Anatomy of the Nose

The Ear

• The middle ear functions as a collecting organ.
• The external ear also acts as a collecting organ.
• The internal ear is the organ responsible for equilibrium and hearing.
• The pharyngotympanic tube is synonymous with the auditory tube and the Eustachian tube.

External Ear

• The auricle, also known as the pinna, constitutes the external ear.
• It's made of elastic cartilage covered by thin skin.
• Depressions include the triangular fossa of the antihelix and the concha.
• Elevations include the helix, scapha, antihelix, and tragus.
• The lobule comprises fibrous tissue, fat, and blood vessels.
• The meatus is lined by hairs and sebaceous/ceruminous glands for protection.

Extrinsic Muscles of the Ear

• Extrinsic muscles of the ear receive motor innervation through CN VII.
• They developed from the 2nd pharyngeal arch.
• The auricularis anterior receives motor innervation from the temporal branch of CN VII.
• The auricularis anterior receives sensory innervation from the auriculotemporal nerve (V3).
• The auricularis superior receives sensory innervation from the lesser occipital nerve.
• The auricularis superior receives motor innervation from the posterior auricular nerve (CN VII).
• The auricularis posterior receives motor innervation from the posterior auricular nerve (CN VII).
• The auricularis posterior receives sensory innervation from the lesser and greater occipital nerves.

Cutaneous Innervation of the Auricle

• Anterior to the auricle, the auriculotemporal nerve provides cutaneous innervation.
• The auriculotemporal nerve services the area anterior to the external acoustic meatus.
• Posterior to the auricle, the great auricular nerve (posterior and lateral part) provides cutaneous innervation.
• Posterior to the auricle, the lesser occipital nerve (upper part of cranial medial surface) provides cutaneous innervation.

Sensory Innervation of the Concha and Eminence

• The auriculotemporal nerve (VCN 3) supplies the skin of the auricle's anterior lateral surface.
• This includes the rim of the concha, crus of the helix, and tragus.
• The auricular branch of the Vagus nerve: innervates the skin of the concha.
• The Vagus (CN X) and facial (CN VII) nerves make a minor contribution to the skin of the concha and its eminence.

Arterial Blood Supply to Auricle

• Primarily derived from branches of the external carotid artery
• Posterior auricular artery
• Superficial temporal artery

Veins Related to the Auricle

• Related veins include the superficial temporal vein and artery.
• The posterior auricular vein is related to the auricle.
• The retromandibular vein (anterior and posterior branches).
• The external jugular vein (cut).

Lymphatic Drainage of the Auricle

• The cranial surface of the superior half of the auricle drains into the mastoid & deep cervical lymph nodes.
• The lateral surface of the superior half of the auricle drains into the superficial parotid lymph nodes.
• The superficial cervical lymph nodes drain the remainder of the auricle, including the lobule.

Cauliflower Ear (Perichondrial/Auricular Hematoma)

• Trauma or repeated friction can cause it.
• Direct blows or constant rubbing create a hematoma between the cartilage and perichondrium.
• Cartilage blood supply is disrupted, predisposing it to necrosis, fibrosis, and a "bumpy" shape.
• Untreated or inadequately drained hematomas can also cause it.
• Failure to properly drain and compress the hematoma leads to persistent fluid, inflammation, and scarring.
• Infections (less common) can also cause it.
• Infections or perichondritis can damage cartilage, leading to similar deformities.

External Acoustic (Auditory) Meatus

• An inward canal through the temporal bone, approximately 2-3 cm in adults.
• Lined with skin
• Contains a cartilaginous part with ceruminous and sebaceous glands.
• Also contains a bony part lined with skin.
• Innervated by the auriculotemporal and auricular branch of CN X.
• Receives blood from the superficial temporal artery.
• Receives blood from the posterior auricular artery.
• Receives blood from the deep auricular branch (from the maxillary artery).

Tympanic Membrane (Eardrum)

• An oval semitransparent membrane with three layers.
• Covered by skin (externally), fibrous tissue (intermediate), and mucous membrane (internally).
• Oriented like a "mini radar".
• Demonstrates concavity toward the external acoustic meatus.
• About 1 cm in diameter
• It directs sound waves to the middle ear.

