Lec 1 - Nose Flashcards
Talk about :-
•Shape
•Parts of external nose
•Parts of its skeleton
1- pyramidal in shape
2- between nasal bone , frontal is nasion/ root
Tip - dorsum/ nasal bridge - ala - anterior nares/ nostril - columella
3- skeleton consists of
Bony part :
• two nasal bones
• nasal process from frontal bone
• nasal process from maxillary bone
Cartilage part
• upper, lower lateral cartilage
• septal cartilage
Talk about nasal cavity
Two cavities separated by a septum
Its boundries
-Roof : cribriform plate
-Floor : hard palate
- 2 openings
Anterior nares : medially columella , laterally ala
Choana : medially vomer , laterally medial pterygoid plate
-Medial wall : nasal septum which is formed of
* quadrangular cartilage : antero inferior
* peripendicular plate of ethmoid bone : posterosuperior
* vomer bone : posteroinferior
* membranous part : between cullomella , quadrangular
* maxillary crest
-Lateral wall
Has 3 elevations , inbetween 4 spaces
Elevations = chonca / turbinate
Spaces = have meatus in it
• inferior turbinate :
Rich in blood supply
Drainage : nasolacrimal duct
• middle turbinate :
Middle in size , site
Its meatus shows following feature
* uncinate process : bony shelf medial to bulla
* hiatus semilunaris : semilunar groove under bulla
* bulla ethmoidalis : round projestion , the largest cell in anterior ethmoid sinus
Drainage : anterior group of sinus
Frontal sinus drains through frontal recess to most anterior part of it
Maxillary : posterior part
Anterior ethmoid : middle of it
It is called osteomeatal complex
• superior turbinate :
Small in size
Drainage : posterior ethmoid
• sphenoethmoidal recess
Drainage : spenoid sinus
-Medial wall : nasal septum which is formed of
* quadrangular cartilage : antero inferior
* peripendicular plate of ethmoid bone : posterosuperior
* vomer bone : posteroinferior
* membranous part : between cullomella , quadrangular
* maxillary crest
-Lateral wall
Has 3 elevations , inbetween 4 spaces
Elevations = concha / turbinate
Spaces = have meatus in it
• inferior turbinate :
Rich in blood supply
Drainage : nasolacrimal duct
• middle turbinate :
Middle in size , site
Its meatus shows following feature
* uncinate process : bony shelf medial to bulla
* hiatus semilunaris : semilunar groove under bulla
* bulla ethmoidalis : round projestion , the largest cell in anterior ethmoid sinus
Drainage : anterior group of sinus
Frontal sinus drains through frontal recess to most anterior part of it
Maxillary : posterior part
Anterior ethmoid : middle of it
It is called osteomeatal complex
• superior turbinate :
Small in size
Drainage : posterior ethmoid
• sphenoethmoidal recess
Above superior turbinate
Drainage : spenoid sinus
• nasal valves : the narrowest area , junction between upper , lower carilage , anterior to the end of inferior turbinate
What is omc
Osteomeatal complex
Site of drainage of anterior group to middle meatus bordered laterally by lamina papyrasea
( medial orbital wall) Medially be middle turbinate
Talk about
blood supply
Innervation
Lymph node
Histology
• arterial
Ica ~> opthalmic a ~> anterior ethmoidal
~> posterior ethmoidal
Eca ~> maxillary ~> sphenopalatine
Greater palatine
~> facial ~> superior labial
*they gather in area called little area except posterior ethmoidal , most common for epistaxis
• venous
They drain into ophthalmic veins ~> cavernous sinus
• innervation
Sensory : maxillary nerve from terigiminal
Olfactory for smelling : 1st cranial n
Autonomic : nerve to pterygoid canal ( VIDIAN) which
Has sympathetic vasoconstrictor : deep petrosal
Has parasympathetic secretomotor : gspn from facial
• lm
Anterior part of nose , anterior group of sinus ~> submandibular
Posterior part of nose , posterior group of sinus ~> retro pharyngeal
All ~> upper deep cervical lm
• histology
Lower part ( vestibule ) ~> skin with vebrissae hair
Middle part , sinuses~> respiratory mucosa
Upper part ( olfactory ) ~> olfactory neuroepithelium
Talk about paranasal sinus
It is divided into
- anterior group : anterior ethmoid , frontal, maxillary
- posterior group : posterior ethmoid , sphenoid
• maxillary (3)
- pyramidal in shape
- its apex towards zygomatic bone
- boundries :
Roof : orbit, infra orbital nerve , vessels
Floor : aleveolar process ( 2nd premolar, 1st molar teeth )
Anterior : cheek
Posterior : pterygopalatine fossa ( contains maxillary n, v and pterygopalaine ganglia)
Medial : nasal cavity
• frontal (1)
It doesnt exist with birth , starts to appear 2:4 years ( etmoid , maxillary exist since birth)
•ethmoid (1)
Between anterior , posterior ground lamella
• sphenoid (3)
- it exists within the sphenoid body bone
- pituitary gland is above it in sella turcisca
- related to ica , optic n
Talk about dangerous area
•Area of face in which infection goes to cavernous sinus
• boundries : Root of nose superiorly
Angle of mouth on each side inferiorly
Function of nose ?
(5)
1- respiration
2- smelling
3- drainage of lacrimation
4- resonance of voice
5- protection
• vebrissae hair filter large particles
• cilia filter small particles
• humidification and warming of air
• sneezing reflex
• lyzozomes in nasal secretions
Function of paranasal sinus ?
