Clinical anatomy of the external nose. Clinical anatomy of the nose

Nose- This is an organ that is the initial section of the respiratory tract, or respiratory tract, of a person. It performs a number of functions, such as: (1) carrying air down the throat; (2) partial humidification and warming of the air; (3) purification of the air from dust particles and pathogens, and (4) the paranasal sinuses are involved in speech production, as they are good resonators for sounds.

There are two sections of the nose: external nose and nasal cavity. External nose in shape it resembles a pyramid, the base of which is directed downwards, and consists of a bone and cartilaginous part. The nasal bones attach directly to the frontal bone and form the bridge of the nose. Among the cartilages, the lateral cartilages that form are mainly important. The nasal bones, together with cartilage, form an anatomical structure called the nasal clivus. The external nose is an anatomical formation that is present only in humans. It is not even found in higher anthropoid primates. Its appearance is evolutionarily associated with the development of bipedal locomotion, the weakening of the strength of the masticatory muscles and the opening of the nose, and the cartilage of the nasal septum with the development of articulate speech. In the cavity of the external nose, the warming, humidification and purification of the inhaled air is already partially taking place.

Unlike the external nose, nasal cavity has a much more complex structure. It is located inside the skull and borders on such important anatomical formations as the oral cavity - from below, the anterior cranial fossa - from above (the location of the frontal lobes of the brain), the eye sockets on the sides. The nasal cavity itself has two communications: with the pharynx through the choanae and with the vestibule of the nose through the pear-shaped opening formed by the nasal and facial bones.

In the structure of the nasal cavity, there are several walls formed by the bones of the face and skull: (1) outdoor– ethmoid bone, (2) internal– bony nasal septum, (3) upper- ethmoid bone, as well as (4) lower- palatine processes of the right and left upper jaws. The outer wall of the nasal cavity is more complicated than others: it bears three bony protrusions called nasal conchas: inferior turbinate(completely independent bone, has the largest dimensions of all three shells) and top and middle sinks(processes of the ethmoid bone). Under each sink there is a nasal passage, of which there are also, respectively, only three: upper, middle and lower. Between the three nasal conchas and the nasal septum is a free space, which is called the common nasal passage. This system of cavities is essential in warming and humidifying the air.

The mucous membrane of the nasal cavity performs a large number of important functions. Depending on this, it is divided into two functionally unequal departments: respiratory and olfactory. The respiratory mucosa lines most of the nose. It has many structural features aimed at processing the air passing through the nasal cavity. The respiratory mucosa of the nasal cavity bears a huge number of cilia that cover its entire surface. All dust particles that enter the nasal cavity are deposited on them. Due to the constant fluctuations of the cilia towards the exit of the nose, all impurities are quickly removed.

Almost as thick as cilia, specific mucous glands are located on the surface of the nasal mucosa. The mucus they secrete also collects dust particles and harmful microbes on its surface and evacuates them. It also contains many substances that fight pathogenic viruses and bacteria. Under the mucous membrane in the wall of the nasal cavity there is a large number of veins that form plexuses. Their main function is to heat the air entering the nose. During colds, they greatly expand and, together with nasal mucus, disrupt breathing - a condition such as nasal congestion is observed.

The olfactory region of the nose is specialized. It begins at the level of the superior nasal concha and contains a large number of olfactory receptors that perceive odors. These receptors may lose their function in whole or in part with frequent colds, constant exposure to toxic substances (nicotine smoking, work in dusty and smoky conditions).

The nasal cavity has a number of "utility" rooms - the so-called nasal sinuses. They open into the nasal cavity and perform functions such as additional warming of the air and resonance of spoken sounds. Paranasal sinuses The nose is covered with the same mucous membrane as the nasal cavity itself. There are the following types of nasal sinuses:

1. Maxillary (maxillary) - located in the thickness of the upper jaw on the right and left. Their entrances are almost completely closed by the mucous membrane.
2. The frontal sinuses are also paired, located in the frontal bone.
3. The ethmoid sinus in the body of the ethmoid bone, which is represented by many small cells.
4. The sphenoid sinus is single, located in the body of the sphenoid bone under the Turkish saddle.

Unfortunately, the mucous membrane of the sphenoid sinuses, as well as the nasal cavity, is subject to inflammatory processes. They, as a rule, proceed for a long time and are treated in specialized ENT clinics. joans- these are paired openings that connect the nasal cavity with the pharyngeal cavity and ensure the passage of air into the lower respiratory tract. In humans, the choanae have such an anatomical arrangement that free breathing is possible even during meals. Choanal atresia, when they are completely absent, is a severe congenital malformation.

Clinical anatomy of the external nose

Hoc (nasus) consists of the external nose and nasal cavity.

The external nose (nasus externus) is represented by a pyramidal bone-cartilaginous framework (Fig. 1.1), covered with skin. It distinguishes the tip, root (bridge), back, slopes and wings.

The bony part of the skeleton consists of paired flat nasal bones and frontal processes of the upper jaw. These bones, together with the anterior nasal spine, form the pear-shaped opening of the facial skeleton. Cartilaginous part of the skeleton consists of paired triangular and pterygoid, as well as additional cartilages; the wings of the nose in their lower posterior part are devoid of a cartilaginous base. The skin in the lower third of the nose has many sebaceous glands. Bending over the edge of the entrance to the nose (nostrils), it lines the walls of the vestibule of the nose (vestibulum nasi) for 4-5 mm. Here on the skin there is a large amount of hair, which causes the possibility of boils and sycosis. In the area of ​​\u200b\u200bthe wings of the nose, under the skin, there are muscles that expand and narrow the entrance to the nose.

The external nose, like all soft tissues of the face, is characterized by an abundant blood supply: branches anastomosing to each other from the maxillary and ophthalmic arteries, from the system of external and internal carotid arteries, respectively, go to it. The veins of the external nose drain blood through the anterior facial vein into the internal jugular vein and in large quantities through the veins of the nasal cavity, then through the ophthalmic veins into the venous plexus of the pterygopalatine fossa (plexus pterygoideus) and into the cavernous sinus (sinus caver-nosus), middle cerebral ( v.meningea media) and then into the internal jugular (v.jugularis interna) vein.

Lymph drainage from the external nose is carried out mainly in the submandibular lymph nodes. The muscles of the external nose are innervated by branches of the facial nerve (n.facialis), the skin - by the first (ophthalmic nerve - n.ophtalmicus) and the second (maxillary nerve - n.maxillaris) branches of the trigeminal nerve, supraorbital (n.supraorbitalis) and infraorbital (n.infraorbitalis) ) nerves.

The plastic skin-cartilaginous structure of the anterior part of the external nose allows, within certain limits, to shift it to the sides without subsequent permanent deformation. However, a strong mechanical impact on the bony part of the nose is often accompanied by fractures of the nasal bones, often with displacement of fragments, and with a more severe injury, a fracture of the frontal processes of the upper jaw.

Clinical anatomy of the nasal cavity

The nasal cavity (cavum nasi) is located between cavitymouth and anterior cranial fossa, and from the sides - betweenpaired upper jaws and paired ethmoid bonesmi. The nasal septum divides it sagittally into two halves, opening anteriorly with the nostrils and backwards, into the nasopharynx, with the choanae. Each half of the nose is surrounded by four paranasal sinuses: maxillary,ethmoidal labyrinth, frontal and sphenoid, which communicate on their side with the nasal cavity (Fig. 1.2). The nasal cavity has four walls: lower, upper, medial and lateral; posteriorly, the nasal cavity communicates with the nasopharynx through the choanae, remains open in front and communicates with the outside air through openings (nostrils).

Inferior wall (bottom of the nasal cavity) formed by two palatine processes of the upper jaw and, in a small area posteriorly, by two horizontal plates of the palatine bone (hard palate). Along an akin line, these bones are connected by a suture. Violations of this connection lead to various defects (non-closure of the hard palate, cleft lip). In front and in the middle in the bottom of the nasal cavity there is a nasopalatine canal (canalis incisivus), through which the nerve and artery of the same name pass into the oral cavity, anastomosing in the canal with the great palatine artery. This circumstance must be taken into account when performing submucosal resection of the nasal septum and other operations in this area in order to avoid significant bleeding. In newborns, the bottom of the nasal cavity is in contact with the tooth germs, which are located in the body of the upper jaw.

Upper wall (roof) the nasal cavity in front is formed by the nasal bones, in the middle sections - by the cribriform plate (lamina cribrosa) and the cells of the ethmoid bone (the largest part of the roof), the posterior sections are formed by the anterior wall of the sphenoid sinus. Threads of the olfactory nerve pass through the holes of the cribriform plate; the bulb of this nerve lies on the cranial surface of the cribriform plate. It must be borne in mind that in a newborn, lamina cribrosa is a fibrous formation that ossifies only by 3 years.

medial wall, or nasal septum(septum nasi), consists of the anterior cartilaginous and posterior bone sections (Fig. 1.3). The bone section is formed by a perpendicular plate (lamina perpendicularis) of the ethmoid bone and a vomer (vomer), the cartilaginous section is formed by a quadrangular cartilage, the upper edge of which forms the anterior part of the back of the nose. In the vestibule of the nose anteriorly and downward from the anterior edge of the quadrangular cartilage, there is a skin-membranous movable part of the nasal septum (septum mobile) visible from the outside. In a newborn, the perpendicular plate of the ethmoid bone is represented by a membranous formation, the ossification of which ends only by 6 years. The nasal septum is usually not exactly in the median plane. Significant curvature of it in the anterior section, more common in men, can cause breathing problems through the nose. It should be noted that in a newborn, the height of the vomer is less than the width of the choana, so it appears as a transverse slit; only by the age of 14, the height of the vomer becomes greater than the width of the choana and it takes the form of an oval, elongated upwards.

Structure lateral (outer) wall of the nasal cavity more complex (Fig. 1.4). In its formation take part in the front and middle parts medial wall and frontalmaxillary process, lacrimal and nasal bone, medialsurface ethmoid bone, in the back, forming the edges of the choana, - the perpendicular process of the palatine bone and the pterygopalatine processes of the sphenoid bone. On the outer (lateral) wall are located three turbinates(conchae nasales): lower (concha inferior), middle (concha media) and upper (concha superior). The lower shell is an independent bone, the line of its attachment forms an arc convex upwards, which should be taken into account when puncturing the maxillary sinus and conchotomy. The middle and superior shells are processes of the ethmoid bone. Often the anterior end of the middle shell is swollen in the form of a bubble (conhae bullosa) - this is an air cell of the ethmoid labyrinth. Anterior to the middle shell there is a vertical bony protrusion (agger nasi), which can be expressed to a greater or lesser extent. All turbinates, attached with one lateral edge to the lateral wall of the nose in the form of oblong flattened formations, with the other edge hang down and medially in such a way that under them are formedvenous lower, middle and upper nasal passages, whose height is 2-3 mm. The small space between the superior concha and roof of the nose, called the sphenoethmoid, is usually referred to as the superior nasal meatus. Between the nasal septum and the nasal conchas there remains a free space in the form of a gap (3-4 mm in size), which extends from the bottom to the roof of the nose - the common nasal passage.

In a newborn, the lower concha descends to the bottom of the nose, there is a relative narrowness of all nasal passages, which leads to the rapid onset of difficulty in nasal breathing in young children, even with a slight swelling of the mucous membrane due to its catarrhal state.

