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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. 1.63Olfactory epithelium showing (1) ciliated receptor cells , (2) supporting cells
bearing microvilli, (3) basal epithelial cells, (4) axons, and (5) Bowman glands.
For the nasal surgeon, it is of utmost importance to
recognize that olfactory cells and nerve endings are
present at the upper part of the middle turbinate.
Resection of the middle turbinate may therefore deprive
the patient of a part of his olfactory sense. Resection of the
middle turbinate as a routine procedure in surgery for
nasal polyps and sinusitis must, therefore, be condemned.
1.2Histological Features of the Main
Nasal Structures and Their Implications
for Nasal Surgery
This chapter is devoted to the functional anatomy and
histology of the most important nasal structures. Special
attention is paid to the consequences of the anatomical and
histological features for the practice of nasal and sinus
surgery.
The data presented here are from the research carried out
in the Department of Anatomy of Utrecht University
Medical Centre (Heads: Prof. Dr. B. Hillen, Prof. Dr. RLAW
Bleys) by fellows of the Department of Otorhinolaryngology
([339] and [340]; [97]; [255]; and [16]).
All histological sections are from adult Caucasian noses.
Some of them were dissected to study different
macroscopic anatomical issues. The other specimens were
fixated in 10% neutral buffered formalin, washed in
buffered phosphate 0.1 M at pH 7.4 for 1 day, decalcified
with 5% HNO3 for 7 days, dehydrated in increasing
concentrations of alcohol for 5 days, and put in xylene for 3
days. They were then embedded in paraffin or in
carboxymethylcellulose and frozen to -20 °C. An adhesive
tape was then fixed to the surface of the paraffin block.
Subsequently, the specimens were sectioned with a
microtome (PMV 200) into serial sections of 25 µm
thickness at 150 or 250 µm intervals in different planes
(coronal, transverse, or parallel to the nasal dorsum).
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The sections were then stained with a modified Mallory–
Cason trichrome technique (MC), hematoxylin and eosin
(H&E), or a combination of the MC method and resorcinfuchsin (MC-RF). Finally, together with the tape they were
mounted on glass slides for microscopic study.
MC staining was used in the majority of the sections, as
this method allows a fine differentiation between the
various histological tissues. MC-RF staining was used to
distinguish between fibrous structures.
In the studies of the perichondrial envelope of the septal
and the lobular cartilages, the tissues were stained
according to the MC, Azan, Herovici, Verhoeff–van Gieson,
and Lawson methods, as well as by immunohistochemistry
to demonstrate the presence of collagen type I and II.
1.2.1Septum
Septal Cartilage: Chondrocytes and Extracellular
Matrix
In the periphery we find the young chondrocytes. They are
numerous, small, flat, and oriented parallel to the surface.
In the intermediate zone they are less numerous and more
ovaloid, and their axis runs more perpendicular to the
surface. The lowest density of chondrocytes is found in the
central zone. Here, they are spheroidal and more or less
aligned in columns perpendicular to the cartilaginous
surface (▶ Fig. 1.64 and ▶ Fig. 1.65).
Fig. 1.64Septal cartilage (MC staining). In the periphery of the septal cartilage, we find
numerous young, small, and flat chondrocytes, which are oriented parallel to the
cartilaginous surface. In the intermediate zone, they are less numerous and more
ovaloid, and their axis runs more perpendicular to the surface.
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Fig. 1.65Septal cartilage (MC staining). The extracellular matrix of the septal cartilage
shows a distinct difference in composition between the peripheral and central zones. The
cells in the periphery are surrounded by homogeneous material with a high bluishstained collagen type II.
The extracellular matrix of the septal cartilage shows a
distinct difference in composition between the peripheral
and central zones. The cells in the periphery are
surrounded by homogeneous material with a high collagen
type II content and higher density of young collagen fibers
as compared to the more central zones. There are no
elastic fibers in the cartilage (▶ Fig. 1.65).
Septal Cartilage: Perichondrium
The perichondrium of the septal cartilage consists of a
homogeneous layer of collagen type I fibers and elastic
fibers. The elastic fibers have a network-like arrangement.
Clearly distinguishable zones in the septal perichondrium
have been previously suggested (by ourselves) but could
not be observed. The suggested existence of a dense inner
and a loose outer layer was probably due to a processing
artifact (▶ Fig. 1.66).
Fig. 1.66Septal cartilage and perichondrium (MC staining). The existence of a dense
inner and a loose outer perichondrial layer is suggested but is probably due to a
processing artifact.
Chondrospinal Junction
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The base of the cartilaginous septum widens slightly at the
level of the anterior nasal spine. Various paraseptal
cartilages, each in its own perichondrial envelope, lie
adjacent to this pear-shaped broadening. In this specimen
(▶ Fig. 1.67 and ▶ Fig. 1.68), the medial paraseptal cartilages
are positioned horizontally, the lateral ones more vertically.
Their perichondrium holds them together. The form and
position of the paraseptal cartilages provide the
cartilaginous septum with a broader base that rests on the
surface of the anterior nasal spine. The cranial part of the
anterior nasal spine widens like the bow of a ship,
providing a pedestal for the septum. The septum and the
spine are separated by a relatively wide gap of about 0.5
mm, which is filled with loose connective tissue. This allows
a certain degree of mobility. At the chondrospinal area,
stability is thus combined with a certain amount of mobility.
Fig. 1.67Chondrospinal junction (coronal section, MC staining). Cartilaginous septum
(1); anterior nasal spine (2); paraseptal cartilages (3); junctional gap with loose
connective tissue (4); septal turbinates (5).
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Fig. 1.68Chondrospinal junction (high magnification of detail of ▶ Fig. 1.67). Base of
the cartilaginous septum (1); anterior nasal spine (2); two large, horizontally positioned
and two small, vertically positioned paraseptal cartilages (3); wide junctional gap with
loose connective tissue fibers (4).
Chondropremaxillary Complex
At the chondropremaxillary complex, the cartilaginous
septum is thinner in the middle than at its cranial and
caudal end. Its base shows a considerable bilateral
broadening, the processus lateralis ventralis. The left and
right premaxillary bones are unified in the midline. The
unified premaxilla has two wings that serve as a pedestal
for the septal cartilage. Two almost vertically positioned
paraseptal cartilages cover the lateral side of the junction.
They are kept in place by tight perichondrium that
surrounds each of them individually. The narrow gap
between the cartilage and the bone is filled with dense
connective tissue. Three types of fiber can be recognized:
lateral fibers, which run from the perichondrium of the
septal cartilage to the periosteum of the lateral wall of the
premaxilla; medial fibers, which run from the
perichondrium of the septal cartilage into the “joint area”;
and “crossing” fibers, which traverse the junction and
terminate in the premaxilla bone or its periosteum. The
function of all these structures seems to be to provide
maximal stability and rigidity (▶ Fig. 1.69, ▶ Fig. 1.70, ▶ Fig.
1.71, and ▶ Fig. 1.72).
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