Clinical anatomy, physiology

and examination of the

nose, paranasal sinuses.

ZAPOROZHYE STATE MEDICAL UNIVERSITY

Otorhinolaryngology department
 External nose
External nose (nasus externus). There are the external nose, the
nasal cavity and the paranasal sinuses. The skeleton of the external
nose is formed by bones and cartilages. The bony part of the nose is
formed by paired nasal bones and by the frontal processed of the
maxilla. The free ends of these bones form a piriform aperture. The
cartilaginous framework of the nose includes triangular cartilage, paired
ala cartilage, and the accessory cartilage. The skin on the external nose
has many sebaceous and sweat glands. The upper narrow part of the
nose is called the root. The lateral movable parts of the nose ( ala)
slightly protrude outside to form the nost­rils, which, together with the
nasal septum, form the entrance (vestibule) to the nasal cavity. The
inner part of the nostrils (about 4-5 mm) is covered with fine hairs
(cilia) and sebaceous glands.
The external nose is supplied with blood via branches of the
ophthalmic artery. The blood outflows through the anterior facial and
angular veins into the superior ophthalmic vein which communicates
with the cavernous sinus. The external nose is innervated by the fifth
and seventh pairs of the cranial nerves.
External nose
External nose
 Nasal cavity
Nasal cavity (cavum nasi). The nasal cavity is divided by the septum
into the right and left parts. The anterior part of the nasal cavity opens
with a piriform sinus (anteriorly) and choanae (posteriori). The nasal
cavity has four walls, namely, the superior, inferior, internal, and external
walls. The inferior wall (the floor) of the nasal cavity is the hard (bony)
palate. The superior wall (the roof) of the nasal cavity includes the bones
of the nose anteriorly, the cribriform plate of the ethmoid bone in the
middle (the greater part of the roof) and the anterior wall of the
sphenoidal sinus. The fibbers of the olfactory nerve and the branches of
the ethmoidal artery and the veins pass through the perforations of the
cribriform plate. The medial (internal) wall, or the septum, consists of the
anterior cartilaginous and posterior bony parts. The bony part of the
septum is formed by the perpendicular plate of the ethmoid and the
vomer. The lateral (external) wall of the nasal cavity has a more complex
structure.
Nasal cavity
 Nasal cavity
Three nasal conch extend from the external wall toward the nasal
septum: the superior, middle and inferior conch. Three nasal meatuses
are distinguished accordingly: the superior, middle, and inferior
meatuses. The space between the nasal conch and the septum,
extending from the floor to the roof of the nasal cavity, is called the
common nasal meats. A nasolacrimal duct opens into the anterior part
of the inferior nasal meats. The middle meatus contains a crescent-
shaped semilunar hiatus where the maxillary and frontal sinuses, and
also the anterior and middle cells of the ethmoidal labyrinth open. The
posterior cells of the ethmoidal labyrinth and sphenoid sinus open into
the superior nasal meatus.
Nasal cavity
Nasal cavity
 Nasal cavity
The nasal cavity is lined with the mucous which is continuous with
the mucous of the paranasal sinuses, the pharynx, and the middle ear.
The nasal cavity can be divided into three parts: the anterior
(vestibule), respiratory, and the olfactory. The respiratory part of the
nasal cavity extends from the floor to the inferior border of the middle
conch. The mucous lining this cavity consists of multilayered columnar
ciliated epithelium rich in goblet cells, which produce mucus, and
serous glands producing serous or seromucous secretion. The mucous
of the conch overlies the cavernous tissue which can become engorged
instan­taneously, thus narrowing the nasal meatuses or, on the
contrary, become contracted.
Nasal cavity
 Nasal cavity
The olfactory part of the nose is found in the superior regions of
the nasal cavity; it extends from the inferior border of the middle conch
to the roof. The mucous of this part of the nasal cavity is lined with
olfactory cells. The axons of these bipolar cells run up through the
openings of the cribriform plate of the nasal roof to the olfactory bulb
in the cranial cavity, then it continues into tracts olfactorius, septum
pelucidum and ends into the cortex centers (gyres hippocampus, gyres
dentate, sulks olfactorius) The nasal cavity, is supplied with blood via
the branches of the external carotid arteries (a.sphenopalatina) and
internal carotid artery (aa. ethmoidales anterior and posterior, the
branches of a.ophthalmica). The outflow of the blood is through the
anterior facial and ophthalmic veins. The veins of the posterior parts of
the conch empty into the pharyngeal veins. The anterior part of the
nasal septum has an area (Kiesselbach's area) which is usually covered
with a small vascular varicosity. It is often called the bleeding area,
because it is a common locus of nasal bleeding.
