Oto-rhino-laryngologyRhinology

Department of Otolaryngology, 1st Affiliated Hospital

Sun-Yat sen University, Guangzhou

Huabin Li, MD. PhD

Nose is the gate of airway

Nose consists of three parts:

External nose

Nasal cavity

Nasal sinus

External nose: Skin; Soft tissue; Bone

nasal rootnasal bridge

nasal apex

anterior nares

nasal columun

alaer nasi

nasaolabial fold

nasal dorsum

Bony skeloton of external nose:

The upper part of the maxilla borders the nasal bone , and its

frontal process projects upward to the frontal bone.

frontal bone

frontal process of maxilla

nasal bone

The shape of the external nose is defined by the nasal bones, a pair

of rectangular bones in the upper nasal dorsum, and by the paired

lateral cartilages (upper nasal cartilages) and alar cartilages

(major alar cartilages) in the central and lower portions of the

nose. The lateral portions of the nasal alae also contain several

small accessory cartilages, called the minor alar cartilages.

Nasal cavity: Nasal vestibule; Nasal fossa proper

Anterior nares;

Posterior

nares(choanae);

Inner wall: nasal septum

Lateral wall: turbinates

Roof: cribriform plate

Bottom:palate

Nasal cavity: Nasal vestibule; Nasal fossa proper

The nasal cavities begin anteriorly at the nasal vestibule, which is

bordered posteriorly by the internal nasal valve (limen nasi)

located between the posterior border of the alar cartilage and the

anterior border of the lateral cartilage. This valve area is the

narrowest portion of the upper respiratory tract and, as such,

has a major bearing on the aerodynamics of nasal airflow.

Nasal cavity: Nasal vestibule; Nasal fossa proper

The anterior bony opening of the nasal cavity, called the

piriform aperture, is bounded laterally and inferiorly by the

maxilla and superiorly by the nasal bone.

Lateral nasal wall: Superior turbinate;Middle turbinate;Inferior turbinate

Inner nasal wall: Nasal septum

Septal cartilages

Perpendicular plate of

ethmoid bone

Vomer

Palatal process of

maxilla

Nasal sinus

Frontal sinus

Ethmoidal sinus

Sphenoidal sinus

Maxillary sinus

Nasal sinus

Nasal sinus

The maxillary sinus borders the nasal cavity laterally, and the

orbital floor separates the upper part of the sinus from the orbit.

Behind the maxillary sinus is the pterygopalatine fossa, which is

traversed by the maxillary artery along with branches of the

trigeminal nerve and autonomic nervous system. The floor of

the maxillary sinus is closely related to the roots of the second

premolar and first molar teeth. This creates a potential route for

the spread of dentogenic infections, and a tooth extraction may

create a communication between the oral cavity and maxillary

sinus (oroantral fistula).

Nasal sinus The maxillary sinus

The frontal sinus is located in the frontal bone, its floor forming

the medial portion of the orbital roof. The sinus, which is

highly variable in its extent, is bounded behind by the anterior

cranial fossa. Inflammations of the frontal sinus can give rise to

serious complications because of its close proximity to the orbit

and cranial cavity (orbital cellulitis, epidural or subdural

abscess, meningitis).

Nasal sinus The frontal sinus

The ethmoid air cells are a labyrinthine system of small,

pneumatized sinus cavities that are separated from one another by

thin bony walls and extend posteriorly between the middle

turbinate (medial border) and orbit to the sphenoid sinus. The

orbital plate of the ethmoid bone, called also the lamina

papyracea, forms the lateral bony wall that separates the ethmoid

air cells from the orbit. Paranasal sinus inflammations can spread

through this lamina to involve the orbit (orbital complications). The

posterior ethmoid cells are closely related to the optic nerve. The

ethmoid roof and cribriform plate ( 1.2) form the bony boundary

that separates the ethmoid cells from the anterior cranial fossa.

