Medial walls of the maxillary sinuses. Features of the structure and function of the maxillary sinus, diseases of the nasal sinuses. Blackout: what does an x-ray show?
Paranasal sinuses. Topography of the paranasal sinuses. Maxillary sinus. Maxillary sinus. Topography of the maxillary (maxillary) sinus.
Adjacent to the nasal cavity on each side top maxillary and frontal sinuses, ethmoid labyrinth and partly sphenoid sinus.
Maxillary, or Gaimorova , sinus, sinus maxillaris, located in the thickness of the maxillary bone.
It is the largest of all the paranasal sinuses; its capacity in an adult is on average 10-12 cm3. The shape of the maxillary sinus resembles a tetrahedral pyramid, the base of which is located on the side wall of the nasal cavity, and the apex is at the zygomatic process of the upper jaw. The facial wall faces anteriorly, the superior, or orbital, wall separates the maxillary sinus from the orbit, the posterior wall faces the infratemporal and pterygopalatine fossae. The lower wall of the maxillary sinus is formed by the alveolar process of the maxilla, separating the sinus from the oral cavity.
Inner, or nasal, wall of the maxillary sinus from a clinical point of view the most important; it corresponds to most of the lower and middle nasal passages. This wall, with the exception of its lower part, is quite thin, and gradually becomes thinner from bottom to top. The hole through which the maxillary sinus communicates with the nasal cavity, hiatus maxillaris, is located high under the very bottom of the orbit, which contributes to the stagnation of inflammatory secretion in the sinus. The nasolacrimal canal is adjacent to the anterior part of the inner wall of the sinus maxillaris, and the ethmoidal cells are located to the posterosuperior part.
The superior, or orbital, wall of the maxillary sinus thinnest, especially in the posterior region. With inflammation of the maxillary sinus (sinusitis), the process can spread to the orbital area. The canal of the infraorbital nerve passes through the thickness of the orbital wall; sometimes the nerve and blood vessels are directly adjacent to the mucous membrane of the sinus.
Anterior, or facial, wall of the maxillary sinus formed by the area of the upper jaw between the infraorbital margin and the alveolar process. This is the thickest of all the walls of the maxillary sinus; it is covered with soft tissues of the cheek and is accessible to palpation. A flat depression in the center of the anterior surface of the facial wall, called the “canine fossa,” corresponds to the thinnest part of this wall. At the upper edge of the “canine fossa” there is an opening for the exit of the infraorbital nerve, foramen infraorbitale. rr pass through the wall. alveolares superiores anteriores et medius (branches of the n. infraorbitalis from the II branch of the trigeminal nerve), forming the plexus dentalis superior, as well as aa. alveolares superiores anteriores from the infraorbital artery (from a. maxillaris).
The lower wall, or bottom of the maxillary sinus, is located near the posterior part of the alveolar process of the upper jaw and usually corresponds to the sockets of the four posterior upper teeth. This makes it possible, if necessary, to open the maxillary sinus through the corresponding dental socket. With an average size of the maxillary sinus, its bottom is approximately at the level of the bottom of the nasal cavity, but is often located lower.
Nosebleeds can occur unexpectedly; some patients experience prodromal phenomena - headache, tinnitus, itching, tickling in the nose. Depending on the volume of blood lost, there are minor, moderate and severe (severe) nosebleeds.
Minor bleeding usually occurs from the Kisselbach area; blood in a volume of several milliliters is released in drops over a short time. Such bleeding often stops on its own or after pressing the wing of the nose against the septum.
Moderate nosebleeds are characterized by more heavy blood loss, but not exceeding 300 ml in an adult. In this case, hemodynamic changes are usually within the physiological norm.
With massive nosebleeds, the volume of lost blood exceeds 300 ml, sometimes reaching 1 liter or more. Such bleeding poses an immediate threat to the patient's life.
Most often, nosebleeds with large blood loss occur with severe facial injuries, when the branches of the sphenopalatine or ethmoidal arteries, which arise from the external and internal carotid arteries, respectively, are damaged. One of the features of post-traumatic bleeding is its tendency to recur after several days and even weeks. Large blood loss during such bleeding causes a drop in blood pressure, increased heart rate, weakness, mental disorders, and panic, which is explained by brain hypoxia. Clinical guidelines for the body’s reaction to blood loss (indirectly, the volume of blood loss) are the patient’s complaints, the nature of the facial skin, blood pressure level, pulse rate, and blood test results. With minor and moderate blood loss (up to 300 ml), all indicators remain, as a rule, normal. A single blood loss of about 500 ml can be accompanied by slight deviations in an adult (dangerous in a child) - pale facial skin, increased heart rate (80-90 beats/min), decreased blood pressure (110/70 mm Hg), in In blood tests, the hematocrit number, which quickly and accurately responds to blood loss, may decrease harmlessly (30-35 units), hemoglobin levels remain normal for 1-2 days, then they may decrease slightly or remain unchanged. Repeated moderate or even minor bleeding over a long period of time (weeks) causes depletion of the hematopoietic system and deviations from the norm of the main indicators appear. Massive severe simultaneous bleeding with blood loss of more than 1 liter can lead to the death of the patient, since compensatory mechanisms do not have time to restore the impairment of vital functions and, first of all, intravascular pressure. The use of certain therapeutic treatment methods depends on the severity of the patient’s condition and the predicted pattern of disease development.
Maxillary sinusitis (sinusitis) is a disease caused by an inflammatory process in the mucous membrane of the maxillary sinus.
The spread of inflammation to the mucous membrane of the maxillary sinuses in most cases occurs from the nasal cavity through the natural anastomosis. However, the close topographic-anatomical relationship of the maxillary sinus with the teeth of the upper jaw is the cause of the development of odontogenic maxillary sinusitis.
The maxillary sinus (sinus maxillaries) is located in the body of the upper jaw and is the largest air cavity of the skull. It is formed as a result of the ingrowth of the mucous membrane of the middle nasal meatus into the spongy bone tissue of the upper jaw.
(after Racoveanu V. [et al.], 1964)
Stages of development of the maxillary sinus:
1 - in a newborn; 2 - at the age of 1 year; 3 - at 4 years old; 4 - at 7 years old; 5 - at 12 years old; 6 - in adults; 7 - in old people; 8 - middle turbinate; 9 - nasal septum; 10 - inferior nasal concha
Simultaneously with the formation of the maxillary sinuses, the nerve trunks that innervate them grow in the tissue, a network of arterial, venous and lymphatic vessels is laid down and develops, and a complex mucoglandular and reticular apparatus is formed. According to A.G. Likhachev (1962), the volume of the sinus in an adult ranges from 3 to 30 cm 3, on average 10-12 cm 3. The inner, or nasal, wall of the maxillary sinus is the lateral wall of the nose and corresponds to most of the lower and middle nasal passages. The maxillary sinus opens into the nasal cavity through an opening located in the posterior part of the semilunar notch in the middle meatus under the middle turbinate. In approximately 10% of cases, in addition to the main hole, there is an additional one (hiatus accessorms maxillaries). The medial wall of the maxillary sinus, with the exception of its lower parts, is quite thin, which makes it easy to puncture it (in the middle third of the arch of the lower nasal passage under the inferior nasal concha), but often its thickness in this place is so significant that it is very difficult to puncture it. In the middle meatus, the bony wall becomes thinner or may be absent. In this case, the upper sections of the sinus are separated from the nasal cavity by a duplicate - a swarm of mucous membrane.
The upper, or orbital, wall of the maxillary sinus is the thinnest, especially in the posterior section, where bone clefts are often observed or even bone tissue is absent altogether. The canal of the infraorbital nerve passes through the thickness of the orbital wall, opening
An opening at the upper edge of the canine fossa of the anterior wall of the maxillary sinus (foramen infraorbitale). Sometimes the bony canal is absent, while the infraorbital nerve and accompanying blood vessels are directly adjacent to the sinus mucosa. This structure of the wall of the maxillary sinus increases the risk of intraorbital and intracranial complications in inflammatory diseases of this sinus (Onodi A., 1908).
The lower wall, or floor, of the maxillary sinus is located near the posterior part of the alveolar process of the upper jaw and usually corresponds to the sockets of the four posterior upper teeth, the roots of which are sometimes separated from the sinus only by soft tissue. Variants of the bays of the maxillary sinus that arise in ontogenesis in the process of resorption of the spongy bone of the body of the upper jaw during the formation of the sinus are shown in the figure.
(after Portmann G., 1966):
1 - palatine bay; 2 - orbital-ethmoidal bay; 3 - molar bay; 4 - maxillary sinus; 5 - alveolar bay
With the pneumatic type of the non-maxillary sinus, its bottom is low and can descend into the alveolar process and form an alveolar bay.
The low location of the bottom determines the location of the roots of the teeth and their sockets near or even inside the maxillary cavity. The sockets of the roots of the molars, especially the first and second, and sometimes the second premolar, protrude into the maxillary cavity with their relief, either separated from it by a thin layer of bone substance at the bottom of the socket, or directly adjacent to the mucous membrane lining the bottom. The sockets of the teeth protruding into the sinus have holes through which the periosteum of the root comes into contact with the mucous membrane of the sinuses. In this case, odontogenic infection in the corresponding teeth easily spreads to the mucous membrane of the maxillary sinus.
If the bottom of the maxillary sinus is low, it can be opened during tooth extraction.
The innervation of the maxillary sinuses is carried out by a complex system of nerve endings, represented by sensory, sympathetic and parasympathetic nerves. Sensitive innervation of the maxillary sinuses is carried out by the second branch (nervus maxillaries - maxillary nerve) of the trigeminal nerve (V pair of cranial nerves).
The maxillary nerve exits the cranial cavity through the foramen rotundum 4 into the pterygopalatine fossa.
