NOSE

From Big Medical Encyclopedia

NOSE [nasus (PNA, JNA, BNA)] — the unpaired body which is initial department of respiratory tracts and the olfactory analyzer.

The embryology

in the field of primary oral cavity between frontal and maxillary shoots on the 3rd week of an embryogenesis occurs gradual immersion of the olfactory poles which are differentiated from an ectoderm, a bottom to-rykh, becoming thinner at immersion, opens on the seventh week in an oral cavity. From maxillary shoots palatal rollers develop; the forming sky divides oral and nasal cavities. As continuation of a perpendicular plate of a sievebone develops N.'s partition which is growing together with palatal shoots in the field of their connection. On the 4th month from lateral departments of laying of a sievebone the educations supporting upper and average nasal sinks and subordinate clauses form (okolonosovy, T.) bosoms: bosoms of a sievebone, frontal, Highmore's (maxillary, T.) and wedge-shaped.

In development the epithelial vystilka of a cavity of N. is differentiated in different types of an epithelium — in a multilayer flat epithelium in the field of N.'s threshold, a multirow prismatic ciliary epithelium in other part except for certain sites of upper and average nasal sinks and N.'s partition where the olfactory epithelium is differentiated.

Anatomy

Distinguish outside N. and N.'s cavity (internal N.). Outside N. — the formation of a facial skull acting in the form of the wrong tripartite pirakhmida. The form, length of a back, an arrangement of a root, the direction have N.'s reasons specific and age features.

Fig. 1. Diagrammatic representation of an osteoarticular skeleton of an outside nose: 1 — a nasal bone; 2 — small cartilages of wings of a nose; 3 — a big cartilage of a wing of a nose (a side leg); 4 — an additional nasal cartilage; 5 — a lateral cartilage.
Fig. 2. Diagrammatic representation of bone and cartilaginous parts of a partition of a nose: 1 — a frontal sinus; 2 — a wedge-shaped bosom; 3 — a share; 4 — a nasal crest; 5 — a bony palate; 6 — the incisal channel; 7 — a big cartilage of a wing; 8 — a cartilage of a partition of a nose; 9 — a perpendicular plate of a sievebone; 10 — a nasal bone.

In the field of a root outside N. borders on a forehead; on the line connecting a root and N.'s tip N.'s back is located; in the plane of a tip of N. on the lower bound of N. with a facial skeleton there is a basis of N. Side convex surfaces (N.'s wings) and the bottom of a partition are mobile. The skeleton of upper part H. formed partially frontal and nasal bones, lateralno borders on frontal shoots of an upper jaw, and their bottom edge forms the upper bound of piriform opening. Bone educations of outside N. are continued in its cartilaginous skeleton (tsvetn. fig. 1). Pair lateral cartilages (cartilagines nasi lat.) triangular shape, form a middle part of a wall of N. and in the field of N.'s back connect to a cartilage of a partition of N. Big cartilages of wings of H. (cartilagines alares majores) is also pair, consist of two plates, from to-rykh a lateral leg creates the bottom of a verkhnebokovy surface of N., and the medial leg borders on the cartilage of the opposite side of the same name and a partition of N. Small cartilages of wings of H. (cartilagines alares minores) are located in back departments of wings of N. Between lateral and big cartilages additional nasal cartilages meet. The cartilage of a partition of N. is located with zadnenizhny edge in a groove of a share and a nasal crest of an upper jaw, and is attached by anterosuperior edge to a nasal bone (tsvetn. fig. 2). Cartilaginous strips, adjacent here to a partition, call nasal cartilages. The osteoarticular skeleton of N. is covered outside of kszhy, closely connected with muscles. Among them distinguish the muscles raising an upper lip and N.'s wing; the muscles narrowing a nasal opening and lowering N.'s wing; the muscles lowering a partition.

Color table. The back fibroskopiya of a nasal cavity is normal (fig. 1 — 2) and at various diseases (fig. 3 — 5). Fig. 1. Habit view of a nasal cavity: in the center the nasal partition, on the right and to the left of it — upper and average nasal sinks is visible. Fig. 2. The average nasal course, the arrow specified an opening in a Highmore's bosom. Fig. 3. Synechias of a nose (it is specified by an arrow) between the lower nasal sink and a bottom of a nasal cavity. Fig. 4. Atresia of an upper part of the left postnaris. Fig. 5. Papilloma (it is specified by an arrow) back department of the right half of a nose. Fig. 6. A melanoma of a nasal cavity with an ulceration.

