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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. 2.124The bony and cartilaginous pyramid is examined by gently stroking with the
index finger.
Fig. 2.125The pyramid is examined with the index finger and thumb, or with both
index fingers.
Fig. 2.126The skin over the bony pyramid is moved to and fro with both index fingers
to investigate whether the skin is freely mobile over the bony skeleton.
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Fig. 2.127The projection and support of the cartilaginous dorsum and tip are tested by
gentle pressure with the index finger.
Fig. 2.128The position of the caudal end of the septum and the columella is examined
by lifting the tip with the thumb.
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Fig. 2.129The lateral crus and dome are examined for size, shape, thickness, and
rigidity with the index finger and thumb.
2.3.3Examination of the Internal Nose
Inspection and Palpation
Inspection and palpation of the internal nose starts with
inspection (and, if indicated, palpation with a cotton wool
applicator) of the nostrils, vestibules, and valve areas. This
is done as follows:
Without instruments during normal breathing, and at
forced inspiration (see breathing tests);
With an alar retractor (▶ Fig. 2.130); or
By using two blunt hooks or retractors to
simultaneously inspect the lateral and the medial wall
of the vestibule (▶ Fig. 2.131).
Fig. 2.130The vestibule and valve area are inspected using a blunt, four-pronged
hook.
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Fig. 2.131The vestibule is inspected using two blunt, two-pronged dull retractors.
Note
A nasal speculum is not the proper instrument to inspect
the vestibulum and valve area as it distorts their anatomy.
Anterior Septum
The position of the caudal end of the cartilaginous septum
is examined by pushing the nasal tip and columella upward
with the thumb. In this way, dislocation and a protrusion of
the caudal end of the septum may be visualized (▶ Fig.
2.128). The position of the base, cartilaginous septum, and
their relation to the nasal spine and premaxilla may be
studied by retraction of the columella to the other side with
a blunt hook, and by palpation with a slender cotton wool
applicator (▶ Fig. 2.132a, b).
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Fig. 2.132a, b The septum and the turbinates may be palpated with a cotton wool
applicator.
Valve Area
The valve area is examined first without instruments and
then using an alar retractor or one or two blunt, twopronged retractors. The ala should not be lifted too high to
avoid alteration of the valvular configuration (▶ Fig. 2.130
and ▶ Fig. 2.131).
Posterior Septum and Turbinates
The posterior septum, turbinates, ethmoidal infundibulum,
frontal recess, and sinus ostia are examined as follows.
First, the various areas are inspected using a nasal
speculum. The mucosal membranes are then decongested
(and anesthetized) with small gauzes soaked in
xylometazoline 0.1% (and lidocaine 4%). Nasendoscopy
with a 0° and/or 30° endoscope is then carried out. Finally,
certain structures may be palpated with a cotton wool
applicator or a probe. This is helpful in several respects: to
better diagnose defects of the cartilaginous and bony
septum; to examine the quality of the margins of a septal
perforation; to determine whether we are dealing with
mucosal hyperplasia or polyposis; and to confirm the
presence of turbinate hyperplasia and concha bullosa.
2.3.4Analysis of Nose, Face, and
Dentition
In nasal surgery, we are operating upon a part of the face.
The characteristics of the external nasal pyramid strongly
affect our judgment of the face, just as the dimensions of
the face highly influence our judgment of the nose.
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