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34 Vomeronasal Organ
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Physiology oftheNasal Cartilages
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andTheir Importance
toRhinosurgery
WolfgangPirsig
35
Core Messages
• The complex framework of the human nasal
cartilages, unique among mammals, is the
mobile portal to the respiratory system providing conditions for the passage of airstreams
and the generation of nasal resistance and
turbulence.
• The septodorsal (septolateral) cartilage is the
dominating structure for nasal and midfacial
growth and is decisive for the appearance and
several functions of the nose. Together with
the erectile lining of the nasal cavities, the cartilaginous framework enables air-conditioning
and the acting of the nasal cycle.
• The anterior nose with the nasal valve as its
crucial functional region is the narrowest part
of the upper airways and provides two-thirds
of the total airaway resistance.
• Due to its protruding exposition, it is especially vulnerable to external injuries and may
react as a protecting crumpled zone. This
exposition also is the reason why most of the
obstructing structures of the nasal airways are
diagnosed in the anterior nose.
• Long-term observations have shown that the
most effective outcome after functional and
aesthetic rhinosurgery is achieved by focusing
on restoring the physiological functions of the
W. Pirsig (*)
Department of Otorhinolaryngology,
University Hospital Ulm, Ulm, Germany
e-mail: wolfgang.pirsig@uni-ulm.de
anterior nose, the site of the most resistive
nasal segments.
The human nose, with its prominent bridge, its
elongated tip, and its downturned nostrils, is
unique. Besides snifng strange odours, it acts as
a vital air-conditioning unit, warming, cleaning,
and moistening the air we breathe in before it
reaches the delicate lungs. Assisting this—and
also adding resonance to the voice—are the nasal
sinuses, but the price we pay for possessing these
valuable cavities is an all too common susceptibility to local infections.
This precise summing up of the appearance
and functions of the nose including its Achilles’
heel tendon, the diseases, was published in 1985
by the zoologist Desmond Morris in his outstanding book Bodywatching [1].
In the following chapter, I’ll focus on some
functional aspects of the cartilaginous framework
of the human nose with an emphasis on its vulnerability and long-term results following surgical treatment. Why do we have a nose of such a
protruding shape, which is divided by the septum
into two parallel halves? Why is this mobile
organ built up by a complex framework of hyaline cartilages and covered by muscles? Why do
we need this nose at all, although we can survive
by breathing through the mouth? I asked anatomists, physiologists, rhinosurgeons, biologists,
and also engineers for stream technology. The
answers varied, several ended with a question
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Ö. Ö. Celebi, T. M. Önerci (eds.), Nasal Physiology and Pathophysiology of Nasal Disorders,
https://doi.org/10.1007/978-3-031-12386-3_35
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W. Pirsig
mark, but in all of them the terms ‘turbulence’,
‘resistance’, and ‘air-conditioning’ were somehow mentioned.
35.1 Part I: Anatomical
Considerations
35.1.1 Nomenclature
The lower two-thirds of the nose are built up by a
framework of the following hyaline cartilages:
septal cartilage (quadrangular cartilage in adulthood), a partition separating the two nasal cavities; soft tissue part of the septum is the septal
turbinate (septal body or intumescentia septi or
septal tuberculum); two triangular (upper lateral)
cartilages as expansions of the septal cartilage
forming together the T-bar-shaped framework
also known as septodorsal or septolateral cartilage; two paraseptal (vomeronasal) cartilages,
lying along the inferior margin of the caudal septal cartilage, attached to the vomer posteriorly
and to the maxillary crest anteriorly; two alar
(lower lateral or lobular) cartilages composed of
a medial and lateral crus melted together at the
dome on the tip; and some sesamoid (accessory)
cartilages in the soft tissue area between triangular cartilage, lateral crus and piriform aperture, in
the so-called hinge area.
In this chapter, the terms septum, septal, septodorsal, paraseptal, triangular, alar and sesamoid
cartilages will be used.
35.1.2 Intrauterine Development
A two-tube system and a still unrufed entrance
are recognisable in the fourth month of foetal
development of the cartilaginous nose (Fig.35.1).
The cartilaginous framework consists of a T-barshaped bilateral vault fused in the midline to the
septal cartilage. The complete sidewall of the cartilaginous nasal capsule is superiorly connected
with the spheno-ethmoidal cartilage and dorsally
with the septal cartilage which posteriorly merges
into the cartilaginous anterior skull base with the
crista galli. Both vaults are separated by the
supraseptal groove. Caudally, the margin of the
sidewall bends medially to join with the inferior
turbinate. Thus, the palatine bone, the vomer and
the paraseptal cartilage are visible.
