Made By : Dr. Priyanjal Gautam P.G. 1st Yr.

(ENT)

Development of Nose
Face develops from 5 projections :

Frontonasal process (ectoderm over forebrain) + 2 Maxillary processes + 2 Mandibular processes (1starch)
An ectodermal olfactory placode divides frontonasal

process, which give rise to external nasal skeleton.

Olfactory placode deepens into olfactory pit & later

olfactory sac which forms nasal cavities.

Nasal septum develops from mesodermal tectoseptal

expansion from Rathkes pouch.

Development of nasal sac, nasal cavity & primitive palate

6 wk. embryo showing Development of palatal process

DEVELOPMENT OF NASAL PIT & NASOLACRIMAL FURROW

DEVELOPMENT OF NASOLACRIMAL GROOVE & NASAL PIT

DEVELOPMENT OF PARANASAL SINUSES

PNS develop as outpouchings from the mucous

membrane of lateral wall of nose.

At birth only maxillary & ethmoid sinuses are present. Growth of sinuses continues during childhood & early

adult life.
Radiologically maxillary sinuses can be identified at

4-5 months, ethmoids at 1 yr. , frontals at 6yrs & sphenoids at 4yr. 0f life.

SINUSES

APPEARS FIRST

FIRST X-RAY APPEARANCE

REACH ADULT SIZE BY

MAXILLARY

AT BIRTH

4 MONTHS

15 YR.

ETHMOIDAL

AT BIRTH

1 YR.

12 YR.

SPHENOID

2 YR.

4 YR.

18 YR.

FRONTAL

4 YR.

6 YR.

15 YR.

DEVELOPMENT OF PARANASAL BONES

1. MAXILLA :

It arises during 6th & 7th wk. from 5 ossification centres. In the 4th wk. of Intra-uterine life (IUL) these fuse to form the alveolar, palatine, zygomatic & frontal processes & floor of the orbit. A further centre appears in the medial floor of the pyriform aperture, forming the pre-maxilla in which the upper incisor teeth develop. The pre-maxilla forms the Anterior nasal spine & fuses with the vomero-nasal cartilages laterally & septal cartilage superiorly.

2. ETHMOID BONE :
It ossifies in the cartilagenous nasal capsule from

3 centres : one for each labyrinth & 1 for the perpendicular plate.
The centres for the labyrinth are present from the

4th or 5th IUL so, they are partially ossified at birth.

The perpendicular plate & crista galli develop from 1

centre during the 1st yr. after birth & fuse with the labyrinths at the beginning of the 2nd yr.
Both this centre & those for the labyrinth contribute

to the cribriform plate.

3. FRONTAL BONE :
It ossifies in the membrane from 2 centres : 1 in each

superciliary ridge appearing in the 8th wk. of IUL.

At birth, the bone is composed of 2 halves seperated

by a frontal or metopic suture, which begin to fuse from the 2nd yr.
This usually complete by the 8th yr. , through may

persist in some races, such as the Japanese.

4. SPHENOID BONE :
The Sphenoid is divided into 2 parts : (a) Pre-sphenoidal (b) Post-sphenoidal

The Pre-sphenoidal portion anterior to the tuberculum sellae continuous with the lesser wings made up of 6 separate ossification centres.

The Post-sphenoidal part composed of the sella turcica & dorsum sellae associated with the greater wing & pterygoid peocesses derived from 8 centres.
The pre & post-sphenoidal parts of the body fuse around 8th wk. of IUL. At birth, the sphenoid bone consists of 3 pieces : a central portion consisting of the body & lesser wings and 2 lateral parts, each consisting of the greater wing & pterygoid process which begin to fuse at 1yr. after birth.

TURBINATES BONES :
They appears on the lateral wall of the nose from the

6th wk. of IUL which forms the turbinates.

The most inferior or maxilloturbinal forms the inferior

turbinate.
The middle, superior & supreme turbinates results

from reduction of the complex ethmo-turbinal system.

Primitive nasoturbinal is represented by the agger nasi

region & uncinate process.

ANATOMY OF NOSE
EXTERNAL NOSE :
It is pyramidal in shape

with its root upwards & base directed downwards.

Nasal pyramid consists of

osteo-cartilaginous framework covered by muscles & skin.

