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Bakhshaee M, MD

Rhinologist
Assistant Professor of Mashad University of Medical Sciences

Four sessions:

1.

Anatomy, Physiology, and Immunology of the Nose, Paranasal Sinuses, and


Face

2.

History and Clinical Examination of the Nose; Tumors of the External Nose
and Face

3.

Malformations and common disorders of the Nose, Paranasal Sinuses, and


Face

4.

Inflammations of the External Nose, Nasal Cavity, and Facial Soft Tissues

Estimated time for each session is 100 min

Including:
1.Initial assessment: 10 min
2.Lesson delivery: 60 min
3.Discussion: 15 min
4.Question and problems of previous

session: 10 min
5.A brief talking on next session: 5
min

Anatomy, Physiology, and Immunology of the Nose, Paranasal


Sinuses, and Face

Basic Anatomy of the Nose, Paranasal Sinuses, and Face

Morphology of the Nasal Mucosa

Basic Physiology and Immunology of the Nose

The

relaxed skin
tension lines (RSTLs):
Scars can be made less
conspicuous by taking
these tension lines into
account
The

aesthetic units of
the face:
an important
consideration in the
treatment larger softtissue defects

Knowing the various


components of the
bony facial
skeleton and their
relationship to one
another
is important in trauma
management and also
in
the diagnosis and
treatment o
inflammatory diseases
of the facial skeleton
and their
complications.

Nasal Vestibule
Nasal Septum
Nasal Valve
Lateral nasal Wall
Choana

Bony Structure:
1.Maxilla
2.Ethmoid
3.Palatine
4.Inferior Turbinate
5.Sphenoid

Functional apparatus:
1.Turbinate
2.Meatus
3.Sinus ostia
4.Nasolacrimal

orifice

duct

Roof:
1.Cribriform palate
2.Ethmoid fovea

Floor:
Hard palate
1.Maxilla (Ant)
2.Palatine (Pos)

Air-filled
cavities
that
communicate
with
the
nasal
cavities
All but the sphenoid
sinus are present as
outpunching
of
the
mucosa
during
embryonic
life,
but
except for the ethmoid
air cells, they do not
develop
into
bony
cavities until after birth.

Medial:
Lateral nasal
wall

Superior:
Orbital floor

Posterior:
Pterygopalatine
fossa

Inferior:
Alveolar ridge
( root of second
premolar and first
molar)

Medial:
Middle turbinate

Superior:
Fovea
ethmoidalis ( Ant
cranial fossa)

Posterior:
Sphenoid sinus

Lateral:
Lamina
papyruses ( orbit)

Inferior:
Nasopharynx

Superior:
Ant and middle
cranial fossa ,
Sellae tursica

Posterior:
Clivus and
posterior cranial
fossa

Lateral:
Optic nerve
Internal carotid
Cavernous sinus

Inferior:

Orbital roof
Posterior:

Anterior cranial fossa

Innervation

Muscular attachments

Mucus:
Squamous epithelium
Respiratory Mucosa
Olfactory Mucosa

Respiratory Mucosa:
1.Epithelium
2.Lamina Properia:
Venous erectile tissue
Nasal glands
Immunocompetent cells

Olfactory Mucosa:
primary olfactory center
( olfactory bulb)
secondary olfactory
center (olfactory cortex)
tertiary olfactory
centers (including the
hippocampus,
anterior insular region, and
reticular formation)

Nose is of major importance in conditioning


the air before it reaches the lower airways

Nasal Air Flow


Laminar vs Turbulent

Nasal Cycle
Regulate

by
autonomic nervous
system
80% of human each 2
hours

Humidification
Temperature
regulation

Nonspecific
Defense
Mechanisms
1.Mechanical

defenses
(mucociliary apparatus)
2. Nonspecific protective
factors (Interferon,
Proteases, Protease
inhibitors , Lysozyme
Antioxidants)
3.Cellular defenses
(phagocytic cells)

Specific Immune
Responses
1.Humoral

immune

response
2.Cellular immune
response
3.The endothelial cells
4.The epithelial cells

Various organ systems are involved in the production of voice and


speech:

Glottis,
Supraglottic vocal tract,
Central nervous system
must be coordinated in order to produce a normal voice sound

Hyponasal speech (rhinophonia clausa) : occurs when these


segments contribute less to sound production as a result of partial or
complete nasal obstruction or mass lesions in the nasopharynx

Hypernasal speech (rhinophonia aperta): develops when the


nasopharynx
and nasal cavities over contribute to sound production.
cleft palate, velar palsy due to various causes

The human olfactory system consists


of

1.
2.
3.
4.

