What nerve is the specific innervation of the nose. Clinical anatomy of the nose

06.03.2020

10-01-2013, 20:57

Description

External nose consists of a cartilaginous (mobile) part and a bony skeleton, formed in the upper section by the processes nasales of the frontal bone and nasal bones, to which the frontal processes of the maxillary bone adjoin from below and from the side.

The cartilaginous part is composed of a number of cartilages (paired triangular and wing cartilages, as well as sesamoid ones, varying in both number and size).

Triangular lateral cartilage (cartilago triangularis) the medial side is parallel to the dorsum of the nose; the lower part merges with the cartilaginous part of the nasal septum. The posterior part of the triangular cartilage reaches the lower edge of the nasal bone, and its lower side is bordered by the upper edge of the pterygoid cartilage.

Wing cartilage(cartilagines alares) of both sides, touching along the midline, form the tip of the nose and take part in the formation of a solid base of the wing of the nose, limiting the nasal openings - nostrils (nares) of each side.

Cartilage is connected to each other by fibrous tissue.

The muscles of the external nose are located in the area of \u200b\u200bthe nasal wings and serve to expand the entrance to the nose (mm.levatores alae nasi) and narrow the nasal openings (mm.compressores nasi et depressores alae nasi).

Blood supply to the external nose is carried out through the branches of the external and internal jaw arteries, namely a. dorsalis nasi (from a. ophthalmica - the system of the internal carotid artery), anastomosed with a. angularis branch a. maxillaris externa (external carotid artery system), as well as from a. septi mobilis nasi (from a. labialis).

Blood from the veins of the external nose flows to the anterior facial vein. The venous system of the external nose is closely related to the venous system of the nasal mucosa.

Lymphatic system associated with the submandibular and anterior parotid glands.

Motor innervation of the outer nose carried out by branches of the facial nerve, and sensory fibers go from the ethmoid nerve (from n. ophthalmicus I branch of the trigeminal nerve) and the inferior orbital (from n. maxillaris - II branch of the trigeminal nerve) to the cartilaginous part of the external nose and from the superior and inferior orbital nerves to the nasal skeleton.

The nasal cavity is located between the orbits, the oral cavity and the anterior cranial fossa (Fig. 1).

Fig. 1. Bone skeleton of the nasal cavity; anterior sections. Front view (according to V.P. Vorobiev).

In front, it communicates through the anterior nasal openings with the outer surface of the face, and from the back through the choanae with the upper part of the pharynx (nasopharynx). The nasal septum is divided into two non-communicating halves (right and left), each of which has an external opening and a choana (Fig. 2).

Fig. 2. Bone skeleton of the nasal cavity from the back (frontal cut through the anterior sections of the zygomatic arches).

Vestibule of the nasal cavity (vestibulum nasi). The skin covering the outer nose is tucked inward and retains its properties throughout the entire vestibule; it is covered with a significant number of hairs (vibrissae), especially in older men. The hairs are to a certain extent a filter that traps large dust particles, but in some cases they can become a source of development of boils, since staphylococci nest in the hair follicles.

The entrance to the bony part of the nose (apertura piriformis) is pear-shaped, the edges of which are formed by the frontal processes of the upper jaw and the lower edges of both nasal bones.

The nasal cavity itself, being a continuation of the canal of the vestibule of the nose, bounded by the skeleton and covered with mucous membrane... She, in addition to the nasopharynx, communicates with the paranasal cavities and through the foramen sphenopalatinum - with the pterygopalatine fossa, as well as with the lacrimal canal and through it with the conjunctival sac.

The canal of each half of the nasal cavity is limited by four walls: inner (common for both halves), outer, upper (roof) and lower (bottom).

The inner, or medial, wall is the nasal septum. It consists of a perpendicular plate hanging downward (lamina perpendicularis ossis ethmoidalis; Fig. 1, e, Fig. 2), supplemented downward and posteriorly with a vomer (vomer; Fig. 3, b),

Fig. 3. Bone skeleton of the nasal cavity, posterior sections. Frontal cut through the temporal processes of the zygomatic bones (according to V.P. Vorobiev). a - choanas; b - opener; c - opener wings; d - horizontal plate of the palatine bone; e - vertical plate of the palatine bone; e - crista turbinalis; g - maxillary sinus; h - mastoid process; and - the zygomatic process of the temporal bone (sawn off); k - foramen sphenopalatinum; l - cells of the lattice labyrinth; m - opening of the main sinus; k - opening of the optic nerve.

and anteriorly by quadrangular cartilage, which, at the border of the nasal cavity and vestibule, passes into the skin part of the septum. The last two sections make up the movable part of the nasal septum, as opposed to the fixed bony section (the posterior part of the septum). The outer wall of the nasal cavity, common with the inner wall of the maxillary sinus, is the most complex in its anatomical structure. Acquaintance with topographic anatomy the lateral wall of the nasal cavity is necessary not only for the rhinologist, but also for the ophthalmologist, since the lacrimal canal passes here.

Outer wall (fig. 4 and 5)

Fig. 4. The outer wall of the skeleton of the nasal cavity (according to V.P. Vorobyov). a - frontal sinus; b - nasal bone; c - spina frontalis; d - lacrimal bone; d - inferior turbinate; e - canalis incisivus; g - alveolar process; h - crista galli; and - palatine process of the maxillary bone; k - lower nasal passage; l-middle nasal passage; m - upper nasal passage; n - middle turbinate; o - superior nasal concha; n - main cavity; p - foramen sphenopalatinura; c - opening of the main sinus.

Fig. five. The outer wall of the skeleton of the nasal cavity (after removal of the upper, middle and part of the lower turbinate) (according to V.P. Vorobiev). a - frontal sinus; b - the probe from the frontal cavity protrudes into the lumen of the lunar fissure; c - semicanalis obliquus (hiatus semilunaris); d - proc. uncinatus ossis ethmoidalis; e - bulla ethmoidalis; e - os lacrimale; g - inferior turbinate; h - probe in the lacrimal canal; and - canalis incisivus; k - palatine process of the maxillary bone; l - maxillary sinus; m - the body of the main bone; k - Turkish saddle; o - opening of the optic nerve; n - the main sinus; p - opening of the rear cells of the lattice labyrinth; c - sieve, or perforated, plate; t - opening of the anterior cells of the trellised labyrinth; y - middle turbinate (cut off); f - upper turbinate (cut off); x - hole of the main cavity.

formed by the nasal bone, the nasal (medial) surface of the body of the maxillary bone with its frontal process, the lacrimal bone, the ethmoid bone (with its upper and middle turbinates, bulla ethmoidalis et processus uncinatus), the vertical plate of the palatine bone and the pterygoid process of the sphenoid bone, taking part in the formation of the choana. In addition to the upper and middle turbinates (Fig. 4, o and n), belonging to the ethmoid bone, there is an inferior turbinate on the outer wall of the nose (Fig. 4, e), which is an independent bone (os turbinale). It attaches with its upper edge in front to a linear protrusion (crista turbinalis; Fig. 3, f) on the frontal process of the upper jaw, and behind - to the ridge of the palatine bone. The outlet of the lacrimal canal opens under the arch of the inferior concha (Fig. 5, h).

