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everybody
OTOLARYNGOLOGY
Rhinolog
y
 Anatomy of Nose
• External nose
• Nasal cavity
• paranasal sinuses
 The external
nose
• The external nose is triangular-shaped
projection in the center of the face, consists
of osteocartilaginous framework covered by
muscles and skin.
 The external nose
Landmark
Root of nose

Nasal dorsum
Nasal bridge

Nasolabial fold

Alae nasi
Anterior naris
(nostril)

Nasal apex columella

The external nose
Framework(cartilaginous
)
The external nose
Framework(bony)
Nasal bone
frontal processes of
the maxilla.

pyriform
aperture
• Bony Part
• Upper one-third of the external nose is bony
while lower two-thirds are cartilaginous.
The bony part consists of two nasal bones
which meet in the midline and rest on the
upper part of the nasal process of the frontal
bone , held between the frontal processes of
the maxillae.
Nasal bone
fracture
Nasal bone fractures
are prevalent in
sport, particularly in
collision and contact
sports.
 DANGER TRIANGLE
OF THE FACE

No valve in facial vein,blood bidirectional flow

Due to the special
nature of the blood
supply to the human
nose and surrounding
area, it is possible for
retrograde infections from the nasal area to spread to the brain. For this
reason, the area from the corners of the mouth to the region between
The eyes including the nose and maxilla, is known to doctors as the
dangertriangle of the face.
 Vein of external nose

Cavernous
sinus
Superior &
inferior
ophthalmic
v.

Facial
v.
 Nasal cavity
• Nasal vestibule
Nasal vestibule is the anterior
and inferior part of nasal cavity. It
is lined by skin and contains
sebaceous glands,hair follicles
and hair(vibrissae). easy to
infection.
• Nasal cavity
proper
Furuncle of nasal
vestibule
Nasal cavity proper

• The roof .
Anterior sloping part
of the roof is formed
by nasal bones; Posterior sloping part
by the body of sphenoid bone;and the
middle horizontal part, by the
cribriform plate of ethmoid.
Nasal cavity proper

• The floor .
The floor of the nose
is formed by the palatal
process of the maxilla and
the horizontal process of the
palate bones.
 Nasal cavity proper

• Medial wall.
Nasal septum.

vomer
Septal Anatomy
• Quadrangular Cartilage: septal cartilage
• Perpendicular Plate of the Ethmoid: projects from cribiform plate
to septal cartilage
• Vomer: posterior and inferior to perpendicular plate
• Maxillary Crest (Palatine Bone): trough of bone that supports the
septal cartilage
• Anterior Nasal Spine: bony projection anterior to pyriform aperture
Nasal cavity proper

• Laterior wall.

