Anatomy of nose
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DR PRIYANKA
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EMBRYOLOGY
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OSTEOLOGY OF NOSE
MAXILLA
FRONTAL ( UNPAIRED )
ETHMOID ( “ )
SPHENOID ( “ )
INFERIOR TURBINATE
LACRIMAL
PALATINE
NASAL BONES
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Sphenoid bone
Bone spanning the width of middle cranial fossa
Consists of central body and three processes; greater and lesser wings and pterygoidprocess (pos. view)
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Sphenoid Bone (Floor of Cranium) (Green Colored Bone)
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Maxilla
The largest bones of the face, except for the mandible and form, by their union, the whole of the upper jaw.
Each assists in forming the boundaries of three cavities, namely, the roof of the mouth, the floor and lateral wall of the nose, and the floor of the orbit.
Zygomatic, frontal, palatine and alveolar process Landmarks:
Infra Orbital foramen: hole below the orbit, for blood vessels and nerves
Alveolar process: arch of the maxilla containing the upper teeth
Palatine process: horizontal projection of the maxilla forming the anterior ¾ of the hard palate.
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Maxilla
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Lacrimal canal : groove posterior to frontonasalprocess, lacrimalbone and lacrimalprocess of inferior turbinate
Infraorbitalforamen
Greater palatine canal
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Ethmoid Bone An irregularly shaped, spongy bone that provides the floor of the front part
of the skull and the roof of the nasal cavity.
The ethmoid consists of two masses of thin plates enclosing air cells and looks like a sieve.
Landmarks:
Lateral masses: form most of the wall between the nasal cavity and the orbits
Perpendicular plate: forms the superior portion of the nasal septum
Cribiform plate: forms the roof of the nasal cavity
Olfactory foramina: small holes within the cribiform plate for passage of the first cranial nerve (for smell)
Crista galli: upward extension of bone above the cribiform plate, acts as an anchoring point for one of the coverings of the brain.
Nasal concha (turbinates): two scroll-shaped projections with a mucus membrane on either side of the nasal septum. Function to cause air turbulence and trap inhaled particles.
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Ethmoid bone - landmarks
Cribiform plates Forms roof of nasal
cavity, fits into the notch in frontal bone, foramina : olfactory nerve
Horizontal and vertical lamella lamella
Crista galli Attachment of the
dura mater which secures brain in cavity
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Nasal Bones
Bridge of nose
Internal surface : groove for anterior ethmoidal nerve
Superior border articulates with frontal bone
Lateral border : frontonasal process of maxilla
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Lacrimal BonesSmallest and most
fragile bone of the
face
Contains the lacrimal
sac and the naso-
lacrimal duct.
Orbital surface : posterior lacrimalcrest
Btwn anterior and posterior lacrimalcrest : lacrimal sac
Lacrimal bone
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Palatine bones
Fragile L shaped bone
It contributes to the
walls of three
cavities: the floor
and lateral wall of
the nasal cavity,
the roof of the
mouth, and the
floor of the orbit
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Horizontal plate
Posterior section of hard palate
Perpendicular plate
Part of the posterolateralwalls of nasal cavity
Greater palatine canal
Orbital surface
Part of inferior medial aspect of orbit
Processes :
Orbital process
Sphenoid process
Between the two : sphenopalatine notch
Pyramidal process
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Inferior Nasal Conchae
Extends horizontally
along the lateral wall
of the nasal cavity
and consists of a
lamina of spongy
bone, curled upon
itself like a scroll.
Inferior Nasal Conchae
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NOSE Consists of:
External Nose
Nasal cavity
The external nose :
Is a pyramidal projection
of face
tip
Root
dorsum
ala of nose bounding inferiorly a pair of nostrils
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EXTERNAL NOSEOsteocartilaginous
framework:
Bony pyramid –upper 1/3rd
Cartilaginous part –
lower 2/3rd
(Upper & lower
cartilaginous vault)
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BONY VAULT Formed by Nasal bones and frontal
process of maxilla
Paired nasal bones, each one is tapered, thin and bevelled below but gradually thickens upwards encroaching upon the nasal cavity
Two nasal bones form a crest in midline
Articulates
Upwards with nasal spine of frontal & perpendicular plate of ethemoid
Laterally with frontal process of maxilla (is thick below n thin above) by nasomaxillary suture
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Cartilaginous vault
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UPPER CARTILAGENOUS VAULT Paired, Triangular ULC and part of
septal cartilages enclosed in common perichondrial sheath
Base at septum, Apex at pyriform fossa
Cephalic attachment to nasal bones Nasal bones overlap over ULC 1cm Held in place with intimate fusion
b/w perichondrium and periostium
Medial borders are thick and continuous with dorsal border of septal cartilage.