When one of the anterior cells of the ethmoidal labyrinth enters the anterior end of the middle shell, this shell takes the form of a swollen bubble (concha bullosa).

According to the three shells, three nasal passages are distinguished:

lower (the space between the lower turbinate and the bottom of the nasal cavity),
medium (between the middle and lower turbinates)
and the upper one (above the middle shell) (Fig. 4, k, l, m).

The area bounded on the medial side by the septum of the nose, and on the outside by the shells, is called the common nasal passage (meatus nasi communis). It is usually divided into two sections: upper (regio olfactoria) and lower (regio respiratoria).

In clinical and diagnostic terms, the most important part of the outer wall of the nasal cavity is middle nasal passage (Fig. 4, l), into which the excretory openings of the maxillary and frontal cavities, as well as the anterior and partly middle cells of the ethmoid labyrinth open.

On the macerated skull, this area corresponds to the hiatus maxillaris, significantly narrowed, since it is covered with bony formations (hook-shaped process - proc. Uncinatus of the ethmoid bone, processes of the inferior turbinate). Places devoid of bone are tightened by fontanelles (fountains), i.e., duplication of accrete layers of the mucous membrane of the nasal and maxillary cavities. Usually there are two fountains, of which the posterior one is bounded by the ethmoid process, the posterior end of the hook-shaped process and the perpendicular plate of the palatine bone, and the anterior one is located between the hook-shaped process, the inferior concha and its ethmoid process.

On a fresh preparation, after removing the middle turbinate or part of it, a lunar or crescent-shaped slit (hiatus semilunaris; Fig. 5, c), first described by NI Pirogov and named by him semicanalis obliquus, is visible.

It is bounded in front and below by the aforementioned hook-shaped process of the ethmoid bone (Fig. 5, d) with bony protrusions extending from it downward and posteriorly, and behind and from above - by the bulge (bone bladder) of one of the cells of the ethmoidal labyrinth (bulla ethmoidalis; Fig. 5 , e). Small gaps between the individual projections of the uncinate process lead to the maxillary sinus, and on a fresh specimen they are tightened with a duplication of the mucous membrane. Only the posterior part of the lunate fissure remains free from the mucous membrane and is a permanent opening of the maxillary sinus (ostium maxillare). In the posterior part of the lunar fissure there is an extension that narrows towards the maxillary cavity in the form of a funnel (infundibulum), at the bottom of which is the outlet of the maxillary sinus (ostium maxillare).

Along with the permanent hole, it is not uncommon to see accessory opening of the maxillary sinus (ostium maxillare accessorium), also opening into the middle nasal passage.

In the anterior-upper part of the lunar fissure, the excretory opening of the frontal cavity (ductus naso-frontalis; Fig. 5, b) opens.

The anterior and part of the posterior cells of the ethmoidal labyrinth usually open on the anterior and posterior walls of the lunar fissure, as well as in the angle between bulla ethmoidalis and the middle turbinate. Sometimes, near the excretory opening of the frontal sinus, one of the anterior cells of the ethmoid labyrinth opens.

We will dwell on the question of the options for the location of the excretory ducts of the paranasal cavities in the middle nasal passage when it comes to the anatomy of the sinuses.

When empyema of the anterior sinuses, namely the maxillary and frontal sinuses, as well as the anterior and part of the middle cells of the ethmoid labyrinth, pus flows down through the above excretory ducts and accumulates in the deepening of the lunar fissure. Using rhinoscopy, it is possible in such cases to detect pus in the middle nasal passage.

The posterior and part of the middle cells of the ethmoid labyrinth, as well as the main cavity, open with their excretory openings into the upper nasal passage and into the depression located between the surface of the body of the sphenoid bone and the upper nasal concha (recessus spheno-ethmoidalis). The presence of pus found on posterior rhinoscopy always indicates a purulent process in the posterior paranasal cavities.

The upper wall of the nasal cavity is mainly formed by sieve, or perforated, plate (lamina cribrosa), supplemented in front by the frontal and nasal bones, frontal processes of the upper jaw, and behind - by the front wall of the main cavity. The sieve, or perforated, plate (Fig. 5, c) is permeated with a large number of holes where fila olfactoria passes, the fibers of the olfactory nerve penetrate into the olfactory bulb (bulbus olfactorius) of the corresponding half of the nose, which lies on the cranial surface of the sieve plate, lateral to the cockscomb. The anterior ethmoid artery and the veins and nerve of the same name also penetrate through the openings of the sieve plate from the nose into the cranial cavity.

The lower wall of the nasal cavity formed by the palatine processes of the upper jaw (Fig. 2), supplemented posteriorly by horizontal plates of the palatine bone (Fig. 3, d), and is concave in the frontal and sagittal planes.

The mucous membrane covering the respiratory region of the nose, from the vestibule to the olfactory region, is covered with multilayer cylindrical ciliated epithelium. The mucous membrane of the olfactory region, which extends to the surface of the superior concha, the upper part of the middle concha and the part of the nasal septum corresponding to these areas, is lined with a special olfactory epithelium, which consists of cells of two genera: olfactory and supporting... The olfactory cells are the peripheral nerve receptors of the olfactory analyzer. The central processes of the olfactory cells extending from the bottom of the flask form olfactory fibers (fila olfactoria) in the openings of the sieve plate, through which they penetrate, heading to the olfactory nerve.

The arteries of the nasal cavity depart from the general and external carotid arteries.

Arterial nutrition provided by a. sphenopalatina from a. maxillaris interna - VIII branch of the external carotid artery, entering from the fossa pterygopalatina into the nasal cavity through foramen sphenopalatinum and breaking up here into aa. nasales posteriores with branches (a. nasalis posterior lateralis et a. nasalis posterior septi nasi) and on a. nasopalatina. Through these branches, arterial blood is supplied to the lower, middle and upper turbinates, the corresponding nasal passages, as well as part of the nasal septum.

The upper part of the outer wall of the nose and partially the septum receive blood from the anterior and posterior ethmoid arteries, which are branches of a. ophthalmica.

The veins of the nasal cavity repeat the course of the arteries of the same name. A large number of venous plexuses connect the veins of the nasal cavity with the veins of the orbit, skull, face and pharynx.

