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Nose and paranasal sinuses
 

Nose and paranasal sinuses

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    Nose and paranasal sinuses Nose and paranasal sinuses Presentation Transcript

    • NOSE AND PARANASAL SINUSES ANATOMY AND PHYSIOLOGY JIM CALUAG, M.D.
    • ANATOMY
    • EXTERNAL NOSE
      • Superiorly – frontal process of maxilla and nasal bone plates
      • Inferiorly - group of cartilages (lateral nasal cartilage, medial and lateral crura of greater alar cartilages) and connective tissue covering the nose
      • Nostrils – formed by 2 major alar cartilages, flexible and bent to form both lateral and medial walls of the nares
      • Columella – formed by lower margin of septal cartilage, anterior nasal spine and the medial portion of the 2 alar cartilages
    • INTERNAL NOSE
      • Air-conditioning chamber that houses the septum and turbinates with rigid walls and floors that measures about 2 inches in height and 3 inches in length lined by thick, red ,moist mucosae
      • Posteriorly opens into the pharynx via the 2 choanae
      • CHOANAE – oval opening about ½ inch transverse diameter and about 1 inch in height
      • Largely filled with septum and turbinates (conchae) with irregular spaces between them which form the “Flues” for the flow of air
      • Septum – functions to divide the nasal cavity into 2 equal compartments
      • Common meatuses are vertical spaces next to the septum
      • Superior, middle and inferior meatus – spaces between the superior, middle and inferior turbinates in which the widest portion is the inferior meatus
      • Combined volume of these spaces is 15-20cc with about 7-10cc volume of each side
      • The septal skeletal framework is composed of:
      • 1. Quadrangular cartilage
      • 2. Perpendicular plate of the ethmoid
      • 3. Vomer
      • 4. Rostrum of the sphenoid
      • 5. Crest of the palate
      • 6. Crest of the maxilla
          • Septal deviations that may interfere with the nasal airflow must be surgically corrected
          • The middle and inferior turbinates are long fleshy mass of tissue hanging downwards from the lateral nasal wall extending horizontally
          • The turbinates are nasal radiators supplied by erectile tissue which serves to adjust their size
          • MIDDLE MEATUS – where the ostium of the frontal, maxillary and ethmoid sinuses drains
          • Posterior ethmoids and sphenoid sinuses drains through the superior meatus via the spheno-ethmoidal recess
          • The nasolacrimal duct opens to the inferior meatus
          • In the middle meatus, the ostia of the frontal, maxillary and anterior ethmoids opens into the Hiatus Semilunaris
          • The ETHMOIDAL BULLAE is a vestigial structure arising from the fusion of the ethmo-turbinals found in the upper margin of the Hiatus Semilunaris
          • ETHMO-TURBINALS – carry olfactory epithelium and are well-developed in lower animals in which some lies within the frontal and sphenoidal sinuses
          • Man has a relatively rudimentary sense of smell and the olfactory epithelium is confined to the uppermost middle area of the nasal septum
          • PARANASAL SINUSES – irregular shaped air-spaces lies adjacent to the nose, they vary size ,configuration and symmetry
          • FRONTAL SINUS – lies between the outer and inner table of the frontal bone with the superior wall of the orbit makes up it’s floor
          • MAXILLARY SINUS – lies beneath the maxillary bone with which the floor of the orbit serves it’s roof and the apices of the molars serves to form it’s floor
          • SPHENOID SINUS – extends to the wings of the sphenoid, the clinoid process and the lateral margins of the pterygoid plates
          • Anterior and Posterior Ethmoids – housed in the ethmoid labyrinth medially bounding the orbital cavity
          • Sinuses present at birth: maxillary and ethmoids
          • The mucous membrane of the respiratory tract lines the nasal cavity, sinuses, nasopharynx, Eustachian tubes, middle ear space and mastoid down to the respiratory bronchioles
          • Pseudostratified columnar ciliated epithelium – lines the respiratory epithelium composed long columnar cells surmounted by cilia of about 100 to a cell underlain with 3-4 layers of replacement cells
          • Pseudostratified cuboidal epithelium – lines the paranasal sinuses with only 1-2 layers of replacement cells
          • The glands and blood vessels in the stroma of the submucosae vary in number and in size in direct proportion of the air flow and they furnish the mucous blanket
          • The olfactory epithelium – high cylindrical type of cells with distinct type of basal cells
          • 3 types of cells makes up the olfactory epithelium :
          • 1 cuboidal cells forming the basal layer
          • 2 tall cylindrical supporting cells & sense cells
          • Sense cells – bipolar nerve cells forming the tract of C.N.S. and evenly distributed among the supporting cells
