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The SKULL
Air Sinuses: means the rooms or spaces filled with air within the bones of the skull
those which we refer to as Paranasal sinuses. Paranasal sinuses actually is not a correct
scientific term because when we look to its meaning “para means around”. The correct
scientific name is air sinuses because those are spaces filled with air but since most of
them are located around the nasal area and opening into the nose, they refer to them as
paranasal sinuses. The only exception is one of them which is para acoustic or para
auditory that is located around the ear and it opens into the middle ear (the mastoid air
cells). If you put your finger and palpate behind the auricle of the ear, you will feel the
bony prominence “the mastoid process of temporal bone” if you fracture it from inside it
opens usually into the middle ear .
So these are air sinuses, all of them are paranasal except one which is para acoustic.
In general they started to use the term paranasal to describe them all including the
mastoid air cells.
The word itself comes from that these sinuses are around the nose and they open there
, so their definition is they are air containing spaces within the skull bones “ more
accurate” or within the cranial bones . They are lined with the same epithelium lining the
respiratoy system which is Psudostratified columnar epithelium.

E The function of these air sinuses:
Until now there’s no 100% sure function for these sinuses
1) To reduce the skull weight: (the most speculated “ expected “ function)
the skull is based on the vertebral column and the vertebral column has intervertebral
disks , so to reduce the pressure on the vertebral column we empty the skull bones
from inside and fill them with air.



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2) Voice modification: They consider them sometimes ( تامخضم توصلل ) This
functions comes from the idea that when you have an inflammation in these
sinuses “sinusitis” ( ةيفنلا بويجلا باهتلا ) you will see that the sound of the speaker
becomes different . So they have something related to the voice production and the
tone of the voice.

3) Thermal Insulation effect : During the winter, when you exhale you exhale a hot
air so you lose its temperature and then you inhale a cold air , so what’s happening
there that is when you exhale part of this warm air will get into these sinuses and
keep the area of the head warm that’s how you keep the temperature .


E The sinuses are :








O The maxillary sinuses (the biggest one) :
They are two sinuses (left & right) found within the body of the maxillary bones. They
are pyramidal in shape. They open into the middle meatus which is an area on the lateral
wall of the nasal cavity.




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O The frontal air sinuses:
Found within the frontal bone above the orbit. They open into the middle meatus in the
nasal cavity
O Sphenoid sinuses:
Found within the sphenoid body. They open into sphenoethmoidal recess “in the superior
corner of the nasal cavity”. Look at the picture in the previous page.
O Ethmoidal air cells:
These are group of small spaces; they aren’t sinuses anymore , they’re like small cells
C Those air cells are classified into groups :
1- Anterior air cells: they are arranged in an oblique way inside the body of the
ethmoid bone. They are four in number. It opens into the middle meatus in the nasal
cavity
2-Middle air cells: it opens into the middle meatus in the nasal cavity
3-Posterior air cells: It opens into the superior meatus in the nasal cavity
O Mastoid air cells:
Within the mastoid process behind
the middle ear in the temporal bone,
they gather in the mastoid antrum
( لخدملا ) and they open into the
middle ear




All of the air sinuses open into the nasal cavity with exception of mastoid air
cells which open into the middle ear




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E Skull fractures:
We are speaking clinically now. The skull fractures we classify them according to the
classification of the skull (facial bones and neurocranial bones):
× If the fracture was in one of the eight cranial bones >>> CRANIAL or
NEUROCRANIAL fracture
Since the cranial bones are classified into cranial vault and cranial base so there are also
cranial vault fractures and cranial base fractures
× If the fracture was in one of the fourteen facial bones >>> FACIAL fracture
There are two types :
I. Complicated fracture: involving more than one bone (more complicated
because the bones are smaller. They were classified into three sub classifications
by Rene’ Le Fort who is a French surgeon. E.g. the fracture of the two maxillary
bones
II. Single facial fracture: involving only one bone. The most common single facial
fracture is the fracture of the nasal bones and the second most common is the
fracture of the mandible.
let’s talk In more details :
ª cranial vault fractures or fractures of the calvaria:
There are two ways or two mechanisms for the cranial vault to resist fractures or to
resist the force of blows or hits:
1. The convexity of the skull: always the convex surface is stronger than the flat
surface. WHY?? Because when you have a blow or a hit affecting a convex
surface the waves of force can be distributed all the way around into all bones so
that it will reduce the effects of this blow.
2. The diploid bone: it’s also called “diploic” which means double or two layers of
bone. The skull bones which are formed by intermembranous ossification in the
cranial vault ( parietal , frontal, the squamous of occipital and temporal ) when you



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look at them in a cross section or in a sagittal view you will see that they are made
of two layers (an outer and inner layers) which are called two tables of compact
bone.
You will first see an external table of compact bone then you will see the
trabeculae (the spongy bone) and between these trabeculae is the bone marrow
then you have another table called the internal table of compact bone. So if you have a
blow or a hit on one of these diploic bones it can produce a fracture on the outer table
then there’s another table to resist this fracture. If the blow was very strong it might
fracture the two layers.



The fractures were classified according to the nature of the fracture
itself:
I. Linear fractures : for example if you have a hit with a very small stone in a very
fast speed it will hits on the skull directly , this force will be directly radiated into
two directions forming a linear fracture from the centre of the blow. They are the
most frequent type of fractures to the cranial vault.
II. Comminuted fractures: comminuted means multiple pieces .if the subject was
large when it hits it makes many centers for the fracture so it will produce many
fracture segments or pieces of skull bones. The fracture doesn’t produce only one
line INSTEAD it produces a network of lines that producing fractured separated
segments.
These two types of fractures (mentioned above) are common in brittle skulls in
adults which are hard enough to be fractured.
III. Depressed fracture (thin areas): if this large object is pressuring over the skull
of a child, it’s still not that much ossified, so when you produce pressure on them
there will not be a fracture there will be a depression because the bones are
resilient. When the stone hits the skull of a child the bone will be pressured inside
not fractured and pressuring into the brain.
You know that there are two types of bones: compact bone and spongy bone
(it’s trabeculae which runs between the compact bone)
All of the air sinuses open into the nasal cavity with exception of mastoid air
cells which open into the middle ear




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IV. Pterion fractures :
It’s the most dangerous one because: The pterion is located 2-3 fingers above the
mid of the zygomatic arch on the lateral wall demarcated by H-shaped suture. It’s the
weakest point of the skull and the anterior arch of the middle meningeal artery is
passing there. So any fracture in this area or separation of this suture will lead to
“epidural hemorrhage”. 80% of epidural hemorrhage happens in the pterion region
because of fractures there affecting the anterior branch of the middle meningeal
artery.

ª The cranial base fractures :
The cranial base have three depressions from inside: anterior cranial fossa , middle
cranial fossa and posterior cranial fossa . We have anterior cranial fossa fracture,
middle cranial fossa fracture and posterior cranial fossa fracture; so we classify
the fractures here according to the location NOT to the nature of the fracture
.
+ Anterior cranial fossa fractures:

1) Fracture of the cribriform plate: One of the weakest areas is the cribriform plate
of ethmoid; always when there are perforations or spaces in the bone this is an
area of weakness because there aren’t enough ossification (not enough calcium in
these areas) to provide strength.
Usually if you have a fracture in the anterior cranial fossa the cribriform plate will
be easily fractured. The cribriform plate of ethmoid is the roof of the nasal cavity and
the floor of the anterior cranial fossa and through it passes the olfactory nerve and the
olfactory nerve fibers decends into the nasal cavity. When this area is fractured crista
galli is fractured also and there will be tearing of the meningis which is attached to
crista galli, the fracture of the cribriform plate of ethmoid has two representations:
× NASAL BLEEDING “epistaxis”: the blood comes down from the cribriform
plate in the anterior cranial fossa into the nose and then to the outside, this happens
when there’s an injury to an artery or a vein.



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× Leakage of the cerebrospinal fluid into the nose “cerebrospinal rhinorrhea ( حشر ) ”






In these fractures affecting the cranial base usually the patient is going into a coma.