Laterally ULC are short of pyriform edge of maxilla, the gap is filled by dense fibrofatty tissue (empty triangle)
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Lowermost part of nasal fossae, bounded superiorly by caudal edge of ULC is vestibule.
Lined by thin skin having coarse hairs and sebaceous , sweat glands.
Internal nasal valve-triangular area bounded lat by caudal edge of ULC ,septum medially, nasal cavity floor inf,is narrowest part of nasal cavity
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LOWER CARTILAGENOUS VAULT Paired alar cartilages (few sesamoid
cartilages)
can move freely over ULC and septal
Contribute to formation of lobule, columella and ala.
Each one made up of single piece of C-shaped cartilage ,having parts medial, middle and lateral crura
Lateral crus - 1 mm in thickness
Starts at domal segment and arch outwardly convex
• Middle crus-
from columella to lateral crus
Divided into domal and lobular segment
Medial crus-
It starts at footplate and extends into columella
lies under the thin skin of columella and two med crura are attached by fibrous tissue and to lower end of septum by membranous septum
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COLUMELLA Extends between upper lip and
tip of the nose Divided into three almost equal
parts , upper –lobular, middle and basal part –wider
Consist of paired medial crura with covered skin, variable length of crura may produce projecting or depressed tip
Anteriorly- diverging crura form an angle of 30 degrees for tip formation.
Posteriorly - also diverge to receive post septal angle, adjoining septal cartilage and anterior nasal spine.
Shape of columella depends on size and shape of medial crura.
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SOFT TISSUE COVERING Nasal skin : thick over-nasion,
supratip area and thin at rhinion over lower firmly adherent to
cartilages over nasal bones and ULC is mobile
Subcutaneous tissue covering thickens gradually downwards from rhinion: has 4 layers
1. Superficial panniculus2. Fibromuscular layer3. Deep fatty layer4. Periosteum/ perichondrium
Incisions in rhinoplasty are given deep to all these layers since blood vessels run in deep fatty layer.
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NASAL MUSCULATURE
Elevators: Procerus Levator labii
superioris alaquenasi
Depressors: Alar part of nasalis Depressor septiCompressor: Tranverse part of
Nasalis Compressor narium
minor Dilators:
dilator naris
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ARTERIAL SUPPLY
Dorsal and external nasal branch of ophthalmic artery
Infra orbital br. of maxillary artery
Lateral nasal and angular br. of facial artery
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Venous drainage
•External veins of nose drain to angular and opthalmic veins
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NERVE SUPPLY TO EXTERNAL NOSE
Sensory supply:
By branches of ophthalmic and maxillary div. Of trigeminal
infra trochlear branch-skin of root and adjacent sides of nose
infra orbital, external nasal nerve- skin of lower half of nose
terminal branches of palatine nerves – skin of base of columella
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NERVE SUPPLY TO INTERNAL NOSE
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NASAL SEPTUM NASAL SEPTUM HAS 3 PARTS :
COLUMELLAR : Columellar septum. It is formed of
columella
Containing the medial crura of alar cartilages united
together by fibrous tissue and covered on either side by
skin.
Membranous septum. It consists of double layer of skin
with no bony or cartilaginous support. It lies between the
columella and the caudal border of septal Cartilage. Both
columellar and membranous parts are freely movable from
side to side.
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Septum proper. It consists of osteocartilaginous
framework, covered with nasal mucous membrane.
Cartilagenous portion composed of quadrilateral cartliage,
contributions from lower and upper lateral cartilages.
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Bony septum : mainly by perpendicular plate of
ethmoid and vomer
Minor contributions : crest of nasal bone
nasal spine of frontal bone
rostrum of sphenoid
crest of palatine bone
crest of maxilla
anterior nasal spine of maxilla
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Bony septum: perpendicular plate of ethmoid forms
the superior and anterior bony septum, which is
continuous above with the cribriform plate and crista
galli.
Vomer defined as keel shaped bone, extends anteriorly
from spenoid and superiorly from nasal crest of
maxilla and palatine bone.
forms the posterior and inferior nasal septum and
articulates by its two alae with the rostrum of sphenoid
creating vomerinovaginal canals which transmit
pharyngeal branches of maxillary artery.
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The upper margin expands which is connected to the upper lateral cartilages.
Bound firmly by collagenous fibres to the nasal bones And to the perpendicular plate of the ethmoid and vomer
Inferior border of vomer articulates with nasal crest formed by maxillae and palatine bones.
Anterior border articulates with perpendicular plate of ethmoid and septal cartilage inferiorly.
