Functional Reconstructive Nasal Surgery E-Book

Egbert H. Huizing

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 934

Veröffentlichungsjahr: 2015

Beschreibung

Professor Huizing's brilliant text with Dr. John de Groot's magnificent surgical drawings on functional reconstructive nasal surgery is now available in a new and updated second edition. Maintaining its focus on modern surgical concepts and techniques, the book now also includes state-of-the-art contributions from a team of leading international specialists. From surgical anatomy and physiology to diagnosis of nasal syndromes to step-by-step surgical techniques, Functional Reconstructive Nasal Surgery, Second Edition, is unrivalled for its clear, lucid coverage and instructive illustrations of all topics.

Special Features:

• A magnificent art program of more than 1,000 detailed surgical drawings and photographs that elucidate every concept
• A logical continuum from essential anatomic concepts to specific incisions and surgical approaches to the septum, pyramid, lobule, turbinates, and nasal cavity
• Special sections on pediatric nasal surgery, transplants, acute nasal trauma, mentoplasty, implants, patient complaints, and medicolegal issues
• Extensive appendices of materials, instruments, nomenclature, and historical developments
• Every chapter revised and updated, with expanded sections on complications, new techniques for saddle nose correction, and much more

With the goal of improving surgical skill as well as understanding structural basics, the book clearly explains why restoring nasal function and form take priority over purely aesthetic considerations for successful surgical outcomes. This is an essential text and clinical problem solver for otorhinolaryngologists, maxillofacial surgeons, facial plastic surgeons, and residents who perform complex reconstructive rhinologic procedures.

Leseprobe

Functional Reconstructive Nasal Surgery

2nd Edition

Egbert H. Huizing, MD, PhD

Professor Emeritus and Former ChairmanDepartment of OtorhinolaryngologyUniversity Medical Center UtrechtThe Netherlands

John A.M. de Groot, MD, PhD

Formerly Assistant ProfessorDepartment of OtorhinolaryngologyUniversity Medical Center UtrechtThe Netherlands

869 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

© 2015 by Georg Thieme Verlag KG

Thieme Publishers StuttgartRüdigerstrasse 14, 70469 Stuttgart, Germany+49 [0]711 8931 421, [email protected]