2) Fracture of orbital plate of frontal bone: If it’s fracturing it there will be a
bleeding or cerebrospinal fluid leakage into the area of the orbit , because the
orbital plate of frontal bone is the roof of the orbits so if it’s fractured the bleeding
won’t go into the nose it goes into the orbits, as soon as it gets into the orbit it will
increase the pressure of fluids there , this pressure will push the eyeball to outside.
because the orbit has a limited area and the fluid enters it so where this fluid is
going to settle down , it can do nothing but pressing , behind it there’s bone it
can’t push it , anteriorly there’s the eyeball it can easily push it to the outside
“exophthalmos” نيعلا ظوحج

+ Middle cranial fossa fractures:
They are the most common fractures in the cranial base because it’s the weakest part
in the cranial base due to numerous openings there; foramina and canals which mean that
the least amount of bone is there. It’s possible that a fracture in this area produces a
fracture in one of these foramina and any structure passing through these foramina will be
affected. E.g. in the foramen rotundum passes the maxillary nerve which supplies the
upper teeth, if the fracture radiating across foramen rotundum it will lead to injury of the
maxillary nerve and you will lose sensation of the upper teeth and in the area of the face
over the maxilla “paresthesia” ناردخ
Cerebrospinal fluid is a clear colorless fluid which results by the
filtration of blood so it’s “plasma”. Cerebro means cerebrum ( خملا )
& spinal means the spinal cord because this fluid is located around
the brain and the spinal cord. From outside there’s the meningis,
from inside the brain and spinal cord, in between there is this
liquid or aqueous environment to protect the brain as a cushion.




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If the fracture is over the ovale, the mandibular nerve will be affected and so on ….
Now if you look to the foramina here in the middle cranial fossa usually the nerves
passing across them which can be injured are the CRANIAL NERVES (3
rd
-6
th
)
according to the area of fracture : foramen ovale>>> mandibular , foramen
rotundum>>>maxillary , foramen spinosum>>> middle meningeal artery which leads to
epidural hemorrhage .
If the fracture going more posteriorly in the middle cranial fossa and fracturing the
petrous part of temporal bone which is the border between the middle cranial fossa and
posterior cranial fossa. The petrous part has anterior and posterior walls, the anterior is
much thinne. If it’s fractured there will be leakage of blood or CSF through external
auditory meatus ( ةيعمسلا ةانقلا ) into inside petrous part of temporal bone which contains the
middle ear then to the external ear and to the outside eventually .

+ Posterior cranial fossa fractures :
It’s kind of a strong area so the fractures are not that much there unless the blow
comes from the back and there will be bleeding into the post vertebral muscles. The
bleeding will decends through the foramen magnum and goes into the neck posteriorly.
Now the area of the muscles in the posterior neck is tough and very thick. The most
common one of these muscles is the trapezius. so the bleeding will get stuck between the
vertebral column and the post vertebral muscles , it usually takes 1-2 days to discover this
leakage by finding a bulge there especially if the fracture and the leakage is not that
severe .
Some of the fractures in the posterior cranial fossa affect one of the large foramina:
jugular and magnum.
What will happen if the fracture passes through the foramen magnum where the medulla
oblongata ends and the spinal cord starts??
¯ Medulla oblongata contains two important centers controlling two vital structures
in the body: the respiratory centre and the cardiovascular centre, so it’s controlling



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the heart beating, the rate of the heartbeat and the process of respiration. If
medulla oblongata was injured it leads to direct death.
¯ If the damage goes a little bit downward into the spinal cord it leads to
quadriplegia ( يعابر للش ) : paralysis of the upper and lower limbs.
What will happen if the fracture is passing in the jugular area?
¯ The internal jugular vein will be damaged which will lead to hemorrhage
¯ Damage to one or all of the cranial nerves from the 9
th
to the 11
th
.