N.'s cavity opens outside front nasal openings — nostrils (nares). N.'s partition divides N.'s cavity into two not quite symmetric half, each of to-rykh by means of back openings — a postnaris (choanae) — is reported with a nasopharynx (see. Throat ). The medial wall of a cavity of N. is formed by an awn of a frontal bone, a perpendicular plate of a sievebone, a crest of a wedge-shaped bone, a share and nasal crests of an upper jaw and palatal bone. The upper wall (arch) is created by partially frontal bone, a trellised plate of a sievebone and the small site of a wedge-shaped bone. The lower wall (bottom) is formed by a palatal shoot of an upper jaw and a horizontal plate of a palatal bone. The back wall is presented by a nasal body surface of a wedge-shaped bone. Lateral wall of a cavity And. the nasal bone, a frontal shoot and the nasal surface of an upper jaw, the lacrimal bone, a trellised labyrinth, the lower sink, a perpendicular plate of a palatal bone and a medial plate of an alate shoot form. On this wall there are three nasal sinks dividing the upper, average and lower nasal courses (tsvetn, the tab. of fig. 1). Upper and average sinks are formed by a sievebone, and lower — a separate bone.

Fig. 1. A lateral wall of a nasal cavity (the most part of a sink is removed): 1 — openings of front cells of a sievebone; 2 — the line of a cut of an average sink; 3 — the line of a cut of an upper sink; 4 — openings of back cells of a sievebone; 5 — the line of a cut of the lower sink; 6 — the mouth of the lacrimonasal channel; 7 — a maxillary crevice; 8 — openings of average cells of a sievebone.

In N.'s cavity allocate the general nasal course limited to a medial wall, the arch and nasal sinks and also a threshold, border between the Crimea and actually N.'s cavity is the threshold of a cavity of N. V the upper nasal course the wedge-shaped bosom, back cells of a sievebone and a splenopalatine foramen where there pass the vessels of the same name and nerves open. In the average nasal course front and average cells of a sievebone, a Highmore's bosom (tsvetn, the tab. of fig. 2), the trellised funnel which is reported with cells of a sievebone and a frontal sinus open (see. Paranasal sinuses ). In the closing nasal stroke the lacrimonasal channel and the incisal channel (fig. 1) open. In the first months of life of the child the lower nasal sinks still close the closing nasal stroke; it opens on the 3rd month (the upper nasal course opens on the 2nd month). By 7 years N.'s cavity increases (in comparison with newborns) twice.

The histology

N.'s Skin contains hair sacks, hair, sweat glands, and also sebaceous glands, especially large and numerous in back department of wings and on a tip of N. In the field of front openings of N. skin is wrapped in his cavity, covering a threshold the multilayer flat epithelium supplied with hair. The wall of a cavity of N. is covered by the mucous membrane covered with the ciliate pseudo-multilayer epithelium consisting of ciliate, scyphoid, and also short and long inserted epithelial cells. Ciliate epithelial cells have the sokratitelny cilia 3 — 5 microns long which are carrying out movement of the dust particles getting to N. and also the slime cosecreted in a cavity of N.

The apical surface of long inserted epithelial cells has microvillis — cytoplasmatic outgrowths up to 1,5 — 1,8 microns in size. The epithelium on a basal membrane is located, to a cut connecting fabric with a large amount of elastic fibers, trailer departments of glands and limf, follicles in turn prilezhit. The mucous membrane of olfactory area H. is formed by the epithelial-like receptor layer located on a basal membrane. The surface of a receptor layer up to 500 mm2 is covered with an internal olfactory membrane and differs in yellowish color from an epithelium of respiratory area, and the cells forming this layer are presented by olfactory neurosensory supporting cells.

Fig. 3. The diagrammatic representation of vessels and nerves of a sidewall of a nasal cavity (the mucous membrane is partially removed): 1 — a front trellised artery; 2 — olfactory nerves; 3 — a trellised plate; 4 — a wedge-shaped bosom; 5 — pterygopalatine nerves; 6 — a nerve of the alate channel; 7 — a pterygopalatine node; 8 — lateral back nasal arteries and veins; 9 — the descending palatal artery; 10 — lateral upper back nasal branches; 11 — a big palatal nerve; 12 — the lower back nasal branches of a big palatal nerve; 13 — a big palatal artery; 14 — a nasopalatine nerve; 15 — the closing nasal stroke; 16 — the lower nasal sink; 17 — the average nasal course; 18 — an average nasal sink; 19 — the upper nasal course; 20 — an upper nasal sink; 21 — lateral nasal branches of a front trellised nerve; 22 — nasal branches of a front trellised nerve; 23 — a frontal sinus.

