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    Orbit and Nose H&N

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    ue Lies a four raed errand Ml an ape’, Love and 4 wal APEX: At #42 optit canal rn the lesser wing Sf sphenst Bace : scemmamorerial opening on Face Roof : orbitae plas of frontal brn\_\ peppieseh exes yh sphenord | |= F100¥: naainly by Mayilla povsty by x yA0rregtic % palatine boné= F ) medial. arpitot plate | wan * ofpasids font sof +h eo. ie nerves. PROCES. Of ymaxilia A6iLacrimal glandlt has already been studiedis Cha i sualiAxis-and OrbitalAxis passing through centres of anterior and peste" of the ‘makes is known as visual axis. It le of 20-25° with the orbital axis (ee ig. nite of Bt iphine passing through optic canal 2‘ margins ions orbital fascia ina ener ene 1 A proces of the faacia holds the Pore ny tendon mi the superior oblique sc c. Another forms the Teldges the lacrimal groove wt abel Fasclal Sheath of Eveball or Bulbo Scanned with CamScanner wat eal junction or limbus. It is om the sclera by the episcleral space d by delicate fibrous bands. The move within this sheath. muscles. the entrance of ‘off a number of expansions. ach orbital muscle. aistrong triangular ‘of the medial rectus lacrimal bone. a strong triangular sheath of the later=! rectus to the zygomatic bone (Fig. 13.3). It is ‘and narrow at its extremities, a hammock below the eyeball. Itis ‘of the margins of the sheaths of the the inferior oblique muscles with check ligaments. —— 1 Ber superontn the levator palpebrae superiors is the covlometon aus, muscle, The upper division of FIDE cite lie between these! two muscles, orbit look for letra A the lateral wall of the specs ae ene pana reach the Follow the tendon of superior oblique muscle passit passing nena beneath the superior rectus to be Inserted into sclera behind the equator. After identifica |, divide frontal nerve, levator palpebrae superioris and superior rectus in the middle of the orbit and reflect them apart. Identify the optic nerve and other structures crossing it. These are nasociliary nerve, ophthalmic artery and superior ophthalmic vein. With the optic nerve find two long ciliary nerves and 12-20 short ciliary nerves are seen. Remove the orbital fat and look carefully in the posterior part of the interval between the optic nerve and lateral rectus muscle along the lateral wall of the orbit and identify the pin head sized ciliary ganglion. Trace the roots connecting it to the nasociliary nerve and nerve to inferior oblique muscle. Lastly, identify the abducent nerve closely adherent to the medial surface of lateral rectus muscle. Incise the inferior fornix of conjunctiva and palpebral J fascia, Elevate the eyeball and remove the fat and fascia to identify the origin of inferior oblique muscle from the floor of the orbit anteriorly. Identity the levator palpebrae superioris and superior rectus above the eyeball, superior oblique supero- medially, medial rectus medially, lateral rectus laterally, and inferior rectus inferiorly. “The voluntary muscles are miniature ribbon muscles, having short tendons of origin and long tendons of insertion. Vowntory Muscles > KI77 table } Four recti: a. Superior rectub. b. Inferior rectust c. Medial rectus. d. Lateral rectus. a Two obliques: b. a 3 geese: Involuntary Muscles: | Baa beelaaniedr ope eens 1 ere Se upper margin superior tarsus. It elev: rod Scanned with CamScanner Lacrimal fascia Lacrimal sac Lacrimal bone Medial check ligament Sheath of medial rectus Orbital fascia Ethmoid bone ‘Sheath of lateral rectus. ‘Sheath of optic nerve Orbital fascia I acrenci Fig. 13.2: Orbital fascia and fascial sheath of the eyeball as seen in transverse section 2 The inferior tarsal muscle extends from sheath of the inferior rectus and inferior. the lower margin of the inferior tarsus. ligt depresses the lower eyelid. 