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W. Pirsig
Fig. 35.7 Female newborn with a non-replaceable nasal
deviation (left). 12years later, the girl presents with an
inverted C-shaped nasal deviation and nasal obstruction
deviations, spurs or crests. Eight of these nine
children had malocclusion, two of them having
been treated orthodontically. We considered
these eight children as having a ‘physiological
septal deviation’ in an asymmetrical skull, as
described by Zuckerkandl in 1882 [32].
However, ve girls of the 14 children showed a
deviation of the nasal pyramid to the same side
as found at birth, in one girl markedly
(Fig.35.7—right), in a second girl only minor
and in three cases slightly. In four of these ve
girls, a longitudinal deviation, corresponding to
the deviation of the bony pyramid, was evaluated by nasal endoscopy and measured by
acoustic rhinometry. One of the ve girls complained of moderate obstructive breathing,
which was caused by allergic rhinitis. All ve
girls showed malocclusion, two of them being
under orthodontic therapy.
35.3.5 Acromegaly
Acromegaly is an endocrine disease due to
growth hormone excess originating from somatotrophic adenoma of the pituitary gland. Patients
(right). Note the longer right and the short steeper left
nasal wall ([39]; unpublished)
complain about the coarsening of the facial contours caused by a bony proliferation of the skull
and mandible and by excessive nasal growth. Our
groups in Ulm and Zurich [40] investigated the
growth mechanism of the septal cartilage in six
acromegalic patients. Small strips of septal cartilage were obtained during septoplasty from
healthy adults or during transnasal hypophysectomy from acromegalic patients. Growth activity
in ve different areas of the septal cartilage was
measured by in vitro incorporation of
35S-labelled sulphates and 3 H-labelled thymidines. The growth activities in the posterior area,
which is situated anterior to the septoethmoidal
junction, were signicantly enhanced compared
to a control group of hormonally normal adults.
Growth activities in the anterior caudal end and
in the suprapremaxillary area were not different
in both groups. This indicates that growth hormone excess in acromegaly enhances human septal growth by stimulating the growth activities in
the posterior area.
In another study [41], ve different enzymatic
pathways were analysed in these septal areas.
Cathepsin D, an acid proteinase, was not inuenced by the augmented growth hormone level
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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481
in acromegaly, whereas cathepsin B, a neutral
proteinase, showed its highest activity in the
caudal prolongation and the posterior area and
was signicantly increased in all areas in acromegaly. Beta-hexosaminidase activity was highest in the central and posterior area and caudal
prolongation of the septum. In acromegaly, a signicant increase in its activity was found in the
suprapremaxillary and posterior areas. Acid
phosphatase activity was highest in the caudal
prolongation of the septum, but its activity was
signicantly increased in all tested areas in acromegaly. Alkaline phosphatase activity could
only be found in the posterior area and the caudal prolongation in healthy adults. However, in
acromegaly, this enzyme could be detected in the
central area and the posterior end of the suprapremaxillary area, suggesting an altered process
of mineralisation. Thus, a distinct local pattern
of enzymes related to intercellular substance
metabolism and mineralisation can be demonstrated in the septal cartilage of healthy adults
and acromegalic patients.
35.3.6 Damaged or Lacking
Triangular Cartilage
What happens when parts of the septodorsal cartilage are damaged or removed? Verwoerd and
Verwoerd-Verhoef [42] found that the behaviour
of hyaline cartilage of the human nose appeared
to be comparable to that of other mammals, especially rabbits. Their results can be supported by
the following own observation. Because of histologically suspected sarcoma, the left nasal bone
and triangular cartilage in a 6-year-old boy had to
be resected in 1973 [39]. Fortunately, a curable
circumscribed osteomyelitis was diagnosed.
Following this boy 7 years later, we found a
shortened left nostril with the bony pyramid deviating to the left and the nasal tip deviating to the
non-operated side. The left piriform aperture was
positioned higher and the left nasal process of the
maxilla was reduced. The left inferior turbinate
was smaller than the right-sided one, and the caudal end of the septal cartilage slightly deviated to
the right (Fig.35.8). Thus, the resection of one
Fig. 35.8 6-year-old boy before resection of left triangular cartilage (left); midfacial growth inhibition at age of
13years (right) [39]
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triangular cartilage and the nasal bone in connection with an infection affected the growth of nasal
and midfacial structures. These ndings are similar to Poublon’s results from the Rotterdam group
after unilateral resection of the triangular cartilage in growing rabbits [43].
