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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4450_Библиотеки_им_академика_М_И_Перельмана
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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 turbinatelike structures can be distinguished (▶ Fig. 1.43 and ▶ Fig.
1.44).
Fig. 1.43Inferior, middle, superior, and septal turbinate.
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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:
1. The inferior turbinate (concha nasalis inferior)
2. The middle turbinate (concha nasalis media)
3. The superior turbinate (concha nasalis superior)
4. The agger nasi, and in some cases
5. The supreme turbinate (concha nasalis suprema)
On the medial nasal wall we find:
1. The septal turbinate (also known as tuberculum septi,
intumescentia septi, and Kiesselbach ridge), and in
some cases several
2. 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
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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.
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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).
Fig. 1.46a–c Middle turbinate. (a) Plate or lamellar type. (b) Cancellous or spongy
type. (c) Bullous type.
The lamellar type is characterized by a curved bony
plate extending from the lamina papyracea. This plate
divides the ethmoid bone into an anterior and posterior
part. Its free end may be more or less straight, curved
inward, or curved outward.
The spongy type is less common. The bony skeleton is
made up of two cortical layers and spongiotic bone with
bone marrow in between. As a result, the turbinate may
be relatively thick, which may play a role in pathology.
The bullous type is a common variation found in about
25% of normal individuals. The skeleton consists of an
ovaloid ethmoidal cell with thin walls. Its inside is lined
with mucosa, and it usually drains through an ostium
into the infundibulum. A concha bullosa may have a
considerable size and may be multichambered. As a
result, it may be in permanent contact with the septum
and/or obstruct the infundibulum. Although a normal
variation, a concha bullosa may thus play a role in nasal
and sinus pathology.
The cavernous parenchyma of the middle turbinate is less
voluminous than that of the inferior turbinate. It is thinnest
at its head and thicker in the middle part and tail. It varies
from 1 mm in the decongested state to 2 to 3 mm in the
congested state. The mucosa of the middle turbinate is of
moderate thickness and has numerous glands.
The superior turbinate is also part of the ethmoid bone. It
is comparable with the ethmoidoturbinale II in mammals. It
has little or no functional and pathological significance. It is
a rudimentary structure consisting of a ridge at the
cranioposterior wall of the nasal cavity of about 2 cm in
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length with some cavernous tissue and a relatively thin
mucosa (see ▶ Fig. 1.87 and ▶ Turbinates ).
The supreme turbinate is the remains of the
ethmoidoturbinale III in mammals. In humans it is only
present in about one-third of individuals.
Turbinate-Like Structures
The septal turbinates present themselves as local
thickenings or ridges of the septal mucosa. Considering
their histology and location, these mounds and plicae
should be considered turbinates as they play a role in
regulating and conditioning inspired air.
The tuberculum septi anterior (intumescentia septi),
the most conspicuous septal turbinate, lies opposite the
head of the middle turbinate. It was described by
Morgagni (1706), and later by [342]). Its height is 1 to 2
cm, its length about 2 cm (▶ Fig. 1.43 and ▶ Fig. 1.47).
See also ▶ Fig. 1.87 and ▶ Fig. 1.92; ▶ Turbinates. The
underlying perpendicular plate in this area is usually of
the spongy type.
Fig. 1.47Septal turbinate, lateral view.
Septal ridges (plicae septi, tuberculum septi posterior):
Two or three narrow mucosal ridges or folds may be
seen running downward on the lower (vomeral) part of
the bony septum. Their course is parallel to the course
of the inspiratory airstream. They are more common in
children than in adults.
The agger nasi is a mound or ridgelike elevation at the
lateral nasal wall anterior to the head of the middle
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