R.

ISMA NURUL AINI

SUPERVISOR : dr Arif Dermawan, M Kes Sp THTKL (K)

Dept of Otorhinolaryngology Head and Neck Surgery

Hasan Sadikin General Hospital
Bandung
2015

Embriology

Leung RM, Walsh WE, Kern RC : Bailey Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

Growth of paranasal
sinus

Leung RM, Walsh WE, Kern RC : Bailey Head & Neck Surgery Otolaryngology, 5th ed, .

External
Structure

Mucosa
Mucous
blanket

Internal
Structure

NOSE

- Upper airway
- Lateral wall
- Nasal septum
- Paranasal sinuses

Nervous
system

Blood
supply

External Structures

Osseus Structures Of
Lateral Nasal Wall
Frontal bone

Ethmoid bone

Maxilla bone

Lacrimal bone

Bony part of the

inferior turbinate

Sphenoid bone

Palatine bone

Nasal Septum
Frontal bone
Frontal sinus
Nasal bone
Perpendicular plate
of the ethmoid
Septal cartilage
Greater ala cartilage

Crista galli
Cribriform plate
Sphenoid sinus
Sphenoid bone
Medial & lateral plates
of pterygoid process

Vomeronasal
of cartilage
Crest of maxilla
Incisive canal
Palatine process
of maxilla

Vomer
Crest of palatine bone
Palatine bone

Internal Structures
Sphenoethmoidal
Recess

Frontal Sinus

Sphenoid Sinus
Middle Turbinate

3
2

Inferior Turbinate

Vestibulum

Supreme Turbinate

5
6

Superior Turbinate
Eustachian Tube
Orifice

Endoscopic View

2
1

3 4

6
7

7
9

Sagital View of the

Lateral Nasal Wall
Frontal Sinus

Sphenoethmoidal
recess

Superior turbinate
(cut edge)

Sphenoid sinus
ostium

Middle turbinate
(cut edge)
Frontal recess

Sphenoid sinus
Superior meatus

Uncinate process

Posterior Ethmoid
sinus ostium

Middle meatus
Inferior turbinate
(cut edge)

Eustachiantube
orifice

vestibule

Sphenopalatine
foramen

Nasolacrimal
duct orifice
Inferior meatus

Maxillary sinus
ostium

Hiatus semilunar

10

Coronal Section

11

Anterior Rhinoscopy
Olfactory cleft
1

Middle turbinate
Middle meatus

Inferior turbinate
Inferior meatus

1. From the posterior ethmoid sinus & sphenoid sinus to the superior meatus
2. From the frontal sinus & anterior ethmoid sinus to the middle meatus
3. From maxillary sinus & anterior ethmoid sinus to the middle meatus
12

Posterior Rhinoscopy
Torus tubarius
1
2
3

Posterior edge
of choanae
Pharyngeal opening
of the auditory tube
Superior turbinate
Middle turbinate
Inferior turbinate
Uvula

1.From the sphenoid sinus to the olfactory clefts

2.From the posterior ethmoid sinus to the superior meatus
3.From the frontal sinus, anterior ethmoid sinus and maxillary sinus to the middle meatus
13

Nasal Mucosa
Columnar epithelium cilia
Globular cells mucus
Acellular basement membrane
barrier
Submucosa
collagenous fibriles
Glands

14

Blood Supply of the

Turbinate
Sub epithelial capilaries

Glandular capilar
Sinusoids
Venous plexus
Muscle bundles
Arteriole
Venule
15

Autonomic Nervous
System of the Nasal
Mucous Membrane
8

1
3

14
12

13

11

10

1.Sensory nucleus of trigeminal nerve

2.Maxillary nerve
3.Superior salivary nucleus
4.Greater petrosal nerve
5.Nerve of the pterygoid canal
6.Pterygo palatine ganglion
7.Post nasal nerve

8.Nasal gland
9.Arteri & vein
10.Thoracolumbar region of the spinal cord
11.Superior cervical ganglion
12.Periarterial plexus on the carotid
13.Carotid artery
14.Deep petrosal nerve

16

Paranasal Sinuses
Four sets of air filled cavities
maxillary, etmoid, sphenoid,
frontal
Steril normal under condition
Sinusitis is inflammation or
infection of the mucosa of the
nasal passage and at least
one of the paranasal sinuses

17

Nose and Paranasal

Sinuses
Frontal sinus

Superior turbinate

Ethmoid sinus
Orbit

Superior meatus
Maxillary sinus
ostium

Middle turbinates

Maxillary sinus

Middle meatus
Anatomical Variants
- Agger nasi cells
- Haller cells
- Onodi cells
- Concha bullosa