The lateral wall is marked

by three scroll-like bone
projections called turbinates
or conchae.Below and
lateral to each turbinate is
the corresponding meatus.
 Nasal cavity
proper
Laterior wall.
Nasolacrimal duct opens in the anterior
part of inferior meatus.
The anterior group of sinuses
(frontal,marxillary and anterior ethmoidal
sinuses) open to the infundibulum in
middle meatus.
Posterior ethmoidal sinuses open into
superior meatus.
The openning of sphenoid sinus situate
is phenoethmoidal recess lies above the
superior turbinate.
 Lateral wall.
• (a) Inferior meatus. Whole length of the
lateral wall, nasolacrimal duct opens in its
anterior part.
 Lateral wall
• (b) Middle meatus
• posterior half of the lateral wall, a rounded bulge
called bulla ethmoidalis which is due to the
middle ethmoidal air cell which opens on or above
it. Clinically, bulla ethmoidal is belongs to
anterior group of ethmoidal cells as it lies anterior
to the ground lamella of middle turbinate. Below
and in front of the bulla is a gap called hiatus
semilunaris, which leads into a funnel-shaped
space called ethmoidal infundibulum. Floor and
medial wall of the infundibulum are formed by the
uncinate process of the ethmoid .
 Lateral wall
• (b) Middle meatus
• Frontal sinus opens into the
infundibulum. Anterior ethmoidal
sinuses also open into the
infundibulum. Maxillary sinus opens
into posterior part of the infundibulum.
Sometimes, it may also have an
accessory opening.
 Lateral wall
• (b) Middle meatus
• Atrium of the middle meatus is a
shallow depression lying in front of the
middle meatus and above the vestibule.
Agger nasi is a curved ridge running
downwards and forwards above the
atrium and may contain air cells (agger
cells) deep to it.
• • Uncinate Process: sickle-shaped thin bone part of
the ethmoid bone, covered by mucoperiosteum,
medial to the ethmoid infundibulum and lateral to
the middle turbinate (derived from the second
ethmoidal turbinal)
• Ethmoid Infundibulum: pyramidal space that
houses opening to spatial relationship of frontal
sinus drainage (80% attach to the lamina
papyracea resulting in frontal sinus drainage
medial to the uncinate, 20% attach to the skull base
or middle
• Semilunar Hiatus: gap that empties the ethmoid infundibulum,
located between the uncinate process and the ethmoid bulla
• Sphenopalatine Foramen: posterior to inferior attachment of the
middle turbinate, contains sphenopalatine artery, sensory nerve
fibers, and secretomotor fibers (parasympathetic fibers from vidian
nerve to pterygopalatine ganglion)
• Concha Bullosa: an aerated middle turbinate, may result in nasal
obstruction
Ostiomeatal complex
The ostiomeatal complex is the
sinus "hot spot," one of the most
important anatomical regions with
regard to sinus health and disease.
That comprises maxillary sinus
ostia,anterior ethmoid cells and
their ostia,ethmoid infundibulum,
hiatus semilunaris, and middle
meatus.
 Lateral wall
• (c) Superior meatus
• posterior third of lateral wall. Posterior
ethmoidal sinuses open into it.
• (d) Sphenoethmoidal recess
• lies above the superior turbinate and
receives the opening of the sphenoid sinus.
 Posterior naris (choanae)

Nasal septum

Inferior turbinate
Nasal Cycles and Respiratory Airflow
• nasal airflow is regulated through the volume of the venous
sinusoids (capacitance vessels) in the nasal erectile tissue
(located primarily in the inferior turbinate and to a lesser
extent in the anterior septum)temperature and is humidified
to almost 100% humidity
• Sneeze Reflex: induced by allergens, ammonia,
viral infections,exercise, and phase, glottic
and velopharyngeal closure (increases subglottic
pressure), followed by a sudden glottic opening
(sneeze) changes in other irritants which stimulates
trigeminal afferents, complex efferent input results in
a slow inspiratory body position,hyperventilation,
cold air, sulfur, histamine, and other irritants;
lasts 15–30 minutes
• Regulation Response Types
1. Asymmetrical Congestive Response (The Nasal Cycle):
normal physiological congestion/decongestion cycle
alternating between nasal sides every 2–7 hours
2. Symmetrical Congestive Response: temporary bilateral
congestion induced by exercise
Lining Membrane of Internal Nose

• Vestibule. It is lined by skin containing hair, hair follicles

and sebaceous glands.
• Olfactory region. Upper one-third of lateral wall (up to
superior concha), corresponding part of the nasal septum
and the roof of nasal cavity form the olfactory region.
Here, mucous membrane is paler in colour.
• Respiratory region. Lower two-thirds of the nasal cavity
form the respiratory region. It is highly vascular and also
contains erectile tissue. Its surface' is lined by
pseudostratified ciliated columnar epithelium which
contains plenty of goblet cells.
 Nasal cavities: Microanatomy

Mucosal lining
• Respiratory epithelium
– columnar
– goblet cells
– mucus blanket
ciliated pseudostratified
– cilia columnar epithelium

