1. Nose and Paranasal Sinuses
Bakhshaee M, MD
Rhinologist
Assistant Professor of Mashad University of Medical Sciences
Nose and Paranasal Sinuses

2. Course Plan Four sessions:
Anatomy, Physiology, and Immunology of the Nose, Paranasal Sinuses, and Face
History and Clinical Examination of the Nose; Tumors of the External Nose and Face
Malformations and common disorders of the Nose, Paranasal Sinuses, and Face
Inflammations of the External Nose, Nasal Cavity, and Facial Soft Tissues
Estimated time for each session is 100 min

3. Session’ Items Including: Initial assessment: 10 min
Lesson delivery: 60 min
Discussion: 15 min
Question and problems of previous session: 10 min
A brief talking on next session: 5 min

4. Session 1
Anatomy, Physiology, and Immunology of the Nose, Paranasal Sinuses, and Face

5. 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

6. Facial Skin and Soft Tissues
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 soft-tissue defects

7. The Facial Skeleton 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.

8. External Nose

9. Nasal Cavities Nasal Vestibule Nasal Septum Nasal Valve
Lateral nasal Wall
Choana

10. Lateral Nasal Wall Bony Structure: Maxilla Ethmoid Palatine
Inferior Turbinate
Sphenoid
Functional apparatus:
Turbinate
Meatus
Sinus ostia
Nasolacrimal duct orifice

11. Nasal Cavities Roof: Cribriform palate Ethmoid fovea Floor:
Hard palate
Maxilla (Ant)
Palatine (Pos)

12. Paranasal Sinuses
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.

13. Maxillary Sinus Medial: Lateral nasal wall Superior: Orbital floor
Posterior: Pterygopalatine fossa
Inferior:
Alveolar ridge ( root of second premolar and first molar)

14. Ethmoid air cells Medial: Middle turbinate Superior:
Fovea ethmoidalis ( Ant cranial fossa)
Posterior:
Sphenoid sinus
Lateral:
Lamina papyruses ( orbit)

15. Sphenoid Sinus Inferior: Nasopharynx Superior:
Ant and middle cranial fossa , Sellae tursica
Posterior:
Clivus and posterior cranial fossa
Lateral:
Optic nerve
Internal carotid
Cavernous sinus

16. Frontal Sinus
Inferior:
Orbital roof
Posterior:
Anterior cranial fossa

17. Vascular Supply

18. Nerve Supply
Innervation

19. Anatomy External
Muscular attachments

20. Ostiomeatal Unit

21. Morphology of the Nasal Mucosa
Mucus:
Squamous epithelium
Respiratory Mucosa
Olfactory Mucosa
Respiratory Mucosa:
Epithelium
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)

22. Basic Physiology and Immunology of the Nose
Nose is of major importance in conditioning
the air before it reaches the lower airways

23. Physical Principles of Nasal Airflow
Laminar vs Turbulent
Nasal Cycle
Regulate by autonomic nervous system
80% of human each 2 hours

24. Conditioning of the Inspired Air
Humidification
Temperature regulation

25. Protective Functions of the Nasal Mucosa
Nonspecific Defense Mechanisms
Mechanical defenses (mucociliary apparatus)
Nonspecific protective factors (Interferon, Proteases, Protease inhibitors , Lysozyme Antioxidants)
Cellular defenses (phagocytic cells)
Specific Immune Responses
Humoral immune response
Cellular immune response
The endothelial cells
The epithelial cells

26. Speech Production
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

27. Olfaction The human olfactory system consists of
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.

28. Questions 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.

29. Session 2
History and Clinical Examination of the Nose; Tumors of the External Nose and Face

30. History
Patients should be given an opportunity to describe their complaints “in their own words,”

31. Common Complains Nasal obstruction Discharge Epistaxis
Specific allergy history
Headaches
Olfactory dysfunction
Facial pressure or pain

32. Nasal airway obstruction
Acute and chronic rhinitis (e.g., allergic, atrophic)
• Sinusitis
• Deviated septum (congenital, acquired)
• Nasal pyramid fracture
• Septal perforation
• Nasal polyps
• Cephalocele
• Adenoids
• Tumors of the nose, paranasal sinuses, and nasopharynx
• Foreign bodies (especially in small children)
• Drugs
Adverse effects: oral contraceptives, antihypertensive agents (e.g., reserpine, propranolol, hydralazine), antidepressants (e.g., amitriptyline)
Drug abuse: e.g., oxymetazoline , phenylephrine

33. Olfaction Disturbance
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)
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

34. Clinical Examination Inspection Mouth breathing
Shape of the external nose
Skin changes such as erythema

35. Exam,con Palpation Useful for detecting bony discontinuities
In patients with suspected neuralgias

36. Anterior Rhinoscopy
To evaluate the nasal vestibule and the anterior portions of the nasal cavity

37. Posterior Rhinoscopy
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

38. Nasal Endoscopy
Nasal endoscopy has become the most important and rewarding clinical examination method in rhinologic diagnosis

