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Flashcards in Week 8- The nose Deck (68):
1

What are the functions of the nose and nasal cavity?

  • Sense of smell (olfaction)
  • Provides a route for inspred air 
  • Filters inspired air removing particles by trapping in the nasal hair or mucous
  • Moistens and warms inspired air (when you have a cold you can get a tickly cough as the nasopharynx and oropharynx aren't moistened)
  • Resonating chamber for speech (so you sound funny when you have a blocked nose)

2

Q image thumb

  1. Vestibule 
  2. Pharyngotympanic (eustachian) tube
  3. Floor of nasal cavity (hard and soft palate)
  4. Nasopharynx

3

What two components is the external nose made up of?

  • Cartilage and bone

4

Which bones make up the external nose?

  • Nasal bones (medially) and the frontal process of the maxilla (laterally)

5

What gives the external nose its shape?

The cartilage (this is hyaline cartilage) 

6

What is the most commonly fractured bone of the face?

The frontal bone (as it is prominent)

7

What does the eustachian tube connect the nasal cavity to?

The middle ear

8

What is the vestibule of the nose? What is it lined with?

  • The entrance to the nasal cavity (anything posterior to it is the nasal cavity)
  • It is lined with skin (same as external nose) and has sebaceous glands and hair cells 

9

Q image thumb

  1. Nare (nostril)
  2. Philtrum 
  3. Nasal septum 
  4. Apex/tip
  5. Bridge 

10

What is the bit just superior to the bridge of the nose called?

The root

11

If there is fracture of the nasal bone why is the patient often sent home for a few days before being treated?

To allow swelling to go down

12

What must we also examine for if someone presents with a nasal fracture?

  • Other fractures or injury e.g. of head, neck or other facial bones due to the large amount of force required for a nasal fracture 

13

If someone is punched in the nose what happens to the force?

Some of it is absorbed by the cartilagenous part of the nose but it is the bone that will fracture 

14

What makes up the lateral and medial walls and the roof and floor of the nasal cavity?

  • Lateral Walls 
    • Maxilla 
    • There are bony projections called the supeiror, middle and inferior conchae (turbinates) and the gaps beneath these are called meatus
  • Medial wall
    • Nasal septum
    • Perpendicular plate of ethmoid bone postero-superiorly
    • Vomer postero-inferiorly 
    • Cartilage anteriorly 
  • Roof
    • Sphenoid, crista galli and cribriform plate of ethmoid, frontal and nasal bone
  • Floor 
    • Roof of oral cavity- hard and soft palate 
      • Hard palate (anteriorly) made up of maxilla and palatine bone posteriorly 
      • Soft palate is soft tissue and muscle

15

What are the conchae covered in?

  • Respiratory mucosa (pseudostratified columnar ciliated epithelium)

16

Where is the spheno-ethmoidal meatus found?

Above the superior concha on the lateral wall of the nasal cavity

17

What is the role of the irregularity of the lateral wall of the nasal cavity?

  • Slows airflow and increases the area over which air passes to aid with the humidification of air 

18

What are the holes through which sinuses open into the nasal cavity called?

Ostium 

19

What can force/injury to the nose cause?

Nasal bone fracture or septal deviation 

20

What is a septal haematoma?

  • Cartilage of septum receives blood supply from overlying perichondrium 
  • Trauma to the nose can cause shearing of blood vessels and blood to accumulate in the space between cartilage and perichondrium 
    • This is a septal haematoma

21

What must you always examine patients with nasal injury for?

Septal haematoma

22

What is the treatment of septal haematoma?

  • Draining of the blood (often by ENT) and then it needs to be packed to push the perichondrium back against the cartilage to get the blood supply back

23

What deformity can occur if septal haematoma is not treated?

  • Avascular necrosis of the cartilage 
    • Due to lack of blood supply 
    • and pressure necrosis due to build up of blood in small space
  • Cartilage gives nose its shape so if necrosis then the nose buckles in on itself giving a saddle deformity
  • This has significant cosmetic consequences

24

As well as saddle deformity what other pathology can occur due to not treating a septal haematoma?

  • Septal abcsess
  • The collection of blood in a small space creates a good breeding site for bacteria so it can become infected forming an abscess (collection of infection) in the septum

25

Why can someone being punched in the nose lead to CSF rhinorrhoea?

  • Nasal cavity has close realtionship to anterior fossa of cranial cavity (holds brain and meninges) and th crista galli of ethmoid bone 
  • If someone is punched the force can transmit though crista galli and through the dura attached to it causing CSF to run through cribriform foramina and out of the nose

26

What are the two mucous membranes of the nasal cavity and thier roles?

  • Olfactory Mucous membrane 
    • Olfaction (smell)
  • Respiratory mucous membrane 
    • Filters (mucous from goblet cells and cilia)
    • Humidifies (watery secretions)
    • Warms (rich blood supply)

27

Why does the inside of the nose appear pink?

