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By: Y. Agenak, M.A.S., M.D.
Deputy Director, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine
The pharyngobasilar fascia is a fibrous layer firmly attached superiorly to the basilar region of the occipital bone and petrous part of the temporal bone medial to the carotid canal allergy testing york buy cheap astelin 10ml on line. It bridges below the Eustachian tube and extends forwards to be attached to the posterior border of the medial pterygoid plate and the pterygomandibular raphe allergy medicine doesn't work cheap astelin 10ml without a prescription. Posterior end of the mylohyoid line on the inner surface of the mandible Anterior and lateral part of the upper surface of the palatine aponeurosis 1 allergy medicine and depression buy 10ml astelin with mastercard. Posterior edge of the lower part of the stylohyoid ligament and lesser horn of the hyoid 2 allergy shots and kidney disease buy generic astelin on-line. Lateral surface of the cricoid cartilage and inferior horn of the thyroid cartilage Side of the cricoid cartilage Course Fibres pass backward as a quadrilateral sheet Insertion 1. Medial pharyngeal raphe Function Contracts in a coordinated way to propel the food bolus Innervation Pharyngeal plexus 2. Fans out before insertion Same place on the opposite cricoid cartilage Salpingopharyngeus See Refs 1, 2, 3. Posterior border of the thyroid cartilage see palatopharyngeus Elevates the larynx and shortens the pharynx Branch of the glossopharyngeal nerve Pharyngeal plexus Chapter 149 Anatomy of the pharynx and oesophagus] 1949 1 2 3 4 5 6 7 8 8a 9 10 11 11a 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 11 1 2 3 4 5 6 7 8 9 10 16 17 18 19 20 21 22 23 24 25 12 13 14 15 26 Figure 149. On the outer surface of the middle constrictor lie the lingual artery, hyoglossus muscle, hypoglossal nerve and the tendon of the posterior belly of the digastric. On the outer surface of the inferior constrictor lie the external laryngeal nerve, thyroid gland, sternothyroid, sternohyoid and omohyoid muscles. The palatine branch of the ascending pharyngeal artery curls over the upper edge of the superior constrictor. The stylopharyngeus enters the pharynx between the middle and superior constrictors, it then blends with the fibres of the palatopharyngeus. The stylopharyngeus is accompanied by the glossopharyngeal nerve which supplies it before passing forwards to the tongue. The internal laryngeal nerve and superior laryngeal nerve pierce the thyrohyoid membrane between the middle and inferior constrictors and come to lie submucosally on the lateral wall of the piriform fossa. Understanding the position of the internal laryngeal nerve and superior laryngeal vessels is crucial to the safe surgical dissection of the upper pole of the thyroid gland. The close anatomical relationship of the recurrent laryngeal nerves, the carotid artery and the inferior thyroid artery, is described by an inverted rightangled triangle with the carotid artery forming the vertical side laterally, the inferior thyroid artery forming the horizontal base at the top passing from medial to lateral, and the recurrent laryngeal nerve forming the hypotenuse (or longest side) travelling from medial to lateral at a relatively shallow angle on the left and a more acute angle on the right. The nerves may sometimes pass superficially or deep to the inferior thyroid artery but the triangular relationship remains constant and is the only safe way of identifying the nerve. The retropharyngeal and parapharyngeal space are filled with loose areolar tissue, fat and a number of lymph nodes. They communicate with each other and the submandibular spaces, which allows the spread of infection and tumour along fascial planes with little resistance. Nerve supply of the pharynx the pharyngeal plexus is formed by the pharyngeal branches of the glossopharyngeal and vagus nerves with sympathetic fibres from the superior cervical ganglion. Many of the vagal fibres come from the cranial root of the accessory, which joins the vagus at its superior ganglion. The pharyngeal branches of the vagus supply all the muscles of the pharynx via the pharyngeal plexus, except the stylopharyngeus which is supplied by the glossopharyngeal nerve. The cricopharyngeus has an additional supply from the external laryngeal nerve and receives parasympathetic vagal fibres from the recurrent laryngeal nerve (relaxation) and postganglionic sympathetic fibres from the superior cervical ganglion (contraction). Sensation to the pharynx is provided by the pharyngeal plexus with the glossopharyngeal nerve supplying sensation to the upper part of the pharynx including the surface of the tonsil, which is also supplied by the lesser palatine branch of the maxillary nerve and posterior third of the tongue. The tongue in front of the valleculae and the valleculae themselves are supplied by the internal laryngeal nerve, a branch of the superior laryngeal nerve of the vagus. Sympathetic fibres reach the pharynx on the blood vessels supplying it and are derived from the superior cervical ganglion. The space is closed above by the base of the skull and on each side by the carotid sheath. The parapharyngeal space is lateral to the pharynx on each side and can be visualized as an inverted cone with its base under the temporal bone and its apex in the neck at the hyoid bone (Figure 149. Laterally, it is bounded by the fascia overlying the pterygoid muscles, the medial aspect of the deep lobe of the parotid gland and the ascending ramus of the mandible. Medially, the space abuts the fascia overlying the pharyngeal constrictors and the tensor and levator palatini. Anteriorly, it is bounded by the pterygomandibular raphe and the posterior wall is Chapter 149 Anatomy of the pharynx and oesophagus] 1951 to the minor salivary glands of the pharynx comes by way of the nasal palatine and pharyngeal branches of the pterygopalatine ganglion. These are derived from the nervus intermedius and pass through the facial nerve to the greater petrosal nerve and pterygopalatine ganglion. Pharyngeal vasculature the ascending pharyngeal artery arises from the medial aspect of the external carotid artery just above its origin. Its palatine branch passes over the upper free edge of the superior constrictor to supply the inner aspect of the pharynx and soft palate. The pharynx receives an extra supply from the ascending palatine and tonsillar branches of the facial artery and the greater palatine and pterygoid branches of the maxillary artery. The veins of the pharynx are arranged in an internal submucous and external pharyngeal plexus with numerous communicating branches between the two plexuses and veins on the dorsum of the tongue, the superior laryngeal veins and the oesophageal veins. The pharyngeal plexus drains to the internal jugular vein and anterior facial veins, it also communicates with the pterygoid plexus.