1- lightening of weight skull
2- humidification and warming of air
3- resonance of voice
4- additional source for mucus to nasal cavity
5- thermal insulator
Talk about muco ciliary clearance ( mucus blanket )
*Two layers
• superficial thick viscid layer ( gel )
• deep thin watery layer ( sol )
*The cilia are embeded in sol layer , move backwards towards nasopharynx to clear the gel layer in biphasic movement of rapid active phase and slow recovery phase
*it is inhibited by
• smoking
• infection
• temperature changes : exsseive heat and cold
Symptoms of nasal diseases
(6+6s)
- nasal obstruction
- nasal discharge
- epistaxis
- facial pain
- headache
- orbital symptoms
- snoring
- sleep apnea
- smelling disorder
- sneezing
- swelling
- deformity
Methods of examination ?
(4)
1- external examination
( SAP)
Shape : to detect deformity or swelling
Airflow : for nasal patency
Palpation : for tenderness
2- anterior rhinoscopy : by nasal speculam , we can see up to middle turbinate , meatus
3- posterior rhinoscopy : by posterior rhinoscope mirror , we can see post nasal space ( nasopharynx) but commonly used as nasal endoscope
4- nasal endoscope : by rigid nasal endoscope ,we san see whole nasal cavity , nasopharynx
Talk about choanal atresia
(7)
1- congenital obstruction of choana ( posterior nasal opening)
2- causes : persistent bucconasal membrane
3- types : bony or membranous , uni or bilateral
4- symptoms:
-In unilateral cases
It passes unnoticed till childhood
•Unilateral nasal obstruction
•Unilateral nasal discharge
- in bilateral cases
ENT emergency, as the baby is obligate nose breather inthe first 2:3 months
• bilateral nasal obstruction
• bilateral nasal discharge
• difficulty in suckling
• cyanosis that improves on crying ( diagnostic)
5- signs
• rubber catheter can’t pass from nose to nasopharynx
• colored drops can’t pass from nose to nasopharynx
• nasal endoscope ( infantile size ) : see atresia
6- investigations
CT to see if it is bony , membranous
7- treatment
Unilateral case : operation is not urgent in neonatal life so postponed to 2:3 years
Bilateral case : emergency
1- saving the airway after birth by maintaining mouth opened through
- plastic oral airway
- endotracheal intubation
- mcgovern nipple
2- when the condition is improved we proceed to operation
Trans nasal endoscope
Trans palatal ( old tecnique , not commonly used )
Talk about traumatic fracture of nasal bone
(5)
1- cause : blow or car accident
2- symptoms: (6)
- history of trauma
- pain
- epistaxis
- nasal obstruction
- swelling
- deformity
3- signs 3(6)
Inspection
- deformity : deviation or depression
- swelling : due to edema , hematoma ,surgical emphysema ( air under skin)
Palpation
Tenderness
Crepitus
Anterior rhinoscopy
- lacerated mucosa ( blod clots )
- dislocated septum
4- investigations
X ray for medicolegal purposes
5- treatment
1- contral epistaxis ( if present )
2- reduction of fractured bone
- if no edema :( few hours within trauma )
Reduction immediately under ga either manually or instrument ( walshams forceps for nasal bones , asch forceps for nasal septum )
- if there is edema : wait one week till edema is healed then reduction
- after 2 weeks :( malunion)
Wait 3 months , then rhinoplasty
3- anterior nasal packing : to maintain nasal bones from inside for 48h
4- fixation : by plaster of paris or aluminum sheet to maintain nasa bones from outside for 2 months
5- prophlactic antibiotics , analgesics , anti inflammatory
Talk about foreign body in nose
(6)
1- type of patient : child or mentally retarded
2- type of fb : vegetable, non vegetable
3- symptoms:
- unilateral nasal obstruction
- unilateral basal offensive discharge
4- signs
Anterior rhinoscopy : see fb or discharge
Nasal endoscope ( sometimes ) : if is small
5- complications
Nasal
- early : infection ( rhinitis , sinusitis)
- late : stine formation ( rhinolith)
Pulmonary
Fb inhalation ~> respiratory obstruction
6- treatment
If the child is co operative : removal of it by forceps , hook , suction
If the child is not co operative :
Removal under ga with cuffed endotracheal intubation to avoid respiratory obstruction
Talk about oro antral fistula
(6)
1- def : fistula between oral cavity , maxillary antrum ( oro maxillary )
2- causes
•Traumatic
Surgical :
- dental extraction ( 2nd premolar , 1st molar )
- removal of dental , dentigerous cyst
- radical antrum operation
Accidental : penetrating injury
• inflammatory: maxillary osteomyelitis, sphilitic osteitis
• neoplactic : maxillary cancer eroding the aleveolar process
3- symptoms
* unilateral regurgitation of food , fluid
* unilateral nasal offensive discharge ( sinusits)
* discharge from fistula to mouth
4- signs
* fistula can be seen through oral cavity
*probe can pass from oral cavity to fistula ( not preferred)
5- investigations
CT : fistula , sinusitis
6- treatment
Recent case : ( first 24 h after dental extraction )
If fistula is small : heals spontaneously
If fistula is large : surgical closure ( buccal or platal flap )
Old case :
~ radical antrum operation to clean associated maxillary sinusitis
~ refreshning of fibrosed edge
~ surgical closure ( palatal or buccal flap)
Failed case : dental obturator
