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Oto-rhino-laryngologyRhinology
Department of Otolaryngology, 1st Affiliated Hospital
Sun-Yat sen University, Guangzhou
Huabin Li, MD. PhD
Nose is the gate of airway
Nose consists of three parts:
External nose
Nasal cavity
Nasal sinus
External nose: Skin; Soft tissue; Bone
nasal rootnasal bridge
nasal apex
anterior nares
nasal columun
alaer nasi
nasaolabial fold
nasal dorsum
Bony skeloton of external nose:
The upper part of the maxilla borders the nasal bone , and its
frontal process projects upward to the frontal bone.
frontal bone
frontal process of maxilla
nasal bone
The shape of the external nose is defined by the nasal bones, a pair
of rectangular bones in the upper nasal dorsum, and by the paired
lateral cartilages (upper nasal cartilages) and alar cartilages
(major alar cartilages) in the central and lower portions of the
nose. The lateral portions of the nasal alae also contain several
small accessory cartilages, called the minor alar cartilages.
Nasal cavity: Nasal vestibule; Nasal fossa proper
Anterior nares;
Posterior
nares(choanae);
Inner wall: nasal septum
Lateral wall: turbinates
Roof: cribriform plate
Bottom:palate
Nasal cavity: Nasal vestibule; Nasal fossa proper
The nasal cavities begin anteriorly at the nasal vestibule, which is
bordered posteriorly by the internal nasal valve (limen nasi)
located between the posterior border of the alar cartilage and the
anterior border of the lateral cartilage. This valve area is the
narrowest portion of the upper respiratory tract and, as such,
has a major bearing on the aerodynamics of nasal airflow.
Nasal cavity: Nasal vestibule; Nasal fossa proper
The anterior bony opening of the nasal cavity, called the
piriform aperture, is bounded laterally and inferiorly by the
maxilla and superiorly by the nasal bone.
Lateral nasal wall: Superior turbinate;Middle turbinate;Inferior turbinate
Inner nasal wall: Nasal septum
Septal cartilages
Perpendicular plate of
ethmoid bone
Vomer
Palatal process of
maxilla
Nasal sinus
Frontal sinus
Ethmoidal sinus
Sphenoidal sinus
Maxillary sinus
Nasal sinus
Nasal sinus
The maxillary sinus borders the nasal cavity laterally, and the
orbital floor separates the upper part of the sinus from the orbit.
Behind the maxillary sinus is the pterygopalatine fossa, which is
traversed by the maxillary artery along with branches of the
trigeminal nerve and autonomic nervous system. The floor of
the maxillary sinus is closely related to the roots of the second
premolar and first molar teeth. This creates a potential route for
the spread of dentogenic infections, and a tooth extraction may
create a communication between the oral cavity and maxillary
sinus (oroantral fistula).
Nasal sinus The maxillary sinus
The frontal sinus is located in the frontal bone, its floor forming
the medial portion of the orbital roof. The sinus, which is
highly variable in its extent, is bounded behind by the anterior
cranial fossa. Inflammations of the frontal sinus can give rise to
serious complications because of its close proximity to the orbit
and cranial cavity (orbital cellulitis, epidural or subdural
abscess, meningitis).
Nasal sinus The frontal sinus
The ethmoid air cells are a labyrinthine system of small,
pneumatized sinus cavities that are separated from one another by
thin bony walls and extend posteriorly between the middle
turbinate (medial border) and orbit to the sphenoid sinus. The
orbital plate of the ethmoid bone, called also the lamina
papyracea, forms the lateral bony wall that separates the ethmoid
air cells from the orbit. Paranasal sinus inflammations can spread
through this lamina to involve the orbit (orbital complications). The
posterior ethmoid cells are closely related to the optic nerve. The
ethmoid roof and cribriform plate ( 1.2) form the bony boundary
that separates the ethmoid cells from the anterior cranial fossa.
