[UNIT 6]: M.

02 PHYSIOLOGY OF THE NOSE AND PARANASAL SINUSES OTORHINOLARYNGOLOGY

Dr. Adaci Saint Louis University
02.28.2022-03.04.2022 School of Medicine

OUTLINE
I. Physiology of the Nose
A. Functions of the nose
II. Physiology of Paranasal Sinuses
A. Functions
III. Tests
A. Test of nasal physiology
B. Test for ciliary function
C. Test for olfaction

I. PHYSIOLOGY OF THE NOSE

Ø Nasal physiology is greatly dependent on the physical structure
of the nose
Ø Anatomical changes may alter nasal airflow and may impair the
olfactory ability of the nose
A. FUNCTIONS OF THE NOSE
a. RESPIRATION
Ø Start of normal breathing pattern is for air to enter the body
through the nose
Ø The human breath begins at the ring of the nostrils
Ø The act of breathing conveys air through the upper and lower
respiratory tract to the alveoli of the lung in sufficient volume,
with sufficient pressure, moisture, warmth, and cleanliness, to
assure optimal conditions for oxygen uptake
Ø In the reverse process to assure the optimal elimination of
carbon dioxide brought to the alveoli by the blood stream
Ø Natural pathway for breathing
Ø Humans are obligatory nasal breathers especially during the 1st
6 months of life
Ø 85% of adults are natural nose breathers
• Breathing through the mouth is always pathological
Ø Two important factors to consider: Nasal airflow and nasal
resistance
1. AIR FLOW
Ø Passage of air thru the nose
• The air funnels through the vestibule of the nose, squeezes
through the nasal valve and disperses in the nasal cavity.
Studies show that airflow is accelerated to a linear velocity
of 16 m2 through the nasal valve and velocity will
decelerate as it enters the nasal cavity where it is
humidified and conditioned
Ø Single most important variable in nasal airflow is the diameter
of the nasal passage
Ø Two types of Nasal Airflow:
• Laminar Flow
օ Noted during inspiration
օ Inspiratory air passes vertically up the anterior nares
then across the middle part of the nose between the
septum and the middle turbinate
օ The uncinate process protects the sinuses by
diverting air flow posteriorly going to the nasopharynx
օ Required for cleaning & conditioning the air as
inspired air contains contaminant
• Turbulent Flow
օ noted during expiration
օ Expired air passes eddies at the inferior and middle
turbinates and ventilates the sinuses through the
ostia
օ Creates a perception of increased resistance thus air
is able to squeeze through the ostia to ventilate the
sinuses
Figure 1. Nasal Airflow
During inspiration (laminar flow), the pattern/layer of air is very
smooth and uniform going posteriorly. During expiration (turbulent
airflow), the pattern is irregular. Magnitude and direction is not
uniform thus it increases resistance for it to be able to enter
through the sinuses.
2. NASAL AIRWAY RESISTANCE
Ø Forces that impede the flow of air through the nose
Ø Evaluated by simultaneously measuring nasal airflow and the
resultant pressure gradient in the nasopharynx
Ø Dimensions and shape of the airway lumen and airflow velocity
determine the magnitude of resistance
• Low airway resistance during inspiration (laminar flow)
• High airway resistance during expiration (turbulent
airflow)
Ø Varies inversely and exponentially with lumen cross sectional
area
Ø Nasal valve with the lowest dimension – 40-70% of total airway
resistance
• Nasal valve – highest airway resistance because of having
the lowest lumen dimension
Ø Modified and controlled by the erectile tissue of the nasal
mucosa
• Parasympathetic – vasodilation, increase in nasal airway
resistance
• Sympathetic – vasoconstrictor, decrease in nasal airway
resistance
Ø Factors affecting nasal resistance
• Age (maximum in infants)
• Exercise
• Posture
• Drugs (decongestants and anti-hypertensives)
• Temperature of surrounding air (cold air – high resistance)
Ø Emotional and psychological problems also may regulate the
erectile tissues
Ø Endocrinological disorders
• Hypothyroidism
• Hyperthyroidism
• Pregnancy
Ø The sniff is also an important part of nasal airflow as it provides
a way to force air into the superior nasal vault and into better
contact with the olfactory mucosa
3. NASAL CYCLE
Ø Physiological cycle of alternating nasal congestion and
decongestion between two nasal cavities
Ø Heetderks – 1927, alternating turgescence of the inferior
turbinates in 80% normal population
• When the turbinates in one fossa is filled up or congested,
the turbinates on the other side are decongested. When it
starts to decongest, the other starts to become congested.
This occurs in an alternating pattern
• Further observed that in a lateral decubitus position, the
turbinates in the dependent fossa is filled or congested
while the other side is decongested or normal

