Nasal cavity is the most superior part of the respiratory system. Blood supply of nose and Cavernous Sinus. Epistaxis causes and locations. Allergic Rhinitis and Non-allergic rhinitis with eosinophilia (NARES). Ostiomeatal complex (OMC) Sinusitis. Nasal polyps. Headaches types. Neuralgia.

1. The Nose
Hamzeh Yacoub
Medical student at AQU
Oct. 2021

2. The external nose
• pyramidal shape.
• nasal root superiorly and linked to forehead.
• Nasal apex inferiorly ends in a rounded tip.
• Between the root and apex is the dorsum of the nose.
• inferiorly to the apex are the nostrils (openings into nasal
cavity).
• Nostrils are bounded medially by septum (nasal septum).
• Nostrils are bounded laterally by ala nasi (cartilaginous
wing)

3. The external nose
• 2/3 of nose composed of nasal bone, maxillae and frontal bone.
• 1/3 of nose composed of cartilage, inferiorly, two lateral
cartilages, two alar cartilages and one septal cartilage.
• The skin over the cartilaginous part is thicker due to the
presence of sebaceous glands, hair follicles, and sweat glands.

4. The external nose

5. Nasal cavity
• Nasal cavity is the most superior part of the respiratory
system.
• Nasal cavity divisions:
• 1) Vestibule: the area around the nostrils.
• 2) Respiratory region: lined with ciliated pseudostratified
columnar epithelium with goblet cells.
• 3) Olfactory region: at the apex, lined with olfactory cells
and receptors.

6. Nasal cavity

7. Nasal Cavity
• Opens on the face through anterior nasal aperatus (nostrils)
anteriorly and linked posteriorly through a posterior opening
with the nasopharynx (the conchae).
• Nasal cavity boarders:
A) Roof: nasal bone, ethmoid bone, frontal bone, sphenoid bone.
Ethmoid bone has the cribriform plate which transmits olfactory
nerve (CNII)
B) Floor: palatine process of maxilla and horizontal plate of
palatine bone.
The floor passes the nasopalatine nerve and terminal branches
of sphenopalatine artery through the incisive foramen.

8. Nasal cavity
• Medial wall: nasal septum, formed by the perpendicular
plate of ethmoid bone, vomer
• Lateral wall: superior and middle conchae of the ethmoid
bone and the inferior concha.
• While the superior and middle nasal conchae form part of
the perpendicular plate of the ethmoid bone, the inferior
nasal concha is a bony structure by itself.

9. Nasal cavity

10. Nasal Conchae (Turbinates)
• inferior, middle and superior Conchae.
• Function: increase the surface area of nasal cavity, they
also slow-down the fast air flow, so the air lasts longer in
nasal cavity to get humidified.
• They divide nasal cavity into 4 regions:
• Inferior meatus, middle meatus, superior meatus, and
spheno-ethmoidal recess.

12. BLOOD SUPPLY to the external
Nose
• Skin of ala, dorsum and lower septum are supplied by
angular artery and lateral nasal artery, branches
of facial artery.
• the skin of external nose is supplied by dorsal nasal
branch of ophthalmic artery, and infraorbital artery a
branch of maxillary artery.

14. External Nose arteries anastomosis
• Anastomosis of Dorsal nasal artery (branch of
ophthalmic) and lateral nasal artery (branch of facial)
and infraorbital artery ( branch of maxillary)
• Anastomosis of Angular artery (branch of facial) and
dorsal nasal artery (branch of ophthalmic)
• Dorsal nasal artery has 2 branches, one anastomosis with
lateral nasal artery, another anastomosis with angular
artery.

15. BLOOD SUPPLY TO THE NASAL
CAVITY
• The nose has a very rich vascular supply – this allows it to
effectively change humidity and temperature of inspired air.
• They are divided in relation to two main arteries: ICA
and ECA
• Internal carotid first branch is the ophthalmic artery,
ophthalmic artery gives rise to anterior and posterior
ethmoidal arteries which supply nasal cavity.
• branches from external carotid branches:
Sphenopalatine, Greater palatine, Superior labial, and
angular arteries.

