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Rhinology > Anatomy & Physiology > Flashcards

Anatomy & Physiology Flashcards

1
Q

√Describe the various epithelial linings of the nasal cavity and sinuses.

A
  1. Nasal vestibule: Stratified squamous epithelium
  2. Nasal cavity and paranasal sinuses: Pseudostratified ciliated columnar epithelium
  3. Olfactory cleft and superior nasal cavity: Olfactory Neuroepithelium
  4. Limen Vestibuli = transition point between the stratified squamous epithelium and pseudostratified columnar epithelium at the vestibule
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2
Q

√Describe the cell types and types of epithelium that make up the nasal epithelium. 6

A
  1. Pseudostratified ciliated columnar epithelium (~50 cilia per cell beating, ~12/second at physiologic temperature, moves mucous 3-25mm/minute)
  2. Pseudostratified non-ciliated columnar epithelium - possess microvilli that expand the surface area of the epithelium
  3. Goblet cells
  4. Basal cells
  5. Stratified squamous epithelium in nasal vestibule
  6. Olfactory epithelium found along roof of nose
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3
Q

√Describe the two mucous layers present in the respiratory tract and functions of each.

A

Mucous blanket has 2 layers:
1. OUTER GEL LAYER
- Thick, viscous layer that lies on top of the cilia
- Goblet cells and submucosal glands produced mucoglycoproteins are contained in this layer
- Functions to trap airborne particles
- Propelled by ciliated epithelium - antibacterial and clearance of foreign particles

  1. INNER SOL LAYER
    - Thin “periciliary layer” produced by microvilli
    - Less viscous layer underlying the gel layer that allows ciliary movement to propel the overlying layer of mucous and particles

Cilia beat 1000 times per minute
Mucous travels 3-35mm/min

Kevan page 23

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4
Q

√What is the Cavernous Sinus?
1. Define the borders.
2. What does the cavernous sinus receive drainage from? 6

A

Cavernous sinus: paired dural venous sinus within middle cranial fossa on either side of the sella turcica of the sphenoid bone. Infection in the area of the central nose/anterior skull base region is concerning due to risk of cavernous sinus thrombosis (danger zone)

  • Anterior: Superior orbital fissure
  • Posterior: Petrous part of the temporal bone
  • Medial: Body of the sphenoid bone (sella)
  • Lateral: Meningeal layer of dura running from roof to floor of middle cranial fossa
  • Roof: Meningeal layer of dura attaching to anterior and middle clinoid process of sphenoid bone
  • Floor: Endosteal layer of dura overlying base of greater wing of sphenoid

RECEIVES DRAINAGE FROM:
1. Ophthalmic veins (superior orbital fissure)
2. Central vein of the retina (into superior ophthalmic vein or directly into CS)
3. Sphenoparietal sinus (anterior aspect of CS)
4. Superficial middle cerebral vein (drains cerebrum)
5. Pterygoid plexus (infratemporal fossa)
6. Inferior and superior petrosal sinuses

Nadia Rhinology Resident Lecture
Kevan Rhinology Page 32
Vancouver 453
Kevan Gen #42

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5
Q

√What are the contents of the Cavernous Sinus?

A

Cranial Nerves:
1. CN 3
2. CN 4
3. CN V1 + V2 (not V3)
4. CN 6

Internal Carotid artery
Venous plexus

Nadia Rhinology Resident Lecture photos

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6
Q

√What are the frontal veins of Breschet?

A

Veins of Breschet aka. frontal diploic veins
- Diploic (ie. perforating from inner to outer skull) veins through the frontal bone
- Connect the intracranial and extracranial venous drainage systems
- Potential avenue for spread of infection
- Must be cleared completely during frontal sinus obliteration (otherwise can be a source of remnant mucosa –> mucopyocele or mucocele)

https://www.kenhub.com/thumbor/l7B9xkXYg4n0N2Vl-cmkqvA5neg=/fit-in/800x1600/filters:watermark(/images/logo_url.png,-10,-10,0):background_color(FFFFFF):format(jpeg)/images/library/13703/image1.jpg

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7
Q

√Describe the order of
devleopment of the sinuses.

A

MESF

  1. Maxillary Sinuses (10 weeks GA)
  2. Ethmoid Sinuses (14 weeks GA)
  3. Spheonid sinuses (15 weeks GA)
  4. Frontal Sinuses (starts at 5 years of age) - Not present at birth

Ethmoid sinuses Rule of 14s:
1. Start devleopment at 14 weeks GA
2. Complete development at 14 year old
3. First sinuses to fully mature

Completion of development:
- Ethmoids ~14 yo
- Maxillary ~15 yo
- Frontal/Sphenoid variable, but ~15 yo

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8
Q

√Describe briefly the embryology of the nasal cavity and sinuses in terms of what the main ridges and furrows form.

A

RIDGES:
1. 1st Ethmoturbinal
- Ascending portion = Agger nasi
- Descending portion = Uncinate process
2. 2nd Ethmoturbinal = Bulla ethmoidalis
3. 3rd Ethmoturbinal = Middle turbinate
4. 4th Ethmoturbinal = Superior turbinate
5. 5th + 6th Ethmoturbinal = Fuse and usually degenerate, occasionally form supreme turbinate
5. Maxilloturbinal = Inferior turbinate (does not arise from the ethmoturbinals)

FURROWS
1. 1st furrow: between 1st and 2nd ethmoturbinate.
- Ascending portion = middle meatus, infundibulum, hiatus semiluminaris
- Descending portion = frontal recess
2. 2nd furrow = superior meatus
3. 3rd furrow = supreme meatus

See Rhinology Notability notes

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9
Q

Describe in detail what the embryological development of the nasal cavity and sinuses are.

