CHAPTER – 15

The Nose And The Paranasal Sinuses

Sense of smell perceived in the upper part of nasal cavity by olfactory nerve
rootlets ends in olfactory bulb, which is connected to uncus and also to the dorsal
nucleus of vagus in medulla oblongata. Good smell of food, thus stimulates
secretion of gastric juice through vagus nerve.
Most of the mucous membrane of the nasal cavity is respiratory and is
continuous with various para-nasal sinuses. Since nose is the most projecting part
of the face, its integrity must be maintained and efforts should be made to see
that nose is “not cut”. Great mythological war has been fought for “cutting the
nose”.
Environment pollution causes inhalation of unwanted gases and particles,
leading to frequent attacks of sinusitis, respiratory diseases including asthma.
Nasal mucous membrane is quite vascular. Sometimes picking of the nose
may cause bleeding from “Little’s area”, called the epistaxis.
THE NOSE
The nose performs two functions. It is a respiratory passage. It is also the organ
of smell. The receptors for smell are placed in the upper one-third of the nasal
cavity. This part is lined by olfactory mucosa. The rest of the nasal cavity is lined
by respiratory mucosa. The respiratory mucosa is highly vascular and warms the
inpired air. The secretions of numerous serous glands make the air moist ; while
the secretion of mucous glands trap dust and other and other particles. Thus the
nose acts as an air conditioner where the inspired air is warmed, moistened and
cleansed before it is passed on to the delicate lungs.
The olfactory mucosa lines the upper one-third of the nasal cavity including
the roof formed by cribriform plate and the medial and lateral walls up to the
level of the superior concha. It is thin and less vascular than the respiratory
mocosa. It contains receptors called olfactory cells.
For descriptive purposes the nose is divided into two main parts, the
external nose and the nasal cavity.

External Nose
Some features of the external nose have been described in Chapter 2. The
external nose has a skeletal framework that is partly bony and partly
cartilaginous. The bones are the nasal bones, which form the bridge of the nose,
and the frontal processes of the maxillae. The cartilages are the superior and
inferior nasal cartilages, the septal cartilage, and some small cartilages (Fig.
15.1A, B). The skin over the external nose supplied by the external nasal.
Infratrochlear and infraorbital nerves (Fig. 2.19).

Nasal Cavity
The nasal cavity extends from the external nares or nostrils to the posterior nasal
apertures, and is subdivided into right and left halves by the nasal septum. Each
half has a roof, a floor, and medial and lateral walls. Each half measures about 5
cm in heights, 5-7 cm in length, and 1.5 cm in width near the floor. The width
near the roof is only 1-2 mm.
The roof is abolut 7 cm long and 2 mm wide. It slopes downwards, both in front
and behind. The middle horizontal part is formed by the cribriform plate of the
ethmoid. The anterior slope is formed by the nasal part of the frontal bone, nasal
bone, and the nasal cartilages. The posterior slope is formed by the inferior
surface of the body of the sphenoid bone.
The floor is about 5 cm long and 1.5 cm wide. It is formed by the palatine process
of the maxilla and the horizontal plate of the palatine bone. It is concave from
side to side and is slightly higher anteriorly than posteriorly.

Nasal Septum
The nasal septum is median osseocartilaginous partition between the two halves
of the nasal cavity. On each side, it is covered by mucous membrane and forms
the medial wall of both nasal cavities.
The bony part is formed almost entirely by (1) the vomer and (2) the
perpendicular plate of the ethmoid. However, its margins receive contributions
from the nasal spine of the frontal bone, the rostrum of the sphenoid, and the
nasal crests of the nasal, palatine and maxillary bones.
The cartilaginous part is formed by (1) the septal cartilage, and (2) the septal
processes of the inferior nasal cartilages.
The cuticular part of lower end is formed by fibrofatty tissue covered by skin. The
lower margin of the septum is called the columella.
The nasal septum is rarely strictly median. Its central part is usually deflected to
one or the other side. The deflection is produced by overgrowth of one or more
of the constituent parts.
The septum has (a) four borders, superior, inferior, anterior and posterior ; and
(b) two surfaces, right and left.
Anterial Supply
Anterosuperior part is supplied by the anterior ethmoidal artery.
Posteroinferior part : is supplied by the Sphenopalatine artery.
Anteroinferior part : by the superior labial branch of facial artery.
Posteroinferior part : by the posterior ethmoidal artery.
The anteroinferior part or vestibule of the septum contains anastomoses
between the septal ramus of the superior labial branch of the facial artery,
branch of sphenopalatine artery, and of anterior ethmoidal artery. These form a
large capillary network called the Kiesselbach’s plexus. This is a common site of
bleeding from the nose or epistaxis, and is known a Little’s area.

Venous Drainage
The veins form a plexus which is more marked in the lower part of the septum or
Little’s area. The plexus drains anteriorly into the facial vein, posteriorly through
the sphenopalatine vein to pterygoid venous plexus.

