This ppt contains anatomy and physiology of Nose and Paranasal sinuses, tried to explain all the structures with the help of CT scans.

1. NOSE AND PNS
ANATOMY &
PHYSIOLOGY
Dr. Shraddha Joshi
Ph.D. 1st year
Shalakya Tantra
ITRA, Jamnagar

2. External Nose
 Skeletal frame work: Bony (upper 1/3rd) and
Cartilaginous (Lower 2/3rd).
 Root of Nose : Continues with forehead.
 Base of Nose: Triangular in shape.
2 openings- Nostrils (separated by columnella).

3. Bony Part:
 Supports upper part of
external nose.
 Consist of:
Nasal Bone.
Nasal Spine of Frontal bone.
Frontal process of Maxilla.

4. Cartilaginous Part:
 Supports lower part of
external nose.
 Consist of:
1.Paired upper lateral cartilage.
2.Paired lower lateral cartilage.
3.Alar Cartilage.
4.Septal Cartilage.

5. Upper lateral cartilages: Intra nasally lower free border is seen as
Limen vestibuli/ Nasal Valve/Limen nasi.

6. Alar cartilages: Forms contour and nasal tip.
Naso- Septal cartilage: Nasal lateral cartilages and septal cartilage.

7. Nasal Musculature
Procerus
Nasalis (transverse and alar parts)
Levator labii superioris alaeque
nasi
Anterior and posterior dilator nares
Depressor septi.
Nasal Skin
Over Nasal Bones and upper lateral cartilages: freely movable.
Over alar cartilages: Adherent
Contains sebaceous glands: (Hypertrophy- Rhinophyma)

8. Internal Nose
 Nasal cavities:
• Divided into 2 parts: Vestibule (Skin lined)
Nasal cavity proper (Mucosa lined).
• Vestibule: Sebaceous gland, hair follicles and vibrissae.
• Nasal valve: Narrowest area of nose and regulates airflow and
resistance on inspiration.

9. Cottle’s test
Used in nasal obstruction due to
abnormality of nasal valve.
Intended to help focus on the where
in the nasal airway congestion is
centered.
The possibilities are several:
congestion can be caused by enlarged
nasal turbinates, collapsed nasal
valves, a damaged, deviated septum,
from nose tip to bridge), or a sinus
condition that affects the nasal
passages.

10. Cold Spatula Test

11. Dangerous area of face

12. Dangerous area of Nose
 Infection may spread into meninges along the pia and arachnoid
sheath of olfactory nerves.
 This area is also connected to superior sagittal sinus and cavernous
sinus by venous channels.

13.  The nose forms the gateway of the respiratory system and
serves the following important functions.
1. Respiratory passage: Normally, breathing takes place through
the nose.
• The inspired air passes upwards in a narrow stream medial to
the middle turbinate and then downwards and backwards in the
form of an arc, and thus respiratory air currents are restricted to
the central part of the nasal chambers.
• Any anatomical or pathological obstructive lesion in this region
is important, as this disturbs the air flow.
Physiology

14. 2. Filtration: The nose serves as an effective filter for the inspired
air.
• Vibrissae (nasal hair) in the nasal vestibule arrest large
particulate matter of the inspired air.
• The fine particulate matter and bacteria are deposited on the
mucus blanket which covers the nasal mucosa.
• The mucus contains various enzymes like lysozymes having
antibacterial properties.
• The mucus with the particulate matter is carried by the ciliary
movements posteriorly to the oropharynx, to be swallowed.

15.  Acute infective condition of the root of the hair follicle or sebaceous gland
in the nasal vestibule.
 Caused by Staphylococcus aureus.
 Predisposing factors-Trauma as in nose picking
Pulling of hair are the usual.
 C/F- Very painful and these tissues are very tender.
Localised redness with swelling of the nasal vestibule
and adjacent columella.
 Dangerous condition as the infection can spread to adjacent tissues of face
and upper lip causing cellulitis of the face.
 Tt.- Local heat, antibiotic, analgesics.
 Squeezing or incising the furuncle should be avoided as this can lead to
dissemination of the infection.
 Recurrent boils- Either due to frequent trauma like in nose picking or
suggest an underlying debilitating disease like diabetes.
Furunculosis of Nose

16. Thudicum Nasal Speculum

17. VESTIBULITIS
 Diffuse infection of the skin of
the anterior nares.
 Causes: Frequent trauma as in
nose picking. This produces
traumatic ulceration and
crusting, thus giving a foothold
to the infection.
 Types: Acute and Chronic.
 Persistent nasal discharge leads
to excoriation and infection of
the skin of the nasal vestibule.
 T/t: Avoid predisposing factors.
Cleaning with hydrogen
peroxide.
Local ointment

18. Erysipelas
 Inflammation of skin and
subcutaneous tissue of the nose.
 Streptococcal infection.
 C/F: Bright red, Shiny and well
defined lesion in the midface.
Resembles butterfly shape.
Lesion: Tender and may be
associated with lymphadenopathy.
 Millian’s sign is positive.
Millians sign to differentiate erysipelas
from cellulitis.
Pinna has no deeper dermis and
subcutaneous tissue so there cannot be
cellulitis.

