بسم الله الرحمن الرحيم NOSE I & IV DR. SAMI ALHARETHY associate. PROF. FACIALPLASTIC CONSULTANT KSU

Functions Of The Nose Respiratory channel Warming and humidifying inspired air Cleaning and filtering inspired air Olfaction

Function of Paranasal Sinuses to act as resonators to the voice They also reduce the weight of the skull When the apertures of the sinuses are blocked or they become filled with fluid, the quality of the voice is markedly changed

ANATOMY OF SINO-NASAL TRACT External nose Nasal cavity Paranasal sinuses

Anatomy of the External Nose

THE NASAL CAVITY Nasal Vestibule Nasal Cavity Proper

THE NASAL VESTIBULE

THE NASAL CAVITY Roof Floor Lateral wall Medial wall (septum)

The Roof

The Floor

The Medial Wall (Nasal Septum)

Lateral Nasal Wall

Lateral Nasal Wall

The Lining Mucosa Respiratory mucosa Olfactory mucosa skin

The Olfactory Mucosa

The Respiratory Mucosa

Arterial Blood Supply External Carotid Internal Carotid Maxillary Facial Internal Carotid Ophthalmic

Blood Supply Of The Nasal Cavity Lateral Wall Nasal Septum

Venous Drainage Facial vein Internal jugular Angular vein Ophthalmic Cavernous sinus

Venous Drainage

Lymphatic Drainage Submandibular Retropharyngeal Superior deep cervical

Nerve Supply Of The Nasal Cavity Olfactory General sensory: Trigeminal nerve Autonomic: sphenopalatine ganglion

Olfactory Nerve Supply

Sensory Nerve Supply Ophthalmic and maxillary branches of the trigeminal

ANATOMY OF THE PARANASAL SINUSES

The Maxillary Sinus

The Maxillary Sinus

The Maxillary Sinus Sinus ostium located in the middle meatus

The Ethmoid Sinuses

The Ethmoid Sinuses

The Ethmoid sinuses Anterior ethmoids: drain into the middle meatus Posterior ethmoids: drain into superior meatus

The Frontal Sinus Rarely present at birth; usually not visible until age 2 Great variability in size; congenitally absent in 5%

The Sphenoid Sinus

The Sphenoid Sinus

Lining of the Sinuses Pseudostratified columnar epithelium with goblet cells (respiratory epithelium) which is continuous with the nasal epithelium

Blood Supply Branches from the internal and external carotids

Nerve Supply Branches from the trigeminal

Investigation of Nasal Diseases Endoscopy Rhinometry Measurement of olfaction Skin allergy test Mucociliary clearance tests Imaging

Endoscopy

Rhinometry Objective measurement of the nasal resistance or the flow of air in the nasal cavities Poiseuille's Law

Skin allergy test

Imaging of The Paranasal Sinuses Plain X-Rays CT scan MRI

Occipitomental View (Water’s View)

Occipito-frontal View (Caldwell View)

Lateral View

Submento-vertical view

CT Paranasal Sinuses Axial Coronal

Normal Axial

Normal coronal

MRI

Development of the sinuses A) at birth B) at 10-years C) at 15

Development of the sinuses

CONGENITAL ANOMALIES

Anterior Nares Deformity

Dermoid cysts

Glioma

Glioma

Meningo and encephaloceles

Meningo and encephaloceles

CHOANAL ATRESIA

THE CHOANA

Choanal Atresia ? Due to persistence of the primitive bucconasal membrane Unilateral or bilateral Bony, membranous or mixed

Unilateral Choanal Atresia

Unilateral Choanal Atresia Usually diagnosed late in life Presents by unilateral nasal obstruction and unilateral mucoid nasal discharge Treatment is by elective surgical repair

Bilateral Choanal Atresia Isolated anomaly in 60-70% May be linked to CHARGE association

CHARGE ASSOCIATION Coloboma Heart disease Atresia Retarded growth Genital hypoplasia Ear deformity

Bilateral Choanal Atresia Usually presents at birth by attacks of cyclic cyanosis and respiratory obstruction Nasal discharge

Diagnosis Clinical examination: “mirror test” Inability to pass a catheter into the nasopharynx Endoscopy Radiographs

Management Emergency Definitive surgery Immediate airway support with oral airway, McGovern nipple, or intubation Definitive surgery

THE NASAL VESTIBULE

Acute Infections Acute vestibulitis Furunculosis

Acute Vestibulitis Inflammation of the skin of the vestibule, usually due to Staphylococcus aureus

Causes Habitual rubbing of the nose Allergy Rhinorrhea

Clinical Features Pain Irritation Redness and swelling Crusting

Treatment Local antibiotics and corticosteroids

Furunculosis Acute infection of the hair follicles with Staphylococcus aureus

Complications Local abscess Spreading cellulitis Cavernous sinus thrombophlebitis

Treatment Avoid squeezing Local application of heat Antibiotics

Other Conditions of Vestibule and External Nose Erysipelas Impetigo Herpes simplex and zoster Warts Lupus vulgaris Syphilis Basal and squamous cell carcinoma

بسم الله الرحمن الرحيم NOSE –IV- DR. SAMI ALHARETHY Associte PROF. FACIALPLASTIC CONSULTANT KSU

Diseases of the nasal septum Epistaxis Turbinate hypertrophy Nasal operations SAMI ALHARETHY

Diseases of the nasal septum Deviated nasal septum Septal hematoma and abscess Perforated septum

DEVIATED NASAL SEPTUM

Etiology Trauma Maldevelopment

Symptoms Nasal obstruction

Symptoms Nasal obstruction External deformity Crusting, epistaxis

Examination

Radiology Unnecessary in most cases

Treatment No treatment Septoplasty

Septoplasty

Complications of Septoplasty Septal hematoma & abscess Septal perforation Nasal deformity Synechia (adhesion)

HEMATOMA OF THE SEPTUM

Etiology Direct trauma Operative trauma Blood dyscrasias

Clinical Features

Complications Cartilage necrosis Septal abscess Permanent thickening of the septum

Treatment Incision and drainage Systemic antibiotics

PERFORATION OF SEPTUM

Clinical features Asymptomatic Crusting Epistaxis Whistling

Treatment No treatment Nasal wash Surgical closure

Surgical Reduction of the Inferior Turbinates Turbinate resection, total or partial Outfracturing of the inferior turbinate Destructive procedures, including electrocautery, cryosurgery, laser surgery, and submucous resection

EPISTAXIS

Why bleeding from the nose ? Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa Arterial to venous anastamoses ICA and ECA blood flow

SITES Anterior ( Little’s area) Posterior (vicinity of sphenopalatine foramen)

Kesselbach’s Plexus/Little’s Area: Anterior Ethmoid (Opth) Superior Labial A (Facial) Sphenopalatine A (IMAX) Greater Palatine (IMAX) Woodruff’s Plexus: -Sphenopalatine A (IMAX)

LOCAL CAUSES Acute trauma Chronic trauma Deviated septum Inflammation of the nose and sinuses Tumors Idiopathic

SYSTEMIC CAUSES Coagulation and bleeding diseases Atherosclerosis Familial hemorrhagic telangiectasia

MANAGEMENT General measures Stop the bleeding Prevent further bleeding

CONTROL THE BLEEDING Digital pressure Cautery Anterior nasal packing Postnasal pack Arterial ligation Maxillary, Ethmoids, External carotid Arterial embolization

Anterior nasal packing

Postnasal packing

Arterial ligation

Arterial ligation

Arterial embolization

ANGIOFIBROMA Juvenile nasopharengeal Benign Adolcent Males Frequent chronic epistaxis Nasal obstruction Rhinorrhea Conductive hearing loss Diplopia Otitis Media Treatment: embolization & Surgery

What do you think? 25 years old man post RTA with fever and nasal obstruction. What is your diagnosis? What is your management?

What is this radiological study? What is A,B and C?

This is a CT scan of a newborne who presented with respiratory distress. A- what is your diagnosis? B- what is the management?

thanks