NOSE & PARANASAL

SINUS ANATOMY
Presenter: Haben MD, ORL/HNS-Resident
Moderator: Dr. Mesele ENT-surgeon
 Outline
 Introduction
 External nose surface anatomy
 External nose gross anatomy
 Internal nose anatomy
 Osteomeatal complex
 Paranasal sinus anatomy
 Reference
Introduction to the nose
 Is the first part of the upper respiratory tract &
may be subdivided into an external nose and an
internal chamber

 The female nose is slightly smaller and narrower

than the male nose; it is often slightly concave in
profile view, with a slightly obtuse nasolabial
angle (increased tip rotation)
 105–120° in females and 90–105° in males
External nose surface anatomy
 The nose is pyramidal structure in the midline of
the midface & varies considerably in size and
shape
 differences in the nasal cartilages

 In general, the nose occupies the central

horizontal third of the face, from the glabella to
the subnasale, and central vertical fifth, between
the medial canth
Surface anatomy
Aesthetic topographic subunits of the nasal surface
External nose
 Skin over the nasal bridge
 Thick & firmly adherent over the tip & alar cartilage
 Thin & loosely adherent over the dorsum & sides of the nose

 The skin of the nose is separated from the underlying

osteocartilaginous framework by four layers

 Superficial fatty panniculus

 Fibromuscular layer, a continuation of the facial superficial musculo-
aponeurotic system (SMAS)

 Deep fatty layer

 Periosteum or perichondrium
Osteocartilaginous framework
 The bony part of the nose consists of the:
 Nasal bones
 Frontal processes of the maxillae
 Nasal part of the frontal bone and its nasal spine
 Bony part of the nasal septum

 The cartilaginous part of the nose consists of five main

cartilages:
 Two lateral cartilages
 Two alar cartilages
 Septal cartilage
Muscles of external nose
 Depressor septi nasi muscle
 Origin: alveolus of maxilla
 Insertion: Nasal septum
 Function: depress the septum and tip, constrict the external nares
 Nerve supply: buccal branch of CN VII
 Arterial supply: superior labial branch of the facial artery

 Nasalis muscle:
 Transverse part ( compressor nares)
 Origin: the maxilla above and lateral to the incisive fossa, and lateral to the
alar part
 Insertion: thin aponeurosis that merges with its counterpart across the bridge
of the nose, with the aponeuroses of procerus

 Alar part (dilator nares) arises beneath the nasomaxillary suture and attaching by a
short thin tendon to the skin of the nasal ala
 Nerve supply: buccal branch of CN VII

Arterial supply: facial artery and from the infraorbital branch of the maxillary artery.
 Levator labii superioris alaequae nasi
 Origin: frontal process of the maxilla
 Insertion: lateral crus' of the lower lateral cartilage & Lateral surface of
upper lip
 Function: Elevate lip & dilate the nostril
 Nerve supply: zygomatic & buccal braches of CN VII
 Arterial supply: facial artery and the infraorbital branch of the maxillary artery

 Procerus muscle: a continuation of frontalis

 Origin: Nasal bone & aponeurosis of transverse part of nasalis
 Insertion: Skin of nasal bridge

 Function: Shortens the nose & facial movement (transverse wrinkles on the nasal
bridge) of the area between the eyebrows (depressor glabellae)
 Nerve supply: temporal branch of CN VII
 Arterial supply: branches from the facial artery
Vascular supply of external nose
 Arterial supply:
 Lateral nasal, alar &
septal branches of the
facial artery: the alae
and lower part of the
nasal septum

 Dorsal nasal branch

of the ophthalmic
artery and the
infraorbital branch of
the maxillary artery:
lateral aspects and
dorsum of the nose
 Venous drainage
 Facial vein: frontomedian region of the face, including
the nose
 Ophthalmic veins: orbitopalpebral area of the face,
including the root of the nose

 Lymph drainage
 Submandibular group of nodes: primary
 Superficial parotid nodes: root of the nose
 Vascular supply of External nose

Nerve supply
 Infratrochlear and external
nasal branches of the
nasociliary nerve (ophthalmic
division, trigeminal nerve)

 Nasal branch of the

infraorbital nerve (maxillary
division, trigeminal nerve)
Nasal cavity
 The nasal cavity is an irregular space between the roof of the mouth
and the cranial base
 Choana
 Measures 2.5 cm in vertical height and 1.3 cm transversely
 size is not usually affected by deviations of the nasal septum

