For medical, nursing, and physiotherapy undergraduates, and postgraduates

1. NOSE, NASAL CAVITY AND
PARANASAL SINUSES
DR. SUNDIP CHARMODE
ASSISTANT PROFESSOR

2. OBJECTIVES
• Boundaries and features of nasal cavity
• Structure, blood supply, nerve supply and lymphatic
drainage of nasal septum
• Structure, blood supply, nerve supply and lymphatic
drainage of lateral wall of nose
• Clinical correlates

3. NOSE - COMPONENTS
• External nose
• Nasal cavity

5. FRAME WORK OF EXTERNAL NOSE
• Upper part – nasal, frontal processes of maxilla,
nasal notch of maxilla, nasal notch of frontal bone
• Lower part –
– Anterior border of septal cartilage
– Upper lateral nasal cartilage (continuous with
septal cartilage)
– Lower lateral nasal cartilage (major alar cartilage)
– A few minor alar cartilages
– Fibro fatty tissue in lower part of ala

6. ARTERIAL SUPPLY OF EXTERNAL NOSE
1. Dorsal nasal branch of Ophthalmic artery
2. Infra-orbital branch of Maxillary artery
3. Alar and septal branches of Facial artery

7. NERVE SUPPLY OF EXTERNAL NOSE
1. External nasal and infra-trochlear branches of
Ophthalmic nerve
2. Infra-orbital branch of Maxillary nerve

8. NASAL CAVITY

10. NASAL CAVITY
• The nasal cavity is divided into two halves by
median nasal septum
• Anterior nares:
• Posterior nares (choanae):
– 2.5 cm in height
– 1.25 cm in width

11. NASAL CHOANAE
• Inferiorly: Posterior border of the horizontal plate of
the palatine bone;
• Laterally: Posterior margin of the medial plate of the
pterygoid process
• Medially: Posterior border of the vomer
• Roof:
– Anteriorly: Ala of the vomer and the vaginal
process of the medial plate of the pterygoid
process
– Posteriorly: Body of the sphenoid bone

13. NASAL CAVITY – GATEWAYS
• There are a number of routes by which nerves
and vessels enter and leave the soft tissues
lining each nasal cavity.
1. Cribriform plate
2. Sphenopalatine foramen
3. Incisive canal
4. Small foramina in the lateral wall, and around
the margin of the nares.

15. NASAL CAVITY - GATEWAYS
CRIBRIFORM PLATE
• Olfactory nerves from nasal
cavity to cranial cavity
• Anterior ethmoidal nerve
and vessels from orbit to
cranial cavity and then
down to nasal cavity
• Nasal veins communicate
through foramen caecum
with superior sagittal sinus
SPHENOPALATINE FORAMEN
• This is a route of communication
between the nasal cavity and the
pterygopalatine fossa
– Sphenopalatine branch of the
maxillary artery
– Nasopalatine branch of the maxillary
nerve
– Superior nasal branches of the
maxillary nerve
• Superior to the attachment of the
posterior end of the middle nasal
concha.

16. NASAL CAVITY - GATEWAYS
INCISIVE CANAL
• Immediately lateral to
the nasal septum and
just posterosuperior to
the root of the central
incisor in the maxilla.
• Transmits:
1. Nasopalatine nerve
from the nasal cavity
into the oral cavity
2. Terminal end of the
greater palatine artery
from the oral cavity
into the nasal cavity
SMALL FORAMINA IN LATERAL WALL
1. Internal nasal branches of the
infra-orbital nerve of the
maxillary nerve
2. Alar branches of the nasal
artery from the facial artery
loop around the margin of the
naris to gain entry to the lateral
wall of the nasal cavity from the
face
3. Inferior nasal branches from
the greater palatine branch of
the maxillary nerve enter the
lateral wall of the nasal cavity
from the palatine canal

18. NASAL CAVITY - BOUNDARIES
• Each half of nasal cavity presents:
• Roof
• Floor
• Medial wall/Nasal septum
• Lateral wall

