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METHODS FOR STUDYING THE NOSE AND NANOSAXIS
The study of the nose and paranasal sinuses, after identifying the needles and clarifying the anamnesis, begins with an external examination and palpation. Upon examination, pay attention to the condition of the skin and soft tissues, the absence or presence of defects, the symmetry of both halves of the face, as well as the shape of the external nose.
Palpation should be done carefully. Soft movements of the hands establish the presence or absence of pain in the nose and projection of the paranasal sinuses. If a nasal bone fracture is suspected, the mobility of the bone fragments and the presence of crepitus are determined.
Endoscopic examination of the nose. Examination of the nasal cavity (rhinoscopy) is performed using a light source. Most often with rhinoscopy, as with other types of endoscopy, a frontal reflector is used to illuminate the object of study. Inspection can also be carried out using one of the types of endoscopes with an autonomous light source or with fiber optics. Examination of the vestibule of the nose is carried out by simply lifting the tip of the nose with the thumb of the left hand, while the remaining fingers of the examiner rest on the patient's forehead (Fig. 2.3.1). This allows you to examine the inner surface of the vestibule of the nose, the movable part of the septum of the nose and the condition of the skin lining them from the inside with hairs. This technique is often used when examining young children who do not allow, for fear of inserting an instrument into their nose.
Further examination is carried out using special dilators - nasal mirrors. The design of modern instruments originates from the nasal dilator, developed by the Slovak doctor Marcusovsky (1860).
The nasal mirror, held in the left hand, is carefully inserted on the eve of the nose of the subject in the closed state. An open mirror is displayed so as not to infringe on the hairs of the vestibule of the nose. Gradually pushing the branches, expand the nostril and slightly lift it up. It is necessary to avoid pressing the mirror onto the nasal septum, and also not to enter the mirror deeply, which can cause pain.
If the instrument is in the doctor’s left hand, then it fixes the patient’s head with the right hand, which allows you to change its position when examining the posterior sections of the nose. An examination of the nasal cavity through its front sections is called anterior rhinoscopy. It is performed in two positions (Fig. 2.3.2): 1) with the head of the examinee straight (first position) and 2) with the head folded back (second position). In the first position, most of the vestibule of the nose, the antero-inferior half of the nasal septum, the anterior end of the inferior concha and the common nasal passage are visible. In the second position, it is possible to examine the upper and deeper parts of the nasal cavity. It is possible to see the upper part of the nasal septum, the middle nasal passage, the anterior third of the middle nasal concha and the olfactory gap. Turning the head of the subject, you can examine in detail the listed structures of the nasal cavity.
To examine the deeper parts of the nose, the so-called medium or deep rhinoscopy. In this case, use a nasal mirror with elongated sponges (Killian's middle nasal mirror), having previously performed anesthesia of the mucous membrane with one of the types of surface anesthetic (Sol. Dicaini 2%). With swelling of the nasal concha, they must be reduced by lubricating with vasoconstrictors (for example, adding 3 drops of 0.1% adrenaline solution in 1 ml of dicain solution). It is even better to use a 3 - 5% cocaine solution, which has not only anesthetic, but also a vasoconstrictive effect.
Examination of the posterior sections of the nose and nasopharynx is called posterior rhinoscopy and is carried out using a special small (nasopharyngeal) mirror with a diameter of 6 to 10 mm attached to a metal rod at an angle of 115 °. Recall that the laryngeal mirror differs from the nasopharyngeal one not only in larger size, but also in a larger angle of attachment to the rod (120 - 125 °). For convenience, the mirror rod is fixed with a screw in a special handle. Historically, posterior rhinoscopy was developed earlier by the front Czech scientist Czermak in 1859, shortly after the introduction of laryngoscopy into clinical practice (Turk and Czermak, 1857).