(according to Krylova N.V., Nekrepko I.A., 1986):
A - pterygopalatine nerves; B - zygomatic nerve; 1 - trigeminal node; 2 - maxillary nerve; 3 - middle branch of the meninges; 4 - round hole; 5 - pterygopalatine node; 6 - greater petrosal nerve; 7 - parasympathetic fibers - secretory; 8 - inferior orbital fissure; 9,10 - zygomaticotemporal and zygomaticofacial branches of the zygomatic nerve; 11 - connecting branch; 12a, 12b, 12c - superior alveolar nerves; 13 - upper dental plexus; 14 - inferior orbital foramen; 15 - branches of the lower eyelid; 16 - external nasal branches - innervate the skin of the lateral surface of the nose; 17 - branches of the upper lip
Here the pterygopalatine nerves A depart, which enter the pterygopalatine ganglion 5. As part of these nerves, postganglionic parasympathetic fibers pass (dashed line), which join the maxillary nerve 2, then as part of the zygomatic nerve B and then the connecting branch 11 and unite with the frontal nerve and sympathetic fibers from the orbital plexus and provide secretory innervation to the lacrimal gland. The zygomatic nerve is divided into two branches: zygomaticotemporal 9 and zygomaticofacial 10. Both branches exit the zygomatic bone through the same holes 13 and innervate the skin of the lateral part of the forehead, temporal region, cheek, and lateral corner of the eye.
The inferior orbital nerve (n. infraobritalis), like the zygomatic nerve, enters the orbital cavity through the inferior orbital fissure 8, runs along its lower wall in the inferior orbital groove and canal (sulcus et canalis infraorbital), in which the superior alveolar nerves (nn) depart from the nerve alveolares superiores). The infraorbital nerve exits to the skin of the face through the infraorbital foramen 14, which ends the infraorbital canal. Upon exiting the canal, the infraorbital nerve branches and innervates the skin of the lower eyelids (ramipalpebrales inferiores) 15, the skin of the lateral surface of the nose (rami nasales externi) 16 and the skin of the wings of the nose and upper lip, the mucous membrane of the gums and upper lip (rami labiates superiores) 17.
The extensive reflexogenic zone of the maxillary sinus with its numerous arterial, venous and lymphatic plexuses, rich in glandular apparatus, is provided by parasympathetic and sympathetic innervation.
Parasympathetic innervation of the maxillary sinuses is carried out by the peripheral part of the parasympathetic nervous system; its fibers go as part of the greater petrosal nerve, which departs from the facial nerve and enters the pterygopalatine ganglion. This is a parasympathetic node that provides stimulation of the cholinoreactive structures of the maxillary sinuses, manifested by vasodilation, increased secretion of mucous glands, increased permeability of the vascular wall, which leads to tissue edema. These signs are characteristic of vasomotor-allergic sinusopathy.
Sympathetic innervation of the maxillary sinuses, stimulating the corresponding adrenergic structures, ensures their trophism.
It is carried out in two ways: 1) through the nerve plexuses surrounding the numerous vascular branches of the sphenopalatine and ethmoidal arteries (see below); 2) along the branch of the internal carotid plexus (plexus caroticus internus), constituting the deep petrosal nerve (n. petrosus profundus), which, together with the greater petrosal nerve 6, forms the nerve of the pterygoid canal (n. canalis pterygoidei), entering through the canal of the same name into the pterygopalatine hole.
Thus, the maxillary nerve innervates the dura mater (DRM), the skin of the cheek, lower eyelid, upper lip, lateral surface and wings of the nose; mucous membrane of the posterior parts of the nasal cavity, maxillary sinus, palate, upper lip and gums of the upper jaw; upper teeth. Through connections with the VII pair it provides proprioceptive innervation of facial muscles.
The blood supply to the maxillary sinuses provides a number of primary and secondary physiological processes in them. The first includes the supply of tissues with nutrients, oxygen, immunity factors, etc. The second includes those secondary functions of the blood supply that create certain conditions for optimizing the respiratory function, in which the maxillary sinuses participate (moisturizing, warming, regulating air flow speed, removing foreign particles from the sinuses by the ciliated epithelium).
The main vessel supplying the tissues of the maxillary sinuses is the sphenopalatine artery (a. sphenopalatina) - a branch of the maxillary artery (a. maxillaris). It enters the nasal cavity through the pterygopalatine opening, accompanied by the vein and nerve of the same name. The main trunk of the pterygopalatine artery is divided into medial and lateral branches, which vascularize the maxillary sinuses. Speaking about the blood supply to the maxillary sinuses, it should be noted the presence of anastomoses between the system of external and internal carotid arteries, which supply blood to the orbits and the anterior cranial fossa.
The venous network of the maxillary sinuses is also associated with the anatomical formations mentioned above. The veins of the maxillary sinuses follow the course of the arteries of the same name, and also form a large number of plexuses connecting the veins of the maxillary sinuses with the veins of the orbits and face. The veins of the maxillary sinuses are also connected to the veins of the pterygoid plexus, the blood from which flows into the cavernous sinus and veins of the dura mater. All this plays an exceptional role in the occurrence and implementation of inflammatory processes in this area, the development of intraorbital and intracranial complications in particularly virulent and chronic infections of the maxillary sinuses. The lymphatic vessels of the maxillary sinuses, along with the veins, play an important physiological role in the processes of trophism, metabolism and immune defense of the anatomical areas of which they are collectors. The lymphatic system of the maxillary sinuses consists of superficial and deep layers. The direction of the draining lymphatic vessels of the mucous membrane of the maxillary sinuses corresponds to the course of the main trunks and branches of the arteries feeding the mucous membrane.
(according to Denker A., Kaller O., 1912):
1 - nasofrontal; 2 - corner; 3 - anastomosis between the inferior orbital vein and the pterygoid plexus; 4 - front facial; 5 - chin; 6 general facial; 7 - internal jugular; 8 - back front; 9 - superficial temporal; 10 - pterygoid plexus; 11 - lower orbital; 12 - cavernous plexus; 13 - superior orbital
The commonality of innervation, arterial, venous and lymphatic vessels of the maxillary sinus and the alveolar process of the upper jaw and the sockets of the four posterior upper teeth located in it contributes to the transition of inflammation from odontogenic foci to the mucous membrane of the maxillary sinuses.
The transition of inflammation from odontogenic foci to the mucous membrane of the maxillary sinus can occur through the lymphatic tract without direct contact of its mucous membrane with the lesion by involving the nerve branches through the superior dental plexus, which is intimately connected with the mucous membrane of the sinuses. The richness of the arterial network of vessels of the upper jaw and the richness of anastomoses between individual branches also determine the possibility of the spread of odontogenic processes along the blood vessels.
The maxillary sinuses are lined with mucous membrane covered with multirow prismatic ciliated epithelium. The main morphofunctional units of the epithelium in the sinuses are ciliated, intercalary and goblet cells.
(according to Maran A., Lund V., 1979):
1 - ciliated cell; 2- basal cell; 3 - goblet cell; 4 - insertion cell; 5 - eyelashes; 6 - microforks; 7 - mitochondria; 8 - mucus granules; 9 - cell nucleus
Ciliated cells have on their surface 50-200 cilia, 5-8 in length, 0.15-0.3 microns in diameter (Richelman G., Lopatin A.S., 1994). Each cilium has its own motor device - an axoneme, which is a complex complex consisting of 9 pairs (doublets) of peripheral microtubules arranged in the form of a ring around two unpaired central microtubules. The movement of cilia is carried out thanks to the myosin-like protein they contain (Vinnikov Ya. L., 1979). The beating frequency of the cilia is 10-15 strokes per minute, the motor activity of the cilia of the ciliated epithelium ensures the movement of nasal secretions and particles of dust and microorganisms settled on it in the maxillary sinuses in the direction from their bottom towards the excretory anastomosis.
(according to Fred S., Herzon M., 1983):
1 - ciliary membrane;
2 - central pair of microtubules;
3 - peripheral pair of microtubules (doublet); 4, 5, 6 - subunits of the peripheral doublet
Modern ideas about the movement of cilia of the ciliated epithelium are based on the results of studies by A. M. Lucas and L. C. Douglas, published in 1934.
(after Lucas A. and Douglas L., 1934):
a - effective phase of cilia movement; b - phase of return movement; 1 - upper viscous layer of mucus; 2 - lower less viscous (periciliary) layer of mucus; 3 - microorganisms and foreign bodies
According to A. M. Lucas and L. S. Douglas (1934), each cycle of this movement resembles a rowing stroke and consists of two phases: effective and return. In the first phase, the cilia move like a straight, rigid rod, the upper end of which describes an arc of 180°, reaching the surface of the mucus layer covering it. In the second phase of movement, the cilia move like flexible threads, pressing their free ends to the surface of the cell.
Mutations that cause changes in the structure of cilia proteins lead to disruption of their function. Thus, with Kartagener syndrome, which is an autosomal recessive hereditary disease accompanied by a triad of symptoms: 1) bronchiectasis with chronic bronchopneumonia; 2) chronic polypous rhinosinusitis and 3) inversion of internal organs, immobility of the cilia of the ciliated epithelium of the entire respiratory tract occurs. The latter is caused by the absence of denenin arms (subunits of peripheral doublets) of the cilia axoneme (Bykova V. P., 1998). This lack of normal physiological locomotion of the ciliated epithelium leads to disruption of the drainage function of the maxillary sinus and causes its numerous diseases.
Under the influence of various unfavorable factors (aerosols, toxins, concentrated solutions of antibiotics, changes in pH in the acidic direction, a decrease in the temperature of inhaled air, as well as the presence of contact between the opposing surfaces of the ciliated epithelium), the movements of the cilia slow down and may stop completely.
Normally, ciliated cells are renewed every 4-8 weeks. (Herson F. S., 1983). When exposed to pathological factors, they quickly undergo degeneration.
The intercalary cells, located between the ciliated ones, have 200-400 microvilli on their surface, facing the lumen of the respiratory organ. Together with ciliated cells, intercalary cells carry out and regulate the production of periciliary fluid, determining the viscosity of the secretion of the mucous membrane of the maxillary sinus.
Goblet cells are modified columnar epithelial cells and are single-celled glands that produce viscous mucus (Baslanum S.V., 1986). Ciliated cells are related to goblet cells in a 5:1 ratio (Naumann N., 1996; Herzon F., 1983).