A

1) Embryo head develops into structure with two distinct nasal cavities

2) Lateral walls invaginate to form turbinates (complex folds) and sinuses

3) Week 4-8 GA: Fronto-nasal process and maxillary process join
- Fronto-nasal process: grows over the forebrain, contributes to formation of nasal olfactory placodes
- Medial and Lateral nasal prominences develop on either side of the placodes and becomes the nares
- Nasal placode –> invaginate and forms the nasal pit which becomes the nasal sac.
- Medial nasal prominence + maxillary process = upper maxilla and upper lip philtrum
‣ Fusion Failure = Cleft Lip
- Septum = Posterior midline growth of the frontonasal process + midline extensions of mesoderm from the maxillary processes
- Primary and secondary palatal shelves separate the nasal cavity and nasopharynx from the oral cavity and oropharynx
‣ Fusion Failure = Cleft Palate
- Descending septum merges with fused palatal plates to create 2 nasal cavities

4) Week 6 GA: Mesenchyme forms simple lateral nasal wall

5) Week 7 GA: 3 axial furrows form, giving rise to the 3 turbinates

6) Week 10 GA:
- Middle meatus invaginates –> maxillary sinus
- Uncinate process and Bulla ethmoidalis form a narrow groove –> hiatus semilunaris

7) Week 14 GA:
- Several invaginations from the upper middle meatus –> anterior ethmoidal cells
- Invaginations from floor of the superior meatus –> posterior ethmoidal cells

8) Week 36 GA:
- Lateral nasal wall developed with turbinates at adult proportions
- Paranasal sinuses are present to varying degrees in the newborn (however have specific periods of significant growth after birth)

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10
Q

√During development, what are the structures that come together to form:
1. External nose
2. Lip
3. Columella, philtrum, upper lip
4. Maxillary arch, lateral nose
5. Nasal pit

A
  1. External nose = Lateral nasal prominence + medial nasal prominence
  2. Lip = Medial nasal prominence + maxillary prominence
  3. Columella, Philtrum, upper lip = Medial nasal process
  4. Maxillary arch, lateral nose = Lateral nasal prominence
  5. Nasal pit = ectoderm on lateral frontonasal prominence

Vancouver 404
See Facial plastics notes

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11
Q

Briefly discuss the development of the maxillary sinus

A
  1. Begins at the 10th week GA, along with the hiatus semilunaris
  2. Present at birth, conspicuous growth by 3 years, second sinus to fully develop
  3. Inferior expansion starts with permanent dentition (7-8 years, overlies the 2nd bicuspid to 2nd molar)
  4. Reaches adult size by mid-adolescence; volume up to 15cc
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12
Q

Briefly discuss the development of the Ethmoid sinuses

A
  1. Begins at the 14th week of gestation
  2. Present at birth, first sinus to fully develop
  3. Pneumatization begins significantly at 3-7 years, reaches adult form by 12-14 years, with ~14 cells (2-3cc)
  4. Develops from anterior ethmoid cell
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13
Q

Briefly discuss the development of the Sphenoid sinuses

A
  1. Begins during the 3rd month of gestation
  2. Later becomes Ossiculum of Bertini; third sinus to fully develop
    - Nasal mucosa invaginates into the posterior portion of the nasal capsule
    - The invagination expands to form a pouch like cavity called the cupolar recess of the nasal cavity
    - This cavity is ossified in lateral months of fetal development
  3. Does not pneumatize and become clinically significant until 4-5 years
  4. Growth complete by mid-adolescence, variable pneumatization
  5. Grows from a posterior ethmoid cell
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14
Q

Briefly discuss the development of the frontal sinus

A
  • Last sinus to fully develop
  • Not present at birth
  • Begins to grow in the 3rd to 5th year, and continues into adolescence
  • Pneumatization highly variable; volume up to 7cc; 5-10% atretic
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15
Q

What are the 3 stages of sphenoid sinus pneumatization?

A

Hamberger Staging

  1. Sellar (86%)
  2. Presellar (11%)
  3. Conchal (3%)
  • Pneumatization starts between 5 + 7 years of age, complete by 20-25 years

Vancouver Pg 404

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16
Q

What are the bony partitions of the ethmoid sinus?

A

Ethmoid sinuses separated by a series of recesses demarcated by five bony partitions or lamellae, named from most anterior to posterior

  1. FIRST LAMELLAE: Uncinate Process
  2. SECOND LAMELLAE: Bulla Ethmoidalis
  3. THIRD LAMELLAE: Basal Lamella (middle turbinate)
  4. FOURTH LAMELLAE: Superior Turbinate
  5. FIFTH LAMELLAE: Supreme Turbinate
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17
Q

In which plane is each 1/3 part of the middle turbinate? Which one can be removed without destabilizing the turbinate?

A

The simplified structure of the middle turbinate can be divided into thirds:

  1. Anterior 1/3: “Saggital”
  2. Middle 1/3 (basal lamella): “Coronal” - this can be removed
  3. Posterior 1/3: “Axial”

Vancouver Pg 405 diagram

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18
Q

Name the plain film projections useful for each sinus

A
  1. Frontal: Lateral and Caldwell (occipital-frontal)
  2. Ethmoid: Lateral and Caldwell
  3. Maxillary: Waters (Occipital-mental)
  4. Sphenoid: Lateral and Submentovertex
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19
Q

What bones make up the medial nasal wall/septum?