3 The orbitalis bridges the inferior orbital fs action is uncertain (Fig. 13.1). Voluntary Muscles, Origim 1 The four recti arise from a common an tendinous ring of zinn. The ring is atac ake ital Fsure (Bg tio. al orl: Lesser wing 5% Lovatorpapeoae Common tens” Frontal nerve ‘Superior oblia® ‘Superior ophthalmic vein. Medial rectus Body of sphend Upper and lower divisions pte ‘of oculomotor nerve artery in opt ‘Abducent nerve Nasoctiary #° Inferior ophthalmic vein. Greater wing of sphenoid of the orbit showing the origins of th i A eerr oral sire a Inferior recs ca Super . Taocular muscle, the common tendinous tid Scanned with CamScanner Ral 2 Thetend, (ON Of the - i fibrocarti Superior obli que arises from the laginous lique passes through sphenoid, cuperonnsurface fossa Of the frontal bog, ted to the rochear edial to the Aaterally, downwargen one tendon then passes Superior rectus rare! ad backward below the the : teh and the aes re between the superior fetiot oblique is laterail que is fleshy throughout. It passes pei ediemasand backwards below the inferior aiden, ‘deep to the lateral rectus. The inferior ligueisinserted close tothe superior obliques lite below and posterior tothe later 4 The flat tendon of the levator splits into a superior or voluntary and an inferior or involuntary lamellae. tothe sclera, alittle posterior ‘Superior lamella of the levator is inserted into the eral junction). Th antetior surface of the superior tarsus, and into n Hinetion). The average the skin ofthe upper eyelid. The inferior lamella the insertions from the cornea are: (smooth part) is inserted into the upper margin of the superior tarsus (see Fig, 2.21b) and into superior conjunctival fornix. : 1 Thesuperoroblgu any eV alo trochlear nerve (¢ ig. 13.6). 2 The lta rec i sup ‘by the VI cranial oF 4 ape mining five extraocular muscles sere inferior and medial ret inferior oblique so PY of levator palpebrae superiors ar the III cranial of oculomotor nerve: Aciions e 1 The movements ofthe areas fo Scanned with CamScanner Head and Neck 2 oe 4 'b. Around a vertical ais * Medial rotation or adduction (50°). * Lateral rotation or abduction (50°). . Around an anteroposterior fxis * Intorsiont * Extorsion! ¥ The rotatory movements of the eyeball upwards, downwards, medially or laterally, are defined in ‘terms of the direction of movement of the centre , Of the pupill The torsions are defined in terms of »” the direction of movement of the upper margin of the pupil at 12 o'clock position. d. The movements given above can take place in various combinations. Actions of individual muscles shown in Fig. 13.7a and “Table 13.1. Single or pure movements are produced by combined actions of muscles. Similar actions get added together, while opposing actions cancel each other enabling pure movements (Fig. 13.7b). a. Upward rotation or elevation: By the superior rectus and the inferior oblique. “B. Downward rotation or depression: |BY the inféridr Tectus and the superior oblique. Lateral rotation or abduction: By the lateral rectus, the superior oblique and the inferior oblique. e. Intorsion: By the superior oblique and the stiperidt rectus. {. Extorsion: By RGInteHorOBiqueanaleAeror Combined movements of the eyes” Normally, movements of the two eyes are harmoni- ously coordinated. Such coordinated movements of both‘eyes are called conjugate ocular movements (Fig. 13.7c). * Weakness or paralysis of amuscle causes squint or . strabismus, which may be concomitant or paralytic. ‘Concomitant squint is’ congenital! there is no limitation of movement, and no diplopia (Fig. 13.8). aralytic squint, movements are limited, nips present, head is turrjed diplopia and vertigo are p Hp OF larection of the function of paralysed muscle, entation of the field of vision. e is a false orient aa characterized by involuntary, Nystagmus io svements of the eyes. This Phythaicaloslatory movements of ees, dinatio scles. - oo iver vestibula® or cerebellar, or even may,be,e congenital in the direct Sar ti Trace the ophthalmic artery alter it was pe ’ ‘over the optic nerve along with Nasocilian superior ophthalmic vein. Identity its bran" the central artery of the retina which ig an ‘on 2 OPHTHALMIC ARTERY Origin ‘igs 13.9 and 13.10). Course and Relations 1 The artery enters the orbit through the opi lying inferolateral to the optic nerve. Botht and nerve lie in a common dural sheath Inthe orbit, the artery pierces the dura mate, over the lateral side of the optic nerve, and above the nerve from lateral to medial sit With the nasociliary