PRACTICAL CONSIDERATIONS : THE PHARYNX. 1607 



The posterior wall of the pharynx is separated from the anterior surfaces of the 

 bodies of the first five cervical vertebrae only by some loose connective tissue and by 

 the prevertebral fascia and muscles. Through it, by pushing the finger up above 

 the soft palate, the basilar process of the occipital bone may be felt, and below the 

 bodies of the upper four cervical vertebrae in children the upper six may be pal- 

 pated. The hard palate, or the lower margin of the posterior nares, and the anterior 

 arch of the atlas are on the same level. 



In disease of the body of the sphenoid, in fracture of the base of the skull 

 involving the basilar process, or in fracture or dislocation of the cervical vertebrae 

 the information gained by this examination will often be of great value. 



The retropharyngeal alveolar tissue which is necessarily loose to permit of 

 the movements of the pharynx during deglutition and of its distensibility is some- 

 times the seat of infection which may have gained access through the pharynx itself, 

 or through the lymphatics which spring from the posterior nares, the summit of the 

 pharynx and the prevertebral muscles, and which empty into a lymph-gland situ- 

 ated between the prevertebral fascia and the pharyngeal wall. Abscess in this 

 situation may by gravity descend by the side of the oesophagus into the mediasti- 

 num and has been known to reach the base of the thorax (page 553, Fig. 546). 

 During its descent it may cause much dyspnoea by setting up oedema in the region 

 of the glottis. Usually it first pushes forward the posterior wall of the pharynx, 

 and can be recognized as a fluctuating swelling and opened by direct incision. 



Collections of fluid resulting from tuberculous disease of the cervical vertebrae 

 may occupy the same space after perforating the thin prevertebral fascia and may 

 take the same course, or they may be guided by the lateral expansions of that 

 fascia to the posterior and lateral portions of the root of the neck or to the axilla 

 (page 552, Fig. 545)- As in these cases the avoidance of mixed infection is very 

 important, such tuberculous collections, when they require opening, should be 

 approached through the neck by an incision along the posterior border of the 

 sterno-mastoid. 



Retropharyngeal abscess of any type should never be allowed to open spon- 

 taneously on account of the danger of immediate suffocation from flooding of the 

 larynx with pus. 



In cases of fracture of the posterior fossa of the base of the skull, with hemor- 

 rhage into the pharynx (fracture of the basilar process), or of the middle fossa, 

 with hemorrhage reaching the pharynx through the Eustachian tube (fracture of 

 the petrous portion of the temporal), the need for frequent and persistent attempts 

 to make and keep the pharynx as nearly aseptic as possible should never be 

 forgotten. 



The adenoid tissue of the posterior wall the pharyngeal tonsil may undergo 

 hypertrophy, cause deafness or respiratory obstruction, and require removal. 



The lateral walls of the pharynx are in such close relation with the internal 

 carotid artery that in aneurism of that vessel the pulsations may most easily be felt 

 and seen through the pharynx. In many instances the vessel has been opened in 

 penetrating wounds of the pharyngeal wall by foreign bodies. The internal jugular 

 vein is not so exposed to injury and is more rarely wounded. In one instance of 

 pulsating tumor of the pharynx, pressure on the external carotid arrested the pulsa- 

 tions (Barnes). 



The styloid process and a rigid or ossified stylo-hyoid ligament can be felt 

 through the lateral wall. Attempts have been made (in cases of hysterical persist- 

 ence of pharyngeal symptoms after the supposed swallowing of a foreign body) to 

 remove these structures or a cornu of the hyoid bone, under the impression that 

 they were the offending substances. 



The pharynx is very distensible, and foreign bodies, if not of great size, are 

 apt to pass through it as far as the level of the cricoid cartilage, where its diameter 

 is only 18 mm. (^ in.), In an adult this point is beyond the reach - of an average 

 finger, as it is about the entrance of the oesophagus, which is about six inches from 

 the incisor teeth. 



For the removal of impacted foreign bodies, or for operation on malignant dis- 

 ease, the pharynx may be reached, after a preliminary tracheotomy, by an incision 



