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Quick Review: Fossa of pharyngeal recess or the fossa of Rosenmüller Rosenmüller. The nasopharynx is a fibromuscular sling suspended from the skull base. The human nasopharynx is mainly derived from the primitive pharynx. It represents the nasal portion of the pharynx behind the nasal cavity and above the free border of the soft palate. The nasopharynx communicates with the nasal cavities through posterior nasal apertures. The choanal orifices along with the posterior edge of the Saggital section of the postnasal space (L E Loh et al 1991) nasal septum form the anterior boundary of the nasopharynx. The The superior constrictor muscle does superior surface of the soft palate not reach the base of skull hence a constitutes its floor and lateral gap (sinus of Morgagni) is velopharyngeal isthum provides created. Fossa of Rosenmüller is a communication between nasopharynx herniation of the nasopharyngeal and oropharynx. The body of mucosa through this deficiency sphenoid, basiocciput and first and between skull base and superior most second cervical vertebrae combine to fibers of the superior constrictor form roof of the nasopharynx. muscle. Through this gap bridged only by the pharyngobasilar fascia, the The part of nasopharynx proximal to eustachian tube enters the the tubal orifice is innervated by the nasopharynx with its two muscles, one maxillary division of the trigeminal (V) on each side. Along the inferior border nerve, and that posterior to the tubal of the two muscles the Fossa of orifice by the glossopharyngeal (IX) Rosenmüller is separated from the nerve. parapharyngeal space by mucosa and pharyngobasilar fascia. Functional studies with contrast and cinefluorography reveal structural The borders of the Fossa of differences between the two Rosenmüller are: components. Contractility is observed only in the posterior portion of Anterior: The eustachian tube, nasopharynx. the levator palatini. Anterolaterally: Tensor veli The key feature of the lateral wall of palatini muscle nasopharynx is the pharyngeal orifice Posteriorly: The of the Eustachian tube. Located in the retropharyngeal space, middle of the wall, it is about 1.5 cm Inferiorly: The upper edge of equidistant from the roof, posterior the superior constrictor muscle wall, choana and the floor. The tubal Laterally: The tensor veli elevation (torus tubarius), formed by palatini muscle and the elastic cartilage of the tube, is parapharyngeal space. particularly prominent in its upper and The superior border is the base posterior lip. Behind the posterior of the skull with the foramen margin of the torus, between it and lacerum medially, the petrous the posterior wall, lies the lateral apex and carotid canal posteriorly, and the foramina the age group of 18-66 years. Their ovale and spinosum findings are tabulated below: anterolaterally. 1 Range of depth 1.7 to 18.8 These anatomic relationships provide mm explanations for the symptoms 2 Range of width 1.6 to 7.4 commonly found in patients with mm disorders of the nasopharynx and the 3 No. of FOR> 10 22 (48%) pathways for direct extension of the mm in depth disease. 4 No. of FOR> 10 40 (87%) mm in depth 5 No. of FOR with 36 (78%) Anatomical relations of the fossa depth > width of Rosenmüller (FOR) are: 6 No. of FOR with 10 (22%) width > depth Anteriorly: Eustachian tube 7 Angle between 45 degrees and levator palatini. saggital plane and Posteriorly: Pharyngeal wall long axis of FOR mucosa overlying the 9 No. of FOR with 23 (50%) pharyngobasilar fascia and depth > 10mm retropharyngeal space. and orifice width Medially: Nasopharyngeal <5mm cavity. Superiorly: Foramen lacerum Their study reported that the FOR is and floor of carotid canal. deeper than perceived and that it has Posterolateral (apex): a relatively narrow orifice. The FOR Carotid canal opening and points laterally with its long axis petrous apex posteriorly, making an average angle of 45 foramen ovale and spinosum degrees with the Saggital plane. There laterally. is little variation between the left and Laterally: Tensor palatine and right FOR in any patient; the the mandibular nerve, and the difference in depth varies between 2 prestyloid compartment of the and 3 mm and difference in width of parapharyngeal space. The orifice within 1 mm. fossa forms the medial border of the most superior part of the FOR is far too deep and narrow for parapharyngeal space. clinical inspection be it with a postnasal mirror or nasopharyngoscope. 