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Dentist in pune.(BDS. MDS) - Dr. Amit T. Suryawanshi. Nose & Paranasal sinuses.

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Dentist in pune. (BDS. MDS) - Dr. Amit T. Suryawanshi. Seminar- Nose & Paranasal sinuses.
Email ID- amitsuryawanshi999@gmail.com
Contact -Ph no.-9405622455

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Dentist in pune.(BDS. MDS) - Dr. Amit T. Suryawanshi. Nose & Paranasal sinuses.

  1. 1. SURGICAL ANATOMY OF NOSE& PARANASAL SINUSES. Dr. Amit T. Suryawanshi Dentist & Oral and Maxillofacial Surgeon Pune, India Contact details : Email ID - amitsuryawanshi999@gmail.com Mobile No - 9405622455
  2. 2. CONTENTS • INTRODUCTION • EMBRYOLOGY OF NOSE & PARANASAL SINUSES • ANATOMY OF NOSE & NASAL CAVITY • FUNCTIONS OF PARANASAL SINUSES • PARANASAL SINUSES - EMBRYOLOGY - ANATOMICAL RELATIONS. - NEUROVASCULAR SUPPLY. • CONCLUSION
  3. 3. INTRODUCTION • The nose & nasal cavities are a complex arrangement of hard & soft tissues. • The complexity of the paranasal sinuses anatomy as well as their many functions make them an interesting topic to study. • It is imperative for the surgeon to know the anatomy of the nose and associated paranasal sinuses, so as to deal with the disorders involving them.
  4. 4. EMBRYOLOGY • Developmentally nose and paranasal sinuses are interlinked. • The frontonasal process inferiorly differentiates into two projections known as “Nasal Placodes”. These structures later fuse to become the nasal cavity and primitive choana, separated from the stomodeum by the oronasal membrane. • The primitive choana forms the point of development of posterior pharyngeal wall and the various paranasal sinuses.
  5. 5. Nasal placodes- These structure fuses to form the nasal cavity and primitive choana. Choana – forms the point of development of posterior pharyngeal wall and paranasal sinuses. The oronasal membrane - It gives rise to the floor of the nose and palate
  6. 6.  The frontonasal prominence gives rise to inferior mesodermic projection which goes on to form the nasal septum dividing the nose into two cavities. • The skeletal system develops from mesoderm.
  7. 7. • At about 25 – 28 weeks of gestation, three medially directed projections arise from the lateral wall of the nose. • This serves as the beginning of the development of paranasal sinuses. • Between these projections small lateral diverticula invaginate to eventually form the meati of the nose.
  8. 8. The medial projections arising from the lateral wall of the nose forms the following structures: • The anterior projection forms the agger nasi • The inferior projection forms the inferior turbinate and maxillary sinus • The superior projection forms the superior turbinate, middle turbinate, ethmoidal air cells and their corresponding drainage channels. • The middle meatus develops between the inferior and middle turbinate.
  9. 9. • The middle meatus invaginates laterally to form the embryonic infundibulum and uncinate process.
  10. 10. Nose • Nose – part of upper respiratory tract. • Two halves of nasal cavity opens into the face through the nares. • Nares continues posteriorly as nasopharynx through posterior nasal aperture.
  11. 11. •The NOSE consists two parts: - internal part - external part. •The internal part is much larger than the external part. •The external nose is the part that projects from the face.
  12. 12. Skeleton of external nose Framework is composed of bone and fibroelastic cartilages. Bony framework supports – upper part of nose . It comprises of following bones: - nasal bones - frontal process of maxilla - nasal process of frontal bone. - vomer bone - bony septum. - perpendicular plate of ethmoid bone.
  13. 13. DIAGRAM SHOWING BONES FORMING SKELETON OF EXTERNAL NOSE
  14. 14. Cartilaginous frame work consists of : 1) median quadrilateral septal cartilage 2) paired upper lateral cartilage 3) major and minor alar nasal cartilage
  15. 15. Cartilagenous skeleton of the external nose Septal cartilage – • Quadrilateral in side view • Antero-inferior part of nasal septum is devoid of cartilage & membranous septum continues with columnella.