EXTERNAL

NOSE

OSTEO-CARTILAGINOUS FRAMEWORK OF NOSE

It consists of 2 parts :
(i) Bony part (Upper 1/3rd) (ii) Cartilaginous part

(Lower 2/3rd )

BONY PART :

It consists of 2 nasal bones which meet in the mid-line & rest on the upper part of the nasal process of the frontal bone & are held b/w the frontal processes of the maxillae.

CARTILAGINOUS PART :
It consists of : (i) Upper Lateral Cartilages (ii) Lower Lateral Cartilages (Alar Cartilages) (iii) Lesser Alar Cartilages (Sesamoid Cartilages) (iv) Septal Cartilage

UPPER LATERAL CARTILAGES

They extend from the under

surface of the nasal bones above, to the alar cartilages below.

They fuse with each other &

with the upper border of the septal cartilage in the midline anteriorly. lateral cartilage is seen intranasally as nasal valve/limen vestibuli on each side.

The lower free edge of upper

LOWER LATERAL CARTILAGES (ALAR CARTILAGES)

Each alar cartilage is U-shaped.
It has a lateral crus which forms the ala & a medial

crus which runs in the columella.

Lateral crus overlaps lower edge of upper lateral

cartliage on each side.

UPPER LATERAL CARTILAGES & ALAR CARTILAGES

LESSER ALAR CARTILAGES (SESAMOID CARTILAGES)

They are 2 in number. They lie above & lateral to alar cartilages.

Note :
The various cartilages are conneted with one another &

with the adjoining bones by perichondrium & periosteum.

Most of the free margin of nostril is formed by fibrofatty

tissue & not by the alar cartilage.

SEPTAL CARTILAGE :
Its anterosuperior border runs from under the nasal

bones to the nasal tip.

It supports the dorsum of cartilaginous part of the

nose.
In septal abscess or after excesssive removal of septal

cartilage as in SMR operation, support of the nasal dorsum is lost & a supratip depression results.

NASAL MUSCULATURE

NASAL MUSCULATURE
Osteo-cartilaginous framework of nose is covered by

muscles, which bring about movements of the nasal tip, ala & the overlying skin.
The muscles are :

1.
2. 3. 4. 5. 6.

Procerus Nasalis (Transverse & alar parts) Levator Labii Superioris Alaque Nasi Anterior Dilator Nares Posterior Dilator Nares Depressor Septi

NOSE

MUSCLES

NASAL SKIN
The skin over the nasal bones

& upper lateral cartilages is thin & freely mobile while that covering the alar cartilages is thick & adherent & contains many sebaceous glands.

INTERNAL NOSE :
It is divided into Rt. & Lt. nasal cavities by nasal septum. Each nasal cavity communicates with the exterior through

anterior naris or nostril & with the nasopharynx through posterior nasal aperture or the chonae
Each nasal cavity consists of :

(i) Vestibule (Lined by skin)

(ii) Nasal cavity proper (Lined by mucosa)

NASAL VESTIBULE :
Anterior & inferior part of nasal cavity is called the

vestibule.
It (i) (ii) (iii)

is lined by : Skincontaining sebaceous glands Hair follicles & Hair (vibrissae)

Its upper limit on the lateral wall is marked by nasal valve (limen nasi) which is formed by the caudal margin of upper lateral cartilage. Its medial wall is formed by the columella & lower part of the nasal septum upto its mucocutaneous junction.

LATERAL NASAL WALL :

It consists of 3-4 bony conchae covered with mucosa to

form turbinates.

From below upwards they are inferior, middle & superior.

Sometimes, a 4th turninate, concha suprema, is also present.

Space below & lateral to turbinate is called meatus.

Inferior meatus runs along the whole length of the lateral

wall.

Middle meatus contains a round bulla ethmoidalis

seperated from uncinate process by hiatus semilunaris that leads to a funnel shaped ethmoidal infundibulum.

MEDIAL WALL :
Nasal septum forms the medial wall. It consists of 3 parts :

1.

Columellar septum

2. Membranous septum 3. Septum proper

1. COLUMELLAR SEPTUM : It made up of columella

containing medial crura of alar cartilages united together by fibrous tissue & covered on either side by skin.

2. MEMBRANOUS SEPTUM:

It consists of double layer of skin with no bony or cartilagenous support. It lies b/w columella & caudal border of septal cartilage. Both columellar & membranous parts are freely movable from side to side.

3. SEPTUM PROPER
It consists of osteo-cartilaginous framework, covered with nasal mucous

membrane.