Outside N.'s blood supply in the field of its root and a back is carried out by a dorsal artery of N., a branch of an eye artery, in wings and a partition — branches of a facial artery (tsvetn. fig. 3). Outflow of blood is carried out through the accompanying arteries, nasal veins; outflow of a lymph happens in mental (submental, T.) and submaxillary (Submandibular, T.) limf. nodes. N.'s cavity is supplied with blood generally wedge-shaped and palatal artery (from a maxillary artery) getting into N.'s cavity through the opening of the same name and branching on back nasal lateral and septal arteries. Branches of an eye artery, front and back trellised arteries also supply with blood a lateral wall of a cavity of N., but its generally front part, and there is a significant amount of an anastomosis with branches of the ascending palatal artery. Outflow of a venous blood from N.'s cavity is carried out by hl. obr. by means of the branches falling into an alate veniplex, directly into an upper sagittal sine. Plentiful blood supply of walls of a cavity of N. promotes warming or cooling of the air arriving at breath. The texture of wide veins in the field of edges of the lower and average nasal sinks, the back end of an upper sink and on a medial wall during the filling by their blood causes considerable swelling of a mucous membrane that complicates breath. Veins N.'s cavities form superficial, smaller, and deep venous networks. In the field of a bottom, at the basis of a partition of a cavity of N., superficially located arteries have poorly developed muscular and elastic component of a vascular wall what weak contractility of vessels and the raised bleeding of this area designated as the field Kis-selbakha is connected with.

Limf, capillaries and vessels of a cavity of N. form superficial and deep networks, outflow of a lymph from to-rykh is carried out in retropharyngeal and deep cervical limf. nodes.

N. preferential of a branch of facial (intermediate) and trigeminal nerves innervate.

The physiology

carries out N.'s Cavity respiratory, olfactory (see. Sense of smell ), protective and resonator functions. An air stream, arriving through nasal openings, rises up, to the nasal arch, passes on the average nasal course then dugoobrazno falls kzad and from top to bottom, going through a postnaris to a nasopharynx. Passing through a nasal cavity, air is warmed and moistened. Warming (or cooling) is reached by means of heat exchange with the blood filling cavernous tissue of a mucous membrane of N. Vzveshennye in air dust particles are late at an entrance in Nov thanks to the filter which is available here from hair. At the further movement of a current of air on a mucous membrane of twisting walls of a cavity of N. settles up to 40% of the dust which is contained in inhaled air. Further dust particles thanks to action of ciliate epithelial cells of a pseudo-multilayer epithelium get into a nasopharynx. The bacteria which got to N. with air and are not removed together with dust particles are substantially neutralized and killed with bactericidal effect of nasal slime and contained in it lysozyme (see). The air coming to N. is moistened before almost full saturation at the expense of nasal slime. The mucous membrane of N. excretes apprx. 500 ml of nasal slime within 24 hours.

N.'s cavity is richly supplied with nerve terminations, the irritation to-rykh quite often leads to emergence of various reflexes; so, e.g., from N.'s cavity carry to protective reflexes sneezing (see) and reflex to a slizeotda the leniye, a cut is quite often shown by sudden plentiful mucifying without inflammatory changes.

N.'s cavity with adnexal bosoms and a nasopharynx serve as motionless resonators for voices (see); they strengthen its sound and give it a timbre and individual sonority.

Methods of a research

perform Inspection of a cavity of N. by method front and back rinoskopiya (see), the cavity allowing to examine all departments N. Funkts, the research of a cavity of N. is conducted for the purpose of check of respiratory and olfactory functions N. Passability of a cavity of N. for a stream of inhaled air is defined at a deep breath and the strengthened exhalation by each half of a nose separately. More exact definition of passability of a cavity of N. make by means of any rinopnevmometr (a rinopnevmometra Daynyak, Undritsa, rinoanemometr Goldstein, etc.), olfactory function is investigated by method olfaktometriya (see).

Pathology

Anomalies of development. Malformations of outside N. — outside N.'s doubling, development of median fistulas, splitting of a tip of N., or «Nov of a mastiff» when both nostrils are divided by a groove — meet quite seldom. Observe defects of nasal bones slightly more often. Malformations of nasal sinks (change of their size and a form) meet very seldom.

Treatment operational.

Damages. Vystoyashchy position H., relative fragility of a skeleton promote its frequent bruises. They usually are followed by bleeding, changes of a gleam of N., all outside N.'s deformation are quite often observed and as a result of they are persons. N.'s damages put with blunt objects, and also arising during the falling in most cases happen closed and can be followed by fractures of a cartilaginous and bone skeleton without injury of skin. Small changes of free edge of nasal bones in such cases can not be followed by visible deformation and are defined only at a palpation, sometimes on the basis of crepitation, and is more often at X-ray inspection. As a rule, nasal bones are injured, frontal shoots of an upper jaw are more rare. Only discrepancy of bone seams is sometimes observed. As a result of injuries of a partition of N. its curvatures, dislocations, breaks or changes are possible. Injuries of cartilaginous part H. owing to elasticity of cartilages lead to N.'s deformation less often. At blow in front there is a longitudinal fracture of nasal bones, the form H. becomes flat owing to retraction of a back in bone and partly in a cartilaginous part, considerable deformation of a partition of N. is formed or its change with formation of a hematoma and a rupture of a mucous membrane is possible.

