WELCOME TO RHINOLOGY

1. WELCOME TO RHINOLOGY Dr.Fahad AlFawwaz

2. The nasal cavities The nasal cavities are separated: from each other by a midline nasal septum; from the oral cavity below by the hard palate; from the cranial cavity above by parts of the frontal, ethmoid, and sphenoid bones. Lateral to the nasal cavities are the orbits Each nasal cavity has a floor, roof, medial wall, and lateral wall

3. The anterior apertures of the nasal cavities are the nares, which open onto the inferior surface of the nose. The posterior apertures are the choanae, which open into the nasopharynx.

4. Regions Each nasal cavity consists of three general regions the nasal vestibule is a small dilated space just internal to the naris that is lined by skin and contains hair follicles; the respiratory region is the largest part of the nasal cavity, has a rich neurovascular supply, and is lined by respiratory epithelium composed mainly of ciliated and mucous cells; the olfactory region is small, is at the apex of each nasal cavity, is lined by olfactory epithelium, and contains the olfactory receptors. In addition to housing receptors for the sense of smell (olfaction), the nasal cavities adjust the temperature and humidity of respired air, and trap and remove particulate matter from the airway.

5. Ethmiod bone Ethmoid bone The single ethmoid bone is one of the most complex bones in the skull. It contributes to the roof, lateral wall, and medial wall of both nasal cavities, and contains the ethmoidal cells (ethmoidal sinuses).

6. Walls, floor, and roof Medial wall The medial wall of each nasal cavity is the mucosa-covered surface of the thin nasal septum, which is oriented vertically in the median sagittal plane and separates the right and left nasal cavities from each other.

7. Septum include the Nasal bones Vomer Frontal bone Palatine bone Maxilla and premaxilla Perpendicular plate of the ethmoid Quadrilateral cartilage Nasal septum

8. Nasal septum Significance: functional and aesthetic : Main support of the external nose Divides the nose into two cavities Supports the mucosal lining

9. Floor The floor of each nasal cavity is smooth, concave, and much wider than the roof. It consists of: soft tissues of the external nose; the upper surface of the palatine process of the maxilla, and the horizontal plate of the palatine bone, which together form the hard palate. The naris opens anteriorly into the floor.

10. Roof The roof of the nasal cavity is narrow and is highest in central regions where it is formed by the cribriform plate of the ethmoid bone

11. Nares Nares The nares are oval apertures on the inferior aspect of the external nose and are the anterior openings of the nasal cavitie They are held open by the surrounding alar cartilages and septal cartilage, and by the inferior nasal spine and adjacent margins of the maxillae. Although the nares are continuously open, they can be widened further by the action of the related muscles of facial expression (nasalis muscle, depressor septi nasi, and levator labii superioris.

12. Turbinates

14. Turbinates Thin bone covered by an adherent mucoperiosteum The turbinates Maximize surface area Rapidly humidify Warm the inspired air

15. Epithelium Anteriorly (Skin) Stratified squamous epithelium All other surfaces : Pseudostratified ciliated columnar (respiratory epi) Muocsa secretes ? Mucous blanket Cleaning Filtering (traps bacteria) Maintain the moisture nose

16. Physiology Respiration ( nasal cycle 1-3 hrs) Air conditioning of inspired air Filtration Temperature control Humidification Protection of lower airway Mucociliary mechanism Enzymes and immunoglobulins sneezing

17. Physiology Vocal resonance (M,N,NG) Nasal reflex functions Smell of food secretion of saliva and gastric juice Irritation of mucosa sneezing Olfaction

18. Anatomy of sinuses 4 paired paranasal sinuses Maxillary, Ethmoid, Frontal and Sphenoid “Anterior” and “posterior” sinuses

19. Maxillary Sinus The largest sinus The infraorbital nerve runs along roof

20. Maxillary sinus

21. Frontal sinus ????????? ????????? ????????? ??????????? ???????? ??????????? , ????? ??????????? ?????? ?????? ??????? ????????? ????????? ????????? ??????????? ???????? ??????????? , ????? ??????????? ?????? ?????? ???????

