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SECTION I — Diseases of Ear
hearing aid, in persons with hearing loss, not only improves hearing but also provides a masking effect.
Tinnitus maskers can be used in patients who have
no hearing loss. They are worn like a hearing aid. Use of
tinnitus masker for a short time may provide, in some
individuals, a symptom-free period for several hours due
to the phenomenon of residual inhibition.
TINNITUS INSTRUMENT
It is a combination of a hearing aid and a masker in one
device. Looks like a hearing aid. Both hearing aid and
masking device have independent volume controls.
TINNITUS RETRAINING THERAPY (TRT)
Jastreboff from University of Maryland described a neurophysiologic model for generation of tinnitus and the
basis for habituation therapy. It presumes that tinnitus
does not cause as much annoyance as the emotional reactions generated from the limbic and autonomic systems.
His therapeutic model aims to attenuate connections between auditory, limbic and autonomic nervous systems
and thus create tinnitus habituation. It occurs at two levels.
1. Habituation of reaction. It is uncoupling of brain and
body from negative reactions to tinnitus.
2. Habituation of tinnitus. It is blocking the tinnitus-
related neuronal activity to reach level of consciousness. With this therapy patients suffering from
tinnitus lose awareness of tinnitus and also do not get
annoyed even when they do have tinnitus.
Therapy consists of two major components: (i) coun-
selling and (ii) sound therapy.
Counselling. It is important to educate the patient
about tinnitus, its mechanism of generations, perception
of tinnitus at subcortical and cortical levels and the plasticity of brain which can habituate any sensory stimuli.
Limbic system (emotions) and autonomic system (body
reactions) are the primary sources of negative reactions to
tinnitus, i.e. sleep disturbance, inability to concentrate,
annoyance, anxiety and depression and not the tinnitus
per se.
Sound therapy. Patient is exposed to environmental
sounds, music radio, television, or use of hearing aids (in
case he suffers from hearing loss). In general, he should
avoid silent environment. To produce external sound for
habituation, sound generators are used which produce
continuous low-level, broad-band noise for at least 8 h
a day. Sound, here is used not for masking the tinnitus
but is adjusted to remain at a low level, for habituation.
TRT needs a long period of 18–24 months but gives a
significant improvement in more than 80% of patients.
SECTION II
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Diseases of Nose and
Paranasal Sinuses
S e c t i o n o u t l i n e
23 Anatomy of Nose, 149
24 Physiology of Nose, 157
25 Diseases of External Nose and Nasal Vestibule, 161
26 Nasal Septum and Its Diseases, 165
27 Acute and Chronic Rhinitis, 171
28 Granulomatous Diseases of Nose, 175
29 Miscellaneous Disorders of Nasal Cavity, 181
30 Allergic Rhinitis, 187
31 Vasomotor and Other Forms of Nonallergic Rhinitis, 191
32 Nasal Polypi, 193
33 Epistaxis, 197
34 Trauma to the Face, 203
35 Anatomy and Physiology of Paranasal Sinuses, 209
36 Acute Rhinosinusitis, 213
37 Chronic Rhinosinusitis, 217
38 Complications of Sinusitis, 223
39 Benign and Malignant Neoplasms of Nasal Cavity, 227
40 Neoplasms of Paranasal Sinuses, 231
41 Proptosis, 237
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Chapter 23
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Anatomy of Nose
EXTERNAL NOSE
It is pyramidal in shape with its root up and the base
directed downwards. Various terms used in its description are shown in Figure 23.1. Nasal pyramid consists of
osteocartilaginous framework covered by muscles and
skin.
OSTEOCARTILAGINOUS FRAMEWORK
Bony Part
Upper one-third of the external nose is bony while lower
two-thirds are cartilaginous. The bony part consists of
two nasal bones which meet in the midline and rest on
the upper part of the nasal process of the frontal bones
and are themselves held between the frontal processes of
the maxillae (Figure 23.2).
Cartilaginous Part
It consists of:
1. Upper lateral cartilages. They extend from the undersurface of the nasal bones above, to the alar cartilages
below. They fuse with each other and with the upper
border of the septal cartilage in the midline anteriorly.
The lower free edge of upper lateral cartilage is seen
intranasally as limen vestibule, nasal valve or limen nasi
on each side.