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 [UNIT 6]: M.02 PHYSIOLOGY OF THE NOSE AND PARANASAL SINUSES OTORHINOLARYNGOLOGY
Dr. Adaci Saint Louis University
02.28.2022-03.04.2022 School of Medicine

• Left lateral decubitus position: turbinates on the left are
congested, right turbinates are decongested/normal
• Right lateral decubitus position: left will decongest back to
having normal resistance, right side will become
congested
Ø Under control of Autonomic Nervous System
Ø Alternating cycle between right and left nasal cavities
Ø Mean duration of 2.5 hours
Ø Affected by allergy, infection, emotion, exercise, hormones
especially during pregnancy and puberty, drugs, sexual activity
b. AIR CONDITIONING OF THE INSPIRED AIR
Ø Inspired air is warmed (or cooled) to near body temperature and
its relative humidity is brought to above 80%
Ø Sensation of nasal airflow could also depend on thermal and
sensitive stimulation of inhaled air
Ø How is the temperature of inspired air controlled/regulated?
• Counter current mechanism
օ Blood flows in opposite direction to inspired air
օ Contact between air and the rich blood supply of the
nasal membranes, especially the inferior turbinate
mucosa regulates the temperature of inspired air to
near body temperature (36-37°C)
1. HUMIDIFICATION
Ø Occurs simultaneously with temperature control
Ø Relative humidity of the inspired air is adjusted to above 80% up
to 100%
Ø Occurs by evaporation of moisture/water from the mucosal
blanket to saturate the inspired air
Ø Required for proper mucociliary clearance and effective gas
exchange at the lungs
Ø Adults conditions more than 14,000 liters of air per day,
requiring more than 680 grams of water, approximately 20% of
our daily water intake
Ø The irregular internal anatomy of the nasal passages causes
eddies in the inspired air, resulting in a deposition of particulate
matter in the nose and nasopharynx
• Excreted by blowing the nose or by expectoration
Ø Foreign materials including bacteria and viruses, is either
expectorated or carried by mucociliary transport to the stomach
for sterilization by gastric secretions
2. MUCOCILIARY CLEARANCE
Ø Nasal mucus clears the airway of the particulate matter it has
filtered by mucociliary clearance
Ø Respiratory mucosa is coated by thin layer of secretions called
mucous blanket which entraps fine particles during inspiratory
phase and passes them to pharynx to stomach for digestion
• Layers of mucous blanket
օ Superficial thick mucous layer – viscous – gel
օ Deep thin serous layer – watery – sol
օ Mucous layer secreted by nasal glands and goblet
cells
3. CILIA
Ø Respiratory tract: lined by ciliated pseudostratified columnar
epithelium with goblet cells
Ø Outer gel layer of the mucous blanket moves by beating of cilia
• Propels the mucous blanket towards nasopharynx
• Beats at 10-20 times per second
օ < 10-20 times per second: transport of the mucous
blanket towards the nasopharynx is lengthened
• Acts best at pH 7 – pH of nasal secretions
• Factors affecting cilia beating
օ Pollution
օ Smoking
օ Viral and bacterial infection
օ Heat or cold
օ Humidity
օ Drugs

