Images de page
PDF
ePub
[merged small][ocr errors][merged small][merged small][merged small][merged small][merged small]

From the posterior surface of the glosso-palatine arch a thin triangular fold of mucous membrane, called the plica triangularis, passes backwards. Its base corresponds to the glosso-palatine arch, its superior border is free, and passes downwards and backwards, frequently overlapping the tonsil

. Its lower border is attached to the side of the tongue. It covers, medially, the inferior part of the tonsillar fossa.

The palatine tonsil presents very different forms in different individuals.

It may project from the fossa into the cavity of the pharynx, or it may be fat and limited to the tonsillar fossa. In some cases the plica triangularis is fused with the free surface of the tonsil, and the lymph tissue may in some cases be developed on the medial surface of that plica.

Internal jugular vein Hypoglossal nerve

Accessory nerve Internal carotid artery
Digastric muscle

Vagus nerve
Sympathetic trunk

Ascending pharyngeal artery
Stylo-hyoid

Glossopharyngeal nerve

Parotid gland Posterior facial

Retro-pharyngeal vein

lymph gland External carotid artery

Superior Styloglossus

constrictor musele Ascending

Pharyngo-palatine palatine artery

arch

Palatine tonsil
Internal pterygoid

Pharyngo-epiglottie
Epiglottis

fold Glosso-epiglottic

Glosso-palatine fold

arch Masseter

-Vallate papille Pharyngeal portion

of tongue

[graphic]

Tre arterie Erbes of th all, and tt

side of Herres.-T Te branches

[ocr errors]

The lymph 3d, whence wel of the ph se of the ho

structure of
Iob cells wi

iguales,
pun its m

e adjacen
7, terme
To On its 1

[ocr errors]
[ocr errors]
[ocr errors]

Pars La
* larynx (E
o maintai
Tiere, poste
2 Esophag

this latter
T:2.906

The anta Tat by th ra the ph erior ape seal to th 12.905

Fig. 905.-HORIZONTAL SECTION THROUGH MOUTH AND PHARYNX AT THE LEVEL OF THE PALATINE TOssis.
The stylopharyngeus, which is shown immediately to the medial side of the external carotid artery, and the

prevertebral muscles, are not indicated by reference lines.

The palatine tonsils are oval in shape, with the long axes directed vertically, and each presents a medial and a lateral surface, and a superior and inferior pole, and an anterior and posterior margin.

The medial surface is prominent and free, studded with small pit-like depressions called the fossulæ or crypts of the tonsil.

The lateral, or attached surface, is enclosed in a distinct fibrous capsule, connected with the pharyngo-basilar fascia, and this capsule separates the tonsil from the superior constrictor muscle of the pharynx.

The superior pole is rounded and blunt, and presents numerous fossulæ. The inferior pole projects downwards towards the tongue. The anterior margin looks towards the glosso-palatine arch, and is often overlapped by the plica triangularis

, the posterior margin is directed towards the pharyngo-palatine arch.

interior sur

la poster Falls of the

The reces
ce between
Tered from
ate, the wi
ezind, the
Wil je forme
2000us mem
mon, by the

Relation
I once evide

1 Throu
Erneural col
nebral fib
maryngeal
atral co

Relations of the Tonsil.— The lateral relations of the tonsil consist of the fibrous capsule and the superior constrictor nuscle. Lateral to the pharyngeal wall lies the internal pterygoid muscle, and behind it a region filled with connective tissue, containing blood-vessels and nerves.

The nearest and most important vessel is the external maxillary artery, which, especially if tortuous, has a very close relation to the pharyngeal wall at this level.

The ascending palatine and tonsillar branches of the artery are also in close relation.

The internal carotid artery and internal jugular vein lie considerably further back (i to 1 inch) and to the lateral side, and the external carotid artery is still more lateral.

The ascending pharyngeal artery is well behind the tonsil.

The size of the palatine tonsils is extremely variable, but as a rule, in early life, they measure something under 1 inch (20 to 22 mm.) from above downwards, about 1 inch (18 to 20 mm.) antero-posteriorly, and 1 inch (12 to 15 mm.) mediolaterally.

The arteries of the palatine tonsil are derived from the ascending palatine and tonsillar branches of the external maxillary artery, the ascending pharyngeal branch of the external carotid, and the dorsalis linguæ of the lingual. The veins pass to the tonsillar plexus, on the lateral side of the tonsil, which is an offshoot of the pharyngeal venous plexus.

