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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. 2.97Asymmetrical nostrils.
The nares are asymmetrical in size, shape, and/or position.
The columella is asymmetrical and oblique. This is seen in
congenital anomalies, particularly in cleft-lip patients, and
in cases with traumatic deformities of the anterior septum
and cartilaginous pyramid.
Stenosis of the Nostril (▶ Fig. 2.98)
Fig. 2.98Stenosis of the nostril.
Stenosis of the nostril is seen in congenital malformations,
such as cleft-lip. Another common cause is soft-tissue
trauma (e.g., traumatic avulsion of the ala, dog bites,
accidental caustic damage from treating epistaxis). It may
also occur following surgery when too many incisions have
been made in the vestibule, particularly when they have
been inadequately sutured.
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Vestibule
Stenosis of the Vestibule (▶ Fig. 2.99 and ▶ Fig. 2.100)
Fig. 2.99Stenosis of the vestibule (scarring).
Fig. 2.100Stenosis of the vestibule (subluxation).
The most common cause of vestibular stenosis is
dislocation of the caudal part of the cartilaginous septum.
Other causes are congenital malformations, such as cleft
lip, and scarring following soft-tissue trauma. Vestibular
deformities are often combined with deformities of the
nostril, columella, and valve area. Breathing, especially
inspiration, is usually severely disturbed.
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Stenosis of the vestibule may be caused by dislocation and
protrusion of the septal caudal end (subluxation).
Protrusion of the Lateral Crura (▶ Fig. 2.101)
Fig. 2.101Protrusion of the lateral crura.
The lower margin of the lateral crus protrudes into the
vestibule. This may cause inspiratory collapse of the
vestibule. It may occur after lobular modifying surgery, or
when the connection between the lobular cartilage and the
triangular cartilage is disrupted.
2.2.6Valve Area
Narrow Valve Area (▶ Fig. 2.102)
Fig. 2.102Narrow valve area.
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The valve area is narrow and high, and the valve angle is
abnormally small (less than 20°). This is seen in Caucasians
in prominent-narrow pyramid syndrome. Other common
causes are septal deviations and convexities, abnormalities
of the triangular cartilage, and too much infraction of the
lateral bony wall after osteotomy.
Wide Valve Area (▶ Fig. 2.103)
Fig. 2.103Wide valve area.
The valve area is wide and low, and the valve angle is
abnormally large. A wide valve area is normal in black
people and Asians. In Caucasians, a wide valve area is a
common feature of low-narrow pyramid syndrome or saddle
nose. In these cases, the valve area is usually more circular
than triangular. The valve angle is large and may even
measure 80 to 90°. This is seen in patients with a missing
anterior septum with retraction of the soft tissues that have
replaced the septal cartilage. Nasal breathing may be
subjectively disturbed because of an abnormal inspiratory
airstream.
Obstructed Valve Area (▶ Fig. 2.104)
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Fig. 2.104Obstructed (narrow) valve area.
The nasal valve area may be obstructed for a number of
reasons. Narrowing of the valve area may be related to the
septum, triangular cartilage, nasal mucosa, or head of the
inferior turbinate, or to synechiae, scarring of the
vestibule, nasal form (high, narrow pyramid), or a
combination of these pathologies. (For a clear overview, see
[170].) Inspiratory breathing is impaired even in minor
pathology.
2.2.7Septum
Pathology of the septum ranks high among the deformities
of the human body. It has been stated that a normal septum
is rare. Fortunately, many septal deformities do not cause
functional complaints. The degree and location of the
deformity determine the likelihood and severity of
symptoms.
Classification of Septal Pathology
Classification of septal deformities may be based on their
morphology, localization, etiology, and complaints
(functional effects).
Morphology
From the very beginning of rhinology as a clinical science
in the last quarter of the 19th century, it has been common
practice to describe septal deformities on the basis of their
morphological character. Terms such as septal deviations,
crests, spurs (spines), and convexities are generally
accepted. These descriptive terms are understood by every
rhinologist and should therefore not be replaced by
complicated systems. Some authors have tried to integrate
the various deformities in a simple system, for example
Mladina (1987), who has proposed a division into seven
classes.
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