OUTLINE:

I. NASAL CAVITY II. PARANASAL AIR

AIR SINUSES FOOD III. PALATE IV. PALATINE TONSILS TRACHEA ESOPHAGUS

Problem: Nasal Cavity and Oral Cavity open to ; Path of air crosses path of food intake; Permits breathing when chewing Solution: Soft Palate functions as flap valve Clinical: Burrito story; Other - sinus infections, tonsillitis NASAL CAVITY

Upper most part of Ant. Opening = Anterior Functions: Nares

1) Modifies air – warms, humidifies and filters 2) Sense smell – Post opening = hunt animals, enjoy Posterior Nares flowers, avoid = Choanae noxious odors, (ko'-an-ay) allure (greek for of perfume funnels) A. NASAL CARTILAGES

SEPTAL SEPTAL CARTILAGE CARTILAGE

LATERAL NASAL CARTILAGES ALAR CARTILAGES MIDLINE = VIEW OF

Nasal Cartilages - 1) Septal cartilage with fused Lateral Nasal Cartilages 2) Alar cartilages - surround medial side of Function of Cartilages - flexible, opening inferiorly directs inhalation toward mouth (smell what you eat) CORONAL CT of INTERIOR OF NASAL CAVITY

ORIENT PLANE

Projections that increase surface area called Nasal Conchae (con'-key)= Turbinates

AIR

Cavity is lined with mucoperiosteum NASAL SEPTUM

SPACE BELOW CONCHA IS CALLED MEATUS (L. passage) B. BOUNDARIES OF NASAL CAVITY

Nasal Frontal Boundaries Ethmoid Sphenoid Floor = Palate 1) Maxillary Bone (Palatine Process) 2) Palatine Bone (Horizontal Plate)

Roof 1) 2) Frontal Bone 3) Ethmoid (Cribriform Plate) Palatine 4) Sphenoid (Body) Maxillary NOSE B. BOUNDARIES OF NASAL CAVITY

ANT. CRANIAL FOSSA

Medial = Nasal Septum 1) Septal Cartilage 2) Ethmoid (Perpendicular Plate) 3) Vomer

NOSE ** CLINICAL – Fracture of nose can break Cribriform plate, floor of Ant. Cranial fossa - leak CSF from nose; can result in Meningitis ETHMOID BONE (anterior view) CRISTA GALLI

CRIBRIFORM PLATE

ETHMOID AIR CELLS (SINUS)

PERPENDICULAR PLATE MIDDLE CONCHA ETHMOID - Gk. for sieve or strainer CRIBRIFORM - structure with many holes C. LATERAL WALL OF NASAL CAVITY

Sphenoid Ethmoid

Lateral Wall Nasal

1) Nasal Bone 2) Maxillary Maxillary Palatine 3) Inferior Concha Inf. Concha 4) Palatine 5) Ethmoid 6) Sphenoid

NOSE C. LATERAL WALL OF NASAL CAVITY

Projections = Conchae (shell) or turbinates – increase surface area 1) Superior Concha - Ethmoid 2) Middle Concha - Ethmoid 3) Inferior Concha - separate bone

Middle Inferior

In nasal speculum view, See only Middle and Inferior Conchae (Turbinates) CORONAL CT of NASAL CAVITY

1) Superior Concha - Ethmoid 2) Middle Concha - Ethmoid 3) Inferior Concha - separate bone NASAL CAVITY: SPACES

a. Spheno-Ethmoidal Recess - above Sup. Concha b. Superior Meatus - Below Sup. Concha c. Middle Meatus - Below Mid. Concha d. Inferior Meatus - Below Inf. Concha

Meatus = Passage (Latin), located below concha NASAL CAVITY: REMOVE (REFLECT) CONCHAE IN DISSECTION Ethmoidal Bulla- Rounded elevation below Middle Concha

3) Middle Meatus Below Mid. Concha

4) Inferior Meatus Below Inf. Concha

Meatus = Passage (Lat.) ORIENT/TERMINOLOGY: STRUCTURES IN MIDDLE MEATUS

Terms Ethmoid Bulla Infundibulum 1) Ethmoidal Bulla- Rounded elevation cut edge of below Middle Middle Concha Concha - Formed by projection of Middle Ethmoidal air cells