• Olfactory epithelium
– Small area near roof
 Nerve innervation of the nose
• Olfactory nerves
(cranial nerve I)
• Nerves of common
sensation
• Autonomic nerves
 Nerve of the nose
• (a) Olfactory nerves. They carry sense of smell
and supply olfactory region of nose. They are the
central filaments of the olfactory cells and are
arranged into 12-20 nerves which pass through the
cribriform plate and end in the olfactory bulb.
These nerves can carry sheaths of dura, arachnoid
and pia with them into the nose. Injury to these
nerves can open CSF space leading to CSF
rhinorrhoea or meningitis.
 Nerve of the nose
• (b)Nerves of common sensation
• (i) Anterior ethmoidal nerve.
• (ii) Branches of sphenopalatine ganglion.
• (iii) Branches of infraorbital nerve. They supply vestibule of
nose both on its medial and lateral side.
• Most of the posterior two-thirds of nasal cavity (both septum and
lateral wall) is supplied by branches of sphenopalatine ganglion
which can be blocked by placing a pledget of cotton soaked in
anaesthetic solution near the sphenopalatine foramen situated at
the posterior extremity of middle turbinate. Anterior ethmoidal
nerve which supplies anterior and superior part of the nasal
cavity (lateral wall and septum) can be blocked by placing the
pledget high up on the inside of nasal bones where the nerve
enters.
 Nerve of the nose
• Autonomic nerves
• Parasympathetic nerve fibres supply the
nasal glands and control nasal secretion.
They come from greater superficial petrosal
nerve, travel in the nerve of pterygoid canal
(vidian nerve) and reach the sphenopalatine
ganglion where they relay before reaching
the nasal cavity. They also supply the blood
vessels of nose and cause vasodilation.
 Nerve of the nose

• Autonomic nerves
• Sympathetic nerve fibres come from upper two
thoracic segments of spinal cord, pass through
superior cervical ganglion, travel in deep petrosal
nerve and join the parasympathetic fibres of greater
petrosal nerve to form the nerve of pterygoid canal
(vidian nerve). They reach the nasal cavity without
relay in the sphenopalatine ganglion. Their
stimulation causes vasoconstriction. Excessive
rhinorrhoea in cases of vasomotor and allergic
rhinitis can be controlled by section of the vidian
nerve.
Blood supply of nasal cavity

anterior posterior
ethmoidal a. ethmoidal a.

sphenopalatine a.

iternal maxillary a.