On the lateral wall of the lower nasal passage at a distance of 1 cm in children and 1.5 cm in adults from the anterior end of the shell is the outlet opening of the nasolacrimal canal. This opening is formed after birth; if its opening is delayed, the outflow of tear fluid is disrupted, which leads to cystic expansion of the canal and narrowing of the nasal passages. The bone of the lateral wall of the lower nasal passage at the base is much thicker than at the line of attachment of the inferior shell (this must be kept in mind when puncturing the maxillary sinus). The posterior ends of the inferior conchas come close to the pharyngeal mouths of the auditory (Eustachian) tubes on the lateral walls of the pharynx, as a result of which, with hypertrophy of the conchas, the function of the auditory tubes may be impaired and their disease may develop.

middle nasal passage located between the lower and middle shells, on its lateral wall there is a sickle-shaped (lunate) gap (hiatus semilunaris), the posterior section of which is located below the anterior one (first described by N.I. Pirogov). The following are opened into this gap: in the posterior section - the maxillary sinus through an opening (ostium 1 maxil-lare), in the anterior superior section - the opening of the frontal sinus canal, which does not form a straight line, which must be borne in mind when probing the frontal sinus. The crescent-shaped gap in the posterior region is limited by the protrusion of the ethmoid labyrinth (bulla ethmoidalis), and in the anterior region - by the hook-shaped process (processus uncinatus), which extends anteriorly from the anterior edge of the middle turbinate. The anterior and middle cells of the ethmoid bone also open into the middle nasal passage.

superior nasal passage extends from the middle concha to the roof of the nose and includes the sphenoethmoid space. At the level of the posterior end of the superior concha, the sphenoid sinus opens into the superior nasal passage through an opening (ostium sphenoidale). The posterior cells of the ethmoid labyrinth also communicate with the superior nasal passage.

The mucous membrane of the nasal cavity covers all its walls in a continuous layer and continues into the paranasal sinuses, pharynx and middle ear; she is does not have a submucosal layerrye is generally absent in the respiratory tract, with the exception of the subvocal region of the larynx. The nasal cavity can be divided into two sections: anterior - nasal vestibule(vestibulum nasi) and actually nasal cavity(cavum nasi). The latter, in turn, is divided into two areas: respiratory and olfactory.

The respiratory region of the nasal cavity (regio respiratoria) occupies the space from the bottom of the nose up to the level of the lower edge of the middle shell. In this area, the mucosathe shell is covered with multi-row cylindrical ciliatedepithelium.

Under the epithelium is the actual tissue of the mucous membrane (tunica propria), consisting of connective tissue collagen and elastic fibers. Here there are a large number mucus-secreting goblet cells andtubular-alveolar branched glands producingserous or serous-mucous secret, which through the excretoryduct exits to the surface of the mucous membrane. Somewhat below these cells on the basement membrane are basal cells that do not undergo desquamation. They are the basis for the regeneration of the epithelium after its physiological and pathological desquamation (Fig. 1.5).

The mucous membrane throughout its entire length is tightly soldered to the perichondrium or periosteum, which forms with it whole, therefore, during the operation, the shell is separated along with these formations. In the region of the predominantly medial and lower sections of the inferior shell, the free edge of the middle shell and their posterior ends, the mucous membrane is thickened due to the presence of cavernous tissue, consisting of dilated venous vessels, the walls of which are richly supplied with smooth muscles and connective tissue fibers. Areas of cavernous tissue can sometimes occur on the nasal septum, especially in its posterior section. Filling and emptying of the cavernous tissue with blood occurs reflexively under the influence of various physical, chemical and psychogenic stimuli. The mucous membrane containing the cavernous tissue can instantly swell (thereby increasing the surface and warming the air to a greater extent), causing a narrowing of the nasal passages, or contract, exerting a regulatory effect on the respiratory function. In children, cavernous venous formations reach full development by 6 years. At a younger age, in the mucous membrane of the nasal septum, rudiments of Jacobson's olfactory organ are sometimes found, located at a distance of 2 cm from the anterior edge of the septum and 1.5 cm from the bottom of the nose. Cysts can form here and inflammatory processes develop.

The olfactory region of the nasal cavity (regio olfactoria) is located in its upper sections, from the arch to the lower edge of the middle turbinate. In this area, the mucous membrane covers olfactory epithelium, the total area of ​​which in one half of the nose is about 24 cm 2 . Among the olfactory epithelium in the form of islets is the ciliated epithelium, which performs a cleansing function here. The olfactory epithelium is represented by olfactory spindle-shaped, basal and supporting cells. The central fibers of spindle-shaped (specific) cells pass directly into the nerve fiber (fila olfactoria); the tops of these cells have protrusions into the nasal cavity - olfactory hairs. Thus, the spindle-shaped olfactory nerve cell is both a receptor and a conductor. Surfaceolfactory epithelium is covered with a secret of specific tubeschato-alveolar olfactory (Bowman) glands, whichis a universal solvent of organic substances.

The blood supply to the nasal cavity (Fig. 1.6, a) is provided by the terminal branch of the internal carotid artery (a.ophthalmica), which in the orbit gives off the ethmoid arteries (aa.ethmoidales anterior et posterior); these arteries feed the anterior superior sections of the walls of the nasal cavity and the ethmoid labyrinth. The largest artery of the nasal cavity- a. spherenopalatina(branch of the internal maxillary artery from the systemexternal carotid artery) it leaves the pterygopalatine fossa through an opening formed by the processes of the vertical plate of the palatine bone and the body of the main bone (foramen sphenopalatinum) (Fig. 1.6, b), gives the nasal branches to the side wall of the nasal cavity, septum and all paranasal sinuses. This artery projects on the lateral wall of the nose near the posterior ends of the middle and inferior turbinates, which must be kept in mind when performing operations in this area. Features of vascularization of the nasal septum is the formation of a dense vascular network in the mucous membrane in the region of its anterior third (locus Kisselbachii), here the mucous membrane is often thinned (Fig. 1.6, c). From this place more than from other areas, nosebleeds occur, so it was called the "bleeding zone of the nose." Venous vessels accompany arteries. A feature of the venous outflow from the nasal cavity is its connection with the venous plexuses (plexus pterigoideus, sinus cavernosus), through which the nasal veins communicate with the veins of the skull, orbit and pharynx, as a result of which there is the possibility of infection spreading along these pathways and the occurrence of rhinogenic intracranial and orbital complications, sepsis, etc.

Lymph outflow from the anterior sections of the nose is carried out to the submandibular lymph nodes, from the middle and posterior sections to the deep cervical ones. It is important to note the connection of the lymphatic system of the olfactory region of the nose with the intershell spaces, carried out along the perineural pathways of the olfactory nerve fibers. This explains the possibility of meningitis after surgery on the ethmoid labyrinth.

In the nasal cavity, olfactory, sensitive and secretory innervation are distinguished. Olfactory fibers (fila olfactoria) depart from the olfactory epithelium and through the cribriform plate penetrate into the cranial cavity to the olfactory bulb, where they form synapses with the dendrite of the cells of the olfactory tract (olfactory nerve). The parahippocampal gyrus (gyrus hippocampi), or seahorse gyrus, is the primary center of smell, the hippocampal cortex (Ammon's horn) and the anterior perforative substance are the highest cortical center of smell.

Sensitive innervation of the nasal cavity is carried out by the first (n.ophtalmicus) and second (n.maxillaris) branches of the trigeminal nerve (Fig. 1.7). The anterior and posterior ethmoid nerves depart from the first branch of the trigeminal nerve, which penetrate the nasal cavity along with the vessels and innervate the lateral sections and the roof of the nasal cavity. The second branch is involved in the innervation of the nose directly and through the anastomosis with the pterygopalatine node, from which the posterior nasal nerves depart mainly to the nasal septum. The inferior orbital nerve departs from the second branch to the mucous membrane of the bottom of the nasal cavity and the maxillary sinus. The branches of the trigeminal nerve anastomose with each other, which explains the irradiation of pain from the nose and paranasal sinuses to the area of ​​the teeth, eyes, dura mater (pain in the forehead, back of the head), etc. The sympathetic and parasympathetic innervation of the nose and paranasal sinuses is represented by the nerve of the pterygopalatine canal (Vidian nerve), which originates from the plexus on the internal carotid artery (upper cervical sympathetic ganglion) and the geniculate ganglion of the facial nerve (parasympathetic portion).

Clinical anatomy of the paranasal sinuses

The paranasal sinuses are located around the nasal cavity and communicate with it (Fig. 1.8). There are four pairs of air sinuses: maxillary, cells of the ethmoid labyrinta, forehead and wedge-shaped. There are anterior (maxillary, frontal, anterior and middle cells of the ethmoid bone) and posterior (sphenoid and posterior cells of the ethmoid bone) sinuses. This division is convenient, since the pathology of the anterior sinuses is somewhat different from that of the posterior ones. In particular, anterior sinuses communicate with the cavitynose through the middle nasal passage, and the posterior- through the top what is important in the diagnostic plan; diseases of the posterior sinuses, especially the sphenoid sinuses, are much less common than the anterior ones.

Maxillary sinuses(sinus maxillaris) are paired, located in the body of the upper jaw (see Fig. 1.8). They are the largest: the volume of each of them is on average 10.5-17.7 cm 3 (from 1.5 to 31.5 cm). The inner surface of the sinuses is covered with a mucous membrane about 0.1 mm thick. The multi-row cylindrical ciliated epithelium covering the mucous membrane functions (has clearance) in such a way that the mucus moves in a circle upward, to the medial angle of the sinus, where the fistula with the middle nasal passage of the nasal cavity is located. In the sinus, the anterior and posterior, upper and lower, as well as the medial walls are distinguished.

On the front, or front, wall outside there is a recess - canine, or dog, fossa (fossa canina). It should be borne in mind that when this wall is felt through the soft tissue of the cheek, immediately above the fossa, the infraorbital nerve (n.infraorbitalis) comes out of the bone. The canine fossa can be of various depths (on average 4-7 mm). With its considerable depth, the anterior and upper walls of the sinus are in close proximity to the medial. In such cases, when puncturing the sinus through the lower (and even more so through the middle) nasal passage, the needle, imperceptibly for the surgeon, can penetrate through the anterior or upper wall into the soft tissues of the cheek or orbit, which can lead to the development of purulent complications. In the region of the canine fossa, the anterior wall is the thinnest.

The medial (nasal) wall of the sinus is bone, only in its upper part the bone may be absent, and then in this place the wall is represented only by a duplication of the mucous membrane. The medial wall corresponds to the lower and middle nasal passages. In its anterior section, the nasolacrimal canal passes, and in the upper, corresponding to the middle nasal passage, under the orbital edge, there is a sinus opening into the nasal cavity (ostium maxillare). Sometimes there is not a simple hole, but a channel several millimeters long. The location of the exit from the sinus in its upper section, its relative narrowness (diameter 2-6 mm) and in some cases the presence of not an opening, but a channel (or several openings - fontanel) create unfavorable conditions for the outflow of discharge from the sinus, which contributes to the development of an inflammatory process. In the upper part, the medial wall of the sinus borders on the cells of the ethmoid bone, which often allows the inflammatory process to spread in this direction.

The upper wall of the maxillary sinus is also the lower wall of the orbit; this wall is the thinnest; the canal of the infraorbital nerve and the vessels of the same name pass through it; sometimes dehiscences (congenital clefts in the bones) are formed here, closed only by the mucous membrane. In this regard, during the operation, it is possible to damage the contents of the orbit through such dehiscences. In some cases, the upper and medial walls of the sinus are at a small distance from each other; in such conditions, sinus puncture through the nasal passage is dangerous, since the needle can penetrate the orbit and cause purulent inflammation in it.

The lower wall, or bottom, of the sinus is the alveolar process of the upper jaw; in most cases, in adults, the bottom of the sinus is below the bottom of the nasal cavity. It is important to note that in adults, the 2nd premolar and 1st molar are closest to the bottom of the sinus, in some cases the tops of the roots of the teeth will stand in the sinus and are covered only by the mucous membrane. This explains the often observed spread of the inflammatory process from the corresponding teeth to the sinus.