In the lamina propria of the mucous membrane there are glands that produce serous and mucous secretions. In the secretion covering the epithelium of the maxillary sinuses, two layers are distinguished: a less viscous periciliary layer, adjacent to the surface of the epithelial cells, and a more viscous upper layer, located at the level of the tips of the cilia (Reissing M. A., 1978; Kaliner M. A., 1988) .
Ciliated and mucous cells form the so-called mucociliary apparatus, the normal functioning of which ensures the capture, envelopment of mucus and movement of most particles with a diameter of up to 5-6 microns, including particles containing viruses, bacteria, aerosols, from the sinus cavity to the excretory opening. Dysfunction of the mucociliary apparatus is considered as one of the important factors contributing to the penetration of an infectious pathogen into the mucous membrane, giving rise to the development of maxillary sinusitis (Drettner B., 1984).
Nasal mucus in healthy people has an alkaline reaction (pH 7.4 ± 0.3). It contains a number of nonspecific (lysozyme, complement, protease inhibitors) and specific (immunoglobulins) protective factors (Naumann N., 1978).
The maxillary sinuses open into the nasal cavity through openings known as the ostium. The openings of the maxillary sinuses are located on the lateral walls of the nasal cavity in the ethmoidal funnels of the middle nasal passage. The area in the nasal cavity where the maxillary sinus opens is called the ostio-meatal, or bone-canal complex.
The ostio-meatal complex is the region of the lateral wall of the nasal cavity where the uncinate process, the maxillary foramen, the middle turbinate, the ethmoidal vesicle and the ethmoidal infundibulum are located.
The uncinate process is a small and thin piece of bone with periosteum, covered with mucous membrane, which runs parallel and medial to the lateral wall of the nose in the anterior part of the middle meatus.
In front and below, the bone connects to the side wall of the nose. The rear upper edge ends freely without connecting to other structures. This posterior edge is concave and runs parallel to the anterior surface of the spherical protrusion of the ethmoid bone. The flat gap between the greater ethmoid vesicle and the uncinate process is known as the hiatus semilunaris. It is the entrance to a cavity connected medially with the uncinate process and laterally with the lateral wall of the nose. This three-dimensional cavity is known as the ethmoidal funnel (ethnzoid infimdibulurri). The maxillary sinus, as well as the frontal sinus and the anterior cells of the ethmoid sinus open into the ethmoidal funnel, and then into the semilunar fissure.
The complex is important because all sinuses are drained through its very narrow slits. When the mucous membrane thickens or with any congenital anomaly, there is a very high probability of congestion, stagnation and recurrent infection entering the maxillary sinus. Functional endoscopic surgery of the maxillary sinuses is based on the concept that this complex must be drained to restore normal drainage function of the sinuses.
Inflammatory diseases of the paranasal sinuses (sinusitis) are among the most common diseases of the upper respiratory tract. According to the literature, patients with sinusitis make up about 1/3 of the total number of people hospitalized in ENT hospitals (Kozlov M. Ya., 1985; Soldatov I. B., 1990; Piskunov G. Z. [et al.], 1992; Arefieva N A., 1994). Most authors, in terms of the frequency of involvement in the inflammatory process, put the maxillary sinus (maxillary sinusitis) in first place. According to the course, acute and chronic sinusitis are distinguished. In the etiology of both acute and chronic sinusitis, infection penetrating the sinuses is of primary importance. The most common route is through the natural anastomosis that connects the sinus with the nasal cavity. In acute infectious diseases (typhoid, diphtheria, scarlet fever, measles), infection of the sinuses is possible hematogenously. In the etiology of maxillary sinusitis, purulent foci of the dental system, especially large and small molars adjacent to the lower wall of the sinus, also play a role. The most common cause of odontogenic maxillary sinusitis is foreign bodies penetrating into the sinus from the oral cavity, filling material, fragments of broken dental instruments, fallen tooth roots, and turundas. Granulomas at the root of the tooth, subperiosteal abscesses, and periodontal disease can also lead to the occurrence of odontogenic maxillary sinusitis (Ovchinnikov Yu. M., 1995).
Acute odontogenic maxillary sinusitis(sinusitis) is one of the most well-known diseases of the paranasal sinuses. With this sinusitis, patients are bothered by a headache localized in the area of the projections of the maxillary sinus. However, in many cases its distribution is noted in the forehead, zygomatic bone, and temple. It can radiate to the orbital region and to the upper teeth, that is, the pain practically covers the entire half of the face.
A very characteristic increase and sensation of a “tide” of heaviness in the corresponding half of the face when the head is tilted forward. Headache is associated with secondary trigeminal neuralgia and impaired sinus barofunction as a result of swelling of the mucous membrane and blockage of the anastomosis. There may be swelling of the cheek on the affected side.
Palpation in the area of the sinus projection increases pain. Severe swelling of the face and eyelids is more typical for complicated sinusitis. Patients note nasal congestion and mucous or purulent discharge, as well as a decreased sense of smell on the side of inflammation.
Anterior rhinoscopy allows you to establish hyperemia and swelling of the mucous membrane of the lower and especially the middle nasal concha. The presence of serous or purulent discharge (purulent track) in the middle nasal meatus is characteristic, which can also be determined by posterior rhinoscopy. In cases where the purulent path is not detected (with severe swelling of the mucous membrane overlying the anastomosis), it is also recommended to anemize the area of the middle nasal passage and turn the patient's head in the healthy direction. In this position, the outlet of the sinus is at the bottom, and pus (if any) will appear in the middle nasal meatus.
The diagnosis of acute odontogenic sinusitis is established on the basis of complaints, analysis of the described symptoms and the results of an X-ray examination. X-ray examination currently continues to be the leading one among radiation and other non-invasive diagnostic methods. For X-ray examination of the maxillary sinuses, nasofrontal and nasomental placement are used, as well as an orthopantomogram and targeted photographs of the teeth. A more informative x-ray examination is linear tomography. Computed tomography (CT) and magnetic resonance imaging (MRI) are even more informative.
. Frontal (coronal) projection. The slice passes through the maxillary sinuses (1) and the cells of the ethmoidal labyrinth (2):
a - the anastomosis of the maxillary sinuses with the nasal cavity (arrow), the uncinate process (two arrows), forming the ostio-meatal complex, are clearly visible; b - in the left maxillary sinus and the left ethmoidal labyrinth there is an inflammatory process involving the structures of the ostio-meatal complex. Gaperostosis of the left maxillary sinus is noted, indicating chronic inflammation (arrow)
X-ray and CT examination methods produce a known radiation dose. Therefore, in cases where it is not desirable (for example, for persons who have received radiation damage), it is advisable to use methods that are not based on ionizing radiation. The most famous and simple method is diaphanoscopy. A diaphanoscope is a small-sized device that allows local illumination of the paranasal sinuses. In a dark room, the diaphanoscope illuminator is inserted into the patient’s mouth. Normally, the air-containing maxillary sinuses are well illuminated and appear as pink fields under the eye sockets. If there is pus or tumor in these sinuses, they are not visible. The results of the study during diaphanoscopy are indicative. In recent years, methods of ultrasonic dowsing, thermography and thermal imaging have been introduced into outpatient practice. These methods are distinguished by their safety and speed of obtaining results. However, their information content is inferior to X-ray, CT and MRI studies.
When examining the maxillary sinuses, puncture and trephine puncture are also used.
The most common manipulation is puncture of the maxillary sinus. The puncture is performed under epimucosal (application) anesthesia with a 2% dicaine solution or a 3-5% cocaine solution with the addition of a few drops of a 0.1% adrenaline solution. The sinus is punctured with a Kulikovsky needle, which is inserted under the inferior nasal concha, 2 cm from its anterior end at the point where the concha attaches to the lateral wall, where its thickness is the smallest. Possible complications (among them a needle getting into the eye socket) are described in the monograph by I. Ya. Temkin (1963). The puncture can be performed with a trocar, through which an endoscope can be inserted to view the sinus.
For acute sinusitis characterized by homogeneous darkening of the sinuses involved in the inflammatory. If the picture is taken in a vertical position of the subject, then if there is exudate in the sinus, it is possible to observe the fluid level. Treatment of uncomplicated acute odontogenic maxillary sinusitis is usually conservative. It can be performed on an outpatient or inpatient basis. Polysinusitis, as well as maxillary odontogenic sinusitis, accompanied by severe headache, swelling of the soft tissues of the face and the threat of developing orbital and intracranial complications, should be treated in a hospital. Treatment of acute odontogenic sinusitis, as well as other focal infections, consists of a combination of general and local methods. The local treatment of acute sinusitis is based on the well-known principle “ubi pus bi evacuo” (if there is pus, remove it).
All therapeutic measures underlying this principle are aimed at treating teeth adjacent to the lower wall of the maxillary sinuses and improving the outflow of purulent secretions from the sinuses. The first and simplest of them is anemization of the nasal mucosa, which can be accomplished using official vasoconstrictors (naphthyzin, sanorin, galazolin). It is more effective for a doctor to specifically coat the mucous membrane in the area of the middle nasal passage with a 3-5% solution of cocaine or an anesthetic - a 2% solution of dicaine with 3-4 drops of a 0.1% solution of adrenaline per 1 ml of the drug. Anemization of the mucous membrane and a decrease in its volume contribute to the expansion of sinus anastomosis and facilitate the outflow of exudate. This is also facilitated by thermal procedures (sollux, diathermy, UHF). However, they should be prescribed provided there is good outflow from the sinuses. The compress has not lost its meaning either. Correctly applied to the corresponding half of the face, the compress improves microcirculation in the area of the inflammatory process, reduces swelling of the soft tissues of the face and nasal mucosa, restoring the patency of the anastomosis and drainage of the sinuses. UHF is poorly tolerated by patients with vascular disorders, including vegetative-vascular dystonia.
The range of physiotherapy treatments has expanded in recent years. New devices for microwave therapy have appeared (for example, “Luch-2”), which make it possible not only to increase tissue heating, but also to localize precisely dosed energy to a limited area, which reduces the risk of unwanted side effects. These requirements are also met by new methods such as laser therapy, magnetic and magnetic laser therapy.