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ISBN 978-3-13-129412-8

Also available as an e-book:eISBN 978-3-13-164122-9

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Contents

Preface

Contributors

1     Basics

1.1    Surgical Anatomy

1.1.1 Face

1.1.2 External Nose (External Pyramid)

1.1.3 Internal Nose

1.1.4 Vasculature of the Nose

1.1.5 Nerve Supply of the Nose

1.2    Histological Features of the Main Nasal Structures and Their Implications for Nasal Surgery

1.2.1 Septum

1.2.2 Turbinates

1.2.3 Bony Pyramid

1.2.4 Cartilaginous Pyramid

1.2.5 Lobule

1.2.6 Lobular Cartilages

1.3    Nasal Development and Growth

1.3.1 The Phases

1.3.2 Developmental Phase

1.3.3 Growth Phase

1.3.4 Disturbance of Development and Growth—Consequences for Nasal Pathology and Surgery

1.4    Surgical Physiology

1.4.1 Olfaction

1.4.2 Respiration

1.4.3 Air Conditioning (Heating and Humidification)

1.4.4 Defense

1.4.5 Speech

1.4.6 Facial Beauty and Facial Expression

2     Pathology and Diagnosis

2.1    Nasal Syndromes

2.1.1 Deviated Pyramid Syndromes

2.1.2 Hump Nose (Dorsal Nasal Deformity)

2.1.3 Prominent-Narrow Pyramid Syndrome (Tension Nose)

2.1.4 Low-Wide Pyramid Syndrome (Saddle Nose)

2.1.5 Ski-Slope Nose

2.1.6 Open Roof Syndrome

2.1.7 Lobular Inspiratory Insufficiency Syndrome (“Alar Collapse”)

2.1.8 Middle Meatus Obstructive Syndrome

2.1.9 Wide Nasal Cavity Syndrome (“Empty Nose” Syndrome)

2.1.10 Dry Nose Syndrome

2.1.11 Cleft Lip–and Cleft Palate–Nose

2.1.12 Congenital Nasal Hypoplasia (Nasomaxillary Dysplasia, Binder Syndrome)

2.1.13 Facial Syndromes

2.1.14 Nasal Neuralgias

2.2    Nasal Symptoms—The Most Common Deformities, Abnormalities, and Anatomical Variations

2.2.1 Pathology and Variations of Nasal Dimensions

2.2.2 Humps

2.2.3 Saddling and Sagging

2.2.4 Bony and Cartilaginous Pyramid

2.2.5 Lobule

2.2.6 Valve Area

2.2.7 Septum

2.2.8 Turbinates

2.3    Diagnosis and Documentation

2.3.1 Making the Diagnosis

2.3.2 Examination

2.3.3 Examination of the Internal Nose

2.3.4 Analysis of Nose, Face, and Dentition

2.3.5 Imaging

2.3.6 Photographic Diagnosis and Documentation

2.4    Function Tests

2.4.1 Breathing Tests

2.4.2 Olfactometry

2.4.3 Measuring Air-Conditioning Capacity

2.4.4 Measuring Nasal Defense

2.4.5 Allergy and Hyperreactivity Testing

3     Surgery—General

3.1    Concepts of Functional Reconstructive Nasal Surgery

3.1.1 Surgery for Function and Form

3.1.2 Concepts

3.1.3 Basic Principles

3.2    Endonasal versus External Approach

3.2.1 Historical Development

3.2.2 Advantages and Disadvantages of the Two Different Approaches

3.2.3 Which Approach to Use When?

3.2.4 Sequence of the Surgical Steps

3.3    Preoperative and Postoperative Care

3.3.1 Preoperative Care

3.3.2 Postoperative Care

3.4    Anesthesia and the Bloodless Surgical Field

3.4.1 Local or General Anesthesia?

3.4.2 Local Anesthesia

3.4.3 General Anesthesia

3.4.4 The Bloodless Surgical Field

3.5    Antibiotics and Corticosteroids in Nasal Surgery

3.5.1 Antibiotics

3.5.2 Corticosteroids

4     Incisions and Approaches

4.1    General

4.1.1 Terminology

4.1.2 External versus Internal Incisions

4.1.3 Basic Principles

4.2    Main Incisions

4.2.1 Caudal Septal Incision (Hemitransfixion)

4.2.2 Intercartilaginous Incision

4.2.3 Vestibular Incision

4.2.4 Infracartilaginous Incision

4.2.5 Transcolumellar Inverted V Incision

4.3    Special Incisions—External

4.3.1 Labiogingival Incision

4.3.2 Sublabial Incision

4.3.3 Paranasal Incision

4.3.4 Lateral Columellar Incision

4.3.5 Rim Incision

4.3.6 Alar-facial Incision (Long-Arm-U Incision; Alatomy)

4.3.7 V Incision of the Columellar Base

4.3.8 Dorsal Incisions—Horizontal Dorsal and Dorsal Reversed V Incision

4.4    Special Incisions—Endonasal

4.4.1 Transfixion

4.4.2 Transcartilaginous Incision

4.4.3 Incisions in the Turbinate Mucosa

4.4.4 Incisions in the Septal Mucosa

4.5    Stab Incisions

4.5.1 Vestibular Stab Incision

4.5.2 Paranasal Stab Incision

4.5.3 Nasion (Glabellar) Stab Incision

4.5.4 Alar-facial Stab Incision

4.6    Incisions to Avoid

4.6.1 Vertical Midcolumellar Incision

4.6.2 Horizontal Columellar Incision

4.6.3 Vertical Dorsal Incision

5     Septal Surgery

5.1    Septal Surgery—An Essential Element of Functional Reconstructive Nasal Surgery

5.1.1 Sequence of Surgical Steps in Functional Reconstructive Nasal Surgery

5.2    Basics of Septal Surgery—The Six Phases of Septal Surgery

5.2.1 Phase 1: Approach

5.2.2 Phase 2: Mobilization

5.2.3 Phase 3: Resection

5.2.4 Phase 4: Repositioning

5.2.5 Phase 5: Reconstruction

5.2.6 Phase 6: Fixation

5.3    Special Problems of Septal Surgery

5.3.1 Dislocated (Fractured) Caudal End

5.3.2 Missing (or Irreversibly Deformed) Caudal End

5.3.3 Convexity of the Caudal End

5.3.4 Convexity of the Whole Cartilaginous Septum

5.3.5 Basal Crest

5.3.6 High Deviation

5.3.7 Vomeral Spur

5.3.8 Vertical Fracture

5.3.9 Horizontal Fracture

5.3.10 Anterior Convexity

5.3.11 Missing Septum: (Sub) Total Septal Reconstruction

5.4    Septal Surgery in Children

5.4.1 Indications

5.4.2 Age Factor

5.4.3 Most Common Deformities

5.4.4 Surgical Techniques

5.4.5 Long-Term Effects

5.5    Septal Hematoma and Abscess

5.5.1 Septal Hematoma

5.5.2 Septal Abscess

5.6    Septal Perforation

5.6.1 Classification

5.6.2 Prevention

5.6.3 Treatment Options

6     Pyramid Surgery

6.1    Osteotomies—Mobilizing and Repositioning the Bony Pyramid

6.1.1 Mobilizing the Bony Pyramid

6.1.2 Types of Osteotomy

6.1.3 Repositioning the Bony Pyramid

6.1.4 Instruments Used for Osteotomies

6.1.5 Techniques of Osteotomy

6.2    Wedge Resection

6.2.1 Principles

6.2.2 Surgical Technique

6.2.3 Complications

6.3    Hump Removal

6.3.1 Types of Hump

6.3.2 Surgical Techniques

6.3.3 Complications

6.4    Saddle Nose Correction

6.4.1 Types of Saddling and Sagging

6.4.2 Surgical Techniques

6.4.3 Complications

6.5    Valve Surgery

6.5.1 Pathology of the Valve Area

6.5.2 Surgical Techniques

6.5.3 Prosthesis

6.5.4 Complications

7     Lobular Surgery

7.1    Approaches to the Lobule

7.1.1 The Five Main Approaches: Advantages, Disadvantages, and Indications

7.1.2 Surgical Techniques

7.2    Tip Surgery

7.2.1 Characteristics of the Tip

7.2.2 Mechanics of the Tip

7.2.3 Deformities, Abnormalities, and Variations of the Tip and Their Surgical Correction

7.2.4 Surgical Techniques

7.3    Alar Surgery

7.3.1 Deformities, Abnormalities, and Variations of the Ala and Their Surgical Correction

7.3.2 Surgical Techniques

7.4    Columellar Surgery

7.4.1 Deformities, Abnormalities, and Variations of the Columella and Their Surgical Correction

7.4.2 Surgical Techniques

7.5    Vestibular Surgery

7.5.1 Deformities

7.5.2 Surgical Techniques

7.5.3 Prosthesis

8     Surgery of the Nasal Cavity

8.1    Turbinate Surgery

8.1.1 General

8.1.2 Inferior Turbinate

8.1.3 Middle Turbinate

8.2    Surgery of the Wide Nasal Cavity

8.2.1 Pathology

8.2.2 Treatment

8.2.3 Surgical Techniques

8.3    Endonasal Surgery of the Infundibulum, Ethmoid Bone, and Maxillary Sinus

8.3.1 Pathology of the Infundibulum and Middle Meatus

8.3.2 Surgical Techniques

8.3.3 Complications

9     Special Subjects

9.1    Acute Nasal Trauma

9.1.1 Nasal Trauma in the Newborn

9.1.2 Acute Nasal Trauma in Childhood

9.1.3 Acute Nasal Trauma in Adults

9.2    Nasal Surgery in Children

9.2.1 General

9.2.2 Clinical and Experimental Evidence

9.2.3 When Should Nasal Surgery in Children Be Performed?

9.2.4 Conclusions

9.3    Nasal Surgery in the Unilateral Cleft-Lip Nose

9.3.1 Pathology

9.3.2 Treatment

9.3.3 Surgical Techniques

9.4    The Nose and Sleep Disordered Breathing

9.4.1 Pathology and Causative Factors

9.4.2 Treatment

9.5    Rhinopexy in the Elderly

9.6    Retrusion of the Mandible and Mentoplasty

9.6.1 Diagnosis

9.6.2 Treatment Modalities

9.7    Special Approaches

9.7.1 Endonasal and Transseptal–Transsphenoidal Approach to the Hypophysis

9.7.2 Lateral Rhinotomy

9.7.3 Sublabial Rhinotomy

9.8    Transplants and Implants

9.8.1 Terminology

9.8.2 Requirements for the “Ideal” Transplant and Implant

9.8.3 Materials

9.9    Complications—Prevention and Treatment

9.9.1 Complications or Mistakes?

9.9.2 General Recommendations on Prevention

9.9.3 Prevention and Treatment of Specific Complications

9.10    Patient Complaints and Medicolegal Problems

9.10.1 Dissatisfied Patient

9.10.2 Claims and Lawsuits

10     Appendix

10.1    Materials

10.1.1 Sutures

10.1.2 Needles

10.1.3 Internal Dressings

10.1.4 Tapes

10.1.5 External Splints (Stents)

10.1.6 Septal Splints

10.1.7 Intranasal Sheets

10.1.8 Septal Prosthesis (Septal Button)

10.1.9 Commercially Available Biological Materials

10.2    Instruments

10.2.1 Instruments for Cleansing the Vestibules and Trimming the Vibrissae (“Trim Set”)

10.2.2 Instruments and Medications for Anesthesia and Vasoconstriction

10.2.3 Specula

10.2.4 Knives

10.2.5 Retractors

10.2.6 Hooks

10.2.7 Elevators

10.2.8 Forceps

10.2.9 Scissors

10.2.10 Chisels, Osteotomes, Saws, and Mallets

10.2.11 Rasps and Files

10.2.12 Various

10.2.13 List of Basic Instruments

10.3    Physical Laws Governing Airstreams

10.3.1 Bernoulli's Law

10.3.2 Hagen–Poiseuille's Equation

10.3.3 Reynolds Number

10.3.4 The Venturi Effect

10.3.5 Starling Valve

10.3.6 Rohrer's Equation

10.4    Schemes of Vascularization and Nerve Supply

10.5    Historical Development of Functional Reconstructive Nasal Surgery

10.5.1 “What's Past is Prologue”

10.6    Bibliography

10.6.1 References

10.6.2 Textbooks and Major Chapters on Nasal Surgery in Chronologic Order

Index

Preface

It is rewarding that our book has been used and appreciated in so many teaching clinics in Europe, the United States, Asia, and South America. We were also pleased to witness publication of the first edition in Italian, Turkish, and Chinese—and even some illegal copies!

Some time ago, Mr. Stephan Konnry from Thieme Publishers Stuttgart persuaded us to bring out a second and revised edition of our book. This posed a problem, as we both resigned from the practice of Rhinology and Rhinosurgery several years ago. We felt that this made us unable to update a book like ours. Fortunately, many of our younger colleagues currently teaching in functional reconstructive nasal surgery were willing to update the various chapters without impairing the concept of the book. We are extremely grateful to all of our contributors for their loyalty and help.

Apart from the main contributors, we gratefully acknowledge the remarks given by Dr. René Poublon (Rotterdam) and Dr. Koen Ingels (Nijmegen).

