Surgical anatomy of the external nose. Clinical anatomy of the nasal cavity

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). The upper part of the 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 have no great practical significance. 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 of breastfeeding, since without nasal breathing the child 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 of the 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. Long-term infusion of any drugs into the nose disrupts the function of the ciliated epithelium, which must be borne in mind when treating 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 the 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 the upper edge of the canine fossa there is an 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 regions. 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 of the air goes 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) during inflammatory processes, polyposis 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).

Rice. one. The basis of the cartilaginous section of the external nose is the lateral cartilage, the upper edge of which borders on the nasal bone of the same side and partially on the frontal process of the upper jaw. The upper faces of the lateral cartilages constitute a continuation of the back of the nose, adjoining in this section to the cartilaginous part of the upper parts of the nasal septum. The lower face of the lateral cartilage borders on the large cartilage of the wing, which is also paired. The large cartilage of the wing has a medial and lateral crura. Connecting in the middle, the medial legs form the tip of the nose, and the lower sections of the lateral legs are the edge of the nasal openings (nostrils). Sesamoid cartilages of various shapes and sizes can be located between the lateral and greater cartilages of the wing of the nose in the thickness of the connective tissue.

The alar of the nose, in addition to the large cartilage, includes connective tissue formations, from which the posterior inferior parts of the nasal openings are formed. The inner sections of the nostrils are formed by the movable part of the nasal septum.

The outer nose is covered with the same skin as the face. The external nose has muscles that are designed to compress the nasal openings and pull down the wings of the nose.

The blood supply to the external nose is provided by the ophthalmic artery (a. ophtalmis), dorsal nasal (a. dorsalis nasi) and facial (a. facialis) arteries. Venous outflow is carried out through the facial, angular and partially ophthalmic veins, which in some cases contributes to the spread of infection in inflammatory diseases of the external nose to the sinuses of the dura mater. Lymphatic drainage from the external nose occurs in the submandibular and upper parotid lymph nodes. The motor innervation of the external nose is provided by the facial nerve, the sensory innervation is provided by the trigeminal (I and II branches).

The anatomy of the nasal cavity is more complex. The nasal cavity is located between the anterior cranial fossa (above), the orbits (laterally) and the oral cavity (below). From the front, the nasal cavity communicates with the external environment through the nostrils, from behind, with the help of the choanas, to the nasopharyngeal region.

There are four walls of the nasal cavity: lateral (lateral), internal (medial), upper and lower. The most complex structure is the side wall of the nose, formed by several bones and carrying the nasal conchas. Of the bone formations, it consists of the nasal bones, the upper jaw, the lacrimal bone, the ethmoid bone, the inferior nasal concha, the vertical plate of the palatine bone and the pterygoid process of the sphenoid bone. On the side wall there are three longitudinal protrusions formed by shells. The largest is the inferior turbinate, it is an independent bone, the middle and superior shells are outgrowths of the ethmoid bone.

The lower wall of the nasal cavity (the bottom of the nasal cavity) is actually a hard palate, it is formed by the palatine process of the upper jaw (in the anterior sections) and the horizontal plate of the palatine bone. At the anterior end of the bottom of the nose there is a canal that serves to pass the nasopalatine nerve (n. Nasopalatinus) from the nasal cavity into the oral cavity. The horizontal plate of the palatine bone limits the lower sections of the choanae.

The inner (medial) wall of the nasal cavity is the nasal septum (Fig. 2). In the lower and posterior sections, it is represented by bone formations (the nasal crest of the palatine process of the upper jaw, the perpendicular plate of the ethmoid bone and an independent bone - the vomer). In the anterior sections, these bone formations adjoin the quadrangular cartilage of the nasal septum (cartilage septi nasi), the upper edge of which forms the anterior section of the back of the nose. The posterior edge of the vomer limits the choanae medially. In the anteroinferior section, the cartilage of the nasal septum adjoins the medial processes of the large cartilage of the alar of the nose, which, together with the skin part of the nasal septum, constitute its mobile part.