Rear rhinoscopy is performed as follows. With the spatula taken in the left hand, squeeze the front 2/3 of the tongue of the subject (a deeper introduction of the spatula causes a gag reflex). The nasopharyngeal mirror, without touching the mucous membrane and the root of the tongue, is inserted into the oropharynx behind the soft palate (Fig. 2.3.3). To avoid fogging, the mirror is preheated over the flame of the spirit lamp (mirror, but not the metal side!) Or in a vessel with hot water. Making light turns of the mirror, they sequentially examine the entire nasopharynx, focusing on the posterior edge of the nasal septum (opener). At the same time, the choanas and the posterior ends of the nasal concha, the lateral walls with the pharyngeal mouths of the auditory tubes, the nasopharynx, pharyngeal tonsil are examined. It should be emphasized that while with anterior rhinoscopy we can see only the lower and middle nasal concha, then with a posterior rhinoscopy, all three. In fig. 2.3.4 (a) and (b) presents a diagram of the anterior and posterior rhinoscopic picture.
Posterior rhinoscopy is the most difficult endoscopic examination method. It is important that the subject does not strain and breathe with his nose. In this case, the soft palate hangs, which allows a mirror to be inserted into the nasopharynx. If a pronounced pharyngeal reflex makes it difficult to examine, then in this case they resort to anesthesia of the mucous of the root of the tongue and nasopharynx with one of the mucous anesthetics. In some cases, it is necessary to pull the soft palate with one or two rubber catheters conducted through the nasal cavity into the oral cavity (Fig. 2.3.5). Examination of the nasopharynx can be carried out using a special endoscope also after preliminary anesthesia of the mucous membrane. In this case, the endoscope (depending on its diameter and condition of the nasal cavity) can be inserted to examine the nasopharynx both through the nose and through the pharynx (Fig. 2.3.6).
In early childhood, as a rule, posterior rhinoscopy cannot be performed. In such cases, they resort to a digital examination of the nasopharynx.
When evaluating the endoscopic picture, the color, gloss of the mucous membrane, volume of the nasal concha, width of the nasal passages, defects of the nasal septum, its deformation and contents of the nasal cavity are consistently paid attention to.
Normally, the mucosa is moderately pink in color. With inflammation, it becomes more red (hyperemia). In vasomotor processes, it can have a bluish, marble color (in cases of the neurocirculatory form of vasomotor rhinitis) or pale and even white in the allergic form of vasomotor rhinitis.
Normally, the mucous membrane has a wet sheen. During atrophic processes, it becomes dry and acquires the so-called dry shine.
Enlarged nasal concha are called hypertrophic. Hypertrophy may be false or true. With false hypertrophy, the nasal concha easily contract under the action of vasoconstrictor drugs (observed with vasomotor and simple inflammatory rhinitis). True hypertrophy can be caused by an increase in the bony skeleton of the nasal concha or the development of connective tissue elements in the submucosal layer (for example, with chronic hyperplastic rhinitis). In this case, there is no or almost no contraction of the mucous membrane and, consequently, the volume of the nasal concha.
In atrophic processes (atrophic rhinitis and especially in the fetid runny nose of the lake), atrophy of the nasal concha occurs and the nasal cavity becomes wide, while with anterior rhinoscopy, one can easily examine the posterior pharyngeal wall and other details of the nasal cavity, which are usually not visible normally.
The pathological contents of the nasal cavity are primarily mucopurulent discharge. In acute and chronic rhinitis, discharge is usually in the general nasal passage. With inflammation of the paranasal sinuses, they are found in the middle nasal passage (with anterior rhinoscopy), as well as in the nasopharynx and on its posterior wall, which can be established with posterior rhinoscopy. With atrophic processes, crusts accumulate in the nasal cavity, especially pronounced and have an unpleasant odor in the lake.
Radiation research metols. Inspection of the nasal cavity gives a well-known idea about the condition of the paranasal sinuses. However, more specific information about them can be obtained using radiation diagnostic methods.
Currently, the most common radiation method is radiography. However, the anatomical and topographic features of the location of various paranasal sinuses to obtain sufficient information about their condition require the use of various styling (projections). In clinical practice, the most commonly used are 1) nasal-frontal, 2) nasal-chin, and 3) lateral projections (Fig. 2.3.7). With a nasal-frontal projection, the patient’s head is laid in such a way that the forehead and the tip of the nose lie on the cassette. An x-ray is directed from the back of the head, slightly below protuberantia occipitalis. The frontal, ethmoid, and maxillary sinuses are visible in the image thus obtained. The bony massifs of the skull, such as the pyramids of the temporal bones and the lower jaw, are projected outside the sinuses - the pyramids appear to lie on the orbits, and the lower jaw is located below the maxillary sinuses (Fig. 2.3.7, a).