A
  1. Vomer
  2. Perpendicular plate of the ethmoid
  3. Maxilla: Made by the Maxillary crest and anterior nasal spine
  4. Palatine bone (maxillary crest)
  5. Sphenoid (rostrum)
  6. Nasal spine of the frontal bone (not actually part of the septum however)
  7. Crest of nasal bone (not included in the septum)

Kevan Page 46

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20
Q

What bones make up the lateral nasal wall? 8

A
  1. Maxillary bone
  2. Nasal bone
  3. Frontal bone
  4. Ethmoid bone
  5. Sphenoid bone (e.g. medial pterygoid)
  6. Palatine bone
  7. Lacrimal bone
  8. Inferior concha (considered a separate bone)

Kevan Page 46

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21
Q

What is the agger nasi?
What is the agger nasi cell?
What is it formed by?
What are the boundaries of the agger nasi cell?

A

Agger nasi = Anterior most part of the ethmoid

Agger nasi cell = Cell in the agger nasi (anterior to frontal recess)

Formation:
- Product of the 1st ethmoturbinal
- Found superior, lateral, and anterior to attachment of the middle turbinate

BOUNDARIES:
- Anterior: frontal process of maxilla
- Anterolateral: Nasal bones
- Superior: Frontal recess
- Inferolateral: Lacrimal bone
- Inferomedial: Uncinate process

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22
Q

What is the ethmoid bulla?

A

Largest anterior ethmoid cell

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23
Q

What is the Fovea Ethmoidalis?

A

Superior border of the ethmoid cells, separating the ethmoids from the anterior cranial fossa. More accurately known as the ethmoid roof.

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24
Q

What is the Crista Galli? What attaches to this?

A

Anterior midline projection of bone above the cribriform plates (comes off the ethmoid bone). The falx cerebri attaches to this.

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25
Q

What is the Suprabullar recess?

A
  • If the ethmoid bulla reaches the ethmoid roof (fovea ethmoidalis), then it forms the posterior wall of the frontal recess
  • If not, then the recess between the ethmoid roof and the ethmoid bulla is called the suprabullar recess

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQKvkLDhW7j6Mc9jE74tA_FYwOsHbIyErz-AK3aRXTvhcjsRW3aXFpBVFdwrS99V_aRyqI&usqp=CAU

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26
Q

What is the Sinus Lateralis?

A
  • Now referred to as the retrobullar recess
  • Cavity that is formed when the ethmoid bulla is separate from the basal lamella of the middle turbinate

Location:
- Posterior and superior to the ethmoid bulla in the anterior ethmoid region

Bounaries:
- Superior: Ethmoid roof
- Lateral: Lamina papyracea
- Posterior: Vertical portion of the basal lamella

SINUS LATERALIS = Suprabullar recess + retrobullar recess

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27
Q

What is the Terminal Recess?

A

Formed when the superior attachment of the uncinate is attached to the lateral nasal wall (e.g. lamina) - 80%.

  • This results in a blind end to the ethmoid infundibulum (superior boundary of ethmoid infundibulum)
  • Frontal recess drains medial to the uncinate process in this instance (middle meatus)

https://www.semanticscholar.org/paper/The-frontal-sinus-drainage-pathway-and-related-Daniels-Mafee/4dc9d1e54c9cecc9bd6aaa0d9e87c538b9ed47a8/figure/9

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28
Q

What is a Haller cell?

A

An Infraorbital ethmoid cell that pneumatizes into the maxilla
- Cause of recurrent CRS post-FESS (if entered Haller cell instead of Maxillary antrostomy)

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29
Q

What is an Onodi cell?

A

aka. Sphenoethmoidal cell
- Posterior ethmoid cell that pneumatizes into the sphenoid (the superior cell!)
- Can be identified by a horizontal septation in the sphenoid
- Most common in asian people
- Concern: Optic nerves can be very close by if Onodi is entered by accident and risk of injury

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30
Q

What is the basal lamella?

A

All turbinates have a basal lamella which reflects their embryology.

The basal lamella (attaches middle turbinate to lateral nasal wall) of the middle turbinate divides the anterior and posterior ethmoids.

Rhinology Notability notes

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31
Q

What is the concha bullosa?

A

Aerated middle turbinate that may obstruct the ostiomeatal complex

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32
Q

What is the ethmoid infundibulum?

A

3-D in the ethmoid labyrinth of the nasal wall, bounded by the lamina papyracea, ethmoid bulla, and uncinate

Opens into the hiatus semiluminaris (2D space)

Ethmoid infundibulum is a pyramidal space that facilitates the drainage of the maxillary, anterior ethmoid, and frontal sinuses.

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33
Q

What are the borders of the ethmoid infundibulum?

A

Lateral: Lamina Papyracea
Posterior: Anterior face of ethmoid bulla
Medial: Uncinate process
Inferior: Opens into semilunar hiatus

Kevan Page 47

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34
Q

What is the hiatus Semiluminaris?

A

2D space
- Crescent shaped cleft between the uncinate process and the ethmoid bulla
- Forms the entrance to the ethmoid infundibulum (2D space leading to 3D space)
- Also called ‘Inferior semilunar hiatus’

Another definition of Hiatus Semilunaris Inferior: Shortest distance between the free posterior margin of the uncinate process and anterior face of the ethmoid bulla

Boundaries:
- Medial: Infundibulum
- Lateral: Middle meatus

Vancouver Pg 406

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35
Q

What is the superior semilunar hiatus?

