Anatomy of Nose & Sinus

1. external nose

- Bony part : 2 nasal bone - Cartilaginous part a. upper lateral cartilage b. lower lateral cartilage (alar cartilage) c. septal cartilage d. accessory cartilage

-Keystone area

-Skeletal Anatomy

Tip support mechanism

Arterial Supply of Nose

-external nose blood supply

Arterial supply 1). External carotid a. - facial a. : angular br., alar br., septal br., external nasal br. 2). Internal carotid a. - ophthalmic a. : dorsal nasal br.

2. nasal septum

- 7 parts 1) the vomer (below) 2) perpendicular plate of the ethmoid bone (post) 3) quadriangular(septal) cartilage (ant) 4) nasal crest of maxillary & palatine bone 5) anterior nasal spine : formed by the midline fusion of the palatal processes of maxilla 6) membranous septum : memb. connecting columella to septal cartilage 7) columella : medial crura of the greater alar cartilage

3. lateral nasal wall

Turbinates: inferior, middle, superior, supreme Meatus: inferior, middle, superior Inferior meatus: Hasners valve Middle meatus: opening of frontal, ant. ethmoid, & maxillary sinus Superior meatus: post. ethmoid & sphenoid sinus

4. middle meatus

5. nasal ostium

6. nasal valve

Nasal valve: most resistant portion Upper lateral cartilage, septum, anterior part of inferior turbinate . Septal valve: soft tissue of middle turbinate and septum

7. Acoustic rhinometry Cross section

8. Artery of lateral nasal wall & septum

ICA: anterior and posterior ethmoid artery ECA: sphenopalatine artery- posterior superolateral / posterior inferolateral / anterior inferolateral a. / greater palatine a. / superior labial a. / septal branch

9. Blood Supply of Inf. Turbinate

9. Kiesselbachs area

10. Woodruffs plexus

11. Nerves of nose

Autonomic nerve Sympathetic nerve : vasoconstricture : noradrenaline(NA), neuropeptide Y(NPY), avian pancreaqtic

polypeptide(APP) Parasympathetic nerve : secretion, vvasodilatation : acetylcholine, vasoactive intestinal polypeptide(VIP), peptide histidine isoleucine(PHI),nitro oxide(NO) Sensory nerve trigeminal nerve (C V) : protective reflaex (sneezing, secretion, BP) : substance P, neuropeptide K, calcitonin gene-related peptide(CGRP)

olfactory nerve (C I)

12. paranasal sinus

13

Ostiomeatal Unit(OMU)

14. Development of Paranasal sinus

15. Possible Functions of Sinus Air conditioning Pressure damping Reduction of skull weight Heat insulation

Flotation of skull in water Increasing the olfactory area Mechanical rigidity Vocal resonance and diminution of auditory feedback

16. Lamella

2 5 1 4 3

1st lamella 2nd lamella 3rd lamella 4th lamella 5th lamella

Uncinate process Bulla Middle turbinate Superior turbinate Supreme turbinate

-17. Sphenoid sinus

-18. Optic Nerve & Internal Carotid Artery

Optic nerve

Internal
19. normal CT 1)lacrimal fossa and duct

carotid artey

20. endoscopic finding 1)inferior turbinate

2) middle turbinate -Paradoxical MT

3)uncinate process

4) Ethmoidal bulla

5) Superior turbinate

6) Double middle turbinate

7) Inferior turbinate polyp

8)septal perforation

Physiology of Nose & Sinus

1. Function of nose 1. Respiratory function

2.

Olfactory function

3.

Voice resonance

2. Respiratory function ?

Respiratory passage ( )

Control of inspired air

( ) Maximal distribution

Control of temperate & humidification Air cleaning & protection mucous blanket ciliary movement neural reflex : reflex apnea, sneezing

2. Respiration

Nasal air flow . . . Inspiratory flow: laminar flow Expiratory flow: turbulent flow Velocity of flow: central > lateral

3. Nasal resistance Disturbance of air flow in airway Nose : 50 % of total airway resistance Complex anatomy of nose, mucous seretion Nasal alae Nasal cavum Nasal valve : most resistant portion

4. Nasal resistance increase

Hyperventilation Supine position Cold air Alcohol Rhinitis except atropy Aspirin, diuretics, pill antihypertensive drug Sympathetic antagonist

4. Nasal resistance decreased Exercise Erect position Sympathomimetics Rebreathing Atrophic rhinitis PGE2

5. Nasal cycle Alternative increase or decrease of nasal resistance 80 % of normal adult, short cycle in children Blood volume change of capacitance vessel Controlled by autonomic nerve system

Insensible 0.5 - 3 hours/cycle Allergy, infection, exercise, hormone, pregnancy, emotion, posture

6. Nasal Blood Vessel Resistant vessels (arterioles, precapillary spincter) : control of blood flow to nasal mucosa Exchange(nutrient) vessels (capillary bed, AV anastmosis) : filtration and absorption of fluid Capacitance vessels (AV anastmosis, vein, venous sinusoid) : determines nasal patency by tones of vessels : nasal cycle

7. Paradoxical nasal obstruction Septal deviation Nasal obstruction in concave site Adaptation of convex site Increased resistance in concave site by nasal cycle nasal obstruction in concave site

8. Rhinomanometry (nasal resistance)

9. Acoustic rhinometry (Cross section)

10. Control of temperature & humidification Temperature : 35 0C Humidity : 95% saturation in inspired air 100% in expiration capillary and submucous gland

11. Composition of secretion Mucous mucin Serous lysozyme(LZ), lactoferrin(LF) secretory leukocyte protease inhibitor, s-Ig A, albumin

12. Mucociliary transport

13.

14. Nasal secretion transport

14. Abnormality of cilia

15.

Structure 200 / cell Length : 6 7 m, Diameter : 0.2- 0.3 m Deeper into mucus layer < 0.5 m Axoneme : the structure of a cilium mainly composed of microtubules (9+2 or 9 + 2 structures) surrounded with cell membrane 9+2 VS 9+0

Inner microtubule : direction Inner arm : bending form Outer arm : frequency

16. 17.

Functions of cilia Clearing mucus and debris from airway

Circulate spinal fluid in the ventricle of the brain

Contribute to the movement of the ovum in the fallopian tube

Control left-right asymmetry in embryonic node

Primary ciliary disease Cilia beat frequency : 5 -20 Hz

Primary ciliary dyskinesia (PCD) Cilia microstructure defect Cilia with decreased or total absence of motility Sinusitis, chronic bronchitis, bronchiectasis, and male infertility

Katargener syndrome PCD + Sinus inversus

18. Cilia beat Effective phase maximum velocity : 1 mm/s maximum arc : 110 2-3 X faster than recovery stroke

Resting phase

Recovery phase close to the cell surface clockwise sweep from above

CBF increase : all phase are shortened (especially resting phase)

19. Factors affecting CBF

Increase Purinergic receptor agonist adrenergic receptor antagonist prostaglandin E1, E2, F2a

Decrease Purinergic receptor antagonist Local anesthesia (lidocane) Temperatue (< 5 0C, > 40 0C) Histamine acetylcholine, methacholine topical steroid

20. Olfaction

Cribriform plate , septum, middle & sup. Turbinate

21. Olfactory epithelium PCCE Cribriform plate , septum, middle & sup. turbinate 9+2 dynein arm . Bowmans glands in lamina propria

Bipolar cell, microvilli, supporoting cell, basal cells