Posterior border forms the free edge
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LATERAL WALL OF NOSE
The lateral wall of nose:
Maxillary bone
Ethmoid bone
Sphenoid bone
Inferior turbinate
Lacrimal bone
Palatine bone
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The nasal turbinates are embryologically derived from a series of outgrowths from the foetal lateral nasal wall.
The outgrowths form a series of ridges, referred to as “ethmoturbinals” which are separated by furrows.
Each ridge has an anterior ascending portion and a posterior descending portion.
The uncinate process develops from the descending portion of the first ridge, which is also known as the “nasoturbinal”
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The agger nasi develop from its ascending portion.
The second ridge forms the bulla lamella, or the bulla ethmoidalis when pneumatized.
The middle turbinate develops from the third ridge, which is the first permanent ethmoturbinal.
The fourth ridge, the second permanent ethmoturbinal, forms the superior turbinate.
Based upon this, variations in development and pneumatization of the ethmoturbinalsmay lead to anatomical variations within the bony structures of the ethmoidal complex.
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Nasal turbinates:
The turbinates are the most prominent feature of the lateral nasal wall . They are usually three or sometimes four in number. These turbinates appear as scrolls of bone, delicate, covered by ciliated columnar epithelium. These turbinates sometimes may contain an air cell, in which case it is termed as a concha.
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Inferior turbinate, meatus
Largest turbinate and largest meatus
Highest at the jnctn of ant and middle 3 rd (1.6-2.3 cm)
Separate bone covered by thick mucous membrane
Nasolacrimal opening in anterior portion of lateral wall of inferior meatus
Slit like opening is protected by fold of mucous membrane, the plica lacrimalis or valve of Hasner
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Middle turbinate/meatus
Portion of ethmoid bone
It recieves drainage from the frontal, maxillary and antethmoidal cells
hiatus semilunaris and ethmoid infundibulum.
maxillary hiatus.
ant and post fontanelles
recesses terminalis
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MIDDLE MEATUS
Infundibulum – Air passage
connecting the maxillary sinus
ostium to middle meatus
Hiatus Semilunaris – Gap
between the uncinate process
and bulla ethmoidalis. Medially
it communicates with middle
meatus. Laterally & inf it
communicates with
infundibulum
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Middle turbinate
3 parts
Anterior 1/3rd : saggital plane : cribriform plate at the junction of medial and lateral lamella
Middle 1/3rd : coronal plane; lamina papyracea : ground lamella / basal lamella
Posterior 1/3rd : horizontal plane : lamina papyraceaand perpendicular plate of palatine bone.
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OSTEO MEATAL COMPLEX The osteomeatal complex is the key anatomic area
addressed by endoscopic sinus surgeons. Blockage of the
osteomeatal complex prevents effective mucociliary
clearance, thus leading to a stagnation of secretions and
therefore leading to recurrent or chronic sinusitis.
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OSTEO MEATAL COMPLEX The OMC is bounded
medially by the middle
turbinate,
posteriorly and superiorly
by the basal lamella, and
laterally by the lamina
papyracea.
Inferiorly and anteriorly
the OMC is open.
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OSTEO MEATAL COMPLEX
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Uncinate process:
This is the most stable landmark in the lateral nasal wall.
Horizontal and vertical limb
It is a wing or boomerang shaped piece of bone. It attaches anteriorly to the posterior edge of the lacrimalbone, and inferiorly to the superior edge of the inferior turbinate .
Superior attachment of the uncinate process is highly variable, may be attached to the lamina palyracea ( 80 % ),or sometimes to the middle turbinate or lie freeewithin middle meatus
The configuration of the ethmoidal infundibulum and its relationship to the frontal recess depends largely on the behavior of the uncinate process
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Variations in the superior insertion of the uncinate process are classified according to criteria developed by Landsber & Friedman
A: Type 1 (insertion into the lamina papyracea). B: Type 2 (insertion into the posterior wall of agger nasi
cell). C: Type 3 (insertion into the lamina papyracea and junction
of the middle turbinate with the cribriform plate). D: Type 4 (insertion in to junction of the middle turbinate
with the cribriform plate). E: Type 5 (insertion into the skull base). F: Type 6 (insertion into the middle turbinate)
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Uncinate attached to lamina : frontal sinus drainage : medial to uncinate process
Attached to skull base : frontal sinus drains into infundibulum : disease from frontal sinus spreads to maxillary
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The Agger Nasi Air Cell :
Its an ethmoturbinal remnant present in nearly all patients ( 93 % )
The ANC is the most constant and anterior of the ethmoidal air cells.
Located anterior to the vertical attachment of the middle turbinate to the skull base.
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The degree of ANC pneumatization varies and has a significant effect on both the size of the frontal sinus ostium and the shape of the recess.
