common

Common Carotid Artery: carotid artery

 Origin: Rt: Brachiocephalic artery, Lt: Aortic arch [has no branches]

 Surface marking: Sternoclavicular joint; Tubercle of lateral process of C6 (chassaignac’s tubercle)
 Bifurcation level: Greater cornu of the hyoid external
carotid artery
internal carotid
artery
 Enclosed with
 Carotid sheath which contains also vagus nerve & internal jugular vein
 Internal Jugular vein is located lateral & posterior to the carotid artery
 Vagus Nerve: in between
 Covered by: Sternocledomastoid muscle; Infrahyoid muscles
 Relation:
 Anteriomedially: Thyroid gland; Larynx; Trachea; Inferior constrictor muscle
 Posteriorly: Longus colli & capitus, Cervical sympathetic trunk, Anterior tubercle of C4-7 vertebrae, Veterbral artery
Inte rnal and External Carotid artery:
Carotid sinus:
 Dilation at point of division the vessels
 may be confined to origin of internal carotid artery
 histologically, the media is thinner & adventitia thicker
 stretch receptors are innervated by glossopharyngeal nerve
and they are the main baroreceptors
Carotid Body
 located deep to the bifurcation
 reddish-brown in color, measures 6*3mm
 features glomus cells containing dopamine
 innervated by glossopharyngeal nerve
Internal Carotid artery
 The internal carotid artery enters the skull base:
 Medial to: Glenoid fossa, Styloid process, Stylomastoid foramen
 Posterior to: Sphenoid sinus
 Posteriomedial to: Eustachian tube
 Anterior to: jugular foramen
 becomes encased in the petrous portion of the temporal bone, positioned:
 Posterior to the ET & sphenoid spine
 Medial to Glenoid fossa
 Anterior to styloid process
 The spine of the sphenoid bone is the most consistent and reliable extracranial
landmark for locating ICA where it enters the petrous portion of the temporal bone
 Vertical segment: anterior to the hypotympanum, Gives caritotympanic branches
to the middle ear cavity
 Horizontal segment
 when it passes medially to the osseous eustachian tube then artery bends in an
anteromedial direction to form the horizontal segment.
 It runs under the gasserian ganglion and separated from it by thin bony plate
 It is not uncommon for the osseous eustachian tube to be dehiscent where it is
in contact with the internal carotid artery.
 The GSPN is the most reliable intracranial landmark for the petrous portion of
the internal carotid artery
 The course of the GSPN is directly above and in the same direction as the
horizontal portion of the petrous portion of the internal carotid artery.
 nd
2 Vertical segment:
 turns vertically across the foramen lacerum to pass alongside the lateral wall of
the sphenoidal sinus & medial wall of the cavernous sinus.
 The impression of the internal carotid artery within the lateral wall of the sinus
usually can be seen with endoscopy.
 The internal carotid artery traverses the cavernous venous sinus just before entering the intracranial space
 Branches of external carotid artery external
External carotid branches in sequence: [SALFO PIS] carotid
1. Superior thyroid a artery
2. Ascending pharyngeal a
3. Lingual a
4. Facial a
5. Occipital a anterior posterior terminal
medial
6. Posterior auricular a group group group group
7. Internal Maxillary a
8. Superficial temporal a
 1-5 branches in the carotid triangle
 the terminal branch of carotid artery at the level of superior occipital
internal
thyroid a ascending artery
mandibular condyle branch into mandibular & temporal maxillary a
pharyngeal posteior
lingual a superficial
Superior thyroid artery artery auricular
facial a temporal a
artery
 Located in the muscular triangle + carotid triangle
 Supplies the area between the thyroid and hyoid bone
 Arise below the hyoid bone

SUPERIOR
THYROID
ARTERY

infrahyoid a superior
cricothyroid a
sternoclenomasto laryngeal a
id a supply the infra which supply the
which supply the
hyoid muscles thyroid gland
laryngeal muscles

Ascending pharyngeal artery

 The ascending pharyngeal artery is the smallest branch given off from the
external carotid artery.
 It arises from the back part of that artery about one-half of an inch above the
bifurcation of the common carotid artery.
 It ascends between the internal carotid artery and the side of the pharynx and
beneath the stylopharyngeus muscle and the glossopharyngeal nerve to the
base of the skull.
 They also communicate through canals with the ascending palatine artery from the anterior facial arteries
off of the external carotid
 It is divided into: ascending
 Pharyngeal trunk (extracranial): pharyngeal
 Superior pharyngeal artery artery

 Middle pharyngeal artery

palatine
 Inferior pharyngeal artery artery
pharyngeal Inferior meningeal prevertebral
artery tympanic
 Eustachian tube artery largest
inter via
jugular
 Inferior tympanic artery ( via inferior branch foramen
superior & rectus
tympanic canaliculus): middle ear cavity tympanic
middle capitus
cavity
 Neurocranial trunk (Intracranial): soft constrictor anterior
 Cival branch palate stylopharyng hypoglossa
eus l neve
 Jugular branch ( via dorello's canal): tonsils
mucus
supply XI,X,XI ET membrane of sympatheti
the pharynx c chain
 Hypoglossal branch (via hypoglossal
canal): supply XII
Lingual artery
 The lingual artery arises from the external carotid artery opposite
the tip of the greater cornu of the hyoid bone.
 1st part of the artery:
 lies in the carotid triangle
 Superficial to the middle constrictor of the pharynx.
 It forms a characteristic upward loop which is crossed by the
hypoglossal nerve.
 The lingual loop permits free movements of the hyoid.
 2nd part of the artery:
 lies between the hyoglossus muscle & middle constrictor
 hypoglossus muscle which separates it from the hypoglossal
nerve.
 Dorsalis branch arise from this part
 3rd/deep part/arteria profunda linguae:
 run upwards along the anterior margin of the hyoglossus;
 Forward to the tip of the tongue.
 Lies between the genioglossus muscle & mylohyoid muscle.
 Branches: deep lingual + sublingual artery
 So middle constrictor+ genioglossus are deep to the lingual artery
 Hypoglossus + mylohyoid are superficial to the lingual artery
 Glossopharyngeal nerve lies medial to the lingual artery
 Note that the lingual nerve is deep to the hypoglossal nerve
 Terminal branch of the lingual artery is the deep lingual artery

lingual artery

suprahyoid a Tonsillar baranch Dorsal lingual a deep lingual a sublingual a

base of the tongue

suprahyoid supply the apex supply the
body of the tongue sublingual galnd
muscles of the tongue
palatoglossus mylohyoid muscle
tonsills floor of the
epiglottis mouth
Facial artery

 Pathway of the facial artery

 The external carotid: medial to the mandible: over the submandibular salivary gland: around the inferior border of
the mandible to the lateral side: anterior to the masseter muscle: runs upward medially along the lateral side of the
nose: terminates at the medial canthus of the eye.
 The terminal branch of the facial nerve is the angular branch
Relationship of the ascending palatine artery & Tonsillar
branch:
Ascending palatine artery:
 1st branch of the facial artery
 Goes through the gap between the skull base & superior
constrictor
 Lies deep to the styloglossus muscle
Tonsillar branch:
 2nd branch
 Penetrates the superior constrictor
 Lies superficial to the stylogossus muscle
facial
artery

cervical facial
branches branches

ascending tonsillar superior inferior lateral

grandular submental
palatine artery branch labial labial nasal

superior inferior lateral

1st branch submandibula mylohyoid m surface
lip lip
supply soft palate r gland &
digastric nasal
palatine muscles submandibulr dorsum
L.N septum of the
tonsil nose

Occipital artery
 The occipital artery arises from the external carotid artery opposite
the facial artery
 It is covered by the posterior belly of the Digastricus and the
Stylohyoideus, and the hypoglossal nerve winds around it from behind
forward
 Branches
 Sternocleidomastoid branches
 Auricular branch
 Mastoid branch
 Descending branches
 Occipital branches
Posterior Auricular Artery
 The posterior auricular artery arises from the external carotid artery, above the Digastric muscle and Stylohyoid
muscle, opposite the apex of the styloid process
 The posterior auricular artery supplies blood to the scalp posterior to the auricle and to the auricle itself.
 Branches: stylomastoid branch which becomes the posterior tympanic artery which gives 2 branches:
1- stapedius branch
2- mastoid branch
 Superficial temporal artery
 Its pulse is palpable superior to the zygomatic
arch, anterior and superior to the tragus.
Internal maxillary artery
 It passes forward either lateral or medial to
the pterygoid muscles
 If it takes the medial course, the artery then
turns laterally again to emerge between the 2
heads of the muscle
 The artery is divided into 3 divisions by the
lateral pterygoid muscle with 5 branches
coming from each part:
 Mandibular part: to bone
 Pterygoid part: to soft tissue
 Pterygopalatine part: with the nerves

The maxillary artery enters the Infratemporal fossa between the sphenomandibular* ligament & the neck of mandible
inferior & parallel to Auriculotemporal branch
Then goes to the Pterygopalatine fossa via the Pterygomaxillary Fissure
* Sphenomandibular ligament: extends from the sphenoid spine to the angle of the mandible

The 1st part of the maxillary artery gives off 5 branches to bones:
1. Deep auricular a: Supply the external auditory canal
2. Anterior tympanic: Supply the middle ear cavity
3. Middle Meningeal a:
 Passes between the sphenomandibular ligament &
lateral pterygoid muscle
 Between the 2 roots of Auriculotemporal nerve
 Give branch to:
1- superior tympanic artery which goes with lesser
petrosal nerve through superior tympanic
canaliculus
2- superficial petrosal a which goes with greater
petrosal N through the facial hiatus
 4. Inferior alveolar artery:
 Passes down 2 join the inferior alveolar nerve 2 enter the Mandibular foramen
 Give mylohyoid artery before the entry into the Mandibular
foramen
5. Accessory Meningeal a
The 2nd part of the maxillary artery gives off 5 branches to the soft tissue
(muscles of mastication):
1. Anterior Deep Temporalis muscle: run deep to the Temporalis fascia
and superficial to the skull
2. Posterior Deep Temporalis muscle
3. Masseteric : masseter muscles
4. Lateral & medial pterygoid muscles
5. Buccal artery & lingual artery

The 3rd part of the artery:

 Moves through the Pterygomaxillary fissure from the Infratemporal fossa into the Pterygopalatine fossa
 gives the 5 branches within the Pterygopalatine fossa except the superior posterior alveolar branch which branch
in the Infratemporal fossa
 branches go with Nerves
1. Posterior superior alveolar artery:
 The only branch that does not divide in the Pterygopalatine
fossa
 Goes through the posterior superior alveolar foramen
 Give supply to : gum, molar, premolar, maxillary sinus
2. Infra-orbital artery:
 terminal branch of the maxillary artery
 Goes through the infratemporal fissure
 supply the floor of the orbit & lateral aspect of the nose
3. Sphenopalatine artery
 goes through the sphenopalatine foramen
 emerge in the nose posterior to the posterior end of the middle
turbinate
 gives intranasally the following branches:
1) posterior superior lateral nasal branches: supply the
posterior superior part of the lateral wall of the nasal cavity
2) posterior superior septal/medial branch:
 supply the posterior superior part of the septum
 continues ant along the septum to enter the hard palate via incisive canal
4. Descending palatine artery:
 go through the palatine canal
 divide into Greater & lesser palatine artery and emerge from the greater & lesser palatine foramen
a. greater palatine artery:
 emerge from the greater palatine artery
 pass anterior to the incisive foramen
 supply the hard palate gingival, mucosa, glands
 anastamose with sphenopalatine artery at the incisive canal
b. lesser palatine artery supply: soft palate, tonsil
5. Vidian artery
 goes through the vidian/pterygoid canal to supply the vidian nerve
 supply the auditory tube + sphenoid sinus
6. Pharyngeal Artery
 Goes through palatovaginal Canal
 Supply the auditory tube + Nasopharynx
Note:
 The maxillary artery after it gives the infra-orbital artery & posterior superior alveolar artery is enters the
pterygomandibular fissure
 The name of the maxillary artery after it enters the pterygomandibular artery is sphenoplatine artery