 Piriform (pear-shaped) openings, the nares (nostrils, anterior nasal

apertures), which are bound
 Laterally: alae (wings) of the nose
 Inferolaterally: maxilla
 Medially: nasal septum
 Superiorly: nasal bones

 Usually measure 1.5–2 cm anteroposteriorly and 0.5–1 cm transversely

 Narrower in front & occupy approximately 2/3rd of the height of the base
 Mucosa lines the nasal cavities, except the nasal vestibule, which
is lined with skin

 Most distal portion of the nasal cavity is lined with a thin,

lightly keratinized, stratified squamous epithelium that extends
into the nasal vestibule bilaterally

 The inferior 2/3rd of the nasal mucosa is the respiratory area,

and the superior 1/3rd is the olfactory area

 Each half of the nasal cavity has a vestibule, roof, floor, medial
(septal) and lateral walls
VESTIBULE
 The vestibule is the dilated passageway leading from the external
nares into the nasal fossae demarcated by the limen nasi, at the
superior margin of the lower lateral cartilage

 It is lined by skin bearing coarse hairs or vibrissae (though without

erector muscles), sebaceous glands and sweat glands

 Boundry
 Posterosuperiorly: nasal valve
 Posteromedially( septal side of nasal cavity): superior edge of medial
crus of alar cartilage
 Medially: mobile septum containing culumela & underlying medial
crura of alar cartilage
 Nasal valve: is found proximal
to the nasal vestibule
 Boundry
 Superolaterally: caudal end of
upper lateral cartilage

 Superomedially: nasal septum

 Laterally: bony piriform

aperture and the fibrofatty tissue
of the ala

 Inferiorly: floor of piriform

aperture
 Posteriorly: head of the inferior
turbinate
 Nasal valve area: internal nasal valve (limen nasi)
 Maximum resistance to flow

 At the communication between the nasal vestibule and the nasal

valve area

 Mucosa of the nose transitions to a ciliated pseudostratified

columnar respiratory-type epithelium, which is contiguous with
most of the upper and lower respiratory tract

 except superiorly in the olfactory cleft, where the olfactory

epithelium is present
 Olfactory mucosa
 covers approximately 5 cm2 of the
posterior upper parts of the lateral
nasal wall
 upper part of the vertical portion of the
middle concha and the opposite part of
the nasal septum

 Superior concha,
sphenoethmoidal recess, upper part
of the perpendicular plate of the
ethmoid and the portion of the roof
of the nose
ROOF
 Is formed by frontal, nasal, ethmoidal, and sphenoidal
bones

 Anteriorly: Anterior nasal spine of frontal bone & nasal

bones
 Centrally: Cribriform plate of ethmoid

 Multiple small perforations: olfactory nerves

 Anterior foramen: anterior ethmoidal nerve and vessels

 Posteriorly: anterior aspect of the body of the

sphenoid
FLOOR
 Is smooth and concave transversely, formed by
Hard palate
 Palatine process of maxilla (forms greater part)
 Horizontal plate of palatine bone

 Anteriorly, near the septum, slight depression in

the overlying mucosa with a small infundibular
opening for incisive canals that descend to the
incisive fossa
 Nasopalatine nerves and vessels
MEDIAL WALL
 is the nasal septum, a thin sheet of bone
(posteriorly) and cartilage (anteriorly) that lies
between the roof and floor of the cavity

 Bony septum
 Postero superiorly: Perpendicular plate of ethmoid
 Postero inferiorly: Vomer, nasal crest of palatine bone
 Antero inferiorly: Nasal crest of maxilla
 Posteriorly: Rostrum& crest of sphenoid
 Superiorly: Nasal crest of frontal bone
Bony & cartilaginous septum
 Cartilaginous septum: is almost quadrilateral

 The cartilaginous septum anterior to the spine is essential in

tip support and should not be excised during septal surgery
in order to prevent columellar retraction or loss of tip
support

 Membranous septum
 Antero inferior part of the nasal septum
 Devoid of cartilage
 Is continuous with the columella anteriorly
 Kiesselbach (little's) area
LATERAL WALL
 is formed by
 Antero-inferiorly: Maxilla
 Posteriorly: Perpendicular plate of the palatine bone
 Superiorly: Labyrinth of the ethmoid bone

 It contains three projections of variable size

 inferior, middle and superior nasal conchae or turbinates
 The conchae curve inferomedially in general, each roofing
a groove, or meatus, which is open to the nasal cavity
Inferior concha and inferior meatus

 The inferior concha is a thin, curved, independent bone

& articulates
 Nasal surface of the maxilla
 Perpendicular plate of the palatine bone

