1、鼻应用解剖及生理学鼻应用解剖及生理学症状学症状学浙江大学医学院附属邵逸夫医院耳鼻咽喉头颈外科胡孙宏解剖相沟通解剖相沟通生理相关联生理相关联病理相影响病理相影响检查有共性检查有共性治疗相辅佐治疗相辅佐鼻应用解剖 外鼻：面部正中间 后方为鼻腔 鼻腔：前鼻腔固有鼻腔 鼻窦：上颌窦筛窦额窦蝶窦 外 鼻 骨骨 软骨软骨 皮肤皮肤外鼻外鼻标志外鼻骨性支架 额骨的鼻突（部）鼻骨 上颌骨额突 腭突Nasal Bone vary in size considerably fused and form bridge of nose the point of junction with the frontal bo
2、ne is the nasion articulates with 2 cranial and 2 facial bones Nasal bone fracture the most common facial fracture type.etiology:assault,motor vehicle collision,falls,sports,occupations.may cause deformity of the nose,swelling,skin laceration,epistaxis,cerebrospinal rhinorrhea.treatment:closed reduc
3、tion and open reduction.Trauma Nasal bone fracture is diagnosed by palpation,not x-ray.If other facial fractures are suspected,the most useful study is a thin-cut(1-3 mm)axial CT of the face with coronal reconstructions Nasal fracture is quite common during birthgreenstick type simple treat adult fr
4、acturesmash both to one side -frontal blow depress bone -various other injures -facial fracture inferior orbital rim or zygomaTrauma External nose lacerated compound fracture may exist Usually simple nasal fracture Cartilage of septum injure but not nasal bone Both Cartilage of septum and nasal bone
5、 Occasionally the tip of nose injure independently The intercanthal line demarcates the transition point between thicker nasal bone superiorly and thinner bone inferiorly.Most nasal fractures will occur below this levelExamples of nasal fracture patternsTrauma Treatment is not difficult Aim of ruduc
6、tion are to obtain a satisfactory airway and to restore the original appearance of the nose Lateral type of fracture smash inward and other outward simple thumb press back on the convex side Depressed fracturereduction under local or general anesthesia an elevator or a hemostat cover with a thin rub
7、ber tubing is used to pry up the nasal boneClosed nasal reduction.After marking the distance of the intercanthal line on the elevator with a thumb,the tip of the instrument is used to reduce the medialized fragment.The opposite thumb may simultaneously reduce a contralateral outfractured nasal bone
8、Closed septal reduction using Asch forceps.A,Deviated nose prior to septoplasty.B,The significant correction of the deviated nose with septoplasty aloneTraumaComom errors Set nasal fracture many years previously a new trauma X-ray reneal no fracture but actually there is little pracal value clinic j
9、udgement is much more important An easy-to-reduce fracture too seriously or a severe fracture too lightly Wait too long to reduce the fracture within 1 week梨状孔和隔背软骨外鼻软骨支架外鼻皮肤 薄：鼻根鼻梁及其侧面皮下组织疏松皱纹 厚：鼻尖鼻翼鼻前庭软骨膜紧密炎症疼痛剧烈 鼻尖鼻翼皮肤含有较多汗腺及皮脂腺，粉刺座疮疖肿及酒渣鼻好发部位外鼻神经外鼻动脉外鼻动脉 外鼻由鼻背动脉筛前动脉额动脉面动脉上唇动脉眶下动脉的分支外鼻静脉Dangerous