35.3.7 Some Histological Aspects
ofTraumatised Nasal
Cartilage
As there is a detailed description of this topic by
Verwoerd-Verhoef in this book about the sequelae
of different kinds of injury to the nasal cartilage
in man and especially in growing animals, I conne to three topics associated with the pathophysiology of the human nasal cartilages.
The rst aspect is the effects of incomplete
fractures which are the main reasons for the more
or less obstructive bending of the septal cartilage.
During nasal surgery these bends are often difcult to transform into a straight septal plate, a
problem which Hunter Fry associated with the
disturbed interlocked stresses within the hyaline
nasal cartilage [44]. Ten Koppel etal. [45] added
new convincing data to this problem, more discussed below. Figure35.9 shows the biopsy from
a vertical strip of septal cartilage with an incomplete fracture. The 8-year-old boy had a nasal
trauma some years ago and underwent a septoplasty alio loco because his anterior septum
obstructed both anterior nasal cavities [46]. In
Fig.35.9, a scar of brous tissue is lling the cartilaginous defect, measuring approximately 30%
of the thickness of the intact cartilage. According
to the nds of Fry [44] and Ten Koppel etal. [45],
one should expect a bending of the cartilage to
the other side. One possible explanation for the
bending to the opposite direction may be that the
power of the granulation tissue which rst lls
the incomplete fracture during healing is strong
enough to achieve the bending to the unexpected
direction. In the 1960s and 1970s when septoplasty was often performed only by unilateral
elevation (tunnelling) of the mucoperichondrium
W. Pirsig
Fig. 35.9 Histological section of a biopsy of septal cartilage with a vertical incomplete fracture lled with scar
tissue in an 8-year-old boy. Haematoxylin-eosin [46]
from the septum, recurrences of septal bending
were observed, although the septum looked
straight at the end of the operation [47]. One reason was that small incomplete cartilaginous fractures on the side with the mucoperichondrium
left attached could cause bending because the
elevated mucoperichondrium had changed the
balance of the interlocked stresses within the cartilage in an unpredictable manner. That’s why
many rhinosurgeons bilaterally elevate the mucoperichondrium to better recognise pathologies
and incomplete scars of the septal cartilage.
The second aspect is the partial regeneration
of pieces of septal cartilage within its traumatised
inner perichondrium in children. The nasal perichondrium is built up of a thick outer layer and a
thin inner layer. The inner layer usually remains
connected with the hyaline cartilage when
properly elevating the mucoperichondrium from
the septal cartilage during surgery, because it
contains bres which end inside the cartilage. In
case of damage by surgical or nonsurgical trauma,
the inner layer has the potential to create new cartilage [26, 46, 48]. Figure35.10 shows the histological section from a piece of destroyed anterior
septal cartilage removed during septoplasty in a
12-year-old boy. In the right upper corner, two
pieces of new cartilage are visibly grown within
the torn perichondrium of the damaged septal
cartilage after the untreated nasal injury at the
age of 3years [46].
In Fig.35.11, the histological section shows
an accumulation of regenerated hyaline cartilag-
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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The third histological example demonstrates
how the lack of nasal cartilage leads to the atrophy of nasal erectile lining. It is well known that
submucous septal resection may induce atrophy
of the septal mucoperichondrium and septal perforation while interposing pieces of cartilage
between the mucoperichondrial aps can markedly reduce this tendency to atrophy [49]. Nasal
septa from cadavers with previous submucous
septal resection were histologically investigated
and compared with age-matched nonoperated
Fig. 35.10 Histological section of a biopsy of a traumatised septal cartilage at the age of 3years, taken from the
12-year-old boy. In the upper right corner, two pieces of
regenerated cartilage grow within the damaged perichondrium. Haematoxylin-eosin [46]
septa [49, 50]. In areas where the cartilaginous
septum had been removed, most of the secretory
epithelium was replaced by squamous cells. The
submucous layer was markedly reduced in thickness (Fig.35.13). The submucous vessels were
reduced in number and size, and the submucosal
glands were partly atrophic. The site of the former septal cartilage was lled with dense connective tissue containing only a few vessels. These
nds demonstrate the importance of interposing
autogenic cartilage plates between the elevated
perichondrium aps at the end of septoplasty to
reduce the propensity for mucosal atrophy.
