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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. 1.91Wall of a concha medial bullosa (MC staining). Outer mucosa with columnar
ciliated epithelium (1); bony wall (2); inner ciliated mucosa (3).
Septal Turbinate
The septal turbinate is a localized thickening of the mucosa
of the septum in area 4, opposite the anterior and middle
part of the middle turbinate (▶ Fig. 1.92). It has previously
also been called “intumescentia” or “tuberculum” septi.
Like the other turbinates, the septal turbinate may
hypertrophy according to physiological demands and as a
result of pathology. Compare ▶ Fig. 1.47, ▶ Fig. 1.78, ▶ Fig.
1.81, and ▶ Fig. 1.87.
Fig. 1.92Septal turbinate (coronal section of the anterior part of the nasal cavity, MC
staining). Cartilaginous septum (1); perpendicular plate (2); septal turbinates (3);
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turbinate-like tissue on the lateral nasal wall (4). Note the opening of the vomeronasal
organs at the septal base.
1.2.3Bony Pyramid
Junction between the Triangular Cartilage and Nasal
Bones
The upper border of the triangular cartilage is rigidly
attached to the lower margin of the inner wall of the bony
pyramid. The bone overlaps the cartilage for about 1 to 3
mm, as can be seen in ▶ Fig. 1.93. The cartilage is tightly
fixed to the inside of the bone (▶ Fig. 1.94). A traumatic
dislocation of the cartilage from the bone is therefore
difficult to correct. Each nasal bone has its own periosteal
envelope. Both periostea fuse at the internasal suture. As a
consequence, it is impossible to create a subperiosteal
tunnel on the bony dorsum, contrary to what has often
been claimed. As soon as the periosteum is elevated, it will
tear.
Fig. 1.93Junction between the cartilaginous and bony vault (coronal section at the level
of the anterior nasal spine, MC staining). The bony pyramid overlaps the cranial end of
the triangular cartilage (1). Note the broadening and partial ossification of the cranial
end of the septum at the K area (2); internasal suture (3).
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Fig. 1.94High magnification detail of ▶ Fig. 1.93. Caudal margin of bony vault (1);
cranial margin of triangular cartilage (2); tight junction between cartilage and bone (3).
1.2.4Cartilaginous Pyramid
Septolateral Cartilage: Cartilaginous Septum and
Triangular Cartilages
The cartilaginous septum and the two triangular cartilages
comprise a single anatomical structure, the dorsolateral
cartilage (▶ Fig. 1.95). The two triangular cartilages
constitute a vault that is supported by the septum. The
dorsum of the cartilaginous vault is more or less flat or
slightly grooved. The lower part of the triangular cartilage
forms the mobile lateral wall of the valve area. The lower
margin of the triangular cartilage is overlapped by the
medial part of the lateral crus of the lobular cartilage. The
intercartilaginous area consists of loose connective tissue
with some sesamoid cartilages, allowing the lateral nasal
wall to move during respiration (▶ Fig. 1.95). Above the
perichondrium of the cartilaginous vault is a thin sheet of
loose connective tissue.
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Fig. 1.95Cartilaginous vault and lobule (coronal section, HE staining). The cartilaginous
septum (1) and the two triangular cartilages (2) forming one structure; dorsal groove of
cartilaginous vault (3); lateral crus of lobular cartilage overlapping the lower margin of
the triangular cartilage (4); intercartilaginous area with loose connective tissue and
sesamoid cartilages (5); valve (6); cul de sac (7).
Undermining of the dorsal skin in surgery should be
performed in this plane because the nasal muscles,
vasculature, and nerve supply lie immediately above. The
inside of the cartilaginous pyramid is covered with mucosa,
whereas the vestibule and its cul de sac are lined with skin
(see also ▶ Fig. 1.96 and ▶ Fig. 1.97).
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Fig. 1.96Intercartilaginous joint area (coronal section, MC staining). Lateral crus of
lobular cartilage (1) overlapping the lower margin of the triangular cartilage (2);
intercartilaginous area with loose connective tissue and sesamoid cartilages (3); valve
(4).
Fig. 1.97High magnification of detail of ▶ Fig. 1.96. Lateral crus of lobular cartilage (1)
overlapping the lower margin of the triangular cartilage (2); intercartilaginous loose
connective tissue with sesamoid cartilage (3); valve (4); plane of undermining of the skin
(5), vasculature (6), and musculature (7).
Valve Area
The lower margin of the triangular cartilage (limen nasi)
constitutes the nasal valve, the mobile part of the lateral
wall of the valve area (area 2). The valve area is the
narrowest region of the internal nose. In the Caucasian
leptorrhine nasal pyramid, the angle between the caudal
margin of the triangular cartilage and the septum measures
only about 15°. In mesorrhine and platyrrhine noses, it is
considerably larger. The valve area is the major region of
nasal resistance and acts as an accelerator of inspired air.
As a consequence, the airstream becomes more turbulent,
which improves contact between the air and the mucosa
(see ▶ Inspiratory Airflow). Since the caudal end of the
triangular cartilage moves in and out with respiration, it
has been compared with a valve. Actually, it is not a valve
in the strict sense of the word; rather it is a variable
isthmus which acts as a resistor and a diffusor or
turbulizer.
The lateral nasal wall (valve) should be mobile, moving in
and out with respiration. On the other hand, it must be
rigid enough to withstand the negative intranasal pressure
during inspiration, and prevent inspiratory collapse. The
special relationship between the triangular and lobular
cartilage and the anatomy of the lateral lobular wall makes
this structure mobile yet rigid. In most cases, the cranial
margin of the lateral crus of the lobular cartilage slightly
overlaps the medial part of the triangular cartilage. This
adds to the rigidity. At the same time, the intercartilaginous
area consists of loose connective tissue with a few small
sesamoid cartilages. This allows inward and outward
movement of the lateral wall. The intercartilaginous area
thus acts more or less as a joint, while the lateral softtissue area serves as a hinge (see ▶ Lateral soft-tissue area
(hinge area)). The cul de sac also plays a role in this system,
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