

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 Median Rhomboid glossitis
o Embryonic failure ___

 Lingual Thyroid
o Embryonic failure of the thyroid gland to descend from the foramen cecum
o Characterized by multiple nodules of thyroid tissue on the dorsum of the tongue
o For small discrete lesion – no tx
o Larger lesions should be surgically removed.

 Ankyloglossia – tongue tie

o Inability to elevate tip above the line extending to eh comisures due to short lingual frenulum
o “A, D, N”
o Surgically released once dx is confirmed.

 Cleft Lip and Palate

o May involve upper lip only and or the nostril with involvement of the hard and soft palate
o Isolated cleft lip maybe unilateral or bilateral,
 If uni – more common on left side (75%)
 Bi – 25%
o 85% of bilateral cleft lip and 70% of unilateral cleft lip are seen with cleft palate
o 10% of cases incomplete cleft lip – simonart’s bands (skin bridges)
o Surgical repair of cleft lip (Cheiloplasty) is usually performed using “10”
 10 weeks old
 10 pounds
 Hct of 10
o Surgical incomplete cleft palate (Staphylorraphy) and complete cleft palate (Uranoplasty) before it reaches 2 years.

 Acrocephalosyndactyly (Apert’s Syndrome)

o Anterior fontanelle fails to close while other cranial sutures specifically the coronal tends to close prematurely
o Presence of the midfacial___

 Crouzon’s Syndrome
o Aka craniofacial dysostosis
o Underdevelopment of the midface with mandibular prognathism
o Skull tends to be high dome-like with obliterated coronal sagitall and lamboid sutures
o Anterior fontanelle remains open and wide
o Exopthalmos ___

 Treacher Collin’s syndrome – Mandibulofacial Dysostosis

o Presence of ocular anomalies such as antimongoloid obliquity of the lids and coloboma of the lower lid, abnormal external
and middle ears
o ___

 Congenital Choanal Atresia

o Failure of bucconasal membrane to rupture before birth
o 90% bony, 10% membranous
o Bilateral choanal atresia is an emergency, unless the baby cries, nasal obstruction produces pallor and cyanosis

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o Emergency tx – rubber nipple taped in the mouth, temporary oral airways
o Definitive tx is surgery via a transnasal approach, carefully doing currretage of the bony plate and perforating the
membrane with a blade #11.
o Antoerh approach is via intraoral through a transpalatal procedure with direct access by resecting a portion of the vomel
and the palatine bone with preservation of the palatine vessel