Nasal sinus The ethmoidal sinus

The sphenoid sinus is located at the approximate center of the

skull above the nasopharynx. Its posterior wall is formed by the

clivus. It relates laterally to the cavernous sinus, the internal

carotid artery, and cranial nerves II–VI, and it is very closely

related to the optic canal. The optic nerve and internal carotid

artery may run directly beneath the mucosa of the lateral wall of

the sphenoid sinus, without a bony covering. The sphenoid sinus is

bordered superiorly by the sella turcica and pituitary and by the

anterior and middle cranial fossae.

Nasal sinus The sphenoid sinus

Nasal sinus

Frontal sinus

Anterior ethmoidal sinus

Sphenoidal sinus

Maxillary sinus

Posterior ethmoidal sinus

Anterior

Posterior

DrainageMiddle meatus

Drainage

Superior meatus

Nasal sinus: drainage

Ostiomeatal complex

Nasal mucosa

Olfactory mucosa

Respiratory mucosa

The epithelium of the respiratory mucosa is composed of

ciliary cells, goblet cells, and basal cells and provides an initial,

mechanical barrier against infection. The ciliary cells dominate

the surface of the respiratory epithelium. Each ciliary cell has

approximately 150–200 cilia, which are composed of

microtubules and are interlinked by “dynein arms.”

Nasal mucosa

Each ciliary cell has approximately 150–200 cilia, which are

composed of microtubules and are interlinked by “dynein arms.”

动力蛋白臂Dynein arm

成对纤丝Peripheral doublet

纤毛杆Central singleton

中央鞘Central Sheath

轮辐radial spokes

连接桥

接键nexin link

Ciliary cell

Nasal mucosa

The ciliary action.

Ciliary cell

Nasal mucosa

Respiratory mucosa

This cytoskeleton of the ciliary cells and the activity of dynein, a

specialized protein, enable the typical, synchronous beating of

the cilia in the respiratory epithelium. This ciliary action propels

a blanket of mucous secretions (from the goblet cells) and serous

secretions (from the nasal glands) toward the nasopharynx,

mechanically cleansing the inspired air in a mechanism called

mucociliary transport .

Nasal mucosa

Olfactory mucosa

The olfactory mucosa covers the olfactory region, which

occupies the anterior superior part of the nasal septum and

adjacent areas of the lateral nasal wall. Usage subject to terms

and conditions of license. including the side of the superior

turbinate facing the septum and part of the middle turbinate.

The external nose derives most of its blood supply from the

facial artery, which arises from the external carotid artery,

and from the ophthalmic artery, which springs from the

internal carotid artery.

The internal nose receives blood from the territories of the

external and internal carotid arteries: the terminal branches

of the sphenopalatine artery, which arises from the

maxillary artery, and the anterior and posterior ethmoid

arteries, which arise from the ophthalmic artery.

Vascular supply

A detailed knowledge of the vascular supply is particularly

important in the management of intractable epistaxis

(nosebleed), which requires vascular ligation or angiographic

embolization as a last recourse.

The venous drainage of the facial region is handled by the

facial vein, retromandibular vein, and internal jugular

vein.

The regional lymphatic drainage of the face and external

nose is handled mainly by the submandibular lymph nodes,

while the nasal cavity is additionally drained by the

retropharyngeal and deep cervical lymph nodes.

Vascular supply

The facial skin receives its sensory innervation from terminal

branches of the trigeminal nerve that enter the facial region

through the supraorbital, infraorbital, and mental foramina.

Only the skin over the mandibular angle and the lower portions

of the auricle are supplied by the great auricular nerve.

Nerve supply

The facial muscles are classified as mimetic or masticatory,

each of these groups receiving different motor innervation.

While the mimetic muscles of the face develop from the

blastema of the second branchial arch (the hyoid arch) and

accordingly are supplied by the facial nerve, the masticatory

muscles trace their embryonic development to the first

branchial arch (the mandibular arch) and are therefore supplied

by mandibular nerve branches arising from the trigeminal

nerve.