In the pathology of inflammatory diseases of the orbit, the connection of the anterior and posterior ethmoid veins with the veins of the orbit is of great importance, and through the orbital veins, the connection with the cavernous sinus is carried out. One of the branches of the anterior ethmoid vein, penetrating through the sieve plate into the cranial cavity, connects the nasal cavity, and with it the orbit with the venous plexus of the soft meninges.

The lymphatic system of the nasal cavity consists of the superficial and deep layers of blood vessels, which are associated with the subdural and subarachnoid space of the meninges.

Sensitive innervation of the nasal cavity carried out by the II branch of the trigeminal nerve, as well as due to ganglion sphenopalatinum.

From the I branch of the trigeminal nerve (n. Ophthalmicus and its branches n. Nasociliaris) nn are directed to the nasal cavity. ethmoidales anterior et posterior, and also rr. nasales mediales et laterales.

From the II branch of the trigeminal nerve (n. Maxillaris) branch off to the nasal cavity of the n. infraorbitalis - rr. nasales externi et interni.

From the olfactory epithelium of the mucous membrane of the nasal cavity, nerve fibers (fila olfactoria) of each side go through the holes in the sieve plate to the olfactory bulb and further as part of tractus olfactorius et trigonum olfactorium, forming a common trunk, first reach the subcortical centers of smell in the gray matter, and then the cerebral bark (gyrum hippocampus et gyrus subcallosus).

The connection between the innervation of the nasal cavity and the eye is provided through n. nasociliaris et ganglion nasociliare.

Sympathetic innervation stands in connection with the superior cervical sympathetic node. Sympathetic fibers originating from the plexus caroticus are sent to the gasser node, and from there in the n. ophthalmicus and n. maxillaris (branches I and II of the trigeminal nerve) penetrate into the nasal cavity, paranasal sinuses and orbit. The bulk of the fibers are n. maxillaris through the pterygopalatine ganglion (ganglion spheno-palatinum), in which they are not interrupted, and then branch into the nasal cavity and in the paranasal sinuses. A smaller part of the fibers (anterior and posterior ethmoid nerves - branches of n. Ophthalmicus) penetrates into the nose through the corresponding openings on the inner wall of the orbit.

Parasympathetic fibers, starting in the corresponding centers of the medulla oblongata, are part of the facial nerve and along n. petrosus major reach the pterygopalatine node, where they are interrupted, and then, in the form of postganglionic fibers, reach the nasal cavity and orbit.

From the above data, it follows that there is a close neural connection between the nasal cavity, its paranasal sinuses and the orbit, which is carried out due to trigeminal sympathetic and parasympathetic innervation through the ganglion cervicalis superior, ganglion Gasseri, ganglion, ciliaris (in the orbit) and ganglion sphenopalatinum (in nose).

The blood supply to the nasal cavity is provided by the terminal branch of the internal carotid artery (a. Ophthalmica), which in the orbit gives off the ethmoid arteries (aa. Ethmoidales anterior et posterior); these arteries feed the anteroposterior parts of the walls of the nasal cavity and ethmoid labyrinth. The largest artery in the nasal cavity is a. sphenopalatina (a branch of the internal jaw artery from the external carotid artery system) gives nasal branches to the lateral wall of the nasal cavity, the septum, and all the paranasal sinuses.

A feature of the vascularization of the nasal septum is the formation of a dense vascular network in the mucous membrane in the area of \u200b\u200bits anterior third (locus Kisselbachii), here the mucous membrane is often thinned. From this place more often than from other areas there are nosebleeds, which is why it is called the [bleeding area of \u200b\u200bthe nose] (Fig. 5).

Venous vessels accompany the arteries. A feature of the venous outflow from the nasal cavity is its connection with the venous plexuses (plexus pterigoideus, sinus caverno-sus), through which the veins of the nose communicate with the veins of the skull, orbit, pharynx, which creates the possibility of the spread of infection along these paths and the occurrence of rhinogenic intracranial, orbital complications , sepsis, etc.

Lymphatic drainage from the anterior parts of the nose is carried out into the submandibular lymph nodes, from the middle and posterior parts to the deep cervical. For the clinic, it is important to note the connection of the lymphatic system of the olfactory region of the nose with the intershell spaces, carried out along the perineural pathways of the olfactory nerve fibers... This explains the possibility of meningitis after ethmoid labyrinth surgery.

In the nasal cavity, there are olfactory, sensory and secretory innervation.

The olfactory fibers (fila olfactoria) depart from the olfactory epithelium and through the perforated plate penetrate into the cranial cavity to the olfactory bulb, where they form synapses with the dendrite of cells of the olfactory tract (olfactory nerve). and the anterior perforated substance is the highest cortical center of smell.

Sensitive innervation of the nasal cavity is carried out by the first (item ophtalmicus) and the second_ (item maxillaris) branches of the trigeminal nerve. From the first branch of the trigeminal nerve, the anterior and posterior ethmoid nerves depart, which penetrate into the nasal cavity together with the vessels and innervate the lateral sections and the fornix of the nasal cavity. The second branch participates in the innervation of the nose directly and through the anastomosis with the pterygopalatine node, from which the posterior nasal nerves depart mainly to the nasal septum. From the second branch, the inferior orbital nerve departs to the mucous membrane of the bottom of the nasal cavity and to the maxillary sinus. The branches of the trigeminal nerve anastomose each other, which explains the irradiation of pain from the nose and paranasal sinuses to the area of \u200b\u200bthe teeth, eyes, dura mater (pain in the forehead, occiput), etc. Sympathetic and para-sympathetic innervation of the nose and paranasal sinuses is represented the vidian nerve, which originates from the plexus on the internal carotid artery (upper cervical sympathetic node) and from the geniculate node of the facial nerve (parasympathetic portion).

The blood supply to the maxillary sinus has been studied in most detail. This sinus feeds on the branches of a. maxillaris int., and namely a. alveolaris sup. post., a. nasalis post. lat. (branch a. sphenopalatina), a. palatina descendens and a. alveolaris sup. ant. (branch a. infraorbitalis). The frontal sinus is supplied with blood from the arteries of the nasal cavity (a. Nasalis post.) And the branches of a. ophtalmica. The ethmoid sinus receives blood mainly from the vessels of the mucous membrane of the nasal concha and a. ethmoidalis. The main sinus is supplied with branches a. nasalis post., a. pterygopalatina, a. vidiana and the branches of the arteries of the meninges.

The outflow of blood from the paranasal sinuses is carried out through the vessels that anastomose with each other and communicate with the veins of the nose, face, orbit, cranial cavity, venous plexuses (pl.pterygoideus, pl.ophtalmicus) and even with cranial sinuses (sinus cavernosus, sinus longitudinalis sup . (V.O. Kalina).