Laterpositions of N are most frequent. On the party of blow the seam between a nasal bone and a frontal shoot of an upper jaw can disperse from a change of a frontal shoot on the opposite side. Also changes of a partition of N. and dislocation of nasal bones from a frontal seam are observed.

During the Great Patriotic War of an injury of N. and adnexal bosoms won first place among gunshot wounds of ENT organs. The isolated gunshot wounds of N. and its adnexal bosoms and combined getting into a head cavity, an eye-socket, a pterygopalatine or infratemporal pole etc. meet. Extensive destructions of N. with a separation of soft tissues and bone parts of the face are observed at missile wounds. In such cases all outside N.'s separation or separate its hour-stey (a tip, a back) and injury of adnexal bosoms is quite often possible.

N.'s damage is followed by pain up to the phenomena of shock, nasal bleedings, a swelling and hemorrhages in the area H. and surrounding parts of the face, sometimes release of cerebrospinal liquid in case of a crack in an upper wall of a cavity of N. At a rupture of a mucous membrane of N. and the strengthened smorkaniye hypodermic emphysema a century, persons and necks can develop; the cutaneous dropsy and a mucous membrane of N. usually quickly increases that complicates diagnosis.

At the closed damages treatment consists in a stop of bleeding (see. Nasal bleeding ) and in perhaps early reposition of fragments. By the simple receptions (manual reposition and by means of an elevator) applied directly after an injury it is quite often possible to correct those defects, for elimination to-rykh in later terms difficult plastic surgeries are required. In case of considerable hypostasis of fabrics it is better to start reposition of fragments in 2 — 3 days. The research shall precede actions for reposition of fragments rentgenol. In the presence of a hematoma of a partition of N. it is required to make immediately a wide section with the subsequent introduction in Nov of a tampon to prevent formation of abscess and destruction of a cartilage of a partition of N. At open wounds, as first-aid treatment, bleeding from outside departments of N. is stopped a compressing bandage or ligation in a wound on larger vessels. At considerable bleedings from a nasal cavity the front tamponade of a nose is necessary, and at its insufficient success resort to a back tamponade. N.'s wound and its adnexal bosoms thanks to plentiful blood supply well heal.

Very often, especially at children, hit in a nose is noted foreign bodys (see).

Diseases. The acute and chronic inflammation of a mucous membrane of a nasal cavity is most often shown in the form of acute and hron, rhinitis (see). In rare instances develops hron, the disease of a cavity of N. which is characterized by the expressed mucosal atrophy and a bone skeleton of nasal sinks, dense sticky separated, drying up in crusts and exuding a fetid smell (see. Ozena ).

Hematoma and abscess of a partition of a nose. Outside N.'s damage (blow to N., falling on N. etc.) leads to hemorrhage under a mucous membrane of a partition of N. and to education hematomas (see), almost always passes edges under the influence of consecutive infection in abscess (see). Formation of abscess usually is followed by temperature increase, headaches and impassability of a cavity of N. Chasto the outside part H. type of a remirovan which swelled up a little is sensitive with a pressure upon a tip of N. At a rinoskopiya the hematoma and abscess are presented in the form of the semicircular fluctuating education located on both sides of N.'s partition near a nasal opening.

Treatment consists in suction of blood the syringe and a dense tamponade of N. At suppuration — opening of abscess and a tamponade. Use of antibiotics accelerates involution of the inflammatory phenomena.

Furuncles of a nose often happen one of manifestations of the general furunculosis. At furuncle (see) N.'s morbidity, hypostasis, fascinating sometimes and the next parts of the face is noted; skin on a tip or on N.'s wing becomes sharply red, intense and very sensitive at a palpation. At survey of an inner surface of an entrance to N. on the limited site cone-shaped infiltrate, a hyperemia and strong morbidity at touch is defined. At development of abscess body temperature can be considerably increased.

Treatment at a furuncle conservative, consists in use of indifferent ointments. Sometimes in N. put every 3 — 4 hour the gauze tampon moistened in solution of burovsky liquid. Appoint antibiotics, locally UVCh. Such injuring manipulations as expression, massage, opening of a furuncle in the early period since it can lead to thrombophlebitis of veins of the person, thrombosis of a cavernous sine and meningitis are prohibited.

