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Topology of the lateral nasal cartilagesThe anatomical relationship of the lateral nasal to the greater alar cartilage lateral crus.

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Topology of the Lateral Nasal Cartilages: The
Anatomical Relationship of the Lateral Nasal
to the Greater Alar Cartilage, Lateral Crus '
GLENN W. DRUMHELLER
Department of Physiology, Chicago College of Osteopathic Medicine,
1122 East 53rd Street, Chicago, Illinois 60615
ABSTRACT
This investigation was undertaken to help fulfill the practical
need of the rhinologic surgeon for a more accurate anatomical knowledge of the
cartilages of the nasal tip.
Four adult Caucasian noses aged 62-88 years were embedded en bloc and
serially sectioned. The nasal cartilages of one were reconstructed in wax. Anatomical relationships of the lateral nasal cartilage to the lateral crus of the
greater alar cartilage were compared. The findings were compared with descriptions found in the literature.
The lateral nasal cartilage curls to varying degrees laterally and upward on
its inferior margin where it underrides the lateral crus of the greater alar cartilage. The curl is greater anteriorly and diminishes postero-laterally to the point
where the cartilage lies flat. The lateral crus of the greater alar cartilage also
may curl medially and downwards on its superior margin where i t overrides the
lateral nasal cartilage. Sesamoid cartilages are present in all specimens.
These findings, although known to many rhinologic surgeons, are not clearly
established in the literature.
In recent years, techniques in rhinologic
surgery have been developed which make
it possible to repair the damaged or deformed nasal tip. Much of the surgery is
accomplished through incisions inside the
nose. With the anatomy not visible, the
surgeon desires to have a thorough knowledge of the detailed morphology and
topology of the normal and abnormal nasal
tip. Preservation or restoration of the
proper anatomical relationships between
the lateral nasal and lateral crus of the
greater alar cartilages is one of his prime
considerations. These relationships not
only influence the shape of the nasal tip,
but also determine the normal or abnormal
physiologic function of the nose (Cottle,
'55, '60). The literature on this topic, however, is not unequivocal.
In the last 70 years little research has
been done to clarify the detailed anatomical relationships of the nasal tip cartilages.
The major text books of anatomy and
surgery today still present the anatomy of
the cartilages as set forth in the last cenANAT. REC., 176: 321-328.
tury. A survey of the more important views
is presented in figure 1.
Straatsma and Straatsma ('51) state
that the lateral nasal cartilages extend
superiorly from 2-15 mm under the nasal
bones. In the surgical and anatomical texts
of the day the lateral nasal cartilages were
shown to "abutt" against the nasal bones.
Their work carefully clarified the relationship of the lateral nasal cartilage to the
nasal bones and to the cartilaginous
septum. They did not, however, investigate
the relationship of the lateral nasal cartilage to the lateral crus of the greater alar
cartilage, these two cartilages to the valve
and the role of the sesamoids.
Cottle ('55) reviewed the construction
of the human nasal vestibule including the
greater alar cartilages, the cul-de-sac, and
nasal valve. He indicated differences as to
Received SeDt.
20., '72. Accented Mar. 14. '73.
1This
work was conducted Drimarilv
primarily in
- ..._-research
..the Department of
of Biological Structur;,
Structure, Schod
School of
Medicine, The University of Wash%gton,
Medicine
Wash*gton,
Seattle.
Washin&on
Washington 98105.
98105, under the SUneMslOn
supeMslOn of Edward
C. Roos&Runge,
Roosen-Runge, M.D.
321
322
GLENN W. DRUMHELLER
BALLENGER
GRAY’S
CONVERSE
MORRIS‘
CUNNINGHAM’S
Fig. 1 External nasal cartilages as shown in major textbooks of anatomy and surgery.
FB, facial process of the maxillary bone; LNC, lateral nasal Cartilage; GAC, greater alar
cartilage; NB, nasal bones.
race and age, and discussed how they relate to the function of the nose. Cottle did
not present the detailed anatomy of the
cartilages, but suggested that they were
vital to proper function of the nose. In his
text on reconstructive surgery of the nasal
tip, a fine commentary on nasal surgical
anatomy and nasal function, he reaffirmed
this view (Cottle, ’60).