19. Examination of External Nasal Framework
 Skin: Inflammation, scar, sinus, discoloration, vesicles, fistula,
swelling.
• Inflammation: Furunculosis.
• Scar: Surgery, Trauma
• Discoloration: Erysipelas, Sarcoidosis, Lupus Perino.
• Vesicles: Herpes simplex and Zoster.
• Swelling: Dermoid, Glioma, Encephalocele, Mucocele,
Osteoma, Keloid.
**Dermoid- in midline of root of the nose and fluctuant, trans-
illumination test negative.
**Encephalocele and Mningiocele- Frustenberg sign positive.

20. Dermoid

21. Lupus Perino Sarcoidosis

22. Herpes Nasal Keloid

23.  Darier’s Line
 Thickening of skin of tip of the nose.
 Fistula
 BCC- Common site- Ala nasi.
• Slightly raised nodule, break down to form crust and edges are
raised and rolled, but not elevated so high.
 SCC
• Elevation of skin, which later forms a nodule that breaks to
form an ulcer, which is everted, with raised edges, indurated
base.
 Anaesthesia of Malar area.(in orbital fracture, fracture of
osteomyelitis of maxillary sinus, malignancy of maxillary
sinus).
 Broadening of nose

24. Darier’s line Fistula of nose
SCC BCC

25.  Congenital: Hump, Saddle Nose, Columnellar retraction or
destruction, Bifid nose, Supra tip depression, crooked nose.
 Acquired:
• Hump nose Polly beaked nose
• Saddle nose Pig nose deformity
• Crooked nose Knock knee deformity
• Deviated nose Step ladder deformity
• Inter-canthal distance increased
Hump nose Saddle nose

26. Polly beak nose
Pig nose deformity
Crooked nose

27. Palpation
 Skin mobility:
• Decreased- Scar, malignancy, Surgery.
• Increased thickness- abscess, cyst, rhinophyma,.
• Fluctuation- Abscess and cyst.
• Pain, tenderness, rise in temp.- inflammation.
• Crepitation over nasal bone- fracture.
Columella examination
Look for:
• Furuncle
• Fissure
• Crusting
• Ulceration

28. Vestibule examination
 Look for:
• Follicles- Folliculitis
• Pus pointing- Furunculosis
• Oedema- Vestibulitis
• Scar- Trauma, Sx, Malignancy
• Crust- Eczema, Vestibulitis, Rhinitis sicca
• Stenosis- Infection, Rhinoscleroma, Post surgical, Synechia

29. Nasal Septum
 Osteo-cartilaginous partition between two halves of nasal cavity.
 Columella- Small anterior skin lined area. Membranous part.

30. Blood Supply

31. Venous drainage
Nerve Supply
 Facial Vein
 Sphenopalatine vein
 Internal nasal branch of anterior ethmoidal
nerve.
 Nasopalatine branch of maxillary and
olfactory nerve

32. Nerve Supply

33.  Bleeding point (in little’s area)
 DNS
 Spur
 Ulcer (due to trauma, Irritant)
 Perforation (look for site, size, if associated with crust)
 Swelling ( Septal abscess, Septal Haematoma, Foreign body)
 Growth (look for site, extent, bleed on touch)
Examination of Nasal Septum

34. Deviated Nasal Septum
 Compensatory hypertrophy
 Cottle’s Classification: Simple DNS, Obstructed DNS,
Impacted DNS.

35. DNS
Normal Septum

36. Anterior Dislocation Septal deviation and
perforation

37.  Etiology:
• Trauma
• Developmental errors.
 C/F: OSMHEAD
• Nasal Obstruction
• Sinusitis
• Middle Ear Infection
• Headache
• Epistaxis
• Anosmia
• External Deformity