Intranasal olfactory mucosa


Primary olfactory center
Secondary olfactory center
Tertiary olfactory center

The precise sequence of events that are involved in


olfaction is still uncertain.

1.
2.
3.
4.
5.

Name the main the nasal


septum structure.
Name the functions of the
nose?
The major artery of the nose is
.
Sphenoid sinus is drained to .
Orbital cellulitis is seen often
due to sinus involvement.

History and Clinical Examination of the Nose; Tumors of the External


Nose and Face

Patients

should be given an
opportunity to describe their
complaints in their own words,

Nasal obstruction
Discharge
Epistaxis
Specific allergy history
Headaches
Olfactory dysfunction
Facial pressure or pain

Acute and chronic rhinitis (e.g., allergic, atrophic)


1. Sinusitis
2. Deviated septum (congenital, acquired)
3. Nasal pyramid fracture
4. Septal perforation
5. Nasal polyps
6. Cephalocele
7. Adenoids
8. Tumors of the nose, paranasal sinuses, and nasopharynx
9. Foreign bodies (especially in small children)
10. Drugs

Adverse effects: oral contraceptives, antihypertensive agents


(e.g., reserpine, propranolol, hydralazine), antidepressants (e.g.,
amitriptyline)
Drug abuse: e.g., oxymetazoline , phenylephrine


1.
2.
3.
4.

1.
2.
3.
4.
5.

Transport of odorants
Nasal obstruction Deviated
septum, mucosal
swelling, polyps, tumor
Scar tissue occluding the
olfactory groove
After intranasal surgery
Perception: damage to
the olfactory epithelium
caused by:
Toxic substances SO2, NO,
ozone,
Heavy metals, varnishes
Drugs
Viral infections Influenza
Radiotherapy (rare)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Stimulus conduction and


processing
Avulsion of fila olfactoria Skull
base fracture
Aplasia of the olfactory bulb
(rare)
Kallmann syndrome
Injury to olfactory centers
Contusion or hemorrhage due to
head injury
Neurodegenerative diseases
Alzheimer disease,
Parkinson disease,
Diabetes mellitus
Olfactory hallucinations after
epileptic seizures, in
schizophrenia

Inspection
1.Mouth breathing
2.Shape of the external
3.Skin changes such as

nose
erythema

Palpation
Useful

for detecting bony


discontinuities
In patients with suspected neuralgias

To

evaluate the nasal


vestibule and the anterior
portions of the nasal
cavity

Posterior rhinoscopy was formerly done to


evaluate the nasopharynx and posterior
nasal cavity (choanae, posterior ends of
the turbinates, posterior margin of the
vomer)

Endoscopy is commonly used to examine


this region

Nasal endoscopy has become


the most important and
rewarding clinical
examination method in
rhinologic diagnosis

First the examiner


advances the endoscope
into the nasopharynx and
inspects:

Eustachian tube orifice


Torus tubarius
Posterior pharyngeal wall
Roof of the nasopharynx

Nasal

endoscopy is
particularly useful for
evaluating the
ostiomeatal unit

Nasal
Hold

Patency:

a reflective metal plate


under the nose
Holding a wisp of cotton in front
of each nostril
Active anterior rhinomanometry
Acoustic rhinometry

Skin

Tests

The

total immunoglobulin E (IgE)


assay

Nasal

provocation test

The

total immunoglobulin E (IgE)


assay

Several types of test substance are used:

1.

Pure odorants that stimulate only the olfactory nerve


(coffee, cocoa, vanilla, cinnamon, lavender)
Odorants with a trigeminal component (menthol,
acetic acid, formalin)
Substances that also have a taste component
(chloroform, pyridine).

2.
3.

Patients with a complete loss of smell (anosmia) cannot


perceive pure odorants but can at least sense or taste the
other substances.

