Anatomy of the nose and paranasal sinus The nose and paranasal sinuses form a complex unit of different

cavities at the entrance of the upper airway. The anatomic structures and the physiology of the nose and paranasal sinuses are tied up with one other and form a complete system with highly specific functions. These functions include air conditioning, filtering, and warming of inspired air and potentially forming a immunologic response for allergens, pollutants, and other particles to protect the delicate structures of the lower airway. The nose itself can be divided into the external nose and the nasal cavity. External nose It is the prominent part of the face, with pyramidal in shape. The apex is the tip of the nose, the base is the attached area to the forehead. The external nose projecting downwards and is perforated by two apertures called the nostrils separated by the columella. The lateral surfaces joined along the dorsum of the nose where it meets the forehead. External nose made up from bony and cartilaginous parts.

Bony framework is formed by the following bones: (1) The nasal bones. (2) The nasal processes of the frontal bone (3) The frontal processes of the maxilla. Cartilaginous Framework is formed by small cartilages and the quadrilateral septal cartilage. Blood supply is by Facial and Ophthalmic arteries and the veins. Lymphatic Drainage passes to the pre-auricular and sub-mandibular lymph nodes. Nasal cavity The nasal Septum divides the nose into 2 nasal cavities. These two nasal cavities lie below the cranial cavity, above the oral cavity and between the orbits.

Each nasal cavity communicates with (1) Exterior through the anterior nares (2) Nasopharynx through the posterior nares (choana) (3) Paranasal sinuses through the Ostia. (4) Middle ear through Eustachian tube The anterior part of the nasal cavity opens anteriorly in the nostril while the nose communicates posteriorly with the rhinopharynx. Usually, nasal cavity divide into three parts: the nasal vestibule, the olfactory region and the respiratory region. The junction of the vestibule with the nasal cavity is called the internal nasal valve. It is situated between the caudal end of the upper alar cartilage laterally, and the septum medially. Its apical angle has an angulation of less than 15'. It is the narrowest site of the nasal cavity, only 0.3 cm2 on each side. Excluding the olfactory region, which consists of the upper part of the nasal cavity and the superior turbinates, the remainder of the nasal cavity constitutes the respiratory region. The total surface area of both nasal cavities reaches about I 50 cm2 and the total volume about 15 ml. 1) The vestibule The anterior and inferior portion of the nasal cavity that is lined by skin in contrast to the rest of the nasal cavity. It bears sebaceous glands and hair follicles. The hairs are called vibrissae. 2) Olfactory region The roof of the nasal cavity, the region above the superior turbinate and the adjoining septum. It is lined by the yellow olfactory neuro-epithelium having bipolar sensory cells. 3) The respiratory region The lower 2/3 of the nasal cavity is lined by pseudo stratified ciliated columnar epithelium rich in goblet cells. The mucosal here is very vascular and has erectile tissue. It is pink in colour. It is continuous with the mucosa of the sinuses,nasopharynx and Eustachian tubes. The ciliary movement propels the nasal secretions backwards towards the posterior choanae. The sub-epithelial tissue is also loose, very vascular and erectile. There are many mucous and serous glands. The lateral nasal wall supports the three turbinates (inferior, middle, superior and sometimes there is even a supreme) that divide this lateral wall into three meatus (inferior, middle, superior). Before 9 weeks of gestation, three soft- tissue elevations (the preturbinates) can be identified within the nasal cavity; they are orientated both in size and position in a similar way to the inferior, middle and superior turbinates in the adult (14). The turbinates contain cartilage at 9 weeks of gestation. The inferior turbinate ossification appears to precede that of the middle turbinate (1 7 weeks vs 19 weeks of gestation] ( 15). The head of the inferior turbinate interferes directly with the entering airflow and its tail, in case of hypertrophy, can significantly reduce the choanal size. The middle turbinate covers the ostium of the major sinuses medially, while the supreme turbinate is not always present.

The picture of nasal cavity. Sphenoethmoid recess (arrow above 1), superior concha (1), superior meatus (tip of arrow), middle concha (2), middle meatus (tip of arrow), inferior concha (3), inferior meatus (ti of arrow)

Functions of the Nose (1) Respiration: The nose is for breathing. Mouth breathing occurs when the nose is blocked. (2) Air conditioning: The air inhaled through the nose is warmed and moistened before it reaches the lungs. (3) Protection: Inhaled air is purified in the following ways: Vibrissae filter coarse particles. Cilia remove smaller particles which stick to the mucosa in the nose and are passed backwards into the pharynx by the ciliarys movements. The mucous which reaches the pharynx is swallowed. Lysozymes can kill the bacteria. Sneezing throws out irritating particles or fumes from the nose. (4) Olfaction is an important function of the nose and it has a protective value against approaching dangers. (5) Resonance is added to the voice by the nasal cavity. (6) Eustachian Tube functioning: The nose permits equalization of pressure of air between the external atmosphere and the middle ear cavity through the Eustachian tube. (7) Drainage: The paranasal sinuses and nasolacrimal duct drain into the nasal cavity. (8) Reflexes: Sneezing is a reflex action that has a protective function. When the individual is exposed to irritants, the respiration may be stopped temporarily. Olfactory sense may also reflexly stimulate salivary and gastric secretions.