Subclavian artery
 Scalinus anterior muscle divides the Subclavian artery into 3 divisions
 Each Subclavian artery:
 enters the neck behind the sternoclavicular joint
 ends by becoming the axillary artery
 origin:
 left side: aortic arch
 right side: brachiocephalic trunk
 branches:
 First Part:
 Vertebral artery
 Thyrocervical trunk:
o Inferior thyroid artery
o Transverse cervical artery
o Suprascapular artery
 Internal thoracic artery
 Second Part:
 Costocervical trunk
 Dorsal scapular artery
 Relations: From anterior to Posterior:
 Subclavian vein: anteroir scalenous muscle: Subclavian artery: brachial plexus: middle scalenous muscle
 Vagus nerve + Phrenic nerve lies between the 1st part of the Subclavian artery & Subclavian vein
 Phrenic nerve is then becomes superficial to scalenus anterior
 The subclavian artery gives rise to the thyrocervical trunk. The transverse cervical and suprascapular arteries usually
course laterally over the surface of the phrenic nerve. This relation allows identification of these structures
 Vertebral Artery Triangle: an important triangle extending from the root of the neck
 Borders:
 scalenus anterior muscle
 longus colli muscle
 superior aspect of the 1st part of the subclavian artery
 (Pre)Vertebral Fascia surrounds this area.
 Contents of the triangle of the vertebral artery:
 Vertebral artery (from the first division of the Subclavian artery) and vein ascend to the apex of triangle and enter
the foramen transversarium of C6.
 Embryology of the head and neck

 the 1st 8th weeks constitute the period of greatest embryonic

development of the head & neck
Pharyngeal/Branchial apparatus:
1. Pharyngeal arch (#6)
2. Pharyngeal cleft (#6)
3. Pharyngeal pouch (#6)
4. Pharyngeal membrane
Pharyngeal apparatus consists of all 3 trilaminar embryo layers:
1. Cleft (externally): Ectoderm
2. Arch: Mesoderm & neural crest
3. Pouch (internally): endoderm
1- The pharyngeal /branchial arch:
 Series of externally visible tissue bands lying under the early brain over the
ventrolateral surface of the head and neck region
 Starts to form in the 4th week
 In humans, 6 arches form:
 The 5th arch do not form or degenerates rapidly (1,2,3,4 and 6)
 The 4th and 6th arch fuses
 So only four are externally visible on the embryo.
 Each arch has own Cartilage, Nerve, muscle, artery (= aortic arch artery)
 The nerves are located ante rior to the arteries except in the 5th or it is called the 6th cartilage
 Each nerve innervates structures derived from its associated arch
1. Arch 1 (Mandibular Arch) has 2 prominances:
 [post-trematic nerve: mandibular V3, pre-trematic nerve: Corda tympani VII]
 Maxillary process: forms maxilla, zygomatic process, squamous part temporal bone and
secondary palate
 mandibular process: forms lower jaw and anterior 2/3 of the tongue; contains Meckel's
cartilage
o Meckel's cartilage:
 upper part: the malleus (head & neck), incus (body & short process)
 middle part: anterior malleolar ligament and sphenomandibular ligament
 lower part: mandibule
2. Arch 2 (Hyoid Arch)
 [post-trematic nerve: Facial VII, pre-trematic nerve: Jacobson’s nerve (of glossopharyngeal IX]
 Lesser horn+ upper part of the hyoid bone
 Reichert's cartilage (manubrium of malleus, long process & lenticular process incus, stapes except the
vestibular face of the footplate (it is derived from the otic capsule, hence otosclerosis a disease of otic
capsule will affect primarly the footplate)
 The second (hyoid) arch enlarges and grows so that by the 6th week it will overlap
the 3rd, 4th and 6th arches and covers them.
o It fuses with the neck skin( C2 ) burying the ectoderm of the 3rd,4th & 6th arch
o The space between the 2nd arch and the other 3 arches is called the cervical sinus
of his.
o The cervical sinus is lined by ectoderm.
o There is not normally communication with the pharyngeal lumen
 It can at a later time, enlarge and form cysts that are called cervical cysts
3. Arch 3:
 [post-trematic nerve: glossopharyngeal IX]
 Greater horn +lower part of the hyoid bone
 4. Arch 4: Forms the thyroid cartilage + cuniform cartilage
5. Arch 6: Forms the rest of the larynx cartilages
 Note:
 All Ossicles + the inner ear except the endolymphatic sac are adult size at birth
 The inner ear develops from ectoderm & reach adult size at 4th fetal month
 The endolymphatic sac is the 1st to appear & last one to stop growing
 XII is caudal to all pharyngeal arches
 SCM is derived from the cervical somites (posterior & inferior to the pharyngeal arch)

Note:
 the 1st arch is innervated by 2nd (maxillary) & 3rd divisions (Mandibular) of the trigeminal nerve; gives anterior belly M.
 the 2nd arch gives rise to platysma, Stapedius, facial muscles, auricluar muscles (anterior, posterior and superior),
stylohyoid, posterior belly of digastric M.
 6th is innervated by the recurrent laryngeal nerve of the vagus nerve (motor fibers from cranial accessory nerve)
Pharyngeal arch ectoderm derivatives:
The ectoderm of the 1st arch:
 the epithelium lining the buccal cavity, salivary glands, enamel of the teeth, Epithelium of the body of the tongue
The external surface ectoderm of the 1st arch gives rise to the epithelium over:
 the maxilla, mandible, to some epithelium of the auricle
The ectoderm of the 2nd arch forms:
 Epithelium of part of the auricle, Epithelium of external auditory canal, some of the epithelium behind the ear
The ectoderm of the 3rd and 4th arches:
 mostly covered by the 2nd arch ectoderm.
 What remains can be found around the external ear (innervated by cranial nerve 9), and the external auditory
meatus, external tympanic membrane and back of the ear (innervated by cranial nerve 10).
Pharyngeal arch artery
There are 2 dorsal & 2 ventral aortas in early embryonic life, The 2 ventral aorta fuse completely, The 2 dorsal aorta fuse
caudally, The Fate of the pharyngeal arch artery:
 1st aortic arch: Contribuations are thought to persists as maxillary artery
Sinus derived from 2nd brachial arch 3rd arch Rt 4TH Arch Lt 4th Arch
Relation to the Superficial to it Deep to it Inferior to Inferior to superior
glossopharyngeal N/ superior laryngeal nerve
superior laryngeal N laryngeal nerve
Relation to hypoglossal N Superficial to it Superficial to it Lateral to it Lateral to it
Internal carotid Superficial to it Deep to it Deep to Medial to ligamentum
artery/Subclavian/aortic subclavian arteriosum & arotic
arch artery arch
Peirce The middle constrictor Thyrohyoid membrane above
deep to stylohyoid the internal branch of superior
ligament laryngeal nerve entry
Opens into Tonsillar fossa Upper part of Pyriform fossa Lower part of Lower part of the
pyriform fossa pyriform fossa
 2nd aortic arches: The 2nd arch artery has an upper branch which becomes the Stapedius artery the later on
degenerates during late fetal period but can persists
 3rd aortic arch: Stem of the internal carotid artery (and part of the common carotid artery).
 4th aortic: On the right: the proximal subclavian artery; On the left: portion of the arch of the aorta.
 6th aortic arch:
 On the right: pulmonary arteries
 On the lt: pulmonary arteries & ductus arteriosus in neonate/ligamentum arteriosum in adult
Note: if the Rt 4th artery degenerates the Rt subclavian will arise from the dorsal aorta
Persistent ligamentum arteriosus is an abnormality of the 4th arch
2- Pharyngeal cleft:
 ectodermal cleft between adjacent arches
 the ectoderm of the 1st branchial groove forms the lining of the external auditory meatus and the external
surface of the TM
 the mesenchyme of 1st and 2nd arches which are located on either side of this pharyngeal groove will also
give rise to the auricle
 Collaural fistula:
o 1st brachial cleft defect
o Passes between the external auditory canal & the skin of the neck ( between the neck of the mandibule
& SCM)
3- Pharyngeal pouch:
 out-pocketing from rostral foregut between adjacent arches internally separates each arch, has: ventral & dorsal
wings; Derivatives:
Pouch Dorsal Ventral
Pouch 1 Tubotympanic recess (Eustachian tube +tympanic cavity) Obliterated
Pouch 2 Dorsal pharyngeal wall +nasopharynx +adenoid + Contributes to the middle ear cavity Supratonsillar fossa +Tonsils
Pouch 3 Inferior parathyroid gland Thymus
Pouch 4 Superior parathyroid gland C-cells ( Calcitonin)

 The ET develops from the 1st brachial pouch between the 2nd
pharyngeal arch & pharynx
 The 2nd pouch derivatives are innervated by glossopharyngeal nerve
 The mastoid air cells develops as expansion of the tympanic cavity
 Digeorge syndrome: 3rd + 4th pouch fail to differentiate into thyroid &
parathyroid gland

 As these out pocketing pouches develop into

grandular elements, their connection with the pharyngeal lumen (reffered to
as pharyngobrachial duct) become obliterated
 If the obliteration fails to occur a brachial cyst/sinus is formed
 the brachial sinuses & fistula present at birth
  brachial cysts:
o present in early adult hood (20-30 yr)
o brachial cyst are rarely associated with internal opening
o lined with squamous epithelium & have lymphoid tissue lining their walls
 Pharyngeal pouch anomalies:
o complete branchial fistulas: fistula opens to both the external surface and the pharynx (above the tonsil)
connecting these structures
o incomplete branchial fistulas: open externally on the anterolateral surface of the neck or internally to
the pharynx by way of a ruptured pharyngeal membrane
 note the course of the cyst is deep to its own structures
 the most common internal fistula is the 2nd
 Cutenous opening is always anterior to the SCM
 Tracts are always subplatysma
 Deep to the external carotid artery
4- Pharyngeal membrane: contact area of the ectoderm (of the pharyngeal cl eft) & endoderm (of pharyngeal pouch)
 only 1st pair persist as tympanic membrane
 Larynx embryology
 The entire respiratory system is an outgrowth of the primitive pharynx
 So Any congenital malformation of the pharynx and oesophagus is always associated with certain
degree of malformation of larynx and trachea
 The most common TEF is atresia of the esophagus with distal anastamosis of the esophagus with the
trachea
The lower respiratory system (larynx, trachea, bronchus) begins its development:
 during the 4th week as respiratory diverticulum caudal to the hypobrachial eminence
 respiratory diverticulum: evagination (outgrowth) of the ventral wall of the foregut (pharynx)
 The diverticulum elongates in the caudal direction and soon becomes separated from the foregut by
the esophagotracheal septum
 The cranial end of the tube forms the larynx and trachea and the caudal end the bronchi and lungs
 The endodermal lining of the respiratory diverticulum gives rise to the epithelial lining of the larynx,
trachea, bronchi and alveoli
 Mesoderm of the pharyngeal arch 4 +6th give rise the cartilaginous and muscular components of
the trachea and lungs:
 4th branchial arch give rise to :
 Supraglottic therefore, related to the development of the oral cavity and oropharynx
 cartilage: thyroid cartilage +cuniform cartilage
 nerve: superior laryngeal branch of vagus nerve
 muscles: cricothyroid m
 6th branchial arch:
 Glottis and subglottis
 Cartilage: The rest of the laryngeal cartilage
 Nerve: recurrent laryngeal nerve of the vagus nerve
 Muscles: rest of intrinsic muscles
 During the 6th week the laryngeal lumen becomes obliterated by the mesenchyme
 During the 10th week recanalization occurs
 Details of larynx cartilage development:
 Arytenoid swellings: appear on both sides of the tracheobronchial diverticulum and, as they enlarge, the
epithelial walls of the groove adhere to each other, and the aperture of the larynx is occluded until the third
month
 aryepiglottic folds: The arytenoid swellings grow upwards
and deepen to produce the aryepiglottic folds.
 Epiglottis: The hypobranchial eminence (related to the 4th &
6th arch).
 Thyroid cartilage: develops from the ventral ends of the
cartilages of the 4th pharyngeal arch, appears as two lateral
plates each with two chondrification centres.
 cricoid cartilage and the cartilages of the trachea: develop
from the sixth arch, during the sixth week
 True & false V.C are formed between the 8th & 10th wk
 Ventricle is formed at the 12th wk
 Note:
 Laryngeal movement can be detected by the 3rd month of
gestation
 in the late 2nd trimester occurs the following:
o the epiglottis and soft palate overlaps for the 1st
time
o the larynx remains intranasal during fetal
swallowing
o pulmonary grandular epithelium matures and
produce surfactant
o the skull base undergoes remodeling of its shape
Thyroid Gland Development:
 diverticulu m o f endodermal origin can be identified between the first and second arches on the floor of the pharyn x.
 situated between the tuberculum impar and the copula. (The tuberculum impar together with the lingual swellings becomes the
anterior two-thirds of the tongue, and the copula is the precursor of the posterior one-third of the tongue.)
 The ventral diverticu lu m develops into the thyroid gland.
 During develop ment it descends caudally with in the mesodermal tissues. At 4.5 weeks the connection between the thyroid
diverticulu m and the floor of the pharyn x begins to disappear. By the 6th week it should be obliterated and atrophied, if per sists a
thyroglossal duct cyst is present. tract travels either superficial to, through, or just deep to hyoid and reaches the foramen cecu m
 7th week The thyroid reaches the final Adult position
 Parafollicular C cells arising from neural crest of the 4th pharyngeal pouch as ultimobrachial bodies migrate & infilterate
the forming lateral thyroid lobes
Thyroid part The origin
Medial part Endoderm of 1st +2nd pharyngeal pouch
Lateral part the 4th pharyngeal pouch
Parafollicular C cell Neural crest of the 4th pharyngeal pouch
Congenital anomalies:
1- lingual thyroid: Result from complete arrest of the thyroid gland descend
2- pyramidal lobe:
o Occur if the inferiormost portion of the hyroglossal duct is maintained
o More prominent among children as it undergoes progressive degeneration with age
3- persistent thyroglossal duct: When the thyroglossus duct persist as epithelial tract from the foramen cecum to the
laryngeal level
4- thyroglossal cyst:
 Persistent of the thyroidglossal duct as series of midline blind pouch in close association with the hyoid bone
 So surgery for thyroglossal cyst resection requires:
o resection of the midportion of the hyoid bone
o identification & resection of any cranially extending tract leading toward the base of the tongue
5- complete congenital absence of the thyroid gland: Is seldom noticed until few weeks after birth because the fetus is
supplied with sufficient maternal thyroid hormone to permit normal development

