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Today we will continue about the larynx : Last time we spoke about the larynx ,and as you remember

we said that the larynx is made up from agroup of cartilages , and those cartilage are six in number : -three singles -three pairs Those cartilage are connected together by membranes and ligaments : *membranes are two extrinsic : 1-connectting the thyroid up with hyoide bone thyro hyoide membrane 2- another one that connecting the larynx down to the trachea crico tracheal membrane -two intremsic membrane : 1- sup. one is the ary from arytinoid all the way to the epiglottis ary epiclottis membrane or quadrangular membrane with it is upper folding forming the inlet to the larynx . 2-other membraue down , you can see it is upper margin,it is crico thyroid membrane and it is upper free margin forming the vocal cord . And we said that when you look to the larynx , you can see a space ( black color in the slide ) called rema clottis and rema vestibularis beside it .

*these membranes are moving in order to produce the voice , and in order to move they need a skeletal muscle and now we want to speak about the muscles -we have extrinsic muscle that moving the hall larynx together .

- also we have the intrensic muscles that moving the larynx which are :

*supra hyoid group : elevate the larynx up as they elevate the hyoid bone. *infra hyoid group : depress the larynx down as they depressing the hyoid bone . The intrinsic muscles are between the cartilages it self , and they have to move the cartilages , so once they move them they will move the membrane connecting , in other word they will moving the vocal cords , either by tensing the cord or relaxing them . Or widening the cord (abducting them) or adding them together Now.. the intrensic muscles are two groups : -ones that move the cartilages to move the vocal cord , so these are either tensing the cord or relaxing them.or moving them away from each other abducting the cords or moving them close to each other reducing the rema clottis adding the cords . So.there's a group related to movement of vocal cords and there's a group relatred to the laryngeal opening , so the laryngeal opening also has influence in the voice production and the laryngeal opening as I told you determined by : Anteriorly : epiclottis

Post. The ary tenoid Laterally : ary epiclotic fold

So . Two muscles one widening the inlet and the other narrowing it Those two muscles are :

1. the oblique arytinoid m. this m. going obliquely from one arytinoid towards the other , some muscle fibers of it will pass within the aryepiclotic membrane as it folds , from arytinoid all the way to the epiclottis the oblique arytinoid extend from the muscular process of arytinoid cartilage all the way to the apex of arytinoid and corniculate cartilages in the opposite side part of the m. will continue within the aryepiclotic fold to the epiclottis , and we usually call it the aryepiclotic m. SO . The aryepiclotic m. is acontinuation of oblique arytinoid m. , when it's contract in both side it will narrowing the opening ( laryngeal inlet ) . 2. thyroepiclotic m. from thyroid cartilage anteriorly all the way in to the aryepiclotic fold so once this m. contract from both side , the inlet or opening will be widening .

NOW the other group of muscles , five m. that controlling the vocal cords and they extending from thyroid cartilage all the way to the vocal process of arytinoid cartilage.

The first one ( crico thyroid ) :


It's going from the out side of cricoid cartilage all the way up to the lower part of thyroid cartilage. Now when this m. contracts as they go post. Superior for thyrpid , it will pull the thyroid cartilage anteriorly , when you look in a sup. View , you will see the vocal cords become tensing . So the cricothyroid m. once it's contracts , it will pulls the the thyroid cartilage forward then the vocal cartilages will become tense .

The second one ( thyro arytinoid m. ) :


This m. relaxing the vocal cord , working against the cricothyroid m. this m. located within the cricothyroid it self . Another name vocalis m. because it accompany the vocal cords ( joining them together ). NOW. When this m. contracts , it will return the thyroid cartilages back once it moves back then the vocal cords become relax .

Cricothyroid : tensing the vocal cords Thyroarytinoid : relaxing the vocal cords

two other muscles from the muscular process of arytinoid cartilages


one goes to the lateral side of cricoid we call it lateralcricoarytinoid and the other that goes to the posterior surface of cricoid post. Cricoarytinoid m.

NOW. The post. Cricoarytinoid once it contracts , it moves the muscular process back ward , so it will rotate the arytinoid cartilages to the out side by this , it widening the rema glottis and moving the vocal cords away from each other ( abduct the vocal cords ) . The lateral one which goino to anterior , once it's contracts , it will rotate the arytinoid inside rather than out side , by this the vocal cord will become closer to each other , so it will add them to each other ( adducting the vocal cord ).

