Today we will talk about the nasal cavity and the palate which are the roof of the

oral cavity which Is located between the oral cavity and the cranial cavity The nasal cavity is the passage way between the outside environment and the pharynx posteriorly (The pharynx is a very large structure that divides posteriorly into 1- Behind the nasal cavity, we call it the nasal part of the pharynx (nasopharynx) 2- Part of the pharynx behind the oral cavity (oropharynx) 3- Behind the larynx called (laryengopharynx) ** So you can see that the pharynx is a large structure relatively speaking to the larynx So the nose is the structure that extend anteriorly outside all the way posteriorly until the nasal part of the pharynx , Its covered by skin from outside and by mucus membrane from inside ( mucus membrane covering the inside of the nose is covering by specific type of epithelium called respiratory epithelium which is psedustratified columnar epithelium ciliated ) ** In order to understand the nasal area we subdivide the nose into 2 parts, 1- The external nose which is the prominent part of the face that you see 2- The cavity within the skull that we refer to it as the nasal cavity (the major part)

* The external nose

Its made of bony and cartilaginous part, the bony part is more posteriorly and it is usually formed by: -frontal process of maxilla. -the nasal bone (2 small plates) on the bridge or the dorsum of the nose -the nasal process of the frontal bone

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However the more prominent part in the face is made cartilaginously by the cartilages that we refer to them lateral cartilages ( lateral alar and septal cartilages ) For more description we call them 1- Upper lateral, 2- Lower lateral that are the alar or alar cartilages and those are u shaped so they are extended from the lateral to the medial part of the nose with 2 crura (2 legs, lateral and medial crus) 3- And there is another smaller group we refer to them lesser alar * So the alar are two greater one and behind it there is the lesser alar ** we have one in the middle that helps in separating the nasal cavity into two spaces right and left nasal cavity so we call it the septal cartilage and this one in living human is considered as a part of the nasal septum because it helps in separation the 2 nasal cavities ,, The nasal septum is formed by 2 bony parts the vertical or perpendicular plate of ethmoid superiorly and the vomer inferiorly and more anteriorly in the prominent part in the external nose you will find the cartilage there which is called septal cartilage ( you can see it in a living human not in a skull because its cartilaginous )

**The nasal cavity

** It extend from the outer nares (nostrils) (external nares) which are 2 openings from the outside into the nose ** The inner nares ( choanae ) are the openings between the nasal cavity and the pharynx behind. So it extend from the external nares to the posterior aspect of choanae (its demarcate by the end of the conchae, those elevations or shelves on the lateral walls of the nasal cavity we refer to them as conchae) So the boundaries

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# IN the medial wall we have the nasal septum. #IN the lateral wall: 1- We can see anteriorly a depression area; we refer to it as the vestibule (more related to the external nose) **The vestibule are characterized by covering by a skin so part of the skin folded back inside into the lateral wall of the nose and thats why you can see hair follicles and hair growing inside the nose behind the vestibule there is the conchae. 2- Conchae: a Latin word that means shell (superior, middle and inferior) they are found in the lateral walls also And each space covered by each conchae we call it meatus which is a passage way Superior meatus covered by superior conchae Middle meatus covered by middle conchae Inferior meatus covered by inferior conchae

The posterior wall of the conchae demarcate the end of the nasal cavity so the posterior part of the conchae is the end of the nose where we find the choanae (the opening from the nose into the nasopharynx) # the roof is made of: 1- Part of sphenoid bone. 2- The ciribriform plate of ethmoid bone. 3- The frontal bone and nasal bone. # the floor is the hard palate (the floor of the nasal cavity is the roof of the oral cavity) *the soft palate separating the nasopharynx from the oropharynx *hard palate is made of palatine process of maxilla bone and horizontal plate of frontal bone

