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09-23-10 Nose
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09-23-10 Nose


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  • 1. 09-23-10 Nose & Paranasal Sinuses (Danieleson) –Outline Review of lecture from Neuro Block – no new material was added, but it was posted under the Lab section of 9-23 Nose Facts  Superior part of the respiratory system Nose Anatomy  Anatomical division: o External nose  Dorsum  Nares  Piriform shape  Openings of the nasal cavity  Alae  Septum  Skin extends in to the Vestibule  Vibrissae(Lat.-Stiff hairs)  Function: Air filtration  Cartilage  Five structures: o Lateral cartilage  Lateral process of the septal cartilage-pair o Alar cartilage  Major alar cartilage-pair-dilate and regulate flow of the air o Septal cartilage  Single structure  Nerves  External o CN V1, V2 – Sensory o CN VII – Motor  Blood  Facial A/V o Nasal cavity  Nerves  Posterior inferior portion: o Medial wall/ Nasal septum: Maxillary n.  Nasopalatine nerve o Lateral wall: Greater palatine n. Posterior superior/ Posterior inferior lateral nasal nerves  Anterior inferior portion: o Med/Lateral wall: Ophthalmic n. (CN V1)  Nasociliary n.  Anterior/Posterior Ethmoidal nerves  Cribriformplate: o Nerve terminals  Septal branches  Olfactory bulb/Olfactory Nerve (CN I)  Blood  Anterior ethmoidal artery (Ophthalmic artery) o Medial/Lateral Septal  Posterior ethmoidal artery (Ophthalmic artery) o Medial/Lateral Septal  Sphenopalatineartery (Maxillary artery) o Medial/Lateral Septal  Greater palatineartery (Maxillary artery)  Septal branches of the superior labial artery (Facial artery)
  • 2.  Kiesselbach’s area: Anastomosis of all fivearteries  Submucosal vein plexus drains in to the: o Sphenopalatine veins o Facial veins o Ophthalmic veins  Important: o Communication with the Cavernous sinus  Facial vein  Sup./ Inf. Ophthalmic veins  Pterygoid plexus/Cavernous sinus o Clinical Importance:  Thrombophlebitis of the facial vein  Boundaries  The Roof of the Nasal Cavity: o Curved and Divided in to three segments:  Frontonasal  Ethmoidal  Sphenoidal  The Floor of the nasal Cavity: o Broader and formed by the:  Palatine processes of the Maxilla  Horizontal plates of the Palatine bones  The Medial Wall of the nasal Cavity: o Formed by the:  Nasal septum  Divided By the Nasal Septum:  Boundaries o The Lateral Wall of the nasal cavity o Nasal Conchae (L. Shells):  Superior, Middle, Inferior  Function: Air Warming o Inferior Slits/Recesses aka Meatuses  Superior, Middle, Inferior Meatus  Left nasal cavity  Right nasal cavity  Divides the nose in to two cavities (Bony and Cartilaginouspart): o Superior part: Perpendicular plate of the Ethmoid bone  Descends from the Cribriform plate + Continues superiorly to the plate as Crista Galli o Posterior inferior part: Vomer  Some contribution from nasal crests of Maxillary and Palatine bones o Anterior inferior part: Septal cartilage  Tongue/groove articulation  Nares (Ant.)  Choane / Nasopharynx (Post.)  Lined by Mucosa (except Nasal Vestibule)  Nasal Mucosa:  Attached to the underlyingbones  Continuous with the liningof : o Nasopharynx (Post.) o Paranasal sinuses (Sup. and Lat.) o Lacrimal sac (Sup.) o Conjunctiva (Sup.)
