Pharynx and
pterygopalatine fossa
J. B RADLEY BARGER, PH D
JB BARGER@ UAB .EDU
DENT 1250, 2019
LEARNING OBJECTIVES
1.Describe the boundaries of the pterygopalatine fossa and the openings by which this
fossa communicates with other areas of the head.
2.Describe the contents of the pterygopalatine fossa, especially the branches of the
maxillary nerve and the structures they supply.
3. Describe the bones and cartilages forming the external nose and the walls of the nasal
cavity.
4. Describe the nerve and blood supply of the nasal cavity.
5. Describe the functional significance of the paranasal sinuses and describe where they
drain into the nasal cavity.
6.Describe the clinical significance of the relationships of the paranasal sinuses and be
familiar with their nerve and blood supply.
LEARNING OBJECTIVES
1.Describe the boundaries of the pterygopalatine fossa and the openings by which this
fossa communicates with other areas of the head.
2.Describe the contents of the pterygopalatine fossa, especially the branches of the
maxillary nerve and the structures they supply.
3. Describe the bones and cartilages forming the external nose and the walls of the nasal
cavity.
4. Describe the nerve and blood supply of the nasal cavity.
5. Describe the functional significance of the paranasal sinuses and describe where they
drain into the nasal cavity.
6.Describe the clinical significance of the relationships of the paranasal sinuses and be
familiar with their nerve and blood supply.
BOUNDARIES OF PTERYGOPALATINE FOSSA
1. The PTERYGOPALATINE FOSSA
is a wedge-shaped space deep
on the side of the skull. It
derives its name from the fact
that its post. wall is formed by
the lat. pterygoid plate of the
sphenoid and its med. wall by
the perpendicular plate of the
palatine. The ant. wall is the
post. surface of the maxilla.
The ant. and post. walls
converge inferiorly.
Sphenoid bone
(lateral pterygoid plate)
Palatine bone
(perpendicular plate)
Maxillary bone
COMMUNICATIONS OF PTERYGOPALATINE FOSSA
THE PTERYGOPALATINE
FOSSA COMMUNICATES
WITH OTHER SPACES IN
THE HEAD VIA A
NUMBER OF OPENINGS:
1) via the
PTERYGOMAXILLARY
FISSURE with the
infratemporal fossa
(laterally)
2) via the INF. ORBITAL
FISSURE with the orbit
(anterosuperiorly)
3) via the
SPHENOPALATINE F. with
the nasal cavity
(medially)
COMMUNICATIONS OF PTERYGOPALATINE FOSSA
4) via the (GR. & LSR.) PALATINE
CANALS & FORAMINA with the palate
(inferiorly)
5) via the F. ROTUNDUM with the mid.
cranial fossa (posteriorly)
6) via the PTERYGOID CANAL with the
f. lacerum (middle cranial fossa)
(posteriorly).
7) via the PALATOVAGINAL CANAL
(PHARYNGEAL CANAL) with the
nasopharynx (posteriorly)
These openings allow imp. structures to
enter and leave the pterygopalatine
fossa and should be identified on a skull
in the lab.
MAXILLARY NERVE (V2)
Zygomatic n.
V1
V ganglion
Sensory root of V
V3
V2
Pterygopalatine ganglion
and nerves
TWO OF THE MOST IMP.
CONTENTS OF THE
PTERYGOPALATINE
Zygomaticotemporal n.
FOSSA ARE THE
MAXILLARY N. (V2) &
Zygomaticofacial n.
THE PTERYGOPALATINE
GANGLION. V2 enters
the fossa posteriorly (via
f. rotundum) and leaves
Infraorbital n.
the fossa
Anterior superior alveolar n. anterosuperiorly (via inf.
orbital fissure) to
become the infraorbital
Mucosa of maxillary sinus
n.
Dental and gingival branches
Middle superior alveolar n.
Posterior superior alveolar n.
V2 HAS NUMEROUS BRANCHES, INCLUDING THE FOLLOWING:
1. ZYGOMATIC N. --- This nerve enters the orbit and splits into
Zygomatic n.
the ZYGOMATICOTEMPORAL & ZYGOMATICOFACIAL NN.
V1
Zygomaticotemporal n.
which are cutaneous to the temple and face.
V ganglion
Zygomaticofacial n.
2. INFRAORBITAL N. --- This is the terminal part of the maxillary
Sensory root of V
n. Before reaching the infraorbital f. to supply skin of the
face, the infraorbital n. gives off the MID. SUP.ALVEOLAR N.
Infraorbital n.
to the maxillary premolars and the ANT. SUP. ALVEOLAR N.
Anterior superior alveolar n.
to the maxillary incisors and canine. These nerves run within
V3
the bone of the wall of the maxillary sinus and also supply
V2
Mucosa of maxillary sinus
the mucous membrane of the sinus.
Dental and gingival branches
3. POST. SUP. ALVEOLAR N. --- This nerve arises directly from
Pterygopalatine ganglion
V2. It enters the post. sup. alveolar foramina and canals to
and nerves
Middle superior alveolar n.
supply the maxillary molars and the mucosa of the maxillary
Posterior superior alveolar n.
sinus.
4. PTERYGOPALATINE NN. --- These short nerves connect V2
with the pterygopalatine ganglion. They contain primarily
sensory fibers (GSA) of V2 which pass through the ganglion
WITHOUT SYNAPSE to be distributed to the pharynx, palate
and nasal cavity. The branches of distribution to these areas
are illustrated in the following plate (next slide).
In this MEDIAL VIEW of the
MAXILLARY
pterygopalatine ganglion
some of the OTHER
(INDIRECT) BRANCHES OF V2
can be seen:
1) PHARYNGEAL BR. --Sensory to the roof of the
pharynx (above the auditory
tube).
Posterior superior
2) GR. & LSR. PALATINE NN. lateral nasal brs. (V2)
-- Sensory to the hard and
soft palates (resp.).
Posterior inferior
lateral nasal br. (V2)
3) POST. SUP. & POST. INF.
LAT. NASAL BRS. --- Sensory
to the lateral wall of the nasal
cavity.
4) NASOPALATINE N. --Nasopalatine n. (V2) (cut)
Sensory to the septum (med.
(passing to nasal septum)
wall) of the nasal cavity.