With a nasal-chin projection, the patient lies on the cassette, touching it with his lips. An x-ray beam is directed from the back of the head slightly above protuberantia occipitalis. In this picture, the frontal sinuses are slightly pronounced, slightly enlarged in size, as well as the maxillary sinuses and the ethmoid labyrinth (Fig. 2.3.7, b).
The lateral (bitemporal) projection allows us to judge the state of the sphenoid, frontal sinuses and ethmoid labyrinth (Fig. 2.3.7, d). To obtain such a profile picture, the patient’s head is placed on the cassette so that its sagittal plane is located strictly parallel to the cassette. The x-ray beam is directed in the frontal direction, slightly shifting anteriorly (the width of a finger) from the tragus of the auricle. However, in the profile picture, the sinuses of both sides overlap each other, and therefore, by such an x-ray, only the depth of the sinuses can be judged, and not about the localization of the process. Therefore, to assess the condition of the right and left sphenoid sinuses, an axial, or chin-vertical, projection is used (Fig.
2.3.7, c). To obtain such radiographs, the x-ray beam is directed vertically to the sphenoid sinus.
With the described x-ray projections, with the direction of the beam in the anteroposterior direction, individual bones of the facial skeleton (nasal bones, frontal processes of the upper jaw) can be superimposed on the ethmoid labyrinth, especially with their asymmetry. Therefore, for a more detailed study of the ethmoid labyrinth, it is advisable to use the Rese projection, which is used in ophthalmic practice to assess the condition of the optic nerve channel, as well as a special projection for targeted radiography of the ethmoid labyrinth cells, proposed by Y. A. Fastovsky. A more informative X-ray examination is linear tomography. Computed tomography (CT) (Fig. 2.3.8) and magnetic resonance (MRI) tomography (Fig. 2.3.9) are even more informative.
X-ray and CT methods produce known radiation exposure. Therefore, in cases where it is not desirable (for example, persons who received radiation damage), it is advisable to use methods that are not based on ionizing radiation. The most famous and simplest method is diaphanoscopy. The diaphanoscope is a small-sized device that allows you to locally illuminate the paranasal sinuses. In a dark room, a diaphanoscope illuminator is inserted into the patient's mouth. Normally, the air-containing maxillary sinuses, which appear in the form of pink fields under the orbits, are well lit. If there is pus or a tumor in these sinuses, they are not visible. Diaphanoscopy of the frontal sinuses is performed by installing a device illuminator at the medial corner of the eye separately on the right and left sides. The results of the study with diaphanoscopy are indicative.
In recent years, the method of ultrasound biolocation, thermography and thermal imaging has been introduced into outpatient practice. These methods are safe and quick to get results. However, the information content of these methods is inferior to radiological, CT and MRI studies.
Functional research metols.
The study of respiratory function. The most simple and fairly objective, widely used in clinical practice, allowing to judge the state of the respiratory function of each individual half of the nose, is a "test with a fluff" V.I. Voyacheka. The examiner brings a cotton fluff or gauze thread to the nostril of the subject (Fig. 2.3.10). With normal nose patency, the thread makes a distinct movement. Strengthening or weakening of the movement of the “feathers” may indicate excess or insufficiency of nasal breathing. The method of "breathing spots", based on the principle of rhinogygrometry, proposed by H. Zvaardemacker also belongs to simple methods for studying respiratory function. When breathing on a polished metal plate with semicircular lines deposited on its surface (Glatzel mirror), larger or smaller fogged surfaces appear.
Over the years, a significant number of devices have been proposed that evaluate nasal breathing by the volume of air passing through the nose per unit of time. Known rhinopneumometers V.F. developing in the nasal cavity, and document them fix (Fig. 2.3.11). Apparently, they also have a great future in the further development of rhinology.
Study of olfactory function (odorimetry). There are two thresholds of olfactory sensation: the threshold of sensation of a particular smell and the threshold of recognition of a certain odorous substance. The latter threshold is more valuable in view of the possibility of objective control.
All methods for the study of smell are divided into qualitative and quantitative. Quantitative research methods are not widely used in clinical practice due to their complexity and lack of standard equipment. One of the obstacles to conducting a quantitative method for studying olfactory function is the above-mentioned ability of the olfactory analyzer to quickly adapt to an adequate stimulus.