Nasal sinus The ethmoidal sinus
The sphenoid sinus is located at the approximate center of the
skull above the nasopharynx. Its posterior wall is formed by the
clivus. It relates laterally to the cavernous sinus, the internal
carotid artery, and cranial nerves II–VI, and it is very closely
related to the optic canal. The optic nerve and internal carotid
artery may run directly beneath the mucosa of the lateral wall of
the sphenoid sinus, without a bony covering. The sphenoid sinus is
bordered superiorly by the sella turcica and pituitary and by the
anterior and middle cranial fossae.
Nasal sinus The sphenoid sinus
Nasal sinus
Frontal sinus
Anterior ethmoidal sinus
Sphenoidal sinus
Maxillary sinus
Posterior ethmoidal sinus
Anterior
Posterior
DrainageMiddle meatus
Drainage
Superior meatus
Nasal sinus: drainage
Ostiomeatal complex
Nasal mucosa
Olfactory mucosa
Respiratory mucosa
The epithelium of the respiratory mucosa is composed of
ciliary cells, goblet cells, and basal cells and provides an initial,
mechanical barrier against infection. The ciliary cells dominate
the surface of the respiratory epithelium. Each ciliary cell has
approximately 150–200 cilia, which are composed of
microtubules and are interlinked by “dynein arms.”
Nasal mucosa
Each ciliary cell has approximately 150–200 cilia, which are
composed of microtubules and are interlinked by “dynein arms.”
动力蛋白臂Dynein arm
成对纤丝Peripheral doublet
纤毛杆Central singleton
中央鞘Central Sheath
轮辐radial spokes
连接桥
接键nexin link
Ciliary cell
Nasal mucosa
The ciliary action.
Ciliary cell
Nasal mucosa
Respiratory mucosa
This cytoskeleton of the ciliary cells and the activity of dynein, a
specialized protein, enable the typical, synchronous beating of
the cilia in the respiratory epithelium. This ciliary action propels
a blanket of mucous secretions (from the goblet cells) and serous
secretions (from the nasal glands) toward the nasopharynx,
mechanically cleansing the inspired air in a mechanism called
mucociliary transport .
Nasal mucosa
Olfactory mucosa
The olfactory mucosa covers the olfactory region, which
occupies the anterior superior part of the nasal septum and
adjacent areas of the lateral nasal wall. Usage subject to terms
and conditions of license. including the side of the superior
turbinate facing the septum and part of the middle turbinate.
The external nose derives most of its blood supply from the
facial artery, which arises from the external carotid artery,
and from the ophthalmic artery, which springs from the
internal carotid artery.
The internal nose receives blood from the territories of the
external and internal carotid arteries: the terminal branches
of the sphenopalatine artery, which arises from the
maxillary artery, and the anterior and posterior ethmoid
arteries, which arise from the ophthalmic artery.
Vascular supply
A detailed knowledge of the vascular supply is particularly
important in the management of intractable epistaxis
(nosebleed), which requires vascular ligation or angiographic
embolization as a last recourse.
The venous drainage of the facial region is handled by the
facial vein, retromandibular vein, and internal jugular
vein.
The regional lymphatic drainage of the face and external
nose is handled mainly by the submandibular lymph nodes,
while the nasal cavity is additionally drained by the
retropharyngeal and deep cervical lymph nodes.
Vascular supply
The facial skin receives its sensory innervation from terminal
branches of the trigeminal nerve that enter the facial region
through the supraorbital, infraorbital, and mental foramina.
Only the skin over the mandibular angle and the lower portions
of the auricle are supplied by the great auricular nerve.
Nerve supply
The facial muscles are classified as mimetic or masticatory,
each of these groups receiving different motor innervation.
While the mimetic muscles of the face develop from the
blastema of the second branchial arch (the hyoid arch) and
accordingly are supplied by the facial nerve, the masticatory
muscles trace their embryonic development to the first
branchial arch (the mandibular arch) and are therefore supplied
by mandibular nerve branches arising from the trigeminal
nerve.