  16. 16. Lateral nasal cartilage • Triangular in shape. • Ant. margin is more thicker than posterior margin. • Superior margin attach to nasal bone & frontal process of maxilla. • Inferior margin connected to major alar cartilage by fibrous tissue.
  17. 17. Major alar cartilage- • Thin flexible plate lying below upper lateral cartilage. • Curves acutely around ant. part of naris. • It narrows posteriorly & is connected to frontal process of maxilla by fibrous membrane containing 3-4 minor alar cartilages.
  18. 18. DIAGRAM SHOWING THE ALAR CARTILAGE
  19. 19. Skin of external nose- • Skin covering external nose in the upper portion is thin and loosely connected to underlying structures. • Over apex and alae is thicker and more adherent which bears numerous large sebaceous glands having distinct orifices.
  20. 20. Arterial supply of skin – septal branches of facial artery - dorsal nasal branches of ophthalmic artery - infraorbital branches of maxillary artery. Venous drainage of skin into - facial vein - ophthalmic vein.
  21. 21. Nerve supply: - motor branches to the nasal muscles: buccal branch of the facial nerve. - sensory branches to the skin: - ophthalmic nerve - infratroclear & external nasal branches of nasociliary nerve. - nasal branches of the maxillary nerve.
  22. 22. • The entire nasal cavity extends from the nares (nostrils) anteriorly to the choanae posteriorly Choanae • It is divided into 2 parts by an osseocartilaginous nasal septum
  23. 23. NASAL CAVITY Each half of the nasal cavity has a: • Floor • Roof • Lateral wall • Septal wall
  24. 24. Functions of the nasal cavity : • It forms the superior part of the respiratory tract • A passageway for air to lungs • Filters impurities, especially dust from inspired air • Warms and humidifies inspired air
  25. 25. • Organ of smell • Aids in phonation • Receives secretions from paranasal sinuses • Receives secretions from nasolacrimal duct
  26. 26. The Floor - Smooth, concave transverse and slopes up from anterior to posterior aperture. - It constitutes upper surface of hard palate. Palatine process maxilla Horizontal plate palatine bone
  27. 27. •Anteriorly, near the septum a small infundibular opening in the nasal floor leads to incisive canals that descend to the incisive fossa opening. • It is marked by slight depression in the mucosa.
  28. 28. The Roof • Narrow • Formed by a number of bones and cartilages Nasal Cartilages, Nasal, Frontal, Ethmoid,Sphenoid Bones http://www.netterimages.com/images/vpv/000/000/000/986-0550x0350.jpg
  29. 29. • Anterior slope is formed by nasal spine of the frontal and nasal bones which contributes to external nose. • Central horizontal region is formed by cribriform plate of ethmoid bone which separates the nasal cavity from floor of anterior Cranial fossa. • The posterior Slope is formed by the body of sphenoid bone – interrupted on each side by opening of sphenoidal sinus.
  30. 30. The medial wall (Nasal Septum) - Divides the nasal cavity into right and left halves -It is partly osseous and partly cartilaginous -Bony part is formed by vomer bone & perpendicular plate of ethmoid bone. Perpendicul ar Plate (ethmoid) Vomer Septal Cartilage
  31. 31. •The antero-inferior part of the nasal septum contains anastomosis between a) superior labial branch of facial artery & b)sphenopalatine branch of maxillary artery. •This is called as little’s area or kisselbach’s area. •It is a common site of bleeding from nose(epistaxis).
  32. 32. The Lateral Wall Marked by 3 projections: - Superior concha - Middle concha - Inferior concha Inferolateral to each concha there lies a corresponding passage called as meatus.
  33. 33. •Above the superior concha the triangular spheno-ethmoidal recess bears the opening of sphenoidal sinus. •Sometimes a 4th concha , the highest nasal concha appears on the lateral wall of this recess. •The passage immediately beneath it is termed as supreme nasal meatus. •Bounds most of the paranasal sinus and receives opening from these sinuses.