The lymphatic vessels of the paranasal sinuses drain lymph into the pharyngeal and deep cervical nodes.

In the anatomical overview of the paranasal sinuses, topographic features should be noted.

The maxillary sinus is bordered by the dental arch and the orbit; ethmoid cells - with an orbit, anterior cranial fossa and optic nerve; frontal - with an orbit and anterior cranial fossa; the main one - with the pituitary gland and the anterior cranial fossa, the optic nerve, the internal carotid artery, the cavernous sinus and the III, IV, VI cranial nerves and 1 branch of n. V. All these formations adjacent to the sinuses can be involved in the pathological process with suppurative and other diseases of the accessory sinuses.

4.Clinical anatomy of the paranasal sinuses. (4sinuses).

The paranasal sinuses are adjacent to the nasal cavity. They are bay-like air cavities located in the upper jaws, ethmoid, frontal and main bones. With rather narrow openings and channels, they communicate with the nasal cavity. The mucous membrane lining them is, as it were, a continuation of the nasal mucosa and differs from it only in that it is very thin and does not contain cavernous tissue. A number of factors are involved in the formation of the paranasal sinuses. The sinuses, as such, are believed to arise from bone resorption. A well-known role is also attributed to the inflammatory conditions of the nasal mucosa, namely: the earlier its inflammation occurs, the larger are the paranasal sinuses. Some authors believe that the factor of heredity plays a significant role in the development of the paranasal sinuses.

Of all the paranasal sinuses, the most rapidly pneumatized cells of the ethmoid labyrinth and the main sinus, much more slowly - the maxillary and frontal sinuses. The maxillary (maxillary) sinus at the birth of a child appears as a narrow gap, which begins to expand only after the eruption of the milk incisors - at this age, the sinus is mostly replaced by cancellous bone and dental buds. The frontal sinus is absent at birth, its lumen begins to form only in age 4-6 years and gradually increases over the years. Often there are people with completely undeveloped frontal sinuses.

1. Maxillary sinus, paired, the largest in volume (up to 20 cm3), is located in the upper jaw. In shape, it resembles a tetrahedral pyramid, the base of which (medial wall) is the lateral wall of the nose, and the apex is the zygomatic process. The medial wall of the sinus, corresponding to the lower nasal passage, consists of a fairly dense bone, respectively, the middle one, in the area of \u200b\u200bthe hiatus semilunaris, it is formed by a thin connective tissue plate. In this membranous part there is an opening (ostium maxillare) that communicates the sinus with the nasal cavity. There is also an additional opening (ostium accessorium) located somewhat posterior to the first. The front wall of the sinus is formed by the front part of the jaw, deepened in the form of a fossa (fossa canina). The upper wall is made up of a thin bone plate, which is at the same time the bottom of the orbit. A canal for the infraorbital nerve passes through it. The lower wall of the sinus corresponds to the bay of the alveolar process, in which the roots of the second small molar and the first two large molars are located. The posterior wall of the sinus, a dense bone formation, is bordered by the fossa infratemporalis and fossa retromaxillaris.

2. Frontal sinus in shape and size, different persons are not the same. Its front wall is the frontal tubercle. The lower, thinner wall is the upper wall of the orbit. The posterior wall with its tuberous surface faces the anterior cranial fossa. The medial wall is the septum that separates the right frontal sinus from the left. This septum usually does not stand strictly along the midline, but deviates to one side or the other. In the anteromedial angle, at the bottom of the frontal sinus, there is an opening leading to the nasolabial canal, which opens into the anterior part of the middle nasal passage.

3. Ethmoid sinus, consisting of small cavities - cells (in an amount from 2 to 8), is located in the body of the bone of the same name. The cell walls are very thin plates of bone. The lateral wall of the ethmoid sinus is the medial wall of the orbit, and the medial one is involved in the formation of the lateral wall of the nose. Ethmoid cells are attached to the sieve plate (lam. Cribrosa) and appear to be wedged between the maxillary and frontal sinuses. Lam cribrosa borders on the anterior cranial fossa; the optic nerve passes close to the ethmoid sinuses. Among the cells of the ethmoid bone, anterior and middle cells are distinguished, opening into the middle nasal passage, and the posterior ones, communicating with the upper nasal passage.

4. Main sinus is located in the body of the main bone. Its bottom forms the arch of the nasopharynx. The anterior wall, which is thinner, has an opening (ostium sphenoidale) that connects the sinus with the upper nasal passage.Canalis caroticus passes in the lateral wall, and here the sinus borders on the cavernous sinus, next to which the III, IV and VI cranial nerves pass. The upper, rather massive, bony wall is bordered by the anterior cranial fossa, the Turkish saddle, the epididymis and chiasma n. optici. There is also a medial wall, which is a thin bony septum that divides the sinus into the right and left halves. The size of the sinus is variable. In some individuals it is in the form of a small cavity, while in others it occupies the entire body of the main bone.

Physiology of the nose and paranasal sinuses

The nose performs the following functions: respiratory, olfactory, protective and resonant.

The main function is respiratory. Once in the nasal cavity, the air flow passes through the narrowest place - the nasal valve, twists into a spiral (turbulent movement), then its movement becomes rectilinear, laminar. Further, the main part of the air flow goes along the common nasal passage along the middle turbinate. When inhaling, part of the air comes out of the paranasal sinuses, which contributes to warming and moistening the inhaled air, as well as its partial diffusion into the olfactory region. When you exhale, the main part of the air goes along the general nasal passage, partially along the rest of the nasal passages and enters the paranasal sinuses.

The protective function of the nasal cavity is manifested in cleansing, warming and moisturizing the air. Air warming is provided by reflex expansion and filling of cavernous vessels with blood and contact of air with the mucous membrane. Air humidification occurs due to the secretion of mucous glands, goblet cells, lymph and lacrimal fluid.

Air purification is carried out by the hairs of the vestibule of the nose, mucous secretions with a bactericidal effect, as well as cilia of the ciliated epithelium.

In the olfactory region of the nasal cavity there are peripheral receptors of the olfactory analyzer, which are adequately stimulated by the molecules of odorous substances. On inhalation, odorous substances enter the olfactory region along with the air, which is located upward from the lower edge of the middle turbinate. There are various theories of smell: chemical (dissolution of molecules of odorous substances in a lipoid substance), physical - excitation of olfactory cells by vibrations of molecules of odorous substances, physicochemical - excitation of cells by electrochemical energy of odorous substances.

The paranasal sinuses perform resonator and protective functions. Small sinuses (lattice, wedge-shaped) resonate high sounds, and large sinuses - low (maxillary, frontal).