The posterior wall of the sinus is thick, formed by the maxillary tubercle, which encloses the pterygopalatine fossa in front, where the maxillary nerve, pterygopalatine ganglion, internal maxillary artery, and pterygopalatine venous plexus are located.

ethmoid sinuses, or ethmoid labyrinth (labyrinthus ethmoidalis), are represented by air cells of the ethmoid bone, which are located between the frontal and sphenoid sinuses (see Fig. 1.8). Outside, the ethmoid cells border on the paper plate of the orbit, and the medial wall of the ethmoid bone is the lateral wall of the nasal cavity. The number, volume, and location of the cribriform cells vary, with an average of 8-10 on each side. Often observed variants of the location of the lattice cells are their distribution into the orbit in the anterior or posterior regions. In this case, they border on a different extent and with the anterior cranial fossa. Often there is also a variant when the cells of the ethmoid labyrinth are located lateral to the cribriform plate on both sides of it; in these cases, the border between the cranial cavity and the nasal cavity is both the cribriform plate and the cribriform bone. At the same time, in surgical terms, it is important to note that the ethmoid plate often lies lower than the ethmoid arch on the sides of it, therefore, when opening the cells of the ethmoid labyrinth, one must strictly adhere to the lateral direction so as not to penetrate the cranial cavity through the ethmoid bone.

frontal sinus(sinus frontalis) is located in the scales of the frontal bone (Fig. 1.9). The sinus has four walls: anterior (facial), posterior (cerebral), bordering the cranial fossa, lower (orbital), most of which is the upper wall of the orbit and which, for a short distance, borders on the cells of the ethmoid bone and the nasal cavity, and the medial (intersinus ), which in the lower section is usually located along the midline, and upward may deviate to the sides. The anterior and posterior walls in the upper part of the sinus converge at an angle. On the lower wall of the sinus anteriorly at the septum there is an opening of the fronto-nasal canal, the length of which is about 1 - 1.5 cm; in some cases, the sinus opens into the nasal cavity not with a channel, but with an opening. The canal usually opens in the anterior semilunar fissure in the middle meatus. The configuration and dimensions of this sinus are variable, its average volume is 4.7 cm 3 . Sometimes one or both sinuses are absent, which is important diagnostically. In some cases, the sinuses, spreading laterally, can be large, have bays and partitions.

Sphenoid sinuses(sinus sphenoidalis) are located in the body of the sphenoid bone (see Fig. 1.9). In each sinus, the anterior, posterior, upper, lower, outer and inner walls are distinguished. The sinuses are separated by an inter-sinus septum, or inner wall. In the front wall of each sinus there is an outlet (ostium sphenoidale), leading to the upper nasal passage. Such communication of the sinus with the nasal cavity causes the outflow of discharge into the nasopharynx along its posterior wall. The intersinus septum continues anteriorly to the nasal septum. The lower wall of the sinus partially forms the arch of the nasopharynx, the upper wall is represented by the lower surface of the Turkish saddle; to this wall from above, in addition to the pituitary gland and the optic nerve, there is a part of the frontal lobe of the brain with olfactory convolutions. The posterior wall is the thickest and passes into the basilar region of the occipital bone. The lateral wall of the sphenoid sinus is most often thin (1-2 mm), with it is bordered by the internal carotid artery and cavernousthai sinus(sinus cavernosus); here pass the oculomotor nerve, the first branch of the trigeminal, trochlear and abducens nerves (III, IV, V, VI pairs of cranial nerves).

The newborn has only two pairs of sinuses - maxillary and ethmoid, however, these sinuses are represented only by the rudiments. So, the maxillary sinuses are only diverticula of the nasal mucosa into the thickness of the upper jaw at the inner corners of the orbits in the form of a gap 10 mm long, 2-3 mm wide and high. By the age of 6, these sinuses acquire normal forms, but their sizes are often small; by the age of 8, the bottom of the sinuses descends to the level of the bottom of the nose, and only by the age of 12 - below the bottom of the nasal cavity, as in an adult. Of interest to the clinic is the fact that in infancy, the relationship between the teeth, the orbit and the maxillary sinus have significant features. If an adult has a sinus between the orbit and the teeth, then in an infant, the lower wall of the orbit is located directly above the two rows of rudiments of milk and permanent teeth, and the rudiment of the sinus is medially at some distance from the teeth. With the increase in the age of the child, the teeth gradually take their permanent place, and the maxillary sinus takes on the appropriate size and configuration. In early childhood, the canine is closest to the sinus; at the age of 6, two premolars and a molar are located near the bottom of the sinus, which, for one reason or another, can cause disease of the maxillary sinus (as in an adult). By the age of 12, the topography of these formations approaches the norm of an adult.

The cells of the ethmoid bone are formed by the time of birth, but their number and volume increase with age, especially in the period from 3 to 5 years.

The frontal and sphenoid sinuses are absent in the newborn; their formation begins by 3-4 years. The sphenoid sinuses are, as it were, laced cells of the ethmoid labyrinth, located in the body of the sphenoid bone. The frontal sinuses appear at the upper inner corner of the orbit from the anterior ethmoid cells; the nasal mucosa grows into them, while the spongy bone between the outer and inner cortical plates of the frontal bone continues to dissolve. At the age of 6 years, the height and width of these sinuses are about 8 and 12 mm, respectively; in some cases, only one frontal sinus can form, sometimes both are absent.

Clinical physiology of the nose and paranasal sinuses

Distinguish between the upper and lower respiratory tract. Nose and eyepubic sinuses, pharynx with oral cavity and larynx areto the upper respiratory tract, trachea, bronchi with bronchioles andalveoli- to the bottom.

It is normal for a person to breathe through the nose. The nose performs, in addition to respiratory, protective, resonator and olfactory functions, and also participates in the regulation of the depth of breathing and tear secretion, hemodynamics of the brain.

The respiratory function of the nose is part of the function of the human respiratory apparatus. During inhalation, due to negative pressure in the chest cavity, air rushes into both halves of the nose. Since the plane of the nostrils is located horizontally, the air stream first goes up, most of it - along the common nasal passage, the smaller one - along the middle one. In connection with the continuing thrust towards the choanae, the bulk of the air arcs backwards and goes at the level of the middle nasal passage, although part of the air stream reaches the roof of the nose and here turns towards the choanae. When exhaling, the pressure of air comes from the nasopharynx through the choanae (located vertically) to the nostrils, so the bulk of the air during exhalation goes at the level of the lower nasal passage. Thus, breathing is carried out mainly through the respiratory region (regio respiratoria). When inhaling, part of the air comes out of the paranasal sinuses, which contributes to the warming and humidification of the inhaled air, as well as its diffusion into the olfactory region. When you exhale, warm air enters your sinuses. About half (47%) of the airway resistance falls on the nasal cavity, which is also due to the relative narrowness, curvature of the nasal passages and the uneven surface of their walls. This resistance has a physiological justification: givingblowing a jet of air on the nasal mucosa is involved inexcitation of the respiratory reflex. If breathing occurs through the mouth, the inhalation becomes less deep, resulting in a decrease in the amount of oxygen entering the body. At the same time, the negative pressure from the chest also decreases, which in turn leads to a violation of the hemodynamics of the skull (the outflow of venous blood from the head worsens). Compensatory mechanisms, especially in children, are often insufficient, which leads to the development of a number of pathological processes in the nervous, mental, vascular, hematopoietic and other systems. In particular, at chronical violation of nasal breathing in children decreases withmaintenance of hemoglobin in the blood, the color index decreases, the number of white blood cells increases and decreasesthe number of erythrocytes, reserve alkalinity decreasesblood, oxidative processes change, etc. In adults, these tendencies also take place, although they are less pronounced.

The protective function of the nose is represented by the mechanisms by which the air is warmed, moistened and cleaned during its passage through the nasal passages during inhalation.

Warming of air is carried out due to the heat coming from the surface of the walls of the nose, the area of ​​​​which is large due to the unevenness of the walls. The cavernous bodies, located in the mucous membrane of the lower and partially middle turbinates, are a vascular apparatus designed to warm the air. Cold air as an irritating factor causes a very rapid reflex expansion of the cavernous spaces and filling them with blood, while the volume of the shells increases significantly, their surface also becomes larger, and the nasal passages narrow accordingly. Under these conditions, air passes into the nasal cavity in a thinner stream and flows around a large surface of the mucous membrane, as a result of which warming is more intense. The outside air temperature rises from 20 °C to 36 °C after passing through the nasal cavity to the nasopharynx. The warming effect is more pronounced the lower the outside temperature.

Humidification of the air in the nasal cavity occurs due to its saturation with moisture covering the mucous membrane. Nasal mucus is formed by the infiltration of fluid from blood vessels, mucosal glands, lacrimal glands, and lymph from interstitial spaces. In an adult, more than 500 ml of water is released from the nasal cavity in the form of steam within 1 day, however, this volume depends on the humidity and temperature of the outside air, the condition of the nose and other factors.

Air purification in the nose is provided by several mechanisms. When a jet of air passes through the vestibule of the nose, large dust particles are retained by fairly thick hair on the skin of the vestibule. Finer dust, which has passed through the first filter along with microbes, is deposited on the mucous membrane, covered with a mucous secretion; the narrowness and curvature of the nasal passages contribute to the deposition of dust. About 40-60% of dust particles and microbes in the inhaled air are retained in the mucus and removed along with it. The mechanism that removes mucus from the nose is the ciliated epithelium (Fig. 1.10). Through the oscillatory movements of the cilia, the mucus moves towards the nasopharynx in such a way that their working backward movement occurs in a straightened state, and the return is in a curved state. Since there are islands of ciliated epithelium in the olfactory zone, the removal of mucus is also ensured here. The vibrations of the cilia obey a certain rhythm (about 250 cycles per minute), while one area, as it were, transfers a portion of the moving mucus to another. In the anterior and upper sections of the nasal cavity, the movement of mucus is slower than in the middle and posterior; the total time of passage of mucus from the anterior edge of the inferior turbinate to the choanae can reach 20-30 minutes. The movement of cilia is influenced by various factors: inflammatory, physical, chemical, temperature, pH, etc. If normal conditions are violated, the cilia not only stop fluctuating, but even disappear until the conditions on the mucous membrane normalize. In the treatment of nasal diseases, it must be taken into account that any infusion of drops into the nose, especially long-term, not only has a therapeutic effect, but can also have a negative effect on the drainage function of the ciliated epithelium, so it is necessary to avoid prolonged administration of oil, soda, vasoconstrictor and other solutions into the nose. .

A pronounced disinfecting effect is given by lysozyme, which is contained in the secretion of the lacrimal glands and nasal mucus. Mucus from the nasopharynx is usually swallowed along with saliva, and its final disposal takes place in the stomach.

The sneezing reflex and tearing also belong to the protective mechanisms. Dust particles, mechanical, chemical, cold and other factors can be irritants that cause this reflex. When you sneeze, air is suddenly expelled from the nose with a certain force, thereby removing irritating substances. Sneezing may be accompanied by profuse mucus secretion, although it may occur when exposed to various irritants and without sneezing.

The olfactory function in humans is provided by the olfactory zone of the nasal mucosa, which contains neuroepithelial spindle-shaped olfactory cells, which are chemoreceptors. The olfactory region (regio olfactoria) starts from the olfactory fissure (rirnma olfactoria), which is located between the lower edge of the middle shell and the nasal septum and has a width of 3-4 mm. The olfactory fissure leads upwards to the olfactory region, which is located on the lateral and medial walls up to the roof of the nose. To improve sensation, it is necessary that air diffuses into the olfactory region. This is achieved by short forced breaths through the nose, while a large number of vortexes are formed directed to the olfactory zone (a person makes such breaths when he sniffs). The immediate irritant of the olfactory receptor is the molecules of a gaseous substance, as well as steam, fog, dust, smoke, soluble under normal conditions in water and fats. Such molecules having incompletely saturated atomic bonds are called odorivectors. According to Zwaadermaker's chemical theory of smell, an odorous substance (odorivector), dissolving in the secret (mucus) of the Bowman (olfactory) glands with low osmotic pressure, quickly spreads and comes into contact with the hairs of the olfactory spindle cells. Through these hairs, molecules of an odorous substance penetrate into the protoplasm of cells, where they enter into combination with a certain protein, which is accompanied by olfactory excitation. Both this and other theories do not fully explain the mechanism of smell. The sensitivity of the sense of smell to various substances varies from person to person, but the average threshold for smell in terms of the amount of odorous substance in the air is quite low. For strongly smelling substances, it is in the range of 210 7 per 1 liter of air.