  34. 34. LATERAL WALL OF NOSE
  35. 35. • The middle meatus has two parts : – frontal recess – the descending ramus • The descending ramus is marked by the ethmoid bulla, the uncinate process and the semilunar hiatus • Sometimes there is a complete absence of drainage of maxillary sinus due to adherence between ethmoid bulla and uncinate process
  36. 36. DIAGRAM SHOWING PARTS OF MIDDLE MEATUS
  37. 37. Agger nasi cell: • The cell is found in the lacrimal bone anterior and superior to the junction of the middle turbinate with the nasal wall (often described as the bulge in the lateral nasal wall where the middle turbinate attaches). • It is hidden behind the anterior most aspect of the uncinate process and drains into the hiatus semilunaris.
  38. 38. Agger nasi cell and ethmoidal bulla
  39. 39. • It is the first cell to pneumatize in the newborn and is prominent through childhood.
  40. 40. Diagram showing openings of sinuses in lateral wall of nose.
  41. 41. Openings in the nasal cavity: • Superior meatus : -posterior ethmoidal sinus • Middle meatus : - maxillary sinus - frontal sinus - anterior & middle ethmoidal sinus • Inferior meatus : nasolacrimal duct • Sphenoethmoidal recess : sphenoidal sinus.
  42. 42. OPENING OF SINUSES IN THE LATERAL WALL OF NOSE
  43. 43. • Arterial supply: - anterior & posterior ethmoidal branches of ophthalmic artery. - sphenopalatine branch of maxillary artery. - labial branch of facial artery. - • Venous drainage: - sphenopalatine vein - facial vein - ophthalmic vein
  44. 44. Lymphatic drainage: • Lymph vessels from Anterior Region of nasal cavity pass superficially to external nasal skin – ends in submandibular lymph nodes. • Rest of nasal cavity, paranasal sinuses, nasopharynx all drains to upper deep cervical nodes,through retropharyngeal lymph nodes. • The posterior Nasal floor probably drains to the parotid nodes.
  45. 45. Nerve supply: - anterior ethmoidal branch of nasociliary nerve - infraorbital nerve - anterior superior alveolar nerve - posterior superior nasal nerve - nerve of pterygoid canal. - olfactory nerve.
  46. 46. DIAGRAM SHOWING NERVE SUPPLY OF LATERAL WALL OF NOSE.
  47. 47. PARANASAL SINUSES •Paranasal sinuses are the mucosa lined air spaces present within the bones of the face & skull. •These sinuses are present in the bones of same name.
  48. 48. There are four bilaterally paired paranasal sinuses- - Frontal sinus - Maxillary sinus - Ethmoidal sinus - Sphenoidal sinus
  49. 49. DIAGRAM SHOWING PARANASAL SINUSES
  50. 50. •All sinuses opens into lateral wall of nasal cavity by small aperture that allow the equilibrium of air and movement of mucus. •Position of aperture , form and size of sinus vary enormously between individual. •Mucosa of sinus is continuous with nasal cavity – which favours spread of infection.
  51. 51. • Mucous is secreted by glands and swept through there aperture into the nose by there cilia. • The mucociliary escalators is the normal mechanism for clearing sinuses and maintaining aeration.
  52. 52. DIAGRAM SHOWING PARANASAL SINUSES
  53. 53. FUNCTIONS OF PARANASAL SINUSES • Humidifying and warming the inspired Air. • Imparts resonance to voice • Increases surface area for absorption of noxious gases and trapping of particles in inspired air • Lightens the skull
  54. 54. •Helps in absorbing the shock of blows to the face & thereby limiting the extent of facial injury from trauma. •Serves as an accessory olfactory organ by evenly distributing the inspired air.
  55. 55. MAXILLARY SINUS • Largest of all the paranasal sinuses. • Also known as the “antrum cave of Highmore”– English physician described an infection of sinus in 1651. • First sinus to develop.
  56. 56. • 3rd IU month - mucosal outpouching of the ethmoidal infundibulum (primary pneumatization – confined to mucosa of nasal capsule) • 5th IU month – secondary pneumatization occurs, growth into adjacent maxilla. •At birth - it shows a small ovoid groove in maxilla & close to the orbit.