  • 3.  Functional Division of Nasal Cavity:  Superior 1/3- Olfactory area o Sniffing  Inferior 2/3- Respiratory area o Warming o Filtering o Humidification of air  Openings o Sopheno-Ethmoidal recess  Sphenoid sinus opening o Superior Nasal Meatus  Posterior ethmoid sinuses openings o MiddleNasal Meatus  Opening of the frontal, ethmoidal and maxillary sinuses  Fronto-Nasal duct Ethmoidal infundibulum  Semilunar hiatus  Projection: Ethmoidal bulla (Lat=bulb/bubble)  Bula is formed by the middle ethmoidal cells whose wall protrude in to nasal cavity o Inferior Nasal Meatus  Opening of the nasolacrimal duct o Common Nasal Meatus  Space: Concahe  Nasal septum  Passages o Concahe Form Five Passages:  Spheno-Ethmoidal Recess  Superior Nasal Meatus  MiddleNasal Meatus  Inferior Nasal Meatus  Common Meatus Nose Pathology  External o Nasal Fractures:  Common sportinjury  Associated with Epistaxis (Nosebleed)  Leads to deviation of the nasal septum  Boxing/Traffic accidents  Ethmoid bone-Cribriform plate fractures o Deviation of nasal septum :  Caused by improperly healed nasal trauma  Can be as severe as in the picture (total obstruction)  Obstructs the breathing  Exacerbates snoring  Internal o Nasal Cavity Infections:  They can spread in to the:  Anterior cranial fossa (via-Cribriformplate)  Nasopharynx and retropharyngeal tissue  Middleear (via-Pharyngotympanic tube)  Paranasal sinuses  Lacrimal apparatus and conjunctivae  Dangerous communication:
  • 4.  In normal situations venous blood from facedrains through the: o Deep facial veins o Superior and Inferior ophthalmic veins  In to the Facial vein  Important Note: However these veins also communicatewith Pterygoid plexus o In normal pressure gradient the blood from Facial Vein drains in to Jugular  Thrombophlebitis of the Facial vein o Alternatively-Reversed pressuregradient:  The blood from Facial vein drains in to Pterygoid plexus  This is achieved through the:  Deep facial veins  Superior and Inferior ophthalmic veins  Pterygoid plexus drains via Emissary veins in to o CAVERNOUS SINUS  Pathogenesis:  No valves in these veins  Retrograde flow  Thrombophlebitis of Facial v. o May become Cavernous Sinus Thrombophlebitis  Embolus, Infection may spread easily  Forms danger triangleof the face  Pimplesqueezing can kill you o Epistaxis:  Highly vascularized tissue  Most of the bleeding from Kiesselbach’s area Paranasal Sinuses  Air-filled extensions of the respiratory tract  Extend in to followingbones: o Frontal  Squeezed between the outer and inner tables of the Frontal Bone  Posterior to the:  Superciliary arches  Root of the nose  Detected by the age of 7  Innervation: Supraorbital nerves (ophthalmic nerve)  Vascularization: Branches of the anterior ethmoidal arteries and veins  Drain through the:  Frontonasal duct  Ethmoidal infundibulum  Semilunar hiatus/ Middle nasal meatus o Ethmoidal  Situated within Ethmoid bone ; Location: Between the nasal boneand orbit  Not visibleuntil thesecond year of life (composed of multiple cells)  Innervation:  Ant./Post. Ethmoidal branches of the Nasociliary nerves (CN V1)  Orbital branches of the Pterygopalatineganglion (CN V2)  Vascularization: Branches of the Anterior and Posterior Ethmoidal arteries and veins  Openings  Anterior Ethmoidal cells open in to Middlenasal meatus (via ethmoidal infundibulum)  Middle Ethmoidal cells open in to Middlenasal meatus (AKA bullar cells)
