3. THE NOSE
• The nose consists of the
external nose and the
• Both are divided by a
septum into right and left
4. EXTERNAL NOSE
• The external nose has two
elliptical orifices called the
naris (nostrils), which are
separated from each other by
the nasal septum.
• The lateral margin, the ala
nasi, is rounded and mobile.
6. • The framework of the external
nose is made up above by the
nasal bones, the frontal processes
processes of the maxillae, and the
the nasal part of the frontal bone.
8. BLOOD SUPPLY OF THE EXTERNAL NOSE
• The skin of the external nose is supplied by
branches of the ophthalmic and the
• The skin of the ala and the lower part of the
septum are supplied by branches from the
9. • The infratrochlear and external nasal
branches of the ophthalmic nerve (CN
V) and the infraorbital branch of the
maxillary nerve (CNV).
NERVE SUPPLY OFTHE EXTERNAL
10. NASAL CAVITY
“Nasal cavity, it extends from the external nares (nostrils)
to posterior nasal apertures and is subdivided into right and
left halves by the nasal septum.”
Each half has a floor, roof, medial and lateral walls.
• Measures about
• Height- 5 cm
• Length- 5-7 cm
• Width- 1.5 cm(floor) 1-2 mm(roof)
11. FLOOR OF NOSE
Floor of the nasal cavity is concave from side to side,
flat and almost horizontal antero-posteriorly.
Anterior 34th Palatine process of maxilla.
Posterior 14th Horizontal part of the palatine
12. ROOF OF NOSE
Roof of The Nasal Cavity: is narrow from side to side, the
ethmoidal part is horizontal but the frontonasal & sphenoid part
slope downwards and forwards & downwards and backwards
Nasal Cartilages, Nasal, Frontal, Ethmoid, Sphenoid Bones
13. MEDIAL WALL OF NOSE
■ The Nasal Septum
■ Divides the nasal cavity into right
and left halves
■ It has osseous and cartilaginous
■ Nasal septum consists of the
perpendicular plate of the ethmoid
bone (superior), the vomer (inferior)
and septal cartilage (anterior)
14. LATERAL WALL OF NOSE
■ The lateral wall of the nose is irregular
owing to the presence of 3 shelf like
bony projections called conchae.
■ The lateral wall separates the nose
a) From the orbit above, with the
ethmoidal air sinuses intervening
b) From the maxillary sinus below
c) From the lacrimal groove and
nasolacrimal canal in the front
17. ARTERIAL SUPPLY OF NOSE
The anterosuperior quadrant is
supplied by the anterior
ethmoidal artery assisted by the
posterior ethmoidal and facial
The anteroinferior quadrant is
supplied by the branches of facial
and the greater palatine arteries
The posterosuperior quadrant, is
supplied by sphenopalatine artery
The posteroinferior quadrant is
supplied by the branches from
the greater palatine artery.
18. VENOUS DRAINAGE OF NOSE
The veins form a plexus which drains
Anteriorly into the facial vein
Posteriorly into the pharyngeal plexus of veins
From the anterior half into the submandibular nodes
From the posterior half to the retropharyngeal and upper deep
19. NERVE SUPPLY OF NOSE
General sensory nerves ( derived from the
trigeminal nerve ) are distributed to whole of
the lateral wall .
The anterosuperior quadrant – anterior
ethmoidal nerve ( branch of opthalmic
The anteroinferior quadrant – anterior
superior alveolar nerve ( branch of maxillary
The posterosuperior quadrant --posterior
superior lateral nasal branches from the
pterygopalatine ganglion ( maxillary nerve )
The posteroinferior quadrant ---anterior
palatine branch from the pterygopalatine
22. The paranasal sinuses are
cavities found in the interior
of the maxilla, frontal,
sphenoid, and ethmoid bones
They are lined with muco-
periosteum and filled with air.
They communicate with the
nasal cavity through relatively
23. Drainage of Mucus and Function of
The mucus produced by the mucous membrane is
moved into the nose by cilliary action of the columnar
Drainage of the mucus is also achieved by the siphon
action created during the blowing of the nose.
1) Humidifying and warming inspired air
2) Regulation of intranasal pressure
3) Increasing surface area for olfaction
4) Lightening the skull
6) Absorbing shock
7) Contribute to facial growth
25. DEVELOPMENT & GROWTH OF PARANASAL
SINUSES Status at birth Growth 1st radiologic evidence
Maxillary Present at birth Rapid growth from birth to
3 years and 7-12 years.