Puncture of the maxillary sinuses, despite the known dangers (Temkina I. Ya., 1963), continues to be one of the most common methods of conservative treatment and is used both in inpatient and outpatient practice.
If repeated punctures of the maxillary sinuses are necessary, permanent drainages are used, which are thin polyethylene or fluoroplastic tubes that are inserted into the sinus for the entire period of treatment, relieving the patient of unpleasant manipulations.
Through the inserted drainage tube, the sinus is systematically washed with an isotonic or furatsilin solution (1: 5000) and other medications (usually antibiotics) are administered.
The introduction of medicinal solutions into the maxillary sinuses is possible using the “movement” method according to Proetz. With this method, a vacuum is created in the nasal cavity using surgical suction. It allows you to remove pathological contents from the sinuses, and after infusing medicinal solutions into the nasal cavity, the latter rush into the opened sinuses.
A more successful non-puncture method of treating inflammatory diseases of the paranasal sinuses, especially with polysinusitis, is carried out using the YamiK sinucateter (Markov G.I., Kozlov V.S., 1990; Kozlov V.S., 1997). This device allows you to create controlled pressure in the nasal cavity and paranasal sinuses and thereby evacuate pathological exudate from the sinuses, followed by the introduction of medicinal solutions into them through the opened anastomosis.
As a general treatment for patients with acute odontogenic maxillary sinusitis, analgesics, antipyretics, antihistamines and antibacterial drugs are prescribed. Currently, due to the known adverse side effects of antibiotics (dysbacteriosis, development of fungal flora, allergization, inhibition of antibody production), there is a tendency to narrow the indications for their use. However, if necessary, penicillin 500,000 units 4-6 times a day, as well as other antibiotics with a wider spectrum of action (zeporin, keflin, kefzol, etc.) can be prescribed. The prescription of antibiotics should be adjusted in accordance with the sensitivity of the microflora obtained from the site of inflammation. Sulfonamide drugs (sulfadimethoxine, sulfalene, biseptol, etc.) are prescribed both independently and in combination with antibiotics. Considering the likelihood of the presence of anaerobic flora, usually in acute sinusitis with a severe clinical form, it is recommended to enhance antibacterial therapy with drugs that have an etiotropic effect on anaerobic infection (Trichopol, Metragil).
With odontogenic maxillary sinusitis, when it is necessary to remove the “causal” teeth (complicated caries, periodontitis), an unwanted opening of the maxillary sinus is possible. The resulting canal connecting the sinus to the oral cavity (oroantral fistula) can close on its own or after repeated lubrication with iodine tincture. Otherwise, they resort to plastic closure of the fistula by moving a flap cut from soft gum tissue, which is a difficult operation, most successfully performed by maxillofacial surgeons.
Recently, implantation materials (collagen films with methyluracil and hydroxyapatite-honsuride compositions) have been used to close fresh oroantral communications, which significantly reduces the time and increases the effectiveness of its treatment (Rozhdestvenskaya E. D., 1998). R. G. Anyutin (1999) for this purpose uses other composite materials created on the basis of hydroxyapatite - hydroxyapol and kolapol.
Chronic odontogenic maxillary sinusitis usually arise as a result of repeated and insufficiently cured acute sinusitis. Of significant importance in their development is a combination of unfavorable factors of a general and local nature - such as a decrease in the body's reactivity, impaired drainage and aeration of the sinuses, caused by anatomical abnormalities and pathological processes in the nasal cavity, as well as dental diseases.
The variety of pathomorphological changes in chronic sinusitis, representing various variants of exudative, proliferative and alternative processes, determines the diversity of clinical and morphological forms and the difficulties of their classification.
At present, the classification of chronic sinusitis proposed by B. S. Preobrazhensky (1956) continues to be the most acceptable. According to this classification, there are exudative (catarrhal, serous, purulent) and productive (parietal hyperplastic, polypous) forms of sinusitis, as well as cholesteatoma, necrotic (alterative), atrophic and allergic sinusitis.
In exudative forms, a picture of diffuse inflammatory infiltration with lymphocytes, neutrophils and plasma cells is observed. It is more pronounced in purulent than in catarrhal and serous forms. In these cases, the epithelium is flattened and metaplastic in places. Edema is observed in areas of greatest inflammation.
In hyperplastic forms, the thickening of the mucous membrane is more pronounced than in previous forms. Pathomorphological changes are predominantly proliferative in nature due to the proliferation of connective tissue elements of the own layer of the mucous membrane. The formation of granulation tissue and polyps is noted. The development of connective tissue in some areas can be combined with sclerosis and hardening of the mucous membrane in other places (Voyachek V.I., 1953). The inflammatory process spreads to all its layers, in some cases including the periosteal layer. This leads to periostitis, and if the process develops unfavorably, to osteomyelitis. Due to the development of sclerosis of the mucous membrane and the delay of resorptive processes in bone disease, the formation of pseudocholesteatoma, which is thickened mucus without cholesterol inclusions and with a large number of leukocytes, as well as colonies of putrefactive microbes, is possible. The accumulation of pseudocholesteatoma and caseous masses and the pressure they exert on the walls of the maxillary sinuses lead to bone resorption and the formation of fistulas (Khilov K. L., 1960). It has now been established that such forms of sinusitis can also develop as a result of fungal infections of the sinuses (L. B. Dainyak, N. Ya. Kunelskaya, 1979; A. S. Lopatin, 1995). A special place is occupied by allergic forms of sinusitis, which are combined with similar processes in the nasal cavity and are called allergic rhinosinusitis (rhinosinusopathies). This form is characterized by the appearance of round-shaped formations in the maxillary sinuses. They represent local swelling of the mucous membrane and are often incorrectly called cysts. In these cases, during puncture of the maxillary sinus, the needle pierces this cyst-like formation and an amber-colored serous fluid pours into the syringe, and the walls of the bladder collapse.
The fundamental difference between such a pseudocyst and a true cyst of odontogenic origin is that it has only an outer epithelial lining formed by the sinus mucosa. The pseudocyst cavity is formed as a result of the splitting of the own layer of the mucous membrane by the transudate accumulating in its thickness. A true cyst of odontogenic origin also has an internal epithelial membrane emanating from the periodontium.
:
1 - internal epithelial membrane emanating from the periodontium; 2 - mucous membrane lining the sinus
The size of the pseudocyst (allergic swelling of the mucous membrane) can change under the influence of hyposensitizing therapy and the administration of glucocorticoids.
On radiographs, in cases of odontogenic cysts, a thin, partially resorbed bone layer may be seen contouring the cyst. It is formed as a result of displacement of the lower wall of the maxillary sinus by a developing cyst.
Clinical symptoms in chronic odontogenic maxillary sinusitis outside the acute stage are less pronounced than in acute ones. Some patients may experience decreased ability to work. The nature of the symptoms and their severity largely depend on the form of sinusitis, the localization of the process and its prevalence. Headache with chronic sinusitis is less severe and may be of an uncertain nature. However, in some cases, patients precisely localize the pain in the area of the affected sinus. Nasal congestion is usually moderate, more pronounced in polypous allergic and fungal forms of sinusitis, which is associated with similar lesions of the nasal mucosa. Patients often note a disturbance in their sense of smell.
The nature of nasal discharge also depends on the form of sinusitis. With fungal infections, they have certain characteristic differences. Thus, with mold mycoses, the discharge is usually viscous, sometimes jelly-like, and has a whitish-gray or yellowish color. With aspergillosis, the discharge is gray, possibly blackish patches, which can be thick, resembling cholesteatoma masses. With candidiasis, the discharge is similar to a cheesy, whitish mass.
With fungal sinusitis, neurological pain in the area of the affected sinus is often observed. More often than with other forms of sinusitis, swelling of the soft tissues of the face is observed, usually in the area of the maxillary sinus (Dainyak L. B., Kunelskaya V. Ya., 1979).
With exacerbation of chronic odontogenic maxillary sinusitis, the clinical picture resembles an acute process of sinus damage and often depends on the presence or absence of complications. It is necessary to pay attention to the ability of chronic sinusitis to occur in a mild latent form, when the clinical symptoms are not clear enough. This condition indicates the presence of a certain balance in the development of the pathological process - balance between the body and the disease. Causing overstrain and exhaustion of immune mechanisms, it usually leads to the development of certain, often very serious, complications. It was precisely this feature of latent sinusitis that A.I. Feldman (1929) pointed out, giving them not only an impeccable definition, but also emphasizing their hidden danger. “Latent sinusitis,” according to the author, are those that pass secretly, unnoticed by the patient and even the doctor; their physical symptoms are almost absent, and only some complication from neighboring organs forces both the patient and the doctor to pay attention to the nose. It is interesting to note that back in 1857, Professor of the Medical-Surgical Academy Zablotsky-Desyatovsky, in his work “On diseases of the nose and nasal cavities,” noted that their chronic diseases are often asymptomatic or have few symptoms.
The diagnosis of chronic odontogenic maxillary sinusitis is established on the basis of clinical and radiological data. X-ray, as well as CT and MRI studies are the most important diagnostic methods for identifying various forms of chronic sinusitis. They are supplemented by punctures of the sinuses and laboratory tests of the resulting contents.
It should be noted that carrying out the described diagnostic procedures requires the doctor to have good orientation in the deep parts of the nose and high technique of manipulation.
The treatment tactics for chronic odontogenic maxillary sinusitis is determined by the clinical form of the disease. During exacerbation of chronic sinusitis, its exudative forms (catarrhal, serous, purulent) are treated, as a rule, conservatively. In this case, the same means and treatment methods are used that are used in the treatment of acute sinusitis. Productive forms of chronic odontogenic maxillary sinusitis (polypous, polypous-purulent) are treated surgically. Regardless of the form of chronic sinusitis in the presence of visual and intracranial complications, the main method should be surgical treatment.
At polypous sinusitis, combined with nasal polyposis, preliminary nasal polypotomy is indicated.
The main goal of surgical treatment for chronic odontogenic maxillary sinusitis is to remove the affected teeth and create conditions for restoring the normal function of the affected maxillary sinus. To do this, regardless of the surgical approach, the damaged sinus anastomosis with the nasal cavity is created anew or restored, ensuring its free drainage and ventilation. Thus, we are talking about restoring the impaired function of the ostio-meatal complex.
