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Anatomy and
Physiology of
Nose and
Paranasal Sinuses
Dr. Krishna Koirala
External Nasal Framework
• Nasal Bone
• Frontal Process of Maxilla
• Upper Lateral Nasal Cartilage
• Lower Lateral Nasal (Alar) Cartilage
• Septal Cartilage
• Lesser Alar (Sesamoid) Cartilages
Internal Nose
• Openings: Anterior nares and posterior
nares (Choana)
• Vestibule of nose: lined by skin and
containing hair follicles
• Nasal cavity proper: Lateral Wall , Medial
Wall (Septum) , Roof , Floor
1. Septal cartilage
2. Ethmoid plate
3. Vomer
4. Palatine crest
5. Maxillary crest
6. Vomeronasal
cartilage
7. Medial alar crus
8. Upper lateral
Lateral Nasal Wall
• 3 - 4 bony conchae are covered with
mucosa to form the turbinates
• Space below and lateral to turbinate is
called meatus
• Middle meatus contains a round bulla
ethmoidalis separated from uncinate
process by hiatus semilunaris that leads
Meatal Drainage
1. Inferior meatus: Nasolacrimal duct
2. Middle meatus: Frontal , anterior
ethmoid , maxillary
3. Superior meatus : Posterior ethmoid
4. Spheno - ethmoidal recess: Sphenoid
Ostio-meatal Complex
Complex micro-architectural pathway in
ethmoid labyrinth that drains anterior
• OMC Consists of
–Frontal recess + ethmoid
infundibulum + hiatus semilunaris
+ uncinate process + bulla
ethmoidalis + middle meatus
• O.M.C. pathology leads to infection
Variants in O.M.C.
 Concha bullosa (pneumatized M.T.)
 Paradoxically curved middle turbinate
 Medially turned ( bent) uncinate process
 Large bulla ethmoidalis
 Haller’s cell ( orbital floor)
 Agger nasi cell ( anterior to M.T.)
 Mucosal pathology
Concha Bullosa
Paradoxically curved M.T.
Large bulla ethmoidalis
Blood Supply
1. Sphenopalatine artery (main artery)
2. Greater palatine artery
3. Superior labial artery
4. Anterior Ethmoidal artery
5. Posterior Ethmoidal artery
1, 2, 3 & 4 form Kiesselbach’s plexus
over Little’s area on anterior septum
Venous Drainage
• Ethmoidal veins: → ophthalmic veins →
cavernous sinus
• Sphenopalatine vein: → pterygoid plexus
→ maxillary vein 
• Woodruff’s venous plexus : present on
lateral wall near the posterior end of
middle turbinate
• Retro - columellar vein: behind the
Sensory Nerve Supply
• Long & short Nasopalatine nerves
• Greater palatine nerve
• Infra-orbital nerve branches
• Anterior ethmoidal nerve
• Olfactory nerve
Autonomic Nerve Supply
• Deep petrosal nerve (sympathetic) +
greater superficial petrosal nerve (para-
sympathetic) → Vidian nerve → pterygo-
palatine ganglion → nasal glands
• Sympathetic stimulation →
vasoconstriction + ↓ed nasal secretions
• Para-sympathetic stimulation →
vasodilatation + ↑ed nasal secretions
Lining Epithelium
• Skin: on the nasal vestibule
• Olfactory epithelium: upper 1/3rd
of
nasal cavity above the superior
turbinate
• Respiratory epithelium (pseudo-
Lymphatic Drainage
1. External nose & anterior nasal cavity
⇒ Submandibular lymph nodes
2. Remaining nasal cavity
⇒ Upper deep cervical lymph nodes
3. Nasal roof (dangerous area of nose)
⇒Subarachnoid space along the
olfactory nerve
Paranasal Sinuses
• Anterior group
• Frontal
• Anterior ethmoidal
• Maxillary
• Posterior group
• Posterior ethmoidal
• Sphenoid
Development of P.N.S.