Inferior turbinate
Septum
18

Anatomical Variants
of the Nose

19

Sinus Ethmoidales
Central structures
Sinus Etmoidales
anterior, posteror
lateral medial walls
of the orbits.
Posterior Sphenoid
Superior surface
Skull base (anterior
cranial fossa, the lateral
nasal wall, derived from
basal lamellas, extend
posteroinferiorly from
the skull base )
Leung RM, Walsh WE, Kern RC : Bailey Head &
Neck Surgery Otolaryngology, 5th ed, .
Lippincott Williams & Wilkins, 2014

20

Sinus Maksilaris
The largest
Anterior wall facial
surface
Posterior wall
ptetygopalatine fossa.
Medial wall lateral
wall nasal cavity
Tthe floor alveolar
process,
Superior wall orbital
floor n infraorbitalis
Leung RM, Walsh WE, Kern RC : Bailey Head & Neck Surgery Otolaryngology, 5th ed, .

21

14% of cases infraorbital nerve is dehiscent risk

during endoscopic sinus surgery.

2% of cases The first and second molar tooth roots

dehiscent an oroantral fistula following dental

extraction at these sites.

15% - 40% of subjects Accessory maxillary sinus ostia

superior and posterior to the uncinate process above

the insertion of the inferior turbinat.

A Haller cell, or ethmoidal cell may be present impair

sinus drainage

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

22

Sinus Frontalis
Completely absent (5%)
The floor of the sinus
as the supraorbital
roof,
Drainage pathway is
located in the
posteromedial portion of
the sinus floor.
Ager nasi present
Leung RM, Walsh WE, Kern RC : Bailey Head & Neck Surgery Otolaryngology, 5th ed, .
Lippincott Williams & Wilkins, 2014

23

Sinus Sphenoid
Neurovascular relationships :
Internal carotid artery
lateral sphenoid sinus
An optic nerve
ostium
sphenoethmoidal recess.
Onodi Cell may be present

Leung RM, Walsh WE, Kern RC : Bailey Head & Neck Surgery Otolaryngology, 5th ed, .
Lippincott Williams & Wilkins, 2014

24

Ostiomeatal Complex
(OMC)

- Processus Uncinatus
- Maxillary Ostium
- Middle Turbinate
- Bulla Ethmoid
- Ethmoid Infundibulum

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

25

Physiology

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

26

Functions of the Nose

1. Respiratory airway
2. Conditioning air - temperature and
3. Humidity control
4. Filtration inspired air cilliary action
5. Olfaction
6. Vocal resonance
7. Nasal reflex

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

27

Function of the
1. Humidification and warming
of inspired air
Paranasal
Sinuses
2. To lighten the weight of the skull
3. Improving vocal resonance
4. Absorption of shock to the face or skull
5. Increasing the area of the olfactory membrane
6. Regulation of intranasal pressure
7. Secretion of mucous to keep the nasal chambers moist
Multiple theories exist about the possible functional significance of the paranasal sinuses.
However, all of these theories are not fully proven. As yet, the real functional significance
of the paranasal sinuses is unknown.

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

28

1. Respiratory
Diameter cross sectional anterior nares < posterior choana
different inspiratory air currents
Across superior turbinate and middle turbinate
Anterior nares, smooth anterior ends & surface turbinates
minimal resistent inspiration
Cartilaginous framework nasal alae prevent colapse
Negatif pressure inspiration :
- 6 mmH2O (max 200mmH2O)
Expiration airway similar

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

29

Main Nasal Airway

Stippled area: Olfactory region
Horizontal area: Meatus
septum

MT

Clear area: Inspired air passes

IT

30

Dynamic Airflow
during Inspiration

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

31

Dynamic Airflow
during Expiration

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott

32

Total Airway
Resistance

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott

33

Air Conditioning
Heating
Heating

Vascular
Vascularnasal
nasalmucosa
mucosa
Radiating
Radiatingsurface
surfacelateral
lateralnasal
nasalwall
wall
0
0
Air
Airinspiration
inspirationheated
heated25
250
37
370

Humidification
Humidification

Transudation
Transudationfluid
fluidmucosa
mucosanasal
nasal
Secretion
Secretionglands
glands&&goblet
gobletcells
cells
Parasympatic
Parasympatic
secretomotor
secretomotor&&vasodilator
vasodilator
Air
Airsaturated
saturated75%
75%95%
95%(Nose
(Nosealone)
alone)

34

Humidification of
Inspired Air
1.
1.
2.
2.

Water
Watercontent
contentof
ofambient
ambientair
air
Recovery
Recoveryfrom
fromexpired
expiredair
air

3.
3.
4.
4.