Finally, we would like to thank our editors Mr. Stephan Konnry and Dr. Vicki Gregory (Cambridge, UK) as well as Ms. Nidhi Chopra, Mr. Immanuel Jäger, and Dr. Michael Wachinger for their support.

We hope that this second edition will be received as well as the first one.

Egbert H. Huizing, MD, PhDJohn A.M. de Groot, MD, PhD

Contributors

Ronald L.A.W. Bleys, MD, PhDProfessor of Clinical AnatomyUniversity Medical Center UtrechtUtrecht, The Netherlands

Peter A.R. Clement, MD, PhDEmeritus Professor of OtorhinolaryngologyFree University Brussels (V.U.B.)Ixelles, Belgium

Peter W. Hellings, MD, PhDProfessor of OtorhinolaryngologyUniversity Hospitals LeuvenLeuven, Belgium

Eugene B. Kern, MD, PhDEmeritus Professor of Rhinology and Facial Plastic SurgeryMayo Clinic Medical School Rochester, Minnesota;Emeritus George M. and Edna B. Endicott Professor of MedicineMayo Foundation for Medical Education and Research;Professor of OtorhinolaryngologyState University of New York Buffalo, New York

Jörg Lindemann, MD, PhDProfessor of OtorhinolaryngologyDepartment of Otorhinolaryngology and Head & Neck SurgeryUniversity Hospital UlmUlm, Germany

Adriaan F. van Olphen, MD, PhDFormerly Assistant Professor of OtorhinolaryngologyUniversity Medical Center UtrechtUtrecht, The Netherlands

Wolfgang Pirsig, MD, PhDEmeritus Professor of OtorhinolaryngologyUniversity of UlmUlm, Germany

Marc O. Scheithauer, MD, PhDProfessor of OtorhinolaryngologyDepartment of Otorhinolaryngology and Head & Neck SurgeryUniversity Hospital UlmUlm, Germany

Abel-Jan Tasman, MD, PhDPrivat-Dozent of OtorhinolaryngologyKantonsspital St. GallenSt. Gallen, Switzerland

Chapter 1

Basics

1.1 Surgical Anatomy

1.2 Histological Features of the Main Nasal Structures and Their Implications for Nasal Surgery

1.3 Nasal Development and Growth

1.4 Surgical Physiology

1 Basics

1.1Surgical Anatomy

1.1.1Face

Orientation

Both in diagnosis and surgery, the following terms should be used for orientation (▶ Fig. 1.1):

Fig. 1.1Topographic terminology to be used in nasal surgery.

Cranial (or superior)

Caudal (or inferior)

Dorsal (or posterior)

Ventral (or anterior)

These definitions are to be preferred above others as they are universal and do not change with body position. In the American literature, the term “cephalic” is often used for “cranial.”

Proportions

The human face shows considerable variations in size, form, and proportions. The primary factors involved are race, gender, and age; the secondary factors are growth and trauma. It is therefore difficult to distinguish between normal and abnormal. It is even more difficult—and, in principle, impossible—to define “the beautiful face.” The concept of beauty has not been consistent throughout history, and various human civilizations have aspired to different ideals. Even within the same culture, these ideals have changed over time.

The Western Standard

Our ideas about facial proportions originate in the work of the artists Leonardo da Vinci (1452–1519) and Albrecht Dürer (1471–1528). According to their concept of harmony, the human face may be divided into three equal horizontal and five equal vertical parts (▶ Fig. 1.2 and ▶ Fig. 1.3). It may be helpful to draw horizontal, vertical, and base lines on photographs of the patient when analyzing facial proportions and the relationship of the external nose with other parts of the face. Other than as an aid to partitioning, however, the Leonardo–Dürer concept should not be used. First, the concept is not applicable to all races; second, age and gender play a dominant role; and finally, the concept of beauty is highly subjective. In our opinion, the primary responsibility of a nasal surgeon is to recreate a nose with normal function and normal form. Enhancement of beauty is of secondary importance.

Fig. 1.2Horizontal division of the face into three equal sections.

Fig. 1.3Vertical division of the face into five equal sections.

Horizontal Division

The lower part of the face can be divided into two parts: the upper lip (one-third) and lower lip with chin (two-thirds) (▶ Fig. 1.5).

Fig. 1.5 The height of the upper lip is about half the distance from the gnathion to the stomion.

Vertical Division

The face can be divided into five equal sections: the nasal section, two eye sections, and two lateral sections (▶ Fig. 1.3).

Lobular Base Division

When looked at caudally, the nasal lobule forms a triangle. The height and base of this triangle differ according to race, gender, and age (see ▶ Fig. 1.17). In the Caucasian race, the distance from the lobular base to the upper corner of the nostril (the length of the columella) is about twice as long as the length of the tip (▶ Fig. 1.6).

Fig. 1.6Triangular shape of the lobule. In the Caucasian nose, the distance from the lobular base to the upper corner of the nostril is about twice as long as the length of the tip.

Points

When analyzing the face, several anthropometric points may be used. Some of these are on the skull (bony landmarks), while others are on the skin (clinical points). The following points are important in nasal analysis.

Midline Points (▶ Fig. 1.4)

Vertex (clinical): highest point of the head when it is oriented in the Frankfort horizontal plane

Trichion (clinical): midpoint of the frontal hairline

Glabella (clinical and bony): midline elevation above the nasal root at the level of the eyebrows

Nasion (clinical and bony): midpoint of the frontonasal sutures; deepest point at the transition between the forehead and the nose

Rhinion (clinical and bony): most caudal point of the internasal suture

Tip (pronasale; clinical): most prominent point of the lobule

Subnasale (clinical): midpoint of the nasolabial angle overlying the anterior nasal spine

Stomion (clinical): imaginary point at the crossing of the vertical facial midline and the horizontal labial fissure between the lips

Pogonion (clinical and bony): most ventral midpoint of the chin

Gnathion (clinical and bony): midpoint of the caudal margin of the chin

Keystone or K Area (Clinical)

Fig. 1.7K area or Keystone area.

The keystone or K area is the region where the nasal bones, triangular cartilages, and cartilaginous septum unite. (see ▶ Fig. 1.7) The term was coined by Cottle to emphasize that the nasal vault resembles a Gothic arch closed by a keystone.

Paranasal Points (▶ Fig. 1.8)

Fig. 1.8The most important paranasal points.

Nasal canthus (medial canthus, endocanthion; clinical): inner commissure of the eye fissure

Temporal canthus (lateral canthus, exocanthion; clinical): outer commissure of the eye fissure

Alare (clinical): most lateral point of the alar curvature; used to measure the lobular width

Cheilion (clinical): the point located at each labial commissure

Lateral Points (▶ Fig. 1.9)

Fig. 1.9The most important lateral points.

Euryon (clinical and bony): most prominent lateral point on each side of the skull

Zygion (clinical and bony): most lateral point of the zygomatic arch

Tragion (clinical): notch on the upper margin of the tragus

Lines

The most important lines on the head are the Frankfort horizontal line (FHL) and the facial line (FL). They are used both anthropometrically and clinically. A third line that is helpful in surgery is the nasal base line (NBL) (▶ Fig. 1.10).

Fig. 1.10Frankfort horizontal line (FHL), facial line (FL), and nasal base line (NBL).

Frankfort Horizontal Line

The FHL is the line on the skull from the inferior orbital margin to the upper margin of the external bony ear canal (tragion). In clinical practice, the line between the inferior orbital margin and the upper border of the tragus is used. The FHL should be horizontal when side-view photographs are taken.

Facial Line

The FL is the line from the glabella to the pogonion. It serves as the baseline for calculating the nasofrontal and the nasolabial angles. The FL helps to analyze and define the dimensions of the nasal pyramid in relation to the midface, forehead, and chin.

