George A. (George Arthur) Piersol.

Human anatomy : including structure and development and practical considerations (Volume v.2) online

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are almost invariably infected and proceed to suppuration forming septal abscesses,
the constitutional symptoms (toxaemia) of which may give rise to anxiety if their
local cause is o\-erlooked.

Epistaxis is common not only because of (a) this vascularity of the mucosa, but
also by reason of (d) the frequency of trauma to the nose ; the relation of its veins
(r) to the general venous current so that they may be congested in cardiac or in pul-
monary disease, or in straining, or in paroxysms of coughing, as in whooping cough ;
and (d) to the intracranial sinuses, so that nose-bleed mav be a symptom of cerebral
congestion or tumor ; (e) the bleeding may be vicarious, as in cases of suppressed
menstruation (an illustration of the sexual relations of the nasal apparatus); (/)
it not uncommonly follows ulceration — simple, tuberculous or syphilitic — and in
obstinate cases such ulcers should always be sought for.

The source of hemorrhage from the nose is most frequefitlv in the anterior part,
particularly on the septum, and is then ordinarilv controlled with ease. Usually the
patient should be kept upright, with the head back, (not in the usual position lean-
ing over a basin, increasing the tension of the vessels of the neck and head) and
should be made to take deep breaths with the arms raised, thus fully expanding the
thorax and depleting the cervical veins and, indirectly, the facial and ophthalmic into
which the veins of the nose empty. If ordinary means fail, and this is more likely


if the bleeding point is posterior, the posterior nares may be plugged. For this
purpose a long silk ligature is passed through the nose to the pharynx and out
through the mouth, by means of a Bellocq's cannula or a soft catheter. To the
middle of the ligature is attached a plug of gauze slightly larger than the posterior
nares, which is then drawn by the anterior end of the ligature into the nasal fossa,
which it should tighdy fill.

Postnasal adenoids originate in the normally excessive lymphoid tissue — pharyn-
geal tonsil — of the postnasal space, of which tissue they are a simple hypertrophy.
The growth forms a mass in the vault of the naso-pharynx and often extends down-
ward and forward, filling up Rosenmiiller's fossae and involving the orifices of the
Eustachian tubes. The tonsils are commonly also enlarged.

The symptoms produced are : {a) obstructed nasal respiration, more marked
during sleep, when the mouth is closed by the approximation of the tongue to the
palate ; (/^) as a result of this, broken rest and " night terrors" ; and {c) as a further
consequence (and also from deficient oxygenation), deterioration of the general
health, delayed or arrested growth, and aneemia ; {d) intermittent partial deafness
and recurrent attacks of catarrhal or suppurative otitis media ; {^c ) pigeon-breast from
inequality of intra- and extra-thoracic atmospheric pressure.

The' early removal of adenoids that produce any or all of these symptoms is
usually indicated, and is facilitated by their friability and by the toughness and den-
sity of the submucosa on which they lie, circumstances which permit of their usually
easy enucleation either with the fingers or with the adenoid forceps and curette.

Naso-pharyngeal growths may be either simple fibromata or fibro-sarcomata.
Thev are usuallv dense, and contain large venous channels, which have no definite
sheath and thus do not retract when severed. Incision into them may therefore be
followed by severe hemorrhage with no tendency to spontaneous arrest. Ulceration
or abrasion of the surface of these growths is not infrequent, and is also attended by
repeated and often dangerous loss of blood.

The nasal fossae, already very narrow, are frequently further obstructed by path-
ological conditions, such as deviations of the septum, hypertrophy of the mucous
membrane covering the turbinates, spurs on the septum, polypi and tumors. The
septum is rarely straight after the seventh year, in about se\'enty-fi\e per cent, of
cases being turned to one or the other side, most frequently the left {vide supra').
Both the bony and cartilaginous portions, more especially the anterior cartilaginous,
are in\-olvcd. The deflection is sometimes due to a fracture from blows or falls. The
Avhole nose usually deviates more or less to one side. Spurs on the septum com-
monly occur at the junction of the bony and cartilaginous portions. A deviation of
the septum does not necessarily mean that the narrowed nasal fossa is seriously
obstructed. It frequently, however, comes in contact with the surface of the turbin-
ates, and may result in an adhesion or synechia from the irritati\-e inflammation which
is set up. Operations are often necessary to correct the difificulties arising from
deviation of the septum. The concavity on the opposite side will differentiate it from
a tumor.

