The pharynx

The pharynx is the cranial limit of the alimentary tract and lies behind the nasal, oral and laryngeal cavities – extending from the skull base to the sixth cervical vertebrae. It consists of a thick muscular tube formed from the three constrictor muscles, stylopharyngeus, palatopharyngeus and salpingopharyngeus – lined by the pharyngobasilar fascia internally and buccopharyngeal fascia externally. The nasopharynx communicates with the nasal cavity anteriorly and laterally with the middle ear via the eustachian tubes. The oropharynx extends from the soft palate superiorly to the superior border of the epiglottis below, communicating with the nasopharynx above via the pharyngeal isthmus and oral cavity in front via the oropharyngeal isthmus. It is characterised by Waldeyer’s lymphatic ring. The hypopharynx extends from the epiglottis to the lower border of the cricoid cartilage, where it continues as the oesophagus. Its anterior wall is formed by the inlet of the larynx superiorly and posterior part of the cricoid cartilage inferiorly.

Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept

OBJECTIVEThe endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway.METHODSEight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed.RESULTSThe endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym—VELPPHA—to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach.CONCLUSIONSThe VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the endoscopic endonasal transpterygoid approach expanded to the lateral aspect of the skull base, especially when treating patients with poorly pneumatized sphenoid sinuses.

Tornwaldt Cyst: A Case Report Of Unusual Dental Symptoms

Introduction: Tornwaldt's (Thornwaldt's) or nasopharyngeal cyst is an uncommon developmental benign cyst located in the midline postero-superior wall of nasopharynx. Incidence reported in general population is 0.06%. It occurred in the potential space due to outpouching of ectoderm into the pharyngobasilar fascia at the site where notochord attached to pharyngeal ectoderm. The cyst developed when the epithelial lining of the pouch secrets mucous following recurrent infection or trauma of the nasopharynx. Although majority of the cases are asymptomatic, patients may present with clinically-significant nasal, ear or cervical symptoms. Thus, most of Tornwaldt cyst cases were reported under otorhinolaryngology (ORL)-associated journals. However, patient presented with dental symptoms has never been reported before. This case is the first one as such to be reported.

Regrowth of the adenoids after adenoidectomy down to the pharyngobasilar fascial surface

Objectives:This study aimed to explore adenoid regrowth after transoral power-assisted adenoidectomy down to the pharyngobasilar fascial surface.Methods:Transoral adenoidectomy down to the pharyngobasilar fascia surface was performed on 39 patients under endoscopic guidance, using a power-assisted system. The operation time, amount of blood loss and iatrogenic injury, presence of complications, and success and regrowth rates were recorded to assess the feasibility, safety and effectiveness of our surgical technique.Results:In this adenoidectomy procedure, the pharyngobasilar fascia was left intact. The estimated blood loss was 5–50 ml (mean 15 ml), and the success rate was 97.3 per cent. Early complications occurred in 2.3 per cent of patients, while no long-term complications occurred in the cohort. No regrowth was found in the follow-up assessments, which were performed for 18–36 months after surgery.Conclusion:Adenoid regrowth was rare after adenoidectomy down to the pharyngobasilar fascial surface. The pharyngobasilar fascia can therefore be considered a surgical boundary for adenoidectomy.