2 Nose, Nasal Sinuses, and Face

Transcription

1 6 Nose, Nsl Sinuses, nd Fce Applied Antomy nd Physiology Bsic Antomy Externl Nose The supporting structure of the nose consists of one, crtilge, nd connective tissue. Figure. shows the most importnt elements. The ony superior prt of the nsl pyrmid is often roken in typicl frctures of the nsl ones, ut it my lso e frctured in injuries to the centrl prt of the fce. The crtilginous inferior portion is less t risk, t lest in mild lunt trum, ecuse of its elstic structure, ut it is endngered in st wounds, lcertions, nd gunshot injuries. The shpe, position, nd properties of the one nd crtilge of the nose hve considerle influence on the shpe nd esthetic hrmony of the fce (see p. )nd on the function of the nsl cvity. Fig.. The nsl skeleton., Glell;, nsl one;, lterl nsl crtilge;, crtilginous nsl septum;, lr crtilge with lterl () nd medil crus (); 6, nsl vlve etween the crnil lr nd cudl lterl crtilges. R, Rhinion. The ony portion of the nose is completely rigid. The flexile crtilginous portion egins t the rhinion. The distl cudl lterl crtilges cn move like the wings of utterfly, wheres the lr crtilges move more like the wings of ird. The nsl septum is the center of stility. us: Behrohm u.., Er, Nose, nd Throt Diseses (ISBN ) 009 Georg Thieme Verlg KG

2 Applied Antomy nd Physiology 7 The following lood vessels in the externl nose re of prcticl importnce: Fcil rtery nd its rnches. Dorsl nsl rtery, rising from the ophthlmic rtery. Profuse hemorrhge cn rise from these vessels when the centrl prt of the fce is injured. The ngulr vein is lso cliniclly importnt. Thromophleitis rising from furuncle of the upper lip or the nose cn spred vi the ophthlmic vein to the cvernous sinus, cusing cvernous sinus thromosis (see p. 89 nd Fig..). The externl nose derives its sensory nerve supply from the first nd second rnches of the trigeminl nerve (see Fig.., ). The muscles derive their motor nerve supply from the fcil nerve. Nsl Cvity The interior of the nose is divided y the nsl septum into two cvities, which re usully unequl in size. Ech side my e divided into the nsl vestiule nd the nsl cvity proper (Fig.., ). The nsl vestiule is covered y epidermis contining hirs (virisse)nd seceous glnds. The ltter re the site of origin of nsl furuncle, which cn thus only develop in the nsl cvity in the vestiule. The medil wll of the nsl vestiule encloses the supporting structure of the nterior prt of the crtilginous septum nd the memrnous septum i. e., the columell. The roof of the vestiule is formed y the ird wing shped lower lterl or lr crtilge, the medil crus of which extends into the columell nd the lterl crus of which supports the externl wll of the vestiule (Figs..,., ). The lr crtilge determines the shpe of the nsl tip nd the nsl pertures. Correcting this re is often n importnt prt of rhinoplsty Fig.. Importnt vsculr reltionships in the fce., Site for ligtion of the ngulr vein;, fcil rtery;, fcil vein;, common crotid rtery;, internl jugulr vein; 6, pterygoid plexus; 7, sigmoid sinus; 8, inferior sgittl sinus; 9, superior sgittl sinus; 0, cvernous sinus;, superior petrosl sinus;, inferior petrosl sinus Fig.., Section through the nterior nose, showing the vestiule nd the limen nsi. The dshed line in shows the sectionl plne of. The limen nsi is locted t the junction of the pink nd red res. Medil nsl wll., Bony nsl ridge;, nsl septum;, upper lterl nsl crtilge;, nsl cvity;, lr crtilge; 6, nsl vestiule; 7, nsl l; 8, nsl columell with medil crus of the crtilginous l; 9, filments of the olfctory nerve; 0, olfctory ul;, pltine one;, perpendiculr plte of the ethmoid;, vomer;, phryngel eustchin tue ostium. us: Behrohm u.., Er, Nose, nd Throt Diseses (ISBN ) 009 Georg Thieme Verlg KG