16. BLOOD SUPPLY TO THE NASAL
CAVITY
• Sphenopalatine artery is a branch of maxillary artery
(terminal branch of ECA) .
• Superior labial artery a branch of facial artery
(branch of ECA)
• Anterior and posterior ethmoidal arteries
branches of ophthalmic artery.

17. Kiesselbach’s plexus (Little’s area)
• vascular region of the anteroinferior nasal septum
composed of four arterial anastomoses:
• Anterior ethmoid artery.
• Sphenopalatine artery
• Superior labial artery
• Greater palatine artery
• The importance of this plexus lies in the fact that 90% of
epistaxes occur in this area.

18. Nose venous drainage
• veins of the nose tend to follow the arteries, and they
drain into:
• facial vein.
• pterygoid plexus.
• cavernous sinus.

19. Cavernous Sinus
• Paired Dural venous sinuses located
within the cranial cavity.
• divided into small caves (from which it
gets its name).
• Drains the ophthalmic veins (and
others) and can be found on either side
of the sella turcica.

20. Epistaxis
• medical term for a nose bleed.
• common occurrence in all age groups.
• Most likely to occur in the anterior third of nasal cavity (Kiesselbach
area).
• cause can be local (such as trauma), or systemic (such as
hypertension).
• Posterior epistaxis generally arises from the posterior nasal cavity
via branches of the sphenopalatine arteries.
• Woodruff’s plexus is composed of Sphenopalatine and Posterior
ethmoid arteries.

21. Anterior and posterior epistaxis
• 90% - 95% originate anteriorly, many of the anterior bleeds occur within
Kiesselbach’s plexus, because it receives trauma and dryness more than
posteriorly.
• Anterior bleeds are easily accessible and managed with conservative
measures such as moisturization, pressure, decongestion, or topical cautery.
• Posterior bleeds are generally from the distribution of the sphenopalatine
artery.
• The exact focus of origin is more challenging to identify, and these bleeds
are therefore more likely to require nasal packing as part of intervention.

22. Mild epistaxis management
 Instruct the patient to gently blow the nose, This removes blood/clots.
 Intranasal administration of nasal decongestant spray such as
oxymetazoline (selective alpha-1 agonist / partial alpha-2 agonist).
 Instruct the patient to pinch the nasal alae against the septum to apply
hemostatic pressure, and hold for 10 to 15 minutes, or longer if needed.
 Place a cold compress over the nose, if available.
Having the head tilted posteriorly may result in posterior drainage of blood,
increasing the potential for bloody aspiration and/or gastric irritation with
resultant bloody emesis. And the blood fall back into the throat and
swallowed.
So head should be leaned forward.

23. Nasal pack for posterior Epistaxis

25. Nasal Septum deviation
• Ideally, the left and right nasal
passageways are equal in size.
• it is estimated that as many as 80
percent of people have a nasal septum
that is deviated, which may or may not
cause certain symptoms.

26. Nasal Septum deviation
• Symptoms include:
• sinusitis.
• sleep apnea.
• snoring.
• repetitive sneezing.
• facial pain.
• nosebleeds.
• difficulty with breathing (Mouth-breathing during sleep in adults)
• mild to severe loss of the ability to smell

27. Endoscopic septoplasty
• Most otolaryngologists perform a septoplasty using a headlight and direct
vision for visualization of the surgical field. Many otolaryngologists are now
using the endoscope for enhanced visualization.
• Advantages of this approach include magnification of the surgical field,
improved ergonomics, improved access and visualization for the posterior
nasal cavity, and the potential for more limited dissection in certain cases.
• Disadvantages include a potential inability to adequately address severe
deviations of the anterior and caudal septum.
• Since the endoscope is often used through incisions that are traditionally
used for headlight visualization, a more accurate term for this procedure
may be endoscopic assisted septoplasty.

28. Septoplast procedure
 Decongest nasal cavities with topical oxymetazoline spray. Lidocaine mixed with
epinephrine into the septum bilaterally.
 Make incision near the caudal septum. Elevate flap in the subperichondrial
plane using broad, sweeping movements with the elevator.
 Disarticulate septal cartilage from the bony septum, and resect bony septum as
required.
 Repair any tears in the mucosal flaps primarily if possible with dissolvable
suture.
 Consider replacing the previously excised cartilage into the mucoperichondrial
pocket to decrease
 the risk of septal perforation, taking care not to cause further obstruction of the
nasal cavity. Also consider documenting the precise amount of cartilage excised
or remaining in the operative note, in case revision surgery is ever needed.
 The mucosal incision is then closed with absorbable suture. At this point, the
septum can be quilted with absorbable suture and/or splints can be placed.

29. postoperative course after
septoplasty
• Most patients are discharged home after surgery. Some patients are kept
overnight for observation.
• Recovery can take anywhere from several days to several weeks. During this
time, patients will usually have nasal congestion, moderate nasal and midfacial
pain, mild intermittent bloody nasal drainage, and generalized fatigue.
• Risks include: infection, excessive bleeding, nasal dryness/crusting, persistent
nasal congestion, septal hematoma/abscess, septal perforation, alteration of
sense of smell/taste, numbness, CSF leak, cosmetic deformity, complications of
anesthesia, and need for further surgery.

30. Septoplasty

31. Nerve supply to the nasal cavity
• Special sensation (smell) by
the olfactory nerve from the
olfactory mucous membrane,
which ascends through
cribriform plate of ethmoid to
olfactory bulb

32. Nerve supply to the nasal cavity
• General sensation by
trigeminal nerve branches –
ophthalmic and maxillary

33. Smell
• The olfactory epithelium is located in the superior and posterior aspect of
the nasal cavity.
• The precise location of the olfactory epithelium varies between individuals.
• The olfactory epithelium is a pseudostratified columnar epithelial tissue
comprised of several cell types. Bipolar sensory neurons extend an apical
dendrite to the epithelial surface from which cilia extend to detect odors.
• The basal pole extends into an axon, which crosses the cribriform plate and
enters the olfactory bulb.
• The axons of the sensory neurons are ensheathed by olfactory cells.
• Olfactory receptors are located on the cilia of bipolar sensory neurons within
the olfactory epithelium.

34. Smell process (Physiology)
1) Odorant molecules bind to specific olfactory receptor proteins (GPCRs)
located on cilia of the olfactory receptor cells.
2) When the receptors are activated, they activate G proteins, which activate
adenylate cyclase.
3) Increase in intracellular cAMP opens Na+ channels in the olfactory
receptor membrane and produces a depolarizing receptor potential.
4) The receptor potential depolarizes the initial segment of the axon to
threshold, and action potentials are generated.

35. Olfactory dysfunction
• Anosmia is the absence of olfactory function.
• Hyposmia describes reduced olfactory function.
• Dysosmias are changes in odor quality.
• Parosmia: altered perception of an odor.
• Phantosmia: perception of an odor when that odor is not present.
• Note that: There is a strong relationship between olfaction, emotion, and
memory, in which odorants can strongly evoke emotions related to the
previous experiences associated with that odor.

36. Smell dysfunction examination
• Nasal examination should assess for septal deviation, turbinate
enlargement, allergic appearance of mucosa, or presence of nasal polyps.
• Mucus character and signs of epithelial irritation or inflammation should be
assessed in the nasal cavity.
• Ear examination should assess the middle ear space to rule out disease
affecting the chorda tympani (of facial nerve).

37. Steroids use in smell dysfunction
• Steroid administration is frequently used to reduce inflammation and clear
obstruction of the olfactory cleft.
• Rapid improvement of olfactory function is often observed, usually.
• Improvement is transient but not permanent.
• Systemic administration is more effective then topical application, but
extended administration of systemic steroids puts the patient at risk of side
effects.