Tympanic Membrane Details

• Pars flaccid: A thin membrane without radial and circular fibers.
• Pars flaccid forms the lateral part of the superior recess of the tympanic cavity.
• Pars tensa: Contains radial and circular fibers.
• Cone of light: Reflection of otoscope light in the anterior inferior quadrant.
• External surface innervation: The auriculotemporal nerve, a branch of CN V3.
• Internal surface innervation: The glossopharyngeal nerve (CN IX).

Blood Supply to the Ear

• Deep auricular and anterior tympanic arteries supply the external acoustic meatus and tympanic membrane
• These are branches from the first (mandibular) part of the maxillary artery.
• The middle meningeal artery goes to the pharyngotympanic tube before entering the cranium.

Tympanic Membrane Innervation

• The external surface of the tympanic membrane is innervated by the auriculotemporal nerve (CN V3).
• The external surface of the tympanic membrane is also innervated by the auricular branch of the Vagus nerve (CN X).
• The internal surface of the tympanic membrane is innervated by the glossopharyngeal nerve (CN IX).

The Middle Ear

• It resides in the petrous part of the temporal bone.
• The middle ear transmits sound waves from the ossicles to the inner ear.
• Auditory ossicles include the malleus, incus, and stapes.
• Muscles include the stapedius and tensor tympani.
• The chorda tympani nerve (from CN VII) is present.
• The tympanic plexus of nerves is present.

Tympanic Cavity

• The tympanic cavity proper is directly internal to the tympanic membrane.
• The tympanic cavity proper is lined with mucous membrane, continuous with lining of pharyngotympanic tube, mastoid cells, and mastoid antrum.
• The epitympanic recess is superior to the tympanic membrane.

Auditory Ossicles

• Auditory ossicles include the malleus (hammer), incus (evil), and stapes (stirrup).
• Smallest and first mobile bones to ossify in development
• Mature at birth.
• Extend from the tympanic membrane to the oval window (to vestibule of inner ear)
• Covered by mucous membrane lining the tympanic cavity instead of the periosteal layer.
• These ossicles increase the force but decrease the vibrations from the tympanic membrane to the inner ear.

Ear Conditions

• Acute Otitis Externa: Inflammation of the external acoustic meatus.
• Itching and pain that increases from applying pressure to auricle or tragus.
• Often caused by not drying the meatus well, or a bacterial infection.
• Symptoms of Otitis Media include an earache and red tympanic membrane (pus or fluid).
• Often secondary to upper respiratory infections; and the pharyngotympanic tube may be blocked.
• Symptoms: ear popping and impaired hearing.

Muscles Associated with Auditory Ossicles

• The tensor tympani muscle originates from the cartilage of the auditory tube and the bony walls of its canal.
• It inserts on the handle of the malleus.
• Innervation is from the branch of the medial pterygoid (CN V3).
• It dampens vibrations of malleus by tensing the tympanic membrane to loud noises.

Pharyngotympanic Tube

• Connects the tympanic cavity to the nasopharynx.
• Lined with mucous membrane.
• Equalizes pressure in middle ear.
• It is bony and cartilaginous.

Pharyngotympanic Tube Composition

• Composed of bony (posterolateral 1/3) and cartilaginous (2/3) parts.
• The cartilaginous part typically stays closed except when swallowing or yawning.
• Contraction of the tensor veli palatini and levator veli palatini opens the tube.
• The levator veli palatini contracts longitudinally.
• The tensor veli palatini pulls on the other.
• The salpingopharyngeus muscle aids in elevating the pharynx and opening the tube.

Stapedius Muscle

• Originates from internal walls of the hollow pyramid (posterior wall).
• Insertion- neck of stapes.
• Nerve Supply- CN VII.
• Reduce excessive oscillations of the stapes in order to protect inner ear.
• Its paralysis results in hyperacusis.

Orientation of Ear Components

• The external acoustic meatus runs from lateral to medial.
• Bony and membranous labyrinths have long axes.
• The pharyngotympanic tube has long axes.
• Tensor tympani and levator palatini muscles have long axes.
• These axes run perpendicular to the tympanic membrane and the cochlea as they proceed medially.