Paranasal Sinus The complexity of the paranasal sinuses anatomy, as well as their many functions make the sinuses an interesting and rewarding topic of study. There are a total of four paired sinuses. They include the frontal, ethmoid, maxillary and sphenoid sinuses. These sinuses are essentially mucosa-lined airspaces within the bones of the face and skull. Their development begins in the womb, but results in only two clinically-relevant sinuses by birth--the maxillary and ethmoid sinuses. Paranasal sinuses clinically divided into two groups, the anterior and posterior. Anterior group boils down concha media, in or near the infundibulum, consisting of the frontal sinus, maxillary sinus, and the cells anterior sinus etmoid. Posterior group geared at various places in the concha media composed of cells etmoid posterior sinus and sphenoid sinus. Line concha media attachment on the lateral nasal wall is the boundary between the two group. Maxillary sinus The maxillary sinus is the largest paranasal sinus and lies inferior to the eyes in the maxillary bone. It is the first sinus to develop and is filled with fluid at birth. It grows according to a biphasic pattern, in which the first phase occurs during years 0-3 and the second during years 6-12. The earliest phase of pneumatization is directed horizontally and posteriorly, whereas the later phase proceeds inferiorly toward the maxillary teeth. This development places the floor of the sinus well below the floor of the nasal cavity. The shape of the sinus is a pyramid, with the base along the nasal wall and the apex pointing laterally toward the zygoma. The natural ostium of the maxillary sinus is located in the superior portion of the medial wall. The anterior maxillary sinus wall houses the infraorbital nerve, which runs through the infraorbital canal along the roof of the sinus and sends branches to the soft tissues of the cheek. The thinnest portion of the anterior wall is above the canine tooth, called the canine fossa, which is an ideal entry site for addressing various disease processes of the maxillary sinus. The roof of the maxillary sinus is the floor of the orbit. Behind the posteromedial wall of the maxillary sinus lies the pterygopalatine fossa, a small inverted space that houses several important neurovascular structures and communicates with several skull base foramina. The infratemporal fossa lies behind the posterolateral wall of the maxillary sinus. Frontal sinus The frontal sinus is housed in the frontal bone superior to the eyes in the forehead. It is formed by the upward movement of anterior ethmoid cells after the age of 2. Growth of this sinus increases at the age of 6 and continues until the late teenage years.[1] The frontal sinuses are funnel-shaped structures with their ostia located in the most dependent portion of the cavities. The posterior wall of the frontal sinus, which separates the sinus from the anterior cranial fossa, is much thinner than its anterior wall. Sphenoid sinus The sphenoid sinus originates in the sphenoid bone at the center of the head. It arises not from an outpouching of the nasal cavity but from the nasal embryonic lining. The sinus reaches its full size by the late teenage years. The sphenoid sinus is variably pneumatized and may extend as far as the foramen magnum in some patients.

The thickness of the walls of the sphenoid sinus is variable, with the anterosuperior wall and the roof of the sphenoid sinus (the planum sphenoidale) being the thinnest bones. The sphenoid sinus ostium is located on the anterosuperior surface of the sphenoid face, usually medial to the superior turbinate. Ethmoid sinus The ethmoid sinuses arise in the ethmoid bone, forming several distinct air cells between the eyes. They are a collection of fluid-filled cells at birth that grow and pneumatize until the age of 12. The ethmoid cells are shaped like pyramids and are divided by thin septa. They are bordered by the middle turbinate medially and the medial orbital wall laterally. The ethmoid labyrinth may extend above the orbit, lateral and superior to the sphenoid, above the frontal sinus, and into the roof of the maxillary sinus. Sinus Function The physiology and function of the sinuses has been the subject of much research. Unfortunately, we still are unsure as to all the functions of these air-filled spaces. Multiple theories of function exist. These include the functions of warming/humidification of air, assisting in regulation of intranasal pressure and serum gas pressures (and subsequently minute ventilation), contributing to immune defense, increasing mucosal surface area, lightening the skull, giving resonance to the voice, absorbing shock, and contributing to facial growth. Because of the sinuses' copious mucous production they contribute heavily to the immune defense/air filtration performed by the nose. The nasal and sinus mucosa is ciliated and functions to move mucus to the choanae and the stomach beyond. The thickened superficial layer of nasal mucus serves to trap bacteria and particulate matter in a substance rich with immune cells, antibodies, and antibacterial proteins. The underlying sol layer is much thinner and serves to provide a thinner substrate in which the cilia are able to beat; their tips essentially grabbing the superficial layer and pushing it in the direction of the beat. Unless obstructed by disease or anatomical variance, the sinuses move mucous through their cavities and out of their ostia toward the choane.