38. Allergic Rhinitis
• inflammation of the nasal membranes that is
characterized by sneezing, nasal congestion, nasal
itching, and rhinorrhea.
• not life-threatening (unless accompanied by severe
asthma or anaphylaxis

39. Non-allergic rhinitis with
eosinophilia (NARES)
• A perennial cause of rhinitis and common symptoms include congestion and
clear nasal discharge.
• Nasal cytology demonstrates increased levels of eosinophils similar to
allergic rhinitis, though these patients do not have sensitization on skin
prick testing or specific IgE blood tests.

40. Allergic Rhinitis classification
• Allergic rhinitis is classified based on severity and frequency.
• Intermittent allergic rhinitis has symptoms on fewer than 4 days per week
or for less than 4 weeks.
• Persistent allergic rhinitis is symptoms that occur for more than 4 days per
week or more than 4 weeks.
• Severity is divided into mild and moderate/severe.
• Mild disease has normal sleep and no impairment of daily activities, sports,
and leisure, does not interfere with school and work.
• Moderate to severe disease must have at least one of the following present:
sleep disturbance; impairment of daily activities, leisure, work and school.

41. Pathophysiology of allergic rhinitis
• Allergens in the nasal mucosa are phagocytized by antigen presenting cells
that present antigens to CD4 lymphocytes. Presentation to CD4 T-cells
involves peptide presentation via the MCH class II complex.
• CD4+ T-cells then differentiate into a TH2 subset, where IL-4, IL-5, and IL-
13 mediate eosinophil recruitment and survival.
• IL-4 and IL-13 are also necessary to promote the secretion of IgE from B-
cells.

42. Rhinitis treatment
• Corticosteroids (topical and systemic).
• Topical and oral antihistamines

43. Allergic Rhinitis Signs and
Symptoms

44. Paranasal sinuses
• Four pairs air-filled extensions of the nasal cavity.
• Named according to the bone in which they are located:
• Maxillary
• Frontal
• Sphenoid
• Ethmoid
• Each sinus is lined by ciliated pseudostratified columnar
epithelium with goblet cells.

45. paranasal sinuses:
• Function of paranasal sinuses:
• 1. Act as resonance to the voice.
• 2. Reduce the weight of the skull.
• 3. Protect the eye.
• Bacteria causing sinusitis include: S. pneumoniae, H. influenzae, Maroxella
catarrhali, Less commonly: S. aureus, other streptococci, and anaerobes.

47. Ethmoidal Sinus
• There are three ethmoidal sinuses within ethmoid bone:
• Anterior – Opens onto middle meatus
• Middle – Opens onto the ethmoidal bulla in the lateral wall of
the middle meatus
• Posterior – Opens onto the lateral wall of the superior meatus
• Innervated by the anterior and posterior ethmoidal branches of
the nasociliary nerve and the maxillary nerve.
• Its infection may erode through the thin orbital plate of the
ethmoid bone into the orbit.

48. Frontal Sinuses
• There are two frontal sinuses within the frontal bone.
• The most superior paranasal sinuses.
• Triangular in shape.
• Drain by frontonasal duct, which opens in middle meatus.
• Innervated by supraorbital nerve (branch of ophthalmic).
• Arterial supply by anterior ethmoidal artery (branch of
ophthalmic).

49. Maxillary sinus
• The largest paranasal sinus.
• The only which may present at birth. (some references
say sphenoid sinus as well).
• Drains into the posterior aspect of middle meatus,
underneath frontal sinus opening.
• innervated by the infraorbital nerve
• Infection may spread from frontal sinus and enter
maxillary sinus.

50. Sphenoid Sinuses
• Within the sphenoid bone.
• Open in Spheno-ethmoidal recess (supero-posterior to the
superior concha).
• innervated by the posterior ethmoidal nerve (a branch of
the ophthalmic nerve), and branches of the maxillary
nerve.
• recieve blood supply from pharyngeal branches of the
maxillary arteries.
• Pituitary gland lies above Sphenoid sinus.