          • Olfactory vesicle – distal end of olfactory sense cell which is a modified dendrite protruding above the surface epithelium
          • At the surface of this vesicle there are 6-8 motile cilium that tapers to a thin filament and this is the Axon which joins with other similar Axons forming the Olfactory Nerve
          • The Axons are collected together to pass through the Cribriform Plate into the Olfactory bulb to form a synapse with the dendrites of the mitral cells
          • Axons of these mitral cells forms the Olfactory Tract
          • Cilia – 5-7 micron in length found on the end plate of the surface cells and functions for mucociliary clearance
          • Mucous Blanket – vicid, continous sheet of secretion covering all spaces of the respiratory tract, so sticky, particles adhere to it promptly, with a PH of 7 and renewed at least 2-3 times an hour
    • BLOOD and NERVE SUPPLY, VENOUS and LYMPHATIC DRAINAGE of the NOSE and SINUSES
            • Spheno-palatine branch of the Internal Maxillary Artery – supplies the septum, meatuses and conchae
            • Superior Labial, Infraorbital and Alveolar branches of Internal Maxillary Artery – supplies the Maxillary Sinus
            • Pharyngeal branch of Internal Maxillary artery – supplies the Sphenoid Sinus
            • Anterior and Posterior Ethmoidal branches of Ophthalmic Artery – supplies the roof of the nose, the Frontal and Ethmoid Sinuses
            • Spheno-palatine, Anterior Facial and Ophthalmic Veins – venous drainage
            • Anterior Lymphatic Network – drains along facial vessels and drains the anterior part of the nose
            • Posterior Lymphatic Network – drains the major portion of the nose divided into 3 subgroups
            • Superior Group drains the middle turbinates and drains to the Retropharyngeal Lymph Nodes
            • Middle Group drains the inferior turbinates and inferior meatus and drains to the Jugular Lymph Nodes
            • Inferior Group drains the septum and drains to the lymph nodes along the Internal Jugular Vessels
            • Nerve supply of the nasal space comes from the (1st) Ophthalmic and (2nd) Maxillary Division of the (CN-V) Trigeminal nerve
            • Superior and Anterior – 1st division of CN-V carry sensory afferent impulses
            • Posterior and Inferior – 2nd division of CN-V receives parasympathetic fibers from superficial petrosal nerve from the Geniculate Ganglion of CN-VII and sympathetic fibers from deep petrosal nerve through the spheno-palatine ganglion
    • PHYSIOLOGY
    • 3 Functions of the nose:
      • Respiration and Humidification
      • Phonation
      • Olfaction
      • Odoriferous particles are dissolved in solution and brought by nasal airflow to the nasal roof where olfactory mucosa are found
      • Olfactory bipolar neurons are stimulated and travels through the olfactory nerves to the Brain via the Cribriform Plate
      • In Respiration which acts as a rigid airway for inspiration and expiration also acts to filter minute particles in the inspired air
      • Plays a role in Air moistening and heat exchange
      • Produces about 1 liter of mucus a day which contains an enzyme Muramidase containing Ig-A and Ig-E aids in breakdown of bacterial cell walls
      • Also implicated in the Naso-pulmonary Reflex through the Hypothalamus
      • Functions in Phonation since the nose adds resonance in voice production
    • EMBRYOLOGY
      • Nose forms between the 4th and 8th weeks of embryonic life
      • Region anterior to the forebrain becomes the Fronto-nasal Process in which the nose and jaws develops
      • At the lateral part of the Fronto-nasal Process, the right and left median nasal processes develops
      • While the maxillary and mandibular processes grow medially, from the lateral maxillary process, the lateral nasal process develops
      • Pits forms between the lateral and median nasal process and later develops as the anterior nares
      • The Premaxilla fuses with the maxillary process to form the upper lip and upper jaw
      • The palate develops from the median and lateral palatine processes which is derived from the maxillary process seen during the 7th and 8th weeks AOG
      • During the 8th week, the premaxilla makes an incomplete fusion with the palatine process to form the Incisive Foramen
      • Between the nasal space and the mouth, the palate thins out to form a membrane which eventually opens to form the Choanae
      • Anterior palate ossifies becoming hard and posterior palate did not ossify becoming the soft palate
      • The olfactory sac grows posteriorly to compress a part of the fronto-nasal process which becomes the Septum and fuses to the palate
      • As the face grows down and forward in a more rapid rate than the cranium grows, ossified material in these bones are removed and nasal mucous membrane is sucked into the resulting bony spaces giving rise to bony resorption in the maxillas, frontal, ethmoid and sphenoid bones
      • As a result, the sinuses are irregular in shape and vary in size, number, symmetry and anatomic placement