Objective

olfactory testing is far


more costly and is generally
performed only at large centers

Conventional Radiographs
Computed Tomography (CT)
Magnetic Resonance Imaging
Ultrasonography

Limited

indication these days

Water projection
Caldwell

Acute inflammation
To evaluate midfacial

fractures

WATERS

CALDWELL

If

there is a high index of suspicion


for sphenoid sinus involvement, a
lateral sinus projection should be
added to the study

The

craniocaudal extent of the


frontal and maxillary sinuses can
also be evaluated with this technique

Indications
An occasional malformation,
The main indications for CT scanning

of the nose and paranasal sinuses are


1. Chronic sinusitis
2. Trauma (especially frontobasal
fractures)
3. Tumors

The

normal mucosal lining of the


sinuses is not visualized.

The

bony sinus walls appear


hyperdense (white)

The strength of
MRI lies in its
superior softtissue
discrimination

Disorders that involve the paranasal sinuses


in addition to the cranial cavity or orbit (e.g.,
tumors and congenital malformations such
as encephaloceles)

It can also supply information that is useful in


differentiating soft-tissue lesions within the
paranasal sinuses (mucocele, cyst, polyp)

It can distinguish between solid tumor tissue


and inflammatory perifocal reaction

Patients

with electrically controlled


devices such as a cardiac
pacemaker, insulin pump, cytostatic
pump, or cochlear implant.

Modern

internal fixation materials


such as titanium are usually
nonmagnetic and therefore MRIcompatible

The

paranasal sinuses can also be


visualized with ultrasound.

The

sphenoid sinus is inaccessible to


ultrasound imaging because of its
location.

1.
2.

Inverted
Papilloma
Osteomas

It is a locally aggressive tumor, and


transformation to squamous cell carcinoma
is periodically described

Symptoms and diagnosis:

Nasal airway obstruction, headache, and occasional


epistaxis.
The lesion often has a polyp-like appearance when
inspected by nasal endoscopy

Treatment:

The treatment of choice is surgical removal

Benign bone tumors that may occur as isolated


masses, especially in the ethmoid cells and
frontal sinus

Symptoms and diagnosis:

Often they do not become symptomatic until they


obstruct drainage tracts to or from the paranasal
sinuses, leading secondarily to headaches and
recurrent bouts of sinusitis

Treatment:

As soon as an osteoma becomes symptomatic, it should


be surgically removed

Malignant tumors of the nasal cavity and paranasal


sinuses are far more common than benign masses.

Histologically, the great majority (> 80%) are tumors


of the epithelial series (e.g., squamous cell
carcinoma, adenocarcinoma, adenoid cystic
carcinoma).

Neoplasms of mesenchymal origin, such as


osteosarcomas and chondrosarcomas, as well as
malignant lymphomas are much less common.

Metastases from other malignancies are


occasionally found, with the primary tumor residing
in the kidney, lung, breast, testis, or thyroid gland.

The

main sites of predilection are the


nasal cavity and maxillary sinus,
followed by the ethmoid cells, frontal
sinus, and sphenoid sinus.

Because

many tumors originate in


the paranasal sinuses themselves,
they often do not produce clinical
manifestations until they have
reached an advanced stage

Obstructed nasal breathing


Bloody rhinorrhea
Fetid nasal odor
Swelling of the buccal soft tissues
Swelling at the medial canthus
Headache, facial pain, and
Hypoesthesia or numbness of the cheek
Orbital infiltration can lead to displacement
of the orbital contents, diplopia, or proptosis
Trismous
Epiphorea
Dental loosening

Unilateral

sinusitis that is refractory


to treatment

The clinical examination includes

Endoscopic inspection of the nasal cavity

Search for regional lymph-node metastases by


bimanual palpation of the cervical soft tissues.

Since sinus tumors are apt to invade the


nasal cavity secondarily, endoscopy alone
may provide little information on the extent
of the mass. For this reason, computed
tomography and/or magnetic resonance
imaging should always be performed

is individualized according to the histology


and extent of the malignant tumor, and the
treatment plan should be coordinated with
the radiotherapist and medical oncologist.