Nerves.—The palatine tonsil receives a special branch from the glosso-pharyngeal ; this unites with branches from the pharyngeal plexus to form a small plexus tonsillaris which supplies the organ.

The lymph vessels are extremely numerous. They begin in a plexus which surrounds each Ollicle, whence vessels pass to the lateral surface of the tonsil. Thence they pass through the wall of the pharynx, and pass to the deep cervical glands in the neighbourhood of the greater ornu of the hyoid bone, behind and inferior to the angle of the mandible.

Structure of the Palatine Tonsils.- Each palatine tonsil is composed of masses of small rounded ymph cells with a delicate connective tissue reticulum.' These resemble in structure the folliCulilinguales, q.v.

Upon its medial surface it is covered with epithelium, continuous with the epithelium coverng the adjacent parts of the wall of the pharynx. This surface is very irregular, and on section rypts, termed fossulae tonsillares, are seen to be formed by deep infoldings of the epithelial vall. On its lateral surface, the lymph tissue is invested by a connective tissue capsule.

Pars Laryngea.—The laryngeal part of the pharyngeal cavity lies posterior to he larynx (Fig. 903). It is wide above, where it is continuous with the oral portion, ind maintains a considerable width until within about an inch of its termination, where, posterior to the cricoid cartilage it narrows rapidly and passes down to join he csophagus. Except during the passage of food, the anterior and posterior walls f this latter part are in contact, and its cavity is reduced to a mere transverse slit Fig. 906).

The anterior wall of the laryngeal portion of the pharynx is formed in its whole xtent by the posterior surface of the larynx, of which the following parts are seen rom the pharyngeal cavity (Fig. 901) The epiglottis above; below this the uperior aperture of the larynx, bounded at the sides by the ary-epiglottic folds ; ateral to these folds is seen, on each side, a deep recess, the recessus piriformis Fig. 905). Lower down still, the muscles and mucous membrane which cover the posterior surfaces of the arytenoid and cricoid cartilages are distinguishable.

Its posterior wall and side walls are directly continuous with the corresponding valls of the oral portion, and present no features which require special notice.

The recessus piriformis (0.T. sinus pyriformis) is a deep depression, seen on each ide between the ary-epiglottic fold and the lamina of the thyreoid cartilage. When Fiewed from above, as in laryngoscopic examinations, it appears of a piriform hape, the wider end being directed upwards and forwards. When viewed from ehind, the recess is boat-shaped and elongated in the vertical direction. Its side vall is formed by the thyreoid cartilage and thyreo-hyoid membrane, covered with mucous membrane ; its medial wall is formed by the ary-epiglottic fold, and slightly, elow, by the superior part of the cricoid cartilage.

Relations of the Pharynx.—In considering the relations of the pharynx, it is t once evident that these are very different in the superior and inferior portions.

1. Throughout its whole extent it lies anterior to the cervical region of the ertebral column, and is separated from the bodies of the vertebrae and the interFertebral fibro-cartilages by the loose areolar tissue of the prevertebral or retroharyngeal space, posterior to which lie the anterior longitudinal ligament of the Fertebral column, and the longus capitis and longus colli muscles.

The este
Hale int

Lastly, a
Eternal

The phar

2. In the neck, on each side, it is in contact with the superior part of the thyreoid gland, the carotid sheath, and especially the common and external carotid arteries, and, more posteriorly, the internal carotids.

The branches arising from the inferior part of the external carotid are also in close relation to the pharyngeal wall, viz., the superior thyreoid and lingual arteries in the lower part, while the external maxillary artery, as it passes under the digastric and stylo-hyoid muscles, comes into contact with the superior constrictor: and the ascending pharyngeal artery runs upwards by the side of the pharyngeal wall.

3. The relations of the cranial portion are more complex, but are of great importance. Reference to Fig. 906 will help to elucidate them. At the upper

Internal jugular vein Hypoglossal nerve
Accessory nerve

Internal carotid artery
Digastric muscle

Vagus nerve
Sympathetic trunk
Ascending pharyngeal artery

Dens
Stylo-hyoid,

Glossopharyngeal nerve

Parotid gland Posterior facial

Retro-pharyngeal vein

lymph gland
External carotid
artery

Superior
INC

constrictor muscle
Styloglossus
Ascending

Pharyngo-palatine palatine artery

arch

Palatine tonsil
Internal pterygoid)

Pharyngo-epiglottic
Epiglottis

fold Glosso-epiglottic

Glosso-palatine fold

arch Masseter

Vallate papilla Pharyngeal portion of tongue

Raphe of tongue

Structure 22; it is fit

bed firmly > laryni, > Deck

de tall is Islaris (O.T.

pletely on We of the

These muscs 23, which

e and is

[graphic]

External to

it it is
With the
des of the
20 with the
The fibrous

is firmly a
Tictures as fo
Anore, it b

front
extends
ir temporal
la each side
se, mout
cally lost.