The mucous membrane of the nasal cavity and paranasal sinuses,

Mucous membrane of the cavity the nose is tightly welded to the periosteum, directly passes into the mucous membrane of the paranasal sinuses, does not have a submucous layer. The epithelium of the mucous membrane is multi-row, cylindrical, ciliated, contains goblet and basal cells. Oscillations of the cilia of the ciliated epithelium are directed towards the nasopharynx.

The cavernous tissue is located on the medial surface of the inferior turbinate, the free edge, and the posterior ends of the middle and superior turbinates. It consists of a ball of veins, the walls of which are rich in smooth muscles and elastic fibers. Cavernous tissue under the influence of various factors can instantly expand and contract.

The epithelium of the olfactory region consists of olfactory, basal supporting and tubular-alveolar (Bowman's) cells (Figures 1. ** - 1. **).

The structure of the mucous membrane of the paranasal sinuses practically does not differ from the mucous membrane of the nasal cavity, the outflow of mucus from the sinuses is directed to the outflow openings.

Blood supply to the nasal cavity very abundant and carried out by the branches of the external and internal carotid arteries (Figure 1.10).

The veins of the nasal cavity accompany arterial vessels, have numerous anastomoses with veins of the external nose and face, nasopharynx, pterygopalatine fossa, through the ethmoid veins - with the veins of the orbit, cavernous.

The vasculature of the nasal mucosa in the antero-lower part of the nasal septum is called the "bleeding zone" or "Kisselbach place". Here there are accumulations of terminal branches of the arteries of the nasal septum a.nasalis septi, palatini major, ethmoidalis anterior, labialis superior and venous capillaries. The integumentary epithelium of the Kisselbach zone is thin and with an increase in the blood filling of the vessels, it easily breaks.

Innervation of the nasal mucosa... Distinguish between olfactory, sensitive and vegetative innervation mucous membrane of the cavity.

Sensory innervation is carried out by the branches of the trigeminal nerve. The anterior part of the nasal cavity is mainly innervated by the branches of the orbital nerve, and the posterior one - by the branches of the maxillary nerve. Sympathetic innervation is carried out from the carotid plexus, which is connected to the superior sympathetic node. Parasympathetic innervation goes through the Vidian nerve from the geniculate node of the facial nerve. All the nerves of the nasal cavity are closely interconnected and anastomosed with the dental, ocular and nerves of the dura mater.

Lymphatic system of the nasal cavity... The outflow of lymph from the anterior parts of the nasal cavity is carried out into the submandibular lymph nodes, from the middle and rear - into the deep cervical lymph nodes.

Examination of the external nose. External examination, palpation of the nose and paranasal sinuses is carried out to identify pathological changes: inflammatory, deformation of the bone walls, crepitus and pathological mobility, pain observed in fractures of the nasal bones or the walls of the paranasal sinuses. First, the external nose is examined, the projection of the paranasal sinuses on the face, then the back of the nose, the region of the root, and the slopes are palpated with the index fingers. The anterior and lower walls of the frontal sinus are palpated with the thumbs of both hands. Light pressure is applied at the exit points of the branches of the trigeminal nerve. Normally, there is no pain on palpation of the nose and the walls of the frontal sinuses.

To determine crepitus and pathological mobility, the bony part of the external nose is fixed between the thumb and forefinger of the right hand, and an attempt is made to shift the bones of the nose to the sides. With crepitus, a crunch of bones is heard. With pathological mobility, the bones are easily displaced to the sides. The anterior walls of the maxillary sinuses are also palpated with the thumb of the right hand with pressure on the area of \u200b\u200bthe canine fossa (exit of the II branch of the trigeminal nerve). Normally, soreness when pressed in a dog's fossa is not detected.

Study of the functions of the nose. Respiratory function of the nose (determined separately on both sides using a test with a cotton swab (Voyachek's test). One wing of the nose with the index finger of the left hand is pressed against the nasal septum, a piece of cotton wool is brought to the other vestibule by the hand and the patient is asked to take a short breath in and out. the degree of difficulty in breathing is determined.

Olfactory function of the nosedetermined using a set of odorous substances or a special device with an olfactometer. The set includes odoriferous substances arranged in increasing intensity: soap, wine alcohol, valerian tincture, vinegar. An odorous substance is alternately brought to each nostril (with the second closed), and asked to name the substance. If the patient can distinguish the smells of all the odorous substances of the set, then the sense of smell is normal. If the patient distinguishes only pungent odors - valerian, vinegar, then the patient has a decrease in his sense of smell - hyposmia, and in the absence of the ability to distinguish odors - anosmia. Sometimes the patient smells, but cannot differentiate it - cocosmia.

Anterior rhinoscopy is carried out to assess the condition of the vestibule, nasal passages, mucous membrane of the turbinates, nasal septum, and the contents of the nasal cavity. To inspect the vestibule of the nose, the tip of the nose is raised with the thumb of the right hand. Then, using a nasal mirror, the remaining parts of the nasal cavity are examined one by one. To do this, a nasal mirror is placed with its beak down on the open palm of the left hand, the I finger is pressed against the mirror screw, II and III lie on the branches, IV and V are between the branches. The elbow of the left hand is lowered, the doctor's right hand rests on the crown of the patient to change the position of the head during rhinoscopy. The beak of the mirror in a closed form is introduced in the vestibule of the nose: the right half of the beak should be located in the lower-inner corner of the vestibule of the nose, the left half - in the upper-outer corner. II and III fingers press the jaws, the beak opens. First, the nasal cavity is examined, with the head straight: the color of the mucous membrane is pink, the surface is smooth, the nasal septum is along the midline, the turbinates are not enlarged, the general nasal passage is free. To inspect the bottom of the nasal cavity, the patient's head is tilted downward, the middle nasal passage - posteriorly and to the side, the posterior sections - somewhat posteriorly and upward. The nasal speculum is removed with incomplete closure of the branches (so as not to pinch the hairs). The tip of the beak of the nasal mirror should not be inserted deeper than the beginning of the nasal mucosa in order to avoid injury to the Kisselbach zone. The left side of the nose is also examined.

Posterior rhinoscopy . To perform it, you need: a spatula, a nasopharyngeal mirror, fixed in the handle and warmed up to body temperature. The spatula is taken with the left hand and inserted into the oral cavity from the side of the patient's right corner of the mouth. With the distal end of the spatula, press down the front ⅔ language. The nasopharyngeal speculum is taken with the right hand, like a pen for writing, and the mirror surface is inserted upward through the left corner of the patient's open mouth into the oropharynx, behind the soft palate, without touching the root of the tongue and the posterior pharyngeal wall, the light from the reflector, falling onto the surface of the nasopharyngeal speculum and reflecting, illuminates the nasopharynx and the posterior parts of the nasal cavity. The patient should try to breathe through the nose. At the same time, choanas with the posterior ends of the turbinates and a vomer in the middle, the vault of the nasopharynx, the side walls with the pharyngeal orifices are visible in the mirror. auditory tubes (at the level of the posterior ends of the inferior turbinates) the pharyngeal tonsil on the posterior-superior wall of the nasopharynx.

