Clinical Nasal SlidesFor

Dental Studients

By

Prof. Dr. Foad Abbas

External Nasal skeleton

1. Lower lateral cartilage

2. Upper lateral cartilage

3. Nasal bone2

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External Nasal skeleton

1. Lower lateral cartilage

2. Upper lateral cartilage

3. Nasal bone

4. Alar cartilage1

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Nasal septum1. Frontal bone2. Perpendicular plate of

ethmoid bone3. Nasal bone4. Vomer bone5. Palatine bone6. Maxillary crest7. Anterior nasal spine8. Quadrangular

cartilage9. Upper lateral cartilage10. Caudal end of septum11. Membranous septum12. Sphenoid sinus

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Nasal turbinates

1. Superior turbinate

2. Middle turbinate

3. Inferior turbinate

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2

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Anterior group of

Paranasal sinuses

1. Frontal sinus

2. Ethmoid sinus

3. Maxillary sinus

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Paranasal sinuses

Paranasal sinus Anatomy

Lateral wall of the nose

Superior meatus

Middle meatus

Inferior meatus

The osteomeatal complex

Maxillary sinus

Anatomy of the palate

Anatomy of the palate

Unilateral cleft lip

Cleft palate

• May involve soft palate, hard palate or both• May be unilateral or bilateral

Cleft palate

Soft palate cleft (no bony cleft)

Unilateral Cleft lip and palate

unilateral Cleft lip and palate

Bilateral cleft lip and palate

Bilateral cleft lip and palate

bilateral Cleft lip and palate

Feeding bottle and dental obturators for feeding Cleft Palate patients

Fracture nasal bones

Plain X-ray lateral view nasal bone showing facture nasal bone

Ct scan fracture nasal bone

Walsham Forceps

Ash forceps

Zygoma Fractures

Reduction of zygomatic fracture

Panoramic view of a fracture mandible

Le Fort’s fractures

Le Fort’s fractures

Le Fort I

• Fracture line across the alveolar border

Le Fort II• Triangular fracture involving the nasal

bones without the zygoma

Le Fort III• The midface separates from the cranium

Acute maxillary sinusitisThis is a common complication of a head cold. Apical infection of the teeth related to the antrum, or oro-antral fistula following dental extraction also cause maxillary sinusitis, as may trauma with bleeding into the antrum, or barotrauma. Frontal or facial pain may be referred to the upper teeth. Nasal obstruction and purulent rhinorrhoea are the other symptoms. The antrum is opaque on X-ray and dull on transillumination. There may be tenderness over the sinus but swelling is rare. Pus is seen issuing from the middle meatus.

• Maxillary sinusitis can cause pain in the upper teeth.  Tooth pain is often the symptom that brings patients to the office

• Periapical x-ray of maxillary teeth and sinus floor 10% of sinusitis is due to a dental source.

• First maxillary molar is usually the tooth involved because of its location

Dental sinusitis

The apices of the molar teeth may be extremely close to the antral mucosal lining. The upper wisdom tooth apparent on this X-ray, if infected, would be likely to cause maxillary sinusitis or, if removed, would be clearly at risk to cause an oro-antral fistula.

CT paranasal sinus

Opaque left maxillary antrum

Chronic sinusitis left maxillary cyst

Osteo-meatal complex

Opacity of right maxillary, ethmoid and left maxillary sinuses

Chronic sinusitisleft maxillary thickened mucosa

Antral puncture and lavage

• This involves inserting a trocar and cannula under the inferior turbinate, and puncturing the lateral wall of the nose through the maxillary process of the thin inferior turbinate bone, to enter the antrum.

Antral puncture and lavage

• Water is irrigated through the cannula and the pus emerges through the maxillary ostium. An acutely infected maxillary sinus must not be washed out, until medical treatment has controlled the acute phase; cavernous sinus thrombosis remains a danger.

Antral wash

Antral washout

Aspiration from the antrum for bacteriological examination

The Caldwell-Luc operation

• Chronic maxillary sinusitis may require the Caldwell-Luc operation in which the antrum is opened with a sublabial antrostomy, the antral mucous membrane is removed, and an intranasal antrostomy made.

Caldwell Luc operation

Oro-Antral fistula

Long standing oro-antral fistula with pus coming through the fistula

Maxillary sinusitis

Oro-antral fistula repair by buccal flap

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Dental cyst (x-ray)

• It arises due to infection around the apex of a tooth

Dental cyst

Dentigerous cyst• It is a cyst around unerupted tooth

Torus palatinus

The bony hard midline palatal swelling can be diagnosed confidently by its characteristics. It is a common finding and only requires removal if it interferes with the fitting of a denture. A large torus palatinus may take on a curious irregular appearance, suspicious of a carcinoma.

Adamantinoma (Ameloblastoma)• Locally malignant tumor• Arises from ameloblasts• May be unicystic or multicystic on x-ray• Treatment excision with safety margin

Osteoclastoma • Arises from osteoclasts• Has a honey comb appearance on X-ray• Treatment surgical excision with safety margin

Fibrous dysplasia

• It is not a true tumorbut a proliferation of fibro-osseous tissue

• May be mono-ostotic or poly-ostotic

• Ground glass appearance on CT

Malignant nasal tumours

A nasal polyp that does not appear grey and opalescent should arouse suspicion, as should a polyp that bleeds spontaneously. Granulation tissue in the nose may be malignant granuloma or carcinoma, and biopsy of any suspicious nasal lesion is necessary.