Nasal Base Line

NBL is a slightly oblique line on the skin at the nasal base from the medial canthus to the alar-facial groove. The prominence (projection, salience) of the bony and cartilaginous pyramid and the lobule is measured from this line. In performing lateral osteotomies and wedge resections, the NBL is used as a line of reference.

Angles

The following text describes the most important angles in nasal analysis.

Nasofrontal Angle

The nasofrontal angle is the angle between the FL and the line over the dorsum of the bony pyramid (▶ Fig. 1.11a). Its magnitude depends on race and age. In Caucasian adults, it measures about 150°. In Asians and blacks, it is larger. The magnitude of the nasofrontal angle has no relation to nasal function. From an aesthetic point of view, a large variation is generally acceptable, reflecting ethnic differences.

Fig. 1.11(a) Nasofrontal angle. (b) Nasolabial angle.

Nasolabial Angle

The nasolabial angle is the angle between the base of the columella (subnasale) and the upper lip (▶ Fig. 1.11b). In Caucasian males, this angle measures 80 to 90°, in females 90 to 110°. In Asians and blacks, it is usually larger.

The nasolabial angle is, to a certain extent, related to nasal function. The smaller this angle, the more vertical the inspiratory airstream that enters the nose and the higher in the nasal cavity the air will reach. Also, aesthetically, the nasolabial angle is considered more important than the nasofrontal angle.

Dimensions

Height of pyramid: distance between nasion and subnasale (columellar base) (▶ Fig. 1.12)

Fig. 1.12Height and length of the nose.

Length of pyramid: distance between nasion and tip (▶ Fig. 1.12)

Prominence (projection, salience): ventral projection of the pyramid measured from the NBL (▶ Fig. 1.13)

Fig. 1.13Prominence of the bony pyramid, cartilaginous pyramid, and lobule.

Bony prominence: distance between the NBL and most prominent part of the bony dorsum

Cartilaginous prominence: distance between the most prominent part of the cartilaginous dorsum and the NBL

Lobular (tip) prominence: distance between the tip and the NBL at the alar-facial groove

Width of pyramid: horizontal dimension of the base of the pyramid and of the tip (▶ Fig. 1.14)

Fig. 1.14Width of the pyramid, lobule, and tip.

Pyramidal width: distance at the base of the bony cartilaginous pyramid between the left and right NBL

Lobular width: distance between the lateral walls of left and right alar cartilages

Width of tip: distance between the two domes

Nasal Indices

The following anatomical and clinical indices may be useful in nasal surgery:

Nasal index (anatomical and clinical)

Lobular (tip) index

Projection index

The way they are measured is illustrated in ▶ Fig. 1.15, ▶ Fig. 1.16, ▶ Fig. 1.17, and ▶ Fig. 1.18. Determining nasal indices may be helpful in analyzing nasal abnormalities and assessing the results of surgery (e.g., in shortening the nose, increasing the projection of the tip or the cartilaginous dorsum, and narrowing the lobule).

Fig. 1.15Anatomical nasal index.

Width of piriform aperture (a) × 100

Length of piriform aperture (b)

Normal values:

Leptorrhine (Caucasian): < 46.9

Platyrrhine (black): 47.0–50.9

Chamaerrhine (e.g., Asian): 51.0–57.9

(After Knuszmann 1988.)

Fig. 1.16Clinical nasal index.

Width of piriform aperture (a) × 100

Height of pyramid (b)

Normal values:

Leptorrhine (Caucasian): 55.0–69.9

Platyrrhine (black): 70.0–84.9

Chamaerrhine (e.g., Asian): 85.0–99.9

Hyperchamaerrhine (black): > 100.0

Fig. 1.17Lobular (tip) index.

Width of tip at ventral border of nares (a) × 100

Maximum width of lobule (b)

This index is normally about 70. It is smaller in the platyrrhine, black, and growth-disturbed nose. It is greater in patients with excessive prominence of the nasal pyramid.

Fig. 1.18Projection index.

Projection of dorsum (a) × 100

Projection of lobule (b)

(a) Projection from the nasal base line of the bony dorsum at the nasion.

(b) Projection from the nasal base line of the lobule at the level of the tip.

The projection index is usually 55–65. Its clinical value is limited.

1.1.2External Nose (External Pyramid)

The external nose consists of four major parts (▶ Fig. 1.19):

Fig. 1.19 The four major parts of the external nose: bony pyramid, cartilaginous pyramid, lobule, and soft-tissue areas.

Bony pyramid

Cartilaginous pyramid

Lobule

Soft-tissue areas

The bony pyramid, cartilaginous pyramid, and lobule comprise about one-third of the external nose. Together they form an integrated anatomical–physiological entity. This is the result of the rigid fixation of the cartilaginous vault to the lower margin of the bony pyramid (underlap of 1.0 to 1.5 mm; ▶ Fig. 1.20, and also ▶ Fig. 1.34 and ▶ Fig. 1.93) and the junctions between the lobule and the cartilaginous pyramid, in particular the connection (and overlap) between the lateral crus of the lobular cartilage and the lower margin of the triangular cartilage (▶ Fig. 1.20). At four different areas, the pyramid consists of soft tissue, allowing a certain amount of mobility (▶ Fig. 1.19 and ▶ Fig. 1.30).

Fig. 1.20Bony pyramid, cartilaginous pyramid, lobule, and soft-tissue areas.

The external nasal pyramid is covered (from the outside to the inside) by skin, subcutaneous connective fatty tissue, and muscle fibers. The thickness and extent of these various layers show considerable individual variation.

Bony Pyramid

The bony pyramid (or bony vault) is the bony part of the external nose that projects above and anterior to both NBLs. Its upper midpoint is the depth of the nasofrontal angle or nasion. Its lowest point is the rhinion or K area.

The bony pyramid consists of the nasal bones, the nasal part of the frontal bone including the nasal spine (spina nasalis ossis frontalis), and the two frontal processes of the maxilla (▶ Fig. 1.21).

The nasal bones are small, oblong, and quadrangular. They are thicker and narrower cranially and thinner and wider caudally. They are attached to each other in the midline by slightly serrated borders that form the internasal suture. Cranially, they unite with the nasal part of the frontal bone to form the frontonasal suture. About halfway down the sloping side of the pyramid, their lateral margins meet the frontal process of the maxilla at the frontomaxillary suture. Their inside (dorsal) surface is smooth and forms part of the anterior wall of the nasal cavity. It has an oblong groove, the ethmoidal sulcus, for the anterior branch of the ethmoidal nerve. The nasal bones often show small perforations (nasal foramina) through which blood vessels penetrate.

The frontal processes of the maxillae are situated between the nasal and lacrimal bones and make up the dorsal part of the bony vault. They are thicker than the adjacent caudal parts of the maxillae. Lateral osteotomies are usually carried out in this part of the bony vault.

The piriform aperture is the anterior nasal aperture as seen in a skull (▶ Fig. 1.21). It is bounded by the nasal bones and the maxillae.

Cartilaginous Pyramid

The cartilaginous pyramid or vault is made up by the septolateral cartilage and the two lateral membranous areas with one to three accessory cartilages (▶ Fig. 1.20).

The septolateral cartilage (▶ Fig. 1.22) consists of:

Fig. 1.22Septolateral cartilage with reflection of the medial part of the caudal margin of the triangular cartilage.

The cartilaginous septum (cartilago septi nasi) that rests on the premaxilla including its anterior nasal spine, dividing the internal nose into two cavities, and

The two triangular cartilages that form the greater part of the dorsal and lateral walls of the cartilaginous vault

The attachment of the cartilaginous vault to the bony pyramid is rigid. The upper margin of both triangular cartilages underlap the lower margin of the nasal bones by 1 to 2 mm over a distance of 5 to 10 mm (▶ Fig. 1.20). See also ▶ Fig. 1.93 and ▶ Fig. 1.94; ▶ Junction between the Triangular Cartilage and Nasal Bones. The area where the nasal bones, the septal cartilage, and the two triangular cartilages unite is commonly called the keystone or K area (see ▶ Fig. 1.7).