Tympanic Cavity Boundaries

• The tympanic cavity has six walls.
• The tegmen tympani forms the roof.
• The internal carotid artery is the main relation of the anterior wall.
• The internal jugular vein is the main relation of the floor.
• The facial nerve (CN VII) is a main feature of the posterior wall.
• The tympanic membrane forms most of the membranous (lateral) wall; The epitympanic recess is superior to it.
• Branches of the tympanic plexus innervate the mucosa of the middle ear and adjacent pharyngotympanic tube.
• The lesser petrosal nerve conveys presynaptic parasympathetic fibers to the otic ganglion for secretomotor innervation of the parotid gland.

Tegmental Wall (Roof)

• A thin plate of bone separates the cavity from the middle cranial fossa.
• Infection and cholesteatoma causes bone erosion.
• Tegmen Tympani creates a route for infection to spread into the middle cranial fossa.

Jugular Wall (Floor)

• A thin, bony floor separates from the jugular bulb.
• Erosion through this thin bone results in severe middle ear infections.
• It can potentially lead to thrombophlebitis or extension of infection along the venous channels.

Lateral (Membranous) Wall

• The tympanic membrane mainly forms it.
• A small portion formed by the epitympanic recess.
• The handle of the malleus is attached to the tympanic membrane.

Risks in the Lateral Wall

• Tympanic membrane (TM) perforation is a risk.
• Risks of TM include Otitis media, trauma and high risk for infections and conductive hearing loss.
• Risks of the Chorda tympani nerve injury.
• Chorda tympani nerve injury results from Surgical damage and disease in this area.
• Chorda tympani nerve injury creates altered taste (loss of sweet/salty taste) on the anterior two-thirds of the tongue.

Medial (Labyrinthine) Wall Composition

• Formed by the promontory (the basal turn of the cochlea).
• The oval and round window are component structures.
• All lay just lateral to the inner ear structures.
• The nearby structures include the tympanic segment of the facial nerve.

Risks of Surgery to Medial Wall of Tympanic Cavity

• Inner ear is involved for surgery involving the tympanic Cavity.
• Breaching the oval or round window can occur in surgery to the TYMPANIC cavity.
• Pathogens or inflammatory processes can enter the labyrinth (inner ear).
• Labyrinthitis and Sudden sensorineural hearing loss and/or vertigo can result from breaches.
• Facial nerve injury is possible.
• A potential outcome is facial paralysis or weakness.
• Fistula formation can occur, if an infection erodes the bone around, leading to abnormal communication.
• Related symptoms include vertigo, fluctuating hearing loss, loss, inner ear.

Posterior (Mastoid) Wall

• Connects to the mastoid cells through the aditus (L. access).
• -The mastoid antrum is a cavity in the mastoid process containing mastoid cells.
• Mastoiditis is a potential infection of mastoid air cells.

Facial Nerve Involvement

• The facial nerve (CN VII) runs behind the posterior wall.
• The damage to these structures results from infection/trauma causing potential facial paralysis or paresis.
• The injury to the chorda tympani is traversing from posterior to anterior.
• The injury risks at near the lateral well while entering or exitting the Middle ear.

Mastoiditis

• Infection of mastoid antrum and mastoid cells, usually from a middle ear infection.
• Infections may cause osteomyelitis and spread to the middle cranial fossa

Sigmoid Sinus Risk

• The sigmoid sinus is a major venous sinus, lying just behind the mastoid air cells.
• Infection can erode and cause potentially causing lateral sinus thrombophlebitis.

Anterior (Carotid) Wall

• Separates the tympanic cavity from the carotid canal.
• If infection erodes the bony wall exposure is a risk.
• There is potentially complications if the erosion to the internal carotid artery is prevalent.

Middle Ear Sensory Innervation

• Composed of tympanic plexus that innervates a branch of CNIX and caroticotympanic nerves
• Forms the Jacobson's nerve, a branch of CNIX from nerves of internal carotid plexus
• Forms the Somatic/general tympanic nerve
• Conveys presynaptic parasympathetic fibers - Lesser petrosal nerve.

The Pharyngotympanic Tube

• Fibers travel to the tympanic plexus, and receives receives fibers from the pterygopalatine ganglion.

Blood Supply to the Pharyngotympanic Tube

• The blood supply is derived from the Ascending pharyngeal from external carotid artery
• Maxillary artery
• Middle meningeal and Artery of the pterygoid canal
• Drains into the pterygoid plexus for oral and pharyngeal regions.

Lymphatic Drainage Structure

• Deep cervical nodes drain the structure.