Adult size-15 years
4-5 month after birth
Ethmoid Present at birth
Ant. Group: 5×2×2mm
Reach adult size at 12
Frontal Not present Invades frontal bone at the
age of 4 years. Size
increases until teens
Sphenoid Not present Reaches sella turcica by
the age of 7 year dorsum
sellae by late teens and
basisphenoid by adult age.
Reaches full size between
15 year to the adult age
26. Clinically, paranasal sinuses are:-
o Maxillary sinus
o Frontal sinus
o Ant. Ethmoidal sinus
o Post. Ethmoidal sinus
o Sphenoidal sinus
27. MAXILLARY SINUS
Also known as Antrum of Highmore, Sinus Maxillaris.
“Maxillary sinus is a pneumatic space that is lodged
inside the body of the maxilla & that communicate with
the environment by way of the middle nasal meatus and
the nasal vestibule.”
The maxillary sinus is the largest paranasal sinus.
28. Pyramidal in shape.
Volume of approximately 15 -30 ml.
Height 3.5 cm
Apex is directed lateralward, is formed
by the zygomatic process.
Base(4-sided) : Lateral nasal wall
29. • Medial wall : Lateral wall of
• Superior wall (roof): Orbital
• Anterior wall : Facial wall of
• Posterolateral: Infratemporal
• Inferior (floor): Alveolar
process of the maxilla.
30. The Floor:
Projecting into the floor of the antrum are several
conical processes, corresponding to the roots of the first
and second molar teeth; in some cases the floor is
perforated by the roots of the teeth.
Because of the close relationship with the dentition
dental disease can cause maxillary infection, and tooth
extraction can result in oral-antral fistulae.
31. • The Roof :
Related to the intraorbital vessels and nerves
and tear ducts.
The infraorbital canal usually projects into the
cavity as a well-marked ridge extending from the
roof to the anterior wall.
33. BLOOD SUPPLY OF MAXILLARY SINUS
■ Mucosal: Sphenopalatine artery, anterior & posterior lateral nasal
■ Osseous: Facial, Infraorbital, greater palatine arteries.
The bony wall receives dual blood supply from periosteum on
■ Veins accompanying arteries – Anterior facial – pterygoid plexus.
■ Medial wall via sphenopalatine vein
36. Lymphatic drainage: Submandibular or deep cervical nodes.
Nerve Supply: Superior & inferior posterior lateral nasal branches of
V2; posterior, middle & anterior superior alveolar
37. MICROSCOPIC FEATURES
■ From inward outward the sinus is lined with 3 layers. Epithelial layer, basal lamina and sub
epithelial layer including periosteum.
■ Epithelium: -
– Pseudostratified columnar and ciliated (derived from olfactory epithelium of middle
meatus) containing mucous secreted goblet cells.
– Basal cells, columnar non ciliated.
– Cilia is composed of microtubules and provide mobile apparatus.
■ By ciliary beating, the mucous blanket lining the epithelial surface move from interior of
the sinus toward the nasal cavity.
■ Mucociliary Flow:
■ There are 3 types:
– Smooth: moving at 0.58 cm/min.
– Jerky: moving at 0.3 cm/min.
– Mucostasis: moving less than 0.3 cm/min.
38. FRONTAL SINUS
Contained within the frontal bone.
Separated from each other by a bony
Each sinus is roughly triangular.
Extending upward above the medial
end of the eyebrow and backward
into the medial part of the roof of
Opens into the middle meatus.
39. • Height, width and anteroposterior depth are
about 2.5 cm
• Better develop in male
• Arterial supply:- Supraorbital artery
• Venous drainage:- Anastomotic veins in the
supraorbital and superior opthalmic vein
• Nerve supply:- Supraorbital nerve
• Lymphatic drainage:- Submandibular nodes.
40. SPHENOID SINUS
• Began as outpunching's of the
superior nasal vault around the
fourth month of gestation
• Rarely present at birth, usually
seen around age 4
• Drain into the superior meatus
in the spheno-ethmoidal
• Ostia of variable size.
41. • Arterial supply :- Posterior ethmoidal and
internal carotid artery
• Venous drainage :- Pterygoid venous plexus
and cavernous sinus
• Nerve supply :- Posterior ethmoidal nerve
and orbital branch of the pterygopalatine
• Lymphatic drainage :- Retropharyngeal
42. ETHMOIDAL SINUSES
• Ethmoidal sinus are numerous
small intercommunicating spaces
which lies within the labyrinth of
the ethmoid bone.