Lacrimation
Lacrimationvia
viathe
thenasolacrimal
nasolacrimalduct
duct
Secretion
Secretionfrom
fromthe
theparanasal
paranasalsinuses
sinuses

5.
5.
6.
6.

Salivation
Salivation
Secretions
Secretionsof
ofthe
thegoblet
gobletcells
cellsand
andseromucinous
seromucinousglands
glandsof
of
the
thenasal
nasaland
andparanasal
paranasalsinus
sinusmucosa
mucosa

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott

35

Warming of Inspired Air

during Nasal Breathing

36

Warming of Inspired Air

during Mouth Breathing

37

2. Olfaction
Olfactory center
Primary olfactory
neurons

Secondary
olfactory
neurons

Olfactory
epithelium

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

38

Olfactory Mucosa
Bowmans gland
Basement membrane

Lamina propria

Horizontal basal cell

Globose basal cell

Olfactory receptor cell

Olfactory
epithelium

Supporting cell
Dendritic knob

Mucus layer

Olfactory cilia

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

39

3. Protection

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

40

Ciliary Movement and

Frequency ciliary beatBlanket
10-20 Hz
Mucous
100x/minute

2 layer mucous blanket

Gel layer : relative viscous
fluid
Sol layer : serous fluid
Effective stroke gel layer
Recovery stroke sol layer

Disturb ciliary function

1. Large change temperature
<100 or >450 (N: 280-300)
2. pH (N: 6.4 - 8.5)
3. Infection
4. Solution <0.2% or >4%

Leung RM, Walsh WE, Kern RC : Head &

Neck Surgery Otolaryngology, 5th ed, .

41

42

Ciliary Movement and

Mucous Blanket

Mucous
Mucousblanket
blanket
protective
protectivefunction
function
Filtered
Filteredinspired
inspiredair
air
Mechanisms
Mechanisms

Impaction
Impactionparticles
particleson
onsurface
surfacemucous
mucousmembrane
membrane
Two
Twoconstituents
constituentsmucous
mucousblanket
blanket

Muramidase
Muramidaseor
orlysozyme
lysozyme

Immunoglobulin
Immunoglobulinor
orsecretory
secretoryimmunoglobulin
immunoglobulin
Three
Threecilliary
cilliarystreams
streams
1.1.Superior
Superiormeatus
meatus
2.2.Sphenoid
Sphenoidsinus
sinus
3.3.Middle
Middleturbinate
turbinate
Anterior
Anteriorpharyngeal
pharyngealostium
ostiumtorus
torustubarius
tubarius

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

43

Mucocilliary Transport
Non-ciliary area

10 mm per hour

1-2 mm per hour

Remove particle
> 15

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott
Williams & Wilkins, 2014

44

Other functions :
Vocal Resonance
Another
Anotherfunction
functionof
ofthe
thenose
nose
Quality
Qualityof
ofthe
thevoice
voice
normal
normalnasal
nasalresonance
resonance
Nasal
Nasalconsonants
consonantsM,
M,N,
N,NG
NG
--Vibrating
Vibratingair
aircolumn
columnlarynx
larynxnose
nose
Change
Changewith
withnasal
nasalobstruction,
obstruction,cleft
cleftpalate
palate

45

Other Functions :
Nasal
Reflex
Two
primary
Two primarygroups
groups
--Olfactory
Olfactoryarea
area
--Trigeminal
Trigeminalarea
area(CN
(CNV)
V)

Olfactory
Olfactorygroup
groupreflexes
reflexesrelated
relateddigestive
digestiveactions
actions
(Salivary,
(Salivary,gastric,
gastric,pancreatic
pancreaticglands)
glands)
Trigeminal
Trigeminalnerve
nervereflexes
reflexes
--Musculature
Musculaturelarynx
larynx&&bronchial
bronchial
--Heart
Heartrate
rate
--Pulmonary
Pulmonaryventilation
ventilation
--Reflex
Reflexsneezing
sneezing

46

SUMMARY
Sinonasal
Sinonasalembryology
embryologycan
canbe
bedivided
dividedinto
into
two
twoongoing
ongoingproces
proces
The
Theethmoidal,
ethmoidal,maxillary,
maxillary,sphenoid,
sphenoid,and
andfrontal
frontal
sinuses
sinusesmake
makeup
upthe
theparanasal
paranasalsinuses
sinuses
The
Thethree
threemajor
majorfungtions
fungtionsof
ofthe
thenose
noseare
arerespiratory
respiratory
olfaction
olfactionand
andprotection
protection
Understanding
Understandinganatomy
anatomynasal
nasalstructure
structure&&functions
functions
important
importantunderstanding
understandingthe
thepathophysiology
pathophysiologyof
of
nasal
nasaldiseases
diseases
47

48