Hvpertrophy of the ethmoidal labyrinth, or bulla ethmoidalis, is sometimes so
far advanced as to obstruct the nasal fossa on that side. The middle turbinate over-
lies and yields before this expanded cell, and may even press against the septum
to such an extent as to make it bend and obstruct the opposite nasal fossa to
a greater or lesser degree. The removal of the middle turbinate is sometimes
practiced in these cases" (Taylor), or the bulla itself may be obliterated by means of
the cutting forceps or curette. Over-development of the bulla ethmoidalis may at
times be so great as to occasion obstruction of the upper portion of the corresponding
nasal fossa.

The floor of the nose is the widest part, and slopes gradually backward and
downward in the upright position, so that collecting mucus tends to run backward
and drop into the throat. Rhinoliths, which are incrustations usually about a foreign
bodv, are most frequendy found in the inferior meatus, which is the largest The
posterior nares are below the level of the respiratory portion, so that any discharge
above the middle turbinate cannot be blown from the nose. The anterior portion of
the inferior turbinate slopes downward and forward, and its anterior end is attached



so near the floor of the nose that the roomiest portion of the inferior meatus is
posterior. Therefore, the entrance of air into the lower part of the nasal fossa is
obstructed, and is favored toward the u])per — "respiratory" — (x^rtion, especially
throu).;h the wide anterior openinj,^ of the middle meatus, which reaches as hi^di as
the tendo-oculi. This anatomical arran.i,^ement is the explanation of the fact already
mentioned, that odors on expired air are not rec(}jrnizcd.

The relations of the nasal chambers explain why a corvza may cause (a) lach-
rymation, by atTectint,^ the tear duct, lachrymal sac, and conjunctiva ; (d) dyspha^da,
by extendiiiij to the pharynx by way of the posterior nares ; (rj hoarseness or couj'h,
by further extension to the respiratory tract ; id) fnjntal headache, by involvini^ the
frontal sinuses ; (r) "face ache," by implicating the antrum ; (/) ^nxvii intraorbital
or intracranial disease, by way of either the ethmoidal cells or the sphenoidal sinuses •
basal meningitis by extending alont; the perineural or perivascular sheaths, or by
way of the lymphatics throuj^^h the cribriform foramina to the floor of the anterior
cranial fossa; (,^) extension to the retropharyngeal lymph node <" page 955), into
which certain of the nasal lymjihatics empty, may result in a retropharyngeal ab-
scess ; or (/^) infection (pyogenic or tuberculous) of the submaxillary, i>reauricular,
or deep cervical nodes may follow nose diseases. The gra\er of these complications
are, of course, associated with the severer infecti\e f(jrms of rhinitis. Malignant
growths — commonly sarcomatous — may begin in the nasal chambers and may extend
in any of the directions abo\e mentioned.


The nasal fossee communicate with a nuniber of remarkable ca\-ities, hollowed
out within the surrounding bones, which are tilled with air and lined by mucous
membrane directly continuous with that of the meatuses. These pneumatic spaces
include the ynaxillary, the frontal, the sphc7ioidal and the palatal simcses and the

Roof of inferior meatus

Right maxillary sinus






Masseter muscle





Internal carotid artery

Lower lateral cartilage

Roof of inferior meatus

Inferior turbinate

Roof of
Temporal muscle
Masseter muscle

pterygoid muscle

Eustachian tube

Condvle of

Pharyngeal tonsil

External pterygoid muscle
Fosa of Rosenmiiller

Portion of transverse section of head passing through na^al fossw just below middle turbinates; the inferior surface
of the section has been drawn and the nasal fossae and other spaces are viewed from below.

ethmoidal air-cells, all paired and within the corresponding bones. Since the
mucous membrane is thin and intimately adherent to the bones, the form of the cavi-
ties as observed in the recent condition corresponds closely to that seen in the
macerated skull. The size and extent of the spaces vary not only at difTerent periods



of life, but also often on the two sides of the same individual ; their communications
with the nasal fossae, however, are fairly constant.

The Maxillary Sinus. — This space, Csinus maxillarisj, or the antrum of
Highmore, the largest of the pneumatic cavities, lies to the outer side of the nasal
fossa and resembles in its general form a three-sided pyramid (Fig. 1184). It
occupies the greater part of the superior maxillary bone, so that its walls, with the
exception of the postero-inferior one, are very thin and often in places of papery
delicacy TFig. 256 ). The median wall, or base, is directed toward the nasal fossa, from
which it is separated by a thin osseous partition in the formation of which the vertical
plate of the palate bone, the uncinate process of the ethmoid, the maxillary process
of the inferior turbinate and a small part of the lachrymal bone assist. The apex lies
at the zygomatic process of the maxilla. The upper or orbital wall is thin and often

Fig. 1 184.