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Fig. 35.11 Histological section of a biopsy from a
cartilage- like layer attached to the fractured anterior septum of a 9-year-old boy. Islands of regenerated cartilage
and vessels in the scared perichondrium. Haematoxylineosin [26]
inous islands embedded in connective tissue
with vessels. The biopsy was taken from the
cartilage- like layer rmly attached to the remnant of the anterior septal cartilage of a 9-yearold boy during septoplasty. These islands had
developed in the multiply torn perichondrium of
the damaged anterior septum within 8years of
impeded nasal growth. The boy suffered a severe
frontal nasal injury at the age of 1year which
caused a hypoplastic nose with obstruction of
the anterior nose (Fig. 35.12). Unfortunately,
such a layer of ‘oppy cartilage’ can only be
used as ‘lling tissue’, but not for anterior septal
reconstruction [26].
35.3.8 Transposition Technique
In cases of severe destruction of the anterior septal cartilage due to a frontal trauma, an established technique to reconstruct the caudal septum
and the valve area is to remove the remnants of
the anterior septum and replace them with a
boomerang- shaped cartilaginous or bony part
from the posterior septum. In the late 1960s, I
learnt this procedure from Helmut Masing in
Erlangen, Germany, who termed it ‘transposition
technique’. After satisfying results in adults, we
used this technique in an 11-year-old boy suffering from bilateral nasal obstruction after a frontal
nasal injury some years ago. Via the hemitransxion incision, an ‘empty columella’ was found
with a few small cartilaginous remnants isolated
from the scars between the mucoperichondrial
aps. From the posterior septum which was not
yet ossied, boomerang-shaped cartilage was
harvested. This transplant was anteriorly xed
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W. Pirsig
Fig. 35.12 Three pre- and one intraoperative photographs of the 9-year-old boy in Fig.35.11. Figures of base (1), with
damaged bite (2), intraoperative (3), and frontal view (4). (Pirsig, unpublished)
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bony structures. A mostly satisfying repair is
much easier to perform in the nose injured by a
lateral load with lateral distortions of the nasal
tissues than in the nose after an anteroposterior
load with infraction and dislocation of the bony
and cartilaginous nose. In Fig.35.15, we see a
girl with an untreated frontal nasal trauma at the
age of 6 years (left). The nose shows a slight
bony deviation to the right side, a minor
Fig. 35.13 Histological section through septal remnant
after submucous septal resection 10 years ago in a
51-year-old man; Giemsa staining (Pirsig, unpublished)
C-shaped bending of the dorsum, and a small
saddle. The harmony of the midfacial proportions is not yet disturbed. Her photograph at age
17 (Fig.35.15—middle) shows an underdevel-
between the hypoplastic anterior nasal spine and
the supra-tip region under the nasal dorsum to
restore the valve angles. The cartilaginous
remnants from the anterior septal region were
inserted into the posterior septal region. A follow-up after 11years postoperatively including
an X-ray lm of the nose (Fig. 35.14—right)
revealed the ossication of the posterior autogenic transplant. This was one reason why the
transplant did not grow within the 11years postoperatively. As a consequence, I prefer to use
autogenic cartilage from the ear to reconstruct
the destroyed anterior septum in children instead
of harvesting cartilage from the posterior septum
(see back-to-back technique). The nasal appearance after 16 postoperative years is shown in
Fig. 35.14. The young man reported normal
breathing all the years. The nose with a slightly
depressed lobule showed a retracted columella
and a slight maxillary retrusion as signs of growth
inhibition.
