MBBS FRCS(c) Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

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1 Dr. Abdulrahman Hagr Al-Ghamdi MBBS FRCS(c) Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

2 Embryology Anatomy Physiology Investigation Nose Nasal septum, vestibule & choanal atresia

3 Nose Embryology Anatomy Physiology Investigation Nasal septum, vestibule & choanal atresia

4 Nose 2 nasal pits invaginate nasobuccal membrane NBM (ChoanalChoanal Atresia) NBM ruptures (10 w) communication nose + Nasopharynx

5 Sinuses Maxillary Sinuses Present at birth Ethmoid Sinus Evaginations of the lateral nasal wall (3 rd m gestation) Are present at birth Adult size by age 12 Frontal Sinus Evagination of the anterior nasal capsule (4 th m gestation) Rarely present at birth; visible until age 2 Sphenoid Sinus Outpuchings of the superior nasal vault (4 th m gestation) Rarely present at birth, usually seen around 4y

7 Congenital masses Dermoid sinuses and cysts Gliomas Encephaloceles

8 Congenital masses Have potential intracranial connections Mass on nasal dorsum or as intranasal mass Biopsy can lead to meningitis and CSF leak Treatment is surgical excision

9 Dermoids Cyst or sinus Most common congenital midline mass Ectodermal and mesodermal Midline nasal pit, fistula Tract with hair at opening Secrete pus or sebaceous material

10 Complications Intermittent inflammation Abscess Osteomyelitis Broaden nasal root Meningitis Cerebral abscess

11 Gliomas

12 Encephaloceles

13 Cleft Anatomy - The Nose Ipsilateral LLC flattened rotated downward Short columella Bifid tip

14 Cleft Antatomy: continued Bilateral Cleft Lip/Alveolus/nose

15 Embryology Anatomy Physiology Investigation Nose Nasal septum, vestibule & choanal atresia

16 Epithelium Anteriorly (Skin) Stratified squamous epithelium All other surfaces. Pseudostratified ciliated columnar (respiratory epi) Muocsa secretes Mucous blanket Cleaning Filtering (traps bacteria) Maintain the moisture nose.

17 Sub-mucosa (Temp) Sinusoids Capillaries

18 Nasal septum Significance: functional and aesthetic. 1. Main support of the external nose 2. Divides the nose into two cavities 3. Supports the mucosal lining

19 Nasal septum Septum include the 1. Nasal bones. 2. Vomer 3. Frontal bone 4. Palatine bone 5. Maxilla and premaxilla, 6. Perpendicular plate of the ethmoid, 7. Quadrilateral cartilage

20 Turbinates Inferior, middle, and superior Thin bone covered by an adherent mucoperiosteum. The turbinates Maximize surface area Rapidly humidify Warm the inspired air

21 لحميات

22 Adenoid الناميات = النامية : الكرم ة ذا ت ن وا م آثير ة

23 Polyps سليلات = منحد ر / خارج س ليل أسرة آذا أي منحد ر منها سيف االله ال م س ل ول " الس ي ف ال م س ت ل م ن غ م د ه

24 محار= Turbanate

25 Concha قرينات =

26 External Carotid Artery -Sphenopalatine artery -Greater palatine artery -Ascending pharyngeal artery -Posterior nasal artery -Superior Labial artery Internal Carotid Artery Blood Supply -Anterior Ethmoid artery -Posterior Ethmoid artery

27 سباتي = Carotid (و ي و م لا ي س ب ت و ن لا ت ا ت يه م )سبت لانقطاع الا يام عند ه...انقطاع الدم عنده

28 Anatomy of the Nasal Cavity and Vasculature

29 Sphenopalatine AA Ethmoid AA Greater Palatine A

32 Venous Drainage Valve-less To Cavernous sinus Bermuda triangle

33 Innervation Autonomic vidian vascular tone, turbinate congestion Nasal secretions Smell olfactory Sensory components. Trigeminal Pain Temperature Touch.

34 Anatomy 4 paired paranasal sinuses Maxillary, ethmoid, frontal and sphenoid Anterior and posterior sinuses

35 Sinus Anatomy: Front View frontal sinus=black check maxillary sinus=red, anterior ethmoid sinuses=green posterior ethmoid sinuses= purple, sphenoid sinus=yellow

36 Sinus Anatomy: Side View frontal sinus=black check maxillary sinus=red, anterior ethmoid sinuses=green posterior ethmoid sinuses= purple, sphenoid sinus=yellow

38 الجبهي Frontal= (ي و م ي ح م ى ع ل ي ه ا ف ي ن ار ج ه نم ف ت ك و ى ج ب اه ه م ب ه ا...)التوبة

39 الجيوب الغربالية= Ethmoid sinuses الحطيي ة يذم زوجته أغ ر بالا إذا است ود ع ت س را وآان ونا على الم ت ح دث ينا تنحي فاجلسي مني بعيدا اراح االله منك العالمين

40 The Maxillary Sinuses The largest sinus The infraorbital nerve runs along roof Drainage!?? ((وما اوتيتم من العلم إلا قليلا))

41 الجيب (الغار) الفكي= Maxillary antrum (فك ر ق ب ت ه )... "م ق ت ل ال رج ل بين ف ك ي ه " :وأريد لسانه