Post. Cricoarytinoid abducts Lateral cricoarytinoid adducts

the last one ( tranverse arytinoid m. ) :


btw the two arytinoids , going transversily from the post. Surface of one arytinoid to post. Surface of other arytinoid . once this m. going transversily contracts , it will bring the arytinoid toward each other , so it will close the post. Part of rema glottis . SO THESE ARE THE FIVE M. YOU HAVE TO KNOW THEIR ORIGION , INSERTION , NERVE SUPPLY , ACTION. FROM YOUR TEXT BOOK .

BLOOD SUPPLY TO THE LARYNX

We divide blood supply to the larynx based on the vocal cords above and below it .

Above the vocal cords : blood supply come from the sup. Laryngeal artery ,
which is abranch from the sup. Thyroid a.

SO the sup. Laryngeal a. as it branches from sup. Thyroid a. , it will penetrate thyrohyoid membrane to get inside the larynx , provide blood supply to rvery thing in the larynx above vocal cords .

Below vocal cords : blood supply comes from the inf. Laryngeal a. which is
abranch from the inf. Thyroid a.

Nerve supply
Above the vocal cord: it comes from the internal laryngeal branch of the sup. Laryngeal branch of vagus n. SO . Sensory and motot innervationfor the larynx specifically is from the vagus n. , but depend on which branch.. there are two nerves : sup. Laryngeal n. : penetrating the larynx from above , it starts from the thyroid ends at cricoid . as you see , the vagus n. as it descends down . It will give sup. Nerve , we call it sup. Laryngeal n. that reach the larynx from above . recurrent n. : as the vagus n. descends down toward the thorax it will give areturning nerve that can loop around subclavian a. in the right , this is called recurrent laryngeal n. , in the left side it will turns around the arch of aorta in the thorax and return back from the thorax cross the root of the neck all the way to the larynx .

NOW when it return back on each side it will pass through agroove btw trachea ant. And esophagus post. Until it reaches the larynx .

Every thing regarding innervation of the larynx sensory or motor is from vagus nerve but which branch of vagus
We have sup. Laryngeal n. and arecurrent laryngeal n. on each side.

*** the sup. Laryngeal n. before it reaches the larynx it divides in to : *internal laryngeal n. : one that go inside the larynx penetrating thr thyrohyoid membrane to get inside the larynx ,which is totally sensory n. for every thing above vocal cord in the larynx . * external laryngeal n. : one that can't get inside the larynx , which is amotor n. that provide motor innervation to one m. crico thyroid m.

*** recurrent laryngeal n. will pass back and get inside the larynx , it will give sensation to every thing below vocal cords and it will give motor innervation to the remaining m. of the larynx.

NOTE
all muscles of the larynx are innervated by recurrent laryngeal n. except cricothyroid which innervated by external laryngeal n. And both sup. Laryngeal and recurrent laryngeal n. are branches from vagus nerve . ( 10th cranial n. )

This is every thing about the larynx read it carefully

Now we move to the other part of our lecture which is the pharynx

the pharynx

-the pharynx is 3 time larger than the larynx . -the larynx is at the level C4-C5-C6 but the pharynx from the base of the skull behind the nasal cavity all the way down to the C6. the pharynx at the C6 will become esophagus . -so the pharynx extend behind the nasal cavity this part behind the nasal cavity we will call it nasopharynx , the part behind the oral cavity we will call it the oropharynx and the part behind the larynx we will call it the laryngeopharynx . -So the pharynx is much larger than the larynx , it's divided into 3 part :
1- nasopharynx behind the nose 2- oropharynx behind the mouth 3- laryngeopharynx behind the larynx .