53. Sinusitis
• Upper respiratory tract infection can spread
to the sinuses.
• Infection of the sinuses causes inflammation
(pain and swelling of the mucosa).
• If more than one sinus is affected, it is
called pansinusitis.
• The maxillary nerve supplies both the
maxillary sinus and maxillary teeth, and so
inflammation of maxillary sinus can present
with toothache

54. Ostiomeatal complex (OMC)
• It is a common channel that links the frontal sinus, anterior ethmoid air cells
and the maxillary sinus to the middle meatus, allowing airflow and mucociliary
drainage.
• Ostiomeatal complex is composed of five structures:
1) maxillary ostium: drainage channel of the maxillary sinus
2) infundibulum: common channel that drains the ostia of the maxillary antra
and anterior ethmoid air cells to the hiatus semilunaris
3) ethmoid bulla: usually a single air cell that projects over the hiatus semilunaris
4) uncinate process: hook-like process that arises from the posteromedial aspect of
the nasolacrimal duct and forms the anterior boundary of the hiatus
semilunaris
5) hiatus semilunaris: final drainage passage; a region between the ethmoid bulla
superiorly and free-edge of the uncinate process

55. Sinusitis
• sinusitis rarely occurs without concurrent
rhinitis.
• Rhinosinusitis affects an estimated 35 million
people per year in the United States.
• more common in females, and the highest
incidence is between the ages 45 to 64 years.
• When the apertures of the sinuses are blocked or
they become filled with fluid, the quality of the
voice is markedly changed.

56. Sinusitis pathophysiology
• The most common cause of acute sinusitis is an upper respiratory tract
infection of viral origin.
• The viral infection can lead to inflammation of the sinuses that usually
resolves without treatment in less than 14 days.
• If symptoms worsen after 3 to 5 days or persist for longer than 10 days and
are more severe than normally experienced with a viral infection, a
secondary bacterial infection is diagnosed.
• The inflammation can predispose to the development of acute sinusitis by
causing sinus ostial blockage.
• Although inflammation in any of the sinuses can lead to blockade of the
sinus ostia, the most commonly involved sinuses in both acute and chronic
sinusitis are the maxillary and the anterior ethmoid sinuses.

57. Sinusitis pathophysiology
• Nasal mucosa responds to the virus by producing mucus and recruiting
mediators of inflammation, such as white blood cells, to the lining of the
nose, which cause congestion and swelling of the nasal passages.
• The resultant sinus cavity hypoxia and mucus retention cause the cilia
which move mucus and debris from the nose to function less efficiently,
creating an environment for bacterial growth.
• If the acute sinusitis does not resolve, chronic sinusitis can develop from
mucus retention, hypoxia, and blockade of the ostia.
• This promotes mucosal hyperplasia, continued recruitment of inflammatory
infiltrates, and the potential development of nasal polyps. However, other
factors can predispose to sinusitis.

58. Sinusitis Signs and Symptoms
• Pain over cheek and radiating to frontal region or teeth,
increasing with straining or bending down.
• Redness of nose, cheeks, or eyelids.
• Postnasal discharge.
• A blocked nose.
• Persistent coughing or pharyngeal irritation.
• Facial pain
• Hyposmia (reduced ability to smell and to detect odors).

59. Sinusitis Treatment
• Antibiotics 3 to 6 weeks: Augmentin (40-50 mg/kg/day), amoxicillin is the
best for children (80-90 mg/kg/day), macrolide (clarithromycin),
fluoroquinolone (levofloxacin), clindamycin, Metronidazole.
• Topical nasal steroid, saline therapy
• Surgery if medical therapy fails or fungal sinusitis.*
• **Removal of all diseased soft tissue and bone, post-op drainage and
obliteration of pre-existing sinus cavity

60. Ethmoidal sinusitis
• inflammation in the ethmoidal sinuses that may
erode the medial wall of the orbit, causing an orbital
cellulitis that may spread to the cranial cavity.
Orbital plate of the ethmoid bone is thin.