4. MUCOUS SECRETIONS
Ø Produced by nasal glands and goblet cells
Ø Rich in lysozymes – enzyme causing bacterial/viral destruction
Ø Contains IgA and IgE – provides immunity, neutralizes allergies
and bacterial toxins
Ø Contains interferon – provides immunity
Ø Contains water and ions
Ø Contains glycoproteins

5. SNEEZING
Ø Protective reflex as a response to irritants and harmful stimuli
which are expelled
Ø Copious nasal secretions following sneezing helps to wash the
foreign material out
Figure 2. Air conditioning and humidification
Majority of the blood supply of the nasal cavity originates posteriorly and
is directed anteriorly. When the air is inspired, it comes in contact with
the blood vessels, regulating the temperature. At the same time, the
moisture from the nasal mucosa saturates the air. By the time it enters
the nasopharyngeal area, it is already conditioned and humidified.

c. PROTECTION OF THE RESPIRATORY TRACT

1. FILTRATION AND PURIFICATION
Ø First defense: inspired air is free of contaminants before it
enters the lower respiratory tract
Ø The hairs of the skin-lined nasal vestibule play a role in air
filtration trapping particles up to 3 μm
Ø Nasal mucus traps particles from 0.5-3 μm
Ø Less than 0.5 μm can enter lower airway
Figure 3. Mucociliary Transport System

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 [UNIT 6]: M.02 PHYSIOLOGY OF THE NOSE AND PARANASAL SINUSES OTORHINOLARYNGOLOGY
Dr. Adaci Saint Louis University
02.28.2022-03.04.2022 School of Medicine

As the cilia beats, it propels the mucous blanket posteriorly to the g. DRAINAGE OF SECRETIONS
nasopharynx (effective stroke). Recovery stroke seen at the bottom.
These strokes occur in an alternating cycle. h. EUSTACHIAN TUBE FUNCTION
Ø Nose permits equalization of pressure between atmosphere
d. VOCAL RESONANCE and middle ear cavity
Ø Nasal cavities act as resonators of voice especially to some • Maintains middle ear pressure – aeration of middle ear
consonants like M and N cavity
Ø Add nasal tone to voice
• Nose helps in the proper pronunciation of letters and i. PROVIDES BEAUTIFUL SHAPE TO THE FACE
words Ø Aesthetic function
Ø When nose is blocked, speech becomes denasal/hyponasal
Ø Reverse is true in velopharyngeal insufficiency (cleft palate) –
hypernasal

e. NASAL REFLEX FUNCTION

Ø Appetite
• Good smell of food – reflex secretions of saliva and gastric
juice
Ø Nasopulmonary and nasobronchial reflex
• Helps in lung function
Ø Cardiopulmonary reflex
• Breathing cessation and bradycardia