[ocr errors]

The fascia 1722 on each te the sinu

muscle Mucous

mane of the

Luse in the up
Ir part of

constitut ume tissit --Tartal port There are a susulis, an Pharyngea

Fig. 906.-HORIZONTAL SECTION THROUGH MOUTH AND PHARYNX AT THE LEVEL OF THE PALATINE TONSIS.
The stylopharyngeus, which is shown immediately to the medial side of the external carotid artery, and the

prevertebral muscles, are not indicated by reference lines.
part, the wall of the pharynx is related to the internal pterygoid muscles, separated
from them by the levator and tensor veli palatini muscles. As each internalípterygoid
passes posteriorly and downwards to its insertion, it diverges away from the pharynx,
and a triangular space is left between its medial surface and the wall of the pharynx.
The styloid process, and the muscles which arise from it, project downwards into
this space, and lying beside them are numerous vessels and some nerves. Thus,
the styloglossus and stylopharyngeus come into contact with the side wall, and, with
the stylo-pharyngeus, the glosso-pharyngeal nerve. The ascending palatine and
tonsillar branches of the external maxillary artery ascend in close relation to
the pharyngeal wall.

The internal carotid artery lies rather further back, with the vagus, accessory and hypoglossal nerves.

es see PP isernal to Tbe fascia 93-pharynge - above, ne To they are

strecythene erugzal tub

Tessels and

wading pb 283 palatit War of este e mternal In the car 77 ad plesu The lymph

The external carotid lies more superficially, and is here separated by a conderable interval from the pharyngeal wall.

Lastly, a process of the parotid gland may insert itself on the medial aspect of ne internal pterygoid, and come into contact with the pharynx.

The pharyngeal plexus of nerves lies in contact with the side wall.

Structure of the Pharyngeal Wall.—The wall of the pharynx is strong and obile ; it is firmly fixed above to the base of the skull, but below that level it is not tached firmly to any surrounding structures, except to the hyoid bone and the skeleton

the larynx, and hence the inferior end can easily be displaced from side to side in le neck.

The wall is composed of a strong fibrous membrane, called the fascia pharyngosilaris (0.T. pharyngeal aponeurosis), lined internally by mucous membrane, and covered completely on its outer surface by a series of three overlapping muscles, the constrictor uscles of the pharynx.

These muscles are themselves covered externally by a thin layer of fibrous tissue fascia, which passes forwards, at its superior part, on to the surface of the buccinator uscle, and is called the fascia buccopharyngea.

External to this fascia the wall of the pharynx is in contact with loose cellular tissue which it is connected to and separated from adjacent structures. With the wall of the pharynx are associated several accessory muscles, viz., the iscles of the soft palate and the stylopharyngeus and pharyngo-palatine muscles, which end with the wall but are also attached to the larynx (see p. 466). The fibrous aponeurosis which forms the principal constituent of the pharyngeal ll is firmly attached (round the margins of the openings into the pharynx) to other ructures as follows :

Above, it blends with the periosteum covering the basilar portion of the occipital ne in front of the pharyngeal tubercle, and body of the sphenoid bone, and on each Le it extends out to the angular spine of the sphenoid and the apex of the petrous part the temporal bone.

On each side, it is attached to the structures which lie on each side of the orifices of e nose, mouth, and larynx. As it descends it gradually becomes thinner, and is entually lost.

The fascia pharyngo-basilaris is particularly strong in the superior part, where there is area on each side which is not covered by the superior constrictor muscle. This area ms the sinus of Morgagni, and here the tuba auditiva and tensor and levator veli atini muscles pass through the wall. Mucous Membrane of the Pharynx.—The superficial layer of the mucous mbrane of the pharynx consists, in the lower part, of a stratified squamous epithelium, ile in the upper or nasal portion it is, in part, composed of ciliated epithelium. In the verior part of the pharynx and in the side wall