A

Second crescent shaped cleft between the back wall of the ethmoid bulla and the basal lamella of the middle turbinate
- Accesses the retrobullar recess

Vancouver Pg 406

36
Q

What is the Sphenoethmoidal Recess?

A

Cavity in front of the sphenoid face, medial to the superior turbinate, and lateral to the septum
- Natural os of the sphenoid opens into this, usually at the level of the superior turbinate

37
Q

What is the distance between the maxillary ostia and the nasolacrimal duct?

A

~10mm

38
Q

What percentage of patients have both an anterior and posterior ostia of the maxillary sinus?

A

15-40% patients

39
Q

What percentage of patients have dehiscent molar roots into the the maxillary sinus?

A

1st or 2nd molar root dehiscent into maxillary sinus in 2% of patients

40
Q

What is the difference between the inferior and superior semilunar hiatus?

A

Inferior Semilunar Hiatus:
- Usually referred to as just the semilunar hiatus
- Cleft between: Uncinate process, and anterior wall of ethmoid bulla
- Opens into the ethmoid infundibulum

Superior Semilunar Hiatus:
- Semilunar cleft between: Posterior wall of the ethmoid bulls and basal lamella of the middle turbinate
- Opens into the retrobullar recess (if present)

41
Q

What is the ostiomeatal complex? What are its components?

A

Functional unit and physiological concept comprising the final clefts and drainage pathways of the fronta, maxillary, and anterior ethmoid sinuses.

Combines the drainage pathways of:
1. Middle meatus
2. Anterior ethmoids
3. Frontal recess
4. Suprabullar recess
5. Ethmoid infundibulum

Components of the unit (HI EMU)
H: Hiatus Semiluminaris
I: Infundibulum (ethmoid)
E: Ethmoid Bulla & anterior ethmoid ostia
M: Maxillary sinus ostium
U: Uncinate process
Others: Frontal recess, middle turbinate

42
Q

What is the uncinate process? List its possible attachments. What is the clinical significance?

A

Uncinate process = thin, sickle shaped projection of the ethmoid bone

Possible attachments:
1. Lamina papyracea (70%) - Frontal sinus drains medially next to middle turbinate
2. Ethmoid roof - FSDP drains into infundibulum
3. Middle turbinate - FSDP drains into infundibulum

Clinical Significance:
- Affects the frontal sinus drainage pathway (FSDP)
- A terminal recess of the infundibulum is formed when the uncinate attaches to the lamina papyracea

Kevan Page 48

43
Q

How does the attachment of the uncinate affect the frontal sinus drainage pathway?

A

70% - uncinate attaches to lateral nasal wall
- FSDP will include the middle ematus

30% - uncinate attaches to skull base/middle turbinate
- FSDP will include the ethmoid infundibulum

Kevan Page 48

44
Q

Describe the attachments of the middle turbinate

A

Anterior (vertical): Skull base

Middle (coronal/oblique: Lamina Papyracea

Posterior (horizontal/axial): Lateral lasal wall - palatine bone, maxilla, orbit

Kevan Page 49

45
Q

Describe the direction of mucociliary flow in the frontal and maxillary sinuses

A

Maxillary Sinuses:
- Always moves towards the maxillary ostium

Frontal Sinuses:
- Moves in a rotary fashion superiorly and laterally away from midline, before exiting out the frontal sinus drainage pathway
Essentially:
- Medial to the ostium: Flows superiorly then laterally along the roof
- Lateral to the ostium: Flows medially and inferiorly towards the ostium
- 60-70% recirculates up the medial wall, while only 30-40% actually exits via the ostium

Kevan Page 49

46
Q

What are the drainage pathways for the anterior and posterior ethmoid cells?

A

Anterior ethmoids: Middle meatus
Posterior ethmoids: Superior meatus (via sphenoethmoidal recess)

47
Q

Name the anatomic structures that are visible as elevations on the walls of the sphenoid, from top to bottoms.

A
  1. Optic nerve (projects into sinus less commonly ~50%) - Bone dehiscent in 4-6%
  2. Opticocarotid recess
  3. Internal carotid artery - medial deflection into lateral wall called “carotid sulcus”, present 65-98% of time; bone dehiscent in 7-22%
  4. V2
  5. Lateral recess between V2 and vidian nerve
  6. Vidian nerve
  7. Pharyngeal canal medially

Kevan Page 51
Vancouver 410
Anterior and posterior clinoid process: https://upload.wikimedia.org/wikipedia/commons/7/76/Sphenoid_bone_with_anterior_clinoid_processes_highlighted.png

48
Q

Label the following structures on the sphenoid face

A

PS = Planum Sphenoidale
OP = Optic nerve
OCR = Opticocarotid recess
CR = Clival recess
C = Clivus
CPs = Parasellar ICA
CPc = Paraclival ICA

Kevan Page 52
Vancouver 410

49
Q

What is the lateral craniopharyngeal canal and what can arise within it?

A
  • Used to be called Sternberg’s canal
  • Located in the lateral recess of the sphenoid sinus
  • Lateral to foramen rotundum & vidian canal
  • Results from the incomplete fusion of the greater wings of the sphenoid with the basissphenoid (at base of skull)
  • Acts as a weak spot of the skull base
  • Can lead to development of an encephalocele

Vancouver 410

50
Q

What is Jacobson’s organ? Where is it located

A
  • Human Vomeronasal orgin
  • Blind ending diverticulum in the nasal septum, 2cm from the nostril
  • Vestigial organ for sensing phermones located on the anterior inferior septum
  • No known function in humans
51
Q

What is the nasal septal body? Where is it located

A

Other names:
1. Septal Turbinate
2. Septal cavernous body
3. Kiesselback’s body
4. Septal erectile tissue

What is it:
- Widened area of the septum located superior to the inferior turbinate and anterior to the middle turbinate
- Considered to be one of the erectile tissues of the nose (helps with warming and filtering of inspired air)

52
Q

What structures pass through the superior orbital fissure?