The role of the paranasal sinuses in the act of nasal breathing is very conditional. At the same time, they apparently cannot be considered only as rudimentary formations. There are two main functions of the paranasal sinuses - protective and resonant.

The protective function of the paranasal sinuses is expressed, firstly, in the fact that the presence of the sinuses themselves serves as protection from external influences for deeper and vital formations of the facial and cerebral skull; secondly, the sinuses are additional reservoirs of warmed, moistened and purified air. The mucous membrane of the sinuses has properties that prevent the development of an infectious inflammatory process in them. In particular, in the maxillary sinuses, the ciliated epithelium carries out the movement (clearance) of a thin layer of mucus along a certain circular path from the lateral, anterior and posterior walls downwards and towards the medial wall upwards into the area of ​​​​the entrance to the sinus and further into the nasal cavity. This mucosal clearance can easily be reduced, especially in the maxillary sinuses, where the fistula is located against the upper wall, which leads to a violation of the drainage function and explains the more frequent occurrence of inflammation than in other sinuses.

The resonator function of the paranasal sinuses takes an active part in the formation of the original timbre and other characteristics of the voice. This is due to the fact that the sinuses, being air cavities (resonators), surround the nasal cavity and together with it, as well as other parts of the upper respiratory tract and the chest, form a characteristic (and unique) voice for each person.

The resonator function of the nasal cavity and paranasal sinuses is to enhance the various tones of the voice. Small cavities (cells of the ethmoid labyrinth, sphenoid sinuses) resonate higher sounds, and large ones (maxillary and frontal sinuses) resonate lower ones. Since the sinus cavities do not change normally in an adult, the timbre of the voice remains constant throughout life. Small changes in the timbre of the voice occur during inflammation of the sinuses due to thickening of the mucous membrane (singers notice this well). The position of the soft palate to a certain extent regulates the resonance, blocking off the nasopharynx, and hence the nasal cavity, from the middle part of the pharynx and larynx, where the sound comes from. At the moment of pronouncing some sounds (“m”, “n”), the soft palate hangs freely, the nasopharynx and choanae remain open, while the voice acquires a nasal tone. Paralysis (or absence) of the soft palate is accompanied by open nasality (rhinolalia aperta), obstruction of the nasopharynx, choanae, nasal cavity (adenoids, polyps, hypertrophy of the turbinates, swelling, etc.) - closed (rhinolalia clausa).

Nose examination methodsand paranasal sinuses

Examination of the external nose, places of projection of the paranasal sinuses on the face is carried out.

Palpation of the external nose: the index fingers of both hands are located along the back of the nose, with light massaging movements they feel the root, slopes, back and tip of the nose.

Palpate the anterior and lower walls of the frontal sinuses, while finding out the sensations of the patient. The thumbs of both hands are placed on the forehead above the eyebrows and gently pressed, then the thumbs are moved to the region of the upper wall of the orbit to its inner corner and pressed again. The exit points of the first branches of the trigeminal nerve are palpated. Normally, palpation of the sinus walls is painless.

During palpation of the anterior walls of the maxillary sinuses, the thumbs of both hands are placed in the canine fossa on the anterior surface of the maxillary bone and gently pressed, the exit points of the second branches of the trigeminal nerve are palpated.

Palpate the submandibular and deep cervical regional lymph nodes. Deep cervical lymph nodes are palpated alternately on one side and the other. The patient's head should be slightly tilted forward. When palpating the lymph nodes on the right, the doctor's right hand lies on the crown of the subject, and with his left hand he makes massaging movements with the tips of the phalanges of the fingers in front of the anterior edge of the sternocleidomastoid muscle. Palpation of the lymph nodes on the left left hand put on the crown, and the right one is palpated. Submandibular lymph nodes are palpated using the same techniques. With the head slightly tilted forward, the submandibular region is palpated with light massaging movements with the tips of the phalanges of the fingers in the direction from the middle to the edge of the lower jaw. Normal lymph nodes are not palpable.

Determination of respiratory function but-with a. The study is carried out alternately, first for one half of the nose, then for the other. For this purpose, the right wing of the nose is pressed against the nasal septum II with the finger of the left hand, and with the right hand they bring a small piece of cotton wool to the left vestibule and ask the patient to take a short, normal inhale and exhale. According to the deviation of the wool, the degree of difficulty in the passage of air is determined. To determine breathing through the right half of the nose with the second finger of the right hand, press the left wing of the nose to the nasal septum, and with the left hand bring a ball of cotton to the right vestibule and also ask the patient to take a short breath and exhale.

Breathing through the nose may be normal, labored, or absent. The respiratory function of the nose is assessed on the basis of the patient's complaints, the results of the cotton test and the rhinoscopy picture. A more accurate study of the function of nasal breathing is carried out using a rhinopneumometer L. B. Dainyak, N. A. Melnikova.

Determination of the olfactory function of the nose a. The study is carried out in turn for each half of the nose using odorous substances from the olfactometric kit or olfactometer. To determine the olfactory function of the nose on the right, the second finger of the right hand presses the left wing of the nose against the nasal septum, and with the left hand they take a bottle with an odorous substance and bring it to the right vestibule of the nose. The patient is asked to take a short breath in the right half of the nose and name the smell of this substance. The sense of smell through the left half of the nose is determined in the same way, only the right wing of the nose is pressed with the second finger of the left hand, and the odorous substance is brought with the right hand to the left half of the nose.

The sense of smell may be normal (normosmiya), lowerednym (hyposmia), perverted (cocosmia) or missing(anosmia).

Anterior rhinoscopy. To examine the vestibule of the nose I, with the finger of the right hand, lift its tip. Normally, the vestibule of the nose is free, its walls are covered with hair. Alternately produce anterior rhinoscopy of one and the other halves of the nose. On the open palm of the left hand, the nasopharynx is placed with the beak down - the first finger of the left hand is placed on top of the nasopharynx screw, the II and III fingers are placed on the outside on the branch. IV and V fingers should be between the jaws of the nasal dilator. This arrangement of the fingers makes it possible to open and close the nasal dilator. The elbow of the left hand is lowered, the hand with the nasal dilator must be movable; the palm of the right hand is placed on the crown of the subject to give the head the position necessary for rhinoscopy. The beak of the nasal dilator in a closed form is inserted 0.5 cm into the vestibule of the right half of the patient's nasal cavity (Fig. 5.2). The right half of the beak of the nasal dilator should be in the lower inner corner of the nasal vestibule, the left half - in the upper outer corner of the vestibule (near the wing of the nose); II and III fingers of the left hand press on the branch of the nasal dilator and open the right vestibule of the nose so that the tip of the beak of the nasal dilator does not touch the nasal mucosa.

With the head in a straight position, the right half of the nose is examined and characterized: the color of the mucous membrane is pink, the surface is smooth; nasal septum in the midline; the turbinates are not enlarged, the common nasal passage is free. Then examine the left half of the nasal cavity.

The anterior sections of the lower nasal passage and the bottom of the nasal cavity are better seen with a slight inclination of the head of the subject anteriorly; to examine the middle nasal passage, the head is tilted backward and somewhat towards the half of the nose being examined. The doctor tilts the head of the subject with his right hand, located on his crown. Normally, the nasal mucosa is pink and moist, and the nasal passages are free, with an inflammatory process, for example, in the paranasal sinuses, purulent discharge can be determined in the nasal passages (Fig. 5.3).

The nasal dilator is removed in the following order: fingers IV and V move the right handle of the nasal dilator so that the jaws of its working part are not completely closed, and the nasal dilator is removed from the nose (complete closing of the jaws of the working part can lead to infringement of the nasal vestibule hair).

Examination of the left half of the nose is carried out in the same way: the doctor holds a nasopharynx in the left hand, and the right one lies on the crown of the head. In this case, the right branch of the working part of the nasal dilator is located in the upper inner corner of the left nostril, and the left branch is in the lower outer corner.

Microendoscopic examination of the nasal cavity and paranasal sinuses. Microendoscopy of the nasal cavity and paranasal sinuses can be performed using a conventional operating microscope and endonasal endoscopes in order to perform diagnostic studies and surgical interventions. Currently, sets of endoscopes and instruments for endonasal microsurgery from Storz are used more often.

In the practice of an otorhinolaryngologist, an operating microscope is unreasonably little used to examine and perform operations in the nasal cavity. Mastering this technique does not present great difficulties for a doctor who knows the methods of examining ENT organs. The use of an operating microscope during endonasal examinations and interventions makes it possible to obtain a more complete endoscopic picture and refines the operation technique, mainly in the initial parts of the nasal cavity.

Microendoscopy with the help of endoscopes is an original method of examination and surgery of the nose and paranasal sinuses, since, unlike other methods of examination, it makes it possible to perform studies and surgical interventions with an increase in all the details of a complex configuration of intranasal structures throughout the entire depth of the nasal cavity. When viewed with endoscopes at different angles of view (0°, 30°, 70°), all complex surfaces of the nasal cavity and paranasal sinuses are accessible to the eye and instrument, which allows not only to determine the state of one or another object, but also to perform microsurgical intervention.

First, the nasal cavity is examined with an endoscope with direct optics (0 °). Typically, a 4 mm endoscope is used. Endoscopic examination before surgery is performed in a certain sequence. First inspect nose vestibule the narrowest point of entry into the nasal cavity, bounded medially by the nasal septum, from below by the bottom of the nasal cavity, laterally in the lower half by the anterior end of the inferior turbinate and laterally from above by the triangular cartilage above the anterior end of the inferior turbinate. This area is called "anterior (ventral) nasal valve". Normally, the angle of the nasal valve between the triangular cartilage and the nasal septum (Fig. 5.4) is about 15°. A decrease in this angle and a narrowing of the nasal valve causes difficulty in nasal breathing, while a suction effect of the wing of the nose may occur, which indirectly leads to the appearance of snoring during sleep. It is necessary to pay attention to the fact that during conventional anterior rhinoscopy, the nasal dilator, moving the ala of the nose, increases the upper angle and does not allow a complete picture of the state of the ventral nasal valve, so it must be examined with an endoscope.

Next, the endoscope is advanced deep into the nasal cavity along the edge of the inferior turbinate along the common nasal passage. They examine the mucous membrane, the relief of the nasal septum, the posterior end of the inferior nasal concha, the choanae, the nasopharynx, the mouth of the auditory tube. During the reverse movement, all departments of the middle turbinate are sequentially examined; back, middle and especially carefully the front end. In the initial section of the middle nasal passage is the so-called osteomeatal complex, which is a system of anatomical structures in the anterior region of the middle turbinate (Fig. 5.5). It is bounded medially by the middle turbinate, laterally uncinate process(KO), which is presented in the form of a sickle-shaped bone plate of the ethmoid bone of varying severity. KO is attached to the lateral wall of the nasal cavity, goes obliquely from top to bottom and backwards. In front and slightly above the KO at the level of attachment of the middle turbinate there are lattice cells nasal ridge(agger nasi), which open into the lunar fissure. KO is the front wall funnels(infundibulum ethmoidale), the fistula of the maxillary sinus opens into its lower part. Often, with endoscopy, under the middle nasal concha, you can see an enlarged cell of the ethmoid labyrinth - the ethmoid bulla (bulla ethmoidalis). The funnel is located in the semilunar fissure in the middle nasal passage, where the natural fistula of the frontal sinus. Natural fistula topnon-maxillary casucha with nasal cavity KO is covered in front, therefore, as a rule, it cannot be seen when examining the nasal cavity with an endoscope. A common variant of the structure is the presence of one or two additional openings (fontanelles) of the maxillary sinus, which are usually located next to the main opening (ostium maxil-lare).