nerve. It then runs fer along the medial wall of the orbit bet superior oblique and the medi) rect 5, Pafallel to the nasociliary nerve : oa v (Fig. 13.9). Branches While still within the dural sheath, the 0 artery gives off the central artery of the piercing the dura mater, it giv branch that runs along the lateral. of main artery runs towards the medial wl) giving off a number of branches. The v2" are described below. Central Artery of Retina The central artery of retina (Fig. 1310) 8 most important branch of the ophthal™ 00 lies below the optic nerve. Itpierces #4 the nerve and runs forwards for 2°) 0 these two. It then enters the 5 cil nerve and runs forwards in its net disc (Fig. 13.9). Hereitdividesintob™™ the retina (see Fig. 19.10). ‘The central artery of the retina is)", not have effective anastomoses * Occlusion of the artery results i", intraocular part of the artery can be *, 0) through an ophthalmoscope (se Fé uel Scanned with CamScanner —~4-t Reting 7 2PraRcmd | 7 Arte; A Reasrvent mm Ry >) Beebo a fe ieee 1 Bra — palpaberad 2 Twd reson toe RCRA “ed oS amg aera ha Sepia =v Glare Orbit x thed Anfeyey rallg 3 lal Rca a (ee eee aA Pater mediog branche, be Pagpaberad oni 5 M Sup ref orcas Nasag 1 They BRANCH AREA SUPPLIED * chig——___ | ae supp Centre Artery Supplies yerting of retng u “pt aygorratico— Supplies anterior — + | See _| temple Fygomatico Ei © i on Supplies . Face | Branch ee vad supplios tocewmal 1 ex {Janae glal Di Recusrent, | amitomocis with Menir ynighle _meninge. MUSCULaY Muscles of orbit ’ p LUBY | BBR I isc long) prin wis’ "| SUP Ia trechlear| supplies Fore head %y me pinned oe Shost oliany Supplies Gen) erent + rede tones 20mg ciliary Su pl cilitry body +3xic “Spracrbitas | ace seoilp + Porenead od POSTEDOY CTIA Ethmerdall | Carpe peste on leth modal cet. Antoriey supplier bes aah alts le ethmoj cells 4— oe sy Part OF nose oe Stbus Melty ' A "~ fiieboae | 5474 eect Dorsal nay, S$UPPIEr cnpe, 5 i a Ppea part 1 Fig. {FAW Single movement us ue eye of nase Scanned with CamScanner 7 lata orbital + opthalimic branches muscles attached ° ‘The ante ater es ciliary, muscular muscular ae ne terior ethmoidal be branches enter wall of the orbit to supply the muses. They then then enter the ant . The ‘byanches of the anterior © terminate ai supply parti branches supply the rach supplies the uPpet Pat of Scanned with CamScanner The inferior ophthalmic vein: Iepuns below the opticnerve. It receives tributaries from the lacrimal sac, the lower orbital muscles, and the eyelids, and ends either by joining the superior ophthalmic vein or drains directly into the cavernous sinus. It communicates a pterygoid plexus of veins by small veins passing through the inferior orbital fissure. Scanned with CamScanner lymphatics of the Orbit : E The lymphatics drain into the preauricular parotid lymph nodes (see Fig. 2.25). NERVES OF THE ORBIT Only opticnerve, ciliary ganglion branches of V1 and some branches of V2 and sympathetic nerves are described in this Chapter. III, IV and VI cranial nerves are described in Chapter 4, Volume 4. OPTIC NERVE The optic nerve is the nerve of sight. It is € nerve is about 4 cm lon are intraorbital, 5 mm intracanalicular, and 10 mm intracranial. The entire nerve is enclosed in three meningeal sheaths. The subarachnoid space extends around the nerve up to the eyeball (Fig. 13.10). Relations in the Orbit 1 At the Grex of the orbit, the nerve is closely sur- rounded by the recti muscles. The ciliary gavel, lies between the opticnerve and the lateral oceasn 2 The central artery and vein of the retina pierce the optic nerve inferomedially about 1.25 cm behind the eyeball (Fig. 13.9), 3 The optic nerve is crossed su, ophthalmic artery, the nasocilia superior ophthalmic vein. 4 The optic nerve is crossed inferiorly by the nerve to the medial rectus. 5 Near the eyeball, the nerve is surrounded by fat containing the ciliary vessels and nerves (see Fig. 19.2) Structure 1 There are about 1.2 million myelinated fibres in each opticnerve, out of which about 53% cross in the optic chiasma. 