Since the great majority of lesions are


squamous cell carcinomas, however, the
treatment of choice will usually consist of
surgery and postoperative radiation

Since only about 20% of sinonasal


malignancies metastasize to regional lymph
nodes, a neck dissection is necessary only
in patients who have clinically positive
cervical nodes

Many of these cases will require


postoperative radiotherapy

Is a rare neurogenic malignancy that arises


from the sensory cells of the olfactory
region and generally occurs in adults

Advanced, the tumor causes obstructed


nasal breathing, recurrent epistaxis, and
particularly hyposmia or anosmia.

Some of these tumors become symptomatic


only after invading the cranial cavity or
orbit, causing headache or visual
deterioration

is based on endoscopy and


especially computed
tomography or magnetic
resonance imaging; only
these modalities can
accurately define the tumor
extent

Based on a combination of tumor


resection and postoperative
radiotherapy

1.
2.
3.
4.
5.

Name five more common


sinonasal symptoms.
How you check the nasal patency?
What imaging modality is the best
for sinonasal evaluation?
Name the common symptoms and
signs of sinonasal tumor.
Which tumor is specific for the
nasal cavity?

Malformations of the Nose, Paranasal Sinuses,


and Face

Malformations involving the


nose may be caused by
developmental abnormalities of
the nasal floor, palate, nasal
roof, and intranasal region

Incidence of one in 5000 to one in 10,000 births.


More often unilateral than bilateral.
The atresia is bony in 90% of cases and membranous
in only 10%.

Bilateral choanal atresia is an acutely


life threatening emergency because the
neonate, except when crying, is an obligate
nasal breather until about the sixth week
of life.

Cyanosis that is present at rest and


improves with exertion is called
paradoxical cyanosis because of its
opposite pattern relative to cyanosis with a
cardiac cause

Unilateral choanal atresia may be


manifested by a purulent nasal discharge
on the affected side.

Choanal atresia may be associated


with various other anomalies:

CHARGE syndrome (coloboma; heart


disease; atresia of the choanae; retarded
growth, development and/or central
nervous system anomalies; genital
hyperplasia; ear anomalies or deafness).

The clinical suspicion of


choanal atresia can be
confirmed by examination
with a rigid or flexible
endoscope

The acute care of choanal atresia in asphyxia


consists of intubation followed by perforation of
the atresia plate

The definitive surgical repair of bilateral choanal


atresia is performed during the first weeks or
months of life.

Surgery for unilateral atresia can be postponed


until school age, when the anatomy of the region
is more similar to that encountered in adults

Incidence of dysraphias involving


the anterior skull base is
approximately one in 20,000 to one in
40,000 births

Various

manifestations that

include:
1. Dorsal nasal fistulas
2. Dermoids
3. Frontonasal extracerebral
4. Frontonasal extracerebral

cephaloceles

gliomas

A dorsal nasal fistula consists of a

fistulous tract that is lined by


keratinized squamous epithelium and
forms a tiny opening on the dorsum
or tip of the nose

Fistulas that terminate blindly are


usually manifested clinically at an
older age due to inflammation around
the fistulous opening.

If the fistula communicates with the


subarachnoid space, it can lead to
severe complications such as
cerebrospinal fluid leakage,
meningitis, or brain abscess

The diagnosis is established by


computed tomography or magnetic
resonance imaging.

Diagnostic catheterization or contrast


injection is contraindicated due to
the risk of intracranial complications.

Treatment consists of complete


removal of the fistulous tract

Cephaloceles are herniations of


intracranial contents through a bony
defect in the skull

Most cephaloceles are congenital, but


rare cases are post-traumatic

Sincipital cephaloceles are located

near the glabella, forehead or orbit.


Basal cephaloceles are found mainly

in the nasal cavity or nasopharynx.

Most are
manifested
clinically
during
childhood.
The sincipital
forms appear
as:
a pulsating mass
near the glabella,
often associated
with a broad
nasal dorsum and
hypertelorism

Basal forms present as :

an intranasal mass, typically with


associated nasal airway obstruction.
They closely resemble intranasal
polyps and should be considered in
the differential diagnosis of children
with suspected nasal polyps, which
are rare in this age group

Computed tomography (CT) and


magnetic resonance imaging (MRI)

Always surgical and consists of


removing the cephalocele and
repairing the dural defect