  • 5. o Form Ethmoid Bulla (superior swelling of the Semilunar Hiatus)  Posterior Ethmoidal cells open directly in to Superior nasal meatus o Sphenoid  Location: Body of the Sphenoid  Unevenly divided in to L and R by Septum  Closecontact with: o Optic Nerve o Optic Chiasm o The Pituitary Gland o Internal Carotid Artery o Cavernous sinuses  Formed by the Invasion of Sphenoid bone by Posterior ethmoid sinuses (age2)  Innervation/Vascularization:  Posterior ethmoidal arteries and nerves  Can be used as a approach method to the hypophyseal fossa- Pituitary gland surgery o Maxilla  Largest of all of the sinuses  Occupy Maxillary bone  Segments:  Apex: Extends towards Zygomatic bone  Base: Forms the inferior partof the lateral wall of nasal cavity  Roof: Formed by the floor of the orbit  Floor: Alveolar Partof the Maxilla  Clinical Note: First two molars- conical elevations in to the sinus  Drains by one (Maxillary Ostium) or more openings in to the MiddleNasal Meatus  Via Semilunar Hiatus  Vascularization:  Superior alveolar branches of the Maxillary a.  Branches of descendingand greater Palatinearteries  Innervation: Anterior, Middle and Posterior Alveolar nerves (Maxillary nerve)  Named by the bones in which they are located  Pathology o Sinusitis  Inflammation of paranasal sinuses  Pansinusitis-multiplesinuses involved o Infection of the Ethmodial sinuses  If there is no drainageinfection can break through medial wall of the orbit  Consequences:  Blindness o Post . Ethmoidal cells in proximity to optic canal o affect the Optical nerve and Ophthalmic artery  Optic neuritis o Will affectthe dural nerve sheet o Infection of the Maxillary Sinus  Most common -Due to :  Small Ostia  Ostia Positioning o High (Only drain when sinus is full) o Medial wall only (Only drain when head is tilted)  Sinuses can be cannulated and drained o Teeth and Maxillary sinus  Three molar teeth are potential problem
  • 6.  Incorrectremoval can lead to the infection of the sinus  Broken root of the tooth can be pushed in to sinus  Communication between the mouth and sinus  Infection  Both innervated by alveolar branches of maxillary nerve  Pain from sinus is reflected to molar teeth Pharynx  Extends: o From: The cranial baseto the inferior border of cricoid cartilageanteriorly To: The inferior border of C6 vertebra-posteriorly. o Pharynx is divided in to 3 specific anatomic regions.  Nasopharynx:  Soft palate -anterior border →the level of the uvula  Respiratory function  Choane openings  Lymphoid tissue-Tonsils: o Pharyngeal tonsils (adenoids) o Roof and the posterior wall of the pharynx  Tubal tonsils o Embedded in Torus Tubarius o Surrounds the orifice of Pharyngotympanic tube  Vertical-Salpingopharyngeal fold o Salpingopharyngeus muscle o Opens the auditory tube during swallowing  Pharyngeal recess o Extends lat.-post.  Tonsillar Blood Vessels/ Oropharynx: o Facial artery o Pharyngeal,Palatineand Lingual arteries  Innervation of the tonsils: o Tonsillar Plexus:  Glossopharyngeal and Vagus nerves o Sensory:  Glossopharyngeal fibers  Oropharynx:  From the uvula → the epiglottis  Digestive function  Oral cavity opens into the oropharynx through the fauces.  Two (2) sets of tonsils: o Palatine  Collection of lymphoid tissue  Located in the tonsillar bed o Lingual  Located near the fauces o Tonsillar bed is located between the:  Palatoglossal and Palatopharyngeal arches  Bed is formed by the:  Superior pharyngeal muscle  Pharyngobasilar fascia  Pharyngeal plexus: o Glossopharyngeal and Vagus nerves o Sensory:
  • 7.  Glossopharyngeal fibers  Ant/ Sup Nasopharynx: o Sensory:  Maxillary nerve(V2)   Laryngopharynx:  the tip of the epiglottis →  the openings of the larynx / esophagus.  Pathology o o A quinsy is a peritonsillar abscessin thelooseconnective tissueoutsidethe capsuleof the tonsil.  Waldeyer’s Tonsillar Ring  Peritonsillary abscess (Quinsy)  Uvula displaced towards the unaffected side o Tonsilectomy  Dissection of palatinetonsilsfromthe tonsillarbed (snareor guillotine)  Watch for: External palatinevein, Tonsillar artery and Glossopharyngeal nerve(CN IX) Damage: Inability to swallow  Deadly mistake: Internal Carotid  ICA Aneurysm  Also watch for the Lingual Nerve (Anterior to the tonsil) o Adenoids  Enlargement of pharyngeal tonsils  Blockageof pharyngotympanic tubes  Middleear infection-hearingloss