2 The optic nerve is ; Out of which 25 mm periorly by the Ty nerve and the in the strict sense as .Itis actually a tract. Developmentally, the teeth or paranasal sinuses, sey syphilis, and even vitamin B deficiency * Opticnerve has no neutilemma set ower of regeneration. Iisa tract andy * Optic atrophy may be caused by a raj ss Temay be primary or seconay CILIARY GANGLION iteral rectus sensory and sympathetic ot? ot Roots and branches Scanned with CamScanner ‘comes from pees me are j Infateoidal ' “fibres for the eyeball. The fe tt > Lacrimay ——ANtetior eth, ; Mion (Fig. 13.11). lo anc to the up ih a a nee eyelid and from the ine oe tains potzanglonic fibres arising THiS isthe smatey jon from lateral mae ene QPthalmic nerve (ig eaee minal branch of FA inal it ; Ss scle, i ppe in the short ciliary Para receives con any with ial ary. Aner rt imunicati ati si vessels of the eyeball. They also ene deep to the sone aa ; part of the ea ceil ipper eyelid. eee ae lacrimal gland, the o upper eyelid. Its own fil off8 to 10 short ciliary nerves which gland are sensory. The secretomotor fibres a edhe come from the greater petrosal nerve through its Spbranches, and then pierce the sclera . nce of the optic nerve. They contain Fa ee en Een oer lacie ioe xe three roots of the ganglion. 7 rcrimat Nerve Frontal Nerve This is the largest of the three terminal branches of the ophthalmic nerve (Figs 13.12a and b). It begins in the lateral wall of the anterior part of the cavernous sin Itenters the orbit through the lateral the superior orbital fissure, and runs forwards on lpebrae superioris. At the/ surface of the levator P sridalle ofthe orbit, it divides intoa small supra french and a large supraorbital branch. Scanned with CamScanner Head and Neck retiree tea the trochlea about one Jane. Itsupplies the conjunctiva, the upper P small aren of the skin ofthe forehead above of the nose (see Figs 2.5 and 2.16). The: ges from the orbit above breadth from the median and the root ital nerveemerges from the orbit through the supraorbital notch or foramen about two fingers breadth from the median plane. It divides into medi and lateral branches which runs upwards over the forehead and scalp. It supplies the conjunctiva//the central part of the upper eyelid, the frontal air sinus and the skin of the forehead and scalp up to the vertex, or even up to the lambdoid suture. Nasocilicry Nerve the oculomotor nerve (Fig. nerves. Its branches are as follows. with the sympathetic root (Fig. 13.12b). dilator pupillae. posterior ethmoidal fora ethmoidal and sphenoidal air sinuses. upper half of the external nose (see Fig. 2.16). This is one of the terminal branches of the ophthalmic division of the trigeminal nerve (Fig. 13.12b). It begins in the lateral wall of the anterior part of the cavernous srs ene the oitvough he mile part ofthe superior orbital fissure between the two divisions of and runs along the medial wall of the orbit between the superior oblique and the medial rectus. It ends at the anterior ethmoidal foramen by dividing into the infratrochlear and anterior ethmoidal 1 A communicating branch to the ciliary ganglion forms the sensory root of the ganglion. It is often mixed 2 Two or three long ciliary nerves run on the medial side of the optic nerve, pierce the sclera, and supply sensory nerves to the comea, the iris and the ciliary body. They also carry sympathetic nerves to the 3 The posterior ethmoidal nerve passes through the and supplies the 4 The infratrochlear neroe is the smaller terminal branch of the nasociliary nerve given off at the anterior cA en yes from the orbit below the trochlea for the tendon of the superior oblique and appears on the face above the medial angle of the eye. It supplies the conjunctiva, the lacrimal sac and caruncle, the medial ends of the eyelids and the 5 The anterior ethmoidal nerve is the larger terminal branch of the nasociliary nerve. It es the orbit by It rs, for a very short distance, in the anterior eal fossa, above the cribriform plate of the ethmoid bone. It then descends into the nose through aslitatthe side of the anterior par, In the nasal cavity, it lies deep 4, gives off two internal nasal bray Tateral to the mucosa of the nose, i", at the lower border of the nasal p,.'):i4 nasal nerve which supplies the skin a he, of the nose. tte, IE BRANCHES OF MAXILLARY