19. NASAL CAVITY - ROOF
• Very narrow from side to side
• Anterior/Fronto-nasal part – slopes down and
forward
• Intermediate/Ethmoidal part – horizontal -
cribriform plate of ethmoid bone
• Posterior/Sphenoidal part – anterior and inferior
surface of body of sphenoid bone
• Openings in the roof:

20. NASAL CAVITY - ROOF
 Anterior:
– Nasal spine of the frontal bone and the nasal bones,
and
– Lateral processes of the septal cartilage and major alar
cartilages of the external nose
 Posterior:
– Anterior surface of the sphenoid bone,
– Ala of the vomer and adjacent sphenoidal process of
the palatine bone, and
– Vaginal process of the medial plate of the pterygoid
process.

22. NASAL CAVITY - FLOOR
• Almost horizontal, concave from side to side, wide
– 7.5 cm long
– 1.5 cm wide
• It consist of:
• Soft tissues of the external nose, and
• The upper surface of the palatine process of the
maxilla, and the horizontal plate of the palatine
bone, which together form the hard palate.

24. NASAL CAVITY - REGIONS
• Three regions
• Nasal vestibule: small dilated space just internal to naris
that is lined by skin and contain hair follicles
• Respiratory region: largest area, rich neuro-vascular
supply, lined by respiratory epithelium composed mainly
of ciliated and mucous cells
• Olfactory region: small, at the apex of each nasal cavity,
lined by olfactory epithelium with olfactory receptors

26. NASAL CAVITY – SKELETAL
FRAMEWORK
• Bones forming framework are:
• The unpaired ethmoid, sphenoid, frontal bone and
vomer
• The paired nasal, maxillary, palatine and lacrimal
bone and inferior conchae
• Of all the bones associated with the nasal cavities,
the ethmoid is a key element.

29. NASAL SEPTUM

32. INTRODUCTION
• Often deflected from the median plane
making each half of nasal cavity asymmetrical.
• Lined by mucous membrane except the
anterior mobile part which is covered by skin.
• The septum is formed partly by bones and
partly by cartilages.

33. BONY PART
 Principal bones:
–Perpendicular plate of Ethmoid
–Vomer
 Accessory bones:

36. PERPENDICULAR PLATE OF ETHMOID
• Forms antero-superior part of septum and
articulates with following :
• Upper margin: continuous with cribriform plate
• Antero-superiorly: nasal spine, nasal crest
• Antero-inferiorly: septal cartilage
• Postero-superiorly: sphenoidal crest
• Postero-inferiorly: vomer

38. VOMER
• Forms the postero-inferior part of septum -
Quadrilateral
• Grooved upper margin: grooved upper margin
between the diverging alae receives sphenoid
rostrum
• Lower margin: nasal crest
• Tip: fits in incisor crest
• Posterior border: free
• Anterior border:
– Perpendicular plate of ethmoid
– Septal cartilage

39. ACCESSORY BONES
• Above and front:
• Nasal spine of frontal bone
• Crest formed by articulation of nasal bones
• Above and behind:
• Sphenoidal crest and Rostrum
• Below:
• Nasal crest formed by palatine process of maxillae
and horizontal parts of both palatine bones

40. CARTILAGINOUS PART
• Antero-inferior part of septum
1. Septal cartilage
2. Septal processes of lower nasal cartilage
3. Vomero-nasal cartilage

41. SEPTAL CARTILAGE
• Forms anterior part of septum, quadrilateral
• Antero-superiorly: Upper lateral cartilage
• Antero-inferiorly: Septal process of lower nasal
cartilage (major alar) on each side
• Postero-superiorly: Perpendicular plate of ethmoid
• Postero-inferiorly: Vomer, incisor crest and anterior
nasal spine

44. SEPTAL PROCESSES OF LOWER NASAL
CARTILAGE
• Each process is connected by fibrous tissue with that
of opposite cartilage
• It is covered by skin and is the mobile part of the
septum.