Internal Ear

• The inner ear is in the petrous part of the temporal bone.
• Includes the bony and membranous labyrinths.
• These structures convert sound waves into nerve impulses for hearing.
• These structures detect head position and movement for balance.
• The relay information to the brain with the cochlear and vestibular divisions of the vestibulocochlear nerve (CN VIII).

Parts of the Internal Ear

• The bony labyrinth includes the cochlea, vestibule, and semicircular canals.
• The membranous labyrinth includes sacs and ducts suspended in the bony labyrinth filled with endolymph
• The equilibrium of parts includes the Utricle, Saccule and semicircular ducts hearing of cochlear labyrinth includes the cochlear duct.

Peripheral Auditory System injuries

• Injuries cause the following:
• Hearing Loss
• Vertigo
• Tinnitus

Perceived Tinnitus

• Perception of sound - ringing, hissing that comes from acoustic source ( hearing loss and noise).

Sound Transmission Diagram

• Diagram showcases cochlea , and sound stimuli - entering via the External- ear -
• Then striking the tympanic membrane. In the tympanic membrane sound waves causes vibrations -
• vibrations are transfered that causes audibility with sound that can then be heard.

Vestibulocochlear Nerve Details

• It is composed of the cochlear and vestibular nerves.
• There are two components of hearing and balance.
• The cell bodies of the sensory fibers make up these structures.
• The auditory signals result in the auditory sensory fibers from and spiral - vestibular ganglia.
• Signals related the balance sensory fibres are connected to a part of and spiral - vestibular ganglia.

Internal Acoustic Details

• Internal acoustic is the pathway through that the CN route can travel.
• Travel for the facial nerves that pass through from internal.
• Internal passage passes through cranial fossa to enter the internal ear structure.

Nose, Nasal Cavity and Air Sinuses

• Composed of a bony base and primarily a cartilaginous framework.
• The shape and size vary based on the nasal cartilages.
• It's located in the upper respiratory tract, superior to the hard palate.
• It contains the peripheral organ of smell and sensory neurons that respond to odors within the olfactory epithelium.
• Olfactory epithelium is in the upper recesses, not the CNS.

Functions of the Nose and Nasal Cavity

• Olfaction (smell)
• Respiration (breathing)
• Filtration of dust
• Humidification of inspired air
• Reception of secretions from the paranasal sinuses and nasolacrimal ducts.

External Nose

• Extends from the superior angle (root) to the apex (tip).
• The inferior surface has two piriform openings, also known as the Nares.
• Nares are the nostrils or anterior nasal apertures.
• The Nares are bounded laterally by the alae of the nose.
• The Nares are separated by the nasal septum.
• The vestibule is lined with skin containing hairs or vibrissae to filter particulate matter from inspired air.

Skeleton of the External Nose

• The bony part includes the Nasal bones, Frontal process of maxillae, Nasal part of the frontal bone and its nasal spine.
• The cartilaginous part has hyaline cartilage. It Includes a 2 lateral cartilages, 2 alar cartilages, and 1 septal cartilage.
• The alar cartilages are U-shaped, free, and movable, which dilate or constrict the nares when nasal muscles contract.

Nasal Septum

• The Nasal Septum is partly bony and partly cartilaginous.
• Nasal Septum divides the nose into two nasal cavities.
• It is formed by the perpendicular plate of the ethmoid bone which occupies the posterosuperior third of the septum, descends from the cribiform plate, and attaches to the septal cartilage, sphenoid bone, and vomer.
• The Vomer, a thin flat bone with its base facing posteriorly, attaches to ethmoid, palatine bones, and maxillae, and forms the posteroinferior part of the nasal septum.
• The posterior edge of the septal cartilage fits between the ethmoid perpendicular plate and the vomer.
• The anterior edge is curved, forming the lower half of the nose's anterior margin.
• The completed septum divides the nasal cavity into right and left sides.
• Blood supply is rich from maxillary and facial artery branches.
• The mucosa is thick, especially in the septum's lower half.
• The horizontal cribiform plates (ethmoid bone) form the superior recess allowing olfactory epithelium axons to enter the skull, sending olfactory information to the brain.

Nasal Cavity

• The cavity it opens on the face through the nares (or nostrils).
• The cavity communicates with the nasopharynx posteriorly through the choanae.
• The boundaries are mucosa-lined, except for the vestibule which is lined by skin.
• Mucosa is firmly bounded to the periosteum and perichondrium.
• Continuous with the nasopharynx (posteriorly), paranasal sinuses (superiorly and laterally), and lacrimal sac and conjunctiva (superiorly).