Appear
first
First X-ray
appearanc
e
Reach
adult size
by
Maxillary At birth 4 mth 15 yr
Ethmoidal At birth 1yr 12 yr
Sphenoid 2 yr 4 yr 18 yr
Frontal 4 yr 6 yr 15 yr
Physiology of
Nose & PNS,
Olfaction
Functions of Nose
• Respiration
– Heat exchange
– Humidification
– Filtration
– Nasal resistance
– Nasal fluids & ciliary function
– Nasal neurovascular reflexes
– Voice modification
• Olfaction
Functions of PNS
• Vocal resonance
• Air conditioning of the inspired air
• Pressure damper
• Reduction of skull weight
• Floatation of skull in water
• Increasing the olfactory area
Respiration
• Inspiration
– Air current passes along mid-portion of
nasal cavity in lamellar flow
• Expiration
– Resistance of nasal valve & turbinates
leads to formation of eddy current in
expired air
Respiration
Air conditioning
• Filtration : Particles > 3 μm in inspired air are
trapped by nasal vibrissae
• Temperature control
–Heat exchange between blood in
cavernous venous sinusoids of
turbinates & inspired air,
(radiation)
• Humidification
–secretions of nasal & PNS
mucosa; for better ciliary
Protection of lower airway
• Muco-ciliary blanket: traps pathogens in
inspired air > 0.5 μm & transports them to
nasopharynx for swallowing
• Sneezing: protects against irritants
• Lysozyme: kills bacteria & viruses
• Immunoglobulins A & E :protection against
bacteria
Muco-ciliary blanket
• Goblet cells in nasal mucosa secrete a
mucous blanket that moves backwards
like a conveyer belt into the
nasopharynx
• Consists of
– Superficial mucous or gel layer
– Deep serous or sol layer
Muco-ciliary blanket
Ge
l
Sol
Ciliary cycle
Factors decreasing mucociliary function
• Dry atmosphere (absence of humidity)
• Smoking, air pollutants & nasal irritants
• Infection
• Extremes of temperature
• Hypoxia
• Drugs: anesthetics, sedatives, topical nasal
decongestants, beta blockers
Ventilation of PNS
•Inspiration
–Negative pressure created in
nasal cavity sucks out air
from paranasal sinuses via
their ostium
•Expiration
–Eddies within nasal cavity
create positive pressure that
ventilates paranasal sinuses
Ventilation of PNS
Drainage of sinuses
• Anterior sinuses
drain in lateral
pharyngeal gutter
• Posterior sinuses
drain over posterior
pharyngeal wall
Nasal resistance
Nasal resistance to
expired air ( by
nasal valve) keeps
positive pressure in
respiratory tract &
prevents alveolar
collapse
Vocal Resonance
• Nasal cavity & paranasal sinuses provide vocal
resonance for nasal consonants M, N, nG
• De-nasal voice( Hyponasal Voice)
–Seen in nasal obstruction
– Nasal consonants M, N & nG
pronounced as B, D & G
respectively
Nasal Reflexes
• Smell reflex : Increases secretions of saliva &
gastric juice
• Naso-pulmonary reflex : Chronic, severe nasal
obstruction leads to increased pulmonary
resistance and pulmonary hypertension
• Sneeze reflex : Protection against F.B., irritants
Nasal Cycle
• Reflex, periodic alternation in nasal airflow
resistance between two nasal cavities
• Regulated by autonomic nervous system
• Due to congestion & decongestion of venous
sinusoids of inferior turbinates & anterior nasal
septum
• Each cycle lasts for 4-12 hours
Factors modifying nasal
cycle
• Temperature & humidity of surrounding air
• Head position
• Body temperature
• Physical activity
• Emotional & psychological status
• Hypothyroidism & hyperthyroidism
• Nasal decongestants & anti- hypertensives
Olfaction