  57. 57. •At 9 years – 60 % adult size, becomes tubular in shape. •12 years- Antral floor parallels to nasal floor. •15-18 years- Adult size, pyramidal in shape.
  58. 58. DIAGRAM SHOWING GROWTH OF MAXILLAY SINUS
  59. 59. -Sinus growth correspond to eruption of permanent teeth. -Sinus enlarges by bone resorption at all the walls except the medial where deposition is accompanied by resorption at the nasal cavity thus expanding the nasal cavity
  60. 60. DIAGRAM SHOWING CORONAL CUT SECTION OF FACE
  61. 61. The dimensions of maxillary sinus are: At adulthood: 3.2-3.4 cm Anteroposterior (depth) 3.0-3.5 cm ( vertical height) 2.3-2.5 cm (width) -with a volume of approximately15-20 mL.
  62. 62. According to the shape, maxillary sinus is classified as under: 1-Semi-ellipsoid (15%) 2-Paraboloid (30%) 3-Hyperbolic (47%) 4-Cone-shaped(8%)
  63. 63. ANATOMY OF MAXILLARY SINUS The maxillary sinus has a horizontal pyramidal shape that consists of : - base - an apex - four sides i.e - a) Superior wall b) Anterolateralwall c) Posterolateralwall d) Inferior wall.
  64. 64. BASE OF SINUS: -the base of maxillary sinus is formed by lateral wall of nose.
  65. 65. APEX OF THE SINUS: - It is formed by junction of the maxillary bone & the zygomatic bone. - On an average the distance between base and the apex measures around 25mm. - Sometimes,when the sinus is large the apex extends into the zygoma.
  66. 66. MAXILLARY SINUS(SAGITTAL SECTION)
  67. 67. SUPERIOR WALL: - This wall forms both- roof of sinus & floor of the orbit. • It is thinnest wall & mostly flat slopes slightly anteriorly and laterally. • The Infraorbital canal runs along this wall and crosses from back to front- accentuates the fragility of wall.
  68. 68. •This wall is frequently involved in orbital and maxillary trauma. •Because of the relative thinness of this wall position of the Infraorbital Tumors of maxillary sinus can erode this wall readily.
  69. 69. ANTERO-LATERAL WALL : •Anterior aspect of the maxilla extents from : - piriform aperture medially to the zygomatico-maxillary suture laterally - superiorly infraorbital rim ,to alveolar process and maxillary teeth inferiorly. •Convex towards sinus. Thickness is 2-5mm.Thinnest portion over canine fossa .
  70. 70. •From the outer surface of this wall passes the facial artery & the facial vein. •Labial Levator muscles & inferior portion of orbicularis oculi is attached to this wall above the infra-orbital foramen. • These attachments direct the spread of infection from maxillary teeth.
  71. 71. • This wall also contains the Anterior & middle superior alveolar nerves. • Any surgical procedure through this wall may jeopardise the nerve supply to these teeth.
  72. 72. POSTEROLATERAL / INFRATEMPORAL WALL • This wall is made up of zygomatic bone & greater wing of sphenoid bone. • Separates maxillary sinus from infratemporal and pterygopalatine fossae. • This wall is convex, bulging out posteriorly.
  73. 73. POSTERO-LATERAL WALL OF MAXILLARY SINUS
  74. 74. • Posterior superior alveolar nerves and vessels sometimes present in close contact with the sinus mucosa. •In such instances , acute sinusitis is accompanied by pain in multiple maxillary posterior teeth. •Immediately posterior to this wall, vital structures include: -maxillary nerve & maxillary artery - nerve of pterygoid canal - sphenopalatine ganglion.
  75. 75. • Access to the pterygopalatine fossa is accomplished by careful removal of this wall.
  76. 76. FLOOR OF THE SINUS • The floor of sinus is formed by maxillary alveolar process. • It is approximately1.5 cm below the floor of nasal cavity. • It corresponds to the line drawn laterally from ala of the nose. • Descending order of proximity to sinus-, 2nd molar, 1st molar, 3rd molar, 2nd Premolar, 1st Premolar, canine.
