Bakhshaee M, MDRhinologistAssistant 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 min2.Lesson delivery: 60 min3.Discussion: 15 min4.Question and problems of previous

session: 10 min5.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 soft-tissue defects

Knowing the various components of the bony facialskeleton and their relationship to one anotheris important in trauma management and also inthe diagnosis and treatment o inflammatory diseasesof the facial skeleton and their complications.

Nasal VestibuleNasal SeptumNasal ValveLateral nasal WallChoana

Bony Structure:

1.Maxilla2.Ethmoid3.Palatine4.Inferior Turbinate5.Sphenoid

Functional apparatus:

1.Turbinate 2.Meatus3.Sinus ostia4.Nasolacrimal duct orifice

Roof:

1.Cribriform palate2.Ethmoid fovea

Floor:

Hard palate1.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 epitheliumRespiratory MucosaOlfactory Mucosa

Respiratory Mucosa:1.Epithelium2.Lamina Properia:Venous erectile tissueNasal glandsImmunocompetent 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 conditioningthe air before it reaches the lower airways

Nasal Air FlowLaminar vs Turbulent

Nasal CycleRegulate by autonomic nervous system80% of human each 2 hours

Humidification

Temperature regulation

Nonspecific Defense Mechanisms1.Mechanical defenses (mucociliary apparatus) 2. Nonspecific protective factors (Interferon, Proteases, Protease inhibitors , Lysozyme Antioxidants)3.Cellular defenses (phagocytic cells)

Specific Immune Responses1.Humoral immune response2.Cellular immune response3.The endothelial cells4.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. Intranasal olfactory mucosa 2. Primary olfactory center 3. Secondary olfactory center 4. Tertiary olfactory center

The precise sequence of events that are involved in olfaction is still uncertain.

1. Name the main the nasal septum structure.

2. Name the functions of the nose?

3. The major artery of the nose is ….

4. Sphenoid sinus is drained to ….5. 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 obstructionDischargeEpistaxisSpecific allergy historyHeadachesOlfactory dysfunctionFacial pressure or pain

Acute and chronic rhinitis (e.g., allergic, atrophic)1. • Sinusitis2. • Deviated septum (congenital, acquired)3. • Nasal pyramid fracture4. • Septal perforation5. • Nasal polyps6. • Cephalocele7. • Adenoids8. • Tumors of the nose, paranasal sinuses, and nasopharynx9. • 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

Transport of odorants1. Nasal obstruction Deviated

septum, mucosal2. swelling, polyps, tumor3. Scar tissue occluding the

olfactory groove4. After intranasal surgery Perception: damage to

the olfactory epithelium caused by:

1. Toxic substances SO2, NO, ozone,

2. Heavy metals, varnishes3. Drugs4. Viral infections Influenza5. Radiotherapy (rare)

Stimulus conduction and processing

1. Avulsion of fila olfactoria Skull base fracture

2. Aplasia of the olfactory bulb (rare)

3. Kallmann syndrome4. Injury to olfactory centers 5. Contusion or hemorrhage due to

head injury6. Neurodegenerative diseases7. Alzheimer disease,8. Parkinson disease,9. Diabetes mellitus10. Olfactory hallucinations after

epileptic seizures, in schizophrenia

Inspection

1.Mouth breathing2.Shape of the external nose3.Skin changes such as 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 Patency:

Hold a reflective metal plate under the nose

Holding a wisp of cotton in front of each nostril

Active anterior rhinomanometryAcoustic 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)

2. Odorants with a trigeminal component (menthol, acetic acid, formalin)

3. 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.

Objective olfactory testing is far more costly and is generally performed only at large centers

Conventional RadiographsComputed Tomography (CT)Magnetic Resonance ImagingUltrasonography

Limited indication these days

Water projectionCaldwell

Acute inflammationTo 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 soft-tissue 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 MRI-compatible

The paranasal sinuses can also be visualized with ultrasound.

The sphenoid sinus is inaccessible to ultrasound imaging because of its location.

1. Inverted Papilloma

2. 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. Name five more common sinonasal symptoms.

2. How you check the nasal patency?

3. What imaging modality is the best for sinonasal evaluation?

4. Name the common symptoms and signs of sinonasal tumor.

5. 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 gliomas4.Frontonasal extracerebral

cephaloceles

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