45. VOMERO-NASAL CARTILAGE
• Intervenes between the Vomer and Septal cartilage
• Contains on each side a mucous pouch called
Vomero-nasal organ of Jacobson
• Extends upwards blindly from lateral incisive canal
for 2-6mm, lined by olfactory epithelium supplied by
olfactory nerves.

46. ARTERIAL SUPPLY
• Antero-superior part: Anterior Ethmoidal branch
• Postero-superior part: Spheno-palatine and Greater
Palatine branch of Maxillary artery
• Mobile part of septum: Septal ramus of superior labial
branch of Facial artery

47. LITTLE’S AREA/KIESSELBACH’S
TRAINGLE
• An area on the antero-inferior part of septum
• Highly vascular
• Anastomoses between septal branch of facial, long
spheno-palatine and terminal branches of greater
palatine arteries.

50. VENOUS DRAINAGE
• Antero-superior part: Superior ophthalmic vein
• Postero-inferior part: Pterygoid venous plexus
• Mobile part of septum part: Internal Jugular vein
through the facial vein.
• Upper part of septum: veins accompany olfactory
nerves and drain into inferior cerebral veins

51. VENOUS DRAINAGE
• Few veins communicate with Superior Sagittal sinus
through the Foramen Caecum.
• Acts as nature’s safety procedure, how?
• In severe hypertensive crisis in elderly, severe,
sudden nasal bleeding can occur due to rupture of
these communications which reduces increased
intra-cranial vascular pressure.

52. LYMPHATIC DRAINAGE
• Anterior part: Sub-mandibular lymph nodes
• From Intermediate and posterior part: Retro-
pharyngeal lymph nodes
• Upper part: few lymphatics accompany Olfactory
nerves along the Peri-neural sheaths and drain into
CSF of subarachnoid spaces.

53. NERVE SUPPLY –SPECIAL SENSORY
• Olfactory zone: supplied by 15-20 bundles of
olfactory nerves formed by central processes of
bipolar olfactory cells. These olfactory nerves pierce
cribriform plate and make synaptic contacts with
mitral cells of olfactory cells.

54. NERVE SUPPLY – GENERAL SENSORY
• Remaining zone:
• Antero-superior part: Anterior ethmoidal br. of
Naso-ciliary nerve (V1)
• Intermediate part: Long Spheno-palatine br. of
Pterygo-palatine ganglion (conveying fibers of
Maxillary nerve) (V2)

55. NERVE SUPPLY – GENERAL SENSORY
• Posterior part: Short spheno-palatine nerves, nerve
of Pterygoid canal and nasal branches of greater
palatine nerve (V2)
• Antero-inferior part: Anterior superior alveolar
nerve (V2)
• Mobile part: External Nasal nerve (V1)

58. LATERAL WALL

59. FORMATION
1. Nasal bone
2. Frontal process of maxilla
3. Lacrimal bone
4. Middle nasal concha of labyrinth of ethmoid
5. Superior nasal concha of labyrinth of
ethmoid
6. Inferior nasal concha
7. Perpendicular plate of palatine bone
8. Medial pterygoid plate of Sphenoid

62. INFERIOR NASAL CONCHAE
• It is a separate bone with lower free margin
• It extend horizontally backwards and ends 1.25 cm
in front of pharyngeal tube opening
• The space under cover of inferior concha is called
inferior meatus which receives termination of Naso-
lacrimal duct.

63. MIDDLE NASAL CONCHAE
• Part of ethmoid labyrinth
• Lower border of middle concha corresponds with
lower surface of body of sphenoid
• Space under the middle concha - middle meatus
• Bulla ethmoidalis – bony bulging – middle ethmoidal
sinus
• Hiatus semilunaris – crescentic space
• Floor of hiatus – opening of maxillary sinus
• A mucous diverticulum – Ethmoidal diverticulum –
frontal and anterior ethmoidal sinuses

64. SUPERIOR NASAL CONCHAE
• Part of ethmoid labyrinth
• Space under cover of superior concha – superior
meatus – posterior ethmoidal sinuses
• The area intervening between superior concha and
the nasal roof – Supreme meatus
• Above and behind the superior concha – spheno-
ethmoidal recess - opening of sphenoidal sinus

69. ARTERIAL SUPPLY
• Antero-superior part: Anterior ethmoidal br.
• Antero-inferior part: Alar br. of Facial and
Terminal branches of Greater palatine artery.
• Postero-superior part: Spheno-palatine br.
• Postero-inferior part: Branches of Greater
palatine piercing perpendicular plate of
Palatine bone.