oped nose, still a ‘child’s nose’, with a marked
bony deviation, the saddling more pronounced
and the lobule hypoplastic. The maxilla is
retruded. The midfacial harmony is severely disturbed. On the sketch (Fig.35.15—right), drawn
during the open approach at age 17, the pathologies of the bony and cartilaginous nasal structures are clearly visible: distorted, asymmetric,
infractured nasal bones, asymmetric piriform
aperture, scars in the fractures of the bent triangular cartilages and the deformed and fractured
caudal septal cartilage. A closed reposition at
the time of the nasal trauma would probably
have prevented the development of the crooked
bony pyramid, but not the formation of the
numerous scars due to the incomplete and complete fractures of ‘the T- bar-shaped septodorsal
cartilage’, to use a term of Carel Verwoerd from
Rotterdam, the Netherlands. This is an example
of an acutely injured nose which cannot properly be treated by immediate surgery because
the whole septodorsal framework is irreversibly
disturbed by the anteroposterior load!
35.3.9 Frontal Nasal Trauma
485
As mentioned above, the septodorsal cartilage is
the dominating structure for nasal and midfacial
growth. This also means if the septodorsal cartilage is markedly damaged by mechanical loads
or diseases, this is mirrored in the whole nose
and often in adjacent midfacial tissues. Thus, as
to the long-term outcome of a septorhinoplasty,
the crucial effect of the nasal reconstruction
depended on the repair of the damaged septodorsal cartilage and not of the distorted nasal
35.3.10 Lateral Nasal Trauma
In Fig.35.16, we see the preoperative photographs
of a girl of 11years who had an untreated mainly
lateral nasal trauma at the age of 6years and complained of permanent mouth breathing and
severely reduced olfaction. At school, she was
teased as ‘butter witch’. A functional and aesthetic
septorhinoplasty was performed including paramedian, lateral and transverse osteotomies and
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W. Pirsig
Fig. 35.14 Young man, 16years after a septoplasty at the age of 11 using the transposition technique. Ossication of
the transplant visible on X-ray lm 11years postoperatively (Pirsig, unpublished)
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Fig. 35.15 Untreated nasal trauma in a 6-year-old girl (left), at 17years (middle), and drawing with pathologic nds
of the nasal bones and septodorsal cartilage (right) [39]
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Fig. 35.16 Girl of 11/4years preoperatively [51]
removal of a cartilaginous-bony hump [51]. In
Fig.35.17 we look into the face of a self- condent
young woman with an inconspicuous nasal appearance, 8 years after nasal surgery. Her sense of
olfaction had markedly improved. If this girl at the
time of her nasal injury had been treated with a
closed nasal reposition, most of her emotional and
physical suffering due to her nose problem would
probably have been avoidable. This example dem-
onstrates how the osteotomised nasal bones follow
the position of the reconstructed septodorsal cartilaginous framework. It also underlines the experience that nasal osteotomies do not impede nasal
growth in children. Further, it shows that the outcome of repaired noses damaged by a lateral load
is much better than the long-term results after
reconstructing noses damaged by a frontal load as
seen in Fig.35.14.
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Fig. 35.17 Young woman as in Fig. 35.16, 8 years after functional and aesthetic septorhinoplasty (Pirsig,
unpublished)
W. Pirsig
35.3.11 Scoring theNasal Cartilages
Cartilage can be shaped by scoring, gridding or
cross hedging to straighten a convexity or sculpt
it. In an ex vivo experiment on nasal septal
cartilage of adult rabbits, Ten Koppel etal. [45]
demonstrated that there is a clear linear relationship between the depth of the incision and the
resulting degree of cartilage bending when incisions are made up to half of the cartilage thickness. If the incision surpasses half of the cartilage,
the resulting bending becomes unpredictable. In
addition, their in vivo experiments showed
10weeks after surgery that the scored cartilage of
the healed septum maintained the imposed shape
and its degree of bending in all animals towards
the non-scored side. The authors conclude that
with the results of this model, the effect of cartilage scoring can be better predicted during rhinosurgery. This may hold true for adult nasal
cartilages.