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** Nasal conchae and Meatus

As I told you the conchae are bony projections that project inferiorly like shelves. * Superior conchae and middle conchae comes from ethmoid bone * Inferior one is a separate bone Beneath each concha we have a space we call it meatus. The conchae are there to protect the opening of the paranasal sinuses which opens into the meatus, not the air sinus!! Whats the difference??? ** paranasal sinuses are air sinus that will open into the nose because we have additional air cell which called mastoid air cells that will open in the middle ear so the paranasal sinuses are : 1- ethmoidal air cell ( anterior , middle and posterior) 2- the frontal 3- the sphenoid 4- the maxillary which is the largest one

1- In the superior meatus we will have the opening of posterior ethmoidal air cells. 2- In the middle we have the middle and anterior air cells, the frontal and maxillary. So most of the air sinuses opens in the middle meatus ** The arrangement of ethmoidal air cells is oblique and going in a horizontal and vertical way,

So

# the anterior most anterior inferior

# the middle more posterior superior # the posterior is the more posterior and the most superior one (because its the most superior one) 4|Page

4- in inferior meatus there is no air sinus opening into it ** There is another opening that connect the lacrimal sac with the inferior meatus lacremal apparatus is containing the lacremal gland that gonna secrete the tears that will be collected in the medial inferior angle of the orbit in the lacremal sac when the sac is filled the tears start to drop and through a duct connecting the orbit with the inferior meatus of the nose (nosolacrimal duct) so the tears start to fall from the nostrils thats why when you cry you have a runny nose * We still have the sphenoid air sinus >>> they open into an angle between sphenoid and ethmoid bone in a place above the superior conchae we call it sphenoethmoidal recess ( pocket ) that form because of the angulation between the sphenoid and ethmoid bone There is another opening that connect the lacrimal sac, IF YOU REMEMBER (the lacrimal apparatus is made up of lacrimal glandes & sacs ,the lacrimal glands secret the tears which will accumulate in the lacrimal sac in the inferior &medial corner of the orbit , when the lacrimal sac is filled now , the tears start to drop down outside the eye and through a duct that is called nasolacrimal duct ,connect the orbit with the inferior meatus of the nose ,so the tears start to drop down from the nostrils, that is why when you start to cry, you have a runny nose . SO, in the superior meatus <<<there is posterior ethmoidal air cells In the middle meatus <<<frontal maxillary air cells + anterior &middle ethmoidal air cells In the inferior meatus <<< nasolacrimal duct did we mess anyone????? YES , sphenoidal air cells which are not opening in any meatus << it is actually opens into recess or pocket between sphenoidal &ethmoidal bones ,so it opens above the superior concha in the space called SPHENOETHMOIDAL RECESS (pocket) formed by angulation which is form due to the presence of sphenoidal bone & ethmoidal bone . SO, sphenoethmoidal recess opens above the sup.meatus, and it is received sphenoidal air cells. 5|Page

You gonna be asked about all of these air cells, and you must be able to distinguish each of them.

Q: posterior ethmoidal air cells open into??? 1- sphenoethmoidal recess 2-superior meatus 3- inferior meatus ANSWER << the superior meatus Q: Which of the air sinus open into inferior meatus??? 1-anterior ethmoidal 2-posterior ethmoidal 3-midlle ethmoidal 4- none of the above ANSWER << none of the above
All air sinus open into meatus EXCEPT << sphenoethmoidal air cells THE BLOOD SUPPLY OF THE NOSE The nose is one of the richest areas in the blood supply in the body. AS I TOLD YOU PREVIOUSLY , there is 2 important areas that are very rich in blood supply : 1- the scalp 2- the nose why they are very rich in the blood supply ??? Because they receive blood supply from both large ECA& ICA, so the branches of ECA&ICA usually anastomoses in the scalp and nose. And that is why the injury in these regions will lead to severe bleeding 1) The first artery provide blood supply to the nose called sphenopalatine artery it is terminal branch of maxillary artery (we have 15 branches of maxillary artery) NOTE: the terminal branch of maxillary artery << sphenopalatine artery BUT the terminal branch of maxillary nerve << infraorbital nerve This artery enters through foramen that connects the infratemporal fossa with the nasal cavity. There is an opening laterally, that allow the branches of maxillary artery