Very often, endoscopy reveals an enlarged anterior end (bulla) of the middle turbinate - the so-called concha bullosa, due to excessive pneumatization of the middle turbinate (Fig. 5.6).

The middle nasal concha is attached in an arcuate fashion from top to bottom to the lateral wall of the nasal cavity and divides lattice labyrinth into two departments front and rear.

The posterior and anterior cells of the ethmoid labyrinth and the sphenoid sinus, unlike the maxillary and frontal sinuses, open directly into the tyoca cavity and nasopharynx. Natural openings of the posterior cells of the ethmoid labyrinththat located lateral to the superior turbinate, where there may be polyps, and the openings of the sphenoid sinus are located on its front wall, medial to the superior turbinate closer to the nasal septum.

Endoscopic research methods, in addition to identifying anatomical formations in the nasal cavity, help to identify adenoids, neoplasms, nasopharyngeal cysts,

assess the condition of the nasopharyngeal and tubal tonsils, confirm the presence bags (cysts) of Thornwaldt, which can obstruct nasal breathing, cause snoring and nasality.

Endoscopy of the maxillary sinus. The study is carried out using rigid endoscopes with direct vision (0°), and if necessary, use 30° or 70° optics. After injection of a local anesthetic under the mucosa, using a trocar, the anterior wall of the canine fossa is perforated with uniform rotational movements. The hole is imposed, as a rule, between the roots of the 3rd and 4th teeth. Endoscopes are inserted into the tube (sleeve) of the trocar or funnel, previously inserted into the hole, and a targeted study of the contents and walls of the sinus is carried out, features of the anatomical structure and condition of the sinus mucosa are revealed. At the end of the study, the trocar sleeve is advanced with the same careful rotational movement as during insertion. The perforation site should not be sutured. The patient should refrain from intense blowing of the nose for 5-6 days.

Examination of the anastomosis of the sinus with the nose is carried out with 30° or 70° endoscopes, while determining the presence or absence of pathological changes in the mucous membrane of the anastomosis (swelling, hypertrophy, polypous formations, etc.), its size, filling with liquid contents, etc. The data obtained allow decide on the next treatment strategy. In those cases when, with the help of an endoscope, various microforceps and nippers, it is possible to eliminate a limited pathological process, for example, free and expand the anastomosis, perform a biopsy (including through the nose), etc., the intervention ends there. If extensive pathological changes are detected with the help of microendoscopy, indications for performing a wider surgical intervention are established.

CLINICAL ANATOMY OF THE NOSE AND PARANASAL SINS

The upper respiratory tract contains nose, paranasal sinuses, pharynx and larynx.

Nose (nasus) is the initial part of the respiratory apparatus, in which the peripheral section of the olfactory analyzer is located. In clinical anatomy, the nose (or nasal cavity) is usually divided into external and internal.

2.1.1. Clinical anatomy of the external nose

External nose (nasus externus) it is represented by a bone-cartilaginous skeleton and has the shape of a trihedral pyramid, with its base facing down (Fig. 2.1). Top part external nose, bordering the frontal bone, is called the root of the nose (radix nasi). Down the nose goes into back of the nose (dorsum nasi) and ends tip of the nose (apex nasi). The lateral surfaces of the nose in the region of the apex are mobile and constitute wings of the nose (alae nasi), their free edge forms the entrance to the nose or nostrils (nares), separated from each other by the movable part of the nasal septum (septum mobilis nasi).

The bone part of the skeleton consists of paired flat nasal bones (ossa nasalia), constituting the back of the nose, laterally on both sides adjoin the nasal bones frontal processes of the upper jaw(processus frontalis maxillae), forming together with the cartilaginous part

Rice. 2.1. External nose: a - frontal projection; b - lateral projection; c - vestibule of the nasal cavity: 1 - nasal bones; 2 - frontal processes of the upper jaw; 3 - lateral cartilages of the nose; 4 - a large cartilage of the wing; 5 - medial leg; 6 - lateral leg; 7 - cartilage of the nasal septum

external nose slopes and nose crest. These bones, together with the anterior nasal spine in the anterior section, make up pear-shaped aperture (hole) (apertura piriformis) facial skeleton.

The cartilaginous part of the external nose is firmly soldered to the bones of the nose and has paired superior lateral cartilage - cartilago nasi lateralis(triangular cartilage) - and paired inferior lateral cartilages (large cartilages of the wings) (cartilago alaris major). The greater cartilage of the wing has medial and lateral legs (crus mediale and laterale). Between the lateral and large cartilages of the wings of the nose are usually unstable, of different sizes, small cartilages of the wings - cartilagines alares minores(sesamoid cartilage).

The skin of the external nose contains many sebaceous glands, especially in the lower third. Bending over the edge of the entrance to the nasal cavity (nostrils), the skin lines the walls of the nasal vestibule for 4-5 mm (vestibulum nasi). Here it is equipped with a large amount of hair, which creates the possibility of pustular inflammation, boils, sycosis.

The muscles of the external nose in humans are rudimentary in nature and of great practical value Dont Have. They play a role in the expansion and narrowing of the entrance to the nasal cavity.

Blood supply. The external nose, like all soft tissues of the face, has abundant blood supply(Fig. 2.2), mainly from the system of the external carotid artery:

- angular artery (a. angularis)- from the anterior facial artery (a. faciales anterior).

- dorsal artery of the nose (a. dorsalis nasi), which is the terminal branch of the ophthalmic artery (a. ophthalmica),- from the system of the internal carotid artery.

Connecting to each other in the region of the root of the external nose, the angular artery and the artery of the back of the nose form an anastomosis between the systems of the internal and external carotid arteries.

Rice. 2.2. Blood supply to the external nose:

1 - angular artery; 2 - facial artery; 3 - dorsal artery of the nose

Rice. 2.3. Veins of the external nose: 1 - facial vein; 2 - angular vein; 3 - superior ophthalmic vein; 4 - cavernous sinus; 5 - internal jugular vein; 6 - pterygoid plexus

Veins of the external nose(Fig. 2.3). The outflow of blood from the soft tissues of the external nose is carried out into the facial vein (v. facialis), which is formed from the angular vein (v. angularis), external nasal veins (vv. nasales externae), superior and inferior labial veins (vv. labiales superior and inferior) and deep vein of the face (v. faciei profunda). Then the facial vein flows into the internal jugular vein (v. jugularis interna).

Clinically important is the fact that the angular vein also communicates with the superior ophthalmic vein. (v. ophthalmica superior), which empties into the cavernous sinus (sinus cavernosus). This makes it possible for the infection to spread from the inflammatory foci of the external nose to the cavernous sinus and the development of severe orbital and intracranial complications.

Lymph drainage from the external nose is carried to the submandibular and parotid lymph nodes.

innervation external nose:

Motor - carried out by the facial nerve (n. faciales);

Sensitive - I IP branches of the trigeminal nerve (n. trigeminus)- supra- and infraorbital nerves - nn. supraorbitalis et infraorbitalis).

2.1.2. Clinical anatomy of the nasal cavity

nasal cavity (cavum nasi) located between the oral cavity (from below), the anterior cranial fossa (from above) and the orbits (lateral-

but). It is divided by the nasal septum into two identical halves, in front through the nostrils it communicates with the external environment, posteriorly through the choanae - with the nasopharynx. Each half of the nose is surrounded by four paranasal sinuses - maxillary (maxillary), ethmoid, frontal and sphenoid (Fig. 2.4).

Rice. 2.4. Paranasal sinuses: a - frontal projection: 1 - frontal; 2 - maxillary; 3 - cells of the lattice labyrinth;

b - side view: 1 - sphenoid sinus; 2 - superior nasal concha; 3 - middle turbinate; 4 - lower nasal concha

The nasal cavity has four walls: lower, upper, medial and lateral (Fig. 2.5).

bottom wall(bottom of the nasal cavity) is formed in front by two palatine processes of the upper jaw and posteriorly by two horizontal plates of the palatine bone. In the midline, these bones are connected by a suture. Deviations in this connection lead to various defects (cleft palate, cleft lip). In the anterior section, the bottom of the nasal cavity has an incisal canal (canalis incisivus), through which the nasopalatine nerve (n. nosopalatinus) and nasopalatine artery (a. nosopalatina). This must be kept in mind during submucosal resection of the nasal septum and other operations in this area in order to avoid significant bleeding. In newborns, the bottom of the nasal cavity is in contact with the tooth germs, which are located in the body of the upper jaw.

Rice. 2.5. Walls of the nasal cavity:

1 - top; 2 - lateral; 3 - medial; 4 - lower

Upper wall of the nasal cavity or roof (arch), in the anterior section formed by the nasal bones, in the middle sections - by the ethmoid (perforated, sieve) plate of the ethmoid bone (lamina cribrosa ossis ethmoidalis), in the posterior section - the anterior wall of the sphenoid sinus. The perforated plate of the ethmoid bone in the arch has a large number of holes (25-30), through which the threads of the olfactory nerve, the anterior ethmoid artery and the vein connecting the nasal cavity with the anterior cranial fossa pass into the nasal cavity. The newborn has a cribriform plate (lamina cribrosa) is a fibrous plate, which ossifies by the age of three years.

medial wall, or nasal septum (septum nasi), consists of anterior cartilaginous and posterior bone sections (Fig. 2.6). The cartilaginous section is formed by the cartilage of the nasal septum - cartilago septi nasi (quadrangular cartilage), the upper edge of which forms the anterior part of the back of the nose, and the anteroinferior part is involved in the formation of the movable part of the nasal septum (pars mobilis septi nasi). The bone department is formed in the posterior superior region and in the middle region perpendicular plate of the ethmoid bone (lamina perpendicularis), and in the posterior inferior - an independent bone of the nasal septum - coulter (vomer).

Rice. 2.6. Medial wall of the nasal cavity:

1 - nasal septum; 2 - the movable part of the nasal septum; 3 - perpendicular plate of the ethmoid bone; 4 - coulter

In a newborn, the perpendicular plastic of the ethmoid bone is represented by a membranous formation. Between the perpendicular plate and the vomer, between the cartilage of the nasal septum and the vomer, a strip of cartilage remains - growth zone. Damage to the growth plate in children (for example, during surgical interventions) can cause deformity of the septum and external nose. Complete formation and ossification of the nasal septum ends by the age of 10, further growth of the septum occurs due to growth zones.

In the area of ​​the growth zones, due to the different rates of development of cartilage and bone tissue, spikes and ridges of the nasal septum can form, causing a violation of nasal breathing.

Lateral(lateral, external) wall of the nasal cavity- the most complex in its structure, formed by several bones. In the anterior and middle sections, it is formed frontal process of the maxilla, medial wall of the maxilla, lacrimal bone, ethmoid cells. In the posterior sections, they are involved in its formation the perpendicular plate of the palatine bone and the medial plate of the pterygoid process of the sphenoid bone, which form the edges of the choanae. joans limited medially to the posterior

the edge of the vomer, laterally - the medial plate of the pterygoid process of the sphenoid bone, above - the body of this bone, below - the posterior edge of the horizontal plate of the palatine bone.

Three turbinates are located on the lateral wall in the form of horizontal plates. (conchae nasales): lower, middle and upper (conchae nasalis inferior, media et superior). The inferior nasal concha, the largest in size, is an independent bone, the middle and superior conchas are formed by the ethmoid bone.

All turbinates, attached to the lateral wall of the nasal cavity in the form of oblong flattened formations, form under them, respectively. lower, middle and upper nasal passages. Between the nasal septum and the turbinates, a free space is also formed in the form of a gap, it extends from the bottom of the nasal cavity to the arch and is called common nasal passage.