If the ANC is small, then the “beak” of the frontal process of the maxilla, lying anteriorlyand superiorly, will be prominent and extend posteriorly into the frontal recess, resulting in a narrow ostium.
If the ANC is large, the beak will be small, resulting in a wider ostium but potentially causing obstruction more inferiorly.
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ETHMOID BULLA Well pneumatized most constant anterior ethmoid cell
8% rudimentary/ absent
Separated posteriorly from ground lamella by retrobullar recess
if does not extend upto skull base, suprabullar recess.
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If both suprabullar and retrobullar recess are absent : semilunar space above and behind the bulla : sinus lateralis
Sinus lateralis opens into middle meatus by a cleft : hiatus semilunaris superioris
Frontal recess may drain into sinus lateralis
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FRONTAL RECESS• The frontal recess is an hourglass like narrowing
between the frontal sinus and the anterior middle meatus through which the frontal sinus drains
• Bounded anteriorly by agger nasi cell
Posteriorly by bulla ethmoidalis
Laterally by lamina papyracea
Medially by middle turbinate, lateral wall of olfactory fossa.
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Roof of frontal recess formed by fovea ethmoidalis: thick bone : resistance to injury
Anterior ethmoid artery runs across fovea ethmoidalis
When ther is a suprabullar recess : ethmoid artery will be in the frontal recess
Anterior ethmoidal artery may lie in a mesentry in 15-45% pts, suspended from the skull base.
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Anatomical variants
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Fronto-ethmoid/kunh cells/bulla frontalis
Are the anterior ethmoid cells which invade the frontal bone, bulging its floor
They are more easily demonstrated at saggital view, where they appear as ethmoid air cells located above the ethmoid bulla and as an extension towards the frontal sinus.
Depending on their size and pneumatization extent, such cells may affect the frontal sinus drainage.
These air cells, are categorized into four types depending on their number and degree of extension into the frontal sinus.
They are all located superior to the ANC.
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Type 1 (most common): Single cell superior to the ANC that does not extend into the frontal sinus
Type 2: Two or more cells superior to the ANC that may or may not extend into the frontal sinus.
Type 3: Single frontal cell superior to the ANC that extends into the frontal sinus.
Type 4: Completely contained in the frontal sinus. This configuration is rare.
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This is formed by lateral and posterior pneumatization of the most posterior ethmoid cells over the sphenoid sinus.
The presence of Onodi cells increases the chance that the optic nerve and / or carotid artery would be exposed in the pneumatized cell.
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VARIATIONS OF THE CRIBRIFORM PLATE
The cribriform plate may present at variable levels and, it is classified according to the criteria developed by Keros.
It is based on the height of the olfactory fossa in relation to the roof of the ethmoid sinus as compared with the length of the lateral lamella of cribriformplate.
The higher the Keros grade, the greater the chance of injury of the cribriform plate and olfactory fossa.
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A: Type 1 (lateral cribriform lamella of 1–3 mm, the cribriform plate and the ethmoid cell roof are practically parallel to each other).
B: Type 2 (lateral lamella of 4-7 mm, cribriform plate is much below the nasal cavity as compared with the ethmoid roof).
C: Type 3 (lateral lamella of cribriform plate of 8–16 mm, ethmoid cell roof is located much above the plate
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Haller cell Infraorbital ethmoid cells
or Haller cellsareethmoid air cells located anteriorly to the ethmoidbulla, along the orbital floor, adjacent to the natural ostium of the maxillary sinus, which may cause mucociliary drainage obstruction, predisposing to the development of sinusitis.
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VARIATIONS IN MIDDLE TURBINATE Concha bullosa is a
variation originated from pneumatization of the bone plate by extension of ethmoid sinus cells.
Such variation may be either uni- or bilateral.
Varied degrees of pneumatization of the concha may be observed, possibly causing middle meatus or infundibulumobstruction.
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PARADOXICAL TURBINATES Paradoxical turbinates occur as the convexity of the middle
turbinate is directed towards the medial wall of the maxillary sinus.
Depending on the degree of curvature of the paradoxical turbinate compression of the infundibulum and sinusalobstruction may be observed.
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A)horizontal uncinate
b)hypertrophy of lt uncinate.
C)pneumatisation of lt uncinate.
D)vertical lt uncinate.
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ACCESSORY MAXILLARY OSTIA Accessory maxillary ostia are generally solitary, but
occasionally may be multiple.
Easily seen, circular : tunnel like, ovoid
Such variation may be congenital or secondary to sinusaldiseases.
Possible mechanisms involved in the development of such variation include:
main ostium obstruction, maxillary sinusitis or anatomical/pathological factors in the middle meatus, resulting in rupture of membranous areas.
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