The most widely used in clinical and expert practice was V.I. Voyacheka, proposed by him back in 1925. The basis of this method is the use of several odorous substances well known to most people, standard solutions of which are arranged in the order of smells ascending in strength;
- 0.5% acetic acid solution (faint odor),
- pure wine alcohol (smell of medium strength);
- simple valerian tincture (strong smell);
- ammonia (super strong odor);
- pure water (to detect dissimulation).
It should be noted that ammonia simultaneously causes irritation of the branches of the trigeminal nerve.
Solutions of odorous substances should be in bottles of the same size and shape (preferably dark glass), indicated by numbers. The subject is closed with one finger on one nostril and arranged to sniff a piece of filter paper soaked in the solution with the other half of the nose.
The listed substances in a strict sequence under the numbers are entered in the table, which is called odorimetric passport. The results of the study (? Or 0) are also recorded in the passport, on the basis of which a conclusion is made about the state of smell in the subject. Example of odorimetric passport:
Conclusion: left-sided hyposmia of the III degree.
Assessment of the olfactory analyzer function is as follows. With the perception of all smells - the sense of smell of I degree; medium and stronger odors - sense of smell P degree; strong smell - sense of smell. With the perception of only the smell of ammonia - the lack of smell (anosmia). Inability to perceive the smell of ammonia indicates both anosmia and the absence of excitability of the trigeminal nerve endings.
With a more in-depth study of the functional state of the nose, the transport, caloriferous, absorption and excretory functions of the nose (ciliated epithelium) are examined.
The transport function of the ciliated epithelium is investigated by several methods. Most of them are based on determining the time of movement of any aerosol indicator substances (coal dust, carcass, saccharin, labeled radioisotopes) with mucus. In our country, in clinical practice, the most commonly used method is G.I. Markova (1985). Charcoal is used as an indicator powder. The latter is mixed with starch-agar gel (starch - 0.2, agar-agar - 0.05, coal powder - 1.0, water - 10.0). The state of motor activity of the ciliary epithelium is assessed according to the following scheme: normal - up to 15 minutes, I degree of violation - up to 30 minutes, II degree of violation - 31-45 minutes, III degree of violation - 46-50 minutes. Транспортная функция мерцательного эпителия может оцениваться и по количеству активных клеток мерцательного эпителия в соскобах, полученных со слизистой полости носа (Бондарук В.В., 1996).
Калориферная функция слизистой оболочки определяется измерением температуры в области переднего конца нижней носовой раковины (с помощью электротермометра). В норме температура находится в пределах 34-34,5?С. Калориферная (согревающая) функция слизистой носа зависит от состояния и кровенаполнения сосудистой системы кавернозных тел носовой полости. Поэтому о калориферной функции носа можно судить и на основании реографических исследований (Дайняк Л.Б.,1994).
Исследование всасывательной и выделительной функций обычно производят параллельно. Достаточно информативным является метод, преложенный А.А.Арутюновым. Всасывательная функция определяется по времени появления йодида калия в моче спустя некоторое время после введения в полость носа тампона, смоченного 10% раствором этой соли. В норме показатели всасывательной функции составляют в пределах до 40 мин. Выделительная функция определяется по времени появления йодида калия в полости носа после приема его во внутрь (в норме через 17-40 мин).
Всасывательную функцию слизистой оболочки носа можно определить и более простым методом С.Г.Боржима. При этом марлевую полоску 0,5х1 см, смоченную 0,3 мл 0,1% раствора атропина, вводят в полость носа под нижнюю носовую раковину на 10 мин. Оценка всасывающей активности слизистой оболочки носа производится на основании изменения частоты пульса.
Выделительная (секреторная) функция слизистой оболочки носа, обусловленная прежде всего функцией бокаловидных клеток (Козлов М.Я., 1985), может быть определена с помощью стандартного ватного шарика диаметром 0,5 см, введенного в полость носа между перегородкой и нижней носовой раковиной на 1 мин, по изменению его веса (в амбулаторных условиях - визуально, по степени влажности шарика).
