The external nose
– Root, dorsum or bridge, tip, alae, base, nares
( nostril) separated by the septum
• Motor, facial to muscles
• Sensory, to infratrochlear from nasociliary
br. Of ophthalmic(V) to skin of root, alae,
nostril; infraorbital br. To maxillary(V) to
sides of nose
• Arteries: facial to side, alae, septum;
dorsal nasal br. Of ophthalmic to root and
dorsum; infraorbital branch of maxillary to
• Veins, drain into ophthalmic and anterior
• Is responsible for posterior bleeds.
• This area is located over the posterior end of the middle turbinate.
• The anastomosis here is made up of branches from the internal
maxillary artery namely its sphenopalatine and ascending
• The maxillary sinus ostium forms the dividing line between the
anterior and posterior nasal bleeds.
• Posterior nasal bleeds are difficult to treat because bleeding area is
not easily accessible.
• Bleeding from Woodruff's plexus commonly occur in patients with
extremely high blood pressure. Infact this plexus acts as a safety
valve in reducing the blood pressure in these patients, lest they will
bleed intracranially causing more problems.
• In patients with posterior bleeds it is difficult to access the amount of
blood loss because most of the blood is swallowed by the patient.
• Etiology: The etiology of epistaxis is not just simple or straight nasal
• Hyaline cartilage
– Septal, between right and left nasal cavities,
attachment: perpendicular plate of ethmoid,
vomer, maxilla, nasal, septal process of lower
– Lateral nasal ( upper lateral), attached to
nasal bone, frontal process of axilla, lower
nasal cartilage continuous with septal
• Hyaline cartilage
– Greater alar (lower lateral alar),
• U shaped, open posteriorly, has medial and lateral
• Medial crura attach with each other and upper
– Lesser alar.
– 2 nasal bones
– Frontal process of
• Separated by nasal septum into L and R
• Anterior aperture: ( nares) open into:
– Vestibule, a dilated area bounded by ala and
crus of nasal cartilage.
Boundaries of nasal cavities
• Roof = frontonasal, ethmoidal, sphenoidal
• Floor = wider, formed by palatine process
• Medial wall = nasal septum
• Lateral wall = nasal conchae, irregular
• Conchae = form a meatus, a passage of
the nasal cavity
• Lateral wall: division created by the nasal
– Sphenoethmoidal recess, above superior
– Superior meatus, below superior concha,
above middle concha.
– Middle meatus, below lateral to middle
concha, above inferior concha.
– Inferior meatus, below and lateral to middle
concha above palate.
• Openings into the meatus or recesses:
– Sphenoethmoidal recess: sphenoidal sinis
– Superior meatus: posterior ethmoidal air cells
– Middle meatus:
• Anteriorly, forntonasal duct, ant. Ethmoidal air cells
• post.: ostium from maxillary sinus
• On or above bulla: middle ethmoidal air cells
– Inferior meatus: naso lacrimal duct
• Medial wall: recess, spaces, or hiatus
– Nasopalatine recess: depression in septum
over incisive canal.
– Vomeronasal organ
• Posterior aperture: 2 choanae opening
• Anterior aperture: pear shaped, bounded
by nasal bone and anterior border of
– Medial (septal) wall
• Septal cartilage
• Perpendicular plate of ethmoid
• Projections of other bones :palatine, maxillary,
frontal, nasal, sphenoid.
– Lateral wall:
• Superior and middle conchae ( turbinates) of ethmoid.
• Inferior conchae ( turbinate)
• Nasal bone
• Frontal process and nasal surface of maxilla
• Lacrimal bone
• Perpendicular plate of palatine.
• Medial pterygoid plate and body of sphenoid.
• Inferior & middle conchae project medially & inferiorly
– Upper nasal cartilage
– Nasal bone
– Spine of frontal bone
– Cribriform plate of ethmoid bone.
– Body of sphenoid bone
– Palatine process of maxilla
– Horizontal plate of palatine bone.
– Posterior choanae opens into the nasopharynx.
Vasculature and innervation
• Sphenopalatine artery
• Anterior and posterior ethmoidal arteries
• Greater palatine artery
• Superior labial artery
• Lateral nasal branches of facial artery
• Maxillary nerve = to posteroinferior half by
nasopalatine and greater palatine
• Nasocilliary nerve = via the anterior and
posterior ethmoidal nerves
• Deviated septum
• Rhinitis is an inflammation of the nasal mucous
membrane ( nasal catarrh)
• Nasal polyp, a focal submucosal thickening due
to edema, pinkish gray and edematous and may
attain a large size.