2. Lower lateral cartilages (alar cartilages). Each alar
cartilage is U-shaped. It has a lateral crus which forms
the ala and a medial crus which runs in the columella.
Lateral crus overlaps lower edge of upper lateral cartilage on each side.
3. Lesser alar (or sesamoid) cartilages. Two or more in
number. They lie above and lateral to alar cartilages.
The various cartilages are connected with one another and with the adjoining bones by perichondrium
and periosteum. Most of the free margin of nostril is
formed of fibrofatty tissue and not the alar cartilage.
4. Septal cartilage. Its anterosuperior border runs from
under the nasal bones to the nasal tip. It supports the
dorsum of the cartilaginous part of the nose. In septal
abscess or after excessive removal of septal cartilage as
in submucosal resection (SMR) operation, support of
nasal dorsum is lost and a supratip depression results.
NASAL MUSCULATURE
Osteocartilaginous framework of nose is covered by muscles which bring about movements of the nasal tip, ala
and the overlying skin. They are the procerus, nasalis
(transverse and alar parts), levator labii superioris alaeque
nasi, anterior and posterior dilator nares and depressor
septi.
NASAL SKIN
The skin over the nasal bones and upper lateral cartilages
is thin and freely mobile while that covering the alar cartilages is thick and adherent, and contains many sebaceous
glands. It is the hypertrophy of these sebaceous glands
which gives rise to a lobulated tumour called rhinophyma
(see p. 162).
INTERNAL NOSE
It is divided into right and left nasal cavities by nasal
septum. Each nasal cavity communicates with the exterior through naris or nostril and with the nasopharynx
through posterior nasal aperture or the choana. Each nasal
cavity consists of a skin-lined portion—the vestibule and
a mucosa-lined portion, the nasal cavity proper.
VESTIBULE OF NOSE
Anterior and inferior part of nasal cavity is called vestibule. It is lined by skin and contains sebaceous glands,
hair follicles and the hair called vibrissae. Its upper limit
on the lateral wall is marked by limen nasi (also called
nasal valve).
1. Nasal valve. It is bounded laterally by the lower border of upper lateral cartilage and fibrofatty tissue and
anterior end of inferior turbinate, medially by the
cartilaginous nasal septum, and caudally by the floor
of pyriform aperture. The angle between the nasal
septum and lower border of upper lateral cartilage is
nearly 30°.
2. Nasal valve area. It is the cross-sectional area bounded
by the structures forming the valve. It is the least crosssectional area of nose and regulates airflow and resistance on inspiration.
NASAL CAVITY PROPER
Each nasal cavity has a lateral wall, a medial wall, a roof
and a floor.
Lateral Nasal Wall
Three and occasionally four turbinates or conchae
mark the lateral wall of nose. Conchae or turbinates are
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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 23.1. Various parts of nose and related facial structures.
scroll-like bony projections covered by mucous membrane. The spaces below the turbinates are called meatuses (Figures 23.3 and 23.4).
inFerior Turbinate. It is a separate bone and below
it, into the inferior meatus, opens the nasolacrimal duct
guarded at its terminal end by a mucosal valve called
Hasner’s valve.
middle Turbinate. It is an ethmoturbinal—a part of
ethmoid bone. It is attached to the lateral wall by a bony
lamella called ground or basal lamella. Its attachment is
not straight but in an S-shaped manner. In the anterior
third, it lies in sagittal plane and is attached to lateral
edge of cribriform plate. In the middle third, it lies in
frontal plane and is attached to lamina papyracea while
in its posterior third, it runs horizontally and forms roof
of the middle meatus and is attached to lamina papyracea
and medial wall of maxillary sinus.
The ostia of various sinuses draining anterior to basal
lamella form anterior group of paranasal sinuses while those
Figure 23.2. Osteocartilaginous framework of nose. (A) Lateral view. (B) Basal view.
which open posterior and superior to it form the posterior
group.
middle Meatus. It shows several important structures
which are important in endoscopic surgery of the sinuses
(Figure 23.5).
Uncinate process is a hook-like structure running in
from anterosuperior to posteroinferior direction. Its posterosuperior border is sharp and runs parallel to anterior
border of bulla ethmoidalis; the gap between the two is
called hiatus semilunaris (inferior). It is a two-dimensional
space of 1–2 mm width.
