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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. 1.57Nerve supply of the nasal cavity.
1, 2 = posterior superior lateral nasal branches; 3 = posterior inferior lateral nasal
branches; 4 = anterior superior alveolar nerve; 5 = nasopalatine nerve; 6 = incisive
nerve
Superior–anterior: anterior ethmoidal nerve
Superior–posterior: posterior ethmoidal nerve and
nasal nerves (posterior superior lateral nasal branches
and posterior superior medial nasal branches to the
lateral wall and septum, respectively)
Inferior–anterior: anterior superior alveolar nerve,
nasopalatine nerve (to septum)
Inferior–posterior: nasal nerves (posterior inferior nasal
branches of the greater palatine nerve)
The ethmoidal nerves are derived from the ophthalmic
nerve (V1). All other branches are derived from the
maxillary nerve (V2). Fibers of many maxillary nerve
branches (posterior superior lateral and medial nasal
branches) traverse the pterygopalatine ganglion without
synapsing before entering the nasal cavity through the
sphenopalatine foramen. Hence these branches are often
described as branches of the pterygopalatine ganglion. The
nasopalatine nerve is the largest of the posterior superior
medial nasal branches and continues as the incisive nerve
through the incisive canal to the anterior portion of the
hard palate.
There is again an extensive overlap (and also a certain
variation, e.g., as a result of previous surgery) between the
areas supplied by these different nerves.
The fibers of the parasympathetic system (see following
text) run together with the sensory fibers. Most fibers of
the sympathetic system follow the blood supply, but some
are also distributed via sensory nerves.
The Incisive Nerve and the Maxilla–Premaxilla
Approach
In making an anterior–inferior septal tunnel, the
mucoperiosteum of the septal base and nasal floor is
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elevated from the bone. In this procedure, the incisive
nerve may be severed. This may produce anesthesia of the
palatal mucosa just posterior to the incisor teeth. The
incisive nerve is the terminal branch of the nasopalatine
nerve (▶ Fig. 1.57). This nerve courses through the deep
layers of the periosteum in a groove on the vomer, and in
the perichondrium of the septal cartilage. Its final branch
enters the incisive canal under the premaxillary wing about
12 mm dorsal to the piriform aperture (▶ Fig. 1.58). It leaves
this canal just behind the first incisor tooth and innervates
a small triangular medioventral area of palatal mucosa (▶
Fig. 1.59). The greater palatine artery runs upward in the
incisive canal to contribute to the vascular supply of the
septum. Normally there are two incisive canals, a left one
and a right one. For further details, see ▶ Fig. 1.76 and ▶ Fig.
1.77; ▶ Incisive Nerve.
Fig. 1.58Nasopalatine nerves and incisive nerve in relation to the premaxilla and
incisive canal.
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Fig. 1.59Innervation of the palate.
Damage to the incisive nerve is sometimes unavoidable in
extensive septal surgery if the premaxilla and anterior
nasal spine have to be completely dissected. Fortunately,
only a minority of patients notice and complain of a
temporary loss of sensitivity in the medial anterior part of
the palate. In cases with limited pathology of the
premaxillary area, laceration of the nerve can be avoided
by making the inferior tunnel from above (see ▶ Inferior
Tunnel from Above: Cranioposterior Approach).
Motor Nerve System
The nerve supply of the nasal musculature is derived from
the facial nerve, in particular its buccal and zygomatic
branches. Innervation of the dilating muscles is part of a
reflex arc consisting of mechanoreceptors of the lung,
viscerosensory nerve fibers, the inspiratory breathing
center in the medulla oblongata, and the facial nerve fibers
to the nasal musculature.
Sympathetic Innervation
The sympathetic innervation of the mucosal lining of the
nasal cavity, including the turbinates, originates in a center
in the thoracic part of the spinal cord. The preganglionic
fibers reach the sympathetic trunk and synapse in the
superior cervical ganglion, acetylcholine (ACh) being the
neurotransmitter (▶ Fig. 1.60). Postganglionic fibers are
distributed to the nose via blood vessels as perivascular
plexuses, and via the internal carotid nerves along the ICA.
