Download Naso-orbital Ethmoid and Frontal Sinus Fractures

THE NOSE AND
PARANASAL SINUSES
Dr. Mohamad S. Aziz
Otolaryngologist
CABMS (ORL-HNS)
ENT Dept, College of Medicine, University of Mosul
Undergraduate, The Nose, 2016/2017
The external nose is supported by
bone and cartilage. The bony part is
formed mainly by the nasal bones and by
the frontal process of the maxillary bone.
The cartilaginous portion is formed by
several cartilages which support and give
shape to the lower part of the nose.
Is the midline partition of the nasal cavity. It is
formed by:
Anteriorly  quadrilateral cartilage.
Posterosuperiorly  perpendicular plate of ethmoid.
Posteroinferiorly  vomer.
The nasal septum
The nasal septum
Is the entrance of the nasal cavity lined by hairbearing squamous epithelium which ends at the
mucocutaneous junction at which the nasal cavity
begins. This hair is called the vibrissae.
Are two irregular cavities
extending from the vestibule (anterior nares)
to the nasopharynx (posterior nares or choanae)
. The nasal cavity has its axis at right angle to the
face. The lining of the cavity is mainly
pseudostratified ciliated columnar epithelium
(respiratory type).
Floor: maxilla and palatine bones.
Roof: Nasal bones, cribriform plate of ethmoid and
sphenoid bone.
Medially: nasal septum.
Laterally: there is a system of ridges (turbinates or
conchae), each of which overhangs a groove
(meatus). The turbinate is formed from erectile
tissue covered by a mucous membrane.
The turbinates are three in number.
The superior and middle turbinates
are part of the ethmoid bone, while
the inferior turbinate is a separate
bone.
The lateral nasal wall
1. Inferior meatus:
nasolacrimal duct
2. Middle meatus:
• Maxillary sinus
• Frontal sinus
• Anterior ethmoid
3. Superior meatus:
posterior ethmoid
4. Sphenoethmoidal
recess: sphenoid
sinus
Sagital section
1. Sphenopalatine artery (maxillary).
2. Greater palatine artery (maxillary).
3. Superior labial artery (facial).
(External carotid artery)
4. Anterior ethmoidal artery (ophthalmic artery)
5. Posterior ethmoidal artery (ophthalmic artery) (Internal
carotid artery)
These vessels anatomse forming Kiesselbach’s plexus in
Little’s area.
Facial + ophthalmic vein  cavernous sinus.
Submandibular, retropharyngeal and deep cervical
chain.
1. Sensory: ophthalmic (anterior ethmoid) and
maxillary (sphenopalatine) nerve.
2. Secretory: Vidian nerve (nerve of pterygoid canal)
which is formed by the junction of the greater
petrosal nerve, a branch of the facial nerve
(parasympathetic) and the deep petrosal nerve
(sympathetic) derived from the sympathetic plexus
on the internal carotid artery .
- Greater petrosal nerve (parasymp.)  Dilates blood
vessels + enhance glandular secretion.
- Deep petrosal nerve (symp.)  constricts blood
vessels.
3. Olfactory: The olfactory epithelium which is
yellowish in colour occupies the cribriform plate, the
upper one third of lateral nasal wall (up to superior
turbinate) and corresponding part of nasal septum.
The oflactory nerves (18-20) on each side  pass
through the cribriform plate to synapse in the
oflactroy bulb. Injury to these nerves can open CSF
space leading to CSF rhinorrhea or meningitis.
Are air filled cavities located inside the facial bones,
lined by an evagination of the mucous membrane of the nose
and have communication with the nasal cavity.
Ant. Group Frontal.
Maxillary (Middle meatus)
Anterior ethmoidal

