Anatomy ,physiology and

clinical examination of the

nose and PNS

Dr Sarab Yassin
Arab board
ORL , Head & Neck surgery
 The lecture will include the following:

I. Anatomy of the Nose

II.Anatomy of the PNS
III.Physiology and function of the nose
& PNS
IV.Histology of the nose & PNS
I. External nose
II. Nasal cavity
III. Paranasal sinuses
 I. External nose
Osteocartilaginous Framework of Nose
Is made up of upper 1/3 is bony
Will the lower 2/3 is cartilaginous

Bony part :
1.Two Nasal bone
2.The two frontal process of the maxilla.
3.Nasal part of the frontal bone.

Cartilaginous part :
1.Upper lateral cartilages
2.Lower lateral cartilages
3.Septal cartilage
• Bony component – located superiorly, and is
comprised of contributions from the nasal
bones, maxilla and frontal bone.
• Cartilaginous component – located inferiorly,
and is comprised of the two lateral cartilages,
two alar cartilages and one septal cartilage.
There are also some smaller alar cartilages
present.
 II. The nasal cavity

• The nasal cavity or the internal nose is divided into two nostrils by the
septum forming the most superior part of the respiratory tract.
• It extends from the vestibule of the nose to the nasopharynx, and has
three divisions:
• Vestibule – the area surrounding the antero-inferior or external opening
to the nasal cavity.
• Respiratory region
• Olfactory region – located at the apex of the nasal cavity..

Content :
1. Floor
2. Roof
3. Medial (septum)
4. Lateral wall
• Floor : formed by the hard and soft palate, it
separate the noose from the oral cavity.
• Roof: cribriform plate of ethmoid bone (floor
of ant. Cranial fossa).
• Medial wall (Septum)
• The nasal septum
divides the internal nose
into two halves right
and left nasal cavities.
• The nasal cavities
communicate with the
open anteriorly through
anterior nares (nostrils)
and posteriorly with the
nasopharynx (posterior
nasal choanae)
 Medial wall: (septum )
The Septum has Three Parts
a. Columellar septum: This is formed by the
fusion of the two medial crura of alar cartilages.
b. Membranous septum: Just above the
columellar cartilage is an area devoid of
any cartilage. Only the skin of both sides
are meeting here
c. Septum proper: Above membranous
septum is the septum proper which is an
osteocartilagenous framework
1. Quadrangular Cartilage
2. Perpendicular plate of ethmoid
3. Vomer bone
4. Maxillary crest.
 Lateral wall
• Is formed of Projections called conchae (or
turbinates) to the nasal cavity they are curved
shelves of bones.
• They are three conchae
Inferior, Middle and Superior
• The superior and middle turbinates are parts
of ethmoid bone whereas inferior turbinate is
an independent separate bone attached to it.
• They project into the nasal cavity, creating
four pathways for the air to flow.
• These pathways are called meatuses:
Inferior meatus – between the inferior concha and floor of the nasal cavity.

Middle meatus – between the inferior and middle concha.

Superior meatus – between the middle and superior concha.

Spheno-ethmoidal recess – superiorly and posteriorly to the superior

concha
 Lateral wall
Is formed of
1. Inferior turbinate with inferior meatus in which
nasoacrimal duct opens. This opening of nasolacrimal
duct is bounded by a valve known as valve of Hasner.
2. Middle turbinate with middle meatus and
osteomeatal complex (OMC)
3. Superior turbinate with superior meatus below it in
which the post. ethmoid air cells open.
4. Sphenoethmoidal recess is above the superior
turbinate in which the sphenoid sinus open .
5. Supreme turbinate (variant)
 III. Paranasal sinuses:
• On each side there are four paranasal air
sinuses in four cranial bones arranged into 2
groups :
Frontal, Maxilla, Ethmoid and Sphenoid.
 III. Paranasal sinuses cont
They are divided into two groups:
1. Anterior Group: open to
(Osteomeatal complex).
i. Maxillary
ii. Frontal
iii. Anterior ethmoid sinuses
2. Posterior group:
i. Posterior ethmoid
ii. Sphenoid sinuses.
The posterior ethmoidal sinuses open in the superior meatus
and sphenoid sinuses open in sphenoethmoidal recess.
 Anterior

1 2 5
6
1,2,3 open
into the OMC into
sphenoethmoidal
recess

4
 Middle meatus OMC Picadle’s circle
• It lies lateral to the middle turbinate with the opening of
anterior group of sinuses.
• The bulla ethmoidalis is the most prominent anterior
ethmoidal sinus cell which appears as a bulge .
• Below the bulla ethmoidalis is the uncinate process a sickle
shaped bone.
• In between the bulla above and uncinate below there is a
hiatus semilunaris. Through the hiatus semilunaris we enter
to the infundibulum .
 Vasculature of the nose
I. External nose:
• Blood Supply
The skin of the external nose receives arterial supply from
Maxillary and ophthalmic arteries.
The septum and alar cartilages receive additional supply from
Facial artery via the angular artery and lateral nasal artery.
• Venous drainage is into the facial vein, and then in turn
into the internal jugular vein.
• Lymphatic drainage from the external nose is via superficial
lymphatic vessels accompanying the facial vein and drain
into the deep cervical lymph nodes.
 Vasculature of the nose cont.