  • The rich blood supply of the respiratory mucous membrane 

28

What drains into the nasal cavity?

  • Paranasal sinuses
  • Nasolacrimal duct (from eye)

29

What carries general sensation to the nasal cavity?

  • trigeminal nerve 
  • N.B. The olfactory nerve is purely special sensory, it has nothing to do with general pain, temperature etc. 

30

What are nasal polyps?

  • Fleshy, benign swellings arising from the nasal mucosa (kind of like an outpouching of mucosa)

31

Describe the appearance of nasal polyps

  • Pale or yellow 
    • However can also be fleshy or reddened or even the same colour as the rest of the nasal cavity 
  • Typically bilateral 

32

Who are nasal polyps particularly common in?

Over 40s

33

What are the symptoms of nasal polyps?

  • Blocked nose and watery rhinorrhoea 
    • As polyp is lined with resp mucosa so excess mucosal secretions 
  • Post nasal drip
    • can occur at back of nose and go into back of nasal cavity and nasopharynx causing tickly cough 
  • Decreased smell and reduced taste 

34

What may suggest a tumour?

  • Unilateral nasal polyp or/and if secretions are blood-tinged 

35

How can we tell the difference between a polyp and turbinate when we touch them?

  • polyp is painless and mobile
  • Turbinate is painful and immobile 

36

What is rhinitis?

  • Inflammation of the nasal mucosal lining
  • It becomes more vascular and engorged so more secretions; swelling can also block the nasal cavity
  • Symptoms:
    • Nasal congestion 
    • Rhinnorhoea ('runny' nose)
    • Sneezing
    • Nasal irritation 
    • Postnasal drip

37

what are common causes of rhinitis?

  • Simple acute infective rhinitis (viral- the common cold)
  • Allergic rhinitis (hayfever)

38

If a child presents with smelly, blood-stained discharge from a single nostril what it is likely to be?

A foreign body

39

What are paranasal sinuses?

  • Air filled spaces that are extensions of the nasal canal and are lined with respiratory mucosa (so are ciliated and secrete mucous)

40

Describe the appearance of  paranasal sinuses at birth

Rudimentary or absent

41

What are the 3 parts of the ethmoidal sinus?

  • Posterior, anterior and middle air cells 

42

What is the function of the paranasal sinuses?

  • To warm and humidify inspired air and to reduce the weight of the skull

43

which paranasal sinus is most commonly affected by infection?

the maxillary 

44

what are important anatomical relations to the paranasal sinuses?

  • The orbit
  • The anterior cranial fossa (ethmoidal air cells and frontal sinus)
  • Roots of the upper teeth can project into the maxillary sinus 
    • dental abscess involving the upper teeth can spread into the maxillary sinus

45

what is acute sinusitis? What is it often secondary to?

  • an acute inflammation of the lining of the sinus (respiratory mucosa) lasting less than 4 weeks
  • Often infective and secondary to viral infection of the nasal cavity (common cold)

46

Diagnosis of acute sinusitis is often based on examination and history. What is found?

  • non-resolving cold or flu-like illness
  • Pyrexia
  • Rhinorrhoea +/- green/yellow discharge 
  • Headache/facial pain (in the area of the affected sinus) worse on leaning forwards
  • Blocked nose

47

What can increase the risk of acute sinusitis?

  • Conditions which block the ostia of the sinuses e.g. nasal polyps, deviated septum
  • Also dental infection can lead to infection of maxillary sinus 

48

How can primary infection lead to a secondary infection in sinusitis?

  • Primary infection e.g. rhinitis leads to reduced ciliary function, oedema of nasal mucosa and increased nasal secretions; drainage from the sinus is impeded
  • This causes secretions in the sinus to become stagnant which is an ideal breeding ground for bacteria causing a secondary infection e.g. strep or haemophilus 

49

How is acute sinusitis treated?

  • Often self limiting (normally within a week but can take 2-3)
    • Symptomatic treatment given e.g. nasal decongestants and pain killers
  • Antibiotics only given for severe of prolonged episodes 

50

Complications of acute sinusitis are rare; what are they?

  • Infections in ethmoidal air cells can break through thin medial wall of orbit 
  • This causes infection of periorbital tissue spreading into the orbit to cause orbital cellulitis
  • This can be sight-threatening as the infection can involve the optic nerve or track back to involve intracranial structures 

51

Where do the paranasal sinuses drain into?

  • Sphenoid sinus
    • Into sphenoethmoidal meatus 
  • Posteior ethmoid sinus
    • Superior meatus
  • Anterior ethmoid sinus, frontal sinus, maxillary sinus
    • Middle meatus

52

What is the blood supply of the nasal mucosa?