• Rhinorrhea, discharge from nasal mucous
– CSF rhinorrhea, fracture of cribriform plate, tearing of
• Fracture of the nose:
• Common and usually transverse.
• Caused by a direct blow, the horizontal
plate of ethmoid is often fractured.
Causes of epistaxis:
1. Vascular anamolies
2. Infections and inflammatory
states of the nasal cavity,
4. Iatrogenic injuries
5. Neoplasms and foreign bodies.
• a. infection
• b. inflammation of mucosa
6. Chronic granulomatous lesions
8. Anatomical deformities
9. Septal perforations
• To manage post nasal bleed a post nasal pack is a must. Post nasal packing
can be done in 2 ways:
• Post nasal packing (conventional): A gauze roll about the size of the patient's
naso pharynx is used here. Three silk threads must be tied to the gauze roll.
One at each end and the other one at the middle. The patient should be in a
recumbent position. After anesthetising the nasal cavity with 4% xylocaine the
mouth is held open. Two nasal catheters are passed through the nasal cavities
till they reach just below the soft palate. These lower ends of the catheters are
grasped with forceps and pulled out through the mouth. The silk tied to the
ends of the gauze is tied to the nasal catheters. The post nasal pack is
introduced through the mouth and gradually pushed into the nasopharynx, at
the same time the nasal catheters on both sides of the nose must be pulled out.
When the pack snugly sits inside the nasopharynx, the two silk threads tied to
its end would have reached the anaterior nares along with the free end of the
nasal suction catheter.
• Problems of nasal packing:
1. Epiphora (watering of eyes)
occur due to blocking of the
nasal end of the nasolacrimal
2. Heaviness /headache due to
blocking of the normal sinus
3. Prolonged post nasal pack can
cause eustachean tube block
and secretory otitis media.
4. Prolonged nasal packing can
cause secondary sinusitis due
to blockage of sinus ostium.
Application of Nasal pack
• Divisions: vestibule, respiratory area, olfactory
– Vestibule, skin turned in at nares with coarse hairs
and sebaceous glands.
– Olfactory, over sup. Concha, roof, upper 3rd of
septum, thick epithelial layer with supporting and
– Respiratory: covers remainder of nasal cavity,
continuous into sinuses. Epithelium is pseudostratified
columnar ciliated with goblet cells.
• Air filled extensions of the nasal cavities
lined with mucous membrane.
– Frontal, behind supercillary ridges of frontal
bone, divided by septum, drains into
frontonasal duct thru rostral ethmoidal cells to
– Ethmoidal, aggregations of thin walled spaces
in ethmoidal labyrinth between orbit and nasal
cavities in 3 sets. Drainage:
• Anterior into infundibulum of middle meatus
• Middle, above ethmoid bulla in mid meatus
• Posterior, into superior meatus, to sphenoid sinus.
• Sphenoidal sinus
– Located at body of sphenoid, divided by
septum. Drain into sphenoidal recess.
• Maxillary sinus ( largest)
– Located at body of maxilla, roofed by orbit,
wall of nasal cavity is medial, alveolar process
is lateral and sinus extends to zygoma.
– Drain into semilunar hiatus of mid meatus.
Blood and nerve supply
• Supraorbital artery & nerve, major suppliers of
• Anterior & posterior ethmoidal vessels & nerves,
orbital branch of pterygopalatine ganglia.
• Posterior ethmoidal vessels & nerves & orbital
branch of pterygopalatine ganglia supply the
• Branches of ant.post, mid, superior alveolar and
infraorbital nerve supply to maxillary sinus.
• Vessels are: facial, infraorbital, greater palatine.
• Mucous membrane, motile cilia and rich
blood supply, adapt to purifying,
moistening and warming air to protect the
• Sinuses are effectively making the head
• Numerous connections to nasal cavities prone to easy
• Swelling of nasal mucosa around orifice slows discharge
• Maxillary & sphenoid, largest portion of sinus lie below
opening into nose, making drainage difficult.
• Proximity of maxillary sinus to root of upper teeth, to
distinguish, sinusitis from toothache is difficult.
• Thin bone separating meninges and sinuses making a
good chance for infection of meninges.
• Sinusities, an inflammation of the mucousa of one or
more accessory nasal sinuses & maybe acute or
Arteries of the nose
• Anterior ethmoidal
– Origin = ophthalmic
– Distribution = lateral
wall and septum,
surface of nose.