Optical rhinoscopy . The method of optical rhinoscopy consists in examining all parts of the nasal cavity using optical rhinoscopes. The examination begins with the introduction of a rhinoscope into the nasal cavity without anesthesia or with surface anesthesia with a solution of 10% lidocaine: the general nasal passage, the inferior turbinate, the nasal septum, the nasopharynx are examined, then the middle turbinate, the middle nasal passage with the ostiomeatal complex, the upper nasal passage and upper nasal concha with sphenoethmoidal pocket.

Optical sinusoscopy - This is a study of the paranasal sinuses using optics. It is performed to examine the maxillary sinuses, which are the most susceptible to the inflammatory process and are available for research. The essence of the technique is to puncture the maxillary sinus through its anterior wall or lower nasal passage, followed by examination of the sinus with a Hopkins telescope and the possible removal of the mucous membrane for histological examination or removal of cysts.

Probing and puncture... Probing of the anatomical structures of the nasal cavity is carried out in order to determine their consistency, mobility, and prevalence. To perform this manipulation, a buttoned or a probe with a thread and a quilted jacket is used.

Probing of the paranasal sinuses is carried out with special cannulas, more often with a therapeutic purpose: washing, administration of medicinal substances. This study can only be performed by an experienced specialist and therefore has not received wide application in practice.

Puncture of the paranasal sinuses is used quite widely, both for diagnostic and therapeutic purposes. Most often, punctures are performed for diseases of the maxillary sinus, less often for frontal sinusitis, sphenoiditis, ethmoiditis. Puncture of the maxillary sinus is carried out under local anesthesia with a 10% lidocaine solution through the lower nasal passage with a Kulikovsky needle, 2 cm away from the anterior end of the inferior turbinate. Then the contents are aspirated and washed with saline, an antibiotic or antiseptic is injected. Drainage and long-term treatment can be carried out through a puncture needle into the maxillary sinus. If the puncture of the maxillary sinus is performed correctly, there are no complications.

The nasal cavity (cavum nasi) is located between the oral cavity and the anterior cranial fossa, and on the lateral sides - between the paired upper jaws and paired ethmoid bones. The nasal septum divides it sagittally into two halves, opening anteriorly with the nostrils and posteriorly, into the nasopharynx, by the choanas. Each half of the nose is surrounded by four paranasal sinuses: maxillary, ethmoid labyrinth, frontal and wedge-shaped

The nasal cavity has four walls: lower, upper, medial and lateral:

1. Bottom wall (the bottom of the nasal cavity) is formed by two palatine processes of the upper jaw and in a small area posteriorly - by two horizontal plates of the palatine bone (hard palate). On a similar line, these bones are connected by a suture.

2.Top wall (roof) the nasal cavity in front is formed by the nasal bones, in the middle sections - by the ethmoid plate (lamina cribrosa) and the ethmoid cells (the largest part of the roof), the posterior sections are formed by the anterior wall of the sphenoid sinus.

3. Medial wall, or nasal septum (septum nasi), consists of the anterior cartilaginous and posterior bone sections. The bony section is formed by the perpendicular plate (lamina perpendicularis) of the ethmoid bone and the vomer (vomer), the cartilaginous - quadrangular cartilage, the upper edge of which forms the anterior part of the nasal dorsum.

4. On the outer (lateral) wall there are three conchae nasales: lower (concha inferior), middle (concha media) and upper (concha superior).

Blood supply to the nasal cavity provided by the final branch of the internal carotid artery (a.ophthalmica), which in the orbit gives off trellised arteries (aa.ethmoidales anterior et posterior); these arteries feed the anteroposterior parts of the walls of the nasal cavity and ethmoid labyrinth. The largest artery of the nasal cavity is a.sphenopalatina (a branch of the internal jaw artery from the external carotid artery system), it leaves the pterygopalatine fossa through the opening formed by the processes of the vertical plate of the palatine bone and the body of the main bone (foramen sphenopalatinum), gives the nasal branches to the side wall nasal cavity, septum and all paranasal sinuses.

Lymphatic drainagefrom the anterior parts of the nose it is carried out to the submandibular lymph nodes, from the middle and posterior parts to the deep cervical.

In the nasal cavity, there are olfactory, sensory and secretory innervation.Olfactory fibers (fila olfactoria) depart from the olfactory epithelium and through the ethmoid plate penetrate into the cranial cavity to the olfactory bulb. Sensory innervation of the nasal cavity is carried out by the first (n.ophtalmicus) and the second (n.maxillaris) branches of the trigeminal nerve.

44. Paranasal sinuses: maxillary (Gaimorova), main, frontal, ethmoid labyrinth. Walls, structure, excretory canals.

There are 4 pairs of sinuses: maxillary (Gaimorova), frontal, wedge-shaped, lattice. All paranasal sinuses are lined with mucous membranes and normally contain air.

1 the maxillary sinus the largest. The upper wall of the sinus is the bottom of the orbit. The cracks in this wall cause the breakthrough of pus into the orbit with purulent sinusitis. The front wall is the front, on it is the canine fossa (canine). Through this site, access to the sinus is carried out during sinusitis. The nasal (medial) wall corresponds to the lower and middle nasal passages. The bottom of the sinus is the alveolar process of the upper jaw. In adults, the roots of the 5,6,7 teeth of the upper jaw are most close to the bottom of the sinus, which causes the transition of inflammation from the root of the causative tooth to maxillary sinus... The posterior wall of the sinus is bordered by the pterygo-palatine fossa. The high position of the ostium relative to the bottom causes poor drainage of the sinus, which leads to the most frequent inflammation... The sinus feeds on the branches of the maxillary artery.

2.Frontal sinus located in the scales of the frontal bone. The anterior wall is the front, the posterior wall is the cerebral (bordered by the cranial fossa), the lower is the orbital, the medial is the meso-axillary. It feeds on the posterior nasal and orbital arteries. The frontal sinus communicates with the nasal cavity through a thin tortuous canal that opens into the anterior part of the middle nasal passage.

3.The sphenoid (main) sinus are located in the body of the sphenoid bone. The superior wall is bordered by the anterior cranial fossa, Turkish saddle, pituitary gland and chiasm optic nerves... Adjacent to the outer wall is the cavernous sinus, the internal carotid artery, the oculomotor, block, abducent nerves and the first branch of the trigeminal nerve. The posterior wall is bordered by the posterior cranial fossa. The blood supply is the branches of the posterior nasal and pterygopalatine arteries, the artery of the Vidian canal and the branches of the meninges.