2) Hiatus Semilunaris = C- shaped slit below Bulla - Infundibulum is anterior part of Hiatus Hiatus Semilunaris NASAL CAVITY: OPENINGS a. SUMMARY CHART IN HANDOUT 1) Olfactory Foramina 2) Sphenoid air sinus b. Superior Meatus – Post. Ethmoidal air cells c. Middle Meatus 1) Middle ethmoidal air cells - Bulla 2) Ant. Ethmoidal air cells - Hiatus Sem. 3) Max. Sinus - Hiatus Semilunaris 4) - Infundibulum. d. Inferior Meatus – opening of Nasolacrimal duct C. AND D. NERVES of NASAL CAVITY Nerves 1.Olfactory N. - SMELL Olfactory Area OLFACTORY N. PTERYGO- PALATINE 2.General Sensation - GANGLION ANT. NASAL ALL SOMATIC ETHMOIDAL BR. N. SENSORY touch, pain, etc. V1 + V2 - V1 Anterior Ethmoidal* N. - V2 Nasal Branches - V2 Nasopalatine N. 3. Mucous Glands of nose - VISCERAL MOTOR PARASYMP. - VII - Facial N. by NASOPALATINE N. Pterygopalatine Ganglion OLFACTORY AREA = area of Olfactory nerve endings * RESPIRATORY AREA = rest of nasal cavity E. and F. ARTERIES/VEINS, LYMPHATICS SPHENO- PALATINE ANT. ETHMOIDAL A. 1. Arteries A. a. Sphenopalatine Artery - from Maxillary A. b. Ant. and Post Ethmoidal A. - from Ophthalmic A. c. Branches of Facial A. 2. Veins a. Ethmoidal vein br. of drain to Ophthalmic v. FACIAL b. Other branches to A. Pterygoid Venous Plexus c. Facial Vein F. Lymphatics- Retro- Note: Epistaxis (nosebleed)** can be extensive pharyngeal due to Anastomoses – Spurting if arterial Nodes II. PARANASAL AIR SINUSES

1) Air filled extensions of Nasal Cavity 2) All Paired - Develop After birth - Lined by - Serve to lighten bones 3) A mistake of evolution? - If filled bones with spongy (cancellous) bone, would not get infected PARANASAL AIR SINUSES VIEW: FLOOR OF ANT. CRAN. FOSSA All usually paired WITH BONE REMOVED NOSE A. Frontal - separate by septum, variable size

C. Ethmoid- also called air cells (Ant., Mid., Post.)

B. Sphenoid - in body of Sphenoid bone

Ethmoid - Blocked Sinus Infection Can Spread* to Orbit PARANASAL AIR SINUSES C. Ethmoid

A. Frontal B. Sphenoid

D. Maxillary (opened) Google search - cute baby PARANASAL AIR SINUSES 1.5 billion results

No Sinuses at birth = Baby Face CUTE BABY Maxilla – Small - No Maxillary Air Sinus - No Teeth Mouth is under eyes 3 YEAR OLD BOY

Cute - correlated with undeveloped (also teeth not erupted)? PARANASAL AIR SINUSES

D. Maxillary Sinus - Largest - Occupies entire Body of Maxilla - Roof = Floor of Orbit - Nasal Cavity is medial to sinus

CLINICAL - Roots of Maxillary Teeth are in Floor of Sinus - can damage by tooth * extraction PARANASAL AIR SINUSES: NERVES

Infraorbital N. - gives rise to Ant. Sup Alveolar N.

Post. Sup. Alveolar N.

V2 - Ant. & Post. Sup. Alveolar N. supply Max Sinus* & *Teeth; (Infected sinus can feel like a tooth ache) III. PALATE

INCISIVE B. Anatomy FORAMEN

1. Hard Palate a. Maxillary Bones (palatine process)

b. Palatine bones (horizontal plate) DEVELOPMENT OF FACE 2. Medial and Lateral Nasal 3. Medial nasal process and Processes – form at Maxillary Process – fuse to form margins of nasal placodes upper lip PHILTRUM fusion OF UPPER eye LIP

Lateral nasal Medial nasal Medial nasal Maxillary process process process process A. PALATE DEVELOPMENT a. Primary Palate – Anterior to Incisive Foramen formed by union Medial Nasal Processes LANDMARK INCISIVE * PRIMARY PALATE FORAMEN

MAX MAX PROC. PROC.