Rice. 2. Nasal septum 1. Lamina cribrosa 2. Crista sphenoidalis 3. Apertura sinus sphenoidalis 4. Sinus sphenoidalis 5. Ala vomeris 6. Clivus 7. Pars ossea 8. Pars cartilaginea 9. Septum nasi 10. Lamina medialis processus pterygoidei 11. Processus palatineus maxillae 12. Crista nasalis 13. Canalis incisivus 14. Spina nasalis anterior 15. Cartilago alaris major 16. Cartilago vomeronasalis 17. Cartilago septi nasi 18. Cartilago nasi lateralis 19. Vomer 20. Processus posterior 21. Os nasale 22. Lamina perpendicularis ossis ethodidal moidalis 23. Crista gali 24. Sinus frontalis

Rice. 2. The upper wall of the nasal cavity (roof) in the anterior sections is formed by the nasal bones, the frontal processes of the upper jaw, and a partially perpendicular plate of the ethmoid bone. In the middle sections, the upper wall is formed by the ethmoid (perforated) plate (lamina cribrosa) of the ethmoid bone, in the posterior - by the sphenoid bone (anterior wall of the sphenoid sinus). The sphenoid bone forms the superior wall of the choana. The cribriform plate is pierced by a large number (25-30) holes through which the branches of the anterior ethmoidal nerve and the vein that accompanies the anterior ethmoid artery and connects the nasal cavity with the anterior cranial fossa pass.

The space between the nasal septum and the turbinates is called the common nasal passage. In the lateral sections of the nasal cavity, respectively, there are three nasal passages (Fig. 3). The lower nasal passage (meatus nasi inferior) is limited from above by the inferior nasal concha, from below - by the bottom of the nasal cavity. In the anterior third of the lower nasal passage, at a distance of 10 mm from the anterior end of the shell, there is an opening of the nasolacrimal canal. 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 the puncture of the maxillary sinus (correction of the nasal septum) is performed precisely in this area: 2 cm away from the anterior end of the lower shells

Rice. 3. Nasal cavity 1. Bulla ethmoidalis 2. Concha nasalis inferior 3. Concha nasalis media 4. Concha nasalis superior 5. Apertura sinus sphenoidalis 6. Sinus sphenoidalis 7. Meatus nasi inferior 8. Meatus nasi medius 9. Bursa pharyngealis 10. Meatus nasi inferior 11. Tonsilla pharyngealis 12. Torus tubarius auditivae 13. Ostium pharyngeum tubae 14. Palatum molle 15. Meatus nasopharyngeus 16. Palatum durum 17. Plica lacrimalis 18. Ductus nasolacrimalis 19. Labium superius 20. Vestibulum nasolacrimalis 21.2 Apex nasi 21.2 Apex nasi 21.2 Apex nasi 21.2 Apex nasi nasi 23. Agger nasi 24. Dorsum nasi 25. Processus uncinatus 26. Hiatus semilunaris 27. Radix nasi 28. Aperturae sinus frontalis 29. Sinus frontalis

Rice. 3. The middle nasal passage (meatus nasi medius) is located between the lower and middle nasal conchas. Its lateral wall is represented not only by bone tissue, but also by a duplication of the mucous membrane, which is called "fontanels" (fontanelles). If the middle turbinate is partially removed, then the semilunar cleft (hiatus semilunaris) will open, in the anteroinferior sections it is limited by the bone plate (uncinate process), in the posterior superior regions by the bone vesicle (bulla etmoidalis). In the anterior sections of the semilunar fissure, the mouth of the frontal sinus opens, in the middle sections - the anterior and middle cells of the ethmoid sinuses, and in the posterior sections there is a depression formed by a duplication of the mucous membrane and called a funnel (infundibulum), which ends with a hole leading to the maxillary sinus.

The superior nasal passage (meatus nasi superior) is located between the superior and middle nasal conchas. The posterior cells of the ethmoid bone open into it. The sphenoid sinus opens into the sphenoid-ethmoid recess (recessus spheno-ethmoidalis).

The nasal cavity is lined with a mucous membrane that covers all the bone sections of the walls, and therefore the contours of the bone section are preserved. The exception is the vestibule of the nasal cavity, which is covered with skin and has hairs (vibrissae). In this area, the epithelium remains stratified squamous, as in the area of ​​the external nose. The mucous membrane of the nasal cavity is covered with multi-row cylindrical ciliated epithelium.