great
palatine a.
 paranasal sinuses
The sinuses are air-filled
bony cavities located in the
face and skull adjacent to
the nose.
 paranasal sinuses
• Maxillary sinus
• Ethmoid sinus
• Frontal sinus
• Sphenoid sinus
 Maxillary sinus
The maxillary sinus is the
largest one, present in the
maxilla bone one either
side of nose and below the
eyes. The sinus drains into the
nasal cavity through its ostium
that is situated in the middle
meatus.
• Maxillary Sinus
• • Embryology: first to develop in utero, biphasic growth at 3
• • Volume at Adult: typically 15 ml (largest paranasal sinus)
• • Drainage: ethmoid infundibulum (middle meatus, 10–30% have
• accessory ostium)
• • Vasculature: maxillary and facial artery, maxillary vein
• • Innervation: infraorbital nerve (V2)
• • Plain Film: Water’s view
• • Adjacent Structures: lateral nasal wall, alveolar process of maxilla
• (contains second bicuspid and first and second molars), orbital floor,
• posterior maxillary wall (contains pterygopalatine fossa housing the
• maxillary artery, pterygopalatine ganglion, and branches of the
• trigeminal nerve)
 Ethmoid sinus
This sinus comprises a group
of air cells, which form one of
the most complex structures in
the body. Hence the sinus is
rightly named the ethmoid
‘labyrinth’.
• Ethmoid Sinus
• • Embryology: 3–4 cells at birth (most developed paranasal sinus at
• birth), formed from 5 ethmoid turbinals
• • Volume at Adult: 10–15 aerated cells, total volume of 2–3 ml (adult
• size at 12–15 years old)
• • Drainage: anterior cells drain into the ethmoid infundibulum,
• posterior cells drain into the spheno-ethmoid recess (superior
• meatus)
• • Vasculature: anterior and posterior ethmoid arteries (from
• ophthalmic artery), maxillary and ethmoid veins (cavernous sinus)
• • Innervation: anterior and posterior ethmoidal nerves (from
• nasociliary nerve, V1)
 Frontal sinus
The frontal sinuses are
situated beneath the bone
of the forehead and just in
front of the bone overlying
the brain. And drains
through the frontal recess
to the middle meatus.
• Frontal Sinus
• • Embryology: does not appear until 5–6 years old
• • Volume at Adult: 4–7 ml by 12–20 years old (5–10%
• underdeveloped)
• • Drainage: frontal recess in anterior middle meatus either medial or
• lateral to the uncinate (posterior and medial to agar nasi cells), may
• also be lateral to agar nasi cells
• • Vasculature: supraorbital and supratrochlear arteries, ophthalmic
• (cavernous sinus) and supraorbital (anterior facial) veins
• • Innervation: supraorbital and supratrochlear nerves (V1)
• • Plain Film: lateral and Caldwell view
• • Foramina of Breschet: small venules that drain the sinus mucosa
• into the dural veins
 Sphenoid sinus
The sphenoid sinuses are deep within the
skull behind the ethmoid sinuses. The sinus
opens in the upper part of anterior wall and
drains into the sphenoethmoidal recess.
• Sphenoid Sinus
• • Embryology: evagination of nasal mucosa into sphenoid bone
• • Volume at Adult: 0.5–8 ml (adult size at 12–18 years old)
• • Drainage: sphenoethmoid recess in the superior meatus
• • Vasculature: sphenopalatine artery (from maxillary artery), maxillary
• vein (pterygoid plexus)
• • Innervation: sphenopalatine nerve (parasympathetic fibers and V2)
• • Plain Film: lateral and submentovertex (basal)
• • Adjacent Structures: pons, pituitary (sella turcica), carotid artery
• (lateral wall), optic nerve (lateral wall), cavernous sinus (laterally),
• maxillary and abducens nerves, clivus
Physiology of the nose
Physiology of nose
• Olfaction(smell)
Odorant molecules,
dissolved in olfactory
mucous, are transmitted
by the olfactory nerve
(CN I) to the olfactory
bulb then to the brain.
Olfactory nerves
 Physiology of nose----olfaction
• Olfactory pathways. Smell is perceived in the olfactory
region of nose which is situated high up in the nasal cavity.
This area contains millions of olfactory, receptor cells.
Peripheral process of each olfactory cell reaches the
mucosal surface and is expanded into a ventricle with
several cilia on it. This acts as a sensory receptor to receive
odorous substances. Central processes of the olfactory
cells are grouped into olfactory nerves which pass through
the cribriform plate of ethmoid and end in the mitral cells
of the olfactory bulb. Axons of mitral cells form olfactory
tract and carry smell to the prepiriform cortex and the
amygdaloid nucleus where it reaches consciousness.
Olfactory system is also associated with autonomic system
at the hypothalamic level.
 Physiology of nose----olfaction
• Disorders of smell. It is essential for the
perception of smell that the odorous