Nasal cavity
 Nasal cavity
Four types of innervation are distinguished in the nase: the
olfactory, sensory, motor and secretory. The olfactory fibbers (about
20) originate from highly differentiated cells and pass to the olfactory
bulb through the cribriform plate. The sensory innervation of the nasal
cavity is accomplished by the first and second branches of the
trigeminal nerve. The motor innervation of the external nose is
accomplished by facial nerve. The secretory innervation of the nasal
cavity is represented by the sympathetic nervous system. The fibbers
of the sympathetic nerve pass from the pterygopalatine ganglion. They
serve to communicate with the sympathetic nerves of the thoracic,
abdominal, and endocrine organs. All this establishes reflex connection
between the nasal cavity and other organs and systems.
Nasal cavity
 Nasal cavity
aa. ehtmoidales a. sphenopalatina
 Paranasal sinuses
Paranasal sinuses. The paranasal sinuses are located by sides
of the nasal cavity and communicate with it. There are four paired air
cavities, namely, the maxillary, cells of the ethmoidal labyrinth, frontal,
and sphenoid.
The maxillary sinuses are located inside the maxilla; these are
the largest paranasal sinuses. The anterior surface of the maxillary
sinus has a depression which is known as the canine fosse. The medial
wall of the maxillary sinus, or the lateral wall of the nasal cavity, has
opening at the level of the middle nasal meats, through which the
sinus communicates with the nasal cavity. The upper wall of the
maxillary sinus is at the same time the inferior wall of the orbit. The
alveolar process of the maxilla forms the lower wall (the floor) of the
sinus. In most adults, the floor of the sinus is found below the floor of
the nasal cavity. The posterior wall of the sinus is thick; it is formed by
the maxillary tuberosity.
Paranasal sinuses
 Paranasal sinuses
 The ethmoidal sinuses (ethmoidal labyrinth) consist of air cells of
the ethmoid which is located between the frontal and the sphenoid
sinuses. Anterior, middle, and posterior cells of the labyrinth are
distinguished (6-7 cells of each type on either side). In healthy man
the cells are filled with air.
 The frontal sinuses are found in the squama of the frontal bone.
Each sinus has four walls: the anterior (facial); the posterior, which
borders with the cranial fosse; the inferior, which in most cases is
the superior wall of the orbit and borders with the cells of the
ethmoid and the nasal cavity over a small area; and the internal
wall (the septum).
Paranasal sinuses
 Paranasal sinuses
The sphenoid sinuses are found in the body of the sphenoid bone.
The septum separating the sinuses extends anteriorly to the nasal
septum. The roof is formed by the bone underlying the optic chiasm,
the clinoid processes, and the cella turcica with the pituitary gland.
The posterior wall is formed by the solid bone of the basissphenoid.
The lateral wall is in relation to the optic foramen and nerve, the
cavernous sinus and the internal carotid artery. The floor is the roof of
the nasopharynx. In the anterior wall is the natural orifice which
opens into superior nasal meats.
A neonate has only ethmoidal; these sinuses are only in their initial
stage of development. The maxillary, frontal and sphenoid sinuses are
absent in neonates. All of the sinuses normally continue to grow
during childhood and reach their final size at about the age of
puberty. The maxillary sinus begins to take shape from the fifth to
fourteenth year during the constant teething. The topography of the
paranasal sinuses approaches its final development by the age of 20.
Paranasal sinuses
Paranasal sinuses
 CLINICAL PHYSIOLOGY
Nasal respiration is very important because, in addition to the
respiratory function, the nose also performs the protective, resonating,
and olfactory functions.
The respiratory function of the nose is part of the entire respiratory
function in man. During inspiration, which is due to creation of negative
pressure in the chest, air enters both parts of the nasal cavity mostly
through the respiratory part of the nose. The inspired air passes
upwards and then descends by the superior and middle meatuses and
passes posteriori to the choanae. The pressure of the air on the nasal
mucous excites the inspiratory reflex. If a subject breathes through his
mouth, the inspiration becomes shallow and the amount of the air
oxygen intake decreases; this in turn can cause a patho­logical effect on
the nervous, vascular, circulatory, and other systems of man (especially
in children).