Depending on the structural features of the nasal mucosa, the respiratory and olfactory sections are distinguished. The respiratory section occupies the area from the bottom of the nasal cavity to the middle of the middle turbinate. Above this limit, the ciliated columnar epithelium is replaced by a specific olfactory epithelium. The respiratory section of the nasal cavity is characterized by a large thickness of the mucous membrane. Its subepithelial section contains numerous alveolar-tubular glands, which, according to the nature of the secret, are divided into mucous, serous, and mixed. The respiratory part of the mucous membrane is characterized by the presence in its thickness of cavernous plexuses - varicose venous sheaths with a muscular wall, due to which they can contract in volume. Cavernous plexuses (cavernous bodies) provide regulation of the temperature of the air passing through the nasal cavity. Cavernous tissue is contained in the thickness of the mucous membrane of the inferior turbinates, located along the lower edge of the middle turbinate, in the posterior sections of the middle and superior turbinates.

In the olfactory region, in addition to the specific olfactory epithelium, there are supporting cells that are cylindrical, but lack cilia. The glands present in this section of the nasal cavity secrete a more liquid secret than the glands located in the respiratory part.

The blood supply to the nasal cavity is carried out from the system of external (a. carotis externa) and internal (a. carotis interim) carotid arteries. The main palatine artery (a. sphenopalatina) originates from the first artery; passing through the main palatine opening (foramen sphenopalatinum) into the nasal cavity, it gives off two branches - the posterior nasal lateral and septal arteries (aa. nasales posteriores laterales et septi), which provide blood supply to the posterior sections of the nasal cavity, both lateral and medial walls. The ophthalmic artery originates from the internal carotid artery, from which the branches of the anterior and posterior ethmoidal arteries (aa. ethmoidales anterior et posterior) depart. The anterior ethmoidal arteries pass into the nose through the cribriform plate, the posterior ones through the posterior ethmoidal foramen (foramen ethmoidale post.). They provide nutrition to the area of ​​the ethmoidal labyrinth and the anterior parts of the nasal cavity.

The outflow of blood is carried out through the anterior facial and ophthalmic veins. Features of the outflow of blood often cause the development of ophthalmic and intracranial rhinogenic complications. In the nasal cavity, especially pronounced venous plexuses are found in the anterior sections of the nasal septum (locus Kilsselbachii).

Lymphatic vessels form two networks - superficial and deep. The olfactory and respiratory regions, despite their relative independence, have anastomoses. Lymph outflow occurs in the same lymph nodes: from the anterior parts of the nose to the submandibular, from the posterior to the deep cervical.

Sensitive innervation of the nasal cavity is provided by the first and second branches of the trigeminal nerve. The anterior part of the nasal cavity is innervated by the first branch of the trigeminal nerve (anterior ethmoid nerve - n. ethmoidalis anterior-branch of the nasociliary nerve - n. nasociliaris). The nasociliary nerve from the nasal cavity penetrates through the nasociliary foramen (foramen nasociliaris) into the cranial cavity, and from there through the cribriform plate into the nasal cavity, where it branches in the region of the nasal septum and the anterior sections of the lateral wall of the nose. The external nasal branch (ramus nasalis ext.) between the nasal bone and the lateral cartilage extends to the back of the nose, innervating the skin of the external nose.

The posterior sections of the nasal cavity are innervated by the second branch of the trigeminal nerve, which enters the nasal cavity through the posterior ethmoid foramen and branches in the mucous membrane of the posterior cells of the ethmoid bone and the sinus of the sphenoid bone. The nodal branches and the infraorbital nerve depart from the second branch of the trigeminal nerve. The nodal branches are part of the pterygopalatine node, however, most of them pass directly into the nasal cavity and innervates the posterior superior part of the lateral wall of the nasal cavity in the region of the middle and superior turbinates, the posterior cells of the ethmoid bone and the sinus of the sphenoid bone in the form of rr. nasales.

Along the nasal septum in the direction from back to front there is a large branch - the nasopalatine nerve (n. Nasopalatinus). In the anterior parts of the nose, it penetrates through the incisive canal into the mucous membrane of the hard palate, where it anastomoses with the nasal branches of the alveolar and palatine nerves.