71. VENOUS DRAINAGE
• From Front: Facial vein
• From Behind: Retro-pharyngeal vein and
Pterygoid venous plexus
• From Above: Inferior Cerebral veins

73. LYMPHATIC DRAINAGE
• Anterior half: Submandibular group of lymph
nodes
• Posterior half: Retro-pharyngeal and Upper
deep cervical group of lymph nodes.

75. NERVE SUPPLY
• Sensory (Special): From the olfactory zone
through olfactory nerves.
• Sensory (General): Derived from Trigeminal
nerve
• Antero-superior part: Anterior Ethmoidal br.
of Ophthalmic
• Antero–inferior part: Antero-superior alveolar
nerve br. of Maxillary nerve.

77. NERVE SUPPLY
 Postero-superior part: Posterior lateral nasal
br. of pterygo-palatine ganglion from Maxillary
nerve
 Postero-inferior part: Anterior palatine br. of
pterygo-palatine ganglion from Maxillary
nerve

78. NERVE SUPPLY
 Secreto-motor supply: Postganglionic secretomotor
fibers for nasal glands are derived from pterygo-
palatine ganglion which receives preganglionic fibers
from superior salivatory nucleus
 Vasomotor supply: Derived from sympathetic
system. Preganglionic fibers – lateral horn cells of
upper 3 or 4 thoracic segments; postganglionic fibers
- superior cervical ganglion

80. CLINICAL CORRELATION
1. Fracture of cribriform plate – anosmia and
CSF rhinorrhoea
2. Deviated nasal septum
3. Sinusitis
4. Little’s area/Kiesselbach’s area
5. Dangerous area of face
6. Epistaxis

81. PARA-NASAL
SINUSES
DR. SUNDIP CHARMODE
ASSISTANT PROFESSOR

82. INTRODUCTION
• They are air containing bony spaces around nasal
cavity and lined by mucous membrane of ciliated
columnar epithelium
• They are arranged in pairs and named according to
the bone in which it is found:
– Frontal
– Ethmoidal
– Maxillary
– Sphenoidal

85. CHARACTERISTICS
• The paranasal sinuses develop as outgrowths
from the nasal cavities and erode into the
surrounding bones. All are:
1. lined by respiratory mucosa, which is ciliated
and mucus secreting;
2. open into the nasal cavities; and
3. innervated by branches of the trigeminal
nerve [V].

86. CHARACTERISTICS
• Ethmoidal sinuses are arranged in three groups:
– Anterior
– Middle
– Posterior
• All sinuses are in rudimentary form at birth except
frontal sinuses which start development 2-3 years
after birth
• Two spurts are observed:
– At 7-8 years during dentition
– At puberty

87. FUNCTIONS
1. The contained air of sinuses adds humidity and
temperature to inspired air, and serve as air
conditioning chambers
2. They act as resonating chambers for the production
of sounds
3. The sinuses make the facial bones lighter and
establish the facial contour
4. The mucus secretion of the sinuses is drained into
the meatuses of the nose partly by movement of
cilia and partly by negative pressure of nasal cavity.

88. FRONTAL SINUSES
• Two in number, triangular
• Contained within the two tables of squamous part of
frontal bone, deep to medial end of super-ciliary
arches
• Dimensions:
• Vertical – 3 cm
• Transverse – 2.5 cm
• Antero-posterior – 1.8 cm
• Communications: Each sinus communicate with
middle meatus through the ethmoidal infundibulum
and hiatus semilunaris via fronto-nasal duct.