• Divided in three group
o Anterior group
o Middle group
o Posterior group
43. ANTERIOR GROUP
• Made up of 1 to 11 air cell
• Open into anterior part of hiatus semilunaris of the
• Supplied by anterior ethmoidal nerve and vessel
• Lymph:- Submandibular lymph nodes
44. MIDDLE GROUP
• Made up of 1 to 7 air cell
• Open:- Middle meatus of nose
• Supplied by the posterior ethmoidal nerve and vessel
and the orbital branch of the pterygopalatine
• Lymph:- Submandibular nodes
45. POSTERIOR GROUP
• Made up of 1 to 7 air cell
• Open:- Superior meatus of nose
• Supplied by the posterior ethmoidal nerve and
vessel and the orbital branch of the
• Lymph:- Retropharyngeal nodes
46. DIAGNOSTIC EVALUATION
Detailed medical and dental history.
Clinical evaluation (inspection,
palpation, percussion, and
Radiographs (Conventional, CT, MRI).
Special test (endoscopy).
47. CLINICAL EVALUATION
Clinical evaluation should include the
Middle 3rd of the face should be inspected
Ecchymosis or hematoma.
■ Palpation of the lateral wall
of sinus over prominence of
cheek and intraorally on
lateral surface of maxilla
between canine eminence
and zygomatic buttress
■ Affected sinus is markedly
tender to gental tapping or
■ Transillumination of maxillary sinus is done
by placing flash or fiber optic light against
the palatal or facial surfaces of the sinus
and observing transmission of the light
through the sinus in the darkened room.
■ The affected sinus shows less transmission
of light due to accumulation of fluid, debris,
pus and thickening of antral wall mucosa.
■ The test helps to distinguish between sinus
disease that may cause radiating pain to
upper teeth and exposure or abscess related
to molars or premolars.
■ Normal sinus appears as a radiolucent cavity with well defined dense
– Lateral occlusal
– Waters view(15’ or 30’ occipitomental view)/ PNS view
– Submentovertex view
– PA skull view
– Lateral skull view
53. ULTRASOUND/ CT SCAN/ MRI SCAN
Ultrasound is a non-invasive, safe and quick
diagnostic screening tool.
High resolution axial and coronal CT & MRI
examinations are most revealing non- invasive
techniques for paranasal sinuses.
Allows direct optical evaluation of the antral floor region.
It is an optimal method for the assessment of the foreign
body such as root filling materials and root tips that have
penetrated the maxillary sinus.
Trans-oral via canine fossa
Trans-alveolar via oroantral communication or fistula.
55. APPLIED ANATOMY
■ Lesions within the sinus may penetrate through anterior and
posterior walls as they are thin walls.
■ Lesions may also penetrate through palatal or appear as swelling
in the buccal vestibule.
■ Lesions may resorb the alveolar bone and result in loosening of
maxillary post teeth.
■ Anterior, middle and posterior superior alveolar nerves pass
through the sinus wall, therefore pathosis of the sinus may result in
pain radiating to the teeth or facial bones at the side of the sinus.
– Lesions may press on the pulp of the teeth in the affected side
resulting in pulp necrosis.
– Post. wall penetration by tumors may result in paresthesia of the
gum in post. segment due to destruction of posterior superior
– According to the fact that venous drainage of the sinus is a part of
maxillary drainage, joining facial and jugular veins may drain in
upward direction transferring infection to ethmoidal, frontal and
cavernous sinuses and may infect anterior cranial fossa.
– Pneumatization of the sinus into alveolus or approximation of the
roots of the teeth to the sinus or even senile bone resorption may
result in OAC during extraction or surgery.
– Infections related to the teeth that are close to the sinus, when
progress resorb bone and transfer infection to the sinus or may
cause perforation in the sinus floor.
57. MAXILLARY SINUS INFECTION
“When inflammation develops in the sinus either due to
infection or allergy, it is defined "sinusitis" and it's the most
common disease of the sinus.”
Maxillary sinusitis could be broadly divided into:
59. CLINICAL FEATURES
May occur at any age and has rapid onset
Feeling of pressure, pain or fullness in the vicinity of the affected sinus
Headache is common especially in the morning
Discomfort increases in intensity and is accompanied with facial erythema &
swelling, malaise and fever
Drainage of foul smelling mucopurulent material into nasal cavity and
Pain is exacerbated on lying down or bending , due to increased intracranial
pressure from blood flow
Dull pain may be present over premolars and molars upon mastication.