The anteroinferior border of uncinate process is attached to the lateral wall. Posteroinferior end of uncinate process is attached to inferior turbinate dividing the
membranous part of lower middle meatus into anterior
and posterior fontanelle. The fontanel area is devoid of
bone and consists of membrane only and leads into maxillary sinus when perforated. Upper attachment of uncinate process shows great variation and may be inserted
into the lateral nasal wall, upwards into the base of skull
Figure 23.3. Structures on lateral wall of nose.
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Chapter 23 — Anatomy of Nose
151
or medially into the middle turbinate (Figure 23.6). This
also accounts for variations in drainage of frontal sinus.
The space limited medially by the uncinate process
and frontal process of maxilla and sometimes lacrimal
bone, and laterally by the lamina papyracea is called in-
fundibulum.
Natural ostium of the maxillary sinus is situated in the
lower part of infundibulum. Accessory ostium or ostia of
maxillary sinus are sometimes seen in the anterior or posterior fontanel (Figure 23.7).
bulla Ethmoidalis. It is an ethmoidal cell situated behind the uncinate process. Anterior surface of the bulla
forms the posterior boundary of hiatus semilunaris. Depending on pneumatization, bulla may be a pneumatized
cell or a solid bony prominence. It may extend superiorly
to the skull base and posteriorly to fuse with ground lamella. When there is a space above or behind the bulla,
Figure 23.4. Lateral wall of nose with turbinates removed showing openings of various sinuses.
it is called suprabullar or retrobullar recesses, respectively
(Figure 23.8). The suprabullar and retrobullar recesses together form the lateral sinus (sinus lateralis of Grunwald).
The lateral sinus is thus bounded superiorly by the skull
base, laterally by lamina papyracea, medially by middle
turbinate and inferiorly by the bulla ethmoidalis. Posteriorly the sinus lateralis may extend up to basal lamella of
middle turbinate. The cleft-like communication between
the bulla and skull base and opening into middle meatus
is also called hiatus semilunaris superior in contrast to hiatus semilunaris inferior referred to before.
atrium oF the Middle Meatus. It is a shallow depression lying in front of middle turbinate and above the nasal vestibule.
agger Nasi. It is an elevation just anterior to the attachment of middle turbinate. When pneumatized it contains
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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 23.5. Lateral wall of nose. Middle turbinate is reflected upwards to show structures of the middle meatus.
Figure 23.6. Upper attachment of uncinate process: (A) into lamina papyracea, (B) into skull base and (C) into middle turbinate thus affecting
drainage of frontal sinus.
Figure 23.7. (A) Coronal section through middle meatus. Uncinate process forms the medial wall and floor of the infundibulum. (B) Coronal
section showing relationships of uncinate process, bulla ethmoidalis, middle turbinate, maxillary sinus, orbit and cribriform plate.
Figure 23.8. Axial view showing middle meatus and its structure.
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Note also the retrobullar recess.
air cells, the agger nasi cells, which communicate with
the frontal recess. An enlarged agger nasi cell may encroach on frontal recess area, constricting it and causing
mechanical obstruction to frontal sinus drainage.
Pneumatization of middle turbinate leads to an enlarged ballooned out middle turbinate called concha bul-
losa. It drains into frontal recess directly or through agger
nasi cells. Haller cells are air cells situated in the roof of
maxillary sinus. They are pneumatized from anterior or
posterior ethmoid cells. Enlargement of Haller cells encroaches on ethmoid infundibulum, impeding draining
of maxillary sinus.
superior turbinate. It is also an ethmoturbinal and
is situated posterior and superior to middle turbinate. It
may also get pneumatized by one or more cells. It forms
an important landmark to identify ostium of sphenoid
sinus which lies medial to it.
superior meatus. It is a space below the superior turbinate. Posterior ethmoid cells open into it. Number of
posterior ethmoid cells varies from 1 to 5. Onodi cell is a
posterior ethmoidal cell which may grow posteriorly by
the side of sphenoid sinus or superior to it for as much
distance as 1.5 cm from the anterior surface of sphenoid.
Onodi cell is surgically important as the optic nerve may
be related to its lateral wall.
sphenoethmoidal recess. It is situated above the superior turbinate. Sphenoid sinus opens into it.
supreme turbinate. It is sometimes present above the
superior turbinate and has a narrow meatus beneath it.