The pro-butting ulcer of a partition of a nose develops as result of front dry rhinitis: in a cartilaginous part of a partition of N. there is a limited ulcer of a round or oval form, to 1 cm in the diameter, edges are gradually led to a perforation of a partition of N. This disease is caused by the trophic changes of an epithelium and small injuries arising during removal of crusts from N. Probodayushchaya an ulcer of a partition of N. is observed sometimes at the working cement and accumulator works, the productions connected with getting and processing of chromic salts, arsenic, copper, corrosive sublimate, etc., and also at the addicts taking cocaine by drawing it on a mucous membrane of N.

The diagnosis is easy. At differential diagnosis it is necessary to exclude tubercular and syphilitic defeat of a partition of N. The tubercular ulcer is always surrounded with uneven edges with granulations, syphilitic affects more bone part of a partition of N.

At the formed perforation carefully clear edges of an ulcer and impose 2% yellow mercury ointment. Process of healing goes very slowly. Prevention of professional defeats provides the actions directed to removal of harmful impurity from air.

The sycosis of a vestibule of the nose is characterized by development of pyoinflammatory process in hair sacks of skin of N. and the fabric surrounding them, often combined with a sycosis of an upper lip and chin (see. Sycosis ). Cause of illness — the staphylococcal infection which got from adnexal bosoms of N. or brought by the contaminated fingers of hands from the outside. At this disease the nasal course is covered with the separate small, superficially located pustules penetrated by a hair. Their purulent contents quickly dry up in the crusts which are closely soldered to a hair. Skin is edematous, intense, painful. The sycosis is very often combined with eczema of a threshold of N. At treatment of a sycosis of a crust soften indifferent ointment, depilate tweezers, skin is disinfected by 1% solution of salicyl alcohol. Appoint lotions from burovsky liquid, 1 — 5% an emulsion of synthomycin. In hard cases conduct a course of antibacterial therapy. A recurrence of a disease is often observed.

Eczema of a threshold a nose and is the frequent satellite acute and hron, rhinitis, purulent damage of adnexal bosoms of N. and a nasopharynx. Eczema develops owing to irritation of skin of a threshold of N. following from N. patol, a secret. The frequent smorkaniye, N.'s wipe cause the long course of process. In acute cases the hyperemia and a swelling at an entrance to N., superficial exfoliating of an epithelium, serous and hemorrhagic or purulent crusts are noted. Eczema of a threshold of N. can be one of manifestations by the general eczemas (see). Treatment is directed to elimination of the main reason, i.e. N.'s diseases, a nasopharynx and adnexal bosoms. Fortifying means are shown: drugs of arsenic, iron, vitamins. For removal of crusts enter the tampons impregnated with indifferent ointment into a nose. At sharply proceeding becoming wet eczema resorcin has the drying-up effect (lotions from 1 — 2% of solution).

The ugly face of a nasal cavity develops usually for the second time, owing to transition of process from face skin. Primary ugly face of a cavity of N. meets seldom, as entrance gate for a streptococcal infection serve cracks and grazes in N. Zabolevaniye's wings begins with a fever, fervescence to 39 — 40 °, the painful redness extending from N. to the person and which is sharply delimited from healthy sites of skin, hypostasis of fabrics. The recurrent, so-called usual ugly face often is explained by existence of damage of adnexal bosoms of N. The diagnosis usually does not cause difficulties. Treatment is carried out by antibiotics. Appoint fortifying therapy, uv radiation of the center of an inflammation of 1 — 2 time is shown by an erythema dose.

Tuberculosis of a nose is shown in the form of the infiltrate or an ulcer which are located on N.'s partition on lower less often on an average sink. Disintegration of tubercular hillocks leads to formation of the ulcerations covered purulent, sometimes with bloody crusts. The diagnosis of tuberculosis of N. does not cause difficulties in the presence of other tuberculous focuses. Tumorous tubercular infiltrates need to be differentiated with sarcoma; in these cases the diagnosis is established on the basis of data of a biopsy. Treatment: appoint Ftivazidum, PASK and other antituberculous remedies, as well as at other forms tuberculosis (see).

Syphilis of a nose. Primary syphilis of N. meets seldom. Secondary syphilis, in the form of an erythema, is followed by hypostasis of a mucous membrane of N., and also department of a serous and hemorrhagic or mucous secret. Syphilitic differs from simple rhinitis in more long and persistent current.

The tertiary form of syphilis of N. is characterized by emergence of syphilitic infiltrates, syphilomas and products of their disintegration. Course of syphilis almost always progressing. If treatment is timely not begun, then there occurs deformation of N. Treatment is carried out by antisyphilitic means according to certain schemes depending on a stage syphilis (see).