The cartilaginous vault is a T-shaped construction. Its angle gradually diminishes from about 15° at the lower margin of the triangular cartilage to almost 90° at the K area (▶ Fig. 1.23). See also ▶ Fig. 1.95 and ▶ Fig. 1.96; ▶ Septolateral Cartilage: Cartilaginous Septum and Triangular Cartilages. In this way, a funnel-type construction is created that plays an important role in breathing and conditioning of the inspired air (see ▶ Respiration).

Fig. 1.23Cross sections through the septolateral cartilage at the valve area, posterior to the valve, and at the K area.

The septal cartilage (cartilaginous septum) rests with its base on a bony pedestal consisting (from ventral to dorsal) of the anterior nasal spine, the anterior part of the nasal crest of the maxilla (often referred to as the premaxilla), and the vomer. Caudally, it has a free, somewhat mobile end that is connected to the columella by the membranous septum. Dorsally, it is united with the perpendicular plate of the ethmoid bone. Ventrally, it is continuous with the two triangular (or upper lateral) cartilages. Together they make the cartilaginous vault and dorsum. See also ▶ Fig. 1.67, ▶ Fig. 1.68, ▶ Fig. 1.69, and ▶ Fig. 1.70; ▶ Chondrospinal Junction and ▶ Chondropremaxillary Complex.

The triangular cartilages (upper lateral cartilages) are continuous with each other and with the septal cartilage. Together they constitute the cartilaginous vault. Cranially, their margins are underlying, and firmly fixed to, the caudal margin of the nasal bones. Medially, the triangular cartilage is lined by mucosa. It covers the inside of the cartilaginous part of the internal nasal cavity. Dorsally, it is connected with the lateral soft-tissue or “hinge” area (see ▶ Fig. 1.20). Ventrally, it is continuous with the septum in its upper two-thirds, while in its lower third, a small cleft with loose connective tissue is found between its medial margin and the septum (medial soft-tissue area or paraseptal cleft). The length of this cleft is variable and related to the length of the nose.

The caudal margin of the triangular cartilage is free and protrudes into the vestibule. Its lateral side is covered by skin (the “cul de sac”). The medial third of the caudal margin is usually rotated upward 160 to 180°. This is called returning, scrolling, or curling (see ▶ Fig. 1.22).

The caudal margin of the triangular cartilage moves inward and outward with respiration (valve function). These movements are possible because of its relatively loose fixation to the medial and lateral soft-tissue areas (the cleft and the hinge areas, respectively). The reflection of the medial part of the lower margin, on the other hand, increases its rigidity and thus counteracts an easy collapse of the lateral nasal wall on inspiration.

The relationship between the triangular cartilage and the lateral crus of the lobular cartilage shows large variations. The most common relationship is a certain overlap of the caudal margin of the triangular cartilage by the cranial margin of the lateral crus of the lobular cartilage. Other relationships that may be found are: “end-to-end,” “scroll,” and “opposed scroll” ([53]) (▶ Fig. 1.24). In the dense connective tissue that connects the lateral crus to the triangular cartilage, several sesamoid cartilages can be found. They provide both mobility and stability, allowing the intercartilaginous area to act more or less as a joint (see also ▶ Fig. 1.95, ▶ Fig. 1.96, and ▶ Fig. 1.97; ▶ Septolateral Cartilage: Cartilaginous Septum and Triangular Cartilages).

Fig. 1.24Most common relationships between the triangular cartilage (TC) and the lobular cartilage (LC).

Nomenclature of Triangular Cartilage

Nomina Anatomica (NA): cartilago nasi lateralis (lateral nasal cartilage)

North America: upper lateral cartilage (ULC)

Germany: Seitenknorpel

France: cartilage laterale

This book: triangular cartilage (TC)

Lobule

The lobule is the mobile lower third of the external nasal pyramid. It is made up of two lobular cartilages, muscle fibers, subcutaneous connective and fatty tissue, and a relatively thick skin with sebaceous glands. The major structures of the lobule are illustrated in ▶ Fig. 1.25 and ▶ Fig. 1.26.

Fig. 1.25Lateral view of the lobule with its major anatomical–clinical structures.

Fig. 1.26Base view of the lobule with its main structures.

Tip

The tip (apex nasi) consists of the two domes, the interdomal connective tissue fibers, and the overlying skin.

Supratip area: a slight depression just cranial to the tip (“the dip before the tip”)

Tip-defining point: most prominent area of the dome of the lobular cartilage; the tip is made up of the two tip-defining points

Infratip area: part of the lobule anterior (ventral) to the nostrils and the columella

Alae

The alae are the mobile lateral walls of the lobule that are made up of the lateral crura of the lobular cartilage and the overlying muscles and skin.

Alar rim: caudal margin of the ala; together with the columella and the nostril sill, it forms the nostril (ostium externum or naris)

Alar base (alar foot): area of attachment of the ala to the face

Facet: flat area at the ventrocaudal part of the ala corresponding to the caudal lobular notch (see ▶ Fig. 1.30)

Vertical alar groove: vertical groove or depression of the ala just medial to the dome

Supra-alar groove or crease: horizontal groove just above the cranial margin of the lateral crus

Alar-facial groove: fold at the alar base between the ala and face

Columella

The columella is the midline structure running from the upper part of the lobule to the upper lip, consisting of the medial crura of the lobular cartilage. The columella is more or less broadened due to the lateral (outward) curvature of the end of the medial crura.

Columellar break: slight bend of the lower margin of the columella at the level of the upper (ventral) margin of the nostril

Midcolumellar groove: vertical groove in the skin between the medial crura

Nostril (Naris, Ostium Externum)

The orifices of the lobule are usually called the nostrils or nares. They are bounded by the columella, lower alar rim, and the nostril sill.

Nostril sill: inferior (dorsal) rim of the nostril

Vestibule

The vestibule is the skin-covered cavity between the nostril and the valve area. Its upper part, lateral to the protruding caudal margin of the triangular cartilage, is a blind-ending pouch commonly called the cul de sac. The caudal part of the vestibule bears hairs (vibrissae) that help protect the entrance of the respiratory tract against insects, etc.

Nomenclature of Lobular Cartilage

Nomina Anatomica (NA): cartilago alaris major (greater alar cartilage)

North American: lower lateral cartilage; alar cartilage

German: Flügelknorpel

This book: lobular cartilage

Lobular Cartilages

The lobular cartilages are horseshoe-shaped cartilages that support the structured anatomy of the whole lobule. They determine the position and form of the tip, the alae, and the columella as well as the configuration of the nares and vestibules.

The lobular cartilage can be divided into three or four parts (▶ Fig. 1.27):

Fig. 1.27Left lobular cartilage with its anatomical parts.

Medial crus

Intermediate part (not always identifiable)

Dome

Lateral crus

Medial Crus

The medial crus is the slightly bent medial part of the lobular cartilage. It supports the columella, nares, and tip. Its length and width vary greatly. As the medial crura run into the columella, they become closely associated and form a support for the septal cartilage. Their free ends protrude slightly into the vestibules, broadening the columellar base (▶ Fig. 1.28). The space between the medial crura is filled with loose connective tissue. There are no crossing fibers between the two crura. See also ▶ Fig. 1.101 and ▶ Fig. 1.102; ▶ Intercrural Area.

Fig. 1.28Lobular cartilages in relation to the tip, alae, and columella.

Intermediate Part

The intermediate part may be defined as the transitional segment between the medial crus and the dome. It cannot always be clearly identified as a separate part of the lobular cartilage. Many authors therefore do not recognize it as a separate structure.