substance be volatile and that it should
reach the olfactory area unimpeded.
 Physiology of nose----olfaction
• Anosmia is total loss of sense of smell while
hyposmia is partial loss. They can result from nasal
obstruction due to nasal polypi, enlarged turbinates or
oedema of mucous membrane as in common cold,
allergic or vasomotor rhinitis. Anosmia is also seen in
atrophic rhinitis, a degenerative disorder or nasal
mucosa; peripheral neuritis (toxic or influenzal);
injury to olfactory nerves or olfactory bulb in
fractures of anterior cranial fossa; and intracranial
lesions like abscess, tumour or meningitis which
cause pressure on olfactory tracts.
 Physiology of nose----olfaction
• Parosmia is perversion of smell; the person
interprets the odours incorrectly. Often
these persons complain of disgusting
odours. It is seen in the recovery phase of
postinfluenzal anosmia and the probable
explanation is misdirected regeneration of
nerve fibres. Intracranial tumour should be
excluded in all cases of parosmia.
 Physiology of nose----olfaction
• Sense of smell can be tested by asking the
patient to smell common odours such as
lemon, peppermint, rose, garlic or cloves
from each side of the nose separately, with
eyes closed. Quantitative estimation
(quantitative olfactometry) requires special
equipment.
 Physiology of nose
• Respiration(breath)
Airway
Heat exchange
Humidification
Self-cleansing
Protection
 Physiology of nose---respiration
• Nose is aptly called the "air-conditioner" for
lungs. It filters and purifies the inspired air
and adjusts its temperature and humidity
before it passes it on to the lungs.
Physiology of nose---- respiration
• During quiet respiration, inspiratory air current
passes through middle part of nose between the
turbinates and nasal septum.
• During expiration, air current follows the same
course as during inspiration, but the entire air
current is not expelled directly through the nares.
Friction offered at limen nasi converts it into
eddies under cover of inferior and middle
turbinates and this ventilates the sinuses through
the ostia.
 Physiology of nose ----Air-
conditioning of Inspired Air
• (a) Filtration and purification. Nasal
vibrissae at the entrance of nose act as
filters to sift larger particles like fluffs of
cotton. Finer particles like dust, pollen and
bacteria adhere to the mucus which is
spread like a sheet all over the surface of
the mucous membrane.
 Physiology of nose ----Air-
conditioning of Inspired Air
• (b) Temperature control of the inspired air is
regulated by large surface of nasal mucosa, in the
region of middle and inferior turbinates and
adjacent parts of the septum is highly vascular
with cavernous venous spaces or sinusoids which
control the blood flow, and this increases or
decreases the size of turbinates. This makes an
efficient "radiator" mechanism to warm up the
cold air.
 Physiology of nose ----Air-
conditioning of Inspired Air
• (c) Humidification. Nasal mucous
membrane adjusts the relative humidity of
the inspired air to 75% or more. Water, to
saturate the inspired air, is provided by the
nasal mucous membrane which is rich in
mucous and serous secreting glands.
 Physiology of nose ------Protection
of Lower Airway
• (a) Mucociliary mechanism.
• Nasal mucosa is rich in goblet cells, secretory glands both
mucous and serous. Their secretion forms a continuous
sheet called mucous blanket spread over the normal
mucosa. Mucous blanket consists of a superficial mucus
layer and a deeper serous layer, floating on the top of cilia
which are constantly beating to carry it like a "conveyer
belt" towards the nasopharynx . The inspired bacteria,
viruses and dust particles are entrapped on the viscous
mucous blanket and then carried to the nasopharynx to be
swallowed.
•
Physiology of nose -----Protection of
Lower Airway
• (b) Enzymes and immunoglobulins.
• Nasal secretions also contain an enzyme
called muramidase (lysozyme) which kills
bacteria and viruses. Immunoglobulins IgA
and IgE, and interferon are also present in
nasal secretions and provide immunity
against upper respiratory tract infections.
 Physiology of nose ------Protection
of Lower Airway
• (c) Sneezing. It is a protective reflex.
Foreign particles which irritate nasal
mucosa are expelled by sneezing.
• The pH of nasal secretion is nearly constant
at 7. The cilia and the lysozyme act best at
this pH. Alteration in nasal pH, due to
infections or nasal drops, seriously impair
the functions of cilia and lysozyme.
 Physiology of nose
• Resonance to the voice
• Nose forms a resonating chamber for
certain consonants in speech.
 Nasal Cycle