The ostium of sphenoid sinus is situated in the sphenoethmoidal recess medial to the superior or supreme
turbinate. It can be located endoscopically about 1 cm
above the upper margin of posterior choana close to the
posterior border of the septum.
Chapter 23 — Anatomy of Nose
153
Medial Wall
Nasal septum forms the medial wall and is described on
p. 165.
Roof
Anterior sloping part of the roof is formed by nasal bones,
posterior sloping part is formed by the body of sphenoid
bone and the middle horizontal part is formed by the
cribriform plate of ethmoid through which the olfactory
nerves enter the nasal cavity.
Floor
It is formed by palatine process of the maxilla in its anterior three-fourths and horizontal part of the palatine
bone in its posterior one-fourth.
LINING MEMBRANE OF INTERNAL NOSE
1. Vestibule. It is lined by skin containing hair, hair follicles and sebaceous glands.
2. olFactory Region. Upper one-third of lateral wall
(up to superior concha), corresponding part of the nasal
septum and the roof of nasal cavity form the olfactory
region. Here, mucous membrane is paler in colour.
3. respiratory Region. Lower two-thirds of the nasal
cavity form the respiratory region. Here mucous membrane shows variable thickness being thickest over nasal
conchae especially at their ends, quite thick over the nasal septum but very thin in the meatuses and floor of the
nose. It is highly vascular and also contains erectile tissue.
Its surface is lined by pseudostratified ciliated columnar
epithelium which contains plenty of goblet cells. In the
submucous layer of mucous membrane are situated serous, mucous, both serous and mucous secreting glands,
the ducts of which open on the surface of mucosa.
NERVE SUPPLY
1. olFactory NerVes. They carry sense of smell and
supply olfactory region of nose. They are the central filaments of the olfactory cells and are arranged into 12–20
nerves which pass through the cribriform plate and end
in the olfactory bulb. These nerves can carry sheaths of
dura, arachnoid and pia with them into the nose. Injury
to these nerves can open CSF space leading to CSF rhinorrhoea or meningitis (Figure 23.9).
2. nerVes oF Common Sensation. They are:
1. Anterior ethmoidal nerve.
2. Branches of sphenopalatine ganglion.
3. Branches of infraorbital nerve. They supply vestibule
of nose both on its medial and lateral side.
Most of the posterior two-thirds of nasal cavity (both
septum and lateral wall) are supplied by branches of sphenopalatine ganglion which can be blocked by placing a
pledget of cotton soaked in anaesthetic solution near
the sphenopalatine foramen situated at the posterior
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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 23.9. Nerve supply of nose. (A) Lateral wall. Sphenopalatine ganglion situated at the posterior end of middle turbinate supplies most of
posterior two-thirds of nose. (B) Nerves on the medial wall.
extremity of middle turbinate. Anterior ethmoidal nerve
which supplies anterior and superior part of the nasal
cavity (lateral wall and septum) can be blocked by placing
the pledget high up on the inside of nasal bones where
the nerve enters.
3. autonomic NerVes. Parasympathetic nerve fibres
supply the nasal glands and control nasal secretion. They
come from greater superficial petrosal nerve, travel in the
nerve of pterygoid canal (vidian nerve) and reach the sphenopalatine ganglion where they relay before reaching the
nasal cavity. They also supply the blood vessels of nose
and cause vasodilation.
Sympathetic nerve fibres come from upper two thoracic
segments of spinal cord, pass through superior cervical
ganglion, travel in deep petrosal nerve and join the
parasympathetic fibres of greater petrosal nerve to form
the nerve of pterygoid canal (vidian nerve). They reach the
Chapter 23 — Anatomy of Nose
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155
nasal cavity without relay in the sphenopalatine ganglion.
Their stimulation causes vasoconstriction. Excessive rhinorrhoea in cases of vasomotor and allergic rhinitis can be
controlled by section of the vidian nerve.
BLOOD SUPPLY
Both the internal and external carotid systems supply the
nose. Details of blood supply are given on p. 197.
LYMPHATIC DRAINAGE
Lymphatics from the external nose and anterior part
of nasal cavity drain into submandibular lymph nodes
while those from the rest of nasal cavity drain into upper
jugular nodes either directly or through the retropharyngeal nodes. Lymphatics of the upper part of nasal cavity
communicate with subarachnoid space along the olfactory nerves.
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