Nasal Cavity Boundaries

• The roof is made of the frontonasal, ethmoidal (cribiform plate), and sphenoidal sections.
• The floor consist of the palatine process of the maxilla, and horizontal plate of the palatine bone.
• The nasal septum makes up the medial wall.
• Superior and middle conchae of the ethmoid bone and the inferior nasal conchae comprise the lateral wall, in which the inferior nasal conchae is an independent bone and the longest and broadest of the three conchae which may block the nose when infected.
• The nasal conchae divide the nasal cavity into four passageways that drain into the paranasal sinuses, and the nasolacrimal duct drains tears.

Passages

• Sphenoethmoidal recess is superior to the superior conchae and contains the opening of the sphenoid sinuses.
• Superior meatus is narrow, between the superior and middle conchae, and contains the opening of the posterior ethmoidal air cells.
• Middle meatus is longer and wider than the superior meatus, holding the opening of the frontal sinus into the ethmoidal infundibulum, middle ethmoidal air cells on the ethmoidal bulla, anterior ethmoidal air cells, and maxillary sinus in the hiatus semilunaris.
• Inferior meatus is the location of the nasolacrimal duct opening.

Vasculature of the Nose

• Arteries from both the external and internal carotid arteries supply the nose.
• Ophthalmic artery contributes the anterior ethmoidal artery and its terminal branches. This includes the internal and external nasal arteries on the upper portion of the nose to the vestibule.
• The medial and lateral walls are supplied by the sphenopalatine artery, which is a branch of the maxillary artery. The sphenopalatine provides the posterior septal arteries to the posterior nasal septum, and posterior lateral nasal branches which supply the conchae/meatuses of the lateral nasal wall.
• The ophthalmic artery provides the anterior and posterior ethmoidal arteries to these regions.
• The maxillary artery provides the greater palatine artery, which supplies the lower portion of the nasal septum and anastomoses with sphenopalatine artery.
• The facial artery provides the superior labial artery and nasal branches to the basal part of the septum and vestibule.
• Kiesselbach area is the location where arteries that supply the septum anastomose.

Veins of the Nose

• A rich venous plexus drains into the sphenopalatine, facial, and ophthalmic veins.
• Vasodilation and vasoconstriction of this plexus is a mechanism of heat exchange.
• Inflammation of the vascular plexus causes congestion and respiratory obstruction like allergic rhinitis and nose inflammation.

Innervation of the Nose

• Ophthalmic nerve (V1) and Maxillary nerve (V2) with the Olfactory nerve (CN I).

Ophthalmic Nerve (V1)

• The Ophthalmic nerve supplies the anterosuperior portion of the nasal mucosa. It uses the anterior and posterior ethmoidal nerve, which are branches from the nasociliary.

Maxillary Nerve (V2)

• The Maxillary nerve supplies the posteroinferior half to two-thirds of the mucosa, via the Nasopalatine nerve – to the nasal septum and via the posterior lateral nasal branches of the greater palatine nerve to lateral wall.

Olfactory Nerve (CN I)

• The Olfactory nerve includes cell bodies in the olfactory epithelium.
• It conveys special visceral afferent (SVA) sensations for smell or olfaction.
• The nerve also has axons that travel through the cribiform foramina in the cribriform plate of ethmoid bone to enter the anterior cranial cavity - to end in the olfactory bulb.

Air Sinuses or Paranasal Sinuses

• The air sinuses are air-filled extensions of the respiratory tract and drain their secretions into it.
• The functions are unknown.
• Development is slow, with a fully developed set present several years after birth and their names come from the bones where they occur
• Locations of the sinuses include the frontal, ethmoidal, sphenoidal, and maxillary area.

Frontal Sinuses

• Lie in the frontal bone and are both posterior to the superciliary arches, and the root of the nose.
• The sinuses are variable in number, size, and shape.
• They are undetectable at birth but are radiographically demonstrable after the age of 7, their size still increases until the late teens.
• They drain through the frontonasal duct into the infundibulum, which then open into the semilunar hiatus of the middle meatus.
• Arterial supply is via supraorbital and supratrochlear arteries derived from the ophthalmic artery.
• Venous drainage is via the superior ophthalmic vein running through the superior orbital fissure into the cavernous sinus posteriorly
• Innervation occursvia branches of the supraorbital, and supratrochlear branches of the ophthalmic division (V1).