Pterygopalatine ganglion
NERVE (V2) (CONTINUED)
Greater palatine n. (V2)
Maxillary n. (V2)
Greater petrosal n. (VII)
(presynaptic parasympathetic)
Nerve of pterygoid canal
Pharyngeal br. (V2)
Lesser palatine n. (V2)
Also note the PTERYGOID CANAL (containing a
nerve of the same name) which passes from the f.
lacerum through the sphenoid to open into the
post. wall of the pterygopalatine fossa.
MAXILLARY NERVE (V2) (CONTINUED)
Maxillary n. (V2)
Posterior superior
lateral nasal brs. (V2)
Posterior inferior
lateral nasal br. (V2)
Greater petrosal n. (VII)
(presynaptic parasympathetic)
Nerve of pterygoid canal
Nasopalatine n. (V2) (cut)
(passing to nasal septum)
Pharyngeal br. (V2)
Pterygopalatine ganglion
Greater palatine n. (V2)
Lesser palatine n. (V2)
Pterygopalatine Nerve (Vidian) of
pterygoid canal
ganglion
Lacrimal gland
Deep petrosal n.
Greater petrosal n.
VII
Nerves to palate,
nose & pharynx
Int. carotid n.
Sup. cervical ganglion
T1 & T2 spinal nerves
Lateral horn
of T1 & T2
Presynaptic symp.
Postsynaptic symp.
Presynaptic parasymp.
Postsynaptic parasymp.
PTERYGOPALATINE
GANGLION (SCHEMA)
1. The PTERYGOPALATINE GANGLION is
a parasympathetic ganglion. Only
presynaptic parasympathetic fibers
from the gr. petrosal br. of VII
synapse in this ganglion (GSA fibers
from V2 and postsynaptic
sympathetic fibers from the deep
petrosal n. pass through the ganglion
without synapse). Postsynaptic
parasympathetic fibers supply the
glands of the orbit (lacrimal gl.), roof
of the nasopharynx, palate and nasal
cavity (secretomotor). (Note: the
postsynaptic sympathetic fibers in the
deep petrosal n. are destined mainly
for blood vessels).
The 3RD PART OF THE MAXILLARY
A. also lies in the pterygopalatine
fossa. It has numerous brs., the
most imp. of which are:
1) INFRAORBITAL A. --- In the floor
of the orbit this artery gives off the
MID. SUP. ALVEOLAR A. to the
premolars and the ANT. SUP.
ALVEOLAR A. to the incisors and
canine.
2) POST. SUP. ALVEOLAR A. --Supplies the molar teeth.
3) DESCENDING PALATINE A. --Not shown.
4) SPHENOPALATINE A. --- Not
shown.
MAXILLARY ARTERY (3RD PART)
Infraorbital a.
Post. superior alveolar a.
Mid. superior alveolar a.
Ant. superiro alveolar a.
Maxillary a. (1st part)
Inferior alveolar a. & n.
Ext. carotid a.
MAXILLARY ARTERY (3RD PART)(CONTINUED)
Sphenopalatine a.
Infraorbital a.
Post. superior alveolar a.
Descending
palatine a.
Left and right
greater palatine aa.
Left and right
lesser palatine aa.
Maxillary a.
(3 part)
Maxillary artery
(3rd rd
part)
1. The other BRS. OF THE 3RD PART OF
THE MAXILLARY A. are shown here. The
DESCENDING PALATINE A. splits into two
brs. --- the gr. and lsr. palatine aa. which
supply the hard and soft palates (resp.).
The SPHENOPALATINE A. passes through
the foramen of the same name to supply
the nasal cavity.
2. Note that the 2nd part of the maxillary a.
(in the infratemporal fossa) passes
through the pterygomaxillary fissure to
enter the pterygopalatine fossa.
LEARNING OBJECTIVES
1.Describe the boundaries of the pterygopalatine fossa and the openings by which this
fossa communicates with other areas of the head.
2.Describe the contents of the pterygopalatine fossa, especially the branches of the
maxillary nerve and the structures they supply.
3. Describe the bones and cartilages forming the external nose and the walls of the nasal
cavity.
4. Describe the nerve and blood supply of the nasal cavity.
5. Describe the functional significance of the paranasal sinuses and describe where they
drain into the nasal cavity.
6.Describe the clinical significance of the relationships of the paranasal sinuses and be
familiar with their nerve and blood supply.
EXTERNAL NOSE (SKELETAL FRAMEWORK)
Frontal bone
Nasal bones
Maxilla (frontal pr.)
Lateral processes of
septal cartilage
Septal cartilage
Lat. crus (grtr. alar cart.)
Med. crus (grtr. alar cart.)
Alar fibrofatty tissue
1. The EXTERNAL NOSE has
both a BONY &
CARTILAGINOUS
FRAMEWORK. The bones
are the nasal, frontal and
maxilla (frontal pr.). The
cartilages are the septal , lat.
nasal and greater alar.
EXTERNAL NOSE (MUSCLES, NERVES & VESSELS)
Procerus m.
Dorsal nasal a.
Infratrochlear n.
Ext. nasal a. & n.
Nasalis m. (transverse pt.)
Infraorbitl a. & n.
Lateral nasal a.
Depressor septi nasi m.
1. Various mm. of ext. nose
(mm. of facial expression,
innervated by VII).
2. Cutaneous innervation by
brs. of V1 and V2.
3. Vessels by brs. of
ophthalmic and facial aa.
REGIONS OF NASAL CAVITY
1. The nose consists of two parts: the external nose (visible
on face) and the nasal cavity (part which extends further
back into the skull).
2. The nasal cavity consists of three regions:
A. Nasal vestibule is a small dilated space just internal to
the naris that is lined with skin and contains hairs (filter air)
B. Respiratory region is the largest part of the nasal cavity.
It has a rich neurovascular supply, and is lined by respiratory
epithelium composed mainly of ciliated and mucous cells
(thus air is warmed and moistened as is passes over this
epithelium). The nasal cavity is literally an “air conditioner”.
C. Olfactory region is small. It is lined by olfactory
epithelium which contains olfactory neurons, the axons of
which constitute the olfactory n. (I) (The sense of smell in man
is poor compared to animals such as dogs).
NASAL CONCHAE AND MEATUSES
1. The nasal cavity has a roof, floor (palate), a
medial wall (septum) and a lateral wall (A).
2. Projecting from the lateral wall are three curved
shelves of bone termed the sup., mid., and inf.
conchae (B)
3. Inferior to each concha is a space (passage)
termed the sup., mid. and inf. meatus (C)
(Coronal section).
The space superior to the sup. concha is the
sphenoethmoidal recess.