Secretory and vascular innervation is carried out from the superior cervical sympathetic ganglion, the postganglionic fibers of which penetrate the nasal cavity as part of the second branch of the trigeminal nerve; parasympathetic innervation is carried out through the pterygopalatine ganglion (gang. pterigopalatinum) due to the nerve of the pterygoid canal. The latter is formed by a sympathetic nerve extending from the superior cervical sympathetic ganglion and a parasympathetic nerve originating from the geniculate ganglion of the facial nerve.

Specific olfactory innervation is carried out by the olfactory nerve (n. olfactorius). Sensory bipolar cells of the olfactory nerve (I neuron) are located in the olfactory region of the nasal cavity. The olfactory filaments (filae olfactoriae) extending from these cells penetrate the cranial cavity through the cribriform plate, where, when combined, they form an olfactory bulb (bulbus olfactorius), enclosed in a vagina formed by the dura mater. The pulpy fibers of the sensory cells of the olfactory bulb form the olfactory tract (tractus olfactorius - II neuron). Further, the olfactory pathways go to the olfactory triangle and end in the cortical centers (gyrus hippocampi, gyrus dentatus, sulcus olfactorius).

The nasal cavity is supplied with blood by branches of the internal and external carotid arteries. The ophthalmic artery departs from the internal carotid artery. This artery enters the orbit and gives off the anterior and posterior ethmoid arteries. Both ethmoidal arteries leave the orbit, accompanied by the nerves of the same name, through the corresponding openings in the medial wall of the orbit. Further, the arteries pass into the anterior cranial fossa, and from there through the perforated plate into the nasal cavity. Branches of both arteries feed the posterior superior section of the lateral wall of the nasal cavity and nasal septum and also enter the ethmoid labyrinth.

The external carotid artery, through the facial artery, gives branches to the movable part of the nasal septum and to the wings of the nose. The main artery of the nasal cavity, the pterygopalatine, departs from the maxillary artery (see figure below).

3 - pterygopalatine artery; 4 - palatine artery;
5 - posterior nasal branches.

The latter passes from the pterygopalatine fossa into the nasal cavity through the opening of the same name and gives branches (posterior nasal) to the lateral wall of the nasal cavity (turbinates and corresponding passages), to all paranasal sinuses, to the nasal septum (posterior septal artery (see figure below).

1 - anterior ethmoid arteries; 2 - posterior ethmoid arteries;
3 - posterior artery of the nasal septum; 4 - vascular plexus of the nasal septum;
5 - nasopalatine artery; 6 - branch to the upper lip.

The veins of the nasal cavity follow the general plan of passage of arteries and nerves. Specific is the formation in the deep parts of the face of plexuses connecting the veins of the nasal cavity with neighboring areas (see figure below).

1 - nasolabial vein; 2 - angular vein; 3 - anterior facial vein; 4 - submandibular vein; 5 - common facial vein; 6 - superior ophthalmic vein; 7 - anastomosis between the inferior ophthalmic vein and the venous plexus of the pterygopalatine fossa; 8 - cavernous sinus; 9 - venous plexus of the pterygopalatine fossa; 10 - superficial temporal vein; 11 - posterior facial vein; 12 - internal jugular vein.

This is of great clinical importance due to the possibility of infection spreading from the veins of the nasal cavity and its paranasal sinuses to the cranial cavity, orbit, face, pharynx, and indirectly to more distant areas of the body.

"Bleeding and thrombosis in otorhinolaryngological diseases",
G.A. Feigin, B.I. Kuznik

The main arterial trunk of the pharynx is the ascending artery of the pharynx. The region of the palatine tonsils is supplied with blood from the ascending palatine artery, and the lower pharynx is supplied with blood from the superior thyroid artery. Arterial branches to the palatine tonsils come mainly from the ascending palatine and ascending pharyngeal arteries. The veins of the pharynx drain blood from the venous plexus of the pharynx, located mainly on the outer surface of the back ...