Gunter (’69) studied the relationship of
the greater alar cartilage to the architecture of the nasal tip, but did not discuss
the detailed relationship of the lateral nasal cartilage to the lateral crus of the
greater alar cartilage.
Hinderer (’71), in his text on nasal
anatomy and surgery, shows the most
complete description to date of the anatomical relationships of the lateral nasal
cartilage (LNC) to the lateral crus of the
greater alar cartilage (GAC lat. crus) and
clearly demonstrates how the GAC lat. crus
“overrides” the LNC, a point neglected by
the major texts of anatomy and surgery
and rarely mentioned in the literature. He
does not, however, further define the detail
of this relationship, (fig. 2).
The LNC is most frequently described
as “joining” with the GAC lat. crus, (fig.
3). For example, Schaeffer (’20) states
the lower edge of the LNC . is attached
by fibrous tissue to the upper edge of the
lateral crus of the greater alar cartilage,”
Seltzer (‘49) agrees. Gray’s Anatomy of
the Human Body (’66) states of the LNC
that “Its inferior margin is connected by
fibrous tissue with the greater alar cartilage,” (fig. 1 ) . Similar views are found in
“. .
TOPOLOGY OF THE LATERAL NASAL CARTILAGES
323
Cunningham’s (’64) and Morris’s Anatomy Jackson and Jackson (’59) and Ballinger
(’66), and in McIndoe (’38), Lillie and (’69) share similar views, as do Griesman
Simonton (’39), Truex (’48), and Pern- (’44), Daly (’47), Cottle ( ’ 6 0 ) , Brown and
kopf ( ’ 6 3 ) .
McDowell ( ’ 6 5 ) , and Hinderer (’71).
However, one also finds presentations
In addition to the concept of “overriding”
emphasizing that the cartilages “override” of the GAC lat. crus over the LNC is the
(fig. 3). Converse (’55, ’64) writes “The concept of “curling” of the edges of these
lateral cartilages are connected below to cartilages, where they meet, towards each
the alar (lower lateral) cartilages by other, (fig. 3). This concept was demonmeans of dense connective tissue, the strated by Cottle in 1954 in a n American
upper edge of the alar cartilage overlapping Medical Association exhibit where he rethe lower aspect of the lateral cartilage.” ferred to it as “returning” of the LNC.
Cottle (’60) states that inferiorly the
LNC’s become thin and delicate and their
terminal portions “valves” lie under the
upper edges of the GAC lat. crus and that
the LNC is prevented from completely collapsing on inspiration by its tendency to
curl away from the septum. Gray (’70)
confums this “outward curling” of the
caudal margin of the LNC as he sees it
surgically.
The early as well as the late investigators studied nasal tip anatomy by dissection, but because the cartilages and surrounding fibrous tissues are very pliable
and fragile, dissection on cadavers may
disturb and distort grossly their true relationships. Only Straatsma and Straatsma
__
sectioned their specimens.
It is clear that modern surgery and
Fig. 2 External nasal cartilages as shown in
anatomy
are not in agreement on the subHinderer’s text on nasal reconstructive surgery
demonstrating the overriding of the GAC lat. crus ject of nasal tip structure. The present
study is a further attempt to clarify the
over the LNC.
w
/-SEPT.
SUPERIOR
LNC
GAC
00
JOINING
0VER.RI DI N G
CURLING
Fig. 3 Diagrams of the three relationships of the LNC to the GAC as described in the
literature (shown in sectiorfs cut in a plane parallel to the dorsum). “Joining”- the most
frequently presented view, Overriding” - a less prevalent vicw, and “Curling” - a rarely
presented view.
324
GLENN W. DRUMHELLER
A E P T
morphology and topology of the LNC and
GAC lat. crus, on cadaver specimens, by
the method of sectioning and wax plate
reconstruction.