• Nasal cycle is a spontaneous reciprocating

cycle of nasal congestion and decongestion .
The nasal cycle is known to be regulated by
the sympathetic and parasympathetic
branches of the autonomic nervous system
(ANS).
DISEASES OF EXTERNAL NOSE
AND NASAL VESTIBULE
• DISEASES OF EXTERNAL NOSE:
• Cellulitis
• The nasal skin may be invaded by
streptococci or staphylococci leading to a
red, swollen and tender nose. Treatment is
systemic antibacterials, hot fomentation and
analgesics.
DISEASES OF EXTERNAL NOSE---
nasal deformities
• Saddle Nose
• Depressed nasal dorsum may involve bony, cartilaginous
or both bony and cartilaginous components of nasal
dorsum. Nasal trauma causing depressed fractures is the
most common aetiology. It can also result from excessive
removal of septum in submucous resection, destruction of
septal cartilage by haematoma or abscess, sometimes by
leprosy, tuberculosis or syphilis. The deformity can be
corrected by augmentation rhinoplasty by filling the
dorsum with cartilage, bone or a synthetic implant.
 DISEASES OF EXTERNAL NOSE
-----nasal deformities
• Hump Nose
• This may also involve the bone or cartilage
or both bone and cartilage. It can be
corrected by reduction rhinoplasty.
 DISEASES OF EXTERNAL NOSE
-----nasal deformities
• Crooked or a Deviated Nose
• In crooked nose, the midline of dorsum from
frontonasal angle to the tip, is curved in a C or S
shaped manner. In a deviated nose, the midline is
straight but deviated to one side.
• Usually, these deformities are traumatic in
origin.The deviated or crooked nose can be
corrected by rhinoplasty or septorhinoplasty. Aim
of these operations is to correct not only the outer
appearance of nose but also its function.
 DISEASES OF EXTERNAL NOSE
----Tumours
• 1. Congenital Tumours
• Dermoid cyst:
• (a) Simple dermoid. It occurs as a midline
swelling under the skin but in front of the
nasal bones. It does not have any external
opening.
 DISEASES OF EXTERNAL NOSE ----Tumours

• 1. Congenital Tumours
• Dermoid cyst:
• (b) With a sinus. It is seen in infants and children and is
represented by a pit or a sinus in the midline of the dorsum
of nose. Hair may be seen protruding through the sinus
opening. In these cases, the sinus track may lead to a
dermoid cyst under the nasal bone in front of upper part of
nasal septum or may have an intracranial dural connection.
Meningitis occurs if infection travels along this path.A
combined neurosurgical otolaryngologic approach is
required in those extending intracranially so as to close
simultaneously any bony defect through which the
fistulous tract passes.
 DISEASES OF EXTERNAL NOSE
----Tumours
• 1. Congenital Tumours
• Dermoid cyst:
• (b) With a sinus
• Treatment is neurosurgical; severing the tumour
stalk from the brain and repairing the bony defect
through which herniation has taken place.
 DISEASES OF EXTERNAL NOSE ----Tumours

• 2. Benign Tumours
• They arise from the nasal skin and include papilloma (skin
wart), haemangioma, neurofibroma or tumour of sweat
glands.
• Rhinophyma or potato tumour is a slow-growing benign
tumour due to hypertrophy of the sebaceous glands of the
tip of nose often seen in cases of long-standing acne
rosacea. It presents as a pink, lobulated mass over the nose
with superficial vascular dilation, mostly affects men past
middle age. Treatment consists of paring down the bulk of
tumour with sharp knife or carbon dioxide laser and the
area allowed to .re-epithelialise. Sometimes, tumour is
completely excised and the raw area skin-grafted.
 DISEASES OF EXTERNAL NOSE ----Tumours

2. Benign Tumours
 DISEASES OF EXTERNAL NOSE ----Tumours

• 3. Malignant Turnours
• (a) Basal cell carcinoma (rodent ulcer)
• This is the most common malignant tumour involving skin
of nose (87%), equally affecting males and females in the
age group of 40-60. Common sites on the nose are the tip
and the ala. It may present as a cyst or papulo-pearly
nodule or an ulcer with rolled edges. It is very slow-
growing and remains confined to the skin for a long
time.Early lesion can be cured by cryosurgery, irradiation
or surgical excision with 3-5 mm of skin around the
palpable borders of the tumour.
 DISEASES OF EXTERNAL NOSE ----Tumours