При исследовании околоносовых пазух, в зависимости от их анатомических особенностей, применяют зондирование, пункцию и трепанопункцию пазух.
Наиболее распространенной манипуляцией является пункция верхнечелюстной пазухи (рис. 2.3.12). Пункция производится под эпимукозной (аппликационной) анестезией 2% раствором дикаина или 3-5% раствором кокаина с добавлением нескольких капель 0,1% раствора адреналина. Прокол пазухи производится иглой Куликовского, которая вводится под нижнюю носовую раковину отступя 2 см от ее переднего конца и в месте прикрепления раковины к латеральной стенке, где ее толщина - наименьшая. Возможные при этом осложнения (среди них попадание иглы в глазницу) описаны в монографии И.Я.Темкиной (1963). Пункция может быть произведена троакаром, через который возможно введение эндоскопа для обозрения пазухи (рис. 2.3.13).
Передняя стенка лобной пазухи достаточно толстая, что затрудняет выполнение пункции, поэтому используется трепанопункция лобной пазухи с помощью специального трепана (рис. 2.3.14).
В клинической практике нередко применяется метод зондирования пазух (в частности, клиновидной и лобной) через естественные соустья (рис. 2.3.15).
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МЕТОДЫ ИССЛЕДОВАНИЯ НОСА И ОКОЛОНОСОВЫХ ПАЗУХ
- Research methods for the nose and paranasal sinuses
They produce an external nose nose, places of projection of the paranasal sinuses of the nose on the face. Patch of the external nose: the index fingers of both hands are located along the back of the nose, with light massaging movements they feel the areas of the root, slopes, back and tip of the nose. Palpate the front and lower walls of the frontal sinuses, figuring out the patient's sensations. Thumbs of both hands
- Microendoscopic methods of surgical intervention in the nasal cavity and paranasal sinuses
There are a number of options for endonasal endoscopic microoperations, however, all the techniques can be combined into two main varieties - these are the classic methods according to Messerklinger and Wiegand, they are designed to restore the natural ventilation and drainage paths, with the smallest changes in the anatomical structures and the maximum gentleness of the mucous membrane. Most widely
- TUMORS OF THE NOSE AND NANOPINASUS SINAS
In the nasal cavity and paranasal sinuses, as in other ENT organs, there are benign and malignant neoplasms, very diverse in morphological structure and clinical manifestation. A distinct border is often impossible to draw with many benign and malignant tumors. Modern classifications of tumors, including the nose and paranasal sinuses, are bulky and
- Malignant tumors of the nose and paranasal sinuses
Malignant diseases of this localization - cancer and isarcoma, as a rule, are primary. They are relatively rare, more often in middle-aged and elderly men. Most often, the primary malignant process affects the maxillary, then the ethmoid, frontal and sphenoid sinuses. Rarely, the nasal septum is the source of the malignant tumor. Malignancy
- Clinical physiology of the nose and paranasal sinuses
Distinguish between upper and lower respiratory tract. The nose and paranasal sinuses, pharynx with the oral cavity and larynx belong to the upper respiratory tract, the trachea, bronchi with bronchioles of the alveoli - to the lower. Normal for a person is breathing through the nose. The nose performs, in addition to the respiratory, protective, resonant and olfactory functions, and also participates in the regulation of the depth of breathing and lacrimation,
- CLINICAL PHYSIOLOGY OF THE NOSE AND NANOSAXIS
The nose and its paranasal sinuses, being the upper part of the respiratory tract, play an important role in the interaction of the body with the environment, while performing a number of interrelated physiological functions. The following nasal functions are distinguished: 1) respiratory, 2) protective, 3) resonator (speech) and 4) olfactory. In addition, the nose, as an important element in the formation of a single ensemble of the face, is endowed with and
- Surgery for diseases of the nose and paranasal sinuses
The most common operations for diseases of the nose and paranasal sinuses include polypectomy, endoscopic interventions in the paranasal sinuses, opening the maxillary sinus (Caldwell-Luc operation), rhinoplasty, septoplasty. Preoperative period Patients often have marked nasal breathing disorders due to polyps, nasal curvature
- Foreign bodies of the nose and paranasal sinuses