Ethmoidal Sinuses

• Ethmoidal Sinuses has comprised of multiple cavities (10-20 cells).
• These cell are positioned laterally to the lateral nasal walls.
• They are not X-ray visible before age 2 but will be seen with computerized tomography (CT) and, by age 12, are almost adult size.
• Arterial blood supply from the maxillary artery via the nasal branches of the sphenopalatine artery.
• Venous drainage may follow two routes via nasal veins (maxillary vein) or ethmoidal veins that drain to ophthalmic tributaries of the cavernous sinus , which may caused Cavernous sinus thrombosis after ethmoid sinusitis.
• Innervated by anterior and posterior ethmoidal branches of the nasociliary nerves (CN V1) in which cells are divided based on area of drainage.
• The three areas of drainage are, drain anterior ethmoidal cells directly or indirectly into the middle meatus and infundibulum, Middle ethmoidal cells, which also drain directly into the middle meatus and form a the ethmoidal bulla (a swelling on the superior border of the semilunar hiatus) and the the Posterior ethmoidal cells, which open directly into the superior meatus.

Sphenoidal Sinuses

• Sphenoidal area contains two (left and right) sinuses.
• Sinuses are separated by a bony septum in the sphenoid body that might extend into the wings of the same bone.
• The sinuses are derived from ethmoidal cells that invade the sphenoid bone (begins at age 2), and development is not complete until after puberty.
• They open into the sphenoethmoidal recess of the nasal cavity, lying superior to the optic chiasma and the pituitary gland, and the cavernous sinuses lie to their lateral sides.
• Arterial supply Comes from internal (orbit region and posterior ethmoidal arteries of the ophthalmic artery) and external (sphenopalatine branches of the maxillary artery) carotid arteries.
• -Venous drainage is supplied via both the maxillary vein and pterygoid venous plexus.
• The posterior ethmoidal branch in Nasociliary V1 innervates the area.

Maxillary Sinuses

• Maxillary are the largest paranasal sinuses that may have or may not be be present at birth.
• The apex Extends into the zygomatic bone, base forms the inferior lateral nasal wall region and roof forms form orbital floor as the floor makesup the area.
• The sinus drains by means of an opening or the Maxillary Ostium through - - the middle meatus through the Semilunar Hiatus.
• Arterial supply Is the main branch in maxillary areas, via Superior.
• Alveolar branch with facial artery to supply contribution/ help area.
• Main venous and arterial are from greater and lesser palatine region.
• Veins also travel anteriorly and join with retromandibular and the maxillary
• Innervated by branches of the maxillary nerves (CN V2 through anterior, middle, and posterior superior alveolar nerves

Clinical Notes

• Clinical notes included are the Nasal fractures, CSF rhinorhea. rhinitis or sinusitis conditions.

Nasal Fractures

• Fractures of the nose are among the most common facial fractures related to automobile in accidents, and in athletic sports events.
• Nosebleeds (epistaxis) are common due to the rich and vast rich vasculature.
• Meningitis is common due to skull tear, and be due to bacteria can be inccoulating to be produced inside.

CSF Rhinorrhea

• CSF causes injury Usually related to brain injury CSF leakage , this area can tears the main vessel and the sinus.
• The cranium may tear causing meningites and can happen 48 hours to cause risk of rhinorhea.

Rhinitis

• Irritation occurs with Infections with URI area - these areas might affect the cranium plate and effect with soft , the throat.
• Also , It effects with middle , effects the Sinus area and can affect and conjuctiva. Effects in lacrimal, conjuctiva tissues and area there.

Sinusitis

• Infection from the area which Causes aperture in the nasal cavity, effects the inflammation causing.
• Sweling effects can inflammation and block if is two and more causing sinus swelling.
• This results from the disease or condition Panusitis.

Infections

• Infections can come from the sinus area which are inflammated.
• Infection effects with denatl symptom.
• Area that is involved with denal branch that involves with maxillary issues in sign with dental branch pain.
• Test: Transillumination , Bright is placed in mouth side , It will appear a glow in the sinus , If there is an excess or inflammation, It won't appear due to that there is infection.