In children, the relative narrowness of all nasal passages is noted, the lower shell descends to the bottom of the nasal cavity, which causes a rapidly onset difficulty in nasal breathing even with a slight swelling of the mucous membrane during catarrhal inflammation. The latter circumstance entails a violation breastfeeding because without nasal breathing, the baby cannot suckle. In addition, in young children, the short and wide auditory tube is located horizontally. Under such conditions, even with minor inflammation in the nasal cavity, nasal breathing becomes much more difficult, which creates the possibility of throwing infected mucus from the nasopharynx through the auditory tube into the middle ear and the occurrence of acute inflammation of the middle ear.

Lower nasal passage (meatus nasi inferior) located between the inferior turbinate and the floor of the nasal cavity. In the region of its arch, at a distance of about 1 cm from the anterior end of the shell, there is excretory opening of the nasolacrimal duct (ductus nasolacrimalis). It is formed after birth, the delay in its opening interferes with the outflow of tears, which leads to cystic expansion of the duct and narrowing of the nasal passages. The lateral wall of the lower nasal passage in the lower sections is thick (has a spongy structure), closer to the place of attachment of the lower nasal concha it becomes significantly thinner, and therefore it is easiest to puncture the maxillary sinus in this place, making an indent of about 1.5 cm from the anterior end of the shell.

Middle nasal passage (meatus nasi medius) located between the lower and middle turbinates. The lateral wall in this area has a complex structure and is represented not only by bone tissue, but also by duplication of the mucous membrane, which is called "fountains"(fontanels). On the lateral wall of the middle nasal passage, under the nasal concha, is the semilunar (crescent) gap (hiatus semilunaris), which in the back forms a small extension in the form funnels (infundibulum ethmoidale)(Fig. 2.7). An outlet opens into the lattice funnel anteriorly and upwards. sinus canal, and backwards and downwards - natural fistula of the maxillary sinus. In the semilunar gap open anterior and middle cells of the ethmoid labyrinth. The natural anastomosis of the maxillary sinus in the infundibulum is covered uncinate process - processus uncinatus(a small sickle-shaped plate of the ethmoid bone), delimiting the semilunar fissure in front, therefore, the sinus outlets, as a rule, cannot be seen during rhinoscopy.

On the side wall of the nasal cavity in the region of the anterior end of the middle turbinate, one or a group of air cells can sometimes be identified - the nasal ridge (agger nasi) in the form of small protrusions of the mucous membrane, bordering from below the surface of the uncinate process.

A common variant of the structure is the pneumatized anterior end of the middle turbinate - bulla (concha bullosa ethmoidale), which is one of the air cells of the ethmoid labyrinth. The presence of a vesicle (bulla) of the middle turbinate can lead to impaired aeration of the paranasal sinuses with their subsequent inflammation.

In recent years, due to the active introduction of endoscopic methods of surgical intervention, it is necessary to know the details anatomical structure and the main "identifying" anatomical formations of the nasal cavity. First of all, the concept "ostiomeatal complex" - this is a system of anatomical formations in the anterior region of the middle turbinate. Its composition includes uncinate process(crescent plate), which is the medial wall of the infundibulum (infundibu- lum). Anterior to the uncinate process, at the level of attachment of the upper end of the middle turbinate, are located nasal ridge cells (agger nasi). The latter can be represented by a single

Rice. 2.7. The structure of the lateral wall of the nasal cavity:

a - bone skeleton of the lateral wall of the nasal cavity after removal of soft tissues: 1 - frontal process of the upper jaw; 2 - nasal bone; 3 - superior nasal concha; 4 - middle turbinate; 5 - lower nasal concha; 6 - perpendicular plate of the palatine bone;

7 - inner plate of the pterygoid process of the sphenoid bone;

8 - lacrimal bone; 9 - wedge-palatine opening; 10 - horizontal plate of the palatine bone; b - lateral wall of the nasal cavity after removal of the turbinates: 1 - semilunar cleft; 2 - lattice funnel; 3 - outlet opening of the canal of the frontal sinus; 4 - outlet openings of the sphenoid sinus and posterior cells of the ethmoid labyrinth; 5 - superior nasal concha; 6 - middle turbinate; 7 - lower nasal concha; 8 - nose roller; 9 - front nasal valve; 10 - outlet openings of the maxillary sinus and anterior cells of the ethmoid labyrinth

cavity, but more often it is a system of individual cells that open into the ethmoid funnel. Behind the uncinate process, under the anterior end of the middle turbinate, you can see a large cell of the anterior group of the ethmoid sinuses - large ethmoid vesicle (bulla ethmoidalis). Finally, the opposite section of the nasal septum is also included in the concept of "ostiomeatal complex" (Fig. 2.8).

Rice. 2.8. Ostiomeatal complex (endoscopy picture): 1 - uncinate process; 2 - cells of the nasal ridge; 3 - large lattice vesicle; 4 - nasal septum; 5 - base of the middle turbinate; 6 - anterior section of the middle turbinate; 7 - common nasal passage

Superior nasal passage (meatus nasi superior) extends from the middle turbinate to the vault of the nose. At the level of the posterior end of the upper shell in the upper nasal passage there is a wedge-ethmoid depression (sphenoethmoid space), where the sphenoid sinus opens ostium sphenoidale and posterior cells of the ethmoid labyrinth.

The nasal cavity and paranasal sinuses are lined with mucous membranes. An exception is the vestibule of the nasal cavity, which is covered with skin containing hair and sebaceous glands. The mucous membrane of the nasal cavity does not have a submucosa, which is absent in the respiratory tract (with the exception of the subvocal

cavities). Depending on the structural features of the mucous membrane and functional purpose, the nasal cavity is divided into two sections: respiratory (respiratory) and olfactory.

Respiratory area of ​​the nose (regio respiratoria) occupies the space from the bottom of the nasal cavity to the level of the lower edge of the middle turbinate. In this area, the mucous membrane is covered stratified columnar ciliated epithelium(Fig. 2.9). On the apical surface of the ciliated cells, there are about 200 thin cilia 3–5 μm long, forming an almost continuous carpet. The ciliated microvilli move posteriorly towards the nasopharynx, and in the most anterior part towards the vestibule. The oscillation frequency of the cilia is about 6-8 per second. In the mucous membrane there are also multiple goblet cells that secrete mucus, and tubular-alveolar branched glands that produce a serous or serous-mucous secret, which through the excretory ducts comes to the surface of the mucous membrane of the nasal cavity. Ciliated microvilli are immersed in the secretion of the tubular alveolar glands, pH is normal in the range of 7.35-7.45. Shifts in the pH of the nasal mucus to the alkaline or acidic side slow down the fluctuations of the cilia up to a complete stop and their disappearance from the surface of the cells. After normalization of pH, depending on the degree of damage, restoration of cilia and clearance of the nasal mucosa occurs. Prolonged infusion into the nose of any medicines disrupts the function of the ciliated epithelium, which must be borne in mind in the treatment of nasal diseases. Throughout the entire length of the mucous membrane is tightly soldered to the perichondrium and periosteum, so it is separated during the operation together with them.

Rice. 2.9. Micrograph of ciliated epithelium (x 2600)

On the medial surface of the inferior turbinate and in the anterior sections of the middle turbinate, the mucous membrane of the nasal cavity thickens due to cavernous (cavernous) tissue, consisting of venous vascular dilations, the walls of which are richly supplied with smooth muscles. When exposed to certain stimuli ( cold air, muscle load, etc.) the mucous membrane containing cavernous tissue can instantly swell or contract, thereby narrowing or expanding the lumen of the nasal passages, exerting a regulatory effect on the respiratory function. Normally, both halves of the nose usually breathe unevenly during the day - either one or the other half of the nose breathes better, as if giving the other half a rest.

In children, cavernous tissue reaches full development by the age of 6 years. At a younger age, in the mucous membrane of the nasal septum, a rudiment of the olfactory organ is sometimes found - the vomero-nasal organ (Jacobson), located at a distance of 2.5-3 cm from the anterior edge of the nasal septum, where cysts can form, and inflammatory processes occur.

Olfactory region (regio olfactoria) located in the upper parts of the nasal cavity - from the lower edge of the middle turbinate to the arch of the nasal cavity. The space between the medial surface of the middle turbinate and the opposite part of the nasal septum is called olfactory fissure. The epithelial lining of the mucous membrane in this area consists of olfactory bipolar cells, represented by spindle-shaped, basal and supporting cells. In some places there are ciliated epithelial cells that perform a cleansing function. Olfactory cells are a peripheral nerve receptor, have a long filamentous shape with a thickening in the middle, in which there is a round nucleus. Thin filaments depart from the olfactory cells - about 20 (filae olfactoriae), which through the ethmoid plate of the ethmoid bone enter into olfactory bulb (bulbus olfactorius), and then into the olfactory tract (tr. olfactorius)(Fig. 2.10). The surface of the olfactory epithelium is covered with a specific secret produced by special tubular-alveolar glands (Bowman's glands), which contributes to the perception of olfactory irritation. This secret, being a universal solvent, absorbs odorous substances (odorivectors) from the inhaled air, dissolves them and forms complexes,

Rice. 2.10. Olfactory region of the nasal cavity:

1 - olfactory threads; 2 - ethmoid plate of the ethmoid bone; 3 - olfactory tract

which penetrate the olfactory cells and form a signal (electrical) transmitted to the olfactory zone of the brain. More than 200 natural and artificial odors can be distinguished by the human olfactory analyzer.

BLOOD SUPPLY OF THE NOSE CAVITY

The largest artery in the nasal cavity - wedge-palatine (a. sphenopalatine) a branch of the maxillary artery from the system of the external carotid artery (Fig. 2.11). Passing through the sphenopalatine foramen (foramen sphenopalatina) near the posterior end of the inferior turbinate, it provides blood supply to the posterior nasal cavity and paranasal sinuses. From it into the nasal cavity depart:

posterior nasal lateral arteries (aa. nasales posteriores laterales);

septal arteries (a. nasalis septi).

The anterior upper sections of the nasal cavity and the region of the ethmoid labyrinth are supplied with blood ophthalmic artery (a. ophthalmica) from the internal carotid artery. From it through the cribriform plate into the nasal cavity depart:

anterior ethmoid artery (a. ethmoidalis anterior); posterior ethmoid artery (a. ethmoidalis posterior).

Rice. 2.11. Blood supply to the nasal cavity:

1 - sphenoid-palatine artery; 2 - lattice arteries

A feature of the vascularization of the nasal septum is the formation of a dense vascular network in the mucous membrane in its anterior third - the Kiesselbach place (locus Kisselbachii). Here the mucous membrane is often thinned. In this place, more often than in other parts of the nasal septum, there are nosebleeds, so it got the name bleeding area of ​​the nose.

Venous vessels. A feature of the venous outflow from the nasal cavity is its connection with the veins of the pterygoid plexus (plexus pterigoideus) and beyond the cavernous sinus (sinus cavernosus), located in the anterior cranial fossa. This creates the possibility of spreading the infection along these routes and the occurrence of rhinogenic and orbital intracranial complications.

Lymph outflow. From the anterior sections of the nose, it is carried out to the submandibular, from the middle and posterior sections - to the pharyngeal and deep cervical lymph nodes. The occurrence of tonsillitis after surgery in the nasal cavity can be explained by the involvement of deep cervical lymph nodes in the inflammatory process, which leads to stagnation of lymph in the tonsils. In addition, the lymphatic vessels of the nasal cavity communicate with the subdural and subarachnoid space. This explains the possibility of meningitis during surgical interventions in the nasal cavity.

In the nasal cavity there are innervation:

Olfactory;

sensitive;

Vegetative.