3 8 Nose, Nsl Sinuses, nd Fce e c d f I II III Fig.. Lterl nsl wll. I, Superior metus; II, middle metus; III, inferior metus., Nsl vestiule;, opening of the nsolcriml duct;, origin of the inferior turinte;, semilunr hitus;, insertion of the middle turinte; 6, sphenoid sinus; 7, insertion of the superior turinte; 8, frontl sinus., Dringe of the ntrl cvity;, dringe of the frontl sinus; c, dringe of the nterior ethmoid cells; d, dringe of the posterior ethmoid cells; e, dringe of the sphenoid sinus; f, re of infundiulum (dotted re). The internl nsl vlve or limen nsi is very importnt structure from the physiologic point of view. It lies t the junction of the vestiule nd the nsl cvity. It is formed y prominence of the nterior edge of the upper lterl or tringulr crtilge on the lterl wll of the nose (Fig..). The internl nsl vlve is normlly the nrrowest point in the entire cross-section of the nsl cvity, mking it n importnt fctor in nsl respirtion (see p. ). The nsl cvity extends from the internl nsl vlve to the chon. The structure of the floor nd roof of the nose, the medil wll, nd the nsl septum is shown in Fig..,. The outline of the lterl wll of the nsl cvity is more complex thn tht of the medil wll. It contins severl structures tht re importnt in the functioning of the nose nd nsl cvity (Fig..): Three nsl turintes (superior, middle, nd inferior) Dringe of the prnsl sinuses (frontl sinus nd mxillry sinus through the hitus semilunris in the middle metus, locted etween the inferior nd middle turinte; the sphenoid sinus hs n ostium of its own in the sphenoethmoidl recess) Opening of the nsolcriml duct into the inferior metus The superior, middle, nd inferior metus re locted inferior to the three turintes (Fig..); the prnsl sinuses nd the nsolcriml duct open into them. These openings re of dignostic nd therpeutic importnce. The inferior metus, locted etween the floor of the nose nd the insertion of the lower turinte, lcks sinus ostium, ut contins the opening of the nsolcriml duct cm posterior to the externl nsl opening nd mm posterior to the hed of the inferior turinte (Fig..). The middle metus, etween the inferior nd middle turinte, is of clinicl importnce ecuse the frontl recess, the nterior ethmoid cells, nd the mxillry ntrum open into it (Fig..). The superior metus, etween the middle nd superior turinte, contins the opening for the posterior ethmoid cells. The sphenoid ostium is locted on the nterior wll of the sphenoid sinus, t the level of the superior metus (Fig..). us: Behrohm u.., Er, Nose, nd Throt Diseses (ISBN ) 009 Georg Thieme Verlg KG

4 Applied Antomy nd Physiology Fig.. d Frontl section through the nsl cvity. The nsl mucos is constricted on the left side nd norml on the right. Respirtory mucos., Middle turinte;, ntrum with ostium;, nsl septum;, inferior turinte;, lyer of mucus; 6, respirtory epithelium with cili; 7, golet cells; 8, mucosl glnds. c Sgittl section through the nose with the septum reflected superiorly., Olfctory region;, middle turinte;, inferior turinte. d, Scent molecules dock onto receptors;, ipolr nerve cells;, olfctory ul with, glomerulus (microcenter) nd, mitrl cells. c d Fig..6,, Scent molecules,, scent receptors. Ech olfctory cell ers only single type of receptor. There re 0 types of receptor in humns. A receptor cn recognize up to 00 structurlly similr molecules in scent ctegory. Scent molecules only fit one specific receptor. They trigger iochemicl rection nd susequent electricl signl, which is trnsmitted to the olfctory center in the rin. The nsl cvity is lined y two types of epithelium: respirtory nd olfctory (Figs.. d,.6, ). Respirtory epithelium cots the entire irwy nd its projections nd extensions (e. g., the prnsl sinuses nd the middle er), from the nsl introitus to the ronchi. It shows morphologic vrition in different prts of the respirtory trct. Figure.c, d shows the structure of the respirtory epithelium of the nsl cvity. The epithelium is columnr-cilited with golet cells nd lyer of mixed glnds, firly well demrcted lymphoid cell zone nd well developed venous cvernous spces in the turintes nd round the osti (Fig..). The olfctory mucos, innervted y fiers of the olfctory nerve, covers the re of the olfctory cleft, the criri- us: Behrohm u.., Er, Nose, nd Throt Diseses (ISBN ) 009 Georg Thieme Verlg KG