• Posterior ethmoidal
– Origin, ophthalmic
– Distribution, ethmoidal
sinus, lateral wall,
septum of nose
– Origin = 3rd part of maxillary
– Distri = posterior lateral
nasal branches to
– Posterior septal branches
to nasal septum
• Greater palatine
– 3rd part maxillary
– Distri = to septum
• Septal, alar branches
– Origin = superior labial
branch of facial
– Distri = rostral inferior
septum and vestibule
– Source of nose bleeding
especially in children.
• Injuries to membrane lead to profuse bleeding. If
bleeding are severe in posterior end of mid
conchae and roof of nose, ligation of external
carotid or ethmoidal artery is necessary.
• Epistaxis, nose bleeding, due to broad
anastomosis of the major arteries in the anterior
lower portion of nasal septum.
• Bleeding at the back end of middle conchae,
sphenopalatine artery is involved, packing is
• Bleeding from roof of the nasal cavity comes
from ethmoidal arteries.
Nerves of nasal cavity
• Special sensory:
– Olfactory (1) nerve of smell
– Receptor: neuroepithelial cells of olfactory
mucosa lie on the upper 3rd of nasal septum
• General sensory:
– Ophthalmic div, of Trigeminal nerve(V),
nasociliary to anterior of nasal septum and
lateral wall, to cutaneous tip of nose.
A. Maxillary/mandibular nerve
B. Sphenopalatine ganglion
• General sensory
• Maxillary division
– Pterygopalatine nerves.
• Greater palatine nerve. To
the inferior nasal concha,
inferior and middle
• Posterior superior nasal
branches to superior and
Nasopalatine nerve to
– Anterior superior alveolar
nerve to rostral part of inferior
meatus and floor of nasal
• Motor: autonomic system distributed to the
glands and blood vessels of the mucous
– Craniosacral division (parasympathetic)
• Preganglionic fibers from superior salivatory
nucleus of the Pons via nervus intermedius and
greater petrosal nerve to pterygopalatine ganglion.
• Postganglionic fibers from cells in the
pterygopalatine ganglion to the pterygopalatine
– Thoracolumbar (sympathetic)
– Preganglionic fibers from intermediolateral
gray column of upper thoracic to the superior
– Postganglionic fibers from cells in the superior
cervical ganglion to form the nerve of the
Name Nuclei origin Distribution Function
I Olfactory Central / deep Nasal mucous Sense of
process of membrane
sensory olfactory bulb smell
II Optic Ganglionic Retina of Sense of
cells of retina eye sight
III Oculomotor Nucleus in floor Sup, inf, med, Motion
of cerebral recti; inf oblique
Motor aqueduct ciliaris;
IV Trochlear Nucleus in floor Superior oblique Motion
of cerebral of eye
Name Nuclei origin Distribution Function
Sensory from Ophthto cornea, Sensation
V Trigeminal ciliary BD,iris,
lacrimal gld, eye,
Mixed ganglion nose. Max. to nose Sensation
Motor from pons Mandibular to ear,
VI Abducens 4th ventricle Lat. Rectus of Motion
Sensory from Ant.2/3 tongue,mid Taste
VII Facial geniculate ganglion ear,Face, scalp,
auricle,neck, Gen. sensation
Mixed Motor from pons,
sup. Salivatory sublingual gland secretion
Cochlear, bipolar To organ of corti Sense of hearing
VIII Acoustic spiralganglion
To semicircular Sense of equilibrium
Sensory Vestibular, bipolar
Name Nuclei origin Distribution Function
Sensory from inf. Mucus membrane of Taste
IX Glosso Ganglion, nucleus fauces, tonsils,
pharyngeal ambiguus & inf. pharynx, post 1/3 Gen. sense of
Mixed Salivatory nucleus tongue, pharynx, motion
secretory fibers of
Sensory from sup. Mucus membrane Sensation
X Vagus Gang. Inf gang. larynx, trachea, lungs,
Nodosum esophagus, stomach,
Mixed SI, LI, larynx, esopha.
Motor from nuc Stom, excitatory fibers Motion
ambiguus n medulla
Gastric,pancreatic gld. Secretion
Cranial from nuc. To pharyngeal Motion
XI Accessory Ambiguus laryngeal brs. Of vagus
to pharynx & larynx
Cranial, spinal Spinal: spinal cord To sternocleidomastoid
C5 & trapezius Motion
XII Hypoglossal Hypoglossal nuc. Muscles of tongue Motion