OFTHE TRIGEMINAL NERVE” O™HOy Infraorbital Nerve Itis the continuation of the maxillary ney, the orbit through the inferior orbital fase? forwards on the floor of the orbit or yo! maxillary sinus, at firstin the infraohital gna in the infraorbital canal remaining »e periosteum of the orbit. It emerges on the, the infraorbital foramen and terminates by j palpebral, nasal and labial branches (sr F nerve is accompanied by the infraorbitl third part of the maxillary artery and the acum vein, Branches 1 The middle superior alveolar nerve arises orbital groove, runs in the lateral walloft sinus, and supplies the upper premol The anterior superior alveolar nerve 2 infraorbital canal, and runs in a sinuous a complicated course in the anterior maxillary sinus. It supplies the uppet canine teeth, the maxillary sinus, an! inferior part of the nasal cavity whe! cates with branches of anterior &t anterior palatine nerves (see Fig. 15.5) Terminal branches—palpebral, nasal aad j Supply a large area of skin on the supply the mucous membrane of the ? cheek (see Fig. 2.16). Zygomatic Nerve j » eo Ttis a branch of the maxillary ne Se Pterygopalatine fossa. It enters the O° ia lateral end of the inferior orbital fis"! 94 the lateral wall, outside the petios¥f? zygomatic bone. Just before or afte yy Ae into its two terminal brane a ial and zygomaticotemporal ner?®> ©. of", skin of the face and of the ante Py (see Fig. 2.16). The communicating lacrimal nerve, which contains $y the lacrimal gland, arises from they nerve, and runs in the lateral ¥* Chapter 2) Scanned with CamScanner CILIARY GiANGILION thetic sym ie a frat From Nasochdiany From internat Peete jibes mews Canotiol plexus ” 5 al dont velo cn andtionic ui bars alunger werten garqion’ Pmt pr segrment Ciliag gants'on post ganglionic -flees 0 t t in q oe cenitad Short cibiony ewes on es Sphindrey pupillae + F Ciliary fs ont relay in short ci brary ynewes ies lpload verse? “a eyeboouts Scanned with CamScanner TABLE 8.8. EXTRA-OCULAR MUSCLES OF ORBIT Muscle Origin Insertion Innervation Main Action* Levator palpebrae Lesser wing of sphenoid | Superior tarsus and skin of | Oculomotornerve (CN Ill); deep | Elevates superior eyelid superioris bone, superior and ‘superior eyelid layer (superior tarsal muscle) is anterior to optic canal supplied by sympathetic fibers. Superior oblique (SO) | Body of sphenoid bone | Its tendon passes through | Trochlear nerve (CN IV) Abducts, depresses, and a fibrous ring or trochlea, medially rotates eyeball changes its direction, and inserts into sclera deep to superior rectus muscle. Inferior oblique (10) | Anterior part of floor Sclera deep to lateral rectus Abducts, elevates, and of orbit muscle laterally rotates eyeball Superior rectus (SR) Elevates, adducts, and ‘Oculomotor nerve (CN Ill) rotates eyeball medially Inferior rectus (IR) ; . Depresses, adducts, and Common tendinous ring | Sclera lust ee *0 cor rotates eyeball laterally Medial rectus (MR) ‘Adducts eyeball eae] ERT TTT reno) Scanned with CamScanner BONY SKELETON Gy Nasal bones x (1) Frontal precess of maritia Git) Nasal part ef frontal 1 bone & nasal spire, § Gi) bony partef 5a) m erat une CARTILAGINOUSMSKELETON act E two sateral es fe tt i two bataiay cartilage, | fineme septal cartilage i AR CARTLAGIE 1 ! We ed alar carhlage a TB the superior concha. It is thin and i ate a ie pipie D the respiratory mucosa. It contains re cn free moO olfactory cell eo or constrict He For descriptive purposes, the noses ae ee ccs of} BIG wo main pars the external nose and ns s nose conivact | 32 | Some fe pe 4 in Chapter 2, ge 59. These are roo! 5 anterior nares, nasal septum and columel i J The external nose has a skeletal fr bpp Partly bony and partly cartilaginous. The’ f= J nasal bones, which form the bridge of the no 4) the frontal processes of the maxillae. The cat the superior and inferior nasal cartilages, th cartilage, and small alar cartilages (Figs 1 The skin over the external nose is si J external nasal, infratrochlear and infra __. (Gee Fig. 2.16). Bessy Oe cap es Og eT a 5m in height, 5-7 cm in length, and 15 cm ‘near the floor. The width near the roof is on! The roof is about 7 em long and 2 mm wi s downwards, both