  77. 77. •Septa may be present in the alveolar recess of the sinus - between the 2nd premolar and 1st molar. •Bone may be dehisced exposing the roots to the sinus mucosa - periapical & sinus pathology may be indistinguishable from symptoms alone. •Risk of creating oroantral fistula increases with age.
  78. 78. DIAGRAM SHOWING GROWTH OF MAXILLARY SINUS
  79. 79. • The ostium : – Communication between maxillary sinus and nasal cavity. – Located 2 cm from the anterior aspect , 2 cm from the posterior wall and 4 cm from the floor of the sinus. – Opens into posterior part of the hiatus semilunaris in the middle meatus.
  80. 80. DIAGRAM SHOWING OSTIUM
  81. 81. •It doesn’t opens directly in the nasal cavity but opens into a narrow ethmoid infundibulam. •Ostium is occasionally considered as canal of 3 to 5 mm length ,it is the location of the invagination of the nasal mucosa in the embryological phase.
  82. 82. PHYSIOLOGY OF MAXILLARY SINUS • Lined with respiratory epithelium continuous with the nose and other paranasal sinuses. • Mucoperiosteal lining: Epithelium (pseudostratified ciliated columnar epithelium) + lamina propria + periosteum (intimately attached) Schneiderian membrane • Numerous mucus secreting goblet cells. • Sinus drainage by mucociliary mechanism– mucociliary blanket – particulate matter from sinus towards ostium - nasal cavity - nasopharynx
  83. 83. • Spiral movements - 1000 strokes/min – flow rate of 6 mm/min • Ciliary function may hampered by inflammation, dehydration, injury, tobacco smoking.
  84. 84. NEUROVASCULAR SUPPLY Arterial supply: - Facial artery - Infraorbital artery - Greater palatine artery. Venous drainage: - by the facial vein - infraorbital vein - greater palatine vein.
  85. 85. Lymphatic Drainage :- Into the Submandibular Lymph nodes. Nerve supply : -Infraorbital nerve -Anterior , Middle & Posterior superior alveolar nerves.
  86. 86. FRONTAL SINUS • The frontal sinuses are rudimentary or absent at birth. • They are developed between 7th & 8th year of life but reach the full size only after puberty. • More prominent in males.
  87. 87. DIAGRAM SHOWING PARANASAL SINUSES
  88. 88. • Paired frontal sinuses situated posterior to the superciliary arches lies between the outer and inner tables of frontal bone. • Each underlies a triangular area on surface . • The inner table is much thinner than the outer table. • As a result the chances of fracture of the inner table are more frequent ,even without the fracture of outer table.
  89. 89. The angles of frontal sinus are formed by: - nasion - a point 3cm above the nasion - junction of medial third & lateral two third of supraorbital margin.
  90. 90. DIAGRAM SHOWING FRONTAL SINUS
  91. 91. • Average dimensions are – - Vertical height - 3.2 cm, - transverse breadth- 2.6cm, - Anteroposterior depth- 1.8cm. • Each extends upward above the medial part of the eye brow and back into medial part of roof of orbit
  92. 92. •The aperture of each sinus opens into the anterior part of the corresponding middle meatus of nose. •It opens by the ethmoidal infundibulum or through the frontonasal duct.
  93. 93. Arterial supply: - supraorbital artery - anterior ethmoidal artery Venous drainage: - into the anastomotic vein in the supraorbital notch connecting the supraorbital & superior ophthalmic veins.
  94. 94. Lymphatic drainage: - into submandibular nodes. Nerve supply: - supraorbital nerve.
  95. 95. Variations in frontal sinus: •Two sinuses are rarely symmetrical the septum between them usually deviating from median plane. •The frontal sinus is sometimes divided into a number of communicating recess by incomplete bony septa. •Rarely one or both sinuses may be absent, may be racial differences also can be seen.
  96. 96. •The part extending superiorly in the frontal bone may small than part extending in supraorbital region. •Some times one sinus may overlap in front of the other. •Sinus may extend posteriorly, as far as the lesser wing of sphenoid bone but may not invade it.
  97. 97. ETHMOIDAL SINUS- • These are small, thin walled cavities in the ethmoidal labyrinth. • These sinuses are small at the time of birth. • They grow rapidly between 6-8 years of life & after puberty.