4. The air stream passes through the nares,
meatuses and choanae to the nasopharynx (D)
5. The conchae serve to increase the surface area
of the respiratory mucosa which covers them.
MEDIAL WALL OF NASAL CAVITY (NASAL SEPTUM)
Frontal bone (nasal spine)
Nasal bone
Vomer
Groove for
nasopalatine n.
Septal cartilage
Incisive canal
Palatine process of maxilla
1. The NASAL SEPTUM (MED. WALL) is formed by
three elements: 1) the septal cartilage 2) the
Cribriform plate of ethmoid
perpendicular plate of the ethmoid and 3)
Perpendicular plate of ethmoid
the vomer. The nasal septum in adults is
Body of sphenoid
frequently deviated to one side; if severe,
surgical correction may be necessary to restore
free breathing.
2. The FLOOR of the nasal cavity is formed by the
hard palate, ie, the palatine pr. of the maxilla
and the horizontal plate of the palatine.
3. The ROOF of the nasal cavity has sloping ant.
and post. parts and a horizontal middle part.
The ant. part of the roof is composed of the
nasal cartilages, nasal bone and frontal bone
while the post. part is formed by the body of
the sphenoid. The middle part is the
cribriform ("sieve-like") plate of the ethmoid
which is perforated for the bundles of the
Horizontal plate of palatine
olfactory n. (I).
LATERAL WALL OF NASAL CAVITY
Lacrimal
Ethmoid bone
Middle nasal concha
Superior nasal concha
Supreme nasal concha
Sphenopalatine f.
Sphenoid
(med. pterygoid plate)
Maxilla (frontal process)
Inf. nasal concha
Palatine (perpendicular plate)
1. The LAT. WALL of the nasal
cavity is uneven and is formed
by numerous bones: maxilla,
lacrimal, ethmoid, inf. nasal
concha, perpendicular plate
of palatine and med.
pterygoid plate of sphenoid.
The sup. and mid. conchae
(and sometimes the supreme
concha) are parts of the
ethmoid; the inf. concha is a
separate bone. Note that the
palatine bone is L-shaped; the
perpendicular plate and
horizontal plate contribute to
the lat. wall and floor (resp.) of
the nasal cavity. Note also the
sphenopalatine f. in the
posterosuperior part of the
lat. wall.
LATERAL WALL OF NASAL CAVITY
(CONCHAE PARTLY REMOVED)
Ethmoidal bulla
Middle nasal
concha
(cut away)
Semilunar hiatus
Uncinate process
In this dissection the MID. NASAL CONCHA
HAS BEEN CUT AWAY to expose some
deeper structures.
1. The ETHMOIDAL BULLA is a bulge
produced by the mid. ethmoidal air
cells. Inferior to the bullla is a curved
ridge of bone called the UNCINATE PR.
Between the bulla and uncinate pr. is a
curved groove, the SEMILUNAR HIATUS,
which receives the openings of some of
the paranasal sinuses.
1. The ethmoid bone is the KEY
bone of the nasal cavity. It
contributes to the roof
(cribriform plate), septum
(perpendicular plate) and
lateral wall (ethmoidal
labyrinth) of the nasal cavity.
2. The two ethmoidal labyrinths
(one on each side) are box-like
parts that contain the
ethmoidal air cells. The
middle ethmoidal air cells
cause a swelling called the
ethmoidal bulla. Projecting
from the ethmoidal labyrinths
are the superior and middle
conchae. (Note that the
inferior concha is a separate
bone).
PARTS & RELATIONSHIPS OF ETHMOID BONE
Hiatus semilunaris
3. The uncinate process of
the ethmoid lies below
the bulla and is separated
from the bulla by the
hiatus semilunaris .
4. Also note crista galli of
ethmid projecting into
ant. cranial fossa.
PARTS & RELATIONSHIPS OF ETHMOID BONE
Hiatus semilunaris
NERVE SUPPLY OF NASAL CAVITY
1. The NERVES OF
GENERAL SENSATION
(GSA) ARE BRS. OF V1 &
V2. The ANT.
ETHMOIDAL N. (V1)
supplies the
anterosuperior part of
both the septum and lat.
wall. The remainder of
the septum is supplied
by the NASOPALATINE
N. (V2), while the
remainder of the lat.
wall is by the POST. SUP.
& POST. INF. LAT. NASAL
BRS. OF V2.
NERVE SUPPLY OF NASAL CAVITY
2. The OLFACTORY REGION OF
THE NASAL CAVITY is
confined to the roof and
adjacent parts of the
septum and lat. wall.
Bipolar olfactory neurons
send their axons (SVA)
through the cribriform plate
of the ethmoid to end in
the olfactory bulb. Loss of
smell (ANOSMIA) may occur
following fractures of the
cribriform plate. (NB There
is also a gradual loss of
olfactory neurons with age
(~1% per year). Since each
one-half of the nasal cavity
contains ~ 25 million
olfactory neurons in a
young adult I don't think
this is something to worry
about.)
ARTERIAL SUPPLY OF NASAL CAVITY
Region of
epistaxis
1. The ARTERIAL SUPPLY to the nasal cavity is from the SPHENOPALATINE A. and the ANT. &
POST. ETHMOIDAL AA. The sphenopalatine a. enters the nasal cavity through the
sphenopalatine f. and divides into brs. for both the septum and lat. wall. (The ant. and
post. ethmoidal aa. do the same.)
2. In the REGION OF THE ANTEROINFERIOR PART OF THE SEPTUM the sphenopalatine a.
anastomoses with the septal br. of the sup. labial a. and with the gr. palatine a. This is the
region where EPISTAXIS (NOSEBLEED) USUALLY OCCURS. (Epistaxis may be the result of
trauma, infections or hypertension . If it is so severe that it cannot be controlled by the
usual means ligation of the ext. carotid a. may be required.)
LEARNING OBJECTIVES
1.Describe the boundaries of the pterygopalatine fossa and the openings by which this
fossa communicates with other areas of the head.
2.Describe the contents of the pterygopalatine fossa, especially the branches of the
maxillary nerve and the structures they supply.
3. Describe the bones and cartilages forming the external nose and the walls of the nasal
cavity.
4. Describe the nerve and blood supply of the nasal cavity.
5. Describe the functional significance of the paranasal sinuses and describe where they
drain into the nasal cavity.
6.Describe the clinical significance of the relationships of the paranasal sinuses and be
familiar with their nerve and blood supply.