 The protective function of the nose consists in warming the inspired
air, its moistening and filtering. Cold air stimulates a rapid expansion of
the cavernous sinuses and their filling with blood. The volume of the
conch thus increases significantly; their surfaces become enlarged as
well, and the nasal passages are narrowed accordingly. The inspired air
is moistened by the wet mucous. As the air passes through the vestibule
of the nose, large dust particles are retained by thick hairs. Fine dust
and air-borne microbes, that pass first filter, are precipitated on the
nasal mucous moistened with mucous secretion. Dust is also retained
because the nasal passages are narrow and curved. About 40-60 per
cent of dust particles and microbes inspired with air are retained in the
nose and then removed from it with mucus. This function is performed
by ciliated epithelium. Lysocyme, contained in the nasal mucus and
secretion of the lachrymal glands, has a marked disinfecting property.
The sneezing and lachrymal reflexes are also important protective
mechanisms. Dust particles, cold, chemical, mechanical, and other
factors can stimulate these reflexes. The olfactory, trigeminal, and facial
nerves are involved in the reflex arc to stimulate contraction of the
muscles of the face, trunk, and the limbs.
 CLINICAL PHYSIOLOGY
The olfactory function in man is provided by the olfactory mucous
that contains the neuro-epithelial fusiform olfactory cells, which are
chemoreceptors. The molecules of gases, vapor, mist, dust, or smoke
stimulate the olfactory receptors. It should be noted that man can also
perceive odor of some substances (e. g. spirit of ammonia that act on
the endings of the trigeminal nerve).
The resonating function of the nose accounts for the special timbre
of the human voice. Pathological changes in the nasal cavity or in the
nasopharynx (polyps, hypertrophy of the conchae, inflammation of the
nasal mucous, tumor, adenoids, and other changes) cause rhinolalia
clause (nasal speech). If the nasal cavity has unusually large
communication with the nasopharynx (e.g. due to the absence of the
soft palate or its paralysis), the patient develops rhinolalia aperta.
 METHODS OF EXAMINATION
The external nose should be palpated. Palpation should also be
used to examine the anterior and inferior walls of the frontal sinuses,
the anterior walls of the maxillary sinuses, and also the cervical
regional lymph nodes.
The respiratory function of the nose should be examined separately
on each side. To that end, the wing of the one nostril is pressed to the
nasal and the patient is asked to breathe air quietly in and out; a small
piece of cotton wool held close to that will show if the passage is free.
A special rhinopneumometer is used for a more accurate assessment of
the nasal breathing function.
The olfactory function of each side of the nose is tested separately
using odoriferous substances from a special olfactometric set, or using
a special instrument called olfactometer. The technique for testing the
olfactory function is the same as that described for testing the
respiratory function. Olfaction can be normal (normosmia), decreased
(hyposmia), perverted (cacosmia), or it can be absent (anosmia).
 METHODS OF EXAMINATION
Rhinoscopy can be anterior, middle, and posterior. Anterior
rhinoscopy should be carried out on both sides of the nose. The normal
color of the nasal mucous is pink; its surface is smooth; the normal
position of the septum is central. The other side of the nose should be
examined in a similar way.
Inspection of the posterior parts of the nose is called posterior
rhinoscopy (epipharyngoscopy). The posterior parts of the nasal cavity
are inspected by slightly turning the speculum to the required side. The
posterior ends of the nasal conchae, the nasal meatuses, and the vomer
can thus be inspected. The nasopharynx can be examined in a similar
way.
ANTERIOR RHINOSCOPY
 Examination of the paranasal sinuses
According to the contemporary achievements of science and
thechnics, basic methods of investigation are: endoscopic,
roentgenological ones, compjuter X-ray tomography, magneto-resonance
tomography, radio nuclide scintigraphy and such additional methods as
ultrasonar biolocation, distance infra-red thermography, SHF-radiometry.