What is the annulus of zinnn and what is its relationship with the structures above?

A

Annulus of Zinn: the common tendinous ring/fibrous ring that surrounds the optic canal and part of the superior orbital fissure at the orbital apex, and gives origin to the four rectus muscles

Structures passing through the superior orbital fissure:
- CN III (Superior and inferior division)
- CNIV (Trochlear nerve)
- CNVI (Abducens nerve)
- CNV1 Opthalmic branches - nasociliary nerve, frontal nerve, lacrimal nerve
- Superior ophthalmic vein
- Inferior opthalmic vein

Passing OUTSIDE the annulus of Zinn (LFTS)
1. Lacrimal branch of V1
2. Frontal branch of V1
3. Trochlear nerve (CN4)
4. Superior ophthalmic vein

Passing THROUGH the annulus of Zinn
1. Superior branch of III
2. Inferior branch of III
3. Nasociliary branch of V1
4. Abducent nerve (CN6)

https://i1.wp.com/entokey.com/wp-content/uploads/2019/07/f01-01-9780323323086.jpg

Kevan Page 53

53
Q

Describe the borders of the frontal recess

A

ANTERIOR: Agger nasi
POSTERIOR: Skull base, Ethmoid bulla +/- suprabullar recess
- If ethmoid bulla reaches the skull base it forms the back wall
- Otherwise if it does not, the space is the suprabullar recess

MEDIAL: Middle turbinate
LATERAL: Lamina Papyracea

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54
Q

Describe the Kuhn Classification of Fronto-ethmoidal air cells

A

Type 1: Single air cell superior to the agger nasi but below the floor of the frontal sinus (20% on CT)

Type 2: Multiple air cells (tier) superior to the agger nasi but below floor of frontal sinus (10% on CT)

Type 3: Large air cell pneumatizing into the frontal sinus

Type 4: Single air cell completely within the frontal sinus, not located within the frontal recess (0% on CT)

“STeMI”
- Single cell
- Tier of cells
- Massive cell
- Inside the frontal

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55
Q

Describe the International Frontal Sinus Anatomy Classification System

A

IFAC Classification: New system to classify frontal sinus air cells. Classifies cells based on their position in the frontal sinus drainage pathway (anterior, posterior, medial)

ANTERIOR CELLS (Lie above the agger, push the FSDP posterior or posteromedially)
1. Agger nasi cell (ANC)
2. Supra-agger cell (SAC) - anterior cell above the agger nasi cell, does not pneumatize into the frontal sinus
3. Supra-agger frontal cell (SAFC) - Anterior cell above the agger nasi, pneumatizes into the frontal sinus

POSTERIOR CELLS (Lie above the bulla ethmoidalis, push the FSDP anterior)
1. Supra-bullar cells (SBC) - posterior cell above the bulla ethmoidalis, does not pneumatize into the frontal sinus
2. Supra-bulla frontal cell (SBFC) - posterior cell above the bulla ethmoidalis, pneumatizes into the frontal cell
3. Supraorbital Ethmoid Cell (SOEC) - Anterior(??) ethmoid cell that pneumatizes over the roof of the orbit, usually near the anterior ethmoid artery (Risk of injury)
- A SOEC was defined as the ethmoid cell immediately posterior and lateral to the frontal ostium with lateral pneumatization beyond the plane of the most medial portion of the lamina papyracea

MEDIAL CELLS (lies at the septum, push the FSDP lateral)
1. Frontal Septal Cell (FSC) - medial cell attached to the interfrontal sinus septum

56
Q

Describe the borders and contents of the infratemporal fossa

A

BORDERS:
- Lateral: Zygomatic arch and ramus of the mandible
- Medial: Connects to PPF via pterygomaxillary fissure, so lateral pterygoid plate
- Superior: Skull base (greater wing of sphenoid)
- Inferior: Posterior belly of digastric
- Anterior: Posterolateral wall of maxilla
- Posterior: No bony limit, but where medial pterygoid attaches to mandible

CONTENTS:
1. Arteries - Internal Maxillary artery
- Middle meningeal artery
- Inferior alveolar artery
- Accessory meningeal artery

  1. Veins - Pterygoid venous plexus
  2. Muscles - Pterygoid muscles
  3. Nerves
    - Chorda tympani
    - Mandibular nerve (V3) and its branches: inferior alveolar nerve
    - Lesser petrosal nerve (from IX) - from inferior salivatory nucleus –> then goes through foramen ovale –> synapses in otic ganglion –> carries post-ganglionic fibres through the auriculotemporal nerve –> parotid
  4. Ganglion: Otic ganglion
  5. Foramina: Foramen ovale, foramen spinosum
  6. Communications: Temporal fossa (superior), Pterygopalatine fossa (medial)

HOW TO REMEMBER:
- Foramen ovale and spinosum communicate with ITF
- Mnemonic for structures passing through foramen ovale = OVALE
O: Otic ganglion
V: V3
A: Accessory meningeal artery (from IMAX)
L: Lesser petrosal nerve
E: Emissary veins (feed to pterygoid venous plexus)

57
Q

What is the mechanism behind the oculocardiac reflex?