Olfactory innervation is carried out by the olfactory nerve (n. olfactorius). Olfactory filaments extending from the sensory cells of the olfactory region (I neuron) penetrate the cranial cavity through the cribriform plate, where they form the olfactory bulb (bulbus olfactorius). Here begins the second neuron, the axons of which go as part of the olfactory tract, pass through the parahippocampal gyrus (gyrusparahippocampalis) and ends in the hippocampal cortex (hipocampus) which is the cortical center of smell.

Sensitive innervation of the nasal cavity is carried out first (ophthalmic nerve - n. ophthalmicus) and the second (maxillary nerve - n. maxillaris) branches of the trigeminal nerve. The anterior and posterior lattice nerves depart from the first branch, which penetrate the nasal cavity along with the vessels and innervate the lateral sections and the roof of the nasal cavity. The second branch is involved in the innervation of the nose directly and through the anastomosis with the pterygopalatine node, from which the posterior nasal branches depart (mainly to the nasal septum). The infraorbital nerve departs from the second branch of the trigeminal nerve to the mucous membrane of the bottom of the nasal cavity and the maxillary sinus. The branches of the trigeminal nerve anastomose with each other, which explains the irradiation of pain from the nose and paranasal sinuses to the area of ​​the teeth, eyes, dura mater (pain in the forehead, back of the head), etc. The sympathetic and parasympathetic (vegetative) innervation of the nose and paranasal sinuses is represented by the nerve of the pterygoid canal (Vidian nerve), which originates from the plexus on the internal carotid artery (upper cervical sympathetic ganglion) and from the geniculate ganglion of the facial nerve.

2.1.3. Clinical anatomy of the paranasal sinuses

To the paranasal sinuses (sinus paranasalis) include the air cavities surrounding the nasal cavity and communicating with it through holes. There are four pairs of airways:

Maxillary;

Sinuses of the ethmoid bone;

Wedge-shaped.

In clinical practice, the paranasal sinuses are divided into front(maxillary, frontal, anterior and middle ethmoid sinuses) and rear(sphenoid and posterior ethmoid sinuses). This division is convenient because the pathology of the anterior sinuses is somewhat different from that of the posterior sinuses. In particular, communication with the nasal cavity of the anterior sinuses is carried out through the middle one, and the posterior ones through the upper nasal passage, which is important in the diagnostic sense. Diseases of the posterior sinuses (especially the sphenoid sinuses) are much less common than the anterior ones.

Maxillary sinuses (sinus maxillaris)- paired, located in the body of the upper jaw, the largest, the volume of each of them is on average 10.5-17.7 cm 3. The inner surface of the sinuses is covered with a mucous membrane about 0.1 mm thick, the latter is represented by a multi-row cylindrical ciliated epithelium. The ciliated epithelium functions in such a way that the movement of mucus is directed in a circle upward to the medial angle of the sinus, where the anastomosis with the middle nasal passage of the nasal cavity is located. In the maxillary sinus, the anterior, posterior, superior, inferior, and medial walls are distinguished.

Medial (nasal) wall sinus from a clinical point of view is the most important. It corresponds to most of the lower and middle nasal passages. It is represented by a bone plate, which, gradually thinning, in the region of the middle nasal passage, can pass into a duplication of the mucous membrane. In the anterior part of the middle nasal passage, in the semilunar fissure, duplication of the mucous membrane forms a funnel (infundibulum), at the bottom of which there is an opening (ostium maxillare) connects the sinus to the nasal cavity.

In the upper part of the medial wall of the maxillary sinus, there is an excretory fistula - ostium maxillare, in connection with which the outflow from it is difficult. Sometimes, when viewed with endoscopes, an additional outlet of the maxillary sinus is found in the posterior parts of the semilunar fissure. (foramen accesorius), through which the polyposis-altered mucous membrane from the sinus can protrude into the nasopharynx, forming a choanal polyp.

front, or front, wall extends from the lower edge of the orbit to the alveolar process of the upper jaw and is most dense in the maxillary sinus, covered with soft tissues of the cheek and accessible to palpation. Flat bone cavity

on the anterior surface of the front wall is called canine, or canine, fossa (fossa canina), which is the thinnest part of the front wall. Its depth can vary, but averages 4-7 mm. With a pronounced canine fossa, the anterior and upper walls of the maxillary sinus are in close proximity to the medial. This must be taken into account when performing a sinus puncture, because in such cases the puncture needle can penetrate into the soft tissues of the cheek or into the orbit, which sometimes leads to purulent complications. At top edge The canine fossa contains the infraorbital foramen through which the infraorbital nerve (n. infraorbitalis).

upper, or eye wall, is the thinnest, especially in the posterior region, where there are often digescences. In its thickness passes the canal of the infraorbital nerve, sometimes there is a direct fit of the nerve and blood vessels to the mucous membrane lining the upper wall of the maxillary sinus. This should be taken into account when scraping the mucous membrane during surgery. The posterior superior (medial) sections of the sinus directly border on the group of posterior cells of the ethmoid labyrinth and the sphenoid sinus, and therefore the surgical approach to them is also convenient through the maxillary sinus. The presence of a venous plexus associated with the orbit by the cavernous sinus of the dura mater can contribute to the transition of the process to these areas and the development of formidable complications, such as thrombosis of the cavernous (cavernous) sinus, orbital phlegmon.

Back wall sinuses thick, corresponds to the tubercle of the upper jaw (tuber maxillae) and with its posterior surface faces the pterygopalatine fossa, where the maxillary nerve, pterygopalatine node, maxillary artery, pterygopalatine venous plexus are located.

bottom wall, or the bottom of the sinus, is the alveolar process of the upper jaw. The bottom of the maxillary sinus, with its average size, lies approximately at the level of the bottom of the nasal cavity, but is often located below the latter. With an increase in the volume of the maxillary sinus and a lowering of its bottom towards the alveolar process, protrusion of the roots of the teeth into the sinus is often observed, which is determined radiologically or during surgery on the maxillary sinus. This anatomical feature increases the possibility of developing odontogenic sinusitis (Fig. 2.12). Sometimes on the walls

Rice. 2.12. Anatomical relationship between the maxillary sinus and the roots of the teeth

the maxillary sinus has bony scallops and lintels that divide the sinus into bays and very rarely into separate cavities. Both sinuses often have a different size.

Sinuses of the ethmoid bone (sinus ethmoidalis)- consist of separate communicating cells, separated by thin bone plates. The number, volume and location of the lattice cells are subject to significant variations, but on average there are 8-10 of them on each side. The ethmoid labyrinth is a single ethmoid bone that borders the frontal (top), sphenoid (behind) and maxillary (lateral) sinuses. The cells of the lattice labyrinth laterally border on the paper plate of the orbit. A common variant of the location of the lattice cells is their spread into the orbit in the anterior or posterior sections. In this case, they border on the anterior cranial fossa, while the cribriform plate (lamina cribrosa) lies below the vault of the cells of the lattice labyrinth. Therefore, when opening them, one must strictly adhere to the lateral direction so as not to penetrate into the cranial cavity through lattice plate (lam. cribrosa). The medial wall of the ethmoid labyrinth is simultaneously the lateral wall of the nasal cavity above the inferior turbinate.

Depending on the location, the anterior, middle and posterior cells of the ethmoid labyrinth are distinguished, with the anterior and middle cells opening into the middle nasal passage, and the posterior ones opening into the upper one. The optic nerve runs close to the ethmoid sinuses.

Anatomical and topographic features of the ethmoid labyrinth can contribute to the transition of pathological processes to the orbit, the cranial cavity, to the optic nerve.

Frontal sinuses (sinus frontalis)- paired, located in the scales of the frontal bone. Their configuration and sizes are variable, on average the volume of each is 4.7 cm 3, its triangular shape can be noted on the sagittal section of the skull. The sinus has 4 walls. The lower (orbital) for the most part is the upper wall of the orbit and, for a short distance, borders on the cells of the ethmoidal labyrinth and the nasal cavity. The anterior (front) wall is the thickest (up to 5-8 mm). The posterior (brain) wall borders on the anterior cranial fossa, it is thin, but very strong, consists of a compact bone. The medial wall (septum of the frontal sinuses) in the lower part is usually located along the midline, and upward it may deviate to the sides. The anterior and posterior walls converge at an acute angle in the upper section. On the lower wall of the sinus, anterior to the septum, there is an opening of the canal of the frontal sinus, through which the sinus communicates with the nasal cavity. The channel may be about 10-15 mm long and 1-4 mm wide. It ends in the anterior semilunar fissure in the middle nasal passage. Sometimes the sinuses spread laterally, may have bays and partitions, be large (more than 10 cm 3), in some cases they are absent, which is important to keep in mind in clinical diagnosis.

Sphenoid sinuses (sinus sphenoidalis)- paired, located in the body of the sphenoid bone. The size of the sinuses is very variable (3-4 cm 3). Each sinus has 4 walls. The intersinus septum delimits the sinuses into two separate cavities, each of which has its own excretory opening leading to a common nasal passage (sphenoethmoid pocket). This arrangement of the anastomosis of the sinus contributes to the outflow of discharge from it into the nasopharynx. The lower wall of the sinus is partly the vault of the nasopharynx, and partly the roof of the nasal cavity. This wall usually consists of spongy tissue and is of considerable thickness. The upper wall is represented by the lower

the surface of the Turkish saddle, the pituitary gland and part of the frontal lobe of the brain with olfactory convolutions are adjacent to this wall from above. The posterior wall is the thickest and passes into the basilar part of the occipital bone. The lateral wall is most often thin (1-2 mm), it is bordered by the internal carotid artery and the cavernous sinus, the oculomotor, the first branch of the trigeminal, trochlear and abducens nerves pass here.

Blood supply. The paranasal sinuses, like the nasal cavity, are supplied with blood from the maxillary (branch of the external carotid artery) and ophthalmic (branch of the internal carotid) arteries. The maxillary artery provides nutrition mainly to the maxillary sinus. The frontal sinus is supplied with blood from the maxillary and ophthalmic arteries, the sphenoid - from the pterygo-palatine artery and from the branches of the meningeal arteries. The cells of the ethmoid labyrinth are fed from the ethmoidal and lacrimal arteries.

Venous system sinuses is characterized by the presence of a wide-loop network, especially developed in the area of ​​​​natural anastomoses. The outflow of venous blood occurs through the veins of the nasal cavity, but the branches of the sinus veins have anastomoses with the veins of the orbit and cranial cavity.

Lymph drainage from the paranasal sinuses is carried out mainly through the lymphatic system of the nasal cavity and is directed to the submandibular and deep cervical lymph nodes.

innervation paranasal sinuses is carried out by the first and second branches of the trigeminal nerve and from the pterygopalatine ganglion. From the first branch - the ophthalmic nerve - (n. ophthalmicus) the anterior and posterior ethmoid arteries originate n. ethmoidales anterior posterior, innervating the upper floors of the nasal cavity and SNP. From the second branch (n. maxillaris) branches depart n. sphenopalatinus and n. infraorbitalis, innervating the middle and lower floors of the nasal cavity and SNP.

2.2. CLINICAL PHYSIOLOGY OF THE NOSE AND PARANASAL SINS

The nose performs the following physiological functions: respiratory, olfactory, protective and resonator(verbal).

respiratory function. This function is the main function of the nose. Normally, all inhaled and exhaled air passes through the nose. During inhalation due to negative

pressure in the chest cavity, air rushes into both halves of the nose. The main air flow is directed from below upwards in an arcuate manner along the common nasal passage along the middle nasal concha, turns backwards and downwards, goes towards the choanae. When inhaling, part of the air comes out of the paranasal sinuses, which contributes to the warming and humidification of the inhaled air, as well as its partial diffusion into the olfactory region. When exhaling, the bulk air is coming at the level of the inferior nasal concha, part of the air enters the paranasal sinuses. The arcuate path, complex relief and narrowness of the intranasal passages create significant resistance to the passage of an air stream, which is of physiological importance - the pressure of an air stream on the nasal mucosa is involved in the excitation of the respiratory reflex. If breathing is done through the mouth, the inhalation becomes less deep, which reduces the amount of oxygen entering the body. At the same time, the negative pressure from the chest also decreases, which, in turn, leads to a decrease in the respiratory excursion of the lungs and subsequent hypoxia of the body, and this causes the development of a number of pathological processes in the nervous, vascular, hematopoietic and other systems, especially in children. .

protective function. During passage through the nose, the inhaled air cleans, warms and moisturizes.