SECONDARY PALATE b. Secondary Palate – Posterior to Incisive Foramen- formed by fusion of Maxillary processes MALFORMATIONS: CLEFT PALATE 2) Posterior Cleft Palate - Not fuse 1:2500 Secondary palate births (not fuse Maxillary * Processes each side)

1) Anterior Cleft 1:1000 Palate - Not fuse Births Medial Nasal Process and Maxillary Process* Note: Ant. Cleft Can be unilateral Palate is same or bilateral as Cleft Lip OPENING OF AUDITORY TUBE 2. SOFT PALATE

Collection of muscles With central aponeurosis (tendon) - functions as Flap Valve closes off nasopharynx during swallowing POSTERIOR VIEW OF SOFT PALATE

Nasal Cavity

Soft Palate

Oral cavity MUSCLES OF SOFT PALATE NASAL CAV. 1) Tensor Palati - O - Auditory tube; I - Palatine Aponeurosis (tendon under hamulus of medial pterygoid plate A - Tenses Soft Palate

2) Levator Palati - O - Temporal Bone, Auditory hamulus of Tube; I - Palatine medial Aponeurosis; A - Elevates pterygoid plate Soft Palate

3) Musculus uvuli - O - Palatine aponeurosis, I - Uvula; A - Raises Uvula

palatine aponeurosis Note: Contraction of Tensor and Levator Palati VIEW: POST. SIDE OF when Swallowing opens Auditory tube (origin of NASAL AND ORAL CAVITIES both muscles); equilibrate pressure on Tympanic membrane (ears 'pop'). * MUSCLES OF SOFT PALATE

Tensor Palati Levator Palati

Lateral Pterygoid Plate

Superior Constrictor of Pharynx

Buccinator 231 TENSOR TENDON CAN APPEAR WHITE MUSCLES OF SOFT PALATE Tensor AUDITORY Levator Innervation - All TUBE X except Tensor (V3) 4) Palatoglossus O - Palatine aponeurosis, I - Side of tongue; A - Draws palate down, raises tongue Palato- Musculus glossus Uvuli

TONGUE MUSCLES OF SOFT PALATE Tensor AUDITORY Levator Innervation - All TUBE X except Tensor (V3) 4) Palatoglossus O - Palatine medial aponeurosis, pterygoid I - Side of tongue; plate A - Draws palate down, raises tongue Palato- pharyngeus Palato- glossus

TONGUE ARTERIES, NERVES AND

INCISIVE FORAMEN LYMPHATICS 3. Blood Supply - a. Descending Palatine Artery (from Maxillary A.) - divides to Greater Pal. A. to hard palate and Lesser Pal. A. to soft palate b. Sphenopalatine artery - branch through Incisive Foramen c. Ascending Palatine Artery (from Facial A.)

4. Nerves - ALL from V2 GREATER, LESSER (Somatic Sensory) PALATINE FORAMINA a. Greater Palatine N. and ** Nasopalatine N. to hard Palate QUESTION: TUMOR BLOCKING WHICH b. Lesser Palatine N. to Soft Palate FORAMEN PRODUCES ANESTHESIA OF PALATE? 5. Lymphatics to Retropharyngeal Nodes IV. PHARYNX - LONGITUDINAL MUSCLES - involved in swallowing

1. Stylopharyngeus

O - Styloid process of Temporal bone I - Thyroid Cartilage A - Raise pharynx and pull walls laterally Inn - IX (BRANCHIO- MOTOR) PHARYNX

HARD PALATE Opening of Auditory Tube Orient – Hard Palate – SOFT bone PALATE Soft Palate - muscles Orient SOFT HARD PALATE PALATE Opening of Auditory Tube

tongue PALATINE TONSIL

Palatoglossal arch PHARYNX - LONGITUDINAL MUSCLES

1. Salpingo-pharyngeus Palato- O - Auditory glossus Tube

Salpinx = Gk. for Trumpet HARD PALATE 2. Palato-Pharyngeus O - Soft Palate

Both I - Thyroid Cartilage and fuse to middle TONGUE constrictor A - Raise Pharynx Inn - Vagus (X) SAY AAH! PALATO- UVULA GLOSSAL ARCH - overlies Palatoglossus muscle PALATO- PHARYNGEAL ARCH - overlies Palatopharyngeus muscle PALATINE TONSIL

PALATOGLOSSAL ARCH = SITE OF OROPHARYNGEAL MEMBRANE = BOUNDARY, BETWEEN ORAL CAVITY AND PHARYNX (PRECISE AND IMPRECISE SENSATION) INTRODUCTION TO EDIFYING TALE

Innervation Innervation Nasal Cavity, Oral Cavity - Pharynx - SOMATIC VISCERAL SENSORY SENSORY (GSA) (GVA) not mucosa sensitive, not highly precise sensitive, precise sensation MUSCLES OF SOFT PALATE: VOLUNTARY CONTROL

Basic Facts – Palate acts as a flap valve, closing off nasopharynx from oropharynx Muscles of Soft Palate – Branchiomotor skeletal muscle (SVE) under voluntary control; Move when talk, say AAH!