A

Oculocardiac reflex: Increased intraocular pressure results in bradycardia, aka. Aschner reflex

Mechanism: Due to connection between V1 nasociliary nerve branches and the vagus nerve CNX

Treatment:
1. Usually transient and self resolves
2. Can give atropine if necessary

58
Q

List, by thirds, the branches of the Internal Maxillary Artery (IMAX)

A

16 Branches with 3 sections, based on the relationship to the lateral pterygoid muscle:
1. Mandibular (First) part: Posterior to lateral pterygoid
2. Pterygoid (Second) part: Within lateral pterygoid
3. Pterygopalatine (Third) part: Anterior to lateral pterygoid

MANDIBULAR PART (5): Ear, brain, teeth
1. Deep auricular artery
2. Anterior tympanic artery
3. Middle meningeal artery
4. Inferior alveolar artery
5. Accessory meningeal artery

PTERYGOID PART (5): Muscles of Mastication
1. Masseteric artery
2. Pterygoid artery
3. Deep temporal artery - branches to anterior and posterior deep temporal artery
4. Buccinator artery

PTERYGOPALATINE PART (6): Corresponds to openings of the PPF
1. Sphenopalatine artery (terminal branch of IMAX)
2. Descending palating artery
3. Infraorbital artery
4. Pharyngeal artery
5. Posterior superior alveolar artery
6. Vidian artery (Artery of the pterygoid canal)

Mnemonic: DAM I AM Piss Drunk But Stupid Drunk I Prefer. Please Vote!

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59
Q

At the base of which structure is the anterior ethmoid artery commonly located?

A

Non-pneumatized lamella of the ethmoid bulla

60
Q

What are the four bony components of the medial orbital wall. Bonus 5

A
  1. Frontal process of the maxilla
  2. Lacrimal bone
  3. Lamina papyracea of the ethmoiid
  4. Sphenoid bone (just anterior to the optic canal)
  5. Orbital process of the palatine bone (also near the apex, more inferior than lateral)
61
Q

What are the six foramina of the maxilla?

A
  1. Infraorbital
  2. Superior alveolar canal(s)
  3. Incisive canal
  4. Maxillary/Accessory Ostium
  5. Pyriform aperture
  6. Greater palatine canal
62
Q

What is the maxillary line? Discuss the important landmarks during endoscopic dacryocystorhinostomy.

A

Maxillary line = A curvilinear eminence along the lateral nasal wall that runs from the anterior attachment of the middle turbinate to the root of the inferior turbinate, corresponding to lacrimomaxillary suture
- Midportion of the line is called “M point”

Important landmarks during endoscopic DCR:
1. Maxillary line Bisects the lacrimal sac
2. Posterior to the maxillary line corresponds to the thin lacrimal bone and posterior half of the lacrimal sac

63
Q

What are 4 structures that pass through the sphenopalatine foramen?

A
  1. Sphenopalatine artery
  2. Sphenopalatine vein
  3. Posterior superior lateral nasal nerve (branches supply posterosuperior parts of septum and lateral nasal wall)
  4. Nasopalatine nerves (along the roof of the nose to the posterior septum –> anteriorly to the incisive canal –> supplies hard palate and gingiva behind the incisors

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64
Q

What anatomic sinus variation is more common in asians?

A

Sphenoethmoidal / Onodi cells

65
Q

What are the 6 anatomic relationships of the sphenoid ostium?

A
  1. 7cm from the anterior nasal spine (posterior sphenoid wall ~9cm)
  2. 30 degree angle from the floor of the nose (most reliable)
  3. 1-1.5cm above the upper limit of the choana
  4. 1/3 up from the choana to the skull base
  5. Adjacent to the posterior border of the nasal septum (2-3mm)
  6. Inferomedial to the posterior attachment of the superior turbinate on sphenoid face (Parson’s ridge)
  7. Inferior limit in the same plane as the roof of the maxilla
66
Q

What are the internal carotid artery branches supplying the internal nose?

A
  1. Anterior ethmoid artery (found on CT between superior oblique and medial rectus muscles
  2. Posterior ethmoid artery
  3. Branches off the ophthalmic artery, each divides into a medial branch (little’s area and septum) and a lateral branch (superior & middle turbinates)
  4. Vidian artery can arise from the ICA or ECA (IMAX usually)
67
Q

What are the external carotid artery branches supplying the internal nose?

A

MAXILLARY ARTERY:
1. Descending palatine artery –> Greater palatine artery –> artery of the incisive canal –> Little’s area
2. Sphenopalatine artery –> Medial (nasoseptal artery) and Lateral nasal artery (middle and inferior turbinate)
3. Pharyngeal branch (posterior nose and nasopharynx)

FACIAL ARTERY:
1. Superior labial artery –> nasal septum branch and columellar branches

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68
Q

What are the major landmarks along the medial orbital wall?

How do you determine where the anterior and posterior ethmoid artery on at the medial orbital wall?

A

Blood vessels found along the frontoethmoidal suture divides the anterior cranial fossa from the ethmoid sinuses.