Its principal constituents are : (i) Perpendicular plate of Ethmoid (ii) Vomer (iii) Large septal cartilage (quadrilateral) wedged b/w the above 2 bones (i) (ii) (iii) (iv) (v) (vi)

Other bones which make minor contributions are : Crest of nasal bones Nasal spine of frontal bone Rostrum of sphenoid Crest of palatine bones Crest of maxilla & Anterior nasal spine of maxilla

 Septal cartilage forms a partition b/w Rt. & Lt. nasal cavities. It lies in a groove in the anterior edge of vomer & rests

anteriorly on anterior nasal spine.

It provides support to the tip & dorsum of cartilaginous part of

nose.
Destruction of septal cartilage (eg. Septal abscess, injuries,

tuberculosis or excessive removal of septal cartilage during septal surgery) leads to : (i) Depression of lower part of nose & (ii) Drooping of the nasal tip

During trauma, septal cartilage may get dislocated from anterior nasal spine or vomerine groove causing caudal septal deviation.

BLOOD SUPPLY OF NOSE

Nose is richly supplied by both the external & internal carotid

systems, both on the septum & the lateral walls.

NASAL SEPTUM
Internal Carotid System : (i) Anterior ethmoidal artery (ii) Posterior ethmoidal artery External Carotid System : (i) Sphenopalatine artery (branch of maxillary artery), gives nasopalatine & posterior nasal septal branches. (ii) Septal branch of greater palatine artery (branch of maxillary artery) (iii) Septal branch of superior labial artery (branch of facial artery)

Branches of ophthalmic artery

LATERAL WALL Internal Carotid System : (i) Anterior ethmoidal (ii) Posterior ethmoidal External Carotid System : (i) Posterior lateral nasal branches from sphenopalatine artery (ii) Greater palatine artery from maxillary artery (iii) Nasal branch of anterior superior dental from infraorbital branch of maxillary artery Branches of ophthalmic artery

(iv) Branches of facial artery to nasal vestibule

LITTLES AREA :
It is situated in the anterior inferior part of nasal septum, just above

the vestibule.

4 arteries anastomose here to form a vascular plexus called

Kiessel bachs plexus.

The 4 arteries which anastomose are :

1. Anterior ethmoidal 2. Septal branch of superior labial 3. Septal branch of sphenopalatine

4. Greater palatine

Littles area is the usual site for epistaxis in children & young adults.

NOSE BLOOD SUPPLY

VENOUS DRAINAGE OF NOSE

Ethmoidal veins drains into : Opthalmic veins &

Cavernous sinus
Sphenopalatine veins drains into : Pterygoid plexus

Maxillary vein
Woodruffs venous plexus : present on lateral wall of

nose near posterior end of middle turninate.

Retrocolumellar vein : runs vertically downwards just

behind the columella, crosses the floor of nose & joins venous plexus on lateral nasal wall. (common site of venous bleeding in young people)

SENSORY NERVE SUPPLY OF NOSE

Long & short nasopalatine nerves
Greater palatine nerve Infra-orbital nerve branches Anterior ethmoidal nerve Olfactory nerve

SENSORY NERVE SUPPLY OF NOSE

Long & short

nasopalatine nerves
Greater palatine nerve Infra-orbital nerve

branches
Anterior ethmoidal nerve

Olfactory nerve

MEATAL DRAINAGE
1. Inferior Meatus : Nasolacrimal duct (gaurded at its

end by a mucosal valve called Hasners valve)

2. Middle Meatus :

(a) Frontal sinus (b) Anterior ethmoid (c) Maxillary sinus (natural + accessory ostia)
3. Superior Meatus : Posterior ethmoid
4. Spheno-ethmoid recess : Sphenoid sinus

OSTEO-MEATAL COMPLEX (OMC)

It is a complex micro-architectural pathway in ethmois

labyrinth that drains anterior group of para nasal sinuses.

It (i) (ii) (iii) (iv) (v) (vi)

consists of : Frontal recess Ethmoid infundibulum Hiatus semilunaris Uncinate process Bulla ethmoidalis Middle meatus OMC pathology leads to infection of all anterior paranasal sinuses.

VARIANTS OF OMC
1. 2. 3. 4. 5. 6. 7. 8.