MATERIALS AND METHODS
The following specimens, entire nasal
tips removed in one piece, were used:
Number 1 - 67 year old female Caucasian,
embalmed; number 2 - 88 year old male
Caucasian, embalmed; number 3 - 62
year old male Caucasian, fresh; number 4
- 76 year old male Caucasian, fresh. The
latter two nasal tips were fwed in 10%
buffered formalin. The specimens were embedded in nitrocellulose (Parlodion@) and
mounted for sectioning. Specimen number
1 was sectioned at 50
(in a coronal
plane) and every fifth sectlon saved for
staining and mounting. Specimens 2, 3 ,
and 4 were sectioned at 60 (in a plane
parallel to the anterior aspect of the nose
or dorsum) and every fourth section
stained with H and E and mounted.
The sections of specimen 1 were enlarged by projection on photographic paper
at a magnification of X 6.5 and the outlines of the cartilages were transferred to
wax plates of appropriate thickness, cut
out, serially arranged and stacked into a
model. An enlarged model of the LNC and
GAC and the nasal septum was thus obtained. The slides of specimens 2,3 and 4
were used for comparison with information
gained from the model of specimen 1.
&@
G-A-C
MED. CRUS
INFERIOR
Fig. 4 A tracing of a section through the
model demonstrating the overriding of the superior boarder of the GAC lat. crus over t h e inferior boarder of the LNC, and the curling of the
LNC laterally on its inferior edge underneath the
GAC lat. crus. The right LNC shows a curl of
105O and the left LNC shows a curl of 180'.
Specimen 2 also shows the GAC lat. crus
overriding the LNC and shows the LNC
curling 180" on the right and 110" on the
left (fig. 5).
Specimen 3 also shows the GAC lat. crus
overriding the LNC which curls laterally
on its inferior edge. The right LNC shows
a curl of 170" and the left a curl of 45".
More
posteriorly in this specimen, in a
RESULTS
plane parallel to the dorsum, the GAC lat.
The model obtained demonstrates the crus was seen to curl medially nearly 80"
morphology of each cartilage of the nose, on its cranial margin on the right. The left
the LNC with its valve area and roof area GAC lat. crus did not curl, but a process
(embryological terminology), and the mor- of cartilage, joining like a peninsula to
phology of the GAC with its medial crus the GAC lat. crus laterally, extended into
and lateral crus, and the morphology of the fibrous tissue connecting the LNC to
sesamoids present. The GAC lat. crus over- the GAC lat. crus. A similar piece of carrides the LNC which is curled back upon tilage was seen on the right.
itself laterally along its inferior edge a few
Specimen 4 does not show overriding of
millimeters underneath the GAC lat. crus. the GAC lat. crus except to a small degree
This is clearly seen in figure 4 which is a deep (postero-laterally ) in the specimen.
tracing made from the model in a plane Two to three fragments of cartilage are
parallel to the dorsum, and about one third
Fig. 5 A photograph of a section of specimen
the thickness down. The right LNC curls
laterally on its inferior edge 105" and the 2 cut parallel to the dorsum showing overriding
the GAC lat. crus and lateral curling of the
left LNC curls laterallv 180". The curling
- by
LNC's on their inferior boarders, arrows. The
is greater anteriorly and diminishes POS- right LNC shows a curl of i80° and the left LNC
tero-laterally until the cartilages lie flat. shows a curl of 110'.
TOPOLOGY OF THE LATERAL NASAL CARTILAGES
325
326
GLENN W. DRUMHELLER
interposed in the dense fibrous tissue joining the LNC and GAC lat. crus. The right
LNC curls 45" and the left curls 105".
The GAC lat. crus on both the right and
left sides of this specimen curl medially
to 90" on their superior edges.
The GAC lat. crus in all specimens
where it overlapped the LNC was seen to
lie from 1-4 mm laterally to the LNC.
In all specimens, these cartilages of the
lateral side of the nose are joined by a
band of fibrous tissue which surrounds
each cartilage and is continuous from one
to another. Between the cartilages the
fibers appear to decussate.
Cartilage fragments (sesamoids), found
in the dense fibrous connective tissues
joining the LNC to the GAC lat. crus were
present in all specimens.
DISCUSSION
It is well known that the nasal cartilages
are all derived from a single cartilaginous
framework as found in the four month old
fetus (Schaeffer, '20; Macklin, '14). As the
fetus continues to develop, lines of cleavage arise which outline the future cartilages of the adult nose. Along these lines
of cleavage, cartilage is absorbed and
dense fibrous tissue, which is continuous
with fibrous tissue (envelope) surrounding
the newly formed cartilaginous structures,
is laid down in its place.