10、 triangle of the face From corners of the mouth to nasion of the nose It is possible(although very rare)for retrograde infections from the nasal area to spread to the brain外鼻淋巴外鼻淋巴鼻腔鼻腔冠状观鼻腔分区鼻前庭 前鼻孔和固有鼻腔之间位于鼻腔最前起于鼻缘止于鼻内孔或鼻阈 鼻翼软骨内侧面 鼻阈有调节呼吸功能 鼻前庭被覆皮肤丰富皮脂腺汗腺疖肿好发固有鼻腔鼻腔内侧面 为鼻中隔有骨和软骨组成鼻中隔鼻中隔偏曲鼻腔外侧壁 复杂和鼻窦
11、密切联系 由上颌骨泪骨下鼻甲骨筛骨腭骨垂直板及蝶骨构成 三个阶梯状排列骨性组织:上鼻甲中鼻甲下鼻甲Spheno-Ethmoidal Recess-Above Sup.ConchaSuperior Meatus-Below Sup.Concha Middle Meatus-Below Mid.Concha Inferior Meatus-Below Inf.Concha Inferior meatus 1)opening of nasolarimal duct 2)maxillary sinus acupuncture Middle meatus 1)opening of frontal sin
12、us and anterior ethmoid 2)ostiomeatal complex(OMC):obstruction cause sinusitis Superior meatus:opening of posterior ethmoid Ostiomeatal Complex(OMC)Agger nasi,nasofrontal recess,infundibulum,uncinate process,ethmoidal bulla and the anterior group of ethmoidal air cells.Anterior ethmoid,frontal and m
13、axillary sinuses drain Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it Important landmark in FESS窦口鼻道复合体 中鼻甲中鼻道及其附近区域，其解剖异常和病理改变与鼻窦炎关系密切 内镜鼻窦手术的基础Landmarks in FESS 1)uncinate process:a curved lamina projects downward and backward 2)ethmoidal bull
14、a:rounded elevation below middle concha,formed by projection of middle ethmoidal air cells 3)hiatus semilunaris:C shaped slit between uncinate process and bulla鼻腔黏膜 嗅区黏膜：鼻腔顶中部，下至中隔上部和鼻腔外侧壁上部 呼吸部黏膜：前1/3自前向后为鳞状上皮移行上皮假复层上皮后2/3为假复层纤毛上皮鼻腔顶壁顶壁鼻腔底壁底壁前后鼻孔前后鼻孔鼻腔血管Internal carotid arteryExternal carotid arter
15、yLittle areaBlood supply Anterior ethmoidal arterySeptal branch of the sphenopalatine arteryGreater palatineBranch from superior labial a(facial artery)These vessels anastomose in the region about 1.5cm behind the anterior mucocutaneous junction鼻腔血管鼻腔淋巴淋巴回流鼻窦 鼻窦头颅骨的含气空腔 上颌窦 筛窦 额窦 蝶窦鼻窦Development of
16、SinusesEthmoid are present at birth and developed at 3 years of age Maxillary are present at birth and developed by 3 years of age Sphenoid are present at 3 years of age and developed by 12 year of age Frontal are present at 8 years of age and developed by 12 years of age Drainage Frontal:nasofronta
17、l duct into the ethmoid infundibulum of the middle meatus Anterior ethmoid:middle meatus Posterior ethmoid:superior meatus Sphenoid:sphenoethmoid recess上颌窦上颌窦The Maxillary Sinus-Largest,occupies entire body of maxilla-Roof:floor of Orbit-Floor:alveolar process of maxilla and hard palate-Medial:nasal
18、 lateral wall-Anterior:canine fossa-Posterior:infratemporal space,pterygomaxillary fossa The Maxillary Sinus MS:maxillary sinus,MT:middle turbinate MO:maxillary sinus ostium *:hiatus semilunaris Coronal imageThe Maxillary Sinus MS:maxillary sinus,NLD:nasolacrimal duct,IT:inferior turbinate Axial ima
19、ge 筛窦筛骨前面观筛骨上面观The Ethmoid Sinuses a)Orbit-papyraceous lamina b)Lamina cribrosa-horizontal ethmoidal bonec)Nasal septumd)Superior conchae)Middle concha f)Inferior conchag)Ethmoid cellaeh)Maxillary sinus i)Hard palateThe Ethmoid Sinuses CG:crista galli MT:middle turbinate IT:inferior turbinateCoronal