Concha bullosa (Pneumatized Middle Turbinate)

Paradoxically curved middle turbinate

Medially turned uncinate process Large bulla ethmoidalis Hallers cell in orbital floor Agger nasi cell anterior to middle turbinate Onodi cells with dehiscent optic nerve Mucosal pathology

OSTEO-MEATAL COMPLEX

NASAL ENDOSCOPY
Nasal endoscopy examination allows a thorough evaluation of intranasal anatomy & gross pathology of nose & paranasal sinuses which may not be assessable by anterior & posterior rhinoscopy.

PREPARATION :
Explain the procedure to the patient before doing

endoscopy. This helps the patient to relax & co-operate with the examiner.
A nasal speculum & head light/head mirror are used to

perform anterior rhinoscopy to see the condition of nasal mucosa, any secretions or ulcerations & spray topical decongestant & local anaesthetic.
While waiting for the medications to take effect, the

examiner can perform rest of the otolaryngologic examination as well as prepare the endoscope, light source, camera & ensure other needed equipment is ready.

EQUIPMENTS : Commonly used nasal endoscope is 4 mm, 0 & 30 degree rigid scope for adults and 2.7 mm, 0 & 30 degree Rigid/flexible scope for children.

POSITION :
Nasal endoscopy can be performed with patient either

in sitting or in supine position, depending on the preference of examiner & patient.

Note : The examiner should always use universal

precautions, such as gloves & mask when dealing with potential contact with secretions & blood.

TECHNIQUE :
Once the patient is properly positioned & equipment

is prepared, the endoscopy can be started.

All attempts are made to be as atraumatic as possible. This minimises patient discomfort & any bleeding that

could impair the examination.

The endoscope is held lightly in left hand using thumb

& 1st 2 fingers & is introduced under direct vision.

An organised nasal endoscopy can be accomplished in

3 passes.

Ist Pass :
It is done along the floor of the nose.

Sinonasal mucosa, changes with decongestion & anatomy of

sinonasal cavity is visualized.

Inferior meatus is the 1st area to inspect. If the inferior turbinate is lateralised or it is too narrow,

medialization of the inferior turbinate may be performed after application of additional topical anaesthetic.
After this, Freer elevator/cotton tip applicator can be used to

medialize the turbinate.

 Once adequate access is established, the examiner will

be able to see nasolacrimal duct. Tears can be seen after gentle pressure over the lacrimal sac. An inferior nasal antral window will allow visualization into the maxillary sinus if present.
After examination of inferior meatus, the endoscope is

advanced through the nasal cavity towards the nasopharynx.

The Eustachian tube orifices, torus tubaris, adenoid pad

(if present) & entire nasopharynx can be visualized by rotating the endoscope (30 degree).

 Secretions coming from the OMC drain below the

eustachian tube orifice & those coming from posterior ethmoid or sphenoid sinuses will pass above the torus tubaris.

The effect of palatal musculature on the eustachian

tube orifice can be visualized by telling the patient to swallow at this point of examination.

2nd Pass : The endoscope is reinserted b/w the inferior & middle turbinates .
While advancing the endoscope in a posterior direction, the

inferior portion of the middle turbinate, middle meatus, fontanelles & any accessory maxillary ostia are examined.
The sphenoethmoidal recess is visualized by passing the

endoscope medial to the posterior aspect of the middle turbinate & rotating it superiorly.
Often superior turbinate & natural sphenoid os can be

visualized.
Thorough examination of this area require multiple

applications of topical decongestants.

3rd Pass :
The final portion of the endoscopic examination

occurs withdrawing the endoscope.

The endoscope is rotated laterally beneath the

posterior aspect of the middle turbinate to gain access to deeper areas of the middle meatus.
Bulla ethmodalis, hiatus semilunaris & infundibular

entrance is seen.
As the endoscope is withdrawn even further, an

excellent view of uncinate process & its overlying mucosa is seen.

 Examination of the middle meatus is dependent upon

the anatomy & co-operation of patient.

Middle meatal examination can be performed from

anterior , typically after displacing the middle turbinate medially, which is achieved by applying topical anaesthesia on cotton both to the site where pressure will be applied to the turbinate as well as to its anterior attachment.
The turbinate is then gently displaced medially using a

Freer elevator.

THANK YOU
DR. S. P. SRIVASTAVA
DR. AMIT MODWAL DR. PRADEEP SHARMA DR. RAKESH SABOO DR. GURLEEN KAUR (P.G. Ist yr.)