38. Nasal Spur

39. Caudal dislocation Jacobson’s organ

40. Perforation
 Size-
• Small- Upto 1 cm in
diameter
• Medium- 1-2 cm in
diameter
• Large- Over 2 cm in
diameter

41. Septal abscess Septal Haematoma

42. Fractures of Nasal septum
 Etiology:
• Trauma- from front, side or below.
• Fracture- vertically, horizontally, buckle on itself or crushed
into pieces.
 Clinical features:
• Profuse epistaxis (with mucosal tears)
• Septal Haematoma (with intact mucosa)
 Jarjaway fracture
 Chevallate fracture

44.  Jarjaway- when front blow.
 Chevallet- in blow from below.
 Haematoma- Drain
 Dislocation and fracture- Repositioned.
 Nasal Packing

45. Nasa Sharira
 नासा घ्राणेन्द्रिय स्थानं |
 पान्द्थिवास्तु गरधो गरधेन्द्रियं |
 Synonyms- नस्य, कुलय, गरधवह, गरध, घ्राण, नान्द्सका, घोण
 नासा प्रमाण-
‘ स्वाङ्गुली प्रमाणेन चतुरङ्गुला नान्द्सका’ (Ch.Vi.)
 नासापुट प्रमाण-
‘न्द्िभागेत्यन्द्ि अङ्गुलस्य न्द्िभागेन सह अङ्गुल न्द्िभागा ङ्गुलं’
(Dalhan)
Nasaputa is 1 1/3 anguli as inner breadth and 2 anguli as
external breadth.

46.  Features of Nasa suggesting longevity in a baby/ Nasa
Sampata:
• Riju- Regular straight bridge of nose.
• Mahoshvasa- No any obstruction and allows free breath.
• (Ch. Sha.) नाताग्र – Downward tip of nose.
• (Va. Sha.) उरनताग्र – Tip of nose is upwards.
 Nasa Asthi/ Bones:
• Taruna Asthi (Charaka- Ghonasthi).
• Number- 03
 Nasa Sandhi:
• Number- 02

47.  Nasa Peshi:
• Number- 02
 Nasagata Sira:
• 24 Sira (V- 06, P-06, K-06, R-06)
• Avedhya Sira- 04 (Venesection is contraindicated)
• Siravedhana is indicated in case of anosmia and other diseases
of nose.
 Nasagata Dhamni:
• Number-02
• For perception of smell.

48.  Bahirmukha Strotasa:
• 2 Nasaputa/ Nasa Randhra.
• Pranavaha Strotasa commences from Bahya Nasa Randhra.
 Marma:
घ्राण मागं उभयतः स्रोतोमागि प्रन्द्तबद्धे अभ्यरतरतः फ़णे, ति गरधाज्ञानं |(Su.Sha.)
फ़णावुभयतो घ्राण मागं श्रोि पथानुगो | (Va. Sha.)
• Sira Marma,
• Vaikalyakara Marma

49.  Shringataka Marma:-
• Palm sized
• Near Talu, where confluence of nourishing dhamnis/ strotas of
nose, ear, eye and tongue are situated.
• Number- 04
• Sira Marma
• Sadhya Pranahara Marma

50. घ्राणे भृशं िाह समन्द्रवते तु न्द्वन्द्नःसरेि धूमं इवेहः वायुः | (Su.Utt.)
रक्ते न नासा िग्धेव बह्यरतः स्पशिनासहा |
भवेि धूमो उच्च्शच्च्शवास ....... (Va. Utt.)
Nasa Dipta
Severe burning
sensation
Pitta and Rakta Dosha is vitiated.
Feeling as if nose id
ignited both from inside
and outside
Severe Hyperasthesis

51. Nasa Paka
घ्राण आन्द्श्रते न्द्पत्तमरुन्द्रि कुयाित अन्द्स्मन न्द्वकारे बलवांश च पाकं |
........... न्द्वक्लेि न्द्वकोथश्च अन्द्प यि .........|| (Su.Utt.)
पचेत् नासापुटे न्द्पत्तं त्वक् मांसं िाह शुलवत |(Va. Utt.)
Severe suppurative
changes in tvaka and
mamsa
 Pitta and Rakta Dosha is vitiated.
Multiple boils and
ulcerations
With burning sensation
and pain
Necrosis
Excessive
moistening

52. Nasal Cavity Proper
 Roof
 Floor
 Lateral wall
 Medial wall

53. Lateral wall

54.  Inferior turbinate:
 Separate bone.
 NLD opening- Inf. Meatus.
 Hasner’s valve.

55.  Middle turbinate:
 Part of ethmoid bone.
 Attached to lateral wall by basal
lamella.
 Attachment is in S shape manner.
• Ant. 3rd lies in sagittal plane and
attached to lateral edge of
cribiform plate.
• Middle 3rd- frontal plane- lamina
papyracea.
• Post. 3rd- Horizontally- forms roof
of middle meatus- attached to
lamina papyracea & medial wall of
maxillary sinus.