Most often, foreign bodies are found in children who have the habit of putting various objects (beads, buttons, stones, coins, berry seeds, seeds and other small objects) in the nose of themselves or their gullible peers. In adults, foreign bodies get into the nose under random circumstances (for example, during sleep on the hayloft, a piece of straw may be drawn into the nose when breathing). More
- Fracture of the bones of the nose and paranasal sinuses
Case: Face asymmetry is determined in the form of deformation of the external nose, sinus front wall sagging, skin damage, palpation pain (sometimes with a crunch, crepitation of bone fragments and air in the subcutaneous tissues), edema, eyelid hematoma and usually bleeding from the nose. Depending on the depth of damage, fractures can be isolated or combined with a head injury
- DISEASES OF THE NOSE AND NEXTILOUS SINAS, THROATS, Larynx and Ear
The upper respiratory tract (nose, paranasal sinuses, pharynx and larynx) perform the most important life-supporting functions, a detailed description of which is given in Part I. The next part is devoted to diseases of these organs. Based on the functional significance in the clinic of each of the organs - reflex, humoral and other connections of these organs with the body as a whole, we can conclude
- DISEASES OF THE NOSE AND SINUS NANOSIS
DISEASES OF THE NOSE AND NEXTLINE
- CLINICAL ANATOMY OF THE NOSE AND NANOSAXIS
CLINICAL ANATOMY OF THE NOSE AND NANOSIS
- Treatment of injuries of the nose and paranasal sinuses at the stages of evacuation
Self-help and mutual assistance. It is carried out in the manner of self-help, mutual assistance by a nurse or medical examiner. In case of bruises accompanied by nosebleeds, try to stop the bleeding by pressing the wings of the nose to the nasal septum. Snow, ice, or cloth moistened with cold water is applied to the outer nose. With abrasions on the skin or superficial wounds
- CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND NANOSAXIS
CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND PALNOSIS
- Anatomy of the paranasal sinuses
The paranasal sinuses, sinus paranasalis, are located in the bones of the facial and brain skull and communicate with the nasal cavity. They are formed as a result of the ingrowth of the mucous membrane of the middle nasal passage into the spongy bone tissue. In fig. 2.1.4 presents a diagram of the development of the paranasal sinuses in the age aspect. Phylogenetically paranasal sinuses are derivatives of the ethmoid labyrinth
- Diseases of the paranasal sinuses
Inflammatory diseases of the paranasal sinuses account for 25-30% of the stationary pathology of the LOP organs. Most often, inflammation occurs in the maxillary (maxillary) sinus (sinusitis). This is due to the fact that evacuation of the contents from the sinus is difficult due to the location of the anastomosis with the nasal cavity in the upper third of its medial wall, as well as the fact that the inflammation of the roots of the four posterior
- Injuries to the paranasal sinuses
In adults and children, the frontal sinuses are most often damaged, then the maxillary sinuses, the ethmoid labyrinth and very rarely the sphenoid sinus. Usually, a trauma to a sinus is combined with damage to other parts of the facial skeleton, cranial cavity, and eyes. A mechanical or gunshot wound to the frontal sinus is often accompanied by damage to the anterior lobe of the brain, ethmoid labyrinth, sieve
- INFLAMMATORY DISEASES OF THE NANOLAIN SINAS
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 hospitals hospitalized in ENT (Kozlov M.Ya., 1985; Soldatov IB, 1990; Piskunov GZ et al., 1992; Aref'eva N.A. , 1994). The foci of inflammation in the paranasal sinuses can be a source
- The structure of the paranasal sinuses
The paranasal sinuses are located around the nasal cavity and communicate with it (Fig. 3). Only four pairs of airways: sinuses, maxillary labyrinth cells, frontal and sphenoid. There are anterior (maxillary, frontal, anterior and middle cells of the ethmoid bone) and posterior (sphenoid and posterior cells of the ethmoid bone) sinuses. Such a unit is convenient because pathology
- Clinical anatomy of the paranasal sinuses
The paranasal sinuses are located around the nasal cavity and communicate with it (Fig. 1.8). Only four pairs of airways: sinuses, maxillary labyrinth cells, frontal and sphenoid. There are anterior (maxillary, frontal, anterior and middle cells of the ethmoid bone) and posterior (sphenoid and posterior cells of the ethmoid bone) sinuses. Such a unit is convenient because pathology