Nerve supply
Ventilation:conditioning the inspired air to warm and humid
Olfaction
Defense:mechanical defenses and immune response
Speech production
Function of nose
Physical principles of nasal airflow
Function of nose
Laminar flow and turbulent flow
The “nasal cycle” is a physiologic phenomenon marked by an
alternation between luminal narrowing and widening of the
nasal cavities. This alternate congestion and decongestion of the
nasal mucosa is effected mainly through reactions of the venous
capacitance vessels of the inferior and middle turbinates, which
are regulated by the autonomic nervous system.
Nasal cycle
The mucociliary transport system consists of the cilia of the
respiratory epithelium and a mucous blanket composed of two
layers: a deeper, less viscid “sol layer” in which ciliary motion
occurs, and a superficial, more viscid “gel layer”.
Mucociliary clearance
Disturbances of mucociliary transport can have various causes,
such as increased viscosity and thickness of the periciliary sol
layer, hampering ciliary movements, or changes in the
viscoelasticity of the gel layer resulting in ineffectual mucus
transport. Finally, various pathogenic mechanisms can produce
changes in the cilia themselves, regardless of the viscosity of the
mucous blanket.
Mucociliary clearance
Allergic rhinitis
Allergic rhinitis (AR) is a common manifestation of allergic
diseases, affecting approximately 500 million people
worldwide. AR is increasing in prevalence. For example, the
prevalence of AR in Japan increased from 29.8% in 1998 to
39.4% in 2008. The prevalence of pollinosis, the typical
seasonal AR, has been increased from 19.6% in 1998 to 29.8%
in 2008.
Allergic rhinitis
AR is increasing in prevalence
Allergic rhnitis and its impact on asthma (ARIA)Global guideline for AR management
Definition
AR is defined as a symptomatic disorder of the nose induced
after allergen exposure by an IgE-mediated inflammation.
It is an inflammation of the lining of the nose and is
characterized by nasal symptoms including anterior or
posterior rhinorrhoea, sneezing, nasal blockage and/or
itching of the nose.
These symptoms occur during two or more consecutive days
for more than 1 h on most days.
Allergen
Most causal antigens for AR are inhalant allergens.
House dust mite, animal dander, pollens and fugus are the
principal allergens.
Other inhalant allergens include feather, insect and grass
pollen.
Food allergens inckude peanut, egg, milk etc.
Pathophysiology
Onset of three major AR symptoms
Sneezing (consecutive)
Sensory nerves containing substance P (SP) and calcitonin
gene-related peptide (CGRP) are distributed throughout the
epithelial and subepithelial layers of the nasal mucosa. Sensory
nerve terminals are located in the epithelial junctions and
subepithelial layers. When various chemical mediators are
applied to the nasal mucosa, histamine is the only mediator that
induces a significant sneezing reflex.
Sneezing
The sneezing reflex following allergen challenge is a respiratory
reflex induced by the interaction between histamine and the H1
receptor at the sensory nerve terminals containing SP and CGRP
and might be a sensory stimulation response amplified by
hyperreactivity in the nasal mucosa.
Onset of three major AR symptoms
Onset of three major AR symptoms
Itching nose
Also, sensory nerve terminals are located in the epithelial
junctions and subepithelial layers. When various chemical
mediators are applied to the nasal mucosa, histamine is the only
mediator that induces the sensory nerve terminals to be itching.
Onset of three major AR symptoms
Rhinorrhoea (Watery)
Synchronously with the sneezing reflex, sensory stimulation on
the nasal mucosa induces excitation reflexively in the
parasympathetic centre.After allergen challenge on the hemilateral
nasal mucosa of patients with allergic rhinitis, the weight of
rhinorrhoea induced in both sides of nasal cavities is correlated
with the number of sneezes. In addition, the weight of rhinorrhoea
in the nasal cavity with allergen challenge is correlated with that
on the opposite side. Therefore, rhinorrhoea can be regarded as
the secretion from the mucous glands by parasympathetic
stimulation.