39. Nasopharynx
First the examiner advances the endoscope into the nasopharynx and inspects:
Eustachian tube orifice
Torus tubarius
Posterior pharyngeal wall
Roof of the nasopharynx

40. Ostiomeatal unit
Nasal endoscopy is particularly useful for evaluating the ostiomeatal unit

41. Special Rhinologic Tests

42. Testing Nasal Patency Nasal Patency:
Hold a reflective metal plate under the nose
Holding a wisp of cotton in front of each nostril
Active anterior rhinomanometry
Acoustic rhinometry

43. Allergy Testing Skin Tests The total immunoglobulin E (IgE) assay
Nasal provocation test

44. Serologic Tests
The total immunoglobulin E (IgE) assay

45. Subjective Olfactory Testing
Several types of test substance are used:
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).
Patients with a complete loss of smell (anosmia) cannot perceive pure odorants but can at least sense or taste the other substances.

46. Objective Olfactory Testing
Objective olfactory testing is far more costly and is generally performed only at large centers

47. Imaging of the Nose and Paranasal Sinuses
Conventional Radiographs
Computed Tomography (CT)
Magnetic Resonance Imaging
Ultrasonography

48. Conventional Radiographs
Limited indication these days

49. To evaluate midfacial fractures
Indications
Water projection
Caldwell
Acute inflammation
To evaluate midfacial fractures

50. Waters
Caldwell

51. Lateral View
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

52. Computed Tomography (CT)
Indications
An occasional malformation,
The main indications for CT scanning of the nose and paranasal sinuses are
Chronic sinusitis
Trauma (especially frontobasal fractures)
Tumors

53. Coronal

54. Coronal

55. Normal The normal mucosal lining of the sinuses is not visualized.
The bony sinus walls appear hyperdense (white)

56. Axial

57. Magnetic Resonance Imaging
The strength of MRI lies in its superior soft-tissue discrimination

58. MRI
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

59. Contraindications
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 MRI-compatible

60. Ultrasound
The paranasal sinuses can also be visualized with ultrasound.
The sphenoid sinus is inaccessible to ultrasound imaging because of its location.

61. Tumors of the Nasal Cavity and Paranasal Sinuses

62. Benign Tumors
Inverted Papilloma
Osteomas

63. Inverted Papilloma
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

64. Osteomas
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

65. Malignant Tumors
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.

66. Location
The main sites of predilection are the nasal cavity and maxillary sinus, followed by the ethmoid cells, frontal sinus, and sphenoid sinus.

67. Symptoms
Because many tumors originate in the paranasal sinuses themselves, they often do not produce clinical manifestations until they have reached an advanced stage

68. Alarm Signs 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

69. Notice
Unilateral sinusitis that is refractory to treatment

70. Diagnosis The clinical examination includes
Endoscopic inspection of the nasal cavity
Search for regional lymph-node metastases by bimanual palpation of the cervical soft tissues.

71. Imaging
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

72. Imaging

73. Tumor

74. Treatment
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

75. Neck Metastasis
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

76. Esthesioneuroblastoma
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

77. Diagnosis
is based on endoscopy and especially computed tomography or magnetic resonance imaging; only these modalities can accurately define the tumor extent

78. Treatment
Based on a combination of tumor resection and postoperative radiotherapy

79. Questions 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?

80. Session 3
Malformations of the Nose, Paranasal Sinuses,
and Face

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

82. Choanal Atresia Epidemiology
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%.

83. Symptoms
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

84. Symptoms
Unilateral choanal atresia may be manifested by a purulent nasal discharge on the affected side.

85. Syndromic
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).

86. Diagnosis
The clinical suspicion of choanal atresia can be confirmed by examination with a rigid or flexible endoscope

87. Treatment
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

88. Frontobasal Dysraphias
Incidence of dysraphias involving the anterior skull base is approximately one in 20,000 to one in 40,000 births

89. Manifestations Various manifestations that include:
Dorsal nasal fistulas
Dermoids
Frontonasal extracerebral gliomas
Frontonasal extracerebral cephaloceles

90. Dorsal nasal fistula
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

91. Symptoms
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

92. Diagnosis
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.

93. Treatment
Treatment consists of complete removal of the fistulous tract

94. Cephalocele
Cephaloceles are herniations of intracranial contents through a bony defect in the skull

95. Etiology
Most cephaloceles are congenital, but rare cases are post-traumatic

96. Classification
Sincipital cephaloceles are located near the glabella, forehead or orbit.
Basal cephaloceles are found mainly in the nasal cavity or nasopharynx.

97. Presentation 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

98. Presentation 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

99. Diagnosis
Computed tomography (CT) and magnetic resonance imaging (MRI)

100. Treatment
Always surgical and consists of removing the cephalocele and repairing the dural defect