Topology of the lateral nasal cartilagesThe anatomical relationship of the lateral nasal to the greater alar cartilage lateral crus.код для вставкиСкачать
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. Snunders, Philadelphia, pp. 694-702. Cottle, M. H. 1955 The structure and function of the nasal vestibule. AMA Archives of Otolaryngology, 62: 173-181. 1960 Corrective Surgery Nasal Septum and External Pyramid, American Rhinologic Society, Chicago, pp. 7-26. Cottle, M. H. 530 Hawthorne Place, Chicago, Illinois 60657. Daly, J. 1948 Morphologic deformities of the lower lateral cartilages. Archives of Otolaryngology, 147: 49-63. Drumheller, G. H. 1515 Pacific Avenue, Everett, Washington 98201. Gray, H., and C. M. Goss (eds.) 1966 Anatomy of the Human Body. Twenty-eighth ed. Philadelphia, Lea and Fcbiger, pp. 1118-1120. Gray, V. D. 1970 Physiologic returning of the upper lateral cartilane. Rhinolo!zv. 8: 56-59. Gray, V. D. 2080 Centuw Park Eaii,’Los Angeles, California 90017. Griesman, B. 1944 Muscles and cartilages from the standpoint of a typical rhinopl&y. Archives of Otolaryngology, 39: 334-341. Gunter, J. P. 1969 Anatomical observations of lower lateral cartilages. Archives of Otolaryngology, 89: 599-601. 327 Hinderer, K. 1971 Fundanentals of Anatomy and Surgery of the Nose. Aesculapius Publishing Co., Birmingham, pp. 10-19. Jackson, C., and C. L. Jackson 1959 Diseases of the Nose, Throat and Ear. Saunders, Philadelphia, pp. 1-3. Krmpotic, J. 1971 Morphological and histological changes responsible for the droop of thc nasal tip in advanced age. ACTA Otolaryngologica, 71 : 278-281. Lillie, H. I., and K. M. Simonton 1939 Nasal obstruction caused by collapse of the nasal alac. Annals of Otolaryngology, 48: 600-608. Macklin, S. C. 1914 The skull of the human fetus of 40 mm. Am. J. Anat., 16: 317-426. McIndoe, A. H. 1938 Correction of alar deformity in cleft lip. Lancet, 1 : 607-609. Pernkopf, E., and F. Helmut (ed.) 1963 Atlas of Topographical and Applied Human Anatomy. Vol. 1. Saunders, Philadelphia, p. 18. Rosec!ale, R. S. 1945 Anatomic and physiologic principles underlying plastic surgery. Ohio State Medical Journal, 41: 724-728. Romanes, G. J. (ed.) 1964 Cunningham’s Textbook of Anatomy. Oxford University Press, New York, pp. 828-829. Schaeffer, J. P. 1920 The Nose, Paranasal Sinuses, Nasolacrimal Passageways and OIfactory Organ in Man. Blakiston, Philadelphia, pp. 66-70. Seltzer, A. P. 1949 Plastic Surgery of the Nose. Lippencott, Philadelphia, pp. 18. Straatsma, B., and C. Straatsma 1951 The anatomical relationship of the upper lateral cartilage to the nasal bone and the cartilaginous septum. Plastic and Reconstructive Surgery, 8: 443-455. Truex, R. C., and C. E. Kellner 1948 Detailed Atlas of the Head and Neck, Oxford University Press, New York.