  • Branches of ophthalmic artery (branch of internal carotid)
    • These come from the top of the cavity 
    • There are anterior and posterior ethmoid arteries
  • Branches of the maxillary artery (branch of external carotid)
    • Comes from posterior of cavity 
    • Sphenopalatine artery

 

There is a rich blood supply to allow warming and humidification and the nasal mucosa is susceptible to injury and bleeding

53

What is the arterial anastamoses in the anterior septum called? what is its relevance?

  • Called Kiesselbach's or Little's area
  • It is the area which is compressed to stop nosebleeds (epistaxis)
  • 90% of epistaxis occurs from this point 

54

90% of epistaxis occurs from Little's area. Where does the other 10% occur from? Why is bleeding harder to stop from here?

  • From the sphenopalatine artery at the posterior of the nasal cavity 
  • It is further back so harder to compress
  • Also the blood in the sphenopalatine artery tends to be at higher pressure 

55

What can cause epistaxis?

  • Can occur spontaneously or with very minor trauma to the nose e.g. nose blowing or picking
  • There may be underlying systemic problems:
    • Abnormal coagulation 
    • Connective tissue disorders

56

Who is epistaxis most common in?

  • Very young (2-10 years)
  • Old (>50-60)

57

Are nose bleeds even a big deal tho?

  • They can lead to significant blood loss and rarely can even lead to death 
  • so yeh they r a big deal fam 

58

How are epistaxis managed?

  • Compression and leaning forwards
  • If not successful:
    • Cauterise visible bleed with silver nitrate
  • If not successful or bleeding is severe so hard to cauterise:
    • Anterior packing using nasal tampons (these expand within the nasal cavity and tamponade the area of bleeding)
  • If not successful:
    • Posterior packing
  • If not successful:
    • Surgical intervention e.g. embolisation, ligation of blood vessels 

59

What should be monitored in severe epistaxis?

  • Airways, breathing and circulation (ABCs)
  • Blood tests should be done to check Hb levels and clotting 
    • Any underlying systemic problems for the bleeding should be treated e.g. coagulopathies

60

What is the venous drainage of the nasal cavity?

  • Into cavernous sinus, facial vein and pterygoid plexus 

61

What is the nervous supply of the nasal cavity and paranasal sinuses?

  • Antero-superior portion (and most of paranasal sinuses):
    • Ophthalmic nerve (CN Va)
    • (blood supply is branches of ophthalmic artery)
  • Postero-inferior portion (including maxillary sinus)
    • Maxillary nerve (CN Vb)
    • (blood supply is branches of maxillary artery)

62

A tumour is going to be removed from the pituitary gland and the operation involves going up through the nostril to reach it. Which bones will the surgeon need to drill through?

  • Sphenoid
  • It is known as a trans-sphenoidal approach and is often done to remove pituitary adenomas

63

Which nerves run through the cavernous sinus?

  • It is CN III - CN VI
    • EXCEPT CN Vc
  • So:
    • CN III (oculomotor)
    • CN IV (trochlear)
    • CN Va (ophthalmic branch of trigeminal)
    • CN Vb (maxillary branch of trigeminal)
    • VI (abducens)

64

Which features of the nasal cavity allow for slowing of inspired air? Why is this helpful?

  • Air goes from narrow nostril and vestibule into much larger cross-sectional area of the nasal cavity so slows
  • Also slowing is caused by turbulence due to turbinates
  • This provides time for ait to be warmed, humidified and filtered 
  • Air is then directed posteriorly through a narrow exit causing increase in velocity again through the nasopharynx

65

why might a patient with sinusitis complain of toothache?

  • Tooth infection may be the reason for sinusitis due to relationship between roots of upper teeth and maxillary sinus
  • OR sensory innervation of maxillary sinus is infra-orbital nerve and alveolar nerves (branches of maxillary division of trigeminal)
    • These nerves also supply the skin of the cheek, the upper jaw and the teeth
    • Can be difficult to determine which structure is causing pain when there is shared sensory innervation 

66

What injury, not relating to the face, can lead to periorbital bruising (ecchymosis)?

  • Fracture in anterior cranial fossa e.g. involving frontal bone (basilar skull fracture)
  • Orbital plate fracture would tear surrounding blood vessels so allow passage of blood into the orbits so bruising seen around the eyes

67

Why can basilar skull fractures be missed?

  • They do not have localising signs 
  • They are suspected from indirect signs e.g. bleeding from the fracture site into surrounding strcutures
  • Should suspect fracture if history of significant trauma to the head/face

68

What are two ways in which trauma to head can cause damage to the olfactory nerve and so loss of smell?

  • Trauma to the head can cause shearing of the olfactory nerves as they pass through the cribriform plate
  • Fracture involving the cribriform plate, causing direct injury to the olfactory nerves