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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. 2.12Prominent-narrow pyramid syndrome. The nostrils are slitlike and their axis
almost vertical; the columella is long and narrow; the alae are thin and stretched.
The entire external pyramid is narrow and prominent. Its
length and height are greater than normal. The bony
dorsum is straight or slightly humped, and the overlying
skin is usually thin. The cartilaginous pyramid is narrow
and prominent, and its dorsum is often slightly convex. The
frontonasal angle is relatively small, and the nasolabial
angle is larger than normal. The piriform aperture is high
and narrow. The clinical nasal index is less than 70. The
skull is dolichocephalic. Retrognathism of the mandible is a
frequent feature. The valve area is narrow and high and
easily collapsible. The lobule is narrow and projecting. The
tip is narrow and may be pulled down slightly by the
tension of the stretched alae and columella. There is a
positive “OO phenomenon” (see ▶ Fig. 2.142). By puckering
the lips, as when pronouncing the vowel sound “OO,” the
tip is drawn down and backward due to the tension
(overstretch) of the columella and the upper lip.
The columella is relatively long and slender; the alae are
thin and (over)stretched. The nares are more or less slitlike
and their axis is almost vertical instead of oblique. As a
consequence, the alae may collapse on inspiration. The
septum is usually normal, although small deformations may
be present. The upper lip is usually short, and
retrognathism of the mandible is common.
Patients with prominent-narrow pyramid syndrome may ask
for surgery for aesthetic reasons. However, there may also
be functional reasons; for example, breathing impairment
due to inspiratory collapse of the alae and/or obstruction of
the valve area.
Cottle has named the prominent external pyramid the
“tension nose.” He pointed out that the soft tissues are
under tension as a result of the strong ventral growth of
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the septum and bony pyramid in comparison to the soft
tissues.
2.1.4Low-Wide Pyramid Syndrome
(Saddle Nose)
The low-wide pyramid syndrome or saddle nose is a very
common nasal syndrome that may be either congenital
(congenital nasal hypoplasia) or the result of severe septal
pathology (trauma, septal abscess, inadequate septal
surgery). The bony pyramid is broad and lacks prominence
(▶ Fig. 2.13 and ▶ Fig. 2.14). The dorsum is flat. The nasal
bones are usually thick. The bony pyramid is more or less
round or trapezoid rather than pyramidal. The
cartilaginous pyramid is low and wide. The clinical nasal
index is more than 85.
Fig. 2.13Low-wide pyramid syndrome. The external nasal pyramid is low and wide; the
bony and cartilaginous pyramids are depressed and low; the nasal bones are thick; the
lobule is low and wide.
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Fig. 2.14Low-wide pyramid syndrome. The bony and cartilaginous pyramids are low;
the nasal bones are thick; the lobule is low, wide, and underprojected.
The cartilaginous dorsum sags, lacking support and
projection (▶ Fig. 2.13 and ▶ Fig. 2.14). This is due to a
defective anterior septum and scarring of the soft tissues.
The triangular cartilages are often atrophic. The fibrous
connections between the cartilaginous and the bony
pyramid may have been lost, making the lower margins of
the nasal bones visible.
The lobule is underprojected, lacking support. Its shape
resembles that of the lobule in childhood (▶ Fig. 2.15). This
is partially due to causative trauma or infection, and
partially the result of disturbed nasal growth. Because of
the absence of (septal) support, the tip can easily be
pressed downward—the so-called rubber nose phenomenon
(▶ Fig. 2.16). The tip is broad and flat. The columella is short
and retracted, especially at its base. The alae are more
convex and thicker than normal. The nostrils are round and
ballooning.
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Fig. 2.15Low-wide pyramid syndrome. The lobule is underprojected and broad. The tip
is flat and depressed; the columella is short and retracted; the nostrils are wide and
rounded; the alae are ballooning.
Fig. 2.16Low-wide pyramid syndrome. The lobule and tip lack projection and support.
The lobule is easily compressed by pressing with the finger on the tip (the so-called
rubber nose).
The vestibule and the valve area are broad and low (▶ Fig.
2.17). The valve angle is depressed and considerably
increased, sometimes even up to 90°.
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Fig. 2.17Low-wide pyramid syndrome. The valve is low and very wide due to loss of the
cartilaginous septum and retraction of the soft tissues of the septum.
Patients with low-wide pyramid syndrome usually have both
functional and aesthetic complaints. Their breathing is
often disturbed, although their nasal passages are wide
enough. Because of deformity of the vestibule and the valve
area, the inspiratory airstream will be less turbulent than
normal. This may compromise the air-conditioning and
cleansing functions of the nose. The mucosa is usually of
poor quality. The cilia may be partially missing, and
mucociliary clearance is impaired, leading to local
infection, crusting, and bleeding. All these factors will, to
some degree, negatively influence nasal function.
Apart from being part of a syndrome, saddling and sagging
may also occur in isolation as a symptom. We distinguish
the following five types of saddle nose:
Bony saddle
The bony pyramid is concave whereas the
cartilaginous dorsum is normal (see ▶ Fig. 2.52).
Cartilaginous saddling or sagging
The cartilaginous dorsum is concave and
depressed, while the bony dorsum is normal (see ▶
Fig. 2.53 and ▶ Fig. 2.54).
Linea nasalis dorsalis
A linea nasalis dorsalis is a pathological horizontal
crease over the cartilaginous dorsum just above the
lobule (see ▶ Fig. 2.58).
Dorsal step
The cartilaginous pyramid is detached from the
bony pyramid. The junction between the triangular
cartilages and the nasal bones is disrupted (see ▶
Fig. 2.55 and ▶ Fig. 2.56).
Sagging of the supratip area
The area just cranial to the tip is depressed (see ▶
Fig. 2.57).
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