PARANASAL SINUSES
1. The PARANASAL SINUSES are AIR-FILLED SPACES WITHIN THE FRONTAL, SPHENOID, ETHMOID
AND MAXILLARY BONES. All of the sinuses are paired (even the sphenoid) and all open into the
nasal cavity because they develop as outgrowths of that cavity. The paranasal sinuses are lined
with mucous membranes that contain cilia. They vary considerably in size between individuals
and may be asymetrical in the same person. The ethmoid sinus consists of a series of small cells
(3-18) rather than a single space.
2. The FUNCTIONS which have been ascribed to the paranasal sinuses are numerous. Among these
are: 1) act as resonating chambers for the voice 2) lighten the skull 3) bring about an equal
distribution of weight in the head (this could explain their asymetry in some individuals) 4) add
moisture (in the form of mucus) to the nasal cavity and 5) produce nitric oxide! (In a recent study
it was shown that exhaled nitric oxide in humans originates mainly from the sinuses, and it was
speculated that this contributes to the control of bacteria and to the functioning of the epithelial
cilia). The morphology of the frontal sinus is also useful in forensic medicine because it can be
used to identify skeletal remains.
3. DRAINAGE of the sinuses is by ciliary action and perhaps by suction during blowing of the nose.
Sometimes the sinuses become infected (sinusitis) and do not drain properly.
DEVELOPMENT OF PARANASAL SINUSES
Orbit
Frontal sinus
Birth
1 year
4 years
7 years
12 years
Adult
Nasal septum
Old age
Maxillary sinus
Molar tooth
Palate
1. The paranasal sinuses are either absent
(eg., frontal) or very small (eg.,
maxillary) at birth.
2. Growth of the sinuses during childhood
is imp. in altering the size and shape of
the face, and in adding resonance to the
voice during adolescence.
DRAINAGE OF PARANASAL SINUSES
Frontal sinus
Opening into sphenoethmoidal recess
Probe passing via frontonasal duct
into middle meatus
Sphenoid sinus
Superior nasal meatus
w/openings of posterior
ethmoidal cells
Ethmoidal bulla
Openings of mid. ethmoid cells
Semilunar hiatus w/openings
of anterior ethmoidal cells
Opening of nasolacrimal duct
Opening of maxillary
sinus
1. The OPENINGS OF THE PARANASAL SINUSES INTO THE NASAL CAVITY are shown (note that the mid. and
inf. conchae have been removed). The SPHENOID SINUS opens through its ant. wall into the
sphenoethmoidal recess. The FRONTAL SINUS opens into the ant. part of the mid. meatus. The
MAXILLARY SINUS opens into the post. part of the semilunar hiatus. The ETHMOIDAL CELLS are divided
into ant., mid. and post. groups. The ANT. GROUP opens into the ant. part of the semilunar hiatus, the
MID. GROUP onto the ethmoidal bulla and the POST. GROUP into the sup. meatus. The NASOLACRIMAL
DUCT (from the lacrimal sac) empties into the ant. part of the inf. meatus.
RELATIONSHIPS OF THE FRONTAL SINUS
Brain
(in ant. cranial fossa)
Frontal sinus
Nasal cavities
Orbit
1. The frontal sinus is related to the orbit
and nasal cavity inferiorly, and to the
anterior cranial fossa superiorly.
2. The nerve and blood supply are by the
supraorbital n. and a.
Nasal cavities
RELATIONSHIPS OF ETHMOID SINUS
Ethmoidal cells
1. The ethmoid sinus is related to the nasal cavity
medially and to the orbit laterally. Careless
exploration of posterior ethmoid air cells has
resulted in blindness by damaging the optic n.
2. Nerve and blood supply to ethmoid sinus is by
the anterior and posterior ethmoidal nn. and aa.
Medial wall of orbit
(lamina papyracea)
Optic n.
RELATIONSHIPS OF SPHENOID SINUS
1. Sphenoid sinus is related to
pituitary gland superiorly,
nasopharynx inferiorly, nasal cavity
anteriorly (note opening in its
anterior wall leading to
sphenoethmoidal recess), and the
pons posteriorly. Pituitary gland
can be approached surgically
through nasal cavity and sphenoid
sinus.
2. Nerve and blood supply to sinus is
via pharyngeal n. (V2) and posterior
ethmoidal n. (V1), and
corresponding aa.
Pituitary gland
Opening of sphenoid
sinus into nasal cavity
Pons
Nasopharynx
Sphenoid sinus
RELATIONSHIPS OF SPHENOID SINUS
1. Sphenoid sinuses (note bony
partition) are related
laterally to the cavernous
sinuses (which contain ICAs).
Int. carotid a.
in cavernous sinus
Sphenoid sinus
Nasopharynx
Pituitary gland
RELATIONSHIPS OF MAXILLARY SINUS
Opening of sinus into middle meatus
of nasal cavity
Maxillary sinus
Orbital surface
Facial surface
Roots of teeth
Infratemporal surface
1. The MAXILLARY SINUS is the largest of the paranasal sinuses.
Note its RELATIONSHIPS:
1) FACE (anteriorly)
2) INFRATEMPORAL & PTERYGOPALATINE FOSSAE (posteriorly)
3) ORBIT (superiorly)
*4) ALVEOLAR PR. OF MAXILLA (WITH ROOTS OF MOLAR TEETH --- AND SOMETIMES PREMOLARS
AND CANINE AS WELL) (inferiorly). The relationships of the maxillary sinus to the roots of the teeth is
imp. because tooth infections can spread into the sinus. Extractions may also result in breaking off the root
tips which may become lodged in the sinus.
2. The opening of the maxillary sinus into the mid. meatus is HIGH on the med. wall of the sinus --- a poor location in terms
of drainage. Because of this fact the maxillary sinus is the sinus most frequently infected. (Sometimes MAXILLARY
SINUSITIS IS ACCOMPANIED BY TOOTHACHE. This is because the mucosa lining of the sinus is innervated by the three
superior alveolar nerves --- the same nerves that innervate the maxillary teeth. This is an example of referred pain. In
some cases of sinusitis it may be necessay to surgically widen the opening into the nasal cavity. The approach used is
through the thin bone of the canine fossa).
3. The three superior alveolar aa. supply blood to the sinus.
LEARNING OBJECTIVES
1. Describe the functions of the pharynx.
2. Describe the different parts of the pharynx and their boundaries and relationships to each other.
3. Describe the main anatomical features seen in each part of the pharynx and their functional and clinical
significance.
