Physiology of Nose & P.N.S.

Dr. Vishal Sharma

Functions of nose
1. Respiration

2. Air conditioning of inspired air

3. Protection of lower airway 4. Ventilation & drainage of P.N.S. 5. Olfaction: increased on sniffing 6. Nasal resistance 7. Vocal resonance 8. Nasal reflexes

Functions of P.N.S. (?)

1. Air conditioning of inspired air 2. Vocal resonance

3. Thermal insulators for orbit & cranium from

fluctuating nasal temperature 4. Lightens weight of skull

Respiration
Inspiration: air current passes along mid-portion of nasal cavity in lamellar flow. Expiration: resistance of nasal valve & turbinates leads to formation of eddy current in expired air. This results in awareness of breathing & ventilation of paranasal sinus.

Respiration

Air conditioning
Filtration: particles > 3 m in inspired air are

trapped by nasal vibrissae

Temperature control: Heat exchange b/w blood in cavernous venous sinusoids of turbinates & inspired air, by radiation

Humidification: by secretions of nasal & P.N.S.

mucosa; for better ciliary function

Protection of lower airway

1. Muco-ciliary blanket: traps pathogens in

inspired air > 0.5 m & transports them to

nasopharynx for swallowing

2. Sneezing: protects against irritants

3. Lysozyme: kills bacteria & viruses

4. Immunoglobulins A & E: for bacteria

5. Interferon: for protection against virus

Muco-ciliary blanket
Goblet cells in nasal mucosa secrete a mucous blanket; moved backwards like a conveyer belt into nasopharynx. Consists of: Superficial mucous or gel layer Deep serous or sol layer

Muco-ciliary blanket

Muco-ciliary blanket

Ciliary cycle

Factors decreasing mucociliary function

Dry atmosphere (absence of humidity) Smoking, air pollutants & nasal irritants Infection Extremes of temperature Hypoxia Drugs: anaesthetics, sedatives, topical nasal decongestants, beta blockers

Ventilation of P.N.S.
Inspiration: negative pressure created in nasal cavity sucks out air from paranasal sinuses via their ostium. Expiration: eddies within nasal cavity create positive pressure ventilates paranasal sinuses via their ostium.

Ventilation of P.N.S.

Drainage of sinuses

Drainage of sinuses
Anterior sinuses
drain in lateral

pharyngeal gutter
Posterior sinuses

drain over posterior

pharyngeal wall

Drainage of sinuses

Nasal resistance
Nasal resistance to expired air keeps positive pressure in respiratory tract & prevents alveolar collapse

Nasal Resistance
Nose provides 50-60 % of total airway resistance Nasal resistance is provided by 3 areas: Nasal vestibule Nasal valve (maximum contribution) Nasal turbinates

Nasal valve
Anterior nasal valve (ostium internum) is located at

limen nasi, 1.5 cm posterior to anterior nares.

Consists of inferior margin of upper lateral nasal

cartilage + anterior end of inferior turbinate + adjacent

nasal septum. Cross-section of airway here is 20-40

mm2 on each side. It is narrowest part of upper

respiratory tract. Cottles test checks valve patency.

Vocal resonance
Nasal cavity & paranasal sinus cavity provide vocal resonance for nasal consonants M, N & nG De-nasal voice is seen in nose block. Nasal consonants M, N & nG are uttered as B, D & G respectively

Nasal reflexes
1. Smell reflex: increases secretions of

saliva & gastric juice

2. Naso-pulmonary reflex: Chronic, severe nasal obstruction increased pulmonary resistance

pulmonary hypertension
3. Sneeze reflex: protection against F.B.

Nasal Cycle

Nasal Cycle
Reflex, periodic alternation in nasal airflow resistance b/w two nasal cavities Regulated by autonomic nervous system

Due to congestion & decongestion of venous

sinusoids of inferior turbinates & anterior nasal

septum
Each cycle lasts for 2-12 hrs (average 2-4 hrs)

Factors modifying nasal cycle

Temperature & humidity of surrounding air

Head position
Body temperature

Physical activity
Emotional & psychological status

Hypothyroidism & hyperthyroidism

Nasal decongestants & anti-hypertensives

Olfactory area of nose

Olfactory neural pathway

Olfactory receptors on nasal mucosa 20

Olfactory nerve bundles synapse with Mitral &

Tufted cells in Olfactory bulb Axons unite to

form Olfactory tract flattens distally to form

Olfactory trigone trifurcates into Olfactory

striae synapse with 10 & 20 Olfactory cortex +

hypothalamus + hippocampus + amygdala.

Olfactory neural pathway

Olfactory neural pathway

Olfactory neural pathway

Olfaction is the only sensation to reach cerebral cortex directly without first relaying at thalamus Olfactory pathway incorporates limbic system & is concerned with emotional behaviour, mood & recent memory

Olfactory dysfunction causes

1. Upper respiratory viral infection (30 %)

2. Idiopathic (25 %)
3. Head trauma (20 %) 4. Obstructive sino-nasal disease (15 %) Rhino-sinusitis Nasal polyp / neoplasm 5. Neurologic & Psychiatric diseases 6. Intra-cranial neoplasm 7. Toxic chemicals & surgical trauma

Classification
Conductive loss: obstruction of nasal passages chronic nasal inflammation, polyposis Sensorineural loss: damage to neuroepithelium viral infection, airborne toxin

Central olfactory neural loss: C.N.S. damage

tumors, neurodegenerative disorders

Olfactory dysfunction types

1. Anosmia: absence of olfactory sensation 2. Hyposmia: decreased olfactory sensation 3. Parosmia / cachosmia: perception of a pleasant odour as unpleasant odour 4. Phantosmia: perception of odour in absence of olfactory stimulus 5. Hyperosmia: increased olfactory sensation 6. Olfactory agnosia: unable to identify odour

Tests for olfactory disorders

1. Tests for nasal airflow

a. Simple Rhino-manometry: anterior & posterior

b. Acoustic Rhino-manometry: uses sound waves

2. Tests for ciliary function

a. Saccharine test

3. Tests for olfaction

4. CT scan & MRI of PNS & brain

Rhino-manometry
Test of nasal function, measures air pressure & rate of nasal airflow during respiration. These are used to calculate nasal airway resistance.

anterior rhino-manometry: pressure sensor

placed at tip of each nostril in turn.

posterior rhino-manometry: pressure sensor

(small plastic tube) placed behind nasal cavity.

Anterior Rhino-manometry

Posterior Rhino-manometry

Rhinogram

Acoustic rhino-manometry

Saccharin Test
Evaluates ciliary function by

measuring time taken for a

drop of saccharin to be tasted

in throat when applied to

inferior turbinate (anterior tip).

Normal speed = 5-10 mm / min.

Normal time = 10-20 min.

Olfactory function tests

1. Supra-threshold test: only identifies odour Smell bottles Smell Identification Test (S.I.T.) 2. Threshold Olfactometry: measures weakest perceptible odour with help of serial dilution

Manual
Dynamic (automatic)

University of Pennsylvania Smell Identification Test

U.P.S.I.T. consists of 4 test booklets, each
containing 10 stimuli for smell. All 40 stimuli are presented in rectangular areas. Subjects scratch & then sniff them. They are required to pick 1 from 5 multiple choices present for each stimuli.

36 - 40 normal; 6 - 15 total anosmia;

16 - 35 partial anosmia 0 - 5 malingering

Hyposmia or anosmia Nasal block treat nasal disease Upper respiratory tract infection medical tx Old age counseling Head trauma Neurosurgical referral Smoking quit smoking

Toxin exposure avoid exposure

Congenital Endocrine referral Parosmia with seizures Neurology referral psychiatry symptoms Psychiatry referral

Counseling & Precautions

1. Beware of the following: Spoiled food Explosive gases: use electric stoves Smoke & fire: use detectors with visual alarms Socially unacceptable odors 2. Food enjoyment: flavor additives

Thank You