A pigmented polyp may be a malignant melanoma.

Carcinoma of the antrum or ethmoid

These may extend not only into the nasal fossa and cheek but may present in the oral cavity appearing as a dental lesion. The antrum is opaque on X-ray with evidence of bony destruction

Prognosis when radiotherapy is followed by maxillectomy is quite good for an early maxillary carcinoma, but poor when there is extensive invasion. Exenteration of the orbit with maxillectomy is necessary when the eye is involved, but carcinoma with posterior spread to the base of the skull is inoperable. The use of cytotoxic drugs results in regression in some of these paranasal sinus neoplasms and is a further line of treatment. Extension of a neoplasm superiorly into the anterior cranial fossa involves resection superiorly of the dura and involved frontal lobe of the brain in continuity with the nasal and sinus neoplasm (cranio-facial resection).

Cancer maxilla destroying the palate and presenting the mouth

Cancer maxilla CT

Cancer maxilla CT

Nasal carcinoma

Osteogenic sarcoma of the maxillary sinus,

cronal CT• Invasive bony

destructive lesion with necrotic debris filling remainder of the sinus. Tooth roots exposed

• Contra-lateral mucosal retention cyst

Dental obturator

Epistaxis

Little’s areaIt is the commonest site of epistaxis. Is a circle ½ in diameter, it lies ½ an inch from the floor of the septum & ½ an inch from the vestibule

Arterial supply:

1. From internal carotid artery

2. From the external carotid

Compression of Epistaxis

For unilateral epistaxisWrong method of compression

Anterior Nasal pack

Posterior pack

Nasal Balloon

TMJ artheritis

Causes of nasal obstruction

Posterior choanal atresia

Bilateral atresia presents with dyspnoea soon after birth. Immediate surgical correction is required. A membranous atresia may be perforated and dilated using metal sounds, but if the atresia is bony it must be opened with a drill.

Causes of nasal obstruction

Deviated nasal septumA congenital or traumatic dislocation of the septal cartilage into one nasal fossa causes unilateral nasal obstruction.

Deviated septum

Lip ulcersLip ulceration has numerous causes, either traumatic, inflammatory, or neoplastic: the provisional diagnosis can be made from the history and type of ulcer. Biopsy is necessary to confirm the diagnosis. The lesion is a pyogenic granuloma. Although these lesions are frequently small and related to trauma, they may enlarge from secondary infection and take several weeks to heal.

secondary infection

Traumatic ulcer

• Irregular with slightly elevated borders

Palatal trauma

Muco-cutaneous candidiasis

• Deep fissuring of the tongue is the end result of long-term infection

Black hairy tongueThis may be. fungal (Aspergillus niger) and related to prolonged antibiotic therapy. Tobacco may be a cause. Scraping and cleaning the tongue temporarily improves the appearance but is unnecessary for this condition is harmless.

Primary herpetic stomatitis• Is the result of first infection by the Herpes I virus and

occurs most commonly in children and in young adults.• The lesions are initially vesicular and may occur at the

junction any site in the oral cavity. Usually they are wide spread.

• The vesicles rapidly break down and it is unusual to see them intact

Herpes simplex

Herpes simplex of the lip showing the characteristic vesicles which later crust.

crust

• the vesicles may partially breakdown with the production of ulcerated areas covered by yellow sloughs.

• Malaise, pyrexia and marked cervical lymphadenopathy are present.

Primary herpetic stomatitis

Herpes simplex

Herpes zosterIn the head and neck, the herpes zoster virus may affect the Gasserian ganglion of the Vth cranial nerve. The vesicular type of skin eruption is confined to the distribution of the nerve. The ophthalmic division of V is most frequently involved, but all three divisions of V are rarely affected at the same time.

mandibular division

maxillary division

Vitamin C deficiency (scurvy)

• The characteristic oral change in scurvy is a gingivitis, the papillae being swollen, with a purple tint and a re fragile.

• Patients often has neglected oral hygiene

Primary syphilis (chancre)

• Appears as an indurated swelling 2-3 weeks after infection. At first, the surface is glazed but later becomes crusted

Aphthous ulcers

• The aetiology of these extremely common ulcers remains unknown

• An area of white superficial ulceration is surrounded by a hyperaemic mucous membrane. These commonly occur in crops of two or more and heal spontaneously in about one week. They are acutely tender and affect the nonkeratinised oral mucous membrane.

• Aphthous ulcers on the tongue margin are often traumatic from tooth irregularity

• An aphthous-like ulcer overlying the apex of this deciduous tooth suggests the diagnosis of an apical dental abscess.

Minor salivary gland tumor

A palatal swelling which is not bony and hard may be a cyst if midline, but if placed to one side, it is almost certainly a tumour of one of the minor salivary glands. Biopsy is necessary.

Hard palatal carcinoma

Carcinoma of the tongueThis usually occurs on the margin or from the extension of an ulcer on the floor of the mouth (as shown here). Biopsy of this proliferative ulcer showed squamous cell carcinoma. Partial glossectomy in continuity with a neck dissection, or radiotherapy are the current treatments.

Cancer oral cavity

Skin sensitivity test

Good luck