Anterior ethmoidal cells

Left raaxillarj- sinus

.nferior meatus
Place where frontal sinus was attached

Anterior ethmoidal cells

Maxillary sinus
Posterior ethmoidal cells

Left sphenoidal cell

Right sphenoidal cell


Cast of nasal fossae and accessory air-spaces, viewed from above; casts of frontal sinuses have been removed;

natural size. (KaUius.)

modelled by the ridge containing the infraorbital canal. The anterior wall presents
towards the face and is varyinglv impressed by the canine fossa. The postero-
inferior wall is normally the thickest, but is sometimes reduced by extension of the
sinus into the adjacent alveolar border. The sinuses are often so modified by local
enlargements that the typical pyramidal form is lost and their dimensions materially
influenced. As an indication of the size of the average sinus, a sagittal diameter of
35 mm. (i^ in.), and a vertical and frontal one of 27 mm. ("about i in.) each
(Kallius), may be taken as approximate measurements. Not infrequently, however,
considerable asymmetry exists even to the extent of one antrum being almost twice as
large as the other. The usual capacity of the antrum is between 12-18 cc. (3^-4^
fl. dr.) with an average of approximately 15 cc. , or 4 fl. dr. (Braune and Clasen).

The antrum communicates indirectly with the middle meatus by means of an
aperture rostium raaxillare; that pierces the upper and anterior part of the base to
open into the infundibulum, and thence by way of the hiatus semilunaris, into the



meatus. The ostium, wliich is usually in the lateral wall of the infiiudiljulum,
ahoiU one centiinetc-r from the upjx-r end of the hiatus, is an cn'al or ellijHieal eleft
of variable size, with extrenus of length from 3-19 mm. ( Zuckerkandl ;, and from
2-5 mm. in wiilth. An additional ecjmmunication (ostium accessoriuiu;, present
in about 10 per cent., likewise opens into the infundibulum, lying behind the chief
aperture. It is ordinarily small, its diameter being only a few millimeters. The
mucous membrane lining the maxillary sinus is directly continuous with that
co\ering the lateral wall of the nasal fossa. With the exception of being thinner, it
corres])onds in structure with the mucous membrane of the respiratory region, Ixjing
in\'ested with ciliated columnar epithelium and possessing numerous, although small
and scattered, tubo-alveolar glands.

Variations. Tin- iiivcstipatioiisof ZuckerkaiKJl (Kallius) have shown tnat enlargement of
the maxillary sinus maybe produced by: (i) hollowinj^ out of the alvec^lar process (alveolar
recess) ; (2) excavation of the floor of the nasal fossa by extension of the alveolar recess
between the plates of tlie hard palate (palatal recess); (3) encroachment of the sinus into the
frontal process of the maxilla ; (4) hoUowinti; out of the zygomatic process of the malar bone
(malar recess); (5) extension to and appropriation of an air-cell within the orbital process of
the palate bone (palatal recess). Contraction of the maxillary sinus, on the other hand, may
follow : (i) imperfect absorption of the cancellated bone on the floor of the sinus, or secondary
thickenint;: of its walls ; (2) encroachment due to approximation of the facial and nasal walls,
unusual depression of the canine fossa, excessive bulging of the lateral nasal wall, or imperfectly
erupted teeth.

The cresceniic projections which quite commonly are seen protruding from the walls into
the interior, occasionally are replaced by septa that completely divide the sinus into two cavities,
each having its independent opening into the nasal fossa, but not being in communication with each
other. These partitions vary in position and direction, sometimes subdividing the antrum into an
anterior and a posterior compartment, and at others, into an upper and a lower chamber. In
the last case the lower space may communicate with the inferior meatus (Zuckerkandl, Briihl).

Fig. 1 185.

Right frontal sinus -

' Left frontal sinus

Passas:e leading into
infundibulum and
middle meatus

Nasal septum

Portion of frontal section exposing frontal sinuses which are asymmetrical.