50% of patients have a depth of more than 10 mm and orifice narrower than 5 mm. In these cases, the FOR, in particular the floor of FOR, constitutes a blind spot of the postnasal space. Perhaps in these cases the postnasal space can never be declared normal based solely on clinical inspection. (L E Loh et al 1991) CT scan of FOR with patent orifice (L E Loh et al 1991) Lymphatic drainage L E Loh et al (1991) attempted to Lymphoid tissue is abundant in the study the anatomy of FOR using CT nasopharynx. Three main groups of scan in 23 patients (comprising 46 submucosal collecting pathways drain fossae of 17 males and 6 females) in the pharynx, the superior, middle, and inferior pathways. The superior and intracranial spread. (John Hoe, pathway provides the primary 1989) drainage of the nasopharynx along with a small contribution by the CT has been the most reliable and middle pathway. It drains the well-established imaging technique for oropharynx, soft palate, eustachian staging and assessing the extent of tube and fossa of Rosenmüller, nasopharyngeal carcinoma (NPC), tympanic cavity, and nasal fossae. although MR imaging is now replacing CT as the examination of choice in the The superior pathway is divided into nasophanynx. NPC has a tendency for median and lateral groups. submucosal spread, and diagnosis of the disease is usually not difficult on The median group drains the CT scans. The typical finding is roof and posterior border of the asymmetry of the fossa of nasopharynx into the lateral Rosenmuller manifested as blunting or retropharyngeal node. obliteration, often with associated thickening of the deglutitional muscle The lateral group drains the layer caused by tumor infiltration. As lateral nasopharynx, including NPC characteristically results in deep the fossa of Rosenmüller, and infiltration, there is often obliteration flows into the lateral half of the or displacement of the upper internal jugular chain or paraphanyngeal space. (John Hoe, into the lateral retropharyngeal 1989) node. The lateral group is often a single node or several confluent nodes, termed the node of Rouviere. Occasionally, the node is absent on 1 side and usually non palpable. (Simon Lo et al 2009) Nasopharyngeal carcinoma (NPC) arises most often posterosuperiorly in the postnasal space in the region of the Fossa of Rosenmuller. NPC may be entirely submucosal in site and in its early stages when it has not infiltrated through the pharyngobasilar fascia. This malignancy is a squamous cell carcinoma with varying degrees of differentiation arising from the epithelial lining of the CT scan of the nasopharynx and paranasal sinus demonstrates an asymmetry of the fossa of nasopharynx. (Sham JS, 1990) Rosenmuller with obliteration of the left parapharyngeal space Clinical examination, including (http://www.ispub.com/ostia/index.php?xmlFilePath =journals/ijhns/vol1n1/nerve.xml) endoscopic examination of the nasopharynx can provide valuable information on mucosal involvement and local tumor extension. It however cannot determine deep extension of the tumor such as skull base erosion Bibliography L E Loh, TSG Chee, AB John Sham JS,Wei WI,Zong YS,Choy :The anatomy of the Fossa of D,Guo YQ,Luo Y,et al. Detection Rossenmuller- Its possible of subclinical nasopharyngeal influence on the detection of carcinoma by fibreoptic occult nasopharyngeal endoscopy and multiple biopsy. carcinoma: Singapore Medical Lancet 1990 Feb 17;335 Journal; Vol 32 : 154-55 (8686):371–374. Simon Lo: Nasopharynx, Baharudin, H. Shahid, J. Wan Squamous Cell arcinoma. Shah, S. Din Suhaimi & S. http://emedicine.medscape.co Zulkiflee : A Rare Isolated m/ Bilateral Abducens Nerve Palsy file:///C:/Documents%20and% In Nasopharyngeal Carcinoma 20Settings/Admin/Desktop/foss (NPC) . The Internet Journal of a%20of%20rossen/Nasopharyn Head and Neck Surgery. 2007 x,%20Squamous%20Cell%20C Volume 1 Number 1 arcinoma%20%20[Print]%20- %20eMedicine%20Radiology.ht m (Accessed on 18/07/2010) John Hoe: CT of Nasopharyngeal Carcinoma: ________________________________ Significance of Widening of the (Document downloaded from Preoccipital Soft Tissue on Axial www.entlectures.com) Scans. AJR 153:867-872, ________________________________ October 1989 .
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  • Nose, Nasal Cavity & Paranasal Sinuses & Pharynx

    Nose, Nasal Cavity & Paranasal Sinuses & Pharynx

    Nose, Nasal cavity, Paranasal Sinuses & Pharynx Objectives . At the end of the lecture, the students should be able to: . Describe the boundaries of the nasal cavity. Describe the nasal conchae and meati. Demonstrate the openings in each meatus. Describe the paranasal sinuses and their functions . Describe the pharynx and its parts Nose . The external root (anterior ) nares or nostrils, lead to the tip nasal cavity. ala septum external nares Formed above by: 1 Bony skeleton 2 . Formed 3 below by plates of hyaline cartilage. Nasal Cavity . Extends from the external (anterior) nares to the posterior nares (choanae). Divided into right & left halves by the nasal septum. Each half has a: . Roof . Lateral wall . Medial wall (septum) . Floor Roof . Narrow & formed (from 3 2 4 behind forward) by the: 1 1. Body of sphenoid. 2. Cribriform plate of ethmoid bone. 3. Frontal bone. 4. Nasal bone & cartilage Floor • Separates it from the oral cavity. • Formed by the hard (bony) palate. Medial Wall (Nasal Septum) . Osteocartilaginous partition. Formed by: 1. Perpendicular plate of ethmoid 1 bone. 3 2. Vomer. 2 3. Septal cartilage. Lateral Wall . Shows three horizontal bony projections, the superior, middle & inferior conchae . The cavity below each concha is called a meatus and are named as superior, middle & inferior corresponding to the conchae. The small space above the superior concha is the sphenoethmoidal recess. The conchae increase the surface area of the nasal cavity. The recess & meati receive the openings of the: .Paranasal sinuses. .Nasolacrimal duct. Nasal mucosa – Olfactory : – It is delicate and contains olfactory nerve cells. It is present in the upper part of nasal cavity: .