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to pass through it and open into the nose, this opening called the SPHENOPALATINE FORAMEN. The sphenopalatine foramen usually located behind the superior and middle conchae, sometime may located behind the middle concha but most of the time it is located in the gap (area) between sup & middle conchae SO , in the lateral wall of the nose there is sphenopalatine foramen allow the passage of maxillary artery into the nasal cavity , once it enters there, it is called sphenopalatine artery (which is terminal branch of maxillary artery) , and here it is starting to provide blood supply to the lateral wall & the nasal septum posteriorly. 2)Now, the anterior part of the nasal cavity is supplied by septal branch from superior labial artery which is branch from facial artery.

3)The roof of the nasal cavity ( that separates the cranial cavity from nasal cavity ) , there is 2 artery coming from there , called : 1- anterior ethmoidal artery 2- posterior ethmoidal artery both of them come from ophthalmic artery , which is branch from ICA and it locate within the orbit . 4) The floor of the nasal cavity (which is the hard palate) supplied by greater palatine artery << which is branch from descending palatine artery << which is branch from maxillary artery. So, descending palatine artery dives 2 arteries: 1- one goes anteriorly to the hard palate = greater palatine artery 2- one goes posteriorly to the soft palate= lesser palatine artery AS A REVIEW : the blood supply to the nasal cavity comes from 4 main arteries : 1- spthenopalatine artery << supply the posterior part 2- superior labial artery << supply the anterior part 3- ethmoidal artery << supply the superior part 4- greater palatine artery << supply the inferior part These entire arteries unite or anastomoses in the anterior inferior aspect of the nasal septum in area called KIESSELBACHS AERA. So in this area all arteries anastomoses with each other, that is why it is

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very common area for bleeding ( most of the nasal bleeding EPISTAXIS take place in this area where all arteries unite). What are the causes for epistaxis??? there are more than 100 causes , so we will not gonna mention them here , but you have to know that , these causes are arranged from very simple causes like picking up with your nose , or from injury to the artery or vein , or from trauma << to more systemic condition like hemophilia or chronic hypertension ( elevation in the blood pressure ), the location of epistaxis most common in the antrio-inferior part of the nasal septum (kisselbachs area) from the septal branch of sphenopalatine artery (which is the largest artery supply the nose) and superior labial artery. NOTE: septal<< branch goes medially to the nasal septum Treatment = promoting the blood clot, HOW??? 1) By packing the nasal cavity by absorbent material (like tissue paper). 2) Apply direct pressure on the external nose for 5 minutes with the head at which position??? Backward, forward, nothing: P????? The position will not make differences because if you get backward = you will swallow your blood, and if you get forward = there is a possibly of enhancing the bleeding more. So, it is better to keep the person in the normal position. But if you afraid from swallowing the blood (like if the patient in comma), so this will obstruct the air way << in this situation it is better to make the position of the patient forward.

Innervation of the nasal cavity:

there is a special sensory and general sensory to the Nasal cavity * special one in the nose smells by the olfactory cranial nerve NO# 1 USUALLY IN THE OLFACTORY EPITHELIUM

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The epithelium found in the nasal cavity is respiratory epi psudosratified columnar epi except upper region or upper third just above the sup concha the epi will become simple columnar olfactory epithelium and contain the ends or receptor of the olfactory nerve fibers .