Landmarks: (distance from Anterior Lacrimal Crest of maxilla - Maxillolacrimal suture, ie. where the maxilla and lacrimal bone meet)

  1. Anterior Ethmoid artery ~24mm posterior to the anterior lacrimal crest (14-22)
  2. Posterior Ethmoid artery ~12mm posterior to the AEA (10-12)
  3. Optic nerve ~6mm posterior to the posterior ethmoid artery (4-7

24-12-6

69
Q

Describe the venous drainage of the nose

A
  1. Greater palatine vein - posterior facial vein, into external jugular vein
  2. Septal and angular veins - drain to anterior facial vein, into IJV
  3. Anterior and posterior ethmoidal veins - drain to ophthalmic veins, to cavernous sinus, to IJV
  4. Sphenopalatine vein - drain to maxillar vein, to cavernous sinus, to IJV

GASES
Greater palatine (EJ)
Angular (IJ)
Septal (IJ)
Ethmoidal (IJ)
Sphenopalatine (IJ)

70
Q

Describe the two nasal vascular arterial plexuses and their blood supply

A
  1. Kiesselbach’s plexus: Little’s area, found on the anterior septum
    - Anterior ethmoid
    - Sphenopalatine
    - Greater palatine
    - Superior labial
  2. Woodruff’s plexus (naso-nasopharyngeal plexus): Venous plexus, located in the posterior lateral nasal wall inferior to the inferior turbinate. Contributions arterially from:
    - Pharyngeal branch of IMAX
    - Sphenopalatine artery (posterior septal and nasal)

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71
Q

What are four neural systems of the nose?

A
  1. CN0: Loose plexus of fine nerve fibers throughout the nose; high GnRH content (gonadotropin releasing hormone)
  2. CNI: Olfactory nerve
  3. CNV: Nasociliary V1, Nasopalatine V2, Maxillary nerve V2 (irritaiton, burning, touch, temperature; reflex - secretions and sneezing)
  4. Vomeronasal organ (VNO) - Tudimentary, non-functioning in humans
  5. Vidian nerve: Sympathetics/parasympathetics
72
Q

Describe the autonomic innervation of the sinuses

A

PARASYMPATHETIC
- Superior salivary nucleus –> nervus intermedius (nerve of Wrisberg) –> geniculate ganglion –> GSPN –> vidian nerve –> PPG –> nasal mucosa
- Neurotransmitter = acetylcholine

SYMPATHETIC
- Sympathetic chain –> superior cervical gangion –> deep petrosal nerve –> vidian nerve (joins GSPN) –> PPG –> fibers to nasal mucosa
- Neurotransmitter = norepinephrine

73
Q

Describe the sympathetics autonomic supply to the nasal mucosa

A

Vasoconstrictor tone

Pre-ganglionic:
- From sympathetic chain synapse in the superior cervical ganglion

Post-ganglionic:
- Travel with internal carotid artery
- Split off as deep petrosal nerve
- Goes through foramen lacerum
- Joins with Greater superficial petrosal nerve (GSPN)
- GSPN + DPN = Forms the vidian nerve
- Passes through the pterygopalatine ganglion WITHOUT synapsing
- Forms the sphenopalatine nerve
- Goes through sphenopalatine foramen to supply nasal cavity mucosa

74
Q

Describe the parasympathetics autonomic supply to the nasal mucosa

A

Vasodilation of capacitance and resistance vessels, also mediate nasal secretion

Preganglionic:
- Arise in superior salivatory nucleus
- Nervus intermedius (VII)
- Geniculate ganglion (no synapse)
- GSPN
- Vidian nerve
- Pterygopalatine ganglion (SYNAPSE)

Post-ganglionic after PPG:
- Distributed with V2 branches to all glands above the oral fissure:
1. Mucosal glands in nasal cavity (sphenopalatine nerve)
2. Salivary glands along the palate (greater and lesser palatine nerves)
3. The lacrimal gland (off the zygomatic nerve)

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75
Q

What are 3 important factors for normal nasal function?

A
  1. Ostial patency
  2. Mucociliary function
  3. Quantity and quality of nasal secretions

Blockage of sinus ostia = hypoxia, vasodilation, ciliary dysfunction, mucous gland dysfunction

76
Q

What are the 3 main functions, and 6 subfunctions, of the nasal airway

A
  1. Respiration
    - Warming (37deg)
    - Humidification (85%)
    - Nasal airflow (which can be altered through airway resistance by congestion and decongestion of the mucosa)
  2. Protection
    - Filtration
    - Mucociliary clearance
    - Immune protection
  3. Olfaction (to sense the environment through the specialized and general sensory nerves (olfactory & trigeminal V1/V2)
77
Q

What are five factors present in nasal secretions which fight infection

A
  1. IgA/G
  2. Mucoglycoproteins
  3. Interferon
  4. Lysozyme
  5. Lactoferrin

IM ILL

78
Q

What is the differences between mucosa of the nose vs sinuses? 4

A
  1. Ciliated cells more concentrated at the ostia
  2. Increased number of goblet cells present in the nose
  3. No olfactory neuroepithelium in the sinuses
  4. Nitric oxide concentration is higher in the sinuses
79
Q

What are 7 factors that affect nasal airflow?

A
  1. Nasal cycle / vasomotor control
  2. Head and body position
  3. Autonomic regulation of nasal vasculature / Vascular reflex (sympathetically driven) - e.g. Hypercapnea/hypoxia decreases nasal resistance
  4. Exercise (epinephrine)
  5. Nitric oxide (affects nasal and pulmonary blood flor, ciliary beat frequency)
  6. Nasal anatomy
  7. Sex Hormones (Puberty, menstruation, pregnancy)
80
Q

What are the structures that contribute to nasal resistance? 3

A
  1. Nasal vestibule (1/3 of resistance)
  2. Internal nasal valve (narrowest, largest contribution)
  3. Turbinated nasal cavity (minimal contribution)
81
Q

Discuss what the Nasal cycle is, the physiology of how it works, and the 3 purpose of it.

