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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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The lower margin of the triangular cartilage or
limen nasi
The fibrofatty tissue area
The head of the inferior turbinate
Caudally by:
The skin-covered floor of the piriform aperture
The medial wall of the valve area is rigid, whereas the
lateral wall is mobile. On inspiration, it moves inward due
to the negative pressure caused by the inspiratory airflow.
On expiration, it moves outward. The inward movement is
counteracted by the mass and stiffness of the triangular
and lobular cartilages, soft-tissue areas, and the connecting
fibers and musculature (see also ▶ Fig. 1.95, ▶ Fig. 1.96, and
▶ Fig. 1.97; ▶ Septolateral Cartilage: Cartilaginous Septum and
Triangular Cartilages).
Terminology of the Valve Area
Valve area: narrowest area (area 2) of the internal nose
Valve: the moving part of the lateral wall of the valve
area (i.e., the caudal margin of the triangular cartilage)
Valve angle: the angle between the caudal margin of
the triangular cartilage and the septum
Ostium internum: old name for the valve area; this
name was introduced by anatomists (Zuckerkandl
1883) in the 19th century in contrast to “ostium
externum” (naris, nostril)
Isthmus: narrowest area of the nasal cavity (valve area)
Limen nasi: lower margin of the triangular cartilage
(valve)
External Nasal Valve
Recently, some authors (e.g., [269]) suggest the presence of
another valvular structure, the external nasal valve. They
attribute a valvular function to the relative narrowing of
the nasal vestibule that is caused by the slightly protruding
caudal margin of the lateral crus (sometimes named the
vestibular fold) and the protruding caudal end of the medial
crus. [49] named these protrusions “baffles” and pointed
out that they add to nasal resistance and influence
airstream. [32] recognized four components of the nasal
valve. It is well known that pathology of the lateral crus or
the medial crus may, indeed, lead to inspiratory breathing
obstruction. This condition is usually called alar collapse.
We doubt if the term external nasal valve is justified to
describe the function of these two vestibular airway
resistors that only indirectly affect the functioning of the
much more important (internal) nasal valve.
Septum
The nasal septum consists of: (1) the cartilaginous septum;
(2) the perpendicular plate of the ethmoid bone; (3) the
vomer; and (4) the septal framework.
Cartilaginous Septum
The cartilaginous septum is part of the septolateral
cartilage. The following structures are of special clinical
and surgical interest (▶ Fig. 1.37):
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Fig. 1.37Septolateral cartilage consisting of the cartilaginous septum and the two
triangular cartilages.
The free caudal end
The processus lateralis ventralis: a broadening of its
caudal margin in the area where the cartilage is
connected to the premaxilla
The ventrocaudal corner (anterior–inferior corner)
The sphenoidal process (posterior process): a posterior
extension of the cartilaginous septum between the
perpendicular plate and the vomer; see also ▶ Fig. 1.67,
▶ Fig. 1.68, ▶ Fig. 1.69, and ▶ Fig. 1.70; ▶ Chondrospinal
Junction and ▶ Chondropremaxillary Complex.
Perpendicular Plate of the Ethmoid Bone (Lamina
Perpendicularis)
The perpendicular plate of the ethmoid bone is a more or
less quadrangular, thin, bony plate. Its upper border is
ventrally attached to the posterior surface of the nasal
spine of the frontal bone (frontoethmoidal suture). More
posteriorly, it is united to the inferior surface of the
cribriform plate (▶ Fig. 1.38). The posterior margin unites
with the sphenoidal crest (sphenoidal suture). The caudal
margin is attached to the anterior border of the vomer. The
ventral margin unites with the cartilaginous septum. This
part often has two cortical layers with spongiotic bone
marrow in between. On rare occasions, a bulla may be
present (see also ▶ Fig. 1.73 and ▶ Fig. 1.74).
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Fig. 1.38Perpendicular plate of the ethmoid bone and the vomer.
Vomer
The vomer is an unpaired, oblong, quadrangular bone
resembling a plowshare. Its cranial margin is broad and
split into two lateral leaves (alae vomeris). These are
attached to the sphenoid bone. Its posterior margin forms
the medial wall of the choanae. Its inferior margin, which is
sharp and serrated, is connected to the nasal crests of the
maxilla and palatine bone. The anterior (to some extent
also cranial) margin is somewhat thickened. It has a groove
in which the inferior margin of the perpendicular plate and
the cartilaginous septum are fixed.
Septal Framework
The septal framework holding the septum consists of eight
different anatomical structures (▶ Fig. 1.39):
Fig. 1.39Septal framework.
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Caudally:
Anterior nasal spine (spina nasalis anterior)
Premaxilla with the premaxillary table and the
premaxillary wings
Maxillary crest (crista nasalis maxillae)
Palatine crest (Crista nasalis ossis palatini)
Membranous septum (septum membranaceum)
Ventrally:
Bony ridge at the dorsal side of the nasal bones
Cranially:
Bony ridge at the junction of the cribriform plates
Dorsally:
Sphenoidal crest (crista sphenoidalis), a bony ridge
at the junction of the two sphenoidal sinuses
Junctions between the Septum and its Framework
Precise knowledge of the connections between the various
parts of the septum is of the utmost importance in septal
surgery. In particular, the junctions between the
cartilaginous septum and the anterior nasal spine and the
premaxilla are of great importance. Detailed information is
presented in ▶ Fig. 1.39, ▶ Fig. 1.40, ▶ Fig. 1.41, and ▶ Fig. 1.42
(and also in ▶ Fig. 1.67, ▶ Fig. 1.68, ▶ Fig. 1.69, ▶ Fig. 1.70, ▶
Fig. 1.71, ▶ Fig. 1.72, ▶ Fig. 1.73, and ▶ Fig. 1.74).
Fig. 1.40Chondropremaxillary complex (a) and the chondromaxillary junction (b).
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Fig. 1.41Premaxilla and premaxillary wings.
Fig. 1.42Premaxilla and incisive canal.
Incisive Bone
Although the terminology of ▶ Fig. 1.39, ▶ Fig. 1.40, ▶ Fig.
1.41, and ▶ Fig. 1.42 is common in clinical practice, it is
different from that found in major anatomical textbooks.
The existence of an incisive bone (os incisivum) is
indisputable since it has centers of ossification that are
distinct from those of the main maxillary mass. The fusion
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