When we look to the wall of the pharynx are deficient anteriority that make sense because they are opening or comminuted with the nose , mouth and larynx . however posteriorly laterally it's made up of muscle those muscles with their tendon fibrous

covering and muscular covering and they cover by mucus membrane . the pharynx is funnel shape it's very wide superiorly and very narrow inferiorly until it reach the esophagus . so the narrowest part of pharynx it's meet the esophagus but the widest part most superior . why it's funnel shape ??because it's made of 3 muscles these 3 muscles actually funnel shape we call them the constrictors of the pharynx ( sup , middle , inf ). =>The constrictor muscle : They pass posterior superior , and overlap with each other in direction inferior to superior. The inferior constrictor cover the lower part of the middle constrictor , and the middle constrictor cover the lower part of superior constrictor , anterior to each one there's an opening that's why the anterior wall is deficient. We cut opposite the nose ,opposite to oral cavity and a cut opposite to the larynx . now what's happing between these constrictor why it's made like this ??? Because the (successive) sequential contraction of these 3 muscle will produce the action of swallowing , as will you swallow the food , the food bolus first when it get inside into the first part of pharynx the superior constrictor will contract once it contract the bolus will go down the middle will contract so pushing the bolus more down and the inferior will contract pushing the bolus of food into the esophagus .producing the action

of swallowing superior then middle then inferior that's why it's funnel shape because it's made of funnel shape muscle , 3 muscles that overlap each other and the main function is producing the action of swallowing . So the pharynx is made of 6 muscles . the main 3 ones that forming the pharynx actually complete wall of the pharynx are the constrictor (superior , middle , inferior ) , they run in a circular direction with their fibrous and they are attached posteriorly in one tendon so we call it the pharyngeal tendon or pharyngeal raphe . The successive contraction of these muscle produce the action of swallowing ( the contraction of the muscle the sup, middle , inf ) they overlap each other from inf to sup . The 3 muscle there attachment and origin: 1- the superior one usually originate from the medial pterygoid plate (now u know why we have the medial pterygoid plate ) we have the narrow (medial) pterygoid plate and wide (lateral) pterygoid plate . The lateral pterygoid plate wider because we have 2 muscle of mastication attach to it lateral and medial pterygoid , but the medial pterygoid plate narrower because we have one muscle attach to it which is the superior constrictor of the pharynx , it's coming up form medial pterygoid plate from pterygomandiblular raphe ( it's a ligament extending

from medial pterygoid plate (pterygoid hamulus) all the way down onto the posterior end of mylohyoid line on the mandible ) It's very important ligament in our practice because this ligament it's actually the origin of superior constrictor and also it's providing an attachment of another muscle of facial expression the buccinators , so this raphe provide an attachment arterially to buccinators muscle ( it's go all the way and enter the cheek fascia and skin ) and posteriorly to superior constrictor muscle . It's going from pterygomandiblular plate to the mandible ( posterior end of mylohyoid line ) Pterygomandiblular raphe u can see it in oral cavity , back to the pterygomandiblular raphe should be the mucus membrane covering the superior constrictor and anterior to pterygomandiblular raphe the membrane covering the buccinators . Pterygomandiblular raphe very important because it's your land mark to give the inferior dental bock Anastasia , when u gain a work in posterior teeth u have to Anastasias them , for filling and extraction so the ID block is the Anastasia that u give to Anastasias inferior alveolar nerve before it enters into the mandible through the mandibular foramen u Anastasias there so that the whole nerve Anastasias so the whole teeth on this side getting the Anastasia so this is called block the whole teeth . so u have to put the needle lateral to pterygomandiblular raphe because this is ur mark line u just put ur

finger( index) at the ramus of the mandible . so u have to put the needle lateral to pterygomandiblular raphe and medal to the anterior border of the ramus of the mandible . so that's why pterygomandiblular raphe is ur key mark in the oral cavity for ID block . the needle have to be always lateral to pterygomandiblular raphe , which muscle u penetrating here ?? the buccinators , penetrating the buccinators passing all the way backward toward the medial surface of the ramus of the mandible .