  98. 98. It is formed by following bones- - Frontal - Maxillary - Lacrimal - Sphenoid - Palatine
  99. 99. BASE OF SKULL SHOWING ETHMODAL SINUS
  100. 100. • They lie between the upper part of the nasal cavity and the orbit. • Separated from the orbit by paper-thin orbital plate of ethmoid . • Ethmoidal sinus is of 3 groups - Anterior group - Middle group - Posterior group
  101. 101. Anterior group- • Also called as the infundibular sinus. • They lie in the agger nasi and also encroach on the frontal sinus. • These are 11 in numbers and open into the ethmoidal infundibulam or in the frontonasal duct.
  102. 102. DIAGRAM SHOWING ETHMOIDAL SINUS (SAGITTAL SECTION) -
  103. 103. Middle group- • Also called as a Bullar Sinus. • They are 3 in number and open in the middle meatus by one or more orifices on or above the ethmoidal bulla.
  104. 104. ETHMOIDAL BULLA: • This is the most constant landmark for surgery. It lies above the infundibulum and it's lateral/inferior surface and the superior edge of the uncinate process forms the hiatus semilunaris. • The anterior ethmoid artery usually decends across the roof of this cell.
  105. 105. DIAGRAM SHOWING ETHMOIDAL BULLA.
  106. 106. Posterior group- • It lies very close to the optic canal and the optic nerve. • These are 1-7 in number and open into superior meatus. • Also one or more opens in the sphenoidal sinus.
  107. 107. NEUROVASCULAR SUPPLY – • Arterial Supply- - Sphenopalatine artery. -Anterior and posterior ethmoidal -arteries • Venous drainage- - into the corresponding veins
  108. 108. • Lymphatic drainage- - Anterior and middle groups drain in the submandibular nodes . - Posterior group drains into retropharyngeal nodes. • Nerve Supply- - Anterior and posterior ethmoidal nerves - Orbital branches of pterygopalatine ganglion.
  109. 109. Sphenoidal Sinus • These are paired sinus . • At birth, the sinuses are minute cavities and their main development occurs after puberty. • These are present posterior to the upper part of the nasal cavity within the body of the sphenoid bone.
  110. 110. Sphenoidal sinus
  111. 111. Relations : i)Superiorly– optic chiasma & pituitary gland. ii)Inferiorly– roof of pharynx iii)On either side – cavernous sinus & internal carotid artery iv) Anteriorly – sphenoethmoidal recess v) Posteriorly – Pons & medulla
  112. 112. • Average diameter : - Vertical height - 2cm - Transverse breadth- 1.8 cm - Anteroposterior depth- 2.1 cm
  113. 113. Diagram of base of skull showing ethmoidal & sphenoidal sinuses
  114. 114. Variations in the Sphenoidal Sinus • They are rarely symmetrical , one often being larger and extending across the median plane • One or both may approach closely to optic canal and partly encircle it . • If exceptionally large, they extend into the roots of pterygoid processes and may invade into the basilar part of the occipital bone.
  115. 115. • The aperture of each sphenoidal sinus opens into the corresponding spheno-ethmoidal recess high in its anterior wall.
  116. 116. Neurovascular Supply – Arterial Supply- - Posterior ethmoidal artery. Venous drainage- - into the ethmoidal vein.
  117. 117. Lymphatic drainage- - Into the retropharyngeal lymphnodes Nerve supply- - posterior ethmoidal nerves - Orbital branches of pterygopalatine ganglion.
  118. 118. CONCLUSION •It is imperative for the oral & maxillofacial surgeon to know the anatomy of the nose and associated paranasal sinuses ,So as to deal with the disorders involving them & to preserve the vital structures.
  119. 119. REFERENCES • Grays anatomy,39th edition • Oral and maxillofacial surgery clinics of north america vol 11 no 1 feb 1999. • Oral and maxillofacial surgery – Fonseca • Oral surgery vol 1- Daniel laskin • Atlas of anatomy- Patrick tank, Thomas gest. • Netter’s atlas of anatomy.
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