4. Name the layers that compose the pharyngeal wall.
5. Describe the arrangement of the muscles of the pharynx, as well as their attachments, functions and
innervations.
6. Describe the mechanism of swallowing.
7. Describe the sensory innervation of the pharynx.
8. Describe the composition of the pharyngeal nerve plexus.
9. Describe the blood supply and lymphatic drainage of the pharynx.
10. Name the bony structures that form the atlanto-occipital (AO) and atlanto-axial (AA) joints and the ligaments
associated with these joints. Also, describe the types of movement permitted at these joints.
11. Describe the attachments, functions and innervation of the prevertebral muscles.
12. Describe the structure of the cervical part of the sympathetic trunk and the anatomical basis for the condition
known as “Horner’s syndrome.”
LEARNING OBJECTIVES
1. Describe the functions of the pharynx.
2. Describe the different parts of the pharynx and their boundaries and relationships to each other.
3. Describe the main anatomical features seen in each part of the pharynx and their functional and clinical
significance.
4. Name the layers that compose the pharyngeal wall.
5. Describe the arrangement of the muscles of the pharynx, as well as their attachments, functions and
innervations.
6. Describe the mechanism of swallowing.
7. Describe the sensory innervation of the pharynx.
8. Describe the composition of the pharyngeal nerve plexus.
9. Describe the blood supply and lymphatic drainage of the pharynx.
10. Name the bony structures that form the atlanto-occipital (AO) and atlanto-axial (AA) joints and the ligaments
associated with these joints. Also, describe the types of movement permitted at these joints.
11. Describe the attachments, functions and innervation of the prevertebral muscles.
12. Describe the structure of the cervical part of the sympathetic trunk and the anatomical basis for the condition
known as “Horner’s syndrome.”
SUBDIVISIONS OF THE PHARYNX
NASAL CAVITY
NASOPHARYNX
ORAL CAVITY
OROPHARYNX
LARYNX
C6
Trachea
AIR
FOOD
LARYNGOPHARYNX
Esophagus
PHARYNX IN POSTERIOR VIEW
Base of skull
(5 cm)
CV6
(1.5 cm)
Esophagus
NASOPHARYNX (MUCOSA INTACT)
Pharyngeal tonsil
Choana
Orifice of auditory tube
Pharyngeal recess
Torus tubarius
Torus levatorius
Salpingopharyngeal fold
Uvula
Pharyngeal
isthmus
NASOPHARYNX (MUCOSA REMOVED)
Cartilage of auditory tube
Tensor (veli) palatini
Levator (veli) palatini
Salpingopharyngeus
PHARYNGOTYMPANIC (AUDITORY) TUBE
Nasopharynx
Tympanic cavity
Pharyngotympanic (auditory) tube
OROPHARYNX IN ANTERIOR VIEW
(BOUNDARIES OF OROPHARYNGEAL ISTHMUS)
Soft palate
Palatoglossal arch
Dorsum of tongue
Epiglottis
Median glossoepiglottic fold
Lateral glossoepiglottic fold
Vallecula
Root
Body
Palatopharyngeal arch
Palatine tonsil
Lingual tonsil
Palatoglossal arch
TONSILLAR BED
Tonsillar br. of facial a.
External palatine
(paratonsillar) v.
Glossopharyngeal n. (IX)
Superior constrictor
Choanae
NASOPHARYNX
Soft palate
OROPHARYNX
Root of tongue
Epiglottis
LARYNGOPHARYNX
Aryepiglottic fold
Piriform recess
with fold over internal
laryngeal n.
NERVES DEEP TO MUCOSA OF
PIRIFORM RECESS
Internal laryngeal n.
Recurrent laryngeal n.
WALDEYER’S RING
LEARNING OBJECTIVES
1. Describe the functions of the pharynx.
2. Describe the different parts of the pharynx and their boundaries and relationships to each other.
3. Describe the main anatomical features seen in each part of the pharynx and their functional and clinical
significance.
4. Name the layers that compose the pharyngeal wall.
5. Describe the arrangement of the muscles of the pharynx, as well as their attachments, functions and
innervations.
6. Describe the mechanism of swallowing.
7. Describe the sensory innervation of the pharynx.
8. Describe the composition of the pharyngeal nerve plexus.
9. Describe the blood supply and lymphatic drainage of the pharynx.
10. Name the bony structures that form the atlanto-occipital (AO) and atlanto-axial (AA) joints and the ligaments
associated with these joints. Also, describe the types of movement permitted at these joints.
11. Describe the attachments, functions and innervation of the prevertebral muscles.
12. Describe the structure of the cervical part of the sympathetic trunk and the anatomical basis for the condition
known as “Horner’s syndrome.”
WALL OF PHARYNX
1. Mucous membrane
2. Pharyngobasilar fascia
3. Muscle layer
4. Buccopharyngeal fascia
1. The WALL OF THE PHARYNX consists of
FOUR LAYERS: 1) MUCOSA (innermost)
2) PHARYNGOBASILAR FASCIA (esp.
thick near the base of the skull) 3)
MUSCULAR (with inner longitudinal and
outer circular parts) and 4)
BUCCOPHARYNGEAL FASCIA
(outermost).
2. I will concentrate on the muscular layer.
THREE PHARYNGEAL CONSTRICTOR MUSCLES
Superior constrictor
Pterygomandibular raphe
Middle constrictor
Inferior constrictor
Esophagus
1. The OUTER LAYER OF PHARYNGEAL MUSCLES is
composed of the THREE CONSTRICTORS. The fibers of
the constrictors are circularly arranged with the inf.
constrictor overlapping the mid. constrictor, and the
mid. constrictor overlapping the sup. constrictor (like
three stacked flower pots). The constrictors take their
origin from bones and cartilages anteriorly and sweep
back to a common insertion into a median raphe
posteriorly. Thus, they contribute to the lat. and post.
walls of the pharynx but not to the ant. wall.
1. The SUP. CONSTRICTOR M. originates from the
pterygomandibular raphe and the bone at either end
of the raphe (ie, the pterygoid hamulus and the post.
end of the mylohyoid line of the mandible). The raphe
also serves for part of the origin of the buccinator m.
2. The MID. CONSTRICTOR M. originates from the hyoid
bone and the lower end of the stylohyoid lig.