From these nerves, the deep petrosal nerve branches out in
the foramen lacerum and joins the greater petrosal nerve.
The combined nerve travels as the nerve of the pterygoid
canal (vidian nerve) through the pterygoid canal to the
pterygopalatine fossa. The sympathetic fibers pass through
the pterygopalatine ganglion without synapsing and are
distributed to the nasal mucosa along the sensory nerves
(i.e., the posterior superior lateral and medial nasal
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branches of the maxillary nerve). The majority of the fibers
terminate in the walls of the arterioles, venules, and venous
sinoids, and have a vasoconstrictive effect. A minority
terminate at the nasal glands and modify secretion.
Fig. 1.60Sympathetic innervation of the nasal mucosa with its neurotransmitters.
(Modified from Lundblad.)
ACh = acetylcholine; NKA = neurokinin A; NPY = neuropeptide Y; V = vein; A = artery.
Parasympathetic Innervation
The parasympathetic fibers for the nasal cavity originate in
the superior salivatory nucleus and leave the brainstem via
the sensory root of the facial nerve, the intermediate nerve.
These fibers leave the facial nerve in the greater petrosal
nerve, which joins the deep petrosal nerve to form the
nerve of the pterygoid canal (vidian nerve, see previous
text). In the pterygopalatine fossa, the fibers synapse in the
pterygopalatine ganglion (neurotransmitter: ACh,
vasoactive intestinal peptide [VIP], peptide histidine
isoleucine amide [PHI], etc.) and are distributed to the
nasal mucosa along the sensory nasal nerves just like the
sympathetic nerve fibers (▶ Fig. 1.61). In the mucosa, they
dilate small vessels and stimulate secretion by the nasal
glands. Pterygopalatine ganglion is the official term
according to the Terminologia Anatomica; however, in
literature the ganglion is often called the sphenopalatine
ganglion.
Fig. 1.61Sensory and parasympathetic innervation of the nasal mucosa with its
neurotransmitters. (Modified from Lundblad.)
A = artery; CGRP = calcitonin gene-related peptide; ggl = ganglion; PHI = peptide
histidine isoleucine amide; SP = substance P; V = vein.
Olfactory Organ
The olfactory organ is located in the superior nasal passage
on the upper middle part of the middle turbinate and the
adjoining area of the septum. In humans, the olfactory
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region is a very irregular area with a somewhat yellowbrownish color with a total surface of some 100 to 500
mm2. Its size and shape show very large individual
variation (▶ Fig. 1.62). In general, the olfactory region
decreases with age. Due to its irregularity, it is almost
impossible to distinguish it from the respiratory region of
the nasal mucosa. On average, however, the olfactory
region does not extend further than 2.0 to 2.5 cm below the
lamina cribrosa.
Fig. 1.62Olfactory region on the most cranial area of the lateral nasal wall and septum.
(After Brunn.)
The olfactory region consists of two to three layers of
columnar cells with small (Bowman’s) glands in between.
In contrast to the main mucosa of the nasal cavity, there is
no basement membrane. Similar to other sensory organs,
the cells are of two different types: sensory and supporting.
The sensory cells are long and slender. On top they are
provided with 8 to 18 hairs that protrude into a thin layer
of mucus. Their base extends into a nerve fiber with several
neurotubules, which transport the signal to the central
olfactory system. Unlike other sensory organs, there is no
synapse between the sensory cell and the nerve fiber.
Groups of nerve fibers covered by basal cells at the base of
the epithelium combine to form so-called fila olfactoria
(olfactory nerves). These are surrounded by a sheath of
Schwann, penetrate the lamina cribrosa, and terminate in
the olfactory bulb where the first synapse is located (▶ Fig.
1.63).
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