Embryology of salivary glands: All salivary glands originates from the ectoderm of the 1st pouch

Summary of structure origin

Structure Origin
Epiglottis Hypobrachial eminence
Thyroid cartilage 4th arch
Cuniform cartilage
Cricothyroid muscle
Rest of the larynx 6th arch

Structure Time of development

Epiglottis 3rd wk
Thyroid & cricoid cartilage 5th wk
Arytenoids( vocal process last 1 2 develop) & corniculate 12th wk
Cuneiform 28th wk
 Anatomy of the larynx
 The larynx is short (1.5 Inch= 44 mm)
 Lies
 Below the base of the hyoid and the tongue
 Anterior to the esophagus
 Between C3/4-C7 vertebra in men (from the tip of the epiglottis to inferior surface of
the cricoids cartilage)
 Boundaries
 Superior border: the tip of the epiglottis and the aryepiglottic folds
 Inferior Border: the inferior rim of the cricoid cartilage
 Anterior boundary:
o lingual surface of the epiglottis
o Thyroid cartilage
o Anterior arch of the cricoid cartilage
o Thyrohyoid membrane
o Cricothyroid membrane
 Posterior boundary: cricoid cartilage and the arytenoid region.
 Adult Vs Infantile larynx:
 Infant larynx is shorter, narrower, more funnel shape, higher
 Smaller compared to the body size
 The cartilage is softer & can easily prolapse during forced inspiration
 The narrowest part is the junction between the Subglottic area with the trachea and even slight swelling at this
area may result in marked airway obstruction
 Larynx in male VS female:
 There is a little difference in the size of the larynx between boys & girls
 At puberty the AP diameter doubles in men to reach a final diameter of 36 mm in men & 26 mm in women
 Higher in women
 Function of the larynx:
 Protection of the entry into the airways (primary function)
 Respiration
 Phonation
The frame work of the larynx:
 The larynx is made of:
 Hyoid bone
 9 cartilages: 3 paired and 3 single cartilages
 Ligaments and membranes that connects the cartilage to give it stability
 2 set of muscles:
o intrinsic muscles the control the tension & orientation of the vocal cords
o Extrinsic muscles that adjust the position of larynx during swallowing
 Respiratory mucosa: covers the interior surface of the larynx which is continuous above with the pharynx and
below with trachea
A- Hyoid Bone:
 U shaped bone
 It is suspended into the styloid process by the stylohyoid ligament
 lies beneath the mandible but above the larynx near the level of C3
 Provides the upper attachment of many of the extrinsic laryngeal muscles
 Suspends the larynx in the Neck
 Consists of:
o Body anteriorly from which the greater cornua projects backwards on each side
o The lesser cornua are 2 small conical eminences which are attached to the upper part of the body of the hyoid
by a fibrous band (at the junction between the body & the greater cornu) & sometimes to the greater cornua
by way of synovial joint
o Ossification occurs around the puberty
 B- Cartilage
o 9 cartilages: 3 paired and 3 single cartilages
o Types of cartilage:
 Hyaline cartilage: Thyroid, cricoids, arytenoids
 Elastic cartilage: Epiglottis, corniculate and cuneiform cartilage
o They have areas of deficiency in the perichondrium
o Ossification timing:
 Male: 3rd decade
 Female: 4th decade
o The cartilage is more susceptible to tumor invasion when they are ossified

Ossification/calcification of the larynx cartilage:

 Calcification occurs in the hyaline cartilage not in the elastic cartilage
 So the following cartilages do not undergo calcification:
1. Epiglottis
2. Apex of the arytenoid cartilage
3. Corniculate cartilage
4. Cuniform cartilage
5. Pinna
 Calcification of laryngeal cartilages start 25 year and ends around 65 years:
1. Hyoid Bone:
 6 ossification centers
 Starts to ossify shortly after birth
 Ossification ends at the age of 2 years
2. Thyroid cartilage:
 2 ossification center
 Starts to ossify at the age of puberty
 From inferior superior
 Superior margin are never calcified
3. Cricoids cartilage:
 Ossifies later
 Starting from posteriosuperior caudally
4. Arytenoid except the apex:
 Ossifies in the 3rd decade

Single cartilage:
1- Thyroid cartilage:
 The most prominent & the largest laryngeal cartilage
 It acts as the anterior “protective housing” of the vocal mechanism.
 It has a shield shape that is made of 2 lamina
 The inferior 2/3 of these laminae are fused anteriorly in the medial
plane in a wedge shape to form a projection called the laryngeal
prominence (adam’s apple)
 The angle of fusion: 90 in men 120 in women
 So the larynx is more prominent in men because of the smaller angle of
thyroid lamina fusion & the longer AP diameter
 Immediately superior to the laryngeal prominence is a V-shaped thyroid
notch.
 It has anterior attachment of the vocal folds and posterior articulation with
cricoid cartilage.
 The superior border of the thyroid lamina gives attachment to thyrohyoid
ligament
 The Inferior border (on the medial portion of its inner aspect) gives
attachment to cricothyroid ligament
  On the external surface of the thyroid lamina:
 Oblique line curves downward, forward from the superior thyroid tubercle (situated at the root of the superior
horn) to the inferior thyroid tubercle (at the lower border of the lamina).
 This line provides attachment for:
1- inferior constrictor muscle of the pharynx
2- sternothyroid muscle
3- thyrohyoid muscles.
 On the Internal surface of the thyroid lamina:
 Just below the thyroid notch in the midline is attached the thyroepiglottic ligament
 Below the attachment of the thyroepiglottic ligament on each side of midline is attached
 Vestibular ligament/false vocal cord
 Vocal cords; the fusion of the anterior ends of the 2 vocal ligaments produce the anterior commissure
 Vocalis muscles
 Thyroepiglottic muscle
 Thyroarytenoid muscle
 The remaining part of the inner surface of the thyroid cartilage is smooth & lined with loosely attached mucus
membrane
 Thyroid cartilage horns
 The posterior border of each lamina projects superiorly as the superior horn and inferior as the inferior horn
(L. cornua).
Superior cornua Inferior cornua
Long Shorter
Narrow Thicker
curves upwards backwards & medially curves downward & medially
Attached to the lateral thyroid ligament articulation with the cricoid cartilage
 Inferior cornua:
 On the medial surface of its lower end is a small oval facet joint for articulation with the cricoid carti lage
which allows the thyroid cartilage to tilt anteriorly or posteriorly in a visor-like manner
 The thyroid cartilage begins to gradually ossify after the age of 20 years:
 This process accounts for many age-related changes in pitch and resonance of the voice.
2- cricoid cartilage:
 Located at C6
 It has a signet ring shape
 The only cartilage that forms a complete Ring in the respiratory system
 It is thicker and stronger than the thyroid cartilage
 It forms the Inferior part of the anterior and lateral walls & most of the posterior
wall of the larynx
 Made of:
Arch Lamina
narrow portion wide portion
Located anteriorly Located Posteriorly
1 cm in height 2 cm in height
 Articulation:
 Arytenoid: Superior surface of the posterior aspect is flattened centrally to provide an area of articulation
for the arytenoid cartilages.
 Thyroid cartilage: Posterolaterally at the junction between the arch & the lamina there is Facet for
articulation with the inferior cornu of the thyroid cartilage
 This articulation forms a visorlike apparatus, allowing rotation in a sagittal plane, which opens or closes the
anterior cricothyroid space.
 Calcification of the posterior part of the lamina can be confused radiologically with F.B
 External surface: Vertical ridge in the midline of the lamina gives attachment to the longitudinal muscles of the
esophagus & produce a shallow concavity on each side for the origin of posterior cricoarytenoid muscle
 Inner surface: Lined entirely with mucus membrane
 3- Epiglottis:
 Thin Leaf like
 Covered with pale mucous membrane
 Points posteriorly into the hypopharynx
 The epiglottic cartilage forms:
o superior part of the anterior wall
o superior margin of the inlet of the larynx.
 It is situated:
o At the level of C5
o Posterior to the root of the tongue and body of the hyoid bone
o Anterior to the inlet of the larynx
 Anterior surface:
o Forms the posterior wall of the vallecula (vallecula is situated between the base of the tongue & the
epiglottis)
o Covered with mucous membrane superiorly
o The mucous membrane reflects on to the base of the tongue, forming median glossoepiglottic fold & 2
lateral glossoepiglottic fold
 Posterior surface:
o Intended by numerous small pits into which mucus gland projects
o The inferior part of the posterior surface of the epiglottic cartilage that projects posteriorly is called
the epiglottic tubercle.
 Epiglottic attachment:
1- thyroepiglottic ligament: attach the inferior part of the epiglottis to the thyroid cartilage in the midline just
inferior to the thyroid notch
2- Hyoepiglottic ligament: attach the anterior surface of epiglottic to the hyoid bone
The space between these ligaments forms the pre-epiglottic space
3- Aryepiglottic fold:
o Free fold of mucus membrane
o arise from the side of the epiglottis pass down to the apex of the arytenoids
o lies within them cuneiform cartilage
o separates the glottis from pyriform fossa
o During swallowing the extrinsic muscles elevates the larynx and the epiglottis flattens as it strikes the
base of the tongue
Paired cartilage:
1- arytenoid cartilage:
 The chief moving part of the larynx (muscles that adduct & abduct vocal cords acts by moving arytenoids
cartilage)
 Articulates with posterior superior surface of cricoid cartilage
 Small three-sided Pyramid made of:
o 3 surfaces:
 Posterior Surface: Concave; Attachment site for arytenoid muscles ( transverse & oblique); Covered by
the transverse arytenoids muscle
 Medial surface: narrow, smooth, and flattened, covered by mucous membrane; form the lateral
boundary of the intercartilaginous part of the rima glottidis (posterior part); interarytenoid muscle
connects the medial surfaces of the these cartilages
 Anteriolateral Surface: irregular situated between the vocal process & muscular process, divided into 2
fossa by a crest running from the apex (curves at first backward and then downward and forward to the
vocal process): the upper triangular fossa gives attachment to the vestibular ligament, the lower fossa
gives attachment to the vocalis M & lateral cricoarytenoid
 Apex: superiorly, attached to the aryepiglottic fold is curved backward and medially and is flattened for
articulation with the corniculate acrtilage
 Base: smooth and concave surface articulate with the slopping shoulder of the upper border of the
cricoid cartilage
  this cricoarytenoid joint is a complex synovial joint(shallow ball and socket) with loose capsule which allow:
o multiaxial rotation but minimal translation: :moves the vocal process medially & laterally
o gliding movement: adduct & abduct the arytenoids
o the posterior cricoarytenoid ligament prevent forward movement of the arytenoid cartilage
o The movement of the arytenoids controls the position and the length of the vocal cords
 Muscular process (lateral angle) attached to the posterior cricoarytenoid & lateral cricoarytenoid
 Vocal process (Anterior angle): attached to the Posterior part of the vocal cord (thyroarytenoid muscle)
2- corniculate cartilage (santorini):
 A pair of small conical nodules
 articulate with the arytenoids through synovial joint
 They are located in the posterior part aryepiglottic folds
3- cuniform cartilage (wrisberg):
 A pair of elongated pieces of cartilage placed within the aryepiglottic
fold in front of the arytenoids cartilages.
 So the corniculate & cuniform cartilages support the aryepiglottic fold
Ligaments & membranes of the larynx
Extrinsic Ligaments:
1- The ligaments connecting the thyroid cartilage wit h the hyoid bone:
The Thyrohyoid Membrane:
 Stretch between the upper border of the thyroid cartilage &
posterior surface of the body & greater horn of the hyoid
bone
 Made of fibroelastic tissue reinforced by fibrous tissue in the
midline as the medial thyrohyoid ligament and Posteriorly the
lateral thyrohyoid ligaments.
 The lateral ligaments connect the tips of the superior horns of
the thyroid cartilage to the posterior ends of the greater horn
of the hyoid bone.
 The ligaments often contain a small nodule of cartilage
(cartilage triticea)
 The membrane is piereced by superior thyroid artery &
internal branch of the superior laryngeal nerve
2- hyoepiglottic ligament: attaches the hyoid to the epiglottis
3- Cricotracheal ligament: Connects the lower border of the cricoids cartilage with
the 1st tracheal ring

 Note that the following structures

form a barrier for tumor spread:
o Quadrangular membrane
o conus elasticus
o thyrohyoid membrane
o thyroid pericondrium
Intrensic ligaments
 Quadrangular ligament
 conus elasticus
Quadrangular membrane cricothyroid membrane
Support Supraglottic glottis and subglottis
Attachment Anteriorly: lateral edges of the epiglottis Superiorly: anteriorly: anterior commissure, posteriorly:
Posteriorly: arytenoids vocal processes of artenoid
Inferiorly: superior border of the cricoid cartilage
Vocal cord The inferior free edge is Continuous with: Its medial upper free edge is:
relation vestibular ligament (false V.C) vocal ligament (True V.C)
Other structures The superior free edge: aryepiglottic fold Thickened anteriorly to form conus elasticus
As it extends inferiorly, it becomes:
Medial wall of the piriform sinus
Mucosa l lining of the larynx:
Attachment of the mucous membrane:
 Closely attached over:
1- posterior surface of the epiglottis
2- corniculate cartilage
3- cuneiform cartilages
4- Over the vocal ligame nt.
 loosely attached: Elsewhere and prone to oedema
Type of mucosal lining:
 Most of the larynx is lined by pseudo stratified ciliated
columnar 'respiratory' epithelium.
 Structures that is lined w ith stratifie d squamous epithe lium:
1- Anterior surface of epiglottis
2- upper 1/2 of the posterior surface of the epiglottis
3- upper part of the aryepiglottic fold
4- posterior glottis ( arytenoid)
5- vocal folds
6- .5 cm below the true vocal cord
Mucous glands distribution:
 freely distributed throughout the mucous membranes
 particularly numerous on:
1- posterior surface of the epiglottis where they form indentations into the cartilage
2- margins of the lower part of the aryepiglottic folds
3- saccules.
 The free edge of the vocal folds do not possess any glands , It is lubricated from the glands within the saccules , The
squamous epithelium of the vocal folds is therefore prone to desiccation if these glands cease to function, for example
after radiation
True vocal folds:
The true vocal cords are made up of 5 layers:
1- Epithelium ( stratified, transitional, respiratory):
 stratified nonkertinized squamous epithelium
 The mucosal cover of most of the upper airway is respiratory epithelium, with numerous mucous glands
 Over the free edge of the vocal fold, mucosa is adapted for periodic vibration with squamous epithelium and no
mucous glands; This layer does not contain any mucous glands, and hence the mucoid secretions lining the cord
must travel from the glands located anteriorly, superiorly and posteriorly to the edges of the vocal fold
 Note: that the infra glottis surface of the vocal cords has mucus glands
2- lamina propria:
 A highly specialized lamina propria separates the epithelium from underlying muscle.
 The lamina propria serves as a shock absorber, or impedance matcher, so that the epithelium can vibrate
freely, without restriction by the bulky underlying muscle.
 The lamina propria of the vocal fold contains 3 layers:
 Each layer has unique mechanical properties because of varying densities of elastic and collagenous fibers.
A- The deep layer: the stiffest, due to a high concentration of collagen fibers.
B- The intermediate layer:
 like rubber bands
 Elastic fibers are most numerous in this layer and gradually decrease toward the epithelium and
muscle
C- The superficial layer:
 jelly-like substance, acellular and composed of extracellualar matrix proteins (hyloric
acid), water, loosely arranged fibers of collagen and elastin (lowest concentration of both
elastic and collagenous fibers and offers the least impedance to vibration)
 often referred to as Reinke space, although it is not actually a potential space.
3- Vocalis muscle (Medial part of the Thyroarytenoid muscle): inserts into thyroid cartilage as broyles’ tendon (serves
as a pathway for tumor extension into thyroid cartilage)
 the main body of the vocal fold, and very stiff
 there is fibrous connection to conus elasticus
 So the vocal cords are made of:
 Cover: epithelium + superficial layer of the lamina propria
 Transition: vocal ligament: intermediate + deep layer of the lamina propria
(which are the free upper edge of cricothyroid membrane)
 Body: vocalis muscle
The vocal fold mucosa and vocal ligame nt cover:
1- the vocalis muscle
2- entirety of the vocal process.
Vibration
 the cover is the vibratory part
 the anterior 2\3 of the vocal fold is the phonatory, or membra nous
portion
 The posterior 1\3 of the vocal fold is the aphonatory (respiratory), or
cartilaginous portion
 The max vibratory part of V.C is at the junction between the
anterior 1/3 & poste rior 2/3=middle of the V.C membranous part
 The true vocal cords have a curved inferior surface with concavity
directed inferiorly this shape offers minima l resistance to air outflow and
resists pressure from above.
 Note:
 true V.C are triangular in shape
 thicker & wider posteriorly
 False vocal cords lie superior & lateral to the true vocal cord
 The ventricle of morgagni is a narrow space between the true and false folds
 Arytenoids process is the posterior attachment for both true & false vocal cords
 false vocal cord cannot be closed independently of true vocal cords
Larynx subdivisions
The larynx is subdivided into:
From To
Supraglottic Epiglottis beginning of the squamous epithelium at the junction between the
area lateral wall and the floor of the ventricle of morgagni (superior
border of the true vocal cord)
Glottis area Vertical plan .5-1cm below the free border of true VC (Junction between
squamous and respiratory epithelium)
Subglottic area .5 -1 cm below the free border of true V.C Inferior border of the cricoids cartilage
1- Supraglottic area:
 Made of: Epiglottis, Arytenoids cartilage, Corniculate cartilage, Conieform cartilage, Aryepiglottic fold*,
Interartenoid notch, False vocal cord
 Divided into:
o 1-Vestibule, 2- Ventricle
o 3- Laryngeal aditus: The plane of aditus is directed posteriorly & slightly rostary
o Bounderies:
 anteriorly: epiglottis
 Laterally: aryepiglottic fold
 Posteriorly: tips of corniculate cartilage & interarytenoid muscle
2- Glottic area:
 It is the narrowest part of the larynx
 The anteriorposterior diameter of the glottis: anterior commissurecricoid cartilage
 Total length: Adult male= 2.5cm, Adult female= 1.6 cm
 The vocal cord and the space between them is called glottis
 The Glottis abduct into triangular shape during inspiration; Reduce (adduct) into a slit during voice production .
 Made of:
 Anteriorly: True vocal cord
 Posteriorly: posterior third of the vocal cords, the posterior commissure with the interarytenoid muscle, the cricoid
lamina, the cricoarytenoid joints, the arytenoids, and the overlying mucosa
 Superiorly: ventricle
3- Subglottic area:
 Extends 1 cm below the vocal cords to the inferior surface of the cricoids cartilage
 The cricoid cartilage is the skeletal support of the subglottis
 So The subglottis is the only point in the airway with a completely rigid diameter
 It has a smaller cross-sectional area than the trachea, so that a single foreign body that is small enough to pass
through the subglottis does not cause total airway obstruction
Spaces in the larynx
 The spaces around the larynx are filled with adipose tissue & loose
connective tissue & are key in understanding the spread of tumours within
the larynx; tumor may spread more easily through these spaces
 Pre-epiglottic space:
 C-shaped space located anterior to the epiglottis
 Bounded by:
 superiorly: by the median glossoepiglottic ligament
 inferiorly: by the thyroid cartilage
 Anteriorly: by the thyrohyoid membrane
 posterolaterally by the epiglottis and aryepiglottic folds.
 Not part of the larynx, but is an important area for the spread of
laryngeal cancer
 Paraglottic space:
 Space located on either side of the epiglottis
 The paraglottic space is lateral to the ventricles
 It' encompasses the laryngeal ventricles and saccules
 between the laryngeal introitus and the medial wall of the pyriform sinus
 Continued with the pre-epiglottic space (the posterolateral extension of the preepiglottic space).
 Thus the preepiglottic and paraglottic spaces form a horseshoe-shaped fatty space surrounding the internal
laryngeal structure
 Bounded by:
 anteriorly: the mucosa covering the lamina of thyroid cartilage
 Posteriorly: the anterior reflection of the pyriform fossa mucosa.
 Medially: conus elasticus and quadrangular membranes (vestibular fold)
 Laterally: anterior mucosa covering thyroid cartilage + mucosa of medial wall of pyriform fossa
Intrinsic muscles :
Intrinsic muscles
 Called intrinsic cause they Originate
and insert into on the larynx,
connecting elements of the larynx
 Function: responsible for altering the
length, tension, shape, and spatial
position of the vocal folds by changing
the orientation of the muscular and
vocal processes of the arytenoids with
the fixed anterior commissure.
 More interdigitaed than the limb
muscles
 Fast twitch
Open & close the glottis:
Note:
 The posterior cricoarytenoid muscle is
the only abductor of the vocal cords
 The Transverse arytenoid muscle is
the only unpaired intrinsic muscle
 Transverse + oblique arytenoid
muscle = interarytenoid muscle
 Origin Insertion Action
Posterior Posterior cricoids lamina Muscular process of the  external rotation of the arytenoids
cricoarytenoid arytenoids process  rotating the arytenoid out & up( lateral
&cephalad)
 abduct the V.C
Lateral Lateral cricoids arch Muscular process of the  Internal rotation of the arytenoid
cricoarytenoid arytenoid process  Medialization & downward & forward
displacement of the V.C
 Adduct v.c
Transverse Posterior surface of the muscular process Crosses over and attaches  Adduct v.c
arytenoid + arytenoids to the same  closes the posterior glottis
point on the other
arytenoids Vocal process
Oblique Posterior surface of the muscular process Apex of the other  Adduct v.c
arytenoid (superficial to the transverse) arytenoid

Control the tension of the vocal folds:

Thyroarytenoid muscle:
 2 compartments:
 Medial vocalis muscle = internal intensor of vc: Deeper & lower part
 External: Small portion inserts on quadriangular membrane as thyroarytepiglottic muscle which narrows the
laryngeal inlet
Note: the thyroarytenoid has the fastest contraction time due to heavily myocin content of its fibers
Thyroarytenoid Cricothyroid
Origin Anterior interior surface of the thyroid cartilage Lateral surface of the anterior arch of the cricoid.
Fibres fan out & pass backwards in two groups
Insertion Vocal process & anterior surface of the arytenoids Lower oblique pass:
cartilage Backwards & laterally to the anterior border of the inferior
cornu of the thyroid cartilage.
Anterior straight fibres: ascend to the posterior part
of the lower border of the thyroid lamina
Action Shortens, thickens the vocal folds the entire fold (all layers):
Stiffness: Elongates, thins the vocal folds
a- The body of the fold: actively stiffened Stiffens the vocal folds
b- The transition layers: passively slackened
The edge of the fold to be rounded. The edge of the vocal fold becomes sharp
drop vocal pitch Increase the pitch
The cricothyroid muscle lengthens the vocal folds by increasing the distance between the angle of the
thyroid cartilage and arytenoids.
Cricothyroid: The only muscle that is not attached to the arytenoid
Note that both cricothyroid muscle + vocalis muscle (medial part of thyroarytenoid muscle) are: tensor muscles
 Alter the shape of the laryngeal inlet:
Aryepiglottic muscle Thyroepiglottic muscle
Continuation of Oblique arytenoid Thyroarteynoid (lateral part)
Origin Posterior aspect of the muscular process of Back of the thyroid prominence
the arytenoid
Insertion Aryepiglotic fold Aryepiglottic fold
Action weak sphincter of the laryngeal inlet (closes) Widens the inlet of the larynx pulling the aryepiglottic fold apart
Clinical application:
 With very strong respiratory demand, the posterior cricoarytenoid muscle continues contracting during expiration, after
the diaphragm has relaxed. This results in decreased resistance and faster outflow of air shortens the duration of
expiration increases the rate of breathing.
 During most conditions of breathing, respiratory rate is primarily controlled by varying the rate of exhalation

Extrensic muscles:
 Connects the larynx to other structures
 they act as a whole upon the larynx during swallowing
1. Depressor (strap muscles):
a) Omohyoid (C2+C3)
b) Sternohyoid (C2+3)
c) Sternothyroid
d) thyrohyoid muscles (C1) : can lower the hyoid or elevate the thyroid cartilage( according which part is fixed)
2. Elevator:
a) Geniohyoid: C1
b) Mylohyoid : V
c) Stylohyoid: VII
d) Digastrics muscle : anterior belly V, posterior belly VII
e) Pharyngeal muscles (pharyngeal plexus):
a) Middle constrictor muscle
b) Inferior constrictor muscle
o Pull the larynx superior posterior
o Cricopharyngeus:
 Lower part of the inferior constrictor muscle
 Continuous muscle
 Attaches to each side of the cricoids cartilage
 Forms the upper esophageal sphincter
Nerve supply of the larynx
The larynx is supplied by 2 branches of vagus nerve:
a) Superior laryngeal nerve:
 Exit the nerve at nodose ganglion
 Divides into 2 branches:
A- External branch (motor): Supply the cricothyroid muscle
B- Internal branch (Sensory ):
 Carries sensation from at and above the glottis
 Enters through the lateral thyrohyoid membrane with B.V
 Runs submucosally in the pyriform fossa
b) Recurrent laryngeal nerve:
 Gives motor innervations to all ipsilateral intrinsic laryngeal muscles except cricothyroid (superior laryngeal)
 interarytenoid m ( receive bilateral innervations)
 Carries sensation from: Glottic & Subglottic (below the vocal cords) and trachea Ligation of the superior
 Nucleus: laryngeal nerve results in:
1. Dysphonia
 Motor nucleus: nucleus ambiguous
2. Loss of sensation in the
 Sensory: nucleus solitaries via nodose ganglion
a) Supraglottic area
b) False vocal cord
c) Pyriform fossa
Recurrent laryngeal nerve paralysis:
a) Complete paralysis:
 Both adductors (except the cricothyroid) + abductor muscles will be paral ysied
 So the vocal cord will lie in cadaveric position ( intermediate)
 There is enough space between V.C so the patient will not develop stridor
 but no vocal cord movement = difficulty in speech
b) Incomplete paralysis:
 Abductor will be affected 1st
 So the V.C will be in adducted position
 This will lead into breathing difficulty
Course of recurrent laryngeal nerve:
Left recurrent laryngeal nerve:
 Descends into the chest with vagus nerve
 Leaves the vagus in the mediastinum
 Loop around ligamentum arteriosum and aortic arch
 Continues upward in the tracheoesophageal groove
 Enter the larynx behind the cricothyroid joint
Right recurrent laryngeal nerve:
 The loop occurs around the right subclavian artery
 There is 1% of the population with non-recurrent right laryngeal nerve
 The course of the left recurrent laryngeal nerve is longer than the right side
 The course of recurrent laryngeal nerve differs between the Right and left side due to embryological development
 The recurrent laryngeal nerve is the nerve of the 6th brachial arch
 The artery of the 6th brachial arch on the left is ductus arteriosus which is responsible for pulling the recurrent laryngeal
nerve on the left side
 While on the right side the 6th segmental artery disappear so the recurrent laryngeal nerve is only pulled as inferior as
the artery of the 4th arch (subclavian artery)
Incidence of injury of recurrent laryngeal nerve:
 Thyroidectomy: equal for right+ left
 Chest surgery: left more the right
Non-recurrent recurrent laryngeal nerve is likely to be associated with anomalous Rt Retro-esophageal Subclavian artery in
which Rt subcalvian artery arise from descending part of the aorta then pass behind the esophagus

Blood supply
Arterial supply:
 Superior thyroid artery: branch of external carotid artery
 Inferior thyroid artery: branch of thyrocervical trunk
Venous drainage:
 Superior thyroid vein +Middle thyroid veins : join the internal jugular vein
 inferior thyroid vein: empties into the left brachiocephalic vein.
Lymphatic drainage:
 Lymphatic drainage is separated into upper and lower drainage groups by the vocal folds
 The larynx above the vocal folds (supraglottic):
 drain by vessels that accompany the superior laryngeal vein and pierce the thyrohyoid membrane emptying
into the upper deep cervical lymph nodes + pre-epiglottic
 The larynx below the vocal folds (glottis & supglottic):
 drain into the lower deep cervical chain often through prelaryngeal and pretracheal nodes.
 The vocal folds themselves:
 firmly bound down to the underlying vocal ligament and there are no lymphatics present in this plan
 Infants vs adult larynx
Infant Adult
Location of the larynx as a whole more anterior and superior in the neck
Inlet orientation Less oblique which predispose to aspiration
Subglottic orientation Downward & backward Vertically oriented
 This high position brings the epiglottis and the palate into close proximity (overlap)
 This overlap leads to formation of 2 separate paths: 1st for feeding, 2nd for breathing
 The child can: drink fluid & breath in the same time (obligatory nose breather in the first few months of life)
 this overlap is usually constant but may be interrupted during: crying, swallowing of dense bolus
 The tongue in high larynx is entirely intra-orally
Location of the epiglottis tip Basiocciput/C1 C3/C4
Location of the inferior margin of C4 C7
the cricoid cartilage
 The larynx starts to descend at the 2nd year & reach the final position at adulthood
 At birth: C4 At 2 years: C5 At 5 years: C6  At 15 years: C7
 This descend is the result of the cranial cavity expansion
 The epiglottis & soft palate will no longer overlap (so in children older than 3 years the epiglottis can no longer
approximate the soft palate even during maximum swallowing)
 There will be creation of the oropharynx (supralarngeal space)
 The low larynx allows expanded supralaryngeal pharynx (oropharynx) which:
o serves as resonating chamber for modifying the fundamental frequencies of speech sounds
 Infant cannot enounce full range of vowel sounds because the high larynx limits the vocal tract
 The posterior part of the tongue will make the upper Anterior wall of the pharynx
 The epiglottis in adults:
 Becomes largely vestigial structure
 So patients who had partial/full epiglottectomy don’t develop difficulty in swallowing
 The digestive & respiratory system will cross over so breathing & eating can't occur in same time
 predisposing to: 1- chocking 2-aspiration of regurgitated food
relationship of the hyoid bone to close approximation of the larynx to the hyoid
the thyroid cartilage
larynx size ratio 1/3 of the adult larynx but it is proportionally larger than the adult larynx compared with
the rest of the tracheobronchial tree
Vocal cord consistency 1/2 the vocal cord is cartilaginous (vocal process 1/3-1/4th of the V.C is cartilaginous
of the arytenoid)
AP dimension of Glottis opening 6-8mm Male 24 mm
(Vocal cord length) Female 16 mm
Posterior transverse dimension 4mm
Subglottic AP diameter
Mature neonates 4.5-5.5 mm (narrowest part of URT in children)
Premature neonates 3.5 mm (So if the tip of bronchoscopy of 3 mm in diameter could not pass through the
subglottic area the child is diagnosed to have congenital subglottic stenosis)
Epiglottic configuration changes Omega shape, Softer, Narrower
More acute angle between the epiglottis &
glottis
Thyroid cartilage angle 110-120 90 in male
Stay the same in female
Collapse of laryngeal cartilage Easily collapsed because it is softer
Tracheal diameter Premature 3mm 25mm
Fully mature 6 mm
Treacheal ring 2 mm wide
Average distance between the 5.7cm 12 cm (tracheal length)
glottis & tracheal bifurcation
The predisposing factor for chocking in adults:
1. Low position of the larynx allows Crossing over of the digestive & respiratory system which
allow a bolus of food to lodge easily in the laryngeal aditus
2. The crossing allows more frequent in coordination of these activity than is usually in
mammals with largely separated tracts
3. The expanded oropharynx allows large bolus of food to be passed over the larynx over
swallowing rather around it into the pyriform fossa
Narrowing the lumen in infants:
 Circumferential mucosal edema of 1 mm within the larynx of an infant narrows the
subglottic space by more than 60%.
 edema will cause a marked diminution in potential airflow (Poiselleure's law states that flow
is inversely proportional to radius)
Breathing and the larynx

Movement of the vocal cords during quite respiration: Inspiration=abduct; Expiration= adduct
posterior cricoarytenoid muscle contraction:
 begin to contract with each inspiration before activation of the diaphragm
 Widen the glottis during inspiration
 Ceases only during: sleep; deep anesthesia
 its action varies with the respiratory needs:
1. quiet breathing: imperceptible during unlabored breathing
2. With increasing respiratory drive: increases proportionately with diaphragmatic
activity.
3. During strong respiratory demand: continues contracting during expiration after the
diaphragm has relaxed, thus delaying expiratory adduction and facilitating the
outflow of air.
 Differences between posterior cricoarytenoid muscle contraction and diaphragmatic
behavior: (oppose)

When the upper airway is partially occluded, inspiration generates negative airway
pressure, which is a potent stimulus to the posterior cricoarytenoid muscle to dilate
the upper airway.
 In contrast, the diaphragm responds by: decreasing inspiratory force (force of
contraction) increasing the duration of inspiration.
 Note:
 Increasing diaphragmatic force increases the negative pressure, favoring airway
collapse.
 So to inspire the same volume, the diaphragm extends the duration of
inspiration
 PCA and the diaphragm contraction have opposing effects on patency of the
lumen. PCA contraction dilates the airway, opposing the effects of the
diaphragm.
Laryngeal spasm:
 Occurs in response to mechanical stimulation (by secretions) of the larynx
 Mostly occurs under light anesthesia
 Results in: Apnea, Bradycaria, Hypertension
 Treated by: Positive-pressure ventilation through a bag/mask, 100% O 2, succinylcholine

Larynx and phonation

 The sound is produced when air is forced out the lungs through an adducted larynx
 Phases of speech: Pulmonary, Laryngeal, Oral
 Phonation requirements:
1. Breath support (Not necessary normal vital capacity)
2. Vocal cord approximation (not tight closure)
3. Favorable vibration prosperities (normal lamia propria)
4. Favorable vocal cord shape
 5. Control of vocal cord length and tension (not necessary to be tight V.C)

 Phonatory vibration of the vocal cords:

1. Mucosal upheaval moves from caudal to rostral
2. Vocal folds separate at mid cycle
3. Vocal folds change shape
4. The inferior vocal fold edge touches first
 Vocal cord vibration:
 vocal folds vibrate at rates of 75 to 1000 cycles/second
 Vibration involves the V.C cover and the body is stationary
 Vibration propagate by subglottic air forces
 Reinke's edema interfere with mucosal wave
 Vocal cord lubrication Affected by: air flow, Subglottic pressure
 Parameters of voices:
1. Loudness:
a) Subglottic air pressure
b) Glottal resistance
c) Rate of airflow
d) Amplitude of vibration
2. Pitch:
a) Length of V.C
b) Tension of V.C
c) Cross sectional mass of the V.C
d) Frequency
3. Quality: Symmetry of vocal fold vibration
Cough & larynx
 Coughing is the process by which material is expelled from the airway
 Cough reflex consists of 4 phases:
1- rapid inspiration
2- forceful closure of both the vocal and vestibular folds : Air pressure is then built up below the adducted folds as the
diaphragm ascends spasmodically until the folds separate explosively and mucus or foreign material is expelled
3- exspiration
4- cessation
General notes:
 True vocal cord has a curved inferior surface with concavity directed inferiorly, this shape offers:
 Minimal Resistance to air outflow
 Resists pressure from above (resist a pharyngeal pressure of 150mmHg)
 The false vocal cord function:
 Mainly: mechanical flap valve preventing egress of air (resists tracheal pressure of 30mmHg)
 Helps produce the increase in intratracheal pressure needed for coughing, sneezing, micturation,
parturition
 Has little resistance to ingress of air
 Useful in preventing aspiration of foreign material by physiological muscular contraction
cricoarytenoid unit is the basic functional unit of the larynx, consists of :
1. arytenoid cartilage
2. cricoid cartilage
3. associated musculature
4. superior laryngeal nerve
5. Recurrent laryngeal nerves.
 Preservation of at least one functional cricoarytenoid unit makes it possible to consider an organ preservation procedure.
 It is the cricoarytenoid unit, not the vocal folds, that allows for physiologic speech and swallowing without the permanent
need for a tracheostomy after supracricoid laryngectomy
 Trachea

General levels
 C3: hyoid bone
 C4:
o upper border of the thyroid cartilage
o Bifurcation of common carotid artery
 C6:
o cricoids cartilage
o Beginning of trachea
o Beginning of esophagus
 T4-T5: bifurcation of the trachea into left and right bronchus (carina)
General information:
 It is completely encircled by only the 1st ring
 The rest of cartilages are deficient posteriorly
 Number of circle 16-20
 The thyroid isthmus overlies 2nd to the 5th rings
 Tracheostomy is made by removing the anterior half of the 3rd or the 4th ring
 Blood supply is from:
 Inferior thyroid artery
 Bronchial artery supply the thoracic part
EMBRYOLOGY:
 The trachea develops from evagination of the foregut mesenchyme in the 4th week of development
 The incidence of Foreign body aspiration is equal between the Rt & Lt in children because: The left main bronchus is
not obliquely directed as adult
Postnatal development:
 Normal ratio of the tracheal cartilage to membranous wall is approximately 4:1
 The trachea is approximate 4 cm in length at birth, 12 cm in the adult
 The neonatal trachea is more compliant than the adult trachea and therefore more likely to collapse
 The lung continue to grow until the age of 8 years
Vessels that in direct contact with the trachea:
 Brachiocephalic artery
 Left Brachiocephalic vein
 In 10 % of people we have also thyroid ima artery
The thyroidea ima artery:
 It ascends infront of the trachea to the lower part of the thyroid gland, which it supplies.
 It appears to compensate for deficiency or absence of one of the other thyroid vessels.
 The thyroidea ima artery, when present, arises from the brachiocephalic trunk (innominate artery).

 What is the average tracheal wall mucosal capillary pressure? 20-30 mm Hg.
 What is the significance of a thyroidea ima artery to a head and neck surgeon? It can cause excess bleeding while
performing a tracheostomy.
 What is the average fundamental frequency for a child? Adult female? Adult male? 250 Hz; 200 Hz; 120 Hz.
 What is the average decibel level of the human voice? 65-75 dB.
 What is the maximum range of fundamental frequency for the human voice? 36-1760 Hz.
 What is the average maximum phonation time for an adult male? Adult female? 17-35 seconds; 12-26 seconds.
 What percent of neonates less than 5 days old have a functioning cough reflex? 25%.
 Unlike the glottic closure reflex, laryngospasm is mediated solely by stimulation of what ne rve? Superior laryngeal
nerve.
 Neck
Triangles:
 The sternocleidomastoid divides the neck into anterior and posterior triangles
 The muscle itself is in neither triangle.
 Using the hyoid bone as a keystone, the superior belly of omohyoid & Digastric
muscles subdivided the anterior triangle into:
1. Submental triangle
2. Submadibular triangle
3. Muscular triangle
4. Carotid triangle
 The posterior triangle is divided by the inferior belly of the omohyoid muscle into:
1. Occipital
2. Supraclavicular (Omoclavicular)
 Note apical lymph node of the posterior triangle is enlarged in rubella
& scalp infection
 The boundaries of submental are
 the anterior belly of the digastrics
 midline
 Hyoid bone.
 The bounderies of submandibular/digastrics are:
 anterior & posterior belly of digastrics muscle
 base of the mandibule
 line from the angle of the mandibule to the mastoid process
 The bounderies of muscular:
 hyoid bone
 anterior belly of omohyoid
 anterior border of scm
 midline
 the bounderies of supraclavicular:
 posterior surface of scm
 clavicle
 posterior belly of omohyoid
Hypoglossal nerve course in the neck:
 Moves from the carotid
triangle into the
submandibular triangle
 Medial to:
o stylohyoid insertion
o posterior belly of digastrics
o mylohyoid
 Lateral to:
o Hypoglossal muscle
Triangle Blood vessel Nerves Special structures
Sub-mental  Anterior jugular v  Submental salivary gland
Submandibular/  Facial artery & v  Marginal madibular branch of  Submandibular gland
Digastrics  Submental a & v facial nerve  Infe rior portion of
 Mylohyoid branch of V3 parotid gland
 Hypoglossus
Carotid  Common carotid  Vagus nerve
 Internal carotid  External & internal laryngeal
 External carotid & its branches
branches except the terminal  Small part of Accessory nerve
& posterior auricular  Hypoglossus
 Internal jugular  glossopharyngeal
Muscular  Lower part of the carotid  Anas cervicalis  Strap muscles, Thyroid
sheath  External & internal laryngeal gland, Parathyroid,
 Superior thyroid artery branches Larynx, Trachea,
 Anterior jugular vein esophagus
Occipital  Occipital artery  Spinal root of Accessory nerve
 Transverse cervical a  Cervical plexus:
o Greater & lesser occipital
o Greater auricular
o Transverse occipital
o suprascapular
Supra-  Subclavian vessels  Brachial plexus  Pleura
clavicular  Thyrocervical trunk
 Suprascapular a
 External jugular vein
Fascia of the Neck:
1. Superficial cervical fascia
2. The deep cervical fascia:
a. superficial layer (investing): carotid sheath
b. middle, pretracheal or visceral layer:
1) muscular/infra-hyoid portion
2) pretracheal
3) bucopharyngeal
c. deep layer or prevertebral:
1) alar layer
2) prevertebral division
1. Superficial cervical Fascia:
 Lies deep to the dermis layer of the skin
 Thin layer that invests the platysma muscle & muscles of facial expressions
 It is closely associated with adipose tissue.
 It contains cutenous nerve
 This fascia is penetrated by the blood vessels that supply the neck skin.
 The subplatysmal flap therefore protects the blood supply to the skin.
2. Deep cervical Fascia:
1) Superficial investing Fascia:
 arise from:
o ligamentum nuchae
o spinous processes of the cervical vertebrae
 It splits into anterior & posterior layer to enclose:
1. trapezius
2. omohyoid
3. sternocleidomastoid
4. parotid gland
5. submandibular gland
  superior attachment is to :
 external occipital protuberance
 superior nuchal lines
 mastoid tip
 zygomatic arch
 Anterior attachment: hyoid.
 Inferior attachments: acromium, the clavicle and the sternum
 The splitting of this fascial layer around the parotid forms a deep layer,
which fuses with the fascia around the internal carotid artery.
 It also forms the stylomandibular ligament (which separates the anterior
inferior tip of the parotid gland from the submandibular gland).
 Deep to this layer runs the spinal accessory nerve
 Forms the roof of the posterior triangle
2) Middle layer/pretracheal/visceral layer:
 This is derived from the superior layer of the deep cervical fascia
 Muscular portion: encircles the strap muscles
 Pretrachea
 passes deep to the strap muscles
 encircles: thyroid (anterior layer of the pretracheal fascia splits to encloses
the thyroid cartilage), larynx, trachea, pharynx, oesophagus
 Movement of the hyoid and strap muscles during swallowing elevates the
fascia so that thyroid lumps characteristically move on deglutition.
 buccopharyngeal fascia:
 portion of the middle layer that is related to and encloses the pharynx posteriorly
 Below the level of the pharynx it is called the visceral layer
 covers the external surface of the buccinator and superior constrictor muscles (both muscles arise
from the pterygomandibular raphe)
 Allow the pharynx to move freely, relative to neighbouring
structures such as the carotid sheath and vertebrae.
 Adheres inferiorly into the pretracheal & visceral fascia
 Forms
o midline raphe: through which Adheres at the midline to
prevertebral fascia
o pterygomandibular raphe : adheres to the lateral pharynx
 Note: layers of the muscles:
o facial expression: mastication: buccinators
o Platysma: SCM , trapezius & omohyoid: strap muscle
3) Deep Layer / pre-vertebral fascia:
 Forms a tubular sheath for the vertebral column and the muscles
 Arises from the ligamentum nuchae and the spinous processes of the cervical vertebrae (like investing layer)
 It forms the floor of the posterior triangles and allows the pharynx to glide during deglutition. While the
investing layer forms the roof of the posterior triangle
 deep layer of deep cervical fascia (At the transverse processes of cervical spine) is divided into 2 distinct layers:
1. The prevertebral fascia: (posterior)
 adheres to the anterior aspect of the vertebral bodies
 extends from the skull base down the length of the spine
 Extends laterally over the prevertebral musculature to fuse with the transverse processes and their
attached ligaments.
 It extends posteriorly to enclose the extensor musculature of the neck
 It is attached in the posterior midline to the spinous process of the vertebrae.
 The prevertebral division forms:
 the posterior wall of the so called danger space which extends from the skull base to the diaphragm
 constitute the anterior wall of the prevertebral space.
 Consequently, endogenous infections such as tuberculosis involving the vertebral bodies extend
into the prevertebral space but not into the danger space, from which they are separated by the
prevertebral fascia.
 2. The alar fascia: (anterior)
 lies between the prevertebral fascia and the visceral
division of the middle layer of deep cervical fascia.
 It courses from the transverse process to the
contralateral transverse process
 vertically from the skull base to T2, where it fuses
with the visceral layer of the middle layer of deep
cervical fascia which lies in front of it. ( This seals
inferiorly the (retro)Pharyngeal space)
 forms :
o anterior wall of the danger space
o posterior lateral portion of the
retropharyngeal space
Carotid Sheath:
 This is derived from the superficial + middle + deep layer of
deep cervical fascia medial to the sterncleidomastoid
 Extends from the skull base to the adventitia of the aortic arch
 It contains 80 % of the lymph nodes of the neck, the carotid
arteries, the internal jugular vein, vagus nerve.
 Constituents of the anas cervicalis are embedded in the carotid
sheath
 It is a potential venue for infection spread, called Lincoln high
way of the neck