3. The INF. CONSTRICTOR M. has two parts: 1)
THYROPHARYNGEUS (originates from thyroid
cartilage) and 2) CRICOPHARYNGEUS (originates from
cricoid cartilage). The cricopharyngeus acts as a
sphincter to prevent air from entering the esophagus
(causing "gas"). Clinically the cricopharyngeus is imp.
because it may undergo spasm leading to obstruction
of the food channel. As a result an outpocketing of the
pharyngeal wall (HYPOPHARYNGEAL DIVERTICULUM)
may develop. Such a diverticulum may become so
large that it may interfere with the nutrition of the
individual and have to be treated surgically!
4. All three constrictor muscles insert into a midline raphe
in the posterior wall of the pharynx.
Pterygomandibular raphe
Superior pharyngeal constrictor m.
Middle pharyngeal constrictor m.
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Inferior pharyngeal constrictor m.
Zone of sparse muscle fibers
Cricopharyngeus m.
(part of inferior constrictor m.)
Posterior Pharyngeal Wall: Opened
Styloid process
Cartilaginous part of
pharyngotympanic tube
Stylopharyngeus m.
Salpingopharyngeus m.
Palatopharyngeus m.
Pharyngobasilar fascia
Pharyngeal raphe
Stylopharyngeus m.
Superior constrictor m.
Middle constrictor m.
Longitudinal pharyngeal mm.
Inferior constrictor m.
Cricopharyngeus m.
Posterior border of thyroid cartilage lamina
1. The INNER LONGITUDINAL LAYER OF
PHARYNGEAL MUSCLES is composed of
the stylopharyngeus, palatopharyngeus
and salpingopharyngeus. The
STYLOPHARYNGEUS descends from the
styloid pr. and passes between the sup.
and mid. constrictor mm. (useful
relationship for identifying the
constrictor mm. in lab).
2. The PALATOPHARYNGEUS descends
from the palate. The stylo- and
palatopharyngeus blend inferiorly and
have a common insertion into the
thyroid cartilage and wall of the
pharynx.
3. The SALPINGOPHARYNGEUS is a tiny
muscle which descends from the
cartilage of the auditory tube ("salpinx"
means tube) and blends with the
palatopharyngeus.
(Mechanism of Swallowing)
Tensor palati m.
Levator palati m.
Salpingopharyngeus m.
Passavant’s ridge
Superior constrictor m.
Palatopharyngeus m.
Mylohyoid m.
Stylopharyngeus m.
Middle constrictor m.
Inferior constrictor m.
Cricopharyngeus m.
Circular esophageal m.
SWALLOWING (DEGLUTITION) can be described in three
stages. In the FIRST STAGE, which is voluntary and occurs in
the mouth, the bolus of food is pushed back into the
oropharynx by the tongue and mylohyoid mm.
The SECOND STAGE is involuntary and occurs in the pharynx.
This is a rapid and complex stage. The respiratory passage is
closed off both below (at the laryngeal inlet) and above (at
the pharyngeal isthmus). The pharyngeal isthmus is closed
by pulling the soft palate against the post. pharyngeal wall.
The tensor and levator palati mm. move the soft palate
while the uppermost fibers of the palatopharyngeus m.
(Passavant's ridge) pull the pharyngeal wall forward. The
pharynx is then elevated by the three longitudinal muscles
(stylo-, palato- and salpingopharyngeus) to receive the
bolus. This is followed by the serial contraction of the three
constrictors which push the bolus toward the esophagus.
The THIRD STAGE occurs in the esophagus. It is also
involuntary and occurs rapidly. Peristaltic action of the
esophageal musculature forces the bolus inferiorly toward
the stomach.
FOUR GAPS IN THE PHARYNGEAL MUSCULATURE
Various structures pass
through gaps in the pharyngeal
musculature:
1. Levator palati m. passes
through the gap between the
base of the skull and the sup.
constrictor m.
2. Stylopharyngeus m. and
IX pass through the gap
between the sup. and mid.
constrictor mm.
3. Int. laryngeal n. and sup.
laryngeal a. pass through the
gap between the mid. and inf.
constrictor mm.
4. Rec. laryngeal n. and inf.
laryngeal a. pass deep to the
inferior border of the inf.
constrictor m.
Levator palati
Superior constrictor
Stylopharyngeus & IX
Internal laryngeal n.
& superior laryngeal a.
Middle constrictor
Inferior constrictor
Recurrent laryngeal n.
& inferior laryngeal a.
LEARNING OBJECTIVES
1. Describe the functions of the pharynx.
2. Describe the different parts of the pharynx and their boundaries and relationships to each other.
3. Describe the main anatomical features seen in each part of the pharynx and their functional and clinical
significance.
4. Name the layers that compose the pharyngeal wall.
5. Describe the arrangement of the muscles of the pharynx, as well as their attachments, functions and
innervations.
6. Describe the mechanism of swallowing.
7. Describe the sensory innervation of the pharynx.
8. Describe the composition of the pharyngeal nerve plexus.
9. Describe the blood supply and lymphatic drainage of the pharynx.
10. Name the bony structures that form the atlanto-occipital (AO) and atlanto-axial (AA) joints and the ligaments
associated with these joints. Also, describe the types of movement permitted at these joints.
11. Describe the attachments, functions and innervation of the prevertebral muscles.
12. Describe the structure of the cervical part of the sympathetic trunk and the anatomical basis for the condition
known as “Horner’s syndrome.”
MOTOR INNERVATION OF PHARYNX
Glossopharyngeal n.
(to stylopharyngeus)
1. The MOTOR INNERVATION TO THE
PHARYNGEAL MUSCLES is via IX
and X. The STYLOPHARYNGEUS
(shown but not labelled) is
innervated by a small twig from
the glossopharyngeal n. (IX). Note
how IX "winds around" the
stylopharyngeus on its way to the
tongue. ALL OF THE OTHER
PHARYNGEAL MM. receive their
innervation from the pharyngeal
br. of X. (In both cases the
functional component is SVE).
Pharyngeal branch of X
(to other pharyngeal mm.)
X
(Medial view)
Trigeminal (V2)
via pharyngeal branch of
pterygopalatine ganglion
Glossopharyngeal (IX)
via pharyngeal plexus
via tonsillar branches
taste plus general
sensation via
lingual branches
Vagus (X)
via internal laryngeal n.
Trigeminal n. (V)
Glossopharyngeal n. (IX)
Vagus n. (X)
Facial n. (VII)
1. The SENSORY INNERVATION OF THE
PHARYNX is via three cranial nerves.
ABOVE THE ORIFICE OF THE
AUDITORY TUBE the nerve supply is
V2 (GSA). BETWEEN THE AUDITORY
TUBE AND LARYNGEAL INLET the
innervation is by IX (GVA). BELOW
THE LARYNGEAL INLET the
innervation is by X (also GVA).