The frontal sinus receives blood from the posterior nasal artery and branches of the ophthalmic artery. The main sinus is supplied with blood by branches of the posterior nasal artery, the pterygopalatine artery, the vidian canal artery, and branches of the dura mater arteries. The ethmoid labyrinth is fed with blood from the vessels of the mucous membrane of the nasal concha, ethmoid arteries and branches of the arterial network surrounding the lacrimal sac. The veins that collect from the capillaries of the mucous membrane form ...

In the most anterior section of the floor of the nasal cavity, the septum has a nasopalatine canal. The nasopalatine artery and vein pass through it. Thus, the arteries and veins of the nasal cavity anastomose with the great palatine artery and its accompanying vein. We draw attention to this anatomical feature, since premature removal of the lower nasal septum during its submucosal resection can…

Features of blood supply and innervation of the cavity nose

The blood supply to the nasal cavity comes from a.sphenopalatina, aa. ethmoidales anterior et posterior, a. nasopalatina (branch fffi^jcx^ /i of the carotid artery). These arteries anastomose in the anterior and lower sections of the septum with a.alveolans inferior and a.palatina major.

Bleeding area of ​​the nose (locus Kisselbachii). It is located in the region of the anterior third of the nasal septum due to the presence of a dense vascular network here. This site is the source of 70% of nosebleeds. Also, bleeding can occur from the upper and lower branches of a.sphenopalatina.

The outflow of blood occurs along v.facialis and v.ophtalmica. They anastomose with the plexus pterygoideus, sinus cavernosus, which provides a connection between the nasal veins and the veins of the skull, orbit, and pharynx (this is important for the development of complications).

Lymph drainage is carried out in the submandibular and deep cervical lymph nodes. The lymphatic pathways of the olfactory region of the nose are connected with the intershell spaces of the brain.

Innervation of the nasal cavity:

Olfactory. Olfactory fibers depart from the spindle-shaped cells of the olfactory epithelium and through the lamina cribrosa penetrate into the cranial cavity to the olfactory bulb.

Sensitive. It is carried out by I (n.ophthalmicus) and II (n.maxillaris) branches of the trigeminal nerve. The anterior and posterior ethmoidal nerves (nn.ethmoidalis anterior el posterior) depart from the I branch, which innervate the lateral sections and the arch of the nasal cavity. The 11th 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 II 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, so pain from the nose and paranasal sinuses radiates to the area of ​​the teeth, eyes, forehead, and back of the head.

Secretory. The sympathetic and parasympathetic innervation of the nose and paranasal sinuses is represented by the vidian nerve, which originates from the superior cervical sympathetic ganglion and from the ganglion node of the facial nerve.

Respiratory function of the nose. The importance of nasal breathing for the body

The respiratory function of the nose is to conduct air (aerodynamics). Breathing is carried out mainly through the respiratory region. 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, air enters your sinuses. About 50% of the resistance of all airways is in the nasal cavity. Air pressure on the mucous membrane of the nasal cavity is involved in the excitation of the respiratory reflex. Air must enter the lungs at a certain speed

The importance of nasal breathing for the body

If breathing occurs through the mouth, the inhalation becomes less deep, so only 78% of the required amount of oxygen enters the body.

If nasal breathing is disturbed, the hemodynamics of the skull is disturbed, which leads (especially in children) to headaches, fatigue, and memory loss.

Persistent obstruction of nasal breathing can lead to a disorder of the nervous system and a number of diseases: bronchial asthma, in children - epileptiform seizures, bedwetting.

Prolonged violation of nasal breathing in childhood adversely affects the development of the skeleton of the chest. It leads to deformation of the facial skeleton: a high and narrow "Gothic" palate is formed, the nasal septum is bent, and improper teething occurs.

When breathing through the nose, humidification, warming, purification from dust impurities, as well as air disinfection occur.

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

posterior nasal lateral arteries (aa. nasalesposteriores late-rales);

septal arteries (a. nasalis septi).

The anterior superior sections of the nasal cavity and the region of the ethmoid labyrinth are supplied with blood by the ophthalmic artery (a. ophthalmica) from the system of 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).

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 - Kisselbach's 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 is called the bleeding zone 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 then 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, innervation is distinguished:

olfactory;

sensitive;

vegetative.

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

Sensitive innervation of the nasal cavity is carried out by the first (ophthalmic nerve - n. ophtalmicus) and 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.