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3 Physiology of the Nose and Paranasal Sinuses Physiology of the Nose and Paranasal Sinuses 29 3 Physiology of the Nose and Paranasal Sinuses Davide Tomenzoli CONTENTS source of suffering for patients and a focus of atten- 3.1 Introduction 29 tion for clinicians. 3.2 Breathing 29 “Physiologic” breathing occurs through the nose; 3.3 Mucociliary System 30 it may be supplemented by oral respiration under 3.4 Filtration 30 demanding conditions of exercise or of severe nasal 3.5 Heating and Humidifi cation 31 3.6 Antimicrobial Defense 31 obstruction. Nasal fossae may not only be considered 3.7 Refl ex Action 31 the front door of the respiratory system, but are also 3.8 Recovery of Water 31 characterized by peculiar and signifi cant functions 3.9 Resonance 32 other than breathing: conditioning and moistening 3.10 Olfactory Function 32 of the nasal air-fl ow, fi ltration of inspired noxious 3.11 The Role of Paranasal Sinuses 32 3.11.1 Lighten the Skull for Equipoise of the Head 32 materials, specifi c and non-specifi c antibacterial and 3.11.2 Impart Resonance to the Voice 32 antiviral activities, refl ex action, collection of water 3.11.3 Increase the Olfactory Area 33 from expired airfl ow, olfactory function. 3.11.4 Thermal Insulation of Vital Parts 33 3.11.5 Secretion of Mucus to Moisten the Nasal Cavity 33 3.11.6 Humidify and Warm the Inspired Air 33 3.11.7 Absorption of Stress with Possible Avoidance of Concussion 33 3.2 3.11.8 Infl uence on Facial Growth and Architecture 33 Breathing References 34 Every day 10,000 l of ambient air reach lower respi- ratory airways for pulmonary ventilation. Air enters the nose through the nostrils, as a consequence of a pressure gradient existing between external ambi- 3.1 ent and pulmonary alveoli, and converges through Introduction the so-called nasal valve, positioned in the anterior part of the nasal fossa just behind the nasal vestibu- Many papers and investigations on nasal physiol- lum. The term “nasal valve” refers to an area lying ogy have been published in the last 40 years; as a on a perpendicular plane to the anteroposterior axis consequence, knowledge of nasal functions has now of the nasal fossa, which is bordered medially by the been well established. In contrast, however, the role nasal septum, laterally by the head of the inferior of the human paranasal sinuses remains as much turbinate and superiorly by the posterior margin of an enigma today as it was nearly two millennia ago the lateral crus of the alar cartilage. This restricted (Blaney 1990). According to Cole (1998), the con- area accounts for about 50% of the total resistance clusive evidence of a functional relevance of the of the respiratory system and gives rise to a laminar paranasal sinuses has yet to be found. Even though airfl ow. As inspiratory air leaves the narrow valvular the existence of the paranasal sinuses may be unex- area and enters the much larger cross-section of plained, their susceptibility to disease is a common the nasal fossa, its velocity decelerates from 18 m/ s to 4 m/s and the laminar airfl ow becomes tur- bulent. When airfl ow reaches nasal fossa it splits into three air streams, the largest of which fl ows D. Tomenzoli, MD over the superior edge of the inferior turbinate. A Department of Otorhinolaryngology, University of Brescia, second smaller airfl ow (about 5%–10%) runs along Piazzale Spedali Civili 1, Brescia, BS, 25123, Italy the olfactory mucosa localized on the roof of the 30 D. Tomenzoli nasal fossa, the medial surface of the upper and of mucus and an underlying layer of serous fl uid. middle turbinates, and the opposed part of the sep- This fl uid is deep enough to avoid entanglement tum. Finally, a minimal fl ow runs on the fl oor of the of the cilia with the viscoelastic mucus that fl oats nasal fossa (Fig. 3.1). The subdivision of the nasal on its surface enabling the mucus (which contains airfl ow and the presence of a turbulent fl ow allows entrapped contaminants, microorganisms and de- the maximal distribution of inspired air throughout bris) to be propelled along well-established routes the nasal cavity, enabling exchanges of heat, water to the pharynx, where it is swallowed (Fig. 3.2). and contaminants between the inspired air and the Serous and seromucinous glands localized in the respiratory mucosa. intermediate layer of the lamina propria, and the intraepithelial goblet cells are the producers of the periciliary fl uid and the thick viscoelastic mucus (Cole 1998; Nishihira and McCaffrey 1987). Fig. 3.1. Breathing at rest. Inspired air once it has passed through the nasal valve (red area, 1) divides into three air streams. The main one fl ows along the middle turbinate (2); the second and third fl ow along the ethmoid roof (3) and nasal Fig. 3.2. Prechambers and paths