f. OLFACTION
Ø Less developed in man compared to lower animals
Ø Women smell better than men
Figure 4a. Olfactory Pathway
Ø Required for enjoying the taste of food, perception of flavor and
Olfaction starts when the olfactory epithelium sense odorant particles in
palatability, regulation of food intake
the inspired air. The receptor cells will then form the olfactory nerves
Ø Protective function
which pass through the cribriform plate going into the olfactory bulb. The
• Detection of toxic substances
olfactory bulb contains the mitral cells whose axons form the olfactory
Ø Regulation of reproduction behavior in lower animals
tract.
Ø Humans can detect >10,000 odors and discriminate between
5,000 of them
Ø Sniffing increases the amount of inspired air available for
olfaction
Ø Age related – loss of smell after 70 years
Ø Olfactory pathway
• Olfactory epithelium is present above the superior
turbinate, corresponding nasal septum, cribriform plate
high up in nasal cavity
օ Olfactory epithelium contains olfactory receptor cells,
basal cells and supporting cells which will sense the
odorant particles in inspired air
• Central process of these receptor cells forms the olfactory
nerves which passes through cribriform plate of ethmoid
and end in olfactory bulb
• Olfactory bulb contains mitral cells whose axons form the
olfactory tract
Figure 4b. Olfactory Pathway
• Olfactory tract carries sensation to cerebrum particularly
From the olfactory bulb, sensation goes through the mitral cells which
to the prepyriform cortex and amygdaloid nucleus where it
form the olfactory tract. Olfactory tract is divided into a medial olfactory
reaches consciousness
straia and lateral olfactory straia. The medial branch goes into the
Ø Vomero nasal organ of Jacobson
contralateral paraolfactory area while the lateral branch goes into the
• Accessory olfactory tissue located behind the caudal end amygdaloid nucleus, where the sensation is then processed.
of septum, 3 mm above the nasal floor
Ø Olfactory cortex
Branches of the Olfactory Tract
• Areas that receive input directly from the olfactory bulb
Medial olfactory straia à Paraolfactory area
օ Pyriform cortex: encodes representations of odor Lateral olfactory straia à Amygdaloid nucleus
quality, identity, memory and the coordination of
olfaction, vision and taste II. PHYSIOLOGY OF PARANASAL SINUSES
օ Thalamus: helps in interpretation of results
օ Amygdala: responds to the intensity of emotionally A. FUNCTIONS
significant pleasant or unpleasant odor Ø Air conditioning of the inspired air by providing large surface
օ Entorhinal cortex: preprocesses information entering area over which air is humidified and warmed
the hippocampus which is involved in learning and Ø Mucocililary clearance – helps to replace contaminated nasal
memory secretions by the secretion of mucus through the ostia to keep
օ Orbitofrontal cortex: provides interpretative nasal cavities moist
processing Ø Thermal insulators to protect delicate structure in the orbit and
the cranium from variations in the intranasal temperature

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 [UNIT 6]: M.02 PHYSIOLOGY OF THE NOSE AND PARANASAL SINUSES OTORHINOLARYNGOLOGY
Dr. Adaci Saint Louis University
02.28.2022-03.04.2022 School of Medicine

Ø Lighten the skull bones

Ø Contributes to facial growth
Ø Protection of brain and orbit from trauma – by acting as a
buffer
Ø Local immunological defense against microbe
Ø Regulates intranasal pressure
Ø Sinuses are not ventilated during inspiration because there is a
laminar airflow and the uncinate process blocks the entrance of
air into the ostia.
Ø Ventilation of the sinuses only occurs during expiration through
the ostia because of the eddying set up of the air at the level of
nasal valve, and inferior and middle turbinates.
Ø Emptied of air during inspiration and filled with air during
expiration Figure 6.
Ø NO (nitrogen oxide) synthesized in PNS gets added to the There is only one direction.
inspiratory air: From the lateral wall (red line) going into the
• Helps in better oxygenation and perfusion medial wall (blue line) down into the middle
• Toxic to bacteria and viruses meatus (yellow line).
• Increases ciliary motility
Ø Functioning for mucociliary clearance, the mucus secreted in It drains Through sphenoethmoidal recess before
the sinus spreads to the ostium in a spiral manner and propelled going to the superior meatus
by the cilia towards the meatus subsequently to nasopharynx. Sphenoid There is only one direction.
sinus *Refer to Figure 6.
Secretions start from floor of sinus going up the From the middle wall (blue line) going to the lateral
sinus walls until it reaches the uppermost & wall (red line) and out own into the medial wall
posterior part of sinus. (yellow line).
After which, it drains from the ostium through the Secretions are transported inward along the
ethmoidal infundibulum, into middle meatus then interfrontal septum going to the roof, into the
posteriorly going to the nasopharynx. lateral wall, into the floor, until it reaches ostium of
the sinus. Then, it will drain through the ostium,
It never drains though accessory ostia. into the frontal recess going to the ethmoidal
infundibulum, going to the middle meatus and
finally the nasopharynx

Maxillary Some secretions are recycled from frontal recess

sinus back to sinus through ostium (green line) for
another cycle (green arrows).