Rhinisporidiosis. N.'s disease an infectious origin, is observed only in tropical countries. It is characterized by emergence of tumorous educations in lower parts of a cavity of N. They have more or less wide basis, reddish color, remind berry of raspberry, their surface is covered with the smallest white points — a sporangium (see. Rhinisporidiosis ). These educations can be single or multiple. The main symptom is N.'s mortgaging, the serous discharge sometimes strengthened; bleedings do not happen. The correct diagnosis can be made only by means of microscopic examination of educations. Duration of a disease is from 10 to 20 years. Treatment — - operational removal of education within a healthy mucous membrane. Multiple formations of a rhinisporidiosis very often recur.

Polyps arise owing to inflammatory diseases of adnexal bosoms of N. Polyps have gray, sometimes yellowish-red color, a jellylike consistence and a smooth surface. The size and their number strongly fluctuate. Klien, a picture at N.'s polyps is various: patients complain of N.'s congestion, a mucous discharge, a headache, fatigue, neuralgia is possible.

The diagnosis of polyps is established by means of a front and back rinoskopiya and a research by the probe.

Treatment operational also consists polyps under local anesthesia by means of a wire loop at a distance. After greasing of 5% solution of cocaine or 1 — 2% solution of Dicainum with adrenaline enter a loop into N., impose on a polyp, advance it to the place of an attachment and then tighten. Small, it is reserved the sitting polyps delete with various conchotomes or the cutting nippers.

Fig. 2. The diagrammatic representation of a configuration of a partition of a nose and nasal sinks at deformations of a partition of a nose (in black color the nasal cavity is shown): 1 — an easy curvature of a partition of a nose; 2 — a curvature of a partition of a nose with a hypertrophy of her mucous membrane; 3 — a S-shaped curvature of a partition of a nose; 4 — a curvature of a partition of a nose at an angle.

Deformations can be both inborn, and acquired, resulting from various diseases. Distinguish curvatures of a partition of N., a synechia and an atresia. Curvatures of a partition of N. can be in all departments, the back bone department is surprised much less often. The partition can be curved all in one party or S-shapedly (fig. 2). Sometimes an upper part is bent at an angle in relation to lower (a curvature in the form of a break). Thickenings of a partition of N. in the form of thorns and crests usually happen on its convex part, preferential on site connections of a cartilage with the upper edge of a share; thickenings happen as in back, and front departments of a partition of N., in one cases on a smooth direct part it, develop in others in the form of the isolated thickening (comb) throughout a partition (more often). Thickenings of a partition of N. without its simultaneous curvature meet seldom. Considerably less than curvatures of a partition, are observed swellings on the front end of an average sink (concha bullosa), to-rye are strongly stuck out inside and push aside a nasal partition to the opposite side, complicating passing of air.

At a curvature of a partition the main symptom is difficulty of breath through one or both half of N. The diagnosis is made on the basis of a front rinoskopiya and usually comes easy.

Treatment at the expressed curvatures of a partition of N. operational; it consists in partial or its full submucosal resection. Indications to operation are such curvatures, to-rye are followed funkts, frustration, difficulty of breath. Removal of crests and thorns of a partition of P. usually matches operation for a curvature. Swellings delete by means of a loop or a conchotome.

Also inborn and acquired unions in a cavity of N meet. At unions distinguish front and back synechias, i.e. formation of crossing points or thin bridges between separate parts H., and the atresias which are more or less closing a gleam of a cavity of N. Unions can be cartilaginous, bone or connective tissue. Synechias, in most cases, as well as atresias, are a consequence of ulcer processes in N.'s cavity at acute and chronic inf. diseases (smallpox, diphtheria, syphilis, rhinoscleroma and so forth). The atresias which are located at a postnaris more often happen unilateral, quite often have bone character, most of them are inborn. Unions in front departments of N. are more often acquired.

Find synechias and atresias by external examination and a rinoskopiya, a manual research of a nasopharynx, sounding of a cavity of N., a contrast X-ray analysis (tsvetn, the tab. of fig. 3 and 4).

Synechias usually split or excise hems with the subsequent use of laying. Treatment of choanal and especially bone atresias is more difficult, at the same time it is necessary to resort to a gouging their chisel with the subsequent recovery of a gleam of a postnaris.

Tumors. Classification of tumors of N. provides their clinical, morphological and gistogene-tichesky characteristic, and also extent of distribution of tumoral process. N.'s tumors on a wedge, to a current and structure divide on high-quality and malignant. Tumors of the epithelial nature meet more often, is more rare connective tissue and neurogenic.