Tenderness to percussion in the affected side
Nasal blockage and discharge
Anterior Rhinoscopy- reveals erythema and edema of mucosa
with mucopurulant discharge.
Transillumination- affected side, which is full of pus, will not
transmit the fiber optic light.
PNS view X-Ray- affected antrum is uniformly opaque and there
is > 4 mm of mucosa thickening.
CT & MRI Scans.
62. NASAL DECONGESTANTS
Ephedrine sulpahate -0.5% or 1% in normal saline –
dispensed as drops 6 hourly.
Xylometazoline HCL -0.1%. Reduces the increased
Antihistaminic like pseudoephedrine or Levocetrizine
Are administered orally.
Empirical therapy is started with amoxicillin 500 mg, TDS for
10-13 days (Oral).
Trimethoprim-Sulfamethoxazole (in 1st time cases)
Amoxicillin with Clavulanate (Augmentin), Cefuroxime
axetil & Clarithromycin
If Pt. fails to respond tiothe initial treatment within 72
Culture and sensitivity should be considered.
For Nosocomial infections (Staph. Aureus and gram
negative bacilli)- Broad spectrum IV therapy eg. Naficillin
64. MUCOLYTIC AGENT
Tincture Benzoin compound in boiling water (Steam
Inhalation)- 6 hourly.
Camphor,Chlorbutol & Menthol (Karvol Plus)
Significant amount of pain is experienced in sinusitis. Thus
analgesics like (NSAID's) or opioids must be given to pt. after
establishing a complete medical history.
Nasal irrigation with saline, or other therapeutic solutions, is
directed towards the medial canthus(inner margin of the eye).
This aims the irrigant towards the site of drainage of the
frontal, ethmoid and maxillary sinuses into the nose.
66. CHRONIC SINUSITIS
Pt. may be asymptomatic but will have repeated
attacks of actual mucopurulent rhinitis.
Pain and tenderness are not common except in acute
exacerbation of chronic disease.
Foul unilateral discharge is confined to post nasal
It is confirmed by history and inspection of
oropharynx which shows pharyngeal exudates.
PNS view X-rays.
Eradication of predisposing factors(dental if
Surgical removal of polyps if present.
Long term antibiotics , decongestants , and
antihistaminics are prescribed to the patient
69. DENTAL IMPLICATION OF MAXILLARY SINUS
Maxillary sinusitis of dental origin.
Toothache of sinus origin.
Odontogenic pain versus sinusitis.
Oro-antral communication and fistula.
Foreign body of dental origin in max. sinus
Zinc oxide based cement.
70. ORO-ANTRAL COMMUNICATION & FISTULA
■ Oro-Antral Communication:
(OAC) Is an abnormal connection
between the oral cavity and
antral cavity (maxillary sinus) as
a result of loss of the soft and
hard tissues that normally
separate both compartments.
71. ■ Oro-Antral Fistula: (OAF) is a
pathological fistular canal
lined with epithelium
epithelium) which may or may
not be filled with granulation
tissue or polyposis of the sinus
72. Factors influencing creation of OAC:
Teeth size and configuration of the roots.
Hypercementosis and bulbous roots.
Density of alveolar bone and thickness of sinus floor.
Size of the sinus.
Fracture that may involve sinus walls.
Relation of sinus to the root of upper teeth.
Rough extraction and misguided manipulation.
Periodontal diseases which may erode sinus floor.
Presence of cysts and neoplasm.
Invasive surgery e.g. cleft and dental implants placement.
73. Signs and Symptoms of OAC:
Visible defect between mouth and
Salty tasting discharge or unpleasant
Bone fragment with small concave
upper surface (antral floor) adhering to
the apex of the extracted tooth.
Food and drink rhinorrhea.
Air bubbles at the socket. Discharge into the mouth.
Bubbling of blood from the socket or
Escape of air when blowing the nose.
Change in speech tone and resonance. Difficulty playing a wind instrument or
Radiographical evidence of sinus
Symptoms of acute or chronic sinusitis.
History : Patient’s complain
Communication or fistula is
Radiographic examination (radio-
■ General principles:
1. OAC 2mm or less- Don’t panic.
If antral membrane is intact avoid puncture.
Heals spontaneously without surgical intervention.
Patient instructions: 10-14 days
a. Avoid blowing the cheek or nose.
b. Avoid sucking straw.
c. Avoid smoking.
d. Open the mouth during sneezing.
e. Avoid catching cold.