92. FRONTAL SINUSES
• Blood supply: Supraorbital vessels
• Lymph drainage: Submandibular lymph nodes
• Nerve supply: Supra orbital nerves

93. ETHMOIDAL SINUSES
• The sinuses are contained within the ethmoidal
labyrinth
• They are situated between the medial wall of orbit
and lateral wall of nose
• 3-18 in number
• Three groups based on their location of openings:
– Anterior
– Middle
– Posterior

95. ETHMOIDAL SINUSES - COMMUNICATIONS
• Anterior sinuses: 3- 7 in number, open in middle
meatus through the ethmoidal infundibulum and
hiatus semilunaris
• Middle sinuses: 1-3 in number, form bulla
ethmoidalis and drain into middle meatus on or
above the bulla
• Posterior sinuses: 1-11 in number, drain in superior
meatus partly and partly into supreme meatus

98. ETHMOIDAL SINUSES
• Blood supply: Anterior and Posterior ethmoidal
branches of ophthalmic artery
• Lymph drainage:
– Anterior and Middle group- Submandibular group
of lymph nodes
– Posterior group – Retro-mandibular group of
lymph nodes

101. MAXILLARY SINUSES - STRUCTURE
• Largest of all paranasal sinuses
• Pyramidal in shape, contained within the body of
maxilla
• Apex: directed laterally
• Base: directed medially
• Dimensions:
• Vertical – 3.5 cm
• Transverse – 2.5 cm
• Antero-posterior -3.25 cm

103. MAXILLARY SINUSES - BOUNDARIES
• Apex: Zygomatic process of maxilla
• Base: Nasal surface of body of maxilla
• Roof: Orbital surface of maxilla (traversed by infra-
orbital vessels and nerve in a bony canal)
• Floor: Supported by alveolar process of maxilla
• Anterior wall:
– Infra-orbital plexus of vessels and nerves
– Origin of muscles of upper lip
• Posterior wall: Forms the anterior boundary of infra-
temporal and pterygo-palatine fossa

105. MAXILLARY SINUSES - COMMUNICATIONS
• Drains into the middle meatus through the floor of
hiatus semilunaris.
• Opening lies just below the bulla ethmoidalis
• The opening lies much higher from the floor of the
sinus – disadvantageous

107. MAXILLARY SINUSES
• Blood supply: Anterior, middle and posterior
superior alveolar vessels of maxillary artery
• Lymph drainage: Submandibular lymph nodes
• Nerve supply: Anterior, middle and posterior
superior alveolar nerves, branches of maxillary and
infra-orbital nerves

108. SPHENOIDAL SINUSES
• Located within the body of sphenoid bone, above
and behind the nasal cavity
• Dimensions:
– Vertical: 2 cm
– Transverse: 1.5 cm
– Antero-posterior – 2 cm
• Extent:
• Posteriorly: up to anterior margin of foramen
magnum
• Anteriorly: encroach on the roof of orbit
• Laterally: up to pterygoid canal

110. SPHENOIDAL SINUSES - RELATIONS
• Above: Optic chaisma and hypophysis cerebri
• Below: Roof of nasopharynx
• On each side: Cavernous sinus and internal carotid
artery
• Behind: Pons and medulla oblongata separated by
basilar venous plexus
• In front: Spheno-ethmoidal recess

111. SPHENOIDAL SINUSES
• Communications: Drains into the spheno-ethmoidal
recess and thence into the superior meatus
• Blood supply: Posterior ethmoidal vessels
• Lymph drainage: Retro-pharyngeal nodes
• Nerve supply: Posterior ethmoidal nerve and orbital
branch of pterygopalatine ganglion

113. CLINICAL CORRELATION
1. Fracture of cribriform plate leads to lesions of
olfactory nerves resulting in loss of sense of smell
(anosmia) and csf rhinorrhoea
2. Deviation of nasal septum involves cartilage or bone
leads to u/l nasal obstruction. Submucosal resection
or septoplasty is done.
3. Accumulation of infected material in paranasal
sinuses is common esp. Maxillary sinus where
drainage is poor. Surgical drainage is done by
breaking lateral wall of inferior meatus.

117. THANK YOU