SCENARIO 4

"Blocked nose, Lucky Drag"

Mr. Butcher, 35 years working as a butcher in the market, came to the health center with a chief
complaint Poli cold for 4 days. Complaints accompanied by thick mucus discharge and
congestion making it hard to smell a rat. Sometimes patients complain of headaches, especially
in the morning and when used for prostration during prayer. This complaint is currently selling
very disturbing activities. To confirm the diagnosis, the doctor checks the anterior rhinoscopy,
olfactory test, and transillumination sinus.

ANALYSIS PROBLEM

1. Anatomy Nasal
The nose is divided into two parts;
A. Nose Affairs
1) The base Nose (Radix Nasi)
2) Rod nose (dorsum Nasi)
3) Peak Nose (Apex Nasi)
4) Ala Nasi
5) Columella
6) Hole Nose (Anterior Nares)

External nose is formed by bone and cartilage skeleton covered by skin.

Skeletal framework consists of:

a. Nasal bone (Os Nasal)

b. Proc. os frontal maxilla

c. Proc. os nasal frontal

While the cartilage framework consists of:

a. A pair of superior lateral nasal cartilage

b. A pair of lateral inferior nasal cartilage

c. Alaris major

d. The anterior edge of the septal cartilage

B. Nose Interna

1) cavity Nasi

Nasal cavity consists of:

a. Vestibule covered by submucosal cells as protection.

b. Hair found in the nasal cavity that acts as an air filter

c. Konka structure that serves as protection against outside air because of the layered
structure.

d. Ciliary cells whose role is to throw foreign objects out in an attempt to clear the
airway.

Internal parts of the nasal cavity aisle is separated into right and left nasal cavity by
narrow vertical divider, called the septum. Each nasal cavity is divided into three
channels by turbinasi or turbinate protrusion of the lateral wall.

There are 6 limit nasi cavity, namely:

a. Namely the medial border of the nasal septum.

b. The lateral limits of Konka nasi is superior, superior meatus nasi, nasi Konka medius,
meatus nasi medius, nasi inferior turbinate and meatus nasi inferior.

c. Namely the anterior margin of nares (introitus pouch of nasi).

d. Ie posterior border koane.

e. Namely the superior border of the lamina kribrosa.

f. Namely the inferior border of the hard palate.

2) septum Nasi

The medial wall of the nose is the nasal septum, which is formed by bone and cartilage.

Bone part consists of:

a. Lamina perpendicularis os ethmoid

b. Vomer

c. Crista nasalis os maxilla

d. Crista nasalis os palatine

Part cartilage:

a. Lamina quadrangular

b. Columella

3) Concha

The lateral wall of the nasal concha there are four;

a. Concha superior

b. Concha media

c. Concha inferior

Among concha-concha there is a narrow cavity called meatus. Meatus is the estuary of
the paranasal sinuses.

a. Superior meatus: estuaries where ethmoidalis posterior sinus, frontal sinus

b. Meatus medius: estuaries where ethmoidalis anterior sinus, sinus sphenoidalis, and
sinus maxillaries.

c. Inferior meatus: the estuary of the ductus nasolacrimalis.

 4) paranasal sinuses

There are two major categories paranasal sinuses, namely:

a. Paranasal sinus anterior group, namely the frontal sinus, anterior ethmoidalis sinus
and maxillary sinus.

b. Paranasal sinus posterior groups, namely ethmoidalis posterior sinus and sphenoidal
sinus.

Paranasal sinus ostia anterior group is in the meatus nasi medius.

Paranasal sinus ostia posterior group is in the meatus nasi superior. Pus in the meatus
nasi medius will flow into the vestibule nasi. Pus in the meatus nasi superior will flow
into the pharynx.Nasal cavity

2. Histology
a. Nasal General
Lined by stratified squamous and respiratory type pseudostratified columnar
epithelium, separated by transitional epithelium in some places.
Respiratory mucosa (also called Schneiderian membrane) may contain goblet
cells; may undergo squamous metaplasia.
Superior third of nasal septum, superior turbinate and cribriform plate are covered
with thinner olfactory mucosa, usually patchy in adults, which has neuroendocrine
features
Seromucinous glands (resembling salivary glands) are present in submucosa,
numerous near eustachian tube opening of nasopharynx, may undergo oncocytic
metaplasia with increasing age
b. Paranasal sinuses

Mucosa is continuous with nasal cavity and identical (respiratory type

epithelium), but thinner and with fewer goblet cells and seromucinous glands
3. Physiology
a. RESPIRATION

The nose is a natural pathway for breathing. During respiration the nose acts as an air
conditioning unit by performing humidification, heat transfer, and filtration. The
nasal mucosa can help adjust the humidity and temperature of the air before it
reaches the lungs. The large surface area of the nasal mucosa helps regulate the
temperature and humidity of inspired air. The nasal cycle is a rhythmic cycle of
growth of venous sinusoids that alters between the left and right nasal passages. The
activation of sympathetic nerve fibers (part of the autonomic, i.e. automatic, nervous
system) controls blood flow to the nasal cavity and nasal mucosa. Alternating the
volume of blood between the left and right nasal passages varies between individuals
but on average occurs every 4 hours. Nasal secretions and mucus production is
controlled by parasympathetic autonomic innervation and is also cyclical with
increased secretion on the side with the greatest airflow. This diurnal nasal cycle is
normal, but can be a source nasal obstruction for some patients that may require
evaluation.

b. VOCAL RESONANCE

The nose is thought to be a resonating chamber for certain consonants in speech

during exhalation. This is evident during phonation (making the sound) of M, N, and
NG, as sound passes upwards through the nasopharynx and is emitted through the
nose. Many nasal conditions causing obstruction of the nose affect the quality of the
voice.