 The inferior meatus is the largest meatus, extending

along almost all the lateral nasal wall

 Deepest at the junction of anterior and middle thirds,

where it admits the inferior opening of the nasolacrimal
canal
Middle concha and middle meatus

 The middle concha is a medial process of the ethmoidal

labyrinth and may be pneumatized (conchal sinus)

 It extends back to articulate with the perpendicular plate

of the palatine bone

 Middle meatus
 Deeper in front than behind
 lies below and lateral to the middle concha
 Continues anteriorly into a shallow fossa above the vestibule,
termed the atrium of the middle meatus
 The main features of the lateral nasal wall(middle
meatus) are
 Bulla ethmoidalis (rounded elevation): consists of a
group of the largest and least variable anterior
ethmoidal cells

 Hiatus semilunaris (curved cleft): formed by the

posterior edge of the uncinate process and the
anterior face of the ethmoidal bulla
 Ethmoidal infundibulum, a 3D, funnel-shaped cleft between
the uncinate and lateral wall of the nose, lateral to semilunar
hiatus

 Maxillary ostium is normally found lateral to the

anteroinferior aspect of the uncinate process

 Uncinate process in a thin, hook-shaped bone that

articulates with
 Perpendicular plate of the palatine bone
 Ethmoidal process of the inferior concha
 Ostiomeatal complex or unit
 is a functional complex rather than a clearly defined
anatomical structure & includes the maxillary sinus
ostium, ethmoidal infundibulum and the hiatus
semilunaris

 Drainage of secretions from

 Maxillary sinus
 Anterior group of ethmoidal sinuses
 Frontal sinus
Anatomy of the ostiomeatal unit
 Sphenopalatine foramen (really a fissure): posterior to
the middle meatus
 Sphenopalatine artery
 Nasopalatine and superior nasal nerves from the
pterygopalatine fossa

 bounded
 Superiorly: body and concha of the sphenoid
 Inferiorly: superior border of the perpendicular plate of the
palatine bone
 Anteriorly: orbital bone, crista ethmoidalis
 Posteriorly: sphenoidal processes of the palatine bone
Superior concha and superior meatus

 Is formed by medial process of the ethmoidal labyrinth

 is the shortest and shallowest of the three conchae

 Sphenoethmoidal recess (triangular): Above the superior concha

 Drainage for sphenoidal sinus

 The superior meatus is a short oblique passage extending

about halfway along the upper border of the middle concha

 Drainage for posterior ethmoidal sinuses (via a variable number of

apertures, into its anterior part)
 Its roof is formed by superior conchae
Blood supply of nasal cavity
 Arterial supply:
 Anterior and posterior ethmoidal branches of the ophthalmic
artery supply the ethmoidal and frontal sinuses and the roof of the
nose (including the septum)

 Sphenopalatine branch of the maxillary artery supplies the mucosa

of the turbinates, meatuses and posteroinferior part of the nasal
septum, i.e. it is the principal vessel supplying the nasal mucosa

 Greater palatine branch of the maxillary artery supplies the region

of the inferior meatus

 Septal branch of superior labial artery: anteroinferior part of

septum
 Venous drainage
 A rich submucosal cavernous plexus is especially dense in the
posterior part of the septum and in the middle and inferior
turbinates

 Veins from the posterior part of the nose generally pass to the
sphenopalatine vein that runs back through the sphenopalatine
foramen to drain into the pterygoid venous plexus

 The anterior part of the nose is drained mainly through veins

accompanying the anterior ethmoidal arteries, and these
veins subsequently pass into the ophthalmic or facial veins
 Lymphatic drainage

 Submandibular nodes: Anterior region of the nasal

cavity

 Upper deep cervical nodes (either directly or through

the retropharyngeal nodes): Rest of the nasal cavity

 Parotid nodes: Posterior nasal floor

INNERVATION OF THE NASAL CAVITY

 Olfaction is mediated via the olfactory nerves

 General sensation (touch, pain and temperature)

from the nasal mucosa is carried by branches of the
ophthalmic and maxillary divisions of the
trigeminal nerves

 Autonomic fibres innervate mucous glands and

control cyclical and reactive vasomotor activity
CN V innervations
 Anterior ethmoidal nerve supply the roof of the nasal cavity

 Lateral internal branch to supply the anterior part of the

lateral wall
 Medial internal branch to the anterior and upper parts of the
septum