It is possible as these lines of cleavage
arise and the cartilages of the nose are
delineated that the GAC lat. crus which
is less rigidly fixed is drawn superiorly by
tissue tensions toward and over the LNC.
As this is occurring, the fibrous tissue between the LNC and the GAC lat. crus may
exert forces upon each which draws the
LNC laterally and the GAC lat. crus
medially to develop the curling demonstrated by this study. The degree of tension
exerted upon these cartilages would determine to what extent the cartilages curl,
be it slight, 45", moderate, go", or complete, 180".
The relationship which is developed
early in life persists until advancing age,
when the nose begins to sag and the cartilages, where they curl, begin to weaken,
fragment and straighten (Krmpotic, ' 7 0 ) ,
as seen in specimen 4.
Although all of the specimens show
some degree of curling, the number studied
is not truly representative of a significant
sampling of human Caucasian noses. For
this reason, I have attempted to enquire
into the experiences of rhinologic surgeons.
In personal communications M. H. Cottle,
M.D., G. H. Drumheller, M.D., and V. D.
Gray, M.D. have essentially confirmed
that curling of the LNC occurs in a majority of their surgical cases.
G. H. Drumheller, M.D., states that
curling of the LNC is more often seen than
no curling. It is found so frequently as to
be considered a normal finding by his colleagues. He cautions, however, that the
curling may be an expression of injury,
improper development, lack of resorbtion,
or accelerated growth of the cartilages.
M. H. Cottle, M.D., states that the curling of the LNC on its inferior edge as seen
in surgery is a normal expression of development, and that it may occur in
degrees. There may be some curling, 45",
moderate curling, 90 ", considerable curling, 135", or complete curling, 180". He
also states that the GAC lat. crus may also
be seen to curl medially upon itself. Cottle
feels that 90" of curling of the LNC is
physiologic.
Vernon Gray, M.D., states that his dissections during over 300 surgeries showed
99% with some degree of curling. The
degree, he states, varies from almost 0" to
180". He considers the curling to be a
normal expression of development, and a
moderate degree to be physiologic. He also
states that he sees curling of the GAC lat.
crus medially on its superior edge.
It appears imperative that further work
be done to clarify nasal tip anatomy, correlate it with age and race, and integrate
this knowledge with rhinologic experience.
ACKNOWLEDGMENTS
( 1 ) University of Washington Department of Biological Structure, E. C. RoosenRunge, M.D.
(2) American
Rhinologic Society,
Maurice H. Cottle, M.D., Founder.
( 3 ) Chicago Medical School, Department of Anatomy, Hans Elias, Ph.D.
( 4 ) Chicago College of Osteopathic
Medicine, Department of Physiology, Albert
F. Kelso, PhD., Jackson Lucus Research
Histologist.
TOPOLOGY OF THE LATERAL NASAL CARTILAGES
LITERATURE CITED
Anson, B. J. (ed.) 1966 Morris’ Human Anatomy. Blakiston Co., New York, pp. 1387-1391.
Ballinger, J. J. 1969 Diseases of the Nose,
Throat and Ear. Lca and Fcbiger, Philadelphia,
pp. 1-3.
Brown, J. B., and F. McDowell 1965 Plastic
Surgery of the Nose. Thomas, Springfield, pp.
22-25.
Convcrsc, J. M. 1955 The cartilaginous structures of the nose. Annals of OtorhinolaryngolO W , 64: 220-229.
1964 Reconstructive Plastic Surgery.
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Cottle, M. H. 1955 The structure and function
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Otolaryngology, 62: 173-181.
1960 Corrective Surgery Nasal Septum
and External Pyramid, American Rhinologic
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Cottle, M. H. 530 Hawthorne Place, Chicago,
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upper lateral cartilane. Rhinolo!zv. 8: 56-59.
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327
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Romanes, G. J. (ed.) 1964 Cunningham’s
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Sinuses, Nasolacrimal Passageways and OIfactory Organ in Man. Blakiston, Philadelphia,
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Seltzer, A. P. 1949 Plastic Surgery of the Nose.
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