The border of infratemporal fossa the lateral pterygoid plate and the ramus of the mandible , so in the infratemporal the mandibular nerve will divide ant nerve ( lingual nerve ) in the middle the inferior alveolar and the third one the should go posterior auriculotemporal nerve

In the infratemporal fossa the mandibular nerve will divide into 3 sensory branches: the most anterior one : lingual nerve The middle one: inferior alveolar nerve the posterior one : oriculotemporal nerve
Borders of the infratemporal fossa : 1- Lateral teregoid plate 2- Ramus of the mandible

when we do ID block ( inferior dental block ) we anesthetize the the inferior alveolar nerve before it inters to the mandible through the mandibular foramen .

both branches

( the lingual and the inferior alveolar nerves ) are anaesthetized by the ID block and thats why when we give ID block to the patient we ask him if he has Numbness on his tongue because it is an indication that the anesthesia is working on the inferior alveolar and the lingual nerve SO always put the needle lateral to the terigomanibuldar raphe => So the proper way to do ID block : 1- insert your finger and palpate the ramus and handle it 2- tense the mucosa to make easier to find the terigo mandibular raphe 3- insert the needle always lateral to the outside of the raphe.

3- Inferior constrictor muscle:


it is a very large muscle consists attached to the obliqe line of thyroid cartilage + cricoid cartilage

Recall that we have 3 muscles attached to the obliqe line of the thyroid cartilage : 1- sternothyroid 2- thyrohyoid

.
3- inferior constrictor muscle

=> so it consists from two parts : 1- the upper part : which arises from the thyroid cartilage , we call it thyropharyngeus and it helps in the swallowing process because it has a successive contraction . it fibers are going up and backward . involved in the swallowing 2- the lower part : Which arises from the cricoid cartilage , we call it cricopharengeus its fibers are going horizontally so once it contract it acts as asphincter to make sure that the bullas of the food wont return back so once it contract it will close the pharynx preventing the food from regurgitation.

We can see a gap between the two parts (thyropharyngeus and the cricopharyngeas ) ; because of the difference in the fiberes direction of these two parts this small tearing will develop we call it Killains Dehisence

Killains Dehisence : - located in the inferior constrictor muscle . - week area presents between the two parts of the inferior constrictor muscle: sup : thyropharyngeus inf : cricopharyngeus - clinical significant if the tearing was big the mucus membrane in some patient can protrude in

this gap and make a pouch there (pharyngeal pouch ) so sometimes the very smooth food can stick there producing uncomfortable feeling and difficulty in swallowing dysphasia So these are the main 3 muscles in the pharynx whose fiberes run in a somewhat circular direction , and we still have to talk about the other 3 muscles whose fibers run in a somewhat longitudinal direction and these are ( stylopharyngeus , salpingopharyngeus and the palatopharyngeus ) .

4- stylopharyngeus :
-Arises from styloid process all the way to the posterior border of the thyroid cartilage . - passes between two muscles which are the ( superior constrictor + middle constrictor ) . Innervated by the glossopharyngeal .

All the muscles of the pharynx are innervated by the pharyngeal plexus which is a network of nerves formed by cranial nerves # 9,10, 11 , ( glossopharyngeal (sensory) / vegus(motor)/ accessory respectively ) EXCEPT : the stylopharyngeus m which is innervated by the glossopharyngeus #9 only .

Gag reflex : when we work on the posterior teeth and touch the soft palate or when we try to place a denture once we try to touch the posterior part of the oropharynx we will induce an irretation there , this irretation will induce sensory signals in the glossopharyngeal nerve these signals now will go to the vegus as an action potential inducing contractions there ( in the constrictor muscles ) but this contraction will be inverted so the inferior constrictor will contract first then the middle then the superior one pushing upward not downward .

All the muscles of the larynx are innervated by the recurrent laryngeal nerve except the cricothyroid which innervated by the external laryngeal nerve .

5- palatopharyngeus :
Extend from the soft palate (palatal aponurosis) to the posterior border of the thyroid cartilage . - Part of the palate and the pharynx . - The palatopharyngeus is covered by a mucus membrane to become palatopharyngeus fold which demarcating the posterior end of the tonsillar bed .

6- salpingopharyngeus :
Descends from the medial end of the eostacian tube ( auditory tube) all the way down to be merge with the palatopharyngeus muscle . Action : Once it contract it opens the pharyngeal orifice ( for the auditory tube ) so the air can pass to the middle ear to balance the pressure on both sides on the tympanic membrane

Auditory tube : A tube that communicates with the pharynx all the way posteriolaterally with the middle ear . Forgive us for our mistakes wish you all the best in the exam study will Happy Easter for you guys <3 enjoy it with head&neck <3

done by : ramz rabadi areej ra2ed