61. Frontal sinusitis
• inflammation in the frontal sinus that may erode the
thin bone of the anterior cranial fossa, producing
meningitis or brain abscess.

62. Maxillary sinusitis
• mimics the clinical signs of maxillary tooth abscess; in
most cases, it is related to an infected tooth. Infection
may spread from the maxillary sinus to the upper teeth
and irritate the nerves to these teeth, causing
toothache.
• It may be confused with toothache because only a thin
layer of bone separates the roots of the maxillary teeth
(upper teeth) from the sinus cavity.
• The maxillary sinus is particularly prone to infection
because its drainage orifice near the roof of the sinus,
the sinus has to fill up with fluid before it can
effectively drain with the person in the upright
position.

63. Sphenoidal sinusitis
• infection in the sphenoidal sinus that may spread.
• may come from the nasal cavity or from the
nasopharynx, and may erode the sinus walls to reach
the cavernous sinuses, pituitary gland, optic nerve,
or brain stem.
• potential injury during pituitary surgery and
possible spread of infection to other structures.

64. Chronic sinusitis
• Chronic sinusitis symptoms never go away for long periods of
time, while recurrent sinusitis, you have 4 or more episodes of
sinusitis in one year + having symptom-free periods in
between.
• Causes could be:
• Asthma or allergies or even cystic fibrosis.
• Bacterial, viral, fungal infections.
• Abnormal nose structures; deviated septum
• Polyps (growths).
• A weak immune system.

65. Chronic Sinusitis with polyps
• Sinusitis lasts more than 12 weeks, associated with nasal
polyps.
• Polyps arise when the mucosa becomes very inflamed and
swollen with fluids and proteins until it resembles a fluid-filled
sac.
• Polyps block the air in nasal cavity which can’t reach the area
where the smell nerves are located. Therefore, the patient can’t
taste well, because much of our sense of taste is related to our
sense of smell.

66. Nasal polyps
more likely to develop in people who have
allergies or asthma.
Treated by Corticosteroids
And Sometimes by surgery.

67. Common Types of Headaches
• There are over 150 types of headaches, but the most
common types are:
• 1) Tension Headaches
• 2) Migraine Headaches
• 3) Cluster Headaches
• 4) Sinus Headaches
• 5) Posttraumatic Headaches

68. Tension Headache
• Most common type of headache.
• May be episodic (1-14 times monthly), or Chronic
(more than 15 times).
• It may be familial, as genetics causes.
• Stress, anxiety, depression are risk factors.
• More common at age ≥ 40.

69. Tension Headaches Symptoms
• Moderate, bilateral, non-pulsating head pain.
• Band-like distribution, without worsening during
physical activity.
• Association of Photophobia / Phonophobia.
• Stiffness/tenderness of head, neck, and shoulder muscles
• Lasts few minutes to one week.

70. Tension headache diagnosis
• By these criteria:
• Absence of nausea, vomiting.
• Light/sound hypersensitivity without other aura symptoms.
• ≥ two of following
 Both sides of head affected
 Non-throbbing quality
 Moderate intensity
 No worsening during physical activity

71. Tension headache treatment
• Analgesics
• ▫ NSAIDs
• ▫ Paracetamol
• ▪ Caffeine
• ▪ Butalbital (barbiturate).
• Prophylactic management by Antidepressants:
Tricyclic antidepressants (amitriptyline,
nortriptyline/protriptyline) and Mirtazapine/venlafaxine

72. Migraine
• Characterized by one-sided head pain.
• Neuronal hyperexcitability.
• Three types of migraine:
• 1) migraine with aura
• 2) Migraine without aura
• 3) Probable migraine (Attacks similar to migraine
without one feature needed for migraine diagnosis).

73. Migraine Causes and Risk factors
• Inheritance (neuronal excitability) and familial
causes (Familial hemiplegic migraine).
• Risk factors are:
• 1) female (age 30-39).
• 2) Stress and irregular sleeping / eating
• 3) Alcohol, Tobacoo
• 4) syndromes associated with migraine: recurrent GI
disturbances, benign paroxysmal vertigo, Torticollis.
Low serum N-acetyl-aspartate levels.