in front and behind ats as an air conditioner where the inspired air is warmed, moistened and cleansed before it is passed on to the delicate lungs : The posterior slope is formes bythe infos ‘The olfactory mucosa lines the upper one-third of the _ the body ofthe sphenoid bone (Fig. 155 nasal cavity including the roof formed by crbriform The floor is about 5 em long and 15 <2" Pinte and the medial and lateral walls upto thelevelof formed by the palatine proces of the Scanned with CamScanner — Anterior ettmoidl sinuses Orta pate of thoi aby Perpendicular plate Mile ethmodal sinus and bula etcides Inferior concha Vorner Opening of maxilary ai sinus cose tots oot Plate fring floor of nasal cary Upper tooth fig. 75.2: Coronal section through the nasal caviy andthe maxilary ar sinuses late of the palatine bone. It is concave from ‘ide and’ is slightly higher anteriorly than ig, 15.2). cold or rhinitis is the commonest infection Itmay be infective or allergic oF both. ge of the seasons: infected from commonest of ly occurs during chan; air sinuses may 8¢" Maxillary sinusitis is the cl cranial «Fracture of cribriform plate ofethmoid with tear f of the meninges may tear the olfact sootfets In sich cases,CSEmay drip from thenasal cavity. It is called CSF rhinorshoea (Fig 153). Scanned with CamScanner Arterial Supply “Anterosuperior part is supplied ¥, for ethmotdal arteries (hi, ay “Anteroinferior partis supplied by branch of facial arte: x Posterosuperior partis supplied byw “Bitery. It is the main artery: < ior part is supplied by by * ero eget ion, ‘The anteroinferior Pi contains anastomoses between the sepia Superior labial branch of the facial al sphenopalatine artery, greater palatine ethmoidal artery, These form a large ca called the Kiesselbach’s plexus. This is a. yon Neha ‘medial wall of both nasal cavities. The bony pert i formed almost ent bs i Wer enis BM 2 The veins form a plexus which is more ma a a ‘ lower part of septum or Little's area, The ‘margins receive contributions from! Fant “al vei Plens of the frontal bone, th ae anteriorly into the facial vein, posteriorly th ne, the rostrum of the Gilaopalatine vein to pterygoid " and the nasal crests of the nasal) jalat . maxillary bones (Fig. 15.4). The cartilaginous partis f Tiecrigeer orm IMM | a ay nee dng on in b. heseptal processes SARSMENON MEUM. | 2 distributed to whole of the septum (Fy us seers ie iealarparbockoa ena 5 b nasal branches of the fe z aes b. = anteroinferior jpart is supplied bya The nasal septum is rarely strictly m superior alveolar nerve. art is usually deflected to one or the ¢, Theposterostiperior part is supplied by eta deflection is produced by overgrowth of & rt posterior superior nasal branches of the pe of the constituent parts. ‘ palatine ganglion. The septum has: ’ a. Four borders—superior, inferior, Nerve supp! posterior. b. Two surfaces—right and left. where is Kiesethach plexus 20c Scanned with CamScanner Ontactoryrootlots Fee spore “oe jy 186 Nerve SUPPY OF nasal septum _osonieriog pats supplied by ey xus, gph ‘rom the nose or epistaxis (Fig. 15.5). ideviation of the nasal septum is often for repeated attacks of common cold, ‘hnitis, sinusitis, etc. It requires surgical Wall of the nose H three shelf-tike IF Owing, to the o, ORY Projections called The lateral wall ae Separates the nose: to > sinuses CrP above, with the ethmoidal ir » From the maxillary si ‘axillary sinus below. ©. From the lacrimal. 4 s EGE (Gey 220) and nasolacrimal duct in The lateral wall can be subdivided into three parts. ] 2. Asmall depressed area in the anterior partis called the vestibule. It is lined by modified skin Containing short, stiff, curved hairs called vibrissae b. The iniddlé part is known as the atrium of the middle meatus. ¢. The posterior part contains the conchaé. Spaces separating the conchae are c: (Fig. 15.8). The skeleton of the lateral wall is partly bony, partly cartilaginous, and partly made up only of soft tissues. The bony part is formed from before backwards by the following bones: a. Nasal. b. Frontal process of maxilla (see Fig. 1.21) c. Lacrimal. ; ddl d. Labyrinth of ethmoid with superior and middle conchae. be e. Inferior ae made up of spongy bone