With the flap mobilized allergy hacks cheap astelin 10ml overnight delivery, initial inset into the defect is completed in a layered fashion (Figure 192 allergy medicine effect on liver 10 ml astelin sale. Two to three weeks after the harvest of the flap allergy medicine to take while breastfeeding purchase astelin mastercard, the pedicle is divided and the final insetting of the flap is completed allergy forecast ontario canada cheap astelin 10ml. The Estlander modification of the cross-lip flap is used to reconstruct the oral commissure. Estlander flap is a laterally based Abbe flap that is used when defects affect the commissure. Venous compromise of the flap is usually due to leaving too thin a bridging pedicle or too tight a closure. Note the anterior limit of the incision at the vermillion border; (e) the upper lip rotation has been inserted into the lower lip and the donor site repaired; (f) three weeks later, just prior to incising the pedicle. The tissue is rotated from the nasolabial region and this tissue is shifted medially and rotated into the lower lip. Resection of the tumour on the lower lip is performed in the usual manner and then the skin incisions for elevation of the Karapandzic flap are made. It is important to avoid division of the muscle fibres containing the neuromuscular control of the orbicularis under the skin. To aid mobilization, mucosal incisions are placed in the gingival labial and gingival buccal sulcus on each side. The flap is elevated in a subcutaneous plane remaining superficial to the orbicularis oris muscle. Sufficient length in the mucosal incisions must be performed to permit medial mobilization of both flaps for a midline closure. The repair of the defect begins with the vertical midline closure of the lower lip with approximation of the vermilion border by a temporary nylon suture. The advanced muscle in the orbicularis oris is closed in the midline followed by external skin closure. Following this, reapproximation of the suture line between the advanced cutaneous margin of the flap and the residual cutaneous margin of the chin and nasolabial region is undertaken (Figure 192. The larger the defect, the tighter the reconstructed lip will be, and thus a certain amount of microstomia can be present following Karapandzic flap reconstruction. This is more easily accommodated in the elderly edentulous patient where there is a certain amount of skin laxity. The restricted oral aperture will stretch gradually over the course of a few months and the stretching can be augmented by physiotherapy. The flap is now pedicled on labial vessels and can be advanced unilaterally or bilaterally and closed in layers. The modified fan flap differs from a classical fan flap in that the flap rotates around the angle of the mouth to fill in the defect. The vermilion is reconstructed by mucosal advancement of a tongue mucosal flap which is divided at ten to fourteen days (Figure 192. In the Webster cheek advancement flap, horizontal incisions are extended laterally from the base of the defect and the commissure. The resulting four Burrows triangles are excised above and below the lateral aspect of the flaps. The flaps are advanced bilaterally and closed in layers, and the resulting triangles are closed. The buccal mucosa from the base of the excised Burrows triangles are rotated inferiorly over the free margin of the triangle and used to reconstruct the lateral vermilion of the lip. The two flaps are advanced medially, the triangles closed and the flaps are approximated in layers (Figure 192. Free tissue transfer is required for lip reconstruction when the total remaining lip or adjacent rotated tissue is insufficient to create a reasonable circular and symmetrical mouth. In this case, a radial artery free forearm flap using the palmaris longus tendon to suspend the lower lip is used. This reconstruction technique, however, is insensate and immobile and merely provides a static platform for the mobile upper lip to close against. The flap is used as a double paddled flap rotated on the underlying palmaris longus tendon. The skin and contour match is not as accurate as when using adjacent rotated tissue. The lip can remain ptotic and may require wedge excisions a few months following reconstruction to improve the lip tone, allowing the formation of an adequate seal with the upper lip. Surgical excision of small lip tumours involves relatively minor surgery, often under local anaesthetic and may be therefore less burdensome for the patient than a course of radiotherapy. Perialar crescentic advancement flaps can be used to disguise the advancement of the upper lip when the advancement encroaches on the medial part of the nose. Bilateral perialar crescentic excisions are required to provide adequate advancement. Using a single anterior field, a fractionated course of 50 Gy in 15 fractions over three weeks is given.