Nerve supply

Ventilation:conditioning the inspired air to warm and humid

Olfaction

Defense:mechanical defenses and immune response

Speech production

Function of nose

Physical principles of nasal airflow

Function of nose

Laminar flow and turbulent flow

The “nasal cycle” is a physiologic phenomenon marked by an

alternation between luminal narrowing and widening of the

nasal cavities. This alternate congestion and decongestion of the

nasal mucosa is effected mainly through reactions of the venous

capacitance vessels of the inferior and middle turbinates, which

are regulated by the autonomic nervous system.

Nasal cycle

The mucociliary transport system consists of the cilia of the

respiratory epithelium and a mucous blanket composed of two

layers: a deeper, less viscid “sol layer” in which ciliary motion

occurs, and a superficial, more viscid “gel layer”.

Mucociliary clearance

Disturbances of mucociliary transport can have various causes,

such as increased viscosity and thickness of the periciliary sol

layer, hampering ciliary movements, or changes in the

viscoelasticity of the gel layer resulting in ineffectual mucus

transport. Finally, various pathogenic mechanisms can produce

changes in the cilia themselves, regardless of the viscosity of the

mucous blanket.

Mucociliary clearance

Allergic rhinitis

Allergic rhinitis (AR) is a common manifestation of allergic

diseases, affecting approximately 500 million people

worldwide. AR is increasing in prevalence. For example, the

prevalence of AR in Japan increased from 29.8% in 1998 to

39.4% in 2008. The prevalence of pollinosis, the typical

seasonal AR, has been increased from 19.6% in 1998 to 29.8%

in 2008.

Allergic rhinitis

AR is increasing in prevalence

Allergic rhnitis and its impact on asthma (ARIA)Global guideline for AR management

Definition

AR is defined as a symptomatic disorder of the nose induced

after allergen exposure by an IgE-mediated inflammation.

It is an inflammation of the lining of the nose and is

characterized by nasal symptoms including anterior or

posterior rhinorrhoea, sneezing, nasal blockage and/or

itching of the nose.

These symptoms occur during two or more consecutive days

for more than 1 h on most days.

Allergen

Most causal antigens for AR are inhalant allergens.

House dust mite, animal dander, pollens and fugus are the

principal allergens.

Other inhalant allergens include feather, insect and grass

pollen.

Food allergens inckude peanut, egg, milk etc.

Pathophysiology

Onset of three major AR symptoms

Sneezing (consecutive)

Sensory nerves containing substance P (SP) and calcitonin

gene-related peptide (CGRP) are distributed throughout the

epithelial and subepithelial layers of the nasal mucosa. Sensory

nerve terminals are located in the epithelial junctions and

subepithelial layers. When various chemical mediators are

applied to the nasal mucosa, histamine is the only mediator that

induces a significant sneezing reflex.

Sneezing

The sneezing reflex following allergen challenge is a respiratory

reflex induced by the interaction between histamine and the H1

receptor at the sensory nerve terminals containing SP and CGRP

and might be a sensory stimulation response amplified by

hyperreactivity in the nasal mucosa.

Onset of three major AR symptoms

Onset of three major AR symptoms

Itching nose

Also, sensory nerve terminals are located in the epithelial

junctions and subepithelial layers. When various chemical

mediators are applied to the nasal mucosa, histamine is the only

mediator that induces the sensory nerve terminals to be itching.

Onset of three major AR symptoms

Rhinorrhoea (Watery)

Synchronously with the sneezing reflex, sensory stimulation on

the nasal mucosa induces excitation reflexively in the

parasympathetic centre.After allergen challenge on the hemilateral

nasal mucosa of patients with allergic rhinitis, the weight of

rhinorrhoea induced in both sides of nasal cavities is correlated

with the number of sneezes. In addition, the weight of rhinorrhoea

in the nasal cavity with allergen challenge is correlated with that

on the opposite side. Therefore, rhinorrhoea can be regarded as

the secretion from the mucous glands by parasympathetic

stimulation.