Olfactory area of nose
•Located on the
roof of the
nasal cavity
•Superior part of
the nasal septum
•Cribriform plate
•Superior turbinate
•Upper part of middle
turbinate
Olfactory neural
pathway
Olfactory receptors on nasal mucosa → Olfactory
nerve bundles (20) → synapse with Mitral &
Tufted cells in Olfactory bulb → Axons unite to
form Olfactory tract → flattens distally to form
Olfactory trigone → trifurcates into Olfactory
striae → synapse with 10
& 20
Olfactory cortex +
• Olfaction is the only sensation to reach
cerebral cortex directly without first relaying at
thalamus
• Olfactory pathway incorporates limbic system
& is concerned with emotional behaviour,
mood & recent memory
Causes of Olfactory
dysfunction
1. Upper respiratory viral infection (30 %)
2. Idiopathic (25 %)
3. Head trauma (20 %)
4. Obstructive sinonasal disease (15 %)
• Rhino-sinusitis , nasal polyp , neoplasm
5. Neurologic & Psychiatric diseases
6. Intra-cranial neoplasm
Classification
• Conductive loss: obstruction of nasal passages
– Chronic nasal inflammation,
polyposis
• Sensorineural loss: damage to neuroepithelium
– Viral infection, airborne toxin
• Central olfactory neural loss: C.N.S. damage
Types of Olfactory dysfunction
1. Anosmia: absence of olfactory sensation
2. Hyposmia: decreased olfactory sensation
3. Parosmia / cachosmia: perception of a
pleasant odour as unpleasant odour
4. Phantosmia: perception of odour in
absence of olfactory stimulus
5. Hyperosmia: increased olfactory sensation
Olfactory function tests
1. Supra-threshold test: only identifies odour
• Smell bottles
• Smell Identification Test (S.I.T.)
2. Threshold Olfactometry: measures weakest
perceptible odour with help of serial dilution
• Manual
• Dynamic (automated)
Manual Threshold
Olfactometry
Dynamic Threshold
Olfactometry
University of Pennsylvania Smell
Identification Test (UPSIT)
• Most commonly used test of smell worldwide
• 4 booklets of 10 microencapsulated odors
stimuli
• Scratch and sniff format
• Four responses accompanying each odor
• Forced choice design
Smell Identification Test
sample
Results
36 – 40 :Normal
16-35 :Partial anosmia
6-15 :Total anosmia
0-5 :Malingering
Thank you !

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Anatomy and physiology of nose and PNS

  • 1. Anatomy and Physiology of Nose and Paranasal Sinuses Dr. Krishna Koirala
  • 3. • Nasal Bone • Frontal Process of Maxilla • Upper Lateral Nasal Cartilage • Lower Lateral Nasal (Alar) Cartilage • Septal Cartilage • Lesser Alar (Sesamoid) Cartilages
  • 4. Internal Nose • Openings: Anterior nares and posterior nares (Choana) • Vestibule of nose: lined by skin and containing hair follicles • Nasal cavity proper: Lateral Wall , Medial Wall (Septum) , Roof , Floor
  • 5. 1. Septal cartilage 2. Ethmoid plate 3. Vomer 4. Palatine crest 5. Maxillary crest 6. Vomeronasal cartilage 7. Medial alar crus 8. Upper lateral
  • 6.
  • 7.
  • 8.
  • 9. Lateral Nasal Wall • 3 - 4 bony conchae are covered with mucosa to form the turbinates • Space below and lateral to turbinate is called meatus • Middle meatus contains a round bulla ethmoidalis separated from uncinate process by hiatus semilunaris that leads
  • 10. Meatal Drainage 1. Inferior meatus: Nasolacrimal duct 2. Middle meatus: Frontal , anterior ethmoid , maxillary 3. Superior meatus : Posterior ethmoid 4. Spheno - ethmoidal recess: Sphenoid
  • 11.
  • 12.
  • 13. Ostio-meatal Complex Complex micro-architectural pathway in ethmoid labyrinth that drains anterior
  • 14. • OMC Consists of –Frontal recess + ethmoid infundibulum + hiatus semilunaris + uncinate process + bulla ethmoidalis + middle meatus • O.M.C. pathology leads to infection
  • 15. Variants in O.M.C.  Concha bullosa (pneumatized M.T.)  Paradoxically curved middle turbinate  Medially turned ( bent) uncinate process  Large bulla ethmoidalis  Haller’s cell ( orbital floor)  Agger nasi cell ( anterior to M.T.)  Mucosal pathology
  • 19. Blood Supply 1. Sphenopalatine artery (main artery) 2. Greater palatine artery 3. Superior labial artery 4. Anterior Ethmoidal artery 5. Posterior Ethmoidal artery 1, 2, 3 & 4 form Kiesselbach’s plexus over Little’s area on anterior septum
  • 20.
  • 21.
  • 22.
  • 23. Venous Drainage • Ethmoidal veins: → ophthalmic veins → cavernous sinus • Sphenopalatine vein: → pterygoid plexus → maxillary vein  • Woodruff’s venous plexus : present on lateral wall near the posterior end of middle turbinate • Retro - columellar vein: behind the
  • 24. Sensory Nerve Supply • Long & short Nasopalatine nerves • Greater palatine nerve • Infra-orbital nerve branches • Anterior ethmoidal nerve • Olfactory nerve
  • 25.
  • 26.
  • 27. Autonomic Nerve Supply • Deep petrosal nerve (sympathetic) + greater superficial petrosal nerve (para- sympathetic) → Vidian nerve → pterygo- palatine ganglion → nasal glands • Sympathetic stimulation → vasoconstriction + ↓ed nasal secretions • Para-sympathetic stimulation → vasodilatation + ↑ed nasal secretions
  • 28. Lining Epithelium • Skin: on the nasal vestibule • Olfactory epithelium: upper 1/3rd of nasal cavity above the superior turbinate • Respiratory epithelium (pseudo-
  • 29. Lymphatic Drainage 1. External nose & anterior nasal cavity ⇒ Submandibular lymph nodes 2. Remaining nasal cavity ⇒ Upper deep cervical lymph nodes 3. Nasal roof (dangerous area of nose) ⇒Subarachnoid space along the olfactory nerve
  • 30. Paranasal Sinuses • Anterior group • Frontal • Anterior ethmoidal • Maxillary • Posterior group • Posterior ethmoidal • Sphenoid
  • 31.
  • 32.
  • 33. Development of P.N.S. Appear first First X-ray appearanc e Reach adult size by Maxillary At birth 4 mth 15 yr Ethmoidal At birth 1yr 12 yr Sphenoid 2 yr 4 yr 18 yr Frontal 4 yr 6 yr 15 yr
  • 34. Physiology of Nose & PNS, Olfaction
  • 35. Functions of Nose • Respiration – Heat exchange – Humidification – Filtration – Nasal resistance – Nasal fluids & ciliary function – Nasal neurovascular reflexes – Voice modification • Olfaction
  • 36. Functions of PNS • Vocal resonance • Air conditioning of the inspired air • Pressure damper • Reduction of skull weight • Floatation of skull in water • Increasing the olfactory area
  • 37. Respiration • Inspiration – Air current passes along mid-portion of nasal cavity in lamellar flow • Expiration – Resistance of nasal valve & turbinates leads to formation of eddy current in expired air
  • 39. Air conditioning • Filtration : Particles > 3 μm in inspired air are trapped by nasal vibrissae • Temperature control –Heat exchange between blood in cavernous venous sinusoids of turbinates & inspired air, (radiation) • Humidification –secretions of nasal & PNS mucosa; for better ciliary
  • 40. Protection of lower airway • Muco-ciliary blanket: traps pathogens in inspired air > 0.5 μm & transports them to nasopharynx for swallowing • Sneezing: protects against irritants • Lysozyme: kills bacteria & viruses • Immunoglobulins A & E :protection against bacteria
  • 41. Muco-ciliary blanket • Goblet cells in nasal mucosa secrete a mucous blanket that moves backwards like a conveyer belt into the nasopharynx • Consists of – Superficial mucous or gel layer – Deep serous or sol layer
  • 43.
  • 45. Factors decreasing mucociliary function • Dry atmosphere (absence of humidity) • Smoking, air pollutants & nasal irritants • Infection • Extremes of temperature • Hypoxia • Drugs: anesthetics, sedatives, topical nasal decongestants, beta blockers
  • 46. Ventilation of PNS •Inspiration –Negative pressure created in nasal cavity sucks out air from paranasal sinuses via their ostium •Expiration –Eddies within nasal cavity create positive pressure that ventilates paranasal sinuses
  • 49. • Anterior sinuses drain in lateral pharyngeal gutter • Posterior sinuses drain over posterior pharyngeal wall
  • 50. Nasal resistance Nasal resistance to expired air ( by nasal valve) keeps positive pressure in respiratory tract & prevents alveolar collapse
  • 51. Vocal Resonance • Nasal cavity & paranasal sinuses provide vocal resonance for nasal consonants M, N, nG • De-nasal voice( Hyponasal Voice) –Seen in nasal obstruction – Nasal consonants M, N & nG pronounced as B, D & G respectively
  • 52. Nasal Reflexes • Smell reflex : Increases secretions of saliva & gastric juice • Naso-pulmonary reflex : Chronic, severe nasal obstruction leads to increased pulmonary resistance and pulmonary hypertension • Sneeze reflex : Protection against F.B., irritants
  • 53. Nasal Cycle • Reflex, periodic alternation in nasal airflow resistance between two nasal cavities • Regulated by autonomic nervous system • Due to congestion & decongestion of venous sinusoids of inferior turbinates & anterior nasal septum • Each cycle lasts for 4-12 hours
  • 54. Factors modifying nasal cycle • Temperature & humidity of surrounding air • Head position • Body temperature • Physical activity • Emotional & psychological status • Hypothyroidism & hyperthyroidism • Nasal decongestants & anti- hypertensives
  • 56. Olfactory area of nose •Located on the roof of the nasal cavity •Superior part of the nasal septum •Cribriform plate •Superior turbinate •Upper part of middle turbinate
  • 57. Olfactory neural pathway Olfactory receptors on nasal mucosa → Olfactory nerve bundles (20) → synapse with Mitral & Tufted cells in Olfactory bulb → Axons unite to form Olfactory tract → flattens distally to form Olfactory trigone → trifurcates into Olfactory striae → synapse with 10 & 20 Olfactory cortex +
  • 58.
  • 59.
  • 60. • Olfaction is the only sensation to reach cerebral cortex directly without first relaying at thalamus • Olfactory pathway incorporates limbic system & is concerned with emotional behaviour, mood & recent memory
  • 61. Causes of Olfactory dysfunction 1. Upper respiratory viral infection (30 %) 2. Idiopathic (25 %) 3. Head trauma (20 %) 4. Obstructive sinonasal disease (15 %) • Rhino-sinusitis , nasal polyp , neoplasm 5. Neurologic & Psychiatric diseases 6. Intra-cranial neoplasm
  • 62. Classification • Conductive loss: obstruction of nasal passages – Chronic nasal inflammation, polyposis • Sensorineural loss: damage to neuroepithelium – Viral infection, airborne toxin • Central olfactory neural loss: C.N.S. damage
  • 63. Types of Olfactory dysfunction 1. Anosmia: absence of olfactory sensation 2. Hyposmia: decreased olfactory sensation 3. Parosmia / cachosmia: perception of a pleasant odour as unpleasant odour 4. Phantosmia: perception of odour in absence of olfactory stimulus 5. Hyperosmia: increased olfactory sensation
  • 64. Olfactory function tests 1. Supra-threshold test: only identifies odour • Smell bottles • Smell Identification Test (S.I.T.) 2. Threshold Olfactometry: measures weakest perceptible odour with help of serial dilution • Manual • Dynamic (automated)
  • 67. University of Pennsylvania Smell Identification Test (UPSIT) • Most commonly used test of smell worldwide • 4 booklets of 10 microencapsulated odors stimuli • Scratch and sniff format • Four responses accompanying each odor • Forced choice design
  • 69. Results 36 – 40 :Normal 16-35 :Partial anosmia 6-15 :Total anosmia 0-5 :Malingering Thank you !