Apertura
externa
Cartilago
paranasalis
Cartilago
paraseptalis
Os maxillare
Fig. 35.1 Nasal skeleton of a foetus (8cm) in oblique side view [2]
Cartilago
spheno-ethmoidalis
Foramen opticum
Os lacrimale
Os palatinum
Os vomeris
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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cartilages. The same happens to small processes
of the lateral sidewall which are concealed by the
semicircular cartilage in Fig.35.2. The paraseptal
cartilages are concealed by the caudal part of the
semicircular cartilages. The triangular cartilages
are not yet differentiated. In the newborn, they
are still continuous with the cartilaginous anterior skull base. Their caudal margins are rmly
connected to the alar cartilages and to the piriform aperture. In the newborn, the alar cartilages
are developed as separate structures as in the
adult and overlap with their cranial margins and
the caudal margins of the triangular cartilages.
35.1.3 Postnatal Development
The septal cartilage of the newborn is progressively transformed from posteriorly, cranially
and caudally into a unit of posterior bone and
remaining anterior quadrangular cartilaginous
plate as clearly depicted by Virchow in 1857 [3].
This old knowledge has recently been supported
Fig. 35.2 Model of the cartilaginous nasal capsule of a
foetus (27.5cm, 30–32weeks) [2]
In the sixth foetal month, ingrowth of connective tissue divides the cartilaginous nasal capsule
into the individual septal cartilage, lateral cartilages and alar cartilages. Thus, the complex cartilaginous nasal portal is developed which later
forms the cartilaginous framework of the mobile
nose.
In the model of the foetal cartilaginous capsule aged 30–32weeks (Fig.35.2), we look at the
two vaults of the lateral cartilages fused together
with the septal cartilage in the supraseptal groove.
The median portion bida septi remains as the
rest of the fusion of the vaults. Two semicircularshaped cartilaginous bars have been almost completely separated from the caudal septal cartilage.
They encompass the nasal vestibule medially,
dorsally and laterally to form the denite alar cartilages. In the medial upper angle of the alar cartilage, an isolated piece of cartilage is visible on
the right-hand side, while on the left-hand side, it
is still a process in connection with the left sidewall. Later, these pieces become the sesamoid
by Kim etal. [4] who evaluated the anatomical
correlations among components of the nasal septum using computed tomography. They found
again that the area of the cartilaginous septum
decreases with age, while the area of the perpendicular plate increases with age at the expense of
the area of the septal cartilage. However, the area
of the total nasal septum remains constant.
In the rst decade of life, the triangular cartilages show regression from the cephalic to the
caudal end under the nasal bones until being
transformed into the approximately triangular
shape of the adult nose. Only a small cartilaginous remnant of the triangular cartilage remains
overlapped by the caudal margin of the nasal
bone. Caudally, the triangular cartilages are
overlapped by the cranial margins of the alar
cartilages.
Very rarely the regression process of the triangular cartilage is retarded or even impeded. This
may happen in the case of a median nasal stula
or of a nasal dermoid cyst which can cranially
end at the crista galli. Nasal bidity is another
congenital malformation with impeded regression of the triangular cartilages.
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W. Pirsig
Potter etal. [5] studied 35 adults, white cadaveric specimens and specially focused on the caudal attachment of the triangular cartilage to the
septal cartilage, where usually a small cleft facilitates mobility between the caudal edge of the triangular cartilage and the septum, the so-called
weak triangle of Converse. The attachment
ranged from no cartilaginous connection (68%)
to complete fusion (32%), i.e. a coincident location of the anterior septal angle and the caudal
edge of the triangular cartilage.
In the adult, the relationship between the triangular cartilage and the lateral crus of the alar
cartilage shows four variations [6]. Most often
Dion etal. found an overlap of the caudal margin
of the triangular cartilage by the cranial margin
of the lateral crus. Less frequently are the relationships ‘end to end’, ‘scroll’ and ‘opposed
scroll’.
Each cartilage of the cartilaginous vault is
encased in its own brous capsule, whose bres
decussate, form a brous band or aponeurosis
and join the capsule of adjacent cartilage. This
aponeurosis, acting as a exible membrane,
allows freedom of movement between the neighbouring cartilages. According to Hinderer [7], the
most distinctive bres are:
Besides their mimic function, some muscles act
as dilators of the valve region or openers of the
nostrils or provide stability for the lateral nasal
wall [9]. Especially, the dilator naris accompanies each nasal inspiration, thus directly varying
with ventilation, nasal resistance, hypoxia and
hypercapnia. It stabilises the anterior nasal airway and precedes diaphragmatic contractions
and ceases to act with mouth or tracheostomal
breathing [10].
The framework of nasal cartilages with their
brous connections and covering muscle layer
acts as a shield and portal to the erectile lining of
the nasal cavities. Eugene Kern from Rochester,
USA, termed the nasal mucosa ‘the organ of the
nose’ to sum up all its many functional tasks
which are described in other chapters of this
book. While the nasal vestibule is covered with
squamous epithelium continuing some millimetres around the edge of the caudal margin of the
triangular cartilages, the nasal mucosa with ciliated cylindrical epithelium starts in the posterior
valve region [11, 12]. Figure35.3 shows the histological section through the posterior valve
1. Those between the terminal ends of the triangular cartilage and septum that supply the
mobility necessary for valve action between
these two structures.
2. Those between the caudal end of the septum
and the medial crura of the columella which
form the membranous septum.
3. Those between the caudal margin of the triangular cartilages and the cranial border of the
alar cartilages.
A permanent continuity between the encasing
brous capsule of the triangular cartilage and the
periosteum of the nasal bone was found by
Bruintjes etal. [8], supporting the clinical observation of the rm connection between the nasal
bones and the triangular cartilages.
Additional mobility of the interacting nasal
cartilages is provided by the thin layer of seven
muscles covering the external nasal pyramid.
Fig. 35.3 Section through the posterior valve region of a
newborn cadaver specimen. Note heads of the inferior turbinates deviated anterior septal cartilage with septal body
and asymmetric maxilla. Haematoxylin-eosin (gift of
Lindsay Gray/Perth to author 1975)
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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475
region of a newborn. The heads of the inferior
turbinates catch our eyes as elevations from the
mucosal lining of the lateral walls. The slightly
deviated cartilaginous septum with its mucosal
lining presents its thickening in the middle covered by the thick pad of erectile mucosa, the septal body or intumescentia septi. The different
thickness of the vertically cut septal cartilage is
clearly visible: the thick cranial part merges caudally with a thin segment to end in the broad
deviated cartilaginous foot embedded in the premaxillary bone. This pattern of different cartilaginous thicknesses remains persistent
throughout its lifetime as investigated by van
Loosen etal. [13].
35.2 Part II: Functional Aspects
In this book, nasal functions like breathing, resistance, turbulence and nasal cycle are treated in
special chapters in detail. Thus, I can conne to a
few comments on functions where nasal cartilages are essentially involved like in the nasal
valve region or the vulnerable anterior septum.
The anterior septodorsal cartilage, the paraseptal and the alar cartilages with the sesamoid
cartilages form the framework of the nasal lobule and thus the portal to the upper airways. Soft
tissue connections between the cartilages of
varying thickness and several small muscles acting on their outside enable mobility and/or stability of the lateral nasal walls. Thus, the entrance
to the nose can be dilated and narrowed to modify the inspiratory and expiratory airstreams. The
entrance of the airow is comparable with two
at, oval, hollowed structures, the nasal vestibules, which terminate in the aperture between
the septum and the caudal end of the triangular
cartilages, both parts of the nasal valve region.
The vestibule is at an oblique angle to the cavum
[11]. According to Cole’s studies [10, 14] the
nasal valve region consists of four anatomical
airow-resistive components: the aperture
between the septum and triangular cartilage, the
bony entrance to the nasal cavum which is occupied by erectile tissues of both lateral (head of
inferior turbinate) and septal nasal walls (includ-
ing the septal body) that modulate the crosssectional area of the airway and airow
resistance. Two-thirds of the total nasal resistance during inspiration is provided by the nasal
valve region. This has clearly been proved by
Haight and Cole [15] using pressure-sensing
cannulas. As two- thirds of the total airway resistance to breathing is created in the nose—onethird is provided by the open mouth [16]—the
nasal valve region is the main resistor of the total
airway. The narrow nasal valve region with the
smallest cross- sectional area of the nasal cavum
accelerates the inspired air, creating turbulence.
Valve constrictions disrupt the laminar characteristics of the inspired air as it enters the body of
the cavum and thereby enhance exchanges with
the nasal mucosa of heat, water and noxious
materials. In the widened nasal cavum, airow
decreases its speed [14].
In clinical praxis, the physician has to face
several patients complaining of breathing problems which are caused by a disturbed anatomy of
the nasal valve region, especially patients with a
tension nose or a saddle nose. A patient with a
tense nose presents with a prominent, curved,
small dorsum due to a too large and too high septum. Other characteristics are the increased projection of the tip, slitlike nostrils with an
elongated columella and elongated thin nasal
alae. The feet of the medial crura are cranially
shifted, thus broadening the base of the columella. The nasolabial angle is enlarged and often
the upper incisivi are showing. The valve angle is
less than 10° which results in a bilateral alar collapse during inspiration.
In the cartilaginous saddle nose, the septum is
too short mostly due to fractures or perforations.
The caudal septodorsal cartilage is depressed
which causes an enlargement of the valve angle
to more than 20°. The nostrils with ballooning
alae are elliptically distorted; the columella is
shortened and often retracted. Although the nasal
cavities look very wide, the main complaint of
the patients is insufcient breathing due to too
much turbulence of the airstreams.
The fact that the nasal septum divides the nose
into two parallel halves is the condition for cyclic
activities of the erectile nasal mucosa. Kayser in
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W. Pirsig
1895 [17] rst reported on the spontaneous,
cyclical congestion and decongestion in the nasal
cavities. The anatomic conditions for this
mucosal behaviour are mainly provided by its
capacitance vessels. The ‘working phase’ of one
nasal cavity characterised by decongestion of the
cavernous tissues alternates with the ‘resting
phase’ characterised by congestion of the mucosa
[14, 18, 19]. Changes in ow and resistance during the nasal cycle have been studied using rhinomanometry [18, 20]. By means of acoustic
rhinometry, Fisher et al. [21] measured the
changes in the cross-sectional areas in the nasal
cavities due to congestion and decongestion.
Using the combination of endoscopic imaging, rhinomanometry and acoustic rhinometry,
Lang etal. [19] observed a periodic change in
turbulence behaviour in addition to the known
cyclical changes in ow resistance and nasal
width. In the resting phase, the mainly laminar
ow was found. During the working phase, the
onset of turbulence occurred already at low
velocities. The increase of turbulence during
the working phase was created by the increase
in cross-sectional area in the anterior cavum
due to decongestion of the mucosa of the head
of the inferior turbinate and the septal body. A
special insight into the behaviour of the nasal
cycle is measurable using the new method of
long-term rhinoowmetry which yields information about the nasal cycle over a 24-h period
[22]. This method is also of practical value in
Sleep Medicine to investigate sleep-disordered
breathing.
The nasal cartilages are insofar involved in the
process of the nasal cycle as they provide the anatomical trigger zones for the transition from laminar to turbulent airow, namely, the anterior
nasal cavum between the nasal valve region and
the head of the middle turbinate.
Bruintjes etal. [8] studied the kinematics of
the lateral nasal wall which is made up of three
parts: (a) the osseous-cartilaginous chain of the
nasal bone, triangular cartilage and the lateral
crus of the alar cartilage; (b) the hinge area with
the sesamoid cartilages between the lateral piriform aperture and the lateral margin of the lateral
crus; and (c) the ala, the part between piriform
aperture and alar cartilage, not supported by cartilage. While part (a) is relatively stable and part
(b) much more compliant, they found part (c) to
be the most compliant part of the lateral nasal
wall. They also studied the muscles inuencing
the lateral nasal wall and its compliance. With
this knowledge of the mechanical properties of
the lateral nasal wall, they were able to analyse
pathological clinical conditions, which may
occur at the level of the nasal valve and at the
level of the vestibule or nostril. Thus, they could
explain, for instance, the physiological alterations caused by facial nerve palsy where muscle
denervation may lead to alar collapse [23].
Loss of alar stability with nasal obstruction
during inspiration is often caused by inadequate
surgical procedures for the nasal lobule. Mostly
the continuity of the osseous-cartilaginous chain,
‘nasal bone-triangular cartilage-lateral crus of
alar cartilage’, is destroyed [24]. Detailed knowledge of these anatomical connections could help
to reduce such adverse surgical sequelae.
The alar collapse associated with the drooping
tip of elderly people may result from nasal muscle atrophy, a change in cartilage resilience and
stretching of the intercartilaginous brous tissue
with loss of cartilage overlap in the intercartilaginous junction [25]. The surgical procedure of the
so-called rhinolift could reduce the breathing
problems of elderly people. Via intercartilaginous incisions in the limen nasi, the cephalic
margins of the lateral alar crura are bilaterally
partly resected. After elevating the dorsal skin of
the nasal pyramid and excision of an oval piece
of skin in the nasal root, both mobilised alar cartilages can be lifted and xed, thus widening the
angles of the nasal valves.
The elastic nasal cartilages are useful elements for protective functions. The 9-year-old
boy in Fig.35.12 is a good example to explain the
function of the septal cartilages as a ‘crumpled
zone’ in case of severe anteroposterior load.
Between 1970 and 1972, I performed septorhinoplasty according to the techniques of Cottle,
Goldman and Masing in 92 children with a mean
age of 10.5 years [27]. The indication was
obstructed nasal breathing due to established
post-traumatic nasal deformities. Intraoperatively,
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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477
fractures and defects were visible in the anterior
septodorsal cartilage with involvement of the
nasal valves and sometimes of alar cartilages in
44/92 noses. These noses were damaged by loads
from frontal and/or below. About 23/92 noses
showed fractures in the septodorsal cartilage like
the previous group and in addition fractures of
the nasal bones and perpendicular plate were
caused by the mainly anteroposterior load. This
means that 67/99 or 72% of the children suffered
nasal obstruction due to damaged nasal cartilages
in the anterior nose.
The build-up of the septal cartilage in regions
of different thicknesses [13] throughout the
whole life is one component to react more elastically to front load. The second component of
more compliance is the vaultlike construction of
the septodorsal and alar cartilages with their
joint-like brous interconnections [8]. Note the
distortion of the caudal septodorsal cartilage of
the boy in Fig.35.12 (3): a 90° angle of the caudal septum with fractures in the caudal edge and
depressed edges of the triangular cartilages. Van
Velzen et al. [28] published the prepared septal
cartilage of a 4-year-old boy who died in a frontal
accident. The fracture lines in the cartilaginous
septum followed the thin regions of the cartilage
as sites of minor resistance in reaction to the load.
In idealised and patient-specic models, Lee
etal. [29] recently published the reactions of the
human septal cartilage exposed to anteroposterior load. They found the maximum stress areas
in the nasal septum in the vicinity of the bonycartilaginous junction and the anterior nasal
spine, which are consistent with clinical experience. The ndings of their study also suggest that
the septum does function as a ‘crumpled zone’,
absorbing a signicant amount of stress before it
is transmitted to the skull.
The extreme variant of a damaged crumpled
zone nose is the classic boxer’s nose, the socalled rubber nose, mainly formed by the alar
cartilages. The septodorsal cartilage is shrunken
to a minimum; nasal bones and anterior nasal
spine are pressed down to the level of the piriform aperture or resorbed.
35.3 Part III: Alterations ofNasal
Cartilages
The functions of the nasal cartilages can best be
recognised in children and adults with a disturbed
cartilaginous framework. The growing nose is
inuenced by genetic and epigenetic inuences
such as oxygen supply, nutrition, hormones,
medication, infections and injuries including
nasal surgery as a controlled trauma, to name a
few. In this part, examples are presented describing some long-term inuences on the nasal cartilages citing literature and own case reports.
35.3.1 Lacking Septodorsal
Cartilage
Already in utero, the septodorsal cartilage, being
composed of the septal and both triangular cartilages, develops as the dominating structure for
nasal and midfacial growth. This was shown in
1791 by Soemmerring [30] who published a newborn’s skull with a lacking septodorsal cartilage
and the skull of a healthy newborn for comparison (Fig. 35.4). In the deformed newborn, the
nasal bones and the incisive parts of the maxilla
are not developed. The size of the piriform aperture is reduced to one-third in width compared
with the healthy newborn. The height and width
of the maxilla are reduced, while the contours of
the orbital cavities are distorted compared with
the healthy newborn.
35.3.2 Lacking Alar Cartilages
The following case shows that congenitally lacking both alar cartilages did not impede the growth
of the nose and midface apart from the complete
lacking nasal lobule (Fig.35.5). The 15-year-old
boy came from a family with no genetic nasal
disorders and an uneventful pregnancy of his
mother. There was a complete absence of both
alar cartilages. The pseudo-columella was formed
by skin covering the caudal septal cartilage. The
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Fig. 35.4 Skulls of newborns lacking septodorsal cartilage (left), with normal midface (right) [30]
W. Pirsig
Fig. 35.5 Fifteen-year-old boy with congenital lack of both alar cartilages [31]
caudal margins of the triangular cartilages were
covered by thick skin on the right and thin skin
on the left side. All the other nasal structures
were inconspicuous. The boy’s breathing was
normal [31].
35.3.3 Physiological Septal
Deviation
The anatomical term ‘physiological septal deviation’ was introduced by Zuckerkandl [32] who
dened this type of septal deformation as a bent
septum within the asymmetrical human skull. He
published several examples on beautiful lithographs (Fig. 35.6). Comparable histologic sec-
tions of his own cases were published by Gray
[33] who kindly left me a few of them like in
Fig.35.3. In more recent publications [34, 35] on
this topic, the incidence of the physiological septal deviation is reported between 30% and 75%
for children and between 13% and 96% in adults,
with strikingly less patients reporting to suffer
from subjective symptoms [36]. From the physiological point of view, it is practical to characterise the physiological septal deviation by normal
endonasal resistance [34]. Many of these physiological septal deviations develop during foetal
life in connection with asymmetrical maxillary
growth. Often the non-pathological role of this
deviation is not recognised and a septal operation
is indicated, although it is useless or even wors-
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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injury is documented in Lindsay Gray’s Fig.35.3.
In neonates, two types of nasal deviation are
observed: a septal dislocation that can easily be
replaced in the midline and a nasal deviation that
cannot be replaced by manipulation. The rst
type is considered as nasal trauma during delivery. The second type had been published by several authors since the end of the nineteenth
century [37] and more detailed by Cottle [38]
who generally concluded: ‘For these, expectant
waiting is recommended unless there is complete
inability to breathe and eat. One sees remarkable
Fig. 35.6 Physiological septal deviation in an asymmetrical skull; The thicker spongiosa (a) compared to the
thinner one (b) narrows the right maxillary sinus [32]
improvement in the appearance and development
of these noses without surgical intervention.
During the rst decade, however, some will
require surgical aid’. To nd out the incidence of
ens the nasal symptoms. A septal body may be
mistaken as pathological septal deviation or the
real cause of nasal obstruction such as a problem
of the nasal valve or an inspiratory ala collapse is
failed to be recognised.
Until now, the diagnosis of the ‘physiological septal deviation’ has mainly been made by
nasal endoscopy and the subjective history of
the patient to be free of nasal breathing problems. In a prospective cohort study, Gogniashvili
etal. [34] investigated 158 patients between 18
and 40years using rhinoresistometry, acoustic
rhinometry, endoscopy and visual analogue
scales for subjective complaints. They dened
the normal one-sided nasal resistance as less or
equal to 0.35 sPalcm3 at a ow velocity of
250 cm3/s. Applying this benchmark, the
unselected group of non-rhinological patients
was differentiated into 144 subjects with physiological nasal resistance and 44 with pathological septal deviation. This means an incidence of
72.2% physiological septal deviation in an
unselected cohort which ts well with the data
mentioned above.
these two types of nasal deviation, we investigated 3425 children, born in 2 years between
1980 and 1981, in the Obstetric Department of
the University of Ulm, Germany. A total of 110
(3.23%) of these neonates, belonging to the
Caucasian population, showed deviated nasal
structures. 81 (2.37%) of these dislocated septa
could easily be replaced by a closed reposition.
In 29 (0.86% of 3425) newborns, repositioning
the deviated nasal structure was impossible, thus
leaving the baby with a deviated septum and
bony pyramids like the neonate in Fig.35.7 (left)
who presents nasal deviation to the left, oblique
columella and asymmetrical nostrils. Typically is
also the oblique bony pyramid with asymmetrical
slope and length on both sides.
Over a period of 11–12years, 14 children out
of 29 newborns with non-replaceable nasal
deviation were prospectively followed by the
author and a second otorhinolaryngologist [37].
No child had a history of nasal trauma in the
meantime. The results show that the newborns’
noses, which deviated intrauterinely due to
some unknown reasons, did not spontaneously
restore in each case. Nine children had a completely straight bony pyramid, symmetric nos-
35.3.4 Congenital Nasal Deviations
trils and reported subjectively normal breathing.
Four children had proven nasal allergy and pre-
The histological depiction of a slight septal deviation in a newborn without signs of an acute
sented bilateral hypertrophy of the inferior turbinates. Eight of the nine septa showed slight
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