5 0 Nose, Nsl Sinuses, nd Fce Fig..7, The prnsl sinuses. Arrngement of the prnsl sinuses in the fcil skeleton. The mucosl surfce of the prnsl sinuses is sustntilly lrger thn tht of the nose. The rrows indicte the mucociliry trnsporttion of secretions out of the sinuses to the nose., Frontl sinus;, ethmoid cell system; c, mxillry sinus; d, sphenoid sinus. s their dependent sinuses, cn ecome disesed, contriuting to the symptoms nd pthophysiology of sinusitis. Fig..8 Antomy of the ethmoid one., Lyrinth;, perpendiculr lmin;, ethmoidl ull;, cristglli. form plte, prt of the superior turinte, nd the prt of the septum lying opposite it. The structure is shown in Fig.. d, nd its topogrphic extent in Fig..c. Bowmnglnds occur specificlly in this re. They produce lipo-lipid secretion tht covers the olfctory region nd ids in olfctory perception due to the enzymes it contins. It is entirely dissimilr to the secretion of the glnds of the respirtory epithelium. Prnsl Sinuses The prnsl sinuses re pneumtized cvities in the one djcent to the nose (Fig..7, ). Ostiometl Complex The ostiometl complex is functionl entity in the nterior ethmoid complex tht represents the finl common pthwy for dringe nd ventiltion of the frontl, mxillry, nd nterior ethmoid cells (see Fig..9). Any or ll cells, clefts, nd osti, s well Ethmoidl Lyrinth The centrl structure in this system of pneumtized cvities is the ethmoid one. The nterior ethmoid is the morphologic connection nd secretion chnnel etween the nose nd the frontl nd mxillry sinuses. The tight spces nd clefts normlly ensure ventiltion nd dringe of the sinus mucos. The nterior ethmoid is centrl to the pthogenesis of cute, recurrent, nd chronic inflmmtions of the frontl nd mxillry sinuses, since 90 % of ll diseses of the frontl nd mxillry sinuses egin here. The centrl prt of the ethmoid one is T-shped. In themedinplne, thecrist glli projects into the nterior foss (Fig..8).Theflx cereri inserts here. The perpendiculr plte (lmin perpendiculris) uts nteriorly onto the septl crtilge nd dorslly onto the vomer. The pired ethmoidl lyrinth is situted etween the nose nd orit. It consists of 0 to pneumtized cells lined with respirtory epithelium. The volume vries individully; roughly, it is the size of mtchox stnding on its short side. The lmin criros psses into the ethmoidl notch (incisur ethmoidlis)of the frontl one. The olfctory nerves extend from the olfctory rim to the olfctory ul. The ethmoid ir cells re differentited into nterior nd posterior groups. They re derived from n emryonic pired nlge tht colesces in the first yer of life to form single ethmoid cell. There re communictions etween ll of the ethmoid cells on one side. There re often lso common osti for the nterior ethmoid complexin the us: Behrohm u.., Er, Nose, nd Throt Diseses (ISBN ) 009 Georg Thieme Verlg KG