Anatomy of Nose &

Paranasal Sinuses
Supervisor: dr. Oscar Djauhari, Sp.THT-KL

Presented by:
Doni Ananda Kusuma A’ Clerkship of Ear Nose Throat – Head and Neck Department
Rezky Wulandari Putri Regional Hospital R. Syamsudin SH

Dera Seta Saputri

External Nose
 External Nose

▰ Pyramidal shape
▰ Skeleton  partly bony and partly cartilaginous and
membranous
▰ Nasal bone
 Narrow and thicker above
 Wider and thinner below
 Articulate firmly above with the nasal part of the
frontal bone with each other laterally with the nasal
process of the maxilla
 External Nose

 Inferior: the upper lateral cartilages  continuous with the

cartilaginous septum.
 The lobule of the nose is formed mostly by the lower
lateral cartilages, which consist of a medial and lateral
crus. There are several small cartilages within the nasal
ala.
 The chief arterial supply of the nose is from the facial artery
through the angular artery and superior labial arteries.
Venous drainage is similar, with a component gaining
access to the ophthalmic vein through draining vessels
from the trochlear and angular veins.
Nasal Cavity
 Nasal Cavity

 = nasal fossae
 Nasal septum  nasal septal cartilage, nasal
crest of the maxilla, nasal crest of the palatine
bone, the vomer, and the perpendicular plate of
the ethmoid bone.
 The lateral nasal wall  nasal turbinates
 The meatus are situated below the
corresponding turbinates
Lateral nasal wall.

1. frontal sinus; 2. middle nasal

concha; 3. middle nasal meatus; 4.
agger nasi; 5. atrium of middle nasal
concha; 6. limen; 7. vestibule; 8.
inferior nasal meatus; 9. incisive
canal; 10. palatine process of
maxilla; 11. soft palate; 12.
pharyngeal recess; 13. eustachian
tube orifice; 14. torus tubarius; 15.
adenoid; 16. sphenoid sinus, 17.
sphenoid sinus opening; 18.
sphenoethmoidal recess; 19. inferior
nasal concha; 20. superior nasal
meatus; 21. superior nasal concha;
22. palatine bone.
Nasal septum.

1, Perpendicular plate; 2,
cribriform plate; 3, crista galli;
4, frontal bone; 5, nasal bone; 6,
septal cartilage; 7, medial crus; 8,
anterior nasal spine; 9, incisive
canal; 10, palatine process; 11,
perpendicular plate; 12, postnasal
spine; 13, horizontal plate; 14,
lateral pterygoid plate; 15, medial
pterygoid plate; 16,sphenoid
sinus; 17, crest; 18, body.
10
 Blood Supply of Nasal Cavity
 The arterial supply is from:
 Internal carotid sources through the anterior and posterior ethmoid arteries
(branches of the opthtalmic artery)
 External carotid source through the sphenopalatine artery (terminal branch of
the internal maxillary artery).
 The greater palatine vessels
 The septal branch of the superior labial artery
 Kiesselbach plexus, gives rise to anterior bleeding, which accounts for most
nosebleeds  sphenopalatine, greater palatine, superior labial, anterior ethmoid
arteries
 Woodruff plexus gives rise to posterior bleeding
12
“ Type of Paranasal Sinuses
▰Frontal sinus
▰Ethmoid sinus
▰Maxillary sinus
▰Sphenoid sinus
 Anatomy of Paranasal Sinuses

Paranasal sinuses are

mucosa-lined structures
continuous with the
nasal cavity
 Frontal Sinuses

 Located in the frontal bone

 It’s floor forming the medial portion of the orbital roof
 Bounded behind by the anterior cranial fossa
 Inflammations can give rise to serious complications because of
its close proximity to the orbit and cranial cavity
 Orbital cellulitis
 Epidural or subdural abscess
 Meningitis
 Two, three, or even more frontal sinuses on a side have been
reported, and some persons have no frontal sinus.
 Ethmoid Sinuses
 Composed of multiple individual cells, separated into anterior and
posterior
 Superior and medial to the maxillary sinus are the ethmoid air cells
 Anterior ethmoid cells – anterior and below: open into the
infundibulum of the middle meatus
 Posterior ethmoid cells – posterior and above: into the superior
meatus
 Boundaries: lateral: lamina papyracea orbita; medial: middle turbinate
(anterior)/superior turbinate (posterior); superior: ethmoid roof
 They lie on either side of the superior halves of the nasal cavities and
are separated from the orbits by the laminae papyraceae.
 Sphenoid Sinuses
 Located at the approximate center of the skull above the nasopharynx.
 Borders:
 Its posterior wall is formed by the clivus.
 It relates laterally to the cavernous sinus, the internal carotid artery, and
cranial nerves II – VI, and it is very closely related to the optic canal.
 The optic nerve and the internal carotid artery may run directly beneath the
mucosa of the lateral wall of the sphenoid sinus
 Superiorly by the sella tursica and pituitary
 The anterior and middle is cranial fossae
 The degree of pneumatization of the sphenoid sinus varies  an
important factor in surgical approaches to the pituitary gland.
 Maxillary Sinuses