Onset of three major AR symptoms

Rhinorrhoea

Therefore, rhinorrhoea can be regarded as the secretion from the

mucous glands by parasympathetic stimulation. Furthermore,

allergic inflammation induced by nasal allergen exposure

augments this ‘naso-nasal’ reflex. Possible mechanisms for

sensory nerve hyperresponsiveness include the increased release

of nerve growth factor during allergic inflammation. Chemical

mediators including histamine, cysLTs, and PAF induce plasma

exudation directly from the blood vessels in the nasal mucosa,

which constitutes a part of rhinorrhoea.

Other onset of AR symptoms

Nasal congestion

The underlying causes of nasal congestion in the early phase of

allergic rhinitis are the relaxation of the smooth muscle layer

of capacitance vessels in the nasal mucosa and the

interstitial oedema induced by plasma exudation.Swelling of

the nasal turbinate is induced by the parasympathetic reflex

and the axon reflex through the nerve centre and the direct

effects of the chemical mediators on the vascular system.

Nasal congestion

When sensitized subjects inhale antigens, the antigens pass

through the epithelial tight junctions in the nasal mucosa to bind

IgE on the surface of mast cells in the epithelial layer of the

nasal mucosa, inducing the release of chemical mediators

including histamine, prostaglandins and cysLTs by aggregation

of FceRI. Histamine regulates tight junctions via the coupling of

H1 receptors and increases paracellular permeability.

Other onset of AR symptoms

Nasal congestion

This increased permeability allows DC to penetrate epithelial

tight junctions easily and enhance antigen presentation to T cells.

The early-phase response, which consists of sneezing, rhinorrhoea

and nasal congestion, is caused by interactions between chemical

mediators and the sensory nerve terminals and blood vessels in

the nasal mucosa.

Other onset of AR symptoms

Nasal congestion

Dilation of the capacitance vessels and plasma exudation after

excitation of the parasympathetic centre are caused by the nitric

oxide (NO) released from parasympathetic terminals and vascular

endothelial cells. However, the participation of the nerve reflex in

nasal turbinate swelling after allergen challenge is minor

compared with the direct effects of chemical mediators, such as

histamine, cysLTs,PAF and prostaglandinD2 (PGD2) and kinin,on

the vascular system in the nasal mucosa.

Other onset of AR symptoms

Nasal congestion

Nasal congestion in the late phase is induced by the allergic

inflammation.The secondary reaction with inflammatory cells and

their mediators, especially the cysLTs produced by eosinophils,

causes oedema of the nasal mucosa. This inflammation, which

develops 6–10 h after the allergen challenge, is referred to as the

late-phase response.

Other onset of AR symptoms

Diagnosis of AR

Skin prick test (SPT)

Diagnosis of AR

Specific IgE assay

Diagnosis of AR

Intermittent allergic rhinitis (IAR):

Less than 4 days a week.

Or for less than 4 weeks.

Persistent allergic rhinitis (PAR):

More than 4 days a weeks.

And for more than 4 weeks.

New classification of AR

MildNo sleep disturbance.No impairment of daily activities 、 leisure 、 and/or sport.No impairment of school or work.No troublesome symptoms.

New classification of AR

Moderate/severe

One or more the following items are present:

Sleep disturbance.

Impairment of daily activities 、 leisure 、 and/or

sport.

Impairment of school or work.

Troublesome symptoms.

New classification of AR

1 、 Avoidance of allergen

Management

2 、 Drug treatment

Management

H1-antihistamines （ oral or topical ）Intranasal glucocorticoid

Leuketriene antagonist

Local cromones

Decongestants (oral or topical)

Anticholinergic agents

Management

Management

Management

Management

3 、 Immunotherapy

Management

3 、 Immunotherapy

Management

Management

4 、 Surgical intervention

Treating nasal septal deviationvidian neurectomy

Thank you for your attention