4 lattice sinus are small, irregularly shaped, air-containing cells lined with a mucous membrane. The anterior and middle cells communicate with the middle nasal passage, the posterior ones with the upper one. From above, the ethmoid cells are separated from the anterior cranial fossa by the ethmoid plate. The posterior cells are in contact with the oculomotor, block, trigeminal, and abducent cranial nerves. The sinuses feed on ethmoid arteries.

Outflow of blood from the paranasal sinuses is carried out through the vessels that anastomose with each other, with the veins of the nose, face, orbit, cranial cavity, as well as with cranial sinuses.

Lymphatic vessels paranasal sinuses divert lymph into the pharyngeal and deep cervical nodes. Innervation The paranasal sinuses are carried out by the branches of the trigeminal nerve.

13279 0

general characteristics

When describing the anatomy of the nose, it is customary to distinguish between the following directions that orient the surgeon to the appropriate location of certain anatomical structures: caudal, cephalic, lateral (external), medial (internal), posterior and anterior (Fig. 36.1.1).

Fig. 36.1.1. The main directions used to describe the anatomy of the external nose.
C - cephalic; K - caudal; L - lateral; M - medial; P - front; З - back.

The bridge of the nose begins in the region of the bridge of the nose, and the narrowest part of its bony part is located at the level of the medial corners of the eyes. The nasal bones then expand caudally. The bony skeleton of the nose is represented by relatively small nasal bones and the frontal processes of the upper jaw located posterior to them.

The lateral cartilages of the nose (upper-lateral), which have a triangular or rectangular shape, are adjacent to the nasal bones (Fig. 36.1.2).

Fig. 36.1.2. The most important anatomical structures that form the skeleton of the external nose.
1 - nasal bone; 2 - upper lateral cartilage; 3 - the edge of the pear-shaped hole; 4 - large wing cartilage; 5 - additional cartilage; 6 - root of the nose; 7 - anterior nasal process; 8 - dome.

The skeleton of the caudal part of the nose is represented by large wing cartilages connected by fibrous bridges to the superior lateral cartilages, and the caudal edge of the nasal septum. The domes of the wing cartilage normally form the most protruding part of the nose and are manifested by two points that are noticeable only in people with thin or normal skin with sufficient sharpening of the domes.

The configuration of the sub-apical (located below the tip) part of the nose depends on the location, size and shape of the middle and medial pedicles of the wing cartilage. In this area of \u200b\u200bthe nose, due to the very thin skin that is fused with cartilage, even small changes in the shape of the cartilaginous skeleton become noticeable, which is often the object of the surgeon's influence.

Behind the large wing cartilages are additional cartilages and fibro-adipose tissue that forms the wing of the nose.

Covering tissue

Leather. The skin covering the nose is unevenly thick and thickens from top to bottom. In general, its thickness is in direct proportion to the severity of the subcutaneous layer of soft tissues, which has a significant impact on both the content of operations and their results. So, thin skin and a thin subcutaneous tissue layer are able to shrink after a decrease in certain sizes of the nose to a much greater extent than thick skin with a more significant subcutaneous tissue layer.

This allows the surgeon to plan, with thin skin, making relatively large changes in the shape of the nose and obtaining a sharper relief of the cat's nose. On the other hand, in these cases, even minimal irregularities of the bone-cartilaginous skeleton of the back and cat's nose become noticeable, which, in turn, can lead to patient dissatisfaction.

With thick skin and a significant thickness of subcutaneous tissue, the "chiseled" tip of the nose with two distinct points protruding under the skin will not work, and the size of the nose itself can only be changed to a relatively small extent.

The subcutaneous tissue is presented in four layers. Subcutaneous adipose tissue is permeated with vertical fibrous bridges connecting the deep layer of the dermis with the fibromuscular layer. The thickness of the fiber is greatest in the region of the bridge of the nose, decreases to a minimum in the area of \u200b\u200bthe osteocartilaginous transition of the nasal dorsum and then increases again above the tip of the nose and above the cephalic edges of the large wing cartilages.

The fibromuscular layer is represented by bundles of collagen fibers that surround the muscles of the nose, forming the superficial and deep fascia for each muscle so that all these formations act as one functional unit. Thus, the superficial muscular-aponeurotic system of the nose is formed, all parts of which are interconnected.

The deep fat layer is represented by loose tissue, which separates the periosteum (perichondrium) from the muscle layer, thereby increasing the mobility of muscles in relation to the skeleton of the nose.

The periosteum (perichondrium) covers the bony (cartilaginous) structures and, going beyond the large wing and upper-lateral cartilages, creates additional support for additional cartilage. The corresponding parts of the large wing cartilage are connected by fibrous bridges, which are a continuation of the perichondrium.

Blood supply and innervation of the external nose

Sources of blood supply to the tissues of the external nose originate from the system of the internal and external carotid arteries (Fig. 36.1.3).

Fig. 36.1.3. The main sources of arterial blood supply to the external nose (explanation and text).
1 - supraorbital artery; 2 - supra-block artery; 3 - rear nasal artery; 4 - the external nasal branch of the anterior ethmoid artery; 5 - infraorbital artery; 6 - lateral nasal artery; 7 — angular artery; 8 - superior labial artery; 9 - facial artery.

Two circumstances are of the greatest importance. First, the branches of the corresponding paired arteries anastomose with each other at the level of the nasal dorsum, forming a wide anastomotic network. Secondly, the blood supply to the tip of the nose is carried out from three main sources: 1) arteries descending along the back of the nose; 2) the lateral nasal artery and 3) the superior labial artery. Damage to the latter when using open access does not lead to disruption of the blood supply to the skin, if other sources of blood supply are preserved.

Sensory innervation of the nose is provided by the cutaneous branches of the fifth pair of cranial nerves (Fig. 36.1.4).

Fig. 36.1.4. The main sources of sensitive innervation of the external nose.
1 - supraorbital nerve; 2 - supra block nerve; 3 - subblock nerve; 4 - the outer nasal branch of the anterior ethmoid nerve; 5 - infraorbital nerve.

A special role among these branches is played by the external nasal branch of the anterior ethmoid nerve, which appears between the nasal bone and the upper lateral cartilage, accompanying the artery of the same name. This branch innervates the skin of the dorsum of the nose at a more caudal level, including the tip of the nose, and its damage during rhinoplasty causes numbness. To prevent this complication, the surgeon should maximally limit the volume of endonasal intervention and separate tissues, moving directly along the surface of the cartilage.

The skin of the caudal part of the nose is innervated by a branch of the inferior orbital nerve, the blockage of which is necessary during operations under local anesthesia.