investing layer Pre-vertebral fascia

Origin the same: ligamentum nuchae and the spinous processes of the cervical vertebrae
Relation to trapezoid muscle Encloses the muscle Deep to the muscle
Relation to the post triangle Roof Floor
 NECK SPACES
 Knowledge of these potential neck spaces is important in the
understanding of the spread of infection and tumors in the neck.
 They contain only loose areolar fascia.
Spaces limited to the above of the hyoid
Sublingual space:
 Bounderies:
 Superiorly: floor of mouth and tongue
 Inferiorly: mylohyoid muscle
 Anteriorly and laterally: mandible
 Posteriorly: hyoid bone
 Medially: genioglossus, geniohyoid, and
styloglossus muscles
 This space communicates freely with that of
the opposite side because no true fascial
separation exists between them.
 The sublingual space also communicates
anteriorly with the submental space below
through dehiscences in the mylohyoid
muscle and raphe.
 Get infections from: anterior teeth, bicuspids , first molar tooth
 Management: Intra-oral incision (but avoid the posteriolateral region which
contains the lingual nerve)
Submandibular space
 Boundaries:
 Superiorly: separated from the sublingual space
 Medially by: mylohyoid, hyoglossus, and styloglossus muscles
 Laterally by: body of the mandible.
 Inferior boundary: anterior and posterior bellies of the digastric muscle
 Posterior border: Stylomandibular ligament + posterior belly of digastric
 Lateral border: overlying skin, superfical layer of deep cervical fascia,
platysma muscle
 The contents of this space: tail of the
submandibular gland, Wharton's duct, lingual
nerve, hypoglossal nerves, facial artery, some
lymph nodes and fat.
 Note the submandibular gland lies in both the
submandibular & sublingual space
 Submental space (mylohyoid divides it into 2 parts)
 Source of infection: infections of the 2nd and 3rd
mandibular molar teeth
 Clinically, a tense, ill-defined swelling is generally
present below the mandible, which makes
palpation of its inferior border difficult.
 Management is by an external transverse cervical incision
placed 2 finger breath beneath the body of the mandibule to
avoid injury to the mandibular nerve
 Communication:
 across midline: opposite submandibular space
 Anteriorly: Communicate freely with the submental space
 Midway: It communicates with the floor of mouth around
the posterior border of the mylohyoid
 Posteriorly: Communicate with the parapharyngeal space
 It is subdivided by the mylohyoid muscle into : Sublingual, Submaxillary
 Ludwig Angina
 Definition: the collective involvement of the submandibular and sublingual spaces bilaterally and the submental
space (spread by the facial planes not by the way of lympahtics)
 Dental origin; arise from infections of the Mandibular molar teeth
 The causative organisms include a variety of aerobic and anaerobic gram-positive cocci (staph & strep) and gram-
negative rods (bacteriod).
 Clinically: collar of brawny edema extends across the entire upper anterolateral neck with elevation and progressive
induration of the floor of the mouth
 Since the mandible and superficial layer of deep cervical fascia provide unyielding barriers superiorly and
laterally, the tongue is forced upward and posteriorly giving rise to airway obstruction. This is the most
important danger in Ludwig's angina (rapidly spreading cellulitis involving the floor of the mouth)
 Complications
1. Spread of infection to parapharyngeal and retropharyngeal spaces and hence to the mediastinum.
2. Airway obstruction due to laryngeal oedema, or swelling and pushing back of the tongue.
3. Septicaemia.
4. Aspiration pneumonia
Masticator space:
 Collection of spaces defined by a splitting of the investing layer of the deep cervical
fascia, As it approaches the mandible and extends superiorly:
o temporal space
o Masseteric space
o pterygomandibular space
 Boundaries:
o External: fascia overlaying Masseter muscle
o Inte rnal: fascia medial to pterygoid muscle
 Contents:
 Masseter muscle, Medial & lateral pterygoid muscle
 Ramus & posterior body of the mandible
 Tendon of insertion of Temporalis muscle
 Infe rior alveolar nerve (pterygomandibular space)
 Inte rnal maxillary artery (pterygomandibular space)
 Infection source: mandibular/maxillary 3 rd molar teeth
 Involves all masticator muscles
 Relation to othe r spaces:
 Lies anterior & lateral to the parapharyngeal space
 Inferior to temporal space
 Medial to the infratemporal space
Peritonsilar space:
 This lies between the tonsil and supe rior constrictor.
 It communicates through the fibres of the superior constrictor with
retropharyngeal and parapharyngeal spaces.
Parapharyngeal /lateral space/pharyngomaxillary:
 It is shaped like an inverted pyramid with the Base under temporal
bone & apex in the neck at hyoid (C3)
 Located on either side of the pharynx (Nasopharynx & oropharynx)
 Borders:
 superiorly: the base of skull (petrous part of temporal bone)
 Inferior part: the greater cornu of the hyoid bone
 Medial Border:
 lateral naso+oropharyngeal wall
 Pharyngobasilar fascia
 Tensor palatine
 levator palatine
 pharyngeal constrictors
 Lateral border:
 fascia covering medial pterygoid muscles
 Ascending Ramus of the Mandible
 Deep lobe of parotid gland
 SCM at the level of C5
 Anterior border: pterygomandibular raphe
 Posterior Border:
 posterior part of the carotid sheath
 Prevertebral fascia
 Note:
 parapharyngeal space has no anatomical floor, allowing communication from skull base to superior mediastinum
 So infections can extend intracranially or into the mediastinum
 Middle ear infections can spread via involvement of the petrous apex
or jugular foramen into the neck
 Parapharyngeal abscess the approach is:
 Anterior to the SCM for abscess low in the neck
 Posterior to the SCM for abscess high in the neck
 Fascial borders:
 Medial: middle layer of deep fascia
 Lateral: superficial layer of deep fascia (buccopharyngeal fascia)
 Posterior: anterior layer of carotid sheath
 Masses in the parapharyngeal space can be palpable anterior to the
upper part of scm
 Parapharyngeal space divisions:
 The parapharyngeal space is divided by A layer of fascia (bucopharyngeal fascia) that extends from the medial
pterygoid plate and tensor palati to the spine of the sphenoid and the styloid process loosely divides into:
a) The Prestyloid space (muscular):
o anterolaterally
o contains: Fat, Lymph Node, Medial & lateral pterygoid muscle,
Styloid muscle, Internal maxillary artery, Ascending palatine branch
of facial artery, Ascending pharyngeal artery, Mandibular branches
(Auriculotemporal, Inferior alveolar, Lingual nerve), Deep lobe of
parotid gland
o majority of tumors are salivary gland tumors
b) The poststyloid contains (neurovascular) (carotid space):
o Posteromedially
o Contains:
 carotid sheath: carotid arteries, internal jugular vein, cranial
nerves IX, X, XI, XII (9-12): note that VI courses posteriolaterally
after leaving the jugular foramen & is not involved to any extent
in parapharyngeal space infections
 cervical sympathetic chain, Deep cervical lymph nodes.
o The majority of tumors are either neurogenic or vascular in origin
  Parapharyngeal space communicates with:
 retropharyngeal space (not free communication: there is condensation of fascia around the carotid sheath, which
separates the parapharyngeal & retropharyngeal space)
 submandibular space
 Peritonsillar space
 Note: bilateral spread of the infection is rare in the neck.
 The most common causes of parapharyngeal abscess is: Tonsillitis, Dental infection (esp 3 rd molar)
 Others: salivary gland infection, Middle Ear infections (base of the parapharyngeal space is the petrous bone), Spread of
retropharyngeal infections
 This space is the most complex and clinically most important space Due to its central location and its relationship to
other spaces in the neck:
 pharyngeal mucosal space : medial
 masticator space: anterolateral
 parotid space: lateral
 carotid space: posterior
 retropharygeal space: posteromedial

The parapharyngeal space contains a fat pad, which is located centrally.

The radiological displacement pattern of this fat pad is useful for diagnosing lesions in this area. Prestyloid and lateral l esions
will displace the fat posteromedially, while poststyloid lesions will displace this fat anteriorly
Parotid space masses: push the fat medially
Masseter space masses: posterior
Carotid + retropharyngeal: anteriolateral

 Manifestation of parapharyngeal space infections:

 Retromandibular fullness, Medial displacement of the lateral pharyngeal wall,
Parotid edema
 Dysphagia, Trismus: due to irritation of the mastication muscles
 Complication of parapharyngeal infection:
 Internal jugular thrombosis, Carotid artery erosion, Mediastinitis
 Cranial nerve pariesis:
o Horner syndrome: sympathetic chain
o Horsness of voice: vagus
o Tongue paresis: XII
Spaces extending the whole length of the neck

These spaces communicates with mediastinum

Retropharyngeal space
 This sits between the 2 parapharyngeal spaces and is continuous with both (but not freely)
 Borders :
 Superior boundary: the skull base
 Anterior boundary: the musculature of the pharynx (buccopharyngeal Fascia)
 posterior limit: alar division of prevertebral fascia
 Infe rior limit: It continues inferiorly behind the oesophagus and eventually communicates with the
posterior mediastinum.
 Contents : retropharyngeal lymph nodes of rouvier + loose alveolar tissue
 retropharyngeal abscess: points to Posterior pharyngeal wall OR Posterior triangle of the Neck
 May predispose to pus aspiration/mediastinitis
 acute vs chronic abscess:
acute retropharyngeal abscess Chronic retropharyngeal abscess
Age group Infants Adult
Cause results from suppuration in the retropharyngeal due to T.B
lymph node following URTI cervical vertebra may be involved
Approach of drainage drained through the mouth external approach through the neck
Danger space:
 Between the alar division and the pre- verterbral division of the Prevertebral fascia
 Lies between retropharyngeal & prevertebral
 Extends from skull base to the diaphragm
Prevertebral
 This is the potential space that lies between the cervical vertebrae and anterior longitudinal ligament posteriorly
and the prevertebral fascia anteriorly.
 It extends down to the third thoracic (T3) vertebra where the fasica is bound to the vertebra.
 The prevetebral fascia is thin and infections in this space can rupture directly through into the posterior
mediastinum.

Spaces limited below the hyoid

Pretracheal space/anterior visceral space

 Located:
 anterior and lateral to the thyroid cartilage
 deep to the strap muscles
 It contains the delphian node
 It communicates with the superior medastinum.
 Muscles of the neck
Group I :Superficial ne ck muscle : platysm a
Group II: Lateral Neck muscle: sternoclenomastoid, trapizus muscle
Group III: Suprahyoid muscle: Superficial layer: Digastrics, Stylohyoid; Intermediate layer: Mylohyoid; deep layer: Geniohyoid muscle
Group IV: Infrahyoid muscle : Sternohyoid, Omohyoid, Sternothyroid, Thyrohyoid

Anteriolateral muscles of the Neck

Group 1: superficial muscles of the Neck:
Platysma:
 Origin: Superficial fascia over the upper part of the pectoralis
fascia and the deltoid muscle
 Course: Fibers cross the clavicle, and proceed obliquely
upward and medially along the side of the neck.
 Insertion:
 Anterior fibers: Interlace, below and behind the
symphysis menti, with the fibers of the muscle of the
opposite side
 Posterior fibers: cross the mandible, Some being
inserted into the bone below the oblique line, Others
into the skin and subcutaneous tissue of the lower part
of the face. Many of these fibers blend with the muscles about the angle and lower part of the mouth
 Relationship: Beneath it, the external jugular vein descends from the angle of the mandible to the clavicle.
 Innervation: Cervical branch of Facial nerve
 Blood supply: Submental branch of the facial artery
 Action:
 Draws the corners of the mouth inferiorly & widens it (as in expressions of sadness & fright).
 Expression of surprise (pull the corner of the mouth downward & laterally partially opening the mouth)
 With maximum contraction pulls the skin over the clavicle upward causing wrinkles
 draws the skin of the neck superiorly when u clench the teeth
 Increase neck diameter (In forced rapid respiration)
Group II: Lateral muscles of the Neck
1- Sternoclenomastoid Muscle:
 Origin:
 Sternal head: thick tendon, which inserts into the anterior & lateral surface of the manubrium
 Clavicular head: muscular and inserts into the medial 1/3 of the clavicle.
 Insertion: clavicular head mainly to Lateral aspect of the mastoid tip & sterna head mainly to the
lateral 1/2 of the superior nuchal line.
 Action: The muscle combines a cruciate and spiralized arrangement
of fibres, This gives a complex action which:
 Tilts the head to the shoulder on the same side
 Rotates the head to the opposite side
 assist longus coli in neck flexion
 Nerve Supply:
 Motor: Spinal accessory motor C2-3
 Sensory & proprioceptive Nerve Supply: Anterior/ventral
Rami of C2-4 segments
 Fibrositis of the uppe r part of the SCM cause reffered
otalgia
 Blood supply:
 Comes from the superior and inferior ends of the muscle with anasta moses in the middle of the muscle.
 The superior pedicle: branches of the occipital artery
 The inferior pedicle: Branches of the s upe rior thyroid vessels
 Relation to othe r structures: External jugular vein & Cutenous nerves lies deep to the playtysma and
superficial to SCM
2- Trapezius
 Origin: medial 1/3 of the superior nuchal line, ligamentum nuchae down to the seventh cervical vertebra,
and all the spinous processes and interspinal ligaments down to the 12th thoracic vertebra.
 Insertion:
o Superior fibers: insert into the clavicle and acromium
o Inferior fibers (from the thoracic vertebrae): insert into the spine of the scapula.
 Action:
 Rotate the scapula so that the glenoid fossa points up.
 The trapezius is the major antigravity muscle of the shoulder girdle
 Nerve supply:
 Motor: spinal part of the accessory nerve from roots Cl-6, Cervical plexus (some fibers)
 Proprioceptive: the cervical plexus.
 Paralysis: a common consequence of surgical damage to the accessory nerve in the posterior triangle due
to malrotation of the scapula and traction on the brachial plexus, which leads to severe chronic neck pain.
Group III: Suprahyoid muscle:
 As a group assists in:
 Elevating the Hyoid bone during swallowing
 Depress the mandible & open the mouth when the hyoid
is fixed by the infrahyoid muscles
 Superficial layer:
1- Digastric muscle:
 Origin of Posterior Belly: Digastric ridge (which
is on the me dial aspect of the mastoid tip)
 Course:
o Posterior Belly Runs anteroinferiorly and becomes an intermediate tendon, which runs below a
fibrous ring that is attached to the lesser cornu of the hyoid (so is not directly attached into the
hyoid bone), Movement of this tendon is lubricated by a synovial sheath.
o Anterior belly then runs anterosuperiorly
 Insertion of the anterior belly: digastric fossa on the inner surface of the mandible.
 Action: elevates hyoid during swallowing and assists the late ral pterygoid in depressing mandibule
 Innervation:
 Posterior belly: facial nerve: Digastric branch
 Anterior belly: trigeminal nerve: mandibular division: inferior alveolar branch: a branch from the
nerve to mylohyoid,Reflecting its 1st and 2nd branchial arch embryology
 This muscle encloses the Digastric triangle, forms a landmark for the main trunk of the facial nerve
and represents a deep boundary of dissection for safe avoidance of the Hypoglossal nerve
 Note that the posterior belly is longer than the anterior belly
 The relationship of the posterior belly of digastrics muscle to other structures:
 All vessels and nerves cross deep to this belly except for:
o cervical branches of the facial nerve (CN VII)
o facial branches of the great auricular nerve
o EJV and its connections ( superficial to SCM)

