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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. 1.32The seven most important nasal muscles superimposed on a 3D computerized
reconstruction (artist’s impression) of the bony and cartilaginous structures in a 45-yearold male (from [22]).
1 = procerus muscle; 2 = levator labii alaeque nasi muscle; 3 = transverse part of
nasalis muscle; 4 = alar part of nasalis muscle; 5 = dilator naris muscle (m. dilatator
naris); 6 = depressor septi muscle; 7 = apicis nasi muscle.
The procerus muscle is an unpaired layer of muscle
fibers. These originate in the nasofrontal suture area,
fan in a caudal direction (hence the alternative name,
pyramidalis), and insert in the skin over the bony
pyramid. These muscle fibers produce transverse
wrinkling of the skin at the root of the nose. Some
fibers may reach as low as the ala and thus may assist
in elevating the ala and dilating the nostril.
The levator labii superioris alaeque nasi muscle arises
from the frontal process of the maxilla. It has a small
medial part that inserts into the perichondrium of the
lateral crus. It can thus act as a dilatator of the nostril
and elevator of the lateral lobular wall.
The nasalis muscle (transverse part) originates in the
maxilla above the canine tooth and the skin over the
nasolabial fold. It runs to the midline of the nasal
dorsum. It acts as a stabilizer of the lateral nasal wall.
See also ▶ Fig. 1.99 and ▶ Fig. 1.100; ▶ Interdomal Area.
The nasalis muscle (alar part) also originates in the
maxilla but at a point somewhat more medial than the
transverse part. It inserts at the lateral and lower
margin of the ala. These fibers may draw the ala
laterally and dilate the valve area. This muscle is the
most important stabilizer of the lateral nasal wall.
The dilator naris arises from the lateral crus and
superimposing alar skin and inserts into the skin of the
nasolabial groove. However, not all authors accept this
view. The muscle acts together with the alar part of the
nasalis muscle as alar abductors and openers of the
nostril.
The depressor septi muscle originates in the maxilla
above the incisor tooth, together with the fibers of the
alar part of the nasal muscle, and inserts in the medial
crus. It pulls the membranous septum down, widening
the nostril.
The apicis nasi muscle is a very small muscle lying on
the lower medial part of the lateral crus. Its function is
a matter of debate.
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1.1.3Internal Nose
Anatomically, embryologically, and physiologically we
distinguish:
Two nasal cavities (two noses)
Three nasal passages on both sides: the lower, middle,
and upper meatus
Three nasal openings on both sides: the nostril
(external ostium, naris), the valve area (internal
ostium), and the choana
Anatomical–Physiological Subdivision of the Nasal
Organ
Over the years, several systems have been suggested to
divide the different parts of the nose on the basis of
anatomical, physiological, and/or pathological differences.
External versus Internal Nose
The oldest subdivision is the distinction between the
external and the internal nose: the external nose, specific
to humans, is the prominent bony, cartilaginous and softtissue pyramid in the middle of the face; while the internal
nose, with its mucosa, turbinates, and septum, is the nasal
organ proper.
Five-Area Division of Cottle
For the purpose of diagnosis and documentation, as well as
to correlate pathology with symptomatology, [45] proposed
to divide the internal nasal cavity into five areas (▶ Fig.
1.33).
Fig. 1.33The five areas of the internal nose according to [45]: Area 1 = level of nostril;
Area 2 = valve area; Area 3 = region underneath the cartilaginous vault (“the attic”);
Area 4 = region of the heads and anterior parts of the inferior and middle turbinate; Area
5 = region of the posterior parts of the inferior and middle turbinates.
Area 1: nostril (external ostium, naris), formed by the
alar rim, the lateral border of the columella, and the
floor of the vestibule
Area 2: the nasal valve area (internal ostium, isthmus)
Area 3: the area underneath the cartilaginous vault
(also called the “attic”)
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Area 4: the anterior half of the nasal cavity, including
the heads of the turbinates and the infundibulum or
ostiomeatal complex
Area 5: the posterior half of the nasal cavity, including
the tails of the turbinates
This five-area division was adopted by several authors
including ourselves. In several German textbooks (Masing
1977, Ey 1984, Rettinger 1988), however, the denomination
“area 3” was given to a different region (the premaxillary
area) than in the Cottle system. This has diminished the
value of the five-area division.
Five-Structure Division of Bachmann–Mlynski
[9], and more recently [215], have divided the nose on the
basis of its inspiratory function into five different structural
elements: the vestibulum, the isthmus, the anterior cavity,
the area of the turbinates, and the posterior cavity,
choanae, and epipharynx.
Three-Structure Division (This Book)
In this book we suggest a subdivision into three
anatomical–physiological parts ([130]) (see also ▶ Fig. 1.119):
The anterior segment or upstream area, consisting of
the nostril, vestibule, and valve area
The middle segment or functional area proper,
consisting of the mucosa-lined nasal cavity with the
turbinates, septum, and sinus ostia
The posterior segment or downstream area, with the
tails of the turbinates, anterior wall of the sphenoid,
and choanae
Nostril (Naris, External Ostium)
The nostril is formed by the alar rim, the lateral border of
the columella with the protruding end of the medial crura,
and the nostril sill (▶ Fig. 1.34). In a normal adult Caucasian
nose, the nostril has an ovaloid form with a slightly oblique
axis. In newborns and young children, it is almost round. It
gradually changes to the adult ovaloid aperture during
school age and puberty.
Fig. 1.34Structures bounding the nostril.
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In the noses of blacks and Asians, the nares are also more
round. In some types of noses of blacks, the external ostium
may have an almost horizontal axis. These racial and age
variations are also expressed in the magnitude of the
lobular index.
Vestibule
The vestibule is the skin-covered inner part of the lobule (▶
Fig. 1.35). The following structures are of clinical and
surgical significance (see also ▶ Fig. 1.95, ▶ Fig. 1.96, and ▶
Fig. 1.104):
Fig. 1.35Vestibule and valve area with its various structures.
Medially:
The columella with the medial crus of the lobular
cartilage
The membranous septum (the membrane that
connects the medial crura of the lobular cartilage
to the lower edge of the septal cartilage) and its
covering skin
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The skin covering the caudal end of the septal
cartilage
Internal ostium or laterally:
The inside of the ala with the lateral crus and its
more or less protruding end
The cul de sac or infundibulum, a shallow pouch
bounded laterally by the cranial part of the lateral
crus and medially by the caudal part of the
triangular cartilage
Valve Area (Internal Ostium)
The valve area is a more or less triangular or teardropshaped area that gives access to the internal nasal cavity (▶
Fig. 1.36). Its original name was ostium internum ([341]) or
isthmus nasi. Later, it was considered a “valvular device
controlling the inflow of air” ([211], [213]). Nowadays, we
call it the valve area ([170]). As the narrowest region of the
internal nose, it causes the greatest resistance to
breathing. The valve area is bounded:
Fig. 1.36Nasal valve area.
1 = valve angle; 2 = cartilaginous septum; 3 = ventrolateral process of the cartilaginous
septum and premaxillary wing; 4 = caudal margin of the triangular cartilage (limen
nasi); 5 = fibrofatty tissue area; 6 = head of the inferior turbinate; 7 = nasal floor.
Medially by:
The cartilaginous septum
The premaxillary wing
Laterally by:
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