There may be some overlap in the
regions supplied.
2. The GAG REFLEX is elicited when the
posterior wall of the oropharynx is
touched (eg, with a toothbrush).
This causes elevation of the soft
palate and movement of the
tongue. The afferent limb of the
reflex is IX (and perhaps X); the
efferent limb involves X and XII.
PHARYNGEAL PLEXUS OF NERVES
Pharyngeal br. of IX (GVA)
Pharyngeal br. of X (SVE)
The PHARYNGEAL PLEXUS OF NERVES is
a network of fibers located primarily on
the mid. constrictor m. It receives
contributions from three sources: 1)
pharyngeal br. of IX (GVA, sensory to
mucosa of pharynx) 2) pharyngeal br. of
X (SVE, motor to most of the pharyngeal
muscles) and 3) pharyngeal br. of sup.
cervical sympathetic ganglion (not
shown)(GVE, vasomotor).
ARTERIAL SUPPLY TO PHARYNX
1. The ARTERIAL SUPPLY TO THE
PHARYNX is from the ascending
pharyngeal a. and the sup. and inf.
thyroid aa.
Ascending pharyngeal a.
Superior constrictor m.
Ascending pharyngeal a.
Superior thyroid a.
Inferior thyroid a.
VENOUS DRAINAGE OF PHARYNX
1. The PHARYNGEAL PLEXUS OF VV. lies
on the post. wall of the pharynx. This
plexus drains into the IJV.
Retropharyngeal nodes
Jugulodigastric node
Superior deep cervical
nodes
1. LYMPHATIC DRAINAGE OF THE
PHARYNX is to the
retropharyngeal and sup. deep
cervical nodes. The
jugulodigastric node (the
uppermost deep cervical node)
receives most of the lymph from
the palatine tonsil and is
therefore sometimes referred to
as the tonsillar node.
NEUROVASCULAR RELATIONSHIPS
1. The last four cranial nerves and the
sympathetic trunk are related to the
pharynx.
2. IX winds around stylopharyangeus m.
X descends in carotid sheath (look also for
sup. laryngeal br. of X)
XI passes into deep surface of SCM.
XII curves inferiorly and anteriorly toward
tongue, crossing lateral to both carotid aa.
(Note that XII is closely bound to
X at skull base and at first appears to be a
branch of X).
3. Sympathetic trunk has been pulled
medially in this slide. It lies just posterior to
carotid sheath.
XI
IX
XII
Sympathetic trunk
Com. & int. carotid aa.,
IJV, X
LEARNING OBJECTIVES
1. Describe the functions of the pharynx.
2. Describe the different parts of the pharynx and their boundaries and relationships to each other.
3. Describe the main anatomical features seen in each part of the pharynx and their functional and clinical
significance.
4. Name the layers that compose the pharyngeal wall.
5. Describe the arrangement of the muscles of the pharynx, as well as their attachments, functions and
innervations.
6. Describe the mechanism of swallowing.
7. Describe the sensory innervation of the pharynx.
8. Describe the composition of the pharyngeal nerve plexus.
9. Describe the blood supply and lymphatic drainage of the pharynx.
10. Name the bony structures that form the atlanto-occipital (AO) and atlanto-axial (AA) joints and the ligaments
associated with these joints. Also, describe the types of movement permitted at these joints.
11. Describe the attachments, functions and innervation of the prevertebral muscles.
12. Describe the structure of the cervical part of the sympathetic trunk and the anatomical basis for the condition
known as “Horner’s syndrome.”
Ant. tubercle
REVIEW: C1-C2
Facet for dens
Ant. arch
Lateral mass
Transverse pr.
Tubercle for
transverse lig.
Transverse foramen
Sup. facet for
occipital condyle
Post. arch
Post. tubercle
Groove for vertebral a.
ATLAS (C1): SUPERIOR VIEW
Dens
Sup. facet for atlas
Interarticular part
Inf. articular pr.
Post. facet for
transverse lig.
Body
Transverse pr.
Spinous pr.
AXIS (C2): POSTEROSUPERIOR VIEW
1. Atlas:
a. Atlas is essentially a ring of bone, consisting of two lateral masses connected by ant. and post. arches.
b. Transverse processes project further laterally than other cervical vertebrae (giving mechanical advantage to
muscles that attach to it (eg., inf. oblique). Transverse foramen for passage of vertebral a.
c. Ant. tubercle is for attachment of ant. longitudinal lig. and upper end of longus colli m.
d. Atlas has no spine, just a post. tubercle on post. arch.
e. Post. arch has groove for vertebral a.
f. Lateral masses have concave, kidney-shaped facets superiorly for reception of the occipital condyles.
g. Each lateral mass also has a tubercle for attachment of the transverse ligament of the atlas which runs from
one lateral mass to the other.
h. Anterior arch has a facet on its posterior aspect for articulation w/ the dens.
2. Axis
a. Strongest of cervical vetebrae.
b. Has two large, flat bearing surfaces, superior articular facets, for articulation w/the atlas above.
c. Dens (odontoid process) represents body of atlas and projects superiorly to articulate with the ant. arch of
the atlas. Dens also has a facet on its posterior aspect for the transverse lig. of the atlas.
d. Spinous process of axis is large and bifid.
1. The joints between the sup. articular facets of the atlas and the occipital condyles are the ATLANTOOCCIPITAL (AO) JOINTS. Together the
two joints act as an ELLIPSOID JOINT. They permit flexion and extension of the head, as well as lateral flexion (bending to the side).
2. There are three ATLANTOAXIAL (AA) JOINTS. The TWO LAT. AA JOINTS are between the inf. articular facets of the atlas and the sup.
articular facets of the axis. These are GLIDING JOINTS. The MEDIAN AA JOINT is a PIVOT JOINT. It is formed by the articulation between the
dens and the ant. arch of the atlas, and between the dens and the transverse lig. of the atlas . When one rotates the head from side to side (eg,
shaking the head "no"), the skull + atlas rotate together around a central stationary pivot --- the dens.