On the other side, we know from van Loosen
etal. [13] who investigated septa from birth to
62years that the thickness of the septal cartilage is considerably variable in both the anteroposterior and cranial-caudal direction. This
pattern of cartilaginous thickness remains persistent throughout the lifetime, but cannot
exactly be evaluated during surgery with the
mucoperichondrium attached or elevated from
the septal cartilage. The surgeon can only recognise the cartilaginous thickness at dened
sites by cutting through the whole cartilage. If
only one side of the cartilaginous surface is
incised, one cannot nd out where half of the
septal cartilage is reached (see Fig. 35.9).
Therefore, a vertical scoring of exactly the
same depth over a length of 3cm, for instance,
will result with slight differences in bending
due to the diverse thickness of the septal cartilage over this length in the valve region. This
means the predictability of the amount of bending becomes questionable.
Another reason for the unpredictability of the
scoring effect is connected with the incomplete
wound healing of the septal cartilage [46, 52, 53].
After healing of an incompletely incised cartilaginous surface, a scar of connective tissue lls
the cartilaginous gap, which inuences the
amount and direction of bending. Figure 35.18
shows the part of distorted septal cartilage
(3.7 cm long) removed during revision septoplasty at the age of 14years [39]. The boy had
been operated 6years before alio loco because of
traumatic septal deviation. The previous surgeon
had unilaterally scored the septal surface by
oblique, nearly parallel incomplete incisions
which resulted in the markedly distorted piece of
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Fig. 35.18 Remnants of the anterior septal cartilage of a
14-year-old boy. The cartilage had been scored by 10 incisions 6years ago, which resulted in partial resorption and
unpredictable bending of the surface [39]
Fig. 35.19 Septal abscess 10days ago. Histological section through a biopsy of the partially necrotising septal
cartilage; toluidine blue [46]
septal cartilage removed at revision septoplasty.
One can recognise the remnants of the parallel
scorings and their diverse mode of healing ranging from resorption with small cartilaginous
defects to hardly visible scars on the cartilaginous surface. This irregular surface pattern is due
to the different thicknesses of the septal cartilage
and its incomplete wound healing following scoring. That’s why I don’t recommend scoring septal
cartilage in children.
helps to explain the rapidity of the cartilage
destruction (Fig. 35.19) in many cases of the
septal abscess [46].
Immediate action is required. After puncture
for bacterial culture, the abscess is drained
through a hemitransxion incision. Pus and
necrotic tissues are removed. The defect is immediately reconstructed by transplantation of autogenic ear cartilage to avoid dorsal saddling and
columellar retraction. The incision is left partially open for drainage. Loose internal dressings
35.3.12 Nasal Septal Abscess
are applied; antibiotics are administered systemically. It has been shown that each septal abscess
Among the acquired nasal injuries during childhood, the septal abscess can not only destroy the
septal cartilage but also affect midfacial tissues.
The growth inhibition is more pronounced the
earlier the abscess happened, especially in the
rst decade. The majority of septal abscess is
caused by acute nasal injury. Blood vessels are
disrupted in the mucoperichondrium, which is
not torn because it is thicker and more elastic in
children than in adults. The resulting hematoma
is highly susceptible to infection. White blood
cells invade the cartilage, create an acid pH and
destroy it within some hours. This happens due
to cathepsin D, a necrolytic and autolytic
collagen- degrading enzyme with the optimum
acid pH.This enzyme is normally distributed all
over the healthy septal cartilage. This nding
will result in some nasal growth inhibition.
However, the immediate transplantation of autogenic cartilage can mostly prevent the typical
saddle nose formation [54, 55].
Figure 35.20 shows that the amount of growth
inhibition caused by a septal abscess depends on
the age of the affected child: the earlier the nasal
injury, the more pronounced is the damage to the
nose and midface [55]. The three adolescent girls
came for nasal surgery, all at the age of 16years.
All had a history of a drained septal abscess.
During surgery in all of them, a subtotal loss of
the septal cartilage was revealed. The nasal injury
occurred at 3years (left), 5years (middle) and
7.5years (right). The differences in nasal length,
height, tip projection and maxillary retrusion are
striking.
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