The Frontal Sinus. — The air-spaces between the outer and inner tables of
the frontal bones (sinus frontales) are very variable in extentand form. The relative
development and general position of these cavities are usually indicated by the
degree of prominence of the superciliary ridges, but by no means invariably, since
numerous exceptions to this correspondence occur. The sinuses are frequently
quite asymmetrical (Fig. 1 185), one cavity being enlarged, sometimes at the expense
of the other, with accompanying displacement of the intervening septum. The
latter, usually approximately median in position, is often very thin, but only rarely



incomplete; so that the spaces very seldom communicate. Numerous instances have
been observed in which one sinus was entirely wanting. The average dimensions of
the h-ontal sinus, as given by A. L. Turner, include a height of 31 mm. (i}{ in.), a
width of 30 mm., and a depth of 17 mm. The capacity varies from 3-8 cc. (Hriihl).
These spaces are not recognizable in the new-born child, first appearing about the
seventh year, after the absorption of the cancellated bone. It is not until after
puberty, however, that they attain their full size. . They are usually larger in the
male than in the female.

•The typical pyramidal fonii of the space is often moditic-d by the enlargement
of the sinus beyond its usual limits, since when exceptionally developed it may
extend into the orbital plate of the frontal bone, at times reaching as far as the
lesser wing of the sphenoid, or into the median orbital w^all, or laterally into the
external angular process, or, exceptionally, into the nasal spine beneath the root of
the nose. On the other hand, the frontal sinus may be encroached upon by
projecting ethmoidal cells.

The frontal sinus communicates with the middle nasal meatus through either the
infundibulum, or a passage between the anterior attachment of tlie middle turbinate
and the uncinate process, or both. Its aperture (ostium frontalis) lies from 2-10
mm. from the upper end of the hiatus semilunaris. The frontal sinus is lined by a
prolongation of the respiratory nasal mucous membrane, diminished in thickness but
otherwise of its usual structure.

Fig. 1 186.

Sphenoidal sinus

Superior meatus

Middle meatus

Frontal sinus


Entrance to
middle meatus

Inferior meatus

Vestibule and
nasal aperture

Choana (posterior raris

Maxillary sinus
Cast of nasal fossae and accessory air-spaces, viewed from right side ; natural size, (h'allius.)

The Ethmoidal Air-Ceils. — These spaces (cellulac ethmoidales) include a
series of pneumatic cavities, very variable in number and size, that from birth lie
between the upper part of the nasal fossae and the orbits, from which they are separated
by osseous plates of papery thinness. They are all lined with mucous membrane
which covers the thin bony partitions that separate the spaces from one another.
When these partitions are deficient, as they often are in old subjects, the intervening
septa are entirelv membranous. The ethmoidal air-spaces, completed by the articu-
lation of the ethmoid with the frontal, maxillary, lachrymal, sphenoid and palate
bones, usually form three groups, the anterior, the middle and the posterior eelh.
Every space communicates with the nasal fossa, either direcdy by means of an
independent aperture, or indirectly through one or more cells of the same group.
Sometimes the cells are so fused that two general cavities, an anterior and a poste-
rior, replace the corresponding groups. When typically arranged, the anterior cells
communicate with the middle meatus by means of apertures that open into the
upper part of the infundibulum. The middle cells also open into the middle meatus,



usually by a crescentric ck'ft u|)()ii or above tlic ethmoidal bulla, but sometimes into
the iufuiidibulum. The /xw/rvvV/' alls communiiate with the su|)erior meatus by one
or more openiniis overhung by the upper concha. Very exceptionally the ethmoidal
cells may communicate with the sjjhenoidal or the maxillary sinuses, or may extend
into the substance of the micklle turbinate bom-. 'Ihe mucous membrane clothing
the ethmoidal cells is exceedini^ly thin, but corresponds in its general structure,
even in possessing glands, with that lining the respiratory region of the adjacent
nasal fossa'.

The Sphenoidal Sinus. — The paired air-spaces (sinus splK'noifialcsj j»roducetl
by the absorption of the cancellated tissue within the body of the sphenoid b(jne are
separated by an osseous partition and seldom conuiumicate. They are very variable
in size and often asynunetrical, with corresponding displacement of the septum. A
length of 22 mm., a width of 15 nun., and a height of 12 mm., are the approximate
dimensions of the average sinus. The capacity of the latter, as determined by Briihl,
is fnMU 1-4 cc. When large, the spaces may appropriate not only a large part of
the sphenoid, extending into both wings, the i)terygoid jjrocesses and the rostrum,
but also include the basilar process of the occipital bone. Not infrequently one (jr«

Fig. 1 1 87.