2- Stylohyoid Muscle: Narrow muscle located superior and anterior to the posterior belly of the Digastric muscle
o Origin: Posterio-lateral aspect of the Styloid process
o Insertion: Body of the hyoid at the Junction between the lesser horn and the body of the hyoid bone
o Action: Retracts & elevates the Hyoid; Elongates the floor of the mouth
o Innervation: Facial Nerve
 Inte rmediate layer
3- Mylohyoid Muscle: A flat triangular muscle that with its opposite form the floor of the mouth
 Origin: Oblique line of the mandible from the mandibular Symphsis to the last molar
 Insertion:
 Anterior + middle fibers: median raphe
 Posterior Fibers: body of the hyoid
  Action:
 Elevates the floor of the mouth
 Elevates the hyoid and assist in elevating the tongue upward or protrude the tongue
 Lower the mandibule and assists in opening the mouth; Acts in swallowing, sucking, mastication, blowing
 Innervation: Trigimnal nerve: mandibular division: inferior alveolar branch: Mylohyoid branch
 Blood supply:
 lingual artery (sublingual branch)
 maxillary artery (the mylohyoid branch of the inferior alveolar artery)
 facial artery (submental branch)

 Deep layer:
4- Geniohyoid muscle: Narrow muscle that is located deep to the medial aspect of the Mylohyoid muscle
o Origin: Inferior mental spine in the inner surface of the mandibular symphysis
o Course: Inferioposterior
o Insertion: The Contralateral Mylohyoid muscle; Body of the hyoid bone
o Action:
 pulls & elevates the hyoid causing shortening of the floor of the mouth during swallowing
 Retracts and depresses the mandible when the hyoid bone is fixed by the infrahyoid muscle
o Innervation: C1 root of the hypoglossal nerve
Group IV: Infrahyoid muscles: strap muscles:
 Made of 4 muscles that cover thyroid, larynx & trachea: Sternohyoid, Omohyoid, Sternothyroid, Thyrohyoid
 Forms the floor of the muscular triangle
 The lowe r part is covered by the sternoclenomastoid
 The strap muscles are retracted to reach the thyroid and the trachea
 Form the anterior boundaries of neck level
 Action:
 Move the larynx; Depress the mandible
 Innervation: from C1, C2 & C3 via anas Cervicalis
Omohyoid:
 Origin: hyoid bone just lateral to the attachment of sternohyoid
 Course: it courses inferiorly, it diverges laterally, runs deep to the
sternomastoid and crosses the internal jugular vein at which point it
becomes a tendon.
 It is a useful landmark for the internal jugular vein.
 Lateral to the internal jugular vein the inferior muscle belly develops, runs across
the posterior triangle
 Insertion: Suprascapular ligament and the lateral acromium.
 Nerve supply : ansa cervicalis
 Embryologically: Its distal insertion is to the medial clavicle and it migrates
laterally to the adult position
 Function: is obscure.
Level Triangle/neck area Subzones Drained structures
Level 1 Submental Zone 1a anterior floor of mouth, lower lip, ventral tongue
Submandibular Zone 1b Rest of the oral cavity
Level 2 Upper jugular L.N Zone IIa Parotid, oropharynx, hypopharynx, larynx
Zone IIb(submascular recess)
Level 3 Middle jugular Pharynx, larynx
Level 4 Lower jugular Hypopharyx, larynx
Level 5 Posterior triangular Zone Va = occipital nasopharynx
Zone Vb= supraclavicular Thyroid gland
Level 6 Central /anterior Paratracheal, pertracheal, peri thyroidal Delphian (precricoid)
Jugular Lymph node/deep cervical
 80% of lymph nodes in the neck are closely associated with the internal jugular vein.
 Upper Jugular / deep cervical
 The most superior segment of the vein extends from the skull base to the level of
the carotid bifurcation which coincides with the level at which the greater cornu of
the hyoid bone crosses the internal jugular vein.
 At the most superior extent of the vein, it runs deep to the digastrics muscle.
 Nodes found here are referred to as the jugulodigastric nodes.
 They drain the palatine tonsil
LEVEL II: The course of the spinal accessory nerve divides this level into two subzones:
 Level IIa lies anteroinferior to the spinal accessory nerve
 lIb posterosuperior (submuscular recess).
 It is a clinically useful anatomical differentiation because positive level IIa disease
mandates lIb dissection
 However elective dissection for laryngeal and hypopharyngeal malignancy can
exclude level lIb.
 Middle jugular/ deep cervical nodes
 Found between the carotid bifurcation and the level at which the omohyoid
tendon crosses the internal jugular vein.
 Lower jugular/ deep cervical nodes:
 are those between the tendon of omohyoid and down to the thoracic inlet.
They are sometimes referred to as the prescalene group of nodes.
 They form an important confluence between the mediastinal node group, the
axillary group and the neck.
 This communication can be a reason why neck nodes may appear secondary to disease outside the neck.
Note: the middle & lower jugular L.N lies below the level of hyoid bone and drain the hypopharynx
 LEVEL V sub zones:
 Va:
o lies superior to the inferior belly of the omohyoid muscle
o contains the chain of nodes along the accessory nerve, which drain the nasopharynx
 Vb:
o inferior to the omohyoid muscle.
o contains nodes related to the thyrocervical trunk which drains the thyroid gland.
Note:
 Nasopharynx: drain into retropharyngeal & upper deep cervical
 All areas of the pharynx will drain ultimately into the lower deep cervical
 Base of the tongue has rich bilateral drainage, hence the high incidence of neck metastases of tongue base CA
 Tonsils drain into jugulodigastric lymph node
 Pyriform fossa drain into para+pre tracheal L.N
 Thyroid gland
Arterial blood supply
Superior thyroid artery Inferior thyroid artery
Origin external carotid artery thyrocervical trunk which arise from the
Subclavian artery
Course along the inferior constrictor muscle along the anterior scalene muscle
crossing beneath the long axis of the
common carotid artery
behind the cricothyroid joint
inferior to the inferior constrictor
Relation to the nerve posteriolateral to the superior laryngeal Lies in 70% anterior to the recurrent
nerve laryngeal nerve
Then The nerve will cross deep to the
inferior thyroid artery at the inferior pole
approximately 70% of the time and often
branches above the level of the inferior
thyroid artery before entry into the larynx
Relation to the thyroid pole Enter the upper pole anteriorly Enter the lower pole Posteriorly
 Inferior thyroid artery is also the
primary blood supply of the superior
& inferior parathyroid gland

Venous drainage of the thyroid gland:

 Superior and middle thyroid veins,
drain into the anterior facial and
internal jugular veins,
 inferior thyroid and thyroid ima veins
which drain into the innominate
veins brachiocephalic trunk
Lymphatic drainage of the thyroid gland:
1. Superior deep cervical
2. Inferior deep cervical
3. Paratracheal
4. Superior pretracheal L.N

Thyroid capsule:
 The thyroid gland is enclosed by
the visceral layer of the middle
layer of the deep cervical fascia
 The true thyroid capsule is tightly adherent to the thyroid gland and continues into the parenchyma to form
fibrous septa separating the parenchyma into lobules.
 The surgical capsule is a thin, film-like layer of tissue lying on the
true thyroid capsule.
 Posteriorly, the middle layer of the deep cervical fascia condenses
to form the posterior suspensory ligament, or Berry's ligament,
connecting the lobes of the thyroid to the cricoid cartilage and the
first two tracheal rings.

Thyroid gland position :

 Isthmus 2nd-4th tracheal ring
 The inferior lobe may extend into the 6th tracheal ring
Pyramidal lobe:
Approximately 40% of patients have a pyramidal lobe that arises from either lobe or the midline isthmus and
extends superiorly

 What is the embryologic origin of the thyroid gland?

The median downgrowth of the first and second pharyngeal pouches in the area of the foramen c ecum.
 From which pharyngeal pouches are the inferior parathyroid glands derived? Third.
 What is the predominant glycoprotein found in colloid? Thyroglobulin.
 What is the function of pendrin?
Mediates exchange of iodide from the thyrocyte to the colloid, which is one of the first steps of thyroid
hormone synthesis.
 What is the NIS?
A Na/I symporter that serves to concentrate I- into cells. It is found in the thyroid gland, salivary glands,
gastric mucosa, placenta, ciliary body of the eye, the choroids plexus, the mammary glands, and certain
cancers. Except for the thyroid gland, the NIS in these tissues does not respond to TSH.
 What are the three plasma proteins that bind thyroid hormonse?
Albumin, transthyretin, and thyroxine-binding globulin (TBG).
 What percent of the population has more than four parathyroid glands? 10%.
 What percent of the population has only three parathyroid glands? 3%.
 What percent of parathyroid glands are located in the mediastinum? 2%.
 True/False: The inferior glands vary more in location than the superior glands. True.
 Where are the inferior parathyroids typically located?
Inferior and anterior to the inferior thyroid artery.
 Where are the superior parathyroids typically located?
Superior and posterior to the inferior thyroid artery and more likely to extend posteriorly and inferiorly or be
found retroesophageally.
 What is the primary blood supply of the parathyroid glands?
The superior and inferior parathyroid arteries, which are usually branches of the inferior thyroid artery.
 What are the three types of cells comprising the parathyroid glands? Chief cells, dear cells, and oxyphil cells.
 Which cells produce PTH? Chief cells.
 What percent of a parathyroid gland is composed of fat? 20-30%.
 Which terminal of PTH is active? N-termmal.
 Venous Drainage

 Superficial temporal vein + internal maxillary vein = retromandibular vein

 Retromandibular vein has 2 branches (anterior & posterior)
 Facial vein + anterior retromandibular vein = common facial vein
 Common facial vein drain into the internal jugular vein
 Posterior auricular vein + posterior retromandibular vein = external jugular vein
 Note:
 retromandibular vein = temporomaxillary vein = posterior facial vein
 inferior petrosal vein + sigmoid sinus= jugular bulb
 tributaries of internal jugular vein:
 pharyngeal plexus
 common facial
 lingual
 superior & middle thyroid vein
 subclavian
note the inferior thyroid vein drain into the brachiocephalic trunk
 General information

Note:

 Pharyngeal branch of vagus lies in between

the bifurcation
 superior laryngeal nerve deep to it
 inferior laryngeal branch of the vagus nerve is
not related to carotid artery

Relationship of nerves & internal jugular vein

 superficial: spinal accessory nerve

 deep : hypoglossal nerve

Vagus nerve:

 superficial: hypoglossal nerve

superior & inferior roots of anas
cervicalis
 deep: C1

Phrenic nerve:

 Can be identified by its location

 Superficial to: ant scalene muscle
 Deep to: transverse cervical artery

Ipsilateral ptosis of the upper eyelid following radical neck dissection is due to:

 Inadverrent dissection deep to common carotid artery (injury to the sympathetic chain)