76. ■ Antibiotics.
e.g. penicillin or penicillin derivatives.
■ Analgesics and NSAIDS
e.g. paracetamol, profen (PRN)
■ Nasal decongestant
e.g. ephedrine or otrivin (oxymetazoline hydrochloride) nasal drops
3 drops/ 3 times daily/ 7 days
■ Steam inhalation
e.g. menthal and benzoin 40 good sniffs should follow nasal
78. Keys for successful OAC closure
1. A disease free sinus.
2. Coverage of OAC with vascularized tissue.
3. Tension-free closure.
4. Aggressive antibiotic coverage.
5. Emphasize firmly on patient's instructions.
6. Any evidence of sinus infection
Don’t close drainage first, With antibiotic coverage and culture
and sensitivity test if needed and when the infection is controlled then
you can now surgically close.
79. CHRONIC ORO-ANTRAL FISTULA /
It might be a complication of:
Unrecognized (overlooked) fistula.
Failure of spontaneous closure of OAC.
Failure of surgically repaired communication.
80. Primary management of Chronic OAF
■ It is aimed to eliminate any sinus infection:
– Excision of any mucosal polyp or purulent
granulation to promote drainage.
– Regular irrigation with warm water or saline.
– Single course of antibiotics and nasal inhalation
– Acrylic base plate (surgical stent).
81. Surgical management
Principles & requirements:
Success of operation is not always granted.
Flap should have good blood supply.
Flap tissue must be handled gently.
Flap should lie in its new position without tension.
Good homeostasis must be achieved before discharging the patient.
Types of repair:
Buccal advancement flap.
Bridge (pedicle) flap.
Palatal rotation flap.
Tongue based flap.
Buccal fat pad.
84. Displacement of A Root or Tooth into Maxillary
Sinus Lining or Sinus Proper
■ It is basically a mishap incident
results from a neglected act by the
operator while applying wrong force.
■ Occurs rarely but the 3rd molar and
2nd premolar are the most at risk of
■ May occur with severe maxillofacial
85. Immediate Investigation &
■ Confirm the existence of oro-antral fistula and the presence of tooth or
root in sinus using dental, occlusal, panoramic and occipitomental
■ Locate the precise position of the foreign body within the sinus lining
or in the sinus cavity proper.
■ Reflect mucoperiosteal flap.
■ Reduce alveolar bone height.
■ Retrieve the tooth or the root by permitting their movement away from
■ If root or tooth dislodged into the sinus proper, consider Caldwell-luc
86. CALDWELL–LUC OPERATION
George Caldwell in 1893 & Henry Luc in 1897
■ Definition :-
“This procedure involves making a temporary opening into the
maxillary sinus and reestablishing an opening into the sinus from
the nose if necessary.”
Purpose of Procedure
This procedure is done for several reasons:
To remove abnormal tissue growths,
To treat infection,
To assist in repair of an injury to the extraction socket.
■ First of all the incision is made from lateral
incisor to the second molar tooth.
■ Then the flap of mucosa and periosteum is
elevated and dissected to expose the anterior
wall of sinus and then anterior wall is opened
in the canine fossa where the bone is relatively
thin with the drill.
■ The opening can be enlarged by hayek or
kerrison punch forceps to produce hole
sufficiently large to provide access for example
to allow removal of sinus mucosa or
introduction of an endoscope and instruments.
89. ■ The entire lining of sinus is dissected and removed as the
success of the operation in chronic rhinosinusitis. Packing
of nasal cavity and sinus is sometime required.
■ Suturing of buccal incision is recommended with
absorbable suture material.
■ The patient should be advised against overenthusiastic
blowing of the nose for at least a week
91. NASAL BLEEDING( EPISTAXIS)
■ ETIOLOGY- TRAUMA
Anterior part (injury to Kisselbach’s
Posterior part (in inferior meatus)
vessel involved is Int.max.artery
1. B.D. CHAURASIA’S HUMAN ANATOMY- VOL.3 – 7TH EDITION
2. THE MAXILLARY SINUS- MEDICAL & SURGICAL MANAGEMENT
BY JAMES A. DUNCAVAGE.
3. TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY BY
NEELIMA ANIL MALIK – 4TH EDITION.
Notas del editor
Anterior ethmoidal branch of ophthalmic artery. Greater palatine branch of third div of maxillary. Sphenopalatine branch of maxillary.
siphon means pipe or tube; in gravity direction fluid drainage from nose to sinus.