Nose anatomy and physiology

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. 1 st year Shalakya Tantra ITRA, Jamnagar

2. External Nose Skeletal frame work: Bony (upper 1/3 rd ) and Cartilaginous (Lower 2/3 rd ). 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 N asalis (transverse and alar parts) Levator labii superioris alaeque nasi A nterior 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 v ibrissae. 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. 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. Cont ….

15. Acute infective condition of the root of the hair follicle or sebaceous gland in the nasal vestibule. C aused by Staphylococcus aureus . P redisposing 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 . D angerous 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 - E ither due to frequent trauma like in nose picking or suggest an underlying debilitating disease like diabetes. Furunculosis of Nose

16. Thudicum Nasal Speculum Cont ….

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 , O steoma , 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 Cont ….

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 O bstruction S inusitis M iddle Ear Infection H eadache E pistaxis A nosmia External D eformity Cont ….

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

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

44. Nasa Sharira नासा घ्राणेन्द्रिय स्थानं | पार्थिवास्तु गन्धो गन्धेन्द्रियं | Synonyms- नस्य, कुलय, गन्धवह, गन्ध, घ्राण, नासिका, घोण नासा प्रमाण- ‘ स्वाङ्गुली प्रमाणेन चतुरङ्गुला नासिका’ ( Ch.Vi .) नासापुट प्रमाण- ‘त्रिभागेत्यदि अङ्गुलस्य त्रिभागेन सह अङ्गुल त्रिभागा ङ्गुलं’ ( Dalhan ) Nasaputa is 1 1/3 anguli as inner breadth and 2 anguli as external breadth.

45. Features of N asa 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 . ) उन्नताग्र – Tip of nose is upwards. Nasa Asthi / Bones: Taruna Asthi (Charaka- Ghonasthi ). Number- 03 Nasa Sandhi : Number- 02 Cont ….

46. 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. Cont ….

47. Cont …. Bahirmukha Strotasa : 2 Nasaputa / Nasa Randhra . Pranavaha Strotasa commences from Bahya Nasa Randhra . Marma : घ्राण मार्गं उभयतः स्रोतोमार्ग प्रतिबद्धे अभ्यन्तरतः फ़णे, तत्र गन्धाज्ञानं | (Su.Sha.) फ़णावुभयतो घ्राण मार्गं श्रोत्र पथानुगो | ( Va. Sha .) Sira Marma , Vaikalyakara Marma

48. 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 Cont ….

49. घ्राणे भृशं दाह समन्विते तु विनिःसरेद धूमं इवेहः वायुः | ( Su.Utt .) रक्तेन नासा दग्धेव बह्यन्तः स्पर्शनासहा | भवेद धूमो उच्च्श्वास ....... ( 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

50. Nasa Paka घ्राण आश्रिते पित्तमरुन्षि कुर्यात अस्मिन विकारे बलवांश च पाकं | ........... विक्लेद विकोथश्च अपि यत्र .........|| ( Su.Utt .) पचेत् नासापुटे पित्तं त्वक् मांसं दाह 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

51. Nasal Cavity Proper Roof Floor Lateral wall Medial wall

52. Lateral wall

53. Inferior turbinate: Separate bone. NLD opening- Inf. Meatus. Hasner’s valve. Cont ….

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

55. Maxillary sinus ostium

56. Frontal sinus recess

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

58. Lamina Papyracea Middle turbinate Skull base

59. 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.

60. Concha bullosa

61. Haller cells

62. 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.

63. Posterior Ethmoidal cells

64. Onodi cells

65. Spheno-Ethmoidal Recess

66. Anatomy of Paranasal Sinus

67. 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- O pens into superior meatus Sphenoid sinus- Opens into SER.

68. 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)

69. 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:

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

71. 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.

72. 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

73. Ethmoidal Sinus Thin walled air cavities. Number: 3 to 18. Occupy space between upper 3 rd 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

74. 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. Cont ….

75. Agger nasi cells Supra orbital cells

76. Haller cells Onodi cells

77. Sphenoid Sinus

78. 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.

79. 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 . Cont ….

80. Physiology of ParaNasal Sinuses

81. 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.

82. Ventilation of sinuses: During inspiration Negative pressure in nose. (i.e. -6mm to -200 mmH 2 O) During Expiration Positive pressure in nose. Sets up eddies Ventilates the sinus **Sinuses are filled during expiration and emptied during inspiration.

83. 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 2 nd 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.

84. Frontal sinus drainage

85. 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.

86. Physiology of Nose

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

88. Natural Pathway Choanal atresia- A sphyxia- Death During Expiration- Entire current is not expelled. Friction offered at limen nasi - coverts it into e ddies – ventilates the sinuses through the ostia . B reathing:

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

90. 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:

91. 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.

92. 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:

93. 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.

94. 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 PO 2 Pulmonary HTN- in adenoids and tonsilar hypertrophy.