23. Sphenoid sinus ???? ????????? ????? ?????????? ????? ?????? ??????????? ?????????? ????? ???????????? ???????????? ?????? ???????? ?????? ????????? ?????? ????????? . ???? ????????? ????? ?????????? ????? ?????? ??????????? ?????????? ????? ???????????? ???????????? ?????? ???????? ?????? ????????? ?????? ????????? .

24. Sphenoid Sinuses Superiorly Optic nerve Posteriorly Pons Lateraly Cavernous sinus CNIII, IV and VI Carotid artery (Dehiscent in 50% )

26. Examination

29. Investigation

31. A through I, Coronal computed tomography (CT) of paranasal sinus anatomy and thin-section coronal CT images of a cadaver. The anterior osteomeatal unit is shown in images F through H. The frontal recess (small curved lines), the middle meatus (dashed lines), the infundibulum (small arrows), and the primary ostium of the maxillary sinus (large white arrows) are seen. F, Frontal sinus; A, agger nasi cell; b, ethmoid bulla; M, maxillary sinus; black arrow, the basal lamella; S, sphenoid sinus; 1, inferior turbinate; 2, middle turbinate; 3, superior turbinate. (From Som PM, Curtin HD: Head and neck imaging, ed 3, St Louis, 1996, Mosby.)A through I, Coronal computed tomography (CT) of paranasal sinus anatomy and thin-section coronal CT images of a cadaver. The anterior osteomeatal unit is shown in images F through H. The frontal recess (small curved lines), the middle meatus (dashed lines), the infundibulum (small arrows), and the primary ostium of the maxillary sinus (large white arrows) are seen. F, Frontal sinus; A, agger nasi cell; b, ethmoid bulla; M, maxillary sinus; black arrow, the basal lamella; S, sphenoid sinus; 1, inferior turbinate; 2, middle turbinate; 3, superior turbinate. (From Som PM, Curtin HD: Head and neck imaging, ed 3, St Louis, 1996, Mosby.)

34. NASAL SEPTUM AND ITS DISEASES

35. Nasal Fractures Fractures of nasal bones are the most common because of the projection of nose on the face Types : Depressed : d/2 frontal blow Angulated : d/2 lateral blow

39. Associated injuries Dislocated or fractured nasal septum Septal haematoma Epistaxis

40. Clinical Features Swelling of nose : appears within few hours and may obscure details of examination Periorbital ecchymosis Tenderness Nasal deformity Crepitus and mobility of fractured fragments Nasal obstruction Lacerations of the nasal skin

41. Diagnosis Diagnosis is best made on physical examination X-rays : may or may not show fracture

42. Treatment No treatment Closed reduction : Walsham or Asche's forceps Open reduction Septorhinoplasty

43. DEVIATED NASAL SEPTUM (DNS) Aetiology : Trauma Developmental error Racial factors : Caucasians are affected more than Negroes Hereditary factors : Several members of the same family may have deviated nasal septum

44. Types of DNS

48. Clinical Features Nasal obstruction Epistaxis Sinusitis External deformity

49. Treatment Minor degrees of septal deviation with no symptoms are commonly seen in patients and require no treatment Septoplasty

50. Septal Hematoma It is collection of blood under the perichondrium or periosteum of the nasal septum It often results from nasal trauma or septal surgery In bleeding disorders, it may occur spontaneously

52. Treatment Small haematomas can be aspirated with a wide bore sterile needle Larger haematomas are incised and drained Systemic antibiotics should be given, to prevent septal abscess and necrosis of the cartilage

54. Septal Abscess Mostly, it results from secondary infection of septal haematoma It may follows furuncle of the nose or upper lip

55. Furunculosis 55 y male Fever Headache L.O.C. Died

56. Venous Drainage Valve-less To Cavernous sinus Bermuda triangle

58. Epistaxis

59. Epistaxis 10% of the population experience an episode of epistaxis each year 10% of those will see a physician 1% of those seeking medical care will need a specialist

60. Why bleeding from the nose ? Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa Arterial to venous anastamoses ICA and ECA blood flow

62. Thanks