II. The medial wall

I. External Carotid System
1. Maxillary Artery
a)Sphenopalatine artery:
b)Greater palatine artery
c)Nasal branch of anterior superior dental
artery, which is a branch of infraorbital
artery.
2. Facial Artery
Superior labial artery
II. Internal Carotid System
1.Anterior ethmoidal art.
2.Posterior ethmoidal art.

(Little’s area) which is the main source of nasal bleeding (epistaxis).

*Venous drainage:
Ophthalmic veins → cavernous sinus.
The triangular area extends from lat. Sides of
both eyes to the corner of mouth on each side is
called dangerous triangle of the face. Infection
in which may lead to cavernous sinus
thrombosis.
 Clinical Relevance:
Danger Triangle of the Face
• The venous drainage of the nose and surrounding
area is unique as a result of communication
between the facial vein and cavernous sinus, via
the ophthalmic vein.
• As the cavernous sinus lies within the cranial
cavity, this enables infections from the nasal area
to spread to the brain. This retrograde spread of
infection can therefore cause cavernous sinus
thrombosis, meningitis or brain abscess.
*Lymphatic drainage:
Ant. part to submandibular LN.
Post. part to retro- pharyngeal LN
then both to upper deep cervical LN.
 Innervation
• The innervation of the nasal cavity can be functionally divided
into special and general innervation.
• Special sensory innervation refers to the ability of the nose to
smell. This is carried out by the olfactory nerves. Branches of the
olfactory nerve run through the cribriform plate to provide special
sensory innervation to the nose.
• General sensory innervation to the septum and lateral walls is
delivered by the nasopalatine nerve (branch of maxillary nerve) and
the nasociliary nerve (branch of the ophthalmic nerve).
• Innervation to the external skin of the nose is supplied by
the trigeminal nerve
• Motor innervation to the nasal muscles of facial expression is via
the facial nerve (CN VII).
• Nerve of ptergoid canal (vidian )
Formed by sympathetic (Deep petrosal nerve ) and parasympathetic
(great Superficial Petrosal nerve )
Innervation of the nose
 The physiology & Functions of the
nose
1. Breathing
2. Smell and Olfaction
3. Humidification and temperature regulation
4. Protection of lower airway by:
*Filtration of particles large particles by vibrissae hair
and small particle by Cilia
*Sneezing reflex
* Lysozymes secretion
5. Ventilation and drainage of p.n.s
6. Nasal resistance
7. Vocal resonance
 Normal Functions of the Components
of the Sinuses
• Conchae (Turbinate)
- To increase the surface area of the nasal
cavity→this increases the amount of inspired air
- They also disrupt the fast, laminar flow of the air,
making it slow and turbulent. The air spends longer in the
nasal cavity→ humidified
• Ostia
– Drain secretions from sinuses
– Allow pressure equalization

• Cilia
– Beat at frequency 1000 strokes/min toward
ostia
– Push secretions out of sinus
• Patency of ostiomeatal complex is required for
sinusitis resolution
Nasal air current
Respiration
• The main current of airflow passes through the
middle part of the nose in a parabolic curve both
during inspiration and expiration
• During expiration, the narrowest part of nasal
cavity, i.e. the nasal valve area, offers maximum
resistance to the nasal airflow leading to the
formation of eddy currents which ventilates the
sinuses.
• So the ventilation of sinuses occurs during
expiration.
 Muco-ciliary clearance
(Mucociliary blanket)
Ciliated mucosa that protect the airway structure
1.Superficial mucus or gel layer (Thick)
2.Deep serous and sol layer (thin )
• Goblet cells in nasal mucosa secrete a mucous
blanket moving backward like a conveyer belt into
nasopharynx
• The cilia is embedded in the deep thin layer
and move backwards to the nasopharynx this
movement is biphasic formed of active rapid
phase and slow recovery phase )
• The normal ciliary action is inhibited by
1. Change in temperature : excessive heat or
cold .
2. Smoking
3. infection
• Nasal secretion contain enzymes which kills
bacteria and viruses
• Immunoglobullins IgA and IgE and interferon
are also present in nasal secretion and provide
immunity against upper respiratory tract
infections.
 Mucous membrane
of the nose
• Upper 1/3 olfactory region mucous membrane –more
delicate and yellowish
• Lower 2/3Respiratory region
• Lined by pseudostratified ciliated columnar epithelial
mucoeriosteum.
• Thick spongy highly vascular with numerous mucous
gland .
• Mucous membrane covering vestibule of the nose
carries stiff hairs
• Rich arteriovenous anastomosis warms the air passing
through it.