Carry papilloma to benign tumors (see. Papilloma, papillomatosis ), adenoma (see), fibroma (see. Fibroma, fibromatosis ), hemangioma (see) the bleeding polyp, chondroma (see), neurinoma (see), osteoma (see). Distinguish papillomas of a threshold and a cavity of N. Papillomas of a threshold of N. of usually small sizes, gray color, dense, with a fleecy surface; they do not reach the considerable sizes and do not malignizirutsya (tsvetn, the tab. of fig. 5). Papillomas of a cavity of N. are more often localized in the field of the lower nasal sinks or a partition. This lobular or polipovidny formation of a soft consistence of gray-white color, by the form reminds a cauliflower, slightly bleeds. N.'s papillomas cause difficulty of nasal breath, emergence of slizistognoyny allocations, is frequent with impurity of blood. Persistent recuring of papillomas after their removal, prevalence of defeat and emergence of signs of destruction of a bone testify to a malignancy of papilloma.

Adenoma of a mucous membrane of N. meets seldom and the encapsulated tumor on the wide basis, by size usually no more than 2 cm in dia is localized in the field of nasal sinks, a share, back departments of a cavity of N. Eto., pink-gray color, covered with not changed mucous membrane. Adenoma is distinguished by the slow growth in this connection nasal breath is at a loss gradually. The malignancy of adenoma is followed by bystry increase in its sizes and germination in surrounding fabrics.

N.'s fibroma has a chicken skin, the wide basis, grayish and cyanotic color, an elastic consistence, grows slowly. An early wedge, a symptom of a tumor — difficulty of nasal breath. At an ulceration the slizistognoyny discharge with impurity of blood appears. Growth of a tumor can cause the shift of a partition of N. and deformation of outside N.

N.'s hemangiomas (capillary and cavernous) carry to rare tumors. They are localized, as a rule, on a lateral wall N. Opukhol differs in rapid growth, is followed by frequent nasal bleedings. Hemangiomas are inclined to a recurrence after removal, their malignancy is possible.

The bleeding polyps of cartilaginous department of a partition of N. have rounded shape, a smooth surface, red color. The wedge, a picture is characterized by sudden plentiful nasal bleedings.

The chondroma, neurinoma and osteoma of a cavity of N. meet extremely seldom, grow slowly. Their wedge, a current depends on the sizes, localization and the direction of growth of a tumor.

Treatment of benign tumors of a nose of hl. obr. operational, is sometimes applied cryosurgery (see). The volume of an operative measure is defined by localization and prevalence of defeat, and also gistol, a form of a tumor. During the carrying out operation both endonasal, and outside accesses can be used.

Radiation therapy is applied in a combination with operational treatment in cases of recuring of process, and also in the preoperative period for the purpose of reduction of the sizes of a tumor. It is used both intracavitary, and tele-irradiation. Exposure doses are chosen individually; single doses make 100 — 500 is glad (1 — 5 Gr), total doses 2000 — 4000 is glad (20-40 Gr).

Malignant tumors of a nose. Among all malignant tumors make 0,5%. Planocellular cancer (80%) meets more often, ferruterous cancer, a tsistadenoidny carcinoma, undifferentiated cancer is more rare (see. Cancer ) and not epithelial malignant tumors — sarcoma, a melanoma, an este-zioneyroblastoma, etc. Malignant tumors are localized preferential on a lateral wall of a nasal cavity — in the field of the average nasal course or an average nasal sink and usually quickly burgeon in a trellised labyrinth, a Highmore's bosom, a nasopharynx. They are distinguished by rare regional and remote innidiation, thus limf, nodes of submaxillary area are surprised more often (a submandibular triangle, T.) and upper third of a deep jugular chain, bone of a skeleton, brain. Because patients often arrive on treatment with widespread tumoral process, there are difficulties with definition of initial localization of a tumor.

Prevalence of tumoral process is classified by stages: I \the tumor is limited to one anatomic part without transition to adjacent areas and without destruction of a bone wall, regional metastasises are not defined; The Pa — a tumor extends to other wall of a nasal cavity, causing destruction of a bone tissue, but does not go beyond a cavity, regional metastasises are not defined; 11b — a tumor of the same degree or smaller distribution, but with a single metastasis on the party of defeat; Sha — a tumor affects the next anatomic cavities, goes beyond bone walls or passes to the second half of a nasal cavity, regional metastasises are not defined; 11 Ig — a tumor of the same or smaller degree of prevalence, as II 1a, but with multiple regional metastasises — bilateral or on the party of defeat; IVa — the tumor sprouts a base of skull, face skin, with extensive destruction of bones, without regional and remote metastasises; IVg — a tumor of any degree of local prevalence with the motionless regional or remote metastasises.