of normal mucous drainage. fossa fl oor (4) Structures are demonstrated after subtotal removal of middle turbinate. Frontal sinus, anterior ethmoid cells, and maxillary sinus drain into the middle meatus (red arrows). The sphenoid sinus and posterior ethmoid cells drain into the superior me- atus (blue arrows). Arrowheads indicate the insertion of the 3.3 middle turbinate’s ground lamella on the lateral nasal wall. FS, Mucociliary System frontal sinus; B, bulla ethmoidalis; PEC, posterior ethmoid cells; SS, sphenoid sinus; UP, uncinate process; IT, inferior turbinate Nasal mucosa presents a ciliated columnar pseu- dostratifi ed epithelium that lines the nose and the paranasal sinuses and is bounded by squamous epithelium at the level of the nasal vestibulum. The 3.4 area of the luminal surface of the sinonasal epi- Filtration thelium is greatly expanded by 300–400 microvilli x cell. Also, columnar cells bear about a hundred The inspired air contains a great amount of sus- cilia x cell beating 1000 x/min in sequence with pended exogenous particulate material. The upper those of neighboring ciliated cells (Mygind 1978). respiratory tract, especially the nose, must act as the The cilia beat in a serous periciliary fl uid of low fi rst line of defense and plays a signifi cant role as a viscosity. The beat of a single cilium consists of protective fi lter for particles as well as for irritant a rapid forward beat and a slow return beat with gases. Turbulence and impingement cause deposi- a time ratio of 1:3. Within a limited mucosal area tion of particles just behind the constricted area all cilia beat in the same direction; the cilia beat of the nasal valve. Thus, the nose is normally the synchronously in parallel ranks one after another principal site of particle deposition, but the effi cacy forming metachronous waves that transport the ex- of this nasal fi lter depends on the diameter of the ogenous particles toward rhinopharynx. Cilia are particles inhaled (Muir 1972). Few particles greater plunged in a mucus blanket that is made up of than 10 µm are able to penetrate the nose during a double liquid layer: a superfi cial viscous sheet breathing at rest, while particles smaller than 1 µm Physiology of the Nose and Paranasal Sinuses 31 are not fi ltered out, reaching the delicate structures 3.6 of the alveoli. Deposited particles, between 10 and Antimicrobial Defense 1 µm in diameter, are removed from the nasal mu- cosa within 6–15 min depending on the effi cacy of In addition to physical removal of microorganisms the mucociliary system. and other noxious materials by mucociliary trans- port, an important line of defense is provided by the surface fl uids that contain macrophages, basophils and mast cells, leucocytes, eosinophils, and antibacte- 3.5 rial/antiviral substances that include immunoglobu- Heating and Humidifi cation lins, lactoferrin, lysozymes and interferon. These cells and substances discourage microbial colonization The blood vessels of the nasal mucosa are of paramount and enhance the protective properties of the sinona- importance for the functions of heating and humidifi - sal mucosa against infections. cation. As reported by detailed studies (Cauna 1970) the arterioles of the nasal mucosa are characterized by the total absence of the internal elastic membrane so that the endothelial basement membrane is con- 3.7 tinuous with the basement membrane of the smooth Refl ex Action muscle cells. In addition, nasal blood vessels are also characterized by porosity of endothelial basement Nasal mucosa is supplied by nerves from the so- membrane so that the subendothelial musculature matic and autonomic systems. The sensory fi bers of these vessels may be rapidly infl uenced by agents travel with the trigeminal nerve, while the parasym- and drugs carried in the blood. Between the capil- pathetic fi bers are derived from the facial nerve and laries and the venules are interposed the cavernous the sympathetic fi bers from the superior cervical sinusoids; these are localized in the lower layer of the ganglion. lamina propria especially on the inferior turbinates. Afferent impulses are transported via the sensory Cavernous sinusoids are regarded as specialized capil- fi bers to the central nervous system giving rise to laries adapted to some of the functional demands of tickling or pain. Efferent impulses are propagated the airway, i.e. moistening and heating of the inspired through autonomic, vasomotor and secretory-mo- air. Nasal blood vessels can be classifi ed according to tor nerve fi bers. The stimulation of nasal mucosa their principal function into capacitance, resistance results in sneezing, watery rhinorrhea and changes and exchange vessels. The amount of sinonasal blood in blood fl ow (Allison and Powis 1971).
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