Note: The smell occurs in the superior part of the nasal cavity. The general sensation now comes from the trigeminal nerve: 1. Ophthalmic nerve: V1 most anterior part and prominent one When you touch the tip of the nose, its V1 2. Maxillary nerve: the remaining Middle and Inferior part of the nasal cavity. Paranasal sinuses You can read it by yourself they dont have any thing . 1.sphenoid 2.frontal 3.maxillary 4.ethmoidal largest one is the maxillary ,, we afraid when we have Sinusitis which may lead and spread to the Meninges Leading into infection of the meninges (meningitis ) For more details and information please go to the slides and the 3rd script of the first exam. Palate : when we speak about the palate we know that is form the floor of the nasal cavity and the roof of the oral cavity , it made by 2 parts hard and soft one * HARD PALATE : containing hard tissue bone *SOFT PALATE : containing soft tissue muscles

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The first 3 quadrants of the palate is hard and the remaining is soft Hard Palate: Hard palate: consist of the palatine process of maxilla and horizontal palate of the palatine Soft palate: Fibro muscular fold covered with mucosa & attached to post. Border of Hard palate

Composed of: -Mucous Membrane: that covers the surfaces - Palatine aponeurosis FIBROUS sheet which made the fibrous part of the soft palate which is dens regular connective tissue with epithelial lining. Its the key stone of the soft palate expanded tendon of Tensor veli palatine ( nerve supply V3) In addition there is another muscles that covered with this mucous membrane together it will become 5 muscles First one of them the TENSOR VELI PALATINE : 2 from each side come down from the base of the skull all the way to reach the trigoid hamulus extended part of the medial part of the trigoid plate of sphenoid bone.

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The function of the hamulus to allow the tensor palatine to go or turn horizontally to make the 2 tendons of the muscle in each side meet each other ,, because the tensor palatine come vertically from the base of the skull . when this muscle contract the tendons tense and forming the foundation of the soft palate plalatine aponeurosis : formd by the 2 tendons of the tensor veli palatine the teigoid hamulus found only in the medial teigoid plate no one in the lateral cus its attach to the 2 muscles of mastication (lateral and medial. terigoid

*From the base of the skull there is another muscle that will descend all the way to this aponuroese if it contract it will elevate the soft palate So we call it Levator veli palatine

2 muscles above: Anterior: tensor veli palatine

posterior: levator veli palatine

2 muscles going below: anterior: Palatoglossus m. from the soft palate to

the tongue posterior: Palatopharyngeus m. from the soft palate all the way to the pharynx and join the wall of it. The 5th one uvula: a conical projection from post. Border of soft Palate if you cut it you will find a mucus membrane surrounded a muscle. 11 | P a g e

Palatoglossus m and the Palatopharyngeus m Important clinically Why?! they are mucus membrane covered and this membrane form a folds when it each them so they are demarcating the tonsilar bed where dose the palatine tonsils found,, if you dont see them in the mouth of the patient that is Healthy state but if they have any enlargement in size that will be tonsillitis Arterial blood supply to the palate : 1. Greater palatine artery for the hard palate 2. Lesser palatine artery for the soft palate both of them come from the descending palatine artery which come from the Maxillary artery and pass from the greater and lesser palatine foramens

*Additional Arteries* 1. From the ECA ,, Ascending pharyngeal artery when it go to the pharynx 2.From Facial artery ,, first branch Ascending palatine artery from superior Palatine Innervation : 1. Greater palatine nerve : hard palate 2. Lesser palate nerve : soft palate 3.nasopalatine nerve : Incisive nerve supply the primary palate which is the first part formed of the palate found behind the anterior teeth and have a folds ,, There is another important area in the palate Vibrating Line : important of the prosthodontics in the upper teeth , its the border between the movable and non-movable part of the soft palate the palate is fibro muscular the tendons part is fixed area when you open your mouth and say ahhhhhh you see the vibration in the soft palate as the muscle contract but in the first 2mm in the soft palate we have palatine aponurouses, it is non-movable but the muscular one is movable, so the vibration line is the junction between the movable and non-movable parts of the soft palate. Posterior edge of the upper denature must be in the non-movable part of the soft palate because it depend on the negative pressure.

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Done by: Heba Radaideh, Haya Momani & Sondos Harbeih. Edited by: C.W.T

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