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Rhinologist
Assistant Professor of Mashad University of Medical Sciences
Four sessions:
Nasal Vestibule
Nasal Septum
Nasal Valve
Lateral nasal Wall
Choana
Lateral Nasal Wall
Bony Structure:
1. Maxilla
2. Ethmoid
3. Palatine
4. Inferior Turbinate
5. Sphenoid
Functional apparatus:
1. Turbinate
2. Meatus
3. Sinus ostia
4. Nasolacrimal duct orifice
Nasal Cavities
Roof:
1. Cribriform palate
2. Ethmoid fovea
Floor:
Hard palate
1. Maxilla (Ant)
2. Palatine (Pos)
Paranasal Sinuses
Medial:
Lateral nasal wall
Superior:
Orbital floor
Posterior:
Pterygopalatine fossa
Inferior:
Alveolar ridge ( root of
second premolar and first
molar)
Ethmoid air cells
Medial:
Middle turbinate
Superior:
Fovea ethmoidalis ( Ant
cranial fossa)
Posterior:
Sphenoid sinus
Lateral:
Lamina papyruses ( orbit)
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
Frontal Sinus
Inferior:
Orbital roof
Posterior:
Anterior cranial fossa
Nerve Supply
Innervation
Anatomy
External
Muscular attachments
Ostiomeatal Unit
Morphology of the
Nasal Mucosa
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
Physical Principles of
Nasal Airflow
Nasal Cycle
Regulate by autonomic
nervous system
80% of human each 2 hours
Conditioning of the
Inspired Air
Humidification
Temperature regulation
Protective Functions
of the Nasal Mucosa
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
1. Mouth breathing
2. Shape of the external nose
3. Skin changes such as erythema
Palpation
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).
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
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.
1. Inverted
Papilloma
2. Osteomas
It is a locally aggressive tumor, and transformation
to squamous cell carcinoma is periodically described
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
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).
Anterior rhinoscopy
Endoscopy
The treatment of choice is functional
septorhinoplasty, with correction of the
nasal septum and external nose
Nosebleed is a relatively common, usually
harmless symptom that may reflect a
number of diseases of variable severity
1. Perforation 1. allergy
2. traumatic 2. acute rhinitis
3. iatrogenic 3. Traumatic aneurysm
4. Inflammatory of the internal
5. spurs or ridges carotid
6. Foreign bodies 4. Benign neoplasms
7. rhinoliths 5. malignant
8. trauma (including neoplasms
nose picking)
1. Atherosclerosis 1. Platelet disorders
2. Infection Congenital
3. Pregnancy Acquired: uremia,
4. Diabetes mellitus dysproteinemia, adverse
5. Congenital: e.g., effects of dextrann and
hemophilia A and B, acetylsalicylic acid (ASA)
Willebrand disease therapy Schnlein
6. Acquired: e.g., Henoch purpura
anticoagulant therapy,
7. Hepatocellular 1. Osler disease
insufficiency
Nosebleed requires a simultaneous,
coordinated protocol of diagnostic and
therapeutic actions
The diagnostic work-up begins with blood
pressure measurement.
Inspection
Crepitus noted on palpation confirms the
suspicion of a fracture
Imaging
1. Subperichondria
l hemorrhage
with hematoma
2. Septal Abcess
Lateral midfacial fractures are usually caused by
blunt trauma to the side of the face.
1. Swelling
2. subcutaneous hemorrhage
3. Asymmetry of the affected facial
4. Enophthalmos
Palpation:
2-transferrin
Computed tomography
Olfactory testing
Every confirmed fracture of the anterior
skull base should be treated surgically in
operable patients, regardless of whether or
not a CSF leak has been detected
Life-threatening rise of intracranial
pressure due to intracranial hemorrhage
Catarrhal stage
Watery, initially serous nasal discharge and nasal
obstruction due to mucosal swelling, which
mainly involves the turbinates.
Bacterial
Superinfection
Pharmacologic treatment
1. Mast-cell stabilizers
2. Local and systemic H1 antihistamines
3. Local steroids
Surgical options
Resembles allergic rhinitis in its clinical
features, but there is no evidence that the
patient has been previously sensitized.
Antihistamines
corticosteroid-containing nasal sprays
Secondary forms
1. Extensive prior tumor resection
2. Excessive use of nose drops drug abuse (cocaine)
3. Previous radiotherapy for nasal and sinus
tumors
Conservative:
Symptomatic measures (saline nasal douche,
soothing mucosal ointments).
Surgery :
reduce the nasal cavity by the submucous
implantation of cartilage grafts.
Occurs mainly during pregnancy and is
believed to be caused by estrogen-induced
swelling of the mucosa with nasal airway
obstruction.
This disease occurs mainly as a side effect
from the long-term use of decongestant
nose drops
Antihypertensive drugs
Beta-blockers,
Angiotensin-converting enzyme (ACE) inhibitors
Oral contraceptive
Clinical
symptoms consist of obstructed nasal breathing, dry
mucosa, and occasional olfactory disturbances.
Intranasal anatomic changes such as:
Septal deviation
Septal spurs
Chronic inflammation
Allergy
Trauma
Neoplasms
Sinus surgery
The modern surgical treatment of chronic
sinusitis is performed intranasally under
endoscopic or microscopic control.
Genetic causes
Chronic irritation of the mucosa, like that
occurring in chronic rhinitis or sinusitis
In response to allergic rhinitis and
acetylsalicylic acid (ASA) intolerance
Nasal polyps are rarely observed in
children.
Surgical treatment
The prognosis is guarded even with modern
surgical techniques most meticulous
ablative sinus surgery cannot prevent a
recurrence
Adhesions due to
Postinflammatory
Post-traumatic
Postoperative
MRI
The treatment of choice is surgical removal
of the mucocele
They occur with highest frequency in children
under 6 years of age
1. Orbital edema
2. Periosteitis
3. Subperiosteal abscess
4. Orbital cellulitis
5. Orbital apex syndrome
6. Cavernous sinus thrombosis
Osteomyelitis occurs mainly as a
complication of frontal sinusitis
Symptoms