Dome

The dome is the strongly bent part of the lobular cartilage between the medial and lateral crura. Its curvature varies greatly from 80° (ballooning type) to 10° (narrow type). Its cranial border is often notched. The two domes together make the nasal tip. It has been suggested that the two domes are connected by a bundle of midline crossing fibers, an interdomal ligament, or Pitanguy ligament. In a histological study ([340]), we were unable to confirm the presence of horizontal, midline-crossing fibers, and certainly not a ligament (see ▶ Fig. 1.98, ▶ Fig. 1.99, and ▶ Fig. 1.100).

Although a true ligament characterized by highly organized fiber directions is not present, the connecting tissue between the domes and adjacent intermediate parts of the lobular cartilages is biomechanically important.

Lateral Crus

The lateral crus is the lateral extension of the lobular cartilage supporting the ala. Its shape may be convex, convex–concave, concave–convex, concave, or flat (▶ Fig. 1.29). The convex type is the most frequent. Its length (mediolateral dimension) varies from 16 to 30 mm, its maximal height (craniocaudal dimension) from 6 to 16 mm. The distance of its caudal margin to the alar rim increases in the ventrodorsal direction.

Fig. 1.29Most common shapes of the lateral crus of the lobular cartilage.

Soft-Tissue Areas

The external nasal pyramid has four soft-tissue areas. Unfortunately, there is considerable confusion about their terminology in the literature. We suggest using the following nomenclature (▶ Fig. 1.30):

Fig. 1.30The four soft-tissue areas.

Paraseptal cleft or paraseptal soft-tissue area

Lateral soft-tissue area or hinge area

Caudal lobular notch

Alar soft-tissue area

The paraseptal cleft (paraseptal soft-tissue area) is a narrow triangular opening between the cartilaginous septum and the lower third of the medial margin of the triangular cartilage, filled with loose connective tissue. It allows the outward and inward movement of the lower part of the triangular cartilage during respiration.

The lateral soft-tissue area (hinge area) is a more or less triangular soft-tissue area between the lateral margin of the triangular cartilage and the lateral wall of the piriform aperture. It consists of relatively dense connective tissue fibers with two to three accessory cartilages. It allows outward and inward movements of the triangular cartilages (and valve) and alae. It is therefore also called the hinge area.

The caudal lobular notch is found medially at the lower margin of the lateral crus. It does not seem to have any special functional significance. It deserves special attention and needs to be carefully preserved during lobular surgery.

The alar soft-tissue area is the most dorsal and caudal part of the ala inferior to the lateral crus of the lobular cartilage. The ala is not completely occupied by the lobular cartilage.

Skin and Connective, Muscular, and Fatty Tissues Overlying the External Nose

The external nasal pyramid is covered from outside to inside by:

An epidermis of varying thickness and a dermis with sebaceous glands and hair follicles

A connective tissue layer of varying thickness containing the vascular and nerve supply, and a variable amount of fatty tissue

A muscle layer

A thin, loose connective tissue layer permitting gliding movements of the overlying tissues

A periosteal or perichondrial layer that is attached to the bone or cartilage

Nowadays, some authors like to speak of a superficial musculoaponeurotic system (SMAS), consisting of a superficial fatty layer, a fibromuscular layer, a deep fatty layer, a longitudinal fibrous layer, and an intercrural ligament ([187]). However, we prefer to reserve the term SMAS for a connective tissue layer containing a variable number of muscle fibers that extends cranially from the platysma, covers the parotid gland and facial nerve branches, and stops at the level of the zygomatic arch. Anteriorly, the SMAS is continuous with the orbicularis oculi and zygomaticus major muscles. Because this layer is in the same level as the facial muscles, it can best be regarded as the vestige of the facial muscle layer in a region where such muscles are not needed anymore (i.e., the parotid region). Indeed, in primates, the cranial border of the platysma runs as high as the zygomatic arch ([159]). Therefore, we do not follow the distinction between the various layers as described by [187]; moreover these layers show considerable differences in the various parts of the external nasal pyramid. See also ▶ Fig. 1.95, ▶ Fig. 1.96, and ▶ Fig. 1.97; ▶ Septolateral Cartilage: Cartilaginous Septum and Triangular Cartilages.

The bony pyramid is covered in its upper part by relatively thick skin with a considerable amount of subcutaneous connective tissue and muscle fibers (procerus). In its lower part, the nasal bones are covered by a rather thin skin, a thin layer of loose connective tissue, and some transverse muscle fibers (transverse part of nasalis) (▶ Fig. 1.31).

Fig. 1.31Thickness of the skin and subcutaneous tissues overlying the external pyramid.

The loose subcutaneous layer allows movement of the skin over the bone while offering protection against trauma and pain from pressure. This is illustrated by patients in whom this layer has not been preserved during surgery; they often complain of tenderness in this region.

The cartilaginous pyramid is covered by a somewhat thicker layer of soft tissue. The skin has a larger number of sebaceous glands and hair follicles. The muscle fiber layer is also thicker. See also ▶ Fig. 1.95 and ▶ Fig. 1.96; ▶ Septolateral Cartilage: Cartilaginous Septum and Triangular Cartilages.

The lobule has a thick covering consisting of epidermis, dermis with hair follicles and numerous sebaceous glands, fat, connective tissue with the vascular supply, lymph vessels and nerves, muscle fibers, and areolar tissue.

The thickness and quality of the skin depend on a great number of factors, including gender, age, and climatological influences. The subcutaneous connective tissue layer is relatively thick, especially between the cartilages. A variable amount of fatty tissue can be found in the midline just above the interdomal area and laterally. See also ▶ Fig. 1.104 and ▶ Fig. 1.105; ▶ Alae.

Four different muscles can be distinguished. The fibers run from the lobular cartilage into the skin, adding to the rigidity of the lateral lobular wall or ala. As a result, the lobular skin is not freely movable over the lobular cartilage.

Musculature

The external nasal pyramid is almost completely covered by a thin layer of musculature. There is no consensus on the number of muscles that can be distinguished and no agreement on their names.

[70] recognizes five nasal muscles. Most anatomical and rhinosurgical textbooks, however, mention seven or nine.

All nasal muscles have a mimic function. Some of them also play a role in breathing and provide stability for the lateral nasal wall. In this section we follow the work of [22], who recognized seven different nasal muscles (▶ Fig. 1.32).

The procerus muscle is an unpaired layer of muscle fibers. These originate in the nasofrontal suture area, fan in a caudal direction (hence the alternative name, pyramidalis), and insert in the skin over the bony pyramid. These muscle fibers produce transverse wrinkling of the skin at the root of the nose. Some fibers may reach as low as the ala and thus may assist in elevating the ala and dilating the nostril.

The levator labii superioris alaeque nasi muscle arises from the frontal process of the maxilla. It has a small medial part that inserts into the perichondrium of the lateral crus. It can thus act as a dilatator of the nostril and elevator of the lateral lobular wall.

The nasalis muscle (transverse part) originates in the maxilla above the canine tooth and the skin over the nasolabial fold. It runs to the midline of the nasal dorsum. It acts as a stabilizer of the lateral nasal wall. See also ▶ Fig. 1.99 and ▶ Fig. 1.100; ▶ Interdomal Area.

The nasalis muscle (alar part) also originates in the maxilla but at a point somewhat more medial than the transverse part. It inserts at the lateral and lower margin of the ala. These fibers may draw the ala laterally and dilate the valve area. This muscle is the most important stabilizer of the lateral nasal wall.

The dilator naris arises from the lateral crus and superimposing alar skin and inserts into the skin of the nasolabial groove. However, not all authors accept this view. The muscle acts together with the alar part of the nasalis muscle as alar abductors and openers of the nostril.

The depressor septi muscle originates in the maxilla above the incisor tooth, together with the fibers of the alar part of the nasal muscle, and inserts in the medial crus. It pulls the membranous septum down, widening the nostril.