Warming air is carried out due to the irritating effect of cold air, which causes reflex expansion and filling of the cavernous vascular spaces with blood. The volume of the shells increases significantly, and the width of the nasal passages narrows accordingly. Under these conditions, the air in the nasal cavity passes in a thinner jet, comes into contact with a larger surface of the mucous membrane, which is why the warming is more intense. The warming effect is more pronounced the lower the outside temperature.

Moisturizing air in the nasal cavity occurs due to the secret secreted reflexively by the mucous glands, goblet cells, lymph and lacrimal fluid. In an adult, about 300 ml of water is released in the form of steam from the nasal cavities during the day, but this volume depends on the humidity and temperature of the outside air, the condition of the nose, and other factors.

cleansing air in the nose is provided by several mechanisms. Large dust particles are mechanically retained in pre-

door and nose with thick hair. Finer dust that has passed through the first filter, along with microbes, is deposited on the mucous membrane, covered with mucous secretion. The mucus contains lysozyme, lactoferrin, and immunoglobulins that have a bactericidal effect. The narrowness and curvature of the nasal passages contribute to the deposition of dust. About 40-60% of dust particles and microbes of the inhaled air are retained in the nasal mucus and are neutralized by the mucus itself or are removed along with it. The self-cleaning mechanism of the airways, called mucociliary transport (mucociliary clearance), carried out by ciliated epithelium. The surface of the ciliated cells is covered with numerous cilia that make oscillatory movements. Each ciliated cell has on its surface 50-200 cilia 5-8 µm long and 0.15-0.3 µm in diameter. Each cilium has its own motor unit - the axoneme. The frequency of the beating of the cilia is 6-8 strokes per second. The motor activity of the cilia of the ciliated epithelium ensures the movement of the nasal secretion and particles of dust and microorganisms that have settled on it towards the nasopharynx. Foreign particles, bacteria, chemicals that enter the nasal cavity with the flow of inhaled air stick to the mucus, are broken down by enzymes and are swallowed. Only in the most anterior sections of the nasal cavity, at the anterior ends of the inferior turbinates, the mucus current is directed towards the entrance to the nose. The total time of passage of mucus from the anterior parts of the nasal cavity to the nasopharynx is 10-20 minutes. The movement of cilia is influenced by various factors - inflammatory, temperature, exposure to various chemicals, changes in pH, contact between opposite surfaces of the ciliated epithelium, etc.

When treating diseases of the nose, it must be taken into account that any infusion of vasoconstrictor or other drops into the nose for a long time (more than 2 weeks), along with a therapeutic effect, has a negative effect on the function of the ciliated epithelium.

Defense mechanisms also include the sneeze reflex and mucus secretion. Foreign bodies, dust particles entering the nasal cavity cause a sneeze reflex: air suddenly with a certain

forcefully ejected from the nose, thereby removing irritating substances.

Olfactory function. The olfactory analyzer refers to the organs of the chemical sense, the adequate irritant of which is the molecules of odorous substances (odorivectors). Odorous substances reach the olfactory region along with air when inhaled through the nose. Olfactory region (regio olfactorius) starts from the olfactory fissure (rima olfactorius), which is located between the lower edge of the middle turbinate and the nasal septum, goes up to the roof of the nasal cavity, has a width of 3-4 mm. For the perception of smell, it is necessary that air diffuses into the olfactory region. This is achieved by short forced breaths through the nose, while a large number of vortexes are formed directed to the olfactory zone (a person takes such a breath when he sniffs).

There are various theories of smell.

Chemical theory (Zwaardemaker). Molecules of odorous substances (odorivectors) are adsorbed by the liquid covering the hairs of the olfactory cells, and, coming into contact with the cilia of these cells, dissolve in the lipoid substance. The resulting excitation propagates along the chain of neurons to the cortical nucleus of the olfactory analyzer.

Physical theory (Geiniks). Different groups of olfactory cells are excited in response to a certain frequency of vibrations characteristic of a certain odor vector.

Physico-chemical theory (Muller). According to this theory, the excitation of the olfactory organ occurs due to the electrochemical energy of odorous substances.

In the animal world, there are anosmatics (dolphins), microsmatics (humans) and macrosmatics (rodents, ungulates, etc.). The sense of smell in animals is much more developed than in humans. So, for example, in a dog it is 10,000 times stronger, which is due to the close connection of vital functions with the sense of smell.

Smell impairment may be primary, when it is associated with damage to receptor cells, pathways or central parts of the olfactory analyzer, and secondary- in violation of the flow of air to the olfactory region.

The sense of smell is sharply reduced (hyposmia) and sometimes disappears (anosmia) when inflammatory processes, polypous changes in the mucous membrane, atrophic processes in the nasal cavity.

In addition, a perverted sense of smell - cocosmia - is rare. The paranasal sinuses play mainly resonator and protective functions.

resonator function nose and paranasal sinuses lies in the fact that, being air cavities, along with the pharynx, larynx and oral cavity, they participate in the formation of an individual timbre and other characteristics of the voice. Small cavities (ethmoid cells, sphenoid sinuses) resonate higher sounds, while large cavities (maxillary and frontal sinuses) resonate lower tones. Since the size of the sinus cavity in a normal adult does not change, the timbre of the voice remains constant for life. Small changes in the timbre of the voice occur during inflammation of the sinuses due to thickening of the mucous membrane. The position of the soft palate to a certain extent regulates the resonance, blocking off the nasopharynx, and hence the nasal cavity, from the middle part of the pharynx and larynx, where the sound comes from. Paralysis or absence of the soft palate is accompanied by an open nasal (rhinolalia aperta), obturation of the nasopharynx, choanae, nasal cavities are accompanied by a closed nasal (rhinolalia clausa).

The nose (nasus) consists of the external nose and nasal cavity.

The external nose (nasus externus) is represented by an osteochondral skeleton in the form of a pyramid (Fig. 1.1), covered with skin. It distinguishes the tip, root (bridge), back, slopes and wings.

Rice. 1.1. External nose.

: 1 - nasal bone; 2 - frontal process of the upper jaw; 3 - triangular lateral cartilage; 4 - large cartilages of the wings of the nose; 5 - cartilage of the nasal septum, b - side view: 6 - sesamoid cartilage.

The bone part of the skeleton consists of paired flat nasal bones and frontal processes of the upper jaw. These bones, together with the anterior nasal spine, form the pear-shaped opening of the facial skeleton. The cartilaginous part of the skeleton consists of paired triangular and pterygoid, as well as additional cartilages; the wings of the nose in their lower posterior part are devoid of a cartilaginous base.

The skin in the lower third of the nose has many sebaceous glands. Bending over the edge of the entrance to the nose (nostrils), it lines the walls of the vestibule of the nose (vestibulum nasi) for 4-5 mm.

Here on the skin there is a large amount of hair, which causes the possibility of boils and sycosis.

In the area of ​​\u200b\u200bthe wings of the nose, under the skin, there are muscles that expand and narrow the entrance to the nose.

The external nose, like all soft tissues of the face, is characterized by an abundant blood supply: branches from the maxillary and ophthalmic arteries that anastomose with each other, from the system of the external and internal carotid arteries, respectively, go to it. The veins of the external nose drain blood through the anterior facial vein into the internal jugular vein and in large quantities through the veins of the nasal cavity, then through the ophthalmic veins into the venous plexus of the pterygopalatine fossa (plexus pterygoideus) and into the cavernous sinus (sinus cavernosus), middle cerebral (v. meningea media) and then into the internal jugular (v.jugularis interna) veins.

L and m f o from the outflow from the external nose is carried out mainly in the submandibular lymph nodes. The muscles of the external nose and nervate with the branches of the facial nerve (n.facialis), the skin - the first (ophthalmic nerve - n.ophtalmicus) and the second (maxillary nerve - n.maxillaris) branches of the trigeminal nerve, supraorbital (n.supraorbitalis) and infraorbital (n.infraorbitalis) nerves.

The plastic skin-cartilaginous structure of the anterior part of the external nose allows, within certain limits, to shift it to the sides without subsequent permanent deformation. However, a strong mechanical impact on the bony part of the nose is often accompanied by fractures of the nasal bones, often with displacement of fragments, and with a more severe injury, a fracture of the frontal processes of the upper jaw.

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The external nose can be compared to a trihedral pyramid, the base of which is turned backwards. The upper, narrow part of the external nose, bordering the frontal region, is called the root of the nose (radix nasi), down from which is the back of the nose (dorsum nasi), passing into the top of the nose (arex nasi). The lateral surfaces of the external nose form the wings of the nose (alaris). This division of the external nose is caused by the need to localize certain pathological manifestations in these areas.

The lower free edge of the wings of the nose, together with the movable part of the nasal septum, forms a cutout of the nostrils located in a horizontal plane.

The skeleton of the external nose is represented by two very thin nasal bones (right and left) that are connected to each other along the midline and form the back of the external nose in its upper section. The upper jagged edges of the nasal bones are connected to the nasal part of the frontal bone. Laterally, the nasal bones are connected to the frontal processes of the upper jaws and together with them form the slopes of the nose. The cartilaginous part of the external nose consists of paired lateral (triangular), as well as large and small alar cartilages.

1 - nasal bones; 2 - frontal process of the upper jaw; 3 - lateral cartilage of the nose; 4 - a large cartilage of the wing of the nose; 5 - small cartilage of the wing of the nose.

The skin of the root, back and side slopes of the nose is thin, well displaced and therefore can be widely used in various plastic surgeries. The skin covering the wings of the nose and its apex, on the contrary, is very firmly fused with the underlying tissues, and it is not possible to collect it into a fold. In the skin of the wings of the apex of the nose there are a lot of sebaceous glands, with chronic inflammation, as well as blockage of the excretory ducts of which acne can develop. This area of ​​the external nose also contains many sweat glands.

blood supply

The blood supply to the external nose is characteristics, mainly due to the outflow of venous blood. The skin of the external nose receives blood from the anterior facial artery (a. facialis ant.), its terminal branch - the angular artery (a. angularis) in the corner of the eye connects to the branch of the superior ophthalmic artery (a. ophtalmica sup.) and the artery of the back of the nose ( a. dorsum nasi), which is one of the branches of the external maxillary artery (a. maxillaris ext.). At the apex of the nose, the arteries form a very wide vascular network that provides a good arterial supply to this area, which explains the rapid healing of wounds, as well as significant tissue bleeding when this area is damaged.

1 - pharyngeal; 2 - cervical; 3 - submandibular; 4 - chin nodes.

Venous outflow from the region of the external nose (apex, wings), as well as the upper lip, is carried out due to the anterior facial vein (v. facialis ant.), Which passes into the superior ophthalmic vein (v. ophtalmica sup.), Which flows into the cavernous sinus (sinus cavernosus), located in the middle cranial fossa. This circumstance makes the development of a furuncle in the region of the external nose and upper lip extremely dangerous due to the possibility of the spread of purulent emboli along the venous tract into the cranial cavity, which can lead to the development of sepsis.

Lymph outflow from the external nose is carried out through the lymphatic vessels accompanying the arteries and veins of this area; at the level of the oral fissure, they deepen into the subcutaneous tissue and flow into the submandibular lymph nodes.

A number of lymphatic vessels flow into the deep and superficial cervical lymph nodes, which should be taken into account when lymphadenitis occurs in these areas.

The skin of the external nose is innervated by the orbital and maxillary branches of the trigeminal nerve.

Yu.M. Ovchinnikov, V.P. Gamow