Roentgenography and clinical analyse of rentgenological signs is one of
the main methods of investigation of PNS. The next special projections
are used for the best observation of sinuses: naso-frontal, naso-mental,
mento-parietal, lateral and semi-axial ones. Every type of pathology is
characterized by the certain structural shadings, changes of bone
walls.The typical signs of the inflammatory diseases are: near-wall
thickening of mucous membrane, liquid level by the exudative forms,
"spotty" shading by polyposis. Osteo-destructive changes of the walls,
dilation of sinuses, the presence of tissues of high intensity with the
clear contours are character for the volume formations (tumours, cysts).
Layer investigation - tomography in the certain depth, contrast
investigation by jodolipol of the injuried sinus are used to specify the
pathological process.
X-ray examination
 Compjuter X-ray tomography (CT). By CT the picture is got
not in the X-ray film but is synthetized with the help of electronic
compjuter (EC). X-rays, coming from the tube in differents
directions (the set of irradiation is turned around the patient), are
perceived by semi-conducting detectors, where the quanta make
flashes. The flashes are calculated, turned into the figures with the
help of analogue-figure transformer and they come to the EC, where
the layer is reconstructed in the form of tomogram. CT lets to see
bones and soft tissues of paranasal sinuses and nasal cavity in the
same time and measure their X-ray density. So, with the help of CT we
can carry out differential diagnose of inflammatory processes and
tumours of PNS, determine the presence of osteo-destructive
changes. The scale of density, expressed by relative Haunsfild's (H)
units. Water density is accepted as 0 H, bone density - +1000 H, air
density - -1000 H
 Nucleo-magnetic resonance. Diagnostic picture, got by
magneto-resonance tomography (MRT) (such investigation is called MR-
tomography). MRT reflects two-dimensional distribution of water
protons' density (water makes 60-99% of our organism). Protons of
hydrogen become excited and then, coming to the initial condition,
they irradiate got power. This signal is registered, and EC
reconstructs the picture of organ's layer on the base of it. Air, bones,
calcifications almost don't give MR-signal. MRT-investigation lets to
carry out differentiation between inflammatory processes and
tumours, determine their localization, dimensions and spread, contours,
invasion of the neighbour anatomical structures.
Radio-nuclide scintigraphy. Radio-isotope diagnostics is based on
the registration and mesuring of irradiations form the radio-
pharmaceutical matters (RPM), introduced to the organism. Scanning
and scintigraphy are intended to get gamma-topographical picture of
ENT-organs and parts of body, concentrating RPM. The character of
pathological process is estimated by the degree of RPM fixing in the
injuried organ. Higher degree is evidence of tumour, lower degree is
evidence of inflammation.
 Unionizing methods. Last times such methods of ray diagnostics,
as thermography, SHF-radiometry, ultrasonar biolocation, became
widespread. They are absolutely undangerous and unharmful, cheap.
That's why they can be used during professional observations, in
children's otorinolaryngology, in pregnant women. But these
methods don't give enough information about tumours of PNS,
inflammatory processes in the back sinuses (middle and back cells of
ethmoidal labyrinth, sphenoidal sinus).However, they can be used as
the methods of pre-clinical express-diagnostics, and for the
undangerous and repeated control of the dynamic during the treatment.
Infrared thermography. It is based on the registration of heat
irradiation from the surface of human body. It is intended for the
measure of temperature by the diseases of paranasal sinuses and
nasal cavity. During the estimation they determine the presence of
asymmetrical heat picture and the difference between the investigated
regions to within 0.1C. Compjuter lets to find and calculate the
parts of thermogram, measure the coefficient of asymmetry.
 SHF-radiometry. This method is based on the receiving of human
irradiation, provoked by the heat movement of electrons in tissues in
radio-frequental diapason. Penetrating ability of SHF-radiometry 2-3
times more than thermometry. The intensity of registered irradiation
is directly proportional to the temperature of investigated region. The
depth of irradiating layer increases togehter with the length of wave.
Ultrasonar biolocation. Ultrasound (2-3 mHz) can penetrate
through the tissue, be absorbed and reflected in the border between
different tissues. US-screening is recommended for the diagnostics
of pathology in PNS. Scanning investigation is carried out with a help
of medical sound generator. The depth of US-location is 40-80 mm.
Reflected signal gets receiver and provokes the lighting of
corresponding photodiode. The lighting of every photodiode
corresponds to 2.5-5 mm (depending on the generator's conditions