ig. 15.8). st only ee ate of palatine bone together ‘with f, Perpendicular pl ‘henoidal processes. its orbital and sphenox g Medial pterygoid Pia ay ilaginous part is forme 15.1). The cartilagi jor nasal carilage (Fig. 15.) asl cartilage: d meatuses pen cas Scanned with CamScanner = mom ge trion (itl gaa ne ep, UPEricx surmace of i yippiate sierax maler on he crarheal caw/ty Maxitery a ss 2p erng ot roe ‘Sr srws in rortonasa det Opening of nasotscrins ct 'n err meatus of ose Route of spread inpeckon “from ae mr shthminasal cavty seo 0 '- Brough pharyngeal Sey WSthmus it cFophar@ 2 Tiegh asoint ote — auets inte” exes) = 3- Into vanous paw-= OSL airy sinuses 4- Through eustachian Fabe Te middle € ThrOUgGh Cribs form plote into the anrei cranial Fossq 3 The superior concha is also medial surface of the ethmo the smallest concha situated just atu Posterior part of the middle concha (Fig 18 The miehtuses of the nose are passages bese overhanging conchae. Each meatus comm freely with the y proper (Fig, 159) 1 ies underneath the argest of the three Features: The nasal conchae are curved bi directed downwards and medially=The three conchae are usually found: ypens into itat he Scanned with CamScanner Us, sliesundeme, fe, ath them ie hort pas, eirend of thethiatus,"LP2ssage apy, ing of frontal air sinus” *¥nto Go tit ind the oper - he three recess is a triangu Morconcha. It receives the er rig, 158) meatus is lar foss a jtist ope Ng Of the a a shallow depre. (fine middle meatus anq aboveline jose. Itis limited above by a faint sige embrane, the agger nasi, which rues ards from the upper end of the ‘ofthe middle concha (Fig. 15.8), ésion In saine as septum quadrant is supplied by the anterior assisted by the posterior ethmoidal iof quadrant is supplied by branches artery (Fig. 15.10). 164 ftom the branches of te to, whole of th 3 hole of the the anterior Of ophthalmic neve nraorbia, ey) * Posterosuperio eae ponte i ran 's supplied by the latest septum, Superior nasal branches from tne Plerygopalatine ganglion, « | Posteroinferior quadrants supplie Palatine branch fr. Banglion 2 Special sensory ngries o to the upper part of ctibriform plate of the ethmoid up to the concha, Note that the olfactory mucosa lies partly on the lateral wall and partly on the nasal septum the anterior ‘om the pterygopalatine Scanned with CamScanner NERVE suppry o¢ NASAL CAVITY Owego fer eat af ‘aco roots dsalbronenae Nasopaatine Lymphatic Drainage Same. as Paranasal sinuses are ai-illed spaces rr, fg SUS Lymphatics from the anterior half in Pass to the submandibular nod some ere aa cavities. The sin “ae Ais Posterior hal, to the retropharyn; p frontal, maxillary, sphenoidal and ethmeid pea 152), ANC i fervieal nodes. ‘pen ito the ada cavity eg Ae (Fig. 15.12). The function of the sinuses st. skull lighter, warm up and humidify th nse xdd resonance to the Voice. in sive the sinuses or sinusitis, the voice is altered og The sinuses are rudimentary, or even shud They enlarge rapidly during the ages of 61 fg ic. time of eruption of permanent teeth and hain golated max ze of openin, pped by the iatus is ne t extends 0 aygomatic Fronts! — Anttor ang thei MAXTULARY SINUS Ape: bene oe nov part of Lakrof WO TE ed Roof : fleor of orbit + Alueotay part oF sea maxilla . ut two molar teeth Of ep nti Preduce elevation in Poor : innus of si kejerente > (elm Scanned with CamScanner ‘ifthe eyebrow, ang pratds at ®P tothe Fie or the roof ofthe orpackande 8 a he DPE inemiddle meatus of iB. 1513)” he onsets ether gyre Atthe ater Bihan arcane ae = . fone or both may be ao MGUA in, om are jn females. bette To submandibular Supréorbital nerve. [ppillary sinus lies in ¢ pedis the largest cro ae mala Itis pyramidal in shape, with its base y towards the lateral wall of thenose, erecta Interaly in the zygomatic jinto the middle meatus of the nos ofthe hiatus semilunaris (Fig. foe nearer the roof (Fig. 15.12). maxilla, the opening or hiatus of the is large. However, in the intact skull, ‘of opening is reduced to 3 or 4 mm as it is by the following: by the perpendicular plate of the one (Fig. 15.9. It is further reduced in thick mucosa of nose. 1s is variable. Average measuremen’s ‘cm, width-—2.5 cm and