Atlas and Axis
(superior view)
Dens
Facet for
occipital
condyle
Facet for
transverse
ligament
C1
C2
C3
C4
Atlanto-occipital Joints (Ellipsoid)
Allow flexion/extension of head (nodding “yes”)
Allow lateral flexion of head
Lateral atlanto-axial joints (gliding)
Median atlanto-axial joint (pivot)
ROTATION OF THE HEAD OCCURS AT THE ATLANTO-AXIAL JOINTS
Spinous processes and parts of vertebral
arches removed: posterior view
Basilar part of occipital bone
Tectorial membrane
Capsule of AO
joint
Atlas (C1)
Capsule of lateral
AA joint
Axis (C2)
Deeper (accessory part) of tectorial membrane
Posterior longitudinal ligament
Alar ligaments
Capsule of
zygopophysial joint
(C2-C3)
Atlas (C1)
Superior longitudinal band
CRUCIATE
LIGAMENT
Transverse ligament of atlas
Inferior longitudinal band
Deeper (accessory part)
of tectorial membrane
Axis(C2)
Principal part of tectorial membrane
removed: posterior view
Left side of plate
1. The POST. LONGITUDINAL LIG. runs along the post. surfaces of the vertebral bodies
within the vertebral canal. Its upward continuation (above the axis) is the TECTORIAL
MEMBRANE.
Right side of plate
2. Deep to the tectorial membrane are some imp. ligaments related to the median AA
joint. The thick TRANSVERSE LIG. OF THE ATLAS holds the dens against the ant.
arch of the atlas. The SUP. & INF. LONGITUDINAL FIBERS pass to the ant. margin of
the f. magnum and the body of the axis (resp.). The transverse lig. + the sup. and inf.
longitudinal fibers form the CRUCIFORM LIG. The strong ALAR LIGS. pass
superolaterally from the dens to the med. aspects of the occipital condyles.
Atlas (C1)
Apical ligament of dens
Alar ligament
Facet of dens
(for transverse lig.)
Alar ligament
Anterior tubercle of atlas
Synovial cavities
Axis (C2)
Dens
Cruciate ligament removed:
posterior view
Transverse ligament
of atlas
Median atlantoaxial joint: superior view
ON THE LEFT SIDE OF THE PLATE note the ALAR LIGS. These ligs. are also known as "check ligs." because they function to check
(restrict) the amount of rotation at the median AA joint. Rupture of an alar ligament results in an increase of ~ 30% in the range
of movement to the contralateral
note the TRANSVERSE LIG. OF THE ATLAS. Along with the ant. arch of the atlas, the transverse lig. forms a fibrous/bony ring
surrounding the dens of the axis. This ring rotates around the dens forming a pivot joint. By keeping the dens against the ant.
arch of the atlas, the transverse lig. prevents the dens from post. displacement which could damage the spinal cord.
FRACTURE & DISLOCATION OF THE ATLAS
(JEFFERSON OR BURST FRACTURE)
Note the fractures of both the anterior and posterior
arches of the atlas, and the lateral displacement of
the lateral masses.
A Jefferson fracture in itself does not necessarily
result in spinal cord injury, b/c the dimensions of the
bony ring actually increase. Spinal cord injury is more
likely, however, if the transverse ligament is also
ruptured. (On left) Note that the lateral masses are
wedge-shaped, with the thick sides of the wedges
directed laterally. Thus, vertical compressive forces
(as would result from striking the bottom of a pool in
a diving accident) tend to drive the lateral masses
laterally (arrows), fracturing one or both of the bony
arches of the atlas. If the force is great enough, the
transverse ligament of the atlas will also rupture. This
type of fracture is called a Jefferson (or burst)
fracture.
Coronal section (on right) showing direction of
vertical compressive forces and lateral movement of
the lateral masses of the atlas resulting in a Jefferson
fracture.
FRACTURE & DISLOCATION OF THE ATLAS
(JEFFERSON OR BURST FRACTURE)
Basilar part
of occipital bone
Jugular process
of occipital bone
Longus capitis m. (cut)
Occipital condyle
Rectus capitis anterior m.
Rectus capitis lateralis m.
Transverse process of atlas
Longus capitis m.
Longus colli m.
1. O ,I, F of prevertebral mm.
a. Longus colli m.
O – upper thoracic and lower
cervical vertebrae
I - cervical vertebrae (more
superiorly) (reaches as high as the ant.
tubercle of the atlas)
F – flexes neck
b. Longus capitis m.
O – ant. tubercles of transverse prs.
of C3 – C6
I - basilar part of occipital bone
F – flexes head
Basilar part
of occipital bone
Jugular process
of occipital bone
Longus capitis m. (cut)
Occipital condyle
Rectus capitis anterior m.
Rectus capitis lateralis m.
Transverse process of atlas
Longus capitis m.
Longus colli m.
c. Rectus capitis anterior
O – lateral mass of atlas
I - basilar part of occipital bone
F – flexes head
d. Rectus capitis lateralis
O - transverse process of atlas
I - jugular process of occipital bone
F – flexes head
2. All of the prevertebral muscles are
innervated by the ventral rami of cervical
nerves.
LEARNING OBJECTIVES
1. Describe the functions of the pharynx.
2. Describe the different parts of the pharynx and their boundaries and relationships to each other.
3. Describe the main anatomical features seen in each part of the pharynx and their functional and clinical
significance.
4. Name the layers that compose the pharyngeal wall.
5. Describe the arrangement of the muscles of the pharynx, as well as their attachments, functions and
innervations.
6. Describe the mechanism of swallowing.
7. Describe the sensory innervation of the pharynx.
8. Describe the composition of the pharyngeal nerve plexus.
9. Describe the blood supply and lymphatic drainage of the pharynx.
10. Name the bony structures that form the atlanto-occipital (AO) and atlanto-axial (AA) joints and the ligaments
associated with these joints. Also, describe the types of movement permitted at these joints.
11. Describe the attachments, functions and innervation of the prevertebral muscles.
12. Describe the structure of the cervical part of the sympathetic trunk and the anatomical basis for the condition
known as “Horner’s syndrome.”
Internal carotid n.
Superior cervical ganglion
External carotid a. & plexus
Gray rami communicantes
Middle cervical ganglion
Vertebral ganglion
Vertebral a. & plexus
Cervicothoracic (stellate) ganglion
Ansa subclavia
PATIENTS WITH HORNER’S SYNDROME
SYMPTOMS:
1. MIOSIS (PARALYSIS OF
DILATOR PUPILLAE M.)
2. PTOSIS (PARALYSIS OF
SUPERIOR TARSAL M.
3. REDNESS & INCREASED
TEMPERATURE OF SKIN
(VASODILATION)
4.
ANHIDROSIS (SWEAT GLANDS
CAN’T SECRETE)