Malignant tumors of a cavity of N. have an appearance of the hilly ulcerating infiltrate or remind a polyp of gray color with a cyanotic shade. In early stages the disease proceeds asymptomatically. Initial the wedge, manifestations remind inflammatory processes, but with more permanent disturbance of functions H. which is not giving in to therapy. There is an incremental unilateral disturbance of nasal breath. The discharge from N. becomes plentiful, gains mucopurulent character, sometimes with impurity of blood. There are nasal bleedings, dacryagogue less often, increase cervical limf. nodes. For sarcomas (see), besides, the combination of disturbance of nasal breath to periodic plentiful bleedings from the struck half of a nose is characteristic.

Melanoma (see) meets seldom, strikes various departments of a cavity of N. and has an appearance of an exophytic tumor of characteristic crimson and cyanotic or black color, sometimes with an ulceration. The tumor early metastasizes in regional limf, nodes (tsvetn. tab. of fig. 6).

Fig. 3. Microdrug of an estezioneyroblastoma: rounded shape of a cell are located with the correct ranks and form arkadopodobny structures (are specified by an arrow); coloring hematoxylin - eosine; x 150.

Estezioneyroblastoma — the rare tumor developing from an olfactory neuroepithelium. Histologically it consists of the cells of a rounded or oval shape with a round large kernel reminding bipolar neuroblasts. Tumor cells are located with tyazha, quite often forming arkadopodobny structures (fig. 3). Stroma of a tumor friable, edematous. The tumor is more often localized in the field of an upper nasal sink and represents the myagkotkanny polyp which is quite often filling all half of a nose; it burgeons in adnexal bosoms of N., an eye-socket, a base of skull, a frontal lobe of a brain. The tumor metastasizes in limf, nodes of a neck, a mediastinum, a pleura, lungs, bones.

Diagnosis of malignant tumors at early stages of a disease is difficult. Careful studying of the anamnesis is necessary, shall be used a rinoskopiya and faringoskopiya (see), X-ray analysis (see) using contrast agents, tomography (see), tsitol, a research of punctates (see. Cytologic research ), biopsy (see).

Treatment of malignant tumors of N. is performed by the combined method consisting of radiation therapy and an operative measure, sometimes apply a cryosurgery. At the small tumors located in lower parts of a cavity of N. operation on Denker's method can be made (see. Denkera operation ), at localization of a tumor in upper parts — by Moore's method (see. Moura operation ). However more often the volume of an operative measure extends due to removal of anatomical structures of adnexal bosoms of N.

Existence of metastasises in regional limf, nodes of a neck is the indication for one - or bilateral fascial futlyarnogo excisions of cellulose of a neck. If metastasises are soldered to an internal jugular vein and grudino - a clavicular and mastoidal muscle, make operation on Krayl's method (see. Krayla operation ).

Radiation therapy of the malignant tumors which are subject to operational treatment is carried out in the preoperative or postoperative periods. If the tumor extends not more deeply than a submucosa, radiation is carried out by an intracavitary method daily on 300 — 700 I am glad (3,0 — 7,0 Gr) in a total dose 4000 — 7000 is glad (40,0 — 70,0 Gr). In cases when the tumor burgeons out of limits of a submucosa, carry out remote radiation therapy. At preirradiation the single dose makes 200 — 600 is glad (2,0 — 6,0 Gr), total 2000 — 5000 is glad (20,0 — 50,0 Gr); at postoperative — respectively 200 I am glad (2,0 Gr) and 3000 — 4500 I am glad (30,0 — 45,0 Gr).

When operational treatment is not shown, the combined radiation therapy can be carried out: intracavitary radiation in a total dose 2000 — 3000 I am glad (20,0 — 30,0 Gr) and tele-irradiation in a total dose 3000 — 4000 I am glad (30,0 — 40,0 Gr). If intracavitary radiation therapy does not manage to be carried out, the total dose of tele-irradiation is led up to 6000 — 7000 I am glad (60,0 — 70,0 Gr). The exposure dose, carried out with the palliative purpose, makes 4000 — 4500 is glad (40,0-45,0 Gr).

During performing radiation therapy apply a complex of preventive to prevention of beam injuries of skin, a mucous membrane of an oral cavity, eyes and upper respiratory tracts and to lay down. actions (see. Beam damages ). At the same time carry out a fortifying and symptomatic treatment. Appoint sedatives, transfusion of whole blood, blood substitutes, glucose with isotonic solution. In case of inclusion in the radiation zone of eyes it is possible keratitis (see) with the menacing perforation, panophthalmia (see), secondary glaucoma (see) in this connection systematic observation of the ophthalmologist is necessary.

The forecast at malignant tumors of N. is more often adverse.



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A. G. Likhachev; E. E. Antipov (An.), O. M. Maximova, A. I. Paches (PMC.), G. V. Muravskaya (I am glad.).

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