c. OLFACTION

Our ability to smell stems from specialized olfactory neuroepithelium found high in
the nasal cavity. Impaired olfaction is commonly observed in patients with sinonasal
disease with a prevalence reported up to 30-60% of this patient population and is a
criterion used for the diagnosis of chronic rhinosinusitis. Olfactory dysfunction in
rhinosinusitis is likely due to many different reasons, stemming from both physical
 obstruction and an inflammatory component that damages the olfactory
neuroepithelium.

d. FILTRATION OF THE AIRWAY

As we breathe, the nose is constantly exposed to inhaled debris and microbes

(viruses, bacteria, and fungus). The respiratory system has developed several lines of
defense to combat this continuous assault. Larger particles are trapped by the nasal
vibrissae (hairs at the front of the nose). Smaller particles are trapped in the mucus,
considered to be one of the initial defenses of the airway. Mucus is designed to trap
inhaled particles (including microbes) that are subsequently cleared from the
airways. Nasal secretions also contain enzymes, anti-microbial mediators, and
immune cells, which kill unwanted bacteria and viruses. The vast majority of mucus
is propelled into the throat where it is swallowed and destroyed by the products of
the stomach. Mucus containing pathogens and debris can also be coughed up or
sneezed out.

e. CILIA

The mechanism by which mucus is propelled to the throat involves the rhythmic
beating of very small cellular projections, known as cilia (which look like hair),
which line the airways.

In order for the mucus produced in the sinuses to reach the throat, the cilia
throughout the sinonasal cavity are “programmed” to beat in a very specific
direction. Each sinus has an ostium (opening) that the cilia carry the mucus towards
and through into defined anatomical areas within the sinonasal cavity (see sinus
anatomy). The middle meatus is located lateral to the middle turbinate and accepts
drainage from the frontal, maxillary, and the anterior ethmoid sinuses. Posteriorly,
the superior meatus is below the superior turbinate, which accepts drainage from the
posterior ethmoid sinuses. The drainage continues medially into the sphenoethmoidal
recess, which also accepts drainage from the sphenoid sinus and ends up in the
nasopharynx or the upper part of the throat and subsequently swallowed.
 Cilia continuously beat to drive the debris-laden mucus from the airways. Ciliated
cells have multiple sensors that allow the cell to respond to locally produced
mediators and/or certain cues, such as changes in mucus thickness and mucus loads
to make their cilia increase the speed at which they beat. By increasing the speed at
which they beat, the cilia can generate more force and thus continue to clear the
heavier mucus, or clear normal mucus at a faster rate. Conversely, when mucociliary
clearance is inhibited or slowed there may be an increased incidence of
rhinosinusitis, as seen in patients with cystic fibrosis (see cystic fibrosis).

4. Biochemistry

First the physical properties, but the smell that wafted bkn only because of the
physical nature of the composition → interaction with the receptor protein.

The second role of the gene, some people and animals specific anosmia → → →
usually inherited mutations of receptor genes in each individual.

Mechanism.

Odor detected in a special area on the olfactory epithelium of the nose → → → nerve
sensory cilia containing receptor protein to bind odors - smells → mucosal cavity nasi

Biochemical studies in the 1980s against the cilia mice that had been exposed odors -
smells ↑ → pe cellular cAMP and GTP levels → involvement of G proteins and receptors
7tm

Reed → find the G protein subunit α → G (olf).

7tm receptor → to identify the olfactory receptors.

Axel - Buck → cDNA:

- Expressed on sensory nerves in the nasal epithelium

- Coding group 7tm receptors

- Present in a large and varied group to store information of various odors - smells.
 Olfactory receptor (OR):

Polynomial.

20% similar to the protein β - aderenergic receptors.

30-60% similar to one another.

At the transmembrane helix 4 and 5 at most variations → molecule binding sites

Each olfactory nerve represent only 1 gene OR

Principle: the binding molecules of smells to the OR on the surface of nerve signal
transduction → → → Action potential combinations with neural → perception of certain
odors.

Conducted research to match each - each OR with one or more molecules of smells:

Almost all odors activate multiple receptors and almost every receptors activated by more
than one smells

There remains a unique combination → can distinguish smells.

Nerves carry the gene OR → → traced the olfactory bulb

Nerves that carry specific OR genes linked to certain specific locations → map response
odors in the olfactory bulb.

5. Sinus Test
a. Anterior Rhinoscopy
Examination of the Vestibule
1) Look for:
- Boil or Abcess
- Ulcerations and abrasions
- Excoriation because of discharge.
2) Examination of the nasal cavity using a nasal speculum
b. Posterior Rhinoscopy
 Using Post Nasal Mirror: It consists of a handle on which a small mirror is attached to
shaft at an angle of 110
1) Hold the mirror like a pen in the right hand.
2) Warm the mirror
3) Ask the patient to open the mouth.
4) Depress the anterior 2/3rds of the tongue
5) Feel the warmth of the mirror on the back of the wrist. It should not be hot.
6) Introduce the mirror from the angle of the mouth over the tongue depressor and
slide it behind the uvula. Avoid touching the posterior wall of the pharynx as it
may trigger gagging.
7) Instruct the patient to breath through the nose.
8) Tilt the mirror in different direction tot see various structures of the nasopharynx.
c. Transillumination Test
1) Dim the room lights.
2) Place the lighted otoscope directly on the infraorbital rim (bone just below the
eye).
3) Ask the patient to open their mouth and look for light glowing through the
mucosa of the upper mouth.
4) Principle: In the setting of inflammation, the maxillary sinus becomes fluid filled
and will not allow this transillumination.