 Infraorbital nerve supplies the nasal vestibule

 Anterior superior alveolar nerve supplies part of the septum,

the floor near the anterior nasal spine and the anterior part of
the lateral wall as high as the opening of the maxillary sinus
 Greater palatine nerve (lateral posterior superior nasal
and the posterior inferior nasal branches) of the together
supply the posterior 3/4th of the lateral wall, roof and
floor

 Medial posterior superior nasal nerves and the

nasopalatine nerve supply the inferior part of the nasal
septum

 branches from the nerve of the pterygoid canal supply the

upper and posterior part of the roof and septum
Autonomic innervations
 Deep petrosal nerve (postganglionic sympathetic fibres) and
greater petrosal nerve (preganglionic parasympathetic
fibres) converge to form the nerve of the pterygoid canal
(Vidian nerve in the Vidian canal)

 Vidian nerve joins pterygopalatine ganglion (pterygopalatine

fossa)
 parasympathetic fibres synapse (secretomotor supply to the
nasal mucous glands, and are distributed via branches of the
maxillary nerves)
 sympathetic fibres pass through without synapsing (Vasomotor
fibers to nasal blood vessels)
Paranasal Sinuses
 The paranasal sinuses are air-filled cavities
that communicate with the nasal cavities
FRONTAL SINUS
 are posterior to the superciliary arches, between the outer
and inner tables of the frontal bone

 Each usually underlies a triangular area on the surface of

the face, its angles formed by the
 Infero medially: nasion
 Superomedially: point 3 cm above the nasion
 Laterally: junction of the medial third and lateral two-thirds of
the supraorbital margin

 The two sinuses are rarely symmetric

 The average dimensions of an adult frontal sinus are: height
3.2 cm; transverse breadth 2.6 cm; and anteropoteror depth
1.8 cm

 Each usually has a frontal portion that extends upwards above

the medial part of the eyebrow, and an orbital portion that
extends back into the medial part of the roof of the orbit

 One or both sinuses may rarely be hypoplastic or even absent

 In contrast, unilateral aplasia of the frontal sinus is present in

15% of adults, and present bilaterally in 5%.
 Uncinate process attachment determines whether the frontal
sinus drains lateral to the ethmoidal infundibulum or into it

 Lateral nasal wall (50%): frontal sinus will drain into the
middle meatus (medial to the hiatus semilunaris)

 Anterior cranial fossa (25%): the sinus will drain into the
infundibulum, and thus near or into the maxillary ostium

 Middle concha (25%) the sinus will drain into the

infundibulum, and thus near or into the maxillary ostium
 The frontal recess is actually the most anterior part of
the anterior ethmoidal complex
 Lateral wall: lamina papyracea
 Medial wall: middle turbinate

 Posteriorly, the wall is made up of either the cranial base,

in a suprabullar recess, or the insertion of the bulla, if this
reaches the cranial base

 Anteriorly, the wall extends from the frontal sinus proper to

the anterior attachment of the middle turbinate
 Vascular supply
 Arterial supply Lymphatic drainage
 Supraorbital aa Submandibular nodes
 Supratrochlear aa
Nerve supply
 Anterior ethmoidal aa Supraorbital nerves
(general sensation)
Supratrochlear nerves
 Venous drainage
 Supraorbital vein Orbital branches of the
 Superior ophthalmic pterygopalatine ganglia
veins (parasympathetic
secretomotor fibres)
SPHENOIDAL SINUS
 Irregular cavities within the body of the sphenoid
 Drain in to sphenoethmoidal recess via an aperture high
on the anterior wall of the sinus

 The average dimensions of the adult sphenoid are:

vertical height 2 cm; transverse breadth 1.8 cm; and
anteroposterior depth 2.1 cm

 Usually separated by a septum that usually deviates from

the midline, so that they are unequal in size and form
 The sinuses may be classified into three main types:
 Sellar (most common type): sinus extends for a variable
distance beyond the tuberculum sellae

 Presellar: sinus occasionally extends posteriorly

towards, but not beyond, the tuberculum sellae

 Conchal (rarest type): a small sinus is separated from

the sella turcica by approximately 10 mm of trabecular
bone
 Extent of pneumatisation of surrounding bone is highly variable may
extend into

 Greater and lesser wings of the sphenoid

 Pterygoid processes, separating the pterygoid (Vidian) canal and foramen
rotundum

 May even invade the basilar part of the occipital bone almost to the
foramen magnum

 Sphenoethmoidal cell (Onodi cell) are posterosuperior extension of

posterior ethmoidal sinus in to the sphenoid sinuses
 Anterior clinoid process may be pneumatised in up to 15% of sphenoidal
cells
 Arterial supply
 Posterior ethmoidal arteries
 Nasal branches of the sphenopalatine arteries
 Venous drainage
 Posterior ethmoidal veins draining into the superior ophthalmic veins