Nerve Supply
I. General sensory nerves, arising from trigeminal nerve, are distributed to
whole of the septum.
1. The anterosuperior part of the septum is supplied by the internal
nasal branch of the anterior ethmoidal nerve.
2. The posteroinferior part is supplied by the nasopalatine branch of the
pterygopalatine ganglion.
3. The posterosuperior part is supplied by the medial posterior superior
nasal branches of the pterygopalatine ganglion.
II. Special sensory nerves or olfactory nerves are confined to the upper part
or olfactory area.

Ltmphatic Drainage
Anterior half to the submandibular nodes.
Posterior half to the retropharyngeal and deep cervical nodes.

CLINICAL ANATOMY
1. Little’s area on the septum is a common site of bleeding from the nose of
epistaxis.
 2. Pathological deviation of the nasal septum is often responsible for repeated
attacks of common cold, allergic rhinitis, sinusitis, etc. It requires surgical
correction.

Lateral wall of Nose

The lateral wall of the nose is irregular owing to the presence of three shelf-like
bony projections called conchae. The conchae increase the surface area of the
nose for effective air-conditioning of the inspired air.

The lateral wall separates the nose : (a) From the orbit above, with the ethmoidal
air sinuses intervening ; (b) from the maxillary sinus below ; and (c) from the
lacrimal groove and nasolacrimal canal in front.

The lateral wall can be subdivided into three parts. (a) A small depressed area in
the anterior part is called the vestibule. It is lined by modified skin containing
short, stiff, curved hairs called vibrissae. (b) The middle part is known as the
atrium of the middle meatus. (c) The posterior part contains the conchae. Spaces
separating the conchae are called meatuses.

The skeleton of the lateral wall is partly bony, partly cartilagenous, and partly
made up only of soft tissue as follows.

The bony part is formed from before backwards by the following bones : (1)
Nasal ; (2) frontal process of maxilla ; (3) lacrimal ; (4) labyrinth of ethmoid with
superior and middle conchae ; (5) inferior nasal concha ; (6) perpendicular plate
of the palatine bone together with its orbital and sphenoidal processes ; and (7)
medial pterygoid plate.

The cartilaginous part is formed by : (a) The superior nasal cartilage ; (b) the
inferior nasal cartilage ; and (c) 3 or 4 small cartilages of the ala.

The cuticular lower part is formed by fibrofatty tissue covered with skin.

Chonchae and Meatuses

The nasal conchae are curved bony projections directed downwards and
medially. The following three conchae are usually found :
1. The inferior conch is an independent bone.
2. The middle concha is a projection from the medial surface of the ethmoidal
labyrinth.
3. The superior concha is also a projection from the medial surface of the
ethmoidal labyrinth. This is the smallest concha situated just above the
posterior part of the middle concha.

The meatuses of the nose are passages beneath the overhanging conchae.
Each meatus communicates freely with the nasal cavity proper.

1. The inferior meatus lies underneath the inferior concha, and is the largest
of the three meatuses. The nasolacrimal duct opens into it at the junction
of its anterior one-third and posterior two-thirds. The opening is guarded by
the lacrimal fold, or Hasner’s valve.
2. The middle meatus lies underneath the middle concha. It presents the
following features : (a) The ethmoidal bulla, is a rounded elevation
produced by the underlying middle ethmoidal sinuses. (b) The hiatus
semilunaris, is a deep semicircular sulcus below the bulla. (c) The
infundibulum is a short passage at the anterior end of the hiatus. (d) The
opening of the frontal air sinus is seen in the anterior part of the hiatus
semilunaris. (e) The opening of the maxillary air sinus is located in the
posterior part of the hiatus semilunaris. It is often represented by two
openings. (g) The opening of the middle ethmoidal air sinus is present at
the upper margin of the bulla.

3. The superior meatus lies below the superior concha. This is the shortest and
shallowest of the three meatuses. It receives the openings of the posterior
ethmoidal air sinuses.

The sphenoethmoidal recess is a triangular fossa just above the superior

concha. It receives the openings of the sphenoidal air sinus.

The atrium of the middle meatus is a shallow depression just in front of the
middle meatus and above the vestibule of the nose. It is limited above by a
faint ridge of mucous membrane , the agger nasi, which runs forwards and
downwards from the upper end of the anterior border of the middle
concha.
Anterial Supply of Lateral Wall
1. The anterosuperior quadrant is supplied by the anterior ethmoidal artery
assisted by the posterior ethmoidal anc facial arteries.
2. The anteroinferior quadrant, is supplied by branches from the facial and
greater palatine arteries.
3. The posterosuperior quadrant, is supplied by the sphenopalatine artery.
4. The posteroinferior quadrant is supplied by branches from the greater
palatine artery which pierce the perpendicular plate of the palatine bone.

Venous Drainage
The veins