Modern ideas about the functional significance of the mucous membrane (the transport function of the ciliated epithelium) determine the maximum sparing of tissues. In this regard, some authors (Proetz, 1953) compare curettage of the sinus mucosa during surgery for chronic sinusitis with removal of the bronchial mucosa during bronchitis. Other authors adhere to a similar position (Voyachek V.I., 1953; Khilov K.L., 1960; Piskunov S.Z., Piskunov G.Z., 1991).
There are a significant number of different options and modifications of surgical interventions on the maxillary sinuses, proposed for the treatment of sinusitis. All of them, depending on the approach, are divided into extranasal and endonasal.
The nature of anesthesia during sinus surgery depends on the age of the patient, his general condition, the presence of concomitant diseases, complications and the volume of surgery. Anesthesia can be local (a combination of epimucosal, infiltrative and conductive) and general.
Extranasal operations - operations on the maxillary sinus. The most common in clinical practice are the Caldwell-Luc, A.I. Ivanov and Denker operations, which are performed through the vestibule of the mouth.
Caldwell-Luke operation. After retracting the upper lip with blunt hooks, an incision is made in the mucous membrane and periosteum along the transitional fold, starting from the second incisor (at a distance of 3-4 mm from the frenulum) and ending at the level of the second large molar.
:
a - incision of the mucous membrane along the anterior wall of the sinus; b - expansion of the burr hole; c - overlap of the sinus anastomosis with the lower nasal meatus
The mucous membrane and periosteum are separated upward until fossa canina is exposed. Using a Voyachek grooved chisel or a grooved chisel, a small hole is made in the thinnest part of the anterior wall of the sinus, allowing a preliminary examination of the sinus with a button probe. After orientation, it is expanded using Gaek's forceps or wider Vojacek's chisels to the size necessary for a detailed revision of the sinus and subsequent manipulations. Pathological contents are removed (purulent and necrotic masses, granulations and polyps), as well as the mucous membrane in a limited area of the medial wall of the sinus, where the anastomosis is supposed to overlap with the nasal cavity. Most of the slightly changed sinus mucosa is preserved. Using a chisel or chisel, part of the bone wall between the sinus and the nasal cavity is removed. An elliptical hole is formed. Its upper edge should not be higher than the attachment of the inferior turbinate. The lower edge of the hole is smoothed with a sharp spoon so that there is no threshold between the bottom of the nose and the bottom of the sinus. A curved button-shaped probe is inserted into the lower nasal passage, with which the mucous membrane of the lateral wall of the nose protrudes into the maxillary sinus. Using a sharp eye scalpel, a U-shaped flap is cut out from the side of the sinus, which is placed on the lower edge of the formed anastomosis. However, in most cases, if the mucous membrane in the sinus is preserved, there is no need for a U-shaped flap and it is removed. To prevent postoperative bleeding, the sinus cavity is loosely tamponed with a long tampon soaked in an antiseptic with vaseline oil. The end of the tampon is brought out through the formed anastomosis and fixed with a cotton “anchor” along with loop tampons of the corresponding half of the nose. The wound is sutured with catgut sutures. Tampons are removed after 2 days.
Operations on the maxillary sinus according to A.F. Ivanov and Denker are variants of operations according to Caldwell-Luc. A.F. Ivanov suggests making a hole on the anterior wall of the sinus somewhat laterally, and Denker, on the contrary, more medially. In this case, part of the wall of the pyriform opening is removed. The Denker operation is performed in cases where a broader approach is needed not only to the maxillary sinus, but also to the deeper parts of the nasal cavity and nasopharynx.
It should be noted that most maxillofacial surgeons, in the surgical treatment of odontogenic maxillary sinusitis, especially in the presence of persistent oroantral communication, operate using the traditional technique of radical maxillotomy and communication plastics.
However, an analysis of the study of complaints from patients in the long term after surgery shows that most often patients complain of nasal discharge on the side of the operation, a feeling of heaviness and discomfort in the area of the operated upper jaw, disturbances in the sensitivity of the skin and mucous membrane of the upper lip on the corresponding side, on numbness of the mucous membrane of the gums and a feeling of numbness in the teeth of the upper jaw (Tsvigailo D. A., 2001). In this case, an important role is played by postoperative cicatricial changes in the lining mucous membrane of the maxillary sinus, as a result of which zones of stagnation are formed that prevent the advancement of secretion in the sinus, normally directed to the natural anastomosis due to the oscillatory movements of the villi of the ciliated epithelium. All this creates favorable conditions for the development of a chronic inflammatory process in the operated sinus. In such a situation, swelling of the nasal mucosa, which occurs during colds, is the trigger for the exacerbation of chronic odontogenic maxillary sinusitis.
Therefore, at present, surgical treatment of chronic odontogenic maxillary sinusitis with persistent oroantral communication in specialized clinics is carried out using a gentle endoscopic maxillotomy technique with simultaneous plastic surgery of the oroantral communication.
Endonasal operations of the paranasal sinuses were developed almost simultaneously with extranasal ones. However, only with the advent of modern endoscopes with fiber optics and long-focus operating microscopes, endonasal operations began to be introduced into clinical practice.
Modern endonasal sinusotomies are based on surgical techniques developed at the beginning of the 20th century. Galle, O. Girsch, A.F. Ivanov, F.S. Bokshtein, etc. It is appropriate to add that endonasal operations are the real embodiment of V.I. Voyachek’s sparing principle in otorhinolaryngology, which he promoted throughout his long clinical career.
Here is a description of modern endonasal polysinsotomy. The operation begins with a preliminary examination of the nasal cavity using an endoscope (with 0° optics). A detailed average rhinoscopy is performed with the identification of all anatomical formations and identification points. Then the middle turbinate is pushed medially with a rasp. The uncinate process is identified by inserting the tip of a button probe behind it. Posterior to the process is the anterior wall of the ethmoid bulla. These formations form the semilunar fissure. Using a sickle-shaped knife, the uncinate process is cut off from top to bottom and removed with nasal forceps. The same forceps are used to perforate the anterior wall of the ethmoidal bulla, and the instrument penetrates into its cavity. By removing the bone bridges, all cells of the ethmoidal labyrinth are sequentially opened. Its roof, which is the base of the skull, is exposed. The bone in this area tends to have a whiter hue. It should be remembered that too medial manipulation of the skull base may cause damage to the cribriform plate and lead to penetration of the instrument into the anterior cranial fossa. On the other hand, too lateral direction of the instrument can lead to damage to the paper plate and the contents of the orbit; to expand the anastomosis of the maxillary sinus, after preliminary removal of the uncinate process, it is preferable to use an endoscope with 30° optics. It is placed in the middle nasal meatus. Using a button probe, the natural anastomosis of the maxillary sinus is identified. Using anthrotomy nippers, the so-called reverse nipper or a sharp spoon (curette), the anastomosis is widened.
:
a - nasal forceps-nippers (reverse pliers) for antrotomy (opening the maxillary sinus); b - spoon type Siebermann - Yu. B. Preobrazhensky; c - a spoon with sharp edges (the so-called catfish), proposed at the Department of Otolaryngology of the Academy
It should extend posteriorly from the upper edge of the inferior turbinate and anteriorly to the level of the lacrimal tubercle, having a diameter of 5-7 mm. It should be taken into account that expansion of the anastomosis anteriorly beyond the level of the lacrimal tubercle is fraught with damage to the lacrimal ducts, and posteriorly to the level of the posterior end of the middle turbinate is dangerous with damage to a. sphenopalatina. Excessive upward expansion of the anastomosis can lead to orbital injury.
"Diseases, injuries and tumors of the maxillofacial area"
edited by A.K. Iordanishvili
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- the largest of the paranasal sinuses (see Fig. 1). The shape of the sinus generally corresponds to the shape of the body of the upper jaw. The volume of the sinus has age-related and individual differences. The sinus can continue into the alveolar, zygomatic, frontal and palatine processes. The sinus is divided into superior, medial, anterolateral, posterolateral and inferior walls. It appears earlier than other sinuses and in newborns it appears in the form of a small pit. The sinus gradually increases during puberty, and in old age it becomes even larger due to the resorption of bone tissue.
Upper wall of the sinus, separating it from the orbit, consists of a compact substance for a greater extent and has a thickness of 0.7-1.2 mm, thickening at the infraorbital margin and the zygomatic process. The lower wall of the infraorbital canal and infraorbital groove are very thin. Sometimes in some areas of the bone it is completely absent, and the nerve and vessels passing in this canal are separated from the mucous membrane of the maxillary sinus only by the periosteum.
Medial wall, bordering the nasal cavity, consists entirely of a compact substance. Its thickness is smallest in the middle of the lower edge (1.7-2.2 mm), greatest in the area of the anteroinferior angle (3 mm). At the point of transition to the posterolateral wall, the medial wall is thin; at the transition to the anterior wall, it thickens and contains the canine alveolus. In the superoposterior section of this wall there is an opening - the maxillary cleft, connecting the sinus with the middle nasal passage.
Anterolateral wall in the area of the canine fossa it is somewhat depressed. In this place it consists entirely of a compact substance and has the smallest thickness (0.2-0.25 mm). As you move away from the fossa, the wall thickens (4.8-6.4 mm). At the alveolar, zygomatic, frontal processes and the inferolateral edge of the orbit, the compact plates of this wall are divided by spongy substance into outer and inner. The anterolateral wall contains several anterior alveolar canaliculi, running from the infraorbital canal to the roots of the anterior teeth and serving for the passage of blood vessels and nerves to the anterior teeth.
Rice. 1. Maxillary sinus; frontal section of the skull, rear view:
1 - groove of the superior sagittal sinus; 2 - cockscomb; 3 - cribriform plate; 4 - frontal sinus; 5 - lattice labyrinth; 6 - eye socket; 7 - maxillary sinus; 8 - opener; 9 - incisive hole; 10 - palatine process; 11 - inferior nasal concha; 12—middle turbinate; 13 - superior nasal concha; 14 - perpendicular plate of the ethmoid bone
Posterolateral wall over a larger extent it is a compact plate, expanding at the transition to the zygomatic and alveolar processes and containing spongy substance in these places. The wall thickness is the smallest in the superoposterior region (0.8-1.3 mm), the greatest - near the alveolar process at the level of the 2nd molar (3.8-4.7 mm). The posterior alveolar canaliculi pass through the thickness of the posterolateral wall, from which branches arise that connect with the anterior and middle alveolar canaliculi. With severe pneumatization of the upper jaw, as well as as a result of pathological changes, the inner wall of the tubules becomes thinner and the mucous membrane of the maxillary sinus is adjacent to the alveolar nerves and vessels.
The inferior wall has the shape of a groove where the anterolateral, medial and posterolateral walls of the sinus meet. The bottom of the groove in some cases is flat, in others it has protrusions corresponding to the alveoli of the 4 front teeth. Protrusion of the alveoli of the teeth is most pronounced in the jaws, in which the bottom of the sinus is at the level of the nasal cavity or below it. The thickness of the compact plate separating the bottom of the alveolus of the 2nd molar from the bottom of the maxillary sinus often does not exceed 0.3 mm.
Ossification: in the middle of the 2nd month of intrauterine development, several points of ossification appear in the connective tissue of the maxillary and medial nasal processes, which merge by the end of the 3rd month, forming the body, nasal and palatine processes of the upper jaw. The incisive bone has an independent ossification point. At the 5th-6th month of the intrauterine period, the maxillary sinus begins to develop.
Human anatomy S.S. Mikhailov, A.V. Chukbar, A.G. Tsybulkin
Maxillary (maxillary) sinus(sinus maxillaris) - steam room and the largest of the paranasal sinuses of the nasal cavity. Its shape and size depend on many factors, primarily on the degree of development of the upper jaw.
The medial wall of the sinus is adjacent to the middle and lower nasal passages. Such relationships are important for understanding the possibility of difficulty in the outflow of pathological fluid during sinusitis, since the canal connecting the sinus cavity and the nasal cavity opens in the area of the middle nasal meatus and is located above its bottom. In addition, the lower part of its inner wall can be used to provide access to the sinus for the purpose of drainage. It is also necessary to note the possibility of additional natural openings on this wall; most often they are located posterior to the permanent one.
The anterior outer wall is somewhat depressed at the location of the canine fossa. Inside this wall are the anterior alveolar canaliculi, running from the infraorbital canal to the roots of the anterior teeth, through which vessels and nerves pass to their roots.
The upper wall is very thin, at the same time it is the lower wall of the orbit and contains in its anterior section the inferoorbital canal with the vessels and nerve of the same name. Sometimes the canal does not have a lower wall, and then the nerve is separated from the sinus cavity only by the periosteum. This explains trigeminal neuralgia in
pathological processes in the sinus. The wall is not an obstacle to the spread of inflammatory processes from the sinus cavity to the tissue of the orbit.
The lower wall (bottom) of the sinus has varying thickness. Sometimes there may be no bone tissue between the roots of the teeth and the sinus cavity, and the bottom consists only of the periosteum and mucous membrane. This close location creates the possibility of inflammatory processes transferring from the apex of the tooth and surrounding tissues to the mucous membrane of the maxillary sinus.
The bottom of the sinus corresponds to the location of the roots of the second small molar, the first and second large molars. Less frequently, the bottom extends anteriorly to the level of the first small molar and canine, and posteriorly - to the roots of the third large molar.
Rice. 10.18. Relationship between tooth roots and maxillary sinus. 1 - maxillary cleft; 2 - pterygopalatine fossa; 3 - maxillary sinus; 4 - roots of teeth; 5 - eye socket; 6 - frontal sinus
The posterior outer wall is a compact bone over a larger area. In the places of transition to the zygomatic and alveolar processes it contains spongy substance. The posterior alveolar tubules pass through its thickness, from which branches extend, connecting with the anterior and middle tubules of the same name.
Frontal sinus(sinus frontalis) steam room (Fig. 10.19). The right one is separated from the left by a septum located approximately along the midline. The position of the sinuses corresponds to the superciliary arches. They look like triangular pyramids with the base pointing down. The formation of sinuses occurs between the ages of 5 and 20 years. The sinuses extend upward beyond the brow ridges, outward to the outer third of the upper edge of the orbit or to the supraorbital notch, and descend downward into the nasal bone. The anterior wall of the sinuses is represented by the superciliary tubercle, the posterior one is relatively thin and separates the sinus from the anterior cranial fossa, the lower one forms part of the upper wall of the orbit and at the midline of the body - part of the nasal cavity, the inner wall is a partition that separates the sinuses from each other. The upper and outer walls are missing, since the front and back walls meet at an acute angle. A small proportion of people do not have frontal sinuses. There may be no septum separating the right and left frontal sinuses.
Rice. 10.19. Frontal, sphenoid sinuses and labyrinth of the ethmoid bone. (from: Zolotareva T.V., Toporov G.N., 1968):
1 - frontal sinus; 2 - labyrinth of the ethmoid bone; 3 - sphenoid sinus
They open into the middle nasal passage in front of the opening of the maxillary sinus with a canal up to 5 mm long. Sometimes the frontal sinuses can open into the maxillary sinuses.
Sphenoid sinus(sinus sphenoidalis) is embedded in the body of the sphenoid bone and is divided by a septum into two communicating cavities. It develops between the ages of 2 and 20 years and is extremely variable in shape and size. The sizes of the right and left halves of the sinus are different. Opens into the middle nasal meatus. Sometimes the sinus may be absent.
Ethmoid sinuses(sinus ethmoidalis) are represented by cells corresponding to the level of the superior and middle turbinates and form the upper part of the lateral wall of the nasal cavity. Cells communicate with each other. On the outside they are delimited from the orbit by a very thin bone plate. If it is damaged, air can enter the tissue of the orbit, which can lead to exophthalmos. From above, the cells are delimited by a septum from the anterior cranial fossa. The anterior and middle groups of cells open into the middle nasal passage, the posterior - into the upper nasal passage.
MOUTH AREA
Region mouth (regio oris) consists of the oral cavity and its walls. Topographically, it is located between the bottom of the nasal cavity and the hyoid bone, extending posteriorly to the anterior wall of the pharynx.
Borders areas of the mouth: above - a horizontal line drawn through the base of the nasal septum, below - a horizontal line drawn along the supramental fold, on the sides correspond to the nasolabial folds.
Lips
Borders lips The upper lip has its upper border at the base of the nasal septum and the nasolabial groove. The lower lip is separated from the chin by the chin-labial groove. In older people, from the corner of the mouth downwards, as a continuation of the nasolabial fold, there is a labiomarginal groove separating the lower lip from the cheek.
The upper and lower lips are connected at the corners of the mouth by commissures.
The lips consist of three parts: cutaneous, intermediate and mucous. Leather The lips are somewhat compacted and contain appendages in the form of sebaceous and sweat glands, hair follicles.
Intermediate part has a red border - an area in which the venous network is visible through the non-keratinizing epithelium. On the upper lip, this area is delimited from the skin by a line called “Cupid’s bow.” In this part of the lip, only the sebaceous glands are preserved. In newborns, this part of the lips is covered with a large number of papillae.
Mucous part lips facing the vestibule of the oral cavity, contains the salivary labial glands. In infants, the mucous membrane is very thin, mobile, its folds and frenulum are more clearly expressed.
Sensory innervation is carried out by the superior labial nerves (from the infraorbital nerve), the inferior labial nerves (from the mental nerve), and in the area of the corners of the mouth - by branches of the buccal nerve.
The shape and size of the lips vary significantly. The upper lip usually stands forward and covers the lower lip. Significant enlargement of the lips is called macrocheylia, strong reduction - microchylia, protruding lips - prochylia, straight lips - ortoheylia, sunken lips - epistocheylia.
Subcutaneous fat moderately expressed.
Muscular part The lips are formed by the circular muscle of the mouth (m.orbicularis oris), which consists of two parts - labial and marginal (facial). The labial part is located within the red border, and the marginal part is in the area of the lips covered with skin. The labial part is formed by circularly arranged fibers (sphincter), the facial part is formed by an interweaving of circular fibers and muscle bundles running from the oral opening to the places of fixation on the bones of the facial part of the skull.
The muscles that determine the position and shape of the lips include:
Muscles that lift the upper lip and wing of the nose (mm. levator labii superuiores et alae nasi);
Muscles that lift the angle of the mouth (mm. levator anguli oris);
Small zygomatic muscles (mm. zygomatici mino);
Large zygomatic muscles (mm. zygomatici major);
Muscles that lower the lower lip (mm. depressor labii inferiores);
Muscles that lower the angle of the mouth (mm. depressor anguli oris);
Mental muscle (m. mentalis);
Laughter muscle (m. risorius);
Upper and lower incisor muscles (mm. incisivi superior et inferuior);
Buccal muscles (mm. in uccinator).
The muscles are innervated by branches of the facial nerve.
Through the muscle spaces, the submucosa of the lips communicates with the subcutaneous fatty tissue.
Along the free edge in the submucosal layer there are the upper and lower labial vessels (aa., vv. labiales superiores et inferiores). The arteries are branches of the facial arteries, and the veins drain into the facial veins. Both arterial and venous vessels anastomose with each other, forming the perioral vascular circles. Additional blood flow occurs from the branches of the infraorbital (a. infraorbitalis; from the maxillary artery), mental artery (a. mentalis; from the inferior alveolar) and the transverse artery of the face (a. transversa faciei; from the superficial temporal artery).
Lymphatic drainage carried out in the submandibular, chin, buccal, parotid, superficial and deep cervical lymph nodes.
Oral cavity
When the mouth is closed, the oral cavity is divided by the alveolar processes of the jaws and teeth into the anterior section - the vestibule of the oral cavity and the posterior section - the oral cavity itself.
Vestibule of the oral cavity limited in front and sides by the lips and cheeks, and behind by the alveolar processes of the jaws and teeth. The volume of the vestibule can be increased due to the pronounced extensibility of the anterior and lateral walls. Communication with the oral cavity proper is carried out through the interdental spaces and slit-like spaces behind the third large molars.
In anticipation of the oral cavity, on the mucous membrane of the cheek at the level of the first and second upper molars, the excretory ducts of the parotid salivary glands open.
The mucous membrane of the lips is mobile due to loose submucosal tissue containing a large number of mucous glands. From the lips in the lateral sections the mucous membrane passes into the mucous membrane of the cheeks, and at the top and bottom it wraps around the gums. Along the midline of the lips in the sagittal plane there are folds formed by the mucous membrane - the frenulum.
The oral cavity itself. With the jaws closed, the oral cavity is a slit-like space located between the back of the tongue and the vault of the soft palate.
Anterolateral wall formed by the alveolar processes of the jaws and teeth. Cells are located on the alveolar processes
roots of teeth. Correspondingly, the cells on the outer surface of the processes are contoured by ridges covered with mucous membrane. The mucous membrane covering the alveolar processes is tightly fused with the periosteum; in addition, it also covers the necks of the teeth. Behind the posterior large molars there is a fold of mucous membrane corresponding to the ligament lig. sphenomandibulare, serving as a guide for conduction anesthesia of the inferior alveolar nerve.
The upper wall is formed by the hard palate (Fig. 10.20). It is concave in the anteroposterior and lateral directions. The bony basis of the hard palate is made up of the palatine processes of the upper jaws and the horizontal plates of the palatine bones. The degree of concavity depends on the height of the alveolar process. In people with a dolichomorphic body type, the arch of the palate is high, while in people with a brachymorphic body type, it is flatter. Newborns usually have a flat palate. The vault of the palate is formed as the upper jaw develops, its alveolar process and growth
Rice. 10.20. Hard and soft palate (from: Zolotareva T.V., Toporov G.N., 1968): a - covered with mucous membrane: 1 - incisive papilla; 2 - transverse palatal folds; 3 - palatal suture; 4 - mouths of the palatine glands; 5 - palatine tonsil; 6 - tongue. b - after removing the mucous membrane: 1 - palatine glands; 2 - velopharyngeal muscle; 3 - palatoglossus muscle; 4 - reed muscle; 5 - palatine tonsil; 6 - muscle that lifts the soft palate; 7 - palatine arteries
teeth. In old age and senility, with the loss of teeth, regression of the alveolar process and flattening of the vault of the hard palate occur.
In newborns, the palatine processes of the upper jaw are connected to each other by a layer of connective tissue. With age, the layer of connective tissue decreases. By the age of 35-45, the bony fusion of the palate suture ends and the junction of the processes will acquire a certain relief: concave, smooth or convex. With a convex shape of the suture, a protrusion is noticeable in the middle of the palate - the palatine ridge (torus palatinus). Sometimes the cushion may be located to the right or left of the midline. The presence of a pronounced palatine ridge makes prosthetics of the upper jaw difficult.
When the palatine processes are underdeveloped, a diastasis remains between them, characteristic of a congenital defect (“cleft palate”).
The palatine processes of the upper jaw, in turn, fuse with the horizontal plates of the palatine bones, forming a transverse bone suture.
The thickness of the mucous membrane varies. In the lateral sections it is thicker and thins towards the midline. Sometimes a longitudinal cord is visible along the midline, corresponding to the suture of the palatine processes. In the area of the palatal suture and in areas of the palate adjacent to the teeth, the submucosal layer is absent, and the mucous membrane is fused directly with the periosteum. In the anterior sections, there is adipose tissue in the submucosal layer, and in the posterior sections there are accumulations of mucous glands.
A number of elevations are visible on the mucous membrane. At the anterior end of the longitudinal suture near the central incisors, the incisive papilla (papilla incisiva) is clearly visible, which corresponds to the incisive fossa located here (fossa incism). In this fossa, the incisive canals (canales incisivi) open, in which the nasopalatine nerves (nn. nasopalatini) pass. Here local anesthesia is performed to numb the anterior part of the palate (Fig. 10.21).
In the anterior third of the hard palate, to the sides of the suture there are transverse palatine folds (plicae palatinae transversae) in the amount of 2-6, usually 3-4. In children, the transverse palatal folds are well expressed, in adults they are smoothed out, and in old people they can disappear. At the level of the third large molars, at a distance of 1-1.5 cm inward from the gingival margin, there are large palatine openings through which the large palatine arteries, veins and nerves pass (aa., vv., nn. palatini majores), and posterior to them - projections of the small palatine foramen of the greater palatine
palatine canal, through which small palatine blood vessels and nerves exit to the palate (aa., vv., nn. palatini minores). In some people, the projection of the greater palatine foramen shifts to the level of the 2nd or 1st molar, which is important to consider when performing local anesthesia and surgical interventions. Venous vessels drain blood into the pterygoid venous plexus and the veins of the submucosal plexus of the nose (through an anastomosis with the anterior nasal veins in the area of the incisive foramen).
Lymph from the hard palate flows through vessels located in the thickness of the palatine arches, into the lymph nodes of the lateral wall of the pharynx and the deep cervical lymph nodes.
At the back, the hard palate passes into the soft palate, which in a calm state hangs freely downwards and backwards, touching its free edge with the root of the tongue, thus constituting the posterior wall of the oral cavity. When the soft palate contracts, it rises and forms a pharynx, through which the oral cavity communicates with the pharyngeal cavity. In people with a brachymorphic body type, the soft palate is flattened and lies horizontally. In persons with a dolichomorphic physique, it descends more vertically. In newborns, the soft palate consists of two halves, fused after birth, and is located horizontally.
Soft sky formed by a fibrous plate - the palatine aponeurosis (aponeurosis palatinus) and paired muscles: the muscle that lifts the soft palate (m. levator veli palatin), the muscle that strains the soft palate (m. tensor veli palatini), the lingual palatine muscle (m. palatoglossus), pharyngeal-palatine muscle (m.palatopharyngeus), uvula muscle (m.uvulae). Anteriorly, the fibrous plate is attached to the hard palate. The soft palate has the shape of an irregular quadrangle and is covered with a mucous membrane.
The submucosa of the soft palate contains a large number of mucous glands. On the posterior edge there is a protrusion - the uvula palatina; two arches are formed on the sides: the anterior - lingual-palatine - goes from the middle part of the soft palate to the lateral surface of the posterior part of the tongue, the posterior - pharyngeal-palatine - goes to the side wall of the pharynx. Between the arches there is a tonsillar fossa, its lower part is deepened and is called the tonsil sinus. It houses the palatine tonsil.
Blood supply the soft palate is carried out by the small and large palatine arteries, as well as branches from the arteries of the cavity walls
nose Venous outflow is carried out into the veins of the same name and further into the pterygoid venous plexus, pharyngeal veins and facial vein.
Lymphatic drainage occurs in the peripharyngeal, retropharyngeal and upper deep cervical lymph nodes.
Innervation carried out by the small palatine nerves from the pharyngeal nerve plexus. The muscles that tense the velum palatine are innervated by the mandibular nerve.
Rice. 10.21. Blood supply and innervation of the palate (from: Elizarovsky S.I., Kalashnikov R.N., 1979):
1 - incisive hole; 2 - nasopalatine nerve; 3 - greater palatine nerve; 4 - greater palatine foramen; 5 - lesser palatine foramen; 6, 7 - small palatine nerves; 8 - palatine tonsil; 9 - small palatine arteries; 10 - great palatine artery; 11 - anastomosis with the artery of the nasal septum
Bottom wall(bottom) of the oral cavity is formed by soft tissues located between the lower jaw and the hyoid bone (Fig. 10.22), as well as the muscle of the oral diaphragm - the mylohyoid muscle (m. mylohyoideus). On the sides of the midline above the diaphragm of the mouth there is the geniohyoid muscle (m.geniohyoideus), as well as the muscles of the tongue, starting from the hyoid bone. Below the diaphragm of the mouth lie the anterior bellies of the digastric muscles.
The floor of the mouth is covered with mucous membrane in front, partly on the sides of the tongue, between it and the gums of the lower jaw. A series of folds are formed at the transition points of the mucous membrane:
The frenulum of the tongue (frenulum linguae) is a vertical fold that runs along the lower surface of the tongue to the bottom of the mouth;
Rice. 10.22. Frontal cut through the floor of the mouth (from: Zolotareva T.V.,
Toporov G.N., 1968):
1 - paired bed of sublingual salivary glands; 2 - unpaired intermuscular space between the genioglossus muscles; 3 - muscular-fascial gap between the anterior bellies of the digastric muscles and the mylohyoid muscles; 4 - paired intermuscular spaces between the genioglossus and geniohyoid muscles; 5 - paired interfascial gaps between the subcutaneous muscle of the neck, covered with superficial fascia, and the second fascia of the neck, forming the vagina of the submandibular gland
Sublingual folds (plicae sublinguales) lie on the sides of the frenulum along the elevations (ridges) formed by the sublingual salivary glands. The small ducts of these glands open here. At the medial ends of the ridges there are sublingual papillae (carunculae sublinguales), on which the ducts of the submandibular glands and large sublingual ducts open.
Anterior to the salivary papillae near the lower jaw are the ducts of the small incisive salivary glands, which are located behind the incisors under the mucous membrane.
A feature of the structure of the mucous membrane is the presence of a well-defined submucosa, consisting of loose connective and adipose tissue. The mucous membrane easily folds.
Under the mucous membrane of the floor of the mouth, between the underlying muscles and anatomical structures, there are a number of cellular spaces.
Lateral cellular spaces limited from above by the mucous membrane passing from the tongue to the gum, from below - by the mylohyoid muscles, from the inside - by the tongue, from the outside - by the lower jaw; they contain the sublingual glands, surrounded by fiber. These spaces can be the site of localization of suppurative processes.
The sublingual salivary gland usually has an ovoid or triangular shape, with a lobular structure. In approximately 15% of cases, the lower process of the gland is found, penetrating through the gap in the mylohyoid muscle into the submandibular triangle. The gland is covered with a thin fascial capsule.