 Lymphatic drainage
 Retropharyngeal nodes

 Nerve supply
 Posterior ethmoidal branches of the ophthalmic nerves (general sensation)
 Orbital branches of the pterygopalatine ganglia (parasympathetic
secretomotor fibres)
ETHMOIDAL SINUSES
 Lie between the upper part of the nasal cavity and the orbit
 Separated from the orbit by the paper-thin lamina papyracea or
orbital plate of the ethmoid (poor barrier to infection, which may
spread into the orbit)

 Differ from the other paranasal sinuses??

 formed of multiple thin-walled cavities in the ethmoidal labyrinth
 Number and size vary, from 3 large to 18 small sinuses on each
side

 Divided clinically into anterior and posterior groups on each

side
 Separated from each other by the basal lamella of middle turbinate
 Anterior ethmoidal sinuses
 Up to 11air cells drain into
the ethmoidal infundibulum
by one or more orifices
 Agger nasi cells are the most
anterior group, developmental
remnants of the first
ethmoturbinals (almost
always present)

 Infraorbital (Haller) cells

may develop medially
beneath the orbital floor
Posterior ethmoidal sinuses
 Up to 7 air cells usually drain by a single orifice into the
superior meatus
 One may drain into the supreme meatus when present
 One or more into the sphenoidal sinus

 Optic nerve injury is a devastating potential complication of

endoscopic sinus surgery, particularly if a sphenoethmoidal cell
(Onodi cell) is present
 lies very close to the optic canal and optic nerve

 Sphenoethmoidal cell is usually regarded as the most posterior

ethmoidal cell and is intimately associated with the optic nerve
Vascular supply
 Arterial supply
 Nasal branches of the sphenopalatine artery
 Anterior and Posterior ethmoidal arteries
 Venous drainage is veins accompanying the arteries

 Lymphatic drainage
 Anterior group drain to the submandibular nodes
 posterior group to the retropharyngeal

 Nerve supply
 Anterior and Posterior ethmoidal branches of the ophthalmic nerves
(general sensation)
 Orbital branches of the pterygopalatine ganglia (parasympathetic
secretomotor fibres)
MAXILLARY SINUS
 Is pyramidal in shape & largest of all paranasal sinuses
 Base (medial): lateral wall of the nasal cavity
 Maxillary ostium high up near the roof
 Fontanelles are covered only by periosteum and mucosa

 Floor (below the nasal floor): alveolar process and part of

the palatine process of the maxilla

 Related to the roots of 2nd premolar and 1st molar, but may
extend posteriorly to the 3rd molar tooth and/or anteriorly to
incorporate the 1st premolar, and sometimes the canine
 Roof: major part of the floor of the orbit
 Infraorbital canal: anterior superior alveolar nerve and
vessels
 Apex: extends into the zygomatic process of the
maxilla
 Anterior wall: facial surface of the maxilla
 Canalis sinuosus: anterior superior alveolar nerve and
vessels
 Posterior wall: infratemporal surface of the maxilla
 alveolar canals: posterior superior alveolar vessels and
nerves to the molar teeth
Vascular supply
 Arterial supply is derived mainly from the maxillary arteries via
 Anterior, middle and posterior superior alveolar arteries
 Infraorbital and greater palatine arteries

 Venous drainage: veins corresponding to the arteries drain into the

facial vein or pterygoid venous plexus

 Lymph drainage: Submandibular nodes

 Nerve supply
 Infraorbital and anterior, middle and posterior superior alveolar branches
of the maxillary nerves (general sensation)
 Nasal branches of the pterygopalatine ganglia (parasympathetic
secretomotor fibres)
 Greys anatomy; the anatomical basis of clinical practice: section 4, chapter 33,
pages 556- 570
 Essential clinical anatomy: Keith L. Moore PhD, 3rd edition ;chapter 7, pages
563-568

 Netter’s Advanced Head and Neck Neil S. Norton, PhD; nose & paranasal
sinus anatomy
 Diseases of ear, nose & throat, 4th edition; dinghra,Chapter 35: pages 178-180
 Scout browns otolaryngology head & neck surgery; 7th edition, part 13: nose
& paranasal sinuses; pages 1315-1343

 Head & Neck Surgery - Otolaryngology, 4th Edition Bailey, Byron J; part II,
Section 24; pages 351-353
 Cumming`s Otolaryngology 5th edition; chapter 34
THANK YOU