Post Group
Posterior ethmoidal (Superior Meatus)
Sphenoid (Sphenoethmoidal recess)
This sinus is pyramidal in shape with base
towards lateral wall of nose and apex directed
laterally into the zygoma. Its roof is the floor of
the orbit and its floor lies over the 1st premolar –
3rd molar teeth.
The ostium of the sinus is situated high in the
medial wall (1 cm) and hence drainage is
dependent on ciliary action and not gravity.
The sinus is not present at birth but appear at
the age of 5 years. The sinus is frontal in location
ethmoidal in origin. The frontal sinuses are rarely
symmetrical and they are separated by a thin
bone. The roof of the orbit forms the floor of the
frontal sinus.
The ethmoid bone is made up of five parts; the
perpendicular plate, the horizontal cribriform
plate, the crista galli and two lateral labyrinths of
cells suspended by the horizontal plate.
The ethmoidal sinuses are multiple air cells (7-15)
in number and divided into anterior and posterior
groups which drain respectively into middle and
superior meati. They are separated from the orbit by
a thin plate of bone known as lamina papyracea.
This sinus occupies the body of the sphenoid
bone and drains into the sphenoethmoidal recess.
The pituitary gland is located on its roof whereas
the lateral wall is in contact with the cavernous
sinus and its contents (internal carotid artery, and
II, III, IV, V and VI cranial nerves). The Vidian
nerve passes below this sinus.
1. Olfaction.
2. Respiration
a. Provide an airway for respiration.
b. Filtration of air.
c. Humidification and warming of the inspired air.
3.Vocal resonance.
4. Collect moisture from the expired air to prevent
excessive loss.
5. The mucus is transported by the action of the cilia and
contains antibodies which act as a defense mechanism
olfaction
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Particles
Dissolved in mucous
Carried to olfactory
mucosa [Nerve endings]
Olfactory bulb
Olfactory nucleus,
hypothalamus &
thalamus
1. Air conditioning of the inspired air.
2. Reduce the weight of the skull (shock absorber).
3. Vocal resonance.
4. Thermal insulation of the skull base.
Nasal Cycle
Nasal mucosa undergoes rhythmic cyclical
congestion and decongestion, thus controlling the
airflow through nasal chambers. Nasal cycle varies
every 2-4 hours.

I. Nasal obstruction:
Anatomical abnormality: Congenital choanal atresia or
deviated nasal septum.
Abnormality of the mucous membrane: Nasal polyposis
or turbinate hypertrophy.
Abnormalities of autonomic control of the mucosa:
Vasomotor rhinitis.
Symptomatology: Bilateral Obstruction Nasal
1- Congenital
Bil. Choanal atresia
2- Traumatic
Foreign body
Accident: Fracture- Haematoma
Iatrogenic: Pack-Haematoma
3- Inflammatory
Acute nonspecific: Common cold-Abscess
Acute specific: Diphtheria
Chronic nonspecific: At. - Hypertrophic
Chronic specific: $ – T.B. - Scleroma
4- Neoplastic
Benign: Ostioma -papilloma
Malignant: Carcinoma - Sarcoma
Allergy
Polyps
5- Others
Deviated septum
II. Nasal Discharge:
-Watery clear discharge: Onset of common cold,
allergic rhinitis or CSF rhinorrhea.
-Mucopurulent:
Yellow pus: Sinusitis.
Unilateral foul discharge in a child: FB in the nose.
Crusts in adults: Atrophic rhinitis.
-Thick blood stained discharge: Tumour.
-Postnasal mucopurulent discharge: Disease of the
posterior group of sinuses.
III. Sneezing: Allergic rhinitis or common cold.
IV. Pain:
Severe local pain: Folliculitis.
Early morning headache: Sinusitis.
V. Epistaxis.
VI. Disturbance of smell:
1. Anosmia and hyposmia: Complete or partial loss of the
sense of smell. It is often described as loss of taste as
flavours are largely perceived through the olfactory
apparatus. The causes are:
-Nasal obstruction from common cold or nasal polyposis.
-Vasomotor rhinitis.
-Peripheral neuritis particularly following influenza virus.
-Atrophic rhinitis.
-Trauma: Base of skull fracture involving the cribriform
plate.
2. Cacosmia: The perception of a bad smell. The
causes are:
-Maxillary sinusitis.
-Foreign body in the nose.
-Chronic suppurative otitis media. Pus discharge through
Eustachian tube.
3. Parosmia: The perversion of the sense of smell
or subjective sensation of non-existing odours.
Causes:
Functional.
Organic.
-Influenzal neuritis.
-Epileptic aura.
-Drugs: Streptomycin.
Investigations: Differential diagnosis
Endoscopy
CT
Endoscopic Nasal Examination
Nasal
Septum
Inferior
Turbinate
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