A

Nasal Cycle: Nasal airflow is greater in one nostril than in the other, and the “greater airflow nostril” shifts between left and right over time, while keeping the overall nasal flow constant
- Alternates over 30 mins to 6 hours, ~2.5hr average

Physiology:
- Asymmetry in blood flow leading to engorgement of erectile tissue in the anterior part of the nasal septum and inferior turbinate of one nostril over the other
- Related to unilateral sympathetic dominance on one side (vasoconstriction) and parasympathetic dominance on the other side (vasodilation)

Purpose (debated):
- Assist mucociliary clearance
- Protection against respiratory infections/allergens
- Assist olfaction

82
Q

Where is nitric oxide produced? How is it impacted when there is high vs. low nasal airflow? What are the effects and functions of nitric oxide on the nasal epithelium? 5

A

Nitric Oxide = neurotransmittor
- Concentrations of NO depend on nasal airflow
- NO is produced significantly in the paranasal sinuses
- High airflow = NO goes to lungs, where it acts as a vasodilator
- Low airflow = NO stays in the sinuses, where it affects the sinonasal epithelium

Effects of NO on nasal epithelium:
1. Stimulates higher ciliary beat frequency
2. Vasodilatory properties
3. Antimicrobial effect - bacteriostatic/viral protective
4. Immunological modulation
5. Bronchodilator (lungs)

“ABCD I love you” (like the song)
A - Antimicrobial effect (bacteriostatic, viral protective)
B - Bronchodilator (lungs)
C - Ciliary beat frequency increases
D - vasoDilating function

83
Q

What are the mechanisms of innate immunity in the nose? 4

A
  1. Barrier: Epithelial tight junctions
  2. Enzymes/Peptide antibiotics - locally secreted in mucous
    - IgA/G
    - Mucoglycoproteins
    - Interferron
    - Lactoferrin
    - Lysozyme
  3. Phagocytes (neutrophils, macrophages)
  4. PAMP Receptors
    - Detect pathogen associated molecular patterns to distinguish from non-self
    - Expressed on epithelium and phagocytes
    - Cause secretion of immune mediators via mast cells/basophils –> histamiine, leukotrienes
84
Q

List the 3 methods to objectively assess nasal airflow.

A
  1. Acoustic Rhinometry
  2. Rhinomanometry
  3. Peak Nasal Inspiratory Flow

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85
Q

Discuss Rhinomanometry:
1. How does it work?
2. What is the limitation?
3. What are the 3 types?
4. How do you interpret the results?
5. What situations would make rhinomanometry not useful?

A

RHINOMANOMETRY:
- Measures the amount of resistance to airflow in the nose
- How? By measuring transnasal pressure (Pa) and airflow (cm^3/s) –> used to calculate the resistance (Pa/cm^3/s)
- Usually displayed as a pressure-flow curve with change in transnasal pressure on the x-axis and airflow on the y-axis
- Resistance (R) = Pressure (P) / Air Flow (V)

Limitation: Cannot identify specific site of obstruction

3 methods of measurement:
1. Anterior Rhinomanometry
- Pressure detector with inflatable cuff placed at opening of nostril and occludes it, which measures nasopharyngeal pressure
- Limitation: Non-physiologic measure (cuz all the airflow will happen through the other unoccluded nostril)

  1. Posterior Rhinomanometry:
    - Pressure detector placed in mouth at oropharynx
    - Advantage: More accurately measure nasopharyngeal pressure; more physiologic measure of nasal resistance through both nostrils simultaneously
  2. Postnasal (Pernasal) Rhinomanometry):
    - Pressure detector placed in the posterior nose/nasopharynx through one nostril/nasal cavity

INTERPRETING RESULTS:
- Total nasal resistance > 0.3 Pa/cmsquared/sec usually is symptomatic
- Normal = 0.15-0.3
- > 35% reduction in resistance after decongestion infers mucosal disease
- < 35% reduction in resistance infers a structural cause
- Not useful if: complete occlusion, septal perforation, floppy septum

86
Q

Discuss Acoustic Rhinometry:
1. What is it?
2. How does it work?
2. How do you interpret the results?
3. What are the points of measurement?
4. What are the three main areas of nasal resistance?

A

ACOUSTIC RHINOMETRY:
- Uses sound waves to measure a cross sectional area of the nose, before and after decongestion

How it works:
- Analyzes 10msec sound pulses reflected from the airway
- Identifies the minimal cross-sectional area (MCA), the location of the MCA, and the cross-sectional area at various distances from the nostrils
- Does NOT rely on airflow or measure nasal airflow dynamics, cannot measure the effects of narrow regions on airflow dynamics or resistance

Results:
- Graph will show distance from nostril on x-axis and cross-sectional area of y-axis
- Usually will show a minimum of 3 notches (deflections) which represent the narrowest area of the nasal cavity

Points of measurement:
1. I-Notch: Isthmus of the internal nasal valve, within 2cm of nostril, usually narrowest = 0.73 cmsquared
2. C-Notch: Anterior inferior Concha (head of inferior turbinate), ~3.3cm from nostril
3. 3rd notch is usually variable

Three areas of nasal resistance:
1. Vestibule (Contributes 1/3 of resistance)
2. Valve (1/2-2/3)
3. Turbinated cavity is the rest

Note: Some studies show that acoustic rhinometry is not good

87
Q

Discuss Peak Nasal inspiratory flow and how it works

A

PEAK NASAL INSPIRATORY FLOW:
- Patient asked to inspire through the nose as hard and fast as possible
- 2-3 of these are done, and the peak nasal inspiratory flow is the highest result from these

Rhinology (11 decks)

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