uvula AAH! V. MECHANISM OF SWALLOWING: DEGLUTITION

BOLUS BACK STARTS INVOLUNTARY FORM BOLUS CONTRACTIONS Voluntary: Involuntary: 1) Form Bolus – 3) Elevate soft chew, form wad palate - contract with tongue; Tensor, Levator, palate down Stylopharyngeus by Palatoglossus 4) Down tube – 2) Push Bolus contract back – contract Pharyngeal Mylohyoid, Constrictors, BURRITO Styloglossus Pull larynx * BURRITO forward with Hyoid muscles STAGES OF SWALLOWING RADIOPAQUE MATERIAL MECHANISM OF SWALLOWING: DEGLUTITION

FINAL VOLUNTARY STAGE

*

STAGES OF SWALLOWING RADIOPAQUE MATERIAL HOT BURRITO SALSA! V. MECHANISM OF SWALLOWING: DEGLUTITION

BOLUS BACK STARTS INVOLUNTARY FORM BOLUS CONTRACTIONS Voluntary: Involuntary: 1) Form Bolus – 3) Elevate soft chew, form wad palate - contract with tongue; Tensor, Levator, palate down Stylopharyngeus by Palatoglossus 4) Down tube – 2) Push Bolus contract back – contract Pharyngeal Mylohyoid, Constrictors, BURRITO Styloglossus Pull larynx * BURRITO forward with Hyoid muscles STAGES OF SWALLOWING RADIOPAQUE MATERIAL SOMETHING TERRIBLY WRONG OCCURS: NASAL CAVITY - INITIATE TALKING WHILE SWALLOWING PRECISE SENSATION OF BURRITO IN NASOPHARYNX 1) Chewing Burrito at PAIN (HOT ENTERING NASAL CAVITY SALSA) lunch 2) Swallow - palate starts tense, elevate start involuntary phase but then 3) TALK! - Palate down, Voluntary 4) Burrito - enters Nasopharynx and Nasal cavity 5) Hot Salsa - agony 6) Embarrassed

Lesson - Don’t talk when chewing and swallowing DEATH DUE TO CHOKING: HIGH PREVALENCE IN ELDERLY

Choking is the fourth leading cause of unintentional injury death.

>65: Unintentional injury death VI. PALATINE TONSILS

PHARYNGEAL Palatine Tonsil TONSIL =

Palatine Tonsil - lymphoid tissue In oropharynx between Palatoglossal and Palatopharyngeal Tonsillectomy- Arches incise mucosa to remove Palatine tonsil Palatine tonsil TONSILLITIS = inflammation of (Palatine) tonsils

Cause - bacterial (Streptococcus) or viral infection

Paulina Skaff, MD, Class of 2018

hi mag image: tilt head Palatine Tonsil PALATINE TONSILS

A. Arteries- TONSILLAR BR. From Tonsillar branch of OF FACIAL A. Facial Artery - can be large

B. Veins – join Pharyngeal Plexus of Veins – Drain to Facial lingual or Inf. Jugular

C. Lymphatics –Deep cervical nodes *Jugulo-Digastric- Enlarged

Note: 1) Glossopharyngeal Nerve only covered by Pharyngo- Tonsillar ‘Bed’ – Basilar Fascia can be Formed by IX damaged 1) Superior Constrictor of 2) Extensive bleeding after tonsillectomy - tonsillar*** Pharynx 2) Styloglossus branch of Facial Artery FACIAL ARTERY

NOSE

FACIAL A. COURSE = 'WIGGLE' X 3 SUPERIOR THYROID A. FACIAL ARTERY- BRANCHES MEDIAL TO MANDIBLE a) ASCENDING PALATINE IMPORTANT IN ARTERY - TONSILLECTOMY PALATE

NOSE

b) TONSILLAR BRANCH - PALATINE TONSIL

LINGUAL A. FACIAL ARTERY- BRANCHES MEDIAL TO MANDIBLE

PALATINE TONSIL

what muscle?

NOTE: TONSILLECTOMY - Post-operative bleeding of Tonsillar branch of Facial artery is b) TONSILLAR complication of BRANCH - removal of palatine** PALATINE tonsils; also damage IX TONSIL

note: Board question POSTOPERATIVE BLEEDING FOLLOWING TONSILLECTOMY

Palliative Technique: Eat Palatoglossal arch Uvula ice cream without spoon

Note: define Palliative - relieving pain without Blood clot dealing with the cause of the condition.