 The largest of the paranasal sinuses

 4 major boundaries:
 Anterior: facial surface of the maxilla
 Posterior: the pterygomaxillary space
 Medial: process of the palatine bone
 Superior: orbital floor
 The infraorbital nerve traverses along the roof of maxillary sinus
and exits through the infraorbital foramen roughly 6-7 mm
below the infraorbital rim.
 Drainage of Paranasal Sinuses

Meatus superior Meatus media Meatus inferior

• Located below the  Located between the  Situated below the
superior turbinate and medial turbinate and inferior turbinate
above the medial inferior turbinate  The biggest meatus
turbinate  Drainage  the frontal  An orifice of the
• Drainage  the posterior sinus, maxillary sinus, ipsilateral naso-
ethmoid sinuses and and anterior ethmoid lacrimal duct.
sphenoid sinus sinus
Paranasal sinuses.
1, Nasal septum;
2, frontal sinus;
3, nasal cavities;
4, ethmoidal cells;
5, middle nasal concha;
6, middle nasal meatus;
7, maxillary sinus;
8, inferior nasal concha;
9, hard palate.
 Osteomeatal Complex

• A small constricted region which is prone to obstruction

• Contained in the middle third of lateral wall of the nose, in
the meatus medius, there orifice channel of maxillaryy
sinus, frontal sinus, anterior ethmoid sinuses.
• 5 structures:
 Maxillary ostium
 Infundibulum
 Ethmoidal bullae
 Uncinate process
 Hiatus semilunaris
Physiology of Paranasal Sinuses

 Acting as resonating chambers for the voice

 Moisturize and humidify ambient air
 Lightening the weight of the facial skeleton
Physiology of the Nose and Paranasal
Sinuses

 Respiratory function  air conditioning

 Smelling
 Fonetic function
 Static and mechanic function  lightening the
weight of facial skeleton, protection
 Nasal reflex
Case
Allergy Rhinitis

28
Name : Mr. AH
Gender : Male
Age : 17 years old
Race : Sundanese
Occupation : Student
Address : Cibadak, Sukabumi
Chief Complaint :
Stinky secret from his both nostril from three weeks.
Additional Complaint : Headche
 The patient came to the hospital with complaints of stinky yellowish
discharge from his both nostril since 3 weeks ago. The discharge is
not massive, but it smells bad. He also complained about severe
headache The history of postillnes he has nasal congestion if going
into a dusty room since 10 years old.. Currently he is not taking any
drugs medication, and there is no family history of tumors, hearing
problems.
History of Past Illness
 Allergy :
 drugs (-), food like egg
and seafood (-), dust (+)
 Trauma of the nose : (-)
 Operative history : (-)
History of Family Illness
 His mother has bronchial
asthma. The symptoms
exacerbate when his
mother was cleaning up a
room.
 General condition : Moderately ill
 Arousal : compos mentis (GCS 15)
 Vital sign
 Blood pressure : 120 / 80 mmHg
 Pulse : 84 beats / minute
 Respiratory rate : 20 times / minute
 Temperature : 36,6 C
 Antropometric status
 Body weight : 48 kg
 Height : 150 cm
 IMT : 21,33 kg/m2 (normal)
 RIGHT EAR EAR LEFT EAR
Deformity (-) Auricula Deformity (-)
hyperemic (-), edema (-), mass (-), External auditory hyperemic (-), edema (-), mass (-),
laceration (-) secretion (-), canal laceration (-) secretion (-),
cerumen (-) cerumen (-)

Intact (+), hyperemic(-), bulging Tymphanic Intact (+), hyperemic (-), bulging
(-), retraction (-), light reflex (+) membrane (-), retraction (-), light reflex (+)

Within normal range Pre-auricula Within normal range

Within normal range Retro-auricula Within normal range
 RIGHT SIDE NASAL LEFT SIDE
livid (+), edema (+), boggy Cavum nasal livid (+), edema (+), boggy
appereance (+), crust (-), (Mucosa) appereance (+), crust (-), laceration
laceration (-), mass(-) (-), mass(-)
Inferior conchae : Conchae Inferior conchae : hyperthrophy
hyperthrophy (+), (+), hyperemic(+)
hyperemic(+)
watery and clear (+) Discharge watery and clear (+)

(-) Septum deviation (-)

Decreased Air pasage decreased
 RIGHT SIDE OROPHARYNX LEFT SIDE
T1, hyperemic (-) Palatine Tonsil T1, hyperemic (-)
hyperemic (-), edema (-) Posterior pharynx hyperemic (-), edema (-)
(-) Crypta, detritus (-)
symmetrical Uvula symmetrical
no abnormatlities Palatum no abnormatlities
no abnormatlities Tongue no abnormatlities
no abnormatlities Dental no abnormatlities
 RIGHT SIDE MAXILLOFACIAL LEFT SIDE
AND
NECK
symmetric Inspection symmetric
Tenderness (-) Palpation Tenderness (-)
symmetric Dorsum of nose symmetric

lymphadenopathy (-) Neck lymphadenopathy (-)

mass (-) mass (-)
A 17 years old men came to the hospital with complaints of stinky yellowish discharge from his
both nostril since 3 weeks ago. The discharge is not massive, but it smells bad. The history of
nasal congestion if going into a dusty room since 10 years old. He also complained about severe
headache. Currently he is not taking any drugs medication, and there is no family history of
tumors, hearing problems, hypertensive disease, diabetes mellitus.
Result of physical examination :
 General condition : Moderately ill

RIGHT SIDE NASAL LEFT SIDE

livid (+), edema (+), boggy Cavum nasal livid (+), edema (+), boggy
appereance (+) (Mucosa) appereance (+)

Inferior conchae : Conchae Inferior conchae : hyperthrophy

hyperthrophy (+), (+), hyperemic(+)
hyperemic(+)
watery and clear (+) Discharge watery and clear (+)

decreased Air pasage decreased

 Rhinosinusitis e.c. susp. allergic rhinitis
 Skin prick test: Allergy to dust mites (++)
 Key = Education :
 avoid the environment
 face mask
 changing cloth after cleaning room
 Pharmacotherapy:
 Antibiotic : Amoxicillin + Clavulanate acid syrup 2x5ml per
oral for 10-14 days
 Decongestan : Pseudoephedrin syrup 2 x 5ml per oral for 3-
5 days
 Major factors  Minor factors

 Facial pain/pressure*  Headache

 Facial congestion/fullness  Fever (in nonacute cases)

 Nasal obstruction/blockage  Halitosis

 Nasal  Fatigue
discharge/purulence/discolored  Dental pain
postnasal
 Cough
 discharge
 Ear pain/pressure/fullness
 Hyposmia/anosmia
 Purulence in nasal cavity on
examination
 Fever (acute rhinosinusitis only)
 Diagnosis of chronic sinusitis can be made with the use of rhinoscopy and endoscopy of the
nasal cavity, observing the lateral wall of the nose (obstructed meatus, secrete in the meatus)
and the post nasal drip.
 Plain film radiograph such as the waters position may show the opacification of the sinuses
involved, and the upright position to show the air-fluid level in the sinuses involved.
 The best instrument to diagnose the chronic sinusitis is the use of CT scan, where we can
observe :
 The infundibular pattern (obstruction in the maxillary infundibulum, resulting in isolated
maxillar sinusitis)
 Osteomeatal unit pattern (middle meatus obstruction leading to ipsilateral sinusitis—affecting
the frontal, maxillary sinuses, and the anterior of the ethmoid cells)
 The sphenoethmoid recess (obstruction results in posterior ethmoid and sphenoid sinusitis)
 Sinonasal polyposis pattern (opacification of tissues)
 Unclassified ( mucoceles, mucosal thickening without obstruction, retention cyst)
 Incomplete treatment of the sinusitis may result in the complication due to the
extension of the infection to the adjacent structures:
a. Orbital Cellulitis