Auditory feedback is frequently carried out with an earpiece or from side speakers but in some performances this is impossible allergy symptoms throat astelin 10 ml free shipping, making it difficult for the performer to judge what the audience can hear allergy forecast eau claire wi generic 10ml astelin fast delivery. The Lombard effect is the tendency to increase vocal intensity in response to increased background noise allergy testing queanbeyan generic astelin 10 ml otc. Singers performing in large halls or outdoor concerts with no auditory feedback tend to over-sing and strain their voices allergy medicine levothyroxine cheap 10ml astelin overnight delivery, especially early in their careers. An inexperienced performer may take on roles outside their range and indeed may be under considerable pressure to do this. The hours of rehearsal are frequently demanding, often with eight performances a week. Some roles are beyond the capacity of one performer although, thankfully, musical/theatre directors are now acknowledging this and are beginning to appoint two performers for one extremely challenging role. Even the more established performer may also require a great deal of courage to be in conflict with the director as his or her reputation may be adversely affected. Performers are now requested to be more versatile and not only singers but also actors and, specifically, dancers. The constricting costumes and physical activity can affect their classical breathing technique. Singers are also asked to sing in different styles, for example, in opera the larynx needs to be lower or vertical and the main emphasis is on vowels. Lifestyle/travel the normal humidity in a plane is 5 percent but at the end of a transatlantic flight can be up to 28 percent. The ambient noise on an aeroplane can be greater than 60 dB and again it is advisable for professional voice users to use their voice minimally during flight. Jet lag is equally important and indeed, in a recent survey, general fatigue was one of the main complaints from performing voice users. Performance anxiety Environment Numerous old theatres are dusty, especially in the wings, off stage and in the curtains during change of scenes. A recent performer was seen in the clinic who was found to be allergic to feathers but, unfortunately, for his part of Captain Hook in Peter Pan, was required to wear a large feather in his hat. Artificial smokes and fogs used for special effects are also known to have an irritant and drying effect on the voice. The acoustics of sound are also important and although modern theatres are built with better acoustics it is well known that one of the newest theatres in London is particularly bad for this. The microphone should never be placed directly in front of the lips and indeed, should be 20 cm the voice is the window of the soul and has an emotional as well as a mechanical and technical component (Figure 168. It is known that there is a slight amount of vocal fold oedema immediately before menstruation and female performers were often given grace days because of this. The condition is known as laryngopathia premenstrualis and is now well recognized. Standing on the podium with a dry mouth, sweaty hands and heavy legs is a normal reaction of the body to stress and adrenaline production. Beta blockers have been used by musicians and athletes to prevent tremor but they have had no benefit for the voice. We have already mentioned the importance of resonance and the formants of voice and specific vocal quality. Vocal tract surgery can be more catastrophic than surgery on the vocal folds themselves. A laryngeal mask should be used rather than an endotracheal tube as an endotracheal tube by definition will cause some oedema of the vocal folds which, in the vast majority of cases, is temporary but potentially could be permanent. Most professional singers have a good musical ear and can vary their technique to accommodate for vocal tract surgery but it is still a high risk situation. Patients should be warned of the risk and, ideally, quantitative measures should be taken pre- and post-surgery for each individual surgeon. It is known that an internationally famous female singer would move to a different area of the house a week before a performance and avoid using any of the crockery of her family to prevent an upper respiratory tract infection. It is important to differentiate between an upper respiratory tract infection with or without laryngeal involvement. An upper respiratory tract infection can be managed conservatively with adequate hydration and steam inhalations. In the acute emergency, if it is the phonosurgeon who says the performance should be cancelled, then quantitative measures are important as large sums of money may be involved and records called upon. Aspirin is associated with vocal fold haemorrhage by its action on the platelets and is something that should be avoided at all times by the professional voice user. Confidence Many of the best phonosurgeons are either musically trained or have a musical background themselves. This not only reflects their interest in this area but also allows them to be more compassionate and understanding to the performer. To the scientist, the use of modal voice with falsetto at the upper range and vocal fry at the lower range will mean very little to a performer who would rather discuss head and chest voices and persaggio. A laryngologist who understands these terms will inspire confidence in his or her diagnosis, which is essential for the performer. Education of voice users has improved greatly with many presentations and articles by laryngologists in musical journals. A professional voice user would expect to be seen in a voice clinic with a full range of equipment which includes a stroboscope and, indeed, it is almost impossible to make an accurate diagnosis without it. It is desirable that a speech therapist and also a singing coach are present when performers are seen.
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