59. Maxillary sinus ostium

60. Frontal sinus recess

61. Structures of Middle meatus
 Uncinate process
 Bulla Ethmoidalis
 Antrum of middle meatus
 Agger Nasi cells
 Uncinate process:
• Hiatus semilunaris.
• Attachments
• Infundibulum

62.  Lamina Papyracea
 Middle turbinate
 Skull base

63.  Bulla Ethmoidalis:
• Ethmoidal cell
• Situated behind uncinate
process.
• May extend superiorly to
skull base.
• Posteriorly to fuse with
ground lamella.
• Supra bullar or retro bullar
recess.

66. Concha bullosa

67. Haller cells

68. Superior Turbinate
 Ethmo-turbinal
 Situated post. and
superior to Middle
turbinate.
 May get pneumatized.
 Important landmark
to identify ostium of
sphenoid sinus which
lies medial to it.

71. Posterior Ethmoidal cells

72. Onodi cells

73. Spheno-Ethmoidal Recess

75.  They are air conditioning cavities in certain bones of skull.
 Anterior group sinuses: They opens into middle meatus.
 Maxillary
 Frontal
 Ethmoidal
 Posterior group sinuses:
 Posterior ethmoidal sinuses- Opens into superior meatus
 Sphenoid sinus- Opens into SER.

76. Maxillary Sinus
 Largest of all Sinuses.
 Pyramidal in shape.
 Base- towards lateral wall of nose.
 Apex- laterally into zygomatic process of
maxilla.
 Capacity- 15 ml (in adult)

78.  Anterior wall:
 Facia surface of maxilla.
 Soft tissues of cheek.
 Posterior wall:
 Infra temporal fossa
 Pterygo-palatine fossa
 Roof:
 Floor of orbit.
 Traversed by infra-orbital nerve and vessles
Boundaries:

80.  Medial wall:
 Middle and inferior meatuses
 Uncinate process
 Floor:
 Alveolar and palatine processes of maxilla.
 Roots of 2nd pre molar and 1st molar teeth.
**Oro-antral fistula can result from extraction of these teeth.
** Dental infection can also be the cause of maxillary sinusitis.

82. Frontal Sinus
 Between inner and outer tables of frontal bone.
 Above to the supra orbital margin.
 Varies in shape and size.
 2 frontal sinuses are often asymmetric.
 May be very large extending into orbital plate in the roof of
orbit. May be deficient.
 Anterior wall:
 Skin over forehead.
 Interior wall:
 To orbit and its contents.
 Posterior wall:
 Meninges and frontal lobe of brain.

83. Frontal Recess
 Drainage: through its ostium into the frontal recess.
 Ostium and frontal recess forms- hour glass structure.
 Situation: In anterior part of middle meatus.
 Medially- Middle turbinate
 Laterally-Lamina Papyracea
 Anteriorly- Agger Nasi cells
 Posteriorly- Bulla Ethmoidalis

85. Ethmoidal Sinus
 Thin walled air cavities.
 Number: 3 to 18.
 Occupy space between upper 3rd of lateral nasal wall and
medial wall of orbit.
 Anterior Ethmoidal group and Posterior Ethmoidal group
divided by basal lamina.
 Anterior Ethmoidal group- opens into middle meatus.
 Posterior Ethmoidal group- opens into superior meatus.
 Roof: Medial extension of orbital plate of frontal bone, which
shows depression on its undersurface- Fovea ethmoidalis.
 Lateral wall: Lamina payracaea

88.  Anterior group cells:
 Agger nasi cells-
 Ethmoidal Bulla- forms posterior boundary of the hiatus
semilunaris.
 Supra orbital cells
 Fronto ethmoidal cells
 Haller cells
 Posterior group of cells-
 Sphenoethmoidal cell (Onodi cells)- Extends along the lamina
papyracea, lateral or superior to the sphenoid.

89. Agger nasi cells
Supra orbital cells

90. Haller cells Onodi cells

91. Sphenoid Sinus

92.  Occupies the body of
sphenoid.
 2 sinus, separated by a thin
bony septum.
 Ostium of sphenoid sinus is
situated high up in the
anterior wall and opens into
sphenoethmoidal recess.
 Sphenoethmoidal recess:
 Medial to superior or
supreme turbinate.
 Slit like, oval or round.