Frontal sinus

Figure 5.
Floor of meatus(green line)àsinus walls (blue
line)àostium at uppermost and posterior part of
sinusà drain though ostiumà ethmoidal
infundibulum (red line) à middle meatus (yellow
line)
The ethmoidal sinuses:
Anterior à drain through middle meatus
Posterior à drain through superior meatus

Ethmoidal Figure 7.
sinus interfrontal septum(black line)à roof (yellow line)
à lateral wall (red line)à floor (blue line) à reach
ostium (green line) at floor of sinusà drain
through ostium à frontal recess à ethmoidal
infundibulum à middle meatus à nasopharynx

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 [UNIT 6]: M.02 PHYSIOLOGY OF THE NOSE AND PARANASAL SINUSES OTORHINOLARYNGOLOGY
Dr. Adaci Saint Louis University
02.28.2022-03.04.2022 School of Medicine

Two ways of drainage: Ø Gamma camera obtains dynamic images over 10-20 minutes
Landmark: Eustachian tube (ET) orifice (i.e. tubal to measure transport time between a reference point and the
orifice) distance traveled to nasopharynx
1. Infra tubal stream
-- Secretions from middle meatus drains below and C. TEST FOR OLFACTION
in front of tubal orifice (inferior and anterior) Ø Loss of smell and taste – included in the list of COVID
2. Supra tubal stream symptoms
Secretions in --Secretions from superior/supreme meatus and Ø Prevalence of loss of smell and taste is very high, affecting 60%
nasopharynx sphenoethmoidal recess drain above and behind of people with COVID-19
the tubal orifice (superior and inferior) • Recovery time ranges from 2 weeks or more, to as short as
-- During infection, it can overflow ET orifice à 5 days
middle ear infection.
--Finally, drain though oropharynx into stomach a. SMELL IDENTIFICATION TESTS
and digested. 1. Assess and diagnose smell disorders
Ø Some questions that should be answered include:
• Can the person smell?
• Can he identify the smell?
• Can he characterize the smell?
2. Most important is to use things with distinctive smell that are easily
identifiable and are familiar to those being tested
Ø Unfamiliar scents may not be recognized by the patient causing
a failure in the identification test
3. Use non-irritating substances like orange, vanilla, lemon, coffee, or
garlic which will only stimulate your olfactory receptors
Ø Do not use irritating odors such as camphor or menthol as these
will stimulate the (1) trigeminal sensory receptors in addition to
Figure 8. Diagram of nasopharynx
(2) olfactory receptors, potentially giving a false result
Blue dot: Middle meatus; Green dot: Superior
meatus; Red figure/arrow: ET orifice
PROCEDURE:
Blue arrow: Infra tubal stream
1. Put the patient in a comfortable position.
Green arrow: Supra tubal stream
2. Patient places an index finger over one nostril to block it.
3. Closes the eyes.
III. TESTS
4. Instruct the patient to sniff repetitively and to tell you when an
odor is detected, identifying the odor if recognized.
A. TEST OF NASAL PHYSIOLOGY
5. Bring the test odor up to within 30 cm or less of the nose.
Ø Assess nasal resistance and nasal airflow
6. Do not touch the patient and do not move. Movement of your
body will give a clue as to when the test object is being
a. RHINOMANOMETRY
presented.
Ø Standard diagnostic tool to objectively evaluate the respiratory
7. Repeat the process with the other nostril.
function of the nose
Ø Attempts to quantify nasal airflow and total nasal area during
INTERPRETATION OF RESULTS:
exclusive nasal breathing
Ø Smell (or CN I) is intact when the patient reports detection of an
Ø Differential pressure measurements are obtained by placing a
odor.
nasal catheter into the nasopharynx
• If the patient has no reaction, it means the patient cannot
Ø Nasal resistance measurement assesses all resistive
smell.
components of the nasal airway from the anterior nares to the
Ø Recognition of the odor involves olfactory memory, which is a
nasopharynx and is sensitive to small changes in airway caliber.
higher cortical function.
Ø Available in St. Luke’s
• Thus, a need for test objects to which the patient is already
b. ACOUSTIC RHINOMETRY familiar with.
Ø Newer technique for evaluating cross-sectional area of the • A normal person may not be able to identify an odor of
nose and the volume of the nasal cavity by analysis of incident which he has no memory of.
and reflected sound during a brief cessation of nasal breathing
Ø It is minimally invasive, quick to perform and requires little UNIVERSITY OF PENNSYLVANIA SMELL IDENTIFICATION TEST
patient cooperation (UPSIT)
Ø A more comprehensive smell identification test
c. NASAL INSPIRATORY PEAK FLOW Ø Most widely used olfactory test
Ø Objective and physiologic measurement of nasal airflow Ø 40 item test- four booklets containing ten
Ø Portable equipment and easy to use microencapsulated (scratch & sniff) odorants.
Ø Procedure is the same as presented but with the addition of
B. TEST FOR CILIARY FUNCTION • 4 booklets containing 10 pages each, with 10
microencapsulated (scratch and sniff) odorants.
a. SACCHARIN TEST օ In each page, there is different scratch and sniff
Ø Evaluates ciliary function by measuring the time it takes for a strip which are embedded with
drop of saccharin to be tasted in the back of the throat when microencapsulated odorant
applied to the anterior tip of the inferior turbinate օ In each page, there is also a 4-choice multiple
choice question.
b. 99Tc-MACROAGGREGATED ALBUMIN SCINTIGRAPHY • The scent is released with a pencil, then the patient
Ø Radiolabeled droplet placed in anterior nasal wall smells the level and detects the odor from the 4
choices.