      • Maxillary Sinus – outgrowth of the middle meatus, largest paranasal sinus with a volume of 15cc per sinus
      • Frontal Sinus – arises from the expansion of the anterior air cells from the ethmoids with a volume 6-7cc per sinus
      • Sphenoid Sinus – develops as an excavation into the sphenoid bone with a volume of 7.5cc
      • Ethmoid Sinus – develops as outpocketings of the middle meatus with a volume of 14cc
    • SPECIAL DIAGNOSTIC PROCEDURES
    • Radiographic Examinations:
      • CALDWELL VIEW – “forehead-nose” view to evaluate maxilla, maxillary and frontal sinus, ethmoid air cells, lamina papyracea and fronto-zygomatic suture
      • WATER’S VIEW – “chin-nose” or “occipito-mental” view for evaluation of the paranasal sinuses and facial skeleton such as frontal process of maxilla, nasal bones, orbit, orbital rim’ zygomatic arch and coronoid process of the mandible
      • Basal View – “submento-vertical” view to evaluate the sphenoid, the posterior ethmoids, the maxillary and frontal sinuses
      • SOFT TISSUE LATERAL VIEW – same as lateral view only giving emphasis on the soft tissue to evaluate the degree of “step-down” deformity exhibited by nasal fracture
    • TOMOGRAMS
      • COMPUTERIZED TOMOGRAPHY – a scintillation detector that passes through a body section processed by a digital computer useful in delineating the extent of the lesion
      • Magnetic Resonance Imaging – non-invasive imaging procedure with no known biological hazards, has certain advantages over the conventional X-Rays and C-T Scans due to it’s exquisite soft tissue contrast useful for evaluation of head and neck neoplasms
    • PHYSICAL EXAMINATION
      • Anterior Rhinoscopy – done with the use of a nasal speculum for initial screening of the nasal status, externally and internally, useful in evaluation of nasal obstruction
    • CONGENITAL ANOMALIES
      • The possible aftereffects of a postnatal injury to any growing skeletal part of the body includes accelerated growth rate or decelerated growth rate to complete growth arrest
      • Maternal diseases particularly viral infections and maternal use of medications toxic to the fetus results in congenital anomalies
      • The vomeronasal organ of Jacobson appears in the medial wall of the nasal cavity by the 5th week obtaining full growth by the 2nd trimester and then degenerates
      • Special V-shaped cartilages supporting this organ may persist in adult life as preseptal cartilages giving rise to obstructing nasal spurs in the adults
      • At birth , most of the septum is still cartilaginous, showing bones only in the anterior nasal spine, premaxilla and vomer in which these bones have V-shaped grooves where the cartilaginous septum rest
      • Any process that would interfere the growth rate of these bones will result in buckling of the cartilages they support
      • Such process maybe influenced by medications taken by the mother, maternal diseases, intrauterine injuries and nutritional deficiencies of the developing individual
    • Genetic deformities are usually obvious at birth which includes:
      • Hemangioma - a congenital benign tumour or vascular malformation
      • Hamartoma - a benign, focal malformation that resembles a neoplasm in the tissue of its origin.
      • Rubinstein-Taybi’s Syndrome – with a bird-like beak.
      • Wardenburg’s Syndrome – with a wide flat nose
      • Meningoceles and Encephaloceles – results from incomplete closure of chondrocranium
        • Syphilis, measles and chicken pox – diseases of pregnancy affecting the nose
        • Coumadine and Reserpine – causes adverse effect in nasal development when administered to a pregnant mother
        • Untoward influences in the 1st trimester such as development of only 1 nasal process instead of 2 will result to absence of the nose at birth
        • Congenital Dermoid Cyst are epithelial structure persisting in the fusion line of intranasal fissure
        • Injured development in the 4th fetal month results to bifid or cleft noses or double noses with combination of cleft lips and palates
        • Failure of resolution of the temporary epithelial plug of the nostril on the 6th fetal month results to congenital stenosis of the nostril
        • If the preseptal cartilages fails to resolve in the 3rd trimester – results to septal spurs, chondromas and impacting vomer ridges
        • A healed intrauterine fractures during the 3rd trimester caused by accidental fall of the mother or by pressure of the nose against the mother’s pelvic bones usually results to displacement of a well developed nose on 1 side
        • Majority of nasal fractures in infancy heals to normal without medications
        • Contributory factors affecting the incidence of birth injuries includes racial characteristics, birth canal presentations, intrauterine pressures and fetal positions
        • Nasal deformities during the active growth period are usually associated with tooth malalignment of the upper incisor teeth and malocclusion
      • ………… .THE END…THANK YOU……..…