Base of the nose

The base of the nose is divided into the following main parts: the lobule, the skin-membranous movable part of the nasal septum, or column (from the English columella), the bottom of the nostril, the vestibule, the base of the wing, the wall of the wing of the nose.The characteristics of these parts are largely determined by the shape and size of the large wing cartilage ...

Each large wing cartilage is conventionally divided into three legs (sections): lateral, medial and middle (intermediate — Fig. 36.1.5). The lateral legs of the large wing cartilage are also called inferolateral cartilage.

Fig. 36.1.5. Anatomical zones of the large wing cartilage.
1 — lateral leg; 2 - middle leg; 3 - medial leg; 4 - dome of the middle leg; 5 - lobule of the middle leg; b — column (columel) of the medial pedicle; 7 - the base of the medial stem.

The middle peduncle is considered more than just a link between the medial and lateral pedicles. Its shape and size play an extremely important role in the formation of the shape of the nose, its assessment and in drawing up the plan of the operation.

The medial pedicles are divided at the apex of their curvature into two sections: the base and the column segment. The magnitude of the angle of this curvature significantly affects the location of the base of the medial pedicles and, in turn, how much they protrude under the skin, narrowing the entrance to the nasal canal. The position of the base of the medial pedicle is also influenced by the location of the caudal edge of the nasal septum, as well as the volume of soft tissue at the base of the column.

The length of the nostril also depends on the length of the column segment, and in the location of the medial legs, there are three main options: 1) asymmetric parallel, 2) symmetrical expanded and 3) symmetrical straight (Fig. 36.1.6).

Fig. 36.1.6. The main options for the location of the medial pedicles and lobules of their middle segments.
a - asymmetric parallel; b - symmetrical extended; c - symmetrical straight line.

Loose connective tissue, including vessels, is located between the two paired segments. Therefore, with open access, this tissue should be included in the formed flap, which contributes to the maximum preservation of its blood supply.

The segment of the column passes into the lobule of the middle leg at the break point, the location and angle of which significantly affects the profile of the nose. Excessive or, on the contrary, insufficient standing of this point is a frequent reason for surgical correction.

The middle (intermediate) legs are conventionally divided into a lobule and a dome. The cephalic margins of the cartilage at the level of the lobule are located close to each other, while the caudal margins are deflected outward. Their location, length, and shape also determine the shape of the sub-apical region of the nose tip.

Domes are usually the thinnest and narrowest areas of large wing cartilage and can be asymmetric due to congenital structural features or due to childhood trauma. Their size and shape, as well as the volume of soft tissues located between them, are the most important indicators that determine the shape of a cat's nose. The appearance of the latter largely depends on three main characteristics: 1) the peculiarities of the curvature of the leg at the level of the dome; 2) the relative position of the domes; and 3) the thickness of the soft tissues covering the domes. The first two parameters are most often corrected during rhinoplasty.

A significant role is played by the appearance and location of the points of the tip of the nose (protruding under the skin of the dome of the large wing cartilage), which are very important in its aesthetic characteristics. The indicators of the supra-apical zone of the tip of the nose are also significant, largely determined by the thickness of the soft tissues. With their excess, the contour of the nose in the supra-apical zone is displaced in the cephalic direction, and with a deficiency, the so-called split nose is formed.

The lateral peduncles are the largest part of the large wing cartilage and play an important role in determining the shape of the antero-outer part of the nose, and in particular the lateral wing wall. The outer edge of the lateral legs rests on accessory cartilage located along the edge of the pear-shaped foramen and can have a different (concave or convex) shape. However, due to the masking effect of soft tissue, this can often only be determined by exposing the cartilage. With the excessive size and convex shape of the lateral legs (in combination with smoothed domes), the tip of the nose loses its outline and takes on a bulbous appearance.

The structure of the contact zone between the cephalic edges of the lateral legs and the caudal edges of the upper lateral cartilage is different: they can interlock, overlap each other (the most common variant), or be matched "edge to edge".

Osteochondral vault of the nose

The bony arch has a pyramidal shape and is covered with a significant layer of soft tissues in the cephalic part. Together, this determines the depth and height of the bridge of the nose, which are the most important characteristics of the profile of the nose and are often corrected during rhinoplasty.

According to PSullivan et al., The width of the nasal bones, on average, is greatest in the region of the nasolabial suture (14 mm), minimal in the region of the bridge of the nose (10 mm), below which it expands again (9-12 mm). The nasal bones are at their greatest thickness (on average 6 mm) above the level of the bridge of the nose and progressively thinner in the caudal direction. In the place where bone grafts are usually fixed with screws (5-10 mm below the bridge of the nose), the thickness of the nasal bones is 3-4 mm.

The cartilaginous vault is a single cartilaginous unit that can be located at different distances from the bridge of the nose and is formed by a pair of upper-lateral cartilages connected to the dorsal edge of the cartilaginous part of the nasal septum. At different levels, the osteochondral vault has a different cross-section, the variants of which have a great influence on the technique for correcting the shape and size of the nasal dorsum /

Nasal septum

The nasal septum is represented in the posterior-anterior direction by various components: bone, cartilage and membranous portion (Fig. 36.1.7). Deformities of the nasal septum are often manifested by impaired nasal breathing, the improvement of which is one of the tasks of rhinoplasty.

Fig. 36.1.7. Components of the nasal septum.
1 - perpendicular plastics of the ethmoid bone; 2 - opener; 3 - septal cartilage; 4 - nasal bone; 5 - anterior septal angle; 6 - posterior septal angle; 7 - anterior nasal process; 8 - nasal crest of the upper jaw.

The perpendicular plate of the ethmoid bone forms the cranial third of the nasal septum and connects anteriorly with the nasal bone, caudally with the cartilage of the nasal septum, and downwardly with the vomer. The contact zone of the vomer with the ethmoid plate depends on how far the septal cartilage is introduced between them.

The opener is shaped like a "boat keel" and attaches to the crest of the upper jaw. The most caudal part of this junction is the anterior nasal process of the maxilla.

The cartilage of the nasal septum has an irregularly rectangular shape and takes part in the formation and maintenance of the cartilaginous part of the nasal dorsum.The thickness of the cartilage usually decreases significantly in its anterior regions.

The size of the cartilaginous plate can significantly affect the contours of the nose, and in particular the height of the nasal dorsum, the projection of the cat's nose, and the location of the medial pedicles of the wing cartilage.

In the nasal septum, two septal angles are distinguished: anterior and posterior. The anterior septal angle is formed by the dorsal and anterior edges of the cartilaginous plate and is directly related to the cartilaginous formations that make up the tip of the nose. The posterior septal angle is formed by the anterior edge of the septal cartilage and its base. It is in direct contact with the nasal process of the upper jaw (see Fig. 36.1.7).

IN AND. Arkhangelsky, V.F. Kirillov