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 [UNIT 6]: M.02 PHYSIOLOGY OF THE NOSE AND PARANASAL SINUSES OTORHINOLARYNGOLOGY
Dr. Adaci Saint Louis University
02.28.2022-03.04.2022 School of Medicine

• There is an answer column at the back of the test

booklet, and the test is scored out of 40 items.
Ø Test results are in terms of a percentile score of a patient’s
performance relative to age- and sex-matched controls.
Ø Olfactory function can be classified on an absolute basis
into 1 of 6 categories:
• Normosmia (normal level of smell)
• Mild microsmia
• Moderate microsmia
• Severe microsmia
• Anosmia (total loss of smell)
• Probable malingering

** Clinical importance of testing is to distinguish patients who have a

disorder from those who malinger and seek compensation. At the
end of testing for olfaction, you should be able to answer the
question:
Ø Can the patient smell?
Ø Is there loss of smell?
Ø At what level is the loss of smell? Mild, moderate or severe?
Ø Is the patient malingering?

CHECKPOINT
T/F
1. The single most important variable in nasal airflow is the diameter of
the nasal passage.
2. Nasal valve has the highest dimension therefore has the lowest
airway resistance.
3. Inspired air is warmed/cooled to near body temperature and its
relative humidity is brought to above 90%.
4. Less than 0.5 um particles can enter the lower airway.
5. Sneezing is a protective reflex as a response to irritants and harmful
stimuli which are expelled.

IDENTIFICATION
1. The posterior ethmoidal sinus will drain through _______.
2. Standard diagnostic tool to objectively evaluate the respiratory
function of the nose.
3. Irritating odors will stimulate these receptors.
4. Most widely used olfactory test
5. A drop of saccharin is applied into what part of the turbinates?

5. anterior tip of the inferior turbinate

4. UPSIT
3. trigeminal sensory receptors & olfactory receptors
2. Rhinomanometry
1. Superior meatus
Identification
T, T
T, F – lowest dimension, highest airway resistance, F – above 80%,
T/F
ANSWERS

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