Onset of three major AR symptoms
Rhinorrhoea
Therefore, rhinorrhoea can be regarded as the secretion from the
mucous glands by parasympathetic stimulation. Furthermore,
allergic inflammation induced by nasal allergen exposure
augments this ‘naso-nasal’ reflex. Possible mechanisms for
sensory nerve hyperresponsiveness include the increased release
of nerve growth factor during allergic inflammation. Chemical
mediators including histamine, cysLTs, and PAF induce plasma
exudation directly from the blood vessels in the nasal mucosa,
which constitutes a part of rhinorrhoea.
Other onset of AR symptoms
Nasal congestion
The underlying causes of nasal congestion in the early phase of
allergic rhinitis are the relaxation of the smooth muscle layer
of capacitance vessels in the nasal mucosa and the
interstitial oedema induced by plasma exudation.Swelling of
the nasal turbinate is induced by the parasympathetic reflex
and the axon reflex through the nerve centre and the direct
effects of the chemical mediators on the vascular system.
Nasal congestion
When sensitized subjects inhale antigens, the antigens pass
through the epithelial tight junctions in the nasal mucosa to bind
IgE on the surface of mast cells in the epithelial layer of the
nasal mucosa, inducing the release of chemical mediators
including histamine, prostaglandins and cysLTs by aggregation
of FceRI. Histamine regulates tight junctions via the coupling of
H1 receptors and increases paracellular permeability.
Other onset of AR symptoms
Nasal congestion
This increased permeability allows DC to penetrate epithelial
tight junctions easily and enhance antigen presentation to T cells.
The early-phase response, which consists of sneezing, rhinorrhoea
and nasal congestion, is caused by interactions between chemical
mediators and the sensory nerve terminals and blood vessels in
the nasal mucosa.
Other onset of AR symptoms
Nasal congestion
Dilation of the capacitance vessels and plasma exudation after
excitation of the parasympathetic centre are caused by the nitric
oxide (NO) released from parasympathetic terminals and vascular
endothelial cells. However, the participation of the nerve reflex in
nasal turbinate swelling after allergen challenge is minor
compared with the direct effects of chemical mediators, such as
histamine, cysLTs,PAF and prostaglandinD2 (PGD2) and kinin,on
the vascular system in the nasal mucosa.
Other onset of AR symptoms
Nasal congestion
Nasal congestion in the late phase is induced by the allergic
inflammation.The secondary reaction with inflammatory cells and
their mediators, especially the cysLTs produced by eosinophils,
causes oedema of the nasal mucosa. This inflammation, which
develops 6–10 h after the allergen challenge, is referred to as the
late-phase response.
Other onset of AR symptoms
Diagnosis of AR
Skin prick test (SPT)
Diagnosis of AR
Specific IgE assay
Diagnosis of AR
Intermittent allergic rhinitis (IAR):
Less than 4 days a week.
Or for less than 4 weeks.
Persistent allergic rhinitis (PAR):
More than 4 days a weeks.
And for more than 4 weeks.
New classification of AR
MildNo sleep disturbance.No impairment of daily activities 、 leisure 、 and/or sport.No impairment of school or work.No troublesome symptoms.
New classification of AR
Moderate/severe
One or more the following items are present:
Sleep disturbance.
Impairment of daily activities 、 leisure 、 and/or
sport.
Impairment of school or work.
Troublesome symptoms.
New classification of AR
1 、 Avoidance of allergen
Management
2 、 Drug treatment
Management
H1-antihistamines ( oral or topical )Intranasal glucocorticoid
Leuketriene antagonist
Local cromones
Decongestants (oral or topical)
Anticholinergic agents
Management
Management
Management
Management
3 、 Immunotherapy
Management
3 、 Immunotherapy
Management
Management
4 、 Surgical intervention
Treating nasal septal deviationvidian neurectomy
Thank you for your attention