Anterior ethmoidal cells

Probe passes to middle meatus

Sphenoidal sinuses

Pituitary body

Openings of sphenoidal sinus
and posterior ethmoidal cells

Internal carotid arterv

Portion of section of frozen formalin-hardened head, exposing ethmoidal and sphenoidal air-spaces;

viewed from above.

more of the posterior ethmoidal air-cells projects or opens into the sphenoidal sinuses.
Very exceptionally these spaces may come into close relations with or even open into
the maxillary antrum (Zuckerkandl) — a condition normally found in some apes.
The sphenoidal sinus of each side communicates with the nasal fossa by means of
the spheno-ethmoidal recess, above the superior turbinate and close to the roof of
the fossa, by an aperture that pierces the upper part of the anterior wall of the sinus.
Through this opening, reduced in the recent condition, the respirator}- mucous
membrane is prolonged into the sinus which it lines.

The palatal sinus, the small air-space within the orbital process of the palate
bone, communicates indirectlv with the nasal fossa by either the posterior ethmoidal
cells or the sphenoidal sinus into which it opens.

Vessels. — Of the arteries supplying the nasal fossa the spheno-palatine branch
of the internal maxillary is the largest and most important. Entering the nose
through the spheno-palatine foramen, it divides into external (posterior nasal) and
internal (naso-palatine) branches, which supply an extended tract reaching from the
posterior to the anterior nares. The external branches are distributed to the turbinate


bones and the mucous membrane of the meatuses, including the lower part of the
olfactory region, and in addition send twigs to the ethmoidal cells and the frontal
and maxillary sinuses. The naso-palatine artery supplies the septum and upper part
of the olfactory region. Numerous smaller, and for the most part collateral, twigs
derived from the anterior and posterior ethmoidal branches of the ophthalmic pass to
the upper part of the fossa; from the descending palatine, branches are distributed
to the posterior part; and from the lateral nasal and septal, branches from the facial
twigs supply the nostril. In addition to those from the posterior nasal, the antrum
receives branches from the infraorbital. The sphenoidal sinus is supplied chiefly
by the pterygo-palatine artery. The ultimate distribution is eftected by capillary
net-works which supply the periosteum, the glands and the tunica propria.

The veins returning the blood from the rich venous plexuses and the cavernous
tissue within the nasal mucous membrane follow three chief paths passing {a) for\vard
to the facial vein, {b) backward to the spheno-palatine, and {c) upward into the
ethmoidal veins. The latter communicate with the ophthalmic \ein and the \eins
and superior sagittal sinus within the dura mater. A communication of greater
importance, however, is established by a vein that accompanies the anterior ethmoidal
artery through the cribriform plate into the anterior central fossa and empties either
into the venous plexus of the olfactory tract or into one of the larger veins on the
orbital surface of the frontal lobe (Zuckerkandl).

The lymphatics within the mucous membrane are represented by an irregular
plexus of lymph-vessels in addition to perineural lymph-sheaths surrounding the
olfactory ner\e-bundles. Both sets may be filled by injection from the subarachnoid
space. The larger lymphatics pass backward toward the posterior nares and join
two trunks, oneof which is continued to the prevertebral node and the other to the
hyoid nodes. According to Schiefferdecker, the basal canals (page 951 ) communi-
cate with the Ivmphatics and probably facilitate the escape of fluid which aids the
glands in keeping moist the epithelium lining the nasal fossae.

The nerves include the special olfactory fibres concerned in the sense of smell,
and those of common sensation derived from the ophthalmic and superior maxillary-
divisions of the trigeminal ner\e. The lateral wall of the nasal fossa is supplied from
several sources, including the upper posterior nasal branches from Meckel's ganglion
and the lower posterior nasal branches from the larger palatine nerve behind, and,
in front, the external di\ision of the nasal wQVxe and the nasal branch of the anterior
superior dental which also distributes twigs to the floor of the fossa. The septum
receives its chief supply from the naso-palatine ner\e, supplemented by branches
from Meckel's ganglion behind and by the internal division of the nasal nerve
in front. The mucous membrane lining the antrum receives filaments from the
infraorbital nerxe by means of its superior dental branches. The frontal sinus is
supplied by twigs from the supraorbital and the nasal nerves ; the ethmoidal air-cells
by minute branches from the nasal, and the sphenoidal sinus by filaments from the

Online LibraryGeorge A. (George Arthur) PiersolHuman anatomy : including structure and development and practical considerations (Volume v.2) → online text (page 64 of 160)