, there are found large masses of lymph sue, constituting the pharyngeal tonsil in the roof, and the palatine tonsil on each side. e same tissue is found in considerable amount in the pharyngeal recess and on the ryngeal portion of the dorsum of the tongue. There are also numerous racemose glands, of the mucous type, in the walls of the s nasalis, and in the soft palate, and in the ary-epiglottic folds. Pharyngeal Muscles.—For the details of the attachment and relations of these scles, see pp. 464-467. External to the pharyngeal muscles lies the fascia buccopharyngea. The fascia pharyngobasilaris, which is thick above and thin below, and the fascia eco-pharyngea, which is thin above and stouter below, are practically blended into one er above, near the base of the skull, where the muscular coat is absent. Lower en they are separated by the constrictors, and become two distinct sheets. They

strengthened in the median plane posteriorly by a fibrous band descending from the ryngeal tubercle. Vessels and Nerves of the Pharynx.— The arteries of the pharynx are derived from-1, ascending pharyngeal; 2, the ascending palatine branch of the external maxillary; 3, the deding palatine from the internal maxillary, with a few twigs from the dorsalis linguæ, illar (of external maxillary), the artery of the pterygoid canal, and the pharyngeal branch the internal maxillary. The veins go to the pharyngeal venous plexus, which is found ween the constrictors and the bucco-pharyngeal fascia. The plexus communicates with the rygoid plexus above and with the internal jugular or common facial vein below. The lymph vessels of the pharynx pass chiefly to the superior set of deep cervical glands. Those from the superior part of the posterior wall join a few retro-pharyngeal glands which are found on each side between the pharynx and the rectus capitis anterior muscle. These latter glands, which are large in the child, small in the adult, but apparently always present (Fig. 906), are of considerable clinical interest, as they often form the starting-point of post-pharyngea. abscess. For fuller details see section on Lymph Glands.

The nerves of the pharynx, both motor and sensory, are derived chiefly from the pharyngeal plexus, which is formed by branches of the vagus, glosso-pharyngeal, and sympathetic The soft palate and the neighbourhood of the palatine tonsil are supplied by the palatine branches of the spheno-palatine ganglion. The tonsil receives a branch from the glosso-pharyngeal diret The vault of the pharynx, and the region around the orifice of the tuba auditiva, as well as the orifice itself, are supplied by branches from the spheno-palatine ganglion.' Finally, the internal laryngeal nerve supplies the mucous membrane of the back of the larynx, where it formas the anterior wall of the laryngeal portion of the pharynx.

ESOPHAGUS.

Trachea

-Aortic arch

Left bronchus

Thoracic aorta

The oesophagus or gullet is the portion of the digestive canal which intervenes between the pharynx above and the stomach below. With the exception of the

pylorus, it is the narrowest, and at the Hyoid bone same time one of the most muscular parts

of the whole alimentary tube. - Thyreoid cartilage It extends from the termination of the -Cricoid cartilage

pharynx, at the inferior border of the cricoid cartilage and opposite the sixth cervical

vertebra, to the cardiac orifice of the stomach, (Esophagus

opposite the eleventh thoracic vertebra. Between those two points it traverses the inferior part of the neck, the whole length of the thorax, and, having pierced the diaphragm, it enters the abdomen, and immediately afterwards joins the stomach. In its course it does not adhere to the median plane of the body, but twice leaves it, and

curves to the left. The first of the curvaEsophagus

tures corresponds to the inferior part of the

neck and the superior part of the thorax, Aperture in diaphragin where the cesophagus projects beyond the

left margin of the trachea to the extent of } or inch (4 to 6 mm.). It returns to the median plane at the level of the fourth thoracic vertebra, posterior to the · aortic arch.' Lower down, posterior to the pericardium, it again passes to the left, and at the same time forwards, in order tv reach the resophageal opening in the dia

phragm (which is placed anterior to and -Jejunum

to the left of the aortic opening), and it maintains this direction until the stomach is reached. It leaves the median plane at the seventh thoracic vertebra, crosses anterior to the aorta at the level of the eighth thoracic vertebra, and traverses the diaphragm at the level of the tenth.

In addition to the curvatures just deFig. 907.-DIAGRAM TO SHOW THE COURSE OF

scribed, it is also curved in the anteroTHE (ESOPHAGUS.

posterior direction, in correspondence with the form of the vertebral column, upon which it, in great part, lies.

In length it usually measures about ten inches (25 cm.).

Its breadth, where the tube is widest, varies between half an inch (13 mm. in the empty contracted condition and an inch or more (25 to 30 mm.) in the fully distended state.

Thoracic duct 12th thoracic

vertebra Abdominal aorta

STOMACH

Duodenum

[ocr errors]
« PrécédentContinuer »