ª Facial fractures :
C Complicated fractures : The most common type of fractures in the face is
COMPLICATED involving more than one bone . It has been classified by a
French surgeon called René Le Fort. He used to go to the cemetery, dig the
graves take the skulls and goes over a high building and throws them from there.
Then he studies the patterns of fractures.
He finally concluded that these kinds of fractures if it’s complicated it will go in
three patterns from the simplest to the most complicated:
A. Le fort I: called transmaxillary (Trans means cross) involving the two maxillary
bones. It usually involves the fracture or the separation of the alveolar processes of
the maxillary bones or the separation of the alveolar processes from the palatine
processes which produces “the floating palate”. sometimes it extends more
posteriorly to affect the pterygoid processes of the sphenoid bone








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B. Le fort II : called pyramidal or the scientific name is subzygomatic because it
doesn’t involve the zygomatic bone; the zygomatic bone is still attached . It
involves the maxillary bones, the lacrimal bones and the nasal bones.











C. Le fort III: called suprazygomatic or craniofacial fracture because the facial
skeleton separates from the cranial one. This time the zygomatic bone is involved.







You are supposed to memorize the name of the fracture, its classification and the involved
bones for each of these
Any fracture in the bone means that there also will be damage to the soft tissue overlying;
the skin, the muscles, there will be edema, hemorrhage, pain.





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C Single fractures :

1) The nasal bones fracture is the most common fracture because of prominence of
the nose. Most of the professional boxer’s don’t have the nasal bones because
when they are fractured they are too small to be treated so surgeons remove them
instead. This fracture has complications: fracture of orbital margin and injury to
frontal or ethmoidal sinuses.

2) The mandibular fractures are classified according to the location (the area of
fracture):









1. Condylar fractures: The most common reason for condylar fractures is that you
have a blow to the chin anteriorly, this blow will push the mandible posteriorly
and since the mandible can’t be pushed back because of the presence of Trusses
( فلخلا ىلا عوجرلا نم يلفسلا كفلا عنمت تاماعد ) in the mandibular fossa then the neck of
the condyle fractures which is the weakest area there. This is common in car
accidents when the driver is not putting the seat belt.
2. Body fractures: usually happens in the canine region, why? For two reasons:
A) The mandible is a ring bone “U shaped” when the bone becomes convex and
angular it becomes weaker and easier to be fractured and the most angular region
is in the canine region. B) The canine has the largest root from all lower teeth.



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When the root is large, its socket is large and the socket of the canine is the largest
socket indicating the least amount of bone. Body fractures results from lateral
blows “side to side fractures”
Condylar and body fractures are the most common types of the mandibular
fractures with a percentage of 30% for the condylar and 25% for the body fractures.
3. Angular and ramus fractures are not clinically significant.
4. Coronoid process fractures: it’s the least common one (1-2%).When it’s
fractured the coronoid segment will be pushed superiorly because it’s attached to
the temporalis muscle which raises the mandible and in that side of the mandible
you see kind of a “mandibular drop”. Some muscles (the medial pterygoid and
the Masseter) will be still supporting the mandible so it’s not a complete drop.

E Three important rules to distinguish mandibular fractures :
C The mandible is one bone from side to side .If you see a fracture in one side of the
mandible expect another fracture, this rule is called “Ring Bone Rule”. That is the
difference between a dentist and an excellent one , he’s not always looking in the
area of complain but he goes comprehensively all the way around , so you always
have to look in both sides and if you see a fracture or dislocation in the mandible
look for another one on the opposite side.
The hyoid bone is another example of the bones that follow the ring bone rule.
C Panoramic X-Ray is the best to diagnose mandibular fractures. NOTHING else
will be better than panoramic x-ray. Panoramic means comprehensive view.
C Look for cortical margins and mandibular canal discontinuity. In the mandible
there are two cortical margins: the lower cortical margin and the border of the
alveolar process. In the area of the mandibular canal you see a translucency داوس
which indicates a space containing air , it’s the canal in which the mandibular
nerve passes through to supply the root of the lower teeth. You look along with
the mandibular canal also because sometimes the fracture is inside only and
doesn’t reach into the cortical margins. So follow these three areas: the margin
of the alveolar bone , the lower cortical margin and the mandibular canal.



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What’s the difference between a symptom and a sign ???
The symptom is what the patient is complaining of. E.g. when a patient comes to the
doctor and says “I’ve blood coming out from my nose”.
The sign is what the doctor discovers and the patient isn’t aware of. E.g. the doctor
measures the temperature of a patient and sees that he’s fevered.

Made and
Reviewed by :
AREEJ KLAIB

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