• 3. Malignant Turnours
• (b) Squamous cell carcinoma (epithelioma). This is the
second most common malignant tumour (11 %), equally
affecting both sexes in 40-60 age group. It occurs as an
infiltrating nodule or an ulcer with rolled out edges affect­
ing side of nose or columella. Nodal metastases are seen in
20% of cases.
• Early lesions respond to radiotherapy; more advanced
lesions or those with exposure of bone or cartilage require
wide surgical excision and plastic repair of the defect.
 DISEASES OF EXTERNAL NOSE ----Tumours

• 3. Malignant Tumours
• (c) Melanoma. This is the least common
variety.
• Clinically, it is superficially-spreading type
(slow-growing) or nodular invasive type.
Treatment is surgical excision.
 DISEASES OF NASAL
VESTIBULE
•Furuncle or Boil:
 DISEASES OF NASAL
VESTIBULE
• Furuncle or Boil:
• It is an acute infection of the hair follicle by
Staphylococcus aureus. Trauma from picking of
the nose or plucking the nasal vibrissae, is the
usual predisposing factor. The lesion is small but
exquisitely painful and tender.
• Treatment of furuncle consists of warm
compresses, analgesics to relieve pain, and topical
and systemic antibiotics directed against
staphylococcus. If a fluctuant area appears,
incision and drainage can be done.
 DISEASES OF NASAL
VESTIBULE
• Vestibulitis
• It is diffuse dermatitis of nasal vestibule. Nasal discharge,
due to any cause such as rhinitis, sinusitis or nasal allergy,
coupled with trauma of handkerchief, is the usual
predisposing factor. The causative organism is Staph. aureus.
Vestibulitis may be acute or chronic.
• In acute form, vestibular skin is red, swollen and tender;
crusts and scales cover an area of skin erosion or excoriation.
• In chronic form, there is induration of vestibular skin with
painful fissures and crusting.
• Treatment consists of cleaning the nasal vestibule of all crusts
and scales with cotton applicator soaked in hydrogen
peroxide and application of antibiotic-steroid ointment
 DISEASES OF NASAL
VESTIBULE
• Stenosis and Atresia of the Nares
• Accidental or surgical trauma to the nasal
tip or vestibule can lead to web formation
and stenosis of anterior nares. In Young's
operation, vestibular skin flaps are raised to
create deliberate closure of nares in the
treatment of atrophic rhinitis.
 DISEASES OF NASAL
VESTIBULE
Stenosis and Atresia of the Nares
 Nasal septum---- Anatomy

• Nasal septum consists of three parts:

• 1. Columellar septum. it is formed of columella
containing the medial crura of alar cartilages united
together by fibrous tissue and covered by skin.
• 2. Membranous septum. it consists of double layer
of skin with no bony or cartilaginous support, lies
between the columella and the caudal border of
septal cartilage. Both columellar and membranous
parts are freely movable from side to side.
 Nasal septum---- Anatomy
• Nasal septum consists of three parts:
• 3. Septum proper. it consists of osteocartilaginous
framework, covered with nasal mucous membrane.
• Its principal constituents are:
• (i) the perpendicular plate of ethmoid
• (ii) the vomer
• (iii) a large septal (quadrilateral) cartilage wedged between
the above two bones anteriorly. Other bones which make
minor contributions at the periphery are: crest of nasal
bones, nasal spine of frontal bone, rostrum of sphenoid,
crest of palatine bones and the crest maxilla, and the
anterior nasal spine of maxilla.
Nasal septum---- Anatomy
Nasal septum----artery
• Little's area or Kiesselbach's plexus.
• This is the vascular area in the antero-inferior part
of nasal septum just above the vestibule. Anterior
ethmoidal, sphenopalatine, greater palatine and
septal branch of superior labial arter­ies and their
corresponding veins form an anastomosis here.
This is the commonest site for epistaxis.
• This is also the site for origin of the "bleeding
polypus" (haemangioma) of nasal septum.
• Fractures of Nasal Septum:
• Trauma inflicted on the nose from the front, side
or below can result in injuries to the nasal septum.
The sep­tum may buckle on itself, fracture
vertically, horizontally or be crushed to pieces as
in a smashed nose. The fractured pieces of septum
may overlap each other or project into the nasal
cavity through mucosal tears.
• Fractures of Nasal Septum:
• Septal injuries with mucosal tears cause
profuse epistaxis while those with intact
mucosa result in septal haematoma which,
if not drained early, will cause absorption of
the septal cartilage and saddle nose
deformity.
• Fractures of Nasal Septum:
• "Jarjaway" fracture of nasal septum results from
blows from the front; it starts just above the
anterior nasal spine and runs horizontally
backwards just above the junction of septal
cartilage with the vomer.
• "Chevallet" fracture of septal cartilage results
from blows from below; it runs vertically from the
anterior nasal spine upwards to the junction of
bony and cartilagi­nous dorsum of nose.
• Treatment
• Early recognition and treatment of septal injuries
is essential. Haematomas should be drained.
Dislocated or fractured septal fragments should be
repositioned and supported between
mucoperichondrial flaps with mattress sutures and
nasal packing. Fractures of nasal pyramid are
often complicated with fractures of the septum and
both should be treated concomitantly.
 DEVIATED NASAL SEPTUM
(DNS)---factors
• Trauma and errors of development form the two
important factors in the causation of deviated
septum.
• 1.Trauma. A lateral blow on the nose may cause
dis­placement of septal cartilage from the vomerine
groove and maxillary crest, while a crushing blow
from the front may cause buckling, twisting,
fractures and duplication of nasal septum with
telescoping of its fragments.
 DEVIATED NASAL SEPTUM
(DNS) ----factors
• 2. Developmental error. Nasal septum is
formed by the tectoseptal process which
descends to meet the two halves of the
developing palate in the midline.
• Unequal growth between the palate and the
base of skull may cause buckling of the
nasal septum.
 DEVIATED NASAL SEPTUM
(DNS)---- factors
• 3. Racial factors. Caucasians are affected
more than Negroes.
• 4. Hereditary : Several members of the
same family may have deviated nasal
septum.
 Types of DNS

• Types
• Deviation may involve only the cartilage, bone or
both the cartilage and bone.
• 1.Anterior dislocation. Septal cartilage may be
dislocated into one of the nasal chambers.
• 2. C-shaped deformity. Septum is deviated in a
sim­ple curve to one side. Nasal chamber on the
concave side of the nasal septum will be wider and
may show compensatory hypertrophy of
turbinates.
 Types of DNS
• Types
• 3. S-shaped deformity. Septum may show as-
shaped curve either in vertical or anteroposterior
plane. Such a deformity may cause bilateral nasal
obstruction.
• 4. Spurs. A spur is a shelf-like projection often
found at the junction of bone and cartilage. A spur
may press on the lateral wall and gives rise to
headache. It may also pre­dispose to repeated
epistaxis from the vessels stretched on its convex
surface.
• 5. Thickening. Due to organised haematoma or
over-riding of dislocated septal fragments.
Types of DNS
 Septum deviation

Result in －
• Nasal obstruction
• Nasal bleeding
• Headache
• Anosmia
• Sinusitis
• External deformity
 Treatment of DNS
• Submucous resection (SMR) operation
• It is generally done in adults under local
anaesthesia. It consists of elevating the
mucoperichondrial and mucoperiosteal flaps on
either side of the septal framework by a single
incision made on one side of the septum,
removing the deflected parts of the bony and
cartilaginous septum, and then repositioning the
flaps.
 Treatment of DNS
• Submucous resection (SMR) operation
• Septoplasty. It is a conservative approach to septal
surgery. In this operation, much of the septal
framework is retained. Only the most deviated
parts are removed. Rest of the septal framework is
corrected and repositioned by plastic means.
Mucoperichondrial/periosteal flap is generally
raised only on one side of the septum, retaining
the attachment and blood supply on the other.
Septoplasty has now almost replaced SMR
operation.
• Septal surgery is usually done after the age of 17
so as not to interfere with the growth of nasal
skeleton.