74. Migraine SIGNS & SYMPTOMS
• One-sided, pulsatile headache, worsened by physical
activity.
• maximum pain at supraorbital location.
• Prodromal symptoms (appear hours/days before
attack):
• ↑ irritability to light, sound, smells. + food cravings,
+ mood changes, + constipation/diarrhea.

75. Migraine Treatment
• NSAIDs
• Paracetamol
• Moderate- severe cases are treated with:
• Serotonin agonists (Triptans) which constrict blood vessels.
• Dopamine antagonists.
• Ergots (dihydroergotamine).
• Dexamethasone
• Beta blockers
• Antidepressants

76. CLUSTER HEADACHE
• One-sided headache in ophthalmic nerve distribution
region with autonomic symptomatology.
• More common in males.
• Common in Stressful periods, allergic rhinitis,
excessive alcohol and tobacco use patients.

77. Cluster headache SIGNS &
SYMPTOMS
• Headache: One-sided sharp, stabbing, burning
orbital/supraorbital/temporal head pain.
• Autonomic: Ipsilateral conjunctival hyperemia with
lacrimation, nasal discharge, miosis, edema, drooping
eyelid
• Episodes: 1–8 per day; lasts five minutes to three
hours
• DIAGNOSTIC IMAGING: CT scan/MRI.

79. Functional endoscopic sinus surgery
• The goal of functional endoscopic sinus surgery is to correct underlying
anatomic abnormalities or obstructions while preserving mucosa in order to
restore mucociliary flow and normal sinus function.
• Nasal endoscopy should be performed preoperatively to evalute the specific
nasal anatomy along with assessment of the nasal mucosa.
• Fine cut computed tomography (CT) is an important objective measure
performed to identify a patient’s specific anatomy used in preparation for
sinus surgery.

80. Functional endoscopic sinus surgery
• Restoring the normal drainage of the sinuses through their natural ostia.
• Part or all of the ethmoid partitions may be removed to promote drainage of
the ethmoid cells.
• The ostia of the affected frontal, sphenoid, or maxillary sinuses may then be
widened to promote their drainage into the nasal cavity.
• The remaining mucosa is maximally preserved to restore normal
mucociliary clearance.
• Previous to FESS, mucosa was thought to be irreversibly diseased and was
therefore removed. This removal destroyed the normal mucociliary
clearance, leading to dysfunctional sinuses that depended on gravity to
drain.

81. Functional endoscopic sinus surgery

82. Choanal atresia
• failure of the posterior nasal cavity to communicate with the nasopharynx,
due to failure of the nasobuccal membrane to rupture.
• Two thirds of cases are unilateral and usually present later in life with
chronic rhinorrhea and congestion.
• Bilateral atresia usually presents in the neonatal period with cyanotic
events during feeding that are relieved with crying.
• 50% - 75% of patients will have an associated congenital anomaly.

83. Choanal atresia genetic syndrome
• Associated with CHARGE SYNDROME:
• C = Coloboma
• H = Heart anomalies
• A = Atresia of the choanae
• R = Retardation of growth and development
• G = Genitourinary disorders (hypoplasia for males)
• E = Ear anomalies and/or hearing loss

84. Neuralgia
• Neuralgia is a stabbing, burning, and often severe pain due to an irritated or
damaged nerve. The nerve may be anywhere in the body, and the damage
may be caused by: aging, diseases such as diabetes or multiple sclerosis, or
infection, such as shingles.

85. Neuralgia types
• Postherpetic neuralgia: This type of neuralgia occurs as a complication of
shingles and may be anywhere on the body.
• Trigeminal neuralgia: This type of neuralgia is associated with pain from the
trigeminal nerve, which travels from the brain and branches to different
parts of the face.
• Glossopharyngeal neuralgia: Pain from the glossopharyngeal nerve, not
very common. This type of neuralgia produces pain in the neck and throat.