The large sublingual duct begins near the inner surface of the gland and runs along it to the sublingual papilla. In addition, small excretory ducts originate from individual lobules of the gland (especially in its posterolateral sections), which open independently into the oral cavity along the sublingual fold.
Blood supply gland is carried out by the sublingual (branch of the lingual) and submental (branch of the facial) arteries. Venous drainage occurs in the sublingual vein.
Lymphatic drainage carried out to the submandibular lymph nodes.
Innervation occurs due to the submandibular and sublingual nerve ganglia, as well as sympathetic nerves running in the adventitia of the hypoglossal artery from the superior cervical ganglion.
Internal intermuscular space unpaired, located between the two genioglossus muscles, filled with loose fatty tissue.
External intermuscular spaces paired, located between the genioglossus and hyoid-glossus muscles.
Lower intermuscular space unpaired, lies between the mylohyoid and anterior bellies of the digastric muscles.
Submandibular cellular spaces paired, formed from the outside by the inner surface of the lower jaw below the mylohyoid muscles, from the inside - by the splitting of the second fascia of the neck (proper fascia, deep layer of the own fascia of the neck). One plate of fascia lines the mylohyoid muscle, and the second goes superficial to the submandibular salivary gland and is attached to the base of the lower jaw. The space contains the submandibular salivary gland, lymph nodes, vessels and nerves. May be the location of phlegmon.
Blood supply The floor of the oral cavity is carried out by the lingual, facial, and superior thyroid arteries. The outflow of blood occurs into the veins of the same name.
Lymphatic drainage from the floor of the oral cavity occurs in the deep cervical and mental groups of lymph nodes.
Innervation carried out by the lingual, hypoglossal, maxillary-hyoid (from the lower alveolar) nerves, as well as from the facial nerve (posterior belly of the digastric muscle, styloglossus muscle).
Topography of teeth
The timing of the eruption of primary and permanent teeth is presented in table. 10.1.
Incisors. Externally, in the crown area, the incisors resemble a chisel (Fig. 10.23). The upper internal incisors have a wider crown, while the external ones have a much smaller crown. The lower teeth are smaller than the upper ones, but the external ones are slightly wider than the internal ones. There is a tubercle on the lingual surface of the incisors. All incisors
Table 10.1. Timing of eruption of primary and permanent teeth
(according to A.F. Tour, 1955)
cognate; the roots are round in shape and taper towards the top. Sometimes root duplication occurs on the lower internal incisors; in this case, the labial and lingual parts are distinguished.
Fangs. A distinctive feature of these teeth is the presence of a single long root of a powerful cone-shaped crown, tapering towards the cutting edge and ending in a pointed tubercle. A longitudinally located ridge is visible on the labial surface, and there is a tubercle on the lingual surface. The roots are compressed from the sides. A feature of the topography of the upper roots is that they can reach the base of the frontal process of the upper jaw and approach the lower edge of the orbit - the eye teeth. Sometimes on the lower canines there is a bifurcation of the roots into the lingual and labial parts.
Small molars. These teeth have an irregular prismatic crown with an oval chewing surface on the top. On the latter, the buccal and lingual tubercles are distinguished. The roots are usually single. The exception is the first upper molar, in which the root can be bifurcated to varying degrees. On the upper jaw, the roots are somewhat compressed in the anteroposterior direction, and longitudinal grooves are located on the surfaces. On the lower jaw, the roots are cone-shaped.
Large molars. The crowns of these teeth are the largest, resembling a cube. The size of the teeth decreases from the 6th to the 8th. The third large molar is called the wisdom tooth. Chewable
Rice. 10.23. Anatomy and topography of the tooth in the alveolus (from: Kishsh F., Sentagotai Ya., 1959)
1, 14 - alveolar process of the upper jaw; 2 - tooth root canal; 3 - compact plate of the tooth socket; 4, 11 - periosteum of the upper jaw; 5, 12 - periosteum of the alveoli; 6 - gums; 7 - dentin; 8 - tooth enamel; 9 - interglobular spaces; 10 - dental pulp; 13 - periodontium; 15 - hole of the tooth root canal
The surfaces on the 6th and 7th teeth of the upper jaw bear 4 tubercles - 2 buccal and 2 lingual. On the lower jaw, the 6th tooth bears 5 tubercles on the chewing surface - 3 buccal and 2 lingual, the 7th tooth has 4 tubercles.
The roots on the 6th and 7th teeth of the upper jaw are triple, with one of them being lingual and two being buccal. On the lower jaw, these teeth have double roots - anterior and posterior. The anterior root is located almost vertically, the posterior one is compressed in the anteroposterior direction and inclined posteriorly. The teeth on the lower jaw are larger than those on the upper jaw.
Wisdom teeth are often underdeveloped and have a wide variety of shapes and positions. They are the smallest of the large molars. There are three cusps on the chewing surface of the crown. The roots are often single, short, conical.
All teeth, when exposed to physical activity, wear down at different times. In addition, the type of bite also influences this.
Blood supply teeth of the upper jaw is carried out from the basin of the maxillary artery - the superior posterior alveolar, superior anterior alveolar and infraorbital arteries. The teeth of the lower jaw are supplied with blood by the branches of the inferior alveolar artery.
Outflow of venous blood carried out through the veins of the same name into the pterygoid venous plexus from the upper jaw and into the retromandibular vein or pterygoid plexus from the lower jaw.
Innervation carried out by the branches of the maxillary nerve (n. maxillaris) for the teeth of the upper jaw (upper alveolar nerves to the large molars, middle alveolar nerves to the small molars and anterior alveolar nerves to the incisors and canines) and the mandibular nerve (n. mandibularis) for the teeth of the lower jaw (lower alveolar nerve).
Lymph drainage from the teeth of the lower jaw it is carried out to the submandibular, parotid and retropharyngeal, and from the teeth of the upper jaw - to the submandibular lymph nodes.
Language
The tongue (lingua) is located at the bottom of the mouth. There is a fixed part - the root of the tongue (radix linguae), located horizontally, a free part - the body (corpus linguae) and the apex (apex linguae). The movable section fills the space limited by the arch of the alveolar process of the lower jaw. The boundary between the root and body of the tongue is a V-shaped line formed by the papillae,
surrounded by a rampart. The tongue has two surfaces - a convex upper (back of the tongue) and lower. They are separated by the edges of the tongue.
From the tip of the tongue to the foramen cecum (the remnant of the reduced thyroglossal duct - the rudiment of the thyroid gland), a median groove is located along. The second groove, the border one, is located from the foramen cecum to the sides across the tongue.
On the lower surface of the tongue, a fold is formed located in the sagittal plane - the frenulum of the tongue (Fig. 10.24). Under the mucosa
Rice. 10.24. The lower surface of the tongue (from: Elizarovsky S.I., Kalashnikov R.N., 1979):
1 - lingual gland; 2 - edge of the cut mucous membrane; 3 - styloglossus muscle; 4 - genioglossus muscle; 5 - deep artery of the tongue; 6 - lingual nerve; 7 - lower longitudinal muscle; 8 - submandibular duct; 9 - sublingual gland; 10 - sublingual papilla; 11 - sublingual fold; 12 - lingual frenulum; 13 - fringed fold
The membrane of the floor of the mouth is contoured by ridges corresponding to the location of the sublingual glands. The mucous membrane of the root of the tongue, moving to the epiglottis, forms three folds: the middle lingual epiglottis and two lateral folds, running from the tongue to the edges of the epiglottis. Between these folds, depressions are formed into which foreign bodies usually fall.
Noteworthy is the tight fusion of the mucous membrane of the tongue with the underlying tissues. The glands are adjacent to the hypoglossal and geniohyoid muscles and the inner surface of the body of the lower jaw.
The mucous membrane of the root of the tongue, passing to the epiglottis, forms three folds: the middle lingual-epiglottis and two lateral folds, running from the tongue to the edges of the epiglottis.
In the mucous membrane of the root of the tongue, posterior to the border sulcus, there are accumulations of lymphoid tissue in the form of follicles. Together they form the lingual tonsil, which is part of the Waldeyer-Pirogov lymphoid pharyngeal ring.
Blood supply the tongue is carried out by the lingual artery, which forms the intraorgan vascular bed. The outflow of blood occurs through the lingual vein, which flows into the basin of the internal jugular vein.
Lymphatic drainage occurs in the mental, submandibular and retropharyngeal lymph nodes.
Innervation muscles of the tongue occurs due to the hypoglossal nerve, the mucous membrane in the anterior 2/3 - lingual (from the mandibular), and the posterior 1/3 - by the glossopharyngeal nerve, and the section of the root of the tongue adjacent to the epiglottis - by the upper laryngeal (from the vagus). As part of the chorda tympani (from the intermediate nerve), nerve fibers are directed to the taste buds of the fungiform and leaf-shaped papillae, and as part of the glossopharyngeal nerve - to the taste buds of the vallate papillae.
The term “pharynx” refers to the space through which the oral cavity communicates with the pharyngeal cavity. It is delimited laterally by the palatine arches, below by the root of the tongue, and above by the soft palate. At the base of the arches there are muscles - the palatoglossus and the palatopharyngeal. At the moment of contraction of the first, the size of the pharynx decreases, and when the second contracts, the hypopharynx and larynx rise.
Between the arches are the tonsil fossae, in which the palatine tonsils lie. The area of the bottom of the fossa is formed by the lateral wall of the pharynx. Above the tonsils, the arches converge with each other. This is how the supramyngdal fossa is formed.
Blood supply tonsils is carried out by the branches of the ascending pharyngeal artery (from the external carotid). Venous drainage occurs in the pterygoid venous plexus. Lymphatic drainage goes to the submandibular, parotid and retropharyngeal nodes. Innervate tonsil branches of the glossopharyngeal, lingual, vagus nerves, borderline sympathetic trunk and pterygopalatine ganglion.
The pharyngeal tonsils are part of the Waldeyer-Pirogov lymphoid ring. In addition to them, it is formed by the unpaired lingual tonsil, located at the root of the tongue, the pharyngeal tonsil, located on the back wall of the pharynx (expressed only in childhood) and two tubal tonsils lying near the nasopharyngeal openings of the Eustachian tube.