20、 imagearrowhead showing lateral attachment of basal lamellae to lamina papyracea marked by the arrow The Ethmoid Sinuses AE:anterior ethmoid PE:posterior ethmoid NS:nasal septum SpS:sphenoid sinus Axial image The Ethmoid Sinuses AE:anterior ethmoid PE:posterior ethmoid sinuses.FS:frontal sinus AG:ag
21、ger nasi cell SpS:sphenoid sinus MT:middle turbinate arrow showing vertical attachment of basal lamellae to anterior skull base separating AE and PE sinuses.The Ethmoid SinusesArrowhead demonstrating anterior ethmoid drainage to hiatus semilunaris and middle meatus.Arrow showing posterior ethmoid dr
22、ainage to sphenoethmoidal recess and superior meatus.额窦额窦The Frontal SinusAxial image Coronal imageThe Frontal Sinus*:shows frontal sinus ostium arrow:pointing to the superior compartment of the FSDP.FS:frontal sinus AG:agger nasi PE:posterior ethmoid SpS:sphenoid sinus MT:middle turbinate IT:inferi
23、or turbinate蝶窦蝶窦的位置及开口The Sphenoid Sinus*:sinus ostium SER:sphenoethmoidal recess PE:posterior ethmoid sinusThe Sphenoid Sinus FR:foramen rotundum VC:vidian canal OC:optic canal AC:anterior clinoid PtP:pterygoid plate Coronal imageEndoscopic view of the right sphenoid ostium The sphenoid ostium(arro
24、w)can be found at SER and provides an important landmark for the level of the sphenoid sinus.SER:sphenoethomoid recesslandmarks on the posterior wall of the sphenoid sinus The asterisk indicates the tuberculum sellae C=clivus ICA=internal carotid artery OCR=opticocarotid recess ON=optic nerve S=sell
25、a SP=sphenoid planum.鼻窦血管鼻窦血管鼻窦血管鼻窦血管鼻窦神经鼻窦神经鼻窦淋巴鼻颅相关解剖学 鼻颅底：筛板 额窦后壁 筛窦顶 蝶窦的上后侧壁与颅相连 鼻前颅底 前部：额窦的后壁 薄 黏膜与硬脑膜仅 有极薄的骨板 静脉相通 中央部：鼻腔顶的筛板和筛窦顶部 筛静 脉流入眼静脉入海绵窦 筛顶 与筛板的连接关系（高台型 倾 斜型 平台型 混合型鼻颅相关解剖学 鼻中颅底 蝶窦区域 碟鞍 颈内动脉 海绵窦 视神经 管 视交叉及III IV V VI颅神经 蝶窦顶壁 蝶窦侧壁 鼻侧颅底（鼻与翼腭窝）上颌骨与翼突间 前为上颌骨后为翼突 和蝶骨大翼顶为蝶骨体 内侧壁为腭骨鼻眼相关解剖学 鼻窦
26、与视神经管 后组筛窦和蝶窦关系密切 鼻窦与眶内侧壁 上颌骨额突 额骨 鼻突 泪骨 筛骨纸样板 蝶骨 鼻腔和泪囊 泪囊长12-15mm 宽4-7mm 内侧壁与鼻腔：鼻腔黏膜 上颌骨额突和泪骨 泪囊向下鼻泪管 长约15-20mm开口于下鼻 道顶端外鼻生理 人种或种族有差异 外形和轮廓高低对容貌重要影响 鼻翼活动助于面部表情和鼻阻力的调整鼻腔生理呼吸功能鼻腔气流层流和紊流鼻腔生理呼吸功能鼻阻力保护肺泡气体交换鼻周期到小时交换，睡眠翻身解除疲劳温度调节加温鼻腔生理呼吸功能湿度调节24小时分泌1000ml液体加湿过滤和清洁作用鼻毛黏液毯纤毛系统柱状细胞250-300纤毛1000/分前后黏液波5mm/分防
27、御功能黏液毯纤毛溶菌酶鼻腔生理嗅觉功能嗅区黏膜和嗅细胞识别、报警、增加食欲和影响情绪的作用鼻腔生理发声共鸣功能鼻腔共鸣作用声音悦耳鼻塞性鼻音：鼻腔阻塞开放性鼻音：腭裂鼻腔生理反射功能鼻肺反射:鼻黏膜三叉神经传入，支气管平滑肌的迷走神经传出支，迷走N和三叉N核为中枢的反射弧喷嚏反射：鼻腔黏膜三叉N末梢刺激后发生系列反射动作鼻腔生理免疫功能非特异：溶菌酶、铁乳蛋白特异性：IgA IgG鼻腔生理吸收功能150cm2 血管丰富排泄泪液功能鼻窦生理 增加呼吸区黏膜，促进加温加湿 声音共鸣 减轻头颅重量 缓冲冲撞力保护器官鼻的症状学鼻的症状学 鼻病有各种症状某一症状不一定鼻病 鼻病可致邻近区域或全身症状
28、邻近部位或其他系统疾病可致鼻病鼻塞 持续性鼻塞：结构异常幼儿单侧：异物 间歇性或交替性：感染变态反应药物内分泌失调单侧：肿物双侧：慢性炎症 病史单侧或双侧程度特点及病程时间伴随症状近日用药鼻溢 水样鼻溢变态反应血管运动性急性鼻炎早期 脑脊液鼻漏：外伤或活动后清亮无粘不凝结黄色：鼻窦囊肿破裂 粘液性鼻溢：多量粘蛋白慢性鼻炎鼻窦炎 粘脓性鼻溢：慢性鼻鼻窦炎或急性鼻窦炎恢复期黄绿色臭味:牙源性上颌窦炎 血性鼻溢：急性期异物肿瘤真菌病喷嚏 正常鼻内保护性反射三叉神经反射 多：急性鼻炎变态反应性鼻炎血管运动性鼻炎 顽固性：精神障碍 病史：发作时间程度诱因其他鼻部症状月经前鼻出血 鼻腔局部疾病 全身性 外伤鼻源性头痛 感染性：鼻鼻窦急性感染 非感染性：变应性鼻炎萎缩性鼻炎中隔偏曲鼻鼻窦肿瘤 依据：麻醉中甲后端外方及前端前方嗅觉障碍 嗅觉减退或缺失：鼻塞为主鼻病 神经末梢病变 嗅觉过敏 嗅觉倒错 幻嗅共鸣障碍 闭塞性鼻音：气体不能进入鼻腔 开放性鼻音：与口腔开放的鼻腔使共鸣减弱腭裂腭麻痹腭关闭不全Thank you