The apicis nasi muscle is a very small muscle lying on the lower medial part of the lateral crus. Its function is a matter of debate.

1.1.3Internal Nose

Anatomically, embryologically, and physiologically we distinguish:

Two nasal cavities (two noses)

Three nasal passages on both sides: the lower, middle, and upper meatus

Three nasal openings on both sides: the nostril (external ostium, naris), the valve area (internal ostium), and the choana

Anatomical–Physiological Subdivision of the Nasal Organ

Over the years, several systems have been suggested to divide the different parts of the nose on the basis of anatomical, physiological, and/or pathological differences.

External versus Internal Nose

The oldest subdivision is the distinction between the external and the internal nose: the external nose, specific to humans, is the prominent bony, cartilaginous and soft-tissue pyramid in the middle of the face; while the internal nose, with its mucosa, turbinates, and septum, is the nasal organ proper.

Five-Area Division of Cottle

For the purpose of diagnosis and documentation, as well as to correlate pathology with symptomatology, [45] proposed to divide the internal nasal cavity into five areas (▶ Fig. 1.33).

Area 1: nostril (external ostium, naris), formed by the alar rim, the lateral border of the columella, and the floor of the vestibule

Area 2: the nasal valve area (internal ostium, isthmus)

Area 3: the area underneath the cartilaginous vault (also called the “attic”)

Area 4: the anterior half of the nasal cavity, including the heads of the turbinates and the infundibulum or ostiomeatal complex

Area 5: the posterior half of the nasal cavity, including the tails of the turbinates

This five-area division was adopted by several authors including ourselves. In several German textbooks (Masing 1977, Ey 1984, Rettinger 1988), however, the denomination “area 3” was given to a different region (the premaxillary area) than in the Cottle system. This has diminished the value of the five-area division.

Five-Structure Division of Bachmann–Mlynski

[9], and more recently [215], have divided the nose on the basis of its inspiratory function into five different structural elements: the vestibulum, the isthmus, the anterior cavity, the area of the turbinates, and the posterior cavity, choanae, and epipharynx.

Three-Structure Division (This Book)

In this book we suggest a subdivision into three anatomical–physiological parts ([130]) (see also ▶ Fig. 1.119):

The anterior segment or upstream area, consisting of the nostril, vestibule, and valve area

The middle segment or functional area proper, consisting of the mucosa-lined nasal cavity with the turbinates, septum, and sinus ostia

The posterior segment or downstream area, with the tails of the turbinates, anterior wall of the sphenoid, and choanae

Nostril (Naris, External Ostium)

The nostril is formed by the alar rim, the lateral border of the columella with the protruding end of the medial crura, and the nostril sill (▶ Fig. 1.34). In a normal adult Caucasian nose, the nostril has an ovaloid form with a slightly oblique axis. In newborns and young children, it is almost round. It gradually changes to the adult ovaloid aperture during school age and puberty.

Fig. 1.34Structures bounding the nostril.

In the noses of blacks and Asians, the nares are also more round. In some types of noses of blacks, the external ostium may have an almost horizontal axis. These racial and age variations are also expressed in the magnitude of the lobular index.

Vestibule

The vestibule is the skin-covered inner part of the lobule (▶ Fig. 1.35). The following structures are of clinical and surgical significance (see also ▶ Fig. 1.95, ▶ Fig. 1.96, and ▶ Fig. 1.104):

Fig. 1.35Vestibule and valve area with its various structures.

Medially:

The columella with the medial crus of the lobular cartilage

The membranous septum (the membrane that connects the medial crura of the lobular cartilage to the lower edge of the septal cartilage) and its covering skin

The skin covering the caudal end of the septal cartilage

Internal ostium or laterally:

The inside of the ala with the lateral crus and its more or less protruding end

The cul de sac or infundibulum, a shallow pouch bounded laterally by the cranial part of the lateral crus and medially by the caudal part of the triangular cartilage

Valve Area (Internal Ostium)

The valve area is a more or less triangular or teardrop-shaped area that gives access to the internal nasal cavity (▶ Fig. 1.36). Its original name was ostium internum ([341]) or isthmus nasi. Later, it was considered a “valvular device controlling the inflow of air” ([211], [213]). Nowadays, we call it the valve area ([170]). As the narrowest region of the internal nose, it causes the greatest resistance to breathing. The valve area is bounded:

Medially by:

The cartilaginous septum

The premaxillary wing

Laterally by:

The lower margin of the triangular cartilage or limen nasi

The fibrofatty tissue area

The head of the inferior turbinate

Caudally by:

The skin-covered floor of the piriform aperture

The medial wall of the valve area is rigid, whereas the lateral wall is mobile. On inspiration, it moves inward due to the negative pressure caused by the inspiratory airflow. On expiration, it moves outward. The inward movement is counteracted by the mass and stiffness of the triangular and lobular cartilages, soft-tissue areas, and the connecting fibers and musculature (see also ▶ Fig. 1.95, ▶ Fig. 1.96, and ▶ Fig. 1.97; ▶ Septolateral Cartilage: Cartilaginous Septum and Triangular Cartilages).

Terminology of the Valve Area

Valve area: narrowest area (area 2) of the internal nose

Valve: the moving part of the lateral wall of the valve area (i.e., the caudal margin of the triangular cartilage)

Valve angle: the angle between the caudal margin of the triangular cartilage and the septum

Ostium internum: old name for the valve area; this name was introduced by anatomists (Zuckerkandl 1883) in the 19th century in contrast to “ostium externum” (naris, nostril)

Isthmus: narrowest area of the nasal cavity (valve area)

Limen nasi: lower margin of the triangular cartilage (valve)

External Nasal Valve

Recently, some authors (e.g., [269]) suggest the presence of another valvular structure, the external nasal valve. They attribute a valvular function to the relative narrowing of the nasal vestibule that is caused by the slightly protruding caudal margin of the lateral crus (sometimes named the vestibular fold) and the protruding caudal end of the medial crus. [49] named these protrusions “baffles” and pointed out that they add to nasal resistance and influence airstream. [32] recognized four components of the nasal valve. It is well known that pathology of the lateral crus or the medial crus may, indeed, lead to inspiratory breathing obstruction. This condition is usually called alar collapse. We doubt if the term external nasal valve is justified to describe the function of these two vestibular airway resistors that only indirectly affect the functioning of the much more important (internal) nasal valve.

Septum

The nasal septum consists of: (1) the cartilaginous septum; (2) the perpendicular plate of the ethmoid bone; (3) the vomer; and (4) the septal framework.

Cartilaginous Septum

The cartilaginous septum is part of the septolateral cartilage. The following structures are of special clinical and surgical interest (▶ Fig. 1.37):

Fig. 1.37Septolateral cartilage consisting of the cartilaginous septum and the two triangular cartilages.

The free caudal end

The processus lateralis ventralis: a broadening of its caudal margin in the area where the cartilage is connected to the premaxilla

The ventrocaudal corner (anterior–inferior corner)

The sphenoidal process (posterior process): a posterior extension of the cartilaginous septum between the perpendicular plate and the vomer; see also ▶ Fig. 1.67, ▶ Fig. 1.68, ▶ Fig. 1.69, and ▶ Fig. 1.70; ▶ Chondrospinal Junction and ▶ Chondropremaxillary Complex.

Perpendicular Plate of the Ethmoid Bone (Lamina Perpendicularis)

The perpendicular plate of the ethmoid bone is a more or less quadrangular, thin, bony plate. Its upper border is ventrally attached to the posterior surface of the nasal spine of the frontal bone (frontoethmoidal suture). More posteriorly, it is united to the inferior surface of the cribriform plate (▶ Fig. 1.38). The posterior margin unites with the sphenoidal crest (sphenoidal suture). The caudal margin is attached to the anterior border of the vomer. The ventral margin unites with the cartilaginous septum. This part often has two cortical layers with spongiotic bone marrow in between. On rare occasions, a bulla may be present (see also ▶ Fig. 1.73 and ▶ Fig. 1.74).