42 وتدي = Sphenoid (أ ل م ن ج ع ل الا ر ض م ه ادا و ال ج ب ال أ و ت ادا (

43 Sphenoid Sinuses Superiorly Optic nerve Posteriorly Pons Lateraly Cavernous sinus CNIII, IV and VI Carotid artery (Dehiscent in 50% )

44 Osteomeatal Complex Anterior ethmoids Containing the ostia of Maxillary Frontal, Anterior ethmoid sinuses Lateral to the middle turbinate

45 Embryology Anatomy Physiology Investigation Nose Nasal septum, vestibule & choanal atresia

46 Nose Physiology 20,000 L of air we breathe in each day 50% of total airway resistance at all ages Obligate nose breathers until >3 months Problems when mouths closed or feeding Infant: nose blockage= respiratory distress

47 Physiology: Effect of Edema Poiseuille s s law R = 8 n l 8 n l Π r 4 If radius is halved,, resistance increases 16fold

48 Nasal Physiology (وفي أنفسكم أفلا تبصرون) On inspiration Airstream funnels through the vestibule Squeezes through the narrow valve velocity decelerates by r4 in the nasal cavity Warming Humidification Removal of antigenic particles Smell

49 Turbinates Physiology (وفي أنفسكم أفلا تبصرون) Side filled up while the opposite Decongested. Controlled by autonomic nervous system 2.5 hours duration Turn from one side to the other while sleeping

50 Embryology Anatomy Physiology Nose Investigation Nasal septum, vestibule & choanal atresia

61 Embryology Anatomy Physiology Investigation Nose Nasal septum, vestibule & choanal atresia

62 Nasal septum Vestibule DNS Epistaxis

63 Vestibule Hair Skin Cartilage

64 Furunculosis 55 y male Fever Headache L.O.C. Died

65 D.N.S

66 Physiology: Effect of Edema Poiseuille s s law R = 8 n l 8 n l Π r 4 If radius is halved,, resistance increases 16fold

68 Cx Septoplasty

69 Septal hematoma

71 Epistaxis 10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.

72 Anatomy/Physiology of Epistaxis Anatomy Nasal cavity Vascular supply Physiology Vascular nature Mucosa

73 Kesselbach s Plexus/Little s Area: -Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX) Woodruff s Plexus: -Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

75 Why bleeding from the nose? Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa (not squamous) Arterial to venous anastamoses ICA and ECA blood flow

$Nasal fracture$

76 Local Factors - Trauma Nose picking Nose blowing/sneezing Nasal fracture Nasogastric/nasotracheal intubation

77 Local Factors Cold, dry air more common in wintertime Dry heat Phoenix and Death valley Anatomic abnormalities

78 Local Factors - Other Self-inflicted (pedi) Foreign bodies Infectio Septal perforation Chemical (cocaine, nasal sprays, ammonia, etc.)

79 Systemic Factors -- Vascular Hypertension/Arteriosclerosis Hereditary Hemorrhagic Telangectasias (OWR)

80 Systemic Factors Coagulopathies Thrombocytopenia Platelet dysfunction Systemic disease (Uremia) Drug-induced (Coumadin/NSAIDs/..) Clotting Factor Deficiencies Hemophilia VonWillebrand s disease Hepatic failure Hematologic malignancies

81 Etiology and Age Children Foreign body Nose picking Coagulation d/o) Adults trauma, idiopathic Middle age tumors Old age--hypertension

82 Initial Management ABC s Medical history/medications Vital signs need IV? Physical exam Anterior rhinoscopy Endoscopic rhinoscopy Laboratory exam Radiologic studies

83 bayonet forcepts vaseline gauze good light bacitracin suction epistat anesthetic gelfoam endoscopes silver nitrate suction bovie/bipolar merocels surgicel

84 Treatments Control of hypertension Correction of coagulopathies Topical decongestants/vasocontrictors Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of time) Surgery/embolization

85 TSS Nugauze vs. Merocel Electron microscopy

87 Non-surgical treatments Humidity/emolients Discontinue offending meds Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining/bed rest

88 Choanal Atresia Airway Concerns CHARGE association Bilateral immediate airway support If definitive surgery delayed b/c of other anomalies, tracheotomy necessary

89 C.H.A.R.G.E. 1. Coloboma 2. Heart defect (tetralogy of Fallot,ASD,VSD) 3. Atretic choanae 4. Retarded growth 5. Genitourinary anomalies 6. Ear malformations *must have 4 out of 6 categories

91 Choana قمع =

92 Atresia رتق = ال ر ت ق : الشيء المرتوق أي المسدود والملتي م ) أ و ل م ي ر ا لذ ين آ ف ر وا أ ن ال سم وات و الا ر ض آ ان ت ا ر ت ق ا ف ف ت ق ن اه م ا)

95 25 Y in RTA, fever nasal obstruction

96 What is A & B? B A

97 Give 2 complications of this infection

Commen Nose Diseases

Commen Nose Diseases Symptoms List: Nasal obstruction. Nasal discharge: Anterior (Rhinorrhea). Posterior (Postnasal discharge). Epistaxis. Hyposmia and Anosmia. Headache. Snoring. Nasal Obstruction Definition: