Nasal Cavity and Pterygopalatine Fossa R. Shane Tubbs, MS, PA-C, PhD

columella Five major cartilages

Piriform aperture Anterior nasal spine Nasal septum Nasal bones

Nasal Cavity: Borders Roof: frontal, ethmoid (cribriform), sphenoid, nasal bones Floor: maxillary and palatine bones Medial: nasal septum Lateral: nasal conchae, lacrimal, maxillary, palatine bones

Nasal Septum vomer Perpendicular plate Septal cartilage Vomer Medial crus of > alar cartilage Nasal crests of maxillary, palatine, and sphenoid bones Nasal spine of frontal bone vomer

Vomeronasal Cartilage Along inferior border of septal cartilage Rudimentary in man Vomeronasal nerve of Jacobson in lower animals- pheromones

sphenopalatine foramen ethmoid maxillary inferior concha sphenopalatine foramen

bulla uncinate process

Features Bulla (bubble) Nasofrontal duct Uncinate process Semilunar hiatus

Valve of Hasner (Czech Ophthalmologist 1819-1892) Iatrogenic closure

Features Vestibule: skin/vibrissae, sweat and sebaceous glands Upper 1/3 Lower 2/3 Limen (entrance) nasi (lateral nasal cartilage) Agger (mound) nasi (ethmoid air cells)

Olfactory Nerves ~ 20 pairs Most commonly injured cranial nerve CSF rhinorrhea Do not regenerate in elderly

Pterygopalatine ganglion Vidian anterior ethmoidal greater palatine nasopalatine

Arterial Supply Sphenopalatine Anterior ethmoidal Posterior ethmoidal Greater palatine Superior labial and lateral nasal branch of facial

Plexus Cavernosi Concharum

Nasal Veins/Lymphatics Veins: Drain via sphenopalatine foramen into pterygoid plexus and some via ethmoidal foramina to superior ophthalmic vein Lymphatics: Majority join pharyngeal plexus and thus drain into retropharyngeal nodes

Paranasal Air Sinuses

Paranasal Air Sinuses Function Named for the bones they occupy Paired Surrounded by diploic space of contiguous bones

Frontal Sinus Frontonasal duct- semilunar hiatus Innervation: supraorbital n. Variation Acromegaly Eskimos Related to anterior cranial fossa Tubbs et al. J Neurosurgery, 2002

Ethmoid Sinus (3-18 pairs) Named on the basis of their openings anterior: semilunar hiatus middle: ethmoidal bulla or directly into middle meatus posterior: superior meatus Innervation: anterior and posterior ethmoidal nerves and branches of pterygopalatine ganglion

Sphenoid Sinus Sphenoethmoidal recess Most variable cavity in the body! 15% of all cases of sinusitis Ostium is 1.5 cm superior to its floor Innervation: Posterior ethmoidal nerve and branches of pterygopalatine ganglion Related to middle cranial fossa

ostium

Maxillary Sinus Maxillary: semilunar hiatus Innervation: ant, middle, posterior superior alveolar nerves, infraorbital (V2) Most commonly infected sinus Drains superiorly as does sphenoid sinus

ostium

Antrum of Highmore (British surgeon 1613-1685)

mastoid air cells

Pterygopalatine Fossa “A pyramidal space inferior to the apex of the orbit and lateral to the nasal cavity” ~ 2 x 1 cm Arteries: post sup alveolar, descending palatine, pterygoid canal, pharyngeal, sphenopalatine Maxillary nerve Nerve of pterygoid canal (Vidian) Pterygopalatine ganglion (posterior to middle nasal concha) Pterygopalatine nerves

Four canals: Vidian, vomerovaginal, palatovaginal, greater palatine canal Two foramina: rotundum, sphenopalatine Two fissures: inferior orbital, pterygomaxillary

pterygopalatine fossa

Pterygopalatine Fossa Lateral: pterygomaxillary fissure Medial: perpendicular plate of palatine with sphenopalatine foramen Posterior: Pterygoid process with Vidian canal, rotundum Anterior: maxillae with inferior orbital fissure, posterior superior alveolar foramen (lateral) Roof: > wing sphenoid, superior orbital fissure Inferior: pyramidal process, palatine canal (oral cavity)

perpendicular plate

Pterygopalatine Ganglion Parasympathetic root Sympathetic root Sensory root

Distribution of Pterygopalatine Ganglion Sphenoid sinus (pharyngeal branch) Posterior ethmoid cells Nose Hard and soft palate Inner gingivae of maxillary teeth Palatine tonsil Choana Uppermost pharynx Orbit

geniculate ganglion

Vidian Nerve Course

Sluder’s neuralgia (pterygopalatine neuralgia) excessive tearing, cluster HA Vidian neurectomy Crocodile tears