antero- s 51), ig 15) ais trvene formed by the out 1 cm below 7 Ariert Plating agZP¥: Facial, ine arteries 2131, infraorbi i Heh scapeltt acral and great oe roraluen ay Sipe aR AEE IO he acl ein ana dBase Lomphati — Ne rom SUPP Superior alver ft sphenoid ph sinuses lie within the bonel(Fig. 15.1 Taal aly ee of omespondinghal °he 2 d superiorly tothe optic chiasma cerebri; and lateral typ iy to the (erg aes ater and the cavernous sins 3 Arterial supply: Bésterior ethmoid arotid arteries. ——— Venous drainage: Intojpterygoid venous plewus and Lymphatic drainige:To the retcopharyngeal nodes. Nerve supply Rasteronethmoida nersé sn obit riches of plecygopalatine ganclion dunderined ane mois oe ‘Ethimoidal Sinuses 1 Ethmoidal sinuses are numerous small inter- ie within the labyrinth, ig. 15.2). They are completed from above by the orbital plate ofthe frontal bone, from behind by the ‘sphenoidal conchae and the orbital process of the palatine bone, and anteriorly by the lacrimal bone. The sinuses are divided vo Perit, middle and posterior groups (Fig. 15.12. ‘The anterior ethoida sinus is made up of 1 to11 at rit, opens into the anterior pat ofthe Natus Semilunaris ofthe nose. It shear -famoidal sinus consisting of 1107 air cells id oe idle meatus of the nose tS Beal he anterior ethmoidalnerveand vesso\s SUPP he onbital branches of the plerygoralatine “nglion. Lym jes drain into the submandi odes (Fig: 158) Scanned with CamScanner us HEAD AND NECK ‘4 The posterior ethmoidal sinus consisting cells open into the superior meatus of the nowe_| Supplied by the posterior ethmoidal nerve and aaa of the pterys, Wty MAKILLARY s/NUS IS MORE ComMonicy INVOLVED * 3" " (N INFECTION? Probably becavse of He TE Smail openings that are Located higit on their SIFISMMt causes Supermmedich walk - Seite opening is obstructed BY sessed sinus is congesfian oh mucous membrane monly involved Bez of higher location head Osta [ openings rebanye Peer is taoe to Hoor Arasnage +s ia kine a Fie Ut unt (Sinus 24 spilepee of the ean SF pus a a the natural orifice with position (Fig. 15.13). Ge b. An opening can be made at the© through the vestibule of the mouth, 4gep upper lip (Caldwell-Luc operation). © Carcinoma of the maxillary sinus arises fréthythe mucosal lining. Symptoms depend on the direction ‘growth. 4 of a. Invasion of the orbit causes proptosis and diplopia. If the infraorbital nerve is.involved, there is facial pain and anaesthesia of the skin over the maxilla. b. Invasion of the floor may produce a bulging . _ and even ulceration of the palate. ¢. Farward growth obliterates the canine fossa and produces a swelling of the face. d. Backward growth may involve the palat nerves and produce severe pain referred to upper teeth. : e, Growth in a’medial direction produces nas = obstruction, epistaxis and epiphora. Growth in a lateral direction produ swelling on the face and a palpable mass in 5 ival = ‘+ Ffontal sinusitis and ethmoiditis can canse ‘oedema of the lids secondary to.infection of the from ethimoid air sinus maybe re‘erved to d,s, both are supplied by ophtliimic 2 J SRR pg underies on the skull BOUNDARIES — Aoterorly : posterior Sutface : Of mexiliq posten'orly z pterygoid Plocey, oh cp hersid superio rly: lncompler ro formed Cy iN Fratempen} Beas of Greater ong pb sp henvid 38 : preperdueular mMedialuf : pidge &f) palatine bone | Meciattys pyrau ida proces rosenar a paling bone { Mais is’small pyramidal space situated deeply, ppex“of the orbit (Fig. 15.14) Ante pSmedial part of the posterior sit ptepygoid process and af face of the greater wing part Medial: Up) palatine bor Se) bad by the pyramidaligs Inferior: boneii the angle between the maxi process. “se Communications Anteriorly: With the orbit through the ®™ the inferior orbital fissure (Fig. 15.14). j ye Scanned with CamScanner posterior Surface of maxitg foramen (on medial way) Maxitory ar sinus Greater palatine canal the oral cavity through the greater and e canal ee shalten any all of them. fine ganglion and its numerousbranches fibres of the maxillary nerve mixed with ds ion, runs forwar nus below the © Tau Be e) pee Mae Stn a) Bas neve te eos etal a Area

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