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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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Fig. 1.52Vascularization of the external nasal pyramid by a network of anastomoses
between the internal and external carotid system.
The facial artery branches into the superior labial artery at
the corner of the mouth. This artery courses along the
labial margin between the mucous membrane and the
orbicularis oris muscle, and communicates with its
contralateral fellow. It gives rise to an alar branch and, in
the midline, to the columellar artery that supplies the
columella and the lobular tip. The columellar artery also
sends a branch to the nasal septum. Therefore, in the
Terminologia Anatomica, the columellar artery is called the
nasal septal branch.
By the side of the nose at the level of the ala, the facial
artery branches into the lateral nasal branch, which
supplies the dorsum and ala of the nose. The part of the
facial artery distal to the lateral nasal branch is called the
angular artery. The angular artery proceeds alongside the
margin of the nose to the medial angle of the eye. It has
several side branches towards the nasal dorsum and the
cheek, and usually communicates with a medial branch of
the infraorbital artery.
Facial artery branches to the external nasal pyramid may
anastomose broadly with each other, their fellows from the
opposite side, and the dorsal nasal artery.
Vasculature of the Septum
The septum receives its blood supply through five different
arteries which originate both in the ICS as well as in the
ECS (▶ Fig. 1.53):
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Fig. 1.53Vascularization of the septum. Anastomoses between the internal (ethmoidal
arteries) and external (superior labial and sphenopalatine arteries) carotid system.
Superior–anterior: anterior ethmoidal artery
(ophthalmic artery–internal carotid artery [ICA])
Superior–posterior: posterior ethmoidal artery
(ophthalmic artery–ICA)
Inferior–anterior: superior labial artery (facial artery–
external carotid artery [ECA]) and greater palatine
artery (maxillary artery–ECA)
Inferior–posterior: sphenopalatine artery (maxillary
artery–ECA)
As illustrated in ▶ Fig. 1.53, there is a wide overlap between
these five providers. This explains why, in some cases, it is
so difficult to deal with epistaxis.
The well-known locus Kiesselbach is a vulnerable area on
the anterior septum where the terminal vessels of the
various arteries meet and anastomose.
Vasculature of the Lateral Wall and Turbinates
The lateral nasal wall and the turbinates are supplied in a
similar way to the septum (▶ Fig. 1.54).
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Fig. 1.54Vascularization of the lateral nasal wall. Anastomoses between the internal
(ethmoidal arteries) and external (sphenopalatine artery) carotid system.
Anterior ethmoidal artery: lateral wall area 3, 4; head
of turbinates; anterior ethmoidal cells
Posterior ethmoidal artery: lateral wall area 4, 5;
superior turbinate; posterior ethmoidal cells
Sphenopalatine artery: lateral wall area 5; turbinates;
nasal floor
Superior labial artery: vestibule
Resistance and Capacitance Vessels
The nasal mucosa has a very complex and characteristic
vasculature. Two types of vessels may be distinguished: a
rich capillary network in the subepithelial zone and around
the seromucous glands, and a cavernous venous plexus
deep in the lamina propria. The capillaries are named the
resistance vessels; the plexus of venous sinusoids, the
capacitance vessels. The latter are so well developed that
they resemble erectile tissue. They may contract and
distend. When congested, they cause swelling of the
mucosa and increased nasal resistance. They are
particularly found in the anterior half of the inferior
turbinates and the anterior part of the septum.
1.1.5Nerve Supply of the Nose
The nasal structures have an intricate nerve supply
involving four different systems (▶ Table 1.1):
Table 1.1The four nervous systems of the nose, their neurotransmitters and effects
System Neurotransmitters Effects
Somatosensory SP, NKA, CGRP, etc. Sensibility skin and mucosa
Somatomotor ACh Musculature
Sympathetic NA, NPY, etc. Vasoconstriction
Quality of secretion
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System Neurotransmitters Effects
Parasympathetic ACh, VIP, PHI, etc. Vasodilation
Stimulation of secretion
Abbreviations: Ach, acetylcholine; CGRP, calcitonin gene–related peptide; NA,
noradrenaline; NKA, neurokinin A; NPY, neuropeptide Y; PHI, peptide histidine isoleucine
amide; SP, substance P; VIP, vasoactive intestinal peptide
Somatosensory system
Somatomotor system
Sympathetic system (visceromotor)
Parasympathetic system (visceromotor)
Sensory Innervation
The sensory innervation of both the external pyramid and
the nasal cavity is derived from the trigeminal nerve (▶ Fig.
1.55). See also ▶ Fig. 10.57 for more details.
Fig. 1.55Schematic diagram of internal and external nasal innervation.
Sensory Innervation of the External Pyramid
The external pyramid receives its nerve supply through five
different nerves. Four of them originate in the ophthalmic
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nerve (V1) and one in the maxillary nerve (V2), as shown in
▶ Fig. 1.56:
Fig. 1.56Nerve supply of the external nose by four branches of the ophthalmic nerve.
Supraorbital nerve: nasal root, upper eyelid,
conjunctiva, forehead, frontal sinus
Supratrochlear nerve: bony pyramid, upper eyelid,
conjunctiva, frontal sinus
Infratrochlear nerve: bony and cartilaginous pyramid,
eyelids, conjunctiva, and lacrimal sac
External nasal branch of the anterior ethmoidal nerve:
medial part of cartilaginous pyramid and the lobule
Infraorbital nerve: lateral part of cartilaginous pyramid
and lobule, cheek, upper lip, and lower eyelid
As always in the nasal domain, there is a wide overlap
between the distributional areas of these five nerves. Local
anesthesia of the external nose is therefore carried out by
blocking the exits of the supraorbital, infraorbital, and
anterior ethmoidal nerve (see ▶ Fig. 10.56).
Sensory Innervation of the Nasal Cavity
A large number of nerves contribute to the nerve supply of
the nasal cavity. They are derived from all three main
branches of the trigeminal nerve (▶ Fig. 1.57).
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