Fig. 1.38Perpendicular plate of the ethmoid bone and the vomer.

Vomer

The vomer is an unpaired, oblong, quadrangular bone resembling a plowshare. Its cranial margin is broad and split into two lateral leaves (alae vomeris). These are attached to the sphenoid bone. Its posterior margin forms the medial wall of the choanae. Its inferior margin, which is sharp and serrated, is connected to the nasal crests of the maxilla and palatine bone. The anterior (to some extent also cranial) margin is somewhat thickened. It has a groove in which the inferior margin of the perpendicular plate and the cartilaginous septum are fixed.

Septal Framework

The septal framework holding the septum consists of eight different anatomical structures (▶ Fig. 1.39):

Fig. 1.39Septal framework.

Caudally:

Anterior nasal spine (spina nasalis anterior)

Premaxilla with the premaxillary table and the premaxillary wings

Maxillary crest (crista nasalis maxillae)

Palatine crest (Crista nasalis ossis palatini)

Membranous septum (septum membranaceum)

Ventrally:

Bony ridge at the dorsal side of the nasal bones

Cranially:

Bony ridge at the junction of the cribriform plates

Dorsally:

Sphenoidal crest (crista sphenoidalis), a bony ridge at the junction of the two sphenoidal sinuses

Junctions between the Septum and its Framework

Precise knowledge of the connections between the various parts of the septum is of the utmost importance in septal surgery. In particular, the junctions between the cartilaginous septum and the anterior nasal spine and the premaxilla are of great importance. Detailed information is presented in ▶ Fig. 1.39, ▶ Fig. 1.40, ▶ Fig. 1.41, and ▶ Fig. 1.42 (and also in ▶ Fig. 1.67, ▶ Fig. 1.68, ▶ Fig. 1.69, ▶ Fig. 1.70, ▶ Fig. 1.71, ▶ Fig. 1.72, ▶ Fig. 1.73, and ▶ Fig. 1.74).

Fig. 1.40Chondropremaxillary complex (a) and the chondromaxillary junction (b).

Fig. 1.41Premaxilla and premaxillary wings.

Fig. 1.42Premaxilla and incisive canal.

Incisive Bone

Although the terminology of ▶ Fig. 1.39, ▶ Fig. 1.40, ▶ Fig. 1.41, and ▶ Fig. 1.42 is common in clinical practice, it is different from that found in major anatomical textbooks. The existence of an incisive bone (os incisivum) is indisputable since it has centers of ossification that are distinct from those of the main maxillary mass. The fusion of the incisive bone with the maxillary bone takes place well before birth and does not leave a trace on its facial aspect. On the palatine side, however, a suture (the incisive suture), running from the incisive fossa in the anterolateral direction, is visible at birth. This suture may persist for several decades.

The incisive bone might therefore be described as the part of the maxilla anterior to the incisive fossa and incisive canals. It may be considered the same bone as the premaxilla, which is a separate bone in most vertebrates. In anatomical textbooks, the structure referred to as the premaxilla in ▶ Fig. 1.39, ▶ Fig. 1.40, ▶ Fig. 1.41, and ▶ Fig. 1.42 is described as the most anterior part of the nasal crest of the maxilla, and is also known as the incisor crest. It is the highest part of the nasal crest. It projects ventrally, together with its contralateral fellow, as the anterior nasal spine, and flattens superiorly to form the premaxillary table and wings (▶ Fig. 1.40a and ▶ Fig. 1.41).

Turbinates and Turbinate-Like Structures

In each nasal cavity, six to eight turbinates and turbinate-like structures can be distinguished (▶ Fig. 1.43 and ▶ Fig. 1.44).

Fig. 1.43Inferior, middle, superior, and septal turbinate.

Fig. 1.44Lateral nasal wall with inferior turbinate (1), middle turbinate (2) superior turbinate (3), agger nasi (4), and supreme turbinate (5).

On the lateral nasal wall we find:

The inferior turbinate (concha nasalis inferior)

The middle turbinate (concha nasalis media)

The superior turbinate (concha nasalis superior)

The agger nasi, and in some cases

The supreme turbinate (concha nasalis suprema)

On the medial nasal wall we find:

The septal turbinate (also known as tuberculum septi, intumescentia septi, and Kiesselbach ridge), and in some cases several

Posterior septal ridges or folds

(See also ▶ Fig. 1.87).

Hippocrates called the turbinates “sleeves.” Casserius (1610) gave them their present name. (He wrote: “[…] the use of the turbinate bones is to break the force of the entering air and warm it and cleanse it.”)

Turbinates

The turbinates should be considered separate structures with a similar, but not completely identical, function. Their bony skeleton may be lamellar, spongy, or bullous.

The lamellar type is the most common, especially in the inferior turbinate. Its architecture may differ in the way the bony lamella protrudes into the nasal cavity.

The spongy type is frequently seen in the inferior and middle turbinates and also in the bony septum underlying the septal turbinate.

The bullous type is present in the middle turbinate in about 25% of the population. It is a very rare finding in the inferior turbinate.

The cavernous parenchymal tissue is by far the most developed in the inferior turbinate. It is also relatively thick at the medial and posterior part of the middle turbinate. It is negligible in the superior turbinate. These variations illustrate the functional differences of the turbinates and their parts.

The mucosal lining of the various turbinates also shows certain differences in the number of cilia-bearing cells and glands.

Because of their extensive submucosal capillary bed and the abundance of serous and mucous glands, the mucosal surface greatly contributes to the humidification, warming, and cleansing of inspired air. This is made possible by the thick mass of cavernous tissue in between the submucosa and the bony skeleton. The conchal parenchyma is made up of arterioles, venules, and an extensive capillary bed embedded in loose connective tissue. Congestion and decongestion of the cavernous plexus is regulated by a complex autonomic nerve system that is influenced by a number of endogenous and exogenous factors (see ▶ Vasculature of the Lateral Wall and Turbinates).

The inferior turbinate is the largest of the four lateral turbinates. It is an independent bone which is attached to the maxilla. As in mammals, it may therefore be called the “maxilloturbinale.” For clinical and surgical purposes we distinguish a turbinate head, body, and tail. These three parts differ in terms of function and pathology.

The bony skeleton consists of a solid or spongiotic lamella extending from the lateral bony nasal wall into the nasal cavity (see ▶ Inferior Turbinate and ▶ Fig. 1.88). The angle between the turbinate bone and the bony lateral nasal wall may vary considerably, from about 20 to 90° (▶ Fig. 1.45). These differences may contribute to inferior turbinate pathology. They should therefore be taken into account in planning turbinate surgery. The mucosa of the inferior turbinate is thicker than in the upper part of the nasal cavity. The cavernous parenchyma of the inferior turbinate is much more massive than that of other turbinates. In the congestive state, it may increase its volume three to four times compared with its decongested state, thereby almost completely blocking the inferior nasal passage (see also ▶ Turbinates, ▶ Fig. 1.87, ▶ Fig. 1.90, and ▶ Fig. 1.91).

Fig. 1.45a, b CT scans of the inferior turbinate demonstrating the large variation of the angle between the turbinate bone and the bony lateral nasal wall. (a) Large angle, almost 90 degrees. (b) Small and asymmetric angles; the asymmetry suggests that apart from genetic factors, postnatally developed pathology may play a role.

The middle turbinate is part of the ethmoid bone. This explains why its skeleton may be more or less pneumatized. It is comparable to the ethmoidoturbinale I in mammals. The bony skeleton (▶ Fig. 1.46) may be of the lamellar, spongy (concha spongiosa), or bullous type (concha bullosa).