94.  Mucus Membrane of PNS:
 Lined by mucus membrane which is continuous with that of nasal
cavity.
 Thinner and less vascular.
 Ciliated columnar epithelium.
 Goblet cells present.
 Cilia are more marked near the ostia.

97.  Functions of Paranasal Sinuses:
 Air conditioning of the inspired area.
 Provide resonance of voice.
 Act as thermal insulator.
 Lighten the skull bones.
 Provide extended surface for olfaction.
 Provide local immunologic defence.
 Act as buffers against trauma and this protects brain
against injury.

98. Ventilation of
sinuses:
During inspiration
Negative pressure in nose.
(i.e. -6mm to -200 mmH2O)
During Expiration
Positive pressure in nose.
Sets up eddies
Ventilates the sinus
**Sinuses are filled during
expiration and emptied
during inspiration.

99. Mucus clearance:
 Maxillary Sinus:
 Through natural ostium.
 Frontal Sinus:
 Mucus travels to inter-frontal septum (Along the roof, along
the floor) and then to natural ostium.
 One just above the ostium and 2nd in frontal recess, mucus
recycles through the sinus.
 Anti-clockwise in Right frontal sinus.
 Clock wise in Left frontal sinus.
 Sphenoid sinus:
 Towards the ostium into the spheno-ethmoidal recess.

100. Frontal sinus
drainage

101.  Ethmoidal sinus:
 Anterior group of sinuses: Joins that from the frontal and
maxillary sinuses and travels towards Eustachian tube, from
there to torus tubaris and into the naso-pharynx.
 Posterior ethmoidal sinuses: superior and supreme meatus,
Joins the secretion of sphenoid sinus in SER , passes above
and behind the torus tubaris into nasopharynx.
** Infected discharge from the anterior group of sinuses, passes
behind posterior pillars and causes hypertrophy of lateral
pharyngeal band.
**Infected discharge from Posterior group of sinus spreads over
the posterior pharyngeal wall.

103. Functions of Nose:
Respiration
Air-conditioning of inspired air
Protection of lower airway.
Olfaction
Vocal resonance
Nasal reflex functions

104.  Natural Pathway
 Choanal atresia- Asphyxia- Death
 During Expiration- Entire current is not expelled.
 Friction offered at limen nasi- coverts it into eddies –
ventilates the sinuses through the ostia.
Breathing:

106.  Under autonomic nervous system- Nasal mucosa
undergoes rhythmic cyclic congestion and
decongestion- Controls air flow.
 Cycle lasts 2-12 hours.
Nasal Cycle:

107.  Air-conditioner for lungs.
 Adjusts temperature and humidity of inspired air.
 Filter and Purify the inspired air.
 Filtration and Purification:
 Front of nose: upto 3 micro m
 Nasal mucus traps: 0.5 to 3.0 micro m
 Passes to lower tract: smaller than 0.5 micro m
 Temperature control:
 Large surface area of nasal mucosa.
 Highly vascular with cavernous venous spaces or
sinusoids which control blood flow.
 Radiator mechanism.
Air Conditioning:

108.  Humidification:
 Process goes on simultaneously with temperature
control.
 Air dry in winter and moistened in summer.
 Nasal mucosa adjusts the relative humidity upto 75%
of inspired air.
 Water is provided by: Mucus and serous secreting
glands.
 1000 ml of water is evaporated in 24 hrs.

109.  Mucociliary Mechanism:
 Mucous blanket.
 Moves like conveyer belt.- at the speed of 5-10mm/
min.
 Complete sheet of mucus is cleared in 10-20 min.
 Turbinates doubles the surface area
 600-700 ml of nasal secretions are produced in 24 hrs.
Protection of lower airways:

110.  Beating of Cilia:
 Effective stoke
 Recovery stroke
***Immotile cilia syndrome- Rhinosinusitis and bronchoectasis.
 Enzymes and Immunoglobulins:
 Muramidase
 IgA and IgE
 Interferon
 Sneezing:
 Helps noxious substances to wash out.
 pH is constantly 7.

111.  Vocal resonance:
 Nasal consonants (M/N/ NG)- sound passes through
nasopharyngeal isthmus and emitted through nose.
 Nose blocked- M/N/ NG- B/D/G respectively.
 Nasal Reflexes:
 Smell- reflex secretion of saliva and gastric juice.
 Nasal obstruction- Pulmonary resistance increased.
 Nasal Packing- Lowering of PO2
 Pulmonary HTN- in adenoids and tonsilar hypertrophy.